Perioperative Nursing Definition of Surgery is any procedure

Perioperative Nursing Definition of Surgery is any procedure performed on the human body that uses instruments to alter tissue or organ integrity

Perioperative Nursing l Perioperative Nursing connotes the delivery of patient care in the preoperative, intraoperative, and postoperative periods of the patients surgical experience through the framework of the nursing process. The nurse assesses the patientcollecting, organizing, and prioritizing patient data; establishing nursing diagnosis; identifies desired patient outcomes; develop and implements a plan of care; and evaluates that care in terms of outcomes achieved by the patient.

Perioperative Nursing Phases Preoperative phase – begins when the decision to have surgery is made and ends when the client is transferred to the OR table. l Intraoperative phase – begins when the client is transferred to the OR table and ends when the client is admitted to the PACU. l Postoperative phase - begins with the admission of the client to the PACU and ends when the healing is complete. l

Perioperative Nursing Types of Surgery l Purpose/reasons l Degree of urgency – necessity to preserve the client’s life, body part, or body function. l Degree of risk – involved in surgical procedure is affected by the client’s age, general health, nutritional status, use of medications, and mental status. l Extent of surgery – Simple and radical

Perioperative Nursing Type of Surgery (Purpose) l l l l Diagnostic-Allows to confirm or establishes Diagnostic diagnosis. Corrective Excision or removal of diseased body part. Reconstructive-Restore function or appearance Reconstructive to traumatized or malfunctioning tissues. Ablative – Removes a diseased body parts Palliative – Relieves or reduces pain or symptoms of a disease; it does not cure Transplant – Replaces malfunctioning structures Cosmetic Performed to improve personal appearance.

Perioperative Nursing Types of Surgery (Urgency) Emergency- performed immediately to preserve function or the life of the client. l Elective – is performed when surgical intervention is the preferred treatment for a condition that is not imminently life threatening or to improve the client’s life. l Urgent – Necessary for client’ health to prevent additional problem from developing; not necessarily an emergency. l Required – has to be performed at some point; can be pre-scheduled. l

Perioperative Nursing Type of Surgery (Degree of Risk) l l l l Major – involves a high degree of risk. Minor – normally involves little risk. Age – very young and elder clients are greater surgical risks than children and adult. General health surgery is least risky when the client’s general health is good. Nutritional Status – required for normal tissue repair. Medications – regular use of certain medications can increase surgical risk. Mental status – disorder that affect cognitive function

Perioperative Nursing Surgical settings l Surgical suites l Ambulatory care setting l Clinics l Physician offices l Community setting l Homes

Perioperative Nursing Surgical settings Disadvantages Less time for rapport Less time to assess, evaluation, teach Risk of potential complication post D/C. l Advantages of outpatient: outpatient Low cost Low risk of infection Less interruption of routine Less than from work Less stress l

Preoperative Nursing Consent l l l Nature and intention of the surgery Name and qualifications of the person performing the surgery. Risks, including tissue damage, disfigurement, or even death Chances of success Possible alternative measures The right of the client to refuse consent or later withdraw consent.

Preoperative Nursing Assessment (Nursing History) l l l l l Current health status. Allergies Medications- list all current medications Previous surgeries Understanding of the surgical procedure and anesthesia Smoking Alcohol and other-altering substances Coping Social resources Cultural considerations

Preoperative Nursing Care Physical assessment l Cardiovascular system l Respiratory system l Renal system l Neurological system l Musculoskeletal system l Nutritional status l Gerontological considerations

Perioperative Nursing Care Physical assessment/clinical manifestations General survey gestures and body movements may reflect decreased energy or weakness caused by illness. l Cardiovascular system alterations in cardiac status are responsible for as many as 30% of perioperative death. l Respiratory system a decline in ventilatory function, assessed through breathing pattern and chest excursion, may indicate a client’s risk for respiratory complications. l

Perioperative Nursing Care Physical assessment/clinical manifestations l Renal system-abnormal system renal function can altered fluid and electrolyte balance and decrease the excretion of preoperative medications and anesthetic agents. l Neurologic system a client’s LOC will change as a result of general anesthesia but should return to the preoperative LOC after surgery.

Perioperative Nursing Care Physical assessment/clinical manifestations Musculoskeletal system Deformities may interfere with intraoperative and postoperative positioning. Avoid positioning over an area where the skin shows signs of pressure over bony prominences. l Gastrointestinal system alteration in function after surgery may result in decreased or absent bowel sound and distention. l Head and Neck the condition of oral mucous membranes reveals the level of hydration. l

Preoperative Nursing Care Gerontological Considerations l Cardiovascular Coronary flow decreases Heart rate decreases Response to stress decreases Peripheral vascular decreases Cardiac output decreases Cardiac reserve decreases

Preoperative Nursing Care Gerontological Considerations l Respiratory System Static lung volumes decreases Pulmonary static recoil decreases Sensitivity of the airway receptors decreases l Nervous system Increased incidence of post. op. confusion. Increased incidence of delirium Increased sensitivity to anesthetic agents

Preoperative Nursing Care Gerontological Considerations l Renal System Renal blood flow declines 1. 5% per year. Renal clearance reduced l Gastrointestinal Decreased intestinal motility Decreased liver blood flow Delayed gastric emptying

Preoperative Nursing Care Gerontological Considerations l Musculoskeletal Decreased mass, tone, strength Decreased bone density l Integumentary Decreased elasticity Decreased lean body mass Decreased subcutaneous fat

Preoperative Nursing Care Psychosocial considerations l Level of anxiety l Coping ability l Support systems

Preoperative Nursing Care Laboratory and diagnostic studies l Screening tests depend on the condition of the client and the nature of the surgery. If test reveals severe problems the surgery may be cancel until the condition is stabilized. l Routine screening test-CBC, Blood test grouping and X-match, Lytes, fasting blood sugar, BUN & Creatinine, ALT, AST, and bilirubin, Serum albumin, and Total protein, Urinalysis, Chest X-ray, ECG

Preoperative Nursing Care Common nursing diagnosis l Knowledge deficit l Anxiety l Risk for ineffective airway clearance l Fear related to l Disturbed sleep pattern l Anticipatory grieving related to

Preoperative Nursing Care Preop. teaching The education plan should begin with assessment, including baseline knowledge of the patient and family, readiness to learn, barriers to learning, patient and family concern and learning styles and preferences. l The content focuses on information that will increase patient’s familiarity with procedural events. This includes surgical experience (procedural), what the pt. may experience (sensory) and what actions may help decrease anxiety (behavioral). l

Preoperative Nursing Care Anxiety l The nurse must consider the pt’s family and friends when planning psychological support. l Empowering their sense of control. Activities that decreasing anxiety are deep breathing, relaxation exercises, music therapy, massage and animalassisted therapy. l Use of medication to relieve anxiety.

Preoperative Nursing Care Preanesthesia Management Physical Status Categories l l l l ASA 1: Healthy patient with no disease ASA 11: Mild systemic ds without fx limitations ASA 111: Severe systemic ds associated with definite fx limitations ASA 1 V: Severe systemic ds that is a constant threat to life. ASA V: Moribund pt. Who is not expected to survive without the operation. ASA V 1: A declared brain-death whose organ are being recovered for donor. E: Emergency

Preoperative Nursing Care Final Preparation for surgery l All personal belongings are identified and secured. l Jewelry is usually removed. l Dentures are removed, labeled and placed in a denture cup. l Pt. to verbally confirm the surgical procedures and the surgical site. This verification process is documented in the medical record on the preop. checklist.

Preoperative Nursing Care Pre-op. medications l Prior to administering – check permits l Purpose: Allay anxiety Decrease pharyngeal secretions. Decrease gastric secretion. Decrease side effects of anesthesia. Induce amnesia

Preoperative Nursing Care Medications l Sedatives/hypnotics- Nembutal l Tranquilizers-Ativan, versed, valium l Opiate analgesics- Demerol, morphine l Anticholinergics-Atropine sulfate, atarax l H 2 o blockers. - Tagamet, Zantac l Antiemetic- Reglan, Phenergan

Intraoperative Phase Surgical Team l. Surgeon l. Anesthesiologist l. Scrub Nurse l. Circulating Nurse l. OR techs

Intraoperative Nursing Care Roles of team members Surgeon responsible for determining the preoperative diagnosis, the choice and execution of the surgical procedure, the explanation of the risks and benefits, obtaining inform consent and the postoperative management of the patient’s care. l Scrub nurse- (RN or Scrub tech)- preparation of supplies and equipment on the sterile field; maintenance of pt. s safety and integrity: observation of the scrubbed team for breaks in the sterile fields; provision of appropriate sterile instrumentation, sutures, and supplies; sharps count. l

Perioperative Nursing Care Surgical team l Circulating Nurse - responsible for creating a safe environment, managing the activities outside the sterile field, providing nursing care to the patient. Documenting intraoperative nursing care and ensuring surgical specimens are identified and place in the right media. In charge of the instrument and sharps count and communicating relevant information to individual outside of the OR, such as family members

Perioperative Nursing Care Surgical team l Anesthesiologist and anesthetist- anesthetizing the pt. providing appropriate levels of pain relief, monitoring the pt’s physiologic status and providing the best operative conditions for the surgeons. l Other personnel- pathologist, radiologist, perfusionist, EVS personnel.

Perioperative Nursing Care Surgical team Nursing Roles: Staff education Client/family teaching Support and reassurance Advocacy Control of the environment Provision of resources Maintenance of asepsis Monitoring of physiologic and psychological status

Intraoperative Nursing Care Surgical asepsis l Ensure sterility l Alert for breaks

Intraoperative Phase Anesthesia Greek word- anesthesis, meaning “negative sensation. ” Artificially induced state of partial or total loss of sensation, occurring with or without consciousness. l Blocks transmission of nerve impulses Suppress reflexes Promotes muscle relaxation Controlled level of unconsciousness

Intraoperative Phase Anesthesia l Factors influencing dosage and type: 1. Type and duration of the procedure 2. Area of the body being operated on 3. Whether the procedure is an emergency 4. Options of management of post. Op. pain 5. How long it has been since the client ate, had any liquids, or any medications 6. Client position for the surgical procedures

Intraoperative Phase Types of Anesthesia l General- method use when the surgery requires that the patient be unconscious and/or paralyzed. l A general anesthetic acts by blocking awareness centers in the brain so that amnesia (loss of memory), analgesia (insensibility to pain), hypnosis (artificial sleep), and relaxation (rendering a part of the body less tense) occur.

Intraoperative Phase Stages of General Anesthesia l Stage 1 - Analgesia and sedation, relaxation l Stage 2 - Excitement, delirium l Stage 3 - Operative anesthesia, surgical anesthesia l Stage 4 - Danger

Intraoperative Phase Complications of General Anesthesia Overdose Hypoventilation Related to anesthetic agents Malignant hyperthermia Related to intubation

Intraoperative Phase Local or Regional Anesthesia Temporarily interrupts the transmission of sensory nerve impulses from a specific area or region. Motor function may or may not be affected Client does not lose consciousness Gag reflex remains intact Supplemented with sedatives, opioids, or hypnotics

Types of Regional Anesthesia l Topical (surface) l Local l Nerve Block l Intravenous (Bier Block) l Spinal l Epidural (peridural)

Intraoperative Phase Complications of Local/Regional Anesthesia Anaphylaxis Administration technique Systemic absorption Overdosage

Spinal Anesthesia Indications -surgical procedures below the diaphragm -patients with cardiac or respiratory disease l Advantages -mental status monitoring -shorter recovery l Disadvantages -necessary extra expertise -possible patient pain l Contraindications -coagulopathy -uncorrected hypovolemia l

Spinal Anesthesia l Involved medications -lidocaine -bupivacaine -tetracaine l Patient assessment -continuous heart rate, rhythm, and pulse oximetry monitoring -level of anesthesia -motor function and sensation return monitoring

Spinal Anesthesia l Complications -hypotension -bradycardia -urine retention -postural puncture headache -back pain

Spinal analgesia l Indications -postoperative pain from major surgery l Involved medications -lipid-soluble drugs -preservative-free morphine l Monitoring recovery -respiratory depression -urine depression -pruritus -nausea and vomiting

Examples of location for Spinal and Epidural Anesthesia.

Nerve Block Sites

Intraoperative Phase Conscious Sedation Administration of IV sedative, hypnotic, and opioid medications. Produces a depressed level of consciousness Retains ability to maintain a patent airway Able to respond to verbal commands or physical stimulation Used for relatively short procedures

Postoperative Nursing Care Nursing assessment in the PACU l l l l Vital signs- presence of artificial airway, 02 sat, BP, pulse, temperature. LOC- ability to follow command, pupillary response Urinary output Skin integrity Pain Condition of surgical wound Presence of IV lines Position of patient

Postoperative Nursing Care Nursing Diagnosis l Ineffective airway clearance- increased secretions 2 to anesthesia, ineffective cough, pain l Ineffective breathing pattern- anesthetic and drug effects, incisional pain l Acute pain l Urinary retention l Risk for infection

Postoperative Phase Assessment of the Postanesthesia Client Airway Vital signs Cardiac monitoring Peripheral vascular assessment Level of consciousness (LOC) Fluid and electrolytes GI system Integumentary system Discomfort/pain

Perioperative Nursing Care Postoperative Management l Maintain a patent airway l Stabilize vital signs l Ensure patient safety l Provide pain l Recognize & manage complications

Postoperative Nursing Care When caring for post-surgical patient, think of the “ 4 W’s” l Wind: prevent respiratory complications l Wound: prevent infection l Water: monitor I & O l Walk: prevent thrombophlebitis

Postoperative Phase Complications l l l l Respiratory- atelectasis, pulm. Embolus Cardiovascular- venous thrombosis Gastrointestinal-Hiccoughs, N/V, abd. Distention, paralytic ileus, stress ulcer. GU- urinary retention Hemorrhage-slipping of a ligature(suture) Wound infection. Wound dehiscence and evisceration-

Dehiscence l Partial or complete separation of the outer layer of the wound. l Possible causes: Poor suturing technique Distention Excessive vomiting Excessive coughing Dehydration Infection

Evisceration Total separation of the layers & protrusion of internal organs or viscera through the open wound. l Causes: same as dehiscence l Treatment: Call for help Cover with sterile NS soaked gauze/towels Keep moist DO NOT ATTEMPTS TO REINSERT ORGANS. Keep in supine position with knees/hips bent Assessment/VS q 5 min. until MD arrive Prepare for surgery. l

Postoperative Phase

Postoperative Phase

Postoperative Nursing Care Gerontologic considerations l Mental status- attributed to medications, pain, anxiety, depression. l Delirium- infection, malignancy, trauma, MI, CHF, opioid use. l Dementia-sundowning-sleep disturbances, lack of structure in the afternoon or early morning, sleep apnea.