nursing management of clients with peri-operative stressors nur133 lecture #2 & #3 k. burger,...
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Nursing Management ofClients with
Peri-Operative Stressors
NUR133
Lecture #2 & #3
K. Burger, MSEd, MSN, RN, CNE
What is Medical-Surgical Nursing?Blend of technical skills & caring relationshipsSpecialty of nursingNursing care of adults 18yrs +Requires broad scope of knowledgeEncompasses many roles/competenciesAcademy of Medical-Surgical Nurses (AMSN)
= specialty organization
Take some time to…
Review the Academy of Medical Surgical Nurses (AMSN) website @http://www.medsurgnurse.org
Click on and read:Learn more about Medical Surgical Nursing
What are your opinions about the role of the medical surgical nurse as outlined in this AMSN statement?
Peri-Operative Nursing
SURGERYDEFINITION = A planned alteration of physiologic processes within the body in an attempt to arrest or eliminate disease or illness
PHASES = Pre-operativeIntra-operativePost-operative
Goal of Peri-Operative Nursing
To prepare the client mentally and physically for surgery and to assist in full recovery in the shortest time possible with the least discomfort.
Classifications of Surgery
PURPOSE
Diagnostic
Curative-Ablative-Restorative
-Reconstructive
Palliative
Cosmetic
Transplant
URGENCY
Elective
Urgent
Emergency
SERIOUSNESS
Minor
Major
Variables Affecting Surgical Outcome
Age Nutrition Fluid Balance Life-style Habits Medical Conditions Medication History Family History Prior Surgical Experiences Spiritual and/or Cultural Beliefs Anxiety and Coping Mechanisms
Pre-Operative Phase
Begins when a decision is made to perform a surgical procedure and ends when the client enters the operating room
Nursing goals = Assessing for risk factorsEmotional support of client Client teachingPhysical preparation of client
Pre-operative Nursing Assessment
HISTORYAgeMedication Medical history AllergiesPrior surgeries and outcomesAnesthesia history / personal & familialLifestyle habits: alcohol / smoking/ exercise
Pre-operative Nursing Assessment
PHYSICAL
VS Head & Neck Skin Turgor Thorax & Lungs Heart & Vascular System Abdomen Neurological Status
Pre-Operative Nursing Assessment
LABS
Complete Blood Count (CBC)
Basic Metabolic Panel (BMP)
Coagulation Studies PT/PTTUrinalysisBlood typing / screeningAdditional tests as indicated
DIAGNOSTICS
Chest X-Ray(CXR)
Electrocardiogram(ECG)
Additional tests as indicated
LABORATORY NORMALS
Students should research/fill-in/memorize the following lab values ( See pg 302-303 Iggy)
KNaClFBSBUNCrWBCHgbHct
Pre-operative Nursing Assessment
Knowledge
Informed ConsentAnxietyCoping mechanismsAvailability of support
Common Pre-operativeNursing Diagnosis
Anxiety r/t situational crisis, change in health status, fear of unknown, fear of pain and/or disfigurement
Knowledge deficit r/t pre/post operative procedures
Disturbed Sleep r/t anxiety about upcoming surgery
Pre-operative Nursing InterventionsEmotional Support
Utilize positive communication techniquestouch – eye contact validating statements
Active listeningEncourage verbalization of fears/anxietiesAvoid negative communication techniques
false-reassurancejudgmental statements
Pre-Operative Nursing InterventionsClient Teaching
Peri-operative progression & sensationsDescription of Pre and Post operative eventsDescription of events in OR and PACUPain managementCoughing & Deep Breathing ExercisesIncentive SpirometryTurning & Positioning Leg Exercises & Ambulation
Client TeachingPain Management
Pre-operative assessment of individual pain perception on 1-10 scale
Reassurance that pain reports WILL bebelieved and acted upon
Use of PCA Benefits of ATC versus PRNAllaying of fears regarding addictionPotential side-effects of narcoticsHow pain management promotes recovery
Client TeachingPulmonary Exercises
Method for diaphragmatic breathing:Hands on ribs, inhale thru nose allowing abdomen to expand, hold 3-5 sec, exhale thru pursed lips, 10X /hr while awake
Method for controlled coughingDeep breath X2 , then inhale,hold breath 2-3 sec, coughforcefully 2-3X consecutively
Method for splinting
Client TeachingPulmonary Exercises
Instruction on use of Incentive Spirometer:Take 2-3 normal breathes, close lips on mouthpiece, inhale to reach set goal, hold 3-5 sec, release mouthpiece & exhale, 10X/hr while awake.
Client TeachingActivity
LEG EXERCISESDorsi/Plantar flexion, ankle rotation, knee/hip flexion, 5X each leg/hr w.a.
AMBULATIONDiscuss importance of early ambulation and method for getting out of bed
TURNING AND POSITIONINGUse of side rails
External pneumatic compression devices (Sequentials, SCDs, Flowtron)
Pre-operative Nursing InterventionsPhysical Preparation of Client
Implementing dietary restrictionsInitiation of surgical prepsInsertion of tubes/drains/vascular accessCompletion of pre-operative checklistAdministration of pre-operative medication
Pre-operative Nursing ResponsibilitiesMedical Record Review
Informed ConsentHistory and PhysicalMedical Clearance Advance DirectivesAllergies / Previous anesthesia reactionsPresence of autologous blood bankLabs and Diagnostics
Intra-Operative Phase
Begins when client arrives in surgical area and lasts until they are in the PACU
Nursing Goals =Prevention of injury to clientMaintenance/Promotion of: oxygenation, cardiac output, balanced I & O
The Intra-operative Team
Surgeon Surgical Assistants: MD, PA, STAnesthesiologist and/or Nurse AnesthetistRegistered Nurses: Circulating, Scrub
Anesthesia
Anesthesia is defined as the absence of normal sensation. This also includes loss of protective reflexes!
Anesthesia provides:amnesia – analgesia – muscular relaxation
Stages I-IV of Anesthesia ( Guedel’s Signs)Types:
GeneralLocalConscious Sedation
General Anesthesia
Inhalation Intravenous Balanced = use of both
Mechanical Ventilation – presence of ET tube Use of adjuvant medications such as:
Hypnotics: VersedOpioids: FentanylNeuromuscular Blocking Agents: Pavulon Anectine
Important Factors in theCare of the Anesthetized Client
Use protective positioning techniquesHandle gentlyChange positions slowlyKeep client warm
Potential Complications ofGeneral Anesthesia
OverdoseUnrecognized hypoventilationComplications of intubationAnaphylaxisHypothermiaInjury r/t positioning, burnsMalignant hyperthermia
Malignant Hyperthermia
Rare but extreme emergencyOccurs most often with inhalantsGenetic predisposition Uncontrolled acceleration of muscle
metabolism and increased BMRLife threatening elevated temperature,
hyperkalemia, acidosis
Emergency Treatment of Malignant Hyperthermia
Stop surgical procedure/anesthesia if possible
Hyperventilate with 100% oxygenAdminister DANTROLENE intravenouslyUndertake body cooling measures:
Iced NS intravenouslyCooling blanket
Local Anesthesia
Advantages
Client remains conscious
Cost effective Minimal recovery time Vasoconstrictive
agents decrease bleeding
Disadvantages
Client remains conscious
Potential for local tissue irritation
Potential for sudden systemic reaction such as hypotension
Regional AnesthesiaTypes
Field BlockInjected around the operative field
Nerve BlockInto or around a nerve or nerve group
SpinalInto subarachnoid space
Epidural Into epidural space
Regional Anesthesia
Advantages
Patient remains conscious
No respiratory depression or irritation
Enhanced pain management post-operatively
Disadvantages
Patient remains conscious
Circulatory depression/stasis
Potential trauma/infection @ site of injection
Edema - potential for spinal headache
Conscious Sedation
IV administered hypnotic, opioid, or sedative
Reduces LOC but does not produce unconsciousness
Airway maintainedClient can respond to simple commandsProvides short amnesia actionCommonly used for: scopes, caths etc.
Intra-operative Nursing Diagnosis
Risk for positioning Injury Risk for Fluid Volume ImbalanceRisk for HyperthermiaPotential for HypoventilationRisk for AspirationRisk for Impaired Skin Integrity
(see EBP page 335 Iggy)“Pressure ulcers do occur in surgery”
Post-Operative Phase
Begins upon admission to the PACU and continues through entire recovery phase
Nursing Goals =Promoting physiological recovery of all body systems, prevention of complications, pain management, client teaching and emotional support
Focused Assessment in PACU
Respiratory – patent airway, + O2 status (Most common PACU complication)
CNS – monitor gradual return of function Surgical Incision site – bldg? drainage? Vital Signs – cardiac function
hypothalmus depression GI- nausea/vomiting common, aspiration risks GU- strict Intake and Output, check for retention
Comfort – administer analgesia IV per MD orders
Discharge CriteriaPACU
(Modified Aldrete Score) Consciousness
2 = Fully awake1 = Responds to name0 = No response
Activity on command2 = Moves all extremities1 = Moves two extremities0 = No movement
Respiration2 = Free deep breathing1 = Dyspneic, hyperventilating, obstructed breathing0 = Apneic
Circulation2 = Blood pressure within 20% of pre-op level1 = Blood pressure within 50%–20% of pre-op level0 = Blood pressure 50%, or less, of pre-op level
Oxygen saturation2 = SpO2 >92% on room air1 = Supplemental O2 required to maintain SpO2 >92%0 = SpO 2 <92% with O2 supplementation
Total Score10 = Score = 9 needed to leave PACU
Focused Assessmentfor Post-Operative Client
Upon arrival on Nursing Unit
VS – compare against PACU data, take frequently until stable
Respiratory status: auscultate, pulse ox Cardiac status: HR – peripheral pulses LOC Skin – surgical site and other areas Abdomen – listen for return of bowel sounds
check for distention ( flatus vs urine) Tubes – IV, NG, Drains, Foley Comfort – Administer analgesics; check PACU record
Nursing DiagnosisPost-Operative Clients
Acute PainRisk for Ineffective Tissue Perfusion r/t
hypovolemia, circulatory stasisRisk for Ineffective Breathing Pattern r/t
pain, effects of anesthesia/narcoticsRisk for Infection r/t invasive procedure,
respiratory stasisRisk for Deficient Fluid Volume r/t fluid
losses during surgery
Post-Operative Nursing Interventions
Prevention of complications:
Respiratory:-Assess for s/s pneumonia, atelectasis, pulmonary embolus-Encourage C & DB and Incentive Spiro-Position with HOB elevated-Encourage ambulation
Post-Operative Nursing Interventions
Prevention of complications
Cardiovascular:-Assess for s/s hemorrhage, shock, thrombophlebitis-Utilize sequential TEDs -Encourage leg exercises and/or ambulation-Position to promote venous return
Post-operative Nursing Interventions
Preventions of complications
Elimination:-Assess for s/s of constipation, urinary retention, ileus, UTI-Encourage ambulation -Maintain IV and/or PO fluid intake-Provide privacy, proper positioning and other strategies to promote elimination
Post-Operative Nursing Interventions
Prevention of Complications
Wound:-Assess for s/s of infection, dehiscence, evisceration-Promote wound healing through careful aseptic handling-Encourage balanced diet w/ sufficient protein, Vit C, Iron, Zinc- Administer prescribed antibiotics
Antibiotic Medications Students should research the following classes of
antibiotics for important nursing implications of each: (Chapter 37 & 38 Lilley)Penicillens Ex: UnasynCephalosporins Ex: RocephinSulfonamides Ex: BactrimTetracycline Ex: VibramycinAminoglycosides Ex: GentamicinQuinolines Ex: LevaquinMacrolides Ex: ErythromycinCarbapenems Ex: ImipenemMiscellaneous Ex: Vancomycin
Post-operative Nursing Interventions
Comfort and Rest:
Pain managementKeep linens clean and dryProvide for personal hygiene needsKeep environment quiet
Post-operative Nursing Interventions
Fluids and Nutrition:
Monitor I & OProvide good oral hygieneIce chips / water sipsAssess for return of peristalsisAssess for gag reflex Gradual diet progression – clear, full, soft
Post-Operative Nursing Interventions
Emotional support-Encourage expression of feelings-Utilize positive communication techniques
Knowledge deficit-teach wound care, s/s infection, dietary recommendations, activity restrictions, medication regime
Transfusion Therapy
Pretransfusion responsibilities:
Verify prescription and other concommitant orders Test donor’s and recipient’s blood for compatibility
ABO and Rh TYPE & CROSSMATCH Obtain consent and apply “blood bracelet”per hospital
policy Determine patency of IV AND angiocath lumen
(20gauge minimum) Collect supplies:
250 mL bag Normal SalineY-set blood tubing with filter
Pre-Tranfusion Responsibilities
Obtain blood product from lab per protocol With another nurse confirm:
- physician order- client identification
- blood bag label, attached tag, and requisition slip for ABO and Rh compatability
- client blood bracelet matches blood bank number on unit of blood to be administered
-expiration date Inspect blood for discoloration, gas bubbles, or
cloudiness.
Transfusion Responsibilities
Assess vital signs. Prime Y-tubing with NS
Gently agitate blood bagSpike and attach blood bag
Begin transfusion slowly and stay with client first 15 minutes. Take VS Q 5 minutes.
Ask client to report unusual sensations such as chills, shortness of breath, hives, or itching.
After 15 minutes without reaction increase flow rate to administer blood product per agency protocol.(usually 11/2 hr – 2 hrs for PC)
Continue to monitor client closely with VS q 15-q30m Flush line with NS after infusion is complete
Types of Transfusions
Packed red blood cellsPlateletsPlasma transfusions: fresh frozen
plasmaCryoprecipitateGranulocyte (white cell) transfusions
Transfusion Reactions
Clients can develop any of the following transfusion reactions: Hemolytic Allergic Febrile Bacterial Circulatory overload Iron overload Hypocalcemia Hyperkalemia
NURSING INTERVENTIONS
STOP TRANSFUSION
CHANGE IV TUBING
KEEP IV PATENT WITH NS
NOTIFY MD