Peri-operative NursingPeri-operative Nursing

Phases of Peri-operative periodPhases of Peri-operative period

PRE- operative phasePRE- operative phase

INTRA- operative phaseINTRA- operative phase

POST- operative phase POST- operative phase

PRE-Operative PhasePRE-Operative Phase

Begins when the decision to have surgery is made and ends when the client is transferred to the operating table

INTRA-Operative PhaseINTRA-Operative Phase

Begins when the client is Begins when the client is transferred to the operating table transferred to the operating table and ends when the client is and ends when the client is admitted to the post-anesthesia admitted to the post-anesthesia unitunit

Post-operative PhasePost-operative Phase

Begins with the admission of the Begins with the admission of the client to the PACU and ends when client to the PACU and ends when healing is complete healing is complete

PERIOPERATIVE TEAMPERIOPERATIVE TEAM

1.1. ANESTHESIOLOGIST or NURSE ANESTHESIOLOGIST or NURSE ANESTHESISTANESTHESIST

- makes preoperative assessment to - makes preoperative assessment to plan type of anesthetic to be plan type of anesthetic to be administeredadministered

- to evaluate client’s physical status- to evaluate client’s physical status

2.2. PROFESSIONAL O.R. NURSEPROFESSIONAL O.R. NURSE

- makes preop nursing assessments - makes preop nursing assessments and documents intraoperative care planand documents intraoperative care plan

PERIOPERATIVE TEAMPERIOPERATIVE TEAM

3. 3. CIRCULATING NURSECIRCULATING NURSE

- manages the OR- manages the OR

- protects client’s safety and health - protects client’s safety and health needs by monitoring activities of needs by monitoring activities of

members of the surgical teammembers of the surgical team

- monitors conditions in the OR- monitors conditions in the OR

PERIOPERATIVE TEAMPERIOPERATIVE TEAM4. 4. SCRUB NURSESCRUB NURSE

- responsible for scrubbing before - responsible for scrubbing before surgerysurgery

- sets up sterile tables & equipment- sets up sterile tables & equipment

- assists surgeon and surgical assistants - assists surgeon and surgical assistants during the operation itselfduring the operation itself

5. 5. PACU NURSEPACU NURSE

- cares for the client until he/she - cares for the client until he/she recovers from the effects of anesthesiarecovers from the effects of anesthesia

PRINCIPLES OF SURGICAL PRINCIPLES OF SURGICAL ASEPSISASEPSIS

1.1. OR personnel must practice strict OR personnel must practice strict Standard PrecautionsStandard Precautions

2.2. All items used in the OR must be All items used in the OR must be sterilesterile

3.3. All personnel must perform a All personnel must perform a surgical scrubsurgical scrub

PRINCIPLES OF SURGICAL PRINCIPLES OF SURGICAL ASEPSISASEPSIS

4. All OR personnel are required to wear 4. All OR personnel are required to wear specific, clean attire – “shedding” the specific, clean attire – “shedding” the environmentenvironment

- must wear:- must wear:

a. sterile gowna. sterile gown

b. glovesb. gloves

c. special shoe coversc. special shoe covers

d. hair cover – capd. hair cover – cap

e. maske. mask

PRINCIPLES OF SURGICAL PRINCIPLES OF SURGICAL ASEPSISASEPSIS

5. Any personnel harboring pathogenic 5. Any personnel harboring pathogenic microbes must report themselves unable microbes must report themselves unable to be in the ORto be in the OR

6. Scrubbed personnel wearing sterile 6. Scrubbed personnel wearing sterile attire should touch only sterile itemsattire should touch only sterile items

7. Sterile gown and drapes have defined 7. Sterile gown and drapes have defined borders of sterility.borders of sterility.

8. Unsterile personnel must stay at the 8. Unsterile personnel must stay at the periphery of the sterile operating areaperiphery of the sterile operating area

PRINCIPLES OF SURGICAL PRINCIPLES OF SURGICAL ASEPSISASEPSIS

9. Sterile supplies are unwrapped and 9. Sterile supplies are unwrapped and delivered by the circulating nursedelivered by the circulating nurse

10. The utmost caution & vigilance 10. The utmost caution & vigilance must be used when handling sterile must be used when handling sterile fluidsfluids

11. Anything that is used for one client 11. Anything that is used for one client must be must be discardeddiscarded or, in some or, in some cases, cases, resterilizedresterilized

Activities in the Pre-opActivities in the Pre-op

Assessing the clientsAssessing the clients

Identifying potential or actual health Identifying potential or actual health problems problems

Planning specific carePlanning specific care

Providing pre-operative teaching Providing pre-operative teaching

Ensure consent is signedEnsure consent is signed

Consent Consent

The surgeon is responsible for The surgeon is responsible for obtaining the consent for surgeryobtaining the consent for surgery

No sedation should be administered No sedation should be administered before SIGNING the consentbefore SIGNING the consent

The nurse may serve as The nurse may serve as witness witness

Activities during the Intra-opActivities during the Intra-op

Assisting the surgeon as scrub nurse Assisting the surgeon as scrub nurse and circulating nurse and circulating nurse

Activities in the POST-op Activities in the POST-op

Assessing responses to surgeryAssessing responses to surgery

Performing interventions to promote Performing interventions to promote healing healing

Prevent complicationsPrevent complications

Planning for home-carePlanning for home-care

Assist the client to achieve optimal Assist the client to achieve optimal recoveryrecovery

TYPES of SURGERYTYPES of SURGERY

According to PURPOSEAccording to PURPOSE

According to degree of URGENCYAccording to degree of URGENCY

According to degree of RISKAccording to degree of RISK

According to PURPOSEAccording to PURPOSE

Diagnostic Establishes a diagnosis

Palliative Relieves or reduces pain or symptoms

Ablative Removes a diseased body part

Constructive Restores function or appearance

Transplant Replaces malfunctioning structures

According to degree of urgencyAccording to degree of urgency

Emergency Emergency surgerysurgery

Preserves function or lifePreserves function or life

Performs immediately Performs immediately

Elective surgery

Performed when condition is not imminently life threatening

According to degree of RISKAccording to degree of RISK

Major Major Surgery Surgery

Involves high degree of riskInvolves high degree of risk

Complicated or prolongedComplicated or prolonged

Minor Minor SurgerySurgery

Involves low riskInvolves low risk

Produces few complicationsProduces few complications

Performed as day surgeryPerformed as day surgery

Surgical RiskSurgical Risk

Extremes of ageExtremes of age

MalnourishedMalnourished

ObeseObese

Co-morbid conditionsCo-morbid conditions

Concurrent medications Concurrent medications

Pre-operative InterventionsPre-operative Interventions

Ensure signed consent formEnsure signed consent form

Obtain nursing history, PE and lab examObtain nursing history, PE and lab exam

Provide pre-operative teaching as to the Provide pre-operative teaching as to the nature of surgery, what to expect and nature of surgery, what to expect and ways to manage post-operative ways to manage post-operative discomfortsdiscomforts

Perform physical preparations- shaving, Perform physical preparations- shaving, hygiene, enema, NPO, medicationshygiene, enema, NPO, medications

Pre-op nutritionPre-op nutrition

Assess order for NPOAssess order for NPO

Solid foods are withheld for about 8 Solid foods are withheld for about 8 hours before general anesthesia hours before general anesthesia

Pre-op elimination Pre-op elimination

Laxatives, enemas or both may be Laxatives, enemas or both may be prescribed the night before surgeryprescribed the night before surgery

Have the client void immediately Have the client void immediately BEFORE transferring them to the ORBEFORE transferring them to the OR

Foley catheter may be inserted as Foley catheter may be inserted as orderedordered

Pre-op hygiene Pre-op hygiene

Bath the night before surgery with Bath the night before surgery with antiseptic soapantiseptic soap

Shaving of the skin is usually done in Shaving of the skin is usually done in the ORthe OR

Removal of jewelry and nail polishRemoval of jewelry and nail polish

Pre-op psychological preparationPre-op psychological preparation

Be alert to the client’s anxiety levelBe alert to the client’s anxiety level

Answer questions or concernsAnswer questions or concerns

Allow time for privacy Allow time for privacy

Pre-operative medications Pre-operative medications Pre-op DrugsPre-op Drugs ExampleExample PurposePurpose

Anti-anxiety Anti-anxiety Diazepam Diazepam To decrease nervousnessTo decrease nervousness

Promote relaxationPromote relaxation

Anti-Anti-cholinergiccholinergic

AtropineAtropine Decreases secretionsDecreases secretions

Prevent bradycardiaPrevent bradycardia

Muscle Muscle relaxantrelaxant

SuccinylcholineSuccinylcholine To promote muscle To promote muscle relaxation relaxation

Anti-emeticAnti-emetic PromethazinePromethazine To prevent nausea and To prevent nausea and vomitingvomiting

AntibioticAntibiotic CephalosporinCephalosporin To prevent infection To prevent infection

Pre-operative medications Pre-operative medications Pre-op DrugsPre-op Drugs ExampleExample PurposePurpose

AnalgesicsAnalgesics MeperidineMeperidine To decrease pain and To decrease pain and decrease anesthetic dose decrease anesthetic dose

Anti-histamineAnti-histamine DiphenhydramineDiphenhydramine To decrease occurrence To decrease occurrence of allergyof allergy

H-2 H-2 antagonistantagonist

CimetidineCimetidine To decrease gastric fluid To decrease gastric fluid and acidity and acidity

Pre-operative screening testPre-operative screening testCBCCBC Determine Hgb and Hct, infection

Blood typeBlood type Determined in case of blood transfusion

Serum Serum electrolyteselectrolytes

Evaluates the fluid and electrolyte status

FBSFBS Evaluates diabetes mellitus

BUN, CreatinineBUN, Creatinine Assess the renal function

ALT, AST, ALT, AST, BilirubinBilirubin

Evaluates the liver function

Serum albuminSerum albumin Evaluates nutritional status

CXR and ECGCXR and ECG Respiratory and Cardiac status

Pre-operative teaching Pre-operative teaching Leg exercisesLeg exercises To stimulate blood circulation To stimulate blood circulation

in the extremities to prevent in the extremities to prevent thrombophlebitis thrombophlebitis

Deep breathing Deep breathing and Coughing and Coughing

Exercises Exercises

To facilitate lung aeration and To facilitate lung aeration and secretion mobilization to secretion mobilization to prevent atelectasis and prevent atelectasis and hypostatic pneumoniahypostatic pneumoniaDone every two to four hoursDone every two to four hours

Positioning and Positioning and Ambulation Ambulation

To circulation, stimulate respiration, To circulation, stimulate respiration, decrease stasis of gasdecrease stasis of gas

Intra-operative phase Intra-operative phase interventionsinterventions

Determine the type of surgery and Determine the type of surgery and anesthesia usedanesthesia usedPosition client appropriately for Position client appropriately for surgerysurgeryAssist the surgeon as circulating or Assist the surgeon as circulating or scrub nursescrub nurseMaintain the sterility of the surgical Maintain the sterility of the surgical field field Monitor for developing complicationsMonitor for developing complications

Anesthesia Anesthesia

General anesthesiaGeneral anesthesia Loss of all sensation and Loss of all sensation and

consciousness consciousness

Regional or Local anesthesiaRegional or Local anesthesia Loss of sensation in ONE area Loss of sensation in ONE area

with consciousness present with consciousness present

GENERAL AnesthesiaGENERAL Anesthesia

Protective reflexes are lost Protective reflexes are lost

Amnesia, analgesia and hypnosis Amnesia, analgesia and hypnosis occuroccur

Administered in two ways: Administered in two ways: InhalationalInhalational Intravenous Intravenous

REGIONAL AnesthesiaREGIONAL AnesthesiaTOPICAL TOPICAL Applied directly on the skin Applied directly on the skin

INFILTRATIONINFILTRATION Injected into a specific area of Injected into a specific area of skin skin

NERVE BLOCKNERVE BLOCK Injected around a nerveInjected around a nerve

SPINAL SPINAL SubarachnoidSubarachnoid

Low spinal anesthesia Low spinal anesthesia

EPIDURALEPIDURAL Epidural space is injected with Epidural space is injected with anesthesia anesthesia

Patient PositioningPatient Positioning

Provides optimal visualizationProvides optimal visualization

Provides optimal access for Provides optimal access for assessing and maintaining assessing and maintaining anesthesia and functionanesthesia and function

Protects patient from harm Protects patient from harm

Position Patient Position Patient during Surgeryduring Surgery

Abdominal surgeriesAbdominal surgeries SupineSupine

Bladder surgeryBladder surgery Slightly trendelenburgSlightly trendelenburg

Perineal surgeryPerineal surgery LithotomyLithotomy

Brain surgeryBrain surgery Semi-fowler’s Semi-fowler’s

Spinal cord surgeriesSpinal cord surgeries Prone mostly Prone mostly

Lumbar puncture Lumbar puncture Side lying, flexed body Side lying, flexed body

Functions of the nurse during OR procedureFunctions of the nurse during OR procedure

SCRUB NURSESCRUB NURSE Assists the surgeonAssists the surgeon

Maintains sterilityMaintains sterility

Handles instrumentsHandles instruments

Drapes patient Drapes patient

Counts sponges Counts sponges

Wears sterile gown, glovesWears sterile gown, gloves

CIRCULATING CIRCULATING NURSENURSE

Assists the Scrub nurseAssists the Scrub nurse

Positions the patient forPositions the patient for

surgerysurgery

Positions any equipmentsPositions any equipments

POST Operative Interventions POST Operative Interventions

Maintain patent airway

Monitor vital signs and note for early manifestations of complications

Monitor level of consciousness

Maintain on PROPER position

NPO until fully awake, with passage of flatus and (+) gag reflex

POST Operative Interventions POST Operative Interventions

Monitor the patency of the drainage

Maintain intake and output monitoring

Care of the tubes, drains and wound

Ensure safety by side rails up

Pain medication given as ordered

Measures to PREVENT post-op Complications

Post-operative interventionsPost-operative interventions

PAIN MANAGEMENTPAIN MANAGEMENT

Pain is usually greatest during the Pain is usually greatest during the 12-12-36 hours after surgery36 hours after surgery

Narcotic analgesics and NSAIDS may Narcotic analgesics and NSAIDS may be prescribed together for the early be prescribed together for the early period of surgeryperiod of surgery

Provide back rub, massage, diversional Provide back rub, massage, diversional activities, position changes activities, position changes

Post operative interventions Post operative interventions

POSITIONINGPOSITIONING

Clients who have spinal anesthesia is Clients who have spinal anesthesia is usually placed usually placed FLATFLAT on bed for 8-12 on bed for 8-12 hourshours

Unconscious client is placed Unconscious client is placed side lyingside lying to drain secretions to drain secretions

Other positions are utilized BASED on Other positions are utilized BASED on the type of surgery the type of surgery

Post-operative InterventionsPost-operative InterventionsSome Examples of Position Post OpSome Examples of Position Post Op MastectomyMastectomy Semi-fowlers’, affected Semi-fowlers’, affected

arm elevatedarm elevated

ThyroidectomyThyroidectomy Semi fowlers’ , head Semi fowlers’ , head midlinemidline

HemorrhoidectomyHemorrhoidectomy Semi-prone, side-lying Semi-prone, side-lying

LaryngectomyLaryngectomy Fowler’s Fowler’s

PneumonectomyPneumonectomy Lateral, affected sideLateral, affected side

LobectomyLobectomy Lateral, Lateral, ununaffected affected side side

Post-operative InterventionsPost-operative InterventionsSome Examples of Position Post OpSome Examples of Position Post Op

Aneurysmal repair Aneurysmal repair (abdomen)(abdomen)

Fowler’s 45 degreesFowler’s 45 degrees

Amputation of lower Amputation of lower extremitiesextremities

Flat, with stump Flat, with stump elevated with pillowelevated with pillow

Cataract surgery Cataract surgery Fowler’s 45 degreesFowler’s 45 degrees

Supratentorial Supratentorial craniotomycraniotomy

Folwers’ Folwers’

Infratentorial Infratentorial craniotomy craniotomy

Flat on bed, supineFlat on bed, supine

Spina bifida repairSpina bifida repair Prone Prone

Post-operative Interventions Post-operative Interventions

Deep breathing and coughing Deep breathing and coughing exercises Q2-4 hours exercises Q2-4 hours to remove to remove secretionssecretions

Leg exercises Q 2 hours Leg exercises Q 2 hours to to promote circulation promote circulation

Ambulation ASAP prevents prevents respiratory, circulatory, urinary respiratory, circulatory, urinary and gastrointestinal complications and gastrointestinal complications

Post-operative Interventions Post-operative Interventions

Hydration after NPO to maintain to maintain fluid balance fluid balance

Suction, either gastro or respiratory to relieve distention, to relieve distention, to remove respi secretions to remove respi secretions

Diet progressive, usually given progressive, usually given when bowel sounds and gag reflex when bowel sounds and gag reflex returnreturn

WoundWound CareCare

Inspect dressing hourlyInspect dressing hourly

Change dressing daily Change dressing daily

Inspect for signs of infectionInspect for signs of infection redness, swelling, purulent redness, swelling, purulent exudateexudate

Maintain wound drainage

DietDiet

NPO usually immediately after surgeryNPO usually immediately after surgery

Progressive dietProgressive diet

Assess the return of the bowel sounds Assess the return of the bowel sounds

Liquid Diet Vs Soft dietLiquid Diet Vs Soft dietClear liquidClear liquid Full liquidFull liquid Soft dietSoft diet

CoffeeCoffee

TeaTea

Carbonated Carbonated drinkdrink

BouillonBouillon

Clear fruit Clear fruit juicejuice

PopsiclePopsicle

GelatinGelatin

Hard candyHard candy

Clear liquid PLUS:Clear liquid PLUS:

Milk/Milk prodMilk/Milk prod

Vegetable juicesVegetable juices

Cream, butterCream, butter

YogurtYogurt

PuddingsPuddings

CustardCustard

Ice cream and Ice cream and sherbetsherbet

All CL and FL All CL and FL plus:plus:

MeatMeat

VegetablesVegetables

FruitsFruits

Breads and Breads and cerealscereals

Pureed foodsPureed foods

Urinary Elimination Urinary Elimination

Offer bedpansOffer bedpans

Allow patient to stand at the bedside Allow patient to stand at the bedside commode if allowedcommode if allowed

Report to surgeon if NO URINE output Report to surgeon if NO URINE output noted within 8 hours post-opnoted within 8 hours post-op

CPTCPTChest PhysiotherapyChest Physiotherapy

Chest physiotherapy is based on the Chest physiotherapy is based on the fact that mucus can be knocked or fact that mucus can be knocked or shaken form the walls of the airways shaken form the walls of the airways and helped to drain from the lungs. and helped to drain from the lungs.

The usual PVD SEQUENCE is as The usual PVD SEQUENCE is as follows- POSITIONING, Percussion, follows- POSITIONING, Percussion, Vibration, and removal of secretions Vibration, and removal of secretions by SUCTIONING or Coughing by SUCTIONING or Coughing followed lastly by oral hygiene followed lastly by oral hygiene

Incentive SpirometryIncentive SpirometryThis operates on the principle that This operates on the principle that spontaneous sustained maximal spontaneous sustained maximal inspiration is most beneficial to the inspiration is most beneficial to the lungs and has virtually no adverse lungs and has virtually no adverse effects. effects.

The incentive spirometer measures The incentive spirometer measures roughly the inspired volume and roughly the inspired volume and offers the “incentive” of measuring offers the “incentive” of measuring progress progress

Post operative complications Post operative complications Atelectasis Atelectasis

PneumoniaPneumonia

Collapsed Collapsed alveoli due to alveoli due to secretionssecretions

Inflammation Inflammation of alveoliof alveoli

Assess breath Assess breath soundssounds

RepositioningRepositioning

Deep breathing Deep breathing and coughingand coughing

Chest physioChest physio

Suctioning Suctioning

AmbulationAmbulation

ThrombophlebitisThrombophlebitis Inflammation Inflammation of the veinsof the veins

Leg exercises Leg exercises

Monitor for Monitor for swellingswelling

Elevated Elevated extremitiesextremities

Post-operative ComplicationsPost-operative ComplicationsHypovolemic Hypovolemic Shock Shock

Loss of Loss of circulatory circulatory fluid volumefluid volume

Shock positionShock position

Determine cause and Determine cause and prevent bleedingprevent bleeding

O2, IVFO2, IVF

Urinary Urinary retention retention

Involuntary Involuntary accumulation accumulation of urineof urine

Encourage ambulationEncourage ambulation

Provide privacyProvide privacy

Pour warm waterPour warm water

CatheterizeCatheterize

Pulmonary Pulmonary embolismembolism

Embolus Embolus blocking the blocking the lung blood lung blood flowflow

Notify physicianNotify physician

Administer O2wAdminister O2w

Post-operative complicationsPost-operative complicationsConstipation Constipation Infrequent Infrequent

passage of passage of stoolstool

High fiber dietHigh fiber diet

Increased fluidIncreased fluid

Ambulation Ambulation

Paralytic ileusParalytic ileus Absent bowel Absent bowel soundsound

Encourage Encourage ambulation ambulation

NPO until NPO until peristalsis returnsperistalsis returns

Wound Wound infection infection

Occurs about Occurs about 3 days after 3 days after surgery surgery

Daily wound Daily wound dressingdressing

AntibioticsAntibiotics

Maintain drain Maintain drain

Post-operative complicationsPost-operative complicationsWound Wound dehiscence dehiscence

Separation of Separation of wound edges at wound edges at the suture linethe suture line

Cover the wound Cover the wound with sterile normal with sterile normal saline dressingsaline dressing

Place in low-Place in low-Fowler’sFowler’s

Notify MDNotify MD

Wound Wound evisceration evisceration

Protrusion of Protrusion of the internal the internal organs and organs and tissues through tissues through woundwound

Cover the wound Cover the wound with saline padwith saline pad

Place in low-Place in low-fowler’sfowler’s

Notify MDNotify MD

To emphasizeTo emphasize

The over-all goal of nursing care during The over-all goal of nursing care during the PRE-OPERATIVE phase is to the PRE-OPERATIVE phase is to prepare the patient mentally and prepare the patient mentally and physically for the surgeryphysically for the surgery

To emphasizeTo emphasize

The over-all goal of nursing care during The over-all goal of nursing care during the INTRA-OPERATIVE phase is to the INTRA-OPERATIVE phase is to maintain client safetymaintain client safety

To emphasizeTo emphasize

The over-all goals of nursing care The over-all goals of nursing care during the POST-OPERATIVE phase during the POST-OPERATIVE phase are to promote healing and comfort, are to promote healing and comfort, restore the highest possible wellness restore the highest possible wellness and prevent associated risk and prevent associated risk