Perioperative Nursing

PERIOPERATIVE NURSING Perioperative Nursing Practice- includes those activities performed by the registered nurse during the preoperative, intraoperative and postoperative phase of the patients surgical experience. It encompasses the patient’s total experience when surgical intervention is accepted as the treatment of choice. Perioperative- refers to events during the entire surgical period, from preparation for surgery to recovery from the temporary effects of surgery and anesthesia. This period is divided into preoperative, intraoperative and postoperative phases.

Preoperative phase- starts when the patient is admitted to the surgical floor and prepare him physically, psychologically, spiritually and legally for the surgical procedure until he is transported to the operating room.

Intraoperative phase- is when the patient is transferred to the operating room where he is anesthetized and undergoes the scheduled surgical procedure.

Postoperative phase- is the time during which the patient is transferred to the recovery room/post anesthesia unit where the nurse assist and observes the patient as he recovers from anesthesia and from the stress of surgery itself; to the time he is transferred back to the surgical floor, discharged from the hospital until the follow-up care. ESTIMATION OF SURGICAL RISKS General Risks factors:  Obesity  Fluid and Electrolyte and Nutritional problems  Presence of diseases  Concurrent or prior pharmacotherapy

Edison O. Dangkeo, RN

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Other factors:  Nature of condition  Location of the condition  Magnitude and urgency of the surgical procedure  Mental attitude of the person toward surgery  Caliber of the professional staff and health care facilities The effects of surgery upon the patient:  Stress response is elicited.  Defense against infection is lowered.  Vascular system is disrupted.  Organ functions are disturbed.  Body image may be disturbed.  Lifestyle might change. GENERAL CONSIDERATIONS: a) Basic Types of Pathologic Conditions Requiring Surgery  Obstruction  Perforation  Erosion  Tumors b) Major Categories of Surgical Procedures (according to:) 1) Purpose  Diagnostic 

Curative •

Ablative

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Constructive

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Reconstructive

 Palliative

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2) Degree of Risk  Major Surgery  Minor Surgery 3) Urgency

 Emergency – to be done immediately in order to; •

save the life of the patient

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save the function of an organ or limb

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removed a damaged organ or limb as necessary

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stop hemorrhage

 Imperative or Urgent  Planned Required  Elective  Optional  Day (ambulatory surgery)

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PREOPERATIVE PHASE  Goals 

Assessment & Correction of physiologic & psychological problems that may increase surgical risks.

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

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Instructing & demonstrating exercises that will benefit the person during the postoperative period.

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

 Physiologic Assessment 

Age

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Presence of pain

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Nutritional Status

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Fluid & Electrolyte Balance

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Infection

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Cardiovascular Function

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Pulmonary Function

 Liver Function 

Gastrointestinal Function

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Liver Function

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Endocrine Function

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Neurologic Function

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Hematologic Function

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Use of Medication

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Presence of Trauma

 Psychosocial Assessment & Care 

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Causes of Fears of Preoperative Patients: 

Fear of the unknown

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Fear of Anesthesia

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Fear of pain

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Fear of death

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Fear of Disturbance of Body Image

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Worries

Manifestations of Fear 

Anxiousness

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Bewilderment

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Anger

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Tendency to exaggerate

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Sad, evasive, tearful, clinging

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Inability to concentrate

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Short attention span

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Failure to carry out simple directions

 Nursing Interventions to Minimize Anxiety 

Explore patient’s feelings

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Allow patient to speak openly about fears/concerns

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Give accurate information regarding surgery

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Give empathetic support

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

 Informed Consent (Operative Permit/Surgical Consent)

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

Purposes:

 To ensure that the patient understands the nature of the treatment including the potential complications and disfigurement.  To indicate that the patient’s decision was made without pressure.  To protect the client against unauthorized procedure.  To protect the surgeon and the hospital against legal action by a client who claims that an unauthorized procedure was performed. 

Circumstances Requiring a Permit  Any surgical procedure where scalpel, scissors, suture, thermostats electro coagulation may be used.  Entrance into a body cavity.  General anesthesia, local infiltration, local anesthesia.

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Requisites for validity of informed consent  Written permission is best and is legally acceptable.  Signature is obtained with the client’s complete understanding of what is to occur.  Secured without pressure.  A witness is desirable.  For minor (below 18 years old), unconscious, psychologically incapacitated, permission is required from responsible family member (parent/legal guardian).

 

Physical Preparation

Before Surgery

 Correct any dietary deficiencies  Reduce an obese person’s weight  Correct fluid and electrolyte imbalances  Restore adequate blood volume with blood transfusion

Edison O. Dangkeo, RN

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 Treat chronic diseases – DM, heart disease, renal insufficiency  Halt or treat any infectious process  Treat an alcoholic person with vitamin supplementation, IVF or oral fluids if dehydrated. Teaching preop exercises

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Deep breathing exercises

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Incentive spirometry

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Coughing exercises

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Turning exercises

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Foot and leg exercises Preparing the patient the evening before surgery

 Preparing the skin – have full bath to reduce microorganisms in the skin.  Preparing the G.I. tract – NPO cleansing enema as required.  Preparing for anesthesia – avoid alcohol and cigarette smoking for at least 24 hours before surgery.  Promoting sleep – administer sedatives as ordered. 

Preparing the patient on the day of surgery

Early Morning Care:  Awaken one hour before preop medications  Morning bath, mouth wash  Provide clean gown  Remove hairpins, braid long hairs, cover hair with cap  Remove dentures, foreign materials, colored nail polish, hearing aid, contact lens, wedding ring – tie with gauze and tie around the wrist.  Check ID band, skin prep

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

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 Check NPO  Have patient void before preop medication  Check baseline V/S before preop medication  Continue to support emotionally  Accomplish “preop care checklist” Preoperative medication/preanestheic drugs

 A. Goals:

1. To allay anxiety 2. To decrease the flow of pharyngeal secretions 3. Reduce the amount of anesthesia given 4. Create amnesia for the events that precede surgery. B. Types of preoperative medications: 1. Tranquilizers 2. Sedatives 3. Analgesics 4. Anticholinergics 5. Histamine – H2 Receptor Antagonist

C. Recording – all final preparation and emotional responses before surgery are noted down. 

Transporting the patient to the Operating Room

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Patient’s Family

o

Direct proper visiting room

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Doctor informs the family immediate after surgery

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Explain reason for long interval of waiting

o Explain what to expect postoperatively *** Nursing Diagnosis for a Preoperative Patient***

Edison O. Dangkeo, RN

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Anxiety related to lack of knowledge about preoperative routines, physical preparations for surgery, postoperative care and potential body image change.

INTRAOPERATIVE PHASE  Goals  Asepsis  Homeostasis  Safe administration of Anesthesia  Hemostasis  The Surgical team  The surgeon  The Anesthesiologist  The Circulating Nurse  The Scrub Nurse  Direct Assistant to the Surgeon

 Commonly Used Operative Positions  Dorsal Recumbent (Supine) – coronary artery bypass, hernia repair, explor lap, cholecystectomy, mastectomy, bowel resection, etc.

Edison O. Dangkeo, RN

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 Prone – for back and rectal surgery.  Trendelenburg – head and body are flexed by “breaking the table”. This position permits displacement of the intestines into the upper abdomen and is often used during surgery of the lower abdomen or pelvis.  Reverse Trendelenburg – head is elevated and feet are lowered.  Lithotomy – thighs and legs are flexed at right angles and then simultaneously placed to stirrup. This position exposes the perineal area and is ideal for perineal repairs, dilatation and curretage and most abdomino-perineal resection. (APR)  Lateral – used in kidney, chest and hip surgeries.  Laminectomy positions – used during surgical procedures involving the spine.  Other position: Thyroidectomy – head is hyperextended, a small sand bag, pillow on neck and shoulders to provide exposure of thyroid gland. Nursing Management:  Explain purpose of the position.  Avoid undue exposure.  Strap the patient to prevent falls.  Maintain adequate respiratory and circulatory function.  Maintain good body alignment.

ASSISTING WITH SURGICAL WOUND CLOSURE Skin closure (sutures) are used to approximate wound edges until wound healing is complete or to occlude the lumen or a blood vessel. A contaminated wound may be left open or partially open. The surgical wound is closed with:  Sutures  Staples

Edison O. Dangkeo, RN

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 Skin closure strips  Retention sutures  Zipper-like devices After the incision is closed, a dressing is applied:  To prevent wound contamination.  Absorb drainage.  To provide support for the incision. If healing progresses without complications, the sutures, clips, and staples are usually removed after 7-10 days. ASSESSING DRAINAGE A drain is placed in the incision to drain blood, serum and debris from the operative site. Drains may be free draining, attached to suction or self-contained drainage with suction. Nursing Interventions: •

Maintenance of pulmonary ventilation (patent airway and adequate respiratory function)

 Position patient to lateral position with neck extended.  Keep airway in place until fully awake.  Suction secretions.  Encourage deep breathing.  Administer humidified oxygen as ordered. •

Maintenance of circulation

 Monitor vital signs and report abnormalities.  Observe signs and symptoms of shock and hemorrhage.  Promote comfort and maintain safety.  Continuous constant surveillance of the patient until completely out of anesthesia.  Recognize stress factors that may affect the patient and minimize these factor.

Edison O. Dangkeo, RN

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5 Physiologic Parameters in the Discharge of Patient from Recovery Room  ACTIVITY- able to obey commands. Example: move four extremities voluntarily on commands, deep breathing, coughing.  RESPIRATION- able to breath deeply and cough freely with easy and noiseless breathing.

 CIRCULATION- BP is within + 20 mmHg of the preoperative level.  CONSCIOUSNESS – fully awake; responsive  COLOR- pinkish skin and mucus membrane

POSTOPERATIVE PHASE  Goals  Maintain adequate body systems functions.  Restore homeostasis.  Alleviate pain and discomfort.  Prevent postoperative complications.

 Ensure adequate discharge planning and teaching. 1. Post Anesthetic Care Immediate post op (immediate post anesthesia recovery- RR) Assist patient in returning to safe physiologic level by providing safe and individualized nursing care. Transport of the patient from the OR to RR.  Avoid exposure.  Avoid rough handling.  Avoid hurried movement and rapid changes in position. a.) Get the baseline assessment of the patient.  Appraise air exchange status and skin color.

Edison O. Dangkeo, RN

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 Verify identity, operative procedure and surgeon.  Assess neuro status.

 Determine vital signs and skin temperature. (CV status)  Examine operative site and check dressings.  Perform safety checks. o

Position for good body alignment.

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Side rails.

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Restraints for IVF’s, blood transfusion

 Require briefing on problems encountered in OR. 2. Intermediate postop care When the patient returns from RR to the surgical unit; directed towards prevention of complications and postoperative discomforts. 

Initial assessment  Respiratory Status.  Cardiovascular status  LOC ( Level of Consciousness)  Tubes – Drainage, NGT, T-tube  Position

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Ongoing Assessment, Goals and Interventions.  Goals  Restore homeostasis and prevent complications.  Maintain adequate cardiovascular and tissue perfusion.  Maintain adequate respiratory function. Causes of airway obstruction:

 Mucus collection in the throat  Aspirated mucus/vomitus

Edison O. Dangkeo, RN

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 Loss of swallowing reflex  Loss of control of the muscles of the jaw and tongue.  Laryngospasm due to intubation.  Bronchospasm. Causes of hypoventilation:  Medications  Pain  Chronic Lung Disease  Obesity Signs and Symptoms of Respiratory Obstruction and Hypoventilation  Restlessness  Attempt to sit up on bed  Fast, thready pulse (early sign)  Air hunger  Nausea, apprehension, confusion  Stridor/ snoring/ wheezing  Cyanosis (late sign)  Interventions  Maintain adequate nutrition and elimination.  Maintain adequate fluid and electrolyte balance.  Maintain adequate renal function.  Promote adequate rest, comfort and safety.  Promote wound healing.  Promote and maintain activity and mobility.  Provide adequate psychological support. 3. Extended Postop Period

Edison O. Dangkeo, RN

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2-3 days after surgery  Self care activities  Activity Limitation  Diet and Medication at Home  Possible Complications  Referrals, follow up check-up Post Discomfort  Nausea and Vomiting  Restlessness and Sleeplessness  Thirst  Constipation  Pain

POSTOPERATIVE COMPLICATIONS SHOCK- response of the body to a decrease in the circulating blood volume, which results to poor tissue perfusion and inadequate tissue oxygenation. (tissue hypoxia) Impaired Tissue Metabolism

Cell/ Organ Death HEMORRHAGE- the copious escape of blood from the blood vessel.  Capillary- slow, generalized oozing  Venous- dark in color and bubble out.  Arterial – spurts and is bright red in color. Clinical Manifestations:  Apprehension  Deep, rapid RR, low body temperature

Edison O. Dangkeo, RN

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 Low BP, Low Hgb

 Circumoral pallor, ringing in ears  Progressive weakness, the death ensues Management:  Vitamin K (Aquamephyton), Hemostan  Ligation of Bleeders  Pressure Dressings  Blood Transfusion; IV fluids FEMORAL PHLEBITIS/ DEEP THROMBOPHLEBITIS- often occurs after operations on the lower abdomen or during the course of septic conditions as ruptured ulcer or peritonitis. Causes:  Injury; damage to vein  Hemorrhage  Prolonged Immobility  Obesity/ Debilitation Clinical Manifestations:  Pain  Redness  Swelling  Heat/ warmth  (+) homan’s sign Nursing Interventions: •

Prevention

 Hydrate adequately to prevent hemoconcentration.  Encourage leg exercises and ambulate early.  Avoid any restricting devices that can constrict and impair circulation.

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 Prevent use of bed rolls, knee gatches, dangling over the side of the bed with pressure on the popliteal area. •

Active Interventions  Bed rest, elevate the affected leg with pillow support.  Wear anti embolic support from the toes to the groin.  Avoid massage on the calf of the leg.  Initiate anticoagulant therapy as ordered.

PULMONARY COMPLICATIONS  Atelectasis  Bronchitis  Bronchopneumonia  Lobar Pneumonia  Hypostatic Pneumonia  Pleurisy Nursing Interventions:  Reinforce deep breathing , coughing, turning exercises.  Encourage early ambulation.  Incentive spirometry. URINARY DIFFICULTIES

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Retention- occurs most frequently after operation of the rectum, anus, vagina, lower abdomen, caused by the spasm of the bladder sphincter.

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Incontinence – 30-60 ml every 15-30 minutes, the bladder is over distended, there is overflow incontinence caused by loss of tone of the bladder sphincter.

Nursing Interventions: Implement measures to induce voiding. INTESTINAL OBSTRUCTION- loop of intestine may kink due to inflammatory adhesions. Clinical Manifestations:  Intermittent sharp, colicky abdominal pains.

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 Nausea and vomiting.  Abdominal distention, hiccups  Diarrhea (incomplete obstruction), No bowel movement (complete obstruction)  Return flow of enema is clear.  Shock, then death occurs. Nursing Interventions:  NGT insertion  Administer electrolyte/IV as ordered.  Prepare for possible surgical intervention.

HICCUPS- intermittent spasms of the diaphragm causing a sound (“hic”) that result from the vibration of closed vocal cords as air rushes suddenly into the lungs------ caused by irritation of the phrenic nerve between the spinal cord and terminal ramifications on the undersurface of the diaphragm. Nursing Interventions:  Remove the cause. e.g abdominal distention  Hold breath by taking a large swallow of water.  Pressing on the eyeball thru closed lids for several minutes.  Breath in or out paper bag.  Plasil as ordered. WOUND INFECTIONS Clinical Manifestations:  Redness, swelling, pain, warmth  Pus or other discharge on the wound.  Foul smell from the wound.  Elevated temperature, chills  Tender lymph nodes on the axilla or groin closes to the wound.

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Preventive Measures:  Housekeeping cleanliness in the surgical environment.  Strict aseptic techniques.  Wound care.  Antibiotic therapy. WOUND COMPLICATIONS Kinds: Hemorrhage/Hematoma, Wound Dehiscence, Wound Evisceration Nursing Management:  Apply abdominal binders.  Encourage proper nutrition.  Stay with client, have someone call for the doctor.  Keep on bed rest.  Supine or semi-fowlers position, bend knees to relieve tension on abdominal muscles.  Cover exposed intestine with sterile, moist saline dressing.  Prepare for surgery and repair of wound.

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