Transcript pre – operative

Perioperative nursing: {peri – operative}
Is a term used to describe the nursing care provided
in the total surgical experience of the patient:
• Preoperative phase { pre – operative}
• Intraoperative phase { intra – operative}
• Postoperative phase { post – operative}
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Preoperative phase
Begins when the decision for surgery is made and
ends with the transfer of the patient to the operating
room.
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Intraoperative phase
From the time the patient is received in the
operating room until he admitted to the post
anesthesia care unit (PACU).
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Postoperative phase
From the time of admission to the PACU to the last
follow-up evaluation.
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Surgical classifications
Surgery may be performed for a variety of reasons
1. Diagnostic : biopsy
2. Curative : appendectomy
3. Reparative: when multiple wounds must be repaired
4. Reconstructive : cosmetic
5. Palliative : to alleviate { relief } pain
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According to the degree of urgency
1. Optional :
Surgery is scheduled at the preference of the patient (cosmetic
surgery).
2. Elective :
The approximate time for surgery is at the convenience of the
patient.
• failure to have surgery is not catastrophic (e.g., a superficial cyst,
simple hernia).
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3. Required :
Surgery required within few weeks (eye cataract).
4. Urgent :
Surgery required within 24 -48 hours (cancer)
5. Emergent :
Immediate surgery without delay ( intestinal obstruction)
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Preoperative phase
Informed consent
Is a written form signed by the patient and (witness)
to have a permission to do the surgery .
Involves informing the patient about the surgical procedure; risks and
possible complications of surgery and anesthesia.
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Purposes of informed consent
1. To ensure that the patient understands the nature of the
treatment.
2. To indicate that the patient's decision was made without
pressure.
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3. To protect the patient against unauthorized procedures.
4. To protect the surgeon and hospital against legal action by
a patient.
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Notes
1. Before the patient signs the consent form, the surgeon
must provide a clear and simple explanation of what the
surgery will entail.
2. Sign a separate form for each procedure or operation.
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3. When the patient is a minor or unconscious or
incompetent, permission must be obtained from a
responsible family member
4.
In an emergency, it may be necessary for the surgeon to
save the patient without the patient’s informed
consent. Every Effort, however, must be
made to contact the patient’s family
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pre-operative assessment
Assessment of health factors that affect patient operatively:
1. Nutritional and fluid status (weight loss , dehydration ).
2. Drug or alcohol use.
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3. Respiratory Status: surgery is usually postponed when the
patient has a respiratory infection, Patients who smoke are urged
to stop 2 months before surgery.
4. Cardiovascular Status: blood pressure should be under
controlled, assess hypoxia, fluid over load.
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5. Hepatic and Renal Function: assess liver and kidney
function, surgery is contraindicated when a patient has acute
nephritis, acute renal insufficiency with oliguria or anuria.
6. Endocrine function: assess fasting blood sugar, S&S of
hyper& hypoglycemia, maintain glucose level less than 200
mg/dl, monitor blood glucose level before, during & after
surgery.
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7. Immune Function: assess allergies, sensitivity to medications,
Immunosuppression.
8. Previous Medication Use: Anticoagulants, Steroids, Diuretics,
Phenothiazines, Antidepressants, certain antibiotics.
9. Psychosocial Factors
10. Spiritual and Cultural Beliefs
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Pre- operative teaching
Teaching should be started as soon as possible form the first
day of admission.
Information and instruction should be started by
conversation and discussion.
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Considerations:
• Begin at level of understanding.
• Include family members.
• Encourage the patient to ask questions and express his concerns
• Explain the details of preoperative preparation.
• Offer general information on the surgery.
• Discuss anticipated postoperative care.
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Preoperatively, the patient will be instructed in the following
postoperative activities:
1. Deep breathing and cough
2.
Changing positions
3. Foot and leg exercises
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Pre- operative nursing intervention
1. Fluid &food are restricted preoperatively overnight to
prevent aspiration { NPO }
2. Fluid can be administered IV. In special cases to prevent
fluid volume deficit
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3. Enemas are not commonly ordered unless the patient
undergoing abdominal surgery.
4. Skin preparation (hair must be removed , and skin
should be cleaned by using soap containing germicide
agent}
5. The patient is dressed in hospital gown (open in the
back )
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6. Hair pins are removed &should be covered with a
disposable cap.
7. Dentures should be removed.
8. Jewelry should be removed.
9. Instruct the patient to void.
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10. Administration of pre-operative medications such as
anticholinergic, barbiturates, prophylactic antibiotics.
11. Consent form should be attached, also identification,
verification, and patient records
12. Transferred the patient in bed or stretcher, and the
stretcher should be as comfortable as possible.
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Intraoperative nursing management
1. Providing for the safety and well-being of the
patient.
2. Coordinating the OR personnel.
3. Performing scrub and circulating activities.
4. Supports coping strategies and reinforcement.
5. Monitor factors that can cause injury such
patient position, equipment malfunction,
and environmental hazards.
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Postanasthesia care unit {PACU}
• Also called Postanasthesia recovery room.
• The anesthesiologist should remain with the patient until
regain full consciousness.
• During transport, the anesthesiologist should remains at
head of the stretcher to maintain patent airway and the
surgical team members remain at the opposite end.
• The patient must be moved slowly and carefully.
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Nursing management (Immediate post op. care )
1. Assessing the patient
• Assessment of : O2 saturation ,plus , depth and nature of
respirations , skin color , level of consciousness and ability to
respond to commands.
• Vital signs are monitored and the patient general status is
assessed at least every 15 min.
N.B: Patency of the airway and respiratory function are always evaluated
first
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2. Maintaining patent airway
•
•
•
•
Maintain pulmonary ventilation , prevent hypoxemia,
Administered O2 as prescribed and as needed
Assess RR & breath sounds
Tongue may fall backward due to muscle relaxation
•
Signs of obstruction include choking, cyanosis, noisy and
irregular respiration
Rubber or plastic airway may be left in patient mouth until
gag reflex is returning.
•
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•
The patient may require mechanical ventilation.
•
Assess for excessive secretion of mucus or aspiration of
vomitus , turn patient to one side, the head of the
bed is elevated 15 to 30 degrees unless contraindicated.
•
Mucus or vomits is suctioned ( caution is necessary in
suctioning the throat of a patient who has had a
tonsillectomy or other oral or laryngeal surgery )
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3. Maintaining cardio vascular stability
•
Assess the patients mental status , vital signs, cardiac
rhythm, skin temp. , color , moisture and urine output.
•
Monitor CVP and arterial line if required.
•
Assess the patency of I.V. lines.
•
Assess and manage cardio vascular complications.
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 Hypotension and shock:
•
Can result from loss of blood, hypoventilation, position
changes or side effects of medications or anesthetics.
•
If blood loss exceeds 500 ml replacement is indicated.
•
Hypovolemic shock is the most common serious post op.
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•The classic sign of shock :pallor, cool moist skin, rapid
breathing, cyanosis, pulse pressure BP , and
concentrated urine.
•Hypovolemic shock can be prevented by inserting IV fluids
(Ringer's lactate ) or blood.
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 Hemorrhage:
•
Can result in death.
•
Can occur in the immediate post op. period or up to several
days after surgery.
•
When blood loss is extreme , the patient is apprehensive ,
restless and thirsty , the skin is cold, moist and pale, increase
HR, decrease temp., repaid breathing.
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•If continue determine the cause of bleeding , give blood
transfusion.
• Inspect surgical site for signs of bleeding.
• Place the patient in shock position.
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 Hypertension and Dysrhythmias :
• Hypertension occurs secondary to hypoxia, bladder
distension, & pain
• Dysrhythmia occurs due to electrolyte imbalance, pain, &
stress
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4. Reliving pain and anxiety
. Analgesics drug should be given
. Provide psychological support
5. Determine readiness for discharge (Re. Rom)
• Stable vital signs
• Orientation to person, place, events, and time
• Uncompromised pulmonary function
• Pulse oximetry readings indicating adequate blood oxygen
saturation
•Urine output at least 30 mL/h
•Nausea and vomiting absent or under control
•Minimal pain
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The hospitalized postop. patient
Receiving the patient in the clinic .
 The Postanasthesia Care Unit (PACU), nurse report the
baseline data of the patient condition to the receiving nurse.
 The receiving nurse reviews the Post op. orders , admits the
patient to the unit, perform an initial assessment and
attends the patients immediate needs.
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Nursing management during the first hours:
1. Continuing to help the patient recover from effects
of anesthesia, monitoring for complications,
managing pains & implementing measures to achieve
full recovery.
•
•
Vital signs are recorded every 15 min. for first hour, and
every 30m for the next 2 hours.
The temperature is monitored every 4 hours for the first
24 hours.
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2. Assessing and managing ventilation:
• The patient is observed for airway patency and the quality of
respiration.
• Auscultate chest to verify normal breath sounds,
noisy breathing may be due to obstruction by secretion or
the tongue.
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Assessing and managing hemodynamic stability:
•
Assess for signs of hemorrhage and shock.
•
IV fluid replacement in the first 24 hours.
•
I&O recorded.
•
Maintain open IV lines.
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• Urine output ↓ 30ml/hr is reported.
• Hgb & HCT are monitored
• Observe for S&S of dehydration and DVT.
• Leg exercise, early ambulation and anti _embolism
stockings are recommended.
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3. Assessing and managing the surgical site
• Observe surgical site for bleeding , integrity of dressing and
drains.
Drains:
•
•
Closed (wound suction device) .
Open (into the dressing ).
• Drains help to remove blood , which is good media for
bacteria to growth, sometimes hemovac drain is used to get
rid of bleeding or serous fluids.
o Assess the amount &type of secretion.
o Dressing should be reinforced in case of bleeding.
.
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5. Assessing and managing pain:
• Giving pain medications such as pethidine to↓pain ( P.R.N or
q 6 hrs )
• Changing position , using distraction , washing the face ,
back massage are helpful.
6. Maintaining normal body temp.:
• Monitor temp / 4 hours in the first 24 hours.
• Maintain comfortable & warm room to prevent hypothermia.
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7. Assessing mental status:
• Level of consciousness , speech , orientation.
8. Assess neurovascular status:
• Observe signs & symptoms of thrombosis.
• Ask the patient to move hand and feet.
• Assess peripheral pulse.
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9. Assessing and managing gastrointestinal function:
•
N&V are common after anesthesia.
•
Common in lengthy surgery and obese women .
•
Ingestion of food and fluid before resuming of peristalsis.
•
Antiemetic may be given .
•
NG tube may be inserted.
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•
Turn patient to one side to avoid aspiration.
•
Hiccup due to phrenic nerve irritation , if persist.
phenothiazine may be needed.
•
Start fluid and diet gradually as prescribed.
•
Sips of H2o, clear full soft regular diet.
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 Assessing and Managing Voluntary Voiding:
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Urinary retention.
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Assess for bladder distension.
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Patient expect to 8 hours after surgery.
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Catheterization may be required.
-
All methods to encourage voiding should be used.
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 Encouraging activity:
• Encourage early ambulation as early as possible to avoid postop
complications. (such as Atelactasis and DVT)
• Orthostatic hypotension
• Bed exercise
 Arm exercises
 Hand + finger exercise
 Root exercise
 Leg flexion
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 Maintaining a safe environment:
- Side rails up.
- Assess level of consciousness , orientation.
- The patient may need for glasses or hearing aids.
The first postop. Day to day of discharge:
. Vital signs
. Pain level
. Nutritional status
. ABD. Destination
. Monitor Hgb &HCT
. Assess respiratory rate
. Wound integrity
. Bowel sounds
. Passage of flatus or stool
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 NSG. Diagnosis:
1.Pain R/ T surgical incision.
2.Risk for ineffective airway clearance R/T depressed
respiratory function.
3.Activity intolerance R/T pain.
4.Weakness secondary to surgery.
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Post Operative Complication
1. Shock:
a- Hypovolemic shock :lack of tissue perfusion
(inadequate cellular oxygenation ) caused by fluid volume
deficit , hemorrhage ,& inadequate fluid replacement
b- Neurogenic shock : dysfunction of the nervous system
due to spinal anesthesia characterized by hypotension
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2. Hemorrhage:
•
Primary hemorrhage :occur at time of surgery.
•
Intermediate hemorrhage :first few hours after surgery.
•
Secondary hemorrhage :occur some time after surgery
because of insecurely tide of suture.
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3. Deep Venous Thrombosis (DVT):
A condition in which the blood changes from a liquid to
solid state and produces a blood clot in the deep vein rather
than in superficial one.
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4. Pain
5. Pulmonary embolism:
 ... Embolus is a foreign body (blood clot , air , fat ) that
lodged in an artery and obstruct blood flow.
Pulmonary Embolism : obstruction of the pulmonary
artery by an embolus , usually a blood clot derived
from phlebothrombosis of the leg veins .
 The patient will have dyspnea ,chest pain & dysrhythmia
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6. Respiratory complications

Hypoxemia : a constant low level of O2

Atelactasis : incomplete expansion of the lung

Bronchitis : inflammation of the bronchi occurs within
the first 5 to 6 days postoperatively

Pleurisy : inflammation of the pleura , it occurs
postoperatively due to pneumonia the patient
will have sever pain on deep breathing
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7. Urinary retention
Urine retention occur postoperatively due to spasm of the
bladder sphincter
8. Gastrointestinal complications :
Intestinal obstruction : the symptoms occur between the
third and fifth days postoperatively, the case is
some obstruction of the intestinal flow
9. Wound infection
appear 5 days after surgery
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Nursing interventions for postoperative complications
 Relieving pain:
• Assess pain level, effectiveness of pain medication.
• Offer pain medication of intervals.
• Relaxation and massage.
 Preventing Resp. complications (Atelactasis)
• Perform deep breathing and cough
• Early ambulation and exercise
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 Preventing DVT:
- Surgery , dehydration, are risk factors for thrombosis
- Assess for homans' signs :( pain felt in the calf when the foot is
flexed backwards)
- Early ambulation , exercise , & adequate hydration are
considered as preventive measure
- Elastic stocking may be used
- Low dose of heparin can be used
Preventing wound infection
. Surgical site infection is the most common nosocomial
infection
. Risk factors(age ,nutritional status ,DM, smoking , obesities)
. Risk factor related to surgical procedure
. Method of skin preparation
. Method of sterile dropping
. Drain
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. Assess signs & symptoms of infections:
• Pain
• Redness
• Hotness
• Loss of function
• Swelling
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Managing wound complications
Hematoma :
. If small, will be absorbed
. If big , several sutures are removed to evacuated blood
Infection
. Assess s&s of infection
. Risk factor
. When diagnosed one or more sutures are removed
intestine are covered with sterile dressing moistened with
sterile saline
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 Wound Dehiscence and Evisceration:
. Dehiscence : disruption of surgical incision
. Evisceration : profusion of wound contents
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