Perioperative Nursing - it is the nursing care rendered to the total surgical experience of the patient.

3 Phases Preoperative phase Intraoperative phase Postoperative phase Effects of Surgery on a Client A. Physical Effects B. Psychological Effects The Surgical Risk Patients 1. 2. 3. 4. 5. 6. 7. Extremes of age Malnourished (emaciation/obesity) Dehydrated patients Patients with severe trauma or injury, infection or sepsis Patients with cardiovascular disease Endocrine dysfunction Hepatic/Renal disease Medications That Can Affect the Surgical Client
      

Antibiotics Antidysrhythmics Anticoagulants Corticosteroids Insulin Diuretics Antidepressant Classifications of Surgery According to Urgency:

1. Emergent requires immediate attention; Disorders maybe life-threatening. 2. Urgent- surgical problem requires prompt attention within 24-30hrs 3. Required- condition requires surgery within a few weeks

4. Elective- approximate time for surgery is at the convenience of the patient, failure to have surgery is not catastrophic 5. Optional- is scheduled completely at the preference of the patient.


According to Degree of Risk: Major- high degree of risk > maybe complicated/prolonged > large losses of blood may occur > vital organs maybe involved > post-op complications may be likely Minor- little risk with few complications > often performed in a day According to Purpose

1. 2. 3. 4. 5.

Diagnostic- verifies suspected diagnosis Exploratory- estimates the extent of the disease or injury Curative- removes/repairs damage tissues Ablative- Removing diseased organ that cant wait anymore Reconstructive-partial or complete restoration; bringing back orig. appearance and function 6. Constructive- repairing damaged tissue/congenitally defective organ 7. Palliative relieves symptoms but does not cure the underlying diseases Preoperative Phase Informed Consent (Operative Permit) Obtaining Inform Consent

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

The surgeon is responsible for obtaining the consent for surgery. No sedation should be administered to the client before he/she signs the consent. Minors may need a parent or legal guardian to sign the consent form. Older client may need a legal guardian to sign the consent form. The nurse may witness the clients signing of the consent form. If the patient is unable to write, an X to indicate his sign is acceptable if there is a signed witness to his mark. Procedures Requiring Permit

1. Surgical procedures where scalpel,scissors, suture, hemostats or electrocoagulation maybe used. 2. Entrance into a body cavity 3. Radiologic procedure, particularly if contrast material is required. 4. General anesthesia, local infiltration and regional block Physical Preparation of Patient the Night Before Surgery 1. NPO- 6-8hrs (general and spinal anesthesia) 2-4hrs (local anesthesia) 1. Bowel Prep- for major abdominal surgery 1. Skin prep- shower with antibacterial soap Preoperative Teaching/Visit q Physical Preparation q Psychological Preparation Postoperative Exercises Deep breathing - every 2hrs Coughing Splinting Turning every 2hrs Foot and Leg Exercise Incentive Spirometer Positive Effects - provides stimulus for a spontaneous deep breath - reduces atelectasis - opens airways - stimulates coughing - encourage active individual participation in recovery

Preoperative Medications 1. Narcotic analgesic 2. Anticholinergics 3. Sedatives 4. Prophylactic antibiotic

Surgical Checklist q Identification and verification q Review of patients record q Consent form q Patient preparedness 1. NPO status 2.Proper attire (hospital gown) 3. Skin prep, if ordered 4. IV started with correct gauge needle 5. Dentures or plates removed 6. Jewelry, contact lenses 7. allow patient to void IV Cannulas G18 - green G20 - pink G22 -blue G24 yellow INTRAOPERATIVE PHASE Aseptic Technique A group of procedures that prevent contamination of microorganisms through the knowledge of contain and control. Sterile Technique Methods by which contamination of an item is prevented by maintaining the sterility of an item/area involved with the procedure. Basic Principles of Aseptic Technique 1. All items used within the sterile field must be sterile. 2. A sterile barrier that has been permeated must be considered contaminated. 3. The edges of a sterile wrapper or container are considered unsterile once the package is opened. 4. Gowns are considered sterile from chest to the level of the sterile field, and the sleeves to 2inches above the elbows. 5. Tables are sterile at table level only. 6. Sterile persons and items touch only sterile areas; unsterile persons and items touch only unsterile areas. 7. Movement around the sterile field must not contaminate the field. 8. All items and areas of doubtful sterility are considered contaminated. Recommended Practice III

Items used within the sterile field should be sterile Event-related sterility system - sterility is not altered overtime, but may be compromised by certain events/environmental conditions Shelf life - refers to the time an item may remain on the shelf and still maintain its sterility. Spaulding Criteria - are used to determine the potential for transmission of infectious agents. Recommended Practice IV All items introduced to a sterile field should be opened, dispensed and transferred by methods that maintain item sterility and integrity. 1. The surgical team should practice careful aseptic technique during all invasive surgical procedures. 2. Unscrubbed individuals should open wrapped sterile supplies by opening the wrapper flap farthest away from them first. 3. Sharps and heavy objects should be presented to the scrubbed person/opened on a sterile surface. 4. Peel pouches should be presented to the scrubbed person. 5. Rigid container systems should be opened on a separate surface. When dispensing solutions, the solution receptacle on the sterile field should be placed near the tables edge, or held by scrubbed person. v Strike- through - contamination of sterile surface by moisture that has originated from a non-sterile surface and penetrated the protective covering of the sterile item Medications should be delivered to the sterile field in an aseptic manner.

Recommended practice V A sterile field should be maintained and monitored constantly. 1. A sterile field should be prepared in the location in which it will be used. 2. For unsterile personnel, movement around the sterile field should maintain a distance of at least12 inches from the sterile field. 3. Sterile fields should be prepared as close as possible to the time of use. 4. Sterile field should not be covered. 5. Conversations in the presence of a sterile field should be kept to a minimum. Recommended Practice VI All personnel moving within or around a sterile field should do so in a manner that maintains the sterile field. Unscrubbed personnel

- should face sterile fields on approach - should not walk between two sterile fields Scrubbed personnel - should keep their arms and hands above the level of the waist at all times. - arms should not be folded with the hands in the armpits - should avoid changing levels. The number and movements of the surgical team should be kept to a minimum. When a break in the sterile technique occurs, corrective action should be taken immediately. Recommended Practices for traffic Patterns in the Perioperative Practice Setting Non- Restricted Area Semi-Restricted Area Restricted Area Transition Zone Recommended Practices for Surgical Attire Surgical Attire Helps contain bacterial shedding and promotes environmental control. If a two-piece pantsuit is worn, the top of the scrubsuit should be secured at the waist or fit close to the body. Should be changed daily or whenever it becomes visibly soiled, contaminated or wet. Lab coats/cover gowns should be removed before entering a semirestricted/restricted area Non-scrubbed personnel should wear long-sleeved jackets that are buttoned/snapped closed during use. Head Cover Headgear should be donned before the scrub attire to prevent fall-out from the hair collecting on the scrub attire. Personnel should cover head and facial hair, including sideburns and necklines, when in the semi-restricted and restricted areas of the surgical suit. Contaminated headgear must be removed and laundered by the facility. Surgical Mask Should fully cover both mouth and nose and be secured in a manner that prevents venting. Double mask is unacceptable, doesnt increase filtration. Should be removed by handling only the ties, should be discarded immediately. Should not be saved by hanging them around the neck or tucking them into a pocket for future use

Gloves Sterile gloves must be worn when performing sterile procedure. Medical, non sterile gloves are recommended for non-sterile activities. Should be changed between patient contacts/contaminated items. Hand hygiene should be performed after gloves are removed. Recommended Practices for Standard and Transmission based Precautions in the Perioperative Practice setting Standard Precautions to prevent pathogen transmission should be used during all invasive procedures. Standard Precautions should include use of protective barriers and frequent hand washing to reduce risk of exposure to potentially infectious materials. Personnel should take precautions to prevent injuries caused by scalpels and other sharp instruments. Personnel should handle specimens as potentially infectious material. Work practices should be designed to minimize risk of occupational exposure to bloodborne and other potentially infectious pathogens. Transmission based precautions should be used in addition to standard precautions for patients who are known or suspected to be infected with highly transmissible pathogens. 1. Airborne precautions - examples: rubeola, varicella, tuberculosis - respiratory protection to be worn by susceptible persons - placing surgical mask on patients during transport - elective surgical procedures on TB patients should be delayed until patient is no longer infectious. 2. Droplet precautions - examples: diptheria,pertussis,influenza,mumps - wearing a mask when within three feet of patients - positioning patients at a distance of at least three feet from other patients 3. Contact Precautions - wearing gloves when caring for patients/coming in contact with items that may contain high concentrations of microbes. - wearing gowns when it is anticipated that clothing will have substantial contact with patients/items in aegs. environment - precautions are maintained during transport. - adequately cleaning and disinfecting patient care equipment and items before use w/ each patient. Surgical Hand Scrub

Goals: Mechanical removal of soil and transient microbes from the hands and forearms Chemical reduction of the resident microbial count to as low a level as possible Reduction of potential of rapid rebound growth of microbes. Antimicrobial Agents Iodophors Chlorhexidine gluconate Anatomic Hand Scrub Technique Sequence in Removing Soiled Gowns and Gloves at the End of the Procedure Preparation of Surgical Supplies Decontamination contaminates are removed either by hand cleaning or mechanical methods using specific solutions. Disinfection-to use to destroy/kill/inhibit growth of microbes thru application of antiseptic solution. Sterilization- rendering an item totally free of all living microorganisms including spores. Members Of the Surgical Team
   

Surgeon Anesthesiologist Scrub Nurse Circulating Nurse Circulating Nurse Sets up the Operating room Ensures that necessary supplies and equipment are readily available, safe and functional Receives patient endorsement Assists in the transferring of client in the OR bed Positions patient in the OR bed Performs surgical skin preparation Opens and dispenses additional needed supplies /medications during surgery Manages catheters, tubes, drains and specimens Reviews the results of any diagnostic tests or lab studies Ensures that the surgical team maintains sterile technique and a sterile field. Monitors traffic in the OR Manages the flow of information to and from the surgical team members scrubbed at the field Manages personnel, equipment, supplies and the environment during surgery

Performs sharps, sponge and instrument count at appropriate time Documents all care, events, findings and patients responses intra-op Dressing of wound and drainage Care of the tissue specimen Scrub Nurse Performs scrubbing, gowning and gloving Prepares sterile field for scheduled/emergency surgery Assists with instrumentation, sponges and suture presentation Anticipate needs for surgical team Performs sharps, sponge, and instrument count Prepares sterile dressing w/c will be applied when surgery is completed Aftercare of instruments and other materials Care of tissue specimen Paraprofessionals/Ancillary Positions Prepares and maintains supplies, equipment and environment Assists nursing staff before, during and after surgical procedure Anesthesia and Related Complications Common Anesthetic Technique Minimal Sedation Patient remains conscious Protective reflexes remain intact Can respond to verbal commands Moderate Sedation -state of depressed level of consciousness that does not impair patients ability to maintain a patent airway and to respond to physical stimulation and verbal commands. Deep Sedation - Drug induced state during which the patient cant be easily aroused but can respond purposefully after repeated stimulation General Anesthesia Complete loss of consciousness A reversible state that provides analgesia, muscle relaxation and sedation It depresses the cerebral cortex where conscious interpretation of pain takes place Protective reflexes are lost Produced by IV/inhaled anesthetics Nitrous Oxide Colorless, odorless non-explosive gas Is rarely used alone

When combined with other agents and oxygen----it already serves as potentiator for other inhalation agents High concentration nitrous oxide can produce hypoxia induction agent given with oxygen used alone for short procedures used as inhalation analgesic Inhalation Anesthesia Volatile agents Halothane
         

safe to use producing rapid smooth induction non-flammable/non-explosive very potent seldom causes nausea and vomiting non-irritating to mucous membranes excellent bronchodilator hepatotoxic Decreases bp Causes malignant hyperthermia Forane (Isoflourane) Provides rapid induction, rapid emergence Low incidence of nausea and vomiting Does not stimulate excessive secretions Non-hepatotoxic/non-nephrotoxic Excellent choice for neurosurgery Not recommended for children under 2 years of age------due to longer airway irritation Enflurane Has similar effects to halothane Muscle relaxation is stronger Hepatotoxicity is not a problem Induces electroencephalographic changes causing seizure.

Complications of General Anesthesia 1. Aspiration

2. 3. 4. 5. 6.

Oral trauma Hypoventilation Cardiac dysrrythmias Hypothermia Malignant Hyperthermia Regional Anesthesia Production of anesthesia in a specific body part Injecting local anesthetics in close proximity to appropriate nerves Spinal Anesthesia Local anesthetic is injected into lumbar intrathecal space/sub arachnoid space Anesthetic blocks conduction in spinal nerve roots and dorsal ganglia Paralysis and analgesia occur below level of injection Produces excellent analgesia and relaxation to abdominal and pelvic procedures Positioning Surgical Patient (Spinal Anesthesia)

 

Sitting Position Lateral Position Epidural Anesthesia Injecting local anesthetic into epidural space by way of a lumbar puncture Associated with obstetric surgery; anorectal and perineal procedure Administered via bolus Peripheral Nerve Blocks Anesthetic is injected around a nerve that supplies sensation to a small area of the body Intravenous Block Involves IV injection of a local agent and the use of an occlusion tourniquet Procedures involving the arm, wrist and hand

Local Anesthesia (Infiltration) Used for minors and superficial procedures The agent is injected in the surgical site Topical Anesthesia Anesthetic agent is directly applied to the skin and mucous membranes Complications of Spinal Anesthesia

Hypotension Nausea and vomiting Urinary retention Post spinal headache Quadrants Of the Abdomen slide 62 Regions of the Abdomen Positioning: A Team Concept 5 Factors to be considered when positioning a surgical patient Anatomy involved with the procedure Surgical Approach/surgeons preference Patient comfort Patient and staff safety Respiratory and circulatory freedom Supine (Dorsal Recumbent) Procedures: Abdominal Extremity Vascular Chest Neck Facial Ear Breast Lithotomy Procedures: Perineal Vaginal Combined abdominal-vaginal Lateral Recumbent Procedures: Chest Kidney Trendelenburg Procedures: Lower abdominal Pelvic Organs Kraske (Jacknife)

Procedures: Rectal Procedures Sigmoidoscopy Colonoscopy Prone Procedures: Surgeries involving the posterior surface of the body Spine Neck Buttocks Lower extremities What is surgical skin prep? v an aseptic procedure that is used to reduce the resident and transient flora naturally present on the skin surface. v Accomplished by application of anti-microbial agents. v Rendering the skin surgically clean v Is performed by the circulating nurse v Prior to draping

Antimicrobial Solutions 1. Povidone /Iodine Betadine 2. Chlorhexidine Gluconate

     

Rapid acting Have a broad spectrum of activity Have minimal harsh effect on skin Inhibit rapid rebound of microbes Economical to use Based on documentation in scientific literature Special Areas of Consideration

  

Eyes Traumatic open wounds Fractures

  

Tumors, Aneurysm and Ovarian Cyst Dirty Contaminated Areas Emergency Preps Abdominal Prep

 

Breastline to upper 3rd of thigh Table line to table line when in supine position Chest and Breast

   

Shoulders Upper arm elbow Axilla Chest wall to table-line and 2 inches beyond the sternum to the opposite shoulder Lateral/Thoracotomy

   

Axilla Chest Abdominal-from neck to iliac crest Area should extend beyond the midline anteriorly and posteriorly Knee/ Lower leg

 

Entire circumference of affected leg Extends from the foot to upper part of thigh Hip/ Lower Extremity

    

Abdomen on the affected side Thigh- knee Buttocks table line Groin Pubis Rectoperineal / Vaginal Sutures Absorbable sutures

Examples: Chromic, Plain,Polydiaxone (PDS), Polyglactin 910 (Vicryl),Polyglycolic Acid(Biovek) Used for those who cant return for suture removal/in internal body tissues Non-Absorbable sutures Examples: Silk,Nylon,Prolene (Polypropylene) Used either on skin wound closure/in stressful internal environments where absorbable sutures will not suffice Less scarring because they provoke less immune response Sutures Is a medical device used to hold tissue together after an injury or surgery till healing takes place. Absorbable Sutures


material is digested by body cells and fluids during the healing period. Plain dissolves within 5-10 days, Yellow Chromic- dissolves within 1 month, Brown Vicryl/Safil- dissolves within 60-90 days, Lavender PDS (Polydioxone)- dissolves 2 times longer than the other absorbable sutures, White Non absorbable Sutures Material is not absorbed or digested by tissues during healing period Types: Silk- is an animal product from silk worm cocoons. (Black) Cotton- made from long staple cotton, treated to make it smooth, (White) Prolene- biosynthetic, non-absorbable suture material, as substitute to silk Wire- gives the greatest strength to any suture material

Different Types Of Needles Slide 81 The Basic Surgical Instruments Cutting and Dissecting Grasping and Holding Retracting and Exposing Clamping and Occluding Miscellaneous Cutting and Dissecting Instruments

     

Scalpel holder Curved and Straight Mayo Scissors Metzenbaum Lister/Bandage Scissors Suture Scissors Stitch Scissors

Grasping and Holding Instruments Tissue Forceps These are available in various lengths, with or without teeth, and smooth or serrated jaws.
  

DeBakey Tissue Forceps Adson Tissue Forceps Russian Tissue Forceps Russian Tissue Forceps They have serration up to the tips, allowing better grasp of tissue with minimum trauma. They Are used to hold tissue, drapes or sponges.

      

Randall Stone Forceps Backhaus Towel Clamp Allis Clamp Tenaculum Babcock Clamp Foester / Ovum Sponge Forceps Kocher/ Oschsner Clamp Hook and Dissector Randall Stone Forceps To hold/remove kidney stones Retracting and Exposing Instruments

 

Richardson US Army Navy

         

Senn Deaver Malleable Vein Retractor Volkmann Rake Green Goiter Weitlaner Langenbeck Skin Hooks Vaginal Speculum Clamping and Occluding Instruments They are used to compress blood vessels or hollow organs for hemostasis or to prevent spillage of contents.

    

Straight Mosquito Kelly Clamp Crile Clamp Pean (Rochester-Pean) Clamp Right-Angled (Mixter /Dissector) Forceps Suturing Instruments

Postoperative Phase 3 Stages Immediate Stage - (1-4hrs) after surgery Intermediate Stage - (4 -24hrs) after surgery Extended Stage - (1-4days) after surgery/last follow-up visit with the attending physician Immediate Postoperative Period Respiratory Position - left lateral with neck extended and upper arm supported on a pillow. - supine with head to side and chin extended forward Check presence of gag reflex

Maintain artificial airway until gag reflex returned Oxygen Assess rate and depth of respiration Assess breath sounds Monitor for signs of atelectasis, pneumonia, pulmonary embolism Cardiovascular Assess skin and check capillary refill Assess peripheral edema Monitor for bleeding Assess pulse rate and rhythm Monitor for hypo/hypertension Monitor for cardiac dysrhythmias Assess for Homans Sign Monitor Respiratory Status coughing/deep breathing q 1-2 hrs turning in bed q 2hrs early ambulation auscultate lungs q 4hrs Monitor Cardiovascular Status leg exercises q 2hrs apply anti-embolic stockings vital signs, color, temp of skin Promote Fluid and Electrolyte Balance Measure I and O Promote Optimum Nutrition maintain IV infusion as ordered Assess return of peristalsis -Progressive increase in diet Promote Return of Urinary Function Assess ability to void/ bladder distention Report to surgeon if client has not voided after8hrs post-op Transferring the patient from the PACU Transfer Criteria: Patient coming out of General Anesthesia Vital signs are stable for at least 30mins and are within normal range Patient is breathing easily Reflexes has returned to normal Patient is responsive and oriented to time and place Patient who had regional anesthesia

Sensation is restored and circulation is intact Reflexes has returned Vital signs have stabilized for at least 30mins Adequate urine output Control of pain Control or absence of vomiting

Post-operative Complications Atelectasis - a collapse of the alveoli with retained mucus secretions - Usually develop 1-2days post-op Aspiration - caused by inhalation of food, gastric contents, water or blood into the tracheobronchial system. - anesthetics and narcotics depress the CNS,causing inhibition of cough and gag reflex Pneumonia an inflammatory response in which cellular material replaces alveolar gas. - may develop 3-5days post-op Assessment: Dyspnea, increased RR Crackles over involved lung area Elevated temp Productive cough and chest pain Hypotension Decreased breath sounds Pulmonary Embolism -An embolus blocking the pulmonary artery disrupting blood flow to one or more lobes of the lungs Assessment: Dyspnea Sudden sharp chest/upper abdominal pain Cyanosis Tachycardia A drop in blood pressure Cardiovascular Complications

Thrombophlebitis Inflammation of the vein, often accompanied by clot formation 7-14 days post-op Assessment: Vein inflammation Aching or cramping pain Vein feels hard and cordlike and is tender to touch Elevated temperature Positive Homans sign Intervention v hydrate patient adequately v Avoid massaging to calves or thighs v Avoid standing or sitting in one pace or crossing legs v Avoid inserting IVs into legs v Assess for Homans Sign Circulatory Complications Hemorrhage -The loss of a large amount of blood externally/internally for a short period of time Shock -Loss of circulatory fluid volume caused by hemorrhage Assessment: Restlessness Weak rapid pulse Hypotension Tachypnea Cool clammy skin Reduced urine output Constipation Paralytic Ileus - paralysis of intestinal peristalsis Wound Infection - occurs 3-6 days post op Wound Dehiscence - Separation of wound edges on the suture line - occurs between 5th and 8th day post op Wound Evisceration - Protrusion of the internal organs and tissues through an opening in the wound edges

Urinary Retention -Involuntary accumulation of urine in the bladder as a result of loss of muscle tone - Due to effects of anesthetics/narcotics Assessment: Inability to void Restlessness and diaphoresis Lower abdominal pain, distended bladder Elevated BP

Postoperative Discharge Teaching Focus on: Proper wound dressing Medications Diet Follow-up visit removal of sutures in 7-10 days/ removal of staples in7-14 days Activity levels-no lifting for 6 weeks - not to lift anything (>10lbs) Return to work in 6-8 weeks Signs and symptoms of complications

Post Chest or Lung Surgery(Pneumonectomy) Discharge Instruction Breathing exercises for 3 wks Arm and shoulder exercise -5times a day(10-20 repetitions /exercise Practice standing straight with shoulders even on the affected side No heavy lifting of more than 20lbs for 3-6mos Stop any activity that causes dypnea,chest pain,excessive fatigue Obtain influenza and pneumonia vaccine Report intermittent cough with sputum Drains q are placed in wounds only when abnormal fluid collections are present/expected q Are placed near the incision site: q In compartments that are intolerant to fluid accumulation q In areas with large blood supply q In infected draining wounds q Areas that have sustained large superficial tissue dissection q Greatest amt is expected during the first 24 hrs

q are removed when amount of drainage decreases Types of Drains Gravity 1. Penrose Drain 2. T-Tube Mechanic - these are portable self contained closed wound mechanical devices that suction fluid after collapsing them and closing the valve thus forcing the fluid to be pulled into the collection chamber. 1. Jackson-Pratt Drain 2. Hemovac

Types of Wound Healing First Intention Healing Wounds are made aseptic by minor debridement and irrigation with a minimum tissue damage and tissue reaction Wound edges are properly approximated with suture Granulation tissue is not visible/scar formation minimal Intention Healing Wounds are left open to heal spontaneously or surgically closed at a later date Examples include burns, traumatic injuries, ulcers and suppurative infected wounds Cavity of the wound fills with a red, soft, sensitive tissue (granulation tissue), which bleeds easily, a scar eventually forms. In infected wounds, drainage may be accomplished by use of special dressings and drains. Produces deeper wider scar

Care and Handling of Surgical Specimens Types of Surgical Specimen Routine specimen -specimen that doesnt require immediate attention -placed in a preservation fluid -labeled and sent to Pathology Department ff conclusion of the procedure - scrub nurse should separate like specimens from different locations

-specimens not immediately passed off the field should be kept moist in saline -calculi should not be placed in formalin, same with foreign bodies - amputated extremities are wrapped before sending them to the pathology/morgue Diagnostic Specimen Frozen Section Requires special handling and immediate examination by the pathologist With verbal report of the findings communicated to the surgeon during the surgical procedure Examples include breast biopsy/any organ, tumor or lesion Specimen is sent dry and is properly labeled.

Cultures Are taken on a patient who comes to the OR with a known/suspected infection 2 types: aerobic and anaerobic, requires different medium for growth This will determine the antibiotic that will specifically affect the microbes Are obtained under sterile condition, using appropriate collection tube. Exact procedure for collecting cultures for specific test will vary from each institution Must be sent to the lab immediately for accurate processing