1. Medical Surgical Nursing I Unit III: Perioperative Care Pre, Intra and Post operative nursing care Dr. J.C. HELEN SHAJI, Ph.D(N) Asst.Prof of Medical Surgical Nursing

3. Caring for perioperative clients Contents Outline 1.Objectives. 2.Introduction. 3.Phases of perioperative care. 4.Types of surgery. 5.Categories of surgery based on urgency. 6.Preoperative assessment. 7.Surgical risk factors. 8.Preoperative preparation. 9.Nursing diagnosis and intervention in preoperative phase. 10.Postoperative care. 11.Nursing diagnosis and intervention in postoperative period. 12.Postoperative complications.

4. Objectives : At the end of this lecture, the student must be able to: 1.Differentiate the phases of perioperative care. 2.Define the types and categories of surgery. 3.Identify the preoperative assessments. 4.Develop a preoperative teaching plan. 5.Identify surgical risk factors. 6.Describe the preoperative preparation. 7.Discuss assessments needed in immediate and later postoperative period. 8.Identify the postoperative complications. Caring for perioperative clients

6. What is meant by perioperative? Perioperative is a term used to describe the entire span of surgery, including what occurs before, during, and after the actual operation.

7. Phases of perioperative care Preoperative : begins with the decision to perform surgery and continues until the client has reached the operating area. Intraoperative : includes the entire duration of the surgical procedure, until transfer of the client to the recovery area. 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.

8.  INPATIENT SURGERY-  PROCEDURES ON A CLIENT WHO IS ADMITTED TO THE HOSPITAL.  OUTPATIENT SURGERY-  OPERATIVE PROCEDURES PERFORMED ON CLIENTS WHO RETURN HOME THE SAME DAY.  LASER SURGERY-  OUTPATIENT SURGICAL PROCEDURES WITH THE USE OF A LASER.

9. Diagnostic → Removal and study of tissue to make a diagnosis.(Pathology) Exploratory → Most extensive means to involve exploration of a body cavity or use of scopes inserted though small incision. Curative → Removal or replacement of defective tissue to restore function.(Joint) Palliative→ Relief of symptoms or enhancement of function without cure. (Thiroidectomy) Cosmetic→ Correction of defects, improvement of appearance, or change to a physical feature. Types of surgery

10. Categories of Surgery Urgent Emergency Optional Elective Required

11. 1. Optional surgery: decision rests with patient (eg, cosmetic surgery). 2. Elective surgery refers to procedures that scheduled at the client's convenience (eg, cyst removal, repair of scars simple hernia or vaginal repair). 3. Required surgery: is warranted for conditions necessitating intervention within a few weeks (eg, cataract surgery, thyroid disorders). 4. Urgent surgery: is indicated for a problem requiring intervention within 24 to 48 hours (eg, some cancers, acute gallbladder infection and appendicitis, Kidney stones). 5. Emergency surgery: describes procedures that must be done immediately to sustain life or maintain function (eg, repair of a ruptured aortic aneurysm, gunshot, or knife wounds, extensive burns, fractures skull, intestinal obstruction)

12.  CONDUCT A NURSING ASSESSMENT  PROVIDE PREOPERATIVE TEACHING  PERFORM METHODS OF PHYSICAL PREPARATION  ADMINISTER MEDICATIONS  ASSIST WITH PSYCHOSOCIAL PREPARATION  COMPLETE THE SURGICAL CHECKLIST

13. Client assessment varies depending on the urgency of the surgery. Time for preoperative assessment, nursing diagnosis, and evaluation of the nursing management may be limited when a client is admitted for ambulatory surgery or admitted shortly before surgery. Recognition of the client’s immediate preoperative needs is important. When the client is admitted, the nurse review preoperative instructions, such as diet restriction, skin preparation, to ensure the client has followed them. The nurse immediately notifies the surgeon if the client has not carried out a specific portion of the instruction. Assessment

14. : Preoperative Assessment I. Review preoperative laboratory and diagnostic studies II. Review the client ’ s health history and preparation for surgery III. Assess physical needs IV. Assess psychological needs V. Assess cultural needs

15. I. Review preoperative laboratory and diagnostic studies: Complete blood count. Blood type and cross match. Serum electrolytes. Urinalysis. Chest X-rays. Electrocardiogram. Other tests related to procedure or client ’ s medical condition, such as: prothrombin time, partial thromboplastin time, blood urea nitrogen, creatinine, and other radiographic studies.

16. II. Review the client ’ s health history and preparation for surgery: History of present illness and reason for surgery Past medical history Medical conditions (acute and chronic) Previous hospitalization and surgeries History of any past problem with anesthesia Allergies Present medications Substance use: alcohol, tobacco, street drugs Review of system

17. III. Assess physical needs: Ability to communicate Vital signs Level of consciousness Confusion Drowsiness Unresponsiveness Weight and height Skin integrity Ability to move/ ambulate Level of exercise Prostheses Circulatory status

18. IV. Assess psychological needs: Emotional state Level of understanding of surgical procedure, preoperative and postoperative instruction Coping strategies Support system Roles and responsibilities V. Assess cultural needs: Language-need for interpreter

19. INFORMED CONSENT Before surgery, the client must sign a surgical consent form or operative permit. Clients must sign a consent form for any procedure that requires anesthesia and has risks of complications. If an adult client is confused, unconscious, a family member or guardian must sign the consent form. If the client is younger than 18 years of age, a parent or legal guardian must sign the consent form. In an emergency, the surgeon may have to operate without consent, health care personnel, however, makes every effort to obtain consent by telephone, or fax. Each nurse must be familiar with agency policies and state laws regarding surgical consent forms. Clients must sign the consent form before receiving any preoperative sedatives. The nurse is responsible for ensuring that all necessary parties have signed the consent form and that it is in the client’s chart before the client goes to the operating room (OR).

20.  Teaching clients about their surgical procedure and expectations before and after surgery is best done during the preoperative period.  Clients are more alert and free of pain at this time.  Clients and family members can better participate in recovery if they know what to expect.  The nurse adapts instructions and expectations to the client’s ability to understand.  Information in a preoperative teaching plan varies with the type of surgery and the length of the hospitalization.

21.  Preoperative medication- when they are given and their effects.  Post operative pain control.  Explanation and description of the post anesthesia recovery room or post surgical area.  Discussion of the frequency of assessing vital signs and use of monitoring equipment.  Explanation and demonstration deep breathing and coughing exercises, use of incentive spirometry, how to support the incision for breathing exercises and moving, position changes, and feet and leg exercises.

22.  Information about intravenous (IV) fluids and other lines and tubes such as nasogastric tubes.  Preoperative teaching time also gives the client the chance to express any anxieties and fears and for the nurse to provide explanations that will help alleviate those fears.  When clients are admitted for emergency surgery, time for explanation is unavailable; explanations will be more complete during the postoperative period.

23.  Deep breathing is a form of controlled ventilation that opens and fills small air passages in the lungs to prevent atelectasis and pneumonia.  Coughing is a natural method of clearing secretions from the airways.  Leg exercises help promote circulation and reduce the risk of forming a thrombus in the veins.  Antiembolism stockings help prevent thrombi and emboli by compressing superficial veins and capillaries redirecting blood to larger and deeper veins, where it flows more effectively toward the heart.

26.  ANTICHOLINERGICS: Glycopyrrolate (robinal) decreases respiratory secretions.  ANTIANXIETY: Lorazepam (ativan) reduces anxiety.  HISTAMINE-2 RECEPTOR ANTAGONIST: Cimetidine (tagamet) decreases gastric acidity and volume.  NARCOTICS: Demerol (meperidine) decreases the amount of anesthesia needed to sedate the client.  SEDATIVES: Midazolam (versed) promotes sleep or conscious sedation and decrease anxiety.  ANTIBIOTICS: Kanamycin (Kantrex) destroy enteric microorganisms.

27.  History and physical examination.  Name of procedure on surgical consent.  Signed surgical consent.  Laboratory results.  Client is wearing an identification bracelet.  Allergies have been identified.  NPO.  Skin preparation completed.  Vital signs assessed.

28.  Jewelry removed.  Dentures removed.  Client is wearing a hospital gown and hair cover.  Client has urinated.  Location of IV site, type of intravenous solution, rate of infusion is identified.  The prescribed preoperative medication has been given.

30. Surgical Risk Factors:  Age → Very young – Elderly  Nutritional Status → Malnourished – Low weight – Obese  Medical Problems → Acute and chronic respiratory problems – Hypertension – Liver dysfunction – Renal failure – Diabetes

32.  Physical Preparation.  Skin preparation  Elimination  Food and fluids  Care of valuables  clothing/ grooming  Prostheses  Psychosocial Preparation.  Careful preoperative teaching can reduce fear and anxiety of the clients.

33. Nursing Diagnosis Anxiety related to results of surgery and postoperative pain. Knowledge deficit related to preoperative procedures and postoperative expectations.

35. INTRAOPERATIVE CARE

36. 1. General Anesthesia (inhaled or intravenously) refers to drug – induced depression of the central nervous system that produces analgesia, amnesia and unconsciousness (affects whole body). 2. Regional anesthesia is a form of local anesthesia that suspends sensation and motion in body region or part; the client remains awake. Continuous monitoring is required in the event the block is not totally effective and the client experiences pain or reactions to blocking agents (e.g. nausea, cardiovascular collapse). Regional anesthesia differs in terms of location and size of the anatomic area anesthetized and the volume and type of anesthesia agent used.

37. 3. Spinal Anesthesia is local anesthesia injected into the subarachniod space at lumbar level to block nerves and suspend sensation and motion to the lower extremities, perineum, and lower abdomen. 4. Conduction Blocks suspend sensation and motion on various groups of nerves such as epidural block (i.e. anesthetic into space around the dura mater); Para vertebral block (i.e. produces anesthesia of the chest, abdominal wall and extremities) and Tran sacral (caudal) block (i.e. anesthesia of the perineum).

39. ◦ Surgeon performs the surgical procedure and heads the surgical team. ◦ An anesthesiologist or anesthetist makes a preoperative assessment to plan the type of anesthetic to be administered and to evaluate the client's physical status. ◦ Circulating nurse manages the operating room and protects the patient’s safety and health by monitoring the activities of the surgical team, checking the operating room conditions, and continually assessing the patient for signs of injury and implementing appropriate interventions. Verify consent, ensure cleanliness, proper temperature, humidity, and lighting; the safe functioning of equipments; and the availability of supplies and materials. ◦ Scrubbing nurse setting up the sterile tables; preparing sutures, and special equipments; and assisting the surgeon and the surgical assistants during the procedure by anticipating the instruments that will be required - Scrub nurse and circulatory count all needles, sponges; and instruments used.

40.  Verifying consent  Coordinating the team  Ensuring cleanliness, proper temp., humidity & lighting  Safe functioning of equipment  Availability of supplies and materials

41.  Performing a surgical hand scrub  Setting up the sterile tables  Preparing sutures, ligatures & special equipment  Assisting the surgeon during the procedure

44.  Nausea and vomiting  Anaphylaxis  Hypoxia  Hypothermia  Malignant hyperthermia  Disseminated Intravascular Coagulopathy

45.  Physiologic status (LOC)  Psychosocial status (anxiety level, coping mechanisms)  Physical status (surgical site, skin condition, immobile joints)

46. POST OPERATIVE CARE

47. Postoperative Care: Immediate postoperative period. Initial Assessment Airway patency Effectiveness of respiration Presence of artificial airways Mechanical ventilation, or supplemental oxygen Circulatory status, vital signs Wound condition, including dressings and drains Fluid balance, including IV fluids, output from catheters and drains and ability to void Level of consciousness and pain

48. Postoperative Care: Later postoperative period Ongoing Assessment Respiratory function General condition Vital signs Cardiovascular function Fluid status Pain level Bowel and urinary elimination Dressings, tubes, drains, and IV lines

49. When caring for post-surgical patient, think of the “4 W’s” 1. Wind: prevent respiratory complications 2. Wound: prevent infection 3. Water: monitor I & O 4. Walk: prevent thrombophlebitis

50. 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. Altered Comfort (nausea and vomiting) related to effects of anesthesia or side effects of narcotics. 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.

51. Nurse’s Responsibilities in Postoperative Phase Ensures a patent airway Helps maintain adequate circulation Prevents or assist with the treatment of shock Maintains proper position and function of drain tubes and IV infusion Monitor for potential complications

52. Immediate Postoperative Complications 1. Hemorrhage 2. Shock 3. Hypoxia 4. Aspiration

57.  CARE OF THE INCISION.  SIGNS OF COMPLICATIONS.  DRUGS FOR PAIN MANAGEMENT.  HOW TO SELF ADMINISTER PRESCRIBED MEDICATIONS.  ACTIVITY LEVEL.  AMOUNT OF WEIGHT THAT CAN BE LIFTED.  DIET.  RETURN FOR A MEDICAL APPOINTMENT.