Perioperative Nursing

Must of an OR Nurse
You must work very rapidly after under tension  You must have a quick reaction time and make changes for unexpected situation without notice  You must anticipate the surgeons needs and keep 1 step ahead of time  You must fit in and work smoothly as a member of closely functioning team  You must be specially able to organized your work effectively so that not a single minute is lost, not a notion superfluous


You must be patient for those who may sometimes become impatient in tense situation, because some degree of tension may be present at times  You must have initiative and stamina combined with honesty and dependability  You must be responsible and with pleasing personality  You must gain the patients confidence and reassure him  You must be quiet yet responsive  You must be able and willing to take your turn on call without complaint  You must have a sense of humor, an open mind and flexibility


Preoperative phase
 Extends

from the time the client is admitted in the surgical unit, to the time he/ she is prepared physically, psychosocially, spiritually and legally for the surgical procedure, until he is transported in to the operating room.

Intraoperative phase


Extends from the time the client is admitted to the operating room, to the time of administration of anesthesia, surgical procedures is done, until he/ she is transported to the RR/ PACU.

Postoperative phase
 Extends

from the time the client is admitted to the recovery room, to the time he is transported back into the surgical unit, discharged from the hospital, until the follow-up care. follow-

4 Major types of Pathologic Processes Requiring Surgical Intervention (OPET):



Obstruction Perforation Erosion tumors

Classification of surgical procedures



According to purpose
Diagnostic Exploratory Curative  Ablative- involves removal of an organ. Ablative Constructive- involves repair of Constructivecongenitally defective organ.  Reconstructive- involves repair of Reconstructivedamaged organ Palliative

 According
 High

to Degree of RISK

Major Surgery
risk  Large amount of blood loss  Vital organs may be handled or removed  Great risk of complications

Minor Surgery
 Involves

less risk  Small amount of blood loss

 According

to URGENCY

Emergency- to be done immediately to Emergencysave life. Imperative- to be done within 24 to 48 Imperativehours. Elective- not absolutely necessary for Electivesurvival. Optional- requested by the client. Optional-

Surgical Risks
electrolyte and nutritional problems  Age  Presence of disease/s  Mental attitude of the person toward surgery  Caliber of the professional staff and health care
 Fluid,

The Effects of Surgery to the Client

 Stress  Defense

against infection is lowered  Organ functions are disturbed  Body image may be disturbed  Lifestyle may change

Methods of Sterilization


Mechanical
1. Autoclave 2. Carbolization

Chemical
1. Glutaral dehyde/ cidex 2. Cutasept

Gas
1. E.O gas 2. Hydrogen peroxide- sterrad machine peroxide-

Preoperative Phase
 Goals

Assessing and correcting physiologic and psychologic problems that might increase surgical risk. Instructing and demonstrating exercises that will benefits the person during post op period.

Physiologic assessment of the client undergoing surgery Age Presence of pain Nutritional status Fluid and electrolyte balance Infection Cardiovascular function Pulmonary function Renal function GI function Liver function Endocrine function Neurologic function Hematologic function Use of medication Presence of trauma

 Psychosocial

Assessment and Care

Fear of the unknown Fear of anesthesia Fear of pain Fear of death Fear of disturbance of body image Worries

 Nursing

Interventions to Minimize

Anxiety
Explore clients feelings Allow clients to speak openly about fears/ concerns Give accurate information regarding surgery Give empathetic support Consider the persons religious preferences and arrange for visit by priest/ minister as desired

 Informed

Consent

Purposes
 To

ensure that the client understands the nature of the treatment  To indicate that the clients decision was made without pressure  To protect the client against unauthorized procedure  To protect the surgeon and hospital against legal action by a client who claims that an unauthorized procedure was performed

 Circumstances Requiring a Permit

 Any

surgical procedure where scalpel, scissors, suture, hemostats of electrocoagulation may be used.  Entrance into a body cavity  General anesthesia, local infiltration, regional block.

 Requisites for Validity of Informed Consent

 Written

permission is best and is legally acceptable.  Signature is obtained with the clients complete understanding of what is to occur  Secured without pressure or duress  A witness is desirable  In an emergency, permission via telephone or telefax is acceptable  For minor (below 18 yrs.), unconscious, psychologically incapacitated, permission is required from responsible family member.

 Physical

Preparations

Before Surgery
 Correct

any dietary deficiencies  Reduce an obese persons weight  Correct fluid and electrolyte imbalances  Restore adequate blood volume with blood transfusion  Treat chronic diseases  Halt or treat any infectious process  Treat an alcoholic person with vitamin supplementation, IVFs or oral fluids, if dehydrated.

 Teaching Preop Exercises

 Deep

breathing exercises  Incentive spirometry  Coughing exercises  Turning exercises  Foot and leg exercises

 Preparing

the Person the Evening before Surgery

Preparing the skin.
 Have

full bath cleansing enema as required sedatives as ordered

Preparing the G.I. Tract

 NPO;

Promoting rest and sleep

 Administer

 Preparing

Surgey

the Person On the Day of

Early A.M. Care

 Awaken

1 hour before preop medications  Morning bath, mouth wash  Provide clean gown  Remove hairpins, braid long hair, cover hair with cap  Remove dentures, foreign materials, colored nails polish, hearing aid, contact lens  Take baseline VS before preop medication  Check ID band, skin prep  Check for special orders  Check NPO  Have client void before preop medication  Continue to support emotionally  Accomplish preop care checklist

Intraoperative

Role of Circulating Nurse

1. Checking of all supplies and equipments needed in particular operation 2. Receiving the patient in OR table 3. Preparing the patient in OR table 4. Vital signs assessment 5. Assisting the anesthesiologist 6. Position the patient for anesthesia 7. Attending the needs of the surgeon and scrub nurse 8. Counting the instruments and sponges before, during and after surgery 9. Carrying out intra OP orders 10. Proper documentation and labeling of specimen 11. Opening and serving sterile items

 Skin

Preparation Of:

Wearing gloves Scrub skin starting at the site of the incision in circular motion; use enough friction and pressure

 Contaminated

Areas:

Umbilicus, stoma, drainage, skin ulcers, vagina, anus Separate sponges/ last to be prepared

Roles of Scrub Nurse

1. Set up the operating room together with the circulating nurse 2. Do- surgical scrubbing, gowning, gloving Do3. Preparing the instruments/ sterile field needed for particular surgery 4. Arranging of instruments and back table 5. Serving of sterile gowns and gloves 6. Assisting the surgeon/ proper serving of instruments 7. Anticipate the needs of the surgeon 8. Washing and decontaminating used instruments 9. Packing of instruments

Role of Anesthesiologist
1. Inducting the anesthesia 2. Monitor vital signs 3. Monitoring blood loss, urine output, level of consciousness of the client 4. Determine if the patient may be move in PACU 5. Check patients airway

Role of Surgeon
1. Captain of the ship 2. Performs operative procedure 3. Draping of patients

Postoperative Period

 Goals

Maintain adequate body system functions Restore homeostasis Alleviate pain and discomfort Prevent postop complications Ensure adequate discharge planning and teaching

 Nursing

Care of patient during the Immediate Postop

Post anesthesia Recovery
 Transport

of the client from OR to RR

Avoid exposure Avoid rough handling Avoid hurried movement and rapid change in position

 Nursing Assessment and Interventions

 Assessment

Appraise air exchange status and note skin color Verify identity, operative procedure, surgeon Assess neurologic status Determine VS and skin temperature Examine operative site and check dressings Perform safety checks Require briefing on problems encountered in OR

 Interventions
 Ensure

maintenance of patent airway and adequate respiratory function.

Lateral position with neck extended Keep airway in place until fully awake Suction secretions Encourage deep breathing Administer humidified oxygen as ordered

 Assess

status of circulatory system

Monitor VS and report abnormalities Observe signs and symptoms of shock and hemorrhage Promote comfort and maintain safety Continuous, constant surveillance of the client until he/ she is completely out of anesthesia Recognize stress factor that may affect the client

 Transfer

of the Client from RR to the Surgical unit

Parameters for discharge from RR
 Activity.  Respiration  Circulation  Consciousness  Color

 Nursing

Care of the client During the intermediate Postop period

Baseline Assessment
 Respiratory

Status  Cardiovascular Status  LOC  Tubes  position

 Ongoing

Assessment, Goals and Interventions

Goals
 Restore

homeostasis and prevent complications  Maintain adequate cardiovascular and tissue perfusion  Maintain adequate respiratory function

Causes of Obstruction Airway

1. 2. 3. 4. Mucous collection in the throat Aspirated mucus/ vomitus Loss of swallowing reflex Loss of control of the muscle of the jaw and tongue 5. Laryngospasm due to intubation 6. bonchospasm

Causes of Hypoventilation
1. 2. 3. 4. Medications Pain Chronic lung disease Obesity

 Nursing

Care of Clients During the Extended Postop Period

2-3 days after surgery
 Self

care activities  Activity limitations  Diet and medications at home  Possible complications  Referrals, follow-up check up follow-

Postoperative Complications
 shock

Impaired tissue metabolism

Cell / organ death

 Hemorrhage

Copious escape of blood from the blood vessel

 CapillaryCapillary-

slow, generalized oozing  Venous- dark in color and bubble out Venous Arterial- spurts and is bright red in color Arterial-

 Clinical Manifestation
 Apprehension;

restlessness; thirst; cold; moist; pale skin  Deep, rapid RR; low body temperature  Low CO  Low BP, low hgb  Circumoral pallor; spots before the eye, ringing in the ears  Progressive weakness, then death ensues

 Management
 Vit.

K, hemostan  Ligation of bleeder  Pressure dressings  Blood transfusion; IV fluids

 Femoral

Phlebitis

Often occurs after operations on the lower abdomen or during the course of septic conditions as ruptured ulcer or peritonitis
 Causes:

prolong immobility Obesity

 Clinical

Manifestation

Pain Redness Swelling Heat/ warmth + homans sign

 Nursing

Intervention

Prevention
 Hydration

leg exercise  Early ambulation

 Encourage

Active Intervention
 Bed

rest  Elevate the affected leg with pillow support  Avoid massage on the calf of the leg  Initiate anticoagulant therapy as ordered

 Pulmonary  Urinary

Complications

Difficulties Obstruction

 Intestinal
 Colicky

Clinical Maniestation
abdominal pain  Abdominal distention  Diarrhea  No bowel movement

 Hiccups  Wound  Wound

Infection Complication

Wound dehiscence- disruption in the dehiscencecoaptation of wound edges Wound evisceration- dehiscence+ eviscerationoutpouching of abdominal organs