PERIOPERATIVE NURSING

SURGERY

Branch of medicine that encompasses preoperative, intraoperative, and postoperative care of patients. The discipline of surgery is both an art and a science.

SURGICAL PROCEDURE

Invasive incision into body tissues or a minimally invasive entrance into a body cavity for either therapeutic or diagnostic purposes during which protective reflexes or self-care abilities are potentially compromised

CONDITIONS REQUIRING SURGERY

OBSTRUCTION PERFORATION EROSION TUMOR

TYPES OF SURGERY According to Purpose

Diagnostic

Exploratory
Curative
Ablative Reconstructive Constructive

Palliative

TYPES OF SURGERY According to Degree of Risk

Major Surgery

Minor Surgery

Involves vital organs Prolonged

Involves non-vital parts Generally not prolonged Lesser blood loss Lesser complications

TYPES OF SURGERY According to Urgency

Emergent Urgent Required Elective Optional
Without delay Within 24-30 hours Within few weeks or months Failure to have surgery is not catastrophic Personal preference

AMBULATORY SURGERY

OUTPATIENT, SAME-DAY or SHORT-STAY surgery Laparosopic and minimally invasive surgery Admission to an inpatient hospital setting for less than 24 hours Requires Preadmission Testing (PAT) Admitted in preoperative holding area of the Operating Room and stays in the PostAnesthesia Care Unit (PACU) prior to discharge

SURGICAL TERMINOLOGIES
Suffixes
-ectomy -otomy -ostomy -plasty -orrhaphy

Meaning
excision; removal cut into or incision make artificial opening plastic repair suturing; repair

SURGICAL TERMINOLOGIES
Root Word angio aorto arterio cardio / corono phlebo cholecysto colo or colono duodeno esophago gastro hepato Meaning vessel aorta artery heart vein gallbladder colon duodenum esophagus stomach liver
cholangio
lapar procto Root Word jejuno oro / stomato Meaning jejunum mouth

pancreato
pharyngo choledocho

pancreas
pharynx common bile duct

common bile duct

abdomen rectum

ano
adreno hypophyso thyro

anus
adrenal gland pituitary gland thyroid

ileo

ileum

SURGICAL TERMINOLOGIES
Root Word Meaning

Root Word pyelo urethro balano prostato scroto vaso arthro chondro costo cranio ligamento myo / myoso

Meaning renal pelvis urethra penis prostate scrotum vas deferens joint cartilage rib skull ligament muscle

orchio / orchido testis oophoro salphingo ovary fallopian tube

cervico
colpo / vagino hystero / utero mammo lymphadeno spleno nephro / reno uretero

cervix
vagina uterus breast lymph node spleen kidney ureter

cysto / vesico

urinary bladder

SURGICAL TERMINOLOGIES
Root Word osteo pelvo spondyl tendino cerebello cerebro encephalo neuro alveolo broncho epiglotto rhino Meaning bone pelvis vertebra tendon cerebellum cerebrum brain nerve alveoli bronchial tube epiglottis nose
phako retino eye lens retina Root Word phreno pneumono/pulmo tracheo auro /oto lung trachea ear Meaning diaphragm

myringo/tympano
oculo/ophthalmo

eardrum
eye

blephar
cheilo palato/urano

eyelid
lip palate

cutaneo/dermo

skin

SURGICAL TERMINOLOGIES
Abbreviation / Acronym Meaning

MRM
ORIF ADSF

Modified Radical Mastectomy

Open Reduction Internal Fixation Anterior Decompression Spinal Fusion

ECCE
TAHBSO TURP CS AKA BKA CABG APR

ExtraCapsular Cataract Extraction

Total Abdominal Hysterectomy Bilateral Salphingooophorectomy TransUrethral Resection of the Prostate Ceasarean Section Above the Knee Amputation Below the Knee Amputation Coronary Artery Bypass Graft Abdomino-Perineal Resection

PERIOPERATIVE NURSING

Refers to activities performed by the professional nurse which encompasses a clients total surgical experience

PHASES OF PERIOPERATIVE NURSING

PreOperative Phase IntraOperative Phase

PostOperative Phase

PREOPERATIVE PHASE

PREOPERATIVE PHASE

Begins at the time of decision for surgery and ends when the client is transferred to the OR This period is used to physically and psychologically prepare the client for surgery

The nurse plays a major role in client teaching and in relieving the clients and the familys anxieties

PREOPERATIVE PHASE: GOALS OF CARE

Assessing and correcting physiologic and psychologic problems that might increase surgical risk Giving the person and significant others complete learning/ teaching guidelines regarding surgery Instructing and demonstrating exercises that will benefit the person during post-op period Planning for discharge and any projected changes in lifestyle due to surgery

PSYCHOLOGIC PREPARATION: CAUSES OF FEARS

Fear of pain Fear of anesthesia, vulnerability while unconscious Fear of death Fear of disturbance of body image Worries: loss of finances, employment, social and family roles

The MOST DEVASTATING FEAR of a surgical client is the FEAR OF THE UNKNOWN.

PSYCHOLOGIC PREPARATION: MANIFESTATIONS OF FEARS

Anxiousness Confusion Anger Tendency to exaggerate Sad, evasive, tearful, clinging Inability to concentrate Short attention span Failure to carry out simple directions Dazed

PSYCHOLOGIC PREPARATION: NURSING INTERVENTIONS

Assess clients fears, anxieties, support systems and patterns of coping Establish a trusting relationship with the client and significant others

Encourage verbalization of fears

Explain routine procedures and allow client to ask questions

Provide spiritual care if appropriate

LEGAL ASPECT OF PREOPERATIVE PHASE

All invasive procedures requires for an INFORMED CONSENT

SURGICAL CONSENT

OPERATIVE PERMIT / INFORMED CONSENT A document describing that the client has full knowledge of the instructions of the exact surgical procedure to be performed and has given permission to have the procedure performed on him

SURGICAL CONSENT

The SURGEON is the ultimate responsible for obtaining the surgical consent. The Surgeon must inform the patient of the benefits, alternatives, possible risks, complications, disfigurement, disability and removal of body parts.

VALID SURGICAL CONSENT

Consent should be FREELY GIVEN, without coercion The patient signing the consent must be MENTALLY COMPETENT and of LEGAL AGE (at least 18 years of age). For minors or mentally incompetent patient, the parent, legal guardian, spouse or relative next of kin will sign the consent EMANCIPATED MINORS (minors who are married and self-sufficient) can sign their own consent

VALID SURGICAL CONSENT

It must be witnessed by an authorized person a nurse or another doctor It is part of the nurses role as a witness and a client advocate to confirm that the client understands information given It must be obtained before the patient receives sedation It has been signed at least a day before the surgery

SURGICAL CONSENT

In an emergency, permission via the telephone is acceptable. Have a second listener on phone when telephone permission being given.

SURGICAL CONSENT
CONSENTS ARE NOT NEEDED for emergency care if all four of the following criteria are met:

There is an immediate threat to life Experts agree that it is an emergency Client is unable to consent A legally authorized person cannot be reached

Case Analysis
A client is brought to the ER after being hit by a car. The name of the client is not known. The client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. In regard to informed consent for the surgical procedure, what is the best nursing action?

Case Analysis
A client, 22 year old female, is brought to the ER with an apparent head injury after being involved in a serious motor vehicle accident. She is unconscious on arrival and exhibits signs of increasing ICP. He is accompanied by an adult friend and fianc. What is the best nursing action on a legal stand point?

PREOPERATIVE ASSESSMENT: NURSING HISTORY

Allergies Bleeding tendencies Cortisone use Diabetes Mellitus Emboli

PREOPERATIVE ASSESSMENT

Nutritional and Fluid Status Dentition Drug or Alcohol Use Respiratory Status Cardiovascular Status Hepatic and Renal Function Endocrine Function Immune Function

PREOPERATIVE ASSESSMENT: PREVIOUS MEDICATION USE

Agents Effects of Interactions with Anesthesia / Surgery

Corticosteroids Prednisone (Deltasone) Diuretics Hydrochlorothiazide (HydroDIURIL) Phenothiazines Chlorpromazine(Thorazin e) Tranquilizers Diazepam(Valium) Insulin

Cardiovascular collapse may occur if discontinued suddenly Respiratory depression may occur with anesthesia use Increases hypotensive effects of anesthesia Anxiety, tension and seizures may occur when withdrawn suddenly Intravenous insulin may be needed to regulate blood glucose level during surgery

PREOPERATIVE ASSESSMENT: PREVIOUS MEDICATION USE

Agents Effects of Interactions with Anesthesia / Surgery Risk for respiratory paralysis when combined with muscle relaxant Increases the risk of bleeding during the intraoperative and postoperative period Intravenous administration is needed to prevent seizure during surgery Intravenous administration may be needed during the postoperative period to maintain thyroid levels

Antibiotics Erythromycin(Ery-Tab) Anticoagulants Warfarin(Coumadin) Antiseizure agents Thyroid Hormone Levothyroxine sodium (Levothroid)

Opioids

Chronic use may alter response to analgesic agents

PREOPERATIVE ASSESSMENT

All diagnostic examination should be completed before surgery which include:

Chest ECG Complete

X-ray

Blood Count (CBC) Coagulation studies Urinalysis

PREOPERATIVE TEACHINGS

Assess the clients level of understanding of surgical procedure and its implications Answer questions, clarify and reinforce explanations given by surgeon Explain routine pre and post procedures and any special equipment to be used

PREOPERATIVE TEACHINGS

Demonstrate exercises that prevents postoperative complications

Deep

breathing / Diaphragmatic breathing Coughing Incentive Spirometry Leg Exercises Turning to Side

PHYSICAL PREPARATION THE DAY BEFORE SURGERY

Withholding food and fluid Preparing the Bowel Preparing the Skin

IMMEDIATE PREOPERATIVE NURSING INTERVENTIONS

Hospital gown is worn that is left untied and open in the back Braid long hair and remove hair pins Provide oral care Inspect the mouth and remove dentures or plates Remove eyeglasses and prosthetic devices

IMMEDIATE PREOPERATIVE NURSING INTERVENTIONS

Remove make-up Remove all jewelry and body piercings Remove nail polish Obtain baseline vital signs Complete the Preoperative Checklist Administer Preop Medications as ordered

VRP MEDICAL CENTER

163 EDSA, Mandaluyong City

VRP MEDICAL CENTER

163 EDSA, Mandaluyong City

PRE-OPERATIVE CHECKLIST
Name of Patient _______________________________ Room No. ________________ Attending Physician _____________________________ SURGERY Contemplated ________________________ Anesthesiologist _______________________________ Date of Surgery_______________ Time ____________ Consent for Surgery Yes No Anesthesia Consent Yes To O.R. External Preparation ____________________________ (Specify Area) Enema Voided Foley Catheter Nasogastric Tube (NGT) IVF Line Removed: Dentures Nail Polish Wigs Lipstick Hairpins Jewelry Laboratory Results: CBC Stool Exam Blood Typing Request for Blood Urinalysis Reserved Prepared X-Ray Results History Physical Examination ECG X-Ray Plates

PRE-OPERATIVE CHECKLIST
Name of Patient _______________________________ Room No. ________________ Attending Physician _____________________________ SURGERY Contemplated ________________________ Anesthesiologist _______________________________ Date of Surgery _______________ Time ___________ Consent for Surgery Yes No Anesthesia Consent Yes To O.R. External Preparation ____________________________ (Specify Area) Enema Voided Foley Catheter Nasogastric Tube (NGT) IVF Line Removed: Dentures Nail Polish Wigs Lipstick Hairpins Jewelry Laboratory Results: CBC Stool Exam Blood Typing Request for Blood Urinalysis Reserved Prepared X-Ray Results History Physical Examination ECG X-Ray Plates

Vital Signs Blood Pressure _________________________ Pulse Rate_____________________________ Respiration ____________________________ Temperature ___________________________ Others: ______________________________________ ______________________________________ Pre-Operative Medication Drug Dosage Route Time ____________________________________________ ____________________________________________ ____________________________________________ Signature of Floor Nurse _________________________ Signature of OR Nurse __________________________ V-GWU-016-03

Vital Signs Blood Pressure _________________________ Pulse Rate_____________________________ Respiration ____________________________ Temperature ___________________________ Others: ______________________________________ ______________________________________ Pre-Operative Medication Name Dosage Route Time ____________________________________________ ____________________________________________ ____________________________________________ Signature of Floor Nurse _________________________ Signature of OR Nurse __________________________ V-GWU-016-03

PREANESTHETIC MEDICATION

PREOP MEDICATION Usually given 30 to 45 minutes before the patient is transported to the OR or On call to OR Given in the holding area of the OR for ambulatory surgery

PURPOSES OF PREOP MEDICATIONS

To allay fear and anxiety To produce some amnesia To reduce reflex irritability To raise the pain threshold To lower the body metabolism To decrease respiratory and mouth secretions

COMMON PREOP MEDICATIONS

Sedative and Tranquilizers
Narcotic Analgesics Anticholinergics Histamine-receptor antagonists
Secobarbital Diazepam (Valium)
Morphine Meperidine HCl (Demerol) Atropine sulfate Scopolamine

Cimetidine (Tagamet)

Nursing Responsibilities Before Administration of Preop Medication

Check for drug allergy Ensure the surgical consent has been signed Instruct the patient to void Obtain the baseline vital signs

Nursing Responsibilities After Administration of Preop Medication

Instruct the patient to stay in bed Raise the side rails up to ensure safety

SAFETY PROTOCOLS
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

2003 Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery 2009 National Patient Safety Goals

Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery

Preoperative verification process Marking the operative site in an unambiguous manner Time Out

2009 National Patient Safety Goals

Improve the accuracy of patient identification Improve effectiveness of communication among caregivers Improve safety of using medications Reduce the risk of health care-associated infections Accurately and completely reconcile medications across continuum of care Reduce the risk of patient harm resulting from falls Reduce the risk of influenza and pneumococcal disease in institutionalized older adults

2009 National Patient Safety Goals

Reduce the risk of surgical fires Implement applicable National Patient Safety Goals and associated requirements by components and practitioner sites Encourage patients active involvement in their own care as a patient safety strategy Prevent health care-associated pressure ulcers Identify safety risks inherent in the organizations patient population Improve recognition and response to changes in a patients condition

Patient Transport to the Operating Room

The patient is transferred to the holding area or presurgical suite in a bed or a stretcher about 30 to 60 minutes before the anesthetic is given The stretcher should be comfortable with a small pillow and sufficient blankets Ensure safety during transport