NURSING MANAGEMENT OF THE PERIOPERATIVE PATIENT

Michael Dosch CRNA MS

January 2003

(References to Tables or Figures are from the text-- Lewis and Collier.)

  1. INTRODUCTION

"Operations are good for people"

Surgery is an important/expensive area of the Hospital.

References

Definitions

Standards of practice

Classification Of Surgery Table 16-1

Major and minor surgery

Types of surgery

Urgency of surgery

Settings

  1. PSYCHOSOCIAL REACTIONS TO SURGERY

Stress Surgery is a stressor in all areas of functioning, physiologic and psychologic.

Preoperative Anxiety is a normal adaptive response

  1. PATIENT INTERVIEW / PREOP ASSESSMENT Table 16-2, 16-3, Figure 16-1

Vital Signs

Past surgical history

Allergies

Nutritional State

Body Weight

Fluid / Electrolyte Balance

Infections

Habits Affecting Anesthesia

Chronic Illness

Integumentary Status: pressure ulcers from immobility

Drug History: Prescription as well as OTC usage

Diagnostic Studies: Table 16-6

 

  1. NURSING MANAGEMENT PREOP

 

Preoperative Teaching Table 16-7

Instruction is essential. Research demonstrates that those who are informed will have better recovery. Best time to teach is the afternoon or evening before surgery. Challenging when most are same day admits - even carotids or heart surgery. Important because it decreases anxiety, influences recovery, promotes patient satisfaction.

General Principles of Preop teaching

  1. Some things everyone having surgery has to knowósee TABLE 16-7
  2. Reinforce what the patient has been told about surgery. Find out patientís understanding of procedure first. Know enough basic information about common procedures to anticipate and answer the common questions.
  3. Balance telling too little vs too much
  4. Avoid anxiety producing words -- "pain" (discomfort)
  5. Include family members, if possible
  6. Have the patient explain, give return demonstrations
  7. Prepare for situations (cold, bright light, never left alone)

 

Patient Teaching About Postoperative Care

  1. Therapeutic devices: indwelling catheter, n/g tube, chest tube
  2. Medications for Pain: assured that medication will be available, PCA devices.
  3. Postoperative self-care procedures: C & DB, splinting, leg exercises, turning
  4. Ambulation- donít bound OOB, donít do a sit up, sit at BS for a moment to check dizzyness

 

Preop legal preparationóthe Operative Permit Figure 16-2

 

Day of surgery preparation

Physical Preparation

Medications Table 16-8, 16-9

  1. Sedative to ensure adequate rest and to decrease anxiety (midazolam, diazepam, lorazepam). Preanesthetic agent may be given 30 minutes to 1 hour before surgery to promote sleep and relaxation. No consent if sedated-- get it signed before giving. Also, void before giving.
  2. Sedatives: decrease the anxiety ie benzodiazepines, barbiturates
  3. Narcotic analgesic: reduce the amount of anesthetic needed. Given 30 minutes to 1 hour before sx, often IM
  4. Anticholinergic: reduce secretions. Also cause dry mouth and dilatation of the pupils. (Atropine or Robinul).
  5. Tranquilizer: may be given instead of a narcotic, especially to the elderly. (Valium or Phenergan).

Note Example of 2,3,4 combined as Demerol-Vistaril-Atropine.

Note Also expect Antibiotics (given within the 1 hr prior to incision).

Note common to see anti-aspiration meds ie Bicitra, Reglan, ranitidine

Information for the family

 

Preoperative Checklist / Transportation to the OR Fig. 16-5

Nursing responsibility to see that the checklist is completed--important, shows that the patient is ready for transfer to the OR. Unusual observations and abnormal labs are reported to the physician. "If you want to take care of the patient, take care of the paperwork"

  1. THE INTRAOPERATIVE PHASE

Introduction

The players & their roles in surgery

All wear scrub suit to decrease the number of bacteria

Anesthesia

Types of anesthesia

Conscious sedation

Regional Anesthesia

General anesthesia

Wound Closure

 

  1. NURSING MANAGEMENT OF THE POSTOPERATIVE PATIENT

 

Transfer to Recovery Room (PACU) Table 18-1

 

Immediate postoperative complications "ABC"

Airway obstruction

Breathing: Respiratory insufficiency

Circulation

 

Transfer to floor Table 18-4, 18-5

Ready to be discharged to the floor once

Aldrete score is Activity, Respiration, Circulation, Consciousness, Pulse oximetry

 

Admitting the patient to the general nursing unit Nursing Care Plan 18-1

Postop care includes:

Drains are soft rubber tubular structures placed in wounds to

 

Complications Related To Surgery Fig 18-2, Table 18-3

Stress can cause serious complications and nursing care is aimed at preventing complications. Vigilant assessment can determine presence of complications, and good nursing care can help prevent some complications.

Pulmonary Problems Table 18-7

Cardiovascular Problems

Neurologic problems

Hypothermia

Pain

Nausea and vomiting

Fluid and electrolyte problems

 

Incisional Problems

Discharge Teaching:

Individualize to the needs of the patient