NURSING 1022C Perioperative ATI & Medsurg.docx
Perioperative Nursing
• 3 phases –
o Preoperative: Begins with the decision to proceed with
... [Show More] surgical intervention and
ends with transfer of the patient into the OR.
o Intraoperative: Begins when the patient is transferred to the OR bed and ends with admission into the PACU.
o Postoperative: Begins with the admission of the patient into PACU and ends with a follow up evaluation in the clinical setting or home.
Informed Consent
• Informed Consent is the patient’s autonomous decision about whether to undergo a surgical procedure.
• Necessary in the following circumstances:
o Invasive procedures (surgical incision, biopsy, cystoscopy, or paracentesis)
o Procedures requiring sedation and/or anesthesia
o Nonsurgical procedure (arteriography)
o Procedures involving radiation
o Blood product administration
• Must be of legal age and mentally capable, otherwise is obtained from a surrogate, who most often is a responsible family member.
Preoperative Assessment
• Detailed history: medical, surgical, tolerance of anesthesia, medication use, complementary or alternative practices (herbals), substance use, psychosocial history, and cultural history.
• Allergies: Medications, latex, contrast agents and food products.
o Allergies to banana or kiwi can indicate allergy to latex
o Eggs or soybean contraindication for use of Propofol for anesthesia
o Shellfish can result in a reaction to povidone-iodine.
• Anxiety Level: Regarding the procedure, support systems, and coping mechanisms
o Older patients can be more fearful due to financial concerns and lack of social
support.
• Baseline Data: Head-to-Toe assessment, vital signs, and oxygen saturations
• Venous Thromboembolism Risk: Evaluation based on surgical procedure, patient history, and anticipated time to the client will be immobilized following surgery.
• Diagnostics:
o Urinalysis, Blood Type and cross-match, CBC, pregnancy test, clotting studies,
Electrolyte levels, Serum Creatinine and BUN, ABGs, Chest x-ray, 12-lead ECG.
• Patient Education:
o A goal of preoperative nursing care is to educate the patient how to promote
optimal lung expansion and resulting blood oxygenation after anesthesia.
▪ Demonstrate how to take a deep, slow breath and how to exhale slowly. Take short breath, and cough deeply in the lungs.
o Teach splinting to minimize pressure and control pain.
▪ Placing hands across incision site as an effective support when coughing.
o Teach early ambulation if applicable, should be taught and used as tolerated to
help prevent complications.
Surgical Team
• Consists of the patient, anesthesiologist or CRNA, the surgeon, RNs, surgical technicians, and registered first assistant nurses or certified surgical technologists (assistants).
o Circulating Nurse: Qualified RN works in collaboration with surgeons, anthologists, and other health care providers. The RN manages the OR and protects the patients safety and health by monitoring the activities of the surgical team, checking the OR conditions, and continually assessing the patient for signs of injury and implementing appropriate interventions.
o Scrub Technician: Setting up the sterile equipment, tables and sterile field; preparing sutures, ligatures, and special equipment, and assists the surgeon and surgical assistants during the procedure by anticipating the instruments and supplies that will be required. Performs counts, to be sure that they are all accounted for and not retained as a foreign body in the patient.
o Surgeon: Performs the surgical procedure, heads the surgical team, and is a licensed physician.
o RN First Assistant: Practices under direct supervision of the surgeon. Include handling tissue, providing exposure at the operative field, suturing, and maintaining hemostasis.
o Anesthesiologists/CRNA: Administers anesthetic agents, assesses the patient before surgery, selects anesthesia, administers it, intubates the patient if necessary, manages any technical problems related to the administration of the anesthetic agent, and supervises the patient’s condition throughout the surgical procedure.
Potential Intraoperative Complications
• Nausea and Vomiting: if gagging occurs patient is turned onto their side.
• Anaphylaxis
• Hypoxia and Respiratory Complications: Inadequate ventilation, occlusion of the airway, inadvertent intubation of the esophagus, and hypoxia significant complications associated
with general anesthesia.
• Hypothermia: Temperature may fall, glucose metabolism is reduced, and as a result, metabolic acidosis may develop. Indicated by a core body temperature that is lower than normal.
• Malignant Hyperthermia: Rare inherited muscle disorder that is chemically induced by anesthetic agents. This disorder can be triggered by myopathies, emotional stress, heatstroke, neuroleptic malignant syndrome, strenuous exercise exertion, and trauma.
o Signs include cardiovascular, respiratory, and abnormal musculoskeletal activity. Heart rate greater than 150bpm. Late sign of rising temperature can rise 2* to 4* every 5 minutes.
o Treatment goals are discontinuing anesthesia immediately. Decrease metabolism, reverse metabolic and respiratory acidosis, correct dysrhythmias, decrease body temperature, provide oxygen, correct electrolyte imbalance.
Postoperative
• Postoperative period extends from the time the patient leaves the OR until the last follow- up visit with the surgeon.
Nursing Management Care
• Provide care until the patient has recovered from the effects of anesthesia including, the patient is oriented, has stable vital signs, and shows no evidence of hemorrhage or other complications.
• Frequent assessment of airway, respiratory function, cardiovascular function, skin color, level of consciousness, and ability to respond to commands.
• Hypotension can result from blood loss, hypoventilation, position changes, pooling of blood in the extremities or side effects of medications and anesthetics. (most common blood loss and plasma loss exceeds 500mL)
• Shock can occur as a result of hypovolemia and decreased intravascular volume.
o Signs of hypovolemic shock include pallor, cool moist skin; rapid breathing;
cyanosis of the lips, gums, and tongue; rapid, weak, thread pulse; narrowing pulse pressure; low blood pressure; and concentrated urine.
• Hemorrhage can present insidiously or emergently at any time in the immediate postoperative period or up to several days after surgery.
o Signs: Hypotension; Rapid, thready pulse; disorientation; restlessness; oliguria; and cold pale skin.
o Early phase will result in feeling of apprehension, decreased cardiac output, and vascular resistance. Breathing becomes labored and “air hunger”, will be exhibited; patient will feel cold and may experience tinnitus.
• Hypertension and Dysrhythmia: Common in immediate postoperative period. Associated with electrolyte imbalance, altered respiratory function, pain, hypothermia, stress, and
anetic agents. [Show Less]