Periop Slides.edt

Definition of Perioperative Nursing The provision of nursing care by an RN preoperatively, intraoperatively, and postoperatively to a patient undergoing an operative or invasive procedure.

Areas in Which Perioperative Nursing Is Practiced • Perioperative nursing is practiced in – Hospital operating rooms – Interventional radiology suites – Cardiac catheterization labs – Endoscopy suites – Ambulatory surgery centers – Trauma centers – Pediatric specialty hospitals – Physician offices

Functions of the Perioperative Nurse • • • • •

Advocate Protector Teacher Change agent Manager of patient care

Nursing Roles in the OR – Circulating Nurse – Scrub person – RN first assistant (RNFA) – Perioperative educator – Specialty team leader – Perioperative manager

Surgical Attire • • • • • •

Gowns Gloves Masks Hair covering Protective eyewear Surgical shoe covers

Goals of Patient Safety

• Provide safe patient care – Knowledge of procedure – Ensure the correct patient, correct site, correct level, and correct procedure – Knowledge of positioning – Adhere to safe medication administration guidelines – Perform surgical counts

• Provide a safe environment – Adhere to asepsis – Promote coordinated and effective communication

Phases of Perioperative period • PRE- operative phase • INTRA- operative phase • POST- operative phase

PRE-Operative Phase • Begins when the decision to have surgery is made and ends when the client is transferred to the operating table

INTRA-Operative Phase • Begins when the client is transferred to the operating table and ends when the client is admitted to the post-anesthesia unit

Post-operative Phase • Begins with the admission of the client to the PACU and ends when healing is complete

Activities in the Pre-op • Assessing the clients • Identifying potential or actual health problems • Planning specific care • Providing pre-operative teaching • Ensure consent is signed

Consent • The surgeon is responsible for obtaining the consent for surgery • No sedation should be administered before SIGNING the consent • The nurse may serve as witness

Activities during the Intra-op

Assisting the surgeon as scrub nurse and circulating nurse

Activities in the POST-op • Assessing responses to surgery • Performing interventions to promote healing • Prevent complications • Planning for home-care • Assist the client to achieve optimal recovery

TYPES of SURGERY • According to PURPOSE • According to degree of URGENCY • According to degree of RISK

According to PURPOSE Diagnostic

Establishes a diagnosis

Palliative

Relieves or reduces pain or symptoms

Ablative

Removes a diseased body part

Constructive

Restores function or appearance

Transplant

Replaces malfunctioning structures

According to degree of urgency Emergency surgery

Preserves function or life Performed immediately

Elective surgery

Performed when condition is not imminently life threatening

According to degree of RISK Major Surgery

Involves high degree of risk Complicated or prolonged

Minor Surgery

Involves low risk Produces few complications Performed as day surgery

Classification I.Emergent life threatening II Urgent III. Required IV. Elective V. Optional

Indication for surgery Without delay

examples trauma

24-30 hrs

AP, Cholecystitis Plan within Cataracts, weeks or month thyroid No emergency CS, hernia Personal preference

Cosmetic surgery

Health factors that affect preoperatively • • • • • • • • • •

Nutritional status Drug or alcohol abuse Respiratory status Cardiovascular status Hepatic and renal Factors Endocrine Function Immune function Previous medication use Psychosocial factors Spiritual and cultural beliefs

Surgical Risk • • • • •

Extremes of age Malnourished Obese Co-morbid conditions Concurrent medications

Pre-operative Interventions • Ensure signed consent form • Obtain nursing history, PE and lab exam • Provide pre-operative teaching as to the nature of surgery, what to expect and ways to manage post-operative discomforts • Perform physical preparations- shaving, hygiene, enema, NPO, medications

Pre-op nutrition • Assess order for NPO • Solid foods are withheld for about 8 hours before general anesthesia

Pre-op elimination • Laxatives, enemas or both may be prescribed the night before surgery • Have the client void immediately BEFORE transferring them to the OR • Foley catheter may be inserted as ordered

Pre-op hygiene • Bathe the night before surgery with antiseptic soap • Shaving of the skin is usually done in the OR • Removal of jewelry and nail polish

Pre-op psychological preparation • Be alert to the client’s anxiety level • Answer questions or concerns • Allow time for privacy

• Preparing the skin • Administering Preanesthetic medications • Transporting the patient to the presurgical area

Pre-operative medications Pre-op Drugs Example

Purpose

Anti-anxiety Diazepam

To decrease nervousness Promote relaxation Decreases secretions Prevent bradycardia

Anticholinergic Muscle relaxant Anti-emetic

Atropine

Antibiotic

Cephalosporin To prevent infection

Succinylcholine

To promote muscle relaxation

Promethazine

To prevent nausea and vomiting

Pre-operative medications Pre-op Drugs

Example

Purpose

To decrease pain and decrease anesthetic dose Diphenhydramine To decrease occurrence of allergy

Analgesics Meperidine Antihistamine

H-2 antagonist

Cimetidine

To decrease gastric fluid and acidity

Pre-operative screening test CBC

Determine Hgb and Hct, infection

Blood type Serum electrolytes FBS

Determined in case of blood transfusion Evaluates the fluid and electrolyte status Evaluates diabetes mellitus

BUN, Creatinine

Assess the renal function

ALT, AST, Bilirubin Serum albumin

Evaluates the liver function

CXR and ECG

Respiratory and Cardiac status

Evaluates nutritional status

Pre-operative teaching Leg exercises

To stimulate blood circulation • Pre-operative teaching in the extremities to prevent thrombophlebitis

Deep breathing and Coughing Exercises

To facilitate lung aeration and secretion mobilization to prevent atelectasis and hypostatic pneumonia Done every two to four hours

Positioning and Ambulation

To stimulate circulation, stimulate respiration, decrease stasis of gas

ARE YOU READY FOR YOUR OPERATION?

Intra-operative phase interventions • Determine the type of surgery and anesthesia used • Position client appropriately for surgery • Assist the surgeon as circulating or scrub nurse • Maintain the sterility of the surgical field • Monitor for developing complications

Basic Guidelines in Surgical Asepsis • All materials in contact with the surgical wound and used within the sterile field must be sterile. • Gowns are considered sterile in front from the chest to the level of the sterile field. • Sterile drape • Items should be dispensed to a sterile field by methods that preserve the sterility

• Movement of the surgical team are from sterile to sterile and from unsterile to unsterile area. • When a sterile barrier is breached, the area , must be considered contaminated

PUT CAP AND MASK FIRST BEFORE SCRUBBING

THIS IS HOW TO SCRUB

USE FOOT PADDLE OR ELBOW IN OPENING OR CLOSING FAUCET AND SOAP DISPENSER

ASSISTING IN GLOVING

CIRCULATING NURSE ASSISTING THE SCRUB NURSE

• state of narcosis (severe CNS depression produced by pharmacological agents), analgesia, relaxation and reflex loss • loses the ability to maintain ventilatory function and require assistance in maintaining a patent airway. • Cardiovascular function may be affected as well

Anesthesia • General anesthesia – Loss of all sensation and consciousness

• Regional or Local anesthesia – Loss of sensation in ONE area with consciousness present

Minimal sedation - drug induced state in which a patient can respond normally in verbal commands - cognitive function and coordination may be impaired

Moderate sedation - depressed level of consciousness that does not impair ability to maintain a patent airway - calm, sedate a patient combined with analgesic - Midazolam/Diazepam

Deep Sedation - a drug induced state in which a patient cannot be easily aroused but can respond purposefully after repeated stimulation - inhaled or intravenous - Volatile anesthetic (halothane, Isoflurane) - Gas anesthetic (Nitrous oxide)

Stages • Stage I (Beginning Anesthesia) - patient may have ringing, still conscious, sense inability to move extremities - noises are exaggerrated - avoid unnecessary noises or motions

• Stage II: Excitement - Characterized by struggling, shouting, talking, crying. - pupils dilate, rapid pulse and irregular RR - restrain the patient • Stage III - Surgical anesthesia is reached - pt unconscious and lies quietly - respirations are regular and CR - may be maintained in hours if properly given

• Stage IV: Medullary Depression - stage is reached when too much anesthesia is given - RR becomes shallow, pulse is weak and thready, pupils widely dilated - Without proper treatment death will follow - Discontinue anesthetic abruptly

Methods of Anesthesia Administration • • • • •

Inhalation Intravenous Regional Anesthesia Conduction and spinal anesthesia Local Infiltration

GENERAL Anesthesia • Protective reflexes are lost • Amnesia, analgesia and hypnosis occur • Administered in two ways: – Inhalational – Intravenous

REGIONAL Anesthesia TOPICAL

Applied directly on the skin

INFILTRATION

Injected into a specific area of skin

NERVE BLOCK

Injected around a nerve

SPINAL Subarachnoid

Low spinal anesthesia

EPIDURAL

Epidural space is injected with anesthesia

Potential adverse effects of anesthesia • • • • • • • • •

Myocardial depression, bradycardia Nausea and vomiting anaphylaxis CNS agitation, seizures, respiratory arrest Oversedation or under sedation Agitation and disorientation Hypothermia Hypotension Malignant hyperthermia

Patient Positioning • Provides optimal visualization • Provides optimal access for assessing and maintaining anesthesia and function • Protects patient from harm

Position Patient during Surgery Abdominal surgeries

Supine

Bladder surgery

Slightly trendelenburg

Perineal surgery

Lithotomy

Brain surgery

Semi-fowler’s

Spinal cord surgeries

Prone mostly

Lumbar puncture

Side lying, flexed body

Operating Room Team direct patient care team • The team is likely a symphony orchestra • Each person is an integral entity in harmony with his colleagues 5. THE STERILE TEAM 6. THE UNSTERILE TEAM

SCRUB OUT !!!

The Sterile Team – Operating surgeon – Assistants to the surgeon – Scrub person – They: • scrub their hands and arms • Don sterile gloves and gown • Enter the sterile field (all items for the surgical procedure are sterilized)

The Unsterile Team – Anesthesiologist or anesthetist – Circulating nurse – Technicians – They: • Don’t enter the sterile field • Function outside of it • Maintain sterile technique

Functions of the nurse during OR procedure

SCRUB NURSE •Assists the surgeon

CIRCULATING NURSE

•Maintains sterility •Handles instruments •Drapes patient •Counts sponges •Wears sterile gown, gloves •Assists the Scrub nurse •Positions the patient for surgery • Positions any equipment

Scrub Nurse – Maintain safety of the sterile field – Knows the sterile and aseptic technique – Prepares the instruments – Assists the surgeon with the instruments – PRIVATE SCRUB NURSE (employed by the surgeon)

Circulating Nurse – Monitors/coordinates all activities – Controls the physical and emotional atmosphere in the room

POST Operative Interventions • Maintain patent airway • Monitor vital signs and note for early manifestations of complications • Monitor level of consciousness • Maintain on PROPER position • NPO until fully awake, with passage of flatus and (+) gag reflex

POST Operative Interventions • • • • • •

Monitor the patency of the drainage Maintain intake and output monitoring Care of the tubes, drains and wound Ensure safety by side rails up Pain medication given as ordered Measures to PREVENT post-op Complications

Post-operative interventions PAIN MANAGEMENT • Pain is usually greatest during the 1236 hours after surgery • Narcotic analgesics and NSAIDS may be prescribed together for the early period of surgery • Provide back rub, massage, diversional activities, position changes

Post operative interventions POSITIONING • Clients who have spinal anesthesia is usually placed FLAT on bed for 8-12 hours • Unconscious client is placed side lying to drain secretions • Other positions are utilized BASED on the type of surgery

Post-operative Interventions Some Examples of Position Post Op Mastectomy

Hemorrhoidectomy

Semi-fowlers’, affected arm elevated Semi fowlers’, head midline Semi-prone, side-lying

Laryngectomy

Fowler’s

Pneumonectomy

Lateral, affected side

Lobectomy

Lateral, unaffected side

Thyroidectomy

Post-operative Interventions Some Examples of Position Post Op Aneurysmal repair (abdomen) Amputation of lower extremities Cataract surgery

Fowler’s 45 degrees

Supratentorial craniotomy Infratentorial craniotomy Spina bifida repair

Fowlers’

Flat, with stump elevated with pillow Fowler’s 45 degrees

Flat on bed, supine Prone

Post-operative Interventions • Deep breathing and coughing exercises Q2-4 hours  to remove secretions • Leg exercises Q 2 hours  to promote circulation • Ambulation ASAP prevents respiratory, circulatory, urinary and gastrointestinal complications

Post-operative Interventions

• Hydration after NPO to maintain fluid balance • Suction, either gastro or respiratory to relieve distention, to remove respiratory secretions • Diet progressive, usually given when bowel sounds and gag reflex return

Wound Care • Inspect dressing hourly • Change dressing daily • Inspect for signs of infection redness, swelling, purulent exudate • Maintain wound drainage

Diet • NPO usually immediately after surgery • Progressive diet • Assess the return of the bowel sounds

Liquid Diet Vs Soft diet Clear liquid Coffee Tea Carbonated drink Bouillon Clear fruit juice Popsicle Gelatin Hard candy

Full liquid Clear liquid PLUS: Milk/Milk prod Vegetable juices Cream, butter Yogurt Puddings Custard Ice cream and sherbet

Soft diet All CL and FL plus: Meat Vegetables Fruits Breads and cereals Pureed foods

Urinary Elimination • Offer bedpans • Allow patient to stand at the bedside commode if allowed • Report to surgeon if NO URINE output noted within 8 hours post-op

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

Chest Physiotherapy

Incentive Spirometry • This operates on the principle that spontaneous sustained maximal inspiration is most beneficial to the lungs and has virtually no adverse effects. • The incentive spirometer measures roughly the inspired volume and offers the “incentive” of measuring progress

Incentive Spirometry

Post operative complications Atelectasis

Pneumonia

•Assess breath Collapsed alveoli due to sounds •Repositioning secretions

Inflammation of alveoli

Thrombophlebitis Inflammation of the veins

•Deep breathing and coughing •Chest physio •Suctioning •Ambulation •Leg exercises •Monitor for swelling •Elevated extremities

Post-operative Complications Hypovolemic Loss of Shock circulatory fluid volume

•Determine cause and prevent bleeding •O2, IVF

Urinary retention

Involuntary accumulation of urine

•Encourage ambulation •Provide privacy •Pour warm water •Catheterize

Pulmonary embolism

Embolus blocking the lung blood flow

•Notify physician •Administer O2

Post-operative complications Constipation

Infrequent passage of stool

Paralytic ileus

Absent bowel sound

Wound infection

•High fiber diet •Increased fluid •Ambulation

•Encourage ambulation •NPO until peristalsis returns Occurs about 3 •Daily wound days after dressing surgery •Antibiotics •Maintain drain

Post-operative complications Wound dehiscence

Wound evisceration

•Cover the wound with sterile normal saline dressing •Place in lowFowler’s •Notify MD •Cover the wound Protrusion of with saline pad the internal •Place in loworgans and tissues through fowler’s •Notify MD wound

Separation of wound edges at the suture line

Wound dehiscence

Wound evisceration

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

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

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