Perioperative care

Types of Surgeries

What is the difference between Inpatient and Outpatient surgery?

Inpatient Admitted to hospital

before and after surgery

Outpatient Performed outside of

the hospital Under local or

general anesthesia

Purpose of Surgery

Diagnostic/Exploratory-est. diagnosisCurative-remove pathologic causeAblative-remove diseased body partReconstructive-restore function/appearancePalliative-pain relief or symptom of disease

General Classification of surgery

Major Longer intra-op time, lg loss of blood, higher risk for

post-op complications, vital organs are involved

Minor Outpt surgery, few complications

Surgical Urgency Classification

Emergent-life-saving, nowUrgent-prompt-next 24 hrsRequired-Not acute but necessary, wk-monElective-Will improve life but necessaryOptional-client preference

Phases of Perioperative Nursing

Preoperative phase

Intraoperative phase

Postoperative phase

Pre-op stage -begins with the decision for surgery and ends when the client is transferred to operating room.

Intra-op- clients entry into the operating room

Post-op - begins when pt is admitted to PACU ends with complete recovery

Preoperative PeriodNursing Responsibilities

Client’s historyPhysical examLabs/Diagnostic TestingTeachingInformed ConsentSkin PrepVSIV/Foley if orderedTEDS/SCD

MedicationsNPORemove personal items-

clothing, jewelry, dentures

Keep hearing aid in or glasses on-tell OR nurse

Put hospital gownEmpty bladderComplete pre-op check

list

Laboratory/Diagnostic Studies (Preoperative)

Complete blood count (CBC)

Blood type and cross match

Serum electrolytes (BMP)

Serum creatine Arterial Blood Gases Coagulation studies Urinalysis Chest x-ray Electrocardiogram

(ECG)

Check for infection/immune status

transfusion readiness electrolyte imbalances Renal status Oxygenation status risk for bleeding or

thrombosis r/o infection, renal function

and r/o pregnancy baseline info about size,

shape and condition of heart and lungs.

Cardiac status

TABLE 9-3 Laboratory Tests for Perioperative Assessment.

TABLE 9-3 (continued) Laboratory Tests for Perioperative Assessment.

Pre-operative Medications

Benzodiazipines Midazolam (Versed),Diazepam

(Valium),Lorazepam (Ativan) Uses: Decrease anxiety and produce sedation,

substantial amnesiaOpiod Analgesics

Morphine, Merperdine (Demerol) Uses: decrease anxiety and provide analgesia

Pre-operative Medications (2)

H2 Receptor Antagonists Cimetidine (tagament), Famotidine (pepsid),

Ranitidine (Zantac) Uses: Reduce gastric acid volume and concentration

Anticholinergics Atropine Sulfate, Glycopyrrolate (Robinal) Uses Reduces oral and respiratory secretions to

decrease risk of aspiration, vomiting or laryngospams.

Pre-operative Medications

Barbiturates Phenobarbital Uses: Enhances the effects of the Opioids, CNS

depressant

Antinausea Compazine, Phenergan Uses: reduce possible vomitting/aspiration

Prophylactic antibiotics

Physical Preparation of Client for Surgery

Skin preparation Cleanse-shower in am then site is cleaned with

antimicrobial agent before surgery Hair remove from surgical site-clip don’t shave Cosmetics and nail polish is removed

Insertion of indwelling urinary catheterBowel preparationWithholding of food and fluids (NPO)No insulin is given if NPOMarking the site-visible, clear, no X

Psychological Preparation of Client and Family for Surgery

Significant and stressful event that produces anxiety

Listen actively to verbal and nonverbal communication

Establish trusting relationshipUse of therapeutic communication

Informed ConsentLegal document required for procedures

or therapeutic measuresProtects the client, nurse, physician,

health care facilityMost states require 18 years of age or

older to signMarried minors and emancipated minors

may sign consentSpouses, children, significant other cannot

sign instead of a capable adult

Informed Consent

MD is responsible for obtaining consentNurses can ONLY witness signature-client

has capacity, authority, and is voluntarily signing

Emergency-MD becomes “legal guardian” if next of kin is not located and pt CAN’T give consent

Pt needs to understand-reason, benefits/risk, likelihood of success, alternative tx, risk if not done, and they have the right to refuse

Surgical Risk Factors

Advanced age Obesity Malnutrition Dehydration/

electrolyte imbalance Cardiovascular

disorders Respiratory disorders Diabetes mellitus

Renal and liver dysfunction

Alcoholism Smoking Medications Anticoagulants Diuretics Antihypertensives/

antidepressants

BOX 9-3 Focus on Older Adults: Older Adult Undergoing Surgery.

Preoperative Assessment

Medical historyAccurate height and weightAssistance after the surgical procedureUnderstanding of surgical procedureInformed consentVital signs-with in 4 hrs of surgeryComplete medication list

Preoperative Teaching

Pre-op exercisesDiaphragmatic Breathing ExerciseCoughing ExerciseLeg, ankle, and foot exercises1. Muscle pumping exercise for calves2. Leg exercises3. Ankle and foot exercises

Preoperative Teaching

Labs/diagnostic testsMedicationsTimetable-when to arrive, when is the

surgery scheduled and recovery roomLocation on waiting roomAnticipated postoperative routine, devices,

equipmentPostoperative pain control-medication, PCAPost-op care-wounds, diet, activity, wounds,

drains-what they are going to look like

Intraoperative Phase

Time frame-admitted to OR to admission into PACU

Universal Protocol Right- pt, procedure, site Pre-op verification process-procedure, consent, labs,

ect Site marked-correct “Time Out”-final verification-check client, site,

procedure

Intraoperative Medications

General anesthesia-inhalant or IV-produces CNS depression (decrease LOC, no pain, skeletal muscle relax, reflexes diminished)

Regional anesthesia-instilled around the peripheral nerves to block transmission on nerve impulses in a particular area. Awake and conscious but does not perceive pain-spinal

Conscious sedation-provide analgesia and amnesia but allow the pt to remain conscious-versed

Antidotes for reversal of effects-Narcan Can respond, patent airway

Stages of General Anestesia

Stage 1-drowsy, dizzy, pain sensation is decreased

Stage 2-irregular breathing & involuntary motor movements-avoid stimulating client (may cause vomiting)

Stage 3-When surgery takes place, skeletal muscles are relaxed, constricted pupils

Stage 4-Medullary depression-client is near death, pupils-fixed and dilated, respirations are weak, pulse is rapid and thready

Surgical Team

SurgeonSurgical assistant-works with surgeon-not always

presentAnesthesiologist-administers anesthesia and assume

responsibility for the pt’s general well beingCirculating nurse-RN oversees physical aspects of OR

and equipment, transferring, site prepped, everyone remains sterile, assist with others documentation

Scrub nurse-hands instruments to surgeonBoth Circulating and scrub RN account for used

instruments and devices during and after surgery

Nursing Responsibilities in Intraoperative Phase

Administer IV infusions and medicationsPosition clientProvide emotional/physical support if awakeAccount for all equipment and suppliesAseptic environmentPhysiological monitoringMonitor fluid loss or gainMonitor client’s response to medicationsMonitor-cardiac, respiratory, neurological

status

Principles of Intraoperative Asepsis

Surgical asepsis-see box 44-1If sick-stay homeSurgical scrub-pg 786Maintain sterile fieldCheck expiration dates and don’t use open

containers“Lip” solution-pour out a sm amount into

waste container to cleanse bottle lid

Potential Intraoperative Complications

N/V-need to be NPOHypoxia

From cough reflex lost and aspiration, respiratory depression from medications, positioning can negatively affect lung expansion

Monitor respirations, pulse oxHypothermia

OR temp and exposure to internal organs Limit exposure of nonsurgical body part, warm IVF

Malignant Hyperthermia Excessive heat production from stress, trauma, infection-

tachycardia, tachypnea, skin is flushed then mottled and syanotic 100% O2, cooling blanket, ice packes, cool IVF, stomach

irrigation Can be fatal

Excessive fluid and blood loss

Postoperative Nursing Care

PACU-recovery Get report-how are they, VS, pain, meds given-last

dose, tubes/drains-note them, IVF/drips, est. blood loss, all over picture

Management Maintain patent airway

Monitor rate, lung sounds, return of gag reflex Maintain cardiovascular stability

VS-every 15 minutes until stable then every 30 Monitor for hypotension/shock

S/S-restlessness, decrease urine output, cool moist skin, pallor, dropping blood pressure and increase pulse

Continue

Monitor hemorrhage Look at dressing/drains, urine output, distention of body

tissuesMonitor HTN/dysrhythmiasRelieve pain and anxiety

Determine location/cause Administer prescribed medication

Monitor neurological status LOC, frequently attempt to wake up pt, orient to

environment-keep quietTemp

Warm blankets or bear huggerIntegumentary

Monitor incisions, dressing, drains, skin breakdown

Discharge Criteria from PACU

VS stable with spontaneous respirationsGag reflex is presentEasily arousableD/C ed home

A and Ox3, no respiratory distress, TCDB, no N/V, voided, minimal pain and bleeding, someone to drive them home

Postoperative Care on the Floor

Monitor VS, breathingCheck surgical sites/drain/dressings-do wound

carePain eval and managementMonitor IVF/dripsMonitor urine output-30 mL/hr, bladder distentionTCDB q 2 hrs while awake-splinting incisionLeg exercises, TEDs, SCDsMonitor for infectionDiet fluidsEmotional support for pt and family

Postoperative Complications

Cardiovascular complications Shock Hemorrhage Deep venous thrombosis-Thromblophlebitis Pulmonary embolism

Postoperative Complications

Respiratory complications Pneumonia Atelectasis

Elimination complications Urinary retention Altered bowel elimination Paralytic Ileus

Postoperative Complications

Wound complicationsInfection

DehiscenceEvisceration

Postoperative Teaching

Wound careManifestations of a wound infectionHow and when to take a temperatureLimitations or restrictions on activitiesControl of pain

Discharge Instructions

Diet 6-8 glasses of fluid Diet restrictions

Activity Activity restrictions Avoid heavy lifting for 6 weeks, 10lbs with abdominal incision

Medications Pain meds, talk about all their medications

Wound Care How to take care of, what to look for, steri strips come off by

themselves, staples/sutures will be removed in office after 7-14 days

Follow-up Care When to call surgeon Important to keep follow up appt Explain home health care if ordered