A Primer for Perioperative Education

Introduction to Perioperative Nursing

Perioperative Nursing Definition of Surgery

Surgery is any procedure performed on the human body that uses instruments to alter tissue or organ integrity.

Perioperative Nursinghttp://www.viddler.com/v/802cd6a4

Perioperative Nursing- connotes the delivery of patient care in the preoperative,intraoperative, and postoperative periods of the patients surgical experience through the framework of the nursing process. The nurse assesses the patient- collecting,organizing, and prioritizing patient data; establishing nursing diagnosis;identifies desired patient outcomes;develop and implements a plan of care; and evaluates that care in terms of outcomes achieved by the patient.

Perioperative Nursing Phases

Preoperative phase – begins when the decision to have surgery is made and ends when the client is transferred to the OR table.

Intraoperative phase – begins when the client is transferred to the OR table and ends when the client is admitted to the PACU.

Postoperative phase - begins with the admission of the client to the PACU and ends when the healing is complete.

Perioperative Nursing Types of Surgery

Purpose/reasons - Degree of urgency – necessity to preserve

the client’s life, body part, or body function.

Degree of risk – involved in surgical procedure is affected by the client’s age, general health, nutritional status, use of medications, and mental status.

Extent of surgery – Simple and radical

Perioperative Nursing Type of Surgery (Purpose)

Diagnostic-Allows to confirm or establishes diagnosis.

Corrective- Excision or removal of diseased body part.

Reconstructive-Restore function or appearance to traumatized or malfunctioning tissues.

Ablative – Removes a diseased body partsPalliative – Relieves or reduces pain or

symptoms of a disease; it does not cureTransplant – Replaces malfunctioning

structuresCosmetic- Performed to improve personal

appearance.

Perioperative Nursing Types of Surgery (Urgency)

Emergency- performed immediately to preserve function or the life of the client.

Elective – is performed when surgical intervention is the preferred treatment for a condition that is not imminently life threatening or to improve the client’s life.

Urgent – Necessary for client’ health to prevent additional problem from developing; not necessarily an emergency.

Required – has to be performed at some point; can be pre-scheduled.

Perioperative NursingType of Surgery (Degree of Risk)

Major – involves a high degree of risk.Minor – normally involves little risk.Age – very young and elder clients are greater

surgical risks than children and adult.General health- surgery is least risky when the

client’s general health is good.Nutritional Status – required for normal tissue

repair.Medications – regular use of certain

medications can increase surgical risk.Mental status – disorder that affect cognitive

function

Perioperative Nursing Surgical settingsSurgical suitesAmbulatory care settingClinicsPhysician officesCommunity settingHomes

Perioperative Nursing Surgical settingsDisadvantages

Less time for rapportLess time to assess, evaluation, teachRisk of potential complication post D/C.

Advantages of outpatient:Low costLow risk of infectionLess interruption of routineLess than from workLess stress

Preoperative Nursing Consent

Nature and intention of the surgeryName and qualifications of the person

performing the surgery.Risks, including tissue damage, disfigurement,

or even deathChances of successPossible alternative measuresThe right of the client to refuse consent or later

withdraw consent.

Preoperative Nursing Assessment (Nursing History)

Current health status-AllergiesMedications- list all current medicationsPrevious surgeriesUnderstanding of the surgical procedure and

anesthesiaSmokingAlcohol and other-altering substancesCopingSocial resourcesCultural considerations

Preoperative Nursing Care Physical assessment

Cardiovascular systemRespiratory systemRenal systemNeurological systemMusculoskeletal systemNutritional statusGerontological considerations

Perioperative Nursing CarePhysical assessment/clinical manifestations

General survey- gestures and body movements may reflect decreased energy or weakness caused by illness.

Cardiovascular system- alterations in cardiac status are responsible for as many as 30% of perioperative death.

Respiratory system- a decline in ventilatory function, assessed through breathing pattern and chest excursion, may indicate a client’s risk for respiratory complications.

Perioperative Nursing CarePhysical assessment/clinical manifestations

Renal system-abnormal renal function can altered fluid and electrolyte balance and decrease the excretion of preoperative medications and anesthetic agents.

Neurologic system- a client’s LOC will change as a result of general anesthesia but should return to the preoperative LOC after surgery.

Perioperative Nursing CarePhysical assessment/clinical manifestations

Musculoskeletal system- Deformities may interfere with intraoperative and postoperative positioning. Avoid positioning over an area where the the skin shows signs of pressure over bony prominences.

Gastrointestinal system- alteration in function after surgery may result in decreased or absent bowel sound and distention.

Head and Neck- the condition of oral mucous membranes reveals the level of hydration.

Preoperative Nursing Care Gerontological ConsiderationsCardiovascular

Coronary flow decreasesHeart rate decreasesResponse to stress decreasesPeripheral vascular decreasesCardiac output decreasesCardiac reserve decreases

Preoperative Nursing Care Gerontological Considerations

Respiratory SystemStatic lung volumes decreasesPulmonary static recoil decreases

Sensitivity of the airway receptors decreases

Nervous systemIncreased incidence of post.op. confusion.Increased incidence of deliriumIncreased sensitivity to anesthetic agents

Preoperative Nursing Care Gerontological Considerations

Renal SystemRenal blood flow declines 1.5% per year. Renal clearance reduced

GastrointestinalDecreased intestinal motilityDecreased liver blood flowDelayed gastric emptying

Preoperative Nursing Care Gerontological Considerations

MusculoskeletalDecreased mass, tone, strengthDecreased bone density

IntegumentaryDecreased elasticityDecreased lean body massDecreased subcutaneous fat

Preoperative Nursing Care Psychosocial considerationsLevel of anxietyCoping abilitySupport systems

Preoperative Nursing Care Laboratory and diagnostic studies

Screening tests depend on the condition of the client and the nature of the surgery. If test reveals severe problems the surgery may be cancel until the condition is stabilized.

Routine screening test-CBC,Blood grouping and X-match, Lytes, fasting blood sugar, BUN & Creatinine, ALT,AST, and bilirubin,Serum albumin, and Total protein, Urinalysis, Chest X-ray,ECG

Preoperative Nursing Care Common nursing diagnosisKnowledge deficitAnxietyRisk for ineffective airway clearanceFear related toDisturbed sleep patternAnticipatory grieving related to

Preoperative Nursing Care Preop. teaching

The education plan should begin with assessment, including baseline knowledge of the patient and family, readiness to learn,barriers to learning, patient and family concern and learning styles and preferences.

The content focuses on information that will increase patient’s familiarity with procedural events. This includes surgical experience (procedural), what the pt. may experience (sensory) and what actions may help decrease anxiety (behavioral).

Preoperative Nursing Care AnxietyThe nurse must consider the pt’s

family and friends when planning psychological support.

Empowering their sense of control. Activities that decreasing anxiety are deep breathing, relaxation exercises, music therapy, massage and animal-assisted therapy.

Use of medication to relieve anxiety.

Preoperative Nursing CarePreanesthesia Management Physical Status Categories

ASA 1: Healthy patient with no diseaseASA 11: Mild systemic ds without fx limitationsASA 111:Severe systemic ds associated with

definite fx limitationsASA 1V: Severe systemic ds that is a constant

threat to life.ASA V: Moribund pt. Who is not expected to

survive without the operation.ASA V1: A declared brain-death whose organ are

being recovered for donor.E: Emergency

Preoperative Nursing CareFinal Preparation for surgeryAll personal belongings are identified

and secured.Jewelry is usually removed.Dentures are removed, labeled and

placed in a denture cup.Pt. to verbally confirm the surgical

procedures and the surgical site. This verification process is documented in the medical record on the preop. checklist.

Preoperative Nursing Care Pre-op. medications

Prior to administering – check permitsPurpose: Allay anxiety

Decrease pharyngeal secretions- Decrease gastric secretion.

Decrease side effects of anesthesia.

Induce amnesia

Preoperative Nursing Care MedicationsSedatives/hypnotics- NembutalTranquilizers-Ativan, versed, valiumOpiate analgesics- Demerol, morphineAnticholinergics-Atropine

sulfate,ataraxH2o blockers.- Tagamet, ZantacAntiemetic- Reglan, Phenergan

Intraoperative Phase Surgical Team

SurgeonAnesthesiologistScrub NurseCirculating NurseOR techs

Intraoperative Nursing Care Roles of team members

Surgeon-responsible for determining the preoperative diagnosis, the choice and execution of the surgical procedure, the explanation of the risks and benefits, obtaining inform consent and the postoperative management of the patient’s care.

Scrub nurse- (RN or Scrub tech)- preparation of supplies and equipment on the sterile field; maintenance of pt.s safety and integrity: observation of the scrubbed team for breaks in the sterile fields; provision of appropriate sterile instrumentation, sutures, and supplies; sharps count.

Perioperative Nursing CareSurgical team

Circulating Nurse - responsible for creating a safe environment, managing the activities outside the sterile field, providing nursing care to the patient. Documenting intraoperative nursing care and ensuring surgical specimens are identified and place in the right media. In charge of the instrument and sharps count and communicating relevant information to individual outside of the OR, such as family members.

Perioperative Nursing CareSurgical team

Anesthesiologist and anesthetist- anesthetizing the pt. providing appropriate levels of pain relief, monitoring the pt’s physiologic status and providing the best operative conditions for the surgeons.

Other personnel- pathologist, radiologist, perfusionist, EVS personnel.

Perioperative Nursing Care Surgical team

Nursing Roles:Staff educationClient/family teachingSupport and reassuranceAdvocacyControl of the environmentProvision of resourcesMaintenance of asepsisMonitoring of physiologic and psychological

status

Intraoperative Nursing Care Surgical asepsis

Ensure sterilityAlert for breaks

Intraoperative Phase Anesthesia

Greek word- anesthesis, meaning “negative sensation.” Artificially induced state of partial or total loss of sensation, occurring with or without consciousness.

Blocks transmission of nerve impulses Suppress reflexes Promotes muscle relaxation Controlled level of unconsciousness

Intraoperative Phase AnesthesiaFactors influencing dosage and type:

1.Type and duration of the procedure2.Area of the body being operated on3.Whether the procedure is an emergency4.Options of management of post. Op. pain5.How long it has been since the client ate,

had any liquids, or any medications6.Client position for the surgical procedures

Intraoperative Phase Types of Anesthesia

General- method use when the surgery requires that the patient be unconscious and/or paralyzed.

A general anesthetic acts by blocking awareness centers in the brain so that amnesia (loss of memory), analgesia (insensibility to pain), hypnosis (artificial sleep), and relaxation (rendering a part of the body less tense) occur.

Intraoperative Phase Stages of General Anesthesia

Stage 1- Analgesia and sedation, relaxationStage 2- Excitement, deliriumStage 3- Operative anesthesia, surgical

anesthesiaStage 4- Danger

Intraoperative Phase

Complications of General Anesthesia Overdose Hypoventilation Related to anesthetic agents Malignant hyperthermia Related to intubation

Intraoperative Phase

Local or Regional AnesthesiaTemporarily interrupts the transmission of sensory nerve impulses from a specific area or region.

Motor function may or may not be affected Client does not lose consciousness Gag reflex remains intact Supplemented with sedatives, opioids, or

hypnotics

Types of Regional Anesthesia

Topical (surface)LocalNerve BlockIntravenous (Bier Block)SpinalEpidural (peridural)

Intraoperative Phase

Complications of Local/Regional Anesthesia Anaphylaxis Administration technique Systemic absorption Overdosage

Spinal AnesthesiaIndications

-surgical procedures below the diaphragm

-patients with cardiac or respiratory disease

Advantages-mental status monitoring

-shorter recoveryDisadvantages

-necessary extra expertise-possible patient pain

Contraindications-coagulopathy

-uncorrected hypovolemia

Spinal Anesthesia

Involved medications-lidocaine

-bupivacaine-tetracaine

Patient assessment-continuous heart rate, rhythm,

and pulse oximetry monitoring-level of anesthesia

-motor function and sensation return monitoring

Spinal Anesthesia

Complications-hypotension-bradycardia-urine retention-postural puncture headache-back pain

Spinal analgesiaIndications

-postoperative pain from major surgery

Involved medications-lipid-soluble drugs-preservative-free morphine

Monitoring recovery-respiratory depression-urine depression-pruritus-nausea and vomiting

Examples of location for Spinal and Epidural Anesthesia.

Nerve Block Sites

Intraoperative Phase

Conscious SedationAdministration of IV sedative, hypnotic, and

opioid medications.

Produces a depressed level of consciousness

Retains ability to maintain a patent airway Able to respond to verbal commands or

physical stimulation Used for relatively short procedures

Postoperative Nursing CareNursing assessment in the PACU

Vital signs- presence of artificial airway, 02 sat,BP,pulse, temperature.

LOC- ability to follow command, pupillary response

Urinary outputSkin integrityPainCondition of surgical woundPresence of IV linesPosition of patient

Postoperative Nursing CareNursing Diagnosis

Ineffective airway clearance- increased secretions 2 to anesthesia, ineffective cough, pain

Ineffective breathing pattern- anesthetic and drug effects, incisional pain

Acute painUrinary retentionRisk for infection

Postoperative Phase

Assessment of the Postanesthesia Client Airway Vital signs Cardiac monitoring Peripheral vascular assessment Level of consciousness (LOC) Fluid and electrolytes GI system Integumentary system Discomfort/pain

Perioperative Nursing Care Postoperative Management

Maintain a patent airwayStabilize vital signsEnsure patient safetyProvide painRecognize & manage complications

Postoperative Nursing CareWhen caring for post-surgical patient, think of the “4 W’s”

Wind: prevent respiratory complications

Wound: prevent infectionWater: monitor I & OWalk: prevent thrombophlebitis

Postoperative Phase ComplicationsRespiratory- atelectasis, pulm. EmbolusCardiovascular- venous thrombosisGastrointestinal-Hiccoughs, N/V,abd.

Distention, paralytic ileus, stress ulcer.GU- urinary retentionHemorrhage-slipping of a ligature(suture)Wound infection-Wound dehiscence and evisceration-

Dehiscence

Partial or complete separation of the outer layer of the wound.

Possible causes:Poor suturing techniqueDistentionExcessive vomitingExcessive coughingDehydrationInfection

EviscerationTotal separation of the layers & protrusion of internal

organs or viscera through the open wound.Causes: same as dehiscenceTreatment:

Call for helpCover with sterile NS soaked gauze/towelsKeep moistDO NOT ATTEMPTS TO REINSERT

ORGANS.Keep in supine position with knees/hips bentAssessment/VS q 5 min. until MD arrivePrepare for surgery.

Postoperative Phase

Postoperative Phase

Postoperative Nursing CareGerontologic considerations

Mental status- attributed to medications, pain, anxiety, depression.

Delirium- infection, malignancy, trauma, MI, CHF, opioid use.

Dementia-sundowning-sleep disturbances, lack of structure in the afternoon or early morning, sleep apnea.