PERIOPERATIVE NURSING

Prepared by: Annabeth K. Salonga RN,MAN

PHASES OF SURGERY
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 into 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 procedure is done, until he/she is transported to the recovery room/ postanesthesia care unit. 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.

Four Major Types of Pathologic Processes Requiring Surgical Intervention

Obstruction - Impairment to the flow of vital fluids. E.g. blood, urine, CSF, bile. Perforation - Rupture of an organ. Erosion - Wearing off of a surface or membrane. Tumors - Abnormal new growths.

Classification of Surgical Procedures

According to PURPOSE

Diagnostic - To establish the presence of a disease condition, e.g. biopsy.

Exploratory - To determine the extent of the disease condition, e.g. exploratory laparotomy. Curative - To treat the disease condition. Ablative - Involves removal of an organ. (Suffix used is "ectomy") e.g. appendectomy

Classification of Surgical Procedures

According to PURPOSE

Constructive - Involves repair of congenitally defective organ (suffixes used are '"plasty/5 "orrhaphy/" "pexy") e.g. cheiloplasty, orchidopexy* Reconstructive - Involves repair of damaged organ, e.g. plastic surgery after severe bums. Palliative - To relieve distressing signs and symptoms, not necessarily to cure the disease.

Classification of Surgical Procedures

According to Degree of RISK (Magnitude/Extent)

A. Major Surgery High risk Extensive Prolonged Large amount of blood loss Vital organs may be handled or removed Great risk of complications B. Minor Surgery Generally not prolonged Leads to few serious complications Involves less risk

Classification of Surgical Procedures

According to URGENCY
Emergency - To be done immediately to save life or limb. Imperative - To be done within 24 to 48 hours. Planned Required - Necessary for well - being. May be scheduled weeks or months. Elective - Not absolutely necessary for survival. Delay or omission will not cause adverse effect. Optional - Requested by the client. Usually for aesthetic purposes. Day (Ambulatory Surgery) - Done on out - patient basis.

Surgical Risks
General Risk Factors 1. Obesity 1. Fluid, electrolyte and nutritional problems 2. Age 3. Presence of disease/s 4. Concurrent or prior pharmacotheraphy Other Factors 1. Nature of condition 1. Location of the condition 2. Magnitude and urgency of the surgical procedure 3. Mental attitude of the person toward surgery 4. Caliber of the professional staff and health care facilities

The Effects of Surgery to the Client

1. Stress response is elicited 2. Defense against infection is lowered. 1. Vascular system is disrupted. 2. Organ functions are disturbed.

3. Body image may be disturbed.

4. Lifestyles may change

Preoperative Phase
Goals
1. Assessing and correcting physiologic and psychologic problems that might increase surgical risk. 2. Giving the person and significant others complete learning / teaching guidelines regarding surgery, 3. Instructing and demonstrating exercises that will benefits the person during postop period. 4. Planning for discharge and any projected changes in lifestyle due to surgery.

Physiologic Assessment of the Client Undergoing Surgery

1. Age 2. Presence of Pain 3. Nutritional Status 4. Fluid and Electrolyte Balance 5. Infection 6. Cardiovascular Function 7. Pulmonary Function 8. Renal Function 9. Gastrointestinal Function 10. Liver Function 11. Endocrine Function 12. Neurologic Function 13. Hematologic Function 14. Use of Medication 15. Presence of Trauma

Psychosocial Assessment and Care

Causes of Fears of the Preoperative Clients

Fear of the unknown

Fear of anesthesia, vulnerability while unconscious Fear of pain Fear of death

Fear of disturbance of body image

Worries - loss of finances,, employment, social and family roles

Psychosocial Assessment and Care

Manifestations of Fears
1. 2. 3. 4. 5. 6. 7. 8. 9. Anxiousness Bewilderment Anger Tendency to exaggerate Sad, evasive, tearful, clinging Inability to concentrate Short attention span Failure to carry out simple directions Dazed

Psychosocial Assessment and Care

Nursing Interventions To Minimize Anxiety

1. Explore client's feelings

2. Allow client's to speak openly about fears / concerns 3. Give accurate information regarding surgery 4. Give empathetic support

5. Consider the person's religious preferences

and arrange for visit by priest/ minister as desired

Informed Consent (Operative Permit / Surgical Consent)

Purposes
1. To ensure that the client understands the nature of
the treatment including the potential complications and disfigurement (explained by AP),

2. To indicate that the client's decision was made

without pressure. 3. To protect the client against unauthorized

procedure.
4. To protect the surgeon and hospital against legal action by a client who claims that an unauthorized

procedure was performed,

Informed Consent (Operative Permit / Surgical Consent)

Circumstances Requiring a Permit
1. Any surgical procedure where scalpel, scissors, suture, hemostats of etectrocoagulation may be used.

2. Entrance into a body cavity - e.g. paracentesis,

bronchoscopy, cystocopy, colonoscopy, proctosigmoidoscopy

3. General anesthesia, local infiltration, regional block.

4. Requisites for Validity of Informed Consent 5. Secured without pressure or duress

6. Written permission is best and is legally acceptable.

Informed Consent (Operative Permit / Surgical Consent)

Circumstances Requiring a Permit
7. Signature is obtained with the client's complete understanding of what is to occur. a. Adults sign their own operative permit. b.Obtained before sedation. 8. A witness is desirable - nurse, physician or other authorized persons. 9. In an emergency, permission via telephone or telefax is acceptable. 10. For minor (below 18 yrs.), unconscious, psychologically incapacitated, permission is required from responsible family member (parent / legal guardian),

Physical Preparations
Before Surgery
1. 2. 3. 4. 5. 6. 7. Correct any dietary deficiencies Reduce an obese persons weight Correct fluid and electrolyte imbalances Restore adequate blood volume with blood transfusion Treat chronic diseases - DM, heart disease, renal insufficiency Halt or treat any infectious process Treat an alcoholic person with vitamin supplementation, IVF's or oral fluids, if dehydrated. 8. Teaching Preop Exercises 1. Deep breathing exercises - diaphragmatic 2. Incentive spirometry 3. Coughing exercises 4. Turning exercises 5. Foot and leg exercises

Physical Preparations
Preparing the Person the Evening Before Surgery
1. Preparing the skin. Have full bath to reduce microorganisms in the skin. 1. Preparing the G.I. Tract NPO; cleansing enema as required. 2. Preparing for Anesthesia Avoid alcohol and cigarette smoking for at least 24 hours before surgery. 3. Promoting rest and sleep Administer sedatives as ordered.

Physical Preparations
Preparing the Person On the Day of Surgery
Early AM 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 (chewing gum), colored nail polish, hearing aid, contact lens (wedding ring - tie with gauze and fasten around the wrist). Take baseline VS before preop medication. Check ID band, skin prep Check for special orders - enema, G.I. tube insertion, IV line Check NPO p Have client void before preop medication. Continue to support emotionally o Accomplish "preop care checklist5

Preoperative Medications/ Preanesthetic Drugs

Goals:

To facilitate the administration of any

anesthetic.
To minimize respiratory tract

secretions and
rate).

changes in HR (heart

To relax the client and reduce anxiety.

Preoperative Medications/ Preanesthetic Drugs

Commonly used Preop Meds.

Tranquilizers

Sedatives
Analgesics

Anticholinergics
Histamine~H2 Receptor Antagonist

Transporting The Client to the OR

Patient's Family

Direct proper visiting room. Doctor informs family immediately after surgery. Explain reason for long interval of waiting: anesthesia prep, skin prep, surgical procedure, RR. Explain what to expect postop.

Intraoperative Phase
Goals of Care:

1. Asepsis

2. Homeostasis
3. Safe Administration of Anesthesia 4. Hemostasis

STERILE TECHNIQUES AND THEIR APPLICATIONS

1. Strict aseptic and sterile techniques are needed at all times in the operating room. Sterile techniques prevent transfer of microorganisms into body tissues. Freshly incised or traumatized tissue can become infected easily. Intact skin and mucous membranes are the bodys first line of defense against infection. 2. Operative procedures are formed under sterile conditions, i.e., contamination with microorganisms is prevented to maintain sterility throughout to operation. 3. A sterile field is created around the site of incision into tissues or for introduction of sterile instruments into a body orifice.

STERILE TECHNIQUES AND THEIR APPLICATIONS

4. Conversely, terminal decontamination and sterilization of all material and equipment used during an operation is performed with the assumption that every patient is a potential source of infection for other persons.

5. The patient is the center of the sterile field, which includes the areas of the patient, operating table and furniture covered with sterile drapes, and the personnel wearing sterile attire.
6. Strict adherence to sound principles at sterile techniques and recommended practices is

Principles of Aseptic Techniques

1. Only sterile items are used within sterile field 2. If you are in doubt the sterility of anything, consider it not sterile 3. Gowns are considered sterile only in front from chest to level of sterile field, and the sleeves

from above elbows of cuffs

4. Tables are sterile only at table level 5. Persons who are sterile touch only sterile items or areas; persons who are not sterile touch only unsterile items or areas

Principles of Aseptic Techniques

6. Unsterile persons avoid reaching over a sterile field; sterile persons avoid leaning over an unsterile area 7. Edges of anything that encloses sterile contents

are considered unsterile

8. Sterile field is created as close as possible to

time of use
9. Sterile areas are continuously kept in view 10. Sterile persons keep well within the sterile area

Principles of Aseptic Techniques

11. Unsterile person avoid sterile areas

12. Destruction of integrity of microbial barriers

results in contamination 13. Microorganisms must be kept to an irreducible minimum 14. Skin cannot be sterilized

The Surgical Team

The Surgical Team

Includes:

1. Surgeon
2. Anesthesiologist 3. Assistant Surgeon (Surgical Resident) 4. Surgical Intern (optional) 5. Scrub Nurse 6. Assistant Scrub Nurse (optional) 7. Circulating Nurse

Positions During Surgery

1. Dorsal Recumbent - hernia repair, mastectomy, bowel resection 2. Trendelenburg - lower abdomen, pelvic surgeries 3. Lithotomy - vaginal repairs, D and C, rectal surgery, APR(Abdomino - Perineal Resection) 4. Prone - spinal surgeries, laminectomy 5. Lateral - kidney, chest, hip surgeries 6. Sitting pulmonary (thoracostomy) 7. Jackknife (Knee-Chest) procto-surgeries

Positions During Surgery

SURGICAL ANESTHESIA

SURGICAL ANESTHESIA
Medically induced insensitivity to pain: Induced loss of sensitivity to pain in all or a part of the body for medical reasons. Methods include drugs, acupuncture, and hypnosis. The procedure may render the patient unconscious or merely numb a body part

Types of Anesthesia
General Anesthesia
Total loss of consciousness and sensation Produces amnesia Uses IV - IV Barbiturate, Pentothal Na 5 - 10% Inhalation of Volatile Liquids (Ethyl Ether) Rectal - Anectine

Types of Anesthesia
General Anesthesia

1. Gas Inhalation 2. Intravenous General Anesthesia 3. Rectal General Anesthesia

Types of Anesthesia
Regional Anesthesia
Reduce all painful sensation in one region of the body without inducing unconsciousness. Types 1. Spinal Anesthesia 2. Epidural Block 3. Field Block (Peripheral Block/ Bier Block) Uses
Procaine (Novocaine) Tetracaine (Pontocaine) Lidocaine (Xylocaine) Mepivacaine (Carbocaine) Bupivacaine (Marcaine

Types of Anesthesia
Regional Anesthesia
1. Spinal Anesthesia

Types of Anesthesia
Regional Anesthesia
2. Epidural Block

Types of Anesthesia
Regional Anesthesia
3. Field Block (Peripheral Block)

Types of Anesthesia
Regional Anesthesia
3. Field Block (Bier Block)

Types of Anesthesia
Local Infiltration
- merely numb a body part 1. Xylocaine (lidocaine) 2% Injection 2. Topical 3. Ointment

Stages of Anesthesia
1. Onset / Induction - Extends from the administration
of anesthesia to the time of loss of consciousness.

2. Excitement / Delirium - Extends from the time of

loss of consciousness to the time of loss of lid reflex. It may be characterized by shouting, struggling of the client.

3. Surgical - Extends from the loss of lid reflex to the loss

of most reflexes. Surgical procedure is started.

4. Medullary / Stage of Danger - It is characterized

by respiratory / cardiac depression or arrest. It is due to overdose of anesthesia. Resuscitation must be done.

Complications and Discomforts of Spinal Anesthesia

1. Hypotension o Nausea / Vomiting
2. Headache

3. Respiratory Paralysis
4. Neurologic Complications (paraplegia,

severe muscle weakness of the legs)

Surgical Incisions
Butterfly. For craniotomy. Limbal. For eye surgeries. Halstead / Elliptical. For breast surgeries. Abdominal. For abdominal surgeries. Mc Bumeys. For appendectomy. Lumbotomy / Transverse. For kidney surgeries

Postoperative Period
GOALS: 1. Maintain adequate body system functions. 2. Restore homeostasis 3. Alleviate pain and discomfort 4. Prevent postop complications

5. Ensure adequate discharge planning and

teaching.

Nursing Care of Patient During the Immediate Postop (Immediate Postanesthesia Recovery - RR)
Transport of the Client from the OR to RR 1. avoid exposure 2. avoid rough handling 3. avoid hurried movement and rapid changes in position.

Nursing Assessment and Interventions

ASSESSMENT 1. Appraise air exchange status and note skin color 2. Verify identity, operative procedure, surgeon 3. Assess neurologic status (LOC) 4. Determine VS and skin temperature (CV status) 5. Examine operative site and check dressings 6. Perform safety checks a. position for good body alignment b. side rails c. restraints for IVF's, Blood transfusion 7. Require briefing on problems encountered in OR

Interventions (RR)
1. Ensure maintenance of patent airway and adequate respiratory function. a. lateral position with neck extended. b. keep airway in place until folly awake a suction secretions a encourage deep breathing c. administer humidified oxygen as ordered. 2. Assess status of circulatory system a. monitor VS and report abnormalities b. observe signs and symptoms of shock and hemorrhage 3. promote comfort and maintain safety 4. continuous, constant surveillance of the client until he/she is completely out of anesthesia. 4. recognize stress factors that may affect the client in RR and minimize these factors.

Transfer of the Client from RR to the Surgical Unit

Parameters for Discharge from RR

1.Activity - Able to obey commands, e.g. deep breathing, coughing 2.Respiration - Easy, noiseless breathing. 3.Circulation - BP is within 20 mmHg of the preop level. 4.Consciousness - Responsive. 5.Color - Pinkish skin and mucus membrane.

POSTOPERATIVE

COMPLICATIONS

POSTOPERATIVE COMPLICATIONS
1. SHOCK 2. HEMORRHAGE 3. FEMORAL PHLEBITIS / DEEP THROMBOPHLEBITIS 4. PULMONARY COMPLICATIONS 5. URINARY DIFFICULTIES 6. INTESTINAL OBSTRUCTION HICCUPS 7. WOUND INFECTIONS 8. WOUND COMPLICATIONS 9. POSTOP PSYCHOLOGICAL DISTURBANCES

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). INTERVENTION 1. Immediate Blood Transfusion 2. IVF infusion 3. O2 inhalation 4. Elevate lower extremities

HEMORRHAGE
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: 1. Apprehension; restlessness; thirst; cold, moist, pale skin 2. Deep, rapid RR; low body temperature 3. Low CO (cardiac output) 4. Low BP, low hgb 5. Circumoral pallor; spots before the eyes, ringing in ears 6. Progressive weakness, then death ensues Management: 1. Vit. K (aquamephyton), Hemostan 2. Ligation of bleeders 3. Pressure dressings 4. 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: 1. Injury: damage to vein 2. Hemorrhage 3. Prolonged immobility 4. Obesity /Debilitation Clinical Manifestations 1. Pain 2. Redness 3. Swelling 4. Heat/warmth 5. + Homan's sign

FEMORAL PHLEBITIS / DEEP THROMBOPHLEBITIS

Nursing Interventions 1. Prevention 2. Hydrate adequately to prevent hemoconcentration. 3. Encourage leg exercises and ambulate early. 4. Avoid any restricting devices that can constrict and impair circulation. Prevent use of bed rolls, knee gatches, dangling over the side of the bed with pressure on popliteal area. Active Intervention 1. Bed rest, elevate the affected leg with pillow support 2. Wear anti embolic support hose from the toes to the groin. 3. Avoid massage on the calf of the leg. 4. Initiate anticoagulant therapy as ordered.

PULMONARY COMPLICATIONS
1. 2. 3. 4. 5. 6. Atelectasis Bronchitis Bronchopneumonia Lobar pneumonia Hypostatic pulmonary congestion Pleurisy

Nursing Interventions Reinforce deep breathing, coughing, turning exercises (DBCT) Encourage early ambulation Incentive spirometry

URINARY DIFFICULTIES
1. Retention
Occurs most frequently after operation of the rectum, anus, vagina, lower abdomen. Caused by spasm of the bladder sphincter.

2. Incontenence
(30 - 60 ml. q 15-30 mins, - overdistened bladder overflow incontenence). Loss of tone of the bladder sphincter.

Nursing Interventions
Implement measures to induce voiding.

INTESTINAL OBSTRUCTION (3rd to 5th Postop Day)

Loop of intestine may kink due to inflammatory adhesions Clinical Manifestations 1. Intermittent sharp, colicky abdominal pains 2. Nausea and vomiting (fecaloid) 3. Abdominal distortion, hiccups 4. Diarrhea (incomplete obstruction), no bowel movement (complete) 5. Return flow of enema is clear 6. 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. Cause Irritation of phrenic nerve between the spinal cord and terminal ramifications on undersurface of the diaphragm. Nursing Interventions 1. Remove the cause e. g. abdominal distention - NGT insertion 2. Hold breath while taking a large swallow of water. 3. Pressing on the eyeball through closed lids for several minutes. 4. Breath in and out paper bag (C02) 5. Plasil (methochlorpramide) as ordered.

WOUND INFECTIONS
Causes:
1. 2. 3. 4. 5. Staphylococcus aureus Escherichia coli Proteus vulgaris Pseudomonas aeruginosa Anaerobic bacteria

Clinical Manifestations:
1. 2. 3. 4. 5. 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 closest to wound

WOUND INFECTIONS
Rule of Thumb
1. Fever 1st 24-pulmonary infection 2. Within 48 - UTI (urinary tract infection) 3. Within 72 - wound infection

Preventive Interventions:
1. Housekeeping cleanliness in the surgical environment 2. STRICT ASEPTIC TECHNIQUES 3. Wound care 4. Antibiotic therapy

WOUND COMPLICATIONS
Kinds: 1. Hemorrhage / Hematoma 2. Wound Dehiscence - disruption in the coaptation of wound edges (wound breakdown) 3. Wound Evisceration ~ dehiscense + outpouching of abdominal organs Nursing Interventions: 1. Apply abdominal binders 2. Encourage proper nutrition - high CHON, Vit. C 3. Stay with client, have someone call for the doctor 4. Keep in bed rest 5. Supine or semi - Fowler's position, bend knees to relieve tension on abdominal muscles 6. Cover exposed intestine with sterile, moist saline dressing 7. Reassure, keep him/her quiet and relaxed 8. Prepare for surgery and repair of wound.

POSTOP PSYCHOLOGICAL DISTURBANCES

Delirium (Mental Aberration) ACS (Acute Confusional State) Causes: 1. Dehydration 2. Insufficient oxygenation 3. Anemia 4. Hypotension 5. Hormonal imbalances 6. Infection 7. Trauma (especially in nervous persons)

POSTOP PSYCHOLOGICAL DISTURBANCES

Manifestations:
1. 2. 3. 4. 5. 6. 7. Poor memory Restlessness Inattentiveness Inappropriate behavior Wild excitement, hallucinations, delusions, depression Disoriented Sleep disturbances

Nursing Interventions
1. 2. 3. 4. 5. Sedatives to keep client quiet and comfortable Explain reasons for interventions Listen and talk to the client and significant others Provide physical comfort Treat the underlying cause