NCM202B_A Perioperative Nursing Mrs. Fe Corazon Elefan, RN MN Perioperative Nursing Overview 3 Phases a. Pre-operative b. Intraoperative c.

. Post-operative *** prioritize problem identified based on clients need Course Content I. Introduction A. Definitions and Suffixes B. Responsibilities of Perioperative nurse C. Operative Phase II. Preoperative Nursing Care Management A. General Physical Assessment System Assessment Nutritional Status Assessment Gerontologic Considerations B. Nursing Process in the care of clients requiring surgery C. Preoperative Nursing Interventions Legal Preparations Physiological Preparations --- chest x-ray, hepatitis test, full stomach Psychological Preparations 1. Preoperative health teachings 2. Teaching cognitive coping strategies D. Immediate Preoperative Nursing Interventions on the day Administering pre anesthetic medications Maintaining pre-operative record (pre-op. checklist) Transporting the patient to pre surgical suite Attending the family needs III. Intra operative Nursing Care Management A. The Surgical Team B. Surgical Environment Principles of surgical Aseptic Technique Health Hazards Associated with Surgical Environment C. Surgical Experience Anesthesia Patient Position in the Operating Table Caring of the Patient during Surgery MIO, vs. IV. Post Operative Nursing Care Management A. Immediate post Operative Care in the PACU / PAR / SICU Admitting the patient in PACU Nursing Care Management in the PACU Physical Assessment 1

NCM202B_A Perioperative Nursing Mrs. Fe Corazon Elefan, RN MN Relieving pain and anxiety B. The hospitalized Post Operative Patient C. The Patient Recovering from Surgery D. Promoting Home and Community-based care *** most common in respi pneumonia; hemorrhage (first 48 hours after surgery); wound infection Criteria of evaluation: Quizzes 50% Term Examination 40% Attendance / Participation / Requirements (Case study) 10% References: Operating Room Techniques by Barry and Kohn Fundamentals of Operating Room Nursing, Shirley Brooks Medical Surgical Nursing, Clinical Management for Positive Outcomes, Black and Hawks Differentiating Surgical Instruments, Colleen J. Rutherford Perioperative Nursing Nursing Care of preoperative client that begins when the patient decides to have surgery and ends when surgery related nursing care is no longer needed. - A comprehensive nursing care of client before, during and after surgery *** starts before admission; when the patient decides to have surgery and ends after full recovery (extended when there are still follow-up checkups; does not end upon discharge) Surgery - The art and science of treating diseases, injuries, and deformities by operation and instrumentation. Treatment of an illness by invasive means (imposes physical and mental stressors) - Places the patient at risk for injury due to effects of anesthesia *** takes 1 month for wound to completely heal; but consider individual differences To avoid pneumonia deep breathing exercises RESPONSIBILITIES OF PERIOPERATIVE NURSE: 1. Provide care to the client during forced dependency. anesthesia/sedation 2. Ensure continuity of care by coordinating with other members of the surgical team and documenting all the events during peri-operative period. -- charting format: problem oriented 3. Keeping abreast of the continually changing technology. 4. Incorporating the knowledge of the classification of surgery into the plan of care. Classifications: According to risk, purpose, and time available for both pt. and surgical team

NCM202B_A Perioperative Nursing Mrs. Fe Corazon Elefan, RN MN Classification of Surgery I. According to the Degree of risks (complications) refers to the relative threat surgery poses to the patient. 1. Major Surgery May pose great threat to the patient - Usually requires hospitalization - Prolonged procedures, involving major body organs - E.g. Bilroth II Gastro-jejunostomy 2. Minor Surgery Poses a minimal threat - Usually takes place in the clinic. Brief procedure and has few complications (bleeding, infection) - E.g. Excision of mass/cyst done in outpatient dept.; suturing According to the Degree of Urgency Degree of urgency refers to the time available for the patient, family and surgical team to decide whether or not surgery will be performed - Corresponds to the severity of illness and injuries 1. OPTIONAL Surgery is scheduled completely at the preference of the patient. - E.g. Vasectomy and BTL 2. ELECTIVE The approximate time for surgery is at the convenience of the patient. Failure to have surgery is not a great threat to the health of the client. - E.g. For goiter ( there is advice from doctor as to the time) Thyroidectomy; Palatoplasty (6months) 3. REQUIRED The condition of the client requires surgery within few weeks or months - E.g. Cheiloplasty (1st operation), Jatene 4. URGENT Surgical problem requires attention within 24-48 hours - E.g. Ruptured appendicitis, major gunshot wound involving major arteries *** Anoplasty + colostomy (temporary 2yrs after anoplasty, it is closed) *** Permanent colostomy malignancy in rectum/bowel 5. EMERGENT The condition of the client requires surgical intervention or attention without delay - E.g. STAT Appendectomy, repair of punctured lung, STAT CS *** 2 hours to cross-match the blood According to Purpose 1. Diagnosis to determine the cause of symptoms 3

II.

III.

NCM202B_A Perioperative Nursing Mrs. Fe Corazon Elefan, RN MN 2. E.g. Diagnostic curettage (to bring uterine endometrial scrapings to lab for physiological studies to pts. With dysfunctional bleeding); excision and biopsy Curative / Ablative Surgical removal, or repair of the damaged organ (s) to restore function (s) - C&C (to remove placental fragments), appendectomy Restorative To strengthen weakened area (herniorrhaphy), rejoin disconnected or injured area (bone pinning internal fixation), or correct deformities (ORIF), bone fixators for internal reduction and internal fixation (pins, plates and screws, rods) Palliative To relieve symptoms without curing / treating the disease - E.g. Sympathectomy (sympathetic nerve fibers removed to minimize pain and discomfort of patient with pts who have very low pain threshold), colostomy Aesthetic / Cosmetic To improve physical features that are within the normal range - Ex. Mammoplasty, reduction or augmentation Rhinoplasty correction of the external appearance of the nose (can also be curative) Blepharoplasty excision of the protruding intraorbital fat and resection of excessive redundant skin of the eyelids (eyebags) Cheiloplasty cleft lip repair (series) Palatoplasty cleft palate repair Preventive - Removal of moles, warts, polyps (rectal, cervical) before it becomes malignant Reconstructive Partial or complete restoration of a body part that is congenitally malformed - E.g. Orchiopexy Transformative Removal of damaged organs or tissues and replacing it with functional ones - E.g. Transplants, skin grafting, bone marrow transplant Exploratory Estimation of the extent of disease or confirmation of diagnosis E.g. Exploratory laparotomy, pelvic laparotomy

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Perioperative Nursing Objectives Utilize nursing process in the care of surgical clients. Describe the nursing intervention for each of the three phases of surgery. Identify factors and health conditions that may influence or alter the well being of a surgical client. Pre-operative Phase Begins when the patient decides to have surgery and consist primarily of collecting and analyzing data used to plan intra-operative events. 4

NCM202B_A Perioperative Nursing Mrs. Fe Corazon Elefan, RN MN Focus of Client Care: Assessment enables the nurse to provide individualized care. Preoperative Assessment includes: I. Medical / Health History a. Present health history Chief complaints, duration of present health problem b. Past health history Previous surgery, experiences with anesthesia Serious illness or trauma A allergy to medicines, chemicals (betadine, rubber gloves) and other environmental products B bleeding tendencies or the use of medications that deter clotting (blood thinners aspirin) C cortisone or steroid use D diabetes mellitus under stress, blood sugar goes up E emboli, previous embolic events may recur because of prolonged immobility c. Alcohol, Recreational Drug or Nicotine use potential problem with the administration of anesthesia or analgesia and risk for withdrawal symptoms. Eg. Amphetamines, cocaine Alcohol addiction may result to malnutrition thiamine deficiency (excreted through urine) Withdrawal to alcohol may require dosage alterations in anaesthesia and analgesia Smokers may have damaged lung tissue (COPD) Nicotine is a potent vasoconstrictor resulting to less oxygen available for tissue repair May cause hypercoagulability resulting to thrombus or clot formation d/t nicotine d. Current Discomfort Pre-existing painful condition may require alternate methods of pain reduction - Clients who drink considerable amount of coffee often develop headache related to NPO status e. Chronic Illness Ex. Arthritis, neck and back are considered in positioning client during surgery and intubation f. Advanced age Older clients have specific peri-operative needs g. Medication history Medications with prescription or over the counter drugs may increase operative risks 5

NCM202B_A Perioperative Nursing Mrs. Fe Corazon Elefan, RN MN Example 1. Antibiotic penicillin, gentamicin may produce mild respiratory depression, mask infection and affect metabolism of muscle relaxant (diazepam). 2. Antidysrhythmic Propanolol, Quinidine Gluconate, Procainamide HCl affects tolerance of anesthesia. Depress cardiac function, potentiates anesthetic agents are neuromuscular blockers 3. Antihypertensive Methyldopa, Captopril - May alter response to muscle relaxant and narcotics - May cause intra-operative and post operative hypertensive crisis 4. Corticosteroids Dexamethasone, Hydrocortisone, Prednisone - May mask infection - Increases risk of hemorrhage - Dec stress response (steroid replacement during surgery) 5. Anticoagulants - Warfarin Na, Heparin Na, NSAIDs - Inc risk for hemorrhage intra-operatively and post-operatively 6. Antidiabetic Agents - Basic insulin needs remain when client is on NPO - Glucose levels may fluctuate because of physiologic stress brought about by surgery Insulin alteration is needed 7. Tricyclic Antidepressant - Amitryptiline, Amoxapine, Doxapin - Lowers BP inc risk of shock d/t hypotension - Potentiates affects of narcotics and barbiturates 8. Thiazide Diuretics - Hydrochlorothiazide; Furosemide - Can deplete K, can cause F and E imbalance - Results to dysrhythmia 9. Street Drugs

II.

III.

Psychological History a. Knowledge of Cultural beliefs and practices b. Ability to tolerate Perioperative stress Psychological factors (anxiety, fear of the unknown) + Physiological factors (blood loss, anesthesia, pain, immobility) promote physiologic stress response Physical Exam > Head to toe exam 1. LOC > Assess cognition all through the exam 2. Cardiovascular Assessment - ECG, Hgb, Hct, F and E deter 6

NCM202B_A Perioperative Nursing Mrs. Fe Corazon Elefan, RN MN 3. > check and document SOB on minor exertion; hypertension, heart murmurs All cardiac conditions can lead to a dec tissue perfusion with impairment of surg wound healing Respiratory Assessment - CXR, Pulse Ox, ABG - > Check and document SOB, wheezing, clubbing of fingers, chest pain (subjective validate through pain scale and correlate with vital signs), coughing, expectoration of copious discharges - > Chronic lung conditions such as emphysema, asthma, bronchitis impair gas exchange in the alveoli predisposing clients to post operative pulmonary complications Musculoskeletal Assessment - AROM and PROM, History provided by client and family. Medical Records - History of Arthritis, fracture, contracture, joint injury, other musculoskeletal impairment is important in surgical positioning and post op support GI Assessment - Radiologic Study (Ba enema, Ba swallow) - G.I. conditions associated with poor surgical outcome: severe malnutrition; prolonged nausea and vomiting, long history of constipation (may have more difficulty with regular function) - Gastroesophageal reflux; hiatal hernia increase risk o aspiration - Opioid analgesics inc constipation - *** Sigmoidoscopy - *** Esophagoscopy Renal Assessment - Ask patient for voiding pattern. Lab Tests: BUN, serum creatinine levels (indicate the ability of the kidney to excrete urea and CHON waste products; UA result may indicate UTI, DM, Malnutrition, Renal Disease, Dehydration (check urea, RBC, protein in urine) - Adequate renal function in necessary to eliminate protein wastes, to preserve F and E balance, to remove anesthetic agents - ***dehydration dark colored urine; normal amber colored - Renal and Related Disorders Advanced Renal Insufficiency, Acute Nephritis, BPH (anticholinergic drugs is Given) Skin Integrity - Operative site must be clear of any rashes, blisters, or any infectious process - > Note the size, color, and location of skin impairment. - > Body piercings (maybe removed according to surgeon preference) - > Tattoos should be noted Liver Functions Assessment - > Liver disease is manifested by dec albumin levels dec immunoglobulin and fibrinogen levels clotting disorders 7

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NCM202B_A Perioperative Nursing Mrs. Fe Corazon Elefan, RN MN > Dec albumin level predispose the client to fluid shifts, surgical infection and ineffective coagulation *** Edema - hard to start IV; close monitoring of I&0, make sure no imbalance of intake more than output; check if pitting or non-pitting) > liver cirrhosis inc clients surg risk, because impaired liver cant detoxify medications and anesthetic agents

9. Cognitive and Neurologic Assessment - > Determine baseline neurologic functions by checking reflex response of upper and lower extremities, sensory reflex; testing cranial nerves and cerebral responses - Assess condition preoperatively to determine postoperative effects of surgery - Surgery and medication frequently lead to temporary cognitive deficiencies. 10. Endocrine Assessment - DM is the most frequently pre-existing path-physiologic drugs - Thyroid replacement is usually continued throughout Perioperative. Stopping thyroid medication period - > Stopping thyroid medications may result to hypothyroidism with manifestation of bradycardia, hypotension, hypothermia Additional Assessment: 1. Age - Take note of the normal physiologic changes that occur with aging - > chronic conditions commonly found in older client; malnutrition, anemia, dehydration, atherosclerosis, COPD, cerebrovascular changes and peripheral vascular diseases - > Observe for full assessment of pain if present - In infants: weight, thermo-regulation; immature body systems. 2. Nutritional Status: - > Obese clients are malnourished (in terms of excess intake) - > Associated with poor surgical outcome. - > Adipose tissue inc technical difficulty. - > Fatty tissue is less vascular, prone to have an infection, incision hernias, wound dehiscence (opening of suture) and evisceration (bodily organs are out of the body) - > Absorbed anesthetic agents wears off slower, delaying recovery - Obese client freq suffer from hypertension, heart failure, and metabolic problems. Susceptible to postoperative complications Dec the efficiency of coughing and breathing exercises Pressure of the abdominal contents on the diaphragm and lungs may lead to hypoventilation Prone to post operative immobility, inc the risk for venous stasis, DVT, pulmonary embolism, pressure sores (encourage client to turn) 3. F and E Balance in severe dehydration Irritability and confusion 8

NCM202B_A Perioperative Nursing Mrs. Fe Corazon Elefan, RN MN 4. Infection and Immunity dec WBC may indicate risk for infection 5. Hematologic function - blood coagulation disorders are at risk for hemorrhagic and hypovolemic shock during and after the surgery Herbal preparation: Ginkgo biloba, garlic, ginger and ginseng may prevent clot formation excess blood loss. St. Johns Wort (antidepressant); Kava-Kava (relaxant) may prolong sedative effects of anesthesia ***rrhaphy repair, ostomy create an opening, plasty - reconstruction

Preoperative Preparation: 1. Legal Preparation: a. Voluntary and Informed Consent (MD can do surg without consent in cases of emergency) Considerations: Of legal age signed in the presence of a witness Must be mentally clear and competent at the time of signing If minor/an adult is incapable of signing the consent, obtain consent from the next kin Criteria of Informed Consent: 1. Client must understand the nature of surgery 2. Client must be informed of the risk and benefits of surgery *** Nurse may act as a witness and reinforce what was said when surgeon explained the procedure to the client 2. Psychological Preparation Surgery is a potential or actual threat to persons bodily integrity and can interfere with the attainment of goals in any phase of surgery Stress Reactions a. Psychologic stress reaction (fear and anxiety) b. Physiologic stress reaction (neuroendocrine responses) 1. Stimulation of the autonomic nervous system (sympathetic nervous system) 2. Stimulation of selected hormones such as aldosterone and glucocorticoid hormones (adrenal cortex) Aldosterone plays an important role in regulating BP, Na and K levels in the blood and tissue In the kidney, Na draws H2O in the blood inc blood volume in BP Glucocorticoid affects CHO metabolism by inc blood sugar level and the amount of glycogen in the liver inc blood sugar levels Implementation of Psychological Preparation 1. Provide expression of concern 2. Support from family and friends 3. Provide means of control allow to participate in decision making *** delay taking of vital signs from the client; site or parenteral medication; site for IM; type of cut during CS 9

NCM202B_A Perioperative Nursing Mrs. Fe Corazon Elefan, RN MN 4. Help client meet his physical need during preoperative phase to provide feeling of security *** Promises should be implemented 5. Preoperative Teaching to ensure positive surgical experience *** lessen clients anx, envi, brief client Preoperative Teaching Involves emotional energy on the part of the nurse Produces behavioral changes in patients to become better prepared physically and emotionally Three Levels 1. Information: explanation of procedures, patient care activities (V/S), physical feelings that the patient may encounter (A/C in room, temp of solution and instruments). 2. Psychosocial support: enhance coping mechanisms to deal with anxiety, fears and provide emotional support. 3. Skill training: guided practice of specific task to be performed by the patient in the postoperative period can dec anx, hasten recovery and help prevent complications coughing and deep breathing exercises ROM exercises Turing from side to side, gradual ambulation Wound dressing, start from center, handwashing 3. Physiological Preparation Made by both the physician and the nurse, directed to toward safe and comfortable surgical experience a. Food and fluids are usually withheld 6-8 hours before the surgery to dec gastric contents and risk, of Gastroesophageal reflux aspiration aspiration pneumonia, respi arrest, or death Non compliance of NPO order may necessitate cancellation of surgery (elective) Skin preparation: ideally a depilatory agent is the best method of removing hair (check for allergies) Depilatory creams are not recommended because they can cause serious irritation and rashes in a significant number of patients, which may lead to wound infection (Hamilton et al 1997) Shaving will do as long as the shaving of the incision site is done immediately before the surgical procedure and preferably in the operating room Clipping should be used as the standard process of hair removal in the operating room immediately before the surgery without significantly increasing the wound infection rate provided the clipper head is sterile. (Alexander et al 1983, Masterson et al 1984) For GIT surgical procedures: enemas, cathartics are usually given to expel bowel contents, provide easier access to surgical site. Urinary catheterization: usually ordered for pelvic procedures to decompress the site U. Bladder to provide better access to the superficial site and to prevent inadvertent laceration of the bladder. Common Preoperative Laboratory Tests: U/A to assess renal status, hydration, UTI/Dse; inc in urates calculi CXR to assess pulmonary disorders, cardiac enlargement 10

b.

c. d. e.

NCM202B_A Perioperative Nursing Mrs. Fe Corazon Elefan, RN MN Blood studies: CBC, Hgb, Hct, Clotting and Bleeding time; to assess immune system status and anemia FBS to assess metabolic status, DM BUN, Creatinine assess renal functions ECG assess Cardiac status, electrolyte imbalances; remove all jewelries and coins, keep still, dont hold anything and relax, otherwise somatic interference may result Blood typing and cross matching blood compatibility and replacement IV line is inserted for fluid replacement and for drug administration

f.

Preoperative Medication Purposes: 1. To relieve anxiety 2. To facilitate induction of anesthesia 3. To reduce secretions in the oropharynx (AtSO4 anticholinergic) 4. Inhibit stimulation of the vagus nerve 5. Reduce the possibility of aspiration if gastric contents and or secretions 6. Minimize damage to the lungs in case of aspiration Factors affecting Type and Dosages 1. Age and weight 2. Physical condition 3. Anx level 4. Tolerance to depressant drugs 5. Type of surgery Routes of Administration 1. Oral Sips of Water (5cc can flush pill to stomach) 2. IM 3. IV 4. Subcu injection 5. Nasal Instillation Considerations in Giving Pre-op Meds 1. Given 60-90 minutes before surgery or would depend on the MDs order 2. Preoperative medication may be order on call to OR (wait call from OR and if received, give the meds, nurse-nurse orders, get name of the caller) 3. No Pre-operative medications should be given until consent is signed. (patient is no longer competent to sign of consent after medicated) 4. Family member cannot sign for the patient unless he/she is the legal guardian. (next to kin) Nursing Responsibilities 1. Assess patients level of anx 2. Ensure that consent form has been signed 11

NCM202B_A Perioperative Nursing Mrs. Fe Corazon Elefan, RN MN 3. Have patient empty his bladder before giving preoperative medication. 4. Not to get out of bed after medicated. 5. Put the bed as its lowest position, side rails up, call light with reach, to promote safety and reduce incidence of falls. 6. Obtain baseline vital signs, determine LOC, monitor and document medication effects (before and after medication is given in order to compare and gauge the effect of the drug). 7. Assist with the transfer of the patient from the hospital bed to the stretcher. 8. Check ID band and chart to ensure all information are documented Common Pre-operative Medication 1. Narcotic: MOA: Produce analgesia Alter perception and emotional response to pain. E.g. Morphine, Demerol (meperidine Hchloride), Dilaudid, Nubain (nalbuphine Hcl), Stadol (butorphanol titrate), Narcotic antagonist: Narcan (naloxone) 2. Barbiturates: MOA: Cause generalized CNS depression E.g. Nembutal (pentobarbital) Seconal (secobarbital) Anti-Anx Agents/ Minor Tranquilizers replaced Barb MOA: dec patient fear and apprehension Facilitates easy induction of anesthesia E.g. Benzodiazepines diazepam (Valium) trazepam Phenothiazines hydroxyzine (vistaril) Anti-cholinergic Agents (Anti-Muscarinics) MOA: Dec secretions in the oropharynx Dec incidence of vagal induced bradycardia E.g. Rubinul (glucopyrrolate) Patient Care on Operative Day 1. Promote sleep and risk 2. Prevent injury or loss 3. Removal of accessories (wedding ring, nail polish) 4. Application of anti-embolic stockings indicated to patient who are at high risk for post-operative thromboembolism (elderly, marked varicosities); pelvic surgery; prolonged post operative bed rest.. 5. Bladder emptying 12

NCM202B_A Perioperative Nursing Mrs. Fe Corazon Elefan, RN MN 6. Safe Guarding patients personal belongings Nursing Dx: 1. Fear r/t experience, loss of control and unknown. 2. Knowledge deficit r/t preoperative or post operative procedures. Pre-operative Checklist A tool that reflects comprehensive nursing care given to surgical clients Anesthesia A partial or complete loss of sensation with or without loss of consciousness Goals of General Anesthesia 1. To provide amnesia. 2. To provide analgesia or pain control. 3. To eliminate somatic, autonomic, and endocrine, reflexes including coughing, gagging, vomiting, and sympathetic responsiveness. 4. To achieve skeletal muscle relaxation. Anesthetic Agents 1. Ketamine (ketalar), a dissociative agent, produces unconsciousness, profound analgesia and amnesia. 2. Inhalation Agents: rapidly induce loss of consciousness and allow rapid recovery. A. NO2 (laughing gas) *** contained in a blue tank B. Halothane (fluothane) a bronchodilator C. Enflurane (Ethrane) a vasodilator (not used in neurosurg because it inc ICP) D. Isoflurane (Forane) most widely used volatile inhalation agents stabilizes CV functions 4 Stages of General Anesthesia Stages may vary depending on the drug used (rapidity of action) and the skill of the anesthesiologist Stage I extends from the beginning of administration of anesthetic agent to the beginning of loss of consciousness (Amnesia/Analgesia) Stage II extend from loss of consciousness to loss of eyelid reflexes. (Stage of excitement/delirium) ***patient secured in OR table by means of straps Stage III extends from loss of eyelid reflex to cessation of respi effort. (Stage of surgical anesthesia) *** Anesthesiologist signals surgeon to cut Stage IV extends of over dosage or danger. Death will follow if anesthesia administration is not immediately DC ***Code Blue Types of Anesthesia 1. General: Inhalation Intravenous

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NCM202B_A Perioperative Nursing Mrs. Fe Corazon Elefan, RN MN Conscious Sedation *** e.g. cocktail of drugs (Midazolam HCl - Dormicum sedative + Nalbuphine HCl Nubain synth narcotic - Form of IV anesthesia that causes depression of the LOC without impairment of patients ability to maintain patent airway and to respond appropriately to physical and verbal command 2. Regional: Spinal Epidural Field block IV regional block with tourniquet 3. Local Topical Spray Injection Factors that Determine Choice of Anesthesia 1. Health status 2. Health History 3. Emotional Stability inc dosage 4. Factors relation to operative procedure Purposes of Skin Prep 1. To remove dirt and transient (Pseudomonas aeruginosa) microorganism from the skin 2. To reduce resident (Staph and Strep) microorganism to sub pathogenic amounts in short time with least tissue irritation 3. Inhibit rapid growth of microorganism Types of Sutures 1. Absorbable Example: Plain surgical gut Chromic surgical gut Synthetic absorbable polymers: PDS (polydiaxonone) absorb in 90 days Maxon (polyglyconate) absorb in 60 days (brown) Vicryl (polyglactin) 910 absorb in 40 days (violet) Dexon (polyglyconic acid) absorb in 30 days 2. Non- absorbable Example: Surgical silk (black) Surgical Cotton (white) Staples Common Suturing Techniques (count instruments and sponges before and after surg) 1. Primary suture line are sutures that hold wound edges in approx during healing by first intention. *** most widely used in lacerations or superficial wound 14

NCM202B_A Perioperative Nursing Mrs. Fe Corazon Elefan, RN MN 2. Continuous suture a series of stitches used to close peritoneum, blood vessels. Provides a leak proof suture line. 3. Interrupted suture each stitch is taken and suture separately. *** each suture is knotted and cut 1cm above the knot 4. Buried suture suture is placed under the skin. May be interrupted or continuous. ***Does not leave mark 5. Subcuticular suture line a continuous suture placed beneath the epithelial layer of skin in short lateral stitches 6. Pursed String Suture a continuous suture placed around the lumen and tightened in drawstring fashion to close lumen. Use in inverting the stump for the appendix 7. Secondary suture line to reinforce and support primary suture line, and obliterate dead space and to prevent fluid accumulation in wound during healing by first 1st intention Ex. retention suture *** used for infected wounds 8. Traction suture to retract suture to one side. Infection Control in Surgery Health care-associated infection (HAIs) are largely preventable Surgical Site Infections (SSI) account 40% of all HAIs Studies show that patients who develop SSI are twice as likely to die as to those who do not, 60% most likely to require ICU admission, remain in the hospital twice as long and rate of readmission 6x higher. Consideration in Infection Control among Surgical Clients Preventing the patient from getting infection Preventing the patient from giving infection to surgical staff Preventing the spread of infection to others outside surgery Operating Room should be Cleaned ASAP after surg By: cleaning all surfaces; correct disposal; of sharps and clinical wastes After Care of Instruments: Instruments must be immersed in warm water and soap, (to prevent congealing or solidifying of blood) Instruments must be thoroughly cleaned in a designated clean-up area before sterilization If possible used instruments must be washed mechanically rather by hand Skin Prep Skin prep will do as long as the shaving of the incision is done immediately before the surgical procedure Is done preferably in the OR Skin Drapes As general rule: cotton fabric drapes is recommended. Disposable plastic drapes does not reduce the infection rate of clean wounds as compared to fabric in drapes Fabric drapes are properly sterilized, packaged stored and handled *** C Curve position spinal anesthesia Infiltration, Topical (spray, cream, ointment) *** Anesthesia screen, screen separating the head from the working area *** Consult anesthesiologist before wheeling patient to the OR 15

NCM202B_A Perioperative Nursing Mrs. Fe Corazon Elefan, RN MN *** Nurse should accompany patient to the OR with the attendant *** Holding area, temporary area before wheeling client to OR for further assessment by the circulating nurse; CLMMRH hallways is the holding area

*** Abdominal Ex Lap - wide incision (6 inches) in the abdomen *** Adhesion - intestines stick together; pain, abdominal distention; may happen years post-op; Adhesiolysis releasing of intestines *** By laparoscopic means and organs are examined Abdominal laparoscopy - incision is 3-4 inches. *** Esophagoscopy person is sedated; viewing of esophagus *** Neurogenic Shock shock from pain *** Minor surgery is less than 30 minutes *** Minor surgery biopsy, circumcision, Removal of foreign object ***As long as an incision is made to remove foreign object - minor surgery *** Penrose Drain and Cigarette Drain; for Incision and Drainage (I and D); I and D is not sutured; minor surgery and procedure *** Debridement removal of necrotic tissue *** Ungectomy removal of ingrown toenail; Ungulum med term for toenail *** Cataract Removal *** Tonsillectomy is Major surgery *** Vaginal Landscaping is Minor

*** Major Surgery *** Head *** Hydrocephalus Ventricular Shunt; Ventriculoperitoneal Shunt *** Cranioectomy part of cranium is removed *** Removal of Brain Tumor *** Neck *** Tonsillectomy *** Thyroidectomy

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NCM202B_A Perioperative Nursing Mrs. Fe Corazon Elefan, RN MN Prepare pt. for surgery Goal of Pre-op Protect patient from injury Goal of Intra-op Immediate Post Op Recovery Specifics from OR Nurse Overall tolerance of patient to pain Type of surgery Type of anesthetics Results complications I&O Number 1 concern: Respiratory Status of Patient position head to side or lateral sims Assess: Vital signs Respiratory rate Color Fluid intake IV therapy Special equipment Dressing ***refer accordingly the stoma (5 peso coin size) of the incision; surgeon does the COD Nursing Goals 1. Maintain Normal Respiratory Function Airway till gag reflex is ok -- plastic airway to prevent falling back of tongue to ensure airway is not obstructed Position side lying position, hyperextend the head to maintain patent airway Suction Cough/deep breathing O2 inhalation -- as prescribed by the doctor Mechanical support mechanical ventilator or ambu bag Breath sounds 2. Incision Area Drainage T-tube (cover the tube using gloves - CLMMRH)for Cholecystectomy Record output from drains 3. Balanced Fluid Status *** Increase pre-op and post op anti-diuretic hormone = increased aldosterone; assess through skin turgor Blood loss? IV rate Outputs Bladder distension Electrolytes Hydration skin turgor: to check for hydration (resilient = hydrated) 17

NCM202B_A Perioperative Nursing Mrs. Fe Corazon Elefan, RN MN Character of drainage -- describe color and amount from NGT, Hemovac (negative pressure must be maintained; after mastectomy), Jackson Pratts drainage system (placed also after mastectomy) NGT Nausea and vomiting? due to untoward effect of anesthesia Prevent aspiration prevented through positioning (side lying) 4. Psychological Equilibrium procedure itself is a stressor Speak calmly low tone of voice Orient Quiet atmosphere Body alignment position pt properly Explain Remember hearing last to go; and the first to be activated Client returns to room if: o Vital signs ok o Awake o Dressings ok o Airway ok Positioning skin preparation draping PAIN ANALYSIS inspect, palpate, observe Pain is a universal symptom Subjective Factors meaning Location/Duration Detailed history Assessment/Intervention o Bladder full palpate or check output o Pain meds given every 6 hours o Infiltrated IV o Non patent tube o Gas o Surgical discomfort Provoking Quality Region Severity Timing

Question Child Use rating scale 18

NCM202B_A Perioperative Nursing Mrs. Fe Corazon Elefan, RN MN Evaluative Secure if restless Take into account pathology Objective Data General assessment Affective behavior Verbal behavior BP and RESPI *** If in pain, vital signs usually go up; take into consideration the pathology of the disease

Analysis

Nursing Dx o Anx o Alteration o Fear Plan and implement Nursing Care Non-invasive pain management ... Cutaneous stimulation diversion of pain through the hand ... Relaxation reduction of pain; breathing exercises Medications for relief o PCA o Narcotics o Non narcotics o Non steroidal

POST-OPERATIVE Complications Hemorrhage Evisceration Infection Dehiscence Dehiscence separation or splitting open of layers of a surgical wound Evisceration extrusion of viscera or intestine through a surgical wound *** use abdominal binders; when coughing, splint pillow on abdomen, press, inhale deeply and cough Place client in low fowler`s, warm saline solution soaked in big sponge, cover the viscera; tell pt. not to cough, not to drink and not to eat because the patient will be brought back to the OR Classification of Suture (Refer to page14 and Perioperative Nsg Skills Lab) 1. Absorbable: suture that is broken down and dissolved by enzymes produced by the body 19

NCM202B_A Perioperative Nursing Mrs. Fe Corazon Elefan, RN MN E.g. CATGUT derived from the sub mucosa of the sheeps intestine or serosa of beefs intestine Rate of Absorption is influenced by: Type of tissue absorbed rapidly in serous or mucous membrane Condition of tissue can be used in the presence of infection use bigger suture! Healing by 2nd intention General Health status of the patient absorbed more rapidly in undernourished or diseased tissues E.g. a. Plain surgical gut absorbed within 70 days; used to ligate small blood vessels and suture subcutaneous fat Chromic surgical gut absorbed within 90 days, used to ligate large blood vessels b. Synthetic Absorbable Polymers absorbed by a slow hydrolysis process in the presence of tissue fluids Immediate Post-operative Care (RR PACU SCU) from transfer to recovery room till the person does not need surgical care anymore Post-op 1. Maintenance of airway (patency) 2. Promote gas exchange Oxygen inhalation Breathing, coughing, turning to side, etc. Nebulization 3. Prevent hypotension 4. Identify cardiac arrhythmias 5. Promote fluid and electrolyte balance 6. Prevent injury 7. Provide comfort ***pneumonia may lead to atelectasis; do coughing and breathing exercise Pulmonary Complications a. Atelectasis collapse of alveoli in the lungs b. Pneumonia an acute inflammation of the lungs

Clinical Signs and Symptoms of High Risk for Pulmonary Complication Increased or dry respiratory secretions Decreased thorax expansion Decreased diaphragm mobility Depressed respiratory centre due to drugs or aspirated gastric contents Factors influencing Wound Healing o Age o Nutritional status o Circulation status 20

NCM202B_A Perioperative Nursing Mrs. Fe Corazon Elefan, RN MN

Complications of Wound Healing o Hemorrhage- likely to occur within 1st 48 hours o Infection Symptoms o Fever after 3rd day post-op o Increased WBC (leukocytosis) o Incisional swelling o Erythema

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