perioperative concepts and management. association of perioperative nurses aorn standards of care ...
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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
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
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 post-anesthesia
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 surgery2. The urgency for surgery3. The degree of risk of surgery4. The anatomic location of the surgery5. The extent of the surgery required
Surgical Settings
Inpatient Outpatient/ambulatory Hospital-based ambulatory surgery
center Free-standing surgical center Physician’s office surgery Ambulatory Care Centers
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 & InterventionsDx: Knowledge deficit
Ensuring informed consent Client self-determination Implementing dietary restrictions Administration of medications Intestinal preparation Skin preparation Vascular access
Pre-operative TeachingDx: 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 reductionDx: 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
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
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 AnesthesiaEndotracheal 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
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 3-5) 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
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