Mel's Perioperative Client Nursing Care

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Describe surgery according to degree of urgency (3 categories): 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): 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: 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?: * 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: 1. Nitrous Oxide (NO2)
2. Flourothane
Describe 8 parts of surgical asepsis: 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): 1. Halothane (Flourothane, Somnothane)
2. Methoxyflurane (Penthrane)
3. Enflurane
4. Isoflurane (Forane)
Describe 4 topics to include in pre-op education: 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: 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: 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: 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: 1) promoting pulmonary circulation
2) promoting exchange of gases
3) promoting the removal of secretions
4 SIGNS AND SYMPTOMS OF DVT: * REDNESS OF THE EXTREMITY
* PAIN / TENDERNESS OF CALF
* SWELLING--VEINS BULGING
* HOMAN'S SIGN- PAIN ON DORSIFLEXION
INTERVENTIONS TO PREVENT POST-OP DVT: 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: 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: * increased heart rate
* clammy hands
* muscular tension
* behavioral manifestations, such as rapid speech and irritability
Common IV agents used for / with general anesthesia: 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: 1) procedures performed
2) positioning/draping
3) fluid balance
4) vitals
5 instrument count
Problems in the intraoperative phase: 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: * 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?: 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: * 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: * 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: * 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: * 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: 1) culture the wound
2) antibiotics
3) incision and drainage
4 Post Operative Interventions: Urinary elimination: *assist with position (males)
* monitor for urge
* monitor for bladder distention in 8 hours
* normal 30 mL/h
2 Post Operative Interventions: Self Concept: * body image disturbance (amputations, mastectomy)
* promote involvement in care (ex: dressing change)
3 Post Operative Interventions: Home Care: * 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): * 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: * 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: * 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

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