Perioperative Periopera tive Nursing - it is the nursing nursing care rendered rendered to the total total surgical experience of the patient. 3 Phases Preoperative phase y
y
Intraoperative Intraoperative phase
y
Postoperative phase
ects Eff ects
of Surg Surgery ery on a Client A . Physical Effects
B. Psychological Effects
The A .
B. C. D. E. F. G.
Surgical Risk Patients
Extremes of age Malnourished (emaciation/obesity) Dehydrated patients patients Patients with severe trauma or injury, injury, infectio infection n or sepsis Patients with cardiovascular disease Endocrine dysfunction Hepatic/Renal Hepatic/Renal disease
Medications That
Surgical Client ntibiotics A ntibiotics ntidysrhythmics A ntidysrhythmics nticoagulants A nticoagulants
Corticosteroids Insulin Diuretics ntidepressant A ntidepressant
Can Aff ect ect the
Classif ications ications of Surgery According to Urgency: 1. Emergent requires requires immediate immediate attention; attention; Disorders maybe life-threatening. 2. Urgent Urgent-- surgical problem requires requires prompt attention attention within 24-30hrs 3. Required Required-- condition condition requires requires surgery surgery within a few weeks weeks 4. Elective Elective-- approximate time for surgery is at the convenience convenience of the th e patient, failure to have surgery surgery is not catastrophic 5. Optional Optional-- is scheduled completel completelyy at the prefere preference nce of the patient.
y
Classif ication ication of Surgery y
According to Degree of Risk: Major-- high Major high degr degree ee of risk > maybe complicated/prolonged > large large losses of blood may occur > vital organs organs maybe involved > post-op post-op complications complications may be likely Minor- little Minorlittle risk risk with with few complicat complications ions > often performed performed in a day
Classif ications ications Of Surgery According to Purpose Diagnostic-- verifies verifies suspect suspected ed diagnosi diagnosiss 1. Diagnostic 2. Exploratory - estimates the extent extent of the disease or injury 3. Curative Curative-- removes/repairs removes/repairs damage tissues 4. A blativeblative - Removing Removing diseased organ that that cant wait wait anymore 5. Reconstructive Reconstructive-partia -partiall or complete restoration; bringing back back orig. appearance and function
y
y
y
y
Cont. Constructive- repairing Constructiverepairing damaged damaged tissue/cong tissue/congenitally enitally defective organ Palliative relieves relieves symptoms but does not not cure cure the underlying diseases
Preoperative Preopera tive Phase
ormed Inf ormed
Consent (Operative Permit)
Obtaining Inf orm orm Consent 1.
2. 3. 4. 5. 6.
The surgeon surgeon is responsible respons ible for obtaining the consent for surgery. No sedation sedatio n should be administered to the client before he/she signs the consent. Minors may need a parent or legal guardian gu ardian to sign the consent form. Older client may need a legal guardian to sign the consent form. The nurse may witness the clients clients signing of the consent form. If the patient is unable to write, an X to indicate his sign is acceptable acceptab le if there is a signed witness to his mark.
Pocedures Requiring Permit Surgical procedures where where scalpel,scissors, scalpel,scissors, suture, hemostats or electrocoagulation maybe used. 2. Entrance into a body cavity 3. Radiologic procedure, procedure, particularly if contrast contrast material is required. 4. General anesthesia, anesthesia, local infiltration and regional block 1.
Physical Preparation of Patient the Night Bef ore ore Surgery 1.
NPO- 6-8hrs 6-8hrs (general (general and spinal spinal anesthesia anesthesia)) 2-4hrs (local anesthesia)
2. Bowel Bowel Prep- for major abdominal surgery surgery
prep- shower shower with antibacterial soap 3. Skin prep-
Preoperative Teaching/Visit
Physical Physical Preparation
Psychological Psychological Preparation Preparation
Postoperative Exercises
y
Deep breathin breathing g - every every 2hrs Coughing Splinting
y
Turning urning every every 2hrs 2hrs
y y
Foot
and Leg Exercise
Incentive
Spirometer y
Positive Effects - provides provides stimulu stimuluss for a spontaneous deep breath - reduces reduces atelectasi atelectasiss - opens opens airw airway ayss - stimulates stimulates coughing coughing - encourage encourage active individual participation in recovery recovery
Preoperative Medications 1.
Narcotic analgesic
2.
nticholinergics A nticholinergics
3. Sedatives 4. Prophylactic Prophylactic antibiotic
Surgical Checklist Identification and verification patients record record Review of patients Consent form Patient preparedness 1. NPO status 2.Proper 2.Proper attire (hospital (hospital gown) 3. Skin Skin prep, prep, if ordered 4. IV IV started with correct gauge needle 5. Dentures or plates removed removed 6. Jewelry, Jewelry, contact lenses lenses 7. allow allow patient to void void
IV Cannulas
G 22 G 24
G 20
G18
INTRAOPERATIVE
PHASE
As
tic Tech i y
e
A group
of procedures of procedures that prevent contamination of microorganisms microorganisms through the knowledge of contain and control.
Steril St erile e Tech echniqu nique e contam amin ina atio tion of Methods by which cont an item is prevented by maintaining the sterility of an item/area involved with the proc proced edur ure. e.
Basic Principles of Aseptic Technique
ll 1. A ll
items used within the sterile field must be sterile sterile.. 2. A sterile barrier that has been permeated must be considered contaminated. 3. The edges of a sterile wrapper or containe containerr are considered considered unsterile uns terile once the package is opened. steril e from chest to 4. Gowns are considered sterile the level of the sterile field, and the sleeves to 2inches above above the elbows.
Table ables s are are ster sterilile e at tabl table e lev level el only only.. Ste Sterile rile perso rsons an and ite items ms tou touch only sterile areas; unsterile persons and items touch only unsterile areas. Movem ovemen entt arou around nd the the ster sterilile e fie field must must not contaminate the field. All All ite items ms and area areas s of of dou doubt btfu full ste steri rilility ty are considered contaminated.
Recommended Practice III y
Items used within the sterile field should be sterile
y
Ev ent-related ent-related sterility system
altered overtime, but b ut may be compromised - sterility is not altered by certain certain events/environmental conditions y
y
Shelf
life - refers to the time an item may remain on the shelf and still maintain its sterility. Spaulding Criteria Criteria - are used to to determine determine the potential potential for transmission of infectious agents.
Recommended Practice IV items introduced to a sterile sterile field f ield should shoul d be opened, dispensed and transferred by methods that maintain item sterility and integrity. integrity. 1. The surgical team should practice careful careful aseptic aseptic technique during all invasive surgical procedures. Unscr Unscrubb ubbed ed indi indi v iduals iduals should open wrapped sterile 2. supplies suppli es by opening the t he wrapper wrapper flap f lap farthest away away from them first. 3. Sharps and hea v y objects should be presented to the scrubbed person/opened on a sterile surface. 4. Peel pouches should be presented to the scrubbed person. 5. Rigid container systems should be opened on a separate surface. y
ll A ll
y
hen W hen
dispensing solutions, the solution receptacle on the sterile field fi eld should be placed near the tables tables edge, or held by scrubbed person.
Strik ikee Str
through throug h - conta contamination mination of sterile surface surface by moisture that has originated from a non-sterile non-s terile surface and penetrated penetrated the protective protective covering covering of the sterile item
y
Medications should be delivered delivered to the sterile field in an aseptic manner.
Recommended Recommended practice V A sterile field should be maintained and monitored constantly. 1. A sterile field should be prepared in the location in which it will be used. 2. For unsterile personnel, movement around the sterile sterile field should should maintain a distance distance of at least 12 inches from the sterile field. 3. Sterile fields should be prepared prepared as close as possible to the time of use. 4. Sterile field should not be covered. 5. Conversations in the presence of a sterile field should be kept to a minimum. y
Recommended y
y
y
y
y
A ll ll
Practice VI
personnel moving within or around a sterile field should do so in a manner that maintains the t he sterile field. Unscrubb Unscrubbed ed personnel personnel - should face face sterile sterile fields on approach approach - should not walk walk between between two sterile fields Scrubbed personnel - should keep their arms and hands above above the level of the waist at all times. - arms should not be be folded with the hands in the armpits - should avoi avoid d changing changing levels. levels. The number and movements of the surgical team should be kept to a minimum. hen a break in the sterile technique occurs, corrective action W hen should be taken immediately.
Recommended Practices f or or traff ic ic Patterns in the Perioper Per ioperative ative Practice Setting y
NonNo n- Restr Restrict icted ed A rea rea
y
Semi-Restricted A rea rea
y
Restricted A rea rea
y
Transition Zone
Recommended Practices f or or Surgical Attire Surgical A ttire ttire y
y
y
y
y
Helps contain contain bacterial shedding and promotes environmental environmental control. If a two-piece two-piece pantsuit is worn, the top of the scrubsuit should be secured at the waist or fit f it close to the th e body. body. Should be changed daily or whenever it becomes visibly soiled, contaminated or wet. Lab coats/cover gowns should be removed before entering a semi- restricted restricted/restri /restricted cted area area Non-scrubbed personnel should wear long-sleeved jackets that are buttoned/snapped closed during use.
Head Cover y
y
y
Headgear should should be donned donned before before the scrub attire to prevent fall-out fall-o ut from the hair collecting collecting on the scrub attire. Personnel should should cover head and facial hair, hair, including sideburns and necklines, when in the semi-restricted and restricted areas areas of the surgical suit. Contaminated headgear headgear must be removed removed and laundered laundered by the facility facil ity..
Surgical Mask y
y
y
y
Should Should fully cover cover both mouth and nose and be secured in in a manner that prevents venting. Double Double mask is unacceptable, doesnt increase filtration. Should be removed by handling only the ties, should be discarded immediately. immediately. Should not be saved by hanging them around the neck or tucking them into a pocket for future use
Gloves y
y
y
y
Sterile gloves must be worn worn when performing performing sterile procedure. Medical, non non sterile gloves are recommended for nonsterile activities. Should be changed between patient contacts/contaminated items. Hand hygiene should be performed performed after gloves are removed.
Recommended Practices f or or Standard and Transmission based Precautions in the Perioper Perioperativ ative e Pra Practice ctice setting setting y
y
y
y
y
Standard Precautions to prevent pathogen transmission should be be used during all invasive procedures. Standard Precautions should include use of protective barriers and frequent f requent hand washing to reduce risk of exposure to potentially infectious infecti ous materials. Personnel should shou ld take precautions to prevent prevent injuries caused by scalpels and other sharp instruments. Personnel should handle specimens as potentially infectious material. ork practices should be designed to minimize risk of W ork occupational occ upational exposure exposure to bloodborne and other potentially potentially infectious pathogens.
y
1.
2.
Transmission based precautions should be used in addition to standard precautions precaution s for patients who are known or suspected to be infected with highly transmissible transmiss ible pathogens.
Airborne precautions - examples: rubeola, v aricella, aricella, tuberculosis - respiratory protection to be worn by susceptible persons - placing surgical mask on patients during transport - elective elective surgical surgical procedures procedures on TB patients should be delayed until patient is no longer infectious. Droplet precautions - exam exampl ples es: diptheria,pertussis,influenza,mumps - wearing a mask when within three feet of patients - positioning positi oning patients at a distance of at least three feet from other patients
3. Contact Precautions
- wearing gloves when caring for patients/coming in contact with with items items that may contain contain high concentrations concentrati ons of microbes. - wearing gowns gowns when when it is anticipated that clothing will have have substantial contact cont act with patients/items in aegs. ae gs. environment - precautions are maintained during transport. transport. - adequately cleaning and disinfecting disinfecting patient care equipment equipment and items items before use w/ each patient. patient.
Surgical Hand Scrub Goals: y
y
y
y y
Mechanical Mechanical removal of soil and transient microbes from the hands and forearms Chemical reduction of the resident microbial count to as low a level as possible Reduction of potential of rapid rebound growth of microbes. Antimicrobial Ag Agents ents Iodophors Chlorhexid Chlorhexidine ine gluconat gluconatee
Anatomic
Hand Scrub Technique
Sequence in Removing Soiled Gowns and Gloves at the End of the Procedure
Preparation of Surgical Supplies y
y
y
Decontamination contaminates contaminates are are remo v ed ed either by hand cleaning or mechanical methods using specific solutions. Disinfection-to used to destroy/kill/inhibit growth of microbes thru application of antiseptic solution. rendering an item item totally totally free free of all Sterilization- rendering li v ing ing microorganisms including spores.
Members Surgeon nesthesiologist A nesthesiologist Scrub Nurse Circulating Nurse
Of the Surgical Team
Circulating Nurse/Scrub Nurse/Scrub Nurse
Circulating Nurse y y
y y y y y
y y
Sets up the Operating room Ensures that necessary necessar y supplies supplies and equipment are readily available, safe and functional Receives patient endorsement endorsement ssists in the transferring of client in the OR bed A ssists Positions patient in the OR bed Performs surgical skin preparation Opens and dispenses additional needed supplies supp lies /medications during surgery Manages catheters, tubes, drains and specimens Reviews the results of any diagnostic diagnost ic tests or lab studies
y
y y
y
y
y
y y
Ensures that the surgical team maintains sterile technique and a sterile sterile field. fiel d. Monitors traffic in the OR Manages the flow of information to and from the surgical team members scrubbed at the field f ield Manages Manages personnel, equipment, supplies and the environment during surgery Performs sharps, sharps, sponge and instrument instrument count at appropriate time Documents all care, events, findings f indings and patients responses intra-op Dressing of wound and drainage Care of the tissue specimen specimen
Scrub Nurse Performs scrubbing, gowning and gloving Prepares sterile field for scheduled/emergency surgery ssists with instrumentation, sponges and suture A ssists presentation nticipate needs for surgical team A nticipate Performs sharps, sharps, sponge, sponge, and and instrument instrument count Prepares sterile dressing w/c will be applied when surgery is completed ftercare of instruments and other materials A ftercare Care of tissue specimen y y y
y y y
y y
Paraprof essionals/Ancillary essionals/Ancillary Positions y
y
Prepares and maintains supplies, equipment and environment ssists nursing staff before, during and after surgical surgical A ssists procedure
Anesthesia and Related Complications Common Anesthetic Technique Minimal Sedation Patient remains conscious Protective reflexes remain intact Can respond to verbal commands Moderate Sedation -state of depressed level of consciousness that does not impair patients ability to maintain a patent airway and to respond to physical stimulation and verbal commands. Deep Sedation - Drug induced state state during which which the patient patient cant cant be easily aroused but but can respond purposefully purpos efully after repeated repeated stimulation y y y
General Anesthesia
y y
y
y y
Complete loss of consciousness A reversibl reversiblee state that provides analgesia, muscle muscl e relaxation and sedation It depresses the cerebral cortex where conscious interpretation of pain takes place Protective Protective reflexes ref lexes are lost Produced by IV/inhaled anesthetics
Nitrous Oxide y y y
y y y y
Colorless, odorless non-explosiv non-explo sivee gas Is rarely used alone alone hen combined with other other agents and oxygen---oxygen----it it W hen already serves as potentiator potentiator for other inhalation inhalation agents High concentration nitrous nitrou s oxide can produce hypoxia induction induction agent given with oxy oxygen gen used alone for short procedures used as inhalation analgesic
alat atio ion n Inhal y
Anes An estthesia
Volatile agents 1. Halothane - safe safe to use - produci producing ng rapid rapid smooth induct induction ion - non-f non-f lammable/ lammable/non-e non-expl xplosiv osivee - very potent potent - seldom causes nausea nausea and vomiting vomiting - non-irritating to mucous membranes membranes -excellent bronchodilator - hepat hepatot oto oxic -decreases bp - causes malignant hyperthermia hyperthermia
Forane (Isof lourane) lourane) y y y y y y
Provides rapid induction, rapid emergence Low incidence of nausea nausea and vomiting vomiting Does not stimulate stimul ate excessive excessive secretions Non-hepatotoxic/non-nephrotoxic Excellent choice for neurosurgery Not recommende recommended d for children under 2 years of age-----due to longer airway irritation irritatio n
lurane Enf lurane y y y y
Has similar effects to halothane Muscle relaxati relaxation on is stronger Hepatotoxi Hepatotoxicity city is not a problem Induces electroencephalographic changes causing seizure.
Complications of General Anesthesia 1.
spiration A spiration
2. 3. 4. 5. 6.
Oral trauma Hypoventilation Cardiac dysrrythmias Hypothermia Malignant Hyperthermia
From
To
Patient¶s response
Patient care consideration
of Beginning to lose general anesthesia consciousness
Drowsy, dizzy d izzy,, hearing becomes exagerrated, pain sensation is decreased
Close OR doors, keep room quiet
Loss of conciousness,e xcitement phase
Relaxation,light hypnosis
Loss of consciousness, consciousness,loss loss of lid reflexes.incresed muscle tone and involuntary motor response
Lightly restrain patient, remain at patient¶s side but ready to assist
Regular pattern of respiration
Total paralysis of interco intercostal stal muscles muscles and cessation of voluntary respiration
Regular respiration,contracted pupils reflexes disappear
Position patient and prepare skin
Induction
Danger stage, vital Respiratory functions too failure,possible depressed cardiac arrest
Not breathing,little or Prepare for no pulse or heart beat cardiopulmonary resuscitation
OXYGEN
TANK
COMPRESSED AIR
NITROUS OXIDE
Regional Anesthesia Production of anesthesia in a specific body bo dy part Injecting local lo cal anesthetics in close c lose proximity proximity to appropriate nerves Spinal Anesthesia Local anesthetic is injected into lumbar intrathecal space/sub space/sub arachnoid arachnoid space space nesthetic blocks conduction in spinal nerve roots A nesthetic and dorsal ganglia Paralysis and analgesia occur below level of injection Produces excellent excellent analgesia and relaxation rela xation to abdominal and pelvic procedures y y
y
y
y y
Positioning Surgical Patient (Spinal Anesthesia)
Sitting Position Lateral Position
Epidural Anesthesia
y
y
y
Injecting Injecting local anesthetic into epidural space by way of a lumbar puncture ssociated with obstetric obstetric surgery; surgery; anorectal and A ssociated perinea perineall proc procedu edure re dministered via bolus A dministered
Peripheral Ner v e Blocks nesthetic is injected around a nerve that supplies A nesthetic sensation sensation to a small area of the body bo dy y
Intr ntrav avenous enous y
y
Block
Involves IV injection injection of a local local agent and the use of an an occlusion tourniquet Procedures involving involving the the arm, wrist and hand
Local Anesthesia y y
(Infiltration) Used for minors and superficial superf icial procedures The agent is injected in the surgical site s ite
Topical Anesthesia nesthetic agent agent is directly applied to the skin and A nesthetic mucous membranes y
Complications of Spinal Anesthesia y
Hypotension
y
Nausea and vomiting
y
Urinary retention
y
Post spinal headache
Quadrants Of the Abdomen
Regions of the Abdomen
Abdominal
Incisions
Positioning: Position ing: A Team Team Concept
Positioning Surgical Patient
5 Factors to be considered when positioning positioning a surgical patient y y y y y
natomy involved involved with the the procedure A natomy Surgical A pproach/surgeon pproach/surgeonss preference Patient comfort Patient and staff safety Respiratory and circulatory freedom
Supine (Dorsal Recumbent) Procedures:
Lithotomy Procedures: Perineal Vaginal Combined abdominalvaginal
Abdominal Extremity Vascular Chest Neck Facial Ear Breast
Lateral Recumbent Procedures: Chest Kidney
Trendelenburg Procedures: Lower abdominal Pelvic Organs
Kraske Kras ke (Ja (Jackn ckniif e) Procedures: Rectal Procedures Sigmoidoscopy Colonoscopy
Prone Procedures: Surgeries involving the posterior surface of the body Spine Neck Buttocks Lower extremities
What
is surgical skin prep?
an
aseptic procedure that is used to reduce the resident resident and transient flora naturally present on the skin surface.
ccomplished A ccomplished Rendering
Is
by application of anti-microbial agents.
the skin ski n surgically clean
performed by the circulating nurse
Prior to draping
Antimicrobial Antimicr obial Solutions 1.
Povid ovidone one /I /Iodine odine Betadine
2. Chlorhexidine
Gluconate
Rapid acting Have a broad spectrum spectrum o Have of activity Have minimal harsh o Have effect on skin o Inhibit rapid rebound of microbes Economical to use o Economical o Based on documentation in scientific literature o
Special Areas of Consideration Eyes open wounds o Traumatic open o Fractures neurysm and Ovarian Cyst o Tumors, A neurysm reas o Dirty Contaminated A reas o Emergency Preps o
Abdominal Prep Breastline Breastline to to
upper 3rd of thigh Table line to table line when in supine position
Chest and Breast
Shoulders Upper Upper arm elbow elbow xilla A xilla Chest wall wall to table-line and 2 inches beyond the sternum to the opposite shoulder
Lateral/Thoracotomy xilla A xilla
Chest bdominal-from A bdominal-from neck to iliac crest rea should should extend A rea beyond the midline anteriorly and posteriorly
Knee/
Lower leg
Entire circumference of affected leg
Extends from the foot to upper part of thigh thigh
Hip/ Lower Extremity bdomen on the A bdomen
affected side Thig Thighh- knee knee Buttock Buttockss table line Groin pubis
Rectop Rect oper erin inea eall / Vaginal
Sutures bsorbable sutures A bsorbable Examples: Chromic, Plain,Polydiaxone Plain,Polydiaxone (PDS), Polygla olyglacti ctin n 910 (Vicryl),Polyglycolic A cid(Biovek) cid(Biovek) - Used for those who cant return for suture removal/in internal body tissues Non- A bsorbable bsorbable sutures Examples: Silk,Nylon,P Silk,Nylon,Prolen rolenee (P (Polypr olypropylen opylene) e) - Used either on skin wound wound closure/in closure/in stressful internal in ternal environments where where absorbable absorbable sutures will not suffice - Less scarring because they provoke less immune response y
y
Sutures y
Is a medical device used to hold hold tissue together after an injury or surgery till healing takes place.
bsorbable Sutures A bsorbable
material is digest digested ed by body cells and fluids f luids during the healing period.
dissolvess within within 5-10 days, Yell Yellow ow Plain dissolve Chromic- dissol dissolvves withi within n 1 month, Brown days, Lavender Lavender Vicryl/Safil- dissolves within 60-90 days, PDS PD S (Polydio (Polydioxo xone)ne)- dissolve dissolvess 2 times longer longer than than the other absorbable sutures, W hite hite
Non ab absor sorbab bable le Sutur Sutures es Material is not absorbed or digested by tissues during healing period Types: y
Silk-
is an animal product from silk worm cocoons. cocoons. (Black) staple cotton, cotton, treated to make Cotton- made from long staple it smooth, ( W hite) hite) biosynthetic, ic, non-absorbab non-absorbable le suture suture material, material, Prolene- biosynthet as substitute substitute to to silk any suture material material Wire- gives the greatest strength to any
Diff erent erent Types
Of Needles
Skin
Subcutaneous
Fascia
Muscle
Peritoneum
Organ
20 10
11 12
15
Surgical Blades
The Basic Surgical Instruments
Cutting and Dissecting Grasping and Holding Retracting and Exposing Clamping and Occluding Miscellaneous
Cutting and Dissecting Instruments
Scalpel holder
Curved and Straight Mayo Scissors
Lister/Bandage Scissors
Suture Scissors
Metzenbaum
Stitch Scissors
Blade Handle
Curve and Str Straig aight Scissor Scissorss
Metzenbaum
Grasping
and Holding Instruments (Tissue Forceps)
These are available in various lengths, with or without teeth, and smooth or serrated jaws.
DeBakey Tissue Forceps
Adson
Tissue Forceps
Russian Tissue Forceps
Grasping
and Holding Instruments
Russian Tissue Forceps
They have serration up to the tips, allowing better grasp of tissue with minimum trauma.
Grasping and Holding Instruments
They Are used to hold tissue, drapes or sponges.
Backhaus Towel Clamp
Allis
Randall Stone Forceps
Clamp
Tenaculum
Babcock Clamp
Foester
/ Ovum Sponge Forceps
Kocher/ Oschsner Clamp
Hook and Dissector
Grasping
and Holding Instruments
Randall Stone Forceps
To hold/remove hol d/remove kidney stones ston es
Retracting and Exposing Instruments
Richardson
US Army
Malleable
Vein Retractor
Weitlaner
Navy
Langenbeck
Senn
Volkmann Rake
Skin Hooks
Deaver
Green Goiter
Vaginal Speculum
Richardson Retractor
Vein retractor
Senn Se nn Ret etrrac acttor
Clamping and Occluding Instruments They are used to compress blood bloo d vessels or hollow organs for hemostasis hemostas is or to prevent spillage of contents.
Crile Clamp
Straight Mosquito
Kelly Clamp
Right-Angled (Mixter /Dissector) Forceps Pean (Rochester-Pean) Clamp
Suturing Instruments Instruments
Postoperative Phase 3 Stages Immediate Immediate Stage - (1-4hrs) after surgery Intermediate Stage - (4 -24hrs) -24hrs) after after surge surgery ry Extended Stage - (1-4days) after surgery/last surgery/las t follow-up visit with the attending physician
Immediate
Postoperative Period
Respiratory Position - left lateral lateral with neck extended extended and upper arm supported on a pillow. - supine with head to side and chin extende extended d forward Check presence of gag reflex Maintain artificial airway until gag reflex ref lex returned returned Oxygen Assess rate and depth of respiration respiration Assess breath sounds Monitor for signs of atelectasis, pneumonia, pulmonary embolism
Cardiovascular Cardio v ascular ascular Assess skin and c heck capillary refill Assess peripheral edema Monitor for bleeding Assess pulse rate and rh ythm Monitor for h ypo/h ypertension Monitor for cardiac dysrh ythmias Assess for Homans Sign y
ntermediate e Post op Intermediat y
y
Period
Monitor Respiratory Status - coughing/deep breathing q 1-2 hrs - turning in bed q 2hrs - early early ambulat ambulation ion - ausc auscul ulta tatte lung lungss q 4hrs Monitor Cardio v ascular ascular Status - leg exercises q 2hrs - apply anti-emboli anti-embolicc stockin stockings gs - vital signs, color, color, temp temp of skin
Promote Fluid and Electrolyte Balance Measure I and O y
y
Promote Optimum Nutrition - maintain IV infusion as ordered - A ssess ssess return of peristalsis -Progressive increase in diet Promote Return of Urinary Function ssess ability to void/ void/ bladde bladderr distention - A ssess - Report to surgeon surgeon if client has not not voided after 8hrs post-op
Transf erring erring the
patient f rom rom the PACU
Transfer Criteria: Patient coming out of General A nesthesia nesthesia Vital signs signs are stable for at least 30mins 30mins and are within normal normal range Patient is breathing easily Reflexes Ref lexes has returned returned to normal Patient is responsive respo nsive and oriented oriented to time and place y
y y y
Patient who had regional anesthesia
y y y y y y
Sensation is restored and circulation is intact Reflexes Ref lexes has returned returned Vital signs have stabilized for at least 30mins dequate urine output A dequate Control Control of pain Control or absence of vomiting
Post-operative Complications Atelectasis - a collapse collapse of the alveoli alveoli with retained retained mucus secretions secretions - Usually Usually develop develop 1-2days post-op Aspiration - caused by inhalation inhalation of food, gastric contents, contents, water water or blood into the tracheobronc tracheobronchial hial system. - anesthetics and narcotics narcotics depress depress the CNS,causing inhibition of cough and gag reflex ref lex
3.
Pneumonia
- an inflammatory response in which cellular material
replaces alveolar gas. - may may dev develop elop 3-5day 3-5dayss post-op post-op Assessment: Dyspnea, increased RR Crackles over involved involved lung lung area Elevated temp Productive cough cough and chest chest pain Hypotension Decreased breath sounds
y y y y y y
Pulmonary Embolism - A n embolus blocking the pulmonary artery disrupting blood flow f low to to one or more lobes of the lungs ssessment: A ssessment Dyspnea Sudden sharp chest/upper abdominal pain Cyanosis Tachycardia A drop in blood pressure y y y y y y
Cardiovascular Cardiov ascular Complica Complications tions Thrombophlebitis Inflammation Inf lammation of the vein, vein, often accompanied by clot formation 7-14 days post-op y
y
y y y y y y
ssessment: A ssessment Vein V ein inflammation inf lammation ching or cramping pain A ching Vein V ein feels feels hard and cordlike cordlike and is tender to touch Elevated temperature Positive Homans sign
Intervention
hydrate hydrate patient adequately adequately void massaging massaging to calves or thighs A void standing or sitting in one pace or crossing legs leg s A A void inserting IVs into legs ssess for Homans Sign A ssess
rcu a ory
omp ca ons
Hemorrhage age -The loss loss of a large amount of blood b lood externally/internally for a short period of time Shock -Loss of circulatory fluid f luid volume caused by hemorrhage Assessment: Restlessness W eak rapid pulse Hypotension Tachypnea Cool clammy skin Reduced urine output y y y y y y
9. 10. Paralytic
Constipation
Ileus
- paraly paralysis sis of intestina intestinall peristalsis peristalsis 11. Wound Infection - oc occurs curs 3-6 days days post post op 12. Wound Dehiscence - Separation of wound edges edges on the suture line - oc occurs curs between between 5th and 8th day post op isceration 1 3. Wound Ev isceration - Protrusion of the internal internal organs and tissues through through an opening in the wound wound edges
Urinary Re Retention tention -Involuntary -Involuntar y accumulation accumulation of urine in the bladder bl adder as a result of loss of muscle tone tone - Due to to effects of anesthetics/ anesthetics/nar narcoti cotics cs ssessment: A ssessment Inability Inability to void void Restlessness and diaphoresis Lower Lower abdominal pain, distended bladder Elevated BP y y y y y
Postoperative Post operative Disc Discharge Teaching Focus on: Proper wound wound dressing dress ing Medications Diet Follow-up ollow-up visit removal removal of sutures in 7-10 days/ removal of staples in7in7-14 days ctivity levels-no lifting for 6 weeks 6 weeks A ctivity - not to lift anythin anything g (>10lbs 0lbs)) Return to work in 6-8 weeks Signs and symptoms s ymptoms of complications y y y y
y y y y
Post Chest or Lung Surgery(Pneumonectomy) Surgery(Pneumonectomy) Discharge Instruction y y
y
y y
y y
Breathin Breathing g exerci exercises ses for 3 wks rm and shoulder shoulder exercise exercise -5times - 5times a day(10-20 A rm repetitions /exercise Practice standing straight with shoulders shoul ders even on the affected side No heavy lifting of more than 20lbs for 3-6mos Stop any activity that causes causes dypnea,chest dypnea,chest pain,exces pain,excessiv sivee fatigue fatigue Obtain influenza inf luenza and pneumonia vaccine Report intermittent cough with with sputum sputum
Drains
are placed in wounds wounds only when abnormal f luid collections are present/expected A re re placed placed near near the incision incisio n site: In compartments that are intolerant to fluid accumulation In areas with large large blood supply sup ply In infected draining wounds A reas reas that have sustained large superficial tissue dissection Greatest amt is expected expected during the first 24 hrs are removed removed when amount am ount of drainage drainage decreases
Types
Gra v ity
Penrose Drain 2. T-Tube
1.
of Drains
Mechanic Jackson-Pratt Drain 2. Hemo v ac ac 1.
B. Mechanical - these are portable self contained contained closed closed wound mechanical devices devices that suction fluid f luid after collapsing collapsing them and closing closing the valve thus forcing the f luid to to be pulled into the collection chamber. examples: Hemovac Jacks Jacksonon- Prat Prattt
Types of Wound Healing First Intention Healing - W ounds are made aseptic by minor debridement and irrigation irr igation - with a minimum tissue tiss ue damage damage and tissue tiss ue reaction - W ound edges are properly approximated with suture - Granulation tissue is not visible/scar formation minimal
y
Secondary
Intention Healing
- W ounds ounds are left open to heal spontaneous spo ntaneously ly or surgically closed at a later date - Examples include burns, traumatic injuries, ulcers and suppurative infected wounds - Cavity of the wound fills with a red, soft, sensitive tissue (granulation (granulati on tissue), tiss ue), which bleeds easily easi ly,, a scar eventually eventually forms. - In infected wounds, drainage may be accomplis accomplished hed by use us e of special dressings and drains. - Produces deeper wider scar
Care and Handling of Surgical Specimens
Types of Surgical Specimen Routine specimen 1. -specimen that doesnt doesnt require immediate attention -placed in a preservation fluid -labeled and sent to Pathology Department ff conclusion of the procedure - scrub nurse should separate like specimens from different locations -specimens not immediately passed off the field should be kept moist in saline -calculi should not be placed in formalin, same with foreign bodies - amputated extremities are wrapped before sending them to the pathology/morgue
.Diagnosti osticc 2.Diagn
y
-
Specimen Spec imen
Frozen Section Requires Requires special handling and immediate examination by the pathologist ith verbal verbal report report of the findings findings communicated to W ith the surgeon surgeon during the surgical procedure Examples include breast biopsy/any organ, tumor or lesion Specimen is sent dry and is properly labeled.
Cultures y
y
y
y
y
y
re taken on a patient who comes to the OR with a A re known/suspected known/suspected infection 2 types: aerobic and anaerobic, requires different medium for growth This will determine the antibiotic that will specifically affect the microbes re obtained obtained under sterile conditio condition, n, using A re appropriate collection collection tube. Exact procedure for collecting cultures cultures for specific specif ic test will vary from each institution Must be sent to the lab immediately immediately for accurate processing
