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Perioperative Nursing Perioperative nursing is a uniquely exciting specialty area focused on care for patients undergoing any type

of surgery. The nurses provide care pre-operatively (before), intra-operatively (during), and post-operatively (after surgery). Fundamental nursing skills are the foundation for perioperative nurses, however, their education continues beyond the basic nursing programs, Perioperative nursing encompasses caring for the patient as a whole being, taking into account physiological, psychological, sociocultural, and spiritual issues. The perioperative nurse is responsible for patient safety throughout the surgery. PERIOPERATIVE CARE Peri-op care is the care that is given before, during and after surgery. It takes places in hospitals, in surgical centers attached to hospitals, in freestanding surgical centers or health care providers' offices. This period is used to prepare the patient both physically and psychologically for the surgical procedure and after surgery. For emergent surgeries this period can be short and even oblivious to the patient; for elective surgeries "preops" can be quite lengthy. Information obtained during preoperative assessment is used as a basis for the care plan for the patient.

Three Phases Preoperative - Care given before surgery when physical and psychological preparations are made for the operation, according to the individual needs of the patient. The preoperative period runs from the time the patient is admitted to the hospital or surgicenter to the time that the surgery begins. Intraoperative - refers to the time during surgery. Intraoperative care is patient care during an operation and ancillary to that operation. Postoperative - Postoperative care begins in the recovery room and continues throughout the recovery period.

Categories and Purposes Reason/Purpose o Diagnostic, curative, restorative, palliative, cosmetic Degree of Urgency o Urgent immediate attention o Elective a planned, non-emergency procedure o Optional surgery performed at patients discretion Degree of Risk o Major - any surgical procedure that involves anesthesia or respiratory assistance

o Minor - any surgical procedure that does not involve anesthesia or respiratory assistance Anatomic location Extent of surgery- minimal, open, simple and radical - refers to the removal of blood supply, lymph nodes and sometimes adjacent structures
of a diseased organ or tumor during surgery

Preoperative Phase- Assessment Risk Factors o age, nutritional, health status, fluid and electrolytes imbalances, radiation, cardiopulmonary, chemotherapy, meds, family history, prior surgical experiences (positive/negative), type of surgery, location/site Nursing History o past & present, meds, diet, allergies (latex), personal habits, occupation, finances, family support, knowledge of surgery, attitude Physical Exam Diagnostic Tests CBC, electrolytes, creatinine, urinalysis, x-ray exams, EKG, Blood Type, PTT (is a blood test that looks at how long it takes for blood to clot. It can help tell if you have bleeding or clotting problems), PT (is a blood test that measures the time it takes for the liquid portion (plasma) of your blood to clot), Platelet Blood donations Radiographic Bloodless Surgery/Discharge

Psychological Response Informed Consent - Nurse witness Mentally competent If minor, a guardian, parent, or court order will sign permit; state will dictate age. Sociological DNR - document is a binding legal document that states resuscitation should not be attempted if a person suffers cardiac or respiratory arrest Nursing Process Preoperative Care Assessment History, Physical Exam, Lab/Radiology, Health Status, Risk Factors, Meds Nursing Diagnosis Planning Goal statement EOC (expected outcome criteria) Preoperative -Implementation

Informed Consent Nutrition/fluids - IV ; NPO after MN Elimination -enemas, Foley Hygiene - skin scrub; remove nail polish, hair pins, hospital gown Vital Signs Height/ Weight Special orders -(insert tubes, medications) Promote Comfort - Anti-anxiety meds Skin preparation Pre-op Teaching leg and deep breathing exercises; ROM exercises Moving patient ; coughing and splinting Monitor pt and diagnostic tests. TEDS (thromboembolism deterrent stockings), Elastic Wraps, Pneumatic Compression devices, early ambulation

pneumatic compression device

Elastic wraps Day of Surgery - complete pre-op checklist sheet in medical record, V/S, skin prep, removal of prosthetics, hair pins, dentures, bowel and bladder prep, IV, NG Tube, ID band, and pre-op medications.

Pharmocology Purpose - facilitate effective anesthetics, minimize respiratory tract secretions and relax, reduce anxiety. Types - Opiates, Anticholinergics, Barbiturates, Prophylactic antibiotics
- Opiates - is any substance that comes from opium, and the opium poppy. heroin, morphine, codeine, hydrocodone(vicodin), oxycodone(oxycontin,percocet), fentanyl, tramadol. they are all opiates and narcotic analgesics (painkillers) anticholinergics - is a substance that blocks the neurotransmitter acetylcholine in the central and the peripheral nervous system. Example: atropine sulfate barbiturates - are drugs that act as central nervous system depressants, and, by virtue of this, they produce a wide spectrum of effects, from mild sedation to total anesthesia. They are also effective as anxiolytics, as hypnotics, and as anticonvulsants. They have addiction potential, both physical and psychological. Example: Phenobarbital Prophylactic antibiotics

Hazardous to Surgery Certain antibiotics Anti-depressants Phenothiazines hypotensive phenomena may develop Diuretics hypotensive phenomena Steroids - immunosuppressant Anticoagulants bleeding

Preoperative Evaluation Evaluate goals and outcome criteria

Intraoperative Care

From the holding room to the operating room and then to recovery room. Implementations of anesthesia for analgesic, sedative, and muscle relaxant purposes as well as control Autonomic Nervous System. Holding area - enter prior to OR; nurse continues to prepare patient (insert Foley catheter or start IV) Nurse assist in transfer to and from OR, maintain proper body alignment.

Staff Surgeon, surgical assistant Surgical scrub, gowning, surgical asepsis Anesthesia Anesthesiologist, CRNA (certified registered nurse anesthetist) Holding Area Nurse Circulating Nurse - a registered nurse who makes preparations for an operation and continually

Scrub Nurse/Surgical Technologist (ORTs)

monitors the patient and staff during its course, who works in the operating room outside the sterile field in which the operation takes place, and who records the progress of the operation, accounts for the instruments, and handles specimens

Specialist Nurse - are clinical experts in the diagnosis and treatment of illness, and the delivery

of evidence-based nursing interventions (ANA, 2004). CNSs work with other nurses to advance their nursing practices and improve outcomes, and provide clinical expertise to effect system-wide changes to improve programs of care

Preoperative -Anesthesia General is a treatment that renders you unconscious during medical procedures, so
you don't feel or remember anything that happens. General anesthesia is commonly produced by a combination of intravenous drugs and inhaled gasses (anesthetics).

Regional - is anaesthesia affecting only a large part of the body, such as a limb Local - is any technique to render part of the body insensitive to pain without affecting
consciousness

Common General Anesthetics Inhaled General Anesthetics o Nitrous oxide, cyclopropane Inhaled liquid o halothane, enflurane, isoflurane Intravenous Anesthetic o Pentothal (thiopental)

Nursing Concerns-Preop Patent Airway Therapeutic Response to Anesthesia Proper Positioning Maintain Surgical Asepsis Intraoperative Care-Complication Hypoventilation (also known as respiratory distress) occurs when ventilation is inadequate to
perform needed gas exchange.

Oral Trauma - endotracheal intubation Hypotension Cardiac dysrhythmia abnormal rhythm of the heart Hypothermia Peripheral nerve damage Malignant hyperthermia - due to abnormal and excessive intracellular collection of Ca+ resulting in hypermetabolism and increased muscle contraction. Signs and Symptoms - high fever, tachycardia, muscle rigidity, heart failure, pseudotetany, and CNS damage.

Treatment of Malignant Hyperthermia

discontinue inhalent anesthetic, Give Dantrium, oxygen, dextrose 50%, diuretic, antiarrhythmics, sodium bicarbonate, and hypothermic measurescooling blanket, iced IV saline or iced saline lavage of stomach, bladder, rectum.

Adjunctive Anesthetic Agents Opioid analgesic o Alfenta o Demerol and Morphine Benzodiazepine o Valium, Versed Anticholinergic o Atropine, scopolamine Sedative-hypnotic o Atarax, Vistaril, Seconal, Nembutal Intraoperative-Drug Interaction Antihypertensives- hypotension Beta-Blockers- myocardium decreased Tetracycline--renal toxicity Anesthesia Local/Regional o Epidural - a form of regional anesthesia involving injection of drugs through a catheter
placed into the epidural space. The injection can cause both a loss of sensation (anaesthesia) and a loss of pain (analgesia), by blocking the transmission of signals through nerves in or near the spinal cord.

o Infiltration - An anesthesia induced by injecting the anesthetic solution directly into or


around the tissues to be anesthetized; used for operative procedures on the maxillary premolar, anterior teeth, and mandibular incisors.

o Nerve Block - Conduction anesthesia in which a local anesthetic is injected about the o
peripheral nerves. Spinal - is a form of regional anaesthesia involving injection of a local anaesthetic into the Subarachnoid space

o Topical - is a local anesthetic that is used to numb the surface of a body part. Anesthetic agents o Xylocaine, Novocain, carbocaine Topical o Dermoplast (benzocaine) o cocaine o ethyl chloride Geriatric concerns Address safety issues - sensory decline Hepatic, cardiac, respiratory and renal decline

Assess for preexisting problems such as cardiac, renal, hepatic, or respiratory.

Postoperative Care State of complications in wound healing.


Wound bleeding: Bleeding may indicate a dislodged clot, slipped sutures, coagulation problems, and trauma to blood vessels or tissues. This type of bleeding could show up on the wounds dressing, while internal hemorrhaging can occur inside the cavity of the body while the dressing stays dry and shows no signs of collecting blood. Dehiscence: this is the medical term for when the wound layers separate. The feeling you may experience when this happens is the feeling of something giving away. Most people may experience this after coughing, sneezing or vomiting. In the event your wound separates you should immediately place a sterile dressing over the area until a physician can evaluate the area. Evisceration: this is the medical term for when the abdominal organs protrude through the opening of an incision. This is a medical emergency and in the event of this happening you are to dial 911 and contact your physician immediately. Remain in bed and the wound is to contents are to be covered in warm, sterile saline dressings. This type of complication will require surgical repair. The most common form of complication of wound healing is wound infection. The CDC (Center for Disease Control) labels a wound "infected" when it contains purulent drainage. Purulent drainage is another meaning for pus. Someone with an infected wound may display a fever, tenderness or pain at the site of the wound, edema (swelling) and/or an elevated white blood count. Purulent drainage will have an odor and depending on the pathogen causing the infection it can be brown, green or yellow in color.

Immediate Anesthetic Care (PACU) Respiratory Status - patent airway Cardiovascular - regular, strong heart rate and stable BP (VS); peripheral pulses; Homans Sign Neurological level of consciousness; orientation, sensation Fluid and Electrolyte, Acid Base Balance Post op Drug Therapy Pain Pain Assessment Opioids in IV small doses Hypotension, respiratory GI motility GI bleed (Motrin) Narcan/Romazicon antidote Complementary and Alternative Therapies Positioning, Massage, relaxation and diversion, guided imagery, biofeedback, music. Post Operative Care Nutrition

Clear Liquids Full Liquids Soft Regular

Nursing Care Post Op Physical Assessment Renal Function Gastrointestinal Dressings Pain Thermoregulation Elderly Care in Postop Respiratory System diminished airway reflexes and cough Cardiovascular myocardium weakness Hypothermia less subcutaneous tissue, muscle, slow metabolic rate Pain more intense, confusion, impaired circulation and sensory Complications in Postop Hypotension Dysrhythmia Venous Thrombosis Pulmonary Embolism Hiccoughs Adbominal distention - paralytic ileus Immobility with skin integrity Urinary retention Urinary tract infection Wound infection, dehiscence, hemorrhage evisceration, Postop Care Psychological Anxiety Altered body image Finances, Family responsibility Future changes Immediate Anesthetic Care Airway/breathing ex. VS, Pulses IV

ABGs Pulse oximetry Pupil Respond Level of conscious Safety Dressings Drains/Tubes I&O; renal function Medications Laboratory work Hemodynamics Position/ROM Comfort

Discharge Plans Patient/Family Education and Psychosocial Support is throughout. Return MD Visit Dressing Care and Comfort Optimum respiratory, circulatory function, diet, meds(antibiotics, analgesic) Adequate hydration and body temperature Adequate renal function, safety in ADL Postoperative Care Same care as immediate anesthetic care Decrease frequency of vital signs to every 4 hours, IVs will be discontinued in time, increase ADL, decrease in breathing exercises and breathing treatments, advance diet. Recovery Period - 4 to 6 weeks Summary Specific Nursing Duties for each phase: Preoperative, Intraoperative, Postoperative Throughout Perioperative Care, the nurse will always: Monitor patients response to therapeutic regime, prevent complications, patient education and promote optimum well-being