King Saud University College of Nursing Adult Nursing (NUR 316) Pre, Intra and Post Operative Nursing Management
Pre, Intra and Post Operative Nursing Management Perioperative Period: The time that constitute the surgical experience, include the preoperative, intraoperative, postoperative phases. Preoperative Phase: The time from when decision for surgical intervention is made to when the patient is transferred to the operating room table. Intaroperative Phase: Period of time from when the patient is transferred to the operating room table to when he or she is admitted to the postanesthesia care unit. Postoperative Phase: Period of time that begins with the admission of the patient to the postanesthesia care unit and ends after follow-up evaluation in the clinical setting or home.
Purposes of surgery - Diagnostic→e.g. Biopsy Exploratory→e.g. laparotomy Curative →e.g. excision of a tumor or an inflamed appendix - Reconstructive or cosmetic → e.g.mammoplasty - Palliative→ relieve of symptoms as pain
Categories of surgery 1- Emergency: Must be performed immediately: 1)Maintain life 2)Maintain organ or limb function 3)Stop hemorrhage (Intestinal obstruction/Gunshot & stab wounds). 2- Urgent: Must be performed within 24 to 48 hours(Bleeding of duodenal ulcer)
3- Planned Scheduled weeks or months ahead of the proposed operation (cataract removal) 4- Elective Not absolutely necessary (hernia) 5- Optional Requested by the person (Mammoplasty)
Risk factors for surgical complications: - Age, obesity, malnutrition, immobility, hypovolemia, infection, pregnant, diabetes mellitus, hepatic disease, cardiovascular disease, renal disease and pulmonary disease. - Nature of condition (Malignant) - Location of condition (Heart/Brain)
IV-Nursing intervention I- Psychological Aspect: Provide explanations or printed information about health care facility routines & visiting hours & meal times Explain the procedures involved in the upcoming surgery (Complete idea of what the pre, intra & post operative course entails). Introduce the person who is to undergo a major surgical procedure to people who have successfully recovered from this operation. Helps to relieve anxiety
2. Informed Consent : Anyone undergoing surgery must sign an operative permit. It protects the health care facility staff from legal action 3. Physiologic Aspects Before the day of surgery Correct any dietary deficiencies Reduce an obese person's weight. Correct fluid & electrolyte imbalances. Restore adequate blood volume with blood transfusion. Treat chronic disease. Cure infections process
Preparing the person the evening before surgery. Hygienic care ( bathing or scrubbing ) Skin preparation( shaving) Document observation of the surgical site. (note cuts or breaks) Restricting food & fluid eight to ten hours preop. NPO after midnight. intravenous infusions may receive for debilitated or malnourished patient Enemas not routinely ordered except for G.I.T s NG tube sometimes is inserted the evening before or the morning of surgery
Remove colored nail polish Assist the person in donning a hospital gown, cap Check for laboratory record Blood available Pre-anesthetic medication given e,g. 1 gram claforan
Pre-operative teaching: Deep breathing and coughing exercises To prevent pneumonia Incentive spirometer Turning & moving, leg exercise to prevent DVT Getting out of bed Pain management
Preoperative Preparations
Intraoperative Phase Begins when patient is transferred to operating room table Provide for patient safety Maintain aseptic environment Provide surgeon with supplies and instruments Documentation
Surgical Team
Intraoperative nursing management: I-Nurse's roles in the operating room a. Circulating nurse b. Scrub nurse A-Circulating nurse.Prepares operating room with necessary equipment and supplies and ensures that equipment is functional..Arrange sterile and nonsterile supplies; opens sterile supplies for scrub nurse..Sends for client at proper time..Visits with client preoperatively; explains role, verifies operative permit, identifies client, and answers any questions..Confirms client's allergies..Checks medical record for completeness.
. Assists in safe transfer of client to operating room table..Positions client on operating room table in accordance with type of procedure, and surgeon's preference..Counts sponges, needles, and instruments with scrub nurse before surgery..Assists scrub nurse and surgeons by tying gowns and preparing client's skin..Assists scrub nurse in arranging tables to create sterile field..Maintains continuous observations during surgery to anticipate needs of client, scrub nurse, surgeons, and anesthesiologist..Provides supplies to scrub nurse as needed.
. Observes sterile field closely for any breaks in aseptic technique and reports..Cares for surgical specimen..Documents operative record and nurses' notes..Counts sponges, needles, and instruments when closure of wound begins..Transfers client to stretcher for transport to recovery area.Accompanies client to a recovery room and provides a report.
b. Scrub nurse. Performs surgical hand scrub..Dons sterile gown and gloves aseptically.. Arranges sterile supplies and instruments in manner prescribed for procedure..Checks instruments for proper functioning..Counts sponges, needles, and instruments with circulating nurse..Gowns and gloves surgeons as they enter operating room.
Assists with surgical draping of client. Maintains sterile field. Recognizes and corrects breaks in aseptic technique. Observes progress of surgical procedure. Hands surgeon instruments, sponges, and necessary supplies during procedure" Identifies and handles surgical specimens correctly. Watches sponges, needles, and instruments so none will be misplaced or lost in wound.
Postoperative Phase Admission to the recovery room Maintain airway Monitor vital signs Assess effects of anesthesia Assess for complications of surgery Provide comfort and pain relief Ends with follow-up evaluation in clinical setting or home
Nursing management in the post anesthesia care unit: I-Assessing the patient: Frequent assessment of the patient oxygen saturation, pulse volume and regularity, depth and nature of respiration, skin color,depth of consciousness. II- Maintaining a patent airway: − The primary objectives are to maintain pulmonary ventilation and prevent hypoxia and hypercapenia. − The nurse applies oxygen, and assesses respiratory rate and depth, oxygen saturation.
Nursing management in the post anesthesia care unit: III- Maintaining cardiovascular stability: − The nurse assesses the patient’s mental status, vital signs, cardiac rhythm, skin temperature, color and urine output. − Central venous pressure, arterial lines and pulmonary artery pressure. − The primary cardiovascular complications include hypotension, shock, hemorrhage, hypertension and dysarrythmias.
Nursing management in the post anesthesia care unit: IV- Relieving pain and anxiety: − Opioid analgesic. V- Assessing and managing the surgical site: − The surgical site is observed for bleeding, type and integrity of dressing and drains. VI- Assessing and managing gastrointestinal function: − Nausea and vomiting are common after anesthesia. − Check of peristalsis movement.
Nursing management in the post anesthesia care unit: VII- Assessing and managing voluntary voiding: − Urine retention after surgery can occur for a verity of reasons. Opioids and anesthesia interfere with the perception of bladder fullness. - Abdominal, pelvic,hip may increase the like hood of retention secondary to pain. VIII- Encourage activity: − Most surgical are encouraged to be out of bed as soon as possible. Early ambulation reduces the incidence of post operative complication as,atelectasis,pneumonia, gastrointestinal discomfort and circulatory problem.
Post Operative Complication: 1- Shock: Is the response of the body to a decrease in the circulating volume of blood, tissue perfusion impaired, cellular hypoxia and death. 2- Hemorrhage: Is the escape of blood from a blood vessel. 3- Deep vein thrombosis. (DVT). Occur in pelvic vein or in lower extremities, and it’s common after hip surgery.
Post Operative Complication: 4- Pulmonary embolism. It’s the obstruction of one or more pulmonary arterioles by an embolus originating some where in the venous system or in the right side of heart. 5- Urinary Retention. 6- Intestinal obstruction. Result in partial or complete impairment to the forward flow of intestinal content.
Potential Intraoperative complication: –Nausea and vomiting –Anaphylaxis –Hypoxia and other respiratory complication –Hypothermia