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Peri Operative Nursing

Peri Operative Nursing

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Published by John Ervin Agena
Peri Operative Nursing
Peri Operative Nursing

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Published by: John Ervin Agena on May 06, 2013
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Peri-operative Nursing

Perioperative Nursing
is used to describe the nursing care provided in the total surgical experience of a patient.

= The provision of nursing care by an RN preoperatively, intraoperatively, and postoperatively to a patient undergoing an operative or invasive procedure

Areas in Which Perioperative Nursing Is Practiced         Hospital operating rooms Interventional radiology suites Cardiac catheterization labs Endoscopy suites Ambulatory surgery centers Trauma centers Pediatric specialty hospitals Physician offices .

Nursing Roles in the OR       Circulating Nurse Scrub person RN first assistant (RNFA) Perioperative educator Specialty team leader Perioperative manager .

Surgical Attire Gowns Gloves Masks Hair covering Protective eyewear .

and correct procedure Knowledge of positioning Adhere to safe medication administration guidelines Perform surgical counts Provide a safe environment   Adhere to asepsis Promote coordinated and effective communication . correct level.Goals of Patient Safety Provide safe patient care      Knowledge of procedure Ensure the correct patient. correct site.

operative phase POST.Phases of Peri-operative period PRE.operative phase .operative phase INTRA.

PRE-Operative Phase Begins when the decision to have surgery is made and ends when the client is transferred to the operating table .

INTRA-Operative Phase Begins when the client is transferred to the operating table and ends when the client is admitted to the post-anesthesia unit .

Post-operative Phase Begins with the admission of the client to the PACU and ends when healing is complete .

Conditions requiring Surgery: Perforation = rupture of an organ. artery or bleb Tumor = abnormal growth Obstruction or Blockage Erosion = wearing away of a surface of a tissue .

TYPES of SURGERY According to PURPOSE According to degree of URGENCY According to degree of RISK .

Cleft palate Ablative Constructive Transplant Replaces malfunctioning structures ex. Nephrectomy Restores function or appearance. repair of a congenitally defective organ ex.According to PURPOSE Diagnostic Palliative To verify a suspected diagnosis Ex. Heart transplant . biopsy Relieves or reduces pain or symptoms Removes a diseased body part Ex.

Exploratory Laparotomy .Reconstructive – partial or complete restoration of a damaged organ Exploratory – to estimate extent of a disease  Ex.

According to degree of urgency Emergency surgery Preserves function or life Performed immediately Elective surgery Performed when condition is not imminently life threatening .

According to degree of RISK Major Surgery Involves high degree of risk Complicated or prolonged Minor Surgery Involves low risk Produces few complications Performed as day surgery .

Required or planned IV. weeks or month thyroid No emergency Personal preference CS. Emergent life threatening II Urgent or imperative III. Optional Indication for surgery Without delay 24-30 hrs examples trauma AP. Elective V. hernia Cosmetic surgery . Cholecystitis Plan within Cataracts.Classification I.

Other types of Surgery PROPHYLACTIC Prevents a more PREVENTATIVE serious condition from developing INPATIENT SURGERY OUTPATIENT SURGERY Client has been in the hospital prior to the decision to have a surgery Client enters the hospital to have surgery done .

nurses and hospital .Surgical Risk Extremes of age – premature baby & elderly persons Nutritional Status – malnourished & obese at risk General health – infectious process increase operative risk State of fluid and electrolyte balance – dehydration & hypovolemia predispose a client to post op complications Economic & occupational status Co-morbid conditions Concurrent medications – types of drugs taken regularly – anticoagulants can cause hemorrhage. antibiotics can combine with the anesthesia Mental health The extent of the disease The magnitude of the required operation Resources and preparation of the surgeon.

PRE –OP PREPARATIONS .

Activities in the Pre-op Assessing the clients Identifying potential or actual health problems Planning specific care Providing pre-operative teaching Ensure consent is signed .

PE and lab exam Provide pre-operative teaching as to the nature of surgery. enema. what to expect and ways to manage post-operative discomforts Perform physical preparations. NPO.shaving. hygiene.Pre-operative Interventions Obtain nursing history. medications .

Informed Consent The surgeon is responsible for obtaining the consent for surgery No sedation should be administered before SIGNING the consent The nurse may serve as witness This is to protect the surgeon and hospital against a claim that an unauthorized surgery was performed & patient is aware of potential risk of complications This is also to protect the patient in undergoing unauthorized surgery .

INFORMED CONSENT EMANCIPATED MINORS .below legal age of 18 but who is living independently from parents or those who are already living in with partners and with children of their own .

Hct etc) Renal preparation – routine urinalysis . Hgb.Physiologic Preparation Respiratory preparation – includes xray order by the surgeon Cardiovascular preparation – ex. CBC. ECG ( blood test eg.

Pre-op nutrition Assess order for NPO Solid foods are withheld for about 8 hours before general anesthesia WATER can be given up to 4 hours prior to surgery .

enemas or both may be prescribed the night before surgery Have the client void immediately BEFORE transferring them to the OR Foley catheter may be inserted as ordered .Pre-op elimination Laxatives.

dentures . hearing aids. contact lenses.Pre-op hygiene Bath the night before surgery with antiseptic soap Shaving of the skin is usually done in the OR Removal of jewelry and nail polish.

expected duration of hospitalization. probable outcome. length of absence from work and residual effects Be alert to the client‟s anxiety level Answer questions or concerns Allow time for privacy Pre-operative visits . cost.Pre-op psychological preparation Preparation for hospital admission – includes explanation of procedure to be done.

Preparing the skin Administering Preanesthetic medications Transporting the patient to the presurgical area .

vagolytic Muscle relaxant Anti-emetic Antibiotic Atropine Succinylcholine Promethazine Cephalosporin To prevent infection .Pre-operative medications Pre-op Drugs Example Purpose To decrease nervousness Promote relaxation Decreases secretions Prevent bradycardia To promote muscle relaxation To prevent nausea and vomiting Anti-anxiety Diazepam Anticholinergic.

Pre-operative medications Pre-op Drugs Example Purpose To decrease pain and decrease anesthetic dose Analgesics Meperidine Anti-histamine Diphenhydramine To decrease occurrence of allergy H-2 antagonist Cimetidine To decrease gastric fluid and acidity .

AST. Creatinine Evaluates the fluid and electrolyte status Evaluates diabetes mellitus Assess the renal function ALT. Bilirubin Evaluates the liver function Serum albumin CXR and ECG Evaluates nutritional status Respiratory and Cardiac status . infection Determined in case of blood transfusion Serum electrolytes FBS BUN.Pre-operative screening test CBC Blood type Determine Hgb and Hct.

Pre-operative teaching Leg exercises To stimulate blood circulation in the extremities to prevent thrombophlebitis Deep breathing and Coughing Exercises To facilitate lung aeration and secretion mobilization to prevent atelectasis and hypostatic pneumonia Done every two to four hours Positioning and Ambulation To circulation. stimulate respiration. decrease stasis of gas .

“SPLINT” thoracic & abdominal incision to minimize pain. Turning exercises – every 1-2 hours post op Extremity exercises – prevents circulatory problems & post-op “gas pains” or flatus. . Done 5-10 times every hour in post op period Coughing exercises – deep breathe.Instructional and Preventive aspects Note: The best time to instruct the client is relatively close to the time of the surgery DBE – use of diaphragmatic abdominal breathing. exhale through the mouth then follow with short breaths while coughing.

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Terminologies Analgesia – decrease pain Analgesic – drug to reduce pain Anesthesia – loss of sensation Anesthetic – drug that produces local or general loss of sensitivity Induction – start from anesthetic administration until pt. loses consciousness Narcosis – loss of consciousness .

OK ARE YOU READY SIR FOR YOUR OPERATION? .

Activities during the Intra-op Assisting the surgeon as scrub nurse and circulating nurse .

Intra-operative phase interventions Determine the type of surgery and anesthesia used Position client appropriately for surgery Assist the surgeon as circulating or scrub nurse Maintain the sterility of the surgical field Monitor for developing complications .

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Principles of Sterile Technique .

This adherence reflects one’s surgical conscience. which includes the: areas of the patient the operating table and furniture covered with sterile drapes and the personnel wearing the OR attire. .Principles of Sterile Technique Sterile field The patient is the center of the sterile field. Strict adherence to sound principles of sterile technique and recommended practices is mandatory for the safety of the patient.

it is the degree of adherence to them that varies. Maintenance of sterility and asepsis throughout the operative procedure 5. Preparation for operation by sterilization of necessary materials and supplies 2. The principles of sterile technique are applied in the following: 1. Terminal sterilization and disinfection at the conclusion of the operation . Preparation of the operating team to handle sterile supplies and intimately contact wound 3. to prevent contamination of the surgical wound 4. including the preparation and draping of the patient.Principles remain the same. Creation and maintenance of the sterile field.

. Persons who are sterile touch only sterile articles. Persons who are not sterile touch only unsterile articles. All supplies for the sterile team members reach them by means of the circulating nurse. A. Unsterile persons have not. Sterile persons have scrubbed and are gowned and gloved.The sterile technique is the basis of modern surgery. through the medium of sterile forceps or wrappers on sterile packages.

or basins may be obtained from the stock supply of sterile packages. Every person who dispenses a sterile article must be sure of its sterility and of its remaining sterile until used. such as instruments.B. Others. Proper packaging. may be sterilized immediately preceding the operation and removed directly from the sterilizer to the sterile table. Some items such as linen. and handling should provide such assurance. sterilizing. Only sterile items are used within the sterile field. . sponges.

If uncertain about actual timing or operation of sterilizer: Items processed in a suspect load are considered unsterile. if a sterile table or sterile articles are left unguarded and uncovered for more than 30 minutes 5. it must then be discarded.If you are in doubt about the sterility of anything. If sterile package falls to the floor. consider it not sterile. If unsterile person comes into close contact with a sterile table and vice-versa 4. for example: 1. Known or potentially contaminated items must not be transferred to the sterile field. If sterile package is found in the nonsterile workroom 2. . If sterile table or unwrapped sterile items are not under constant observation. 3.

C. Hands are kept away from the face. When wearing a gown. . consider only the area you can see down to the waist as the sterile area. Hands are never folded under arms because of perspiration in the axillary region. The following practices must be observed: 1. Gowns are considered sterile only from the waist to shoulder level in front. and the sleeves. Elbows are kept close to sides. Sterile persons keep hands in sight and at or above waist level. 2.

the area of the gown below waist must not brush against sterile tables or draped areas. Items dropped below waist level are considered unsterile and must be discarded. 4. Changing table levels is avoided.3. eg. it is discarded. If sterile person must stand on a platform to reach the operative field. when picking up a gown. if the top of the gown drops below waist level. .

In unfolding sterile drape. the part that drops below table surface is not brought back up to table level. Only the top of a sterile draped table is considered sterile. 1. Edges and sides of drape extending below the table level are considered unsterile. Scrub nurse does not touch the part hanging below table level. such as sutures are considered unsterile and are discarded. Tables are sterile only at table level. 2. . Anything falling over or extending over table edge. 3.D.

Persons who are sterile touch only sterile items or areas.E. Persons who are not sterile touch only unsterile items or areas. Supplies for sterile team members reach them by means of the circulating nurse who opens wrapper on sterile packages. 2. . 1. Sterile team members maintain contact with sterile field by means of gowns and gloves. Nonsterile circulating nurse does not directly come into contact with the sterile field. 3.

drapes a table away from her first. 1. 2. using sterile forceps. 5. The circulating nurse stands near the edge of the table to fill them. The circulating nurse. 4. Unsterile persons avoid reaching over a sterile field. The scrub nurse sets basin or glasses to be filled at the edge of the sterile table. The sterile nurse drapes a nonsterile table toward self first to protect gown. The circulating nurse stands at a distance from the sterile field to adjust the light over it. 3.F. Sterile persons avoid leaning over an unsterile area. . The surgeon turns away from the sterile field to have perspiration mopped from his brow.

G. Sterile persons lift contents from packages by reaching down and lifting them straight up. . 3. holding elbows high. ex: the edges of wrappers on sterile packages. 4. Edges of anything that encloses sterile contents are considered unsterile. The circulating nurse peels the cover of a solution bottle or test tube. 2. caps on solution bottles and test tube covers 1. Steam reaches only the area within the gasket of a sterilizer. Instrument trays should not touch the edge of the sterilizer outside the gasket. the tray must not touch the edge of the sterilizer when lifting it out. the edge of the cover never touches the lip. If the instruments are boiled.

It is difficult to uncover a table of sterile contents without contamination. Sterile field is created as close as possible to time of use. . 1. 2. Covering sterile tables for later use is not recommended. Sterile tables are set up just prior to the operation.H. Degree of contamination is proportionate to length of time sterile items are uncovered and exposed to the environment.

someone must remain in the room. Inadvertent contamination of sterile areas must be readily visible. 2. 1.I. . Sterile persons face sterile areas. or a sterile field is set up. Sterile areas are continuously kept in view. When sterile packs are opened in a room.

Allow a wide margin of safety when passing unsterile areas and follow these rules: 1. Sterile persons keep well within the sterile area. 4. Sterile person turns back to nonsterile person or area when passing.J. 2. 3. Sterile persons pass each other back to back. Sterile persons stand back at a safe distance from the operating table when draping the patient. . Sterile person faces sterile area to pass it.

7. They do not walk around or go outside the room. Sterile persons stay within and around a sterile field. 6. Movement within and around a sterile area is kept to a minimum to avoid contamination of sterile items or persons. . Sterile person asks nonsterile individual to step aside rather than risk contamination.5.

Sterile persons keep contact with sterile areas to a minimum. 1. .K. Sitting or leaning against a nonsterile surface is a break in technique. If the sterile team sits to operate. Sterile persons do not lean on sterile tables and on the draped patient. 2. they do so without proximity to nonsterile areas.

4. Unsterile persons avoid sterile areas. 2.L. A wide margin of safety must be maintained when passing sterile areas. Circulating nurse restricts to a minimum activity near sterile field. Unsterile persons maintain at least one foot distance from any area of the sterile field. 1. between sterile instrument tables. 3. eg. Unsterile persons face and observe a sterile area when passing it to be sure they do not touch it. Unsterile persons never walk between two sterile areas. .

Sterile packages are laid on dry surfaces. A package is considered nonsterile if any of it comes in contact with moisture. The integrity of a sterile package or sterile drape is destroyed by perforation.may transport bacteria to sterile area). 2. To ensure sterility: 1. Destruction of the integrity of microbial barriers results in contamination. it is resterilized or discarded. . puncture or strike-through (soaking of moisture through unsterile layers to sterile layers or vice versa.M. If sterile packages become damp or wet.

5. Sterile areas are stored in clean dry areas. Undue pressure on sterile pack is avoided to prevent forcing sterile air out and pulling unsterile air into the pack. . Drapes are placed on a dry field. the wet area is covered with impervious sterile drape or towels. 6. Packages wrapped in muslin or paper are permitted to cool after removal from the sterilizer to avoid steam condensation and resultant contamination. 8. 7. 4. If solution soaks through sterile drape to nonsterile area. Sterile packages are handled with clean dry hands.3.

Skin is a potential source of contamination in every operation. It is generally agreed that: 1. this does not obviate the necessity for sterile technique.N. Microorganisms must be kept to an irreducible minimum. . Although all the microorganisms cannot be eliminated. Perfect asepsis in the operative field is the ideal. Skin cannot be sterilized.

Preventive measures include: Transient and resident flora are removed from skin around operative site of patient and the hands and arms of sterile team members by mechanical washing and chemical antiseptics. c. (without touching with their bare hands) Sterile gloved hands do not directly touch skin and then deeper tissues. All possible means are used to prevent entrance of microorganisms into wound.a. . b. (shaved and scrubbed) Gowning and gloving of operating team is accomplished without contamination of sterile exterior of gowns and gloves.

If glove is pricked or punctured by a needle or instrument. Needle or instrument is discarded from sterile field. The knife used for the skin incision is placed in a specimen basin which thereafter is considered contaminated. all the skin area is covered except the site of incision. h. .d. glove is changed immediately. In draping. f. e. g. All operators scrub their hands and arms. Operators scrub between cases to remove bacteria that may have emerged from the pores with perspiration under the gloves.

Surgeon makes an effort to use a sponge only once. . Various parts of the body. nose.2. throat or anus. such as the GIT and the vagina. Some areas cannot be scrubbed. The following steps may be taken to reduce the number of microorganisms present in these areas and to prevent scattering them: a. When the operative field includes the mouth. the number of microorganisms is great. usually are resistant to infection from flora that normally inhabit these parts. then discards it.

colostomy is walled off from the operative site when possible . The GIT .b. .gastric route when possible . Measures are taken to prevent spreading this contamination.antibiotics given preoperatively .cautery when cutting across a lumen .septic routine clean-up after procedure on the colon . especially the colon. is contaminated.

Doors from corridors into the OR are kept closed. . . Examples of control measures: .OR attire is not worn outside the surgery suite. 4. .Talking is kept to minimum.Masks are worn over the nose and mouth. The team avoids spreading the contamination. not dry-swept as dust may float in the air for a long time.Sneezing and coughing are avoided.Wash hands before and after the care of each client. .Floors are wet-mopped.3. Air is contaminated by dust and droplets. . Infected areas are grossly contaminated. .(fit snugly) .

SUMMARY Principles of Sterile Techniques 1. it must be considered not sterile. 4. 2. Sterile surface touching sterile surface means sterile. Sterile surface touching un-sterile surface becomes contaminated. When there is doubt about the sterility of any item. Reaching across or above sterile with bare hands or arms or other non-sterile item must be avoided. . 3.

The wrapper of a sterile pack must be opened. 8. hands must be kept in sight. the lateral flaps next. Coughing. . away from the body. 7. and the proximal flap toward the body last.5. When wearing sterile gloves. Sterile materials must kept dry. 6. moisture transmits microorganism and contaminated. away from un-sterile objects and above waist level. thus it unnecessary to reach over the sterile field. the distal flap first. sneezing or unnecessary talking near or over a sterile field must be avoided.

10.The floor must be recognized as the most grossly contaminated area. 12. falls. If you do.The sterile field must be kept in sight at all times. or touches below these levels is considered contaminated.9. The sterile zone is confined to the tabletop or to above waist level. . you cannot be sure that it is still sterile.Any area of 1 inch or so surrounding the outer edge of the sterile field must be considered unsterile. Do not turn your back on it or leave. Clean or sterile items that fall on the floor should be discarded or decontaminated. 11. Anything that hangs.

SEDATION MINIMAL SEDATION MODERATE SEDATION DEEP SEDATION ANESTHESIA .

LEVEL OF ANESTHESIA: Minimal sedation .calm.cognitive function and coordination may be impaired Moderate sedation .Midazolam/Diazepam . sedate a patient combined with analgesic .depressed level of consciousness that does not impair ability to maintain a patent airway .drug induced state in which a patient can respond normally in verbal commands .

inhaled or intravenously .deep sedation is a drug induced state in which a patient cannot easily be aroused but can respond purposefully after repeated stimulation.Volatile anesthetic (halothane. Isoflurane) .Gas anesthetic (Nitrous oxide) .Deep Sedation . .

.ANESTHESIA means the absence of sensation.

Cardiovascular function may be affected as well . analgesia.state of narcosis (severe CNS depression produced by pharmacological agents). relaxation and reflex loss loses the ability to maintain ventilatory function and require assistance in maintaining a patent airway.

amnesia & unconsciousness characterized by loss of reflexes & muscle tone Regional or Local anesthesia  Loss of sensation in ONE area with consciousness present .Types of Anesthesia General anesthesia  Loss of all sensation and consciousness  State of analgesia.

cocaine 2. Pudendal block 5. Lidocaine ( emla).Types of Regional Anesthesia 1. Infiltration Anesthesia –injected into a specific area of the skin Types: 1. Epidural Block – injected into the epidural space 3. Nerve block – injected around a nerve 2. Caudal block 4. Spinal subarachnoid – low spinal anesthesia .Topical anesthesia –applied directly on the skin ex.

3. Procaine ( novocaine) Cocaine ( tetracaine) Lidocaine ( xylocaine) . Spinal anesthesia Saddle block ( used in vaginal delivery) 4. Local anesthesia    Ex.

nylons. wool or any material which can set off sparks Do not allow cautery to be used Do not touch the vicinity of the breathing area to prevent sparks Do not wear shoes that are not conductive Do not use bed materials that are not conductive. Examples: Volatile liquid – halothane.Safety rules:       Do not wear slips. ether Gas anesthetic – nitrous oxide. cyclopopane .

Methods of Anesthesia Administration Inhalation Intravenous Regional Anesthesia Conduction and spinal anesthesia Local Infiltration .

REGIONAL Anesthesia TOPICAL INFILTRATION Applied directly on the skin Injected into a specific area of skin NERVE BLOCK SPINAL Subarachnoid Injected around a nerve Low spinal anesthesia EPIDURAL Epidural space is injected with anesthesia .

GENERAL ANESTHESIA the patient is unconscious and does not see. . hear. or feel anything. muscle relaxation. and amnesia so you don't remember the details of your surgery. It provides pain relief.

= for prevention of pain & anxiety DISADV = circulatory & respiratory depression  Intravenous .GENERAL Anesthesia Administered in two ways:  Inhalational ADV.

G A: INHALATIONAL ADMINISTRATION .

G A: INTRAVENOUS ADMINISTRATION .

Advantages: pleasant odor Disadvantages: little pain relief (combined with other agents to control pain) Adverse reactions:   cardiac dysrhythmia Hepatotoxicity .G A: HALOTHANE is a powerful anesthetic and can easily be overadministered.

G A: ENFLURANE (ETHRANE) is less potent and results in a more rapid onset of anesthesia and faster awakening than halothane. Adverse reaction: Increases ICP and the risk of seizure (contraindicated among patients with seizure disorders) .

Isofluorane is often used in combination with intravenous anesthetics for anesthesia induction.G A: ISOFLURANE (FORANE) is not toxic to the liver but can cause some cardiac irregularities. . Awakening from anesthesia is faster than it is with halothane and enfluorane.

G A: SEVOFLURANE Does not cause cardiac arrhythmias and coughing that is why this is replacing halothane for induction of pediatric clients this agent is rapidly eliminated and allows rapid awakening .

NITROUS OXIDE (LAUGHING GAS) is a weak anesthetic and is used with other agents. . to produce surgical anesthesia. such as thiopental. Adverse effect: it diffuses rapidly into aircontaining cavities and can result in a collapsed lung (pneumothorax) or lower the oxygen contents of tissues (hypoxia). It has the fastest induction and recovery and is the safest because it does not slow breathing or blood flow to the brain.

Intravenous Anesthesia:. Thiopental sodium ( Pentothal Na) 2. Low incidence of N&V Disadvantages: 1. Ketamine ( ketalar) 3. Advantages: 1.usually employed as an induction prior to administration of the more potent inhalation anesthetic agents. Absence of explosive hazards 3. Hypotension 3. rapid pleasant induction 2. Laryngeal spasm & bronchospasm 2. Commonly used in minor operations. Mtethohexital ( Brevital) . Respiratory arrest Examples: 1. Fentanyl ( Innovar) 4.

POST. lightheadedness. or faintness drowsiness mood or mental changes nausea or vomiting sore throat nightmares or unusual dreams .G A Effects Headache vision problems. including blurred or double vision shivering or trembling muscle pain dizziness.

bradycardia Anaphylaxis CNS agitation.Potential adverse effects of anesthesia Myocardial depression. respiratory arrest Oversedation or under sedation Agitation and disorientation Hypothermia Hypotension Malignant hyperthermia . seizures.

PRECAUTION A complete medical history including a history of allergies in family members. even if there is no previous personal history of reaction. is an important precaution. WARNING SIGN: TACHYCARDIA . Patients may have a potentially fatal allergic response to anesthesia known as malignant hyperthermia (a muscular disorder induced by anesthesia).

Discharge Instructions post.GA Do not consume alcohol Do not drive a car or operate heavy machinery Do not sign any legal documents Do not make any important decisions Someone should stay with you at least for the first 24 hours after your surgery. .

Establishing AIRWAY PATENCY: ENDOTRACHEAL INTUBATION .

LARYNGOSCOPE

PURPOSES OF GENERAL ANESTHESIA pain relief (analgesia) blocking memory of the procedure (amnesia) producing unconsciousness inhibiting normal protective body reflexes to make surgery safe and easier to perform relaxing the muscles of the body

sensation of pain is not lost . sense inability to move extremities .Beginning Anesthesia or Analgesia) .noises are exaggerrated -NI: avoid unnecessary noises or motions .Stages of General Anesthesia Stage I (Stage of Induction .patient may be still conscious.

talking. REM Stage III: Stage of Surgical Anesthesia . crying. rapid pulse and irregular RR .pt unconscious and lies quietly . irregular respiration.may be maintained in hours if properly given .increased muscle tone.Stage II: Delirium or Excitement .Surgical anesthesia is reached .restrain the patient .respirations are regular and CR .pupils dilate. .Characterized by struggling.reflexes absent .extends from loss of eyelid reflexes to cessation of respiratory effort . shouting.extends from loss of consciousness to loss of eyelid reflexes .

Respiratory Paralysis.Without proper treatment death will follow .stage is reached when too much anesthesia is given .Discontinue anesthetic abruptly .Stage IV: Stage of Medullary Depression. pulse is weak and thready.RR become shallow. pupils widely dilated . Toxic Stage .

1. intrathecal (subarachnoid) . hernia repairs.g. appendectomy.INTRASPINAL ANAESTHESIA best reserved for operations below the umbilicus e. gynaecological and urological operations and any operation on the perineum or genitalia. epidural 2.

INTRASPINAL ANESTHESIA TETRACAINE .

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EPIDURAL ANESTHESIA .

INTRATHECAL (SUBARACHNOID) .

Patient Positioning Provides optimal visualization Provides optimal access for assessing and maintaining anesthesia and function Protects patient from harm .

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Position Patient during Surgery Abdominal surgeries Bladder surgery Perineal surgery Brain surgery Spinal cord surgeries Lumbar puncture Supine Slightly trendelenburg Lithotomy Semi-fowler‟s Prone mostly Side lying. flexed body .

. mastectomy Prone – for back and rectal surgery. cholecystectomy.Supine – for hernia repair. explore lap. This should be done gradually and slowly to adjust cardiovascular system to change in position. the patient will be returned to the supine position. ( Note: after surgery. Rapid turning can cause a drop in BP. Lateral position – used in kidney & chest surgery Lithotomy – thighs & legs are flexed at right angles & then simultaneously placed in a stirrup.

lungs or hips Modified Fowler’s – sitting position.Positions for Surgery Supine/ Dorsal – usual position for induction of general anesthesia and for entering the major body cavities Modified Trendelenburg – used for lower abdominal surgery and some lower extremity surgery Reverse Modified Trendelenburg – used for upper abdominal. used mostly in neurosurgery Modified jacknife – for rectal surgery . neck and face surgery Lithotomy – used in operation requiring perineal approach Prone – used in surgery on the posterior part of the body Lateral – used for operation on the kidneys.

Operating Room Team direct patient care team The team is likely a symphony orchestra Each person is an integral entity in harmony with his colleagues 1. THE STERILE TEAM 2. THE UNSTERILE TEAM

The Sterile Team

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Operating surgeon Assistants to the surgeon Scrub person They:
scrub their hands and arms Don sterile gloves and gown Enter the sterile field (all items for the surgical procedure are sterilized)

Unsterile team: Anesthesiologist Circulating nurse Technician They:


Don’t enter the sterile field Function outside of it Maintain sterile technique

SCRUB OUT !!!

Scrub duties .

instruments and sponges.R. •Draw medications properly. •Count needles. •Re-gown and glove when breaks in technique occur. mayo stand and O. basins). •Check instruments for proper functions. •Assist the 1st scrub in setting up case (back table.R. . mayo stand and O. •Gown and glove using closed glove technique. •Gown and glove surgeon and assistant.). •Prepare irrigating solution. •Arrange instruments and supplies (back table.Scrub duties •Perform surgical hand scrub. •Assist with draping.

Proper identification and handling of specimen. Help apply wound dressing. Transport soiled drapes and trash properly. sponge. suction and light handles for proper use. Pass instruments to surgeon and assistant. Discard soiled drapes and trash properly.Scrub duties Prepare electric cautery. Dispose of sharps properly. . Retract. Anticipate the surgeon and assistant needs. Anticipate the operative procedure needs. Prepare necessary sutures. and suction during case as necessary. Prepare instruments for decontamination at completion of case.

Circulating Responsibilities .

Gather all supplies. Arrange O.Circulating Responsibilities Clean operating room prior to case. Assist with IV therapy. . Assist with the skin preparation. Open and flip sterile supplies for the surgical procedure. Assist the anesthesiologist.R. furniture properly. instruments and equipment necessary for case. Tie gowns of the scrub nurse and surgeon.

Turn and help adjust lights as necessary. Supply the scrub nurse with necessary supplies. Help apply wound dressing. Pull case for following procedure. Receive and label specimen properly.Circulating Responsibilities Provide scrub personnel with sitting stools and foot stools as necessary. . Log and deliver specimen to pathology properly.

It is standard practice to count supplies (instruments. screws and sponges): •Before beginning a case •Before final closure •On completing the procedure . needles.SPONGE AND INSTRUMENT COUNTS It is essential to keep track of the materials being used in the operating room and during any complicated procedure in order to avoid inadvertent disposal or the potentially disastrous loss of sponges and instruments in the wound.

Pay special attention to small items and sponges. Create and make copies of a standard list of equipment for use as a checklist to check equipment as it is set up for the case and then as counts are completed during the case.The aim is to ensure that materials are not left behind or lost. When trays are created with the instruments for a specific case. such as a Caesarean section. also make a checklist of the instruments included in that tray for future reference. . Include space for suture material and other consumables added during the case.

Abdominal Surgical Incisions Paramedian – vertical incision ( rarely used – intestinal problems) Longitudinal midline –( middle laparotomy) begins at the level of the xiphoid to the supra pubic region ( for gastrectomy & intestinal ressection) Right Subcostal (Kochers) – from epigastric area and extends laterally & obliquely below the lower margin – biliary. spleen and liver .

Bilateral subcostal –Mercedes Benz or Chevron incision– liver transplant Mc Burney – for appendectomy Rocky Davis – for appendectomy Pfannenstiel – pelvic procedures. hysterectomy or CS Inguinal – inguinal herniorrhaphy .

Pancreaticoduodenectomy (Whipple‟s) 5. Pancreatectomy 6.A. ABDOMINAL SURGERY 1. Herniorrhaphy 3. Splenectomy 7. Bariatric Surgery . Cholecystectomy 4. Abdominal Laparotomy 2.

Breast Lifting . Breast Biopsy 3. Mammoplasty 4. Breast Augmentation. BREAST SURGERY 1.B. Mastectomy 2. Breast Repair.

Ceasarian Section – low transverse. Pfannensteil („bikini cut‟) . Vaginal/Abdominal Hysterectomy 3. Salphingo-Oophorectomy 5. OBSTETRIC & GYNECOLOGIC SURGERY 1.C. Tuboplasty of the Fallopian tubes 6. Perineorrhaphy 4. D & C 2. classical.

Ureterolithotomy 8.D. Nephrectomy 7. GENITOURINARY SURGERY 1. Pyelolithotomy . Orchiectomy 4. Transurethral Resection of the Prostate/Bladder (TURP/TURB) 6. Circumcision 2. Cystectomy 5. Vasectomy 3.

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fluid status. postop orders When stable. 2. surgical site. pain control. vital signs. . discharge to hospital room or home 1. recovery from anesthesia.Post-Anesthesia Care/Recovery Unit Immediate and continuous assessment every 15 minutes initially Check airway patency.PACU. drain. 3.

Activities in the POST-op Assessing responses to surgery Performing interventions to promote healing Prevent complications Planning for home-care Assist the client to achieve optimal recovery .

with passage of flatus and (+) gag reflex .POST Operative Interventions Maintain patent airway Monitor vital signs and note for early manifestations of complications Monitor level of consciousness Maintain on PROPER position NPO until fully awake.

POST Operative Interventions Monitor the patency of the drainage Maintain intake and output monitoring Care of the tubes. drains and wound Ensure safety by side rails up Pain medication given as ordered Measures to PREVENT post-op Complications .

position changes . massage.Post-operative interventions PAIN MANAGEMENT Pain is usually greatest during the 1236 hours after surgery Narcotic analgesics and NSAIDS may be prescribed together for the early period of surgery Provide back rub. diversional activities.

Post operative interventions POSITIONING Clients who have spinal anesthesia is usually placed FLAT on bed for 8-12 hours Unconscious client is placed side lying to drain secretions Other positions are utilized BASED on the type of surgery .

affected arm elevated Semi fowlers‟ . affected side Lateral. side-lying Fowler‟s Lateral. head midline Semi-prone. unaffected side .Post-operative Interventions Some Examples of Position Post Op Mastectomy Thyroidectomy Hemorrhoidectomy Laryngectomy Pneumonectomy Lobectomy Semi-fowlers‟.

Post-operative Interventions Some Examples of Position Post Op Aneurysmal repair (abdomen) Amputation of lower extremities Cataract surgery Supratentorial craniotomy Infratentorial craniotomy Spina bifida repair Fowler‟s 45 degrees Flat. with stump elevated with pillow Fowler‟s 45 degrees Fowlers‟ Flat on bed. supine Prone .

Tonsillectomy – prone or side lying .

PARAMETERS to consider before discharging a postop patient from PACU: 1. RESPIRATION – can deep breath and cough 3. CIRCULATION 4. ACTIVITY – can move all 4 extremities 2. COLOR . CONSCIOUSNESS – fully awake 5.pink .

circulatory.Post-operative Interventions Deep breathing and coughing exercises Q2-4 hours  to remove secretions Leg exercises Q 2 hours  to promote circulation Ambulation ASAP prevents respiratory. urinary and gastrointestinal complications .

either gastro or respiratory to relieve distention. usually given when bowel sounds and gag reflex return . to remove respi secretions Diet progressive.Post-operative Interventions Hydration after NPO to maintain fluid balance Suction.

Wound Care Inspect dressing hourly Change dressing daily Inspect for signs of infection redness. purulent exudate Maintain wound drainage . swelling.

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Diet NPO usually immediately after surgery Progressive diet Assess the return of the bowel sounds .

butter Yogurt Puddings Custard Ice cream and sherbet Soft diet All CL and FL plus: Meat Vegetables Fruits Breads and cereals Pureed foods .Liquid Diet Vs Soft diet Clear liquid Coffee Tea Carbonated drink Bouillon Clear fruit juice Popsicle Gelatin Hard candy Full liquid Clear liquid PLUS: Milk/Milk prod Vegetable juices Cream.

Urinary Elimination Offer bedpans Allow patient to stand at the bedside commode if allowed Report to surgeon if NO URINE output noted within 8 hours post-op .

Vibration. Percussion. and removal of secretions by SUCTIONING or Coughing followed lastly by oral hygiene .CPT Chest Physiotherapy Chest physiotherapy is based on the fact that mucus can be knocked or shaken form the walls of the airways and helped to drain from the lungs. The usual SEQUENCE is as followsPOSITIONING.

Chest Physiotherapy .

The incentive spirometer measures roughly the inspired volume and offers the “incentive” of measuring progress .Incentive Spirometry This operates on the principle that spontaneous sustained maximal inspiration is most beneficial to the lungs and has virtually no adverse effects.

Incentive Spirometry .

SPLINTING WHILE COUGHING .

SPLINTING WHILE COUGHING .

LEG EXERCISES .

POSTMASTECTOMY EXERCISES .

POSTMASTECTOMY EXERCISES .

POSTMASTECTOMY EXERCISES .

POSTMASTECTOMY EXERCISES .

Post operative complications Atelectasis Assess breath Collapsed alveoli due to sounds Repositioning secretions Pneumonia Inflammation of alveoli Deep breathing and coughing Chest physio Suctioning Ambulation Thrombophlebitis Inflammation of the veins Leg exercises Monitor for swelling Elevated extremities .

ATELECTASIS .

PNEUMONIA .

DEEP VENOUS THROMBOSIS *HOMAN‟S SIGN .

DEEP VENOUS THROMBOSIS (+)HOMAN‟S SIGN .

EMBOLUS: MIGRATION OF A CLOT

Post-operative Complications
Hypovolemic Loss of Shock circulatory fluid volume
Shock position Determine cause and prevent bleeding O2, IVF
Encourage ambulation Provide privacy Pour warm water Catheterize

Urinary retention

Involuntary accumulation of urine

Pulmonary embolism

Embolus blocking the lung blood flow

Notify physician Administer O2w

HYPOVOLEMIC SHOCK
MODIFIED TRENDELENBURG

Post-operative complications
Constipation Infrequent passage of stool
High fiber diet Increased fluid Ambulation

Paralytic ileus Absent bowel Encourage ambulation sound Wound infection
NPO until peristalsis returns Occurs about Daily wound dressing 3 days after Antibiotics surgery Maintain drain

WOUND DISRUPTION .

Post-operative complications Wound dehiscence Cover the wound Separation of wound edges at with sterile normal the suture line saline dressing Place in lowFowler‟s Notify MD Wound evisceration Cover the wound Protrusion of with saline pad the internal Place in loworgans and tissues through fowler‟s Notify MD wound .

Wound dehiscence .

Wound DEHISCENCE .

Wound evisceration .

INCISIONAL HERNIA .

INCISIONAL HERNIA .

INCISIONAL HERNIA .

WOUND HEALING PRIMARY INTENTION SECONDARY INTENTION TERTIARY INTENTION .

To emphasize The over-all goal of nursing care during the PRE-OPERATIVE phase is to prepare the patient mentally and physically for the surgery .

To emphasize The over-all goal of nursing care during the INTRA-OPERATIVE phase is to maintain client safety .

To emphasize The over-all goals of nursing care during the POST-OPERATIVE phase are to promote healing and comfort. restore the highest possible wellness and prevent associated risk .

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