Interventions for Preoperative Clients

1. Interventions for Preoperative Clients Francisco Felix

2. Perioperative Nursing Definition of Surgery Surgery is any procedure performed on the human body that uses instruments to alter tissue or organ integrity.

3. Purposes of Surgery • Diagnostic • Curative • Restorative • Palliative surgery, which makes the client more comfortable • Cosmetic surgery, which reconstructs the skin and underlying structures

4. Perioperative NursingTypes of Surgery • Degree of urgency – necessity to preserve the client’s life, body part, or body function. • Degree of risk – involved in surgical procedure is affected by the client’s age, general health, nutritional status, use of medications, and mental status. • Extent of surgery – Simple and radical

5. Perioperative NursingTypes of Surgery (Urgency) • Emergency- performed immediately to preserve function or the life of the client. • Elective – is performed when surgical intervention is the preferred treatment for a condition that is not imminently life threatening or to improve the client’s life. • Urgent – Necessary for client’ health to prevent additional problem from developing; not necessarily an emergency. • Required – has to be performed at some point; can be pre-scheduled.

6. Perioperative NursingType of Surgery (Degree of Risk) • Major– involves a high degree of risk. • Minor – normally involves little risk. • Age – very young and elder clients are greater surgical risks than children and adult. • General health- surgery is least risky when the client’s general health is good. • Nutritional Status – required for normal tissue repair. • Medications – regular use of certain medications can increase surgical risk. • Mental status – disorder that affect cognitive function

7. Perioperative Nursing Surgical settings • Surgical suites • Ambulatory care setting • Clinics • Physician offices • Community setting • Homes

8. Perioperative Nursing Surgical settings • Disadvantages Less time for rapport Less time to assess, evaluation, teach Risk of potential complication post D/C. • Advantages of outpatient: Low cost Low risk of infection Less interruption of routine Less than from work Less stress

9. Collaborative Management Assessment • History and data collection • Age • Drugs and substance use • Medical history, including cardiac and pulmonary histories • Previous surgery and anesthesia • Blood donations • Discharge planning

10. Physical Assessment/Clinical Manifestations • Obtain baseline vital signs. • Focus on problem areas identified by the client’s history on all body systems affected by the surgical procedure. • Report any abnormal assessment findings to the surgeon and to anesthesiology personnel.

11. System Assessment • Cardiovascular system • Respiratory system • Renal/urinary system • Neurologic system • Musculoskeletal system • Nutritional status • Psychosocial assessment • Gerontological Considerations

12. Preoperative Nursing CarePsychosocial considerations • Level of anxiety • Coping ability • Support systems

13. Preoperative Nursing CareGerontological Considerations • CardiovascularCoronary flow decreases Heart rate decreases Response to stress decreases Peripheral vascular decreases Cardiac output decreases Cardiac reserve decreases

14. Preoperative Nursing CareGerontological Considerations • Respiratory System Static lung volumes decreases Pulmonary static recoil decreases Sensitivity of the airway receptors decreases • Nervous system Increased incidence of post.op. confusion. Increased incidence of delirium Increased sensitivity to anesthetic agents

15. Preoperative Nursing CareGerontological Considerations • Renal SystemRenal blood flow declines 1.5% per year. Renal clearance reduced • GastrointestinalDecreased intestinal motility Decreased liver blood flow Delayed gastric emptying

16. Preoperative Nursing CareGerontological Considerations • MusculoskeletalDecreased mass, tone, strength Decreased bone density • IntegumentaryDecreased elasticity Decreased lean body mass Decreased subcutaneous fat

17. Laboratory Assessment • Urinalysis • Blood type and crossmatch • Complete blood count or hemoglobin level and hematocrit • Clotting studies • Electrolyte levels • Serum creatinine level • Pregnancy test • Chest x-ray examination • Electrocardiogram

18. Preoperative Nursing Consent • Nature and intention of the surgery • Name and qualifications of the person performing the surgery. • Risks, including tissue damage, disfigurement, or even death • Chances of success • Possible alternative measures • The right of the client to refuse consent or later withdraw consent.

19. Deficient Knowledge Interventions • Informed consent • The surgeon is responsible for obtaining signed consent before sedation is given and surgery is performed. • The nurse’s role is to clarify facts presented by the physician and dispel myths that the client or family may have about surgery.

20. Implementing Dietary Restrictions • Client is given nothing by mouth (NPO) for 6 to 8 hours before surgery. • NPO status decreases the risk for aspiration. • Failure to adhere can result in cancellation of surgery or increase the risk for aspiration during or after surgery.

21. Administering Regularly Scheduled Medications • Consult the medical physician and anesthesia provider for instructions about drugs, such as those taken for diabetes, cardiac disease, glaucoma, regularly scheduled anticonvulsants, antihypertensives, anticoagulants, antidepressants, or corticosteroids.

22. Intestinal Preparation • Bowel or intestinal preparations are performed to prevent injury to the colon and to reduce the number of intestinal bacteria. • Enema or laxative may be ordered by the physician.

23. Skin Preparation • The skin is the body’s first line of defense against infection; a break in the barrier increases the risk for infection. • Shower using antiseptic solution. • Shaving as a procedure before surgery is viewed as controversial.

24. Preparing the Client • Possible placement of tubes, drains, and vascular access devices • Teaching about postoperative procedures and exercises: • Breathing exercises, incentive spirometry, coughing and splinting (Continued)

25. Preparing the Client(Continued) • Leg procedures and exercises, antiembolism stockings and elastic wraps, early ambulation, and range-of-motion exercises

26. Anxiety Interventions • Preoperative teaching • Encouraging communication • Promoting rest • Using distraction • Teaching family and significant others

27. Preoperative Nursing CareAnxiety • The nurse must consider the pt’s family and friends when planning psychological support. • Empowering their sense of control. Activities that decreasing anxiety are deep breathing, relaxation exercises, music therapy, massage and animal-assisted therapy. • Use of medication to relieve anxiety.

28. Preoperative Chart Review • Ensure all documentation, preoperative procedures, and orders are complete. • Check the surgical consent form and others for completeness. • Document allergies. • Document height and weight. (Continued)

29. Preoperative Chart Review(Continued) • Ensure results of all laboratory and diagnostic tests are on the chart. • Document and report any abnormal results. • Report special needs and concerns.

30. Preop Client Prep • Client should remove most clothing and wear a hospital gown. • Valuables should remain with family member or be locked up. • Tape rings in place if they can’t be removed. • Remove all pierced jewelry. (Continued)

31. Preop Client Prep(Continued) • Client wears an identification band. • Dentures, prosthetic devices, hearing aids, contact lenses, fingernail polish, and artificial nails must be removed.

32. Preoperative Medication • Reduce anxiety. • Promote relaxation. • Reduce pharyngeal secretions. • Prevent laryngospasm. • Inhibit gastric secretion. • Decrease amount of anesthetic needed for induction and maintenance of anesthesia.

33. Preoperative Nursing CareMedications • Sedatives/hypnotics- Nembutal • Tranquilizers-Ativan, versed, valium • Opiate analgesics- Demerol, morphine • Anticholinergics-Atropine sulfate,atarax • H2o blockers.- Tagamet, Zantac • Antiemetic- Reglan, Phenergan

35. Preoperative Nursing CarePreanesthesia Management Physical Status Categories • ASA 1: Healthy patient with no disease • ASA 11: Mild systemic ds without fx limitations • ASA 111:Severe systemic ds associated with definite fx limitations • ASA 1V: Severe systemic ds that is a constant threat to life. • ASA V: Moribund pt. Who is not expected to survive without the operation. • ASA V1: A declared brain-death whose organ are being recovered for donor. • E: Emergency

36. Members of the Surgical Team • Surgeon • Surgical assistant • Anesthesiologist • Certified registered nurse anesthetist • Holding area nurse • Circulating nurse • Scrub nurse • Surgical technologist • Operating room technician

37. Perioperative Nursing CareSurgical team Nursing Roles: Staff education Client/family teaching Support and reassurance Advocacy Control of the environment Provision of resources Maintenance of asepsis Monitoring of physiologic and psychological status

38. Environment of the Operating Room • Preparation of the surgical suite and team safety • Layout • Health and hygiene of the surgical team • Surgical attire • Surgical scrub

39. Intraoperative Nursing CareSurgical asepsis • Ensure sterility • Alert for breaks

40. Intraoperative PhaseAnesthesia • Greek word- anesthesis, meaning “negative sensation.” Artificially induced state of partial or total loss of sensation, occurring with or without consciousness. • Blocks transmission of nerve impulses • Suppress reflexes • Promotes muscle relaxation • Controlled level of unconsciousness

41. Anesthesia • Induced state of partial or total loss of sensation, occurring with or without loss of consciousness • Used to block nerve impulse transmission, suppress reflexes, promote muscle relaxation, and, in some instances, achieve a controlled level of unconsciousness

42. General Anesthesia • Reversible loss of consciousness is induced by inhibiting neuronal impulses in several areas of the central nervous system. • State can be achieved by a single agent or a combination of agents. • Central nervous system is depressed, resulting in analgesia, amnesia, and unconsciousness, with loss of muscle tone and reflexes.

43. Stages of General Anesthesia • Stage 1: analgesia • Stage 2: excitement • Stage 3: operative • Stage 4: danger

44. Administration of General Anesthesia • Inhalation: intake and excretion of anesthetic gas or vapor to the lungs through a mask • Intravenous injection: barbiturates, ketamine, and propofol through the blood • Adjuncts to general anesthetic agents: hypnotics, opioid analgesics, neuromuscular blocking agents

45. Balanced Anesthesia • Combination of intravenous drugs and inhalation agents used to obtain specific effects • Combination used to provide hypnosis, amnesia, analgesia, muscle relaxation, and reduced reflexes with minimal disturbance of physiologic function (Continued)

46. Balanced Anesthesia(Continued) • Example: thiopental for induction, nitrous oxide for amnesia, morphine for analgesia, and pancuronium for muscle relaxation

47. Complications from General Anesthesia • Malignant hyperthermia: possible treatment with dantrolene • Overdose • Unrecognized hypoventilation • Complications of specific anesthetic agents • Complications of intubation

48. Local or Regional Anesthesia • Sensory nerve impulse transmission from a specific body area or region is briefly disrupted. • Motor function may be affected. • Client remains conscious and able to follow instructions. • Gag and cough reflexes remain intact. • Sedatives, opioid analgesics, or hypnotics are often used as supplements to reduce anxiety.

49. Local Anesthesia • Topical anesthesia • Local infiltration • Regional anesthesia • Field block • Nerve block • Spinal anesthesia • Epidural anesthesia

50. Complications of Local or Regional Anesthesia • Anaphylaxis • Incorrect delivery technique • Systemic absorption • Overdosage (Continued)