Perioperative nursing


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Perioperative nursing

  1. 1. Lecture Notes on Perioperative Nursing 1Prepared By: Mark Fredderick R Abejo R.N, MAN According to URGENCY Classification Indication Examples for Surgery Emergent – patient - severe requires immediate Without bleeding attention, life delay - gunshot/ threatening condition. stab wounds MEDICAL AND SURGICAL NURSING - Fractured skull PERIOPERATIVE NURSING Urgent / Imperative – Within 24 to - kidney / patient requires prompt 30 hours ureteral Lecturer: Mark Fredderick R. Abejo RN, MAN attention. stones __________________________________________ Required – patient Plan within a - cataract needs to have surgery. few weeks or - thyroid d/o PERIOPERATIVE Elective – patient months Failure to - repair of NURSING should have surgery. have surgery scar not - vaginal catastrophic repairPerioperative Nursing – used to describe the nursingcare provided in the total surgical experience of the Optional – patient’s Personal - cosmeticpatient: preoperative, intraoperative and postoperative. decision. preference surgeryPreoperative Phase, extends from the time the client is According to DEGREE OF RISKadmitted in the surgical unit, to the time he/she is Major Surgeryprepared for the surgical procedure, until he is - High risk / Greater Risk for Infectiontransported into the operating room. - Extensive - ProlongedIntraoperative Phase, extends from the time the client is - Large amount of blood lossadmitted to the OR, to the time of administration of - Vital organ may be handled or removedanesthesia, surgical procedure is done, until he/she is Minor Surgerytransported to the RR/PACU. - Generally not prolonged - Leads to few serious complicationPostoperative Phase, extends from the time the client is - Involves less riskadmitted to the recovery room, to the time he istransported back into the surgical unit, discharged from Ambulatory Surgery/ Same-day Surgery / Outpatientthe hospital, until the follow-up care. Surgery4 Major Types of Pathologic Process Requiring Advantages:Surgical Intervention (OPET) - Reduces length of hospital stay and cuts costs - Reduces stress for the patient Obstruction – impairment to the flow of vital fluids - Less incidence of hospital acquired infection (blood,urine,CSF,bile) - Less time lost from work by the patient; minimal Perforation – rupture of an organ. disruptions on the patient’s activities and family life. Erosion – wearing off of a surface or membrane. Disadvantages: Tumors – abnormal new growths. - Less time to assess the patient and perform preoperative teaching. - Less time to establish rapportClassification of Surgical Procedure - Less opportunity to assess for late postoperative complication.According to PURPOSE: Diagnostic – to establish the presence of a disease Example of Ambulatory Surgery condition. ( e.g biopsy ) Teeth extraction Exploratory – to determine the extent of disease Circumcision condition ( e.g Ex-Lap ) Vasectomy Curative – to treat the disease condition. * Ablative – removal of an organ Cyst removal * Constructive – repair of congenitally Tubal ligation defective organ. * Reconstructive – repair of damage organ Surgical Risks Palliative – to relieve distressing sign and symptoms, Obesity not necessarily to cure the disease. Poor Nutrition Fluid and Electrolyte Imbalances AgeMS Perioperative Nursing Abejo
  2. 2. Lecture Notes on Perioperative Nursing 2Prepared By: Mark Fredderick R Abejo R.N, MAN Presence of Disease (Cardiovascular dse., DM, Fear of Pain Respiratory dse. ) Fear of Death Concurrent or Prior Pharmacotherapy Fear of disturbance on Body image other factors: Worries – loss of finances, employment, social and- nature of condition family roles.- loc. of the condition- magnitude / urgency of the surgery Manifestation of Fears- mental attitude of the patient - anxiousness- caliber of the health care team - bewilderment - anger - tendency to exaggerate - sad, evasive, tearful, clinging PREOPERATIVE PHASE - inability to concentrate - short attention spanGoals - failure to carry out simple directions Assessing and correcting physiologic and - dazed psychologic problems that may increase surgical risk. Giving the person and significant others complete Nursing Intervention to Minimize Anxiety learning / teaching guidelines regarding surgery. Explore client’s feeling Instructing and demonstrating exercises that will Allow client’s to speak openly about fears/concerns benefits the person during postop period. Give accurate information regarding surgery Planning for discharge and any projected changes in (brief, direct to the point and in simple terms) lifestyle due to surgery. Give empathetic support Consider the person’s religious preference andPhysiologic Assessment of the Client Undergoing arrange for visit by a priest / minister as desired.Surgery Age Presence of Pain INFORMED CONSENT Nutritional & Fluid and Electrolyte Balance Cardiovascular / Pulmonary Function Renal Function Purposes: Gastrointestinal / Liver Function To ensure that the client understand the nature of Endocrine Function the treatment including the potential complications Neurologic Function and disfigurement Hematologic Function ( explained by AMD ) Use of Medication To indicate that the client’s decision was made Presence of Trauma & Infection without pressure. To protect the client against unauthorizedRoutine Preoperative Screening Test procedure. To protect the surgeon and hospital against legalTest Rationale action by a client who claims that an authorizedCBC RBC,Hgb,Hct are important to the procedure was performed. oxygen carrying capacity of blood. WBC are indicator of immune Circumstances Requiring Consent function. Any surgical procedure where scalpel, scissors,Blood grouping/ Determined in case blood transfusion suture, hemostats of electrocoagulation may beX matching is required during or after surgery. used.Serum To evaluate fluid and electrolyte Entrance into body cavity.Electrolyte status Radiologic procedures, particularly if a contrastPT,PTT Measure time required for clotting to material is required. occur. General anesthesia, local infiltration and regionalFasting Blood High level may indicate undiagnosed block.Glucose DMBUN / Evaluate renal function Essential Elements of Informed ConsentCreatinine the diagnosis and explanation of the condition.ALT/AST/LDH Evaluate liver function a fair explanation of the procedure to be done andand Bilirubin used and the consequences.Serum albumin Evaluate nutritional status a description of alternative treatment or procedure.and total CHON a description of the benefits to be expected.Urinalysis Determine urine composition material rights if any.Chest Xray Evaluate resp.status/ heart size the prognosis, if the recommended care, procedureECG Identify preexisting cardiac problem. is refused.Psychosocial Assessment and Care Requisites for Validity of Informed ConsentCauses of Fears of the Preoperative Clients Written permission is best and legally accepted. Fear of Unknown ( Anxiety ) Signature is obtained with the client’s complete Fear of Anesthesia understanding of what to occur.MS Perioperative Nursing Abejo
  3. 3. Lecture Notes on Perioperative Nursing 3Prepared By: Mark Fredderick R Abejo R.N, MAN - adult sign their own operative permit  Interlace his fingers and place hands over the - obtained before sedation proposed incision site, this will act as a splint and For minors, parents or someone standing in their will not harm the incision. behalf, gives the consent.  Lean forward slightly while sitting in bed.  Breath, using diaphragm Note: for a married emancipated minor parental  Inhale fully with the mouth slightly open. consent is not needed anymore, spouse is accepted  Let out 3-4 sharp hacks.  With mouth open, take in a deep breath and quickly For mentally ill and unconscious patient, consent give 1-2 strong coughs. must be taken from the parents or legal guardian If the patient is unable to write, an “X” ia accepted Turning if there is a witness to his mark  Changing positions from back to side-lying (vice Secured without pressure and threat versa ) stimulates circulation, encourages deeper A witness is desirable – nurse, physician or breathing and relieve pressure areas authorized persons.  Help the patient to move onto his side if assistance is When an emergency situation exists, no consent is needed. necessary because inaction at such time may cause  Place the uppermost leg in a more flexed position greater injury. (permission via telephone/cellphone than that of the lower leg and place a pillow is accepted but must be signed within 24hrs.) comfortably between the legs.  Make sure that the patient is turned from one side to the back and onto the other side every 2 hours. PREOPERATIVE CARE Foot and Leg Exercise  Moving the legs improves circulation and muscle tone.Physical Preparation  Have the patient lie supine, instruct patient to bend a knee and raise the foot – hold it a few seconds andBefore Surgery lower it to the bed.  Repeat above about 5 times with one leg and then Correct any dietary deficiencies with the other. Repeat the set 5 times every 3-5 Reduce an obese person’s weight hours. Correct fluid and electrolyte imbalances  Then have the patient lie on one side and exercise the Restore adequate blood volume with BT legs by pretending to pedal a bicycle. Treat chronic diseases  For foot exercise, trace a complete circle with the Halt or treat any infectious process great toe. Treat an alcoholic person with vit. supplementation, IVF or fluids if dehydrated Turning to the Side  Turn on your side with the uppermost leg flexed most Preoperative Teaching and supported on a pillow.  Grasp the side rails as an aid to maneuver to the side.Incentive Spirometry Encouraged to use incentive spirometer about 10 to 12 times per hour. Deep inhalations expand alveoli, which prevents atelectasis and other pulmonary complication. There is less pain with inspiratory concentration than with expiratory concentration.Diaphragmatic Breathing Refers to a flattening of the dome of the diaphragm during inspiration, with resultant enlargement of upper abdomen as air rushes in. During expiration, abdominal muscles contract. In a semi-Fowlers position, with your hands loose- fist, allow to rest lightly on the front of lower ribs. Breathe out gently and fully as the ribs sink down and inward toward midline. Then take a deep breath through the nose and mouth, letting the abdomen rise as the lungs fill with air. Hold breath for a count of 5. Exhale and let out all the air through your nose and mouth. Repeat this exercise 15 times with a short rest after each group of 5.Coughing Promotes removal of chest secretions.MS Perioperative Nursing Abejo
  4. 4. Lecture Notes on Perioperative Nursing 4Prepared By: Mark Fredderick R Abejo R.N, MANPreparing the Patient the Evening Before Surgery Check ID band, skin prep Preparing the Skin Check for special orders – enema, IV line - have a full bath to reduce microorganisms in the Check NPO skin. Have client void before preop medication - hair should be removed within 1-2 mm of the skin Continue to support emotionally to avoid skin breakdown, use of electric clipper is Accomplished “preop care checklist preferable. Preparing the G.I tract - NPO, cleansing enema as required PREOPERATIVE MEDICATIONS ASA (American Society of Anesthesiologists) Guidelines for Preoperative Fasting Goals: To aid in the administration of an anesthetics. Liquid and Food Intake Minimum To minimize respiratory tract secretion and changes Fasting Period in heart rate.Clear Liquids 2 To relax the patient and reduce anxiety.Breast Milk 4Nonhuman Milk 6 Commonly used Preop Meds.Light Meal 6 Tranquilizers & SedativesRegular / Heavy Meals 8 * Midazolam * Diazepam ( Valium ) Preparing for Anesthesia * Lorazepam ( Ativan ) - Avoid alcohol and cigarette smoking for at least 24 * Diphenhydramine hours before surgery. Analgesics Promoting rest and sleep * Nalbuphine ( Nubain ) - Administer sedatives as ordered Anticholinergics * Atropine SulfatePreparing the Person on the Day Of Surgery Proton Pump Inhibitors * Omeprazole ( Losec )Early A.M Care * Famotidine Awaken 1 hour before preop medications Morning bath, mouth wash Transporting the Patient to the OR Provide clean gown Adhere to the principle of maintaining the comfort Remove hairpins, braid long hair, cover hair with cap and safety of the patient. if available. Accompany OR attendants to the patient’s bedside Remove dentures, colored nail polish, hearing aid, for introduction and proper identification. contact lenses, jewelries. Assist in transferring the patient from bed to Take baseline vital sign before preop medication. stretcher. Complete the chart and preoperative checklist. Make sure that the patient arrive in the OR at the proper time.MS Perioperative Nursing Abejo
  5. 5. Lecture Notes on Perioperative Nursing 5Prepared By: Mark Fredderick R Abejo R.N, MANPatient’s Family  Each procedure room should maintained with Direct to the proper waiting room. positive pressure, which forces the old air out of Tell the family that the surgeon will probably contact the room and prevents the air from surrounding them immediately after the surgery. areas from entering into the procedure room Explain reason for long interval of waiting: anesthesia prep, skin prep, surgical procedure, RR. • Electrical Safety Tell the family what to expect postop when they see  Faulty wiring, excessive use of extension cords, the patient poorly maintained equipment and lack of current safety measures are just some of the hazardous factors that must be constantly INTRAOPERATIVE PHASE checked  All electrical equipment new or used, should beGoal: routinely checked by qualified personnel. Asepsis  Equipment that fails to function at 100% Homeostasis efficiency should be taken out of service immediately. Safe Administration of Anesthesia Hemostasis • Communication System The Surgical TeamSurgical Environment SurgeonUnrestricted Area • Primary responsible for the preoperative - provides an entrance and exit from the surgical suite medical history and physical assessment.for personnel, equipment and patient • Performance of the operative procedure - street clothes are permitted in this area, and the area according to the needs of the patients.provides access to communication with personnel within • The primary decision maker regarding surgicalthe suite and with personnel and patient’s families technique to use during the procedure.outside the suit. • May assist with positioning and prepping the patient or may delegate this task to otherSemi-restricted Area members of the team - provides access to the procedure rooms andperipheral support areas within the surgical suite. Assistant Surgeon - personnel entering this area must be in proper • May be a resident, intern , physician’s assistantoperating room attire and traffic control must be or a perioperative nurse.designed to prevent violation of this area by • Assists with retracting, hemostasis, suturing andunauthorized persons any other tasks requested by the surgeon to - peripheral support areas consists of: storage areas facilitate speed while maintaining qualityfor clean and sterile supplies, sterilization equipment and during the procedure.corridors leading to procedure room AnesthesiologistRestricted Area • Selects the anesthesia, administers it, intubates - includes the procedure room where surgery is the client if necessary, manages technicalperformed and adjacent substerile areas where the scrub problems related to the administration ofsinks and autoclaves are located anesthetic agents, and supervises the client’s - personnel working in this area must be in proper condition throughout the surgical procedure.operating room attire • A physician who specializes in the administration and monitoring of anesthesia while maintaining the overall well-being of theEnvironmental Safety patient.• The size of the procedure room Scrub Nurse  Usually rectangular or square in shape • May be either a nurse or a surgical technician.  20 x 20 x 10 with a minimum floor space of • Reviews anatomy, physiology and the surgical 360 square feet procedures. • Assists with the preparation of the room.• Temperature and humidity control • Scrubs, gowns and gloves self and other  The temperature in the procedure room should members of the surgical team. maintained between 68 F - 75 F ( 20 - 24 • Prepares the instrument table and organizes degrees C) sterile equipment for functional use.  Humidity level between 50 - 55 % at all times • Assists with the drapping procedure. • Passes instruments to the surgeon and assistants• Ventilation and air exchange system by anticipating their need.  Air exchange in each procedure room should be • Counts sponges, needles and instruments. at least 25 air exchanges every hour, and five of • Monitor practices of aseptic technique in self that should be fresh air. and others.  A high filtration particulate filter, working at • Keeps track of irrigations used for calculations 95% efficiency is recommended. of blood lossMS Perioperative Nursing Abejo
  6. 6. Lecture Notes on Perioperative Nursing 6Prepared By: Mark Fredderick R Abejo R.N, MANCirculating Nurse Surgical Incisions • Must be a registered nurse who, after additional education and training, specialized in Incision Site Type of Surgery perioperative nursing practice. Butterfly For craniotomy • Responsible and accountable for all activities Limbal For eye surgeries occurring during a surgical procedure including Halstead / Elliptical For breast surgeries the management of personnel equipment, Subcostal Gallbladder and biliary tract supplies and the environment during a surgical surgery procedure. Paramedian Right side – gallbladder, biliary • Patient advocate, teacher, research consumer, tract leader and a role model. Left side - splenectomy • May be responsible for monitoring the patient Transverse Gastrectomy during local procedures if a second Rectus Right side – small bowel perioperative nurse is not available. resection • Ensure all equipment is working properly. Left side – sigmoid colon • Guarantees sterility of instruments and supplies. resection • Assists with positioning. McBurney Appendectomy • Monitor the room and team members for breaks Pfannenstiel Gynecologic surgery in the sterile technique. Lumbotomy For kidney surgeries • Handles specimens. • Coordinates activities with other departments, Position During Surgery such as radiology and pathology. • Documents care provided. Position Type of Surgery • Minimizes conversation and traffic within the Dorsal Recumbent Hernia repair, mastectomy, operating room suite. bowel resection Trendelenburg Pelvic Surgeries Lithotomy Vaginal repair, D&C, rectalPrinciples of Surgical Asepsis surgery, APR Prone Spinal surgery, laminectomy Sterile object remains sterile only when touched by Lateral Kidney, chest, hip surgery another sterile object Jack Knife Position Rectal procedures, Only sterile objects may be placed on a sterile field sigmoidoscopy and colonosc A sterile object or field out of range of vision or an Reverse Upper abdominal, head, neck object held below a person’s waist is contaminated Trendelenburg and facial surgery When a sterile surface comes in contact with a wet, Position contaminated surface, the sterile object or field becomes contaminated by capillary action Explain the purpose of position Fluid flows in the direction of gravity Avoid undue exposure The edges of a sterile field or container are Strap the person to prevent falls considered to be contaminated (1 inch) Maintain adequate respiratory and circulatory functions. Medical Asepsis vs. Surgical Asepsis Maintain good body alignment ANESTHESIA • State of “Narcosis” • Anesthetics can produce muscle relaxation, block transmission of pain nerve impulses and suppress reflexes. • It can also temporary decrease memory retrieval and recall. The effects of anesthesia are monitored by considering the following parameters: - Respiration - O2 saturation / CO2 level - HR and BP - Urine output Types of Anesthesia 1. General Anesthesia reversible state consisting of complete loss of consciousness and sensation. protective reflexes such as cough and gag are lost provides analgesia, muscle relaxation and sedation. produces amnesia and hypnosis.MS Perioperative Nursing Abejo
  7. 7. Lecture Notes on Perioperative Nursing 7Prepared By: Mark Fredderick R Abejo R.N, MANTechniques used in General Anesthesia E. Intravenous Block ( Beir block ) often used for arm,wrist and hand procedureA. Intravenous Anesthesia an occlusion tourniquet is applied to the extremity to prevent infiltration and absorption of the injected IV This is being administered intravenously and agents beyond the involved extremity. extremely rapid. Its effect will immediately take place after thirty minutes of introduction. It prepares the client for smooth transition to the surgical anesthesia.B. Inhalation Anesthesia This comprises of volatile liquids or gas and oxygen. Administered through a mask or endotracheal tube2. Regional Anesthesia temporary interruption of the transmission of nerve impulses to and from specific area or region of the body. achieved by injecting local anesthetics in close proximity to appropriate nerves. reduce all painful sensation in one region of the body Indicating a site for insertion of the lumber puncture without inducing unconsciousness. needle into the subarachnoid space of the spinal agents used are lidocaine and bupivacaine. canal.Techniques used in Regional Anesthesia:A. Topical Anesthesia applied directly to the skin and mucous membrane, open skin surfaces, wounds and burns. readily absorbed and act rapidly used topical agents are lidocaine and benzocaine.B. Spinal Anesthesia ( Subarachnoid block ) local anesthetic is injected through lumbar puncture, between L2 and S1 anesthetic agent is injected into subarachoid space surrounding the spinal cord. F. Caudal Anesthesia - Low spinal, for perineal/rectal areas Is produced by injection of the local anesthetic into - Mid spinal T10 ( below level of umbilicus) the caudal or sacral canal for hernia repair and appendectomy. - High spinal T4 ( nipple line ), for CS G. Field Block Anesthesia anesthetic block conduction in spinal nerve roots and The area proximal to a planned incision can be dorsal ganglia; paralysis and analgesia occur below injected and infiltrated with local anesthetic agents. level of injection agents used are procaine, tetracaine, lidocaine and Stages of Anesthesia bupivacaine.  Onset / Induction. Extends from the administration of anesthesia to the time of lossC. Epidural Anesthesia of consciousness. achieved by injecting local anesthetic into epidural space by way of a lumbar puncture.  Excitement / Delirium. Extends from the time result similar to spinal analgesia of loss of consciousness to the time of loss of agents use are chloroprocaine, lidocaine and lid reflex. Increase in autonomic activity and bupivacaine. irregular breathing. It may be characterized by shouting, struggling of the client.D. Peripheral Nerve Block  Surgical. Extends from the loss of lid reflex to achieved by injecting a local anesthetic to anesthetize the loss of most reflexes. surgical procedure is the surgical site. started. agents use are chloroprocaine, lidocaine and bupivacaine.  Medullary / Stage of Danger. It is characterized by respiratory and cardiac depression or arrest. It is due to overdose of anesthesia. Resuscitation must be done.MS Perioperative Nursing Abejo
  8. 8. Lecture Notes on Perioperative Nursing 8Prepared By: Mark Fredderick R Abejo R.N, MANComplication and Discomforts of Anesthesia Hypoventilation - inadequate ventilatory support POSTOPERATIVE PHASE after paralysis of respiratory muscles. Goals: Oral Trauma Maintain adequate body system functions Malignant Hyperthermia Restore homeostasis Hypotension - due to preoperative hypovolemia or Alleviate pain and discomfort untoward reactions to anesthetic agents. Prevent postop complication Cardiac Dysrhythmia - due to preexisting Ensure adequate discharge planning and teaching. cardiovascular compromise, electrolyte imbalance or untoward reaction to anesthesia. Hypothermia - due to exposure to a cool ambient OR environment and loss of thermoregulation PACU CARE capacity from anesthesia. Peripheral Nerve Damage - due to improper positioning of patient or use of restraints. Transport of client from OR to RR Nausea and Vomiting avoid exposure Headache avoid rough handling avoid hurried movement and rapid changes in position.MS Perioperative Nursing Abejo
  9. 9. Lecture Notes on Perioperative Nursing 9Prepared By: Mark Fredderick R Abejo R.N, MANInitial Nursing Assessment  Use mechanical ventilation to maintain adequate pulmonary ventilation if required. Verify patient’s identity, operative procedure and the surgeon who performed the procedure. Assessing Thermoregulatory Status Evaluate the following sign and verify their level of  Monitor temperature per protocol to be alert for stability with the anesthesiologist: malignant hyperthermia or to detect hypothermia. - Respiratory status  Report a temperature over 37.8 C or under 36.1 C - Circulatory status  Monitor for postanesthesia shivering, 30-45 minutes - Pulses after admission to the PACU. - Temperature  Provide a therapeutic environment with proper - Oxygen Saturation level temperature and humidity. - Hemodynamic values Determine swallowing and gag reflex , LOC and Maintaining Adequate Fluid Volume patients response to stimuli. Evaluate lines, tubes, or drains, estimate blood loss,  Administer I.V solutions as ordered. condition of wound, medication used, transfusions and  Monitor evidence of F&E imbalance such as N&V output. and weakness. Evaluate the patient’s level of comfort and safety.  Evaluate mental status, skin color and turgor Perform safety check; side rails up and restraints are  Recognized signs of: properly in placed. a. Hypovolemia Evaluate activity status, movement of extremities. - decrease BP - decrease urine output Review the health care provider’s orders. - decreased CVP - increased pulseInitial Nursing Interventions b. Hypervolemia - increase BPMaintaining a Patent Airway - changes in lung sounds (S3 gallop ) - increased CVP Allow the airway ( ET tube ) to remain in place until  Monitor I&O the patient begins to waken and is trying to eject the airway. Minimizing Complications of Skin Impairment The airway keeps the passage open and prevents the tongue from falling backward and obstructing the air  Perform handwashing before and after contact with passages. the patient Aspirate excessive secretions when they are heard in  Inspect dressings routinely and reinforce them if the nasopharynx and oropharynx. necessary.  Record the amount and type of wound drainage.Assessing Status of Circulatory System  Turn patient frequently and maintain good body alignment. Take VS per protocol, until patient is well stabilized. Monitor intake and output closely. Maintaining Safety Recognized early symptoms of shock or hemorrhage:  Keep the side rails up until the patient is fully awake. - cool extremities  Protect the extremity into which I.V fluids are - decreased urine output ( less than 30ml/hr ) running so needle will not become accidentally - slow capillary refill ( greater than 3 sec. ) dislodged. - lowered BP  Avoid nerve damage and muscle strain by properly - narrowing pulse pressure supporting and padding pressure areas. - increased heart rate  Recognized that the patient may not be able to * initiate O2 therapy, to increase O2 complain of injury such as the pricking of an open availability from the blood. safety pin or clamp that is exerting pressure. * place the patient in shock position with his  Check dressing for constriction feet elevated ( unless contraindicated ) Promoting ComfortMaintaining Adequate Respiratory Function  Assess pain by observing behavioral and physiologic manifestations. Place the patient in lateral position with neck  Administer analgesic and document efficacy. extended ( if not contraindicated ) and upper arm  Position the patient to maximize comfort. supported on a pillow. Turn the patient every 1 to 2 hours to facilitate breathing and ventilation. Parameter for Discharge from PACU/RR Encourage the patient to take deep breaths, use an incentive spirometer. Activity. Able to obey commands Assess lung fields frequently by auscultation. Periodically evaluate the patient’s orientation – Respiratory. Easy, noiseless breathing response to name and command. Circulation. BP within 20mmHg of preop level Note: Alterations in cerebral function may suggest Consciousness. Responsive impaired O2 delivery. Color. Pinkish skin and mucus membrane Administer humidified oxygen if required.MS Perioperative Nursing Abejo
  10. 10. Lecture Notes on Perioperative Nursing 10Prepared By: Mark Fredderick R Abejo R.N, MANNursing Care of the Client During the IntermediatePostop Period (RR – Unit ) Goals: o Restore homeostasis and prevent complication.Baseline Assessment o Maintain adequate cardiovascular and tissue Respiratory Status perfusion. Cardiovascular Status o Maintain adequate respiratory function. - VS o Maintain adequate nutrition and elimination. - Color and Temperature of Skin o Maintain adequate fluid and electrolyte balance. Level of Consciousness o Maintain adequate renal function. Tubes o Promote adequate rest, comfort and safety. - Drain o Promote adequate wound healing. - NGT o Promote and maintain activity and mobility. - T-tube o Provide adequate psychological support. PositionMS Perioperative Nursing Abejo
  11. 11. Lecture Notes on Perioperative Nursing 11Prepared By: Mark Fredderick R Abejo R.N, MANMS Perioperative Nursing Abejo
  12. 12. STI Global City College of Nursing / QMMC Surgery Ward ExposureLecture Notes on Perioperative Nursing 12Prepared By: Mark Fredderick R Abejo R.N Clinical Instructor WOUND CAREFrequently used Dressing Materials Common dressing Irrigating a woundMontgomery Straps holding dressing The strips of tape should be placed at the ends of the dressing and must be sufficiently long and wide to secure the dressing. The tape should adhere to intact skin.Cleaning Surgical Site Cleaning a wound outward from the incisionCleaning from top to bottom Cleaning around aStarting at the center Penrose drain siteMS Perioperative Nursing Abejo
  13. 13. STI Global City College of Nursing / QMMC Surgery Ward ExposureLecture Notes on Perioperative Nursing 13Prepared By: Mark Fredderick R Abejo R.N Clinical Instructor INCISION SUPPORTINGBODY PRESSURE AREAS:MS Perioperative Nursing Abejo
  14. 14. STI Global City College of Nursing / QMMC Surgery Ward ExposureLecture Notes on Perioperative Nursing 14Prepared By: Mark Fredderick R Abejo R.N Clinical Instructor POST OPERATIVE COMPLICATIONS Problem Description Cause Clinical Signs Nursing InterventionRESPIRATORYPneumonia Inflammation of the Infection - elevated temp. Deep breathing exercises lung parenchyma / Toxin / irritants - cough Coughing exercise alveoli causing - blood tinged Early ambulation inflammatory sputum process - dyspnea - chest painInfectious Cause byPneumonia streptococcus pneumoniae / Staphylococcus aureusHypostatic ImmobilityPneumonia Impaired ventilationAspiration Aspiration ofPneumonia gastric contents, foodAtelectasis A condition in Mucous plugs - Fever ( 1st 24 Deep breathing exercises which alveoli blocking bronchial hours) Coughing exercise collapsed and are passageways - Dyspnea Early ambulation not ventilated Inadequate lung - Tachycardia expansion - Diaphoresis Immobility - Pleural pain - Dull or absent lung sounds - Dec. SaO2Pulmonary Blood clot that has Immobility - Sudden chest TurningEmbolism moved to the lungs Use of oral pain Ambulation and blocks a contraceptives - SOB Anti embolic stockings pulmonary artery Coagulation - Cyanosis Compression devises and obstruct blood problem - Tachycardia Prevent massaging the flow to the lungs - Low BP lower extremitiesCIRCULATIONHypovolemia Inadequate Hemorrhage - Tachycardia Fluid and blood circulating blood Fluid deficit - Dec. urine replacement volume output - Dec. BPHemorrhage Internal or external Disruption of - Cold, moist and Fluid and blood bleeding sutures pale skin replacement Insecure ligation of - Deep, rapid RR Vit.k and hemostat Capillary – slow blood vessels - Low temp Ligation of bleeders generalized oozing - Increase pain Pressure dressing Venous – dark in - Inc. abd. girth color and bubble out - Swelling or Arterial – spurts, bruising around bright red in color incisionMS Perioperative Nursing Abejo
  15. 15. STI Global City College of Nursing / QMMC Surgery Ward ExposureLecture Notes on Perioperative Nursing 15Prepared By: Mark Fredderick R Abejo R.N Clinical Instructor Overt Bleeding - Dressing saturated with bright blood - Bright, free- flowing blood in drains or tubes.Thrombophlebitis Inflammation of the Slowed venous - Homan’s Sign Early ambulation veins, usually of the blood flow due to pain, discomfort in Anti embolic stocking legs and associated immobility or calf when foot is Encourage leg exercise with a blood clot. prolonged sitting dorsiflexed Hydrate adequately Trauma to the vein - Aching, cramping Avoid any restricting Increased blood pain devices that impaired coagulability. - Swollen, red and circulation hot to touch Avoid massage on the - Vein feels hard calf of the leg Initiate anticoagulant Arterial therapy - Pain - Pallor on the affected Blood clot attached extremities to wall of vein or - Dec./absent ofThrombus artery peripheral pulse Note: Careful maintenance of Embolus in the IV catheters Foreign body or clot Broken IV catheter venous system that has moved from Fat usually becomes aEmbolus its site of formation Amniotic fluid pulmonary to another area of embolus the bodyURINARYUrinary Inability to empty Depressed bladder - Larger fluid Monitor I & ORetention the bladder, with muscle tone from intake than output Interventions to facilitate excessive narcotics and - Inability to void voiding accumulation of anesthetics - Bladder Urinary Catheterization urine in the bladder Handling of tissue distention as needed during surgery on - Suprapubic adjacent organs discomfort Spasm of the - Restlessness bladder sphincterUrinary Inability of the Loss of tone of the - 30 – 60 ml of Monitor I & OIncontinence bladder to hold bladder sphincter urine q 15-30 mins accumulated urineUrinary Tract Inflammation of the Immobilization - Fever ( 48 hours Adequate fluid intakeInfection bladder, ureters or Limited fluid postop) Early ambulation urethra intake - Burning sensation Aseptic catheterization as when voiding needed - Urgency Good perineal hygiene - Cloudy urine - Lower abdominal painMS Perioperative Nursing Abejo
  16. 16. STI Global City College of Nursing / QMMC Surgery Ward ExposureLecture Notes on Perioperative Nursing 16Prepared By: Mark Fredderick R Abejo R.N Clinical InstructorGASTRO-INTESTINALNausea and Pain - Complaints of IV fluids until peristalsisVomiting Abdominal feeling sick to the returns distention stomach Progressive diet ( clear Ingestion of fluid - Retching liquid then full fluids, soft or food before the - Gagging then regular diet) return of peristalsis Anti emetics as orderedTympanities Retention of gases Slowed motility of - Abdominal Early ambulation within the intestines the intestines due to distention Avoid using straw effects of anesthesia - Absence of bowel Provide ice chips soundHiccups Intermittent spasms Irritation of - A sound NGT insertion as needed of the diaphragm phrenic nerve bet. “hic” that result Hold breath while taking the spinal cord and from the vibration a large swallow of water terminal of closed vocal Breath in and out on a ramifications on cords as air rushes paper bag undersurface of the suddenly into the Anti emetics as ordered diaphragm lungs Abdominal distentionIntestinal Kink loop of Due to - Intermittent NGT insertion as neededObstruction intestines inflammatory sharp, colicky Administered IVF as( 3rd-5th day adhesions abdominal pains orderedpostop) - Nausea & Prepare for possible Vomiting surgery - Abdominal distention - Hiccups - No bowel movementConstipation Infrequent or no Lack of dietary - Absence of stool Adequate hydration stool passage for roughage elimination High fiber diet abnormal length of Analgesics - Abdominal Encourage early time Immobility distention ambulation ( within 48 hours - Abdominal after solid diet discomfort started )Paralytic Ileus Lack of peristaltic Due to anesthetics - Abdominal pain Encourage early activity Immobility - Abdominal ambulation distention - Constipation - Absence of bowel soundsWOUNDWound Infection Inflammation and Poor aseptic - Fever ( 72 hours Keep wound clean and infection of incision techniques postop) dry or drain site - Redness, swelling Surgical aseptic technique , pain and warmth when changing dressing - Pus or discharge Antibiotic therapy on the wound site - Foul smelling dischargeMS Perioperative Nursing Abejo
  17. 17. STI Global City College of Nursing / QMMC Surgery Ward ExposureLecture Notes on Perioperative Nursing 17Prepared By: Mark Fredderick R Abejo R.N Clinical InstructorWound Separation of a - Increased incisionDehiscence suture line before drainage Apply abdominal binders the incision heals - Tissues Encourage high protein Malnutrition underlying skin diet and Vit.C intake emaciation/obesity become visible Keep in bed rest Excessive strain on suture lineWound Extrusion of internal Poor circulation - Opening of Semi-Fowlers, bendEvisceration organ or tissues incision and visible knees to relieve tension on through the incision protrusion of the abdominal muscles organs Splinting on coughing Cover exposed organ with sterile , moist saline dressing Reassure, keep him/her quite and relaxed Prepare for surgery and repair of woundPSYCHOLOGICPostoperative Altered Mood Weakness - Anorexia Adequate restDepression Surprise nature of - Tearfulness Physical activity “E” surgery - Withdrawal Opportunity to express News of - Rejection of anger and other negative malignancy others feelings Severely altered - Sleep body image disturbancesDelirium / Acute Dehydration - Poor memory Sedatives to keep clientConfusional State Insufficient - Restlessness quite and comfortable oxygenation - Inattentive Explain reasons for Anemia - Inappropriate interventions Hypotension behavior Listen and talk to the Hormonal - Wild excitement client Imbalances - Hallucination Provide physical comfort Infection - Delusions - Disoriented Trauma - Sleep disturbancesMS Perioperative Nursing Abejo
  18. 18. STI Global City College of Nursing / QMMC Surgery Ward ExposureLecture Notes on Perioperative Nursing 18Prepared By: Mark Fredderick R Abejo R.N Clinical Instructor STUDY HARD GOD BLESS YOU THANKS Mark Fredderick R. Abejo R.N, M.A.N Clinical InstructorMS Perioperative Nursing Abejo