Perioperative Nursing

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This PPT was downloaded from the internet and enhanced by me several years ago.

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Perioperative Nursing:

Perioperative Nursing Preoperative Phase Intraoperative Phase Postoperative Phase 1

PERIOPERATIVE NURSING:

PERIOPERATIVE NURSING The special field known as perioperative and perianesthesia nursing includes a wide variety of nursing functions associated with the patient’s surgical experience during the perioperative period. Perioperative and perianesthesia nursing addresses the nursing roles relevant to the three phases of the surgical experience: Preoperative Intraoperative Postoperative 2

Peoperative Phase:

Peoperative Phase The preoperative phase begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient on to the operating room table. The scope of nursing activities during this time can include: Establishing a baseline evaluation of the patient before the day of surgery by carrying out a preoperative interview (which includes not only a physical but also an emotional assessment, previous anesthetic history, and identification of known allergies or genetic problems that may affect the surgical outcome) 3

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Ensuring that necessary tests have been or will be performed (preadmission testing) Arranging appropriate consultative services, and providing preparatory education about recovery from anesthesia and postoperative care. On the day of surgery, patient teaching is reviewed, the patient’s identity and the surgical site are verified. Informed consent is confirmed, and an intravenous infusion is started. If the patient is going home the same day, the availability of safe transport and the presence of an accompanying responsible adult is verified. 4

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ADMISSION to the Surgical Unit Preparation for Surgery: Physical, Psychosocial, Spiritual, Legal Transport to Operating Room 5

Intraoperative Phase:

Intraoperative Phase The intraoperative phase begins when the patient is transferred onto the operating room table and ends when he or she is admitted to the postanesthesia care unit (PACU). In this phase, the scope of nursing activity can include: Providing for the patient’s safety Maintaining an aseptic environment Ensuring proper function of equipment Providing the surgeon with specific instruments and supplies for the surgical field. Completing appropriate documentation 6

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Providing emotional support by holding the patient’s hand during general anesthesia induction. Assisting in positioning the patient on the operating room table using basic principles of body alignment Acting as scrub nurse, circulating nurse, or registered nurse first assistant (RNFA) 7

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ADMISSION to the OR ANESTHESIA SURGERY Recovery Room/ PACU 8

Postoperative Phase:

Postoperative Phase The postoperative phase begins with the admission of the patient to the PACU and ends with a follow-up evaluation in the clinical setting or at home. The scope of nursing care covers a wide range of activities during this period. In the immediate post-operative phase, the focus includes: Maintaining the patient’s airway Monitoring vital signs Assessing the effects of the anesthetic agents Assessing the patient for complications Providing comfort and pain relief. 9

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Nursing activities then focus on promoting the patient’s recovery and initiating the teaching, follow-up care, and referrals essential for recovery and rehabilitation after discharge. 10

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ADMISSION to the RR/ PACU Back to the Surgical Unit DISCHARGE Follow-Up Care 11

Types of Conditions Requiring Surgery:

Types of Conditions Requiring Surgery Obstruction – Impairment to the flow of vital fluids. eg. blood, urine, bile, cerebrospinal fluid. Perforation – Rupture of organ. eg. ruptured appendicitis, ruptured uterus. Erosion – wearing off a surface or membrane. eg. peptic ulcer. Tumors – abnormal new growths. eg. breast tumor, bone tumor, lung tumor, brain tumor. 12

Surgical Classifications:

Surgical Classifications According to PURPOSE: Diagnostic – to confirm presence of a disease condition eg . biopsy Exploratory – to determine the extent of the disease condition eg . ex-lap Curative – to treat disease condition. 2 types: Ablative – removal of an organ. “ ectomy ” eg . appendectomy Constructive – involves repair of congenitally defective organ. “ plasty ”, “ orrhaphy “, “ pexy ” eg . cheiloplasty (repair of cleft lip) Reconstructive – repair of damaged organ. eg . plastic surgery after severe burns. Palliative – to relieve distressing signs and symptoms, not necessarily to cure the disease. eg . colostomy, debridement of necrotic tissues. 13

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According to URGENCY: Emergency – should be done immediately to save the client’s life or limb. eg. hysterectomy Imperative – the procedure should be done within 24-48 hours eg. evacuation of blood clots from the brain. Planned Required – the procedure is necessary for the well being of the client however it may be scheduled weeks or months later. Elective – the procedure is not absolutely necessary for survival; delay or omission will not cause side effect. eg. removal of simple goiter Optional – the procedure is requested by the client; it is usually for aesthetic purposes. eg. Rhinoplasty. 14

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Surgery may also be classified according to the degree of urgency involved: Emergent – patient requires immediate attention; disorder may be life threatening; eg . severe bleeding, bladder or intestinal obstruction, fractured skull, gunshot or stab wounds, extensive burns. Urgent – patient requires prompt attention; within 24-30 hours; eg . acute gallbladder infection, kidney or ureteral stones. Required – patient needs to have surgery; plan within a few weeks or months; eg . cataracts, thyroid disorders. 15

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Elective – patient should have surgery; failure to have surgery not catastrophic; eg . repair of scars, simple hernia, vaginal repair. Optional – decision rests with patient; personal preference; eg . cosmetic surgery. 16

Preparation for surgery:

Preparation for surgery Informed Consent: Voluntary and written informed consent from the patient is necessary before nonemergent surgery can be performed. Written consent protects the patient from unsanctioned surgery and protects the surgeon from claims of an unauthorized operation. In the best interests of all parties concerned, sound medical, ethical, and legal principles are followed. The nurse may ask the patient to sign the form and may witness the patient’s signature. It is the physician’s responsibility to provide appropriate information. 17

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Criteria for Valid Informed Consent Voluntary Consent Valid consent must be freely given, without coercion. Incompetent Patient Legal definition: individual who is not autonomous and cannot give or withhold consent ( eg , individuals who are mentally retarded, mentally ill, or comatose) Informed Subject - Informed consent should be in writing. It should contain the following: Explanation of procedure and its risks Description of benefits and alternatives An offer to answer questions about procedure Instructions that the patient may withdraw consent A statement informing the patient if the protocol differs from customary procedure Patient Able to Comprehend Information must be written and delivered in language understandable to the patient. Questions must be answered to facilitate comprehension if material is confusing 18

Purpose of the Written Consent:

Purpose of the Written Consent To ensure that the client understands the nature of the treatment including the potential complications and disfigurement as explained by the surgeon. To indicate that the client’s decision was made without pressure. To protect the surgeon and the hospital against legal action by a client who claims that an unauthorized procedure was performed. 19

Circumstances Requiring Written Informed Consent:

Circumstances Requiring Written Informed Consent Any surgical procedure where scalpel, scissors, suture, hemostats of electrocoagulation may be used. Any invasive procedure, or procedure that involves entry into a body cavity. Any procedure that involves general anesthesia, local infiltration anesthesia or regional block anesthesia. 20

The Requiites for Validity of Written Informed Consent:

The Requiites for Validity of Written Informed Consent Written permit/consent is best & is legally acceptable. Patient’s signature is obtained with the client’s complete understanding of what is to occur. Adults sign their own consent unless he/she is physically and mentally incapacitated. Consent is obtained before sedation. The patient is not under the influence of drugs or alcohol. The consent is secured without pressure or duress. Signature of witness is required. The nurse, physician or other authorized persons may sign as witness. In an emergency, permision via phone or telefax i s accceptable. The physician should document the nature of the emergency. Emancipated minors are allowed to sign without parents consent. 21

Preoperative Nursing Interventions:

Preoperative Nursing Interventions Nurses have long recognized the value of preoperative instruction. Each patient is taught as an individual, with consideration for any unique concerns or needs; the program of instruction should be based on the individual’s learning needs. Multiple teaching strategies should be used( eg , verbal, written, return demonstration), depending on the patient’s needs and abilities. Preoperative teaching is initiated as soon as possible. It should start in the physician’s office and continue until the patient arrives in the operating room. 22

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Preoperative teaching for patients undergoing surgery includes instruction in breathing and leg exercises used to prevent postoperative complications, such as pneumonia and deep vein thrombosis. These exercises may be performed in the hospital or at home. Diaphragmatic Breathing Diaphragmatic breathing refers to a flattening of the dome of the diaphragm during inspiration, with resultant enlargement of the upper abdomen as air rushes in. During expiration, the abdominal muscles contract. Practice in the same position you would assume in bed after surgery: a semi-Fowler’s position, propped in bed with the back and shoulders well supported with pillows. With your hands in a loose- fist position, allow the hands to rest lightly on the front of the lower ribs, with your fingertips against lower chest to feel the movement 23

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Breathe out gently and fully as the ribs sink down and inward toward midline. Then take a deep breath through your nose and mouth, letting the abdomen rise as the lungs fill with air. Hold this breath for a count of five . Exhale and let out all the air through your nose and mouth. Repeat this exercise 15 times with a short rest after each group of five . Practice this twice a day preoperatively. Coughing Lean forward slightly from a sitting position in bed, interlace your fingers together, and place your hands across the incisional site to act as a splint-like support when coughing 25

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Breathe with the diaphragm as described under “Diaphragmatic Breathing.” With your mouth slightly open, breathe in fully. “Hack” out sharply for three short breaths. Then, keeping your mouth open, take in a quick deep breath and immediately give a strong cough once or twice. This helps clear secretions from your chest. It may cause some discomfort but will not harm your incision. Leg Exercises Lie in a semi-Fowler’s position and perform the following simple exercises to improve circulation. Bend your knee and raise your foot—hold it a few seconds, then extend the leg and lower it to the bed. 26

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Do this five times with one leg, then repeat with the other leg. Then trace circles with the feet by bending them down, in toward each other, up, and then out. Repeat these movements five times. Turning to the Side Turn on your side with the uppermost leg flexed most and sup-ported on a pillow. Grasp the side rail as an aid to maneuver to the side. Practice diaphragmatic breathing and coughing while on your side. Getting Out of Bed Turn on your side. Push yourself up with one hand as you swing your legs out of bed. 27

Preparation of the Patient the Evening Before the Surgery:

Preparation of the Patient the Evening Before the Surgery Preparing the Skin. High Impact Concepts: Human skin normally harbors transient and resident bacterial flora, some of which are pathogenic. Skin cannot be sterilized without destroying skin cells. Friction enhances the action of detergent antiseptics. It is ideal for the patient to bathe or shower, using a bacteriostatic soap to reduce microorganisms in the skin. Shaving should be performed as close to the operative time as possible. Hair grows again overnight. Shaving should be done in the direction of hair growth. 28

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Preparing the Gastrointestinal Tract Preparing of the bowel for intestinal surgery to prevent escape of bacteria and sepsis includes the following: Cathartics (purging meds) and enemas. Oral antimicrobials to reduce bacterial flora. Enemas “until clear” the evening before surgery. No more than three enemas should be given to prevent fluid – electrolyte imbalances. NPO for 6 hours before surgery. Patients having morning surgery are kept NPO from midnight. Clear fluids like water may be given up to 4 hours before surgery if ordered to help client swallow medications. 29

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Preparing for Anesthesia The patient should avoid alcohol and cigrarette smoking for at least 24 hours before surgery. This can help reduce potential complications of anesthesia. Pomoting Rest and Sleep Provide comfort measures. eg. clean gown and linens, correct room temperature, subdued lighting, back rub. Administer sedative as ordered. 30

Preparing the Patient on the Day of the Surgery:

Preparing the Patient on the Day of the Surgery Awaken the patient, one hour before preoperative medications. Provide morning bath and mouth wash. Morning bath reduces microorganisms in the skin. Mouthwash prevents surgical parotitis. Provide clean gown. Remove haripins, braid long hairs and cover hair with cap. Remove dentures, foreign materials (chewing gum) from patient’s mouth. Remove colored nail polish, hearing aid, contact lenses, jewelries. If the patient refuses to remove the wedding ring, tie it with gauze and fasten around the wrist. 31

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Take baseline vital signs before administration of preop medications. Check patient identification (ID) band and area of “skin prep” as applicable. Check for special orders. eg. enema, gastrointestinal tube insertion, IV line. Ensure that these orders are carried out. Check if NPO is maintained. Have client void before administration of preop medications. Some preop medications may cause hypertension and increase risk for falls. For patient safety, put up side rails, put call light within patient’s reach, and instruct patient to ask for help if he/she needs to void. Continue to support the patient emotionally. Anxiety level may be high at this time. Accomplish the “Preop Care Checklist.” 32

The Patient:

The Patient As the patient enters the operating room, he or she may feel relaxed and prepared, or fearful and highly stressed. Fears about loss of control, the unknown, pain, death, changes in body structure or function, and disruption of lifestyle all may contribute to a generalized anxiety The patient is also subject to several risks. Infection, failure of the surgery to relieve symptoms, temporary or permanent complications related to the procedure or the anesthetic, and death. In addition to fears and risks, the patient undergoing sedation and anesthesia temporarily loses both cognitive function and biologic self-protective mechanisms. 33

The Circulating Nurse:

The Circulating Nurse The circulating nurse (also known as the circulator) must be a registered nurse. He or she manages the operating room and protects the patient’s safety and health by monitoring the activities of the surgical team, checking the operating room conditions, and continually assessing the patient for signs of injury and implementing appropriate interventions. The main responsibilities include: verifying consent coordinating the team ensuring cleanliness, proper temperature, humidity, and lighting ensuring safe functioning of equipment ensuring the availability of supplies and materials. The circulating nurse monitors the patient and documents specific activities throughout the operation. 34

The Scrub nurse:

The Scrub nurse Activities of the scrub nurse include: performing a surgical hand scrub setting up the sterile tables preparing sutures, ligatures, and special equipment (such as a laparoscope) assisting the surgeon during the procedure by anticipating the instruments that will be required, such as sponges, drains, and other equipment. As the surgical incision is closed, the scrub person and the circulator count all needles, sponges, and instruments to be sure they are accounted for and not retained as a foreign body in the patient. Tissue specimens obtained during surgery must also be labeled by the scrub person and sent to the laboratory by the circulator. 35

The Surgeon:

The Surgeon The surgeon performs the surgical procedure and heads the sur-gical team. He or she is a licensed physician (MD). 36

The anesthesiologist:

The anesthesiologist An anesthesiologist  is a physician specifically trained in the art and science of anesthesiology. An anesthetist is a qualified health care professional who administers anesthetics. Most anesthetists are nurses who have graduated from an accredited nurse anesthesia program and have passed examinations sponsored by the American Association of Nurse Anesthetists to become a certified registered nurse anesthetist (CRNA). The anesthesiologist or anesthetist interviews and assesses the patient prior to surgery, selects the anesthesia, administers it, intubates the patient if necessary, manages any technical problems related to the administration of the anesthetic agent, and supervises the patient’s condition throughout the surgical procedure. 37

Exposure to Blood and Bloody Fluids:

Exposure to Blood and Bloody Fluids Since the advent of the acquired immunodeficiency syndrome(AIDS) epidemic, OR attire has changed dramatically. Double gloving is routine, at least in trauma surgery where sharp bone fragments are present. In addition to the routine scrub suit and double gloves, some surgeons wear rubber boots, a waterproof apron, and sleeve protectors. Goggles, or a wrap-around face shield, are worn to protect against splashing when the surgical wound is irrigated or when bone drilling is performed. In hospitals where numerous total joint procedures are performed, a full bubble mask may be used. This mask provides full barrier protection from bone fragments and splashes. Safe ventilation is accomplished through an accompanying hood with a separate air- filtration system 38

Anesthesia:

Anesthesia General anesthesia consists of four stages, each associated with specific clinical manifestations. When opioid agents (narcotics)and neuromuscular blockers (relaxants) are administered, several of the stages are absent. The anesthesia level consists of general anesthesia and spinal or major regional anesthesia but does not include local anesthesia. Anesthesia is a state of narcosis (severe central nervous system depression produced by pharmacologic agents), analgesia, relaxation, and reflex loss. Patients under general anesthesia are not arousable , even to painful stimuli. They lose the ability to maintain ventilatory function and require assistance in maintaining a patent airway. Cardiovascular function may be impaired as well. 39

Stages of Anesthesia:

Stages of Anesthesia STAGE I: Beginning Anesthesia As the patient breathes in the anesthetic mixture, warmth, dizziness, and a feeling of detachment may be experienced. The patient may have a ringing, roaring, or buzzing in the ears and, though still conscious, may sense an inability to move the extremities easily. During this stage, noises are exaggerated; even low voices or minor sounds seem loud and unreal. For this reason, the nurse avoids making unnecessary noises or motions when anesthesia begins. 40

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STAGE II: Excitement The excitement stage, characterized variously by struggling, shouting, talking, singing, laughing, or crying, is often avoided if the anesthetic is administered smoothly and quickly. The pupils dilate, but contract if exposed to light; the pulse rate is rapid, and respirations may be irregular. Because of the possibility of uncontrolled movements of the patient during this stage, the anesthesiologist or anesthetist must always be assisted by someone ready to help restrain the patient. A strap may be in place across the patient’s thighs, and the hands may be secured to an armboard . The patient should not be touched except for purposes of restraint, but restraints should not be applied over the operative site. Manipulation increases circulation to the operative site and thereby increases the potential for bleeding. 41

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STAGE III: Surgical Anesthesia Surgical anesthesia is reached by continued administration of the anesthetic vapor or gas. The patient is unconscious and lies quietly on the table. The pupils are small but contract when ex-posed to light. Respirations are regular, the pulse rate and volume are normal, and the skin is pink or slightly flushed . With proper administration of the anesthetic, this stage may be maintained for hours in one of several planes, ranging from light to deep, depending on the depth of anesthesia needed. 42

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STAGE IV: Medullary Depression This stage is reached when too much anesthesia has been administered. Respirations become shallow, the pulse is weak and thready , and the pupils become widely dilated and no longer contract when exposed to light. Cyanosis develops and, without prompt intervention, death rapidly follows. If this stage develops, the anesthetic is discontinued immediately and respiratory and circulatory support is initiated to prevent death. Stimulants, although rarely used, may be administered; narcotic antagonist scan be used if over dosage is due to opioids . During smooth administration of an anesthetic, there is no sharp division between the first three stages, and there is no stage IV. The patient passes gradually from one stage to another, and it is only by close observation of the signs exhibited by the patient that an anesthesiologist or anesthetist can control the situation. The responses of the pupils, the blood pressure, and the respiratory and cardiac rates are probably the most reliable guides to the patient’s condition. 43

The Patient During Surgery:

The Patient During Surgery Assessment Nursing assessment of the intraoperative patient involves obtaining data from the patient and the patient’s record to identify variables that can affect care and serve as guidelines for developing an individualized plan of patient care. The intraoperative nurse uses the focused preoperative nursing assessment documented on the patient record. This includes assessment of physiologic status(eg, health–illness level, level of consciousness), psychosocial status (eg, anxiety level, verbal communication problems, coping mechanisms), physical status (eg, surgical site, skin condition andeffectiveness of preparation; immobile joints), and ethical con-cerns 44

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NURSING DIAGNOSES Based on the assessment data, some major nursing diagnoses may include the following: Anxiety related to expressed concerns due to surgery or OR environment Risk for perioperative positioning injury related to environmental conditions in the OR Risk for injury related to anesthesia and surgery Disturbed sensory perception (global) related to general anesthesia or sedation 45

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Planning and Goals Goals for care of the patient during surgery include reducing anxiety, preventing positioning injuries, maintaining safety, maintaining the patient’s dignity, and avoiding complications. Nursing Interventions REDUCING ANXIETY The OR environment can seem cold, stark, and frightening to the patient, who may be feeling isolated and apprehensive. Introducing yourself, addressing the patient by name warmly and frequently, verifying details, providing explanations, and encouraging and answering questions provide a sense of professionalism and friendliness that can help the patient feel secure. When discussing what the patient can expect in surgery, the nurse uses common, basic communication skills, such as touch and eye contact, to reduce anxiety. Attention to physical comfort (warm blankets, position changes) helps the patient feel more comfortable. Telling the patient who else will be present in the OR, how long the procedure is expected to take, and other details helps the patient prepare for the experience and gain a sense of control 46

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PREVENTING INTRAOPERATIVE POSITIONING INJURY The patient’s position on the operating table depends on the surgical procedure to be performed as well as on his or her physical condition. The potential for transient discomfort or even permanent injury is clear because many positions are awkward. Hyperextending joints, compressing arteries, or pressing on nerves and bony prominences usually results in discomfort simply because the position must be sustained for a long period. Factors to consider include the following: The patient should be in as comfortable a position as possible, whether asleep or awake. The operative field must be adequately exposed An awkward position, undue pressure on a body part, or use of stirrups or traction should not obstruct the vascular supply. Respiration should not be impeded by pressure of arms on the chest or by a gown that constricts the neck or chest. 47

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Nerves must be protected from undue pressure. Improper positioning of the arms, hands, legs, or feet may cause serious injury or paralysis. Shoulder braces must be well padded to prevent irreparable nerve injury, especially when the Trendelenburg position is necessary. Precautions for patient safety must be observed, particularly  with thin, elderly, or obese patients, or those with a physical deformity. The patient needs gentle restraint before induction in case of excitement. The usual position for surgery, called the dorsal recumbent position, is flat on the back. One arm is positioned at the side of the table, with the hand placed palm down; the other is carefully positioned on an armboard to facilitate intravenous infusion of fluids , blood, or medications. This position is used for most abdominal surgeries except for surgery of the gallbladder and pelvis. 48

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The Trendelenburg position usually is used for surgery on the lower abdomen and pelvis to obtain good exposure by displacing the intestines into the upper abdomen. In this position, the head and body are lowered. The patient is held in position by padded shoulder braces. The lithotomy position is used for nearly all perineal , rectal, and vaginal surgical procedures. The patient is positioned on the back with the legs and thighs flexed . The position is maintained by placing the feet in stirrups. The Sims or lateral position is used for renal surgery. The patient is placed on the non operative side with an air pillow 12.5 to15 cm (5 to 6 inches) thick under the loin, or on a table with a kidney or back lift. Other procedures, such as neurosurgery or abdominothoracic surgery, may require unique positioning and supplemental apparatus, depending on the operative approach. 49

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PROTECTING THE PATIENT FROM INJURY Providing a safe environment. Verifying information, checking the chart for completeness, and maintaining surgical asepsis and an optimal environment are critical nursing responsibilities. Verifying that all required documentation is completed is one of the first functions of the intraoperative nurse. The patient is identified , and the planned surgical procedure and type of anesthesia are verified . It is important to review the patient’s record for the following: Correct informed surgical consent, with patient’s signature Completed records for health history and physical examination Results of diagnostic studies Allergies (including latex) In addition to checking that all necessary patient data are complete, the perioperative nurse obtains the necessary equipment specific to the procedure. The need for nonroutine medications, blood components, instruments, and other equipment and supplies is assessed, and the readiness of the room, completeness of physical setup, and completeness of instrument, suture, and dressing set ups are determined. 51

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Any aspects of the OR environment that may negatively affect the patient are identified . These include physical features, such as room temperature and humidity; electrical hazards; potential contaminants (dust, blood,and discharge on floor or surfaces, uncovered hair, faulty attire of personnel, jewelry worn by personnel); and unnecessary traffic . The circulating nurse also sets up and maintains suction equipment in working order, sets up invasive monitoring equipment, assists with insertion of vascular access and monitoring devices, and initiates appropriate physical comfort for the patient. Preventing physical injury includes using safety straps and bedrails and not leaving the sedated patient unattended. Transferring the patient from the stretcher to the OR table requires safe transferring practices. Other safety measures include properly positioning the grounding pad under the patient to prevent electrical burns and shock, removing excess povidone iodine ( Betadine ) or other surgical germicide from the patient’s skin, and promptly and completely draping exposed areas after the sterile field has been created to decrease the risk for hypothermia. 52

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Nursing measures to prevent injury from excessive blood loss include the administration of blood products. Few patients undergoing an elective procedure require blood transfusion, but those undergoing higher-risk procedures (such as orthopedic or cardiac surgeries) may require an intraoperative transfusion. The circulating nurse should anticipate this need, check that blood has been cross-matched and held in reserve, and be prepared to administer blood SERVING AS PATIENT ADVOCATE Because the patient undergoing general anesthesia or moderate sedation experiences temporary sensory/perceptual alteration or loss, he or she has an increased need for protection and advocacy. Patient advocacy in the OR entails maintaining the patient’s physical and emotional comfort, privacy, rights, and dignity. Patients, whether conscious or not, should not be subjected to excess noise, inappropriate conversation, or, most of all, derogatory comments. 53

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As surprising as this sounds, banter in the OR occasionally includes jokes about the patient’s physical appearance, job, personal history, and so forth. Cases have been reported in which seemingly deeply anesthetized patients recalled the entire surgical experience, including disparaging personal remarks made by OR personnel. As an advocate, the nurse never engages in this conversation and discourages others from doing so. Other advocacy activities include correcting for the clinical, dehumanizing aspects of being a surgical patient by making sure the patient is treated as a person, respecting cultural and spiritual values, providing physical privacy, and maintaining confidentiality. 54

Nursing Care of Clients During the Immediate Postoperative Recovery:

Nursing Care of Clients During the Immediate Postoperative Recovery Admission of the Client to the Recovery Area Position client to promote patent airway and prevent aspiration. Avoid exposure of the client. To protect privacy and prevent chills. Avoid rough handling of the patient. This affects his/ her comfort. Avoid hurried movement and rapid changes in position. This may cause hypotension. Perform baseline assessment: Vital signs Status of respirations, pulse oximetry General color Neurologic status (LOC) Type and amount of fluid infusing (IV’s, BT) Special equipment dressings 55

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Determine specifics regarding the operation from the operating room nurse. Client’s overall tolerance of surgery Type of surgery performed Type of anesthetic agents used Results of prodecure Any specific complications to watch for Status of fluid intake and urinary output Common postoperative complications: eg. Hemorrage, urinary retention, intestinal obstruction, wound infection, wound dehiscence/ evisceration. {client’s respiratory status is a priority concern on admission to the operating room and throughout the postoperative recovery period} 56

Nursing Management During Recovery:

Nursing Management During Recovery Ensure maintenance of patent airway and adequate respiratory function. Lateral position with neck extendend or back with the head turned to the side to prevent aspiration. Leave airway in place until gag reflex has returned. The airway keeps the passage open and prevents the tongue from falling backward and obstructing the air passages. Suction excess secretions and prevent aspiration. Encourage coughing and deep breathing to promote chest expansion. Administer humidified oxygen. Ascultate breath sounds. 57

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Maintain cardiovascular activity Monitor vital signs every 15 minutes until condition is stable. Observe signs and symptoms of shock and heorrhage. Report blood pressure that is continually dropping 5-10 mmHg with each reading. Evaluate quality of pulse and presence of dysrhythmias. Evaluate adequate of cardiac output and tissue perfusion. Cool extremities, decreased urine output, slow capillary refill, tachycardia, narrowing pulse pressure are often indication of decreased cardiac output. 58

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Maintain adequate fluid status. Evaluate blood loss in surgery and response to fluid replacement. Measure urine output. Evaluate for bladder distension. Evaluate electrolyte status. Evaluate hydration status. Observe amount and character of drainage on dressing or drainage in collecting containers. Assess amount and character of gastric drainage if nasogastric tube is in place. Evaluate amount and characteristic of any emesis. 59

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Maintain incisional areas. Evaluate amount and character of drainage from incision and drains. Check and record status of Hemovac, Jackson-Pratt, Penrose or any other wound drainage. Sersanguinouos drainage is normal during the first 24 hours postop. 60

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Maintain psychological equilibrium. Speak to client frequently in clam, unhurried manner. Continually orient client; it is important to tell client that surgery is over and where he or she is. Maintain quiet, restful atmosphere. Promote comfort by maintaining proper body alignment. Explain all procedures, even if the client is not awake. In the anesthetized client, sense of hearing is the last to be lost and the first to return. 61

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