Perioperative Nursing
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Lecture Notes on Perioperative Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN
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According to URGENCY Classification Emergent – patient requires immediate attention, life threatening condition. Urgent / Imperative – patient requires prompt attention. Required – patient needs to have surgery. Elective – patient should have surgery. Optional – patient’s decision. Indication for Surgery Without delay Examples - severe bleeding - gunshot/ stab wounds - Fractured skull - kidney / ureteral stones - cataract - thyroid d/o - repair of scar - vaginal repair - cosmetic surgery
MEDICAL AND SURGICAL NURSING PERIOPERATIVE NURSING Lecturer: Mark Fredderick R. Abejo RN, MAN __________________________________________
Within 24 to 30 hours Plan within a few weeks or months Failure to have surgery not catastrophic Personal preference
PERIOPERATIVE NURSING
Perioperative Nursing – used to describe the nursing care provided in the total surgical experience of the patient: preoperative, intraoperative and 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, extends from the time the client 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, 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. 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.
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 Teeth extraction Circumcision Vasectomy Cyst removal Tubal ligation Surgical Risks Obesity Poor Nutrition Fluid and Electrolyte Imbalances Age
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 * Constructive – repair of congenitally defective organ. * Reconstructive – repair of damage organ Palliative – to relieve distressing sign and symptoms, not necessarily to cure the disease.
MS Perioperative Nursing
Abejo
Lecture Notes on Perioperative Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN
2
Presence of Disease (Cardiovascular dse., DM, Respiratory dse. ) Concurrent or Prior Pharmacotherapy 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
Fear of Pain Fear of Death Fear of disturbance on Body image 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 Explore client’s feeling Allow client’s to speak openly about fears/concerns Give accurate information regarding surgery (brief, direct to the point and in simple terms) Give empathetic support Consider the person’s religious preference and arrange for visit by a priest / minister as desired.
PREOPERATIVE PHASE
Goals Assessing and correcting physiologic and psychologic problems that may increase surgical risk. Giving the person and significant others complete learning / teaching guidelines regarding surgery. Instructing and demonstrating exercises that will benefits the person during postop 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 & Fluid and Electrolyte Balance Cardiovascular / Pulmonary Function Renal Function Gastrointestinal / Liver Function Endocrine Function Neurologic Function Hematologic Function Use of Medication Presence of Trauma & Infection Routine Preoperative Screening Test Test CBC Rationale RBC,Hgb,Hct are important to the oxygen carrying capacity of blood. WBC are indicator of immune function. Determined in case blood transfusion is required during or after surgery. To evaluate fluid and electrolyte status Measure time required for clotting to occur. High level may indicate undiagnosed DM Evaluate renal function Evaluate liver function Evaluate nutritional status Determine urine composition Evaluate resp.status/ heart size Identify preexisting cardiac problem.
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 Consent Any surgical procedure where scalpel, suture, hemostats of electrocoagulation used. Entrance into body cavity. Radiologic procedures, particularly if a material is required. General anesthesia, local infiltration and block.
Blood grouping/ X matching Serum Electrolyte PT,PTT Fasting Blood Glucose BUN / Creatinine ALT/AST/LDH and Bilirubin Serum albumin and total CHON Urinalysis Chest Xray ECG
scissors, may be
contrast regional
Essential Elements of Informed Consent the diagnosis and explanation of the condition. a fair explanation of the procedure to be done and used and the consequences. a description of alternative treatment or procedure. a description of the benefits to be expected. material rights if any. the prognosis, if the recommended care, procedure is refused. Requisites for Validity of Informed Consent Written permission is best and legally accepted. Signature is obtained with the client’s complete understanding of what to occur.
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Psychosocial Assessment and Care Causes of Fears of the Preoperative Clients Fear of Unknown ( Anxiety ) Fear of Anesthesia
MS Perioperative Nursing
Lecture Notes on Perioperative Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN
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- adult sign their own operative permit - obtained before sedation 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 For mentally ill and unconscious patient, consent must be taken from the parents or legal guardian If the patient is unable to write, an “X” ia 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.)
Interlace his fingers and place hands over the proposed incision site, this will act as a splint and will not harm the incision. Lean forward slightly while sitting in bed. Breath, using diaphragm Inhale fully with the mouth slightly open. Let out 3-4 sharp hacks. With mouth open, take in a deep breath and quickly give 1-2 strong coughs. Turning Changing positions from back to side-lying (vice versa ) stimulates circulation, encourages deeper breathing and relieve pressure areas Help the patient to move onto his side if assistance is needed. Place the uppermost leg in a more flexed position than that of the lower leg and place a pillow comfortably between the legs. Make sure that the patient is turned from one side to the back and onto the other side every 2 hours. Foot and Leg Exercise Moving the legs improves circulation and muscle tone. 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. Repeat above about 5 times with one leg and then with the other. Repeat the set 5 times every 3-5 hours. Then have the patient lie on one side and exercise the legs by pretending to pedal a bicycle. For foot exercise, trace a complete circle with the great toe. Turning to the Side Turn on your side with the uppermost leg flexed most and supported on a pillow. Grasp the side rails as an aid to maneuver to the side.
PREOPERATIVE 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 Preoperative Teaching Incentive Spirometry Encouraged to use incentive spirometer about 10 to 12 times per hour. Deep inhalations expand alveoli, which prevents atelectasis and other pulmonary complication. There is less pain with inspiratory concentration than with expiratory concentration. Diaphragmatic Breathing 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. In a semi-Fowlers position, with your hands loosefist, allow to rest lightly on the front of lower ribs. Breathe out gently and fully as the ribs sink down and inward toward midline. Then take a deep breath through the nose and mouth, letting the abdomen rise as the lungs fill with air. Hold breath for a count of 5. 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 5. Coughing Promotes removal of chest secretions.
MS Perioperative Nursing
Abejo
Lecture Notes on Perioperative Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN
4
Preparing the Patient the Evening Before Surgery 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. Preparing the G.I tract - NPO, cleansing enema as required
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
PREOPERATIVE MEDICATIONS ASA (American Society of Anesthesiologists) Guidelines for Preoperative Fasting Liquid and Food Intake Clear Liquids Breast Milk Nonhuman Milk Light Meal Regular / Heavy Meals Minimum Fasting Period 2 4 6 6 8
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.
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 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.
MS Perioperative Nursing
Abejo
Lecture Notes on Perioperative Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN
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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
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
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INTRAOPERATIVE PHASE
Goal: Asepsis Homeostasis Safe Administration of Anesthesia Hemostasis
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. Communication System
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Surgical Environment 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 suit. 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 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
The Surgical Team Surgeon • 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 Assistant Surgeon • 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 • 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 • 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
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Environmental Safety • The 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 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.
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MS Perioperative Nursing
Lecture Notes on Perioperative Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN
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Circulating Nurse • 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. • 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.
Surgical Incisions Incision Site Butterfly Limbal Halstead / Elliptical Subcostal Paramedian Type of Surgery For craniotomy For eye surgeries For breast surgeries Gallbladder and biliary tract surgery Right side – gallbladder, biliary tract Left side - splenectomy Gastrectomy Right side – small bowel resection Left side – sigmoid colon resection Appendectomy Gynecologic surgery For kidney surgeries
Transverse Rectus
McBurney Pfannenstiel Lumbotomy
Principles of Surgical Asepsis 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 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) Medical Asepsis vs. Surgical Asepsis
Position During Surgery Position Type of Surgery Dorsal Recumbent Hernia repair, mastectomy, bowel resection Trendelenburg Pelvic Surgeries Lithotomy Vaginal repair, D&C, rectal surgery, APR Prone Spinal surgery, laminectomy Lateral Kidney, chest, hip surgery Jack Knife Position Rectal procedures, sigmoidoscopy and colonosc Reverse Trendelenburg Position Upper abdominal, head, neck and facial surgery
Explain the purpose of position Avoid undue exposure Strap the person to prevent falls Maintain adequate respiratory and circulatory functions. Maintain good body alignment
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 level - HR and BP - Urine output Types of Anesthesia 1. General Anesthesia reversible state consisting of complete loss of consciousness and sensation. protective reflexes such as cough and gag are lost provides analgesia, muscle relaxation and sedation. produces amnesia and hypnosis.
MS Perioperative Nursing Abejo
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Lecture Notes on Perioperative Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN
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Techniques used in General Anesthesia A. Intravenous Anesthesia This is being administered intravenously and extremely rapid. Its effect will immediately take place after thirty minutes of introduction. It prepares the client for smooth transition to the surgical anesthesia. B. Inhalation Anesthesia This comprises of volatile liquids or gas and oxygen. Administered through a mask or endotracheal tube 2. Regional Anesthesia temporary interruption of the transmission of nerve impulses to and from specific area or region of the body. achieved by injecting local anesthetics in close proximity to appropriate nerves. reduce all painful sensation in one region of the body without inducing unconsciousness. agents used are lidocaine and bupivacaine. Techniques used in Regional Anesthesia: A. Topical Anesthesia applied directly to the skin and mucous membrane, open skin surfaces, wounds and burns. readily absorbed and act rapidly used topical agents are lidocaine and benzocaine. B. Spinal Anesthesia ( Subarachnoid block ) local anesthetic is injected through lumbar puncture, between L2 and S1 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 anesthetic block conduction in spinal nerve roots and dorsal ganglia; paralysis and analgesia occur below level of injection agents used are procaine, tetracaine, lidocaine and bupivacaine. C. Epidural Anesthesia achieved by injecting local anesthetic into epidural space by way of a lumbar puncture. result similar to spinal analgesia agents use are chloroprocaine, lidocaine and bupivacaine.
E. Intravenous Block ( Beir block ) often used for arm,wrist and hand procedure an occlusion tourniquet is applied to the extremity to prevent infiltration and absorption of the injected IV agents beyond the involved extremity.
Indicating a site for insertion of the lumber puncture needle into the subarachnoid space of the spinal canal.
F. Caudal Anesthesia Is produced by injection of the local anesthetic into the caudal or sacral canal G. Field Block Anesthesia The area proximal to a planned incision can be injected and infiltrated with local anesthetic agents. Stages of Anesthesia Onset / Induction. Extends from the administration of anesthesia to the time of loss of consciousness. Excitement / Delirium. Extends from the time of loss of consciousness to the time of loss of lid reflex. Increase in autonomic activity and irregular breathing. It may be characterized by shouting, struggling of the client. Surgical. Extends from the loss of lid reflex to the loss of most reflexes. surgical procedure is started. Medullary / Stage of Danger. It is characterized by respiratory and cardiac depression or arrest. It is due to overdose of anesthesia. Resuscitation must be done.
D. Peripheral Nerve Block achieved by injecting a local anesthetic to anesthetize the surgical site. agents use are chloroprocaine, lidocaine and bupivacaine.
MS Perioperative Nursing
Abejo
Lecture Notes on Perioperative Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN
8
Complication and Discomforts of Anesthesia Hypoventilation - inadequate ventilatory support after paralysis of respiratory muscles. Oral Trauma Malignant Hyperthermia Hypotension - due to preoperative hypovolemia or untoward reactions to anesthetic agents. Cardiac Dysrhythmia - due to preexisting cardiovascular compromise, electrolyte imbalance or untoward reaction to anesthesia. Hypothermia - due to exposure to a cool ambient OR environment and loss of thermoregulation capacity from anesthesia. Peripheral Nerve Damage - due to improper positioning of patient or use of restraints. Nausea and Vomiting Headache
POSTOPERATIVE PHASE
Goals: Maintain adequate body system functions Restore homeostasis Alleviate pain and discomfort Prevent postop complication Ensure adequate discharge planning and teaching.
PACU CARE
Transport of client from OR to RR avoid exposure avoid rough handling avoid hurried movement and rapid changes in position.
MS Perioperative Nursing
Abejo
Lecture Notes on Perioperative Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN
9
Initial Nursing Assessment Verify patient’s identity, operative procedure and the surgeon who performed the procedure. Evaluate the following sign and verify their level of stability with the anesthesiologist: - Respiratory status - Circulatory status - Pulses - Temperature - Oxygen Saturation level - Hemodynamic values Determine swallowing and gag reflex , LOC and patients response to stimuli. Evaluate lines, tubes, or drains, estimate blood loss, condition of wound, medication used, transfusions and output. Evaluate the patient’s level of comfort and safety. Perform safety check; side rails up and restraints are properly in placed. Evaluate activity status, movement of extremities. Review the health care provider’s orders. Initial Nursing Interventions Maintaining a Patent Airway Allow the airway ( ET tube ) to remain in place until the patient begins to waken and is trying to eject the airway. The airway keeps the passage open and prevents the tongue from falling backward and obstructing the air passages. Aspirate excessive secretions when they are heard in the nasopharynx and oropharynx. Assessing Status of Circulatory System Take VS per protocol, until patient is well stabilized. Monitor intake and output closely. 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 Place the patient in lateral position with neck extended ( if not contraindicated ) and upper arm supported on a pillow. Turn the patient every 1 to 2 hours to facilitate breathing and ventilation. Encourage the patient to take deep breaths, use an incentive spirometer. Assess lung fields frequently by auscultation. Periodically evaluate the patient’s orientation – response to name and command. Note: Alterations in cerebral function may suggest impaired O2 delivery. Administer humidified oxygen if required.
MS Perioperative Nursing
Use mechanical ventilation to maintain adequate pulmonary ventilation if required. Assessing Thermoregulatory Status Monitor temperature per protocol to be alert for malignant hyperthermia or to detect hypothermia. Report a temperature over 37.8 C or under 36.1 C Monitor for postanesthesia shivering, 30-45 minutes after admission to the PACU. Provide a therapeutic environment with proper temperature and humidity. Maintaining Adequate Fluid Volume Administer I.V solutions as ordered. Monitor evidence of F&E imbalance such as N&V and weakness. Evaluate mental status, skin color and turgor 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 Monitor I&O Minimizing Complications of Skin Impairment Perform handwashing before and after contact with the patient Inspect dressings routinely and reinforce them if necessary. Record the amount and type of wound drainage. Turn patient frequently and maintain good body alignment. Maintaining Safety Keep the side rails up until the patient is fully awake. Protect the extremity into which I.V fluids are running so needle will not become accidentally dislodged. Avoid nerve damage and muscle strain by properly supporting and padding pressure areas. 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. Check dressing for constriction Promoting Comfort Assess pain by observing behavioral and physiologic manifestations. Administer analgesic and document efficacy. Position the patient to maximize comfort.
Parameter for Discharge from PACU/RR Activity. Able to obey commands Respiratory. Easy, noiseless breathing Circulation. BP within 20mmHg of preop level Consciousness. Responsive Color. Pinkish skin and mucus membrane
Abejo
Lecture Notes on Perioperative Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN
10
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
Goals: o Restore homeostasis and prevent complication. o Maintain adequate cardiovascular and tissue perfusion. o Maintain adequate respiratory function. o Maintain adequate nutrition and elimination. o Maintain adequate fluid and electrolyte balance. o Maintain adequate renal function. o Promote adequate rest, comfort and safety. o Promote adequate wound healing. o Promote and maintain activity and mobility. o Provide adequate psychological support.
MS Perioperative Nursing
Abejo
Lecture Notes on Perioperative Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN
11
MS Perioperative Nursing
Abejo
STI Global City College of Nursing / QMMC Surgery Ward Exposure Lecture Notes on Perioperative Nursing Prepared By: Mark Fredderick R Abejo R.N Clinical Instructor
12
WOUND CARE Frequently used Dressing Materials
Common dressing
Irrigating a wound
Montgomery Straps holding 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 a wound outward from the incision Cleaning from top to bottom Starting at the center Cleaning around a Penrose drain site
MS Perioperative Nursing
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STI Global City College of Nursing / QMMC Surgery Ward Exposure Lecture Notes on Perioperative Nursing Prepared By: Mark Fredderick R Abejo R.N Clinical Instructor
13
INCISION SUPPORTING
BODY PRESSURE AREAS:
MS Perioperative Nursing
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STI Global City College of Nursing / QMMC Surgery Ward Exposure Lecture Notes on Perioperative Nursing Prepared By: Mark Fredderick R Abejo R.N Clinical Instructor
14
POST OPERATIVE COMPLICATIONS
Problem RESPIRATORY Pneumonia Inflammation of the lung parenchyma / alveoli Infection Toxin / irritants causing inflammatory process Cause by streptococcus pneumoniae / Staphylococcus aureus Immobility Impaired ventilation Aspiration of gastric contents, food Mucous plugs blocking bronchial passageways Inadequate lung expansion Immobility - elevated temp. - cough - blood tinged sputum - dyspnea - chest pain Deep breathing exercises Coughing exercise Early ambulation Description Cause Clinical Signs Nursing Intervention
Infectious Pneumonia
Hypostatic Pneumonia
Aspiration Pneumonia Atelectasis A condition in which alveoli collapsed and are not ventilated
- Fever ( 1st 24 hours) - Dyspnea - Tachycardia - Diaphoresis - Pleural pain - Dull or absent lung sounds - Dec. SaO2 - Sudden chest pain - SOB - Cyanosis - Tachycardia - Low BP
Deep breathing exercises Coughing exercise Early ambulation
Pulmonary Embolism
Blood clot that has moved to the lungs and blocks a pulmonary artery and obstruct blood flow to the lungs
Immobility Use of oral contraceptives Coagulation problem
Turning Ambulation Anti embolic stockings Compression devises Prevent massaging the lower extremities
CIRCULATION Hypovolemia Inadequate circulating blood volume Internal or external bleeding Capillary – slow generalized oozing Venous – dark in color and bubble out Arterial – spurts, bright red in color
MS Perioperative Nursing
Hemorrhage Fluid deficit
Hemorrhage
Disruption of sutures Insecure ligation of blood vessels
- Tachycardia - Dec. urine output - Dec. BP - Cold, moist and pale skin - Deep, rapid RR - Low temp - Increase pain - Inc. abd. girth - Swelling or bruising around incision
Fluid and blood replacement
Fluid and blood replacement Vit.k and hemostat Ligation of bleeders Pressure dressing
Abejo
STI Global City College of Nursing / QMMC Surgery Ward Exposure Lecture Notes on Perioperative Nursing Prepared By: Mark Fredderick R Abejo R.N Clinical Instructor
15
Overt Bleeding - Dressing saturated with bright blood - Bright, freeflowing blood in drains or tubes. Thrombophlebitis Inflammation of the veins, usually of the legs and associated with a blood clot. Slowed venous blood flow due to immobility or prolonged sitting Trauma to the vein Increased blood coagulability. - Homan’s Sign pain, discomfort in calf when foot is dorsiflexed - Aching, cramping pain - Swollen, red and hot to touch - Vein feels hard Arterial - Pain - Pallor on the affected extremities - Dec./absent of peripheral pulse Note: Embolus in the venous system usually becomes a pulmonary embolus Early ambulation Anti embolic stocking Encourage leg exercise Hydrate adequately Avoid any restricting devices that impaired circulation Avoid massage on the calf of the leg Initiate anticoagulant therapy
Thrombus
Blood clot attached to wall of vein or artery
Embolus
Foreign body or clot that has moved from its site of formation to another area of the body
Broken IV catheter Fat Amniotic fluid
Careful maintenance of IV catheters
URINARY Urinary Retention
Inability to empty the bladder, with excessive accumulation of urine in the bladder
Urinary Incontinence Urinary Tract Infection
Inability of the bladder to hold accumulated urine Inflammation of the bladder, ureters or urethra
Depressed bladder muscle tone from narcotics and anesthetics Handling of tissue during surgery on adjacent organs Spasm of the bladder sphincter Loss of tone of the bladder sphincter Immobilization Limited fluid intake
- Larger fluid intake than output - Inability to void - Bladder distention - Suprapubic discomfort - Restlessness - 30 – 60 ml of urine q 15-30 mins - Fever ( 48 hours postop) - Burning sensation when voiding - Urgency - Cloudy urine - Lower abdominal pain
Monitor I & O Interventions to facilitate voiding Urinary Catheterization as needed
Monitor I & O
Adequate fluid intake Early ambulation Aseptic catheterization as needed Good perineal hygiene
MS Perioperative Nursing
Abejo
STI Global City College of Nursing / QMMC Surgery Ward Exposure Lecture Notes on Perioperative Nursing Prepared By: Mark Fredderick R Abejo R.N Clinical Instructor
16
GASTROINTESTINAL Nausea and Vomiting Pain Abdominal distention Ingestion of fluid or food before the return of peristalsis Retention of gases within the intestines Slowed motility of the intestines due to effects of anesthesia Irritation of phrenic nerve bet. the spinal cord and terminal ramifications on undersurface of the diaphragm Abdominal distention Due to inflammatory adhesions - Complaints of feeling sick to the stomach - Retching - Gagging IV fluids until peristalsis returns Progressive diet ( clear liquid then full fluids, soft then regular diet) Anti emetics as ordered Early ambulation Avoid using straw Provide ice chips NGT insertion as needed Hold breath while taking a large swallow of water Breath in and out on a paper bag Anti emetics as ordered
Tympanities
Hiccups
Intermittent spasms of the diaphragm
- Abdominal distention - Absence of bowel sound - A sound “hic” that result from the vibration of closed vocal cords as air rushes suddenly into the lungs
Intestinal Obstruction ( 3rd-5th day postop)
Kink loop of intestines
- Intermittent sharp, colicky abdominal pains - Nausea & Vomiting - Abdominal distention - Hiccups - No bowel movement - Absence of stool elimination - Abdominal distention - Abdominal discomfort - Abdominal pain - Abdominal distention - Constipation - Absence of bowel sounds
NGT insertion as needed Administered IVF as ordered Prepare for possible surgery
Constipation
Paralytic Ileus
Infrequent or no stool passage for abnormal length of time ( within 48 hours after solid diet started ) Lack of peristaltic activity
Lack of dietary roughage Analgesics Immobility
Adequate hydration High fiber diet Encourage early ambulation
Due to anesthetics Immobility
Encourage early ambulation
WOUND Wound Infection
Inflammation and infection of incision or drain site
Poor aseptic techniques
- Fever ( 72 hours postop) - Redness, swelling , pain and warmth - Pus or discharge on the wound site - Foul smelling discharge
Keep wound clean and dry Surgical aseptic technique when changing dressing Antibiotic therapy
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- Increased incision drainage - Tissues underlying skin become visible
Wound Dehiscence
Separation of a suture line before the incision heals Malnutrition emaciation/obesity Excessive strain on suture line Poor circulation
Apply abdominal binders Encourage high protein diet and Vit.C intake Keep in bed rest
Wound Evisceration
Extrusion of internal organ or tissues through the incision
- Opening of incision and visible protrusion of organs
Semi-Fowlers, bend knees to relieve tension on the abdominal muscles Splinting on coughing Cover exposed organ with sterile , moist saline dressing Reassure, keep him/her quite and relaxed Prepare for surgery and repair of wound
PSYCHOLOGIC Postoperative Depression Altered Mood Weakness Surprise nature of “E” surgery News of malignancy Severely altered body image Dehydration Insufficient oxygenation Anemia Hypotension Hormonal Imbalances Infection Trauma - Anorexia - Tearfulness - Withdrawal - Rejection of others - Sleep disturbances - Poor memory - Restlessness - Inattentive - Inappropriate behavior - Wild excitement - Hallucination - Delusions - Disoriented - Sleep disturbances Adequate rest Physical activity Opportunity to express anger and other negative feelings
Delirium / Acute Confusional State
Sedatives to keep client quite and comfortable Explain reasons for interventions Listen and talk to the client Provide physical comfort
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STUDY HARD GOD BLESS YOU THANKS Mark Fredderick R. Abejo R.N, M.A.N Clinical Instructor
MS Perioperative Nursing
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According to URGENCY Classification Emergent – patient requires immediate attention, life threatening condition. Urgent / Imperative – patient requires prompt attention. Required – patient needs to have surgery. Elective – patient should have surgery. Optional – patient’s decision. Indication for Surgery Without delay Examples - severe bleeding - gunshot/ stab wounds - Fractured skull - kidney / ureteral stones - cataract - thyroid d/o - repair of scar - vaginal repair - cosmetic surgery
MEDICAL AND SURGICAL NURSING PERIOPERATIVE NURSING Lecturer: Mark Fredderick R. Abejo RN, MAN __________________________________________
Within 24 to 30 hours Plan within a few weeks or months Failure to have surgery not catastrophic Personal preference
PERIOPERATIVE NURSING
Perioperative Nursing – used to describe the nursing care provided in the total surgical experience of the patient: preoperative, intraoperative and 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, extends from the time the client 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, 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. 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.
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 Teeth extraction Circumcision Vasectomy Cyst removal Tubal ligation Surgical Risks Obesity Poor Nutrition Fluid and Electrolyte Imbalances Age
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 * Constructive – repair of congenitally defective organ. * Reconstructive – repair of damage organ Palliative – to relieve distressing sign and symptoms, not necessarily to cure the disease.
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Lecture Notes on Perioperative Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN
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Presence of Disease (Cardiovascular dse., DM, Respiratory dse. ) Concurrent or Prior Pharmacotherapy 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
Fear of Pain Fear of Death Fear of disturbance on Body image 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 Explore client’s feeling Allow client’s to speak openly about fears/concerns Give accurate information regarding surgery (brief, direct to the point and in simple terms) Give empathetic support Consider the person’s religious preference and arrange for visit by a priest / minister as desired.
PREOPERATIVE PHASE
Goals Assessing and correcting physiologic and psychologic problems that may increase surgical risk. Giving the person and significant others complete learning / teaching guidelines regarding surgery. Instructing and demonstrating exercises that will benefits the person during postop 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 & Fluid and Electrolyte Balance Cardiovascular / Pulmonary Function Renal Function Gastrointestinal / Liver Function Endocrine Function Neurologic Function Hematologic Function Use of Medication Presence of Trauma & Infection Routine Preoperative Screening Test Test CBC Rationale RBC,Hgb,Hct are important to the oxygen carrying capacity of blood. WBC are indicator of immune function. Determined in case blood transfusion is required during or after surgery. To evaluate fluid and electrolyte status Measure time required for clotting to occur. High level may indicate undiagnosed DM Evaluate renal function Evaluate liver function Evaluate nutritional status Determine urine composition Evaluate resp.status/ heart size Identify preexisting cardiac problem.
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 Consent Any surgical procedure where scalpel, suture, hemostats of electrocoagulation used. Entrance into body cavity. Radiologic procedures, particularly if a material is required. General anesthesia, local infiltration and block.
Blood grouping/ X matching Serum Electrolyte PT,PTT Fasting Blood Glucose BUN / Creatinine ALT/AST/LDH and Bilirubin Serum albumin and total CHON Urinalysis Chest Xray ECG
scissors, may be
contrast regional
Essential Elements of Informed Consent the diagnosis and explanation of the condition. a fair explanation of the procedure to be done and used and the consequences. a description of alternative treatment or procedure. a description of the benefits to be expected. material rights if any. the prognosis, if the recommended care, procedure is refused. Requisites for Validity of Informed Consent Written permission is best and legally accepted. Signature is obtained with the client’s complete understanding of what to occur.
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Psychosocial Assessment and Care Causes of Fears of the Preoperative Clients Fear of Unknown ( Anxiety ) Fear of Anesthesia
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- adult sign their own operative permit - obtained before sedation 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 For mentally ill and unconscious patient, consent must be taken from the parents or legal guardian If the patient is unable to write, an “X” ia 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.)
Interlace his fingers and place hands over the proposed incision site, this will act as a splint and will not harm the incision. Lean forward slightly while sitting in bed. Breath, using diaphragm Inhale fully with the mouth slightly open. Let out 3-4 sharp hacks. With mouth open, take in a deep breath and quickly give 1-2 strong coughs. Turning Changing positions from back to side-lying (vice versa ) stimulates circulation, encourages deeper breathing and relieve pressure areas Help the patient to move onto his side if assistance is needed. Place the uppermost leg in a more flexed position than that of the lower leg and place a pillow comfortably between the legs. Make sure that the patient is turned from one side to the back and onto the other side every 2 hours. Foot and Leg Exercise Moving the legs improves circulation and muscle tone. 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. Repeat above about 5 times with one leg and then with the other. Repeat the set 5 times every 3-5 hours. Then have the patient lie on one side and exercise the legs by pretending to pedal a bicycle. For foot exercise, trace a complete circle with the great toe. Turning to the Side Turn on your side with the uppermost leg flexed most and supported on a pillow. Grasp the side rails as an aid to maneuver to the side.
PREOPERATIVE 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 Preoperative Teaching Incentive Spirometry Encouraged to use incentive spirometer about 10 to 12 times per hour. Deep inhalations expand alveoli, which prevents atelectasis and other pulmonary complication. There is less pain with inspiratory concentration than with expiratory concentration. Diaphragmatic Breathing 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. In a semi-Fowlers position, with your hands loosefist, allow to rest lightly on the front of lower ribs. Breathe out gently and fully as the ribs sink down and inward toward midline. Then take a deep breath through the nose and mouth, letting the abdomen rise as the lungs fill with air. Hold breath for a count of 5. 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 5. Coughing Promotes removal of chest secretions.
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Lecture Notes on Perioperative Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN
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Preparing the Patient the Evening Before Surgery 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. Preparing the G.I tract - NPO, cleansing enema as required
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
PREOPERATIVE MEDICATIONS ASA (American Society of Anesthesiologists) Guidelines for Preoperative Fasting Liquid and Food Intake Clear Liquids Breast Milk Nonhuman Milk Light Meal Regular / Heavy Meals Minimum Fasting Period 2 4 6 6 8
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.
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 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.
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Lecture Notes on Perioperative Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN
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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
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
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INTRAOPERATIVE PHASE
Goal: Asepsis Homeostasis Safe Administration of Anesthesia Hemostasis
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. Communication System
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Surgical Environment 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 suit. 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 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
The Surgical Team Surgeon • 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 Assistant Surgeon • 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 • 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 • 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
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Environmental Safety • The 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 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.
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Circulating Nurse • 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. • 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.
Surgical Incisions Incision Site Butterfly Limbal Halstead / Elliptical Subcostal Paramedian Type of Surgery For craniotomy For eye surgeries For breast surgeries Gallbladder and biliary tract surgery Right side – gallbladder, biliary tract Left side - splenectomy Gastrectomy Right side – small bowel resection Left side – sigmoid colon resection Appendectomy Gynecologic surgery For kidney surgeries
Transverse Rectus
McBurney Pfannenstiel Lumbotomy
Principles of Surgical Asepsis 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 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) Medical Asepsis vs. Surgical Asepsis
Position During Surgery Position Type of Surgery Dorsal Recumbent Hernia repair, mastectomy, bowel resection Trendelenburg Pelvic Surgeries Lithotomy Vaginal repair, D&C, rectal surgery, APR Prone Spinal surgery, laminectomy Lateral Kidney, chest, hip surgery Jack Knife Position Rectal procedures, sigmoidoscopy and colonosc Reverse Trendelenburg Position Upper abdominal, head, neck and facial surgery
Explain the purpose of position Avoid undue exposure Strap the person to prevent falls Maintain adequate respiratory and circulatory functions. Maintain good body alignment
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 level - HR and BP - Urine output Types of Anesthesia 1. General Anesthesia reversible state consisting of complete loss of consciousness and sensation. protective reflexes such as cough and gag are lost provides analgesia, muscle relaxation and sedation. produces amnesia and hypnosis.
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Techniques used in General Anesthesia A. Intravenous Anesthesia This is being administered intravenously and extremely rapid. Its effect will immediately take place after thirty minutes of introduction. It prepares the client for smooth transition to the surgical anesthesia. B. Inhalation Anesthesia This comprises of volatile liquids or gas and oxygen. Administered through a mask or endotracheal tube 2. Regional Anesthesia temporary interruption of the transmission of nerve impulses to and from specific area or region of the body. achieved by injecting local anesthetics in close proximity to appropriate nerves. reduce all painful sensation in one region of the body without inducing unconsciousness. agents used are lidocaine and bupivacaine. Techniques used in Regional Anesthesia: A. Topical Anesthesia applied directly to the skin and mucous membrane, open skin surfaces, wounds and burns. readily absorbed and act rapidly used topical agents are lidocaine and benzocaine. B. Spinal Anesthesia ( Subarachnoid block ) local anesthetic is injected through lumbar puncture, between L2 and S1 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 anesthetic block conduction in spinal nerve roots and dorsal ganglia; paralysis and analgesia occur below level of injection agents used are procaine, tetracaine, lidocaine and bupivacaine. C. Epidural Anesthesia achieved by injecting local anesthetic into epidural space by way of a lumbar puncture. result similar to spinal analgesia agents use are chloroprocaine, lidocaine and bupivacaine.
E. Intravenous Block ( Beir block ) often used for arm,wrist and hand procedure an occlusion tourniquet is applied to the extremity to prevent infiltration and absorption of the injected IV agents beyond the involved extremity.
Indicating a site for insertion of the lumber puncture needle into the subarachnoid space of the spinal canal.
F. Caudal Anesthesia Is produced by injection of the local anesthetic into the caudal or sacral canal G. Field Block Anesthesia The area proximal to a planned incision can be injected and infiltrated with local anesthetic agents. Stages of Anesthesia Onset / Induction. Extends from the administration of anesthesia to the time of loss of consciousness. Excitement / Delirium. Extends from the time of loss of consciousness to the time of loss of lid reflex. Increase in autonomic activity and irregular breathing. It may be characterized by shouting, struggling of the client. Surgical. Extends from the loss of lid reflex to the loss of most reflexes. surgical procedure is started. Medullary / Stage of Danger. It is characterized by respiratory and cardiac depression or arrest. It is due to overdose of anesthesia. Resuscitation must be done.
D. Peripheral Nerve Block achieved by injecting a local anesthetic to anesthetize the surgical site. agents use are chloroprocaine, lidocaine and bupivacaine.
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Complication and Discomforts of Anesthesia Hypoventilation - inadequate ventilatory support after paralysis of respiratory muscles. Oral Trauma Malignant Hyperthermia Hypotension - due to preoperative hypovolemia or untoward reactions to anesthetic agents. Cardiac Dysrhythmia - due to preexisting cardiovascular compromise, electrolyte imbalance or untoward reaction to anesthesia. Hypothermia - due to exposure to a cool ambient OR environment and loss of thermoregulation capacity from anesthesia. Peripheral Nerve Damage - due to improper positioning of patient or use of restraints. Nausea and Vomiting Headache
POSTOPERATIVE PHASE
Goals: Maintain adequate body system functions Restore homeostasis Alleviate pain and discomfort Prevent postop complication Ensure adequate discharge planning and teaching.
PACU CARE
Transport of client from OR to RR avoid exposure avoid rough handling avoid hurried movement and rapid changes in position.
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Initial Nursing Assessment Verify patient’s identity, operative procedure and the surgeon who performed the procedure. Evaluate the following sign and verify their level of stability with the anesthesiologist: - Respiratory status - Circulatory status - Pulses - Temperature - Oxygen Saturation level - Hemodynamic values Determine swallowing and gag reflex , LOC and patients response to stimuli. Evaluate lines, tubes, or drains, estimate blood loss, condition of wound, medication used, transfusions and output. Evaluate the patient’s level of comfort and safety. Perform safety check; side rails up and restraints are properly in placed. Evaluate activity status, movement of extremities. Review the health care provider’s orders. Initial Nursing Interventions Maintaining a Patent Airway Allow the airway ( ET tube ) to remain in place until the patient begins to waken and is trying to eject the airway. The airway keeps the passage open and prevents the tongue from falling backward and obstructing the air passages. Aspirate excessive secretions when they are heard in the nasopharynx and oropharynx. Assessing Status of Circulatory System Take VS per protocol, until patient is well stabilized. Monitor intake and output closely. 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 Place the patient in lateral position with neck extended ( if not contraindicated ) and upper arm supported on a pillow. Turn the patient every 1 to 2 hours to facilitate breathing and ventilation. Encourage the patient to take deep breaths, use an incentive spirometer. Assess lung fields frequently by auscultation. Periodically evaluate the patient’s orientation – response to name and command. Note: Alterations in cerebral function may suggest impaired O2 delivery. Administer humidified oxygen if required.
MS Perioperative Nursing
Use mechanical ventilation to maintain adequate pulmonary ventilation if required. Assessing Thermoregulatory Status Monitor temperature per protocol to be alert for malignant hyperthermia or to detect hypothermia. Report a temperature over 37.8 C or under 36.1 C Monitor for postanesthesia shivering, 30-45 minutes after admission to the PACU. Provide a therapeutic environment with proper temperature and humidity. Maintaining Adequate Fluid Volume Administer I.V solutions as ordered. Monitor evidence of F&E imbalance such as N&V and weakness. Evaluate mental status, skin color and turgor 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 Monitor I&O Minimizing Complications of Skin Impairment Perform handwashing before and after contact with the patient Inspect dressings routinely and reinforce them if necessary. Record the amount and type of wound drainage. Turn patient frequently and maintain good body alignment. Maintaining Safety Keep the side rails up until the patient is fully awake. Protect the extremity into which I.V fluids are running so needle will not become accidentally dislodged. Avoid nerve damage and muscle strain by properly supporting and padding pressure areas. 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. Check dressing for constriction Promoting Comfort Assess pain by observing behavioral and physiologic manifestations. Administer analgesic and document efficacy. Position the patient to maximize comfort.
Parameter for Discharge from PACU/RR Activity. Able to obey commands Respiratory. Easy, noiseless breathing Circulation. BP within 20mmHg of preop level Consciousness. Responsive Color. Pinkish skin and mucus membrane
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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
Goals: o Restore homeostasis and prevent complication. o Maintain adequate cardiovascular and tissue perfusion. o Maintain adequate respiratory function. o Maintain adequate nutrition and elimination. o Maintain adequate fluid and electrolyte balance. o Maintain adequate renal function. o Promote adequate rest, comfort and safety. o Promote adequate wound healing. o Promote and maintain activity and mobility. o Provide adequate psychological support.
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STI Global City College of Nursing / QMMC Surgery Ward Exposure Lecture Notes on Perioperative Nursing Prepared By: Mark Fredderick R Abejo R.N Clinical Instructor
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WOUND CARE Frequently used Dressing Materials
Common dressing
Irrigating a wound
Montgomery Straps holding 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 a wound outward from the incision Cleaning from top to bottom Starting at the center Cleaning around a Penrose drain site
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INCISION SUPPORTING
BODY PRESSURE AREAS:
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STI Global City College of Nursing / QMMC Surgery Ward Exposure Lecture Notes on Perioperative Nursing Prepared By: Mark Fredderick R Abejo R.N Clinical Instructor
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POST OPERATIVE COMPLICATIONS
Problem RESPIRATORY Pneumonia Inflammation of the lung parenchyma / alveoli Infection Toxin / irritants causing inflammatory process Cause by streptococcus pneumoniae / Staphylococcus aureus Immobility Impaired ventilation Aspiration of gastric contents, food Mucous plugs blocking bronchial passageways Inadequate lung expansion Immobility - elevated temp. - cough - blood tinged sputum - dyspnea - chest pain Deep breathing exercises Coughing exercise Early ambulation Description Cause Clinical Signs Nursing Intervention
Infectious Pneumonia
Hypostatic Pneumonia
Aspiration Pneumonia Atelectasis A condition in which alveoli collapsed and are not ventilated
- Fever ( 1st 24 hours) - Dyspnea - Tachycardia - Diaphoresis - Pleural pain - Dull or absent lung sounds - Dec. SaO2 - Sudden chest pain - SOB - Cyanosis - Tachycardia - Low BP
Deep breathing exercises Coughing exercise Early ambulation
Pulmonary Embolism
Blood clot that has moved to the lungs and blocks a pulmonary artery and obstruct blood flow to the lungs
Immobility Use of oral contraceptives Coagulation problem
Turning Ambulation Anti embolic stockings Compression devises Prevent massaging the lower extremities
CIRCULATION Hypovolemia Inadequate circulating blood volume Internal or external bleeding Capillary – slow generalized oozing Venous – dark in color and bubble out Arterial – spurts, bright red in color
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Hemorrhage Fluid deficit
Hemorrhage
Disruption of sutures Insecure ligation of blood vessels
- Tachycardia - Dec. urine output - Dec. BP - Cold, moist and pale skin - Deep, rapid RR - Low temp - Increase pain - Inc. abd. girth - Swelling or bruising around incision
Fluid and blood replacement
Fluid and blood replacement Vit.k and hemostat Ligation of bleeders Pressure dressing
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Overt Bleeding - Dressing saturated with bright blood - Bright, freeflowing blood in drains or tubes. Thrombophlebitis Inflammation of the veins, usually of the legs and associated with a blood clot. Slowed venous blood flow due to immobility or prolonged sitting Trauma to the vein Increased blood coagulability. - Homan’s Sign pain, discomfort in calf when foot is dorsiflexed - Aching, cramping pain - Swollen, red and hot to touch - Vein feels hard Arterial - Pain - Pallor on the affected extremities - Dec./absent of peripheral pulse Note: Embolus in the venous system usually becomes a pulmonary embolus Early ambulation Anti embolic stocking Encourage leg exercise Hydrate adequately Avoid any restricting devices that impaired circulation Avoid massage on the calf of the leg Initiate anticoagulant therapy
Thrombus
Blood clot attached to wall of vein or artery
Embolus
Foreign body or clot that has moved from its site of formation to another area of the body
Broken IV catheter Fat Amniotic fluid
Careful maintenance of IV catheters
URINARY Urinary Retention
Inability to empty the bladder, with excessive accumulation of urine in the bladder
Urinary Incontinence Urinary Tract Infection
Inability of the bladder to hold accumulated urine Inflammation of the bladder, ureters or urethra
Depressed bladder muscle tone from narcotics and anesthetics Handling of tissue during surgery on adjacent organs Spasm of the bladder sphincter Loss of tone of the bladder sphincter Immobilization Limited fluid intake
- Larger fluid intake than output - Inability to void - Bladder distention - Suprapubic discomfort - Restlessness - 30 – 60 ml of urine q 15-30 mins - Fever ( 48 hours postop) - Burning sensation when voiding - Urgency - Cloudy urine - Lower abdominal pain
Monitor I & O Interventions to facilitate voiding Urinary Catheterization as needed
Monitor I & O
Adequate fluid intake Early ambulation Aseptic catheterization as needed Good perineal hygiene
MS Perioperative Nursing
Abejo
STI Global City College of Nursing / QMMC Surgery Ward Exposure Lecture Notes on Perioperative Nursing Prepared By: Mark Fredderick R Abejo R.N Clinical Instructor
16
GASTROINTESTINAL Nausea and Vomiting Pain Abdominal distention Ingestion of fluid or food before the return of peristalsis Retention of gases within the intestines Slowed motility of the intestines due to effects of anesthesia Irritation of phrenic nerve bet. the spinal cord and terminal ramifications on undersurface of the diaphragm Abdominal distention Due to inflammatory adhesions - Complaints of feeling sick to the stomach - Retching - Gagging IV fluids until peristalsis returns Progressive diet ( clear liquid then full fluids, soft then regular diet) Anti emetics as ordered Early ambulation Avoid using straw Provide ice chips NGT insertion as needed Hold breath while taking a large swallow of water Breath in and out on a paper bag Anti emetics as ordered
Tympanities
Hiccups
Intermittent spasms of the diaphragm
- Abdominal distention - Absence of bowel sound - A sound “hic” that result from the vibration of closed vocal cords as air rushes suddenly into the lungs
Intestinal Obstruction ( 3rd-5th day postop)
Kink loop of intestines
- Intermittent sharp, colicky abdominal pains - Nausea & Vomiting - Abdominal distention - Hiccups - No bowel movement - Absence of stool elimination - Abdominal distention - Abdominal discomfort - Abdominal pain - Abdominal distention - Constipation - Absence of bowel sounds
NGT insertion as needed Administered IVF as ordered Prepare for possible surgery
Constipation
Paralytic Ileus
Infrequent or no stool passage for abnormal length of time ( within 48 hours after solid diet started ) Lack of peristaltic activity
Lack of dietary roughage Analgesics Immobility
Adequate hydration High fiber diet Encourage early ambulation
Due to anesthetics Immobility
Encourage early ambulation
WOUND Wound Infection
Inflammation and infection of incision or drain site
Poor aseptic techniques
- Fever ( 72 hours postop) - Redness, swelling , pain and warmth - Pus or discharge on the wound site - Foul smelling discharge
Keep wound clean and dry Surgical aseptic technique when changing dressing Antibiotic therapy
MS Perioperative Nursing
Abejo
STI Global City College of Nursing / QMMC Surgery Ward Exposure Lecture Notes on Perioperative Nursing Prepared By: Mark Fredderick R Abejo R.N Clinical Instructor
17
- Increased incision drainage - Tissues underlying skin become visible
Wound Dehiscence
Separation of a suture line before the incision heals Malnutrition emaciation/obesity Excessive strain on suture line Poor circulation
Apply abdominal binders Encourage high protein diet and Vit.C intake Keep in bed rest
Wound Evisceration
Extrusion of internal organ or tissues through the incision
- Opening of incision and visible protrusion of organs
Semi-Fowlers, bend knees to relieve tension on the abdominal muscles Splinting on coughing Cover exposed organ with sterile , moist saline dressing Reassure, keep him/her quite and relaxed Prepare for surgery and repair of wound
PSYCHOLOGIC Postoperative Depression Altered Mood Weakness Surprise nature of “E” surgery News of malignancy Severely altered body image Dehydration Insufficient oxygenation Anemia Hypotension Hormonal Imbalances Infection Trauma - Anorexia - Tearfulness - Withdrawal - Rejection of others - Sleep disturbances - Poor memory - Restlessness - Inattentive - Inappropriate behavior - Wild excitement - Hallucination - Delusions - Disoriented - Sleep disturbances Adequate rest Physical activity Opportunity to express anger and other negative feelings
Delirium / Acute Confusional State
Sedatives to keep client quite and comfortable Explain reasons for interventions Listen and talk to the client Provide physical comfort
MS Perioperative Nursing
Abejo
STI Global City College of Nursing / QMMC Surgery Ward Exposure Lecture Notes on Perioperative Nursing Prepared By: Mark Fredderick R Abejo R.N Clinical Instructor
18
STUDY HARD GOD BLESS YOU THANKS Mark Fredderick R. Abejo R.N, M.A.N Clinical Instructor
MS Perioperative Nursing
Abejo
