Perioperative Nursing CarePerioperative Nursing Care

I. Types of SurgeryI. Types of SurgeryA. A. DiagnosticDiagnostic - determination of presence and/or extent - determination of presence and/or extent

of pathology, ex. lymph node biopsyof pathology, ex. lymph node biopsy

B. B. TherapeuticTherapeutic - curative. Elimination/repair of - curative. Elimination/repair of pathology, ex. appendectomypathology, ex. appendectomy

C. C. PalliativePalliative - relieve or alleviate without curing, - relieve or alleviate without curing, ex. g-ex. g-tube placementtube placement

D. D. PreventivePreventive - stop another problem from happening - stop another problem from happening ex. suspicious moleex. suspicious mole

E. E. CosmeticCosmetic - optional. Decision rests with patient. - optional. Decision rests with patient.Other TypesOther Types

EmergencyEmergency - required immediately. May be life - required immediately. May be life threateningthreatening

ElectiveElective - should operate, not catastrophic - should operate, not catastrophic

-ectomy: removal-otomy: incision-plasty: change shape-oscopy: look

A. AgeA. Age

B. AllergiesB. Allergies

C. Vital sign trendC. Vital sign trend

D. Nutritional statusD. Nutritional status

E. Habits affecting tolerance to E. Habits affecting tolerance to anesthesiaanesthesia– drug & alcohol usedrug & alcohol use– smoking: 6x risk increasesmoking: 6x risk increase

II. Preoperative Nursing II. Preoperative Nursing AssessmentAssessment

II. Preoperative Nursing II. Preoperative Nursing AssessmentAssessment

F. Presence of infectionsF. Presence of infections

G. Use of drugs that are contraindicated G. Use of drugs that are contraindicated prior to surgeryprior to surgery

EverythingEverything! Including OTC herbal ! Including OTC herbal supplements, etc.supplements, etc.

H. Physiological status / labsH. Physiological status / labsFull H&P by physicianFull H&P by physician

I. Psychological state of the patientI. Psychological state of the patient

III. Patient preparationIII. Patient preparation

A. Operative consent. Nurse is advocate. 3 A. Operative consent. Nurse is advocate. 3 conditions:conditions:

• adequate disclosure of Dx, nature & purpose of Rx, adequate disclosure of Dx, nature & purpose of Rx, risks & consequencesrisks & consequences

• must demonstrate clear understanding & must demonstrate clear understanding & comprehension of informationcomprehension of information

• must be given voluntarilymust be given voluntarilyInformed consent: active shared decision making process between provider and patient. Protects all involved. Responsibility of surgeon to have it signed.Contains anticipated procedures, other procedures that might need to be done, and anything that can happen to the patient, including death.Patient must be of legal age or parent/guardian responsible. Must be signed voluntarily, never through coercion.

Informed consentInformed consent

B. Preoperative learning needsB. Preoperative learning needs

Individualized for ptIndividualized for pt’’s needs.s needs.

Common needs:Common needs:

• Deep breathing and coughingDeep breathing and coughing

• Turning and active body movementTurning and active body movement

• Pain control and medicationsPain control and medications– Educate pt. on notifying nurse if pain occurs.Educate pt. on notifying nurse if pain occurs.

• Tubes, drains, dressings, other devices to Tubes, drains, dressings, other devices to expect (SEDs, TEDs, IS, etc.)expect (SEDs, TEDs, IS, etc.)

• Cognitive control – psychosocial aspects.Cognitive control – psychosocial aspects.

Explain rationale, too.

Teaching splinting the incision

Teaching – PCA pumpDuring TCDB, etc. to maintain incision integrity

C. Interventions the day/evening C. Interventions the day/evening prior to surgeryprior to surgery• Intake restrictionsIntake restrictions

– NPO after midnightNPO after midnight– Although, evidence that pt. can have clear liquids Although, evidence that pt. can have clear liquids

up to 2 hours before surgeryup to 2 hours before surgery

• Cleansing enema or laxative night before Cleansing enema or laxative night before (bowel preps)(bowel preps)– For purpose of preventing defecation during For purpose of preventing defecation during

surgery, promoting intestinal deflation in case of surgery, promoting intestinal deflation in case of surgical site local to bowelssurgical site local to bowels

• Skin prepSkin prep– Ex. hot shower before surgery & additional skin prep Ex. hot shower before surgery & additional skin prep

in ORin OR

D. Interventions the day of D. Interventions the day of surgerysurgery

• NPO NPO

• May receive preanesthetic medication May receive preanesthetic medication

• Skin prepSkin prep

• Jewelry removed or tapedJewelry removed or taped– Defibrillation or cauterization will cause Defibrillation or cauterization will cause

burns burns

• Void right before going to surgeryVoid right before going to surgery

• Preoperative check listPreoperative check list

Preoperative check listPreoperative check list

IV. Intraoperative nursing IV. Intraoperative nursing considerationsconsiderationsA. Nursing rolesA. Nursing roles1. 1. Circulating RN Circulating RN - - manages OR room. Nonsterile manages OR room. Nonsterile

activities. Protects safety & health needs of patient by activities. Protects safety & health needs of patient by monitoring all activities of members of surgical team & monitoring all activities of members of surgical team & conditions of OR. conditions of OR.

2. 2. Scrub RNScrub RN• Sterile activitiesSterile activities

• Scrub for surgeryScrub for surgery

• Set up sterile table, prepare sutures, special equipmentSet up sterile table, prepare sutures, special equipment

• Assist surgeon during procedure - anticipate needsAssist surgeon during procedure - anticipate needs

• Ensure equipment/instrument count with circulating RNEnsure equipment/instrument count with circulating RN

B. Perioperative asepsisB. Perioperative asepsis• Main priority of surgery - prevent patient problems Main priority of surgery - prevent patient problems

• Includes protecting patient from infectionIncludes protecting patient from infection

1. All materials in sterile field must be sterile1. All materials in sterile field must be sterile

2. Sterile items in contact with non-sterile items are 2. Sterile items in contact with non-sterile items are contaminatedcontaminated

3. Remove contaminated items immediately3. Remove contaminated items immediately

4. Sterile team members wear sterile gowns4. Sterile team members wear sterile gowns

5. Keep wide margin between sterile & non-sterile field5. Keep wide margin between sterile & non-sterile field

6. Tables sterile only at tabletop level6. Tables sterile only at tabletop level

7. Edges of sterile package contaminated once package is 7. Edges of sterile package contaminated once package is openedopened

8. Bacteria travel on airborne particles8. Bacteria travel on airborne particles

9. Bacteria travel by capillary action through moist fabrics9. Bacteria travel by capillary action through moist fabrics

11. Bacteria harbor on patients and team members11. Bacteria harbor on patients and team members’’ hair, skin, hair, skin, and resp. tractsand resp. tracts

• Preparation of a sterile fieldzPreparation of a sterile fieldz

Sterile clothing is worn in the ORPreparation of a sterile field

An OR suite

C. Types of anesthesiaC. Types of anesthesia

Factors to consider in anesthetics:Factors to consider in anesthetics:

• current health status and historycurrent health status and history

• emotional stabilityemotional stability

• factors relating to operative factors relating to operative procedureprocedure

C. Types of anesthesiaC. Types of anesthesia

• GeneralGeneral - loss of sensation with loss of - loss of sensation with loss of consciousnessconsciousness

• LocalLocal - loss of sensation without loss of - loss of sensation without loss of consciousness consciousness

• ConsciousConscious sedationsedation - minimally depressed - minimally depressed LOC, twilight sleepLOC, twilight sleep

• RegionalRegional - loss of sensation without loss of - loss of sensation without loss of consciousness when specific nerve is consciousness when specific nerve is blocked, ex. spinal anestheticblocked, ex. spinal anesthetic

1. General Anesthesia1. General Anesthesia

• IV AnesthesiaIV Anesthesia

• Inhalation AgentsInhalation Agents

• Adjuncts to General AnesthesiaAdjuncts to General Anesthesia– Muscle relaxation & reflex controlMuscle relaxation & reflex control– Relieve pain & anxietyRelieve pain & anxiety– Amnesia, LOCAmnesia, LOC

• Begin with IV induction of short acting Begin with IV induction of short acting barbituratebarbiturate

Anesthesia induction

2. Regional Anesthesia2. Regional Anesthesia

• Suspends sensation in parts of body Suspends sensation in parts of body

• Injected around nerves so area Injected around nerves so area supplied by nerves is anesthetizedsupplied by nerves is anesthetized

• Effect depends on type of nerve Effect depends on type of nerve involved involved

• Spinal anesthesiaSpinal anesthesia

• Epidural blockEpidural block

Spinal and Epidural Spinal and Epidural AnesthesiaAnesthesia

D. Patient positioningD. Patient positioning

Depends on surgery & condition of pt. Depends on surgery & condition of pt.

• correct skeletal alignmentcorrect skeletal alignment

• undue pressure on nerves, skin over bony undue pressure on nerves, skin over bony prominences, eyesprominences, eyes

• adequate thoracic excursionadequate thoracic excursion

• occlusion of arteries and veinsocclusion of arteries and veins

• modestly in exposuremodestly in exposure

• recognize and respect individual needsrecognize and respect individual needs

Operative positionsOperative positions

E. Temperature alterations E. Temperature alterations during interoperative period during interoperative period

May be intentional. May be caused by:May be intentional. May be caused by:

• low temp in ORlow temp in OR

• infusion of cold fluidinfusion of cold fluid

• inhalation of cold gasesinhalation of cold gases

• open body wounds or cavitiesopen body wounds or cavities

• decreased muscle activitydecreased muscle activity

• advanced ageadvanced age

• drugs used (vasodilators)drugs used (vasodilators)

Malignant hyperthermia – hypermetabolic condition of very high temperatures associated with muscle rigidity in the skeletal muscles. Occurs in some people exposed to certain anesthetics. Can lead to cardiac dysrhythmia. Mortality rate >50%

V. Postoperative careV. Postoperative care

A. Preparation for admitting the new A. Preparation for admitting the new postoperative patientspostoperative patients

B. Initial assessment and interventions B. Initial assessment and interventions upon receiving the patientupon receiving the patient

C. Selected data from the chart that is C. Selected data from the chart that is of importanceof importance

D. Post operative nursing D. Post operative nursing assessment and concerns assessment and concerns

• Ineffective airway clearanceIneffective airway clearance

• Pain & other postoperative discomfortsPain & other postoperative discomforts

• Risk for altered body temperatureRisk for altered body temperature

• Risk for injury related to postanesthesiaRisk for injury related to postanesthesia

• Altered nutrition – less than body requirementsAltered nutrition – less than body requirements

• Altered urinary eliminationAltered urinary elimination

• ConstipationConstipation

• Impaired physical mobilityImpaired physical mobility

Anesthetic into body through inhalation, out through expiration. Encourage deep breaths immediately to expel post-op.

Post-operative positionPost-operative position

Postoperative CarePreparing for post-operative patient

Initial Assessment and Interventions

Selecting important data from chart

General post-op assessment & interventions

Preparing for Post-operative Patient

Is there 02 in the room?

IV or PCA pumps/poles?

Pt arriving by bed or gurney?

Does the patient need suction?

Is traction required?

Are tracheostomy supplies needed?

Is the nurse’s assistant prepared?

Initial Assessment & InterventionsLOC: Alert and oriented

Comfort: Pain, nausea, pruritus

Vital Signs: All especially respirations

Wound: Incision

Drains: Color, amount, location(s)

Support equipment:

Compression & Sequential stockings

CPM PCA IV 02

NOTE: Nursing Care Plan Table 20-1 in Lewis

Dressing: drainage, mark with pen and date to monitor for bleeding

Selecting Important Data from the Patient’s Chart

Doctor’s orders

History & Physical (H&P)

Allergies

Pre-op vital signs

Pre-op medications

Pre-op lab levels

General Post-op

Assessment & Interventions Continue with initial Assessment then…

Pain management

Ambulate or ROM (per MD orders)

Cough, deep breath & Incentive Spirometer

Incisions and drains

Antibiotic therapy

Anti-DVT/PE interventions

Potential Postoperative Complications

Hematological Respiratory

Cardiovascular Urinary

Gastrointestinal Neurological

Immunological Wound

Psychological

Potential Postoperative Complications

Hematological

Hemorrhage:

S/S: External: Surgical site (dressing, drains, linens)

Internal: tenderness, swelling B/P changes, CBC levels. Symptoms of hypovolemia

Potential Postoperative Complications

Respiratory

Atelectasis: Collapse of alveoli

Pneumonia: Fluid infiltration

Pulmonary embolism: DVT moved to lung

Prevention: Deep breath, cough & Incentive spirometer, hydrations, antibiotics, anti-embolism interventions & Rxs

Postoperative AtelectasisPostoperative Atelectasis

Potential Postoperative Complications

Cardiovascular

Hypotension: Hypovolemic: Hemorrhage, dehydration, due to NPO status, poor IV access

Cardiac dysrhythmias: Due to dehydration, previous condition, anesthesia, electrolyte imbalance.

Deep Vein Thrombosis

Prevention: Assessment & intervention, hydration, continue previous meds.

Potential Postoperative Complications

Thromboembolism: DVT/PE#1 cause of mortality in Post-op &

Hospitalized patients

200,000-600,000 cases annually

60,000-200,000 die annually

(APHA, 2003)

Potential Postoperative Complications

Thromboembolism Continued…

Causes: Dehydration,immobility, vascular manipulation or injury, hormones &

birth control, history of DVT

S/S: Redness, swelling, pain, chest pain, SOB, dyspnea

Prevention: Turn, cough, deep breath, ROM, ambulation, hydration, exercisesantiembolism & sequential

stockings and anticoagulants

Assessing for HomanAssessing for Homan ’’s signs sign

Post-operative Leg Post-operative Leg ExercisesExercises

Potential Postoperative Complications

Urinary

Urinary retention: (bladder related)

S/S: Tenderness, low or no output, distension, incontinence.

Low urine output: (renal) < 30mL/hr rule

Causes: Anesthesia, anticholinergic and narcotics, dehydration, position,

ARF or CRF.

Palpation for bladder Palpation for bladder distentiondistention

Potential Postoperative Complications

Gastrointestinal

Paralytic ileus:

Causes: Intestinal manipulation, narcotics, premature introduction of food

Tx: NG tube to suction, NPO

Constipation:

Causes: Narcotics, NPO, dehydration, inactivity, previous hx.

Tx: Hydration, ambulation, stool softeners and/or fiber.

Potential Postoperative Complications

Neurological

CVA or stroke:

Causes: DVT

Prevention: Same as DVT/PE

Narcosis or “narcotized state”

Causes: Opiod Naïve, anesthesia, narcotic overload.

Sensory changes: peripheral and urinary

Potential Postoperative Complications

Immunological

Infection:

Signs & Symptoms:

Assessment: Fever, tenderness, redness, swelling, drainage color changes or c/o “feeling lousy.”

Lab: Elevated WBCs

Prevention:

Aseptic technique when handling wounds, dressings and drains.

Jackson-Pratt DrainJackson-Pratt Drain

Hemovac DrainHemovac Drain

Cleaning a Drain SiteCleaning a Drain Site

Penrose drain

Cleaning a Wound SiteCleaning a Wound Site

Montgomery TiesMontgomery Ties

Potential Postoperative Complications

Wound

Dehiscence: Spontaneous opening of incision

Evisceration: Escape of Organs

Infection: Invasion of organisms w/ potential of causing disease

Prevention: Hand washing, assessment, aseptic technique, binder, splinting and patient teaching.

Dehiscence and EviserationDehiscence and Eviseration

Abdominal BinderAbdominal Binder

Splinting MethodsSplinting Methods

Surgical wound Surgical wound classificationsclassifications

Potential Postoperative Complications

Psychological:

Body image Problems: Scarring, drains, amputation, ostomy.

Pain Management:

• Pre-op pain vs. post-op pain

• Chronic pain vs. acute pain