Perioperative Nursing

Perioperative Nursing-nursing care given to surgical patients preoperatively, Intraoperatively, and postoperatively by a registered nurse or a delegated professional person.

PRE- beforeINTRA-duringPOST-after

Conditions Requiring Surgerya. Obstruction or blockage-impairment to the flow of te fluidsb. Perforation or rupture of an organc. Erosion or wearing away of the surface of a tissued. Tumors or abnormal growth

Types of SurgeryCommonly grouped according to:

a. Purposeb. Degree of Urgencyc. Degree of Risk

According to Purpose:1. Diagnostic- to verify suspected diagnosis e.g. Biopsy of mass in the breast2. Exploratory-to estimate the extent of the disease e.g.exploratory laparotomy3. Palliative-to relieve pain, relieve distressing signs and symtpoms4. Currative-to remove or repair damaged or diseased organs or tissues

Types of Curative Surgery1. Ablative-removal of diseased organs e.g. appendectomy,histerectomy2. Reconstructive-partial or complete restoration of a damaged organ e.g plastic surgery after

burns3. Constructive-repair of a congenitally defective organ

a. Plasty-reconstruction or plastic repair Ex.cheiloplasty,rhinoplastyb. Pexy-suspension or fixation Ex. Orchidopexyc. Orrhaphy-repair of Ex.staphylorraphy, hernioraphy

According to Degree of Risk to Client:a. Major Surgery- high degree of risk

-prolonged intraoperative period-large amount of blood loss-extensive, vital organs may be handled or removed-great risk of complications ex.liver biopsy

b. Minor Surgery-lesser degree of risk to client-generally not prolonged, described as ‘one day surgery’ or outpatient surgery-leads to few serious complications-Involves less risk ex.cyst removal

According to Urgency

a. Emergency Surgery-performed immediately to preserve function of the life of the patientEx. Surgery to control internal hemmorhage or repair of a fracture

b. Elective Surgery-performed when surgical intervention is the preferred treatment for a condition that is not imminently life threatening but may ultimately threaten life or well-being or to improve clients lifeEx. Cholecystectomy for chronic gallbladder disease, hip replacement surgery, plastic surgery

Factors affecting the Estimation of Surgical Risk

a. Physical and Mental Condition of the Client Age-premature babies and elderly persons are at risk Nutritional Status-malnourished and obese are at risk State of fluid and electrolyte balance-dehydration and hypovolemia predispose a person

to complications General health-infectious process increase operative risk Mental Health-affects the ability to understand and cope with the stresses of surgery Economic and Occupational Status Medications

o Corticosteroids-interfere with the wound healing and increase risk of infectiono Anticoagulants-increase blood coagulation that leads to increase bleeding

during pregnancyo Tranquilizers-potentiate the effect of narcotics and increase the risk of infectiono Diuretics-may affect fluid and electrolyte

Factors affecting the estimation of Surgical Risk

a. The Extent of the diseaseb. The Magnitude of the required Operationc. Resources and Preparation of the Surgeon, Nurses and the Hospital

Other Suffixes-ostomy – make artificial opening ex. Colostomy-otomy – cut into or incision ex. Phlebotomy-oscopy- visualization ex. Endoscopy

Perioperative Team

SURGEON

Head of the surgical team Perform operative procedure safely and correctly Visits the patient before anesthesia is inducted, if needed, assist in the positioning of the patient Responsible for being certain that all team members are aware of what they need during the

procedures and that all necessary equipments are available. If he/she is responsible to give the anesthesia (in cases of local anesthesia), it will either be given

before scrubbing or after the patient has been draped After the operation: surgeon secures the dressings in place After the anesthesiologist gives his/her permission, the surgeon should assist in moving the

patient to the stretcher to be brought to the Post Anesthesia Care Unit (PACU)

ANESTHESIOLOGIST/ANESTHETIST

Person who gives the anesthesia to the patient Must be properly attired in the operating room, although there is no need to scrub Responsible for making sure that all equipment and supplies necessary for the induction of

anesthesia are available and then checks the patient and the chart for any last minute changes Monitoring equipments such BP apparatus, cardiac monitor are attached to the patient Helps position the patient During the surgery: monitors the patient’s vital signs, reponsible for keeping the surgeon aware

of the condition of the patient, he/she gives the fluids and blood transfusion needed during the operation

Responsible to inform the operating nurse of the time for the next patient to be pre-medicated Determines if the patient is to be brought to the PACU after surgery is completed. Usually

checks the patient’s airway or vital signs before moving the patient to PACU

ASSISTANT SURGEON

Help the surgeon in any way possible Must be properly attired May help with the drapes and final placement of equipment and supplies May close the incision and help with the dressing In our hospital, the assistant surgeons are usually the residents.

CIRCULATING NURSE

He/she does not need to scrub, but a good hand washing technique should be done In charge of the overall running of the OR before, during and after surgery One of the most important duty: Sterility is maintained at all times Preparing the operating room Assisting the scrub nurse, especially during sponge count Caring for the patient before and after the operation Assisting the anesthesiologist

Positioning the patient and preparing the operative site Assisting the scrub team before and during surgery Caring for the patient after surgery Cleaning the operating room after the surgery has been completed

SCRUB NURSE

Must be properly attired, scrubbed, gowned and gloved Assist the circulating nurse in the preparation of the operating room Must familiarize itself with the procedure and supplies & equipments needed to avoid delay Set up back table Assist surgeon & assistant surgeon in their gowns and gloves, Drapes the operative site Should anticipate the surgeon’s needs Wash the instruments

Principles of Perioperative Asepsis

General Keep sterile supplies dry and unopened Check package sterilization expiration date to verify sterility Maintain general cleanliness in surgical suite Maintain Surgical Asepsis- activities designed to keep sites free from the presence of

microorganisms throughout the procedure

Personnel

a. Personnel with the signs of illness should not report to workb. Surgical scrub, a specific hand washing technique used by operating room personnel designed to

reduced microorganisms in the hands and arms, is done for the length of time designed by hospital policy

Surgical Scrub

a. A sensor-controlled or knee-or foot-operated faucet allows the water to be turned on and off without the use of the hands

b. Remove all rings and watchesc. Use liquid soaps to prevent the spread of microorganismsd. Keep the finger nails short and well-trimmed e. Clean finger nails with a nail stick under running waterf. Hold the hands higher than the elbows throughout the hand washing procedure so that run-off

goes to the elbowsg. Allows the cleanest part of the arms to be the hands h. A scrub brush facilitates the removal of microorganismsi. Clean all areas of skin on the hands and arms in sequence starting at the hands and ending at

the elbows

j. After rinsing, dry the hands with paper towels, drying first one arm from the hand to the elbow, then using a second towel to dry the second hand

Maintaining a Sterile Field

a. Create a sterile field using sterile drapesb. Use the sterile field to place sterile supplies where they will be available during the procedurec. Drape equipment prior to used. Keep drapes dry and out of contact with non sterile objectse. Utilize sterile technique while adding or removing supplies from sterile fileds

Sterile Supplies and Solutions

a. Check expiration dates for sterilityb. Don’t use solutions that were opened prior to current usec. “Lip” the solution after initial use by pouring small amount of liquid out of the bottle into a

waste container to cleanse the bottle lip

Principles of Surgical Asepsis

1. OR personnel must practice Standard Precautions(i.e. blood and body substance isolation)2. All items used in the sterile fields must be sterile3. Sterile objects become unsterile when touched by unsterile objects4. Sterile objects that are out of vision sterile or below the waist level of the nurse are considered

unsterile5. Sterile objects can become unsterile by prolonged exposure to the airborn organism6. The skin cannot be sterilized and is unsterile

All personnel must perform a surgical scrub7. All OR personnel are required to wear specific, clean attire, with the goal “Shedding” the outside

environment Specific clothing requirements are prescribed and standardized for all ORs: OR personnel must wear a sterile gown,gloves, and specific shoe covers Hair must be completely cover Mask must be worn at all times in the OR for the purpose of minimizing airborne

contamination and must be changed between operations or more often if necessary8. Any personnel who harbors pathogenic organisms must report themselves unable to be in the OR to

protect the client from outside pathogens9. Scrubbed personnel wearing sterile attire should touch only sterile items10. Sterile gowns and sterile drapes have defined borders for sterility

Sterile surfaces or articles may touch other sterile surfaces or articles and remain sterileContact with unsterile objects at any point renders a sterile area contaminated

11. The circulator and unsterile personnel must stay at the periphery of the sterile operating area to keep the sterile area free from contamination

12. Sterile supplies are unwraaped and delivered by the circulator following specific standard protocol so as not to cause contamination

13. The utmost caution and vigilance must be used when handling sterile fluids to prevent splashing or spillage

14. Anything that is used for one client must be discarded, or in some cases sterelized

PERIOPERATIVE PHASE

-begins at the time of decision for surgery and ends when the client is transferred to the Operating Room

Goals:

a. Assessing and correcting physiologic and physiologic problems that might increase surgical riskb. Giving the person and significant others complete learning/teaching guidelines regarding

surgeryc. Instructing and demonstrating exercises that will benefits the person during postoperative

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

Physiologic Preparation for the Surgery

Preparation for hospital admission includes explanation of the procedure to be done, probable outcome, expected duration of hospitalization,cost, length of absence fro work, and residual effects

Causes of Fears

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

Legal Aspect: Informed Consent, Operative Permit, Surgical Permit

This is to protect the surgeon and the hospital against claims that unauthorized surgery has been performed and the patient was unaware of the potential risks of complications involved

Protects the client from undergoing unauthorized surgery

a. The surgeon obtains operative permit or informed consent and provides information to the client or guardian. The nature and reason for the surgery All available options and the risk associated with each option The risk of the surgical procedure and its potential outcomes Name and qualifications of the surgeon performing the procedure The right to refuse the consent or later withdraw consent

*Note

Nurse serves as a witness during the signing of the consent form

b. Informed consent is necessary for each operation performed, however: It is also necessary for major diagnostic procedures where major body cavity is entered e.g.

thoracentesisc. Adult client over 18 years old signs own permit unless unconscious or mentally incompetent

If unable to sign relative or guardian will sign

Consents are not needed for emergency case if all four of the following criteria are met:

a. There is an immediate threat to life b. Experts agree that it is an emergencyc. Client is unable to consentd. A legally authorized person cannot be reached

d. Minor(under 18) must have consent signed by an adult(i.e. parent, legal guardian). An emancipated guardian may sign own consent:

Married College students living away from home In military service Any pregnant female or anybody who has given birth

e. Witness to informed consent may be nurse, other physician, clerk or authorized personf. If nurse witnesses informed consent, specify whether witnessing explanation of surgery or just

signature of client

Physiologic Preparation prior to Surgery

a. Respiratory Preparation- chest X-rayb. Cardiovascular Preparation-ECG, CBC, blood typing, cross-matching, PT/PTT(prothrombin time,

partial prothrombin time), serum electrolytesc. Renal preparation-urinalysis

Obtain history of past medical conditions, allergies, dietary restrictions, and medications

A-Allergy to medications, chemicals and other environmental products(latex) All allergies are reported before the beginning of the surgery If allergy exist, an allergy band must be placed in the clients arm immediately

B-Bleeding tendencies or the use of medications that defer clotting, such as aspirin, heparin, and warfarin sodium

Herbal medications may also increase bleeding time or mask potential blood-related problems

C-Cortisone and steroid use

D-Diabetes Mellitus, a condition that not only requires strict control of blood glucose levels but also known to delay wound healing

E-Emboli, previous embolic events such as lower leg blood clots may recur because of prolonged immobility

Instructional and Preventive Aspects:

Coughing Exercise: deep breath, exhale through the mouth, and then follow with a short breath while coughing; splint thoracic and abdominal incision to minimize pain

Turning exercise every 1-2 hours post-operative Extremity exercise-prevents circulatory problems and post operative gas pains or flatus Assure that pain medications will be available post –op

Physical Preparation

On the Night of the Surgerya. Preparing the client’s skin(follow hospital protocol):shave against the grain of the hair shaft to

ensure clean and close shave

b. Preparing the GIT: NPO after midnight Administration of enema(if necessary) Insertion of gastric or intestinal tubes(if necessary)

On the Day of Operation

a. Early morning care about 1 hour prior to the preoperative medication schedule Vital signs taken and recorded Patient changes into hospital gown that is left untied and open at the back Braid long hair and remove hair pin Provide oral hygiene Prosthetic devices, eyeglasses, dentures removed Remove jewelries Remove nail polish Patient should void immediately before going the OR Make sure that the patient has not taken food for the last 10 hours by asking the client

b. Pre-operative medications Generally administered 60-90 min. before induction of anesthesia

Types Pre-Operative Medications

1. Sedative Given to decrease clients anxiety to lower BP and PR Reduce the amount of general anesthesia: an overdose can result to respiratory

depression2. Tranquilizer

Lowers the client’s anxiety level

3. Narcotic Analgesics Given to patients to reduce anxiety and to reduce the amount of narcotics given

during surgery

4. Vagolytics or Drying Agents To reduce the amount of tracheobronchial secretions which can clog the pulmonary

tree and result in atelectasis and pneumonia

INTROPERATIVE PHASE

-Begins when the client is transferred to the Operating table and ends when the client is admitted to the Postanesthetic Care Unit(PACU)

Types of Anesthesia

a. General Anesthesia- a state of analgesia, amnesia, and unconsciousness characterized by the loss of reflexes and muscle tone-protective reflexes such as cough and gag reflexes are lost-acts by blocking awareness center in the brain so that amnesia, analgesia, hypnosis, and relaxation occur-usually administered by IV or inhalation of gases through a mask or ET inserted to the trachea

b. Regional Anesthesia-temporary interruption of the transmission of nerve impulses to and from a specific area or region of the body-the client losses sensation in an area of the body but remains conscious

Techniques 1. Topical Anesthesia- applied directly to the skin and mucous membrane, open skin surfaces,

wounds and burnsEx. Lidocaine

2. Local Anesthesia-is injected into specific area and is used for minor surgical procedures such as suturing a wound or biopsyEx. Lidocaine or Tetracycline 01%

3. Nerve block-is a technique in which the anesthetic agent is injected into and around a nerve or small nerve group that supplies sensation to a small area of the body

4. Intravenous Block(Bier Block)-used most often for procedures involving the arm, wrist, and hand. Occlusion tourniquet is applied to the extremity to prevent infiltration and absorption of the injected intravenous agent beyond the involved extremity

5. Spinal Anesthesia/Subarachnoid Block(SAB)-requires lumbar puncture through one of the interspaced between lumbar disc 2(L2) and the sacrum(S1)-lower spinal(saddle or Caudal Blocks) are primarily used for surgeries involving the perineal or rectal

-Mid-Spinal- (below the level of the umbilicus T10) can be used for hernia repairs or appendectomies-High-Spinal-(Nipple Line T4) can be used for surgeries such as Ceasarean Sections

6. Epidural Anesthesia- is an injection of anesthesia agent into the epidural space the area inside the spinal column but outside the duramater

POSTOPERATIVE PHASE

-Begins when the admission f the client to the postanesthesic area and ends when healing is complete(follow-up home or clinic evaluation)

Post Anesthetic Care

Nursing Responsibilities

a. Maintenance of Pulmonary VentilationPosition the client as ordered*Note

Spinal Anesthesia usually flat on bed 8-12 hours Unconscious or semiconscious-placed on one side with head slightly elevated(if

possible) or Position that allows fluids to drain from the mouth

Oropharyngeal or Nasopharyngeal airway:

-is left in place following administration of general anesthetic until pharyngeal reflexes have returned

It is only removed as soon as the client begins to awaken and has regained the cough and swallowing reflexes

All clients should received O2 at least unil they are conscious and are able to take deep breaths on command

b. Maintenance of CirculationMost common cardiovascular complications:

Hypotension Cardiac Arythmias

c. Protection from injury and promotion of comfort Provide side rails Turning frequently and placed in good body alignment to prevent nerve damage from

pressure Administration of narcotic analgesics to relieve incisional pain

Dismissal of Client from the Recovery Room: Modified Aldrete Score for Anesthesia Recovery Criteria

The Five Physiological Parameters:

a. Activity- able to move four extremities voluntarily on commandb. Respiration – able to breath effortlessly and deeply, and cough freelyc. Circulation – BP is (+20%) or (-20%) of pre-anesthetic leveld. Consciousness – fully awake, oriented to time, place and persone. Color – pink(lips), for blacks:tongue

Post- Operative Care

Begins when the client returns from the recovery room or surgical suite to the nursing unit and ends when the client is discharged

It is directed toward prevention of complications and post-operative discomfort

Post-Operative Complications

a. Respiratory Complications: atelectasis and Pneumonia Suspected whenever there is a sudden rise of temperature 28-48 hours after surgery Collapse of the alveoli is highly susceptible to infection:pneumonia Occurs usually in high abdominal surgery when prolonged inhalation anesthesia has

been necessary and vomiting has occurred during the operation or while the patient is recovered from anesthesia

Nursing Management

-Measures to prevent pooling of secretions Frequent changing of position High-fowlers position Moving out bed

-Measures to liquefy and remove secretions Increase oral fluid intake Breathing moist air Deep breathing exercise followed by coughing Administer analgesics before coughing is attempted after thoracic and abdominal

surgery Splint operative area with draw sheet or towel to promote comfort while coughing

-Other measures to increase pulmonary ventilation Blow bottle exercise Rebreathing tubes, increase C02 stimulates the respiratory center to increase the depth

of breathing thus increasing the amount of inspired air IPPB: intermittent positive pressure breathing apparatus

b. Circulatory Complication: venous stasisCauses of venous stasisMuscular rigidityRespiratory and circulatory depression

Increased pressure on blood vessels due to tight dressingIntestinal distentionProlonged maintenance of sitting

Most Common circulatory complications:

Phlebothrombosis Thrombophlebitis

Nursing Management

Limbs must never be massaged for a post-op client If possible, client should lie on his abdomen for 30min. several time a day to prevent

pooling of blood in the pelvic cavity Do not allow the client to stand unless pulse has returned close to baseline to prevent

orthostatic hypotension Wear elastic bandages or stockings when in bed and when walking for the first time

c. Fluids and Electrolyte Imbalance:

Causes:

Blood loss Increased insensible fluid loss through the skin:

o After surgery through vomiting, from copious wound drainage, and from the tube drainage as in NGT

Since surgery is a stressor, there is an increased production of ADH for the first 12-24 hours following surgery resulting to fluid retention by the kidney

o The potential for over hydration therefore exists since fluids being given IV may exceed fluid output by the kidney

Electrolyte imbalance

Particularly Na and K imbalance as a result of blood loss Stress of surgery increases adrenal hormonal activity resulting to increased aldosterone and

glucocorticosteroids, resulting in sodium reabsorption by the kidney And as Na is reabsorbed, K coming from tissue breakdown is excreted

o Action: IV of D5W alternate with D5NSS or half-strength NSS to prevent Na excess