Perioperative Nursing Definition of Surgery

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Perioperative Nursing Definition
of Surgery

• Surgery is any procedure performed on the human
  body that uses instruments to alter tissue or
  organ integrity.

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Perioperative Nursing

• Perioperative Nursing- connotes the delivery of
  patient care in the preoperative,intraoperative,
  and postoperative periods of the patients
  surgical experience through the framework of the
  nursing process. The nurse assesses the patient-
  collecting,organizing, and prioritizing patient
  data establishing nursing diagnosisidentifies
  desired patient outcomesdevelop and implements a
  plan of care and evaluates that care in terms of
  outcomes achieved by the patient.

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Perioperative Nursing Phases

• Preoperative phase begins when the decision to
  have surgery is made and ends when the client is
  transferred to the OR table.
• Intraoperative phase begins when the client is
  transferred to the OR table and ends when the
  client is admitted to the PACU.
• Postoperative phase - begins with the admission
  of the client to the PACU and ends when the
  healing is complete.

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Perioperative Nursing Types of
Surgery

• Purpose/reasons -
• Degree of urgency necessity to preserve the
  clients life, body part, or body function.
• Degree of risk involved in surgical procedure
  is affected by the clients age, general health,
  nutritional status, use of medications, and
  mental status.
• Extent of surgery Simple and radical

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Perioperative Nursing Type of
Surgery (Purpose)

• Diagnostic-Allows to confirm or establishes
  diagnosis.
• Corrective- Excision or removal of diseased body
  part.
• Reconstructive-Restore function or appearance to
  traumatized or malfunctioning tissues.
• Ablative Removes a diseased body parts
• Palliative Relieves or reduces pain or symptoms
  of a disease it does not cure
• Transplant Replaces malfunctioning structures
• Cosmetic- Performed to improve personal
  appearance.

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Perioperative Nursing Types of Surgery
(Urgency)

• Emergency- performed immediately to preserve
  function or the life of the client.
• Elective is performed when surgical
  intervention is the preferred treatment for a
  condition that is not imminently life threatening
  or to improve the clients life.
• Urgent Necessary for client health to prevent
  additional problem from developing not
  necessarily an emergency.
• Required has to be performed at some point can
  be pre-scheduled.

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Perioperative NursingType of Surgery
(Degree of Risk)

• Major involves a high degree of risk.
• Minor normally involves little risk.
• Age very young and elder clients are greater
  surgical risks than children and adult.
• General health- surgery is least risky when the
  clients general health is good.
• Nutritional Status required for normal tissue
  repair.
• Medications regular use of certain medications
  can increase surgical risk.
• Mental status disorder that affect cognitive
  function

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Perioperative Nursing Surgical
settings

• Surgical suites
• Ambulatory care setting
• Clinics
• Physician offices
• Community setting
• Homes

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Perioperative Nursing Surgical
settings

• Disadvantages Less time for
  rapport Less time to assess, evaluation,
  teach Risk of potential complication post D/C.
• Advantages of outpatient Low cost Low
  risk of infection Less interruption of
  routine Less than from work Less stress

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Preoperative Nursing
Consent

• Nature and intention of the surgery
• Name and qualifications of the person performing
  the surgery.
• Risks, including tissue damage, disfigurement, or
  even death
• Chances of success
• Possible alternative measures
• The right of the client to refuse consent or
  later withdraw consent.

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Preoperative Nursing Assessment
(Nursing History)

• Current health status-
• Allergies
• Medications- list all current medications
• Previous surgeries
• Understanding of the surgical procedure and
  anesthesia
• Smoking
• Alcohol and other-altering substances
• Coping
• Social resources
• Cultural considerations

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Preoperative Nursing Care Physical
assessment

• Cardiovascular system
• Respiratory system
• Renal system
• Neurological system
• Musculoskeletal system
• Nutritional status
• Gerontological considerations

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Perioperative Nursing CarePhysical
assessment/clinical manifestations

• General survey- gestures and body movements may
  reflect decreased energy or weakness caused by
  illness.
• Cardiovascular system- alterations in cardiac
  status are responsible for as many as 30 of
  perioperative death.
• Respiratory system- a decline in ventilatory
  function, assessed through breathing pattern and
  chest excursion, may indicate a clients risk for
  respiratory complications.

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Perioperative Nursing CarePhysical
assessment/clinical manifestations

• Renal system-abnormal renal function can altered
  fluid and electrolyte balance and decrease the
  excretion of preoperative medications and
  anesthetic agents.
• Neurologic system- a clients LOC will change as
  a result of general anesthesia but should return
  to the preoperative LOC after surgery.

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Perioperative Nursing CarePhysical
assessment/clinical manifestations

• Musculoskeletal system- Deformities may interfere
  with intraoperative and postoperative
  positioning. Avoid positioning over an area where
  the the skin shows signs of pressure over bony
  prominences.
• Gastrointestinal system- alteration in function
  after surgery may result in decreased or absent
  bowel sound and distention.
• Head and Neck- the condition of oral mucous
  membranes reveals the level of hydration.

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Preoperative Nursing Care
Gerontological Considerations

• Cardiovascular Coronary flow
  decreases Heart rate decreases Response to
  stress decreases Peripheral vascular
  decreases Cardiac output decreases Cardiac
  reserve decreases

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Preoperative Nursing Care Gerontological
Considerations

• Respiratory System
• Static lung volumes decreases
• Pulmonary static recoil decreases
• Sensitivity of the airway receptors decreases
• Nervous system
• Increased incidence of post.op. confusion.
• Increased incidence of delirium
• Increased sensitivity to anesthetic agents

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Preoperative Nursing Care Gerontological
Considerations

• Renal System Renal blood flow declines 1.5
  per year. Renal clearance reduced
• Gastrointestinal Decreased intestinal
  motility
• Decreased liver blood flow Delayed gastric
  emptying

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Preoperative Nursing Care Gerontological
Considerations

• Musculoskeletal Decreased mass, tone,
  strength Decreased bone density
• Integumentary Decreased elasticity Decreas
  ed lean body mass Decreased subcutaneous fat

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Preoperative Nursing Care Psychosocial
considerations

• Level of anxiety
• Coping ability
• Support systems

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Preoperative Nursing Care Laboratory
and diagnostic studies

• Screening tests depend on the condition of the
  client and the nature of the surgery. If test
  reveals severe problems the surgery may be cancel
  until the condition is stabilized.
• Routine screening test-CBC,Blood grouping and
  X-match, Lytes, fasting blood sugar, BUN
  Creatinine, ALT,AST, and bilirubin,Serum albumin,
  and Total protein, Urinalysis, Chest X-ray,ECG

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Preoperative Nursing Care Common nursing
diagnosis

• Knowledge deficit
• Anxiety
• Risk for ineffective airway clearance
• Fear related to
• Disturbed sleep pattern
• Anticipatory grieving related to

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Preoperative Nursing Care
Preop. teaching

• The education plan should begin with assessment,
  including baseline knowledge of the patient and
  family, readiness to learn,barriers to learning,
  patient and family concern and learning styles
  and preferences.
• The content focuses on information that will
  increase patients familiarity with procedural
  events. This includes surgical experience
  (procedural), what the pt. may experience
  (sensory) and what actions may help decrease
  anxiety (behavioral).

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Preoperative Nursing Care Anxiety

• The nurse must consider the pts family and
  friends when planning psychological support.
• Empowering their sense of control. Activities
  that decreasing anxiety are deep breathing,
  relaxation exercises, music therapy, massage and
  animal-assisted therapy.
• Use of medication to relieve anxiety.

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Preoperative Nursing CarePreanesthesia
Management Physical Status Categories

• ASA 1 Healthy patient with no disease
• ASA 11 Mild systemic ds without fx limitations
• ASA 111Severe systemic ds associated with
  definite fx limitations
• ASA 1V Severe systemic ds that is a constant
  threat to life.
• ASA V Moribund pt. Who is not expected to
  survive without the operation.
• ASA V1 A declared brain-death whose organ are
  being recovered for donor.
• E Emergency

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Preoperative Nursing CareFinal Preparation for
surgery

• All personal belongings are identified and
  secured.
• Jewelry is usually removed.
• Dentures are removed, labeled and placed in a
  denture cup.
• Pt. to verbally confirm the surgical procedures
  and the surgical site. This verification process
  is documented in the medical record on the preop.
  checklist.

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Preoperative Nursing Care Pre-op.
medications

• Prior to administering check permits
• Purpose Allay anxiety Decrease pharyngeal
  secretions- Decrease gastric
  secretion.
• Decrease side effects of anesthesia.
• Induce amnesia

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Preoperative Nursing Care Medications

• Sedatives/hypnotics- Nembutal
• Tranquilizers-Ativan, versed, valium
• Opiate analgesics- Demerol, morphine
• Anticholinergics-Atropine sulfate,atarax
• H2o blockers.- Tagamet, Zantac
• Antiemetic- Reglan, Phenergan

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Intraoperative Phase Surgical
Team

• Surgeon
• Anesthesiologist
• Scrub Nurse
• Circulating Nurse
• OR techs

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Intraoperative Nursing Care Roles of
team members

• Surgeon-responsible for determining the
  preoperative diagnosis, the choice and execution
  of the surgical procedure, the explanation of the
  risks and benefits, obtaining inform consent and
  the postoperative management of the patients
  care.
• Scrub nurse- (RN or Scrub tech)- preparation of
  supplies and equipment on the sterile field
  maintenance of pt.s safety and integrity
  observation of the scrubbed team for breaks in
  the sterile fields provision of appropriate
  sterile instrumentation, sutures, and supplies
  sharps count.

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Perioperative Nursing CareSurgical team

• Circulating Nurse - responsible for creating a
  safe environment, managing the activities outside
  the sterile field, providing nursing care to the
  patient. Documenting intraoperative nursing care
  and ensuring surgical specimens are identified
  and place in the right media. In charge of the
  instrument and sharps count and communicating
  relevant information to individual outside of the
  OR, such as family members.

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Perioperative Nursing CareSurgical team

• Anesthesiologist and anesthetist- anesthetizing
  the pt. providing appropriate levels of pain
  relief, monitoring the pts physiologic status
  and providing the best operative conditions for
  the surgeons.
• Other personnel- pathologist, radiologist,
  perfusionist, EVS personnel.

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Perioperative Nursing Care Surgical team

• Nursing Roles
• Staff education
• Client/family teaching
• Support and reassurance
• Advocacy
• Control of the environment
• Provision of resources
• Maintenance of asepsis
• Monitoring of physiologic and psychological status

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Intraoperative Nursing Care Surgical
asepsis

• Ensure sterility
• Alert for breaks

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Intraoperative Phase Anesthesia

• Greek word- anesthesis, meaning negative
  sensation. Artificially induced state of partial
  or total loss of sensation, occurring with or
  without consciousness.
• Blocks transmission of nerve impulses
• Suppress reflexes
• Promotes muscle relaxation
• Controlled level of unconsciousness

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Intraoperative Phase
Anesthesia

• Factors influencing dosage and type
• Type and duration of the procedure
• Area of the body being operated on
• Whether the procedure is an emergency
• Options of management of post. Op. pain
• How long it has been since the client ate, had
  any liquids, or any medications
• Client position for the surgical procedures
  

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Intraoperative Phase Types of
Anesthesia

• General- method use when the surgery requires
  that the patient be unconscious and/or paralyzed.
• A general anesthetic acts by blocking awareness
  centers in the brain so that amnesia (loss of
  memory), analgesia (insensibility to pain),
  hypnosis (artificial sleep), and relaxation
  (rendering a part of the body less tense) occur.

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Intraoperative Phase Stages of
General Anesthesia

• Stage 1- Analgesia and sedation, relaxation
• Stage 2- Excitement, delirium
• Stage 3- Operative anesthesia, surgical
  anesthesia
• Stage 4- Danger

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Intraoperative Phase

• Complications of General Anesthesia
• Overdose
• Hypoventilation
• Related to anesthetic agents
• Malignant hyperthermia
• Related to intubation

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Intraoperative Phase

• Local or Regional Anesthesia
• Temporarily interrupts the transmission of
  sensory nerve impulses from a specific area or
  region.
• Motor function may or may not be affected
• Client does not lose consciousness
• Gag reflex remains intact
• Supplemented with sedatives, opioids, or
  hypnotics

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Types of Regional Anesthesia

• Topical (surface)
• Local
• Nerve Block
• Intravenous (Bier Block)
• Spinal
• Epidural (peridural)

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Intraoperative Phase

• Complications of Local/Regional Anesthesia
• Anaphylaxis
• Administration technique
• Systemic absorption
• Overdosage

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Spinal Anesthesia

• Indications -surgical procedures below the
  diaphragm
• -patients with cardiac or respiratory disease
• Advantages -mental status
  monitoring -shorter recovery
• Disadvantages -necessary extra
  expertise -possible patient pain
• Contraindications -coagulopathy -uncor
  rected hypovolemia

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Spinal Anesthesia

• Involved medications -lidocaine -bupivac
  aine -tetracaine
• Patient assessment -continuous heart rate,
  rhythm, and pulse oximetry monitoring -leve
  l of anesthesia -motor function and sensation
  return monitoring

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Spinal Anesthesia

• Complications -hypotension -bradycardia
  -urine retention -postural puncture
  headache -back pain

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Spinal analgesia

• Indications -postoperative pain from major
  surgery
• Involved medications -lipid-soluble
  drugs -preservative-free morphine
• Monitoring recovery -respiratory
  depression -urine depression -pruritus
  -nausea and vomiting

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Examples of location for Spinal and Epidural
Anesthesia.
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Nerve Block Sites
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Intraoperative Phase

• Conscious Sedation
• Administration of IV sedative, hypnotic, and
  opioid medications.
• Produces a depressed level of consciousness
• Retains ability to maintain a patent airway
• Able to respond to verbal commands or physical
  stimulation
• Used for relatively short procedures

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Postoperative Nursing CareNursing assessment in
the PACU

• Vital signs- presence of artificial airway, 02
  sat,BP,pulse, temperature.
• LOC- ability to follow command, pupillary
  response
• Urinary output
• Skin integrity
• Pain
• Condition of surgical wound
• Presence of IV lines
• Position of patient

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Postoperative Nursing CareNursing Diagnosis

• Ineffective airway clearance- increased
  secretions 2 to anesthesia, ineffective cough,
  pain
• Ineffective breathing pattern- anesthetic and
  drug effects, incisional pain
• Acute pain
• Urinary retention
• Risk for infection

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Postoperative Phase

• Assessment of the Postanesthesia Client
• Airway
• Vital signs
• Cardiac monitoring
• Peripheral vascular assessment
• Level of consciousness (LOC)
• Fluid and electrolytes
• GI system
• Integumentary system
• Discomfort/pain

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Perioperative Nursing Care Postoperative
Management

• Maintain a patent airway
• Stabilize vital signs
• Ensure patient safety
• Provide pain
• Recognize manage complications

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Postoperative Nursing CareWhen caring for
post-surgical patient, think of the 4 Ws

• Wind prevent respiratory complications
• Wound prevent infection
• Water monitor I O
• Walk prevent thrombophlebitis

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Postoperative Phase
Complications

• Respiratory- atelectasis, pulm. Embolus
• Cardiovascular- venous thrombosis
• Gastrointestinal-Hiccoughs, N/V,abd. Distention,
  paralytic ileus, stress ulcer.
• GU- urinary retention
• Hemorrhage-slipping of a ligature(suture)
• Wound infection-
• Wound dehiscence and evisceration-

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Dehiscence

• Partial or complete separation of the outer layer
  of the wound.
• Possible causes
• Poor suturing technique
• Distention
• Excessive vomiting
• Excessive coughing
• Dehydration
• Infection

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Evisceration

• Total separation of the layers protrusion of
  internal organs or viscera through the open
  wound.
• Causes same as dehiscence
• Treatment
• Call for help
• Cover with sterile NS soaked gauze/towels
• Keep moist
• DO NOT ATTEMPTS TO REINSERT ORGANS.
• Keep in supine position with knees/hips bent
• Assessment/VS q 5 min. until MD arrive
• Prepare for surgery.

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Postoperative Phase
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Postoperative Phase
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Postoperative Nursing CareGerontologic
considerations

• Mental status- attributed to medications, pain,
  anxiety, depression.
• Delirium- infection, malignancy, trauma, MI, CHF,
  opioid use.
• Dementia-sundowning-sleep disturbances, lack of
  structure in the afternoon or early morning,
  sleep apnea.