Care of the Preoperative & Post Operative Client

NUR 102

Central Maine Medical Center College of Nursing & Health Professions Professions
Spring 2012
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Objectives
By the end of this presentation you will be able to:
Use the nursing process as a framework for providing individualized care. Incorporate individualized risk factors when developing a perioperative care plan. Describe the legal accountability regarding surgical consent. Identify safety concerns for the postoperative client and prioritize nursing interventions. Develop a client teaching plan. Describe the rationale for therapeutic interventions to prevent postoperative complications. Identify complementary and /or alternative care measures that could promote healing and wellness. Perform a nursing assessment of the perioperative client

Resources Lewis :Ch 18 and 20 Lilley Chapter 12

Wilkinson, J., Treas Chapter 37

History of Surgery

Trepanation

www.personal.psu.edu

Perioperative Nursing

Preoperative

Postoperative Intraoperative

Categories of Surgery
Seriousness Major- Significant risk Anesthesia Minor- Without Significant risk often w/o Anesthesia Urgency Elective- Planned for non-acute problem..client choice Urgent- Prompt intervention May be life threatening if delayed 24-48 hours Emergency-Immediate intervention Life threatening Extent Simple- Area obviously involved Radical- Beyond area obviously involved Root Cause

Categories of Surgery
Purpose
Diagnostic- Determine disease origin and cause Cure- Elimination or removal of pathology Palliation- Relieve symptoms Does not cure Cosmetic- Alter or enhance physical appearance Exploration- surgical examination to determine cause of disease.. Prevention- ie removal of a mole before it becomes cancerous. Procurement- Organ removal for transplant

Ambulatory vs Inpatient Surgery?

Patient Interview
Check documented information prior to interview
Avoids repetition

Occurs in advance or on day of surgery Purpose

Obtain health information Determine expectations Provide and clarify information on procedure Assess emotional state and readiness

Nursing Assessment
Overall goal 1. Identify risk factors 2. Plan care to ensure patient safety Determine psychological status to reinforce coping strategies Determine psychological factors of procedure contributing to risks Establish baseline data Identify medications and herbs taken that may affect surgical outcome Identify, document, and communicate results of laboratory/diagnostic tests Identify cultural and ethnic factors that may affect surgical experience Determine receipt of adequate information from surgeon in order to sign informed consent

Assessment and Preoperative Care

Surgical Risk factors Age > 65 Medications- NSAIDS, Antihypertensives, Anticoagulants Medical HX- Immunity, Diabetes, COPD, Cardiac Disease, Hemodynamic Instability, Chronic disease etc Prior Surgery- Emotional, Anesthesia issues, Post-op complications Health HX- Nutrition/Obesity, Meds, Tobacco, etOH, Coping issues Family HX- Malignant Hyperthermia, Bleeding Type of SurgeryNeck/oral/face, Chest/Upper Abdomen, Abdominal

Assessment and Preoperative Care

Physical examination
Cardiovascular Status- 30% of Surgical deaths Respiratory Integument Renal- Dysuria painful, Nocturia night, Oliguria <400
ml/day

Neurological Nutritional Psychosocial

Anxiety, ability to learn

Review Table 18-5 in Lewis for Physiological Assessment of the Perioperative Patient

Baseline vitals, Anxiety

Diagnostics- Labs DiagnosticsComplete blood count (CBC) WBC 4500-11000 cells/mm3 Platelets 150-450 x 103/mm3 Hemoglobin 13.2-17.3g/dL 11.7-15.5 g/dL Hematocrit 43-49% 38-44% Serum electrolytes K+ 3.5-5 mEq/L, Na+ 135-145 mEq/L, Cl- 90-110 mEq/L Coagulation studies PT 10-13s, INR <2 , PTT 25-39s Serum creatinine 0.5-1.1 mg/dL Blood urea nitrogen (BUN) 10-20mg/dL Glucose 70-110 mg/dL

Diagnostics- Test DiagnosticsDiagnostic screenings

X-rays ECGs CT scans MRIs Others

Preoperative Nursing DX
Nursing diagnosis
Anxiety Knowledge deficit Disturbed sleep Ineffective Coping Anticipatory Grief Disturbed Body Image Disabled Family Coping Powerlessness

Planning
Planning- Knowledge Deficit Client will:

Explain purpose and expected results Ask Q? When term or procedure is not known Follow NPO requirements State understanding of pre-op prep Explain and Demonstrate the Correct use of Devices after surgery

Interventions/Implementation
Review Planned Surgery Client HX Complete Physical Assessment Explain describe preadmission TX and DX test Interpret labs/DX test as appropriate Provide time for Q and A Discuss post-op DC plans Care taker ability Review IS, Pneumatic compression devices, Vents, ROM, ambulation expectations, cough/deep breath, tubes and lines

Informed Consent- Tell me about it

Consent for surgery

Informed consent must include Adequate disclosure Understanding and comprehension Voluntarily given consent Surgeon responsible for obtaining consent Nurse may obtain and witness signature Verify patient has understanding Permission may be withdrawn at any time Medical emergency may override need for consent

Planning/Interventions
Planning- Anxiety Client will:
Express reduced anxiety Will show reduced objective signs of anxiety

Interventions
Preoperative Teaching Encourage Communication Promote rest Distraction Family Teaching

Evaluation Before you ship them out Evaluation

Successfully evaluate the client see if they

1. can state an understanding of informed consent and preoperative procedures. 2. can demonstrate postoperative exercises and techniques for the prevention of complications. 3. have reduced anxiety

Postoperative Care
Immediate care: PACU Surgical information Nursing assessments Interventions Discharge criteria: ambulatory and acute care surgical settings

Postoperative Care When Your patient ends up on the Medical-Surgical Unit MedicalOverall assessment
Airway Breathing Mental Status Surgical Incision site Vitals- Temperature, Pulse, BP IV Fluids Tubes Foley, NG, Drains, Chest tubes does the drainage look like?

What

Postoperative Assessment
Respiration Circulation Temperature control Fluid and electrolyte balance Neurological function Skin integrity and wound condition Genitourinary function Gastrointestinal function Comfort Client expectations

Assessment Issues
Respiratory complications
Atelectasis Pneumonia Hypoxemia Pulmonary embolism

Assessment Issues
Circulatory complications
Hemorrhage Hypovolemic shock Thrombophlebitis Thrombus formation Embolus

Assessment Issues
Gastrointestinal complications
Abdominal distention Paralytic ileus Nausea and vomiting Urinary retention Urinary tract infection

Assessment Issues
Integumentary complications
Wound infection Dehiscence Evisceration Skin breakdown

Pain
Pain Control techniques Rating and TX

Nursing diagnoses
Impaired Gas Exchange Risk for aspiration Impaired skin integrity Acute pain Other Nursing Diagnosis?

Planning Impaired Gas Exchange

Expected Outcomes PaO2 in normal range ??? What is the difference between PAO2 and PaO2 PaCO2 in normal range O2 Saturation in normal range

Airway Interventions
Maintaining respiratory function
Positioning and turning Suctioning Deep breathing (incentive spirometer), coughing Comfort Early ambulation Oral hygiene Oxygen

Interventions
Preventing circulatory stasis
Leg exercises TED stockings Early ambulation Positioning Anticoagulants Fluid intake

Interventions
Achieving rest and comfort
Analgesics PCA Pain assessment Complimentary / Alternative Therapies 1. Positioning 2. Massage 3. Relaxation and Diversion Maintaining fluid and electrolyte balance IV therapy Oral intake when appropriate

Interventions
Temperature regulation
Warmed blankets Monitoring for hypothermia and malignant hyperthermia- Dantrolene sodium Assessment for signs of infection

Neurological function
Orientation to the environment Level of consciousness

Interventions
Promote normal elimination & adequate nutrition
Gradual progression of dietary intake Ambulation and exercise Adequate fluid and food intake Elimination aids: fiber, medications Control of nausea and pain

Interventions
Promoting urinary elimination
Normal positioning Frequent assessment Assessment of bladder distention I&O

Promoting wound healing

Protect surgical site Prevent strain on wound Observe healing process Provide wound care

Interventions
Maintaining/enhancing self-concept
Provide privacy Maintain clients hygiene Prevent drainage devices from overflowing Maintain a pleasant environment Offer opportunities for client and family to express feelings and participate in care

Evaluation
Outcomes
Maintains adequate lung expansion and respiratory function Has complete wound healing without complications Has acceptable comfort level after surgery

Review
Use the nursing process as a framework for providing individualized care. Incorporate individualized risk factors when developing a perioperative care plan. Describe the legal accountability regarding surgical consent. Identify safety concerns for the postoperative client and prioritize nursing interventions. Develop a client teaching plan. Describe the rationale for therapeutic interventions to prevent postoperative complications. Identify complementary and /or alternative care measures that could promote healing and wellness. Perform a nursing assessment of the perioperative client

Conscious Sedation

Objectives
By the end of this presentation the student will: Identify safety concerns for the postoperative client and prioritize nursing interventions. Discuss the pharmacologic management and nursing implications for perioperative clients. Perform a nursing assessment of the perioperative client .

Conscious sedation
Procedural sedation is a clinical technique that creates a decreased level of awareness for a patient yet maintains protective airway reflexes and adequate spontaneous ventilation. The goals of procedural sedation are to provide analgesia, amnesia, and anxiolysis during a potentially painful or frightening procedure. To keep things simple Two pharmacologic agents may used in procedural sedation sedatives and analgesics. Using a combination of a sedative/analgesic provides a synergistic combination that generally gives consistent clinical results

Levels of Sedation (4 Total)

Sedation occurs in a dose-related continuum, is variable, and depends on pts response to various drugs. Minimal Sedation (Anxiolysis): Reduce or eliminate pain and anxiety in a conscious patient. The patient responds normally to verbal commands. Cognition and coordination may be impaired, ventilatory and cardiovascular functions are unaffected. Moderate Sedation and Analgesia (conscious sedation): A depressed level of consciousness patient responds purposefully to verbal commands & is able to maintain a airway. Cardiovascular function is usually maintained.
Patients At risk for progressing to deep sedation and losing protective reflexes.

Levels of Sedation cont cont

Deep Sedation and Analgesia: A state of depressed consciousness. The patient is not easily aroused will respond purposefully to repeated or painful stimulation.
Significant risk of partial or complete loss of protective reflexes

General Anesthesia: Drug induced loss of consciousness during which patients are not arousable, even by painful stimulation.
Airway, ventilation, and cardiovascular stability may require support.

Minimum competencies for an RN who administers sedatives or monitors a patient receiving sedation
Certified Advanced Cardiac Life Support (ACLS) Completion of Sedation training Knowledge of medications used for moderate and deep sedation, including common doses, administration, and interventions for adverse reactions; Recognition of and intervention for a compromised airway; Assessing patient care needs or parameters, including but not limited to respiratory rate and depth, oxygen saturation, blood pressure, heart rate, and level of consciousness; Ability to intervene in the event of complications.

Pre-Sedation Protocol PrePatients acceptable for nurse-monitored sedation and analgesia should be in good general health and have adequate ventilatory reserve. History and physical performed by physician, including an assessment of the airway when deep sedation is anticipated Vital signs: heart rate, blood pressure, respiratory rate, and oxygen saturation Height and weight Current medications , allergies, and reactions to anesthesia Smoking, alcohol, and substance abuse history Verification of NPO status Documentation of informed consent

American Society of Anesthesiologist Physical Status Classification

Class I A normal healthy patient. Class II A patient with mild systemic disease that results in no functional limitation. Ex: Well controlled hypertension, diabetes mellitus, and chronic bronchitis.

Class III A patient with severe systemic disease that results in functional limitation. Ex: Poorly controlled hypertension, pulmonary disease that limits activity, morbid obesity. Class IV A patient with severe systemic disease that is a constant threat of life. Ex: Uncompensated congestive heart failure, advanced pulmonary, renal, or hepatic dysfunction. Class V A patient who is not expected to survive without the operation. Ex: Ruptured abdominal aortic aneurysm. Head injury with increased ICP

Medications for Pain Control

Drug Duration Onset/Peak Minimal suggested dosage

Morphine

4-5 h

2-5 min / 30min

25mg IV over 5 min; repeat q 5 min with 2-5 mg increments 2550mcg IV over 2 min; repeat q 5 min with 10-15 mcg increments to a max of 500 mcg in 4h

Fentanyl (Sublimaze)

30-60 min

1 min / 5-7 min

Meperidine (Demerol)

14h

2 min / 5-15 min

25-50mg over 2 min; repeat q 5 min with 10-15 mg increments to a max dose of 150mg

Medications for Sedation

Drug Diazepam (Valium) Midazolam (Versed) Duration 15-60 min Onset/Peak Minimal suggested dosage 15 min / 1-5 min 0.52mg IV over 2 min; repeat q 5 min with 0.5 mg increments to 5mg total. 15 min / 25mg IV over 5 min; Immediate repeat q 5 min with 2 mg increments to 10 mg total. 5 min / 10-15 min 0.52mg IV (Slow) 4mg max 40 sec / unk Bolus dose not recommended

2-6 h

Lorazepam Propofol

6-8 h 3-5 min

Reversal Agents
Drug Duration Onset/Peak Minimal suggested dosage 0.2 mg IV over 15 sec; repeat q 1 min to a max of 1 mg. 0.02 mg 0.04 mg IV over 30 sec; repeat q 1 min intervals max of 10 mg

Flumazenil 45-90 (Romazicon) min varies Naloxone (Narcan) 1-4 h varies

12 min / 610min

2 min / 5-15 min

Recovery Client reaches pre-procedure status Recovery preor Aldrete Score 9 (Numbers may vary by institution)

Review
Safety concerns for the postoperative client and prioritize nursing interventions. Pharmacologic management and nursing implications for perioperative clients. Nursing assessment of the perioperative client .