Fundamental Nursing Skills and Concepts

Fundamental Nursing Skills and Concepts Chapter 27 PAGE 567

PERIOPERATIVE CARE • Perioperative care is the nursing care provided to a client before, during, and after surgery. Before surgery is preoperative, during surgery is intraoperative and postoperative is after surgery. • Current trend to facilitate as short a perioperative period as possible • Control hospital costs by facilitating the client’s recovery in the comfort and support of his or her home environment • Surgeries according to their urgency page 568 table 27-1

PREOPERATIVE PERIOD • Starts when the client is aware of the necessity for surgery and ends when the client is transported to the operating room • INPATIENT SURGERY-PROCEDURES ON A CLIENT WHO IS ADMITTED TO THE HOSPITAL for a period of time, at least overnight.* Able to establish a client nurse relationship. * Time to teach.(TCDB). *Time to prepare by having lab and diagnostic tests done. * prior to inpatient surgery they may have undergone prior testing

PREOPERATIVE PERIOD • OUTPATIENT SURGERY-OPERATIVE PROCEDURES PERFORMED ON CLIENTS WHO RETURN HOME THE SAME DAY, also known as ambulatory surgery. Client walks in has surgery, recovers and leaves same day. * unable to establish client nurse relationship. * Patient needs to be in good health for this type surgery. * Dismissed if not nauseated, has voided, v/s stable. *Mostly outcome is uneventful. Page 569 lists advantages and disadvantages.

PREOPERATIVE PERIOD • LASER SURGERY-OUTPATIENT SURGICAL PROCEDURES WITH THE USE OF A LASER . Light energy converted to heat, vaporizes tissue and coagulates bleeding vessels. Being used for many previously conventional surgeries. It is cost effective. Minimal blood loss is a great advantage. Less pain, reduced scaring, reduced need for general anesthesia, smaller incision, less time recuperating. Laser surgery involves protecting the eyes, preventing fires and reducing heat and managing the risks from vaporized tissue.

PREOPERATIVE PERIOD • Eye protection is needed for all in the laser surgery area, even the patient. Goggles are worn , no contact lenses. • Fire and heat protection, lasers produce heat, so fire and electrical safety is a major concern. • No flammable substances are used around surgical area. • To avoid light being reflected from surgical instruments, they may be coated black. This includes no jewelry, of fillings to be shown.

PREOPERATIVE PERIOD • Vapor protection, vaporized tissue is referred to as plume. Plume contains carbon, water, and may contain intact cells. A concern is that this plume and smoke containing airborne cells possibly HIV or any transmittable virus could be inhaled and transmitted in this way. • High efficiency respirator masks provide more protection than conventional surgical masks.

INFORMED CONSENT • Information on the surgical procedure is provided by the physician, reinforced by the nurse. • Explanation includes permission a client gives after an explanation of the risks, benefits, and alternatives

INFORMED CONSENT • A signed form, witnessed by a nurse is evidence that consent has been obtained, the nurse signs and dates the form as well. Informed consent good for 72 hours. So the nurse puts the hour down the consent was signed. Page 570 an example. • If the client is mentally confused, unconscious, or mentally incompetent, the client’s spouse, nearest blood relative, or someone with durable power of attorney for the client’s health care must sign the consent form

A Concern • Donated blood, may contain bloodborne disease. A patient may want to pre-donate for an upcoming surgery.

PREOPERATIVE BLOOD DONATION • AUTOLOGOUS TRANSFUSION: Self donated blood, either by pre-donation or by recycling blood that is suctioned, cleaned, and filtered during a surgical procedure. Table 27.5 page 571 is criteria for blood donation. 40 – 3 days prior to need. • SELF DIRECTED DONORS: Blood donors chosen from among the client’s relatives and friends. Criteria on page 571. May donate 1 unit 20-3 days prior to need.

PREOPERATIVE NURSING CARE • CONDUCT A NURSING ASSESSMENT • PROVIDE PREOPERATIVE TEACHING • PERFORM METHODS OF PHYSICAL PREPARATION • ADMINISTER MEDICATIONS • ASSIST WITH PSYCHOSOCIAL PREPARATION • COMPLETE THE SURGICAL CHECKLIST

RISK FACTORS THAT INCREASE PERIOPERATIVE COMPLICATIONS • EXTREMES IN AGE • DEHYDRATION • MALNUTRITION • OBESITY • SMOKING • DIABETES • CARDIOPULMONARY DISEASE • DRUG AND ALCOHOL ABUSE • BLEEDING TENDENCIES • LOW HEMOGLOBIN AND RED CELLS • PREGNANCY

PREOPERATIVE TEACHING • PREOPERATIVE MEDICATIONS: WHEN THEY ARE GIVEN AND THEIR EFFECTS • POSTOPERATIVE PAIN CONTROL • EXPLANATION AND DESCRIPTION OF THE POSTANESTHESIA RECOVERY ROOM OR POSTSURGICAL AREA • DISCUSSION OF THE FREQUENCY OF ASSESSING VITAL SIGNS AND USE OF MONITORING EQUIPMENT

DEEP BREATHING, COUGHING, LEG EXERCISES • Deep breathing is a form of controlled ventilation that opens and fills small air passages in the lungs to prevent atelectasis and pneumonia. Preoperative teaching, teach to inhale deeply using the abdominal muscles. Hold the breath for several seconds and exhale slowly. Pursing the lips may extend exhalation time. This exercise reduces post-op. risk for respiratory complications such as atelectasis, (airless, collapsed lung areas), and pneumonia which is a lung infection, both of which can lead to hypoxemia. • Incentive spirometers- promotes deep breathing, gives feedback to client on how well he is doing with his breathing. Evaluates breathing effectivness.

DEEP BREATHING, COUGHING, LEG EXERCISES • Coughing is a natural method of clearing secretions from the airways. Coughing is necessary for clients who have deminished or moist lung sounds and those that need to move thick sputum. It is very helpful to eliminate anesthesia also. Forced coughing is purposely produced. • A patient is much more compliant if he is not hurting, so make sure he is medicated before initiating the forced coughing technique. Page 573. • Incision must be splinted, by pressing on the incision with both hands, or by pressing on a pillow placed over the incision, or wrapping a bath blanket about the patient. (( the patient that needs to avoid coughing is)) ---eye surgery pt.---why?

DEEP BREATHING, COUGHING, LEG EXERCISES • Leg exercises help promote circulation and reduce the risk of forming a thrombus or blood clots in the veins. Why do clots form you ask? Venous circulation is sluggish, fluid component of blood becomes reduced due to reduced intake of fluid and foods, blood loss during surgery, blood pools in lower extremeties as a result of stationary position during surgery and reluctance to move after surgery. Page 573 performing leg exercises.

DEEP BREATHING, COUGHING, LEG EXERCISES • Thrombus stationary blood clots. Embolism moving clot. May help thrombus=tom stays home. Emily= embolism travels. • Antiembolism stockings or TED hose – help prevent development of thrombi and emboli. They compress superficial veins and capillaries. They redirect blood to larger and deeper veins where it flows more effectively toward the heart. Page 574 shows leg exercises. Dorsiflex assess thrombus in the legs. TED’S must fit and be applied correctly. If you wash them by hand, dry flat to prevent loss of elasticity. Skill 27-1 page 584.

THE NURSE Performs • Physical prep.- skin prep. Shower with antimicrobial soap or agent before coming to surgery. If hair is shaved most times it is done under sterile technique in surgical suite, but there is a chance you will need to know how or are responsible for completing a shave prep, so on page 586 you will see skill 27-2. electric clippers may be used as well. • Elimination • Restriction of food and fluids • Care of valuables, care or disposition of prothesis • Surgical attire

PREOPERATIVE MEDICATIONS • ANTICHOLINERGICS-Glycopyrrolate (robinal) decreases respiratory secretions • ANTIANXIETY-Lorazepam (ativan) reduces anxiety • HISTAMINE-2 RECEPTOR ANTAGONIST-Cimetidine (tagamet) decreases gastric acidity and volume • NARCOTICS-Demerol (meperidine) decreases the amount of anesthesia needed to sedate the client • SEDATIVES-Midazolam (versed) promotes sleep or conscious sedation and decrease anxiety • ANTIBIOTICS-Kanamycin (Kantrex) destroy enteric microorganisms

Pre-op check list • Most useful tool, identifies all those essential activities that need to be carried out before surgery. The patients assigned nurse is the responsible party for making sure all the check list is completed and signed. It is reviewed by operating room personnel at the time of transport to the OR. If the check list is not complete the nurse will be the one that has to answer for it. • What is verified is on page 575. A nice layout of a pre-op check list is on page 576. notice 2 personnel sign off on the checklist.

PREOPERATIVE CHECKLIST • History and physical examination • Name of procedure on surgical consent • Signed surgical consent • Laboratory results • Client is wearing an identification bracelet • Allergies have been identified • NPO • Skin preparation completed • Vital signs assessed

Preoperative Checklist • Jewelry removed • Dentures removed • Client is wearing a hospital gown and hair cover • Client has urinated • Location of IV site, type of intravenous solution, rate of infusion is identified • The prescribed preoperative medication has been given

INTRAOPERATIVE PERIOD • Intraoperative period is the time during which the client undergoes surgery. • Intraoperative period is in the operating suite

INTRAOPERATIVE PERIOD • Receiving room-client is observed until the surgical team is ready. Holding room, patient is observed until operating room has been readied for the case. In the holding room may receive pre-op medication to coordinate sedation more closely. Skin prep may be done. IV may be started. Foley may be inserted. • Operating room-Where the care and safety are in the hands of the surgical team. Operating room, team of physicians and nurses render care and safety to the patient. Family and friends are directed to a surgical waiting area where they may find comfort, support and information about how surgery is progressing.

ANESTHESIA • General anesthesia-eliminates all sensation and consciouness of or memory for the event • Regional anesthesia- blocks sensation in an area, but consciousness is unaffected • Conscious sedation • Anesthesiologist- physician who administers chemical agents that temporarily eliminate sensation and pain. • Anesthetist- nurse specialist who administers anesthesia under the direction of a physician. • Top page 569 – types of anesthesia- good to know.

POSTOPERATIVE PERIOD • Begins when the patient is transported from the operating room to the recovery room also known as PACU. Postanesthesia care unit-nurses ensure the safe recovery of surgical clients in which they are intensely monitored • Post operative care- care after surgery until the pt. is discharged. • The immediate postoperative period refers to the first 24 hours after surgery • Nurses prepare the room for the post-op patient and should monitor for potential complications.

To prepare the room, • The beds are made with fresh linen and the top sheet is folded to the foot or to the side of the bed. The bed is in high position. Additional blankets are near. A warmed blanket is so nice to your chilled patient. • The nurse must also supply needed items such as oxygen equipment, an IV pole, an emesis basin, tissues, a speci pan for collecting and measuring urine. Suction canisters. The nurse systematically checks….578A. • Monitoring for complications, table 27.6 page 579

To prepare the room, • Nursing guidelines 580 • Continuing postoperative care page 578 • Ambulate as soon as possible • Food and oral fluids with held until awake, free of nausea and vomiting, and their bowel sounds are active. Progress from clear to surgical soft diet.

To prepare the room, • I&O are extremely important to watch to make sure the patient is hydrated. • Condition of the wound • Drainage characteristics assessed each shift • Dressings changed or reinforced if saturated • Removal of sutures or staples in a few days to 2 weeks • Discharge within 3-5 days

INITIAL POSTOPERATIVE ASSESSMENTS • Level of consciousness • Vital signs • Effectiveness of respirations • Presence or need for supplemental oxygen • Location of drains and drainage characteristics • Location, type, and rate of intravenous fluid • Level of pain and need for analgesia • Presence of a urinary catheter and urine volume

DISCHARGE INSTRUCTIONS • CARE OF THE INCISION • SIGNS OF COMPLICATIONS • DRUGS FOR PAIN MANAGEMENT • HOW TO SELF ADMINISTER PRESCRIBED MEDICATIONS • ACTIVITY LEVEL • AMOUNT OF WEIGHT THAT CAN BE LIFTED • DIET • RETURN FOR A MEDICAL APPOINTMENT

NURSING IMPLICATIONS: NURSING DIAGNOSES • DEFICIENT KNOWLEDGE • FEAR • ACUTE PAIN • IMPAIRED SKIN INTEGRITY • RISK FOR INFECTION • RISK FOR DEFICIENT FLUID VOLUME • INEFFECTIVE BREATHING PATTERN • INEFFECTIVE AIRWAY CLEARANCE • RISK FOR IMPAIRED GAS EXCHANGE • DISTURBED BODY IMAGE • RISK FOR INEFFECTIVE THERAPEUTIC REGIMEN MANAGEMENT

GERONTOLOGICAL CONSIDERATIONS • Chronic medical problems increases risk of complications • Sensory deprivation interferes with communication in the operative period • Period of fluid restriction should be shortened before surgery to prevent dehydration • Older adults needed instructions on care and medications • Anticoagulant therapy increases the risk of bleeding • Carefully monitor cardiac status • A change in mental status is indicative of infection

Fundamental Nursing Skills and Concepts