3 Perioperative care
Nursing diagnoses for preoperative patients
Nursing diagnosis:
Deficient knowledge
related to unfamiliarity with surgical procedure, preoperative routine, and postoperative care
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Preoperatively: | |
| Evaluate patient’s desire for knowledge about diagnosis and procedure. | Some individuals find detailed information helpful; others prefer very brief and simple explanations. |
| Assess patient’s understanding about the diagnosis, surgical procedure, preoperative routine, and postoperative regimen. | Assessment should include patient’s primary language and whether an interpreter is needed; patient’s readiness to learn; limitations on patient’s ability to learn such as blindness or decreased hearing; and patient’s self-assessment as to which modes of learning he or she finds most helpful, such as reading, listening, visual aids, or demonstration. |
| Determine past surgical experiences and their positive or negative effect on patient. Assess the nature of any concerns or fears related to surgery. Document and communicate these assessment data to others involved in patient’s care. | Assessing patient’s knowledge, past experiences, and concerns about the surgical procedure will enable the nurse to focus on individual areas in need of greatest intervention. |
| Based on your assessment, clarify and explain diagnosis and surgical procedure accordingly. When possible, emphasize associated sensations (e.g., dry mouth, thirst, muscle weakness). Provide ample time for instruction and clarification and reinforce health care provider’s explanation of the procedure. | This information provides a knowledge base from which patient can make informed therapy choices and consent for procedures and presents an opportunity to clarify misconceptions. |
Use anatomic models, diagrams, and other audiovisual aids when possible. Provide simply written information to reinforce learning. Provide written and verbal information in patient’s native language for non–English-speaking patients. | Because individuals learn differently, using more than one teaching modality will provide teaching reinforcement of verbal information given. |
| Document if patient provides an advance directive (see p. 100). | Laws about advance directives differ for each state. |
| Explain perioperative course of events. Review the following with patient and significant other: | These measures increase patient’s knowledge of the surgical procedure, which optimally will promote adherence and minimize stress. |
| Patient will need information regarding location of the preoperative testing center, parking arrangements, and expected length of time such testing will require. | |
| Patient may be in postanesthesia care unit (PACU), intensive care unit (ICU), or specialty unit. | |
| Including sensory information in patient teaching is consistent with current nursing research that has determined patient outcomes are improved when expected sensations are explained. | |
| This information increases likelihood of successful pain management. Some patients mistakenly expect to be pain free; others fear becoming addicted to narcotics (opioids). | |
| Pain assessment tools aid in the evaluation of pain and effectiveness of interventions. | |
| Patient may be unfamiliar with use and purpose of these devices. Learning about them and seeing them in advance of surgery may help decrease fears and anxieties perioperatively. | |
| These garments/devices prevent venous stasis and decrease risk of thrombus formation. | |
| Traditionally, health care providers have progressed patients from clear liquids to a regular diet after surgery for a variety of reasons, including ease of swallowing and digestion and liquid diet being more readily tolerated in the presence of an ileus. However, practitioners are questioning the scientific basis of this diet advancement. Recent studies are indicating that a clear liquid diet may not always be indicated. | |
| For example, patients undergoing hip arthroplasty have specific positional limitations. | |
| Inhalation of toxic fumes/chemical irritants can damage lung tissue by decreasing ciliary function. Cilia line the respiratory tract and carry particles to the lower pharynx. Damaged lung tissue increases likelihood of hypoxemia and lung infections, including pneumonia. | |
| Families may feel less anxious when they are aware of a designated area where they can wait and receive updates on progress of the surgery. Knowledge of visiting hours likely will reassure them they will have access to patient after surgery. | |
| Postoperatively: | |
| Explain postoperative activities, exercises, and precautions. Have patient give a return demonstration of the following devices and exercises, as appropriate: | Adherence is enhanced when patients are knowledgeable about activities, exercises, and precautions. Patients gain confidence when they practice new skills before surgery and are provided feedback on their technique. |
| These actions help prevent atelectasis, pneumonia, and other respiratory disorders that can occur during the postoperative period. | |
| Caution: Individuals for whom increased intracranial, intrathoracic, or intraabdominal pressure is contraindicated should not cough. | Coughing increases intracranial, intrathoracic, and intraabdominal pressure. Patients undergoing intracranial surgery, spinal fusion, eye and ear surgery, and similar procedures should avoid vigorous coughing because it raises intracranial pressure, which could cause harm. Coughing after a herniorrhaphy and some thoracic surgeries should be done in a controlled manner, with the incision supported carefully, to avoid raising intraabdominal and intrathoracic pressure dramatically. |
| This device, when used with coughing and deep breathing, expands alveoli and mobilizes secretions, which helps prevent atelectasis, pneumonia, and other respiratory disorders. | |
– Calf-pumping, ankle-circling, and footboard-pressing exercises (see “Venous Thromboembolism” p. 183, for more information). | These exercises promote circulation and help prevent thrombophlebitis/deep venous thromboembolism (DVT) in the legs. |
| Adequate pain management increases mobility, which decreases risk of nosocomial pneumonia and thrombosis formation and aids in the return of GI peristalsis. | |
| Logrolling, raising self by using a trapeze device, and gradual movement are techniques that may be required. | |
| Before patient is discharged, teach prescribed activity precautions. | This teaching helps prevent excessive strain on the operative site. A patient who has a total hip replacement, for example, will need to follow activity precautions to prevent dislocation of the new joint. Increasing exercises gradually to tolerance, avoiding heavy lifting (more than 10 lb), and avoiding driving a car are precautions given to many surgical patients for safety because of potential for decreased attention span and impaired reflexes resulting from opioid use. Lifting precautions may reduce stress on surgical incisions. Restrictions on sexual activity are indicated by the surgical procedure. Returning progressively to preoperative activity level promotes physical and psychosocial well-being. |
| Provide time for patient to ask questions and express feelings of anxiety; be reassuring and supportive. Be certain to address patient’s main concerns. | Expressing feelings of anxiety and having questions answered are essential ways of reducing anxiety while learning new information. |
Nursing diagnosis:
Risk for injury
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess need for holding, administering, or adjusting patient’s maintenance medications before or immediately after surgery. Consult health care provider as necessary. | Some medications, such as anticonvulsants and cardiac medications, should be continued throughout the perioperative period. Sometimes patients need to be weaned from medications such as baclofen for the perioperative period because stopping them suddenly could result in seizures or hallucinations. Other medications may require increased dosages during surgery (i.e., hydrocortisone in place of prednisone and with increased dosage for steroid-dependent patients) or alternative routes. |
| Reinforce importance of NPO status. | Maintaining NPO status reduces risk of aspiration postoperatively. Clear liquids may be allowed up to 2 hr before surgery in patients with low risk of pulmonary aspiration. NPO policies vary widely from facility to facility. |
| Verify completion of preoperative activities and procedures, and document on preoperative checklist or nursing documentation. | Documentation on patient’s preoperative checklist or inpatient’s medical record helps ensure communication among health care team members, continuity, and optimal patient outcomes. |
| Note: The preoperative verification process must confirm the correct patient, procedure, and site of operation. | This verification process should take place upon admission to the facility, before patient leaves the preoperative area, upon entry to the surgical room, just prior to incision or start of procedure, and anytime responsibility for patient care is transferred to another caregiver. The verification process should involve the patient while still awake and aware if possible. |
| Verify that an appropriate member of the surgical team has used a sufficiently permanent-type marker that will remain visible after completion of skin prep and has marked the operative site. | The mark should be at or near the incision site and be unambiguous (i.e., use of initials or “YES” and/or a line representing proposed incision). |
| Document allergies, any evidence of skin breakdown, bruises, rashes, or wounds, and presence of dressings, drains, or ostomy. | Documentation decreases risk of untoward outcomes. Noting patient’s preexisting wounds, dressings, and drains also helps ensure appropriate intraoperative positioning. |
| Assess for and document patient’s exposure to actual or potential abuse or neglect. | All states require health care providers to report suspected abuse and neglect of children and vulnerable adults who are in their care. |
| Document patient’s access to care and transportation upon discharge. | Surgery, pain, and analgesic medications may impede the patient’s ability to care for self adequately after discharge. |
| Be sure that consent has been signed and witnessed and patient appears to understand what the procedure involves. Answer questions, or call health care provider to answer patient’s questions. Ensure that patient’s identification bracelet, blood transfusion bracelet, and allergy alert bracelet are in place. | These interventions help ensure that all appropriate documentation is present and that all steps have been taken to provide for patient’s safety and well-being. |
| Review medical record to ensure that all appropriate documentation is present; report untoward findings to health care provider. | Health care provider may not be aware of recent abnormal electrocardiogram (ECG), suspicious chest radiograph, or abnormal laboratory findings. |
| Prepare surgical site and perform additional presurgical procedures as prescribed. | This may involve clipping of hair or use of depilatory agent (shaving is not usually recommended) and patient showering with antimicrobial agent. Additional presurgical procedures may involve, for example, douche, enema, or eye drops. |
| Administer preoperative analgesia, sedation, or other medications as prescribed and on time. | This intervention helps ensure adequate serum levels of the prescribed drug. Giving antibiotics preoperatively may decrease risk of infection postoperatively. |
| Make provisions for patient safety following administration (e.g., bed in lowest position, side rails up, and reminding patient not to get out of bed without assistance). | Sedatives administered preoperatively may alter mental status and coordination, increasing patient’s risk for injury. |
| Be aware that once patient is in the location in which the procedure will be conducted and just before the procedure is started, a “time out” must be performed. | “Time out” must involve the entire operative team and confirm correct patient identity, procedure, site, and position and availability of any special equipment, implants, and other requirements that help ensure patient’s safety and well-being. |
Nursing diagnoses for postoperative patients
Nursing diagnosis:
Ineffective airway clearance
Desired Outcome: Patient’s airway becomes clear as evidenced by normal breath sounds to auscultation, respiratory rate (RR) 12-20 breaths/min with normal depth and pattern (eupnea), normothermia, normal skin color, and O2 saturation greater than 92% on room air.
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess respiratory status, including breath sounds, q1-2h during immediate postoperative period and q8h during recovery. | This assessment will determine presence of rhonchi that do not clear with coughing, labored breathing, tachypnea (RR more than 20 breaths/min), mental status changes, restlessness, cyanosis, and presence of fever (38.3° C [101° F] or higher), which are all signs of respiratory system compromise. |
| Use pulse oximetry to assess oxygen saturation as indicated, and report saturation 92% or less to health care provider. | Pulse oximetry is a noninvasive measure of arterial oxygen saturation. Values 92% or less are consistent with hypoxia and probably signal need for oxygen supplementation or workup to determine cause of desaturation. Pulse oximetry is especially indicated in patients with chronic obstructive pulmonary disease (COPD), respiratory or cardiovascular disease, morbid obesity, cardiothoracic surgery, major surgery, prolonged general anesthesia, and surgery for a fractured pelvis or long bone, as well as in debilitated patients and older adults, all of whom are at increased risk for desaturation. |
| Administer humidified oxygen as prescribed. | This intervention supplements oxygen and prevents further drying of respiratory passageways and secretions via added humidity. |
| Keep emergency airway equipment (e.g., Ambu bag and mask, intubation tray, endotracheal tubes, suctioning equipment, tracheostomy tray) readily available. | This ensures their availability in the event of sudden airway obstruction or ventilatory failure. |
| Encourage deep breathing and coughing q2h or more often for the first 72 hr postoperatively. In the presence of fine crackles (rales) and if not contraindicated, have patient cough to expectorate secretions. Facilitate deep breathing and coughing by demonstrating how to splint abdominal and thoracic incisions with hands or a pillow. If indicated, medicate ½ hr before deep breathing, coughing, or ambulation to promote adherence. | These actions expand alveoli and mobilize secretions. The effects of anesthesia and immobility may collapse alveoli and place patient at risk for nosocomial pneumonia and atelectasis. Proper positioning promotes chest expansion and ventilation of basilar lung fields. |
| If patient has a weak cough or poor reserve, try the “step-cough” technique. Coach patient to cough in rapid succession. | A few weak coughs in a row may stimulate a larger, productive cough at the end of the cycle to clear the bronchial tree of secretions. Caution: Vigorous coughing may be contraindicated for some individuals (e.g., those undergoing intracranial surgery, spinal fusion, eye and ear surgery, and similar procedures). Coughing after a herniorrhaphy and some thoracic surgeries should be done in a controlled manner, with incision supported carefully. |
| Consider whether patient may be more motivated to perform pulmonary toilet with incentive spirometer or positive expiratory pressure (PEP) device. | Devices may be a motivating factor because patient has a visual indicator of effectiveness of the breathing effort. |
Nursing diagnosis:
Ineffective breathing pattern (or risk of same)
Desired Outcome: Patient exhibits effective ventilation as evidenced by relaxed breathing, RR 12-20 breaths/min with normal depth and pattern (eupnea), clear breath sounds, normal color, return to preoperative O2 saturation on room air, Pao2 80 mm Hg or greater, pH 7.35-7.45, Paco2 35-45 mm Hg, and HCO3− 22-26 mEq/L.
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| See assessment/interventions under Ineffective Airway Clearance, p. 45. | |
| Perform preoperative baseline assessment of patient’s respiratory system, noting rate, rhythm, degree of chest expansion, quality of breath sounds, cough, and sputum production, as well as smoking history and current respiratory medications. Note preoperative O2 saturation and arterial blood gas (ABG) values if available. | Baseline assessment enables rapid detection of subsequent postoperative problems and timely intervention for same. |
| If appropriate, encourage patient to refrain from smoking for at least 1 wk after surgery. Explain effects of smoking on the body. | Inhalation of toxic fumes/chemical irritants can damage lung tissue, increasing likelihood of hypoxemia and respiratory infection. |
| Monitor O2 saturation continuously via oximetry in high-risk individuals (e.g., patients who are heavily sedated, patients with preexisting lung disease, morbidly obese patients, patients having undergone upper airway surgery, or older patients) and at periodic intervals in other patients as indicated. | Pulse oximetry is a noninvasive method of measuring saturated hemoglobin in tissue capillaries. |
| Notify health care provider of O2 saturation 92% or less. | O2 saturation of 92% or less may signal need for supplemental oxygen. |
| Evaluate ABG values, and notify health care provider of low or decreasing PaO2 and high or increasing PaCO2. Also assess for signs of hypoxia. | Declining PaO2 may signal hypoxemia and need for supplemental oxygen. Early signs of hypoxia include restlessness, dyspnea, tachycardia, tachypnea, and confusion. Cyanosis, especially of the tongue and oral mucous membranes, and extreme lethargy or somnolence are late signs of hypoxia. Hypercapnia combined with acidosis and hypoxemia may result in pulmonary vasoconstriction that may be severe and life threatening. |
| Assist patient with turning and deep-breathing/coughing exercises q2h for the first 72 hr postoperatively. | These activities promote expansion of lung alveoli and prevent pooling of secretions, which could lead to nosocomial pneumonia. |
| If patient has an incentive spirometer or PEP device, provide instructions and ensure adherence to its use q2h or as prescribed. | These devices promote expansion of the alveoli and aid in mobilizing secretions in the airways; subsequent coughing further mobilizes and clears secretions. |
| Unless contraindicated, assist patient with ambulation by second postoperative day. | Ambulation promotes circulation and ventilation, which helps prevent formation of deep vein thrombosis and pulmonary embolus. |
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