perioperative concepts and nursing management

8/13/2019 Perioperative Concepts and Nursing Management

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Perioperative Nursing

Preoperative Nursing

Intraoperative Nursing

Postoperative Nursing


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Perioperative NursingPreoperative phase- the period of timefrom when the decision for surgicalintervention is made to when thepatient is transferred to the operatingroom table


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Intra-operative phase- period oftime from when the patient is

transferred to the operating tableto when he or she is admitted tothe post anesthesia care unit


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Postoperative phase- period of timethat begin with the admission of the

patient to the post anesthesia care unitand ends after a follow-up evaluation inthe clinic setting or home


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PREOPERATIVE NURSINGMANAGEMENT


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Examples of PerioperativeNursing Activities

Preoperative Phase

Preadmission Testing

a. Initiates initial preoperative assessmentb. Initiate teaching appropriate to patients

needs

c. Involves family in interviewd. Verifies completion of preoperative testinge. Assess patients need need for

postoperative transportation and care


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Admission to Surgical Unit

a. Completes preop assessment

b. Assesses for risk for post op complications

c. Reports unexpected findings or anydeviationsfrom normal

d. Verifies that operative consent has beensigned

e. Coordinates patient teaching with othernursing staff

f. Reinforce previous teaching


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g. Explain phases in perioperative period andexpectations

h. Answers patients and family questions

i. Develops a plan of care

Holding Areaa. Assess patient status

b. Review chart

c. Identifies patientd. Verifies surgical site

e. Establishes IV line


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f. Administers preop meds

g. Takes measures to assure patients

comfort

h. provides psychological support

i. Communicates patients emotional status toother appropriate member of health careteam


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Preoperative NursingManagement

Surgical Classifications/ Categories of SurgicalProcedures

1. Diagnostic- discovery or confirmation of a

diagnosis- biopsy2. Curative- removal of damaged or diseased

tissue or organs- excision of

tumor/appendectomy/ hysterectomy3. Constructive- repair of congenitally defective

body part- cleft palate/lip repair


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4. Reconstructive/cosmetics-partial/complete restoration of body

part- mammoplasty/facelift/ total hipreplacement

5. Aesthetic- improvement of physical

features that are within the normalrange- breast augmentation


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Classification of Surgery According toDegree of Urgency

1. Emergency- patient requires immediateattention; discomfort may be lifethreatening; without any delay eg.

Severe bleeding, bladder/intestinalobstruction, fractured skull, gunshot/stabwounds, extensive burns

2. Urgent- patient requires promptattention; within 24-30 hours, eg. Acutegallbladder infection, kidney and urethralstone


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3. Required- patient need to have surgery;plan within few weeks or months eg.

Prostatic hyperplasia without bladderobstruction, thyroid disorder and cataracts

4. Elective- patient should be operated on;

failure to have surgery not catastrophic eg.Repair of scar, simple hernia and vaginalrepair

5. Optional- decision rest to patient; personalpreference eg. Cosmetic surgery


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Preop assessment

1. Medical/ health history- history and

experience with anesthesia, serious illness,trauma-(a. allergy; b. bleeding tendencies;c.cortisone/ steriod; d. dm; e. emboli) alcohol,

chronic illness, advanced age, medicationhistory

2. Psychological examination- knowledge of

cultural beliefs/practices/ traditional healthcare, alternative and complementarypractices; lifestyle, ability to tolerate pain


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3. Physical examination- specific bodysystem assessment

4. Additional- age, pain nutritional status,F&E, infection and immunity, hematologicfunctions


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Medication History

Assess for possible drug to drug

interaction

a. adrenalcorticosteriods- should not be stopabruptly- CV collapse

b. Diuritics- excessive resp. depression

c. Phenobiazines- inc. hypotensive action ofanesthetics

d. Anti-depressants- MAO inhibitors;hypotensive action of anesthetics


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Informed Consent

Voluntary/ written/ signed before surgery

Protects the patient from unsanctioned surgeryand protects the surgeon from claims of anauthorized surgery

Physician provide simple clear explanation ofwhat the surgery entail

Inform the patient of alternative, possible risks,

complications, disfigurement, disability,removal of body parts


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Not valid if patient signed is under theinfluence of substances/ medications

that affect judgment and decisionmaking capability

Consent necessary:

a. Procedure is invasiveb. Anesthesia is used

c. Non-surgical procedure with risk-

anteriogramd. Procedures with radiations


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Patient signs the consent in legalage/mentally capable

Life saving measures may perform operationwithout consent

No patient should be urged or coerced to

sign a consent; valid consent must be freelygiven without coercion, threat, force, urge

Refusing to undergo a surgical procedure isa persons legal right and privilege

Cant sign patient who are mentallyretarded, ill and comatose


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The consent should be written andcontain:

a. Explanation of procedure/risk

b. Description of benefits/ alternatives

c. Offer Q&A about procedure

d. Instruction to withdraw from consent

e. Other changes from routine procedure

Written in language understandable to thepatient Q&A open communication forconfusion


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Immediate Preop Care

PHYSICAL CARE

a. Prepare the skin- shower/bathing

b. GIT- dec. vomiting/aspiration/ dec. possiblebowel obstruction; 8-10h food/fluidrestricted

c. Nutritional care-inc. CHO, CHON, vit. C, Kand minerals


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d. Preoperative teaching

1. Sensory information

2. Psychosocial information- copingabilities, worries about family,concerns

3. Procedural information- before, duringand after surgery; before surgery pxshould be taught with deep breathing,

coughing, turning, ambulating,paincontrol and equipments


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Immediate Preop Activities1. Allergies recorded2. VS3. Correct identification4. Consent form signed

5. Skin prep6. Check special orders7. NPO

8.Client voided/cath. Recorded

9. Oral hygiene/ other physical care completed10. Check for presence of dentures or prosthesis


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11. Valuables should be endorsed/ kept anddocumented

12. Jewelry removed- wedding band allowed-secured; remove wigs, hair pins

13. Hearing aide- for communication

14. Hospital gown with cap on

15. Colored nail polish removed

16. Make-up removed for for skin color to beobserved

C l d


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Commonly Used PreopMedications

1. Tranquilizers- Diazepam (valium)- dec.anxiety; se. dizziness, clumsiness or

confusion; Properidol (inapsine)- dec. anxietyse. anxiety, hypotension

2. Sedatives- midazola HCl- induces sleep, dec.anxiety se. dec BP, resp. depression

Phenergan (promethazines HCl) - dec.anxiety/ antiemetic se. dec. BP

3. Secobarbital Na/ pentobarbital Na- dec.

anxiety/ sedation se. disorientation


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4. Anlgesics- morphine sulfate- relieves pain, anddec. anxiety/sedation se. resp/ circulatory

depression, dec. BP, GI motility, vomiting5. Anticholenergics- atropine SO4 se. dry mouth,

tachycardia

6. Histamine H2- receptor antagonistcimetidine(Tagamet)- dec. gastric acid production se.mild dizziness, diarrhea somnolence and rash


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Focus of planning/ goal/implementation is to decrease preop

anxiety and increase knowledge ofpreop preparations and post opexpectations

Transport patient to or room safely andsecurely medical record, smoothtransfer to avoid nausea and dizziness


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Preop Nursing Diagnosis

Anxiety related to the surgical experience(anesthesia and pain) and the outcome of

the surgeryRisk for ineffective management oftherapeutic regimen r/t knowledge deficit

regarding preoperative procedures andprotocols and postoperative expectations

Anticipatory grieving process related to loss

of limb


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evaluationExpected outcomes:

a. Anxiety is relieved- discusses concerns,verbalized understanding on preanesthesiameds and gen anesthesia; relaxes quietly

b. Prepares for surgical intervention- participatesin preop preparations; demostrate anddescribes exercises to be performed postop,

accepts preop meds, remains in bed, relaxesduring transportation, states rationale for siderails

c. Participates in discharge planning

INTRAOPERATIVE NURSING


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INTRAOPERATIVE NURSINGMANAGEMENT

I t ti N i


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Intraoperative NursingManagement

Nursing care focuses on the clientsemotional well-being and physical

factors such as safety, positioning,maintaining asepsis and controlling thesurgical environment


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Example activities during Intraoperative Phase

Maintenance of Safety

1. Positions the patienta. Functional alignmentb. Exposure of surgical site

c. Maintenance of position throughout theprocedure

2. Applies grounding device to patient

3. Provide physical support4. Ensures that sponges, needles and

instrument counts are correct

5. Maintains aseptic technique


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6. Effectively manages human resources

Physiologic Monitoring

1. Calculates effects on patient ofexcessive fluid loss or gain

2. Distinguishes normal from abnormalCP data; reports any changes in pulse,resp, temp, and BP


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Psychological Support before Induction

while Conscious1. Provides emotional support

2. Stands near or touches patient during

the induction of anesthetics3. Continues to assess patients

emotional status


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Members of the Surgical Team

a. Surgeon- head of surgical team; makesdecision on surgical procedures; secondsurgeon or specially trained nurse may serve

as assistantb. Anesthesiologist- alleviates pain; promote

relaxation with meds; provides/ maintains

airway, monitor circulation, resp, estimatesblood and fluid loss, infuses blood and fluids,alerts surgeon if any complication occurs

c Nurse anesthetist- trained to induct


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c. Nurse anesthetist- trained to inductanesthesia; 2 yrs additional edu. BSN + Iyear ICU experience; work under

anesthesiologist

d. Circulating nurse- core member of thesurgical team; maintains the coordination of

team members; client advocate, RN, dontwear sterile clothing can go in and out in or;ensuring all equipments working properly;

maintains sterility of instruments/supplies;assisting with positioning; performing skinprep; monitoring the room and teammembers for break on sterile technique


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Assisting anesthesia personnel; handlingspecimen; coordinate with other department;

documenting care rendered and minimizingconversation and traffic with in operating suite

e. Scrub nurse- RN or surgical technician;

scrubbing for surgery; setting up sterile table;preparing sutures, ligatures, special equipment;assisting surgeon; anticipating needs; keeping

tract of the time/ time wound opened; countsall needles, sponges and instruments beforeclosing the incision

Labels specimen/ send to lab;should be


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Labels specimen/ send to lab;should be

RN or PN or surgical technician

f. Registered nurse first assistant- providingexposure of the surgical area; usinginstrument to hold and cut; retracting andhandling tissue; providing hemostasis;

suturing; and must work with a surgeon;not an independent practitioner


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Anesthesia

Artificial induction state of partial orcomplete loss of sensation with or

without loss of consciousness it canproduce muscle relaxation, block nervepain impulses transmission, suppressesreflexes and temp. dec. in memoryretrieval and recall

Types


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Types1. General- block pain stimulus at cerebral

cortex and induces depression of CNS/effects: analgesia, amnesia, unconsciousness,loss of reflexes and muscle tone- resp; cv;neuro; suited for surgery of head, neck ,

upper torso, back, prolonged surgicalprocedures or cant lie for long period of time

2. Regional-blocks the pain stimulus at its

origin, along afferent neurons, or along thespinal cord; does not result tounconsciousness of patient + sedative-

drowsiness


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Four Stages of Anesthesia

I. Onset- loss of consciousness; pt.Drowsy;dizzy; auditory and visualhallucination; nurse must close the door,quiet, stay in the side of the client

II. Excitement- loss of consciousness; loss ofeyelid reflexes; inc. autonomic activity,irregular breathing; struggle- remain quieton side ; assist anesthetist


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III. Surgical anesthesia- loss of eyelid reflexes;dec. vital functions; pt. Unconscious,

muscles relax, no blink or gag reflexesIV. Danger (death)- vital functions depressed;

client not breathing; no heart beat- est.

airway, prep cardiac arrest tray, drugs,syringes, close/ open cardiac massage

Administration of General


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Administration of GeneralAnesthesia

Most common method is neuroleptic orbalanced anesthesia combination ofinhalation agent; O2, narcotic,and neuro

blocking agentTypes:

a. IV- rapid transition stages 1-3 eg.

Thiopental, ketalar, fentanyl citrate- dec.motor activity; resp; allergy; dont mix withatropine /contra- CVA, HPN, inc. ICP,

alcoholics, COPD, renal dysfunctions


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b. Inhalations- mixture of volatile liquidsor gas + oxygen ; maintains the client

in stage 3; given thru mask or ET eg.halothane; forane; nitrous oxide ;enflurane- dont give with seizure

history, check for BP and pulse, dontgive patient in labor

Administration of Regional


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Administration of RegionalAnesthesia

Types:

1. Spinal- subarachnoid space; comp-

hypotension; trendelenburg ; increaseIV; NV;Headache- flat on bed 6-8hpostop, binder, analgesic; resp.

paralysis- artificial resp; neurologiccomplications- muscle weakness,paraplegia

2 Epidural- epidural block- injected in epidural


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2. Epidural epidural block injected in epiduralspace; hypotension, resp. paralysis,dysfunctions

3. Caudal-used with OB clients commonly

4. Topical

5 . Local infiltration-skin and SQ

6. Field block-the area of incision; avoid bloodvessel for systemic effect

7. Peripheral nerve block- individual nerves8. Bier block(IV regional extremity block

anesthesia) lidocaine injected to veintourniquet is applied to control distribution


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Intraoperative Nursing Care

Maintain safety and prevent injury

Position the patient:

a. supine/ dorsal recumbent- bypass,mastectomy, bowel resectionb. Trendelenburg- intestinal; lower abd,

pelvis

c. Lithotomy- perineal and rectal, vaginalrepairs

d. Lateral- kidney chest/ hip injury

Provide equipment safely- counting surgical


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Provide equipment safely counting surgicalsuppliessuch as needles, sponges, andinstrument with 2 persons when?

a. Before initial incision

b. During surgery

c. Before wound is close

All plugs, wires and equipment should bechecked for their proper functioning and avoidelectrical burn

Maintain surgical asepsis- surgeon, assistantsand scrub personnel


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Assisting with wound closure- sutures,staples, skin strips tapes, drain is place-

promote healing prevent infection,characteristic of drainage

Monitoring body temperature- 60-70 degrees

F- comfort, inhibit bacterial growth, coolingbody dec. metabolic rate; patient should becovered heat loss is great; infant/burn warm

the environment; weakness, fainting andnausea leave the room

a. Malignant hyperthermia- occur when succinyl

choline and inhalation agent esp. halothane


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Monitoring for emergency

a. Malignant hyperthermia-genetic-uncontrollable skeletal muscle contraction;occur when succinyl choline and inhalationagent esp. halothane; 30 min after induction

or several hours; inc. CO2, muscle rigiditycardiac dysrhythmias, hypermetabolic rate,fever of 43 degrees C; treatment:

datholene- skeletal muscle relaxant- dec.muscle rigidity

b. Allergic reaction- latex, solutions and

materials

c N and V full stomach turn px to side with


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c. N and V- full stomach, turn px to side withbasin, suction saliva and vomitus

d. Cardiac and resp. arrest- crash cart available;death- surgeon resp. to communicate withfolks

d.Hypoxia/ pulmonary complications- inadequate

ventilation, pulse oximeter- monitoring, canocclude salive, blood or vomitus

e. hypothermia- anesthesia; temp in or; cold

infusion IV; cold gases inhalation, openwound and cavities; dec muscle activitiy;advance age, drugs- vasodilation likephenothiazine and gen. anesthesia


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Intraop Nursing Diagnosis

AnxietyRisk for injury related to anesthesia andsurgery

Risk for perioperative positioning injuryrelated to required position and loss ofprotective responses secondary to anesthesia

Sensory/ perceptual alteration r/t to generalanesthesia or conscious sedation


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evaluation

Exhibits low level of anxiety

No threat to security

Free from surgical positioning injuriesMaintain environmental safety

Dignity preserved

Free from complications or experiencesuccessful management of adverseeffects of surgery and anesthesia

Moving and Transporting the


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Moving and Transporting theClient

Wipes excess blood and debris; put onnew gown

Avoid rapid movementIV patent

Avoid rough handling

Side rails upstrapped;with warmblanket

Maintain patients modesty

Major causes of death during


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Major causes of death duringor after surgery

Pneumonia

Renal failure

Cardiac arrestStroke

Pulmonary emboli

Sepsis

Peritonitis

hypovolemic shock


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The classic sign of shock:

Pallor

Cool, moist skin

Rapid breathingCyanosis of lips, gums, and tongue

Reapi, weak, thready pulse

Decreasing pulse

Low blood pressure and concentrated urine

POSTOPERATIVE NURSING


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POSTOPERATIVE NURSINGMANAGEMENT


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Postoperative Nursing

Example of activities post op phase:Transfer of patient to postanesthesia care unit

1. Communicates intraoperative information

a. Identify patient by name

b. States surgery performed

c. Identifies type of anesthesia used

d. Reports patients response to surgicalprocedure


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e. Describe intraop factors eg. Insertionof drains, catheter, adm of blood,

analgesic agentsf. Describe physical limitations

g. Reports patients preop level of

consciousnessh. Communicates accessory equipments


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Postoperative Assessment Recovery Area

1. Determine patients immediate

response to surgical intervention2. Monitor patients physiologic state

3. Maintains patients safety- airway,

breathing, safety4. Adm medication , fluids and blood

5. Assess patients readiness to transfer to


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pinhospital unit or for discharge

Surgical Unit:

1. Continues close monitoring of patientsphysical and psychological response tosurgical intervention

2. Provides teaching during immediaterecovery period

3. Assist patient in recovery and preparationfor discharge home

4. Identifies patient psychological status

5. assisting with discharge planning

Cl


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Home or Clinic:

1. Provides follow-up care during office or

clinic visit or by telephone contact2. Reinforce previous teaching; answer

their questions about surgery and

follow-up care3. Assess pts response to surgery and

anesthesia and their effects on body

image and function4. Determine familys perception of sugery

and its outcome


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Postop Period

3 Phases:

1. Initial period of time for recovery from

anesthesia2. Discharge from PACU to the first day

after surgery; pt recovering from

effects of surgery; beginning to eat andambulate

3. Time of healing, last for weeks, months

or even years

P t th i i d iti l ti th t


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Post anesthesia period- critical time thatneeds close and constant observation,

positioning, patent airway, suctionmachine available in bedside

Immediate Assessment: airway; breathing-

abnormalities, stay in bedside until gagrefrex return; circulation- bp, pulse, color,wound status, dressing, pulse oximeter,electrolyte imbalances, pain, hypovolemia

Others- level of consciousness, musclestrength, drains, temp

Assessment of the postop


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Assessment of the postopclient:

Assess resp status

Assess circulation

Assess neurologic status- level ofconsciousness

Monitor wound- appearance, drainage,

discomforts; infn- 3-4 days post op,redness beyond incision line, edema,drainage, fever, malaise, anorexia, inc

WBC


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Dehiscence- opening of incision

Evisceration- incision site opened withinternal organ- cover organ with steriledressings moisten with NSS, VS, calmthe pt. Notify the physician

Monitor intravenous lines- patency,type, rate , I/O

Monitor drainage tube- NGT, suction,characteristic, document


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Promote comfort- pain, prn meds, descriptionof pain, effects of pain common N and V

Reduce N and V- morphine, meperidine,cardiac glycosides, and amphetamines tocontrol: anticholinergics; antidopaminergics

and GI antispasmodicsDischarge instructions and care- informationand skills needed to continue care, meds

instructions, wound care, appointments, opencommunicatin for questions, collaborate withhealth care workes in community andrehabilitation services

Home Care Teaching Check


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Home Care Teaching CheckList

State procedure performed

Describe post op medication and

treatmentDescribe procedure for changingdressing and providing wound care

State activities to avoid- driving,operating machinery

State allowed activities


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State dietary restrictions

Describe signs and symptoms of

complicationsState time and date follow-upappointments

State how to reach health provider withquestions or complications


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Postop Nursing Diagnosis

Risk for injuryHypothermia

Risk for infection

Pain r/t surgical incisionRisk for ineffective airway clearance r/t decresp function

Self care deficit r/t post op fatigue andpain

Impaired skin integrity r/t surgical incision

and drainage


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Body image disrurbance

Risk for altered nutrition: less than r/t

dec intake and inc need for nutrientsecondary to surgery

Risk for altered elimination: constipation

r/t effects of meds, diet change,immobility


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Potential Complications:

a. Atelectasis and pneumonia

b. Deep vein thrombosisc. Wound infection

d. Dehiscence/ evisceration

e. Paralytic ileus

f. Hemorrhage/ hypovolemic shock


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SAMPLE QUESTION

Keeping tract of the time patient under

anesthesia and time of incision is

made are functions primarily by a:a. anesthesiologist

b. scrub nurse

c. circulating nursed. surgical assistant


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Ans.B


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SAMPLE QUESTION

Handling specimen and documenting carerendered to patient during intra-operative period are tasks to

accomplish by a:a. Registered Nurse First Assistant

b. scrub nurse

c. OR managerd. circulating nurse


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ANS. D


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ANS. B


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SAMPLE QUESTION

1. During the initial interview, the nurse hasassessed for history of seafood allergy withMrs. L. Which nursing action is appropriate?

a. administer anti-histamine

b. prepare resuscitative equipment andemergency medication postoperatively

c. prominently note allergies of patient on chart

d. do not give pre-op medication an hour beforethe schedule of surgery


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ANS. C


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SAMPLE QUESTION

One of the patients in surgical ward scheduledfor amputation in the next two daysverbalized, Im going to miss my leg.

Which of the following nursing diagnosis isappropriate in the statement presented:

a. Fear and anxiety related to surgery

b. Potential for injury related to hemorrhage

c. Anticipatory grieving process related to lossof limb

d. Immobility related to loss of limb functioning


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ANS. C


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SAMPLE QUESTION

Which of the following is not included in

the physical preparation of patient

undergoing surgery?a. assessing level fear and concerns

b. sedation for sleep

c. cleansing of the colond. informed consent


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ANS. A


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SAMPLE QUESTION

The following must be observed by the ward

nurse on the day of surgery, EXCEPT:

a. patient must wear hospital gown

b. jewelry must be removed includingprosthesis

c. pre-op medication given 30 min in

anticipated time scheduled. long hair braided


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ANS. D


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SAMPLE QUESTION

Atropine sulfate is given to operative patient to

counteract the effects of vagal stimulation.

This medication is classified as:

a. sedative

b. narcotic

c. anticholenergic

d. neuro-blocking agent


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ANS. C


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SAMPLE QUESTION

Mrs. had undergone surgical laparotomy 2days post op, because of fear of pain,patient refuses to do coughing exercise.

Which nursing action appropriate tominimize pain during coughing exercises?

a. Splint the area of incision with hands andapply pressure

b. splint abdominal area with elastic bandagec. give sedative to lessen post-op pain

d. turn patient side


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ANS. A


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SAMPLE QUESTION

Healing of surgical wound is most apt to

be retarded by inadequate intake of:

a. carbohydrateb. fat

c. minerals and vitamins

d. protein


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ANS. D


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SAMPLE QUESTION

Which of the following nursing interventions should beconsidered by the nurse if evisceration will exist to apost op patient?

a. keep patient calm and place a sterile gauze with

D5LR solutionb. cover the incision site with sterile gauze or towel

moisten with isotonic solution

c. cover with gauze only since moisture could attractmicroorganism and can cause contamination

d. look for the surgeon and never perform any nursingintervention with the wound since this incident needsdoctors order to avoid malpractice


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ANS. B


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SAMPLE QUESTION

Early ambulation should be initiated

primarily to:

a. prevent thrombophlebitisb. fast relief o post-op pain

c. early healing of wound

d. prevent pneumonia


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ANS. A


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SAMPLE QUESTION

Patient Mr. G. complains of postop pain aftergaining consciousness, your nextappropriate nursing action:

a. give morphine sulfate after checking therespiratory rate

b. check bowel sounds

c. encourage deep breathing and coughingexercises

d. frequent change of position as desired


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ANS. A


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SAMPLE QUESTION

The fourth stage of anesthesia is

characterized by:

a. uncontrolled movementb. flushed skin

c. elevated BP

d. non-reactive pupil


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ANS. D


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SAMPLE QUESTION

The stage of anesthesia induction where

the patient may perceive things and

sounds heard differently?

a. danger stage

b. excitement stage

c. onset staged. surgical anesthesia stage

S Q S O


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SAMPLE QUESTION

The scrub nurse together with circulating nursecounts the instruments and sponges:

a. prior to the removal of oxygen and before

closure of surgical incisionb. before the start of the abdominal incision

and before the closure of the fascia

c. prior the abdominal incision and after the

closure of perineumd. before the start of abdominal incision and

prior to closure of peritoneum

ANS D


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ANS. D

SAMPLE QUESTION


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SAMPLE QUESTION

Which of the following activities improvesbowel and bladder a day aftersurgery?

a. deep breathingb. leg exercises

c. coughing

d. walking

d


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end

Thank you!!!

perioperative concepts and nursing management

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