peri-op nsg

7/31/2019 peri-op nsg.

1/73


2/73

Peri-operative Nursing


3/73


4/73

Phases of Peri-operative period

PRE- operative phase

INTRA- operative phase

POST- operative phase


5/73

PRE-Operative Phase

Begins when the decision to havesurgery is made and ends when

the client is transferred to theoperating table


6/73

INTRA-Operative Phase

Begins when the client istransferred to the operating table

and ends when the client isadmitted to the post-anesthesiaunit


7/73

Post-operative Phase

Begins with the admission of theclient to the PACU and ends when

healing is complete


8/73

PERIOPERATIVE TEAM

1. ANESTHESIOLOGIST or NURSEANESTHESIST

- makes preoperative assessment toplan type of anesthetic to be

administered

- to evaluate clients physical status2. PROFESSIONAL O.R. NURSE

- makes preop nursing assessments

and documents intraoperative care plan


9/73

PERIOPERATIVE TEAM

3. CIRCULATING NURSE

- manages the OR

- protects clients safety and healthneeds by monitoring activities of

members of the surgical team

- monitors conditions in the OR


10/73

PERIOPERATIVE TEAM

4. SCRUB NURSE- responsible for scrubbing before

surgery

- sets up sterile tables & equipment

- assists surgeon and surgical assistants

during the operation itself

5. PACU NURSE

- cares for the client until he/she

recovers from the effects of anesthesia


11/73

PRINCIPLES OF SURGICALASEPSIS

1. OR personnel must practice strict

Standard Precautions

2. All items used in the OR must besterile

3. All personnel must perform a

surgical scrub


12/73


4. All OR personnel are required to wear

specific, clean attireshedding the

environment

- must wear:

a. sterile gown

b. glovesc. special shoe covers

d. hair cover cap

e. mask


13/73


5. Any personnel harboring pathogenicmicrobes must report themselves unableto be in the OR

6. Scrubbed personnel wearing sterileattire should touch only sterile items

7. Sterile gown and drapes have defined

borders of sterility.8. Unsterile personnel must stay at the

periphery of the sterile operating area


14/73


9. Sterile supplies are unwrapped and

delivered by the circulating nurse

10. The utmost caution & vigilancemust be used when handling sterile

fluids

11. Anything that is used for one clientmust be discarded or, in somecases, resterilized


15/73

Activities in the Pre-op

Assessing the clients

Identifying potential or actual healthproblems

Planning specific care

Providing pre-operative teaching

Ensure consent is signed


16/73

Consent

The surgeon is responsible forobtaining the consent for surgery

No sedation should be administeredbefore SIGNING the consent

The nurse may serve as witness


17/73

Activities during the Intra-op

Assisting the surgeon as scrub nurseand circulating nurse


18/73

Activities in the POST-op

Assessing responses to surgery

Performing interventions to promotehealing

Prevent complications

Planning for home-care

Assist the client to achieve optimalrecovery


19/73


20/73

TYPES of SURGERY

According to PURPOSE

According to degree of URGENCY

According to degree of RISK


21/73

According to PURPOSE

Diagnostic Establishes a diagnosis

Palliative Relieves or reduces pain or

symptomsAblative Removes a diseased body part

Constructive Restores function or appearance

Transplant Replaces malfunctioningstructures


22/73

According to degree of urgency

Emergencysurgery

Preserves function or life

Performs immediately

Elective

surgery

Performed when condition

is not imminently lifethreatening


23/73

According to degree of RISK

MajorSurgery

Involves high degree of risk

Complicated or prolonged

Minor

Surgery

Involves low risk

Produces few complicationsPerformed as day surgery


24/73

Surgical Risk

Extremes of age

Malnourished

ObeseCo-morbid conditions

Concurrent medications


25/73

Pre-operative Interventions

Ensure signed consent form

Obtain nursing history, PE and lab exam

Provide pre-operative teaching as to thenature of surgery, what to expect andways to manage post-operativediscomforts

Perform physical preparations- shaving,hygiene, enema, NPO, medications


26/73

Pre-op nutrition

Assess order for NPO

Solid foods are withheld for about 8hours before general anesthesia


27/73

Pre-op elimination

Laxatives, enemas or both may beprescribed the night before surgery

Have the client void immediatelyBEFORE transferring them to the OR

Foley catheter may be inserted asordered


28/73

Pre-op hygiene

Bath the night before surgery withantiseptic soap

Shaving of the skin is usually done inthe OR

Removal of jewelry and nail polish


29/73

Pre-op psychological preparation

Be alert to the clients anxiety level

Answer questions or concerns

Allow time for privacy


30/73


31/73

Pre-operative medications

Pre-op Drugs Example Purpose

Analgesics Meperidine To decrease pain anddecrease anesthetic dose

Anti-histamine Diphenhydramine To decrease occurrenceof allergy

H-2

antagonist

Cimetidine To decrease gastric fluidand acidity


32/73


33/73

Pre-operative teaching

Leg exercises To stimulate blood circulationin the extremities to preventthrombophlebitis

Deep breathingand Coughing

Exercises

To facilitate lung aeration andsecretion mobilization toprevent atelectasis andhypostatic pneumonia

Done every two to four hours

Positioning andAmbulation

To circulation, stimulate respiration,decrease stasis of gas


34/73


35/73

Intra-operative phaseinterventions

Determine the type of surgery andanesthesia used

Position client appropriately for

surgeryAssist the surgeon as circulating orscrub nurse

Maintain the sterility of the surgicalfield

Monitor for developing complications


36/73


37/73

Anesthesia

General anesthesia

Loss of all sensation and

consciousness

Regional or Local anesthesia

Loss of sensation in ONE areawith consciousness present


38/73

GENERAL Anesthesia

Protective reflexes are lost

Amnesia, analgesia and hypnosis

occurAdministered in two ways:

Inhalational

Intravenous


39/73

REGIONAL Anesthesia

TOPICAL Applied directly on the skin

INFILTRATION Injected into a specific area ofskin

NERVE BLOCK Injected around a nerve

SPINAL

Subarachnoid

Low spinal anesthesia

EPIDURAL Epidural space is injected withanesthesia


40/73

Patient Positioning

Provides optimal visualization

Provides optimal access forassessing and maintaininganesthesia and function

Protects patient from harm


41/73

Position Patient during Surgery

Abdominal surgeries Supine

Bladder surgery Slightly trendelenburg

Perineal surgery Lithotomy

Brain surgery Semi-fowlers

Spinal cord surgeries Prone mostly

Lumbar puncture Side lying, flexed body


42/73

Functions of the nurse during OR procedure

SCRUB NURSEAssists the surgeon

Maintains sterility

Handles instruments

Drapes patient

Counts sponges

Wears sterile gown, gloves

CIRCULATINGNURSE

Assists the Scrub nurse

Positions the patient for

surgery

Positions any equipments


43/73


44/73

POST Operative Interventions

Maintain patent airway

Monitor vital signs and note for early

manifestations of complicationsMonitor level of consciousness

Maintain on PROPER position

NPO until fully awake, with passageof flatus and (+) gag reflex


45/73

POST Operative Interventions

Monitor the patency of the drainage

Maintain intake and output

monitoringCare of the tubes, drains and wound

Ensure safety by side rails up

Pain medication given as ordered

Measures to PREVENT post-opComplications


46/73

Post-operative interventions

PAIN MANAGEMENT

Pain is usually greatest during the 12-36 hours after surgery

Narcotic analgesics and NSAIDS maybe prescribed together for the earlyperiod of surgery

Provide back rub, massage, diversionalactivities, position changes


47/73

Post operative interventions

POSITIONING

Clients who have spinal anesthesia isusually placed FLAT on bed for 8-12hours

Unconscious client is placed side lyingto drain secretions

Other positions are utilized BASED onthe type of surgery

P i I i


48/73

Post-operative Interventions

Some Examples of Position Post Op

Mastectomy Semi-fowlers, affectedarm elevated

Thyroidectomy Semi fowlers , head

midlineHemorrhoidectomy Semi-prone, side-lying

Laryngectomy Fowlers

Pneumonectomy Lateral, affected side

Lobectomy Lateral, unaffected

side

P i I i


49/73


Some Examples of Position Post Op

Aneurysmal repair(abdomen)

Fowlers 45 degrees

Amputation of lower

extremities

Flat, with stump

elevated with pillowCataract surgery Fowlers 45 degrees

Supratentorial

craniotomy

Folwers

Infratentorialcraniotomy

Flat on bed, supine

Spina bifida repair Prone


50/73


Deep breathing and coughingexercises Q2-4 hours to removesecretions

Leg exercises Q 2 hours topromote circulation

Ambulation ASAP preventsrespiratory, circulatory, urinary

and gastrointestinal complications


51/73


Hydration after NPO to maintainfluid balance

Suction, either gastro orrespiratory to relieve distention,to remove respi secretions

Diet progressive, usually givenwhen bowel sounds and gag reflex

return


52/73

WoundCare

Inspect dressing hourly

Change dressing daily

Inspect for signs of infection redness, swelling, purulent

exudate

Maintain wound drainage


53/73


54/73


55/73


56/73


57/73


58/73


59/73


60/73


61/73

Diet

NPO usually immediately after surgery

Progressive diet

Assess the return of the bowel sounds


62/73

Liquid Diet Vs Soft diet

Clear liquid Full liquid Soft dietCoffee

Tea

Carbonated

drink

Bouillon

Clear fruit

juice

Popsicle

Gelatin

Hard candy

Clear liquid PLUS:

Milk/Milk prod

Vegetable juices

Cream, butter

Yogurt

Puddings

Custard

Ice cream and

sherbet

All CL and FL

plus:

Meat

Vegetables

Fruits

Breads and

cereals

Pureed foods


63/73

Urinary Elimination

Offer bedpans

Allow patient to stand at the bedsidecommode if allowed

Report to surgeon if NO URINE outputnoted within 8 hours post-op

C


64/73

CPTChest Physiotherapy

Chest physiotherapy is based on thefact that mucus can be knocked orshaken form the walls of the airwaysand helped to drain from the lungs.

The usual PVD SEQUENCE is asfollows- POSITIONING, Percussion,

Vibration, and removal of secretionsby SUCTIONING or Coughingfollowed lastly by oral hygiene


65/73

Incentive Spirometry

This operates on the principle thatspontaneous sustained maximalinspiration is most beneficial to thelungs and has virtually no adverse

effects.

The incentive spirometer measuresroughly the inspired volume and

offers the incentive of measuringprogress


66/73

Post operative complications

Atelectasis

Pneumonia

Collapsedalveoli due tosecretions

Inflammationof alveoli

Assess breathsounds

Repositioning

Deep breathingand coughing

Chest physio

Suctioning

Ambulation

Thrombophlebitis Inflammationof the veins

Leg exercisesMonitor for

swelling

Elevated

extremities


67/73

Post-operative ComplicationsHypovolemicShock

Loss ofcirculatoryfluid volume

Shock position

Determine cause andprevent bleeding

O2, IVF

Urinaryretention

Involuntaryaccumulationof urine

Encourage ambulation

Provide privacy

Pour warm water

Catheterize

Pulmonaryembolism

Embolusblocking thelung blood

flow

Notify physician

Administer O2w


68/73

Post-operative complications

Constipation Infrequentpassage ofstool

High fiber dietIncreased fluid

Ambulation

Paralytic ileus Absent bowelsound

Encourageambulation

NPO untilperistalsis returns

Woundinfection Occurs about3 days aftersurgery

Daily wounddressing

Antibiotics

Maintain drain


69/73

Post-operative complicationsWounddehiscence

Separation ofwound edges atthe suture line

Cover the wound

with sterile normalsaline dressing

Place in low-Fowlers

Notify MD

Woundevisceration

Protrusion ofthe internal

organs andtissues throughwound

Cover the woundwith saline pad

Place in low-

fowlers

Notify MD


70/73

To emphasize

The over-all goal of nursing care duringthe PRE-OPERATIVE phase is toprepare the patient mentally and

physically for the surgery


71/73

To emphasize

The over-all goal of nursing care duringthe INTRA-OPERATIVE phase is tomaintain client safety


72/73

To emphasize

The over-all goals of nursing careduring the POST-OPERATIVE phase areto promote healing and comfort,

restore the highest possible wellnessand prevent associated risk


73/73

Documents

peri-op nsg