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Definition of Perioperative Nursing

The provision of nursing care by an RN preoperatively, intraoperatively, and postoperatively to a patient undergoing an operative or invasive procedure.

MLNGCeleste, RN, MD

Areas in Which Perioperative Nursing Is Practiced

• Perioperative nursing is practiced in– Hospital operating rooms– Interventional radiology suites– Cardiac cath labs– Endoscopy suites– Ambulatory surgery centers– Trauma centers– Pediatric specialty hospitals– Physician offices MLNGCeleste, RN, MD

Functions of thePerioperative Nurse

• Advocate

• Protector

• Teacher

• Change agent

• Manager of patient care

MLNGCeleste, RN, MD

Nursing Roles in the OR

– Circulating Nurse– Scrub person– RN first assistant (RNFA)– Perioperative educator– Specialty team leader– Perioperative manager

MLNGCeleste, RN, MD

Surgical Attire

• Gowns

• Gloves

• Masks

• Hair covering

• Protective eyewear

MLNGCeleste, RN, MD

Goals of Patient Safety

• Provide safe patient care– Knowledge of procedure– Ensure the correct patient, correct site, correct level, and correct

procedure– Knowledge of positioning– Adhere to safe medication administration guidelines– Perform surgical counts

• Provide a safe environment– Adhere to asepsis– Promote coordinated and effective communication

MLNGCeleste, RN, MD

Phases of Perioperative period

• PRE- operative phase

• INTRA- operative phase

• POST- operative phase

MLNGCeleste, RN, MD

PRE-Operative Phase

• Begins when the decision to have surgery is made and ends when the client is transferred to the operating table

MLNGCeleste, RN, MD

INTRA-Operative Phase• Begins when the client is

transferred to the operating table and ends when the client is admitted to the post-anesthesia unit

MLNGCeleste, RN, MD

Post-operative Phase • Begins with the admission

of the client to the PACU and ends when healing is complete

MLNGCeleste, RN, MD

TYPES of SURGERY

• According to PURPOSE

• According to degree of URGENCY

• According to degree of RISK

According to PURPOSE

Diagnostic Establishes a diagnosisEg. Biopsy, laparoscopy

Palliative Relieves or reduces pain or corrects a problem eg. Gastrostomy tube insertion

Ablative Removes a diseased body partEg. appendectomy

Constructive Restores function or appearanceEg. Face lift

Transplant Replaces malfunctioning structures eg. Kidney transplant

According to degree of URGENCY

Emergency surgery

Preserves function or life

Performed immediately

Elective surgery

Performed when condition is not imminently life threatening

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OTHER Classification

Indication for

surgery

examples

I.Emergent

life threatening

Without delay Trauma (gunshot, etc.)

II Urgent 24-30 hrs AP, Cholecystitis

III. Required Plan within weeks or month

Cataracts, thyroid

IV. Elective No emergency CS, hernia

V. Optional Personal preference

Cosmetic surgery

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Other types of SurgeryPROPHYLACTIC

PREVENTATIVE

Prevents a more serious condition from developing

INPATIENT SURGERY

Client has been in the hospital prior to the decision to have a surgery

OUTPATIENT SURGERY

Client enters the hospital to have surgery done

According to degree of RISK

Major Surgery

Involves high degree of risk

Complicated or prolonged, Large amount of blood loss

Minor Surgery

Involves low risk

Produces few complications

Performed as day surgery

MLNGCeleste, RN, MD

Activities in the Pre-op• Assessing the clients: Nursing history, physical and

emotional assessment, medication history• Identifying potential or actual health problems

(comorbidities)• Ensure necessary test were done including proper

referrals and consultation• Educate about recovery from anesthesia and

postoperative care• Providing pre-operative teaching • Ensure consent is signed• Start an IV infusion• Address questions of the patient and family

Consent

• The surgeon is responsible for obtaining the consent for surgery

• No sedation should be administered before SIGNING the consent

• The nurse may serve as witness

INFORMED CONSENT

• EMANCIPATED MINOR- below legal age of 18 but who is living independently from parents or who is already living in with a partner; with children of their own

Health factors (Preoperative) that may affect the outcome of the Surgery• Nutritional status• Drug or alcohol abuse• Respiratory status• Cardiovascular status• Hepatic and renal Factors• Endocrine Function• Immune function• Previous medication use• Psychosocial factors• Spiritual and cultural beliefs

Surgical Risk

• Extremes of age• Malnourished• Obese• Co-morbid conditions (HPN,

cardiac disease, diabetes, renal failure)

• Concurrent medications (aspirin, diuretic, insulin, antihypertensives, steroids)

Pre-operative Interventions

• Secure consent (operative permit)• Obtain nursing history, PE and lab exam• Provide pre-operative teaching as to the

nature of surgery, what to expect and ways to manage post-operative discomforts

• Perform physical preparations- shaving, hygiene, enema, NPO, medications

Pre-op nutrition

• Assess order for NPO

• Solid foods are withheld for

about 8 hours before general anesthesia

Pre-op elimination • Laxatives, enemas or both may

be prescribed the night before surgery

• Have the client void immediately BEFORE transferring them to the OR

• Foley catheter may be inserted as ordered

Pre-op hygiene • Bathe the night or morning before

surgery with antiseptic soap• Shaving of the skin is usually done in

the OR• Removal of jewelry and nail polish

*CONTACT LENSES/ HEARING AIDS/ DENTURES

Pre-op psychological preparation

• Be alert to the client’s anxiety level

• Answer questions or concerns

• Allow time for privacy

• Preparing the skin (shaving, using antiseptic solution)

• Asking the patient to void

• Administering Preanesthetic medications

• Transporting the patient to the presurgical area

Pre-operative medications

Pre-op Drugs Example Purpose

Anti-anxiety

Diazepam To decrease nervousness

Promote relaxation

Anti-cholinergic

Atropine Decreases secretions

Prevent bradycardia

Muscle relaxant

Succinylcholine To promote muscle relaxation

Anti-emetic Promethazine To prevent nausea and vomiting

Antibiotic Cephalosporin To prevent infection

Pre-operative medications

Pre-op Drugs

Example Purpose

Analgesic Meperidine (DEMEROL)

To decrease pain and decrease anesthetic dose

Anti-histamine

Diphenhydramine (BENADRYL)

To decrease occurrence of allergy

H-2 antagonist

Cimetidine (TAGAMET)

To decrease gastric fluid and acidity

• Pre-operative teaching Leg exercises To stimulate blood circulation

in the extremities to prevent thrombophlebitis

Deep breathing and Coughing

Exercises

To facilitate lung aeration and secretion mobilization to prevent atelectasis and hypostatic pneumonia

Done every two to four hours

Positioning and Ambulation

To stimulate circulation, stimulate respiration, decrease stasis of gas

Pre-operative teachingPre-operative teaching

Assisting patient to semi-Fowler’s position, leaning forward.

Having patient splint a chest or abdominal incision by holding a

folded bath blanket or pillow against the incision.

Telling patient to take a deep breath and hold it for three seconds.

Encouraging patient to "hack" out three short coughs after holding

breath.

With mouth open, patient should take a quick breath.

Encouraging patient to cough deeply once or twice and then take

another deep breath.

An incentive spirometer helps increase lung volume and promotes

inflation of the alveoli.

Assisting patient to semi-Fowler’s position.

Setting the volume goal indicator on the spirometer.

Patient holding the device and placing lips around the mouthpiece to create a seal, then taking a deep

breath in.

The patient can observe progress toward the goal by watching the balls or diaphragm of spirometer

elevate or lights go on (depending on equipment used). Have patient

repeat exercise 5 to 10 times every 1 to 2 hours while awake

Assisting patient to a semi-Fowler’s position with knees bent.

Raising patient’s right foot and keeping it elevated for a few

seconds.

Extending the lower portion of the leg.

Lowering the entire leg to the bed. This exercise is repeated five times

with each leg.

Patient pointing toes of both feet toward the foot of the bed, with

both legs extended.

Patient pulling toes toward chin, as if a string were attached to them

Having patient make circles with both ankles, first one way and then

the other.

Instructing patient to raise one knee and reach across to grasp the side rail on the side of the bed toward which he or she will be turning.

Helping patient to rollover while he or she pushes with the bent leg and

pulls on the side rail.

Showing patient how to use a small pillow to splint a chest or abdominal

incision while turning.

After patient is turned, providing support with pillows behind the

patients back.

Pre-operative screening test

CBC Determine Hgb and Hct, infection

Blood type Determined in case of blood transfusion

Serum electrolytes

Evaluates the fluid and electrolyte status

FBS Evaluates diabetes mellitus

BUN, Creatinine Assess the renal function

ALT, AST, Bilirubin

Evaluates the liver function

Serum albumin Evaluates nutritional status

CXR and ECG Respiratory and Cardiac status

MLNGCeleste, RN, MD

Activities during the Intra-op

Provide patient safety, maintain an aseptic environment, ensure proper function of the equipments, position the client, emotional support, assisting the surgeon as scrub nurse, circulating nurse, nurse assistant,

Intra-operative phase interventions

• Determine the type of surgery and anesthesia used

• Position client appropriately for surgery

• Assist the surgeon as circulating or scrub nurse

• Maintain the sterility of the surgical field

• Monitor for developing complications

Principles of Sterile TechniqueMLNGCeleste, RN, MD

Basic Guidelines in Surgical Asepsis

• All materials in contact with the surgical wound and used within the sterile field must be sterile.

• Gowns are considered sterile in front from the chest to the level of the sterile field.

• Sterile drape

• Items should be dispensed to a sterile field by methods that preserve the sterility

• Movement of the surgical team are from sterile to sterile and from unsterile to unsterile area

• Movement around a sterile field must not cause contamination of the field

• When a sterile barrier is breached, the area , must be considered contaminated

Operating Room Team

direct patient care team

• The team is likely a symphony orchestra

• Each person is an integral entity in harmony with his colleagues

1. THE STERILE TEAM

2. THE UNSTERILE TEAM

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The Sterile Team– Operating surgeon– Assistants to the surgeon: Another surgeon

(1st assist), surgical resident doctor (2nd assist), RN assist (3rd assist)

– Scrub Nurse– They:

• Scrub their hands and arms• Don sterile gloves and gown• Enter the sterile field (all items for the surgical

procedure are sterilized)

MLNGCeleste, RN, MD

The Unsterile Team– Anesthesiologist or anesthetist– Circulating nurse– Technicians – They:

• Don’t enter the sterile field• Function outside of the sterile field• Maintain sterile technique

MLNGCeleste, RN, MD

Functions of the nurse during OR procedure

SCRUB NURSE •Assists the surgeon

•Maintains sterility

•Set up sterile tables, Prepares and Handles instruments, sutures

•Drapes patient

•Counts sponges, needles, instruments

•Wears sterile gown, gloves

CIRCULATING NURSE

•Assists the Scrub nurse

•Positions the patient for

surgery

• Positions any equipment

•Monitors/coordinates all activities•Controls the physical and emotional atmosphere in the room•Protects the pt’s safety and health

Scrub Nurse– Maintain safety of the sterile field– Knows the sterile and aseptic technique– Prepares the instruments– Assists the surgeon with the instruments– PRIVATE SCRUB NURSE (employed by the

surgeon)

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Circulating Nurse– Monitors/coordinates all activities

– Controls the physical and emotional atmosphere in the room

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SEDATION

• MINIMAL SEDATION

• MODERATE SEDATION

• DEEP SEDATION

• ANESTHESIA

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Minimal sedation

- drug induced state in which a patient can respond normally in verbal commands

- cognitive function and coordination may be impaired

Levels of Sedation

Moderate sedation

- depressed level of consciousness that does not impair ability to maintain a patent airway

- calm, sedate a patient combined with analgesic

- Midazolam/Diazepam

Deep Sedation - a drug induced state in

which a patient cannot be easily aroused but can respond purposefully after repeated stimulation

- inhaled or intravenous - Volatile anesthetic

(halothane, Isoflurane) - Gas anesthetic (Nitrous

oxide)

ANESTHESIA

• absence of sensation

• state of narcosis (severe CNS depression produced by pharmacological agents), analgesia, relaxation and reflex loss

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• Loss of the ability to maintain ventilatory function

• Client requires assistance to maintain a patent airway.

• Cardiovascular function may be affected as well

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Anesthesia - a state of narcosis, analgesia,

relaxation and reflex loss

• General anesthesia– Loss of all sensation and

consciousness; cardiovascular and ventilatory functions are impaired

• Regional or Local anesthesia– Loss of sensation in ONE area with

consciousness present

Methods of Anesthesia Administration

• Inhalation

• Intravenous

• Regional Anesthesia: Epidural & Spinal

• Local Conduction Blocks: Local Infiltration

GENERAL ANESTHESIA• the patient is unconscious and does

not see, hear, or feel anything. It provides pain relief, muscle relaxation, and amnesia so you don't remember the details of your surgery.

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GENERAL Anesthesia

• Administered in two ways: – Inhalational

– Intravenous

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PURPOSES OF GENERAL ANESTHESIA• pain relief (analgesia) • blocking memory of the procedure (amnesia) • producing unconsciousness • inhibiting normal protective body reflexes to

make surgery safe and easier to perform • relaxing the muscles of the body

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Stages of General Anesthesia• Stage I (Beginning Anesthesia/ INDUCTION

PHASE)

- patient may still be conscious, senses inability to move extremities

- patient feels warm, dizzy with a feeling of detachment

- patient may have ringing, buzzing in the ear, still conscious, sense inability to move extremities

- noises are exaggerrated

- avoid unnecessary noises or motions

• Stage II: Excitement - time from loss of consciousness to loss of reflexes - Characterized by struggling,

shouting, talking, crying. - pupils dilate, rapid pulse and

irregular RR - restrain the patient

Stage III: SURGICAL ANESTHESIA

(MAINTENANCE PHASE)

- Surgical anesthesia is reached

- patient is unconscious and lies

quietly

- respirations and CR are regular- may be maintained in hours

(if properly given)

*EMERGENCE PHASE90

• Stage IV: Medullary Depression - stage is reached when too much

anesthesia is given - RR becomes shallow, pulse is

weak and thready, pupils widely dilated and become unresponsive to light, cyanotic

- Without proper treatment death will follow

- Discontinue anesthetic abruptly, cardiopulmonary support is initiated

G A: INHALATIONAL ADMINISTRATION

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G A: INTRAVENOUS ADMINISTRATION

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G A: HALOTHANE

• is a powerful anesthetic and can easily be overadministered.

• Advantages: pleasant odor• Disadvantages: little pain relief

(combined with other agents to control pain)

• Adverse reactions: – cardiac dysrhythmia– Hepatotoxicity

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G A: ENFLURANE (ETHRANE)

• is less potent and results in a more rapid onset of anesthesia and faster awakening than halothane.

• Adverse reaction: Increases ICP and the risk of seizure (contraindicated among patients with seizure disorders)

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G A: ISOFLURANE (FORANE)

• is not toxic to the liver but can cause some cardiac irregularities.

• Isofluorane is often used in combination with intravenous anesthetics for anesthesia induction.

• Awakening from anesthesia is faster than it is with halothane and enfluorane.

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G A: SEVOFLURANE

• Does not cause cardiac arrhythmias and coughing that is why this is replacing halothane for induction of pediatric clients

• this agent is rapidly eliminated and allows rapid awakening

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NITROUS OXIDE (LAUGHING GAS)

• is a weak anesthetic and is used with other agents, such as thiopental, to produce surgical anesthesia.

• It has the fastest induction and recovery and is the safest because it does not slow breathing or blood flow to the brain.

• Adverse effect: it diffuses rapidly into air-containing cavities and can result in a collapsed lung (pneumothorax) or lower the oxygen contents of tissues (hypoxia).

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• LARYNGOSCOPE

Establishing AIRWAY PATENCY: ENDOTRACHEAL INTUBATION

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POST G.A. Effects• Headache • vision problems, including blurred

or double vision

• shivering or trembling • muscle pain • dizziness, lightheadedness, or faintness • drowsiness • mood or mental changes • nausea or vomiting • sore throat • nightmares or unusual dreams

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Potential adverse effects of anesthesia

• Myocardial depression, bradycardia• Anaphylaxis• CNS agitation, seizures, respiratory

arrest• Oversedation or under sedation• Agitation and disorientation• Hypothermia• Hypotension• Malignant hyperthermia

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PRECAUTION

• A complete medical history including a history of allergies in family members, is an important precaution. Patients may have a potentially fatal allergic response to anesthesia known as malignant hyperthermia (a muscular disorder induced by anesthesia), even if there is no previous personal history of reaction.

• WARNING SIGN: TACHYCARDIA

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Discharge Instructions post- GA

• Do not consume alcohol• Do not drive a car or operate heavy

machinery• Do not sign any legal documents• Do not make any important decisions• Someone should stay with you at least

for the first 24 hours after your surgery.

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INTRAVENOUS MEDICATIONS FOR G A

• used to induce or maintain surgical anesthesia & hypnosis with use of barbiturates, benzodiazepines, hypnotics and opioid agents

• nonexplosive, require little equipment and easy to administer

• useful for short procedures

• disadvantage: respiratory depressants• EX : ketamine, thiopental (a barbiturate),

methohexital (Brevital), etomidate, propofol (Diprivan)

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Commonly Used IV MedicationsMedication Usage Advantage DisadvantageMuscle Relaxant

Succinlcholine

(Anectine)

Intubation

Short cases

Rapid onset

Short duration

Myalgias, fasciculation, tissue trauma, paralysis

Anxiolytic/Sedative

Diazepam

Amnesia,

Hypnotic

Good sedation Prolonged duration, residual effects

Barbiturates

Thiopental

Induction Offers good induction

Cause laryngospasm

Dissociative Anesthesia

Ketamine (ketalar)

Induction

Short cases

Pt maintains airway

Large doses may cause hallucination,respiratory depression

Opioid Analgesic

Morphine

Perioperative

pain

Inexpensive, good

CV stability

Dec in BP and RR

Opioid Analgesic

Fentanyl (sublimaze

Postoperative

pain

Good CV stability

MLNGCeleste, RN, MD

REGIONAL Anesthesia- a form of local anesthesia

- the patient is awake

TOPICAL Applied directly on the skin

INFILTRATION Injected into a specific area of skin

NERVE BLOCK Injected around a nerve

SPINAL Subarachnoid

Low spinal anesthesia

EPIDURAL Epidural space is injected with anesthesia

INTRASPINAL ANESTHESIA

• best reserved for operations below the umbilicus e.g. appendectomy, hernia repairs, gynecological and urological operations and any operation on the perineum or genitalia.

1. epidural

2. intrathecal (subarachnoid)

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INTRASPINAL ANESTHESIA

TETRACAINE

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EPIDURAL ANESTHESIA

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INTRATHECAL (SUBARACHNOID)

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Patient Positioning• Provides optimal visualization

• Provides optimal access for assessing and maintaining anesthesia and function

• Protects patient from harm

MLNGCeleste, RN, MD

Position Patient during Surgery

Abdominal surgeries Supine

Bladder surgery Slightly trendelenburg

Perineal surgery Lithotomy

Brain surgery Semi-fowler’s

Spinal cord surgeries Prone mostly

Lumbar puncture Side lying, flexed body

MLNGCeleste, RN, MD

A. ABDOMINAL SURGERY1. Abdominal Laparotomy2. Herniorrhaphy3. Cholecystectomy4. Pancreaticoduodenectomy (Whipple’s)5. Pancreatectomy6. Splenectomy7. Bariatric Surgery

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B. BREAST SURGERY1. Mastectomy

2. Breast Biopsy

3. Mammoplasty

4. Breast Augmentation, Breast Repair, Breast Lifting

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C. OBSTETRIC & GYNECOLOGIC SURGERY1. D & C2. Vaginal/Abdominal Hysterectomy3. Perineorrhaphy4. Salphingo-Oophorectomy5. Tuboplasty of the Fallopian tubes6. Ceasarian Section – low transverse, classical, Pfannensteil (‘bikini cut’)

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D. GENITOURINARY SURGERY1. Circumcision2. Vasectomy3. Orchiectomy4. Cystectomy5. Transurethral Resection of the Prostate/Bladder (TURP/TURB)6. Nephrectomy7. Ureterolithotomy8. Pyelolithotomy

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MLNGCeleste, RN, MD

Activities in the POST-op • Maintain patent airway• Monitor VS• Assessing responses to surgery and anesthesia• Performing interventions to promote healing • Prevent complications• Planning for home-care• Assist the client to achieve optimal recovery

POST Operative Interventions

• Transfer the postoperative patient to the PACU: anesthesiologist/anesthetist

• Nursing Objective: provide care until the patient recovers from the effects of anesthesia, is oriented, has stable VS and shows no evidence of hemorrhage or other complications

• ASSESS your patient

PACU- Post-Anesthesia Care/Recovery Unit

1. Immediate and continuous assessment every 15 minutes initially

2. Check airway patency, vital signs, surgical site, drain, recovery from anesthesia, pain control, fluid status, postop orders

3. When stable, discharge to hospital room or home

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POST Operative Interventions

• Maintain patent airway• Maintain cardiovascular stability• Monitor vital signs and note for early

manifestations of complications• Monitor level of consciousness• Maintain on PROPER position• NPO until fully awake, with passage

of flatus and (+) gag reflex

POST Operative Interventions

• Monitor the patency of the drainage• Maintain intake and output monitoring• Care of the tubes, drains and wound • Ensure safety by side rails up• Pain medication given as ordered• Measures to PREVENT post-op

Complications

POST Operative Interventions PARAMETERS to consider before

discharging a postop patient from PACU1. ACTIVITY – can move all 4 extremities2. RESPIRATION – can deep breath and cough3. CIRCULATION 4. CONSCIOUSNESS – fully awake5. COLOR - pink

Post-operative interventions

PAIN MANAGEMENT

• Pain is usually greatest during the 12-36 hours after surgery

• Narcotic analgesics and NSAIDS may be prescribed together for the early period of surgery

• Provide back rub, massage, diversional activities, position changes

Post operative interventions

POSITIONING

• Clients who have spinal anesthesia is usually placed FLAT on bed for 8-12 hours

• Unconscious client is placed side lying to drain secretions

• Other positions are utilized BASED on the type of surgery

Post-operative InterventionsSome Examples of Position Post Op

Mastectomy Semi-fowlers’, affected arm elevated

Thyroidectomy Semi fowlers’, head midline

Hemorrhoidectomy Semi-prone, side-lying

Laryngectomy Fowler’s

Pneumonectomy Lateral, affected side

Lobectomy Lateral, unaffected side 149

Post-operative InterventionsSome Examples of Position Post Op

Aneurysmal repair (abdomen)

Fowler’s 45 degrees

Amputation of lower extremities

Flat, with stump elevated with pillow

Cataract surgery Fowler’s 45 degrees

Supratentorial craniotomy

Fowlers’

Infratentorial craniotomy

Flat on bed, supine

Spina bifida repair Prone 150

Wound Care

• Inspect dressing hourly

• Change dressing daily

• Inspect for signs of infection redness, swelling, purulent exudate (SEROUS EXUDATE – normal)

• Maintain wound drainage

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Diet

• NPO usually immediately after surgery

• Progressive diet

• Assess the return of the bowel sounds

Post-operative Interventions

• Hydration after NPO to maintain fluid balance

• Suction, either gastro or respiratory to relieve distention, to remove respiratory secretions

• Diet progressive, usually given when bowel sounds and gag reflex return

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Liquid Diet Vs Soft dietClear liquid Full liquid Soft diet

Coffee

Tea

Carbonated drink

Bouillon

Clear fruit juice

Popsicle

Gelatin

Hard candy

Clear liquid PLUS:

Milk/Milk prod

Vegetable juices

Cream, butter

Yogurt

Puddings

Custard

Ice cream and sherbet

All CL and FL plus:

Meat

Vegetables

Fruits

Breads and cereals

Pureed foods

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Urinary Elimination

• Offer bedpans

• Allow patient to stand at the bedside commode if allowed

• Report to surgeon if NO URINE output noted within 8 hours post-op

Post-operative Interventions • Deep breathing and coughing

exercises Q2-4 hours to remove pulmonary secretions

• Leg exercises Q 2 hours to promote circulation

• Ambulation ASAP prevents respiratory, circulatory, urinary and gastrointestinal complications

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DEEP BREATHING

• Aka ABDOMINAL BREATHING

• CHEST and ABDOMEN ENLARGE OR EXPAND

• Diaphragm is depressed• 10 deep breaths each time• Deep breathing FULLY

EXPANDS THE ALVEOLI166

CPTChest Physiotherapy• Chest physiotherapy is based on the

fact that mucus can be knocked or shaken form the walls of the airways and helped to drain from the lungs.

• The usual PVD SEQUENCE is as follows- POSITIONING, Percussion, Vibration, and removal of secretionsby SUCTIONING or Coughing followed lastly by oral hygiene

Chest PhysiotherapyChest Physiotherapy

PERCUSSION & VIBRATION

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VIBRATING

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PERCUSSION

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Incentive Spirometry

• This operates on the principle that spontaneous sustained maximal inspiration is most beneficial to the lungs and has virtually no adverse effects.

• The incentive spirometer measures roughly the inspired volume and offers the “incentive” of measuring progress

INCENTIVE SPIROMETRY

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Incentive Spirometry

SPLINTING WHILE COUGHING

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SPLINTING WHILE COUGHING

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LEG EXERCISES

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POSTMASTECTOMY EXERCISES

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POSTMASTECTOMY EXERCISES

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POSTMASTECTOMY EXERCISES

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Post operative complicationsAtelectasis

Pneumonia

Collapsed alveoli due to secretions

Inflammation of alveoli

•Assess breath sounds•Repositioning•Deep breathing and coughing•Chest physio•Suctioning •Ambulation

Thrombophlebitis Inflammation of the veins

•Leg exercises •Monitor for swelling•Elevated extremities

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ATELECTASIS

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PNEUMONIA

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DEEP VENOUS THROMBOSIS

*HOMAN’S SIGN184

DEEP VENOUS THROMBOSIS

(+)HOMAN’S SIGN

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EMBOLUS: MIGRATION OF A CLOT

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PULMONARY EMBOLISM

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Post-operative ComplicationsHypovolemic Shock

Loss of circulatory fluid volume

•Determine cause and prevent bleeding•O2, IVF

Urinary retention

Involuntary accumulation of urine

•Encourage ambulation

•Provide privacy

•Pour warm water

•Catheterize

Pulmonary embolism

Embolus blocking the lung blood flow

•Notify physician•Administer O2

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HYPOVOLEMIC SHOCK

MODIFIED TRENDELENBURG

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Post-operative complications

Constipation Infrequent passage of stool

•High fiber diet•Increased fluid•Ambulation

Paralytic ileus Absent bowel sound

•Encourage ambulation •NPO until peristalsis returns

Wound infection

Occurs about 3 days after surgery

•Daily wound dressing•Antibiotics•Maintain drain

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WOUND HEALINGPRIMARY INTENTION

SECONDARY INTENTION

TERTIARY INTENTION

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WOUND DISRUPTION

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Post-operative complications

Wound dehiscence

Separation of wound edges at the suture line

•Cover the wound with sterile normal saline dressing•Place in low-Fowler’s•Notify MD

Wound evisceration

Protrusion of the internal organs and tissues through wound

•Cover the wound with saline pad•Place in low-fowler’s•Notify MD 193

Wound DEHISCENCE

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Wound DEHISCENCE

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Wound EVISCERATION

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INCISIONAL HERNIA

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INCISIONAL HERNIA

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INCISIONAL HERNIA

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NURSING MANAGEMENT in the POSTOPERATIVE PHASE

• Preventing respiratory complications

• Relieving pain• Encouraging activity• Promoting wound healing• Maintaining normal body

temperature• Managing GI function• Nutrition• Resumption of urinary function

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MLNGCeleste, RN, MD

To emphasize

• The over-all goal of nursing care during the PRE-OPERATIVE phase is to prepare the patient mentally and physically for the surgery

To emphasize

• The over-all goal of nursing care during the INTRA-OPERATIVE phase is to maintain client safety

To emphasize

• The over-all goals of nursing care during the POST-OPERATIVE phase are to promote healing and comfort, restore the highest possible wellness and prevent associated risk

SCRUB OUT !!!