FUNDAMENTALS of NURSING: special lecture on Perioperative NursingPrepared by: Ronivin Garcia Pagtakhan, RN, MAN (c)
Perioperative Nursing – a clinical specialty, refers to the role of the nurse during the preoperative (before surgery), intraoperative (during surgery) and post operative (after surgery) phases of the client’s surgical experience
What are the different types of surgery?- Severity/ Risk- Urgency- Reason
major surgeryThese are surgeries of the head, neck, chest, and abdomen.The recovery time can be lengthy and may involve a stay in intensive care or several days in the hospital.There is a higher risk of complications after such surgeries.Types of major surgery may include: removal of brain tumors correction of bone malformations of the skull and face repair of congenital heart disease, transplantation of organs, and repair of intestinal malformations correction of spinal abnormalities and treatment of injuries sustained from major blunt trauma correction of problems in fetal development of the lungs, intestines, diaphragm, or anus.
minor surgeryThe recovery time is short and patient return to their usual activities rapidly.These surgeries are most often done as an outpatientComplications from these types of surgeries are rare.Examples of the most common types of minor surgeries may include, but are not limited to, the following: placement of ear tubes hernia repairs correction of bone fractures removal of skin lesions biopsy of growths
ACCORDING TO DEGREE OF URGENCY Emergent – life-threatening – without delay Severe bleeding Urgent – prompt attention – 24-30 hrs Cholecystitis Required – needs – weeks-months Cataract Elective – should be, not catastrophic Scar repair Optional – personal reference cosmetic
Biopsy is the removal of a piece of tissue from an organ or other part of the body for microscopic examination to confirm or establish a diagnosis, estimate prognosis, or follow the course of a disease. Curative surgery is the removal of the entire tumor. Even after curative surgery, you may still be given chemotherapy or radiation to kill micro- metastases. Micro-metastases are cancer cells that may still be in the body but cannot be detected by current technology.
Cryosurgery involves the use of liquid nitrogen or a very cold probe to freeze cancer cells. Debulking surgery is when the entire cancer cannot be removed without serious damage to the body so the surgeon takes out only that portion of the tumor that can be removed safely. The rest of the tumor may be killed with radiation therapy or chemotherapy. Electrosurgery uses an electrical current to destroy cancer cells. Laser surgery is surgery in which a beam of light is used instead of a scalpel. Mohs surgery is the removal of skin cancer by shaving off one layer at a time. The dermatologist (skin doctor) looks at each layer under a microscope. When the layers look normal (no cancer) the surgeon stops removing skin.
Prophylactic surgery to prevent cancer when there is a good chance that a particular body tissue will become cancerous in the future. Palliative surgery does not treat the underlying disease but is done to control symptoms of cancer, such as pain. Restorative or reconstructive surgery commonly called plastic surgery restores the function and appearance of an area after a previous surgery.
Staging surgery determine the extent of the cancer, or how large it is and how much it has spread throughout the body. This is very important, as it will determine the course of treatment. Ablative Removal of a diseased organ
Surgery is affected by: age general health nutrition medications mental status
PHYSICAL PREPARATION - Preoperative checklist Nutrition and hydration Consumption of clear liquids up to 2 hours before elective surgery requiring general anesthesia. Fasting for 4 hours prior to surgery after ingesting milk products Eating a light breakfast 6 hours before the procedure A heavier meal 8 hours before surgery Fasting for 8 hours prior to surgery after eating fatty foods
Elimination Catheter insertion, Enema Rest and Sleep Hygiene Bath ,Remove cosmetics, Remove all hairpins and clips, OR gown Medication Discontinued, Preop meds
Personal valuables and prosthesis Care of belongings, Remove all body prostheses Special orders NGT, insulin, etc Special skin preparation PREOPERATIVE TEACHING proper timing PAINMANAGEMENT PHYSICAL ACTIVITIES DBE , Coughing exercises , Leg exercises, Turning in bed EMOTIONAL SUPPORT
PREOP CHECKLIST CONSENT HEALTH TEACHING (SPEC. POST OP PROCEDURES) LAB TESTS,ECG,X-RAY SKIN PREP BOWEL PREP IV’S NPO PREOP MEDS,SEDATION AND ANTIBIOTICS REMOVAL OF DENTURES,NAILPOLISH AND JEWELRY NUTRITION-TPN OR ENTERAL FEEDINGS PREOP
INFORMED CONSENT protects the patient from unsanctioned surgery and protects the surgeon from claims of an unauthorized operation nurse may ask patient to sign the form and witness the patient’s signature the physician provides appropriate information: flow of surgery alternatives possible risks, complications, disfigurement what to expect early and late post op
Indications of Informed Consent invasive procedure/ surgery use of anesthesia nonsurgical by there might be slight risk involves radiation Criteria of Informed Consent Consent voluntarily given (without coercion) Competent subject
Appendectomy An appendectomy is the surgical removal of the appendix, a small tube that branches off the large intestine, to treat acute appendicitis. Appendicitis is the acute inflammation of this tube due to infection.
Breast biopsy A biopsy is a diagnostic test involving the removal of tissue or cells for examination under a microscope. This procedure is also used to remove abnormal breast tissue. A biopsy may be performed using a hollow needle to extract tissue (needle aspiration), or a lump may be partially or completely removed (lumpectomy) for examination and/or treatment.
carotid endarterectomy Carotid endarterectomy is a surgical procedure to remove blockage from carotid arteries, the arteries located in the neck that supply blood to the brain. Left untreated, a blocked carotid artery can lead to a stroke.
cataract surgery Cataracts cloud the normally clear lens of the eyes. Cataract surgery involves the removal of the cloudy contents with ultrasound waves. In some cases, the entire lens is removed.
cesarean section Cesarean section (also called a c-section) is the surgical delivery of a baby by an incision through the mothers abdomen and uterus. This procedure is performed when physicians determine it a safer alternative than a vaginal delivery for the mother, baby, or both.
cholecystectomy A cholecystectomy is surgery to remove the gallbladder (a pear-shaped sac near the right lobe of the liver that holds bile). A gallbladder may need to be removed if the organ is prone to troublesome gallstones, if it is infected, or becomes cancerous.
coronary artery bypass surgery Most commonly referred to as simply "bypass surgery," this surgery is often performed in people who have angina (chest pain) and coronary artery disease (where plaque has built up in the arteries). Bypass surgery consists of grafting veins or arteries from the aorta (a major artery that carries blood from the heart to the rest of the body) to the coronary artery, bypassing areas that are blocked. Veins are usually taken from the leg.
debridement of wound, burn, or infection Debridement involves the surgical removal of foreign material and/or dead, damaged, or infected tissue from a wound or burn. By removing the diseased or dead tissue, healthy tissue is exposed to allow for more effective healing.
dilation and curettage (Also called D & C.) A D&C is a minor operation in which the cervix is dilated (expanded) so that the cervical canal and uterine lining can be scraped with a curette (spoon-shaped instrument).
free skin graft A skin graft involves detching healthy skin from one part of the body to repair areas of lost or damaged skin in another part of the body. Skin grafts are often performed as a result of burns, injury, or surgical removal of diseased skin. They are most often performed when the area is too large to be repaired by stitching or natural healing.
hemorrhoidectomy A hemorrhoidectomy is the surgical removal of hemorrhoids, distended veins in the lower rectum or anus.
hysterectomy A hysterectomy is the surgical removal of a womans uterus. This may be performed either through an abdominal incision or vaginally. hysteroscopy Hysteroscopy is a surgical procedure used to help diagnose and treat many uterine disorders. The hysteroscope (a viewing instrument inserted through the vagina for a visual examination of the canal of the cervix and the interior of the uterus) can transmit an image of the uterine canal and cavity to a television screen.
mastectomy A mastectomy is the removal of all or part of the breast. Mastectomies are usually performed to treat breast cancer.There are several types of mastectomies, including the following: partial (segmental) mastectomy, involves the removal of the breast cancer and a larger portion of the normal breast tissue around the breast cancer.
total (or simple) mastectomy, in which the surgeon removes the entire breast, including the nipple, the areola (the colored, circular area around the nipple), and most of the overlying skin, and may also remove some of the lymph nodes under the arm, also called the axillary lymph glands.
modified radical mastectomy, in which the surgeon removes the entire breast (including the nipple, the areola, and the overlying skin), some of the lymph nodes under the arm, and the lining over the chest muscles. In some cases, part of the chest wall muscles is also removed.
radical mastectomy, involves removal of the entire breast (including the nipple, the areola, and the overlying skin), the lymph nodes under the arm, and the chest muscles.
partial colectomy A partial colectomy is the removal of part of the large intestine (colon) which may be performed to treat cancer of the colon or long-term ulcerative colitis.
prostatectomy The surgical removal of all or part of the prostate gland, the sex gland in men that surrounds the neck of the bladder and urethra - the tube that carries urine away from the bladder. This may be performed for an enlarged prostate, benign prostatic hyperplasia (BPH), or if cancerous.
tonsillectomy The surgical removal of one or both tonsils. Tonsils are located at the back of the mouth and help fight infections.
INTRAOPERATIVE PHASE begins with the admission of the client to the surgical area and ends when the client is transferred to the recovery area.
INTRA-OPERATIVE CAREMAINTAIN SURGICAL ASEPSIS, MONITOR CLIENTSTATUS,, APPROPRIATE GROUNDING DEVICES,FLUID BALANCE AND SPONGE/INSTRUMENTCOUNT SCRUB NURSE – HANDLES EQUIPMENT , MATERIALS TO THE SURGEON, SPONGE AND INSTRUMENT COUNT ( STERILE) CIRCULATING NURSE- ENSURES ADEQUACY OF SUPPLIES, SKIN PREP , DOCUMENTATION , HANDLES STERILE EQUIPMENTS BY FORCEPS
The OPERATING ROOM freefrom contaminating particles, dusts, pollutants, radiation, noise ZONES Unrestricted – street clothes are allowed Semi-restricted – scrubs, shoe covers, cap and mask Restricted zone
SURGICAL SKIN PREPARATION Cleaning, shaving, applying antimicrobials POSITIONING Performed after anesthesia is given Provide correct position for the specific procedure Protect bony prominences Avoid strain or injury to muscles, bones and joints Protect the skin – lift rather than pull or roll the client into position
OTHER RESPONSIBILITIES Draping Assist in preparing and maintaining the sterile field Open sterile packages during surgery Provide meds and solutions for the sterile field Monitor and maintain sterile environment Manage catheters, tubes, drains and specimens Perform sponge, instrument and sharp counts Document care provided and client responses Transferring of client to RR Endorsement
THE SURGICAL EXPERIENCE ANESTHESIA stateof narcosis (severe CNS depression) Analgesia, relaxation, reflex loss General Anesthesia – inhaled, most common Volatile liquid agents – vapors Halothane, enflurane, isoflurane, sevoflurane Gas anesthetics – with oxygen, N2O
IV ANESTHESIA Barbiturates, benzodiazepines, non-barbiturates Opioids used for induction (initiation) or mainstream used to produce conscious sedation Advantages Contraindications onset is pleasant children non-explosive powerful easy to administer respiratory decreased nausea depressant and vomiting
CONSCIOUS SEDATION depression of LOC without impairment of the patient’s ability to maintain a patent airway and to respond to physical stimulation and verbal command Medazolam (Versed), Diazepam first dose is given by the physician succeeding doses – RN, Nurse-anesthetist WOF: dysrhythmias, CNS, Respi depression O2, resuscitation, pulse oximetry, cont. ECG, VS Adjunctive Agents : Neuromuscular blockers – purified curare
REGIONAL ANESTHESIA form of local anesthesia anesthetic agent is injected around nerves so that the area supplied is anesthetized
SPINAL ANESTHESIA extensive conduction nerve block local anesthetic agent into subarachnoid space at the lumbar level (L4, L5) lower extremities, perineum, lower abdomen knee-chest position, place supine after injection if high level block, head and shoulders are lowered anesthesia and paralysis of toes, perineum then legs and abdomen may also reach upper thoracic and cervical spine resp paralysis
CONDUCTION BLOCKS Epidural anesthesia injection of local anesthetic into the spinal canal in the space around the dura mater higher dose than spinal no headache disadvantage: epidural space vs. subarachnoid space
Brachial plexus arm Paravertebral anesthesia chest, abdominal wall, extremities Transsacral (caudal) perineum, lower abdomen Local Infiltration Anesthesia Advantages – simple, economical, nonexplosive, minimal equipment, postop recovery is shortened, no GA side effects, short superficial surgical procedures
TAKE NOTE: Anesthesia Halothane-respiratory and cardiovascular depression-monitor VS, open IV site-ABC’s prevent aspiration Nitrous Oxide- Hypotension and nausea and vomiting- adequate O2 IV thiopental Na- decreased BP , respiratory depression, laryngospasm- ABC spinal and saddle – hypotension and HA- increased OFI conduction block/epidural block- hypotension and respiratory depression-HA not experienced local – excitability and hypersensitivity;no epinephrine on fingers
STAGES OF ANESTHESIA STAGE 1. BEGINNING ANESTHESIA, analgesia, sedation and relaxation warmth, dizziness, feeling of detachment ringing, roaring, buzzing in ears aware of being unable to move the extremities noises are exaggerated
STAGE 2. EXCITEMENT, DELIRIUM struggling, shouting, talking, singing, laughing, crying – decreased if anesthesia is given quickly and smoothly pupil dilates but constricts if with light PR rapid, RR irregular Vomiting Restraining
STAGE 3. SURGICAL ANESTHESIA, OPERATIVE ANESTHESIA unconscious pupils – small but reactive RR irregular, PR normal Skin – pink, flushed No hearing
STAGE 4. MEDULLARY DEPRESSION, DANGER if anesthesia is too much RR shallow Pulse weak, thready Pupils – widely dilated, non reactive Cyanosis death
Suture medical device use to hold skin, internal organs, blood vessels and all other tissues of the human body together after they have been severed by injury, incision or surgery.
Assessment of the suture line: Stitched too tight or too loose Too many or too few stitches Suture holes not equidistant for the edges so that the bite is not uneven, or uneven spacing between sutures Inversion or eversion of tissue edges Edges of tissue overlapping and heaped on each other.
Types of stitch: Simple interrupted suture Inserted singly through each side of the wound and tied with a surgeon’s knot. Several of these may be used at short intervals ( 4— 8mm apart) to close large wounds and share tension. Easy to keep clean, can be replaced singly and will evert edges of the flap.
Horizontal mattress suture Evert the mucosal or skin margins, thereby bringing greater areas of raw tissue into contact. Useful for closing wounds over bony deficiencies such as oro-antral fistulae or cyst cavities.
Vertical mattress suture Specially designed for use in the skin. Pass through at two levels: (i) Deep—provides support and adduction of wound surface (ii) Superficial—draw edges together and evert them
Vertical Mattress is a suture technique most commonly used in anatomic locations which tend to invert, such as the posterior aspect of the neck or the palm of the hand. This type of suture is good for deep lacerations, instead of combining two layers of deep and superficial sutures.
Continuous suture Disadvantaged that if they cut out at one point the whole suture will slacken. Advantage—only two knots present. ¨ Simple continuous— applies pull on the wound obliquely ¨ Continuous blanket stitch—more firm and stable. Gives traction on the wound edges at right angles to the wound ¨ Purse string suture—useful as a deep suture for wounds of the skin of the face.
Suture sizes: defined by the United States Pharmacopeia (U.S.P.). Sutures were originally manufactured ranging in size from #1 to #6, with #1 being the smallest. Modern sutures range from #5 (heavy braided suture for orthopedics) to #11-0 (fine monofilament suture for ophthalmics).
Types of Suture MaterialPlain catgut Absorbable biological suture material. taken from bovine intestines. absorbed by enzymatic degradation.
Chromic Absorbable biological suture material. taken from bovine intestines. offers roughly twice the stitch-holding time of plain catgut. absorbed by enzymatic degradation. Note– catgut is no longer used in the UK for human surgery.
Indication Plain catgut Chromic Polyglycolic Polydioxanone acid (P.G.A.) (PDS)-all surgical -all surgical Subcutaneou - combination ofprocedures procedures s, an absorbable- for tissues - for intracutaneo sutureregenerating tissues that us closures, - extendedfaster are regenerate abdominal wound supportinvolved. faster. and thoracic is desirable,- General surgeries pediatricclosure, cardiovascularophthalmic, surgery,orthopedics, ophthalmicobstetrics/gyne surgery, GI
Removal of Sutures facial wounds 3–5 days scalp wound 7–10 days trunk of the body 7–10 days. limbs 10–14 days joints 14 days
Others…. Tissue adhesives topical cyanoacrylate adhesives ("liquid stitches"), combination or alternative to, sutures in wound closure. adhesive is liquid exposed to water/water- containing substances/tissue cures (polymerizes) forms a flexible film that bonds to the underlying surface. act as a barrier to microbial penetration as long as the adhesive film remains intact. Contraindications: near eyes and a mild learning curve on correct usage.
Antimicrobial sutures sutures coated with antimicrobial substances to reduce the chances of wound infection.
Malignant Hyperthermia d/tanesthetic agents, muscle relaxants, syphatomimetics, theo/aminophylline, anticholinergic, cardiac glycosides Risks: bulky, strong muscles, muscle cramps, weakness CM: tachycardia, SNS stimulation (vent.dysrhythmias, hypotension, dec CO, oliguria, cardiac arrest, tetany-like movements, increased temperature 1 degree every 15 minutes Mgt: critical assessment 10-20 mins post induction or 24 hrs postop; stop anesthesia, surgery; 100% oxygen; DANTROLENE Na – muscle relaxant, NaHCO3
POSTOPERATIVE PHASE begins with the admission of the client to the PACU and ends when healing is complete PHASE I – Immediate postoperative care, intensive nursing care PHASE II – Ongoing postoperative care Step down, Sit up or Progressive Care Unit – 4-6 hours
NURSING RESPONSIBILITIES ASSESSMENT Respiratory Status Airway patency, O2 sat, Effectiveness of ventilation Cardiovascular Status BP, All pulses, Color, skin temp, edema , Urine output CNS LOC, Orientation, Reflexes, Ability to move extremities Fluid Status IVF, Urine output, Wound drainage, Drainage from catheters, tubes and drains, Skin turgor, edema, VS
Status of wound Dressing and drainage Pain Nausea and Vomiting Keep all lines patent Assure that monitors and equipments are functioning Positioning Help arouse and orient the client Facilitate oxygenation Treat hypotension Provide for safety AND comfort
Readiness for Discharge from PACU uncompromised pulmonary function pulse oximetry ok stable VS oriented U/O > 30cc/hr N/V under control Minimal pain
Assess and Manage Hemodynamic stability Shock and hemorrhage WOF dec BP 90 mmHg, dec, 5 mmHg q 15mins IVF FVE I&O Venous stasis – d/t dehydration, immobility, pressure on legs DVT (Homan’s sign, pain swelling on calf, fever, chills, diaphoresis) = leg exercises, antiembolism stocking, early ambulation, low dose heparin
Assess and Manage the Surgical Site WOF bleeding, dressing, drains Hematoma Infection after 5 days, wound dehiscence and evisceration Assess and Manage Pain Maintain body temperature Assess Mental status and NVS LOC, speech, orientation Assess GI function N/V, hiccups, NGT, Antiemetics, phenothiazine Liquid - clear liquid soft solid food
Assess and manage voluntary voiding Urinary retention Void within 8 hours post surgery non catheter interventions catheter Encourage Activity Earlyambulation Bed exercises Maintain safe environment Provide emotional support to the patient and family
POST-OPERATIVE COMPLICATIONS SHOCK PARALYTIC ILEUS ATELECTASIS AND PNEUMONIA - 2ND DAY EMBOLISM- 2ND DAY WOUND INFECTION-3-5D DEHISCENCE AND EVISCERATION-5-6D PSYCHOSIS CARDIOVASCULAR COMPROMISE URINARY RETENTION-8-12H URINARY INFECTION -5-8 D DVT-6-14 DAYS-1 YEAR
POST-OPERATIVE CARE POST OP- MONITOR VS Q15X4;Q30X2;Q1HX2 THEN PRN MONITOR I AND O , K LEVEL , CVP, BOWEL SOUNDS, BREATH SOUNDS AND LOC RESPIRATORY PHYSIOTHERAPY,TCBD INCENTIVE SPIROMETRY-20 SECS INHALATION ENCOURAGE AMBULATION REFER IF UNABLE TO VOID IN 8 HOURS APPLY TED HOSE AND PNEUMATIC COMPRESSION DEVICE,CHECK FOR HOMAN’S SIGN