Perioperative nursing Care Adult health nursing 351 Lecturer Name year

Outline Preoperative nursing care Intra operative nursing care Postoperative nursing care

Preoperative Preparation 1. Preparing the person the evening before surgery Bathing or scrubbing a local skin area with an antiseptic The surgeon will usually specify the site for a local skin scrub if indicated Restricting food and fluid: nothing per mouth (NPO) after midnight

Preoperative Preparation 1. Preparing the person the evening before surgery Perform enema for GIT surgeries only Promote rest and sleep through: A well ventilated room Comfortable, clean bed Back rub Warm fluid Sleeping medication as doctor order

Preoperative Preparation 2. Preparing the person on the day of surgery Make sure the patient has had no solid food for at least 6 hours and no water for at least 2 hours before surgery. Make sure the chart contains all necessary information, such as signed surgical consent, diagnostic test results, health history, and physical examination.

Preoperative Preparation 2. Preparing the person on the day of surgery Tell the patient to remove jewelry , makeup, hairpins and nail polish. Perform mouth care. Ask the patient void Put on a surgical cap and gown.

Preoperative Preparation 2. Preparing the person on the day of surgery Instruct patient to remove dentures or partial plates, contact lenses, glasses, or prostheses (such as an artificial eye). You may remove his hearing aid. However, if the patient wishes to keep his hearing aid in place, inform operating room and PACU staff of this decision

Preoperative Preparation 2. Preparing the person on the day of surgery Take and record vital signs. Make sure the informed consent form is signed by the patient or a responsible family member The site of surgery should be marked with a permanent marker by the surgeon.

Preoperative Preparation 2. Preparing the person on the day of surgery Check for and carry out special orders (administering enema, NGT insertion, IV line) Check the identification band Administer preoperative medication as ordered.

Perioperative Medication Types:- Opiates- Morphine Anticholinergics: Atropine (reduce resp. Tract secretions and prevent sever reflex of slowing of heart) 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.

Perioperative Medication Types:- Prophylactic antibiotics: just before or during surgery Purpose:- Facilitate effective anesthetics, minimize respiratory tract secretions and relax, reduce anxiety. 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.

Common nursing diagnosis in preoperative phase Knowledge deficit Anxiety related to surgical operation Disturbed sleep pattern related to unfamiliar environment and outcome of surgery

Nursing diagnosis 1. Anxiety related to results of surgery and postoperative pain. Goal: the patient will decrease level of anxiety Nursing intervention:- Activities that decreasing anxiety are deep breathing, relaxation exercises, music therapy, massage and animal-assisted therapy. Administer medication to relieve anxiety as doctor orders

Nursing diagnosis Nursing intervention:- Explain the surgical procedures for patient Allow the patient to ask questions Reassessment

Nursing diagnosis 2. Knowledge deficit related to the preoperative procedure Goal: the patient will explain the preoperative procedure Nursing intervention:- Explain the surgical procedures for patient Explain the preparation of operation for patient

Nursing diagnosis Nursing intervention:- Instruct the patient about type of anesthesia is planned, such as general, regional, or balanced Teach patient measure to decrease postoperative pain Teach patient postoperative care, including diet, mobility, leg and deep breathing exercises, Range of motion exercises and treatments.

Intraoperative care Intraoperative: includes the entire duration of the surgical procedure, until transfer of the client to the recovery area.

Intraoperative Anesthesia It is an artificially induced state of partial or total loss of sensation, occurring with or without consciousness. There are three types of anesthesia: General Regional local

Intraoperative Anesthesia General anesthesia Blocks awareness centers in the brain • Produces unconsciousness, body relaxation, and loss of sensation • Is administered by inhalation or I.V. infusion

Intraoperative Anesthesia 2. Regional anesthesia Inhibits excitatory processes in nerve endings or fibers Provides analgesia over a specific body area Doesn’t produce unconsciousness Is administered by spinal or epidural

Intraoperative Anesthesia 3. Local anesthesia Blocks transmutation of nerve impulses at the site of action, analgesia over limited tissue area and doesn’t produce unconsciousness Is administered by topical

Intraoperative Staff Surgeon, surgical assistant Anesthesiologist Holding Area Nurse Circulating Nurse Scrub Nurse/Surgical Technologist (ORT’s) Specialist Nurse Nosocomial, surgical team, not break sterile field. Anesthesians – monitor level of consciousness, sensation, movement, cardiopulmonary function, vs, IV, I&O, possible blood components

Role of nurse in operating room Operating room responsibilities are divided between the scrub nurse and the circulating nurse Nosocomial, surgical team, not break sterile field. Anesthesians – monitor level of consciousness, sensation, movement, cardiopulmonary function, vs, IV, I&O, possible blood components

Role of nurse in operating room Scrub nurse Nosocomial, surgical team, not break sterile field. Anesthesians – monitor level of consciousness, sensation, movement, cardiopulmonary function, vs, IV, I&O, possible blood components

Role of nurse in operating room Scrub nurse Perform surgical hand scrub, wear sterile gloves, gown, and mask before the operation Sets up the sterile table, prepares and counts sutures and special equipment Provides help to the surgeon and his assistants throughout the operation. Assists in draping and skin preparation Nosocomial, surgical team, not break sterile field. Anesthesians – monitor level of consciousness, sensation, movement, cardiopulmonary function, vs, IV, I&O, possible blood components

Role of nurse in operating room Circulating nurse Nosocomial, surgical team, not break sterile field. Anesthesians – monitor level of consciousness, sensation, movement, cardiopulmonary function, vs, IV, I&O, possible blood components

Role of nurse in operating room Circulating nurse Nosocomial, surgical team, not break sterile field. Anesthesians – monitor level of consciousness, sensation, movement, cardiopulmonary function, vs, IV, I&O, possible blood components

Postoperative nursing care Postoperative: begins with admission to the recovery area and continues until the client receives a follow up evaluation at home, or is discharged to a rehabilitation unit.

Postoperative phases Immediate ( post-anaesthetic ) phase (1) Intermediate ( hospital stay ) phase (2): starts with complete recovery from anesthesia and lasts for the rest of the hospital stay. Recovery ( after discharge to full recovery )

Aim of phases 1 & 2 Homeostasis Treatment of pain Prevention & early detection of complications

Postoperative Nursing Care 1. Immediate postoperative care “recovery room” - In this stage the patient is assessed every 10 to 15 minutes initially level of consciousness; orientation, sensation, ability to follow command, pupillary response and ability to move extremity following regional anesthesia Respiratory Status - patent airway and ability to deep breath and cough

IMMEDIATE POST-OPERATIVE PERIOD

Postoperative Nursing Care Immediate postoperative care a. Assess patient for the following items: Cardiovascular: regular, strong heart rate and stable BP ; peripheral pulses Position of patient Safety: need for side rails, draining tubes unobstructed Assess patient’s pain Wound condition: including dressings and drains

Postoperative Nursing Care Immediate postoperative care Presence of IV lines Drainage system such as nasogastric, chest, urinary) Ability to void Urinary output > 30 ml/hr Fluid balance, including IV fluids, output from catheters and drains

Postoperative Nursing Care B) Respiratory Care according to patient condition: O2 mask. Ventilator. Tracheal suction. Chest physiotherapy. C) Position in bed and mobilization: Turning in bed usually every 30 min. until full mobilization. Special position required sometimes. DVT prevention mechanically through leg and calf muscle exercise.

Postoperative Nursing Care D) Diet: NPO until return the bowel movement then: Liquids, Soft diet and finally Normal or special diet. E) Administration of I.V. fluids according to Daily requirements. F) Administration of Medication such as Antibiotics, analgesic or sedatives.

The Intermediate Post-Operative period (phase 2)

Postoperative Nursing Care - The following are the criteria for patient discharge from recovery room: Demonstrate quiet respirations Be awake or easily aroused to answer simple questions Have stable vital signs with a patent airway and spontaneous respirations Have a gag reflex Feel minimal pain

Postoperative Nursing Care Assessment Ongoing Assessment Respiratory function General condition Vital signs Cardiovascular function Fluid input and urine output and fluid balance chart Pain level and characteristics Bowel and urinary elimination Surgical site and wound drainage systems Intravenous sites for patency and infusions for correct rate and solution

Postoperative Nursing Care Assessment Monitor vital signs including Blood pressure, Respiration, Pulse rate , O2 saturation and Temperature : 15mins for first hour 30mins for next 2hours Hourly for next 2 Then if stable 4 hourly While monitoring these vital signs it is also important to observe (look, feel, listen)

Postoperative Nursing Care Nursing Diagnosis Risk for altered respiratory function related to immobility, effects of anesthesia, analgesics and pain. Pain related to surgical incision and manipulation of body structures. Nausea and vomiting related to effects of anesthesia or side effects of narcotics.

Postoperative Nursing Care Nursing Diagnosis Risk for Infection related to break in skin integrity (surgical incision, wound drainage devices). Activity Intolerance related to decreased mobility and weakness secondary to anesthesia and surgery.

1. Pulmonary care Encourage changing position at least every 2 to3 hours for bed patient Encourage deep breathing and coughing exercises every hour while he’s awake Encourage worm fluid

1. Pulmonary care Encourage patient to use incentive spirometer for person at high risk for pulmonary complications Monitor breath sounds until patient is ambulatory

2. Care of the wound Dressing can be removed 3-4 days after operation or according to hospital policy. Wet dressing should be removed earlier and changed. Symptoms and signs of infection should be looked Good nutrition.

3. Management of drains The drains are used to drain fluids accumulating after surgery, blood or pus. Should be removed as long as no function. Should come out throw separate incision to minimize risk of wound infection. Inspection of drain’s contents and its amount.

4. Maintain nutrition NPO until peristalsis returns, it is usually takes about 24hs. Gradual return of oral feeding from liquids to normal diet. Teach patients to select foods high in protein and vitamin C to enhance wound healing Improve patient immunity through nutration

5. Control pain Teach pain relieving measures such as relaxation techniques and position changes Splinting the incision may help the patient reduce pain when he coughs or moves especially following chest or abdominal surgery

5. Control pain Instruct the patient to use the bed’s side rails for support when he moves and turns. He should move slowly and smoothly, without sudden jerks. Position patient in comfortable position Administer analgesic as ordered

6. Promote activity Encourage leg exercises for the bed patient Encourage patient to carry out activity of daily life Encourage progressive ambulation as soon as permitted Avoidance of heavy lifting, pushing or pulling for at least 6 weeks after major surgery

7. Maintain elimination Encourage fluids and maximal activity within prescribed limits to prevent constipation Use measures to encourage defecation if patient has not has a bowel movement 2 to 3 days after peristalsis returns

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