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Chapter 20: Caring for the Perioperative Client

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Title: Chapter 20: Caring for the Perioperative Client


1
Chapter 20 Caring for the Perioperative Client
  • Medical Surgical Nursing 1--

2
Perioperative
  • Term used to describe the entire span of surgery,
    including what occurs before, during and after
    actual procedure
  • Three phases of perioperative care are
  • Preoperative
  • Intraoperative
  • Postoperative

3
Definitions
  • Perioperative term used to describe the entire
    span of surgery, including what occurs before,
    during, and after the actual operation.
    Preoperative begins with the decision to
    perform surgery and continues until the client
    has reached the operating area.

4
Definitions
  • Intraoperative includes the entire duration of
    the surgical procedure, until the client is
    transferred to the recovery area.
  • Postoperative begins with admission to the
    recovery area and continues until the client
    receives a follow-up evaluation at home or is
    discharged to a rehabilitation unit.

5
Reasons Categories of Surgery
  • Categories of Surgery Based On Urgency --Table
    20-2 pg 239
  • Reasons for Surgery Table 20-1 pg 239

6
Preoperative
  • Must have complete assessment
  • Must identify which client is more at risk for
    complications
  • weight
  • use of alcohol, tobacco and other substances
  • Physical conditions
  • Medical problems
  • Liver kidney function

7
Surgical Risk Factors
  • See Table 20-3 on pg 241

8
Assessment
  • Review pre-op instructions to make sure they are
    completed
  • diet restrictions
  • skin prep
  • thorough hx and physical exam
  • assess for knowledge of procedure, post-op
    expectations and if he can participate in post op
    care

9
Assessment
  • There may be strong cultural beliefs about
    disposal of body parts and blood transfusions

10
Surgical Consent
  • Dr. explains, must be informed consent
  • Client or family signs permission--nurse cosigns
    and dates
  • Notify Dr. if any questions
  • Do not sign after narcotic or sedative given
  • Consent must be obtained for any invasive
    procedures that requires anesthesia and has risks
    or complications

11
Surgical Consent
  • If adult is confused, unconscious or not mentally
    competent, family member or guardian must sign.
  • A minor under 18 who is living away from home and
    is self supporting is an emancipated minor and
    may sign form
  • Must be informed consent!!

12
Surgical Consent
  • In an emergency, the Dr.. may operate without
    consent but every effort should be made to get
    consent via phone, telegram or fax. Must have 2
    witnesses if over phone.

13
Preoperative Teaching
  • When doing pre-op teaching, simple, factual
    explanations adjusted to clients ability and
    need are essential

14
Pre-op Teaching
  • Pre-op meds, post-op control of pain
  • why frequent vital signs taken
  • Explain recovery room
  • Practice coughing and deep breathing exercises,
    splinting, leg and feet exercises
  • Explain how to use spirometer and why it is
    needed
  • IV, catheter, NG tubes

15
Insentive-Spirometer Video
  • http//www.smiths-medical.com/catalog/lung-expansi
    on/insentive-spirometer/disposable-coach-spiromete
    r.html

16
Skin Prep
  • Shaving prevents contamination of surgical area
    because micros are on hair. It also prevents hair
    from entering the wound and interferes with
    healing
  • Shaving, clipping hair or creams used
  • Some hosp do not allow shaving as risk injury to
    the skin, which provides an entry for
    microorganisms.

17
Elimination
  • Bladder distention makes surgery more difficult
    and increases risk to bladder during surgery
  • Enemas prevents straining after surgery and
    prevents incontinence during surgery
  • If not catheterized, must void prior to pre-op
    med--put time of voiding on chart

18
Food and Fluids
  • MD gives specific orders on how long food and
    fluids are to be withheld before surgery at
    least 8 to 10 hours is customary.
  • Many NPO after midnight

19
Food and Fluids
  • Many ambulatory surgical centers allow clear
    fluids up to 3 to 4 hours before surgery.
  • Encourage good nutrition prior to this to help
    meet increased need for nutrients during healing
    process
  • Protein and vitamin C are especially important to
    wound healing

20
Care of Valuables
  • Place in hosp. safe if unable to give to family
    to take home.Itemize valuables and place in
    envelope. Chart who you gave it to.
  • Remove all jewelry. May keep wedding ring but
    tape to finger or tie with gauze.
  • Chart what you did with valuables
  • Remove glasses, contacts, dentures and store
    safely

21
Attire
  • Cotton hospital gowns
  • Hair protector, booties
  • Some minor out patient surgery can wear own
    clothes with gown over them.
  • No make-up, nail polish, or hair pins or
    barrettes
  • Give good mouth care before surgery
  • Prostheses removed unless otherwise ordered

22
Prostheses
  • Depending on agency policy and physician
    preference, the client removes full or partial
    dentures.
  • Doing so prevents the dentures from becoming
    dislodged or causing airway obstruction during
    administration of a general anesthetic.

23
Pre-op Meds
  • Before pre-op meds given
  • Time on call
  • consent signed, allergies?
  • Voided? chart time
  • follow rights
  • contact anesthesia if questions
  • take vitals

24
Pre-op Meds
  • After med given
  • Side rails up, bed in low position, call bell
    near
  • Instruct not to get up...chart it
  • rearrange room for stretcher
  • take vitals 30 to 45 minutes later

25
Pre-op Meds
  • Tranquilizers and sedatives reduce anxiety
  • Hypnotics (sleeping pills) night prior to surgery
  • Anesthesiologist orders pre-op---may be a
    combination---Demerol, phenergan, atropine
  • Narcotic and antiemetic and drugs to decrease
    resp. tract secretions--phenergan enhances
    sedation of narcotic

26
Psychosocial Preparation
  • Anxiety and fear, if extreme, can affect a
    clients condition during and after surgery
  • anxious clients have a poor response to surgery
    and are prone to complications.
  • Call clergy if requested

27
Preoperative Checklist
  • Read over Preopeative Checklist on own pg 243

28
Intraoperative Care
  • Surgical team consists of an anesthesiologist,
    surgeon assistants, and the intraoperative
    nurses.
  • Read on own

29
Anesthesia
  • Is the partial or complete loss of the sensation
    of pain with or without the loss of
    consciousness.
  • Surgical procedures are performed with general,
    regional, or local anesthesia.

30
General Anesthesia
  • General anesthesia produces loss of sensation,
    reflexes, and consciousness by acting on the
    central nervous system.
  • Vial functions such as breathing, circulation,
    and temperature control are not regulated
    physiologically when general anesthetics are
    used.

31
General Anesthesia
  • May be administered as IV, intramuscular,
    inhaled, or rectal medications.
  • Has 4 distinct but overlapping stages.

32
4 Stages of General Anesthesia
  • 1. Induction or beginning stage this short
    period of time is crucial for producing
    unconsciousness. (Et tube)
  • The client experiences dizziness, detachment, a
    temporary heightened sense of awareness to noises
    and movements, and a sensation of heavy
    extremities and not being able to move them. (IV
    or inhaled)

33
4 Stages of General Anesthesia
  • 2. Maintenance of surgical anesthesia during
    this stage the client is maintained in an
    unconscious state, ranging from light to deep,
    depending on the depth of anesthesia required for
    the surgery.
  • Generally this stage is maintained with a
    combination of IV and inhaled anesthetics.
  • VS closely monitored

34
4 Stages of General Anesthesia
  • 3. Emergence from surgical anesthesia this
    sage is critical for the client as the
    anesthetics are carefully withdrawn.
  • Generally the client wakes enough to follow
    commands and demonstrate the ability to breathe
    independently.
  • ET tube may be removed while in the OR or may be
    left in place for much of the recovery phase.

35
4 Stages of General Anesthesia
  • 4. Recovery period this period can be brief or
    long. Many of the effects of general anesthesia
    take some time to be eliminated completely.
  • Clients often do not remember much about the
    initial recovery period.

36
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37
General Anesthesia
  • Throughout the duration of and recovery from
    anesthesia the client is closely monitored for
    effective breathing and oxygenation, effective
    circulatory status including blood pressure,
    pulse within normal ranges, effective regulation
    of temperature, and adequate fluid balance.

38
Regional Anesthesia
  • Uses local anesthetics to block the conduction of
    nerve impulses in a specific region.
  • The client experiences loss of sensation and
    decreased mobility to the specific area that is
    anesthetized.
  • Does not lose consciousness.
  • See Table 20-4 pg. 247

39
Regional Anesthesia
  • Advantages less risk for resp, cardiac, or GI
    complications.
  • Needs to be monitored for signs of allergic
    reactions, changes in VS, and toxic reactions.

40
The OR Environment
  • The OR or surgical suite environment is
    physically isolated from other areas of the
    hospital or surgical clinic.
  • Air is filtered and positive pressure maintained
    to reduce the number of possible microbes that
    can cause infection.
  • Separate clean and contaminated areas.

41
The OR Environment
  • Temperature below 70 to provide a cooler
    environment that does not promote bacterial
    growth, Personnel comfort
  • Operating Room Attire Box 20-5 pg. 248

42
The OR Environment
  • Nursing Management ASEPSIShigh risk of
    infection due to break in skin integrity
  • Varies with type of surgery, anesthesia, pt. ..

43
Possible Intraoperative Complications
  • Infection
  • Break in aseptic procedure
  • Risk for the retention of foreign objects in the
    wound. Count must be accurate

44
Possible Intraoperative Complications
  • Fluid volume excess or deficit
  • The circulating nurse is responsible for
    recording ad keeping a running total of IV fluids
    administered.
  • If has an indwelling catheterurine output
    measured

45
Possible Intraoperative Complications
  • Injury Related To Positioning
  • Careful positioning and monitoring help to
    prevent interruption of blood supply and nerve
    injury secondary to prolonged pressure, nerve
    injury r/t prolonged pressure, postoperative
    hypotension, dependent edema, and joint injury
    r/t poor body alignment.

46
Possible Intraoperative Complications
  • Malignant Hyperthermia manifested by a rapid
    and progressive rise in body temperature.
  • There is an uncontrolled increase in muscle
    metabolism and heat production in response to
    stress and some anesthetic agents.
  • Symptoms tachycardia, tachypnea, cyanosis,
    fever, muscle rigidity, diaphoresis, mottled
    skin, hypotension, irregular heart rate,
    decreased urine output and cardiac arrest.

47
Possible Intraoperative Complications
  • Symptoms tachycardia, tachypnea, cyanosis,
    fever, muscle rigidity, diaphoresis, mottled
    skin, hypotension, irregular heart rate,
    decreased urine output and cardiac arrest
  • Prevention essential because the mortality rate
    is high.

48
Possible Intraoperative Complications
  • Clients at risk include those with bulky, strong
    muscles, a history of muscle cramps or muscle
    weakness and unexpected temperature elevation and
    an unexplained death of a family member during
    surgery that was accompanied by a febrile
    response.
  • If temp starts to rise rapidly, anesthesia is
    d/cd and the OR team implements measures to
    correct physiologic problems, such as fever or
    arrhythmia

49
Hypothermia
  • Nursing interventions to prevent or reverse
    hypothermia include warming intravenous fluids to
    body temperature
  • Replacing wet drapes and gowns with dry ones
  • Warming the client gradually

50
Hypothermia
  • Monitoring the clients temp and other v/s
    constantly
  • Maintaining the clients oxygenation and
    assessing the clients fluid balance.

51
Immediate Post Op
  • 1st nursing assessment made by the nurse is
    airway patency

52
Recovery Room-Post Anesthesia
  • Rapid assessment of general condition. Airway,
    vitals, LOC, drainage, suction
  • Inspect dressings, tubes, drains, IV
  • Connect drains to machines or equipment
  • Observe for shock, hemorrhage, hypoxia, vomiting
    and aspiration

53
Postoperative Complications
  • During the first 24 hours after surgery, the
    nurse closely observes the client for signs of
    hemorrhage, shock, hypoxia, vomiting, and
    aspiration.

54
Hemorrhage
  • Can be internal or external
  • Inspects dressings frequently for signs of
    bleeding and checks the bedding under the client
    because blood may pool under the body and be more
    evident on the bedding than on the dressing.

55
Hemorrhage
  • Note color of bleeding. Bright red blood is fresh
    blood..dark, brownish indicates old blood.
  • Notes the amount and color of the blood on the
    chart.
  • Reinforce dressing. Need Drs order to change.
    Mark dressing and put time. call Dr. if it
    continues.

56
Shock
  • NARCOTICS are not administered to a client in
    shock until a physician evaluates the client.
  • Should remain flat.
  • Some advocate elevation of the legs to enhance
    the flow of venous blood to the heart.

57
Hypoxia
  • Factors such as residual drug effects or
    overdose, pain, poor positioning, pooling o
    secretions in the lungs, or obstructed airway
    predispose the client to hypoxia (decreased
    oxygen).
  • O2 and suction equipment must be available for
    immediate use.

58
Hypoxia
  • Breathing may be obstructed if the tongue falls
    back and obstructs the nasopharynx
  • If this occurs, insert an oropharyngeal airway.
    Position the client on his or her side to relieve
    nasopharyngeal obstruction.
  • Restlessness, crowing, or grunting respirations,
    diaphoresis, bounding pulse, and rising blood
    pessure may indicate resp obstruction.

59
Vomiting
  • Can be caused by the anesthetics used.
  • Have emesis basin within easy reach.
  • A NG tube may be inserted
  • Antiemetics given

60
Aspiration
  • From saliva, mucus, vomitus, or blood exists
    until the client is fully awake and able to
    swallow.
  • Suction equipment must be kept at the clients
    bedside until the danger of aspiration no longer
    exists.
  • Unless contraindicated, the client is placed in a
    side-lying position until oral secretions can be
    swallowed.

61
Post-op Assessment
  • respiratory function
  • general condition
  • vitals q 15 x4 q 30 x2q hr x 4 or until stable
  • cardiovascular and fluid status
  • pain level
  • bowel and urinary elimination
  • inspect dressing, tubes, drains, IV

62
Evisceration
  • Separation of wound edges and protrusion of
    organs.
  • cover with sterile dressing moistened with
    sterile normal saline and call Dr. stat--prepare
    for surgery
  • Put in a position that puts the least strain on
    incision

63
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64
Dehiscence
  • Separation of wound edges without the protrusion
    of organs
  • Predisposing factors for evisceration
    dehiscence are malnutrition, particularly
    insufficient vitamin C and protein, defective
    suturing, unusual strain on incision (severe
    cough, sneezing, vomiting, hiccups, obesity,
    weakened abd. wall from other surgeries














































65
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66
Evisceration Dehiscence
  • Most likely to occur within 7 to 10 days
    following surgery
  • Complain of something giving away. Pinkish
    drainage may appear suddenly on dressing.
  • Surgical emergency...call Dr. stat!

67
Paralytic Ileus
  • Intestines are paralyzed and nothing moves thru.
    bowel sounds are absent, abdomen is distended and
    abdominal pain is severe. Vomiting may occur.
  • Palpate for rigidity, auscultate for bowel sounds
  • NG tube usually ordered kept NPO

68
Acute Gastric Dilatation
  • Stomach becomes distended with fluids, similar to
    ileus
  • May regurgitate small amts of liquid
  • Abdomen distended and may get shocky
  • NG tube inserted and low suction used to take out
    fluids and gas.

69
Elimination
  • May have flatus post-op as intestines manipulated
    and large amounts of air. Ambulation helps
  • May have difficulty voiding. Monitor amounts if
    voiding--if catheter monitor amount also.
  • If unable to void in 8 hours post-op call Dr.
    Assess for restlessness, lower abd. pain,
    discomfort or distention and I O

70
When to Notify Dr.
  • chills or fever
  • drainage from incision -some normal
  • foul odor or pus
  • redness, streaking, pain, or tenderness around
    incision
  • other symptoms not present when discharged
    (diarrhea, vomiting, cough, chest or leg pain

71
Important Information
  • Review standards and nursing care on page 249-252
  • Includes patient teaching and nursing care.
  • Nursing Guidelines 20-2 pg. 257
  • Nursing Guidelines 20-1 pg. 254
  • Lots of patient teaching on your board
    exams...start now so you will be ready!!
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