Treatment Aspects in Perioperative Nursing

7/31/2019 Treatment Aspects in Perioperative Nursing

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G U I D EM R . A B H I S H E K N A I R S I R L E C T U R E R S S C N

P R E S E N T E D B Y S H I B I N J A C O BM . S C N U R S I N G 1 S T Y E A R

TREATMENT ASPECTS INPERIOPERATIVE NURSING


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INTRODUCTION

Perioperative nursing includemajor three phases

PreoperativeIntraoperative

Postoperative


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Preoperative phase

From the time of decisionmaking of surgical interventionto the transfer of patient to theoperation room


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Intra operative phase

From the time of the patient isreceived in the operating roomuntil admitted to the postanesthesia care units (PACU )


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Post operative phase

From the time of admission toPACU to the follow-up evaluation

until the discharge


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Surgery

The treatment of injury disease or deformity through a invasive operative procedure

Major presenting little risk to life

Minor possibility of involving risk to the life View of a client vantage point

Surgery is a major stressor for all clientsFear of the unknown is the most prevalent fear prior tosurgery and is to assist nure to help client to overcome


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Types of surgeries Optional: - surgery is scheduled completely at the preferenceof a patients (E.g. cosmetic surgery)Elective: - the appropriate time of surgery is at theconvenience of the patient. Failure of the surgery iscatastrophic (E.g. superficial cysts)Required the condition requires surgery within few weeks(E.g. cataract)Urgent the surgical intervention required attention within24-48 hours (cancer)

Emergency the situation requires immediate surgicalattention without delay (E.g. accidents, gunshot injuries)

Ambulatory surgeries -the surgery plans and done and thepatient discharged on the day same day (EG cystoscopy)


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PERI OPERATIVE NURSING

Has a continuous goalTo provide a standard of excellence in the care of theclient before during and after surgery

Perioperative nursing is a client oriented and must be generated to meet the clients needs and psychosocial need as the immediate physical needs


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1)

PREOPERATIVE

NURSING


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PREOPERATIVE NURSING

Role of nursenursing baseline data evaluation of the patient before one day of surgery by carried out a postoperative interview it includenot only a physical but only also an emotional; assessment

previous anesthetic history and identification of knownallegories or genetic problems may affect the surgical outcomeEnsuring the preadmission testsarranging the appropriate consulting services providing a

preoperative education


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PREOPERATIVE PHYSIOLOGIC ASSESSMENT

Informed consent assessment AgeNutritional statusFluid and electrolyte balanceRespiratory statusMedications (previous use)Cardiovascular status

Renal & hepatic status Alcohol or drug abuseNeurological, musculoskeletal and integlumetary statusEndocrine and immunological status


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Common laboratory tests

Hemoglobin & hematocrit / complete CBCBlood typing and cross matchingRFT (renal function tests)

LFT (Liver function tests)Coagulation profile including PT & APTT (prothrombine time & activated partialthromboplastin time

Urine analysisX RAY VIRAL MARKERS (HIV, HbSCG & HCV


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Assessment of client psychologicalcondition

The psychological condition of a client can havestronger influence than does the physical condition,Encourage the client to express their feelings and

fears about the surgery and receiving anesthesiaObserve the client for nonverbal clues indicatinganxiety To reduce the anxiety explain the client what will behappening throughout the surgical experience


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Psychosocial health assessment

Cultural beliefs can influence persons perception of surgery The client should be provided the opportunity to

express their spiritual values and beliefsPatient education

Purpose of pre operative teaching To answer questions and concerns about the surgery

To ascertain the needs or desire for additional informationTo provide information in a manner of conductive to learning


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General instructions

Preoperatively the patient will be instructed in thefollowing postoperative activities this will allows achance for practice and familiarity

Incentive spirometry CoughingTurningFoot and leg exercises


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Physical preparation

Identifying the client and verifying the operativeprocedurePreparing the operative site

Checking and recording the vitals Assisting in bath and gowning Verifying allergies and reordered

NPOIdentifying sensory defects of the client


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PHARMACOLOGICAL ASPECTS INPREOPERATIVE

Preoperative medications Opiates- such as morphine(ROXONOL)and meperidine aregiven to relax the patient and potentiate the anesthesia Anticholernegics - atropine, glycopyrolate given to reduceprimary top reduce respiratory tract secretions and to preventsevere reflexes slowing of heart doing the anesthesiaBarbiturate/ tranquilizers given in the night for a peacefulsleep

Prophylactic antibiotics _ administered just before the surgery ST skin test


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Final check list

Identification and verificationReview of patient recordConsent form

Patient preparationTransporting patient to operation roomPreoperative medicines

Psychological support to patients family


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2) INTRA

OPERATIVE

PHASE


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Sterile Members

1) SurgeonFirst assistant (physician or registered nurse who assistsurgeon in performing homeostasis, tissue retraction and wound closureScrub nurse ( An LP/VN/RN or a surgical technologist who preparers and maintains integetery safety andefficiency of sterile fields throughout the operation

Nonsterile members Anesthesia providerCirculating nurse R N responsibility for management of personal, equipment supplies, environment andcommunication throughout the procedure


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Sterile field Asepsis Elements of aseptic techniques

Sterile gowns and glowsSterile drapesSterilization of items used in sterile tables


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Intraoperative nursing care

1. Risk of infection related to invasive procedure andexposure to pathogens

2. Risk of injury related to possibility of positioningduring surgery

3. Risk of injury related to foreign bodies in adversely leftin the wound

4. Risk of injury related to chemical physical andelectrical hazards

5. Risk of impaired tissue integrity 6. Risk of alteration in fluid electrolyte balance related to

abnormal blood loss and NPO status


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Anesthesia

Conscious sedationgeneral anesthesia

Four stagesInductionMaintenanceEmergenceRecovery

Regional anesthesia

LocalNerve block Spinal or epidural


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Local anesthesia Consists of local volume of fluid is administered in the skin for

minimal procedures it will become the patient senseless for sometimeE.g. xylocine, lignocane, loxicard bupivaccineSpinal anesthesia

Local anesthesia is injected to lumbar or intrathecal space. Anesthesia blocks conduction in spinal nerve roots and dorsal ganglia,paralysis and analgesia occur below the level of injection. Agents usedprocaine, tetracaine, lidocine, and bupivacaineEpidural anesthesia

Achieved by injecting the local anesthesia in to the epidural space by the way of lumbar puncture

Agents used are chloroprocaine, lidocaine and bupivacinePeripheral nerve block

Achieved by injecting a local anesthesia or anesthetize n to thesurgical site


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Complications

Hypo ventilationInadequate ventilator support to the after paralyzing of respiratory

muscles and ensuring comaOral trauma

Broken teeth, oropharyngeal or laryngeal trauma due to difficultintubation

Hypotension Due to the blood loss or effect of anesthesiaCardiac dysarythemia

Due to the pre exposing cardio vascular compromise electrolyteimbalance, or untoward reactions to anesthetic agentsHypothermia

Due to the exposure to the cool atmosphere in the Operation Theater and tableDue to loss of thermoregulation capability due to anesthetic agentsPeripheral nerve damages

Due to the improper positioning of the patientMalignant hyperthermia


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Malignant hyperthermia

This is a rare reaction to anesthetic agents likeenflurane, fluroxene, and halothaneSuch drugs like theophylline, aminophylline,epinerphine, and digoxinInherited muscle disorder (muscle dystrophy) or ahistory clinical manifestations

TachycardiaPseudotetany Muscle rigidity High feverCyanosisHeart failureCNS damage


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management

Discontinue the inhalant anesthesiaDantroline (dantrium) + oxygen + dextrose 50,diuretics, antiarrhythics, sodium bi carbonate, and

hypothermic measures (cooling blanket, iced salinesolution, iced saline lavage of stomach, bladder, orrectum


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Nursing process

InterventionsSafety Advocacy Verification

Counting instruments sponges needlesEvaluation

ExpectedUnexpected

DocumentedInforming client family Surgical waiting roomOngoing update by OR team


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3)

POSTOPERATIVEPHASE


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ensure the continuity of care from Intraoperative phase to theimmediate postoperative phase in circulating nurse anestheologistor nurse anesthesia with a through report to PACU nurseIT include

Type of surgery performed & Intraoperative complicationsType of anesthesiaDrains and type of dressingNo of suturing & typePresence of ET tube and type of oxygen to be administeredPresence of lines and locations (central, peripheral, arterial line)Catheterization & tubes

Administration of colloids blood crystalloids and electrolyte balance

Drug allergiesPreexisting medical conditionsPost op investigations


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Nursing assessment

Before receiving the patients itself the nurse shouldensure his/her unit should ready to receive thepatient

Checklist Functioning of oxygen and ventilatorFunctioning of suction apparatusCardiac monitor should be ready or not

I V access are preparedCheck for a crash cart


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Assessment after receiving patient

Verify the patient identity The operative procedure and the surgeon whoperformed the procedureEvaluate the following signs and verify their level of stability with the anestheolgist

Respiratory status (airway)BreathingCirculation

Temperature, pulse, respirationOxygen saturation of the bloodHemodynamic status


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Determine the swallowing gag reflexes and LOCincluding patients response to stimuliEvaluate lines, tubes, drains, estimated blood losscondition of wound (open closed packed )

Medications used , infusions, including thetransfusions, and output)Evaluate the level of consciousness and comfort andsafety measures such as pain protective reflexes

Perform safety checks to verify that side rails are inplaced and restrains are properly appliedEvaluate activity status, movements extremitiesRevise physician orders


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Nursing diagnosis

Ineffective airway clearance related to effect of anesthesiaImpaired gas exchange related to ventilation perforationimbalanceIneffective tissue perforation related to cardiopulmonary (hypertension)Risk of imbalanced body temperature related to medicationssedation and cool environmentRisk of fluid imbalance related to related to blood loss NPOstatus and vomiting and indwelling tubesPain related to surgery incision and traumaRisk of injury related to sensory dysfunction and physicalenvironmentDisturbed sensory participation related to effects of medications and anesthesia


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Evaluation or expected outcomes

Breath easily Lung sound clear Vital signs stable

Thermoregulation stableIntake output balanceReport of adequate pain control

Wound edges intact without drainagePosition comfortably and carefully Quiet reassuring environment maintained


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Post operative complications

Nausea vomitingPainConstipation and gas crampsThirstShock HemorrhageDeep vein thrombosisPulmonary embolismUrinary retentionIntestinal obstructionHiccups Wound infection Wound dehiscence and eviscerationPsychological disturbances

DepressionDelirium


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NAUSEA AND VOMITING

Causes Occurs due to thecomplication of in halationanesthesia

Result from anaccumulation of fluids instomach before peristalticmovements returnDue to the abdominaldistentionPsychological induction Adverse effects of opiods


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THIRST

Inhibitions of secretions by preoperativemedications likeglycopyrolate

fluid loss, blood loss,dehydration due to theNBM


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CONSTIPATION AND GAS CRAMPS

trauma andmanipulation of the bowel during the surgery local inflammation,

peritonitis, abscesslong standby bowelproblem this may leads bowel impaction


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PAIN

This is the most important and common symptoms in which patients exhibits afeeling of distress stimulation of or trauma to certain nerve ending as a resultcausing painManagement

Reduce the anxiety due to anticipation of painTeach the patient about pain managementReview analagics with patient and reassure the relief with available quickly Establish a trusting relationship with the patient

Pharmacological management Parental analgesia for 2-4 days initially and later the dose decreased to oralanalgesicThe nurses responsibility to make ensure the drug is given safely andassessed efficiency

Other type of pain management Patient controlled analgesiaEpidural analgesia


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SHOCK

It is a response of the body to a decrease in circulatory volume of blood, tissue perforation is impairedculminating eventually in the cellular hypoxia and deathManagement

Arrange and transfusion of blood if necessary Accurately measure any blood loss and monitor all fluid intake andoutput

Anticipitate the progression of symptoms in earliest manifestationMonitor vital signs as per institutional policy until they are stable


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HEMORRHAGE

Hemorrhage is a copious escape of blood from a blood vesselClassified as 1) general 2) according to blood vessel 3)according to location

General

Primary occurs in the time of operation Intermediately with in the first few hours of the operation after the surgery immediately after the blood pressure comes normal

Secondary occurs some times after the surgery due to ligatures slip from the blood vessel and erosion of the blood vessel

According to blood vessel Capillary slow general oozing from the capillaries Venous - bleeding in dark color blood Artery bleeding that sprats and bright red in colour

According to location External - visible bleeding present in surface Internal (concealed)- bleeding cannot seen


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DEEP VEIN THROMBOSIS

DVT occurs in the pelvic veins and deep vein of lower extremities in postoperative patients most

common in hip surgeriesand abdominal surgeries


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PULMONARY COMPLICATIONS

Atelectasis -incomplete expansion of the lungs or aportion of lung with in 48 hours of the surgery

Aspiration caused by the inhalation of foods or

gastric contents or blood to the trachea bronchialsystemPneumonia this is a inflammatory response in which cellular materials replaces alveolar gases

Pulmonary embolism caused by theobstruction of one or more arterioles by an embolousoriginating in some ware in the venous system


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URINARY RETENTIONINTESTINAL OBSTRUCTION

Bowel obstructs result in partial or completeimpairment to forward flow of intestinal contents

HICCUPS Due to intermittent spasm of diaphragm causing hicthat resulting from vibration of closed vocal cord as airrushes suddenly in to the lungs

WOUND INFECTION

It is the second most nosocomial infections theinfection may limited to the surgicial site 60% to 80% oraffect systematically w


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Due to the inadequate

sutures or excessively tight sutures therupture of skin andabdominal organs are

protududed outthrough the rupturedskin

WOUND DEHISCENCE & EVISCERATION


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WOUND CARE (DRESSING)

The management of the wound is done by thephysician or his assistant by strict sterile and aseptictechniquesPurpose

To protect the wound from the infectionTo splint or immobilize the woundTo protect the wound from mechanical injury To prevent contaminationTo absorbe drainageTo inhibit or kill microorganisms by using dressing withantiseptic r anti microbial properties


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Drains

The drains are the tubesthat kept collecting thedischarges from in wound or surgical site

Purpose Drains are placed only when abnormal fluidcollection is present orexpectedCollection of fluids thatcause harmful to the wound


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PATIENT EDUCATION

Before the discharge of the patient he shouldthoroughly teach the techniques of wound careReport immediately to the health care provider if thefollowing signs will occurReduces or marked swelling surrounding the tissuesPus or usual dischargeChills or fever more than 100Keep suture line clean and neat never vigorously rubnear the incision site

POST OPERATIVE DISCHARGE


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POST OPERATIVE DISCHARGEINSTRUCTION

Rest and activity eatingsleeping wound healing bowels bathingclothing

driving bending and lifting


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SUMMARY

Treatment Aspects in Perioperative Nursing

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