Chapter 20: Caring for the Perioperative Client

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Chapter 20 Caring for the Perioperative Client

• Medical Surgical Nursing 1--

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Perioperative

• Term used to describe the entire span of surgery,
  including what occurs before, during and after
  actual procedure
• Three phases of perioperative care are
• Preoperative
• Intraoperative
• Postoperative

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Definitions

• Perioperative term used to describe the entire
  span of surgery, including what occurs before,
  during, and after the actual operation.
  Preoperative begins with the decision to
  perform surgery and continues until the client
  has reached the operating area.

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Definitions

• Intraoperative includes the entire duration of
  the surgical procedure, until the client is
  transferred to the recovery area.
• Postoperative begins with admission to the
  recovery area and continues until the client
  receives a follow-up evaluation at home or is
  discharged to a rehabilitation unit.

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Reasons Categories of Surgery

• Categories of Surgery Based On Urgency --Table
  20-2 pg 239
• Reasons for Surgery Table 20-1 pg 239

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Preoperative

• Must have complete assessment
• Must identify which client is more at risk for
  complications
• weight
• use of alcohol, tobacco and other substances
• Physical conditions
• Medical problems
• Liver kidney function

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Surgical Risk Factors

• See Table 20-3 on pg 241

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Assessment

• Review pre-op instructions to make sure they are
  completed
• diet restrictions
• skin prep
• thorough hx and physical exam
• assess for knowledge of procedure, post-op
  expectations and if he can participate in post op
  care

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Assessment

• There may be strong cultural beliefs about
  disposal of body parts and blood transfusions
  

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Surgical Consent

• Dr. explains, must be informed consent
• Client or family signs permission--nurse cosigns
  and dates
• Notify Dr. if any questions
• Do not sign after narcotic or sedative given
• Consent must be obtained for any invasive
  procedures that requires anesthesia and has risks
  or complications

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Surgical Consent

• If adult is confused, unconscious or not mentally
  competent, family member or guardian must sign.
• A minor under 18 who is living away from home and
  is self supporting is an emancipated minor and
  may sign form
• Must be informed consent!!

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Surgical Consent

• In an emergency, the Dr.. may operate without
  consent but every effort should be made to get
  consent via phone, telegram or fax. Must have 2
  witnesses if over phone.

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Preoperative Teaching

• When doing pre-op teaching, simple, factual
  explanations adjusted to clients ability and
  need are essential

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Pre-op Teaching

• Pre-op meds, post-op control of pain
• why frequent vital signs taken
• Explain recovery room
• Practice coughing and deep breathing exercises,
  splinting, leg and feet exercises
• Explain how to use spirometer and why it is
  needed
• IV, catheter, NG tubes

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Insentive-Spirometer Video

• http//www.smiths-medical.com/catalog/lung-expansi
  on/insentive-spirometer/disposable-coach-spiromete
  r.html

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Skin Prep

• Shaving prevents contamination of surgical area
  because micros are on hair. It also prevents hair
  from entering the wound and interferes with
  healing
• Shaving, clipping hair or creams used
• Some hosp do not allow shaving as risk injury to
  the skin, which provides an entry for
  microorganisms.

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Elimination

• Bladder distention makes surgery more difficult
  and increases risk to bladder during surgery
• Enemas prevents straining after surgery and
  prevents incontinence during surgery
• If not catheterized, must void prior to pre-op
  med--put time of voiding on chart

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Food and Fluids

• MD gives specific orders on how long food and
  fluids are to be withheld before surgery at
  least 8 to 10 hours is customary.
• Many NPO after midnight

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Food and Fluids

• Many ambulatory surgical centers allow clear
  fluids up to 3 to 4 hours before surgery.
• Encourage good nutrition prior to this to help
  meet increased need for nutrients during healing
  process
• Protein and vitamin C are especially important to
  wound healing

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Care of Valuables

• Place in hosp. safe if unable to give to family
  to take home.Itemize valuables and place in
  envelope. Chart who you gave it to.
• Remove all jewelry. May keep wedding ring but
  tape to finger or tie with gauze.
• Chart what you did with valuables
• Remove glasses, contacts, dentures and store
  safely

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Attire

• Cotton hospital gowns
• Hair protector, booties
• Some minor out patient surgery can wear own
  clothes with gown over them.
• No make-up, nail polish, or hair pins or
  barrettes
• Give good mouth care before surgery
• Prostheses removed unless otherwise ordered

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Prostheses

• Depending on agency policy and physician
  preference, the client removes full or partial
  dentures.
• Doing so prevents the dentures from becoming
  dislodged or causing airway obstruction during
  administration of a general anesthetic.

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Pre-op Meds

• Before pre-op meds given
• Time on call
• consent signed, allergies?
• Voided? chart time
• follow rights
• contact anesthesia if questions
• take vitals

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Pre-op Meds

• After med given
• Side rails up, bed in low position, call bell
  near
• Instruct not to get up...chart it
• rearrange room for stretcher
• take vitals 30 to 45 minutes later

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Pre-op Meds

• Tranquilizers and sedatives reduce anxiety
• Hypnotics (sleeping pills) night prior to surgery
• Anesthesiologist orders pre-op---may be a
  combination---Demerol, phenergan, atropine
• Narcotic and antiemetic and drugs to decrease
  resp. tract secretions--phenergan enhances
  sedation of narcotic

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Psychosocial Preparation

• Anxiety and fear, if extreme, can affect a
  clients condition during and after surgery
• anxious clients have a poor response to surgery
  and are prone to complications.
• Call clergy if requested

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Preoperative Checklist

• Read over Preopeative Checklist on own pg 243

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Intraoperative Care

• Surgical team consists of an anesthesiologist,
  surgeon assistants, and the intraoperative
  nurses.
• Read on own

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Anesthesia

• Is the partial or complete loss of the sensation
  of pain with or without the loss of
  consciousness.
• Surgical procedures are performed with general,
  regional, or local anesthesia.

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General Anesthesia

• General anesthesia produces loss of sensation,
  reflexes, and consciousness by acting on the
  central nervous system.
• Vial functions such as breathing, circulation,
  and temperature control are not regulated
  physiologically when general anesthetics are
  used.

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General Anesthesia

• May be administered as IV, intramuscular,
  inhaled, or rectal medications.
• Has 4 distinct but overlapping stages.

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4 Stages of General Anesthesia

• 1. Induction or beginning stage this short
  period of time is crucial for producing
  unconsciousness. (Et tube)
• The client experiences dizziness, detachment, a
  temporary heightened sense of awareness to noises
  and movements, and a sensation of heavy
  extremities and not being able to move them. (IV
  or inhaled)

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4 Stages of General Anesthesia

• 2. Maintenance of surgical anesthesia during
  this stage the client is maintained in an
  unconscious state, ranging from light to deep,
  depending on the depth of anesthesia required for
  the surgery.
• Generally this stage is maintained with a
  combination of IV and inhaled anesthetics.
• VS closely monitored

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4 Stages of General Anesthesia

• 3. Emergence from surgical anesthesia this
  sage is critical for the client as the
  anesthetics are carefully withdrawn.
• Generally the client wakes enough to follow
  commands and demonstrate the ability to breathe
  independently.
• ET tube may be removed while in the OR or may be
  left in place for much of the recovery phase.

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4 Stages of General Anesthesia

• 4. Recovery period this period can be brief or
  long. Many of the effects of general anesthesia
  take some time to be eliminated completely.
• Clients often do not remember much about the
  initial recovery period.

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General Anesthesia

• Throughout the duration of and recovery from
  anesthesia the client is closely monitored for
  effective breathing and oxygenation, effective
  circulatory status including blood pressure,
  pulse within normal ranges, effective regulation
  of temperature, and adequate fluid balance.

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Regional Anesthesia

• Uses local anesthetics to block the conduction of
  nerve impulses in a specific region.
• The client experiences loss of sensation and
  decreased mobility to the specific area that is
  anesthetized.
• Does not lose consciousness.
• See Table 20-4 pg. 247

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Regional Anesthesia

• Advantages less risk for resp, cardiac, or GI
  complications.
• Needs to be monitored for signs of allergic
  reactions, changes in VS, and toxic reactions.

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The OR Environment

• The OR or surgical suite environment is
  physically isolated from other areas of the
  hospital or surgical clinic.
• Air is filtered and positive pressure maintained
  to reduce the number of possible microbes that
  can cause infection.
• Separate clean and contaminated areas.

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The OR Environment

• Temperature below 70 to provide a cooler
  environment that does not promote bacterial
  growth, Personnel comfort
• Operating Room Attire Box 20-5 pg. 248

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The OR Environment

• Nursing Management ASEPSIShigh risk of
  infection due to break in skin integrity
• Varies with type of surgery, anesthesia, pt. ..

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Possible Intraoperative Complications

• Infection
• Break in aseptic procedure
• Risk for the retention of foreign objects in the
  wound. Count must be accurate

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Possible Intraoperative Complications

• Fluid volume excess or deficit
• The circulating nurse is responsible for
  recording ad keeping a running total of IV fluids
  administered.
• If has an indwelling catheterurine output
  measured

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Possible Intraoperative Complications

• Injury Related To Positioning
• Careful positioning and monitoring help to
  prevent interruption of blood supply and nerve
  injury secondary to prolonged pressure, nerve
  injury r/t prolonged pressure, postoperative
  hypotension, dependent edema, and joint injury
  r/t poor body alignment.

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Possible Intraoperative Complications

• Malignant Hyperthermia manifested by a rapid
  and progressive rise in body temperature.
• There is an uncontrolled increase in muscle
  metabolism and heat production in response to
  stress and some anesthetic agents.
• Symptoms tachycardia, tachypnea, cyanosis,
  fever, muscle rigidity, diaphoresis, mottled
  skin, hypotension, irregular heart rate,
  decreased urine output and cardiac arrest.

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Possible Intraoperative Complications

• Symptoms tachycardia, tachypnea, cyanosis,
  fever, muscle rigidity, diaphoresis, mottled
  skin, hypotension, irregular heart rate,
  decreased urine output and cardiac arrest
• Prevention essential because the mortality rate
  is high.

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Possible Intraoperative Complications

• Clients at risk include those with bulky, strong
  muscles, a history of muscle cramps or muscle
  weakness and unexpected temperature elevation and
  an unexplained death of a family member during
  surgery that was accompanied by a febrile
  response.
• If temp starts to rise rapidly, anesthesia is
  d/cd and the OR team implements measures to
  correct physiologic problems, such as fever or
  arrhythmia

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Hypothermia

• Nursing interventions to prevent or reverse
  hypothermia include warming intravenous fluids to
  body temperature
• Replacing wet drapes and gowns with dry ones
• Warming the client gradually

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Hypothermia

• Monitoring the clients temp and other v/s
  constantly
• Maintaining the clients oxygenation and
  assessing the clients fluid balance.

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Immediate Post Op

• 1st nursing assessment made by the nurse is
  airway patency

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Recovery Room-Post Anesthesia

• Rapid assessment of general condition. Airway,
  vitals, LOC, drainage, suction
• Inspect dressings, tubes, drains, IV
• Connect drains to machines or equipment
• Observe for shock, hemorrhage, hypoxia, vomiting
  and aspiration

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Postoperative Complications

• During the first 24 hours after surgery, the
  nurse closely observes the client for signs of
  hemorrhage, shock, hypoxia, vomiting, and
  aspiration.

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Hemorrhage

• Can be internal or external
• Inspects dressings frequently for signs of
  bleeding and checks the bedding under the client
  because blood may pool under the body and be more
  evident on the bedding than on the dressing.

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Hemorrhage

• Note color of bleeding. Bright red blood is fresh
  blood..dark, brownish indicates old blood.
• Notes the amount and color of the blood on the
  chart.
• Reinforce dressing. Need Drs order to change.
  Mark dressing and put time. call Dr. if it
  continues.

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Shock

• NARCOTICS are not administered to a client in
  shock until a physician evaluates the client.
• Should remain flat.
• Some advocate elevation of the legs to enhance
  the flow of venous blood to the heart.

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Hypoxia

• Factors such as residual drug effects or
  overdose, pain, poor positioning, pooling o
  secretions in the lungs, or obstructed airway
  predispose the client to hypoxia (decreased
  oxygen).
• O2 and suction equipment must be available for
  immediate use.

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Hypoxia

• Breathing may be obstructed if the tongue falls
  back and obstructs the nasopharynx
• If this occurs, insert an oropharyngeal airway.
  Position the client on his or her side to relieve
  nasopharyngeal obstruction.
• Restlessness, crowing, or grunting respirations,
  diaphoresis, bounding pulse, and rising blood
  pessure may indicate resp obstruction.

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Vomiting

• Can be caused by the anesthetics used.
• Have emesis basin within easy reach.
• A NG tube may be inserted
• Antiemetics given

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Aspiration

• From saliva, mucus, vomitus, or blood exists
  until the client is fully awake and able to
  swallow.
• Suction equipment must be kept at the clients
  bedside until the danger of aspiration no longer
  exists.
• Unless contraindicated, the client is placed in a
  side-lying position until oral secretions can be
  swallowed.

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Post-op Assessment

• respiratory function
• general condition
• vitals q 15 x4 q 30 x2q hr x 4 or until stable
• cardiovascular and fluid status
• pain level
• bowel and urinary elimination
• inspect dressing, tubes, drains, IV

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Evisceration

• Separation of wound edges and protrusion of
  organs.
• cover with sterile dressing moistened with
  sterile normal saline and call Dr. stat--prepare
  for surgery
• Put in a position that puts the least strain on
  incision

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Dehiscence

• Separation of wound edges without the protrusion
  of organs
• Predisposing factors for evisceration
  dehiscence are malnutrition, particularly
  insufficient vitamin C and protein, defective
  suturing, unusual strain on incision (severe
  cough, sneezing, vomiting, hiccups, obesity,
  weakened abd. wall from other surgeries
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

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Evisceration Dehiscence

• Most likely to occur within 7 to 10 days
  following surgery
• Complain of something giving away. Pinkish
  drainage may appear suddenly on dressing.
• Surgical emergency...call Dr. stat!

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Paralytic Ileus

• Intestines are paralyzed and nothing moves thru.
  bowel sounds are absent, abdomen is distended and
  abdominal pain is severe. Vomiting may occur.
• Palpate for rigidity, auscultate for bowel sounds
• NG tube usually ordered kept NPO

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Acute Gastric Dilatation

• Stomach becomes distended with fluids, similar to
  ileus
• May regurgitate small amts of liquid
• Abdomen distended and may get shocky
• NG tube inserted and low suction used to take out
  fluids and gas.

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Elimination

• May have flatus post-op as intestines manipulated
  and large amounts of air. Ambulation helps
• May have difficulty voiding. Monitor amounts if
  voiding--if catheter monitor amount also.
• If unable to void in 8 hours post-op call Dr.
  Assess for restlessness, lower abd. pain,
  discomfort or distention and I O

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When to Notify Dr.

• chills or fever
• drainage from incision -some normal
• foul odor or pus
• redness, streaking, pain, or tenderness around
  incision
• other symptoms not present when discharged
  (diarrhea, vomiting, cough, chest or leg pain

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Important Information

• Review standards and nursing care on page 249-252
• Includes patient teaching and nursing care.
• Nursing Guidelines 20-2 pg. 257
• Nursing Guidelines 20-1 pg. 254
• Lots of patient teaching on your board
  exams...start now so you will be ready!!