Week 1: Perioperative Care Chapter 18: Preoperative Care Intro Surgery: the art and science of treating diseases,

, injuries, and deformities by operation and instrumentation Purpose of time-out; right person, site, time, procedure o Called: anytime Classifications of general surgeries Curative/ Ablative: elimination or repair of pathology Palliative: alleviation of symptoms without cure Constructive/ reconstructive: ex. Deviated septum, cleft palate Diagnosis: determination of the presence and/or extent of pathology; ex. biopsy Exploration: surgical examination to determine the nature or extent of a disease Prevention: example: removing a mole before it becomes malignant; ex. colonoscopy Cosmetic improvement: enhance appearance; ex. repairing a burn scar Transplant: exchange of old organ for a new one Classifications of surgeries: Risk Minor: toenail removal Major: C section, open heart surgery Surgical Urgency classifications Optional: no harm present Elective: harm is present, but optional and carefully planned Required: necessary Urgent: risk of ruptured appendix/ ovary emergency surgery: unexpected and urgent; ex. Ruptured appendix/ ovary; can cause systematic damage ambulatory surgery o operating time of less than 2 hours, and require less than 24 hour stay post-op Surgical settings inpatient: stay over night outpatient: leave same day; low risk; ex. Cataract removal, colonoscopy, heart catheter Surgery prep required o knowledge of the nature of the disorder requiring surgery and any coexisting disease processes o identify the individuals response to the stress of surgery o must assess the results of appropriate preoperative diagnostic tests o identify potential risks and complications associated with the surgical procedure and any coexisting medical conditions Patient interview purpose: o obtain the patients health information o provide and clarify information about the planned surgical experience o assess the patients emotional state and readiness for surgery Nursing assessment of the preoperative patient Objective data determine the psychologic and physiologic status establish a baseline

At risk: age, nutritional, health status, fluid and electrolytes imbalances, radiation, cardiopulmonary, chemotherapy, meds, family history, prior surgical experiences (positive/negative), type of surgery, location site -Young: at risk for hyperthermia, ineffective coping skills, weakened kidney/resp./immune system, increased risk for fluid volume -Elderly: sensory impaired -Smokers: need oxygen, abnormal lung sounds, pulse O2, and ABGs altered Subjective data Psychosocial assessment o Anxiety o Common fears Of death Of mutilation or alteration Of pain and discomfort Of anesthesia Of disruption of life functioning or patterns o Hope Past health history o Determine if the pt understands reason for surgery o Document past hospitalizations and reasons for them; any problems experienced with these procedures o Menstrual/ obstetric history o Inherited traits o If pts family has a history of problems with or related with anesthesia Medications o Herbal supplements o Anticoagulants o Diuretics o Aspirin( hold for 7 days before procedure) Allergies o Latex, anesthetics, tape, sutures, malignant hyperthermia Review of systems o Cardiovascular Hypertension, angina, dysrhythmias, heart failure, MI, CHF, pacemaker, fluid overload, edema Current treatment for heart condition

o ht/wt. - old charts o vitals - age identify and document the surgical site and/or side of body identify all medications currently taken respiratory system: smoking results of all lab and diagnostic tests o CBC, PTT/PT, Type and Cross [screen], liver function tests, ekg, urinanlysis cultural and ethnic factors determine if pt has received adequate information

Respiratory Asthma COPD Infection smoking o Neurologic Senses Cognitive function LOC, stroke o Genitourinary Renal or urinary tract diseases Renal dysfunction o Hepatic o Integumentary Skin breakdown, pressure ulcers, rashes o Musculoskeletal o Endocrine Diabetes (slow healing), thyroid dysfunction Addisons disease o Immune o Fluid and electrolyte status o Nutritional status/GI Protein and vitamin A, C, and B complex are necessary for wound healing Obesity Malnutrition Alcohol and drug abuse Functional health patterns Objective data o Diagnostic tests CBC, electrolytes, creatinine, urinalysis, x-ray exams, EKG, Blood Type, PTT, PT, Platelet Blood donations Depending on results of other tests ABGs; report any abnormal lab values especially hyper or hypokalemia. Routine CXR depending on surgery, spinal, MRI, CT scan. Bloodless surgery new techniques and equipment less blood loss, prior to surgery meds to build blood, Vit. C, Vit. B12, folic acid, Procrit,; Advances today recycling blood suctioned during surgery and transfuse back to patient. Physical examination Preoperative teaching 3 types of information Sensory; what are they going to be able to sense during the procedure Process: general flow of the procedure Procedural: specific details about the procedure What to expect: o When to arrive o Informed consent

NPO OR team Skin prep: bowel prep, enema prep, heap cleanse soap, allergy to iodine? Drains/tubes (JP drain= Hemovac) Postop procedures Cast/crutches/ splints PCA pump Automatic vitals General surgery information o Table 18-6; pg. 342 Ambulatory surgery information Pre-op teaching/ Postop procedure o Head of the bed elevated (post-op) o Resp. Care Deep breathing (every 2 hours) Incentive spirometer (lungs expands) Coughing T.C.D.B.: turn, cough, deep breathe o Activity: Turning Leg exercises (prevent DVT, contractures and circulation) Teds/Scds Early ambulation Vital sign frequency (every 15 mins x4; every 30 mins x 4; q1h x 4; q4h x 4) Pain control Decrease anxiety Pre-op Medications-pg. 347 (table 18-10) Opioids, anticholinergics, barbiturates, prophylactic antibodies Meds to avoid!!!!: diuretics, steroids, anticoagulants, phenothiazines, anti-depressants, certain antibiotics Different types of anesthetics- pg. 359 (table 19-4) Table 19-6page 360 Legal preparation for surgery Consent for surgery o 3 conditions to follow: Adequate disclosure of the diagnosis; the nature and purpose of the proposed treatment; the risks and consequences of the proposed treatment; probability of a successful outcome; the availability, benefits, and risks of alternative treatments and if prognosis is not instituted Pt must demonstrate clear understanding and comprehension of the information being provided before sedation Recipient of care must give consent voluntarily Day of surgery preparation Nursing role Preoperative medications o Benzodiazepines: sedation and amnesic properties (Versed and Valium) o Antibiotics may be administered thru out procedure with pts with history of congenital or vavlular heart disease

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Premedications may be administered (Po, Sq, IV); PO meds are given with a small sip of water 60-90 mins pre-op; IV and SQ are usually administered when pt goes into the OR Gerontologic considerations Consider sensory deficits Take complete H & P Chapter 19: Intraoperative Care Physical environment of operating room Departmental layout o Surgical suite: controlled environment designed to minimize the spread of infectious organisms and allow a smooth flow of patients, staff and equipment needed to provide safe patient care Divided into: unrestricted, semirestricted and restricted Unrestricted: street clothes Semi restricted: surgical attire and cover face and hair Restricted: surgical attire + mask Holding area o Special waiting area inside of or adjacent to the surgical suite o Surgical Care improvement Project: natl quality partnership of organizations focused on improving surgical care by significantly reducing the number of complications from surgery Operating room o Filters and controlled airflow in ventilating systems provides dust control o Positive air pressure prevents air from entering OR from halls or corridors o UV light: reduces microorganisms in the air Surgical team Registered nurse (table 19-1) o Circulating nurse Remain in unsterile fields Performs unsterile procedures: admits pt. to OR, assists with preparing room, monitors aseptic practice, assesses pt. emotional and physical status o Scrub nurse Gowned and gloved in surgical attire, remain in sterile fields Help with sterile procedures: draping procedure, count surgical instruments to be used, practice aseptic technique, report medications used by ACP and/or surgeon Licensed practical/vocational nurse and surgical technologist o Equipped with an associate degree, or vocational training program Surgeon and assistant o Surgeons assistant can be a registered nurse or a non-physician Registered nurse first assistant Anesthesia care provider o Anesthesiologists or a nurse anesthetist Nursing management: patient during surgery Room preparation o Aseptic technique Scrubbing, gowning, and gloving Assessment: Time Out

 Diagnosis: impaired skin integrity, infection, pressure ulcer Interventions: o Preop and position o Safety o Monitor for complication Safety considerations/Complications o n/v, hypoxia, hemorrhage, hypothermia o patent airway, theraupetic response to anesthesia, proper positioning, maintain surgical asepsis o Complications: Hypoventilation Oral trauma- endotracheal intubation Cardiac dysrhythmia Hypothermia Peripheral nerve damage Malignant hyperthermia Positioning patient o Various positions can be used: supine, prone, lateral, lithomy and sitting Supine: abdomen, heart and breast surgeries Prone: used for back surgery Lithomy: used for some types of pelvic organ surgery Patient after surgery o Report of patients status and procedure is communicated to the nurse receiving the patient in the PACU to promote safe, continuing care Anesthesia General Classification of anesthesia o General, local and regional o General anesthesia: Used for pts. Having a procedure of long duration, requires skeletal muscle relaxation, uncomfortable operable positions bc of location of incision site, require control of respiration Inhaled general anesthethetics: nitrous oxide, cyclopropane Inhaled liquid: halothane, enflurane, isoflurane IV anesthetic: Pentothal (thiopental) o Local anesthesia: Topical, ophthalmic, nebulized, or injectable Lidocaine- does not require sedation or loss of consciousness Two classes of local anesthetics: esters and amides o Regional anesthesia: using a local anesthetic is always injected and involves a central nerve or group of nerves that innervate a site remote to the point of injection IV agents o Most general anesthetics are began with IV induction agents (hypnotic, anxiolytic, or dissociative agent) Inhalation agents o Enter the body through the alveoli in the lungs o These agents can be volatile liquids or gases Volatile liquids are administered through a specially designed vaporizer after being mixed with oxygen as a carrier gas Contraindications with intraoperative drugs Tetracycline- renal toxicity

o Enflurane- liver disease leads to toxicity o Antihypertensives- hypotension o Beta-blockers: myocardium decreased Adjuncts to general anesthesia o Opioid analgesic (anesthesia induction): Alfenta, Demerol and morphine (pain prevention and relief) o Benzodiazepine: Valium and Versed (amnesia and anxiety) o Anticholinergic: Atropine and scopolamine (dry up excessive secretions) o Sedative- hypnotic: Atarax, Vistaril, Seconal, Nembutal (amnesia and sedation) Dissociative anesthesia Ketamine (Ketalar): common dissociative anesthetic; administered Iv or IM Potent analgesic and amnesic Used in asthmatic pts.: promotes bronchodilation and used in trauma pts.: increases heart rate and helps maintain cardiac output May cause hallucinations and nightmares Midazolam (Versed) Found to reduce hallucinations and nightmares when used concurrently with Ketalar 4 classifications of anesthesia: o Minimal sedation o Moderate sedation- must be certified; conscious sedation o Deep sedation o Anesthesia 4 stages of anesthesia (pg. 359): o preinduction, induction, maintenance and emergence Methods of administration Locals: injected at surgical site, nebulized or topical (with or without compression, of creams, ointments, aerosols, and liquids; applied directly to the skin, mucous membrane, or open surface) Common regional nerve blocks: brachial plexus block, IV Bier block, and femoral, axillary, cervical, sciatic, ankle, and retrobulbar blocks Spinal and epidural anesthesia Spinal: involves injection of local anesthetic into the CSF found in the subarachnoid space, usually below the level L2. The local anesthetic mixes with CSF and depending on extent of its spread, various levels of anesthesia are achieved Epidural block: injection of local anesthetic into the epidural space via a thoracic or lumbar approach o Commonly used for analgesia, or in combination with MAC or general anesthesia in obstetrics, vascular procedures involving the lower extremities, lung resections, and renal and midabdominal surgeries Catastrophic events in operating room Anaphylactic reactions: cause hypotension, tachycardia, bronchospasm, and possibly pulmonary edema Malignant hyperthermia: rare disorder characterized by hyperthermia with ridigity of skeletal muscles that can result in death

Primary Trigger: Succinylcholine (Anectine) Antidote: Dantrolene Sodium (Dantrium)- IV push: central acting skeletal muscle relaxant o Leads to muscle contracture, hyperthermia, hypoxemia, lactic acidosis, hemodynamic and cardiac alterations New and future considerations Use of hypothermia: deliberate lowering of body temperature decreases metabolism Transesophageal echocardiography (TEE): used intraoperatively to assess ventricular function and competency of heart valves and to recognize venous air embolism Ultrasonic guided regional anesthesia: used to visualize nerve or plexus of nerves using ultrasound to place a regional block with more accuracy Chapter 20: Postoperative Care Postoperative Care of the surgical patient o PACU progression/ initial assessment Check resp. status: patent airway Cardiovascular: regular, strong heart rate and stable BP (VS); peripheral pulses; Homans sign Neurological: LOC; orientation, sensation Fluid and electrolyte balance, acid base balance Vital signs Incision/drains Urine output (renal function) GI functions Dressings pain thermoregulation Potential respiratory problems Nursing Management: Respiratory Problems nursing assessment Nursing diagnoses Nursing implementation Potential cardiovascular problems Etiology o PACU o Clinical unit Nursing management: Cardiovascular Problems Nursing assessment Nursing diagnoses Nursing implementation Potential neurologic/Psychologic Problems Neurological (general anesthesia): prolonged somnolence and muscle weakness, renal failure, electrolyte imbalance, confusion, delirium

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Regional anesthesia: anesthetic toxicity, trauma, hypotension, n/v, motor or sensory loss, hypoxia, agitation Fluid/ electrolyte balance: I&O, IV, catheter, fluid imbalance with draining wound, Ng tube, N/v Nursing management: neurologic/Psychologic Problems Nursing assessment Nursing diagnoses Nursing implementation o PACU o Clinical unit

Pain and discomfort -etiology Nursing management: Pain Nursing assessment Nursing diagnoses Nursing implementation Potential alterations in temperature Etiology o Hyperthermia o Fever Nursing management: altered temperature Nursing assessment Nursing diagnoses Nursing implementation Potential gastrointestinal problems Etiology Nursing management: GI problems Nursing assessment Nursing diagnoses Nursing implementation Potential urinary problems Nursing management: urinary problems Nursing assessment Nursing diagnoses Nursing implementation Potential integumentary problems Etiology Nursing management: surgical wounds Nursing assessment Nursing diagnoses Nursing implementation Discharge from the PACU

 Discharge to the clinical unit Ambulatory surgery Phase II and extended observation postoperative care Ambulatory surgery discharge Planning for discharge and follow-up care Gerontologic Considerations: Postoperative Patient