PERIOPERATIVE NURSING BY: LUDY MAE B. NALZARO, RN, MN
PERIOPERATIVE NURSING• Nursing care takes place immediately: – Before – During – After surgery.• A nurse act as independent clinician and a member of a health care team during perioperative nursing.
Goals of Perioperative Nursing• To assist clients and their significant others through the surgical episode• To help promote positive outcomes• To help clients achieve their optimal level of function and wellness after surgery
PERIOPERATIVE PERIOD1.Preoperative Phase (surgical unit to OR) – the period when the client is admitted in the surgical unit, to the period he is prepared physically, psychosocially, spiritually, and legally prepared for the surgical procedure, until he is transported into the operating room.2. Intraoperative Phase (OR-PACU) – the period the client is admitted to the OR → the time of administration of anesthesia → surgical procedure is done →recovery room or post anesthesia care unit.3. Postoperative Phase (PACU-FOLLOW-UP) – the period recovery room/PACU →transported back into the surgical unit → discharged from the hospital, until the follow-up care.
Surgical Classifications• According to Purpose1. Aesthetic (cosmetic) – Improvement of physical features that are within the “normal range”. – Ex. Breast augmentation
Surgical ClassificationsAccording to Purpose2. Constructive – Repair of congenitally defective body part. – Ex. Cleft lip and cleft palate
Surgical ClassificationsAccording to Purpose3. Curative – Removal or repair of damaged or diseased tissue or organs (ex hysterectomy). – Mostly done with definite cancer diagnosis – Operations are conducted to remove or destroy cancerous tissues
SURGICAL CLASSIFICATION• According to Purpose4. Diagnostic – Done when a specific diagnosis is not possible using noninvasive or simple biopsy techniques. – Done for discovery or confirmation of a dx – Ex. Breast biopsy
SURGICAL CLASSIFICATIONAccording to purpose5. Exploratory – Estimation of the extent of the disease or confirmation of a dx – Ex. Exploratory laparotomy
SURGICAL CLASSIFICATIONAccording to purpose6. Palliative – Relief of symptoms but without cure of underlying disases – Ex. Colostomy
SURGICAL CLASSIFICATION7. Reconstructive – Partial or complete restoration of a body part – Ex. Total joint replacement
Surgical Classifications• According to Degree of Risk• Major Surgery – Involves a high degree of risk since these surgeries may be complicated or prolonged, hemorrhage may occur, vital organs may be involved, or postoperative complications are likely to appear.• Minor Surgery – Involve little risks – Produces fewer complications – Often performed in “day surgery” – Performed in the OPD
Surgical Classifications• According to Urgency1. Emergent – Must not be delayed – Almost always life-threatening – Patient requires immediate attention – Ex. Fractured skull, gunshot or stab wounds, extensive burns2. Urgent – Pt requires prompt attention – Indicated within 24-30 hrs – Ex. Acute gallbladder infection, kidney stones3. Required – Pt needs to undergo surgery but could be planned within a few weeks or months – Ex cataracts, thyroid disorders4. Elective – Client should have surgery – However, failure to have surgery does not end in catastrophic consequences – Ex. Vaginal repair, repair of scars5. Optional – The decision to undergo these types of surgeries rest solely on the personal preference of the client – Cosmetic surgeries
PREOPERATIVE PHASEPreoperative AssessmentTo be included in the preop assessment:1. Medical/health hx – Review past medical hx • To determine operative risk – Previous surgery and experience with anesthesia • Untoward reactions to anesthesia – Hypethermia, prolonged n/v • These do not hinder surgery, but need to change the type of anesthetics used
MEDICAL HISTORYSerious Illness or Trauma A – Allergy – Medications, chemicals, latex – All should be reported before the beginning of surgery B – Bleeding tendencies – use of meds that daunt clotting (aspirin, heparin/warfarin) C – Cortisone (At risk for adrenal insufficiency) D – Diabetes mellitus – Other condition that requires strict blood glucose control that known to delay wound healing E – Emboli T - Uncontrolled Thyroid Disease – Overactive: risk of Thyrotoxicosis – Underactive: risk of respiratory depression
MEDICAL HISTORYAlcohol, recreational drug or nicotine use – Indicate potential problem with anesthesia or analgesic administration and risk for withdrawal complications – Alcohol/drugs can cause withdrawal – Tobacco/drug reduces hemoglobin levels making less oxygen available for tissues – Smokers are at high risk for thrombus formation (due to hypercoagulability secondary to nicotine use
MEDICAL HISTORYCurrent Discomforts – With preexisting painful conditions may require alternative methods of pain reduction while under NPOChronic illness – Illness that require consideration when positioning – Arthritis of the neck/backAdvanced age – Older clients have specific perioperative needsMedication hx – OTC may increase operative risk – Ask if they are taking and brought them in the hospital – Medication dosages and administration schedules should be noted in the chart
PSYCHOLOGICAL HX• Client’s cultural beliefs and practices• Client’s emotional reaction towards the whole surgical experience
• Ability to tolerate perioperative stress – Physiologic stress like pain, tissue damage, anesthesia, blood loss, fever and immbilization• Lifestyle habits and social hx• Physical examination – Must be done prior to operation – To identify present health status and to have baseline info – To identify problems and to develop appropriate outcome goals
ASSESSMENT OF SPECIFIC BODY SYSTEMS
CARDIOVASCULAR• Presence of pathologic or cardiac conditions• increase operative risks and could lead to decrease tissue perfusion with impairment of surgical healing. – Angina pectoris – Occurrence of MI in the last 6 mos – Uncontrolled HPN – Heart failure – Peripheral vascular disease
CARDIOVASCULARDocument the ff observations: – SOB on minor exertion – HPN – Heart murmurs or S3 gallops – Chest pain
CARDIOVASCULARDx and lab studies done to measure cardiovascular function a. ECG, esp for cients over 40 yrs b. hemoglobin, hct and serum electrolytes
RESPIRATORY1. Chronic lung conditions - increase operative risks - impair gas exchange in the alveoli - predisposing to postoperative pulmonary complications: a. Emphysema b. Asthma c. Bronchitis
RESPIRATORY2. Assessment of pulmonary conditions must include: a. Examining for presence of SOB b. Wheezing c. Clubbed fingernails d. Chest pain e. Cyanosis f. Coughing with expectoration of copious or purulent mucous g. Obtain hx of smoking and respiratory allergies
RESPIRATORY3. Diagnostic and lab studies to measure respiratory function: a. CXR b. pulse oximetry c. ABG (arterial blood gas) analysis d. Pulmonary function test
MUSCULOSKELETAL1. Assess for hx of the ff disorders that may affect surgical positioning and postop support: a. arthritis b. fractures c. contractures d. joint injury e. musculoskeletal impairment
MUSCULOSKELETAL2. PE that may reveal problems with joint mobility or deformities that may interfere with operative positioning
GASTROINTESTINAL• GI conditions that may be associated with poor surgical outcomes: – Severe malnutrition – Prolonged nausea and vomiting• General assessment of the GI functioning should be done esp for abdominal surgery
INTEGUMENTARY• The skin must be assessed preoperatively to be able to establish baseline data for comparisons postoperatively.• The following should be documented and reported if observed during assessment: 1. Lesions 2. Pressure ulcers 3. Necrotic skin tissue 4. Skin turgor 5. Erythema 6. Discoloration of the skin 7. Tattoos and body piercing
RENAL• adequate renal function is necessary to eliminate protein wastes, to preserve fluid and electrolyte balance, and to remove anesthetic agents.1. Renal and related renal disorders that may affect the outcome of the surgery are the following: a. Advanced renal insufficiency b. Acute nephritis c. Benign prostatic hypertrophy2. Assess renal status by asking about voiding patterns. – Monitor fluid and electrolyte balance by recording intake and output throughout the perioperative phases.3. common preoperative tests done to determine the status of renal function - Blood urea nitrogen (BUN) - serum creatinine - urinalysis are the
Liver Function Assessment1. Cirrhosis of the liver increases client’s surgical risk since an impaired liver cannot detoxify medications and anesthetic agents2. Hx of alcoholism or other substance abuse require careful assessment of the liver function before surgery.3. A high calorie diet or hyperalimentation may be ordered during preop and postop phases – to correct problems of malnourished and debilitated clients with liver disease
Cognitive and Neurologic Assessment1. Assess for serious neurologic conditions such as: - uncontrolled epilepsy - severe Parkinson’s disease - that may increase surgical risk.2. Assess the following through thorough physical assessment and interview to obtain baseline data: a. Severe headache b. Frequent dizziness c. Light-headedness d. Ringing in the ears e. Unsteady gait F. Unequal pupils g. History of seizures h. Neurologic functions (i.e., reflex response of extremities, sensory reflexes, and cerebral responses) i. Orientation to time, person and place
Endocrine Assessment1. Diabetes mellitus (DM) - most common pre-existing endocrine disorder. - puts client at high risk for poor wound healing and increased risk of postoperative infections.Constant monitoring and control of blood glucose should be done all throughout the perioperative period.2. Thyroid functioning may also be assessed preoperatively.Thyroid replacement is usually continued during the perioperative period.
Additional Assessments1. Agea. Physiologic changes normal to aging clients and presence of certain diseases may adversely affect surgical outcomes.b. Surgical risks including: – Malnutrition – Anemia – Dehydration – Atherosclerosis – Chronic obstructive – Pulmonary disease – Diabetes mellitus – Cerebrovascular changes – Peripheral vascular disease may increase due to chronic conditions commonly found to elderly clients.
2. Pain – important physiologic indicator that necessitates careful monitoring. – Clients should be asked whether they are experiencing any pain prior to any surgical procedure. – If pain is present, thorough assessment should be done to identify the cause of the pain.
3. Nutrition - nutritional status is directly related to intraoperative success and postop recovery. - Assessment includes: - acquiring a diet history - observing general appearance - laboratory/diagnostic testing - comparing current weight with ideal body weight.
4. Fluid and electrolyte balanc e - Proper assessment of actual and potential fluid imbalances - Fluid volume deficits such as hypovolemia or hypervolemia predispose a client to complications during and after surgery. - Electrolyte imbalances also increase operative risk - Preoperative laboratory results should be checked to determine whether serum sodium, potassium, calcium, and magnesium concentrations are within normal levels.
5. Infection and immunitya. Any pre-existing infection can adversely affect surgical outcomes since bacteria may be released in the blood stream during surgery.b. Any possible exposure to communicable diseases, presence of skin lesions, or manifestations of an infection (e.g., coughing, sore throat, or fever) should be properly documented during preoperative assessment.c. If existing infection greatly increases surgical risks, rescheduling the surgery may be necessary.
6. Hematologic conditionsa. History of bleeding or diagnosis of pathologic condition such as hemophilia or sickle cell anemiab. Bruising, excessive bleeding following dental extractions, or severe epistaxisc. Hepatic or renal diseased. Use of anticoagulants, aspirin or other non steroidal anti-inflammatory drugse. Abnormal bleeding time, prothrombin time, or platelet count
Informed Consent• A legal document that signifies that the client has been told about and understands all aspects of as specific invasive procedure.• Guards the client against unwanted invasive procedures• Protects the health care facility and health care professionals when the client denies understanding about the procedure• Physician’s responsibility to provide appropriate information,• Nurse’s duty to ask the client to sign the consent form, and may be a witness to the client’s signature
Informed consent is a must in the following circumstances:1. Invasive procedures - surgical incision - a biopsy - cystoscopy - paracentesis)2. Procedures requiring sedation and/or anesthesia3. A nonsurgical procedure - arteriography that carries more than slight risk to the client4. Procedures involving radiation
Criteria for Valid Informed Consent• Voluntary Consent – valid consent must be freely given, without coercion• Incompetent Client – not autonomous – cannot give or withhold consent – mentally retarded, mentally ill, comatose
Criteria for Valid Informed Consent• Informed Subject – informed consent should be in writing and should contain the following:1. Explanation of procedure and its risks2. Description of benefits and alternatives3. An offer to answer questions about procedures4. A statement informing the client if the protocols differ from customary procedures
Criteria for Valid Informed Consent• Client Able to Comprehend – information must be written and delivered in language understandable to the client. – Questions must be answered to facilitate comprehension if material is confusing.
Preoperative TeachingPURPOSE:• To ensure a positive surgical experience for the client• helps to alleviate the client’s fear and anxiety regarding the surgery.
Components of Preoperative Teaching• Sensory Information – addresses the sights, sounds and ambiance of the operating roo – discuss what the client should expect to see, hear, and feel when he/she is transferred to the operating room and on the operating room table.
Components of Preoperative Teaching• Psychosocial Information – addresses the coping abilities and the worries of the client and the family. – To alleviate the client and family’s worries and fears, the nurse together with the help of a social worker or a counselor should address questions such as the following: 1. What if I die? 2. How could we pay for the operation? 3. Who will take care of my children while I’m here?
Components of Preoperative Teaching• Procedural Information – what will happen all throughout the perioperative period including the discharge phase. – All the information that the client wants to know regarding the client care should be addressed.
• The nurse also provides instruction for the following: 1. Deep breathing 2. Coughing 3. Turning 4. Ambulating 5. Pain control
Preoperative Nursing Diagnoses• Deficit knowledge related to unfamiliar surgical experience.• Anxiety/fear related to pain, death, disfigurement, or the unknown
Preoperative Nursing Care1. Preparation of the skin a. shower/bathing the night before a scheduled surgery as per institutional policy. b. Clean the site with soap and water or antimicrobial solution to diminish the # of microbes on the skin2. Clean the area before the surgery3. Padding on bony prominences to prevent trauma in the skin during transfer
Preoperative Nursing Care4. The gastrointestinal tract is prepared the night before the surgery to: – Reduce the possibility of vomiting and aspiration – Reduce the risk of possible bowel obstruction – Allow visualization of the intestine during bowel surgery – Prevent contamination from fecal material in the intestinal tract during bowel or abdominal surgery
Preoperative Nursing Care• Preparations for the gastrointestinal tract include the following:a. Restricting food and fluid 8-10 hrs before the operationsb. Administering enema as needed
Preoperative Nursing Care• Preparations for the gastrointestinal tract include the following: – Restricting food and fluid 8-10 hrs before the operations 1. Explain the reason for restriction 2. Remove food and water from bedside at midnight 3. Place “NPO” signs on the door and bed 4. Mark the care plan or the Kardex with “NPO” 5. Inform the diet and nutrition dept and family about the status 6. If the client has been instructed to take impt meds orally: 1. Allow only small sips of water 2. Explain why this permission is permissible 3. Document the med and amount of fluid taken in the chart
Preoperative Nursing Care• Administering enema as needed1. Especially operation in gastrointestinal tract, perianal area, and pelvic cavity.2. May be done at home or administered by the nurse in the hospital.3. Bowel cleansing in the morning before the surgery may be done as prescribed
Preoperative Preparation Immediately Before Surgery1. All known allergies are recorded and an allergy wristband is present.2. Vitals signs are checked and recorded.3. The identification band is present and correct.4. The consent formed is signed and the surgical procedure is listed correctly.5. Skin preparation is completed if ordered preoperatively.6. Any special orders are completed (enema, IV line)
Preoperative Preparation Immediately Before Surgery7. The client has not eaten or had fluids by mouth for the last eight hours.8. The client has just voided.9. Oral hygiene or other physical/hygiene care is completed.10. The presence of dentures, bridgework, or other prostheses is noted.11. Storage is arranged and documented for valuables according to health care facility policy.
Preoperative Preparation Immediately Before Surgery12. The client has removed jewelry.13. The perioperative nurse is notified about the presence of a hearing aid.14. The client is wearing a hospital gown and protective cap.15. Make-up is removed.16. Preoperative medications are given.17. Transfer the client from bed to a stretcher
Members of the Surgical Team• Group of highly trained professionals who coordinate their efforts to ensure the welfare and safety of the client
• Members of the Surgical Team 1. Surgeon • HEAD 2. Second Surgeon or a Specially Trained Nurse 3. Anesthesiologist • Alleviates pain • Promotes relaxation with medications • Maintain airway • Ensure adequate gas exchange • Monitors circulation and respiration • Estimates blood and fluid loss • Infuses blood and fluids • Maintains hemodynamic stability • Alerts surgeon immediately to any complications 4. Perioperative Nurses
Roles of the Perioperative NurseI. Circulatory Nurse 1. Assessment of client preoperatively. 2. Planning for optimal care during the surgical intervention. 3. Coordinating all personnel within the operating room. 4. Delegating and monitoring unlicensed personnel. 5. Monitoring responsible cost compliance associated with operating room procedures.
Roles of the Perioperative Nurse• Circulatory Nurse6. Ensuring all equipment are working properly7. Guaranteeing sterility of equipment and supplies8. Assisting with positioning9. Performing surgical skin preparation10. Monitoring the room and team members for breaks in sterile technique
• Circulatory Nurse11. Assisting anesthesia personnel with induction and physiologic monitoring12. Handling specimens13. Coordinating activities with other departments, such as radiology and pathology14. Documenting care provided15. Minimizing conversation and traffic within the operating room suite
II. Scrub Nurse – RN or Surgical Technician – Duties: 1. Gathering all necessary equipment for the procedure 2. Preparing all supplies and instruments using sterile technique 3. Maintaining sterility within the sterile field during surgery 4. Handling instruments and supplies during surgery
II. Scrub Nurse 5. Cleaning up after the case 6. Maintains an accurate count of sponges, sharps, and instruments on the sterile field and counts the same materials with the circulating nurse before and after the surgery
III. Registered Nurse First Assistant (RNFA) – New role of perioperative nurses – 1st assistants (to the surgeon) in place of a 2nd or assisting physician – Additional Specialized education – Must work with surgeon and are not independent practitioners1. Providing exposure of the surgical area2. Using instruments to hold and cut3. Retracting and handling tissues4. Providing homeostasis5. Suturing
IV. Certified Registered Nurse Anesthetist (CRNA) – RN with minimum of additional 2 yrs education specializing in the anesthesia administration – BSN, + 1-2 yrs in ICU – Work under the direction of anesthesiologistV. Manager – Extensive experience, additional education in mgt – Reqt: BSN degree, MN – OTHER NAMES: clinical nursing director/ OR manager
VI. Educator – Any RN, although usually with MSN, experienced perioperative nursesVII. Case Manager – Extensive experience – Ability to communicate – Knowledge of the total surgical episode from home before surgery to home care needs after surgery
SURGICAL ENVIRONMENT• Division of Surgical Area – 3 zones (decrease microbes circulating in the OR 1. UNRESTRICTED ZONE • Street clothes or dirty (not sterile) clothing are allowed 2. SEMI-RESTRICTED ZONE • Attire consists of scrub clothes and cap 3. RESTRICTED ZONE Scrub clothes, shoe covers, caps and masks are worn
Eight Basic Principle of Aseptic Technique
Eight Basic Principle of Aseptic Technique1. All materials in contact with the surgical wound and used within the sterile field must be sterile.2. Gowns of the surgical team are considered sterile in front from the chest to the level of the sterile filed. – Sleeves are sterile from 2 inches above the elbow to the stockinette cuff3. Sterile drapes are used to create sterile field. – ONLY the top surface of drape table is sterile4. Items should be dispensed to a sterile field by methods that preserve the sterility of the items and the integrity of the sterile field. – Edges are considered UNSTERILE
Eight Basic Principle of Aseptic Technique5. The movements of the surgical team are from sterile to sterile areas and from unsterile to unsterile areas.6. Movement around the sterile filed must not cause contamination of the field.7. Whenever the sterile barrier is breeched, the area must be considered contaminated.8. Every sterile field should be constantly monitored and maintained. DOUBTFUL STERILITY ARE CONSIDERED UNSTERILE
Surgical Hand Washing (Scrubbing)Purpose of Surgical Hand Washing1. To remove debris and transient microorganisms.2. To reduce the resident microorganisms3. To inhibit rapid rebound growth of microorganisms
Surgical Hand Washing (Scrubbing) 2-3min surgical scrub is the recommended length of time for surgical hand washing by theAssociation of Operating Room Nurses (AORN)
To perform the surgical hand washing (scrubbing):
Surgical Attire Semi-restricted and restricted zones within traditional OR suites requires personnel to wear special surgical attire. Wearing surgical attire helps prevent transmission of microbes from personnel to clients.Consist of: – Scrub gowns – Hair coverings – Masks – Protective eyewear – Shoe covers
PERSONAL PROTECTIVE EQUIPMENT
The following are principles that should be observed when donning surgical attire:1. Surgical attire should be worn only within the surgical site2. If in case there is a need to wear the attire outside the semi-restricted and restricted zones of the OR, it should be covered or changed before reentering the area3. Clean scrub suit should be worn within the surgical environment – TO CONTAIN BACTERIAL SHEDDING FROM THORAX AND ABDOMINAL SKIN4. If a two-piece scrub suit is worn (pants and top), the top must be secured at the waist, tucked into the pants, or fit close to the body
The following are principles that should be observed when donning surgical attire:5. Scrub suits should be changed daily or whenever they become visibly soiled or wet6. Sleeves of scrub suits should be short enough to allow for surgical hand washing to two inches above the elbow7. All head and facial hair, including sideburns and necklines, should be covered by a clean, low-lint surgical hat or hood when one is in the semi- restricted/restricted zones8. The surgical hat or hood should be the first piece of the OR attire that is donned – TO PREVENT HAIR FROM COLLECTING ON THE SCRUB CLOTHES
The following are principles that should be observed when donning surgical attire:9. Shoe covers may be worn inside the OR for sanitation purposes10.All shoe covers should be removed upon leaving the restricted zones, and a new pair should be worn when returning to the OR11.Masks must be worn in specified restricted areas of the surgical suite12.Masks are worn to filter organisms from the exhaled air13.A mask should be secured over the nose, along the sides of the face, and under the chin to prevent venting or escape of air
The following are principles that should be observed when donning surgical attire:14.Surgical masks should be changed between procedures and should be allowed to hang around in the neck15.Use of double masks is unacceptable for it becomes a barrier rather than a filter16.Protective eyewear (goggles with solid side shields, or chin-length face shield) is worn to reduce the incidence of contamination of mucous membranes whenever contamination can be anticipated as a result of splashes, sprays or splatters of blood droplets17.Jewelry should not be worn in the surgical suites
The following are principles that should be observed when donning surgical attire:18.Sterile gown and gloves are donned using the closed method when a scrub nurse enters the operating room19.Gloves should fit properly to ensure ease of handling of the OR instruments and supplies20.Complete surgical hand washing (scrubbing) should be performed before donning sterile gown and gloves
Surgical Draping• the practice of covering a client and the surrounding areas with sterile barriers to create and maintain a sterile field during a surgical procedure.• Sterile surgical drapes protect the client from infection by preventing microbes from making their way into the skin opening created during surgery.• 2 responsibilities of scrub nurse: 1. to provide the correct drapes for a specific surgical procedure 2. to assist surgeons during draping
Surgical Draping• Circulating nurse – Observe for breaks in sterile techniques so that corrective measures should be taken by the surgical team.
Basic Principles of Draping1. Isolate – Isolate “dirty area” from clean area – Accomplished by using impermeable drape, made from a plastic materials2. Barrier – Provides an impermeable layer, must have plastic film to prevent strike-through3. Sterile Field – Achieved thru sterile presentation of drape and aseptic application technique. – If drape is not impermeable, additional impermeable layer should be added.
Basic Principles of Draping4. Sterile Surface – skin cannot be sterilized, it is necessary to apply an incise drape to create a sterile surface. Only an incise drape can create a sterile surface5. Equipment Cover – Sterile drapes cover nonsterile equipment or organize equipment used on the sterile field. – To protect client from equipment – To protect and prolong life of equipment6. Fluid Control
SEDATION & ANESTHESIA• Four Levels of Sedation1. MINIMAL Sedation – Drug-induced state during the client can’t respond normally to verbal command2. MODERATE Sedation – May be administered thru IV – Depressed level of consciousness that does not impair the client’s ability to maintain patent airway – To respond appropriately to physical stimulation and verbal command3. DEEP Sedation – Client can not be easily aroused or respond purposefully after repeated stimulation
FOUR Levels of AnesthesiaStage I: Beginning Anesthesia (Onset)Stage II: ExcitementStage III: Surgical AnesthesiaStage IV: Medullary Depression
LEVELS OF ANESTHESIA• Stage I: Beginning Anesthesia (Onset) – START: during anesthetic administration – END: during loss of consciousness – Client may be drowsy/dizzy with possible auditory or visual hallucinations. – Nursing Intervention: – Close the OR door – Avoid unnecessary noises or motions when anesthesia begins – Stand by to assist client
LEVELS OF ANESTHESIA• Stage II: Excitement – START: during loss of consciousness – END: loss of eyelid reflexes – There is increase autonomic activity, irregular breathing and may struggle. – Nursing Intervention: – Assist anesth in restraining the client – Touch the client only for purpose of restraint.
LEVELS OF ANESTHESIA• Stage III: Surgical Anesthesia – START: loss of eyelid reflexes – END: loss of most reflexes is present and there is depression of vital functions – Client is UNCONSCIOUS, relaxed muscles, blink and gag reflexes are absent – Nursing Intervention: – Begin preparation for surgery only when anesthetist indicates stage III has been reached and client is breathing well, with stable v/s
LEVELS OF ANESTHESIA• Stage IV: Medullary Depression – START: functions are excessively depressed – END: indicates respiratory and circulatory failure. – The client is not breathing; the heartbeat may or may not be present. – Nursing Intervention: – If arrest occurs, respond immediately to assist in establishing airway; – provide cardiac arrest tray, drugs, syringes , long needles; – Assist surgeon with closed or open cardiac massage.
Types of General Anesthesia1. Intravenous Anesthesia2. Inhalation Anesthesia
Types of General Anesthesia1. Intravenous Anesthesia – Rapid induction – Unconsciousness occurs 30 sec after the administration – Promotes rapid transition from conscious to surgical anesthesia stage – Prepare client for a smooth transition to the surgical anesthesia stage since IV anesthetics has calming effects. – Ex. Thiopental sodium and ketamine
Types of General Anesthesia2. Inhalation Anesthesia – A mixture of volatile liquid or gas and oxygen is used. – ease of administration and elimination through the respiratory system. – Usually used to maintain the client in stage III anesthesia following induction. – Mixture is given through mask or an endotracheal tube (ET tube is inserted once the client is paralyzed and unconscious). – Commonly used inhalation anesthetics are halothane and isoflurane – nitrous oxide = commonly used gas anesthetic
Types of Regional Anesthesia1. Spinal Anesthesia2. Epidural Anesthesia3. Topical Anesthesia4. Local Infiltration Anesthesia5. Filed Block Anesthesia6. Peripheral Nerve Block Anesthesia
Types of Regional Anesthesia1. Spinal Anesthesia• used for surgical procedures involving the lower half of the body;• any procedure performed below the level of the diaphragm (e.g., hysterectomy, appendectomy)• Anesthetic technique of choice for older adults• Benefits: – relative safety; – excellent lower-body muscle relaxation, – absence of the effect of unconsciousness. – does not require emptying of the stomach.• achieved by injecting local anesthetics into the subarachnoid space.
Types of Regional Anesthesia2. Epidural Anesthesia• Epidural block is achieved by introduction of an anesthetic agent into the epidural space (entered by a needle at a thoracic, lumbar, sacral, or caudal interspace).• Provide a blockage of the autonomic nerves and hypotension can result.• Respiratory muscles are affected, respiratory depression or paralysis may occur if the level of block is too high.• Caudal Anesthesia – produced by injection of the local anesthetic into the caudal or sacral canal. This is a variation of epidural anesthesia. This method is commonly used with obstetric clients.
Types of Regional Anesthesia3. Topical Anesthesia – agents may be applied directly on the area to be desensitized. – May come in a form of a solution, an ointment, cream, or powder. – a short-acting anesthesia that can block peripheral nerve endings in the mucous membranes of the vagina, rectum, nasopharynx, and mouth.
Types of Regional Anesthesia4. Local Infiltration Anesthesia – involves the injection of an anesthetic agent into the skin and subcutaneous tissue of the area to be anesthetized. – lidocaine (Xylocaine) – block only the peripheral nerves around the area of incision.
Types of Regional Anesthesia5. Filled Block Anesthesia – injected and infiltrated into the area proximal to the planned incision – block forms a barrier between the incision and the nervous system.
Types of Regional Anesthesia6. Peripheral Nerve Block Anesthesia – Anesthetizes nerves or nerve plexus rather than all the local nerves anesthetized by a filed block. – Commonly used drugs lidocaine, bupivacaine, and mepivacaine.
INTRAOPERATIVE NURSING CARE
Maintaining Safety and Preventing Injury1. Position the Client• Consider client’s: – Site of operation – Age – Size of client – Types of anesthetic used – Pain normally experienced by the client on movement• Position must: – Not hinder respiration/circulation, – Not apply excessive pressure to skin surfaces – Not limit surgical exposure
Maintaining Safety and Preventing Injury• Surgical Positions a. Dorsal Recumbent (supine) d. Prone • Commonly used for CABG, – Cervical spine hernia repair, mastectomy, bowel – Posterior fossa craniotomy resection – Back, rectal and posterior leg b. Trendelenburg • Permits displacement of intestines e. Lateral into upper abdomen – Kidney, chest or hip surgery • Often sued during surgery of lower abdomen or pelvis c. Lithotomy • Exposes perineal and rectal areas • Vaginal repair, D&C, rectal surgery
Maintaining Safety and Preventing Injury2. Provide Equipment Safety – Counting of needles, sponges, and instruments are performed by the circulating nurse and the scrub nurse must be done: a. before the initial incision b. during the surgery c. immediately before the incision is closed – A final correct count is announced to the surgeon and charted on the intraoperative chart.
Maintaining Safety and Preventing Injury3. Maintain Surgical Asepsis – Ensure the sterility of supplies and equipment. – Ensure all members of surgical team use sterile technique to minimize postop infections – Be an advocate in maintaining sterile surgical environment
Maintaining Safety and Preventing Injury4. Assisting with Wound Closure – Anticipate the type of closure needed and obtain the supplies necessary for wound closure. – If a surgical drain is used, assess whether the drainage is flowing freely through the system. – Monitoring of the drain’s patency and the characteristic of the drainage is continued when the client is transferred out of the operative area.
Maintaining Safety and Preventing Injury5. Monitoring• Monitor body temperature and watch out for signs of hypothermia.• Offer a blanket to the client immediately upon transfer to the operating room bed.• Report the lowest core body temperature to the postoperative nurse when transferring the client after surgery.• Thermal blankets may be provided• IV solutions can be warmed to assist maintaining warm body temperature
Maintaining Safety and Preventing Injury• Monitor for malignant hyperthermia, a genetic disorder characterized by uncontrolled skeletal muscle contraction leading to potentially fatal hyperthermia. a. This condition can occur 30 minutes of anesthesia induction or several hours after surgery. b. Initial manifestation is increased end-tidal carbon dioxide, jaw muscle rigidity, cardiac dysrhythmias , and a hypermetabolic state caused by anesthetic agents (succinylcholine).• Monitor for respiratory and cardiac arrest. Although an arrest is a rare occurrence, everyone inside the operating room should know where the crash cart is kept so immediate management could be administered.• Monitor for uncontrolled hemorrhage and secondary allergic reactions from drugs and latex.
Documentation• circulating nurse, records every event and action in the operating room.• Information about the following is endorsed to the postoperative nurse upon client transfer:1. Drains, tubes, or other devices remaining on the client after the surgical procedure2. Type of closure and dressing used
Moving and Transporting the Client• wipe off excess blood, skin preparation, and debris from the client’s skin, before moving and transporting the client• Put on a clean gown and blanket.• Ensure that enough personnel are present for moving or transferring a client postoperatively to prevent injuries.• Avoid rapid movements when changing the client’s position.• Gradually move the clients from the operating room table to the stretcher.• Be careful not to catch, kink, or dislodge IV or catheter tubing, drains, or other equipment during transfer.• Avoid rough handling, which may damage fragile skin.
POSTOPERATIVE PHASE1. Initial period of time for recovery from anesthesia, during which the client is monitored closely by post-anesthesia nurses.2. Time from discharge from the post-anesthesia care unit (PACU) to the first day or so after surgery while the client is recovering from the effects of the surgery and is beginning to ambulate.3. the time of healing, which may last for a few weeks, months, or even years after surgery.
Post-Anesthesia Care Unit (PACU) GOAL: To assist an uncomplicated return to safe physiologic function after an anesthetic procedure by providing safe, knowledgeable, individualized nursing care for clients and their family members in the immediate post-anesthesia phase.
Post-Anesthesia Care Unit (PACU)• Immediate Assessment – Supporting vital physiologic functions until the effect of anesthetic agents abate. – Proper positioning of a sedated, unconscious or semiconscious client ensuring airway patency.
Review client’s record noting the following:1. Anesthesia record for IV medications and blood received during surgery2. Any unanticipated complications3. Significant preoperative findings4. Presence of tubes, drains, and types of wound closure5. Length of time the client was in surgery
IMMEDIATE: Perform an assessment which includes the following:1. Airway a. Patency b. Presence of tubes and respiratory assistance device2. Breathing a. Respiration rate and depth b. Presence of bilateral breath sounds, stridor, wheezes, hoarseness , or decreased breath sounds c. Return of gag reflex
IMMEDIATE: Perform an assessment which includes the following: 4. Others3. Circulation a. Level of consciousness a. Pulse, BP, skin color, pulse oximeter b. Muscle strength b. ECG tracing if attached c. Ability to follow commands c. Wound status and dressings d. IV infusions, dressings, drains, and d. Slight increase in the heart rate – special may be normal due to stress response equipments; tubes and drains that must be after surgery attached to containers or suction e. Reddened or bruised areas on the skin unrelated to surgery f. Temperature
Initial Nursing Diagnoses1. Ineffective airway clearance related to effects of anesthesia.2. Impaired gas exchange related to ventilation-perfusion imbalance.3. Altered tissue perfusion related to hypotension postoperatively.4. Risk for altered body temperature related to medications , sedation, and cool environment.5. Risk for fluid volume deficit related to blood loss, food and fluid deprivation, vomiting, and indwelling tubes.6. Pain related to surgical incision and tissue trauma.7. Impaired skin integrity related to invasive procedure, immobilization, and altered metabolic and circulatory state.8. Risk for injury related to sensory dysfunction and physical environment.9. Sensory alterations related to effects of medications and anesthesia.
Nursing Care in the PACU• Protect the Airway1. by positioning the head of a minimally responsive client to the side with the chin extended forward to prevent respiratory obstruction.2. Suctioning is administered to a client who is unable to clear mucus or vomitus from the throat.3. Place an oral or nasal airway, as necessary, to help maintain patency and control the tongue.4. Observe for the development of laryngospasm as manifested by crowing respirations in an extubated client. INTERVENTIONS: 1, immediately ventilate the client by face mask, securing a tight fit over the mouth and nose. 2. Remove irritating stimulus to the airway 3. if >1min, may require muscle relaxant (succinylcholine) to relax the muscles of the larynx6. Administer prescribed medications as needed.7. Administer oxygen using the appropriate method for delivery as prescribed.8. Hook the client on a pulse oximeter to monitor tissue oxygenation.
Nursing Care in the PACUMaintain Normal Blood Pressure1. Monitor for a significant drop in the blood pressure accompanied by increased heart rate which may indicate hemorrhage, circulatory failure, or fluid shifts.2. Monitor for a decrease in blood pressure which may indicate that the anesthesia is wearing off or that the client may be experiencing severe pain.3. Measure pressure every five minutes for 15 minutes to determine the inconsistency in the client’s blood pressure.4. Observe for manifestations of shock (tachycardia, restlessness and apprehensions, cold, moist, pale, or cyanotic skin)
Nursing Care in the PACU5. Provide the following interventions if the client appears to be going into shock:a. Administer oxygen or increase the rate of deliveryb. Raise the client’s legs above the level of the heartc. Increase the rate of IV fluids, unless contraindicatedd. Notify the anesthetist and the surgeone. Provide medications as orderedf. Continue to assess the client and his/her response to interventions
Nursing Care in the PACU• 6. Watch out for older clients with history of hypertension who may exhibit hypertensive episodes after the stress of the surgery.• 7. If blood pressure rises above the baseline, consult with the anesthetist or the surgeon and administer antihypertensive medication as ordered.• 8. If sinus tachycardia happens, – Treat the underlying cause (anxiety, pain, hypovolemia, hypoxia) – Betablockers may be given• 9. If sinus bradycardia happens, – Treat the cause (vagal stimulation, hypoxemia, hypothermia, high spinal anesthesia, certain anesthetic drug – Atropine is the drug of choice
Nursing Care in the PACUMonitor for the Return of Consciousness1. Assess level of orientation by asking the client his/her name.2. Orient the client to place, date and time.3. Monitor for postoperative delirium which usually happens to clients who undergo open heart surgery.
Nursing Care in the PACUAssess for Return of Sensation and Motion1. Monitor the client carefully for return of sensation as the anesthetic wears off.2. Check for return of motion to the extremities by asking client to wiggle his/her toes (this may be delayed if client had spinal anesthesia).
Nursing Care in the PACU• Assess for Normothermia1. Monitor for v/s every 15 minutes until v/s are stable or more often if these are unstable.2. Monitor at least 1 hr until they are discharged from PACU3. When administering measures to warm the client, constant temperature monitoring should be done - to prevent from overwarming causing excessive vasodilation, which can cause fluid shifts and a decrease in BP
Nursing Care in the PACU• Assess Perfusion1. Assess skin color, warmth and turgor2. Observe for development of shock which could be manifested by:a. Dusky, pale, cold, moist skinb. Significantly decreased blood pressurec. Cyanotic lips, nails, and skind. Low oxygen saturatione. Low levels of hemoglobin
Nursing Care in the PACUAssess the Surgical Site1. Check the dressing over the surgical incision frequently.2. Note the color, type, and amount of drainage if dressing is soiled.3. Support dressing but do not change or open it without a physician’s order.4. If seepage is observed, draw an outline of the dressing and note date and time this is observed. Estimate amount of seepage if oozing continues.5. If bleeding is suspected and not visibly seen, inspect under the operated extremity or under the back for signs of leakage.
Nursing Care in the PACUPromote Fluid and Electrolyte Balance1. Intake and output should be assessed hourly.2. Monitor all parenteral fluids (e.g., IV fluids, medications , blood products , nutritional support, and colloidal infusions) – to ensure proper amount of fluids are being infused.3. Upon admission of the client to the PACU, check the amount of solution in the IV fluid including the rate of infusion.4. Check that all types of delivery systems and lines the client has (e.g., pumps, infusion machines, monitoring machines , IV lines, central venous lines, and arterial lines) are patent and functioning.
Nursing Care in the PACU5. Check insertion sites for redness, soreness, and swelling which may indicate infiltration.6. Note medications that have been added to solutions . This ensures that the required dilution of fluid and the next dose of medication are available to prevent lapses in administration.7. Avoid fluid overload through careful monitoring and prompt administration of required parenteral fluids.8. If an indwelling catheter is present, document the amount of output and compare it with the amount of intake via IV fluids.
Nursing Care in the PACUManage Drainage Systems1. Constantly monitor drainage tubes such as T tube, gastric tube, urinary catheter, or wound drains.2. Ensure that the drainage tubes are attached to their respective drainage systems, patent, and draining freely.3. Check that there are no kinks and occlusions on the tubes.4. Document the amount and characters of drainage on a regular schedule.5. Compare the type, amount, and characteristic of drainage with those expected for the surgical nursing.
Nursing Care in the PACUPromote Comfort1. Assess the client’s level of pain carefully and regularly.2. Provide appropriate pain relief/reduction while not overmedicating.Maintain Safety1. Side rails must be raised at all times to protect the client from falling out of the bed.2. Ass ist the client in maintaining circulation and relieving skin pressure by proper body alignment and frequent repositioning.3. Check postoperative equipment prior to receiving clients in the PACU to ensure that they are working properly.
POSTOPERATIVE NURSING CAREEstablish the Postoperative Goals by Revising and Expanding the PostoperativeNursing Care Plan1. Assess the Postoperative Client2. Assess Respiratory Status3. Assess Circulation4. Assess Neurologic Status5. Monitor the Wound6. Monitor Intravenous Lines
7. Monitor Drainage Tubes8. Promote Comfort9. Reduce Nausea and Vomiting10. Discharge Instructions and Care
Assess Respiratory Status1. Assess for patent airway.2. Observe the client and assess the breathing pattern at rest.3. Listen to breath sounds; breath respirations should be unlabored and quiet.4. Observe for clinical manifestations of hypoxia which include confusion, restlessness, pale skin, pulse oximetry readings below 90%, and cool skin temperature.5. Be aware of the major complications following surgery such as decreased lung expansion, atelectasis, or aspiration of retained secretions.6. Assess the lungs by auscultating all the lobes of the lungs, as well as rate and rhythm of respirations.7. Assist client in incentive spirometry to increase lung expansion and keep alveoli open. Best results are achieved when HOB is elevated 45-90 degrees8. Monitor changes in temperature. A body temperature greater than 37.7ºC in the first 24 hours of surgery is frequently caused by atelectasis.
Assess Circulation1. Assess vital signs, skin color, and temperature according to institutional policy.2. Evaluate extremities for weakness, circulation, and numbness.3. Assess bony prominences for deep tissue injuries, which may look like bruises.4. Encourage early ambulation and leg exercises to prevent formation of thrombus.5. Place client in dorsal recumbent position to provide comfort and decreases strain on the incision.6. Be alert when client complains of pain in the extremity, unilateral edema, or warmth in the calf which may indicate thrombus formation.
• Assess Neurologic Status• 1. Ass ess the client for level of consciousness, orientation, and remaining effects of anesthesia on the first 24 hours prior to surgery.• 2. Ensure clients that impaired cognition after surgery is temporary.• 3. Facilitate recovery by promoting cognitive activity, repeating instructions often if necessary, having patience with clients, and fostering hope.• 4. Document changes in condition every shift. Notify the physician immediately if a decrease in the client’s cognition is observed.• 5. Be aware that obese clients may have a delayed return of consciousness after anesthetic procedures.
Monitor the Wound1. Assess the dressing, amount, and character of any drainage present.2. Be attentive to the method of wound care the surgeon prefers. Most surgeons prefer to do the first dressing change.3. If the wound is closed and healing by first intention, dressings on the wound may be minimal and the client may be allowed to shower after 24 hours.4. If the wound healing is to be by second or third intention, then it is left open to heal from the fascia to the skin, and requires special wound handling.5. Measures such as wound packing, dressing, drains, or ostomy bags are included in the wound care depending on wound size, location, and drainage from the wound.6. Measure and record the amount of drainage every shift for comparison with earlier assessments to guide potential care plan changes.7. Assess the client’s willingness to look at the wounds. Do not force the client to look at the wounds if he/she is not yet ready
• Body image is altered in response to surgery thus specific interventions should be directed towards restoration of the client’s body image.1. Show acceptance of the client’s appearance.2. Assist the client in verbalizing feelings about the postoperative appearance and the reactions of others.
SIGNS OF WOUND INFECTIONS• Usually appear 3-4 days postop1. Redness beyond the incision line2. Edema that remains after initial swelling3. Increasing pain4. Increasing drainage that sometimes become purulent5. Fever6. Malaise7. Anorexia8. Leukocytosis• Notify the surgeon of any suspected wound infection• Wound culture may be ordered.
Wound Dehiscence• Be alert for wound dehiscence.• Dehiscence is an opening of a skin wound. It should be treated as open wounds:1. Kept clean with application of packing or dressings2. Allowed to heal by secondary or tertiary intention
Wound Eviceration• a condition wherein the abdominal wounds become infected and the abdominal incision opens, the fascia or internal organs may be visible.• 1. Do not attempt to replace the organs.• 2. Cover the wound with sterile dressings moistened with normal saline.• 3. Monitor client’s vital signs and keep the client as calmas possible.• 4. Notify the physician immediately.
Reduce Nausea and Vomiting• Postoperative nausea and vomiting (PONV) do not occur frequentlyMedications that are used to c ontrol PONV:1. Anticholinergics and histamine type 1 receptor antagonists – reduce excitability of the labyrinth receptors2. Antidopaminergic drugs – depresses the chemoreceptor trigger zone3. Gastrointestinal antispasmodics – promote forward peristaltic movement.• PONV has also been controlled by acupuncture.
Discharge Instructions and Care
Discharge Instructions and Care• Ensure that the client and a family member or caregiver have information and skills needed for continuous recovery.• Teach skills (e.g., wound care) over a period of days, with enough time for questions,demonstration, and return demonstration.• Provide information about home care in writing to the client and family members.• Provide a printed form filled out with specific postoperative information, such as instructions on medications and wound care, an appointment for the next clinic visit, names and contact numbers for emergencies and further questions.• If collaboration with other health care workers (e.g., social services, home nurses, or rehabilitation centers) is needed, proper endorsement should be done.
Miss Nervous Nellie• Miss N is scheduled for a colon resection. A recent biopsy of a polyp revealed a malignancy. During your pre-admission interview Miss N is tearful and keeps saying “I hope this won’t be like it was when my dad had colon surgery.” “I’m so afraid I will die just like he did.” What are Miss N’s psychosocial needs? How will you meet those needs?
Intraoperative Case Study The client, a 62-year-old secretary, has entered the surgical suite about 30 minutes after she has received atropine and midazolam for preoperative medication. The OR schedule lists that she is scheduled to have a vaginal hysterectomy. In addition, the preoperative history indicates that she smokes three packs of cigarettes per day and drinks three cans of beer each day. When you ask her what kind of surgery she is having today, her response is “I am going to have a hemorrhoidectomy.” You ask her if she means hysterectomy and she responds, “Well, it is some kind of operation ‘down there’.”
What Should You Do?• What additional questions should you ask this client?• What should you do with the information?• What effect, if any, will her history of smoking and drinking have on her surgical experience?
The Case ContinuesThe client demonstrates understanding of the surgical procedure and the team proceeds with the planned vaginal hysterectomy. The client weighs 96 pounds.• In what position should you place this client for the surgical procedure?• What areas on this client are most likely to be injured as a result of poor positioning or inadequate padding?• What are the nursing responsibilities related to skin integrity?
Perioperative NursingPhases: Time: – Preoperative Surgical unit to OR – Intraoperative OR-PACU – Postoperative PACU-FOLLOW-UP
Consent• if pt is sedated: – Consent should be from the family member and witnessed by 2 persons
Anxiety before Surgery• Verify pt’s understanding about the upcoming surgery• Clarify certain vague ideas• Do health teaching
Drugs that place clients at risk during perioperative period• Aspirin – Increase bleeding during surgery• Antidepressant – May lower BP during anesthesia – e.g. sertraline (Zoloft)• Anticholinergics• Steroids – risk for adrenal insufficiency)• NSAID – Increase the risk of stress ulcers and displace other drugs from blood proteins – e.g. ibuprofen• Anti-hypertensives• Tranquilizers• Diuretics• Drugs containing bromide – Can accumulate in the body and can produce manifestations of dementia – e.g. Diphenhydramine (Sominex)
Health Teaching• Nurse: – Preoperative teaching should include: • Educating the client about the anticipated postoperative nursing interventions including turning, coughing, deep breathing and leg exercise.• MDs – Preoperative teaching include: • Risks of complications • Proposed surgical procedures • Anesthetic choices