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MODULE 1 | PERIOPERATIVE CONCEPTS AND NURSING MANAGEMENT
Perioperative Nursing →Spans the entire surgical experience. →Communication, teamwork, patient assessment to ensure good patient outcomes in the perioperative settings. →Encompasses behavioral response, physiologic response, and patient safety. Definition of Terms SURGERY → Greek word “Keirurgos” which means working with hands. →The branch of medicine dealing with manual and operative procedures for: A. Correction of deformities B. Repair of injuries C. Diagnosis and cure of certain diseases →The branch of medicine concerned with diseases and conditions which require or are amenable to operative procedures.
OPERATION
→ An invasive modality of treatment.
ASEPSIS
→The process of removing pathogenic microorganisms or protecting against infection by such organisms.
SEPSIS
→A toxic condition resulting from the spread of bacteria or their toxic products from a focus of infection. Settings for Surgery
AMBULATORY
→Patient can go to the clinic; no preparation needed.
OUTPATIENT
→Stays for a longer period , but no overnight stay.
OUTPATIENT
→If the surgery needs the patient for preparation. →Special preparation for surgery is needed to see whether the patient is fit for surgery or not ; the patient is admitted.
Most surgical procedures are given names:
✓ Names that describe the site of surgery and type of surgery performed. Ex. Appendectomy ✓ Some surgeries carry the name of the surgeon who developed the technique. Ex. Billroth procedure (partial gastrectomy) Prefixes SUPRA Above, beyond ORTHO Joint CHOLE Bile Or Gall CYSTO Bladder ENCEPHALO Brain ENTERO Intestine HYSTERO Uterus MAST Breast MENINGO Membrane; Meninges MYO Muscle NEPHRO Kidney NEURO Nerve OOPHOR Ovary PNEUMO Lungs PYELO Kidney Pelvis SALPHINGO Fallopian Tube THORACO Chest VISCERO Organ esp. abdomen Suffixes ECTOMY Removal of an organ or gland RRHAPHY Suturing or stitching of a part or an organ; repairing SCOPY Looking into
MODULE 1 | PERIOPERATIVE CONCEPTS AND NURSING MANAGEMENT
OSTOMY Making an opening or a stoma OTOMY Cutting into PLASTY To repair or restore CELE Tumor ; hernia ; swelling ITIS Inflammation of Classifications of Surgery 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 surgery”. ACCORDING TO PURPOSE DIAGNOSTIC ✓ verifies suspected diagnosis. (Breast biopsy) EXPLORATORY ✓ estimates the extent of the disease or injury. CURATIVE ✓ removes or repairs damaged tissues. (Cholecystectomy, mastectomy, appendectomy) Restorative ✓ to improve client’s functional ability (knee replacement, finger reimplantation) Palliative ✓ to relieve symptoms of a disease process but does not cure (colostomy). Cosmetic or reconstructive ✓ to alter or enhance personal appearance (Rhinoplasty, liposuction)
ACCORDING TO URGENCY
EMERGENT ✓ pt. requires immediate attention because of life threatening consequences. URGENT ✓ pt. requires prompt attention, may be life- threatening if treatment is delayed more than 24-48 hrs. REQUIRED ✓ pt. needs to have surgery. Plan within a few weeks or months ELECTIVE ✓ Patient should have surgery. Failure to have surgery is not catastrophic or it is not necessary for survival. OPTIONAL ✓ personal preference Conditions requiring surgery OBSTRUCTION Impairment to the flow of vital fluids PERFORATION Rupture of an organ EROSION Wearing off a surface membrane TUMORS Abnormal new growths Phases in the Surgical Process
- Preoperative - begins with the decision to have surgery and ends with the transfer of the client onto the operating table.
- Intraoperative - begins when the patient is transferred onto the OR table and ends with admission to the PACU.
- Postoperative – begins with the admission of the patient to the PACU and ends with a follow-up evaluation in the clinical setting or home.
MODULE 1 | PERIOPERATIVE CONCEPTS AND NURSING MANAGEMENT
✓ Excess weight increases cardiac demand, shallow respirations → decreased pulmonary reserves. Patients with disabilities ✓ Mental and physical disabilities ✓ Patients with assistive devises (eyeglasses, hearing aid, prosthesis, braces, ✓ Impaired hearing ✓ Disabilities that affect body positions - > painful positioning (cerebral palsy, postpolio, other neuromuscular problems) ✓ Disabilities related to respiratory problems.
PREOPERATIVE ASSESSMENT
Nutrition
- Poor Nutrition/ Malnutrition
- Body mass index (kg/m₂)
- Healthy range: 18.5 – 24.
- Overweight: >
- Obese: >
- Fluid and Electrolyte Imbalances Drug/Alcohol use
- Ingesting moderate amount of alcohol prior to surgery weakens the immune system. - May impede the effectiveness of some medications. - If emergency surgery is needed, local, spinal, or regional block anesthesia is used; NGT is inserted. - Patients who have mor than 2 drinks of alcohol/day in the 2 wks. before surgery have mor complications. - Alcoholics often have systemic problems, are malnourished. Respiratory Status - For elective cases, surgery is usually postponed if there is respiratory infection. - Underlying respiratory disease (asthma, COPD) are threats to pulmonary status. - Patients who smoke are urged to stop 30 days before surgery. - Patients who smoke are more likely to experience poor wound healing, SSI (surgical site infection) and VTE (venous thromboembolism) and pneumonia. PREVIOUS MEDICATION USED ➢ Possible interactions with medications that might be administered and the anesthetic agent that can cause serious problems. ➢ Aspirin should be discontinued 7-10 days before surgery. ➢ Include any medication – OTC drugs, prescribed drugs, herbal (gingko biloba, ginseng) Previous Surgeries, Family Medical History
MODULE 1 | PERIOPERATIVE CONCEPTS AND NURSING MANAGEMENT
Review Of Systems Cardiovascular system Alterations in cardiac status are responsible for as many as 30% of perioperative death. (eg. Rhd) Respiratory system A decline in ventilatory function, assessed through breathing pattern and chest excursion, may indicate a client’s risk for respiratory complications. (eg. COPD). Renal system Abnormal renal function can alter fluid and electrolyte balance and decrease the excretion of preoperative medications and anesthetic agents. Neurologic system A client’s LOC will change because of general anesthesia but should return to the preoperative LOC after surgery. Musculoskeletal system Deformities may interfere with intraoperative and postoperative positioning. Gastrointestinal system Alteration in function after surgery may result in decreased or absent bowel sound and distention. Endocrine system Hyperglycemia & Hypoglycemia Immune System Lab tests to detect infection; allergic reactions to medications, transfusions, contrast agents, latex, foods; immunosuppression
PSYCHOSOCIAL ASSESSMENT
Fear of the Unknown →This is the greatest fear of most patients undergoing surgery. →this results from uncertainty of the possible outcome of the procedure Fear of Anesthesia →pt. fear their vulnerability while unconscious. Fear of Pain →pts fears the agony, suffering, or distress that may result from surgical procedure especially post op wound & from contraptions. Fear of Death →this is d/t the risk of complications of anesthesia and the surgical procedure itself. Fear of Body Image Disturbance →distortion of appearance of body part, loss of body part or loss of function of a body part. NOTE: Psychological distress directly influences body functioning. SIGNS AND SYMPTOMS OF FEAR
- Anxiousness
- Anger
- Tendency to exaggerate.
- Sadness/ tendency to withdraw.
- Inability to concentrate/short attention span.
- Repeatedly ask so many questions even questions were answered previously.
SPIRITUAL AND CULTURAL BELIEFS
- Play an important role in how people cope with fear and anxiety, therapeutic.
- Obtain spiritual support.
- Showing respect and support facilitates rapport and trust.
- Identify ethnic group.
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PREOPERATIVE TEACHING
EXERCISES DEEP BREATHING AND COUGHING Goal: to promote lung expansion resulting to blood oxygenation; to prevent atelectasis/pneumonia *DIAPHRAGMATIC BREATHING- flattening of the dome of the diaphragm during inspiration, with blood in then abdominal muscles contract during expiration *SPLINTING Diaphragmatic Breathing and Splinting When Coughing MOBILITY AND ACTIVE MOVEMENT Goal : to improve circulation, prevent venous stasis Early and frequent ambulation postoperatively prevents complications. ✓ Turning & Positioning ✓ Foot & Leg Exercises Pain Management ✓ Acute & Chronic Pain Assessment ✓ PCA- Patient Controlled Analgesia Cognitive Coping Strategies
- IMAGERY- pt. concentrates on a pleasant experience or restful scene
- DISTRACTION- pt. thinks of an enjoyable story or recites a favorite poem or song.
- OPTIMISTIC SELF RECITATION - pt. recites optimistic thoughts. General Preparation before Surgery
- Correcting Dietary Deficiencies/Managing Nutrition & Fluid Status
- Preparing the Bowel
- Preparing the Skin MANAGING NUTRITION AND FLUIDS
- Fluid and food are restricted preoperatively overnight and often longer.
- New recommendations by the American Society of Anesthesiologists
- Fast for 8 hours after eating fatty food.
- For 4 hrs. after ingesting milk products
- Clear liquids up to 2 hours before an elective procedure Goal: to prevent vomiting and aspiration
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PREPARING THE BOWEL
For patients who are to undergo abdominal and pelvic surgery Cleansing enema or laxative may be prescribed the evening before surgery and may be repeated the morning of the surgery. ✓ To allow visualization of the surgical site and to prevent trauma to the intestines or contamination of the peritoneum by fecal material. ANTIBIOTICS may be prescribed to reduce intestinal flora. PREPARING THE SKIN Goal : to decrease bacteria without injuring the skin ANTISEPTIC SKIN CLEANSING Generally, hair is not removed unless hair is at or around the incision site and will likely interfere with the operation. If hair must be removed, electric clippers are used. To ensure the correct surgical site, it is typically marked by the surgeon prior to the procedure. Immediate Preoperative NURSING Interventions
- Patient changes into hospital gown
- Long hairs braided (no hairpins) and cover the hair completely with disposable cap.
- Dentures and plates and assistive devices are removed.
- Jewelry is removed.
- Patient should void immediately before going to the OR PREOPERATIVE MEDICATION PURPOSES:
- To relieve fear & anxiety.
- To reduce dose needed for induction & maintenance of anesthesia.
- To prevent reflex bradycardia that happens during induction of anesthesia.
- To minimize oral secretions. Administering preanesthetic medications Usually given in the preoperative holding area
- If it is given, the patient is kept in bed with siderails raised; observe untoward reactions to the medication.
- “ On call to OR ” SEDATIVES/ HYPNOTICS/ TRANQUILIZERS ✓ Decrease anxiety. ✓ Provide sedation. NEMBUTAL Pentobarbital sodium VISTARIL hydroxyzine VALIUM diazepam PHENERGAN Promethazine VERSED Midazolam NARCOTICS ✓ Relieve Pain/Discomfort DEMEROL MS DILAUDID FENTANYL ✓ Check respiratory depression.
MODULE 1 | PERIOPERATIVE CONCEPTS AND NURSING MANAGEMENT
Physiologic Monitoring
- Calculates effects on patients of excessive fluid loss or gain.
- Distinguishes normal from abnormal cardiopulmonary data.
- Reports changes in patient’s vital signs
- Institute measures to promote normothermia.
Psychological Support (before induction
and when patient is conscious)
- Provides emotional support.
- Stands near or touches patient during procedures and induction.
- Continues to assess patient’s emotional status. Members of the Surgical Team 1 Patient 2 Anesthesiologist or anesthetist (physician, CRNA) 3 Surgeon 4 Nurses (Scrub & Circulating) PATIENT ✓ Maybe relax, fearful or highly stressed ✓ The most important member of the surgical team. ✓ Fears about loss of control; unknown; changes in body structures, appearance, function; disruption of lifestyle ✓ FEARS can increase the number of anesthetic medications. ✓ Subject to several risks (SSI, VTE, failure of the surgery, etc.) ✓ Temporary loss of both cognitive function and biologic self-protective mechanisms (pain, reflexes, ability to communicate) ✓ The OR NURSE is the patient’s advocate (safety, well-being, dignity; maintaining surgical standards; identifying risks; minimizing complications). OPERATING SURGEON ✓ perform the operation. REGISTERED NURSE 1ST^ ASST ✓ practices under the direct supervision of the surgeon. ANESTHESIOLOGIST / NURSE ANESTHETIST ✓ administers the anesthetic agent & monitors the pt’s physical status throughout the surgery. SCRUB NURSE ✓ Preforming hand hygiene ✓ Setting up sterile equipment, tables, and sterile field ✓ Preparing sutures and ligatures and special equipment ✓ Assisting the surgeon and the surgical assistants (anticipating the instruments and supplies that will be required) ✓ Counts all needles, sponges, instruments. ✓ Responsible for tissue specimens obtained during surgery. ✓ Prepares sterile supplies. ✓ Sponge Count. ✓ Maintain sterility. ✓ Gown/Gloves assistant.
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CIRCULATING NURSE
✓ Works in collaboration with the surgeon, anesthesiologists, and other healthcare providers to plan the best course of action. ✓ Manages the OR
- Ensures cleanliness.
- Checking OR conditions
- (Ensures cleanliness, proper temperature and humidity, lighting, safe function of equipment, availability of supplies)
- Monitor the activities of the surgical team (breaks in the techniques ✓ Protects the patient’s safety, implementing safety precautions. ✓ Monitors the patient. ✓ Responsible for documentation ✓ Verifies patient’s name, procedure, surgical site, signed informed consent. ✓ Identify potential problems. ✓ Set up room. ✓ Maintains supplies. ✓ Check safety/fx of equipment. ✓ Positions client. ✓ Cleans surgical field before draping. ✓ Coordinates all activities. ✓ IV fluids, blood, etc. ✓ Helps anesthesiologist monitor. ✓ Documentation Prevention of Infection THE SURGICAL ENVIRONMENT →stark appearance & cool temperature. →Located central to all supporting services. UNRESTRICTED ZONE → where street clothes are allowed. SEMI-RESTRICTED ZONE → where attire consists of scrub clothes & caps. RESTRICTED ZONE → where scrub clothes, shoe covers, caps & masks are worn. Basic Guidelines (Surgical Asepsis) ▪ All materials in contact with the wound and within the sterile field must be sterile. ▪ Gowns are sterile in the front from chest to the level of the sterile field, and sleeves from 2 inches above the elbow to the cuff. ▪ Only the top of a draped table is considered sterile. During draping, the drape is held well above the area and is placed from front to back. ▪ Items are dispensed by methods to preserve sterility. ▪ Movements of the surgical team are from sterile to sterile and from unsterile to sterile only. ▪ Movement around the sterile field must not cause contamination of the field. At least a 1- foot distance from the sterile field must be maintained. ▪ Whenever a sterile barrier is breached, the area is considered contaminated. ▪ Every sterile field is constantly maintained and monitored. Items of doubtful sterility are considered unsterile.
MODULE 1 | PERIOPERATIVE CONCEPTS AND NURSING MANAGEMENT
- Maternal awareness during light general anesthesia STAGE I (BEGINNING ANESTHESIA) ✓ Warmth, dizziness , & feeling of detachment. ✓ Ringing, roaring or buzzing in the ears. ✓ Still conscious but may sense inability to move the extremities easily. ✓ Noises are exaggerated – even low voices or minor sounds seem loud & unreal. ✓ Unnecessary noises & motions should be avoided. STAGE II (EXCITEMENT) ✓ Struggling, shouting ,talking, singing, laughing, or crying ✓ Pupils dilate but constrict when exposed to light. ✓ PR rapid & RR irregular. ✓ Uncontrolled movements may be possible
restraining the patient may be necessary. ✓ Vomiting may occur - > prevent aspiration. STAGE III (SURGICAL ANESTHESIA) ✓ Reached by continuous administration of anesthetic vapor or gas. ✓ Pt. is unconscious & lies quietly. ✓ Pupils are small but constrict when exposed to light. ✓ RR regular, PR & volume are normal, skin pink/flushed. ✓ With proper administration of anesthesia, this stage may be maintained for several hours.
STAGE IV (MEDULLARY DEPRESSION)
✓ Reached when too much anesthesia has been administered. ✓ Respirations shallow, pulse weak & tready. ✓ Pupils widely dilated & no longer constrict when exposed to light. ✓ CYANOSIS develops & w/o prompt intervention → DEATH. ✓ THIS IS NOT A PLANNED STAGE OF ANESTHESIA. ❖ Anesthetic agent is discontinued immediately, respiratory, and circulatory support is initiated; narcotic antagonists are administered. REGIONAL ANESTHESIA →involves injection of a local anesthetic (numbing agent) around major nerves or the spinal cord to block pain from a larger but still limited part of the body. TYPES
**1. EPIDURAL
- SPINAL
- LOCAL CONDUCTION BLOCKS** EPIDURAL ANESTHESIA ▪ commonly used conduction block ▪ Injecting a local anesthetic into the epidural space that surrounds the dura matter of the SC. ▪ Blocks sensory, motor & autonomic functions. SPINAL ANESTHESIA ▪ Local anesthetic is introduced @ the lumbar level between L4 & L5. ▪ Produces anesthesia of lower extremities, perineum & lower abdomen.
MODULE 1 | PERIOPERATIVE CONCEPTS AND NURSING MANAGEMENT
▪ Lumbar puncture done →knee – chest position. ▪ As soon as the injection has been made →position pt on his back. PERIPHERAL NERVE BLOCKS →Nerve blocks are most commonly used for procedures on the hands, arms, feet, legs, or face.
- BRACHIAL PLEXUS BLOCK - arm
- PARAVERTEBRAL ANESTHESIA - chest, abdo wall & ext.
- TRANSACRAL (CAUDAL) BLOCK - perineum, lower abdomen LOCAL ANESTHESIA →involves injection of a local anesthetic (numbing agent) directly into the surgical area to block pain sensations. →Usually given with epinephrine INHALATION ANESTHETIC AGENTS EX. INHALATION
- HALOTHANE
- ETHRAINE
- ISOFLURAINE IV
- FENTANYL
- MORPHINE SULFATE LOCAL AND REGIONAL
- XYLOCAINE
- PONTOCAINE
- NOVOCAINE Intraoperative Complications
1 Nausea and vomiting
2 Anaphylaxis
3 Hypoxia & respiratory complications
4 Hypothermia
5 Malignant hyperthermia
6 Disseminated intravascular
coagulation (DIC)
MALIGNANT HYPERTHERMIA
→A rare inherited muscle disorder that is chemically induced by anesthetic agents and other medication. →May also be triggered by emotional stress, heatstroke, strenuous exercise, and trauma. →The S/S are related to hypermetabolic condition and abnormal muscular activity.
- Tachycardia > 15 bpm, Temperature increases rapidly up to 42⁰C.
- Ventricular dysrhythmias, hypotension, decreased cardiac output - > cardiac arrest.
- Hypercapnea
- Muscular rigidity or tetanus-like movements →Occurs in 1 in 50,000 – 100,000 adults. →High mortality →Management
- Discontinue anesthesia.
- Reverse metabolic and respiratory acidosis
- Correct dysrhythmias
- Decrease body temperature.
- Administer O2, correct electrolyte imbalance.
MODULE 1 | PERIOPERATIVE CONCEPTS AND NURSING MANAGEMENT
OBJECTIVES OF NSG MGMT (PACU)
- Provide care for the patient until he/she has recovered from the effects of anesthesia.
- Patient has resumption of motor and sensory function, is oriented, has stable VS, and shows no evidence of hemorrhage or other complications of surgery.
- Frequent skilled assessment of the patient is vital.
4 W’S
WIND prevent respiratory complications WOUND prevent infection WATER monitor I & O WALK prevent thrombophlebitis
RESPONSIBILITIES OF PACU NURSE
- Review pertinent information and baseline assessment upon admission to the unit.
- Assessments include airway and respirations, cardiovascular function, surgical site, function of the central nervous system; also assess IVs and all tubes and equipment.
- Reassess VS and patient status every 15 minutes or more frequently as needed.
- Provide a report and transfer the patient to another unit or discharge the patient to home.
NURSING MANAGEMENT (PACU)
1. Assessing the patient ✓ Skilled assessment of the patient’s air way ✓ Respiratory function ✓ Cardiovascular function ✓ Level of consciousness ✓ Ability to respond to commands. ✓ Baseline assessment ✓ Check surgical site and note for drainage, hemorrhage, drainage tubes and monitoring. 2. Maintaining a patent airway thus preventing hypoventilation that results in:
- Hypoxemia
- Hypercapnea 3. Hypotension and shock ✓ Blood loss (hypovolemic) ✓ Hypoventilation ✓ Position changes ✓ Pooling of blood in the extremities ✓ Effect of medications and anesthesia ✓ Cardiogenic S/S: hypotension, rapid thread pulse, disorientation’ restlessness, oliguria, cold and pale skin, air hunger **4. Hypertension and dysrythmias
- Relieving pain and anxiety
- Controlling nausea and vomiting** Surgical Unit
- Continues close monitoring of patient’s physical and psychological responses to surgery.
- Assesses patient’s pain level and administers appropriate pain-relief measures.
- Monitor complications.
- Provides education to patients during immediate recovery period.
MODULE 1 | PERIOPERATIVE CONCEPTS AND NURSING MANAGEMENT
- Encourage activity.
- Care for wounds
- Assist patient in recovery and preparation for discharge home.
- Determines patient’s psychological status.
- Assists with discharge planning.
WOUND DEHISCENCE
WOUND EVISCERATION
DEHISCENCE VS EVISCERATION
OUTPATIENT SURGERY/DIRECT DISCHARGE
- Discharge planning and discharge assessment - Provide written and verbal instructions regarding follow-up care, complications, wound care, activity, medications, and diet. - Give prescriptions and phone numbers. Discuss actions to take if complications occur. - Give instructions to the patient and a responsible adult who will accompany the patient. - Patients are not to drive home or be discharged to home alone. Sedation and anesthesia may cloud memory and judgment and affect ability. HOME CARE OR CLINIC 1. Provides follow-up care during visits or by telephone contact. 2. Reinforce previous education and answers patient’s and family’s questions about surgery and follow-up care. 3. Assesses patient’s response to surgery and anesthesia and their effects on body image and function. 4. Determines family perception of surgery and its outcome. ADDITIONAL READING - https://ornap.org/about-us/
