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Perioperative concepts and management

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Title: Perioperative concepts and management


1
  • Perioperative concepts and management

2
Association of PeriOperative Nurses
  • AORN
  • Standards of Care
  • Recommended Practices
  • Certification Process CNOR
  • Continuing Education
  • Legislative Issues
  • RN First Assistant RNFA

3
Definition of Perioperative Nursing
  • The practice of nursing directed toward clients
    undergoing operative and other invasive
    procedures
  • The perioperative nurse provides managers,
    teaches and or studies the care of clients
    undergoing operative or other invasive procedures
    in all three phases of the surgical experience

4
Practice Areas
  • Hospital operating rooms
  • Interventional radiology suites
  • Cardiac cath labs
  • Endoscopy suites
  • Ambulatory surgery centers
  • Trauma centers
  • Pediatric specialty centers
  • Physician offices

5
Functions of a Perioperative Nurse
  • Advocate
  • Protector
  • Teacher
  • Change agent
  • Manager of client care

6
The Surgical Team
7
Perioperative Team Members
  • Nursing Roles in the OR
  • Circulating Nurse
  • Scrub Nurse
  • RN First Assistant (RNFA)
  • Perioperative Educator
  • Specialty Team Leader
  • Perioperative Manager/Director

8
Surgical Team
  • Behind the scenes
  • Radiology Technologist
  • Anesthesia Technician
  • Nursing Technician
  • Transport Team
  • Environmental Services Team

9
Perioperative Nursing Skills
  • Assessment
  • Communication
  • Critical thinking
  • Technical skills

10
Surgical Attire
  • Gowns
  • Gloves
  • Masks
  • Hair Covering
  • Protective eyewear

11
Perioperative Nursing
  • Three Phases
  • Preoperative (Preop)
  • Intraoperative (Intraop)
  • Postoperative (Postop)

12
Preoperative Phase
  • Starts when surgery is scheduled
  • Ends when transferred to surgical suite
  • Assessment phase
  • Planning phase
  • Discharge Planning phase
  • Educations phase
  • Getting it all together phase

13
Intraoperative Phase
  • Begins when transferred to the surgical suite
  • Ends when transferred to the post-anesthesia care
    unit (PACU)
  • Surgical phase
  • Anticipatory time
  • Maintaining client advocacy
  • Maintaining communication with family/surgical
    team
  • Surgical team interaction

14
Postoperative Phase
  • Begins upon entry to the PACU
  • Ends when discharge from the PACU
  • Assessment
  • Pain control
  • Education
  • Discharge planning
  • Interdisciplinary team communication

15
Categories of Surgery-Purpose for Surgery
  • Defined by
  • The reason for surgery
  • The urgency for surgery
  • The degree of risk of surgery
  • The anatomic location of the surgery
  • The extent of the surgery required

16
Reason for surgery
  • Diagnostic
  • Curative
  • Restorative
  • Palliative
  • Cosmetic

17
Urgency of the procedure
  • Elective
  • Urgent
  • Emergent

18
Degree of Risk
  • Minor Risk
  • Major Risk

19
Anatomic location
  • General
  • GYN
  • Urology
  • Orthopedic
  • Neurological
  • Plastic
  • Ophthalmology

20
Anatomic location
  • Cardiac
  • Thoracic
  • ENT
  • Vascular
  • Transplant
  • Trauma
  • Bariatric

21
Extent of surgery
  • Simple
  • Radical

22
Surgical Settings
  • Inpatient
  • Outpatient/ambulatory
  • Hospital-based ambulatory surgery center
  • Free-standing surgical center
  • Physicians office surgery
  • Ambulatory Care Centers

23
Preoperative Period
  • Assessment
  • Nursing Management
  • Analysis
  • Planning and Implementation
  • Evaluation

24
Collaborative Management
  • Preoperative HP up to 30 days PTS
  • Primary Care Physician or Nurse Practitioner
  • Faxed to pre-admission center
  • Faxed to PCP or surgeon
  • Reviewed, evaluated, changes PRN
  • Sometimes surgery gets cancelled

25
Nursing Process in Pre-op Phase
  • Planning
  • Correction of any abnormal labs
  • Blood donations
  • Bloodless surgery
  • Nutrition
  • Pain Management
  • Surgery Classes
  • Discharge planning

26
Assessment
  • History
  • Surgical Risk Factors
  • Physical Assessment and manifestations
  • Psychosocial assessment
  • Laboratory/ Radiographic assessment

27
History
  • Present problem, reason for surgery
  • Past medical history
  • Past cardiac history
  • Past surgical history
  • Family history
  • Social history
  • Medications
  • Allergies

28
Surgical Risk Factors
  • Medical history
  • Cardiovascular system
  • Respiratory system
  • Renal/ Urinary system
  • Neurological system
  • Musculoskeletal
  • Age greater than 65

29
Surgical Risk Factors
  • Medication history
  • Past surgical complications
  • Past postoperative complications
  • Nutritional status
  • Social habits
  • Family history of complications
  • Type of surgical procedure planned

30
Nursing Physical Assessment
  • Health status
  • Cardiovascular status
  • Respiratory status
  • Renal/urinary status
  • Neurologic status
  • Musculoskeletal status
  • Nutritional status

31
Psychosocial Assessment
  • Anxiety
  • Fear
  • Coping
  • Support Systems
  • Socioeconomic status
  • Diagnosis
  • Education
  • Physical signs

32
Lab and Radiograph Assessment
  • Baseline
  • Predict potential complications
  • Abnormal results
  • Values according to medications taken

33
Labs
  • UrineUA
  • HematocritHct
  • HemagloblinHgb
  • White blood cell countWBC
  • Prothrombin time/ pro timePT
  • Partial thromboplastin time, activatedaPTT
  • International Normalized ratioINR

34
Labs contd
  • Chemistry electrolytesNa, Cl, K, Glucose, CO2
  • Creatinine
  • Blood urea nitrogen (BUN)
  • Serum pregnancy test

35
Radiographs/Optional tests
  • Chest x-rayCXR
  • ElectrocardiogramEKG
  • Arterial blood gas-ABGs
  • Pulmonary function testsPFTs
  • Films for area of surgery x-rays, MRI, CAT scan

36
Nursing Management
  • Review planned surgery
  • Obtain client history
  • Physical assessment
  • Preadmission treatment/diagnostic testing
  • Interpret diagnostic tests
  • Client expectations
  • QA
  • Caretaker ability

37
Analysis Nursing Diagnoses
  • Knowledge deficit
  • Anxiety
  • Disturbed sleep patterns
  • Ineffective coping
  • Anticipatory grieving
  • Disturbed body image
  • Disabled family coping
  • Powerlessness

38
Planning InterventionsDx Knowledge deficit
  • Ensuring informed consent
  • Client self-determination
  • Implementing dietary restrictions
  • Administration of medications
  • Intestinal preparation
  • Skin preparation
  • Vascular access

39
Pre-operative TeachingDx Anxiety
  • Tubes, drains, additional vascular access
  • Post-op procedures
  • Post-op exercises breathing exercises, incentive
    spirometry, coughing splinting, leg procedures
    and exercises
  • Early Ambulation
  • Range of Motion exercises (ROM)

40
Relaxation stress reductionDx Anxiety
  • Deep breathing
  • Music therapy
  • Touching
  • Familys presence
  • Reassurance
  • Calm mannerisms
  • Pre-operative sedation

41
Collaborative Management Assessment Planning
  • Client interview
  • Correct person for the correct procedure with
    correct preparation on the correct anatomy
  • Risk for perioperative positioning injury
  • Lacks normal defense mechanisms
  • Size, age skin integrity
  • Potential for hypoventilation
  • Potential for hemodynamic shifts
  • Blood loss

42
Preoperative Chart ReviewNursing Responsibility
  • Pre-op check list
  • Surgical informed consent
  • Anesthesia informed consent
  • Blood transfusion consent-TS done?
  • Site verification checklist-Med-Surg RN/OR staff
  • Lab results-report abnormal lab values
  • HP present signed
  • Current vital signs
  • Special Needs

43
Preoperative Client Preparation
  • Clothing removed/don patient gown
  • Jewelry removed including body any piercing/s
  • Prosthesis dentures, wigs, limbs
  • Aides hearing, glasses, cane
  • Arm bands identification, code status, blood
    bracelet, fall risk status bracelet
  • Misc contact lenses, hairpins
  • Nail polish, artificial nails

44
Preoperative Client Preparation
  • Empty bladder
  • Pre-operative medications Versed/Reglan
  • Safe transfer to surgical suite

45
Special Considerations
  • Patients age child elderly
  • Cognition ability to cooperate/understand
  • Ethnic customs
  • Language/communication interpreter, HOH

46
Evaluation what is my outcome?Planned or
unplanned
  • Ms. W, age 77, is admitted for curative surgery
    (hysterectomy). She has a history of asthma is
    currently taking Prednisone. Her weight is 237,
    her height 53.
  • What are her known risk factors?
  • What other questions will you ask?

47
Critical thinking Synthesis of information
  • Assessment physical examination focused on
    clients history planned surgery
  • Assessment of risk factors
  • Clients previous experience w/surgery
  • Clients coping resources
  • Results of pre-op diagnostic tests

48
Critical thinking Synthesis of information
  • Knowledge AP of affected body systems
  • Surgical risk factors
  • Type of surgical procedure to be performed
  • Surgical stress response infection control
    practices

49
Critical thinking Synthesis of information
  • Experience Caring for clients who have had
    surgery
  • Personal experience with surgery

50
Critical thinking Synthesis of information
  • Standards apply standards of care (SOC)
  • Apply AORN standards in operating room
  • Apply American Society of PeriAnesthesia Nurses
    (ASPAN) standards of care

51
Critical thinking Synthesis of information
  • Attitudes Use discipline in collecting a
    complete history
  • Use perseverance to ensure a comprehensive
    assessment

52
Goals of Client Safety
  • Provide safe client care
  • Knowledge of procedure
  • Ensure the correct client, correct site, correct
    level and correct procedure
  • Knowledge of positioning
  • Adhere to safe medication administration
    guidelines
  • Perform surgical counts

53
Safety Client
  • Correct patient, correct surgery, correct side
    Time Out
  • Positioning padding, alignment, eyes, breast,
    penis/scrotum
  • Injury burns
  • Sponge, Needle, Instrument counts
  • Fall prevention-safety straps

54
Goals of Client Safety
  • Provide a safe environment
  • Adhere to asepsis surgical conscious
  • Promote coordinated and effective communication

55
Safety Staff
  • Sharps
  • Equipment
  • Lifting, moving, positioning client
  • Combative client
  • Safety equipment universal protocol goggles
    isolyzer gel
  • OSHA surgical smoke, laser plume

56
Benefits of a Career in Perioperative Nursing
  • Requires
  • The ability to work in a fast paced environment
  • Flexibility
  • Attention to detail
  • Willingness to commit to ongoing learning
  • The ability to work collaboratively as a member
    of the surgical team

57
Patient Outcomes
  • Planned Outcomes
  • Unplanned Outcomes

58
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59
Intraoperative Nursing
  • Break!

60
Intraoperative Phase
  • Begins when the client enters into the surgical
    suite
  • Sedated?
  • Aware?
  • Noises
  • Cold
  • Double teamed

61
Surgical Asepsis
  • Surgical field-defined
  • Surgical tables-green or blue drapes
  • Surgical conscious
  • Infection control practices
  • Physical layout of surgical suite
  • Protocols distance, doors, dress

62
Skin Preparation
  • Clip-electric razor
  • Scrub
  • Shower
  • Purpose

63
Surgical Hand Scrub
  • Purpose
  • Agents soap water vs. liquid hand cleaner
  • Nails
  • Position of hands
  • Donning gown gloves

64
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65
Safety Staff
  • Sharps
  • Equipment
  • Lifting, moving, positioning client
  • Combative client
  • Safety equipment universal protocol goggles
    isolyzer gel
  • OSHA surgical smoke, laser plume

66
Safety Client
  • Correct patient, correct surgery, correct side
    Time Out
  • Positioning padding, alignment, eyes, breast,
    penis/scrotum
  • Injury burns
  • Sponge, Needle, Instrument counts
  • Fall prevention-safety straps

67
My Space-Your Space
  • Defined geographic locations
  • Position of equipment
  • Rules of engagement
  • Color me blue/green
  • Surgical conscious
  • Moving about in the OR
  • OR traffic patterns
  • The Red Line

68
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69
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70
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71
Anesthesia more choices and alternatives
  • General Anesthesia
  • Regional Anesthesia
  • Intravenous Anesthesia
  • Local Anesthesia
  • Balanced Anesthesia

72
General Anesthesia Inhalation Agents
  • Inhalation most controllable method lungs act as
    passageway for entrance exit of agent
  • Gas Agents Nitrous Oxide
  • must be given with oxygen
  • require assisted to mechanical ventilation
  • frequently shiver
  • taken in excreted via lungs
  • Examples halothane, enthrane, florane

73
Anesthesia Cart
  • Supply Cart
  • Syringes
  • IV supplies
  • Intubation supplies
  • Medications
  • Blood transfusion supplies
  • Regional anesthesia supplies

74
General AnesthesiaEndotracheal
Intubation (maintain airway patency/promote
oxygenation)
Used with general anesthesia Alternatives are
mask or LMA
75
Stages of General Anesthesia
  • Stage 1 Analgesia/Sedation/Relaxation
  • Stage 2 Excitement/Delirium
  • Stage 3 Operative Anesthesia
  • (Stage 4 DANGER BAD) not expected/normal
  • Speed of EMERGENCE (recovery from anesthesia)
    depends on type of anesthesia, length of time
    many other factors- try to time with end of
    surgery

76
General Anesthesia Intravenous
  • Intravenous Agents
  • Thiopental Sodium (Pentothal) but is commonly
    called Sodium Pentothal by patients (class
    barbiturate)
  • Diprovan (Propofol)
  • rapid acting
  • monitor vital signs
  • respiratory depression

77
Adjuncts to General Anesthesia
  • Hypnotics (Versed)
  • also used for conscious sedation
  • Opioid Analgesics (Morphine, Fentanyl)
  • respiratory depression
  • Neuromuscular Blocking Agents
  • Causes muscle paralysis
  • Examples Rocuronium, Succinycholine
  • What vital function is affected?

78
Potential General Anesthesia Complications
  • Overdose (consider risk factors)
  • Hypoventilation postoperatively
  • Intubation related sore throat, hoarseness,
    broken teeth, vocal cord trauma
  • MALIGNANT HYPERTHERMIA
  • Genetic predisposition
  • Triggered by anesthetics such as Halothane

79
Balanced Anesthesia (a sample)
  • Start with Pentothal or Propofol
  • Add in some nitrous oxide for amnesia
  • Use inhalation agent such as halothane
  • Stir in a little opiate- morphine, fentanyl, for
    postop analgesia
  • To top it off give Pavulon, a neuromuscular
    blocker, for additional muscular relaxation

80
Regional Anesthesia
  • Field Block
  • Nerve Block
  • Spinal Anesthesia
  • Epidural Anesthesia

81
Regional Anesthesia
  • Loss of sensory nerve impulses motor function
    may or may not be affected
  • No loss of consciousness
  • Field Block caine injected around a nerve or
    group of nerves (dental procedures)
  • May be combined with epinephrine to prolong
  • Approximately 30 min to 2 hours

82
Regional Anesthesia Spinal
  • Local anesthetic
  • (-caine) injected into cerebrospinal fluid
    (approx L 3-5) subarachnoid space

83
Spinal Anesthesia (Subarachnoid Block)
  • Anesthesia tip of xiphoid to toes
  • Risks
  • Loss of vasomotor tone
  • Spinal Headache
  • Infection, Rising anesthesia above diaphragm
  • Nursing KEEP FLAT, MONITOR VS OFFER FLUIDS
    WHEN APPROPRIATE

84
Regional Anesthesia Epidural
  • Injected into epidural space rather than
    subarachnoid fluid (usually safer)
  • Used for OR OB
  • Epidural catheter can be left in place for postop
    pain management (PCA)

85
Regional Anesthetic Risks
  • Anaphylaxis (ALLERGY)
  • Incorrect administration technique
  • Systemic absorption of medication
  • Infection

86
Intravenous Anesthesia
  • Multiple Agents
  • Multiple Purposes
  • Induction
  • Hypnosis
  • Dissociative
  • Opioid Analgesics
  • Neuromuscular blocking agents

87
Conscious Sedation
  • Reduce intensity of pain without loss of
    defensive reflexes
  • Usually a combination of opioid analgesic and
    sedative-hypnotics
  • May be administered by credentialed RN
  • Expect client to be sleepy but arousable
  • JUST BECAUSE HIS EYES ARE CLOSED DOESNT MEAN
    HES ASLEEP!!

88
Local Anesthesia
  • Local/Topical
  • Interrupts transmission of sensory nerve impulses
    so it numbs what it touches
  • Requires multiple injections with CAINE drug
    (Example novacaine, lidocaine)
  • Duration 1 min to 20-30 min
  • -Can be prolonged with added epinephrine
  • Assess for ALLERGY

89
Nursing Process during the Intraoperative Phase
  • Assessment-ongoing
  • Planning
  • Proactive
  • Flexible
  • Forever Changing

90
Nursing Process Intraop Phase
  • Evaluation
  • Expected
  • Unexpected
  • Documented
  • Informing Client Family
  • Surgical Waiting Room
  • Ongoing Updates by OR Team

91
Postoperative Goals
  • Re-establishment of physiologic equilibrium
  • Alleviation of pain
  • Prevention of complications
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