Inflammation Concept: Perioperative Care

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Inflammation Concept Perioperative Care

• Brunner ch.17-19

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Review of Inflammation What It Is and What It
Isnt

• The bodys cellular response to injury,
  infection, or irritation.
• Mechanism is the same regardless of injuring
  agent.
• Always present with infection.
• It is not infection. Infection is not always
  present with inflammation.

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Inflammatory Response

• Intensity depends on extent and severity of
  injury bodys ability to react
• Sequential
• Neutralizes dilutes inflammatory agent
• Removes necrotic materials
• Establishes an environment suitable for healing
  and repair

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Causes of Inflammatory Response

• Heatburn injury
• Radiationsunburn, radiation tx
• Traumasurgery
• Allergenssinuses anaphylactic shock
• Infection

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Steps of Inflammatory Response

• Vascular response
• Cellular response
• Formation of exudate
• Healing

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Manifestations of Inflammation

• Localized response (redness, pain, swelling, etc)
  and systemic response (increased TPR, malaise,
  nausea, anorexia, etc) are the same as in the
  infectious process (see Infection Concept
  Lecture)
• With a high degree of inflammation, and when
  infection is present, WBCs rise

7
Healing Process

• Regenerationreplacement of lost cells and
  tissues with cells of same type
• Repairreplacement of lost cells with connective
  tissue (scar)

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Exemplar Perioperative Care

• Good example of inflammation because inflammation
  is the bodys response to trauma and surgery is
  considered a type of trauma.
• Normal postoperative wound healing is an
  excellent example of the inflammatory process in
  action.

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Stages of Perioperative Care

• Preopfrom time of admission to time of transfer
  to OR
• Intraopfrom time of transfer to OR to time of
  transfer to PACU
• Postopfrom time of transfer to PACU to time of
  discharge from hospital

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Preoperative Legal and Ethical Considerations

• Informed consent (407)MD and nurses
  responsibility. Pt needs
• Adequate disclosure
• A clear understanding
• To consent voluntarily
• Transfusionsmay or may not be part of the
  general form
• Mental competency/Minors
• Advocacy

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Surgical PatientPreoperative Risk Factors

• Ageelderly and children
• Nutritionmalnourished and obese
• Smoking
• Chronic diseases
• Physical disabilities
• Medications
• Allergies
• Patient classification accd to ASA (424)

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Home Risk Factors

• Support systems
• Physical layout
• Hygiene
• Smoking
• Nutrition
• Traffic control
• Distance
• Transportation

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Preop Assessment

• Health hx
• VS, pain, pulse ox, anxiety
• Focus on CV, respiratory systems, and surgical
  area
• Diagnosticslabs and radiology
• Dietary considerationsNPO
• Surgical preps needed
• Education needed

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Patient Needs

• Psychosocial needsfears, therapeutic
  communication, referrals, spiritual and cultural
  needs, support systems, body and self-image and
  lifestyle changes that could occur, past
  experiences
• Developmental needschildren and elderly

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Preoperative Medications

• Given in holding area or On call
• Sedativesinduce sedation, amnesia
• Anxiolyticsreduce anxiety
• Antibioticsprevent, treat infection
• Histamine blockersreduce secretions, increase
  motility
• Anticholinergics
• Pain meds, antiemetics
• Eye gtts
• Routine Rxs

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Provide Education

• Teach to senses
• Postop pain control
• Professional roles
• Prevention of complications
• Equipment
• Family

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Document

• Preop checklist (417)
• Preop assessment (may be on flow sheet or nurses
  notes)
• Consent forms on chart
• Check computer to make sure other necessary
  reports are on chart
• Transfer to OR
• Finish charting before transfer

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Intraoperative Team

• Circulating nurse(RN)In charge of activities,
  safety and verification, equipment, traffic flow,
  contacts, patient assessment, preop meds, IV
  start, counts, Safety Checklist (423) etc.
• Scrub nurse or techsets up sterile fields,
  hands-off to surgeon, labels tissue, counts
• RN first assistantsurgeons right hand, does
  some simple surgical tasks
• Surgeonhead of team, may have others
• Anesthesiologist/CRNA (ACP)gives anesthesia,
  monitors physiologic functions

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OR Environment

• 3 levels unrestricted, semi-restricted,
  restricted
• Aseptic practices
• Preventing complications and injuries
• Electrical and fire
• Mechanical
• Hypothermia
• Hyperthermia

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Types of Anesthesia(427) General

• Given IV or by inhalation. Induces deep sedation
  (Stage III)causes loss of consciousness and
  reflexespt will need ventilatory support
• Given for long procedures, when total muscle
  relaxation is needed, when pt is extremely
  anxious, or if pt is uncooperative or refuses
  other types.
• Advantages rapid induction
• Disadvantages CV and respiratory SEs

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Regional Local

• Localloss of sensation without loss of
  consciousness. May be topical or by injection
• Regional (nerve blocks, spinal, epidural)loss of
  sensation without loss of consciousness. See
  diagram p. 432
• Advantageslittle systemic absorption rapid
  recovery good for hi-risk pts
• Disadvantagestechnical difficulty, HA,
  discomfort, hard to match anesthesia with length
  of surgical procedure

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IV Conscious Sedation

• Also called Moderate Sedation
• Used for routine procedures
• Reduces anxiety, controls pain
• Produces amnesia
• Patient will still have patent airway and be able
  to follow commands
• Pt must be monitored (CV, resp, LOC)
• Must be given by someone specially trained
• Recovery is quick

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Adjunct Meds

• Used for muscle relaxation, analgesia, sedation,
  to prevent N/V, neutralize stomach acid. Some may
  also be used alone for IV conscious sedation to
  induce sedation and amnesia during a procedure.
• Advantagesprovides analgesia and amnesia allows
  intubation and ease of incision lowers risk for
  aspiration
• Disadvantagessynergistic or additive effects can
  increase sedation and add to risk of respiratory
  complications

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Postoperative Nursing Care

• PACU
• Beginning of postoperative phase
• ACP must accompany pt to PACU. Gives report (441)
  and usually checks on pt periodically. Circulator
  may come, too.
• After report, PACU nurse takes responsibility.

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PACU Nurses Responsibilities

• Maintain airway
• Assess and monitor respiratory CV systems. LOC,
  fluid status, op site
• Monitor for complications from anesthesia and
  surgical procedure
• Relieve various discomforts
• Report to CRNA or surgeon for problems

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Discharge from PACU

• Must meet Aldrete criteria (445)
• Phase Ipatients are monitored closely as in ICU
  until ready for phase II.
• Phase IIpatients either go to ambulatory care
  for d/c or inpatient care for continued
  monitoring
• Phase IIIpatients will be discharged either
  directly from PACU or from ambulatory care.

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Gerontologic Considerations

• More likely to have comorbid conditions such as
  CV, resp, or renal impairments causing more risk
  of hypoxia and FE imbalances
• Hypothermia is greater risk
• Transfers are greater risk due to musculoskeletal
  and skin issues
• Slower recovery from anesthesia

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Discharge from SDS (445-6)

• Pt must be able to control pain with po meds
• Must void before d/c
• D/C instructions include wound care, drain mgmt,
  activity, diet, meds, F/U appts, what to watch
  for, who to call for probs.
• Make sure adult is present to take pt home
• F/U care may include HH care, appts with MD or
  others, and phone calls from unit.

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Immediate Nursing Responsibilities for Inpatients

• Prep of room
• When pt returns
• Be available to assist with transfer
• Assess airway and LOC
• Position pt on side or in semi-Fowlers
• Connect and position all tubes, check wound
• Get VSyour 1st, their last
• Receive report from PACU nurse and go over postop
  orders (441 chart again)

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Next..

• Assess for and do same things as PACU nurse did
  on admission to PACU
• Carry out any STAT orders if not done by PACU
  nurse
• Make sure pt is comfortable and in good
  alignment, SR up, items WIR
• Talk to familylet them know how pt is doing

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Ongoing Responsibilities

• VS accd to order, dept policy, or as patient
  condition warrants
• Ongoing head to toe assessments with
  concentration on surgical site (review wound
  care), fluid balance, labs, pain
• Follow orders as written
• Control common, expected side effects of surgery

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Common Postop Side Effects

• Pain
• Weakness
• Chills/decreased circulation
• Shallow breathing
• Low grade temp

• Nausea
• Thirst
• Anorexia
• Gas/decreased BS
• Urinary retention
• Orthostatic BP

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Commonly Given Postop Medications

• NarcoticsPCA, IVP, IM, po
• Non-opioidsIVP, po
• AntibioticsIVPB, po
• AntiemeticsIVP, rectal
• AntipruriticsIVP (epidural SE)
• H2 receptor antagonists
• May or may not give all home meds

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Preventing Complications Why Does the Nurse Do
These?

• TCDB, IS?
• Aseptic wound care?
• Splinting incision?
• Progressive ambulation, AEEs, TEDs?
• Diet progression?
• Fluid managementpo and parenteral?
• Promote elimination?
• Balance activity and rest periods?
• Emotional supporteffect of dx and px?
• Education?

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Assessing for ComplicationsHow does the Nurse
Know?

• Hemorrhageinternal vs. external
• Fever
• Wound infection
• Atelectasis/PN
• Persistent N/V
• DVT
• Fluid imbalance
• Paralytic ileus
• Sepsis

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If Complications Arise, What Does the Nurse Do?

• Hemorrhage

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Fever
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Wound Infection
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Atelectasis/PN
40
Persistent N/V
41
VTE
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Fluid Imbalance
43
Paralytic Ileus
44
Sepsis
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Discharge Instructions