NURS1921 Perioperative Nursing
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What is the purpose of administering PRE-OP ANTACIDS?
To decrease gastric acidity and volume.
What are some common PRE-OP ANTIACIDS and what is their action?
- Pepcid: Famotidine (generic). H2 Receptor antagonist. Blocks the action of histamine on parietal cells in the stomach which decreases the production of acid.
- Protonix: Pantoprazole (generic). Proton pump inhibitor. Long-lasting reduction of gastric acid.
What is the purpose of administering PRE-OP ANALGESICS?
- To facilitate patient sedation and relaxation.
- To decrease the amount of anesthetic agent needed.
What are some common PRE-OP ANALGESICS and what is their action?
- The following medications are all Opioid Agonists which bind to opioid receptors in the CNS, PNS and GI tract to reduce the perception of pain.
- Sublimaze: Fentanyl (generic)
- Morphine: Morphine Sulfate (generic)
- Dilaudid: Hydromorphone (generic)
- Demerol: Meperidine (generic)
What is the purpose of administering PRE-OP ANTIEMETICS?
- To decrease pulmonary and oral secretions.
- To prevent laryngospasm.
What are some common PRE-OP ANTIEMETICS and what is their action?
- Zofran: Ondansetron (generic). Serotonin 5HT3 receptor blocker. 5HT3 receptors in the GI mucosa play a major role in the nausea and vomiting reflex.
- Anzemet: Dolasetron (generic). Serotonin 5HT3 receptor blocker. 5HT3 receptors in the GI mucosa play a major role in the nausea and vomiting reflex.
- Phenergan: Promethazine (generic). Block H1 and dopamine receptors which have an inhibitory effect on the chemoreceptor trigger zone in the medulla, resulting in antiemetic properties.
- Compazine: Prochlorperazine (generic). Block H1 and dopamine receptors which has an inhibitory
- effect on the chemoreceptor trigger zone in the medulla, resulting in antiemetic properties.
- Reglan: Metoclopramide (generic). Dopaminergic blocker & GI motility stimulant which decreases nausea and vomiting.
- Transdermal Scopolamine: Scopalomine hydrobromide (generic). Anticholinergic which corrects the imbalance of acetylcholine and norepinephrine in the CNS, which may be responsible for motion sickness.
What is the purpose of administering PRE-OP ANTIANXIETY medications?
- To alleviate anxiety.
- Decrease recall of events related to surgery.
What are some common PRE-OP ANTIANXIETY medications and what is their actions?
- The following medications are all Benzodiazepines which enhance the effect of the neurotransmitter gamma-aminobutyric acid (GABA), which results in sedative, hypnotic (sleep-inducing) and anxiolytic (anti-anxiety) action.
- Versed: Midazolam (generic)
- Ativan: Lorazepam (generic)
- Valium: Diazepam (generic)
- Patient should not ambulate after administration.
What is DIAGNOSTIC/EXPLORATORY surgery?
- Performed to make or confirm a diagnosis.
- Examples: Breast biopsy, laparoscopy, cholecystectomy and exploratory laparotomy.
What is RECONSTRUCTIVE/COSMETIC surgery?
- Performed to restore function to traumatized or malfunctioning tissue or to improve self-concept.
- Examples: Scar revision, plastic surgery, skin graft, internal fixation of a fracture or breast reconstruction.
What is a CURATIVE/ABLATIVE surgery?
- Performed to remove a diseased body part.
- Examples: Appendectomy, subtotal thuroidectomy, partial gastrectomy, colon resection and amputation.
What is PALLIATIVE surgery?
- Performed to relieve or reduce intensity of an illness; it is not curative.
- Examples: Colostomy, nerve root resection, debridement of necrotic tissue, balloon antioplasties and athroscopy.
What is TRANSPLANTATION surgery?
- Performed to replace organs or structures that are diseased or malfunctioning.
- Examples: Kidney, liver, cornea, heart and joints.
What is an example of a PREVENTATIVE surgery?
- Performed to decrease risk of getting disease in future.
- Example: Prophylactic Mastectomy
What is EMERGENCY surgery?
- Surgery which needs to be performed immediately to preserve life, a body part or function.
- Examples: Control of hemorrhage, repair of trauma, perforated ulcer, intestinal obstruction or tracheotomy.
What is URGENT surgery?
- Surgery that must be done within a reasonably short time frame to preserve health, but is not an emergency.
- Examples: Removal of gallbladder, coronary artery bypass, surgical removal of a malignant tumor, colon resection or amputation.
What is ELECTIVE surgery?
- Surgery which is preplanned and based on the patient's choice and availability of scheduling.
- Examples: Tonsillectomy, hernia repair, cataract extraction and lens implantation, hemorroidectomy, hip prosthesis, scar revision, facelift and mammoplasty.
What is MAJOR surgery?
- Surgery performed to preserve life, restore function or improve/maintain health.
- Usually a higher degree of risk, requires hospitalization and has a higher incidence of complications.
- May be elective, urgent or emergency.
- Examples: Carotid endartetectomy, cholecystectomy, nephrectomy, colostomy, hysterectomy, radical mastectomy, amputation or trauma repair.
What is MINOR surgery?
- Surgery which is primarily elective and may restore function or correct deformities.
- Usually performed in a surgical center or outpatient facility with a low degree of risk and few complications.
- Patient is usually home the same day.
- Examples: teeth extraction, removal of warts, skin biopsy, dilation and curettage, laparoscopy, cataract extraction and arthroscopy.
What is the PREOPERATIVE PHASE?
Phase that begins with the decision to have surgery and lasts until the patient is transferred to the operating room.
What is the INTRAOPERATIVE PHASE?
Phase which extends from admission to the surgical department to transfer to the recovery room.
What is the POSTOPERATIVE PHASE?
Phase which lasts from admission to the recovery room to complete recovery from surgery.
What are some PREOPERATIVE CONSIDERATIONS for INFANTS & CHILDREN?
- Ease preoperative anxiety by using simple and concrete terms when providing information.
- Be sensitive to the anxiety level of the patient and provide support, explanations and patient teaching as needed.
- Accurate weights for correct medication dosages.
- Use developmentally appropriate pain assessment and therapy to ensure adequate pain management.
What are some PREOPERATIVE CONSIDERATIONS for the OLDER ADULT?
- Age-related changes and co morbidities can affect the postoperative course, be prepared.
- Present preoperative teaching information slowly with reinforcement since processing of information can be slower.
- Pain assessment and therapy may be suboptimal due to communication barriers and comorbidities so they need careful and individualized attention.
What are some POSTOPERATIVE CONSIDERATIONS for INFANTS & CHILDREN?
- After receiving general anesthesia, premature infants are at greater risk for apnea.
- Greater risk for temperature-related complication since their body temperature can change rapidly. Have warmed blankets and other warming equipment available to avoid complications.
What are some POSTOPERATIVE CONSIDERATIONS for the OLDER ADULT?
- Higher risk for postoperative pneumonia. Encourage incentive spirometry with deep-breathing exercises.May take longer to return to their normal level or orientation before surgery. Drugs and anesthetics will delay this return.
What should a nurse do if a patient's preoperative lab results are noted to be abnormal?
- Notify the primary care provider.
- Elevated INR & abnormal CBC may postpone surgery.
What should be done if a patient says to a nurse, "I am not sure I really want this surgery"?
- Discuss with the patient why he or she feels this way.
- Notify the primary care provider.
- Patients should not undergo surgery until they are sure that surgery is what they want.
What should be done if a patient's vital signs are progressively increasing or decreasing from the baseline after surgery?
- Notify the primary care provider.
- A continued decrease in BP or an increase in HR could indicate internal bleeding.
What should be done if a patient's dressing was previously clean but now has a large amount of fresh blood?
- Do not remove the dressing. Removing bandages could dislodge any clot that is forming and lead to further blood loss.
- Reinforce the dressing with more bandages.
- Notify the primary care provider.
What should be done if a postoperative patient reports that pain is not relieved by ordered medications?
- Fully assess pain location, description, alleviating factors & causal factors.
- Notify primary care provider.
- Pain can be a cue of other problems, such as hemorrhage.
What should be done if a postoperative patient is febrile within 12 hours of surgery?
- Assist the patient with coughing and deep breathing.
- If ordered, begin incentive spirometry.
- Continue to monitor vital signs and laboratory values, such as CBC.
What should be done if a adult postoperative patient has an unexpected urine output of < 30 mL/hr?
- Notify primary care provider.
- The patient may need more fluid or may need medication to increase BP if it is low.
- Urine output is a good indicator or tissue perfusion.
What are some CARDIOVASCULAR age related changes a nurse should anticipate in operative patients?
- Decreased cardiac output, stroke volume and cardiac reserve.
- Decreased peripheral circulation.
- Increased vascular rigidity.
- Nursing interventions: Baseline vital signs, assess peripheral pulses, teach leg exercises, turning and ambulating, document normal activity levels and tolerance of fatigue, monitor fluid administration rate and allow sufficient time for effects of medications to occur.
What are some RESPIRATORY age related changes a nurse should anticipate in operative patients?
- Reduced vital capacity.
- Diminished cough reflex.
- Decreased oxygenation of blood.
- Decreased chest expansion and strength of intercostal muscles and diaphragm.
- Nursing interventions: Baseline RR and depth, teach coughing and deep-breathing exercises, teach use of incentive spirometer, assess color of skin and explain the use of the pulse ox for monitoring postoperative oxygenation.
What are some CNS age related changes a nurse should anticipate in operative patients?
- Decreased reaction time and coordination.
- Reduced short-term memory.
- Sensory deficits.
- Decreased thermoregulation ability.
- Nursing interventions: orient to surroundings, institute safety measures (keep environment clear of clutter and use a night light), allow additional time for teaching and use appropriate measures to preserve body temperature.
What are some RENAL age related changes a nurse should anticipate in operative patients?
- Decrease renal blood flow.
- Reduced bladder capacity.
- Nursing interventions: monitor amount and times of voiding, monitor fluid and electrolyte status and maintain and record I&O.
What are some GI age related changes a nurse should anticipate in operative patients?
- Increased gastric pH.
- Prolonged gastric-emptying time.
- Decreased hepatic blood flow, liver mass and enzyme function.
- Nursing interventions: Baseline weight, monitor nutritional status and observe for prolonged effects of medications.
What are some INTEGUMENTARY age related changes a nurse should anticipate in operative patients?
- Decreased vascularity.
- Decreased skin moisture and elasticity.
- Decreased subcutaneous fat.
- Nursing interventions: assess skin status, monitor fluid status, pad and protect bony prominences, monitor skin for pressure areas and use minimal amounts of tape on dressings and IV sites.
How can the use of ANTICOAGULANTS affect perioperative patients?
- May precipitate hemorrhage.
- Coumadin cessation for 5-7 before surgery. May switch to heparin which has a shorter half-life.
- In emergency situations when there is not enough time to discontinue the coumadin before the surgery, fresh frozen plasma and vitamin K may be given to reverse the anticoagulation effects of the coumadin.
How can the use of DIURETICS affect perioperative patients?
May cause electrolyte imbalances which may result in respiratory depression from anesthesia.
How can the use of ANTIBIOTICS affect perioperative patients?
When combined with certain muscle relaxers used during surgery may result in respiratory paralysis.
How can the use of ANTIDIABETIC MEDICATIONS affect perioperative patients?
- Because patient is NPO may affect serum glucose levels.
- Long acting medications (NPH and Lantus) may be stopped.
How can the use of STEROIDS affect perioperative patients?
- Abrupt withdraw may cause cardiovascular collapse.
- May affect serum glucose levels.
How does a patient's NUTRITIONAL STATUS affect surgical risk?
- Malnutrition: higher risk for alterations in fluid & electrolyte balance, delay in wound healing and wound infection.
- Obesity: increased risk for respiratory (apnea), cardiovascular and positional injury. Also greater risk for DVT & GI (GERD) problems. Less resistance to infection, delayed wound healing and compromised skin integrity.
How does a patient's use of ALCOHOL affect surgical risk?
- They are at risk for withdraw.
- Medications may need to be administered.
What information should an INFORMED CONSENT include?
- Description of the procedure or treatment along with potential alternative therapies.
- The underlying disease process and its natural course.
- Name and qualifications of the person performing the procedure or treatment.
- Explanation of the risks involved, including risk for damage, disfigurement or death and how often they occur.
- Explanation that the patient has the right to refuse treatment and that consent can be withdrawn.
- Explanation of the expected outcome, recovery and rehabilitation plan and course.
What is an ADVANCE DIRECTIVE and examples?
- A legal document which allows the patient to specify instructions for healthcare treatment should be or she be unable to communicate these wishes postoperatively.
- Living will
- Durable power of attorney
What is the nurse's role the DAY OF SURGERY?
- Review health history.
- Review preoperative check list.
- Administer pre-op medications.
- Prepare patient for what to expect in each phase of surgery.
- Address any questions for the anesthesiologist.
- Verify informed consent has been signed.
- ID the patient and mark the surgical site.
What are some SOCIOCULTURAL FACTORS which affect a patient's perception/reaction to a surgical experience?
- Reaction to pain varies by culture
- Language barriers: Patient does not speak English.
- Family dynamics: Mother died on operating table.
- Cultural variations regarding treatment of illness: No blood transfusions for Jehovah's Witnesses.
What would be RELATED FACTORS & DEFINING CHARACTERISTICS to a postoperative nursing diagnosis of UNRIARY RETENTION?
- Related Factors: any condition that causes incomplete emptying of the bladder, such as neurological effects of anesthesia.
- Defining Characteristics: Urine not eliminated for > 8 hrs, distended/palpable bladder, small/frequent voiding or residual urine.
What would be RELATED FACTORS & DEFINING CHARACTERISTICS to a postoperative nursing diagnosis of ACUTE PAIN?
- Related Factors: any condition that causes actual tissue damage, such as the surgical incision.
- Defining Characteristics: Rating pain as severe on a scale of 0-10 (i.e. as a 9), positioning or guarding self to avoid pain, inability to sleep, loss of appetite, diaphoresis, changes in vital signs, dilated pupils, moaning, crying or sighing.
What would be RELATED FACTORS & DEFINING CHARACTERISTICS to a postoperative nursing diagnosis of DISTURBED BODY IMAGE?
- Related Factors: any condition that causes confusion in the mental image of oneself, including surgical incision, removal of body part, and inability to use body as one did before surgery.
- Defining Characteristics: Verbalization of altered view of one's body in appearance, structure or function, refusal to look at incision or area of surgical treatment, Actual change in one's body from surgery or trauma, actual missing body part or verbalizations of negative feelings about body.
What would be RELATED FACTORS & DEFINING CHARACTERISTICS to a postoperative nursing diagnosis of RISK FOR INFECTION?
- Related Factors: any condition that interferes with normal inflammatory healing process or provides an entry for infectious agents.
- Defining Characteristics: (Risk Factors) Obesity, aging, immunosuppression, malnutrition, presence of incision, decreased ability to cough, deep breath or use incentive spirometer, presence of drains, tubes and catheters and insertion site for IV therapy.
What is ATELECTASIS?
- The incomplete expansion or collapse of alveoli with retained mucus, involving a portion of lung and resulting in poor gas exchange.
- Manifestations: decreased lung sounds, dyspnea, cyanosis, crackles, restlessness and apprehension.
- Primary Goal: ensure oxygenation of tissues.
- NUMBER ONE CAUSE OF ELEVATED TEMPERATURE IN POST-OP PATIENTS
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