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Perioperative care
1. PERIOPERATIVE CARE
NUR 105 ADULT HEALTH I
Shelton State Community College
J. WILLIAMS
2. Perioperative Care
Learning Objectives
s Define key terms.
s Define the three phases of
perioperative care.
s Describe the methods of classifying a
surgical procedure and give an example
of each one.
s Describe the different types of
anesthesia.
3. Perioperative Care
Learning Objectives-continued
s Utilize the nursing process in the care
of a surgical patient.
s Describe the nursing intervention for
each of the three phases.
s Identify factors and health conditions
that may influence or alter the well-
being of an surgical patient.
4. Perioperative Care (contd)
s Describe the nurses’ legal
responsibilities in the preparing the
patient for surgery.
s Identify the appropriate nursing care in
assessing and monitoring for
complications.
s Utilize effective communication
techniques in teaching client and family
about surgery.
5. Perioperative Care
Case Study
s Lula White keeps her appointment with the surgeon. She has
experienced abdominal pain/ cramping and a heavy menstrual flow
for over 2 years, resulting in weakness and chronic anemia. Ms.
White has talked it over with her husband and they both agreed on
her undergoing a total hysterectomy. Ms. White is 48 years,
married for 21 years with 4 children. The oldest child graduated
from high school this year and the youngest is in the 6th grade.
s At today’s office visit, the surgeon arranges for Ms. Hudson to have
lab work drawn through the Outpatient Dept. Laboratory.
s 1. What lab work would be ordered pre-op and the purpose for the
lab work? What other tests may be required prior to surgery?
s 2. Describe what information would you obtain in present and past
health history.
6. Perioperative Care
Case Study - continued
s 3. What kind of information should the doctor discuss
with Ms. White prior to the surgical procedure?
s 4. How would you classify this type of surgery?
s Ms. White is mildly overweight. In the past history,
she reports smoking for years but stopped 10 years
ago. She denies drugs or other tobacco products.
Ms. White took oral contraceptives about five years
ago until she developed hypertension and blood clots
in her lower leg. She remains on diazide and took
coumadin 3-4 years ago in treatment of blood clot.
What risk factors might you be concerned with?
7. Perioperative Care
Three Phases
s Preoperative
s Intraoperative
s Postoperative
8. Perioperative Care
Categories and Purposes
s Reason/Purpose
– Diagnostic, curative, restorative, palliative,
cosmetic
s Degree of Urgency
– urgent, elective, optional
s Degree of Risk
– major, minor
s Anatomic location
s Extent of surgery- minimal, open, simple and
radical
9. Perioperative Care
Preoperative Phase- Assessment
s Risk Factors
age, nutritional, health status, fluid and
lytes imbalances, radiation,
cardiopulmonary, chemotherapy, meds,
family history, prior surgical experiences
(positive/negative), type of surgery,
location site
10. Perioperative Care
Preoperative Phase- Assessment
s Nursing History
– past & present, meds, diet, allergies (latex),
personal habits, occupation, finances, family
support, knowledge of surgery, attitude
s Physical Exam
s Diagnostic Tests
– CBC, electrolytes, creatinine, urinalysis, x-ray
exams, EKG, Blood Type, PTT, PT, Platelet
– Blood donations
s Radiographic
s Bloodless Surgery/Discharge
11. Perioperative Care
Preoperative Care
s Psychological Response
s Informed Consent - Nurse witness
s Mentally competent
s If minor, a guardian, parent, or court
order will sign permit; state will dictate
age.
s Sociological
s DNR
12. Nursing Process – Preoperative Care
s Assessment
– History, Physical Exam, Lab/Radiology,
Health Status, Risk Factors, Meds
s Nursing Diagnosis
s Planning
– Goal statement
– EOC (expected outcome criteria)
13. Perioperative Care
Preoperative -Implementation
s Informed Consent s Vital Signs
s Nutrition/fluids - IV ; s Height/ Weight
NPO after MN s Special orders -
s Elimination (insert tubes,
-enemas, foley medications)
s Hygiene - skin s Promote Comfort -
scrub; remove nail Anti-anxiety meds
polish, hair pins, s Skin preparation
hospital gown
14. Perioperative Care
Preoperative Care - Nursing Care
s Pre-op Teaching -
– leg and deep breathing exercises; ROM
exercises
– Moving patient ; coughing and splinting
s Monitor -
– pt and diagnostic tests.
– TEDS, Elastic Wraps, Pneumatic
Compression devices, early ambulation
15. Perioperative Care
Preoperative - Implementation
s Day of Surgery - complete pre-op
checklist sheet in medical record, VS,
skin prep removal of prosthetics, hair
pins, dentures, bowel and bladder prep,
TEDS, IV, NG Tube, ID band, and pre-
op medications.
16. Perioperative Care
Pharmocology
s Purpose - facilitate effective
anesthetics, minimize respiratory tract
secretions and relax, reduce anxiety.
s Types - Opiates, Anticholinergics,
Barbiturates, Prophylactic antibiotics
17. Perioperative Care
Pharmocology
s Hazardous to Surgery
s Certain antibiotics
s Anti-depressants
s Phenothiazines
s Diuretics
s Steriods
s Anticoagulants
18.
19. Perioperative Care
Preoperative - Evaluation
s Evaluate goals and outcome criteria
20. Perioperative Care
Intraoperative Care
s From the holding room to the operating
room and then to recovery room.
s Implementation of anesthesia for
analgesic, sedative, and muscle
relaxant purposes as well as control
Autonomic Nervous System.
21. Perioperative Care
Intraoperative Care
s Holding area - enter prior to OR; nurse
continues to prepare patient(insert foley
or start IV)
s Nurse assist in transfer to and from OR,
maintain proper body alignment.
22. Intraoperative Care
Staff
s Surgeon, surgical assistant
– Surgical scrub, gowning, surgical asepsis
s Anesthesia
– Anesthesiologist, CRNA
23. Periopereative Nursing Staff
s Holding Area Nurse
s Circulating Nurse
s Scrub Nurse/Surgical Technologist
(ORT’s)
s Specialist Nurse
24. Perioperative Care
Preoperative -Anesthesia
s Types
– General
– Regional
– Local
25. Perioperative Care
Intraoperative Care
s Common General Anesthetics
s Inhaled General Anesthetics
– Nitrous oxide, cyclopropane
s Inhaled liquid
– halothane, enflurane, isoflurane
s Intravenous Anesthetic
– Pentothal (thiopental)
28. Perioperative Care
Intraoperative - Complications 2
s Malignant hyperthermia - due to
abnormal and excessive intracellular
collection of Ca+ resulting in
hypermetabolism and increased muscle
contraction.
s Signs and Symptoms - high fever,
tachycardia, muscle rigidity, heart
failure, pseudotetany, and CNS
damage.
29. Perioperative Care
Adjunctive Anesthetic Agents
s Opioid analgesic s Anticholinergic
– Alfenta – Atropine,
– Demerol and scopolamine
Morphine
s Benzodiazepine s Sedative-hypnotic
– Valium, Versed – Atarax, Vistaril,
Seconal, Nembutal
30. Perioperative Care
Intraoperative-Drug Interaction
s Antihypertensives- hypotension
s Beta-Blockers- myocardium decreased
s Tetracycline--renal toxicity
s Enflurane - liver disease lead to toxicity
31. Perioperative Care
Anesthesia
s Local/Regional s Topical
– Epidural – Dermoplast
– Infltration (benzocaine)
– Nerve Block – cocaine
– Spinal – ethyl chloride
– Topical
s Anesthetic agents
– Xylocaine, Novocain,
carbocaine
32. Perioperative Care
Anesthesia
s Geriatric concerns
s Address safety issues - sensory decline
s Hepatic, cardiac respiratory and renal
decline
s Assess for preexisting problems such
as cardiac, renal, hepatic, or
respiratory.
33.
34. Perioperative Care
Intraoperative Care
s Treatment of Malignant Hyperthermia
– discontinue inhalent anesthetic, Give
Dantrium, oxygen, dextrose 50%, diuretic,
antiarrhythmics, sodium bicarbonate, and
hypothermic measures-cooling blanket,
iced IV saline or iced saline lavage of
stomach, bladder, rectum.
36. Learning Objectives/Outcomes
s Define the time line for the
postoperative period.
s Describe nursing care during the
PACU.
s Describe nursing care during the post
operative period.
s Identify proper technique in care of
surgical wounds.
s State complications in wound healing.
37. Perioperative Care
Immediate Anesthetic Care
(PACU)
s Respiratory Status - patent airway
s Cardiovascular - regular, strong heart
rate and stable BP (VS); peripheral
pulses; Homan’s Sign
s Neurological – level of consciousness;
orientation, sensation
s Fluid and Electrolyte, Acid Base
Balance
38. Post – op
Drug Therapy
s Pain s Complementary and
– Pain Assessment Alternativve
– Opioids in IV small Therapies
doses – Positioning,
– Hypotension, Massage, relaxation
respiratory and diversion,
– GI motility guided imagery,
biofeedback, music,
– GI bleed (Motrin)
etc.
– Narcan/Romazicon
39. Post – Operative Care
Nutrition
sClear Liquids
s Full Liquids
s Soft
s Regular
40. Nursing Care Post Op
Physical Assessment (continued)
s Renal Function
s Gastrointestinal
s Dressings
s Pain
s Thermoregulation
41. Perioperative Care
Elderly Care in Postop
s Respiratory System s Hypothermia
– diminished airway – less subcutaneous
reflexes and cough tissue, muscle, slow
s Cardiovascular metabolic rate
– myocardium s Pain
weakness – more intense,
confusion, impaired
circulation and
sensory
42. Perioperative Care
Complications in Postop
s Hypotension s Immobility with skin
s Dysrhythmia integrity
s Venous Thrombosis s Urinary retention
s Pulmonary s Urinary tract
Embolism infection
s Hiccoughs s Wound infection,
s Adbominal dehiscence,
distention - paralytic hemorrhage
evisceration,
ileus
43.
44. Perioperative Care
Postop Care
s Psychological
– Anxiety
– Altered body image
– Finances, Family responsibility
– Future changes
45. Perioperative Care
Immediate Anesthetic Care
s Airway/breathing ex. s Dressings
s VS, Pulses s Drains/Tubes
s IV s I&O; renal function
s ABG’s s Medications
s Pulse oximetry s Laboratory work
s Pupil Respond s Hemodynamics
s Level of conscious s Position/ROM
s Safety s Comfort
46. Perioperative Care
Discharge Plans
s Patient/Family Education and
Psychosocial Support is throughout.
– Return MD Visit
– Dressing Care and Comfort
– Optimum respiratory,circulatory function,
diet, meds(antibiotics, analgesic)
– Adequate hydration and body temperature
– Adequate renal function, safety in ADL
47. PERIOPERATIVE CARE
Postoperative Care
s Postoperative Care
– Same care as immediate anesthetic care
– Decrease frequency of vital signs to every
4 hours, IV’s will be discontinued in time,
increase ADL, decrease in breathing
exercises and breathing treatments,
advance diet.
– Recovery Period - 4 to 6 weeks
48. PERIOPERATIVE CARE
Summary
s Specific Nursing Duties for each phase:
– Preoperative, Intraoperative, Postoperative
s Throughout Perioperative Care, the
nurse will always:
– Monitor patient’s response to therapeutic
regime, prevent complications, patient
education and promote optimum well-being
Editor's Notes
Palliative – comfort measures; Explorative – Cosmetic surgery – reconstruction term used by some authors . Location – surgical units – outpatient; 24 hours; home same day; inpatient - hospitalizations
History - Medications - insulin every day. Prednisone, anti- coagulant, chemotherapy, cardiac NSAID’s anti-hypertenison drugs. Health conditions - COPD, Diabetes, Anemia, cardiac, etc. Obesity Cancer Poor Nutrition Renal Fluids/Lytes Infections Aging Cardiovascular Disease (CHF) Diabetes Alcoholism COPD
Psycho – threat to life, body image, self-esteem, self-concept, or lifestyle; fear death, pain, helplessness, decreased socioeconomic status, life threatening; anxiety fear to learn to cope, and cooperate. Factors that influence ability to cope: age, health status, resources, coping strategies, past experiences with illness, amount of fear, anxiety, pain. Anxiety – increase heart rate, restless, nervous, agitated, profuse sweating, anger, sleeplessness, diarrhea, urinary frequency. Other diagnostic tests – depending on results of other tests – ABG’s; report any abnormal lab values especially hyper or hypokalemia. Routine – CXR – depending on surgery, spinal, MRI, CT scan. Bloodless surgery – new techniques and equipment less blood loss, prior to surgery – meds to build blood, Vit. C, Vit. B12, folic acid, Procrit,; Advances today recycling blood suctioned during surgery and transfuse back to patient. Discharge – assess home environment, self-care ability, caregiver, support system, etc.
Informed consent – nature and reason, who will perform surgery, options and risks for each one, potential outcomes, risks associated with anesthesia. Sign with X – Phone consent – Client can refuse Special orders – tubes, drains, vascular access devices; skin preparation – OR holding room Medications continue – Anticonvulsants, antihypertensive, anticoagulants, antidepressants, or corticosteriods ( cardiac and respiratory drugs) – doctor will detect with one to take day of surgery with small sip of H20. DM – given one dose of long or intermediate acting insulin – MD will detect with orders.
Day of surgery - MD phisophex bath, special skin scrub in am or night before surgery; hospital gown, values locked or removed with family. Pre-op checklist – chart – patient data present, intact. Night before - good rest prior to test - sedative at hs. OR holding room – check arm band, check chart (preop check list), check surgical site – marked if it is either a right or left. Mark with X. Define Homan’s Sign - TEDS
Preparation of Patient’s room for return after OR. IV pole, open bed, suction, Oxygen, emergency kits, clamps.
Opiates- Morphine, Demerol Anticholinergics-Atropine, Robinul, scopolamine, - reduce resp. Tract secretions and prevent sever reflex of slowing of heart Barbiturates-tranquilizers - Pentobarbital (Nembutal) and other hypnotic - night before ensure rest Prophylactic antibiotics- just before or during surgery - bacterial contamination is expected; given before skin incision; lover GI - bowel surgery colon’s microflora.
Certain antibiotics -combined with curariform muscle relaxant cause respiratory paralysis and apnea. Anti-depressants- MAO inhibitors - second line choice for tx of depression. Cause hypotension effects of anesthesia., St. John’s worts. Parnate, Nardil. Phenothiazines - increase hypotension action of anesthesia. Diuretics- electrolytes imbalance and resp. Depression. Steriods- inhibits wound healing. Anticoagulants-warfarin or heparin-affect bleeding, unexpected bleeding; herbals - ASA, ginkgo, NSAIDS Ticlid , Plavix.
Safety and legalities – still factor; informed consent; advance directive, proper ID, preparation including pre-op teaching; removal of dentures, prothesis, administer medications, drains, communication with client and family regarding pre-op and documentation.
NPO, allergies, vs,
Scrub nurse- Assist surgeon - hand sponges and instruments to MD; Keep record of amount of sponges used, time begin and end, dressings, and medications. Circulating - place pt. On OR table, drape the client, assist surgeon and scrub nurse to don sterile gowns and gloves, remove outer cover, arrange for biopsy specimen to lab, adjust light/work monitor. Anestheologist - administer general - spinal, lo-spinal, nerve block, general, local. Certified registered nurse anesthetist (CRNA) Circulation - Arrange for biopsy, specimens to lab, adjust lights, assist with gowning, gloving. (sterile) Elderly experience - hypothermia; airway patent go. During anesthesia - malignant hypothermia.
Nosocomial, surgical team, not break sterile field. Anesthesians – monitor level of consciousness, sensation, movement, cardiopulmonary function, vs, IV, I&O, possible blood components
Holding area – wait till OR is ready. Procedures such as starting IV’s, catheterizations, check chart for completion of pre-op list including permit, lab work, removal of prothesis, etc- check surgical site. Emotional support, asking questions, etc. during this time. Circulating nurse – position patient, protect from injury in transferring; perform instrument and sponge count. Specialist nurse – operates specific equipment Attire –scrub – decrease sources of bacteria.
General - loss,of all sensations, memory and consciousness; administered by IV, inhalation in gases/vapors through mask or endotracheal tube (ET Tube) inserted in trachea and balanced method pharmacologic effects both IV and inhalation. IV meds – barbituates – mild to deep loss of consciousness. Most often used is Pentothal. Another IV Med – Kentamine (Ketalar) – feeling of separation or dissociative from environment Propofol (Diprivan) - Short acting – Hypnotics – adjunct to general - benzodiazepines – Versed, Ativan, Valium. Regional - loss of sensation in one area. Types: Spinal, Lo spinal, nerve block, lumbar epidural caudal anesthesia Local anesthessia - loss of sensation in a small area of tissue. Ex. Xylocaine, Marcaine
Hypoventilation - inadequate ventilation; severe depression of respirations due to paralysis of respiratory muscles. Oral Trauma - endotracheal intubation- broken teeth, puncture of oral cavity Hypotension- due to hypovolemia or reaction to anesthesia Cardiac dysrhythmia-preexisting cardiovascular compromise. Electrolyte imbalance or untoward reactions to anesthetic agents. Hypothermia-exposure to cool amnient operating room environment and loss of normal thermoregulation from anesthetic agents. Peripheral nerve damage- due to improper positioning of patient or restraints. Malignant hyperthermia- rare but very serious reaction to anesthesia - life threatening. Anesthetic - enflurance, fluroxene, halothane and muscle relaxant - Anectine. Theophyliline, epinephrine (Adrenalin), digoxin (Lanoxin) induce or intensity reaction.
Life threatening; Ca+ and K+ increased; genetic disorder; males more than females. Dantrolene sodium to treat malignant hypertheremia,
Opioid analgesic - anesthesia induction Alfenta Demerol and Morphine pain prevention and pain relief Benzodiazepine Valium, Versed - amnesia and anxiety Anticholinergic- to dry up excessive secretions Atropine, scopolamine Sedative-hypnotic- Amnesia and sedation Atarax, Vistaril, Seconal, Nembutal
Surgical positions page ; common skin closures -page
Respiratory Status - patent airway’ Hypoxemia result of hypoventilation, aspiration, breath sounds, laryngospasm - spasm of muscle tissue and vocal cords - obstruct airway (stridor), irritation of airway dyspnea, hypercapnia or hypoxemia. Cardiovascular - regular, strong heart rate and stable BP; peripheral pulses and capillary refill. Neuro – consciousness, orientation, motor and sensory Neurological - complications with general anesthesia - prolonged somnolence and muscle weakness, renal failure and lyte imbalanc, confusion, delirium. Regional anesthesia - complications - anesthetic toxicity, trauma, hypotension. Nause and motor or sensory loss, hypoxia, agitation. Fluid and Electrolyte Balance – IV, I&O, catheter; fluid imbalance with draining wound, NG tube, n&v
Page 352 – Demerol, Morphine, Dilaudid, Codeine, Stadol Oxycodone – opioids, Narcan – reverse effects of narcotics – administer oxygen, open airway, vs, pulse oximeter, Flumazenil/Romazicon – for benodiazepine overdose
General anesthesia – progress from liquids to regular; bowel sounds first; NPO till Bowel sounds; Clear liquids – all soups ? Describe how clear differs from full.
Renal Function – anesthesia- urinary retention; unable to void 8 hours; 30-50 ml or less per hour; color, consistency, amt., odor Gastrointestinal - nausea and vomiting response to anesthesia , prevent with NPO after MN; N&V – can affect abd. Wound, increase intracranial pressure with head and neck surgery, elevate intraocular pressure with eye surgery Reduced peristalsis – paralytic ileus – auscultate bowel sounds; flatus or bm indicate active bowel sounds. If NG tube suction in progress – be certain this is not what you are hearing instead of bowel sounds. NG tube drainage – color,consistency and amount every 8 hours as part of I & O; normal color – yellowish green; red 0 bleeding – dark brown – coffee grounds – old bleeding. Levine tube, Salem sump ( double lumen) Pain – assessment; PACU - PCA Thermoregulation- hypo and hyper Dressing – dehiscence and evisceration, drains, sutures, staples; drainage – sanguineous (bloody) and serosanquineous (yellow, serum like). Drains – Penrose, T-tube, Jackson-Pratt, Hemovac
Cough and deep breath prevent secretions; positioning; suctioning. Assess for signs of cyanosis -, administering of oxygen, or breathing treatments, pulse oximetry Hypotension - check vs, check meds, fluid volume, electrolytes Dysrhythmia-fluid load, preexisting cardiac conditions, k+ imbalance. Venous Thrombosis- pooling of blood; early ambulation, leg compression devices, TEDs, check lab work PT, PTT, meds - ASA; check pulses, Homan’s sign, check skin color, temp, peripheral check. Pulmonary Embolism- cough and deep breathe Hiccoughs- inhale and exhale in paper bag over nose and mouth; Thorazine; cause unknown think due to irritation of phrenic nerve - to diaphragm. Adbominal distention - prevent with early ambulation; paralytic ileus. Immobility with skin integrity Urinary retention-unable to void in 6 to 8 hours - common in spinal anesthesia; check for when removal of catherization. Urinary tract infection- cath or pooling of urine in bladder Wound infection, dehiscence, hemorrhage evisceration,- splint wound during ADL, splint or binder Safety - positioning, Promote comfort _ PCA
Vital Signs - Respiratory Status, as in OR; heart rate, blood pressure, warm temperature, risk of hemorrhage. I&O – assess fluid overload; assess for fluid deficit; assess for electrolyte imbalances; respiratory or renal dysfunction – acid base imbalance Neuro- LOC Surgical wound - dressing - dry and intact; Urinary output Fluids,electrolytes, blood transfusion Analgesic - PCA Pump; injectable meds. Assess all body systems - Lungs, Heart, Renal, Neuro, Dressing, Fluids, GI, Comfort Safety – call bell light, side rails per institution Page 348, 349 Frequency of care or vs checks depends on how recent is surgical intervention.Dressings with drains – change prn due to drainage.
Pain management; nausea and vomiting antiemetic – prn Other meds – antibiotics, antihypertensive, or oral hypoglycemia or insulin. Activity level – return to school or work; when to shower, or resume other activities Prevent infection – body temperature, etc. How to take temperature.
Nursing Interventions specific to each phase; some nursing interventions are throughout perioperative care as in other areas of nursing. Always optimum level of well-being - physical, mentally and spiritually. Assessment is on-going.
