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Perioperative Nursing Care
Definition of Surgery
Surgery is any procedure performed on
the human body that uses instruments to
alter tissue or organ integrity.
Perioperative Nursing Care
Perioperative Nursing- connotes the delivery of patient
care in the preoperative,intraoperative, and postoperative
periods of the patients surgical experience through the
framework of the nursing process. The nurse assesses the
patient- collecting,organizing, and prioritizing patient data;
establishing nursing diagnosis;identifies desired patient
outcomes;develop and implements a plan of care; and
evaluates that care in terms of outcomes achieved by the
patient.
Perioperative Nursing Care
Type of Surgery
Seriousness: Degree of risk
Major- Involves extensive reconstruction
or alteration in body parts;poses great risks.
Minor- Involves minimal alteration in
body parts;often designed to correct
deformities;involves minimal risk compared
with major procedures.
Perioperative Nursing Care
Types of Surgery
Urgency: reason for procedure:
Elective-Performed on the basis of client’s choice;
not essential and may not necessary for health.
Urgent- Necessary for client’ health,may prevent
additional problem from developing (e.g. tissue
destruction);not necessarily emergency.
Emergent- Must be done immediately to save life
or preserve function of body part.
Required- Has to performed at some point;can be
pre-scheduled.
Perioperative Nursing
Types of Surgery
Diagnostic-Allows to confirm diagnosis.
Corrective- Excision or removal of diseased body
part.
Reconstructive-Restore function or appearance to
traumatized or malfunctioning tissues.
Perioperative Nursing
Types of Surgery
Procurement for transplant- Removal of
organs and/or tissues from a person
pronounced brain death for transplantation
into another person.
Constructive- Restores function lost or
reduced as result of congenital anomalies.
Cosmetic- Performed to improve personal
appearance.
Perioperative Nursing
Types of Surgery
Extent of surgery :
Simple- Only the most overtly affected
areas involved in the surgery.
Radical- Extensive surgery beyond the
area obviously involved; is directed at
finding a root cause.
Location: Based on the area of the body on
which the surgery occurs (e.g abdominal,
heart surgery).
Perioperative Nursing Care
Surgical settings
Surgical suites
Ambulatory care setting
Clinics
Physician offices
Community setting
Homes
Perioperative Nursing Care
Surgical settings
Disadvantages
Less time for rapport
Less time to assess, evaluation, teach
Risk of potential complication post D/C.
Advantages of outpatient:
Low cost
Low risk of infection
Less interruption of routine
Less than from work
Less stress
Perioperative Nursing Care
Method of teaching
Timing-most useful when started the week before
admission and reinforced before surgery and the
client is less anxious.
Content:
Surgical Procedure
Preoperative routines
Intraoperative routines
Postoperative routines
Sensory preparation
Pain relief
Perioperative Nursing Care
Phases
Preoperative-begins with the decision for surgical
intervention and ends with transfer to the OR.
Nursing Interventions
Baseline assessment during interview at
clinic,office or over the phone.
Assessment in the pre-admission unit, client
room, holding area or induction room
Perioperative Nursing Care
Preoperative Surgical Phase
Assessment:
Nursing History-key elements that pertains to
the surgical client’s risks and needs. Information
concerning about advance directives. Ask if the
patient has a durable power of attorney for health
care and a living will.
Medical History- includes past illnesses and
the primary reason for seeking medical care.
Perioperative Nursing Care
Preoperative Surgical Phase
Assessment continue…..
Previous surgeries- past experience with
surgery can reveal potential physical and
psychological responses to procedure and alert
you to special needs and risk factors.
Complications such as anaphylaxis or malignant
hyperthermia.
Medication History- any medications that
might predispose to surgical complications.
Perioperative Nursing Care
Preoperative Surgical Phase
Allergies- to medications, topical agents used to prepare
the skin for surgery, and latex can create significant
risks.
Smoking Habits – greater risks for complications.
Alcohol and Controlled Substance Use and abuse- to
be prepared for adverse reactions, such as withdrawal,
that may occur during surgery.
Client Expectations- to identify the client’s and family
perceptions and expectations regarding surgery and
health care providers.
Perioperative Nursing Care
Preoperative Surgical Phase
Family Support- determine the extent of the client’s
support from family members or friends.
Occupation- surgery may result in physical
alterations that hinder or prevent a person from returning
from work.
Feeling- surgery causes anxiety and a feeling of loss
of control for most clients.
Cultural and Spiritual Factors- cultural differences
in the use of both verbal and nonverbal communication
require you to validate interpretation of cues with the
client and family.
Perioperative Nursing Care
Preoperative Surgical Phase
Coping Resources- assessment of a
client’s feeling and self-concept helps to
reveal whether the client has the ability to
cope with the stress of surgery.
Body image-surgical removal of a
diseased tissue often leaves permanent
disfigurement or alteration in body function.
Perioperative Nursing Care
Selected factors that in increase surgical risk.
Age- Very young and older clients.
Nutrition- a malnourished client is prone to
poor tolerance of anesthesia, infection, poor
wound healing and the potential for
multiple organ failure after surgery.
Obesity- often have difficulty in resuming
normal activity after surgery.
Perioperative Nursing Care
Physical assessment/clinical manifestations
General survey- gestures and body movements
may reflect decreased energy or weakness caused
by illness.
Cardiovascular system- alterations in cardiac
status are responsible for as many as 30% of
perioperative death.
Respiratory system- a decline in ventilatory
function, assessed through breathing pattern and
chest excursion, may indicate a client’s risk for
respiratory complications.
Perioperative Nursing Care
Physical assessment/clinical manifestations
Renal system-abnormal renal function can
altered fluid and electrolyte balance and
decrease the excretion of preoperative
medications and anesthetic agents.
Neurologic system- a client’s LOC will
change as a result of general anesthesia but
should return to the preoperative LOC after
surgery.
Perioperative Nursing Care
Physical assessment/clinical manifestations
Musculoskeletal system- Deformities may interfere with
intraoperative and postoperative positioning. Avoid
positioning over an area where the the skin shows signs of
pressure over bony prominences.
Gastrointestinal system- alteration in function after
surgery may result in decreased or absent bowel sound and
distention.
Head and Neck- the condition of oral mucous membranes
reveals the level of hydration.
Perioperative Nursing Care
Gerontological Considerations
Cardiovascular
Coronary flow decreases
Heart rate decreases
Response to stress decreases
Peripheral vascular decreases
Cardiac output decreases
Cardiac reserve decreases
Perioperative Nursing Care
Gerontological Considerations
Respiratory System
Static lung volumes decreases
Pulmonary static recoil decreases
Sensitivity of the airway receptors decreases
Nervous system
Increased incidence of post.op. confusion
Increased incidence of delirium
Increased sensitivity to anesthetic agents
Perioperative Nursing Care
Gerontological Considerations
Renal System
Renal blood flow declines 1.5% per year
Renal clearance reduced
Gastrointestinal
Decreased intestinal motility
Decreased liver blood flow
Delayed gastric emptying
Perioperative Nursing Care
Gerontological Considerations
Musculoskeletal
Decreased mass, tone, strength
Decreased bone density
Integumentary
Decreased elasticity
Decreased lean body mass
Decreased subcutaneous fat
Perioperative Nursing Care
Laboratory and diagnostic studies
Screening tests depend on the condition of
the client and the nature of the surgery. If
test reveals severe problems the surgery
may be cancel until the condition is
stabilized.
Blood type and screen, urinalysis, 12
lead EKG and chest X-ray are ordered to
screen for pre-existing abnormalities.
Perioperative Nursing Care
Common nursing diagnosis
Knowledge deficit
Anxiety
Risk for ineffective airway clearance
Risk for ineffective peripheral tissue
perfusion
Perioperative Nursing Care
Preop. teaching
The education plan should begin with assessment,
including baseline knowledge of the patient and
family, readiness to learn,barriers to learning,
patient and family concern and learning styles and
preferences.
The content focuses on information that will
increase patient’s familiarity with procedural
events. This includes surgical experience
(procedural), what the pt. may experience (sensory)
and what actions may help decrease anxiety
(behavioral).
Perioperative Nursing Care
Anxiety
The nurse must consider the pt’s family
and friends when planning psychological
support.
Empowering their sense of control.
Activities that decreasing anxiety are
deep breathing, relaxation exercises,
music therapy, massage and animalassisted therapy.
Use of medication to relieve anxiety.
Perioperative Nursing Care
Preanesthesia Management Physical Status Categories
ASA 1: Healthy patient with no disease
ASA 11: Mild systemic ds without fx limitations
ASA 111:Severe systemic ds associated with definite fx
limitations
ASA 1V: Severe systemic ds that is a constant threat to
life.
ASA V: Moribund pt. Who is not expected to survive
without the operation.
ASA V1: A declared brain-death whose organ are being
recovered for donor.
E: Emergency
Perioperative Nursing Care
Final Preparation for surgery
All personal belongings are identified and
secured.
Jewelry is usually removed.
Dentures are removed, labeled and
placed in a denture cup.
Pt. to verbally confirm the surgical
procedures and the surgical site. This
verification process is documented in the
medical record on the preop. checklist.
Perioperative Nursing Care
Pre-op. medications
Prior to administering – check permits
Purpose: Allay anxiety
Decrease pharyngeal secretionsdecrease gastric secretions.
Decrease side effects of anesthesia
Induce amnesia
Perioperative Nursing Care
Medications
Sedatives/hypnotics- Nembutal
Tranquilizers-Ativan, versed, valium
Opiate analgesics- Demerol, morphine
Anticholinergics-Atropine sulfate,atarax
H2o blockers.- Tagamet, Zantac
Antiemetic- Reglan, Phenergan
Perioperative Nursing Care
Phases
Intraoperative- Transferred to OR-ends with the transfer
to the recovery area.
Nursing Interventions
Communicating plan of care
Identifying nursing activities
Establishing priorities
Coordinate care with team members
Coordinate supplies and equipment
Control environment
Document plan of care
Perioperative Nursing Care
Intraoperative Roles
Surgeon
Anesthesiologist
Scrub Nurse
Circulating Nurse
OR techs
Perioperative Nursing Care
Intraoperative Phase- Surgical team
Surgeon-responsible for determining the preoperative
diagnosis, the choice and execution of the surgical
procedure, the explanation of the risks and benefits,
obtaining inform consent and the postoperative
management of the patient’s care.
Scrub nurse- (RN or Scrub tech )- preparation of
supplies and equipment on the sterile field; maintenance
of pt.s safety and integrity: observation of the scrubbed
team for breaks in the sterile fields; provision of
appropriate sterile instrumentation, sutures, and supplies;
sharps count.
Perioperative Nursing Care
Surgical team
Circulating Nurse - responsible for creating a safe
environment, managing the activities outside the
sterile field, providing nursing care to the patient.
Documenting intraoperative nursing care and ensuring
surgical specimens are identified and place in the right
media. In charge of the instrument and sharps count
and communicating relevant information to individual
outside of the OR, such as family members.
Perioperative Nursing Care
Surgical team
Anesthesiologist and anesthetist- anesthetizing
the pt. providing appropriate levels of pain
relief, monitoring the pt’s physiologic status and
providing the best operative conditions for the
surgeons.
Other personnel- pathologist, radiologist,
perfusionist, EVS personnel.
Perioperative Nursing Care
Surgical team
Nursing Roles:
Staff education
Client/family teaching
Support and reassurance
Advocacy
Control of the environment
Provision of resources
Maintenance of asepsis
Monitoring of physiologic and psychological
status
Perioperative Nursing Care
Surgical asepsis
Ensure sterility
Alert for breaks
Perioperative Nursing Care
Types of Anesthesia
Regional
Local
Nerve block
Epidural
Spinal
General
Spinal Anesthesia
Indications
-surgical procedures below the diaphragm
-patients with cardiac or respiratory disease
Advantages
-mental status monitoring
-shorter recovery
Disadvantages
-necessary extra expertise
-possible patient pain
Contraindications
-coagulopathy
-uncorrected hypovolemia
Spinal Anesthesia
Involved medications
-lidocaine
-bupivacaine
-tetracaine
Patient assessment
-continuous heart rate, rhythm, and pulse
oximetry monitoring
-level of anesthesia
-motor function and sensation return
monitoring
Spinal Anesthesia
Complications
-hypotension
-bradycardia
-urine retention
-postural puncture headache
-back pain
Spinal analgesia
Indications
-postoperative pain from major surgery
Involved medications
-lipid-soluble drugs
-preservative-free morphine
Monitoring recovery
-respiratory depression
-urine depression
-pruritus
-nausea and vomiting
Perioperative Nursing Care
Phases
Postoperative- Begins with transfer to PACU and
ends with the discharge of the patients from the
surgical facility or the hospital.
Nursing Interventions
Communicating pertinent information about surgery
to the PACU staff.
Postoperative evaluation in clinic or home.
Perioperative Nursing Care
Nursing assessment in the PACU
Vital signs- presence of artificial airway, o2
sat,BP,pulse, temperature.
LOC- ability to follow command, pupillary
response
Urinary output
Skin integrity
Pain
Condition of surgical wound
Presence of IV lines
Position of patient
Perioperative Nursing Care
Nursing Diagnosis
Ineffective airway clearance- increased
secretions 2 to anesthesia, ineffective
cough, pain
Ineffective breathing pattern- anesthetic and
drug effects, incisional pain
Acute pain
Urinary retention
Risk for infection
Perioperative Nursing Care
Postoperative Management
Maintain a patent airway
Stabilize vital signs
Ensure patient safety
Provide pain
Recognize & manage complications
Perioperative Nursing Care
When caring for post-surgical patient,
think of the “4 W’s”
Wind: prevent respiratory
complications
Wound: prevent infection
Water: monitor I & O
Walk: prevent thrombophlebitis
Perioperative Nursing Care
Complications
Respiratory- atelectasis, pulm. Embolus
Cardiovascular- venous thrombosis
Gastrointestinal-Hiccoughs, N/V,abd.
Distention, paralytic ileus, stress ulcer.
GU- urinary retention
Hemorrhage-slipping of a ligature(suture)
Wound infectionWound dehiscence and evisceration-
Perioperative Nursing Care
Gerontologic considerations
Mental status- attributed to medications,
pain, anxiety, depression.
Delirium- infection, malignancy, trauma,
MI, CHF, opioid use.
Dementia-sundowning-sleep disturbances,
lack of structure in the afternoon or early
morning, sleep apnea.