operative nursing

PERIOPERATIVE NURSING

Michael Angelo Abubo, Biologist, RN, RM, MCN- C

Learning Objectives:• At the end of the discussion, nursing students will

be able toa. State different conditions requiring surgical interventionsb. Classify surgical procedures according to purpose,

degree of risk, urgencyc. Describe the different risk factors to surgery and effects

of surgery to clientd. Design plan of care for a client during the pre, intra and

post operative periode. Appreciate the knowledge, skills and attitudes necessary

for providing quality care of clients undergoing surgery.

Perioperative Nursing- Goal: assist clients and their families and significant

others to achieve a level of wellness after the procedure

Phases of surgery:• Pre-operative phase - begins with the decision to

perform surgery and ends with the clients transfer to the operating room table

• Intraoperative phase –begins when the client is received in the OR and ends with his admission to the PACU

• Postoperative phase – admitted to PACU and extends through follow up home or clinic evaluation

Q: The sterile nurse touch only sterile supplies and instruments. When there is a need for sterile supply which is not in the sterile field, who hands out these items by opening its outer cover?

• a. Circulating Nurse

• b. Anesthesiologist

• c. Surgeon

• d. Nursing Aide

ANSWER:

A. Circulating Nurse

Surgical Team

1. Preop Team• Preop nurse: performs preop assessment;

prepares patient for surgeryPhysician: performs preop history and PE

2. OR team

Sterile MemberSurgeon: performs surgeryScrub nurse: sets up special equipment, sterile table and

suture; assist during the procedure and maintains sterile surgical field

First assistant: assist the surgeon during surgery

Q: It is the responsibility of the pre-op nurse to do skin prep for patients undergoing surgery. If hair at the operative site is not shaved, what should be done to make suturing easy and lessen chance of incision infection?

a. Drapedb. Pulledc. Clippedd. Shampooed

Q: Which of the following should be given highest priority when receiving patient in the OR?

a. Assess level of consciousnessb. Verify patient identification and

informed consentc. Assess vital signsd. Check for jewelry, gown, manicure,

and dentures

Surgical TeamNon sterile Members

Anesthesiologist: administers anesthesia, monitors patient’s VS

Circulating nurse: manages patient care, coordinates activities of OR personnel

3. Post operative Team• Post anesthesia nurse: care of patient in the

post anesthesia care unit (PACU)

Surgical Environment• 3 zones

a. Unrestricted zone (street clothes)

b. Semirestricted zone (attire consists of scrub clothes and caps

c. Restricted zone (scrub clothes, shoe covers, caps and mask are worn)

Four Types of Conditions Requiring Surgery

• OBSTRUCTION

- Impairment to the flow of vital fluids, e.g. blood, urine, bile, CSF

• PERFORATION

- Rupture of an organ

- e.g. ruptured appendicitis, ruptured uterus

Four Types of Conditions Requiring Surgery

• EROSION

- Wearing off of a surface or membrane

- e.g. ruptured uterus

• TUMORS

- Abnormal new growth

- e.g. breast tumor, bone tumor, lung tumor, brain tumor

A client having excess fat suctioned from the thighs for

cosmetic reasons is an example of which category of

surgery?

a. Optionalb. Electivec. Requiredd. Urgent

Answer: A• Rationale:

Cosmetic surgeries by definition, are most often optional, they are done totally at the client’s education

Elective surgery refers to the procedures that are scheduled at the clients convenience (e.g. cyst removal, repair of scars or simple hernia)

Required surgery is warranted for conditions necessitating intervention within a few weeks (e.g. cataract surgery, thyroid disorders)

Urgent/Imperative Surgery is indicated for a problem requiring intervention within 24 to 48 hours (e.g. some cancers, acute gallbladder infection, appendicitis, kidney stones)

Classification of Surgery

A. According to its purpose

1. Diagnostics

- To confirm the presence of a disease condition, e.g. biopsy

2. Exploratory

- Extent of the disease condition e.g. Ex-Lap

Classification of Surgery

A. According to its purpose

3. Curative

- To treat the disease condition

3 types

a. Ablative

b. Constructive

c. Reconstructive

Types of Curativea. ABLATIVE

(removal of an organ, e.g. suffix used is “ectomy”)

b. CONSTRUCTIVE

( repair of congenitally defective organ, e.g. suffix used are “plasty”)

c. RECONSTRUCTIVE

(repair of damaged organ, e.g. plastic surgery after severe pains, scar revision)

4. PALLIATIVE

(to relieve distressing signs and symptoms, not necessarily to cure the disease)

e.g. colostomy, debridement of necrotic tissues, resection of nerve roots)

B. According to Urgency

1. Emergent(procedures must bone immediately to sustain functioning, e.g.

repair of ruptured aortic aneurysm, gunshot or knife wounds, extensive burns, fractured of the skull)

2. Urgent /Imperative ( a problem requiring intervention within 24-48 hours, e.g.

appendicitis)

3. Required(warranted for conditions necessitating intervention within a

few weeks (e.g. catacract surgery, thyroidectomy)

B. According to Urgency

4. Elective(procedures that are schedule at the clients’ convenience , e.g.

cyst removal, vaginal repair)

5. Optional(done totally at the clients discretion, e.g. cosmetic surgery)

Degree of Risk/Magnititue/Extent

a. Major

e.g. craniotomy, open heart surgery, pneumonectomy, TAHBSO

Criteria for major surgery.

1. High risk of morbidity/mortality

2. Extensive and prolonged

3. Large amount of blood loss

4. Involves great risk of occurrence of complications

Minor Surgery• E.g. appendectomy

• Generally, the procedure is not prolonged

• Does not usually involve serious complications

Who are at risk for surgery?a. Aging

b. Obesity

c. Fluid and Electrolyte Imbalance

d. Presence of disease

e. Medication taken

1. AGING • Older clients have less physiologic reserve

than younger clients

• Physiologic reserve

- The ability of an organ to return to normal after a disturbance in its equilibrium

2. Obesity• Increases difficulty in technical aspects of

performing surgery

• Wound dehiscence is greater

• Increases likelihood of infection because of lessened resitance

3. Poor Nutrition• Preoperative malnutrition greatly impairs

wound healing

• Increases risk of infection and shock

4. Fluid and Electrolyte Imbalances

• Dehydration and electrolyte imbalances can have an adverse effect in terms of general anesthesia and the anticipated volume losses associated with surgery, causing shock and cardiac dysrhythmias

5. Presence of Disease• Many surgical procedures may be

complicated in the presence of cardiovascular compromise

• The client may experience dysrhythmias, shock, or cardiac arrest during surgery

6. Presence of Diabetes Mellitus• Hyperglycemia is potentiated by increased

cathecolamines and glucocorticoids due to surgical stress

• Poor wound healing may be experienced by the diabetic client

7. Presence of alcoholism• Alcoholism is usually accompanied by

problems of malnutrition

• Client may also have an increased tolerance to anesthetics

Preoperative phase

Goals:

1.Assessing and correcting physiologic and psychologic problems that are surgical risk

2. Teach the client and the relatives regarding surgery

Preoperative phase

Goals:

3. Instruct and demonstrate exercise that will benefit the person during postoperative period

4. Planning for discharge begins

Basic Guidelines for Surgical Asepsis

• All materials in contact with the wound and within the sterile field must be sterile.

• Gowns are sterile in the front from chest to the level of the sterile field, and sleeves from 2 inches above the elbow to the cuff.

Basic Guidelines for Surgical Asepsis

• Only the top of a draped table is considered sterile. During draping, the drape is held well above the area and is placed from front to back.

• Items are dispensed by methods to preserve sterility.

• Movements of the surgical team are from sterile to sterile and from unsterile to unsterile only.

Basic Guidelines for Surgical Asepsis

• Movement around the sterile field must not cause contamination of the field. At least a 1-foot distance from the sterile field must be maintained.

• Whenever a sterile barrier is breached, the area is considered contaminated.

Basic Guidelines for Surgical Asepsis

• Every sterile field is constantly maintained and monitored. Items of doubtful sterility are considered unsterile.

• Sterile fields are prepared as close as possible to time of use.

Preoperative phase

1. Informed consent

• The surgeon who will perform surgery explains the procedure and the risks

• Responsible for obtaining patient’s signature

• Nurse: witness

Circumstances requiring written consent are as follows:

• Any surgical procedure where special, scissors, suture, hemostats of electrocoagulation may be used

• Any procedure that involves general anesthesia, local infiltration anesthesia or regional block anesthesisa

• Any invasive procedure that involves entry into a body cavity

e.g. paracentesis, bronchoscopy, cystoscopy

Requisites for validity of written informed consent

1. Written permit/consent is best and legally practice

2. Patients’signature is obtained with the client’s complete understanding of what is to occur

- Adults sign their own consent unless he/she is physically and mentally incapacitated

If the patient is a child or minor (below 18 years old), the parent or legal guardian will sign the consent

3. Consent is obtained before sedation

4. The patient is not under the influence of drugs or alcohol

5. Consent is secured without pressure or duress

6. Signature of witness is required

7. In an emergency, permission via telephone or telefax is acceptable

- The physician should document the nature of the emergency situation

8. Emancipated minors are allowed to sign without written consent

• Emancipated minors- Married- Live on their own- Financially independent from their parents

(U.S. only)

Nursing Priority: The consent/permit should be signed before the clients receives preoperative medications

Preoperative phase

2. Physical preparation

a. Restore adequate blood volume with BT

b. Treat any infectious process

c. Teaching: incentive spirometry, DBCT, turning, foot and leg excercises

d. NPO; cleansing enemas

e. Preparing the skin: full bath

f. remove dentures, colored nail polishg. VS before preop medication

h. accomplish the “preop checklist” p. 439 Brunner and Suddarth 2010

Diaphragmatic Breathing and Splinting When Coughing

Leg Exercises and Foot Exercises

BEST PRACTICE• If surgery will be done to a body part which

is present on both sides of the body, e.g. eyes, ears, arms, breast, legs,…practice “TIME OUT” to check if the right patient is sent for surgery

Preparing for anesthesia• The patient should avoid alcohol and

cigarette smoking for atleast 24 hours before surgery

• This can help reduce potential complication

Preoperative MEDICATIONS• Purposes

1. Facilitate admnistration of any anesthetic

2. Minimize respiratory tract secretions and changes in the heart rate

3. To relax the client and reduce anxiety

Types of Pre op Meds• Opiates

-Morphine (Roxanol) & Meperidine (Demerol)

- To relax the patient and potentiate anesthesia

Types of Pre op Meds• Anticholinergic- Atropine SO4, Scopolamine- To reduce respiratory tract secretions - To prevent severe reflex slowing of the heart

during anesthesia

• Barbiturates/Tranquilizers-Phenobarbital (Nembutal)- Hypnotic agents are given the night before

surgery to help ensure a restful night’s sleep

Types of Pre op Meds• Prophylactic Antibiotic

- Before or during surgery when bacterial contamination is expected

- Ideally before skin incision is made

Best Practice• Preanesthetic medications should be

given exactly at the time they are prescribed

• If given too early, the maximum potency will have passed before it is needed

• If given too late, action will not have began before anesthesia is started

Possible Diagnosis during Preop

• Anxiety

• Fear

• Knowledge Deficit

• Pain

Environmental control• Standard OR ventilation – 15 air exchanges/hr • Standard temp. – 20 – 24 C( 68-73 F)• Standard humidity – 30 – 60%

Health Hazards in Environment :

a.Laser risks = smoke evacuators/ “warning signs”

b.Exposure to blood/ body fluids = *“double gloving”

c.Latex allergies p. 432

Intraoperative Phase• Goals of Care

1. Asepsis and Infection Control

2. Homeostasis

3. Safe Administration of Anesthesia

4. Hemostasis

Surgical Conscience – attention to specific principles during the perioperative period

Preparation during intraoperative

• Shaving, clipping, trimming, using a depilatory

• Disinfect the skin

(povidone-iodine, chlorhexidine, alcohol and hexachlorophene)

• Skin of the surgical team is scrubbed

-Use a brush and nail cleaner or foam preaparation

Intraoperative PhaseTypes of anesthesia:1. General: total loss of consciousness and sensation

- Per IV, inhalation- e.g. nitrous oxide (blue tank)

2. Regional: reduce all painful sensation in one region of the body

a. Spinal: anesthesia injected in subarachnoid space; on 3rd or 4th lumbar space 25-26 G spinal needleSE: Hypotension and respiratory depression(monitor VS), spinal headache(flat on bed )

b. Epidural:injection of anesthetic into the epidural space w/o puncturing the dura, intervertebral space depends on location of procedure, 17G or 18 G blunt-tipped needle is used, spinal headache rare

3. Local

Spinal anesthesia

Differences between Epidural and Spinal Anesthesia

• The involved space is larger for an epidural, and subsequently the injected dose is larger, being about 10–20 mL in epidural anaesthesia compared to 1.5–3.5 mL in a spinal.

• In an epidural, an indwelling catheter may be placed that avails for additional injections later, while a spinal is almost always a one-shot only.

• The onset of analgesia is approximately 15–30 minutes in an epidural, while it is approximately 5 minutes in a spinal.

• An epidural often does not cause as significant neuromuscular block unless specific local anaesthetics are used which block motor fibres as readily An epidural may be given at a cervical, thoracic, or lumbar site, while a spinal must be injected below L2 to avoid piercing the spinal cord.

as sensory nerve fibres, while a spinal more often does.

Stages of anesthesia• Onset/Induction: from administration of

anesthesia to time of loss of consciousness• Excitement/Delirium: from time of loss of

consciousness to time of loss of lid reflex• Surgical: from loss of lid reflex to loss of most

reflexes. Surgical procedure is started• Medullary/Depression: characterized by cardiac

and respiratory depression. Due to anesthesia overdose, resuscitation must be done

Complications• Nausea and Vomiting

• Anaphylaxis

• Hypothermia

• Malignant Hyperthermia

• Respiratory Paralysis

• Neurologic Complications (paraplegia)

1. Nausea & vomiting – Intervention : turned to side/ HOB elevated/ offer basin for vomitus

*Tx- Anti-emetic - always check for breath

sounds if suspicious of aspiration2. Anaphylaxis – allergic reaction3. Hypoxia – due to inadequate ventilation/

airway occlusion/ inadequate intubation of esophagus

*Familiarize with the equipment

4. Hypothermia ( <36.6 C , <98 F)*due to – COLD OR/gases/fluids/ GA/specific

surgery such as Bypass surgery *Intervention- “wet” drapes – changed

immediately-hydrate-check OR temp/fluids

5. Malignant hyperthermia* rare inherited muscle disorder induced by anesthetics

Susceptible to Malignant Hyperthermia:Bulky musclesHx of muscle crampsHx of muscle weaknessHx of relatives unexplained death during

surgery with febrile episode*Pathophysio:

-altered mechanism of Calcium function (hypermetabolism)-muscle rigidity/ hyperthermia

Triggering factors : inhalation anesthetics & muscle relaxant ( succinylcholine)

Manifestation : initial – cardiac & musculoskeletal

HR>150 , muscle rigidity Late - INC. temp*

Medical management :GOAL – to DEC. metabolism/ to DEC. tempSTOP anesthesiaHyperventilate with O2 100%

Give Dantrolene Na ( muscle relaxant) + Na BicarbonateRN – s/sx monitoringNursing management : identify those at risks/ sign and

symptom for specific PERIOD/ check availability of meds

6. DIC (disseminated intravascular coagulation)*thrombus in circulation + depletion of coagulation proteins*exact Mech. – “unknown”*precipitating factors – massive trauma/transfusion/head injury/shock

SPINAL HEADACHE• - Due to leakage of CSF form the spinal

puncture needle

• Ensure adequate hydration before, during, and after the procedure

• Maintain flat on bed position 6 to 12 hours after procedure

• Administer analgesics

Dorsal recumbent, Trendelenburg Position, Lithotomy Position, and

Side lying Position:

Positions during surgery…• Dorsal recumbent - hernia, ex lap,

cholecystectomy, mastectomy

• Trendelenburg – lower abdomen

• Lithotomy - perineal, rectal, vaginal surgery

• Prone - back, spine, rectal surgery

• Lateral - lung, kidney surgery

POST OPERATIVE Phase

1. Immediate period

-Admission to the client to recovery area

2. Intermediate Postoperative period

- Transfer from PACU to the surgical unit to Day 1 post op

Immediate Post operative Phase

• After the operation, patient is transferred to recovery room

• Cover patient with blanket.

• Siderails up

• Critical period & VS taken 15 mins

• Adrete Scoring – 7 to 8 points

Criteria in Transferring Patients from RR to Room (intermediate period)

• Stable VS (1hour)

• Intact swallow, cough & gag reflexes

• Patient is awake & can call for assistance

• No postop complications

• Patient with regional anesthesia regains motor & sensory functions

Expected Post operative Discomfort

• Nausea and vomiting

(antiemetic, NGT, deep breathing)

• Thirst

(IVF, oral fluids if tolerated/permitted, moistened gauze square over lips occasionally, hard candies, rinse the mouth)

Expected Post operative Discomfort

• Constipation and gas cramps

(early ambulation, increase hydration, proper diet, assess bowel sounds, encourage non use of analgesia)

• Post-operative pain

(IV parenteral analgesic 2-4 days, then oral)

Best Practices• The client who remains sedated due to

analgesia is at risk for complications such as aspiration, respiratory depression, atelectasis, hypotension, falls and poor postoperative course

• Promotion of client’s safety should be given priority

Nursing Interventions:

• Return of patient to the unit• Unit nurse accompanies patient to room &

facilitate transfer from the OR stretcher to room bed

• Make initial assessment- q 15 mins until stable- q 30 mins for 2 hrs- hourly for 4 hrs- q 4 for 24 – 48 hrs

• Carry out interventions & post op orders

Post-operative Complications

1. Shock: decrease in circulating blood volume due to hypoxia

(have blood available if needed, monitor I and O, VS – hypotachytachy)

2. Hemorrhage – copious escape of blood from the blood vessel

- restlesstness, thirst, cold, moist, pale skin

- (assess possible site of bleeding)

Post-operative Complications

3. Deep vein thrombosis: (+) Homan sign (pain or cramps in the calf)

• Elevate legs

• Administer anticoagulant (heparin, warfarin)

• Anti-embolic stockings

Post-operative Complications

4. Pulmonary complication• DBCT, incentive spirometry

5. Urinary difficulties: absence of voiding, bladder distention

• Encourage normal voiding, catheterization

6. Infection; redness (rubor), pain (dolor), heat (calor), purulent discharge

• - Obtain C/S• - Administer antibiotic and wound irrigation

7. Intestinal Obstruction

- Auscultate the four quadrants of the abdomen for 5 minutes before concluding that there is absence of bowel sounds

8. Wound complication:

• Wound dehisence: wound breakdown

• Wound evisceration: dehiscence + outpouching of abdominal organs

• Cover exposed intestine with sterile moist saline dressing

Q. Which of the following role would be the responsibility of the scrub nurse?

a. Assess the readiness of the client prior to surgery

b. Ensure that the airway is adequate c. Account for the number of sponges,

needles, supplies, used during the surgical procedure.

d. Evaluate the type of anesthesia appropriate for the surgical client

Q. The OR team performs distinct roles for one surgical procedure to be accomplished within a prescribed time frame and deliver a standard patient outcome. While the surgeon performs the surgical procedure, who monitors the status of the client ?

• a. Scrub Nurse• b. Surgeon• c. Anaesthesiologist• d. Circulating Nurse

Care of the Client after surgery

A. Immediate postoperative assessment

a. Respiratory status

b. Cardiovascular status

c. Neurologic status

Nursing Dx (post op)• Fear

• Pain

• Anxiety

• Altered Body Image

Nursing Interventions• Maintain a patent airway

• Maintaining cardiovascular stability

• Relieving pain and anxiety

• Controlling nausea and vomiting

• Discharge from PACU

THANK YOU!!!