PERIOPERATIVE NURSING CARE By Purwaningsih

Surgery The treatment of injury, disease, or deformity through invasive operative methods. Surgery is a unique experience, with no two clients responding alike to similar operations.

From a Client’s Experiences Point Surgery is a major stressor for all clients. Anxiety and fear are normal. Fear of the unknown is the most prevalent fear prior to surgery and is the fear that is the easiest for the nurse to help the client overcome.

Type of Surgery Seriousness: Degree of risk Seriousness: Degree of risk Major- Involves extensive reconstruction or alteration in body parts;poses great risks. Minor- Involves minimal alteration in body parts;often designed to correct deformities;involves minimal risk compared with major procedures.

Types of Surgery Urgency: reason for procedure: Elective-Performed on the basis of client’s choice; not essential and may not necessary for health. Urgent- Necessary for client’ health,may prevent additional problem from developing (e.g. tissue destruction );not necessarily emergency. Emergent- Must be done immediately to save life or preserve function of body part. Required- Has to performed at some point;can be pre-scheduled.

Types of Surgery Diagnostic Diagnostic- Allows to confirm diagnosis. Corrective Corrective- Excision or removal of diseased body part. Reconstructive Reconstructive- Restore function or appearance to traumatized or malfunctioning tissues.

Types of Surgery Procurement for transplant Procurement for transplant- Removal of organs and/or tissues from a person pronounced brain death for transplantation into another person. Constructive Constructive- Restores function lost or reduced as result of congenital anomalies. Cosmetic Cosmetic- Performed to improve personal appearance.

Types of Surgery Extent of surgery Extent of surgery : Simple Simple- Only the most overtly affected areas involved in the surgery. Radical Radical- Extensive surgery beyond the area obviously involved; is directed at finding a root cause. Location Location: Based on the area of the body on which the surgery occurs (e.g abdominal, heart surgery).

Informed Consent A legal form signed by the client and witnessed by another person that grants permission to the client’s physician to perform the procedure described by the physician.

Informed Consent is Required WHEN: Anesthesia is used. Procedure is considered invasive. Procedure is nonsurgical but has more than a slight risk of complications. When radiation or therapy is used.

Informed Consent What is it? When is it necessary? Who can sign? What is the responsibility of the nurse? What are the legal implications?

What is Perioperative Nursing? Three Phases: Preoperative (Preop) Intraoperative (Intraop) Postoperative (Postop)

Preoperative Phase Begins when the client is scheduled for surgery and ends at the time of transfer to the surgical suite 3-6 months 30 days 7 days Day before

Nursing Process in Pre-op Phase

Preoperative Surgical Phase Assessment Assessment: Nursing History Nursing History-key elements that pertains to the surgical client’s risks and needs. Information concerning about advance directives. Ask if the patient has a durable power of attorney for health care and a living will. Medical History Medical History- includes past illnesses and the primary reason for seeking medical care.

Preoperative Surgical Phase Previous surgeries- past experience with surgery can reveal potential physical and psychological responses to procedure and alert you to special needs and risk factors. Complications such as anaphylaxis or malignant hyperthermia. Medication History- any medications that might predispose to surgical complications.

Preoperative Surgical Phase Allergies Allergies- to medications, topical agents used to prepare the skin for surgery, and latex can create significant risks. Smoking Habits Smoking Habits – greater risks for complications. Alcohol and Controlled Substance Useand abuse Alcohol and Controlled Substance Use and abuse- to be prepared for adverse reactions, such as withdrawal, that may occur during surgery. Client Expectations Client Expectations- to identify the client’s and family perceptions and expectations regarding surgery and health care providers.

Preoperative Surgical Phase Family Support Family Support- determine the extent of the client’s support from family members or friends. Occupation Occupation- surgery may result in physical alterations that hinder or prevent a person from returning from work. Feeling Feeling- surgery causes anxiety and a feeling of loss of control for most clients. Cultural and Spiritual Factors Cultural and Spiritual Factors- cultural differences in the use of both verbal and nonverbal communication require you to validate interpretation of cues with the client and family.

Preoperative Surgical Phase Coping Resources Coping Resources- assessment of a client’s feeling and self-concept helps to reveal whether the client has the ability to cope with the stress of surgery. Body image Body image-surgical removal of a diseased tissue often leaves permanent disfigurement or alteration in body function.

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.

Common Preoperative Laboratory Tests Hemoglobin and hematocrit (Hgb and Hct) White blood cell count (WBC) Blood typing and cross matching (screening) Serum electrolytes Prothrombin time (PT) and partial thromboplastin time (PTT) Bilirubin Liver enzymes Urine analysis Blood urea nitrogen (BUN) and creatinine

Nursing Diagnosis Deficient knowledge r/t lack of exposure Anxiety r/t threat of a change in health status or fear of unknown Disturbed sleep patterns r/t internal sensory alteration (illness & anxiety) Ineffective coping r/t impending surgery Disturbed body image r/t anticipated changes

Nursing Diagnosis Disabled family coping r/t temporary family disorganization and role changes Powerlessness r/t health care environment, loss of independence and loss of control of one’s body

Nursing Process in Pre-op Phase Planning: Correction of any abnormal labs Blood donations Bloodless surgery Nutrition Pain Management Surgery Classes Discharge planning

Nursing Process Pre-op Phase Implementation: Explain purpose of planned procedure Asking questions Adhering to NPO status Stating understanding of preop preparations Demonstrating correct use of exercises/techniques to prevent complications

Interventions Ensuring informed consent Client self-determination Implementing dietary restrictions Administration of medications Intestinal preparation Skin preparation Vascular access

Pre-operative Teaching Tubes, drains, additional vascular access Post-op procedures Post-op exercises: breathing exercises, incentive spirometry, coughing & splinting, leg procedures and exercises Early Ambulation Range of Motion exercises (ROM)

Preoperative Chart Review Pre-op check list: Surgical informed consent Anesthesia informed consent Blood transfusion consent Site verification checklist Lab results-report abnormal lab values Current vital signs Special Needs

Preoperative Client Preparation Clothing removed/don patient gown Jewelry removed including body any piercing Prosthesis: dentures, wigs, limbs Aides: hearing, glasses, cane Arm bands: identification, code status, blood bracelet, fall risk status bracelet Misc: contact lenses, hairpins Nail polish, artificial nails

Preoperative Client Preparation Empty bladder Pre-operative medications Safe transfer to surgical suite

Pre-Operative Teaching Reinforce physician’s explanations and instructions Discuss what to expect Instruct in breathing and leg exercises Demonstrate splinting of abdomen (if appropriate) Explain rationale for frequent position changes Discuss pain management Discuss cognitive coping strategies – Imagery, distraction, optimistic self-recitation

Collaborative Management: Assessment & Planning Client interview – Correct person for the correct procedure with correct preparation on the correct anatomy Risk for perioperative positioning injury – Lacks normal defense mechanisms – Size, age skin integrity Potential for hypoventilation Potential for hemodynamic shifts – Blood loss

Purposes of Preoperative Teaching To answer questions and concerns about surgery. To ascertain client’s present knowledge of the intended surgery. To ascertain the need or desire for additional information. To provide information in a manner most conducive to learning.

Physical Preparation Identifying the client and verifying the operative procedure. Preparing operative site. Checking client’s vital signs. Assisting in putting on hospital gown, cap, and, if ordered, antiembolic hose. Verifying allergies. Verifying NPO (nothing by mouth) status. Identifying any sensory deficits in the client.

Members of Sterile Surgical Team Surgeon. First assistant (Physician or RN who assists surgeon in performing hemostasis, tissue retraction, and wound closure). Scrub nurse (an LP/VN, RN, or surgical technologist who prepares and maintains integrity, safety, and efficiency of the sterile field throughout the operation).

Sterile Field The area surrounding the client and the surgical site that is free from all microorganisms.

Non-Sterile Members of the Surgical Team Anesthesia provider. Circulating nurse (an RN responsible for management of personnel, equipment, supplies, environment, and communication throughout a surgical procedure).

Family Needs Explain where to wait Surgeon will talk to them after surgey Never judge seriousness by length of time patient in surgery (keep family updated) Prepare them for what they will see post-op Explain post-op protocol and routines

Responsibilities related to the Medical Record Complete pre-operative check list Place surgical consent form in plain view Send entire medical record (chart) to surgery with patient

Evaluation: Safety Health promotion & maintenance Psychosocial integrity Physiological Integrity

Variables Affecting Surgical Status Age Nutritional status Fluid and electrolyte status Respiratory status Medications Cardiovascular status Renal and hepatic status Neurological, musculoskeletal, and integumentary status Endocrine and immunological status

Disease/Medication Specific Considerations Diabetes Mellitus: – At risk for hyperglycemia or hypoglycemia Long-term corticosteroid use: – At risk for adrenal insufficiency Uncontrolled Thyroid Disease – Overactive: risk of Thyrotoxicosis – Underactive: risk of respiratory depression