29777748 Perioperative Nursing

Lecture Notes on Perioperative Nursing

Prepared By: Mark Fredderick R Abejo R.N, MAN

MS Perioperative Nursing Abejo

1

MEDICAL AND SURGICAL NURSING

PERIOPERATIVE NURSING

Lecturer: Mark Fredderick R. Abejo RN, MAN

__________________________________________

Perioperative Nursing – used to describe the nursing

care provided in the total surgical experience of the

patient: preoperative, intraoperative and 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, extends from the time the client 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, extends from the time the client 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.

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

* Constructive – repair of congenitally

defective organ.

* Reconstructive – repair of damage organ

Palliative – to relieve distressing sign and symptoms,

not necessarily to cure the disease.

According to URGENCY

Classification Indication

for Surgery

Examples

Emergent – patient

requires immediate

attention, life

threatening condition.

Without

delay

- severe

bleeding

- gunshot/

stab wounds

- Fractured

skull

Urgent / Imperative –

patient requires prompt

attention.

Within 24 to

30 hours

- kidney /

ureteral

stones

Required – patient

needs to have surgery.

Plan within a

few weeks or

months

- cataract

- thyroid d/o

Elective – patient

should have surgery.

Failure to

have surgery

not

catastrophic

- repair of

scar

- 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

Teeth extraction

Circumcision

Vasectomy

Cyst removal

Tubal ligation

Surgical Risks

Obesity

Poor Nutrition

Fluid and Electrolyte Imbalances

Age

PERIOPERATIVE

NURSING




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Presence of Disease (Cardiovascular dse., DM,

Respiratory dse. )

Concurrent or Prior Pharmacotherapy

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

Goals

Assessing and correcting physiologic and

psychologic problems that may increase surgical risk.

Giving the person and significant others complete

learning / teaching guidelines regarding surgery.

Instructing and demonstrating exercises that will

benefits the person during postop period.

Planning for discharge and any projected changes in

lifestyle due to surgery.

Physiologic Assessment of the Client Undergoing

Surgery

Age

Presence of Pain

Nutritional & Fluid and Electrolyte Balance

Cardiovascular / Pulmonary Function

Renal Function

Gastrointestinal / Liver Function

Endocrine Function

Neurologic Function

Hematologic Function

Use of Medication

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 matching

Determined in case blood transfusion

is required during or after surgery.

Serum

Electrolyte

To evaluate fluid and electrolyte

status

PT,PTT Measure time required for clotting to

occur.

Fasting Blood

Glucose

High level may indicate undiagnosed

DM

BUN /

Creatinine

Evaluate renal function

ALT/AST/LDH

and Bilirubin

Evaluate liver function

Serum albumin

and total CHON

Evaluate nutritional status

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

Fear of Unknown ( Anxiety )

Fear of Anesthesia

Fear of Pain

Fear of Death

Fear of disturbance on Body image

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

Explore client’s feeling

Allow client’s to speak openly about fears/concerns

Give accurate information regarding surgery

(brief, direct to the point and in simple terms)

Give empathetic support

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

the diagnosis and explanation of the condition.

a fair explanation of the procedure to be done and

used and the consequences.

a description of alternative treatment or procedure.

a description of the benefits to be expected.

material rights if any.

the prognosis, if the recommended care, procedure

is refused.

Requisites for Validity of Informed Consent

Written permission is best and legally accepted.

Signature is obtained with the client’s complete

understanding of what to occur.

PREOPERATIVE PHASE




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- adult sign their own operative permit

- obtained before sedation

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

For mentally ill and unconscious patient, consent

must be taken from the parents or legal guardian

If the patient is unable to write, an “X” ia 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.)

PREOPERATIVE 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

Preoperative Teaching

Incentive Spirometry

Encouraged to use incentive spirometer about 10 to

12 times per hour.

Deep inhalations expand alveoli, which prevents

atelectasis and other pulmonary complication.

There is less pain with inspiratory concentration than

with expiratory concentration.

Diaphragmatic Breathing

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.

In a semi-Fowlers position, with your hands loose-

fist, allow to rest lightly on the front of lower ribs.

Breathe out gently and fully as the ribs sink down and

inward toward midline.

Then take a deep breath through the nose and mouth,

letting the abdomen rise as the lungs fill with air.

Hold breath for a count of 5.

Exhale and let out all the air through your nose and

mouth.

Repeat this exercise 15 times with a short rest after

each group of 5.

Coughing

Promotes removal of chest secretions.

Interlace his fingers and place hands over the

proposed incision site, this will act as a splint and

will not harm the incision.

Lean forward slightly while sitting in bed.

Breath, using diaphragm

Inhale fully with the mouth slightly open.

Let out 3-4 sharp hacks.

With mouth open, take in a deep breath and quickly

give 1-2 strong coughs.

Turning

Changing positions from back to side-lying (vice

versa ) stimulates circulation, encourages deeper

breathing and relieve pressure areas

Help the patient to move onto his side if assistance is

needed.

Place the uppermost leg in a more flexed position

than that of the lower leg and place a pillow

comfortably between the legs.

Make sure that the patient is turned from one side to

the back and onto the other side every 2 hours.

Foot and Leg Exercise

Moving the legs improves circulation and muscle

tone.

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.

Repeat above about 5 times with one leg and then

with the other. Repeat the set 5 times every 3-5

hours.

Then have the patient lie on one side and exercise the

legs by pretending to pedal a bicycle.

For foot exercise, trace a complete circle with the

great toe.

Turning to the Side

Turn on your side with the uppermost leg flexed most

and supported on a pillow.

Grasp the side rails as an aid to maneuver to the side.




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Preparing the Patient the Evening Before Surgery

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.

Preparing the G.I tract

- NPO, cleansing enema as required

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 for Anesthesia

- Avoid alcohol and cigarette smoking for at least 24

hours before surgery.

Promoting rest and sleep

- Administer sedatives as ordered

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

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.




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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

Goal:

Asepsis

Homeostasis

Safe Administration of Anesthesia

Hemostasis

Surgical Environment

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 suit.

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

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

Environmental Safety

• The 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

• 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.

• Communication System

The Surgical Team

Surgeon

• 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

Assistant Surgeon

• 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

• 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

• 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

INTRAOPERATIVE PHASE




6

Circulating Nurse

• 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.

• 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.

Principles of Surgical Asepsis

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

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)

Medical Asepsis vs. Surgical Asepsis

Surgical Incisions

Incision Site Type of Surgery

Butterfly For craniotomy

Limbal For eye surgeries

Halstead / Elliptical For breast surgeries

Subcostal Gallbladder and biliary tract

surgery

Paramedian Right side – gallbladder, biliary

tract

Left side - splenectomy

Transverse Gastrectomy

Rectus Right side – small bowel

resection

Left side – sigmoid colon

resection

McBurney Appendectomy

Pfannenstiel Gynecologic surgery

Lumbotomy For kidney surgeries

Position During Surgery

Position Type of Surgery

Dorsal Recumbent Hernia repair, mastectomy,

bowel resection

Trendelenburg Pelvic Surgeries

Lithotomy Vaginal repair, D&C, rectal

surgery, APR

Prone Spinal surgery, laminectomy

Lateral Kidney, chest, hip surgery

Jack Knife Position Rectal procedures,

sigmoidoscopy and colonosc

Reverse

Trendelenburg

Position

Upper abdominal, head, neck

and facial surgery

Explain the purpose of position

Avoid undue exposure

Strap the person to prevent falls

Maintain adequate respiratory and circulatory

functions.

Maintain good body alignment

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 level

- HR and BP

- Urine output

Types of Anesthesia

1. General Anesthesia

reversible state consisting of complete loss of

consciousness and sensation.

protective reflexes such as cough and gag are lost

provides analgesia, muscle relaxation and sedation.

produces amnesia and hypnosis.




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Techniques used in General Anesthesia

A. Intravenous Anesthesia

This is being administered intravenously and

extremely rapid.

Its effect will immediately take place after thirty

minutes of introduction.

It prepares the client for smooth transition to the

surgical anesthesia.

B. Inhalation Anesthesia

This comprises of volatile liquids or gas and

oxygen.

Administered through a mask or endotracheal tube

2. Regional Anesthesia

temporary interruption of the transmission of nerve

impulses to and from specific area or region of the

body.

achieved by injecting local anesthetics in close

proximity to appropriate nerves.

reduce all painful sensation in one region of the body

without inducing unconsciousness.

agents used are lidocaine and bupivacaine.

Techniques used in Regional Anesthesia:

A. Topical Anesthesia

applied directly to the skin and mucous membrane,

open skin surfaces, wounds and burns.

readily absorbed and act rapidly

used topical agents are lidocaine and benzocaine.

B. Spinal Anesthesia ( Subarachnoid block )

local anesthetic is injected through lumbar puncture,

between L2 and S1

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

anesthetic block conduction in spinal nerve roots and

dorsal ganglia; paralysis and analgesia occur below

level of injection

agents used are procaine, tetracaine, lidocaine and

bupivacaine.

C. Epidural Anesthesia

achieved by injecting local anesthetic into epidural

space by way of a lumbar puncture.

result similar to spinal analgesia

agents use are chloroprocaine, lidocaine and

bupivacaine.

D. Peripheral Nerve Block

achieved by injecting a local anesthetic to anesthetize

the surgical site.

agents use are chloroprocaine, lidocaine and

bupivacaine.

E. Intravenous Block ( Beir block )

often used for arm,wrist and hand procedure

an occlusion tourniquet is applied to the extremity to

prevent infiltration and absorption of the injected IV

agents beyond the involved extremity.

Indicating a site for insertion of the lumber puncture

needle into the subarachnoid space of the spinal

canal.

F. Caudal Anesthesia

Is produced by injection of the local anesthetic into

the caudal or sacral canal

G. Field Block Anesthesia

The area proximal to a planned incision can be

injected and infiltrated with local anesthetic agents.

Stages of Anesthesia Onset / Induction. Extends from the

administration of anesthesia to the time of loss

of consciousness.

Excitement / Delirium. Extends from the time

of loss of consciousness to the time of loss of

lid reflex. Increase in autonomic activity and

irregular breathing. It may be characterized by

shouting, struggling of the client.

Surgical. Extends from the loss of lid reflex to

the loss of most reflexes. surgical procedure is

started.

Medullary / Stage of Danger. It is

characterized by respiratory and cardiac

depression or arrest. It is due to overdose of

anesthesia. Resuscitation must be done.




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Complication and Discomforts of Anesthesia

Hypoventilation - inadequate ventilatory support

after paralysis of respiratory muscles.

Oral Trauma

Malignant Hyperthermia

Hypotension - due to preoperative hypovolemia or

untoward reactions to anesthetic agents.

Cardiac Dysrhythmia - due to preexisting

cardiovascular compromise, electrolyte imbalance or

untoward reaction to anesthesia.

Hypothermia - due to exposure to a cool ambient

OR environment and loss of thermoregulation

capacity from anesthesia.

Peripheral Nerve Damage - due to improper

positioning of patient or use of restraints.

Nausea and Vomiting

Headache

Goals:

Maintain adequate body system functions

Restore homeostasis

Alleviate pain and discomfort

Prevent postop complication

Ensure adequate discharge planning and teaching.

PACU CARE

Transport of client from OR to RR

avoid exposure

avoid rough handling

avoid hurried movement and rapid changes in

position.

POSTOPERATIVE PHASE




9

Initial Nursing Assessment

Verify patient’s identity, operative procedure and the

surgeon who performed the procedure.

Evaluate the following sign and verify their level of

stability with the anesthesiologist:

- Respiratory status

- Circulatory status

- Pulses

- Temperature

- Oxygen Saturation level

- Hemodynamic values

Determine swallowing and gag reflex , LOC and

patients response to stimuli.

Evaluate lines, tubes, or drains, estimate blood loss,

condition of wound, medication used, transfusions and

output.

Evaluate the patient’s level of comfort and safety.

Perform safety check; side rails up and restraints are

properly in placed.

Evaluate activity status, movement of extremities.

Review the health care provider’s orders.

Initial Nursing Interventions

Maintaining a Patent Airway

Allow the airway ( ET tube ) to remain in place until

the patient begins to waken and is trying to eject the

airway.

The airway keeps the passage open and prevents the

tongue from falling backward and obstructing the air

passages.

Aspirate excessive secretions when they are heard in

the nasopharynx and oropharynx.

Assessing Status of Circulatory System

Take VS per protocol, until patient is well stabilized.

Monitor intake and output closely.

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

Place the patient in lateral position with neck

extended ( if not contraindicated ) and upper arm

supported on a pillow.

Turn the patient every 1 to 2 hours to facilitate

breathing and ventilation.

Encourage the patient to take deep breaths, use an

incentive spirometer.

Assess lung fields frequently by auscultation.

Periodically evaluate the patient’s orientation –

response to name and command.

Note: Alterations in cerebral function may suggest

impaired O2 delivery.

Administer humidified oxygen if required.

Use mechanical ventilation to maintain adequate

pulmonary ventilation if required.

Assessing Thermoregulatory Status

Monitor temperature per protocol to be alert for

malignant hyperthermia or to detect hypothermia.

Report a temperature over 37.8 C or under 36.1 C

Monitor for postanesthesia shivering, 30-45 minutes

after admission to the PACU.

Provide a therapeutic environment with proper

temperature and humidity.

Maintaining Adequate Fluid Volume

Administer I.V solutions as ordered.

Monitor evidence of F&E imbalance such as N&V

and weakness.

Evaluate mental status, skin color and turgor

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

Monitor I&O

Minimizing Complications of Skin Impairment

Perform handwashing before and after contact with

the patient

Inspect dressings routinely and reinforce them if

necessary.

Record the amount and type of wound drainage.

Turn patient frequently and maintain good body

alignment.

Maintaining Safety

Keep the side rails up until the patient is fully awake.

Protect the extremity into which I.V fluids are

running so needle will not become accidentally

dislodged.

Avoid nerve damage and muscle strain by properly

supporting and padding pressure areas.

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.

Check dressing for constriction

Promoting Comfort

Assess pain by observing behavioral and physiologic

manifestations.

Administer analgesic and document efficacy.

Position the patient to maximize comfort.

Parameter for Discharge from PACU/RR

Activity. Able to obey commands

Respiratory. Easy, noiseless breathing

Circulation. BP within 20mmHg of preop level

Consciousness. Responsive

Color. Pinkish skin and mucus membrane




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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

Goals:

o Restore homeostasis and prevent complication.

o Maintain adequate cardiovascular and tissue

perfusion.

o Maintain adequate respiratory function.

o Maintain adequate nutrition and elimination.

o Maintain adequate fluid and electrolyte balance.

o Maintain adequate renal function.

o Promote adequate rest, comfort and safety.

o Promote adequate wound healing.

o Promote and maintain activity and mobility.

o Provide adequate psychological support.




11

STI Global City College of Nursing / QMMC Surgery Ward Exposure


Prepared By: Mark Fredderick R Abejo R.N

Clinical Instructor


12

WOUND CARE

Frequently used Dressing

Materials Common dressing Irrigating a wound

Montgomery Straps holding 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 a wound outward

from the incision

Cleaning from top to bottom Cleaning around a

Starting at the center Penrose drain site




Clinical Instructor


13

INCISION SUPPORTING

BODY PRESSURE AREAS:




Clinical Instructor


14

Problem Description Cause Clinical Signs Nursing Intervention

RESPIRATORY

Pneumonia

Infectious

Pneumonia

Hypostatic

Pneumonia

Aspiration

Pneumonia

Inflammation of the

lung parenchyma /

alveoli

Infection

Toxin / irritants

causing

inflammatory

process

Cause by

streptococcus

pneumoniae /

Staphylococcus

aureus

Immobility

Impaired

ventilation

Aspiration of

gastric contents,

food

- elevated temp.

- cough

- blood tinged

sputum

- dyspnea

- chest pain

Deep breathing exercises

Coughing exercise

Early ambulation

Atelectasis

A condition in

which alveoli

collapsed and are

not ventilated

Mucous plugs

blocking bronchial

passageways

Inadequate lung

expansion

Immobility

- Fever ( 1st 24

hours)

- Dyspnea

- Tachycardia

- Diaphoresis

- Pleural pain

- Dull or absent

lung sounds

- Dec. SaO2

Deep breathing exercises

Coughing exercise

Early ambulation

Pulmonary

Embolism

Blood clot that has

moved to the lungs

and blocks a

pulmonary artery

and obstruct blood

flow to the lungs

Immobility

Use of oral

contraceptives

Coagulation

problem

- Sudden chest

pain

- SOB

- Cyanosis

- Tachycardia

- Low BP

Turning

Ambulation

Anti embolic stockings

Compression devises

Prevent massaging the

lower extremities

CIRCULATION

Hypovolemia Inadequate

circulating blood

volume

Hemorrhage

Fluid deficit

- Tachycardia

- Dec. urine

output

- Dec. BP

Fluid and blood

replacement

Hemorrhage Internal or external

bleeding

Capillary – slow

generalized oozing

Venous – dark in

color and bubble out

Arterial – spurts,

bright red in color

Disruption of

sutures

Insecure ligation of

blood vessels

- Cold, moist and

pale skin

- Deep, rapid RR

- Low temp

- Increase pain

- Inc. abd. girth

- Swelling or

bruising around

incision

Fluid and blood

replacement

Vit.k and hemostat

Ligation of bleeders

Pressure dressing

POST OPERATIVE COMPLICATIONS




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Overt Bleeding

- Dressing

saturated with

bright blood

- Bright, free-

flowing blood in

drains or tubes.

Thrombophlebitis

Thrombus

Embolus

Inflammation of the

veins, usually of the

legs and associated

with a blood clot.

Blood clot attached

to wall of vein or

artery

Foreign body or clot

that has moved from

its site of formation

to another area of

the body

Slowed venous

blood flow due to

immobility or

prolonged sitting

Trauma to the vein

Increased blood

coagulability.

Broken IV catheter

Fat

Amniotic fluid

- Homan’s Sign

pain, discomfort in

calf when foot is

dorsiflexed

- Aching, cramping

pain

- Swollen, red and

hot to touch

- Vein feels hard

Arterial

- Pain

- Pallor on the

affected

extremities

- Dec./absent of

peripheral pulse

Note:

Embolus in the

venous system

usually becomes a

pulmonary

embolus

Early ambulation

Anti embolic stocking

Encourage leg exercise

Hydrate adequately

Avoid any restricting

devices that impaired

circulation

Avoid massage on the

calf of the leg

Initiate anticoagulant

therapy

Careful maintenance of

IV catheters

URINARY

Urinary

Retention

Inability to empty

the bladder, with

excessive

accumulation of

urine in the bladder

Depressed bladder

muscle tone from

narcotics and

anesthetics

Handling of tissue

during surgery on

adjacent organs

Spasm of the

bladder sphincter

- Larger fluid

intake than output

- Inability to void

- Bladder

distention

- Suprapubic

discomfort

- Restlessness

Monitor I & O

Interventions to facilitate

voiding

Urinary Catheterization

as needed

Urinary

Incontinence

Inability of the

bladder to hold

accumulated urine

Loss of tone of the

bladder sphincter

- 30 – 60 ml of

urine q 15-30 mins Monitor I & O

Urinary Tract

Infection

Inflammation of the

bladder, ureters or

urethra

Immobilization

Limited fluid

intake

- Fever ( 48 hours

postop)

- Burning sensation

when voiding

- Urgency

- Cloudy urine

- Lower abdominal

pain

Adequate fluid intake

Early ambulation

Aseptic catheterization as

needed

Good perineal hygiene




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GASTRO-

INTESTINAL

Nausea and

Vomiting

Pain

Abdominal

distention

Ingestion of fluid

or food before the

return of peristalsis

- Complaints of

feeling sick to the

stomach

- Retching

- Gagging

IV fluids until peristalsis

returns

Progressive diet ( clear

liquid then full fluids, soft

then regular diet)

Anti emetics as ordered

Tympanities Retention of gases

within the intestines Slowed motility of

the intestines due to

effects of anesthesia

- Abdominal

distention

- Absence of bowel

sound

Early ambulation

Avoid using straw

Provide ice chips

Hiccups Intermittent spasms

of the diaphragm Irritation of

phrenic nerve bet.

the spinal cord and

terminal

ramifications on

undersurface of the

diaphragm

Abdominal

distention

- A sound

“hic” that result

from the vibration

of closed vocal

cords as air rushes

suddenly into the

lungs

NGT insertion as needed

Hold breath while taking

a large swallow of water

Breath in and out on a

paper bag

Anti emetics as ordered

Intestinal

Obstruction

( 3rd

-5th

day

postop)

Kink loop of

intestines Due to

inflammatory

adhesions

- Intermittent

sharp, colicky

abdominal pains

- Nausea &

Vomiting

- Abdominal

distention

- Hiccups

- No bowel

movement

NGT insertion as needed

Administered IVF as

ordered

Prepare for possible

surgery

Constipation Infrequent or no

stool passage for

abnormal length of

time

( within 48 hours

after solid diet

started )

Lack of dietary

roughage

Analgesics

Immobility

- Absence of stool

elimination

- Abdominal

distention

- Abdominal

discomfort

Adequate hydration

High fiber diet

Encourage early

ambulation

Paralytic Ileus Lack of peristaltic

activity Due to anesthetics

Immobility

- Abdominal pain

- Abdominal

distention

- Constipation

- Absence of bowel

sounds

Encourage early

ambulation

WOUND

Wound Infection Inflammation and

infection of incision

or drain site

Poor aseptic

techniques

- Fever ( 72 hours

postop)

- Redness, swelling

, pain and warmth

- Pus or discharge

on the wound site

- Foul smelling

discharge

Keep wound clean and

dry

Surgical aseptic technique

when changing dressing

Antibiotic therapy




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Wound

Dehiscence

Separation of a

suture line before

the incision heals

Malnutrition

emaciation/obesity

Excessive strain on

suture line

- Increased incision

drainage

- Tissues

underlying skin

become visible

Apply abdominal binders

Encourage high protein

diet and Vit.C intake

Keep in bed rest

Wound

Evisceration

Extrusion of internal

organ or tissues

through the incision

Poor circulation

- Opening of

incision and visible

protrusion of

organs

Semi-Fowlers, bend

knees to relieve tension on

the abdominal muscles

Splinting on coughing

Cover exposed organ with

sterile , moist saline

dressing

Reassure, keep him/her

quite and relaxed

Prepare for surgery and

repair of wound

PSYCHOLOGIC

Postoperative

Depression

Altered Mood Weakness

Surprise nature of

“E” surgery

News of

malignancy

Severely altered

body image

- Anorexia

- Tearfulness

- Withdrawal

- Rejection of

others

- Sleep

disturbances

Adequate rest

Physical activity

Opportunity to express

anger and other negative

feelings

Delirium / Acute

Confusional State

Dehydration

Insufficient

oxygenation

Anemia

Hypotension

Hormonal

Imbalances

Infection

Trauma

- Poor memory

- Restlessness

- Inattentive

- Inappropriate

behavior

- Wild excitement

- Hallucination

- Delusions

- Disoriented

- Sleep

disturbances

Sedatives to keep client

quite and comfortable

Explain reasons for

interventions

Listen and talk to the

client

Provide physical comfort




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18

STUDY HARD

GOD BLESS YOU

THANKS

Mark Fredderick R. Abejo R.N, M.A.N

Clinical Instructor

29777748 Perioperative Nursing

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Transcript of 29777748 Perioperative Nursing