Care of Preop Pats

Question 1

Includes three phases below
Preoperative(before surgery)
Postoperative (after surgery)
Together, these time periods are know as the perioperative period
Patient safety (#1 priority) throughout the perioperative period is the number-one priority for all personnel - tons education for operative period; pat advocate always
Primary roles of the nurse: educator - promoter of health, patient advocate, and promoter of health; lot edu, advocacy, and SAFETY

Answer 1

Perioperative Period

Question 2

begins when the patient is scheduled for surgery and ends at the time of transfer to the surgical suite
Time before enter surgical suite

Answer 2

Preoperative(before surgery)

Question 3

starts with completion of surgery and transfer of the patient to a specialized area for monitoring such as the postanesthesia care unit (PACU) and may continue after discharge from the hospital until all activity restrictions have been lifted
May go to ICU

Answer 3

Postoperative (after surgery)

Question 4

Quality measures
Surgical Care Improvement Project (SCIP)
Communication and collaboration with the surgical team are essential - teamwork very imp in surgical area - pats at high risk; all have to work together or pats safety at risk

Answer 4

Patient safety

Question 5

Regulatory things for pat safety
Centers for Medicare and Medicaid Services (CMS) collect this data for tracking patient outcomes and ensuring patient-centered care and accountability on the part of health care facilities - quality measures regulated for surgery

Answer 5

Quality measures

Question 6

wrong-site surgery
patient falls
hospital-acquired pressure ulcers - pressure and high intensity for short period and low intensity for long period time - for surgery is intense pressure because holding pats in awkward positions to surgery so high intensity for short period - looking ways to pad and cushion areas during surgery to reduce ulcers; get skin issues from surgery, and
vascular catheter-associated infections - in and outside surgery get these and bloodstream infections

Answer 6

Centers for Medicare and Medicaid Services (CMS) collect this data for tracking patient outcomes and ensuring patient-centered care and accountability on the part of health care facilities - quality measures regulated for surgery

Question 7

Specific to surgery
Idea: Plan for the reduction and eventual elimination of preventable surgical complications
Very imp

Answer 7

Surgical Care Improvement Project (SCIP)

Question 8

Certain things surgically related that within control to prevent
infection prevention - antibiotics, pulling out catheters post-surgery, pre-op antibiotics (specficially timed because need timed directly to first incision to prevent infections)
prevention of serious cardiac events - NPO before surgery, certain meds (beta blockers before surgery to prevent cardiac comps)
prevention of venous thromboembolism (VTE) - SCDs and stockings in preop
Certain things required under SCIP targeted toward this

Answer 8

Idea: Plan for the reduction and eventual elimination of preventable surgical complications

Question 9

Urgency:
Degree of risk:
Extent: - how invasive

Answer 9

Categories of surgical procedures

Question 10

Elective - scheduled out
Urgent - need do within next 24 hours
Emergent - emergency: disability/death if no surgical intervention now

Answer 10

Urgency:

Question 11

Minor
Major

Answer 11

Degree of risk:

Question 12

Simple - go and remove something
Radical - take something and surrounding tissue
Minimally invasive (MIS) - all new advanced tech with robots with few incisions and scopes; recovery time less and less risks for them and less time under anesthesia

Answer 12

Extent: - how invasiv

Question 13

Age – older than 65
Medications - anticoag: prevent blood clotting increased risk bleeding; NSAIDs - higher risk bleeding; antihypertensive - higher risk cardiac comps; need thorough list
Medical History - resp issues: higher risk with anesthesia; HTN and CVD, arrhythmias - higher risk postop
Prior surgical experiences - postop comps: infections, higher risk future ones; anesthesia comps: if have more likely will in future; psychosocial: pats get very anxious under anesthia and had experience anxiety worse
Family history - malignant hyperthermia, fam members had probs with anesthesia
Type of surgical procedure planned - around mouth: higher risk for airway comps; chest surgery and upper abd - around lungs and higher risk resp comps; abd: DVTs, ileus (intestines not work anymore), dehiscence and eviseration; hip, joint and large bone surgeries - high risk blood clot, PTEs; directs nursing care

Answer 13

Factors that increase the risk for surgical complications (postop/during surgery)

Question 14

The older adult may have a variety of health-related issues that can have an impact on the planning of care and outcome of surgery, including:

Answer 14

Specific considerations for older adults

Question 15

Greater incidence of chronic illness - higher risk comorbities
Greater incidence of malnutrition - sometimes cannot take care self preop and issue postop; not much fam and friends around and CV comps and resp comps big
More allergies
Increased incidence of impaired self-care abilities
Inadequate support systems
Decreased ability to withstand the stress of surgery and anesthesia
Increased risk for cardiopulmonary complications after surgery
Risk for a change in mental status when admitted (related to unfamiliar surroundings, change in routine, drugs) - very high risk out norm enviroment issues with mental status so watching for that
Increased risk for a fall and resultant injury - lot changes MS, safety and preventing falls

Answer 15

The older adult may have a variety of health-related issues that can have an impact on the planning of care and outcome of surgery, including:

Question 16

Cardiovascular system ]
Respiratory system
Musculoskeletal system
Neurologic system
Renal/urinary system
Skin

Answer 16

Age-related changes as surgical risk factors

Question 17

(will have decreased cardiac output, increased blood pressure, decreased peripheral circulation)
Need know where baseline is; checking circ esp if having surgery on extremity: pulses, cap refill, temp, color extremities; close eye on BP, if on beta blocker admin that before hand; checking BP and HR and no CO issues
Determine normal activity levels, and note when patient tires
Monitor vital signs, peripheral pulses, and capillary refill

Answer 17

Cardiovascular system

Question 18

(reduced vital capacity, loss of lung elasticity, decreased oxygenation of blood, more RV - harder for gas exchange, if alveoli collapsed (atlectasis - higher risk for postop lung infections - pneumonia))
Teach coughing and deep-breathing exercises
High risk atlectasis, pneumonia - cough, deep breathing, IS; close eye on resp sys status
Getting up as early as possible
Monitor respirations and breathing effect

Answer 18

Respiratory system

Question 19

(increased incidence of deformities related to osteoporosis or arthritis - increased bony prominences increasing risk for skin issues, move slower, issues with balance)
Assess the patient’s mobility
Safe when ambulating; all fall precautions and interventions in place; take longer to get back to baseline
Teach turning and positioning
Encourage ambulation
Place on falls precautions, if indicated

Answer 19

Musculoskeletal system

Question 20

(sensory deficits, slower reaction time, decreased ability to adjust to changes in the surroundings)
Frequently reOrient the patient to the surroundings if confused; know where everything is; explain ahead of time and re-explain; give imp info
Allow extra time for teaching the patient and processing info esp edu around procedures and post-op care
Provide for the patient’s safety

Answer 20

Neurologic system

Question 21

(decreased blood flow to kidneys (decline GFR - higher risk toxicity meds), reduced ability to excrete waste, decline in glomerular filtration rate, nocturia common)
Monitor intake and output
Assess overall hydration
Monitor electrolyte status - monitoring electrolytes creatinine BUN and making sure stay hydrated
Assist frequently with toileting needs, especially at night - MS and safety issues; need to make sure safely toileting them; not mean catheter because safety imp

Answer 21

Renal/urinary system

Question 22

(dry with less subcutaneous fat makes the skin at greater risk for damage; slower skin healing increases risk for infection, increased bony prominences so increased issues with skin possible)
Assess the patient’s skin before surgery for lesions, bruises, and areas of decreased circulation
Pad bony prominences - preventative dressings on if need to
Use pressure-avoiding or pressure-reducing overlays
Avoid applying tape to skin
Change position at least every 2 hours
Imp prevent pressure ulcers

Answer 22

Skin

Question 23

Complete set of vital signs and report abnormal findings to surgeon and anesthesiologist
Focus on problem areas identified from the patient’s history and on all body systems affected by the surgical procedure - health history, past surgical history, and any body sys high risk; look at labs pertient to pat; abnorm specific to doing
Assess for and report any signs/symptoms of infection - do not want post-op infections but also want know if risk infection prior
Assess for and report factors that could contraindicate surgery, including:
Assess for and report clinical conditions that may need to be evaluated by a provider before proceeding with surgical plans
Psychosocial assessment
Laboratory assessment
Imaging assessment (CXR, CT, MRI) - CXR not common preop, CT/MRI more specific for surgery
Other diagnostic assessments (ECG) - very common esp if any CV history need recent one

Answer 23

Preop assessments

Question 24

report abnormal assessment findings to surgeon/anesthesiology personnel

Answer 24

Focus on problem areas identified from the patient’s history and on all body systems affected by the surgical procedure - health history, past surgical history, and any body sys high risk; look at labs pertient to pat; abnorm specific to doing

Question 25

Looking at labs and letting people know if at risk Increased prothrombin time (PT), international normalized ratio (INR), or activated partial thromboplastin time (aPTT) - coag studies; high: higher risk bleeding - contraindication going through with surgery but up to surgeon; elevated if on anticoags but make report if abnorm high Abnormal electrolytes - risk factors for high and low esp Mg, K, Ca - abnorm high risk for cardiac dysrythmias - make sure watching those Report of possible pregnancy or positive pregnancy test - want know if pregnant but not affected by it if are

Answer 25

Assess for and report factors that could contraindicate surgery, including:

Question 26

Change in mental status, vomiting, rash - going on with pat that is abnorm report it Recent administration of an anticoagulant drug - not want increase risk of bleeding Family or personal history of malignant hyperthermia (comp of anesthesia need assess and no issues with this) with anesthesia

Answer 26

Assess for and report clinical conditions that may need to be evaluated by a provider before proceeding with surgical plans

Question 27

level of anxiety - huge issue, coping ability, support systems - if lot postop needs need make sure help at home if need be Address concerns and needs for pat

Answer 27

Psychosocial assessment

Question 28

Can depend on the patient’s age, medical history, and type of anesthesia and surgery planned - most common May not get all and may get none

Answer 28

Laboratory assessment

Question 29

UA, blood type and screen (if need transfusion) CBC or H/H clotting studies (PT, INR, aPTT, platelet count) electrolyte levels serum creatinine & BUN - kidney func pregnancy test ABG’s may be assessed for patients with chronic pulmonary problems) - if concerned about pulm/resp issues

Answer 29

Can depend on the patient’s age, medical history, and type of anesthesia and surgery planned - most common

Question 30

Consent implies that the patient has sufficient information to understand: The surgeon is responsible for having the consent form signed before sedation is given and before surgery is performed - surgeon responsible for all info to pat Nurse’s responsibility is that the consent form is signed, and you serve as a witness to the signature, not to the fact that patient is informed - not one doing the informing

Answer 30

Informed consent

Question 31

The nature of and reason for surgery Who will be performing the surgery and whether others will be present during the procedure All available options and the risks associated with each option The risks associated with the surgical procedure and its potential outcomes The risks associated with the use of anesthesia - anesthesia have sep consent to surgical consent

Answer 31

Consent implies that the patient has sufficient information to understand:

Question 32

Determining the existence and nature of the patient’s advance directives - address each time admitted to hospital but also imp readress if have not before any surgical procedure Implementing dietary restrictions (NPO) Administering regularly scheduled drugs - certain meds need to admin; importance of infection prevention and certain antibiotics where antibiotics given preop and another dose intra and another post and specifically timed, DC those Ensuring intestinal preparation if needed Performing skin preparation Preparing the patient for tubes, drains, and vascular access - put in IVs or anything else and making sure have vascular access Teaching about postoperative interventions to prevent respiratory complications - do not teach about postop before surgery but often postop very lethargic so do some edu prior Teaching about identification and prevention of cardiovascular complications - talk pats about it and implement Minimize anxiety Plans for pain management after surgery because better manage pain the better get up and moving to help prevent postop comps

Answer 32

Nursing interventions

Question 33

This will be determined by surgeon and anesthesiologist

Answer 33

Implementing dietary restrictions (NPO)

Question 34

Deep diaphragmatic and expansion breathing - turn, cough, deep breathing Incentive spirometry Coughing and splinting - hold incision and cough - helps incision not stretch to increase pain Turning and positioning - getting up and moving around Give some edu before surgery

Answer 34

Teaching about postoperative interventions to prevent respiratory complications - do not teach about postop before surgery but often postop very lethargic so do some edu prior

Question 35

Antiembolism stockings in preop area Pneumatic compression devices - SCDs Leg exercises and early ambulation to promote venous return - tell get up and move around esp if going be d/c

Answer 35

Teaching about identification and prevention of cardiovascular complications - talk pats about it and implement

Question 36

Assess the patient’s knowledge Need little anxiety as possible Allow ample time for questions Encourage communication, incorporating family or supportive persons when go home Promote rest Provide opportunity for distraction

Answer 36

Minimize anxiety

Question 37

Ensure all documentation, preoperative procedures, orders are complete - everything done Check consent forms and others for completeness - labs, ECG if needed done Inform patient that area will be marked before procedure begins - limb making sure marking where surgery performed Record height and weight for proper dosage of anesthetic agents, VS, age - everything doc preop Document allergies Ensure all laboratory, radiographic, and diagnostics test are present Document abnormal results and report them to the surgeon and anesthesia provider Record vital signs within 1-2 hours of the scheduled surgery time Document any significant physical or psychosocial observations Report special needs, concerns, and instructions to the surgical team

Answer 37

Preop chart review

Question 38

Hospital gown - no underwear Antiembolism stockings or pneumatic compression devices, if ordered - no jewelry or dentures Give valuables to a family member or lock them in a safe place ID band in place, bracelet indicating allergies, bracelet indicating type and screen was completed Remove dentures (some facilities allow them in the OR) Remove all prosthetic devices, hairpins, and clips Remove hearing aids (some facilities allow them in the OR) Glasses allowed so can see Per hospital policy, remove nail polish, artificial nails Have the patient empty their bladder After drug administration that can affect cognition or judgment, raise siderails, ensure call system is within easy reach of the patient, and the bed is in low position - hemodazopan or something to relax them before go into OR before full anesthesia so cognizant of safety after given Answer questions and offer reassurance as needed

Answer 38

Preop patient prep

Question 39

Sedatives - aderacs, hydroxine: relax pat Hypnotics - lorazepam, mendazolone: relax pat Anxiolytics - antianxiety: alprozolam Opioid analgesics - fentanyl - shorter ½ life Anticholinergic agents - decrease saliva and mucous secretions, relaxes muscles: atropine: causes dry mouth and tachycardia Antibiotics: prophylaxis: actual infection prior surgery not prophylaxis but sometimes given even if no infection to prevent on Specific – purpose drug May be given “on call” or after the patient is transferred to the preoperative area - pat in acute care/in patient med sent to unit and transfer down with pat so ready access to that

Answer 39

Preop drugs