Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Nursing Management of Clients with Peri-Operative Stressors NUR133 Lecture #2 & #3 K. Burger, MSEd, MSN, RN, CNE 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 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? Peri-Operative Nursing SURGERY DEFINITION = A planned alteration of physiologic processes within the body in an attempt to arrest or eliminate disease or illness PHASES = Pre-operative Intra-operative Post-operative 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. Classifications of Surgery PURPOSE Diagnostic Curative -Ablative -Restorative -Reconstructive Palliative Cosmetic Transplant URGENCY Elective Urgent Emergency SERIOUSNESS Minor Major 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 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 factors Emotional support of client Client teaching Physical preparation of client Pre-operative Nursing Assessment HISTORY Age Medication Medical history Allergies Prior surgeries and outcomes Anesthesia history / personal & familial Lifestyle habits: alcohol / smoking/ exercise Pre-operative Nursing Assessment PHYSICAL VS Head & Neck Skin Turgor Thorax & Lungs Heart & Vascular System Abdomen Neurological Status Pre-Operative Nursing Assessment LABS DIAGNOSTICS Complete Blood Count (CBC) Basic Metabolic Panel (BMP) Coagulation Studies PT/PTT Urinalysis Blood typing / screening Additional tests as indicated Chest X-Ray (CXR) Electrocardiogram (ECG) Additional tests as indicated 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 Pre-operative Nursing Assessment Knowledge Informed Consent Anxiety Coping mechanisms Availability of support Common Pre-operative Nursing 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 Pre-operative Nursing Interventions Emotional Support Utilize positive communication techniques touch – eye contact validating statements Active listening Encourage verbalization of fears/anxieties Avoid negative communication techniques false-reassurance judgmental statements Pre-Operative Nursing Interventions Client 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 Client Teaching Pain Management Pre-operative assessment of individual pain perception on 1-10 scale Reassurance that pain reports WILL be believed 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 Client Teaching Pulmonary 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 coughing Deep breath X2 , then inhale, hold breath 2-3 sec, cough forcefully 2-3X consecutively Method for splinting Client Teaching Pulmonary Exercises Instruction on use of Incentive Spirometer: Take 2-3 normal breathes, close lips on mouthpiece, inhale to reach set goal, hold 35 sec, release mouthpiece & exhale, 10X/hr while awake. Client Teaching Activity LEG EXERCISES Dorsi/Plantar flexion, ankle rotation, knee/hip flexion, 5X each leg/hr w.a. AMBULATION Discuss importance of early ambulation and method for getting out of bed TURNING AND POSITIONING Use of side rails External pneumatic compression devices (Sequentials, SCDs, Flowtron) Pre-operative Nursing Interventions Physical 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 Pre-operative Nursing Responsibilities Medical Record Review Informed Consent History and Physical Medical Clearance Advance Directives Allergies / Previous anesthesia reactions Presence of autologous blood bank Labs and Diagnostics Intra-Operative Phase Begins when client arrives in surgical area and lasts until they are in the PACU Nursing Goals = Prevention of injury to client Maintenance/Promotion of: oxygenation, cardiac output, balanced I & O The Intra-operative Team Surgeon Surgical Assistants: MD, PA, ST Anesthesiologist and/or Nurse Anesthetist Registered Nurses: Circulating, Scrub 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: General Local Conscious Sedation General Anesthesia Inhalation Intravenous Balanced = use of both Mechanical Ventilation – presence of ET tube Use of adjuvant medications such as: Hypnotics: Versed Opioids: Fentanyl Neuromuscular Blocking Agents: Pavulon Anectine Important Factors in the Care of the Anesthetized Client Use protective positioning techniques Handle gently Change positions slowly Keep client warm Potential Complications of General Anesthesia Overdose Unrecognized hypoventilation Complications of intubation Anaphylaxis Hypothermia Injury r/t positioning, burns Malignant hyperthermia 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 Emergency Treatment of Malignant Hyperthermia Stop surgical procedure/anesthesia if possible Hyperventilate with 100% oxygen Administer DANTROLENE intravenously Undertake body cooling measures: Iced NS intravenously Cooling blanket 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 Regional Anesthesia Types Field Block Injected around the operative field Nerve Block Into or around a nerve or nerve group Spinal Into subarachnoid space Epidural Into epidural space Regional Anesthesia Advantages Patient remains conscious No respiratory depression or irritation Enhanced pain management postoperatively Disadvantages Patient remains conscious Circulatory depression/stasis Potential trauma/infection @ site of injection Edema - potential for spinal headache 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. 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” 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 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 Discharge Criteria PACU (Modified Aldrete Score) Consciousness 2 = Fully awake 1 = Responds to name 0 = No response Activity on command 2 = Moves all extremities 1 = Moves two extremities 0 = No movement Respiration 2 = Free deep breathing 1 = Dyspneic, hyperventilating, obstructed breathing 0 = Apneic Circulation 2 = Blood pressure within 20% of pre-op level 1 = Blood pressure within 50%–20% of pre-op level 0 = Blood pressure 50%, or less, of pre-op level Oxygen saturation 2 = SpO2 >92% on room air 1 = Supplemental O2 required to maintain SpO2 >92% 0 = SpO 2 <92% with O2 supplementation Total Score 10 = Score = 9 needed to leave PACU Focused Assessment for Post-Operative Client Upon 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 Nursing Diagnosis Post-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 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 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 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 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 Antibiotic Medications Students should research the following classes of antibiotics for important nursing implications of each: (Chapter 37 & 38 Lilley) Penicillens Cephalosporins Sulfonamides Tetracycline Aminoglycosides Quinolines Macrolides Carbapenems Miscellaneous Ex: Unasyn Ex: Rocephin Ex: Bactrim Ex: Vibramycin Ex: Gentamicin Ex: Levaquin Ex: Erythromycin Ex: Imipenem Ex: Vancomycin Post-operative Nursing Interventions Comfort and Rest: Pain management Keep linens clean and dry Provide for personal hygiene needs Keep environment quiet 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 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 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 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. Transfusion Responsibilities Assess vital signs. Prime Y-tubing with NS Gently agitate blood bag Spike 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 Types of Transfusions Packed red blood cells Platelets Plasma transfusions: fresh frozen plasma Cryoprecipitate Granulocyte (white cell) transfusions 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 Autologous Blood Transfusion Collection and infusion of client’s own blood Eliminates compatibility problems; reduces risk for transmission of bloodborne disease Preoperative autologous blood donation Intraoperative autologous transfusion Postoperative blood salvage