Nursing Management of Clients with Peri-Operative Stressors

1. Nursing Management ofClients with Peri-Operative Stressors NUR133 Lecture #2 & #3 K. Burger, MSEd, MSN, RN, CNE

2. 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

3. Take some time to… • Review the Academy of Medical Surgical Nurses (AMSN) website @http://www.medsurgnurse.org • Click on and read:Learn more about Medical Surgical Nursing • What are your opinions about the role of the medical surgical nurse as outlined in this AMSN statement?

4. 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-operative

5. 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.

6. PURPOSE Diagnostic Curative-Ablative-Restorative -Reconstructive Palliative Cosmetic Transplant URGENCY Elective Urgent Emergency Classifications of Surgery SERIOUSNESS Minor Major

7. 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

8. 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

9. Pre-operative Nursing Assessment HISTORY • Age • Medication • Medical history • Allergies • Prior surgeries and outcomes • Anesthesia history / personal & familial • Lifestyle habits: alcohol / smoking/ exercise

10. Pre-operative Nursing Assessment PHYSICAL • VS • Head & Neck • Skin Turgor • Thorax & Lungs • Heart & Vascular System • Abdomen • Neurological Status

11. 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 Pre-Operative Nursing Assessment

12. 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

13. Pre-operative Nursing Assessment • Knowledge Informed Consent • Anxiety • Coping mechanisms • Availability of support

14. 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

15. Pre-operative Nursing InterventionsEmotional Support • Utilize positive communication techniquestouch – eye contact validating statements • Active listening • Encourage verbalization of fears/anxieties • Avoid negative communication techniquesfalse-reassurancejudgmental statements

16. 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

17. 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

18. Client TeachingPulmonary Exercises • Method for diaphragmatic breathing:Hands 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

19. Client TeachingPulmonary Exercises • Instruction on use of Incentive Spirometer:Take 2-3 normal breathes, close lips on mouthpiece, inhale to reach set goal, hold 3-5 sec, release mouthpiece & exhale, 10X/hr while awake.

20. 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)

21. 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

22. 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

23. 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

24. The Intra-operative Team • Surgeon • Surgical Assistants: MD, PA, ST • Anesthesiologist and/or Nurse Anesthetist • Registered Nurses: Circulating, Scrub

25. Anesthesia • Anesthesia is defined as the absence of normal sensation. This also includes loss of protective reflexes! • Anesthesia provides:amnesia – analgesia – muscular relaxation • Stages I-IV of Anesthesia ( Guedel’s Signs) • Types:GeneralLocalConscious Sedation

26. General Anesthesia • Inhalation • Intravenous • Balanced = use of both • Mechanical Ventilation – presence of ET tube • Use of adjuvant medications such as:Hypnotics: VersedOpioids: FentanylNeuromuscular Blocking Agents: Pavulon Anectine

27. Important Factors in theCare of the Anesthetized Client • Use protective positioning techniques • Handle gently • Change positions slowly • Keep client warm

28. Potential Complications ofGeneral Anesthesia • Overdose • Unrecognized hypoventilation • Complications of intubation • Anaphylaxis • Hypothermia • Injury r/t positioning, burns • Malignant hyperthermia

29. 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

30. Emergency Treatment of Malignant Hyperthermia • Stop surgical procedure/anesthesia if possible • Hyperventilate with 100% oxygen • Administer DANTROLENE intravenously • Undertake body cooling measures:Iced NS intravenouslyCooling blanket

31. 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 Local Anesthesia

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

33. Advantages Patient remains conscious No respiratory depression or irritation Enhanced pain management post-operatively Disadvantages Patient remains conscious Circulatory depression/stasis Potential trauma/infection @ site of injection Edema - potential for spinal headache Regional Anesthesia

34. 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.

35. 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”

36. 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

37. 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

38. 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 50%–20% of pre-op level0 = Blood pressure 50%, or less, of pre-op level • Oxygen saturation2 = SpO2 >92% on room air1 = Supplemental O2 required to maintain SpO2 >92%0 = SpO 2 <92% with O2 supplementation • Total Score10 = Score = 9 needed to leave PACU

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. Post-operative Nursing Interventions • Comfort and Rest: • Pain management • Keep linens clean and dry • Provide for personal hygiene needs • Keep environment quiet

47. 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

48. 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

49. Transfusion Therapy • Pretransfusion responsibilities: • Verify prescription and other concommitant orders • Test donor’s and recipient’s blood for compatibility ABO and Rh TYPE & CROSSMATCH • Obtain consent and apply “blood bracelet”per hospital policy • Determine patency of IV AND angiocath lumen(20gauge minimum) • Collect supplies: 250 mL bag Normal Saline Y-set blood tubing with filter

50. 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.