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PERIOPERATIVE NURSING
JAYESH PATIDAR
SURGERY
Is the use of instruments during an operation to treat injuries, diseases, and deformities
Is a stressful, complex event
The branch of medicine concerned with diseases and trauma requiring operative procedures
Surgical procedures are named according to (1) the involved body organ, part, or location and (2) the suffix that describes what is done during the procedure
Physicians who perform surgery include surgeons or other physicians trained to do certain surgical procedures
SURGICAL PROCEDURE SUFFIXES -ectomy - Removal by cutting
-orrhaphy - Suture of or repair
-oscopy - Looking into
-ostomy - Formation of a permanent artificial opening
-otomy - Incision or cutting into
-plasty - Formation or repair
CLASSIFICATION OF SURGERY
ACCORDING TO URGENCY
Emergent - Patient requires immediate attention; disorder may be life threatening; immediately without delay to maintain life or organ, remove damage, stop bleeding
Urgent/ Imperative - Patient requires prompt attention; within 24 – 30/48 hours
Required/ Planned - Patient needs to have surgery; plan within a few weeks or months
Elective - Patient should have surgery; failure to have surgery not catastrophic; planned/scheduled with no time requirements
Optional - Decision rests with patient; at the preference of patient
ACCORDING TO PURPOSE
Aesthetic - Requested by patient for improvement
Diagnostic - To obtain tissue samples, make an incision, or use a scope to make a diagnosis
Exploratory - Confirmation or measurement of extent of condition
Preventive - Removal of tissue before it causes a problem
Curative (Ablative) - Removal of diseased or abnormal tissue
Reconstructive - Correction of defects of body parts
Palliative - Alleviation of symptoms without curing disease
ACCORDING TO EXTENT
Major - Extensive surgery that involves serious risk and complications, as it involves major organ
High risk, extensive, prolonged, large amount of blood loss, vital organs may be handled or removed, great risk of complications
Minor - Involves minimal complications & blood loss
Generally not prolonged, leads to few serious complications, involves less risk
PRINCIPLES OF SURGICAL ASEPSIS
MOISTURE CAUSES CONTAMINATION
Prevent splashing of liquids in the sterile fields
Place wet objects on sterile, water-impermeable surfaces, such as sterile basin
Rationale: microorganisms travel more easily through moist environment. When sterile surface becomes moist, microorganisms from the unsterile surface may be transmitted into the sterile surface
NEVER ASSUME THAT AN OBJECT IS STERILE
Ensure that it is labeled as sterile
Always check the integrity of the packaging
Always verify the expiration date on the package
Whenever in doubt of the sterility of an object, consider it unsterile
Rationale: commercially prepared products are labeled as sterile on their packaging; special indicators are used to show that objects have completed their sterilization process; packages that are torn, punctured, or moist are considered unsterile
ALWAYS FACE THE STERILE FIELD
Rationale: objects that are out of the line of vision may be inadvertently contaminated
STERILE ARTICLES MAY TOUCH ONLY STERILE ARTICLES OR SURFACES IF THEY ARE TO MAINTAIN THEIR STERILITY
Rationale: anything considered unsterile may transfer microorganisms to the sterile object it touches
STERILE EQUIPMENT OR AREAS MUST BE KEPT ABOVE THE WAIST AND ON TOP OF THE STERILE FIELD
Waist level is the limit of good visual field. Maximum visibility of all sterile objects prevents inadvertent contamination
PREVENT UNNECESSARY TRAFFIC AND AIR CURRENTS AROUND THE STERILE AREA
Close doors
Unfold drapes or wrappers properly
Do not sneeze, cough, or talk excessively over the sterile field
Do not reach across sterile fields
Move around a sterile field to reach for an object, if necessary
Rationale: microorganisms cannot be completely excluded from the air; overreaching across sterile fields will render sterile objects unsterile
OPEN, UNUSED STERILE ARTICLES ARE NO LONGER STERILE AFTER THE PROCEDURE
Rationale: once protective wrapping have been removed, the article is being contaminated by air so, it must be discarded or sterilized before it is used; liquids opened during the procedure that remain in the container are also considered contaminated
A PERSON WHO IS CONSIDERED STERILE WHO BECOMES CONTAMINATED MUST REESTABLISH STERILITY
Rationale: if a “scrubbed” person punctures the gloves or is contaminated by touching an unsterile object, he or she must change the contaminated articles; if a “scrubbed” person leaves the area of the sterile field, he or she must go through the procedure of rescrubbing, gowning, and gloving
SURGICAL TECHNIQUE IS A TEAM EFFORT
A collective and individual “sterile conscience” is the best method of enhancing sterile technique
Rationale: staff members must rely on one another to maintain sterile technique; periodic review of procedures and infection control surveillance reports enhance everyone’s sterile technique
FOUR MAJOR TYPES OF PATHOLOGIC PROCESSES REQUIRING SURGICAL
INTERVENTION (POET)
P – PERFORATION
rupture of an organ
O – OBSTRUCTION
impairment to the flow of vital fluids e.g. blood, urine, CSF, bile
E – EROSION
wearing off of a surface or membrane
T – TUMORS
abnormal new growths
EFFECTS OF SURGERY TO THE CLIENT
Stress response is elicited
Defense against infection is lowered
Vascular system is disrupted
Organ functions are disturbed
Body image may be disturbed
Lifestyles may change
SURGICAL RISK FACTORS
NUTRITIONAL AND FLUID STATUS
Optimal nutrition is an essential factor in promoting healing an resisting infection and other surgical complications
obesity, undernutrition, weight loss, malnutrition, deficiencies in specific nutrients, metabolic abnormalities, and the effects of medication on nutrition
Nutritional needs may be measured through BMI and waist circumference
Nutritional deficiency should be corrected before surgery
Nutrients important for wound healing are: protein, arginine, carbohydrates and fats, water, vitamin C, vitamin B complex, vitamin A, vitamin K, magnesium, copper, zinc
DRUG OR ALCOHOL USE
The person with a history of chronic alcoholism often suffers from malnutrition and other systemic problems that increase surgical risk
AGE
very young
very old
PRESENCE OF DISEASE/S
Respiratory Renal/urinary Cardiovascular Endocrine Hepatic
CONCURRENT OR PRIOR PHARMACOTHERAPY
A medication history is obtained from each patient because of the possible effects of medications on the patient’s perioperative course, including the possibility of drug interactions
Document all medications
Stop aspirin 7-10 days before surgery
Currently it is recommended that the use of herbal products be discontinued 2 to 3 weeks before surgery
OTHER SURGICAL RISK FACTORS
Nature of condition Location of the condition Magnitude and urgency of the surgical
procedure Mental attitude of the person toward
surgery Caliber of the professional staff and
health care facilities
THE SURGICAL TEAM
THE CIRCULATING NURSE
Also known as the circulator
manages the OR and protects the patient’s safety and health by monitoring the activities of the surgical team, checking the OR conditions, and continually assessing the patient for signs of injury and implementing appropriate interventions
verifying consent, coordinating the team, and ensuring cleanliness, proper temperature, humidity, lighting, safe function of equipment, and the availability of supplies and materials
Monitors aseptic practices to avoid breaks in technique
“surgical or pre-procedure pause” or time-out”
THE SCRUB ROLE
Performs a surgical hand scrub
Setting up the sterile tables
Prepares sutures, ligatures, and special equipment
Assists the surgeon and the surgical assistants during the procedure by anticipating the instruments and supplies that will be required
As the surgical incision is closed, the scrub person and the circulator count all needles, sponges, and instruments
Standards call for all sponges to be visible on x-ray and for sponge counts to take place at the beginning of surgery and twice at the end
Tissue specimens obtained during surgery are labeled by the scrub person and sent to the laboratory by the circulator
THE SURGEON
Performs the surgical procedure and heads the surgical team
THE ANESTHESIOLOGIST AND ANESTHETIST
An anesthesiologist is a physician specifically trained in the art and science of anesthesiology
An anesthetist is a qualified health care professional who administers anesthetics
They assess the patient before surgery, selects the anesthesia, administers it, intubates the patient if necessary, manages any technical problems related to the administration of the anesthetic agent, and supervises the patient’s condition throughout the surgical procedure
THE SURGICAL ENVIRONMENT
Known for its stark appearance and cool temperature
Access is limited to authorized personnel
The OR must be situated in a location that is central to all supporting services
The OR must have a specific air filtration devices to screen out contaminating particles, dust, and pollutants
the unrestricted zone (street clothes are allowed); the semi restricted zone (attire consists of scrub clothes and caps); and the restricted zone (scrub clothes, shoe covers, caps, and masks are worn)
Shirts and waist drawstrings should be tucked inside the pants
Wet or soiled garments should be changed
Masks are worn at all times at the restricted zone
Upper respiratory tract infections and skin infections in staff and patients are sources of pathogens and must be reported
PREOPERATIVE PHASE
Extends from the time the client is a admitted in the surgical unit, to the time he/she is prepared physically, psychosocially, spiritually, and legally for the surgical procedure, until he is transported into the operating room
Begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient onto the OR table
involves establishing a baseline evaluation of the patient before surgery by carrying out a preoperative interview
ensuring that necessary tests have been or will be performed
arranging appropriate consultations; and providing education about recovery from anesthesia and postoperative care
On the day of surgery, patient teaching is reviewed, the patient’s identity and surgical site are verified, informed consent is confirmed, and an IV infusion is started
GOALS
Assessing and correcting physiologic and psychologic problems that might increase surgical risk
Giving the person and significant others complete learning/teaching guidelines regarding surgery
Instructing and demonstrating exercises that will benefit the person during post operative period
Planning for discharge and any projected changes in lifestyle due to surgery
PHYSIOLOGIC ASSESSMENT OF THE CLIENT UNDERGOING SURGERY
Age Presence of pain Nutritional status Fluid and electrolyte balance Infection Cardiovascular function
Pulmonary function Renal function Gastrointestinal function Liver function Endocrine function Hematologic function Use of medication Presence of trauma
PSYCHOSOCIAL ASSESSMENT AND CARE
Causes of fears of the preoperative clients Fear of the unknown Fear of anesthesia, vulnerability while
unconscious Fear of pain Fear of death Fear of disturbance of body image Worries – loss of finances, employment,
social and family roles
Manifestations of fears Anxiousness Bewilderment Anger Tendency to exaggerate Sad, evasive, tearful, clinging Inability to concentrate Short attention span Failure to carry out simple directions Dazed
NURSING INTERVENTIONS TO MINIMIZE ANXIETY
Explore client’s feelings
Assist client to identify coping strategies that he or she has previously used to decrease fear
Allow client to speak openly about fears/concerns
Give accurate information regarding surgery
Give empathetic support
Consider the person’s religious preferences and arrange visit by priest/minister as desired
Music therapy
INFORMED CONSENT (OPERATIVE PERMIT/SURGICAL CONSENT)
necessary before non emergent surgery can be performed
permission obtained from a patient to perform a specific test or procedure
PURPOSES:
to ensure that the client understands the nature of the treatment including the potential complications and disfigurement (explained by AMD)
to indicate that the client’s decision was made without pressure
to protect the client against unauthorized procedure
to protect the surgeon and hospital against legal actions by a client who claims that an unauthorized procedure was performed
CIRCUMSTANCES REQUIRING A PERMIT:
any surgical procedure where scalpel, scissors, or sutures may be used
any invasive procedure such as surgical incision, a biopsy, a cystoscopy, or paracentesis
a nonsurgical procedure, such as an arteriography, that carries more than slight risk to the patient
procedures involving radiation
procedures requiring sedation and/or anesthesia
REQUISITES FOR VALIDITY OF INFORMED CONSENT
written permission is best and is legally acceptable
signature is obtained with the client’s complete understanding of what is to occur adults sign their own operative permit obtained before sedation
secured without pressure or duress
a witness is desirable – nurse physicians or authorized persons
in an emergency, permission via telephone or telefax is acceptable
for minor (below 18), unconscious, psychologically incapacitated, permission is required from responsible family member (parent/legal guardian)
INFORMED CONSENT SHOULD CONTAIN THE FOLLOWING:
explanation of procedure and its risks
description of benefits and its 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
PHYSICAL PREPARATION
Before Surgery Correct any dietary deficiencies
Reduce an obese person’s weight
Correct fluid and electrolyte imbalances
Restore adequate blood volume with blood transfusion
Treat chronic diseases
Halt or treat any infectious process
Treat an alcoholic person with vitamin supplementation, IVF’s or oral fluids if dehydrated
TEACHING PREOPERATIVE EXERCISES
Deep breathing exercises Practice in the same position client would
assume in bed after surgery
Allow hands in a loose fist position to rest lightly on the front of the lower ribs with your finger tips against lower chest to feel the movement
Breathe out gently and fully as the ribs sink down and inward toward midline
Take a deep breath your nose and mouth, letting the abdomen rise as the lungs fill with air
Hold this breath for a count of five
Exhale and let out all the air through your nose and mouth
Repeat this exercise 15 times with a short rest after each group of five
Practice twice daily preoperatively
Incentive spirometry
Let client sit upright, at 45 degrees minimum
Take two normal breaths. Place mouthpiece of spirometer in mouth
Inhale until target, designated by spirometer light or rising ball, is reached, and hold breath for 3 to 5 seconds
Exhale completely
Perform 10 sets of breaths each hour
Coughing exercises
Have client sit up and lean forward
Show client how to splint incision with hands, pillow, or blanket
Have client inhale and exhale deeply three times through mouth
Have client take in deep breath and cough out the breath forcefully with three short coughs using diaphragmatic muscles. Take in quick deep breath through mouth, cough deeply, and deep breathe
Turning exercises
Turn on your side with the uppermost leg flexed most and supported on a pillow
Grasp the side rail as an aid to maneuver to the side
Practice diaphragmatic breathing and coughing while on your side
Foot and leg exercises Lie in a semi-Fowler’s position
Bend your knee and raise your foot – hold it a few seconds, then extend the leg and lower it to the bed
Do this five times with each leg
Then trace circles with the feet by bending them down, in toward each other, up, and then out
PREPARING THE PERSON BEFORE SURGERY
Preparing the skin Have full bath to reduce microorganisms in
the skin
Preparing the GI tract NPO; cleansing enema as required
Preparing for anesthesia Avoid alcohol and cigarette smoking for at
least 24 hours before surgery
Promoting rest and sleep Administer sedatives as ordered
PREPARING THE PERSON ON THE DAY OF SURGERY
Early morning care Awaken one hour before preoperative
medications
Morning bath, mouth wash
Provide clean gown
Remove hairpins, braid long hairs, cover hair with cap
Remove dentures, foreign materials (chewing gum), colored nail polish, hearing aid, contact lens
Take baseline vital signs before preoperative medication
Check ID band and skin preparation
Check for special orders – enema, GI tube insertion, IV line
Check NPO
Have client void before preoperative medication
Continue to support emotionally
Accomplish “preoperative care checklist”
PREOPERATIVE MEDICATIONS/ PREANESTHETIC DRUGS
Goals:
To facilitate the administration of any anesthetic
To minimize respiratory tract secretions and changes in heart rate
To relax the client and reduce anxiety
Narcotics Morphine sulfate
Fentanyl (Sublimaze)
Meperidine (Demerol)
Analgesia; enhancement of postoperative pain relief
Antianxiety and sedative hypnotics Diazepam (Valium) Hydroxyzine hcl (Vistaril) Lorazepam (Ativan) Midazolam (Versed) Phenobarnital sodium Sedation; anxiety reduction
Anticholinergic
Atropine sulfate
Scopolamine hydrobromide
Secretion reduction
Antiemetic
Ondansetron (Zofran)
Metoclopramide (Reglan)
Promethazine hcl (Phenergan)
Control nausea and vomiting; may be effective into the postoperative period
H2 antagonist
Cimetidine (Tagamet)
Ranitidine (Zantac)
Famotidine (Pepcid)
Reduction of acidic gastric secretions in case aspiration occurs
Antibiotic
Cefazolin (Ancef)
Ampicillin (Omnipen
Prevention of postoperative infection
INTRAOPERATIVE PHASE
Begins when the client is transferred onto the OR table and ends with admission to the PACU
Extends from the time the client is admitted to the operating room, to the time of administration of anesthesia, surgical procedure is done, until he/she is transported to the recovery room/PACU
Nursing activities include: providing safety, maintaining an aseptic environment, ensure proper functioning of equipment, providing the surgeon with specific instruments and supplies for the surgical field, and proper documentation
GOALS OF CARE (HASH)
H – homeostasis
A – asepsis
S – safe administration of anesthesia
H – hemostasis
POSITIONS DURING SURGERY
Dorsal Recumbent – hernia repair, mastectomy, bowel resection
Trendelenburg – lower abdomen, pelvic
surgeries
Lithotomy – vaginal repairs, D and C, rectal surgery
Prone – spinal surgeries, laminectomy
Lateral – kidney, chest, hip surgeries
Explain purpose of position
Avoid undue exposure
Strap the person to prevent falls
Maintain adequate respiratory and circulatory function
Maintain good body alignment
TYPES OF ANESTHESIA
General Anesthesia is a state of narcosis,
analgesia, relaxation, and reflex loss
Clients under general anesthesia are not arousable, not even to painful stimuli
Produces amnesia
Can be administered through IV or inhalation
Gas anesthetics are administered by inhalation and are always combined with oxygen
Nitrous oxide is the most commonly used gas anesthetic agent
When inhaled, the anesthetics enter the blood through the pulmonary capillaries and act on cerebral centers to produce loss of consciousness and sensation
General anesthesia consists of four stages
Stage I (beginning anesthesia) extends from the administration of
anesthesia to the time of loss of consciousness
The client may have a ringing, roaring or buzzing in the ears, and although still conscious, may sense an inability to move the extremities easily
During this stage, noises are exaggerated
During this stage, noises are exaggerated. Unnecessary noises and motions are avoided when anesthesia begins.
Stage II (excitement/delirium) extends from the time of loss of
consciousness to the time of loss of lid reflex
It may be characterized by shouting, struggling, talking, singing, laughing, or crying of the client but often avoided if anesthetic is administered smoothly and quickly
Assist anesthesiologist/ anesthetist if needed to restrain client. Client should not be touched except for purposes of restraint.
Stage III (surgical anesthesia) extends from the loss of lid reflex to the
loss of most reflexes. Surgical procedure is started
Stage IV (medullary depression) it is characterized by respiratory/cardiac
depression or arrest. It is due to overdose of anesthesia. Resuscitation must be done
Regional Reduce all painful sensations in one region
of the body without inducing unconsciousness
Topical, local infiltration, epidural, spinal
Client receiving regional anesthesia is awake and aware of his/her surroundings unless medications are given to produce mild sedation or to relieve anxiety
Nurse must avoid careless conversation, unnecessary noise, and unpleasant odors
Diagnosis must not be stated allowed if the client is not to know it at this time
A postdural puncture headache may occur after spinal and epidural blocks caused by leakage of CSF. Small-gauge spinal needle (less than gauge 25) helps prevent headaches. Position the client flat and force fluids to relieve headache. A blood patch treatment can be done if headache continues
TRANSFER FROM SURGERY
After surgery client is stabilized for transfer
After local anesthesia, the client may return directly to a nursing unit
After general and spinal anesthesia, the client goes to the PACU or in some cases, the intensive care unit
SAFETY is always a priority at this time!
Never leave client alone
Ensure patent airways and prevent falls an injury
Continuous monitoring of client
POSTOPERATIVE PHASE
Extends from the time the client is admitted to the recovery room, to the time he is transported back into the surgical unit, discharged from the hospital, until the follow-up care
Begins when the client is admitted to the PACU or a nursing unit and ends with the client’s postoperative evaluation in the physician’s office
GOALS:
Maintain adequate body system functions
Restore homeostasis
Alleviate pain and discomfort
Prevent postoperative complications
Ensure adequate discharge planning and teaching
ADMISSION TO PACU
Goal is to promote safe recovery from anesthesia
Administer oxygen by nasal cannula or mask as ordered
Continuous monitoring is done for ECG, pulse oximetry, and BP measurements
Assess surgical site and dressing
Check for patency of catheter, drains and tubes
Measure body temperature
Provide warming blanket
Control shivering by administering Meperidine (Demerol) when anesthesia is the cause
Provide supplemental oxygen during shivering
Perform hand washing between clients
VS taking every 5 to 15 minutes
GENERAL INTERVENTIONS
Avoid exposure
Avoid rough handling
Avoid hurried movement and rapid changes
Assessment Appraise air exchange status and note
skin color
Verify identity, operative procedure, surgeon
Assess neurologic status
Determine VS
Perform safety checks
Ensure maintenance of patent airway and adequate respiratory function Lateral position with neck extended
Keep airway in place until fully awake
Suction secretions
Encourage deep breathing
Administer humidified oxygen as ordered
TRANSFER FROM RECOVERY ROOM TO SURGICAL UNIT
Parameters for Discharge from Recovery Room Activity: able to obey commands
Respiration: easy, noiseless breathing
Circulation: BP is within +/-20 mmHg of the preop level
Consciousness: responsive
Color: pinkish skin and mucus membrane
NURSING CARE OF CLIENT DURING THE EXTENDED POSTOPERATIVE PERIOD
2-3 days after surgery (discharge planning/teaching)
Self-care activities Activity limitation Diet and medications Complications Referrals, follow-up check up
Postoperative discomforts Nausea and vomiting
Restlessness & sleeplessness
Thirst
Constipation
Pain
POSTOPERATIVE COMPLICATIONS
SHOCK
Response of the body to a decrease in the circulating blood volume, which results to poor tissue perfusion and inadequate tissue oxygenation
HEMORRHAGE
Copious escape of blood from the blood vessel Capillary – slow, generalized oozing Venous – dark in color and bubble out Arterial – spurts and is bright red in color
Manifestations Apprehension, restlessness, thirst, cold,
moist, pale skin
Deep rapid respiration, low body temperature
Low blood pressure, low hemoglobin
Circumoral pallor
Progressive weakness
Management Administer Vitamin K as ordered
Pressure dressings
Blood transfusion
IV fluids
FEMORAL PHLEBITIS/ DEEP THROMBOPHLEBITIS
Often occurs after operations on the lower abdomen or during the course of septic conditions as rupture ulcer or peritonitis
Causes Injury – damage to vein Hemorrhage Prolonged immobility Obesity/ debilitation
Manifestations Pain Redness Swelling Heat/warmth Positive Homan’s sign
Nursing Interventions (prevention) Hydrate adequately to prevent
hemoconcentration
Encourage leg exercises and ambulate early
Avoid any restricting devices that can constrict and impair circulation
Prevent use of bed rolls or dangling over the side of the bed with pressure on popliteal area
Nursing Interventions (Active) Bed rest, elevate the affected leg with
pillow support
Wear antiembolic support hose from the toes to the groin
Avoid massage on the calf of the leg
Initiate anticoagulant therapy as ordered
PULMONARY COMPLICATIONS
Atelectasis Bronchitis Bronchopneumonia Lobar pneumonia Pleurisy
Nursing Interventions
Reinforce deep breathing, coughing, and turning exercises
Encourage early ambulation
Incentive spirometry
INTESTINAL OBSTRUCTION
Loop of intestine may kink due to inflamatory adhesions
Manifestations Intermittent, sharp, colicky abdominal
pains
Nausea and vomiting
Abdominal distention
Diarrhea(incomplete obstruction), no bowel movement (complete)
Return flow of enema is clear
Nursing Interventions NGT insertion
Administer electrolyte/ IV as ordered
Prepare for possible surgical intervention
WOUND INFECTIONS Causes
Staphylococcus aureus
Escherichia coli
Proteus vulgaris
Pseudomonas aeruginosa
Anaerobic bacteria
Clinical manifestations Redness, swelling, pain, warmth
Pus or other discharge on the wound
Foul smell from the wound
Elevated temperature; chills
Tender lymph nodes
Rule of thumb: Fever within first 24 hours – pulmonary
infection
Within 48 hours – urinary tract infection
Within 72 hours – wound infection
Preventive interventions Strict aseptic technique
Wound care
Keep unit clean
Antibiotic therapy as ordered
WOUND COMPLICATIONS
Hemorrhage
Wound dehiscence – disruption in the coaptation of wound edges (wound breakdown)
Wound evisceration – dehiscence + outpouching of abdominal organs
Nursing interventions Apply abdominal binders
Encourage proper nutrition (high protein, vitamin C)
Stay with client, have someone call for the doctor
Keep in bed rest
Supine or Semi-Fowler’s position, bend knees to relieve
Cover exposed intestine with sterile, moist saline dressing
Reassure, keep him/her quiet and relaxed
Prepare for surgery and repair of wound
Recommended