Perioperative Nursing (complete)

PERIOPERATIVE
NURSING

Copyright © 2008 Lippincott Williams & Wilkins.

PERIOPERATIVE NURSING
– used to describe the nursing care
provided in the total surgical
experience of the patient:
a. preoperative
b. intraoperative
c. postoperative.

Preoperative Phase
extends from the time the client
is admitted in the surgical unit, to
the time he/she is prepared for the
surgical procedure, until he is
transported into the operating room.


Intraoperative Phase
is admitted to the OR, to the time of
administration of anesthesia, surgical
procedure is done, until he/she is
transported to the RR/PACU.


Postoperative Phase
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.

4 Major Types of Pathologic Process
Requiring Surgical Intervention (OPET)

Obstruction – impairment to the flow
of vital fluids (blood,urine,CSF,bile)
Perforation – rupture of an organ.
Erosion – wearing off of a surface or
membrane.
Tumors – abnormal new growths.

Identify the type of pathologic process
requiring surgery
Hydrocephalus Obstruction

Burn Erosion

Benign Prostatic Hyperplasia Tumor

Cholelithiasis Obstruction

Intussusception Obstruction

Perforation
Ruptured Aneurysm


Classification of Surgical
Procedure


According to PURPOSE:

Diagnostic – to establish the presence of a
disease condition.
( e.g biopsy )

Exploratory – to determine the extent of
disease condition
( e.g Ex-Lap )


Curative – to treat the disease condition.

* Ablative – removal of an organ “ectomy”
* Constructive – repair of congenitally
defective organ “plasty,oorhaphy,pexy”
* Reconstructive – repair of damage organ

Palliative – to relieve distressing sign and
symptoms, not necessarily to cure the
disease.

Identify the type of surgery according to
purpose:
Pap Smear Diagnostic

Tonsilectomy Curative - Ablative
Nephrocapsulectomy Curative - Ablative
Osteoplasty Curative - Constructive
Perineorrhaphy Curative - Reconstructive
Trachelorrhaphy Curative - Constructive
Curative - Reconstructive
Skin Grafting


According to URGENCY

Classification Indication for Surgery Examples
Emergent – patient requires - severe bleeding
immediate attention, life
threatening condition. Without delay - gunshot/ stab wounds
- Fractured skull
Urgent / Imperative – patient Within 24 to 30 hours - kidney / ureteral stones
requires prompt attention.
Required – patient Plan within a few weeks - cataract
or months
needs to have surgery. - thyroid d/o
Elective – patient should have Failure to have surgery - repair of scar
surgery. not catastrophic
- vaginal repair
Optional – patient’s decision. Personal preference - cosmetic surgery


According to DEGREE OF RISK

Major Surgery
- High risk / Greater Risk for Infection
- Extensive
- Prolonged
- Large amount of blood loss
-Vital organ may be handled or removed

Minor Surgery
- Generally not prolonged
- Leads to few serious complication
- Involves less risk

Ambulatory Surgery/ Same-day Surgery / Outpatient
Surgery

Advantages:
- Reduces length of hospital stay and cuts costs
- Reduces stress for the patient
- Less incidence of hospital acquired infection
- Less time lost from work by the patient; minimal
disruptions on the patient’s activities and family life.


Disadvantages:
- Less time to assess the patient and perform preoperative
teaching.
- Less time to establish rapport
- Less opportunity to assess for late postoperative
complication.


Example of Ambulatory Surgery

ｷ Teeth extraction
ｷ Circumcision
ｷ Vasectomy
ｷ Cyst removal
ｷ Tubal ligation


Surgical Risk
ｷ Obesity
ｷ Poor Nutrition
ｷ Fluid and Electrolyte Imbalances
ｷ Age
ｷ Presence of Disease (Cardiovascular dse.,
DM, Respiratory dse. )
ｷ Concurrent or Prior Pharmacotherapy
ｷ other factors:
- nature of condition
- loc. of the condition
- magnitude / urgency of the surgery
- mental attitude of the patient
- caliber of the health care team

PREOPERATIVE PHASE


Goals
ｷ Assessing and correcting physiologic and
psychologic problems that may increase surgical risk.

ｷ Giving the person and significant others complete
learning / teaching guidelines regarding surgery.

ｷ Instructing and demonstrating exercises that will
benefits the person during postop period.

ｷ Planning for discharge and any projected changes in
lifestyle due to surgery.

Physiologic Assessment of the Client Undergoing
Surgery
ｷ Presence of Pain
ｷ Nutritional & Fluid and Electrolyte Balance
ｷ Cardiovascular / Pulmonary Function
ｷ Renal Function
ｷ Gastrointestinal / Liver Function
ｷ Endocrine Function
ｷ Neurologic Function
ｷ Hematologic Function
ｷ Use of Medication
ｷ Presence of Trauma & Infection


Routine Preoperative Screening Test
Test Rationale
CBC RBC,Hgb,Hct are important to the
oxygen carrying capacity of blood.
WBC are indicator of immune function.
Blood grouping/ X Determined in case blood transfusion is
matching required during or after surgery.
Serum Electrolyte To evaluate fluid and electrolyte status
PT,PTT Measure time required for clotting to
occur.
Fasting Blood High level may indicate undiagnosed DM
Glucose

BUN / Creatinine Evaluate renal function
ALT/AST/LDH Evaluate liver function
and Bilirubin
Serum albumin Evaluate nutritional status
and total CHON
Urinalysis Determine urine composition
Chest Xray Evaluate resp.status/ heart size
ECG Identify preexisting cardiac
problem.


Psychosocial Assessment and Care

Causes of Fears of the Preoperative Clients

ｷ Fear of Unknown ( Anxiety )
ｷ Fear of Anesthesia
ｷ Fear of Pain
ｷ Fear of Death
ｷ Fear of disturbance on Body image
ｷ Worries – loss of finances, employment, social and
family roles.


Manifestation of Fears

- anxiousness
- bewilderment
- anger
- tendency to exaggerate
- sad, evasive, tearful, clinging
- inability to concentrate
- short attention span
- failure to carry out simple directions
- dazed


Nursing Intervention to Minimize Anxiety

ｷ Explore client’s feeling
ｷ Allow client’s to speak openly about
fears/concern.
ｷ Give accurate information regarding surgery
(brief, direct to the point and in simple terms)
ｷ Give empathetic support
ｷ Consider the person’s religious preference and
arrange for visit by a priest / minister as desired.


INFORMED CONSENT


Purposes:
To ensure that the client understand the nature
of the treatment including the potential
complications and disfigurement
( explained by AMD )
To indicate that the client’s 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
authorized procedure was performed.

Circumstances Requiring Consent
Any surgical procedure where scalpel, scissors,
suture, hemostats of electrocoagulation may be
used.

Entrance into body cavity.

Radiologic procedures, particularly if a
contrast material is required.

General anesthesia, local infiltration and
regional block.

Essential Elements of Informed Consent

ｷ The diagnosis and explanation of the condition.
ｷ A fair explanation of the procedure to be done
and used and the consequences.
ｷ A description of alternative treatment or
procedure.
ｷ A description of the benefits to be expected.
ｷ The prognosis, if the recommended care,
procedure is refused.


Requisites for Validity of Informed Consent
ｷ Written permission is best and legally accepted.
ｷ Signature is obtained with the client’s complete
understanding of what to occur.
- adult sign their own operative permit
-obtained before sedation

ｷ For minors, parents or someone standing in their
behalf, gives the consent.
Note: for a married emancipated minor parental consent is
not needed anymore, spouse is accepted

ｷ For mentally ill and unconscious patient, consent must
be taken from the parents or legal guardian

ｷ If the patient is unable to write, an “X” is accepted if
there is a witness to his mark

Secured without pressure and threat

A witness is desirable – nurse, physician or
authorized persons.

When an emergency situation exists, no consent is
necessary because inaction at such time may cause
greater injury. (permission via telephone/cellphone is
accepted but must be signed within 24hrs.)

Pre Operative Care


Physical Preparation

Before Surgery
Correct any dietary deficiencies
Reduce an obese person’s weight
Correct fluid and electrolyte imbalances
Restore adequate blood volume with BT
Treat chronic diseases
Halt or treat any infectious process
Treat an alcoholic person with vit.
supplementation, IVF or fluids if
dehydrated

Pre Operative Teaching

Incentive Spirometer
Diaphragmatic Breathing
Coughing
Splinting
Turning
Foot and Leg Exercise
Early Ambulation


Incentive Spirometer


ﾘ Encouraged to use incentive spirometer
about 10 to 12 times per hour.

ﾘ Deep inhalations expand alveoli, which
prevents atelectasis and other pulmonary
complication.

ﾘ There is less pain with inspiratory
concentration than with expiratory
concentration.

Diaphragmatic Breathing

ﾘ Refers to a flattening of the dome of the diaphragm
during inspiration, with resultant enlargement of
upper abdomen as air rushes in. During expiration,
abdominal muscles contract.

ﾘ In a semi-Fowlers position, with your hands loose-
fist, allow to rest lightly on the front of lower ribs.

ﾘ Breathe out gently and fully as the ribs sink down
and inward toward midline.

ﾘ Then take a deep breath through the nose and
mouth, letting the abdomen rise as the lungs fill with
air.

ﾘ Hold breath for a count of 5.

ﾘ Exhale and let out all the air through your nose
and mouth.

ﾘ Repeat this exercise 15 times with a short rest
after each group of 5.

Coughing and Splinting

Quic kTime™ and a
dec ompress or
are needed to see this picture.


ﾘ Promotes removal of chest secretions.
ﾘ Interlace his fingers and place hands over the
proposed incision site, this will act as a splint and
will not harm the incision.
ﾘ Lean forward slightly while sitting in bed.
ﾘ Breath, using diaphragm
ﾘ Inhale fully with the mouth slightly open.
ﾘ Let out 3-4 sharp hacks.
ﾘ With mouth open, take in a deep breath and
quickly give 1-2 strong coughs.


Turning

ﾘ Promotes removal of chest secretions.
ﾘ Interlace his fingers and place hands over the
proposed incision site, this will act as a splint and
will not harm the incision.
ﾘ Lean forward slightly while sitting in bed.
ﾘ Breath, using diaphragm
ﾘ Inhale fully with the mouth slightly open.
ﾘ Let out 3-4 sharp hacks.
ﾘ With mouth open, take in a deep breath and
quickly give 1-2 strong coughs.

Foot and Leg Exercise
ﾘ Moving the legs improves circulation and muscle
tone.
ﾘ Have the patient lie supine, instruct patient to bend
a knee and raise the foot – hold it a few seconds and
lower it to the bed.
ﾘ Repeat above about 5 times with one leg and then
with the other. Repeat the set 5 times every 3-5 hours.
ﾘ Then have the patient lie on one side and exercise
the legs by pretending to pedal a bicycle.
ﾘ For foot exercise, trace a complete circle with the
great toe.

Preparing the Patient the Evening Before Surgery
v Preparing the Skin
- have a full bath to reduce microorganisms in the skin.
- hair should be removed within 1-2 mm of the skin to avoid skin
breakdown, use of electric clipper is preferable.
v Preparing the G.I tract
- NPO, cleansing enema as required
v Preparing for Anesthesia
- Avoid alcohol and cigarette smoking for at least 24 hours
before surgery.
v Promoting rest and sleep
- Administer sedatives as ordered

ASA (American Society of Anesthesiologists) Guidelines
for Preoperative Fasting
Liquid and Food Intake Minimum Fasting
Period

Clear Liquids 2

Breast Milk 4

Nonhuman Milk 6

Light Meal 6

Regular / Heavy Meals 8


Preparing the Person on the Day Of Surgery

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 if
available.
Remove dentures, colored nail polish, hearing aid, contact
lenses, jewelries.
Take baseline vital sign before preop medication.
Check ID band, skin prep
Check for special orders – enema, IV line
Check NPO
Have client void before preop medication
Continue to support emotionally
Accomplished “preop care checklist

Pre Operative Medications


PREOPERATIVE MEDICATIONS

Goals:
To aid in the administration of an
anesthetics.
To minimize respiratory tract secretion
and changes in heart rate.
To relax the patient and reduce anxiety.


Commonly used Preop Meds.
- Tranquilizers & Sedatives
* Midazolam
* Diazepam ( Valium )
* Lorazepam ( Ativan )
* Diphenhydramine

- Analgesics
* Nalbuphine ( Nubain )

- Anticholinergics
* Atropine Sulfate

- Proton Pump Inhibitors
* Omeprazole ( Losec )
* Famotidine

Transporting the Patient to the OR

Adhere to the principle of maintaining the
comfort and safety of the patient.
Accompany OR attendants to the patient’s
bedside for introduction and proper identification.
Assist in transferring the patient from bed to
stretcher.
Complete the chart and preoperative checklist.
Make sure that the patient arrive in the OR at the
proper time.

Patient’s Family

Direct to the proper waiting room.
Tell the family that the surgeon will probably
contact them immediately after the surgery.
Explain reason for long interval of waiting:
anesthesia prep, skin prep, surgical procedure, RR.
Tell the family what to expect postop when they
see the patient


Operative Site Identification


INTRAOPERATIVE
PHASE


Goals

ｷ Asepsis
ｷ Homeostasis
ｷ Safe Administration of Anesthesia
ｷ Hemostasis


Surgical Setting

• Unrestricted Area
- provides an entrance and exit from the
surgical suite for personnel, equipment and patient
- street clothes are permitted in this area, and
the area provides access to communication with
personnel within the suite and with personnel and
patient’s families outside the suite


Surgical Setting

• Semi-restricted Area
- provides access to the procedure rooms and
peripheral support areas within the surgical suite.
- personnel entering this area must be in proper
operating room attire and traffic control must be
designed to prevent violation of this area by
unauthorized persons
- peripheral support areas consists of: storage
areas for clean and sterile supplies, sterilization
equipment and corridors leading to procedure room

Surgical Setting

• Restricted Area
- includes the procedure room where surgery is
performed and adjacent substerile areas where the
scrub sinks and autoclaves are located
- personnel working in this area must be in
proper operating room attire


RMC Operating Room Set Up

Anesthesia Department

Recovery OR Suite
Room

Scrubbing/Washing
Area

Storage OR Suite

Nurse
Station

OR Suite
MD/
Nurses
Dressing
Room

OR Suite

Main
Entrance OR Supervisor
Office
Lounge


QMMC Operating Room Set Up
OR OR
Suite Suite

Scrubbing / Washing Scrubbing / Washing
Area Area

OR OR
Suite Suite

Nurses Storage/Supplies
Station

Recovery Room

Dressing Room

OR Manager
Room
Receiving Area Lounge


Environmental Safety

• The size of the procedure room
• Temperature and humidity control
• Ventilation and air exchange system
• Electrical Safety
• Communication System


Size of the Procedure Room
• Usually rectangular or square in shape
• 20 x 20 x 10 with a minimum floor space of 360 square feet
• Each procedure room must have the following equipment:

- Communication System
- Oxygen and vacuum outlets
- Mechanical ventilation assistance equipment
- Respiratory and Cardiac monitoring equipment
- X ray film illumination boxes
- Cardiac defibrillator
- High-efficiency particulate air filters
- Adequate room lighting
- Emergency lighting system


Temperature and Humidity Control

• The temperature in the procedure room should
maintained between 68 F - 75 F ( 20 - 24 degrees C)
• Humidity level between 50 - 55 % at all times


Ventilation and Air Exchange System
• Air exchange in each procedure room should be at least
25 air exchanges every hour, and five of that should be
fresh air.
• A high filtration particulate filter, working at 95%
efficiency is recommended.
• Each procedure room should maintained with positive
pressure, which forces the old air out of the room and
prevents the air from surrounding areas from entering
into the procedure room


Electrical Safety

• Faulty wiring, excessive use of extension cords, poorly
maintained equipment and lack of current safety
measures are just some of the hazardous factors that
must be constantly checked
• All electrical equipment new or used, should be routinely
checked by qualified personnel.
• Equipment that fails to function at 100% efficiency
should be taken out of service immediately.


The Surgical Team

ｷ The Patient
ｷ The Anesthesiologist or Anesthetist
ｷ The Surgeon
ｷ Scrub Nurse
ｷ Circulating Nurse
ｷ RNFA ( Reg.Nurse First Assistant )
ｷ Surgical Technologists


Surgeon


Responsibilities
• Primary responsible for the preoperative medical history
and physical assessment.

• Performance of the operative procedure according to the
needs of the patients.
• The primary decision maker regarding surgical technique
to use during the procedure.
• May assist with positioning and prepping the patient or
may delegate this task to other members of the team


First Assistant to the Surgeon


Responsibilities

• May be a resident, intern , physician’s assistant or a
perioperative nurse.
• Assists with retracting, hemostasis, suturing and any
other tasks requested by the surgeon to facilitate speed
while maintaining quality during the procedure.


Anesthesiologist


Responsibilities

• Selects the anesthesia, administers it, intubates the
client if necessary, manages technical problems
related to the administration of anesthetic agents,
and supervises the client’s condition throughout the
surgical procedure.

• A physician who specializes in the administration and
monitoring of anesthesia while maintaining the
overall well-being of the patient.


Scrub Nurse


Responsibilities
• May be either a nurse or a surgical technician.
• Reviews anatomy, physiology and the surgical procedures.
• Assists with the preparation of the room.
• Scrubs, gowns and gloves self and other members of the
surgical team.
• Prepares the instrument table and organizes sterile equipment
for functional use.
• Assists with the drapping procedure.
• Passes instruments to the surgeon and assistants by
anticipating their need.
• Counts sponges, needles and instruments.
• Monitor practices of aseptic technique in self and others.
• Keeps track of irrigations used for calculations of blood loss

Circulating Nurse


Responsibilities

• Must be a registered nurse who, after additional
education and training, specialized in perioperative
nursing practice.
• Responsible and accountable for all activities occurring
during a surgical procedure including the management of
personnel equipment, supplies and the environment
during a surgical procedure.
• Patient advocate, teacher, research consumer, leader
and a role model.
• May be responsible for monitoring the patient during
local procedures if a second perioperative nurse is not
available.


Very defined activities during surgery:

• Ensure all equipment is working properly.
• Guarantees sterility of instruments and supplies.
• Assists with positioning.
• Monitor the room and team members for breaks in the sterile
technique.
• Handles specimens.
• Coordinates activities with other departments, such as
radiology and pathology.
• Documents care provided.
• Minimizes conversation and traffic within the operating room
suite.


Medical vs. Surgical Asepsis


Principles of Surgical Asepsis
(Sterile Technique)

• Sterile object remains sterile only when touched by
another sterile object
• Only sterile objects may be placed on a sterile field
• A sterile object or field out of range of vision or an
object held below a person’s waist is contaminated


Principles of Surgical Asepsis
(Sterile Technique)

• When a sterile surface comes in contact with a wet,
contaminated surface, the sterile object or field
becomes contaminated by capillary action
• Fluid flows in the direction of gravity
• The edges of a sterile field or container are
considered to be contaminated (1 inch)


Common Surgical Incision
Incision Site
Butterfly
Limbal
Halstead / Elliptical
Subcostal
Paramedian
Transverse
Rectus
McBurney
Pfannenstiel
Lumbotomy

Position During Surgery
Supine ( Dorsal Recumbent )
- Abdominal,extremity,vascular,chest,neck,facial,ear
breast surgery

Positioning Techniques
• Patient lies flat on back with arms either extended on arm boards
or placed along side of body.
• Small padding placed under patient’s head,neck and under knees
• Vulnerable pressure points should be padded.
• Safety strap applied 2 in. above knees.
• Eyes should be protected by using eye patch and ointment.


Prone Position
- Surgeries involving posterior surface of the body (
spine,
neck,buttocks and lower extremities )
• Chest rolls or bolster are placed on operating table prior to
positioning
• Foam head rest, head turned to side or facing downward
• Patient’s arms are rotated to the padded armboards that face
head, bringing them through their normal range of motion.
• Padding for knees and pillow for lower extremities to prevent
toes from touching mattress.
• Safety strap applied 2 in. above the knees


Trendelenburg Position
- Surgeries involving lower abdomen, pelvic organ when
there is a need to tilt abdominal viscera away from the
pelvic area.

• Patient is supine with head lower than feet.
• Shoulder braces should not be used as they may cause damage
brachial plexus.
• When patient is returned to supine position, care must be taken
move leg section slowly, then the entire table to level position.
• Modification of this position can be used for hypovolemic shock.
• Extremity position and safety strap are the same as for supine.


Reverse Trendelenburg Position
- Upper abdominal, head, neck and facial surgery

Positioning Technique
• Patient is supine with head higher than feet.
• Small pillow under neck and knees.
• Well - padded footboard should be used to prevent slippage to
foot of the table.
• Anti embolic hose should be used if position is to be maintained
for an extended period of time.
• Patient should be returned slowly to supine position.


Lithotomy
- Perineal, vaginal, rectal surgeries; combined abdominal
vaginal procedure

• Patient is placed in supine position with buttocks near lower break
in the table ( sacrum are should be well padded )
• Feet are placed in stirrups, stirrups height should not be
excessively high or low, but even on both sides.
• Knee brace must not compress vascular structures or nerves in
the popliteal space.
• Pressure from metal stirrups against upper inner aspect of thigh
and calf should be avoided.
• Legs should be raised and lowered slowly and simultaneously
( may require two people )

Modified Fowler ( Sitting Position )
- Otorhinology (ear and nose ), neurosurgery

• Patient is supine, positioned over the upper break in the table
• Backrest is elevated, knees flexed
• Arms rest on pillow, placed in lap; safety strap 2 in. above the
knees.
• Slow movement in and out of position must be used to prevent
drastic changes in blood volume movement.
• Anti embolic hose should be used to assist venous return.
• When using special neurologic headrest, eyes must be
protected.


Jack Knife Position
- Rectal procedures, sigmoidoscopy and colonoscopy

• Table is flexed at center break
• All precautions taken with prone position are taken with
Jack knife position.
• Table strap applied over thighs


ANESTHESIA


• State of “Narcosis”
• Anesthetics can produce muscle relaxation, block transmission
of pain nerve impulses and suppress reflexes.
• It can also temporary decrease memory retrieval and recall.
The effects of anesthesia are monitored by considering the
following parameters:
- Respiration
- O2 saturation
- CO2 levels
- HR and BP
- Urine output


Types of Anesthesia
1. General Anesthesia

ｷ reversible state consisting of complete loss of
consciousness and sensation.
ｷ protective reflexes such as cough and gag are
lost
ｷ provides analgesia, muscle relaxation and
sedation.
ｷ produces amnesia and hypnosis.


Techniques used in General Anesthesia
A. Intravenous Anesthesia

ｷ This is being administered intravenously and
extremely rapid.
ｷ Its effect will immediately take place after thirty
minutes of introduction.
ｷ It prepares the client for smooth transition to the
surgical anesthesia.
B. Inhalation Anesthesia

ｷ This comprises of volatile liquids or gas and oxygen.
ｷ Administered through a mask or endotracheal tube.

Stages of General Anesthesia

ﾘ Stage 1: Onset / Induction.
ﾘ Stage 2: Excitement / Delirium.
ﾘ Stage 3: Surgical
ﾘ Stage 4: Medullary / Stage of Danger


2. Regional Anesthesia

ｷ temporary interruption of the transmission of nerve
impulses to and from specific area or region of the
body.

ｷ achieved by injecting local anesthetics in close
proximity to appropriate nerves.

ｷ reduce all painful sensation in one region of the body
without inducing unconsciousness.

ｷ agents used are lidocaine and bupivacaine.

Techniques used in Regional Anesthesia:

A. Topical Anesthesia

ｷ applied directly to the skin and mucous membrane,
open skin surfaces, wounds and burns.
ｷ readily absorbed and act rapidly
ｷ used topical agents are lidocaine and benzocaine.


B. Spinal Anesthesia ( Subarachnoid block )

ｷ local anesthetic is injected through lumbar puncture,
between L2 and S1

ｷ anesthetic agent is injected into subarachoid space
surrounding the spinal cord.

- Low spinal, for perineal/rectal areas
- Mid spinal T10 ( below level of umbilicus)
for hernia repair and appendectomy.
-High spinal T4 ( nipple line ), for CS

ｷ agents used are procaine, tetracaine, lidocaine and
bupivacaine.

C. Epidural Anesthesia
ｷ achieved by injecting local anesthetic into epidural space
by way of a lumbar puncture.
ｷ result similar to spinal analgesia
ｷ agents use are chloroprocaine, lidocaine and bupivacaine.

D. Peripheral Nerve Block
ｷ achieved by injecting a local anesthetic to anesthetize the
surgical site.
ｷ agents use are chloroprocaine, lidocaine and bupivacaine.


E. Intravenous Block ( Beir block )
ｷ often used for arm,wrist and hand procedure
ｷ an occlusion tourniquet is applied to the extremity to prevent
infiltration and absorption of the injected IV agents beyond the
involved extremity.

F. Caudal Anesthesia
ｷ Is produced by injection of the local anesthetic into the caudal
or sacral canal

G. Field Block Anesthesia
ｷ The area proximal to a planned incision can be injected and
infiltrated with local anesthetic agents.


Nursing Management

Assessment
Diagnosis
Planning
Intervention
Evaluation


Complications and Discomforts of Anesthesia

ｷ Hypoventilation - inadequate ventilatory support
after paralysis of respiratory muscles.
ｷ Oral Trauma
ｷ Malignant Hyperthermia - uncontrolled skeletal
muscle contraction
ｷ Hypotension - due to preoperative hypovolemia or
untoward reactions to anesthetic agents.
ｷ Cardiac Dysrhythmia - due to preexisting
cardiovascular compromise, electrolyte imbalance or
untoward reaction to anesthesia.

ｷ Hypothermia - due to exposure to a cool ambient OR
environment and loss of thermoregulation capacity from
anesthesia.
ｷ Peripheral Nerve Damage - due to improper
positioning of patient or use of restraints.
ｷ Nausea and Vomiting
ｷ Headache


Practice Question
A female client, 23 years old was admitted for the first
time at the QMMC, she was diagnosed to have
ruptured appendicitis. She was scheduled to have
emergency Ex-Lap under general anesthesia.

1. Pre-op instructions to the client would include the
following EXCEPT:
a. deep breathing and coughing exercise
b. explaining the procedure
c. turning to the side
d. foot and leg exercise


Answer:

B. Explaining the procedure.

Rationale:

Explaining the treatment, procedure, and outcome is
done by the attending physician


2. During the induction of anesthesia, what is your nursing
priority action?

a. secure informed consent
b. maintain the OR room quite and close the door
c. stay with the patient and assess for possible
anesthesia complication
d. assist the physician in preparing the OR table


Answer:

B.

Rationale:

During the 1st stage of general anesthesia ( onset or
Induction stage ), noises are exaggerated. For this reason
Unnecessary noises and motions are avoided.


POSTOPERATIVE CARE


Goals:

Restore homeostasis and prevent complication
Maintain adequate cardiovascular and tissue perfusion.
Maintain adequate respiratory function.
Maintain adequate nutrition and elimination.
Maintain adequate fluid and electrolyte balance.
Maintain adequate renal function.
Promote adequate rest, comfort and safety.
Promote adequate wound healing.
Promote and maintain activity and mobility.
Provide adequate psychological support.

PACU CARE

Transport of client from OR to RR

ｷ avoid exposure
ｷ avoid rough handling
ｷ avoid hurried movement and rapid changes in
position.


Initial Nursing Assessment
ｷ Verify patient’s identity, operative procedure and the surgeon
who performed the procedure.

ｷ Evaluate the following sign and verify their level of stability
with the anesthesiologist:

- Respiratory status
- Circulatory status
- Pulses
- Temperature
- Oxygen Saturation level
- Hemodynamic values

ｷ Determine swallowing and gag reflex , LOC and patients
response to stimuli. Copyright © 2008 Lippincott Williams & Wilkins.

ｷ Evaluate lines, tubes, or drains, estimate blood loss,
condition of wound, medication used, transfusions and
output.

ｷ Evaluate the patient’s level of comfort and safety.

ｷ Perform safety check; side rails up and restraints are
properly in placed.

ｷ Evaluate activity status, movement of extremities.

ｷ Review the health care provider’s orders.


Initial Nursing
Interventions


Maintaining a Patent Airway

ﾘ Allow the airway ( ET tube ) to remain in place until
the patient begins to waken and is trying to eject the
airway.

ﾘ The airway keeps the passage open and prevents the
tongue from falling backward and obstructing the air
passages.

ﾘ Aspirate excessive secretions when they are heard in
the nasopharynx and oropharynx.


Assessing Status of Circulatory System
ﾘ Take VS per protocol, until patient is well stabilized.
ﾘ Monitor intake and output closely.
ﾘ Recognized early symptoms of shock or hemorrhage:
- cool extremities
- decreased urine output ( less than 30ml/hr )
- slow capillary refill ( greater than 3 sec. )
- lowered BP
- narrowing pulse pressure
- increased heart rate
* initiate O2 therapy, to increase O2
availability from the blood.
* place the patient in shock position with his
feet elevated ( unless contraindicated )

Maintaining Adequate Respiratory Function

ﾘ Place the patient in lateral position with neck extended
( if not contraindicated ) and upper arm supported on a
pillow.
ﾘ Turn the patient every 1 to 2 hours to facilitate breathing
and ventilation.
ﾘ Encourage the patient to take deep breaths, use an
incentive spirometer.
ﾘ Assess lung fields frequently by auscultation.
ﾘ Periodically evaluate the patient’s orientation – response
to name and command.

Note: Alterations in cerebral function may suggest impaired
O2 delivery. Copyright © 2008 Lippincott Williams & Wilkins.

Assessing Thermoregulatory Status

ﾘ Monitor temperature per protocol to be alert for
malignant hyperthermia or to detect hypothermia.

ﾘ Report a temperature over 37.8 C or under 36.1 C

ﾘ Monitor for postanesthesia shivering, 30-45 minutes
after admission to the PACU.

ﾘ Provide a therapeutic environment with proper
temperature and humidity.


Maintaining Adequate Fluid Volume
ﾘ Administer I.V solutions as ordered.
ﾘ Monitor evidence of F&E imbalance such as N&V
ﾘ Evaluate mental status, skin color and turgor
ﾘ Recognized signs of:
a. Hypovolemia
- decrease BP
- decrease urine output
- decreased CVP
- increased pulse
b. Hypervolemia
- increase BP
- changes in lung sounds (S3 gallop )
- increased CVP
ﾘ Monitor I&O Copyright © 2008 Lippincott Williams & Wilkins.

Minimizing Complications of Skin Impairment

ﾘ Perform handwashing before and after contact with
the patient

ﾘ Inspect dressings routinely and reinforce them if
necessary.

ﾘ Record the amount and type of wound drainage.

ﾘ Turn patient frequently and maintain good body
alignment.


Maintaining Safety
ﾘ Keep the side rails up until the patient is fully awake.

ﾘ Protect the extremity into which I.V fluids are running so
needle will not become accidentally dislodged.

ﾘ Avoid nerve damage and muscle strain by properly
supporting and padding pressure areas.

ﾘ Recognized that the patient may not be able to complain of
injury such as the pricking of an open safety pin or clamp that
is exerting pressure.

ﾘ Check dressing for constriction

Parameter for Discharge from PACU/RR

ｷ Activity. Able to obey commands
ｷ Respiratory. Easy, noiseless breathing
ｷ Circulation. BP within 20mmHg of preop level
ｷ Consciousness. Responsive
ｷ Color. Pinkish skin and mucus membrane


Nursing Care of the Client During the Intermediate
Postop Period (RR – Unit )

Baseline Assessment

Respiratory Status
Cardiovascular Status
- VS
- Color and Temperature of Skin
Level of Consciousness
Tubes
- Drain
- NGT
- T-tube
Position Copyright © 2008 Lippincott Williams & Wilkins.

Immediate Post-Op
Assessment and Interventions
Areas of Concern Intervention
Neurological Status Assess LOC– response to name
Return of swallow and gag reflex
Fluid and Electrolyte Intake and Output
Balance IV Fluids

Dressing, Tubes, Drains Color, consistency and amount of
drainage

Pain May need 1/2 to 1/3 less analgesia in
recover room

Safety and Comfort Side rails
Warmth
Aseptic Technique


Areas of Concern Intervention

Respiratory ASSESS !!!
Position on Side
Keep Airway in
Oxygen
Cardiovascular ASSESS !!!
Watch for:
Post-op hypotension; cardiac arrest;
hemorrhage
Signs of Hemorrhage:
↑ pulse and respiratory rate; restlessness;
↓ blood pressure; cold, clammy skin; thirst; pallor


Common Post-Operative Orders
• NPO until fully alert, then ice chips as tolerated.
Advance diet as tolerated.
• Suction prn
• Complete current IV then discontinue if pt. tolerating
fluids.
• Compazine 5 mg prn for nausea and vomiting
• Morphine Sulfate 10 mg IM every 3-4 hours prn


Common Post-Operative Orders
• Accurate intake and output
• T,C, and DB every 2 hours
• Hemoglobin and hematocrit in a.m.
• Catheter if patient can’t void in 8 – 10 hours
• Reinforce dressing prn


WOUND CARE
Commonly Used Wound Dressing


The strips of tape should be placed at the ends of the dressing and must
be sufficiently long and wide to secure the dressing. The tape should
adhere to intact skin.


Cleaning Surgical Site

Cleaning from top Cleaning a wound outward Cleaning around
to bottom, starting at the from the incision Penrose drain site
center


Wound Irrigation


Incision Support


Body Pressure Areas


POST OPERATIVE
COMPLICATIONS


A client has returned from surgery with a fine, reddened rash noted
around the area where Betadine prep had been applied prior to
surgery. Nursing documentation in the chart should include

a. The time and circumstances under which the rash was noted.
b. The explanation given to the client and family of the reason for
the rash.
c. Notation on an allergy list and notification of the doctor.
d. The need for application of corticosteroid cream to decrease
inflammation.


C Suspected reaction to drugs should be reported to the doctor
and noted on list of possible allergies


A 41-year-old woman was brought to the emergency room by two
police officers after she had been standing barefoot in the rain for
more than two hours. The police officers report that the woman
had to be restrained after she resisted and became agitated. The
intake nurse's FIRST action should be to:

a. Complete a physical examination.
b. Maintain a safe environment.
c. Ascertain the client's mental status.
d. Orient the client to place and time.


B implementation; major priority of the nurse is to provide
and maintain safety for the client who is unable to provide for
herself; safe environment will generate trust and rapport; will
decrease resistance to doing preliminary physical exam, which
includes orienting client and doing a mental status exam


The nurse is preparing to insert a Foley catheter into a patient. It
would be MOST important for the nurse to take which of the
following actions?

a. Place all supplies close to the edge of the table.
b. Keep the field holding the supplies in front of the
nurse.
c. Set up the field below the nurse's waist level.
d. Add only clean supplies to the field.


B represents the best technique for a sterile field


A nurse instructs a preoperative client in the proper use of an
incentive spirometer. Postoperative assessment of the
effectiveness of its use is determined if the client exhibits:

a. Coughing
b. Shallow breaths
c. Wheezing in one lung field
d. Unilateral chest expansion


A Incentive devices have many desired and positive effects.
Incentive devices provide the stimulus for a spontaneous deep
breath. Spontaneous deep breathing, using the sustained maximal
inspiration concept, reduces atelectasis, opens airways, stimulates
coughing, and actively encourages individual participation in
recovery. Shallow breaths, wheezing, and unilateral chest
expansion would indicate that the incentive spirometry was not
effective. Wheezing indicates narrowing or obstruction of the
airway, and unilateral chest expansion could indicate atelectasis.


Perioperative Nursing (complete)

Recomendados

Recomendados

Más contenido relacionado

La actualidad más candente

La actualidad más candente (20)

Destacado

Destacado (16)

Similar a Perioperative Nursing (complete)

Similar a Perioperative Nursing (complete) (20)

Más de MarkFredderickAbejo

Más de MarkFredderickAbejo (20)

Último

Último (20)

Perioperative Nursing (complete)