Perioperative concepts and management

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• Perioperative concepts and management

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Association of PeriOperative Nurses

• AORN
• Standards of Care
• Recommended Practices
• Certification Process CNOR
• Continuing Education
• Legislative Issues
• RN First Assistant RNFA

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Definition of Perioperative Nursing

• The practice of nursing directed toward clients
  undergoing operative and other invasive
  procedures
• The perioperative nurse provides managers,
  teaches and or studies the care of clients
  undergoing operative or other invasive procedures
  in all three phases of the surgical experience

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Practice Areas

• Hospital operating rooms
• Interventional radiology suites
• Cardiac cath labs
• Endoscopy suites
• Ambulatory surgery centers
• Trauma centers
• Pediatric specialty centers
• Physician offices

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Functions of a Perioperative Nurse

• Advocate
• Protector
• Teacher
• Change agent
• Manager of client care

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The Surgical Team
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Perioperative Team Members

• Nursing Roles in the OR
• Circulating Nurse
• Scrub Nurse
• RN First Assistant (RNFA)
• Perioperative Educator
• Specialty Team Leader
• Perioperative Manager/Director

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Surgical Team

• Behind the scenes
• Radiology Technologist
• Anesthesia Technician
• Nursing Technician
• Transport Team
• Environmental Services Team

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Perioperative Nursing Skills

• Assessment
• Communication
• Critical thinking
• Technical skills

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Surgical Attire

• Gowns
• Gloves
• Masks
• Hair Covering
• Protective eyewear

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Perioperative Nursing

• Three Phases
• Preoperative (Preop)
• Intraoperative (Intraop)
• Postoperative (Postop)

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Preoperative Phase

• Starts when surgery is scheduled
• Ends when transferred to surgical suite
• Assessment phase
• Planning phase
• Discharge Planning phase
• Educations phase
• Getting it all together phase

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Intraoperative Phase

• Begins when transferred to the surgical suite
• Ends when transferred to the post-anesthesia care
  unit (PACU)
• Surgical phase
• Anticipatory time
• Maintaining client advocacy
• Maintaining communication with family/surgical
  team
• Surgical team interaction

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Postoperative Phase

• Begins upon entry to the PACU
• Ends when discharge from the PACU
• Assessment
• Pain control
• Education
• Discharge planning
• Interdisciplinary team communication

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Categories of Surgery-Purpose for Surgery

• Defined by
• The reason for surgery
• The urgency for surgery
• The degree of risk of surgery
• The anatomic location of the surgery
• The extent of the surgery required

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Reason for surgery

• Diagnostic
• Curative
• Restorative
• Palliative
• Cosmetic

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Urgency of the procedure

• Elective
• Urgent
• Emergent

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Degree of Risk

• Minor Risk
• Major Risk

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Anatomic location

• General
• GYN
• Urology
• Orthopedic
• Neurological
• Plastic
• Ophthalmology

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Anatomic location

• Cardiac
• Thoracic
• ENT
• Vascular
• Transplant
• Trauma
• Bariatric

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Extent of surgery

• Simple
• Radical

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Surgical Settings

• Inpatient
• Outpatient/ambulatory
• Hospital-based ambulatory surgery center
• Free-standing surgical center
• Physicians office surgery
• Ambulatory Care Centers

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Preoperative Period

• Assessment
• Nursing Management
• Analysis
• Planning and Implementation
• Evaluation

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Collaborative Management

• Preoperative HP up to 30 days PTS
• Primary Care Physician or Nurse Practitioner
• Faxed to pre-admission center
• Faxed to PCP or surgeon
• Reviewed, evaluated, changes PRN
• Sometimes surgery gets cancelled

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Nursing Process in Pre-op Phase

• Planning
• Correction of any abnormal labs
• Blood donations
• Bloodless surgery
• Nutrition
• Pain Management
• Surgery Classes
• Discharge planning

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Assessment

• History
• Surgical Risk Factors
• Physical Assessment and manifestations
• Psychosocial assessment
• Laboratory/ Radiographic assessment

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History

• Present problem, reason for surgery
• Past medical history
• Past cardiac history
• Past surgical history
• Family history
• Social history
• Medications
• Allergies

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Surgical Risk Factors

• Medical history
• Cardiovascular system
• Respiratory system
• Renal/ Urinary system
• Neurological system
• Musculoskeletal
• Age greater than 65

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Surgical Risk Factors

• Medication history
• Past surgical complications
• Past postoperative complications
• Nutritional status
• Social habits
• Family history of complications
• Type of surgical procedure planned

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Nursing Physical Assessment

• Health status
• Cardiovascular status
• Respiratory status
• Renal/urinary status
• Neurologic status
• Musculoskeletal status
• Nutritional status

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Psychosocial Assessment

• Anxiety
• Fear
• Coping
• Support Systems
• Socioeconomic status
• Diagnosis
• Education
• Physical signs

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Lab and Radiograph Assessment

• Baseline
• Predict potential complications
• Abnormal results
• Values according to medications taken

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Labs

• UrineUA
• HematocritHct
• HemagloblinHgb
• White blood cell countWBC
• Prothrombin time/ pro timePT
• Partial thromboplastin time, activatedaPTT
• International Normalized ratioINR

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Labs contd

• Chemistry electrolytesNa, Cl, K, Glucose, CO2
• Creatinine
• Blood urea nitrogen (BUN)
• Serum pregnancy test

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Radiographs/Optional tests

• Chest x-rayCXR
• ElectrocardiogramEKG
• Arterial blood gas-ABGs
• Pulmonary function testsPFTs
• Films for area of surgery x-rays, MRI, CAT scan

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Nursing Management

• Review planned surgery
• Obtain client history
• Physical assessment
• Preadmission treatment/diagnostic testing
• Interpret diagnostic tests
• Client expectations
• QA
• Caretaker ability

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Analysis Nursing Diagnoses

• Knowledge deficit
• Anxiety
• Disturbed sleep patterns
• Ineffective coping
• Anticipatory grieving
• Disturbed body image
• Disabled family coping
• Powerlessness

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Planning InterventionsDx Knowledge deficit

• Ensuring informed consent
• Client self-determination
• Implementing dietary restrictions
• Administration of medications
• Intestinal preparation
• Skin preparation
• Vascular access

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Pre-operative TeachingDx Anxiety

• Tubes, drains, additional vascular access
• Post-op procedures
• Post-op exercises breathing exercises, incentive
  spirometry, coughing splinting, leg procedures
  and exercises
• Early Ambulation
• Range of Motion exercises (ROM)

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Relaxation stress reductionDx Anxiety

• Deep breathing
• Music therapy
• Touching
• Familys presence
• Reassurance
• Calm mannerisms
• Pre-operative sedation

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Collaborative Management Assessment Planning

• Client interview
• Correct person for the correct procedure with
  correct preparation on the correct anatomy
• Risk for perioperative positioning injury
• Lacks normal defense mechanisms
• Size, age skin integrity
• Potential for hypoventilation
• Potential for hemodynamic shifts
• Blood loss

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Preoperative Chart ReviewNursing Responsibility

• Pre-op check list
• Surgical informed consent
• Anesthesia informed consent
• Blood transfusion consent-TS done?
• Site verification checklist-Med-Surg RN/OR staff
• Lab results-report abnormal lab values
• HP present signed
• Current vital signs
• Special Needs

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Preoperative Client Preparation

• Clothing removed/don patient gown
• Jewelry removed including body any piercing/s
• Prosthesis dentures, wigs, limbs
• Aides hearing, glasses, cane
• Arm bands identification, code status, blood
  bracelet, fall risk status bracelet
• Misc contact lenses, hairpins
• Nail polish, artificial nails

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Preoperative Client Preparation

• Empty bladder
• Pre-operative medications Versed/Reglan
• Safe transfer to surgical suite

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Special Considerations

• Patients age child elderly
• Cognition ability to cooperate/understand
• Ethnic customs
• Language/communication interpreter, HOH

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Evaluation what is my outcome?Planned or
unplanned

• Ms. W, age 77, is admitted for curative surgery
  (hysterectomy). She has a history of asthma is
  currently taking Prednisone. Her weight is 237,
  her height 53.
• What are her known risk factors?
• What other questions will you ask?

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Critical thinking Synthesis of information

• Assessment physical examination focused on
  clients history planned surgery
• Assessment of risk factors
• Clients previous experience w/surgery
• Clients coping resources
• Results of pre-op diagnostic tests

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Critical thinking Synthesis of information

• Knowledge AP of affected body systems
• Surgical risk factors
• Type of surgical procedure to be performed
• Surgical stress response infection control
  practices

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Critical thinking Synthesis of information

• Experience Caring for clients who have had
  surgery
• Personal experience with surgery

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Critical thinking Synthesis of information

• Standards apply standards of care (SOC)
• Apply AORN standards in operating room
• Apply American Society of PeriAnesthesia Nurses
  (ASPAN) standards of care

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Critical thinking Synthesis of information

• Attitudes Use discipline in collecting a
  complete history
• Use perseverance to ensure a comprehensive
  assessment

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Goals of Client Safety

• Provide safe client care
• Knowledge of procedure
• Ensure the correct client, correct site, correct
  level and correct procedure
• Knowledge of positioning
• Adhere to safe medication administration
  guidelines
• Perform surgical counts

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Safety Client

• Correct patient, correct surgery, correct side
  Time Out
• Positioning padding, alignment, eyes, breast,
  penis/scrotum
• Injury burns
• Sponge, Needle, Instrument counts
• Fall prevention-safety straps

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Goals of Client Safety

• Provide a safe environment
• Adhere to asepsis surgical conscious
• Promote coordinated and effective communication

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Safety Staff

• Sharps
• Equipment
• Lifting, moving, positioning client
• Combative client
• Safety equipment universal protocol goggles
  isolyzer gel
• OSHA surgical smoke, laser plume

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Benefits of a Career in Perioperative Nursing

• Requires
• The ability to work in a fast paced environment
• Flexibility
• Attention to detail
• Willingness to commit to ongoing learning
• The ability to work collaboratively as a member
  of the surgical team

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Patient Outcomes

• Planned Outcomes
• Unplanned Outcomes

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Intraoperative Nursing

• Break!

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Intraoperative Phase

• Begins when the client enters into the surgical
  suite
• Sedated?
• Aware?
• Noises
• Cold
• Double teamed

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Surgical Asepsis

• Surgical field-defined
• Surgical tables-green or blue drapes
• Surgical conscious
• Infection control practices
• Physical layout of surgical suite
• Protocols distance, doors, dress

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Skin Preparation

• Clip-electric razor
• Scrub
• Shower
• Purpose

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Surgical Hand Scrub

• Purpose
• Agents soap water vs. liquid hand cleaner
• Nails
• Position of hands
• Donning gown gloves

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Safety Staff

• Sharps
• Equipment
• Lifting, moving, positioning client
• Combative client
• Safety equipment universal protocol goggles
  isolyzer gel
• OSHA surgical smoke, laser plume

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Safety Client

• Correct patient, correct surgery, correct side
  Time Out
• Positioning padding, alignment, eyes, breast,
  penis/scrotum
• Injury burns
• Sponge, Needle, Instrument counts
• Fall prevention-safety straps

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My Space-Your Space

• Defined geographic locations
• Position of equipment
• Rules of engagement
• Color me blue/green
• Surgical conscious
• Moving about in the OR
• OR traffic patterns
• The Red Line

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Anesthesia more choices and alternatives

• General Anesthesia
• Regional Anesthesia
• Intravenous Anesthesia
• Local Anesthesia
• Balanced Anesthesia

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General Anesthesia Inhalation Agents

• Inhalation most controllable method lungs act as
  passageway for entrance exit of agent
• Gas Agents Nitrous Oxide
• must be given with oxygen
• require assisted to mechanical ventilation
• frequently shiver
• taken in excreted via lungs
• Examples halothane, enthrane, florane

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Anesthesia Cart

• Supply Cart
• Syringes
• IV supplies
• Intubation supplies
• Medications
• Blood transfusion supplies
• Regional anesthesia supplies

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General AnesthesiaEndotracheal
Intubation (maintain airway patency/promote
oxygenation)
Used with general anesthesia Alternatives are
mask or LMA
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Stages of General Anesthesia

• Stage 1 Analgesia/Sedation/Relaxation
• Stage 2 Excitement/Delirium
• Stage 3 Operative Anesthesia
• (Stage 4 DANGER BAD) not expected/normal
• Speed of EMERGENCE (recovery from anesthesia)
  depends on type of anesthesia, length of time
  many other factors- try to time with end of
  surgery

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General Anesthesia Intravenous

• Intravenous Agents
• Thiopental Sodium (Pentothal) but is commonly
  called Sodium Pentothal by patients (class
  barbiturate)
• Diprovan (Propofol)
• rapid acting
• monitor vital signs
• respiratory depression

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Adjuncts to General Anesthesia

• Hypnotics (Versed)
• also used for conscious sedation
• Opioid Analgesics (Morphine, Fentanyl)
• respiratory depression
• Neuromuscular Blocking Agents
• Causes muscle paralysis
• Examples Rocuronium, Succinycholine
• What vital function is affected?

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Potential General Anesthesia Complications

• Overdose (consider risk factors)
• Hypoventilation postoperatively
• Intubation related sore throat, hoarseness,
  broken teeth, vocal cord trauma
• MALIGNANT HYPERTHERMIA
• Genetic predisposition
• Triggered by anesthetics such as Halothane

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Balanced Anesthesia (a sample)

• Start with Pentothal or Propofol
• Add in some nitrous oxide for amnesia
• Use inhalation agent such as halothane
• Stir in a little opiate- morphine, fentanyl, for
  postop analgesia
• To top it off give Pavulon, a neuromuscular
  blocker, for additional muscular relaxation

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Regional Anesthesia

• Field Block
• Nerve Block
• Spinal Anesthesia
• Epidural Anesthesia

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Regional Anesthesia

• Loss of sensory nerve impulses motor function
  may or may not be affected
• No loss of consciousness
• Field Block caine injected around a nerve or
  group of nerves (dental procedures)
• May be combined with epinephrine to prolong
• Approximately 30 min to 2 hours

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Regional Anesthesia Spinal

• Local anesthetic
• (-caine) injected into cerebrospinal fluid
  (approx L 3-5) subarachnoid space

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Spinal Anesthesia (Subarachnoid Block)

• Anesthesia tip of xiphoid to toes
• Risks
• Loss of vasomotor tone
• Spinal Headache
• Infection, Rising anesthesia above diaphragm
• Nursing KEEP FLAT, MONITOR VS OFFER FLUIDS
  WHEN APPROPRIATE

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Regional Anesthesia Epidural

• Injected into epidural space rather than
  subarachnoid fluid (usually safer)
• Used for OR OB
• Epidural catheter can be left in place for postop
  pain management (PCA)

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Regional Anesthetic Risks

• Anaphylaxis (ALLERGY)
• Incorrect administration technique
• Systemic absorption of medication
• Infection

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Intravenous Anesthesia

• Multiple Agents
• Multiple Purposes
• Induction
• Hypnosis
• Dissociative
• Opioid Analgesics
• Neuromuscular blocking agents

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Conscious Sedation

• Reduce intensity of pain without loss of
  defensive reflexes
• Usually a combination of opioid analgesic and
  sedative-hypnotics
• May be administered by credentialed RN
• Expect client to be sleepy but arousable
• JUST BECAUSE HIS EYES ARE CLOSED DOESNT MEAN
  HES ASLEEP!!

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Local Anesthesia

• Local/Topical
• Interrupts transmission of sensory nerve impulses
  so it numbs what it touches
• Requires multiple injections with CAINE drug
  (Example novacaine, lidocaine)
• Duration 1 min to 20-30 min
• -Can be prolonged with added epinephrine
• Assess for ALLERGY

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Nursing Process during the Intraoperative Phase

• Assessment-ongoing
• Planning
• Proactive
• Flexible
• Forever Changing

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Nursing Process Intraop Phase

• Evaluation
• Expected
• Unexpected
• Documented
• Informing Client Family
• Surgical Waiting Room
• Ongoing Updates by OR Team

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Postoperative Goals

• Re-establishment of physiologic equilibrium
• Alleviation of pain
• Prevention of complications