Mel's Perioperative Client Nursing Care
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- Describe surgery according to degree of urgency (3 categories)
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1. Emergency: immediate intervention to sustain life
2. Urgent: intervention to maintain health in situations that are not life threatening
3. Elective: nonemergent, nonurgent, prescheduled at convenience of client and the surgeon - What is ablative surgery?
- amputation of tissue (including
- Describe surgery based on expected outcomes (5 categories)
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1. Diagnostic (e.g, biopsy)
2. Reconstructive (correct a disease process or cosmetic)
3. Curative (repair or remove diseased organ or restore normal functioning)
4. Palliative (decrease the spread of disease to prolong life or alleviate pain)
5. Transplant - Describe the 4 stages of General Anesthesia Administration
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1. Induction: warm, detached floating
2. Excitement: the shakes, rapid pulse
3. Maintenance: unconscious, need to support respiratory system, where most of surgery occurs
4. Emergence: wearing off - What are the risks and side effects of general anesthesia?
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* mouth or throat pain, injury to mouth or teeth, injury to blood vessels, aspiration, pneumonia
* MEDULLARY DEPRESSION: big risk of general anesthesia--when person stops breathing - Name 2 common medications used in general anesthesia
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1. Nitrous Oxide (NO2)
2. Flourothane - Describe 8 parts of surgical asepsis
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1) sterile to sterile
2) all materials for 1 patient
3) scrubbed personnel cannot leave room
4) sterile parts of the body: front, waist shoulders
5) unscrubbed personnel stay at a distance
6) top of patient draped= sterile
7) pkages must be transported closed--edges of packages are unsterile
8) don't touch sterile field when pouring liquids - Common General Anesthetic Inhalation Agents (4 Volatile Liquids)
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1. Halothane (Flourothane, Somnothane)
2. Methoxyflurane (Penthrane)
3. Enflurane
4. Isoflurane (Forane) - Describe 4 topics to include in pre-op education
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1) What to expect intraoperative and post-op
2) mechanical devises they may require (such as incentive spirometer)
3)pain medications
4)resumption of activites (coughing, turning in bed, leg exercises, "splinting the incision") - Name 6 drugs that place surgical clients at risk
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1) ASPIRIN: increased risk of bleeding
2) ANTIDEPRESSANTS: may lower blood pressure during anesthesia
3) BROMIDE in medications (e.g., Sominex) may produce signs of dementia
4) DRUGS WITH ANTICHOLINERGIC EFFECTS: increase the potential for confusion
5) STEROIDS: suppress immunity
6) NSAIDS: increase risk of stress ulcers and displace other drugs from blood proteins - Describe 4 common respiratory complications after surgery and anesthesia
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ANESTHETIC AGENTS AND O2 HAVE A DIRECT DRYING EFFECT ON REPIRATORY MUCOSA, INCREASING THE VISCOSITY OF MUCUS--SHALLOW BREATHING DURING SURGERY AND SUPINE POSITION ALSO ADDS TO POOLING OF FLUIDS IN LUNGS.
1) pulmonary embolism: blood clot that has moved to the lungs causing obstruction
2) atelectasis: decreased ventilation caused from the pooling of secretions in dependent areas of the bronchiole
3) Pneumonia: inflammation of lung tissue
4) Hypoxemia: lowered o2 level in blood - Describe 3 common cirulatory complications after surgery and anesthesia
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ANESTHETIC AGENTS DEPRESS THE METABOLIC AND HEART RATES INCREASING THE RISK OF CIRCULATORY COMPLICATIONS
1) DVT (deep vein thrombophlebitis) inflammation of a vein with the formation of a clot
2) Thrombus: a blood clot in the circulatory system
3) Embolus: a blood clot or air that moves in the circulatory system from its place of origin - 3 reasons why turning, deep breathing, coughing, and using sprirometry helps avoid repsiratory complications
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1) promoting pulmonary circulation
2) promoting exchange of gases
3) promoting the removal of secretions - 4 SIGNS AND SYMPTOMS OF DVT
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* REDNESS OF THE EXTREMITY
* PAIN / TENDERNESS OF CALF
* SWELLING--VEINS BULGING
* HOMAN'S SIGN- PAIN ON DORSIFLEXION - INTERVENTIONS TO PREVENT POST-OP DVT
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1) ANTI-EMBOLITIC STOCKINGS
2) PNEUMONIC PRESSURE MACHINE
3) ANTICOAGULENTS
4) BED REST
5) EARLY AMBULATION AND LEG EXERCISES (CONTINUOUS PASSIVE MOTION DEVICES) - What are the 3 zones of the surgical environment
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1) unrestricted-street clothes okay
2) semi-restricted: surgical attire required; up to 2 feet from sterile fields; circulating nurse
3) restricted: surgical attire--only sterile here - Physical signs / symptoms of anxiety
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* increased heart rate
* clammy hands
* muscular tension
* behavioral manifestations, such as rapid speech and irritability - Common IV agents used for / with general anesthesia
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1) Barbituates (esp w obstetric)
2) Benzodiazepines (diazepam, midzolam)
3) Narcotics: fentanyl
4) Neuromuscular blockers (Curare derivitives--that's the jungle dart); this one is like the one they use to paralyze respirations to put someone on a ventilator - Documentation in the OR
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1) procedures performed
2) positioning/draping
3) fluid balance
4) vitals
5 instrument count - Problems in the intraoperative phase
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1) remaining in the position needed
2) anaphylaxis (reaction to anesthesia)
3) nausea/vomiting
4) respiratory depression
5) hypothermia (OR is cold b/c gases need to be cold--patients BMR--MALIGNANT HYPOTHERMIA is a reaction to anesthesia which seems to effect mostly men ages 30-50
6) Anxiety - REGIONAL VS. LOCAL ANESTHESIA
- Regional blocks nerve impulse to a specific area--local disrupts the sensation at the nerve endings
- CONSCIOUS SEDATION
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* IV
* MOST COMMON: VERSED OR VALIUM
* MAYBE USED WITH INHALATION (LOCAL; REGIONAL; SPINAL)
* WATCH FOR RESPIRATORY DEPRESSION - What 8 criteria need to be met before a post op can be transferred from PACU?
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1. uncompromised breathing (breathing on their own except for cardiac); client can clear the airway and cough effectively
2. adequate o2 sat (95-100)
3. stable vital signs within baseline ranges for 30 minutes
4. conscious, oriented "times 3", can move all extremities, full return of reflexes
5. urinary output 30mL/hr--intake adequate
6. nausea, vomiting, pain all under control
7. dressings dry with minimal drainage
8. client afebrile or febrile condition has been treated - 5 Post Operative Interventions: preventing circulatory complications
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* leg exercises q1hr
* check peripheral pulses, capillary refill, temperature, color of extremities
* encourage early ambulation
* medications such as lovenox, heparin, coumadin
* position -
5 Post Operative Interventions:
preventing respiratory complications -
* deep breathing and cough q2h with splinting
* turn/change position q 1-2h
*early ambulation
*incentive spirometer
*positioning : usually semi-fowlers--depends on type of surgery -
5 Post Operative Interventions:
monitoring stability -
* monitor vital signs, fluid i&o, maintain body temp (shivering can be from body shock, meds or fluid loss)
*promote rest/comfort with adequate pain management (epidural, pca pump)
* assess level of consciousness
* assess neuro function (lower extremity movement and sensations-especially after regional anesthesia)
* inflammatory response sometimes elevates temp slightly--monitor for dysrythmias as temp goes up) -
3 Post Operative Interventions:
Safety -
* side rails/bed in low position
* control and educate about orthostatic hypotension
* assess neuro function and level of consciousness - 5 Post Operative Interventions: Nutrition
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* listen for the reappearance of bowel sounds--elimination in 2 -3 days
* progressive diet: clears, then full liquids (milk/yogurt), then soft food, then regular diet
* stool softeners (colace)
* early ambulation for gas
* monitor i & o - 3 Post Operative Interventions: Wound Healing
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* Monitor and assess wound for discharge and healing
* Use asceptic technique for changing dressings
* Educate patient in proper positioning,"splinting" and avoiding restrictive clothing to avoid stress on suture line -
Wound Healing Complications:
Describe Dehiscence and Eviseration -
**at risk are the obese and elderly
DEHISCENCE: opening of suture line--keep moist with normal saline and call doctor
EVISCERATION: opening of suture line with viscera or other tissue coming out--normal saline and call doctor - Wound Healing Complications: signs and symptoms of infection
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* increased temperature and pulse
* increased white blood cell count
* wound swelling 3 days or more after surger
* tender, pain, reddness, purulent and foul smelling discharge - Who is at risk for post-op infection?
- elderly, abdominal surgery, diabetics, immunosuppressed, very young
- 3 Interventions for post-op infection
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1) culture the wound
2) antibiotics
3) incision and drainage - 4 Post Operative Interventions: Urinary elimination
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*assist with position (males)
* monitor for urge
* monitor for bladder distention in 8 hours
* normal 30 mL/h - 2 Post Operative Interventions: Self Concept
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* body image disturbance (amputations, mastectomy)
* promote involvement in care (ex: dressing change) - 3 Post Operative Interventions: Home Care
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* assess support system (family member/visiting nurse)
* assess limitations (stairs, ADLs, nutritional, meds)
* patient teaching: med admin, wound care, s/s of concern, o/t - Complications of Surgery: Shock (CAUSE, S/S, Prevention)
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* Caused by blood/fluid loss, stress from surgery
* S/S: pallor, cool/moist skin, cyanosis, rapid breathing and rapid weak/thready pulse, decreased b/p, decreased pulse pressure, decreased temperature
* prevention adequate fluids before, during and after surgery, cardiac stimulants, keep warm, continuous monitoring, blood replacement - Pre-op preparation
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* hygiene (scrub/shave)
* mark the area (JCAHO)
* side rails
* empty bladder
* possible medications: antacids, valium, insulin, atropine (dries up secretions), vistaril (anxiety/itching), morphine (decreases respirations, allows for less anesthesia, relax)
* IV, cath - PACU (post anesthesia care unit) assessments
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* all pre-op orders cancelled (like a brand new patient)
*airway in place until gag reflex returns
* assess respiration once extubated
* assess cirulation, possible hypotension (from fluid loss, stress, shock, meds), hemorrhage, dyrhythmias
* assess pain, hypertension (bp increases with pain), wound status, neuro status,
fluid balance (i&o, bladder distention)
* try to get patient more alert/conscious