PERIOPERATIVE NURSING

Prepared by: Ms. Shandz S. de Rosas, RN

DEFINITION OF TERMS
SURGERY
Designates the branch of medicine that encompasses preoperative care, intraoperative judgment, and management of postoperative patients.

IMPORTANCE OF OPERATION
1. Correction of deformities and defects 2. repair of injuries 3. diagnosis and cure of disease processes 4. relief of suffering, and 5. prolongation of life.

PATHOLOGIC PROCESSES REQUIRED FOR SURGERY

1. Obstruction

Impairment of flow
Organ rupture (eg. AP) Wearing off (eg. Gastric ulcer) Abnormal new growths

2. Perforation 3. Erosion

4. Tumors

SURGICAL CONSCIENCE (SURGICAL GOLDEN RULE)

Do unto the patient as you would have other do unto you One must consider each patient as one self or a loved one. Florence Nightingale: The nurse must keep a high sense of duty in her own mind, must aim at the perfection in her care, and must be consistent always in herself

STERILIZATION
The process by which all pathogenic and nonpathogenic microorganisms, including all spores are killed. Spores inactive but viable state of microorganism

TYPES OF STERILIZATION
1. Saturated Pressure
Autoclave

Steam

Under

2. Gas Chemical Sterilization

Ethylene oxide
Cidex
10 min. disinfection 10 hours - sterilization

3. Liquid Chemical Sterilization

ASEPSIS
Types:
1. Medical Asepsis
Clean Dirty

It is the absence of pathologic microorganisms

2. Surgical Asepsis
Free from all microorganism

CATEGORIES OF SURGERY
A. URGENCY
1. Emergency without delay 2. Imperative within 24-48 hours 3. Elective performed for pts well being but not absolutely necessary (eg. keloid removal) 4. Planned Required necessary for wellbeing (eg. Cataract extraction) 5. Optional as requested (eg. aesthetic value)

CATEGORIES OF SURGERY
B. PURPOSE
1. Diagnostic eg. biopsy 2. Exploratory eg. exlap 3. Curative
a) b) c) d) Ablative removal of diseased part Reconstructive/ Restorative skin grafts post burn Constructive repair (eg. Cleft lip repair) Palliative relieve symptoms (eg. Colostomy)

CATEGORIES OF SURGERY
C. DEGREE OF RISK AND EXTENT
1. Major surgery
Regional or general anesthesia Complicated, extensive, and prolonged Blood loss 500cc or more Vital organs involved High risk for postop complications Surgical suite required (hospital setting)

2. Minor surgery
Less risky Few complications OPD, clinic settings, ambulatory

RISK FACTORS OF SURGERY

1. Physical factors
Age very young and old Nutritional status malnourished & obese F/E Balance Presence of a Disease
Cardiovascular cardiac overload DM stressful = hypoglycemia & acidosis Alcoholism Repiratory D/o atelectasis, pneumonia, respi. Failure

2. 3. 4. 5.

Economic expenses Severity of disease good vs poor prognosis Magnitude of operation Available resources

PERIOPERATIVE NURSING
Used to describe the nursing functions in the total surgical experience of the patient. Phases:
1. Preoperative Phase
Begins upon decision making and ends in admission to OR

2. Intraoperative Phase
Begins upon induction of anesthesia to the last stitch of dressing in place
Begins I the recovery room and to the nursing unit until discharged

3. Postoperative Phase

PREOPERATIVE PHASE
1. PSYCHOLOGICAL PREPARATION
a. Hospital admission
Explanation of procedure Outcomes Expected cost and duration Length of absence from work Residual effects

b. Pre-op Visits (ORNAP)

PREOPERATIVE PHASE
c. Anticipated Fears
1. 2. 3. 4. 5. Fear of the unknown Fear of death Fear of anesthesia Fear of disfigurement/ mutilation Threat to sexuality
Orchiectomy (removal of testes)

6. Fear of pain and discomfort 7. Fear of loss of job

PREOPERATIVE PHASE
2. LEGAL PREPARATION
a. Informed Consent
Elements
a. Voluntariness b. Sound Mind c. Right to be given information to make the final decision.

Emergencies
a. Consent required but not essential b. All efforts must be done o contact family (eg. telephone) c. PRIORITY: PT. CONDITION over the operative permit

PREOPERATIVE PHASE
2. Legal Preparation
a. Informed Consent
Nursing Responsibility
Serves as a witness in the acquisition of the informed consent Assures patient able to comprehend Patient advocate

Other Considerations:
Incompetent subjects cannot sign the consent Emancipated minor can sign consent Consent placed at the beginning of the chart

PREOPERATIVE PHASE
3. Physiological Preparation
Respiratory preparation
Eg. X-ray Eg. ECG, Blood tests (CBC, ABG, Blood Typing, Cross Matching)

Cardiovascular preparation

Renal Preparation

Routine U/A
Fecalysis

GI Preparation

PREOPERATIVE PHASE
4. Physical Preparation
a. On the night
Integumentary
Skin prep reduce postop wound infection

GIT
NPO post midnight Administration of enema Insertion of gastric or intestinal tube

Preparing for anesthesia Promoting rest and sleep

Barbiturates Secobarbital Na Nonbarbiturates Flurazepam

PREOPERATIVE PHASE
4. Physical Preparation
a. On the day of the surgery
1. Early morning care
Change OR gown an hour before giving preop meds Baseline VS & VS before transportation Oral Hygiene Remove jewelry/ dentures Remove nail polish and underwear Empty bladder before preop meds Retention catheter as ordered Ensure NPO as ordered

PREOPERATIVE PHASE
4. Physical Preparation
a. On the day of the surgery
2. Preoperative Meds
To allay anxiety Decrease pharyngeal secretions Reduce anesthesia given Create amnesia for the events that precede before surgery Types: Sedatives Tranquilizers Narcotic Analgesics Vagolytic or Drying Agents

PREOPERATIVE PHASE
4. Physical Preparation
a. On the day of the surgery
Note: Recording
All final preparation and emotional response before surgery is noted down.

Transportation to OR
No woolen or synthetic blanket

THE SURGICAL TEAM

1. 2. 3. 4. Operating Surgeon Surgical Assistant Anesthesiologist Nurse Anesthesiologist 5. Circulating Nurse 6. Scrub Nurse

ANESTHESIOLOGIST

SURGICAL ASSISTANT

SCRUB NURSE & STUDENT NURSES

SURGEON

CIRCULATING NURSE

CLINICAL INSTRUCTOR

RESPONSIBILITIES OF THE SCRUB NURSE

1. Setting up sterile tables (mayo and back table) 2. Preparing sutures, ligatures, and sterile equipments 3. Assisting the surgeon and the surgical assistant by anticipating and passing the required instruments. 4. Keeping the time the patient is under anesthesia and wound ope kept to a minimum.

RESPONSIBILITIES OF THE CIRCULATING NURSE

8. 1. 9. 2. 10. 3. 11. 4. Relays messages. Observes the patient Teaches student nurses Assist the scrub team Supervises new nurses Assist the anesthesiologist Coordinator with other Maintain safe environ-ment, medical professionals aseptic condition, general Administer tests and orderliness skin & quiteness. HGT monitoring Connects suction & Report sponge counts electrical equipment. Adjust lights. Records & reports essential data.

12.
5. 13.

6. 7.

ANESTHESIA

TYPES OF ANESTHESIA
1. STAGES GENERAL OF GENERAL ANESTHESIA ANESTHESIA
a. STAGE Inhalation 1. STAGE (Halothane, OF ANALGESIA Isoflurane, Nitrous Oxide) Advantage: Prevention of pain and - administration to loss ofanxiety consciousness Disadvantage: Depression & explosive - pain sensation not lost No static materials (nylon, wool) STAGE 2. NO STAGE OF DELIRIUM AND EXCITEMENT CAUTERY No hours postop - smoking lost of12 consciousness to loss of eyelid reflex - DO NOT STIMULATE! (REM, muscle rigidity, b. Intravenous (Ketamine, Fentanyl, Diprivan) irregular respiration, loss of control) Advantage: pleasant induction STAGE 3. STAGE Rapid OF SURGICAL ANESTHESIA Absence of explosive hazards of lid reflex to cessation - loss Low incidence of nausea and vomiting of respiratory effort ( dilated pupils, negative reflexes) Disadvantage: Laryngeal spasm and bronchospasm Hypotension STAGE 4. STAGE OF DANGER/ MEDULLARY CHANGES - vital Respiratory arrest to depressed functions

 Types: 1. Monopolar (use of cautery pad) 2. Bipolar (2 tips; delicate surgeries: brain)

CAUTERY one way of controlling bleeders; burns blood vessels

LAYERS OF THE ABDOMEN

1. SKIN 2. SUBCUTANEOUS 3. FASCIA 4. MUSCLE 5. PERITONEUM

ABDOMINAL INCISIONS
TYPES:
1. Mc Burneys Appendectomy (always right) 2. Midline Female reproductive tract 3. Paramedian Right: Biliary/ gall bladder Left: Spleenectomy, Gastrectomy, Hernia Repair 4. Pfannensteil CS, gynecologic surgery 5. Rectus Right: Appendectomy Left: Sigmoid colon dissection 6. Subcostal Gallbladder & biliary tract 7. Transverse - Gastrectomy

CLASSIFICATIONS OF INSTRUMENTS

1.Grasping 2.Cutting 3.Retracting

SPONGE COUNT
INITIAL COUNTING
Before the procedure

ISN

Initial counting
Counting with scrub nurse/ circulating nurse

Before 1ST COUNTING closure of the

peritoneum Before closure of fascia

2ND COUNTING

SNI

3RD COUNTING

Before closure of skin

SIN

Reporting

POSTOPERATIVE PHASE
1. Post Anesthesia Care Unit (PACU)
a. Maintenance of pulmonary ventilation
Side-lying or prone to prevent aspiration Oropharyngeal or nasopharyngeal device left in place until reflexes returns after GA Oxygen therapy until conscious and able to deep breath by command and shivering has ceased

b. Maintenance of circulation
VS q 15 x 4 hours until stable Monitor for cardiac arrythmias

POSTOPERATIVE PHASE
c. Protection from injury and comfort
Side rails raised Turn to sides and good body alignment Narcotic analgesics

POSTOPERATIVE PHASE
c. Alderete Scoring in PACU (10pts) 1. Activity 2 4 extremities 1 2 extremities 0 0 extremities 2. Respi. 2 able to cough & DBE 1 dyspnea or limited breathing 0 apneic (20 sec or more)

POSTOPERATIVE PHASE
c. Alderete Scoring in PACU (10pts) 3. Circu- 2 20% drop or incr. BP lation 1 20-50% 0 50% or more 4. LOC 2 Fully awake 1 Arousable on calling 0 Not responding

POSTOPERATIVE PHASE
c. Alderete Scoring in PACU (10pts)
5. Color 2 Pink 1 Pale/ dusky 0 Cyanotic

POSTOPERATIVE COMPLICATIONS
A. RESPIRATORY
1. Atelectasis & Pneumonia
Increased temperature within 2448 hours Collapsed alveoli is susceptible to infection Occurs when there is abdominal surgery (e.g. Cholecystectomy) High inhalation af anesthesia Aspiration during operation

POSTOPERATIVE COMPLICATIONS
Nursing Management
1. Prevent pooling of secretions
Change position every 2 hours High fowlers Ambulation

2. Liquefying and removing secretions

Increase OFI Moist oxygenation Administer analgesics before coughing C/I : eye, brain, and spinal surgery Splint the operative area

3. DBE and coughing

POSTOPERATIVE COMPLICATIONS
B. CIRCULATORY
1. Phlebothrombosis 2. Thrombophlebitis
(+) Homans Sign

3. Postural Hypotension Nursing Management

1. Never massage 2. Lie on the abdomen 30 mins. 2-3 times a day to prevent blood stasis on the pelvic cavity 3. Wear elastic bandages or support stockings 4. Do not allow to stand abruptly

POSTOPERATIVE COMPLICATIONS
C. GASTROINTESTINAL
1. Paralytic ileus
N.I. NPO until peristalsis returns

2. Vomiting
N.I. Side lying or head turned to side - Antiemetics (Plasil)

3. Abdominal Distention & Gas Pain

N.I. Gastric lavage of gas - Ambulation - Rectal tube insertion - Fleet enema

POSTOPERATIVE COMPLICATIONS
4. Constipation
N.I Advise patient to eat increase fiber diet - Increase OFI

D. URINARY
1. Urinary Retention
N.I. Force fluid - Pour warm water over perineum - Proper position - Catheterization as ordered.

POSTOPERATIVE COMPLICATIONS
2. UTI
N.I. Instruct to void completely - Sterile technique in catheterization

E. Postoperative Discomforts
1. Postop Pain
1. Narcotics q 3-4 hours for 48 hours

2. Hiccups paper bag blowing or 5% carbon dioxide + 95% oxygen 5 minutes every hour

POSTOPERATIVE COMPLICATIONS
F. Wound Complications
1. 2. 3. 4. Hemorrhage Infection Dehiscence Evisceration