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Role of the Perioperative Nurse:
Umbrella term that describes care of client from the time decision is made to have the surgery, until discharge from the hospital TERM 2
Role of the Perioperative Nurse: Four phases
of operative experience:
DEFINITION 2 Pre_Op prior to surgery Intaoperative during surgery Immediate post-operative 1-4 hours after surgery Convalescent: Intermediate:4-24HRS POST OP Extended:24-? TERM 3
DIAGNOSTIC SURGERY
DEFINITION 3 Confiration or establishment of a diagnosis. ex. Laproscopic procedures TERM 4
EXPLORATORY SURGERY
DEFINITION 4 (Ex. endometrious find extent of surgery) surgical examination to determine the nature of extent of a disease TERM 5
ABLATIVE SURGERY
DEFINITION 5 remove a diseased body part. (ex. gangren toe removed appendectomy)
Reconstructive or Cosmetic SURGERY
to restore fuction or appearance TERM 7
EMERGENT SURGERY
DEFINITION 7 Preformed immediately to preserve function or the life of the client (ex. C-section, pic of lady shot in face received emergent surgery to save her life) TERM 8
URGENT SURGERY
DEFINITION 8 necessary to be preformed within 1-2 days. (ex. getting a heart stent if not emergent) TERM 9
Elective Surgery
DEFINITION 9 Scheduled and planned to provide preferred treatment for a condition. (ex. planned c section) TERM 10
-ectomy
DEFINITION 10 excission or removal of ex appendectomy
-plasty
repair or reconstruction of ex. mammoplasty TERM 17
operative permit
DEFINITION 17 client must sign a voluntary and informed consent or permit for surgery Protects patient Protects surgeon and hospital staff TERM 18
Informed Consent
DEFINITION 18 active, shared decision-making process between provider and recipient of care Back in the day people with mental retardation were sterilized without informed consent to prevent making more retards. TERM 19
Conditions for valid consent: 1. Adequate
disclosure of diagnosis
DEFINITION 19
- Adequate disclosure of diagnosis Nature and purpose of treatment Risks and complications Probability of success Availability, benefit, and risk of alternative treatment Prognosis without treatment TERM 20
Conditions for valid consent: Dem. of clear
understanding and comprehension of info
provided
DEFINITION 20
- Demonstration of clear understanding and comprehension of information provided Consent signed prior to any preoperative medication is given
Conditions for valid consent: 3. Voluntary
consent
No coercion used to obtain consent Right to refuse consent and surgery Right to withdraw consent after signing permit ex. If women in labor needs an emergent c-section but is refusing surgery and baby dies, that is her choice. Do not judge pt. could have been raped or unplanned and cannot afford baby. TERM 22
Legal Aspects of Surgery Conditions for valid
consent:
DEFINITION 22 If the patient is a minor, unconscious or mentally incompetent, the permission of a responsible family member or legal guardian is obtained If under 18 and living away from home, or under 18 and pregnant, they are considered an emancipated minor and may sign their own consent In emergent situation (life saving) situation and not able to obtain informed consent, surgeon may institute treatment without written consent TERM 23
Surgeons responsibility:
DEFINITION 23 Ensure that client is giving informed consent Explanation of Surgical procedure Risks, including potential for death, need for blood transfusion Alternatives to surgery TERM 24
Legal Aspects of Surgery Role of Nurse
DEFINITION 24 Ensure consent is informed and voluntary Sound mind Not sedated Understands English Understands what the surgeon said Obtains and witnesses the patients signature Contact the physician and explain the need for additional information TERM 25
Legal Aspects of Surgery Role of Student
Nurse
DEFINITION 25 MAY NOT witness consent Ensure pre-op meds are not given prior to consent Relay any questions that the client may have
Surgery as a Stressor Disrupted vascular
system
Disrupted vascular system Interruption in blood vessels Increased platelets may lead to increased clotting TERM 32
Surgery as a Stressor Disturbed Organ
Function
DEFINITION 32 Manipulation of bowel may lead to decreased peristalsis TERM 33
Surgery as a Stressor Body Image
Disturbance
DEFINITION 33 Incision may effect body image amputation of limbs, mastectomy TERM 34
Surgery as a Stressor Lifestyle Changes
DEFINITION 34 Consider the effect of a colostomy, amputation of limbs TERM 35
Assessing Surgical Risk: Age VERY
YOUNG
DEFINITION 35 Poorly developed lungs: less able to tolerate surgery as lungs have less range for stress: increased risk of pulmonary problems Thin skin: Prone to breakdown Increased problems with healing *******young may have oxygenation problems, thin skin, and problems healing. If young in pain less likely to eat making them less likely to thrive/heal properly.
Assessing Surgical Risk: Age Elderly Aeration
and Circulation
Aeration: Decreased gas exchange- Respiratory Acidosis decreased vital capacity decreased cough reflex Circulation: Decreased arterial elasticity Increased plaque formation Risk for clotting can be elevated TERM 37
Asessing Surgical Risk: Age Elderly Renal and
Sensation
DEFINITION 37 Renal: Decreased GFR: Decreased drug excretion Urinary stasis-risk for infection Urinary Incontinence -ego blow for independent elder Sensation: Decreased sight (rods and cones less functional light perception decreases with age) Decreased hearing Decreased short term memory Impaired Balance-make sure bed low, 2 rails up, call light accessible TERM 38
Asessing Surgical Risk: Age Elderly Skin
DEFINITION 38 Skin: Decresased elasticity Dec. collagen Thin, increased risk of impairment TERM 39
Asessing Surgical Risk: Age Elderly Mobility
and Nutrition
DEFINITION 39 Mobility: *Loss of calcium from bones: prone to fracture *Decreased activity: Decreased basal metabolic rate Nutrition: *Dehydration-check hydration status when admitted *Malnutrition-may look fin but be nutrient deficient, this may impair healing TERM 40
Assessing Surgical Risk: Nutrition
Prolonged....
DEFINITION 40 Obese Client: Excess adipose tissue and poor blood supply *Prolonged Surgery -----increased time to make incision ----- increased time to close incision Prolonged excretion of anesthetic agent ---Anesthetic agents stay longer in adipose tissue because of poor blood supply in adipose, this takes them longer to wake up, which will decrease respiratory ability which increases risk of fluid in the lungs pneumonia etc.
Assessing Surgical Risk: Fluid and Electrolyte
Balance
Adequate fluid and electrolyte balance is needed to maintain blood volume and urinary output Excess fluids: Excess Fluids: can effect their cardiac and pulmonary function TERM 47
Adequate fluid and electrolyte balance is
needed to maintain blood volume and urinary
output Electrolyte imbalance
DEFINITION 47 Too little fluids: Results in dehydration and reduced blood volume Low Blood pressure, impaired GFR, and delayed excretion of drugs Electrolyte Imbalance: Can be retaining sodium and water and excreting potassium Hypokalemia- leads to heart arrythmias TERM 48
Impact of Pre-existing Conditions on Surgical
Risk Bleeding disorders
DEFINITION 48 *Bleeding Disorders- Thrombocytopenia and hemophilia may both lead to uncontrolled post-operative bleeding. Pts with thrombocytopenia MUST TELL ANASTESIOLOGIST bc anesthesiologist cannot do epidural or spinal they get local TERM 49
Impact of Pre-existing Conditions on Surgical
Risk: Diabetes
DEFINITION 49 Diabetes: Impaired peripheral circulation contributes to impaired wound healing Stress increases blood glucose, which can further impair wound healing, and increase risk of infection. TERM 50
Impact of Pre-existing Conditions on Surgical
Risk Heart Disease
DEFINITION 50 Heart Disease: Stress increases workload on heart, so increased risk of infarction, MI, angina, CHF
Impact of Pre-existing Conditions on Surgical
Risk Fever
Fever: Pre-operative fever may indicate an infection that can greatly impact surgery: make sure that surgeon and anesthesiologist is aware. TERM 52
Impact of Pre-existing Conditions on Surgical
Risk Upper Resp. Infection
DEFINITION 52 Upper Respiratory Infection Anesthesia and URI may further increase secretions, which can ^ surgical recovery time TERM 53
Impact of Pre-existing Conditions on Surgical
Risk Chronic Respiratory Infection
DEFINITION 53 Chronic Respiratory Disease Emphysema bronchitis, asthma may have difficulty coughing May have difficulty handling ^ secretions TERM 54
Impact of Pre-existing Conditions on Surgical
Risk Liver disease
DEFINITION 54 Liver Disease: At risk for drug toxicity At risk for impaired wound healing TERM 55
Impact of Pre-existing Conditions on Surgical
Risk immune disorders
DEFINITION 55 immune Disorders: At risk for infections Delayed wound healing.
Pre-Op Assess: Nursing Assessment and
History: Endocrine: diabetes
- History of diabetes: what is current treatment regimen? If on oral agents, may need insulin post-op because of stress Frequency of post-op glucose checks Current blood glucose Last intake of insulin or oral meds (metformin?) TERM 62
Pre-Op Assess: Nursing Assessment and Hx:
Endocrine: History of thyroid disease
DEFINITION 62 Plan for pharmacologic therapy pre-op steroids will be needed intra and post op as well 1. History of chronic steroid use: Adrenal glands produce 25 mg/day of cortisol Surgical stress increases this to 250-300 mg/day, providing needed energy for surgery Chronic steroid use atrophies adrenal glands and suppresses cortisol secretion Must supplement with IV cortisol to avoid Addisonian crisis TERM 63
Pre-Op Assess: Nursing Assessment and
History Immunologic
DEFINITION 63
- Allergies: drugs, environmental, latex, tapes, betadine Allergy band and note prominently on chart 2. WBC: Acute infection ***^ WBC : but neutrophils are immature cells known as "bands" ***^ neutrophils ***^ bands TERM 64
Pre-Op Assess: Nursing Assessment and
History: Drug Therapy
DEFINITION 64 1.What prescribed , OTC, and herbal drugs are they currently taking? 2. Coumadin: what is PT/INR 3. Diuretics: can potentiate electrolyte imbalances 4. B/P, cardiac meds: can interact with anesthesia and result in hypotension and bradycardia 5. Insulin St. Johns Wort interferes with anesthesia Ask if they are on steroids TERM 65
Pre-Operative Assessment :Physiological
Common Pre-op Screenings and Examinations
DEFINITION 65 1.CBC 2. UA 3. Chest X-Ray 4. EKG 5. Coagulation studies 6. Electrolytes 7. Serum Creatinine 8. Type & Cross for blood Please review Lewis, Table 18-6 for rationales
Pre-Operative Assessment: Psychological 1.
Anxiety
Look for cues of anxiety Physiological Behavioral Nurse can allay anxiety Therapeutic communication Determine source of anxiety Clear up misconceptions TERM 67
Pre-Operative Assessment: Psychological
Fear: many causes for fear
DEFINITION 67 Unknown: may be first surgery Pain and pain management Concern with body image/ change in image Death Anesthesia Disruption of life: having to be dependent on others TERM 68
Pre-Operative Assessment: Psychological
Ability or inability to cope
DEFINITION 68 Does client exhibit ability to problem-solve? How have they coped with past stressors? Have they had past surgeries? If so, what helped them cope at that time? TERM 69
Pre-Op. Assessment: Psychological Knowledge
surgery, anesthesia, &their role
DEFINITION 69 Does the client know what they need to know? Support system Do they have a support system? What are the post- operative plans? TERM 70
Pre-Operative Assessment: Sociocultural
DEFINITION 70 Support System Economic Plans for convalescence
Knowledge Deficit Pre-op Antiemetics: what to
do with routine, prescribed medications
A. Antiemetics: Reglan, Zofran Antiemetics: Dec N/v Increases GI emptying which decreases risk of aspiration. TERM 77
Nursing Diagnoses: Knowledge Deficit Pre-op
Meds H2 Receptor antagonists
DEFINITION 77 H2 Receptor antagonists: Tagamet, Pepcid, Zantac inhibit gastric secretion Decrease risk of stress ulcers PRESENT ::::::80-90% of people in hospital get H2 receptor antagonist to reduce the risk of stress ulcers. TERM 78
Nursing Diagnoses: Knowledge Deficit Pre-op
Meds Benzodiazepines
DEFINITION 78 Benzodiazepines: Valium, Versed, Ativan Benzos- reduces anxiety increases sedation induces amnesia TERM 79
Nursing Diagnoses: Knowledge Deficit: Pre-op
Med Anticholinergics
DEFINITION 79 Anticholinergics: Atropine, scopolamine, glycopyrrolate Decrease oral and respiratory secretions Prevent bradycardia TERM 80
Nursing Diagnoses: Knowledge Deficit Pre-op
Med: Bowel Preps
DEFINITION 80 Bowel Preps: Enema, Magnesium Citrate, Antibiotics, Low- residue Diet clense bowel prior to bowel surgery.
Nursing Diagnoses: Knowledge Deficit Pre-
Operative Skin Prep
Cleansing skin Clipping or shaving hair TERM 82
Nursing Diagnoses: Knowledge Deficit: Pre-op
Family Support Knowledge Deficit Pre-
Operativ
DEFINITION 82 Tell family when to arrive prior to surgery Direct them to appropriate waiting area Discuss how they will be contacted TERM 83
Nursing Diagnoses: Risk for Injury:Client
preparation on surgical day
DEFINITION 83 Make sure client voids prior to being given meds Double check that consent is signed prior to being given meds Give meds as ordered Ensure safety Siderails up Bed in low Call light TERM 84
Nursing Diagnoses: Risk for Injury 2. Pre-
operative checklist A-G
DEFINITION 84 A. Check ID/Allergy band B. Name on chart C. Permit signed D. H & P/ anesthesia questionnaire on chart, with ht & wt E. Prep done, if ordered F. Pre-op screening/exams on chart G. Recent set of VS on chart TERM 85
Nursing Diagnoses: Risk for Injury 2. Pre-
operative checklist H-M
DEFINITION 85 H. Jewelry removed or secured I. Dentures, glasses, contacts, prosthesis, nail polish, hairpins removed J. Hospital gown on K. Voided prior to being given on call meds L. NPO status verified M. Pre-op meds given if ordered
Concept Map of Anesthesias Effects on
Respiratory System
Anesthesia / \ ^ lung secretions causes respirations to be shallow
/ Secretions in lower airways 1.? 2.? Cough deep breath incentive spirometer TERM 92
Nursing Diagnoses Knowledge Deficit:
Postoperative 5. Cardiovascular exercises
DEFINITION 92 Leg exercises Stimulates circulation by promoting venous return to heart Prevents thrombus formation Kozier Procedure 35-1 Dorsiflexion and plantar flexion of feet Knee flexion and extension Raising and lowering legs TERM 93
Nursing Diagnoses Knowledge Deficit:
Postoperative 5. Cardiovascular exercises/
stuff
DEFINITION 93 Antiemboli Stockings/ Sequential Compression Devices (Kozier Skills 37-2, 51-1) Facilitate venous return Improve arterial circulation to the feet and prevent edema DO NOT TAKE PLACE OF LEG EXERCISES: only facilitates muscle contraction TERM 94
Nursing Diagnoses Knowledge Deficit:
Postoperative 6. Turning
DEFINITION 94 Mobilizes respiratory secretions to dependent portions of the lungs Move q 1-2 hours while awake
