Nursing Management of Clients with Peri-Operative Stressors

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Nursing Management ofClients with
Peri-Operative Stressors

• NUR133
• Lecture 2 3
• K. Burger, MSEd, MSN, RN, CNE

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What is Medical-Surgical Nursing?

• Blend of technical skills caring relationships
• Specialty of nursing
• Nursing care of adults 18yrs
• Requires broad scope of knowledge
• Encompasses many roles/competencies
• Academy of Medical-Surgical Nurses (AMSN)
  specialty organization

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Take some time to

• Review the Academy of Medical Surgical Nurses
  (AMSN) website _at_http//www.medsurgnurse.org
• Click on and readLearn more about Medical
  Surgical Nursing
• What are your opinions about the role of the
  medical surgical nurse as outlined in this AMSN
  statement?

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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-opera
  tive

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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.

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Classifications of Surgery

• PURPOSE
• Diagnostic
• Curative-Ablative-Restorative
• -Reconstructive
• Palliative
• Cosmetic
• Transplant

• URGENCY
• Elective
• Urgent
• Emergency

SERIOUSNESS Minor Major
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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

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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

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Pre-operative Nursing Assessment

• HISTORY
• Age
• Medication
• Medical history
• Allergies
• Prior surgeries and outcomes
• Anesthesia history / personal familial
• Lifestyle habits alcohol / smoking/ exercise

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Pre-operative Nursing Assessment

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

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Pre-Operative Nursing Assessment

• LABS
• Complete Blood Count (CBC)
• Basic Metabolic Panel (BMP)
• Coagulation Studies PT/PTT
• Urinalysis
• Blood typing / screening
• Additional tests as indicated

• DIAGNOSTICS
• Chest X-Ray(CXR)
• Electrocardiogram(ECG)
• Additional tests as indicated

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LABORATORY NORMALS

• Students should research/fill-in/memorize the
  following lab values ( See pg 302-303 Iggy)
• K
• Na
• Cl
• FBS
• BUN
• Cr
• WBC
• Hgb
• Hct

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Pre-operative Nursing Assessment

• Knowledge
• Informed Consent
• Anxiety
• Coping mechanisms
• Availability of support

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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

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Pre-operative Nursing InterventionsEmotional
Support

• Utilize positive communication techniquestouch
  eye contact validating statements
• Active listening
• Encourage verbalization of fears/anxieties
• Avoid negative communication techniquesfalse-reas
  surancejudgmental statements

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Pre-Operative Nursing InterventionsClient
Teaching

• Peri-operative progression sensations
• Description of Pre and Post operative events
• Description of events in OR and PACU
• Pain management
• Coughing Deep Breathing Exercises
• Incentive Spirometry
• Turning Positioning
• Leg Exercises Ambulation

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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 PRN
• Allaying of fears regarding addiction
• Potential side-effects of narcotics
• How pain management promotes recovery

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Client TeachingPulmonary Exercises

• Method for diaphragmatic breathingHands 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

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Client TeachingPulmonary Exercises

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

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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)

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Pre-operative Nursing InterventionsPhysical
Preparation of Client

• Implementing dietary restrictions
• Initiation of surgical preps
• Insertion of tubes/drains/vascular access
• Completion of pre-operative checklist
• Administration of pre-operative medication

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Pre-operative Nursing ResponsibilitiesMedical
Record Review

• Informed Consent
• History and Physical
• Medical Clearance
• Advance Directives
• Allergies / Previous anesthesia reactions
• Presence of autologous blood bank
• Labs and Diagnostics

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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

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The Intra-operative Team

• Surgeon
• Surgical Assistants MD, PA, ST
• Anesthesiologist and/or Nurse Anesthetist
• Registered Nurses Circulating, Scrub

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Anesthesia

• Anesthesia is defined as the absence of normal
  sensation. This also includes loss of protective
  reflexes!
• Anesthesia providesamnesia analgesia
  muscular relaxation
• Stages I-IV of Anesthesia ( Guedels Signs)
• TypesGeneralLocalConscious Sedation

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General Anesthesia

• Inhalation
• Intravenous
• Balanced use of both
• Mechanical Ventilation presence of ET tube
• Use of adjuvant medications such asHypnotics
  VersedOpioids FentanylNeuromuscular Blocking
  Agents Pavulon
  Anectine

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Important Factors in theCare of the Anesthetized
Client

• Use protective positioning techniques
• Handle gently
• Change positions slowly
• Keep client warm

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Potential Complications ofGeneral Anesthesia

• Overdose
• Unrecognized hypoventilation
• Complications of intubation
• Anaphylaxis
• Hypothermia
• Injury r/t positioning, burns
• Malignant hyperthermia

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Malignant Hyperthermia

• Rare but extreme emergency
• Occurs most often with inhalants
• Genetic predisposition
• Uncontrolled acceleration of muscle metabolism
  and increased BMR
• Life threatening elevated temperature,
  hyperkalemia, acidosis

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Emergency Treatment of Malignant Hyperthermia

• Stop surgical procedure/anesthesia if possible
• Hyperventilate with 100 oxygen
• Administer DANTROLENE intravenously
• Undertake body cooling measuresIced NS
  intravenouslyCooling blanket

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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

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Regional AnesthesiaTypes

• Field BlockInjected around the operative field
• Nerve BlockInto or around a nerve or nerve group
• SpinalInto subarachnoid space
• Epidural Into epidural space

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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 _at_ site of injection
• Edema - potential for spinal headache

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Conscious Sedation

• IV administered hypnotic, opioid, or sedative
• Reduces LOC but does not produce unconsciousness
• Airway maintained
• Client can respond to simple commands
• Provides short amnesia action
• Commonly used for scopes, caths etc.

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Intra-operative Nursing Diagnosis

• Risk for positioning Injury
• Risk for Fluid Volume Imbalance
• Risk for Hyperthermia
• Potential for Hypoventilation
• Risk for Aspiration
• Risk for Impaired Skin Integrity(see EBP page
  335 Iggy)Pressure ulcers do occur in surgery

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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

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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

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Discharge CriteriaPACU(Modified Aldrete Score)

• Consciousness2 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 5020 of
  pre-op level0 Blood pressure 50, or less, of
  pre-op level
• Oxygen saturation2 SpO2 gt92 on room air1
  Supplemental O2 required to maintain SpO2 gt920
  SpO 2 lt92 with O2 supplementation
• Total Score10 Score 9 needed to leave PACU

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Focused Assessmentfor Post-Operative ClientUpon
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

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Nursing DiagnosisPost-Operative Clients

• Acute Pain
• Risk for Ineffective Tissue Perfusion r/t
  hypovolemia, circulatory stasis
• Risk for Ineffective Breathing Pattern r/t pain,
  effects of anesthesia/narcotics
• Risk for Infection r/t invasive procedure,
  respiratory stasis
• Risk for Deficient Fluid Volume r/t fluid losses
  during surgery

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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

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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

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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

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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

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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 Erythromycin
• Carbapenems Ex ImipenemMiscellaneous Ex
  Vancomycin

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Post-operative Nursing Interventions

• Comfort and Rest
• Pain management
• Keep linens clean and dry
• Provide for personal hygiene needs
• Keep environment quiet

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Post-operative Nursing Interventions

• Fluids and Nutrition
• Monitor I O
• Provide good oral hygiene
• Ice chips / water sips
• Assess for return of peristalsis
• Assess for gag reflex
• Gradual diet progression clear, full, soft

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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

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Transfusion Therapy

• Pretransfusion responsibilities
• Verify prescription and other concommitant orders
• Test donors and recipients blood for
  compatibility
• ABO and Rh TYPE CROSSMATCH
• Obtain consent and apply blood braceletper
  hospital policy
• Determine patency of IV AND angiocath
  lumen(20gauge minimum)
• Collect supplies 250 mL bag Normal
  Saline Y-set blood tubing with filter

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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.

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Transfusion Responsibilities

• Assess vital signs.
• Prime Y-tubing with NSGently 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

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Types of Transfusions

• Packed red blood cells
• Platelets
• Plasma transfusions fresh frozen plasma
• Cryoprecipitate
• Granulocyte (white cell) transfusions

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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

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Autologous Blood Transfusion

• Collection and infusion of clients own blood
• Eliminates compatibility problems reduces risk
  for transmission of bloodborne disease
• Preoperative autologous blood donation
• Intraoperative autologous transfusion
• Postoperative blood salvage