perioperative nursing (complete)

Copyright © 2008 Lippincott Williams & Wilkins.

PERIOPERATIVE NURSING


PERIOPERATIVE NURSING

– used to describe the nursing care

provided in the total surgical

experience of the patient:

a. preoperative

b. intraoperative

c. postoperative.


Preoperative Phase

extends from the time the client

is admitted in the surgical unit, to

the time he/she is prepared for the

surgical procedure, until he is

transported into the operating room.


Intraoperative Phase


is admitted to the OR, to the time of

administration of anesthesia, surgical

procedure is done, until he/she is

transported to the RR/PACU.


Postoperative Phase


is admitted to the recovery room, to

the time he is transported back into

the surgical unit, discharged from

the hospital, until the follow-up

care.


4 Major Types of Pathologic Process

Requiring Surgical Intervention (OPET)

Obstruction – impairment to the flow

of vital fluids (blood,urine,CSF,bile)

Perforation – rupture of an organ.

Erosion – wearing off of a surface or

membrane.

Tumors – abnormal new growths.


Identify the type of pathologic process

requiring surgery

Hydrocephalus Obstruction

Burn

Benign Prostatic Hyperplasia

Cholelithiasis

Intussusception

Erosion

Tumor

Obstruction

Obstruction

Ruptured Aneurysm Perforation


Classification of Surgical

Procedure


According to PURPOSE:

Diagnostic – to establish the presence of a

disease condition.

( e.g biopsy )

Exploratory – to determine the extent of

disease condition

( e.g Ex-Lap )


Curative – to treat the disease condition.

* Ablative – removal of an organ “ectomy”

* Constructive – repair of congenitally

defective organ “plasty,oorhaphy,pexy”

* Reconstructive – repair of damage organ

Palliative – to relieve distressing sign and

symptoms, not necessarily to cure the

disease.


Identify the type of surgery according to

purpose:

Pap Smear Diagnostic

Tonsilectomy Curative - Ablative

Nephrocapsulectomy Curative - Ablative

Osteoplasty Curative - Constructive

Perineorrhaphy Curative - Reconstructive

Trachelorrhaphy Curative - Constructive

Skin Grafting Curative - Reconstructive


According to URGENCY

Classification Indication for Surgery Examples

Emergent – patient requires immediate attention, life threatening condition. Without delay

- severe bleeding

- gunshot/ stab wounds

- Fractured skull

Urgent / Imperative – patient requires prompt attention.

Within 24 to 30 hours - kidney / ureteral stones

Required – patient

needs to have surgery.

Plan within a few weeks or months

- cataract

- thyroid d/o

Elective – patient should have surgery.

Failure to have surgery not catastrophic

- repair of scar

- vaginal repair

Optional – patient’s decision. Personal preference - cosmetic surgery


According to DEGREE OF RISK

Major Surgery

- High risk / Greater Risk for Infection

- Extensive

- Prolonged

- Large amount of blood loss

-Vital organ may be handled or removed

Minor Surgery

- Generally not prolonged

- Leads to few serious complication

- Involves less risk


Ambulatory Surgery/ Same-day Surgery / Outpatient Surgery

Advantages:

- Reduces length of hospital stay and cuts costs

- Reduces stress for the patient

- Less incidence of hospital acquired infection

- Less time lost from work by the patient; minimal

disruptions on the patient’s activities and family life.


Disadvantages:

- Less time to assess the patient and perform preoperative

teaching.

- Less time to establish rapport

- Less opportunity to assess for late postoperative

complication.


Example of Ambulatory Surgery

ｷ Teeth extraction

ｷ Circumcision

ｷ Vasectomy

ｷ Cyst removal

ｷ Tubal ligation


Surgical Risk

ｷ Obesity

ｷ Poor Nutrition

ｷ Fluid and Electrolyte Imbalances

ｷ Age

ｷ Presence of Disease (Cardiovascular dse.,

DM, Respiratory dse. )

ｷ Concurrent or Prior Pharmacotherapy

ｷ other factors:

- nature of condition

- loc. of the condition

- magnitude / urgency of the surgery

- mental attitude of the patient

- caliber of the health care team


PREOPERATIVE PHASE


Goals

ｷ Assessing and correcting physiologic and

psychologic problems that may increase surgical risk.

ｷ Giving the person and significant others complete

learning / teaching guidelines regarding surgery.

ｷ Instructing and demonstrating exercises that will

benefits the person during postop period.

ｷ Planning for discharge and any projected changes in

lifestyle due to surgery.


Physiologic Assessment of the Client Undergoing Surgery

ｷ Presence of Pain

ｷ Nutritional & Fluid and Electrolyte Balance

ｷ Cardiovascular / Pulmonary Function

ｷ Renal Function

ｷ Gastrointestinal / Liver Function

ｷ Endocrine Function

ｷ Neurologic Function

ｷ Hematologic Function

ｷ Use of Medication

ｷ Presence of Trauma & Infection


Routine Preoperative Screening Test

Test Rationale

CBC RBC,Hgb,Hct are important to theoxygen carrying capacity of blood.

WBC are indicator of immune function.

Blood grouping/ X matching

Determined in case blood transfusion is required during or after surgery.

Serum Electrolyte To evaluate fluid and electrolyte status

PT,PTT Measure time required for clotting to occur.

Fasting Blood Glucose

High level may indicate undiagnosed DM


BUN / Creatinine Evaluate renal function

ALT/AST/LDH and Bilirubin

Evaluate liver function

Serum albumin and total CHON

Evaluate nutritional status

Urinalysis Determine urine composition

Chest Xray Evaluate resp.status/ heart size

ECG Identify preexisting cardiacproblem.


Psychosocial Assessment and Care

Causes of Fears of the Preoperative Clients

ｷ Fear of Unknown ( Anxiety )

ｷ Fear of Anesthesia

ｷ Fear of Pain

ｷ Fear of Death

ｷ Fear of disturbance on Body image

ｷ Worries – loss of finances, employment, social and

family roles.


Manifestation of Fears

- anxiousness

- bewilderment

- anger

- tendency to exaggerate

- sad, evasive, tearful, clinging

- inability to concentrate

- short attention span

- failure to carry out simple directions

- dazed


Nursing Intervention to Minimize Anxiety

ｷ Explore client’s feeling

ｷ Allow client’s to speak openly about

fears/concern.

ｷ Give accurate information regarding surgery

(brief, direct to the point and in simple terms)

ｷ Give empathetic support

ｷ Consider the person’s religious preference and

arrange for visit by a priest / minister as desired.


INFORMED CONSENT


Purposes:

To ensure that the client understand the nature

of the treatment including the potential

complications and disfigurement

( explained by AMD )

To indicate that the client’s decision was made

without pressure.

To protect the client against unauthorized

procedure.

To protect the surgeon and hospital against

legal action by a client who claims that an

authorized procedure was performed.


Circumstances Requiring ConsentAny surgical procedure where scalpel, scissors,

suture, hemostats of electrocoagulation may be

used.

Entrance into body cavity.

Radiologic procedures, particularly if a

contrast material is required.

General anesthesia, local infiltration and

regional block.


Essential Elements of Informed Consent

ｷ The diagnosis and explanation of the condition.

ｷ A fair explanation of the procedure to be done

and used and the consequences.

ｷ A description of alternative treatment or

procedure.

ｷ A description of the benefits to be expected.

ｷ The prognosis, if the recommended care,

procedure is refused.


Requisites for Validity of Informed Consent

ｷ Written permission is best and legally accepted.

ｷ Signature is obtained with the client’s complete

understanding of what to occur.

- adult sign their own operative permit

-obtained before sedation

ｷ For minors, parents or someone standing in their

behalf, gives the consent.

Note: for a married emancipated minor parental consent is

not needed anymore, spouse is accepted

ｷ For mentally ill and unconscious patient, consent must

be taken from the parents or legal guardian


ｷ If the patient is unable to write, an “X” is accepted if

there is a witness to his mark

Secured without pressure and threat

A witness is desirable – nurse, physician or

authorized persons.

When an emergency situation exists, no consent is

necessary because inaction at such time may cause

greater injury. (permission via telephone/cellphone is

accepted but must be signed within 24hrs.)


Pre Operative Care


Physical Preparation

Before Surgery

Correct any dietary deficiencies

Reduce an obese person’s weight

Correct fluid and electrolyte imbalances

Restore adequate blood volume with BT

Treat chronic diseases

Halt or treat any infectious process

Treat an alcoholic person with vit.

supplementation, IVF or fluids if

dehydrated


Pre Operative Teaching

Incentive Spirometer

Diaphragmatic Breathing

Coughing

Splinting

Turning

Foot and Leg Exercise

Early Ambulation


Incentive Spirometer


ﾘ Encouraged to use incentive spirometer

about 10 to 12 times per hour.

ﾘ Deep inhalations expand alveoli, which

prevents atelectasis and other pulmonary

complication.

ﾘ There is less pain with inspiratory

concentration than with expiratory

concentration.


Diaphragmatic Breathing

ﾘ Refers to a flattening of the dome of the diaphragm

during inspiration, with resultant enlargement of

upper abdomen as air rushes in. During expiration,

abdominal muscles contract.

ﾘ In a semi-Fowlers position, with your hands loose-

fist, allow to rest lightly on the front of lower ribs.

ﾘ Breathe out gently and fully as the ribs sink down

and inward toward midline.


ﾘ Then take a deep breath through the nose and

mouth, letting the abdomen rise as the lungs fill with

air.

ﾘ Hold breath for a count of 5.

ﾘ Exhale and let out all the air through your nose

and mouth.

ﾘ Repeat this exercise 15 times with a short rest

after each group of 5.


Coughing and Splinting

Quic kTime™ and a dec ompress or

are needed to see this picture.


ﾘ Promotes removal of chest secretions.

ﾘ Interlace his fingers and place hands over the

proposed incision site, this will act as a splint and

will not harm the incision.

ﾘ Lean forward slightly while sitting in bed.

ﾘ Breath, using diaphragm

ﾘ Inhale fully with the mouth slightly open.

ﾘ Let out 3-4 sharp hacks.

ﾘ With mouth open, take in a deep breath and

quickly give 1-2 strong coughs.


Turning

ﾘ Promotes removal of chest secretions.

ﾘ Interlace his fingers and place hands over the

proposed incision site, this will act as a splint and

will not harm the incision.

ﾘ Lean forward slightly while sitting in bed.

ﾘ Breath, using diaphragm

ﾘ Inhale fully with the mouth slightly open.

ﾘ Let out 3-4 sharp hacks.

ﾘ With mouth open, take in a deep breath and

quickly give 1-2 strong coughs.


Foot and Leg Exercise

ﾘ Moving the legs improves circulation and muscle

tone.

ﾘ Have the patient lie supine, instruct patient to bend

a knee and raise the foot – hold it a few seconds and

lower it to the bed.

ﾘ Repeat above about 5 times with one leg and then

with the other. Repeat the set 5 times every 3-5 hours.

ﾘ Then have the patient lie on one side and exercise

the legs by pretending to pedal a bicycle.

ﾘ For foot exercise, trace a complete circle with the

great toe.


Preparing the Patient the Evening Before Surgery

v Preparing the Skin

- have a full bath to reduce microorganisms in the skin.

- hair should be removed within 1-2 mm of the skin to avoid skin

breakdown, use of electric clipper is preferable.

v Preparing the G.I tract

- NPO, cleansing enema as required

v Preparing for Anesthesia

- Avoid alcohol and cigarette smoking for at least 24 hours

before surgery.

v Promoting rest and sleep

- Administer sedatives as ordered


ASA (American Society of Anesthesiologists) Guidelines for Preoperative Fasting

Liquid and Food Intake Minimum Fasting Period

Clear Liquids 2

Breast Milk 4

Nonhuman Milk 6

Light Meal 6

Regular / Heavy Meals 8


Preparing the Person on the Day Of Surgery

Early A.M Care

Awaken 1 hour before preop medications

Morning bath, mouth wash

Provide clean gown

Remove hairpins, braid long hair, cover hair with cap if

available.

Remove dentures, colored nail polish, hearing aid, contact

lenses, jewelries.

Take baseline vital sign before preop medication.

Check ID band, skin prep

Check for special orders – enema, IV line

Check NPO

Have client void before preop medication

Continue to support emotionally

Accomplished “preop care checklist


Pre Operative Medications


PREOPERATIVE MEDICATIONS

Goals:

To aid in the administration of an

anesthetics.

To minimize respiratory tract secretion

and changes in heart rate.

To relax the patient and reduce anxiety.


Commonly used Preop Meds.- Tranquilizers & Sedatives

* Midazolam* Diazepam ( Valium )* Lorazepam ( Ativan )* Diphenhydramine

- Analgesics* Nalbuphine ( Nubain )

- Anticholinergics* Atropine Sulfate

- Proton Pump Inhibitors* Omeprazole ( Losec )* Famotidine


Transporting the Patient to the OR

Adhere to the principle of maintaining the

comfort and safety of the patient.

Accompany OR attendants to the patient’s

bedside for introduction and proper identification.

Assist in transferring the patient from bed to

stretcher.

Complete the chart and preoperative checklist.

Make sure that the patient arrive in the OR at the

proper time.


Patient’s Family

Direct to the proper waiting room.

Tell the family that the surgeon will probably

contact them immediately after the surgery.

Explain reason for long interval of waiting:

anesthesia prep, skin prep, surgical procedure, RR.

Tell the family what to expect postop when they

see the patient


Operative Site Identification


INTRAOPERATIVE PHASE


Goals

ｷ Asepsis

ｷ Homeostasis

ｷ Safe Administration of Anesthesia

ｷ Hemostasis


Surgical Setting

• Unrestricted Area

- provides an entrance and exit from the surgical suite for personnel, equipment and patient

- street clothes are permitted in this area, and the area provides access to communication with personnel within the suite and with personnel and patient’s families outside the suite


Surgical Setting

• Semi-restricted Area

- provides access to the procedure rooms and peripheral support areas within the surgical suite.

- personnel entering this area must be in proper operating room attire and traffic control must be designed to prevent violation of this area by unauthorized persons

- peripheral support areas consists of: storage areas for clean and sterile supplies, sterilization equipment and corridors leading to procedure room


Surgical Setting

• Restricted Area

- includes the procedure room where surgery is performed and adjacent substerile areas where the scrub sinks and autoclaves are located

- personnel working in this area must be in proper operating room attire


RMC Operating Room Set Up

Anesthesia Department

Recovery OR Suite

Room

Scrubbing/Washing

Area

Storage OR Suite

Nurse

Station

OR Suite

MD/

Nurses

Dressing

Room

OR Suite

Main

Entrance OR Supervisor

Office

Lounge


QMMC Operating Room Set Up

OR OR

Suite Suite

Scrubbing / Washing Scrubbing / Washing

Area Area

OR OR

Suite Suite

Nurses Storage/Supplies

Station

Recovery Room

Dressing Room

OR Manager

Room

Receiving Area Lounge


Environmental Safety

• The size of the procedure room

• Temperature and humidity control

• Ventilation and air exchange system

• Electrical Safety

• Communication System


Size of the Procedure Room

• Usually rectangular or square in shape

• 20 x 20 x 10 with a minimum floor space of 360 square feet

• Each procedure room must have the following equipment:

- Communication System

- Oxygen and vacuum outlets

- Mechanical ventilation assistance equipment

- Respiratory and Cardiac monitoring equipment

- X ray film illumination boxes

- Cardiac defibrillator

- High-efficiency particulate air filters

- Adequate room lighting

- Emergency lighting system


Temperature and Humidity Control

• The temperature in the procedure room should maintained between 68 F - 75 F ( 20 - 24 degrees C)

• Humidity level between 50 - 55 % at all times


Ventilation and Air Exchange System

• Air exchange in each procedure room should be at least 25 air exchanges every hour, and five of that should be fresh air.

• A high filtration particulate filter, working at 95% efficiency is recommended.

• Each procedure room should maintained with positive pressure, which forces the old air out of the room and prevents the air from surrounding areas from entering into the procedure room


Electrical Safety

• Faulty wiring, excessive use of extension cords, poorly maintained equipment and lack of current safety measures are just some of the hazardous factors that must be constantly checked

• All electrical equipment new or used, should be routinely checked by qualified personnel.

• Equipment that fails to function at 100% efficiency should be taken out of service immediately.


The Surgical Team

ｷ The Patient

ｷ The Anesthesiologist or Anesthetist

ｷ The Surgeon

ｷ Scrub Nurse

ｷ Circulating Nurse

ｷ RNFA ( Reg.Nurse First Assistant )

ｷ Surgical Technologists


Surgeon


Responsibilities

• Primary responsible for the preoperative medical history and physical assessment.

• Performance of the operative procedure according to the needs of the patients.

• The primary decision maker regarding surgical technique to use during the procedure.

• May assist with positioning and prepping the patient or may delegate this task to other members of the team


First Assistant to the Surgeon


Responsibilities

• May be a resident, intern , physician’s assistant or a perioperative nurse.

• Assists with retracting, hemostasis, suturing and any other tasks requested by the surgeon to facilitate speed while maintaining quality during the procedure.


Anesthesiologist


Responsibilities

• Selects the anesthesia, administers it, intubates the client if necessary, manages technical problems related to the administration of anesthetic agents, and supervises the client’s condition throughout the surgical procedure.

• A physician who specializes in the administration and monitoring of anesthesia while maintaining the overall well-being of the patient.


Scrub Nurse


Responsibilities

• May be either a nurse or a surgical technician.

• Reviews anatomy, physiology and the surgical procedures.

• Assists with the preparation of the room.

• Scrubs, gowns and gloves self and other members of the surgical team.

• Prepares the instrument table and organizes sterile equipment for functional use.

• Assists with the drapping procedure.

• Passes instruments to the surgeon and assistants by anticipating their need.

• Counts sponges, needles and instruments.

• Monitor practices of aseptic technique in self and others.

• Keeps track of irrigations used for calculations of blood loss


Circulating Nurse


Responsibilities

• Must be a registered nurse who, after additional education and training, specialized in perioperative nursing practice.

• Responsible and accountable for all activities occurring during a surgical procedure including the management of personnel equipment, supplies and the environment during a surgical procedure.

• Patient advocate, teacher, research consumer, leader and a role model.

• May be responsible for monitoring the patient during local procedures if a second perioperative nurse is not available.


Very defined activities during surgery:

• Ensure all equipment is working properly.

• Guarantees sterility of instruments and supplies.

• Assists with positioning.

• Monitor the room and team members for breaks in the sterile technique.

• Handles specimens.

• Coordinates activities with other departments, such as radiology and pathology.

• Documents care provided.

• Minimizes conversation and traffic within the operating room suite.


Medical vs. Surgical Asepsis


Principles of Surgical Asepsis(Sterile Technique)

• Sterile object remains sterile only when touched by another sterile object

• Only sterile objects may be placed on a sterile field

• A sterile object or field out of range of vision or an object held below a person’s waist is contaminated


Principles of Surgical Asepsis(Sterile Technique)

• When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action

• Fluid flows in the direction of gravity

• The edges of a sterile field or container are considered to be contaminated (1 inch)


Common Surgical Incision

Incision Site

Butterfly

Limbal

Halstead / Elliptical

Subcostal

Paramedian

Transverse

Rectus

McBurney

Pfannenstiel

Lumbotomy


Position During Surgery

Supine ( Dorsal Recumbent )

- Abdominal,extremity,vascular,chest,neck,facial,ear

breast surgery

Positioning Techniques

• Patient lies flat on back with arms either extended on arm boards

or placed along side of body.

• Small padding placed under patient’s head,neck and under knees

• Vulnerable pressure points should be padded.

• Safety strap applied 2 in. above knees.

• Eyes should be protected by using eye patch and ointment.


Prone Position

- Surgeries involving posterior surface of the body (

spine,

neck,buttocks and lower extremities )


• Chest rolls or bolster are placed on operating table prior to

positioning

• Foam head rest, head turned to side or facing downward

• Patient’s arms are rotated to the padded armboards that face

head, bringing them through their normal range of motion.

• Padding for knees and pillow for lower extremities to prevent

toes from touching mattress.

• Safety strap applied 2 in. above the knees


Trendelenburg Position

- Surgeries involving lower abdomen, pelvic organ when

there is a need to tilt abdominal viscera away from the

pelvic area.


• Patient is supine with head lower than feet.

• Shoulder braces should not be used as they may cause damage

brachial plexus.

• When patient is returned to supine position, care must be taken

move leg section slowly, then the entire table to level position.

• Modification of this position can be used for hypovolemic shock.

• Extremity position and safety strap are the same as for supine.


Reverse Trendelenburg Position

- Upper abdominal, head, neck and facial surgery

Positioning Technique

• Patient is supine with head higher than feet.

• Small pillow under neck and knees.

• Well - padded footboard should be used to prevent slippage to

foot of the table.

• Anti embolic hose should be used if position is to be maintained

for an extended period of time.

• Patient should be returned slowly to supine position.


Lithotomy

- Perineal, vaginal, rectal surgeries; combined abdominal

vaginal procedure


• Patient is placed in supine position with buttocks near lower break

in the table ( sacrum are should be well padded )

• Feet are placed in stirrups, stirrups height should not be

excessively high or low, but even on both sides.

• Knee brace must not compress vascular structures or nerves in

the popliteal space.

• Pressure from metal stirrups against upper inner aspect of thigh

and calf should be avoided.

• Legs should be raised and lowered slowly and simultaneously

( may require two people )


Modified Fowler ( Sitting Position )

- Otorhinology (ear and nose ), neurosurgery


• Patient is supine, positioned over the upper break in the table

• Backrest is elevated, knees flexed

• Arms rest on pillow, placed in lap; safety strap 2 in. above the

knees.

• Slow movement in and out of position must be used to prevent

drastic changes in blood volume movement.

• Anti embolic hose should be used to assist venous return.

• When using special neurologic headrest, eyes must be

protected.


Jack Knife Position

- Rectal procedures, sigmoidoscopy and colonoscopy


• Table is flexed at center break

• All precautions taken with prone position are taken with

Jack knife position.

• Table strap applied over thighs


ANESTHESIA


• State of “Narcosis”

• Anesthetics can produce muscle relaxation, block transmission of pain nerve impulses and suppress reflexes.

• It can also temporary decrease memory retrieval and recall.

The effects of anesthesia are monitored by considering the following parameters:

- Respiration

- O2 saturation

- CO2 levels

- HR and BP

- Urine output


Types of Anesthesia

1. General Anesthesia

ｷ reversible state consisting of complete loss of

consciousness and sensation.

ｷ protective reflexes such as cough and gag are

lost

ｷ provides analgesia, muscle relaxation and

sedation.

ｷ produces amnesia and hypnosis.


Techniques used in General Anesthesia

A. Intravenous Anesthesia

ｷ This is being administered intravenously and

extremely rapid.

ｷ Its effect will immediately take place after thirty

minutes of introduction.

ｷ It prepares the client for smooth transition to the

surgical anesthesia.

B. Inhalation Anesthesia

ｷ This comprises of volatile liquids or gas and oxygen.

ｷ Administered through a mask or endotracheal tube.


Stages of General Anesthesia

ﾘ Stage 1: Onset / Induction.

ﾘ Stage 2: Excitement / Delirium.

ﾘ Stage 3: Surgical

ﾘ Stage 4: Medullary / Stage of Danger


2. Regional Anesthesia

ｷ temporary interruption of the transmission of nerve

impulses to and from specific area or region of the

body.

ｷ achieved by injecting local anesthetics in close

proximity to appropriate nerves.

ｷ reduce all painful sensation in one region of the body

without inducing unconsciousness.

ｷ agents used are lidocaine and bupivacaine.


Techniques used in Regional Anesthesia:

A. Topical Anesthesia

ｷ applied directly to the skin and mucous membrane,

open skin surfaces, wounds and burns.

ｷ readily absorbed and act rapidly

ｷ used topical agents are lidocaine and benzocaine.


B. Spinal Anesthesia ( Subarachnoid block )

ｷ local anesthetic is injected through lumbar puncture,

between L2 and S1

ｷ anesthetic agent is injected into subarachoid space

surrounding the spinal cord.

- Low spinal, for perineal/rectal areas

- Mid spinal T10 ( below level of umbilicus)

for hernia repair and appendectomy.

-High spinal T4 ( nipple line ), for CS

ｷ agents used are procaine, tetracaine, lidocaine and

bupivacaine.


C. Epidural Anesthesia

ｷ achieved by injecting local anesthetic into epidural space

by way of a lumbar puncture.

ｷ result similar to spinal analgesia

ｷ agents use are chloroprocaine, lidocaine and bupivacaine.

D. Peripheral Nerve Block

ｷ achieved by injecting a local anesthetic to anesthetize the

surgical site.

ｷ agents use are chloroprocaine, lidocaine and bupivacaine.


E. Intravenous Block ( Beir block )

ｷ often used for arm,wrist and hand procedure

ｷ an occlusion tourniquet is applied to the extremity to prevent

infiltration and absorption of the injected IV agents beyond the

involved extremity.

F. Caudal Anesthesia

ｷ Is produced by injection of the local anesthetic into the caudal

or sacral canal

G. Field Block Anesthesia

ｷ The area proximal to a planned incision can be injected and

infiltrated with local anesthetic agents.


Nursing Management

Assessment

Diagnosis

Planning

Intervention

Evaluation


Complications and Discomforts of Anesthesia

ｷ Hypoventilation - inadequate ventilatory support

after paralysis of respiratory muscles.

ｷ Oral Trauma

ｷ Malignant Hyperthermia - uncontrolled skeletal

muscle contraction

ｷ Hypotension - due to preoperative hypovolemia or

untoward reactions to anesthetic agents.

ｷ Cardiac Dysrhythmia - due to preexisting

cardiovascular compromise, electrolyte imbalance or

untoward reaction to anesthesia.


ｷ Hypothermia - due to exposure to a cool ambient OR

environment and loss of thermoregulation capacity from

anesthesia.

ｷ Peripheral Nerve Damage - due to improper

positioning of patient or use of restraints.

ｷ Nausea and Vomiting

ｷ Headache


Practice Question

A female client, 23 years old was admitted for the first

time at the QMMC, she was diagnosed to have

ruptured appendicitis. She was scheduled to have

emergency Ex-Lap under general anesthesia.

1. Pre-op instructions to the client would include the

following EXCEPT:

a. deep breathing and coughing exercise

b. explaining the procedure

c. turning to the side

d. foot and leg exercise


Answer:

B. Explaining the procedure.

Rationale:

Explaining the treatment, procedure, and outcome is

done by the attending physician


2. During the induction of anesthesia, what is your nursing

priority action?

a. secure informed consent

b. maintain the OR room quite and close the door

c. stay with the patient and assess for possible

anesthesia complication

d. assist the physician in preparing the OR table


Answer:

B.

Rationale:

During the 1st stage of general anesthesia ( onset or

Induction stage ), noises are exaggerated. For this reason

Unnecessary noises and motions are avoided.


POSTOPERATIVE CARE


Goals:

Restore homeostasis and prevent complication

Maintain adequate cardiovascular and tissue perfusion.

Maintain adequate respiratory function.

Maintain adequate nutrition and elimination.

Maintain adequate fluid and electrolyte balance.

Maintain adequate renal function.

Promote adequate rest, comfort and safety.

Promote adequate wound healing.

Promote and maintain activity and mobility.

Provide adequate psychological support.


PACU CARE

Transport of client from OR to RR

ｷ avoid exposure

ｷ avoid rough handling

ｷ avoid hurried movement and rapid changes in

position.


Initial Nursing Assessment

ｷ Verify patient’s identity, operative procedure and the surgeon

who performed the procedure.

ｷ Evaluate the following sign and verify their level of stability

with the anesthesiologist:

- Respiratory status

- Circulatory status

- Pulses

- Temperature

- Oxygen Saturation level

- Hemodynamic values

ｷ Determine swallowing and gag reflex , LOC and patients

response to stimuli.


ｷ Evaluate lines, tubes, or drains, estimate blood loss,

condition of wound, medication used, transfusions and

output.

ｷ Evaluate the patient’s level of comfort and safety.

ｷ Perform safety check; side rails up and restraints are

properly in placed.

ｷ Evaluate activity status, movement of extremities.

ｷ Review the health care provider’s orders.


Initial Nursing Interventions


Maintaining a Patent Airway

ﾘ Allow the airway ( ET tube ) to remain in place until

the patient begins to waken and is trying to eject the

airway.

ﾘ The airway keeps the passage open and prevents the

tongue from falling backward and obstructing the air

passages.

ﾘ Aspirate excessive secretions when they are heard in

the nasopharynx and oropharynx.


Assessing Status of Circulatory System

ﾘ Take VS per protocol, until patient is well stabilized.

ﾘ Monitor intake and output closely.

ﾘ Recognized early symptoms of shock or hemorrhage:

- cool extremities

- decreased urine output ( less than 30ml/hr )

- slow capillary refill ( greater than 3 sec. )

- lowered BP

- narrowing pulse pressure

- increased heart rate

* initiate O2 therapy, to increase O2

availability from the blood.

* place the patient in shock position with his

feet elevated ( unless contraindicated )


Maintaining Adequate Respiratory Function

ﾘ Place the patient in lateral position with neck extended

( if not contraindicated ) and upper arm supported on a

pillow.

ﾘ Turn the patient every 1 to 2 hours to facilitate breathing

and ventilation.

ﾘ Encourage the patient to take deep breaths, use an

incentive spirometer.

ﾘ Assess lung fields frequently by auscultation.

ﾘ Periodically evaluate the patient’s orientation – response

to name and command.

Note: Alterations in cerebral function may suggest impaired

O2 delivery.


Assessing Thermoregulatory Status

ﾘ Monitor temperature per protocol to be alert for

malignant hyperthermia or to detect hypothermia.

ﾘ Report a temperature over 37.8 C or under 36.1 C

ﾘ Monitor for postanesthesia shivering, 30-45 minutes

after admission to the PACU.

ﾘ Provide a therapeutic environment with proper

temperature and humidity.


Maintaining Adequate Fluid Volume

ﾘ Administer I.V solutions as ordered.

ﾘ Monitor evidence of F&E imbalance such as N&V

ﾘ Evaluate mental status, skin color and turgor

ﾘ Recognized signs of:

a. Hypovolemia

- decrease BP

- decrease urine output

- decreased CVP

- increased pulse

b. Hypervolemia

- increase BP

- changes in lung sounds (S3 gallop )

- increased CVP

ﾘ Monitor I&O


Minimizing Complications of Skin Impairment

ﾘ Perform handwashing before and after contact with

the patient

ﾘ Inspect dressings routinely and reinforce them if

necessary.

ﾘ Record the amount and type of wound drainage.

ﾘ Turn patient frequently and maintain good body

alignment.


Maintaining Safety

ﾘ Keep the side rails up until the patient is fully awake.

ﾘ Protect the extremity into which I.V fluids are running so

needle will not become accidentally dislodged.

ﾘ Avoid nerve damage and muscle strain by properly

supporting and padding pressure areas.

ﾘ Recognized that the patient may not be able to complain of

injury such as the pricking of an open safety pin or clamp that

is exerting pressure.

ﾘ Check dressing for constriction


Parameter for Discharge from PACU/RR

ｷ Activity. Able to obey commands

ｷ Respiratory. Easy, noiseless breathing

ｷ Circulation. BP within 20mmHg of preop level

ｷ Consciousness. Responsive

ｷ Color. Pinkish skin and mucus membrane


Nursing Care of the Client During the Intermediate

Postop Period (RR – Unit )

Baseline Assessment

Respiratory Status

Cardiovascular Status

- VS

- Color and Temperature of Skin

Level of Consciousness

Tubes

- Drain

- NGT

- T-tube

Position


Immediate Post-Op Assessment and Interventions

Areas of Concern Intervention

Neurological Status Assess LOC– response to name

Return of swallow and gag reflex

Fluid and Electrolyte Balance

Intake and Output

IV Fluids

Dressing, Tubes, Drains Color, consistency and amount of drainage

Pain May need 1/2 to 1/3 less analgesia in recover room

Safety and Comfort Side rails

Warmth

Aseptic Technique


Areas of Concern Intervention

Respiratory ASSESS !!!

Position on Side

Keep Airway in

Oxygen

Cardiovascular ASSESS !!!

Watch for:

Post-op hypotension; cardiac arrest; hemorrhage

Signs of Hemorrhage:

↑ pulse and respiratory rate; restlessness;

↓ blood pressure; cold, clammy skin; thirst; pallor


Common Post-Operative Orders

• NPO until fully alert, then ice chips as tolerated. Advance diet as tolerated.

• Suction prn

• Complete current IV then discontinue if pt. tolerating fluids.

• Compazine 5 mg prn for nausea and vomiting

• Morphine Sulfate 10 mg IM every 3-4 hours prn


Common Post-Operative Orders

• Accurate intake and output

• T,C, and DB every 2 hours

• Hemoglobin and hematocrit in a.m.

• Catheter if patient can’t void in 8 – 10 hours

• Reinforce dressing prn


WOUND CARE

Commonly Used Wound Dressing


The strips of tape should be placed at the ends of the dressing and must

be sufficiently long and wide to secure the dressing. The tape should

adhere to intact skin.


Cleaning Surgical Site

Cleaning from top

to bottom, starting at the

center

Cleaning a wound outward

from the incision

Cleaning around

Penrose drain site


Wound Irrigation


Incision Support


Body Pressure Areas


POST OPERATIVE COMPLICATIONS


A client has returned from surgery with a fine, reddened rash noted

around the area where Betadine prep had been applied prior to

surgery. Nursing documentation in the chart should include

a. The time and circumstances under which the rash was noted.

b. The explanation given to the client and family of the reason for

the rash.

c. Notation on an allergy list and notification of the doctor.

d. The need for application of corticosteroid cream to decrease

inflammation.


C Suspected reaction to drugs should be reported to the doctor

and noted on list of possible allergies


A 41-year-old woman was brought to the emergency room by two

police officers after she had been standing barefoot in the rain for

more than two hours. The police officers report that the woman

had to be restrained after she resisted and became agitated. The

intake nurse's FIRST action should be to:

a. Complete a physical examination.

b. Maintain a safe environment.

c. Ascertain the client's mental status.

d. Orient the client to place and time.


B implementation; major priority of the nurse is to provide

and maintain safety for the client who is unable to provide for

herself; safe environment will generate trust and rapport; will

decrease resistance to doing preliminary physical exam, which

includes orienting client and doing a mental status exam


The nurse is preparing to insert a Foley catheter into a patient. It

would be MOST important for the nurse to take which of the

following actions?

a. Place all supplies close to the edge of the table.

b. Keep the field holding the supplies in front of the

nurse.

c. Set up the field below the nurse's waist level.

d. Add only clean supplies to the field.


B represents the best technique for a sterile field


A nurse instructs a preoperative client in the proper use of an

incentive spirometer. Postoperative assessment of the

effectiveness of its use is determined if the client exhibits:

a. Coughing

b. Shallow breaths

c. Wheezing in one lung field

d. Unilateral chest expansion


A Incentive devices have many desired and positive effects.

Incentive devices provide the stimulus for a spontaneous deep

breath. Spontaneous deep breathing, using the sustained maximal

inspiration concept, reduces atelectasis, opens airways, stimulates

coughing, and actively encourages individual participation in

recovery. Shallow breaths, wheezing, and unilateral chest

expansion would indicate that the incentive spirometry was not

effective. Wheezing indicates narrowing or obstruction of the

airway, and unilateral chest expansion could indicate atelectasis.

perioperative nursing (complete)

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