Peri-operative Nursing

Phases of Peri-operative period

PRE- operative phase

INTRA- operative phase

POST- operative phase

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

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

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

Activities in the Pre-op

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

Consent
Surgeon - 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 SURGERY
According to PURPOSE

According to degree of URGENCY

According to degree of RISK

According to PURPOSE
Diagnostic 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 urgency

Emergency surgery Preserves function or life Performs immediately

Elective surgery

Performed when condition is not imminently life threatening

According to degree of RISK

Major 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 preoperatively

Nutritional 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 Risk
Extremes of age Malnourished Obese Concurrent medications

Pre-operative Interventions
Ensure 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 teachings

leg and hip exercises Deep breathing and Coughing Exercises Splinting Early ambulation

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

Pre-op elimination
Laxatives, 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 hygiene
Bath 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 preparation

Be 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 medications
Pre-op Drugs Example

Purpose
To 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 Atropine

Succinylcholine

Promethazine

Cephalosporin To prevent infection

Pre-operative medications
Pre-op Drugs Example

Purpose
To 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 test

CBC 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 teaching
Leg exercises To stimulate blood circulation in the extremities to prevent thrombophlebitis To facilitate lung aeration and secretion mobilization to prevent atelectasis and hypostatic pneumonia
Done 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-op

Assisting the surgeon as scrub nurse and circulating nurse

Intra-operative phase interventions

Determine 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

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

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

Position Patient during Surgery

Abdominal 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 team
anesthesiologist anesthetist surgeon assistants- 1st, 2nd, 3rd intra-op nurses

Activities in the POST-op

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

POST Operative Interventions

Maintain 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 Interventions

Monitor 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 interventions
PAIN 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 interventions

POSITIONING 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 Op

Mastectomy 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
Deep breathing and coughing exercises Q2-4 hours Leg exercises Q 2 hours Ambulation ASAP

Post-operative Interventions
Hydration after NPO Suction, either gastro or respiratory Diet

Wound Care
Inspect dressing hourly Change dressing daily Inspect for signs of infection Maintain wound drainage

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

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

CPT
Chest 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 Spirometry
This 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 complications

Atelectasis
Assess 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 Complications
Hypovolemic Loss of Shock circulatory fluid volume Urinary retention Pulmonary embolism Involuntary accumulation of urine Embolus blocking the lung blood flow
Shock position Determine cause and prevent bleeding O2, IVF
Encourage ambulation Provide privacy Pour warm water Catheterize

Notify physician Administer O2

Post-operative complications
Constipation Infrequent passage of stool
High 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 complication
Wound dehiscence
Cover 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

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

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

To emphasize
The 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