Lecture Notes on Perioperative Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN MS Perioperative Nursing Abejo 1 MEDICAL AND SURGICAL NURSING PERIOPERATIVE NURSING Lecturer: Mark Fredderick R. Abejo RN, MAN __________________________________________ Perioperative Nursing – used to describe the nursing care provided in the total surgical experience of the patient: preoperative, intraoperative and postoperative. Preoperative Phase, extends from the time the client is admitted in the surgical unit, to the time he/she is prepared for the surgical procedure, until he is transported into the operating room. Intraoperative Phase, extends from the time the client is admitted to the OR, to the time of administration of anesthesia, surgical procedure is done, until he/she is transported to the RR/PACU. Postoperative Phase, extends from the time the client is admitted to the recovery room, to the time he is transported back into the surgical unit, discharged from the hospital, until the follow-up care. 4 Major Types of Pathologic Process Requiring Surgical Intervention (OPET) Obstruction – impairment to the flow of vital fluids (blood,urine,CSF,bile) Perforation – rupture of an organ. Erosion – wearing off of a surface or membrane. Tumors – abnormal new growths. Classification of Surgical Procedure According to PURPOSE: Diagnostic – to establish the presence of a disease condition. ( e.g biopsy ) Exploratory – to determine the extent of disease condition ( e.g Ex-Lap ) Curative – to treat the disease condition. * Ablative – removal of an organ * Constructive – repair of congenitally defective organ. * Reconstructive – repair of damage organ Palliative – to relieve distressing sign and symptoms, not necessarily to cure the disease. According to URGENCY Classification Indication for Surgery Examples Emergent – patient requires immediate attention, life threatening condition. Without delay - severe bleeding - gunshot/ stab wounds - Fractured skull Urgent / Imperative – patient requires prompt attention. Within 24 to 30 hours - kidney / ureteral stones Required – patient needs to have surgery. Plan within a few weeks or months - cataract - thyroid d/o Elective – patient should have surgery. Failure to have surgery not catastrophic - repair of scar - vaginal repair Optional – patient’s decision. Personal preference - cosmetic surgery According to DEGREE OF RISK Major Surgery - High risk / Greater Risk for Infection - Extensive - Prolonged - Large amount of blood loss - Vital organ may be handled or removed Minor Surgery - Generally not prolonged - Leads to few serious complication - Involves less risk Ambulatory Surgery/ Same-day Surgery / Outpatient Surgery Advantages: - Reduces length of hospital stay and cuts costs - Reduces stress for the patient - Less incidence of hospital acquired infection - Less time lost from work by the patient; minimal disruptions on the patient’s activities and family life. Disadvantages: - Less time to assess the patient and perform preoperative teaching. - Less time to establish rapport - Less opportunity to assess for late postoperative complication. Example of Ambulatory Surgery Teeth extraction Circumcision Vasectomy Cyst removal Tubal ligation Surgical Risks Obesity Poor Nutrition Fluid and Electrolyte Imbalances Age PERIOPERATIVE NURSING
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Lecture Notes on Perioperative Nursing
Prepared By: Mark Fredderick R Abejo R.N, MAN
MS Perioperative Nursing Abejo
1
MEDICAL AND SURGICAL NURSING
PERIOPERATIVE NURSING
Lecturer: Mark Fredderick R. Abejo RN, MAN
__________________________________________
Perioperative Nursing – used to describe the nursing
care provided in the total surgical experience of the
patient: preoperative, intraoperative and postoperative.
Preoperative Phase, extends from the time the client is
admitted in the surgical unit, to the time he/she is
prepared for the surgical procedure, until he is
transported into the operating room.
Intraoperative Phase, extends from the time the client is
admitted to the OR, to the time of administration of
anesthesia, surgical procedure is done, until he/she is
transported to the RR/PACU.
Postoperative Phase, extends from the time the client is
admitted to the recovery room, to the time he is
transported back into the surgical unit, discharged from
the hospital, until the follow-up care.
4 Major Types of Pathologic Process Requiring
Surgical Intervention (OPET)
Obstruction – impairment to the flow of vital fluids
(blood,urine,CSF,bile)
Perforation – rupture of an organ.
Erosion – wearing off of a surface or membrane.
Tumors – abnormal new growths.
Classification of Surgical Procedure
According to PURPOSE:
Diagnostic – to establish the presence of a disease
condition. ( e.g biopsy )
Exploratory – to determine the extent of disease
condition ( e.g Ex-Lap )
Curative – to treat the disease condition.
* Ablative – removal of an organ
* Constructive – repair of congenitally
defective organ.
* Reconstructive – repair of damage organ
Palliative – to relieve distressing sign and symptoms,
not necessarily to cure the disease.
According to URGENCY
Classification Indication
for Surgery
Examples
Emergent – patient
requires immediate
attention, life
threatening condition.
Without
delay
- severe
bleeding
- gunshot/
stab wounds
- Fractured
skull
Urgent / Imperative –
patient requires prompt
attention.
Within 24 to
30 hours
- kidney /
ureteral
stones
Required – patient
needs to have surgery.
Plan within a
few weeks or
months
- cataract
- thyroid d/o
Elective – patient
should have surgery.
Failure to
have surgery
not
catastrophic
- repair of
scar
- vaginal
repair
Optional – patient’s
decision.
Personal
preference
- cosmetic
surgery
According to DEGREE OF RISK
Major Surgery
- High risk / Greater Risk for Infection
- Extensive
- Prolonged
- Large amount of blood loss
- Vital organ may be handled or removed
Minor Surgery
- Generally not prolonged
- Leads to few serious complication
- Involves less risk
Ambulatory Surgery/ Same-day Surgery / Outpatient
Surgery
Advantages:
- Reduces length of hospital stay and cuts costs
- Reduces stress for the patient
- Less incidence of hospital acquired infection
- Less time lost from work by the patient; minimal
disruptions on the patient’s activities and family life.
Disadvantages:
- Less time to assess the patient and perform
preoperative teaching.
- Less time to establish rapport
- Less opportunity to assess for late postoperative
complication.
Example of Ambulatory Surgery
Teeth extraction
Circumcision
Vasectomy
Cyst removal
Tubal ligation
Surgical Risks
Obesity
Poor Nutrition
Fluid and Electrolyte Imbalances
Age
PERIOPERATIVE
NURSING
Lecture Notes on Perioperative Nursing
Prepared By: Mark Fredderick R Abejo R.N, MAN
MS Perioperative Nursing Abejo
2
Presence of Disease (Cardiovascular dse., DM,
Respiratory dse. )
Concurrent or Prior Pharmacotherapy
other factors:
- nature of condition
- loc. of the condition
- magnitude / urgency of the surgery
- mental attitude of the patient
- caliber of the health care team
Goals
Assessing and correcting physiologic and
psychologic problems that may increase surgical risk.
Giving the person and significant others complete
learning / teaching guidelines regarding surgery.
Instructing and demonstrating exercises that will
benefits the person during postop period.
Planning for discharge and any projected changes in
lifestyle due to surgery.
Physiologic Assessment of the Client Undergoing
Surgery
Age
Presence of Pain
Nutritional & Fluid and Electrolyte Balance
Cardiovascular / Pulmonary Function
Renal Function
Gastrointestinal / Liver Function
Endocrine Function
Neurologic Function
Hematologic Function
Use of Medication
Presence of Trauma & Infection
Routine Preoperative Screening Test
Test Rationale
CBC RBC,Hgb,Hct are important to the
oxygen carrying capacity of blood.
WBC are indicator of immune
function.
Blood grouping/
X matching
Determined in case blood transfusion
is required during or after surgery.
Serum
Electrolyte
To evaluate fluid and electrolyte
status
PT,PTT Measure time required for clotting to
occur.
Fasting Blood
Glucose
High level may indicate undiagnosed
DM
BUN /
Creatinine
Evaluate renal function
ALT/AST/LDH
and Bilirubin
Evaluate liver function
Serum albumin
and total CHON
Evaluate nutritional status
Urinalysis Determine urine composition
Chest Xray Evaluate resp.status/ heart size
ECG Identify preexisting cardiac problem.
Psychosocial Assessment and Care
Causes of Fears of the Preoperative Clients
Fear of Unknown ( Anxiety )
Fear of Anesthesia
Fear of Pain
Fear of Death
Fear of disturbance on Body image
Worries – loss of finances, employment, social and
family roles.
Manifestation of Fears
- anxiousness
- bewilderment
- anger
- tendency to exaggerate
- sad, evasive, tearful, clinging
- inability to concentrate
- short attention span
- failure to carry out simple directions
- dazed
Nursing Intervention to Minimize Anxiety
Explore client’s feeling
Allow client’s to speak openly about fears/concerns
Give accurate information regarding surgery
(brief, direct to the point and in simple terms)
Give empathetic support
Consider the person’s religious preference and
arrange for visit by a priest / minister as desired.
INFORMED CONSENT
Purposes:
To ensure that the client understand the nature of
the treatment including the potential complications
and disfigurement
( explained by AMD )
To indicate that the client’s decision was made
without pressure.
To protect the client against unauthorized
procedure.
To protect the surgeon and hospital against legal
action by a client who claims that an authorized
procedure was performed.
Circumstances Requiring Consent
Any surgical procedure where scalpel, scissors,
suture, hemostats of electrocoagulation may be
used.
Entrance into body cavity.
Radiologic procedures, particularly if a contrast
material is required.
General anesthesia, local infiltration and regional
block.
Essential Elements of Informed Consent
the diagnosis and explanation of the condition.
a fair explanation of the procedure to be done and
used and the consequences.
a description of alternative treatment or procedure.
a description of the benefits to be expected.
material rights if any.
the prognosis, if the recommended care, procedure
is refused.
Requisites for Validity of Informed Consent
Written permission is best and legally accepted.
Signature is obtained with the client’s complete
understanding of what to occur.
PREOPERATIVE PHASE
Lecture Notes on Perioperative Nursing
Prepared By: Mark Fredderick R Abejo R.N, MAN
MS Perioperative Nursing Abejo
3
- adult sign their own operative permit
- obtained before sedation
For minors, parents or someone standing in their
behalf, gives the consent.
Note: for a married emancipated minor parental
consent is not needed anymore, spouse is accepted
For mentally ill and unconscious patient, consent
must be taken from the parents or legal guardian
If the patient is unable to write, an “X” ia accepted
if there is a witness to his mark
Secured without pressure and threat
A witness is desirable – nurse, physician or
authorized persons.
When an emergency situation exists, no consent is
necessary because inaction at such time may cause
greater injury. (permission via telephone/cellphone
is accepted but must be signed within 24hrs.)
PREOPERATIVE CARE
Physical Preparation
Before Surgery
Correct any dietary deficiencies
Reduce an obese person’s weight
Correct fluid and electrolyte imbalances
Restore adequate blood volume with BT
Treat chronic diseases
Halt or treat any infectious process
Treat an alcoholic person with vit. supplementation,
IVF or fluids if dehydrated
Preoperative Teaching
Incentive Spirometry
Encouraged to use incentive spirometer about 10 to
12 times per hour.
Deep inhalations expand alveoli, which prevents
atelectasis and other pulmonary complication.
There is less pain with inspiratory concentration than
with expiratory concentration.
Diaphragmatic Breathing
Refers to a flattening of the dome of the diaphragm
during inspiration, with resultant enlargement of
upper abdomen as air rushes in. During expiration,
abdominal muscles contract.
In a semi-Fowlers position, with your hands loose-
fist, allow to rest lightly on the front of lower ribs.
Breathe out gently and fully as the ribs sink down and
inward toward midline.
Then take a deep breath through the nose and mouth,
letting the abdomen rise as the lungs fill with air.
Hold breath for a count of 5.
Exhale and let out all the air through your nose and
mouth.
Repeat this exercise 15 times with a short rest after
each group of 5.
Coughing
Promotes removal of chest secretions.
Interlace his fingers and place hands over the
proposed incision site, this will act as a splint and
will not harm the incision.
Lean forward slightly while sitting in bed.
Breath, using diaphragm
Inhale fully with the mouth slightly open.
Let out 3-4 sharp hacks.
With mouth open, take in a deep breath and quickly
give 1-2 strong coughs.
Turning
Changing positions from back to side-lying (vice
versa ) stimulates circulation, encourages deeper
breathing and relieve pressure areas
Help the patient to move onto his side if assistance is
needed.
Place the uppermost leg in a more flexed position
than that of the lower leg and place a pillow
comfortably between the legs.
Make sure that the patient is turned from one side to
the back and onto the other side every 2 hours.
Foot and Leg Exercise
Moving the legs improves circulation and muscle
tone.
Have the patient lie supine, instruct patient to bend a
knee and raise the foot – hold it a few seconds and
lower it to the bed.
Repeat above about 5 times with one leg and then
with the other. Repeat the set 5 times every 3-5
hours.
Then have the patient lie on one side and exercise the
legs by pretending to pedal a bicycle.
For foot exercise, trace a complete circle with the
great toe.
Turning to the Side
Turn on your side with the uppermost leg flexed most
and supported on a pillow.
Grasp the side rails as an aid to maneuver to the side.
Lecture Notes on Perioperative Nursing
Prepared By: Mark Fredderick R Abejo R.N, MAN
MS Perioperative Nursing Abejo
4
Preparing the Patient the Evening Before Surgery
Preparing the Skin
- have a full bath to reduce microorganisms in the
skin.
- hair should be removed within 1-2 mm of the skin
to avoid skin breakdown, use of electric clipper is
preferable.
Preparing the G.I tract
- NPO, cleansing enema as required
ASA (American Society of Anesthesiologists)
Guidelines for Preoperative Fasting
Liquid and Food Intake Minimum
Fasting Period
Clear Liquids 2
Breast Milk 4
Nonhuman Milk 6
Light Meal 6
Regular / Heavy Meals 8
Preparing for Anesthesia
- Avoid alcohol and cigarette smoking for at least 24
hours before surgery.
Promoting rest and sleep
- Administer sedatives as ordered
Preparing the Person on the Day Of Surgery
Early A.M Care
Awaken 1 hour before preop medications
Morning bath, mouth wash
Provide clean gown
Remove hairpins, braid long hair, cover hair with cap
if available.
Remove dentures, colored nail polish, hearing aid,
contact lenses, jewelries.
Take baseline vital sign before preop medication.
Check ID band, skin prep
Check for special orders – enema, IV line
Check NPO
Have client void before preop medication
Continue to support emotionally
Accomplished “preop care checklist
PREOPERATIVE MEDICATIONS
Goals:
To aid in the administration of an anesthetics.
To minimize respiratory tract secretion and changes
in heart rate.
To relax the patient and reduce anxiety.
Commonly used Preop Meds.
Tranquilizers & Sedatives
* Midazolam
* Diazepam ( Valium )
* Lorazepam ( Ativan )
* Diphenhydramine
Analgesics
* Nalbuphine ( Nubain )
Anticholinergics
* Atropine Sulfate
Proton Pump Inhibitors
* Omeprazole ( Losec )
* Famotidine
Transporting the Patient to the OR
Adhere to the principle of maintaining the comfort
and safety of the patient.
Accompany OR attendants to the patient’s bedside
for introduction and proper identification.
Assist in transferring the patient from bed to
stretcher.
Complete the chart and preoperative checklist.
Make sure that the patient arrive in the OR at the
proper time.
Lecture Notes on Perioperative Nursing
Prepared By: Mark Fredderick R Abejo R.N, MAN
MS Perioperative Nursing Abejo
5
Patient’s Family
Direct to the proper waiting room.
Tell the family that the surgeon will probably contact