Perioperative Concepts and Nursing Management, Chapters 14-16

Perioperative Concepts and Nursing Management, chapters 14-16 QSEN- Safety in Perioperative Department. Explain why Knowledge, Skill, and Attitude are essential in surgery Knowledge ensures the nurse understands surgical procedures, anatomy, aseptic technique, anesthesia risks, medications, and potential complications. Without strong knowledge, errors such as wrong-site surgery or medication mistakes can occur. Skills are critical for performing technical tasks accurately, such as maintaining sterility, positioning patients safely, monitoring vital signs and recognizing early signs of complications. Attitude reflects professionalism, vigilance, accountability and advocacy. A safety-focused attitude encourages speaking up, following protocols and prioritizing patient-centered care. Perioperative Nursing P lease explain the three phases of the surgical experience. Preoperative Begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient onto the operating room (OR) bed. Intraoperative Begins when the patient is transferred onto the OR bed and ends with admission to the PACU. Intraoperative nursing responsibilities involve acting as scrub nurse, circulating nurse, or registered nurse first assistant. Post-operative Begins with the admission of the patient to the PACU and ends with a follow-up evaluation in the clinical setting or home. How does nursing care vary from phase to phase? Preoperative: Assessment, patient teaching, consent verification, emotional support Intraoperative: Maintaining sterile filed, monitoring physiologic status, documentation Postoperative: Airway management, pain control, wound care, mobility, education How does the nurse keep the patient safe in each phase? Preoperative: Verify patient identity, procedure, consent and ensure correct pre-op preparation (NPO status, meds, labs) Intraoperative: Perform surgical time- out, maintain sterility, and prevent pressure injuries and hypothermia. Postoperative: Monitor airway, breathing, circulation; prevent infection, DVT and falls How does the nurse advocate for the patient in each phase? Preoperative: Clarifies patient understanding and respects patient wishes Intraoperative: Speaks up if a safety concern arises (wrong site, break in sterility) Postoperative: Ensures adequate pain control, explains care and coordinates follow-up. Surgical Classifications The decision to perform surgery may be based on facilitating a diagnosis, a cure, or repair. Surgery may be constructive or cosmetic or palliative or rehabilitative . Surgeries are also classified as emergency, required, elective or optional. E xplain these classifications: (Table 14-1) Constructive Surgery to restore function or appearance Cosmetic - Surgery to improve appearance without medical necessity Palliative - Relieves symptoms but does not cure disease Rehabilitative - Improves quality of life or function Emergent Must be done immediately to save a life or limb Required - Necessary for health but not immediate Elective - Planned and beneficial but not essential Optional Patient preference only Pre-Admission testing and teaching Explain the focus of pre-admission testing and teaching. Surgical Improvement Project (SCIP )a national partnership of organizations committed to improving safety of surgical patients through reduction of complications. Note, SCIP measures have been retired by the Joint Commission , but it is expected all nurses focus on the safety of the surgical client in the focus of reducing cardiac events, infection, and deep vein thrombosis . ERAS (Enhanced Recovery After Surgery) protocols were designe d to minimize surgical stress , improve patient recovery and satisfaction, reduce post operative complications, and results in shorter hospital stays. Prehospital – education including pain management plan, prehabilitative , patient optimization (medical/ physical ) to reduce surgical risk. Medications to take and to hold prior to surgery. PreoperativeLight meal 6 hours prior to surgery, clear liquids up to 2 hours, with 16-ounce high carbohydrate clear liquid at 2 hours prior to surgery. Initiative multi-modal medications and /or regional block. Discharge medication regimen plan. Discharge education. IntraoperativeOpioid sparing, normovolemia , normoglycemia , and normothermia , N/V prophylaxis, avoid tubes and drains. Postoperativeearly nutrition, early mobilization, judicious IV management , continue/educate multimodal analgesia, patient education. Post Dischargefollow up with surgeon, therapies, monitor for changes in health and when to seek medical care Geriatric Considerations: (page 400) Why do elderly patients present increased risk of perioperative complications? Decreased cardiac, respiratory and renal reserve, altered drug metabolism, higher risk of delirium, infection and falls, and multiple chronic conditions. Bariatric Considerations: Over 40% of the United States is obese; 20% are severely obese. What risks do bariatric patients face with surgery? Difficult airway management, increased risk for DVT and pulmonary embolism, impaired wound healing and infection, and challenges with positioning and equipment sizing Heathy BMI is defined as 18.5- less than 25. Use the BMI calculator to calculate your own BMI. Patients with Disabilities: It is important that nurses identify disabilities in the pre-admission period to be able to accommodate patients with special needs. What are some examples of disabilities that would require nurses to seek appropriate resources? How would the nurse provide safe care and advocacy for these patients? Some examples of disabilities that would require nurses to seek appropriate resources are visual or hearing impairments, cognitive or developmental disabilities, mobility limitations and speech or communication disorders. The nurse can provide safe care and advocacy for these patients by identifying needs early during pre-admission, use interpreters or assistive devices, allow extra time for communication, ensure informed consent and dignity and coordinate interdisciplinary support. Preoperative Phase- Nurse Responsibilities -Please see chart 14-1. Pre-admission Testing (PAT) Starts in the physician office and continues as soon as possible by PAT department of facility that is doing the procedure. Pre-operative check list is started Assessment initiated via telephone Health history, including medications (prescribed and OTC/ herbal remedies). Anticoagulants and anti-platelet medications will be held for 7-10 days before surgery and herbal supplements should be discontinued 14 days before surgery. Diagnostic testing completed- standardized and surgery or patient specific Surgical risk assessment started Information regarding autologous blood donations Allergies- especially latex. Note food allergies, such as banana, kiwi, avocado, or tomato, balloons, **tree nuts (chestnuts, pine nuts, pecans, almonds, walnuts, etc.), adhesive bandages** See latex allergy pp 1062-1064. Patient and family past surgery and anesthesia difficulties Education needs determined and education started regarding procedure and care Family and care givers identified Pre-operative prep taught- questions answered Discuss advanced directives Post-operative transportation and care confirmed Instructions for where to go, what to bring, what to leave home Discuss alcohol and drug use to obtain baseline and risk. History of motion sickness Family history of anesthesia problems Admission to Pre-Operative Area (Health Assessment is completed on admission and Physical Assessment started) Pre-operative check list is continued Health assessment reviewed; physical assessment completed Consents obtained Surgical, anesthesia, blood, sterilization, etc. Site marked by physician and patient, confirmed by nurse (may be done in the holding area) Diagnostics completed and results on chart Further assessment of possible surgical risks Reinforce education from physician office and PAT department (pre-operative and post-operative). Review patient teaching to prevent the W’s and splinting if abdominal surgery to prevent incision complications Explain perioperative routines and answer questions Identify nutritional risks related to obesity, weight loss, malnutrition, deficiency in vitamins, medications Assess for dehydration, hypovolemia, electrolyte imbalances IV access. In-patient with risk for blood transfusions usually will get an 18-gauge needle; outpatient surgery centers often use 20 gauge needles. LR solution of choice for all non-diabetic patients. Diabetics will have their blood sugars monitored and may receive D 5 W, as prescribed. Administration of prescribed pre-operative medications Site prep (such as hair clipping and chlorhexidine scrub) Application of TED hose and/or pneumatic hose Ensure patient voids before going to operating room. Hand off with OR nurse prior to transporting to the operating room holding area Surgical Holding Area (in the OR) Hand off report from pre-operative nurse. Identify patient with 2 identifiers Finish the pre-operative check list- identify risk Check consents for accuracy Medicate as prescribed, ensure patient safety with side rails up Use patient safety alarms after medication Verify site has been marked by physician and patient Provide calm environment for relaxation Advocate for anti-anxiety medications or midazolam for history of motion sickness Ambulatory vs. Emergency Surgery: How do outpatient, same day or short stay surgeries differ from emergency surgery? Ambulatory surgery (outpatient, same day or short stay surgeries) is planned; patient is usually stable, extensive education and preparation and can be discharged same day. Emergency surgery is limited preparation time; consent may be implied, focused on rapid stabilization and safety and life or limb threatening. Explain the 4 Rights of Informed Consent: (Chart 14-2) Teaching/ learning materials that can be used to help patients better understand the surgical procedure. Voluntary consent must be freely given, without coercion. Patient must be at least 18 years of age (unless an emancipated minor), a physician must obtain consent, and a professional staff member must witness patient’s signature. Patient who is incompetent legal definition: individual who is not autonomous and cannot give or withhold consent (e.g., individuals who are cognitively impaired, mentally ill, or neurologically incapacitated). Informed subject Informed consent should be in writing. It should contain the following: explanation of procedure and its risks, description of benefits and alternatives, an offer to answer questions about procedure, instructions that the patient may withdraw consent, a statement informing the patient if the protocol differs from customary procedure. Patient able to comprehend, if the patient is nonEnglish speaking, it is necessary to provide consent (written and verbal) in a language that is understandable to the patient. A trained medical interpreter may be consulted. Alternative formats of communication (e.g., Braille, large print, sign interpreter) may be needed if the patient has a disability that affects vision or hearing. Questions must be answered to facilitate comprehension if material is confusing. Preoperative Assessment Preoperative Assessment is a very important task that the registered nurse must take very seriously. The ultimate goal is for the patient to be as healthy as possible for surgery and to have little to no complicationsthe assessment provides the health care team with important information. Health history guides physical assessment. A set of vitals on admission provid es baseline information that is used throughout the stay. Health history and current medication list will guide the nurse to anticipate co-morbidity risks. Allergies to food, drugs, latex , over the counter medication s, activity level, prior level of function, exercise level must be identified . What foods would alert the nurse to latex allergy? If a patient states that he or she is allergic to kiwi, avocado, or banana, or cannot blow up balloons, there may be an association with an allergy to latex. What manifestations might you see with a latex allergy? Rash, asthma or anaphylactic shock The preoperative assessment should also pay attention to risk of Obstructive Sleep Apnea. What acronym will you remember that helps to assess for risk for OSA? The STOP-Bang is one assessment that may be performed (Snoring, Tired, Observed, Pressure, BMI, Age, Neck, Gender ) to assess for the presence of OSA . Why is it important to screen for interpersonal violence? Health care providers also should be alert for signs of interpersonal violence, including intimate partner violence, which can occur at any age, in either sex, and in any socioeconomic, ethnic, and cultural group. Findings need to be reported accordingly Why is the patient NPO before surgery? Preoperative fasting helps prevent the risk of aspiration and r educes risk of pneumonia and airway obstruction during anesthesia . Nutrition and Fluid Status Dentation: Why is the condition of the mouth important to assess? The condition of the mouth is an important health factor to assess. Dental caries, dentures, and partial plates are particularly significant to the anesthesiologist or CRNA, because decayed teeth or dental prostheses may become dislodged during intubation and occlude the airway. This is especially important for older patients as well as those who may not have regular dental care. The condition of the mouth is also important because any bodily infection, even in the mouth, can be a source of postoperative infection. Drug or Alcohol Use: Today, with the high increase of drug and alcohol abuse reported, it is more important that ever to asses for drug and alcohol use. Explain the reasons why. Excessive alcohol consumption can cause arrhythmias, infections, and withdrawal. These factors can lead to extended hospital stays and increased complications. Identifying patients who have excessive alcohol use presurgically and implementing interventions can reduce the incidence of complications by about 50%. In addition, the use of illicit drugs and alcohol may impede the effectiveness of some medications. Because acutely intoxicated people are susceptible to injury, surgery is postponed if possible. Respiratory: Atelectasis and pneumonia are possible post-operative complications. Atelectasis can occur as early as day zero (day of surgery) and pneumonia is the most common complication on post op day 1 and 2. The patient must be educated about coughing, deep breathing exercises and use of incentive spirometer to decrease risk. What is the purpose of the incentive spirometer in the prevention of post-operative respiratory infections? The patient is educated about breathing exercises and the use of an incentive spirometer, if indicated, to achieve optimal respiratory function prior to surgery. The potential compromise of ventilation during all phases of surgical treatment necessitates a proactive response to respiratory infections. Which underlying respiratory conditions and lifestyle choices can lead to peri-operative and post-operative complications: Preoperative smoking cessation interventions can be effective in changing smoking behavior and reducing the incidence of postoperative complications. Patients who smoke are more likely to experience poor wound healing, a higher incidence of SSI, and complications that include VTE and pneumonia. During the preoperative assessment, patients should be asked about current and previous tobacco use. Patients undergoing elective cases may have their surgery delayed or cancelled due to the potential complications associated with smoking. Those at highest risk of complications are patients scheduled to receive artificial implants such as grafts, total joint replacements, or breast enhancements. Cardiovascular: The cardiovascular system is taxed during surgery, with excess fluids and anesthesia medications. Patients with hypertension have increased risk of complications during and after surgery. An ECG and CXR pre-operatively can give baseline cardiac status information and rule out undiagnosed cardiac conditions. Hepatic and Renal Function: Anesthetic agents are filtered through the liver and excreted by the kidneys. Disorders of either organ may substantially affect how anesthetic agents are metabolized and excreted. Endocrine Function: Explain risks for patients that take long term corticosteroids in perioperative complications. Patients who have received corticosteroids are at risk for adrenal insufficiency. Why does thyroid disease increase patient risks during surgery? Thyrotoxicosis (Thyroid Storm; hyperthyroidism) Respiratory Failure (Hypothyroidism) Explain how diabetes places patients at increased risks during and after surgery. The patient with diabetes who is undergoing surgery is at risk for both hypoglycemia and hyperglycemia. Hypoglycemia may develop during anesthesia or postoperatively from inadequate carbohydrates or excessive administration of insulin. Hyperglycemia, which can increase the risk of SSI, may result from the stress of surgery, which can trigger increased levels of catecholamine. Other risks are acidosis and glucosuria . Although the surgical risk in the patient with controlled diabetes is no greater than in the patient without diabetes, strict glycemic control leads to better outcomes Immune Function: It is essential during the preoperative phase to identify risk for infection and allergy. If there is an elevated temperature or WBC count elective surgeries will be cancelled. Immunosuppression increases risk of infection from surgery. Immunosuppression occurs due to disease or medication complications, such as corticosteroids, organ transplantation (and medications to prevent rejection/ GVH disease), radiation, chemotherapy, cancer. Why is the body temperature a better indication of complications than a white blood cell count with the patient who is immune compromised? Fever is often the earliest indication of infection and immunocompromised patients may not mount a WBC response. Latex Allergy Assessment Questions (p.405) Not all patients know they are latex allergic. Ask the following questions. If they answer yes, there’s a chance they are allergic to latex. Has a doctor ever told you that you are allergic to latex? Do you have on-the-job exposure to latex? Were you born with problems involving your spinal cord? Have you ever had allergies, asthma, hay fever, eczema or problems with rashes? Have you ever had respiratory distress, rapid heart rate or swelling? Have you ever had swelling, itching, hives or other symptoms after contact with a balloon? Have you ever had swelling, itching, hives or other symptoms after a dental exam or procedure? Have you ever had swelling, itching, hives or other symptoms following a vaginal or rectal examination or after contact with a diaphragm or condom? Have you ever had swelling, itching, hives or other symptoms during or within 1 hour after wearing rubber gloves? Have you ever had a rash lasting longer than a week? Have you ever had swelling, itching, hives, runny nose, eye irritation, wheezing, or asthma after contact with any latex or rubber products, such as condoms or adhesive bandages and tape ? Have you ever had swelling, itching, hives or other symptoms after being examined by someone wearing rubber or latex gloves? Are you allergic to foods such tomatoes, bananas, avocados, kiwi, or tree nuts ? Have you ever had an unexplained anaphylactic episode? ** Also please see latex allergy, pp. 1062-1062. Psychosocial Factors- The nurse should anticipate emotional reactions to surgery, normal or abnormal, obvious or hidden. Fear can sometimes be related to the unknown, lack of control, or fear of death and may be influenced by anesthesia, pain, complications, cancer or prior surgical experience. Fear is more specific and can be articulated. Anxiety can occur in response to threat to role in life, permanent incapacity or body integrity, increased responsibilities or burden on family members or life itself. Anxiety is more general and cannot be articulated or related to a specific issue. Explain the different ways people express fear: People express fear in different ways. Some patients may ask repeated questions, regardless of information already shared with them. Others may withdraw, deliberately avoiding communication by reading, watching television, or talking about trivialities. Consequently, the nurse must be empathetic, listen well, and provide information that helps alleviate concerns. The nurse must learn to listen to far more than words! The nurse must use empathy, listen well, and provide information that helps alleviate concerns. How will the nurse focus on the assessment of fear/ anxiety and what actions are important? Why is it not the right time to provide more education? An important outcome of the psychosocial assessment is the determination of the extent and role of the patient’s support network. The value and reliability of available support systems are assessed . Other information, such as knowledge of the usual level of functioning and typical daily activities, may assist in the patient’s care and recovery. Assessing the patient’s readiness to learn and determining the best approach to maximize comprehension provide the basis for preoperative patient education. This is of particular importance in patients who are developmentally delayed and those who are cognitively impaired, where the approach to patient education and consent will include the legal guardian. Spiritual and Cultural Beliefs Showing respect for a patient’s cultural values and beliefs facilitates rapport and trust. Knowledge of a patient’s physiologic, psychosocial, cultural, spiritual, and educational needs allows the nurse to provide holistic care. Each ethnic group is unique, and it is important not to assume how they cope or best approach to helping the patients’ cope- so it is important to ask the patient if there is anything that you can do to help them . The Amish culture has a strong work ethic and stress may come if they are unable to work. In some cultures, avoiding eye contact is impolite but in others making eye contact is impolite- the nurse needs to pay attention to each person, so care is individualized. In some cultures, the top of the head is sacred. It is essential that nurses are unhurried and pay attention to both verbal and nonverbal communication. What cultural or religious practices do you know of Catholic, Jewish, Latter-Day Saints, Jehovah Witness, Muslim religions , etc. ? How will you ensure you help the patient meet their own spiritual and religious needs even if they are different from your own? Showing respect for a patient’s cultural values and beliefs facilitates rapport and trust. Assessment includes identifying the ethnic group to which the patient relates and the customs and beliefs the patient holds about illness and health care providers. Knowledge of the patient’s physiologic, psychosocial, cultural, spiritual, and educational needs allows the perioperative nurse to provide a holistic approach to care. The most valuable skill at the nurse’s disposal is listening carefully to the patient and observing body language, especially when obtaining the history. Invaluable information and insights may be gained through effective communication and interviewing skills. An unhurried, understanding, and caring nurse promotes confidence on the part of the patient. Pre-operative Nursing Interventions/Teaching Teaching/ education needs to be an individualized plan that protects patient against most common complications. Multiple teaching strategies m ust be used to ensure learning. Increased understanding leads to increased compliance. Teaching does NOT mean learning. Patients will have individualized teaching/learning needs based on the patient and the procedure. The initial education will begin at the surgeon office and is continued by Pre-admission Testing (PAT) department. The patient is most often contacted by the PAT approximately 37 days prior to surgery date and meeting is completed either via telephone or face to face meeting . During the PAT appointment the nurse provides written education material, audiovisual resources, and telephone numbers. The nurse will guide the patient through the experience and explain the process and expectations of both patient and facility staff. Beyond description of the procedure, what information will the nurse be sure to include in this teaching session? Education should go beyond descriptions of the procedure and should include explanations of the sensations the patient will experience. Telling the patient that a preoperative medication will cause relaxation before the operation is not as effective as also noting that a medication will act quickly and may result in lightheadedness, dizziness, and drowsiness. Knowing what to expect will help the patient anticipate these reactions and attain a superior degree of relaxation. Overly detailed descriptions may increase anxiety in some patients; therefore, the nurse should be sensitive to this, by watching and listening, and provide less detail based on the individual patient’s needs. The W’s of Pre-operative Complications and Teaching (Chart 14-5) (Postoperative Complications: Revising the Rule of W) Also be sure to watch the recorded W’s lecture I provided in Canvas in the pre-clinical lab area. Waves Wind Water Wound Walk Wonder drug Coughing and Deep Breathing, Incentive Spirometry It is important that the nurse educates the patient pulmonary hygiene. The promotion of lung expansion improves blood oxygenation after anesthesia and prevents complications such as atelectasis and pneumonia. Proper deep breathing, coughing, and incentive spirometry techniques is imperative to patient pulmonary outcomes and also helps with relaxation. When is splinting included in pre-operative teaching? If a thoracic or abdominal incision is anticipated, the nurse demonstrates how to splint the incision to minimize pressure and control pain. Because coughing can include surgical pain, it is imperative to provide analgesics to the patient. Coughing and deep breathing is very important so adequate pain relief must be maintained. What is the goal of coughing and deep breathing? The goal in promoting coughing is to mobilize secretions so that they can be removed. Deep breathing before coughing stimulates the cough reflex. If the patient does not cough effectively, atelectasis (collapse of the alveoli), pneumonia, or other lung complications may occur. How to Use Incentive Spirometer Promoting mobility The goals of promoting mobility post-operatively are to improve circulation, prevent blood stasis and promote optimal lung expansion. Explaining rationale for frequent position changes is helpful because after anesthesia the patient may be drowsy. Extremity exercises are very important in preventing circulatory complications, such as deep vein thrombosis (venous thrombus embolism). Pain management begins with a pain assessment to determine chronic versus acute pain. The PQRST symptom analysis is one mnemonic commonly used to assess pain. P: provoking/palliative events (onset)- What causes the pain? What makes the pain better? Q: quality/ quantity- What does it feel like, such as sharp, dull, tingling, stabbing, burning, or crushing? R: region/radiation- Is the pain focal or does it radiate to a different location? S: severity/scale- Use a scale, such as visual analogue scale, numerical rating scale, faces pain scale, to rate the intensity of the pain. T: time- When did the pain start and how long did it last? Once post-operative pain is identified, a pain intensity scale should be introduced and explained to the patient to promote more effective post-operative pain management. There are several types of medication administration methods, including patient-controlled analgesia (PCA), epidural bolus or infusion, or patient controlled epidural analgesia (PCEA) for those patients that will remain in the hospital. The surgeon and anesthesiologist will select the best method for the patient. For those going home oral medications will be prescribed. In addition to medications, cognitive coping strategies may be useful in relieving tension, overcoming anxiety, decreasing fear and achieving relaxation. Explain imagery, distraction, optimistic self-recitation, and music therapies. Imagery the patient focuses on a pleasant, calming image or memory, such as a beach or peaceful place. This mental focus reduces stress responses and promotes relaxation. Distraction the patient intentionally shifts attention away from anxiety by thinking about something enjoyable, such as telling a favorite story, recalling a happy memory, or reciting a poem or song. Optimistic self-recitation the patient repeats positive, reassuring statements (e.g., “I know this surgery will go well”). This helps counter negative thoughts and increases emotional control. Music therapies the patient listens to soothing or preferred music to promote relaxation. Music therapy is effective because it is noninvasive, inexpensive, and easy to use, and it helps lower anxiety and physiologic stress. Psychosocial interventions include identifying and showing respect for cultural, spiritual, and religious beliefs. What examples does the book provide ? The nurse assesses for any patient specific needs that may affect the spiritual, emotional, or physical surgical experience. In some cultures, for example, people are stoic in regard to pain, whereas in others they are more expressive. These responses should be recognized as normal for those patients and families and should be respected by perioperative personnel. If patients decline blood transfusions for religious reasons (Jehovah’s Witnesses), this information needs to be clearly identified in the preoperative period, documented, and communicated to the appropriate personnel. Although minimally invasive surgery has significantly lowered blood loss, any surgical procedure has the potential for hemorrhage. How will the nurse reduce anxiety and decrease fear for the perioperative patient? Each preoperative patient should be acknowledged as an individual, and each patient’s needs and desires must be assessed. The patient should be thanked for choosing that particular hospital or surgical center. These methods facilitate establishing a positive nurse–patient relationship. Discussion of the surgical experience, its length, and explanation of what will happen may diminish the patient’s anxiety. What are some ways the perioperative nurse shows respect for culture, spiritual and religious beliefs? During the preoperative assessment of psychological factors and spiritual and cultural beliefs, the nurse assists the patient to identify coping strategies that he or she has previously used to decrease fear. Discussions with the patient to help determine the source of fears can help with expression of concerns. The patient benefits from knowing when family and friends will be able to visit after surgery and that a spiritual advisor will be available if desired. Maintaining Patient Safety means protecting patients from injury is the major role of Association of Operating Room Nurses (AORN) and Joint Commission National Patient Safety Goals. All pre-operative, intraoperative, and post-operative policies are developed from these goals. 1. List the 2019 National Patient Safety Goals and think about how the perioperative nurses work together in the three perioperative areas to protect the patient from injury. 1. Identify patients correctly- Use two patient identifiers during all phases of care Managing Fluids and Nutrition: What is the reason that patients are NPO for a period of time prior to surgery? The purpose of withholding food and fluid before surgery is to prevent aspiration What are the guidelines for solid food and drinks, per the Enhanced Recovery After Surgery (ERAS pathway)? Solid food is restricted based on type, with adults fasting 8 hours after fatty foods and 6 hours after milk products. Healthy patients may have clear liquids up to 2 hours before surgery. ERAS protocols allow preoperative carbohydraterich drinks up to 2 hours before surgery for non–gastrointestinal procedures to reduce insulin resistance, postoperative nausea and vomiting, pain, and length of stay. How will you prepare the patient’s bowel for surgery? Bowel preparation is not routinely required unless the patient is undergoing abdominal or pelvic surgery. When indicated, a cleansing enema or laxative may be given the evening before surgery and repeated the morning of surgery. Antibiotics may also be prescribed to reduce intestinal bacteria. The goal is to improve visualization and prevent contamination or injury. Preparing the skin Chlorhexidine - Preoperative skin preparation includes full-body bathing with antimicrobial soap the night before surgery. Additional cleansing with chlorhexidine wipes may be performed in the preoperative area to reduce skin bacteria without causing injury. Electric Clippers Hair removal is done only if necessary and should occur in the preoperative area using electric clippers , not razors, to reduce the risk of skin injury and infection. Mark the Sit e The surgical site is marked by the patient and the surgeon before the procedure to ensure correct-site surgery and prevent errors . Immediate Pre-operative Nursing Interventions- Prior to the procedure, the pre-operative nurse must ensure the patient is prepared for surgery. This includes ID bracelets, fall risk assessments, extremity precautions and code status. The nurse must also verify all labs and diagnostics are completed, results reviewed, and on chart. If any result is abnormal the nurse will call the physician and O.R.. The patient changes into the gown, appl ies surgical head cover, the nurse inspects the mouth and teeth- any broken teeth should be noted . All jewelry will be removed to prevent injury and loss. Jewelry that c annot be removed will be taped. All belongings, such as assistive devices, dentures, glasses, prosthetic devices, will be given to family or placed in safe (follow facility policy). Patients will void before being moved to pre-operative holding area. Be sure to keep the patient warm. Keeping the patient warm reduces shivering that leads to post-operative complications such as increased bleeding , lower infections, decreased pain, and reduced malaise . Pre-warming , li k e preheating the oven before use, is becoming popular. Do not forget about the family! Show the family to the waiting room and provide information regarding routines and where the surgeon will meet to speak with them . Be sure to answer their questions. Imagine the stress your family would endure if you were having surgery… try to keep them informed and answer their questions with patience and kindness. Medications such as dia zepam (Valium), lorazepam (Ativan ) and midazolam (versed) are used for pre-operative anxiety. These drugs are all in the benzodiazepine family of medications. Flumazenil ( Romazicon ) is the antidote for drugs in the benzodiazepine class of medications. Intraoperative Nursing Management (ch 15) Surgery and anesthesia place the patient at risk for several complications and adverse events. Staff must work together to identify risk and to protect the patient against risk and complications and promote high quality patient care and outcomes. The surgical team: Patient Anesthesiologist or CRNA Surgeon Surgical Technicians or RNFAs or scrub nurse Circulating Nurse Geriatric Considerations: One in ten patients undergoing surgery are 65 or older. Age alone increases risk for complications due to loss of muscle mass, increased adipose tissue, co morbidities, advanced systemic disease, increased susceptibility to illness. Please review all the risks associated with the elderly client (page 418). Nursing Care- Each staff member in the operating room has a role unique to themselves. Each person will ensure their own responsibility to safe care; however, it is the circulating nurse that maintains the leadership role to ensure best care is never compromised. The circulating nurse manages the OR and protects patient safety and health by monitoring the activities of the surgical team, checking OR conditions and continually assessing the patient for signs of injury. What responsibilities will the circulating nurse have to ensure patient safety? A foremost responsibility includes verifying consent; if not obtained, surgery may not commence. The team is coordinated by the circulating nurse, who ensures cleanliness, proper temperature, humidity, appropriate lighting, safe function of equipment, and the availability of supplies and materials. The circulating nurse monitors aseptic practices to avoid breaks in technique while coordinating the movement of related personnel (medical, x-ray, and laboratory), as well as implementing fire safety precautions. The circulating nurse also monitors the patient and documents specific activities throughout the operation to ensure the patient’s safety and well-being. In addition, the circulating nurse is responsible for ensuring that the second verification of the surgical procedure and site takes place and is documented. Intra-operative Phase- Nurse Responsibilities Intra-operative (circulating nurse) Obtain hand off from pre-operative nurse Take patient to holding area Verify consents and pre-operative diagnostic results Medicate as needed for anxiety During surgery, ensures cleanliness, proper room and patient temperatures, humidity, lighting, safe equipment, ensure proper supplies and instruments. Monitors surgical asepsis Maintains fire safety precautions (equipment can cause fire risk) Runs time out/ surgical pause with team Runs debriefing session after procedure The circulating nurse manages the OR and protects the patient safety and advocates for the patient. It is the circulators responsibility to verify consent, ensures no break in sterility, proper temperature of room and patient, humidity, lighting, safe function of equipment, availability of supplies. The circulator also completes patient documentation and surgical safety checklist (p. 419). Explain Time Out (surgical pause , universal protocol ): T akes place among the surgical team prior to induction of anesthesia with a briefing about anticipated problems, potential complications, allergies, and comorbidities. Every member of the surgical team verifies the patient’s name, procedure, and surgical site using objective documentation and data before beginning the surgery. Surgical Environment - The surgical suite is behind double doors and access is limited to authorized, appropriately dressed personnel. Explain what this means. The OR is considered a restricted area where careful attention to infection prevention is at the highest standard. In the OR environment, microbial contamination can occur through an airborne or contact route; as a result, the OR has special air filtration devices to screen out contaminating particles, dust, and pollutants. ORs are designed with laminar flow ventilation to circulate particles away from the patient and surgical field. How is the surgical area protected from microbes? To help decrease microbes, the surgical area is divided into three zones: the unrestricted zone, where street clothes are allowed; the semirestricted zone, where attire consists of scrub clothes and caps; and the restricted zone, where scrub clothes, shoe covers, caps, and masks are worn. The surgeons and other surgical team members wear additional sterile clothing and protective devices during surgery . Explain the principles of surgical asepsis and Sterile technique. Surgical asepsis and sterile technique prevent wound contamination and surgical site infections. All instruments, supplies, and the surgical field must be sterile, team members must perform proper hand antisepsis and wear protective attire, and the patient’s skin must be properly prepped and draped, with only scrubbed personnel touching sterile objects . The Surgical Experience (pg. 424) During the surgical procedure the patient will need sedation, anesthesia, or combination of both. The anesthesiologist will meet with the patient to discuss the most appropriate anesthesia for the procedure and the patient’s overall health and well-being. The main types of anesthesia are general (inhalation, IV), regional (epidural, spinal, local conduction blocks) moderate sedation (known as monitored anesthesia care-MAC), sedation, and local anesthesia. General Anesthesia is a state of narcosis, analgesia, relaxation, and reflex loss. Anesthesia is administered by anesthesiologist or CRNA with both inhalation and intravenous medications, using muscle relaxants, analgesics and anesthetic agents. A patient under general anesthesia is not arousable and the airway must be maintained. This means the anesthesiologist must either use the ambu bag (short cases) or insert an endotracheal or Laryngeal Mask Airway (LMA) airway and then connect to a ventilator. Both tubes are inserted by the anesthesiologist once the patient is unconscious to protect airway and allow the ventilator to breathe for the patient. ***There are 4 stages of general anesthesia, but you do not need to know these. An endotracheal tube is a flexible plastic tube that is placed through the mouth into the trachea (windpipe) to help a patient breathe. The endotracheal tube is then connected to a ventilator, which delivers oxygen to the lungs. The process of inserting the tube is called endotracheal intubation. View: Portex Endotracheal Tube Cuff 7.0 mm 100/150/070 The LMA is a supraglottic airway management device that can be used as an alternative to both ambu mask ventilation and endotracheal intubation in appropriate patients. When inserted appropriately, the LMA lies with its tip resting over the upper esophageal sphincter, cuff sides lying over the pyriform fossae, and cuff upper border resting against the base of the tongue. Such positioning allows for effective ventilation with minimal inflation of the stomach. Read: Tricks For LMA Insertion Because general anesthesia poses risks for those with cardiac disease, there are precautions taken to prevent complications. Can you state the precautions as outlined in SCIP? SCIP precautions for patients with cardiac disease include assessing cardiac risk, continuing necessary cardiac medications, closely monitoring ECG and blood pressure during surgery, maintaining stable oxygenation and blood pressure, and providing vigilant postoperative monitoring to prevent cardiac complications. Multimodal Anesthesia uses a combination of narcotics, nonopioid analgesics, and regional anesthesia techniques. Multimodal anesthesia is a growing trend in the Enhanced Recovery After Surgery (ERAS pathway) as it decreases the risk of GA and aids in opioid reduction strategies. To reduce risk of chronic opioid abuse, instead of general anesthesia, regional and local anesthesia is used, non-opioid medications such as acetaminophen and NSAIDS (Celebrex), ketamine, gabapentinoids (gabapentin) are preferred for pain relief. Regional Anesthesia: Is an anesthetic agent that the anesthesiologist or CNRA injects round nerves so that the region supplied by those nerves is anesthetized (numbed). The patient is awake and aware of surroundings; however, often mild to moderate sedation may be given with regional to relieve anxiety. Epidural anesthesia: in achieved by the anesthesiologist or CRNA injecting local anesthetic medication into the epidural space that surrounds the dura mater of the spinal cord. Spinal anesthesia: the anesthesiologist injects local anesthetic medication through the dura mater into the subarachnoid space surrounding the spinal cord. Spinal anesthesia requires fewer medications. Advantage of epidural is the absence of the risk of headache- a complication of spinal anesthetic when spinal fluids leaks out of the subarachnoid space through the puncture site. If the dura is inadvertently punctured and the anesthetic travels toward the head the numbness can travel higher and result in severe hypotension and respiratory depression and respiratory arrest. Medications most often used in regional anesthesia are: lidocaine Bupivacaine, and for longer cases, tetracaine, and sometimes the anesthesiologist will mix in epinephrine to enhance effects. Dermatome Assessment will be discussed in Post-Operative Nursing section Read: Epidural anesthesia: what is it? Moderate Sedation (previously known as conscious sedation) is a type of anesthesia where sedation medications or analgesics are administered via IV to reduce patient anxiety and control pain during procedures. It is administered by anesthesiologist, CRNA, specially trained RNs or credentialed physicians. Sedation is often used in combination with other types of anesthesia (such as regional or local). Sedation does not interfere with the patient’s ability to maintain airway as protective airway reflexes are not compromised. The patient can respond to verbal and physical stimuli. Monitored Anesthesia Care (MAC) is a moderate sedation that is administered by an anesthesiologist or CRNA. This is a much deeper anesthesia that can be transitioned into general anesthesia quickly due to the patient’s ability to handle the sedation during surgery. It is a much deeper sedation that sedation (both light and moderate). Local anesthesia is just that, local numbing of a specific area. Novocain with dental work is an example of local anesthesia that most of us have had at one time or another. In the hospital the anesthesiologists most often will use lidocaine. Local is ideal for short, minor procedures. Often mild sedation is given with local to decrease anxiety. When given alone, the patient is able to drive home and care for self as local does not cross blood brain barrier to impact reflexes or mental status. This is the only anesthesia that the patient is allowed to resume independent activity immediately upon surgery completion. Potential Intraoperative Complications Anesthesia Awareness: this is when the patient wakes up in the middle of surgery. This is never good and will definitely lead to a lawsuit. Can you imagine waking up in the middle of surgery? Can you imagine the post-traumatic stress this would ensue? Nausea and vomiting must be controlled to decrease aspiration risk. Patients should be screened for risk factors, which would include female, age less than 50, history of PONV, opioid administration. Antiemetics, such as ondansetron, can be given preoperative to reduce risk. What is the greatest risk if the patient begins to vomit? What will the nurse immediately do if the patient starts to gag? If the patient vomits while lying flat, what assessment is essential? Where should the HOB be instead of flat? To prevent aspiration, the nurse turns a gagging patient to the side, lowers the table, suctions vomitus, and ensures the head of the bed is elevated while assessing airway, breathing, and oxygenation. Anaphylaxis can occur if a patient comes in contact with a foreign substance. Because medications are a common cause of anaphylaxis, perioperative nurses must be aware of any patient allergies. What signs would the nurse watch for that might indicate risk for potential anaphylaxis? The nurse must be alert to “changes in vital signs and symptoms of anaphylaxis” when a foreign substance is used. Because anaphylaxis can lead to cardiovascular and respiratory collapse, the nurse watches for early changes in vital signs (such as sudden changes in blood pressure, heart rate, or respiratory rate) and any emerging symptoms that could indicate an allergic reaction so that causative agents can be removed and intervention initiated promptly. Hypoxia can result from inadequate ventilation. What measures/assessments will the circulating nurse and anesthesiologist/ CRNA take to monitor for and prevent hypoxia? Vigilant monitoring of the patient’s oxygenation status is a primary function of the anesthesiologist or CRNA and the circulating nurse. Peripheral perfusion is checked frequently, and capnography readings are monitored continuously. Capnography provides instantaneous information about carbon dioxide production, pulmonary perfusion, and respiratory patterns that detect hypoventilation and apnea Hypothermia can occur during surgery from administered medications, temperature of room, infusion of cool fluids (IV, irrigations), cool gases, and the procedure itself as it may produce open body wounds or cavities. The goal is to keep the body temperature greater than 98.60 F or 370 C. It is the circulating nurse/s job to ensure the body temperature remains as close to normal as possible and does this by monitoring temperatures of room and solutions, protecting the patient against loss of body temperature by using forced air warming devices or blankets. Risks of intraoperative hypothermia include cardiovascular events, SSIs, bleeding, and delayed arousal from anesthesia. Conscientious monitoring of core temperature, urinary output, EKG, blood pressure, arterial blood gas levels, and serum electrolyte levels is required. Malignant Hyperthermia is a rare inherited muscle disorder that is chemically induced by anesthetic and other agents or stress in a susceptible person. Patients with strong, bulky muscles, history or muscle cramps or weakness and unexplained death of family member during surgery accompanied by febrile response should be carefully assessed for risk. Pathophysiology is related to a hypermetabolic condition that involves altered mechanisms of calcium function in skeletal muscle cells resulting in hyper-metabolism and increased muscle contraction (rigidity). Manifestations include tachycardia, ventricular dysrhythmias, hypotension, decreased cardiac output, oliguria, hypercapnia, cardiac arrest. Tetany or rigidity in the jaw occurs due to the abnormal transport of calcium- general rigidity is one of the earliest signs. The rise in temperature is a later sign- the rise can increase 1-2 degrees every 5 minutes, as high as 1070F. Goals of medical management i nclude recognizing early symptoms- as it usually manifests about 10-20 minutes after anesthesia induction but can occur during first 24 hours after surgery. Goals of treatment is to reduced metabolism, reverse metabolic and respiratory acidosis, correct arrhythmias, decrease body temperature, provide oxygen and nutrition to tissues, and correct electrolyte imbalance. Dantrolene Sodium is the medication of choice and needs to be administered as soon as MH is suspected and available. Please review the nursing process care plan located on pp. 432-435 to see how all this is applied to a patient care case. Post-Operative Nursing Management- (Ch 16) The post-operative period extends from the time the patient leaves the OR until the last follow up visit with the surgeon. During the post-operative period the nurse focuses care on re-establishing the patient’s physiologic equilibrium, alleviating pain, preventing complications, and educating the patient about self-care. Care of the Post-Operative Patient: The Post anesthesia Care Unit (PACU) is located adjacent to the operating room. In some hospitals and ambulatory centers, PACU is often divided into 2 phases. In Phase 1, intensive nursing care is provided. In the hospital, after this phase, the patient may be transferred to an inpatient bed. Phase 2 is completed on a hospital unit and post operative vitals and assessments are completed often to monitor the patient for complications. If the patient will transition home, phase 2 prepares the patient for discharge. Recliners rather than stretchers are standard. Patients remain in phase 1 and phase 2 until they meet predetermined discharge criteria. Modified Aldrete Scoring Read: What Is It, How It’s Calculated, and More The anesthesiologist/ CRNA and the circulating nurse bring the patient to PACU. Report is given to the receiving RN. Oxygen and monitors are applied. What is the primary nursing objectives for the patient in the PACU? The nursing management objectives for the patient in the PACU are to provide care until the patient has recovered from the effects of anesthesia Post-Operative Assessment: Upon arrival to PACU, the nurse will monitor airway, level of consciousness, cardiac, respiratory, incision and pain. The nurse performs and documents baseline assessment, then checks all drainage tubes, verifies monitoring lines are connected and functioning. IV fluids and medications are correct drug, dose, rate, patient. Vital signs are compared to baseline. Read: NCLEX High Yield's Post View: View various surgical drains Maintaining a Patent Airway is the primary objective in the immediate post operative period. What are ways the nurse monitors patent airway? The nurse assesses respiratory rate and depth, ease of respirations, oxygen saturation, and breath sounds. To monitor cardiovascular stability, the nurse assesses the patient’s LOC, vital signs, cardiac rhythm, skin color, moisture and UOP. What are the primary cardiovascular complications seen in PACU? The primary cardiovascular complications seen in the PACU include hypotension and shock, hemorrhage, hypertension, and arrhythmias. Hypotension can result from: blood loss, hypoventilation, position changes, pooling of blood in the extremities, or side effects of medications and anesthetics. The most common cause is loss of circulating volume through blood and plasma loss. If the amount of blood loss exceeds 500 mL (especially if the loss is rapid), replacement may be considered. Shock, one of the most serious postoperative complications can result from: blood loss, hypoventilation, position changes, pooling of blood in the extremities, or side effects of medications and anesthetics. The most common cause is loss of circulating volume through blood and plasma loss. If the amount of blood loss exceeds 500 mL (especially if the loss is rapid), replacement may be considered. The classic signs of hypovolemic shock are pallor; cool, moist skin; rapid breathing; cyanosis of the lips, gums, and tongue; rapid, weak, thready pulse; narrowing pulse pressure; low blood pressure; and concentrated urine. Hemorrhage can present inconspicuously or emergently in the immediate post op period or several days later. How will the patient present with hemorrhage? The patient presents with hypotension; rapid, thready pulse; disorientation; restlessness; oliguria; and cold, pale skin. The early phase of shock will manifest in feelings of apprehension, decreased cardiac output, and vascular resistance. Breathing becomes labored, and “air hunger” will be exhibited; the patient will feel cold (hypothermia) and may experience tinnitus. Laboratory values may show a sharp drop in hemoglobin and hematocrit levels. If shock symptoms are left untreated, the patient will continually grow weaker but can remain conscious until near death Hypertension is common in the immediate post-operative due to: Hypertension is common in the immediate postoperative period secondary to sympathetic nervous system stimulation from pain, hypoxia, or bladder distention. Dysrhythmia is associated with: Arrhythmias are associated with electrolyte imbalance, altered respiratory function, pain, hypothermia, stress, and anesthetic agents. Pain and anxiety management is important in the immediate post-operative period. Opioid analgesics are given IV in the PACU as they provide immediate pain relief are are short acting. Morphine sulfate (Morphine) is a common analgesic prescribed in the PACU setting for its analgesic and anti-anxiety properties. In some hospitals and outpatient settings, when the patient’s condition permits, a close family member may visit in the PACU to decrease family anxiety. Non-pharmacologic, emotional and psychological support may be used to reduce patient pain and stress. These include: What is the antidote for narcotics, such as morphine? Naloxone Nausea and vomiting: 30-50% of patients experience after surgery. It is important that nurses assess for and control nausea and vomiting before it happens. The most commonly prescribed antiemetic used in PACU is ondansetron. It is well tolerated with few side effects such as headache and drowsiness. Ondansetron has been linked to prolonged T wave on ECG. Some facilities will offer aromatherapy to help with nausea, pain, and anxiety related to surgery. Gerontology/Elderly patients pose increased risk, including increased risk for hypothermia and impairment of the cardiac, respiratory and renal systems. Please see gerontologic considerations on page 441. Bariatric patients have unique postoperative risks such as increased risk for VTE, DVT, and PE. They also have increased risk for OSA. Dermatome Assessment (this is not in your book- please review for class discussion) For patients with regional anesthesia, the nurse will assess dermatome levels in the PACU. Dermatome assessment checks how far a regional anesthetic block has affected sensory nerves by testing skin sensation in areas supplied by specific spinal nerves. A dermatome is a skin area supplied by one spinal nerve, and loss of sensation indicates the level of the block. Nurses assess this by using cold (such as ice) or a pinprick—starting from an unblocked area and moving downward until sensation changes, which helps identify the upper and lower limits of the block on both sides of the body. This ensures the anesthetic covers the intended surgical area and is not too high, which could affect breathing or other functions. View: Dermatomes The area of skin that is supplied by a single spinal nerve is known as a dermatome. Local anesthetics used in regional anesthesia work by blocking nerve impulses on sensory, motor and autonomic nerve fibers. The smallest diameter fibers are most sensitive to the effects of local anesthetics: autonomic fibers will be blocked first then sensory fibers then motor fibers. The sensory fibers respond to pain, temperature, touch and pressure. Since pain and temperature nerve fibers are similarly affected by local anesthetic drugs, changes in temperature perception indicate the area where the epidural is working. The area of sensory block should be assessed using cold sensation (e.g. ice) to establish which dermatome levels are covered. Both left and right sides need to be assessed. It is important to assess sensory block: To ensure the spinal/epidural/caudal is covering the patient's pain. To ensure the block is not too extensive, which may increase the risk of complications. Procedure: Explain procedure and purpose to patient/parent Wrap an ice cube in tissue/paper towel leaving part exposed. Place ice on an area well away from the possible dermatome cover (e.g. face or forearm) and ask them to tell you how cold it feels to them. Apply the ice to an area likely to be blocked on the same side of the body and ask the patient "Does this feel the same cold as your face/arm or different?" Patients may report the ice feeling colder, warmer or the same. Apply the ice to areas above and below this point until it's clear at which level the top and the bottom of the block is. Repeat the procedure on the opposite side of the body. (Blocks may be uneven or unilateral.) Document the blocked dermatomes on the Flow sheet. Record both the upper and lower limits of the block Each facility has policy to which dermatome that patient must reach for discharge out of PACU and even home. Epidural and spinal anesthesia decrease cardiac and pulmonary complication risk as general anesthesia; however, the time spent in the PACU may be increased. Patients going home must be able to walk. Determining Readiness for Discharge: Post-operative Phase- Nurse Responsibilities Phase 1- immediate post-operative period Airway, airway, airway! Head of the bed elevated 15-30 Breathing (Oxygen administration and saturations) Circulation (blood pressure and pulse, stable, skin temperature, color, moisture) Temperature IV site/ solution Neuro (level of consciousness, orientation, follow commands, dizziness, lightheadedness) Bleeding, drainage Urinary output Pain management Nausea management Ice chips and water as tolerated Ice to surgical site (especially orthopedic) Dermatome level determined for regional anesthesia patients Aldrete score initiated, assessed every 5-15 minutes, and achieve 7-10 before discharge. Phase 2 Continue to assess all of the above. Discharge readiness includes stable blood pressure, respiratory function, and oxygen saturation. Baseline is used to determine. Dermatome level per facility policy and ability to walk Review patient discharge orders/ activity orders with the patient and family, including: M edications Routine Pain medications A ctivity needs and restrictions Coughing and deep breathing (Wind) Incentive spirometer (Wind) Leg exercises (Walk) Dressing changes/Wound cares (Wound) Driving restrictions (none for 24 hours) Surgical drains I nformatics available D iet needs and restrictions Advancement Increased fluid needs (Water) Nausea care Alcohol restrictions Cues to report to physician Dizziness, lightheaded, chest pain, etc. (Waves) Infection (Wound) Urinary problems (Water) Leg ache/pain (Walk) S cheduling post-operative appointment Discharge Home Because anesthesia can cloud a memory, what strategies does your book suggest for strong discharge teaching plan? Because anesthesia can impair memory, nurses should begin discharge teaching early (ideally preoperatively), involve family or caregivers in the teaching, use simple written materials and diagrams, and employ methods like teachback to confirm understanding and reinforce key selfcare instructions before discharge. Nurse Responsibility for Inpatient (Phase 2) admission. Help patient transfer from cart to bed Obtain set of vitals, including temperature and oxygen saturation Assess patient A-B-C-N-G-G -S-P Receive report from PACU nurse Check physician orders Medication reconciliation Reinforce W’s education and monitoring Waves Water Wind Wound Walk Wonder drug Routine vital signs and assessments Pain/ nausea control See MAIDCS above for discharge Receiving the patient on the clinical unit- The nurse on an inpatient clinical unit must prepare for the patient return. This includes reading the room by assembling necessary equipment and supplies, such as: Each facility will have its own policy for post-operative vital signs and assessments; however, the Association of Post Anesthesia Nurses suggestions every 15 minutes x 1 hour; every 30 minutes x2 hours and then every 4 hours for the 24 hour period. During this time, the nurse will continue to monitor airway, breathing, circulation, neuro status, GI, GU systems, surgical site and pain (ABCNGGSP). During the first 24 hours, nursing care involves helping the patient recover from anesthesia- monitoring for complications and preventing complications, pain management. Patients will often return to their usual state of health several hours after surgery or the next morning. Pain should be controlled and nausea should resolve prior. It is very important to get the patient of bed and moving as soon as possible. Regular diet can be resumed once nausea passes (and bowel sounds present + physician orders direct otherwise). Please review Home Care Checklist, chart 16-3 and Immediate Postoperative Nursing Interventions, chart 16-4. Please review the nursing process care plan located on pp. 446-458 to see how all this is applied to a patient care case. Hinkle, J. & Cheever, K. (2022). Brunner & Suddarth’s textbook of medical-surgical nursing (15th ed.). New York: Wolters Kluwer