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Perioperative
N110 Perioperative
| Question | Answer |
|---|---|
| Sedation (barbiturates) | Barbiturates, Nembutal, Seconal |
| types of anethesia | regional, surface/topical, local nerve infiltration, nerve blocks, spinal/epidural, conscious sedation, general anethesia |
| regional anethesia | temporary interruption of nerve impulse; medication instilled around nerves to block, produces analgesia/relaxation/decrease reflexes; awake/consious but no pain |
| surface/topical | applied to skin/mucous membranes; readily absorbed and acts rapidly |
| local nerve infiltration | injecting lidocaine to depress nerve sensation; limited area; minor surgery: skin/muscle biopsy & wound suture |
| nerve blocks | anesthetic agent at nerve truck = lack of sensation over specific body area; intravenous block: arm/wrist/hand ...Bier Block; touniquet to extremity |
| spinal | injection into spinal canal below cauda equina to avoid nerve damage; lower dose of anesthetic used; paralysis; vasodilation; careful with positioning & respiratory status |
| epidural | instilled into epidural space around spinal cord; no contact with nerve/roots; paralysis, vasodilation; careful with positioning |
| consious sedation | mild, moderate, deep sedation; drepress LOC without impairment of patent airway; pt able to respond to command/verbalize drugs: versed, valium, morphine, demerol, Narcan |
| tranquilizing agents | Versed, Valium |
| Analgesic agents | morphine, demerol |
| Reversal (agonists) | Narcan (naloxone); given if pt has too many narcotics |
| neuroleptanalgesic | Fentanyl, Droperidol |
| Fentanyl | Sublimaze; more 75-100 potent but shorter action than morphine |
| Droperidol | Inapsine; anitemetic/tranquilizer; pt drowsy, responds to voice but no pain; vasodilation |
| dissociative agents | Ketamine; not asleep/anesthetized but dissociated from surrounding |
| eg Ketamine | can cause psychic aberration (verbal, visual, tactile stimulation) |
| droperidol or diazepam | may eliminate psychic phenomena |
| general anesthesia | loss of all sensation/LOC; CNS depression; amnesia (loss memory); analgesia (insensible to pain); hypnosis (artificial sleep; skeletal muscle relax) |
| general anesthesia routes | inhalation (mask, nasal intubation, oral intubation); IV (Propoful (Diprivan)); muscle relaxers (succinylcholine/Anectine; Pavulon) |
| Propoful | Diprivan--white liquid; short-acting hypnotic/anesthetic; amnesia; respiratory depression; decrease buzzing/dizziness; can cause skeletal muscular rigidity/respiratory impairment) |
| Neuromuscular blockers | muscle relaxers; allows easier access to esp. abd area |
| labs preop | cbc, coags, lytes, urine, ekg, xrays |
| prophylatic antibiotics | cephalosporins |
| psychosocial assess. (preop) | Fear (questions/withdrawal) regarding: surgery, anethesia, pain/death, unknown, body image, financial, prognosis |
| pediatric stress points (preop) that cause anxiety | admission, labs, altered daily routine, injections, separation, return from PACU |
| Preoperative | Assessment (preoperative interview), Identification of potential or actual health problems, planning specific care based on needs, and pre-op teaching |
| Intraoperative phase | procedures to create and maintain a safe therapeutic environment, starting IV, administering meds, monitoring and positioning the patient |
| Postoperative phase | Monitoring client’s responses (physiological and psychological) to surgery, teaching and supporting client and family. The goal is to assist client to achieve most optimal health status possible |
| Surgical classifications | Purpose, Extent of surgery, Urgency |
| Diagnostic or exploratory | these surgeries are performed in order to make a diagnosis or to confirm a suspected diagnosis |
| Diagnostic or exploratory | Example: Biopsy, exploratory laparotomy |
| Curative | to remove a diseased or malformed organ |
| Curative | appendectomy, amputation |
| Reparative | to repair damage to the tissue |
| Reconstructive or cosmetic | to restore function or appearance |
| Reconstructive or cosmetic | For example, skin graft, plastic surgery, total joint replacement |
| Palliative | to relieve pain or restore function |
| Palliative | severing a nerve that carries pain impulses or inserting a g-tube |
| urgency-Emergency | immediate; to maintain life, maintain organ or limb function, remove |
| urgency-Imperative or urgent surgery | surgical intervention is required within 24 to 48 hr. |
| urgency-Planned surgery | required but not urgent; may be scheduled weeks or months |
| urgency-Elective | not absolutely necessary; a surgery the patient chooses to have done, |
| urgency-Optional | surgery done for aesthetic or psychological reasons; is requested by the patient; includes plastic surgery like a face lift, mammoplasty |
| Informed consent | Under the law, consent should be voluntary, without coercion, and should be in writing. |
| Informed consent | an explanation of the procedure, the risks involved (those that are foreseeable), a description of benefits and alternative treatments |
| Who can give consent? | All persons of legal age and who are mentally capable may give consent: age 18, emancipated, under the age of 18 must have consent provided by a parent or guardian, |
| who cannot give consent | Incompetent subjects; because they are mentally ill/retarded, in a vegetative state (coma) or otherwise unable to understand |
| court may appoint a guardian ad litem | someone who is charged with representing the best interest of the child. |
| consent | may be withdrawn |
| Pre-op/pre-admission diagnostic tests | CBC , Electrolytes, Coagulation studies , Urinalysis , EKG , Chest X-ray |
| pre-op assessment should include questions and tests that address | Nutritional status, Chemical substance use (drugs, smoking, alcohol), Respiratory status, Cardiovascular status, Hepatic & renal function, Endocrine function, Immunologic function, Previous medication therapy |
| nutrition and diet pre-operatively | Light meal the evening before/NPO after midnight the night before (to prevent aspiration)/Newer recommendations are for a light meal up to 6 hr. pre-op, then liquids 2 to 4 hr. pre-op |
| Pediatrics preop | No solid food - after 8 - 12 PM (candy, gum is OK)/ Breast-feeding - may continue up to 3 hr. prior/ Clear fluids - continue to 2 hr. prior - (juice drinks, gelatin, broth, Pedialyte, popsicles |
| Preparing the bowel for surgery | Cleansing enema or laxative//Prevent defecation during anesthesia or trauma to intestine during abdominal surgery |
| psychosocial assessment //Fear is often manifested by | questions, withdrawal// some concerns Anesthesia/Pain or death/Unknown/Deformity/Threat to body image/Financial-family responsibility-employment/Prognosis |
| Psychological interventions for peds. | Systematic preparation /Rehearsal of forthcoming events /Supportive care /Play therapy /Increased familiarity with procedures |
| Physiologic reserve | The ability of an organism to return to normal after a disturbance in its equilibrium. Elderly persons have less physiologic reserve than younger patients |
| Teaching should begin | before surgery when the patient is not anxious and can practice with the nurse coaching |
| Deep breathing helps | patient to “blow off” inhalation anesthesia and improves ventilation by getting air to the distant periphery of the lungs |
| Coughing helps | clear secretions that might otherwise lie in the alveoli and cause atelectasis and infection |
| Deep breathing exercises | Practice in semi-Fowlers;hands to rest lightly on front of lower ribs ;Breathe out gently and fully;Take deep breath through nose and mouth;Hold breath for a count of five;Exhale;Repeat 15 times with a short rest after each group of 5 |
| Coughing | splint/Breathe with diaphragm/breathe in fully/Hack” out sharply for three short breaths/quick deep breath and immediately give a strong cough once or twice |
| Leg exercises | Lie in semi Fowlers position*Bend knee and raise foot*Hold a few seconds*Then extend leg and lower it to bed*Do 5 times with each leg*Trace circles with feet *Repeat 5 times |
| Sedation (barbiturates) | used to relax the patient |
| Hypnotics (benzodiazepines) | Valium;Versed |
| Valium | May be given night before surgery to decrease insomnia |
| Versed | often used before (or during) surgery to relax and decrease anxiety; side effect is amnesia |
| Opioids (as adjunct to general anesthesia) | Morphine and Demerol;May depress respiration, cough reflex, and increase risk of respiratory acidosis and aspiration pneumonia// May cause hypotension, nausea, vomiting, constipation and abdominal distention |
| Anticholinergics | reduce respiratory tract secretions (atropine, Robinul) |
| Succinylcholine | can cause bradycardia and dysrhythmias (depolarizing) *These agents do not provide analgesia, but in effect, paralyze the muscles, including muscles of respiration. The patient must have respiratory assist – usually intubated and on a ventilator |
| Pavulon, succinylcholine (Anectine) | These agents do not provide analgesia, but in effect, paralyze the muscles, including muscles of respiration |
| Advantages of general anesthesia | Rapid excretion; Prompt reversal; Produces amnesia; Adjusted for length of operation, age of client, physical condition |
| Disadvantages of general anesthesia | Depresses respiratory and cardiac system*Those with respiratory and circulatory disease have increased risk*Fear of losing control phase* |
| Intraoperative complications | Nausea and vomiting*Hypoxia*Hypothermia *Malignant hyperthermia |
| Nausea and vomiting | Causes: common reaction to medications, food in GI tract*Treat with a N-g tube Salem Sump tube discussed in lab) and suction*Position with head turned to side to prevent aspiration*Histamine-2 receptor antagonist (Tagamet, Zantac) or anti-emetic thru IV |
| Hypoxia | Results from inadequate ventilation, occlusion of airway, inadvertent intubation of esophagus, respiratory depressive effects of anesthetic agents, position, aspiration of vomitus/respiratory secretions*Continuous pulse oximetry is used to detect the earl |
| Hypothermia | temperature below physiologic normal limits (36.6-37.5) |
| Causes of Hypothermia | Decreased temp in OR*Infusion of cold fluids*Inhalation of cold gases*Open wounds or cavities*Decreased muscle activity*Advanced age*Drugs (vasodilators) |
| Hypothermia Prevention | Monitor OR temp*Warm IV fluids*Remove wet gown*Cover with warm blankets*Cover head with shower cap – as we remind you in the winter, the head may account for up to 15 % of body surface, larger if a child or baby |
| Malignant hyperthermia | Inherited muscle disorder that can be chemically induced by anesthetic agents *Calcium continues to accumulate and cause increased muscle contraction (rigidity), elevated temperature and damage to CNS |
| Malignant hyperthermia At risk persons: | Bulky, strong muscles, cramps/ weakness*Family Hx of death in OR with fevers or diagnosis of a muscular disorder |
| Malignant hyperthermia | S/S usually occur about 10-20 min. after anesthesia, but can occur anytime within the first 24 hours after surgery* Primary signs are tachycardia (up to 150 bpm or greater), tachypnea, fever, generalized rigidity, respiratory and metabolic acidosis. |
| Malignant hyperthermia Management | Early recognition of signs is very important*Surgery is stopped and 100% oxygen is administered*Anesthesia is discontinued or a different agent is substituted*Dantrolene sodium (skeletal muscle relaxant) & sodium bicarbonate are given to relax the muscles |
| post-anesthesia care unit (PACU) is | nurses will care for the patient, assessing vital signs, bleeding, and any complications. They will provide IV fluids, oxygen, suction, pain medication, etc. The nurse will also assess any areas that might have been subjected to pressure from positionin |
| nursing diagnoses that might be used for patients in PACU | Risk for ineffective airway clearance*Risk for ineffective breathing pattern*Risk for altered systemic tissue perfusion*Risk for injury*Pain |
| In order to discharge someone from PACU | Airway is patent, gag reflex has returned*Patient is awake enough to answer simple questions*Pain is controlled, vital signs are stable*Urine output is at least 30 cc/ hr*Intra-operative complications are under control |
| Types of pain control used post-op | PCA*Epidural (narcotics, local)*Intrapleural (between parietal and visceral pleura) more effective coughing and DB |
| Non-pharmaceutical methods of pain control | Position changes*Distraction*Cool washcloths*Rubbing back*Relaxation*Visual imagery |
| The hospitalized postoperative client | the nurse will first do an assessment. The ABCs are important – airway, breathing, circulation |
| postop Airway, breathing | Observe airway patency, quality of respirations (depth, rate, lung sounds) |
| ND: ineffective airway clearance | Crackles may be present*TCDB q 1-2 hr (splint incision) – remember pre-op teaching*Incentive spirometer (10 times an hour)*Effective pain relief may permit more effective coughing |
| ND: altered gas exchange | Check oxygen saturation levels frequently*Administer oxygen to relieve hypoxemia |
| postop subacute hypoxemia | constant low level of oxygen although breathing appears normal |
| postop Episodic hypoxemia | develops suddenly and pt is at risk for cerebral |
| Postop Fluid volume abnormalities | Occur due to CV or renal disease, advanced age, release of adrenocorticotropic hormone and ADH (anti diuretic hormone) as a result of stress*Can also occur due to fluid overload*Can cause decreased HCT and HGB |
| Fluid volume abnormalities | Assess jugular vein distention*Can lead to pulmonary edema |
| Fluid volume abnormalities Interventions | Patient will be on IV fluids. Maintain these as ordered, but be alert to signs of fluid volume overload*Monitor vital signs*Assess lung sounds (crackles may indicate fluid in lungs d/t atelectasis or fluid volume excess)*Specific gravity of urine (decrea |
| DVT risks: | At risk because of dehydration, immobility, and pressure on leg veins during surgery Patient may receive an anticoagulant med such as heparin or Lovenox by sub-q injection, or an oral drug like Plavix or Persantine, esp. if surgery was orthopedic or abd. |
| DVT Interventions | Leg exercises*Frequent position changes*Avoid positions that compromise venous return (knee gatch or pillows), sitting for long periods, dangling with pressure at back of knees*Prevented by anti-embolism stockings (SCDs with TEDs are much more effective) |
| Intense pain stimulates stress response which adversely affects | cardiac and immune systems*Muscle tension increases*Local vasoconstriction*Ischemia causes more pain*Myocardial demand and oxygen consumption increases*Hypothalamic stress response responsible for increase in blood viscosity and platelet aggregation |
| Postop Monitor mental status | LOC, speech, orientation*May be a sign of oxygen deficit or hemorrhage*May also indicate that the liver has not metabolized the anesthetic or pain medication efficiently. This is especially true in the elderly and it might be necessary to reduce the dose |
| postop Restlessness or change in LOC | anxiety*Pain *Medication*Oxygen deficit*General discomfort*Distended bladder |
| postop GI functioning | Nausea & vomiting are very common side effects from the anesthetic*Turn patient to side to prevent aspiration*Raise head of bed if possible*An NG tube may be inserted |
| Hiccups | Intermittent spasms of diaphragm secondary to irritation of phrenic nerve* Can be very uncomfortable and interfere with rest and pain control*Phenothiazine meds (including prochlorperazine (Compazine) and promethazine (Phenergan) are frequently ordered PR |
| Hiccups | Phenothiazine meds: prochlorperazine (Compazine) and promethazine (Phenergan) |
| Patient cannot have solid foods until | bowel sounds are present and normal in number and frequency |
| NG tube may be used to relieve | distention and to remove gastric secretions that are not moving through the GI tract |
| postop Bladder | Distention common. Some patients are unable to void or have no urge to do so. Many patients will have a Foley for the first 24 hours or so (longer if unable to ambulate or move self in bed)*Assess by palpation. Be especially alert if pt had a spinal |
| Watch for orthostatic hypotension | (BP falls by 20 mm Hg systolic and/ or 10mm diastolic). The patient can become dizzy, weak, faint*Take BP lying, sitting, standing*Encourage patient to change position slowly |
| Nursing care during surgery | Protecting patient’s safety includes*Preventing intra-op positioning injury*Acting as patient advocate *Managing complications (be alert for S/S)*Reducing anxiety |
| intraop: Acting as patient advocate | Maintain physical-emotional comfort, privacy, rights, dignity*Avoid excess noise, inappropriate conversation, ridicule*Occasionally, patients hear and recall what was said during surgery |
| Preventing intra-op positioning injury | Maintain anatomic position*Pad equipment*Assess peripheral pulses |
| intraop: Protecting patient’s safety includes | Verifying information – patient identity and other vital information*Checking chart for completeness*Maintaining surgical asepsis Using safety straps*Ensuring safe transfers from stretcher to OR table and back |
| intraop: Protecting patient’s safety includes | Maintaining a safe environment (temp, humidity, cleanliness)*Maintaining/checking equipment; preventing injury from chemical burn or electrical burns and shock*Anticipating the need for special supplies |
| intraop: Protecting patient’s safety includes | Counting sponges and other instruments to make sure all are removed from the wound |
| Malignant hyperthermia | Fever can rise by 1 degree C per minute and can go as high as 114 degrees F*Skin will become flushed and rosy because of dilated peripheral vessels, then becomes cyanotic and mottled*Develops a cardiac dysrhythmia which leads to cardiac arrest |
| Malignant hyperthermia drug management | Dantrolene sodium (skeletal muscle relaxant) & sodium bicarbonate are given to relax the muscles and correct acidosis |
| drugs that may be given for Nausea and vomiting | Histamine-2 receptor antagonist (Tagamet, Zantac) or anti-emetic may be given IV |
| possible drugs for hiccups | Phenothiazine meds (including prochlorperazine (Compazine) and promethazine (Phenergan) are frequently ordered PRN |
| drugs that put surgical client at high risk | aspirin, antidepressent, steroids, NSAIDS |
Created by:
aimeeNC
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