perioperative nursing & teaching carol j. mcfadyen, rn, phd modified by sarah jean cooper rn, mn
TRANSCRIPT
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Perioperative Nursing & Teaching
Carol J. McFadyen, RN, PhD
Modified by Sarah Jean Cooper RN, MN
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Objectives – Student will be able to Describe legal requirements for informed
consent Identify risk factors for surgery Identify assessments and care needed
for surgical client Identify factors to consider in developing
a teaching plan Discuss the operative process
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Objective 1: Concept of Perioperative Nursing
Covers all aspects of surgical care • Preoperative -Preparation for surgery
• Intraoperative -Surgery and recovery from anesthesia
• Postoperative-Recovery from surgery to discharge
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Perioperative Nursing
Surgery classified by setting, urgency
– Table 49-1, p. 1208 shows classifications
Usually ambulatory and elective
Goal = provision of safe, effective care
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Objective 2: Informed Consent
Legal Requirement for invasive procedure (Figure 17-1 in “Iggy”shows example)
– Surgeon provides information • Benefits • Risks• Alternatives
– Others only witness signature• Notify surgeon if client confused or needs more
information
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Informed Consent
Special Considerations – Client with dementia – Minors– Implied Consent
• Life threatening • Telephone
Does not speak English
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Objective 3: Preparation of Client for Surgery- AssessmentHealth History
– Screening for Risk Factors– Obtaining base line information
Physical Examination (Table 49-7 p1217)
Identify fears and concerns
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Risk Factors Table 49-3, 49-4, p. 1214
Aging–Increases risk of other diseases
Medical Conditions –Respiratory and Cardiac most
criticalMedication Use
–List all medications used by client – Table 49-5 49-6, p. 1214
–Adverse reactions and interactions
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Nursing Diagnosis
Anxiety • Use therapeutic communication to
elicit • Listen for experience with unusual
occurrence • Explain common occurrences and
procedures• Use a calm, unhurried approach
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Nursing Diagnosis
Anticipatory Grieving • Listen for unusual concerns
Knowledge Deficit• Assess what client knows by asking him
to describe what he has been told and what previous surgical experiences he has had
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Preoperative Preparation Laboratory/Diagnostic Studies - Box
49-2, p. 1218– Complete Blood Count (CBC)
• Hemoglobin and hematocrit (Hgb & Hct) – oxygen carrying capacity
• White blood cell count (WBC) – infection
– Clotting capacity• Prothrombin (PT) or partial thromboplastin
time (PTT)– Urinalysis – bladder & kidney
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Preoperative Preparation
Laboratory and diagnostic studies (cont.)– Chest X-ray
• Respiratory status
– Electrocardiogram• Cardiac function
– Fasting Glucose Level• Diabetic
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Preoperative Physical Preparation
NPO after midnight or for specific period • Inform client and remove pitcher • Post sign on door
Skin preparation • Shower with antibacterial soap• Shaving controversial (usually done in pre-op area)• Additional cleansing for some
Remove contact lenses, glasses, jewelry Void prior to preoperative medications
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Preoperative Documentation
Preoperative Checklist (Box 49-4, p.1224, Figure 17-5 p 258 in “Iggy”
– Assessment & Vital Signs– Informed consent– Reports of diagnostic/laboratory tests – Medications given that AM– Procedures completed
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Objective 4: Develop a plan for providing age appropriate pre-operative teaching
Prevention is an important nursing role and function
Early discharge to home requires client/family to possess knowledge for self-care management
Client has a right to receive understandable information
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Age Appropriate TeachingNrsg Dx = Knowledge Deficit Common Learning Needs–Knowledge re:
– Events and sensations perioperatively• Use language client understands and can
comprehend
– Pain Management• Availability
– Physical Exercises and importance of completing• Turn, deep breathing, leg exercises
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Factors Affecting Client Teaching Literacy level & Language spoken
– Reading level Level of Education
– Health knowledge & Beliefs Age & Developmental level Adult education
– Self directed – motivation– Practical, purposeful – readiness to learn
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Factors that Inhibit Learning (Barriers) Pain, fatigue Acute illness Self image, perception Timing/environmental issues Cultural issues Language client does not understand
(jargon,spoken language, perceptual issues)
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Teaching Plan –Outcome Oriented First assess current knowledge level Learning Objectives – describes the
intended result of learning– Performance, what will the client be
able to do?– Condition, when will the client be
able to do?– Criterion, how well will the client
perform
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Teaching Methods
Active participation important– Discussion – keep it simple– Printed materials– AV presentations– Demonstration– Role playing – works well with children
One on One Group teaching Formal Class or Informal opportunity
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Evaluation of Learning/Documentation Measurable criteria
– Client must do something to document learning
• “Identify symptoms to report”• “Describe cause of disease and prognosis”• “Return demonstration of skill/procedure”
Documentation – Specifics of what was taught– What client knows or can do
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Teaching Activity Checklist
Perform Needs Assessment– Identify special needs– Determine preferred learning style– Establish readiness to learn
Establish priorities Identify goal
– Compose measurable objectives
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Teaching Activity Checklist
Determine method of presentation– Identify required materials
Formulate plan Control distracting environmental
factors Establish a caring, concerned
atmosphere Evaluate effectiveness of teaching.
Was stated outcome achieved?
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Group Activity Meet in groups of 4-5 and identify one
pre-operative or post-operative teaching need.
Identify how you would assess? Write a measurable goal/outcome. Develop a plan for teaching. Include
content (what will be taught) and method
State how you will know that learning has taken place
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Objective 5: Discuss Medications administered during the Perioperative PeriodSedatives/hypnoticsAnticholinergicsH2 anatagonistsAntiemeticsAnalgesics
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Sedatives/Hypnotics (Barbiturates & Benzodiazepines) Action: Depresses the CNS TE: Relief of anxiety,sedation,amnesia
– Potentiate action of opiod analgesics Interventions:
– Monitor vital signs especially Respiratory rate and BP
Evaluate : reduction in anxiety, drowsiness/resting
Examples: Valium, Ativan, Phenergan
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Anticholenergics
Action: Inhibits action of acetylchloline at postganglionic sites located in smooth muscle, secretory glands, and the CNS
TE: Decreases GI & Respiratory secretions (prevents aspiration during surgery)
Interventions: Monitor Monitor VS, I&O and urinary output (may cause retention)
Evaluation: Decreased secretions in OR, client has dry mouth
Examples: Robinul, Atropine
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Antiulcer Agents -H2 Antagonists Action: Inhibits gastric acid secretion TE: Decreased secretion of gastric acid Interventions: Monitor for complaints of
epigastric pain, in elderly watch for confusion, several drug interactions, timing of drug is important
Evaluation: decreased epigastric pain after eating
Examples: Ranitidine, Famotidine,Cimetidine
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Antiemetics (Phenothiazines)
Action:Depresses the chemoreceptor trigger zone in the CNS
TE: Diminished nausea a & vomiting Interventions: Give deep IM, slowly.
Assess VS and for drowsiness. May cause decreased BP on standing
Evaluation: Decreased nausea and vomiting
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Antiemetics – Reglan (Metoclopaminde)
Action:Blocks dopamine receptors in chemoreceptor trigger zone of the CNS. Stimulates motility of upper GI tract and gastric emptying
TE: Decreased nausea & vomiting Interventions: Give before meals (30min)
monitor for excessive drowsiness, extrapyramidal symptoms
Evaluation: decreased nausea and/or vomiting
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Opiod analgesics (may be
combined with ASA or Tylenol) Action:Bind to CNS receptors. Alters perception
of and response to painful stimuli while producing generalized CNS depression
TE: Decrease in severity of moderate pain Interventions: Assess VS (P&R), level of
sedation, Administer on regular basis for best pain relief. Give before pain becomes severe. Constipation is frequent side effect
Evaluation: Relief of pain (<3/10) Examples: Lortab, Vicodin, Percodan,Perocet
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Objective 6: Describe the role of team members during surgery
Team members (Figure 18-5,6 in Iggy)
– Sterile = wear gown, gloves plus cap, mask• Surgeon – Responsible for client during surgery• Assistant – may be specially trained registered nurse• Scrub Technician – passes instruments, monitors sterility
– Unsterile = wears cap and mask• Circulating Nurse – coordinates care (Figure 18-3
shows)• Anesthesiologist/CRNA = Monitors client status
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Objective 7: Health Promotion and Prevention during Surgery Risk for Perioperative positioning
injury• Figure 49-7, p. 1229 shows positions • Loss of pain sensation
– Pad pressure points – Avoid pressure on nerves
• Assess skin integrity before and after• Maintain anatomic position of joints
– Involuntary movements may increase stress
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Measures to Maintain Health-Intraoperative Care Risk for Injury
– Falls• Side rails up • Belts • Teach to not get up post medication
– Burns • Proper grounding of equipment
– Retained foreign objects • Accurate sponge counts
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Intraoperative Care- Measures to Maintain Health Risk for Infection
– Caps, mask, clothing– Skin Preparation – Draping – Surgical asepsis maintained
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Types of Anesthesia
General -Medication given by Intravenous or inhalation routes
– Can be used for all ages and surgeries – Intravenous for Induction – May be given in SDS for young child
– Agents rapidly excreted and action reversed
– Causes cardiac and respiratory depression
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Types of Anesthesia Anesthesia = partial or complete loss of sensation
with or without loss of consciousness– Local –used for small areas – infiltration or topical– Regional – several types
• Medication instilled around or into the nerves blocks nerve transmission (Figure 49-2, p. 1212)
• Client awake during procedure, does not perceive pain
• Disadvantages = hypotension, spinal headache
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Intraoperative Care Types of Anesthesia
– Concious Sedation• Used for diagnostic procedures • Medication given by IV push
– Midazolan hydrochloride (Versed)– Meperidine given for analgesia
• Nurse monitors client – Airway, vital signs, O2 Saturation
• Client sleepy but arouses – Does not remember details of procedure
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Four Phases of Anesthesia (See
Table 18-2, p 270 “Iggy”)
Stage 1 Induction to loss of consciousness – vulnerable to noise
Stage 2 Excitement -starts with loss of consciousness and ends with loss of eyelid reflex – vulnerable to noise & injury
Stage 3 Operative – relaxation to loss of hearing, sensation to pain lost
Stage 4 Extreme depression of functions leads to death if not reversed
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Anesthetic Agents (Table 18-3 & 18-4 p271-
72 “Iggy”
Agents used are dependent on client’s physical condition and nature of surgery(Length of procedure, age of client etc)
PACU & OR RN’s must be knowledgeable about side effects of each agent used in anesthesia in order to protect the client and assist in recovery
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Objective 8: Describe Assessments to Identify and Respond to Potential Anesthesia Complications (PACU)
Monitored by PACU RN– Airway, may have laryngospasm when
extubated
– Vital Signs – LOC – respond to command or stimuli– Bleeding– Pain
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Objective 9: Develop a nursing care plan to restore health for the post surgical client Postoperative assessment for Complications
– Impaired Gas Exchange/Ineffective Breathing Pattern
– Risk for Infection– Fluid Volume Deficit– Alteration in Nutrition:Less than body
requirements (nausea & vomiting, NPO)– Alteration in Elimination– Pain– Altered Tissue Perfusion – Risk for injury/Body Image Disturbance
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Focused Assessment of Post-operative Client Immediate post-op client on unit
– Airway (patent, O2??, breath sounds Resp)– Cardiovascular (BP, Pulse & Temp)– LOC (establish)– Dressings, Tubes/drains (check)– IV fluids/status (rate, solution, site)– Skin Integrity & positioning (condition)– Comfort Level (pain, nausea, last med)– Safety – side rails, call light– New orders
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Focused Post Surgery Shift Assessment Activity Form into groups of 4-5 Draw a picture of assigned client or
problem Identify assessments and rationale for
assessments for the client Identify interventions/rationale to prevent
complications, promote health Report to class
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Postoperative Care
Special Considerations – Elderly
• Recovery slower – Interventions to prevent complications need
to be scrupulous• May be more sensitive to medications
– Confusion – Respiratory depression
• Monitor closely for post op infection
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Postoperative Care
Special Considerations – Children– Use of FACES scale for assessment of pain
• Watch for non verbal behaviors indicating pain in younger
• Medicate prior to painful procedures – Encourage parents to stay with child/assist with care
• Be sure security objects available– Illness/hospitalization may result in < coping
• Provide age appropriate diversion– Explain procedures to child in age appropriate terms
• Prepare child if procedure hurts • Praise for accomplishments