PERIOPERATIVE NURSING

JAYESH PATIDAR

SURGERY

Is the use of instruments during an operation to treat injuries, diseases, and deformities

Is a stressful, complex event

The branch of medicine concerned with diseases and trauma requiring operative procedures

Surgical procedures are named according to (1) the involved body organ, part, or location and (2) the suffix that describes what is done during the procedure

Physicians who perform surgery include surgeons or other physicians trained to do certain surgical procedures

SURGICAL PROCEDURE SUFFIXES  -ectomy - Removal by cutting

-orrhaphy - Suture of or repair

-oscopy - Looking into

-ostomy - Formation of a permanent artificial opening

-otomy - Incision or cutting into

-plasty - Formation or repair

CLASSIFICATION OF SURGERY

ACCORDING TO URGENCY

Emergent - Patient requires immediate attention; disorder may be life threatening; immediately without delay to maintain life or organ, remove damage, stop bleeding

Urgent/ Imperative - Patient requires prompt attention; within 24 – 30/48 hours

Required/ Planned - Patient needs to have surgery; plan within a few weeks or months

Elective - Patient should have surgery; failure to have surgery not catastrophic; planned/scheduled with no time requirements

Optional - Decision rests with patient; at the preference of patient

ACCORDING TO PURPOSE

Aesthetic - Requested by patient for improvement

Diagnostic - To obtain tissue samples, make an incision, or use a scope to make a diagnosis

Exploratory - Confirmation or measurement of extent of condition

Preventive - Removal of tissue before it causes a problem

Curative (Ablative) - Removal of diseased or abnormal tissue

Reconstructive - Correction of defects of body parts

Palliative - Alleviation of symptoms without curing disease

ACCORDING TO EXTENT

Major - Extensive surgery that involves serious risk and complications, as it involves major organ

High risk, extensive, prolonged, large amount of blood loss, vital organs may be handled or removed, great risk of complications

Minor - Involves minimal complications & blood loss

Generally not prolonged, leads to few serious complications, involves less risk

PRINCIPLES OF SURGICAL ASEPSIS

MOISTURE CAUSES CONTAMINATION

Prevent splashing of liquids in the sterile fields

Place wet objects on sterile, water-impermeable surfaces, such as sterile basin

Rationale: microorganisms travel more easily through moist environment. When sterile surface becomes moist, microorganisms from the unsterile surface may be transmitted into the sterile surface

NEVER ASSUME THAT AN OBJECT IS STERILE

Ensure that it is labeled as sterile

Always check the integrity of the packaging

Always verify the expiration date on the package

Whenever in doubt of the sterility of an object, consider it unsterile

Rationale: commercially prepared products are labeled as sterile on their packaging; special indicators are used to show that objects have completed their sterilization process; packages that are torn, punctured, or moist are considered unsterile

ALWAYS FACE THE STERILE FIELD

Rationale: objects that are out of the line of vision may be inadvertently contaminated

STERILE ARTICLES MAY TOUCH ONLY STERILE ARTICLES OR SURFACES IF THEY ARE TO MAINTAIN THEIR STERILITY

Rationale: anything considered unsterile may transfer microorganisms to the sterile object it touches

STERILE EQUIPMENT OR AREAS MUST BE KEPT ABOVE THE WAIST AND ON TOP OF THE STERILE FIELD

Waist level is the limit of good visual field. Maximum visibility of all sterile objects prevents inadvertent contamination

PREVENT UNNECESSARY TRAFFIC AND AIR CURRENTS AROUND THE STERILE AREA

Close doors

Unfold drapes or wrappers properly

Do not sneeze, cough, or talk excessively over the sterile field

Do not reach across sterile fields

Move around a sterile field to reach for an object, if necessary

Rationale: microorganisms cannot be completely excluded from the air; overreaching across sterile fields will render sterile objects unsterile

OPEN, UNUSED STERILE ARTICLES ARE NO LONGER STERILE AFTER THE PROCEDURE 

Rationale: once protective wrapping have been removed, the article is being contaminated by air so, it must be discarded or sterilized before it is used; liquids opened during the procedure that remain in the container are also considered contaminated

A PERSON WHO IS CONSIDERED STERILE WHO BECOMES CONTAMINATED MUST REESTABLISH STERILITY

Rationale: if a “scrubbed” person punctures the gloves or is contaminated by touching an unsterile object, he or she must change the contaminated articles; if a “scrubbed” person leaves the area of the sterile field, he or she must go through the procedure of rescrubbing, gowning, and gloving

SURGICAL TECHNIQUE IS A TEAM EFFORT

A collective and individual “sterile conscience” is the best method of enhancing sterile technique

Rationale: staff members must rely on one another to maintain sterile technique; periodic review of procedures and infection control surveillance reports enhance everyone’s sterile technique

FOUR MAJOR TYPES OF PATHOLOGIC PROCESSES REQUIRING SURGICAL

INTERVENTION (POET) 

P – PERFORATION

rupture of an organ

O – OBSTRUCTION

impairment to the flow of vital fluids e.g. blood, urine, CSF, bile

E – EROSION

wearing off of a surface or membrane

T – TUMORS

abnormal new growths

EFFECTS OF SURGERY TO THE CLIENT

Stress response is elicited

Defense against infection is lowered

Vascular system is disrupted

Organ functions are disturbed

Body image may be disturbed

Lifestyles may change

SURGICAL RISK FACTORS

NUTRITIONAL AND FLUID STATUS

Optimal nutrition is an essential factor in promoting healing an resisting infection and other surgical complications

obesity, undernutrition, weight loss, malnutrition, deficiencies in specific nutrients, metabolic abnormalities, and the effects of medication on nutrition

Nutritional needs may be measured through BMI and waist circumference

Nutritional deficiency should be corrected before surgery

Nutrients important for wound healing are: protein, arginine, carbohydrates and fats, water, vitamin C, vitamin B complex, vitamin A, vitamin K, magnesium, copper, zinc

DRUG OR ALCOHOL USE

The person with a history of chronic alcoholism often suffers from malnutrition and other systemic problems that increase surgical risk

AGE

very young

very old

PRESENCE OF DISEASE/S

Respiratory Renal/urinary Cardiovascular Endocrine Hepatic

CONCURRENT OR PRIOR PHARMACOTHERAPY

A medication history is obtained from each patient because of the possible effects of medications on the patient’s perioperative course, including the possibility of drug interactions

Document all medications

Stop aspirin 7-10 days before surgery

Currently it is recommended that the use of herbal products be discontinued 2 to 3 weeks before surgery

OTHER SURGICAL RISK FACTORS

Nature of condition Location of the condition Magnitude and urgency of the surgical

procedure Mental attitude of the person toward

surgery Caliber of the professional staff and

health care facilities

THE SURGICAL TEAM

THE CIRCULATING NURSE

Also known as the circulator

manages the OR and protects the patient’s safety and health by monitoring the activities of the surgical team, checking the OR conditions, and continually assessing the patient for signs of injury and implementing appropriate interventions

verifying consent, coordinating the team, and ensuring cleanliness, proper temperature, humidity, lighting, safe function of equipment, and the availability of supplies and materials

Monitors aseptic practices to avoid breaks in technique

“surgical or pre-procedure pause” or time-out”

THE SCRUB ROLE

Performs a surgical hand scrub

Setting up the sterile tables

Prepares sutures, ligatures, and special equipment

Assists the surgeon and the surgical assistants during the procedure by anticipating the instruments and supplies that will be required

As the surgical incision is closed, the scrub person and the circulator count all needles, sponges, and instruments

Standards call for all sponges to be visible on x-ray and for sponge counts to take place at the beginning of surgery and twice at the end

Tissue specimens obtained during surgery are labeled by the scrub person and sent to the laboratory by the circulator

 THE SURGEON

Performs the surgical procedure and heads the surgical team

THE ANESTHESIOLOGIST AND ANESTHETIST

An anesthesiologist is a physician specifically trained in the art and science of anesthesiology

An anesthetist is a qualified health care professional who administers anesthetics

They assess the patient before surgery, selects the anesthesia, administers it, intubates the patient if necessary, manages any technical problems related to the administration of the anesthetic agent, and supervises the patient’s condition throughout the surgical procedure

THE SURGICAL ENVIRONMENT

Known for its stark appearance and cool temperature

Access is limited to authorized personnel

The OR must be situated in a location that is central to all supporting services

The OR must have a specific air filtration devices to screen out contaminating particles, dust, and pollutants

the unrestricted zone (street clothes are allowed); the semi restricted zone (attire consists of scrub clothes and caps); and the restricted zone (scrub clothes, shoe covers, caps, and masks are worn)

Shirts and waist drawstrings should be tucked inside the pants

Wet or soiled garments should be changed

Masks are worn at all times at the restricted zone

Upper respiratory tract infections and skin infections in staff and patients are sources of pathogens and must be reported

PREOPERATIVE PHASE

Extends from the time the client is a admitted in the surgical unit, to the time he/she is prepared physically, psychosocially, spiritually, and legally for the surgical procedure, until he is transported into the operating room

Begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient onto the OR table

involves establishing a baseline evaluation of the patient before surgery by carrying out a preoperative interview

ensuring that necessary tests have been or will be performed

arranging appropriate consultations; and providing education about recovery from anesthesia and postoperative care

On the day of surgery, patient teaching is reviewed, the patient’s identity and surgical site are verified, informed consent is confirmed, and an IV infusion is started

GOALS

Assessing and correcting physiologic and psychologic problems that might increase surgical risk

Giving the person and significant others complete learning/teaching guidelines regarding surgery

Instructing and demonstrating exercises that will benefit the person during post operative period

Planning for discharge and any projected changes in lifestyle due to surgery

PHYSIOLOGIC ASSESSMENT OF THE CLIENT UNDERGOING SURGERY

Age Presence of pain Nutritional status Fluid and electrolyte balance Infection Cardiovascular function

Pulmonary function Renal function Gastrointestinal function Liver function Endocrine function Hematologic function Use of medication Presence of trauma

PSYCHOSOCIAL ASSESSMENT AND CARE

Causes of fears of the preoperative clients Fear of the unknown Fear of anesthesia, vulnerability while

unconscious Fear of pain Fear of death Fear of disturbance of body image Worries – loss of finances, employment,

social and family roles

Manifestations 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 INTERVENTIONS TO MINIMIZE ANXIETY

Explore client’s feelings

Assist client to identify coping strategies that he or she has previously used to decrease fear

Allow client to speak openly about fears/concerns

Give accurate information regarding surgery

Give empathetic support

Consider the person’s religious preferences and arrange visit by priest/minister as desired

Music therapy

INFORMED CONSENT (OPERATIVE PERMIT/SURGICAL CONSENT)

necessary before non emergent surgery can be performed

permission obtained from a patient to perform a specific test or procedure

PURPOSES:

to ensure that the client understands 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 actions by a client who claims that an unauthorized procedure was performed

CIRCUMSTANCES REQUIRING A PERMIT:

any surgical procedure where scalpel, scissors, or sutures may be used

any invasive procedure such as surgical incision, a biopsy, a cystoscopy, or paracentesis

a nonsurgical procedure, such as an arteriography, that carries more than slight risk to the patient

procedures involving radiation

procedures requiring sedation and/or anesthesia

REQUISITES FOR VALIDITY OF INFORMED CONSENT

written permission is best and is legally acceptable

signature is obtained with the client’s complete understanding of what is to occur adults sign their own operative permit obtained before sedation

secured without pressure or duress

a witness is desirable – nurse physicians or authorized persons

in an emergency, permission via telephone or telefax is acceptable

for minor (below 18), unconscious, psychologically incapacitated, permission is required from responsible family member (parent/legal guardian)

INFORMED CONSENT SHOULD CONTAIN THE FOLLOWING:

explanation of procedure and its risks

description of benefits and its alternatives

an offer to answer questions about procedure

instructions that the patient may withdraw consent

a statement informing the patient if the protocol differs from customary procedure

PHYSICAL PREPARATION

Before Surgery Correct any dietary deficiencies

Reduce an obese person’s weight

Correct fluid and electrolyte imbalances

Restore adequate blood volume with blood transfusion

Treat chronic diseases

Halt or treat any infectious process

Treat an alcoholic person with vitamin supplementation, IVF’s or oral fluids if dehydrated

TEACHING PREOPERATIVE EXERCISES

Deep breathing exercises Practice in the same position client would

assume in bed after surgery

Allow hands in a loose fist position to rest lightly on the front of the lower ribs with your finger tips against lower chest to feel the movement

Breathe out gently and fully as the ribs sink down and inward toward midline

Take a deep breath your nose and mouth, letting the abdomen rise as the lungs fill with air

Hold this breath for a count of five

Exhale and let out all the air through your nose and mouth

Repeat this exercise 15 times with a short rest after each group of five

Practice twice daily preoperatively

Incentive spirometry

Let client sit upright, at 45 degrees minimum

Take two normal breaths. Place mouthpiece of spirometer in mouth

Inhale until target, designated by spirometer light or rising ball, is reached, and hold breath for 3 to 5 seconds

Exhale completely

Perform 10 sets of breaths each hour

Coughing exercises

Have client sit up and lean forward

Show client how to splint incision with hands, pillow, or blanket

Have client inhale and exhale deeply three times through mouth

Have client take in deep breath and cough out the breath forcefully with three short coughs using diaphragmatic muscles. Take in quick deep breath through mouth, cough deeply, and deep breathe

Turning exercises

Turn on your side with the uppermost leg flexed most and supported on a pillow

Grasp the side rail as an aid to maneuver to the side

Practice diaphragmatic breathing and coughing while on your side

Foot and leg exercises Lie in a semi-Fowler’s position

Bend your knee and raise your foot – hold it a few seconds, then extend the leg and lower it to the bed

Do this five times with each leg

Then trace circles with the feet by bending them down, in toward each other, up, and then out

PREPARING THE PERSON BEFORE SURGERY

Preparing the skin Have full bath to reduce microorganisms in

the skin

Preparing the GI tract NPO; cleansing enema as required

Preparing for anesthesia Avoid alcohol and cigarette smoking for at

least 24 hours before surgery

Promoting rest and sleep Administer sedatives as ordered

PREPARING THE PERSON ON THE DAY OF SURGERY

Early morning care Awaken one hour before preoperative

medications

Morning bath, mouth wash

Provide clean gown

Remove hairpins, braid long hairs, cover hair with cap

Remove dentures, foreign materials (chewing gum), colored nail polish, hearing aid, contact lens

Take baseline vital signs before preoperative medication

Check ID band and skin preparation

Check for special orders – enema, GI tube insertion, IV line

Check NPO

Have client void before preoperative medication

Continue to support emotionally

Accomplish “preoperative care checklist”

PREOPERATIVE MEDICATIONS/ PREANESTHETIC DRUGS

Goals:

To facilitate the administration of any anesthetic

To minimize respiratory tract secretions and changes in heart rate

To relax the client and reduce anxiety

Narcotics Morphine sulfate

Fentanyl (Sublimaze)

Meperidine (Demerol)

Analgesia; enhancement of postoperative pain relief

Antianxiety and sedative hypnotics Diazepam (Valium) Hydroxyzine hcl (Vistaril) Lorazepam (Ativan) Midazolam (Versed) Phenobarnital sodium Sedation; anxiety reduction

Anticholinergic

Atropine sulfate

Scopolamine hydrobromide

Secretion reduction

Antiemetic

Ondansetron (Zofran)

Metoclopramide (Reglan)

Promethazine hcl (Phenergan)

Control nausea and vomiting; may be effective into the postoperative period

H2 antagonist

Cimetidine (Tagamet)

Ranitidine (Zantac)

Famotidine (Pepcid)

Reduction of acidic gastric secretions in case aspiration occurs

Antibiotic

Cefazolin (Ancef)

Ampicillin (Omnipen

Prevention of postoperative infection

INTRAOPERATIVE PHASE

Begins when the client is transferred onto the OR table and ends with admission to the PACU

Extends from the time the client is admitted to the operating room, to the time of administration of anesthesia, surgical procedure is done, until he/she is transported to the recovery room/PACU

Nursing activities include: providing safety, maintaining an aseptic environment, ensure proper functioning of equipment, providing the surgeon with specific instruments and supplies for the surgical field, and proper documentation

GOALS OF CARE (HASH)

H – homeostasis

A – asepsis

S – safe administration of anesthesia

H – hemostasis

POSITIONS DURING SURGERY

Dorsal Recumbent – hernia repair, mastectomy, bowel resection

Trendelenburg – lower abdomen, pelvic

surgeries

Lithotomy – vaginal repairs, D and C, rectal surgery

Prone – spinal surgeries, laminectomy

Lateral – kidney, chest, hip surgeries

Explain purpose of position

Avoid undue exposure

Strap the person to prevent falls

Maintain adequate respiratory and circulatory function

Maintain good body alignment

TYPES OF ANESTHESIA

General Anesthesia is a state of narcosis,

analgesia, relaxation, and reflex loss

Clients under general anesthesia are not arousable, not even to painful stimuli

Produces amnesia

Can be administered through IV or inhalation

Gas anesthetics are administered by inhalation and are always combined with oxygen

Nitrous oxide is the most commonly used gas anesthetic agent

When inhaled, the anesthetics enter the blood through the pulmonary capillaries and act on cerebral centers to produce loss of consciousness and sensation

General anesthesia consists of four stages

Stage I (beginning anesthesia) extends from the administration of

anesthesia to the time of loss of consciousness

The client may have a ringing, roaring or buzzing in the ears, and although still conscious, may sense an inability to move the extremities easily

During this stage, noises are exaggerated

During this stage, noises are exaggerated. Unnecessary noises and motions are avoided when anesthesia begins.

Stage II (excitement/delirium) extends from the time of loss of

consciousness to the time of loss of lid reflex

It may be characterized by shouting, struggling, talking, singing, laughing, or crying of the client but often avoided if anesthetic is administered smoothly and quickly

Assist anesthesiologist/ anesthetist if needed to restrain client. Client should not be touched except for purposes of restraint.

Stage III (surgical anesthesia) extends from the loss of lid reflex to the

loss of most reflexes. Surgical procedure is started

Stage IV (medullary depression) it is characterized by respiratory/cardiac

depression or arrest. It is due to overdose of anesthesia. Resuscitation must be done

Regional Reduce all painful sensations in one region

of the body without inducing unconsciousness

Topical, local infiltration, epidural, spinal

Client receiving regional anesthesia is awake and aware of his/her surroundings unless medications are given to produce mild sedation or to relieve anxiety

Nurse must avoid careless conversation, unnecessary noise, and unpleasant odors

Diagnosis must not be stated allowed if the client is not to know it at this time

A postdural puncture headache may occur after spinal and epidural blocks caused by leakage of CSF. Small-gauge spinal needle (less than gauge 25) helps prevent headaches. Position the client flat and force fluids to relieve headache. A blood patch treatment can be done if headache continues

TRANSFER FROM SURGERY

After surgery client is stabilized for transfer

After local anesthesia, the client may return directly to a nursing unit

After general and spinal anesthesia, the client goes to the PACU or in some cases, the intensive care unit

SAFETY is always a priority at this time!

Never leave client alone

Ensure patent airways and prevent falls an injury

Continuous monitoring of client

POSTOPERATIVE PHASE

Extends from the time the client 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

Begins when the client is admitted to the PACU or a nursing unit and ends with the client’s postoperative evaluation in the physician’s office

GOALS:

Maintain adequate body system functions

Restore homeostasis

Alleviate pain and discomfort

Prevent postoperative complications

Ensure adequate discharge planning and teaching

ADMISSION TO PACU

Goal is to promote safe recovery from anesthesia

Administer oxygen by nasal cannula or mask as ordered

Continuous monitoring is done for ECG, pulse oximetry, and BP measurements

Assess surgical site and dressing

Check for patency of catheter, drains and tubes

Measure body temperature

Provide warming blanket

Control shivering by administering Meperidine (Demerol) when anesthesia is the cause

Provide supplemental oxygen during shivering

Perform hand washing between clients

VS taking every 5 to 15 minutes

GENERAL INTERVENTIONS

Avoid exposure

Avoid rough handling

Avoid hurried movement and rapid changes

Assessment Appraise air exchange status and note

skin color

Verify identity, operative procedure, surgeon

Assess neurologic status

Determine VS

Perform safety checks

Ensure maintenance of patent airway and adequate respiratory function Lateral position with neck extended

Keep airway in place until fully awake

Suction secretions

Encourage deep breathing

Administer humidified oxygen as ordered

TRANSFER FROM RECOVERY ROOM TO SURGICAL UNIT

Parameters for Discharge from Recovery Room Activity: able to obey commands

Respiration: easy, noiseless breathing

Circulation: BP is within +/-20 mmHg of the preop level

Consciousness: responsive

Color: pinkish skin and mucus membrane

NURSING CARE OF CLIENT DURING THE EXTENDED POSTOPERATIVE PERIOD

2-3 days after surgery (discharge planning/teaching)

Self-care activities Activity limitation Diet and medications Complications Referrals, follow-up check up

Postoperative discomforts Nausea and vomiting

Restlessness & sleeplessness

Thirst

Constipation

Pain

POSTOPERATIVE COMPLICATIONS

SHOCK

Response of the body to a decrease in the circulating blood volume, which results to poor tissue perfusion and inadequate tissue oxygenation

HEMORRHAGE

Copious escape of blood from the blood vessel Capillary – slow, generalized oozing Venous – dark in color and bubble out Arterial – spurts and is bright red in color

Manifestations Apprehension, restlessness, thirst, cold,

moist, pale skin

Deep rapid respiration, low body temperature

Low blood pressure, low hemoglobin

Circumoral pallor

Progressive weakness

Management Administer Vitamin K as ordered

Pressure dressings

Blood transfusion

IV fluids

FEMORAL PHLEBITIS/ DEEP THROMBOPHLEBITIS

Often occurs after operations on the lower abdomen or during the course of septic conditions as rupture ulcer or peritonitis

Causes Injury – damage to vein Hemorrhage Prolonged immobility Obesity/ debilitation

Manifestations Pain Redness Swelling Heat/warmth Positive Homan’s sign

Nursing Interventions (prevention) Hydrate adequately to prevent

hemoconcentration

Encourage leg exercises and ambulate early

Avoid any restricting devices that can constrict and impair circulation

Prevent use of bed rolls or dangling over the side of the bed with pressure on popliteal area

Nursing Interventions (Active) Bed rest, elevate the affected leg with

pillow support

Wear antiembolic support hose from the toes to the groin

Avoid massage on the calf of the leg

Initiate anticoagulant therapy as ordered

PULMONARY COMPLICATIONS

Atelectasis Bronchitis Bronchopneumonia Lobar pneumonia Pleurisy

Nursing Interventions

Reinforce deep breathing, coughing, and turning exercises

Encourage early ambulation

Incentive spirometry

INTESTINAL OBSTRUCTION

Loop of intestine may kink due to inflamatory adhesions

Manifestations Intermittent, sharp, colicky abdominal

pains

Nausea and vomiting

Abdominal distention

Diarrhea(incomplete obstruction), no bowel movement (complete)

Return flow of enema is clear

Nursing Interventions NGT insertion

Administer electrolyte/ IV as ordered

Prepare for possible surgical intervention

WOUND INFECTIONS Causes

Staphylococcus aureus

Escherichia coli

Proteus vulgaris

Pseudomonas aeruginosa

Anaerobic bacteria

Clinical manifestations Redness, swelling, pain, warmth

Pus or other discharge on the wound

Foul smell from the wound

Elevated temperature; chills

Tender lymph nodes

Rule of thumb: Fever within first 24 hours – pulmonary

infection

Within 48 hours – urinary tract infection

Within 72 hours – wound infection

Preventive interventions Strict aseptic technique

Wound care

Keep unit clean

Antibiotic therapy as ordered

WOUND COMPLICATIONS

Hemorrhage

Wound dehiscence – disruption in the coaptation of wound edges (wound breakdown)

Wound evisceration – dehiscence + outpouching of abdominal organs

Nursing interventions Apply abdominal binders

Encourage proper nutrition (high protein, vitamin C)

Stay with client, have someone call for the doctor

Keep in bed rest

Supine or Semi-Fowler’s position, bend knees to relieve

Cover exposed intestine with sterile, moist saline dressing

Reassure, keep him/her quiet and relaxed

Prepare for surgery and repair of wound