PERIOPERATIVE NURSING

Prepared by: Rachelle M. Ganuelas RN, MAN

DEFINITION OF TERMS
SURGERY -It is the branch of medicine

concerned with diseases and conditions which require or are amenable to operative procedures. Surgery is the work done by a surgeon. -"Surgery can involve cutting, abrading, suturing, laser or otherwise physically changing body tissues and organs."

 SURGEON - A physician who treats disease,

injury, or deformity by operative or manual methods. A medical doctor specialized in the removal of organs, masses and tumors and in doing other procedures using a knife (scalpel) STERILE - free from living germs or microorganisms; aseptic: sterile surgical instruments.

 ASEPSIS - The state of being free of

pathogenic microorganisms. - The process of removing pathogenic microorganisms or protecting against infection by such organisms. SEPSIS - a toxic condition resulting from the spread of bacteria or their toxic products from a focus of infection; especially : septicemia

 SEPSIS - is a severe illness caused by

overwhelming infection of the bloodstream by toxin-producing bacteria. - is caused by bacterial infection that can originate anywhere in the body. DISINFECTANT - any chemical agent used chiefly on inanimate objects to destroy or inhibit the growth of harmful organisms.

 ANTISEPTICS - is a substance that prevents or

arrests the growth or action of microorganisms either by inhibiting their activity or by destroying them. The term is used especially for preparations applied topically to living tissue STERILIZATION -the destruction of all living microorganisms, as pathogenic bacteria, vegetative forms, and spores.

 BACTERIOSTATIC -Capable of inhibiting the

growth or reproduction of bacteria. - An agent, such as a chemical or biological material, that inhibits bacterial growth. BACTERICIDAL - Capable of killing bacteria. BACTERIOCIDES - is a substance that kills bacteria .Bactericides are either disinfectants, antiseptics or antibiotics.

PREFIXES & SUFFIXES

Prefixes & Suffixes can explain the type of

procedure the client will undergo: PREFIXES Supra above ; beyond Ortho joint Chole bile or gall Cysto bladder Encephalo- brain

Entero intestine Hystero uterus Mast breast Meningo membrane; meninges Myo muscle Nephro kidney Neuro nerve Oophor - ovary

Pneumo lungs Pyelo kidney pelvis Salphingo fallopian tube Thoraco chest Viscero organ esp. abdomen

 SUFFIXES

Oma tumor ; swelling Ectomy removal of an organ or gland Rhapy suturing or stitching of a part or an organ Scopy looking into Ostomy making an opening or a stoma Otomy cutting into

Plasty to repair or restore Cele tumor ; hernia ; swelling Itis inflammation of

 PHASES OF O.R. NURSING :

I.

PREOPERATIVE PHASE The rendering of nursing care to the surgical client as soon as he is admitted & the decision to undergo surgery is made. It ends on the time the client is transferred to the O.R.

 NURSING ACTIVITIES :

Assessment of the client (baseline evaluation of

the pt. before the day of surgery-interview) Identification of potential/actual health problems. PREADMISSION TESTING- ensure necessary tests have been performed Pre-op teaching involving client & support persons.

 Day of surgery :

pt. teaching reviewed

informed consent confirmed pt.s identity & surgical site verified IVF started.

PREPARATION FOR SURGERY

Psychological Support :

a) Assess clients fears, anxieties, support

systems & patterns of coping. b) Establish trusting relationship with client & significant others. c) Explain routine procedures, encourage verbalization of fears & allow client to ask questions.

d) Demonstrate confidence in surgeon & staff.

e) Provide for spiritual care if appropriate.

PREOPERATIVE TEACHING
Frequently done on an outpatient basis.

Assess clients level of understanding of

surgical procedure & its implications. Answer questions, clarify & reinforce explanations given by the surgeon. Explain routine pre- & post-op procedures & any special equipment to be used.

 Preoperative experience Preoperative medication

PREOPERATIVE TEACHING

Breathing exercises, coughing, incentive spirometer

Leg exercises Position changes and movement

Pain management
Reducing anxiety and fear, support of coping Special considerations related to outpatient surgery

Preoperative Nursing Interventions

PHYSICAL PREPARATIONS:

Patient safety is a primary concern.

Obtain history of past medical conditions,

surgical procedures, dietary restrictions & medications. Perform baseline head-to-toe assessment, including VS, height & weight. Ensure that diagnostic procedures pertinent to surgery are performed as ordered:

1.

2.
3. 4. 5. 6.

CBC Electrolytes PT/PTT (Prothrombin Time;Partial thromboplastin time) Urinalysis ECG Blood typing & crossmatch

 NPO- to prevent aspiration

Bowel prep and skin prep

- cleansing enema or laxative before surgery to allow satisfactory visualization of the surgical site. - goal of pre-op skin prep is to decrease bacteria without injuring the skin.

 Immediate preoperative preparation

Complete checklist and chart Hospital gown, voiding, removal of dentures,

jewelry, contacts, etc. Preoperative medication

Transporting the pt. to the Presurgical area

about 30 to 60 minutes before anesthetics is to be given. Attend to family needs

 LEGAL PREPARATION: Surgeon obtains operative permit (informed

consent) 1. Surgical procedures, alternatives , possible complications & disfigurements or removal of body parts are explained. 2. It is part of the nurses role as client advocate to confirm that the client understands information given.

 INFORMED CONSENT is necessary in the ff.

Circumstances: Invasive procedures, such as surgical incisions, biopsy, cystoscopy or paracentesis. Procedures requiring sedation or anesthesia A non-surgical procedure, such as arteriography Procedures involving radiation

 Adult client (over 18 y/o) signs own permit

unless unconcious or mentally incompetent. 1. If unable to sign, relative (spouse or next of kin) or guardian will sign. 2. In an emergency, permission via telephone or telegram is acceptable; have a 2nd listener on phone when telephone permission is given

3. a. b. c. d.

Consents are not needed for emergency care if all 4 of the ff. criteria are met: There is an immediate threat to life. Experts agree that it is an emergency. Client is unable to consent. A legally authorized person cannot be reached.

 Minors (under 18 y/o) must have consent

signed by an adult (i.e. Parent or legal guardian) Emancipated minor (married or independently earning his or her own living)may sign his/ her own consent.

 Witness to informed consent may be a nurse,

another M.D., clerk or any other authorized person. The nurse witnessing informed consent, specifies whether witnessing explanation of surgery or just signature of the client.

PREOPERATIVE MEDICATIONS
PURPOSES:

To relieve fear & anxiety. 2. To reduce dose needed for induction & maintenance of anesthesia. 3. To prevent reflex bradycardia that happens during induction of anesthesia. 4. To minimize oral secretions.
1.

II.

INTRAOPERATIVE PHASE Giving nursing care to client undergoing surgery. It starts from the time the pt. was admitted to the O.R. , during operation until it ends & transferred to the PACU.

 NURSING ACTIVITIES: Activities providing for pts safety.

Maintenance of aseptic environment.

Ensuring proper function of equipments. Providing surgeons with specific instruments &

supplies for surgical field. Completing documentation. Positioning pts. Acting as scrub/circulating nurse.

Members of the Surgical Team

Patient

Anesthesiologi

st or anesthetist Surgeon Nurses (Scrub & Circulating) Surgical technologists

SCRUB TEAM @ WORK

 PATIENT the most important member of the

surgical team. May feel relaxed & prepared, or fearful & highly stressed. - is also subject to several risks. OPERATING SURGEON pre-op dx & care. - performance of operation. - post-op mgt & care - assumes all responsibility for all medical acts of judgement & mgt.

 SURGEON & ASSISTANTS scrub & perform the

surgery. REGISTERED NURSE 1ST ASST. practices under the direct supervision of the surgeon. (handling tissue, suturing, maintaining hemostasis) ANESTHESIOLOGIST / NURSE ANESTHETIST administers the anesthetic agent & monitors the pts physical status throughout the surgery.

 SCRUB NURSE provides sterile instruments &

supplies to the surgeon during the procedure. - performs surgical hand scrub. CIRCULATING NURSE coordinates the care of the pt. in the O.R. - care provided includes assisting with pt. positioning , skin prep, managing surgical specimens & documenting intraoperative events.

 SCRUB NURSE

CIRCULATING

NURSE

Prevention of Infection
The surgical environment stark appearance

& cool temperature. Located central to all supporting services.

Unrestricted zone where street clothes are

allowed. Semirestricted zone- where attire consists of scrub clothes & caps. Restricted zone- where scrub clothes, shoe covers, caps & masks are worn.

THE OPERATING ROOM

SURGICAL ASEPTIC TECHNIQUE

BEFORE AN OPERATION, it is necessary to

sterilize and keep sterile all instruments, materials, and supplies that come in contact with the surgical site. Every item handled by the surgeon and the surgeon's assistants must be sterile. The patient's skin and the hands of the members of the surgical team must be thoroughly scrubbed, prepared, and kept as aseptic as possible.

 DURING THE OPERATION, the surgeon,

surgeon's assistants, and the scrub nurses must wear sterile gowns and gloves and must not touch anything that is not sterile. Maintaining sterile technique is a cooperative responsibility of the entire surgical team. Each member must develop a surgical conscience, a willingness to supervise and be supervised by others regarding the adherence to standards.

BASIC PRINCIPLES OF SURGICAL ASEPSIS

All personnel assigned to the operating room

must practice good personal hygiene. This includes daily bathing and clothing change. Those personnel having colds, sore throats, open sores, and/or other infections should not be permitted in the operating room.

 Operating room attire (which includes scrub

suits, gowns, head coverings, and face masks) should not be worn outside the operating room suite. If such occurs, change all attire before reentering the clean area. (The operating room and adjacent supporting areas are classified as "clean areas.") All members of the surgical team having direct contact with the surgical site must perform the surgical hand scrub before the operation.

 All materials and instruments used in contact

with the site must be sterile. The gowns worn by surgeons and scrub corpsmen are considered sterile from shoulder to waist (in the front only), including the gown sleeves. If sterile surgical gloves are torn, punctured, or have touched an unsterile surface or item, they are considered contaminated.

 The safest, most practical method of sterilization

for most articles is steam under pressure. Label all prepared, packaged, and sterilized items with an expiration date. Use articles packaged and sterilized in cotton muslin wrappers within 28 calendar days. Use articles sterilized in cotton muslin wrappers and sealed in plastic within 180 calendar days

 Unsterile articles must not come in contact

with sterile articles. Make sure the patient's skin is as clean as possible before a surgical procedure. Take every precaution to prevent contamination of sterile areas or supplies by airborne organisms.

HANDLING STERILE ARTICLES

When you are changing a dressing, removing

sutures, or preparing the patient for a surgical procedure, it will be necessary to establish a sterile field from which to work. The field should be established on a stable, clean, flat, dry surface. An article is either sterile or unsterile; there is no in-between. If there is doubt about the sterility of an item, consider it unsterile

 Any time the sterility of a field has been

compromised, replace the contaminated field and setup. Do not open sterile articles until they are ready for use. Do not leave sterile articles unattended once they are opened and placed on a sterile field.

 Do not return sterile articles to a container once

they have been removed from the container. Never reach over a sterile field. When pouring sterile solutions into sterile containers or basins, do not touch the sterile container with the solution bottle. Once opened and first poured, use bottles of liquid entirely. If any liquid is left in the bottle, discard it.

 Never use an outdated article. Unwrap it,

inspect it, and, if reusable, rewrap it in a new wrapper for sterilization.

Intraoperative Complications
Nausea and vomiting

Anaphylaxis
Hypoxia and respiratory complications Hypothermia Malignant hyperthermia Disseminated intravascular coagulation (DIC)

Potential Adverse Effects of Surgery and Anesthesia

Allergic reactions and drug toxicity or reactions

Cardiac dysrhythmias
CNS changes and oversedation or undersedation Trauma: laryngeal, oral, nerve, and skin, including

burns Hypotension Thrombosis

Nursing Goals for the Patient in the Intraoperative Period

Reducing anxiety

Preventing positioning injuries

Maintaining patient safety Maintaining the patient's dignity Avoiding complications

Protecting the Patient from Injury

Patient identification

Correct informed consent

Verification of records of health history and exam Results of diagnostic tests Allergies (include latex allergy) Monitoring and modifying the physical

environment

 Safety measures such as grounding of

equipment, restraints, and not leaving a sedated patient Verification and accessibility of blood

III. POSTOPERATIVE PHASE

Begins with the admission of the client to PACU & ends with discharge of client from hospital or facility providing continuity of care.

Post-Anesthesia Care Unit

The PACU environment

Beds and other equipment

Nursing Management in the PACU

Provide care for the patient until he/she has

recovered from the effects of anesthesia. Patient has resumption of motor and sensory function, is oriented, has stable VS, and shows no evidence of hemorrhage or other complications of surgery. Frequent skilled assessment of the patient is vital

Responsibilities of the PACU Nurse

Review pertinent information and baseline

assessment upon admission to the unit. Assessments include airway and respirations, cardiovascular function, surgical site, function of the central nervous system; also assess IVs and all tubes and equipment. Reassess VS and patient status every 15 minutes or more frequently as needed. Provide report and transfer the patient to another unit or discharge the patient to home.

Outpatient Surgery/Direct Discharge

Discharge planning and discharge assessment Provide written and verbal instructions

regarding follow-up care, complications, wound care, activity, medications, and diet.
Give prescriptions and phone numbers. Discuss

actions to take if complications occur.

Outpatient Surgery/Direct Discharge

Give instructions to the patient and a responsible

adult who will accompany the patient.

Patients are not to drive home or be discharged

to home alone. Sedation and anesthesia may cloud memory and judgment and affect ability.