The document discusses perioperative nursing, which involves 3 phases: preoperative, intraoperative, and postoperative care. It describes various types of surgeries based on factors like blood loss and urgency. The preoperative phase involves assessment, consent, and preparation of the patient. Preparation includes education, testing, restriction of food/fluids, and sometimes medications. The intraoperative phase focuses on the surgical procedure and roles of the surgical team.

1. PERIOPERATIVE NURSING Prepared By: Luis P. Imatani D.D.M.,R.N.

2. PERIOPERATIVE NURSING

3. PERIOPERATIVE NURSING Perioperative nursing It is divided into 3 Phases: 1. Preoperative – From the decision for surgical intervention to transfer to operating room

4. 2. Intra-operative- From reception into the operating room to admission to recovery room

5. 3. Post Operative- Admission to recovery room to follow up evaluation

6. Types of Surgery Acc to degree of blood loss:

7. Major Surgery – Extensive surgery that involves serious risk and complications & loss of blood as it involves major Organs and few blood loss

8. Minor Surgery- Surgery that involves minimal complications and few blood loss

9. Types of Surgery Acc to Urgency of Surgery:

10. Optional Surgery – Surgery at the preference of the client. Surgery is not needed Ex. Cosmetic surgery ; liposuction

11. Elective Surgery – Surgery at the convenience of the patient as failure to have surgery is not life threatening Ex. Excision of superficial cyst.

12. Planned/ Required surgery- The time of the surgery is within a few weeks from time of decision to have surgery as surgery is important ex. Cataract extraction

13. Urgent/ Imperative surgery – Within 24-48 hours from the time of the decision to have surgery Ex. Cancer surgery

14. Emergency Surgery – Immediate surgery without delay to maintain life or organ, to remove damage, to stop bleeding Ex. Intestinal obstruction, gun shot wounds

15. Types of Surgery Acc to Purpose of Surgery:

16. Diagnostic Surgery – To confirm diagnosis Ex. Excision & biopsy

17. Exploratory – To estimate the extent of the disease & confirm diagnosis Ex. Exploratory Laparotomy

18. Curative Surgery a. Ablative – Removal of diseased organ Ex. Hysterectomy b. Constructive – Repair of congenital defects Ex. Repair of Cleft palate

19. c. Reconstructive – Restoration of damaged organ Ex. Total joint replacement

20. Palliative – Relieves Symptom but does not cure the disease Ex. Rhizotomy for pain relief, Myringotomy

21. CLASSIFICATION of PHYSICAL STATUS: ASA I – Healthy person, with no systemic disease, undergoing elective surgery, Not very Young or very old

22. ASA II – Client w/ 1 system well controlled disease. Diseases does not affect daily activities. Those clients w/ mild obesity, alcoholism, and smokers

23. ASA III – Client w/ multiple system disease or well controlled major system diseases. The disease status limits daily Activities. However there is no immediate threat of death due to individual system disease.

24. ASA IV – Client w/ severe incapacitating disease. Typically the disease is poorly controlled, or end stage disease is present. Danger of death related to organ failure is present

25. ASA V - Client is very ill, in imminent danger of death. Operation is the last attempt in preserving life. The client is not expected to live the next 24 hours.

26. PREOPERATIVE ASSESSMENT

27. Past Medical Health History Previous Surgery & Experience with anesthesia = any untoward reaction to anesthesia e.g. malignant hyperthermia, intraoperative death in the family= INFORM physician.

28. Serious Illness or Trauma: ABCDE A – Allergy B- Bleeding C- Cortisone use D – Diabetes mellitus E – Emboli (thromoembolism)

29. Age Infant, Young children, & older Adults are at greater risk for surgery

30. Nutritional Status

31. Nutritional Status Nutritional deficiencies and excesses correlate with post- op recovery

32. Alcohol / Recreational Drug Use Alcohol has an unpredictable reaction with anesthetic agents; Smoking = reduce hemoglobin, Smokers are susceptible to clot formation & Nicotine is a vasoconstrictor

33. Lifestyle Sedentary lifestyle vs. physically fit

34. Fluid & Electrolytes Dehydration & Hypovolemia predispose a client to complications during & after surgery.

35. Hypokalemia, hyperkalemia can compromise the cardiac status; hyper-hyponatremia can offset fluid balance

36. Infection Can adversely affect surgical outcome Current Discomfort Pre-existing pain condition may be misinterpreted later as surgical pain

37. Chronic Illness Ex. History of Arthritis of Neck or other joints has an influence on the intraoperative positioning.

38. MEDICATION HISTORY

39. ANTIBIOTICS Gentamycin Penicillin } May mask symptoms of infection

40. ANTIARRHYTHMIC AGENTS Propanolol HCl; Qunidine gluconate;Procainamide HCl } Depresses cardiac function & affects tolerance to Anesthesia

41. ANTIHYPERTENSIVE Methyldopa Aldomet } May cause intraoperative / p ostoperative hypotensive crisis

42. CORTICOSTEROIDS Prednisone Dexamethasone } Delays wound healing

43. ANTICOAGULANTS Heparin Na Warfarin Na Aspirin NSAIDS } Inc. risk of intraop/postop hemorrhage

44. GLAUCOMA MEDICATIONS Pilocarpine HCl = may cause respiratory or cardiovascular collapse during surgery

45. ANTIDIABETIC AGENTS Insulin needs decrease when client is on NPO

46. TRICYCLIC ANTIDEPRESSANTS (TCA) Amitriptyline (Elavil) = Lowers BP, thus increasing risk of shock

47. THIAZIDE DIURETICS Furosemide ( Lasix) = Can deplete K+ and cause electrolyte imbalances

48. STREET DRUGS Beer Whiskey Cocaine Heroin } increase tolerance to narcotics, requiring more anesthetic agents.

49. Psychological History Knowledge of Cultural & religious practices of the client is an important aspect of nursing care

50. Ability to Tolerate Stress Social History Assess the family support system

51. PHYSICAL ASSESSMENT

52. Cardiovascular assessment MI, angina pectoris for the last six months, may influence tissue perfusion or wound healing

53. Respiratory assessment – Chronic lung conditions ex. emphysema, asthma, bronchitis, increase the operative risk bec. These diseases impair gas exchange = DOB notify the physician.

54. Musculoskeletal assessment – History of fractures, joint injury, arthritis, may influence the positioning of the client during intraoperative phase, or it may cause additional postop pain

55. Skin integrity assessment- Document & report lesions, pressure ulcers, necrotic skin, skin turgor, erythema, cyanosis of the skin, note the size & location so as to compare post op if lesions are stable or worsening.

56. Renal assessment- Adequate renal function is necessary to eliminate protein wastes, to preserve fluid & electrolyte balance & to remove anesthetic agents from the system

57. Liver function assessment - Liver dse like cirrhosis inc. a client’s surgical risk bec a diseased liver cannot detoxify drugs & anesthetic agents, liver dse. May be manifested through albumin levels= low albumin levels predispose to fluid shifts (fluid imbalance)

58. Cognitive assessment- Uncontrolled epilepsy, severe parkinson’s disease, increase the surgical risk

59. other important neurologic assessment; severe head ache, frequent dizziness, light headdeness, ringing in the ears, unsteady gait, unequal pupils & history of seizures.

60. Hematologic function – Clients w/ blood coagulation disorders are at risk for hemorrhage Ex. History of hemophilia, sickle cell anemia. Manifestations of easy brusing and abnormal bleeding time

61. PRESURGICAL SCREENING TESTS: CXR ECG

62. PRESURGICAL SCREENING TESTS: ECG

63. CBC: RBC – 4.5 – 5.5 million/mm3 WBC – 4,500 – 11,000 mm3 Thrombocytes – 150,000- 400,000/ mm3

64. Hemoglobin : Female: 12-16 g/dl Male: 14-18 g/dl Hct : 35-45%

65. Prothrombin time(PT): 11-15 sec Partial thromboplastin time(PTT): 35 sec

66. ELECTROLYTES: K+ = 3.5-5.5 mEq/L Na+ = 135-145 mEq/L Cl- = 98-107 mEq/L Ca ++ = 8.5 – 11 mEq/L

67. URINALYSIS OTHER LABS: ABGs – HCO3 = 22-26 mEq/L ; CO2 – 35-45 mm Hg Fasting glucose = 60-100 mg/dl

68. Creatinine = .5 –1.5 mg/dl – BUN = 10-20 mg/dl indicators of kidney function ALBUMIN = 3.5 – 5.0 g/dl

69. NURSING DIAGNOSES

74. INTERVENTIONS:

81. PREOPERATIVE CARE

84. A preoperative patient may experience a number of fears:

85. 1) fear of anesthesia 2) fear of pain 3) fear of the unknown 4) fear of death 5) fear of change in body image (deformity).

87. a) the patient is of legal age – or if not signed by a parent or legal guardian

88. b) the patient is capable of making the decision for himself – ex. of sound mind not w/ psychiatric disorder

89. c) The patient is not medicated w/ drugs that affect the consciousness

91. 3. PHYSIOLOGIC PREPARATION Respiratory preparation – CXR order by surgeon Cardiovascular – ex. ECG, CBC, Hgb Renal Preparation – routine urinalysis

92. 4. PREOPERATIVE HEALTH TEACHINGS / INSTRUCTIONS The best time to instruct the client is relatively close to the time of the surgery

102. b) Non – Barbiturates – chloral hydrate; flurazepam ( Dalmane)

103. The drugs are given after all pre-op treatments have been completed. If a second barbiturate is needed, it must be given at least 4 hours before pre-op medications is due.

104. On the Day of the Surgery

105. Early Morning Care – ( about 1 hour before the pre-op medication schedule )

108. Pre- Operative Medications – generally administered 60-90 minutes before induction of anesthesia –

110. Types of Pre-Op meds:

111. a) Sedatives – given to decrease the patient’s anxiety to lower BP and pulse and to reduce the amount of General Anesthesia; an overdose of sedatives may lead to respiratory depression

112. ex. Phenobarbital Na, Nembutal Na, Secobarbital Na

113. b) Tranquilizer – lowers a patient’s anxiety Ex. Thorazine 12.5 – 25 mg IM 1-2 hours prior to surgery

114. Phenergan- 12.5 – 25 mg IM 1-2 hours before surgery Note* these tranquilizers may cause dangerous hypotension both during and after the surgery

115. Narcotic Analgesics – Given to reduce anxiety and to reduce the amount of narcotics given during surgery

116. Ex. Morphine sulfate – 8-15 mg SQ one hr pre-op this drug can cause vomiting, respiratory depression and postural hypotension

117. Vagolytic or drying agents – To reduce the amount of tracheobronchial secretions w/c may clog the pulmonary alveoli and may produce atelectasis (lung collapse)

118. Ex. Atropine sulfate 0.3-0.6 mg IM 45 minutes before surgery overdose can cause severe tachycardia

119. *** Important ! – Nursing intervention after giving pre-op meds immediately raise the side rails of the bed for patient’s safety

121. Transportation to OR – Make sure that the name tag of the client is in place. While transferring the patient on the stretcher make sure that the side rails are up

122. Woolen or synthetic blankets must never be sent to OR bec. It causes static electricity and may cause combustion of O2 or Other gases in the OR

123. NURSING DIAGNOSIS

124. Anxiety r/t Lack of Knowledge About Preoperative Routines, Potential Body Image Change, Surgery

125. INTRA OPERATIVE NURSING CARE

126. Intra-operative Surgery & nursing care – begins from the reception of the patient to the OR to the transfer of the client to the PACU. Or RR

127. Duties and responsibilities of the Surgical team:

134. ASSESSMENT

135. 1. Identify the surgical client, make sure that the name tag is in place when receiving client.

136. 2. Assess the emotional & physical status of the patient, assess VS & record 3. Verify information in the checklist

137. POSITIONING THE CLIENT; ( POSITIONS DURING SURGERY)

138. Supine / Dorsal recumbent – Lying on the back – used for hernia repair, bowel resection, eplore lap, mastectomy, cholecystectomy

139. Prone – for back, spine, rectal surgeries, laminectomy- Note** after surgery, the patient will be returned to the supine position. This should be done gradually bec. Sudden turning of the client may cause a rapid drop in BP

140. Trendelenberg – Head and body are flexed by , breaking(bending the head of the table downwards) – pelvic surgeries, lower abdomen.

141. Reverse trendelenberg – Head is elevated and feet are lowered

142. Lithotomy position - Thighs and legs are flexed at right angles and then simultaneously placed in stirrups – vaginal repairs, D&C, rectal surgery,

143. Lateral – used in kidney and chest surgery, hip surgeries

144. Other positions - in Thyroidectomy the head is hyperextended, a small sand bag or pillow on the neck and shoulders to provide exposure of the thyroid gland

147. ANESTHESIA

148. Stages of Anesthesia

149. Stage I . Stage of Analgesia / induction phase

150. This stage extends from the beginning of Administration of an anesthetic to the beginning of the loss of consciousness . The sensation of pain is not lost.

154. Stage II. Stage of Delirium / Excitement

155. Extends from the loss of consciousness to the loss of eyelid reflex. Any stimulation has the potential to cause the client to become difficult to control.

159. Stage III. Stage of Surgical Anesthesia

160. Extends from loss of lid reflex to cessation of respiratory effort or depressed vital functions.

163. Stage IV. Stage of Danger / Medullary stage

164. From vital functions too depressed to Respiratory failure/ Death & Disability due to too high concentration of anesthetic in the CNS.

166. GENERAL ANESTHETICS

181. PRINCIPLES of SURGICAL ASEPSIS

182. Remember the word ASEPSIS

190. Surgical Hand Scrub

191. Is the removal of as many bacteria as possible from the hands and arms by mechanical washing and chemical disinfection before participating in an operation. Done prior to gowning and gloving.

194. 2. Brush stroke method-

202. POST ANESTHETIC CARE:

208. 2. Maintenance of circulation

213. to have a basis of comparison if the blood stain is becoming larger. Report to physician your findings

219. 3.Protection from injury & Promotion of comfort

221. 4. Dismissal from RR to Ward

223. POST OPERATIVE CARE

227. NURSING DIAGNOSES

228. Risk for Infection r/t surgical wound/ incision site Pain r/t Surgical Wound Site

229. Altered Family Processes r/t loss of economic stability Impaired Physical Mobility r/t pain at the incision site

230. Fluid Volume Deficit r/t blood loss Risk for Fluid Volume Deficit r/t blood loss

231. POST OPERATIVE CARE GOALS:

232. Goal 1. Restore Homeostasis & prevent complications

233. Goal 2. Maintain and Promote Adequate Airway and Respiratory Function

237. Interventions:

241. Goal 3. Maintain Adequate Cardiac Function and Promote tissue perfusion

247. GOAL 4. Maintain adequate Fluid & Electrolyte Balance & Adequate Renal Function

253. GOAL 5. Promote Comfort & Rest

255. Goal 6: Promote Adequate Nutrition & Elimination

258. GOAL 7. Promote Wound Healing

260. Wound Complications:

266. 3. Dehiscences & Evisceration