PERIOPERATIVE NURSING Prepared By: Luis P. Imatani D.D.M.,R.N.
PERIOPERATIVE NURSING Perioperative nursing It is divided into 3 Phases: 1. Preoperative – From the decision for surgical intervention to transfer to operating room
2. Intra-operative- From reception into the operating room to admission to recovery room
3. Post Operative- Admission to recovery room to follow up evaluation
Types of Surgery Acc to degree of blood loss:
Major Surgery – Extensive surgery that involves serious risk and complications & loss of blood as it involves major Organs and few blood loss
Minor Surgery- Surgery that involves minimal complications and few blood loss
Types of Surgery Acc to Urgency of Surgery:
Optional Surgery – Surgery at the preference of the client. Surgery is not needed Ex. Cosmetic surgery ; liposuction
Elective Surgery – Surgery at the convenience of the patient as failure to have surgery is not life threatening Ex. Excision of superficial cyst.
Planned/ Required surgery- The time of the surgery is within a few weeks from time of decision to have surgery as surgery is important ex. Cataract extraction
Urgent/ Imperative surgery – Within 24-48 hours from the time of the decision to have surgery Ex. Cancer surgery
Emergency Surgery – Immediate surgery without delay to maintain life or organ, to remove damage, to stop bleeding Ex. Intestinal obstruction, gun shot wounds
Types of Surgery Acc to Purpose of Surgery:
Diagnostic Surgery – To confirm diagnosis Ex. Excision & biopsy
Exploratory – To estimate the extent of the disease & confirm diagnosis Ex. Exploratory Laparotomy
Curative Surgery a. Ablative – Removal of diseased organ Ex. Hysterectomy b. Constructive – Repair of congenital defects Ex. Repair of Cleft palate
c. Reconstructive – Restoration of damaged organ Ex. Total joint replacement
Palliative – Relieves Symptom but does not cure the disease Ex. Rhizotomy for pain relief, Myringotomy
CLASSIFICATION of PHYSICAL STATUS: ASA I – Healthy person, with no systemic disease, undergoing elective surgery, Not very Young or very old
ASA II – Client w/ 1 system well controlled disease. Diseases does not affect daily activities. Those clients w/ mild obesity, alcoholism, and smokers
ASA III – Client w/ multiple system disease or well controlled major system diseases. The disease status limits daily Activities. However there is no immediate threat of death due to individual system disease.
ASA IV – Client w/ severe incapacitating disease. Typically the disease is poorly controlled, or end stage disease is present. Danger of death related to organ failure is present
ASA V - Client is very ill, in imminent danger of death. Operation is the last attempt in preserving life. The client is not expected to live the next 24 hours.
Past Medical Health History Previous Surgery & Experience with anesthesia = any untoward reaction to anesthesia e.g. malignant hyperthermia, intraoperative death in the family= INFORM physician.
Serious Illness or Trauma: ABCDE A – Allergy B- Bleeding C- Cortisone use D – Diabetes mellitus E – Emboli (thromoembolism)
Age Infant, Young children, & older Adults are at greater risk for surgery
Nutritional Status Nutritional deficiencies and excesses correlate with post- op recovery
Alcohol / Recreational Drug Use Alcohol has an unpredictable reaction with anesthetic agents; Smoking = reduce hemoglobin, Smokers are susceptible to clot formation & Nicotine is a vasoconstrictor
Lifestyle Sedentary lifestyle vs. physically fit
Fluid & Electrolytes Dehydration & Hypovolemia predispose a client to complications during & after surgery.
Hypokalemia, hyperkalemia can compromise the cardiac status; hyper-hyponatremia can offset fluid balance
Infection Can adversely affect surgical outcome Current Discomfort Pre-existing pain condition may be misinterpreted later as surgical pain
Chronic Illness Ex. History of Arthritis of Neck or other joints has an influence on the intraoperative positioning.
ANTIBIOTICS Gentamycin Penicillin } May mask symptoms of infection
ANTIARRHYTHMIC AGENTS Propanolol HCl; Qunidine gluconate;Procainamide HCl } Depresses cardiac function & affects tolerance to Anesthesia
ANTIHYPERTENSIVE Methyldopa Aldomet } May cause intraoperative / p ostoperative hypotensive crisis
THIAZIDE DIURETICS Furosemide ( Lasix) = Can deplete K+ and cause electrolyte imbalances
STREET DRUGS Beer Whiskey Cocaine Heroin } increase tolerance to narcotics, requiring more anesthetic agents.
Psychological History Knowledge of Cultural & religious practices of the client is an important aspect of nursing care
Ability to Tolerate Stress Social History Assess the family support system
Cardiovascular assessment MI, angina pectoris for the last six months, may influence tissue perfusion or wound healing
Respiratory assessment – Chronic lung conditions ex. emphysema, asthma, bronchitis, increase the operative risk bec. These diseases impair gas exchange = DOB notify the physician.
Musculoskeletal assessment – History of fractures, joint injury, arthritis, may influence the positioning of the client during intraoperative phase, or it may cause additional postop pain
Skin integrity assessment- Document & report lesions, pressure ulcers, necrotic skin, skin turgor, erythema, cyanosis of the skin, note the size & location so as to compare post op if lesions are stable or worsening.
Renal assessment- Adequate renal function is necessary to eliminate protein wastes, to preserve fluid & electrolyte balance & to remove anesthetic agents from the system
Liver function assessment - Liver dse like cirrhosis inc. a client’s surgical risk bec a diseased liver cannot detoxify drugs & anesthetic agents, liver dse. May be manifested through albumin levels= low albumin levels predispose to fluid shifts (fluid imbalance)
Cognitive assessment- Uncontrolled epilepsy, severe parkinson’s disease, increase the surgical risk
other important neurologic assessment; severe head ache, frequent dizziness, light headdeness, ringing in the ears, unsteady gait, unequal pupils & history of seizures.
Hematologic function – Clients w/ blood coagulation disorders are at risk for hemorrhage Ex. History of hemophilia, sickle cell anemia. Manifestations of easy brusing and abnormal bleeding time
During assessment it is an important opportunity for the nurse to open the gates of communication = assess the possible coping mechanism, family support of the client, the role of the family and friends are important.
Therapeutic communication is used to alleviate the fear of the client: listen, encourage verbalization of feelings,
Do not use false reassurances like: Don’t worry you are in good hands, or Don’t worry your doctor is the best surgeon, / There is nothing to be afraid of= because it blocks communication
Assist in contacting social workers if necessary
Respect the cultural & spiritual beliefs of the client; if certain faith healing or rituals are requested to be performed by a spiritual leader or elder allow them to do so
Respect the behavior particular to a culture ex. Orientals usually avoid direct eye contact, understand that they pay still pay attention to the nurse’s instructions, even if they do not maintain direct eye contact
1. PSYCHOLOGIC PREPARATION for SURGERY:
This includes explanation of the procedures to be done
expected duration of hospitalization;
length of absence from work,
A preoperative patient may experience a number of fears:
1) fear of anesthesia 2) fear of pain 3) fear of the unknown 4) fear of death 5) fear of change in body image (deformity).
2. LEGAL ASPECTS
Protects the surgeon and the hospital against claims that unauthorized has been performed and that the patient was unaware of the potential risks of complications involve.
a) the patient is of legal age – or if not signed by a parent or legal guardian
b) the patient is capable of making the decision for himself – ex. of sound mind not w/ psychiatric disorder
c) The patient is not medicated w/ drugs that affect the consciousness
Informed consent protects the patient from unauthorized surgery
4. PREOPERATIVE HEALTH TEACHINGS / INSTRUCTIONS The best time to instruct the client is relatively close to the time of the surgery
DBE(deep breathing exercises) – use of diaphragmatic – abdominal breathing done 5-10 times in post operative period.
Coughing exercises – deep breathe exhale through mouth then follow with a short breath, While coughing “splint” thoracic and abdominal incision to minimize pain.
Turning or repositioning client— done every 1-2 hours post op to prevent venous stasis & decubitus ulcers
Extremity exercises – Prevents circulatory problems ( venous stasis , thrombophlebitis) & post –op gas pains or flatus.
Ambulation – If the patient is already able ( no more residual effects of anesthesia) & it is not contraindicated early ambulation prevents circulatory problems and promotes early recovery.
5. PHYSICAL PREPARATION
On the Night of Surgery
Make sure that the name tag of the client is in place
Preparing the Patients Skin- Shave against the grain of hair shaft to insure close shave. Most of the time in actual practice this is done before the patient is transferred to OR
Preparing the GIT –
Patient is on NPO after midnight
Administration of enema
Insertion of Gastric or intestinal tubes
Promoting rest & sleep – Use of drugs to promote sleep
a) Barbiturates – secobarbital sodium
( Seconal ); Pentobarbital sodium (Nembutal)
b) Non – Barbiturates – chloral hydrate; flurazepam ( Dalmane)
The drugs are given after all pre-op treatments have been completed. If a second barbiturate is needed, it must be given at least 4 hours before pre-op medications is due.
On the Day of the Surgery
Early Morning Care – ( about 1 hour before the pre-op medication schedule )
VS taken and recorded promptly
Provide oral hygiene
Remove jewelry & dentures
Remove nail polish
Make sure that the patient has not taken food by asking the patient
Pre- Operative Medications – generally administered 60-90 minutes before induction of anesthesia –
To allay anxiety
To decrease the flow of pharyngeal secretions
To reduce the amount of anesthesia to be given
Create amnesia for the events that precede surgery
Types of Pre-Op meds:
a) Sedatives – given to decrease the patient’s anxiety to lower BP and pulse and to reduce the amount of General Anesthesia; an overdose of sedatives may lead to respiratory depression
ex. Phenobarbital Na, Nembutal Na, Secobarbital Na
b) Tranquilizer – lowers a patient’s anxiety Ex. Thorazine 12.5 – 25 mg IM 1-2 hours prior to surgery
Phenergan- 12.5 – 25 mg IM 1-2 hours before surgery Note* these tranquilizers may cause dangerous hypotension both during and after the surgery
Narcotic Analgesics – Given to reduce anxiety and to reduce the amount of narcotics given during surgery
Ex. Morphine sulfate – 8-15 mg SQ one hr pre-op this drug can cause vomiting, respiratory depression and postural hypotension
Vagolytic or drying agents – To reduce the amount of tracheobronchial secretions w/c may clog the pulmonary alveoli and may produce atelectasis (lung collapse)
Ex. Atropine sulfate 0.3-0.6 mg IM 45 minutes before surgery overdose can cause severe tachycardia
*** Important ! – Nursing intervention after giving pre-op meds immediately raise the side rails of the bed for patient’s safety
Recording – All final preparation and emotional response before surgery are noted down
Transportation to OR – Make sure that the name tag of the client is in place. While transferring the patient on the stretcher make sure that the side rails are up
Woolen or synthetic blankets must never be sent to OR bec. It causes static electricity and may cause combustion of O2 or Other gases in the OR
Anxiety r/t Lack of Knowledge About Preoperative Routines, Potential Body Image Change, Surgery
INTRA OPERATIVE NURSING CARE
Intra-operative Surgery & nursing care – begins from the reception of the patient to the OR to the transfer of the client to the PACU. Or RR
Duties and responsibilities of the Surgical team:
1. Surgeon- Heads the team
2. Anesthesiologist – Alleviates pain, promote relaxation, gas exchange, blood loss & hemostasis
. 3. Circulating Nurse
Coordination of all members; patient’s advocate
Equipment, sterility, positioning, skin prep
Monitoring breaks in
4. Scrub nurse
Preparation of supplies
Assist in the
Cleaning up after
5. RN first assistant –
1. Identify the surgical client, make sure that the name tag is in place when receiving client.
2. Assess the emotional & physical status of the patient, assess VS & record 3. Verify information in the checklist
POSITIONING THE CLIENT; ( POSITIONS DURING SURGERY)
Supine / Dorsal recumbent – Lying on the back – used for hernia repair, bowel resection, eplore lap, mastectomy, cholecystectomy
Prone – for back, spine, rectal surgeries, laminectomy- Note** after surgery, the patient will be returned to the supine position. This should be done gradually bec. Sudden turning of the client may cause a rapid drop in BP
Trendelenberg – Head and body are flexed by , breaking(bending the head of the table downwards) – pelvic surgeries, lower abdomen.
Reverse trendelenberg – Head is elevated and feet are lowered
Lithotomy position - Thighs and legs are flexed at right angles and then simultaneously placed in stirrups – vaginal repairs, D&C, rectal surgery,
Lateral – used in kidney and chest surgery, hip surgeries
Other positions - in Thyroidectomy the head is hyperextended, a small sand bag or pillow on the neck and shoulders to provide exposure of the thyroid gland
In positioning the client:
explain the purpose of
Avoid undue exposure
Strap the person to
Strap the person to
Maintain adequate respiratory and circulatory
Maintain good body
Stages of Anesthesia
Stage I . Stage of Analgesia / induction phase
This stage extends from the beginning of Administration of an anesthetic to the beginning of the loss of consciousness . The sensation of pain is not lost.
Stage I . Stage of Analgesia / induction phase
The client maybe
drowsy or dizzy
should close the OR
Stand by to assist
Stage II. Stage of Delirium / Excitement
Extends from the loss of consciousness to the loss of eyelid reflex. Any stimulation has the potential to cause the client to become difficult to control.
Stage II. Stage of Delirium / Excitement
REM ( rapid eye
Retching & Vomiting
should remain quietly
by patient’s side
Assist if needed
Stage III. Stage of Surgical Anesthesia
Extends from loss of lid reflex to cessation of respiratory effort or depressed vital functions.
Stage III. Stage of Surgical Anesthesia
completely dilated & unresponsive pupils
absence of reflex ( muscles completely relaxed)
Client is unconscious
Client is in good control
Stage IV. Stage of Danger / Medullary stage
From vital functions too depressed to Respiratory failure/ Death & Disability due to too high concentration of anesthetic in the CNS.