definition of surgery perioperative nursing care definition of surgery surgery is any procedure...
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Perioperative Nursing Care Definition of SurgeryDefinition of Surgery
Surgery is any procedure performed on Surgery is any procedure performed on the human body that uses instruments to the human body that uses instruments to alter tissue or organ integrityalter tissue or organ integrity.
Perioperative Nursing Care
Perioperative NursingPerioperative Nursing- connotes the delivery of patient care in the preoperative,intraoperative, and postoperativepostoperative periods of the patients surgical experience through the framework of the nursing process. The nurse assesses the patient- collecting,organizing, and prioritizing patient data; establishing nursing diagnosis;identifies desired patient outcomes;develop and implements a plan of care; and evaluates that care in terms of outcomes achieved by the patient.
Perioperative Nursing Care Type of Surgery
Seriousness: Degree of riskSeriousness: Degree of riskMajorMajor- Involves extensive - Involves extensive
reconstruction or alteration in body reconstruction or alteration in body parts;poses great risks.parts;poses great risks. MinorMinor- - Involves minimal alteration in body Involves minimal alteration in body parts;often designed to correct parts;often designed to correct deformities;involves minimal risk compared deformities;involves minimal risk compared with major procedures.with major procedures.
Perioperative Nursing Care Types of Surgery
Urgency: reason for procedure:Elective-Performed on the basis of client’s choice; not
essential and may not necessary for health.Urgent- Necessary for client’ health,may prevent
additional problem from developing (e.g. tissue destruction);not necessarily emergency. Emergent- Must be done immediately to save life or preserve function of body part.
Required- Has to performed at some point;can be pre-scheduled.
Perioperative Nursing Types of SurgeryTypes of Surgery
DiagnosticDiagnostic-Allows to confirm diagnosis.
CorrectiveCorrective- Excision or removal of diseased body part.
ReconstructiveReconstructive-Restore function or appearance to traumatized or malfunctioning tissues.
Perioperative Nursing Types of SurgeryTypes of Surgery
Procurement for transplantProcurement for transplant- Removal of organs and/or tissues from a person pronounced brain death for transplantation into another person.
ConstructiveConstructive- Restores function lost or reduced as result of congenital anomalies.
CosmeticCosmetic- Performed to improve personal appearance.
Perioperative Nursing Types of SurgeryTypes of Surgery
Extent of surgery Extent of surgery :SimpleSimple- Only the most overtly
affected areas involved in the surgery.RadicalRadical- Extensive
surgery beyond the area obviously involved; is directed at finding a root cause.LocationLocation: Based on the area of the body on which the surgery occurs (e.g abdominal, heart surgery).
Perioperative Nursing Care Surgical settingsSurgical settings
Surgical suitesSurgical suites
Ambulatory care settingAmbulatory care setting
ClinicsClinics
Physician officesPhysician offices
Community settingCommunity setting
HomesHomes
Perioperative Nursing Care Surgical settingsSurgical settings
DisadvantagesDisadvantagesLess time for rapportLess time to assess, evaluation, teachRisk of potential complication post D/C.
Advantages of outpatientAdvantages of outpatient:Low costLow risk of infectionLess interruption of routineLess than from workLess stress
Perioperative Nursing CareMethod of teachingMethod of teaching
TimingTiming-most useful when started the week before admission and reinforced before surgery and the client is less anxious.Content:Content:
Surgical ProcedureSurgical ProcedurePreoperative routinesPreoperative routinesIntraoperative routinesIntraoperative routines
Postoperative routinesPostoperative routinesSensory preparationSensory preparationPain reliefPain relief
Perioperative Nursing Care PhasesPhases
PreoperativePreoperative-begins with the decision for surgical intervention and ends with transfer to the OR.
Nursing Interventions
Baseline assessment during interview at clinic,office or over the phone.
Assessment in the pre-admission unit, client room, holding area or induction room
Perioperative Nursing Care Preoperative Surgical PhasePreoperative Surgical Phase
AssessmentAssessment:Nursing HistoryNursing History-key elements that pertains to the surgical client’s risks and needs. Information concerning about advance directives. Ask if the patient has a durable power of attorney for health care and a living will.Medical HistoryMedical History- includes past illnesses and the primary reason for seeking medical care.
Perioperative Nursing Care Preoperative Surgical PhasePreoperative Surgical Phase
Assessment continue…..Assessment continue…..Previous surgeriesPrevious surgeries- - past experience with past experience with
surgery can reveal potential physical and surgery can reveal potential physical and psychological responses to procedure and alert psychological responses to procedure and alert you to special needs and risk factors. you to special needs and risk factors. Complications such as anaphylaxis or malignant Complications such as anaphylaxis or malignant hyperthermia.hyperthermia.
Medication HistoryMedication History- - any medications that any medications that might predispose to surgical complicationsmight predispose to surgical complications ..
Perioperative Nursing Care Preoperative Surgical PhasePreoperative Surgical Phase
AllergiesAllergies- to medications, topical agents used to prepare the skin for surgery, and latex can create significant risks.Smoking HabitsSmoking Habits – greater risks for complications.Alcohol and Controlled Substance UseAlcohol and Controlled Substance Use and abuseand abuse- to be prepared for adverse reactions, such as withdrawal, that may occur during surgery.
Client ExpectationsClient Expectations- to identify the client’s and family perceptions and expectations regarding surgery and health care providers.
Perioperative Nursing Care Preoperative Surgical PhasePreoperative Surgical Phase
Family SupportFamily Support- determine the extent of the client’s support from family members or friends.
OccupationOccupation- surgery may result in physical alterations that hinder or prevent a person from returning from work.
FeelingFeeling- surgery causes anxiety and a feeling of loss of control for most clients.
Cultural and Spiritual FactorsCultural and Spiritual Factors- cultural differences in the use of both verbal and nonverbal communication require you to validate interpretation of cues with the client and family.
Perioperative Nursing Care Preoperative Surgical PhasePreoperative Surgical Phase
Coping ResourcesCoping Resources- assessment of a client’s feeling and self-concept helps to reveal whether the client has the ability to cope with the stress of surgery.
Body imageBody image-surgical removal of a diseased tissue often leaves permanent disfigurement or alteration in body function.
Perioperative Nursing CareSelected factors that in increase surgical riskSelected factors that in increase surgical risk..
AgeAge- Very young and older clients.
NutritionNutrition- a malnourished client is prone to poor tolerance of anesthesia, infection, poor wound healing and the potential for multiple organ failure after surgery.
ObesityObesity- often have difficulty in resuming normal activity after surgery.
Perioperative Nursing CarePhysical assessment/clinical manifestationsPhysical assessment/clinical manifestations
General surveyGeneral survey- gestures and body movements may reflect decreased energy or weakness caused by illness.Cardiovascular systemCardiovascular system- alterations in cardiac status are responsible for as many as 30% of perioperative death.Respiratory systemRespiratory system- a decline in ventilatory function, assessed through breathing pattern and chest excursion, may indicate a client’s risk for respiratory complications.
Perioperative Nursing CarePhysical assessment/clinical manifestationsPhysical assessment/clinical manifestations
Renal systemRenal system-abnormal renal function can altered fluid and electrolyte balance and decrease the excretion of preoperative medications and anesthetic agents.
Neurologic systemNeurologic system- a client’s LOC will change as a result of general anesthesia but should return to the preoperative LOC after surgery.
Perioperative Nursing CarePhysical assessment/clinical manifestationsPhysical assessment/clinical manifestations
MusculoskeletalMusculoskeletal system- Deformities may interfere with intraoperative and postoperative positioning. Avoid positioning over an area where the the skin shows signs of pressure over bony prominences.
Gastrointestinal systemGastrointestinal system- alteration in function after surgery may result in decreased or absent bowel sound and distention.
Head and NeckHead and Neck- the condition of oral mucous membranes reveals the level of hydration.
Perioperative Nursing CareGerontological Considerations
CardiovascularCardiovascularCoronary flow decreases
Heart rate decreasesResponse to stress
decreases Peripheral vascular decreases Cardiac output decreases Cardiac reserve decreases
Perioperative Nursing CareGerontological Considerations
Respiratory SystemStatic lung volumes decreasesPulmonary static recoil decreasesSensitivity of the airway receptors decreases
Nervous systemIncreased incidence of post.op. confusionIncreased incidence of deliriumIncreased sensitivity to anesthetic agents
Perioperative Nursing CareGerontological Considerations
Renal SystemRenal blood flow declines 1.5% per
year Renal clearance reduced
GastrointestinalDecreased intestinal motility
Decreased liver blood flowDelayed gastric emptying
Perioperative Nursing CareGerontological Considerations
MusculoskeletalDecreased mass, tone, strengthDecreased bone density
IntegumentaryDecreased elasticityDecreased lean body massDecreased subcutaneous fat
Perioperative Nursing CareLaboratory and diagnostic studiesLaboratory and diagnostic studies
Screening tests depend on the condition of the client and the nature of the surgery. If test reveals severe problems the surgery may be cancel until the condition is stabilized.
Blood typeBlood type and screenscreen, urinalysisurinalysis, 1212 lead EKGlead EKG and chest X-raychest X-ray are ordered to screen for pre-existing abnormalities.
Perioperative Nursing CareCommon nursing diagnosisCommon nursing diagnosis
Knowledge deficitKnowledge deficit
AnxietyAnxiety
Risk for ineffective airway clearanceRisk for ineffective airway clearance
Risk for ineffective peripheral tissue Risk for ineffective peripheral tissue perfusionperfusion
Perioperative Nursing CarePerioperative Nursing CarePreop. teachingPreop. teaching
The education plan should begin with assessment, including baseline knowledge of the patient and family, readiness to learn,barriers to learning, patient and family concern and learning styles and preferences.The content focuses on information that will increase patient’s familiarity with procedural events. This includes surgical experience (procedural), what the pt. may experience (sensory) and what actions may help decrease anxiety (behavioral).
Perioperative Nursing CarePerioperative Nursing CareAnxietyAnxiety
The nurse must consider the pt’s family and friends when planning psychological support. Empowering their sense of control. Activities that decreasing anxiety are deep breathing, relaxation exercises, music therapy, massage and animal-assisted therapy.Use of medication to relieve anxiety.
Perioperative Nursing CarePreanesthesia Management Physical Status Categories
ASA 1: Healthy patient with no diseaseASA 11: Mild systemic ds without fx limitationsASA 111:Severe systemic ds associated with definite fx limitationsASA 1V: Severe systemic ds that is a constant threat to life.ASA V: Moribund pt. Who is not expected to survive without the operation.ASA V1: A declared brain-death whose organ are being recovered for donor.E: Emergency
Perioperative Nursing CarePerioperative Nursing CareFinal Preparation for surgeryFinal Preparation for surgery
All personal belongings are identified All personal belongings are identified and secured.and secured.Jewelry is usually removed.Jewelry is usually removed.Dentures are removed, labeled and Dentures are removed, labeled and placed in a denture cup.placed in a denture cup.Pt. to verbally confirm the surgical Pt. to verbally confirm the surgical procedures and the surgical site. This procedures and the surgical site. This verification process is documented in the verification process is documented in the medical record on the preop. checklistmedical record on the preop. checklist.
Perioperative Nursing CarePerioperative Nursing CarePre-op. medicationsPre-op. medications
Prior to administering – check permitsPrior to administering – check permits
Purpose: Allay anxietyPurpose: Allay anxietyDecrease pharyngeal secretions- Decrease pharyngeal secretions-
decrease gastric secretions.decrease gastric secretions.Decrease side effects of anesthesiaDecrease side effects of anesthesia
Induce amnesiaInduce amnesia
Perioperative Nursing CarePerioperative Nursing CareMedicationsMedications
Sedatives/hypnotics- Nembutal
Tranquilizers-Ativan, versed, valium
Opiate analgesics- Demerol, morphine
Anticholinergics-Atropine sulfate,atarax
H2o blockers.- Tagamet, Zantac
Antiemetic- Reglan, Phenergan
Perioperative Nursing Care PhasesPhases
IntraoperativeIntraoperative- - Transferred to OR-ends with the transfer Transferred to OR-ends with the transfer to the recovery area.to the recovery area.
Nursing InterventionsNursing Interventions
Communicating plan of care
Identifying nursing activities
Establishing priorities
Coordinate care with team members
Coordinate supplies and equipment
Control environment
Document plan of care
Perioperative Nursing Care Intraoperative RolesIntraoperative Roles
Surgeon
Anesthesiologist
Scrub Nurse
Circulating Nurse
OR techs
Perioperative Nursing CarePerioperative Nursing CareIntraoperative Phase- Surgical teamIntraoperative Phase- Surgical team
SurgeonSurgeon-responsible for determining the preoperative diagnosis, the choice and execution of the surgical procedure, the explanation of the risks and benefits, obtaining inform consent and the postoperative management of the patient’s care.Scrub nurse-Scrub nurse- (RN or Scrub tech )- preparation of supplies and equipment on the sterile field; maintenance of pt.s safety and integrity: observation of the scrubbed team for breaks in the sterile fields; provision of appropriate sterile instrumentation, sutures, and supplies; sharps count.
Perioperative Nursing CarePerioperative Nursing CareSurgical teamSurgical team
Circulating NurseCirculating Nurse - responsible for creating a safe environment, managing the activities outside the sterile field, providing nursing care to the patient. Documenting intraoperative nursing care and ensuring surgical specimens are identified and place in the right media. In charge of the instrument and sharps count and communicating relevant information to individual outside of the OR, such as family members.
Perioperative Nursing CarePerioperative Nursing CareSurgical teamSurgical team
Anesthesiologist and anesthetist-Anesthesiologist and anesthetist- anesthetizing the pt. providing appropriate levels of pain relief, monitoring the pt’s physiologic status and providing the best operative conditions for the surgeons.
Other personnel- pathologist, radiologist, perfusionist, EVS personnel.
Perioperative Nursing Care Surgical teamSurgical team
Nursing Roles:Nursing Roles:Staff educationStaff educationClient/family teachingClient/family teachingSupport and reassuranceSupport and reassuranceAdvocacyAdvocacyControl of the environmentControl of the environmentProvision of resourcesProvision of resourcesMaintenance of asepsisMaintenance of asepsisMonitoring of physiologic and psychological Monitoring of physiologic and psychological
statusstatus
Perioperative Nursing CareSurgical asepsis
Ensure sterility
Alert for breaks
Perioperative Nursing Care Types of AnesthesiaTypes of Anesthesia
RegionalLocal
Nerve blockEpidural
Spinal
General
Spinal Anesthesia
Indications -surgical procedures below the diaphragm
-patients with cardiac or respiratory diseaseAdvantages -mental status monitoring -shorter recoveryDisadvantages -necessary extra expertise -possible patient painContraindications -coagulopathy -uncorrected hypovolemia
Spinal Anesthesia
Involved medications-lidocaine-bupivacaine-tetracaine
Patient assessment-continuous heart rate, rhythm, and
pulse oximetry monitoring-level of anesthesia
-motor function and sensation return monitoring
Spinal Anesthesia
Complications-hypotension
-bradycardia-urine
retention -postural puncture headache
-back pain
Spinal analgesia
Indications -postoperative pain from major surgeryInvolved medications -lipid-soluble drugs -preservative-free morphineMonitoring recovery -respiratory depression -urine depression -pruritus -nausea and vomiting
Perioperative Nursing CarePerioperative Nursing Care PhasesPhases
PostoperativePostoperative- - Begins with transfer to PACU and Begins with transfer to PACU and ends with the discharge of the patients from the ends with the discharge of the patients from the surgical facility or the hospital.surgical facility or the hospital.
Nursing InterventionsNursing Interventions
Communicating pertinent information about surgery Communicating pertinent information about surgery to the PACU staff.to the PACU staff.
Postoperative evaluation in clinic or home.Postoperative evaluation in clinic or home.
Perioperative Nursing CarePerioperative Nursing CareNursing assessment in the PACUNursing assessment in the PACU
Vital signs- presence of artificial airway, o2 sat,BP,pulse, temperature.LOC- ability to follow command, pupillary responseUrinary outputSkin integrityPainCondition of surgical woundPresence of IV linesPosition of patient
Perioperative Nursing CarePerioperative Nursing CareNursing DiagnosisNursing Diagnosis
Ineffective airway clearance- increased secretions 2 to anesthesia, ineffective cough, painIneffective breathing pattern- anesthetic and drug effects, incisional painAcute painUrinary retentionRisk for infection
Perioperative Nursing Care Postoperative ManagementPostoperative Management
Maintain a patent airway
Stabilize vital signs
Ensure patient safety
Provide pain
Recognize & manage complications
Perioperative Nursing CareWhen caring for post-surgical patient, When caring for post-surgical patient, think of the “4 W’sthink of the “4 W’s””
Wind: prevent respiratory complications
Wound: prevent infection
Water: monitor I & O
Walk: prevent thrombophlebitis
Perioperative Nursing CarePerioperative Nursing CareComplicationsComplications
Respiratory- atelectasis, pulm. EmbolusCardiovascular- venous thrombosisGastrointestinal-Hiccoughs, N/V,abd. Distention, paralytic ileus, stress ulcer.GU- urinary retentionHemorrhage-slipping of a ligature(suture)Wound infection-Wound dehiscence and evisceration-
Perioperative Nursing CarePerioperative Nursing CareGerontologic considerationsGerontologic considerations
Mental status- attributed to medications, pain, anxiety, depression.
Delirium- infection, malignancy, trauma, MI, CHF, opioid use.
Dementia-sundowning-sleep disturbances, lack of structure in the afternoon or early morning, sleep apnea.