Perioperative concepts and management

Association of PeriOperative Nurses

AORN Standards of Care Recommended Practices Certification Process: CNOR Continuing Education Legislative Issues RN First Assistant: RNFA

Definition of Perioperative Nursing

The practice of nursing directed toward clients undergoing operative and other invasive procedures

The perioperative nurse provides managers, teaches and or studies the care of clients undergoing operative or other invasive procedures in all three phases of the surgical experience

Practice Areas Hospital operating rooms Interventional radiology suites Cardiac cath labs Endoscopy suites Ambulatory surgery centers Trauma centers Pediatric specialty centers Physician offices

Functions of a Perioperative Nurse

Advocate Protector Teacher Change agent Manager of client care

The Surgical Team

Perioperative Team Members

Nursing Roles in the OR Circulating Nurse Scrub Nurse RN First Assistant (RNFA) Perioperative Educator Specialty Team Leader Perioperative Manager/Director

Surgical Team

Behind the scenes Radiology Technologist Anesthesia Technician Nursing Technician Transport Team Environmental Services Team

Perioperative Nursing Skills

Assessment Communication Critical thinking Technical skills

Surgical Attire

Gowns Gloves Masks Hair Covering Protective eyewear

Perioperative Nursing

Three Phases:

Preoperative (Preop) Intraoperative (Intraop) Postoperative (Postop)

Preoperative Phase

Starts when surgery is scheduled Ends when transferred to surgical

suite Assessment phase Planning phase Discharge Planning phase Educations phase Getting it all together phase

Intraoperative Phase Begins when transferred to the surgical suite Ends when transferred to the post-anesthesia

care unit (PACU) Surgical phase Anticipatory time Maintaining client advocacy Maintaining communication with

family/surgical team Surgical team interaction

Postoperative Phase

Begins upon entry to the PACU Ends when discharge from the PACU Assessment Pain control Education Discharge planning Interdisciplinary team communication

Categories of Surgery-Purpose for Surgery

Defined by:1. The reason for surgery2. The urgency for surgery3. The degree of risk of surgery4. The anatomic location of the surgery5. The extent of the surgery required

Reason for surgery

Diagnostic Curative Restorative Palliative Cosmetic

Urgency of the procedure

Elective Urgent Emergent

Degree of Risk

Minor Risk Major Risk

Anatomic location

General GYN Urology Orthopedic Neurological Plastic Ophthalmology

Anatomic location

Cardiac Thoracic ENT Vascular Transplant Trauma Bariatric

Extent of surgery

Simple Radical

Surgical Settings

Inpatient Outpatient/ambulatory Hospital-based ambulatory surgery

center Free-standing surgical center Physician’s office surgery Ambulatory Care Centers

Preoperative Period

Assessment Nursing Management Analysis Planning and Implementation Evaluation

Collaborative Management

Preoperative H&P up to 30 days PTS Primary Care Physician or Nurse

Practitioner Faxed to pre-admission center Faxed to PCP or surgeon Reviewed, evaluated, changes PRN Sometimes surgery gets cancelled

Nursing Process in Pre-op Phase

Planning: Correction of any abnormal labs Blood donations Bloodless surgery Nutrition Pain Management Surgery Classes Discharge planning

Assessment

History Surgical Risk Factors Physical Assessment and

manifestations Psychosocial assessment Laboratory/ Radiographic assessment

History Present problem, reason for surgery Past medical history Past cardiac history Past surgical history Family history Social history Medications Allergies

Surgical Risk Factors

Medical history Cardiovascular system Respiratory system Renal/ Urinary system Neurological system Musculoskeletal Age greater than 65

Surgical Risk Factors

Medication history Past surgical complications Past postoperative complications Nutritional status Social habits Family history of complications Type of surgical procedure planned

Nursing Physical Assessment

Health status Cardiovascular status Respiratory status Renal/urinary status Neurologic status Musculoskeletal status Nutritional status

Psychosocial Assessment Anxiety Fear Coping Support Systems Socioeconomic status Diagnosis Education Physical signs

Lab and Radiograph Assessment

Baseline Predict potential complications Abnormal results Values according to medications

taken

Labs Urine=UA Hematocrit=Hct Hemagloblin=Hgb White blood cell count=WBC Prothrombin time/ pro time=PT Partial thromboplastin time,

activated=aPTT International Normalized ratio=INR

Labs: cont’d

Chemistry: electrolytes=Na, Cl, K, Glucose, CO2

Creatinine Blood urea nitrogen (BUN) Serum pregnancy test

Radiographs/Optional tests

Chest x-ray=CXR Electrocardiogram=EKG Arterial blood gas-ABGs Pulmonary function tests=PFTs Films for area of surgery: x-rays, MRI,

CAT scan

Nursing Management Review planned surgery Obtain client history Physical assessment Preadmission treatment/diagnostic testing Interpret diagnostic tests Client expectations Q&A Caretaker ability

Analysis: Nursing Diagnoses Knowledge deficit Anxiety Disturbed sleep patterns Ineffective coping Anticipatory grieving Disturbed body image Disabled family coping Powerlessness

Planning & InterventionsDx: Knowledge deficit

Ensuring informed consent Client self-determination Implementing dietary restrictions Administration of medications Intestinal preparation Skin preparation Vascular access

Pre-operative TeachingDx: Anxiety Tubes, drains, additional vascular

access Post-op procedures Post-op exercises: breathing exercises,

incentive spirometry, coughing & splinting, leg procedures and exercises

Early Ambulation Range of Motion exercises (ROM)

Relaxation & stress reductionDx: Anxiety

Deep breathing Music therapy Touching Family’s presence Reassurance Calm mannerisms Pre-operative sedation

Collaborative Management: Assessment & Planning

Client interview Correct person for the correct

procedure with correct preparation on the correct anatomy

Risk for perioperative positioning injury Lacks normal defense mechanisms Size, age skin integrity

Potential for hypoventilation Potential for hemodynamic shifts

Blood loss

Preoperative Chart Review:Nursing Responsibility Pre-op check list: Surgical informed consent Anesthesia informed consent Blood transfusion consent-T&S done? Site verification checklist-Med-Surg RN/OR

staff Lab results-report abnormal lab values H&P present & signed Current vital signs Special Needs

Preoperative Client Preparation Clothing removed/don patient gown Jewelry removed including body any

piercing/s Prosthesis: dentures, wigs, limbs Aides: hearing, glasses, cane Arm bands: identification, code status,

blood bracelet, fall risk status bracelet Misc: contact lenses, hairpins Nail polish, artificial nails

Preoperative Client Preparation

Empty bladder Pre-operative medications:

Versed/Reglan Safe transfer to surgical suite

Special Considerations

Patient’s age: child & elderly Cognition: ability to

cooperate/understand Ethnic: customs Language/communication:

interpreter, HOH

Evaluation: what is my outcome?Planned or unplanned

Ms. W, age 77, is admitted for curative surgery (hysterectomy). She has a history of asthma & is currently taking Prednisone. Her weight is 237, her height 5’3”.

What are her known risk factors? What other questions will you ask?

Critical thinking: Synthesis of information

Assessment: physical examination focused on client’s history & planned surgery

Assessment of risk factors Client’s previous experience

w/surgery Client’s coping resources Results of pre-op diagnostic tests

Critical thinking: Synthesis of information

Knowledge: A&P of affected body systems

Surgical risk factors Type of surgical procedure to be

performed Surgical stress response infection

control practices

Critical thinking: Synthesis of information

Experience: Caring for clients who have had surgery

Personal experience with surgery

Critical thinking: Synthesis of information

Standards: apply standards of care (SOC)

Apply AORN standards in operating room

Apply American Society of PeriAnesthesia Nurses (ASPAN) standards of care

Critical thinking: Synthesis of information

Attitudes: Use discipline in collecting a complete history

Use perseverance to ensure a comprehensive assessment

Goals of Client Safety

Provide safe client care Knowledge of procedure Ensure the correct client, correct site,

correct level and correct procedure Knowledge of positioning Adhere to safe medication administration

guidelines Perform surgical counts

Safety: Client Correct patient, correct surgery,

correct side: Time Out Positioning: padding, alignment, eyes,

breast, penis/scrotum Injury: burns Sponge, Needle, Instrument counts Fall prevention-safety straps

Goals of Client Safety

Provide a safe environment Adhere to asepsis: surgical conscious Promote coordinated and effective

communication

Safety: Staff Sharps Equipment Lifting, moving, positioning client Combative client Safety equipment: universal protocol:

goggles; isolyzer gel OSHA: surgical smoke, laser plume

Benefits of a Career in Perioperative Nursing

Requires The ability to work in a fast paced

environment Flexibility Attention to detail Willingness to commit to ongoing

learning The ability to work collaboratively as a

member of the surgical team

Patient Outcomes

Planned Outcomes Unplanned Outcomes

Intraoperative Nursing

Break!

Intraoperative Phase

Begins when the client enters into the surgical suite Sedated? Aware? Noises Cold Double teamed

Surgical Asepsis

Surgical field-defined Surgical tables-green or blue drapes Surgical conscious Infection control practices Physical layout of surgical suite Protocols: distance, doors, dress

Skin Preparation

Clip-electric razor Scrub Shower Purpose

Surgical Hand Scrub

Purpose Agents: soap & water vs. liquid hand

cleaner Nails Position of hands Donning gown & gloves

Safety: Staff Sharps Equipment Lifting, moving, positioning client Combative client Safety equipment: universal protocol:

goggles; isolyzer gel OSHA: surgical smoke, laser plume

Safety: Client Correct patient, correct surgery,

correct side: Time Out Positioning: padding, alignment, eyes,

breast, penis/scrotum Injury: burns Sponge, Needle, Instrument counts Fall prevention-safety straps

My Space-Your Space Defined geographic locations Position of equipment Rules of engagement Color me blue/green Surgical conscious Moving about in the OR OR traffic patterns The Red Line

Anesthesia: more choices and alternatives

General Anesthesia Regional Anesthesia Intravenous Anesthesia Local Anesthesia Balanced Anesthesia

General Anesthesia: Inhalation Agents Inhalation most controllable method; lungs act as

passageway for entrance & exit of agent Gas Agents : Nitrous Oxide

must be given with oxygen require assisted to mechanical ventilation frequently shiver taken in & excreted via lungs Examples: halothane, enthrane, florane…

Anesthesia Cart

Supply Cart Syringes IV supplies Intubation supplies Medications Blood transfusion supplies Regional anesthesia supplies

General AnesthesiaEndotracheal Intubation (maintain airway patency/promote oxygenation)

Used with general anesthesia; Alternatives are mask or LMA

Stages of General Anesthesia

Stage 1: Analgesia/Sedation/Relaxation Stage 2: Excitement/Delirium Stage 3: Operative Anesthesia (Stage 4: DANGER: BAD) not

expected/normal Speed of EMERGENCE (recovery from

anesthesia) depends on type of anesthesia, length of time & many other factors- try to time with end of surgery

General Anesthesia: Intravenous Intravenous Agents

Thiopental Sodium (Pentothal) but is commonly called “Sodium Pentothal” by patients (class: barbiturate)

Diprovan (Propofol) rapid acting monitor vital signs respiratory depression

Adjuncts to General Anesthesia Hypnotics (Versed)

also used for conscious sedation Opioid Analgesics (Morphine, Fentanyl)

respiratory depression Neuromuscular Blocking Agents

Causes muscle paralysis Examples: Rocuronium, Succinycholine What vital function is affected?

Potential General Anesthesia Complications

Overdose (consider risk factors) Hypoventilation postoperatively Intubation related: sore throat,

hoarseness, broken teeth, vocal cord trauma

MALIGNANT HYPERTHERMIA Genetic predisposition Triggered by anesthetics such as

Halothane

Balanced Anesthesia (a sample) Start with Pentothal or Propofol Add in some nitrous oxide for amnesia Use inhalation agent such as halothane Stir in a little opiate- morphine, fentanyl, for

postop analgesia To top it off give Pavulon, a neuromuscular

blocker, for additional muscular relaxation

Regional Anesthesia

Field Block Nerve Block Spinal Anesthesia Epidural Anesthesia

Regional Anesthesia

Loss of sensory nerve impulses; motor function may or may not be affected No loss of consciousness

Field Block: “caine” injected around a nerve or group of nerves (dental procedures) May be combined with epinephrine to

prolong Approximately 30 min to 2 hours

Regional Anesthesia: Spinal

Local anesthetic (-caine) injected

into cerebrospinal fluid (approx L 3-5) subarachnoid space

Spinal Anesthesia (Subarachnoid Block)

Anesthesia: tip of xiphoid to toes Risks:

Loss of vasomotor tone “Spinal Headache” Infection, Rising anesthesia above

diaphragm Nursing: KEEP FLAT, MONITOR VS &

OFFER FLUIDS WHEN APPROPRIATE

Regional Anesthesia: Epidural

Injected into epidural space rather than subarachnoid fluid (usually safer)

Used for OR & OB Epidural catheter can

be left in place for postop pain management (PCA)

Regional Anesthetic Risks

Anaphylaxis (ALLERGY) Incorrect administration technique Systemic absorption of medication Infection

Intravenous Anesthesia

Multiple Agents Multiple Purposes: Induction Hypnosis Dissociative Opioid Analgesics Neuromuscular blocking agents

Conscious Sedation Reduce intensity of pain without loss of

defensive reflexes Usually a combination of opioid analgesic

and sedative-hypnotics May be administered by credentialed RN Expect client to be sleepy but arousable JUST BECAUSE HIS EYES ARE CLOSED

DOESN’T MEAN HE’S ASLEEP!!

Local Anesthesia Local/Topical

Interrupts transmission of sensory nerve impulses so it: numbs what it touches

Requires multiple injections with “CAINE” drug (Example: novacaine, lidocaine)

Duration = 1 min to 20-30 min

-Can be prolonged with added epinephrine

Assess for ALLERGY

*Nursing Process during the Intraoperative Phase

Assessment-ongoing Planning

Proactive Flexible Forever Changing

Nursing Process Intraop Phase

Evaluation Expected Unexpected Documented Informing Client & Family Surgical Waiting Room Ongoing Updates by OR Team

Postoperative Goals

Re-establishment of physiologic equilibrium

Alleviation of pain Prevention of complications