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Perioperative Nursing

Perioperative Nursing

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Published by: Carmzy Eyla on Nov 09, 2010
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Lecture Notes on Perioperative NursingPrepared By: Mark Fredderick R Abejo R.N, MANMS Perioperative Nursing Abejo
1
MEDICAL AND SURGICAL NURSING
 PERIOPERATIVE NURSING
Lecturer:
 Mark Fredderick R. Abejo RN, MAN __________________________________________
 Perioperative Nursing
 
 – 
used to describe the nursingcare provided in the total surgical experience of thepatient: preoperative, intraoperative and postoperative.
 Preoperative Phase
, extends from the time the client isadmitted in the surgical unit, to the time he/she isprepared for the surgical procedure, until he istransported into the operating room.
 Intraoperative Phase
, extends from the time the client isadmitted to the OR, to the time of administration of anesthesia, surgical procedure is done, until he/she istransported to the RR/PACU.
 Postoperative Phase,
extends from the time the client isadmitted to the recovery room, to the time he istransported back into the surgical unit, discharged fromthe hospital, until the follow-up care.
4 Major Types of Pathologic Process RequiringSurgical Intervention (OPET)Obstruction
 
 – 
impairment to the flow of vital fluids(blood,urine,CSF,bile)
Perforation
 – 
rupture of an organ.
Erosion
 
 – 
wearing off of a surface or membrane.
Tumors
 
 – 
abnormal new growths.
 Classification of Surgical ProcedureAccording to PURPOSE:Diagnostic
 
 – 
to establish the presence of a diseasecondition. ( e.g biopsy )
Exploratory
 
 – 
to determine the extent of diseasecondition ( e.g Ex-Lap )
Curative
 
 – 
to treat the disease condition.*
Ablative
 – 
removal of an organ*
Constructive
 
 – 
repair of congenitallydefective organ.*
Reconstructive
 
 – 
repair of damage organ
Palliative
 
 – 
to relieve distressing sign and symptoms,not necessarily to cure the disease.
According to URGENCYClassification Indicationfor SurgeryExamplesEmergent
 
 – 
patientrequires immediateattention, lifethreatening condition.Withoutdelay- severebleeding- gunshot/ stab wounds- Fracturedskull
Urgent / Imperative
 – 
 patient requires promptattention.Within 24 to30 hours- kidney / ureteralstones
Required
 – 
patientneeds to have surgery.Plan within afew weeks ormonths- cataract- thyroid d/o
Elective
 
 – 
patientshould have surgery.Failure tohave surgerynotcatastrophic- repair of scar- vaginalrepair
Optional
 – 
 
 patient’s
decision.Personalpreference- cosmeticsurgery
According to DEGREE OF RISKMajor Surgery
- High risk / Greater Risk for Infection- Extensive- Prolonged- Large amount of blood loss- Vital organ may be handled or removed
Minor Surgery
- Generally not prolonged- Leads to few serious complication- Involves less risk 
Ambulatory Surgery/ Same-day Surgery / OutpatientSurgery
 Advantages:
- Reduces length of hospital stay and cuts costs- Reduces stress for the patient- Less incidence of hospital acquired infection- Less time lost from work by the patient; minimal
disruptions on the patient’s activities and family life.
 
 Disadvantages:
- Less time to assess the patient and performpreoperative teaching.- Less time to establish rapport- Less opportunity to assess for late postoperativecomplication.
Example of Ambulatory Surgery
Teeth extractionCircumcisionVasectomyCyst removalTubal ligation
Surgical Risks
ObesityPoor NutritionFluid and Electrolyte ImbalancesAge
 
PERIOPERATIVENURSING
 
Lecture Notes on Perioperative NursingPrepared By: Mark Fredderick R Abejo R.N, MANMS Perioperative Nursing Abejo
2
Presence of Disease (Cardiovascular dse., DM,Respiratory dse. )Concurrent or Prior Pharmacotherapyother factors:- nature of condition- loc. of the condition- magnitude / urgency of the surgery- mental attitude of the patient- caliber of the health care team
Goals
Assessing and correcting physiologic andpsychologic problems that may increase surgical risk.Giving the person and significant others completelearning / teaching guidelines regarding surgery.Instructing and demonstrating exercises that willbenefits the person during postop period.Planning for discharge and any projected changes inlifestyle due to surgery.
Physiologic Assessment of the Client UndergoingSurgery
AgePresence of PainNutritional & Fluid and Electrolyte BalanceCardiovascular / Pulmonary FunctionRenal FunctionGastrointestinal / Liver FunctionEndocrine FunctionNeurologic FunctionHematologic FunctionUse of MedicationPresence of Trauma & Infection
 Routine Preoperative Screening TestTest Rationale
CBC RBC,Hgb,Hct are important to theoxygen carrying capacity of blood.WBC are indicator of immunefunction.Blood grouping/ X matchingDetermined in case blood transfusionis required during or after surgery.SerumElectrolyteTo evaluate fluid and electrolytestatusPT,PTT Measure time required for clotting tooccur.Fasting BloodGlucoseHigh level may indicate undiagnosedDMBUN / CreatinineEvaluate renal functionALT/AST/LDHand BilirubinEvaluate liver functionSerum albuminand total CHONEvaluate nutritional statusUrinalysis Determine urine compositionChest Xray Evaluate resp.status/ heart sizeECG Identify preexisting cardiac problem.
Psychosocial Assessment and Care
Causes of Fears of the Preoperative Clients
Fear of Unknown ( Anxiety )Fear of AnesthesiaFear of PainFear of DeathFear of disturbance on Body imageWorries
 – 
loss of finances, employment, social andfamily roles.
 Manifestation of Fears
- anxiousness- bewilderment- anger- tendency to exaggerate- sad, evasive, tearful, clinging- inability to concentrate- short attention span- failure to carry out simple directions- dazed
Nursing Intervention to Minimize Anxiety
Explore client’s feeling
 
Allow client’s to speak openly about fears/concerns
 Give accurate information regarding surgery(brief, direct to the point and in simple terms)Give empathetic support
Consider the person’s religious preference and
arrange for visit by a priest / minister as desired.
INFORMED CONSENT
 Purposes:
To ensure that the client understand the nature of the treatment including the potential complicationsand disfigurement
( explained by AMD )
To indicate that the client’s decision was made
without pressure.To protect the client against unauthorizedprocedure.To protect the surgeon and hospital against legalaction by a client who claims that an authorizedprocedure was performed.
Circumstances Requiring Consent
Any surgical procedure where scalpel, scissors,suture, hemostats of electrocoagulation may beused.Entrance into body cavity.Radiologic procedures, particularly if a contrastmaterial is required.General anesthesia, local infiltration and regionalblock.
 Essential Elements of Informed Consent
the diagnosis and explanation of the condition.a fair explanation of the procedure to be done andused and the consequences.a description of alternative treatment or procedure.a description of the benefits to be expected.material rights if any.the prognosis, if the recommended care, procedureis refused.
 Requisites for Validity of Informed Consent
Written permission is best and legally accepted.
Signature is obtained with the client’s complete
understanding of what to occur.
PREOPERATIVE PHASE
 
Lecture Notes on Perioperative NursingPrepared By: Mark Fredderick R Abejo R.N, MANMS Perioperative Nursing Abejo
3
- adult sign their own operative permit- obtained before sedationFor minors, parents or someone standing in theirbehalf, gives the consent.
 Note: for a married emancipated minor parentalconsent is not needed anymore, spouse is accepted 
For mentally ill and unconscious patient, consentmust be taken from the parents or legal guardianIf the patient is unable to write
, an “X” ia accepted
if there is a witness to his mark Secured without pressure and threatA witness is desirable
 – 
nurse, physician orauthorized persons.When an emergency situation exists, no consent isnecessary because inaction at such time may causegreater injury.
(permission via telephone/cellphoneis accepted but must be signed within 24hrs.)
 
 
 PREOPERATIVE CARE
Physical PreparationBefore Surgery
Correct any dietary deficiencies
Reduce an obese person’s weight
 Correct fluid and electrolyte imbalancesRestore adequate blood volume with BTTreat chronic diseasesHalt or treat any infectious processTreat an alcoholic person with vit. supplementation,IVF or fluids if dehydrated
Preoperative Teaching
 Incentive Spirometry
 
Encouraged to use incentive spirometer about 10 to12 times per hour.
 
Deep inhalations expand alveoli, which preventsatelectasis and other pulmonary complication.
 
There is less pain with inspiratory concentration thanwith expiratory concentration.
 Diaphragmatic Breathing
 
Refers to a flattening of the dome of the diaphragmduring inspiration, with resultant enlargement of upper abdomen as air rushes in. During expiration,abdominal muscles contract.
 
In a semi-Fowlers position, with your hands loose-fist, allow to rest lightly on the front of lower ribs.
 
Breathe out gently and fully as the ribs sink down andinward toward midline.
 
Then take a deep breath through the nose and mouth,letting the abdomen rise as the lungs fill with air.
 
Hold breath for a count of 5.
 
Exhale and let out all the air through your nose andmouth.
 
Repeat this exercise 15 times with a short rest aftereach group of 5.
Coughing
 
Promotes removal of chest secretions.
 
Interlace his fingers and place hands over theproposed incision site, this will act as a splint andwill not harm the incision.
 
Lean forward slightly while sitting in bed.
 
Breath, using diaphragm
 
Inhale fully with the mouth slightly open.
 
Let out 3-4 sharp hacks.
 
With mouth open, take in a deep breath and quicklygive 1-2 strong coughs.
Turning
 
Changing positions from back to side-lying (viceversa ) stimulates circulation, encourages deeperbreathing and relieve pressure areas
 
Help the patient to move onto his side if assistance isneeded.
 
Place the uppermost leg in a more flexed positionthan that of the lower leg and place a pillowcomfortably between the legs.
 
Make sure that the patient is turned from one side tothe back and onto the other side every 2 hours.
 Foot and Leg Exercise
 
Moving the legs improves circulation and muscletone.
 
Have the patient lie supine, instruct patient to bend aknee and raise the foot
 – 
hold it a few seconds andlower it to the bed.
 
Repeat above about 5 times with one leg and thenwith the other. Repeat the set 5 times every 3-5hours.
 
Then have the patient lie on one side and exercise thelegs by pretending to pedal a bicycle.
 
For foot exercise, trace a complete circle with thegreat toe.
Turning to the Side
 
Turn on your side with the uppermost leg flexed mostand supported on a pillow.
 
Grasp the side rails as an aid to maneuver to the side.

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