Pre & post operative nursing care

Pre & post operative nursing care

1. Advance nursing practice presentation on PRE &POST OPERATIVE nursing CARE Presented by, Ms. Flavia Dass M.Sc Nsg 1 st year KIMS Hubli .

2. INTRODUCTION Surgery – can be defined as the art & science of treating disease, injuries & deformities by operation & instruments The surgical procedures involves the interaction of patients, surgeon, anesthesia care provider & nurse. Surgery may be performed for diagnosis, cure, prevention, exploration or cosmetic improvement. Regardless of what the surgery is, the nurse has a vital role in preparing the patient for surgery, caring for patient during surgery & facilitating the patient recovery following surgery.

3. PRE OPERATIVE CARE It begins as soon as the surgeon makes a diagnosis & decides that an operation is necessary for the patient

4. INFORMED CONSENT Voluntary & written informed consent from patient is necessary before non emergent surgery can be performed. The nurse may ask the patient to sign the form & may witness the patient's signature

5. Criteria for valid informed consent Voluntary consent consent must be freely given, without coercion . Incompetent patient individual who is not autonomous & cannot give or withhold consent Informed subject informed consent should be in writing. It should contain

6. Explanation of procedure & its risk Description of benefits & alternatives An offer to answer questions about the procedure Instructions that the patient may withdraw consent Informing the patient if the protocols differ from customary procedure

7. Patient able to comprehend information must be delivered n written in language understandable to the patient. Questions must be answered if material is confusing many ethical principles are integral to informed consent before the patient signs the consent, the surgeon must provide a clear explanation of the surgery. Informed consent is necessary in invasive procedure, procedures needing sedative/ anesthesia, non surgical procedure & radiation procedure.

8. Patient personally signs the consent if he or she is of legal age & mentally capable. When is patient is minor or unconscious or incompetent permission must be obtained from responsible family member or legal guardian State regulations & agency policy must be followed In emergency it may be necessary for the surgeon to operate as a life saving measure without patients consent Refusing to undergo a surgical procedure is a persons legal right & privilege.

9. ASSESSMENT OF HEALTH FACTOR THAT AFFECTS PATIENTS PRE - OPERATIVELY The overall goal in the pre- operative to have as many positive health factors as possible Before any surgical treatment is initiated, a health history, a physical examination and data base is established Blood test , X-rays & other diagnostic test are prescribed.

10. NUTRITIONAL & FLUID STATUS Optimal nutrition is an essential factor in promoting healing & resisting infection & other surgical complications Assess the patients nutritional status Nutritional needs maybe determine by measurement of Body Mass Index & waist circumference Any nutritional deficiency has to be corrected Additional time may be needed to correct fluid & electrolyte deficits to promote best results

11. DRUG OR ALCOHOL USE People who abuse drugs or alcohol frequently deny or attempt to hide it, in such situations, the nurse who is obtaining the patients health history needs to ask frank questions with patience, care & non judgmental attitude. If emergency surgery is required, local, spinal or regional block anesthesia is used for minor surgery.

12. Otherwise to prevent vomiting & potential aspiration a NG tube is inserted before administering general anesthesia. The person with a history of chronic alcoholism often suffers from malnutrition & other system problems that increase the surgical risk. Additionally, alcohol withdrawal delirium may be anticipated up to 72 hours after alcohol withdrawal with a significant mortality rate when it occurs post operatively.

13. RESPIRATORY STATUS The goal for potential surgical patient is optimal respiratory function Breathing exercise & use of an incentive spirometer is taught if indicated Respiratory disease patients are assessed carefully Use of medications that may affect recovery is also assessed. Patients who smoke are urged to stop 2 months before or atleast 24hours preceding surgery.

14. CARDIOVASCULAR STATUS The goal is a well functioning cardiovascular system to meet the oxygen, fluid & nutrition needs of the peri - operative period. In case of uncontrolled HTN, surgery is postponed until under control Because cardiovascular disease increase the risk for complications, patients needs greater than usual diligence during all phases of Nursing management. In case of severe symptoms, surgery may be deferred until patients condition is improved

15. HEPATIC & RENAL FUNCT ION The liver is important in the biotransformation of anesthetic compounds. Therefore any disorders of the liver has an effect on how anesthetic agents are metabolized. Careful assessment is made with the help of various Liver Function Test. Surgery is contraindicated in patients with acute renal problems like acute nephritis. The surgery is performed as a life saving measure or to improve the urinary function.

16. ENDOCRINE FUNCTION The patient with diabetes who is undergoing surgery is at risk for hypoglycemia & hyperglycemia The goal is to maintain the blood glucose level to less than 200mg/dl. Frequent monitoring of the blood glucose level is important Patients who received corticosteroids are at risk for adrenal insufficiency, its use should be reported to anesthetist or surgeon. Thyroid disorders & respiratory failure is assessed.

17. IMMUNE FUNCTION Determining the existence of allergies & the nature of previous allergic reactions is important. It is important to identify & document any sensitivity & signs & symptoms produces by them Mildest symptoms & slightest temperature elevation must be investigated Patients who immunosuppressed are highly susceptible to infection, great care is taken to ensure strict asepsis.

18. PREVIOUS MEDICATION USE A medication history is obtained from patients to avoid possibility of drug interaction Any medication used in the past is documented & the frequency with which they are used Potent medications have effects on physiological functions, interaction of such medications with anesthetic agents can cause serious problem like arterial hypertension

19. The potential effects of prior medication therapy are evaluated by the anesthesiologist or anesthetist, who considers the length of time the patient used medications, the physical condition of the patient & the nature of the proposed surgery. The information is noted in the patients chart & conveyed to the anesthesiologist or anesthetist or surgeon.

20. PSYCHOSOCIAL FACTORS All the patients have some type of emotional reaction before any surgical procedure Psychological distress directly influences body functioning Nurse should take a careful history about the patients concerns that can have a bearing on the course of the surgical experience The nurse must be empathetic, listen well & provide information that helps alleviate concerns

21. SPIRITUAL & CULTURAL BELIEFS Spiritual beliefs play an important role in coping with fear & anxiety. Regardless of the patients religious affiliation, spiritual belief can be as therapeutic as medication The most valuable skill at the nurse’s disposal is listening carefully to the patient, especially when obtaining the history Invaluable information & insight may be gained by engaging in conversation & using communication & interviewing skills.

22. PRE OPERATIVE NURSING INTERVENTION

23. PRE – OPERATIVE TEACHING Nurses have long recognized the value of pre – operative instruction. It should be initiated as soon as possible. It should be started in the physician’s office & continue the patient arrives in the operating room Each patient in taught as an individual Multiple teaching strategies should be used depending on the patients need & abilities.

24. WHEN & WHAT TO TEACH Ideally, instruction is spaced over a period of time to allow the patient to assimilate information & ask questions as they arise Frequently teaching sessions are combined with various preparation procedure to allow flow of information Too many descriptive details will increase their anxiety level During this visit, the patient can meet & ask questions.

25. DEEP – BREATHING, COUGHING & INCENTIVE SPIROMETERS One goal of pre- operative nursing care is to teach the patient how to promote optimal lung expansion & consequent blood oxygenation after anesthesia The patient assumes a sitting position to enhance lung expansion. The nurse then demonstrates deep breathing exercise. The nurse also demonstrates how to use an incentive spirometer.

26. If there is thoracic or abdominal incision, the nurse also demonstrates how the incision line can be splinted to minimize pressure & control pain The patient is informed that medications are available to relieve pain & should be taken regularly for pain relief so that effective deep breathing n coughing exercise can be performed. If the patient does not cough effectively, atelectasis , pneumonia etc may occur.

27. MOBILITY & ACTIVE BODY MOVEMENT Mobility is essential to improve circulation prevent venous stasis & promote optimal respiratory functions The nurse explains the rationale for frequent position change after surgery Any special positions the individual patient will need to maintain after surgery is discussed Exercise of the extremities should be performed The nurse should remember proper body mechanics & to instruct the person the same

28. PAIN MANAGEMENT To asses & determine between acute & chronic pain a pain scale is introduced & its use explained to patient Post – operative, medications are administered to relieve pain & maintain comfort Anticipated methods of administration of analgesic agents for inpatients include patients controlled analgesia(PCA), epidural catheter bolus or infusion or patient – controlled epidural analgesia ( PCEA) These are discussed with the patient before surgery & the patient’s interest & willingness to use those methods are assessed.

29. INSTRUCTION FOR AMBULATORY SURGICAL PATIENTS Pre operative teaching content may be presented in a group meeting, on a video tape etc In additions to the questions & answers, the nurse tells the patient when & where to report, what to bring , what to leave home & what to wear A fasting period of 8 hours or more after a meal that includes fried or fatty foods or meals

30. The anesthesiologist or anesthetist may restrict foods & floods for longer time depending on the patients fluids status, age & pulmonary status & nature of surgery to prevent aspiration Fluid may be administered intravenously in some patients to ensure an adequate fluid volume when oral fluids are restricted

31. COGNITIVE COPING STRATEGIES Cognitive strategies may be useful for relieving tension, overcoming anxiety, decreasing fear & achieving relaxation Examples Imagery Distraction Optimistic self recitation

32. PRE OPERATIVE PSYCHOSOCIAL INTERVENTION REDUCING PRE OPERATIVE ANXIETY Cognitive strategies are useful for reducing anxiety in the pre – operative patient General pre- operative teaching will also help decrease anxiety in many patient Knowing ahead of time about the possible need for a ventilator, drainage tube or other types of equipment will help decrease anxiety in the post operative period

33. DECREASING FEAR The nurse should assist the patient to identify coping strategies that he or she has previously used to decrease fear The patient benefits from knowing when family & friends will be able to visit after surgery Research suggests that hypnosis may be a useful strategy for reducing fear & over coming the anxiety associated with surgery.

34. RESPECTING CULTURAL, SPIRITUAL & RELIGIOUS BELIEFS Identifying & showing respect for cultural, spiritual & religious beliefs The responses should be recognized as normal for those patients & families & respected by peri operative personals When patient declines blood transfusion for religious reasons, the information needs to be clearly identified, documented & communicated to the appropriate personals

35. GENERAL PRE- OPERATIVE NURSING INTERVENTION MANAGING NUTRITION & FLUIDS New recommendation are depends on the age n type of food eaten e.g. adults are advised to fast for 8 hours after eating fatty food & 4 hours after ingesting milk Most patients are currently allowed clear liquids up to 2 hours before an elective procedure

36. PREPARING THE BOWEL FOR SURGERY Enemas are not commonly ordered unless the patient is undergoing abdominal or pelvic surgeries This preparation is to allow satisfactory visualization of the surgical site & to prevent trauma to the intestine or contamination of the peritoneum by faces Additional antibiotics may be prescribed to reduce intestinal flora

37. PREPARING THE SKIN The goal of pre operative skin preparation is to reduce bacteria without injuring the skin If the surgery is not an emergency , the patient is instructed to use soap containing detergent – germicide to clean the area days before OT Generally hair is not removed around the incision site unless it is likely to interfere with surgery If the hair is removed, electric clippers are used for safe hair removal

38. ADMINISTERING PRE ANESTHETIC MEDICATIONS The use of pre anesthetic medication is minimal with ambulatory or outpatient surgery If pre anesthetic drug is administered, the patient is kept in bed with side rails raised because it causes drowsiness During this time, the nurse observes the patient for any untoward reaction to the medications It usually takes 15 to 20 minutes to prepare the patient for operating room

39. MAINTAINING THE PRE OPERATIVE RECORD A pre operative checklist elements that needs to be checked pre operatively The completed chart accompanies the patient to the OT with the surgical consent form attached, along with lab reports & nurses records Any unusual last minute observations are noted at the front of the chart in prominent place

40. TRANSPORTING THE PATIENT TO THR PRE – SURGICAL AREA The patient is transferred to the holding area or pre surgical suite about 30 to 60 minutes before the anesthesia is given The stretcher should nr comfortable with sufficient number of blankets to prevent chills in air condition rooms The surrounding should be kept quiet Using a process to verify the patient identification, surgical procedure & surgical site maximizes patients safety

41. ATTENDING TO FAMILY NEEDS Most hospitals have a waiting room where the family & significant others can wait This room may be equipped with comfortable chairs, TV, telephone & facilities for light refreshment After surgery, the surgeon may meet the family in the waiting room & discuss the outcome After surgery, the patient is taken to the post anesthesia care unit ( PACU)

42. Family members should be informed that the patient might have certain equipment or devices in place after the surgery The surgeon should provide explanations regarding post operative observation that has to be made

43. NURSING PROCESS ASSESSMENT Nursing assessment usually addresses the following parameters Physical condition including respiratory, cardiac & other major body system Results of blood test, x-rays studies etc Nutrition & fluid status Medication used Psychological preparedness for surgery Special considerations like gerontologic condition etc

44. DIAGNOSIS Based on the assessment data, major pre –operative nursing diagnoses of the surgical patient may include Anxiety related to the surgical experience & the outcome of surgery Fear related to perceived threat of the surgical procedure & separation from support system Knowledge deficit of pre – operative procedure & protocols & postoperative expectations

45. COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Failure to identify & communicate pertinent pre operative risk factor may lead to complications.

46. PLANNING AND GOALS The major goals for the pre operative surgical patient may include relief of pre operative anxiety, decreased fear, increased knowledge of peri operative expectations & absence of pre operative complications.

47. NURSING INTERVENTIONS Reducing pre operative anxiety Reducing fear Providing patient education Monitoring & managing potential complication

48. EVALUATION Report relief of anxiety Discusses with anesthesiologist or anesthetist concerns related to types of anesthesia & induction Verbalizes an understanding of the pre- anesthetic of the pre – anesthetic medication & general anesthesia Discusses last minute concerns with nurse or physician.

49. Discusses financial concerns with social workers, when appropriate Requests visits with member of clergy when appropriate Relaxes quietly after being visited by health care team members

50. REPORTS THAT FEAR IS DECREA SED Discusses fear with health care professionals Verbalizes an understanding of the location of family members or significant others during procedure

51. VOICES UNDERSTANDING OF SURGICAL INTERVENTION participates in pre operative preparations Demonstrates & describes exercises he or she is expected to perform post operatively Reviews information about post operative care Accepts pre anesthetic medication Remains in bed once pre medicated Relaxes during transportation to OT Discusses post operative expectations

52. POST OPERATIVE CARE 1 .IMMEDIATE POST OPERATIVE STAGE It is described as the period of 1-4 hours after surgery

53. Respiratory system Monitor vital signs Monitor airways patency & adequate ventilation Monitor for secretion Observe chest movement for symmetry & use of accessory muscles Monitor oxygen administration Monitor pulse oxymetry Encourage deep breathing & coughing exercise Note rate, depth , quality of respirations & breath sound

54. Cardiovascular system Assess shin & check capillary refills Assess peripheral pulses Assess for peripheral edema Monitor bleeding Assess pulse for rate & rhythm Monitor for cardiac dysrrhythmias Assess for homan’s sign

55. Musculoskeletal system Assess the client for the movement of the extremities Review physicians order regarding client positioning & restriction Unless contraindicated place the patient in low Fowler’s position after surgery to increase the size of thorax for lung expansion Avoid positioning the client in a supine position until pharyngeal reflexes have returned If the client is comatose or semi comatose, position on side & keep an oral airway in place

56. NEUROLOGICSL SYSTEM Assess the level of consciousness Frequent periodic attempts to awaken the client should continue till the client awaken Orient the client t the environment Speak in a soft tone, filter out extraneous noises in the environment Maintain body temperature & prevent heat loss by providing the client with warm blankets & raising the room temperature as necessary

57. TEMPERATURE CONTROL Monitor temperature Monitor for signs of hypothermia that result from anesthesia, cool operating room etc Apply warm blankets & continue oxygen as prescribed if the client is shivering

58. INTEGUMENTARY SYSTEM Assess surgical site, drains & wound dressings Monitor for & document any drainage or bleeding from the surgical site Assess the skin for redness, abrasions or breakdown that may have resulted from surgical positioning

59. FLUID AND ELECTROLYTE IMBALANCE Monitor IV fluids administration as prescribed Record intake & output Monitor for signs of hypocalcaemia, hyperglycemia & metabolic or respiratory acidosis or alkalosis

60. GASTRO INTESTINAL SYSTEM Monitor for nausea & vomiting Monitor patency of the NG tube if present Monitor for abdominal distension Monitor for return of bowel sounds

61. RENAL SYSTEM Assess the bladder for distension Monitor color, quality & quantity of urine if a Foley’s catheter is present Expect the client to void 6-8 hours after the surgery, depending on the anesthesia used

62. PAIN MANAGEMENT Assess for pain Assess the type of anesthesia given & pre op medications Enquire about the type & location of pain Ask the patient to rate the pain scale Administer pain medication Ensure the client with controlled analgesia pump understands how to use it

63. 2 . INTERMEDIATE POST OPERATIVE CARE It is the period of 4-24 hours after surgery

64. RESPIRATORY SYSTEM Monitor vital signs Monitor for patency of airway, verifying that the lungs are clear Encourage deep breathing & coughing Continue the same assessment as during immediate stage

65. CARDIOVASCULAR SYSTEM Monitor circulatory status such as peripheral pulses, capillary refill & the absence of edema, numbness & tingling Encourage use of the anti embolisms stocking, if prescribed to promote venous return, strengthen muscle tone & prevent pooling of blood in the extremities

66. MUSCULOSKELETAL SYSTEM Assess for range of motion on all extremities Encourage ambulation, before ambulation instruct the client to sit at the edge of the bed with his or her feet supported to assume balance If the client is unable to get out of bed, turn the client every 1-2 hourly

67. NEUROLOGICAL SYSTEM Assess level of consciousness Maintain orientation to the environment

68. INTEGUMENTARY SYSTEM Assess surgical site & drains Monitor body temperature & wounds for infection Change dressings as prescribed Use abdominal binder Drains should be patent with minimal bleeding or drainage Prepare to assist with removal of drains Turn the client to a side lying position Administer frequent oral care Maintain NPO status until gag reflex & peristalsis return Continue IV fluids as prescribed Assess bowel sound & monitor flatus & encourage ambulation

69. RENAL SYSTEM Monitor urinary output If the client is not catheterized, the client is expected to void within 6-8 hours post operate , with at least 200ml

70. PAIN MANAGEMENT Assess for pain Assess the location of pain Ask the patient to rate the pain scale Enquire about effectiveness of the last pain medication Administer pain medication, as prescribed

71. 3 . EXTENDED POST OPERATIVE STAGE This is the period of at least 1 to 4 days post operatively

72. Continue to assess and observe the client’s body system during this stage Monitor for signs for infection Encourage active range of motion Continue to encourage ambulation Encourage the client to perform as many activities of daily living as possible Diet which are rich in protein & vitamin C is advised

73. POST OPERATIVE COMPLICATIONS IMMMEDIATE Bleeding Shock Atetectasis Urine retension hypoxia

74. EARLY COMPLICATION Pneumonia Wound infection Paralytic ileus Wound dehiscence Wound evisceration Pulmonary embolism

75. LATE COMPLICATION Bowel obstruction Constipation Thrombophelibitis

76. PHARMACOLOGICAL MANAGEMENT OF SOME COMPLICATIONS HAEMORRHAGE Pressure should be provided at the site of bleeding Blood & IV fluids should be administered as prescribed

77. HYPOXIA Vital signs should be monitored The lung sound & pulse oxymetry should be assessed Oxygen should be administered as prescribed The breathing & coughing exercise should be encouraged Turn & reposition the patient

78. PNEUMONIA & ATELECTASIS Encourage the client to do deep breathing Exercise coughing & use of spirometer, Prescribe chest physiotherapy & postural drainage Use suction to clear secretions, encourage fluid intake & early ambulation Antibiotics can be given as doctor prescribed

79. PULMONARY EMBOLIS M It is a life threatening situation & requires emergency action. Notify the physician in case of emergency The vital sign should be monitored Administer oxygen & medications such as anti coagulants as prescribed

80. SHOCK Initial focus on ABC Administer IV fluids, blood products Administer medications like crystalloid, vasodilators, diuretics etc

81. WOUND INFECTION Incision site should be inspected Temperature should be monitored Dressing should be frequently changed Antibiotics to be administered

82. URINARY RETENSION It is caused by the effect of anesthesia or opoid analgesia & appear after 6 to 8hours after surgery Voiding should be monitored Encourage ambulation & increased fluid intake Catheterize the client after all non invasive technique have been attempted

83. CONSTIPATION Increased fluid intake upto 3000ml/day Early ambulation Consumption of fiber rich diet Laxatives & enemas can be used Bisacodyl tablets & suppositories, milk of magnesia lactulose are the more potent drugs used Tegascrod can be used for management of chronic constipation