Perioperative Nursing Care

1. Perioperative Nursing Care Dr. Abdul-monim batiha

2. Perianesthesia and Perioperative Nursing is the field of nursing that addresses the nursing roles associated with the three phases of surgical experiences : pre operative postoperative and intraoperative 

3. Preoperative Nursing Care: •  begins when the decision to proceed with surgical intervention is made and end with the transfer of patient to the operation table 

4. 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

5. 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

6. 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 • Patient & family will need psychological support. • When will the meds be at their peak (timing of administration)

7. Examples of nursing activities in the preoperative phase include : Pre admission testing • Initial preoperative assessment • Initiate teaching appropriate to patients needs • Involve family in interview • Verify completion of preoperative testing

8. Admission to surgical unite or center • Completethe preoperativeassessment  • Assess for risk of complications • Report upnormal findings  • Verify that informed consent obtained • Answers family questions • Develop a plan of care 

9. Others also in the holding area prior to the surgery • Review patient chart • Identify patient • Verify surgical site • Establish intravenous line egcanula • Administer prescribed medications  • Provide support 

10. 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

11. Even turn lights down & be quiet during induction (person going under). • Make sure everything is available (assist during intubation) • Position: know patient history… if they have heart problems, need to make sure patient is positioned safely. Very easy to dislocate joints or break bones while someone is “under”. • Every needle & sponge & supply must be counted before surgery is over!

12. Intraoperative Nursing Care • Begins when patient is transferred to onto the operation table and ends with admission to the post anesthesia care unite   Main  nursing activities include  • Maintain safety  • Maintain aseptic environment  • Transfer patient to operation room or table • Position the patient in correct alignment  • Ensure that instruments count are correct  • Complete documentation 

13. Physiologic monitoring •  Calculate fluid loss or gain  • Distinguish normal and abnormal data • Report changes in vital sign  Physiologic support • Provide emotional support 

14. Postoperative Nursing Care  • Begins when patient is admitted to the post anesthesia care unite and end with follow up evaluation in home or clinical setting  Activities include  • Maintain airway  • Monitor vital sign • Assess the effect of anesthetic agents • Assess complications assess pain • Promote recovery and initiate teaching • Initiate discharge plan 

15. Surgical classification ( according to urgency) .

16. Preparation for Surgery  Informed Consent • process for getting permission before conducting a healthcare intervention on a person. A health care provider may ask a patient  Which procedures need informed consent ? • Invasive procedure such as  need anesthesia • Non surgical procedure that carry considerable risk such as arteriography • Procedures that involve radiation 

17. Criteria for valid informed consent  • Voluntary • Must be written  • Patient must be competent and able to comprehend  • In case of incompetent patient family member or law representatives may give consent  • Should contain explanation of procedure • Instruction that patient can withdraw consent  • Explanation that all patients questions would be answered and if there is any significant notes such as change in customary procedure 

18. Assessment of health factor that affect patient preoperatively •  Nutritional and fluid status  • Drug and alcohol abuse  • Respiratory status  • Cardiovascular status  • Hepatic and renal function  • Endocrine function  • Immune function  • Previous medication use  • Psychosocial factors  • Spiritual and cultural beliefs 

19. Special situations • Ambulatory surgery : patient discharge the same day of surgery  • Obese patient  • Emergency surgery 

20. Preoperative nursing intervention  • Preoperative teaching • Deep breathing coughing exercise  • Teach patient how to promote mobility and active body movement  by frequent position  • Leg exercise  • Getting out of bed  • Pain management  • Coping strategies  • Reduce anxiety and fear 

21. Maintain patient safety  • Manage fluid status  • Prepare the bowel  • Prepare the skin 

22. Immediate preoperative nursing interventions  • Administer pre anesthetic medications  • Maintain preoperative records  • Transport patient to the operation room 

23. 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

24. Smokers: how many packs a day X how many years they have been smoking • Elderly (and very young as well) • Immobilizing: risk for DVT (use compression devices) • Self fulfilling prophecy: if pt says they are very scared of the surgery, as an RN that needs to be explored further… is there a family history of malignent hyperthermia? pretreatment w/ Dantrium or rapidly treat patient… w/out treatment pt will die!

25. 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 = incinitive spirometry • I&O • Homan’s Sign: only 5 to 10% of positive Homan’s sign means DVT

26. Incentive Spirometer

28. 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

29. 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

30. 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

31. Ways to Decrease Anxiety… • Spiritual support (communion, Quran, 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

32. 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

33. 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

36. 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

37. NURSING RESPONSIBLITIES • Informed Consent Form/Patient Advocacy: make sure patient really does understand what is going to happen. • Secure personal belongings: Dentures, glasses, rings, money(try to give to the family… hosp doesn’t want to be responsible) • 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

40. NURSING RESPONSIBLITIES ... • Report anything of note that needs to be brought to the attention of the anesthesiologist, surgeon, or OR nurse • low potassium, Low potassium can cause cardiac arrythemias. • 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

41. 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 ****

42. 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

43. 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

44. 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

45. Peri-Operative Standards of Care (example) • 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

46. 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

47. Peri-Operative Standards of Care … • 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

48. 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

49. Purposes of informed consent