Perioperative Nursing Care
Types of Surgery
Purpose

Inpatient

Ambulatory: outpatient, one-day (same-day surgery), short-stay unit
Extent of surgery

Simple

Radical
Diagnostic: to confirm or establish diagnosis
Corrective: excision or removal of diseased body part
Perioperative Phases: the importance of providing continuity of care for surgical
Reconstructive: restore function or appearance to traumatized of malfunctioning
patient before, during, and following surgery
tissues
Ablative: removes a diseased body parts
Interprofessional Team
Palliative: relieves or reduces pain or symptoms of a disease; it does not cure
Physicians/Surgeons: Internist, endocrinologist, cardiologist, respirologist,
Transplant: replaces malfunctioning structures
anaesthetist
Cosmetic: performed to improve personal appearance
Nurses

Receiving units (s) – RN, RPN Nurse specialists (ET)
Urgency
OT, PT, SW, Pharmacy, Speech Language, Dietician, Pastoral Care
Emergency: performed immediately to preserve function or the life of the client
Child Life Worker Community Partners [Specific services for follow-up on discharge
Urgent: necessary for client’s health to prevent additional problem from developing;
(CCAC)], Receiving agency (nursing home, rehabilitation unit)
not necessarily an emergency (24-30h)
Elective: is performed when surgical intervention is the preferred treatment for a
Preoperative Phase: begins with the decision for surgical intervention and ends with
condition that is not imminently life threatening or to improve the client’s life
transfer to the OR
Required: had to be performed at some point; can be prescheduled
Optional: patient’s choice
Nurses’ Major Responsibility Patient assessment, Physical problems, Emotional
aspects, Understanding surgery/consent, Legal requirements for chart completion,
Degree of Risk
Read and interpret lab results, Preoperative teaching
Major: involves a high degree of risk (extensive reconstruction of or alteration
Minor: normally involves little risk (minimal alteration)
Nursing Assessment  Current health status, Allergies, Medications -list all current
Factors Affecting the Risk
medications, Previous surgeries, Understanding of the surgical procedure and
Age: very young and elder clients are greater surgical risks than children and adult
anesthesia, Smoking (Increased risk for pulmonary complications, Teaching on the
General Health: surgery is least risky when the client’s general health is good
importance of post-op deep-breathing and coughing)
Nutritional Status: required for normal tissue repair

Alcohol and other-altering substances
Medications: regular use of certain medications can increase surgical risk
o
Cross-tolerance to anesthetic agents; required higher dosage
Mental Status: disorder that affect cognitive function
o
Adverse reactions like withdrawal
o
Malnourished: delayed wound healing
o
Needed higher dosage of post-op analgesics
Surgical Settings

Coping, Social resources, Cultural considerations
Medications History: Hazardous to Surgery

Antidepressants, phenothiazines, diuretics, steroids, anticoagulants,
antibiotics, herbal
Nervous System
Physical Assessment/ Clinical Manifestations

Increased incidence of post-op confusion
General Survey: gestures and body movements may reflect decreased energy or

Increased incidence of delirium
weakness caused by illness

Increased sensitivity to anesthetic agents
Cardiovascular system: alterations in cardiac status are responsible for as many as
Renal System
20-30% of perioperative death

Renal blood flow declines with aging
Respiratory System: a decline in ventilatory function, assessed through breathing

Renal clearance reduced
pattern and chest excursion, may indicated a client’s risk for respiratory complications
Gastrointestinal
Renal System: abnormal renal function can alter fluid and electrolyte balance and

Decreased intestinal motility
decrease the excretion of preoperative medications and anesthetic agents

Decreased liver blood flow

Decreased gastric emptying
Neurologic System: a client’s LOC will change as a result of general anesthesia but
should return to the preoperative LOC after surgery
Musculoskeletal
Musculoskeletal System: deformities may interfere with intraoperative and

Decreased mass, tone, strength
postoperative positioning

Decreased bone density
Gastrointestinal system: alteration in function after surgery may result in decreased or
Integumentary
absent bowl sound and distention

Decreased elasticity
Head and Neck: the condition of oral mucous membranes reveals the level of

Decreased lean body mass
hydration

Decreased subcutaneous fat
Obesity
Immune Status
Disabilities
Psychosocial Considerations

Fear of loss of control (anesthesia)

Fear of the unknown (outcome, lack of knowledge)
Gerontological Considerations

Fear of anesthesia (waking up)
Cardiovascular

Fear of pain or inadequate post-operative analgesia (pain control)

Coronary flow decreases

Fear of death (surgery, anesthesia)

Heart rate decreases

Fear of Separation (support groups)

Response to stress decreases

Fear of disruption of life patterns (ADLs, work)

Peripheral vascular decreases

Fear of change in body image and mutilation

Cardiac output decreases

Fear of dietetic of cancer

Cardiac reserve decreases
LEVEL OF ANXIETY, COPING ABLITY, SUPPORT SYSTEMS
Respiratory System

Static lung volume decreases

Pulmonary static recoil decreases

Sensitivity of the airway receptors decreases
Laboratory and Diagnostic Studies

Screening tests depend on the condition of the client and the nature of the
surgery


If test reveals severe problems the surgery may be cancel until the condition
is stabilized
Informed Consent: Must include adequate disclosure of diagnosis, treatment, risks
Routine Screening Test- CBC, blood grouping and x-match, lytes (sodium,
and probability of success
potassium, chloride, and bicarbonate), fasting blood sugar, BUN &

creatinine, ALT, AST, and bilirubin, serum albumin, and total protein,
urinalysis, chest x-ray, ECG
Patient must demonstrate clear understanding and comprehension (Signed
before any preoperative drugs given)

Voluntary consent

Surgeon responsible for obtaining consent
Pre-Operative Teaching: patient has right to know what to expect and how to
o
Nurse may obtain and witness signature (varies)
participate
o
Verify patient has understanding

Increases patient satisfaction

Reduces fear, anxiety, stress, pain and vomiting
Teaching documented in medical record (ptt. Chart)
Explain and demonstrate exercises such as:

Permission may be withdrawn at any time
Day-of-surgery preparation

Final preoperative teaching

Deep breathing and coughing

Assessment & communication of pertinent findings

Diaphragmatic breathing

Ensure completion of pre-op prep orders

Incentive spirometry

Pre-op checklist

Leg exercises

Turning/moving/alignment

Instructions specific to the surgery
o
Labs, Verify signed consent, History and physical exam, Baseline
vital, Consultation records, Nurse’s notes

Patient should not wear any cosmetics
Pain Management, Coping Strategies, When to stop eating and drinking, Medications
o
Observation of skin color is important
info
o
Remove nail polish for pulse oximeter
Child Life Program



Identification and allergy bands

Valuables returned to family member or locked up
or special equipment postoperatively

Dentures, contacts, prostheses are removed
Provide patient with information

Void before surgery: Prevents involuntary elimination under anesthesia or
Inform patients and families if there will be tubes, drains, monitoring devices,
o
o
Fluid/food restrictions (prevents aspiration, N/V)
o
Need for enema
o
Need for shower preoperatively/ skin prep
Wedding ring taped to finger
early postoperative recovery
o
Done before administration of medication
Pre-operative Medications
Legal preparation: Check that all forms are completed, correctly signed, and present

in chart
Purpose: facilitate effective anesthetics, minimize respiratory tract secretions
and relax, reduce anxiety
o
Informed consent, blood transfusion, pre-op survey, pre-op

Types: opiates, anticholinergics, barbiturates, prophylactic antibiotics
checklist

Give as ordered (scheduled time, on call, sent to OR)
o

Safety considerations
Regularly scheduled medications: Verify with the prescriber
o
Implementation of anesthesia for analgesic, sedative, and muscle relaxant
purposes as well as control autonomic nervous system
Cardiac meds, asthma, insulin
Admission to surgical unit or center (same day surgery)

-
Review of pre-op teaching: pre-op teaching should have started in pre-
Intraoperative Care Team: Surgeon, Anesthesiologist, nurse anesthetist, Scrub nurse,
Circulating nurse, OR Techs
admission

Complete the preoperative assessment
Nursing Responsibilities (Before Surgery (in OR)

Assess for risk of complications

Report abnormal findings
Meet the patient in holding area

Verify that informed consent obtained
ü Psychosocial assessment and support

Answers family questions
ü Review baseline data and perform baseline assessment including vital signs

Develop a plan of care
ü Review chart/consents/OR checklist
ü Check all pre-op orders... are they complete?
ü Pre-op procedures such as IV starts, administer pre-op medications
Transportation to OR


In-patients transported by cart to surgery from room
o
Side rails raised and secured
Reducing anxiety
o
Chart and preoperative equipment with patient
Ø Psychosocial support for client (if client is awake), Maintaining client dignity,
o
Family may accompany to holding
Maintaining a safe environment, Proper positioning, Injury prevention; sharps, burns
Outpatients transported by cart, wheelchair, or may walk
o

... Prevention of infection, Prevention of pressure ulcers
Method of transport documented by nurse responsible of transfer
Family instructed on waiting area where they can be informed on progress
Intraoperative Phase: begins with transferring patient to OR-ends with the transfer to
the recovery area
Experience of Pain
PAIN: The International Association for the Study of Pain (1979) …….an unpleasant
Purpose of Declaring Pain to be the
5th
Vital Sign
sensory and emotional experience associated with actual and potential tissue
1.
Assuring pain assessment occurs on a regular basis.
2.
Efficient use of time when in isolation room.
3.
Acknowledging that the pain experience influences the function of HR and
Rights of People with Pain
Resp.
I have the right to have my reports of pain accepted and acted upon by health care
Helping nurses make good use of their time while performing 2
professionals.
assessments.
I have the right to have my pain controlled, no matter what its cause or how severe it
4.
damage, or described in terms of such damage.
may be.
I have the right to be treated with respect at all times. When I need medication for

pain. I should not be treated like a drug abuser.
Relief from pain is a basic human right – continues to be a major health
issue.

Pain itself is now considered a separate disease.
……pain is whatever the experiencing person says it is, existing whenever he says it

Stimulus for pain – physical, mental or both.
does.

It is not the responsibility of the clients to prove they are in pain but our
…..to accept a client’s report of pain, respect that report and to proceed with
responsibility to accept their report of pain.
appropriate assessment and treatment.
Types of Pain
Clients Who Cannot Self-Report: The inability to communicate verbally does not
1.
Acute Pain is: Intensified by anxiety & fear, Present for less than 6 months
negate the possibility that an individual is experiencing pain and is in need of
A source of stress, Occurs abruptly after an injury, procedure or disease,
appropriate pain-relieving treatment.
Diminishes as healing occurs, Responsive to analgesics
Combination of pain evaluation techniques:
2.
Chronic Pain: Can be intermittent, vary with intensity or persistent, Known
1.
Try of obtain self report
cause, a consequence of a disease process, or unknown, There are different
2.
Search for potential causes
types of chronic pain.
3.
Use surrogate reporting
Two of the major, non-cancer chronic pains are:
4.
Attempt analgesic trial if the presence of pain is suspected – appropriate
Musculoskeletal Pain
analgesic, re-evaluate behaviors.
Neuropathic Pain
Nursing Best Practice Guideline: Assessement and Pain Management RNAO
Revised 2013: Applies evidence – informed practices of pain prevention and
Benefits of Effective Pain Management
•
Improves quality of life, Decreases hospital stays and clinic visits – takes
management with clients in various states of health and illness using pharmacological
strain off hospital,  pain, Earlier mobilization & healing,  participation, 
and non-pharmacological measures”.
satisfaction,  stress and anxiety,  postoperative complications, Earlier
return to work
As a nurse, you are ethically responsible for managing pain and relieving suffering.
•
•
Effective pain assessment and management is multidimensional in scope
Physiology of Pain
and requires coordinated interdisciplinary intervention.
Nociceptors: Free nerve endings/receptors capable of responding to painful stimuli
You are also legally and ethically obligated to advocate for change in the
•
Located in various body tissue
care plan when pain relief is inadequate.
•
Activated by thermal, mechanical & chemical stimuli (chemical substances
are released)
The Concept of Pain

Pain is not well understood – you cannot see or feel the client’s pain.
Classification of Pain

Pain is not simple it is extraordinarily complex.
Nociceptive Pain
A) Somatic Pain: Bone, joint, muscle, skin, Aching, throbbing, Well localized
B) Visceral Pain: Visceral organs, heart, GI tract, Pancreas, Fairly well localized to
poorly
Effects of Inadewuately Ttreated Pain
•
Evidence has shown that pain that is not effectively managed can have
Neuropathic Pain: abnormal processing of sensory input
severe physiological and psychological effects on patients and their families
Examples:
(RNAO, 2013).
•
Post herpetic neuralgia
•
Diabetic neuropathy
•
Phantom limb pain
•
However, significant rates of inadequately addressed pain continue to be
reported across all patient populations
Nursing Responsibilities and accountabilities r/t pain
Idiopathic Pain: A complex, multi-faceted state of chronic pain that may have no
obvious cause.
•

Acknowledging and accepting, Preventing pain, Assisting support persons,
Reducing misbeliefs about pain, Reducing pain and axiety, Documentation
It can involve damaged tissue, injury or malfunctioning nerve fibers or
changes in brain processing.
•
An example of neuropathic pain is phantom limb syndrome.
•
The brain still receives signals from nerves that originally carried impulses
from the now missing limb.
•
Other types of neuropathic pain include numbness, burning, "pins and
needles" sensations and shooting pain.
Nociplastic Pain: Altered nociception despite no clear evidence of actual or
threatened tissue damage causing the activation of peripheral nociceptors or
evidence for disease or lesion of the somatosensory system causing the pain.

Sometimes pain persists after a tissue injury has healed and in the absence
of nerve injury.
Nociceptive Pain: Transduction, transmission, perception, modulation
Gate-Control Theory of Pain

In addition to physical sensation, pain has emotional and cognitive
dimensions and pain impulses can be regulated or blocked by the gating
mechanisms located along the CNS

Impulses pass through when gate is open and are blocked when gate is
closed

Closing the gate - basis for pain-relief interventions
Sample #1
Sample #2
PQRST
Pained
P – provoking or
precipitating
P – place/ location(s)
Q – quality of pain
A – amount
R – radiation of pain
I – intensifiers
S – severity of the pain
N – nullifiers - what makes
T – timing
the pain better
E – effects
D –descriptors
T – treatment - what
medications work for you ?
- do you have adverse effects
from your medications?
Pain Assessment Tools
Visual Analog: Place a mark on a line from “no pain” to worst pain”
Faces: happy/sad/crying faces
Step1 Drugs:
•
Step 2 Drugs:
Mild pain (1-3)
Non-opioid ± adjuvant
•
Moderate Pain (4-6)
Weak opioid ± non-opioid ± adjuvant
(eg. antidepressants, anti-inflammatories, muscle-relaxants)
Caution with meperidine (Demerol)  neurotoxicity r/t accumulation of metabolite
normeperidine
Responses to Pain
Injection Kits: distributed by the health unit, they can reverse overdoses cause by

Effect on sleep, emotions, concentration, relationships with others

Effect on ADL’s, physical activities, appetite

May depend on what the pain means to the client…………….
certain drug. A life-saving role for users
Elderly Considerations
Adjuvants/co-analgesics: primary indication other than pain but have been found to
St
±
All steps may include adjuvants/co-analgesics
Affective
St

have analgesic qualities
Aging influences  concentrations of water soluble drugs (Morphine) also fat
soluble drugs also (Fentanyl)
Muscle Relaxants: baclofen

Low albumin –  s/e and toxic effects
Alpha-2-agonists: clonazepam

Decline in renal and liver function – greater peak effect and longer duration
Tricyclic: amitriptyline

Skin changes – topical applications
Anticonvulsants: pregabalin, gabapentin

Polypharmacy

Ability to interpret pain may be complicated by the presence of multiple
disease
Facial expression and cues are among the most frequently used nonverbal signs to
recognize pain in an infant and child.
Pharmacologic Pain Management

Nonsteroidal anti-inflammatory drugs (NSAIDS) and nonnarcotic analgesics
Acetaminophen
Pain Assessment Tools: Assessment tools that combine behavioural and physiologic

Effective for mild-moderate and chronic pain
signs are the most valid for health professionals to use in rating the level of pain in
infants and non verbal children.
Severe Pain Children

Post-surgery or significant injury

Opioids (morphine, codeine)
•
Route – oral, subcutaneous, intramuscular, IV
•
Oral and IV routes preferred – Why? - Oral route preferred bc IM and SC
Assessment of Non Verbal
cause increased pain, stress and anxiety in already anxious child
•
IV preferred bc enables titration of dosage to desired response level
•
Side Effects – N & V, Constipation, Urinary Retention and Pruritis and…
Respiratory Depression – monitor child’s respirations especially
when asleep
Breakthrough Pain

Pain relief should be provided around the clock

Delays in analgesics increases the chances of breakthrough pain – pain that
emerges as the pain med wears off, resulting in loss of pain control and
resulting in the child anticipating and becoming anxious which taxes the
child’s ability to rest and recuperate.
Types of Breakthrough Pain that Extends Beyond Treated Chronic Pain
Incident Pain - predictable and elicited by specific behaviors
End-of-dose Failure Pain – occurs towards end of usual dosing
Spontaneous Pain – unpredictable and not associated with activity or event
Cancer Pain

Chronic or acute

Comprehensive and aggressive

Choice of treatment may change

Pharmacological and non-pharmacological together

Long-acting/controlled release – MS Contin – 8-12h, 72 hour Fentanyl Patch
•
IV button pressed prn

Possible opioid tolerance – higher dose opioids
•
delivered only as ordered

Chronic pain – give analgesics on a regular basis (ATC)
•
parameters are ordered

Begins with NSAIDS, adjuvants, or both and progresses to strong opioids if
•
locked syringe chamber
pain persists
•
history

Variety of routes
Programmed by the health care professional

PCA- improved uniform pain control with fewer peaks and valleys in plasma
Controlled by the older child
concentration, more effective drug action and lower drug dosages
After initial pain control achieved with continuous IV, the child presses a button to
(5 and over)
receive a smaller analgesic dose (bolus dose) for episodic pain relief
Opioids

Tolerance develops in patients who take opioids for prolonged periods.

With tolerance,  usage needed for pain relief.

Dependence with tolerance, physical symptoms when the opioid is d/c’d.

Addiction - need for its psychic effects.
Intraspinal: medication infuses directly into the subarachnoid space and cerebrospinal

Risk of addiction from therapeutic use of opioids is negligible.
fluid
•
pain relieved through opioid binding to opioid receptors in spinal canal
PCA: patient-controlled Analgesia
Epidural: medication deposited in the dura of the spinal canal and diffuses into the
Self-administer opioids
subarachnoid space
Cognitive ability
Infusion pump
Nursing Considerations
Pain relief with fewer side effects (including sedation) than with systemic
Nurse’s Role R/T discharge teaching  discharge medications, pain log, report
analgesics
significant changes, discuss non-pharmacological approaches, relationship pain and
•
Potential spinal headache
health challenge process, document health teaching
•
Respiratory depression possible – opioid antagonist available
•
Possible urinary retention, pruritus, N/V, dizziness, infection at insertion site,
Complimentary: Used in addition to conventional treatment recommended by the
cardiovascular effects
health care provider
Others ……………………………………….
Alternative: may include the same interventions as complementary but frequently
•
•
become the primary treatment
Concomitant Symptoms  N.V, anorexia, headache, dizziness, diarrhea,
restlessness, difficulty sleeping
CNO views complementary therapies as:

Adjuncts to care that may be offered in conjunction with, and not to the
exclusion of, other approaches



Consider how a particular intervention will enhance the overall care for the
Distraction: acute and chronic pain, ?with severe pain, draws attention away from the
client
pain ex. visual, auditory, tactile, intellectual
A nurse may propose the use of complementary therapy to a client if she/he
has the knowledge to believe that the treatment would benefit the client
Training- Specific Therapies
Must be done in collaboration with other members of the team and be
Biofeedback - instrumentation to mirror psychophysiologic processes that an
incorporated into the plan of care
individual is not normally aware of but may be able to bring under voluntary control.
Cognitive Therapy Behaviour
Nursing Accessible Therapies
Physio/Occupational Therapy
Relaxation: relaxing tense muscles that contribute to pain
Therapeutic touch - practitioner uses his/her hands in the client's energy field to bring
Guided Imagery: slow, rhythmic breathing with mental image of relaxation and
that field to balance and harmony - any physical illness can be viewed as an
comfort
imbalance in this energy field.
Chiropractic - manipulate the body's alignment to relieve pain and improve function

Modeling/rehearsal
and to help the body heal itself.
Acupuncture - thin needles into soft tissue – replace pain with sensations of warmth,
Neuropathic Pain and Mirror Therapy
tingling or pressure.
To use mirror therapy, the affected limb is placed behind a mirror and the reflection of
Herbal Therapy - Some herbs may interact with drugs you are receiving for pain or
the other limb moving is witnessed. The brain is “tricked” by this optical illusion and
other conditions and may harm your health.
thinks your affected arm is moving without pain. It is thought that this works by “reorganizing” the brain
Others:
Natural products, pet therapy, deep breathing, aroma therapy, yoga, exercise,
Heat: stimulate nonpain receptors in the same receptor field as the injury
stretching-positioning, progressive muscular relaxation, mind body exercises, comfort
increases blood flow + dilation, dry and moist heat
therapy, rest-sleep
Cold/Ice: immediately after injury or surgery, no longer than 20 minutes at a time,
applied carefully – assess before, after and during, not applied to areas with impaired
Non-Pharmacological Methods for Children (RNAO)
circulation or impaired sensation

Positive reinforcement

Relaxation

Preparation/information

Memory change

DB
•
Small electrical currents to the skin and underlying tissues

Cognitive behavior therapy
•
Electrodes over painful site, regulated current

Hypnosis
•
Wear with adls

Thought stopping and positive self-statements
•
Rotate electrode sites

Distraction
•
Acute and chronic
Vibration: Cutaneous, consider contraindications
TENS (Transcutaneous Electrical Nerve Stimulation)
Controlling Painful Stimuli in the Client’s Environment
•
Lift client into bed – don’t pull
•
Position correctly on bedpan
•
Tighten and smooth bed linens
•
Avoid exposing mm to irritants (ex. Stool)
•
Loosen constricting bandages
•
Prevent urinary retention
•
Change wet dressings or linens
•
Prevent constipation
•
Check temperature of hot or cold applications
•
Reduce lighting and ambient sounds
Routine Clinical Approach to Pain Assessment and Management: ABCDE
A….Ask about the pain regularly. Assess pain systematically
B….Believe the client and family in their report of pain and what
relieves it
C….Choose pain control options appropriate for client, family and setting
D….Deliver interventions in a timely, logical and coordinated manner
E….Empower clients and their families. Enable them to control their course to the
greatest extent possible
Deep Vein Thrombosis, Pulmonary Embolism, Hemorrhage
Deep Vein Thrombosis
Venous Thrombi (plural)
•
RBC, WBC, Platelets, Fibrin along with tail like appendage
•
Tail grow or propagate in the direction of blood
•
Blood clot in a deep vein & artery
•
Likes valves of veins where venous stasis
•
Most serious complication - clot could dislodge and travel to the lungs
•
 size to occlude lumen
•
Medical emergency
•
Range in size from 1 mm in diameter to a mass that can completely obstruct
•
the vein
Exact Cause of VTE Unknown
Incidence increases with age, rare in children
Contributing Factors: Vircho’s Triad

Stasis of the blood/alterations in blood flow
 Bedrest, bedridden, immobilization, Obesity, History of varicosities
Deep Vein

Thin walled (less muscle)
(various veins, twisted large veins), Heart failure/shock, Veins dilated with
•
Run parallel to arteries
certain meds
•
Unidirectional flow back to the heart
SCI, Age, Surgery past 3 months, Surgery – anesthesia, Cast, Driving/flying

Endothelial injury/vessel wall injury
 fracturess + dislocations, Diseases of veins, Trauma, Chemical irritation,
Central venous catheters, Repetitive motion injury
•

Check toes with TEDS
Altered blood coagulability
Blood dyscrasia, OCP, HRT, Polycythemias, Deficient blood volume,
Nursing Considerations
Stress response
•
Assess condition of skin – look for any lesions, gangrenous condition, recent
vein ligation – may compromise circulation
Predisposing Factors: Pregnancy, Cancer, Smoking, Height, Family history, Certain
•
Remove q8h – assess calves for redness, warmth and tenderness
inflammatory diseases, History of DVT + PE
•
Also sensation, movement, edema and palpation of distal pulses
Calf Circumference: unilateral in calf circumference can be an early indication
Upper Extremity Venous Thrombosis
•
Not as common as lower
•
Reasons: IV catheters, Disease states, Trauma, Dialysis catheters, Central
•
Daily, Mark a point on each calf 10 cm from mid patella (> 3cm difference in
circumference btw calves)
•
Thigh – measure those who are prone
lines, Effort thrombosis
Prophylaxis: Doctors Order (prevention)
Prevention
Anticoagulation
Body positioning + position change
•
Unfractionated Heparin (UFH) – 5,000u bid to tid
•
Low Molecular Weight Heparin (LMWH) – daltiparin, enoxaparin
•
Vitamin K Antagonist – warfarin
•
Prophylactically can decrease risk of DVT up to 50%
•
Prevent pressure on posterior knee + deep veins in lower extremities.
Don’t:
•
Cross legs, Sit for long periods – hip flexion compresses large veins of the
legs, Wear clothing that constricts legs or waist, Put pillow under knee,
Mechanical
Massage legs
•
Graduated compression stockings
•
Intermittent pneumatic compression device
Exercise – activity causes contraction of skeletal muscles – puts pressure on veins to
 Prevent blood clots in lower extremities, Decrease venous stasis by
promote venous return – decreases stasis
increasing venous return through deep veins of legs, Connects to pump to
•
ROM – prevent thrombi
inflate and deflate – cycle
•
Ankle pumps
•
Foot circles
•
Knee flexion
Elastic Stockings- TED- Thromboembolic Device Hose or thigh high anti-embolic
stocking
antiembolic exercises q1h w/a
Maintain external pressure on muscles of lower extremities – promote
Others: Life style changes – weight, smoking, activity, Monitor urinary output, Maintain
venous return
BP
•
Accurate size
Clinical Manifestations- Superficial Veins: Pain/tenderness, Redness, Warmth, Most
•
Ensure stockings are insitu
dissolve spontaneously
•
Clean and dry
•
Treatment: BR, Elevation, Analgesics, Anti-inflammatory
•
Can meet this objective but cannot dissolve a thrombus that has already
formed.

No symptoms to nonspecific
Thromboembolytic Therapy

Tenderness affected limb
Surgical Treatment: Thrombectomy, IVC filter, Ligation, clips

Pain

Edema/Swelling

Discoloration or redness
•
Prevent extension or development of new thrombi

Increased skin temp
•
Intermittent or continuous IV infusion for 5 days

Superficial veins prominent
•
Heparin effective when aPTT is 1.5 times the control
Anticoagulation Agents:
(aPTT = activated partial prothrombin time)
Suspected DVT: Reported Immediately
•
Monitored + regulated by aPTT, INR + platelet count
•
Nurse can elevate leg but avoid pressure on suspected thrombus area
•
Oral anticoagulants administered with heparin
•
No one massages area
•
Used with renal insufficiency b/c not cleared by kidneys
•
Homan’s Sign on calf pain on dorsiflexion - * contraindicated when DVT
•
Increased chance of hemorrhagic complications
suspected as vigorous dorsiflexion may dislodge thrombus
Diagnostics
Ultra Sounds: Series of u/s are done over several days
Antidote for Heparin
1.
Protamine sulphate
Blood Tests: Almost all who develop severe DVT have an elevated blood level of a
Considerations r/t antidote?
clot dissolving substance called D Dimer
Dosage r/t amount of heparin in body and 1mg neutralizes 100u of heparin
Venography: Dye injected into a large vein in foot/ankle. Used less frequently b/c less
invasive methods can usually confirm diagnosis
MRI/CT: Visual images can show a clot
•
Used for some dvts - also prevents extension or new thrombi
•
Longer half-life of unfractionated (OD or BID)
•
Fewer bleeding complications than unfractionated
Stop the clot from getting any bigger and preventing the clot from breaking
•
Ex. Enoxaparin, daltiparin
loose and causing a __________.
•
Dosage adjusted by weight
Goal of DVT Management
1.
Anticoagulation Agents: Low-Molecular-Weight Heparin (LMWH)
2.
Reducing chance of deep vein thrombosis again.
3.
Prevent Post Thrombotic Syndrome
Treatment Options
Highest Risk but advantages…………
•
Fondaparinux - selective inhibitor of activated factor X
Anticoagulation Agents: Oral Anticoagulants
Pharmacological Therapy:
•
Warfarin – vitamin K antagonist
Anticoagulant Therapy: Preventing or reducing blood clotting within the vascular
•
Routine coagulation monitoring for therapeutic response over time
system.
•
Narrow therapeutic window + slow onset of action – heparin with warfarin
•
Other meds + intake of foods containing vitamin k
What is the antidote for warfarin (Coumadin)?
1.
•
Usually on for 3 months or longer
•
Must take Warfarin at same time each day + brand
•
Contraindicated in pregnancy (LMWH or SQ Heparin)
Vitamin K
Considerations r/t antidote? More difficult to reverse if no active bleeding – may hold
dose
INR=International
.9 -1.1
Normalized Ratio
Atnicoagulation Agents:
•
Lysis and dissolve thrombus
•
Ex. T-PA, Activase, Urokinase, Streptokinase
•
Given within first 3 days
•
3X higher incidence of bleeding than heparin
•
Less long term damage to valves, reduced chronic venous insufficiency and
post thrombotic syndrome
Surgical Management When:
aPTT= activated partial
28-38 seconds
prothrombin time
PT=prothrombin time
10-14 seconds
Platelets
150-400 x 10 9th/L
Hemoglobin (HGB)
Male 135-170 g/L
Female 115-160 g/L
Hematocrit (HCT)
. Danger of PE
Male .4-.51
Female .34-.48
2. Permanent damage to extremity will probably result
3. Anticoagulants or thrombolytic therapy contraindicated
Such as [many reasons]: bleeding, severe trauma, severe liver or renal disease,
CVA, L+D + + + +
Options: Thrombectomy, Vena cava filter, Filter traps
Anticoagulation
•
IV pump - unfractionated
•
Clotting profile, with ongoing coagulation testing
•
Heparin effective (therapeutic – aPTT is 1.5 times the control)
•
Oral anticoagulants ex.warfarin (coumadin) monitored by PT or INR – effect
is delayed for 3-5 days - usually administered with heparin until desired
anticoagulation achieved (PT is 1.5 to 2 times normal or INR is 2 to 3) when reaches this for 2 consecutive days d/c heparin
•
Warfarin – narrow therapeutic window
Anticoagulation Therapy Monitoring
Bleeding: Often first sign – bleeding from kidney, Bruises, nosebleeds and bleeding
gums, Cuts that continue to bleed, Surgical incisions
What else do we need to consider?? Checking blood levels before administering,
Reddish/brown urine, Melena, Severe headaches, Abdo pain, Hemoptysis
Thrombocytopenia - Decrease in platelets - 150-400 x 109/L
•
Heparin induced thrombocytopenia[HIT]
•
Beginning warfarin with heparin can provide stable INR
•
Less with LMWH
•
Regular monitoring of counts
•
If does occur – platelet aggregation studies, heparin d/c’ed, and protamine
sulfate given
Numerous Drug Interactions:
•
Vitamins
•
Cold medicine

Chronic venous insufficiency
•
Antibiotics

Phlegmasia cerulea dolens
•
ASA
•
Mineral Oil
•
Anti-inflammatory agents [ibuprophen]
•
Herbal/nutritional supplements
Teaching
Complications of DVT- PE
Pulmonary Embolism (PE)
•
Collection of particulate matter (solids, liquid, gaseous) enters systemic
venous circulation and lodges in pulmonary vessels.
•
Obstructs pulmonary circulation causing impaired gas exchange, constriction
Self injections – site and technique
of regional blood vessels and bronchioles thus decreasing oxygenation. Can
- Avoid injury
be fatal.
- Signs and symptoms to report
•
- Medications interactions
- Diet
Can be caused by blood clot (most common), foreign body, tumor, fat
emboli, amniotic fluid, pus.
PE is not a disease but a complication of underlying venous disease/complications
- Routine monitoring required
-
Communicate anti-coagulation to all other HCP
-
Same brand and same time
•
Deep veins of the legs
-
Wear ID
•
Most lethal from femoral or iliac veins
-
Avoid ETOH
•
Right side of heart and upper extremities
-
Check with HCP before stopping
•
Pelvic veins
-
If pregnant or suspect pregnancy
-
Soft tooth brush, electric razor
-
Avoid marked changes in eating
•
Immobilization/paralyzed
-
Hydration
•
Surgery
Pathway
PE RISK FACTORS
•
Trauma
Client Comfort and Healing
•
Increased blood coagulation
Adjuncts to Therapy:
•
History of varicose vein(s),
•
Activity depends…….
•
Obesity, smoking, pregnancy, OCP, CHF, stroke
•
Elevation
•
History
•
Warm moist packs
•
Age
•
Analgesics
•
Septic
•
Walking preferred over sitting/standing
•
Cancer + therapy
•
Bed exercises
•
Hydration
Considerations- PE
•
Completely/partially obstructs a pulmonary artery/branches + alveolar dead
•
Peripheral vascular studies
space 
•
ABG’s
•
Continues to be ventilated but received little or no blood flow
•
Gas exchange impaired or absent in this area
Interventions
•
Substances are released from the clot = regional blood vessels and
Goals
bronchioles constrict

increase alveolar gas exchange
•
ed pulmonary vascular resistance

improve tissue perfusion
•
ed pulmonary vascular resistance and decreased size of pulmonary

get rid of embolism
vascular bed

prevent complications
•
Causes  in pulmonary arterial pressure and in rt ventricular work
•
When workload needed to the rt ventricle exceeds its capacity rt ventricular
Priority Nursing Actions: HOB, Oxygen, VS, O2 sat, Breath sounds, Call, IV, Testing,
failure occurs =  in cardiac output followed by in systemic bp and
Monitoring, Catheter, Medications, Emotional support, Anticipate possible treatment
development of cardiogenic shock!
Anticoagulation
Prevention
•
Prevent DVT
Major Elective Surgery
Heparin and Warfarin – traditional – heparin generally recommended for pt
diagnosed with PE
•
Usually one time Iv bolus [5,000u] then continuous infusion – pump –
•
Low dose of Heparin SQ 2h preop + continued q8-12h until discharged
maintain PTT at 1.5 – 2.0 times the normal level
•
Enhances activity of antithrombin 111, a major plasma inhibitor of clotting
•
Many issues with heparin
factor X
•
Heparin continued with Warfarin until INR within therapeutic range of 2.0 –
Active thrombotic process or undergoing major ortho, prostatectomy, eye or brain
surgery
•
2.5
•
LMWH (low molecular weight heparin)
LMWH (high dose) or heparinoids can be used to maintain therapeutic PTT
while Warfarin adjusted
Signs and Symptoms (PE)  Dyspnea*, Tachypnea*, Tachycardia, Chest pain/chest
•
Warfarin for 3-6 months post (INR 2-3)
wall tenderness*, Syncope, Diaphoresis, Anxiety/apprehension
•
Lepirudin and agrathroban – are alternatives if heparin or heparinoids are
Cough/hemoptysis, Hemoptysis
Diagnostic Tests and Assessment
contraindicated
Thrombolytics
•
D dimer
Thrombolytic Therapy
•
Ventilation-perfusion scan
-Severely compromised – only for PE affecting significant area to lung and causing
•
Pulmonary angiography
hemodynamic instability - resolves quicker
•
Spiral CT
-Bleeding significant s/e
•
CXR
-Contraindications
•
ECG
•
CVA post 2 months + ICP
•
Active bleeding
Common causes:
•
Surgery
•
Tissues that cannot be entirely prevented from bleeding
•
Recent L+D
•
Blood clotting to stop hemorrhage
•
Trauma
•
Clips or ties around vessels become loose
•
Severe hypertension
Blood work checked first, heparin stopped, no invasive procedures – after, started on
Classification of Hemorrhage
anticoagulants
Type of Vessel  Capillary, Venous, Arterial
Visibility  Evident, Concealed, Other considerations
Surgery: embolectomy, clips, filter
Preventing Thrombus:
•
Assessing potential for PE
•
Monitoring Thrombolytic Therapy
•
Managing Pain
•
Maintaining Oxygenation
•
Anxiety
•
Complications – cardiogenic shock, right ventricular failure
Grade 4
–
Debilitati
ng Blood
Loss –
associate
d with
Fatality
Grade 1 –
Petechial
Bleeding
WHO
Gradin
g to
Measur
e
Bleedin
g
Grade 3 –
Gross Blood
Loss
Grade
2–
Mild
Blood
Loss
Hemorrhage Post-Operative Management
Hemo = blood
orrhage = burst forward
Loss of large amount of blood externally or internally in a short period of time
Signs and Symptoms
•
Internal or external
•
Acute or chronic
•
May affect different vessels and have varying results
conjunctive], HR increases + becomes weak, temp decreases, RR rapid and
•
Into closed cavity may cause organ damage
deep, Delayed cap refill, Spots/eyes, Decrease urinary output, Tinnitus,
•
Presentation varies by anatomical location
Mental status changes
•
Apprehensive, Restless, Thirsty, Skin – cool, moist, pale [+lips +
Serious complication
Nursing Interventions: team approach, control bleed, adequate circulating blood
Any point in the immediate post-op period or up to several days after surgery
volume, prevent shock, assess cause!
Time frame:
External
•
primary – time of surgery
•
Rapid assessment
•
intermediary – during first few hours after surgery
•
Place dressing with direct firm pressure
•
Secondary – sometime after surgery
•
Elevate and immobilize if bleeding from extremity
•
Not restricted to the surgical wound
•
Tourniquet – last resort
Internal
•
Blood, Surgery, Supine + raise leg, Warmth, Monitor oxygenation
•
ABG’s
•
Consider – patient safety and special considerations r/t blood loss
replacement