1. Perioperative client By I.KORDA

2. Perioperative period Preoperative Intraoperative Postoperative

3. Care of preoperative client Education Preoperative procedures

4. Purposes of surgery Diagnostic Curative Restorative Palliative Cosmetic

5. Urgency Elective Urgent Emergent

6. Emergent—Patient requires immediate attention Disorder may be life-threatening Without delay  Severe bleeding  Bladder or intestinal obstruction  Fractured skull  Gunshot or stab wounds  Extensive burns

7. Urgent—Patient requires prompt attention Within 24–30 h  Acute gallbladder infection  Kidney or ureteral stones

8. Required—Patient needs to have surgery Plan within a few weeks or months  Prostatic hyperplasia without bladder obstruction  Thyroid disorders  Cataracts

9. Elective—Patient should have surgery Failure to have surgery not catastrophic  Repair of scars  Simple hernia  Vaginal repair

10. Optional—Decision rests with patient Personal preference  Cosmetic surgery

11. Degree of risk Minor Major Category by location  Abdominal  Intracranial  Heart etc.

12. 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. Surgical settings

13. 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.

14.  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.

15. Criteria for Valid Informed Consent Voluntary Consent Explanation of procedure and its risks Description of benefits and alternatives An offer to answer questions about procedure Instructions that the patient may withdraw consent A statement informing the patient if the protocol differs from customary procedure

16. Invasive procedures, such as a surgical incision, a biopsy, a cystoscopy, or paracentesis Procedures requiring sedation and/or anesthesia A nonsurgical procedure, such as an arteriography, that carries more than slight risk to the patient Procedures involving radiation

17. 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.

18.  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).

19. 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.

20. Collaborative management History Physical assessment Psychosocial assessment Laboratory assessment Radiographic assessment Other diagnostic assessment

21. Collaborative Management Assessment History and data collection  Age  Drugs and substance use  Medical history, including cardiac and pulmonary histories  Previous surgery and anesthesia  Blood donations  Discharge planning

22. 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.

23. System Assessment Cardiovascular system Respiratory system Renal/urinary system Neurologic system Musculoskeletal system Nutritional status Psychosocial assessment

24. 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

25. Deficient Knowledge Interventions Preoperative teaching Informed consent  The surgeon is responsible for obtaining signed consent before sedation is given and surgery is performed.  The nurse’s role is to clarify facts presented by the physician and dispel myths that the client or family may have about surgery.

27. Implementing Dietary Restrictions Client is given nothing by mouth (NPO) for 6 to 8 hours before surgery. NPO status decreases the risk for aspiration. Failure to adhere can result in cancellation of surgery or increase the risk for aspiration during or after surgery.

28. Administering Regularly Scheduled Medications Consult the medical physician and anesthesia provider for instructions about drugs, such as those taken for diabetes, cardiac disease, glaucoma, regularly scheduled anticonvulsants, antihypertensives, anticoagulants, antidepressants, or corticosteroids.

29. 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.

30. Skin Preparation The 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.

31. Preparing the Client Possible placement of tubes, drains, and vascular access devices Teaching about postoperative procedures and exercises:  Breathing exercises, incentive spirometry, coughing and splinting (Continued)

32. Preparing the Client (Continued)  Leg procedures and exercises, antiembolism stockings and elastic wraps, early ambulation, and range- of-motion exercises

33. Anxiety Interventions Preoperative teaching Encouraging communication Promoting rest Using distraction Teaching family and significant others

34. Preoperative Chart Review Ensure all documentation, preoperative procedures, and orders are complete. Check the surgical consent form and others for completeness. Document allergies. Document height and weight. (Continued)

35. Preoperative Chart Review (Continued) Ensure results of all laboratory and diagnostic tests are on the chart. Document and report any abnormal results. Report special needs and concerns.

36. Preop Client Prep Client should remove most clothing and wear a hospital gown. Valuables should remain with family member or be locked up. Tape rings in place if they can’t be removed. Remove all pierced jewelry. (Continued)

37. Preop Client Prep (Continued) Client wears an identification band. Dentures, prosthetic devices, hearing aids, contact lenses, fingernail polish, and artificial nails must be removed.

38. Preoperative Medication Reduce anxiety. Promote relaxation. Reduce pharyngeal secretions. Prevent laryngospasm. Inhibit gastric secretion. Decrease amount of anesthetic needed for induction and maintenance of anesthesia.

39. Interventions for Intraoperative Clients

40. 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

41. Environment of the Operating Room Preparation of the surgical suite and team safety Layout Health and hygiene of the surgical team Surgical attire Surgical scrub

42. Anesthesia Induced state of partial or total loss of sensation, occurring with or without loss of consciousness Used to block nerve impulse transmission, suppress reflexes, promote muscle relaxation, and, in some instances, achieve a controlled level of unconsciousness

43. General Anesthesia Reversible loss of consciousness is induced by inhibiting neuronal impulses in several areas of the central nervous system. State can be achieved by a single agent or a combination of agents. Central nervous system is depressed, resulting in analgesia, amnesia, and unconsciousness, with loss of muscle tone and reflexes.

44. Stages of General Anesthesia Stage 1: analgesia Stage 2: excitement Stage 3: operative Stage 4: danger

45. Administration of General Anesthesia 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

47. 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 (Continued)

48. Balanced Anesthesia (Continued) Example: thiopental for induction, nitrous oxide for amnesia, morphine for analgesia, and pancuronium for muscle relaxation

49. Complications from General Anesthesia Malignant hyperthermia: possible treatment with dantrolene Overdose Unrecognized hypoventilation Complications of specific anesthetic agents Complications of intubation

50. Local or Regional Anesthesia Sensory nerve impulse transmission from a specific body area or region is briefly disrupted. Motor function may be affected. Client remains conscious and able to follow instructions. Gag and cough reflexes remain intact. Sedatives, opioid analgesics, or hypnotics are often used as supplements to reduce anxiety.

51. Local Anesthesia Topical anesthesia Local infiltration Regional anesthesia  Field block  Nerve block  Spinal anesthesia  Epidural anesthesia

53. Complications of Local or Regional Anesthesia Anaphylaxis Incorrect delivery technique Systemic absorption Overdosage (Continued)

54. Complications of Local or Regional Anesthesia (Continued) Assess for central nervous system stimulation, central nervous system and cardiac depression, restlessness, excitement, incoherent speech, headache, blurred vision, metallic taste, nausea and vomiting, tremors, seizures, increased pulse, respirations, and blood pressure.

55. Treatment of Complications Establish an open airway. Give oxygen. Notify the surgeon. Fast-acting barbiturate is usual treatment. If toxic reaction is untreated, unconsciousness, hypotension, apnea, cardiac arrest, and death may result.

56. Conscious Sedation IV delivery of sedative, hypnotic, and opioid drugs reduces the level of consciousness but allows the client to maintain a patent airway and to respond to verbal commands. Diazepam, midazolam, meperidine, fentanyl, alfentanil, and morphine sulphate are the most commonly used drugs. (Continued)

57. Conscious Sedation (Continued) Nursing assessment of airway, level of consciousness, oxygen saturation, electrocardiographic status, and vital signs are monitored every 15 to 30 minutes.

58. Collaborative Management Assessment Medical record review Allergies and previous reactions to anesthesia or transfusions Autologous blood transfusion Laboratory and diagnostic test results Medical history and physical examination findings

59. Risk for Perioperative Positioning Injury Interventions include: Proper body position Risk for pressure ulcer formation Prevention of obstruction of circulation, respiration, and nerve conduction

62. 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

63. Potential for Hypoventilation Continuous monitoring of:  Breathing  Circulation  Cardiac rhythms  Blood pressure and heart rate Continuous presence of an anesthesia provider

64. Interventions for Postoperative Clients

65. PACU Recovery Room Purpose is to provide ongoing evaluation and stabilization of clients to anticipate, prevent, and treat complications after surgery. PACU is usually located close to the surgical suite. The PACU nurse is skilled in the care of clients with multiple medical and surgical problems that can occur following a surgical procedure.

66. Collaborative Management Assessment Physical assessment and clinical manifestations  Assess respiration.  Examine surgical area for bleeding  Monitor vital signs.  Assess for readiness to discharge once criteria have been met.

67. Respiratory System Airway assessment Breath sounds Other respiratory assessments

68. Cardiovascular Assessment Vital signs Cardiac monitoring Peripheral vascular assessment

69. Neurologic System Cerebral functioning Motor and sensory assessment important after epidural or spinal anesthesia  Motor function: simple commands; client to move extremities  Return of sympathetic nervous system tone: gradually elevate head and monitor for hypotension

70. Fluid, Electrolyte, and Acid- Base Balance Check fluid and electrolyte balance. Make hydration assessment. Intravenous fluid intake should be recorded. Assess acid-base balance.

71. 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, vomitus, or diarrhea stools. Report a urine output of < 30 mL/hr.

72. Gastrointestinal System Nausea and vomiting are common reactions after surgery. Peristalsis may be delayed because of long anesthesia time, the amount of bowel handling during surgery, and opioid analgesic use. Clients who have abdominal surgery often have decreased peristalsis for at least 24 hours.

73. Nasogastric Tube Drainage Tube may be inserted during surgery to decompress and drain the stomach, to promote gastrointestinal 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. (Continued)

74. Nasogastric Tube Drainage (Continued) Assess drained material every 8 hours. Do not move or irrigate the tube after gastric surgery without an order from the surgeon.

75. Skin Assessment 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.” (Continued )

76. Skin Assessment (Continued)  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.

78. 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 its peak the second day after surgery, when the client is more awake, more active, and the anesthetic agents and drugs given during surgery have been excreted.

79. Impaired Gas Exchange 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 as soon as possible to help remove secretions and promote lung expansion

80. Impaired Skin Integrity Interventions include: Nursing assessment of the surgical area Dressings: first dressing change usually performed by surgeon Drains: provide an exit route for air, blood, and bile as well as help prevent deep infections and abscess formation during healing (Continued)

81. Impaired Skin Integrity (Continued) Drug therapy including antibiotics and irrigations are used to treat wound infection. Surgical management is required for wound opening.

82. Acute Pain Interventions include: Drug therapy Complementary and alternative therapies such as:  Positioning  Massage  Relaxation and diversion techniques

83. Potential for Hypoxemia Interventions include: Maintenance of airway patency and breathing pattern Prevention of hypothermia Maintenance of oxygen therapy as prescribed

84. The classic signs of shock are: Pallor Cool, moist skin Rapid breathing Cyanosis of the lips, gums, and tongue Rapid, weak, thready pulse Decreasing pulse pressure Low blood pressure and concentrated urine

85. Patient’s readiness for discharge from the PACU Stable vital signs Orientation to person, place, events, and time Uncompromised pulmonary function Pulse oximetry readings indicating adequate blood oxygen saturation Urine output at least 30 mL/h Nausea and vomiting absent or under control Minimal pain

87. Health Teaching Prevention of infection Dressing care Nutrition Pain medication management Progressive increase in activity level Use of proper body mechanics

88. The end