peri operative nursing
TRANSCRIPT
Peri-operative NursingPeri-operative Nursing
Phases of Peri-operative periodPhases of Peri-operative period
PRE- operative phasePRE- operative phase
INTRA- operative phaseINTRA- operative phase
POST- operative phase POST- operative phase
PRE-Operative PhasePRE-Operative Phase
Begins when the decision to have surgery is made and ends when the client is transferred to the operating table
INTRA-Operative PhaseINTRA-Operative Phase
Begins when the client is Begins when the client is transferred to the operating table transferred to the operating table and ends when the client is and ends when the client is admitted to the post-anesthesia admitted to the post-anesthesia unitunit
Post-operative PhasePost-operative Phase
Begins with the admission of the Begins with the admission of the client to the PACU and ends when client to the PACU and ends when healing is complete healing is complete
PERIOPERATIVE TEAMPERIOPERATIVE TEAM
1.1. ANESTHESIOLOGIST or NURSE ANESTHESIOLOGIST or NURSE ANESTHESISTANESTHESIST
- makes preoperative assessment to - makes preoperative assessment to plan type of anesthetic to be plan type of anesthetic to be administeredadministered
- to evaluate client’s physical status- to evaluate client’s physical status
2.2. PROFESSIONAL O.R. NURSEPROFESSIONAL O.R. NURSE
- makes preop nursing assessments - makes preop nursing assessments and documents intraoperative care planand documents intraoperative care plan
PERIOPERATIVE TEAMPERIOPERATIVE TEAM
3. 3. CIRCULATING NURSECIRCULATING NURSE
- manages the OR- manages the OR
- protects client’s safety and health - protects client’s safety and health needs by monitoring activities of needs by monitoring activities of
members of the surgical teammembers of the surgical team
- monitors conditions in the OR- monitors conditions in the OR
PERIOPERATIVE TEAMPERIOPERATIVE TEAM4. 4. SCRUB NURSESCRUB NURSE
- responsible for scrubbing before - responsible for scrubbing before surgerysurgery
- sets up sterile tables & equipment- sets up sterile tables & equipment
- assists surgeon and surgical assistants - assists surgeon and surgical assistants during the operation itselfduring the operation itself
5. 5. PACU NURSEPACU NURSE
- cares for the client until he/she - cares for the client until he/she recovers from the effects of anesthesiarecovers from the effects of anesthesia
PRINCIPLES OF SURGICAL PRINCIPLES OF SURGICAL ASEPSISASEPSIS
1.1. OR personnel must practice strict OR personnel must practice strict Standard PrecautionsStandard Precautions
2.2. All items used in the OR must be All items used in the OR must be sterilesterile
3.3. All personnel must perform a All personnel must perform a surgical scrubsurgical scrub
PRINCIPLES OF SURGICAL PRINCIPLES OF SURGICAL ASEPSISASEPSIS
4. All OR personnel are required to wear 4. All OR personnel are required to wear specific, clean attire – “shedding” the specific, clean attire – “shedding” the environmentenvironment
- must wear:- must wear:
a. sterile gowna. sterile gown
b. glovesb. gloves
c. special shoe coversc. special shoe covers
d. hair cover – capd. hair cover – cap
e. maske. mask
PRINCIPLES OF SURGICAL PRINCIPLES OF SURGICAL ASEPSISASEPSIS
5. Any personnel harboring pathogenic 5. Any personnel harboring pathogenic microbes must report themselves unable microbes must report themselves unable to be in the ORto be in the OR
6. Scrubbed personnel wearing sterile 6. Scrubbed personnel wearing sterile attire should touch only sterile itemsattire should touch only sterile items
7. Sterile gown and drapes have defined 7. Sterile gown and drapes have defined borders of sterility.borders of sterility.
8. Unsterile personnel must stay at the 8. Unsterile personnel must stay at the periphery of the sterile operating areaperiphery of the sterile operating area
PRINCIPLES OF SURGICAL PRINCIPLES OF SURGICAL ASEPSISASEPSIS
9. Sterile supplies are unwrapped and 9. Sterile supplies are unwrapped and delivered by the circulating nursedelivered by the circulating nurse
10. The utmost caution & vigilance 10. The utmost caution & vigilance must be used when handling sterile must be used when handling sterile fluidsfluids
11. Anything that is used for one client 11. Anything that is used for one client must be must be discardeddiscarded or, in some or, in some cases, cases, resterilizedresterilized
Activities in the Pre-opActivities in the Pre-op
Assessing the clientsAssessing the clients
Identifying potential or actual health Identifying potential or actual health problems problems
Planning specific carePlanning specific care
Providing pre-operative teaching Providing pre-operative teaching
Ensure consent is signedEnsure consent is signed
Consent Consent
The surgeon is responsible for The surgeon is responsible for obtaining the consent for surgeryobtaining the consent for surgery
No sedation should be administered No sedation should be administered before SIGNING the consentbefore SIGNING the consent
The nurse may serve as The nurse may serve as witness witness
Activities during the Intra-opActivities during the Intra-op
Assisting the surgeon as scrub nurse Assisting the surgeon as scrub nurse and circulating nurse and circulating nurse
Activities in the POST-op Activities in the POST-op
Assessing responses to surgeryAssessing responses to surgery
Performing interventions to promote Performing interventions to promote healing healing
Prevent complicationsPrevent complications
Planning for home-carePlanning for home-care
Assist the client to achieve optimal Assist the client to achieve optimal recoveryrecovery
TYPES of SURGERYTYPES of SURGERY
According to PURPOSEAccording to PURPOSE
According to degree of URGENCYAccording to degree of URGENCY
According to degree of RISKAccording to degree of RISK
According to PURPOSEAccording to PURPOSE
Diagnostic Establishes a diagnosis
Palliative Relieves or reduces pain or symptoms
Ablative Removes a diseased body part
Constructive Restores function or appearance
Transplant Replaces malfunctioning structures
According to degree of urgencyAccording to degree of urgency
Emergency Emergency surgerysurgery
Preserves function or lifePreserves function or life
Performs immediately Performs immediately
Elective surgery
Performed when condition is not imminently life threatening
According to degree of RISKAccording to degree of RISK
Major Major Surgery Surgery
Involves high degree of riskInvolves high degree of risk
Complicated or prolongedComplicated or prolonged
Minor Minor SurgerySurgery
Involves low riskInvolves low risk
Produces few complicationsProduces few complications
Performed as day surgeryPerformed as day surgery
Surgical RiskSurgical Risk
Extremes of ageExtremes of age
MalnourishedMalnourished
ObeseObese
Co-morbid conditionsCo-morbid conditions
Concurrent medications Concurrent medications
Pre-operative InterventionsPre-operative Interventions
Ensure signed consent formEnsure signed consent form
Obtain nursing history, PE and lab examObtain nursing history, PE and lab exam
Provide pre-operative teaching as to the Provide pre-operative teaching as to the nature of surgery, what to expect and nature of surgery, what to expect and ways to manage post-operative ways to manage post-operative discomfortsdiscomforts
Perform physical preparations- shaving, Perform physical preparations- shaving, hygiene, enema, NPO, medicationshygiene, enema, NPO, medications
Pre-op nutritionPre-op nutrition
Assess order for NPOAssess order for NPO
Solid foods are withheld for about 8 Solid foods are withheld for about 8 hours before general anesthesia hours before general anesthesia
Pre-op elimination Pre-op elimination
Laxatives, enemas or both may be Laxatives, enemas or both may be prescribed the night before surgeryprescribed the night before surgery
Have the client void immediately Have the client void immediately BEFORE transferring them to the ORBEFORE transferring them to the OR
Foley catheter may be inserted as Foley catheter may be inserted as orderedordered
Pre-op hygiene Pre-op hygiene
Bath the night before surgery with Bath the night before surgery with antiseptic soapantiseptic soap
Shaving of the skin is usually done in Shaving of the skin is usually done in the ORthe OR
Removal of jewelry and nail polishRemoval of jewelry and nail polish
Pre-op psychological preparationPre-op psychological preparation
Be alert to the client’s anxiety levelBe alert to the client’s anxiety level
Answer questions or concernsAnswer questions or concerns
Allow time for privacy Allow time for privacy
Pre-operative medications Pre-operative medications Pre-op DrugsPre-op Drugs ExampleExample PurposePurpose
Anti-anxiety Anti-anxiety Diazepam Diazepam To decrease nervousnessTo decrease nervousness
Promote relaxationPromote relaxation
Anti-Anti-cholinergiccholinergic
AtropineAtropine Decreases secretionsDecreases secretions
Prevent bradycardiaPrevent bradycardia
Muscle Muscle relaxantrelaxant
SuccinylcholineSuccinylcholine To promote muscle To promote muscle relaxation relaxation
Anti-emeticAnti-emetic PromethazinePromethazine To prevent nausea and To prevent nausea and vomitingvomiting
AntibioticAntibiotic CephalosporinCephalosporin To prevent infection To prevent infection
Pre-operative medications Pre-operative medications Pre-op DrugsPre-op Drugs ExampleExample PurposePurpose
AnalgesicsAnalgesics MeperidineMeperidine To decrease pain and To decrease pain and decrease anesthetic dose decrease anesthetic dose
Anti-histamineAnti-histamine DiphenhydramineDiphenhydramine To decrease occurrence To decrease occurrence of allergyof allergy
H-2 H-2 antagonistantagonist
CimetidineCimetidine To decrease gastric fluid To decrease gastric fluid and acidity and acidity
Pre-operative screening testPre-operative screening testCBCCBC Determine Hgb and Hct, infection
Blood typeBlood type Determined in case of blood transfusion
Serum Serum electrolyteselectrolytes
Evaluates the fluid and electrolyte status
FBSFBS Evaluates diabetes mellitus
BUN, CreatinineBUN, Creatinine Assess the renal function
ALT, AST, ALT, AST, BilirubinBilirubin
Evaluates the liver function
Serum albuminSerum albumin Evaluates nutritional status
CXR and ECGCXR and ECG Respiratory and Cardiac status
Pre-operative teaching Pre-operative teaching Leg exercisesLeg exercises To stimulate blood circulation To stimulate blood circulation
in the extremities to prevent in the extremities to prevent thrombophlebitis thrombophlebitis
Deep breathing Deep breathing and Coughing and Coughing
Exercises Exercises
To facilitate lung aeration and To facilitate lung aeration and secretion mobilization to secretion mobilization to prevent atelectasis and prevent atelectasis and hypostatic pneumoniahypostatic pneumoniaDone every two to four hoursDone every two to four hours
Positioning and Positioning and Ambulation Ambulation
To circulation, stimulate respiration, To circulation, stimulate respiration, decrease stasis of gasdecrease stasis of gas
Intra-operative phase Intra-operative phase interventionsinterventions
Determine the type of surgery and Determine the type of surgery and anesthesia usedanesthesia usedPosition client appropriately for Position client appropriately for surgerysurgeryAssist the surgeon as circulating or Assist the surgeon as circulating or scrub nursescrub nurseMaintain the sterility of the surgical Maintain the sterility of the surgical field field Monitor for developing complicationsMonitor for developing complications
Anesthesia Anesthesia
General anesthesiaGeneral anesthesia Loss of all sensation and Loss of all sensation and
consciousness consciousness
Regional or Local anesthesiaRegional or Local anesthesia Loss of sensation in ONE area Loss of sensation in ONE area
with consciousness present with consciousness present
GENERAL AnesthesiaGENERAL Anesthesia
Protective reflexes are lost Protective reflexes are lost
Amnesia, analgesia and hypnosis Amnesia, analgesia and hypnosis occuroccur
Administered in two ways: Administered in two ways: InhalationalInhalational Intravenous Intravenous
REGIONAL AnesthesiaREGIONAL AnesthesiaTOPICAL TOPICAL Applied directly on the skin Applied directly on the skin
INFILTRATIONINFILTRATION Injected into a specific area of Injected into a specific area of skin skin
NERVE BLOCKNERVE BLOCK Injected around a nerveInjected around a nerve
SPINAL SPINAL SubarachnoidSubarachnoid
Low spinal anesthesia Low spinal anesthesia
EPIDURALEPIDURAL Epidural space is injected with Epidural space is injected with anesthesia anesthesia
Patient PositioningPatient Positioning
Provides optimal visualizationProvides optimal visualization
Provides optimal access for Provides optimal access for assessing and maintaining assessing and maintaining anesthesia and functionanesthesia and function
Protects patient from harm Protects patient from harm
Position Patient Position Patient during Surgeryduring Surgery
Abdominal surgeriesAbdominal surgeries SupineSupine
Bladder surgeryBladder surgery Slightly trendelenburgSlightly trendelenburg
Perineal surgeryPerineal surgery LithotomyLithotomy
Brain surgeryBrain surgery Semi-fowler’s Semi-fowler’s
Spinal cord surgeriesSpinal cord surgeries Prone mostly Prone mostly
Lumbar puncture Lumbar puncture Side lying, flexed body Side lying, flexed body
Functions of the nurse during OR procedureFunctions of the nurse during OR procedure
SCRUB NURSESCRUB NURSE Assists the surgeonAssists the surgeon
Maintains sterilityMaintains sterility
Handles instrumentsHandles instruments
Drapes patient Drapes patient
Counts sponges Counts sponges
Wears sterile gown, glovesWears sterile gown, gloves
CIRCULATING CIRCULATING NURSENURSE
Assists the Scrub nurseAssists the Scrub nurse
Positions the patient forPositions the patient for
surgerysurgery
Positions any equipmentsPositions any equipments
POST Operative Interventions POST Operative Interventions
Maintain patent airway
Monitor vital signs and note for early manifestations of complications
Monitor level of consciousness
Maintain on PROPER position
NPO until fully awake, with passage of flatus and (+) gag reflex
POST Operative Interventions POST Operative Interventions
Monitor the patency of the drainage
Maintain intake and output monitoring
Care of the tubes, drains and wound
Ensure safety by side rails up
Pain medication given as ordered
Measures to PREVENT post-op Complications
Post-operative interventionsPost-operative interventions
PAIN MANAGEMENTPAIN MANAGEMENT
Pain is usually greatest during the Pain is usually greatest during the 12-12-36 hours after surgery36 hours after surgery
Narcotic analgesics and NSAIDS may Narcotic analgesics and NSAIDS may be prescribed together for the early be prescribed together for the early period of surgeryperiod of surgery
Provide back rub, massage, diversional Provide back rub, massage, diversional activities, position changes activities, position changes
Post operative interventions Post operative interventions
POSITIONINGPOSITIONING
Clients who have spinal anesthesia is Clients who have spinal anesthesia is usually placed usually placed FLATFLAT on bed for 8-12 on bed for 8-12 hourshours
Unconscious client is placed Unconscious client is placed side lyingside lying to drain secretions to drain secretions
Other positions are utilized BASED on Other positions are utilized BASED on the type of surgery the type of surgery
Post-operative InterventionsPost-operative InterventionsSome Examples of Position Post OpSome Examples of Position Post Op MastectomyMastectomy Semi-fowlers’, affected Semi-fowlers’, affected
arm elevatedarm elevated
ThyroidectomyThyroidectomy Semi fowlers’ , head Semi fowlers’ , head midlinemidline
HemorrhoidectomyHemorrhoidectomy Semi-prone, side-lying Semi-prone, side-lying
LaryngectomyLaryngectomy Fowler’s Fowler’s
PneumonectomyPneumonectomy Lateral, affected sideLateral, affected side
LobectomyLobectomy Lateral, Lateral, ununaffected affected side side
Post-operative InterventionsPost-operative InterventionsSome Examples of Position Post OpSome Examples of Position Post Op
Aneurysmal repair Aneurysmal repair (abdomen)(abdomen)
Fowler’s 45 degreesFowler’s 45 degrees
Amputation of lower Amputation of lower extremitiesextremities
Flat, with stump Flat, with stump elevated with pillowelevated with pillow
Cataract surgery Cataract surgery Fowler’s 45 degreesFowler’s 45 degrees
Supratentorial Supratentorial craniotomycraniotomy
Folwers’ Folwers’
Infratentorial Infratentorial craniotomy craniotomy
Flat on bed, supineFlat on bed, supine
Spina bifida repairSpina bifida repair Prone Prone
Post-operative Interventions Post-operative Interventions
Deep breathing and coughing Deep breathing and coughing exercises Q2-4 hours exercises Q2-4 hours to remove to remove secretionssecretions
Leg exercises Q 2 hours Leg exercises Q 2 hours to to promote circulation promote circulation
Ambulation ASAP prevents prevents respiratory, circulatory, urinary respiratory, circulatory, urinary and gastrointestinal complications and gastrointestinal complications
Post-operative Interventions Post-operative Interventions
Hydration after NPO to maintain to maintain fluid balance fluid balance
Suction, either gastro or respiratory to relieve distention, to relieve distention, to remove respi secretions to remove respi secretions
Diet progressive, usually given progressive, usually given when bowel sounds and gag reflex when bowel sounds and gag reflex returnreturn
WoundWound CareCare
Inspect dressing hourlyInspect dressing hourly
Change dressing daily Change dressing daily
Inspect for signs of infectionInspect for signs of infection redness, swelling, purulent redness, swelling, purulent exudateexudate
Maintain wound drainage
DietDiet
NPO usually immediately after surgeryNPO usually immediately after surgery
Progressive dietProgressive diet
Assess the return of the bowel sounds Assess the return of the bowel sounds
Liquid Diet Vs Soft dietLiquid Diet Vs Soft dietClear liquidClear liquid Full liquidFull liquid Soft dietSoft diet
CoffeeCoffee
TeaTea
Carbonated Carbonated drinkdrink
BouillonBouillon
Clear fruit Clear fruit juicejuice
PopsiclePopsicle
GelatinGelatin
Hard candyHard candy
Clear liquid PLUS:Clear liquid PLUS:
Milk/Milk prodMilk/Milk prod
Vegetable juicesVegetable juices
Cream, butterCream, butter
YogurtYogurt
PuddingsPuddings
CustardCustard
Ice cream and Ice cream and sherbetsherbet
All CL and FL All CL and FL plus:plus:
MeatMeat
VegetablesVegetables
FruitsFruits
Breads and Breads and cerealscereals
Pureed foodsPureed foods
Urinary Elimination Urinary Elimination
Offer bedpansOffer bedpans
Allow patient to stand at the bedside Allow patient to stand at the bedside commode if allowedcommode if allowed
Report to surgeon if NO URINE output Report to surgeon if NO URINE output noted within 8 hours post-opnoted within 8 hours post-op
CPTCPTChest PhysiotherapyChest Physiotherapy
Chest physiotherapy is based on the Chest physiotherapy is based on the fact that mucus can be knocked or fact that mucus can be knocked or shaken form the walls of the airways shaken form the walls of the airways and helped to drain from the lungs. and helped to drain from the lungs.
The usual PVD SEQUENCE is as The usual PVD SEQUENCE is as follows- POSITIONING, Percussion, follows- POSITIONING, Percussion, Vibration, and removal of secretions Vibration, and removal of secretions by SUCTIONING or Coughing by SUCTIONING or Coughing followed lastly by oral hygiene followed lastly by oral hygiene
Incentive SpirometryIncentive SpirometryThis operates on the principle that This operates on the principle that spontaneous sustained maximal spontaneous sustained maximal inspiration is most beneficial to the inspiration is most beneficial to the lungs and has virtually no adverse lungs and has virtually no adverse effects. effects.
The incentive spirometer measures The incentive spirometer measures roughly the inspired volume and roughly the inspired volume and offers the “incentive” of measuring offers the “incentive” of measuring progress progress
Post operative complications Post operative complications Atelectasis Atelectasis
PneumoniaPneumonia
Collapsed Collapsed alveoli due to alveoli due to secretionssecretions
Inflammation Inflammation of alveoliof alveoli
Assess breath Assess breath soundssounds
RepositioningRepositioning
Deep breathing Deep breathing and coughingand coughing
Chest physioChest physio
Suctioning Suctioning
AmbulationAmbulation
ThrombophlebitisThrombophlebitis Inflammation Inflammation of the veinsof the veins
Leg exercises Leg exercises
Monitor for Monitor for swellingswelling
Elevated Elevated extremitiesextremities
Post-operative ComplicationsPost-operative ComplicationsHypovolemic Hypovolemic Shock Shock
Loss of Loss of circulatory circulatory fluid volumefluid volume
Shock positionShock position
Determine cause and Determine cause and prevent bleedingprevent bleeding
O2, IVFO2, IVF
Urinary Urinary retention retention
Involuntary Involuntary accumulation accumulation of urineof urine
Encourage ambulationEncourage ambulation
Provide privacyProvide privacy
Pour warm waterPour warm water
CatheterizeCatheterize
Pulmonary Pulmonary embolismembolism
Embolus Embolus blocking the blocking the lung blood lung blood flowflow
Notify physicianNotify physician
Administer O2wAdminister O2w
Post-operative complicationsPost-operative complicationsConstipation Constipation Infrequent Infrequent
passage of passage of stoolstool
High fiber dietHigh fiber diet
Increased fluidIncreased fluid
Ambulation Ambulation
Paralytic ileusParalytic ileus Absent bowel Absent bowel soundsound
Encourage Encourage ambulation ambulation
NPO until NPO until peristalsis returnsperistalsis returns
Wound Wound infection infection
Occurs about Occurs about 3 days after 3 days after surgery surgery
Daily wound Daily wound dressingdressing
AntibioticsAntibiotics
Maintain drain Maintain drain
Post-operative complicationsPost-operative complicationsWound Wound dehiscence dehiscence
Separation of Separation of wound edges at wound edges at the suture linethe suture line
Cover the wound Cover the wound with sterile normal with sterile normal saline dressingsaline dressing
Place in low-Place in low-Fowler’sFowler’s
Notify MDNotify MD
Wound Wound evisceration evisceration
Protrusion of Protrusion of the internal the internal organs and organs and tissues through tissues through woundwound
Cover the wound Cover the wound with saline padwith saline pad
Place in low-Place in low-fowler’sfowler’s
Notify MDNotify MD
To emphasizeTo emphasize
The over-all goal of nursing care during The over-all goal of nursing care during the PRE-OPERATIVE phase is to the PRE-OPERATIVE phase is to prepare the patient mentally and prepare the patient mentally and physically for the surgeryphysically for the surgery
To emphasizeTo emphasize
The over-all goal of nursing care during The over-all goal of nursing care during the INTRA-OPERATIVE phase is to the INTRA-OPERATIVE phase is to maintain client safetymaintain client safety
To emphasizeTo emphasize
The over-all goals of nursing care The over-all goals of nursing care during the POST-OPERATIVE phase during the POST-OPERATIVE phase are to promote healing and comfort, are to promote healing and comfort, restore the highest possible wellness restore the highest possible wellness and prevent associated risk and prevent associated risk