dr. ahmad aqel 2020 - nursing lijan

DR. AHMAD AQEL

2020

Perioperative Nursing

Preoperative phase: Period of time from decision for surgery until patient is transferred

into operating room

Intraoperative phase: Period of time from when patient is transferred into operating

room to admission to post-anesthesia care unit (PACU)

Postoperative phase: Period of time from when patient is admitted to PACU to follow-

up evaluation in clinical setting or at home

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The decision to perform surgery may be based on

1. Diagnosis (biopsy, exploratory laparotomy)

2. Cure (excision of a tumor or an inflamed appendix),

3. Repair (e.g., multiple wound repair).

4. Reconstructive or cosmetic (such as mammoplasty )

5. Palliative (Surgery to reduce the size and compression of a tumor to relieve pain or permit comfort).

6. Rehabilitative (e.g., total joint replacement surgery to correct crippling pain)

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SURGICAL CLASSIFICATIONS

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Classification Indications for Surgery Examples

Emergent—Patient requires immediate attention; disorder may be life threatening

Without delay Severe bleeding, Bladder or intestinal obstruction, Fractured skull, Gunshot or stab wounds, Extensive burns

Urgent—Patient requires prompt attention

Within 24–30 h Acute gallbladder infection Kidney or ureteral stones

Required—Patient needs to have surgery

Plan within a few weeks or months

Prostatic hyperplasia without bladder obstruction, Thyroid disorders, Cataracts

Elective—Patient should have surgery

Failure to have surgery not catastrophic

Repair of scars, Simple hernia

Optional—Decision rests with patient

Personal preference Cosmetic surgery

Categories of surgery based on urgency

Pre Operative Assessment

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Pre-admission testing

Teaching based on patient’s needs

Completion of pre op. diagnostic tests.

Understanding of preoperative orders.

Discusses advanced-directive document

Begins discharge planning by assessing patient’s need for postoperative transportation, care


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Informed consent

The patient’s autonomous decision about whether to undergo a surgical procedure, Should be in writing

contains the following:

◦Explanation of procedure, risks , benefits, alternatives by the DR

◦Answer all patient questions about procedure

◦Patient can withdraw consent

◦Any different institutional protocol


• Must be freely given, without coercion

• Patient must be ≥ 18 years

• The nurse may obtain the signature but the physician is responsible to provide explanation

• Patient’s signature must be witnessed by Health care provider.

Voluntary Consent

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Incompetent Patient (Individual who is not autonomous ) such as Cognitively impaired , Mentally ill , unconscious Cannot give or withhold consent

Informed consent is needed in

1. Invasive procedures

2. Procedures requiring sedation or anesthesia

3. A nonsurgical procedure that carries risks such as an arteriography, radiation therapy

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Preoperative Assessment

1. Assess and Correct malnutrition, dehydration, hypovolemia, and electrolyte imbalances to avoid the risk of complications

2. Remove dentures (airway obstruction)

3. Assess drug or alcohol use , May postpone surgery if patient is intoxicated

4. Assess the need for breathing exercises, incentive spirometer

5. Assess for respiratory infection (may postpone surgery)

6. Assess tobacco use (stop smoking 4-8 weeks before surgery

7. Control Blood pressure.

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8. Assess LFT and KFT

9. Monitor blood glucose to avoid hypoglycemia or hyperglycemia

10. Monitor adrenal function If patient on corticosteroids

11. Assess thyroid function. (respiratory failure may develop in hypothyroidism)

12. Assess for allergy

13. Assess for Immunosuppression

14. Assess for pre-operative anxiety

15. Assess for previous medication use.

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Preoperative Assessment

General Pre-operative Nursing Interventions

Patient teaching

Providing psychosocial interventions

Maintaining patient safety

Managing nutrition, fluids

Preparing bowel

Preparing skin

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To promote optimal lung expansion post operatively

A sitting position to enhance lung expansion.

Demonstrate how to Take deep breath from the mouth and exhale through the

mouth.

Take a short breath, and cough from deep in the lungs. (prevent atelectasis and pneumonia)

Demonstrate how to use Incentive spirometry

splint the incision by hands to control pain when coughing

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Pre-operative Nursing Interventions


1. Teach Pt about exercise, changing positions to improve circulation & prevent DVT

2. Explain pain scale & Types of pain ; Reducing anxiety & fear

3. Explain about drainage tubes, or ventilator if indicated.

4. Respecting cultural, spiritual, religious beliefs

5. Maintaining safety (patient identification, medication safety, prevent ulcers)

6. NPO : 8 hours after eating fatty food ; 4 hours after ingesting milk products; clear liquids up to 2 hours before an elective procedure

7. Preparing bowel : Enema, Laxatives for better visualization

8. Preparing skin: shaving surgical site to decrease bacteria. Use antibacterial soap bath

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Immediate Pre-operative Nursing Interventions

1. Wear gown; remove hairpins, jewelry and make up; Voiding

2. Administer pre medications (On call to OR), Keep side rails up and don’t allow to walk (feeling drowsy)

3. Maintain medical record, and Pre operative checklist

4. Send medical chart with patient to OR

5. Transporting patient to pre-surgical area 30-60 m before the anesthesia

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Intraoperative Nursing Management DR AHMAD AQEL

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Patient Circulating nurse Scrub nurse Surgeon RN first assistant Anesthetist

Members of the Surgical Team:

Responsibilities

circulating nurse Verifying consent

Coordinating the team

Ensuring proper temp, humidity, lighting, function of equipment,

Monitors aseptic practices

Monitors the patient

Ensuring that the second verification of the surgical procedure and site takes place

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Scrub nurse

Performing a surgical hand scrub

Setting up the sterile tables

Preparing sutures, and special equipment (eg, laparoscope)

Assisting the surgeon; anticipating the instruments required

The scrub person and the circulator count all needles, sponges, and instruments BEFORE CLOSING the incision

Potential Adverse Effects of Surgery and Anesthesia

Allergic reactions, drug toxicity

Cardiac dysrhythmias

over-sedation, under-sedation

Trauma: laryngeal, oral, nerve, skin, including burns

Hypotension

Thrombosis

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Prevention of Infection

Surgical environment Unrestricted zone: street clothes are allowed

Semi-restricted zone: attire consists of scrub clothes and caps

Restricted zone: scrub clothes, shoe covers, caps, and masks

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Environmental controls

Air filters in OR ventilations

Surface cleansing

Room temperature of 20 C to 24 C

Humidity between 30% and 60%

Positive pressure

Basic Guidelines for Surgical Asepsis

All materials in contact with wound must be sterile

Gowns considered sterile in front from chest to level of sterile field, sleeves from 2 inches above elbow to cuff

Only top of draped tables considered sterile

During draping, drape held well above area, placed from front to back

Items dispensed by methods to preserve sterility

e.g. opening package, the edge is unsterile

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Movement around sterile field must not cause contamination of field

At least 1-foot distance from sterile field must be maintained

When sterile barrier is breached, area is considered contaminated

Items of doubtful sterility considered unsterile

Sterile fields prepared as close as possible to time of use

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Basic Guidelines for Surgical Asepsis

Intraoperative Complications

Nausea, vomiting

Anaphylaxis

Hypoxia, respiratory complications

Hypothermia

Malignant hyperthermia

Disseminated intravascular coagulation (DIC)

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1) Nausea and vomiting Vomiting >> aspiration

Preoperative antiemetic

If gagging occurred • Patient is turned to the side

• The head of the table is lowered

•  Suction to remove saliva and vomitus

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2) Hypoxia

Causes: Inadequate ventilation, occlusion of the

airway, intubation of the esophagus

Respiratory depression caused by anesthetic agent

Aspiration, the patient’s position on the operating table

Monitoring Pulse oximetry: SpO2

Assessing peripheral perfusion

Hypothermia

3) Hypothermia

Core body temperature < 36.6 C

Causes: low temperature in the OR

infusion of cold fluids

inhalation of cold gases

open body wounds or cavities

decreased muscle activity

pharmaceutical agents used (eg, vasodilators)

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Inherited muscle disorder that is chemically induced by anesthetic agents

Increases muscle contraction (rigidity)

Hyperthermia

Damage to the central nervous system

4) Malignant hyperthermia


Nursing Interventions for the Patient in the Intraoperative Period

Reducing anxiety

Reducing latex exposure

Preventing intraoperative positioning injuries

Protecting patient from injury

Monitoring, managing potential complications

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Protecting the Patient from Injury

Patient identification

Correct informed consent

Verification of records of health history, exam

Results of diagnostic tests

Allergies (include latex allergy)

Monitoring

Safety measures restraints, not leaving a sedated patient

Verification, accessibility of blood

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POST OPERATIVE CARE DR AHMAD AQEL

Postoperative Period

Extends from the time the patient leaves the OR until the last F/U visit with the surgeon.

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• immediate recovery and intensive care

Phase 1

• prepare pt for self-care in hospital

Phase 2

• Prepare pt for discharge Phase 3

Prevent strain on the incision

Avoid obstruction of

drains

Avoid orthostatic hypotension

Remove soiled gown

Maintain temperature

Raise side rails

Review post op orders.

monitor and apply o2

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Admitting Pt to PACU

Nursing Management in the PACU

Assess ABCD administer O2, assesse RR and depth, O2 saturation, and breath sounds

Assess LOC; cardiac rhythm; skin temp, color, and moisture; and urine output.

Monitor V/S at least every 15 minutes

report

Systolic BP <90 mm Hg

A dropping BP of 5 mm Hg at each 15-minute reading

Assess pain

Checks the surgical site for hemorrhage

Check IV fluids or medications (patency of lines, verifies dosage and rate).

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Keep oral airway until gag reflex is returned.

Assist in the weaning and extubation if applicable

Elevate the head of bed 15 to 30 degrees unless contraindicated.

Minimize the risk of aspiration.

Suction mucus or vomitus

Be Cautious when suctioning the throat post tonsillectomy (risk of bleeding )

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The primary cardiovascular complications in the PACU

Hemorrhage, hypotension and shock,

Hypertension

Dysrhythmias

Hypotension can result from: blood loss, hypoventilation, position changes, pooling of blood in the extremities, or side effects of medications and anesthetics.

• Blood replacement is indicated if the blood loss > 500 mL

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Types of shock:

hypovolemic, cardiogenic, neurogenic, anaphylactic, and septic

Signs of hypovolemic shock

pallor; cool, moist skin; rapid breathing; cyanosis of the lips, gums, and tongue; rapid weak pulse; narrowing pulse pressure; low BP; and concentrated urine.

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Intervention for hypovolemic shock

• Infusion of LR, 0.9% N/S, blood

• Administer Oxygen

• vasodilator, and corticosteroid may

be prescribed

• flat position with legs elevated.

• Monitor V/S

• keeps the patient warm

• Implement measures to control Pain


Hemorrhage

Monitor patient for S&S OF shock

hypotension; rapid, thready pulse; disorientation; restlessness; oliguria; and cold, pale skin.

The early phase of shock will manifest in

feeling apprehension and decreased cardiac output

Breathing becomes labored and “air hunger” will be exhibited;

the patient will feel cold (hypothermia)

may experience tinnitus.

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Check the surgical site and incision for bleeding.

If bleeding is evident

◦Apply sterile gauze pad and a pressure dressing

◦Elevate the site of the bleeding to heart level if possible.

◦The patient is placed in the shock position (flat on back; legs

elevated at a 20-degree angle; knees kept straight).

◦ If hemorrhage is suspected but cannot be visualized, emergency

exploration of the surgical site.

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Hypertension and dysrhythmias

Treat underlying causes of hypertension and dysrhythmia Hypertension may occur from pain, hypoxia, or bladder distention.

Dysrhythmias are associated with electrolyte imbalance, altered respiratory function, pain, hypothermia, stress, and anesthetic agents.

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Relieving pain and anxiety administering Opioid analgesics as ordered

a family member is allowed to visit in the PACU to decrease the family’s anxiety and make the patient feel more secure.

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Controlling nausea and vomiting

Turn patient to one side to prevent aspiration

(Zofran) is an effective antiemetic with few side effects (the drug of choice).


Determining Readiness for Discharge From the PACU A patient remains in the PACU until fully recovered

Indicators of recovery include ◦ stable BP, adequate RR & oxygen saturation

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Preparing the Postoperative Patient for Direct Discharge

Prior to discharge: verbal and written instructions and information about follow-up care

The Aldrete score is usually

8 to 10 before discharge

from the PACU.

Patients with a score of

less than 7 must remain

in the PACU until their

condition improves or

they are transferred to an

intensive care area

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Modified Aldrete score

Care of the Hospitalized Postoperative Patient

Receiving the Patient in the Clinical Unit Prepare all the necessary equipment and supplies

Reports relevant data about the patient to the receiving nurse

The surgeon speaks to the family related to the pt condition.

The receiving nurse: reviews the postoperative orders, admits the patient

to the unit, performs an initial assessment, and attends to the patient’s

needs.

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Immediate Postoperative Nursing Interventions

Administer oxygen, Monitor V/S and note skin warmth, moisture,

and color.

Assess the surgical site and wound drainage systems.

• Connect all drainage tubes to gravity or suction as indicated

Assess LOC , orientation, and ability to move extremities.

Assess pain, and route of administration of last dose of analgesic.

Administer analgesics as prescribed and assess effectiveness

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Immediate Postoperative Nursing Interventions

Place the call light, emesis basin, bedpan or urinal within reach.

Position the patient to enhance comfort, safety, and lung

expansion.

Assess IV sites for patency, correct rate and solution.

Assess urine output and bladder distention.

Reinforce the need to begin deep breathing and leg exercises.

Provide information to the patient and family

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Nursing Management After Surgery

During the first 24 hours after surgery, Frequently assessing the patient’s physiologic status

Monitoring for complications

Managing pain

Record V/S at least every 15 minutes for the first hour and every 30 minutes for the next 2 hours.

The temperature is monitored every 4 hours for the first 24 hours.

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Nursing Management After Surgery

To assist the postoperative patient in getting out of bed for the first time after surgery, the nurse:

Move gradually from the lying position to the sitting position by raising the head of the bed and encourages the patient to splint the incision when applicable.

Positions the patient completely upright (sitting) and turned so that both legs are hanging over the edge of the bed.

Helps the patient stand beside the bed

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Caring for Wounds

First-Intention Healing

Aseptic Wound with minimum tissue destruction

Minimal scar formation

these wounds are covered with a dry sterile dressing.

Second-Intention Healing

Granulation occurs in infected wounds (abscess) or in

wounds in which the edges have not been approximated.

A drainage tube or gauze packing is inserted into the

abscess pocket to allow drainage to escape easily.

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Third-Intention Healing Secondary suture for deep wounds not sutured early, sutures break down

This results in a deeper and wider scar. packed with moist gauze and covered with a

dry sterile dressing

dr. ahmad aqel 2020 - nursing lijan

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