Perioperative Nursing

PERIOPERATIVE NURSING
PREOPERATIVE PHASE INTRAOPERATIVE PHASE POST-OPERATIVE PHASE
Col Estela L. Yutadco RN, MAN,MM
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PERIOPERATIVE NURSING
Used to describe the wide variety of nursing functions associated with the patients surgical experience An encompassing word that incorporates the three phases of surgeryPREOPERATIVE PHASE, INTRAOPERATIVE PHASE and POSTOPERATIVE PHASE
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PREOPERATIVE PHASE
Extends from the time the patient is admitted to the surgical unit to the time he or she is prepared physically, psychosocially, spiritually, and legally for the surgical procedure Ends until he is transported into the operating room
INTRAOPERATIVE PHASE
Extends from the time the client is admitted to the operating room to the administration of anesthesia, surgical procedure done. Ends until the time he/she is transported to the recovery room or PACU
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POST-OPERATIVE 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.
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FOUR MAJOR TYPES OF PATHOLOGIC CONDITIONS REQUIRING SURGICAL INTERVENTION
OBSTRUCTION
Impairment to the flow of vital fluids like blood, urine, CSF, bile
PERFORATION
Rupture of an organ
EROSION
Wearing off of a surface or membrane
TUMORS
Abnormal new growth
CLASSIFICATION OF SURGICAL PROCEDURES

According to PURPOSE According to DEGREE of RISKS According to URGENCY
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According to PURPOSE
Diagnostic
To establish the presence of a disease condition
Exploratory
To determine extent of the disease condition
Curative
To treat the disease condition
ABLATIVE
Involves removal of an organ (ectomy)
CONSTRUCTIVE
Involves repair of congenitally defective organ (plasty, orraphy, pexy)
RECONSTRUCTIVE
Involves repair of damaged organ
Palliative
To relieve distressing signs and symptoms, not necessarily to 8/15/2013 eloisampeamora cure the disease
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According to DEGREE OF RISKS (Magnitude/Extent)

MAJOR SURGERY
High risk Extensive Prolonged Large amount of blood loss Vital organs may be handled or removed Great risk of complication
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MINOR SURGERY
Generally not prolonged Leads to few serious complication Involves less risks
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According to URGENCY
EMERGENCY
To be done immediately to save life or limb
IMPERATIVE
To be done within 24 hrs
PLANNED / REQUIRED
Necessary for well-being, maybe scheduled in weeks or months
ELECTIVE
Not absolutely necessary for survival. Delay or omission will not cause adverse effect
OPTIONAL
Usually for aesthetic purposes
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PREOPERATIVE PHASE
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NURSING PROCESS OVERVIEW

GOALS
Assessing and correcting PHYSIOLOGIC AND PSYCHOLOGIC PROBLEMS that might increase surgical risks Giving the person and significant others complete learning/teaching guidelines regarding surgery Instructing and demonstrating exercises that will benefit the person during postoperative period Planning for discharged of any projected changes in lifestyle due to surgery

ASSESSMENT
PHYSIOLOGIC ASSESSMENT
Age Presence of pain Nutritional Status Fluid and Electrolyte Balance Infection Cardiovascular Function Pulmonary Function
Renal Function Gastrointestinal Function Liver Function Endocrine System Neurologic Function Hematologic Function Use of Medication Presence of Trauma
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PSYCHOSOCIAL ASSESSMENT
Fears
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
Spiritual Beliefs Cultural Values


NURSING DIAGNOSES
Anxiety related to the surgical experience (anesthesia, pain) and the outcome of surgery Knowledge deficit regarding preoperative procedures and protocols and postoperative expectation
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NURSING INTERVENTION TO MINIMIZE ANXIETY
Explore clients feelings Allow clients to speak openly about fears/concerns Give accurate information regarding surgery Give empathetic support Consider the persons religious preferences and arrange for visit by priest/minister as desired
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EVALUATION
Anxiety is relieved Prepares for surgical intervention
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INFORMED CONSENT
PURPOSES
To ensure that the client understands the nature of the treatment including the potential complications To indicate that the clients decision was made without coercion To protect the client against unauthorized procedure To protect the surgeon and hospital against legal action by a client who claims that an unauthorized procedure was performed
INFORMED CONSENT
NECESSARY WHEN:
Procedure is invasive Anesthesia is used Entrance into a body cavity Procedure where use of radiation or cobalt therapy is used
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INFORMED CONSENT
REQUISITES FOR VALIDITY OF INFORMED CONSENT
Written permission is best and is legally acceptable and valid for 24 hours only. Signature is obtained with the clients complete understanding of what to occur
Adult sign their own operative permit Obtained before sedation
Secured without pressure A witness is desirable For minors (below 18), unconscious, psychologically incapacitated, permission is required from responsible family members (parent/legal guardian)
PHYSICAL PREPARATIONS
BEFORE SURGERY
Correct any dietary deficiency Reduce an obese persons weight Correct fluid and electrolyte imbalances Restore adequate blood volume with blood transfusion Treat chronic diseases- DM, heart disease, renal insufficiency Halt or treat any infectious process Treat an alcoholic person with supplementation, IVFs oral fluids, if dehydrated
TEACHING PREOP EXERCISES
Deep breathing exercises-diaphragmatic Coughing exercises Turning exercises Foot and leg exercises
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PREPARING THE PERSON THE EVENING BEFORE SURGERY
Preparing the skin
Have full bath to reduce microorganisms
Preparing the GIT

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 CLIENT ON THE DAY OF SURGERY
EARLY A.M. CARE

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Awaken one hour before preop medication Morning bath, mouth wash Provide clean gown Remove hairpins, braid long hairs, cover hair with cap Remove dentures, contact lens, foreign materials, colored nail polish, hearing aid, jewelries Take baseline VS before preop medication Check identification Check for special orders-enema, NGT, IV line Check NPO Have client void before preopmedication
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PREOPERATIVE MEDICATIONS
GOALS
To facilitate the administration of any anesthetics To minimize respiratory tract secretions and changes in HR To relax the client and reduce anxiety
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PREOPERATIVE MEDICATIONS
COMMONLY USED PREOPERATIVE MEDICATIONS
Tranquilizers Sedatives Analgesics Anticholinergics H2 receptor antagonist
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TRANSPORTING THE CLIENT TO OR PATIENTS FAMILY
Direct proper visiting room MD informs family immediately after surgery Explain reason for long interval of waiting: anesthesia prep, skin prep, surgical procedure, RR Explain what to expect postop
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GOALS
Asepsis Homeostasis Safe administration of anesthesia Hemostasis
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POSITIONS
Explain the purpose Avoid undue exposures Strap the person to prevent falls Maintain adequate respiratory and circulatory function Maintain good body alignment
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POSITIONS
DORSAL RECUMBENT
For hernia repair, mastectomy, bowel resection
POSITIONS
TRENDELENBURG
Lower abdomen, pelvic surgeries
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POSITIONS
REVERSE TRENDELENBURG
Upper abdominal surgery
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POSITIONS
LITHOTOMY
Vaginal repairs, D and C, rectal surgery
POSITIONS
PRONE
Spinal surgeries
POSITIONS
LATERAL
Kidney, chest, hip replacement
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POSITIONS
KNEE CHEST POSITION
Spinal anesthesia
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PRINCIPLES OF STERILE TECHNIQUE

1. 2. 3. 4. 5. 6. 7. If you are in doubt of the sterility of an object, consider it unsterile Sterile to sterile, unsterile to unsterile Gowns are considered sterile from waist to shoulders in front and the sleeves Tables are only sterile at table level Unsterile persons avoid reaching over a sterile field, sterile persons avoid leaning over a unsterile area Edges of anything that encloses sterile contents are considered unsterile Sterile field are created as close as possible to the time of used Microorganisms must be kept to an irreducible minimum
8.
OR ATTIRE
SCRUB SUITS
Worn only in the operating suite
HEAD COVER
Used to cover hair completely
SHOES
Should be clean, washable, soft-soled covered by shoe covers
MASK
Put on by all personnel before coming into the OR and must be worn over nose and mouth
STERILE GOWN
Are worn over the scrub attire
STERILE GLOVES
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Are worn to complete the attire for eloisampeamora scrubbed team members
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SURGICAL SCRUB
The removal of as many bacteria as possible from arms and hands by mechanical washing and chemical disinfection before participating in an operation Done just prior to gowning and gloving for each operation PURPOSE
To help prevent the possibility of contamination of the operative wound by bacteria on hands and arms
GOWNING
PURPOSES
To exclude skin as a possible contaminant and to create a barrier between sterile and unsterile areas To permit the wearer to come within the sterile field To carry out sterile techniques during an operative procedure
GLOVING
Sterile gloves complete the attire for scrubbed team members Put on immediately after gowning GLOVING TECHNIQUES
CLOSED GLOVE TECHNIQUE
Affords assurance against contamination when gloving oneself since no hare hands is exposed
OPEN GLOVE TECHNIQUES

Uses a skin-to-skin, glove-to-glove technique
DRAPING
The procedure of covering patient and surrounding areas with a sterile barrier to create and maintain an adequate sterile field during an operation
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MEMBERS OF THE SURGICAL TEAM

Anesthesiologist Surgeon Assistant surgeon Scrub Nurse Circulating Nurse
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TYPES OF ANESTHESIA
GENERAL
Total loss of consciousness and sensation Produces amnesia IV, inhalation, rectal
REGIONAL
Reduce all painful sensation in one region of the body without inducing unconsciousness
ROUTES OF ANESTHESIA
Topical, Local Infiltration, Field Block, Nerve Block, Inhalation of Volatile Liquids
Isoflurane
Rectal
Anectine
IV Anesthetics
Thiopental
Spinal Anesthetics
Procaine Lidocaine Bupivacaine
STAGES OF ANESTHESIA
ONSET
Extends from the administration of anesthesia to the time of the loss of consciousness
EXCITEMENT
Extends from the time of loss of consciousness to the time loss of lid reflex. It maybe characterized by shouting, struggling of the client
SURGICAL ANESTHESIA
Extends from the loss of lid reflex to the loss of most reflex. Surgical procedure is started
STAGE OF DANGER
Characterized by respiratory/cardiac depression or arrest Due to overdosage of anesthesia Resuscitation must be rendered
COMPLICATIONS AND DISCOMFORT OF SPINAL ANESTHESIA
Hypotension Nausea and Vomiting Headache Respiratory Paralysis
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TISSUE LAYERS OF THE ABDOMEN

Skin Subcutaneous Fascia Muscle Peritoneum
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POST OPERATIVE PHASE
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GOALS
Maintain adequate body system function Restore homeostasis Alleviate pain and discomfort Prevent postop complication Ensure adequate discharge planning and teaching
NURSING CARE OF PATIENT DURING IMMEDIATE POSTOP (RR)
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TRANSPORT FROM OR TO RR
Avoid exposure Avoid rough handling Avoid hurried movement and rapid changes in position
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ASSESSMENT
Appraise air exchange status and note skin color Verify identity, operative procedure, surgeon Assess neurological status (LOC) Determine vital signs and skin temperature (CV status) Examine operative site and check dressings Perform safety checks
Position for good body alignments Side rails Restraints for IVFs, BT
Require briefing on problems encountered at OR

INTERVENTIONS
Ensure maintenance of patent airway and adequate respiratory function
Lateral position with neck extended Keep an airway in place until fully awake Suction secretions Encourage deep breathing Administer humidified air
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INTERVENTIONS
Monitor status of circulatory system
Monitor VS and report abnormalities Observe signs and symptoms of shock and hemorrhage Promote comfort and maintain safety Continuously, constant surveillance of the patient until he is completely out of anesthesia Recognize stress factors that may affect and minimize these factors
NURSING CARE OF PATIENT DURING INTERMEDIATE POSTOP (RR - UNIT)
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TRANSPORT FROM RR TO UNIT

Parameters for discharge from RR
Activity
Able to obey commands
Respiration
Easy, noiseless breathing
Circulation
BP is within += 20mmHg of the preop level
Consciousness
Responsive
Color
Pinkish skin and mucus membrane
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BASELINE ASSESSMENT
Respiratory status Cardiovascular status LOC Tubes, drainages, NGT Position
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GOALS
Restore homeostasis and prevent complication Maintain adequate CV and tissue perfusion Maintain adequate respiratory function Maintain adequate nutrition and elimination Maintain adequate fluid and electrolyte balance Maintain adequate renal function Promote adequate rest, comfort and safety Promote adequate wound healing Promote and maintain activity and mobility Promote adequate psychological support
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CAUSES OF AIRWAY OBSTRUCTION
Mucus collection in the throat Aspirated mucus/vomitus Loss of swallowing reflex Loss of control of the muscles of the jaw and tongue Laryngospasm due to intubation Bronchospasm
CAUSES OF HYPOVENTILATION
Medications Pain Chronic lung diseases Obesity
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S&S of Airway Obstruction and Hypoventilation

Restlessness Attempt to sit up in bed Fast, thready pulse (early sign) Air hunger Nausea, apprehension, confusion Cyanosis stridor/ snoring/wheezing
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NURSING CARE OF PATIENT DURING EXTENDED POSTOP (2-3 DAYS AFTER)
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DISCHARGE PLANNING/TEACHING
Self-care activities Activity limitation Diet and Medications at home Possible complications Referral. Follow-up check-up
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POSTOP DISCOMFORTS
Nausea and vomiting Restlessness and sleeplessness Thirst Constipation Pain
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POSTOPERATIVE COMPLICATIONS
SHOCK HEMORRHAGE FEMORAL PHLEBITIS PULOMONARY COMPLICATIONS URINARY DIFFICULTIES INTESTINAL OBSTRUCTION HICCUPS WOUND INFECTION WOUND COMPLICATIONS
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SHOCK
A response of the body t a decrease in circulating blood volume, which results in poor tissue perfusion and inadequate tissue oxygenation (hypoxia)
CLASSIC SIGNS OF SHOCK

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Pallor Cool moist skin Rapid breathing Cyanosis A rapid weak thready pulse Decreasing pulse pressure Low BP and concentrated urine
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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
HEMORRHAGE
Apprehension, restlessness, thirst, cold, moist, pale skin Deep rapid RR, low body temp Low Cardiac Output Low BP, low Hgb Circumoral pallor, spots before the eyes, ringing the ears Progressive weakness, then death ensues
HEMORRHAGE
MANAGEMENT
Vit. K, Hemostan Ligation of bleeders Pressure dressing Blood transfusion, IV fluids
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DEEP VEIN THROMBOSIS

Often occurs after operations on the lower abdomen or during the course of septic conditions as ruptured ulcers or peritonitis Mild to severe inflammation of the vein occurs on association with a clotting blood
CLASSICAL SIGN
Homans sign
CAUSES:
Injury: Damage to the vein Hemorrhage Prolonged immobility Obesity/Debilitation
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Pain Redness Swelling Heat/warmth + Homans sign
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INTERVENTION
PREVENTION
Hydrate adequately to prevent hemoconcentration Encourage leg exercises Avoid any constricting clothing or devices that may impair circulation Prevent use of bed rolls, knee gatches, dangling over the side of the bed with pressure on popliteal area

INTERVENTION
ACTIVE INTERVENTION
Bed rest, elevate the affected area with pillow support Wear antiembolic support hose from toes to groin Avoid massage on the calf of the leg Initiate anticoagulant therapy as ordered
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PULMONARY COMPLICATION
Atelectasis Bronchitis Bronchopneumonia Lobar pneumonia Hypostatic pulmonary congestions Pleurisy
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PULMONARY COMPLICATION
INTERVENTION
Reinforce deep breathing, coughing and turning exercises Encourage early ambulation
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URINARY DIFFICULTIES
RETENTION
Occurs most frequently after operation of the rectum, vagina, anus, lower abdomen Caused by spasm of the bladder
INCONTINENCE
30-60 ml every 15 to 30 mins. Overdistended bladderoverflow incontinence Loss of tone of the bladder sphincter INTERVENTION
Implement measures to induce voiding
INTESTINAL OBSTRUCTION
3rd to 5th postop day Loop of intestine may kink due to inflammatory adhesion MANIFESTATION

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Nausea and vomiting (fecaloid) Abdominal distention, hiccups Diarrhea (incomplete obstruction) No bowel movement (complete) Return flow of enema is clear Shock, then death occurs
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KINDS OF INTESTINAL OBSTURCTION
INTUSSUSCEPTION
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VOLVULUS
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INTESTINAL OBSTRUCTION
INTERVENTION
NGT insertion Administer electrolytes as ordered Prepare for possible surgical intervention
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HICCUPS
Intermittent spasms of the diaphragm causing a sound (hic) that results from vibration of closed vocal chords as air rushes suddenly into the lungs CAUSE
Irritation of the Phrenic nerve between the spinal cord and terminal ramifications on undersurface of the diaphragm
HICCUPS
INTERVENTION
NGT insertion Hold breath while taking in a large swallow of water Pressing on the eyeball through closed lids for several minutes Breath in and out of the paper bag Plasil (Metochlopromide) as ordered
WOUND INFECTION
CAUSES
Staphylococcus aureus Escherichia coli Proteus vulgaris Pseudomonas aeruginosa
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WOUND INFECTION
Redness, swelling, pain, warmth Pus or other discharges on the wound Foul smell from the wound Elevated temperature, chills Tender lymph nodes on the axilla, groin closest to the wound
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WOUND INFECTION
RULE OF THUMB FOR FEVER
1ST 24 HRS
Pulmonary infection
WITHIN 48 HRS
UTI
WITHIN 72 HRS
Wound infection
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WOUND INFECTION
PREVENTIVE INTERVENTION
Housekeeping cleanliness STRICT ASEPTIC TECHNIQUE Proper wound care Antibiotic therapy
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WOUND COMPLICATION
HEMATOMA WOUND DEHISENCE WOUND EVISCERATION
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WOUND COMPLICATION
INTERVENTION
Apply abdominal binders Encourage proper nutrition Keep in bed rest Supine or semi-fowlers, bend knees to relieve tension in the abdominal muscles Cover exposed intestine with sterile or moist saline dressing Reassure patient Prepare for surgery and repair
POSTOP PSYCHOLOGICAL DISTURBANCES

DELIRIUM
Toxic delirium Traumatic delirium Alcohol withdrawal delirium (delirium tremens)
ACUTE CONFUSIONAL STATE
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CAUSES
Dehydration Insufficient oxygenation Anemia Hypotension Hormonal imbalances Infection Trauma

MANIFESTATION
Poor memory Restlessness Inattentiveness Inappropriate behavior Wild excitement, hallucination, delusion, depression Disoriented Sleep disturbances

INTERVENTION
Sedatives to keep client quiet and comfortable Explain reasons for intervention Listen and talk to the client and significant others Provide physical comfort
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DRESSINGS
Wet dressings:
Water and medication can be applied to the skin with dressings (finely woven cotton, linen, or gauze) soaked in solution. Wet compresses, especially with frequent changes, provide gentle debridement. These dressings are specifically effective for moist, oozing and weeping lesions.
Dry dressings:
Used to protect the skin, hold medications against the skin, keep clothing and sheets from rubbing, or keep dirt and air away. Such dressings also prevent patients from scratching or rubbing.
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DRESSINGS
Occlusive dressings:
Used with increasing frequency in the treatment of acute wounds, chronic venous, diabetic and pressure ulcers. A variety of dressings are available including films, nontransparent adhesive hydrocolloids, and semitransparent nonadhesive hydrogels, all of which enhance wound healing.
Negative pressure dressings:

This device consists of a pressure distributing wound packing with a connecting tube placed into the wound space and sealed with an occlusive dressing. A partial negative pressure is created on the wound which in turn draws the edges of the wound to the center, assisting in closure of the wound. Application of the negative pressure dressing does not require the skills of a physical therapist.
END OF LECTURE
Thank you and Good luck


Perioperative Nursing

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PERIOPERATIVE NURSING

PREOPERATIVE PHASE INTRAOPERATIVE PHASE POST-OPERATIVE PHASE

Col Estela L. Yutadco RN, MAN,MM

FOUR MAJOR TYPES OF PATHOLOGIC CONDITIONS REQUIRING SURGICAL INTERVENTION

CLASSIFICATION OF SURGICAL PROCEDURES

According to DEGREE OF RISKS (Magnitude/Extent)

NURSING PROCESS OVERVIEW

NURSING PROCESS OVERVIEW

NURSING PROCESS OVERVIEW

Spiritual Beliefs Cultural Values

NURSING PROCESS OVERVIEW

NURSING PROCESS OVERVIEW

NURSING PROCESS OVERVIEW

Preparing the GIT

Preparing for anesthesia

Promoting rest and sleep

PRINCIPLES OF STERILE TECHNIQUE

OPEN GLOVE TECHNIQUES

MEMBERS OF THE SURGICAL TEAM

COMPLICATIONS AND DISCOMFORT OF SPINAL ANESTHESIA

Hypotension Nausea and Vomiting Headache Respiratory Paralysis

TISSUE LAYERS OF THE ABDOMEN

POST OPERATIVE PHASE

NURSING CARE OF PATIENT DURING IMMEDIATE POSTOP (RR)

Require briefing on problems encountered at OR

NURSING CARE OF PATIENT DURING INTERMEDIATE POSTOP (RR - UNIT)

TRANSPORT FROM RR TO UNIT

TRANSPORT FROM RR TO UNIT

TRANSPORT FROM RR TO UNIT

CAUSES OF AIRWAY OBSTRUCTION

S&S of Airway Obstruction and Hypoventilation

NURSING CARE OF PATIENT DURING EXTENDED POSTOP (2-3 DAYS AFTER)

DEEP VEIN THROMBOSIS

DEEP VEIN THROMBOSIS

DEEP VEIN THROMBOSIS

DEEP VEIN THROMBOSIS

KINDS OF INTESTINAL OBSTURCTION

POSTOP PSYCHOLOGICAL DISTURBANCES

ACUTE CONFUSIONAL STATE

POSTOP PSYCHOLOGICAL DISTURBANCES

POSTOP PSYCHOLOGICAL DISTURBANCES

POSTOP PSYCHOLOGICAL DISTURBANCES

Negative pressure dressings:

Thank you and Good luck

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