ARE YOU READY FOR YOUR OPERATION?

Goals of Patient Safety

Provide safe patient care  Knowledge of procedure  Ensure the correct patient, correct site, correct level, and correct procedure  Knowledge of positioning  Adhere to safe medication administration guidelines  Perform surgical counts Provide a safe environment  Adhere to asepsis  Promote coordinated and effective communication

 Circulating Nurse  Scrub person  RN first assistant (RNFA)  Perioperative educator  Specialty team leader  Perioperative manager

Advocate Protector Teacher Change agent Manager of patient

care

 Assessing the clients Identifying potential or

actual health problems Planning specific care Providing pre-operative teaching Ensure consent is signed

Assisting the surgeon as scrub nurse and circulating nurse

 Assessing responses to

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

Probability of

morbidity or death from surgery

 1.

2.

Maybe benign or malignant Location depends on the location of the disease and the organ requiring surgery Duration length of the time the patient has been exposed to the illness dictates the degree of risk involved.

Operative risk is

proportional with the magnitude of the operation

Based on health

status and person s mental attitude toward surgery

Age infants and elderly have the lowest tolerance to the stressful effects of surgery. b. Nutritional status a well-nourished pre-op client is better prepared for surgical stress and return to optimal health after surgery. A. Obesity B. Malnutrition
a.

Fluid and electrolyte problems fluid volume deficit leads to possible intra and post-op complications. d. Presence of diseases increases the operative risk
c.

Pulmonary impairs ability to exchange oxygen and carbon dioxide. b. Cardiovascular a heart that pumps effectively and blood vessels that constrict well is necessary for prevention of shock and fluid and electrolyte imbalance.
a.

Hematologic blood coagulation problem causes severe hemorrhage d. Genito-urinary difficulty in eliminating wastes from the body and preserve fluid and electrolyte balance e. Endocrine affect clients response to surgery
c.

f.

g.

Liver unable to detoxify medications or metabolize carbohydrates, fats and amino acids. Neurologic for possible effect of anesthetic meds which is to depress CNS

h. i. j.

Gastrointestinal changes in GI status. Integumentary bleeding tendencies. Disabilities influences response to surgery including those that affect and limit activity.

e.

Use of medications 1. Tranquilizers causes anxiety, tension and even seizures if withdrawn suddenly 2. Insulin 3. Adrenal corticosteroids cardiovascular collapse might occur if discontinued suddenly

e.

Use of medications 4. Diuretics thiazide may cause excessive respiratory depression during anesthesia 5. Phenothiazines and antidepressants (MAO) may increase hypotensive action of anesthetics 6. Antibiotics when combined with muscle relaxant, nerve transmission is interrupted.

 1. 2. 3. 4. 5. 6.

FEAR Fear of the unknown Fear of anesthesia Fear of pain Fear of death Fear of disturbance of body image Worries

Anxiousness 2. Bewilderment 3. Anger 4. Tendency to exaggerate 5. Sad, evasive, tearful, clingy

1.

6. Inability to concentrate 7. Short attention span 8. Failure to carry out

simple instructions 9. Dazed

Regression behaves in a childlike manner. 2. Denial appears unalarmed 3. Intellectualization would discuss operation and illness rationally but without emotion
1.

Caliber of the

professional staff and health care facilities

Surgeon 2. Assistant to the surgeon 3. Anesthesiologist 4. Nurse anesthetist (CRNA) 5. Circulating nurse 6. Scrub nurse
1.

all major system are disrupted by anesthesia and surgery. Most client can effectively compensate for surgical trauma and effects of anesthesia but all clients are at risk during the operative phase

assists the surgeon and the surgical assistants during the procedure by anticipating / handling instruments and other equipments, maintains sterility of field during procedure together with circulating nurse, counts all needles, sponges and instruments after procedure to ensure patient well being labels tissue specimen obtained during procedure keep track of time the patient is under anesthesia time wound is opened, incisions closed

main responsibilities include verifying consent, coordinating the team, ensuring cleanliness, proper temperature, humidity and lighting, safe functioning of equipments and availability of supplies manages OR & protects the safety and health needs of client assists in positioning clients performs surgical skin preparation monitors aseptic practices to avoid breaks in technique coordinates movement of related personnel (medical, radiography, laboratory) implement fire safety precautions monitors patient and documents specific activities throughout operation to ensure patient s safety and well-being sends tissue specimen to the laboratory

4. Operating Surgeon heads the surgical team; performs and makes decisions concerning surgical procedures 5. Assistant to Surgeon hold retractors to expose operative site, clamp bleeding blood vessels, suction blood to provide clear view of the operative site and assist in suturing or closing the wound 6. Anesthesiologist reassess patient s physical condition immediate prior to initiating anesthesia, administer anesthesia and monitor patient s vital signs during entire procedure 7. Anesthetist works under the direct supervision of an anesthesiologist; most are nurses with required training

Responsible for safety and well-being Coordination of OR personnel Performance of scrub or circulatory nurse activities Responsible for emotional state which has been started by the ward nurse (provide information and realistic reassurance) Supporting coping strategies Reinforcing patient s ability to influence outcomes

1. Stress response is

elicited. 2. Defense against infection is lowered. 3. Vascular system is disrupted.

4.Organ functions are

disturbed. 5. Body image may be disturbed. 6.Lifestyles may change.

Nursing Responsibility: Preoperative Phase

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

For circulation, stimulate respiration, decrease stasis of gas

 Correct any dietary deficiencies. Reduce an obese person s weight. Correct fluid and electrolyte

imbalances. Restore adequate blood volume with blood transfusion. Treat chronic diseases. Halt or treat infectious process. Treat an alcoholic person with vitamin supplementation, IVF or oral fluids if dehydrated.

Preparing the skin Preparing the GI tract Preparing for anesthesia Promoting rest and sleep

Early AM care 1. Awaken an hour before pre-op medications. 2. Morning bath, mouth wash 3. Provide clean gown 4. Remove hairpins, braid long hairs, cover hair with cap.

Early AM care 5. Remove dentures, foreign materials, colored nail polish, hearing aid, contact lens (wedding ring secured to waist). 6. Take baseline VS before pre-op meds. 7. Check ID band 8. Skin prep

Early AM care 9. Check for special orders enema, IV line 10.Check NPO 11.Have client void before pre-op meds. 12.Continue to support emotionally. 13.Accomplish pre-op checklist.

Client has ID band and allergy bracelet Informed consent is signed and witnessed Diagnostic and laboratory test results Client voided Document height and weight Vital signs before exiting the ward Pre-op meds given Document allergy

 Purpose: allay anxiety, produce

amnesia, reduce n&v, dec resp secretions, dec vagal nerve stimulations, inc pain threshold, inc effects of anesthetic agents Peak effect is desired at the time of induction Usually given 45 min before induction

Pre-op Drugs Anti-anxiety

Example Diazepam

Purpose

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

Anti-cholinergic Muscle relaxant Anti-emetic Antibiotic

Atropine Succinylcholine Promethazine Cephalosporin

Pre-op Drugs

Example

Purpose

Analgesics

Meperidine

To decrease pain and decrease anesthetic dose

Anti-histamine Diphenh dramine To decrease occurrence of allerg

H-2 antagonist Cimetidine

To decrease gastric fluid and acidit

Send entire medical record or

chart to the Operating room with patient

Direct proper waiting room. Doctor informs family

immediately after surgery. Explain reason for long interval of waiting. Explain what to expect.

8. LEGAL Considerations

Informed Consent - (Operative Permit / Surgical Consent) - LEGAL document required for certain diagnostic procedures or therapeutic measures, including surgery.

PURPOSES:  To ensure that the client understands the nature of the treatment including the potential complications and disfigurement.  To indicate that the client s decision was made without pressure.  To protect the client against unauthorized procedure.  To protect the surgeon and hospital against legal action by a client who claims that an unauthorized procedure was performed.

1. 2.

3.

The consent must be given voluntarily. The consent must be given to individual who have the capacity to understand. The client must be given information to be the ultimate decision maker.

 Any surgical procedure where

scalpel, scissors, suture, hemostats or electrocoagulation may be used. Entrance into a body cavity General anesthesia, local infiltration, regional block

 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

Written permission is best and is legally acceptable. Signature is obtained with the client s complete understanding of what is to occur. (Adults sign their own operative permit and obtained before sedation) Secured without pressure. Signed at least 24 hours before elective surgery Patient signs own consent if he or she is of age (18 yrs or older), mentally capable, or is an emancipated minor (<18 yrs but independent from parents) In emergency where client is unable to sign or there is immediate threat to life, effort should be made to contact family and 2 surgeons sign the consent

 A witness is desirable. In an emergency, permission via

telephone or telefax is acceptable. For minor, unconscious, psychologically incapacitated, permission is required from a responsible family member.

area around the site of incision into tissue or introduction of any instrumentation into the body orifice that has been prepared for use of sterile supplies and equipments including all furniture covered w/ sterile drapes and personnel who are properly attired.  Sterile Technique method by which contamination w/ microorganism is prevented to maintain sterility throughout the operative procedure.
 Sterile Field

mechanically cleansed but unsterile. Disinfection process of destroying all pathogenic microorganism except spore bearing one. Antiseptic used on tissue and skin and the growth of endogenous bacteria. Incision the result of cutting into a body tissue using sharp instrument.
Surgically Clean

 Medical Asepsis

include all practices intended to confine a specific microorganism to a specific area limiting the new growth and spread of microorganism.  Surgical Asepsis (or sterile technique) refers to those practices that keep an area or object free of all microorganisms including practices destroying all microorganisms and spores.

S RU

UT !!!

1. 2.

3. 4.

Only sterile items are used within the sterile field. Gowns are considered sterile only from the waist to shoulder level in front and sleeves. Tables are sterile only at table level. Persons who are sterile touch only sterile items or areas; persons who are not sterile.

5.

6. 7. 8. 9.

Unsterile persons avoid reaching over a sterile field; sterile persons avoid leaning over an unsterile area. Edges of anything that encloses sterile contents are considered unsterile. Sterile field is created as close as possible to time of use. Sterile areas are continuously kept in view. Sterile persons keep well within the sterile area.

10. Sterile persons keep contact with

sterile areas to a minimum. 11. Unsterile persons avoid sterile areas. 12. Destruction of integrity of microbial barriers results in contamination. 13. Microorganisms must be kept to an irreducible minimum.

PERIOPERATIVE NURSING IS NOT JUST A TECHNICAL WORK ANYONE CAN DO!

IF YOU CAME THROUGH YOUR SURGERY IN GOOD SHAPE, THANK A PERIOPERATIVE NURSE

Surgical Environment: - a surgical suite is designed to promote safe therapeutic environment for the patient. 1. Traffic control - The in and out of the operating room is kept to minimum -3 zones:

Unrestricted
street clothes

Semi-restricted
scrub suit and cap

Restricted
scrub suit, cap, shoe covers, gloves

a. unrestricted area -provide entrance to and exit from the operating room -people may wear street clothes. -it includes the holding area, lounges, dressing room and offices. b. semirestricted area -provide access to the restricted zone and peripheral support areas within the surgical suite

- scrub attire is required with caps c. restricted area -includes the individual OR s, scrub areas, sub sterile room, and clean core areas. -in this area, scrub attire, hair covering and masks must be worn

2. Operating Room Attire a. masks b. headgear - should cover completely the hair, neckline and beard c. gown d. gloves

OR gown/scrub suits Masks Gloves Foot socks Headgear/headcover