Peri-operative Nursing

Phases of Peri-operative period

PRE- operative phase

INTRA- operative phase

POST- operative phase

PRE-Operative Phase
Begins when the decision to have surgery is made and ends when the client is transferred to the operating table

INTRA-Operative Phase
Begins when the client is transferred to the operating table and ends when the client is admitted to the post-anesthesia unit

Post-operative Phase
Begins with the admission of the client to the PACU and ends when healing is complete

PERIOPERATIVE TEAM
1. ANESTHESIOLOGIST or NURSE ANESTHESIST - makes preoperative assessment to plan type of anesthetic to be administered - to evaluate clients physical status 2. PROFESSIONAL O.R. NURSE - makes preop nursing assessments and documents intraoperative care plan

PERIOPERATIVE TEAM
3. CIRCULATING NURSE - manages the OR - protects clients safety and health needs by monitoring activities of members of the surgical team - monitors conditions in the OR

PERIOPERATIVE TEAM
4. SCRUB NURSE - responsible for scrubbing before surgery - sets up sterile tables & equipment - assists surgeon and surgical assistants during the operation itself 5. PACU NURSE - cares for the client until he/she recovers from the effects of anesthesia

PRINCIPLES OF SURGICAL ASEPSIS

1. OR personnel must practice strict Standard Precautions 2. All items used in the OR must be sterile 3. All personnel must perform a surgical scrub

PRINCIPLES OF SURGICAL ASEPSIS

4. All OR personnel are required to wear specific, clean attire shedding the environment - must wear: a. sterile gown b. gloves c. special shoe covers d. hair cover cap e. mask

PRINCIPLES OF SURGICAL ASEPSIS

5. Any personnel harboring pathogenic microbes must report themselves unable to be in the OR 6. Scrubbed personnel wearing sterile attire should touch only sterile items 7. Sterile gown and drapes have defined borders of sterility. 8. Unsterile personnel must stay at the periphery of the sterile operating area

PRINCIPLES OF SURGICAL ASEPSIS

9. Sterile supplies are unwrapped and delivered by the circulating nurse 10. The utmost caution & vigilance must be used when handling sterile fluids 11. Anything that is used for one client must be discarded or, in some cases, resterilized

Activities in the Pre-op

Assessing the clients Identifying potential or actual health problems Planning specific care Providing pre-operative teaching Ensure consent is signed

Consent
The surgeon is responsible for obtaining the consent for surgery No sedation should be administered before SIGNING the consent The nurse may serve as witness

Activities during the Intra-op

Assisting the surgeon as scrub nurse and circulating nurse

Activities in the POST-op

Assessing responses to surgery Performing interventions to promote healing Prevent complications Planning for home-care Assist the client to achieve optimal recovery

TYPES of SURGERY
According to PURPOSE

According to degree of URGENCY

According to degree of RISK

According to PURPOSE
Diagnostic Establishes a diagnosis

Palliative
Ablative Constructive

Relieves or reduces pain or symptoms Removes a diseased body part

Restores function or appearance

Transplant

Replaces malfunctioning structures

According to degree of urgency

Emergency surgery Preserves function or life Performs immediately

Elective surgery

Performed when condition is not imminently life threatening

According to degree of RISK

Major Surgery Involves high degree of risk Complicated or prolonged

Minor Surgery

Involves low risk Produces few complications Performed as day surgery

Surgical Risk
Extremes of age Malnourished Obese Co-morbid conditions Concurrent medications

Pre-operative Interventions
Ensure signed consent form Obtain nursing history, PE and lab exam Provide pre-operative teaching as to the nature of surgery, what to expect and ways to manage post-operative discomforts Perform physical preparations- shaving, hygiene, enema, NPO, medications

Pre-op nutrition
Assess order for NPO Solid foods are withheld for about 8 hours before general anesthesia

Pre-op elimination
Laxatives, enemas or both may be prescribed the night before surgery Have the client void immediately BEFORE transferring them to the OR Foley catheter may be inserted as ordered

Pre-op hygiene
Bath the night before surgery with antiseptic soap Shaving of the skin is usually done in the OR Removal of jewelry and nail polish

Pre-op psychological preparation

Be alert to the clients anxiety level Answer questions or concerns Allow time for privacy

Pre-operative medications
Pre-op Drugs Example

Purpose
To decrease nervousness Promote relaxation Decreases secretions Prevent bradycardia To promote muscle relaxation To prevent nausea and vomiting

Anti-anxiety Diazepam

Anticholinergic Muscle relaxant Anti-emetic

Antibiotic

Atropine
Succinylcholine

Promethazine

Cephalosporin To prevent infection

Pre-operative medications
Pre-op Drugs Example

Purpose
To decrease pain and decrease anesthetic dose

Analgesics

Meperidine

Anti-histamine Diphenhydramine To decrease occurrence of allergy

H-2 antagonist

Cimetidine

To decrease gastric fluid and acidity

Pre-operative screening test

CBC Blood type Determine Hgb and Hct, infection Determined in case of blood transfusion

Serum electrolytes FBS

BUN, Creatinine

Evaluates the fluid and electrolyte status Evaluates diabetes mellitus

Assess the renal function

ALT, AST, Bilirubin Evaluates the liver function Serum albumin CXR and ECG Evaluates nutritional status Respiratory and Cardiac status

Pre-operative teaching
Leg exercises To stimulate blood circulation in the extremities to prevent thrombophlebitis

Deep breathing and Coughing Exercises

To facilitate lung aeration and secretion mobilization to prevent atelectasis and hypostatic pneumonia
Done every two to four hours

Positioning and Ambulation

To circulation, stimulate respiration, decrease stasis of gas

Intra-operative phase interventions

Determine the type of surgery and anesthesia used Position client appropriately for surgery Assist the surgeon as circulating or scrub nurse Maintain the sterility of the surgical field Monitor for developing complications

Anesthesia
General anesthesia

Loss of all sensation and consciousness

Regional or Local anesthesia

Loss of sensation in ONE area with consciousness present

GENERAL Anesthesia
Protective reflexes are lost Amnesia, analgesia and hypnosis occur Administered in two ways:

Inhalational Intravenous

REGIONAL Anesthesia
TOPICAL INFILTRATION NERVE BLOCK SPINAL Subarachnoid EPIDURAL Applied directly on the skin Injected into a specific area of skin Injected around a nerve Low spinal anesthesia Epidural space is injected with anesthesia

Patient Positioning
Provides optimal visualization Provides optimal access for assessing and maintaining anesthesia and function Protects patient from harm

Position Patient during Surgery

Abdominal surgeries Bladder surgery Perineal surgery Brain surgery Spinal cord surgeries Lumbar puncture Supine Slightly trendelenburg Lithotomy Semi-fowlers Prone mostly Side lying, flexed body

Functions of the nurse during OR procedure

SCRUB NURSE

CIRCULATING NURSE

Assists the surgeon Maintains sterility Handles instruments Drapes patient Counts sponges Wears sterile gown, gloves Assists the Scrub nurse Positions the patient for surgery Positions any equipments

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

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 interventions
PAIN MANAGEMENT Pain is usually greatest during the 1236 hours after surgery Narcotic analgesics and NSAIDS may be prescribed together for the early period of surgery Provide back rub, massage, diversional activities, position changes

Post operative interventions

POSITIONING Clients who have spinal anesthesia is usually placed FLAT on bed for 8-12 hours Unconscious client is placed side lying to drain secretions Other positions are utilized BASED on the type of surgery

Post-operative Interventions Some Examples of Position Post Op

Mastectomy Thyroidectomy Hemorrhoidectomy Laryngectomy Pneumonectomy Lobectomy Semi-fowlers, affected arm elevated Semi fowlers , head midline Semi-prone, side-lying Fowlers Lateral, affected side Lateral, unaffected side

Post-operative Interventions Some Examples of Position Post Op

Aneurysmal repair (abdomen) Amputation of lower extremities Cataract surgery Supratentorial craniotomy Infratentorial craniotomy Spina bifida repair Fowlers 45 degrees Flat, with stump elevated with pillow Fowlers 45 degrees Folwers Flat on bed, supine Prone

Post-operative Interventions
Deep breathing and coughing exercises Q2-4 hours to remove secretions Leg exercises Q 2 hours to promote circulation Ambulation ASAP prevents respiratory, circulatory, urinary and gastrointestinal complications

Post-operative Interventions
Hydration after NPO to maintain fluid balance Suction, either gastro or respiratory to relieve distention, to remove respi secretions Diet progressive, usually given when bowel sounds and gag reflex return

Wound Care
Inspect dressing hourly Change dressing daily Inspect for signs of infection redness, swelling, purulent exudate Maintain wound drainage

Diet
NPO usually immediately after surgery Progressive diet

Assess the return of the bowel sounds

Liquid Diet Vs Soft diet

Clear liquid Coffee Tea Carbonated drink Bouillon Clear fruit juice Popsicle Gelatin Hard candy Full liquid Clear liquid PLUS: Milk/Milk prod Vegetable juices Cream, butter Yogurt Puddings Custard Ice cream and sherbet Soft diet All CL and FL plus: Meat Vegetables Fruits Breads and cereals Pureed foods

Urinary Elimination
Offer bedpans Allow patient to stand at the bedside commode if allowed Report to surgeon if NO URINE output noted within 8 hours post-op

CPT
Chest Physiotherapy Chest physiotherapy is based on the fact that mucus can be knocked or shaken form the walls of the airways and helped to drain from the lungs. The usual PVD SEQUENCE is as follows- POSITIONING, Percussion, Vibration, and removal of secretions by SUCTIONING or Coughing followed lastly by oral hygiene

Incentive Spirometry
This operates on the principle that spontaneous sustained maximal inspiration is most beneficial to the lungs and has virtually no adverse effects. The incentive spirometer measures roughly the inspired volume and offers the incentive of measuring progress

Post operative complications

Atelectasis
Assess breath Collapsed alveoli due to sounds Repositioning secretions

Pneumonia

Inflammation of alveoli

Deep breathing and coughing Chest physio Suctioning Ambulation

Thrombophlebitis Inflammation of the veins

Leg exercises Monitor for swelling Elevated extremities

Post-operative Complications
Hypovolemic Loss of Shock circulatory fluid volume
Shock position Determine cause and prevent bleeding O2, IVF
Encourage ambulation Provide privacy Pour warm water Catheterize

Urinary retention

Involuntary accumulation of urine

Pulmonary embolism

Embolus blocking the lung blood flow

Notify physician Administer O2w

Post-operative complications
Constipation Infrequent passage of stool
High fiber diet Increased fluid Ambulation

Paralytic ileus Absent bowel Encourage ambulation sound Wound infection

NPO until peristalsis returns Occurs about Daily wound dressing 3 days after Antibiotics surgery Maintain drain

Post-operative complications
Wound dehiscence
Cover the wound Separation of wound edges at with sterile normal the suture line saline dressing Place in lowFowlers Notify MD

Wound evisceration

Cover the wound Protrusion of with saline pad the internal Place in loworgans and tissues through fowlers Notify MD wound

To emphasize
The over-all goal of nursing care during the PRE-OPERATIVE phase is to prepare the patient mentally and physically for the surgery

To emphasize
The over-all goal of nursing care during the INTRA-OPERATIVE phase is to maintain client safety

To emphasize
The over-all goals of nursing care during the POST-OPERATIVE phase are to promote healing and comfort, restore the highest possible wellness and prevent associated risk