Perioperative Nursing Concept

NCM202B_A Perioperative Nursing – Mrs. Fe Corazon Elefan, RN MN

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Perioperative Nursing Overview

3 Phases

a. Pre-operative

b. Intraoperative

c. Post-operative

*** prioritize problem identified based on client’s need

Course Content

I. Introduction

A. Definitions and Suffixes

B. Responsibilities of Perioperative nurse

C. Operative Phase

II. Preoperative Nursing Care Management

A. General Physical Assessment

System Assessment

Nutritional Status Assessment

Gerontologic Considerations

B. Nursing Process in the care of clients requiring surgery

C. Preoperative Nursing Interventions

Legal Preparations

Physiological Preparations --- chest x-ray, hepatitis test, full stomach

Psychological Preparations

1. Preoperative health teachings

2. Teaching cognitive coping strategies

D. Immediate Preoperative Nursing Interventions – on the day

Administering pre anesthetic medications

Maintaining pre-operative record (pre-op. checklist)

Transporting the patient to pre surgical suite

Attending the family needs

III. Intra operative Nursing Care Management

A. The Surgical Team

B. Surgical Environment

Principles of surgical Aseptic Technique

Health Hazards Associated with Surgical Environment

C. Surgical Experience

Anesthesia

Patient Position in the Operating Table

Caring of the Patient during Surgery – MIO, vs.

IV. Post Operative Nursing Care Management

A. Immediate post Operative Care in the PACU / PAR / SICU

Admitting the patient in PACU

Nursing Care Management in the PACU

Physical Assessment


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Relieving pain and anxiety

B. The hospitalized Post Operative Patient

C. The Patient Recovering from Surgery

D. Promoting Home and Community-based care

*** most common in respi – pneumonia; hemorrhage (first 48 hours after surgery); wound infection

Criteria of evaluation:

Quizzes – 50%

Term Examination – 40%

Attendance / Participation / Requirements (Case study) – 10%

References:

Operating Room Techniques by Barry and Kohn

Fundamentals of Operating Room Nursing, Shirley Brooks

Medical Surgical Nursing, Clinical Management for Positive Outcomes, Black and Hawks

Differentiating Surgical Instruments, Colleen J. Rutherford

Perioperative Nursing

- Nursing Care of preoperative client that begins when the patient decides to have surgery and ends when

surgery related nursing care is no longer needed.

- A comprehensive nursing care of client before, during and after surgery

*** starts before admission; when the patient decides to have surgery and ends after full recovery (extended

when there are still follow-up checkups; does not end upon discharge)

Surgery

- The art and science of treating diseases, injuries, and deformities by operation and instrumentation.

Treatment of an illness by invasive means (imposes physical and mental stressors)

- Places the patient at risk for injury – due to effects of anesthesia

*** takes 1 month for wound to completely heal; but consider individual differences

To avoid pneumonia – deep breathing exercises

RESPONSIBILITIES OF PERIOPERATIVE NURSE:

1. Provide care to the client during forced dependency. – anesthesia/sedation

2. Ensure continuity of care by coordinating with other members of the surgical team and documenting all

the events during peri-operative period. -- charting format: problem oriented

3. Keeping abreast of the continually changing technology.

4. Incorporating the knowledge of the classification of surgery into the plan of care. – Classifications:

According to risk, purpose, and time available for both pt. and surgical team


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Classification of Surgery

I. According to the Degree of risks (complications) refers to the relative threat surgery poses to the

patient.

1. Major Surgery

- May pose great threat to the patient

- Usually requires hospitalization

- Prolonged procedures, involving major body organs

- E.g. Bilroth II Gastro-jejunostomy

2. Minor Surgery

- Poses a minimal threat

- Usually takes place in the clinic. Brief procedure and has few complications (bleeding,

infection)

- E.g. Excision of mass/cyst – done in outpatient dept.; suturing

II. According to the Degree of Urgency

- Degree of urgency refers to the time available for the patient, family and surgical team to decide

whether or not surgery will be performed

- Corresponds to the severity of illness and injuries

1. OPTIONAL

- Surgery is scheduled completely at the preference of the patient.

- E.g. Vasectomy and BTL

2. ELECTIVE

- The approximate time for surgery is at the convenience of the patient. Failure to have

surgery is not a great threat to the health of the client.

- E.g. For goiter ( there is advice from doctor as to the time) Thyroidectomy; Palatoplasty

(6months)

3. REQUIRED

- The condition of the client requires surgery within few weeks or months

- E.g. Cheiloplasty (1st operation), Jatene

4. URGENT

- Surgical problem requires attention within 24-48 hours

- E.g. Ruptured appendicitis, major gunshot wound involving major arteries

*** Anoplasty + colostomy (temporary – 2yrs after anoplasty, it is closed)

*** Permanent colostomy – malignancy in rectum/bowel

5. EMERGENT

- The condition of the client requires surgical intervention or attention without delay

- E.g. STAT Appendectomy, repair of punctured lung, STAT CS

*** 2 hours to cross-match the blood

III. According to Purpose

1. Diagnosis – to determine the cause of symptoms


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- E.g. Diagnostic curettage (to bring uterine endometrial scrapings to lab for physiological

studies to pts. With dysfunctional bleeding); excision and biopsy

2. Curative / Ablative

- Surgical removal, or repair of the damaged organ (s) to restore function (s)

- C&C (to remove placental fragments), appendectomy

3. Restorative

- To strengthen weakened area (herniorrhaphy), rejoin disconnected or injured area (bone

pinning – internal fixation), or correct deformities (ORIF), bone fixators for internal

reduction and internal fixation (pins, plates and screws, rods)

4. Palliative

- To relieve symptoms without curing / treating the disease

- E.g. Sympathectomy (sympathetic nerve fibers removed to minimize pain and discomfort of

patient – with pts who have very low pain threshold), colostomy

5. Aesthetic / Cosmetic

- To improve physical features that are within the normal range

- Ex. Mammoplasty, reduction or augmentation

Rhinoplasty – correction of the external appearance of the nose (can also be

curative)

Blepharoplasty – excision of the protruding intraorbital fat and resection of

excessive redundant skin of the eyelids (eyebags)

Cheiloplasty – cleft lip repair (series)

Palatoplasty – cleft palate repair

6. Preventive

- Removal of moles, warts, polyps (rectal, cervical) before it becomes malignant

7. Reconstructive

- Partial or complete restoration of a body part that is congenitally malformed

- E.g. Orchiopexy

8. Transformative

- Removal of damaged organs or tissues and replacing it with functional ones

- E.g. Transplants, skin grafting, bone marrow transplant

9. Exploratory

- Estimation of the extent of disease or confirmation of diagnosis

- E.g. Exploratory laparotomy, pelvic laparotomy

Perioperative Nursing Objectives

Utilize nursing process in the care of surgical clients.

Describe the nursing intervention for each of the three phases of surgery.

Identify factors and health conditions that may influence or alter the well being of a surgical client.

Pre-operative Phase

- Begins when the patient decides to have surgery and consist primarily of collecting and analyzing data used

to plan intra-operative events.


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Focus of Client Care:

Assessment – enables the nurse to provide individualized care.

Preoperative Assessment includes:

I. Medical / Health History

a. Present health history

- Chief complaints, duration of present health problem

b. Past health history

- Previous surgery, experiences with anesthesia

Serious illness or trauma

A – allergy to medicines, chemicals (betadine, rubber gloves) and other environmental

products

B – bleeding tendencies or the use of medications that deter clotting (blood thinners –

aspirin)

C – cortisone or steroid use

D – diabetes mellitus – under stress, blood sugar goes up

E – emboli, previous embolic events may recur because of prolonged immobility

c. Alcohol, Recreational Drug or Nicotine use potential problem with the administration

of anesthesia or analgesia and risk for withdrawal symptoms.

- Eg. Amphetamines, cocaine

Alcohol addiction may result to malnutrition – thiamine deficiency

(excreted through urine)

Withdrawal to alcohol may require dosage alterations in anaesthesia and

analgesia

Smokers may have damaged lung tissue (COPD)

Nicotine is a potent vasoconstrictor resulting to less oxygen available for

tissue repair

May cause hypercoagulability resulting to thrombus or clot formation – d/t

nicotine

d. Current Discomfort

- Pre-existing painful condition may require alternate methods of pain reduction

- Clients who drink considerable amount of coffee often develop headache related to

NPO status

e. Chronic Illness

- Ex. Arthritis, neck and back are considered in positioning client during surgery and

intubation

f. Advanced age

- Older clients have specific peri-operative needs

g. Medication history

- Medications with prescription or over the counter drugs may increase operative

risks


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- Example

1. Antibiotic – penicillin, gentamicin may produce mild respiratory depression,

mask infection and affect metabolism of muscle relaxant (diazepam).

2. Antidysrhythmic – Propanolol, Quinidine Gluconate, Procainamide HCl affects

tolerance of anesthesia. Depress cardiac function, potentiates anesthetic

agents are neuromuscular blockers

3. Antihypertensive – Methyldopa, Captopril

- May alter response to muscle relaxant and narcotics

- May cause intra-operative and post operative hypertensive crisis

4. Corticosteroids – Dexamethasone, Hydrocortisone, Prednisone

- May mask infection

- Increases risk of hemorrhage

- Dec stress response (steroid replacement during surgery)

5. Anticoagulants

- Warfarin Na, Heparin Na, NSAIDs

- Inc risk for hemorrhage intra-operatively and post-operatively

6. Antidiabetic Agents

- Basic insulin needs remain when client is on NPO

- Glucose levels may fluctuate because of physiologic stress brought about

by surgery

Insulin alteration is needed

7. Tricyclic Antidepressant

- Amitryptiline, Amoxapine, Doxapin

- Lowers BP inc risk of shock d/t hypotension

- Potentiates affects of narcotics and barbiturates

8. Thiazide Diuretics

- Hydrochlorothiazide; Furosemide

- Can deplete K, can cause F and E imbalance

- Results to dysrhythmia

9. Street Drugs

II. Psychological History

a. Knowledge of Cultural beliefs and practices

b. Ability to tolerate Perioperative stress

Psychological factors (anxiety, fear of the unknown) +

Physiological factors (blood loss, anesthesia, pain, immobility) promote physiologic

stress response

III. Physical Exam

> Head to toe exam

1. LOC

> Assess cognition all through the exam

2. Cardiovascular Assessment

- ECG, Hgb, Hct, F and E deter


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- > check and document SOB on minor exertion; hypertension, heart murmurs

- All cardiac conditions can lead to a dec tissue perfusion with impairment of

surg wound healing

3. Respiratory Assessment

- CXR, Pulse Ox, ABG

- > Check and document SOB, wheezing, clubbing of fingers, chest pain

(subjective – validate through pain scale and correlate with vital signs),

coughing, expectoration of copious discharges

- > Chronic lung conditions such as emphysema, asthma, bronchitis impair gas

exchange in the alveoli predisposing clients to post operative pulmonary

complications

4. Musculoskeletal Assessment

- AROM and PROM, History provided by client and family. Medical Records

- History of Arthritis, fracture, contracture, joint injury, other musculoskeletal

impairment is important in surgical positioning and post op support

5. GI Assessment

- Radiologic Study (Ba enema, Ba swallow)

- G.I. conditions associated with poor surgical outcome: severe malnutrition;

prolonged nausea and vomiting, long history of constipation (may have more

difficulty with regular function)

- Gastroesophageal reflux; hiatal hernia increase risk o aspiration

- Opioid analgesics inc constipation

- *** Sigmoidoscopy

- *** Esophagoscopy

6. Renal Assessment

- Ask patient for voiding pattern. Lab Tests: BUN, serum creatinine levels

(indicate the ability of the kidney to excrete urea and CHON waste products;

UA result may indicate UTI, DM, Malnutrition, Renal Disease, Dehydration

(check urea, RBC, protein in urine)

- Adequate renal function in necessary to eliminate protein wastes, to preserve F

and E balance, to remove anesthetic agents

- ***dehydration – dark colored urine; normal – amber colored

- Renal and Related Disorders – Advanced Renal Insufficiency, Acute Nephritis,

BPH (anticholinergic drugs is Given)

7. Skin Integrity

- Operative site must be clear of any rashes, blisters, or any infectious process

- > Note the size, color, and location of skin impairment.

- > Body piercings (maybe removed according to surgeon preference)

- > Tattoos should be noted

8. Liver Functions Assessment

- > Liver disease is manifested by dec albumin levels dec immunoglobulin and

fibrinogen levels clotting disorders


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- > Dec albumin level predispose the client to fluid shifts, surgical infection and

ineffective coagulation

*** Edema - hard to start IV; close monitoring of I&0, make sure no imbalance

of intake more than output; check if pitting or non-pitting)

- > liver cirrhosis inc client’s surg risk, because impaired liver can’t detoxify

medications and anesthetic agents

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9. Cognitive and Neurologic Assessment

- > Determine baseline neurologic functions by checking reflex response of upper

and lower extremities, sensory reflex; testing cranial nerves and cerebral

responses

- Assess condition preoperatively to determine postoperative effects of surgery

- Surgery and medication frequently lead to temporary cognitive deficiencies.

10. Endocrine Assessment

- DM is the most frequently pre-existing path-physiologic drugs

- Thyroid replacement is usually continued throughout Perioperative. Stopping

thyroid medication period

- > Stopping thyroid medications may result to hypothyroidism with

manifestation of bradycardia, hypotension, hypothermia

Additional Assessment:

1. Age

- Take note of the normal physiologic changes that occur with aging

- > chronic conditions commonly found in older client; malnutrition, anemia,

dehydration, atherosclerosis, COPD, cerebrovascular changes and peripheral

vascular diseases

- > Observe for full assessment of pain if present

- In infants: weight, thermo-regulation; immature body systems.

2. Nutritional Status:

- > Obese clients are malnourished (in terms of excess intake)

- > Associated with poor surgical outcome.

- > Adipose tissue inc technical difficulty.

- > Fatty tissue is less vascular, prone to have an infection, incision hernias, wound

dehiscence (opening of suture) and evisceration (bodily organs are out of the body)

- > Absorbed anesthetic agents – wears off slower, delaying recovery

- Obese client freq suffer from hypertension, heart failure, and metabolic problems.

Susceptible to postoperative complications

Dec the efficiency of coughing and breathing exercises

Pressure of the abdominal contents on the diaphragm and lungs may lead to

hypoventilation

Prone to post operative immobility, inc the risk for venous stasis, DVT,

pulmonary embolism, pressure sores (encourage client to turn)

3. F and E Balance – in severe dehydration

Irritability and confusion


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4. Infection and Immunity – dec WBC may indicate risk for infection

5. Hematologic function - blood coagulation disorders are at risk for hemorrhagic and

hypovolemic shock during and after the surgery

Herbal preparation: Ginkgo biloba, garlic, ginger and ginseng may prevent clot

formation excess blood loss.

St. John’s Wort (antidepressant); Kava-Kava (relaxant) may prolong sedative

effects of anesthesia

***rrhaphy – repair, ostomy – create an opening, plasty - reconstruction

Preoperative Preparation:

1. Legal Preparation:

a. Voluntary and Informed Consent (MD can do surg without consent in cases of emergency)

Considerations:

Of legal age signed in the presence of a witness

Must be mentally clear and competent at the time of signing

If minor/an adult is incapable of signing the consent, obtain consent from the next kin

Criteria of Informed Consent:

1. Client must understand the nature of surgery

2. Client must be informed of the risk and benefits of surgery

*** Nurse may act as a witness and reinforce what was said when surgeon explained the

procedure to the client

2. Psychological Preparation

Surgery is a potential or actual threat to person’s bodily integrity and can interfere with the attainment

of goals in any phase of surgery

Stress Reactions

a. Psychologic stress reaction (fear and anxiety)

b. Physiologic stress reaction (neuroendocrine responses)

1. Stimulation of the autonomic nervous system (sympathetic nervous system)

2. Stimulation of selected hormones such as aldosterone and glucocorticoid hormones (adrenal

cortex)

Aldosterone plays an important role in regulating BP, Na and K levels in the blood and tissue

In the kidney, Na draws H2O in the blood inc blood volume in BP

Glucocorticoid affects CHO metabolism by inc blood sugar level and the amount of glycogen in

the liver

inc blood sugar levels

Implementation of Psychological Preparation

1. Provide expression of concern

2. Support from family and friends

3. Provide means of control – allow to participate in decision making *** delay taking of vital

signs from the client; site or parenteral medication; site for IM; type of cut during CS


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4. Help client meet his physical need during preoperative phase to provide feeling of security

*** Promises should be implemented

5. Preoperative Teaching – to ensure positive surgical experience

*** lessen client’s anx, envi, brief client

Preoperative Teaching

Involves emotional energy on the part of the nurse

Produces behavioral changes in patients to become better prepared physically and

emotionally

Three Levels

1. Information: explanation of procedures, patient care activities (V/S), physical feelings that

the patient may encounter (A/C in room, temp of solution and instruments).

2. Psychosocial support: enhance coping mechanisms to deal with anxiety, fears and provide

emotional support.

3. Skill training: guided practice of specific task to be performed by the patient in the post-

operative period can dec anx, hasten recovery and help prevent complications

coughing and deep breathing exercises

ROM exercises

Turing from side to side, gradual ambulation

Wound dressing, start from center, handwashing

3. Physiological Preparation

Made by both the physician and the nurse, directed to toward safe and comfortable surgical

experience

a. Food and fluids are usually withheld 6-8 hours before the surgery to dec gastric contents and risk,

of Gastroesophageal reflux aspiration aspiration pneumonia, respi arrest, or death

Non compliance of NPO order may necessitate cancellation of surgery (elective)

b. Skin preparation: ideally a depilatory agent is the best method of removing hair (check for allergies)

Depilatory creams are not recommended because they can cause serious irritation and rashes in

a significant number of patients, which may lead to wound infection (Hamilton et al 1997)

Shaving will do as long as the shaving of the incision site is done immediately before the surgical

procedure and preferably in the operating room

Clipping should be used as the standard process of hair removal in the operating room

immediately before the surgery without significantly increasing the wound infection rate provided

the clipper head is sterile. (Alexander et al 1983, Masterson et al 1984)

c. For GIT surgical procedures: enemas, cathartics are usually given to expel bowel contents, provide

easier access to surgical site.

d. Urinary catheterization: usually ordered for pelvic procedures to decompress the site U. Bladder to

provide better access to the superficial site and to prevent inadvertent laceration of the bladder.

e. Common Preoperative Laboratory Tests:

U/A – to assess renal status, hydration, UTI/Dse; inc in urates – calculi

CXR – to assess pulmonary disorders, cardiac enlargement


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Blood studies: CBC, Hgb, Hct, Clotting and Bleeding time; to assess immune system status and

anemia

FBS – to assess metabolic status, DM

BUN, Creatinine – assess renal functions

ECG – assess Cardiac status, electrolyte imbalances; remove all jewelries and coins, keep still, don’t

hold anything and relax, otherwise somatic interference may result

Blood typing and cross matching – blood compatibility and replacement

f. IV line is inserted for fluid replacement and for drug administration

Preoperative Medication

Purposes:

1. To relieve anxiety

2. To facilitate induction of anesthesia

3. To reduce secretions in the oropharynx (AtSO4 – anticholinergic)

4. Inhibit stimulation of the vagus nerve

5. Reduce the possibility of aspiration if gastric contents and or secretions

6. Minimize damage to the lungs in case of aspiration

Factors affecting Type and Dosages

1. Age and weight

2. Physical condition

3. Anx level

4. Tolerance to depressant drugs

5. Type of surgery

Routes of Administration

1. Oral Sips of Water (5cc can flush pill to stomach)

2. IM

3. IV

4. Subcu injection

5. Nasal Instillation

Considerations in Giving Pre-op Meds

1. Given 60-90 minutes before surgery or would depend on the MD’s order

2. Preoperative medication may be order on call to OR (wait call from OR and if received, give the

meds, nurse-nurse orders, get name of the caller)

3. No Pre-operative medications should be given until consent is signed. (patient is no longer

competent to sign of consent after medicated)

4. Family member cannot sign for the patient unless he/she is the legal guardian. (next to kin)

Nursing Responsibilities

1. Assess patients level of anx

2. Ensure that consent form has been signed


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3. Have patient empty his bladder before giving preoperative medication.

4. Not to get out of bed after medicated.

5. Put the bed as its lowest position, side rails up, call light with reach, to promote safety and reduce

incidence of falls.

6. Obtain baseline vital signs, determine LOC, monitor and document medication effects (before and

after medication is given in order to compare and gauge the effect of the drug).

7. Assist with the transfer of the patient from the hospital bed to the stretcher.

8. Check ID band and chart to ensure all information are documented

Common Pre-operative Medication

1. Narcotic:

MOA:

Produce analgesia

Alter perception and emotional response to pain.

E.g. Morphine, Demerol (meperidine Hchloride), Dilaudid, Nubain (nalbuphine Hcl), Stadol

(butorphanol titrate), Narcotic antagonist: Narcan (naloxone)

2. Barbiturates:

MOA:

Cause generalized CNS depression

E.g. Nembutal (pentobarbital)

Seconal (secobarbital)

Anti-Anx Agent’s/ Minor Tranquilizers replaced Barb

MOA:

dec patient fear and apprehension

Facilitates easy induction of anesthesia

E.g. Benzodiazepines – diazepam (Valium) trazepam

Phenothiazines – hydroxyzine (vistaril)

Anti-cholinergic Agents (Anti-Muscarinics)

MOA:

Dec secretions in the oropharynx

Dec incidence of vagal – induced bradycardia

E.g. Rubinul (glucopyrrolate)

Patient Care on Operative Day

1. Promote sleep and risk

2. Prevent injury or loss

3. Removal of accessories (wedding ring, nail polish)

4. Application of anti-embolic stockings – indicated to patient who are at high risk for post-operative

thromboembolism (elderly, marked varicosities); pelvic surgery; prolonged post operative bed rest..

5. Bladder emptying


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6. Safe Guarding patients personal belongings

Nursing Dx:

1. Fear r/t experience, loss of control and unknown.

2. Knowledge deficit r/t preoperative or post operative procedures.

Pre-operative Checklist

A tool that reflects comprehensive nursing care given to surgical clients

Anesthesia

A partial or complete loss of sensation with or without loss of consciousness

Goals of General Anesthesia

1. To provide amnesia.

2. To provide analgesia or pain control.

3. To eliminate somatic, autonomic, and endocrine, reflexes including coughing, gagging, vomiting, and

sympathetic responsiveness.

4. To achieve skeletal muscle relaxation.

Anesthetic Agents

1. Ketamine (ketalar), a dissociative agent, produces unconsciousness, profound analgesia and amnesia.

2. Inhalation Agents: rapidly induce loss of consciousness and allow rapid recovery.

A. NO2 (laughing gas) *** contained in a blue tank

B. Halothane (fluothane) – a bronchodilator

C. Enflurane (Ethrane) – a vasodilator (not used in neurosurg because it inc ICP)

D. Isoflurane (Forane) most widely used volatile inhalation agents

stabilizes CV functions

4 Stages of General Anesthesia

Stages may vary depending on the drug used (rapidity of action) and the skill of the anesthesiologist

Stage I – extends from the beginning of administration of anesthetic agent to the beginning of loss of

consciousness (Amnesia/Analgesia)

Stage II – extend from loss of consciousness to loss of eyelid reflexes. (Stage of excitement/delirium)

***patient secured in OR table by means of straps

Stage III – extends from loss of eyelid reflex to cessation of respi effort. (Stage of surgical anesthesia)

*** Anesthesiologist signals surgeon to cut

Stage IV – extends of over dosage or danger. Death will follow if anesthesia administration is not

immediately DC ***Code Blue

Types of Anesthesia

1. General:

Inhalation

Intravenous


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Conscious Sedation *** e.g. cocktail of drugs (Midazolam HCl - Dormicum sedative + Nalbuphine HCl Nubain synth narcotic

- Form of IV anesthesia that causes depression of the LOC without impairment of patient’s ability to

maintain patent airway and to respond appropriately to physical and verbal command

2. Regional:

Spinal

Epidural

Field block

IV regional block with tourniquet

3. Local

Topical

Spray

Injection

Factors that Determine Choice of Anesthesia

1. Health status

2. Health History

3. Emotional Stability inc dosage

4. Factors relation to operative procedure

Purposes of Skin Prep

1. To remove dirt and transient (Pseudomonas aeruginosa) microorganism from the skin

2. To reduce resident (Staph and Strep) microorganism to sub pathogenic amounts in short time with least

tissue irritation

3. Inhibit rapid growth of microorganism

Types of Sutures

1. Absorbable

Example:

Plain surgical gut

Chromic surgical gut

Synthetic absorbable polymers:

PDS (polydiaxonone) – absorb in 90 days

Maxon (polyglyconate) – absorb in 60 days (brown)

Vicryl (polyglactin) 910 – absorb in 40 days (violet)

Dexon (polyglyconic acid) – absorb in 30 days

2. Non- absorbable

Example:

Surgical silk (black)

Surgical Cotton (white)

Staples

Common Suturing Techniques (count instruments and sponges before and after surg)

1. Primary suture line – are sutures that hold wound edges in approx during healing by first intention. ***

most widely used in lacerations or superficial wound


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2. Continuous suture – a series of stitches used to close peritoneum, blood vessels. Provides a leak proof

suture line.

3. Interrupted suture – each stitch is taken and suture separately. *** each suture is knotted and cut 1cm

above the knot

4. Buried suture – suture is placed under the skin. May be interrupted or continuous. ***Does not leave mark

5. Subcuticular suture line – a continuous suture placed beneath the epithelial layer of skin in short lateral

stitches

6. Pursed String Suture – a continuous suture placed around the lumen and tightened in drawstring fashion to

close lumen. Use in inverting the stump for the appendix

7. Secondary suture line – to reinforce and support primary suture line, and obliterate dead space and to

prevent fluid accumulation in wound during healing by first 1st intention Ex. retention suture *** used for

infected wounds

8. Traction suture – to retract suture to one side.

Infection Control in Surgery

Health care-associated infection (HAIs) are largely preventable

Surgical Site Infections (SSI) account 40% of all HAIs

Studies show that patients who develop SSI are twice as likely to die as to those who do not, 60% most

likely to require ICU admission, remain in the hospital twice as long and rate of readmission 6x higher.

Consideration in Infection Control among Surgical Clients

Preventing the patient from getting infection

Preventing the patient from giving infection to surgical staff

Preventing the spread of infection to others outside surgery

Operating Room should be Cleaned ASAP after surg

By: cleaning all surfaces; correct disposal; of sharps and clinical wastes

After Care of Instruments:

Instruments must be immersed in warm water and soap, (to prevent congealing or solidifying of blood)

Instruments must be thoroughly cleaned in a designated clean-up area before sterilization

If possible used instruments must be washed mechanically rather by hand

Skin Prep

Skin prep will do as long as the shaving of the incision is done immediately before the surgical procedure

Is done preferably in the OR

Skin Drapes

As general rule: cotton fabric drapes is recommended.

Disposable plastic drapes does not reduce the infection rate of clean wounds as compared to fabric in

drapes

Fabric drapes are properly sterilized, packaged stored and handled

*** C Curve position –spinal anesthesia

Infiltration, Topical (spray, cream, ointment)

*** Anesthesia screen, screen separating the head from the working area

*** Consult anesthesiologist before wheeling patient to the OR


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*** Nurse should accompany patient to the OR with the attendant

*** Holding area, temporary area before wheeling client to OR for further assessment by the circulating

nurse; CLMMRH – hallways is the holding area

*** Abdominal Ex Lap - wide incision (6 inches) in the abdomen

*** Adhesion - intestines stick together; pain, abdominal distention; may happen years post-op;

Adhesiolysis – releasing of intestines

*** By laparoscopic means and organs are examined

Abdominal laparoscopy - incision is 3-4 inches.

*** Esophagoscopy – person is sedated; viewing of esophagus

*** Neurogenic Shock – shock from pain

*** Minor surgery is less than 30 minutes

*** Minor surgery biopsy, circumcision, Removal of foreign object

***As long as an incision is made to remove foreign object - minor surgery

*** Penrose Drain and Cigarette Drain; for Incision and Drainage (I and D); I and D is not sutured;

minor surgery and procedure

*** Debridement – removal of necrotic tissue

*** Ungectomy – removal of ingrown toenail; Ungulum – med term for toenail

*** Cataract Removal

*** Tonsillectomy is Major surgery

*** Vaginal Landscaping is Minor

*** Major Surgery

*** Head

*** Hydrocephalus – Ventricular Shunt; Ventriculoperitoneal Shunt

*** Cranioectomy – part of cranium is removed

*** Removal of Brain Tumor

*** Neck

*** Tonsillectomy

*** Thyroidectomy


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Prepare pt. for surgery – Goal of Pre-op

Protect patient from injury – Goal of Intra-op

Immediate Post Op Recovery

Specifics from OR Nurse

Overall tolerance of patient to pain

Type of surgery

Type of anesthetics

Results complications

I & O

Number 1 concern: Respiratory Status of Patient position head to side or lateral sims

Assess:

Vital signs

Respiratory rate

Color

Fluid intake – IV therapy

Special equipment

Dressing

***refer accordingly the stoma (5 peso coin size) of the incision; surgeon does the COD

Nursing Goals

1. Maintain Normal Respiratory Function

Airway till gag reflex is ok -- plastic airway to prevent falling back of tongue to ensure airway is not

obstructed

Position – side lying position, hyperextend the head to maintain patent airway

Suction

Cough/deep breathing

O2 inhalation -- as prescribed by the doctor

Mechanical support – mechanical ventilator or ambu bag

Breath sounds

2. Incision Area

Drainage – T-tube (cover the tube using gloves - CLMMRH)for Cholecystectomy

Record output from drains

3. Balanced Fluid Status

*** Increase pre-op and post op anti-diuretic hormone = increased aldosterone; assess through skin

turgor

Blood loss?

IV rate

Outputs

Bladder distension

Electrolytes

Hydration – skin turgor: to check for hydration (resilient = hydrated)


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Character of drainage -- describe color and amount from NGT, Hemovac (negative pressure must be

maintained; after mastectomy), Jackson Pratts drainage system (placed also after mastectomy)

NGT

Nausea and vomiting? – due to untoward effect of anesthesia

Prevent aspiration – prevented through positioning (side lying)

4. Psychological Equilibrium – procedure itself is a stressor

Speak calmly – low tone of voice

Orient

Quiet atmosphere

Body alignment – position pt properly

Explain

Remember hearing last to go; and the first to be activated

Client returns to room if:

o Vital signs ok

o Awake

o Dressings ok

o Airway ok

Positioning – skin preparation – draping

PAIN ANALYSIS – inspect, palpate, observe

- Pain is a universal symptom

Subjective

Factors meaning

Location/Duration

Detailed history

Assessment/Intervention

o Bladder full – palpate or check output

o Pain meds given every 6 hours

o Infiltrated IV

o Non patent tube

o Gas

o Surgical discomfort

Provoking

Quality

Region

Severity

Timing

Question Child

Use rating scale


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Evaluative

Secure if restless

Take into account pathology

Objective Data

General assessment

Affective behavior

Verbal behavior

BP and RESPI

*** If in pain, vital signs usually go up; take into consideration the pathology of the disease

Analysis

Nursing Dx

o Anx

o Alteration

o Fear

Plan and implement Nursing Care

Non-invasive pain management

... Cutaneous stimulation diversion of pain through the hand

... Relaxation – reduction of pain; breathing exercises

Medications for relief

o PCA

o Narcotics

o Non narcotics

o Non steroidal

POST-OPERATIVE

Complications

Hemorrhage

Evisceration

Infection

Dehiscence

Dehiscence – separation or splitting open of layers of a surgical wound

Evisceration – extrusion of viscera or intestine through a surgical wound

*** use abdominal binders; when coughing, splint pillow on abdomen, press, inhale deeply and cough

Place client in low fowler`s, warm saline solution soaked in big sponge, cover the viscera; tell pt. not to

cough, not to drink and not to eat because the patient will be brought back to the OR

Classification of Suture (Refer to page14 and Perioperative Nsg Skills Lab)

1. Absorbable: suture that is broken down and dissolved by enzymes produced by the body


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E.g. CATGUT derived from the sub mucosa of the sheep’s intestine or serosa of beef’s intestine

Rate of Absorption is influenced by:

Type of tissue – absorbed rapidly in serous or mucous membrane

Condition of tissue – can be used in the presence of infection – use bigger suture! Healing by 2nd

intention

General Health status of the patient – absorbed more rapidly in undernourished or diseased

tissues

E.g.

a. Plain surgical gut – absorbed within 70 days; used to ligate small blood vessels and suture

subcutaneous fat

Chromic surgical gut – absorbed within 90 days, used to ligate large blood vessels

b. Synthetic Absorbable Polymers – absorbed by a slow hydrolysis process in the presence of

tissue fluids

Immediate Post-operative Care (RR PACU SCU) – from transfer to recovery room till the person does not

need surgical care anymore – Post-op

1. Maintenance of airway (patency)

2. Promote gas exchange

Oxygen inhalation

Breathing, coughing, turning to side, etc.

Nebulization

3. Prevent hypotension

4. Identify cardiac arrhythmias

5. Promote fluid and electrolyte balance

6. Prevent injury

7. Provide comfort

***pneumonia may lead to atelectasis; do coughing and breathing exercise

Pulmonary Complications

a. Atelectasis – collapse of alveoli in the lungs

b. Pneumonia – an acute inflammation of the lungs

Clinical Signs and Symptoms of High Risk for Pulmonary Complication

Increased or dry respiratory secretions

Decreased thorax expansion

Decreased diaphragm mobility

Depressed respiratory centre due to drugs or aspirated gastric contents

Factors influencing Wound Healing

o Age

o Nutritional status

o Circulation status


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Complications of Wound Healing

o Hemorrhage- likely to occur within 1st 48 hours

o Infection

Symptoms

o Fever after 3rd day post-op

o Increased WBC (leukocytosis)

o Incisional swelling

o Erythema

Perioperative Nursing Concept

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