Comprehensive Guide to Perioperative Nursing

Before you dive into this content, be sure you are free from distractions and can give it your full attention. Be sure that you have read the textbook pages that are associated with this content. Be prepared to actively learn. I will be sharing my knowledge and understanding with you, but you must do the learning. Participate in your learning. You will be the nurse next to that patient, not me. You need to acquire the knowledge, skills, and attitudes to take care of that patient safely, competently, and compassionately. Think beyond your next classroom exam. Rather, think about being that nurse taking care of that patient. That is what you are preparing for, not classroom examinations. Listen with curiosity, asking questions, seeking answers. Imagine being the nurse responsible for the care of this patient. Imagine being the patient needing this nursing care. Think about your prior experiences that are related to this content from both the health care provider's point of view and or the patient's point of view. Think about building knowledge on the foundation of what you already know. Be prepared to change your understanding of this content. if new information is presented. Take advantage of this recorded source. Pause as needed to think about the content or write down notes or questions. Be curious about learning more. Review the content and your notes as needed to gain understanding that you seek. Test yourself on the content to determine if you really learned it or not. The first thing I want you to do is pause and reflect. I want you to start by stopping the recording and thinking and writing down in these three areas. I want you to think about what you already know about this topic and write down at least three to five items. I want you to stop and think about any of your prior experiences related to the content. I want you to write down your thoughts and feelings related to your experiences. Lastly, I want you to think about what you don't know about this content. Think about your gaps of knowledge and understanding. and things that you're curious about learning. Write down at least three to five items, then you'll be ready to dive into the content. This subject matter will discuss three separate phases of Operative states for the patient. This first section will be about preoperative nursing care. This slide contains the learning objectives that you should meet upon completion of this section of the content. I recommend that you pause the recording. Read these carefully and make sure that you understand the purpose of this learning session and that you can measure that you have accomplished them in the end. This slide contains many of the elements that are required in effective pre-op care nursing for a patient under our care. I want you to look over all of the items listed here. I want you to make sure that you understand what they mean and that you understand the rationale for why the pre-op nurse is responsible for these items. Consider the assessment that the patient will have to have before they go into surgery and consider that it might vary depending upon the specific patient and the specific surgery that's being done, different factors that might impact whether this patient has specific safety risks, like other comorbidities. Perhaps this patient has heart failure, or perhaps this patient has COPD, and those are specific. diseases that can impact what's going to happen in this patient's care. Think about the difference in dealing with an older adult who is going under surgery and has different safety considerations than a younger person. Consider that patients with obesity have other specific care concerns and the patients that have various physical disabilities or even mental disabilities are going to have specific pre-operative care concerns and we're going to have to adjust our nursing care to deal with those. Think about the fact that we have patient responsibilities to help them deal with what's going on, prepare them properly and safely. But we also have legal obligations that we do to help protect this patient's safety. We are required to verify the patient's identity and make sure that they understand the purpose of their procedure, that they have had a conversation with the provider and the anesthesiologist to make sure that they are knowledgeable and have given informed consent. to the procedure. Then we get the signed form completed and put in the chart that is required by the law that we do that. We have a lot of preparation that we do, a lot of education that we do. There are a couple of additional resources that are available to you. You have a course point plus video on pre-operative nursing care that I recommend that you watch because they do a pretty good job of showing the process of getting a patient ready for surgery. Additionally, on D2L, there is a pre-op checklist that will be used during one of our simulation experiences and that would be a good resource for you. to refer to as you're going over pre-op care and understand the purpose of each of those elements on the checklist so that you can know why you're doing the things because knowing why is going to help you make the right decisions regarding your patient's care it's time for you to take a moment to pause and think and I would recommend that at this time what you think about are any of the questions that have come to you as you are preparing and studying this material. Think about those. Think about trying to find the answers to them. But in addition, I would consider ask you to consider patient safety in this preoperative stage. Think about all the possible things that could interfere with the patient being safe, and how we as nurses protect the patient in the preoperative stage. And then I also would like you to consider the psychosocial and holistic care concerns for this preoperative patient. Sometimes patients have fears, anxieties, concerns, questions. revolving around their psychosocial and holistic care. And that's part of our nursing care for them as well. So I want you to stop and think about these areas. This slide contains the objectives for the intraoperative phase of nursing care. and you should meet these objectives upon completion of this content. I recommend that you pause the recording, read these carefully, and make sure that you understand the purpose of this learning session and that you can measure that you have accomplished them at the end. Interoperative nursing care starts with thinking about the team that you are a part of. Remember that the patient is part of the team. As a matter of fact, they're the most important member of the team. It's all about them. Everyone who is gathered in the care of this patient needs to have the patient's best interest and safety in mind the entire time. Other members of the team include the surgeon, who will be the leader of the team. The circulating nurse who also has a leadership role. That nurse is responsible for coordinating care between the different team members, protecting the patient's safety, monitoring the OR for safety concerns. This nurse will be the leader of the timeout where all team members stop and verify the patient's identification, verify the procedure that is to be done and which surgical site will be. the location for this procedure so that everyone is on the same page. A circulating nurse also often leads a debriefing session after the surgery in order to identify potential problems for this patient post-operatively and maybe identify potential areas for the team to make improvements on future cases. Another member of the team is the scrub role and that can be a nurse. an RN, an LVN, LPN, or it can be a scrub tech who is a not a nurse that is specially trained to be an assistant during surgery. This person is responsible for setting up the sterile field and the equipment for assisting the surgeon during the procedure, handing instruments and such, and with the circulating nurse along with the circulating nurse this person counts all the needles sponges and instruments to ensure that none are retained within the patient at the end of the procedure they also label all the specimens and give them to the circulating nurse to ensure that they go to the lab there is an rn first assistant in some situations they work under the supervision of the surgeon and their roles vary by state board standards There will be an anesthesiologist and or a certified registered nurse anesthesiologist, CRNA, who oversee the giving of anesthesia and the care of the airway during the surgical procedure. They must discuss the risks with the patient and obtain informed consent and then they also monitor vital signs, EKG, O2 sat, and other assessments during the procedure. Safety and infection prevention are huge in the intraoperative phase of the patient care. There are risks for fire in the OR and they are addressed with certain assessment tools. Your book has an example of this tool and gives you an idea of the items that are checked to assess for the risk in individual cases. Surgical tire is worn and areas are restricted. in the OR to maintain sterility and prevent patient infections. A few words about anesthesia. Anesthesia is a state of narcosis, which means severe central nervous system depression produced by pharmacological agents, and it is associated with analgesia, relaxation, and loss of reflexes. Patients under general anesthesia are not irascible even to painful stimuli, which is why they can have the surgical cutting and some things that if a person was awake, they would hardly be able to stand the pain for that. Think about like doing a total knee arthroplasty, where they actually physically saw part of the bone away to input the prosthetic device that is the replacement joint. The patients sleep right through that with general anesthesia. But during that, they also have a loss of ventilatory function, so they can't breathe on their own or maintain or protect their airway. So it would be a state where if someone wasn't there to help monitor and protect their airway for them, they would die because they would not be able to breathe. Often their cardiovascular function can be impaired as well. So these are considerations for the anesthesiologist. We have different ways of administering anesthesia. There's inhaled anesthesia. There's injected anesthesia, which is put in IV push. Those two kinds, there's chart in your book for each one that you should be familiar with. We have regional anesthesia, which would be where like an epidural or spinal or peripheral nerve block is done so that a certain part of the body doesn't feel the pain response and can be cared for or operated on or even after surgery, sometimes they'll do a regional block to help during the healing process. Light sedation is. where a patient is not really fully put under it's more like a really good hard nap they still don't know really what's going on and they don't feel the things but they're not as deeply asleep as under general anesthesia this is used for shorter procedures like colonoscopies or bronchoscopies then there's local anesthesia and a really good example of that is when you have dental work done and you get a novocaine injection into your gums and that part of your body is numbed so that it can be procedures can be done without pain. There are a number of complications that can come with anesthesia. There's anesthesia awareness whereas a patient is for all outward appearances look like they are put under but there's some part of them that's still awake that recognizes what's going on. There's nausea and vomiting that can happen, and then there's an aspiration potential. Remember, that's one of the main reasons why we do a patient NPO for a certain number of hours prior to being taken to surgery. It's because they're not going to be able to protect their airway, and they're going to be often laying flat on their back, and aspiration could happen if they vomited so we want their GI system empty their upper GI system anaphylaxis which can happen from any medication can also happen from instruments if the patient has a allergy to that substance that it's made out of other foreign bodies or substances that come in contact with the patient any of those things can cause anaphylaxis hypoxia which comes you know with respiratory concerns because the patient cannot manage their own airway hypothermia can be used sometimes intentionally to protect from cellular damage but it's Unintentional happening can cause harm to a patient. There is a rare event called malignant hyperthermia and it is generally inherited in friends and families. It's a muscular disorder that is chemically induced when the patient gets an anesthetic agent. The symptoms are often often cardiovascular, respiratory, and abdominal, as well as musculoskeletal, includes tachycardia, ventricular arrhythmias, hypotension, which leads to decreased cardiac output, oliguria, and later cardiac arrest can happen if this continues. Generalized muscle rigidity is one of the earliest signs, and a rise in temperature is actually a late sign. So we call it malignant hyperthermia, but by the time the patient becomes hyperthermic, it's pretty late in the process. Goals of treatment are to slow down this patient's metabolism. and reverse the metabolic and respiratory acidosis that's going on with this excessive response to the anesthesia. We want to correct arrhythmias, we want to decrease that body temperature, do supportive treatments by providing them with oxygen and nutrition because they're going to be in a state of hyper metabolism and so we want to give them their body the nutrition that it needs to deal with this. And then there's also going to be some electrolyte imbalances that are going on, and we need to reverse those. The treatment for malignant hypertension is a medication called dantrolene, and it has lowered the mortality rates from its past to a current of 10%. People will actually die from malignant hypertension. hyperthermia where it used to be a considerably higher number than that. All right, at this time I would invite you to pause and think. Consider comparing the different types of anesthesia, when each one is used, what advantages and disadvantages each one would have, and what nursing responsibilities there are associated with each one. And then additionally, I want you to consider the patient's family, their family members and their friends, and their care and concern during this intraoperative phase. What do you think would be their care needs if you were able to interact with them while the patient was in surgery? This slide contains the learning objectives for the post-operative nursing care. I would recommend that you pause the recording, read these carefully, and make sure that you understand the purpose of this learning session and that you can measure that you have accomplished them in the end. Here we have a slide that shows the most frequently seen post-operative complications. So every phase of the nursing journey when the patient is going through this operative stages is patient safety. And at this point in patient's care, we're looking at potential complications that come. come from the patient having just had surgery. We're looking at possible circulatory problems. We're looking at possible infections, which will not happen right away. We're gonna have to take good care of them to prevent the infections, but that is still a postoperative complication, even if it doesn't happen until the third or fourth day, postoperatively. Dehiscence, when the surgical site Separates, evisceration, which happens if there is surgery in the abdomen and part of the abdominal organs start coming through a dehist incision site. We're going to see some GI issues. Patients can have nausea and vomiting or abdominal distention after having had anesthesia. Paralytic ileus happens when the bowel doesn't really wake up after anesthesia and there's no movement going on. So there's no bowel sounds, no passing of stool, no passing of flatus. It's like a, well it's a form of bowel obstruction, really. We're looking at possible urinary retention. Pneumonia, which is an infection, so it's also one of those things where we can do prevention to help them not develop pneumonia. They're not going to come out of surgery with pneumonia unless they went into surgery with pneumonia. It doesn't happen that quickly, but if we're not careful, three days later, we're dealing with a patient that has developed pneumonia postoperatively. Often we see atelectasis, which, you know, in your textbook definition is going to say collapse of the lung. And that's true, but postoperative atelectasis is generally part of the lung in the bases where the patient has just not breathed as deeply or cleared those secretions because they were laying flat and had a tube doing their breathing for them. So these are some of your most common post-operative complications and as the post-op nurse these are your job to monitor for to know the signs and symptoms so that you can recognize these things when they occur and intercede as soon as possible because these are emergency situations that require immediate response from nurses. Okay so in general The post-operative nurse, and this is the nurse in the post-anesthesia care unit, which is called the PACU for short, is responsible for doing a head-to-toe assessment. They need to look at this patient top to bottom because they need to get a good baseline. They're also going to do focused assessment on the areas of concern, which would be the surgical site and then the heart and the lungs, all right, and probably the GI system. Their concern is patient safety, always about patient safety. Secondary to that, they want the patient to be comfortable. So this patient might be cold having just come out of surgery. So one of their comfort needs would be to be warmed up. But that's also a safety issue because if the patient stays cold, it increases their metabolic rate and that puts the body in a stress situation, which impacts the rest of the system. and can decrease their healing and make them more prone to other post-op complications. And then this nurse is also going to have increased vigilance focused on those things that might go wrong in the post-operative care of this patient. Now the patient's going to stay in the PACU probably about an hour. They come out of surgery and they have post the post-op nurse will take care of that patient checking their vital signs very frequently at the beginning every five minutes um dealing helping them deal with pain helping them deal with nausea helping them just wake up appropriate um and then if the vital signs stay stable for several readings then they can increase the time to checking vitals every 10 minutes and they'll do that for several sets of vitals and as this progresses the patient should be coming more and more awake um have less complaints of the pain or the nausea because we're dealing with those signs and symptoms as they come up then after a couple of sets of 10 minute vitals and they go to 15 minute vitals and then by the time we get two or three sets of 15-minute vitals, the patient is probably ready to go to their post-op surgical unit in the hospital if this patient is going to stay admitted. Sometimes patients stay in PACU until they are discharged because they're having an outpatient procedure and so they just stay in the PACU until they meet the criteria for discharge. Discharge from the hospital criteria could include the patient is awake enough. to answer questions. They can safely swallow and not complain of the nausea and vomiting. Their pain is under control. They're able to get up and urinate. These kind of things might be the criteria that allows them to be able to discharge home. If the patient's staying in the hospital, if they're going to be admitted to a post-surgical unit, They don't necessarily have to meet all those same criteria because nursing care is going to continue and their recovery is going to continue under the supervision of nurses. Once the patient gets to the post-op floor, the post-surgical unit, those nurses will be monitoring vital signs still more closely than they do on a regular patient. Post-op patients that come to the unit will have their vital signs checked at least every 30 minutes for probably four readings, and then they'll have their vitals checked every hour for four readings. If everything continues in the right direction and the patient continues to be stable, then their vital sign checks will go to every four hours like is common for all admitted patients in the hospital. The nurse that receives the patient from the PACU nurse, they do a handoff. They get all of the data about why the patient came in, what kind of procedure they had, were there any problems in the intraoperative phase, what were the concerns during postoperative phase, are the vital signs stable, is the patient's pain under control, are we dealing with nausea and vomiting, has the patient been able to have ice chips or even eat something? Are they arousable or are they still very sedated? All these kind of things that those two nurses have a conversation about. Additionally, if you're the nurse receiving this patient, you and that PACU nurse need to look at the surgical area. Now I'm not saying take off the dressing because that's not our job. We don't have permission to do that, but you want to see the dressing and make sure that everybody's agreed that this is safe transfer that the patient's dressing is not bled through all the way and that they are um that the dressing is intact and that it's safely covered so that we can assume safe care of this patient on the floor when you're the post-op nurse that nurse generally has one patient at a time. Now they only take care of that patient for about an hour, but they only have that one patient. Now they require a lot of attention the first 20-30 minutes when they get to the post-op unit. Then by the time they get to that second half of that hour, the patient's stabilized and getting very close to being able to transfer to the unit. So that nurse has one patient at a time. When you're the post-surgical unit nurse receiving that patient. This is likely to be one of five patients you're going to be taking care of. So you need to make sure when you're receiving that patient that you can safely add this patient to your current patient load. And if your patient that you're receiving from the PACU has out of control blood pressure, isn't breathing well, has uncontrolled pain, has problems with their dressing, that is going to that's going to add a lot to your care of your already heavy load of patients. So you need to advocate for yourself that you don't receive a patient that's not stable and not ready to come to the floor. Okay, so they need to be meeting certain criteria. Their blood pressure needs to be in a safe place. The respirations need to be in a safe place because you as a med surg nurse on that floor, cannot dedicate one-on-one time to this patient like the PACU nurse did. So by the time they get to you they should be able to and they're going to need extra help they're going to need extra attention because they are fresh PACU from post-op but they shouldn't require all of your attention and if they do then they're not appropriate to come to your unit. So advocate for for yourself and for your patient to get safe care if you're receiving a post-operative patient. All right, so it's time for you to pause and think. I want you to consider priorities for the post-operative patient's care. What would you do if the patient is rating their pain 8 out of 10 but is lethargic and has a respiratory rate of 14? What would you do if you identified the patient was experiencing a hemorrhage or atelectasis or a paralytic ileus? Please stop and think. Think about what you as a nurse would do in these situations. Here is another opportunity for you to pause and think. I want you to imagine that you are the nurse that follows this patient through all three phases of the perioperative care. How would you care for a patient who is having a TKA in each one of these phases of care? How would you care for a patient who is having an emergency appendectomy in each of these phases of care? How would you care for a patient who is having a cesarean section birth in each of these phases of care? Think about what would be the same, what would be different, and what are the safety concerns for each patient in each phase. Now it's time for you to review the content, review your notes, review your readings. Test yourself to see if you have met these learning objectives. If you still have gaps, you need to dig in deeper and look for the answers to the questions so that you can say you have mastered this content and achieved these learning objectives. Once again, you need to review the content and your notes and the readings and test yourself to see if you've met these learning objectives. Remember that if you have gaps, you need to dig in deeper, look for the answers to the questions so that you can say you have mastered this content and achieved these learning objectives. Alright, this is the last set of learning objectives from this learning session. Once again, remember that you need to review the content and your notes and your readings. Test yourself on this knowledge to see if you have met these learning objectives. If you still have gaps, you need to dig in deeper and look for the answers to the questions so that you can say you have mastered this content and achieved these learning objectives.

Participate in your learning. You will be the nurse next to that patient, not me. You need to acquire the knowledge, skills, and attitudes to take care of that patient safely, competently, and compassionately. Think beyond your next classroom exam. Rather, think about being that nurse taking care of that patient.

That is what you are preparing for, not classroom examinations. Listen with curiosity, asking questions, seeking answers. Imagine being the nurse responsible for the care of this patient.

Imagine being the patient needing this nursing care. Think about your prior experiences that are related to this content from both the health care provider's point of view and or the patient's point of view. Think about building knowledge on the foundation of what you already know. Be prepared to change your understanding of this content.

if new information is presented. Take advantage of this recorded source. Pause as needed to think about the content or write down notes or questions.

Be curious about learning more. Review the content and your notes as needed to gain understanding that you seek. Test yourself on the content to determine if you really learned it or not. The first thing I want you to do is pause and reflect. I want you to start by stopping the recording and thinking and writing down in these three areas.

I want you to think about what you already know about this topic and write down at least three to five items. I want you to stop and think about any of your prior experiences related to the content. I want you to write down your thoughts and feelings related to your experiences. Lastly, I want you to think about what you don't know about this content. Think about your gaps of knowledge and understanding.

and things that you're curious about learning. Write down at least three to five items, then you'll be ready to dive into the content. This subject matter will discuss three separate phases of Operative states for the patient.

This first section will be about preoperative nursing care. This slide contains the learning objectives that you should meet upon completion of this section of the content. I recommend that you pause the recording.

Read these carefully and make sure that you understand the purpose of this learning session and that you can measure that you have accomplished them in the end. This slide contains many of the elements that are required in effective pre-op care nursing for a patient under our care. I want you to look over all of the items listed here.

I want you to make sure that you understand what they mean and that you understand the rationale for why the pre-op nurse is responsible for these items. Consider the assessment that the patient will have to have before they go into surgery and consider that it might vary depending upon the specific patient and the specific surgery that's being done, different factors that might impact whether this patient has specific safety risks, like other comorbidities. Perhaps this patient has heart failure, or perhaps this patient has COPD, and those are specific.

diseases that can impact what's going to happen in this patient's care. Think about the difference in dealing with an older adult who is going under surgery and has different safety considerations than a younger person. Consider that patients with obesity have other specific care concerns and the patients that have various physical disabilities or even mental disabilities are going to have specific pre-operative care concerns and we're going to have to adjust our nursing care to deal with those.

Think about the fact that we have patient responsibilities to help them deal with what's going on, prepare them properly and safely. But we also have legal obligations that we do to help protect this patient's safety. We are required to verify the patient's identity and make sure that they understand the purpose of their procedure, that they have had a conversation with the provider and the anesthesiologist to make sure that they are knowledgeable and have given informed consent. to the procedure. Then we get the signed form completed and put in the chart that is required by the law that we do that.

We have a lot of preparation that we do, a lot of education that we do. There are a couple of additional resources that are available to you. You have a course point plus video on pre-operative nursing care that I recommend that you watch because they do a pretty good job of showing the process of getting a patient ready for surgery. Additionally, on D2L, there is a pre-op checklist that will be used during one of our simulation experiences and that would be a good resource for you. to refer to as you're going over pre-op care and understand the purpose of each of those elements on the checklist so that you can know why you're doing the things because knowing why is going to help you make the right decisions regarding your patient's care it's time for you to take a moment to pause and think and I would recommend that at this time what you think about are any of the questions that have come to you as you are preparing and studying this material.

Think about those. Think about trying to find the answers to them. But in addition, I would consider ask you to consider patient safety in this preoperative stage.

Think about all the possible things that could interfere with the patient being safe, and how we as nurses protect the patient in the preoperative stage. And then I also would like you to consider the psychosocial and holistic care concerns for this preoperative patient. Sometimes patients have fears, anxieties, concerns, questions. revolving around their psychosocial and holistic care.

And that's part of our nursing care for them as well. So I want you to stop and think about these areas. This slide contains the objectives for the intraoperative phase of nursing care. and you should meet these objectives upon completion of this content.

I recommend that you pause the recording, read these carefully, and make sure that you understand the purpose of this learning session and that you can measure that you have accomplished them at the end. Interoperative nursing care starts with thinking about the team that you are a part of. Remember that the patient is part of the team. As a matter of fact, they're the most important member of the team. It's all about them.

Everyone who is gathered in the care of this patient needs to have the patient's best interest and safety in mind the entire time. Other members of the team include the surgeon, who will be the leader of the team. The circulating nurse who also has a leadership role.

That nurse is responsible for coordinating care between the different team members, protecting the patient's safety, monitoring the OR for safety concerns. This nurse will be the leader of the timeout where all team members stop and verify the patient's identification, verify the procedure that is to be done and which surgical site will be. the location for this procedure so that everyone is on the same page.

A circulating nurse also often leads a debriefing session after the surgery in order to identify potential problems for this patient post-operatively and maybe identify potential areas for the team to make improvements on future cases. Another member of the team is the scrub role and that can be a nurse. an RN, an LVN, LPN, or it can be a scrub tech who is a not a nurse that is specially trained to be an assistant during surgery.

This person is responsible for setting up the sterile field and the equipment for assisting the surgeon during the procedure, handing instruments and such, and with the circulating nurse along with the circulating nurse this person counts all the needles sponges and instruments to ensure that none are retained within the patient at the end of the procedure they also label all the specimens and give them to the circulating nurse to ensure that they go to the lab there is an rn first assistant in some situations they work under the supervision of the surgeon and their roles vary by state board standards There will be an anesthesiologist and or a certified registered nurse anesthesiologist, CRNA, who oversee the giving of anesthesia and the care of the airway during the surgical procedure. They must discuss the risks with the patient and obtain informed consent and then they also monitor vital signs, EKG, O2 sat, and other assessments during the procedure. Safety and infection prevention are huge in the intraoperative phase of the patient care. There are risks for fire in the OR and they are addressed with certain assessment tools.

Your book has an example of this tool and gives you an idea of the items that are checked to assess for the risk in individual cases. Surgical tire is worn and areas are restricted. in the OR to maintain sterility and prevent patient infections.

A few words about anesthesia. Anesthesia is a state of narcosis, which means severe central nervous system depression produced by pharmacological agents, and it is associated with analgesia, relaxation, and loss of reflexes. Patients under general anesthesia are not irascible even to painful stimuli, which is why they can have the surgical cutting and some things that if a person was awake, they would hardly be able to stand the pain for that.

Think about like doing a total knee arthroplasty, where they actually physically saw part of the bone away to input the prosthetic device that is the replacement joint. The patients sleep right through that with general anesthesia. But during that, they also have a loss of ventilatory function, so they can't breathe on their own or maintain or protect their airway. So it would be a state where if someone wasn't there to help monitor and protect their airway for them, they would die because they would not be able to breathe. Often their cardiovascular function can be impaired as well.

So these are considerations for the anesthesiologist. We have different ways of administering anesthesia. There's inhaled anesthesia. There's injected anesthesia, which is put in IV push.

Those two kinds, there's chart in your book for each one that you should be familiar with. We have regional anesthesia, which would be where like an epidural or spinal or peripheral nerve block is done so that a certain part of the body doesn't feel the pain response and can be cared for or operated on or even after surgery, sometimes they'll do a regional block to help during the healing process. Light sedation is. where a patient is not really fully put under it's more like a really good hard nap they still don't know really what's going on and they don't feel the things but they're not as deeply asleep as under general anesthesia this is used for shorter procedures like colonoscopies or bronchoscopies then there's local anesthesia and a really good example of that is when you have dental work done and you get a novocaine injection into your gums and that part of your body is numbed so that it can be procedures can be done without pain. There are a number of complications that can come with anesthesia. There's anesthesia awareness whereas a patient is for all outward appearances look like they are put under but there's some part of them that's still awake that recognizes what's going on.

There's nausea and vomiting that can happen, and then there's an aspiration potential. Remember, that's one of the main reasons why we do a patient NPO for a certain number of hours prior to being taken to surgery. It's because they're not going to be able to protect their airway, and they're going to be often laying flat on their back, and aspiration could happen if they vomited so we want their GI system empty their upper GI system anaphylaxis which can happen from any medication can also happen from instruments if the patient has a allergy to that substance that it's made out of other foreign bodies or substances that come in contact with the patient any of those things can cause anaphylaxis hypoxia which comes you know with respiratory concerns because the patient cannot manage their own airway hypothermia can be used sometimes intentionally to protect from cellular damage but it's Unintentional happening can cause harm to a patient.

There is a rare event called malignant hyperthermia and it is generally inherited in friends and families. It's a muscular disorder that is chemically induced when the patient gets an anesthetic agent. The symptoms are often often cardiovascular, respiratory, and abdominal, as well as musculoskeletal, includes tachycardia, ventricular arrhythmias, hypotension, which leads to decreased cardiac output, oliguria, and later cardiac arrest can happen if this continues. Generalized muscle rigidity is one of the earliest signs, and a rise in temperature is actually a late sign. So we call it malignant hyperthermia, but by the time the patient becomes hyperthermic, it's pretty late in the process.

Goals of treatment are to slow down this patient's metabolism. and reverse the metabolic and respiratory acidosis that's going on with this excessive response to the anesthesia. We want to correct arrhythmias, we want to decrease that body temperature, do supportive treatments by providing them with oxygen and nutrition because they're going to be in a state of hyper metabolism and so we want to give them their body the nutrition that it needs to deal with this.

And then there's also going to be some electrolyte imbalances that are going on, and we need to reverse those. The treatment for malignant hypertension is a medication called dantrolene, and it has lowered the mortality rates from its past to a current of 10%. People will actually die from malignant hypertension. hyperthermia where it used to be a considerably higher number than that. All right, at this time I would invite you to pause and think.

Consider comparing the different types of anesthesia, when each one is used, what advantages and disadvantages each one would have, and what nursing responsibilities there are associated with each one. And then additionally, I want you to consider the patient's family, their family members and their friends, and their care and concern during this intraoperative phase. What do you think would be their care needs if you were able to interact with them while the patient was in surgery? This slide contains the learning objectives for the post-operative nursing care.

I would recommend that you pause the recording, read these carefully, and make sure that you understand the purpose of this learning session and that you can measure that you have accomplished them in the end. Here we have a slide that shows the most frequently seen post-operative complications. So every phase of the nursing journey when the patient is going through this operative stages is patient safety.

And at this point in patient's care, we're looking at potential complications that come. come from the patient having just had surgery. We're looking at possible circulatory problems. We're looking at possible infections, which will not happen right away. We're gonna have to take good care of them to prevent the infections, but that is still a postoperative complication, even if it doesn't happen until the third or fourth day, postoperatively.

Dehiscence, when the surgical site Separates, evisceration, which happens if there is surgery in the abdomen and part of the abdominal organs start coming through a dehist incision site. We're going to see some GI issues. Patients can have nausea and vomiting or abdominal distention after having had anesthesia. Paralytic ileus happens when the bowel doesn't really wake up after anesthesia and there's no movement going on. So there's no bowel sounds, no passing of stool, no passing of flatus.

It's like a, well it's a form of bowel obstruction, really. We're looking at possible urinary retention. Pneumonia, which is an infection, so it's also one of those things where we can do prevention to help them not develop pneumonia.

They're not going to come out of surgery with pneumonia unless they went into surgery with pneumonia. It doesn't happen that quickly, but if we're not careful, three days later, we're dealing with a patient that has developed pneumonia postoperatively. Often we see atelectasis, which, you know, in your textbook definition is going to say collapse of the lung. And that's true, but postoperative atelectasis is generally part of the lung in the bases where the patient has just not breathed as deeply or cleared those secretions because they were laying flat and had a tube doing their breathing for them. So these are some of your most common post-operative complications and as the post-op nurse these are your job to monitor for to know the signs and symptoms so that you can recognize these things when they occur and intercede as soon as possible because these are emergency situations that require immediate response from nurses.

Okay so in general The post-operative nurse, and this is the nurse in the post-anesthesia care unit, which is called the PACU for short, is responsible for doing a head-to-toe assessment. They need to look at this patient top to bottom because they need to get a good baseline. They're also going to do focused assessment on the areas of concern, which would be the surgical site and then the heart and the lungs, all right, and probably the GI system.

Their concern is patient safety, always about patient safety. Secondary to that, they want the patient to be comfortable. So this patient might be cold having just come out of surgery. So one of their comfort needs would be to be warmed up. But that's also a safety issue because if the patient stays cold, it increases their metabolic rate and that puts the body in a stress situation, which impacts the rest of the system.

and can decrease their healing and make them more prone to other post-op complications. And then this nurse is also going to have increased vigilance focused on those things that might go wrong in the post-operative care of this patient. Now the patient's going to stay in the PACU probably about an hour.

They come out of surgery and they have post the post-op nurse will take care of that patient checking their vital signs very frequently at the beginning every five minutes um dealing helping them deal with pain helping them deal with nausea helping them just wake up appropriate um and then if the vital signs stay stable for several readings then they can increase the time to checking vitals every 10 minutes and they'll do that for several sets of vitals and as this progresses the patient should be coming more and more awake um have less complaints of the pain or the nausea because we're dealing with those signs and symptoms as they come up then after a couple of sets of 10 minute vitals and they go to 15 minute vitals and then by the time we get two or three sets of 15-minute vitals, the patient is probably ready to go to their post-op surgical unit in the hospital if this patient is going to stay admitted. Sometimes patients stay in PACU until they are discharged because they're having an outpatient procedure and so they just stay in the PACU until they meet the criteria for discharge. Discharge from the hospital criteria could include the patient is awake enough. to answer questions. They can safely swallow and not complain of the nausea and vomiting.

Their pain is under control. They're able to get up and urinate. These kind of things might be the criteria that allows them to be able to discharge home.

If the patient's staying in the hospital, if they're going to be admitted to a post-surgical unit, They don't necessarily have to meet all those same criteria because nursing care is going to continue and their recovery is going to continue under the supervision of nurses. Once the patient gets to the post-op floor, the post-surgical unit, those nurses will be monitoring vital signs still more closely than they do on a regular patient. Post-op patients that come to the unit will have their vital signs checked at least every 30 minutes for probably four readings, and then they'll have their vitals checked every hour for four readings. If everything continues in the right direction and the patient continues to be stable, then their vital sign checks will go to every four hours like is common for all admitted patients in the hospital. The nurse that receives the patient from the PACU nurse, they do a handoff.

They get all of the data about why the patient came in, what kind of procedure they had, were there any problems in the intraoperative phase, what were the concerns during postoperative phase, are the vital signs stable, is the patient's pain under control, are we dealing with nausea and vomiting, has the patient been able to have ice chips or even eat something? Are they arousable or are they still very sedated? All these kind of things that those two nurses have a conversation about. Additionally, if you're the nurse receiving this patient, you and that PACU nurse need to look at the surgical area.

Now I'm not saying take off the dressing because that's not our job. We don't have permission to do that, but you want to see the dressing and make sure that everybody's agreed that this is safe transfer that the patient's dressing is not bled through all the way and that they are um that the dressing is intact and that it's safely covered so that we can assume safe care of this patient on the floor when you're the post-op nurse that nurse generally has one patient at a time. Now they only take care of that patient for about an hour, but they only have that one patient. Now they require a lot of attention the first 20-30 minutes when they get to the post-op unit.

Then by the time they get to that second half of that hour, the patient's stabilized and getting very close to being able to transfer to the unit. So that nurse has one patient at a time. When you're the post-surgical unit nurse receiving that patient. This is likely to be one of five patients you're going to be taking care of. So you need to make sure when you're receiving that patient that you can safely add this patient to your current patient load.

And if your patient that you're receiving from the PACU has out of control blood pressure, isn't breathing well, has uncontrolled pain, has problems with their dressing, that is going to that's going to add a lot to your care of your already heavy load of patients. So you need to advocate for yourself that you don't receive a patient that's not stable and not ready to come to the floor. Okay, so they need to be meeting certain criteria.

Their blood pressure needs to be in a safe place. The respirations need to be in a safe place because you as a med surg nurse on that floor, cannot dedicate one-on-one time to this patient like the PACU nurse did. So by the time they get to you they should be able to and they're going to need extra help they're going to need extra attention because they are fresh PACU from post-op but they shouldn't require all of your attention and if they do then they're not appropriate to come to your unit. So advocate for for yourself and for your patient to get safe care if you're receiving a post-operative patient. All right, so it's time for you to pause and think.

I want you to consider priorities for the post-operative patient's care. What would you do if the patient is rating their pain 8 out of 10 but is lethargic and has a respiratory rate of 14? What would you do if you identified the patient was experiencing a hemorrhage or atelectasis or a paralytic ileus?

Please stop and think. Think about what you as a nurse would do in these situations. Here is another opportunity for you to pause and think.

I want you to imagine that you are the nurse that follows this patient through all three phases of the perioperative care. How would you care for a patient who is having a TKA in each one of these phases of care? How would you care for a patient who is having an emergency appendectomy in each of these phases of care? How would you care for a patient who is having a cesarean section birth in each of these phases of care? Think about what would be the same, what would be different, and what are the safety concerns for each patient in each phase.

Now it's time for you to review the content, review your notes, review your readings. Test yourself to see if you have met these learning objectives. If you still have gaps, you need to dig in deeper and look for the answers to the questions so that you can say you have mastered this content and achieved these learning objectives.

Once again, you need to review the content and your notes and the readings and test yourself to see if you've met these learning objectives. Remember that if you have gaps, you need to dig in deeper, look for the answers to the questions so that you can say you have mastered this content and achieved these learning objectives. Alright, this is the last set of learning objectives from this learning session. Once again, remember that you need to review the content and your notes and your readings. Test yourself on this knowledge to see if you have met these learning objectives.

If you still have gaps, you need to dig in deeper and look for the answers to the questions so that you can say you have mastered this content and achieved these learning objectives.

Transcript for:Comprehensive Guide to Perioperative Nursing

Transcript for:
Comprehensive Guide to Perioperative Nursing