Interventions for Preoperative Clients

Perioperative Nursing Definition of Surgery

Surgery is any procedure performed on the human body that uses instruments to alter tissue or organ integrity.

Purposes of Surgery

Diagnostic Curative Restorative Palliative surgery, which makes the

client more comfortable Cosmetic surgery, which

reconstructs the skin and underlying structures

Perioperative Nursing Types of Surgery

Degree of urgency – necessity to preserve the client’s life, body part, or body function.

Perioperative Nursing Types of Surgery (Urgency)

Emergency- performed immediately to preserve function or the life of the client.

Elective – is performed when surgical intervention is the preferred treatment for a condition that is not imminently life threatening or to improve the client’s life.

Urgent – Necessary for client’ health to prevent additional problem from developing; not necessarily an emergency.

Required – has to be performed at some point; can be pre-scheduled.

Perioperative NursingTypes of Surgery

(Degree of risk) Degree of risk – involved in

surgical procedure is affected by the client’s age, general health, nutritional status, use of medications, and mental status.

Perioperative NursingType of Surgery (Degree of Risk)

Major – involves a high degree of risk. Minor – normally involves little risk. Age – very young and elder clients are greater surgical

risks than children and adult. General health- surgery is least risky when the client’s

general health is good. Nutritional Status – required for normal tissue repair. Medications – regular use of certain medications can

increase surgical risk. Mental status – disorder that affect cognitive function

Extent of surgery – Simple and radical

Perioperative Nursing Surgical settings Surgical suites Ambulatory care setting Clinics Physician offices Community setting Homes

Perioperative Nursing Surgical settings

Disadvantages of outpatient Less time for rapportLess time to assess, evaluation, teach

Risk of potential complication post D/C.

Advantages of outpatient:Low costLow risk of infectionLess interruption of routineLess than from workLess stress

Collaborative Management Assessment History and data collection

AgeDrugs and substance useMedical history, including cardiac

and pulmonary historiesPrevious surgery and anesthesiaBlood donationsDischarge planning

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.

System Assessment

Cardiovascular system Respiratory system Renal/urinary system Neurologic system Musculoskeletal system Nutritional status Psychosocial assessment Gerontological Considerations

Preoperative Nursing Care Psychosocial considerations Level of anxiety Coping ability Support systems

Preoperative Nursing Care Gerontological Considerations

CardiovascularCoronary flow decreases

Heart rate decreasesResponse to stress decreasesPeripheral vascular decreasesCardiac output decreasesCardiac reserve decreases

Preoperative Nursing Care Gerontological Considerations

Respiratory SystemStatic lung volumes decreasesPulmonary static recoil decreases

Sensitivity of the airway receptors decreases Nervous system

Increased incidence of post.op. confusion.Increased incidence of deliriumIncreased sensitivity to anesthetic agents

Preoperative Nursing Care Gerontological Considerations

Renal SystemRenal blood flow declines 1.5% per year. Renal clearance reduced

GastrointestinalDecreased intestinal motilityDecreased liver blood flowDelayed gastric emptying

Preoperative Nursing Care Gerontological Considerations

MusculoskeletalDecreased mass, tone, strengthDecreased bone density

IntegumentaryDecreased elasticityDecreased lean body massDecreased subcutaneous fat

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

Preoperative Nursing Consent

Nature and intention of the surgery Name and qualifications of the person

performing the surgery. Risks, including tissue damage,

disfigurement, or even death Chances of success Possible alternative measures The right of the client to refuse consent or

later withdraw consent.

Deficient Knowledge Interventions

Informed consentThe 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.

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.

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.

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.

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.

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)

Preparing the Client (Continued)

Leg procedures and exercises, antiembolism stockings and elastic wraps, early ambulation, and range-of-motion exercises

Anxiety Interventions

Preoperative teaching Encouraging communication Promoting rest Using distraction Teaching family and significant

others

Preoperative Nursing Care Anxiety The nurse must consider the pt’s

family and friends when planning psychological support.

Empowering their sense of control. Activities that decreasing anxiety are deep breathing, relaxation exercises, music therapy, massage and animal-assisted therapy.

Use of medication to relieve anxiety.

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)

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.

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)

Preop Client Prep (Continued)

Client wears an identification band. Dentures, prosthetic devices,

hearing aids, contact lenses, fingernail polish, and artificial nails must be removed.

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.

Preoperative Nursing Care Medications Sedatives/hypnotics- Nembutal Tranquilizers-Ativan, versed,

valium Opiate analgesics- Demerol,

morphine Anticholinergics-Atropine

sulfate,atarax H2o blockers.- Tagamet, Zantac Antiemetic- Reglan, Phenergan

Preoperative Nursing CarePreanesthesia Management Physical Status Categories ASA 1: Healthy patient with no disease ASA 11: Mild systemic ds without fx limitations ASA 111:Severe systemic ds associated with

definite fx limitations ASA 1V: Severe systemic ds that is a constant

threat to life. ASA V: Moribund pt. Who is not expected to

survive without the operation. ASA V1: A declared brain-death whose organ

are being recovered for donor. E: Emergency

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

Perioperative Nursing Care Surgical team

Nursing Roles:Staff educationClient/family teachingSupport and reassuranceAdvocacyControl of the environmentProvision of resourcesMaintenance of asepsisMonitoring of physiologic and psychological

status

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

Intraoperative Nursing Care Surgical asepsis Ensure sterility Alert for breaks

Intraoperative Phase Anesthesia

Greek word- anesthesis, meaning “negative sensation.” Artificially induced state of partial or total loss of sensation, occurring with or without consciousness.

Blocks transmission of nerve impulses Suppress reflexes Promotes muscle relaxation Controlled level of unconsciousness

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

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.

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

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)

Balanced Anesthesia (Continued)

Example: thiopental for induction, nitrous oxide for amnesia, morphine for analgesia, and pancuronium for muscle relaxation

Complications from General Anesthesia Malignant hyperthermia: possible

treatment with dantrolene Overdose Unrecognized hypoventilation Complications of specific

anesthetic agents Complications of intubation

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.

Local Anesthesia

Topical anesthesia Local infiltration Regional anesthesia

Field blockNerve blockSpinal anesthesiaEpidural anesthesia

Complications of Local or Regional Anesthesia

Anaphylaxis Incorrect delivery technique Systemic absorption Overdosage

(Continued)

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.

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.

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)

Conscious Sedation (Continued)

Nursing assessment of airway, level of consciousness, oxygen saturation, electrocardiographic status, and vital signs are monitored every 15 to 30 minutes.

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

Risk for Perioperative Positioning Injury

Interventions include: Proper body position Risk for pressure ulcer formation Prevention of obstruction of

circulation, respiration, and nerve conduction

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

Potential for Hypoventilation

Continuous monitoring of:BreathingCirculationCardiac rhythmsBlood pressure and heart rate

Continuous presence of an anesthesia provider

Interventions for Postoperative Clients

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.

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.

Respiratory System

Airway assessment Breath sounds Other respiratory assessments

Cardiovascular Assessment

Vital signs Cardiac monitoring Peripheral vascular assessment

Neurologic System Cerebral functioning Motor and sensory assessment important

after epidural or spinal anesthesiaMotor function: simple commands; client

to move extremitiesReturn of sympathetic nervous system

tone: gradually elevate head and monitor for hypotension

Fluid, Electrolyte, and Acid-Base Balance

Check fluid and electrolyte balance. Make hydration assessment. Intravenous fluid intake should be

recorded. Assess acid-base balance.

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.

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.

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)

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.

Skin Assessment Normal wound healing Ineffective wound healing: can be seen

most often between the 5th and 10th days after surgeryDehiscence: a partial or complete

separation of the outer wound layers, sometimes described as a “splitting open of the wound.”

(Continued)

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.

Postoperative Phase

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.

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

Impaired Skin IntegrityInterventions 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)

Impaired Skin Integrity (Continued)

Drug therapy including antibiotics and irrigations are used to treat wound infection.

Surgical management is required for wound opening.

Acute Pain

Interventions include: Drug therapy Complementary and alternative

therapies such as:PositioningMassageRelaxation and diversion

techniques

Potential for Hypoxemia

Interventions include: Maintenance of airway patency and

breathing pattern Prevention of hypothermia Maintenance of oxygen therapy as

prescribed

Health Teaching

Prevention of infection Dressing care Nutrition Pain medication management Progressive increase in activity

level Use of proper body mechanics