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

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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).

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

9. 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

10. 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

11. 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

12. 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.

13. 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.

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.

19. 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.

20. 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.

21. 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

22. 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

23. 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

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

25. 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.

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

27. 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).

28. 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.

29. 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

30. 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.

31. 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

32. 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

33. 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

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

35. 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.

36. 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.

37. 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.

38. 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

39. Perioperative Nursing Care Surgical asepsis
Ensure sterility
Alert for breaks

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

41. 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

42. 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

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

44. 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

45. 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.

46. 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

47. 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

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

49. 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

50. 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-

51. 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.