PERI-OPERATIVE NURSING

Perioperative Phases
Pre-operative Intra-operative Post-operative

Describe each of these stages?

What are the essential nursing competencies for each phase?
(Nursing Responsibilities: Chart 18-1, p. 482-483)

Review
Operative Classifications Diagnostic Curative Reparative Reconstructive/cosmetic Palliative Operative Categories Emergent Urgent Required Elective Optional
(Table 18-1, p. 485)

Ambulatory Surgery
How is ambulatory surgery defined? What is the goal of ambulatory surgery? What are the nursing responsibilities associated with ambulatory surgery?

Pre-operative Phase
PAT (blood tests, x-rays, other diagnostics) Teaching Knowledge of Risk Factors for Complications
(Chart 18-3, p. 486)

Important Things to Consider Preoperatively

Stop ASA 7-10 days before surgery Stop herbals 2-3 weeks before surgery Encourage no smoking for 4-8 weeks before surgery; stop smoking at least 24 hours before surgery Monitor immunocompromised patient closely for s/s of infection before surgery Surgery contraindicated if acute renal problems Control hypertension prior to surgery if possible Obesity increases risk and severity of complications

Disease/Medication Specific Considerations

Diabetes Mellitus:
At risk for hyperglycemia or hypoglycemia

Long-term corticosteroid use:

At risk for adrenal insufficiency

Uncontrolled Thyroid Disease

Overactive: risk of Thyrotoxicosis Underactive: risk of respiratory depression

Considerations for the Elderly

Increased risk for complications
Less physiologic reserves

Hazards. . . are proportional to the # and severity of c0-existing health problems and the nature and duration of the operative procedure. (p. 491)

Pre-Operative Teaching
Reinforce physicians explanations and instructions Discuss what to expect Instruct in breathing and leg exercises Demonstrate splinting of abdomen (if appropriate) Explain rationale for frequent position changes Discuss pain management Discuss cognitive coping strategies

Miss Nervous Nellie

Miss N is scheduled for a colon resection. A recent biopsy of a polyp revealed a malignancy. During your pre-admission interview Miss N is tearful and keeps saying I hope this wont be like it was when my dad had colon surgery. Im so afraid I will die just like he did. What are Miss Ns psychosocial needs? How will you meet those needs?

Pre-Operative Care
General Protect from injury
7 patient safety goals (JCAHO)

Immediate

Manage nutrition and fluids

NPO

Prepare bowel (if appropriate) Prepare skin (if appropriate)

Gown Cap (braid long hair, no hairpins) Remove dentures/plates No jewelry Void immediately before transport Cover with bath blanket Administer preanesthetic medication if ordered

Responsibilities related to the Medical Record

Complete pre-operative check list Place surgical consent form in plain view Send entire medical record (chart) to surgery with patient
Includes current MAR

Informed Consent
What is it? When is it necessary? Who can sign? What is the responsibility of the nurse?

What are the legal implications?

Holding Area Responsibilities

Initiation of verification form Pre-anesthesia medication if ordered Foley catheter if ordered Note: Entire peri-operative team should be involved in verification process (correct patient, correct site, etc) Why is the verification process so important?

Family Needs
Explain where to wait Surgeon will talk to them after surgey Never judge seriousness by length of time patient in surgery (keep family updated) Prepare them for what they will see post-op Explain post-op protocol and routines

Intraoperative Phase
An interdisciplinary approach to intraoperative care is essential. Who makes up the interdisciplinary team? What are the responsibilities of team members?

Microbe Management
Controlled Environment
What measures are implemented to control the surgical environment? Discuss the use of zones to decrease mibcrobes.

Surgical Asepsis
List the basic principles of aseptic technique.

Intraoperative Case Study

The client, a 62-year-old secretary, has entered the surgical suite about 30 minutes after she has received atropine and midazolam for preoperative medication. The OR schedule lists that she is scheduled to have a vaginal hysterectomy. In addition, the preoperative history indicates that she smokes three packs of cigarettes per day and drinks three cans of beer each day. When you ask her what kind of surgery she is having today, her response is I am going to have a hemorrhoidectomy. You ask her if she means hysterectomy and she responds, Well, it is some kind of operation down there.

What Should You Do?

What additional questions should you ask this client?
What should you do with the information?

What effect, if any, will her history of smoking and drinking have on her surgical experience?

The Case Continues

The client demonstrates understanding of the surgical procedure and the team proceeds with the planned vaginal hysterectomy. The client weighs 96 pounds. In what position should you place this client for the surgical procedure? What areas on this client are most likely to be injured as a result of poor positioning or inadequate padding?

Health Hazards Associated with Surgical Environment

Laser Risks Exposure to blood and body fluids Latex allergy

Types of Anesthesia
General
4 stages

Regional
Epidural Spinal Local conduction block

Moderate Sedation/Analgesia Monitored Anesthesia Care Local Anesthesia

Potential Intraoperative Complications

Nausea and vomiting Anaphylaxis Respiratory complications
Inadequate ventilation, airway occlusion, intubation of the esophagus, and hypoxia

Hypothermia Malignant hyperthermia Disseminated Intravascular Coagulation

What are measures to prevent or treat these complications?

Postoperative Pain Control

What is the definition of Pain? As nurses, what do we need to remember about the pain experience? What is the key reason to control postoperative pain?

Opioid Analgesics
Commonly prescribed for postoperative pain and immediate postoperative restlessness. Why would this drug be effective for restlessness?

By what route will this drug be adminstered?

Patient Controlled Analgesia

What is a nursing responsibility with PCA? What is the benefits of self administration of analgesia? What are the two requirements for use of PCA?

Epidural Infusions
What is an epidural infusion? Why would an epidural infusion be used? When must epidural infusions be used cautiously?

Intrapleural Anesthesia
What does intrapleural administration mean? What are the benefits to intrapleural anesthesia?

Other Pain Relief Measures

Subcutaneous Pain Management Systems Nonpharmacologic Measures

Postoperative Care: PACU

What is the goal of PACU care? What does PACU care entail?

Immediate General Floor Postoperative Care

What is included in the immediate postoperative care of the individual? How often should vital signs be assessed? What other assessments are needed? What should you do if the systolic pressure is < 90 mm HG?

Post 24 hour Postoperative Care

How does the focus of care shift after the first 24 postoperative hours?