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Perioperative concepts and management Association of PeriOperative Nurses AORN Standards of Care Recommended Practices Certification Process: CNOR Continuing Education Legislative Issues RN First Assistant: RNFA Definition of Perioperative Nursing The practice of nursing directed toward clients undergoing operative and other invasive procedures The perioperative nurse provides managers, teaches and or studies the care of clients undergoing operative or other invasive procedures in all three phases of the surgical experience Practice Areas Hospital operating rooms Interventional radiology suites Cardiac cath labs Endoscopy suites Ambulatory surgery centers Trauma centers Pediatric specialty centers Physician offices Functions of a Perioperative Nurse Advocate Protector Teacher Change agent Manager of client care The Surgical Team Perioperative Team Members Nursing Roles in the OR Circulating Nurse Scrub Nurse RN First Assistant (RNFA) Perioperative Educator Specialty Team Leader Perioperative Manager/Director Surgical Team Behind the scenes Radiology Technologist Anesthesia Technician Nursing Technician Transport Team Environmental Services Team Perioperative Nursing Skills Assessment Communication Critical thinking Technical skills Surgical Attire Gowns Gloves Masks Hair Covering Protective eyewear Perioperative Nursing Three Phases: Preoperative (Preop) Intraoperative (Intraop) Postoperative (Postop) Preoperative Phase Starts when surgery is scheduled Ends when transferred to surgical suite Assessment phase Planning phase Discharge Planning phase Educations phase Getting it all together phase Intraoperative Phase Begins when transferred to the surgical suite Ends when transferred to the postanesthesia care unit (PACU) Surgical phase Anticipatory time Maintaining client advocacy Maintaining communication with family/surgical team Surgical team interaction Postoperative Phase Begins upon entry to the PACU Ends when discharge from the PACU Assessment Pain control Education Discharge planning Interdisciplinary team communication Categories of Surgery-Purpose for Surgery Defined by: 1. The reason for surgery 2. The urgency for surgery 3. The degree of risk of surgery 4. The anatomic location of the surgery 5. The extent of the surgery required Reason for surgery Diagnostic Curative Restorative Palliative Cosmetic Urgency of the procedure Elective Urgent Emergent Degree of Risk Minor Risk Major Risk Anatomic location General GYN Urology Orthopedic Neurological Plastic Ophthalmology Anatomic location Cardiac Thoracic ENT Vascular Transplant Trauma Bariatric Extent of surgery Simple Radical Surgical Settings Inpatient Outpatient/ambulatory Hospital-based ambulatory surgery center Free-standing surgical center Physician’s office surgery Ambulatory Care Centers Preoperative Period Assessment Nursing Management Analysis Planning and Implementation Evaluation Collaborative Management Preoperative H&P up to 30 days PTS Primary Care Physician or Nurse Practitioner Faxed to pre-admission center Faxed to PCP or surgeon Reviewed, evaluated, changes PRN Sometimes surgery gets cancelled Nursing Process in Pre-op Phase Planning: Correction of any abnormal labs Blood donations Bloodless surgery Nutrition Pain Management Surgery Classes Discharge planning Assessment History Surgical Risk Factors Physical Assessment and manifestations Psychosocial assessment Laboratory/ Radiographic assessment History Present problem, reason for surgery Past medical history Past cardiac history Past surgical history Family history Social history Medications Allergies Surgical Risk Factors Medical history Cardiovascular system Respiratory system Renal/ Urinary system Neurological system Musculoskeletal Age greater than 65 Surgical Risk Factors Medication history Past surgical complications Past postoperative complications Nutritional status Social habits Family history of complications Type of surgical procedure planned Nursing Physical Assessment Health status Cardiovascular status Respiratory status Renal/urinary status Neurologic status Musculoskeletal status Nutritional status Psychosocial Assessment Anxiety Fear Coping Support Systems Socioeconomic status Diagnosis Education Physical signs Lab and Radiograph Assessment Baseline Predict potential complications Abnormal results Values according to medications taken Labs Urine=UA Hematocrit=Hct Hemagloblin=Hgb White blood cell count=WBC Prothrombin time/ pro time=PT Partial thromboplastin time, activated=aPTT International Normalized ratio=INR Labs: cont’d Chemistry: electrolytes=Na, Cl, K, Glucose, CO2 Creatinine Blood urea nitrogen (BUN) Serum pregnancy test Radiographs/Optional tests Chest x-ray=CXR Electrocardiogram=EKG Arterial blood gas-ABGs Pulmonary function tests=PFTs Films for area of surgery: x-rays, MRI, CAT scan Nursing Management Review planned surgery Obtain client history Physical assessment Preadmission treatment/diagnostic testing Interpret diagnostic tests Client expectations Q&A Caretaker ability Analysis: Nursing Diagnoses Knowledge deficit Anxiety Disturbed sleep patterns Ineffective coping Anticipatory grieving Disturbed body image Disabled family coping Powerlessness Planning & Interventions Dx: Knowledge deficit Ensuring informed consent Client self-determination Implementing dietary restrictions Administration of medications Intestinal preparation Skin preparation Vascular access Pre-operative Teaching Dx: Anxiety Tubes, drains, additional vascular access Post-op procedures Post-op exercises: breathing exercises, incentive spirometry, coughing & splinting, leg procedures and exercises Early Ambulation Range of Motion exercises (ROM) Relaxation & stress reduction Dx: Anxiety Deep breathing Music therapy Touching Family’s presence Reassurance Calm mannerisms Pre-operative sedation Collaborative Management: Assessment & Planning Client interview Correct person for the correct procedure with correct preparation on the correct anatomy Risk for perioperative positioning injury Lacks normal defense mechanisms Size, age skin integrity Potential for hypoventilation Potential for hemodynamic shifts Blood loss Preoperative Chart Review: Nursing Responsibility Pre-op check list: Surgical informed consent Anesthesia informed consent Blood transfusion consent-T&S done? Site verification checklist-Med-Surg RN/OR staff Lab results-report abnormal lab values H&P present & signed Current vital signs Special Needs Preoperative Client Preparation Clothing removed/don patient gown Jewelry removed including body any piercing/s Prosthesis: dentures, wigs, limbs Aides: hearing, glasses, cane Arm bands: identification, code status, blood bracelet, fall risk status bracelet Misc: contact lenses, hairpins Nail polish, artificial nails Preoperative Client Preparation Empty bladder Pre-operative medications: Versed/Reglan Safe transfer to surgical suite Special Considerations Patient’s age: child & elderly Cognition: ability to cooperate/understand Ethnic: customs Language/communication: interpreter, HOH Evaluation: what is my outcome? Planned or unplanned Ms. W, age 77, is admitted for curative surgery (hysterectomy). She has a history of asthma & is currently taking Prednisone. Her weight is 237, her height 5’3”. What are her known risk factors? What other questions will you ask? Critical thinking: Synthesis of information Assessment: physical examination focused on client’s history & planned surgery Assessment of risk factors Client’s previous experience w/surgery Client’s coping resources Results of pre-op diagnostic tests Critical thinking: Synthesis of information Knowledge: A&P of affected body systems Surgical risk factors Type of surgical procedure to be performed Surgical stress response infection control practices Critical thinking: Synthesis of information Experience: Caring for clients who have had surgery Personal experience with surgery Critical thinking: Synthesis of information Standards: apply standards of care (SOC) Apply AORN standards in operating room Apply American Society of PeriAnesthesia Nurses (ASPAN) standards of care Critical thinking: Synthesis of information Attitudes: Use discipline in collecting a complete history Use perseverance to ensure a comprehensive assessment Goals of Client Safety Provide safe client care Knowledge of procedure Ensure the correct client, correct site, correct level and correct procedure Knowledge of positioning Adhere to safe medication administration guidelines Perform surgical counts Safety: Client Correct patient, correct surgery, correct side: Time Out Positioning: padding, alignment, eyes, breast, penis/scrotum Injury: burns Sponge, Needle, Instrument counts Fall prevention-safety straps Goals of Client Safety Provide a safe environment Adhere to asepsis: surgical conscious Promote coordinated and effective communication Safety: Staff Sharps Equipment Lifting, moving, positioning client Combative client Safety equipment: universal protocol: goggles; isolyzer gel OSHA: surgical smoke, laser plume Benefits of a Career in Perioperative Nursing Requires The ability to work in a fast paced environment Flexibility Attention to detail Willingness to commit to ongoing learning The ability to work collaboratively as a member of the surgical team Patient Outcomes Planned Outcomes Unplanned Outcomes Intraoperative Nursing Break! Intraoperative Phase Begins when the client enters into the surgical suite Sedated? Aware? Noises Cold Double teamed Surgical Asepsis Surgical field-defined Surgical tables-green or blue drapes Surgical conscious Infection control practices Physical layout of surgical suite Protocols: distance, doors, dress Skin Preparation Clip-electric razor Scrub Shower Purpose Surgical Hand Scrub Purpose Agents: soap & water vs. liquid hand cleaner Nails Position of hands Donning gown & gloves Safety: Staff Sharps Equipment Lifting, moving, positioning client Combative client Safety equipment: universal protocol: goggles; isolyzer gel OSHA: surgical smoke, laser plume Safety: Client Correct patient, correct surgery, correct side: Time Out Positioning: padding, alignment, eyes, breast, penis/scrotum Injury: burns Sponge, Needle, Instrument counts Fall prevention-safety straps My Space-Your Space Defined geographic locations Position of equipment Rules of engagement Color me blue/green Surgical conscious Moving about in the OR OR traffic patterns The Red Line Anesthesia: more choices and alternatives General Anesthesia Regional Anesthesia Intravenous Anesthesia Local Anesthesia Balanced Anesthesia General Anesthesia: Inhalation Agents Inhalation most controllable method; lungs act as passageway for entrance & exit of agent Gas Agents : Nitrous Oxide must be given with oxygen require assisted to mechanical ventilation frequently shiver taken in & excreted via lungs Examples: halothane, enthrane, florane… Anesthesia Cart Supply Cart Syringes IV supplies Intubation supplies Medications Blood transfusion supplies Regional anesthesia supplies General Anesthesia Endotracheal Intubation (maintain airway patency/promote oxygenation) Used with general anesthesia; Alternatives are mask or LMA Stages of General Anesthesia Stage 1: Analgesia/Sedation/Relaxation Stage 2: Excitement/Delirium Stage 3: Operative Anesthesia (Stage 4: DANGER: BAD) not expected/normal Speed of EMERGENCE (recovery from anesthesia) depends on type of anesthesia, length of time & many other factors- try to time with end of surgery General Anesthesia: Intravenous Intravenous Agents Thiopental Sodium (Pentothal) but is commonly called “Sodium Pentothal” by patients (class: barbiturate) Diprovan (Propofol) rapid acting monitor vital signs respiratory depression Adjuncts to General Anesthesia Hypnotics (Versed) also used for conscious sedation Opioid Analgesics (Morphine, Fentanyl) respiratory depression Neuromuscular Blocking Agents Causes muscle paralysis Examples: Rocuronium, Succinycholine What vital function is affected? Potential General Anesthesia Complications Overdose (consider risk factors) Hypoventilation postoperatively Intubation related: sore throat, hoarseness, broken teeth, vocal cord trauma MALIGNANT HYPERTHERMIA Genetic predisposition Triggered by anesthetics such as Halothane Balanced Anesthesia (a sample) Start with Pentothal or Propofol Add in some nitrous oxide for amnesia Use inhalation agent such as halothane Stir in a little opiate- morphine, fentanyl, for postop analgesia To top it off give Pavulon, a neuromuscular blocker, for additional muscular relaxation Regional Anesthesia Field Block Nerve Block Spinal Anesthesia Epidural Anesthesia Regional Anesthesia Loss of sensory nerve impulses; motor function may or may not be affected No loss of consciousness Field Block: “caine” injected around a nerve or group of nerves (dental procedures) May be combined with epinephrine to prolong Approximately 30 min to 2 hours Regional Anesthesia: Spinal Local anesthetic (-caine) injected into cerebrospinal fluid (approx L 35) subarachnoid space Spinal Anesthesia (Subarachnoid Block) Anesthesia: tip of xiphoid to toes Risks: Loss of vasomotor tone “Spinal Headache” Infection, Rising anesthesia above diaphragm Nursing: KEEP FLAT, MONITOR VS & OFFER FLUIDS WHEN APPROPRIATE Regional Anesthesia: Epidural Injected into epidural space rather than subarachnoid fluid (usually safer) Used for OR & OB Epidural catheter can be left in place for postop pain management (PCA) Regional Anesthetic Risks Anaphylaxis (ALLERGY) Incorrect administration technique Systemic absorption of medication Infection Intravenous Anesthesia Multiple Agents Multiple Purposes: Induction Hypnosis Dissociative Opioid Analgesics Neuromuscular blocking agents Conscious Sedation Reduce intensity of pain without loss of defensive reflexes Usually a combination of opioid analgesic and sedative-hypnotics May be administered by credentialed RN Expect client to be sleepy but arousable JUST BECAUSE HIS EYES ARE CLOSED DOESN’T MEAN HE’S ASLEEP!! Local Anesthesia Local/Topical Interrupts transmission of sensory nerve impulses so it: numbs what it touches Requires multiple injections with “CAINE” drug (Example: novacaine, lidocaine) Duration = 1 min to 20-30 min -Can be prolonged with added epinephrine Assess for ALLERGY *Nursing Process during the Intraoperative Phase Assessment-ongoing Planning Proactive Flexible Forever Changing Nursing Process Intraop Phase Evaluation Expected Unexpected Documented Informing Client & Family Surgical Waiting Room Ongoing Updates by OR Team Postoperative Goals Re-establishment of physiologic equilibrium Alleviation of pain Prevention of complications