Peri-operative Nursing Phases of Peri-operative period 1. PREPRE- oper operat ativ ivee pha phase se 2. INTR INTRAA- ope opera ratitive ve pha phase se 3. POST POST-- oper operat ativ ivee phas phasee 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 postanesthesia 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 1. Asse Assess ssin ingg the the cli clien ents ts 2. Identi Identifyi fying ng potent potential ial or actua actuall health health proble problems ms 3. Plan Planni ning ng spe speci cifificc care care 4. Provid Providing ing pre-ope pre-operat rative ive teachi teaching ng 5. Ensu Ensure re cons consen entt is sign signed ed Activities during the Intra-op 1. Assist Assisting ing the the surge surgeon on as scrub scrub nurse nurse and and circula circulatin tingg nurse Activities in the POST-op 2. Asse Assessi ssing ng res respo pons nses es to to surg surger eryy 3. Perfor Performin mingg interv intervent ention ionss to promot promotee healing healing 4. Prev Preven entt comp complilica catition onss 5. Plan Planni ning ng ffor or hom homee-ca care re 6. Assist Assist the the clien clientt to achi achieve eve opti optimal mal reco recover veryy TYPES of SURGERY 1. Acco Accord rdin ingg to to PUR PURPO POSE SE 2. Acco Accord rdin ingg to deg degre reee of URG URGEN ENCY CY 3. Acco Accord rdin ingg to to deg degre reee of of RIS RISK K Effects of Surgery on the Client Stress respinse (Neuroendocrine response) is activated Resistance to infection is lowered due to surgical incision Vascular system is disturbed due to severing of blood vessels and blood loss Organ function may be altered due to manipulation Factors influencing Surgical Risk Age Nutrition Fluid and Electrolyte balance General health status: infection, cardiovascular disease, pulmonary problems, liver dysfunctions, renal dysfunctions or metabolic disorders Medications affecting Surgery Anticoagulants like aspirin and NSAIDS should be discontinued 2 weeks Tranquilizers may cause hypotension and shock Antibiotics like aminoglycosides may intensify effects of anesthesia Diuretics may cause electrolyte imbalance antiHPN may cause hypotension
Psychological support Assess client’s fears, anxieties, support system and patterns of coping Establish a trusting relationship with client and family Explain routine procedures, encourage verbalization of fears and allow clients to ask questions Provide for spiritual care if needed Preoperative teaching Assess client’s level of understanding of surgical procedure and its implications implications Answer questions, clarify and reinforce explanations given by the surgeon Explain routine pre-op and post-op procedures Teach coughing and deep breathing exercise, splinting of incision, turning side to side. Explain its importance in preventing complications Assure client that pain medication will be given Pre-operative teaching Physical Preparation Obtain hx of past medical cconditions Perform baseline head to toe examinations including vital signs Ensure that diagnostic exams are performed - CBC, CBC, Elc Elctr trol olyt ytes es,, PT/P PT/PTT TT,, Urina Urinaly lysi sis, s, ECG ECG,, Blood typing, Chest xiray Prepare client skin Shower with antibacterial soap to cleanse skin Skin prep if ordered: shave or clip hairs and cleanse appropriate areas to reduce bacteria on skin Administer enema if ordered Promote adequate rest and sleeep Instruct client to remain NPO after midnight to prevent vomiting and aspiration Pre-op elimination Laxatives, enemas or both may be prescribed the night before surgery client void immediately immediately BEFORE Have the client transferring them to the OR Foley catheter may be inserted as ordered Legal Responsibility Surgeon obtains operative permit (Informed consent) 1. Surgical procedure, alternatives, possible complications, disfigurements 2. Part of nurse’s role as client advocate to confirm that clients understands information given Informed Consent An active shared decision making process between the provider and the recipient of care. 3 conditions 1. Adequa Adequate te disclo disclosure sure of of the diag diagnos nosis, is, natur naturee and purpose of treatment, risk and consequences, probability of successful outcome and prognosis if treatment is not done. 2. Patien Patientt must demo demonst nstrat ratee a clear under understa standi nding ng and comprehension of information being provided 3. Recipi Recipient ent of care care must must give give consent consent volun voluntar tarily ily,, not persuaded or coerced to undergo the procedure. Consent are not needed for emergency care if; 1. There There is is an immedi immediate ate threat threat to life life 2. Expert Expertss agree agree that that itit is an emer emergen gency cy 3. Clie Client nt is unab unable le to cons consen entt
4. A legally authorized person cannot be reached
Preparation Immediately before surgery Obtain a baseline vital signs Provide oral hygiene and remove dentures Remove client’s clothing and dress in clean gown Remove nail polish, cosmetics, jewelry Instruct to empty bladder Check identification band 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 Preparing the surgical site Purpose of prepping is to reduce the unit of organisms available to migrate to the surgical wound. Task is the responsibility of the circulating nurse Principle of scrubbing from the clean area to dirty area is observed at all times Anesthetics Anesthetics are drugs that are used to cause complete or partial loss of sensation. The numerous anesthetics can be broadly classified as : 1. General 2. Local anesthetics General Anesthesia Loss of sensation with loss of consciousness Skeletal muscle relaxation Analgesia Elimination of somatic, autonomic and endocrine response incldg coughing, gagging annd vomiting Protective reflexes are lost Amnesia, analgesia and hypnosis occur Administered in two ways: Inhalational Intravenous IV anesthetics Produces rapid, smooth induction, may be used alone in short procedures Common IV anesthetics: methohexital, Sodium thipental (Penthatol), midazolam Disadvantages: poor relaxation, respiratory and myocardial depression in high doses, bronchospasm, laryngospasm, hypotension and respiratory depression Dissociative Agents Produce state of profound analgesia, amnesia and lack of awareness without loss of consciousness Ketamine (Ketalac) Side effects: tachycardia, hypertension, respiratory depression, hallucinations Precautions: decrease verbal, tactile and visual stimulation during recoverty period Neuroleptics Produces state of neuroleptic analgesia characterized by reduced motor activity and analgesia without loss of consciousness Fentanyl citrate (Innovar)
SE; hypotension, bradycardia, respiratory depression, skeletal muscle rigidity, twitching Precaution: reduce narcotic dose to prevent respiratory depression
Local Anesthesia Local anesthetics are drugs that cause a loss of sensation in limited areas of the body to abolish pain. They are powerful nerve blockers injected locally. Systemic absorption of the anesthetics can produce numerous side effects. Local Anesthesia Examples of Local anesthetics: The “CAINES” Lidocaine Dibucaine Procaine Tetracaine Local Anesthesia The side effects of local anesthetics Local effects- local irritation and skin breakdown CNS effects if systemic absorption occurs- headache, restlessness, anxiety, dizziness, tremors and blurred vision. GI system- nausea, vomiting Cardio- arrhythmias, peripheral vasodilation, myocardial depression, and rarely, cardiac arrest Local Anesthesia Nursing Responsibilities Maintain emergency equipment on standby to provide life-support in cases of severe reactions Ensure that drugs are available for managing hypotension, cardiac arrest and CNS alterations. Provide adequate hydration to patients receiving spinal anesthesia. Position the client supine for up to 12 hours after spinal anesthesia to minimize spinal headache Local Anesthesia Nursing Responsibilities Provide safety and comfort measures such as siderails up, frequent skin care and supportive care Give health teaching to explain things the patient needs to know to allay fears. Stages of Anesthesia Depth Usually trained individuals with the special equipments ready for life support administer the agents The patient undergoes through a predictable stages known as STAGES of ANESTHESIA: 1 to 4 Stages of Anesthesia STAGE 1 Referred to as the Induction Stage is loss of pain sensation with the patient still conscious and able to communicate STAGE 2- the Excitement Stage, A period of excitement and often combative behaviors are present such as restlessness, with signs of sympathetic stimulation (tachycardia, increased respiration and blood pressure changes) STAGE 3
Surgical Anesthesia stage, involves relaxation of skeletal muscles, return of regular respiration, and progressive loss of eye reflexes and pupil dilatation. This is the best stage for surgical procedure.
STAGE 4 Medullary Paralysis stage is a very deep CNS depression with loss of respiratory and vasomotor center stimuli in which death can occur rapidly.
Patient Positioning Provides optimal visualization Provides optimal access for assessing and maintaining anesthesia and function Protects patient from harm Position Patient during Surgery 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 Monitor the patency of the drainage Maintain intake and output monitoring Care of the tubes, drains and wound Ensure safety by side rails up Pain medication given as ordered Measures to PREVENT post-op Complications Maintenance of Circulation Hypotension causes: Moving patient from OR to his bed Reaction to drug and anesthesia Loss of blood and other body fluids Cardiac arrythmia and cardiac failure Inadequate ventilation Pain Assessment Weak , thready pulse with significant drop in BP may indicate hemorrhage or circulatory failure Skin, cold, moist, pale, cyanotic Restlessness or aprehension st Vital signs every 15 mins for the 1 4 hours until stable Cardiac arrythmia Causes: Hypoxemia Hypercapnia Intervention: a. Oxygen therapy b. Drugs - Lidocaine (Xylocaine) - Procainamide (Pronestyl) Post-operative interventions PAIN MANAGEMENT Pain is usually greatest during the 12-36 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 Post-operative Intervention 1.
Deep breathing and coughing exercises Q2-4 hours à to remove secretions 2. Leg exercises Q 2 hours à to promote circulation 3. Ambulation ASAP à prevents respiratory, circulatory, urinary and gastrointestinal complications Post-operative Interventions 1. Hydration after NPO à to maintain fluid balance 2. Suction, either gastro or respiratory à to relieve distention, to remove respi secretions 3. Dietà progressive, usually given when bowel sounds and gag reflex return Post Operative Care Respiratory Complication Atelectasis is suspected when there is sudden rise in temp 24-48 hours after surgery. Collapse of the alveoli are highly susceptible to pneumonia Occurs in high abdominal surgery with prolong inhalation anesthesia and vomiting occurred during operation or anesthesia recovery Measures to prevent pooling of secretions Changing of position Altering height of bed from low to semi fowlers Early ambulation Liquify and remove secretions Increase fluid intake Breathing in moist air
Deep breathing followed by coughing is contraindicated in brain, spinal or eye surgery. Give analgesic before coughing in abdominal or thoracic surgery Splint operative area to promote comfort while coughing
Causes of venous stasis Muscular inactivity Respiratory and circulatory depression Increase pressure on blood vessel Intestinal distention Prolonged sitting Others; obesity, cardiovascular sisease, debility, malnutrition, old age 1. Never massage limbs after OR 2. Patient should lie in the abdomen for 30 minutes 3 times a day to prevent pooling of blood on pelvic cavity. 3. Don’t allow patient to stand unless pulse has returned close to baseline to prevent orthostatic hypotension 4. Elastic bandage or stockings when in bed or walking for the first time Fluid and electrolyte Imbalance Blood loss Increase insensible waterr lodd through skin, thru vomiting, ngt st Increase ADH production for the 1 12 to 24 hours of surgery resulting in fluid retention by kidneys Increase aldosterone and glucocorticoids resulting in increase Na absorption and potassium excretion
IV D5W alt D5NSS to prevent Na excess
Gastrointestinal complications
Paralytic Ileus – cessation of peristalsis due to excessive handling of the GI organs No fluids or food given until peristalsis returns as evidenced by bowel sounds or flatus
Vomiting – due to certain anesthesia on the stomach or eating or drinking water before peristalsis returns Position on side Give ice chips, sips of ginger ale or hot tea, small dry solid foods Antiemetic: Trimethobenzamide HCL (Tigan) Gas pains Aspiration of fluid or gas with NGT Ambulation stimulates return of peristalsis and expulsion of flatus Rectal tube insertion inserted just pass the rectal sphincter and remove after 20 minutes (2-4 inches adults, 1-3 inches in children) Urinary complication Usually after 6-8 hours first voiding not>200 ml or total output may not be >1500ml due to loss of fluids during surgery (Urinary retention) Forced fluids Placed patient on bed pan at regular int. Pouring warm water in perineum Assuring privacy Assuring proper position Catheterization Diet
NPO usually immediately after surgery Progressive diet Assess the return of the bowel sounds Liquid Diet Vs Soft diet 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 followsPOSITIONING, 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 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 INTRAOPERATIVE phase is to maintain client safety To emphasize The over-all goals of nursing care during the POSTOPERATIVE phase are to promote healing and comfort, restore the highest possible wellness and prevent associated risk
