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Chapter 17 Preoperative Nursing Management
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Perioperative Nursing
Preoperative phase: period of time from decision for surgery until patient is transferred into operating room Intraoperative phase: period of time from when patient is transferred into operating room to admission to postanesthesia care unit (PACU) Postoperative phase: period of time from when patient is admitted to PACU to follow-up evaluation in clinical setting or at home
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Surgical Classifications
Seriousness Major Minor Urgency Elective Urgent Emergency Purpose
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Surgical Classifications
Purpose Diagnostic Ablative Palliative Reconstructive/Restorative Procurement Constructive Cosmetic
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Preadmission Testing Initiates initial preoperative assessment
Initiates teaching appropriate to patient’s needs Involves family in interview Verifies completion of preoperative diagnostic testing Verifies understanding of surgeon-specific preoperative orders Discusses, reviews advanced-directive document Begins discharge planning by assessing patient’s need for postoperative transportation, care
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Gerontological Considerations
Cardiac and circulatory compromise Respiratory compromise Renal function Confusion Fluid and electrolyte imbalances Skin Comorbidities Altered sensory Mobility restrictions
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Special Considerations During Preoperative Period
Bariatric patients or persons who are obese Patients with disabilities Patients undergoing ambulatory surgery Patients undergoing emergency surgery
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Informed Consent Client’s decision Responsibility of surgeon
Nurse witness the signature Must be signed prior to premed
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Preoperative Assessment
Nutritional, fluid status Dentition Drug or alcohol use Respiratory status Cardiovascular status Hepatic, renal function
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RED FLAGS Medications Substance Abuse Age Physical Condition
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Preoperative Assessment (cont’d)
Endocrine function Immune function Previous medication use Psychosocial factors Spiritual, cultural beliefs
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Medications that Potentially Affect on Surgical Experience
Corticosteroids Diuretics Phenothiazines Tranquilizers Insulin Antibiotics Anticoagulants Antiseizure medications Thyroid hormone Opioids OTC and herbals
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How Medications Potentially Affect on Surgical Experience
Diuretics during anesthesia may cause excessive respiratory depression resulting from an associated electrolyte imbalance. Corticosteroids can cause cardiovascular collapse if discontinued suddenly. Phenothiazines may increase the hypotensive action of anesthetics. Interaction between anesthetics and insulin must be considered when a patient with diabetes mellitus undergoes surgery.
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Informed Consent Client’s agreement to allow something to happen such as a surgery, treatment or procedure. Should be in writing Should contain the following: Explanation of procedure, risks Description of benefits, alternatives Offer to answer questions about procedure Instructions that patient may withdraw consent Statement informing patient if protocol differs from customary procedure
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Voluntary Consent Valid consent must be freely given, without coercion
Patient must be at least 18 years of age (unless emancipated minor) Consent must be obtained by physician Patient’s signature must be witnessed by professional staff member
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Incompetent Patient Individual who is not autonomous
Cannot give or withhold consent Cognitively impaired Mentally ill Neurologically incapacitated
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Preoperative Checklist
Must be completed prior to client going to surgery Responsibility of nurse sending client to surgery to ensure checklist is complete – Contains critical elements that MUST be checked and verified before client is sent to surgery
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Preoperative Checklist
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Preoperative Check chart for orders for preoperative preps, medications, labs, diagnostic test Ensure client is NPO for at least 6-8 hours prior to surgery – check orders for specific times Ensure all dentures, jewelry, makeup, hair clips, nail polish, glasses etc… removed and placed in a secure place Assess for any changes in client assessment
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Preoperative Preps Enemas Hair Removal Bathing
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Patient Education Deep breathing, coughing, incentive spirometry
Mobility, active body movement Pain management Cognitive coping strategies Instruction for patients undergoing ambulatory surgery
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Preoperative Teaching
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General Preoperative Nursing Interventions
Providing psychosocial interventions Reducing anxiety, decreasing fear Respecting cultural, spiritual, religious beliefs Maintaining patient safety Managing nutrition, fluids Preparing bowel Preparing skin
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Immediate Preoperative Nursing Interventions
Administering preanesthetic medication Maintaining preoperative record Transporting patient to presurgical area Attending to family needs
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Preoperative Instructions to Prevent Postoperative Complications
Diaphragmatic breathing Coughing Leg exercises Turning to side Getting out of bed
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Preoperative Summary Nursing process Preoperative assessment
Formulate nurse diagnosis Expected outcomes Nursing interventions
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Chapter 18 Intraoperative Nursing Management
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Members of the Surgical Team
Patient Circulating nurse Scrub role Surgeon Registered nurse first assistant Anesthesiologist, anesthetist
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Gerontologic Considerations
Older adult patients are at increased risk for complications of surgery, anesthesia due to Increased likelihood of coexisting conditions Aging heart, pulmonary systems Decreased homeostatic mechanisms Changes in responses to drugs, anesthetic agents due to aging changes (decreased renal function), changes in body composition of fat, water
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Prevention of Infection
Surgical environment, refer to Figure 18-1 Unrestricted zone Semirestricted zone Restricted zone Surgical asepsis Environmental controls Refer to Figure 18-2
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Basic Guidelines for Surgical Asepsis
All material within sterile field must be sterile Gowns sterile in front from chest to level of sterile field, sleeves from 2 inches above elbow to cuff Only top of draped tables considered sterile Items dispensed by methods to preserve sterility Movements of surgical team are from sterile to sterile, from unsterile to unsterile only
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Guidelines for Surgical Asepsis (cont’d)
Movement at least 1-foot distance from sterile field must be maintained When sterile barrier is breached, area is considered contaminated Every sterile field is constantly maintained, monitored Items of doubtful sterility considered unsterile Sterile fields prepared as close to time of use
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Surgical Team Roles Circulating nurse Scrub role Surgeon
Registered nurse first assistant Anesthesiologist, anesthetist Note: Role of nurse as patient advocate Refer to Chart 18-1
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Intraoperative Complications
Anesthesia awareness Nausea, vomiting Anaphylaxis Hypoxia, respiratory complications Hypothermia Malignant hyperthermia Disseminated intravascular coagulation (DIC) Infection
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Adverse Effects of Surgery and Anesthesia
Allergic reactions, drug toxicity or reactions Cardiac dysrhythmias CNS changes, oversedation, undersedation Trauma: laryngeal, oral, nerve, skin, including burns Hypotension Thrombosis Refer to Chart 18-2
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Through which route are general anesthetics primarily eliminated?
Question Through which route are general anesthetics primarily eliminated? Kidneys Liver Lungs Skin
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Answer Lungs Rationale: The lungs are the primary route from which general anesthetics are eliminated from the body.
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Comparison of Anesthetic Agents and Delivery Systems
General Inhalation: Refer to Table 18–1; Figure 18-3 (A, B, C) Intravenous: Refer to Table 18-2 Regional: Refer to Table 18-3 Epidural: Refer to Figure 18-4 Spinal: Refer to Figure 18-4
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Nursing Process: Interventions
Reducing anxiety Reducing latex exposure Preventing positioning injuries, refer to Figure 18-5 Protecting patient from injury Serving as patient advocate Monitoring, managing potential complications
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Laparotomy Position, Trendelenburg Position, Lithotomy Position and Side-Lying Position for Kidney Surgery Fig. 18-5
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Positioning Factors to Consider
Patient should be as comfortable as possible Operative field must be adequately exposed Position must not obstruct/compress respirations, vascular supply, or nerves Extra safety precautions for older adults, patients who are thin or obese, and anyone with a physical deformity Light restraint before induction in case of excitement
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Protecting the Patient From Injury
Patient identification Correct informed consent Verification of records of health history, exam Results of diagnostic tests Allergies (include latex allergy) Monitoring, modifying physical environment Safety measures (grounding of equipment, restraints, not leaving a sedated patient) Verification, accessibility of blood
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Chapter 19 Postoperative Nursing Management
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Nursing Management in the PACU
Provide care for patient until patient has recovered from effects of anesthesia Patient has resumption of motor and sensory function, is oriented, has stable VS, shows no evidence of hemorrhage or other complications of surgery Vital to perform frequent skilled assessment of patient
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Postanesthesia Care Unit (Recovery)
Refer to Figure 19-3 PACU environment Beds, other equipment Three phases Phase I- immediate recovery Phase II-client prepare for self care in hospital Phase III-client prepare for discharge
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Responsibilities of the PACU Nurse
Review pertinent information, baseline assessment upon admission to unit Assess airway, respirations, cardiovascular function, surgical site, function of CNS, IVs, all tubes and equipment Reassess VS, patient status every 15 minutes or more frequently as needed Transfer report, to another unit or discharge patient to home, refer to Charts 19-1 and 19-3
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Postoperative The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of hypoxemia and hypercapnia.
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Outpatient Surgery/Direct Discharge
Discharge planning, discharge assessment Refer to Charts 19-2 and 19-5 Provide written, verbal instructions regarding follow-up care, complications, wound care, activity, medications, diet Give prescriptions, phone numbers Discuss actions to take if complications occur
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Outpatient Surgery/Direct Discharge (cont’d)
Give instructions to patient, responsible adult who will accompany patient Patients are not to drive home or be discharge to home alone Sedation, anesthesia may cloud memory, judgment, effect ability
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Maintaining a Patent Airway
Primary consideration: necessary to maintain ventilation, oxygenation Provide supplemental oxygen as indicated Assess breathing by placing hand near face to feel movement of air Keep head of bed elevated 15 to 30 degrees unless contraindicated May require suctioning If vomiting occurs, turn patient to side
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Head and Jaw Positioning to Open Airway
Figure 19-1
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Use of Oral Airway Note: Do Not Remove Oral Airway Until Evidence of Gag Reflex Returns
Figure 19-2
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Maintaining Cardiovascular Stability
Monitor all indicators of cardiovascular status Assess all IV lines Potential for hypotension, shock Potential for hemorrhage Potential for hypertension, dysrhythmias Refer to Table 19-1
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Indicators of Hypovolemic Shock
Pallor Cool, moist skin Rapid respirations Cyanosis Rapid, weak, thready pulse Decreasing pulse pressure Low blood pressure Concentrated urine
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Relieving Pain and Anxiety
Assess patient comfort Control of environment: quiet, low lights, noise level Administer analgesics as indicated; usually short-acting opioids IV Family visit, dealing with family anxiety Refer to Chart 19-6
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Controlling Nausea and Vomiting
Intervene at first indication of nausea Medications Assessment of postoperative nausea, vomiting risk, prophylactic treatment Refer to Table 19-2
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Postoperative The most important nursing intervention when vomiting occurs postoperatively is to turn the patient’s head to prevent aspiration of vomitus into the lungs.
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Gerontologic Considerations
Decreased physiologic reserve Monitor carefully, frequently Increased confusion Dosage Hydration Refer to Chart 19-7 Increased likelihood of postoperative confusion, delirium Hypoxia, hypotension, hypoglycemia Reorient as needed Pain
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Wound Healing First-intention wound healing
Second-intention wound healing Third-intention wound healing Factors that affect wound healing Refer to Chart 19-4 and Table 19-3
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Question Which of the following occurs during the inflammatory stage of wound healing? Blood clot forms Granulation tissue forms Fibroblasts leave wound Tensile strength increases
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Granulation tissue forms during the proliferative phase.
Answer Blood clot forms Rationale: The blood clot forms during the inflammatory phase of wound healing. Granulation tissue forms during the proliferative phase. Fibroblasts leave the wound and tensile strength increases during the maturation phase of wound healing, refer to Table 19-5.
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Types of Surgical Drains
Figure 19-5
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Purpose of Postoperative Dressings
Provide healing environment Absorb drainage Splint or immobilize Protect Promote homeostasis Promote patient’s physical, mental comfort
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Change the Postoperative Dressing
First dressing changed by surgeon Types of dressing materials Sterile technique Assess wound Applying dressing, taping methods Patient response Patient teaching Documentation
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Complications Assess airway, respirations; patient at risk for ineffective airway clearance every 15 minutes Assess VS every 4 hours or as needed, other indicators of cardiovascular status; patients at risk for decreased cardiac output related to shock or hemorrhage Assess pain every 4 hours or per protocol
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Postoperative Complications
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Nursing Diagnosis Activity intolerance Impaired skin integrity
Ineffective thermoregulation Risk for imbalanced nutrition Risk for constipation Risk for urinary retention
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Nursing Diagnosis (cont’d)
Risk for injury Anxiety Risk for ineffective management or therapeutic regimen
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Collaborative Problems
Pulmonary infection/hypoxia Deep vein thrombosis Hematoma/hemorrhage Pulmonary embolism Wound dehiscence or evisceration Refer to Table 19-4
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Wound Dehiscence and Evisceration
Figure 19-6
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Postoperative Nursing Care
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Safety Guidelines for Nursing Skills
Coughing and deep breathing may be contraindicated after brain, spinal, head, neck, or eye surgery. Bariatric patients may have more improved lung function and vital capacity in the reverse Trendelenburg or side- lying position. Report any signs of venous thromboembolism such as pain, tenderness, redness, warmth, or swelling in the upper or lower extremities to the medical team immediately. Ensuring patient safety is an essential role of the professional nurse. To ensure patient safety, communicate clearly with the members of the health care team, assess and incorporate the patient’s priorities of care and preferences, and use the best evidence when making decisions about your patient’s care. When performing the skill in this chapter, remember the following points to ensure safe, individualized, patient-centered care: Coughing and deep breathing may be contraindicated after brain, spinal, head, neck, or eye surgery. Bariatric patients may have more improved lung function and vital capacity in the reverse Trendelenburg or side-lying position. Report any signs of venous thromboembolism, such as pain, tenderness, redness, warmth, or swelling in the upper or lower extremities, to the medical team immediately. Copyright © 2017, Elsevier Inc. All Rights Reserved.
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Summary Nurse plays an important role for the client having surgery
The nurse serves an advocate for client The ultimate goal for the client is maintain safety y prevent harm/injury to client Preop Intraop Postop
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