Perioperative Presentation

8/3/2019 Perioperative Presentation

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PERIOPERATIVENURSING

Prepared by: Annabeth K. Salonga RN,MAN


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PHASES OF SURGERYPreoperative Phase- Extends from the time the client is

admitted in the surgical unit, to the time he / she isprepared physically, psychosocially, spiritually and legallyfor the surgical procedure, until he is transported into theoperating room.

Intraoperative Phase- Extends from the time the client isadmitted to the operating room, to the time ofadministration of anesthesia, surgical procedure is done,until he/she is transported to the recovery room/

postanesthesia care unit.

Postoperative Phase~ Extends from the time the client isadmitted to the recovery room, to the time he is

transported back into the surgical unit, discharged fromthe hos ital until the follow - u care.


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Four Major Types of PathologicProcesses Requiring Surgical

InterventionObstruction- Impairment to the flow of vital

fluids. E.g. blood, urine, CSF, bile.

Perforation- Rupture of an organ.

Erosion- Wearing off of a surface ormembrane.

Tumors- Abnormal new growths.


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Classification of SurgicalProcedures

According to PURPOSE

Diagnostic- To establish the presence of adisease condition, e.g. biopsy.

Exploratory- To determine the extent of thedisease condition, e.g. exploratory laparotomy.

Curative- To treat the disease condition.

Ablative- Involves removal of an organ. (Suffixused is "ectomy") e.g. appendectomy


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According to PURPOSE

Constructive- Involves repair ofcongenitally defective organ (suffixes

used are '"plasty/5 "orrhaphy/" "pexy")e.g. cheiloplasty, orchidopexy*

Reconstructive- Involves repair of

damaged organ, e.g. plastic surgery aftersevere bums.Palliative- To relieve distressing signs and

symptoms, not necessarily to cure thedisease.


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According to Degree of RISK (Magnitude/Extent)

A. Major Surgery High risk

Extensive Prolonged

Large amount of blood loss Vital organs may be handled or removed

Great risk of complicationsB. Minor Surgery

Generally not prolonged Leads to few serious complications

Involves less risk


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According to URGENCYEmergency- To be done immediately to save life

or limb.Imperative- To be done within 24 to 48 hours.Planned Required- Necessary for well - being.

May be scheduled weeks or months.Elective- Not absolutely necessary for survival.

Delay or omission will not cause adverse

effect.Optional- Requested by the client. Usually for

aesthetic purposes.Day (Ambulatory Surgery)- Done on out - patient

basis.


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Surgical RisksGeneral Risk Factors

1. Obesity1. Fluid, electrolyte and nutritional problems2. Age3. Presence of disease/s

4. Concurrent or prior pharmacotheraphyOther Factors

1. Nature of condition1. Location of the condition2. Magnitude and urgency of the surgical

procedure3. Mental attitude of the person toward surgery

4. Caliber of the professional staff and health carefacilities


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The Effects of Surgeryto the Client

1. Stress response is elicited

2. Defense against infection is lowered.

1. Vascular system is disrupted.

2. Organ functions are disturbed.

3. Body image may be disturbed.

4. Lifestyles may change


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Preoperative Phase1. Assessing and correcting physiologic and

psychologic problems that might increasesurgical risk.

2. Giving the person and significant otherscomplete learning / teaching guidelinesregarding surgery,

3. Instructing and demonstrating exercises that

will benefits the person during postopperiod.

4. Planning for discharge and any projectedchanges in lifestyle due to surgery.

Goals


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Physiologic Assessment of the ClientUndergoing Surgery

1. Age

2. Presence of Pain3. Nutritional Status4. Fluid and Electrolyte Balance5. Infection6. Cardiovascular Function7. Pulmonary Function8. Renal Function9. Gastrointestinal Function10. Liver Function

11. Endocrine Function12. Neurologic Function13. Hematologic Function14. Use of Medication

15. Presence of Trauma


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Psychosocial Assessment andCare

Fear of the unknown

Fear of anesthesia, vulnerability while

unconscious

Fear of pain

Fear of death

Fear of disturbance of body image

Worries - loss of finances,, employment, social

and family roles

Causes of Fears of the Preoperative Clients


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1. Anxiousness

2. Bewilderment

3. Anger

4. Tendency to exaggerate

5. Sad, evasive, tearful, clinging

6. Inability to concentrate

7. Short attention span

8. Failure to carry out simple directions

9. Dazed

Manifestations of Fears


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1. Explore client's feelings

2. Allow client's to speak openly about fears /

concerns

3. Give accurate information regarding surgery

4. Give empathetic support

5. Consider the person's religious preferences

and arrange for visit by priest/ minister as

desired

Nursing Interventions To Minimize Anxiety


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Informed Consent (Operative Permit /Surgical Consent)

1. To ensure that the client understands the nature of

the treatment including the potential complications

and disfigurement (explained by AP),2. To indicate that the client's decision was made

without pressure.

3. To protect the client against unauthorized

procedure.

4. To protect the surgeon and hospital against legal

action by a client who claims that an unauthorized

procedure was performed,

Purposes


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1. Any surgical procedure where scalpel, scissors, suture,

hemostats of etectrocoagulation may be used.

2. Entrance into a body cavity - e.g. paracentesis,

bronchoscopy, cystocopy, colonoscopy,

proctosigmoidoscopy

3. General anesthesia, local infiltration, regional block.4. Requisites for Validity of Informed Consent

5. Secured without pressure or duress

6. Written permission is best and is legally acceptable.

Circumstances Requiring a Permit


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7. Signature is obtained with the client's complete

understanding of what is to occur.

a. Adults sign their own operative permit.

b.Obtained before sedation.

8. A witness is desirable - nurse, physician or other

authorized persons.

9. In an emergency, permission via telephone or telefax is

acceptable.10. For minor (below 18 yrs.), unconscious, psychologically

incapacitated, permission is required from responsible

family member (parent / legal guardian),

Circumstances Requiring a Permit


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Physical Preparations1. Correct any dietary deficiencies

2. Reduce an obese persons weight

3. Correct fluid and electrolyte imbalances

4. Restore adequate blood volume with blood transfusion

5. Treat chronic diseases - DM, heart disease, renal insufficiency

6. Halt or treat any infectious process

7. Treat an alcoholic person with vitamin supplementation, IVF's or

oral fluids, if dehydrated.

8. Teaching Preop Exercises1. Deep breathing exercises - diaphragmatic

2. Incentive spirometry

3. Coughing exercises

4. Turning exercises

5. Foot and leg exercises

Before Surgery


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Physical Preparations

1. Preparing the skin.

Have full bath to reduce microorganisms in the skin.

1. Preparing the G.I. Tract

NPO; cleansing enema as required.

2. Preparing for Anesthesia

Avoid alcohol and cigarette smoking for at least 24

hours before surgery.

3. Promoting rest and sleep

Administer sedatives as ordered.

Preparing the Person the Evening Before Surgery


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Physical PreparationsEarly AM Care

Awaken one hour before preop medications.

Morning bath, mouth wash

Provide clean gown

Remove hairpins, braid long hairs, cover hair with cap Remove dentures, foreign materials (chewing gum),

colored nail polish, hearing aid, contact lens (weddingring - tie with gauze and fasten around the wrist).

Take baseline VS before preop medication.

Check ID band, skin prep Check for special orders - enema, G.I. tube insertion, IV

line

Check NPO p Have client void before preop medication.

Continue to support emotionally o Accomplish "preop

care checklist5

Preparing the Person On the Day of Surgery


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Preoperative Medications/Preanesthetic Drugs

To facilitate the administration of any

anesthetic.

To minimize respiratory tract

secretions and changes in HR (heart

rate). To relax the client and reduce anxiety.

Goals:


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Preoperative Medications/Preanesthetic Drugs

Tranquilizers

Sedatives

Analgesics

Anticholinergics

Histamine~H2 Receptor Antagonist

Commonly used Preop Meds.


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Transporting The Clientto the OR

Direct proper visiting room.

Doctor informs family immediately after

surgery.

Explain reason for long interval of waiting:

anesthesia prep, skin prep, surgicalprocedure, RR.

Explain what to expect postop.

Patient's Family


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Intraoperative Phase

1. Asepsis

2. Homeostasis

3. Safe Administration of

Anesthesia

4. Hemostasis

Goals of Care:


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STERILE TECHNIQUES AND THEIRAPPLICATIONS

1. Strict aseptic and sterile techniques are needed at all

times in the operating room. Sterile techniques prevent

transfer of microorganisms into body tissues. Freshly

incised or traumatized tissue can become infected easily.

Intact skin and mucous membranes are the bodys first

line of defense against infection.

2. Operative procedures are formed under sterile

conditions, i.e., contamination with microorganisms is

prevented to maintain sterility throughout to operation.

3. A sterile field is created around the site of incision into

tissues or for introduction of sterile instruments into a

body orifice.


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STERILE TECHNIQUES AND THEIRAPPLICATIONS

4. Conversely, terminal decontamination and sterilization ofall material and equipment used during an operation is

performed with the assumption that every patient is a

potential source of infection for other persons.

5. The patient is the center of the sterile field, which

includes the areas of the patient, operating table and

furniture covered with sterile drapes, and the personnel

wearing sterile attire.

6. Strict adherence to sound principles at sterile techniques

and recommended practices is


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Principles of AsepticTechniques

1. Only sterile items are used within sterile field

2. If you are in doubt the sterility of anything,

consider it not sterile

3. Gowns are considered sterile only in front from

chest to level of sterile field, and the sleeves

from above elbows of cuffs

4. Tables are sterile only at table level

5. Persons who are sterile touch only sterile items

or areas; persons who are not sterile touch

only unsterile items or areas


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6. Unsterile persons avoid reaching over a sterile

field; sterile persons avoid leaning over an

unsterile area

7. Edges of anything that encloses sterile contents

are considered unsterile

8. Sterile field is created as close as possible to

time of use

9. Sterile areas are continuously kept in view

10. Sterile persons keep well within the sterile area


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11. Unsterile person avoid sterile areas

12. Destruction of integrity of microbial barriers

results in contamination

13. Microorganisms must be kept to an irreducible

minimum

14. Skin cannot be sterilized


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The Surgical Team


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Includes:1. Surgeon

2. Anesthesiologist

3. Assistant Surgeon (Surgical Resident)

4. Surgical Intern (optional)

5. Scrub Nurse6. Assistant Scrub Nurse (optional)

7. Circulating Nurse

The Surgical Team


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Positions During Surgery1. Dorsal Recumbent - hernia repair,mastectomy, bowel resection2. Trendelenburg - lower abdomen, pelvic

surgeries

3. Lithotomy - vaginal repairs, D and C, rectalsurgery, APR(Abdomino - PerinealResection)

4. Prone - spinal surgeries, laminectomy5. Lateral - kidney, chest, hip surgeries6. Sitting pulmonary (thoracostomy)

7. Jackknife (Knee-Chest)

procto-surgeries


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Positions During Surgery


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SURGICALANESTHESIA


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Medically induced insensitivity to pain:

Induced loss of sensitivity to pain in all or

a part of the body for medical reasons.

Methods include drugs, acupuncture, and

hypnosis. The procedure may render thepatient unconscious or merely numb a

body part

SURGICAL ANESTHESIA


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General Anesthesia Total loss of consciousness and sensation

Produces amnesia

Uses IV - IV Barbiturate,

Pentothal Na 5 - 10%

Inhalation of VolatileLiquids (Ethyl Ether)

Rectal - Anectine

Types of Anesthesia


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General Anesthesia1. Gas Inhalation

2. Intravenous General Anesthesia3. Rectal General Anesthesia

Types of Anesthesia


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Regional AnesthesiaReduce all painful sensation in one region of the

body without inducing unconsciousness.Types

1. Spinal Anesthesia2. Epidural Block3. Field Block (Peripheral Block/ Bier Block)

Uses

Procaine (Novocaine) Tetracaine (Pontocaine)

Lidocaine (Xylocaine)

Mepivacaine (Carbocaine)

Bupivacaine (Marcaine

Types of Anesthesia


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Regional Anesthesia1. Spinal Anesthesia

Types of Anesthesia


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Regional Anesthesia2. Epidural Block

Types of Anesthesia


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Regional Anesthesia3. Field Block (Peripheral Block)

Types of Anesthesia


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Regional Anesthesia3. Field Block (Bier Block)

Types of Anesthesia


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Local Infiltration- merely numb a body part

1. Xylocaine (lidocaine) 2% Injection2. Topical3. Ointment

Types of Anesthesia


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1. Onset / Induction-Extends from the administrationof anesthesia to the time of loss of consciousness.

2. Excitement / Delirium-Extends from the time ofloss of consciousness to the time of loss of lid reflex. It

may be characterized by shouting, struggling of theclient.

3. Surgical-Extends from the loss of lid reflex to the lossof most reflexes. Surgical procedure is started.

4. Medullary / Stage of Danger-It is characterizedby respiratory / cardiac depression or arrest. It is due

to overdose of anesthesia. Resuscitation must be

done.

Stages of Anesthesia


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1. Hypotension o Nausea / Vomiting

2. Headache

3. Respiratory Paralysis

4. Neurologic Complications (paraplegia,

severe muscle weakness of the legs)

Complications and Discomforts ofSpinal Anesthesia


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Butterfly. For craniotomy.

Limbal. For eye surgeries.

Halstead / Elliptical. For breast surgeries. Abdominal. For abdominal surgeries.

Mc Bumeys. For appendectomy.

Lumbotomy / Transverse. For kidneysurgeries

Surgical Incisions


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Transport of the Client from the OR to RR

1. avoid exposure2. avoid rough handling

3. avoid hurried movement and rapid changesin position.

Nursing Care of Patient During theImmediate Postop (ImmediatePostanesthesia Recovery - RR)


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ASSESSMENT1. Appraise air exchange status and note skin color2. Verify identity, operative procedure, surgeon

3. Assess neurologic status (LOC)4. Determine VS and skin temperature (CV status)5. Examine operative site and check dressings6. Perform safety checks

a. position for good body alignmentb. side railsc. restraints for IVF's, Blood transfusion

7. Require briefing on problems encountered in OR

Nursing Assessment andInterventions


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1. Ensure maintenance of patent airway and adequate

respiratory function.a. lateral position with neck extended.b. keep airway in place until folly awake a suctionsecretions a encourage deep breathing

c. administer humidified oxygen as ordered.2. Assess status of circulatory system

a. monitor VS and report abnormalitiesb. observe signs and symptoms of shock andhemorrhage

3. promote comfort and maintain safety4. continuous, constant surveillance of the client until

he/she is completely out of anesthesia.4. recognize stress factors that may affect the client in RR

and minimize these factors.

Interventions (RR)


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1.Activity- Able to obey commands, e.g. deepbreathing, coughing

2.Respiration- Easy, noiseless breathing.3.Circulation- BP is within 20 mmHg of the

preop level.

4.Consciousness- Responsive.5.Color- Pinkish skin and mucus membrane.

Transfer of the Client from RR to theSurgical Unit

Parameters for Discharge from RR


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POSTOPERATIVECOMPLICATIONS


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POSTOPERATIVE COMPLICATIONS1. SHOCK

2. HEMORRHAGE

3. FEMORAL PHLEBITIS / DEEP

THROMBOPHLEBITIS

4. PULMONARY COMPLICATIONS

5. URINARY DIFFICULTIES

6. INTESTINAL OBSTRUCTION HICCUPS

7. WOUND INFECTIONS

8. WOUND COMPLICATIONS

9. POSTOP PSYCHOLOGICAL DISTURBANCES


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SHOCK-

response of the body to a decrease in thecirculating blood volume, which results to

poor tissue perfusion and inadequate tissue

oxygenation (tissue hypoxia).INTERVENTION

1. Immediate Blood Transfusion

2. IVF infusion

3. O2 inhalation

4. Elevate lower extremities


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HEMORRHAGE Copious escape of blood from the blood vessel

Capillary - slow, generalized oozing

Venous - dark in color and bubble out Arterial - spurts and is bright red in color

Clinical Manifestations:1. Apprehension; restlessness; thirst; cold, moist, pale skin2. Deep, rapid RR; low body temperature3. Low CO (cardiac output)

4. Low BP, low hgb5. Circumoral pallor; spots before the eyes, ringing in ears6. Progressive weakness, then death ensues

Management:1. Vit. K (aquamephyton), Hemostan

2. Ligation of bleeders3. Pressure dressings4. Blood transfusion; IV fluids

FEMORAL PHLEBITIS / DEEP


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THROMBOPHLEBITISOften occurs after operations on the lower abdomen or

during the course of septic conditions as rupturedulcer or peritonitis.

Causes:1. Injury: damage to vein

2. Hemorrhage3. Prolonged immobility4. Obesity /Debilitation

Clinical Manifestations

1. Pain2. Redness3. Swelling4. Heat/warmth5. + Homan's sign

FEMORAL PHLEBITIS / DEEP


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THROMBOPHLEBITISNursing Interventions

1. Prevention2. Hydrate adequately to prevent hemoconcentration.3. Encourage leg exercises and ambulate early.4. Avoid any restricting devices that can constrict and impair

circulation. Prevent use of bed rolls, knee gatches,dangling over the side of the bed with pressure onpopliteal area.

Active Intervention

1. Bed rest, elevate the affected leg with pillow support2. Wear anti embolic support hose from the toes to the groin.3. Avoid massage on the calf of the leg.4. Initiate anticoagulant therapy as ordered.


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PULMONARY COMPLICATIONS1. Atelectasis

2. Bronchitis3. Bronchopneumonia4. Lobar pneumonia5. Hypostatic pulmonary congestion6. Pleurisy

Nursing Interventions

Reinforce deep breathing, coughing, turningexercises (DBCT)

Encourage early ambulation Incentive spirometry


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URINARY DIFFICULTIES1. Retention

Occurs most frequently after operation of therectum, anus, vagina, lower abdomen.

Caused by spasm of the bladder sphincter.

2. Incontenence(30 - 60 ml. q 15-30 mins, - overdistened bladder

overflow incontenence).Loss of tone of the bladder sphincter.

Nursing InterventionsImplement measures to induce voiding.


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INTESTINAL OBSTRUCTION(3rd to 5th Postop Day)

Loop of intestine may kink due to inflammatory adhesionsClinical Manifestations1. Intermittent sharp, colicky abdominal pains2. Nausea and vomiting (fecaloid)

3. Abdominal distortion, hiccups4. Diarrhea (incomplete obstruction), no bowel movement(complete)

5. Return flow of enema is clear6. Shock, then death occurs

Nursing Interventions: NGT insertion Administer Electrolyte / IV as ordered

Prepare for possible surgical intervention


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HICCUPSIntermittent spasms of the diaphragm causing a sound ("hic")

that result from the vibration of closed vocal cords as airrushes suddenly into the lungs.

CauseIrritation of phrenic nerve between the spinal cord and

terminal ramifications on undersurface of the diaphragm.

Nursing Interventions1. Remove the cause e. g. abdominal distention - NGT

insertion

2. Hold breath while taking a large swallow of water.3. Pressing on the eyeball through closed lids for several

minutes.4. Breath in and out paper bag (C02)5. Plasil (methochlorpramide) as ordered.


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WOUND INFECTIONSCauses:

1. Staphylococcus aureus2. Escherichia coli3. Proteus vulgaris4. Pseudomonas aeruginosa5. Anaerobic bacteria

Clinical Manifestations:1. Redness, swelling, pain, warmth2. Pus or other discharge on the wound

3. Foul smell from the wound4. Elevated temperature; chills5. Tender lymph nodes on the axilla or groin closest to

wound


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WOUND INFECTIONSRule of Thumb

1. Fever 1st 24-pulmonary infection

2. Within 48 - UTI (urinary tract infection)

3. Within 72 - wound infection

Preventive Interventions:

1. Housekeeping cleanliness in the surgical environment

2. STRICT ASEPTIC TECHNIQUES3. Wound care

4. Antibiotic therapy


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WOUND COMPLICATIONSKinds:1. Hemorrhage / Hematoma

2. Wound Dehiscence - disruption in the coaptation of woundedges (wound breakdown)

3. Wound Evisceration ~ dehiscense + outpouching ofabdominal organs

Nursing Interventions:1. Apply abdominal binders2. Encourage proper nutrition - high CHON, Vit. C3. Stay with client, have someone call for the doctor4. Keep in bed rest

5. Supine or semi - Fowler's position, bend knees to relievetension on abdominal muscles

6. Cover exposed intestine with sterile, moist saline dressing7. Reassure, keep him/her quiet and relaxed

8. Prepare for surgery and repair of wound.


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POSTOP PSYCHOLOGICALDISTURBANCES

Delirium (Mental Aberration)ACS (Acute Confusional State)

Causes:

1. Dehydration2. Insufficient oxygenation3. Anemia4. Hypotension5. Hormonal imbalances6. Infection7. Trauma (especially in nervous persons)

POSTOP PSYCHOLOGICAL


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DISTURBANCESManifestations:1. Poor memory2. Restlessness3. Inattentiveness4. Inappropriate behavior

5. Wild excitement, hallucinations, delusions, depression6. Disoriented7. Sleep disturbances

Nursing Interventions1. Sedatives to keep client quiet and comfortable2. Explain reasons for interventions3. Listen and talk to the client and significant others4 Provide physical comfort

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