Perioperative Concepts and Nursing Management

HARLEY L. DELA CRUZ BSN RN MAN Candidate

Perioperative Nursing
Preoperative Nursing Intraoperative Nursing Postoperative Nursing

Perioperative Nursing
Preoperative phase- the period of time from when the decision for surgical intervention is made to when the patient is transferred to the operating room table

Perioperative Nursing
Intra-operative phase- period of time from when the patient is transferred to the operating table to when he or she is admitted to the post anesthesia care unit

Perioperative Nursing
Postoperative phase- period of time that begin with the admission of the patient to the post anesthesia care unit and ends after a follow-up evaluation in the clinic setting or home

PREOPERATIVE NURSING MANAGEMENT

Examples of Perioperative Nursing Activities

Preoperative Phase Preadmission Testing a. Initiates initial preoperative assessment b. Initiate teaching appropriate to patients needs c. Involves family in interview d. Verifies completion of preoperative testing e. Assess patients need need for postoperative transportation and care

Admission to Surgical Unit a. Completes preop assessment b. Assesses for risk for post op complications c. Reports unexpected findings or any deviationsfrom normal d. Verifies that operative consent has been signed e. Coordinates patient teaching with other nursing staff f. Reinforce previous teaching

g. Explain phases in perioperative period and expectations h. Answers patients and family questions i. Develops a plan of care Holding Area a. Assess patient status b. Review chart c. Identifies patient d. Verifies surgical site e. Establishes IV line

f. Administers preop meds g. Takes measures to assure patients comfort h. provides psychological support i. Communicates patients emotional status to other appropriate member of health care team

Surgical Classifications/ Categories of Surgical Procedures 1. Diagnostic- discovery or confirmation of a diagnosis- biopsy 2. Curative- removal of damaged or diseased tissue or organs- excision of tumor/appendectomy/ hysterectomy 3. Constructive- repair of congenitally defective body part- cleft palate/lip repair

Preoperative Nursing Management

4. Reconstructive/cosmeticspartial/complete restoration of body part- mammoplasty/facelift/ total hip replacement 5. Aesthetic- improvement of physical features that are within the normal range- breast augmentation

Classification of Surgery According to Degree of Urgency 1. Emergency- patient requires immediate attention; discomfort may be life threatening; without any delay eg. Severe bleeding, bladder/intestinal obstruction, fractured skull, gunshot/stab wounds, extensive burns 2. Urgent- patient requires prompt attention; within 24-30 hours, eg. Acute gallbladder infection, kidney and urethral stone

3. Required- patient need to have surgery; plan within few weeks or months eg. Prostatic hyperplasia without bladder obstruction, thyroid disorder and cataracts 4. Elective- patient should be operated on; failure to have surgery not catastrophic eg. Repair of scar, simple hernia and vaginal repair 5. Optional- decision rest to patient; personal preference eg. Cosmetic surgery

Preop assessment 1. Medical/ health history- history and experience with anesthesia, serious illness, trauma-(a. allergy; b. bleeding tendencies;c. cortisone/ steriod; d. dm; e. emboli) alcohol, chronic illness, advanced age, medication history 2. Psychological examination- knowledge of cultural beliefs/practices/ traditional health care, alternative and complementary practices; lifestyle, ability to tolerate pain

3. Physical examination- specific body system assessment 4. Additional- age, pain nutritional status, F&E, infection and immunity, hematologic functions

Medication History
a.
b. c.
Assess for possible drug to drug interaction adrenalcorticosteriods- should not be stop abruptly- CV collapse Diuritics- excessive resp. depression Phenobiazines- inc. hypotensive action of anesthetics Anti-depressants- MAO inhibitors; hypotensive action of anesthetics

d.

e.tranquilizers- barbiturates, diazepammay cause anxiety, tension, even seizure if withdrawn suddenly f. Insulin g. anti- biotics- mycin drugs such as neomycin/streptomycin + muscle relaxant nerve transmission is interrupted and apnea will occur due to resp. paralysis

Informed Consent
Voluntary/ written/ signed before surgery Protects the patient from unsanctioned surgery and protects the surgeon from claims of an authorized surgery Physician provide simple clear explanation of what the surgery entail Inform the patient of alternative, possible risks, complications, disfigurement, disability, removal of body parts

a. b. c. d.

Not valid if patient signed is under the influence of substances/ medications that affect judgment and decision making capability Consent necessary: Procedure is invasive Anesthesia is used Non-surgical procedure with riskanteriogram Procedures with radiations

Patient signs the consent in legal age/mentally capable Life saving measures may perform operation without consent No patient should be urged or coerced to sign a consent; valid consent must be freely given without coercion, threat, force, urge Refusing to undergo a surgical procedure is a persons legal right and privilege Cant sign patient who are mentally retarded, ill and comatose

a. b. c. d. e.

The consent should be written and contain: Explanation of procedure/risk Description of benefits/ alternatives Offer Q&A about procedure Instruction to withdraw from consent Other changes from routine procedure Written in language understandable to the patient Q&A open communication for confusion

Immediate Preop Care

PHYSICAL CARE a. Prepare the skin- shower/bathing b. GIT- dec. vomiting/aspiration/ dec. possible bowel obstruction; 8-10h food/fluid restricted c. Nutritional care-inc. CHO, CHON, vit. C, K and minerals

d. Preoperative teaching 1. Sensory information 2. Psychosocial information- coping abilities, worries about family, concerns 3. Procedural information- before, during and after surgery; before surgery px should be taught with deep breathing, coughing, turning, ambulating,pain control and equipments

Immediate Preop Activities

1. Allergies recorded 2. VS 3. Correct identification 4. Consent form signed 5. Skin prep 6. Check special orders 7. NPO 8. Client voided/cath. Recorded 9. Oral hygiene/ other physical care completed 10. Check for presence of dentures or prosthesis

11. Valuables should be endorsed/ kept and documented 12. Jewelry removed- wedding band allowedsecured; remove wigs, hair pins 13. Hearing aide- for communication 14. Hospital gown with cap on 15. Colored nail polish removed 16. Make-up removed for for skin color to be observed

Commonly Used Preop Medications

1. Tranquilizers- Diazepam (valium)- dec.
anxiety; se. dizziness, clumsiness or confusion; Properidol (inapsine)- dec. anxiety se. anxiety, hypotension 2. Sedatives- midazola HCl- induces sleep, dec. anxiety se. dec BP, resp. depression Phenergan (promethazines HCl) - dec. anxiety/ antiemetic se. dec. BP 3. Secobarbital Na/ pentobarbital Na- dec. anxiety/ sedation se. disorientation

4. Anlgesics- morphine sulfate- relieves pain, and dec. anxiety/sedation se. resp/ circulatory depression, dec. BP, GI motility, vomiting 5. Anticholenergics- atropine SO4 se. dry mouth, tachycardia 6. Histamine H2- receptor antagonist cimetidine (Tagamet)- dec. gastric acid production se. mild dizziness, diarrhea somnolence and rash

Focus of planning/ goal/ implementation is to decrease preop anxiety and increase knowledge of preop preparations and post op expectations Transport patient to or room safely and securely medical record, smooth transfer to avoid nausea and dizziness

Preop Nursing Diagnosis

Anxiety related to the surgical experience (anesthesia and pain) and the outcome of the surgery Risk for ineffective management of therapeutic regimen r/t knowledge deficit regarding preoperative procedures and protocols and postoperative expectations Anticipatory grieving process related to loss of limb

evaluation
Expected outcomes: a. Anxiety is relieved- discusses concerns, verbalized understanding on preanesthesia meds and gen anesthesia; relaxes quietly b. Prepares for surgical intervention- participates in preop preparations; demostrate and describes exercises to be performed postop, accepts preop meds, remains in bed, relaxes during transportation, states rationale for side rails c. Participates in discharge planning

INTRAOPERATIVE NURSING MANAGEMENT

Intraoperative Nursing Management

Nursing care focuses on the clients emotional well-being and physical factors such as safety, positioning, maintaining asepsis and controlling the surgical environment

Example activities during Intraoperative Phase Maintenance of Safety 1. Positions the patient a. Functional alignment b. Exposure of surgical site c. Maintenance of position throughout the procedure 2. Applies grounding device to patient 3. Provide physical support 4. Ensures that sponges, needles and instrument counts are correct 5. Maintains aseptic technique

6. Effectively manages human resources

Physiologic Monitoring 1. Calculates effects on patient of excessive fluid loss or gain 2. Distinguishes normal from abnormal CP data; reports any changes in pulse, resp, temp, and BP

Psychological Support before Induction while Conscious 1. Provides emotional support 2. Stands near or touches patient during the induction of anesthetics 3. Continues to assess patients emotional status

a. Surgeon- head of surgical team; makes

Members of the Surgical Team

decision on surgical procedures; second surgeon or specially trained nurse may serve as assistant b. Anesthesiologist- alleviates pain; promote relaxation with meds; provides/ maintains airway, monitor circulation, resp, estimates blood and fluid loss, infuses blood and fluids, alerts surgeon if any complication occurs

c. Nurse anesthetist- trained to induct anesthesia; 2 yrs additional edu. BSN + I year ICU experience; work under anesthesiologist d. Circulating nurse- core member of the surgical team; maintains the coordination of team members; client advocate, RN, dont wear sterile clothing can go in and out in or; ensuring all equipments working properly; maintains sterility of instruments/supplies; assisting with positioning; performing skin prep; monitoring the room and team members for break on sterile technique

Assisting anesthesia personnel; handling specimen; coordinate with other department; documenting care rendered and minimizing conversation and traffic with in operating suite e. Scrub nurse- RN or surgical technician; scrubbing for surgery; setting up sterile table; preparing sutures, ligatures, special equipment; assisting surgeon; anticipating needs; keeping tract of the time/ time wound opened; counts all needles, sponges and instruments before closing the incision

Labels specimen/ send to lab;should be RN or PN or surgical technician f. Registered nurse first assistant- providing exposure of the surgical area; using instrument to hold and cut; retracting and handling tissue; providing hemostasis; suturing; and must work with a surgeon; not an independent practitioner

Anesthesia
Artificial induction state of partial or complete loss of sensation with or without loss of consciousness it can produce muscle relaxation, block nerve pain impulses transmission, suppresses reflexes and temp. dec. in memory retrieval and recall

1. General- block pain stimulus at cerebral

Types

cortex and induces depression of CNS/ effects: analgesia, amnesia, unconsciousness, loss of reflexes and muscle tone- resp; cv; neuro; suited for surgery of head, neck , upper torso, back, prolonged surgical procedures or cant lie for long period of time 2. Regional- blocks the pain stimulus at its origin, along afferent neurons, or along the spinal cord; does not result to unconsciousness of patient + sedativedrowsiness

Four Stages of Anesthesia

I.
Onset- loss of consciousness; pt. Drowsy;dizzy; auditory and visual hallucination; nurse must close the door, quiet, stay in the side of the client II. Excitement- loss of consciousness; loss of eyelid reflexes; inc. autonomic activity, irregular breathing; struggle- remain quiet on side ; assist anesthetist

III. Surgical anesthesia- loss of eyelid reflexes; dec. vital functions; pt. Unconscious, muscles relax, no blink or gag reflexes IV. Danger (death)- vital functions depressed; client not breathing; no heart beat- est. airway, prep cardiac arrest tray, drugs, syringes, close/ open cardiac massage

Administration of General Anesthesia

Most common method is neuroleptic or balanced anesthesia combination of inhalation agent; O2, narcotic,and neuro blocking agent Types: a. IV- rapid transition stages 1-3 eg. Thiopental, ketalar, fentanyl citrate- dec. motor activity; resp; allergy; dont mix with atropine /contra- CVA, HPN, inc. ICP, alcoholics, COPD, renal dysfunctions

b. Inhalations- mixture of volatile liquids or gas + oxygen ; maintains the client in stage 3; given thru mask or ET eg. halothane; forane; nitrous oxide ; enflurane- dont give with seizure history, check for BP and pulse, dont give patient in labor

Administration of Regional Anesthesia

Types: 1. Spinal- subarachnoid space; comphypotension; trendelenburg ; increase IV; NV;Headache- flat on bed 6-8h postop, binder, analgesic; resp. paralysis- artificial resp; neurologic complications- muscle weakness, paraplegia

2. Epidural- epidural block- injected in epidural space; hypotension, resp. paralysis, dysfunctions 3. Caudal-used with OB clients commonly 4. Topical 5 . Local infiltration-skin and SQ 6. Field block-the area of incision; avoid blood vessel for systemic effect 7. Peripheral nerve block- individual nerves 8. Bier block(IV regional extremity block anesthesia) lidocaine injected to vein tourniquet is applied to control distribution

Intraoperative Nursing Care

Maintain safety and prevent injury Position the patient: supine/ dorsal recumbent- bypass, mastectomy, bowel resection Trendelenburg- intestinal; lower abd, pelvis Lithotomy- perineal and rectal, vaginal repairs Lateral- kidney chest/ hip injury

a. b.

c.
d.

Provide equipment safely- counting surgical supplies such as needles, sponges, and instrument with 2 persons when? a. Before initial incision b. During surgery c. Before wound is close All plugs, wires and equipment should be checked for their proper functioning and avoid electrical burn Maintain surgical asepsis- surgeon, assistants and scrub personnel

Assisting with wound closure- sutures, staples, skin strips tapes, drain is placepromote healing prevent infection, characteristic of drainage Monitoring body temperature- 60-70 degrees F- comfort, inhibit bacterial growth, cooling body dec. metabolic rate; patient should be covered heat loss is great; infant/burn warm the environment; weakness, fainting and nausea leave the room a. Malignant hyperthermia- occur when succinyl choline and inhalation agent esp. halothane

 Monitoring for emergency a. Malignant hyperthermia-genetic-

uncontrollable skeletal muscle contraction; occur when succinyl choline and inhalation agent esp. halothane; 30 min after induction or several hours; inc. CO2, muscle rigidity cardiac dysrhythmias, hypermetabolic rate, fever of 43 degrees C; treatment: datholene- skeletal muscle relaxant- dec. muscle rigidity b. Allergic reaction- latex, solutions and materials

c. N and V- full stomach, turn px to side with basin, suction saliva and vomitus d. Cardiac and resp. arrest- crash cart available; death- surgeon resp. to communicate with folks d.Hypoxia/ pulmonary complications- inadequate ventilation, pulse oximeter- monitoring, can occlude salive, blood or vomitus e. hypothermia- anesthesia; temp in or; cold infusion IV; cold gases inhalation, open wound and cavities; dec muscle activitiy; advance age, drugs- vasodilation like phenothiazine and gen. anesthesia

Anxiety Risk for injury related to anesthesia and surgery Risk for perioperative positioning injury related to required position and loss of protective responses secondary to anesthesia Sensory/ perceptual alteration r/t to general anesthesia or conscious sedation

Intraop Nursing Diagnosis

evaluation
Exhibits low level of anxiety No threat to security Free from surgical positioning injuries Maintain environmental safety Dignity preserved Free from complications or experience successful management of adverse effects of surgery and anesthesia

Moving and Transporting the Client

Wipes excess blood and debris; put on new gown Avoid rapid movement IV patent Avoid rough handling Side rails up strapped;with warm blanket Maintain patients modesty

Major causes of death during or after surgery

Pneumonia Renal failure Cardiac arrest Stroke Pulmonary emboli Sepsis Peritonitis hypovolemic shock

The classic sign of shock:

Pallor Cool, moist skin Rapid breathing Cyanosis of lips, gums, and tongue Reapi, weak, thready pulse Decreasing pulse Low blood pressure and concentrated urine

POSTOPERATIVE NURSING MANAGEMENT

Postoperative Nursing
Example of activities post op phase: Transfer of patient to postanesthesia care unit 1. Communicates intraoperative information a. Identify patient by name b. States surgery performed c. Identifies type of anesthesia used d. Reports patients response to surgical procedure

e. Describe intraop factors eg. Insertion of drains, catheter, adm of blood, analgesic agents f. Describe physical limitations g. Reports patients preop level of consciousness h. Communicates accessory equipments

Postoperative Assessment Recovery Area 1. Determine patients immediate response to surgical intervention 2. Monitor patients physiologic state 3. Maintains patients safety- airway, breathing, safety 4. Adm medication , fluids and blood

5. Assess patients readiness to transfer to inhospital unit or for discharge Surgical Unit: 1. Continues close monitoring of patients physical and psychological response to surgical intervention 2. Provides teaching during immediate recovery period 3. Assist patient in recovery and preparation for discharge home 4. Identifies patient psychological status 5. assisting with discharge planning

Home or Clinic: 1. Provides follow-up care during office or clinic visit or by telephone contact 2. Reinforce previous teaching; answer their questions about surgery and follow-up care 3. Assess pts response to surgery and anesthesia and their effects on body image and function 4. Determine familys perception of sugery and its outcome

Postop Period
3 Phases: 1. Initial period of time for recovery from anesthesia 2. Discharge from PACU to the first day after surgery; pt recovering from effects of surgery; beginning to eat and ambulate 3. Time of healing, last for weeks, months or even years

Post anesthesia period- critical time that needs close and constant observation, positioning, patent airway, suction machine available in bedside Immediate Assessment: airway; breathingabnormalities, stay in bedside until gag refrex return; circulation- bp, pulse, color, wound status, dressing, pulse oximeter, electrolyte imbalances, pain, hypovolemia Others- level of consciousness, muscle strength, drains, temp

Assessment of the postop client:

Assess resp status Assess circulation Assess neurologic status- level of consciousness Monitor wound- appearance, drainage, discomforts; infn- 3-4 days post op, redness beyond incision line, edema, drainage, fever, malaise, anorexia, inc WBC

Dehiscence- opening of incision Evisceration- incision site opened with internal organ- cover organ with sterile dressings moisten with NSS, VS, calm the pt. Notify the physician Monitor intravenous lines- patency, type, rate , I/O Monitor drainage tube- NGT, suction, characteristic, document

Promote comfort- pain, prn meds, description of pain, effects of pain common N and V Reduce N and V- morphine, meperidine, cardiac glycosides, and amphetamines to control: anticholinergics; antidopaminergics and GI antispasmodics Discharge instructions and care- information and skills needed to continue care, meds instructions, wound care, appointments, open communicatin for questions, collaborate with health care workes in community and rehabilitation services

Home Care Teaching Check List

State procedure performed Describe post op medication and treatment Describe procedure for changing dressing and providing wound care State activities to avoid- driving, operating machinery State allowed activities

State dietary restrictions Describe signs and symptoms of complications State time and date follow-up appointments State how to reach health provider with questions or complications

Postop Nursing Diagnosis

Risk for injury Hypothermia Risk for infection Pain r/t surgical incision Risk for ineffective airway clearance r/t dec resp function Self care deficit r/t post op fatigue and pain Impaired skin integrity r/t surgical incision and drainage

Body image disrurbance Risk for altered nutrition: less than r/t dec intake and inc need for nutrient secondary to surgery Risk for altered elimination: constipation r/t effects of meds, diet change, immobility

a. b. c. d. e. f.

Potential Complications: Atelectasis and pneumonia Deep vein thrombosis Wound infection Dehiscence/ evisceration Paralytic ileus Hemorrhage/ hypovolemic shock

SAMPLE QUESTION
Keeping tract of the time patient under anesthesia and time of incision is made are functions primarily by a: a. anesthesiologist b. scrub nurse c. circulating nurse d. surgical assistant

Ans.B

SAMPLE QUESTION
Handling specimen and documenting care rendered to patient during intraoperative period are tasks to accomplish by a: a. Registered Nurse First Assistant b. scrub nurse c. OR manager d. circulating nurse

ANS. D

SAMPLE QUESTION
Which of the following nursing diagnosis is most priority during post op period? a. Pain related to surgical incision b. Ineffective airway clearance related to decrease respiratory function and pain c. Risk for wound infection related to susceptibility to wound infection d.Alteration in nutrition: less than body requirement related to decrease intake and increase need for nutrients

ANS. B

SAMPLE QUESTION
1. During the initial interview, the nurse has
assessed for history of seafood allergy with Mrs. L. Which nursing action is appropriate? administer anti-histamine prepare resuscitative equipment and emergency medication postoperatively prominently note allergies of patient on chart do not give pre-op medication an hour before the schedule of surgery

a. b. c. d.

ANS. C

SAMPLE QUESTION
One of the patients in surgical ward scheduled for amputation in the next two days verbalized, Im going to miss my leg. Which of the following nursing diagnosis is appropriate in the statement presented: a. Fear and anxiety related to surgery b. Potential for injury related to hemorrhage c. Anticipatory grieving process related to loss of limb d. Immobility related to loss of limb functioning

ANS. C

SAMPLE QUESTION
Which of the following is not included in the physical preparation of patient undergoing surgery? a. assessing level fear and concerns b. sedation for sleep c. cleansing of the colon d. informed consent

ANS. A

SAMPLE QUESTION
The following must be observed by the ward nurse on the day of surgery, EXCEPT: a. patient must wear hospital gown b. jewelry must be removed including prosthesis c. pre-op medication given 30 min in anticipated time schedule d. long hair braided

ANS. D

SAMPLE QUESTION
Atropine sulfate is given to operative patient to counteract the effects of vagal stimulation. This medication is classified as: a. sedative b. narcotic c. anticholenergic d. neuro-blocking agent

ANS. C

SAMPLE QUESTION
Mrs. had undergone surgical laparotomy 2 days post op, because of fear of pain, patient refuses to do coughing exercise. Which nursing action appropriate to minimize pain during coughing exercises? a. Splint the area of incision with hands and apply pressure b. splint abdominal area with elastic bandage c. give sedative to lessen post-op pain d. turn patient side

ANS. A

SAMPLE QUESTION
Healing of surgical wound is most apt to be retarded by inadequate intake of: a. carbohydrate b. fat c. minerals and vitamins d. protein

ANS. D

SAMPLE QUESTION
Which of the following nursing interventions should be considered by the nurse if evisceration will exist to a post op patient? a. keep patient calm and place a sterile gauze with D5LR solution b. cover the incision site with sterile gauze or towel moisten with isotonic solution c. cover with gauze only since moisture could attract microorganism and can cause contamination d. look for the surgeon and never perform any nursing intervention with the wound since this incident needs doctors order to avoid malpractice

ANS. B

SAMPLE QUESTION
Early ambulation should be initiated primarily to: a. prevent thrombophlebitis b. fast relief o post-op pain c. early healing of wound d. prevent pneumonia

ANS. A

SAMPLE QUESTION
Patient Mr. G. complains of post op pain after gaining consciousness, your next appropriate nursing action: a. give morphine sulfate after checking the respiratory rate b. check bowel sounds c. encourage deep breathing and coughing exercises d. frequent change of position as desired

ANS. A

SAMPLE QUESTION
The fourth stage of anesthesia is characterized by: a. uncontrolled movement b. flushed skin c. elevated BP d. non-reactive pupil

ANS. D

SAMPLE QUESTION
The stage of anesthesia induction where the patient may perceive things and sounds heard differently? a. danger stage b. excitement stage c. onset stage d. surgical anesthesia stage

SAMPLE QUESTION
The scrub nurse together with circulating nurse counts the instruments and sponges: a. prior to the removal of oxygen and before closure of surgical incision b. before the start of the abdominal incision and before the closure of the fascia c. prior the abdominal incision and after the closure of perineum d. before the start of abdominal incision and prior to closure of peritoneum

ANS. D

SAMPLE QUESTION
Which of the following activities improves bowel and bladder a day after surgery? a. deep breathing b. leg exercises c. coughing d. walking

end
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