Download Care of the Post-Operative Patient

The Perioperative Experience
Perioperative Nursing – 3 phases
Perioperative Nursing – 3 phases
• Preoperative phase:
– From decision to have surgery to
– Transfer into OR
• Intraoperative phase:
– From transfer to OR  admit to PACU
• Postoperative phase
– From PACU (Recovery Room)  DC from facility
Places where surgery can take
place
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Hospital
Surgical center attached to hospital
Free-standing surgical center
Physician’s office
Knightsbridge Surgery Center
Outpatient/Same-day Surgery
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Also called ambulatory surgery
↓ length of hospital stay
↓ costs
↓ stress
May ↑ need for:
– extra teaching
– home care services
Surgery based on :
• Urgency
– Elective surgery
– Urgent
– Emergency
Surgery based on:
• Degree of Risk
– Major
– Minor
Surgery based on:
• Purpose
– Diagnostic
– Curative
– Preventive
– Ablative
– Palliative
– Reconstructive
– Transplant
– Constructive
Surgery based on:
• Extent of Surgery
– Simple
– Radical
– Minimally invasive
Nurse’s roles
• Significant roles!
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Educator
Promotes health and safety
Prevent complications after surgery, and
Patient advocate
PREOPERATIVE PHASE
Preparation for Surgery
• Includes Pre-admission Testing (P.A.T.):
– Initial preop assessment
– Teaching to fit patient’s needs
– To verify pre-op diagnostic testing
– To verify that patient understands pre-op orders
– Advanced-directive documents are completed and
available
Patient is interviewed for P.A.T.
• Can take place:
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By phone
Physician’s office
Anesthetic clinics
Pre-admission Testing
Dept.
Purpose of Interview
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Obtain patient information
Provide information to patient
Get patient’s consent for surgery
Assess patient’s (and family) emotional state
and readiness for surgery
• Explore patient’s expectations
Roles of the Nurse in Preoperative
Nursing
• Assessment
• Teaching patient and family
Assessment of Pre-op Patient
Assess Patient Risk Factors and
Strengths
• Developmental level
• Medical history
– Lung/heart conditions
• Medications
• Previous surgeries – reaction to anesthesia?
• Nutritional status
– Diabetes, obese, malnourished
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Use of alcohol, illicit drugs, or nicotine
ADL and occupation
Coping patterns, support systems
Sociocultural needs
Assess Surgical Risks of
Medications
• Anticoagulants
• Diuretics
• Tranquilizers
– ↑ hypotensive effects of anesthetic agents
• Steroids
– abrupt withdrawal may cause cardiovascular
collapse
• OTC-ASA
– bleeding
Assess History of Substance Abuse
• Alcoholics - ETOH
– poor liver function
– poor metabolism of anesthesia/meds
• Smokers - should stop 2-6 weeks ahead
Psychosocial Assessment
• Common fears include:
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Nursing Interventions to Meet
Psychological Needs of Surgical Patients
• Allow patient to verbalize fears and concerns.
• Use active listening skills to identify anxiety
and fear.
• Use of touch.
• Answer questions.
Physical Exam
• Prior to the day of surgery or on the day of
surgery
• Completed by anesthesiologist or advanced
practitioner
• Weigh patient
• Vital Signs
• Basic head-to-toe assessment
Usual Presurgical Screening Tests
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Chest x-ray
Electrocardiography
Complete white blood count (WBC)
Electrolyte levels
Urinalysis
Nurse’s Role in Presurgical Testing
• Ensure tests are explained to the patient
• Ensure results are recorded in patient records
before surgery
• Ensure that abnormal results are reported
Nurse’s Role ….
• Preoperative teaching.
• Informed consent:
– Surgeon obtaines signed consent before
sedation and/or surgery.
– The nurse:
• clarifies facts presented by the physician
• dispels myths that the patient or family may
have about surgery.
Informed Consent
• Should be in writing
• Should contain:
– Explanation of procedure, risks
– Description of benefits, alternatives
– Offer to answer questions about procedure
– Instructions that patient may withdraw consent
– Statement informing patient if protocol differs
from customary procedure
Voluntary Consent
• Valid consent freely given, without coercion
• Patient must be at least 18 years of age
(unless emancipated minor)
• Consent must be obtained by physician
• Patient’s signature must be witnessed by
professional staff member
Incompetent Patient
• Individual who is not autonomous
• Cannot give or withhold consent
– Cognitively impaired
– Mentally ill
– Neurologically incapacitated
General Preoperative Nursing
Interventions
• Provide psychosocial interventions
– Reduce anxiety, decrease fear
– Respect cultural, spiritual, religious beliefs
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Maintain patient safety
Manage nutrition, fluids
Prepare bowel
Prepare skin
Provide Preoperative Teaching
• Very important!
• Include:
– Day-of-surgery events
– Time to arrive, time of surgery
Teach:
• What to expect in each
phase
Teach Coughing & Deep Breathing
(C & DB):
• Purpose:
Some Key Points:
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Sit up as straight as possible
Breathe in through nose, out through mouth
Take approximately 3 breaths, then cough
Splint!
Praise your patient!
Teach about Incentive Spirometer
(IS)
• Increases lung volume
• Inflates alveoli
• Prevents atelectasis
Teach other ways to prevent
respiratory complications:
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Turn in bed every 2 hours
Ambulate
Maintain hydration
Avoid positioning that decreases ventilation
Prevent Cardiovascular
Complications
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Be aware of patients at greater risk for DVT
Antiembolism stockings
Pneumatic compression devices
Leg exercises
Mobility
Teach how to Prevent blood clots
• Teach leg exercises:
– 5-10 repetitions each extremity every 1-2 hours
– Gastrocnemius (calf) pumping
• While lying in bed, pull your toes back toward your
knees, then point your toes down.
– Quadriceps (thigh) setting
• While lying in bed, tighten thigh muscles and press
knee into bed. Count to 5 and relax
Apply External Pneumatic
Compression Devices
Promote Turning and Active Body
Movements
• Improves respiratory air exchange
• Improves circulation
• Decreases venous stasis
• Increases peristalsis:
– Prevents constipation or paralytic ileus
– Relieves gas pain
• Turn side to side, up in chair, walk in hall
Implement Dietary Restrictions
• NPO: Patient advised not to ingest anything by
mouth for 6 to 8 hours before surgery:
– Decreases the risk for aspiration.
– Patients should be given written and oral
directions to stress adherence.
– Surgery can be cancelled if not followed.
Administering Regularly Scheduled
Medications
• Consult with MD and anesthesia provider re:
meds taken regularly
– Should patients take them or not?
Preoperative Drugs
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Reduce anxiety
Promote relaxation
Reduce nasal and oral secretions
Prevent laryngospasm
Reduce vagal-induced bradycardia
Inhibit gastric secretion
Decrease the amount of anesthetic needed for
the induction and maintenance of anesthesia
Preop drugs that might be
prescribed:
• Handout
After preanesthetic med is given:
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Keep patient in bed with side rails up
Watch for adverse effects
Keep environment quiet
Medication may be “on call” if surgery is
delayed or schedule changes
Intestinal Preparation
• Bowel or intestinal preparations
performed:
– to prevent injury to the colon
– to reduce number of intestinal bacteria.
• Enema or laxative may be ordered by the
physician.
Skin Preparation
• A break in the skin increases risk for infection.
• Patient may be asked to shower using
antiseptic solution.
Skin Preparation for Common
Surgical Sites
Other
• Use of bedpan or urinal post-operatively
• Pain control
Nursing Interventions just prior to
patient going to OR:
• Administer preanesthetic medication
• Maintain preoperative record
• Verify that patient has followed food/fluid
restrictions
• Have patient empty bladder
• Transport patient to presurgical area
• Attend to family needs
• After patient leaves, prepare room and make a
postoperative bed
Voiding Pre-Operatively
• Immediately before pre-op med
Patient Transfer to Surgical Suite
(Preoperative Holding area)
Nursing Diagnoses for Preoperative
Patient
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Anxiety
Risk for Infection
Knowledge Deficit
And more…
Outcomes for the Surgical Patient
• Be free from injury and adverse effects
• Be free from infection and DVT
• Maintain fluid and electrolyte balance; skin
integrity, normal temperature
• Have pain managed
• Demonstrate understanding of physiologic
and psychological responses to surgery
• Participate in rehabilitation process
• Be educated on what to do after surgery
– In the hospital
– At home