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wvc periop lecture

Purposes of Surgery Diagnostic-to determine origin, cell type; Curative-remove/repair; Restorative-increase functionality; Palliative surgery-makes the client more comfortable; Cosmetic surgery-reconstructs the skin and underlying structures
Urgency of Surgery Elective (THR); Urgent (may be life threatening in 24-48 hours) Emergent (straight to the ER now)
Degree of Risk Minor surgery (not significant risk); Major surgery (increased risk, opening)
Surgical Settings Inpatient; Ambulatory (outpatient)
Collaborative Management Assessment History and data collection; Age; Drugs and substance use; Medical history, including cardiac and pulmonary histories; Previous surgery and anesthesia (how did you react); Blood donations; Discharge planning (how are you getting home?)
Physical Assessment/Clinical Manifestations Obtain baseline vital signs.; Focus on problem areas identified by the client’s history on all body systems affected by the surgical procedure; Report any abnormal assessment findings to the surgeon and to anesthesiology personnel.
System Assessment Cardiovascular system; Respiratory system; Renal/urinary system; Neurologic system; Musculoskeletal system; Nutritional status; Psychosocial assessment
Laboratory Assessment Urinalysis; Blood type and crossmatch ; Complete blood count or hemoglobin level and hematocrit ; Clotting studies; Electrolyte levels; Serum creatinine level; Pregnancy test; Chest x-ray examination; Electrocardiogram
Deficient Knowledge Interventions Preoperative teaching; Informed consent; surgeon is responsible for obtaining consent before sedation; The nurse’s role is to clarify facts presented by the physician and dispel myths that the client or family may have about surgery.
Implementing Dietary Restrictions Client is given nothing by mouth (NPO) for 6 to 8 hours before surgery; NPO status decreases risk for aspiration; Failure to adhere can result in cancellation of surgery or increase risk for aspiration during/ after surgery.
Administering Regularly Scheduled Medications (in light of surgery) Consult physician & anesthesia provider for instructions about drugs for: diabetes, cardiac disease, glaucoma, regularly scheduled anticonvulsants, antihypertensives, anticoagulants, antidepressants, or corticosteroids.
Intestinal Preparation Bowel or intestinal preparations are performed to prevent injury to the colon and to reduce the number of intestinal bacteria; Enema or laxative may be ordered by the physician.
Skin Preparation skin is the body’s first line of defense against infection; a break in the barrier increases the risk for infection; Shower using antiseptic solution; Shaving as a procedure before surgery is viewed as controversial.
Preparing the Client for possible placement of tubes, drains, & vascular access devices; Teaching about postoperative procedures & exercises: Breathing exercises, incentive spirometry, coughing & splinting; Leg procedures & exercises, antiembolism stockings & elastic wraps, early ambulation, & ROM
Anxiety Interventions Preoperative teaching; Encouraging communication; Promoting rest; Using distraction; Teaching family and significant others
Preoperative Chart Review Ensure documentation, preoperative procedures & orders complete; Check consent form & others for completeness; Doc. allergies/ height & weight; Ensure Labs & diagnostic tests are charted; Document & report any abnormal results & special needs/ concerns.
Preop Client Prep removes most clothing & wears gown; Valuables remain w/ fam. or locked; Tape rings if can’t be removed); Remove piercings; wears ID band; Dentures, prosthetic devices, hearing aids, contact lenses, fingernail polish, & artificial nails must be removed.
Preoperative Medication results in Reduce anxiety; Promote relaxation; Reduce pharyngeal secretions; Prevent laryngospasm; Inhibit gastric secretion.
Members of the Surgical Team Surgeon; Surgical assistant; Anesthesiologist;Certified registered nurse anesthetist; Holding area nurse; Circulating nurse; Scrub nurse; Surgical technologist; Operating room technician
Anesthesia Induced state of partial or total loss of sensation, occurring w/ or w/o loss of consciousness; Used to block nerve impulse transmission, suppress reflexes, promote muscle relaxation, and, in some instances, achieve a controlled level of unconsciousness
General Anesthesia Reversible loss of consciousness induced by inhibiting neuronal impulses in several areas of CNS; achieved by single agent or combination of agents. CNS is depressed, resulting in analgesia, amnesia, & unconsciousness, w/ loss of muscle tone & reflexes.
Stages of General Anesthesia Stage 1: analgesia; Stage 2: excitement; Stage 3: operative; Stage 4: danger
Inhalation: intake and excretion of anesthetic gas or vapor to the lungs through a mask
Intravenous injection: barbiturates, ketamine, and propofol through the blood
Adjuncts to general anesthetic agents: hypnotics, opioid analgesics, neuromuscular blocking agents
Balanced Anesthesia Combination of intravenous drugs and inhalation agents used to obtain specific effects; Combination used to provide hypnosis, amnesia, analgesia, muscle relaxation, and reduced reflexes with minimal disturbance of physiologic function
Example of amesthesia therapy thiopental for induction, nitrous oxide for amnesia, morphine for analgesia, and pancuronium for muscle relaxation
Complications from General Anesthesia Malignant hyperthermia: possible treatment with dantrolene; Overdose; Unrecognized hypoventilation; Complications of specific anesthetic agents; Complications of intubation
Interventions for Malignant Hyperthermia (more prominent in males) Stop inhalation anesthetics; Vent. w/ 100% O2; Dantrolene 2-3 mg/Kg IV; stop surgery if possible; Assess ABG’s, If metabolic acidosis, IV NaHC03; ; cooling to V temp; Survival depends on early diagnosis & prompt action
Dantrolene Sodium treatment of malignant hyperthermia 2-3 mg/Kg IV
Local or Regional Anesthesia Sensory nerve impulse transmission from specific body area/ region breifly disrupted; Motor function may be affected; Pt. remains conscious & able to follow instructions; Gag & cough remains intact; Sed. & opioid or hypnotics often used to reduce anxiety.
Local Anesthesia Topical anesthesia; Local infiltration;
Regional anesthesia Field block; Nerve block; Spinal anesthesia; Epidural anesthesia
Complications of Local or Regional Anesthesia Anaphylaxis; Incorrect delivery technique; Systemic absorption; Overdosage
Complications of Local or Regional Anesthesia signs & symptoms Assess for central nervous system stimulation, central nervous system & cardiac depression, restlessness, excitement, incoherent speech, headache, blurred vision, metallic taste, N & V, tremors, seizures, increased pulse, RR & BP.
Treatment for Complications of local or regional anesthesia Establish an open airway; Give oxygen; Notify the surgeon; Fast-acting barbiturate is usual treatment (shield from pain & relax); If toxic reaction is untreated, unconsciousness, hypotension, apnea, cardiac arrest, and death may result.
Conscious Sedation (for minor procedures) IV delivery of sedative, hypnotic, & opioid drugs reduces level of consciousness, allows client to maintain a patent airway & to respond to verbal commands.
Drugs used for conscious sedation Diazepam, midazolam, meperidine, fentanyl, alfentanil, & morphine sulphate are most commonly used drugs.
Conscious Sedation Nursing assessment assessment of airway, level of consciousness, oxygen saturation, electrocardiographic status, and vital signs are monitored every 15 to 30 minutes.
Collaborative Management in surgery (team approach )Assessment; Medical record review; Allergies and previous reactions to anesthesia or transfusions; Autologous blood transfusion; Laboratory and diagnostic test result; Medical history and physical examination findings
Risk for Perioperative Positioning Injury Interventions include: Proper body position; Risk for pressure ulcer formation; Prevention of obstruction of circulation (skin is checked & charted) (proper body position is padded & charted), respiration, & nerve conduction
Impaired Skin Integrity and Impaired Tissue Integrity Interventions include: Plastic adhesive drape; Skin closures, sutures and staples, nonabsorbable sutures; Insertion of drains; Application of dressing; Transfer of client from the operating room table to a stretcher
Potential for Hypoventilation Continuous monitoring of: Breathing; Circulation; Cardiac rhythms; Blood pressure and heart rate; Continuous presence of an anesthesia provider
What is an appropriate expected outcome for the client who experienced malignant hyperthermia during a surgical procedure? monitoring of the client’s temperature, ECG, ABGs, and electrolytes
The client is receiving localized anesthesia using lidocaine (Xylocaine). The nurse should plan to make which of the following her primary intervention? Monitor blood pressure and pulse.
Latex-induced anaphylaxis accounts for what percentage of the anaphylactic reactions occurring during surgery? 10%
Basic laparotomy instruments are essential to accomplish most types of general surgery. Each instrument can be placed into one of the four following basic categories: Retracting and Occluding Instruments; Cutting and Dissecting Instruments; Clamping and Occluding Instruments; Grasping and Holding Instruments
Retracting and Exposing Instruments used to hold back or retract organs or tissue to gain exposure to the operative site. They are either "self-retaining" (stay open on their own) or "manual" (held by hand). When identifying retractors, look at the blade, not the handle.
Cutting and Dissecting Instruments are sharp and are used to cut body tissue or surgical supplies.
7 handle with 15 blade (deep knife) - Used to cut deep, delicate tissue.
3 handle with 10 blade (inside knife) – Used to cut superficial tissue.
4 handle with 20 blade (skin knife) - Used to cut skin.
Straight Mayo scissors - Used to cut suture and supplies. Also known as: Suture scissors. EX: Straight Mayo scissors being used to cut suture.
Clamping and Occluding Instruments are used to compress blood vessels or hollow organs for hemostasis or to prevent spillage of contents.
A hemostat is used to clamp blood vessels or tag sutures. Its jaws may be straight or curved. Other names: crile, snap or stat.
A Kelly is used to clamp larger vessels and tissue. Available in short and long sizes. Other names: Rochester Pean. Kelly, hemostat, mosquito (left to right)
Grasping and Holding Instruments are used to hold tissue, drapes or sponges.
A Backhaus towel clip is used to hold towels and drapes in place. Other name: towel clip.
Pick ups, thumb forceps and tissue forceps are available in various lengths, with or without teeth, and smooth or serrated jaws.
Mayo-Hegar needle holders are used to hold needles when suturing. They may also be placed in the sewing category.
PACU Recovery Room ongoing evaluation & stabilization of clients: anticipate, prevent & treat complications ofsurgery; PACU is located close to surgery suite; PACU nurse is skilled in care of clients w/ multiple medical & surgical problems that can occur following surgery
Physical assessment and clinical manifestations in PACU (A/B/C/D & bleeding) Assess respiration; Examine surgical area for bleeding; Monitor vital signs;
Respiratory System Airway assessment for readiness to discharge from PACU ; Breath sounds; Other respiratory assessments (bronchospasm); o2 stat;
Cardiovascular Assessment for readiness to discharge from PACU Vital signs; Cardiac monitoring; Peripheral vascular assessment; Neurologic System;
Cerebral functioning Motor &sensory assessment (important after epidural or spinal…see where sensory level is) Motor function: simple commands; client to move extremities; Return of sympathetic nervous system tone & vision assessment.
Fluid, Electrolyte, and Acid-Base Balance in PACU assessment Check fluid and electrolyte balance; Make hydration assessment; Intravenous fluid intake should be recorded.
Renal/Urinary System The effects of drugs, anesthetic agents, or manipulation during surgery can cause urine retention(Assess for bladder distention); Consider other sources of output such as sweat, emesis, or diarrhea stools; Report a urine output of < 30 mL/hr.
Gastrointestinal System N & V common after surgery (anti emetics used prevent initiation of vomit cycle); Peristalsis may be delayed b/c of long anesthesia time & bowel handling & opioid analgesic use; Clients have ab.surgery often have decreased peristalsis for at least 24 hrs
Nasogastric Tube Drainage Tube may be inserted during surgery to decompress & drain stomach, promotes GI rest, to allow the lower gastrointestinal tract to heal, to provide an enteral feeding route, to monitor any gastric bleeding, and to prevent intestinal obstruction.
Nasogastric Tube Drainage assessment and management Assess drained material every 8 hours; Do not move or irrigate the tube after gastric surgery without an order from the surgeon.
Skin Assessment associated with surgery Normal wound healing; Ineffective wound healing: can be seen most often between the 5th and 10th days after surgery
Dehiscence: a partial or complete separation of the outer wound layers, sometimes described as a “splitting open of the wound.” (At risk are diabetics and obese persons)
Evisceration: a total separation of all wound layers and protrusion of internal organs through the open wound.
Dressings and drains, including casts and plastic bandages, must be assessed for bleeding or other drainage on admission to the PACU and hourly thereafter.(mark & time saturation on dressing) (changes in type of fluid drainage)
Wound Complications Dehiscence; Dehiscence; Evisceration;
Discomfort/Pain Assessment; Client almost always has pain or discomfort after surgery Pain assessment is started by the postanesthesia care unit nurse; Pain usually reaches peak on 2nd day after surgery, when the client is more awake, more active, & the anesthetic agents/ drugs given during surgery have been excreted.
Impaired Gas Exchange in PACU, Interventions include: Airway maintenance; Positioning the client in a side-lying position or turning his or her head to the side to prevent aspiration; Encouraging breathing exercises; Encouraging mobilization ASAP to help remove secretions & promote lung expansion
Impaired Skin Integrity in PACU Interventions include: Dressings; Drains: provide exit route for air, blood & bile; helps prevent deep infections & abscess formation; Drug therapy including antibiotics & irrigations are used to treat wound infection; Surgical management is required for wound opening.
Acute Pain Interventions include: Drug therapy; Complementary & alternative therapies such as: Positioning; Massage; Relaxation and diversion techniques
Potential for Hypoxemia in PACU Interventions include: Maintenance of airway patency and breathing pattern; Prevention of hypothermia; Maintenance of oxygen therapy as prescribed
Health Teaching for post surgical patients Prevention of infection; Dressing care; Nutrition; Pain medication management; Progressive increase in activity level; Use of proper body mechanics
The client is in the postoperative phase of his surgical experience. In order to avoid undermedicating the client for acute pain, the nurse should b. monitor blood pressure and respirations every 15 to 30 minutes.
When massage is used as an alternative therapy to provide pain relief, the nurse should plan to avoid massaging the calves because of the threat of pulmonary embolus.
When using positioning to decrease acute pain in the postoperative client, the nurse should consider repositioning the client at least every 2 hours.
Dressings Dry or moist; Gauze; Hydrocolloid (Protects the wound from surface contamination); Hydrogel (Maintains a moist surface to support healing) Wound V.A.C (Uses negative pressure to support healing)
Changing dressing Know type of dressing, placement of drains, and equipment needed.
Securing dressing Tape, ties, or binders
Comfort measures Carefully remove tape.; Gently cleanse the wound; Administer analgesics before dressing change.
A postoperative client arrives at an ambulatory care center and states, “I am not feeling good.” Upon assessment, you note an elevated temperature. An indication that the wound is infected would be: It shows purulent drainage coming form the incision site.
A surgical wound requires a Hydrogel dressing. The primary advantage of this type of dressing is that it provides: Moisture needed for wound healing
Domains of Learning Basic Learning Principles; Integrating the Nursing ; and Teaching Process; A relationship exists.
The teaching process focuses on the client’s learning needs and ability to learn.
Nurses need to assess all factors that influence content, ability to learn, and resources available: Expectation of learning; Learning needs; Motivation to learn; Ability to learn; Teaching environment; Resources for learning; Health literacy and learning disability
Iggy 274
Created by: wvc