1. Perioperative Nursing Definition of Surgery
Surgery is any procedure performed on the human body that uses instruments to alter tissue or organ integrity.

2. Perioperative Nursing
Perioperative Nursing- connotes the delivery of patient care in the preoperative,intraoperative, and postoperative periods of the patients surgical experience through the framework of the nursing process. The nurse assesses the patient- collecting,organizing, and prioritizing patient data; establishing nursing diagnosis;identifies desired patient outcomes;develop and implements a plan of care; and evaluates that care in terms of outcomes achieved by the patient.

3. Perioperative Nursing Phases
Preoperative phase – begins when the decision to have surgery is made and ends when the client is transferred to the OR table.
Intraoperative phase – begins when the client is transferred to the OR table and ends when the client is admitted to the PACU.
Postoperative phase - begins with the admission of the client to the PACU and ends when the healing is complete.

4. Perioperative Nursing Types of Surgery
Purpose/reasons -
Degree of urgency – necessity to preserve the client’s life, body part, or body function.
Degree of risk – involved in surgical procedure is affected by the client’s age, general health, nutritional status, use of medications, and mental status.
Extent of surgery – Simple and radical

5. Perioperative Nursing Type of Surgery (Purpose)
Diagnostic-Allows to confirm or establishes diagnosis.
Corrective- Excision or removal of diseased body part.
Reconstructive-Restore function or appearance to traumatized or malfunctioning tissues.
Ablative – Removes a diseased body parts
Palliative – Relieves or reduces pain or symptoms of a disease; it does not cure
Transplant – Replaces malfunctioning structures
Cosmetic- Performed to improve personal appearance.

6. Perioperative Nursing Types of Surgery (Urgency)
Emergency- performed immediately to preserve function or the life of the client.
Elective – is performed when surgical intervention is the preferred treatment for a condition that is not imminently life threatening or to improve the client’s life.
Urgent – Necessary for client’ health to prevent additional problem from developing; not necessarily an emergency.
Required – has to be performed at some point; can be pre-scheduled.

7. Perioperative Nursing Type of Surgery (Degree of Risk)
Major – involves a high degree of risk.
Minor – normally involves little risk.
Age – very young and elder clients are greater surgical risks than children and adult.
General health- surgery is least risky when the client’s general health is good.
Nutritional Status – required for normal tissue repair.
Medications – regular use of certain medications can increase surgical risk.
Mental status – disorder that affect cognitive function

8. Perioperative Nursing Surgical settings
Surgical suites
Ambulatory care setting
Clinics
Physician offices
Community setting
Homes

9. Perioperative Nursing Surgical settings
Disadvantages Less time for rapport Less time to assess, evaluation, teach Risk of potential complication post D/C.
Advantages of outpatient: Low cost Low risk of infection Less interruption of routine Less than from work Less stress

10. Preoperative Nursing Consent
Nature and intention of the surgery
Name and qualifications of the person performing the surgery.
Risks, including tissue damage, disfigurement, or even death
Chances of success
Possible alternative measures
The right of the client to refuse consent or later withdraw consent.

11. Preoperative Nursing Assessment (Nursing History)
Current health status-
Allergies
Medications- list all current medications
Previous surgeries
Understanding of the surgical procedure and anesthesia
Smoking
Alcohol and other-altering substances
Coping
Social resources
Cultural considerations

12. Preoperative Nursing Care Physical assessment
Cardiovascular system
Respiratory system
Renal system
Neurological system
Musculoskeletal system
Nutritional status
Gerontological considerations

13. Perioperative Nursing Care Physical assessment/clinical manifestations
General survey- gestures and body movements may reflect decreased energy or weakness caused by illness.
Cardiovascular system- alterations in cardiac status are responsible for as many as 30% of perioperative death.
Respiratory system- a decline in ventilatory function, assessed through breathing pattern and chest excursion, may indicate a client’s risk for respiratory complications.

14. Perioperative Nursing Care Physical assessment/clinical manifestations
Renal system-abnormal renal function can altered fluid and electrolyte balance and decrease the excretion of preoperative medications and anesthetic agents.
Neurologic system- a client’s LOC will change as a result of general anesthesia but should return to the preoperative LOC after surgery.

15. Perioperative Nursing Care Physical assessment/clinical manifestations
Musculoskeletal system- Deformities may interfere with intraoperative and postoperative positioning. Avoid positioning over an area where the the skin shows signs of pressure over bony prominences.
Gastrointestinal system- alteration in function after surgery may result in decreased or absent bowel sound and distention.
Head and Neck- the condition of oral mucous membranes reveals the level of hydration.

16. Preoperative Nursing Care Gerontological Considerations
Cardiovascular Coronary flow decreases Heart rate decreases Response to stress decreases Peripheral vascular decreases Cardiac output decreases Cardiac reserve decreases

17. Preoperative Nursing Care Gerontological Considerations
Respiratory System
Static lung volumes decreases
Pulmonary static recoil decreases
Sensitivity of the airway receptors decreases
Nervous system
Increased incidence of post.op. confusion.
Increased incidence of delirium
Increased sensitivity to anesthetic agents

18. Preoperative Nursing Care Gerontological Considerations
Renal System Renal blood flow declines 1.5% per year. Renal clearance reduced
Gastrointestinal Decreased intestinal motility
Decreased liver blood flow Delayed gastric emptying

19. Preoperative Nursing Care Gerontological Considerations
Musculoskeletal Decreased mass, tone, strength Decreased bone density
Integumentary Decreased elasticity Decreased lean body mass Decreased subcutaneous fat

20. Preoperative Nursing Care Psychosocial considerations
Level of anxiety
Coping ability
Support systems

21. Preoperative Nursing Care Laboratory and diagnostic studies
Screening tests depend on the condition of the client and the nature of the surgery. If test reveals severe problems the surgery may be cancel until the condition is stabilized.
Routine screening test-CBC,Blood grouping and X-match, Lytes, fasting blood sugar, BUN & Creatinine, ALT,AST, and bilirubin,Serum albumin, and Total protein, Urinalysis, Chest X-ray,ECG

22. Preoperative Nursing Care Common nursing diagnosis
Knowledge deficit
Anxiety
Risk for ineffective airway clearance
Fear related to
Disturbed sleep pattern
Anticipatory grieving related to

23. Preoperative Nursing Care Preop. teaching
The education plan should begin with assessment, including baseline knowledge of the patient and family, readiness to learn,barriers to learning, patient and family concern and learning styles and preferences.
The content focuses on information that will increase patient’s familiarity with procedural events. This includes surgical experience (procedural), what the pt. may experience (sensory) and what actions may help decrease anxiety (behavioral).

24. Preoperative Nursing Care Anxiety
The nurse must consider the pt’s family and friends when planning psychological support.
Empowering their sense of control. Activities that decreasing anxiety are deep breathing, relaxation exercises, music therapy, massage and animal-assisted therapy.
Use of medication to relieve anxiety.

25. Preoperative Nursing Care Preanesthesia Management Physical Status Categories
ASA 1: Healthy patient with no disease
ASA 11: Mild systemic ds without fx limitations
ASA 111:Severe systemic ds associated with definite fx limitations
ASA 1V: Severe systemic ds that is a constant threat to life.
ASA V: Moribund pt. Who is not expected to survive without the operation.
ASA V1: A declared brain-death whose organ are being recovered for donor.
E: Emergency

26. Preoperative Nursing Care Final Preparation for surgery
All personal belongings are identified and secured.
Jewelry is usually removed.
Dentures are removed, labeled and placed in a denture cup.
Pt. to verbally confirm the surgical procedures and the surgical site. This verification process is documented in the medical record on the preop. checklist.

27. Preoperative Nursing Care Pre-op. medications
Prior to administering – check permits
Purpose: Allay anxiety Decrease pharyngeal secretions Decrease gastric secretion.
Decrease side effects of anesthesia.
Induce amnesia

29. Preoperative Nursing Care Medications
Sedatives/hypnotics- Nembutal
Tranquilizers-Ativan, versed, valium
Opiate analgesics- Demerol, morphine
Anticholinergics-Atropine sulfate,atarax
H2o blockers.- Tagamet, Zantac
Antiemetic- Reglan, Phenergan

30. Intraoperative Phase Surgical Team
Surgeon
Anesthesiologist
Scrub Nurse
Circulating Nurse
OR techs

31. Intraoperative Nursing Care Roles of team members
Surgeon-responsible for determining the preoperative diagnosis, the choice and execution of the surgical procedure, the explanation of the risks and benefits, obtaining inform consent and the postoperative management of the patient’s care.
Scrub nurse- (RN or Scrub tech)- preparation of supplies and equipment on the sterile field; maintenance of pt.s safety and integrity: observation of the scrubbed team for breaks in the sterile fields; provision of appropriate sterile instrumentation, sutures, and supplies; sharps count.

32. Perioperative Nursing Care Surgical team
Circulating Nurse - responsible for creating a safe environment, managing the activities outside the sterile field, providing nursing care to the patient. Documenting intraoperative nursing care and ensuring surgical specimens are identified and place in the right media. In charge of the instrument and sharps count and communicating relevant information to individual outside of the OR, such as family members.

33. Perioperative Nursing Care Surgical team
Anesthesiologist and anesthetist- anesthetizing the pt. providing appropriate levels of pain relief, monitoring the pt’s physiologic status and providing the best operative conditions for the surgeons.
Other personnel- pathologist, radiologist, perfusionist, EVS personnel.

34. Perioperative Nursing Care Surgical team
Nursing Roles:
Staff education
Client/family teaching
Support and reassurance
Advocacy
Control of the environment
Provision of resources
Maintenance of asepsis
Monitoring of physiologic and psychological status

35. Intraoperative Nursing Care Surgical asepsis
Ensure sterility
Alert for breaks

36. Intraoperative Phase Anesthesia
Greek word- anesthesis, meaning “negative sensation.” Artificially induced state of partial or total loss of sensation, occurring with or without consciousness.
Blocks transmission of nerve impulses
Suppress reflexes
Promotes muscle relaxation
Controlled level of unconsciousness

37. Intraoperative Phase Anesthesia
Factors influencing dosage and type:
Type and duration of the procedure
Area of the body being operated on
Whether the procedure is an emergency
Options of management of post. Op. pain
How long it has been since the client ate, had any liquids, or any medications
Client position for the surgical procedures

38. Intraoperative Phase Types of Anesthesia
General- method use when the surgery requires that the patient be unconscious and/or paralyzed.
A general anesthetic acts by blocking awareness centers in the brain so that amnesia (loss of memory), analgesia (insensibility to pain), hypnosis (artificial sleep), and relaxation (rendering a part of the body less tense) occur.

39. Intraoperative Phase Stages of General Anesthesia
Stage 1- Analgesia and sedation, relaxation
Stage 2- Excitement, delirium
Stage 3- Operative anesthesia, surgical anesthesia
Stage 4- Danger

40. Complications of General Anesthesia
Intraoperative Phase
Complications of General Anesthesia
Overdose
Hypoventilation
Related to anesthetic agents
Malignant hyperthermia
Related to intubation

41. Local or Regional Anesthesia
Intraoperative Phase
Local or Regional Anesthesia
Temporarily interrupts the transmission of sensory nerve impulses from a specific area or region.
Motor function may or may not be affected
Client does not lose consciousness
Gag reflex remains intact
Supplemented with sedatives, opioids, or hypnotics

42. Types of Regional Anesthesia
Topical (surface)
Local
Nerve Block
Intravenous (Bier Block)
Spinal
Epidural (peridural)

43. Complications of Local/Regional Anesthesia
Intraoperative Phase
Complications of Local/Regional Anesthesia
Anaphylaxis
Administration technique
Systemic absorption
Overdosage

44. Spinal Anesthesia Indications -surgical procedures below the diaphragm
-patients with cardiac or respiratory disease
Advantages mental status monitoring -shorter recovery
Disadvantages necessary extra expertise -possible patient pain
Contraindications coagulopathy uncorrected hypovolemia

45. Spinal Anesthesia
Involved medications -lidocaine bupivacaine tetracaine
Patient assessment continuous heart rate, rhythm, and pulse oximetry monitoring -level of anesthesia -motor function and sensation return monitoring

46. Spinal Anesthesia
Complications hypotension bradycardia urine retention -postural puncture headache -back pain

47. Spinal analgesia Indications -postoperative pain from major surgery
Involved medications -lipid-soluble drugs -preservative-free morphine
Monitoring recovery -respiratory depression -urine depression -pruritus nausea and vomiting

48. Examples of location for Spinal and Epidural Anesthesia.

49. Nerve Block Sites

50. Intraoperative Phase Produces a depressed level of consciousness
Conscious Sedation
Administration of IV sedative, hypnotic, and opioid medications.
Produces a depressed level of consciousness
Retains ability to maintain a patent airway
Able to respond to verbal commands or physical stimulation
Used for relatively short procedures

51. Postoperative Nursing Care Nursing assessment in the PACU
Vital signs- presence of artificial airway, 02 sat,BP,pulse, temperature.
LOC- ability to follow command, pupillary response
Urinary output
Skin integrity
Pain
Condition of surgical wound
Presence of IV lines
Position of patient

52. Postoperative Nursing Care Nursing Diagnosis
Ineffective airway clearance- increased secretions 2 to anesthesia, ineffective cough, pain
Ineffective breathing pattern- anesthetic and drug effects, incisional pain
Acute pain
Urinary retention
Risk for infection

53. Postoperative Phase Assessment of the Postanesthesia Client Airway
Vital signs
Cardiac monitoring
Peripheral vascular assessment
Level of consciousness (LOC)
Fluid and electrolytes
GI system
Integumentary system
Discomfort/pain

54. Perioperative Nursing Care Postoperative Management
Maintain a patent airway
Stabilize vital signs
Ensure patient safety
Provide pain
Recognize & manage complications

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

56. Postoperative Phase Complications
Respiratory- atelectasis, pulm. Embolus
Cardiovascular- venous thrombosis
Gastrointestinal-Hiccoughs, N/V,abd. Distention, paralytic ileus, stress ulcer.
GU- urinary retention
Hemorrhage-slipping of a ligature(suture)
Wound infection-
Wound dehiscence and evisceration-

57. Dehiscence
Partial or complete separation of the outer layer of the wound.
Possible causes:
Poor suturing technique
Distention
Excessive vomiting
Excessive coughing
Dehydration
Infection

58. Evisceration
Total separation of the layers & protrusion of internal organs or viscera through the open wound.
Causes: same as dehiscence
Treatment:
Call for help
Cover with sterile NS soaked gauze/towels
Keep moist
DO NOT ATTEMPTS TO REINSERT ORGANS.
Keep in supine position with knees/hips bent
Assessment/VS q 5 min. until MD arrive
Prepare for surgery.

59. Postoperative Phase

60. Postoperative Phase

61. Postoperative Nursing Care Gerontologic considerations
Mental status- attributed to medications, pain, anxiety, depression.
Delirium- infection, malignancy, trauma, MI, CHF, opioid use.
Dementia-sundowning-sleep disturbances, lack of structure in the afternoon or early morning, sleep apnea.