Introduction to Perioperative Nursing

A Primer for Perioperative Education

Perioperative Nursing
Definition of Surgery

Surgery is any procedure performed on the human body that uses instruments to alter tissue or organ integrity.

Perioperative Nursing
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Perioperative Nursing- connotes the delivery of patient care in the preoperative,intraoperative, and postoperative periods of the patients surgical experience through the framework of the nursing process. The nurse assesses the patientcollecting,organizing, and prioritizing patient data; establishing nursing diagnosis;identifies desired patient outcomes;develop and implements a plan of care; and evaluates that care in terms of outcomes achieved by the patient.

Perioperative Nursing Phases

Preoperative phase begins when the decision to have surgery is made and ends when the client is transferred to the OR table. Intraoperative phase begins when the client is transferred to the OR table and ends when the client is admitted to the PACU. Postoperative phase - begins with the admission of the client to the PACU and ends when the healing is complete.

Perioperative Nursing Types of Surgery

Purpose/reasons Degree of urgency necessity to preserve the clients life, body part, or body function. Degree of risk involved in surgical procedure is affected by the clients age, general health, nutritional status, use of medications, and mental status. Extent of surgery Simple and radical

Perioperative Nursing
Type of Surgery (Purpose)
Diagnostic-Allows to confirm or establishes diagnosis. Corrective- Excision or removal of diseased body part. Reconstructive-Restore function or appearance to traumatized or malfunctioning tissues. Ablative Removes a diseased body parts Palliative Relieves or reduces pain or symptoms of a disease; it does not cure Transplant Replaces malfunctioning structures Cosmetic- Performed to improve personal appearance.

Perioperative Nursing
Types of Surgery (Urgency)
Emergency- performed immediately to preserve function or the life of the client. Elective is performed when surgical intervention is the preferred treatment for a condition that is not imminently life threatening or to improve the clients life. Urgent Necessary for client health to prevent additional problem from developing; not necessarily an emergency. Required has to be performed at some point; can be pre-scheduled.

Perioperative Nursing
Type of Surgery (Degree of Risk)
Major involves a high degree of risk. Minor normally involves little risk. Age very young and elder clients are greater surgical risks than children and adult. General health- surgery is least risky when the clients general health is good. Nutritional Status required for normal tissue repair. Medications regular use of certain medications can increase surgical risk. Mental status disorder that affect cognitive function

Perioperative Nursing
Surgical settings

Surgical suites Ambulatory care setting Clinics Physician offices Community setting Homes

Perioperative Nursing
Surgical settings
Disadvantages Less time for rapport Less time to assess, evaluation, teach Risk of potential complication post D/C. Advantages of outpatient: Low cost Low risk of infection Less interruption of routine Less than from work Less stress

Preoperative Nursing
Consent
Nature and intention of the surgery Name and qualifications of the person performing the surgery. Risks, including tissue damage, disfigurement, or even death Chances of success Possible alternative measures The right of the client to refuse consent or later withdraw consent.

Preoperative Nursing
Assessment (Nursing History)
Current health status Allergies Medications- list all current medications Previous surgeries Understanding of the surgical procedure and anesthesia Smoking Alcohol and other-altering substances Coping Social resources Cultural considerations

Preoperative Nursing Care

Physical assessment

Cardiovascular system Respiratory system Renal system Neurological system Musculoskeletal system Nutritional status Gerontological considerations

Perioperative Nursing Care

Physical assessment/clinical manifestations

General survey- gestures and body movements may reflect decreased energy or weakness caused by illness. Cardiovascular system- alterations in cardiac status are responsible for as many as 30% of perioperative death. Respiratory system- a decline in ventilatory function, assessed through breathing pattern and chest excursion, may indicate a clients risk for respiratory complications.

Perioperative Nursing Care

Physical assessment/clinical manifestations

Renal system-abnormal renal function can altered fluid and electrolyte balance and decrease the excretion of preoperative medications and anesthetic agents. Neurologic system- a clients LOC will change as a result of general anesthesia but should return to the preoperative LOC after surgery.

Perioperative Nursing Care

Physical assessment/clinical manifestations

Musculoskeletal system- Deformities may interfere with intraoperative and postoperative positioning. Avoid positioning over an area where the the skin shows signs of pressure over bony prominences. Gastrointestinal system- alteration in function after surgery may result in decreased or absent bowel sound and distention. Head and Neck- the condition of oral mucous membranes reveals the level of hydration.

Preoperative Nursing Care

Gerontological Considerations

Cardiovascular Coronary flow decreases Heart rate decreases Response to stress decreases Peripheral vascular decreases Cardiac output decreases Cardiac reserve decreases

Preoperative Nursing Care

Gerontological Considerations

Respiratory System Static lung volumes decreases Pulmonary static recoil decreases Sensitivity of the airway receptors decreases Nervous system Increased incidence of post.op. confusion. Increased incidence of delirium Increased sensitivity to anesthetic agents

Preoperative Nursing Care

Gerontological Considerations

Renal System Renal blood flow declines 1.5% per year. Renal clearance reduced Gastrointestinal Decreased intestinal motility Decreased liver blood flow Delayed gastric emptying

Preoperative Nursing Care

Gerontological Considerations

Musculoskeletal Decreased mass, tone, strength Decreased bone density Integumentary Decreased elasticity Decreased lean body mass Decreased subcutaneous fat

Preoperative Nursing Care

Psychosocial considerations
Level of anxiety Coping ability Support systems

Preoperative Nursing Care

Laboratory and diagnostic studies

Screening tests depend on the condition of the client and the nature of the surgery. If test reveals severe problems the surgery may be cancel until the condition is stabilized. Routine screening test-CBC,Blood grouping and X-match, Lytes, fasting blood sugar, BUN & Creatinine, ALT,AST, and bilirubin,Serum albumin, and Total protein, Urinalysis, Chest X-ray,ECG

Preoperative Nursing Care

Common nursing diagnosis
Knowledge deficit Anxiety Risk for ineffective airway clearance Fear related to Disturbed sleep pattern Anticipatory grieving related to

Preoperative Nursing Care Preop. teaching

The education plan should begin with assessment, including baseline knowledge of the patient and family, readiness to learn,barriers to learning, patient and family concern and learning styles and preferences. The content focuses on information that will increase patients familiarity with procedural events. This includes surgical experience (procedural), what the pt. may experience (sensory) and what actions may help decrease anxiety (behavioral).

Preoperative Nursing Care Anxiety

The nurse must consider the pts family and friends when planning psychological support. Empowering their sense of control. Activities that decreasing anxiety are deep breathing, relaxation exercises, music therapy, massage and animalassisted therapy. Use of medication to relieve anxiety.

Preoperative Nursing Care

Preanesthesia Management Physical Status Categories

ASA 1: Healthy patient with no disease ASA 11: Mild systemic ds without fx limitations ASA 111:Severe systemic ds associated with definite fx limitations ASA 1V: Severe systemic ds that is a constant threat to life. ASA V: Moribund pt. Who is not expected to survive without the operation. ASA V1: A declared brain-death whose organ are being recovered for donor. E: Emergency

Preoperative Nursing Care

Final Preparation for surgery

All personal belongings are identified and secured. Jewelry is usually removed. Dentures are removed, labeled and placed in a denture cup. Pt. to verbally confirm the surgical procedures and the surgical site. This verification process is documented in the medical record on the preop. checklist.

Preoperative Nursing Care

Pre-op. medications

Prior to administering check permits Purpose: Allay anxiety Decrease pharyngeal secretionsDecrease gastric secretion. Decrease side effects of anesthesia. Induce amnesia

Preoperative Nursing Care Medications

Sedatives/hypnotics- Nembutal Tranquilizers-Ativan, versed, valium Opiate analgesics- Demerol, morphine Anticholinergics-Atropine sulfate,atarax H2o blockers.- Tagamet, Zantac Antiemetic- Reglan, Phenergan

Intraoperative Phase
Surgical Team

Surgeon Anesthesiologist Scrub Nurse Circulating Nurse OR techs

Intraoperative Nursing Care

Roles of team members

Surgeon-responsible for determining the preoperative diagnosis, the choice and execution of the surgical procedure, the explanation of the risks and benefits, obtaining inform consent and the postoperative management of the patients care. Scrub nurse- (RN or Scrub tech)- preparation of supplies and equipment on the sterile field; maintenance of pt.s safety and integrity: observation of the scrubbed team for breaks in the sterile fields; provision of appropriate sterile instrumentation, sutures, and supplies; sharps count.

Perioperative Nursing Care Surgical team

Circulating Nurse - responsible for creating
a safe environment, managing the activities outside the sterile field, providing nursing care to the patient. Documenting intraoperative nursing care and ensuring surgical specimens are identified and place in the right media. In charge of the instrument and sharps count and communicating relevant information to individual outside of the OR, such as family members.

Perioperative Nursing Care Surgical team

Anesthesiologist and anesthetistanesthetizing the pt. providing appropriate levels of pain relief, monitoring the pts physiologic status and providing the best operative conditions for the surgeons. Other personnel- pathologist, radiologist, perfusionist, EVS personnel.

Perioperative Nursing Care

Surgical team
Nursing Roles: Staff education Client/family teaching Support and reassurance Advocacy Control of the environment Provision of resources Maintenance of asepsis Monitoring of physiologic and psychological status

Intraoperative Nursing Care

Surgical asepsis

Ensure sterility Alert for breaks

Intraoperative Phase Anesthesia

Greek word- anesthesis, meaning negative sensation. Artificially induced state of partial or total loss of sensation, occurring with or without consciousness. Blocks transmission of nerve impulses Suppress reflexes Promotes muscle relaxation Controlled level of unconsciousness

Intraoperative Phase Anesthesia

Factors influencing dosage and type:

1.Type and duration of the procedure 2.Area of the body being operated on 3.Whether the procedure is an emergency 4.Options of management of post. Op. pain 5.How long it has been since the client ate, had any liquids, or any medications 6.Client position for the surgical procedures

Intraoperative Phase
Types of Anesthesia
General- method use when the surgery requires that the patient be unconscious and/or paralyzed. A general anesthetic acts by blocking awareness centers in the brain so that amnesia (loss of memory), analgesia (insensibility to pain), hypnosis (artificial sleep), and relaxation (rendering a part of the body less tense) occur.

Intraoperative Phase
Stages of General Anesthesia
Stage 1- Analgesia and sedation, relaxation Stage 2- Excitement, delirium Stage 3- Operative anesthesia, surgical anesthesia Stage 4- Danger

Intraoperative Phase

Complications of General Anesthesia

Overdose Hypoventilation Related to anesthetic agents Malignant hyperthermia Related to intubation

Intraoperative Phase
Local or Regional Anesthesia Temporarily interrupts the transmission of sensory nerve impulses from a specific area or region.

Motor function may or may not be affected Client does not lose consciousness Gag reflex remains intact Supplemented with sedatives, opioids, or hypnotics

Types of Regional Anesthesia

Topical (surface) Local Nerve Block Intravenous (Bier Block) Spinal Epidural (peridural)

Intraoperative Phase

Complications of Local/Regional Anesthesia

Anaphylaxis Administration technique Systemic absorption Overdosage

Spinal Anesthesia
Indications -surgical procedures below the diaphragm -patients with cardiac or respiratory disease Advantages -mental status monitoring -shorter recovery Disadvantages -necessary extra expertise -possible patient pain Contraindications -coagulopathy -uncorrected hypovolemia

Spinal Anesthesia
Involved medications -lidocaine -bupivacaine -tetracaine Patient assessment -continuous heart rate, rhythm, and pulse oximetry monitoring -level of anesthesia -motor function and sensation return monitoring

Spinal Anesthesia
Complications
-hypotension -bradycardia -urine retention -postural puncture headache -back pain

Spinal analgesia
Indications -postoperative pain from major surgery Involved medications -lipid-soluble drugs -preservative-free morphine Monitoring recovery -respiratory depression -urine depression -pruritus -nausea and vomiting

Examples of location for Spinal and Epidural Anesthesia.

Nerve Block Sites

Intraoperative Phase
Conscious Sedation

Administration of IV sedative, hypnotic, and opioid medications.

Produces a depressed level of consciousness Retains ability to maintain a patent airway Able to respond to verbal commands or physical stimulation Used for relatively short procedures

Postoperative Nursing Care

Nursing assessment in the PACU

Vital signs- presence of artificial airway, 02 sat,BP,pulse, temperature. LOC- ability to follow command, pupillary response Urinary output Skin integrity Pain Condition of surgical wound Presence of IV lines Position of patient

Postoperative Nursing Care

Nursing Diagnosis

Ineffective airway clearance- increased secretions 2 to anesthesia, ineffective cough, pain Ineffective breathing pattern- anesthetic and drug effects, incisional pain Acute pain Urinary retention Risk for infection

Postoperative Phase
Assessment of the Postanesthesia Client
Airway Vital signs Cardiac monitoring Peripheral vascular assessment Level of consciousness (LOC) Fluid and electrolytes GI system Integumentary system Discomfort/pain

Perioperative Nursing Care

Postoperative Management

Maintain a patent airway Stabilize vital signs Ensure patient safety Provide pain Recognize & manage complications

Postoperative Nursing Care

When caring for post-surgical patient, think of the 4 Ws

Wind: prevent respiratory complications Wound: prevent infection Water: monitor I & O Walk: prevent thrombophlebitis

Postoperative Phase

Complications
Respiratory- atelectasis, pulm. Embolus Cardiovascular- venous thrombosis Gastrointestinal-Hiccoughs, N/V,abd. Distention, paralytic ileus, stress ulcer. GU- urinary retention Hemorrhage-slipping of a ligature(suture) Wound infection Wound dehiscence and evisceration-

Dehiscence
Partial or complete separation of the outer layer of the wound. Possible causes: Poor suturing technique Distention Excessive vomiting Excessive coughing Dehydration Infection

Evisceration
Total separation of the layers & protrusion of internal organs or viscera through the open wound. Causes: same as dehiscence Treatment: Call for help Cover with sterile NS soaked gauze/towels Keep moist DO NOT ATTEMPTS TO REINSERT ORGANS. Keep in supine position with knees/hips bent Assessment/VS q 5 min. until MD arrive Prepare for surgery.

Postoperative Phase

Postoperative Phase

Postoperative Nursing Care

Gerontologic considerations

Mental status- attributed to medications, pain, anxiety, depression. Delirium- infection, malignancy, trauma, MI, CHF, opioid use. Dementia-sundowning-sleep disturbances, lack of structure in the afternoon or early morning, sleep apnea.