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61 Cards in this Set
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Perioperative nursing |
Nursing care provided for the patient before, during, and after surgery. The nursing process is used to guide assessments and interventions that promote the recovery of health, prevent further injury or illness, and facilitate coping with alterations in physical structure and function. Conceptual model for perioperative nursing care (figure 30-1) describes 4 domains that surround the patient. 1.safety 2.physiologic responses 3.behavioral responses 4.health system (represents the the structural elements and other health system activities that must be present to support safe, effective, high-quality patient care) |
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Perioperative phases (3) |
1. Preoperative phase - begins when the patient and surgeon mutually decide that surgery is necessary and will take place; ends when patient is transferred to operating room or procedural bed. 2. Intraoperative phase: begins when patient is transferred to the OR bed; ends with transfer to the post anesthesia care unit (PACU) 3.postoperative phase: begins with admission to the PACU or other recovery area; ends with complete recovery from surgery and the last follow-up health care provider visit. It can be divided into 3 phases itself. |
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Postanesthesia care unit (PACU) |
The PACU is an area often adjacent to the surgical suite designed to provide care for patients recovering from anesthesia or moderate sedation/analgesia. |
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Postoperative phases |
1. Phase 1 providing patient care from a totally anesthetized state to one requiring less acute nursing interventions; 2. Phase 2 preparing the patient for self-care or family care or for care in a phase 3 extended environment. 3.phase 3 providing ongoing care for patients requiring extended observation or intervention after transfer or discharge from phase 1 or 2 |
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Surgical Procedure Classification |
Usually classified according to urgency, risk and purpose. |
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Surgery based on urgency (3 categories) |
1. Elective surgery - procedure that is preplanned and based on the patient’s choice and availability of scheduling for the patient, surgeon, and facility. Non urgent procedure that does not have to be done immediately. 2. Urgent surgery - must be done within a reasonably short time frame to preserve health, but is not an emergency. 3. Emergency surgery - must be done immediately to preserve life, a body part, or function. |
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Elective surgery |
Delay of surgery has no I’ll effects; can be scheduled in advance based on patient’s choice. Purpose is to remove or repair a body part, to restore function, to improve health, to improve self-concept. Examples: tonsillectomy, hernia repair, cataract extraction and lens implantation, hermorrhoidectomy, hip prosthesis, scar revision, facelift, mammillary. |
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Urgent surgery |
Usually done within 24-48 hours Purpose: to remove or repair a body part, to preserve or restore health. Examples: removal of gallbladder, coronary artery bypass graft (CABG), surgical removal of a malignant tumor, colon resection, amputation. |
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Emergency surgery |
Done immediately Purpose: to prevent further tissue damage, to preserve life Examples: control of hemorrhage; repair of trauma, perforated ulcer, intestinal obstruction; tracheostomy. |
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Surgery based on degree of risk (2 categories) |
1.Major: may be elective, urgent or emergency 2.Minor: primarily elective |
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Major surgery |
May be elective, urgent or emergency Risk: high, usually done in hospitalization/and specialized care, involves major body organs or life-threatening situations, has greater risk for postoperative complications. Purpose: to preserve life, to remove or repair a body part, to restore function, to improve or maintain health Examples: carotid endarterectomy, cholecystectomy, nephrectomy, colostomy, hysterectomy, radical mastectomy, amputation, trauma repair, CABG |
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Minor surgery |
Primarily elective Risk: low, few complications Usually performed in an outpatient clinic or as a same-day outpatient surgery setting (ambulatory surgery) Purpose: to remove skin lesions, to correct deformities Examples: teeth extraction, removal of warts, skin biopsy, dilation and curettage, laparoscopy, cataract extraction, arthroscopy. |
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Surgery based on purpose (6 categories) |
1. Diagnostic 2. Ablative 3. Palliative 4. Reconstructive 5.transplantation 6. Constructive |
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Diagnostic surgery |
Purpose: to make or confirm a diagnosis Examples: breast biopsy, laparoscopy, exploratory laparotomy |
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Ablative surgery |
Purpose: to remove a diseased body part Example: appendectomy, subtotal thyroidectomy, partial gastric Tony, colon resection, amputation. |
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Palliative surgery |
Purpose: to relieve or reduce intensity of an illness; is not curative. Examples: colostomy, nerve root resection, debridement of necrotic tissue, balloon angioplasties, arthroscopy |
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Reconstructive surgery |
Purpose: to restore function to traumatized or malfunctioning tissue, to improve self-concept Examples: scar revision, plastic surgery, skin graft, internal fixation of a fracture, breast reconstruction. |
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Transplantation surgery |
Purpose: to replace organs or structures that are diseased or malfunctioning Examples: kidney, liver, cornea, heart, joints. |
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Constructive surgery |
Purpose: to restore function in congenital anomalies Examples: cleft palate repair, closure of atrial-septal defect. |
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Anesthesia |
A method and technique of making potentially uncomfortable interventions tolerable and safe. Anesthesia agents can be administered systemically (to the whole body) or regionally (to a specific region of the body) to block nerve conduction. General or systemic anesthesia is a balance of loss of consciousness,analgesia (pain relief), relaxation, and loss of reflexes (temporary paralysis) Regional anesthesia does not cause narcosis (sleepiness), but results in analgesia and reflex loss. Moderate sedation involves intravenous (IV) administration of sedatives and analgesics to produce analgesia and a degree of amnesia that can be promptly reversed, whereas topical or local anesthesia targets a specific tissue of the body. |
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Who administers anesthesia |
Anesthesiologist (medical doctor) or certified registered nurse anesthetists (CRNAs) administer anesthetic agents while monitoring patient’s physiologic response and maintaining homeostasis throughout the procedure and recovery. Nurse anesthesia is an advanced nursing specialty. They are performing preoperative physical assessments, conduct preoperative teaching, administer anesthesia during the surgical procedure, and oversee the patient’s postoperative recovery from the anesthetic. |
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General (systemic) Anesthesia |
Involves the administration of drugs by inhalation or the IV route to produce central nervous system depression. It is typically a combination of both IV and inhalation anesthetic that allows for rapid induction, excretion and reversal of effects. Desired actions: loss of consciousness, amnesia (short-term loss of memory), analgesia (the brain does not respond to pain signals), relaxed skeletal muscles, and depressed reflexes. Risks: major associated risks for the circulatory and respiratory depression, postoperative nausea and vomiting (PONV), and alterations in thermoregulation. Postoperative bronchospasm is another risk, especially in patients with multiple comorbidities. 3 phases of general anesthesia: induction, maintenance and emergence. |
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Induction of general anesthesia |
Begins with administration of the anesthetic agent and continues until the patient is ready for the incision. |
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Maintenance of general anesthesia |
Maintenance continues from this point (the incision) until near the completion of the procedure. |
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Emergence of general anesthesia |
Starts as the patient begins to awaken from the altered state induced by the anesthesia and usually ends when the patient is ready to leave the OR. Length of time depends on the depth and length of anesthesia. |
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Moderate sedation/analgesia |
Also called conscious or procedural sedation, is used for short-term and minimally invasive procedures. The patient maintains cardio respiratory function and can respond to verbal commands. The IV administration of sedatives and analgesics produces a decrease in anxiety and discomfort/pain with some degree of amnesia. Patient retains the ability to keep the airway open and can respond to verbal and tactile stimulation. Who can administer: anesthesiologist, CRNAs, Perioperative, endoscopy, interventional radiology or interventional cardiology nurses with specialized training and competence in administering the medications and monitoring the patient’s cardiac rate and rhythm , respiratory rate, oxygen saturation, level of consciousness, level of pain, blood pressure, and skin condition may administer moderate sedation/analgesia. |
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Regional anesthesia |
Occurs when an anesthetic agent is injected near a nerve or nerve pathway in or around the operative site, inhibiting the transmission of sensory stimuli to central nervous system receptors. The patient remains awake, but loses sensation in a specific area or region of the body. Sometimes reflexes may be lost. Most commonly accomplished through; nerve blocks, spinal anesthesia (subarachnoid block), or epidural anesthesia. |
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Nerve blocks (peripheral) |
Are done by injecting a local anesthetic around a nerve trunk supplying the area of surgery such as a jaw, face and extremities. Onset and duration depend on how much is used and any additional drugs |
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Spinal anesthesia |
Injecting a local anesthetic into the subarachnoid space through a lumbar puncture, causing sensory, motor, and autonomic blockage. Used in surgeries of lower abdomen, perineum and legs. Adverse effects = hypotension, headache, and urine retention. |
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Epidural anesthesia |
Involves the injection of the anesthesia through the intervertebral spaces, usually in the lumbar region (although it may also be used in the thoracic or cervical regions). It is used for surgeries of the chest, abdomen, pelvis and legs; epidurals are also commonly used in childbirth. |
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Local anesthesia |
Is the injection of an anesthetic agent such as bupivacaine, lidocaine, or tetracaine to a specific area of the body. It bathes the tissue around a targeted nerve or infiltrates the underlying tissue in the operative area. Surgeon administers local anesthesia for minor, short-term surgical or diagnostic procedures such as tissue biopsy. Local anesthesia may also be injected during general anesthesia procedures to prolong pain relief after the general anesthetic wears off. |
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Topical anesthesia |
Primarily applied to intact skin, but may be used with mucous membranes and in some cases of wound care. Common topicals: lidocaine, tetracaine, and benzocaine, EMLA (eutectic mixture of local anesthetic - may be used on intact skin prior to injection, catheter placement, or laceration repair. Topical anesthetic may be sprayed, spread, or applied with a compress of drug-saturated gauze or cotton-tipped applicators. Loss of feeling and sensation occur in the specific area where the topical anesthesia is applied. |
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Informed consent and advance directives |
Informed consent reflects a process of effective communication that results in the patient’s voluntary agreement to undergo a particular procedure or treatment (such as surgery) The healthcare provider performing the procedure should provide the following information in everyday language that considers the patient’s health literacy level and is culturally sensitive: Description of the procedure or treatment Underlying disease process and its natural course Name and qualifications of the health care provider performing the procedure or treatment Explanation of the risks and benefits Explanation that the patient has the right to refuse treatment and that consent can be withdrawn Explanation of expected (not guaranteed) outcome, recovery, and rehabilitation plan and course. Informed consent protects the patient, the health care providers, and the health care facility. The signed, dated, and timed form is a legal document as well as an ethical imperative. |
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Advance directives |
Are legal documents, allow patients to specify instructions for health care treatment should they be unable to communicate these wishes postoperatively. Suspension of a do-not-resuscitate (DNR) or allow-natural-death (AND) order, although not required for surgery, should be discussed as part of the informed consent process. |
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Outpatient/same-day surgery |
Places: freestanding surgery centers, hospital-based surgery centers, interventional units, and health care providers’ offices. Usually patients are admitted to the ambulatory surgery center the morning of surgery. Nurses should arrange for older patients or chronically ill who do not have support systems to arrange referrals prior to the date of surgery to provide needed care after the surgery for home care. |
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Assessment of the surgical patient includes: |
Obtaining a healthy history and performing a physical assessment to establish a baseline database Identifying risk factors and allergies that could cause surgical adverse events Identifying medications and treatments the patient is currently receiving Determining the teaching and psychosocial needs of the patient and family Determining postsurgical support and referral needs for recovery **assessment is done a few days prior to surgery = preadmission testing |
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Health history |
Identifies risk factors and strengths in the patient’s physical and psychosocial status, and helps the nurse individualize the preoperative assessment. Important history infor: patient’s developmental level; medical history, including allergies; medication history, including nonprescription drugs; previous surgeries; implants; extremity limitation; perceptions and knowledge of the surgery to be done; nutrition, use of alcohol, illicit drugs or nicotine; activities of daily living and occupation; coping patterns and support systems; and sociocultural needs. |
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Developmental considerations |
Infant: lower total blood volume, making even a small loss of blood a serious concern because of. The risk for dehydration and the inability to respond to the need for increased oxygen during surgery. Airway is small, soft, and pliable; If a child exhibits signs of even mild respiratory infection on the day of surgery, the child’s procedure might be postponed until a later date. Infants also have hard tome maintaining stable body temperature during surgery because the shivering reflex is not well developed, making hypothermia or hyperthermia more likely. The liver is immature until after the first year of life, the effects of muscle relaxants and narcotics may be prolonged. Older adults: physiologic changes which increase the surgical risk More likely to have chronic illness which increases surgical risk |
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Medical history |
Provides information about past and current illnesses. Pathologic changes associated with past and current illnesses increase surgical risk as well as the risk for postoperative complications. |
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Cardiovascular diseases |
Thrombocytopenia, hemophilia, recent myocardial infarction or cardiac surgery, heart failure, and dysrhythmias Increase the risk for anesthesia complications, including hemorrhage and hypovolemic shock, hypotension, venous stasis, thrombophlebitis/thromboembolism, and over-hydration with IV fluids. |
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respiratory disorders |
Pneumonia, bronchitis, asthma, emphysema, and chronic obstructive pulmonary diseases Increase the risk for respiratory depression from anesthesia as well as postoperative pneumonia, atelectasis, and alterations in acid-base balance. |
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Kidney and liver diseases |
Influence the patient’s response to anesthesia, affect fluid and electrolyte as well as acid-based balance, alter the metabolism and excretion of drugs, and impair wound healing. |
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Endocrine diseases |
Especially diabetes mellitus, increase the risk for hypoglycemia or acidosis, slow wound healing, and present an increased risk for postoperative cardiovascular complications. |
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Surgical history |
Physicals implications of previous surgeries are important to the intraoperative and postoperative phases (ie previous heart or lung surgery may necessitate adaptations in anesthesia and in positioning during surgery) Previous surgical complications - such as malignant hyperthermia, latex sensitivity, pneumonia, thrombophlebitis or deep vein thrombosis (DVT) - may put the patient at risk during this surgery, necessitating vigilant intraoperative and postoperative monitoring. The patient’s perceptions and knowledge of the surgical procedure to be performed should be assessed. |
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Deep vein thrombosis (DVT) |
A formation of a blood clot (thrombus) in a deep vein or surgical site infection |
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Medication history |
These drug categories increase surgical risk: Anticoagulants (may precipitate hemorrhage) Diuretics (may cause electrolyte imbalances, with resulting respiratory depression from anesthesia) Tranquilizers (may increase the hypotension effect of anesthetic agents) Adrenal steroids (abrupt withdrawal may cause cardiovascular collapse in long-term users) Antibiotics in the mucin group (when combined with certain muscle relaxants used during slithery, may cause respiratory paralysis) |
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Nutritional status |
Both malnutrition and obesity increase surgical risk. Surgery increases the body’s need for nutrients necessary for normal tissue healing and resistance to infection. Malnourished = greater risk for alterations in fluid and electrolyte balance, delay in wound healing and wound infection. Obese patients = increased risk for respiratory, cardiovascular, positional injury, DVT, and gastrointestinal problems. They may also have gastroesophageal reflux disease (GERD), putting them at risk for aspiration of stomach contents. Fatty tissue has a poor blood supply and therefore, has less resistance to infection. Thus- postoperative complications of delayed wound healing, wound infection, and disruption in the integrity of the wound are more common. |
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Use of alcohol, illicit drugs or nicotine |
Patients with a large habitual intake of alcohol require larger doses of anesthetic agents and postoperative analgesics, increasing the risk for drug-related complications. Patients with illicit drugs are at risk for interactions with anesthetic agents. IV drug use may render veins hardened, inflamed, and unusable for anesthesia drug administration. Smoking-higher risk for respiratory complications after surgery. Because they already have increased mucous secretions and decreased ciliary action in the tracheobronchial tree. The tracheobronchial mucosa is chronically irritated in people who smoke; anesthesia increases this irritation. Smokers are at risk for hypoxia and postoperative pneumonia. Smoking compromises wound healing by constricting blood vessels, impairing blood flow to healing tissues. |
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Activities of daily living and occupation |
Exercise, rest and sleep habits are important for preventing postoperative complications and facilitating recovery. Delay in returning to a career or occupation could affect how the patient earns a living |
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Coping patterns and support systems |
Assessing the patient’s psychological, sociocultural, and spiritual dimensions is as important as the physical history and examination. |
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Sociocultural needs |
Affect the patient’s response to and perceptions of the surgical experience. Cultural background my require that nursing interventions be individualized to meet needs in such areas as language, food preferences, family interaction and participation, personal space and health beliefs and practices. |
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Physical assessment |
Assessing the patient’s current physical status provides data for interventions to decrease surgical risk and potential postoperative complications. Nurse’s role is to ensure that the tests are explained to the patient, appropriate specimens are collected, the results are documented in the patient’s record before surgery and abnormal findings are reported. Presurgical screening tests include: chest x-ray, electrocardiography, complete blood count (CBC), electrolyte levels and urinalysis. Additional cardiac clearance may be indicated for patients with a cardiac history or abnormal (ECK/EKG) glucose testing is done and again the morning of Elevated white blood cell count = presence of infection Decreased hematocrit and hemoglobin level = presence of bleeding, anemia Hyperkalemia or hypokalemia = increased risk for cardiac problems Elevated blood urea nitrogen or urinalysis = potential kidney issues |
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Atelectasis |
Incomplete expansion or collapse of a part of the lungs |
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Hemorrhage |
Excessive blood loss due to the escape of blood from blood vessels |
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Hypothermia |
Low body temperature |
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Never events |
Serious but preventable surgical errors (that should never occur) |
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Pneumonia |
Inflammation or infection of the lungs. |
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Shock |
Body’s reaction to acute peripheral circulatory failure due to an abnormality of circulatory control or to a loss of circulating fluid |
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Thrombophlebitis |
Inflammation in a vein associated with thrombus formation |
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Venous thromboembolism (VTE) |
Blood clot or foreign substance that is dislodged and travels through the bloodstream until it lodges in a smaller vessel |
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Embolism |
Blocking of an artery by a blood clot or by other foreign matter brought to the site by the blood flow. |
