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PERIOPERATIVE NURSING

REYNALDO S. ALIPIO, RN, MD, MHA

PATIENT IN SURGERY


Surgery, branch of medicine concerned with treatment of diseases, deformities, and injuries through manual procedures called operations. operations.

Conditions Requiring Surgery




 

Perforation rupture of an organ, artery or bleb Obstruction or blockage Erosion wearing away of the surface of a tissue Tumors abnormal growth

Purpose
 

Diagnostic to verify suspected diagnosis Exploratory to estimate the extent of the disease Curative to remove or repair damaged or diseased organs or tissues

Types


   

Ablative involves removal of diseased organs ex.: nephrectomy Reconstructive partial or complete restoration of a damaged organ. Ex. Plastic surgery following severe burn Constructive repair of a congenitally defective organ. Ex. Plastic surgery of cleft palate Palliative relieves symptom

Degree of Risk to Patient


 

Major Surgery Minor Surgery

Urgency
  

  

Emergency must be performed immediately Ex. Gunshot wound Imperative or Urgent must be performed as soon as possible within 24 48 hours. Ex. Severe bleeding Planned Required necessary for patients well being Ex. CSection Optional surgery surgery that the patient request Ex. Breast Augmentation Elective Surgery should be performed for patients wellwell-being but which is not absolutely necessary Ex. Simple hernia repair

Effects of Surgery on the Client


1. Physical Effects  A. Stress response (neuroendocrine response) is activated.  B. Resistance to infection is lowered due to surgical incision.  C. Vascular system is disturbed due to severing of blood vessels and blood loss.

2. Psychologic Effects  Common fears: pain anesthesia loss of control disfigurement separation from loved ones alterations in roles or lifelifestyle

Factors Influencing Surgical Risk




A. Age: very young and elderly are at increased risk. B. Nutrition: malnutrition and obesity increase risk of complications. C. Fluid and electrolyte balance: dehydration, hypovolemia, and electrolyte imbalances can pose problems during surgery. D. General health status: infection, cardiovascular disease, pulmonary problems, liver dysfunction, renal insufficiency, or metabolic disorders create increased risk.

E. Type of surgery planned: major surgery (e.g., thoracotomy) poses greater risk than minor surgery (e.g., dental extraction). F. Psychologic status of client: excessive fear or anxiety may have adverse effect on surgery. G. Medications

Medications


ANTIBIOTICS - Potentiate the action of anesthetic agents. ANTIDYSRHYTHMICS - Reduce cardiac contractility and impair cardiac conduction during anesthesia. ANTICOAGULANTS - Alter normal clotting factors and increase the risk of hemorrhaging: discontinue before surgery

ANTICONVULSANTS - Long-term use of Longcertain anticonvulsants can alter the metabolism of anesthetic agents. ANTIHYPERTENSIVES - Can interact with anesthetic agents and cause bradycardia, hypotension, and impaired circulation. CORTICOSTEROIDS - Cause adrenal atrophy and reduce the body's ability to withstand stress.

INSULIN - The need for insulin after surgery in a diabetic either may be reduced because the client's nutritional intake is decreased or may be increased because of the stress response and IV administration of glucose solutions. DIURETICS - Potentiate electrolyte imbalances after surgery.

ANTIDEPRESSANTS - May lower the blood pressure during anesthesia. ANTICHOLINERGICS - Medications with anticholinergic effects increase the potential for confusion.

Legal Responsibilities


A. Surgeon obtains operative permit (informed consent). B. Informed consent is necessary for each operation performed, however minor. It is also necessary for major diagnostic procedures, e.g., bronchoscopy, thoracentesis, etc., where a major body cavity is entered. C. Adult client (over 18 years of age) signs own permit unless unconscious or mentally incompetent.

D. Minors (under 18) must have consent signed by an adult (i.e., parent or legal guardian). An emancipated minor (married, college student living away from home, in military service) may sign own consent. E. Witness to informed consent may be nurse, another physician, clerk, or other authorized person. F. If nurse witnesses informed consent, specify whether witnessing explanation of surgery or just signature of client.

PERIOPERATIVE PHASES


 

A. Preoperative phase - the period of time prior to the surgical procedure. 1. Assessment and correction of physiological and psychological problems that may increase the client's risk factors. 2. Client teaching regarding the surgery. 3. Client teaching regarding postoperative care and activities. 4. Client planning for any anticipated changes in lifestyle at time of discharge.

B. Intraoperative phase - The period of time the client is in the operating room. C. Post operative phase - The period begins with the admission of the client to the post anesthesia recovery (PAR) area, and includes the rest of the client's hospitalization and recovery period.

Preoperative Care
  


A. Client Profile B. Preoperative Teaching C. Preoperative checklist


D. Physical Preparation of Client

Preoperative Care
A. Client Profile.  1. Age  2. Weight  3. Nutritional status  4. Preoperative interview. a. Chronic health problems and previous surgical procedures. b. Post and current drug therapy, including over-theover-the-counter medications. c. History of drug allergies and dietary restrictions.


d. Client's perception of his or her illness and impending surgery. e. Discomfort or symptoms he/she is currently experiencing. f. Religious affiliation. g. Family or significant others.

  

5. Psychosocial needs - Fear of the unknown is the primary cause of preoperative anxiety in the mentally stable client. The surgical experience is unique to each client and represents a time of crisis. Psychosocial preparation 1. Be alert to the client's anxiety level 2. Answer any questions or concerns the client may have regarding surgery 3. Allow time for privacy for the client to prepare for surgery psychologically 4. Provide support and assistance as needed

6. Medications - Some predispose the client to operative complications. Preoperative medications  1. Prepare to administer preoperative medications as prescribed, or on call to the operating room immediately before surgery  2. Instruct the client that he or she will feel drowsy shortly after the medications are administered  3. After administering the preoperative medications, keep the client in bed with the side rails up  4. Place the call bell next to the client; instruct the client not to get out of bed and to call for assistance if needed


        

7. A complete preoperative nursing assessment establishes a data base for postoperative assessment. 8. Check routine laboratory studies. a. Complete blood count/Typing b. Urinalysis. c. VDRL or FTA-ABS. FTAd. Chest x-ray. xe. Electrocardiogram (EKG). f. PT/PTT f. CT/BT Hep profile/aids

Preoperative Teaching


    

The goal is to decrease the client's anxiety and to prevent postoperative com-plications. . Preoperative teaching content. a. Deep breathing and coughing exercises. b. Turning and extremity exercises. c. Pain medication policy. d. Adjunct equipment used for breathing - IPPB, nebulizer, 02 mask. e. Explanation of NPO policy.

Preoperative checklist


1. Ensure that the client is wearing an identification bracelet 2. Assess for allergies (information on latex allergy) 3. Review the preoperative checklist to be sure that each item is addressed before the client is transported to surgery

4. Ensure that informed consent forms were signed for the operative procedure, for any blood transfusions, for disposal of a limb, or for surgical sterilization procedures 5. Ensure that a history and physical exam were completed and documented in the client's record 6. Ensure that consultations prescribed were completed and documented in the client's record

7. Ensure that prescribed laboratory results are documented in the client's record 8. Ensure that the ECG and chest radiograph reports are documented in the client's record 9. Ensure that a blood type and screen or type and cross-match is performed and documented crossin the client's record

10. Remove jewelry, makeup, dentures, hairpins, nail polish, glasses, and prostheses 11. Document that valuables were given to the client's family members or locked in the hospi-tal safe 12. Document the last time the client ate or drank

13. Document that the client has voided prior to Surgery 14. Document that the prescribed preoperative medication was given 15. Monitor and document the client's vital signs

Physical Preparation of Client




1. Skin preparation - purpose is to reduce bacteria on the skin. a. Prepare to clean the surgical site with a mild antiseptic soap the night before surgery, as prescribed b. Prepare to shave the operative site as prescribed

c. Hair should be shaved only if it will interfere with the surgical procedure and only if prescribed d. Shaving of hair, if prescribed, should be done in the direction of hair growth and with a sharp razor, and caution should be used to prevent cuts or epidermal damage

 

2. Gastrointestinal preparation. a. Food and fluid restriction for approximately 6 hours preoperatively. b. Enemas are frequently administered the eve-ning prior to surgery to prevent fecal contamination in the peritoneal cavity. c. Gastric or intestinal intubation may be done in order to remove gastric contents and to promote intestinal decompression.

3. Promote sleep and rest - After the preoperative procedures are completed the client generally receives a sleeping medication to promote rest. Common medications used are the barbiturates.  a. Secobarbital (SECONAL).  b. Pentobarbital (NEMBUTAL).


Nutrition


1. Assess the physician's orders regarding the NPO status prior to surgery 2. Solid foods and liquids are withheld for 6 to 8 hours before general anesthesia and for 3 hours before surgery with local anesthesia, to avoid aspiration 3. Prepare to initiate an IV and administer IV fluids as prescribed 4. Prepare to administer total parenteral nutrition (TPN) to clients who are malnourished, have protein or metabolic deficiencies, or cannot ingest foods

Elimination


 

1. If the client is to have intestinal or abdominal surgery, an enema or laxative or both may be prescribed the night before surgery 2. The client should void immediately before surgery 3. Prepare to insert a Foley catheter if prescribed 4. If there is a Foley catheter in place, it should be emptied immediately before surgery and the amount and quality of urine output documented

Day of Surgery
Nursing Responsibilities.  1. Have client follow routine hygiene care.  2. Record vital signs within four hours of client going to surgery.  3. Remove jewelry, wedding bands may be taped on finger.  4. Remove fingernail polish.  5. Dress client in appropriate clothing.  6. Inform client that dentures and removable bridge work must be removed before surgery.

7. Make sure the NPO policy has been initiated according to orders and the client has adhered to it. 8. Check the client's identification band; validate the information and see it is secure. 9. Check the skin preparation.

10. Identify family and significant others who will be waiting for information regarding client's progress. 11. Check the chart for completeness regarding laboratory reports, consent form, significant client observations, history and physical records.

Preoperative Medications
  

 

1. Purpose. a. Induce anesthesia rapidly and pleasantly. b. Increase safety and maintain desired level of anesthesia. c. Decrease oral pharyngeal secretions. d. Enhance anesthetic agent.

1. Narcotic analgesics (meperidine [Demerol), morphine sulfate) relax client, reduce anxiety, and enhance effectiveness of general anesthesia. 2. Sedatives (secobarbital sodium [Seconal]), sodium pentobarbital [Nembutal) decrease anxiety and promote relaxation and sleep. 3. Anticholinergics (atropine sulfate, scopolamine [Hyoscine]) and glycopyrrolate (Robinul) decrease tracheobronchial secretions to minimize danger of aspirating secretions in lungs, decrease vagal response to inhibit undesirable effects of general anesthesia (bradycardia) .

 

 

Nursing Responsibilities. a. Ask client to void prior to administration of medication. b. Obtain base line vital signs. c. Administer medication 45 minutes to 1 hour prior to surgery, or as ordered. d. Follow "Seven Rights" of medication administration. e. Raise the siderails and instruct the client not to get out of bed.

  

f. Remove dental work. g. Observe for side effects of medication. h. Maintain quiet environment prior to being transported to the operating room. i. Allow parent to accompany child as far as possible.

Arrival in the operating room  1. When the client arrives in the operating room, the operating room nurse will verify the identification bracelet with the client's verbal response and will review the client's chart  2. The operating room nurse will confirm the operative procedure and the site to be operated on

3. The client's chart will be checked for completeness and reviewed for informed consent forms, a history and physical examination, and allergic reaction information 4. Physicians' orders will be reviewed, and that they were carried out will be verified 5. The IV line may be initiated at this time if prescribed 6. The anesthesia team will administer the prescribed anesthesia

Anesthesia
   

Purpose: 1. Promote muscle relaxation. 2. Block transmission of nerve impulses. 3. Achieve a state of reversible unconsciousness.

      

General anesthesia. 1. Ideal general anesthetic. a. Nonirritating, nonflammable. b. Effective in analgesia and muscle relaxation. c. Able to suppress undesirable reflexes. d. Nontoxic. e. Able to permit rapid recovery without nausea and vomiting.

2. Balanced anesthesia - a combination of medications used in order to accomplish all of the desirable traits. 3. Intravenous anesthesia - frequently used as an induction agent prior to the inhalation agent. 4. Inhalation anesthesia - used to progress client from stage n to stage III of anesthesia.

STAGES of ANESTHESIA


Stage I (Induction) - Beginning administration of anesthetic agent - Loss of consciousness - May appear euphoric, drowsy, dizzy

Stage II (delirium or excitement) - Loss of consciousness - Relaxation - Breathing irregular may appear excited very susceptible to external stimuli

Stage III (surgical anesthesia) - Relaxation - Lost of reflexes and depression of vital functions - Regular breathing pattern; corneal reflexes absent; papillary constriction

Stage IV (danger stage) - Vital functions depressed - Respiratory arrest possible cardiac arrest - No respiration; absent or minimal heartbeat dilated pupils

Agents for general anesthesia


 

 

Agents for general anesthesia 1. Inhalation agents - used to progress client from stage n to stage III of anesthesia. a. Gas anesthetics 1) nitrous oxide: induction agent; component of balanced anesthesia; used alone for short procedures; always given in combination with oxygen 2) cyclopropane: obstetric anesthesia; clients with cardiovascular complications; highly flammable and explosive

 

b. Liquid anesthetics 1) halothane (Fluothane): widely used; rapid induction, low incidence of post-op nausea and postvomiting; may cause bradycardia and hypotension; contraindicated in clients with liver disease. 2) enflurane (Ethrane): effects similar to halothane, but muscle relaxation is stronger and hepatotoxicity not a problem; use cautiously in clients with cardiac disease.

3) ether (diethyl ether): infrequently used because of slow, unpleasant induction, excessive secretory action, increased post-op postnausea and vomiting, and flammability. 4) methoxyflurane (Penthrane): very potent agent with slow onset and recovery; circulatory depression at high concentrations; associated with liver and kidney damage; rarely used.

 

2. IV anesthetics: used primarily as induction agents; produce rapid, smooth induction; may be used alone in short procedures such as dental extractions. a. Common IV anesthetics: methohexital (Brevital) , sodium thiopental (Pentathol) b. Disadvantages: poor relaxation; respiratory and myocardial depression in high doses; bronchospasm, laryngospasm; hypotension - frequently used as an induction agent prior to the inhalation agent.

 

3. Dissociative agents: produce state of profound analgesia, amnesia, and lack of awareness without loss of consciousness; used alone in short surgical and diagnostic procedures or for induction prior to administration of more potent general anesthetics. a. Agent: ketamine (Ketalar) b. Side effects: tachycardia, hypertension, respiratory depression, hallucinations, delirium c. Precautions: decrease verbal, tactile, and visual stimulation during recovery period

 

 

4. Neuroleptics: produce state of neuroleptic analgesia characterized by reduced motor activity, decreased anxiety, and analgesia without loss of consciousness; used alone for short surgical and diagnostic procedures, as premedication or in combination with other anesthetics for longer anesthesia. a. Agent: fentanyl citrate with droperidol (Innovar) b. Side effects: hypotension, bradycardia, respiratory depression, skeletal muscle rigidity, twitching c. Precautions: reduce narcotic doses by 1/2 to 1/3 for at least 8 hours postanesthesia as ordered to prevent respiratory depression.

Regional anesthesia - used to anesthetize one region of the body; the client may remain awake and alert throughout the procedure. 1. Produces loss of painful sensation in one area of the body; does not produce loss of consciousness. 2. Uses: biopsies, excision of moles and cysts, endoscopies, surgery on extremities 3. Agents: lidocaine (Xylocaine), procaine (Novocain), tetracaine (Pontocaine), Sersorcaine

   

TopicalTopical- anesthetizing medication is applied to mucous membrane or skin; blocks peripheral nerve endings. 2. Nerve root block - provides autonomic blockage. a. Spinal. b. Saddle. c. Epidural. d. Caudal.

a. Spinal - Anesthetic introduced into subarachnoid space of spinal cord producing anesthesia below level of diaphragm.  b. Saddle - Similar to spinal, but anesthetized area is more limited; commonly used in obstetrics.  c. Epidural - Anesthetic injected extradurally to produce anesthesia below level of diaphragm; used in obstetrics.  d. Caudal - Variation of epidural block: produces anesthesia of perineum and occasionally lower abdomen; commonly used in obstetrics.


Nursing Considerations for Regional Anesthesia


 

 

1. Require anesthesiologist for administration. 2. Will completely relieve pain if administered correctly. 3. Vasodilation below level of anesthesia may precipitate hypotension. 4. Contraindicated in hypovolemic client. 5. Client may experience postanesthesia headache.

 

  

6. Produce blockage of the autonomic nerve fibers: touch, pain, motor, pressure proprioceptive fibers are blocked. 7. Client remains awake throughout procedure. 8. May be used in major surgical procedures below the level of the diaphragm. 9. Peripheral nerve root block - does not block the autonomic nerve fiber; medication injected to block peripheral nerve fibers. a. Pudendal. b. Paracervical. 10. Assess client for effectiveness as anesthesia is initiated. 11. Nursing intervention for client undergoing regional anesthesia

OPERATING ROOM TEAM MEMBERS

OPERATING ROOM TEAM MEMBERS


Surgeon  Assistant to the surgeon  Anesthesiologist  Scrub Nurse (Surgical/OBTechnician) - Instrument Nurse - Suture Nurse  Circulating Nurse  Pathologist


The Scrubbed Sterile Team


  

Operation Surgeon Assistant/s to the surgeon Scrub Nurse

The Unscrubbed Unsterile Team


  

Anesthesiologist Circulating Nurse Pathologist

OPERATING ROOM NURSE


The nurse should be able to:  Identify the operating room team members.  Enumerate each team members responsibility  To define the roles of the team members in giving total care to the patient who is undergoing a surgical procedure.

Surgeon
 

He serves as the leader of the team. He must be certain that all term members are aware of what is needed during the procedure and that all necessary equipments and instruments are available. He performs the surgery.

Assistant to the Surgeon




He may be surgeon, a resident, an intern, or a clinical clerk/PA/CNM He assists the surgeon during the surgery in any way the surgeon requests. He holds retractors in the wound to expose the operative site.

  

He places clamps on blood vessels. He assists in suturing and ligating bleeders. He may perform suctioning in the operative field.

Scrub Nurse
 

Sets up sterile supplies and instruments. Assists the surgeon as needed throughout the surgery. Assists in gowning and gloving and surgical team. Assists in draping the patient and the field.

  

Hands instruments, sutures, sponges, etc. . , as needed in efficient manner. Keeps operative field tidy during the case. Wipes blood from instruments. Keeps close watch on needles, instrument and sponges so that none will be misplaced or lost in the operative field.

 

Keeps separate needle/instrument count, if this is a policy Supplies sterile dressing materials. Discards soiled linen into hamper after checking it for instruments. Cares fro all instruments and supplies left after case.

ANESTHESIOLOGIST
 

A physician who specializes in anesthesiology. Gives and controls the anesthetic for the patient. Must see to it that all the equipment and supplies necessary for the induction of anesthesia are available.

Determines when the surgeon or circulating nurse may proceed with positioning and preparing the operative site. Monitors the patients vital signs during the operation.

Keeps the surgeon aware of the patients condition. Determines when the patient may be moved to the post-anesthesia recovery stretcher after the postoperation has been completed.

CIRCULATING NURSE


   

Functions as the overseer of the room during the procedure to maintain sterility. Assists the entire team and the patient. Sends for patient at appropriate time. Receives, greets, identifies patient. Checks chart for completeness.

 

Assists patient in moving safely to operating room table. Assists anesthesiologist when requested: stays with the patient during induction. Ties scrubbed members gowns. Checks operating room lights in advanced for good working order, turns lights on at appropriate time and adjust when needed.

 

  

Prepares operative site. Connects catheter to drainage bottle, or catheterize if desired by the surgeon. Does the sponge count with the scrub nurse. Positions the patient. Supplies foot stools if needed by the surgical team.

 

Watches foreheads for perspiration. Fills out required operative records completely and legibly. Remains in the room as much as possible to be constantly availably. Watches progress of surgery, anticipates needs, reacts quickly to emergency.

Sees that the surgical team is supplied with every necessary item to perform the operation efficiently. Uses equipment and supplies economically and conservatively. Directs cleaning of the room and preparation for the next operation.

PAHTOLOGIST


A specialist in the scientific study of the alteration in tissue produced by disease. He/she is consulted by the surgeon during or after surgery for a diagnosis by gross or microscopic examination of any tissue removed. He/she is consulted by the surgeon concerning the treatment of some diseases.

Principles of Aseptic Technique




The patient is the center of the sterile field which includes the areas of the patient, the operating table and furniture covered with sterile drapes and personnel wearing the OT attire

Principles of Aseptic Technique are applied in the:


- preparation for operation by sterilization of necessary equipments, materials and supplies

- preparation of the operating team to handle sterile supplies and intimately contact wound - creation and maintenance of the sterile field, including the preparation and draping of patient, to prevent contamination of the surgical wound

Principles:


 

- only sterile items are used within the sterile field - gowns are considered sterile only from the waist to shoulder level front and the sleeves - tables are sterile only at table level - persons who are sterile touch only sterile items or areas; persons who are not sterile touch only unsterile items or areas

- unsterile person avoid reaching areas over a sterile field; persons avoid leaning over an unsterile area - edges of anything that encloses sterile contents are considered unsterile - sterile field is created as close as possible to time of use

 

- sterile areas are continuously kept in view - sterile persons keep well within the sterile area - sterile persons keep contact with sterile areas to a maximum - unsterile persons avoid sterile areas

- destruction of integrity of microbial barriers results in contamination - microorganisms must be kept to an irreducible minimum

Functions of the nurse during OR procedure

SCRUB NURSE

CIRCULATING NURSE

Assists the surgeon Maintains sterility Handles instruments Drapes patient Counts sponges Wears sterile gown, gloves Assists the Scrub nurse Positions the patient for surgery  Positions any equipments


INCISIONS
Importance of knowing the operative incision: For the circulating Nurse:  to know the extent and the area to be prepared.  To prepare the gadgets necessary for positioning the patient. For the Scrub Nurse:  To serve as a guide for draping the operative site.  To have the correct instruments and supplies available.  To be able to assist the surgeon effectively and efficiently.


- maintenance sterility and asepsis throughout the operative procedure - terminal sterilization and disinfection at the conclusion of the operation

COMMONLY USED INCISIONS


Kockers (Sub costal) Incision Upper abdominal Midline Incision (Vertical) Lower Abdominal Midline Incision Paramedian Incision Mcburneys Incision Inguinal Incision Horizontal Flank Incision (Midline Transverse) Lumbotomy Incision (Simple Flank Incision)

Thoracoabdominal Incision Thoracotomy Incision (Lateral Posterothoracic, Right or left) Thoracotomy Incision (AnterolateralApproach) Pfannenstil Incision (Bikini Incision) Infraumbilical Incision

Miscellaneous Incision:  a. Collar line (Curvilinear) Incision Thyroid surgery/Parathyroid surgery  b. Coronal, butterfly incisions craniotomy  c. Limbal incision cataract extraction  d. Elliptical, halted incisions radical mastectomy  e. Post aural, end aural incision mastoidectomy  f. Canine fosse incision Caldwell loc  g. Gibson incision ureterolithotomy

POSITIONING


Positioning is putting the patient in proper body alignment to expose the operative site or area

    

Several factors influence the time at which the patient is positioned: site of operation age and size of the patient pain upon moving kind of anesthetic 1. regional infiltration, topical, nerve block, field block - position the patient first 2. general position the patient last

Qualifications of a Good Position




The most important qualification is maximum safety of the patient Free Respiration
 

to prevent hypoxia to aid in induction of anesthesia to prevent postoperative circulatory disturbances to permit free flow of IV solution or transfusion to help maintain blood pressure

Free Circulation
  

 

No pressure on any nerves may cause serious injury or paralysis Hands and foot supported No undue post operative discomfort no standing rather on the muscles or nerve Accessible Operative area to permit surgeon to reach the operative area

POSITIONS FOR OPERATION


Dorsal Position- used for laparotomies not Positionrequiring extensive exploration such as herniorapphy, appendectomy Fowlers position for craniotomy, tonsillectomy, nasal operation (under local anesthesia) Sitting position for craniotomies involving the occipital region, nasal surgery, mouth surgery Sims position for proctosigmoidoscopy

Lithotomy position for cystoscopy, transurethral resection, cystopanendoscopy, perineal repair, vaginal hysterectomy, dilatationa and curettage, rectal surgery Trendelenburg position - for urinary bladder or colon surgery, gynecology operations Reverse trendelenburg position for thyroidectomy to decrease the blood supply to the area, gallbladder operation to allow the abdominal viscera away from the epigastric region

Prone position for laminectomy, back surgery, excision of bakers cyst Kraske/Jacknife position for rectal surgery Knee Chest position for sigmoidoscopy Kidney position for operation on the kidney and upper ureter, lumbar anterior fusion Chest position I (lateral) used for thoracoplasty, pneumonectomy, esopagectomy and transthoracic gastrectomy Chest position II (anterior) for pneumoectomy and esophagectomy, heart surgery

Immediate Postoperative Recovery




 

     

The client's respiratory status is a priority concern on admission to and throughout the recovery room Admission of client to recovery area. 1. Avoid respiratory complications by positioning client on his or her side (lateral Sims). 2. Obtain baseline assessment. a. Vital signs. b. Status of respirations. c. General color. d. Type and amount of fluid infusing. e. Special equipment. f. Dressing

   

 

3. Determine specifics regarding the operation from the O.R. nurse. a. Client's overall tolerance of surgery. b. Type of surgery performed. c. Type of anesthetic agents used. d. Results of procedure - was the condition corrected. e. Any specific complications to watch for. f. Status of fluid intake and urinary output.

Recovery Room (Immediate Postoperative Care)


 

 

A. Assess for and maintain patent airway. 1. Position unconscious or semiconscious client on side (unless contraindicated) or on back with. head to side and chin extended forward. 2. Check for presence/absence of gag reflex. 3. Maintain artificial airway in place until gag and swallow reflex have returned. B. Administer oxygen as ordered.

 

C. Assess rate, depth, and quality of respirations. D. Check vital signs every 15 minutes until stable, then every 30 minutes. E. Note level of consciousness; reorient client to time, place, and situation. F. Assess color and temperature of skin, color of nailbeds and lips. G. Monitor IV infusions: condition of site, type, and amount of fluid being infused and flow rate. H. Check all drainage tubes and connect to suction or gravity drainage as ordered; note color, amount, and odor of drainage.

I. Assess dressings for intactness, drainage, hemorrhage. J. Monitor and maintain client's temperature; may need extra blankets. K. Encourage client to cough and deep breathe after airway is removed. L. If spinal anesthesia used, maintain supine position and check for sensation and movement in lower extremities.

Dismissal of Client from the Recovery Room


Five (5) Physiological Parameters:


 

Activity able to move 4 extremities voluntarily on command. Breathing - Respiration able to breathe deeply and cough freely Circulation BP is +20% or -20+ of preanesthetic level Consciousness fully awake Color - pink

Care on Surgical Floor




   

A. Monitor respiratory status and promote optimal functioning. B. Monitor cardiovascular status and avoid post-op postcomplications. C. Promote adequate fluid and electrolyte balance. D. Promote optimum nutrition. E. Monitor and promote return of urinary function. F. Promote bowel elimination.

 

G. Administer post-op analgesics as ordered; postprovide additional comfort measures. H. Encourage optimal activity, turning in bed every 2 hours, early ambulation if allowed (generally client will be out of bed within 24 hours; have client dangle legs before getting out of bed). I. Provide wound care. J. Provide adequate psychologic support to client! significant others. K. Provide appropriate discharge teaching: dietary restrictions, medication regimen,

System check
        

1. Respiratory system 2. Cardiovascular system 3. Musculoskeletal system 4. Neurological system 5. Temperature control 6. Integumentary system 7. Fluid and electrolyte balance 8. Gastrointestinal system 9. Renal system

Pain management
  

Immediate Stage - 1- 4 hours post op Intermediate Stage 4 24 hours Extended Stage - 1 to 4 days

Liquid Diet Vs Soft diet


Clear liquid Coffee Tea Carbonated drink Bouillon Clear fruit juice Popsicle Gelatin Full liquid Clear liquid PLUS: Milk/Milk prod Vegetable juices Cream, butter Yogurt Puddings Custard Ice cream and sherbet Soft diet All CL and FL plus: Meat Vegetables Fruits Breads and cereals Pureed foods

POSTOPERATIVE COMPLICATIONS
    

Respiratory Complications Circulatory Complications Wound Complications Complications of Elimination Gastrointestinal Complications

Respiratory Complications
  

Atelectasis Pneumonia Hypoxia

Respiratory Complications
Predisposing factors  1. Type of surgery (e.g., thoracic or high abdomen surgery)  2. Previous history of respiratory problems  3. Age: greater risk over age 40  4. Obesity  5. Smoking  6. Respiratory depression caused by narcotics  7. Severe post-op pain post 8. Prolonged post-op immobility post-

Atelectasis - is a collapse of a portion of the lung, producing an airless state in the alveoli usually occurs 1 to 2 days postoperatively.

Etiology  1. Undetected upperrespiratory infection.  2. Aspiration of vomitus.  3. Increased mucus secretions due to intubation and anesthesia.  4. History of chronic lung disease.  5. Ineffective ventilation postoperatively, par-ticularly in the obese, and elderly client.

Assessment  1. Dyspnea.  2. Decreased or absent breath sounds over affected area.  3. Asymmetrical chest expansion.  4. Tachycardia.  5. Increased anxiety and restlessness.

Nursing Intervention
 

 

1. Prevention. a. Have client turn, cough and deep breathe every 2 hours. b. Maintain adequate hydration (3,000 cc per day, unless contraindicated). c. Avoid large doses of analgesics, in clients with increased susceptibility. d. Prevent abdominal distention. e. Encourage ambulation as soon as possible.

   

2. Position client on unaffected side. 3. Stimulate coughing. 4. Increase humidification of inspired air. 5. Continue to implement preventive measures.

Pneumonia - An acute inflammatory process of the alveolar spaces; the alveoli fill with exudate thereby causing consolidation of lung tissue. - An inflammation of the alveoli caused by an infectious process; may develop 3 to 5 days postoperatively as a result of infection, aspiration, or immobility

Etiology


1.

 

 

 

Undetected upperrespiratory infection. 2. Aspiration of vomitus. 3. Increased mucus secretions due to intubation and anesthesia. 4. History of chronic lung disease. 5. Ineffective ventilation postoperatively, particularly in the obese, and elderly client. 6. Immunosuppressed clients. 7. More common in infants and children.

Assessment


 

 

1. Rapid, shallow respirations/ Dyspnea and increased respiratory rate 2. Fever. 3. Wet breath sounds (rales, rhonchi) or absent breath sounds over affected area. 4. Asymmetrical chest expansion. 5. Productive cough and chest pain

 

6. Client with advanced hypoxia may demonstrate circumoral and nail bed cyanosis. 7. Tachycardia. 8. Leukocytosis.

Implementation
 

1. Assess lung and breath sounds 2. Reposition the client every 1 to 2 hours(turn)/ Position in semi to high-Fowlers. high3. Encourage the client to deep breathe and cough and to use the incentive spirometer 4. Provide chest physiotherapy (CPT) postural drainage as prescribed 5. Suction to clear secretions if the client is unable to cough

  

6. Encourage fluid intake/ Maintain adequate hydration (3,000 cc per day). If no contraindication 7. Encourage early ambulation 8. Administer antibiotics and antipyretics. 9. Maintain humidification of air and oxygen.

HYPOXIA - An inadequate concentration of oxygen in arterial blood

Assessment
     

1. Restlessness 2. Dyspnea 3. Hypertension 4. Tachycardia 5. Diaphoresis 6. Cyanosis

Nursing Interventions
    

1. Monitor for signs of hypoxia 2. Eliminate the cause of hypoxia 3. Monitor lung sounds and pulse oximetry 4. Administer oxygen as prescribed 5. Encourage deep breathing and coughing and use of the incentive spirometer 6. Turn and reposition the client

Circulatory Complications
  

Deep vein thrombosis Pulmonary embolism Shock

SHOCK (Hypovolemic) - A decrease in cardiac output due to loss of circulating blood volume. - Loss of circulatory fluid volume, which is usually caused by hemorrhage HEMORRHAGE - The loss of a large amount of blood externally or internally in a short period of time


      

Most common causes of shock during post-op postperiod 1. Hemorrhage 2. Sepsis 3. Myocardial infarction and cardiac arrest 4. Drug reactions 5. Transfusion reactions 6. Pulmonary embolism 7. Adrenal failure

Assessment


    

1. Hypotension/Decreased/falling blood pressure (systolic <70 mm Hg). 2. Weak, rapid and thready pulse. 3. Shallow respirations. 4. Cool, clammy skin: 5. Reduced urine output/Oliguria. 6. Excessive thirst.

  

7. Changes in sensorium (restlessness, anxiety,confusion, eventually coma). 8. Incisional area or surgical drains show excessive amount of bright red blood. 9. Decrease in CVP. 10. Restlessness 11. Tachypnea

Nursing Intervention


 

1. Initiate IV access; anticipate plasma expanders, whole blood, IV fluid. 2. Place client in supine/trendelenburg position unless contraindicated. 3. Maintain adequate ventilation. 4. Monitor vital signs every 15 minutes, or as necessary . 5. Do not administer medications via PO, IM or SQ; in shock administer IV medications.

PULMONARY EMBOLISM - The movement of a thrombus from its origin into the pulmonary artery. - An embolus blocking the pulmonary artery and disrupting blood flow to one or more lobes of the lung

Etiology


Originates in the venous system of the lower extremities Dislodged the embolus travels through the systemic system to the pulmonary artery Thrombus formation is often precipitated venous pooling due to immobility, and thrombophlebitis of the lower extremities. The severity of the condition is determined the size of the embolus.

Assessment


  

1. Chest pain - ranging from pleuritic in nature severe stabbing pain/ Sudden sharp chest or upper abdominal pain 2. Mild transient dyspnea to severe dyspnea. 3. Tachycardia. 4. Anxiety, apprehension.

    

5. Diaphoresis. 6. Changes in sensorium. 7. Hypotension. 8. Arterial blood gas - low pCO2 and pO2. 9. Cyanosis

Nursing Interventions
 

    

1. Position client in semi-Fowlers. semi2. Administer oxygen and medications as prescribed 3. Establish IV. 4. Monitor vital signs 5. Notify the physician immediately 6. Maintain bedrest. 7. Anticipate administration of anticoagulants and cardiotonics. 8. Remain with client in acute distress.

Deep vein thrombosis




  

A. Predisposing factors to deep vein thrombosis (DVT) 1. Lower abdominal surgery or septic disease (peritonitis) 2. Injury to vein by tight leg straps during surgery 3. Previous history of venous problems 4. Increased blood coagulability due to dehydration, fluid loss 5. Venous stasis in the extremity due to decreased movement during surgery 6. Prolonged post-op immobilization post-

THROMBOPHLEBITIS 1. Inflammation of a vein, often accompanied by clot formation 2. Veins in the legs are most commonly affected


Assessment
  

  

1. Vein inflammation 2. Aching or cramping pain 3. Vein feels hard and cordlike and is tender to touch 4. Elevated temperature 5. Positive Homans' sign 6. Warm skin that is tender to touch

Nursing Intervention


1. Monitor legs for swelling, inflammation, pain, tenderness, venous distention, and cyanosis 2. Elevate the extremity 30 degrees without allowing any pressure on the popliteal area 3. Encourage the use of antiembolism stockings as prescribed; remove stockings twice a day to wash and inspect the legs 4. Use intermittent pulsatile compression device as prescribed

  

5. Perform passive range of motion every 2 hours if the client is on bed rest 6. Encourage early ambulation as prescribed 7. Do not allow the client to dangle the legs 8. Instruct the client not to sit in one position for an extended period of time 9. Administer heparin sodium or warfarin (Coumadin) as prescribed

WOUND COMPLICATIONS
  

WOUND INFECTION WOUND DEHISCENCE WOUND EVISCERATION

 

WOUND INFECTION - An infection of the surgical incision area. 1. Caused by poor aseptic technique or a contaminated wound before surgical exploration 2. Usually occurs 3 to 6 days after surgery 3. Purulent material may exit from the drains or separated wound edges

Etiology


1. Infection occurs in areas of decreased tissue perfusion. 2. Conditions which encourage a decreased perfusion state are obesity, old age and metabolic disorders. 3. Wound infection may also occur in the imunosuppressed client, or may be due to introduction of bacteria in the area during surgery.

Predisposing factors
     

a. Obesity b. Diabetes mellitus c. Malnutrition d. Elderly clients e. Steroids and immunosuppressive agents f. Lowered resistance to infection, as found in clients with cancer

Assessment
   

  

1. Redness, tenderness, heat in area of incision. 2. Presence of purulent wound drainage, drainage 3. Fever and chills 4. Heat in incisional area/ Warm, tender, painful, and inflamed incision site 5. Edematous skin at incision and tight skin sutures 6. Tachycardia. 7. Leukocytosis.

Nursing Intervention
 

 

1. Prevention. a. Identify clients susceptible to wound infections. b. Use sterile technique in dressing change. 2. Obtain culture and sensitivity of wound drainage (S. aureus most frequently cultured) or incisional area before starting antibiotic.

  

3. Evaluate progress of infection. 4. Prevent skin excoriation around wound. 5. Perform cleansing and irrigation of wound as ordered. 6. Administer antibiotic therapy as ordered.

 

7. Monitor temperature 8. Monitor incision site for approximation of suture line, edema, or bleeding, and signs of infection 9. Maintain patency of drains, and assess drainage amount, color, and consistency 10. Keep drain and tubes away from incision line and maintain asepsis

WOUND DEHISCENCE - is the unintentional opening of the surgical wound; may be sudden or gradual. Dehiscence: opening of wound edges 1. Separation of the wound edges at the suture line 2. Usually occurs 6 to 8 days after surgery


Assessment  1. Increased drainage  2. Opened wound edges  3. Appearance of underlying tissues through the wound

Nursing Intervention
 

1. Notify the physician immediately 2. Cover the wound with a sterile normal saline dressing 3. Place the client in low-Fowler's position lowwith knees bent to prevent abdominal tension on an abdominal suture line 4. Apply Steri-Strips to incision. Steri-

 

5. Prevent wound infection 6. Administer antiemetics as prescribed to prevent vomiting and further strain on the abdominal incision 7. Instruct the client to splint the abdominal incision when coughing

WOUND EVISCERATION - is the protrusion of body contents through the wound (characteristically protrusion of a loop of bowel). - protrusion of loops of bowel through incision; usually accompanied by sudden escape of profuse, pink serous drainage - protrusion of the internal organs and tissues through an opening in the wound edges

 

Most common among obese clients, clients who have had abdominal surgery, or those who have poor wound-healing ability woundUsually occurs 6 to 8 days after surgery Wound evisceration is an emergency

Etiology


 

1. Frequently preceeded by general debilitation thereby causing poor tissue healing. 2. Can be precipitated by inadequate wound closure 3. Faulty wound closure, wound infection 4. Severe abdominal stretching (coughing, abdominal distention, lifting heavy objects).

Assessment


 

1. The client may report feeling a popping sensation after coughing or turning 2. Discharge of serosanguinous fluid from a previously dry wound 3. Separation of incision. 4. Visual evidence of bowel protruding through incision. 5. Client may complain of increase in pain.

Nursing Interventions
 

 

a. Place client in supine position. b. Cover protruding intestinal loops with moist normal saline soaks/ sterile normal saline dressing c. Notify physician. e. Place the client in low-Fowler's position lowwith knees bent to prevent abdominal tension d. Check vital signs.

   

e. Observe for signs of shock. f. Start IV line. g. Prevent wound infection h. Administer antiemetics as prescribed to prevent vomiting and further strain on the incision

 

i. Decrease abdominal tension. j. Instruct the client to splint the incision when coughing k. Prepare client for OR for surgical closure of wound.

Complications of Elimination


Genitourinary System: - urinary retention - urinary tract infection

URINARY RETENTION - Client is unable to void normally. 1. Involuntary accumulation of urine in the bladder as a result of loss of muscle tone 2. Due to the effects of anesthetics and narcotic analgesics 3. Appears 6 to 8 hours after surgery


   

Predisposing factors to urinary retention include 1. Anxiety 2. Pain 3. Lack of privacy 4. Narcotics and certain anesthetics that diminish client's sense of a full bladder

Etiology  1. Depression of urinary reflexes by general anesthesia or by preoperative medication (atropine).  2. Swelling of the urinary tract due to procedures or trauma.

Assessment


  

  

1. Inability to void/Unable to void 8 to 10 hours postoperative. 2. Palpable bladder. 3. Frequent voiding of small amounts. 4. Discomfort in suprapubic area/ Lower abdominal pain and a distended bladder 5. Restlessness and diaphoresis 6. Hypertension 7. On percussion, the bladder sounds like a drum

Nursing Intervention
   

 

1. Monitor for voiding 2. Assess for distended bladder 3. Encourage ambulation when prescribed 4. Encourage fluid intake unless contraindicated 5 Assist the client to void by helping to stand 6. Provide privacy

 

7. Maintain adequate hydration 8. Position client in normal voiding position if not contraindicated 9. Pour warm water over the perineum or allow the client to hear running water to promote voiding(Run tap water). 10. Catheterize the client as prescribed after all noninvasive techniques have been attempted ******Have client practice using bedpan or urinal preoperatively.

PostPost-op urinary tract infections are most commonly caused by catheterization; prevention consists of using strict sterile technique when inserting a catheter, and appropriate catheter care (every 8 hours or according to agency protocol).

GASTROINTESTINAL COMPLICATIONS


  

Paralytic ileus (paralysis of intestinal peristalsis) Gastric dilatation Constipation Intestinal Obstruction

 

Gastric dilatation is decreased peristalsis leading to gastric distention. Etiology 1. Common in clients undergoing abdominal surgery. 2. The decreased or absent peristalsis (due to anesthetic or handling the bowel) causes an increase in the distention leading to a decrease in the circulation.

 

Predisposing factors 1. Temporary: anesthesia, manipulation of bowel during abdominal surgery 2. Prolonged: electrolyte imbalance, wound infection, pneumonia

Assessment  1. Absent/ Decreased bowel sounds  2. No passage of flatus  3. Abdominal distention  4. Nausea, vomiting

Nursing Intervention


 

1. Insert nasogastric tube and connect to added suction. 2. Evaluate nasogastric drainage. 3. Evaluate serum electrolytes.

 

4. Position in semi-Fowler's to prevent aspiration semiof vomitus and to facilitate respirations. 5. Instruct client not to take anything by mouth. / Keep client NPO 6. Maintain adequate hydration by IV. 7. Assess for bowel sounds every 4 hours; check for abdominal distention, passage of flatus. 8. Encourage ambulation if appropriate.

PARALYTIC ILEUS - A failure of neuromuscular innervation leading to decreased peristalsis in intestinal area. 1. Failure of appropriate forward movement of bowel contents 2. May occur as a result of anesthetic medications or manipulation of the bowel during the surgical procedure

Etiology same with gastric dilatation

Assessment  1. Decreased or absent bowel sounds.  2. Failure to pass normal stool or flatus.  3. Nausea, vomiting.  4. Abdominal distention.  5. Abdominal tenderness.

Nursing Intervention


 

1. Maintain NPO status until bowel sounds return 2. Insert nasogastric tube and attach to suction./ Anticipate insertion of intestinal decompression tubes (Miller-Abbott, Cantor (Miller3. Evaluate gastric drainage. 4. Maintain patency of NG tube if in place

  

5. Maintain adequate hydration by IV or TPN as prescribed 6. Administer medications to increase peristalsis and secretions 7. Monitor 1& 0 8. Encourage ambulation 9. If ileus occurs, it is first treated nonsurgically by bowel decompression by insertion of an NG tube attached to intermittent to constant suction

CONSTIPATION 1. Infrequent passage of stool 2. When the client resumes a solid diet postoperatively, failure to pass stool within 48 hours is a cause for concern


Assessment  1. Abdominal distention  2. Absence of bowel movements  3. Anorexia, headache, and nausea

   

Assessment 1. Abdominal distention 2. Absence of bowel movements 3. Anorexia, headache, and nausea

Nursing Interventions  1. Assess bowel sounds  2. Encourage fluid intake up to 3000 mL per day unless contraindicated  3. Encourage early ambulation  4. Encourage consumption of fiber foods unless contraindicated  5. Administer stool softeners and laxatives as pre-scribed  6. Provide privacy and adequate time for bowel elimination  7. Administer drug as ordered

AMBULATORY SURGERY
    

A. Criteria for client discharge 1. Is alert and oriented 2. Has voided 3. Has no respiratory distress 4. Is able to ambulate, swallow, and cough

  

5. Has minimal pain 6. Is not vomiting 7. Has minimal, if any, bleeding from incision site 8. A responsible adult is available to drive the client home 9. The surgeon has signed a release form

 

B. Discharge teaching 1. Should be performed prior to the date of the scheduled procedure 2. Provide written instructions to the client and family regarding the specifics of care 3. Instruct the client and family about postoperative complications that can occur

4. Provide appropriate resources for home care support 5. Instruct the client not to drive for 24 hours if he or she has had general anesthesia 6. Instruct the client to call the surgeon, ambulatory center, or emergency department if postoperative problems occur 7. Instruct the client to keep follow-up followappointments with the surgeon

Postoperative Discharge Teaching




 

Assess the client's readiness to learn, educational level, and desire to change or modify lifestyle. Assess the need for resources needed for home care Demonstrate care to the incision and how to change the dressing. Instruct the client to cover the incision with plastic if showering is allowed. Be sure the client is provided with a 48-hour supply of 48dressings for home use.

Instruct the client on the importance of returning to the physician's office for follow-up. followInstruct the client that sutures are usually removed in the physician's office 7 to 10 days after surgery. Inform the client that staples are removed 7 to 14 days after surgery and that the skin may become slightly reddened when they are ready to be removed. SteriSteri- Strips may be applied to provide extra support after the sutures are removed. Instruct the client on the use of medications, their purpose, doses, administration, and side effects.

Instruct the client on diet and to drink 6 to 8 glasses of liquid a day. Instruct the client on activity levels and to resume normal activities gradually. Instruct the client to avoid lifting for 6 weeks if a major surgical procedure was performed. Instruct the client with an abdominal incision not to lift anything weighing 10 pounds or more and not to engage in any activities that involve pushing or pulling Clients usually can return to work in 6 to 8 weeks as prescribed by the physician. Instruct the client on the signs and symptoms of complication and when to call a physician.

To emphasize


The over-all goal of nursing care during the overPREPRE-OPERATIVE phase is to prepare the patient mentally and physically for the surgery

To emphasize


The over-all goal of nursing care during the overINTRAINTRA-OPERATIVE phase is to maintain client safety

To emphasize


The over-all goals of nursing care during overthe POST-OPERATIVE phase are to POSTpromote healing and comfort, restore the highest possible wellness and prevent associated risk

Thank you!!!