peri op aa

7/25/2019 peri op aa

1/128

Which patients require hospital staysafter surgery?

Trauma Pts, Acutely Ill Pts, MajorSurgery Pts

What are the ve categories ofsurgery ase! on urgency?"mergent, #rgent, $equire!, "lective,%ptional

&ene, 'ist In!ications, an! liste(amples of emergent surgery)*Patient requires imme!iate attention,

may e life threatening*Sche!ule surgery +ithout !elay*urns, Severe loo! loss, la!!er or -Iostruction, s.ull fracture, gun or sta+oun!

&ene, 'ist In!ications, an! liste(amples of urgent surgery)*Patient requires prompt attention

*Sche!ule +ithin /0*12 hrs*Acute gallla!!er infection,3i!ney4#tereral stones

&ene, 'ist In!ications, an! liste(amples of require! surgery)*Patient nee!s to have surgery*Sche!ule +ithin a fe+ +ee.s ormonths*Prostatic 5yperplasia +4o ostruction,

Thyroi!, 6ataracts

&ene, 'ist In!ications, an! liste(amples of elective surgery)*Patient shoul! have surgery*7ailure to not have surgery not


2/128

catastrophic*Scar repair, simple hernia, vaginalrepair

&ene, 'ist In!ications, an! liste(amples of optional surgery)*&ecision rests +ith patient*ase! on personal preference*6osmetic

'ist important factors nee!e! toevaluate el!erly patients regar!ingsurgery)

*&isease course *vs* 'ife "(pectancy*State of in!epen!ence*Personal Motivation*$is. factors *vs* non*operativemanagement

What is one of the most importantconsi!erations for el!erly surgicalpatients?

Positioning Which patients are especiallysusceptile to infection !uringsurgery?%ese patients !ue to fatty tissue

When !oes the preoperative phase ofsurgery egin?

egins +hen the !ecision to procee!+ith surgery intervention is ma!e)

When !oes the preoperative phase ofsurgery en!?"n!s +hen the patient is transfere! tothe %$ tale


3/128

&ene informe! consent)8oluntary an! +ritten communicationfrom Pt gathere! efore surgery is

performe! +hich ensures patient isprovi!e! all information to enale themto evaluate surgery efore agreeing toit)

Who otains informe! surgicalconsent?

The surgeon performing the proce!ure)

What are the four asic elements ofinforme! surgical consent?*&ocument that Pt or rep has capacityto ma.e me!ical !ecision*Surgeon !iscusses !etails regar!ing!iagnoses an! treatment so Pt canma.e me!ical !ecisions*Pt un!erstan!s !isclose! information*Pt freely authori9es a specic T( plan

+4o in:uence 'ist all preoperative healthassessmentsI4% Status, &rug4Alcohol use, respiratorystatus, car!io status, hepatic4renalfunction, en!ocrine function, immunefunction, me!ication use, psychosocialfactors, spiritual4cultural eliefs, genetic!isor!ers

'ist preoperative nursing managementpractices)*Appropriate time an! place forteaching*Prepare o+els an! s.in ;enema4ath


4/128

*A!minister pre*op me!s*Promote moility ;$oM restlessness, +ea. an! rapi!pulse, !rop in P, cool clammy s.in* Intervention> Provi!e pressure tolee!ing site, notify the physician,a!minister loo! as prescrie!, prepareclient for surgical proce!ure

Postoperative care, 6omplication,Shoc.* loss of circulatory :ui! volume* Assess for restlessness, +ea. an!

rapi! pulse, !rop in P, cool clammys.inIntervention> elevate the legs,!etermine the source of shoc., monitorlevel of consciousness an! 8S, inputan! output, assess color, temperature,


15/128

an! moisture of s.in an! mucousmemranes

Postoperative care, 6omplication,

thromophleitis* in:ammation of the vein accompanie!y clot formation* Assess> vein in:ammation, aching orcramping pain, veins feels har!ene!Intervention> monitor for leg s+elling,in:ammation, pain, ten!erness, venous!istention) "levate the e(tremity+ithout allo+ing any pressure, $%Me(ercise an! encourage earlyamulation

Postoperative care, 6omplication,#rine retention* involuntary accumulation of urine inthe la!!er as a result of loss of muscletone, cause! y the eGects of opioi!s* assess inta.e an! output, inaility tovoi!, restlessness, lo+er a!ominalpain, !isten!e! la!!er, on percussionla!!er soun!s li.e a !rum* Intervention, encourage earlyamulation, encourage :ui! inta.e,provi!e privacy, pour +arm +ater onthe perineum, catheteri9e the client

Postoperative care, 6omplication,6onstipation

* anormal infrequent passage of stool* Assess o+el soun!s, a!ominal!istention, anore(ia* Intervention, encourage :ui! inta.e upto 1222 ml4!ay, encourage early


16/128

amulation, provi!e privacy, a!ministerstool softener or la(atives as prescrie!

Postoperative care, 6omplication,

Paralytic Ileus* failure of appropriate for+ar!movement of o+el contents;anesthetic, or manipulation of o+els!uring surgery monitor inta.e an!output, maintain patient =P% untilo+el soun!s return, a!minister I8solution or P=, a!minister me!ication toincrease -I motility

Postoperative care, 6omplication,Woun! infection* Assess fever an! chills, +arm, ten!er,painful, an! in:ame! incision site, an!elevate! W6* Intervention> monitor temparture,incision sites, maintain patency of!rains, maintain asepsis an! changethe !ressing as prescrie!

Postoperative care, 6omplication,Woun! !ehiscence* seperation of the +oun! e!ge at thesuture line ;usually occurs B to C !aysafter surgery increase! !rainage, open+oun! e!ges* Intervention> place the client in lo+fo+lers +ith .nees ent, cover the+oun! +ith a sterile =S !ressing


17/128

Postoperative care, 6omplication,Woun! evisceration* protrusion of the internal organsthrough the incision

* Assess> !ischarge of serosanguineous:ui! from a previously !ry +oun!,appearance of loops of o+el or othera!ominal content* Intervention> place the client in lo+fo+lers +ith .nees ent, cover the+oun! +ith a sterile =S !ressing, notifyphysician

FBB) A nurse has just reassesse! thecon!ition of apostoperative client +ho +as a!mitte!F hourago to the surgical unit) The nurseplans to monitor+hich of the follo+ing parametersmostcarefully !uring the ne(t hour?F) #rinary output of /2 m'4hr

/) Temperature of 1H)B 6 ;DD)B 7*66> chec. loo! loss*"lectrolytes, #=, an! creatinine> on

pt +ho are =P%*6oagulation stu!ies*"6- an! series of troponin level*6hest N*$ays

What me!ication is useful forperioperative stro.e?Aspirin 1/Emg

What can cause sei9ures +ithout ahistory of sei9ure?metaolic !erangement, inclu!ingelectrolyte anormalities;hyponatremia, hypocalcemia,hypoglycemia, sepsis, fever, an! !rugs)*If none of the aove is i!entialethen eval +ith hea! 6T follo+e! y alumar puncture)

5o+ can you treat recurrent tonic*clonic sei9ure?Phenytoin

5o+ !o you treat status epilepticus?&ia9epam

Infectious complication +ith high

fever in the rst /0 hours iscommonly the result of astreptococcal or clostri!ial +oun!infection, aspiration pneumonitis, orpree(isting infection)Streptococcal +oun! infection present+ith severe local erythema an!


33/128

incisional pain) Pencillin - or ampicillinis eGective therapy)

1*E !ays postop

+hen is infection anticipate! post*op allo+ questions, e(plain +hy, han!leequipment+hat are goo! tips for school age chil!

allo+ to play +ith equipmentpreschool an! school age teachingpreop

antiiotics an! force :ui!s , 6S sampleimplementation of #TI

antiiotics, aseptic techniques, goo!nutritionimplementation of infection to +oun!from surgery

anticoagulantsimplementation of &8T

aseptic technique+hat type of sterile technique isfollo+e! !uring surgery

aseptic technique

+hat type fo technique is use! tochange! post op !ressing change

atelectasiscollapse of part or ;much lesscommonly< all of a lung)


34/128

atelectasis, pneumonias4s of !yspnea, cyanosis, cough,tachycar!ia, elevate! temp, pain on

aGecte! si!e o+el soun!s, =P%, mouth care, stool,:atus, T"& hose, S6&,assess postop

catheteri9e pt) or have client stan! iftolerate!implementation of urinary retention

!eep reathing, leg e(ercises,incentive spirometer+hat types of teaching are revie+e!efore surgery for post*op

!ehiscenceseparation of +oun! e!ges

!istraction, simple e(planations+hat are some tips for to!!lers eforeproce!ures

!ont cross legs or elevate .nees gatchtell client to avoi! these t+o positions

emolism

s4s !yspnea, pain, hemoptysis, restless,'o+ Pa%/, high P6%/ ;A-I=7"6TI%=SStrict aseptic technique is necessary

efore an! after surgery) If a nursenotices a rea. in aseptic technique sheis to notify the surgeon or %$ personnelimme!iately) The scru nurse an!circulating nurse count all surgicalinstruments, gau9e sponges, an!sharps to prevent retention of foreignojects in the +oun!)

Intraoperative 6omplications> 7'#I&8%'#M"the circulating nurse is responsile forrecor!ing an! .eeping a running total ofI8 :ui!s a!ministere!, theanesthesiologist usually a!!s :ui! tothe I8 lines, ut the circulating nursecan as +ell measure urine %P fromcatheter

Intraoperative 6omplications> I=@#$R$"'AT"& T% P%SITI%=I=-careful positioning of client on the tale!uring surgery help preventinterruption of loo! supply secon!aryto prolonge! pressure, nerve !amage,


60/128

hypo*tension, e!ema, an! joint injury!ue to alinement

Intraoperative 6omplications>

5RP%T5"$MIAclient may e at ris. for hypothermiarelate! to lo+ temp in %$ ;H2 !egMA'I-=A=T 5RP"$T5"$MIA

inherite! !isor!er +hen o!y temp,muscle metaolism, an! heatpro!uction increase rapi!ly SS> ja+muscle rigi!ity, rapi! rise in temp,elevate Pa6%/ an! serum potassium,tachycar!ia, tachypnea, !iaphoresis,mottles s.in, hypotension, irregular 5$,!ecrease! urine %P) If this occurs theanesthesia is !iscontinue! an! %$ teamimplements measures to reverse

Postoperative 6are> PA6# =urseManagement * Initial Post*%perativeAssessment$eport given, 6omplete Assessment*Priority> Air+ay patency, A!equate6irculation, Assess for initialpostoperative complications,5emorrhage, Shoc., 5ypo(ia

Aspiration) 7amily ale to visit)

Postoperative 6are> PA6# =urseManagement * 'ater Post*%perativeAssessment


61/128

=urse also evaluates rea!iness for!ischarge from PA6#> 8ital signs stale,o!y temperature control-oo! ventilatory function, %rientation

to surroun!ingsAsence of complications, Minimal pain,6ontrolle! +oun! !rainage, A!equateurine output

What is the PA6#?Postanesthesia 6are #nit

Al!rete Scale

use! to !etermine ho+ a patient isrecovery from anesthesia score of D orgreater in!icates recovery

Postoperative 6omfortPain assessment ;Pain Scale


62/128

Prevention of Postoperative6omplications> S5%637lui! an! electrolyte loss, trauma,

anesthetics an! post op me!s maycontriute) SS> pallor, fall in P, +ealrapi! pulse, restlessness, cool, moists.in) Treat early to prevent !amage torain, .i!neys an! heart)

Prevention of Postoperative6omplications> 5RP%NIA%(ygen an! suction equipment must e

availale oserve for SS of cyanosisan! !yspnea reposition client on si!eto relieve any ostructing, chec.tongue

Prevention of Postoperative6omplications> $"SPI$AT%$R=urse focuses on promoting gase(change an! preventing atelectasis)

teach client to !eep reathe an! cough,use incentive spirometer %/ may erequire! encourage early moility,frequent position changes, suction asnee!e!

Prevention of Postoperative6omplications> 6A$&I%8AS6#'A$Assess P an! circulation frequently'eg e(ercises ;moility


63/128

Prevention of Postoperative6omplications> -AST$%*I=T"STI%=A'6omplications> Paralytic ileus,a!ominal !istention

nausea vomiting, constipationInterventions> o+el assessment, earlyamulationAntiemetics as or!ere!, progression of!iet ;can usually ta.e :ui!s +ithin 0 */0hr #$I=A$R6omplications> acute urinary retention,#TIInterventions> Assist patient to assumenormal positions !uring elimination,Assess patient frequently for nee! tovoi!, Assess for la!!er !istention, I%if the client cannot voi! +ithin C hrs acatheter is inserte!

Prevention of Postoperative6omplications>I=T"-#M"=TA$R4W%#=&6omplications> Woun! infection, Woun!!ehiscenceWoun! evisceration, &elaye! +oun!healing, S.in rea.!o+nInterventions> Assessment of +oun!,Aseptic technique

5an!+ashing, Teach patient to splint+oun!Promote a!equate nutritional inta.e

Process of Woun! 5ealing> PrimaryIntention


64/128

+oun! layers are suture! together)5eals in C*F2 !ays +ith minimalscarring)

Process of Woun! 5ealing> Secon!aryIntention-ranulating tissue lls in +oun! ) S.inlayers are not appro(imate!)

Process of Woun! 5ealing> TertiaryIntention

The appro(imation of the +oun! e!geis !elaye! secon!ary to infection) When

+oun! is clean of infection the +oun!e!ges are appro(imate!) The scar is+i!er)

What must the nurse e a+are of toprompt +oun! healing?alert to SS of impaire! circulation,such as s+elling, col!ness, asence ofpulse, pallor, mottling an! report the

imme!iately) Provi!e a!equate nutritionan! :ui!s) %esity may contriute topoor +oun! healing e(cess fatprolongs length of surgery an!necessitates the use of forcefulretraction, a!! pressure to +oun!e!ges, !ecreases loo! :o+

Woun! &ehisceneseparation of +oun! e!ges +ithoutprotrusion of organs occurs +hen+oun! separates an! organ protru!esusually occur H *F2 after surgery placeclient in position that places the leaststrain on the +oun!$is. factors> ol!er than BE, chronic


65/128

!iaetes, hypotension, oesity,malnutrition, toacco use, !efectivesuturing

Serous &rainageclear, +atery plasma

Serosanguineous &rainage!rainage is a mi(ture of serous an!some loo! tinge!, seen +ith surgicalincisions) Pale, pin., +atery mi(ture ofclear an! re! :ui!

Sanguineous &rainagecapillary !amage* large $6, severein:ammation) right re! in!icatesactive lee!ing

Purulent &rainageJpusJ, severe in:ammation +4infection,contains leu.ocytes, liquee! !ea!cells, !ea! an! living acteria) Thic.,

yello+, green, tan, or ro+n &rains&rains * special equipment that pulls!rainage from the surgical area +hen+oun! has een close!

Penrose &rainruer type tue +ith openings on oth

en!s, !rainage accumulates on gau9e)

@) P) &rain * ;@ac.son*Pratt

Description:Planne! for correction ofa nonactive prolem)Condition of SurgicalProcedure:6ataract removal, herniarepair, hemorrhoi!ectomy, total jointreplacement)

#rgency of Surgery, #rgent>Description:$equires promptintervention may e life threatening iftreatment is !elaye! more than /0*0Chrs)Condition of SurgicalProcedure:Intestinal ostruction,la!!er ostruction, .i!ney or ureteral


69/128

stones, one fracture, eye injury, acutecholecystitis)

#rgency of Surgery, "mergent>

Description:$equires imme!iateintervention ecause of life*threateningconsequences)Condition of SurgicalProcedure:-unshot or sta +oun!,severe lee!ing, a!ominal aorticaneurysm, compoun! fracture,appen!ectomy)

&egree of $is. of Surgery, Minor>Description:Proce!ure +ithoutsignicant ris. often !one +ith localanesthesia)Condition of SurgicalProcedure:Incision an! !rainage;I&


70/128

Description:"(tensive surgery eyon!the area oviously involve! is !irecte!at n!ing a root cause)Condition of Surgical

Procedure:$a!ical prostatectomy,ra!ical hysterectomy)

"(tent of Surgery, Minimally InvasiveSurgery ;MISDescription:Surgery performe! in ao!y cavity or o!y area through oneor more en!oscopes can correctprolems, remove organs, ta.e tissuefor iopsy, re*route loo! vessels an!!rainage systems is a fast*gro+ing an!ever*changing type of surgery)Condition of SurgicalProcedure:Arthroscopy, tual ligation,hysterectomy, lung loectomy,coronary artery ypass,cholecystectomy)

$is. 7actors the Ac.no+le!ge In ThePreoperative Phase>Age;ol!er than BE


71/128

chest or high a!ominal proce!uresVpulmonary complications, a!ominalsurgery Vparalytic ileus, &8TMedical history;!ecrease! immunity,!iaetes, pulmonary !isease, car!iac!isease, hemo!ynamic instaility,multisystem !isease, coagulation!efect or !isor!er, anemia,!ehy!ration, infection, 5T=,hypotension, any chronic!isease


72/128

past present> me!s, !iet, allergies;late(*=ursing h( ;X*5ave the right to have or to initiatea!vance !irectives, such as living +ill or


73/128

!urale po+er of attorney)*A!vance !irectives provi!e legalinstructions to the health care provi!ersaout the patients +ishes an! are to

e follo+e!) Surgery does notprovide an exception to a patient$sadvance directives or living %ill#

=ame E "(pecte! %utcomes for&ecient 3no+le!ge =ursing&iagnosis>Patient +ill)))*"(plain the purpose an! e(pecte!results of the planne! surgery)*As. questions +hen a term orproce!ure is not .no+n*A!here to the =P% requirements*State an un!erstan!ing of preoperativepreparations ;e)g), s.in preparation,o+el preparation


74/128

Things to 6onsi!er WhenA!ministering $egularly Sche!ule!Me!ications>*Me!ical physicians anesthesia

provi!ers shoul! e consulte! forinstructions aout regularly ta.enprescription me!ications prior tosurgery)*&rugs for car!iac !isease, respiratory!isease, sei9ures, an! 5T= arecommonly allo+e! +ith a sip of +aterefore surgery)*&iaetic patient +ho ta.es insulin maye given a re!uce! or mo!ie! !ose of

interme!iate* or long*acting insulinase! on the loo! glucose level ormay e given regular ;fast*acting*Are performe! to prevent injury to thecolon an! to re!uce the numer ofintestinal acteria)*"nema or la(ative may e or!ere! ythe physician)*Perform s.in preparation to !ecreasethe ris. of impairment of s.in integrity)

S.in Preparation 6onsi!erations>*S.in prep efore surgery is the rststep in the prevention of surgical +oun!infection)*Provi!e a +arm, comfortale, an!private environment !uring theproce!ure since it can e


75/128

uncomfortale to the patient)*If pt is at home, he4she may sho+er+ith antiseptic solution / !ays eforesurgery if in hospital, sho+ering an!

cleaning are repeate! the night eforeor in the morning efore transfer tosurgical suite)

S.in Preparation 6onsi!erations 6ont>*The 6&6 recommen!s that if shaving isnecessary, the hair shoul! e remove!using !isposale sterile supplies an!aseptic principles imme!iately eforethe start of the surgical proce!ure)*Shaving is no+ consi!ere! aninappropriate hair removal metho!only clippers or !epilatories are to euse! for hair removal)

Preparing the Patient for Tues>)ubes:Pt may nee! an in!+ellingurinary catheter ;7oley< efore, !uring,or after surgery) A =- tue may einserte! efore a!ominal surgery to!ecompress or empty the stomach an!the upper o+el)

Preparing the Patient for &rains>Drains:are often place! !uring surgeryto help remove :ui! from the surgicalsite) Some !rains are un!er the!ressing others are visile an! require

emptying)

Preparing the Patient for 8ascularAccess>*ascular Access:is place! forpatients receiving a general anesthetic


76/128

an! most patients receiving other typesof anesthetics) Access is nee!e! to give!rugs an! :ui!s efore, !uring, an!after surgery)

*Patients +ho are !ehy!rate! or are atris. for !ehy!ration may receive :ui!sefore surgery)

Preoperative*Implementation>*Informe! consent*=utrition4:ui!s*I8 =P% after M=*"limination*enemas, foley)*5ygiene* s.in scru remove nailpolish, hair pins, hospital go+n)*8S 5eight4+eight*Special or!ers ;insert tues,me!ications*'eg an! !eep reathing e(ercises*$%M e(ercises*Moving patient*6oughing an! splinting

Preoperative Monitoring>*Patient an! !iagnostic tests*T"& soc.s, elastic +raps, pneumaticcompression !evices, an! earlyamulation)

&eep ;&iaphragmatic< reathing>F) Sit upright on the e!ge of the e! orin a chair, eing sure that your feet areplace! rmly on the :oor or stool) ;Aftersurgery, !eep reathing is !one +iththe patient in 7o+lers position or in


77/128

semi*7o+lers positionF) #nless coughing is contrain!icate!,place a pillo+, to+el, or fol!e! lan.etover surgical incision an! hol! the itemrmly in place)/) Ta.e 1 slo+, !eep reaths tostimulate your cough re:e()1) Inhale through nose, an! then e(halethrough mouth)0) %n 1r! !eep reath, cough to clear

secretions from lungs +hile rmlyhol!ing the pillo+, to+el, or fol!e!lan.et against incision)

Purpose of "(ternal Pneumatic6ompression &evices>


78/128

*To promote venous return an! prevent&8T)'+xamples:3en!all S6& machine,sleeves an! T"& stoc.ings 8eno!yne

pneumatic compression system7lo+tron &8T calf garments)

5o+ to relieve an(iety pre an! intra*operatively>&ecrease an(iety y provi!ing a climateof privacy, comfort, an! con!entiality)nterventions nclude:*Preoperative teaching*"ncouraging communication*Promoting rest*#sing !istraction*Teaching family memers

What to !o on the &ay of Surgery>*6omplete pre*op chec.list sheet inme!ical recor!, 8S, s.in prep removalof prosthetics, hair pins, !entures,o+el an! la!!er prep, T"&S, I8, =-

Tue, I& an!, an! pre*op me!ications)Ma.e sure la informe! ra!iologyreports on chart) e sure an) lasreporte! to M&)'A+-.+S

Preparation of Patients room forreturn after %$>I8 pole, open e!, suction, %(ygen,

emergency .its, an! clamps)

Preoperative Patient Prep>*Patient +ears an i!entication an!)*&entures, prosthetic !evices, hearing


79/128

ai!s, contact lenses, ngernail polish,an! articial nails must e remove!)

Me!ications 5a9ar!ous to Surgery>

Certain Antibiotics:comine! +ithcurariform muscle rela(ant causerespiratory paralysis an! apnea)Anti'Depressants:MA% inhiitors*secon! line choice for t( of !epression)6ause hypotension eGects ofanesthesia, St) @ohns Wart) Parnate,=ar!il)Phenothia/ines:;Thora9ine*antipsychotic) Also for severe =8,sei9ures< increase hypotension action ofanesthesia)

Me!ications 5a9ar!ous to Surgery6ont>Diuretics:electrolytes imalance an!resp !epression)Steroids:inhiits +oun! healingAnticoagulants:+arfarin an! heparin*aGect lee!ing, une(pecte! lee!ingherals*ASA, gin.o, =SAI&S, Ticli!,Plavi()

Intra %perative 6are>Primary concerns of the nurse is thesafety a!vocacy for the patient!uring surgery as the patient is unaleto protect or a!vocate for himself) It is

the responsiility of all of the surgicalteam memers to protect the patient)

Intraoperative 6are, 5ol!ing area>*"nter prior to %$ nurse continues toprepare patient ;insert 7oley or start


80/128

I8When the proce!ure involves a specicsite, vali!ating the si!e on +hich aproce!ure is to e performe! ;e)g), foramputation, cataract removal, herniarepair< is the responsiility of eachhealth care professional efore an! atthe time of surgery) 7acilities usuallyhave the patient an!4or nurse initial thecorrect surgical site)

=T3 efore the Surgery>*6o!e status*Any allergies*The position pt is suppose! to e in*Me!ical h(*What me!s have een ta.en*'ast P% inta.e)

B Positions for Surgery>

*Supine*Tren!elenurg> supine +ith feet slightlylo+ere!)*@ac.nife> li.e leaning over a tale +itharms out to the si!e*'ithotomy> supine +ith feet in stirrups)*'ateral*Prone

InsuYation>A minimally invasive proce!ure +heregas or air is injecte! into a o!y cavityefore surgery to separate organs an!improve visuali9ation)


81/128

What are the 0 types of Anesthesia?.eneral 0inhalation, *,balanced1:!epresses the 6=S,

resulting in analgesia amnesia, an!unconsciousness, +ith loss of muscletone an! re:e(es) #se! for surgery ofhea!, nec., upper torso, an! a!omen)-egional or local:Cryothermia:2ypnosis32ypoanesthesia:

-eneral Anesthesia, Inhalation>

Advantages:Most controllalemetho! in!uction an! reversalaccomplishe! +ith pulmonaryventilation fe+ S")Disadvantages:must e use! incomination +ith other agents forpainful or prolonge! proce!ures limite!muscle rela(ant eGects postopnausea and shiver commone(plosive)Common Agents: Suprance,+thrane, 4luothane5, 6itrous oxide067815

-eneral Anesthesia, I8>Advantages:$api! an! pleasantin!uction lo+ inci!ence of postop =48requires little equipment)Disadvantages:Must e metaoli9e!

an! e(crete! from the o!y forcomplete reversal contrain!icate! inpresence of hepatic or renal !iseaseincrease! car!iac an! respiratory!epression retaine! y fat cells)Common Agents: Pentothal5,


82/128

9etalar, Diprivan 2ypnotics li;eversed, ativan, valium are ad!unctsto general#

-eneral Anesthesia, alance!>Advantages:Minimal !isturance tophysiologic function minimal S" cane use! +ith ol!er an! high*ris.patientsDisadvantages:&rug interactions canoccur pharmacologic eGects on theo!y may e unpre!ictale)Z6ommon Agents> 6%MI=ATI%= %7>=itrous o(i!e, for amnesia morphinefor analgesia pavulon ;Pancuronium*%pioi! analgesic> alfenta, !emerol,morphine)*Anticholinergic> atropine, scopolamine*en9o!ia9epine> valium, verse!*Se!ative*hypnotics> atara(, vistaril,seconal, nemutal)

#se of %pioi! Analgesic for an A!junctAgent>'Anesthesia induction*Alfenta*&emerol an! Morphine> painprevention an! pain relief)

#se of Anticholinergic for an A!junctAgent>')o dry up excessive secretions*Atropine, scopolamine


83/128

#se of en9o!ia9epine for an A!junctAgent>'Amnesia and anxiety*8alium an! 8erse!

#se of Se!ative*5ypnotics for anA!junct Agent>'Amnesia and sedation*Atara(, 8istaril, Seconal, =emutal

A!vantages of $egional or 'ocalAnesthesia>Advantages: gag and cough

reexes stay intact 0decreases ris;for aspiration1 allo%s participationand cooperation by the ptless!isruption of physical emotional o!yfunctions !ecrease! chance ofsensitivity to agent !ecrease!intraoperative stress)

&isa!vantages of $egional or 'ocal

Anesthesia>Disadvantages: not practical forextensive procedures b3c of theamount that %ould be re


84/128

*=ovocain)opical:&ermoplast ;en9ocaine

6onscious se!ation is the I8 !elivery ofse!ative, hypnotic, an! opioi! !rugs tore!uce the level of consciousness utallo+ the patient to maintain a patentair+ay an! to respon! to veralcomman!s)

What are the / common agents use!in conscious se!ation?

8erse!, Ativan

4lum/a/enil3-oma/icon:reversalagent for en9o!ia9epines ;8erse!,Ativan*Patent air+ay ;A6s proper positioning*Maintain surgical asepsis*$is. for infection)*Surgical site> closure of surgical+oun!s +ith stitches, staples, or tapes)$is. for infection)

=ame H Intraoperative 6omplications>*5ypoventilation*%ral Trauma* en!otracheal intuation*5ypotension*6ar!iac !ysrhythmias*5ypothermia


86/128

*Peripheral nerve !amage*Malignant hyperthermia

Malignant 5yperthermia>

&ue to anormal an! e(cessiveintracellular collection of 6aQ resultingin hypermetaolism an! increase!muscle contraction)

Manifestations of Malignant5yperthermia>*Tachycar!ia, !ysrhythmias, musclerigi!ity ;especially of the ja+ an! upper

chest


87/128

*Intuate o(ygen F22L*6ooling> cooling lan.et, ice! I8 salineor ice! saline lavage of stomach,la!!er, rectum)

*More pg /HE 6hart FH*F =ame 1 6omplications &uringIntraoperative 6are>*%ver!ose of anesthesia*#nrecogni9e! hypoventilation*Intuation complications

Who is responsile for accompanying

pt an! provi!ing report to PA6#nurses? An! +hat must they provi!e?*Anesthesiologist an! circulating nurse*Must provi!e a J5an!*%G $eportJ+hich allo+s for /*+ay veralcommunications, information must eclear stan!ar!i9e! ;SA$

*Provi!es ongoing evaluation staili9ation of patients)*To anticipate, prevent, treat anycomplications of surgery)

5o+ often shoul! you loo. at thesurgical incision in PA6#?FEmin

What B things are monitore! in thePA6#?Air%ay:reathing appropriately?'aore!? Why?Mental Status:+hat is it? Is it


88/128

appropriate?Surgical incision:lee!ing? 'oo. at itqFEmin)*S:Temp4Pulse4P

* 4luids:solution type, amount inag, rate8ther )ubes3Drains:7oley, =-, trach,chest

What !o you imme!iately assess +henpt comes into PA6#?Imme!iately assess for patent air+ayan! a!equate gas e(change) Althoughsome patients may e a+a.e an! aleto spea., tal.ing is not a goo! in!icatorof a!equate gas e(change)

What is the or!er of return toconsciousness after generalanesthesia?F) Muscular irritaility/) $estlessness an! !elirium1) $ecognition of pain0) Aility to reason an! control ehavior

What is the or!er of return of motoran! sensory functioning after local orregional anesthesia?F) Sense of touch/) Sense of pain1) Sense of +armth0) Sense of col!

E) Aility to move

What type of assessments are veryimportant after epi!ural or spinalanesthesia?Motor an! sensory assessment


89/128

When !o you test for the return ofsympathetic nervous system tone?*egin after the patients sensation has

returne! to at least the spinal!ermatome level of TF2)*Rou test y gra!ually elevating thepatients hea! an! monitoring forhypotension)

What is the est in!icator of intestinalactivity?*The passage of :atus or stool)

*The presence of active o+el soun!susually in!icates return of peristalsisho+ever, the asence of o+el soun!s!oes not conrm a lac. of peristalsis)

=ame 0 causes of ineGective +oun!healing>*Infection*&istention from e!ema or paralytic

ileus*Stress at the surgical site*5ealth prolems ;e)g), !iaetes*A partial or complete separation of theouter +oun! layers, sometimes!escrie! as Jsplitting open of the+oun!J


90/128

*%ccurs most often et+een the Ethan! F2th !ays after surgery

Woun! "visceration>

*The total separation of all +oun! layersan! protrusion of internal organsthrough the open +oun!)*%ccurs most often et+een the Ethan! F2th !ays after surgery

What E patients !oes +oun!separation occur most in?*%ese

*&iaetic*Immune !eciency*Malnutrition*%nes using steroi!s

Patients are also at ris. for !evelopingpressure ulcers from>*Positioning !uring surgery, prolonge!contact +ith !amp surgical linens, an!

contact +ith unpa!!e! surfaces)*"(amine the patients s.in for areas ofre!ness or open areas)

What are 0 types of &rains?.ravity Drains:Penrose an! T*tue!rain !irectly through a tue from thesurgical area)Closed'Suction DrainageSystem:@ac.son*Pratt an! 5emovac!rain into a collecting vessel)

What is monitore! +ith the Penrose&rain?Monitor the !ressing for !rainage)


91/128

What is assesse! for the @ac.son Pratt 5emovac !rain?Assess suction> compress to re*charge)

C -ui!elines for Post*Surgical&ressings>*Surgeon changes Fst !ressing*6hange! to M& or!er specications orprotocol*#se aseptic technique untilsutures4staples remove!*#sually change! shift +4 sterilesaline) May e left open to air*Staples usually remove! after B*C!ays steri*strips use! remove! y M& ornurse*=ote site appearance, temp, !rainage*Montgomery Straps*Woun! Infections> TN !epri!ement

Montgomery StrapsAre recommen!e! to secure !ressingson +oun!s that require frequent!ressing changes) These straps allo+the nurse to perform +oun! care+ithout the nee! to remove a!hesivestrips thus !ecreasing ris. of s.inirritation an! injury)

They are prepares strips ofnonallergenic tape +ith ties inserte!through holes at one en!) %nset ofstraps is place! on either si!e of a

+oun! an! the straps are tie! li.eshoelaces)[ $eplace the ties an! straps +heneverthey are soile! or every /*1 !ays

=ame F2 6omplications in Postop>


92/128

*5ypotension*&ysrhythmia*8enous Thromosis*Pulmonary "molism

*5iccoughs*A!ominal !istention ;paralytic ileus 6holecystectomy or

total hip replacement Palliative surgery$elief of symptoms or enhancement offunction +ithout sure) "(ample>resection of a tumor to relief pressure)


94/128

6osmetic surgery$eshape normal o!y structures orimprove appearance or change a

physical feature) "(ample> $hinoplasty,cleft lip repair, Mammoplasty)

Preventive or prophylactic surgery$emoval of tissue that !oes not yetcontain cancer cells, ut has a highproaility of ecoming cancerous inthe future) "(ample> Prophylacticilateral oophorectomy)

$econstructive surgery$epair or reconstruct physical!eformities an! anormalities cause!y traumatic injuries, irth !efects,!evelopmental anormalities or!isease)

"mergency surgery

Imme!iate con!ition is life threatening,requiring surgery at once

#rgent surgeryWithin /0*12 hours client requiresprompt attention

$equire! surgeryPlanne! for a fe+ +ee.s or months

after !ecision client requires surgery atsome point

"lective surgery


95/128

6lient +ill not e harme! if surgery isnot performe! ut +ill enet if it isperforme!)

%ptional surgeryPersonal preference, cosmetic surgery

Surgical ris. factorsAge, nutritional status, sustanceause, me!ical prolems ;immune,respiratory, car!iovascular, hepatic,renal, en!ocrine eginning anesthesiaThis short perio! is crucial for pro!ucingunconsciousness) The cliente(periences !i99iness, !etachment, atemporary heightene! sense ofa+areness to noises movements sensation of JheavyJ e(tremities,unale to move)

Stage /> "(citement&uring this stage, the client maystruggle, shout, tal., sing, laugh, cry)May ma.e uncontrolle! movements,team memers shoul! protect the clientfrom falling or other injury) uic. smooth a!ministration of anesthesiacan prevent this stage)

Stage 1> Surgical anesthesia

In this stage, the client remainsunconscious through continuousa!ministration of the anesthetic agent)

This level may e maintaine! for hours+ith a range of light to !eepanesthesia)

Stage 0> Me!ullary !epression

This stage occurs +hen the clientreceives too much anesthesia) Theclient +ill have shallo+ respirations,+ea. pulse, an! +i!ely !ilate! pupilsunresponsive to light) Without promptintervention, !eath can occur)


100/128

$egional Anesthesia#ses local anesthetics to loc. thecon!uction of nerve impulses in a

specic region) The client e(periencesloss of sensation an! !ecrease!moility to the specic area) &o =%Tlose consciousness) They can ese!ative efore to promote rela(ationan! comfort !uring proce!ure)

A!vantages of regional anesthesia'ess ris. for respiratory, car!iac, or

gastrointestinal complications) Se!ation refers to>A pharmacologically in!uce! state ofrela(ation an! emotional comfort)

Proce!ural se!ation%r conscious se!ation !escries astate in +hich the client is free of pain,

fear, an! an(iety an! can tolerateunpleasant proce!ures the clientmaintains in!epen!entcar!iorespiratory function an! theaility to respon! veral comman!san! tactile stimulation)

AnesthesiologistA physician +ho has complete! / years

of resi!ency in anesthesia) They areresponsile for a!ministeringanesthesia to the client an! formonitoring !uring an! after surgicalproce!ure)

Anesthetist


101/128

May e a me!ical !octor +hoa!ministers anesthesia ut has notcomplete! a resi!ency in anesthesia, a!entist +ho a!ministers limite! types of

anesthesia, or an $= +ho hascomplete! an accre!ite! nurseanesthesia program an! passe! thecertication e(am) Are supervise! yan anesthesiologist)

#nrestricte! 9oneInclu!es a central point to monitor thearrival of the patients, personnel, an!supplies) Street clothes are allo+e! inthis area

Semirestricte! 9oneInclu!es the peripheral support areas ofthe surgical suite, +ith storage area forsterile an! clean supplies, +or. areasfor processing storage of instruments corri!ors lea!ing to the restricte!area of the %$) Personnel are require!to +ear surgical attire, inclu!ing t+o*piece pantsuits, cover jac.ets, an!caps)

$estricte! 9oneInclu!es the %$ an! proce!ure room,the clean core, an! scru sin. areas)Personnel are require! to +ear fullsurgical attire an! cover all hea!4 facial

hair) 7ull surgical attire inclu!es t+o*piece pantsuits, cover jac.ets, hea!coverings, shoe covers, mas.s,protective eye+ear, an! otherprotective arriers)


102/128

What is the temperature of the %$.ept at?elo+ H2 !egrees 7) to provi!e coolerenvironment that !oes not promote

acterial gro+th to oGer morecomfort for personnel)

Malignant hyperthermiaAn inherite! !isor!er that occurs +heno!y temperature, muscle metaolism,an! heat pro!uction increase rapi!ly,progressively, an! uncontrollaly inresponse to stress an! some anestheticagents)

Al!rete scaleA useful assessment tool in +hich ratesthe clients moility, respiratory status,circulation, consciousness, an! pulseo(imetry) A score of D or greaterin!icates that the client has recovere!from anesthesia)

WAT

Weight earing as tolerate!

=W=on +eight earing

'Ten!, lift, t+ist

T5PTotal hip precaution

AATA!vance! as tolerate!


103/128

'ater postoperative perio!egins +hen the client arrives in thehospital room or postsurgical care unit)

=ursing assessment !uring laterpostoperative perio!>$espiratory function vital signscar!iovascular function an! :ui! statuspain level o+el urinary elimination !ressings, tues, !rains, I8 lines)

=ursing management to prevent

postoperative respiratory prolems>Inclu!es early moility, frequentposition changes, !eep*reathing an!coughing e(ercises, an! use ofincentive spirometer)

Singultus5iccups

Postoperative pain reaches its pea.+hen?F/*1B hours after surgery an!!iminishes signicantly after 0C hours)

Three types of +oun! suction!evices4!rains>Penrose, @ac.son*Pratt, 5emovac

5o+ soon can most patients egin tota.e :ui!s after surgery?0*/0 hours

If patient is not allo+e! :ui!s +hatcan +e give them?


104/128

Mouth rinse, cool4+et cloth or ice chipsagainst the lips to relieve !ryness)

5o+ shoul! :ui!s e intro!uce! after

surgery?%nly a fe+ sips of +ater or ice chips ata time) -ive slo+ly an! in smallamounts to prevent vomiting) 6an usestra+, ut shoul! e !iscourage!ecause patient ten! to s+allo+ air as+ell, +hich can lea! to a!ominal!istention gastric !iscomfort)

In:ammatory stage7irst phase of +oun! healing +hen aloo! clot forms, s+elling occurs, an!phagocytes ingest the !eris from!amage! tissue the loo! clot) Phaselasts F*0 !ays)

Proliferative phaseSecon! phase of +oun! healing in

+hich collagen is pro!uce! granulation tissue forms) %ccurs over E*/2 !ays)

Maturation or remo!eling phase'ast phase of +oun! healing lasts from/F !ays to several months to even F*/years) &uring this phase, the tensilestrength of the +oun! increasesthrough synthesis of collagen yrolasts an! lysis y collagenaseen9ymes)

Three mo!es of +oun! healing>Primary intention, secon!ary intention,tertiary intention


105/128

Primary intention

The +oun! layers are suture! togetherso that +oun! e!ges are +ell

appro(imate!) This type of incisionusually heals in C*F2 !ays +ith minimalscarring)

Secon!ary intention-ranulating tissue lls in the +oun! forthe healing process) The s.in e!ges arenot appro(imate!) This metho! is use!for ulcers an! infecte! +oun!s) This

type of +oun! healing is slo+, althoughne+ pro!ucts, such as antimicroialun!er !ressings or calcium alginate!ressing, promote healing)

Tertiary intentionThe appro(imation of +oun! e!ges is!elaye! secon!ary to infection) Whenthe +oun! is !raine! cleane! of

infection, the +oun! e!ges are suture!together) The resulting scar is +i!erthan that +ith primary intention)

Woun! !ehiscence

The separation of +oun! e!ges +ithoutthe protrusion of organs

"visceration

%ccurs +hen the +oun! completelyseparates an! organs protru!e)

Anesthesiologistphysician that speciali9es in anesthesia


106/128

Anestheticagent use! to alter sensation so apro!ecure can e !one safely an!painlessly

&ehiscenceopening of a surgical +oun!

"viscerationorgan protru!es out+ar!

5ypothermiao!y temp elo+ DB !egrees 7

=urse anesthetistsame as anesthesiologist just a nurse)5as to have an anesthesiologistsupervision) ;!oesnt have to e in rom loo. ] 8S to assess

SS of hemorrhage an! hypovolemic

shoc.* increase! 5$, threa!y pulse,eventually !ecreases P, in an! out ofconsciousness* cool, clammy, pale s.in* restlessness

treatment of hemorrhage an!hypovolemic shoc.stop the lee!ing if possile, loo!4:ui!replacement, monitor I%, chec. I8, putin tren!elenurg to increase P

PA6# &46 criteria* pt a+a.e> may !o9e ac. oG ut aleto e a+a.ene!


119/128

* 8S stale* no e(cessive lee!ing or !rainage* no respiratory !epression* %/ SAT D2L ;still very lo+< * have pt

reath !eep* report given to nurse on the :oor

amulatory surgery &46 criteria* all PA6# &46 criteria met* no I8 narcotics for last 12 mins* minimal nausea an! vomiting* voi!e!* ale to amulate ;age appropriate, notcontrain!icate! !eep reathing,coughing ;splint the area for comfort fever, chills, pro!uctive cough,chest pain, !yspnea, purulent mucuscough* nursing strategies> antiiotics an!:ui!s, rest !uring treatment ;notmoving aroun! nee! to position

for full lung e(pansion* cough !eep reathing q/h* 8S* incentive spirometer* %/* :ui!s* me!s> maye pre*me!icate so they!ont have as much pain +ith coughingan! !eep reathing* amulation

* hy!ration

74" imalances* can cause car!iac prolems ;monitorP closelyvomiting, lee!ing, +oun! !rainage,suctioning ;measure suctioning

peri op aa

Documents

Transcript of peri op aa