Peri-operative nursing
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Peri-operative nursing

Peri-operative nursing

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    Peri-operative nursing Peri-operative nursing Presentation Transcript

    • Perioperative Nursing Definition of SurgeryDefinition of Surgery Surgery is any procedure performed onSurgery is any procedure performed on the human body that uses instruments tothe human body that uses instruments to alter tissue or organ integrityalter tissue or organ integrity.
    • Perioperative Nursing Perioperative NursingPerioperative Nursing- connotes the delivery of patient care in the preoperative,intraoperative, and postoperativepostoperative periods of the patients surgical experience through the framework of the nursing process. The nurse assesses the patient- collecting,organizing, and prioritizing patient data; establishing nursing diagnosis;identifies desired patient outcomes;develop and implements a plan of care; and evaluates that care in terms of outcomes achieved by the patient.
    • Perioperative Nursing Phases Preoperative phase –Preoperative phase – begins when thebegins when the decision to have surgery is made and endsdecision to have surgery is made and ends when the client is transferred to the OR table.when the client is transferred to the OR table. Intraoperative phase –Intraoperative phase – begins when the clientbegins when the client is transferred to the OR table and ends whenis transferred to the OR table and ends when the client is admitted to the PACU.the client is admitted to the PACU. Postoperative phase -Postoperative phase - begins with thebegins with the admission of the client to the PACU and endsadmission of the client to the PACU and ends when the healing is complete.when the healing is complete.
    • Perioperative Nursing Types of SurgeryTypes of Surgery Purpose/reasonsPurpose/reasons - Degree of urgencyDegree of urgency – necessity to preserve the client’s life, body part, or body function. Degree of riskDegree of risk – involved in surgical procedure is affected by the client’s age, general health, nutritional status, use of medications, and mental status. Extent of surgeryExtent of surgery – Simple and radical
    • Perioperative Nursing Type of Surgery (Purpose)Type of Surgery (Purpose) DiagnosticDiagnostic-Allows to confirm or establishes diagnosis. CorrectiveCorrective- Excision or removal of diseased body part. ReconstructiveReconstructive-Restore function or appearance to traumatized or malfunctioning tissues. AblativeAblative – Removes a diseased body parts PalliativePalliative – Relieves or reduces pain or symptoms of a disease; it does not cure TransplantTransplant – Replaces malfunctioning structures CosmeticCosmetic- Performed to improve personal appearance.
    • Perioperative Nursing Types of Surgery (Urgency)Types of Surgery (Urgency) Emergency-Emergency- performed immediately to preserve function or the life of the client. ElectiveElective – is performed when surgical intervention is the preferred treatment for a condition that is not imminently life threatening or to improve the client’s life. UrgentUrgent – Necessary for client’ health to prevent additional problem from developing; not necessarily an emergency. RequiredRequired – has to be performed at some point; can be pre-scheduled.
    • Perioperative Nursing Type of Surgery (Degree of Risk)Type of Surgery (Degree of Risk) MajorMajor – involves a high degree of risk. MinorMinor – normally involves little risk. AgeAge – very young and elder clients are greater surgical risks than children and adult. General healthGeneral health- surgery is least risky when the client’s general health is good. Nutritional StatusNutritional Status – required for normal tissue repair. MedicationsMedications – regular use of certain medications can increase surgical risk. Mental statusMental status – disorder that affect cognitive function
    • Perioperative Nursing Surgical settingsSurgical settings Surgical suitesSurgical suites Ambulatory care settingAmbulatory care setting ClinicsClinics Physician officesPhysician offices Community settingCommunity setting HomesHomes
    • Perioperative Nursing Surgical settingsSurgical settings DisadvantagesDisadvantages Less time for rapport Less time to assess, evaluation, teach Risk of potential complication post D/C. Advantages of outpatientAdvantages of outpatient: Low cost Low risk of infection Less interruption of routine Less than from work Less stress
    • Preoperative Nursing ConsentConsent Nature and intention of the surgeryNature and intention of the surgery Name and qualifications of the personName and qualifications of the person performing the surgery.performing the surgery. Risks, including tissue damage, disfigurement,Risks, including tissue damage, disfigurement, or even deathor even death Chances of successChances of success Possible alternative measuresPossible alternative measures The right of the client to refuse consent or laterThe right of the client to refuse consent or later withdraw consent.withdraw consent.
    • Preoperative Nursing Assessment (Nursing History)Assessment (Nursing History) Current health status-Current health status- AllergiesAllergies Medications- list all current medicationsMedications- list all current medications Previous surgeriesPrevious surgeries Understanding of the surgical procedure andUnderstanding of the surgical procedure and anesthesiaanesthesia SmokingSmoking Alcohol and other-altering substancesAlcohol and other-altering substances CopingCoping Social resourcesSocial resources Cultural considerationsCultural considerations
    • Preoperative Nursing Care Physical assessmentPhysical assessment Cardiovascular systemCardiovascular system Respiratory systemRespiratory system Renal systemRenal system Neurological systemNeurological system Musculoskeletal systemMusculoskeletal system Nutritional statusNutritional status Gerontological considerationsGerontological considerations
    • Perioperative Nursing Care Physical assessment/clinical manifestationsPhysical assessment/clinical manifestations General surveyGeneral survey- gestures and body movements may reflect decreased energy or weakness caused by illness. Cardiovascular systemCardiovascular system- alterations in cardiac status are responsible for as many as 30% of perioperative death. Respiratory systemRespiratory system- a decline in ventilatory function, assessed through breathing pattern and chest excursion, may indicate a client’s risk for respiratory complications.
    • Perioperative Nursing Care Physical assessment/clinical manifestationsPhysical assessment/clinical manifestations Renal systemRenal system-abnormal renal function can altered fluid and electrolyte balance and decrease the excretion of preoperative medications and anesthetic agents. Neurologic systemNeurologic system- a client’s LOC will change as a result of general anesthesia but should return to the preoperative LOC after surgery.
    • Perioperative Nursing Care Physical assessment/clinical manifestationsPhysical assessment/clinical manifestations MusculoskeletalMusculoskeletal systemsystem- Deformities may interfere with intraoperative and postoperative positioning. Avoid positioning over an area where the the skin shows signs of pressure over bony prominences. Gastrointestinal systemGastrointestinal system- alteration in function after surgery may result in decreased or absent bowel sound and distention. Head and NeckHead and Neck- the condition of oral mucous membranes reveals the level of hydration.
    • Preoperative Nursing Care Gerontological ConsiderationsGerontological Considerations CardiovascularCardiovascular Coronary flow decreasesCoronary flow decreases Heart rate decreasesHeart rate decreases Response to stress decreasesResponse to stress decreases Peripheral vascular decreasesPeripheral vascular decreases Cardiac output decreasesCardiac output decreases Cardiac reserve decreasesCardiac reserve decreases
    • Preoperative Nursing Care Gerontological ConsiderationsGerontological Considerations Respiratory SystemRespiratory System Static lung volumes decreases Pulmonary static recoil decreases Sensitivity of the airway receptors decreases Nervous systemNervous system Increased incidence of post.op. confusion. Increased incidence of delirium Increased sensitivity to anesthetic agents
    • Preoperative Nursing Care Gerontological ConsiderationsGerontological Considerations Renal SystemRenal System Renal blood flow declines 1.5% per year. Renal clearance reduced GastrointestinalGastrointestinal Decreased intestinal motility Decreased liver blood flow Delayed gastric emptying
    • Preoperative Nursing Care Gerontological ConsiderationsGerontological Considerations MusculoskeletalMusculoskeletal Decreased mass, tone, strength Decreased bone density IntegumentaryIntegumentary Decreased elasticity Decreased lean body mass Decreased subcutaneous fat
    • Preoperative Nursing Care Psychosocial considerationsPsychosocial considerations Level of anxietyLevel of anxiety Coping abilityCoping ability Support systemsSupport systems
    • Preoperative Nursing Care Laboratory and diagnostic studiesLaboratory and diagnostic studies Screening tests depend on the condition of the client and the nature of the surgery. If test reveals severe problems the surgery may be cancel until the condition is stabilized. Routine screening testRoutine screening test-CBC, Blood grouping and X-match, Lytes, fasting blood sugar, BUN & Creatinine, ALT,AST, and bilirubin,Serum albumin, and Total protein, Urinalysis, Chest X-ray,ECG
    • Preoperative Nursing Care Common nursing diagnosisCommon nursing diagnosis Knowledge deficitKnowledge deficit AnxietyAnxiety Risk for ineffective airway clearanceRisk for ineffective airway clearance Fear related toFear related to Disturbed sleep patternDisturbed sleep pattern Anticipatory grieving related toAnticipatory grieving related to
    • Preoperative Nursing CarePreoperative Nursing Care Preop. teachingPreop. teaching The education plan should begin with assessment,The education plan should begin with assessment, including baseline knowledge of the patient andincluding baseline knowledge of the patient and family, readiness to learn,barriers to learning,family, readiness to learn,barriers to learning, patient and family concern and learning styles andpatient and family concern and learning styles and preferences.preferences. The content focuses on information that willThe content focuses on information that will increase patient’s familiarity with proceduralincrease patient’s familiarity with procedural events. This includes surgical experienceevents. This includes surgical experience (procedural), what the pt. may experience(procedural), what the pt. may experience (sensory) and what actions may help decrease(sensory) and what actions may help decrease anxiety (behavioral).anxiety (behavioral).
    • Preoperative Nursing CarePreoperative Nursing Care AnxietyAnxiety The nurse must consider the pt’sThe nurse must consider the pt’s family and friends when planningfamily and friends when planning psychological support.psychological support. Empowering their sense of control.Empowering their sense of control. Activities that decreasing anxiety areActivities that decreasing anxiety are deep breathing, relaxation exercises,deep breathing, relaxation exercises, music therapy, massage and animal-music therapy, massage and animal- assisted therapy.assisted therapy. Use of medication to relieve anxietyUse of medication to relieve anxiety..
    • Preoperative Nursing Care Preanesthesia Management Physical Status Categories ASA 1: Healthy patient with no disease ASA 11: Mild systemic ds without fx limitations ASA 111:Severe systemic ds associated with definite fx limitations ASA 1V: Severe systemic ds that is a constant threat to life. ASA V: Moribund pt. Who is not expected to survive without the operation. ASA V1: A declared brain-death whose organ are being recovered for donor. E: Emergency
    • Preoperative Nursing CarePreoperative Nursing Care Final Preparation for surgeryFinal Preparation for surgery All personal belongings are identifiedAll personal belongings are identified and secured.and secured. Jewelry is usually removed.Jewelry is usually removed. Dentures are removed, labeled andDentures are removed, labeled and placed in a denture cup.placed in a denture cup. Pt. to verbally confirm the surgicalPt. to verbally confirm the surgical procedures and the surgical site. Thisprocedures and the surgical site. This verification process is documented inverification process is documented in the medical record on the preop.the medical record on the preop. checklistchecklist.
    • Preoperative Nursing CarePreoperative Nursing Care Pre-op. medicationsPre-op. medications Prior to administering – check permitsPrior to administering – check permits Purpose: Allay anxietyPurpose: Allay anxiety Decrease pharyngeal secretions-Decrease pharyngeal secretions- Decrease gastric secretion.Decrease gastric secretion. Decrease side effects of anesthesia.Decrease side effects of anesthesia. Induce amnesiaInduce amnesia
    • Preoperative Nursing CarePreoperative Nursing Care MedicationsMedications Sedatives/hypnotics- Nembutal Tranquilizers-Ativan, versed, valium Opiate analgesics- Demerol, morphine Anticholinergics-Atropine sulfate,atarax H2o blockers.- Tagamet, Zantac Antiemetic- Reglan, Phenergan
    • Intraoperative Phase Surgical TeamSurgical Team SurgeonSurgeon AnesthesiologistAnesthesiologist Scrub NurseScrub Nurse Circulating NurseCirculating Nurse OR techsOR techs
    • Intraoperative Nursing CareIntraoperative Nursing Care Roles of team membersRoles of team members SurgeonSurgeon-responsible for determining theresponsible for determining the preoperative diagnosis, the choice and execution ofpreoperative diagnosis, the choice and execution of the surgical procedure, the explanation of the risksthe surgical procedure, the explanation of the risks and benefits, obtaining inform consent and theand benefits, obtaining inform consent and the postoperative management of the patient’s care.postoperative management of the patient’s care. Scrub nurse-Scrub nurse- (RN or Scrub tech)- preparation of(RN or Scrub tech)- preparation of supplies and equipment on the sterile field;supplies and equipment on the sterile field; maintenance of pt.s safety and integrity: observationmaintenance of pt.s safety and integrity: observation of the scrubbed team for breaks in the sterile fields;of the scrubbed team for breaks in the sterile fields; provision of appropriate sterile instrumentation,provision of appropriate sterile instrumentation, sutures, and supplies; sharps countsutures, and supplies; sharps count..
    • Perioperative Nursing CarePerioperative Nursing Care Surgical teamSurgical team Circulating NurseCirculating Nurse - Responsible for creatingResponsible for creating a safe environment, managing the activitiesa safe environment, managing the activities outside the sterile field, providing nursing careoutside the sterile field, providing nursing care to the patient. Documenting intraoperativeto the patient. Documenting intraoperative nursing care and ensuring surgical specimensnursing care and ensuring surgical specimens are identified and place in the right media. Inare identified and place in the right media. In charge of the instrument and sharps count andcharge of the instrument and sharps count and communicating relevant information tocommunicating relevant information to individual outside of the OR, such as familyindividual outside of the OR, such as family membersmembers.
    • Perioperative Nursing CarePerioperative Nursing Care Surgical teamSurgical team Anesthesiologist and anesthetist-Anesthesiologist and anesthetist- anesthetizing the pt. providinganesthetizing the pt. providing appropriate levels of pain relief,appropriate levels of pain relief, monitoring the pt’s physiologic statusmonitoring the pt’s physiologic status and providing the best operativeand providing the best operative conditions for the surgeons.conditions for the surgeons. Other personnel- pathologist, radiologist, perfusionist, EVS personnel.
    • Perioperative Nursing Care Surgical teamSurgical team Nursing Roles:Nursing Roles: Staff educationStaff education Client/family teachingClient/family teaching Support and reassuranceSupport and reassurance AdvocacyAdvocacy Control of the environmentControl of the environment Provision of resourcesProvision of resources Maintenance of asepsisMaintenance of asepsis Monitoring of physiologic and psychologicalMonitoring of physiologic and psychological statusstatus
    • Intraoperative Nursing Care Surgical asepsis Ensure sterility Alert for breaks
    • Intraoperative Phase AnesthesiaAnesthesia  Greek word- anesthesis, meaning “negative sensation.” Artificially induced state of partial or total loss of sensation, occurring with or without consciousness.  Blocks transmission of nerve impulses  Suppress reflexes  Promotes muscle relaxation  Controlled level of unconsciousness
    • Intraoperative PhaseIntraoperative Phase AnesthesiaAnesthesia Factors influencing dosage and typeFactors influencing dosage and type:: 1.Type and duration of the procedure 2.Area of the body being operated on 3.Whether the procedure is an emergency 4.Options of management of post. Op. pain 5.How long it has been since the client ate, had any liquids, or any medications 6.Client position for the surgical procedures
    • Intraoperative Phase Types of AnesthesiaTypes of Anesthesia General- method use when the surgery requires that the patient be unconscious and/or paralyzed. A general anesthetic acts by blocking awareness centers in the brain so that amnesia (loss of memory), analgesia (insensibility to pain), hypnosis (artificial sleep), and relaxation (rendering a part of the body less tense) occur.
    • Intraoperative Phase Stages of General AnesthesiaStages of General Anesthesia Stage 1- Analgesia and sedation, relaxation Stage 2- Excitement, delirium Stage 3- Operative anesthesia, surgical anesthesia Stage 4- Danger
    • Intraoperative PhaseIntraoperative Phase Complications of General AnesthesiaComplications of General Anesthesia  Overdose  Hypoventilation  Related to anesthetic agents  Malignant hyperthermia  Related to intubation
    • Intraoperative PhaseIntraoperative Phase Local or Regional AnesthesiaLocal or Regional Anesthesia Temporarily interrupts the transmission of sensory nerve impulses from a specific area or region.  Motor function may or may not be affected  Client does not lose consciousness  Gag reflex remains intact  Supplemented with sedatives, opioids, or hypnotics
    • Types of Regional AnesthesiaTypes of Regional Anesthesia Topical (surface)Topical (surface) LocalLocal Nerve BlockNerve Block Intravenous (Bier Block)Intravenous (Bier Block) SpinalSpinal Epidural (periduralEpidural (peridural)
    • Intraoperative PhaseIntraoperative Phase Complications of Local/RegionalComplications of Local/Regional AnesthesiaAnesthesia  Anaphylaxis  Administration technique  Systemic absorption  Overdosage
    • Spinal Anesthesia Indications -surgical procedures below the diaphragm -patients with cardiac or respiratory disease Advantages -mental status monitoring -shorter recovery Disadvantages -necessary extra expertise -possible patient pain Contraindications -coagulopathy -uncorrected hypovolemia
    • Spinal Anesthesia Involved medications -lidocaine -bupivacaine -tetracaine Patient assessment -continuous heart rate, rhythm, and pulse oximetry monitoring -level of anesthesia -motor function and sensation return monitoring
    • Spinal Anesthesia Complications -hypotension -bradycardia -urine retention -postural puncture headache -back pain
    • Spinal analgesia Indications -postoperative pain from major surgery Involved medications -lipid-soluble drugs -preservative-free morphine Monitoring recovery -respiratory depression -urine depression -pruritus -nausea and vomiting
    • Examples of location for Spinal andExamples of location for Spinal and Epidural Anesthesia.Epidural Anesthesia.
    • Nerve Block SitesNerve Block Sites
    • Intraoperative PhaseIntraoperative Phase Conscious SedationConscious Sedation Administration of IV sedative, hypnotic, andAdministration of IV sedative, hypnotic, and opioid medicationsopioid medications..  Produces a depressed level of consciousness  Retains ability to maintain a patent airway  Able to respond to verbal commands or physical stimulation  Used for relatively short procedures
    • Postoperative Nursing CarePostoperative Nursing Care Nursing assessment in the PACUNursing assessment in the PACU Vital signs- presence of artificial airway, 02 sat,BP,pulse, temperature. LOC- ability to follow command, pupillary response Urinary output Skin integrity Pain Condition of surgical wound Presence of IV lines Position of patient
    • Postoperative Nursing CarePostoperative Nursing Care Nursing DiagnosisNursing Diagnosis Ineffective airway clearance- increased secretions 2 to anesthesia, ineffective cough, pain Ineffective breathing pattern- anesthetic and drug effects, incisional pain Acute pain Urinary retention Risk for infection
    • Postoperative PhasePostoperative Phase Assessment of the Postanesthesia ClientAssessment of the Postanesthesia Client  AirwayAirway  Vital signsVital signs  Cardiac monitoringCardiac monitoring  Peripheral vascular assessmentPeripheral vascular assessment  Level of consciousness (LOC)Level of consciousness (LOC)  Fluid and electrolytesFluid and electrolytes  GI systemGI system  Integumentary systemIntegumentary system  Discomfort/painDiscomfort/pain
    • Perioperative Nursing Care Postoperative ManagementPostoperative Management Maintain a patent airway Stabilize vital signs Ensure patient safety Provide pain Recognize & manage complications
    • Postoperative Nursing Care When caring for post-surgical patient, think of theWhen caring for post-surgical patient, think of the “4 W’s“4 W’s”” Wind: prevent respiratory complications Wound: prevent infection Water: monitor I & O Walk: prevent thrombophlebitis
    • Postoperative PhasePostoperative Phase ComplicationsComplications Respiratory- atelectasis, pulm. Embolus Cardiovascular- venous thrombosis Gastrointestinal-Hiccoughs, N/V,abd. Distention, paralytic ileus, stress ulcer. GU- urinary retention Hemorrhage-slipping of a ligature(suture) Wound infection- Wound dehiscence and evisceration-
    • DehiscenceDehiscence Partial or complete separation of thePartial or complete separation of the outer layer of the wound.outer layer of the wound. Possible causes:Possible causes: Poor suturing techniquePoor suturing technique DistentionDistention Excessive vomitingExcessive vomiting Excessive coughingExcessive coughing DehydrationDehydration InfectionInfection
    • EviscerationEvisceration Total separation of the layers & protrusion of internal organs or viscera through the open wound. Causes: same as dehiscence Treatment: Call for help Cover with sterile NS soaked gauze/towels Keep moist DO NOT ATTEMPTS TO REINSERT ORGANS. Keep in supine position with knees/hips bent Assessment/VS q 5 min. until MD arrive Prepare for surgery.
    • Postoperative Phase
    • Postoperative Phase
    • Postoperative Nursing CarePostoperative Nursing Care Gerontologic considerationsGerontologic considerations Mental status- attributed to medications, pain, anxiety, depression. Delirium- infection, malignancy, trauma, MI, CHF, opioid use. Dementia-sundowning-sleep disturbances, lack of structure in the afternoon or early morning, sleep apnea.