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PERIOPERATIVE NURSING

Basic Concepts
najARRIETA, RN, RM, MANc
Perioperative Nursing

! The total surgical episode is called the


perioperative period
› Preoperative Phase – starts when an informed
consent for surgery has been given until the
patient is placed on the surgical table
› Intraoperative phase – starts from the patient
being placed on the surgical table until
patient is endorsed to the Post-Anesthesia
Care Unit

Perioperative Nursing
Perioperative Nursing
› Post-Operative Phase – begins when the client
is admitted in the PACU and extends through
follow-up home or clinic evaluation
! A perioperative nurse is a registered nurse
who uses the nursing process to design,
plan, and deliver care to meet identified
needs of a client whose protective reflexes
or self-care abilities are potentially
compromised because of the operative
procedures.
Perioperative Nursing
Categories of Surgery

! Optional surgery – is done totally at the


client’s discretion (ie cosmetic surgery)
! Elective surgery – refers to procedures
that are scheduled at the client’s
convenience (ie removal of cyst, repair
of scars, simple hernia, or vaginal repair)
! Required surgery – is warranted for
conditions necessitating intervention
within a few weeks (ie cataract surgery,
tyroid disorders)
Perioperative Nursing
Categories of Surgery

! Urgent or imperative surgery – is


indicated for a problem requiring
interventions within 24 to 48 hours (ie
acute gallbladder infection, appendicitis,
kidney stones)
! Emergency surgery – describes
procedures that must be done
immediately to sustain life or maintain
function (ie repair of ruptured aortic
aneurysm, gunshot, knife wounds)
Perioperative Nursing
The Perioperative Team

! An anesthesiologist or nurse anesthetist


makes preoperative assessment to plan
the type of anesthetic to be administered
and to evaluate client’s physical status
! A professional registered operative room
nurse makes preoperative nursing
assessments and documents the
intraoperative client care plan

Perioperative Nursing
The Perioperative Team

! The surgeon performs the surgical


procedures and heads the surgical team.
! The registered nurse first assistant’s
responsibilities may include handling
tissue, providing exposure at the
operative field, suturing, and maintaining
hemostasis.

Perioperative Nursing
The Perioperative Team
! The circulating nurse manages the operating
room and protects the safety and health
needs of the client by monitoring the
activities of the members of the surgical
team and monitoring conditions in the
operating room
! The scrub nurse is responsible for scrubbing
for surgery, including setting-up the sterile
tables and equipment and assisting the
surgeon and surgical technicians during the
intraoperative period
Perioperative Nursing
The Perioperative Team

! The PACU nurse is responsible for caring


for the client until the client has
recovered from the effects of anesthesia,
is oriented, has stable vital signs, and
shows no evidence of hemorrhage

Perioperative Nursing
Preoperative Nursing Process
Overview
! Assessment
› Identify any obvious risk factors for surgery
related complications
› Assess respiratory status
" Dyspnea and complaints of SOB
" Upper respiratory infection
" Cough and wheezing
" Copious mucus
" Clubbed fingers
" History of smoking
Perioperative Nursing
Preoperative Nursing Process
Overview
› Assess cardiovascular status
" Blood pressure
" Pulse rate (apical is preferred)
" Electrocardiographic readings
" Presence and amplitude of peripheral pulses
› Assess for and report evidence of F/E
imbalance
" Dehydration/hypervolemia
" Vomiting, diarrhea, bleeding
" Abnormal serum electrolyte readings
Perioperative Nursing
Preoperative Nursing Process
Overview
› Assess hepatic and renal function
" History of liver disease (cirrhosis, alcoholism)
" Complaints of dysuria oliguria, or anuria,
incontinence, or urinary tract infections
" Urinalysis results
› Examine client’s records for endocrine or
metabolic problems that could affect his
responses to surgery (ie Diabetes mellitus)

Perioperative Nursing
Preoperative Nursing Process
Overview
› Assess immunologic and hematologic
function
" History of allergies
" Previous reactions to blood transfusions
" Immunosuppresed status
" History of substance abuse
› Assess neurologic function
" History of seizures or other neurological
disorders
" Level of consciousness, mental status,
orientation
Perioperative Nursing
Preoperative Nursing Process
Overview
› Assess integumentary status
" Bleeding tendencies
" Contusions, abrasions, or skin breakdown
› Evaluate medication history that could
increase risk by affecting coagulation time or
interacting with anesthetics
" Steroids
" Diuretics
" Phenothiazines
" Antibiotics
" Anticoagulants
Perioperative Nursing
Preoperative Nursing Process
Overview
› Assess the client for any type of prosthetic
device or metal implants (ie false eye, hip or
knee replacements, pacemakers)
› Assess the client and his family’s knowledge
base
› Consider psychosocial factors that could
affect client’s responses to surgery such as:
" Anxiety and fear
" Defense mechanism
" Self-esteem and body-image concerns
Perioperative Nursing
Preoperative Nursing Process
Overview
! Implementation
› Discuss the surgical experience with the client
and his family to minimize anxiety and
increase knowledge
" Provide a quiet, non-threatening atmosphere
when teaching the client and his family
" Present information at the appropriate
education level of the client, include any
written or visual information, and allow time for
questions and answers

Perioperative Nursing
Preoperative Nursing Process
Overview
! Acquire consent
› Consent is a legal document that signifies
that the client has been told about and
understands all aspects of a specific invasive
procedure.
› Signing should be witnessed.
› Client must be mentally competent and of
legal age or is an emancipated minor
› Should the client fail the above requirement,
a guardian is necessary
Perioperative Nursing
Preoperative Nursing Process
Overview
› Discuss exactly what will happen from the time
the client is being prepared for surgery (ie no oral
intake, removing clothes, jewelry, prosthetics, or
dentures), including when the client will be taken
to the operating room by stretcher, how cold the
operating room will be, the time waiting in the
operative area, and waking up in the
postanesthesia care unit
› Discuss the approximate length of time of surgery
and where the family members should wait for
the surgeon to discuss the client’s surgery

Perioperative Nursing
Preoperative Nursing Process
Overview
› Provide client and family teaching
" Deep breathing and coughing exercises
" Relaxation techniques
" Postoperative exercises of extremities
" Turning and moving techniques
" Pain-control techniques
" Incentive spirometry use
› Perform preoperative skin preparation as
appropriate

Perioperative Nursing
Diaphragmatic Breathing

Perioperative Nursing
Splinting with Coughing

Perioperative Nursing
Foot Exercises

Perioperative Nursing
Leg Exercises

Perioperative Nursing
Preoperative Nursing Process
Overview
› Provide GI preparation as prescribed
" Restricting solid and fluid for 8 to ten hours
" Posting an NPO sign at the client’s bedside
" Administering an enema and inserting a
nasogastric tube as prescribed
› Perform standard preoperative procedures
" Take and record vital signs
" Verify identity
" Complete preoperative medical orders
" Remove jewelry, nail polish, dentures, hairpins
Perioperative Nursing
Preoperative Nursing Process
Overview
" Have the client void and don a clean hospital
gown
" Remove eyeglasses, contacts, and hearing
aids, or send labeled containers with the client
to the OR for safe placement in case removal is
necessary
" Administer preanesthetic medications and
instruct client to stay in bed
› Ensure safe transport of the client to the
surgical suite, transfer patient to the bed

Perioperative Nursing
Principles of Surgical Asepsis

! The surgical environment


› Three zones:
" Unrestricted zone – where street clothes are
allowed
" Semi-restricted zone – where scrub suits and
caps are worn
" Restricted zone – where scrub clothes, caps,
masks, and shoe covers are worn
› OR attire includes close-fitting cotton dresses,
pantsuits, jumpsuits, and gowns
Perioperative Nursing
Perioperative Nursing
Perioperative Nursing
Principles of Surgical Asepsis

› Shirts and waist drawstrings should be tucked


› Masks are worn at all times, the mask may be
on or off and does not hang around the
neck; masks are not to be worn outside the
operating room
› Headgear should completely cover the the
hair
› Shoes should be supportive and comfortable.
Shoes worn outside must be covered with
shoe covers.
Perioperative Nursing
Principles of Surgical Asepsis

! Operating room personnel must practice


strict standard precautions (ie blood and
body substance isolation)
! All items (ie instruments, needles, sutures,
dressings, covers, solutions) used in the
operating room must be sterile
! All operating room personnel must
perform a surgical scrub

Perioperative Nursing
Perioperative Nursing
Principles of Surgical Asepsis
! All operating room personnel are required to
wear specific, clean attire, with the goal of
“shedding” the outside environment.
Specific clothing requirements are
prescribed and standardized for all
operating room.
! Any personnel who harbor pathogenic
organisms (ie those with colds or infections)
must report themselves unable to be in the
operating room to protect the client
Perioperative Nursing
Principles of Surgical Asepsis

! Scrubbed personnel wearing sterile attire


should touch only sterile items
! Sterile gowns and sterile drapes have
defined borders of sterility. Sterile surfaces
or articles may touch other sterile
surfaces or articles and remain sterile;
contact with unsterile object at any point
renders a sterile area contaminated

Perioperative Nursing
Principles of Surgical Asepsis

! The circulator and unsterile personnel


must stay at the periphery of the sterile
operating area to keep the sterile area
free from contamination
! Sterile supplies are unwrapped and
delivered by the circulator following
specific standard protocols so as not to
cause contamination

Perioperative Nursing
Principles of Surgical Asepsis

! The utmost caution and vigilance must


be used when handling sterile fluids to
prevent splashing or spillage.
! Anything that is used for one client must
be discarded or, in some cases,
resterilized.

Perioperative Nursing
Positions: Factors to Consider
! The patient should be in as comfortable a
position as possible, whether asleep or
awake.
! The operative field must be adequately
exposed.
! An awkward position, undue pressure on a
body part, or use of stirrups or traction should
not obstruct the vascular supply.
! Respiration should not be impeded by
pressure of arms on the chest or by a gown
that constricts the neck or chest.
Perioperative Nursing
Positions: Factors to Consider
! Nerves must be protected from undue pressure.
Improper positioning of the arms, hands, legs, or
feet may cause serious injury or paralysis.
Shoulder braces must be well padded to
prevent irreparable nerve injury, especially when
the Trendelenburg position is necessary.
! Precautions for patient safety must be observed,
particularly with thin, elderly, or obese patients,
or those with a physical deformity.
! The patient needs gentle restraint before
induction in case of excitement.

Perioperative Nursing
Perioperative Nursing
Perioperative Nursing
Perioperative Nursing
Perioperative Nursing
The Surgical Experience

! Minimal Sedation
› is a drug-induced state during which the
patient can respond normally to verbal
commands. Cognitive function and
coordination may be impaired, but
ventilatory and cardiovascular functions
are not affected.

Perioperative Nursing
The Surgical Experience

! Moderate sedation
› Depressed level of consciousness that does
not impair the patient’s ability to maintain a
patent airway and to respond appropriately
to physical stimulation and verbal command.
› May be used alone or in combination with
local, regional, or spinal anesthesia

Perioperative Nursing
The Surgical Experience

! Deep Sedation
› Drug induced state which a patient cannot
be easily aroused.
› Gas anesthetics are administered by
inhalation and joined with oxygen.
› Included in this group are halothane
(Fluothane), enflurane (Ethrane), isoflurane
(Forane), sevoflurane (Ultrane), and
desflurane (Suprane).

Perioperative Nursing
Anesthesia

! Anesthesia is a state of narcosis (severe


central nervous system depression
produced by pharmacologic agents),
analgesia, relaxation, and reflex loss.
! Not arousable even with painful stimuli.
! There is loss of ability to maintain
ventilatory function, likewise,
cardiovascular function may be
impaired.
Perioperative Nursing
Types of Anesthesia

! General Anesthesia (inhaled or IV) refers


to drug-induced depression of the
central nervous system that produces
analgesia, amnesia, and
unconsciousness (affects whole body)
! Stages:
› Beginning
› Excitement
› Surgical Anesthesia
› Danger
Perioperative Nursing
Anesthetic Delivery Methods

Perioperative Nursing
Types of Anesthesia

! Regional Anesthesia is a form of local


anesthesia that suspends sensation and
motion in a body region or part; the
client remains awake. Continuous
monitoring is required in the event the
block is not totally effective and the
client experiences pain or nausea and
cardiovascular collapse.

Perioperative Nursing
Types of Anesthesia

! Spinal Anesthesia is a local anesthetic


injected into the subarachnoid space at
the lumbar level to block nerves and
suspend sensation and motion to the
lower extremities, perineum, and lower
abdomen.

Perioperative Nursing
Types of Anesthesia

! Conduction Blocks sensation and motion


on various groups of nerves, such as
epidural block (ie anesthetic around the
dura mater), brachial plexus block (ie
produces anesthesia of the arm),
paravertebral block (ie produces
anesthesia of the chest, abdominal wall,
and extremities), and transsacral
(caudal) block (ie anesthesia of the
perineum)
Perioperative Nursing
Injection sites for Spinal and
Epidural Anesthesia

Perioperative Nursing
Cross-Section of
Injection sites
for Peripheral
Nerve Block,
Epidural Block,
Spinal Block

Perioperative Nursing
Intraoperative Nursing
Process Overview
! Assessment
› Classify the patient’s physical status for
anesthesia
› Assess the client’s records for appropriate
documentation
› Monitor the patient for possible complications
such as malignant hyperthermia or
hypothermia
› Review preoperative checklist

Perioperative Nursing
Perioperative Nursing
Intraoperative Nursing
Process Overview
! Implementation
› Promote measures that maintain adequate
fluid and electrolyte balance
" Monitor intake and output accurately
" Assess for dehydration including skin turgor, and
mucous membranes
" Assess the client for circulatory overload
including breath, peripheral edema, and
jugular vein distention
" Review serum electrolyte levels

Perioperative Nursing
Intraoperative Nursing
Process Overview
› Promote measures that maintain the client’s
normal temperature
" Monitor the client’s temperature routinely
" Warm all IV and irrigating solutions
" Remove all wet gowns and drapes promptly
and replace with dry ones to prevent heat loss
› Promote measures that decrease the risk of
infection
" Maintain sterile procedures and techniques
" Apply sterile dressing on the wound
Perioperative Nursing
Intraoperative Nursing
Process Overview
› Promote measures that ensure adequate
tissue perfusion in the client
› Ensure client’s safety in the operating room
" Set room temperature and humidity
" Remove all potential contaminants
" Keep room noise and talk at a minimum
" Recheck electrical equipment for proper
operation
" Make sure that necessary equipment and
supplies and easily available

Perioperative Nursing
Intraoperative Nursing
Process Overview
› Ensure that instruments, sutures, and dressings
are available
› Count and record sutures, needles,
instruments and sponges
› Assist in transferring the client to the operating
room table
› Cover the client with a warm blanket and
attach safety strap
› Remain at the client’s bedside during
anesthesia induction
Perioperative Nursing
Intraoperative Nursing
Process Overview
› Position client comfortably as needed
› Anticipate the needs of the surgical team
› Document all operating room care
› Coordinate health team activities
› Maintain a quiet, relaxing atmosphere

Perioperative Nursing
Immediate Postoperative
Period
! Perform assessment immediately on the
client’s admission to the PACU
! Aldrete Scoring
› Should be 7 and above to be discharged
from PACU
! Position to ensure adequate airway
patency – lateral Sim’s unless
contraindicated
! ABC assessment
Perioperative Nursing
Immediate Postoperative
Period
! Obtain verbal report from the operating
room nurse and anesthesiologist:
› Client’s age and general condition
› Any intraoperative problems
› Medical diagnosis and pathology
› Fluids administered, blood loss, replacement,
tubings, and drains
› Specific individual problems or deficits

Perioperative Nursing
Penrose
Drain

Perioperative Nursing
Jackson-Pratt
Drain

Perioperative Nursing
Hemovac Drain
Perioperative Nursing
Immediate Postoperative
Period
! Promote measures that address potential
complications
› Continuous assessment every 15 minutes
! Administer prescribed medication
! Maintain airway patency
! Provide pain relief

Perioperative Nursing
Perioperative Nursing
Perioperative Nursing
Perioperative Nursing
Perioperative Nursing
Wound Healing

! Nutrients required:
› Protein
› Vitamin C
› Arginine
! Types of Wound Healing
› Primary intention
› Secondary intention
› Tertiary intention

Perioperative Nursing
Perioperative Nursing
Perioperative Nursing
Perioperative Nursing