PERIOPERATIVE NURSING : PERIOPERATIVE NURSING REY VINCENT H. LABADAN, RN
EARL KRISTOFFER L. PIRANTE, RN
Slide 2: Behavioral Response:
Family & Individual Physiological
Response Intervention Patient Outcome Nursing Diagnosis Patient Outcome Interventions Nursing Diagnosis Patient Outcome Nursing Diagnosis Intervention Structural
Elements Report Cards Benchmarks
Desired Outcomes Health
System Safety Patient PERIOPERATIVE PATIENT-FOCUSED
MODEL
Slide 3: Conditions Requiring Surgery:
Obstruction or blockage (Impairment to the flow of vital fluids)
Perforation or rupture of an organ
Erosion or wearing away of the surface of a tissue
Tumors or abnormal growth
Categories of Surgical Procedures:
According to Purpose:
Diagnostic: to verify suspected diagnosis, e.g. biopsy
Exploratory: to estimate the extent of the disease, e.g. exploratory laparotomy
Curative: to remove or repair damaged or diseased organs or tissues PERIOPERATIVE NURSING: GENERAL CONSIDERATION
Slide 4: Types of Curative Surgery:
Ablative: removal of diseased organs. (-ectomy) e.g. appendectomy, hysterectomy
Reconstructive: partial or complete restoration of a damaged organ, e.g. plastic surgery after burns
Constructive: repair of a congenitally defective organ,
(-plasty, -orrhaphy, -pexy) e.g. cheiloplasty, orchidopexy
Palliative: to relieve pain, relieve distressing S/Sx
According to Degree of Risk to Client:
Major surgery
Minor surgery PERIOPERATIVE NURSING: GENERAL CONSIDERATION
Slide 5: Criteria:
Major surgery: High degree of risk
Prolonged intraoperative period
Large amount of blood loss
Extensive, vital organs may be handled or removed
Great risk of complications, e. g. liver biopsy
Minor surgery: Lesser degree of risk to the client
Generally not prolonged; described as “one-day surgery” or outpatient surgery
Leads to few serious complications
Involves less risk, e.g. cyst removal PERIOPERATIVE NURSING: GENERAL CONSIDERATION
Slide 6: According to Urgency:
Emergency: must be performed immediately without delay, e.g. gunshot wound, severe bleeding,
Imperative or Urgent: must be performed as soon as possible within 24 – 48 hours, e.g. appendectomy
Required: necessary for the well-being of the client, usually within weeks to months, e. g. cholecystectomy, cataract extraction, thyriodectomy
Elective: should be performed for the client’s well being but which is not absolutely necessary, e.g. simple hernia, vaginal repair, repair of scar
Optional: surgery that a client requests, e.g. rhinoplasty, liposuction, mammoplasty PERIOPERATIVE NURSING: GENERAL CONSIDERATION
Slide 7: Factors that Affect the Estimation of Surgical Risk
Physical and Mental Condition of the Client
Age: premature babies and elderly persons are at risk
Nutritional status: malnourished and obese are at risk
State of fluid and electrolytes balance: dehydration and hypovolemia predispose a person to complications
General health: infectious process increase operative risk
Mental health
Economic and occupational status PERIOPERATIVE NURSING: GENERAL CONSIDERATION
Slide 8: Types of drugs taken regularly:
Steroids: may improve the body’s ability to response to the stress of anesthesia and surgery
Anticoagulants and salicylates: may increase bleeding during surgery
Antibiotics: maybe incompatible with or potentiate anesthetic agents
Tranquilizers: potentiate the effect of narcotics and can cause hypotension
Antihypertensives: may predispose to shock by the combined effect of blood pressure reduction and anesthetic vasodilation
Diuretics: may increase potassium loss
Alcohol: will place the surgical client at risk when used chronically PERIOPERATIVE NURSING: GENERAL CONSIDERATION
Slide 9: The Extent of the Disease
The Magnitude of the Required Operation
Resources and Preparation of the Surgeon, Nurses, and the Hospital PERIOPERATIVE NURSING: GENERAL CONSIDERATION
Slide 10: PERIOPERATIVE NURSING: GENERAL CONSIDERATION Suffixes Related to Surgery:
-ostomy (make artificial opening) Colostomy
-otomy (cut into or incision) Phlebotomy
-plasty (plastic repair) Rinoplasty
-orrhaphy (suturing; repair) Herniorrhaphy
-oscopy (visual examination) Endoscopy
-ectomy (excision; removal) Cholecystectomy
Slide 11: Because clients experience varying degrees of anxiety and deficient knowledge related to surgery, careful planning by the nurse can help ensure a positive outcome.
Encompasses a client’s total surgical experience, including preoperative, intra-operative, and postoperative phases
Refers to activities performed by the professional nurse during these phases. PERIOPERATIVE NURSING: PHASES OF PERIOPERATIVE NURSING
Slide 12: PERIOPERATIVE NURSING: PHASES OF PERIOPERATIVE NURSING Pre-Operative Phase: begins with the decision to perform surgery and ends with the client’s transfer to the operating room table
Intra-Operative Phase: begins with the client is received in the OR and ends with his admission to the PARR or PACU
Post-Operative Phase: begins with the client is admitted to PARR or PACU and extends through follow-up home or clinic evaluation
Slide 13: PERIOPERATIVE NURSING: THE PERIOPERATIVE TEAM The Surgeon
An Anesthesiologist or Nurse Anesthetist
Makes the preoperative assessment to plan for the type of anesthesia to be administered and to evaluate the client’s status
The Professional Registered OR Nurse
Makes preoperative assessment and documents the perioperative client care plan (Scrub, Circulating, PACU Nurse)
Slide 14: PERIOPERATIVE NURSING: THE PERIOPERATIVE TEAM The Circulating Nurse
Manages the OR and protects the safety and health needs of the client by monitoring the activities of the members of the surgical team and monitoring the conditions in the OR
The Scrub Nurse
Responsible for scrubbing for surgery, including setting up sterile tables and equipment and assisting the surgeon and surgical technicians during the surgical procedure
The PACU Nurse
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
Slide 15: General:
Keep sterile supplies dry and unopened
Check package sterilization expiration date to verify sterility
Maintain general cleanliness in surgical suite
Maintain surgical asepsis: activities designed to keep sites free from the presence of microorganisms throughout the procedure
Personnel:
Personnel with signs of illness should not report to work
Surgical scrub, a specific hand washing technique used by operating room personnel designed to reduce microorganisms in the hands and arms, is done for the length of time designed by hospital policy PERIOPERATIVE NURSING: PRINCIPLES OF PERIOPERATIVE ASEPSIS
Slide 16: Surgical Scrub
A sensor-controlled or knee- or foot-operated faucet allows the water to be turned on and off without the use of the hands
Remove all rings and watches
Use liquid soaps to prevent the spread of organisms
Keep the finger nails short and well-trimmed
Clean fingernails with a nail stick under running water
Hold the hands higher than the elbows throughout the hand washing procedure so that run-off goes to the elbows
Allows the cleanest part of the arms to be the hands
A scrub brush facilitates the removal of microorganisms
Clean all areas of skin on the hands and arms in sequence starting at the hands and ending at the elbows
After rinsing, dry the hands with paper towels, drying first one arm from the hand to the elbow, then using a second towel to dry the second hand PERIOPERATIVE NURSING: PRINCIPLES OF PERIOPERATIVE ASEPSIS
Slide 17: PERIOPERATIVE NURSING: PRINCIPLES OF PERIOPERATIVE ASEPSIS Maintaining a Sterile Field (a microorganism-free area):
Create a sterile field using sterile drapes
Use the sterile field to place sterile supplies where they will be available during the procedure
Drape equipment prior to use
Keep drapes dry and out of contact with nonsterile objects
Utilize sterile technique while adding or removing supplies from sterile fields
Sterile Supplies and Solutions:
Check expiration dates for sterility
Don’t use solutions that were opened prior to current use
“Lip” the solution after initial use by pouring a small amount of liquid out of the bottle into a waste container to cleanse the bottle lip
Slide 18: OR personnel must practice strict Standard Precautions (i.e., blood and body substance isolation)
All items used in the sterile field must be sterile
Sterile objects become unsterile when touched by unsterile objects
Sterile items that are out of vision sterile or below the waist level of the nurse are considered unsterile
Sterile objects can become unsterile by prolonged exposure to air-born organism
The skin can not be sterilized and is unsterile
All personnel must perform a surgical scrub PERIOPERATIVE NURSING: PRINCIPLES OF SURGICAL ASEPSIS
Slide 19: All OR 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 ORs:
OR personnel must wear a sterile gown, gloves, and specific shoe covers
Hair must be completely cover
Masks must be worn at all times in the OR for the purpose of minimizing air-borne contamination and must be changed between operations or more often, if necessary
Any personnel who harbors pathogenic organisms must report themselves unable to be in the OR to protect the client from outside pathogens PERIOPERATIVE NURSING: PRINCIPLES OF SURGICAL ASEPSIS
Slide 20: Scrubbed personnel wearing sterile attire should touch only sterile items
Sterile gowns and sterile drapes have defined borders for sterility.
Sterile surfaces or articles may touch other sterile surfaces or articles and remain sterile.
Contact with unsterile objects at any point renders a sterile area contaminated.
The circulator and unsterile personnel must stay at the periphery of the 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 protocol so as not to cause contamination PERIOPERATIVE NURSING: PRINCIPLES OF SURGICAL ASEPSIS
Slide 21: 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
Slide 22: Begins at the time of decision for surgery and ends when the client is transferred to the OR
This period is used to physically and psychologically prepare the client for surgery
The nurse plays a major role in client teaching and in relieving the client’s and the family’s anxieties PERIOPERATIVE NURSING: PREOPERATIVE PHASE
Slide 23: Goals:
Assessing and correcting physiologic and psychologic problems that might increase surgical risk
Giving the person and significant others complete learning/ teaching guidelines regarding surgery
Instructing and demonstrating exercises that will benefits the person during post-op period
Planning for discharge and any projected changes in lifestyle due to surgery PERIOPERATIVE NURSING: PREOPERATIVE PHASE
Slide 24: Psychologic Preparation for Surgery
Preparation for hospital admission: includes explanation of the procedure to be done, probable outcome, expected duration of hospitalization, cost, length of absence from work, and residual effects
Causes of Fears:
Fear of the unknown
Fear of anesthesia, vulnerability while unconscious
Fear of pain
Fear of death
Fear of disturbance of body image
Worries: loss of finances, employment, social and family roles PERIOPERATIVE NURSING: PREOPERATIVE PHASE
Slide 25: Manifestations of Fears:
Anxiousness
Confusion
Anger
Tendency to exaggerate
Sad, evasive, tearful, clinging
Inability to concentrate
Short attention span
Failure to carry out simple directions
Dazed PERIOPERATIVE NURSING: PREOPERATIVE PHASE
Slide 26: Nursing Interventions to Minimize Anxiety:
Assess client’s fears, anxieties, support systems, and patterns of coping
Establish trusting relationship with client and significant others
Explain routine procedures, encourage verbalization of fears, and allow client to ask questions
Demonstrate confidence in surgeon and staff
Provide for spiritual care if appropriate PERIOPERATIVE NURSING: PREOPERATIVE PHASE
Slide 27: Legal aspect: “Informed Consent”, operative permit, surgical consent
This is to protect the surgeon and the hospital against claims that unauthorized surgery has been performed and that the patient was unaware of the potential risks of complications involved
Protects the client from undergoing unauthorized surgery PERIOPERATIVE NURSING: PREOPERATIVE PHASE
Slide 28: The Surgeon obtains operative permit or informed consent:
Surgical procedure, alternatives, possible complications, disfigurements, or removal of body parts are explained
Note: It is part of the nurse’s role as a client advocate to confirm that the client understands information given.
Informed consent is necessary for each operation performed, however minor
It is also necessary for major diagnostic procedures where major body cavity is entered, e.g. thoracentesis
Adult client (over 18 years of age) signs own permit unless unconscious or mentally incompetent
If unable to sign, relative, (spouse or next of kin) or guardian will sign PERIOPERATIVE NURSING: PREOPERATIVE PHASE
Slide 29: In an emergency, permission via the telephone is acceptable; have a second listener on phone when telephone permission being given
Consents are not needed for emergency care if all four of the following criteria are met:
There is an immediate threat to life
Experts agree that it is an emergency
Client is unable to consent
A legally authorized person cannot be reached PERIOPERATIVE NURSING: PREOPERATIVE PHASE
Slide 30: Minors (under 18) must have consent signed by an adult (i.e. parent or legal guardian). An emancipated minor may sign own consent:
Married,
College student living away from home,
In military service,
Any pregnant female or anybody who has given birth
Witness to informed consent may be nurse, other physician, clerk, or authorized person
If nurse witnesses informed consent, specify whether witnessing explanation of surgery or just signature of client PERIOPERATIVE NURSING: PREOPERATIVE PHASE
Slide 31: Physiologic Preparation Prior to Surgery:
Respiratory preparation: chest x-ray
Cardiovascular preparation: ECG, CBC, blood typing, cross-matching, PT/PTT (prothrombin time, partial thromboplastin time), serum electrolytes
Renal preparation: urinalysis
Obtain history of past medical conditions, allergies, dietary restrictions, and medications:
A – Allergy to medications, chemicals, and other environmental products such as latex
All allergies are reported anesthesia and surgical personnel before the beginning of surgery
If allergy exist, an allergy band must be placed in the client’s arm immediately PERIOPERATIVE NURSING: PREOPERATIVE PHASE
Slide 32: B – Bleeding tendencies or the use of medications that deter clotting, such as aspirin, heparin, and warfarin sodium.
Herbal medications may also increase bleeding time or mask potential blood-related problems
C – Cortisone and steroid use
D – Diabetes mellitus, a condition that not only requires strict control of blood glucose levels but also known to delay wound healing
E – Emboli; previous embolic events ( such as lower leg blood clots) may recur because of prolonged immobility PERIOPERATIVE NURSING: PREOPERATIVE PHASE
Slide 33: Instructional and Preventive Aspects:
Frequently done on an out-client basis
Assess the client’s level of understanding of surgical procedure and its implications
Answer questions, clarify and reinforce explanations given by surgeon
Explain routine pre and post procedures and any special equipment to be used
Deep breathing exercises: use of diaphragmatic and abdominal breathing PERIOPERATIVE NURSING: PREOPERATIVE PHASE
Slide 34: Coughing exercise: deep breath, exhale through the mouth, and then follow with a short breath while coughing; splint thoracic and abdominal incision to minimize pain
Turning exercise: every 1-2 hours post-operative
Extremity exercise: prevents circulatory problems and post operative gas pains or flatus
Assure that pain medications will be available post-op PERIOPERATIVE NURSING: PREOPERATIVE PHASE
Slide 35: Physical Preparation
On the Night of the Surgery:
Preparing the client’s skin: shave against the grain of the hair shaft to ensure clean and close shave
Preparing the GIT:
NPO after midnight
Administration of enema may be necessary
Insertion of gastric or intestinal tubes
Preparing for Anesthesia
Promoting rest and sleep: use of drugs
Barbiturates: Secobarbital Na, Pentobarbital Na
Non barbiturates: chloral hydrate, Flurazepam
Note: given after all pre-op treatments have been completed. PERIOPERATIVE NURSING: PREOPERATIVE PHASE
Slide 36: On the Day of Operation:
Early morning care: about 1 hour before the pre-operative medication schedule
Vital signs taken and recorded promptly
Patient changes into hospital gown that is left untied and open at the back
Braid long hair and remove hair pin
Provide oral hygiene
Prosthetic devices, eyeglasses, dentures removed
Remove jewelries
Remove nail polish
Patient should void immediately before going to the OR
Make sure that the patient has not taken food for the last 10 hours by asking the client
Urinary catheterization may be performed in the OR PERIOPERATIVE NURSING: PREOPERATIVE PHASE
Slide 37: Pre-Operative Medications:
Generally administered 60-90 min before induction of anesthesia
Purpose:
To allay anxiety: the primary reason for pre-operative medications
To decrease the flow of pharyngeal secretions
To reduce the amount of anesthesia to be given
To create amnesia for the events that precedes surgery
Types of Pre-Operative Medications:
Sedative:
Given to decrease client’s anxiety to lower BP and PR
Reduce the amount of general anesthesia: an overdose can result to respiratory depression
e.g. Phenobarbital PERIOPERATIVE NURSING: PREOPERATIVE PHASE
Slide 38: Tranquilizer:
Lowers the client’s anxiety level
e.g. Thorazine 12.5 - 25 mg IM 1-2 hours prior to surgery
Narcotic analgesia:
Given to reduce patients to reduce anxiety and to reduce the amount of narcotics given during surgery
e.g. Morphine sulfate 8-15 mg SC 1 hour prior to preoperative; *Can cause vomiting, respiratory depression and postural hypotension PERIOPERATIVE NURSING: PREOPERATIVE PHASE
Slide 39: Vagolytic or drying agents:
To reduce the amount of tracheobronchial secretions which can clog the pulmonary tree and result in atelectasis and pneumonia
e.g. Atropine sulfate 0.3-0.6 mg IM 45 min before surgery; * An overdose can result to severe tachycardia
Recording: all final preparation and emotional response before surgery should be noted down
Transportation to the OR, *Woolen or synthetic blankets must never be sent to the OR because they are source of static electricity PERIOPERATIVE NURSING: PREOPERATIVE PHASE
Slide 40: PERIOPERATIVE NURSING: PREOPERATIVE PHASE Nursing Diagnosis for Preoperative Client
Anxiety related to lack of knowledge about preoperative routines, physical preparation for surgery, post operative care and potential body image change
Slide 41: Begins the moment the patient is anesthetized and ends when the last stitch or dressing is in place
Anesthesia – A state or narcosis, analgesia, relaxation and reflex loss (severe central nervous system [CNS] depression produced by pharmacologic agent) PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE
Slide 42: Four Stages of Anesthesia:
Stage I: Onset [Beginning of Anesthesia]
Patient breath in the anesthetic mixture
Warmth, dizziness, & feeling of detachment may be experienced
Ringing, roaring, or buzzing in the ears
Inability to move extremities
Surrounding noise is exaggerated
Still conscious
Stage II: Excitement
Struggling, shouting, singing, laughing or crying may be experienced
Pupils dilate but PERRLA, rapid PR, irregular RR
Patient restrain might be necessary PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE
Slide 43: Stage III: Surgical Anesthesia
Continued administration of anesthetic agent
RR, PR normal, skin pink and flushed
Patient is unconscious
Stage IV: Danger Stage [Medullary Depression]
Reached when to much anesthesia has been administered
Respiration shallow, pulse weak, pupils dilate
Cyanosis develops, without prompt intervention death may ensue PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE
Slide 44: Stages of Anesthesia, summary: PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE
Slide 45: Types of Anesthesia:
General Anesthesia: a state of analgesia, amnesia, and unconsciousness characterized by the loss of reflexes and muscle tone
Inhalation Anesthesia
Advantage: prevention of pain and anxiety
Disadvantage: circulatory and respiratory depression
* Highly inflammable and explosive
Safety rules:
Do not wear slips, nylons, wool, or any material which can set-off sparks
No smoking 12 hours after the operation
Do not wear shoes that are not conductive
Do not rise bed materials that are not conductive, e.g. volatile liquid: halothane, ether; gas anesthetic: e.g. nitrous oxide, cyclopropane PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE
Slide 46: Intravenous Anesthesia: usually employed as an induction prior to administration of the more potent inhalation anesthetic agents. Used commonly in minor procedure
Advantage:
Rapid pleasant induction
Absence of explosive hazards
Low incidence of nausea and vomiting
Disadvantage:
Laryngeal spasm and bronchospasm
Hypotension
Respiratory arrest, e.g. Thiopental Na (Pentothal Na), Ketamine ( Ketalar), Fentanyl ( Innovar) PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE
Slide 47: PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE Regional Anesthesia: it is the injection or application of a local anesthetic agent to produce a loss of painful sensation in only one region of the body and does not result to unconsciousness
Topical anesthesia: e.g. lidocaine
Infiltration anesthesia
Nerve block
Epidural block
Caudal block
Pudendal block
Spinal anesthesia, e.g. Saddle block for vaginal delivery
Local anesthesia, e.g. Procaine, Lidocaine (Xylocaine)
Slide 48: PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE Specialized Methods of Producing Anesthesia:
Muscle relaxants: it is a neuromuscular blocking agent used to provide muscle relaxation
Use: for endotracheal intubation, e.g. Pancuronium bromide (Pavulon), Curarine chloride (Curare)
Hypothermia: it refers to the deliberate reduction of the patient’s body temperature between 28°-30° C
Uses: Heart surgery, Brain surgery, Surgery on large vessels supplying major organs
Slide 49: Methods:
Ice water immersion
Ice bags
Cooling blanket
Complications:
Cardiac arrest
Respiratory depression PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE
Slide 50: PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE Positioning the Client:
Commonly Used Operative Positions
Supine: hernia repair, explore lap, cholecystectomy, mastectomy
Prone: spine surgery, rectal surgery
Trendelenburg
Reverse Trendelenburg
Lithotomy position
Lateral position: kidney and chest surgery
Others: for thyroidectomy- head hyperextended
Slide 51: PERIOPERATIVE NURSING: POSTOPERATIVE PHASE Post Anesthetic Care
Nursing Responsibilities:
Maintenance of pulmonary ventilation:
Position the client to side lying or semi-prone position to prevent aspiration
Oropharyngeal or nasopharyngeal airway:
* Is left in place following administration of general anesthetic until pharyngeal reflexes have returned
It is only removed as soon as the client begins to awaken and has regained the cough and swallowing reflexes
All clients should received O2 at least until they are conscious and are able to take deep breaths on command
Slide 52: Shivering of the client must be avoided to prevent an increase in O2, and should be administered until shivering has ceased
Maintenance of circulation:
Most common cardiovascular complications:
Hypotension
Causes:
Jarring the client during transport while moving client from the OR to his bed
Reaction to drug and anesthesia
Loss of blood and other body fluids
Cardiac arrhythmias and cardiac failure
Inadequate ventilation
Pain PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
Slide 53: Cardiac arrhythmias
Causes: Hypoxemia, Hypercapnea
Interventions: O2 therapy, Drug administration: Lidocaine, Procainamide
Protection from injury and promotion of comfort
Provide side rails
Turning frequently and placed in good body alignment to prevent nerve damage from pressure
Administration of narcotic analgesics to relieve incisional pain
Post-operative dose usually reduced to half the dose the patient will be taking after fully recovered from anesthesia PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
Slide 54: Dismissal of Client from Recovery Room: Modified Aldrete Score for Anesthesia Recovery Criteria
The Five Physiological Parameters:
Activity – able to move four extremities voluntarily on command
Respiration – able to breath effortlessly and deeply, and cough freely
Circulation – BP is (+ 20%) or (- 20%) of pre-anesthetic level
Consciousness – fully awake, oriented to time, place and person
Color – pink (lips), for blacks: tongue PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
Slide 55: Modified Aldrete Score PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
Slide 56: Postoperative Care
Begins when the client returns from the recovery room or surgical suite to the nursing unit and ends when the client is discharged
It is directed toward prevention of complication and post-operative discomfort
Post-Operative Complications
Respiratory Complications: atelectasis and pneumonia
Suspected when ever there is a sudden rise of temperature 24-48 hours after surgery
Collapse of the alveoli is highly susceptible to infection: pneumonia PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
Slide 57: Occurs usually in high abdominal surgery when prolonged inhalation anesthesia has been necessary and vomiting has occurred during the operation or while the patient is recovered from anesthesia
NURSING MANAGEMENT:
Measures to prevent pooling of secretions:
Frequent changing of position
High fowler’s position
Moving out of bed
Measures to liquefy and remove secretions:
Increase oral fluid intake
Breathing moist air PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
Slide 58: Deep breathing followed by coughing
Administer analgesics before coughing is attempted after thoracic and abdominal surgery
Splint operative area with draw sheet or towel to promote comfort while coughing
Other measures to increase pulmonary ventilation
Blow bottle exercise
Rebreathing tubes: increase CO2 stimulates the respiratory center to increase the depth of breathing thus increasing the amount of inspired air
IPPB: intermittent positive pressure breathing apparatus PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
Slide 59: Circulatory Complication: venous stasis
Causes of venous stasis
Muscular inactivity
Respiratory and circulatory depression
Increased pressure on blood vessels due to tight dressing
Intestinal distention
Prolonged maintenance of sitting
Contributing factors for venous stasis:
Obesity
CV disease
Debility
Malnutrition
Old age PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
Slide 60: Most common circulatory complications:
Phlebothrombosis
Thrombophlebitis
NURSING MANAGEMENT:
Limbs must never be massaged for a post-op client
If possible, client should lie on his abdomen for 30 min several time a day to prevent pooling of blood in the pelvic cavity
Do not allow the client to stand unless pulse has returned close to baseline to prevent orthostatic hypotension
Wear elastic bandages or stockings when in bed and when walking for the first time. PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
Slide 61: Fluids and Electrolytes Imbalance:
Causes:
Blood loss
Increased insensible fluid loss through the skin;
After surgery through vomiting, from copious wound drainage, and from the tube drainage as in NGT
Since surgery is a stressor, there is an increased production of ADH for the first 12-24 hours following surgery resulting to fluid retention by the kidney
The potential for over hydration therefore exists since fluids being given IV may exceed fluid output by the kidney PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
Slide 62: Electrolyte Imbalance:
Particularly Na and K imbalance as a result of blood loss
Stress of surgery increases adrenal hormonal activity resulting to increased aldosterone and glucocorticoids, resulting in sodium reabsorption by the kidney
And as Na is reabsorbed, K coming from tissue breakdown is excreted
Action: IV of D5W alternate with D5NSS or half strength NSS to prevent Na excess PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
Slide 63: Complications of Surgery
GIT complications:
Paralytic ileus: Cessation of peristalsis due to excessive handling of GI organs
NURSING MANAGEMENT:
NPO until peristalsis has returned as evidenced by auscultation of bowel sounds or by passing out of flatus
Vomiting: usually the effect of certain anesthetics on the stomach, or eating food or drinking water before peristalsis returns. Psychologic factors also contribute to vomiting
NURSING MANAGEMENT:
Position the client on the side to prevent aspiration PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
Slide 64: When vomiting has subsided, give ice chips, sips of ginger ale or hot tea, or eating small frequent amounts of dry foods thus relieving nausea
Administer anti-emetic drugs as ordered: Trimethobenzamide Hcl (Tigan); Prochiorperasine dimaleate (Compazine)
Abdominal distention: results from the accumulation of non-absorbable gas in the intestine
Causes:
Reaction to the handling of the bowel during surgery
Swallowing of air during recovery from anesthesia
Passage of gases from the blood stream to the atonic portion of the bowel PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
Slide 65: Gas pains: results from contraction of the unaffected portion of the bowel in order to move accumulated gas in the intestinal tract
Management:
Aspiration of fluid or gas: with the insertion of an NGT
Ambulation: stimulates the return of peristalsis and the expulsion of flatus
Enema
Rectal tube insertion: inserted just passed the anal sphincter and removal after approximately 20 minutes
Adult: 2-4 inches, children: 1-3 inches
Prolonged stimulation of the anal sphincter may cause loss of neuromuscular response, and pressure necrosis of the mucous surface PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
Slide 66: Constipation: due to decreased food intake and inactivity
Regular bowel movement will return 3-4 days after surgery when resumption of regular diet and adequate fluid intake and ambulation
GUT Complications
Return of urinary function: usually after 6-8 hours
First voiding may not be more than 200 ml, and total out put may not be more than 1500ml
Due to the loss of fluids during surgery, perspiration, hyperventilation, vomiting, and increased secretion of ADH PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
Slide 67: Complication: urinary retention
Causes:
Prolonged recumbent position
Nervous tension
Effect of anesthetics interfering with bladder sensation and the ability to void
Use of narcotics that reduce the sensation of bladder distention
Pain at the surgical site and on movement
Urinary tract infection
Management:
Instruct the client to empty the bladder completely during voiding
Catheterize if needed, done by sterile technique PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
Slide 68: Post-operative Discomforts
Post-operative pain
Narcotics can be given every 3-4 hours during the first 48 hours post-operatively for severe pain without danger of addiction
Singultus
Brought about by the distention of the stomach, irritation of the diaphragm, peritonitis and uremia causing a reflex or stimulation of the phrenic nerve
Management:
Paper bag blowing; CO2 inhalation: 5% CO2 and 95% O2 x 5 minutes every hour PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
Slide 69: Wound Complications:
Sutures are usually removed about 5th-7th day post-op with the exception of wire retention sutures placed deep in the muscles and removed 14-21 days after surgery
Hemorrhage from the wound
Most likely to occur within the first 48 hours post-op or as late as 6th-7th post-op day
Causes:
Hemorrhage occurring soon after operation: mechanical dislodging of a blood clot or caused by the reestablished blood flow through the vessel
Hemorrhage after few days: Sloughing off of blood clot or of a tissue
Infection PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
Slide 70: Assessment:
Bright red blood
Decreased BP
Increased PR and RR
Restlessness
Pallor
Weakness
Cold, moist skin
Infection
Cause: streptococcus and staphylococcus
Assessment: 3-6 days after surgery, low grade fever, and the wound becomes painful and swollen. There maybe purulent drainage on the dressing PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
Slide 71: Dehiscence and Evisceration
Dehiscence or wound disruption: Refers to a partial-to-complete separation of the wound edges
Evisceration: Refers to protrusion of the abdominal viscera through the incision and onto the abdominal wall
Assessment:
Complain of a “giving” sensation in the incision
Sudden, profuse leakage of fluid from the incision
The dressing is saturated with clear, pink drainage
Management:
Position the client to low Fowler’s position
Instruct the client not to cough, sneeze, eat or drink, and remain quiet until the surgeon arrives
Protruding viscera should be covered warm, sterile, saline dressing PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
Slide 72: Discharge Instructions:
Early discharge, which has become common, typically increases client teaching needs
Be sure to provide information about wound care, activity restrictions, dietary management, medication administration, symptoms to report, and follow-up care
A client recovering from same-day surgery in an outpatient surgical unit must be in stable condition before discharge
This client must not drive home, make sure a responsible adult takes the client home PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
Slide 73: PERIOPERATIVE NURSING: References Textbook of Medical Surgical Nursing 7th Edition by Joyce Black
Brunner and Suddarth’s Textbook of Medical Surgical Nursing 11th Edition by Suzanne Smeltzer
Berry & Kohn’s Operating Room Technique 10th edition by Nancymarie Philips
The Lippincott Manual of Nursing Practice 7th Edition by Sandra Nettina
Mastering Medical-Surgical Nursing 2nd edition by Josie Udan
NCLEX-RN Review Materials
Slide 74: THANK YOU! Daghang Salamat! Nagpaka-hero tungod ug alang kaninyo… Hahaayyy…pastilan…