50005872 4 Perioperative Nursing

8/3/2019 50005872 4 Perioperative Nursing

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PERIOPERATIVEPERIOPERATIVE

NURSINGNURSING

REYNALDO S. ALIPIO, RN, MD, MHAREYNALDO S. ALIPIO, RN, MD, MHA


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PATIENT IN SURGERYPATIENT IN SURGERY

Surgery,Surgery, branchbranch ofof medicinemedicine concerned withconcerned with

treatment of diseases, deformities, and injuriestreatment of diseases, deformities, and injuries

through manual procedures called operationsthrough manual procedures called operations..


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Conditions Requiring SurgeryConditions Requiring Surgery

PerforationPerforation rupture of an organ, artery orrupture of an organ, artery or

blebbleb

Obstruction or blockageObstruction or blockage ErosionErosion wearing away of the surface of awearing away of the surface of a

tissuetissue

TumorsTumors abnormal growthabnormal growth


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PurposePurpose

DiagnosticDiagnostic to verify suspected diagnosisto verify suspected diagnosis

ExploratoryExploratory to estimate the extent of theto estimate the extent of the

diseasedisease CurativeCurative to remove or repair damaged orto remove or repair damaged or

diseased organs or tissuesdiseased organs or tissues


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TypesTypes

AblativeAblative involves removal of diseased organs ex.:involves removal of diseased organs ex.:

nephrectomynephrectomy

ReconstructiveReconstructive partial or complete restoration of apartial or complete restoration of adamaged organ.damaged organ.

Ex. Plastic surgery following severe burnEx. Plastic surgery following severe burn

ConstructiveConstructive repair of a congenitally defective organ.repair of a congenitally defective organ. Ex. Plastic surgery of cleft palateEx. Plastic surgery of cleft palate

PalliativePalliative relieves symptomrelieves symptom


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Degree ofRiskto PatientDegree ofRiskto Patient

Major SurgeryMajor Surgery

Minor SurgeryMinor Surgery


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UrgencyUrgency

EmergencyEmergency must be performed immediatelymust be performed immediately

Ex. Gunshot woundEx. Gunshot wound

Imperative or UrgentImperative or Urgent must be performed as soonmust be performed as soonas possible within 24as possible within 24 48 hours. Ex. Severe48 hours. Ex. Severe

bleedingbleeding Planned RequiredPlanned Required necessary for patients wellnecessary for patients well

being Ex. CSectionbeing Ex. CSection

Optional surgeryOptional surgery surgery that the patient requestsurgery that the patient request

Ex. Breast AugmentationEx. Breast Augmentation

Elective SurgeryElective Surgery should be performed for patientsshould be performed for patientswellwell--being but which is not absolutely necessarybeing but which is not absolutely necessaryEx. Simple hernia repairEx. Simple hernia repair


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EffectsofSurgeryonthe ClientEffectsofSurgeryonthe Client

1. Physical Effects1. Physical Effects

A. Stress response (neuroendocrine response) isA. Stress response (neuroendocrine response) isactivated.activated.

B. Resistance to infection is lowered due toB. Resistance to infection is lowered due to

surgical incision.surgical incision. C. Vascular system is disturbed due to severingC. Vascular system is disturbed due to severing

of blood vessels and blood loss.of blood vessels and blood loss.


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2. Psychologic Effects2. Psychologic Effects

Common fears: painCommon fears: pain

anesthesiaanesthesia

loss of controlloss of control

disfigurementdisfigurement

separation from loved onesseparation from loved onesalterations in roles or lifealterations in roles or life--

stylestyle


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Factors Influencing Surgical RiskFactors Influencing Surgical Risk

A. Age: very young and elderly are at increasedA. Age: very young and elderly are at increasedrisk.risk.

B. Nutrition: malnutrition and obesity increaseB. Nutrition: malnutrition and obesity increaserisk of complications.risk of complications.

C. Fluid and electrolyte balance: dehydration,C. Fluid and electrolyte balance: dehydration,hypovolemia, and electrolyte imbalances canhypovolemia, and electrolyte imbalances canpose problems during surgery.pose problems during surgery.

D. General health status: infection,D. General health status: infection,cardiovascular disease, pulmonary problems,cardiovascular disease, pulmonary problems,liver dysfunction, renal insufficiency, orliver dysfunction, renal insufficiency, ormetabolic disorders create increased risk.metabolic disorders create increased risk.


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E. Type of surgery planned: major surgery (e.g.,E. Type of surgery planned: major surgery (e.g.,

thoracotomy) poses greater risk than minorthoracotomy) poses greater risk than minor

surgery (e.g., dental extraction).surgery (e.g., dental extraction).

F. Psychologic status of client: excessive fear orF. Psychologic status of client: excessive fear or

anxiety may have adverse effect on surgery.anxiety may have adverse effect on surgery.

G. MedicationsG. Medications


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MedicationsMedications

ANTIBIOTICSANTIBIOTICS -- Potentiate the action ofPotentiate the action of

anesthetic agents.anesthetic agents.

ANTIDYSRHYTHMICSANTIDYSRHYTHMICS -- Reduce cardiacReduce cardiaccontractility and impair cardiac conductioncontractility and impair cardiac conduction

during anesthesia.during anesthesia.

ANTICOAGULANTSANTICOAGULANTS -- Alter normal clottingAlter normal clotting

factors and increase the risk of hemorrhaging:factors and increase the risk of hemorrhaging:

discontinue before surgerydiscontinue before surgery


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ANTICONVULSANTSANTICONVULSANTS -- LongLong--term use ofterm use of

certain anticonvulsants can alter the metabolismcertain anticonvulsants can alter the metabolism

of anesthetic agents.of anesthetic agents.

ANTIHYPERTENSIVESANTIHYPERTENSIVES -- Can interact withCan interact withanesthetic agents and cause bradycardia,anesthetic agents and cause bradycardia,

hypotension, and impaired circulation.hypotension, and impaired circulation.

CORTICOSTEROIDSCORTICOSTEROIDS -- Cause adrenal atrophyCause adrenal atrophyand reduce the body's ability to withstand stress.and reduce the body's ability to withstand stress.


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INSULININSULIN -- The need for insulin after surgeryThe need for insulin after surgery

in a diabetic either may be reduced because thein a diabetic either may be reduced because the

client's nutritional intake is decreased or mayclient's nutritional intake is decreased or may

be increased because of the stress response andbe increased because of the stress response and

IV administration of glucose solutions.IV administration of glucose solutions.

DIURETICSDIURETICS -- Potentiate electrolytePotentiate electrolyte

imbalances after surgery.imbalances after surgery.


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ANTIDEPRESSANTSANTIDEPRESSANTS -- May lower the bloodMay lower the blood

pressure during anesthesia.pressure during anesthesia.

ANTICHOLINERGICSANTICHOLINERGICS -- Medications withMedications withanticholinergic effects increase the potentialanticholinergic effects increase the potential

for confusion.for confusion.


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Legal ResponsibilitiesLegal Responsibilities

A. Surgeon obtains operative permit (informedA. Surgeon obtains operative permit (informedconsent).consent).

B. Informed consent is necessary for eachB. Informed consent is necessary for eachoperation performed, however minor. It is alsooperation performed, however minor. It is alsonecessary for major diagnostic procedures, e.g.,necessary for major diagnostic procedures, e.g.,bronchoscopy, thoracentesis, etc., where a majorbronchoscopy, thoracentesis, etc., where a major

body cavity is entered.body cavity is entered. C. Adult client (over18 years of age) signs ownC. Adult client (over18 years of age) signs own

permit unless unconscious or mentallypermit unless unconscious or mentallyincompetent.incompetent.


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D. Minors (under18) must have consent signedD. Minors (under18) must have consent signedby an adult (i.e., parent or legal guardian). Anby an adult (i.e., parent or legal guardian). An

emancipated minor (married, college studentemancipated minor (married, college studentliving away from home, in military service) mayliving away from home, in military service) may

sign own consent.sign own consent. E. Witness to informed consent may be nurse,E. Witness to informed consent may be nurse,

another physician, clerk, or other authorizedanother physician, clerk, or other authorizedperson.person.

F. If nurse witnesses informed consent, specifyF. If nurse witnesses informed consent, specifywhether witnessing explanation of surgery orwhether witnessing explanation of surgery orjust signature of client.just signature of client.


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PERIOPERATIVE PHASESPERIOPERATIVE PHASES

A. Preoperative phaseA. Preoperative phase -- the period of time prior to thethe period of time prior to the

surgical procedure.surgical procedure.

1. Assessment and correction of physiological and1. Assessment and correction of physiological and

psychological problems that may increase the client'spsychological problems that may increase the client's

risk factors.risk factors.

2. Client teaching regarding the surgery.2. Client teaching regarding the surgery.

3. Client teaching regarding postoperative care and3. Client teaching regarding postoperative care andactivities.activities.

4. Client planning for any anticipated changes in4. Client planning for any anticipated changes in

lifestyle at time of discharge.lifestyle at time of discharge.


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B. Intraoperative phaseB. Intraoperative phase -- The period of time theThe period of time the

client is in the operating room.client is in the operating room.

C. Post operative phaseC. Post operative phase -- The period begins withThe period begins with

the admission of the client to the post anesthesiathe admission of the client to the post anesthesiarecovery (PAR) area, and includes the rest of therecovery (PAR) area, and includes the rest of the

client's hospitalization and recovery period.client's hospitalization and recovery period.


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Preoperative CarePreoperative Care

A. Client ProfileA. Client Profile

B. Preoperative TeachingB. Preoperative Teaching

C. Preoperative checklistC. Preoperative checklist D. Physical Preparation of ClientD. Physical Preparation of Client


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Preoperative CarePreoperative Care

A. Client Profile.A. Client Profile.

1. Age1. Age

2. Weight2. Weight

3. Nutritional status3. Nutritional status 4. Preoperative interview.4. Preoperative interview.

a. Chronic health problems and previousa. Chronic health problems and previous

surgical procedures.surgical procedures.b. Post and current drug therapy, includingb. Post and current drug therapy, includingoverover--thethe--counter medications.counter medications.

c. History of drug allergies and dietaryc. History of drug allergies and dietary

restrictions.restrictions.


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d. Client's perception of his or herd. Client's perception of his or her

illness and impending surgery.illness and impending surgery.

e. Discomfort or symptoms he/she ise. Discomfort or symptoms he/she is

currently experiencing.currently experiencing.

f. Religious affiliation.f. Religious affiliation.g. Family or significant others.g. Family or significant others.


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5. Psychosocial needs5. Psychosocial needs -- Fear of the unknown isFear of the unknown isthe primary cause of preoperative anxiety in thethe primary cause of preoperative anxiety in thementally stable client. The surgical experience ismentally stable client. The surgical experience isunique to each client and represents a time ofunique to each client and represents a time ofcrisis.crisis.

Psychosocial preparationPsychosocial preparation 1. Be alert to the client's anxiety level1. Be alert to the client's anxiety level

2. Answer any questions or concerns the client2. Answer any questions or concerns the clientmay have regarding surgerymay have regarding surgery

3. Allow time for privacy for the client to3. Allow time for privacy for the client toprepare for surgery psychologicallyprepare for surgery psychologically

4. Provide support and assistance as needed4. Provide support and assistance as needed


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6. Medications6. Medications -- Some predispose the client to operativeSome predispose the client to operative

complications.complications.

Preoperative medicationsPreoperative medications

1. Prepare to administer preoperative medications as1. Prepare to administer preoperative medications as

prescribed, or on call to the operating roomprescribed, or on call to the operating room

immediately before surgeryimmediately before surgery 2. Instruct the client that he or she will feel drowsy2. Instruct the client that he or she will feel drowsy

shortly after the medications are administeredshortly after the medications are administered

3. After administering the preoperative medications,3. After administering the preoperative medications,

keep the client in bed with the side rails upkeep the client in bed with the side rails up 4. Place the call bell next to the client; instruct the client4. Place the call bell next to the client; instruct the client

not to get out of bed and to call for assistance if needednot to get out of bed and to call for assistance if needed


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7. A complete preoperative nursing assessment7. A complete preoperative nursing assessmentestablishes a data base for postoperativeestablishes a data base for postoperative

assessment.assessment. 8. Check routine laboratory studies.8. Check routine laboratory studies.

a. Complete blood count/Typinga. Complete blood count/Typing

b. Urinalysis.b. Urinalysis. c. VDRL or FTAc. VDRL or FTA--ABS.ABS.

d. Chest xd. Chest x--ray.ray.

e. Electrocardiogram (EKG).e. Electrocardiogram (EKG).

f. PT/PTTf. PT/PTT

f. CT/BTf. CT/BT

Hep profile/aidsHep profile/aids


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Preoperative TeachingPreoperative Teaching

The goal is to decrease the client's anxiety and toThe goal is to decrease the client's anxiety and toprevent postoperative com-plications.prevent postoperative com-plications.

. Preoperative teaching content.. Preoperative teaching content.

a. Deep breathing and coughing exercises.a. Deep breathing and coughing exercises. b. Turning and extremity exercises.b. Turning and extremity exercises.

c. Pain medication policy.c. Pain medication policy.

d. Adjunct equipment used for breathing - IPPB,d. Adjunct equipment used for breathing - IPPB,nebulizer, 02 mask.nebulizer, 02 mask.

e. Explanation of NPO policy.e. Explanation of NPO policy.


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Preoperative checklistPreoperative checklist

1. Ensure that the client is wearing an1. Ensure that the client is wearing anidentification braceletidentification bracelet

2. Assess for allergies (information on latex2. Assess for allergies (information on latex

allergy)allergy) 3. Review the preoperative checklist to be sure3. Review the preoperative checklist to be sure

that each item is addressed before the client isthat each item is addressed before the client is

transported to surgerytransported to surgery


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4. Ensure that informed consent forms were4. Ensure that informed consent forms were

signed for the operative procedure, for any bloodsigned for the operative procedure, for any blood

transfusions, for disposal of a limb, or fortransfusions, for disposal of a limb, or forsurgical sterilization proceduressurgical sterilization procedures

5. Ensure that a history and physical exam were5. Ensure that a history and physical exam were

completed and documented in the client's recordcompleted and documented in the client's record

6. Ensure that consultations prescribed were6. Ensure that consultations prescribed were

completed and documented in the client's recordcompleted and documented in the client's record


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7. Ensure that prescribed laboratory results are7. Ensure that prescribed laboratory results are

documented in the client's recorddocumented in the client's record

8. Ensure that the ECG and chest radiograph8. Ensure that the ECG and chest radiographreports are documented in the client's recordreports are documented in the client's record

9. Ensure that a blood type and screen or type9. Ensure that a blood type and screen or type

and crossand cross--match is performed and documentedmatch is performed and documented

in the client's recordin the client's record


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10. Remove jewelry, makeup, dentures, hairpins,10. Remove jewelry, makeup, dentures, hairpins,

nail polish, glasses, and prosthesesnail polish, glasses, and prostheses

11. Document that valuables were given to the11. Document that valuables were given to theclient's family members or locked in theclient's family members or locked in the

hospi-tal safehospi-tal safe

12. Document the last time the client ate or12. Document the last time the client ate or

drankdrank


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13. Document that the client has voided prior13. Document that the client has voided prior

to Surgeryto Surgery

14. Document that the prescribed preoperative14. Document that the prescribed preoperativemedication was givenmedication was given

15. Monitor and document the client's vital15. Monitor and document the client's vital

signssigns


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Physical PreparationofClientPhysical PreparationofClient

1. Skin preparation1. Skin preparation -- purpose is to reducepurpose is to reduce

bacteria on the skin.bacteria on the skin.

a. Prepare to clean the surgical site with a milda. Prepare to clean the surgical site with a mild

antiseptic soap the night before surgery, asantiseptic soap the night before surgery, asprescribedprescribed

b. Prepare to shave the operative site asb. Prepare to shave the operative site as

prescribedprescribed


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c. Hair should be shaved only if it willc. Hair should be shaved only if it will

interfere with the surgical procedure and onlyinterfere with the surgical procedure and only

if prescribedif prescribed

d. Shaving of hair, if prescribed, should bed. Shaving of hair, if prescribed, should be

done in the direction of hair growth and with adone in the direction of hair growth and with a

sharp razor, and caution should be used tosharp razor, and caution should be used to

prevent cuts or epidermal damageprevent cuts or epidermal damage


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2. Gastrointestinal preparation.2. Gastrointestinal preparation.

a. Food and fluid restriction for approximately 6a. Food and fluid restriction for approximately 6

hours preoperatively.hours preoperatively.

b. Enemas are frequently administered theb. Enemas are frequently administered the

eve-ning prior to surgery to prevent fecaleve-ning prior to surgery to prevent fecal

contamination in the peritoneal cavity.contamination in the peritoneal cavity.

c. Gastric or intestinal intubation may be done inc. Gastric or intestinal intubation may be done in

order to remove gastric contents and to promoteorder to remove gastric contents and to promoteintestinal decompression.intestinal decompression.


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3. Promote sleep and rest3. Promote sleep and rest -- After theAfter the

preoperative procedures are completed thepreoperative procedures are completed the

client generally receives a sleeping medicationclient generally receives a sleeping medication

to promote rest.to promote rest.

Common medications used are the barbiturates.Common medications used are the barbiturates.

a. Secobarbital (SECONAL).a. Secobarbital (SECONAL).

b. Pentobarbital (NEMBUTAL).b. Pentobarbital (NEMBUTAL).


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NutritionNutrition

1. Assess the physician's orders regarding the NPO1. Assess the physician's orders regarding the NPOstatus prior to surgerystatus prior to surgery

2. Solid foods and liquids are withheld for6 to 8 hours2. Solid foods and liquids are withheld for6 to 8 hours

before general anesthesia and for 3 hours before surgerybefore general anesthesia and for 3 hours before surgery

with local anesthesia, to avoid aspirationwith local anesthesia, to avoid aspiration

3. Prepare to initiate an IV and administer IV fluids as3. Prepare to initiate an IV and administer IV fluids as

prescribedprescribed

4. Prepare to administer total parenteral nutrition (TPN)4. Prepare to administer total parenteral nutrition (TPN)to clients who are malnourished, have protein orto clients who are malnourished, have protein or

metabolic deficiencies, or cannot ingest foodsmetabolic deficiencies, or cannot ingest foods


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EliminationElimination

1. If the client is to have intestinal or abdominal1. If the client is to have intestinal or abdominal

surgery, an enema or laxative or both may besurgery, an enema or laxative or both may be

prescribed the night before surgeryprescribed the night before surgery

2. The client should void immediately before2. The client should void immediately beforesurgerysurgery

3. Prepare to insert a Foley catheter if prescribed3. Prepare to insert a Foley catheter if prescribed

4. If there is a Foley catheter in place, it should be4. If there is a Foley catheter in place, it should beemptied immediately before surgery and the amountemptied immediately before surgery and the amount

and quality of urine output documentedand quality of urine output documented


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Day of SurgeryDay of Surgery

Nursing Responsibilities.Nursing Responsibilities. 1. Have client follow routine hygiene care.1. Have client follow routine hygiene care.

2. Record vital signs within four hours of client2. Record vital signs within four hours of client

going to surgery.going to surgery. 3. Remove jewelry, wedding bands may be taped on3. Remove jewelry, wedding bands may be taped on

finger.finger.

4. Remove fingernail polish.4. Remove fingernail polish.

5. Dress client in appropriate clothing.5. Dress client in appropriate clothing.

6. Inform client that dentures and removable bridge6. Inform client that dentures and removable bridge

work must be removed before surgery.work must be removed before surgery.


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7. Make sure the NPO policy has been initiated7. Make sure the NPO policy has been initiated

according to orders and the client has adhered to it.according to orders and the client has adhered to it.

8. Check the client's identification band; validate8. Check the client's identification band; validate

the information and see it is secure.the information and see it is secure.

9. Check the skin preparation.9. Check the skin preparation.


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10. Identify family and significant others10. Identify family and significant others

who will be waiting for informationwho will be waiting for information

regarding client's progress.regarding client's progress. 11. Check the chart for completeness11. Check the chart for completeness

regarding laboratory reports, consent form,regarding laboratory reports, consent form,

significant client observations, history andsignificant client observations, history and

physical records.physical records.


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PreoperativeMedicationsPreoperativeMedications

1. Purpose.1. Purpose.

a. Induce anesthesia rapidly and pleasantly.a. Induce anesthesia rapidly and pleasantly.

b. Increase safety and maintain desiredb. Increase safety and maintain desired

level of anesthesia.level of anesthesia.

c. Decrease oral pharyngeal secretions.c. Decrease oral pharyngeal secretions.

d. Enhance anesthetic agent.d. Enhance anesthetic agent.


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1. Narcotic analgesics (meperidine [Demerol),1. Narcotic analgesics (meperidine [Demerol),

morphine sulfate) relax client, reduce anxiety, andmorphine sulfate) relax client, reduce anxiety, and

enhance effectiveness of general anesthesia.enhance effectiveness of general anesthesia.

2. Sedatives (secobarbital sodium [Seconal]), sodium2. Sedatives (secobarbital sodium [Seconal]), sodium

pentobarbital [Nembutal) decrease anxiety andpentobarbital [Nembutal) decrease anxiety and

promote relaxation and sleep.promote relaxation and sleep.

3. Anticholinergics (atropine sulfate, scopolamine3. Anticholinergics (atropine sulfate, scopolamine

[Hyoscine]) and glycopyrrolate (Robinul) decrease[Hyoscine]) and glycopyrrolate (Robinul) decrease

tracheobronchial secretions to minimize danger oftracheobronchial secretions to minimize danger of

aspirating secretions in lungs, decrease vagal responseaspirating secretions in lungs, decrease vagal responseto inhibit undesirable effects of general anesthesiato inhibit undesirable effects of general anesthesia

(bradycardia) .(bradycardia) .


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Nursing Responsibilities.Nursing Responsibilities.

a. Ask client to void prior to administration ofa. Ask client to void prior to administration ofmedication.medication.

b. Obtain base line vital signs.b. Obtain base line vital signs.

c. Administer medication 45 minutes to 1 hourc. Administer medication 45 minutes to 1 hourprior to surgery, or as ordered.prior to surgery, or as ordered.

d. Follow "Seven Rights" of medicationd. Follow "Seven Rights" of medicationadministration.administration.

e. Raise the siderails and instruct the client not toe. Raise the siderails and instruct the client not toget out of bed.get out of bed.


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f. Remove dental work.f. Remove dental work.

g. Observe for side effects of medication.g. Observe for side effects of medication.

h. Maintain quiet environment prior to beingh. Maintain quiet environment prior to being

transported to the operating room.transported to the operating room.

i. Allow parent to accompany child as far asi. Allow parent to accompany child as far as

possible.possible.


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Arrival in the operating roomArrival in the operating room 1. When the client arrives in the operating room,1. When the client arrives in the operating room,

the operating room nurse will verify thethe operating room nurse will verify the

identification bracelet with the client's verbalidentification bracelet with the client's verbal

response and will review the client's chartresponse and will review the client's chart

2. The operating room nurse will confirm the2. The operating room nurse will confirm the

operative procedure and the site to be operatedoperative procedure and the site to be operated

onon


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3. The client's chart will be checked for3. The client's chart will be checked for

completeness and reviewed for informed consentcompleteness and reviewed for informed consent

forms, a history and physical examination, andforms, a history and physical examination, and

allergic reaction informationallergic reaction information

4. Physicians' orders will be reviewed, and that4. Physicians' orders will be reviewed, and thatthey were carried out will be verifiedthey were carried out will be verified

5. The IV line may be initiated at this time if5. The IV line may be initiated at this time if

prescribedprescribed 6. The anesthesia team will administer the6. The anesthesia team will administer the

prescribed anesthesiaprescribed anesthesia


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AnesthesiaAnesthesia

Purpose:Purpose:

1. Promote muscle relaxation.1. Promote muscle relaxation.

2. Block transmission of nerve impulses.2. Block transmission of nerve impulses.

3. Achieve a state of reversible3. Achieve a state of reversible

unconsciousness.unconsciousness.


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General anesthesia.General anesthesia.

1. Ideal general anesthetic.1. Ideal general anesthetic.

a. Nonirritating, nonflammable.a. Nonirritating, nonflammable.

b. Effective in analgesia and muscle relaxation.b. Effective in analgesia and muscle relaxation.

c. Able to suppress undesirable reflexes.c. Able to suppress undesirable reflexes.

d. Nontoxic.d. Nontoxic.

e. Able to permit rapid recovery withoute. Able to permit rapid recovery withoutnausea and vomiting.nausea and vomiting.


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2. Balanced anesthesia2. Balanced anesthesia -- a combination ofa combination of

medications used in order to accomplish all ofmedications used in order to accomplish all of

the desirable traits.the desirable traits.

3. Intravenous anesthesia3. Intravenous anesthesia -- frequently used asfrequently used as

an induction agent prior to the inhalationan induction agent prior to the inhalation

agent.agent.

4. Inhalation anesthesia4. Inhalation anesthesia -- used to progressused to progress

client from stage n to stage III of anesthesia.client from stage n to stage III of anesthesia.


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STAGES ofANESTHESIASTAGES ofANESTHESIA

Stage I (Induction)Stage I (Induction)

-- Beginning administration of anestheticBeginning administration of anesthetic

agentagent-- Loss of consciousnessLoss of consciousness

-- May appear euphoric, drowsy, dizzyMay appear euphoric, drowsy, dizzy


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Stage II (delirium or excitement)Stage II (delirium or excitement)

-- Loss of consciousnessLoss of consciousness

-- RelaxationRelaxation-- Breathing irregular may appear excitedBreathing irregular may appear excited

very susceptible to external stimulivery susceptible to external stimuli


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Stage IV (danger stage)Stage IV (danger stage)

-- Vital functions depressedVital functions depressed

-- Respiratory arrest possible cardiacRespiratory arrest possible cardiacarrestarrest

-- No respiration; absent or minimalNo respiration; absent or minimal

heartbeat dilated pupilsheartbeat dilated pupils


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Agentsforgeneral anesthesiaAgentsforgeneral anesthesia

Agents for general anesthesiaAgents for general anesthesia

1. Inhalation agents1. Inhalation agents -- used to progress client from stageused to progress client from stage

n to stage III of anesthesia.n to stage III of anesthesia.

a. Gas anestheticsa. Gas anesthetics 1) nitrous oxide: induction agent; component of1) nitrous oxide: induction agent; component of

balanced anesthesia; used alone for short procedures;balanced anesthesia; used alone for short procedures;

always given in combination with oxygenalways given in combination with oxygen

2) cyclopropane: obstetric anesthesia; clients with2) cyclopropane: obstetric anesthesia; clients withcardiovascular complications; highly flammable andcardiovascular complications; highly flammable and

explosiveexplosive


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b. Liquid anestheticsb. Liquid anesthetics

1) halothane (Fluothane): widely used; rapid1) halothane (Fluothane): widely used; rapidinduction, low incidence of postinduction, low incidence of post--op nausea andop nausea andvomiting; may cause bradycardia andvomiting; may cause bradycardia and

hypotension; contraindicated in clients with liverhypotension; contraindicated in clients with liverdisease.disease.

2) enflurane (Ethrane): effects similar to2) enflurane (Ethrane): effects similar tohalothane, but muscle relaxation is stronger andhalothane, but muscle relaxation is stronger and

hepatotoxicity not a problem; use cautiously inhepatotoxicity not a problem; use cautiously inclients with cardiac disease.clients with cardiac disease.


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3) ether (diethyl ether): infrequently used3) ether (diethyl ether): infrequently usedbecause of slow, unpleasant induction,because of slow, unpleasant induction,excessive secretory action, increased postexcessive secretory action, increased post--opop

nausea and vomiting, and flammability.nausea and vomiting, and flammability. 4) methoxyflurane (Penthrane): very potent4) methoxyflurane (Penthrane): very potent

agent with slow onset and recovery;agent with slow onset and recovery;circulatory depression at high concentrations;circulatory depression at high concentrations;associated with liver and kidney damage;associated with liver and kidney damage;rarely used.rarely used.


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2. IV anesthetics: used primarily as induction agents;2. IV anesthetics: used primarily as induction agents;

produce rapid, smooth induction; may be used alone inproduce rapid, smooth induction; may be used alone inshort procedures such as dental extractions.short procedures such as dental extractions.

a. Common IV anesthetics: methohexital (Brevital) ,a. Common IV anesthetics: methohexital (Brevital) ,

sodium thiopental (Pentathol)sodium thiopental (Pentathol)

b. Disadvantages: poor relaxation; respiratory andb. Disadvantages: poor relaxation; respiratory and

myocardial depression in high doses;myocardial depression in high doses;

bronchospasm, laryngospasm; hypotensionbronchospasm, laryngospasm; hypotension

-- frequently used as an induction agentfrequently used as an induction agentprior to the inhalation agent.prior to the inhalation agent.


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3. Dissociative agents: produce state of profound3. Dissociative agents: produce state of profound

analgesia, amnesia, and lack of awareness withoutanalgesia, amnesia, and lack of awareness withoutloss of consciousness; used alone in short surgicalloss of consciousness; used alone in short surgical

and diagnostic procedures or for induction prior toand diagnostic procedures or for induction prior to

administration of more potent general anesthetics.administration of more potent general anesthetics.

a. Agent: ketamine (Ketalar)a. Agent: ketamine (Ketalar)

b. Side effects: tachycardia, hypertension,b. Side effects: tachycardia, hypertension,

respiratory depression, hallucinations, deliriumrespiratory depression, hallucinations, delirium

c. Precautions: decrease verbal, tactile, and visualc. Precautions: decrease verbal, tactile, and visualstimulation during recovery periodstimulation during recovery period


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4. Neuroleptics: produce state of neuroleptic analgesia4. Neuroleptics: produce state of neuroleptic analgesia

characterized by reduced motor activity, decreasedcharacterized by reduced motor activity, decreased

anxiety, and analgesia without loss of consciousness;anxiety, and analgesia without loss of consciousness;used alone for short surgical and diagnostic procedures,used alone for short surgical and diagnostic procedures,

as premedication or in combination with otheras premedication or in combination with other

anesthetics for longer anesthesia.anesthetics for longer anesthesia.

a. Agent: fentanyl citrate with droperidol (Innovar)a. Agent: fentanyl citrate with droperidol (Innovar)

b. Side effects: hypotension, bradycardia, respiratoryb. Side effects: hypotension, bradycardia, respiratory

depression, skeletal muscledepression, skeletal muscle

rigidity, twitchingrigidity, twitching c. Precautions: reduce narcotic doses by 1/2 to 1/3 for atc. Precautions: reduce narcotic doses by 1/2 to 1/3 for at

least 8 hours postanesthesia asleast 8 hours postanesthesia as

ordered to prevent respiratory depression.ordered to prevent respiratory depression.


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Regional anesthesiaRegional anesthesia -- used to anesthetize oneused to anesthetize one

region of the body; the client may remain awakeregion of the body; the client may remain awakeand alert throughout the procedure.and alert throughout the procedure.

1. Produces loss of painful sensation in one area1. Produces loss of painful sensation in one area

of the body; does not produce loss ofof the body; does not produce loss ofconsciousness.consciousness.

2. Uses: biopsies, excision of moles and cysts,2. Uses: biopsies, excision of moles and cysts,

endoscopies, surgery on extremitiesendoscopies, surgery on extremities

3. Agents: lidocaine (Xylocaine), procaine3. Agents: lidocaine (Xylocaine), procaine

(Novocain), tetracaine (Pontocaine), Sersorcaine(Novocain), tetracaine (Pontocaine), Sersorcaine


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TopicalTopical-- anesthetizing medication is applied toanesthetizing medication is applied tomucous membrane or skin; blocks peripheralmucous membrane or skin; blocks peripheral

nerve endings.nerve endings.

2. Nerve root block2. Nerve root block -- provides autonomicprovides autonomic

blockage.blockage.

a. Spinal.a. Spinal.

b. Saddle.b. Saddle.

c. Epidural.c. Epidural.

d. Caudal.d. Caudal.


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a. Spinala. Spinal -- Anesthetic introduced into subarachnoidAnesthetic introduced into subarachnoid

space of spinal cordspace of spinal cordproducing anesthesia below level of diaphragm.producing anesthesia below level of diaphragm.

b. Saddleb. Saddle -- Similar to spinal, but anesthetized area isSimilar to spinal, but anesthetized area is

more limited; commonly used in obstetrics.more limited; commonly used in obstetrics.

c. Epiduralc. Epidural -- Anesthetic injected extradurally to produceAnesthetic injected extradurally to produce

anesthesia below level of diaphragm; used in obstetrics.anesthesia below level of diaphragm; used in obstetrics.

d. Caudald. Caudal -- Variation of epidural block: producesVariation of epidural block: produces

anesthesia of perineum and occasionally loweranesthesia of perineum and occasionally lowerabdomen; commonly used in obstetrics.abdomen; commonly used in obstetrics.


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NursingConsiderationsfor RegionalNursingConsiderationsfor Regional

AnesthesiaAnesthesia

1. Require anesthesiologist for administration.1. Require anesthesiologist for administration.

2. Will completely relieve pain if administered2. Will completely relieve pain if administered

correctly.correctly.

3. Vasodilation below level of anesthesia may3. Vasodilation below level of anesthesia mayprecipitate hypotension.precipitate hypotension.

4. Contraindicated in hypovolemic client.4. Contraindicated in hypovolemic client.

5. Client may experience postanesthesia5. Client may experience postanesthesiaheadache.headache.


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6. Produce blockage of the autonomic nerve fibers:6. Produce blockage of the autonomic nerve fibers:touch, pain, motor, pressure proprioceptive fibers aretouch, pain, motor, pressure proprioceptive fibers areblocked.blocked.

7. Client remains awake throughout procedure.7. Client remains awake throughout procedure.

8. May be used in major surgical procedures below the8. May be used in major surgical procedures below thelevel of the diaphragm.level of the diaphragm.

9. Peripheral nerve root block9. Peripheral nerve root block -- does not block thedoes not block the

autonomic nerve fiber; medication injected to blockautonomic nerve fiber; medication injected to blockperipheral nerve fibers.peripheral nerve fibers.

a. Pudendal.a. Pudendal.

b. Paracervical.b. Paracervical.

10. Assess client for effectiveness as anesthesia is10. Assess client for effectiveness as anesthesia isinitiated.initiated.

11. Nursing intervention for client undergoing regional11. Nursing intervention for client undergoing regionalanesthesiaanesthesia


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OPERATING ROOM TEAMMEMBERSOPERATING ROOM TEAMMEMBERS


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OPERATING ROOM TEAMMEMBERSOPERATING ROOM TEAMMEMBERS

SurgeonSurgeon

Assistant to the surgeonAssistant to the surgeon

AnesthesiologistAnesthesiologist

Scrub Nurse (Surgical/OBTechnician)Scrub Nurse (Surgical/OBTechnician)

-- Instrument NurseInstrument Nurse

-- Suture NurseSuture Nurse

Circulating NurseCirculating Nurse

PathologistPathologist


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The Scrubbed Sterile TeamThe Scrubbed Sterile Team

Operation SurgeonOperation Surgeon

Assistant/s to the surgeonAssistant/s to the surgeon

Scrub NurseScrub Nurse


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The Unscrubbed Unsterile Team

AnesthesiologistAnesthesiologist

Circulating NurseCirculating Nurse

PathologistPathologist


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OPERATING ROOM NURSEOPERATING ROOM NURSE

The nurse should be able to:The nurse should be able to:

Identify the operating room team members.Identify the operating room team members.

Enumerate each team members responsibilityEnumerate each team members responsibility To define the roles of the team members inTo define the roles of the team members in

giving total care to the patient who isgiving total care to the patient who is

undergoing a surgical procedure.undergoing a surgical procedure.


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SurgeonSurgeon

He serves as the leader of the team.He serves as the leader of the team.

He must be certain that all term members areHe must be certain that all term members are

aware of what is needed during the procedureaware of what is needed during the procedure

and that all necessary equipments andand that all necessary equipments and

instruments are available.instruments are available.

He performs the surgery.He performs the surgery.


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Assistanttothe SurgeonAssistanttothe Surgeon

He may be surgeon, a resident, an intern, or aHe may be surgeon, a resident, an intern, or a

clinical clerk/PA/CNMclinical clerk/PA/CNM

He assists the surgeon during the surgery inHe assists the surgeon during the surgery in

any way the surgeon requests.any way the surgeon requests.

He holds retractors in the wound to exposeHe holds retractors in the wound to expose

the operative site.the operative site.


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He places clamps on blood vessels.He places clamps on blood vessels.

He assists in suturing and ligating bleeders.He assists in suturing and ligating bleeders.

He may perform suctioning in the operativeHe may perform suctioning in the operativefield.field.


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Scrub NurseScrub Nurse

Sets up sterile supplies and instruments.Sets up sterile supplies and instruments.

Assists the surgeon as needed throughout theAssists the surgeon as needed throughout the

surgery.surgery.

Assists in gowning and gloving and surgicalAssists in gowning and gloving and surgical

team.team.

Assists in draping the patient and the field.Assists in draping the patient and the field.


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Keeps separate needle/instrument count, if thisKeeps separate needle/instrument count, if this

is a policyis a policy

Supplies sterile dressing materials.Supplies sterile dressing materials.

Discards soiled linen into hamper afterDiscards soiled linen into hamper after

checking it for instruments.checking it for instruments.

Cares fro all instruments and supplies left afterCares fro all instruments and supplies left after

case.case.


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ANESTHESIOLOGISTANESTHESIOLOGIST

A physician who specializes in anesthesiology.A physician who specializes in anesthesiology.

Gives and controls the anesthetic for theGives and controls the anesthetic for the

patient.patient.

Must see to it that all the equipment andMust see to it that all the equipment and

supplies necessary for the induction ofsupplies necessary for the induction of

anesthesia are available.anesthesia are available.


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Determines when the surgeon or circulatingDetermines when the surgeon or circulating

nurse may proceed with positioning andnurse may proceed with positioning and

preparing the operative site.preparing the operative site.

Monitors the patients vital signs during theMonitors the patients vital signs during the

operation.operation.


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Keeps the surgeon aware of the patientsKeeps the surgeon aware of the patients

condition.condition.

Determines when the patient may be moved toDetermines when the patient may be moved to

the postthe post--anesthesia recovery stretcher after theanesthesia recovery stretcher after the

operation has been completed.operation has been completed.


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CIRCULATING NURSECIRCULATING NURSE

Functions as the overseer of the room duringFunctions as the overseer of the room during

the procedure to maintain sterility.the procedure to maintain sterility.

Assists the entire team and the patient.Assists the entire team and the patient.

Sends for patient at appropriate time.Sends for patient at appropriate time.

Receives, greets, identifies patient.Receives, greets, identifies patient.

Checks chart for completeness.Checks chart for completeness.


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Assists patient in moving safely to operatingAssists patient in moving safely to operating

room table.room table.

Assists anesthesiologist when requested: staysAssists anesthesiologist when requested: stays

with the patient during induction.with the patient during induction.

Ties scrubbed members gowns.Ties scrubbed members gowns.

Checks operating room lights in advanced forChecks operating room lights in advanced for

good working order, turns lights on atgood working order, turns lights on at

appropriate time and adjust when needed.appropriate time and adjust when needed.


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Prepares operative site.Prepares operative site.

Connects catheter to drainage bottle, orConnects catheter to drainage bottle, or

catheterize if desired by the surgeon.catheterize if desired by the surgeon.

Does the sponge count with the scrub nurse.Does the sponge count with the scrub nurse.

Positions the patient.Positions the patient.

Supplies foot stools if needed by the surgicalSupplies foot stools if needed by the surgicalteam.team.


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Watches foreheads for perspiration.Watches foreheads for perspiration.

Fills out required operative records completelyFills out required operative records completely

and legibly.and legibly.

Remains in the room as much as possible to beRemains in the room as much as possible to be

constantly availably.constantly availably.

Watches progress of surgery, anticipatesWatches progress of surgery, anticipates

needs, reacts quickly to emergency.needs, reacts quickly to emergency.


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Sees that the surgical team is supplied withSees that the surgical team is supplied with

every necessary item to perform the operationevery necessary item to perform the operation

efficiently.efficiently.

Uses equipment and supplies economicallyUses equipment and supplies economically

and conservatively.and conservatively.

Directs cleaning of the room and preparationDirects cleaning of the room and preparation

for the next operation.for the next operation.


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PAHTOLOGISTPAHTOLOGIST

A specialist in the scientific study of theA specialist in the scientific study of the

alteration in tissue produced by disease.alteration in tissue produced by disease.

He/she is consulted by the surgeon during orHe/she is consulted by the surgeon during or

after surgery for a diagnosis by gross orafter surgery for a diagnosis by gross or

microscopic examination of any tissuemicroscopic examination of any tissue

removed.removed.

He/she is consulted by the surgeon concerningHe/she is consulted by the surgeon concerningthe treatment of some diseases.the treatment of some diseases.


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PrinciplesofAseptic TechniquePrinciplesofAseptic Technique

The patient is the center of the sterile fieldThe patient is the center of the sterile field

which includes the areas of the patient, thewhich includes the areas of the patient, the

operating table and furniture covered withoperating table and furniture covered with

sterile drapes and personnel wearing the OTsterile drapes and personnel wearing the OTattireattire


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Principles of Aseptic Technique arePrinciples of Aseptic Technique are

applied in the:applied in the:

-- preparation for operation by sterilization ofpreparation for operation by sterilization ofnecessary equipments, materials and suppliesnecessary equipments, materials and supplies


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-- preparation of the operating team to handlepreparation of the operating team to handle

sterile supplies and intimately contact woundsterile supplies and intimately contact wound

-- creation and maintenance of the sterile field,creation and maintenance of the sterile field,

including the preparation and draping ofincluding the preparation and draping of

patient, to prevent contamination of thepatient, to prevent contamination of the

surgical woundsurgical wound


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Principles:Principles:

-- only sterile items are used within the sterileonly sterile items are used within the sterile

fieldfield

-- gowns are considered sterile only from thegowns are considered sterile only from the

waist to shoulder level front and the sleeveswaist to shoulder level front and the sleeves

-- tables are sterile only at table leveltables are sterile only at table level

-- persons who are sterile touch only sterilepersons who are sterile touch only sterile

items or areas; persons who are not sterileitems or areas; persons who are not sterile

touch only unsterile items or areastouch only unsterile items or areas


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-- unsterile person avoid reaching areas over aunsterile person avoid reaching areas over a

sterile field; persons avoid leaning over ansterile field; persons avoid leaning over an

unsterile areaunsterile area

-- edges of anything that encloses sterileedges of anything that encloses sterile

contents are considered unsterilecontents are considered unsterile

-- sterile field is created as close as possible tosterile field is created as close as possible to

time of usetime of use


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-- sterile areas are continuously kept in viewsterile areas are continuously kept in view

-- sterile persons keep well within the sterilesterile persons keep well within the sterile

areaarea

-- sterile persons keep contact with sterile areassterile persons keep contact with sterile areas

to a maximumto a maximum

-- unsterile persons avoid sterile areasunsterile persons avoid sterile areas


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-- destruction of integrity of microbial barriersdestruction of integrity of microbial barriers

results in contaminationresults in contamination

-- microorganisms must be kept to anmicroorganisms must be kept to an

irreducible minimumirreducible minimum

Functions of the nurse during OR procedureFunctions of the nurse during OR procedure


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Functions of the nurse during OR procedureFunctions of the nurse during OR procedure

SCRUB NURSESCRUB NURSE

Assiststhe surgeonAssiststhe surgeonMaintainssterilityMaintainssterility

HandlesinstrumentsHandlesinstruments

DrapespatientDrapespatient

CountsspongesCountssponges

Wearssterile gown,glovesWearssterile gown,gloves

CIRCULATINGCIRCULATING

NURSENURSE

Assiststhe ScrubnurseAssiststhe Scrubnurse

Positionsthe patientforPositionsthe patientfor

surgerysurgery

Positions any equipmentsPositions any equipments

INCISIONSINCISIONS


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INCISIONSINCISIONS

Importance of knowing the operative incision:Importance of knowing the operative incision:

For the circulating Nurse:For the circulating Nurse:

to know the extent and the area to be prepared.to know the extent and the area to be prepared.

To prepare the gadgets necessary for positioning theTo prepare the gadgets necessary for positioning the

patient.patient.For the Scrub Nurse:For the Scrub Nurse:

To serve as a guide for draping the operative site.To serve as a guide for draping the operative site.

To have the correct instruments and suppliesTo have the correct instruments and supplies

available.available.

To be able to assist the surgeon effectively andTo be able to assist the surgeon effectively and

efficiently.efficiently.


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-- maintenance sterility and asepsis throughoutmaintenance sterility and asepsis throughout

the operative procedurethe operative procedure

-- terminal sterilization and disinfection at theterminal sterilization and disinfection at the

conclusion of the operationconclusion of the operation


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COMMONLY USED INCISIONSCOMMONLY USED INCISIONS

KockersKockers (Sub(Sub costal)costal) IncisionIncisionUpper abdominal Midline Incision (Vertical)Upper abdominal Midline Incision (Vertical)

Lower Abdominal Midline IncisionLower Abdominal Midline Incision

Paramedian IncisionParamedian Incision

Mcburneys IncisionMcburneys Incision

Inguinal IncisionInguinal Incision

Horizontal Flank Incision (Midline Transverse)Horizontal Flank Incision (Midline Transverse)

Lumbotomy Incision (Simple Flank Incision)Lumbotomy Incision (Simple Flank Incision)


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Thoracoabdominal IncisionThoracoabdominal IncisionThoracotomy Incision (Lateral Posterothoracic,Thoracotomy Incision (Lateral Posterothoracic,

Right or left)Right or left)

Thoracotomy Incision (AnterolateralApproach)Thoracotomy Incision (AnterolateralApproach)Pfannenstil Incision (Bikini Incision)Pfannenstil Incision (Bikini Incision)

Infraumbilical IncisionInfraumbilical Incision


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Miscellaneous Incision:Miscellaneous Incision:

a. Collar line (Curvilinear) Incisiona. Collar line (Curvilinear) IncisionThyroid surgery/Parathyroid surgeryThyroid surgery/Parathyroid surgery

b. Coronal, butterfly incisionsb. Coronal, butterfly incisions craniotomycraniotomy

c. Limbal incisionc. Limbal incision cataract extractioncataract extraction d. Elliptical, halted incisionsd. Elliptical, halted incisions radicalradical

mastectomymastectomy

e. Post aural, end aural incisione. Post aural, end aural incision mastoidectomymastoidectomy

f. Canine fosse incisionf. Canine fosse incision Caldwell locCaldwell loc

g. Gibson incisiong. Gibson incision ureterolithotomyureterolithotomy


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POSITIONING

PositioningPositioning is putting the patient in properis putting the patient in proper

body alignment to expose the operative site orbody alignment to expose the operative site or

areaarea


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Several factors influence the time at which theSeveral factors influence the time at which the

patient is positioned:patient is positioned:

site of operationsite of operation

age and size of the patientage and size of the patient

pain upon movingpain upon moving

kind of anesthetickind of anesthetic

1. regional1. regional infiltration, topical, nerveinfiltration, topical, nerveblock, field blockblock, field block -- position the patient firstposition the patient first

2. general2. general position the patient lastposition the patient last


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Qualificationsofa Good PositionQualificationsofa Good Position

The most important qualification is maximumThe most important qualification is maximumsafety of the patientsafety of the patient

Free RespirationFree Respiration

to prevent hypoxiato prevent hypoxia to aid in induction of anesthesiato aid in induction of anesthesia

Free CirculationFree Circulation

to prevent postoperative circulatory disturbancesto prevent postoperative circulatory disturbances to permit free flow of IV solution or transfusionto permit free flow of IV solution or transfusion

to help maintain blood pressureto help maintain blood pressure


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No pressure on any nervesNo pressure on any nerves may causemay cause

serious injury or paralysisserious injury or paralysis

Hands and foot supportedHands and foot supported

No undue post operative discomfortNo undue post operative discomfort nonostanding rather on the muscles or nervestanding rather on the muscles or nerve

Accessible Operative areaAccessible Operative area to permitto permit

surgeon to reach the operative areasurgeon to reach the operative area


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POSITIONS FOR OPERATION

Dorsal PositionDorsal Position-- used for laparotomies notused for laparotomies notrequiring extensive exploration such asrequiring extensive exploration such as

herniorapphy, appendectomyherniorapphy, appendectomy

Fowlers positionFowlers position for craniotomy, tonsillectomy,for craniotomy, tonsillectomy,nasal operation (under localnasal operation (under local

anesthesia)anesthesia)

Sitting positionSitting position for craniotomies involving thefor craniotomies involving theoccipital region, nasal surgery, mouth surgeryoccipital region, nasal surgery, mouth surgery

Sims positionSims position for proctosigmoidoscopyfor proctosigmoidoscopy


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Lithotomy positionLithotomy position for cystoscopy, transurethralfor cystoscopy, transurethral

resection, cystopanendoscopy,resection, cystopanendoscopy,perineal repair, vaginal hysterectomy, dilatationaperineal repair, vaginal hysterectomy, dilatationaand curettage, rectal surgeryand curettage, rectal surgery

Trendelenburg positionTrendelenburg position -- for urinary bladder orfor urinary bladder orcolon surgery, gynecology operationscolon surgery, gynecology operations

Reverse trendelenburg positionReverse trendelenburg position forforthyroidectomy to decrease the blood supply tothyroidectomy to decrease the blood supply to

the area, gallbladder operation to allow thethe area, gallbladder operation to allow theabdominal viscera away from the epigastricabdominal viscera away from the epigastricregionregion

Prone positionProne position for laminectomy back surgeryfor laminectomy back surgery


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Prone positionProne position for laminectomy, back surgery,for laminectomy, back surgery,

excision of bakers cystexcision of bakers cyst

Kraske/Jacknife positionKraske/Jacknife position for rectal surgeryfor rectal surgery

Knee Chest positionKnee Chest position for sigmoidoscopyfor sigmoidoscopy

Kidney positionKidney position for operation on the kidney andfor operation on the kidney and

upper ureter, lumbar anterior fusionupper ureter, lumbar anterior fusionChest position I (lateral)Chest position I (lateral) used for thoracoplasty,used for thoracoplasty,

pneumonectomy, esopagectomy and transthoracicpneumonectomy, esopagectomy and transthoracic

gastrectomygastrectomy

Chest position II (anterior)Chest position II (anterior) for pneumoectomy andfor pneumoectomy and

esophagectomy, heart surgeryesophagectomy, heart surgery


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Immediate Postoperative RecoveryImmediate Postoperative Recovery


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p yp y

The client's respiratory status is a priority concern onThe client's respiratory status is a priority concern on

admission to and throughout the recovery roomadmission to and throughout the recovery room

Admission of client to recovery area.Admission of client to recovery area.

1. Avoid respiratory complications by positioning client1. Avoid respiratory complications by positioning client

on his or her side (lateral Sims).on his or her side (lateral Sims). 2. Obtain baseline assessment.2. Obtain baseline assessment.

a. Vital signs.a. Vital signs.

b. Status of respirations.b. Status of respirations.

c. General color.c. General color.

d. Type and amount of fluid infusing.d. Type and amount of fluid infusing.

e. Special equipment. f. Dressinge. Special equipment. f. Dressing


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3. Determine specifics regarding the3. Determine specifics regarding the

operation from the O.R. nurse.operation from the O.R. nurse. a. Client's overall tolerance of surgery.a. Client's overall tolerance of surgery.

b. Type of surgery performed.b. Type of surgery performed.

c. Type of anesthetic agents used.c. Type of anesthetic agents used.

d. Results of procedured. Results of procedure -- was the conditionwas the condition

corrected.corrected.

e. Any specific complications to watch for.e. Any specific complications to watch for.

f. Status of fluid intake and urinary output.f. Status of fluid intake and urinary output.

Recovery Room (Immediate PostoperativeRecovery Room (Immediate Postoperative


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y ( py ( p

Care)Care)

A. Assess for and maintain patent airway.A. Assess for and maintain patent airway.

1. Position unconscious or semiconscious client1. Position unconscious or semiconscious client

on side (unless contraindicated) or on back with.on side (unless contraindicated) or on back with.

head to side and chin extended forward.head to side and chin extended forward.

2. Check for presence/absence of gag reflex.2. Check for presence/absence of gag reflex.

3. Maintain artificial airway in place until gag3. Maintain artificial airway in place until gag

and swallow reflex have returned.and swallow reflex have returned.

B. Administer oxygen as ordered.B. Administer oxygen as ordered.


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C. Assess rate, depth, and quality of respirations.C. Assess rate, depth, and quality of respirations.

D. Check vital signs every15

minutes until stable, thenD. Check vital signs every15

minutes until stable, thenevery 30 minutes.every 30 minutes.

E. Note level of consciousness; reorient client to time,E. Note level of consciousness; reorient client to time,

place, and situation.place, and situation.

F. Assess color and temperature of skin, color ofF. Assess color and temperature of skin, color ofnailbeds and lips.nailbeds and lips.

G. Monitor IV infusions: condition of site, type, andG. Monitor IV infusions: condition of site, type, and

amount of fluid being infused and flow rate.amount of fluid being infused and flow rate.

H. Check all drainage tubes and connect to suction orH. Check all drainage tubes and connect to suction or

gravity drainage as ordered; note color, amount, andgravity drainage as ordered; note color, amount, and

odor of drainage.odor of drainage.


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I. Assess dressings for intactness, drainage,I. Assess dressings for intactness, drainage,hemorrhage.hemorrhage.

J. Monitor and maintain client's temperature;J. Monitor and maintain client's temperature;

may need extra blankets.may need extra blankets.

K. Encourage client to cough and deep breatheK. Encourage client to cough and deep breathe

after airway is removed.after airway is removed.

L. If spinal anesthesia used, maintain supineL. If spinal anesthesia used, maintain supine

position and check for sensation and movementposition and check for sensation and movement

in lower extremities.in lower extremities.

DismissalofClientfromthe RecoveryDismissalofClientfromthe Recovery


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yy

RoomRoom

Five (5) Physiological Parameters:Five (5) Physiological Parameters:

ActivityActivity able to move 4 extremities voluntarilyable to move 4 extremities voluntarily

on command.on command.

BreathingBreathing -- RespirationRespiration able to breathe deeplyable to breathe deeplyand cough freelyand cough freely

CirculationCirculation BP is +20% orBP is +20% or --20+ of20+ of

preanesthetic levelpreanesthetic level

ConsciousnessConsciousness fully awakefully awake

ColorColor -- pinkpink

Care on Surgical Floor


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Care on SurgicalFloor

A. Monitor respiratory status and promote optimalA. Monitor respiratory status and promote optimal

functioning.functioning.

B. Monitor cardiovascular status and avoid postB. Monitor cardiovascular status and avoid post--opop

complications.complications. C. Promote adequate fluid and electrolyte balance.C. Promote adequate fluid and electrolyte balance.

D. Promote optimum nutrition.D. Promote optimum nutrition.

E. Monitor and promote return of urinary function.E. Monitor and promote return of urinary function. F. Promote bowel elimination.F. Promote bowel elimination.

G Administer postG Administer post op analgesics as ordered;op analgesics as ordered;


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G. Administer postG. Administer post--op analgesics as ordered;op analgesics as ordered;

provide additional comfort measures.provide additional comfort measures.

H. Encourage optimal activity, turning in bed everyH. Encourage optimal activity, turning in bed every

2 hours, early ambulation if allowed (generally2 hours, early ambulation if allowed (generally

client will be out of bed within 24 hours; have clientclient will be out of bed within 24 hours; have client

dangle legs before getting out of bed).dangle legs before getting out of bed). I. Provide wound care.I. Provide wound care.

J. Provide adequate psychologic support to client!J. Provide adequate psychologic support to client!

significant others.significant others. K. Provide appropriate discharge teaching: dietaryK. Provide appropriate discharge teaching: dietary

restrictions, medication regimen,restrictions, medication regimen,

Systemcheck


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1. Respiratory system1. Respiratory system

2. Cardiovascular system2. Cardiovascular system

3. Musculoskeletal system3. Musculoskeletal system

4. Neurological system4. Neurological system 5. Temperature control5. Temperature control

6. Integumentary system6. Integumentary system

7. Fluid and electrolyte balance7

. Fluid and electrolyte balance 8. Gastrointestinal system8. Gastrointestinal system

9. Renal system9. Renal system

Pain management


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Painmanagement

Immediate StageImmediate Stage -- 11-- 4 hours post op4 hours post op

Intermediate StageIntermediate Stage 44 24 hours24 hours

Extended StageExtended Stage -- 1 to 4 days1 to 4 days

Liquid Diet Vs Soft dietLiquid Diet Vs Soft diet


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LiquidDiet Vs SoftdietLiquidDiet Vs Softdiet

Clear liquidClear liquid Full liquidFull liquid Soft dietSoft dietCoffeeCoffee

TeaTea

CarbonatedCarbonated

drinkdrink

BouillonBouillon

Clear fruit juiceClear fruit juice

PopsiclePopsicle

GelatinGelatin

Clear liquid PLUS:Clear liquid PLUS:

Milk/Milk prodMilk/Milk prod

Vegetable juicesVegetable juices

Cream, butterCream, butter

YogurtYogurt

PuddingsPuddings

CustardCustard

Ice cream andIce cream and

sherbetsherbet

All CL and FLAll CL and FL

plus:plus:

MeatMeat

VegetablesVegetables

FruitsFruits

Breads andBreads and

cerealscerealsPureed foodsPureed foods

POSTOPERATIVE COMPLICATIONSPOSTOPERATIVE COMPLICATIONS


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POSTOPERATIVE COMPLICATIONSPOSTOPERATIVE COMPLICATIONS

Respiratory ComplicationsRespiratory Complications

Circulatory ComplicationsCirculatory Complications

Wound ComplicationsWound Complications

Complications of EliminationComplications of Elimination

Gastrointestinal ComplicationsGastrointestinal Complications

Respiratory Complications


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RespiratoryComplications

AtelectasisAtelectasis

PneumoniaPneumonia

HypoxiaHypoxia

RespiratoryComplications


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Predisposing factorsPredisposing factors 1. Type of surgery (e.g., thoracic or high1. Type of surgery (e.g., thoracic or high

abdomen surgery)abdomen surgery)

2. Previous history of respiratory problems2. Previous history of respiratory problems

3. Age: greater risk over age 403. Age: greater risk over age 40

4. Obesity4. Obesity

5. Smoking5. Smoking

6. Respiratory depression caused by narcotics6. Respiratory depression caused by narcotics

7. Severe post7. Severe post--op painop pain

8. Prolonged post8. Prolonged post--op immobilityop immobility


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AtelectasisAtelectasis -- is a collapse of a portion of theis a collapse of a portion of the

lung, producing an airless state in the alveolilung, producing an airless state in the alveoli

usually occurs 1 to 2 days postoperatively.usually occurs 1 to 2 days postoperatively.


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EtiologyEtiology

1. Undetected upperrespiratory infection.1. Undetected upperrespiratory infection.

2. Aspiration of vomitus.2. Aspiration of vomitus.

3. Increased mucus secretions due to3. Increased mucus secretions due to

intubation and anesthesia.intubation and anesthesia.

4. History of chronic lung disease.4. History of chronic lung disease.

5. Ineffective ventilation postoperatively,5. Ineffective ventilation postoperatively,

par-ticularly in the obese, and elderly client.par-ticularly in the obese, and elderly client.


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AssessmentAssessment

1. Dyspnea.1. Dyspnea.

2. Decreased or absent breath sounds over2. Decreased or absent breath sounds over

affected area.affected area.

3. Asymmetrical chest expansion.3. Asymmetrical chest expansion.

4. Tachycardia.4. Tachycardia.

5. Increased anxiety and restlessness.5. Increased anxiety and restlessness.

Nursing InterventionNursing Intervention


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1

. Prevention.1

. Prevention. a. Have client turn, cough and deep breathea. Have client turn, cough and deep breathe

every 2 hours.every 2 hours.

b. Maintain adequate hydration (3,000 cc perb. Maintain adequate hydration (3,000 cc per

day, unless contraindicated).day, unless contraindicated). c. Avoid large doses of analgesics, in clientsc. Avoid large doses of analgesics, in clients

with increased susceptibility.with increased susceptibility.

d. Prevent abdominal distention.d. Prevent abdominal distention. e. Encourage ambulation as soon as possible.e. Encourage ambulation as soon as possible.


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2. Position client on unaffected side.2. Position client on unaffected side.

3. Stimulate coughing.3. Stimulate coughing.

4. Increase humidification of inspired air.4. Increase humidification of inspired air.

5. Continue to implement preventive measures.5. Continue to implement preventive measures.


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PneumoniaPneumonia -- An acute inflammatory process ofAn acute inflammatory process ofthe alveolar spaces; the alveoli fill with exudatethe alveolar spaces; the alveoli fill with exudate

thereby causing consolidation of lung tissue.thereby causing consolidation of lung tissue.

-- An inflammation of the alveoliAn inflammation of the alveolicaused by an infectious process; may develop 3caused by an infectious process; may develop 3

to 5 days postoperatively as a result of infection,to 5 days postoperatively as a result of infection,

aspiration, or immobilityaspiration, or immobility

EtiologyEtiology


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11

. Undetected upperrespiratory infection.. Undetected upperrespiratory infection. 2. Aspiration of vomitus.2. Aspiration of vomitus.

3. Increased mucus secretions due to intubation3. Increased mucus secretions due to intubationand anesthesia.and anesthesia.

4. History of chronic lung disease.4. History of chronic lung disease. 5. Ineffective ventilation postoperatively,5. Ineffective ventilation postoperatively,

particularly in the obese, and elderly client.particularly in the obese, and elderly client.

6. Immunosuppressed clients.6. Immunosuppressed clients.

7. More common in infants and children.7. More common in infants and children.

..



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1. Rapid, shallow respirations/ Dyspnea and1. Rapid, shallow respirations/ Dyspnea and

increased respiratory rateincreased respiratory rate

2. Fever.2. Fever.

3. Wet breath sounds (rales, rhonchi) or absent3. Wet breath sounds (rales, rhonchi) or absent

breath sounds over affected area.breath sounds over affected area.

4. Asymmetrical chest expansion.4. Asymmetrical chest expansion.

5. Productive cough and chest pain5. Productive cough and chest pain


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6. Client with advanced hypoxia may6. Client with advanced hypoxia may

demonstrate circumoral and nail bed cyanosis.demonstrate circumoral and nail bed cyanosis.

7. Tachycardia.7. Tachycardia.

8. Leukocytosis.8. Leukocytosis.

ImplementationImplementation


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1. Assess lung and breath sounds1. Assess lung and breath sounds 2. Reposition the client every 1 to 2 hours(turn)/2. Reposition the client every 1 to 2 hours(turn)/

Position in semi to highPosition in semi to high--Fowlers.Fowlers.

3. Encourage the client to deep breathe and3. Encourage the client to deep breathe andcough and to use the incentive spirometercough and to use the incentive spirometer

4. Provide chest physiotherapy (CPT) postural4. Provide chest physiotherapy (CPT) postural

drainage as prescribeddrainage as prescribed

5. Suction to clear secretions if the client is5. Suction to clear secretions if the client is

unable to coughunable to cough


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6. Encourage fluid intake/ Maintain adequate6. Encourage fluid intake/ Maintain adequate

hydration (3,000 cc per day). If nohydration (3,000 cc per day). If no

contraindicationcontraindication

7. Encourage early ambulation7. Encourage early ambulation

8. Administer antibiotics and antipyretics.8. Administer antibiotics and antipyretics.

9. Maintain humidification of air and oxygen.9. Maintain humidification of air and oxygen.


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HYPOXIAHYPOXIA -- An inadequate concentration ofAn inadequate concentration of

oxygen in arterial bloodoxygen in arterial blood



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1. Restlessness1. Restlessness

2. Dyspnea2. Dyspnea

3. Hypertension3. Hypertension

4. Tachycardia4. Tachycardia

5. Diaphoresis5. Diaphoresis

6. Cyanosis6. Cyanosis

Nursing InterventionsNursing Interventions


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Nursing InterventionsNursing Interventions

1. Monitor for signs of hypoxia1. Monitor for signs of hypoxia

2. Eliminate the cause of hypoxia2. Eliminate the cause of hypoxia

3. Monitor lung sounds and pulse oximetry3. Monitor lung sounds and pulse oximetry

4. Administer oxygen as prescribed4. Administer oxygen as prescribed

5. Encourage deep breathing and coughing and5. Encourage deep breathing and coughing and

use of the incentive spirometeruse of the incentive spirometer

6. Turn and reposition the client6. Turn and reposition the client

CirculatoryComplicationsCirculatoryComplications


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y py p

Deep vein thrombosisDeep vein thrombosis

Pulmonary embolismPulmonary embolism

ShockShock


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SHOCK (Hypovolemic)SHOCK (Hypovolemic) -- A decrease in cardiacA decrease in cardiacoutput due to loss of circulating blood volume.output due to loss of circulating blood volume.

-- Loss of circulatory fluidLoss of circulatory fluid

volume, which is usually caused by hemorrhagevolume, which is usually caused by hemorrhage

HEMORRHAGEHEMORRHAGE -- The loss of a large amount ofThe loss of a large amount of

blood externally or internally in a short period ofblood externally or internally in a short period of

timetime

Most common causes of shock during postMost common causes of shock during post--opop


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periodperiod

1. Hemorrhage1. Hemorrhage

2. Sepsis2. Sepsis

3. Myocardial infarction and cardiac arrest3. Myocardial infarction and cardiac arrest

4. Drug reactions4. Drug reactions

5. Transfusion reactions5. Transfusion reactions

6. Pulmonary embolism6. Pulmonary embolism

7. Adrenal failure7. Adrenal failure



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1. Hypotension/Decreased/falling blood1. Hypotension/Decreased/falling blood

pressure (systolic


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7. Changes in sensorium (restlessness,7. Changes in sensorium (restlessness,

anxiety,confusion, eventually coma).anxiety,confusion, eventually coma).

8. Incisional area or surgical drains show8. Incisional area or surgical drains show

excessive amount of bright red blood.excessive amount of bright red blood.

9. Decrease in CVP.9. Decrease in CVP.

10. Restlessness10. Restlessness

11. Tachypnea11. Tachypnea

Nursing InterventionNursing Intervention


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1. Initiate IV access; anticipate plasma1. Initiate IV access; anticipate plasmaexpanders, whole blood, IV fluid.expanders, whole blood, IV fluid.

2. Place client in supine/trendelenburg position2. Place client in supine/trendelenburg position

unless contraindicated.unless contraindicated.

3. Maintain adequate ventilation.3. Maintain adequate ventilation.

4. Monitor vital signs every 15 minutes, or as4. Monitor vital signs every 15 minutes, or as

necessary .necessary .

5. Do not administer medications via PO, IM or5. Do not administer medications via PO, IM or

SQ; in shock administer IV medications.SQ; in shock administer IV medications.


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PULMONARY EMBOLISMPULMONARY EMBOLISM -- The movementThe movement

of a thrombus from its origin into theof a thrombus from its origin into the

pulmonary artery.pulmonary artery.

-- An embolusAn embolusblocking the pulmonary artery and disruptingblocking the pulmonary artery and disrupting

blood flow to one or more lobes of the lungblood flow to one or more lobes of the lung

EtiologyEtiology


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Originates in the venous system of the lowerOriginates in the venous system of the lowerextremitiesextremities

Dislodged the embolus travels through theDislodged the embolus travels through the

systemic system to the pulmonary arterysystemic system to the pulmonary artery

Thrombus formation is often precipitated venousThrombus formation is often precipitated venous

pooling due to immobility, and thrombophlebitispooling due to immobility, and thrombophlebitis

of the lower extremities.of the lower extremities.

The severity of the condition is determined theThe severity of the condition is determined the

size of the embolus.size of the embolus.


50005872 4 Perioperative Nursing

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Transcript of 50005872 4 Perioperative Nursing