Perioperative Nursing ABLATIVE – removing diseased organ that can’t wait

Definition of Terms anymore.

Surgery is any procedure performed on the - emergency surgery.
human body that uses instruments to alter tissue or organ PALLIATIVE – relieves symptoms but does not cure the
integrity. underlying disease process.
SURGEON - A physician who treats disease, injury, or RECONSTRUCTIVE – partial or complete restoration of a
deformity by operative or manual methods. damaged organ/tissue to bring back the original appearance
*A medical doctor specialized in the removal of organs, & function.
masses and tumors and in doing other procedures using a CONSTRUCTIVE – repairing the damaged tissue or
knife (scalpel) congenitally defective organ.
STERILE - free from living germs or microorganisms;
aseptic: sterile surgical instruments Accdg. To Degree Of Risk :
ASEPSIS - The state of being free of pathogenic MAJOR – high degree of risk :
microorganisms. >maybe complicated / prolonged, large losses of blood
SEPSIS - a toxic condition resulting from the spread of may occur, vital organs maybe involved, post-op
bacteria or their toxic products from a focus of infection complications may be likely.
DISINFECTANT- any chemical agent used chiefly on MINOR – little risk with few complications.
inanimate objects to destroy or inhibit the growth of harmful - often performed in a “day surgery”.
organisms.
ANTISEPTICS - is a substance that prevents or arrests the According to Urgency :
growth or action of microorganisms either by inhibiting their EMERGENT – patient requires immediate attention ;
activity or by destroying them. disorder maybe life- threatening.
STERILIZATION URGENT – patient requires prompt attention.
-the destruction of all living microorganisms, as > indications for surgery : within 24-30 hours.
pathogenic bacteria, vegetative forms, and spores. REQUIRED – patient needs to have surgery.
BACTERIOSTATIC -Capable of inhibiting the growth or > indications for surgery: plan within few weeks or
reproduction of bacteria. months.
BACTERICIDAL - Capable of killing bacteria. ELECTIVE – patient should have surgery.
BACTERIOCIDES - is a substance that kills > indications for surgery: Failure to have surgery is not
bacteria .Bactericides are either disinfectants, catastrophic.
antiseptics or antibiotics OPTIONAL – decision rests with pt.
> indications for surgery : Personal preference
Perioperative Nursing
Perioperative Nursing- connotes the delivery of patient
care in the preoperative,intraoperative, and postoperative Accdg. To Location :
periods of the patients surgical experience through the INTERNAL – inside the body . Ex. Hysterectomy
framework of the nursing process. EXTERNAL – outside the body .Ex. Skin grafting

FOUR BASIC PATHOLOGIC CONDITIONS THAT REQUIRE

Phases SURGERY (OPET):
 Preoperative phase – begins when the decision to OBSTRUCTION – a blockage ; are dangerous because they
have surgery is made and ends when the client is block the flow of blood, air, CSF, urine & bile through the
transferred to the OR table. body.
 Intraoperative phase – begins when the client is PERFORATION – is a rupture of the organ, artery or bleb.
transferred to the OR table and ends when the EROSION – break in the continuity of tissue surface. It can
client is admitted to the PACU. damage the walls of blood vessels resulting in serious
 Postoperative phase – begins with the admission bleeding.
of the client to the PACU and ends when the healing TUMORS – abnormal growth of tissue that serves no
is complete. physiologic function in the body.

Perioperative Nursing Who are the the SURGICAL RISK PATIENTS?

Purpose/reasons *Extremes of age ( very young & very old )
Degree of urgency – necessity to preserve the client’s life, *Extremes of weight (emaciation, obesity)
body part, or body function. *Dehydrated pts.
Degree of risk – involved in surgical procedure is affected *Nutritional deficits
by the client’s age, general health, nutritional status, use of *Pts. with severe trauma or injury, infection/sepsis
medications, and mental status. *Pts. with cardiovascular disease
Extent of surgery – Simple and radical *Endocrine dysfunction (diabetes mellitus)
*Hypertensive & hypotensive pts.
*Hypovolemia
CLASSIFICATIONS OF SURGERY *Hepatic disease
Accdg. To Purpose : *Pre-existing mental or physical disability
DIAGNOSTIC – verifies suspected diagnosis PROBLEMS THAT MAY ARISE IN SURGERY:
EXPLORATORY – estimates the extent of the disease or  Surgical risk pts – probability of mortality
injury.  Pain
CURATIVE – removes or repairs damaged tissues .  Hemorrhage
 Infection
  UTI - Special considerations related to outpatient surgery
- Diaphragmatic Breathing and Splinting When
PHASES OF O.R. NURSING : Coughing
- Leg Exercises and Foot Exercises
PREOPERATIVE PHASE
- Preoperative Nursing Interventions
 The rendering of nursing care to the surgical client
as soon as he is admitted & the decision to undergo PHYSICAL PREPARATIONS:
surgery is made. - Obtain history of past medical conditions, surgical
 It ends on the time the client is transferred to the procedures, dietary restrictions & medications.
O.R. - Perform baseline head-to-toe assessment, including
VS, height & weight.
NURSING ACTIVITIES : - Ensure that diagnostic procedures pertinent to
 Assessment of the client surgery are performed as ordered
- NPO
 Identification of potential/actual health problems.
- Bowel prep
 Pre-op teaching involving client & support persons. - Skin prep
Day of surgery : - Immediate preoperative preparation
 pt. teaching reviewed - Transporting the pt. to the pre-surgical area about
 informed consent confirmed 30 to 60 minutes before anesthetics is to be given.
 pt.’s identity & surgical site verified - Attend to family needs
 IVF started.
LEGAL PREPARATION:
Assessment (Nursing History) - Surgeon obtains operative permit (informed
- Current health status- consent)
- Allergies - Surgical procedures, alternatives , possible
- Medications- list all current medications complications & disfigurements or removal of body
- Previous surgeries parts are explained.
- Understanding of the surgical procedure and - It is part of the nurse’s role as client advocate to
anesthesia confirm that the client understands information
- Smoking given.
- Alcohol and other-altering substances
- Coping INFORMED CONSENT is necessary in the ff. Circumstances:
- Social resources - Invasive procedures
- Procedures requiring sedation or anesthesia
- Cultural considerations
- A non-surgical procedure
- Procedures involving radiation
PREPARATION FOR SURGERY - Adult client (over 18 y/o) signs own permit unless
 Psychological Support : unconcious or mentally incompetent.
- Assess client’s fears, anxieties, support systems & - Consents are not needed for emergency care if all 4
patterns of coping. of the ff. criteria are met:
- Establish trusting relationship with client & - There is an immediate threat to life.
- Experts agree that it is an emergency.
significant others.
- Client is unable to consent.
- Explain routine procedures, encourage verbalization - A legally authorized person cannot be reached.
of fears & allow client to ask questions. *Minors (under 18 y/o) must have consent signed by an adult
- Demonstrate confidence in surgeon & staff. (i.e. Parent or legal guardian)
- Provide for spiritual care if appropriate.
PREOPERATIVE MEDICATIONS
PREOPERATIVE TEACHING PURPOSES:
 To relieve fear & anxiety.
- Assess client’s level of understanding of surgical  To reduce dose needed for induction & maintenance
procedure & its implications. of anesthesia.
- >Answer questions, clarify & reinforce explanations  To prevent reflex bradycardia that happens during
given by the surgeon. induction of anesthesia.
- Explain routine pre- & post-op procedures & any  To minimize oral secretions.
special equipment to be used.
INTRAOPERATIVE PHASE
 Giving nursing care to client undergoing surgery.
PREOPERATIVE TEACHING
 It starts from the time the pt. was admitted to the
- Preoperative experience
- Preoperative medication O.R. , during operation until it ends & transferred to
- Breathing exercises, coughing, incentive spirometer the PACU.
- ﾘ Encouraged to use incentive spirometer
- about 10 to 12 times per hour. NURSING ACTIVITIES:
- ﾘ Deep inhalations expand alveoli, which  Activities providing for pt’s safety.
- prevents atelectasis and other pulmonary  Maintenance of aseptic environment.
complication.  Ensuring proper function of equipments.
- couging- Promotes removal of chest secretions.  Providing surgeons with specific instruments &
supplies for surgical field.
- Leg exercises - Moving the legs improves circulation  Completing documentation.
and muscle tone.  Positioning pts.
- Position changes and movement  Acting as scrub/circulating nurse.
- Pain management
- Reducing anxiety and fear, support of coping
Members of the Surgical Team - Items are dispensed by methods to preserve
sterility.
 Patient - Movements of the surgical team are from sterile to
 Anesthesiologist or anesthetist sterile and from unsterile to sterile only.
 Surgeon - Movement around the sterile field must not cause
 Nurses (Scrub & Circulating) contamination of the field. At least a 1-foot
 Surgical technologists distance from the sterile field must be maintained.
- Whenever a sterile barrier is breached, the area is
PATIENT considered contaminated.
- the most important member of the surgical team. - Every sterile field is constantly maintained and
monitored. Items of doubtful sterility are
May feel relaxed & prepared, or fearful & highly
considered unsterile.
stressed. - Sterile fields are prepared as close as possible to
- is also subject to several risks. time of use.

OPERATING SURGEON SURGICAL ASEPTIC TECHNIQUE

- pre-op dx & care.  BEFORE AN OPERATION, it is necessary to sterilize
- performance of operation. and keep sterile all instruments, materials, and
- post-op mgt & care supplies that come in contact with the surgical site.
- assumes all responsibility for all medical acts of Every item handled by the surgeon and the
judgement & mgt. surgeon's assistants must be sterile. The patient's
skin and the hands of the members of the surgical
SURGEON & ASSISTANTS team must be thoroughly scrubbed, prepared, and
- scrub & perform the surgery. kept as aseptic as possible.
 DURING THE OPERATION, the surgeon, surgeon's
REGISTERED NURSE 1ST ASST. assistants, and the scrub nurses must wear sterile
- practices under the direct supervision of the gowns and gloves and must not touch anything that
surgeon. (handling tissue, suturing, maintaining is not sterile.
hemostasis) Maintaining sterile technique is a cooperative
responsibility of the entire surgical team.
ANESTHESIOLOGIST / NURSE ANESTHETIST - Each member must develop a surgical conscience, a
- administers the anesthetic agent & monitors the willingness to supervise and be supervised by others
pt’s physical status throughout the surgery. regarding the adherence to standards.

SCRUB NURSE Intraoperative Nursing Care Roles of team members

- provides sterile instruments & supplies to the Surgeon
surgeon during the procedure.  responsible for determining the preoperative
- performs surgical hand scrub. diagnosis, the choice and execution of the surgical
procedure, the explanation of the risks and benefits,
CIRCULATING NURSE obtaining inform consent and the postoperative
- coordinates the care of the pt. in the O.R. management of the patient’s care.
- care provided includes assisting with pt. positioning Scrub nurse
, skin prep, managing surgical specimens &  (RN or Scrub tech)- preparation of supplies and
documenting intraoperative events. equipment on the sterile field; maintenance of pt.s
safety and integrity: observation of the scrubbed
Prevention of Infection team for breaks in the sterile fields; provision of
 The surgical environment appropriate sterile instrumentation, sutures, and
- stark appearance & cool temperature. supplies; sharps count
Located central to all supporting services. Circulating Nurse
 Unrestricted zone  responsible for creating a safe environment,
- where street clothes are allowed. managing the activities outside the sterile field,
 Semirestricted zone providing nursing care to the patient. Documenting
- where attire consists of scrub clothes & intraoperative nursing care and ensuring surgical
caps. specimens are identified and place in the right
 Restricted zone media. In charge of the instrument and sharps
- where scrub clothes, shoe covers, caps & count and communicating relevant information to
masks are worn. individual outside of the OR, such as family
members.
THE OPERATING ROOM Anesthesiologist and anesthetist
Basic Guidelines for Surgical Asepsis  anesthetizing the pt. providing appropriate levels of
pain relief, monitoring the pt’s physiologic status
- All materials in contact with the wound and within and providing the best operative conditions for the
the sterile field must be sterile.
surgeons.
- Gowns are sterile in the front from chest to the
level of the sterile field, and sleeves from 2 inches Other personnel- pathologist, radiologist, perfusionist, EVS
above the elbow to the cuff. personnel.
- Only the top of a draped table is considered sterile.
During draping, the drape is held well above the Nursing Roles:
area and is placed from front to back.  Staff education
 Client/family teaching
  Support and reassurance  Overdosage
 Advocacy
 Control of the environment Spinal Anesthesia
 Provision of resources Indications
 Maintenance of asepsis
-surgical procedures below the diaphragm
 Monitoring of physiologic and psychological status
-patients with cardiac or respiratory disease
 Ensure sterility
 Alert for breaks
Advantages
Intraoperative Phase Anesthesia -mental status monitoring
-shorter recovery
- Greek word- anesthesis, meaning “negative
sensation.” Artificially induced state of partial or
Disadvantages
total loss of sensation, occurring with or without
-necessary extra expertise
consciousness. -possible patient pain
- Blocks transmission of nerve impulses
- Suppress reflexes Contraindications
- Promotes muscle relaxation -coagulopathy
- Controlled level of unconsciousness -uncorrected hypovolemia
Factors influencing dosage and type:
- Type and duration of the procedure Involved medications
- Area of the body being operated on -lidocaine
- Whether the procedure is an emergency -bupivacaine
- Options of management of post. Op. Pain -tetracaine
- How long it has been since the client ate, had any
liquids, or any medications Patient assessment
-continuous heart rate, rhythm, and pulse oximetry
Intraoperative Phase Types of Anesthesia monitoring
General -level of anesthesia
-motor function and sensation return monitoring
- method use when the surgery requires that the
patient be unconscious and/or paralyzed. Complications
- A general anesthetic acts by blocking awareness -hypotension
centers in the brain so that amnesia (loss of -bradycardia
memory), analgesia (insensibility to pain), hypnosis -urine retention
(artificial sleep), and relaxation (rendering a part of -postural puncture headache
the body less tense) occur. -back pain

Stages of General Anesthesia Spinal analgesia

Stage 1- Analgesia and sedation, relaxation Indications
Stage 2- Excitement, delirium -postoperative pain from major surgery
Stage 3- Operative anesthesia, surgical anesthesia
Stage 4- Danger Involved medications
-lipid-soluble drugs
-preservative-free morphine

 Complications of General Anesthesia Monitoring recovery

 Overdose -respiratory depression
 Hypoventilation -urine depression
 Related to anesthetic agents -pruritus
 Malignant hyperthermia -nausea and vomiting
 Related to intubation
Conscious Sedation
Local or Regional Anesthesia Administration of IV sedative, hypnotic, and opioid
 Temporarily interrupts the transmission of sensory medications.
nerve impulses from a specific area or region. - Produces a depressed level of consciousness
 Motor function may or may not be affected
- Retains ability to maintain a patent airway
 Client does not lose consciousness
 Gag reflex remains intact - Able to respond to verbal commands or physical
 Supplemented with sedatives, opioids, or hypnotics stimulation
- Used for relatively short procedures
Types of Regional Anesthesia Postoperative Nursing Care
 Topical (surface) Nursing assessment in the PACU
 Local  Vital signs- presence of artificial airway, 02
 Nerve Block sat,BP,pulse, temperature.
 Intravenous (Bier Block)  LOC- ability to follow command, pupillary response
 Spinal  Urinary output
 Epidural (peridural)  Skin integrity
 Pain
Complications of Local/Regional Anesthesia  Condition of surgical wound
 Anaphylaxis  Presence of IV lines
 Administration technique  Position of patient
 Systemic absorption
Nursing Diagnosis Gerontologic considerations
 Ineffective airway clearance- increased secretions 2  Mental status- attributed to medications, pain,
to anesthesia, ineffective cough, pain anxiety, depression.
 Ineffective breathing pattern- anesthetic and drug  Delirium- infection, malignancy, trauma, MI, CHF,
effects, incisional pain
opioid use.
 Acute pain
 Urinary retention  Dementia-sundowning-sleep disturbances, lack of
 Risk for infection structure in the afternoon or early morning, sleep
apnea.
Assessment of the Postanesthesia Client
 Airway
 Vital signs
 Cardiac monitoring
 Peripheral vascular assessment
 Level of consciousness (LOC)
 Fluid and electrolytes
 GI system
 Integumentary system
 Discomfort/pain

Postoperative Management
 Maintain a patent airway
 Stabilize vital signs
 Ensure patient safety
 Provide pain relief
 Recognize & manage complications

When caring for post-surgical patient, think of the “4

W’s”
 Wind: prevent respiratory complications
 Wound: prevent infection
 Water: monitor I & O
 Walk: prevent thrombophlebitis

Complications
 Respiratory- atelectasis, pulm. Embolus
 Cardiovascular- venous thrombosis
 Gastrointestinal-Hiccoughs, N/V,abd. Distention,
paralytic ileus, stress ulcer.
 GU- urinary retention
 Hemorrhage-slipping of a ligature(suture)
 Wound infection-
 Wound dehiscence and evisceration-

Dehiscence
 Partial or complete separation of the outer layer of
the wound.
Possible causes:
 Poor suturing technique
 Distention
 Excessive vomiting
 Excessive coughing
 Dehydration
 Infection

Evisceration
 Total separation of the layers & protrusion of
internal organs or viscera through the open wound.
Causes: same as dehiscence

 Treatment:
 Call for help
 Cover with sterile NS soaked
gauze/towels
 Keep moist
 DO NOT ATTEMPT TO REINSERT
ORGANS.
 Keep in supine position with
knees/hips bent
 Assessment/VS q 5 min. until MD
arrive
 Prepare for surgery.