1. Chapter 30 Responding to the Needs of the Perioperative Client Fundamentals of Nursing: Standards & Practices, 2E

2.  Copyright 2002 by Delmar, a division of Thomson Learning 30-2 Perioperative Period  Perioperative refers to the management and treatment of the client during the three phases of surgery: preoperative, intraoperative, and postoperative.  Preoperative refers to the time interval that begins when the decision is made for surgery until the client is transferred to the operating room (OR).

3.  Copyright 2002 by Delmar, a division of Thomson Learning 30-3  The intraoperative phase begins when the client is transferred to the OR and ends with the client transfer to a postanesthesia care unit (PACU).  When the client leaves the OR and is taken to a PACU, the postoperative phase begins; this phase continues until the client is discharged from the care of the surgeon.

4.  Copyright 2002 by Delmar, a division of Thomson Learning 30-4 Surgical Interventions  Surgeries are categorized according to the degree of urgency (timely intervention of surgery). Emergency surgery requires immediate intervention to sustain life. Urgent surgery dictates intervention as necessary to maintain health in situations that are not life-threatening.

5.  Copyright 2002 by Delmar, a division of Thomson Learning 30-5 Elective surgery is usually performed at a time convenient to the client.  Types of surgical procedures Diagnostic/exploratory Reconstructive Curative Palliative Transplant

6.  Copyright 2002 by Delmar, a division of Thomson Learning 30-6 Setting  Ambulatory care centers and physician offices are the usual settings for minor surgical procedures.  Outpatient surgery areas (one-day surgery centers or free-standing ambulatory clinics) provide the client and physician with alternative services for urgent and elective surgeries.

7.  Copyright 2002 by Delmar, a division of Thomson Learning 30-7 Perioperative Management of Care  Surgeon responsibilities Determine the need for the surgical intervention. Determine the surgical setting in collaboration with the client. Order diagnostic tests.

8.  Copyright 2002 by Delmar, a division of Thomson Learning 30-8 Obtain client’s consent for the surgical procedure. Teach the client about the outcomes and risks of the procedure. Explain and document evidence that the client understands the nature of the surgical procedure, the risk factors, and expected outcomes of the surgery.

9.  Copyright 2002 by Delmar, a division of Thomson Learning 30-9  Anesthesia provider responsibilities Obtain informed consent for anesthesia. Perform a preanesthesia evaluation that includes a thorough history. Select anesthetic agents. Teach the client regarding the anesthetic medications, their side effects, and risk factors.

10.  Copyright 2002 by Delmar, a division of Thomson Learning 30-10 Perform intubation (the insertion of an endotracheal tube into the bronchus through the nose or mouth to ensure an airway) and extubation (the removal of an endotracheal tube).

11.  Copyright 2002 by Delmar, a division of Thomson Learning 30-11  Nurse responsibilities Schedule the diagnostic tests. Verify that all the necessary documents are on the client’s medical record. Report abnormal diagnostic results to the surgeon. Prepare and teach the client.

12.  Copyright 2002 by Delmar, a division of Thomson Learning 30-12 Anesthesia  Anesthesia means the absence of pain General anesthesia Regional anesthesia Local anesthesia

13.  Copyright 2002 by Delmar, a division of Thomson Learning 30-13 Preoperative Phase  Assessment Nursing history  Medical history  Medications  Allergies  Age-related considerations

14.  Copyright 2002 by Delmar, a division of Thomson Learning 30-14  Social and cultural considerations  Spiritual considerations  Psychosocial status Physical assessment  General survey  Head and neck  Upper extremities

15.  Copyright 2002 by Delmar, a division of Thomson Learning 30-15  Anterior and posterior chest and abdomen  Lower extremities  Nursing diagnosis Common nursing diagnoses for the preoperative client are Deficient Knowledge related to surgery, and Anxiety and Fear.

16.  Copyright 2002 by Delmar, a division of Thomson Learning 30-16  Outcome identification and planning The overall goal is to protect the client from injury related to anesthesia and surgery. Discharge planning considerations include  Psychosocial and spiritual support systems and community resources

17.  Copyright 2002 by Delmar, a division of Thomson Learning 30-17  Financial aspects of the illness  Degree of illness or disability  Rehabilitation  Preventive care  Client teaching needs

18.  Copyright 2002 by Delmar, a division of Thomson Learning 30-18  Implementation Surgical consent form Preoperative checklist Client teaching about interventions to prevent postoperative complications  Postoperative exercises  Incentive spirometer

19.  Copyright 2002 by Delmar, a division of Thomson Learning 30-19  Antiembolism stockings  Pneumatic compression device  Continuous passive motion device  Transcutaneous electrical nerve stimulation unit (TENS)  Patient-controlled analgesia pump (PCA)

20.  Copyright 2002 by Delmar, a division of Thomson Learning 30-20 Physical preparation  Skin preparation  Nutrition  Gastrointestinal preparation  Nasogastric tube  Bowel preparation

21.  Copyright 2002 by Delmar, a division of Thomson Learning 30-21  Urinary elimination  Safety precautions  Medications  Evaluation Preoperative evaluation focuses on the client’s ability to verbalize and demonstrate the exercises.

22.  Copyright 2002 by Delmar, a division of Thomson Learning 30-22 The evaluation of a client’s preoperative preparation for surgery should include understanding of the procedure, verbalization and return demonstration of postoperative exercises, and postoperative expectations resulting from the surgery. Documentation of preoperative activities must be entered in the client’s record.

23.  Copyright 2002 by Delmar, a division of Thomson Learning 30-23 Intraoperative Phase  Surgical environment Unrestricted zone  Can enter in street clothes  Receiving desk, locker rooms Semirestricted zone  Surgical attire required  Hallways, storage areas

24.  Copyright 2002 by Delmar, a division of Thomson Learning 30-24 Restricted zone  Controlled and germ-free  Scrub attire required  OR and rooms where sterile instruments are prepared

25.  Copyright 2002 by Delmar, a division of Thomson Learning 30-25  Surgical team Surgeon Anesthesia provider Surgical assistant Scrub nurse or technician Circulating nurse

26.  Copyright 2002 by Delmar, a division of Thomson Learning 30-26  Occupational hazards There is a risk of exposure to harmful pathogens. Latex allergies, needlesticks, eye splashes, back injuries, and indoor pollution are of particular concern. Precautions should be in place that are in compliance with Occupational Safety and Healthcare Administration (OSHA).

27.  Copyright 2002 by Delmar, a division of Thomson Learning 30-27  Assessment Check the client’s identification band and confirm the surgical site. Check for client alterations that can affect positioning during the procedure. Make sure the OR bed is prepared to receive the client and that accessories are available for a specific position.

28.  Copyright 2002 by Delmar, a division of Thomson Learning 30-28  Nursing diagnosis Common intraoperative nursing diagnoses promote client comfort, safety,and support during the surgical procedure. Risk for perioperative positioning injury, Risk for injury, Risk for infection, Hypothermia.

29.  Copyright 2002 by Delmar, a division of Thomson Learning 30-29  Outcome identification and planning Specific nursing care is planned to encompass the surgeon’s specifications for positioning and to alleviate or prevent any individual client problem. Determine the appropriate mode of client transfer, equipment and positioning aids, as well as the need for ancillary personnel to accomplish positioning.

30.  Copyright 2002 by Delmar, a division of Thomson Learning 30-30  Interventions Surgical asepsis Skin preparation Positioning and draping Electrical hazards Heat loss Monitoring physiological functioning

31.  Copyright 2002 by Delmar, a division of Thomson Learning 30-31  Evaluation Before the client is transferred to the recovery room, the OR nurse evaluates and documents achievement of client outcomes. The nurse documents the specific data on the OR record.

32.  Copyright 2002 by Delmar, a division of Thomson Learning 30-32  Transfer to the PACU While the surgeon is closing the incision, the OR nurse gives a telephone report to a recovery room or PACU nurse regarding the client’s health status, surgical outcomes, special equipment needs, and nursing interventions.

33.  Copyright 2002 by Delmar, a division of Thomson Learning 30-33 The circulating nurse usually plans for personnel and equipment needed to safely transfer the client. The staff uses good body mechanics and assistive devices to allow proper weight distribution of the client (draw sheets, body rollers).

34.  Copyright 2002 by Delmar, a division of Thomson Learning 30-34 The client is at high risk for injury related to the effects of residual anesthesia. The anesthetist stays with the client while the OR nurse gives a report to the PACU nurse. After giving report, the OR nurse documents the time of discharge, method and disposition of transfer, and a general statement regarding the client’s status.

35.  Copyright 2002 by Delmar, a division of Thomson Learning 30-35 Postoperative Phase  The primary goal of nursing care during the immediate postoperative phase is to maintain the “A-B-Cs”: airway, breathing, and circulation.  Ongoing care is directed toward restoring the client to the preoperative health status.

36.  Copyright 2002 by Delmar, a division of Thomson Learning 30-36  Assessment Following the initial assessment of the client’s respiratory status, the nurse performs a total assessment  Airway and respiratory status  Circulatory status  Neurologic status

37.  Copyright 2002 by Delmar, a division of Thomson Learning 30-37  Fluid and metabolic status  Level of discomfort or pain  Wound management  Nursing diagnoses Ineffective airway clearance Ineffective breathing pattern Ineffective tissue perfusion

38.  Copyright 2002 by Delmar, a division of Thomson Learning 30-38 Deficient fluid volume Imbalanced nutrition: less than body requirements Depending on the individual client’s needs, other nursing diagnoses can be included in the plan of care

39.  Copyright 2002 by Delmar, a division of Thomson Learning 30-39  Outcome identification and planning Care planning is done in two parts - immediate care rendered in the PACU area and ongoing post-PACU care. Care is prioritized according to the type of anesthesia and surgical interventions.

40.  Copyright 2002 by Delmar, a division of Thomson Learning 30-40 After discharge, the nurse ensures that the client is knowledgeable about home care. For clients who are hospitalized postoperatively, the nursing care plan encompasses both inpatient and discharge needs.

41.  Copyright 2002 by Delmar, a division of Thomson Learning 30-41  Interventions Maintaining respiratory status Maintaining circulatory status Maintaining neurologic status Maintaining fluid and metabolic status Managing pain

42.  Copyright 2002 by Delmar, a division of Thomson Learning 30-42  Discharge from the PACU Specific client outcomes include  The client is conscious, oriented, and can move all extremities.  The client demonstrates full return of reflexes.  The client can clear the airway and cough effectively.

43.  Copyright 2002 by Delmar, a division of Thomson Learning 30-43  Vital signs have been stable or within baseline ranges for 30 minutes.  Intake and urinary output are adequate to maintain the circulating blood volume.  The client is afebrile or a febrile condition has been treated accordingly.  Dressings are dry or have only minimal drainage.

44.  Copyright 2002 by Delmar, a division of Thomson Learning 30-44  Ongoing postoperative care Ineffective airway clearance Ineffective tissue perfusion Deficient fluid volume Imbalanced nutrition Urinary retention Pain Risk for infection

45.  Copyright 2002 by Delmar, a division of Thomson Learning 30-45  Evaluation Based on client-specific postoperative nursing diagnoses and achievement of outcomes The time frame for achieving the outcomes can vary with the client’s health status, surgical procedure, and other factors such as age.