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By

RANTI & ROHMAWATI


The background
• The major objective of cancer therapy is to treat
the patient effectively with appropriate therapy for
a sufficient duration so that a cure (or control) of
the cancer results with minimal functional and
structural impairment
• Surgery has a major role in the diagnosis staging
and treatment of cancer. It is also an integral part
of the rehabilitation and palliation for patients with
cancer.
• Surgery for cancer tends to be more complex than
similar procedures for benign conditions. This results
in potential for more complications.
Perioperative nursing
• The total episode of surgery is called the perioperative period
(The time before surgery is called preoperative, the time
during surgery is called intraoperative and the time after
surgery is called postoperative).
• Perioperative nurses is a registered nurses who use the nursing
process to design, plan and deliver care to meet the
identified needs of patient whose protective reflexes or self
care abilities are potentially compromised because of the
operative procedures to be performed.
• The perioperative nurses must possess and apply knowledge
of anatomy, physiology, psychology, sociocultural, and
spiritual beliefs and practices, in addition to knowledge of all
aspects of the surgical procedure to be performed.
• The perioperative nurses must be a good communicator,
delegator, and supervisor to ensure that the needs of the
patient are being met throughout the surgical repair.
The goals of perioperative
nursing
The goals of perioperative nursing practice are to
assist patients and their significant others through the
surgical episode, to help promote positive outcomes
and to help patients achieve their optimal level of
function and wellness after surgery
The Pre-Op Nurse
• Assesses physical, psychologic, and social states
• Prepares patients for surgery
• Implements nursing interventions
Preoperative patient assessment
• Identification of the patient with three identifiers-name,
medical record number, & date of birth
• Mental & physiological status of the patient
• Functional status (patient’s ability to perform ADLs)
• Nutritional status (how long has the patient been NPO)
• Cardiovascular , respiratory , renal, liver, endocrine,
hematologic status
• Range of motion & mobility
• Pain
• Skin condition
• Any prosthetics or corrective devices
• Sensory impairment, language barrier, cultural/spiritual needs
• Anxiety previous surgeries & anesthesia experience
• Allergies
• Medications, herbs, nutritional supplements & drug abuse
• The nurse should identify the patient’s support system their
significant other, family or friends that are present
Patient family & education
The key in nursing intervention during the preoperative period is
patient & family education. Take every opportunity during the
patient assessment and preparation of surgery, to provide
information that will:
• Increase patient’s familiarity with the
procedure – decreases anxiety
• Give instructions on activities that will
promote healing and prevent
postoperative complications example
deep breathing exercise, coughing,
turning, extremity, ambulation and pain
control.
• Assess and address individual learning needs
• Involve patients in decision making concerning their care –
allows them to maintain some control over events
• Teach about post operative pain control – to decrease anxiety
and add to the patient’s sense of control
Preoperative Checklist
A pre op checklist is way for the nurse to summarize patient data and ensure
the patient
Is ready for surgery
Pt ID confirmed
ID band
Allergies
Type: Reaction:
Procedure & site verified
Site marked
Consent signed
Jewelry removed
Valuables secured
Advance directives
Vital sign are completed & on chart
Physical assessment done
Make-up is removed
YES NO


Labs, EKG, x-ray on chart
NPO since
Premedications given
Universal Protocol
To ensure patient safety, the universal protocol is a
mandatory Joint Commission quality standard that verifies
• Designed to ensure…
 Correct client identity
 Correct procedure
 Correct surgical site

• Consist of…
 Pre-procedure verification process
 Surgical site marking
 Surgical “time out” immediately prior to starting the
procedure
Premedication given to…
Depending on the anesthesiologist’s preference,
premedication may be given by the pre-op nurse to
• Decrease anxiety
• Provide sedation
• Prevent or decrease nausea and vomiting
• Decrease gastric volume and acidity
• Decrease secretion of saliva gastric juices
• Relieve pain and discomfort
Informed Consent
The legal document that signifies that the patient has been told
about and understands all aspects of specific invasive
procedure.
Informed consent refers to the process in which patient is
informed of the…
• Nature
• Consequences
• Harms
• Benefits
• Risks
• Alternative to the proposed medical treatment

Before surgery, the physician asks the patient to sign a statement


consenting to the surgical procedure
Physician must provide the patient with sufficient information to
weigh the risks and benefits of the surgery, which includes…
• Disease process and diagnosis
• Nature of the surgery with its benefits, risks, and prognosis of
treatment is with held
• Alternative treatment options
Informed Consent
Must include…
• patient’s full legal name
• Surgeon’s name
• Specific procedure(s) to be performed
• Signature of patient, next of kin, or legal guardian
• Witness (usually the nurse)
• Date
 The nurse’s role is that of patient advocate.
 The nurse assess the patient decision-making capacity,
confirms that the patient has received the necessary
information to give informed consent, and clarifies any
misunderstandings
 The nurse should also support the patient’s decision, should
the patient decide to withdraw informed consent and refuse
the surgical procedure.
Preoperative Nursing
Diagnosis
• Deficient knowledge related to unfamiliar surgical
experience and anxiety and fear related to pain,
death, disfigurement, or the unknown.
 Preoperative teaching is very important to ensure a
positive surgical experience for the patient.
 The patient should understand what the
preoperative, intraoperative and postoperative
period course entails.
 Explain all nursing care and any possible discomfort
that may result as a consequence of nursing
interventions. Tell the patient what you will do to
minimize any discomfort.
Intraoperative period
Nursing care during intraoperative is continue assessment
of patient’s physiologic and psychologic status
• Promote safety and privacy, positioning
• Prevent wound infection
• Promote healing
 The surgical team must work together to deliver safe and
effective care the patient in intraoperative phase
 The team is divided into categories based on
responsibilities, and consists of the primary surgeon and
assistants, the scrub tech/nurse, circulating nurse, and
anesthesiologist
Circulating nurse responsibilities
• Coordinating patient care before,
during, and after the surgical
procedure
• Providing emotional support to the
patient and assisting the
anesthesiologist during the initiation
of anesthesia
• Ensuring patient safety, positioning
and monitoring the patient, and
enforcing policies and procedures
throughout the surgery – including a
“time out”
• Maintaining sterile technique while
providing supplies and equipment
for the sterile team
• Documenting all nursing care during the intraoperative
period and making sure that surgical specimens are
labeled correctly and placed in the appropriate media
• Recognizing and resolving environmental hazards that
involve the patient or surgical team, including protecting
the patient from electrical hazards
• Ensuring with the scrub tech that all sponge, instrument,
and sharps counts are completed and documented
• And communicating relevant information to family
members and other healthcare workers outside the OR
Surgical environment designed to provide a
safe therapeutic environment for the patient
• Traffic in and out of OR kept to
a minimum
• Floors, walls, and ceilings made
of materials that are easy to
clean with antimicrobial agents
• Temperature kept between 68-
75 degrees to reduce risk of
infection
• Relative humidity kept between
40-60%, which diminishes
bacterial growth and restricts
static electricity
TIME OUT
 Once the patient is prepped and draped in the OR,
the circulating nurse usually initiates the “time-out”
that takes place between the entire surgical team
 The time out is a verbal agreement that includes, at
a minimum, the following…
• Correct patient?
• Correct site?
• Correct procedure?
• Verify implants or radiologic exams
• Document completion of time-out
Surgical Attire:
Everyone wears:
• Surgical cap
• Mask
• Shoe/bot covers

Dressing in OR Attire Progresses From Head to Toe:


• Surgical hat (to prevent shedding of microbes from
the head/hair to the scrub)
• Surgical scrub suit
• Face mask
• Safety eyewear
• Shoe/boot covers
In the sterile field
• Surgical scrub
• Sterile gown
• Sterile gloves
• Double glove
 Prevent SSI
 Protects
 Healthcare
 providers
• Showering thoroughly with
antiseptic wash prior to surgery
Patient
• Hair removal from the surgical site
(when necessary)
Skin
• Clean incision site with skin Preparation
antiseptic, using the
manufacturer’s recommendation
for contact and drying time
• Skin preparation
 Mechanical scrubbing at the
incision site, moving out in a
circular fashion, away from the site
 Sponge contaminated when it
reaches the outer edge and is
discarded – new sponge is used
each time the area is scrubbed
Type of Anesthetics
Local Anesthetics Regional Anesthetics
 Block conduction of pain
impulses, affecting motor  Uses local anesthetics
and sensory nerves to cause a temporary
 Sign of toxicity: loss of sensation in a
o Tachypnea
particular portion of the
o Tachycardia or bradycardia
o Tinnitus body
o Drowsiness  Types of regional
o Metallic taste anesthesia:
o Numbness around the
mouth o Spinal
o Paresthesias o Epidural
o Tremors
o Seizures o Nerve block
o coma o Bier block
Spinal anesthesia
• Usually used for surgery on the lower abdomen,
groin area, perineum, or lower extremities
• Anesthetic agent injected into CSF in subarachnoid
space
• Risks: hypotension, inadvertent high level of
anesthesia that causes respiratory arrest and
complete paralysis, neurologic complications,
spinal headache, and infection
Epidural anesthesia
• Used for abdominal, genitourinary,
and lower extremity procedures
• Anesthetic agent injected into
epidural space (outside the CSF)
• Compared to spinal, epidural
requires higher doses of
anesthetic, has a slower onset,
and is not dependent on the
patient’s position for the level of
anesthesia
• Provider able to titrate dose
throughout procedure
• Risks: hypotension, headache,
respiratory depression, and
neurologic complication ( but not
as common ad with spinal)
• NERVE BLOCK : local anesthetic is injected around
to peripheral nerve
• BIER BLOCK:
 Intravenous regional anesthetic
 Injected into the veins of an arm or leg while using a
tourniquet to prevent the anesthetic from entering
the systemic circulation
 Technique must be limited to two hours or less, or
tissue damage can occur from the use of the
tourniquent.
Levels of sedation
• Minimal – uses sedatives and anxiolytics that allow the
patient to remain responsive and breathe
independently
• Moderate (conscious sedation) – a drug- induced
depression of consciousness in which the patient is able
to respond purposefully to verbal commands and touch,
maintain adequate spontaneous ventilation, and won’t
remember anything from the procedure
• Deep-a drug - drug- induced depression of
consciousness during which patient cannot be easily
aroused, but respond purposefully following repeated or
painful stimulation. Independent breathing may be
impaired.
General anesthesia
• Depression of the central nervous system by
administration of drugs or inhalation agents
• Patient are not arousable, even by painful stimuli,
and respiratory and cardiovascular functions are
often impaired
Three phases
Induction
• Administration of anesthetic agents
• Endotracheal intubation – possible cricoid pressure
Maintenance
• Patient ready for positioning, skin prep. And incision
• Anesthesiologist maintains appropriate levels of
anesthesia
Emergence
• Anesthesiologist begins to waken the patient
• Patient is extubated
• Nurse assist provider with patient safety and comfort
Causes of decrease in temp
• General anesthetics, muscle relaxants, and opioids
• Cool environment
• Infusion of IV fluids
• Cool skin prep solutions
• Cold, dry anesthetic gases
• Escape through the surgical incision
Keep the patient warm by
• Covering exposed areas as much as possible with
warmed blankets
• Using warmed IV solutions will help prevent
hypothermia
Intraoperative hypothermia
An increase in body temperature of 3.6 degrees F per hour causes :
• Sepsis
• Infection
• Malignant hyperthermia
 Temperature may rise 1.8 to 3.6 degrees F every 5 minutes
 May exceed 109.4 degrees F
 A potentially fatal complication of general anesthesia
 A genetic defect in the muscle cell membrane, making the patient more
susceptible
• Symptoms
 Muscle rigidity
 Respiratory and metabolic acidosis
 Fast heart rate
• Treatment
 Immediately ceasing the causative agent
 Hyperventilating with 100% oxygen
 Cooling with ice packs or cooling blankets
 Restoring acid-base balance
 Treating hypercalcemia
 IV dantrolene (antidote)
STOP COOLING MEASURES AT 100.4 degrees F
Nursing diagnosis post
operative
Nursing diagnosis most common during this period of
care are risk for injury, Hypothermia, Risk for Aspiration,
Acute pain and Disturbed thought Processes
Pacu Nursing Interventions
The goal of post anesthesia nursing is to assist non
complicated return to safe physiologic function after an
anesthetic procedure by providing safe, knowledgeable,
individualized nursing care for patients and their family
• Monitor vital sign
• Monitor airway patency
• Monitor neurological status
• Manage pain
• Assess surgical site
• Assess and maintain fluid and electrolyte balance
• Provide a thorough report of the patient’s status to the
receiving nurse on the unit, as well as the patient’s family
Pacu-post anesthesia care unit
• Each patient care space
• Blood pressure monitoring device
• Cardiac monitor
• Pulse oximeter
• Oxygen
• Airway management equipment
• Suction
• Emergency equipment and medications are often
centrally located
3 phases of post-anesthesia care
1. Immediate post-anesthesia period:
• Patient emerging from anesthesia and requires one-
on-one care
• Pacu nurse assesses the level of consciousness,
breath sounds, respiratory effort, oxygen saturation,
blood pressure, cardiac rhythm, and muscle
strength
• Patient is being prepared for transfer to phase 2,
ICU, or an inpatient nursing unit
3 phases of post-anesthesia care
2. Continued recovery
• Patient’s consciousness returns to baseline
• Patient has stable pulmonary, cardiac, and renal
functioning
• Many patients bypass phase 1 and go directly from
the OR to phase 2; this process is known as ‘fast-
tracking’
• The patient then moves to phase 3, home, or an
extended care facility
3 phases of post-anesthesia care
3. Ongoing care
• For patients needing extended observation and
intervention after phase 1 or 2, such as a 23 hr
observation unit or in-hospital unit
• Nursing care continues until the patient completely
recovers from anesthesia and surgery and is ready
for self-care
Immediate assessment:
• Airway
• Breathing
• Circulation
Nursing care focuses on:
• Maintaining ventilation and circulating
• Monitoring oxygenation and level of consciousness
• Preventing shock
• Managing pain
• The nurse should assess and document respiratory,
circulatory, and neurologic functions frequently
Neurologic function assessment:
• Patient’s response to verbal stimuli
• Pupil’s responsiveness to light and accommodation
• Ability to move all extremities
• Strength and equality of a hand grip
Neurologic function assessment:
• Patient’s response to verbal stimuli
• Pupil’s responsiveness to light and accommodation
• Ability to move all extremities
• Strength and equality of a hand grip
AVPU Scale
Alert & oriented Responds to
Voice Responds to Pain
Unresponsive
Glasgow Coma Scale

EYE OPENING VERBAL RESPOSE MOTOR RESPONSE

Spontaneous > 4 Oriented > 5 Obey commands > 6


To sound > 3 Confused > 4 Localizing > 5
Words > 3 Normal flexion > 4
To pressure > 2
Sounds > 2 Abnormal flexion > 3
None > 1
None > 1 Extension > 2
None > 1
Respiratory assessment
• Pulse oximetry
• Arterial blood gases
• chest x-ray

Respiratory complications
• Airway obstruction
• Hypoxemia
• Hypoventilation
• Aspiration
• laryngospasm
Airway obstruction
A serious complication after general anesthesia
1. Commonly results from:
• Movement of the tongue into the posterior pharynx
• Changes in the pharyngeal and laryngeal muscle tone
• Laryngospasm, edema, and secretions of fluid collecting in
the pharynx, bronchial tress, or trachea

Symtoms Include Treatment Include


• administrering 100% oxygen
Gurgling • Suctioning secretions
Wheezing • Jaw-thrust maneuver to maintain
airway
Stridor • Insertion of an oral or nasal airway
Retractions • If none of these interventions are
success full-endotracheal intubation,
Hypoxemia cricothyroidectomy or tracheostomy
may be necessary
hypercapnia
Respiratory complication-Airway
Obstruction
Obstructive sleep apnea- A complete or partial
collapse of the pharynx during inspiration-at an
increased risk of airway obstruction from the effects
anesthesia.
They are at risk for hypoxemia because of the residual
effects of anesthetic agents. The nurse should monitor
the patient for apnea and dysrhythmias and
continuously monitor oxygen saturation
Hypoxemia
Pulse oximetry <90%, PO2 < 60 per ABG
It may be result of hypoventilation, related to:
 Opiads-causing respiratory center depression
 General anesthesia
 Insufficient reversal of neuromuscular blocking agents-
resulting in residual muscle paralysis
 Increased tissue resistance from emphysema or
infections
 Decreased lung and chest wall compliance from
pneumonia
 Obesity or gastric and abdominal distention
 Incision site close to the diaphragm
 Constrictive dressings
 Postoperative pain
Aspiration
• Gastric contents or blood is inhaled into the
tracheobronchial system
• Usually caused by regurgitation, or blood may result
from trauma or surgical manipulation
• Patients need to be NPO prior to surgery, so there is
nothing in the stomach
• Aspiration can cause pneumonitis, chemical
irritation, destruction of tracheobronchial mucosa,
and secondary infection
Laryngospasm
laryngeal muscle tissue spasms, and causes a complete or partial
closure of the vocal cords, resulting in airway obstruction
• Can result in hypoxia, cerebral damage, and death
• If extubated too quickly, patient at risk for airway spasm,
aspiration, coughing, and airway obstruction
• Repeated suctioning and irritation by ET tube or artificial
airway can cause laryngospasm after extubation
• Symptoms-dyspnea, crowing sounds, hypoxemia, and
hypercapnia
• Treatment – removing the irritating stimulus,
hyperextending the head of the bed, giving oxygen.
Suctioning if necessary, and positive pressure ventilation
by bag and mask. Medication may be given to reduce
swelling and airway irritation, or muscle relaxant may be
needed. Re-intubating is only done as a last resort
Maintaining circulation and
assessing for cardiac complications
Hypotension, hypertension, cardiac Dysrhythmias
Hypotension
• Signs-increased heart rate, systolic pressure of 90 mmHg or less,
decreased urinary output, pale extremities, confusion, and restlessness
• Common cause-blood loss or inadequate fluid replacement
Hypertension
• Cause-pain, pre-existing hypertension, sympathetic stimulation, bladder
distention, anxiety, or reflex vasoconstriction due to hypoxia,
hypercarbia, or hyperthermia
• Untreated hypertension my lead to cardiac dysrhythmias, left ventricular
failure, myocardial ischemia and infarction, pulmonary edema, and
cerebrovascular accident
• Cardiac dysrhythmias that occur as a result of anesthetic agents
affecting the central nervous system, myocardium, and peripheral
vascular system
 Sinus tachycardia, sinus bradycardia, and supraventricular and
ventricular dysrhythmias
 Assess for airway patency, adequate ventilation, and administer
medications and supplemental oxygen ad needed-crash cart should be
readily available
Hypothermia
• Can extend recovery
• Delay wound healing
• Increase postoperative morbidity
• Cause shivering (increases oxygen demand increased
metabolic rate and myocardial workload)
• Impair coagulation
• Cause decreased cerebral blood flow and
vasoconstriction
• Sign-shivering, tachypnea, and tachycardia
**rewarming is essential in the immediate postoperative
care of the patient in PACU
Hyperthermia
• Core temp > 102.2 degrees F
• Caused by infection, sepsis, or malignant
hyperthermia, which can occur for 24-27 hours after
surgery
• If unrecognized or untreated, malignant
hyperthermia result in death
Managing pain
High pain scores:
• nausea
• Respiratory complication
• Slower return of GI function
• Increased risk of DVT
Effective methods of postoperative pain relief include:
• Preemptive analgesia (which is given prior to surgery or
prior to pain)
• Around-the-clock analgesia
• PRN(as needed) dosing
• Management of breakthrough pain
• Non pharmacologic interventions
Other important
postoperative assessments
• Surgical site – dressing dry and intact
• Proper draining of drainage tubes
• Rate & patency of IV fluids
• Level of sensation after regional anesthesia
• Circulation/sensation in the extremities after
orthopedic or vascular surgery
• Patient safety
The nurse in the PACU suspects
laryngospasm in the patient who develops
which of the following symptomps?

1. Decreased oral secretions


2. Sternal retractions
3. Crowing sounds
4. Hypocapnia
Complications
Some complications are due to the preoperative
condition of patient, such as severe heart or
pulmonary disease that could not be controlled
before surgery and the progressive nature of the very
disease for which the operation was done such as
advanced cancer.

• Wound complication: surgical incision can delop


collections of liquefied fat, serum and lymphatic
fluid called a seroma; hematomas.
• Postoperative Fever : persistent fever following
surgery can develop from infectious or
noninfectious causes