1

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

MLNGCeleste, RN, MD

Areas in Which Perioperative Nursing Is Practiced
‡ Perioperative nursing is practiced in
± Hospital operating rooms ± Interventional radiology suites ± Cardiac cath labs ± Endoscopy suites ± Ambulatory surgery centers ± Trauma centers ± Pediatric specialty hospitals ± Physician offices MLNGCeleste, RN, MD

Functions of the Perioperative Nurse
‡ ‡ ‡ ‡ ‡ Advocate Protector Teacher Change agent Manager of patient care

MLNGCeleste, RN, MD

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

MLNGCeleste, RN, MD

Surgical Attire
‡ ‡ ‡ ‡ ‡ Gowns Gloves Masks Hair covering Protective eyewear

MLNGCeleste, RN, MD

Goals of Patient Safety

‡ Provide safe patient care
± Knowledge of procedure ± Ensure the correct patient, correct site, correct level, 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
MLNGCeleste, RN, MD

Phases of Perioperative period
‡ PRE- operative phase ‡ INTRA- operative phase ‡ POST- operative phase

MLNGCeleste, RN, MD

PRE-Operative Phase
‡ Begins when the decision to have surgery is made and ends when the client is transferred to the operating table
MLNGCeleste, RN, MD

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

MLNGCeleste, RN, MD

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

MLNGCeleste, RN, MD

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

According to PURPOSE
Diagnostic Palliative Establishes a diagnosis Eg. Biopsy, laparoscopy Relieves or reduces pain or corrects a problem eg. Gastrostomy tube insertion Removes a diseased body part Eg. appendectomy Restores function or appearance Eg. Face lift Replaces malfunctioning structures eg. Kidney transplant

Ablative Constructive Transplant

According to degree of URGENCY
Emergency surgery Preserves function or life Performed immediately

Elective surgery

Performed when condition is not imminently life threatening
MLNGCeleste, MD,RN 14

OTHER Classification I.Emergent life threatening II Urgent III. Required IV. Elective V. Optional

Indication for surgery Without delay 24-30 hrs

examples Trauma (gunshot, etc.)

AP, Cholecystitis Plan within Cataracts, weeks or month thyroid No emergency Personal preference CS, hernia Cosmetic surgery

MLNGCeleste, MD,RN

15

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

OUTPATIENT SURGERY

According to degree of RISK
Major Surgery Involves high degree of risk Complicated or prolonged, Large amount of blood loss Involves low risk Produces few complications Performed as day surgery

Minor Surgery

MLNGCeleste, RN, MD

Activities in the Pre-op
‡ Assessing the clients: Nursing history, physical and emotional assessment, medication history ‡ Identifying potential or actual health problems (comorbidities) ‡ Ensure necessary test were done including proper referrals and consultation ‡ Educate about recovery from anesthesia and postoperative care ‡ Providing pre-operative teaching ‡ Ensure consent is signed ‡ Start an IV infusion ‡ Address questions of the patient and family

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

INFORMED CONSENT
‡ EMANCIPATED MINOR
- below legal age of 18 but who is living independently from parents or who is already living in with a partner; with children of their own

Health factors (Preoperative) that may affect the outcome of the Surgery
‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Nutritional status Drug or alcohol abuse Respiratory status Cardiovascular status Hepatic and renal Factors Endocrine Function Immune function Previous medication use Psychosocial factors Spiritual and cultural beliefs

Surgical Risk
‡ ‡ ‡ ‡ Extremes of age Malnourished Obese Co-morbid conditions (HPN, cardiac disease, diabetes, renal failure) ‡ Concurrent medications (aspirin, diuretic, insulin, antihypertensives, steroids)

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

Pre-op nutrition
‡ Assess order for NPO ‡ Solid foods are withheld for about 8 hours before general anesthesia

Pre-op elimination
‡ Laxatives, 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 hygiene
‡ Bathe the night or morning before surgery with antiseptic soap ‡ Shaving of the skin is usually done in the OR ‡ Removal of jewelry and nail polish *CONTACT LENSES/ HEARING AIDS/ DENTURES

Pre-op psychological preparation
‡ Be alert to the client¶s anxiety level ‡ Answer questions or concerns ‡ Allow time for privacy

‡ Preparing the skin (shaving, using antiseptic solution) ‡ Asking the patient to void ‡ Administering Preanesthetic medications ‡ Transporting the patient to the presurgical area

Pre-operative medications
Pre-op Drugs Example

Purpose
To decrease nervousness Promote relaxation Decreases secretions Prevent bradycardia

Antianxiety Anticholinergic Muscle relaxant Anti-emetic Antibiotic

Diazepam Atropine

Succinylcholine To promote muscle relaxation

Promethazine To prevent nausea and
vomiting
Cephalosporin

To prevent infection

Pre-operative medications
Pre-op Drugs

Example

Purpose
To decrease pain and decrease anesthetic dose To decrease occurrence of allergy To decrease gastric fluid and acidity

Analgesic Meperidine
(DEMEROL)

Antihistamine

Diphenhydramine (BENADRYL)

Cimetidine H-2 antagonist (TAGAMET)

PrePre-operative teaching
Leg exercises To stimulate blood circulation ‡ Pre-operative teaching in the extremities to prevent thrombophlebitis To facilitate lung aeration and secretion mobilization to prevent atelectasis and hypostatic pneumonia Done every two to four hours To stimulate circulation, stimulate respiration, decrease stasis of gas

Deep breathing and Coughing Exercises

Positioning and Ambulation

Assisting patient to semi-Fowler¶s position, leaning forward.

Having patient splint a chest or abdominal incision by holding a folded bath blanket or pillow against the incision.

Telling patient to take a deep breath and hold it for three seconds.

Encouraging patient to "hack" out three short coughs after holding breath.

With mouth open, patient should take a quick breath.

Encouraging patient to cough deeply once or twice and then take another deep breath.

An incentive spirometer helps increase lung volume and promotes inflation of the alveoli.

Assisting patient to semi-Fowler¶s position.

Setting the volume goal indicator on the spirometer.

Patient holding the device and placing lips around the mouthpiece to create a seal, then taking a deep breath in.

The patient can observe progress toward the goal by watching the balls or diaphragm of spirometer elevate or lights go on (depending on equipment used). Have patient repeat exercise 5 to 10 times every 1 to 2 hours while awake

Assisting patient to a semi-Fowler¶s position with knees bent.

Raising patient¶s right foot and keeping it elevated for a few seconds.

Extending the lower portion of the leg.

Lowering the entire leg to the bed. This exercise is repeated five times with each leg.

Patient pointing toes of both feet toward the foot of the bed, with both legs extended.

Patient pulling toes toward chin, as if a string were attached to them

Having patient make circles with both ankles, first one way and then the other.

Instructing patient to raise one knee and reach across to grasp the side rail on the side of the bed toward which he or she will be turning.

Helping patient to rollover while he or she pushes with the bent leg and pulls on the side rail.

Showing patient how to use a small pillow to splint a chest or abdominal incision while turning.

After patient is turned, providing support with pillows behind the patients back.

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

MLNGCeleste, RN, MD

Activities during the Intra-op

Provide patient safety, maintain an aseptic environment, ensure proper function of the equipments, position the client, emotional support, assisting the surgeon as scrub nurse, circulating nurse, nurse assistant,

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

Principles of Sterile Technique
MLNGCeleste, RN, MD

Basic Guidelines in Surgical Asepsis ‡ All materials in contact with the surgical wound and used within the sterile field must be sterile. ‡ Gowns are considered sterile in front from the chest to the level of the sterile field. ‡ Sterile drape ‡ Items should be dispensed to a sterile field by methods that preserve the sterility

‡ Movement of the surgical team are from sterile to sterile and from unsterile to unsterile area ‡ Movement around a sterile field must not cause contamination of the field ‡ When a sterile barrier is breached, the area , must be considered contaminated

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
MLNGCeleste, RN, MD

MLNGCeleste, RN, MD

64

The Sterile Team
± Operating surgeon ± Assistants to the surgeon: Another surgeon (1st assist), surgical resident doctor (2nd assist), RN assist (3rd assist) ± Scrub Nurse ± They:
‡ Scrub their hands and arms ‡ Don sterile gloves and gown ‡ Enter the sterile field (all items for the surgical procedure are sterilized)

MLNGCeleste, RN, MD

The Unsterile Team
± Anesthesiologist or anesthetist ± Circulating nurse ± Technicians ± They:
‡ Don¶t enter the sterile field ‡ Function outside of the sterile field ‡ Maintain sterile technique

MLNGCeleste, RN, MD

Functions of the nurse during OR procedure

SCRUB NURSE

‡Assists the surgeon ‡Maintains sterility ‡Set up sterile tables, Prepares and Handles instruments, sutures ‡Drapes patient ‡Counts sponges, needles, instruments ‡Wears sterile gown, gloves ‡Assists the Scrub nurse ‡Positions the patient for surgery ‡ Positions any equipment

CIRCULATING NURSE

‡Monitors/coordinates all activities ‡Controls the physical and emotional atmosphere in the room ‡Protects the pt¶s safety and health

Scrub Nurse
± Maintain safety of the sterile field ± Knows the sterile and aseptic technique ± Prepares the instruments ± Assists the surgeon with the instruments ± PRIVATE SCRUB NURSE (employed by the surgeon)

MLNGCeleste, RN, MD

68

Circulating Nurse
± Monitors/coordinates all activities ± Controls the physical and emotional atmosphere in the room

MLNGCeleste, RN, MD

69

MLNGCeleste, RN, MD

70

MLNGCeleste, RN, MD

71

MLNGCeleste, RN, MD

72

MLNGCeleste, RN, MD

73

MLNGCeleste, RN, MD

74

MLNGCeleste, RN, MD

75

MLNGCeleste, RN, MD

76

SEDATION
‡ ‡ ‡ ‡ MINIMAL SEDATION MODERATE SEDATION DEEP SEDATION ANESTHESIA

77

Levels of Sedation
Minimal sedation - drug induced state in which a patient can respond normally in verbal commands - cognitive function and coordination may be impaired

Moderate sedation - depressed level of consciousness that does not impair ability to maintain a patent airway - calm, sedate a patient combined with analgesic - Midazolam/Diazepam

Deep Sedation - a drug induced state in which a patient cannot be easily aroused but can respond purposefully after repeated stimulation - inhaled or intravenous - Volatile anesthetic (halothane, Isoflurane) - Gas anesthetic (Nitrous oxide)

ANESTHESIA
‡ absence of sensation ‡ state of narcosis (severe CNS depression produced by pharmacological agents), analgesia, relaxation and reflex loss
81

‡ Loss of the ability to maintain ventilatory function ‡ Client requires assistance to maintain a patent airway. ‡ Cardiovascular function may be affected as well
82

Anesthesia - a state of narcosis, analgesia,
relaxation and reflex loss ‡ General anesthesia ± Loss of all sensation and consciousness; cardiovascular and ventilatory functions are impaired ‡ Regional or Local anesthesia ± Loss of sensation in ONE area with consciousness present

Methods of Anesthesia Administration ‡ ‡ ‡ ‡ Inhalation Intravenous Regional Anesthesia: Epidural & Spinal Local Conduction Blocks: Local Infiltration

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

85

GENERAL Anesthesia
‡ Administered in two ways:
± Inhalational ± Intravenous

86

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
87

Stages of General Anesthesia
‡ Stage I (Beginning Anesthesia/ INDUCTION
PHASE) - patient may still be conscious, senses inability to move extremities - patient feels warm, dizzy with a feeling of detachment - patient may have ringing, buzzing in the ear, still conscious, sense inability to move extremities - noises are exaggerrated - avoid unnecessary noises or motions

‡ Stage II: Excitement - time from loss of consciousness to loss of reflexes - Characterized by struggling, shouting, talking, crying. - pupils dilate, rapid pulse and irregular RR - restrain the patient

Stage III: SURGICAL ANESTHESIA (MAINTENANCE PHASE) - Surgical anesthesia is reached
- patient is unconscious and lies quietly - respirations and CR are regular - may be maintained in hours (if properly given)
*EMERGENCE PHASE
90

‡ Stage IV: Medullary Depression - stage is reached when too much anesthesia is given - RR becomes shallow, pulse is weak and thready, pupils widely dilated and become unresponsive to light, cyanotic - Without proper treatment death will follow - Discontinue anesthetic abruptly, cardiopulmonary support is initiated

G A: INHALATIONAL ADMINISTRATION

92

G A: INTRAVENOUS ADMINISTRATION

93

G A: HALOTHANE
‡ ‡ ‡ is a powerful anesthetic and can easily be overadministered. Advantages: pleasant odor Disadvantages: little pain relief (combined with other agents to control pain) Adverse reactions:
± cardiac dysrhythmia ± Hepatotoxicity
94

‡

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)

95

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

96

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

97

NITROUS OXIDE (LAUGHING GAS)
‡ is a weak anesthetic and is used with other agents, such as thiopental, to produce surgical anesthesia. ‡ It has the fastest induction and recovery and is the safest because it does not slow breathing or blood flow to the brain. ‡ Adverse effect: it diffuses rapidly into aircontaining cavities and can result in a collapsed lung (pneumothorax) or lower the oxygen contents of tissues (hypoxia).
98

‡ LARYNGOSCOPE

Establishing AIRWAY PATENCY: ENDOTRACHEAL INTUBATION

MLNGCeleste, MD,RN

101

MLNGCeleste, MD,RN

103

105

106

POST G.A. Effects
‡ Headache ‡ vision problems, including blurred
or double vision

‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡

shivering or trembling muscle pain dizziness, lightheadedness, or faintness drowsiness mood or mental changes nausea or vomiting sore throat nightmares or unusual dreams
107

Potential adverse effects of anesthesia ‡ Myocardial depression, bradycardia ‡ Anaphylaxis ‡ CNS agitation, seizures, respiratory arrest ‡ Oversedation or under sedation ‡ Agitation and disorientation ‡ Hypothermia ‡ Hypotension ‡ Malignant hyperthermia
108

PRECAUTION
‡ A complete medical history including a history of allergies in family members, is an important precaution. Patients may have a potentially fatal allergic response to anesthesia known as malignant hyperthermia (a muscular disorder induced by anesthesia), even if there is no previous personal history of reaction. ‡ WARNING SIGN: TACHYCARDIA
109

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.

110

Inhaled Anesthetic Agents
‡ Volatile Liquid agents- produce anesthesia when the vapors are inhaled ‡ Inhaled Gaseous agents- usually combined with oxygen eg. Nitrous oxide - Anesthetic enters the blood through the pulmonary capillaries and act on the cerebral centers to produce loss of consciousness and sensation

Types of Anesthesia
1. General ‡ Pain is controlled by general insensibiikity ‡ Loss of consciousness, Loss of reflexes ‡ Closely monitor respiratory, CNS, circulatory depression! ‡ Level of Anesthesia: light, moderate, deep ‡ 3 methods: 1. inhalation 2. IV injection (TIVA- total intravenous anesthesia) 3. rectal installation (obsolete) indicated in pedia ‡ INHALATION: a. Volatile Liquids ‡ ex. 1. Halothane (Fluothane)
± ± ± Non flammable Widely used,rapid induction, low incidence of post-op nausea & vomiting Causes hypotension and liver damage

-2.Enflurane ± - rapid induction and recovery - potent analgesic, but causes respiratory depression - hepatotoxicity is not a problem 3. Isoflurane - rapid induction and recovery - muscle relaxants are markedly potentiated - profound respiratory depress

b. Gases ± 1. Nitrous Oxide ±( laughing gas) = induction agent - used alone for short procedures - always given in combination with O2 - may produce hypoxia, weak anesthetic, poor relaxant INTRAVENOUS ANESTHESIA - used to induce or maintain surgical anesthesia & hypnosis with use of barbiturates, benzodiazepines, hypnotics and opioid agents - nonexplosive, require little equipment and easy to administer - useful for short procedures - disadvantage: respiratory depressants EX: 1. Brevital, Surital, Pentothal Na ( causes rapid & smooth induction of anesthesia.

Miscellaneous General Anesthesia: A. Dissociative anesthesia Ex. Ketamine ( Ketalar) - used for short diagnostic procedures in combination with other anesthetics - has no analgesic or muscle relaxing properties B. Neuroleptics Ex. Innovar ( Fentanyl - causes psychological apathy & tranquilization without inducing sleep or analgesia - used for pts. Undergoing surgery & dx procedures when cooperation & responsiveness are necessary

INTRAVENOUS MEDICATIONS FOR G A
‡ used to induce or maintain surgical anesthesia & hypnosis with use of barbiturates, benzodiazepines, hypnotics and opioid agents ‡ nonexplosive, require little equipment and easy to administer ‡ useful for short procedures ‡ disadvantage: respiratory depressants ‡ EX : ketamine, thiopental (a barbiturate), methohexital (Brevital), etomidate, propofol (Diprivan)

116

Commonly Used IV Medications
Medication
Muscle Relaxant Succinlcholine (Anectine) Anxiolytic/Sedative Diazepam Barbiturates Thiopental Dissociative Anesthesia Ketamine (ketalar) Opioid Analgesic Morphine

Usage
Intubation Short cases Amnesia, Hypnotic Induction Induction Short cases

Advantage
Rapid onset Short duration Good sedation Offers good induction Pt maintains airway

Disadvantage
Myalgias, fasciculation, tissue trauma, paralysis Prolonged duration, residual effects Cause laryngospasm Large doses may cause hallucination,respirat ory depression Dec in BP and RR

Perioperative pain

Inexpensive, good CV stability Good CV stability

Opioid Analgesic Postoperative Fentanyl (sublimaze pain

MLNGCeleste, RN, MD

REGIONAL Anesthesia - a form of local anesthesia
- the patient is awake
TOPICAL INFILTRATION NERVE BLOCK SPINAL Subarachnoid EPIDURAL

Applied directly on the skin Injected into a specific area of skin Injected around a nerve Low spinal anesthesia Epidural space is injected with anesthesia

INTRASPINAL ANESTHESIA
‡ best reserved for operations below the umbilicus e.g. appendectomy, hernia repairs, gynecological and urological operations and any operation on the perineum or genitalia. 1. epidural 2. intrathecal (subarachnoid)
120

INTRASPINAL ANESTHESIA
TETRACAINE

121

122

MLNGCeleste, RN, MD

123

124

EPIDURAL ANESTHESIA

126

INTRATHECAL (SUBARACHNOID)

127

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

MLNGCeleste, RN, MD

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

MLNGCeleste, RN, MD

A. ABDOMINAL SURGERY 1. Abdominal Laparotomy 2. Herniorrhaphy 3. Cholecystectomy 4. Pancreaticoduodenectomy (Whipple¶s) 5. Pancreatectomy 6. Splenectomy 7. Bariatric Surgery
136

B. BREAST SURGERY 1. Mastectomy 2. Breast Biopsy 3. Mammoplasty 4. Breast Augmentation, Breast Repair, Breast Lifting
137

C. OBSTETRIC & GYNECOLOGIC SURGERY 1. D & C 2. Vaginal/Abdominal Hysterectomy 3. Perineorrhaphy 4. Salphingo-Oophorectomy 5. Tuboplasty of the Fallopian tubes 6. Ceasarian Section ± low transverse, classical, Pfannensteil (µbikini cut¶)
138

D. GENITOURINARY SURGERY 1. Circumcision 2. Vasectomy 3. Orchiectomy 4. Cystectomy 5. Transurethral Resection of the Prostate/Bladder (TURP/TURB) 6. Nephrectomy 7. Ureterolithotomy 8. Pyelolithotomy
139

MLNGCeleste, RN, MD

Activities in the POST-op
‡ ‡ ‡ ‡ ‡ ‡ ‡ Maintain patent airway Monitor VS Assessing responses to surgery and anesthesia Performing interventions to promote healing Prevent complications Planning for home-care Assist the client to achieve optimal recovery

POST Operative Interventions
‡ Transfer the postoperative patient to the PACU: anesthesiologist/anesthetist ‡ Nursing Objective: provide care until the patient recovers from the effects of anesthesia, is oriented, has stable VS and shows no evidence of hemorrhage or other complications ‡ ASSESS your patient

PACU- Post-Anesthesia Care/Recovery Unit
1. Immediate and continuous assessment every 15 minutes initially 2. Check airway patency, vital signs, surgical site, drain, recovery from anesthesia, pain control, fluid status, postop orders 3. When stable, discharge to hospital room or home
MLNGCeleste, MD,RN 143

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

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

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

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, massage, diversional activities, position changes

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

Post-operative Interventions Some Examples of Position Post Op
Mastectomy Thyroidectomy Hemorrhoidectomy Laryngectomy Pneumonectomy Lobectomy Semi-fowlers¶, affected arm elevated Semi fowlers¶, head midline Semi-prone, side-lying Fowler¶s Lateral, affected side Lateral, unaffected side
149

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
150

Wound Care
‡ Inspect dressing hourly ‡ Change dressing daily ‡ Inspect for signs of infection redness, swelling, purulent exudate (SEROUS EXUDATE ± normal) ‡ Maintain wound drainage
151

MLNGCeleste, MD,RN

153

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

Post-operative Interventions

‡ Hydration after NPO to maintain fluid balance
‡ Suction, either gastro or respiratory to relieve distention, to remove respiratory secretions ‡ Diet progressive, usually given when bowel sounds and gag reflex return
162

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, butter Yogurt Puddings Custard Ice cream and sherbet Soft diet All CL and FL plus: Meat Vegetables Fruits Breads and cereals Pureed foods
163

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

Post-operative Interventions
‡ Deep breathing and coughing exercises Q2-4 hours to remove pulmonary secretions ‡ Leg exercises Q 2 hours to promote circulation ‡ Ambulation ASAP prevents respiratory, circulatory, urinary and gastrointestinal complications
165

DEEP BREATHING
‡ Aka ABDOMINAL

‡ ‡ ‡ ‡

BREATHING CHEST and ABDOMEN ENLARGE OR EXPAND Diaphragm is depressed 10 deep breaths each time Deep breathing FULLY EXPANDS THE ALVEOLI
166

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 PVD SEQUENCE is as follows- POSITIONING, Percussion, Vibration, and removal of secretions by SUCTIONING or Coughing followed lastly by oral hygiene

Chest Physiotherapy

PERCUSSION & VIBRATION

MLNGCeleste, RN, MD

169

VIBRATING

170

PERCUSSION

171

Incentive Spirometry ‡ This operates on the principle that spontaneous sustained maximal inspiration is most beneficial to the lungs and has virtually no adverse effects. ‡ The incentive spirometer measures roughly the inspired volume and offers the ³incentive´ of measuring progress

INCENTIVE SPIROMETRY

173

Incentive Spirometry

SPLINTING WHILE COUGHING

MLNGCeleste, RN, MD

175

SPLINTING WHILE COUGHING

176

LEG EXERCISES

MLNGCeleste, RN, MD

177

POSTMASTECTOMY EXERCISES

178

POSTMASTECTOMY EXERCISES

179

POSTMASTECTOMY EXERCISES

180

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 ‡Leg exercises ‡Monitor for swelling ‡Elevated 181 extremities

Thrombophlebitis Inflammation of the veins

ATELECTASIS

182

PNEUMONIA

MLNGCeleste, MD,RN

183

DEEP VENOUS THROMBOSIS

*HOMAN¶S SIGN
184

DEEP VENOUS THROMBOSIS
(+)HOMAN¶S SIGN

185

EMBOLUS: MIGRATION OF A CLOT

186

PULMONARY EMBOLISM

187

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

Urinary retention Pulmonary embolism

Involuntary accumulation of urine Embolus blocking the lung blood flow

‡Notify physician ‡Administer O2
188

HYPOVOLEMIC SHOCK
MODIFIED TRENDELENBURG

189

Post-operative complications
Constipation Infrequent passage of stool Absent bowel sound ‡High fiber diet ‡Increased fluid ‡Ambulation ‡Encourage ambulation ‡NPO until peristalsis returns

Paralytic ileus

Wound infection Occurs about 3 ‡Daily wound days after dressing surgery ‡Antibiotics ‡Maintain drain
190

WOUND HEALING
PRIMARY INTENTION

SECONDARY INTENTION

TERTIARY INTENTION

191

WOUND DISRUPTION

MLNGCeleste, RN, MD

192

Post-operative complications
Wound dehiscence
‡Cover the wound with sterile normal saline dressing ‡Place in lowFowler¶s ‡Notify MD ‡Cover the wound Protrusion of with saline pad the internal ‡Place in loworgans and fowler¶s tissues through wound ‡Notify MD

Separation of wound edges at the suture line

Wound evisceration

193

Wound DEHISCENCE

194

Wound DEHISCENCE

195

Wound EVISCERATION

196

INCISIONAL HERNIA

197

INCISIONAL HERNIA

198

INCISIONAL HERNIA

199

NURSING MANAGEMENT in the POSTOPERATIVE PHASE
‡ Preventing respiratory complications ‡ Relieving pain ‡ Encouraging activity ‡ Promoting wound healing ‡ Maintaining normal body temperature ‡ Managing GI function ‡ Nutrition ‡ Resumption of urinary function
200

MLNGCeleste, RN, MD

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 POSTOPERATIVE phase are to promote healing and comfort, restore the highest possible wellness and prevent associated risk

SCRUB OUT !!!

Sign up to vote on this title
UsefulNot useful