Peri-operative Nursing

Phases of Peri-operative periodPRE- operative phase

INTRA- operative phase

POST- operative phase

PRE-Operative PhaseBegins when the decision to have surgery is made and ends when the client is transferred to the operating table

INTRA-Operative PhaseBegins when the client is transferred to the operating table and ends when the client is admitted to the post-anesthesia unit

Post-operative PhaseBegins with the admission of the client to the PACU and ends when healing is complete

Activities in the Pre-opAssessing the clients Identifying potential or actual health problems Planning specific care Providing pre-operative teaching Ensure consent is signed

ConsentSurgeon - responsible for obtaining the consent for surgery No sedation should be administered before SIGNING the consent minor vs emancipated minor Nurse- witness, documents signing

TYPES of SURGERYAccording to PURPOSE

According to degree of URGENCY

According to degree of RISK

According to PURPOSEDiagnostic Palliative Ablative Constructive Transplant Establishes a diagnosis Relieves or reduces pain or symptoms Removes a diseased body part Restores function or appearance Replaces malfunctioning structures

According to degree of urgencyEmergency surgery Preserves function or life Performs immediately

Elective surgery

Performed when condition is not imminently life threatening

According to degree of RISKMajor Surgery Involves high degree of risk Complicated or prolonged

Minor Surgery

Involves low risk Produces few complications Performed as day surgery

Classification I. Emergent life threatening II Urgent III. Required IV. Elective V. Optional

Indication for surgery Without delay 24-30 hrs

examples trauma AP, Cholecystitis

Plan within Cataracts, weeks or month thyroid No emergency Personal preference CS, hernia Cosmetic surgery

Health factors that affect preoperativelyNutritional status Drug or alcohol abuse Respiratory status Cardiovascular status Hepatic and renal Factors Endocrine Function Immune function Previous medication use Psychosocial factors Spiritual and cultural beliefs

Surgical RiskExtremes of age Malnourished Obese Co-morbid conditions Concurrent medications

Pre-operative InterventionsEnsure signed consent form Obtain nursing history, PE and lab exam Provide pre-operative teaching (pain, leg and foot exercises, splinting, incentive spirometry) Perform physical preparations- shaving, hygiene, enema, NPO, medications

Pre-op exercises and teachingsleg and hip exercises Deep breathing and Coughing Exercises Splinting Early ambulation

Pre-op nutritionAssess order for NPO Solid foods are withheld for about 8 hours before general anesthesia

Pre-op eliminationLaxatives, enemas or both may be prescribed the night before surgery Have the client void immediately BEFORE transferring them to the OR Foley catheter may be inserted as ordered

Pre-op hygieneBath the night before surgery with antiseptic soap Shaving of the skin is usually done in the OR Removal of jewelry and nail polish

Pre-op psychological preparationBe alert to the clients anxiety level Answer questions or concerns Allow time for privacy

Preparing the skin Administering Preanesthetic medications Transporting the patient to the presurgical area

Pre-operative medicationsPre-op Drugs Example

PurposeTo decrease nervousness Promote relaxation Decreases secretions Prevent bradycardia To promote muscle relaxation To prevent nausea and vomiting

Anti-anxiety Diazepam Anticholinergic Muscle relaxant Anti-emetic Antibiotic AtropineSuccinylcholine

Promethazine

Cephalosporin To prevent infection

Pre-operative medicationsPre-op Drugs Example

PurposeTo decrease pain and decrease anesthetic dose

Analgesics

Meperidine

Anti-histamine Diphenhydramine To decrease occurrence of allergy

H-2 antagonist

Cimetidine

To decrease gastric fluid and acidity

Pre-operative screening testCBC Blood type Serum electrolytes FBS BUN, Creatinine ALT, AST, Bilirubin Serum albumin CXR and ECG Determine Hgb and Hct, infection Determined in case of blood transfusion Evaluates the fluid and electrolyte status Evaluates diabetes mellitus Assess the renal function Evaluates the liver function Evaluates nutritional status Respiratory and Cardiac status

Pre-operative teachingLeg exercises To stimulate blood circulation in the extremities to prevent thrombophlebitis To facilitate lung aeration and secretion mobilization to prevent atelectasis and hypostatic pneumoniaDone every two to four hours To stimulate circulation, stimulate respiration, decrease stasis of gas,stimulate peristlsis

Deep breathing and Coughing Exercises and splinting Positioning and Ambulation

Activities during the Intra-opAssisting the surgeon as scrub nurse and circulating nurse

Intra-operative phase interventionsDetermine the type of surgery and anesthesia used Position client appropriately for surgery Assist the surgeon as circulating or scrub nurse Maintain the sterility of the surgical field Monitor for developing complications

Basic Guidelines in Surgical Asepsis All materials in contact with the surgical wound and used within the sterile field must be sterile. Gowns are considered sterile in front from the shoulder to the level of the sterile field and the sleeves. Sterile drape Items should be dispensed to a sterile field by methods that preserve the sterility

Movement of the surgical team are from sterile to sterile and from unsterile to unsterile area. When a sterile barrier is breached, the area , must be considered contaminated

AnesthesiaGeneral anesthesia

Loss of all sensation and consciousness

Regional or Local anesthesia

Loss of sensation in ONE area with consciousness present

Minimal sedation - drug induced state in which a patient can respond normally in verbal commands - cognitive function and coordination may be impaired Moderate sedation - depressed level of consciousness that does not impair ability to maintain a patent airway - calm, sedate a patient combined with analgesic - Midazolam/Diazepam

Deep Sedation - deep sedation is a drug induced state which a patient cannot easily aroused but can respond purposefully after repeated stimulation. - inhaled or intravenously - Volatile anesthetic (halothane, Isoflurane) - Gas anesthetic (Nitrous oxide)

StagesStage I (Beginning Anesthesia) - patient may have ringing, still conscious, sense inability to move extremities - noises are exagerrated - avoid unnecessary noises or motions

Stage II: Excitement - Characterized by struggling, shouting, talking, crying. - pupils dilate, rapid pulse and irregular RR - restrain the patient Stage III - Surgical anesthesia is reached - pt unconscious and lies quietly - respirations are regular and CR - may be maintained in hours if properly given

Stage IV: Medullary Depression - stage is reached when too much anesthesia is given - RR become shallow, pulse is weak and thready, pupils widely dilated - Without proper treatment death will follow - Discontinue anesthetic abruptly

state of narcosis (severe CNS depression produced by pharmacological agents), analgesia, relaxation and reflex loss lose the ability to maintain ventilatory function and require assistance in maintaining a patent airway. Cardiovascular function may be affected as well

Methods of Anesthesia Administration

Inhalation Intravenous Regional Anesthesia Conduction and spinal anesthesia Local Infiltration

GENERAL AnesthesiaProtective reflexes are lost Amnesia, analgesia and hypnosis occur Administered in two ways:

Inhalational Intravenous

REGIONAL AnesthesiaTOPICAL INFILTRATION NERVE BLOCK SPINAL Subarachnoid EPIDURAL Applied directly on the skin Injected into a specific area of skin Injected around a nerve Low spinal anesthesia Epidural space is injected with anesthesia

Potential adverse effects of anesthesia Myocardial depression, bradycardia Nausea and vomitting anaphylaxis CNS agitation, seizures, respiratory arrest Oversedation or under sedation Agitation and disorientation Hypothermia Hypotension Malignant hyperthermia

Patient PositioningProvides optimal visualization Provides optimal access for assessing and maintaining anesthesia and function Protects patient from harm

Position Patient during SurgeryAbdominal surgeries Bladder surgery Perineal surgery Brain surgery Spinal cord surgeries Lumbar puncture Supine Slightly trendelenburg Lithotomy Semi-fowlers Prone mostly Side lying, flexed body

SCRUB NURSE

Assists the surgical team Maintains sterility Handles instruments, prepares sutures,receives specimen, counts Drapes patient Wears sterile gown, gloves Assists the Scrub nurse,opens& obtains instrument, keeps record, adjust lights, receives specimen,coordinates Positions the patient for Sx

CIRCULATING NURSE

surgical teamanesthesiologist anesthetist surgeon assistants- 1st, 2nd, 3rd intra-op nurses

Quiz 11.This stage is referred to as surgical anesthesia stage. 2. This stage Is characterized by exaggerated noises. 3. This stage is met if the anesthesia given exceeds the optimal dose 4. This stage is characterized by agitation and increased VS

Match the following 5. Abdominal surgeries a. lithotomy 6. Bladder surgery b. prone 7.Perineal surgery c. semi-fowlers 8. Brain surgery d. supine 9. Spinal cord surgeries e. modified sims 10. Lumbar puncture f. slightly trendelenburg

Activities in the POST-opAssessing responses to surgery Performing interventions to promote healing Prevent complications Planning for home-care Assist the client to achieve optimal recovery

POST Operative InterventionsMaintain patent airway Monitor vital signs and note for early manifestations of complications Monitor level of consciousness Maintain on PROPER position NPO until fully awake, with passage of flatus and (+) gag reflex

POST Operative InterventionsMonitor the patency of the drainage Maintain intake and output Monitor Temperature Care of the tubes, drains and wound Ensure safety by side rails up Pain medication given as ordered Measures to PREVENT post-op Complications

Post-operative interventionsPAIN MANAGEMENT Pain is usually greatest during the 1236 hours after surgery Narcotic analgesics and NSAIDS may be prescribed together for the early period of surgery Provide back rub, massage, diversional activities, position changes

Post operative interventionsPOSITIONING Clients who have spinal anesthesia is usually placed FLAT on bed for 8-12 hours Unconscious client is placed side lying to drain secretions Other positions are utilized BASED on the type of surgery

Post-operative Interventions Some Examples of Position Post OpMastectomy Thyroidectomy Hemorrhoidectomy Laryngectomy Pneumonectomy Lobectomy Semi-fowlers, affected arm elevated Semi fowlers , head midline Semi-prone, side-lying Fowlers Lateral, affected side Lateral, unaffected side

Post-operative Interventions Some Examples of Position Post OpAneurysmal repair (abdomen) Amputation of lower extremities Cataract surgery Supratentorial craniotomy Infratentorial craniotomy Spina bifida repair Fowlers 45 degrees Flat, with stump elevated with pillow Fowlers 45 degrees 30- 40 degree head elevation Flat on bed, supine Prone

Post-operative InterventionsDeep breathing and coughing exercises Q2-4 hours to remove secretions Leg exercises Q 2 hours to promote circulation Ambulation ASAP prevents respiratory, circulatory, urinary and gastrointestinal complications

Post-operative InterventionsHydration after NPO to maintain fluid balance Suction, either gastro or respiratory to relieve distention, to remove respi secretions Diet progressive, usually given when bowel sounds and gag reflex return

Wound CareInspect dressing hourly Change dressing daily Inspect for signs of infection redness, swelling, purulent exudate Maintain wound drainage

DietNPO usually immediately after surgery Progressive diet Assess the return of the bowel sounds

Liquid Diet Vs Soft dietClear liquid Coffee Tea Carbonated drink Bouillon Clear fruit juice Popsicle Gelatin Hard candy Full liquid Clear liquid PLUS: Milk/Milk prod Vegetable juices Cream, butter Yogurt Puddings Custard Ice cream and sherbet Soft diet All CL and FL plus: Meat Vegetables Fruits Breads and cereals Pureed foods

Urinary EliminationOffer bedpans Allow patient to stand at the bedside commode if allowed Report to surgeon if NO URINE output noted within 8 hours post-op

CPTChest Physiotherapy Chest physiotherapy is based on the fact that mucus can be knocked or shaken form the walls of the airways and helped to drain from the lungs. The usual PVD SEQUENCE is as follows- POSITIONING, Percussion, Vibration, and removal of secretions by SUCTIONING or Coughing followed lastly by oral hygiene

Incentive SpirometryThis operates on the principle that spontaneous sustained maximal inspiration is most beneficial to the lungs and has virtually no adverse effects. The incentive spirometer measures roughly the inspired volume and offers the incentive of measuring progress

Post operative complicationsAtelectasisAssess breath Collapsed alveoli due to sounds Repositioning secretions

Pneumonia

Inflammation of alveoli

Thrombophlebitis Inflammation of the veins

Deep breathing and coughing Chest physio Suctioning Ambulation Leg exercises Monitor for swelling Elevated extremities

Post-operative ComplicationsHypovolemic Loss of Shock circulatory fluid volume Urinary retention Pulmonary embolism Involuntary accumulation of urine Embolus blocking the lung blood flowShock position Determine cause and prevent bleeding O2, IVFEncourage ambulation Provide privacy Pour warm water Catheterize

Notify physician Administer O2

Post-operative complicationsConstipation Infrequent passage of stoolHigh fiber diet Increased fluid Ambulation

Paralytic ileus Absent bowel Encourage ambulation sound Wound infection

NPO until peristalsis returns Occurs about Daily wound dressing 3 days after Antibiotics surgery Maintain drain

Post-operative complicationsWound dehiscenceCover the wound Separation of wound edges at with sterile normal the suture line saline dressing Place in lowFowlers Notify MD Cover the wound Protrusion of with saline pad the internal Place in loworgans and tissues through fowlers Notify MD wound

Wound evisceration

suturesAbsorbable Catgut Polyglycolic acid Polyglyconate Polyglactic acid Polydiaxanone(180 d) Non-absorbable Silk(silkworm larva) Polyester Nylon Polypropylene (vascular) Stainless steel

Wound healingPrimary intention- edges of clean wound are closed Secondary intention- wound is allowed to remain open and heal by granulation Tertiary intention- wound is allowed to remain open for some time and then closed

Suture techniquesTaper-point needle round body, leaves round hole (suturing of soft tissues other than skin) Conventional cutting needle- triangular body (suturing of skin)

stitchesSimple interrupted Vertical mattress( far,far- near,near)-used for difficult to approximate edges Horizontal mattress stitch Simple running stitch Subcuticular stitch ( suture remains longer w/o scar) Pursestring suture stitch which encircles a tube( ex. Gastrostomy tube) Stick tie

quiz1. What type of needle is used in closing muscle and fascia? A. Taper-point needle B. round needle C. Conventional cutting needle D. traditional cutting needle

1. What type of needle is used in closing skin? A. Taper-point needle B. round needle C. Conventional cutting needle D. traditional cutting needle

3. All of the following are examples of clear liquid diet except a. Carbonated drink b. Bouillon c. sherbet d. Gelatin

4. All of the following are examples of general liquid diet except a. Osterized food b. Milk/Milk prod c. Vegetable juices d. bouillon

5. This refers to the Separation of wound edges at the suture line c.Wound infection d.Wound dehiscence e.Wound evisceration f. Wound apposition

6. Protrusion of the internal organs and tissues through wound is called b.Wound infection c.Wound dehiscence d.Wound evisceration e.Wound apposition

Match the following7. Mastectomy 8. Thyroidectomy a. Semi-fowlers b. Lateral, affected side 9. Hemorrhoidectomy c. Lateral, unaffected side 10. Laryngectomy d. prone 11. Pneumonectomy e. flat 12. segmentectomy 13. Amputation of lower extremities 14. Supratentorial craniotomy 15. Infratentorial craniotomy

guidelines1. Number of throws: Silk-3 Gut-4 Vicryl, dexon- 4 Nylon polyester, polyprolene, PDS-6 2. Cutting the end: Silk vessel ties- 1 to 2 mm Abdominal fascia closure- 5 mm Skin sutures, drain sutures- 5 to 10 mm

Guidelines3. when to remove: Face- 3 to 5 days Extremities- 7 days Joints- 7 to 10 days Back- 2 wks Abdomen- 7 days

SURGICAL INSTRUMENTS

Surgical scalpel blades

Shape:Straight - The needle is straight and usually has a cutting surface. Half-curve or Ski - the needle is straight and curves near the point. Curved - The needle is formed in an arc of 1/4, 3/8, 1/2, or 5/8 of a circle

NEEDLES

SURGICAL BLADE HANDLE

Needle holder

Sponge ForcepsSponge forceps or sponge holding forceps are often used in gynecological procedures. They may be straight or curved and have smooth or serrated jaws. The jaws are rounded and provide an atraumatic grip.

SPONGE FORCEP

Dressing ForcepsDressing forceps are also a type of tissue forceps. They are used for dressing wounds and pealing off the dressing. They have scissor-like handles for grasping lint, drainage tubes, etc. Dressing Tweezers may be curved or straight tipped with serrated beak. In some cases it may be smooth.

Dressing Forceps

Suture ForcepsNeedle holder forceps hold needles while suturing. Suture Forcep is also called a needle holder forceps. The typical needle holder has two short, rather blunt, serrated beaks with a groove in each beak. The grooves provide space for the placement and retention of the needle. At the end of the handles, there is a locking mechanism that lets the secure the suture needle in the correct position so as the needle appears to be an extension of the needle holder. The insert in the tip should be carbide steel, and replaceable so that it can be changed when required

Suture Forceps

Surgical HemostatsThey are also called blood vessel forceps and are used for controlling hemorrhage. They are also called Hemostats. They look like needle-holder forceps. The main difference is that the beaks of the hemostatic forceps are longer and more slender.

Hemostatic forceps may have both curved and straight tips or beaks, and there is a locking device on the handle to keep them closed as they are used as vessel clamps. They have transverse serration on beak tips. They have a box hinge and a locking mechanism by the finger rings. all the hemostatic forceps are designed to grab, hold, and crush

They are used for holding blood vessels, and for blunt dissection. These forceps are used in surgery to control hemorrhage by clamping or constricting blood vessels. In dental surgery, they are more used to remove bits of bone chips or parts of teeth, from the oral cavity during the tooth removal.

Surgical Hemostats

Towel ClampsTowel-clamp forceps are used to maintain surgical towels and drapes in the correct position during an operation. They secure drapes to the patients skin and may be used for holding the tissue as well. They are locking type forceps with curved ends. The beak may be pointed or blunt and flat. They may even overlap in closed position.

Towel Clamps

Tubing ForcepsAlso termed as vessel cannulation forceps or tubing introducer forceps, they are useful when a fine plastic tube/ micro catheters have to be introduced into a small blood vessel of almost equal size for medication or diagnostic purposes .

The hollowed beak holds the tubing without deforming it. The tip of the tubing is directed exactly into the vessel opening with a sturdy hand so as not to cause any damage to the vessel from unwanted movement.

Tubing Forceps

Brain ForcepsAlso called Obstetrical Forceps, they are Smoothly shaped and curved, obstetrical forceps. The instrument has two blades and a handle designed to aid in the vaginal delivery of a baby. Though there are many different kinds of brain forceps, the most commonly used ones are thin metal curving into a ring at its tip. This tip fastens the baby's head to protect from damage during the delivery. The use of these forceps is as safe /dangerous as any other surgical tool or drug. They are used for saving babies' lives, when delivery is prudent during fetal distress

Brain Forceps

Grasping ForcepsGrasping forceps are used to remove stones and retrieve foreign objects under direct vision. These forceps are three pronged with hooked tips. This typical design allows the objects to be released easily. The hooks facilitates secure grasping of both large and small objects. The prong wires are rounded to allow atraumatic manipulation. They can be easily passed through the flexible endoscopes.

Grasping Forceps

Mixter ForcepsMixter forceps are the threading forceps used for hemostatic purposes. Hemostatic Forceps are used to wrap the thread around the vessel to stop bleeding. Its beak is such that it grips the thread well.

Mixter Forceps

Mosquito ForcepsMosquito forceps are used for more delicate tissues. They are very fine and small hemostats used during the surgery to control the bleeding of finer vessels.

Mosquito Forceps

Splinter ForcepsSplinter forceps are fine tipped forceps used to remove the finest splinters from the body. The may be curved or straight and may also have an attached magnifying glass for better vision. It is an essential first aid instrument.

Splinter Forceps

Tongue ForcepsTongue forceps are sturdy tools used for holding the tongue while piercing it. They can be locked for a secure grip. They may be slotted or the standard type. Once the piercing is dome and the baebell is in place, the forcep can be removed

Tongue Forceps

Tilley's forcepsThese are commonly called dressing or packing forceps, and are generally used in the nose. You are likely to use them to pack noses and remove foreign bodies

Tilley's forceps

tongue depressorThe wooden ones are disposable and also the most common. Metallic instruments can be used is more force is required. There are different sizes of metallic tongue depressor, and small ones can be used in children or infants.

tongue depressor

laryngeal mirrorIt is used to see over the back of the tongue and into the larynx

local anaestietic spray

otoscope

Allis Tissue Forcep

Tissue Forcep

SURGICAL SCISSOR STRAIGHT

SURGICAL SCISSOR CURVED

Bandage Scissor

Retractors

ARMY NAVY RETRACTOR

SENN Muller Retractor

MATHIEU Retractor

CRILE Retractor

Balfour Retractor Fenestrated end Blades

TROCARS

PATTERSON Trocar

DUKE Trocar And Cannula

OCHSNER Trocars

UNIVERSAL Trocars

OBSTETRICAL INSTRUMENTS

SIMPSON Obstetrical Forceps

SIMPSON-LUIKART Obstetrical Forceps

NAEGELE Obstetrical Forceps

Harrington Retractor

Deaver Retractors

Richardson Retractors

Malleable Ribbon

Balfour Retractor

Bladder Blade for Balfour Retractor

Goulet Retractor

Army Navy Retractors

Gelpi Perineal

Crile Hemostat

Kelly Hemostats

Allises

Babcocks

Mayo Scissors Curved and Straight

Metzenbaums "Mets" Large and Medium

Debakey Tissue Forceps

Plain Tissue Forceps Long and Short

Russian Tissue Forceps Long and Short

Ferris Smith Tissue Forceps

Toothed Tissue Forceps Long and Short

Adison Tissue Forceps Toothed and Plain

#3 Knife Handles Long n Short

Towel Clips

Incision typesKochers- right subcostal incision( cholecytectomy) Middle laparotomy Mcburneys( 1/3 fr ASIS) Paramedian- lateral to linea alba(rarelu used) Pfannenstiels- low transverse abdominal incison Transverse abdominal- used mainly in infants and children or for splenectomy/hemicolectomy

Sternotomy- for heart procedures Thoracotomy- 4th or 5th ICS, anterior or posterior incision Kidney transplant- lower quadrant, kidney placed extraperitonealy Liver transplant- chevron or mercedes-benz incision

To emphasizeThe over-all goal of nursing care during the PRE-OPERATIVE phase is to prepare the patient mentally and physically for the surgery

To emphasizeThe over-all goal of nursing care during the INTRA-OPERATIVE phase is to maintain client safety

To emphasizeThe over-all goals of nursing care during the POST-OPERATIVE phase are to promote healing and comfort, restore the highest possible wellness and prevent associated risk