06 September 2010 − breast augmentation

Perioperative Nursing  ASSESSMENT:

Elvira Lim  client’s diagnosis and the planned surgery
 client’s surgical history d/t major adhesions
 complicating factors
 PRE-OPERATIVE CARE  any allergies; patient can die of anaphylactic shock
 before surgical procedure  client’s false teeth/dentures
 Surgery – treatment of disease, injury, or deformity by  determine when NPO status was initiated
means of manual or instrumental operations  aspiration can occur (usually NPO is 6-8 hours)
 TYPES:  client’s level of understanding
 Diagnostic  make sure signed consent has been obtained
 confirmation of diagnosis  DIAGNOSIS:
 in Ca, malignant/benign  knowledge deficit r/t the surgery and post-operative
 Explorative course
 confirms the type and extent of disease  anxiety
process  fear
 Breast Ca, if Ca has been metastasized to  PLANNING:
other organs  expected outcomes
 Reconstructive  ↓ anxiety after appropriate instructions
 repairs physical deformities or improves  no adverse reactions caused by inadequate
appearance physical preparation
 accidents, reconstruct face with plastic  no loss of belongings / possessions during, after
surgery (very carefully without operation up to recovery stage
sutures/scar)  not experience any disruption or delay of the
 Curative surgery caused by poor pre-op care or planning
 diseased or damaged body organ or  equipment needed
structure is removed or repaired and the  BP cuff
client is cured  stethoscope
 mastectomy (part/full) for malignant  flashlight (penlight)
breast Ca  pre-op checklist (day itself, night before)
 appendectomy for appendicitis  container for denture/glasses
 Transplant  appropriate storage for valuables and clothes
 diseased or damaged body organs  info packets regarding surgery
replaced with donated or artificial organs  surgical consent forms indicating risks
 Palliative  IVF, needles (for intracath)
 alleviates pain or other disease symptoms,  pre-op materials
slows progression of disease but does not  transfer chart
cure  client education needed
 aids in discomfort  ascertain what info was given by physician or
 Urgency qualified practitioner
 Emergent  answer further questions that are appropriate
− preserves function of body parts or life  remind client that there are no “dumb”
of patient (usually to save life of questions
patient)  explain the need for the removal of rings (it can
− accidents like lacerated liver, gunshot loosen), dentures, prosthesis, contacts
wound on vital organs, with ruptured (extensive surgery can cause irritation to eyes)
spleen (it will be removed or glasses
immediately)  explain the reason for not eating prior to
 Urgent surgery d/t aspiration pneumonia
− requires prompt attention with in 24-  inform what to expect pre and post op, long
48 hours waits in the operating suite can be frightening
− acute appendicitis (unruptured) if this is not anticipated, especially if client
 Required don’t know what to expect
− indicated for health problem but  transfer the client directly to another staff
immediacy not necessary member, do not move the client to OR waiting
− to preserve function or life area and leave unattended
− presence of mole in irritating places;  IMPLEMENTATION:
tonsillitis 3-4 times in a year (d/t  wash hands
constant infection)  verify admission orders, types of surgery, risks (VS)
 Elective including recent changes in VS and client
− satisfies client’s desire but not needed preparation
to preserve life or function  verify the client by checking the name tag and asking
name
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//carengreyes
  ask for questions – surgery and understands document the disposition of client’s valuables.
procedure and can explain it noting whether they are left at bedside, given
 complete pre-op checklist to a family member
 perform neurologic assessment (use penlight) –  Medication Administration Record (MAR)
orientation, eye coordination, hand grips, knee  note any pre-op medications given
bends, plantar and dorsiflexion of the feet
 vascular assessment: pulse, BP, apical pulse and
rhythm, temperature, rhythm; compare with
 INTRA-OPERATIVE CARE
previous info (client’s over 50 may require baseline  when patient is given anesthesia up to finish of surgery
ECG)  OBJECTIVES:
 auscultate lungs bilaterally – f/b any wheezes,  clients will:
ronchi, coughs, URI, increase temp.  be protected from trauma and surgery
 GIT system: time of last meal, food allergies, bowel  be able to verbalize procedure and reason
sounds, last fluid intake, last BM  not experience infection secondary to poor site
 GUT system: LMP, last void, state of pregnancy preparation
(estrogen replacement therapy)  not experience disruption to any existing
 assess for skin and muscle tone for any skin appliances, catheters, or any other
breakdown, redness, bruises, ↓ skin integrity, any instrumentation
skin breakdown can be source of infection  ASSESSMENT:
 ascertain any allergies and adverse reaction during  client sensitivity or allergies to scrub solution
previous surgeries or use of anesthesia d/t (alcohol-based)
anaphylactic shock  skin integrity
 obtain medication history: time and date of last  client’s knowledge of surgical preparation procedure
medication  existing appliance, catheters, or other
 ascertain any history of drugs – alcohol use and instrumentation
when they are last used  client’s level of mobility at the surgical site
 sometimes it takes a lot of anesthesia to attain  DIAGNOSIS:
desired amount  risk for infection
 check weight  risk for impaired skin integrity
 check if family is available and who is present  knowledge deficit r/t surgical preparation
 ascertain if client has signed the surgical consent procedures
 determine if client has living will (habilin) or has  risk for perioperative positioning injury (numbness)
designated resuscitation status (if DNR/not)  PLANNING:
 remove all valuables except wedding ring; tape rings  Expected outcomes
in place; check and document whether valuables are  no injury or trauma to the client during the
locked surgical preparation
 should be conscious of all valuables  client will not experience any allergic reaction
 check if client’s eye glasses and dentures are labeled or skin sensitivity secondary to surgical
 administer IV as prescribed preparation
 gauge 18 (usual)  client will understand procedure and reason
 administer meds as ordered  client will not experience any infection
 ascertain if pre-op checklist is complete secondary to poor site preparation
 to avoid complications if there are  client will not experience disruption to any
abnormalities within night before surgery, then appliances, catheters, or any instrumentation
it will be withhold  client will experience injury secondary to
 transport patient to appropriate area perioperative positioning
 inform family members where surgical waiting area  Equipment needed
is and establish a way to contact them when surgery  gloves
is complete  clean: shaving
 for open communication  sterile: cleaning surgical site
 EVALUATION:  razor and sharp blades
 client has ↓ anxiety subsequent to appropriate  sterile gauze – to clean the razor
instruction  warm water
 no adverse reactions caused in adequate  anti-bacterial cleansing agent
preparations  sterile cotton swabs for umbilicus
 client did not experience any delay of surgery  sterile cotton sponges
 no loss of belongings and possessions  transfer forceps in antiseptic solution
 DOCUMENTATION:  solution for surgical site cleaning
 Pre-operative checklist  betadine
 Nurse’s notes  solution basins
 usual findings from pre-operative checklist  Client education needed
 note any pre-operative teaching  explain reason for surgical prep and any
shaving of the area. If the area to be prepped

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//carengreyes
 and shaved is cosmetically important, reinforce
a need for a thorough preparation at the site
 assure the client that the surgery may not
involve the total area prepped
 explain the need for proper positioning for
proper visualization
 IMPLEMENTATION:
 review chart for surgery to be performed and
determine the exact area to be prepped to avoid
errors regarding site to be prepped
 wash hands
 reduces transmission of microogranisms
 LOC and mobility
 determines client’s ability to cooperate with
skill
 explain procedure to the client
 provide comfort and support for the client
 be sure that hairpins, nail polish, jewelry, contact
lenses, prosthesis, and dentures are removed during
pre-op
 removes artifacts that may interfere according
to institution protocol
 transfer of client to OR table
 ensure client’s safety
 position client – optimal access to site
 cover with blanket
 maintains body temperature and provides
privacy; the temperature in operation room is
often lower than the client’s room
 cover hair, if required
 POST-OPERATIVE CARE
 keep loose hair from entering sterile field
 assemble equipment needed
 ensures smooth procedure
 surgical prep sites follow, depending on type of
surgery
 the area to be showed and cleansed for surgery
varies with the type of surgery to be performed
 arrange for adequate light on the area to be
prepared
 light provides good visualization
 use warm water, hold skin taut, hold razor at 45-
degree angle to the direction of hair growth; rinse
the razor carefully to remove accumulated hair
 must stroke in direction of hair growth which
reduces ingrown hair
 dry skin with sterile towel
 clear shaving supply from preparation area
 apply sterile gloves and gown
 scrub surgical site with antibacterial (alcohol-based)
cleaner
 rotary movement, from center
 continue process from 3 to 10 minutes as prescribed
by institution policy
 clean any hidden areas in the surgical site
 ear canals, under fingernails
 rinse with sterile water then pat dry
 cover with sterile drapes leaving surgical site
exposed
 provides a sterile field for surgical procedure
 4 sterile towels
 2 drawsheets
 clips
 laparoscopic
//carengreyes
 EVALUATION:
 surgical done without any inury or trauma
 no allergic reaction or skin sensitivity secondary to
surgical preparation
 no infection secondary to poor site preparation
 no disruption to any existing appliance
 client understands procedure and purpose
 no injury secondary to perioperative positioning
 DOCUMENTATION:
 pre-operative checklist
 completeness
 medical record to ensure the presence of a
properly signed and witnessed surgical consent
 client’s response to surgery preparation
 positioning of the client for surgery
 nurse’s notes
 record the method and story; include area of
shaving, solution for sterilizing, client’s
responses before, during and after procedure
 report special preparation (such as meds/new
IV site)
 note any discrepancies such as dentures still in
lack of preoperative documentation in the
client
 medication record
 IV card
 med: time, dosage, date, route
 finish of surgery, back to recovery room and then to own
room/ward
 ASSESSMENT:
 client’s level of sedation and mental status
 neuro sigsns/asst (pupils), stupurous
 usually, they have to be stimulated
 client’s cardiovascular status – VS
 client’s respiratory status
 DBE, coughing, turning and passive exercise
(dorsiflexion = prevent thrombosis)
 client’s level of pain
 addicted to pain reliever
 surgical site, surgical appliances
 client’s fluid status d/t NPO
 neuro VS: LOC, pupils, strength, extremities
 DIAGNOSIS:
 risk for infection
 risk for altered body temperature
 altered tissue perfusion – cardiopulmonary
 if general anesthesis was admin
 low-grade fever: < 38.5 for first 24hrs
 risk for FVD
 risk for aspiration
 impaired tissue integrity
 risk for perioperative positioning injury
 sensory/Perceptual alterations, secondary to
anesthesia
 pain
 fear
 PLANNING:
 Expected outcomes
 patent airway
 VS is stable for at least an hour
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  client will be alert and oriented when core temperature
stimulated  note complaints/shivering
 respiratory status – O2 sat, RR, tidal volume  neurological
would be adequate  LOC
 client’s pain control would be adequate  equality of response
 client receiving regional anesthesia: motor and  equality of movement
sensory function will be adequate  level of cooperation
 surgical site will be intact with a dry or  verbal response
appropriately reinforced dressing present when  GIT
the client is discharged from the recovery area  n/v
– PAU  NGT – check for placement
 IV site will be intact – no infiltration and  gastric secretions
infection  GUT
 client’s output and temperature– normal  amount and color of urine output
 Equipment needed (presence of blood, evaluate pH, specific
 stethoscope gravity, presence of glucose, ketones,
 sphygmomanometer sediments)
 pulse oxymeter  presence of any abnormalities
 blanket (Bearhug)  assess catheter
 cardiac monitoring equipment  pain
 sterile dressing as needed  level of pain
 client’s chart with post-op orders  controlled analgesics (PCA) system is
 incentive spirometer employed
 supplemental O2  reposition
 sequential / anti-embolic stockings  anti-inflammatory agents, sedatives,
 thermometer narcotics
 Client education needed  fluid balance
 inform client of various purpose of equipment  check I&O
to ease the fear of the unknown  check edema and jugular vein
 inform client of required position changes  IVF
 know if pain, or shiver is noted  VS – q15mins
 explain reason of coughing, deep breathing,  encourage deep breathing, coughing, and use
and turning are encouraged despite client’s of incentive spirometer
recent surgery and discomfort  check physicians order
 reason for frequent VS and neurovascular check  endorse to the nurse in the unit
(pant of routine to prevent problems)  wash hands
 ask if nauseated, or comfortable, pain  EVALUATION:
 encourage to ask questions – surgical  patent airway
procedure, post-op routine, surgical changes  VS stable for an hour
 IMPLEMENTATION:  client is alert and oriented
 wash hands  controlled pain
 gloves  normal motor and sensory function
 monitor VS  intact surgery site
 identify client – armband, chart, ask  IV was intact
 inform client that he’s out of OR – Patient – room  DOCUMENTATION:
 ECG – baseline ECG strip  VS flow chart
 oxymeter – O2 saturation  VS
 IV site  neurological checks, LOC, O2 sat
 check surgical dressing and site  condition of surgical site and any drains or
 complete head-to-toe assessment appliances
 airway  Intake and output record
 patency  IV
 breath sounds – bilaterally  oral intake
 note for ronchi, rales, wheezes  nurse’s notes
 respiratory  time client was received
 supplemental O2 and type of O2 delivery  unusual findings after assessment
 O2 sat
 type, depth, and efficiency of respiration
 cardiovascular
 pulse rate, radial, apical, peripheral
 color and temp of extremities and capillary
refill
 cardiac rhythm, BP and indicate bleeding
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//carengreyes