Perioperative Nursing Care Definition of Surgery Surgery is any procedure performed on the human body that uses instruments to alter tissue or organ integrity.

Perioperative Nursing Care 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 diagnosis;identifies desired patient outcomes;develop and implements a plan of care; and evaluates that care in terms of outcomes achieved by the patient.

Perioperative Nursing Care Type of Surgery 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.

Perioperative Nursing Care 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.

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

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

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

Perioperative Nursing Care Surgical settings Surgical suites Ambulatory care setting Clinics Physician offices Community setting Homes

Perioperative Nursing Care 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

Perioperative Nursing Care Method of teaching Timing-most useful when started the week before admission and reinforced before surgery and the client is less anxious. Content: Surgical Procedure Preoperative routines Intraoperative routines Postoperative routines Sensory preparation Pain relief

Perioperative Nursing Care Phases Preoperative-begins with the decision for surgical intervention and ends with transfer to the OR. Nursing Interventions Baseline assessment during interview at clinic,office or over the phone. Assessment in the pre-admission unit, client room, holding area or induction room

Perioperative Nursing Care Preoperative Surgical Phase Assessment: 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- includes past illnesses and the primary reason for seeking medical care.

Perioperative Nursing Care Preoperative Surgical Phase Assessment continue….. 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.

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

Perioperative Nursing Care Preoperative Surgical Phase Family Support- determine the extent of the client’s support from family members or friends. Occupation- surgery may result in physical alterations that hinder or prevent a person from returning from work. Feeling- surgery causes anxiety and a feeling of loss of control for most clients. 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.

Perioperative Nursing Care Preoperative Surgical Phase 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-surgical removal of a diseased tissue often leaves permanent disfigurement or alteration in body function.

Perioperative Nursing Care Selected factors that in increase surgical risk. Age- Very young and older clients. Nutrition- a malnourished client is prone to poor tolerance of anesthesia, infection, poor wound healing and the potential for multiple organ failure after surgery. Obesity- often have difficulty in resuming normal activity after surgery.

Perioperative Nursing Care Physical 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 client’s risk for respiratory complications.

Perioperative Nursing Care Physical 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 client’s LOC will change as a result of general anesthesia but should return to the preoperative LOC after surgery.

Perioperative Nursing Care Physical 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.

Perioperative Nursing Care Gerontological Considerations Cardiovascular Coronary flow decreases Heart rate decreases Response to stress decreases Peripheral vascular decreases Cardiac output decreases Cardiac reserve decreases

Perioperative 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

Perioperative 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

Perioperative Nursing Care Gerontological Considerations Musculoskeletal Decreased mass, tone, strength Decreased bone density Integumentary Decreased elasticity Decreased lean body mass Decreased subcutaneous fat

Perioperative 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. Blood type and screen, urinalysis, 12 lead EKG and chest X-ray are ordered to screen for pre-existing abnormalities.

Perioperative Nursing Care Common nursing diagnosis Knowledge deficit Anxiety Risk for ineffective airway clearance Risk for ineffective peripheral tissue perfusion

Perioperative 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 patient’s familiarity with procedural events. This includes surgical experience (procedural), what the pt. may experience (sensory) and what actions may help decrease anxiety (behavioral).

Perioperative Nursing Care Anxiety The nurse must consider the pt’s 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.

Perioperative Nursing Care Preanesthesia Management Physical Status Categories ASA 1: Healthy patient with no disease ASA 11: Mild systemic ds without fx limitations ASA 111:Severe 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

Perioperative Nursing Care Final 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.

Perioperative Nursing Care Pre-op. medications Prior to administering – check permits Purpose: Allay anxiety Decrease pharyngeal secretions- decrease gastric secretions. Decrease side effects of anesthesia Induce amnesia

Perioperative 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

Perioperative Nursing Care Phases Intraoperative- Transferred to OR-ends with the transfer to the recovery area. Nursing Interventions Communicating plan of care Identifying nursing activities Establishing priorities Coordinate care with team members Coordinate supplies and equipment Control environment Document plan of care

Perioperative Nursing Care Intraoperative Roles Surgeon Anesthesiologist Scrub Nurse Circulating Nurse OR techs

Perioperative Nursing Care Intraoperative Phase- Surgical team 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 patient’s 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.

Perioperative Nursing Care Surgical 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.

Perioperative Nursing Care Surgical team Anesthesiologist and anesthetist- anesthetizing the pt. providing appropriate levels of pain relief, monitoring the pt’s physiologic status and providing the best operative conditions for the surgeons. Other personnel- pathologist, radiologist, perfusionist, EVS personnel.

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

Perioperative Nursing Care Surgical asepsis Ensure sterility Alert for breaks

Perioperative Nursing Care Types of Anesthesia Regional Local Nerve block Epidural Spinal General

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 -uncorrected hypovolemia

Spinal Anesthesia Involved medications -lidocaine -bupivacaine -tetracaine Patient assessment -continuous heart rate, rhythm, and pulse oximetry monitoring -level of anesthesia -motor function and sensation return monitoring

Spinal Anesthesia Complications -hypotension -bradycardia -urine retention -postural puncture headache -back pain

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

Perioperative Nursing Care Phases Postoperative- Begins with transfer to PACU and ends with the discharge of the patients from the surgical facility or the hospital. Nursing Interventions Communicating pertinent information about surgery to the PACU staff. Postoperative evaluation in clinic or home.

Perioperative Nursing Care Nursing assessment in the PACU Vital signs- presence of artificial airway, o2 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

Perioperative Nursing Care Nursing 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

Perioperative Nursing Care Postoperative Management Maintain a patent airway Stabilize vital signs Ensure patient safety Provide pain Recognize & manage complications

Perioperative Nursing Care When caring for post-surgical patient, think of the “4 W’s” Wind: prevent respiratory complications Wound: prevent infection Water: monitor I & O Walk: prevent thrombophlebitis

Perioperative Nursing Care 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-

Perioperative Nursing Care Gerontologic 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.