Perioperative Nursing

Presented by: Alrene D. Balce, RM, RN

Cherry May B. Olesco, RN

Peri-Operative Nursing

It is used to describe the nursing care provided in the total surgical experience of a patient. The provision of nursing care by an RN preoperatively, intraoperatively, and postoperatively to a patient undergoing an operative or invasive procedure

Peri-Operative Nursing

Hospital operating rooms

Interventional radiology suites

Cardiac catheterization labs

Endoscopy suites Ambulatory surgery

centers Trauma centers Pediatric specialty

hospitals Physician offices

Areas in Which Perioperative Nursing Is Practiced

Perforation - rupture of an organ, artery or bleb

Obstruction - blockage

Erosion - wearing away of a surface of a tissue

Tumor - abnormal growth

Conditions Requiring Surgery

PURPOSE

RISK, DEGREE OF

URGENCY, DEGREE OF

Categories of SURGERY

According to:

According to: PURPOSE Diagnostic

To verify a suspected diagnosis Ex. biopsy

Palliative

Relieves or reduces pain or symptoms

Ablative Removes a diseased body partEx. Nephrectomy

According to: PURPOSE Constructive

Restores function or appearance; repair of a congenitally defective organ ex. Cleft palate

Transplant Replaces malfunctioning structures ex. Heart transplant

Exploratory

To estimate extent of a diseaseEx. Exploratory Laparotomy

According to: PURPOSE Curative

To remove or repair damaged or diseased organs or tissues

Ablative removal of diseased organse.g. nephrectomy, appendectomy

Reconstructive

partial or complete restoration of a damaged organe.g. plastic surgery after burns

Constructive

repair of a congenitally defective organe.g. plastic surgery of a cleft palate, cheiloplasty

Palliative to relieve pain

Types of Curative Surgery:

Major Surge

ry

- Involves high degree of risk- Complicated or prolonged- Large amount of blood loss- Extensive: Vital organs

may be handled or removed

- Ex: liver biopsy, colectomy

According to: RISK, DEGREE OF

Minor Surge

ry

- Involves low risk- Produces few complications- Generally not

prolonged; described as “one-day surgery” or outpatient surgery

- Ex: cyst removal

According to: RISK, DEGREE OF

Emergency

- must be performed immediately- e.g. gunshot wound

Imperative

- must be performed as soon as possible within 24-48 hours

- e.g. severe bleeding

Planned Require

d

- necessary for client well being- e.g. tonsillectomy

According to: URGENCY, DEGREE OF

Optional

- surgery that a client requests- e.g. face lift

Elective - should be performed for the client’s well being but which is not absolutely necessary

- e.g. hernia repair

Required

- necessary for the well-being of the client, usually within weeks to months

- e. g. cholecystectomy

According to: URGENCY, DEGREE OF

PROPHYLACTIC

PREVENTATIVE

Prevents a more serious condition from developing

INPATIENT SURGERY

Client has been in the hospital prior to the decision to have a surgery

OUTPATIENT SURGERY

Client enters the hospital to have surgery done

Other types of Surgery

1. Physical and Mental Condition of the Client

Factors that Affects Surgical Risk Estimation

04/08/2023 16

a)Age: premature babies and elderly persons are at risk

b)Nutritional status: malnourished and obese are at risk

c)State of fluid and electrolytes balance: dehydration and hypovolemia predispose a person to complications

d)General health: infectious process increase operative risk

e)Mental healthf) Economic and occupational status



04/08/2023 17

g) Types of drugs taken regularly:

1). Steroids - may improve the body’s ability to response to the stress of anesthesia and surgery

2). Anticoagulants and salicylates - may increase bleeding during surgery

3). Antibiotics - maybe incompatible with or potentiate anesthetic agents



04/08/2023 18

g) Types of drugs taken regularly: 4). Tranquilizers - potentiate the effect

of narcotics and can cause hypotension

5). Antihypertensives - may predispose to shock by the combined effect of blood pressure reduction and anesthetic vasodilation

6). Diuretics - may increase potassium loss

7). Alcohol - will place the surgical client at risk when used chronically

2. The Extent of the Disease

3. The Magnitude of the Required

Operation

4. Resources and Preparation of the

Surgeon, Nurses, and the Hospital


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POST- operative phase

INTRA- operative

phase

PRE-

operativ

e phase

Phases of Peri-operative period

Pre Operative Nursing

Begins at the time of decision for surgery and ends when the client is transferred to the OR

This period is used to physically and psychologically prepare the client for surgery

The nurse plays a major role in client teaching and in relieving the client’s and the family’s anxieties

Pre-Operative Phase

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Goals: Assessing and correcting physiologic and

psychologic problems that might 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 post-op period

Planning for discharge and any projected changes in lifestyle due to surgery

Pre-Operative Phase

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Pre-Operative Phase

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A.) PSYCHOLOGIC PREPARATION FOR SURGERY

1. Preparation for hospital admission includes:

Explanation of the procedure to be done

Probable outcome Expected duration of hospitalization

CostLength of absence from workResidual effects

Pre-Operative Phase

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2. Nursing Diagnosis for Preoperative Client

Anxiety related to lack of knowledge about preoperative routines, physical preparation for surgery, post operative care and potential body image change


Pre-Operative Phase

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2. Nursing Diagnosis for Preoperative ClientCauses of Fears:

Fear of the unknownFear of anesthesia, vulnerability

while unconsciousFear of painFear of deathFear of disturbance of body imageWorries: loss of finances,

employment, social and family roles


Pre-Operative Phase

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2. Nursing Diagnosis for Preoperative ClientManifestations of Fears:Anxiousness and bewildermentAngerTendency to exaggerateSad, evasive, tearful, clingingInability to concentrateShort attention spanFailure to carry out simple directionsDazed


Pre-Operative Phase

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3. Nursing Interventions to Minimize Anxiety


Assess client’s fears, anxieties, support systems, and patterns of coping

Establish trusting relationship with client and significant others

Pre-Operative Phase

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3. Nursing Interventions to Minimize Anxiety


Explain routine procedures, encourage verbalization of fears, and allow client to ask questions

Demonstrate confidence in surgeon and staff

Provide for spiritual care if appropriate

Pre-Operative Phase

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B.) LEGAL ASPECT: “INFORMED CONSENT”, OPERATIVE PERMIT, SURGICAL CONSENT

This is to protect the surgeon and the hospital against claims that

unauthorized surgery has been performed and that the client was unaware of the potential risks of

complications involvedProtects the client from undergoing

unauthorized surgery

Pre-Operative Phase

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Surgical procedure, alternatives, possible complications, disfigurements, or removal of body parts are explained

It is part of the nurse’s role as a client advocate to confirm that the client understands information given

1.) The Surgeon obtains operative permit or informed consent

Pre-Operative Phase

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If the client is minor allow the parents or the nearest relative to sign the consent for the procedure

For EMANCIPATED CLIENTS, they are allowed to sign the consent

2.) Minor Patients

Pre-Operative Phase

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Signs own permit unless unconscious or mentally incompetent

If unable to sign, relative, (spouse or next of kin) or guardian will sign

In an emergency, permission via the telephone or telegram is acceptable: have a second listener on phone when telephone permission being given

3.) Adult Patients (over 18 y/o)

Pre-Operative Phase

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1. There is an immediate threat to life

2. Experts agree that it is an emergency

3. Client is unable to consent4. A legally authorized person

cannot be reached

Consents are not needed for emergency care if all four of the

following criteria are met:

Pre-Operative Phase

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C.) PHYSIOLOGIC PREPARATION

1) Respiratory preparation: - chest x-ray

2) Cardiovascular preparation: - ECG, CBC, blood typing, cross-matching, PT/PTT (prothrombin time, partial

thromboplastin time), serum electrolytes

3) Renal preparation: - Urinalysis

Pre-Operative Phase

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Allergy to medications, chemicals, and other environmental products such as latex

All allergies are reported to anesthesia and surgical personnel before the beginning of surgery.

If allergy exist, an allergy band must be placed in the client’s arm immediately

4. Past Medical History

A-

Pre-Operative Phase

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Bleeding tendencies or the use of medications that deter clotting, such as aspirin, heparin, and warfarin sodium.

Herbal medications may also increase bleeding time or mask potential blood-related problems


B-

Pre-Operative Phase

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Cortisone and steroid use

This predisposes client to infection


C-

Pre-Operative Phase

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Diabetes mellitus, a condition that not only requires strict control of blood glucose levels but also known to delay wound healing


D-

Pre-Operative Phase

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Emboli; previous embolic events ( such as lower leg blood clots) may recur because of prolonged immobility


E-

Pre-Operative Phase

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D.) INSTRUCTIONAL AND PREVENTIVE ASPECTS Assess the client’s level of

understanding of surgical procedure and its implications

Answer questions, clarify and reinforce explanations given by surgeon

Explain routine pre and post procedures and any special equipment to be used

Deep breathing exercises: use of diaphragmatic and abdominal breathing

Pre-Operative Phase

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D.) INSTRUCTIONAL AND PREVENTIVE ASPECTSCoughing exercise: deep breath,

exhale through the mouth, and then follow with a short breath while coughing; splint thoracic and abdominal incision to minimize pain

Turning exercise: every 1-2 hours post-operative

Assure that pain medications will be available post-op

Pre-Operative Phase

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D.) INSTRUCTIONAL AND PREVENTIVE ASPECTSExtremity exercise: prevents circulatory

problems and post operative gas pains or flatus

Pre-Operative Phase

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E.) PHYSICAL PREPARATION

1. Preparing the client’s skin: shave against the grain of the hair shaft to ensure clean and close shave

On the night of the surgery

Pre-Operative Phase

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2. Preparing the GIT:- NPO after midnight

- Note: the age of the client should be taken in to consideration

- Infants and children has a higher metabolic rate than adult

- This makes it essential for the child or infant to receive CHO regularly to prevent acidosis from occurring


Pre-Operative Phase

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3. Administration of enema4. Insertion of gastric or intestinal tubes


Pre-Operative Phase

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5. Preparing for Anesthesia Promoting rest and sleep: use of drugs

- Barbiturates: Secobarbital Na (Seconal), Pentobarbital Na (Nembutal)

- Non barbiturates: chloral hydrate, Flurazepam (Dalmane)

- Note: given after all pre-op treatments have been completed.

- If a second barbiturate is needed, it must be given at least 4 hours before the pre-op medications are due


Pre-Operative Phase

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1. Vital signs taken and recorded promptly

2. Provide oral hygiene3. Remove jewelries and dentures4. Remove nail polish5. Make sure that the patient has

not taken food for the last 10 hours by asking the client

On the day of the surgery * Early morning care: about 1 hour before the pre-operative medication schedule

Pre-Operative Phase

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PRE-OPERATIVE MEDICATIONSGenerally administered 60-90 min before

induction of anesthesia


Purpose: To allay anxiety: the primary reason for

pre-operative medications To decrease the flow of pharyngeal

secretions To reduce the amount of anesthesia to be

given To create amnesia for the events that

precedes surgery

On the day of the surgery

Pre-Operative Phase

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PRE-OPERATIVE MEDICATIONS


Types of Pre-Operative Medications:1) Sedative:

a) Given to decrease the client’s anxiety to lower BP and pulse

b) Reduce the amount of general anesthesia: an overdose can result to respiratory depression

Ex: Phenobarbital (Seconal Na, Nembutal Na)


Pre-Operative Phase

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Types of Pre-Operative Medications:

2) Tranquilizer- lowers the client’s anxiety level (ataractic)- Ex: Thorazine 12.5 - 25 mg IM 1-2 hours prior to surgery

Phenergan 12.5 - 25 mg IM 1-2 hours prior to surgery

* Note: can cause a dangerous hypotension, both during and after surgery


Pre-Operative Phase

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3) Narcotic analgesia- given to reduce patients to reduce anxiety and to reduce the amount of narcotics given during surgery

- Ex: Morphine sulfate 8-15 mg SC 1 hour prior to preoperative

* Can cause vomiting, respiratory depression and postural hypotension


Pre-Operative Phase

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4) Vagolytic or drying agents- to reduce the amount of tracheobronchial secretions which can clog the pulmonary tree and result in atelectasis and pneumonia

- Ex: Atropine sulfate 0.3-0.6 mg IM 45 min before surgery

* An overdose can result to severe tachycardia


Pre-Operative Phase

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Recording: all final preparation and emotional response before surgery should

be noted down

Transportation to the OR

Woolen or synthetic blankets must never be sent to the OR because they

are source of static electricity

Begins when the client is transferred

to the operating table and ends when the client is admitted

to the post-anesthesia unit

-Gowns-Gloves-Masks-Hair covering-Protective eyewear

Surgical Attire

• Scrub Nurse• Circulating Nurse• Registered Nurse First Assistant (RNFA)

• Perioperative Educator• OR Manager/Director

Intra Operative NursingA. ROLES OF PERIOPERATIVE NURSES

Scrub Nurse


• Responsible for scrubbing for surgery, including setting up sterile tables and equipment and assisting the surgeon and surgical technicians during the surgical procedure

• Gathering all equipment for the procedure

Scrub Nurse


• Preparing all supplies and instruments using sterile technique

• Maintaining sterility within the sterile field during surgery

• Handling instruments and supplies during surgery

Scrub Nurse


• During the surgery, the scrub nurse maintains an accurate count of sponges, sharps, and instruments on the sterile field and counts the same materials with the circulating nurse before and after the surgery

• Cleaning up after the case

Circulating Nurse


• Manages the individual operating

room and care of the patient in the OR• Creates and maintains comfortable, safe environment• Helps all team members work

together

Circulating Nurse


• Works in the OR in the area

outside the sterile field•Ensuring all equipment is working properly

•Guaranteeing sterility of instruments and supplies

Circulating Nurse


• Assisting with positioning

• Performing with the surgical skin preparation

Circulating Nurse


• Works in the OR in the area

outside the sterile field•Ensuring all equipment is working properly

•Guaranteeing sterility of instruments and supplies

Circulating Nurse


• Monitoring the room and team members for breaks in sterile technique

•Assisting anesthesia personnel with induction and physiologic monitoring

Circulating Nurse


•Handling specimens•Documenting care provided

RN First Assistant


• Directly assists surgeon

• Controls patient’s bleeding

• Provides wound exposure

and suturing• Using instruments to hold

and cut

RN First Assistant


• Retracting and handling the tissue

• Involved in care before,

during, and after surgery

Perioperative Educator


• Responsible in giving health teachings to the client who will undergo and already undergone surgical operation

OR Manager / Director


• Makes preoperative assessment and documents the intra-operative client care plan

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

Intra Operative NursingINTERVENTIONS :

1. A sensor-controlled or knee- or foot-operated faucet allows the water to be turned on and off without the use of the hands

Intra Operative NursingB. SURGICAL SCRUB

2) Remove all rings and watches

3) Use liquid soaps to prevent the spread of organisms


4) Hold the hands higher than the elbows throughout the handwashing procedure so that run-off goes to the elbows - Allows the cleanest part

of the arms to be the hands


5) A scrub brush facilitates the removal of microorganisms - Clean all areas of skin on the hands and arms in sequence starting at the hands and ending at the elbows


6) After rinsing, dry the hands with paper towels, drying first one arm from the hand to the elbow, then using a second towel to dry the second hand


6) After rinsing, dry the hands with paper towels, drying first one arm from the hand to the elbow, then using a second towel to dry the second hand


1. Sterile Technique

Intra Operative NursingC. PRINCIPLES OF STERILE TECHNIQUE

The patient is the center of the sterile field, which includes the:-areas of the patient-the operating table-furniture covered with sterile drapes-the personnel wearing the OR attire

1. Sterile Technique


Strict adherence to sound principles of sterile technique and recommended practices is mandatory for the safety of the patient. This adherence reflects one’s surgical conscience

2. Application


Preparation for operation by sterilization of necessary materials and supplies

Preparation of the operating team to handle sterile supplies and intimately contact wound

2. Application


Creation and maintenance of the sterile field, including the preparation and draping of the patient, to prevent contamination of the surgical wound

Maintenance of sterility and asepsis throughout the operative procedure

2. Application


Terminal sterilization and disinfection at the conclusion of the operation

Intra Operative NursingC. PRINCIPLES OF STERILE TECHNIQUE1.Sterile persons have scrubbed and

are gowned and gloved; Unsterile persons have not. Persons who are sterile touch only sterile articles. Persons who are not sterile touch only unsterile articles.- All supplies for the sterile team

members reach them by means of the circulating nurse, through the medium of sterile forceps or wrappers on sterile packages.

Intra Operative NursingC. PRINCIPLES OF STERILE TECHNIQUE2. Only sterile items are used

within the sterile field.

- Some items such as linen, sponges, or basins may be obtained from the stock supply of sterile packages. Others, such as instruments, may be sterilized immediately preceding the operation and removed directly from the sterilizer to the sterile table.


within the sterile field.

- Every person who dispenses a sterile article must be sure of its sterility and of its remaining sterile until used. Proper packaging, sterilizing, and handling should provide such assurance.


within the sterile field. - If you are in doubt about the sterility of anything, consider it not sterile. Known or potentially contaminated items must not be transferred to the sterile field, for example:

1. If sterile package is found in the nonsterile workroom

2. If uncertain about actual timing or operation of sterilizer: Items processed in a suspect load are considered unsterile.


within the sterile field. - If you are in doubt about the sterility of anything, consider it not sterile. Known or potentially contaminated items must not be transferred to the sterile field, for example:3. If unsterile person comes into

close contact with a sterile table and vice-versa

4. If sterile package falls to the floor, it must then be discarded.


within the sterile field. - If you are in doubt about the sterility of anything, consider it not sterile. Known or potentially contaminated items must not be transferred to the sterile field, for example:

5. If sterile table or unwrapped sterile items are not under constant observation; if a sterile table or sterile articles are left unguarded and uncovered for more than 30 minutes

Intra Operative NursingC. PRINCIPLES OF STERILE TECHNIQUE3. Gowns are considered sterile

only from the waist to shoulder level in front, and the sleeves. - Sterile persons keep hands in sight

and at or above waist level- Hands are kept away from the face.

Elbows are kept close to sides. Hands are never folded under arms because of perspiration in the axillary region


only from the waist to shoulder level in front, and the sleeves. - Changing table levels is avoided. If

sterile person must stand on a platform to reach the operative field, the area of the gown below waist must not brush against sterile tables or draped areas


only from the waist to shoulder level in front, and the sleeves. - Items dropped below waist level

are considered unsterile and must be discarded.Example: when picking up a gown, if the top of the gown drops below waist level, it is discarded

Intra Operative NursingC. PRINCIPLES OF STERILE TECHNIQUE4. Tables are sterile only at

table level- Only the top of a sterile draped

table is considered sterile. Edges and sides of drape extending below the table level are considered unsterile

- Anything falling over or extending over table edge, such as sutures are considered unsterile and are discarded. Scrub nurse does not touch the part hanging below table level

Intra Operative NursingC. PRINCIPLES OF STERILE TECHNIQUE4. Tables are sterile only at

table level- In unfolding sterile drape, the

part that drops below table surface is not brought back up to table level

Intra Operative NursingC. PRINCIPLES OF STERILE TECHNIQUE5. Persons who are sterile

touch only sterile items or areas. Persons who are not sterile touch only unsterile items or areas- Sterile team members

maintain contact with sterile field by means of gowns and gloves.


touch only sterile items or areas. Persons who are not sterile touch only unsterile items or areas- Nonsterile circulating nurse

does not directly come into contact with the sterile field


touch only sterile items or areas. Persons who are not sterile touch only unsterile items or areas- Supplies for sterile team

members reach them by means of the circulating nurse who opens wrapper on sterile packages

Intra Operative NursingC. PRINCIPLES OF STERILE TECHNIQUE6. Unsterile persons avoid

reaching over a sterile field. Sterile persons avoid leaning over an unsterile area- The scrub nurse sets basin or

glasses to be filled at the edge of the sterile table. The circulating nurse stands near the edge of the table to fill them


reaching over a sterile field. Sterile persons avoid leaning over an unsterile area- The circulating nurse

stands at a distance from the sterile field to adjust the light over it


reaching over a sterile field. Sterile persons avoid leaning over an unsterile area- The surgeon turns away

from the sterile field to have perspiration mopped from his brow


reaching over a sterile field. Sterile persons avoid leaning over an unsterile area- The sterile nurse drapes a

nonsterile table toward self first to protect gown


reaching over a sterile field. Sterile persons avoid leaning over an unsterile area- The circulating nurse, using

sterile forceps, drapes a table away from her first

Intra Operative NursingC. PRINCIPLES OF STERILE TECHNIQUE7. Edges of anything that

encloses sterile contents are considered unsterile.Ex: the edges of wrappers on sterile packages, caps on solution bottles and test tube covers- Sterile persons lift contents

from packages by reaching down and lifting them straight up, holding elbows high


encloses sterile contents are considered unsterile.Ex: the edges of wrappers on sterile packages, caps on solution bottles and test tube covers- Steam reaches only the area

within the gasket of a sterilizer. Instrument trays should not touch the edge of the sterilizer outside the gasket


encloses sterile contents are considered unsterile.Ex: the edges of wrappers on sterile packages, caps on solution bottles and test tube covers- The circulating nurse peels

the cover of a solution bottle or test tube, the edge of the cover never touches the lip


encloses sterile contents are considered unsterile.Ex: the edges of wrappers on sterile packages, caps on solution bottles and test tube covers- If the instruments are

boiled, the tray must not touch the edge of the sterilizer when lifting it out

Intra Operative NursingC. PRINCIPLES OF STERILE TECHNIQUE8. Sterile field is created as

close as possible to time of use

“ Degree of contamination is

proportionate to length of time sterile items are uncovered and exposed

to the environment.”

Intra Operative NursingC. PRINCIPLES OF STERILE TECHNIQUE8. Sterile field is created as

close as possible to time of use-Sterile tables are set up just prior to the operation.

- It is difficult to uncover a table of sterile contents without contamination. Covering sterile tables for later use is not recommended

Intra Operative NursingC. PRINCIPLES OF STERILE TECHNIQUE9. Sterile areas are

continuously kept in view

- Sterile persons face sterile areas.

- When sterile packs are opened in a room, or a sterile field is set up, someone must remain in the room.

Intra Operative NursingC. PRINCIPLES OF STERILE TECHNIQUE10. Sterile persons keep

well within the sterile area

- Sterile persons stand back at a safe distance from the operating table when draping the patient.

- Sterile persons pass each other back to back.


well within the sterile area

- Sterile person turns back to nonsterile person or area when passing.

- Sterile person faces sterile area to pass it.

- Sterile person asks nonsterile individual to step aside rather than risk contamination


well within the sterile area- Sterile persons stay within and

around a sterile field. They do not walk around or go outside the room.

- Movement within and around a sterile area is kept to a minimum to avoid contamination of sterile items or persons


contact with sterile areas to a minimum- Sterile persons do not lean on

sterile tables and on the draped patient.

- Sitting or leaning against a nonsterile surface is a break in technique. If the sterile team sits to operate, they do so without proximity to nonsterile areas


sterile areas.- Unsterile persons

maintain at least one foot distance from any area of the sterile field.

- Unsterile persons face and observe a sterile area when passing it to be sure they do not touch it


sterile areas.- Unsterile persons never

walk between two sterile areas, eg, between sterile instrument tables.

- Circulating nurse restricts to a minimum activity near sterile field

Intra Operative NursingC. PRINCIPLES OF STERILE TECHNIQUE13. Destruction of the

integrity of microbial barriers results in contamination- Unsterile persons never

walk between two sterile areas, eg, between sterile instrument tables.

- Circulating nurse restricts to a minimum activity near sterile field

Intra Operative NursingC. PRINCIPLES OF STERILE TECHNIQUE13. Destruction of the integrity

of microbial barriers results in contamination

The integrity of a sterile package or sterile drape is destroyed by

perforation, puncture or strike-through (soaking of moisture

through unsterile layers to sterile layers or vice versa- may

transport bacteria to sterile area). To ensure sterility:



- Sterile packages are laid on dry surfaces.

- If sterile packages become damp or wet, it is re-sterilized or discarded. A package is considered nonsterile if any of it comes in contact with moisture.



- Drapes are placed on a dry field

- If solution soaks through sterile drape to nonsterile area, the wet area is covered with impervious sterile drape or towels



- Packages wrapped in muslin or paper are permitted to cool after removal from the sterilizer to avoid steam condensation and resultant contamination

- Sterile areas are stored in clean dry areas



-Sterile packages are handled with clean dry hands

-Undue pressure on sterile pack is avoided to prevent forcing sterile air out and pulling unsterile air into the pack

Intra Operative NursingC. PRINCIPLES OF STERILE TECHNIQUE14. Microorganisms must be

kept to an irreducible minimumPerfect asepsis in the operative field is the ideal.

Although all the microorganisms cannot be eliminated, this does not obviate the necessity for sterile technique. It is generally agreed that:


a. Skin cannot be sterilized- Skin is a potential source of contamination in every operation.

- All possible means are used to prevent entrance of microorganisms into wound

14. Microorganisms must be kept to an irreducible minimum


b. Some areas cannot be scrubbed

When the operative field includes the mouth, nose, throat or anus, the number of microorganisms is great. Various parts of the body, such as the GIT and the vagina, usually are resistant to infection from flora that normally inhabit these parts



c. Infected areas are grossly contaminated- The team avoids

spreading the contamination



d. Air is contaminated by dust and droplets.


Intra Operative NursingD. ANESTHESIA

a. Minimal sedation - drug induced state in

which a patient can respond normally in verbal commands cognitive function and coordination may be impaired

1. Levels of Anesthesia (Sedation)


b. 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



c. Deep Sedation - deep sedation is a drug

induced state in which a patient cannot easily be aroused but can respond purposefully after repeated stimulation.

- inhaled or intravenously- Volatile anesthetic (halothane,

Isoflurane)- Gas anesthetic (Nitrous oxide)


Intra Operative NursingD. ANESTHESIA2. Stages of Anesthesia

Stage Start-point

End-point Physical reactions

Nursing intervent

ion

I. Onset

Anestheticadministration

Loss ofConsciousness

Client maybe drowsy, or dizzyPossible auditory andvisual hallucination

Close operating room doors, keep room quietStand by to assist the client


Stage Start-point

End-point

Physical reaction

s

Nursing interventi

on

II. Excitement

Loss of consciousness

Loss of eyelid reflexes

Increase in autonomic activityIrregular breathingClient may struggle

Remain quietly at client’s sideAssist anesthetist, as needed

Intra Operative NursingD. ANESTHESIA2. Stages of AnesthesiaStage Start-

pointEnd-point

Physical

reactions

Nursing interventio

n

III. Surgical anesthesia

Loss of eyelid reflexes

Loss of most reflexesDepression of vital functions

Client is unconsciousMuscles are relaxedNo blink or gag reflexes

Begin preparation ( if indicated) only when anesthesia indicates stage III has been reached and client is breathing well, with stable vital signs


Stage Start-point

End-point

Physical

reactions

Nursing intervention

IV. Danger (death)

Functions excessivelydepressed

Respiratory and circulatory failure

Client is not breathingA heartbeat may or may not be present

If arrest occurs, respond immediately to assist in establishing airway, provide cardiac arrest tray, drugs syringes, long needlesAssist surgeon with closed or open cardiac massage


Stage Start-point

End-point

Physical

reactions

Nursing intervention

IV. Danger (death)

Functions excessivelydepressed

Respiratory and circulatory failure

Client is not breathingA heartbeat may or may not be present

If arrest occurs, respond immediately to assist in establishing airway, provide cardiac arrest tray, drugs syringes, long needlesAssist surgeon with closed or open cardiac massage

Intra Operative NursingD. ANESTHESIA3. Types of Anesthesia

- A state of analgesia, amnesia, and unconsciousness characterized by the loss of reflexes and muscle tone

- Administered by using a combination of agents based on the client's need with consideration of the type of surgery to be performed

a. General Anesthesia

Intra Operative Nursing

D. ANESTHESIA

1. Types of GA Administration

G A: INTRAVENOUS ADMINISTRATION Usually employed as an

induction prior to administration of the more potent inhalation anesthetic agents.

Used commonly in minor procedure

Dental extraction Unconsciousness

generally occurs 30 seconds after administration

Rapid and smooth transition from conscious stage to surgical anesthesia stage

G A: INTRAVENOUS ADMINISTRATIONAdvantage of IV Anesthesia:

1.Rapid pleasant induction

2.Absence of explosive hazards

3.Low incidence of nausea and vomiting

G A: INTRAVENOUS ADMINISTRATIONDisadvantage of IV Anesthesia:

1. Laryngeal spasm and bronchospasm

2. Hypotension3. Respiratory arrest

Examples:

Thiopental Na (Pentothal Na)

Ketamine (Ketalar)Fentanyl (Innovar)

G A: INHALATION ADMINISTRATION A mixture of volatile

liquids or gas and O2 is used

Usually used to maintain the client in stage III anesthesia following induction

The mixture is given through a mask or through an endotracheal tube which is inserted once the client is paralyzed and unconscious

O2 tank: green color CO2 tank: gray color

G A: INHALATION ADMINISTRATION

Administration by a mask:

The gases flow into the mask via a finely calibrated vaporizer that is controlled by a machine


Administration by ETT:

The gases flow directly into the client’s tracheobronchial tree, resulting in a quick response


Advantage: Ease of

administration and elimination through the respiratory system

Rapid onset Prevention of pain

and anxiety


Disadvantage:circulatory and respiratory depression

* Highly flammable and explosive


Two commonly used Inhalation Anesthetics:

- Halothane- Isoflurane

Commonly used Gas Anesthetic:- Nitrous oxide (Blue tank)

POST GA EFFECT• Headache

• vision problems, including blurred

• or double vision • shivering or trembling • muscle pain • dizziness,

lightheadedness, or faintness

• drowsiness • mood or mental

changes • nausea or vomiting • sore throat • nightmares or unusual

dreams

Intra Operative NursingD. ANESTHESIA3. Types of Anesthesia

It is the injection or application of a local anesthetic agent to produce a loss of painful sensation in only one region of the body

Does not result to unconsciousness

Blocks the conduction of impulses in the nerve fibers without depolarizing the cell membrane

b. Regional Anesthesia

Intra Operative Nursing

D. ANESTHESIA

Types of Regional Anesthesia

R A: SPINAL ADMINISTRATIONOften the anesthetic

technique of choice of older adults

Can be used for almost any type of major procedure performed below the level of the diaphragm

Cholecystectomy

Appendectomy

R A: SPINAL ADMINISTRATION

Spinal Anesthesia is achieved by injecting local anesthetics into the subarachnoid space

Position of client: genu-pectal or knee-chest position

Level of anesthesia: Intervertebral space between

L2 and L3 L3 and L4 Autonomic nerve fibers

are affected first and also the last to recover

COMPLICATIONSOF SA: Hypotension Paralysis of

vasomotor nerves, occurring shortly after induction of anesthesia

Rapid IVF administration before the block

Administer O2 by inhalation

Trendelenburg position 10-20 min after induction

Vasoactive drugs: Ephedrine

COMPLICATIONSOF SA:Nausea and vomiting- Occurs mainly from abdominal surgery because of traction placed on various structures within the abdomen or from hypotension

- Drugs used: antiemetics

COMPLICATIONSOF SA:Headache

- Can be extremely painful and may last a week

- CSF, which cushions the brain, is lost through dural hole

- Leakage of fluid with loss of cushioning effect is increased by:

Use of large spinal needlePoor hydration

- Keep client flat 6-8 hours postoperatively

COMPLICATIONSOF SA:Respiratory paralysis

- Occurs when drug reaches upper thoracic or cervical spinal levels in large amounts or in heavy concentrations

- Do artificial respiration

- Avoid extreme T-position after induction

COMPLICATIONSOF SA:Neurologic complications:- Paraplegia- Severe muscle

weakness in legs- Postoperative

paralysis may be due to:

Unsterile needles, syringes and anesthetic agent

Pre-existing diseases of the CNS

Transient response to anesthetics

Position during surgery

ADVANTAGES OFSA: Relatively safe Excellent lower-

body muscle relaxant

Absence of effect on consciousness

Doe not require empty stomach

R A: EPIDURAL ADMINISTRATIONIntroduction of anesthetic

agent into the epidural space

The needle is carefully positioned in the epidural space without penetrating the dura and without entering the subarachnoid space

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R A: EPIDURAL ADMINISTRATIONEpidural block produces a

blockade of the autonomic nerves and can result to hypotension

If the level of block is too high and respiratory muscles are affected, respiratory depression or paralysis may occur

The epidural space is generally entered by a needle at a thoracic, lumbar, sacral, or caudal interspace

R A: CAUDAL ADMINISTRATION A variation of epidural

anesthesia Produced by injection of

the local anesthetic into the caudal or sacral canal

This method is commonly used with obstetric clients

R A: TOPICAL ADMINISTRATION Application of the agent

directly to the skin, mucous membranes, or open surface to be desensitized

The anesthetic may be a solution, an ointment, a gel, a cream, or a powder

R A: TOPICAL ADMINISTRATION A short-acting form of

anesthesia can block peripheral nerve endings in the mucous membranes of the vagina, rectum, nasopharynx, and mouth

Used in minor procedures: rectal examination with painful hemorrhoids, and bronchoscopy

R A: TOPICAL ADMINISTRATIONCommonly used topical

anesthesia: Solution of 4-10% cocaine

- For topical used only primarily to anesthetize the eye and the mucous membrane of nose, mouth, and urethra

- Highly toxic agent

R A: TOPICAL ADMINISTRATIONOther topical anesthetic agents:

- Tetracaine- Procaine- Mepivacaine- Lidocaine (Xylocaine)

R A: LOCAL INFILTRATION ADMINISTRATION

Involves the injection of an anesthetic agent into the skin and subcutaneous tissue of the area to be anesthesized

Blocks the peripheral nerves around the area of the incision

During administration of the agent, aspiration should be done to ensure that the needle is not in the blood vessel

Inadvertent intravenous injection of the agent can result to cardiovascular collapse or convulsions

R A: FIELD BLOCK ADMINISTRATION

The area proximal to a planned incision can be injected and infiltrated with local anesthetic agents to produce field block.

The block forms a barrier between the incision and the nervous system

A field block actually walls in the area around the incision and prevent transmission of sensory impulses to the brain from that area

R A: PERIPHERAL NERVE BLOCK ADMINISTRATION Anesthetizes individual nerves

or nerve plexusesExamples:

- Digital nerve block: fingers- Brachial plexus nerve block:

entire upper arm- Intercostal nerve block:

chest or abdominal wall

R A: PERIPHERAL NERVE BLOCK ADMINISTRATION

Injection of anesthetic agents along the nerve rather done into the nerve in an effort to decrease the risk of nerve damageAgents commonly used: lidocaine, bupivacaine, and Mepivacaine

Epinephrine-containing agents are not used for surgery involving the extremities, like below the wrist and ankle, because of vasoconstriction

R A: REGIONAL EXTREMITY BLOCK ADMINISTRATION (BIER BLOCK)Regional anesthesia of a limb

can be achieved with an agent when it is injected into a vein of the limb to be anesthetized

A pneumatic dual-cuff tourniquet applied to the anesthetized area prevents the lidocaine from circulating beyond the area undergoing the procedure

R A: REGIONAL EXTREMITY BLOCK ADMINISTRATION (BIER BLOCK)

This type of anesthesia is used most commonly for procedures of the extremities that are of short durationAgent used: lidocaine

POSITIONS FOR

SURGERY

Supine/ Dorsal – usual position for induction of general anesthesia and for entering the major body cavities Modified Trendelenburg – used for lower abdominal surgery and some lower extremity surgeryReverse Modified Trendelenburg – used for upper abdominal, neck and face surgeryLithotomy – used in operation requiring perineal approach Prone – used in surgery on the posterior part of the bodyLateral – used for operation on the kidneys, lungs or hips Modified Fowler’s – sitting position; used mostly in neurosurgeryModified jacknife – for rectal surgery

Positions for Surgery

Position Patient during SurgeryAbdominal surgeries

Supine

Bladder surgery Slightly trendelenburg

Perineal surgery Lithotomy

Brain surgery Semi-fowler’s

Spinal cord surgeries

Prone mostly

Lumbar puncture

Side lying, flexed body

Abdominal Surgical IncisionParamedian vertical incision

( rarely used – intestinal problems)

Longitudinal Midline

( middle laparotomy) begins at the level of the xiphoid to the supra pubic region ( for gastrectomy & intestinal resection)

Right Subcostal (Kochers)

from epigastric area and extends laterally & obliquely below the lower margin – biliary, spleen and liver

Abdominal Surgical IncisionBilateral subcostal –Mercedes Benz or Chevron incision

liver transplant

Mc Burney for appendectomy

Rocky Davis for appendectomy

Pfannenstiel pelvic procedures, hysterectomy or CS

Inguinal inguinal herniorrhaphy

A. ABDOMINAL SURGERY1. Abdominal Laparotomy2. Herniorrhaphy3. Cholecystectomy4. Pancreaticoduodenectomy (Whipple’s)5. Pancreatectomy6. Splenectomy7. Bariatric Surgery

Different Surgeries According to Location

B. BREAST SURGERY1. Mastectomy2. Breast Biopsy3. Mammoplasty4. Breast

Augmentation,Breast Repair, Breast Lifting


D. GENITOURINARY SURGERY

1. Circumcision2. Vasectomy3. Orchiectomy4. Cystectomy5. Transurethral Resection of the Prostate/Bladder (TURP/TURB)

6. Nephrectomy7. Ureterolithotomy8. Pyelolithotomy


OK ARE YOU READY SIR FOR

YOUR OPERATION?

Begins with the admission of the

client to the PACU and ends when healing is

complete

Post- Operative Phase

Home

OT

PACU

Ward

• Responsible for caring for the client until the client:

- Has recovered from the effects of anesthesia

- Is oriented

- Has stable vital signs

- Shows no evidence of hemorrhage

PACU Nurse

POSTANESTHESIA CARE UNIT

DesignEquipmentStaffing

Design- Located near the operating roomsProximity to radiographic, laboratory, and other intensive care facilities on the same floor - Open ward design Each patient space should be well lighted Multiple electrical outlets and at least one outlet for oxygen, air, and suction


Equipment

1. Pulse oximetry (SpO2)2. Electrocardiogram (ECG)3. Automated noninvasive

blood pressure (NIBP) monitors

4. Capnography5. Temperature6. Air warming device, heating

lamps, and warming/cooling blanket


Emergency Equipment

1. Oxygen cannulas2. Masks 3. Oral and nasal airways4. Laryngoscopes , ndotracheal tubes,

laryngeal mask airways, and self-inflating bags for ventilation

5. Defibrillation device6. Tracheostomy, chest tube, and

vascular cutdown trays


Respiratory therapy equipment

1.Continuous positive airway pressure (CPAP)

2.Ventilators 3.Bronchoscope


Staffing- Nurses specifically trained in the

care of patients emerging from anesthesia

- PACU should be under the medical direction of an anesthesiologist

- One nurse to one patient is often needed

- A charge nurse should be assigned to ensure optimal staffing at all times


Home

OT

PACU

Ward

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TRANSPORT FROM THE OPERATING ROOM

This period is usually complicated by the lack of adequate monitors,

access to drugs, or resuscitative equipment

CARE OF THE PATIENT

Patients should not leave the operating room unless they have a stable and

patent airway, have adequate ventilation and oxygenation, and are

hemodynamically stable

TRANSPORT FROM THE OPERATING ROOM

All patients should be taken to the PACU on a bed or trolley that can be placed in either:

Head down (Trendelenburg) hypovolemic

patientsHead-up position pulmonary dysfunctionlateral position prevent airway obstruction

and facilitates drainage of secretions .

CARE OF THE PATIENT

A) Post Anesthetic CareNursing responsibilities:

1) Maintenance of Pulmonary Ventilation:

Position the client to side lying or semi-prone position to prevent aspiration

Post-Operative Phase

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Oropharyngeal or nasopharyngeal airway:

Is left in place following administration of general anesthetic until pharyngeal reflexes have returned

It is only removed as soon as the client begins to awaken and has regained the cough and swallowing reflexes


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All clients should received O2 at least until they are conscious and are able to take deep breaths on command

Shivering of the client must be avoided to prevent an increase in O2, and should be administered until shivering has ceased


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2) Maintenance of Circulation:Most common cardiovascular complications:a) Hypotension

Causes: Jarring the client during transport while moving client from the OR to his bed

Reaction to drug and anesthesia


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Causes: Loss of blood and other

body fluidsCardiac arrhythmias and

cardiac failureInadequate ventilationPain

C. Post-Operative Phase

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b) Cardiac arrhythmiasCauses:

HypoxemiaHypercapnea

Interventions:O2 therapyDrug administration:

LidocaineProcainamide (Pronestyl)


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3) Protection from injury and promotion of comfort

Provide side rails Turning frequently and placed in

good body alignment to prevent nerve damage from pressure

Administration of narcotic analgesics to relieve incisional pain


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B) Dismissal of client from recovery room: Modified Aldrete Score for Anesthesia Recovery Criteria

The Five Physiological Parameters:

1. Activity 2. Respiration3. Circulation 4. Consciousness5. Color


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Post Anesthesia Care UnitMODIFIED ALDRETE SCORE

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After

Area of assessment Point Score

1 hour

2 hours

3 hours

Muscle activity:Moves spontaneously or on command Ability to move all extremities Ability to move 2 extremities Unable to control any extremity

2

1

0

Respiration: Ability to breath deeply and cough Limited respiratory effort (dyspnea and splinting) No spontaneous effort

2

1

0

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After


1 hour 2 hours 3 hours

Circulation: BP +/- 20% of pre-anesthetic level BP +/- 20%-40% of pre-anesthetic level BP +/- 50% pre-anesthetic level

2

1

0

Consciousness Level: Fully awake Arousable on calling Not responding

2

1

0


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After


1 hour

2 hours

3 hours

O2 Saturation: Unable to maintain O2 sat >92% on room air Needs O2 inhalation to maintain O2 sat >90% O2 sat <90% even with O2 supplement

Total Points

2

1

0

Required for discharge from PACU: 7-8


ROUTINE RECOVERY

a) Airway patency, vital signs, and oxygenation should be checked immediately on arrival

b) Blood pressure, pulse rate, and respiratory rate measurements are routinely made at least every 5 min for 15 min or until stable, and every 15 min thereafter

c) Pulse oximetry should be monitored continuously

d) Neuromuscular function should be assessed clinically

e) At least one temperature measurement

f) Pain assessment

g) Presence or absence of nausea or vomiting

CARE OF THE PATIENT

Home

OT

PACU

Ward

PAIN MANAGEMENT

Pain is usually greatest during the 12-36 hours after surgeryNarcotic analgesics and NSAIDS may be prescribed together for the early period of surgeryProvide 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


Deep 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 interventions Hydration 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

Liquid Diet VS Soft dietClear liquid Full liquid Soft dietCoffeeTeaCarbonated drinkBouillonClear fruit juicePopsicleGelatinHard candy

Clear liquid PLUS:Milk/Milk prodVegetable juicesCream, butterYogurtPuddingsCustardIce cream and sherbet

All CL and FL plus:MeatVegetablesFruitsBreads and cerealsPureed foods

Chest PhysiotherapyChest 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 SEQUENCE is as follows- POSITIONING, Percussion, Vibration, and removal of

secretions by SUCTIONING or Coughing followed lastly by oral

hygiene

Chest Physiotherapy

Chest Physiotherapy

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

Incentive Spirometry

Incentive Spirometry

Post operative complications Atelectasis

Pneumonia

Collapsed alveoli due to secretions

Inflammation of alveoli

Assess breath sounds

RepositioningDeep breathing

and coughingChest physioSuctioning Ambulation

Thrombophlebitis Inflammation of the veins

Leg exercises Monitor for

swellingElevated

extremities

ATELECTASIS

PNEUMONIA

DEEP VENOUS THROMBOSIS

*HOMAN’S SIGN

EMBOLUS: MIGRATION OF A CLOT

Post-operative ComplicationsHypovolemic Shock

Loss of circulatory fluid volume

Shock positionDetermine cause and

prevent bleedingO2, IVF

Urinary retention

Involuntary accumulation of urine

Encourage ambulationProvide privacyPour warm waterCatheterize

Pulmonary embolism

Embolus blocking the lung blood flow

Notify physicianAdminister O2w

HYPOVOLEMIC SHOCK

MODIFIED TRENDELENBURG

Post-operative complicationsConstipation Infrequent

passage of stool

High fiber dietIncreased fluidAmbulation

Paralytic ileus Absent bowel sound

Encourage ambulation

NPO until peristalsis returns

Wound infection

Occurs about 3 days after surgery

Daily wound dressing

AntibioticsMaintain drain

WOUND DISRUPTION

Post-operative complicationsWound dehiscence

Separation of wound edges at the suture line

Cover the wound with sterile normal saline dressing

Place in low-Fowler’s

Notify MD

Wound evisceration

Protrusion of the internal organs and tissues through wound

Cover the wound with saline pad

Place in low-fowler’s

Notify MD

Wound DEHISCENCE

Wound evisceration

INCISIONAL HERNIA

INCISIONAL HERNIA

Perioperative Care Discharge Plans

• Patient/Family Education and Psychosocial Support is throughout.– Return MD Visit– Dressing Care and Comfort– Optimum respiratory,circulatory function,

diet, meds(antibiotics, analgesic)– Adequate hydration and body

temperature– Adequate renal function, safety in ADL

DISCHARGE INSTRUCTIONS• CARE OF THE INCISION• SIGNS OF COMPLICATIONS• DRUGS FOR PAIN

MANAGEMENT• HOW TO SELF ADMINISTER

PRESCRIBED MEDICATIONS• ACTIVITY LEVEL• AMOUNT OF WEIGHT THAT

CAN BE LIFTED• DIET• RETURN FOR A MEDICAL

APPOINTMENT

Perioperative Nursing

Documents

surgery client

plastic surgery

day surgery

outpatient surgery ex

degree of u rgency

degree major

degree minor

urpose p r isk