Perioperatove Nursing

is the delivery of nursing care through the framework of the nursing process

Perioperative nursing

It also includes collaborating with members of the healthcare team, making nursing referrals, and delegating and supervising nursing care

Perioperative nursing

Three phases of perioperative nursing

Preoperative, intraoperative, postoperative

Begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient onto the operating room (OR) bed

Preoperative

Begins when the patient is transferred onto the OR bed and ends with admission to the PACU

Intraoperative

Begins with the admission of the patient to the PACU and ends with a follow-up evaluation in the clinical setting or home

Postoperative

Classification of surgery

purpose, degree of urgency, degree of risk

Confirms or establishes a diagnosis

Diagnostic

Example of diagnostic surgery

Biopsy of a mass in a breast

Relieves of reduces pain or symptoms of a disease, it does not cure

Palliative

Example of palliative surgery

Resection of nerve roots

Removes a diseased body part

Ablative

Example of ablative surgery

Cholecystectomy

Restores function or appearance that has been lost or reduced

Constructive

Example of constructive surgery

Cleft palate repair

Replaces malfunctioning structures

Transplant

Example of transplant surgery

Kidney transplant

is performed immediately to preserve function or the life of the client

Emergency surgery

is performed when surgical intervention is the preferred treatment for a condition that is not imminently life threatening (but may ultimately threaten life or wellbeing), or to improve the client's life

Elective surgery

Examples of elective surgery

cholecystectomy for chronic gallbladder disease, hip replacement surgery, and plastic surgery procedures such as breast reduction

Patient requires immediate attention; disorder may be life threatening

Emergent

Indications for emergent surgery

Without delay

Examples of emergent surgery

Severe bleeding, bladder or intestinal obstruction, fractured skull, gunshot or stab wounds, extensive burns

Patient requires prompt attention

Urgent

Indications for urgent surgery

Within 24-30 hrs

Example of urgent surgery

Closed fractures, infected wound exploration/irrigation

Patient needs to have surgery

Required

Indications for required surgery

Plan within a few weeks or months

Examples of required surgery

Prostatic hyperplasia, thyroid disorders, cataracts

Patient should have surgery

Elective surgery

Indications for elective surgery

Failure to have surgery not catastrophic

Examples of elective surgery

Repair of scars, simple hernia, vaginal repair

Decision rests with pt to have surgery

Optional

Indications for optional surgery

Personal preference

Examples of optional surgery

Cosmetic surgery

Major surgery involves a high degree of risk, for a variety of reasons:

• It may be complicated or prolonged

• Large losses of blood may occur

• Vital organs may be involved

• Postoperative complications may be likely

Examples of major surgery

Organ transplant, open heart surgery, removal of a kidney

normally involves little risk, produces few complications, and is often performed in an outpatient setting

Minor surgery

Examples of minor surgery

breast biopsy, removal of tonsils, and cataract extraction

The degree of risk involved in a surgical procedure is affected by:

• client’s age

• general health

• nutritional status

• presence of sleep apnea

• use of medications

• mental status

STOP

• snoring

• tiredness

• obstructed apnea

• high blood pressure

Medications used wherein degree of risk in surgery id affected:

• anticoagulants

• tranquilizers

• corticosteroids

• diuretics

True or False: Although the surgeon maintains legal responsibility for ensuring, that the client has given informed consent, the nurse may witness the client’s signature on the consent form

True

Required preoperative documents

• preoperative consent

• preoperative assessment data

Screening tests

• CBC

• Fasting blood sugar

• Blood group and cross matching

• Serum electrolytes

• BUN and creatinine

• ALT, AST, LDH, bilirubin

• Serum albumin and total protein

• Urinalysis

• Chest x-ray

• ECG

• Pregnancy test

Commonly used preoperative medications include the following:

• Sedative and tranquilizers

• Narcotic analgesics

• Anticholinergics

• Antiemetic

• Histamine-receptor antihistamines

• Neurolept analgesic agents

Safety protocol:

• Requires preoperative verification

• When the procedure is scheduled

• At the time of preadmission testing and

  assessment

1st step

Safety protocol:

• Involves marking of the operative site

• The surgical site marking method be consistent throughout the facility and encourages client involvement

• The facility chooses its own surgical site method (e.g. the client's initials, surgeon's initials, the word "YES")

2nd step

Safety protocol:

• Is called "time-out"

• Before surgery begins the surgical team takes a time-out to conduct a final verification of the correct client, procedure, and site

• Any questions or concerns must be resolved before the procedure can begin

3rd step

Herbs or supplements and possible surgical risk: ephedra (ma-huang)

May interact with medications to cause increased BP and HR

Herbs or supplements and possible surgical risk: Garlic (allium sativum)

Can increase bleeding

Herbs or supplements and possible surgical risk: Gingko biloba

Can increase bleeding

Herbs or supplements and possible surgical risk: Ginseng

Can increase HR and risk of bleeding

Herbs or supplements and possible surgical risk: Kava kava (piper methysticum)

Can increase the effect of anesthesia

Herbs or supplements and possible surgical risk: St. John’s wort (Hypericum perforatum)

May prolong the effects of anesthesia

Herbs or supplements and possible surgical risk: Valerian (Valeriana officinalis)

May prolong the effects of some types of anesthesia

Herbs or supplements and possible surgical risk: Vitamin E

Can increase bleeding and may cause BP problems

Surgical team consists of:

• Patient

• Anesthesiologist (physician) or certified registered nurse anesthetist (CRNA)

• Surgeon

• Nurses

• Surgical technicians

• Registered nurse first assistants (RNFAs) or certified surgical technologists (assistants)

administers the anesthetic agent (substance used to induce anesthesia and monitors the patient's physical status throughout the surgery

anesthesiologist or CRNA

provides sterile instruments and supplies to the surgeon during the procedure by anticipating the surgical needs as the surgical case progresses

Scrub nurse

Intraoperative interventions are carried out by:

• The circulating nurse

• The scrub nurse

• The registered nurse first assistant

Coordinates activities and manages client care by continually assessing client safety and by monitoring aseptic practice and the environment

Circulating nurse

Client positioning

Circulating nurse

Temperature

Circulating nurse

Humidity and lighting

Circulating nurse

Responsible for ensuring that the second verification of the surgical procedure and site takes place and is documented

Circulating nurse

Setting up the sterile equipment, tables, and sterile field the registered nurse first assistant

Scrub nurse

count all needles, sponges, and instruments to be sure that they are accounted for and not retained as a foreign body in the patient

Scrub nurse

Medications and solutions are transferred to the sterile table by the circulating nurse and the name, strength, dosage, and expiration date are labeled by the person in the

Scrub role

Implants are noted with the name, type, size, expiration date, and sterility are verified prior to handoff to the person in the

Scrub role

Assists the surgeon by controlling bleeding, using instruments, handling and cutting tissues, and suturing during the procedure

RNFA

surgical area is divided into three:

Unrestricted, semi restricted, restricted zone

street clothes are allowed

Unrestricted zone

where attire consists of scrub clothes and caps

Semi restricted zone

where scrub clothes, shoe covers, caps, and masks are worn

Restricted zone

state of narcosis, analgesia, relaxation, and reflex loss

Anesthesia

severe central nervous system depression produced by pharmacologic agents

Narcosis

Anesthesia is classified as:

General anesthesia, regional anesthesia, moderate sedation, local anesthesia

General anesthesia is through:

Inhalation or IV

Regional anesthesia is through:

epidural, spinal, and local conduction blocks

Moderate sedation is through

Monitored anesthesia care (MAC)

loss of all sensation and consciousness

General anesthesia

Acts by blocking awareness centers in the brain so that amnesia, analgesia, hypnosis and relaxation occur

General anesthesia

Patients under general anesthesia are

not arousable, even to painful stimuli

General anesthesia is usually administered by:

IV infusion, inhalation of gases through mask, through ET tube inserted into the trachea

Stages of General Anesthesia

Stage I: Beginning Anesthesia

Stage II: Excitement

Stage III: Surgical

Stage IV: Medullary Depression

Dizziness and a feeling of detachment may be experienced during induction

Stage I: beginning anesthesia

During beginning anesthesia, the patient may experience

ringing, roaring, or buzzing in the ears

During this stage, noises are exaggerated; even low voices or minor sounds seem loud and unreal

Stage I: Beginning Anesthesia

Characterized variously by struggling, shouting, talking, singing, laughing, or crying, is often avoided if IV anesthetic agents are given smoothly and quickly

Stage II: Excitement

Can be reached by administration of anesthetic vapor or gas and supported by IV agents as necessary

Stage III: Surgical

With proper administration of the anesthetic agent, this stage may be maintained for hours in one of several planes, ranging from

light (1) to deep (4)

This stage is reached if too much anesthesia has been given

Stage IV: Medullary Depression

Is the temporary interruption of the transmission of nerve impulses to and from a specific area or region of the body

Regional anesthesia

Does the client remain conscious when administering regional anesthesia?

YES

Regional Anesthesia Techniques

Topical (surface) anesthesia, local anesthesia (infiltration), nerve block, spinal anesthesia, epidural

Anesthesia that is applied directly to the skin and mucous membranes, open skin surfaces, wounds, and burns

Topical (surface) anesthesia

Agents used in topical anesthesia

Lidocaine or benzocaine

Anesthesia that is injected into a specific area and is used for minor surgical procedures such as suturing a small wound or performing a biopsy

Local anesthesia

How is local anesthesia administered?

Subcutaneous