preop chapter 1.ppt

8/10/2019 preop chapter 1.ppt

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Miss Iman Shaweesh 1

Adult Health NursingSecond Years Students

Miss: Iman Shaweesh MCH

An Najah University29,August,2008


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Pre operative Nursing

Management

The preoperative phase begins when

the decision to proceed with surgicalintervention is made and ends with thetransfer of the pt into the operatingroom table.

preoperative interview (which include physical, emotional

assessment, previous anesthetic history, allergies or genetic

problems, ensure that Necessary tests performed,

Arranging appropriate consulative services,

t


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Surgical classifications

1. Diagnostic ( biopsy)

2. Curative ( excision of tumor)

3. Reparative (multiple wound repair)

4. Reconstructive or cosmetic ( mamoplasty)

5. Palliative (relief pain or correct a problem)


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According to degree of urgency

Emergent: require immediate attention without delay.

Urgent: require prompt attention within 24-30 hours.

Required: requires operation, plan hospital admissionwithin a few wks or months.

Elective: should be operated on, failure to have surgeryisnt catastrophic.

Optional: the decision rests with the pt, depend onpersonal preference


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The patients major goals are:

Correction or treatment of physical problem

Relief of anxiety, worry and depression

Acceptance of and preparation for surgicalinterventions

Acceptance and tolerance of preanstheticmedications and agents.

Avoidance of injury, Nosocomial infections, and

complications.


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The major nursing goals are to:

Assist the pt in understanding the physical andpsychosocial aspects of the surgical experience

Acquaint the pt and his family with the environment,protocol, and expectations as surgery.

Teach the pt certain procedures that will help in reducingpost operative complications

Prepare the physically and psychologically for theoperation

Collaborative with other members of the health team incoordinating all preoperative procedures.


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Preparation for surgery

1-Informed Consent

Criteria for valid Informed consent:

Voluntary consent

Incompetent pt ( mentally retarded, mentally ill, or

comatose)Informed subject

Explanation

Description of risks and benefits

Answer questions about procedureInstructions

Pt able to comprehend. (Information written inunderstandable language.


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Assessment of health factors that affect

pts preoperatively

Assessment o f Nutr i t ional and f lu id status.

Resp iratory status

Cardio vascu lar status

Assessment of hepat ic and renal funct ion Assessment of endoc r ine funct ion

Assessment of immunolog ical funct ion

Assessment of effects of aging

Assessment of pr ior drug therapy

Assessment pts w ith disabi l i t ies


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Preoperative Nursing Interventions

The two goals of preoperative care are:

To present the pt in the best possible physical and

psychosocial conditions for his operation

To initiate every effort that will eliminate or reducepost operative discomforts and complications.

Nutrition and fluids:

Intestinal preparation

Preoperative skin preparation


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Preoperative Teaching

The goal of preoperative teaching is tofamiliarize the pt with the expected postoperative outcomes such as:

Facilitation of recuperative period.

Attainment of a sense of well-being with minimal fearof the unknown.

Decreased need for analgesicsAbsence of complications

Decrease time for hospitalization


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When and What to teach:

Teaching sessions are combined withvarious preparations to allow for aneasy and timely flow of information andallow time for questions.

Teaching should include descriptionof the procedures and includeexplanations of sensations of the pts

will experience.The ideal timing or preoperative

teaching isnt on the day of operation,but during the preadmission visit when

diagnostic tests are performed.


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Deep breath ing and coughing :

Teaching the pt how to promote optimal lung

expansion and consequent bloody oxygenation

after anesthesia.

The goal in promoting coughing is to mobilize

secretions so they can be removed .If the ptdoesnt cough effectively, Atelectasis (lung

collapse), pneumonia, and other lung

complications may occur.


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Pain Con trol and Management:

Post operatively, medications are administered to relief

pain and maintain comfort without increasing the risks for

inadequate air exchange.

Cognit ive Coping Strategies:Cognitive strategies may be useful for relieving tension,

overcoming anxiety,, Imagery: the pt can concentrates

on a pleasant experience

Distraction: thinks of an enjoyable story or song

Optimal self-recitation: recites optimistic thoughts.


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Preoperative psychosocial interventions

Reducing preoperative anxiety

Cognitive strategies useful for reducing anxiety, musictherapy is an easy to administer, inexpensive,noninvasive intervention

Decreasing Fears

Reflecting Cultural, Spiritual, and ReligiousBeliefs

Include identifying and showing respect for cultural,spiritual, and religious beliefs, such as in pain control, orin blood transfusion.


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Intra operative Nursing Management

Artificial hypotension during operation:

Purpose for: to reduce bleeding at the operative site

espicially in brain surgery.

Malignant hyperthermia:

Due to biochemical disturbances in skeletal muscle involvingcalcium distribution. we use hypothermia blanket, infusion of

ice saline solution high concentration of oxygen, and NaHCO3

to correct metabolic acidosis


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Positions on operating table:

ComfortableAdequately exposed area

Circulation

Respiration freeNerves is protected from undue pressure

Concern for obese, thin, old pt.

Gentle restrains.


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Intra operative Nursing

Positions:

Dorsal Recumbent position

Trendelenburg position

Lithotomy position

For kidney operation

For chest and abdominothoracic operation

Operation on the neck

Operation on the skull and brain.


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Trendelenburg position


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Dorsal Recumbent position
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Lithotomy position
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kidney operation


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Principles of perioperative asepsis:

1. Preoperative:

Preoperative sterilization of surgicalmaterials

Placement of the operation room

Scrubbing of health team

Cleansing the patients skin with antisepticagents

Covering the rest of pts body with steriledrapes


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2. Intraoperat ive:

Asepsis techniques in surgical practice

3. Post operat ive:

Protect the wound from contamination by

sterile dressing

Heat compresses at site of surgery Antimicrobial agents in infected wounds


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Environmental control:

Meticulous housekeeping in the operatingroom

Sterilizing equipment

Laminar air flow system to filter out highpercentage of dust and bacteria.

Constant surveillance and

conscientiousness in carrying out asepticpractice

P i i l di h l h d i


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Principles regarding health and operating

room attire

Clothing Approved

Clean

Close-fitting cotton dressing

MaskNo leak air

Shouldnt interfere with breathing or hinder speech orvision

Compact and comfortable

Avoid forcing expirationMust be changed between operations


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Headgear

Completely cover the hair, clips or dandruff or dust dontfall in sterile field

Shoes

Comfortable and supportive

Tennis shoes, sandals and boots are not permittedunsafe and difficult to be cleaned

Must be worn one time only and removed upon leavingthe restricted area

Gloves


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Intraoperative Nursing Function:

1- Circulating nurse

Manage the operating room

Protect the safety an d health needs of the patient

Ensuring cleanliness, proper temperature, humiditylighting, safety of equipment, availability of supplies

and materials

Coordinate the activities other personnel e.g. X-ray

Monitor aseptic practice


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2- Scrub activities

Scrubbing of the operation room

Setting up the sterile table, preparing sutures and

special equipment Assisting the surgeon and the surgical assistance

Keeping the time the patient is under anesthesia

Check all equipments used in operation are

accounted Send specimens to lab


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Basic rules of surgical asepsis

General:Sterility of surface or articles

Personnel: Scrubbed personnel remain in

the area of the operation . Only a small

part of the scrubbed persons body isconsidered sterile: from front waist to the

shoulder area, forearm and gloves.

Drapping:

Delivery o f steri le supp l ies

Fluids


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Post operative Nursing Management

goal is directed toward the reestablishment of thepatients physiological equilibrium and the prevention ofpain and complications.

Removing the patient from the operating tableThe site of operation should be kept in mind every time.

Check positioning of the head ; extension, lying onunaffected site ,

Check blood pressure; arterial hypotensionRemove the wet gown, keep the pt warm


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Recovery Room:should have

Wall and ceiling painted in soft, pleasing colors

Indirect lightingSound proof ceiling

Equipment that controls or eliminate noise

Isolated quarter for noisy pts.

Equipments:

( Breathing aids; oxygen, laryngoscope, tracheostomyset, bronchial instruments, catheters, mechanicalventilators, suction equipments, equipments for

circulatory needs blood pressure, parental infusions.Surgical dressing materials, drugs especiallyemergency drugs.)


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The pt remains in this room until he has full

recovery from the anesthetic agents,

stable blood pressure, good air passage,

and reasonable degree of consciousness.


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Immediate post operative nursing care:

1- Respiratory considerations

The chief immediate post operative hazards are

those of shock and hypoxemia due to respiratory

difficulties.

Shock can be prevented by administration of

intravenous fluids and blood, appropriate drugs


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Goals of post operative nursing care:

1- To assist the pt in maintaining optimumrespiratory function.

Positioning

Cleaning the airway

Promoting lung expansionRebreathing CO2

2-To assist the cardiovascular status of the pt and

correct any deviation.

3-To promote the comfort and safety of the pt

Restlessness and discomfort

Pain


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Goals of post operative nursing

care4- To promote hemostats through maintenance off luid and electro lyte balance, proper nu tr i t ion and

el iminat ion.

5- To enhance wound heal ing and avoid o r con trol

infect ion.

Nosocomial infection

Invaded of skin and mucous membrane by

tubes and catheters, by the disease processEffect of surgery and anesthesia reduceresistance of the body


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care

Organisms in the hospitals

Poor hand washing practices

This can be reduced by:Continuous health education about infection

control policy

Deep breathing exercise to prevent

accumulation of secretionsSterilization of equipments

Antibiotics therapy


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Goals of post operative nursing care

6-To encourage activity through appropriate exercises,

ambulation and Rehabilitation

Positioning

Ambulation

Ambulation increase respiratory exchange

Prevent stasis of bronchial secretions

Reduce distension

Prevent thrombophlebitis

Increase rate of wound healing

Ambulation done gradually


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care

Bed exercises.

Deep- breathing exercises

Arm exercises

Hand and finger exercises Foot exercises

Exercises to prepare pt for ambulatoryactivities

Abdominal and gluteal contraction exercises


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care7-Psychosocial well-being of the pt and his family. Keep family in bed side for minutes

Expression of feelings

Participate in self care

Attractive grooming

8-Document all phases of nursing process and report data

Any slight symptoms that can increase inseverity

Any progressive and steady change for theworse in the general condition of the pt

The pts complaints


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Post operative discomfort

1- Vomiting- Aspiration

Insert NGT during surgery

Drugs e.g. antiemetics may cause hypotension andrespiratory depression

Prevent aspiration of vomitus

Turn the pt on his side lying position to provide

effective drainage from the throatClean mouth frequently to facilitate breathing


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2-Abdominal distension

Loosing of normal peristalsis within 24-48 hours post

operatively is due to trauma in abdomen. he wasswallowed mucous and secretions during operation, so

he needs to evacuate these things .

3-Thirst. (atropine).

4- Hiccups. It is produced by intermittent spasms ofthe diaphragm and manifested by a coarse sound. The

cause of diaphragmatic spasm is any irritation in the

phrenic nerve from its center in the spinal cord.


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RX.of hiccups

Remove of cause by applying NGT

Finger pressure on the eyeball for several minutes

Induced vomiting

Gastric lavageIV injection of atropine

Inhalation of CO2


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6-Constipation

It can be treated by simple enema, increased in diet

((Constipation has been described as a constantsymptom of complete intestinal obstruction))

((Cathartic drugs should never be given, except when

prescribed by the physician))


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7-Fecal Impaction

1. This complication as a result of neglect

and never should occur. So early

ambulation, proper fluid and diet,

enemas fairly effective. It accompanied

by abdominal discomfort, the pt

represent that he needs to defecate, butno relief.


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Remove the impaction

Enema of liquid petrolatum (oil enema)

Gloved finger

Injection of 30-60cc of H2O2 into the rectum

8- Diarrhea

After operation diarrhea is rare. Fecalimpaction is the main cause


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Post operative Complications

1-Shock:Failure to provide adequate cellularoxygenation accompanied by failure to removethe waste productsof metabolism.

Shock can be occurs with hemorrhage,trauma, burn, infection, and heart disease, andfrom failure of the three aspects of circulation:the heart pump, peripheral resistance, andblood volume , this cause inadequate bloodflow to vital organs or inability of the tissues ofthese organs to utilize oxygen


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Glucagons is released and antidiuritic hormone (ADH)

released

Due to high level of epinephrine, cortisol and glucagons

and lower level of insulin stimulate catabolism,

decreased oxygen utilization, decreased cardiac output,

and insulin insufficiency.


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Classification of Shock:

1-Hypovolemic shock:

is cause by decreased fluid volume due to loss of

blood, plasma or water. Fluid volume usually

decreased post surgery due to local trauma to tissues

and loss of blood and plasma from circulation, which

creates a decrease in the circulating blood volume. It

characterized by a fall in venous pressure, rise in

peripheral resistance and tachycardia.


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2- Cardiogenic shock:It results from cardiac failure or an interference with

heart function, (poor heart pump function, and causing

diminished cardiac output) as in MI, arrhythmias,

tamponate, pulmonary embolism, epidural or general

anesthesia. The signs are increased pressure in the

venous bed and an increase in peripheral resistance.


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3-Neurogenic shock:

It occurs as a result of a failure of arterial resistance

due to spinal anesthesia, quadriplegia. It characterized

by fall in blood pressure, increase heart activity to

maintain normal output (stroke volume); this helps in

filling the dilated vascular system.


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4-Septic shock:

It results from gram negative septicemia (

infection , peritonitis, etc) The pt exhibit fever,

rapid strong pulse, rapid respiration, andnormal or slightly decreased blood pressure,

flushed , warm, dry skin,, then hypovolemia

develops.


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Clinical manifestat ion :The classical signs of shock are pallor ,cool ,moist skin, rapid breathing, ischemia to eyelids,lips, gums and tongue , weak, thready pulse,

small pulse pressure, low blood pressure.

Medical and nu rs ing assessment o f thept wi th shock

The goal in initial assessment is to determine thecause of volume loss and the status of theairway


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Assessment includes the following

Respiration: Hyperventilation is the early sign of septicshock.

Skin: A cold, pale, moist skin is a sign ofvasoconstriction-hypovolmic shock Warm, red skinindicates septic or Neurogenic shock .

Pulse and blood pressure: If each 5-15 minutesinterval shows a fall in pulse and BP the indicateshock.

Urinary output: an indwelling catheter is

recommended, a drop in renal artery pressure and flowproduces renal artery vasoconstriction and resultsdecrease in filtration and decreased in urinary output.Normal urine output= 50 cc per hour. An output 30ccper minute= oliguria or unuria is a suggestive of

cardiac failure.


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Central venous pressure: It has a value on the volumeof blood returning to the heart and the ability of theright heart to propel blood. Average CVP is 5-12 cmwater, near zero indicate hypovolemia

Arterial blood gases: an arterial pressure of oxygenbelow 60 mm Hg indicates respiratory acidosis. APCO2 over 45 mmHg indicated hypoventilation. Inshock PCO2 remain normal.

Serum lactate: lactate elevation and oxygen dept, thehigher the lactate level, the greater the oxygen need.


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Hematocrite: to determine the kind of fluid in

replacement. HCT over 55, plasma and normal saline

are given. HCT less than 20, blood is needed

Level of consciousness: alert in mild shock, to mental

cloudiness immoderate shock. Failure to react or

stimuli is irreversible shock.

Th ti d i t f h k


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Therapeutic and nursing management of shock:

Prevent ion:

Adequate preparation of pt physically.Anticipation of complication

Preparation of special emergency equipments e.g. bloodstudies, BP device, catheters, suction, oxygen, CVP line,IV, defibrillator, solutions.

Decrease any operative trauma during surgery

Control pain

Thermal regulation after surgery

Control of blood loss, if the amount of blood loss

exceeds 500 ml, replacement is usually indicatedPositioning dorsal recumbent position to facilitatecirculation.


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Treatment:

The pt must kept warm, infusions of Ringer lactate is

started, placed in shock position, monitor respiratory and

circulatory status.

The basic approach of treatment of shock is to

determine its cause and correct it if possible.

1-Ensure adequacy of the airway.

2- Restore blood volume.

.


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3-Administer vasodilators.

Vasopressors are not used for the pts in shock

because they have vasoconstriction in the

microcirculation which may cause irreversible damage

to kidney, lungs, liver, and GIT tissues Vasodilatorsare given to reduce peripheral resistance, which

decrease in turn the work of the heart and increase

cardiac output and tissue perfusion. They use Nipride

which stimulate cardiac contractibility and lowerperipheral resistance


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4-Provide psychological support and minimize the pts

energy expenditure.

5-Prevent complications:

Avoid peripheral and pulmonary edema due to fluid

overload from administering fluid faster than the body

can accommodate them.


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Hemorrhage

Hemorrhage is classified as1) primary, when it occurs at the time of theoperation.

2) Intermediary, it occurs within the first fewhours after an operation.

3) Secondary, it occurs some time after the

operation, as result of slipping of a ligaturebecause of infection.

Clinical manifestations:


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Clinical manifestations:

It depends on the amount of blood lost andthe rapidity of its escape. Apprehensiveand restless, and moves continually

Thirsty, skin is cold, moist, and paleIncrease in pulse, fall in temperature, rapidand deep respirations gasping

Decrease cardiac output

Fall of arterial and venous BP and Hb.Palled lips and conjunctiva


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3 Femoral Phlebitis or Thrombosis


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3-Femoral Phlebitis or Thrombosis

Pathophysio logy:

It occurs after operation upon lower abdomen or in thecourse septic diseases e.g. peritonitis or ruptured ulcers.

A mild to severe inflammation of the vein in associationwith a clotting of blood.

Complications occurred due to injury to the vein by tightstraps or leg holders at the time of operation. Pressurefrom blanket-roll under the knees, concentration of blooddue to blood loss or dehydration.

The slowing of blood flow in the extremity leads tolowered metabolism and depression of circulation afteroperation.


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The first symptom is pain or cramps in the calf, followedby swelling of the entire legs due to a soft edema that

pits easily on pressure, slight fever, chills and

perspiration, tenderness.

Phlebitis: indicate intravascular clotting without marked

inflammation of the veins. The clotting occurs on the calf.

The major sign is slight soreness of the calf.


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Medical and nursing Management:

1) Preventive: Adequate administration of fluids after operation to

prevent blood concentration

Leg exercises

Elastic stockings Early ambulation to prevent stagnation of the blood in

the veins of the lower extremity.

Low-dose of heparin prophylactically to prevent deep

vein thrombosis and major pulmonary embolism Avoid blanket-roll, pillowrolls or any form of elevation

that can constrict vessels under the knees


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2)Active treatment

Ligation of the femoral veins , to prevent pulmonaryembolism by eliminating the cause ( thrombi thatcould become detached from femoral veins andcirculate in the blood)

Anticoagulant therapy. Heparin given IV by dripmethod or SC to reduce the coagulability of the bloodrapidly

Wrapping the legs from the toes to groin with elasticstockings, these prevent swelling and stagnation ofvenous blood in the legs and to relief pain with legelevation and legs exercises


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4- Pulmonary Embolism

Emboli: foreign body in the blood stream. Formed byblood clot that becomes dislodged from its original siteand is carried along in the blood. When it is carried to theheart, it is forced by the blood into the pulmonary artery,

where it plugs its artery of the one of its branches.

The signs are:

Sharp, stabbing pains in the chest.

Breathless, cyanotic, and anxious.Pupils dilated, cold perspiration appears.

Rapid, irregular pulse.


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Respiratory Complications

1- Atelectasis: When mucous is plug it closes one of thebronchi, which make collapse of the pulmonary tissue,and massive atelectasis is result.

2- Bronchitis: it occurs within the first 5-6 days. A simplebronchitis is characterized by a cough that producesconsiderable mucopus, with marked elevation intemperature and pulse.

3- Bronchopneumonia: beside a productive enough,elevation of temperature, with an increase in pulse andthe respiratory rate.


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4- Lobar pneumonia: is less frequent complication afteroperation. It begins with chill, high temperature pulse,and respiration. Little or no cough, flushed cheeks.

5- Hypostatic Pulmonary Congestion: In old or veryweak pts, due to weak heart and vascular system thatpermit a stagnation of secretions at the base of thelungs. There is elevation of temperature, pulse and

respiratory rate, dullness in chest and crackles at thebase of the lungs, if it is untreated, it is fatal.

Medical and Nursing Management of


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Pulmonary Complications:

1- Measures to promote the full Aeration of the lung.

Ask the pt to have at least 10 deep breaths every hour

Use incentive Spiro meter to expand the lungs fullyTurning the pt from side to side

Suction when needed.

Early ambulation


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1- Indications for specific measures:

To treat bronchitis; inhalation of a mist or steam

In lobar and bronchopneumonia; take fluids,expectorant and antibiotics drugs

For pleurisy; analgesics or cold applications


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5- Urinary Problems

1-Urinary RetentionIt occurs after operation in the rectum, the anus and thevagina due to spasm of the bladder sphincter.

Nursing management:

Allow the pt to sit beside the bed or stand behind the bedto void

Sound of running water this relax the spasm of the

bladder sphincterUsing a warm bedpan to irrigate the perineum


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A small warm enemaCatheterization: this procedure can be delayed after 12-

18 hours.

Catheterization can be avoided due to: (1) Possibility of

infecting the bladder and cause cystitis. (2) Experiencethat the pt has once catheterization; he will have

recurrent.

2- Urinary incontinenceIt is due to weakness with loss of tone of the bladder

sphincter

3- Urinary Infection


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6- Gastro intestinal Complications

Nutritional considerations

Surgery in gastro intestinal tract may disturb the normal

physiologic processes of the digestion and absorption.

Complications vary according to the location and extend

of surgery.

1- Intestinal Obstruction

It occurs following surgery on the lower abdomen and

the pelvis. The symptoms appear after 3-5 days and

even after years.


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The obstruction is due to kinking of loop of intestine frominflammatory adhesions or is involved with peritonitis or

irritation of the peritoneal surface.

No temperature or pulse elevation, localized pain,distension, vomiting, hiccups proceed the vomiting.

Enemas return clean, showing small amount of intestinal

content has reached the bowel.

Treatment:Constant suction drainage or simple NGT

Operation

IV fluids


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7- Wound Complications

1- Hematoma (Hemorrhage)

The nurse should know the location of the pts incision toinspect the site of operation for bleeding at intervals forthe first 24 hours. Any undue amount of bleeding should

be reported.

2- Infection (Wound Sepsis)

Staphylococcus aureus, E. Coli, Aerobacter aerogenesand pseudomonas aeroginosa. The main important areaof prevention lies on aseptic techniques in wound care,cleanliness and environmental disinfection are important.The symptoms appear within 36-48 hours.


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The temperature and pulse increase, wound becometender, swollen, and warm. Use of warm antisepticsolutions to flush the wound. Take culture at site ofoperation. Specific antibiotics.

3-Disruption, Evisceration (protrusion of woundcenter),or Dehiscence (distruption of surgical wound orincision).

It results from sutures giving way and from infection, and

after marked distention or cough. It occurs because ofincreasing age and the presence of pulmonary orcardiovascular diseases in abdominal surgical pts.


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The sign is usually a gush of serosanguineous

peritoneal fluid from the wound, rupture of wound, coils

of intestine escaping onto the abdominal wall, pain,

vomiting.

When disruption of a wound occurs, the surgeon is

notified at once. The protruding coils of intestine should

be covered with sterile dressing moistures with sterile

saline.

Th k Y


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Thank You


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