Nursing Management ofClients with

Peri-Operative Stressors

NUR133

Lecture #2 & #3

K. Burger, MSEd, MSN, RN, CNE

What is Medical-Surgical Nursing?Blend of technical skills & caring relationshipsSpecialty of nursingNursing care of adults 18yrs +Requires broad scope of knowledgeEncompasses many roles/competenciesAcademy of Medical-Surgical Nurses (AMSN)

= specialty organization

Take some time to…

Review the Academy of Medical Surgical Nurses (AMSN) website @http://www.medsurgnurse.org

Click on and read:Learn more about Medical Surgical Nursing

What are your opinions about the role of the medical surgical nurse as outlined in this AMSN statement?

Peri-Operative Nursing

SURGERYDEFINITION = A planned alteration of physiologic processes within the body in an attempt to arrest or eliminate disease or illness

PHASES = Pre-operativeIntra-operativePost-operative

Goal of Peri-Operative Nursing

To prepare the client mentally and physically for surgery and to assist in full recovery in the shortest time possible with the least discomfort.

Classifications of Surgery

PURPOSE

Diagnostic

Curative-Ablative-Restorative

-Reconstructive

Palliative

Cosmetic

Transplant

URGENCY

Elective

Urgent

Emergency

SERIOUSNESS

Minor

Major

Variables Affecting Surgical Outcome

Age Nutrition Fluid Balance Life-style Habits Medical Conditions Medication History Family History Prior Surgical Experiences Spiritual and/or Cultural Beliefs Anxiety and Coping Mechanisms

Pre-Operative Phase

Begins when a decision is made to perform a surgical procedure and ends when the client enters the operating room

Nursing goals = Assessing for risk factorsEmotional support of client Client teachingPhysical preparation of client

Pre-operative Nursing Assessment

HISTORYAgeMedication Medical history AllergiesPrior surgeries and outcomesAnesthesia history / personal & familialLifestyle habits: alcohol / smoking/ exercise

Pre-operative Nursing Assessment

PHYSICAL

VS Head & Neck Skin Turgor Thorax & Lungs Heart & Vascular System Abdomen Neurological Status

Pre-Operative Nursing Assessment

LABS

Complete Blood Count (CBC)

Basic Metabolic Panel (BMP)

Coagulation Studies PT/PTTUrinalysisBlood typing / screeningAdditional tests as indicated

DIAGNOSTICS

Chest X-Ray(CXR)

Electrocardiogram(ECG)

Additional tests as indicated

LABORATORY NORMALS

Students should research/fill-in/memorize the following lab values ( See pg 302-303 Iggy)

KNaClFBSBUNCrWBCHgbHct

Pre-operative Nursing Assessment

Knowledge

Informed ConsentAnxietyCoping mechanismsAvailability of support

Common Pre-operativeNursing Diagnosis

Anxiety r/t situational crisis, change in health status, fear of unknown, fear of pain and/or disfigurement

Knowledge deficit r/t pre/post operative procedures

Disturbed Sleep r/t anxiety about upcoming surgery

Pre-operative Nursing InterventionsEmotional Support

Utilize positive communication techniquestouch – eye contact validating statements

Active listeningEncourage verbalization of fears/anxietiesAvoid negative communication techniques

false-reassurancejudgmental statements

Pre-Operative Nursing InterventionsClient Teaching

Peri-operative progression & sensationsDescription of Pre and Post operative eventsDescription of events in OR and PACUPain managementCoughing & Deep Breathing ExercisesIncentive SpirometryTurning & Positioning Leg Exercises & Ambulation

Client TeachingPain Management

Pre-operative assessment of individual pain perception on 1-10 scale

Reassurance that pain reports WILL bebelieved and acted upon

Use of PCA Benefits of ATC versus PRNAllaying of fears regarding addictionPotential side-effects of narcoticsHow pain management promotes recovery

Client TeachingPulmonary Exercises

Method for diaphragmatic breathing:Hands on ribs, inhale thru nose allowing abdomen to expand, hold 3-5 sec, exhale thru pursed lips, 10X /hr while awake

Method for controlled coughingDeep breath X2 , then inhale,hold breath 2-3 sec, coughforcefully 2-3X consecutively

Method for splinting

Client TeachingPulmonary Exercises

Instruction on use of Incentive Spirometer:Take 2-3 normal breathes, close lips on mouthpiece, inhale to reach set goal, hold 3-5 sec, release mouthpiece & exhale, 10X/hr while awake.

Client TeachingActivity

LEG EXERCISESDorsi/Plantar flexion, ankle rotation, knee/hip flexion, 5X each leg/hr w.a.

AMBULATIONDiscuss importance of early ambulation and method for getting out of bed

TURNING AND POSITIONINGUse of side rails

External pneumatic compression devices (Sequentials, SCDs, Flowtron)

Pre-operative Nursing InterventionsPhysical Preparation of Client

Implementing dietary restrictionsInitiation of surgical prepsInsertion of tubes/drains/vascular accessCompletion of pre-operative checklistAdministration of pre-operative medication

Pre-operative Nursing ResponsibilitiesMedical Record Review

Informed ConsentHistory and PhysicalMedical Clearance Advance DirectivesAllergies / Previous anesthesia reactionsPresence of autologous blood bankLabs and Diagnostics

Intra-Operative Phase

Begins when client arrives in surgical area and lasts until they are in the PACU

Nursing Goals =Prevention of injury to clientMaintenance/Promotion of: oxygenation, cardiac output, balanced I & O

The Intra-operative Team

Surgeon Surgical Assistants: MD, PA, STAnesthesiologist and/or Nurse AnesthetistRegistered Nurses: Circulating, Scrub

Anesthesia

Anesthesia is defined as the absence of normal sensation. This also includes loss of protective reflexes!

Anesthesia provides:amnesia – analgesia – muscular relaxation

Stages I-IV of Anesthesia ( Guedel’s Signs)Types:

GeneralLocalConscious Sedation

General Anesthesia

Inhalation Intravenous Balanced = use of both

Mechanical Ventilation – presence of ET tube Use of adjuvant medications such as:

Hypnotics: VersedOpioids: FentanylNeuromuscular Blocking Agents: Pavulon Anectine

Important Factors in theCare of the Anesthetized Client

Use protective positioning techniquesHandle gentlyChange positions slowlyKeep client warm

Potential Complications ofGeneral Anesthesia

OverdoseUnrecognized hypoventilationComplications of intubationAnaphylaxisHypothermiaInjury r/t positioning, burnsMalignant hyperthermia

Malignant Hyperthermia

Rare but extreme emergencyOccurs most often with inhalantsGenetic predisposition Uncontrolled acceleration of muscle

metabolism and increased BMRLife threatening elevated temperature,

hyperkalemia, acidosis

Emergency Treatment of Malignant Hyperthermia

Stop surgical procedure/anesthesia if possible

Hyperventilate with 100% oxygenAdminister DANTROLENE intravenouslyUndertake body cooling measures:

Iced NS intravenouslyCooling blanket

Local Anesthesia

Advantages

Client remains conscious

Cost effective Minimal recovery time Vasoconstrictive

agents decrease bleeding

Disadvantages

Client remains conscious

Potential for local tissue irritation

Potential for sudden systemic reaction such as hypotension

Regional AnesthesiaTypes

Field BlockInjected around the operative field

Nerve BlockInto or around a nerve or nerve group

SpinalInto subarachnoid space

Epidural Into epidural space

Regional Anesthesia

Advantages

Patient remains conscious

No respiratory depression or irritation

Enhanced pain management post-operatively

Disadvantages

Patient remains conscious

Circulatory depression/stasis

Potential trauma/infection @ site of injection

Edema - potential for spinal headache

Conscious Sedation

IV administered hypnotic, opioid, or sedative

Reduces LOC but does not produce unconsciousness

Airway maintainedClient can respond to simple commandsProvides short amnesia actionCommonly used for: scopes, caths etc.

Intra-operative Nursing Diagnosis

Risk for positioning Injury Risk for Fluid Volume ImbalanceRisk for HyperthermiaPotential for HypoventilationRisk for AspirationRisk for Impaired Skin Integrity

(see EBP page 335 Iggy)“Pressure ulcers do occur in surgery”

Post-Operative Phase

Begins upon admission to the PACU and continues through entire recovery phase

Nursing Goals =Promoting physiological recovery of all body systems, prevention of complications, pain management, client teaching and emotional support

Focused Assessment in PACU

Respiratory – patent airway, + O2 status (Most common PACU complication)

CNS – monitor gradual return of function Surgical Incision site – bldg? drainage? Vital Signs – cardiac function

hypothalmus depression GI- nausea/vomiting common, aspiration risks GU- strict Intake and Output, check for retention

Comfort – administer analgesia IV per MD orders

Discharge CriteriaPACU

(Modified Aldrete Score) Consciousness

2 = Fully awake1 = Responds to name0 = No response

Activity on command2 = Moves all extremities1 = Moves two extremities0 = No movement

Respiration2 = Free deep breathing1 = Dyspneic, hyperventilating, obstructed breathing0 = Apneic

Circulation2 = Blood pressure within 20% of pre-op level1 = Blood pressure within 50%–20% of pre-op level0 = Blood pressure 50%, or less, of pre-op level

Oxygen saturation2 = SpO2 >92% on room air1 = Supplemental O2 required to maintain SpO2 >92%0 = SpO 2 <92% with O2 supplementation

Total Score10 = Score = 9 needed to leave PACU

Focused Assessmentfor Post-Operative Client

Upon arrival on Nursing Unit

VS – compare against PACU data, take frequently until stable

Respiratory status: auscultate, pulse ox Cardiac status: HR – peripheral pulses LOC Skin – surgical site and other areas Abdomen – listen for return of bowel sounds

check for distention ( flatus vs urine) Tubes – IV, NG, Drains, Foley Comfort – Administer analgesics; check PACU record

Nursing DiagnosisPost-Operative Clients

Acute PainRisk for Ineffective Tissue Perfusion r/t

hypovolemia, circulatory stasisRisk for Ineffective Breathing Pattern r/t

pain, effects of anesthesia/narcoticsRisk for Infection r/t invasive procedure,

respiratory stasisRisk for Deficient Fluid Volume r/t fluid

losses during surgery

Post-Operative Nursing Interventions

Prevention of complications:

Respiratory:-Assess for s/s pneumonia, atelectasis, pulmonary embolus-Encourage C & DB and Incentive Spiro-Position with HOB elevated-Encourage ambulation

Post-Operative Nursing Interventions

Prevention of complications

Cardiovascular:-Assess for s/s hemorrhage, shock, thrombophlebitis-Utilize sequential TEDs -Encourage leg exercises and/or ambulation-Position to promote venous return

Post-operative Nursing Interventions

Preventions of complications

Elimination:-Assess for s/s of constipation, urinary retention, ileus, UTI-Encourage ambulation -Maintain IV and/or PO fluid intake-Provide privacy, proper positioning and other strategies to promote elimination

Post-Operative Nursing Interventions

Prevention of Complications

Wound:-Assess for s/s of infection, dehiscence, evisceration-Promote wound healing through careful aseptic handling-Encourage balanced diet w/ sufficient protein, Vit C, Iron, Zinc- Administer prescribed antibiotics

Antibiotic Medications Students should research the following classes of

antibiotics for important nursing implications of each: (Chapter 37 & 38 Lilley)Penicillens Ex: UnasynCephalosporins Ex: RocephinSulfonamides Ex: BactrimTetracycline Ex: VibramycinAminoglycosides Ex: GentamicinQuinolines Ex: LevaquinMacrolides Ex: ErythromycinCarbapenems Ex: ImipenemMiscellaneous Ex: Vancomycin

Post-operative Nursing Interventions

Comfort and Rest:

Pain managementKeep linens clean and dryProvide for personal hygiene needsKeep environment quiet

Post-operative Nursing Interventions

Fluids and Nutrition:

Monitor I & OProvide good oral hygieneIce chips / water sipsAssess for return of peristalsisAssess for gag reflex Gradual diet progression – clear, full, soft

Post-Operative Nursing Interventions

Emotional support-Encourage expression of feelings-Utilize positive communication techniques

Knowledge deficit-teach wound care, s/s infection, dietary recommendations, activity restrictions, medication regime

Transfusion Therapy

Pretransfusion responsibilities:

Verify prescription and other concommitant orders Test donor’s and recipient’s blood for compatibility

ABO and Rh TYPE & CROSSMATCH Obtain consent and apply “blood bracelet”per hospital

policy Determine patency of IV AND angiocath lumen

(20gauge minimum) Collect supplies:

250 mL bag Normal SalineY-set blood tubing with filter

Pre-Tranfusion Responsibilities

Obtain blood product from lab per protocol With another nurse confirm:

- physician order- client identification

- blood bag label, attached tag, and requisition slip for ABO and Rh compatability

- client blood bracelet matches blood bank number on unit of blood to be administered

-expiration date Inspect blood for discoloration, gas bubbles, or

cloudiness.

Transfusion Responsibilities

Assess vital signs. Prime Y-tubing with NS

Gently agitate blood bagSpike and attach blood bag

Begin transfusion slowly and stay with client first 15 minutes. Take VS Q 5 minutes.

Ask client to report unusual sensations such as chills, shortness of breath, hives, or itching.

After 15 minutes without reaction increase flow rate to administer blood product per agency protocol.(usually 11/2 hr – 2 hrs for PC)

Continue to monitor client closely with VS q 15-q30m Flush line with NS after infusion is complete

Types of Transfusions

Packed red blood cellsPlateletsPlasma transfusions: fresh frozen

plasmaCryoprecipitateGranulocyte (white cell) transfusions

Transfusion Reactions

Clients can develop any of the following transfusion reactions: Hemolytic Allergic Febrile Bacterial Circulatory overload Iron overload Hypocalcemia Hyperkalemia

NURSING INTERVENTIONS

STOP TRANSFUSION

CHANGE IV TUBING

KEEP IV PATENT WITH NS

NOTIFY MD

Autologous Blood Transfusion

Collection and infusion of client’s own blood

Eliminates compatibility problems; reduces risk for transmission of bloodborne disease

Preoperative autologous blood donation

Intraoperative autologous transfusionPostoperative blood salvage