perioperative nursing

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perioperative nursing
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perioperative nursing
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  1. surgery
    is an intervention in which the knowledge and skill of multiple care providers are combined for the welfare of the patient. May be done for a variety of reasons: to cure or minimize disease; to diagnose the specific presence of a disease or condition; to reconstruct or eliminate a defect; to enhance form and function; to prescribe appropriate postoperative treatment and prognosis; to palliate, or offer comfort, when cure is not possible; to follow up or monitor an incurable disease process; and to offer a preventative option when disease is inevitable, such as an elective, prophylactic mastectomy for a woman at high risk for breast cancer. It may be planned or unplanned, elective/optional or necessary, major or minor, and may involve any body part or system. It is a stressor that requires physical and psychosocial adaptations for both the patient and the family. The patient’s recovery from a surgical procedure requires skillful and knowledgeable nursing care, whether the surgery is done on an outpatient basis or in the hospital.
  2. perioperative nursing
    Nursing care provided for the patient before, during, and after surgery.
  3. perioperative continuum
    encompasses the preoperative, intraoperative, and postoperative phases for the patient. This term is used by all members of the interdisciplinary team, including nursing.
  4. perioperative period
    The patient who is having surgery progresses through several distinct phases.
  5. The three phases of perioperative patient care are:
    • • The preoperative phase, beginning when the patient and surgeon mutually decide that surgery is necessary and will take place. It ends when the patient is transferred to the operating room (OR) or procedural bed.
    • • The intraoperative phase, beginning when the patient is transferred to the OR bed, also called a table, until transfer to the postoperative recovery area.
    • • The postoperative phase, lasting from admission to the recovery area to complete recovery from surgery and the last follow-up physician visit.
  6. The postoperative phase can be further divided into:
    phase I (providing patient care from a totally anesthetized state to one requiring less acute nursing interventions), phase II (preparing the patient for self or family care or for care in a phase III extended care environment), and phase III (providing ongoing care for patients requiring extended observation or intervention after transfer or discharge from phase I or II).
  7. Elective
    • is a procedure that is preplanned and based on the patient’s choice and availability of scheduling for the patient, surgeon, and facility. This is a nonurgent procedure that does not have to be done immediately. Delay of surgery has no ill effects; can be scheduled in advance based on patient’s choice. 
    • Purpose:
    • • To remove or repair a body part
    • • To restore function
    • • To improve health
    • • To improve self-concept
    • • To remove or repair a body part
    • • To preserve or restore health
    • • To prevent further tissue damage
    • • To preserve life (plus purposes listed above)
    • Examples: Tonsillectomy, hernia repair, cataract extraction and lens implantation, hemorrhoidectomy, hip prosthesis, scar revision, face lift, mammoplasty.
  8. Urgent
    • must be done within a reasonably short time frame to preserve health, but is not an emergency. Usually done within 24–48 hours
    • Purpose:
    • • To remove or repair a body part
    • • To restore function
    • • To improve health
    • • To improve self-concept
    • • To remove or repair a body part
    • • To preserve or restore health
    • • To prevent further tissue damage
    • • To preserve life (plus purposes listed above)
    • Examples: Removal of gallbladder, coronary artery bypass, surgical removal of a malignant tumor, colon resection, amputation.
  9. Emergency
    • must be done immediately to preserve life, a body part, or function. Done immediately.
    • Purpose:
    • • To remove or repair a body part
    • • To restore function
    • • To improve health
    • • To improve self-concept
    • • To remove or repair a body part
    • • To preserve or restore health
    • • To prevent further tissue damage
    • • To preserve life (plus purposes listed above)
    • Examples: Control of hemorrhage; repair of trauma, perforated ulcer, intestinal obstruction; tracheostomy
  10. Major surgery
    • may require hospitalization and specialized care, is usually prolonged, has a higher degree of risk, involves major body organs or life-threatening situations, and has a greater risk for postoperative complications. May be elective, urgent, or emergency.
    • Purpose:
    • • To preserve life
    • • To remove or repair a body part
    • • To restore function
    • • To improve or maintain health
    • • To remove skin lesions
    • • To correct deformities
    • Examples: Carotid endarterectomy, cholecystectomy, nephrectomy, colostomy, hysterectomy, radicalmastectomy, amputation, trauma repair
  11. Minor surgery
    • Is almost always performed in settings such as a physician’s office, an outpatient clinic, or a same-day, outpatient surgery setting. This classification means that the surgical procedure is usually brief, carries a low risk, and results in few complications. Primarily elective.
    • Purpose: 
    • • To preserve life
    • • To remove or repair a body part
    • • To restore function
    • • To improve or maintain health
    • • To remove skin lesions
    • • To correct deformities
    • Examples: Teeth extraction, removal of warts, skin biopsy, dilation and curettage, laparoscopy, cataractextraction, arthroscopy.
  12. Diagnostic
    • Purpose: to make/confirm a diagnosis.
    • Examples: Breast biopsy, laparoscopy, bronchoscopy, exploratory laparotomy
  13. Ablative
    • Purpose: to remove a diseased body part.
    • Example: Appendectomy, subtotal thyroidectomy, partialgastrectomy, colon resection, amputation
  14. Palliative
    • Purpose: to relieve/reduce intensity of an illness; is not curative
    • Example: Colostomy, nerve root resection, débridement of necrotic tissue, balloon angioplasties, arthroscopy
  15. Reconstructive
    • Purpose: to restore function to traumatized/malfunctioning tissue.
    • Example: Scar revision, plastic surgery, skin graft, internal fixation of a fracture, breast reconstruction.
  16. Transplantation
    • Purpose: to replace organs/structures that are diseased/malfunctioning.
    • Example: Kidney, liver, cornea, heart, joints.
  17. Constructive
    • Purpose: to restore function in congenital anomalies.
    • Example: Cleft palate repair, closure of atrial–septal defect
  18. Anesthesia
    is a method and technique of making potentially uncomfortable interventions tolerable and safe.
  19. Anesthetic agents
    can be administered systemically, to the whole body, or regionally to block nerve conduction.
  20. General, or systemic, anesthesia
    is a balance of loss of consciousness, analgesia (pain relief), relaxation, and loss of reflexes (temporary paralysis).
  21. regional anesthesia
    does not cause narcosis, or sleepiness, but results in analgesia and reflex loss.
  22. Anesthesiologists (medical doctors) or certified registered nurse anesthetists (CRNA)
    administer anesthetic agents while monitoring the patient’s physiologic response and maintaining homeostasis throughout the procedure and recovery.
  23. General anesthesia
    involves the administration of drugs by the inhalation or intravenous (IV) route to produce central nervous system depression. General anesthesia typically is a combination of both intravenous and inhalation anesthetics. The desired actions of general anesthesia are loss of consciousness, analgesia, relaxed skeletal muscles, and depressed reflexes. Choices of route and type of anesthesia are made primarily by the anesthesia provider after discussion with the patient. Many factors influence these choices, including the type and length of surgery and the physical and psychological status of the patient. Inhalation anesthesia is often used because it has the advantage of rapid induction, excretion, and reversal of effects. General anesthesia is advantageous because it can be used for patients of any age and for any surgical procedure, with the patient unaware of the physical trauma of the surgery. There are, however, major associated risks for circulatory and respiratory depression, postoperative nausea and vomiting, and alterations in thermoregulation.
  24. three phases of general anesthesia
    induction, maintenance, and emergence. Induction begins with administrationof the anesthetic agent and continues until the patient is readyfor the incision. Maintenance continues from this point until near the completion of the procedure. Emergence starts as the patient begins to awaken from the altered state induced by the anesthesia and usually ends when the patient is ready to leave the operating room; the length of time depends on the depth and length of anesthesia. New anesthetic agents enable patients to emerge from anesthesia and “wakeup” in a fraction of the time required in the past. As these agents become more commonly used, patients will frequently bypass the PACU. This will enable more surgical procedures to be safely done in doctors’ offices.
  25. Regional anesthesia
    occurs when an anesthetic agent is injected near a nerve or nerve pathway in or around the operative site, inhibiting the transmission of sensory stimuli to central nervous system receptors. The patient receiving regional anesthesia remains awake, but loses sensation in a specific area or region of the body. In some instances, reflexes may also be lost. Although regional anesthesia may be selected for numerous types of surgery and patients, it is especially useful in reducing postsurgical pain, bowel dysfunction,and length of hospital stay for older adult patients. Regional anesthesia may be accomplished through major nerve blocks or through spinal (subarachnoid block), caudal, or epidural blocks.
  26. Nerve blocks
    are accomplished by injecting a local anesthetic around a nerve trunk supplying the area of surgery such as the jaw, face, and extremities. Onset and duration of the block depend on the anesthetic drug, its concentration, the amount injected, and the addition of epinephrine, which prolongs the block.
  27. spinal anesthesia
    is achieved by injecting a local anesthetic into the subarachnoid space through a lumbar puncture, causing sensory, motor, and autonomic blockage. This type of anesthesia is used for surgery of the lower abdomen, perineum, and legs. Adverse effects of spinal anesthesia may include hypotension, headache, and urine retention.
  28. caudal anesthesia
    is the injection of the local anesthetic into the epidural space through the caudal canal in the sacrum; it may be used for procedures on the lower extremities or perineum.
  29. Epidural anesthesia
    involves the injection of the anesthetic through the intervertebral spaces, usually in the lumbar region (although it may also be used in the thoracic or cervical regions). It is used for surgeries of the arms, shoulders, thorax, abdomen, pelvis, and legs.
  30. topical anesthesia
    is used on mucous membranes, open skin surfaces, wounds, and burns. Cocaine in a 4% to 10% solution is the most commonly used agent; others are lidocaine and bupivicaine. Topical anesthetics may be sprayed, spread, or applied with a compress of drug-saturated gauze or cotton tipped applicators.
  31. local anesthesia
    is the injection of an anesthetic agent such as lidocaine, bupivicaine, or tetracaine to a specific area of the body. It is administered by the surgeon in minor, short-term surgical or diagnostic procedures such as tissue biopsy. It bathes the tissue around a targeted nerve or infiltrates the underlying tissue in the operative area. Epinephrine may be mixed with the local anesthetic to minimize bleeding by causing local vasoconstriction. It also helps to prolong the length of analgesia by trapping the anesthetic in the tissue through slowed absorption that results from the vasoconstriction of the surrounding vessels. Local anesthesia may also be injected during general anesthetic procedures to prolong pain relief after the general anesthetic wears off.
  32. Moderate sedation/analgesia, also called conscious or procedural sedation
    is used for short-term and minimally invasive procedures. The patient maintains cardiorespiratory function and can respond to verbal commands while the IV administration of sedatives and analgesics raises the pain threshold and produces an altered mood with some degree of amnesia. The patient retains the ability to keep his/her airway open and can respond appropriately. This type of anesthesia is often administered by a perioperative, endoscopy, interventional radiology or interventional cardiology nurse with specialized training and competence in administering the medications and monitoring the patient’s cardiac rate and rhythm, respiratory rate, oxygen saturation, level of consciousness, level of pain, blood pressure, and skin condition.
  33. What is included in the informed consent?
    • • 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 expected outcome, recovery, and rehabilitation plan and course
  34. What is the nurse's role in an informed consent?
    The nurse may sign as a witness, signifying that the patient signed the consent form without coercion and was alert and aware of the act. The patient always has the right to refuse treatment.
  35. Consent forms are not legal if:
    • -the pt is confused
    • -the pt is unconscious
    • -is sedated
    • -is mentally incompetent
    • -or is a minor (as determined by state laws). Consent may be given in those instances by a parent, spouse, next of kin, or legal guardian. 
    • (In emergency situations, the physician may obtain consent over the telephone or by court order.)
  36. outpatient/same-day (also referred to as ambulatory) surgery
    have become more common, as the HC system has reduced the length of hospital stays to lower HC costs. These surgical settings may be found as freestanding units, in hospitals, and in physicians' offices. Some freestanding surgery centers specialize in selected types of surgery, such as orthopedics or hernia repair. Others perform a wide variety of surgical interventions, including major surgical procedures that formerly required as much as a 3-week stay in a hospital. Typically, pts are admitted to the HC setting the morning of surgery. Allowing the pt to spend the night before surgery at home and to return to his/her own home to recover, reduces much of the stress associated with surgery. Pts who are older/chronically ill or who do not have support systems or access to resources to provide the care needed after surgery may require additional teaching and referral to home care services.
  37. Some of the desired outcomes that frame the plan of care for the surgical patient:
    • • Be free from injury and adverse effects related to positioning, retained foreign objects, or chemical, physical, or electrical hazards
    • • Be free from infection
    • • Maintain fluid and electrolyte balance and skin integrity
    • • Maintain normal body temperature
    • • Be free from deep vein thrombosis (DVT, formation of a blood clot [“thrombus”] in a deep vein)
    • • Have their pain managed
    • • Demonstrate an understanding of the physiologic and psychological responses to the planned surgery
    • • Participate in a rehabilitation process following surgery
  38. Preop assessment of the surgical patient includes:
    • • Obtaining a health history and performing a physical assessment to establish a baseline data base
    • • Identifying risk factors and allergies that could pose surgical complications
    • • Identifying medications and treatments the patient is currently receiving
    • • Determining the teaching and psychosocial needs of the patient and family
    • • Determining postsurgical support and referral needs for recovery
  39. preadmission testing
    assessment that is often conducted several days before surgery as part of preoperative laboratory screening and teaching. It maybe conducted in the hospital, a surgical clinic, an office, or even in the patient’s home.
  40. PREOPERATIVE INFORMATION FOR OUTPATIENT/SAME-DAY SURGERY
    • Provide verbal and written instructions for patients having outpatient/same-day surgery as follows:
    • • List medications routinely taken, and ask the physician which should be taken or omitted the morning of surgery.
    • • Notify the surgeon’s office if a cold or infection develops before surgery.
    • • List allergies, and be sure the operating staff is aware of these.
    • • Remove nail polish and do not wear makeup for the procedure.
    • • Leave all jewelry and valuables at home.
    • • Wear clothing that buttons in front; short-sleeved garments are better for surgery on the hands.
    • • Have someone available for transportation home after recovery from anesthesia.
    • Inform patient of:
    • • Limitations on eating or drinking before surgery, with a specific time to begin the limitations.
    • • When and where to arrive for the procedure, as well as the estimated time when the procedure will be performed.
  41. • Assess skin status.
    • • Monitor fluid status.
    • • Pad and protect bony prominences.
    • • Monitor skin for pressure areas.
    • • Use minimal amounts of tape on dressings and intravenous sites.
  42. what does a health history include?
    health history identifies risk factors and strengths in the patient’s physical and psychosocial status and helps the nurse to individualize the preoperative assessment. Health history information significant to the surgical experience includes the patient’s developmental level; medical history; medications;previous surgeries; perceptions and knowledge of the surgery to be done; nutrition; use of alcohol, illicit drugs, or nicotine;activities of daily living and occupation; coping patterns and support systems; and sociocultural needs.
  43. Developmental Considerations
    Infants and older adults are at a greater risk from surgery than are children and young or middle-aged adults. The infant has a lower total blood volume, making even a small loss of blood a serious concern because of the risk for dehydration and the inability to respond to the need for increased oxygen during surgery. In addition, the airway is small, soft, and pliable and infants and small children frequently have upper respiratory infections, such as colds, that can cause airway obstruction and hypoxia. This patient population can quickly develop bronchospasm, stridor, and respiratory arrest. If a child exhibits signs of even mild respiratory infections on the day of surgery, their procedure will be postponed until it resolves. The infant also has difficulty maintaining stable body temperature during surgery because the shivering reflex is not well developed, making hypothermia or hyperthermia more likely. Their lower glomerular filtration rate and creatinine clearance can lead to a slower metabolism of drugs that require renal biotransformation. Because the liver is immature until after the first year of life, the effects of muscle relaxants and narcotics may be prolonged. Physiologic changes associated with aging increase the surgical risk for older patients.These changes decrease older adults’ ability to respond to the stress of surgery, alter the effects of preoperative and postoperative medications and anesthesia, and prolong or alter wound healing processes. With an increasing older adult population, assessing physiologic changes is crucial to providing knowledgeable, safe, holistic nursing care to older surgical patients. Chronic illnesses, more common in the older population, also increase surgical risk and may require alterations in usual perioperative procedures. For example, a patient with congestive failure may be more easily fatigued and thus unable to be up and about as rapidly after surgery.
  44. medical history
    • Provides information about past and current illnesses. Pathologic changes associated with past and current illnesses increase surgical risk as well as the risk for postoperative complications. Preoperative assessments and documentation are necessary to provide a database for individualized assessments and interventions in the intraoperative and postoperative phases of care. Examples of diseases and associated risks may include:
    • • Cardiovascular diseases, such as thrombocytopenia, hemophilia, recent myocardial infarction or cardiac surgery, heart failure, and dysrhythmias, increase the risk for hemorrhage and hypovolemic shock, hypotension, venous stasis, thrombophlebitis, and overhydration with IV fluids.
    • • Respiratory disorders, such as pneumonia, bronchitis,asthma, emphysema, and chronic obstructive pulmonary diseases, increase the risk for respiratory depression from anesthesia as well as postoperative pneumonia, atelectasis, and alterations in acid–base balance.
    • • Kidney and liver diseases influence the patient’s response to anesthesia, affect fluid and electrolyte as well as acid–base balance, alter the metabolism and excretion of drugs, and impair wound healing.
    • • Endocrine diseases, especially diabetes mellitus, increase the risk for hypoglycemia or acidosis, slow wound healing and present an increased risk for postoperative cardiovascular complications.
  45. Surgical risk is increased by drugs in the following categories:
    • • Anticoagulants (may precipitate hemorrhage)
    • • Diuretics (may cause electrolyte imbalances, with resulting respiratory depression from anesthesia)
    • • Tranquilizers (may increase the hypotensive effect of anesthetic agents)
    • • Adrenal steroids (abrupt withdrawal may causecardiovascular collapse in long-term users)
    • • Antibiotics in the mycin group (when combined with certain muscle relaxants used during surgery, may cause respiratory paralysis)
    • • Oral antidiabetic medications (such as metformin hydrochloride) may react with radiologic (x-ray) iodinized contrast dyes, and cause acute renal failure
  46. PREVIOUS SURGERY
    Data about previous surgeries are important for meeting the patient’s physical and psychological needs throughout the perioperative period. Physical implications of previous surgeries are important to the intraoperative and postoperative phases (e.g., previous heart or lung surgery may necessitate adaptations in anesthesia and in positioning during surgery). Complications during or after prior surgery, such as malignant hyperthermia, latex sensitivity, pneumonia, thrombophlebitis, or surgical site infection, may put the patient at risk during this surgery, necessitating individualized postoperative monitoring. The patient’s past experiences with surgery also affect the plan of care established in the preoperative phase, especially if a past experience was negative. When the interview elicits negative feelings about the surgical experience, pain management, or nursing interventions carried out to prevent complications during previous surgeries, teaching and mutual goal setting take on an even greater importance. In addition to experiences with past surgery, the patient’s perceptions and knowledge of the surgical procedure to be performed should be assessed.
  47. NUTRITIONAL STATUS
    Both malnutrition and obesity increase surgical risk. Surgery increases the body’s need for nutrients necessary for normal tissue healing and resistance to infection. A patient who is malnourished is at a higher risk for alterations in fluid and electrolyte balance, delay in wound healing, and wound infection. Obese patients are at increased risk for respiratory, cardiovascular, positional injury, deep vein thrombosis, and gastrointestinal problems. Overweight patients may have obstructive sleep apnea, putting them at risk for reduced respiratory function. They may also have gastroesophageal reflux disease (GERD), putting them at risk for aspiration of stomach contents. Fatty tissue has a poor blood supply and, therefore, has less resistance to infection; as a result, postoperative complications of delayed wound healing, wound infection, and disruption in the integrity of the wound are more common.
  48. USE OF ALCOHOL, ILLICIT DRUGS, OR NICOTINE
    Patients with a large habitual intake of alcohol require larger doses of anesthetic agents and postoperative analgesics, increasing the risk for drug-related complications. Patients who use illicit drugs are at risk for interactions with anesthetic agents. These are specific to the illicit drug used and should be noted on the medical record for safe anesthetic management. IV drug use may render veins hardened, inflamed, and unusable for anesthesia drug administration. Patients who smoke are at higher risk for respiratory complications after surgery. All patients retain pulmonary secretions during anesthesia, but smokers, who already have increased mucous secretions and decreased ciliary action in the tracheobronchial tree, have more difficulty clearing the respiratory passages after surgery. In addition, the tracheobronchialmucosa is chronically irritated in people whosmoke; anesthesia increases this irritation. Patients whosmoke are at risk for hypoxia and postoperative pneumonia.Smoking compromises wound healing by constricting blood vessels, impairing blood flow to healing tissues.
  49. ACTIVITIES OF DAILY LIVING AND OCCUPATION
    Exercise, rest, and sleep habits are important for preventing postoperative complications and facilitating recovery. A patient with a well-established exercise program has improved cardiovascular, respiratory, metabolic, and musculoskeletal function, thereby lowering the risks of surgery. Rest and sleep are essential to physical and emotional adaptation and recovery from the stress of surgery. Information from the health history allows the nurse to individualize interventions to promote rest and sleep. Many surgical procedures require a delay in returning to a career or occupation or may affect how the patient earns a living. Knowledge of a patient’s usual work and concerns about returning to work help the nurse plan necessary teaching and referrals.
  50. COPING PATTERNS AND SUPPORT SYSTEMS
    Assessing the patient’s psychological, sociocultural, and spiritual dimensions is as important as the physical history and examination. Surgery is a major psychological stressor and affects coping patterns, support systems, and individual human needs. A surgical procedure, whether it is planned or unexpected, major or minor, causes anxiety and fear. While obtaining the health history, the nurse can use cues from the patient’s and family’s verbal and nonverbal communication to identify fears and concerns and to plan nursing interventions to provide the information and emotional support necessary to successful recovery from surgery. Surgery is an unfamiliar experience over which a person has no control; the resulting anxiety and fear may be expressed in many ways such as anger, withdrawal, apathy, confrontation, or questioning. Therapeutic communication skills are essential for establishing the trusting nurse–patient relationship that is necessary to identify and resolve fear. Coping with stress can be facilitated through the support systems identified in the assessment phase of preoperative nursing care. Identifying the patient’s spiritual beliefs aids in meeting the patient’s spiritual needs. These needs can be met through acceptance, participation in prayer or other rituals, and/or referral to a spiritual leader. The need for other support systems can also be identified in the initial interview.
  51. SOCIOCULTURAL NEEDS
    A person’s perceptions of and reactions to the surgical experience are influenced by individual factors, including family health beliefs and practices, economic factors, and cultural/ethnic background. A patient who requires surgery, but has grown up in a family that believes that surgical intervention is the last possible option for treating illness, may be hesitant about the surgery or may be convinced that death will result. The resulting anxiety may make this patient even more susceptible to surgical risk. Reactions to teaching, physical care, and pain are also influenced by family values and cultural/ethnic identity. For example, a male patient reared with the belief that it is unmanly to acknowledge pain may demonstrate a stoic acceptance of pain and refuse needed medications postoperatively. Cultural and ethnic influences also affect the patient’s responses to and perceptions of the surgical experience. The patient’s cultural background may require that nursing interventions be individualized to meet needs in such areas as language, food preferences, family interactions and participation, personal space, and health beliefs and practices.

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