Perioperative Nursing

A. Preoperative period 1. Begins with decision to perform surgery and ends when client enters operating room; the surgery may be inpatient or outpatient 2. Types of surgery a. purpose i. diagnostic ii. curative iii. transplant iv. palliative v. cosmetic b. urgency of surgery i. elective: performed on basis of client's choice, not essential for health ii. urgent: necessary for client's health iii. emergency: must be done immediately to save client's life c. seriousness i. minor: minimally alters body parts, with less ris ii. ma!or: e"tensively reconstructs or alters body parts; greater ris #. $edical conditions that increase the ris of surgery a. bleeding disorders b. heart disease c. diabetes mellitus d. upper respiratory infection e. liver disease f. chronic respiratory disease g. immunological disorders h. drug abuse %. &re'anesthetic medications a. sedatives'hypnotics b. narcotics c. anticholinergics d. tran(uili)ers*antian"iety agents e. +2'receptor antagonists ,. -ursing interventions during preoperative period a. provide psychological support b. e"plain the procedures surrounding the surgery c. teach client i. type of surgery to be performed ii. deep breathing and coughing iii. post'op incisional splinting iv. comfort measures to be used post'operatively v. movement vi. elimination d. obtain baseline vital signs e. administer pre'anesthetic medications as ordered f. administer prophylactic antibiotics if ordered g. remove nail polish and ma eup h. help client to empty bladder i. chec client's identification bracelet !. provide for client safety . remove any dentures or prostheses l. chec that pre'op permit .informed consent/ has been signed and appropriate lab wor is documented m. chec for allergies n. ensure that right site protocol is in use Intraoperative period 1. 0urgery usually ta es place in operating suite 2. 1nesthesia, general

B.

a. b.

c.

d.

drug'induced analgesia, amnesia, muscle rela"ation, and unconsciousness stages: i. induction: start of anesthetic administration, client becomes drowsy and loses consciousness ii. e"citement: muscles become tense and almost spasmodic iii. swallowing and vomiting refle"es remain, may breathe irregularly iv. surgical anesthesia: 2. muscle rela"ation occurs 22. breathing becomes regular 222. vital functions and refle"es are depressed 23. operation begins v. complete respiratory depression types of anesthetic agents i. inhalation: gas and li(uid: nitrous o"ide, cyclopropane halothane, enflurane, ether, metho"yflurane ii. intravenous agents: methohe"ital, sodium thiopental iii. dissociative agents: .no loss of consciousness/ etamine iv. neuroleptics: fentanyl citrate with droperidol ad!uncts to general anesthesia:

#. 4omplication of general anesthesia: malignant hyperthermia a. rapid progressive rise in body temperature b. fatal if not treated c. findings i. tachycardia ii. tachypnea iii. unstable blood pressure iv. diaphoresis .sweating/ v. muscle rigidity d. thought to be caused by alteration of calcium'storing properties of muscle'cell membrane e. familial tendency f. treatment ' dantrolene .5antrium/: s eletal muscle rela"ant g. nursing interventions in malignant hyperthermia

i. administer medications as ordered ii. teach client to wear $edic1lert !ewelry %. -ursing interventions during the intraoperative period a. ensure right site protocol is in use b. provide emotional support during anesthesia induction c. provide for client safety during procedure d. position the client as ordered by procedure e. maintain surgical asepsis f. monitor for electrical ha)ards g. monitor client for effects of heat loss during surgery h. immediately after surgical drapes are removed, apply warm blan ets 1. Principles of Surgical Asepsis 1 sterile ob!ect remains sterile only when touched by another sterile ob!ect. 0terile touching sterile remains sterile. 0terile touching clean becomes contaminated. 0terile touching contaminated becomes contaminated. 0terile touching (uestionable is contaminated. 6nly sterile ob!ects may be placed on a sterile field. 1 sterile ob!ect or field out of range of vision, or an ob!ect held below a person's waist, is contaminated. -ever turn your bac on a sterile field. 1 sterile ob!ect or field becomes contaminated by prolonged e"posure to air. 7hen a sterile surface comes in contact with a wet, contaminated surface, the ob!ect or field becomes contaminated by capillary action. 1lways hold your hands above the level of your elbows. The edges of a sterile field or container are considered contaminated.

2. #. %. ,. 8. 9.

C. Postoperative period I: recovery and discharge home 1. 1nesthesia recovery period ' may range from a few hours to 2# hours a. surgical recovery: priority nursing interventions

b. recovery complications and how to react: c. provide emotional support and reorientation d. assist with notifying the family that the surgery is complete and of the general condition of the client

2. &ost recovery: for clients discharged to home a. discharge criteria include these nine achievements i. ade(uate respiratory function ii. intact gag refle" iii. ability to deep breathe and cough iv. stable vital signs v. normal level of consciousness and muscle strength vi. ability to ambulate with assistance vii. ability to retain oral fluids viii. ability to urinate i". ability to care for incision and any drainage tubes ". flatus*bowel sounds all % (uadrants of abdomen b. instruct clients in eight areas i. medications and side effects ii. care of incision iii. care of any drainage apparatus iv. any re(uired treatments v. findings of infection vi. activity progression or limitation vii. special dietary restrictions viii. when to contact the physician D. Postoperative period II: transfer to a medical-surgical unit 1. 1cute pain management a. temporary pain occurring after a body in!ury i. disappears when in!ury is healed ii. monitor location, severity, (uality, progression and alleviation of pain iii. administer pain medications as ordered .information about pain medications can be found in Pharmacological and Parenteral Therapies/ iv. provide noninvasive pain relief measures as ordered massage distraction

rela"ation hypnosis v. assist with invasive pain relief measures as ordered acupuncture nerve bloc s 2. 6ther postoperative care a. provide restful environment b. encourage the client to turn, breathe deeply and cough c. encourage the client to change position every hour d. assist the client out of bed, an order is re(uired following nec and bac surgery e. change dressing as needed f. use sterile techni(ue g. observe and record amount, color, odor of drainage on dressing h. observe incision for intactness, findings of infection i. assist with 15:s as indicated !. ambulate client, may re(uire physical therapy in some facilities . teach client ; ; ; ; ; to splint incision during coughing wound care importance of progressive activity medications and side effects findings of infection

b. monitorTfor complications P!" #$ PAIN 1. 0uperficial 1. 1rises from local tissues 2. <sually related to a nerve ending disturbance #. :ocali)ed; usually described as constant, sharp, tingling or throbbing B. 3isceral 1. 1rises from somatic structures 2. 5eep pain; may be dull or aching 4. =eferred ' &ain felt in another area separate from source of pain 5. 4entral 1. 4aused by in!ury to central nervous system 2. 3ery intense pain; burning C%A""I$ICATI#N" #$ "&'(ICA% )#&ND" '!%ATI*! T# 'I"+ #$ IN$!CTI#N The higher the class, the higher the ris : a class 23 wound carries much more ris than a class 2. 1. 4lass 2 .clean wound/ 1. -o brea in sterile techni(ue 2. -o inflammation encountered #. >2, =espiratory or >< tract not entered B. 4lass 22 .clean'contaminated wound/ 1. >2, >< or respiratory tract entered with no spillage of contents 2. $inor brea s in techni(ue #. 6perations involving the biliary tract, appendi", vagina, and oropharyn" 4. 4lass 222 .contaminated wound/ 1. 1cute inflammation without pus 2. 0pillage from a hollow viscus occurs #. Trauma from a clean source 5. 4lass 23 .dirty/ 1. &us or a perforated viscus 2. Trauma from a dirty source #. 6rganism causing infection present before surgery %. 0urgical variables that increase ris of infection ,. &rolonged preoperative hospital stay 8. Body location of surgery 9. 0urgical techni(ue: delayed wound closure, e"cess blood loss, presence of drain, improper suture tension ?. &resence of bacteria at closure

#. 4omplications a. wound complications i. dehiscence: complete separation of wound edges or ii. evisceration: wound edges separate; viscera protrude cause: obesity; malnutrition; too much coughing*straining cover with gau)e soa ed in sterile saline and report immediately eep client in flat position iii. infection b. circulatory complications: thrombosis and embolism c. fluid and electrolyte imbalance d. urinary retention i. finding: inability to void ii. causes include trauma to the bladder or its nerve supply during surgery, edema around bladder nec ; refle" spasm due to drugs; spinal or epidural anesthesia iii. interventions encourage ambulation run water so client can hear sound pour warm water over perineum warm bath catheteri)ation if indicated

1. 2. #. %. ,. 8. 9. ?. A.

,I(, 'I"+ ('#&P" $#' P#"T-#P IN$!CTI#N" 2mpaired immunologic system @"tremes of age 5iabetes mellitus 4orticosteroid therapy 4hemotherapy 2nfection elsewhere in the body $alnutrition &resence of staphylococcus aureus on client 4ontaminated environment where in!ury or trauma occurred

e. paralytic ileus i. diminished or absent peristalsis ii. caused by stress response to surgery and anesthesia, trauma or manipulation of abdominal contents, electrolyte imbalance, anesthetics and pain medications, wound infections and immobility iii. occurs to some degree following all abdominal surgeries iv. bowel sounds return gradually over several days v. findings decreased or absent bowel sounds abdominal distention feeling of fullness

f.

interventions withhold fluids until presence of bowel sounds encourage ambulation nasogastric decompression if ordered vii. return of peristalsis signaled by presence of bowel sounds, flatus or bowel movement nausea and vomiting i. caused by anesthetics and analgesics, gastric distention, surgical manipulation, pain, electrolyte imbalance ii. interventions limit oral inta e administer antiemetics as tolerated measure drainage observe color, amount and odor of drainage progress client food inta e: begin with clear li(uids and progress to full diet as tolerated record inta e and output

vi.

)ound drain 1. 2. =emoval of wound drainage Types a. closed drain i. drain attached to collection system ii. uses vacuum to draw drainage into system iii. e"ample: Bac son'&ratt, +emovac iv. specific nursing interventions 2. maintain patency of drain 22. empty collection system and reactivate suction device 222. record amount and characteristics of drainage 23. asepsis 3. standard precautions b. open drain i. removes drainage from wound, deposits it on s in surface ii. e"ample: &enrose drain iii. safety pin usually attached to outside end of drain iv. specific nursing interventions v. prevent inadvertent removal of drain 2. protect s in 22. record characteristics of drainage 222. asepsis 23. standard precautions vi. protect s in surface from irritating effects of drainage vii. wound vacuum 2. removes and collects infectious material from wound 22. computer controlled 222. re(uires a seal at wound site with pressure distributing wound pac ing 23. client may be discharged with device

Dressings- compresses- .andages- irrigation 1. <ses of dressings a. promote healing by absorbing drainage and debriding a wound

2.

b. protect wound from contamination c. promote thermal insulation of wound d. protect wound from further in!ury e. prevent the spread of microorganisms f. control bleeding g. comfort Types of dressing for simple wounds a. most of these are changed daily or more fre(uently

#. Types of dressing for complicated wounds: a. most of these remain on wound over a few days

%. -ursing interventions a. e"plain procedure to client b. maintain standard precautions c. change dressing as ordered according to institutional procedure d. maintain asepsis e. ma e sure dressing is secure f. document i. type and amount of drainage ii. presence of drains iii. condition of wound g. observe for signs of infection h. watch moist dressings for growth of yeast i. weigh dressing if ordered !. teach client i. type and purpose of dressing ii. how to change dressing if change re(uired after discharge iii. findings of wound healing iv. findings of complications, e.g. infection ,. 4ompresses a. moistened piece of gau)e dressing b. may be warm or cool c. uses i. improve circulation ii. reduce edema iii. promote consolidation of pus d. nursing interventions

e"plain procedure to client change warm compresses fre(uently or apply a(uathermic pad to maintain temperature 8. Bandages and binders a. made of gau)e, elastic nit or webbing, muslin or flannel b. uses i. provide e"tra protection ii. create pressure over body part iii. immobili)e body part iv. support a wound v. reduce or prevent edema vi. secure dressings c. bandage types i. circular ii. spiral iii. spiral reverse iv. figure eight v. recurrent d. binder types .illustration / i. abdominal ii. T binder iii. breast e. nursing interventions i. e"plain procedure to client ii. ensure that bandage or binder is not constrictive iii. tell client to report any discomfort with bandage or binder iv. replace soiled bandages and binders

i. ii.

9. 0lings a. supports arm with muscular sprain or fracture b. may be commercially made or home made c. nursing interventions i. e"plain procedure to client ii. support affected e"tremity while applying sling iii. place sling outside normal clothing ?. 2rrigation a. flushing with solution b. uses i. to remove foreign matter or e"udate ii. to ensure patency of drainage tubing iii. involves instilling a solution and withdrawing that solution c. types i. urinary ii. wound iii. nasogastric*gastrostomy*!e!unostomy iv. arterial line v. ostomy vi. ear vii. vagina .douche/ viii. colonic .enema/ i". central line or peripheral 23 ". bladder