Spring 2020 Med Surg First Exam Focus on Preoperative Care 2017 Hospital National Patient Safety Goals The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems in health care safety and how to solve them. Identify patients correctly, improve staff communication, use medicine safely, use alarms safely, identify patient safety risks, prevent infection, prevent mistakes in surgery. Purposes of surgery Diagnosis- exploration, cure, prevention Pallation- cosmetic improvement (colostomy bag, bad burns repair is included here) The Three surgical phases Preoperative phase Intraoperative phase Postoperative Nursing Management of the Surgical Client Knowledge of the nature of the disorder Determine client’s response to the stress of surgery. Assess the results of preoperative diagnostic tests. Client Interview Purpose Check documented information prior to interview Avoids repetition Occurs in advance or on day of surgery Assessment Health history & physical Familial diseases (maligned hyperthermia) Diagnosed medical conditions (previous and current) Previous surgeries and problems Menstrual/obstetric history Medication History Drug intolerance and allergy Diagnostic Testing Subjective Psychosocial assessment Influencing factors Fears, Pain, Hope ANXIETY Anxiety can arise from: Lack of knowledge, and Unrealistic expectations Information lessens anxiety. BASELINE VITALS ARE VERY IMPORTANT Cardiovascular system Report: preexisting disease/problem- have an ecg attaches during surgery Blood pressure, HR, listen to heart, capillary refill, check/inspect legs- checking pulse, edema, check perfusion Any cardiac problems so they can be monitored during the intraoperative period Use of cardiac drugs Presence of pacemaker/ICD (Implantable Cardioverter Defibrillator) Respiratory System Listen to breaths sounds, watch respirations, clubbing, and capillary refill History of dyspnea (difficult breathing), coughing, or hemoptysis (bloody phlegm) reported to operative team COPD or asthma High risk for atelectasis and hypoxemia Smokers Nervous System Baseline, LOC Evaluation of neurologic functioning Vision or hearing loss can influence results. Cognitive function Determine if any deficits are present. Genitourinary System CVA tendency, I and O, Palpate bladder, check Cath History of urinary or renal disease LAB TESTS- Serum creatine, blood urea, nitrogen (BUN) Renal dysfunction leads to altered drug response/ drug elimination Hepatic System Jaundice Liver involved is involved with glucose homeostasis, fat metabolism, and bilirubin formation and secretion Hepatic dysfunction may increase risk of postoperative complications. Increase risk for clotting abnormalities and adverse response Can’t break down drugs Integumentary system Inspect patients’ skin History of skin and musculoskeletal problems History of pressure ulcers Musculoskeletal system Arthritis Cannot flex lumbar spine Endocrine system Clients with diabetes mellitus especially at risk for delay wound healing Clients with thyroid dysfunction change in metabolism Clients with adrenal insufficiency (Addison’s disease) shock can occur, and are horrible healers Immune system Clients with history of compromised immune system or use of immunosuppressive drugs can have delay wound healing Fluid & electrolyte status Watch for dehydration and overhydration Use of diuretics evaluate serum electrolyte levels NPO status Critical assessment for older adult because there is a narrow margin of safety between overhydration and underhydration Nutritional status Obesity- stresses heart and lungsUnderweight- won’t heal as well- no backup Dietary habits that may affect recovery (ex. Caffeine) Nursing Management The Joint Commission (TJC) requires a history and physical Preoperative teaching Client has right to know what to expect and how to participate. Limited time available Address needs of highest priority. Teach deep breathing, coughing, incentive spirometry (IS) & early ambulation as appropriate Pain management plan Practice pain assessment scale Discuss coping strategies for anxiety relief Post op tubes, drains, etc. Surgery-specific information Support family of client as part of the client system Basic information before arrival • Time and place • Fluid and food restrictions • Need for shower Legal preparation All required forms are signed and in chart: Informed consent Blood transfusions Advance directives Power of attorney 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. Consent for surgery Medical emergency may override need for consent. Legally appointed representative of family may consent if client is: A minor, Unconscious, and Mentally incompetent Day-of-surgery preparation: Final preoperative teaching, Assessment and report of pertinent finding, Verify signed consent., Labs, History and physical examination, Baseline vitals, Consultation records, Nurse’s notes (documentation) Day-of-surgery preparation Client should not wear any cosmetics. Dentures, contacts, prostheses are removed Identification and allergy bands on wrist Void before surgery Prevents involuntary elimination under anesthesia or during early postoperative recovery Before medication administration CLASS DRUG PURPOSE AND EFFECTS Antibiotics cefazolin (Ancef) Prevent postoperative infection Anticholinergics atropine (Isopto Atropine) ↓ Oral and respiratory secretions scopolamine (TransdermScop) Prevent nausea and vomiting Antidiabetics insulin (Humulin R) Stabilize blood glucose Antiemetics metoclopramide (Reglan) ↑ Gastric emptying ondansetron (Zofran) Prevent nausea and vomiting midazolam (Versed) Benzodiazepines diazepam (Valium) ↓ Anxiety, induce sedation, amnesic effects lorazepam (Ativan) Beta blockers labetalol (Normodyne) Manage hypertension Histamine (H2)-receptor antagonists famotidine (Pepcid)ranitidine (Zantac) ↓ HCl acid secretion, ↑ pH, ↓ gastric volume morphine (Duramorph) Relieve pain during preoperative procedures Opioids fentanyl (Sublimaze) Focus on intraoperative care Nursing care in the OR requires understanding of: Anesthesia Pharmacology Surgery~WHY?? Surgical interventions- you are the advocate for the patient who is not awake. (The Perioperative nurse) Holding area- outside the OR Surgical Care Improvement Project (SCIP) measures to implement here Drug administration (start IV) Patient warming Application of sequential compression devices (SCDs) Minor procedures National Patient Safety Goals (NPSGs) require a preprocedure verification process, including: Verification of relevant documentation Required blood products and equipment Diagnostic and radiology test results Procedure site marked Surgical suit Provides: Controlled environment Designed to minimize spread of infection Allows smooth flow of clients, personnel, and instruments/equipment Divided into 3 distinct areas: The unrestricted area Locker room Information areas Nursing station Control desk Holding area Waiting area inside or adjacent to surgical area Friends/family allowed The semirestricted area The restricted area Operating rooms Scrub sink areas Sterile environment Scrubbing, gowning, gloving Standard procedure for personnel Waterless products are sometimes used. Sterile gown and gloves are put on after scrub. Head cover, shoes cover All materials in contact with wound or used within sterile field, must be sterile Movements Watched by circulating nurse. Sterile only contact with sterile Cannot turn back One foot away from table is sterile Sterile field monitoring/maintenance Breach- contamination Operating room Positive air pressure- help movement of air so no air outside comes in UV lighting- prevents dust Role of Scrub Nurse- does not have to be a RN, could be a scrub tech Follows designated scrub procedure Gowned and gloved in sterile attire Remains in sterile field Role of Circulating Nurse Not scrubbed, gowned, or gloved Remains in unsterile field Documents Traffic controller- watching movement Counting sponges how many goes in must come out Role of Surgeon Physician who performs the procedure is responsible for: Preoperative medical history Postop management Surgical team Anesthesia care provider (ACP) Administers anesthesia at head of the bed (not sterile) Maintenance of physiologic homeostasis throughout intraoperative period Assisting anesthesia care provider Understand mechanism of anesthetic administration and pharmacologic effects of the agents. Know location of emergency equipment and drugs in the OR Positioning of client Prevent pressure on nerves, skin, bony prominences, or eyes. Provide for adequate thoracic excursion. Prevent injury supine and prone Prevent occlusion of arteries and veins Maintain airway Classification of Anesthesia Loss of sensation with loss of consciousness May be induced (adjunct drug) by IV or inhalation Combination of hypnosis, analgesia, and amnesia Skeletal muscle relaxation Possible impaired ventilatory and cardiovascular function Elimination of coughing, gagging, vomiting, and sympathetic nervous system responsiveness IV agents Beginning of virtually all general anesthesia TIVA (Total IV anesthesia) Monitored anesthesia care (MAC)- breathing on own Clients remain responsive and breathe without assistance sedatives (e.g., benzodiazepines) and opioids are used but at a lower dosage- able to follow commands (endoscopy) Inhalation agents: Easy administration and rapid excretion Irritating to respiratory tract Once initiated, use endotracheal tube or LMA (laryngeal mask airway) Rarely use only one agent Adjuncts Opioids Benzodiazepines- antianxiety Antiemetics- vomiting Neuromuscular blocking agents- skeletal muscle Facilitate endotracheal intubation Relaxation/paralysis of skeletal muscles Interrupt transmission of nerve impulses at neuromuscular junction Dissociative anesthesia Ketamine (Ketalar)- children/ people with asthma widely used intravenous drugs for inducing and maintaining anesthesia not related chemically, but both have short durations and can induce anesthesia rapidly. People wake up a little crazy. PROTOTYPE DRUG Midazolam ( Versed) Classification: Therapeutic: Antianxiety agent, anesthetic Pharmacologic: Benzodiazepine, gamma amino butyric acid ( GABA) receptor agonist Therapeutic Effects and Uses: midazolam is administered to reduce the anxiety and stress associated with surgery. Mechanism of Action: act at the limbic, thalamic, and hypothalamic region of the brain to produce CAN depression and skeletal muscle relaxation PROTOTYPE DRUG: Propofol ( Diprivan) Therapeutic: General anesthetic Pharmacologic: N-methyl-D-aspartate (NMDA) receptor agonist Therapeutic Effects and Uses: indicated for the induction and maintenance of general anesthesia Mechanism of Action: exact mechanism by which propofol produces anesthesia is not clear Endotracheal (ET) Tube/LMA LMA ET Use of atropine to clear up spit to make it easier to put the ET/LMA Local anesthesia Loss of sensation without loss of consciousness Types Topical Ophthalmic Nebulized lungs Injectable Regional anesthesia Blocks ANS response- so watch the vitals- hypotension, bradycardia Loss of sensation in body region without loss of consciousness Specific nerve or group of nerves is blocked by administration of local anesthetic May assist in administration Detailed assessment History with local anesthetics Allergies Regional Nerve Block Inject agent into or around specific nerve or group of nerves assist in client positioning, monitoring vital signs during block delivery, administering oxygen therapy, and obtaining supporting devices Methods of administration Spinal anesthesia- cant get up for 24 hours- or an awful headache Injection of agent into CSF of subarachnoid space Usually below L2- Autonomic, sensory, and motor blockade Epidural block Injection of agent into epidural space Does not enter CSF Binds to nerve roots as they enter/exit the spinal cord Sensory pathways blocked,motor fibers intact Spinal and epidural anesthesia Observe closely for signs of autonomic nervous system (ANS) blockade: Bradycardia, Hypotension, and Nausea/vomiting Highly potent~smaller dose Gerontologic Considerations Key predictors of perioperative complications are preoperative condition & level of function Reduced cardiac output & limited cardiac reserve make client more vulnerable to changes in circulating volume & blood oxygen level Anesthetic drugs should be carefully titrated Physiologic changes in aging- pitting edeama, osteroprosis Assess for poor communication. Perioperative hypothermia Catastrophic Events in the OR Anaphylactic reactions Manifestation may be masked by anesthesia. Vigilance and rapid intervention are essential. Malignant hyperthermia Rare metabolic disease Hyperthermia with rigidity of skeletal muscles Focus on Postoperative Care Care in the Postanesthesia Care Unit (PACU) Phase I Care during the immediate postanesthesia period ECG and more intense monitoring Goal: Prepare client for transfer to Phase II or inpatient unit Phase II Ambulatory surgery clients Goal: Prepare client for transfer to extended observation, home, or extended care facility Rapid PACU progression Fast tracking Potential Problems in the Postoperative Period Potential Respiratory Problems The most common causes of airway compromise are a tongue Clients at risk: have lung disease, are obese, undergo thoracic, airway, or abdominal surgery Airway obstruction Potential Respiratory Problems Atelectasis Most common cause of postoperative hypoxemia May result from bronchial obstruction from retained secretions or decreased respiratory excursion Low oxygen in the tissues- np oxygen exchange Pulmonary edema Aspiration of gastric contents Bronchospasm- irritation Hypoventilation- not waking up fast enough Assessment Evaluate symmetry, respiration, listen to their lungs Auscultate breath sounds anteriorly, laterally, and posteriorly. Notify ACP of crackles (fluids) or wheezes (bronchospasm). Nursing diagnoses Ineffective airway clearance, Ineffective breathing pattern, Impaired gas exchange, and Risk for aspiration Potential complication: Hypoxemia, Potential complication: Pneumonia, and Potential complication: Atelectasis Nursing implementation Lateral position unless contraindicated When conscious client allowed in supine position with HOB elevated Provide oxygen therapy Encourage deep breathing to facilitate gas exchange and promote return to consciousness Diaphragmatic or abdominal breathing Provide adequate and regular analgesics. MANIFESTATIONS OF INADEQUATE OXYGENATION If all other vital signs are okay wake them up, to make them deeply breath. Central Nervous System: Restlessness, Agitation, Muscle twitching, Seizures, Coma Cardiovascular System: Hypertension, Hypotension, Tachycardia, Bradycardia, Dysrhythmias, delayed capillary refill, Decreased oxygen saturation Integumentary System: Flushed and moist skin, Cyanosis Respiratory System Increased to absent respiratory effort, Use of accessory muscles, Abnormal breath sounds, Abnormal arterial blood gases Renal System Urine output <30 ml/hr Potential Cardiovascular Problems Most common complications: Hypotension, Hypertension, and Dysrhythmias Those at greatest risk respiratory problems, cardiac, older or critically ill Hypotension: Low BP with a high pulse. No blood to vital organs. Most common cause is unreplaced fluid and blood loss. Other causes include dysrhythmias, decreased systemic vascular resistance, and measurement errors. Hypertension: Results from sympathetic stimulation from anxiety, pain, and a full bladder (care at 500mL) (Know how much urine in the bladder with a bladder scan or palpate). May result from hypothermia or preexisting hypertension Dysrhythmias: Often a result of an identifiable cause other than myocardial injury. Leading causes: Hypokalemia, hypoxemia, alterations in pH balance, circulatory instability, or preexisting heart disease Potential Cardiovascular Problems Clinical unit Postop fluid and electrolyte imbalances contribute to CV problems. Fluid retention results from hormone secretion and release~ ADH; ACTH & renin-angiotensin-aldosterone system. Caused by fluid overload or fluid deficits Hypokalemia- Occurs because GI loss, diuretics, K+ not replaced Tissue perfusion or blood flow affects CV status. Venous thromboembolism (VTE) pulmonary embolism. (do you use an anticoagulant to prevent this? One may bleed out if you do) Accurate I/O records IV management is critical. Early ambulation Prevention of VTE Slow changes in client’s position Syncope Nursing assessment Frequently monitor vital signs. - Systolic <90 mm Hg or >160 mm Hg Pulse <60 or >120 beats per minute Gradual increases in BP Compare with baseline. Assess apical-radial pulse carefully, and report irregularities. With a patient with AFIB tale the atrial and radial pulse at the same time Assess skin color, temperature, and moisture Potential Cardiovascular Problems Nursing diagnoses Decreased cardiac output, Deficient fluid volume, Excessive fluid volume, Ineffective peripheral tissue perfusion, and Activity intolerance Collaborative problems: Potential complication: Hypovolemic shock and Venous thromboembolism Nursing implementation Treatment of hypotension begins with oxygen therapy. BP and volume status assessed IV boluses to normalize BP Hypertension Address and eliminate cause of SNS stimulation. Rewarm: Corrects hypothermia-induced hypertension Dysrhythmia Treat identifiable causes. Potential Neurologic Problems Emergence delirium~ waking up wild, (or violent emergence) Can induce restlessness, agitation, disorientation, thrashing, and shouting Delayed emergence Commonly caused by prolonged drug action. Obese people will have the anesthesia in the adipose tissue Clinical unit Postoperative cognitive dysfunction- Elderly, fluid and electrolyte imbalance Delirium Can arise from a variety of psychologic and physiologic factors Anxiety, depression Alcohol withdrawal delirium Neurologic Complications Nursing assessment LOC- Orientation, Memory, and Ability to follow commands Size, reactivity, and equality of pupils Sleep/wake cycle Sensory and motor status Nursing diagnoses Disturbed sensory perception, Risk for injury, Acute confusion, Impaired verbal communication, Anxiety, Ineffective coping, Disturbed body image, and Fear Nursing implementation Attention on evaluation of respiratory function Hypoxemia most common cause of postoperative agitation. Sedation may be beneficial for controlling agitation and providing safety. Safety concerns Monitor physiologic status. Clinical unit Maintain normal physiologic function. Orient the client. Limit psychologic problems. Discuss expectations. Pain and Discomfort Result of: Trauma from surgery, Reflex muscle spasms, Anxiety/fear, Positioning (Internal devices), Deep breathing, coughing, ambulating Deep visceral pain may signal complications Can contribute to complications such as: dysfunction of the immune and coagulation systems. Delay return to normal gastric function Increase risk of atelectasis and impaired respiratory function Nursing assessment Self-report is best indicator If not possible, look for other indications of pain Identify location. Nursing diagnoses: Acute pain, and Anxiety Nursing implementation: IV opioids ~most rapid relief, Epidural catheters, PCA, or regional anesthetic blockade, NSAIDs (risk of bleeding), and Comfort measures Do not wait until pain is present try to get patients to take medicine when they can have it instead of waiting for the pain SIGNIFICANCE OF POSTOPERATIVE TEMPERATURE CHANGE we cut you open the body’s response is the inflammatory response which includes a fever. Not okay if it lasts for four days Hypothermia Core temperature <95.0º F Loss of heat due to use of cold irrigants and unwarmed inhaled gases Increased risk associated with the older adult and the intoxicated Complications: Compromised immune function Postoperative pain and shivering Increased bleeding Untoward cardiac events Altered drug metabolism Impaired wound healing Fever if patient has infection fever, WBC, and C reactive protein is increased Wound infection Respiratory tract infection Urinary tract infection Superficial thrombophlebitis Clostridium difficile Septicemia Nursing Management Altered Temperature Nursing assessment Vital signs: Oral, tympanic, or axillary temperature, and Assess color and temperature of skin. Signs of inflammation Risk for imbalanced body temperature: the young, the old and the skinny Nursing implementation Passive rewarming Active rewarming Monitor body temperature at 30-minute intervals when using any external warming device. Care should be taken to prevent skin injuries. Provide oxygen therapy Potential Gastrointestinal Problems Nausea/vomiting are most common complications in postoperative period. Abdominal distention caused by decreased peristalsis. Hiccoughs Nursing assessment Ask questions about feelings of nausea. Document characteristics of vomit Assess the abdomen Auscultate all four quadrants. Nursing diagnoses Nausea, Risk for aspiration, Risk for deficient fluid volume, and Imbalanced nutrition: Less than body requirements Potential complications: Fluid and electrolyte imbalance and hiccoughs Potential Gastrointestinal Problems Nursing implementation Nausea/vomiting Antiemetic drugs and Oral fluids as tolerated (as soon as gag reflex returns.) Positioning Suction at bedside. If NPO, IV infusions to maintain F/E balance Nasogastric tube Nursing implementation Abdominal distention: Early and frequent ambulation, encourage client to expel flatus, Position client on right side, and Bisacodyl (Dulcolax) suppositories Potential Urinary Problems Low urine output 24 hours after surgery is normal. Acute urinary retention may occur as the result of Anesthesia and Location of surgery Voiding ability Oliguria (<30ml/hr) Nursing assessment Examine urine for quantity and quality. Note color, amount, consistency, and odor. Assess indwelling catheter. Most clients urinate 6 to 8 hours after surgery. Nursing implementation Impaired urinary elimination Potential complication: Acute urinary retention Facilitate voiding with positioning.: Provide reassurance. Use helpful techniques. Determine bladder fullness. Bladder scan If ordered, catheterize 6 to 8 hours after surgery if no void. Potential Integumentary Problems Adequate nutrition is essential for wound healing. Factors affecting wound healing: Chronic disease with nutritional deficiency, Obesity, and Older adults Wound infection may result from contamination Incidence is higher with certain types of clients- diabetes, immunodepressed, on steroids Evidence of infection is not apparent for 3 to 5 days. Surgical Wounds Nursing assessment Serous draining is common from any wound More drainage when drain present Drainage should change from red to pink to clear yellow. Wound dehiscence may be preceded by a sudden discharge of drainage. Risk for infection Potential complication: Impaired wound healing Nursing implementation When drainage occurs, note type, amount, color, consistency, odor(Table 20-7) If operative dressing is saturated… check with surgeon When a dressing is changed, note the numbers and types of drains present. Observe for signs of infection. Care of the Client Experiencing Acute Pain Pain Can contribute to complications such as: dysfunction of the immune and coagulation systems delay return to normal gastric function Increase risk of atelectasis and impaired respiratory function Autonomic sympathetic nervous system activated (increase HR and RR) Referred Pain Administration~Pain Medication Focus on prevention or control. Do not wait for severe pain. Constant pain requires around-the-clock administration (not PRN). Fast-acting drugs for breakthrough Scheduling Focus on prevention or control. Titration Use the smallest dose to provide effective pain control with fewest side effects. Nondrug therapy TENS treatment- stimulus (shock) Acupuncture- used for constant pain PENS- TENS with pointy things Heat therapy- vasodilation Cold therapy- Vasoconstriction Cognitive therapies: Distraction, Hypnosis, Imagery, and Relaxation Gerontologic Considerations Treatment cautions!! Metabolize drugs more slowly Risk of GI bleeding with NSAIDs Multiple drug use (interactions) Cognitive impairment, ataxia can be exacerbated by analgesics
