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PERI-OPERATIVE NURSING. UNIVERISTY OF NORTH FLORIDA SCHOOL OF NURSING M. Catherine Hough, PhD, RN, Associate Professor Linda K. Connelly, ARNP, MSN, CNOR. Introduction to Perioperative Nursing. Phases of Perioperative Care

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Peri operative nursing

PERI-OPERATIVE NURSING

UNIVERISTY OF NORTH FLORIDA

SCHOOL OF NURSING

M. Catherine Hough, PhD, RN, Associate Professor

Linda K. Connelly, ARNP, MSN, CNOR


Introduction to perioperative nursing
Introduction to Perioperative Nursing

Phases of Perioperative Care

  • Pre Operative - begins with the patient’s decision to have surgery, ends with entry into the operating room

  • Intra Operative - begins with entry into the operating room and ends with admission to the recovery room

  • Post Operative - begins with admission to recovery room, and ends with discharge from care (varies but usually 6 weeks post op) by physician




Pre operative
Pre-Operative

Responsibilities of Operating Room Nurse:

  • Patient Assessment

  • Physical Problems

  • Emotional Aspects

  • Understanding of surgery/consent

  • Legal requirements for chart completion

  • Read and interpret lab results

  • PeriOperative Teaching


Preoperative nursing considerations
PREOPERATIVE NURSING CONSIDERATIONS

  • COMPLETE PHYSICAL ASSESSMENT

    • Physical & psychological needs

    • Medical & surgical history

    • Completion of required documents

  • DETERMINE READINESS & MODE OF TRANSPORTATION TO OR

  • ACCESS HEALTH CARE TEAM AVAILABILITY

    • Surgeon

    • Anesthesia personnel

    • Circulating nurse

    • Scrub person

    • Other personnel


Pre op meds
PRE-OP MEDS

  • Pharmacologic preparation as necessary & psychological support

  • Facilitates induction of anesthesia & reduces anesthetic requirement

  • Determinants of drug choice

    • Age

    • Weight

    • Level of anxiety

    • Drug allergies

    • Inpatient/outpatient

    • Timing of administration


Preoperative nursing considerations1
PREOPERATIVE NURSING CONSIDERATIONS

  • COMPLETE PHYSICAL ASSESSMENT

    • Physical & psychological needs

    • Medical & surgical history

    • Completion of required documents

  • DETERMINE READINESS & MODE OF TRANSPORTATION TO OR

  • ACCESS HEALTH CARE TEAM AVAILABILITY

    • Surgeon

    • Anesthesia personnel

    • Circulating nurse

    • Scrub person

    • Other personnel


Intra operative
Intra-Operative

  • Provide for quiet environment during induction

  • Assist during intubation

  • Observe aseptic technique

  • Safe operation of equipment (lasers, electrosurgery unit)

  • Position patient safely - CV, nervous, respiratory system

  • Document events, patient care given,

  • Provide all supplies, equipment, to team during surgery

  • Provide for a safe transfer to recovery room


Unsterile team member circulating nurse
Unsterile Team Member - Circulating Nurse

  • Responsible for nursing care in the operating room

  • Responsible for the organization of the workload

  • Responsible for the maintenance of policy and procedures

  • Responsible for signing and documentation

  • The Circulating Nurse is the professional staff member in the operating room, representing the patient (Patient Advocate) and the hospital administration


Surgical nurse 1889
Surgical Nurse 1889

  • A level head & keen eyes, ever watchful for all that may be required, a mind not easily irritated or confused, combined with the facility of keeping out of the way & still being of the greatest help……..Thoroughness, speed, gentleness especially fit the surgical nurse.

    (Asepsis for the Nurse, Clemons, 1889)


1945 discussion of the role of the or nurse
1945Discussion of the role of the OR Nurse

  • “In charge of the operating room, taking care of the needs of the room assigned to her. It is her responsibility to watch the aseptic technique of her team.”

  • “A surgery nurse must have many good qualities; but first of all, she must be conscientious of sterile technique. Speed & efficiency are of no avail if a surgical wound breaks down due to an infection received in the OR. “

    Crawford, 1945


Scrub person

May be a:

RN

LPN

Surgical Tech

Duties:

Usually confined to the intraoperative phase of the patient’s surgical experience, may also be involved in gathering surgical supplies & equipment

SCRUB PERSON


Scrub nurse
SCRUB NURSE

“ The nurse who is the immediate assistant to the surgeon is often called the “scrub” or “sterile” nurse. She first scrubs her hands and arms the required length of time, puts on sterile gown & gloves, and handles only sterile material.”

Crawford 1945


Scenario 1
SCENARIO #1

  • A. Smith, RN & D Jones, RN are assigned to scrub & circulate for a 0800 gastrostomy on WW, a 79 year old emaciated male. Since his hospitalization 3 days ago, he has managed to remove his IV and NG tube several times. Consequently he has been restrained even on the stretcher during his transport to the OR. His medical DX is chronic alcoholism with dementia. WW seems to acknowledge D Jones’s presence with a half glance, however he will not respond to the anesthesia provider’s questions. WW is supported on the stretcher in a semi-flower’s position with several pillows. Further assessment reveals that WW has contractures of his hips and knees.


Surgical positioning
SURGICAL POSITIONING

  • Facilitated through the nursing process

  • Patient’s body must remain in physiologic alignment

  • Dependent Upon:

    • The surgical procedure

    • Exposure at the surgical field

    • Surgeon’s preference and idiosyncrasies

    • Patient’s condition

  • Special Considerations:

    • Geriatric patients

    • Obese patients

    • Malnourished patients


Surgical positioning equipment

Pillow or headrest

Arm boards

Safety belt/strap

Footboard

Padding

Gel pads

Egg crate

Donut rolls

Foam

Padded Shoulder braces

Stirrups (candy canes, Allen, or knee)

Laminectomy Frame

Olympic vac pac (suction beanbag)

3” adhesive tape

SURGICAL POSITIONINGEQUIPMENT



Scenario 2
SCENARIO #2

  • WH is a 36 year old black male who had been scheduled for a hemorrhoidectomy on an outpatient basis. He is 5’ 11”tall and weighs 250 lbs. His HBG is low (12g/dL) secondary to rectal bleeding. WH has a HX of asthma since age 5. He has episodes of difficulty breathing 6X/year, treated with an inhaler at the time of each episode. He does not smoke; ETOH 2 glasses of beer per week. WH’s current BP is 138/96, which he controls by taking a daily antihypertensive med. WH is a high school teacher. He spends most of his days standing and occasionally sitting. His evenings and weekend are spent working on a master’s degree in education. He does not participate in a regular exercise program.


Settings
SETTINGS:

  • Ambulatory Surgery - In and Out in same day

    • Pre-op teaching

    • T&A, Cyst removal, D&C, Cataract removal with lens implants, Biopsy

    • Heart cath

    • scopes


Settings1
SETTINGS…

  • Same Day General Surgery - Admitted to inpatient unit or special same day surgery unit

    • Pre-Op teaching prior to day of surgery

    • Nurses especially trained in Pre-Op assessment (Hysterectomy, Lap Chole, Appendectomy, Mastectomy, C-Section)


Settings2
SETTINGS

  • Main OR Surgery - Patient admitted to hospital prior to surgery OR DAY OF SURGERY

    • Prep and assessment and teaching done in hospital

    • Patient stays @ least overnight, and rehab begins before discharge

    • Major heart surgery such as CABG’s, Bowel Resections, Large tumor removal or Brain surgery


Purpose of surgery
PURPOSE of SURGERY

  • Diagnostic- Determines cause of symptoms (Exploratory laparotomy and biopsy)

  • Curative - Removal of diseased part (Appendectomy, Ovarian Cyst, Cancerous Tumors)

  • Restorative or Reconstructive - Strengthens a weakened part (Herniorrhaphy or cervical rings) rejoins disconnected areas (orthopedic surgeries), corrects deformities, (MVR, joint replacement, etc)

  • Palliative - Relieves symptoms without curing (some lower back surgeries, tumorectomies)

  • Cosmetic - Repairing a burn scar or changing breast shape, altering physical appearance


Patients @ high risk for complications

Smokers

Obese

Chronic Lung Diseases

Elderly

HTN

Thoracic or Abdominal Surgeries

Immobilizing Surgery

UTI

Diabetes

Poor Nutritional Status

Dehydration

Heart Disease

Self-fulfilling Prophecy

Inhalant Anesthesia

Patients @ High risk for Complications


Preventing complications
PREVENTING COMPLICATIONS

DVT, UTI, Aspiration,

Wound Infection, Shock, Constipation

  • Identify those @ risk

  • Provide adequate hydration/nutrition

  • NPO after MN

  • Leg exercises

  • Breathing exercises and IS

  • I&O


Preventing complications1
Preventing Complications…

  • Splint Incision to cough

  • Anticoagulant Therapy - Heparin

  • Ambulate and OOB to BRP - ASAP

  • Discourage smoking

  • Fluid and fiber ASAP, laxatives. Enemas

  • Clean Hands

  • Instruct in proper wound care

  • Sterile bowel prep and skin prep

  • Sleep/Rest


Prepping the patient
PREPPING THE PATIENT

TEACHING

  • Name and purpose of the surgery

  • NPO after MN and why early awakening, shower, remove all jewelry, makeup, etc

  • Anesthesia, Cold Room, Smells, Drowsy Feeling

  • Recovery Room

  • Post-op care - TCDB, leg exercises, pain management, DVT< OOB ASAP

  • Begin discharge planning


Ways to decrease anxiety
WAYS TO DECREASE ANXIETY

COMMUNICATION

  • Early teaching and counseling

  • Diversional activities

  • Encourage family support

  • Encourage verbalization of fears/loss of control

  • Deep breathing, medications, imagery, music


Ways to decrease anxiety1
Ways to Decrease Anxiety…

  • Spiritual support (communion, bible reading, prayers, rituals, chants)

  • Inform family where to wait, buy food, bathroom, phone, overnight and visiting policy

  • Possible use of sedative or tranquilizer or PRN medications

  • Dolls/favorite toy for children


Nursing assessment
NURSING ASSESSMENT

  • Assessment Data Base - vital signs, weight, height

  • Review of Systems

  • Past history of illnesses (i.e. HTN, pneumonia) that may predispose client to complications

  • Past experience with hospitalization or surgery

  • Allergies to medications or foods, tapes, surgical scrubs


Nursing assessment1
Nursing Assessment…

  • Intellectual ability to understand teaching

  • Language differences, social, spiritual or cultural considerations, anxiety level

  • Labs: CBC; U/A; Chemistry (electrolytes: K,CL,NA,CA,BS,BUN,Creatine), total bilirubin, albumin, alkaline phosphatase, SGOT, HCO3, HIV, Pregnancy

  • Other: Chest X-Ray, EKG if > 40 years old


Pre op nursing diagnoses
PRE-OP NURSING DIAGNOSES

  • Knowledge Deficit R/T Unfamiliar Planned or Unplanned Surgery

  • Ineffective individual or family coping R/T Unfamiliar Planned or Unplanned Surgery

  • Anticipatory Grieving R/T Potential for Loss of Life or Body Part


Nursing responsiblities
NURSING RESPONSIBLITIES

  • Informed Consent Form/Patient Advocacy

  • Secure personal belongings: Dentures, glasses, rings, money

  • Administration of pre-op medications on call to OR - i.e. Demerol, Valium, Atropine

  • Complete Pre-op Checklist @ clinical site - remove hair pins, loose teeth, dentures, nail polish, bath, urinate, NPO, VS taken within 15 minutes of going to OR, Ted Hose or compression devices


Nursing responsiblities1
NURSING RESPONSIBLITIES ...

  • Report anything of note that needs to be brought to the attention of the anesthesiologist, surgeon, or OR nurse

    • low potassium,

    • fever,

    • arrthymias,

    • loose teeth,

    • chest pain, or

    • anything unusual

  • Assure patient has ID bracelet on; Send current chart and any old medical records with the patient;

  • EVALUATE patients level of understanding, physical stability, emotionally prepared, fulfilled hospital pre-op policies


  • Types of surgery
    TYPES OF SURGERY

    • MAJOR -- Present a real threat to life

    • MINOR -- Present little threat to life

      NOTE: **** All patients consider their surgery a major thing ****


    Bloodless surgery
    BLOODLESS SURGERY

    • a term that has evolved in the medical literature to refer to a perioperative team approach to avoid allogeneic transfusions and improve patient outcomes

    • utilizing combinations of the numerous blood conservation techniques and transfusion alternatives available


    Benefits of bloodless surgery

    Decreased costs

    Less risk for blood contamination for patients

    Reduce risk of post op fevers and infections usually associated with blood transfusions

    Promotes better quality patient care

    At times decreased death rate

    Can decrease time spent in ICU

    BENEFITS OF BLOODLESS SURGERY


    Catastrophic events in the or
    Catastrophic Events in the OR

    Anticipated:

    • Cardiac Arrest in an unstable patient

    • Massive Blood Loss - during trauma surgery

    • Loss of ability to ventilate a patient


    Catastrophic events in or
    Catastrophic Events in OR ...

    Unanticipated:

    • Latex Allergy Reaction - reactions can range from urticaria to anaphylaxis

    • Maligant Hyperthermia - rare, life-threatening disorder that can be triggered by anesthesia drugs - Is an autosomal dominant trait


    Peri operative standards of care example
    Peri-Operative Standards of Care (example)

    • All Policy & Procedures of the medical and surgical nursing division will be followed.

    • Patients shall ALWAYS wear a legible identification band

    • Operative permit(s) must be signed and witnessed according to hospital policy, The procedure documented on the operative permit MUST MATCH what is scheduled on the OR schedule

    • The history and physical shall be completed according to policy and be part of the medical record prior to surgery

    • All ordered lab work shall be collected and results placed in the medical record in accordance with the physician’s orders

    • Dentures, hairpins, jewelry, wigs, contact lenses, nail polish, make-up and prosthesis shall be removed as requested by the physician

    • Any jewelry not removed shall be secured with tape and documented as such


    Peri operative standards of care
    Peri-Operative Standards of Care …

    • Pre-operative skin prep shall be done without abrading, cutting or irritating the patient’s skin

    • Patient privacy shall be provided at all times

    • Any pre-operative drainage tubes shall be placed without tissue trauma and be completed utilizing sterile techniques when indicated

    • All IV infusions shall be monitored to maintain the appropriate flow rate and type of solution and remain patent without signs of inflammation or swelling

    • The patient shall be provided emotional and educational support to reduce pre-operative anxiety

    • The patients shall be provided a safe and normothermic environment in the pre-op waiting area

    • The patient shall be transferred safely to the OR table and safety straps appropriately applied


    Expected outcomes
    Expected Outcomes:

    • Demonstrate knowledge of physiologic & psychological responses to surgical intervention

    • Absence of infection

    • Maintenance of skin integrity

    • Freedom from injury R/T positioning, equipment

    • Maintenance of fluid and electrolyte balance

    • Satisfaction with pain relief

    • Participation in the rehab process


    Aorn a tradition of excellence
    AORN a tradition of excellence

    • Formally organized between 1949 – 1954

    • A professional organization of periOperative registered nurses whose mission is to provide quality patient care by providing its members with education, standards, services and representation.

    • Membership 340 chapters, 12 specialty assemblies, 25 state councils and 41,000 members


    Perioperative nursing1
    PERIOPERATIVE NURSING

    If you or your family came

    through surgery in good shape,

    thank a perioperative nurse.


    If someone listens, or stretches out a hand, or whispers a kind word of encouragement, or attempts to understand a lonely person, extraordinary things begin to happenLoretta Gizarlis (1920)American writer and educator


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