General

Course

Education Team
 Definition & phases of perioperative.

 Purposes of surgery

 Categories of surgery

 Pre operative assessment & preparation.

 Pre procedure checklist.

 Patient in operating room & time out

 post operative care & Endorsement.

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 post operative diet

 Operative Period:

 The time that constitute the surgical experience, include the preoperative,

intraoperative, postoperative phases.

 Preoperative Phase:

 The time from when decision for surgical intervention is made to when the patient is

transferred to the operating room table.

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 Intaroperative Phase:

 Period of time from when the patient is transferred to the operating room table to

when he or she is admitted to the postanesthesia care unit.

 Postoperative Phase:

 Period of time that begins with the admission of the patient to the post anesthesia
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care unit and ends after follow-up evaluation in the clinical setting or home.
 Diagnostic → e.g. Biopsy

 Exploratory → e.g. laparotomy (Abdominal exploration)

 Curative → e.g. excision of a tumor or an inflamed appendix

 Reconstructive or cosmetic → e.g. mammoplasty

 Palliative→ relieve of symptoms as pain

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 Emergency:

Must be performed immediately:

 Maintain life

 Maintain organ or limb function

 Stop hemorrhage (Gunshot & stab wounds).

 Urgent:

Must be performed within 24 to 48 hours (Bleeding of duodenal ulcer) 6

 Planned:

 Scheduled weeks or months ahead of the proposed operation (cataract removal)

 Elective:

 Not absolutely necessary (hernia)

 Optional:

 Requested by the person (Mammoplasty)

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 Age, obesity, malnutrition, immobility , hypovolemia , infection, pregnant, diabetes

mellitus, hepatic disease, cardiovascular disease, renal disease and pulmonary disease.

 Nature of condition (Malignant)

 Location of condition (Heart/Brain)

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 Review preoperative laboratory and diagnostic studies

 Review the client’s health history

 Assess physical needs

 Assess psychological needs

 Assess cultural needs

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 Fear of the unknown.

 Fear of pain and discomfort.

 Fear of anesthesia.

 Fear of disruption of life patterns

 Separation from family.

 Fear of death.

 Fear of not being in control. 10

 Psychological Aspect:

 Explain the procedures involved in the upcoming surgery (Complete idea of what the

pre, intra & post operative course entails).

 Introduce the person who is to undergo a major surgical procedure to people who

have successfully recovered from this operation.

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 Helps to relieve anxiety
 Before the day of surgery

 Correct any dietary deficiencies

 Reduce an obese person's weight.

 Correct fluid & electrolyte imbalances.

 Restore adequate blood volume with blood transfusion.

 Treat chronic disease.

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 Cure infections process.
 Before the day of surgery

 Identifying the pt. and verifying the operative procedure.

 Preparing operative site.

 Checking client’s vital signs.

 Assisting in putting on hospital gown, cap

 Verifying allergies.

 Verifying NPO (nothing by mouth) status 13

 Skin preparation

 It is necessary to remove dirt and transient micro- organisms from the area.

 Take complete shower with ceteal and betadine .

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 Hair removal

 Against

 Pre operative shaving increases risk of post operative wound infection.

 In favour of shaving:-

 Avoidance of hairs trapping in the incision

 A clear field of vision.

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 Patient fasting

 The major purpose of withholding food and fluid before surgery is to prevent aspiration.

 A fasting period of 8 hours or more is recommended for a meal that includes fried or fatty

foods or meat

 Preparing the bowel for surgery:

 Enema is not commonly ordered, unless the patient is undergoing abdomen or pelvic

surgery e.g (cleansing enema, laxative). 16

 Informed Consent Forms:

 High risk consent (if needed).

 blood transfusion consent.

 surgery consent .

 anesthesia consent
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 Secure personal belongings: glasses, rings, money are the patient’s responsibility.
 Complete Pre-op Checklist at clinical site:Remove hair pins, loose teeth, dentures, nail

polish, urinate, NPO

 Vital signs are taken within 30 minutes before going to OR.

 Assure patient has ID bracelet on

 Send hard copy of diagnostic investigations like CT,MRI & medical records with the patient.

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 Pre-operative teaching:

 Deep breathing and coughing exercises To prevent pneumonia

 Incentive spirometer

 Turning & moving, leg exercise to prevent DVT

 Getting out of bed

 Pain management
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 Use wheelchair or trolley, avoid walking.

 Fall precautions during transfer.

 Use monitor, oxygen or others if needed according to patient condition.

 Psychological support

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 Begins when patient is transferred to operating room table

 Provide for patient safety

 Maintain aseptic environment

 Provide surgeon with supplies and instruments

 Documentation
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 Nurse's roles in the operating room

 Circulating nurse

 Scrub nurse

 Circulating nurse

 Prepares operating room with necessary equipment and supplies and ensures that

equipment is functional.
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 Arrange sterile and nonsterile supplies; opens sterile supplies for scrub nurse.
 Circulating nurse

 Sends for client at proper time.

 Visits with client preoperatively; explains role, verifies operative permit, identifies client,
and answers any questions.

 Confirms client's allergies.

 Checks medical record for completeness.

 Assists in safe transfer of client to operating room table.

 Positions client on operating room table in accordance with type of procedure, and 26

surgeon's preference.
 Counts sponges, needles, and instruments with scrub nurse before surgery.

 Assists scrub nurse and surgeons by tying gowns and preparing client's skin.

 Assists scrub nurse in arranging tables to create sterile field.

 Maintains continuous observations during surgery to anticipate needs of client, scrub

nurse, surgeons, and anesthesiologist.

 Provides supplies to scrub nurse as needed. 27

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 Scrub nurse

 Performs surgical hand scrub.

 Dons sterile gown and gloves aseptically.

 Arranges sterile supplies and instruments in manner prescribed for procedure.

 Checks instruments for proper functioning.

 Counts sponges, needles, and instruments with circulating nurse.

 Gowns and gloves surgeons as they enter operating room. 32

 Assists with surgical draping of client.

 Maintains sterile field.

 Recognizes and corrects breaks in aseptic technique.

 Observes progress of surgical procedure.

 Hands surgeon instruments, sponges, and necessary supplies during procedure"

 Identifies and handles surgical specimens correctly.

 Watches sponges, needles, and instruments so none will be misplaced or lost in wound. 33
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 Use the patient bed/ survo.

 Transfer must be with anaesthesiologist.

 Take care of connections.

 Take care of infusions.

 Fall precautions during transfer.

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 Use monitor.
 Immediate post operative (receiving from OR)

Nurse on the left side Nurse on the right side

 Attaching the patient to MV  Take zero drain and report to the assigned nurse

 Check that ETT is well fixed and at which fixation also connect the drain to low suction and secure

 Attach all the cables to the monitor all the connections

 Take Zero AL, and CVP  Elevate the head of bed to semi fowler position.

 Check that all the hemodynamic are within normal range and reading.  Hang urine bag and take zero urine and fix urine

 Arrange the ICU bed and the surrounding area bag tube.

 Cover the patient with a blanket but before check the patient temp  Take full labs and blood gasses from the AL

on the monitor, put the bair hugger on if not contraindicated  Put the transducer on the rolled linen and fix it
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 Do ECG  Revise the drug calculation
 To be completed within 15 minutes of PT arrival

 Cardiovascular Status:
 Obtain full set of vital signs.

 Obtain a cardiac profile and verify wave forms.

 Verify EKG rhythm; verify evidence of pacer capture if appropriate.

 Note amount/quality of chest tube drainage.

 Note quality of peripheral pulses, temperature and color of extremities.

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 Demand pacemaker settings.
 Arrhythmia:
 Assess for normal heart rate according to the patient age.
 Assess for any abnormal rhythm.
 What is the most common abnormal rhythm
 Junctional Ectopic Tachycardia (JET).
 HR: more than 150.

 Rhythm: regular.
 P wave: absent

 Management of JET:
 Electrolytes correction
 Over pacing 38

 Cooling.
 Inotropes
 Recheck the running dose of all the drugs with the anesthesia nurse before finishing

the handover.

 Check that all the IV lines are patent and working well.

 Check all drugs compatibility.

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 Bleeding:

 Monitor the amount of blood drainage from the chest tubes.

 Normal bleeding post-op is 3-5 ml/kg/hr.

 Bleeding 5-7 ml/kg/hr requires blood replacement.

 Bleeding more than 10 ml/kg/hr is very dangerous and requires reopening.

 Monitor coagulation profile pt, ptt and INR.

 Monitor Activating Clotting Time (ACT).

 Keep the chest drains patent by keeping low-flow suction 40

 Check the patient level of conciseness

 Make sure that the patient is well sedated and hemodynamic is stable, All patients will

come on a morphine infusion at 10-20 mcg/kg/hr you may need to replace with fentanyle.

 Patients may need muscle relaxant if hemodynamic is not controlled.

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 Validate LOC.

 Check for pupil reactivity.

 Check for quality and quantity of motor response.

 Identify type and dose of narcotic or paralyzing agent used.

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 Check ETT size and position.

 Auscultate bilaterally for breath sounds, note presence of adventitious breath sounds.

 Obtain O2 saturation via probe and PaO2 via blood gasses.

 Obtain ABG per MD order.

 Note peak pressures, expiratory volumes and minute Ventilation on current vent settings.

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 Measure urine output.

 Fix the urinary catheter supra pubic no at the thigh.

 Check the need for giving volume or giving diuretics if no urine output.

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 You should review all lines fixation and flushing and tubes fixation as well

 You review medication compatibility doses and flow rate.

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 Proper position according to type of surgery

 Vital signs, ECG monitoring

 Physical assessment

 Wound management

 Chest care

 Respiratory management: MV/ O2

 Breathing, coughing exercise 46

 Early mobilization ASAP

 Care of connections

 Monitor intake, output

 Special consideration for chest drains, drainage.

 Fluid , electrolyte monitoring and management.

 Care of pace maker if present.

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 Prevent and Manage complications

 Prevention of fall, pressure ulcers

 Proper nutrition: TPN/ enteral

 Medication management: inotropes/ other medications

 Pain management
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 Medications

 Wound management

 Mobilization

 Chest care

 Life style, daily activities

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 Fall prevention, pressure ulcer prevention
 Feeding according to its type.

 Connection safety

 Dealing with implantable devices

 Follow up frequency.

 Danger signs.
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 Bleeding

 Cardiac tamponed

 Arrhythmias

 Infection

 Improper wound healing

 Shock (hypovolemic, cardiogenic, anaphylactic, septic) 51

 GI complications

 MV complications

 Devices malfunction

 Pulmonary embolism

 Stroke

 Renal impairment

 Liver impairment 52
 Ascites

 Heart failure

 Electrolyte imbalance

 Psychological problems

 DVT

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 Pressure ulcers