hi block 2 it's professor marshall and welcome to part 1 of our discussion of perioperative nursing as always let's start with our mindful moment now you do not have to participate in this mindful moment but if you choose to do so please sit up straight in your chair put your feet on the floor your hands in your lap take your gaze down and for a deeper mindful moment you may close your eyes if you'd like in a moment i'll ask you to exhale completely and then we'll start the guided breathing exercise feel your body in the chair your feet on the floor exhale completely breathe in two three four hold two three four five six seven out two three four five six seven eight again two three four hold two three four five six seven out two three four five six seven eight in two three four hold two three four five six seven out two three four five six seven eight in two three four hold two three four five six seven out two three four five six seven eight now breathe normally feel your body in the chair your feet on the floor notice your neck your shoulders anywhere you hold tension let that stress go be present today and as you feel ready you can open your eyes and return your gaze to the screen in front of you so let's start by taking a look at what we're planning to cover related to periop um first of all we're going to do a perioperative overview in this section now in the prep work on canvas we've already discussed classification of surgical procedures various surgical settings and patient versus ambulatory surgery optimal surgical outcomes were covered factors contributing to surgical risk things like that so we'll just cover a few more things related to periop in general and then in part two and three we'll talk about pre-operative nursing um elaborating more on the patient interview and nursing assessment patient education patient preparation and also pre-op medications then part four will be intraoperative care and we'll review some of what was covered already in the prep work and then we'll get into the nurse's role and then the final three recordings will be related to post-operative nursing care and we'll cover pacu that immediate post-operative period what happens after the pacu we'll talk about post-op surgical complications post-op fever and then also discharge this infographic has a lot going on but i've started with this because a lot of this has actually been covered for you already in your prep the rest of it will elaborate more on as we go through our discussion but this is going to be just a good resource for you to kind of look over and get a broad overview of the different things related to perioperative nursing care now as it says here on the slide this is strictly fyi but i want you to just have an idea of the specialties with the highest number of surgical patients so don't memorize this just be aware things like ophthalmology gynecology plastics ortho all have high amounts of surgical patients and as the population continues to age the demand for surgeries like cataract surgeries and joint replacements is going to continue to increase rapidly and the other thing i have for you here is this table that um shows you a lot of different suffix suffixes that describe surgical procedures and again it's fyi i'm not going to test you on it however if you can commit some of these things to memory then when you're going through your patient's chart and you see a particular surgery that they're going to um and you know what these suffixes mean then it's going to be much easier to figure out what the patient's going to have done and as the nurse you're going to want to know that because they're going to ask you questions so when you see ectomy that's an excision or removal of a certain body part like an appendectomy if you see otomy that's cutting into or an incision of a particular area so like a tracheotomy okay now in the audio prep i already mentioned the surgical care improvement project and this is a quality national quality partnership of organizations like the joint commission the world health organization centers for medicare medicaid and the whole purpose of this surgical care improvement project is to help ensure optimal surgical outcomes and so what we have are these skip initiatives which are intended to improve surgical care by significantly significantly reducing surgical complications and the hyperlink here is going to take us to the skip initiatives and i want to just talk about those a little bit so what you're seeing here is the surgical care improvement project core measure set and this is another thing that i don't want you to memorize at all but i want to give you a little bit of background to understand how we got to the point where these became so important for our surgical patients now remember the whole premise behind these skip measures is to improve surgical care by reducing complications and you'll see as we talk about some of these that they are all intended to address something that could potentially be a surgical complication now i've been a nurse long enough to remember back in the day how we used to do things and um you know compared to now we are much better at using evidence to guide our nursing practice and that's a good thing that's that's good for us as nurses and our nursing license but that's a really good thing for our patients so um i'll just kind of discuss a bit about what we used to do and what we do now instead and i forgot to mention that i did also post this handout for you on canvas if you want to take a closer look at it or you can access it through that hyperlink in your powerpoint so let's start with the first three measures here which all have to do with antibiotic use for surgical patients now back in the day pretty much every surgical patient got antibiotics the um idea was that you know we're going to cut into them we're going to increase their risk of infection let's give them antibiotics to help reduce that risk and we weren't overly concerned about the timing of antibiotics so they might order an antibiotic to be given on call to surgery meaning when the pre-op area called and said oh you know we're going to be sending for mr smith for his um tonsillectomy then we'd say okay well we'll go ahead and hang the pre-up antibiotic so we'd hang the pre-op antibiotic and then um pre-up would call back 20 minutes later and say you know what sorry the case got bumped um it's going to be a few more hours but antibiotic was already running so we just left it running and things like that so we weren't very like i said cognizant of um timing of the antibiotics well research has shown that antibiotic use obviously does have a purpose for surgical patients but not necessarily every patient undergoing every type of surgery needs prophylactic antibiotics so we're more selective as far as what types of surgical patients get the antibiotics that's what the inf2 is addressing but we're also much more precise about our timing of the antibiotics so if you look at inf one prophylactic antibiotic received within one hour prior to surgical incision so now if a patient has an iv antibiotic order to be given on call to the or usually that is not given until the patient is already in pre-op the surgeon and anesthesiologist are on the premises and we're sure that the surgery is definitely happening because it needs to be within an hour of cut time okay and then number three there deals with the um end of the dosing of the antibiotics so when somebody's getting prophylactic antibiotics for surgery it's usually a cephalosporin which we're going to talk about later but they they're usually given q8 hours times three doses so that first dose within one hour prior to the surgical incision and then inf3 there says prophylactic antibiotics discontinued within 24 hours after the surgery end time so eight hours from that first preop dose is when the second dose should be given we're more careful about the timing and we make sure that after 24 hours then the antibiotic the three doses has been completed now obviously if there's something else going on with the patient that might be a little bit different but i'm talking just in terms of this is just a prophylactic antibiotic to try and prevent infections relating to the surgery and patients that get these um our cardiac surgery patients usually get prophylactic antibiotics because if if they got infected that would be a pretty bad thing um our a lot of our ortho patients get them and a lot of our gi patients like if they're cutting into the abdomen abdominal surgeries obviously when you're cutting into intestines and things like that the risk of contamination is much higher so like i said not everybody gets it before every surgery and we're real careful about making sure that it's timed right because think about what happens with the overuse of antibiotics and the super infections and things that we have out there now okay then we have inf4 here so if you're wondering about this inf if you look one two three four six and nine um inf infection oh i'm sorry and ten also um these have to do with preventing infection as are post-op complications so number four is specific to cardiac surgery patients and what they what we know is that when blood sugar levels are high that increases somebody's risk for infection so in our cardiac patients they want that 6am post-op blood glucose level to be well controlled and what that means is that even if somebody doesn't have diabetes they might receive some insulin postoperatively if they're having cardiac surgery because we want to keep that blood sugar at a normal level and you might recall that any time there's a surgery there's an injury a stress a trauma anything like that then that's going to cause blood sugar levels to rise so they're going to monitor these patients very closely and keep that blood sugar stabilized inf6 is related to appropriate hair removal now um we used to shave patients a lot pre-operatively with you know full-on straight razor and the the idea was that well you know the hair probably harbors more bacteria and we want that to be gone before the incision is made well um through the course of shaving the patient oftentimes they would get little nicks in the skin little abrasions things that you might not even see and that trauma to the tissue actually increases the risk of infection so we don't do a lot of hair removal pre-operatively anymore if we do we kind of do more um just trimming with clippers rather than shaving so that brings us to inf-9 here and this has to do with catheterization um used to be that if you were going to surgery you got a catheter we were very generous you get a catheter you get a catheter and then what do we find out oh no we're causing urinary tract infections with these catheters so we are much more selective now as far as who gets a catheter during surgery and if someone does require a catheter during surgery then it's going to be removed on post-op day number one or post-op day number two and this says with day of surgery being day zero and that's how we always talk about um post-op days like if you had surgery today this is day zero tomorrow is post-op day one and then the next day is post-update two etc so if you get a catheter it's not staying in long out the first or second post-operative day again barring any complications and then the last one related to infection here number 10 is surgery patients with perioperative temperature management so a low temperature is a big risk with surgery and that hypothermia can cause a lot of complications so we're we're we've gotten much better at monitoring patients temp during surgery using things like bear huggers warming devices to make sure that the patient's temperature stays within a normal range during surgery and then obviously also in that post-operative period as well just a few more here and they have to do with preventing cardiac complications and then the last two preventing vte so that card two this is surgery patients on beta blocker therapy prior to arrival who received a beta blocker during the perioperative period basically what this measure addresses is that if a patient was on a beta blocker prior to surgery that's one of those medications they're going to want them to typically take on the day of surgery and we'll get into meds we give men's we hold beta blockers are ones that we typically give and then they're going to make sure that that beta blocker is resumed um in that you know perioperative postoperative period as well of course barring any complications and then finally like i said these last two are meant to help reduce the risk of vte complications after surgery so um vte 1 surgery patients with recommended venous thromboembolism prophylaxis ordered and vte2 surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery so what these mean for us is that most patients unless it's a very very quick surgery are going to usually get some kind of vte prophylaxis that might mean they get ted hoes and or scds in the pre-op area before they even go go to surgery it might mean that they get some heparin or some lobonox low molecular weight heparin in order to prevent vtes and then we're going to get patients up and moving as soon as possible after surgery to help decrease that vte risk and we're going to take additional measures post-operatively to help prevent clots as well so like i said obviously no need to memorize these i just want you to have some background information and i want you to have an idea when we say we've got these skip initiatives to improve surgical care by reducing complications well what kind of complications what kind of things what kinds of things are we addressing so we'll go ahead and stop there for part one if you have any questions please post those in the discussion board so that i can answer them during our webex but otherwise i will see you in part two thanks guys