Perianesthetic Care Preadmission Preop Phase Phase I Phase II Phase III

Preadmission Programs

   Provide comprehensive assessment and teaching.

Obtain lab work, EKG, CXR, other tests as applicable.

Issues that need follow-up prior to admission – minimizes cancellations.

◦ May need clearance from cardiologist, pulmonologist, others.

2

Preadmission Programs

◦ ◦ ◦ ◦ Identify high-risk pts.

History and physical. Preop teaching.

Requirements after surgery.

3

Meds, OTCs and Herbals

◦ ◦ ◦ ◦ ASA, NSAIDS, coagulants Diabetic meds Beta blockers; last time taken. Vitamin. E, fish oil, many herbals affect coagulation.

4

Preadmission Programs

  Can be done with a clinic.

◦ Advantage is written material and hands-on assessment.

◦ Can use different teaching methods.

◦ Pediatric pts can tour facility. ◦ Not all pts will be able to attend.

Can be done with a preop phone call.

◦ Be careful with message left on answering machine.

5

Preadmission Programs

 Can be web-based.

◦ Can include registration. ◦ Advantages: ◦     Proceed at own pace with no interruption of schedule.

Can review and print information.

Disadvantages: No web access.

No one for questions. 6

ASA Guidelines for Anesthesia

   Category 1 – normal, healthy.

Category 2 – pt with mild systemic disease (NIDDM, mild hypertension).

Category 3 – pt with severe systemic disease ( CAD, IDDM, morbid obesity).

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ASA Guidelines for Anesthesia

    Category 4 – pt with severe systemic disease that is a threat to life (chronic CHF, advanced pulmonary insufficiency).

Category 5 – morbid pt who is not expected to survive without the operation.

Category 6 – a declared brain dead pt whose organs are being harvested.

E – emergency.

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Selection of Pts for OPS

   Know the policies and procedures of the institution, including age criteria.

ASA 1, 2, 3.

Surgical procedure.

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Preoperative Phase

  History and assessment ◦ Medical history and physical.

Nursing data collection, including pain hx.

◦ Baselines ◦ Allergies ◦ Meds, including OTCs and herbals ◦ Medication reconciliation ◦ Pregnancy status ◦ Fall risk 1 0

Preoperative Phase

       Perform needed tests.

Obtain signature on needed permits.

Site verification.

Determine availability of transportation home, and an adult caretaker.

Determine NPO status.

Initiate IV.

Preop meds. 1 1

Prevention of Intraop Hypothermia     SCIP recommendation.

Begins in preop area.

Maintenance of normothermia. An ASPAN Clinical Practice Guideline. 12

Non-English Speaking Pt

   Have a legal obligation to provide preop instruction, op permit, and postop education in native language.

Identify head of family; direct conversation to that person. Be familiar with common ethnic cultures in your facility.

1 3

    ASA Practice Guidelines for Preoperative Fasting Were released by the ASA in January 1999.

No fried or fatty foods or meat for 8 hrs before a procedure. May have a light meal 6 hrs before a procedure.

Light meal is toast and clear liquids – tea and toast. 1 4

  ASA Practice Guidelines for Preoperative Fasting May take clear liquids up to 2 hrs before a procedure.

Clear liquids are water, fruit juices without pulp, carbonated beverages, clear tea and black coffee. 1 5

   ASA Practice Guidelines for Preoperative Fasting For breast-fed infants, may take breast milk until 4 hrs before procedure. For infants using formula, may take formula until 6 hrs before procedure. Completely NPO at 2 hrs before a procedure.

1 6

Easy Way to Remember

     8-6-4-2 8 hr – no solid food.

6 hr – no formula. 4 hr – no breast milk.

2 hr – completely NPO. 1 7

   If these guidelines are not followed, can result in hypovolemia the day of surgery.

Esp. true with afternoon surgeries. Is also a patient dissatisfier to be NPO from 2400 til afternoon surgery.

1 8

Shaving vs. Clipping

    Shaving results in microscopic nicks that can result in bacterial growth.

Clipping results in less skin nicks.

Clipping is recommended by the AORN, and by the Guidelines for Prevention of Surgical Site Infections published by the CDC in 1999.

A SCIP criteria. 1 9

Pts with a DNR

    Talk to pt and family, usually by anesthesia provider.

Many facilities suspend the DNR during surgery through PACU stay.

DNR is reactivated after discharge from PACU. http://www.asahq.org/For-Healthcare Professionals/Standards-Guidelines-and Statements.aspx

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Handoff

 ◦ ◦ ◦ Method determined by facility.

◦ Face to face Phone Written report Combination 21

Equipment Needs

  Preop ◦ Fully stocked crash cart with adult and pediatric paddles ◦ Pacing capability Phase I ◦ All of the above and ◦ MH cart ◦ Ventilator readily accessible 2 2

Phase I

    Is a critical care area. Receive report from OR RN and anesthesia provider. Come from OR with pulse ox and O2?

Assess breath sounds .

2 3

Oral Airway

  Remove as soon as the pt wakes up.

To insert an OA: ◦ ◦ ◦ ◦ Turn it up side down and insert into the mouth.

While advancing the OA, turn it 180  .

For children, turn it 90  .

Slide it over the tongue.

2 4

Nasal Airway

      Provides a conduit from the nares to the base of the tongue.

Prior to insertion, examine both nares.

Lubricate with KY or 2% Xylocaine.

Push upwards and backwards on the nose.

Slide the long tip along the nasal septum and the floor of the nasopharnyx to avoid trauma to the middle turbinate.

Can be tolerated by awake pts.

2 5

Extubation

   Awake, VS stable, T  Head lift for 5 sec.

Hand grip for 5 sec.

96, resp. rate  24.

2 6

Extubation

       Suction oropharynx.

Hyperoxygenate.

Deflate cuff (don’t pull the balloon off).

Have pt cough.

Remove ET.

Apply supplemental oxygen.

Monitor for SOB, stridor, dyspnea.

2 7

Removal of LMA

    Should be done with pt deeply anesthetized, or awake.

Not done with pt in halfway stage.

Don’t suction prior to extubation, but may need to do so afterwards.

Swallowing is a sign that LMA can be removed.

2 8

Reflexes as a guide to depth of anesthesia  Reflexes come back in this order: ◦ pupillary  swallow  lid or corneal reflex cough.

 2 9

Pulmonary Toilet

  Treatment of hypoxemia.

Stir-up regimen. ◦ CDB.

◦ Taking a deep breath and holding for 1 sec. is more effective than coughing in treating atelectesis.

◦ Incentive spirometry: Take 1 breath on the IS, then take 2-3 normal breaths.

3 0

Initial Postop Assessment

  Frequency of vital signs. If the readings are not within normal limits, determine what the pt’s preop BP and HR were.

3 1

Bradycardia

    Is the pt symptomatic? What are preop HR and BP?

Atropine.

Robinul.

3 2

Tachycardia

   Many times, do nothing. Tincture of time. Consider influencing variables – anxiety, iatrogenic hyperthermia, presence of epinephrine in local anesthetics used in the nose or face, full bladder.

Use non-pharmacologic measures.

3 3

Hypertension

   Cannot ‘cure’ chronic hypertension.

Opioids.

Can cause stroke, severe hypotension, AMI, conduction disturbances.

3 4

Hypotension

   Most common cause is hypovolemia.

Is especially true of afternoon surgeries when the ASA NPO guidelines are not followed.

Hypovolemia causes other problems – PONV, postural hypotension, inability to void.

3 5

Adult Fluid Replacement Formula  Deficit: the time the pt is NPO to the time the surgery begins.

◦ 4 ml/kg/hr for the first 0-10 kg ◦ 2 ml/kg/hr for the next 11-20 kg ◦ 1 ml/kg/hr for weight greater than 21 kg 3 6

Adult Fluid Replacement Formula ◦ ◦ ◦ ◦ ◦ ◦ Maintenance: Depends on the type of surgical procedure.

Eye, extremity 5 ml/kg/hr.

Mastectomy 8 ml/kg/hr.

Minor abd. (appy, hernia) 8-10 ml/kg/hr.

 Laparotomy, thoracotomy 12 ml/kg/hr.

Extensive – Whipple 15-20 ml/kg/hr.

2004 RediRef

3 7

Temperature

    Assess of admission and discharge from PACU. Active rewarming devices.

◦ Check temp every 15 min. while rewarming. ◦ Stop rewarming when temp is 96.8 or 36.

Keep head covered.

Supplemental oxygen while shivering. 38

Assessment of Operative Site

 Surgery-specific observations.

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   Neurological Assessment of General Surgery Pts Determine baseline LOC. Reorient to surroundings.

Hearing is the first sense to return.

Intra-op stroke or VTE.

4 0

Delayed Awakening

    Meds: benzos, analgesics, ketamine.

Preop meds, supplements.

Respiratory inadequacy – rising CO2.

Intraop stroke.

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Emergence Delirium

  Dysphoria is the hallmark of Stage II of anesthesia ◦ ◦ ◦ Signs and symptoms: ◦ Restlessness Thrashing Combativeness Crying, moaning, and/or screaming.

◦ Fecal and/or urinary incontinence.

4 2

Emergence Delirium

 ◦ ◦ ◦ Negative effects: ◦ Injury of self – extremities, tongue.

Pull IV out.

Pull ETT out.

Disrupt suture lines.

4 3

Emergence Delirium

 ◦ ◦ Treatment ◦ Opioids to put them back to sleep.

Speak in reassuring tones.

Physical restraints as a last resort.

4 4

Postop Pain

      Expect pain after surgery.

Offer opioids early. Use a pain scale. Use descriptive scale before pt is aware enough to rate pain.

If analgesics are not decreasing pain, look for preop pain rating and preop use of opioids. Consider use of preop non-opioid meds. 4 5

Nausea/Vomiting

     As soon as the pt complains of nausea, turn the IV up.

Be aware of hx of CHF.

Administer anti-emetics.

Alcohol swab over nose.

Ginger ale.

4 6

Family Visitation in PACU

 . . . visitation in the Phase I level of care is supported, and that perianesthesia nurses develop guidelines within their own settings to incorporate this into their practice. 4 7

Guidelines for Visitation in PACU

   Appropriate education for families.

Confidentiality of all pts will be maintained.

Visit will occur at an appropriate time for pt, visitor, and staff.

4 8

Guidelines for Visitation in PACU

 Perianesthesia nurses should work . . . to establish a family visitation program supported by appropriate personnel. 4 9

Discharge from PACU

    Must be discharged by an anesthesiologist OR Discharged by criteria as approved by the Department of Anesthesia.

The PACU nurse shall determine the pt meets discharge criteria. This should be stated on the PACU anesthesia orders. 5 0

Phase I Discharge Criteria

     VS WNL including temp.

LOC, including pain.

Surgical site.

Post anesthesia scoring system in used. No time criteria – should be based on pt status. 51

Phase II – Where???

    Phase II care can occur in proximity to Phase I care. Phase I and II do not have to occur in separate areas.

Determining factor is the level of care, not the physical location. Only restriction is that preop pts are separated from postop pts. 5 2

Admission to Phase II

Admission criteria to Phase II should be the same as discharge criteria from Phase I.  Assessment including pain.

5 3

Fast Tracking

    Admission of pt directly from surgery to Phase II bypassing PACU.

Pt must meet discharge criteria of Phase I/admission criteria of Phase II. MDs/hospitals can push for this as it bypasses the expensive PACU.

Phase II RNs must be pt advocates. 5 4

Discharge from Phase II

     VS stable, including resp. status and normothermia. Level of consciousness.

Minimal or no bleeding. Able to ambulate consistent with surgery/baseline.

Able to swallow.

5 5

Discharge from Phase II

     Minimal N/V.

Pain at tolerable levels; comfortable but not too sedated. Give oral analgesic prior to discharge.

Void???

◦ Inguinal herniorrhaphy.

◦ Rectal, pelvic, urinary procedures.

◦ After spinal or epidural anesthesia.

Bladder scanner. 5 6

Discharge from Phase II

   Pt and home care provider understand written discharge instructions.

Safe transportation home. Responsible adult to STAY with pt for 24 hrs. 5 7

Discharge Instructions

      Increase the pt’s or caregiver’s ability to provide competent care.

Decrease anxiety.

Decrease provider and facility liability. All info MUST be in writing. Should be written at a 5 th in large print. grade level, and In possible, in their language. 5 8

Identify Learning Needs

    Observation, including verbal/nonverbal cues.

Open ended questions.

Based on the above, can identify current knowledge level.

Pt advocacy. 5 9

Learner Characteristics

    Present knowledge base.

Age of pt and caregiver.

Learning environment should be conducive to learning. RN should sit if possible. 6 0

Teaching Characteristics

      Use common language.

Goal directed instruction. Repeat important points several times.

Don’t hurry; give pt/sig. other your full attention. Limit non-essential information. Demonstration/return demonstration of skills.

6 1

Prescriptions

   When Rx is filled, will have complete information given to pt.

Some facilities provide written information; some do not. Address when to restart other meds. 6 2

Discharge from Phase II

  Many scoring systems available in the literature. Can make your own based on the discharge criteria as approved by the Department of Anesthesia. 6 3

     Phase III Postoperative Phone Call Not required by TJC. Call 1-2 days after surgery.

Assess presence of complications, adequacy of pain control.

Assess pt’s understanding of discharge instructions. Monitor for emergency readmission, postop infections. 6 4

Pt Satisfaction Surveys

    On-line surveys. Give to pt to fill out and mail back.

Find out about problems (as perceived by pt).

Also find out about good experiences. 6 5

Transfer Agreement

  Freestanding facilities must have a written agreement with a full-service hospital in case of emergency transfers.

Surgeons may admit to a hospital with which they have privileges.

6 6

Latex Allergy

  What is the reaction?

Eliminate aerosolized powder from latex gloves. 67

Patient Privacy

   In Preop.

In PACU.

In Phase II.

6 8

Items for Further Review

     Research Legal Issues Ethics Quality improvement Leadership/management 6 9