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Inflammation Concept: Perioperative Care Brunner ch.17-19 Review of Inflammation: What It Is and What It Isn’t The body’s cellular response to injury, infection, or irritation. Mechanism is the same regardless of injuring agent. Always present with infection. It is not infection. Infection is not always present with inflammation. Inflammatory Response Intensity depends on extent and severity of injury & body’s ability to react Sequential: – Neutralizes & dilutes inflammatory agent – Removes necrotic materials – Establishes an environment suitable for healing and repair Causes of Inflammatory Response Heat—burn injury Radiation—sunburn, radiation tx Trauma—surgery* Allergens—sinuses; anaphylactic shock Infection Steps of Inflammatory Response Vascular response Cellular response Formation of exudate Healing Manifestations of Inflammation Localized response (redness, pain, swelling, etc) and systemic response (increased TPR, malaise, nausea, anorexia, etc) are the same as in the infectious process (see Infection Concept Lecture) With a high degree of inflammation, and when infection is present, WBCs rise Healing Process Regeneration—replacement of lost cells and tissues with cells of same type Repair—replacement of lost cells with connective tissue (scar) Exemplar: Perioperative Care Good example of inflammation because inflammation is the body’s response to trauma and surgery is considered a type of trauma. Normal postoperative wound healing is an excellent example of the inflammatory process in action. Stages of Perioperative Care – Preop—from time of admission to time of transfer to OR – Intraop—from time of transfer to OR to time of transfer to PACU – Postop—from time of transfer to PACU to time of discharge from hospital Preoperative Legal and Ethical Considerations Informed consent (407)—MD and nurse’s responsibility. Pt needs: – Adequate disclosure – A clear understanding – To consent voluntarily Transfusions—may or may not be part of the general form Mental competency/Minors Advocacy Surgical Patient—Preoperative Risk Factors Age—elderly and children Nutrition—malnourished and obese Smoking Chronic diseases Physical disabilities Medications Allergies Patient classification acc’d to ASA (424) Home Risk Factors Support systems Physical layout Hygiene Smoking Nutrition Traffic control Distance Transportation Preop Assessment Health hx VS, pain, pulse ox, anxiety Focus on CV, respiratory systems, and surgical area Diagnostics—labs and radiology Dietary considerations—NPO Surgical preps needed Education needed Patient Needs Psychosocial needs—fears, therapeutic communication, referrals, spiritual and cultural needs, support systems, body and self-image and lifestyle changes that could occur, past experiences Developmental needs—children and elderly Preoperative Medications Given in holding area or “On call” Sedatives—induce sedation, amnesia Anxiolytics—reduce anxiety Antibiotics—prevent, treat infection Histamine blockers—reduce secretions, increase motility Anticholinergics Pain meds, antiemetics Eye gtts Routine Rxs Provide Education Teach to senses Postop pain control Professional roles Prevention of complications Equipment Family Document Preop checklist (417) Preop assessment (may be on flow sheet or nurse’s notes) Consent forms on chart Check computer to make sure other necessary reports are on chart Transfer to OR Finish charting before transfer Intraoperative Team Circulating nurse(RN)—In charge of activities, safety and verification, equipment, traffic flow, contacts, patient assessment, preop meds, IV start, counts, Safety Checklist (423) etc. Scrub nurse or tech—sets up sterile fields, hands-off to surgeon, labels tissue, counts RN first assistant—surgeon’s “right hand”, does some simple surgical tasks Surgeon—head of team, may have others Anesthesiologist/CRNA (ACP)—gives anesthesia, monitors physiologic functions OR Environment 3 levels: unrestricted, semi-restricted, restricted Aseptic practices Preventing complications and injuries – Electrical and fire – Mechanical – Hypothermia – Hyperthermia Types of Anesthesia(427): General Given IV or by inhalation. Induces deep sedation (Stage III)—causes loss of consciousness and reflexes—pt will need ventilatory support Given for long procedures, when total muscle relaxation is needed, when pt is extremely anxious, or if pt is uncooperative or refuses other types. Advantages: rapid induction Disadvantages: CV and respiratory SEs Regional & Local Local—loss of sensation without loss of consciousness. May be topical or by injection Regional (nerve blocks, spinal, epidural)— loss of sensation without loss of consciousness. See diagram p. 432 Advantages—little systemic absorption; rapid recovery; good for hi-risk pts Disadvantages—technical difficulty, HA, discomfort, hard to match anesthesia with length of surgical procedure IV Conscious Sedation Also called Moderate Sedation Used for routine procedures Reduces anxiety, controls pain Produces amnesia Patient will still have patent airway and be able to follow commands Pt must be monitored (CV, resp, LOC) Must be given by someone specially trained Recovery is quick Adjunct Meds Used for muscle relaxation, analgesia, sedation, to prevent N/V, neutralize stomach acid. Some may also be used alone for IV conscious sedation to induce sedation and amnesia during a procedure. Advantages—provides analgesia and amnesia; allows intubation and ease of incision; lowers risk for aspiration Disadvantages—synergistic or additive effects can increase sedation and add to risk of respiratory complications Postoperative Nursing Care PACU – Beginning of postoperative phase – ACP must accompany pt to PACU. Gives report (441) and usually checks on pt periodically. Circulator may come, too. After report, PACU nurse takes responsibility. PACU Nurse’s Responsibilities Maintain airway Assess and monitor respiratory & CV systems. LOC, fluid status, & op site Monitor for complications from anesthesia and surgical procedure Relieve various discomforts Report to CRNA or surgeon for problems Discharge from PACU Must meet Aldrete criteria (445) Phase I—patients are monitored closely as in ICU until ready for phase II. Phase II—patients either go to ambulatory care for d/c or inpatient care for continued monitoring Phase III—patients will be discharged; either directly from PACU or from ambulatory care. Gerontologic Considerations More likely to have comorbid conditions such as CV, resp, or renal impairments causing more risk of hypoxia and F&E imbalances Hypothermia is greater risk Transfers are greater risk due to musculoskeletal and skin issues Slower recovery from anesthesia Discharge from SDS (445-6) Pt must be able to control pain with po meds Must void before d/c D/C instructions include wound care, drain mgmt, activity, diet, meds, F/U appts, what to watch for, who to call for probs. Make sure adult is present to take pt home F/U care may include HH care, appts with MD or others, and phone calls from unit. Immediate Nursing Responsibilities for Inpatients Prep of room When pt returns: – – – – – – Be available to assist with transfer Assess airway and LOC Position pt on side or in semi-Fowler’s Connect and position all tubes, check wound Get VS—your 1st, their last Receive report from PACU nurse and go over postop orders (441 chart again) Next….. – Assess for and do same things as PACU nurse did on admission to PACU – Carry out any STAT orders if not done by PACU nurse – Make sure pt is comfortable and in good alignment, SR up, items WIR – Talk to family—let them know how pt is doing Ongoing Responsibilities VS acc’d to order, dept policy, or as patient condition warrants Ongoing head to toe assessments with concentration on surgical site (review wound care), fluid balance, labs, pain Follow orders as written Control common, expected side effects of surgery Common Postop Side Effects Pain Weakness Chills/decreased circulation Shallow breathing Low grade temp Nausea Thirst Anorexia Gas/decreased BS Urinary retention Orthostatic BP Commonly Given Postop Medications Narcotics—PCA, IVP, IM, po Non-opioids—IVP, po Antibiotics—IVPB, po Antiemetics—IVP, rectal Antipruritics—IVP (epidural SE) H2 receptor antagonists May or may not give all home meds Preventing Complications: Why Does the Nurse Do These? TCDB, IS? Aseptic wound care? Splinting incision? Progressive ambulation, AEEs, TEDs? Diet progression? Fluid management—po and parenteral? Promote elimination? Balance activity and rest periods? Emotional support—effect of dx and px? Education? Assessing for Complications— How does the Nurse Know? Hemorrhage—internal vs. external Fever Wound infection Atelectasis/PN Persistent N/V DVT Fluid imbalance Paralytic ileus Sepsis If Complications Arise, What Does the Nurse Do? Hemorrhage Fever Wound Infection Atelectasis/PN Persistent N/V VTE Fluid Imbalance Paralytic Ileus Sepsis Discharge Instructions