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DR. AHMAD AQEL

2018

Perioperative Nursing

Preoperative phase: from decision for surgery until transferred into operating room

Intraoperative phase: from transferred into operating room to admission to post-

anesthesia care unit(PACU)

Postoperative phase: from admitted to PACU to follow-up evaluation in clinical

setting or at home

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Surgical Classifications

The decision to perform surgery may be based on

1. Facilitating a diagnosis (biopsy, exploratory laparotomy)

2. A cure (excision of a tumor or inflamed appendix),

3. Repair (e.g., multiple wound repair).

4. Reconstructive or cosmetic (such as mammoplasty )

5. Palliative (Surgery to reduce the size and compression of a tumor to relieve pain or permit comfort).

6. Rehabilitative (e.g., total joint replacement surgery to correct crippling pain)

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Classification Indications for Surgery Examples

Emergent:immediate attention; life threatening condition

Without delay Severe bleeding, intestinal obstruction Fractured skull, Gunshot or stab wounds Extensive burns

Urgent—prompt attention Within 24–30 h Acute gallbladder infection Kidney or ureteral stones

Required—Patient needs to have surgery

Plan within a few weeks or months

Prostatic hyperplasia without bladder obstruction, Thyroid disorders, Cataracts

Elective—Patient should have surgery

Failure to have surgery not catastrophic

Repair of scars, Simple hernia, Vaginal repair

Optional—Patient decision Personal preference Cosmetic surgery

Categories of Surgery Based on Urgency

Pre Operative Assessment

• Preoperative assessment

• Teaching based on patient’s needs

• Completion of pre op. diagnostic tests.

• Understanding of preoperative orders.

• Discusses advanced-directive document

• Begins discharge planning by assessing patient’s need for postoperative transportation, care

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• The patient’s autonomous decision to undergo a surgical procedure

• Should be in writing

• contains the following:

• Explanation of procedure, risks , benefits, alternatives by the DR

• Answer all patient questions about procedure

• Patient can withdraw consent

• Any different institutional protocol

Informed consent

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• Must be freely given, without coercion

• Patient must be ≥ 18 years

• The nurse may obtain the signature but the physician is responsible to provide explanation

• Patient’s signature must be witnessed by Health care provider.

Voluntary Consent

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Incompetent Patient Individual who is not autonomous

Cannot give or withhold consent such as Cognitively impaired , Mentally ill ,unconscious

Informed consent is needed in 1. Invasive procedures

2. Procedures requiring sedation or anesthesia

3. A nonsurgical procedure that carries risks such as an arteriography, radiation therapy

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Preoperative Assessment

1. Correct malnutrition, dehydration, hypovolemia, and electrolyte imbalances to avoid the risk of complications

2. Remove dentures (airway obstruction)

3. Assess drug or alcohol use

May postpone surgery if patient is intoxicated

Insert NGT to prevent aspiration

Alcohol withdrawal syndrome may occur between 48 and 96 hours after alcohol withdrawal

Alcohol withdrawal increase mortality post operatively.

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4. Assess the need for breathing exercises, incentive spirometer

5. Assess for respiratory infection (may postpone surgery)

6. Assess tobacco use (stop smoking 4-8 weeks before surgery to reduce pulmonary complications

7. Control Blood pressure.

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8. Assess liver function test(LFT) and kidney function test (KFT)

Surgery is contraindicated in acute nephritis, acute renal insufficiency with oliguria or anuria (unless lifesaving)

9. Monitor blood glucose before, during and after surgery to avoid hypoglycemia or hyperglycemia

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10. Monitor adrenal function If patient on corticosteroids

11. Assess thyroid function.

respiratory failure may develop in hypothyroidism

thyrotoxicosis may develop in hyperthyroidism

12. Assess for allergy

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13.Assess for Immunosuppression(common with corticosteroid therapy, renal transplantation, radiation

therapy, chemotherapy, AIDS and leukemia).

14.Assess for pre-operative anxiety (fear of death, anesthesia, pain, complications)

15. Assess for previous medication use.

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Medication Effect

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General Pre-operative Nursing Interventions

Patient teaching

Providing psychosocial interventions

Maintaining patient safety

Managing nutrition, fluids

Preparing bowel

Preparing skin

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To promote optimal lung expansion post operatively

Patient education:

Sitting position & deep mouth breathing & exhale through the mouth.

How to use Incentive spirometry

Splint chest incision by hands to control pain when coughing

Short breath, exhale from the mouth, cough (prevent atelectasis and pneumonia)

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Pre-operative Nursing Interventions


To improve circulation, respiratory function and prevent venous stasis

Exercise, changing positions

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Exercise of the extremities includes: Extension and flexion of the knee and hip joints (similar to bicycle riding while lying on the side) Contraindicated in hip replacement

Preoperative educationbeginning in the physician’s office, in the clinic, or when diagnostic tests

are performed.

• Pain management – Explain pain scale & Types of pain

• Cognitive Coping strategies– Can help to relieve tension (Distraction)

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Providing psychosocial interventions

– Reducing anxiety, decreasing fear

Knowing ahead of time about the possible need for a ventilator, drainage tubes, or equipment helps decrease anxiety related to the postoperative period

– Respecting cultural, spiritual, religious beliefs

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Maintaining patient safety – Improve the accuracy of patient identification

– Improve safety of using medications

– Prevent health care–associated pressure ulcers

Managing nutrition, fluids – new recommendations fasting for

• Eight hours after eating fatty food

• Four hours after ingesting milk products

• clear liquids up to 2 hours before an elective procedure

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Preparing bowel – Enema, Laxatives

– Better visualization

Preparing skin – Removing hair around the surgical site to decrease bacteria . Use antibacterial soap bath

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Immediate Pre-operative Nursing Interventions

Gown , Remove hairpins, jewelry, make up, Voiding

Administering pre-anesthetic medication – E.g. Diazepam to relieve anxiety

– Keep the side rails up and don’t allow to walk (feeling drowsy)

– On call to OR

Maintain medical record

Pre operative checklist

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Immediate Pre-operative Nursing Interventions

Send medical chart with patient to OR

Transporting patient to pre-surgical area 30-60 minutes before the anesthesia

Keep the patient comfortable: Blanket, avoid noise & respond to family needs

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Pre-operative Instructions to Prevent Post-operative complications

• Diaphragmatic breathing

• Coughing

• Leg exercises

• Turning to side

• Getting out of bed

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Intraoperative Nursing Management DR AHMAD AQEL

Members of the Surgical Team:

Patient

Circulating nurse

Scrub nurse

Surgeon

Registered nurse first assistant

Anesthesiologist, anesthetist

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Circulating Nurse

Verifying consent

Coordinating the team

Ensuring proper temperature, humidity, lighting, function of equipment, and materials

Monitors aseptic practices

Monitors the patient

Ensuring that the second verification of the surgical procedure and site takes place

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Scrub Nurse

Performing a surgical hand scrub

Setting up the sterile tables

Preparing sutures, and special equipment (eg, laparoscope)

Assisting the surgeon; anticipating the instruments required

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The scrub person and the circulator count all needles, sponges, and instruments BEFORE CLOSING the incision

The Registered Nurse First Assistant

• Handling tissue

• Providing exposure at the operative field

• Suturing

• Maintaining hemostasis

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Anesthetist

Administer anesthesia

Intubates the patient if necessary

Manages any technical problems related to the administration of the anesthetic agent

Supervises the patient’s condition

Assess patient before surgery

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Potential Adverse Effects of Surgery and Anesthesia

Allergic reactions, drug toxicity

Cardiac dysrhythmias

CNS changes, over-sedation, under-sedation

Trauma: laryngeal, oral, nerve, skin, including burns

Hypotension

Thrombosis

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Prevention of Infection

Surgical environment Unrestricted zone: street clothes are allowed

Semi-restricted zone: attire consists of scrub clothes and caps

Restricted zone: scrub clothes, shoe covers, caps, and masks

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Prevention of infection

Surgical asepsis Surgical hand and arm

scrubbing

Gown, cap, gloves

Antiseptic solutions

Hair removal

Drape

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Environmental controls

Air filters in OR ventilations

Surface cleansing

Room temperature of 20 C to 24 C

Humidity between 30% and 60%

Positive pressure

Basic Guidelines for Surgical Asepsis

All materials in contact with wound, sterile field must be sterile

Gowns sterile in front from chest to level of sterile field, sleeves from 2 inches above elbow to cuff

Only top of draped tables considered sterile During draping, drape held well above area, placed from front to

back

Items dispensed by methods to preserve sterility e.g. opening package, the edge is unsterile

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Basic Guidelines for Surgical Asepsis

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

When sterile barrier is breached, area is considered contaminated Every sterile field is constantly maintained, monitored

Items of doubtful sterility considered unsterile

Sterile fields prepared as close as possible to time of use

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Types of Anesthesia and Sedation

General Anesthesia Inhalation

Intravenous administration

36DR.AHMAD AQEL 2016

Regional Anesthesia Epidural anesthesia Spinal Anesthesia Local Conduction block

Moderate Sedation Monitored Anesthesia Care Local Anesthesia

General Anesthesia (GA) GA: state of narcosis (severe central nervous system depression produced by pharmacologic agents), analgesia, relaxation, and reflex loss

Anesthetic medications

delivered to the brain at a high partial pressure that enables them to cross the blood–brain barrier


Patients under GA Are not arousable even to painful stimuli

They lose the ability to maintain ventilatory function

Cardiovascular function may be impaired as well


Inhalation Inhaled anesthetic agents include volatile liquid agents (e.g. Halothane) and gases (e.g. Nitrous Oxide [N2O])

Nitrous oxide is the most commonly used

Anesthetic agents enter the blood through the pulmonary capillaries

Administered through laryngeal mask or endotracheal tube


Intravenous administration Such as barbiturates, benzodiazepines, and opioid agents.

Often used in combination with inhalation anesthetic agents

useful for short procedures but is used less often for the longer procedures


Intravenous administration

Advantages: onset of anesthesia is pleasant; there is no dizziness to follow

administration of an inhalation anesthetic agent.

The duration of action is brief, and the patient awakens with little nausea or vomiting

Non-explosive

Require little equipment

Easy to administer


Intravenous administration May include muscle relaxants

IV neuromuscular blockers

block the transmission of nerve impulses at the neuromuscular junction of skeletal muscles.

used to

relax muscles in abdominal and thoracic surgery,

relax eye muscles in certain types of eye surgery,

facilitate endotracheal intubation,

treat laryngospasm, and

assist in mechanical ventilation


Regional Anesthesia Anesthetic agent is injected around nerves so that the region

supplied by these nerves is anesthetized.

Patient is awake


Epidural Anesthesia

Achieved by injecting a local anesthetic agent into the epidural

space

Blocks sensory, motor, and autonomic functions


Spinal Anesthesia Extensive conduction nerve block,

local anesthetic agent is introduced into the subarachnoid space usually between L4 and L5

Anesthesia of the lower extremities, perineum, and lower abdomen

Dose of anesthesia is lower than epidural

Overdose can result in respiratory depression and cardiac arrest


Moderate sedation conscious sedation

IV administration of analgesic medications to reduce pain and anxiety

Drug-induced depression of LOC to a “moderate” level of sedation

Patient is able to maintain a patent airway, retain protective airway reflexes, and respond to verbal and physical stimuli

Need close monitoring Pulse oximetry, ECG monitor, and VS


Monitored Sedation Care (MAC) Moderate sedation administered by an anesthetist qualified to

convert to GA if necessary

Local anesthesia with sedation and analgesia

Used for: healthy patients undergoing relatively minor surgical procedures

some critically ill patients who may be unable to tolerate anesthesia


Moderate sedation and MAC Moderate Sedation is not expected to induce depths of sedation that would impair the patient’s own ability to maintain airway.

MAC patients may experience sedation-induced compromise such as low respiratory rate, airway obstruction

Monitored Anesthesia Care allows for the safe administration of a maximal depth of sedation in excess of that provided during Moderate Sedation


Local Anesthesia

The injection of anesthetic agent into the tissues at the planned incision site (e.g. Lidocaine)

Often administered in combination with epinephrine.

Epinephrine constricts blood vessels, which prevents rapid absorption è prolongs its action


Intraoperative Complications

Nausea, vomiting

Anaphylaxis

Hypoxia, respiratory complications

Hypothermia

Malignant hyperthermia

Disseminated intravascular coagulation (DIC)

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Nausea and Vomiting

Vomiting >> aspiration >> bronchial spasms >> Pneumonitis and pulmonary edema >> hypoxia

Preoperative antiemetic

If gagging occurred

Patient is turned to the side

The head of the table is lowered

Suction to remove saliva and vomitus

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Hypoxia

Causes: Inadequate ventilation

Occlusion of the airway

intubation of the esophagus

Respiratory depression caused by anesthetic agent

Aspiration

The patient’s position on the operating table

Foreign bodies in the mouth

spasm of the vocal cords & relaxation of the tongue

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Hypoxia

Monitoring Pulse oximetry: SpO2

Peripheral perfusion

assessing peripheral pulse

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Hypothermia

Core body temperature < 36.6 C

Causes: low temperature in the OR

infusion of cold fluids

inhalation of cold gases

open body wounds or cavities

decreased muscle activity

pharmaceutical agents used (eg, vasodilators)

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Malignant hyperthermia

Inherited muscle disorder that is chemically induced by anesthetic agents • Result in altered calcium function in skeletal muscle cells.

• lead to increases muscle contraction (rigidity)

• Hyperthermia

• Damage to the central nervous system

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Nursing Interventions for the Patient in the Intraoperative Period

Reducing anxiety

Reducing latex exposure

Preventing intraoperative positioning injuries

Protecting patient from injury

Monitoring, managing potential complications

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Protecting the Patient from Injury

Patient identification

Correct informed consent

Verification of records of health history, exam

Results of diagnostic tests

Allergies (include latex allergy)

Monitoring

Safety measures

restraints, not leaving a sedated patient

Verification, accessibility of blood

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POST OPERATIVE CAREDR AHMAD AQEL

Postoperative Period

The postoperative periodextends from the time the patient leaves the operating room (OR) until the last follow-up visit with the surgeon.

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Phases of Post anesthesia Care

Phases of Post anesthesia care

Phase I, immediate recovery and intensive care is provided.

Phase II, the patient is prepared for self-care or care in the hospital or an extended care setting.

Phase III, the patient is prepared for discharge.

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Admitting the Patient to the PACU

Special care

Prevent strain on the incision.

Avoid obstruction of drains or drainage tubes.

Avoid orthostatic hypotension

Remove soiled gown and replaced with a dry gown.

Maintain body temperature and Raise side rails

Review post operative orders.

Attach Monitor and apply oxygen

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Nursing Management in the PACU

1. Assessing the PatientAssess airway, respiratory function, CV function, skin color, LOC

Documents a baseline assessment

Check the surgical site for drainage or hemorrhage and all tubes are connected and functioning.

Check IV fluids or medications currently infusing and verifies dosage and rate.

Monitor vital signs and documented at least every 15 minutes

Assess pain

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Maintaining a Patent Airway

Administer supplemental oxygen, assesse respiratory rate and depth, ease of

respirations, oxygen saturation, and breath sounds

Keep oral airway until gag reflex is returned.

The nurse assists in: ventilator use, weaning & extubating

If the teeth are clenched, open the mouth manually with tongue depressor.

Elevate the HOB 15 to 30 degrees unless contraindicated

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Nursing alertImmediately report a systolic BP of <90

A previously stable BP that shows a down-ward of 5 mm Hg at each 15-minute should be reported.

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Minimize the risk of aspiration.

• Use nasopharynx or oropharynx suction to a distance of 15 to 20 cm

Maintaining Cardiovascular Stability

Assess VS; cardiac rhythm; skin temperature, color; and urine output.

CVP, pulmonary artery pressure, & arterial lines are monitored if in place.

Assess the patency of all IV lines.

Cardiovascular complications seen in the PACU include:

• Hypotension and shock, hemorrhage, hypertension, and dysrhythmias

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Hypotension

Hypotension can result from blood loss, hypoventilation, position changes, blood pooling in the extremities, side effects of medications

If blood loss exceeds 500 mL (rapid loss), replacement is indicated

ShockTypes of shock: hypovolemic, cardiogenic, neurogenic, anaphylactic, and

septic shock. Signs of hypovolemic shock Pale, cool, moist skin; rapid breathing; cyanosis; rapid weak pulse;

narrowing pulse pressure; low BP; and decreased & concentrated urine.

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The primary intervention for hypovolemic shock

IV fluids: lactated Ringer’s, 0.9% NS, colloids, or blood component

Oxygen by nasal cannula, face mask, or mechanical ventilation.

If fluid administration fails to reverse hypovolemic shock, then vasodilator & corticosteroid prescribed

Flat position with legs elevated.

Monitor V/S & keeps the patient warm

Implement measures to control Pain

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HemorrhageMonitor patient for S&S of shock

The early phase of shock will manifest in

feeling apprehension,

labored breathing and “air hunger”

feeling cold & may experience tinnitus.

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Check the surgical site for bleeding.

If bleeding is evident

◦ Apply sterile gauze & pressure dressing

◦ Position: flat on back; legs elevated at a 20-degree; knees kept

straight).

◦ Internal hemorrhage may need to back to OR for surgical

exploration

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Hypertension and dysrhythmias

Hypertension may occur secondary pain, hypoxia, or bladder distention.

Dysrhythmias are associated with electrolyte imbalance, altered respiratory function, pain, hypothermia, stress, and anesthetic agents.

Treat underlying causes of hypertension and dysrhythmias

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Relieving pain and anxiety

Opioid analgesics as ordered

Family member visit in the PACU decrease the family’s anxiety and make the patient feel more secure.

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Controlling nausea and vomiting

Side lying position prevent aspiration

Administer anti emetics agents (Zofran) is the drug of choice.


Determining Readiness for Discharge From the PACU

A patient remains in the PACU until fully recovered

Indicators of recovery include◦ Stable BP, adequate respiratory function, and adequate oxygen

saturation level compared with baseline.

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Modified Aldrete score 8 to 10 before discharge

from the PACU. a score <7 must remain in

the PACU or transferred to ICU

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Preparing the Postoperative Patient for Direct Discharge

Prior to dischargeverbal and written instructions and information about follow-

up care

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Receiving the Patient in the Clinical Unit

Prepare all the necessary equipment and supplies

The PACU nurse reports about the patient to the receiving nurse

surgeon speaks to the family after surgery (pt condition)

Receiving nurse:

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Review the postoperative orders Admits the patient to the

Performs an initial assessment Attends patient’s immediate needs.

Immediate Postoperative Nursing Interventions

1) Assess breathing and administer oxygen, if prescribed.

2) Monitor V/S and note skin warmth, moisture, and color.

3) Assess the surgical site and wound drainage systems.

4) Assess LOC , orientation, and ability to move extremities.

5) Assess pain and route of administration of last dose of analgesic.

6) Administer analgesics and assess effectiveness

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Immediate Postoperative Nursing Interventions

7) Call light, emesis basin, and bedpan or urinal within reach.

8) Comfortable Position

9) Assess IV for patency & correct rate and solution.

10) Assess urine output, the patient’s urge to void & bladder distention

11) Begin deep breathing and leg exercises.

12) Provide information to the patient and family

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Nursing care on the general surgical unit(first 24 hrs post operative)

Frequently assessing the patient’s physiologic status

Monitoring for complications

Managing pain

Implementing measures designed to achieve the long-range goals of independence with self-care

V/S every 15 minutes for the first hour and every 30 minutes for the next 2 hours.

The temperature is monitored every 4 hours for the first 24 hours.

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Nursing Management After Surgery

To assist in getting out of bed for the first time after surgery, the nurse:

Helps the patient move gradually from the lying position to the sitting position & encourages to splint the incision when applicable.

Positions the patient completely upright (sitting) and turned so that both legs are hanging over the edge of the bed.

Helps the patient stand beside the bed

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Caring for Wounds

First-Intention Healing

Aseptic wound with minimum tissue destruction closed by first intention (primary union).

granulation tissue is not visible and scar formation is minimal.

dry sterile dressing.

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Caring for WoundsSecond-Intention Healing

Granulation occurs in

infected wounds (abscess) or

• edges have not been approximated.

A drainage tube or packing to allow drainage

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Caring for Wounds

Third-Intention Healing

Secondary suture is used for ◦ deep wounds not been sutured early

◦ sutures breakdown and re-sutured later, thus bringing together two apposing granulation surfaces.

Results in a deeper and wider scar.

These wounds packed with moist gauze and covered with dry sterile dressing

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