TREATMENT ASPECTS IN PERIOPERATIVE NURSING

GUIDE MR. ABHISHEK NAIR SIR LECTURER SSCN PRESENTED BY SHIBIN JACOB M . S C N U R S I N G 1 ST Y E A R

INTRODUCTION

Perioperative nursing include

major three phases

Preoperative

Intraoperative
Postoperative

Preoperative phase
From the time of decision

making of surgical intervention to the transfer of patient to the operation room

Intra operative phase

From the time of the patient is

received in the operating room until admitted to the post anesthesia care units (PACU)

Post operative phase

From the time of admission to

PACU to the follow-up evaluation until the discharge

Surgery
The treatment of injury disease or deformity

through a invasive operative procedure

Major presenting little risk to life Minor possibility of involving risk to the life

View of a client vantage point Surgery is a major stressor for all clients Fear of the unknown is the most prevalent fear prior to surgery and is to assist nure to help client to overcome

Types of surgeries
Optional:- surgery is scheduled completely at the preference

of a patients (E.g. cosmetic surgery) Elective: - the appropriate time of surgery is at the convenience of the patient. Failure of the surgery is catastrophic (E.g. superficial cysts) Required the condition requires surgery within few weeks (E.g. cataract) Urgent the surgical intervention required attention within 24-48 hours (cancer) Emergency the situation requires immediate surgical attention without delay (E.g. accidents, gunshot injuries) Ambulatory surgeries-the surgery plans and done and the patient discharged on the day same day (EG cystoscopy)

PERI OPERATIVE NURSING

Has a continuous goal

To provide a standard of excellence in the care of the

client before during and after surgery Perioperative nursing is a client oriented and must be generated to meet the clients needs and psycho social need as the immediate physical needs

1) PREOPERATIVE NURSING

PREOPERATIVE NURSING
Role of nurse nursing baseline data evaluation of the patient before one day of surgery by carried out a postoperative interview it include not only a physical but only also an emotional; assessment previous anesthetic history and identification of known allegories or genetic problems may affect the surgical outcome Ensuring the preadmission tests arranging the appropriate consulting services providing a preoperative education

PREOPERATIVE PHYSIOLOGIC ASSESSMENT

Informed consent

assessment Age Nutritional status Fluid and electrolyte balance Respiratory status Medications (previous use) Cardiovascular status Renal & hepatic status Alcohol or drug abuse Neurological, musculoskeletal and integlumetary status Endocrine and immunological status

Common laboratory tests

Hemoglobin & hematocrit / complete CBC

Blood typing and cross matching

RFT (renal function tests) LFT (Liver function tests) Coagulation profile including PT & APTT (

prothrombine time & activated partial thromboplastin time Urine analysis X RAY VIRAL MARKERS (HIV, HbSCG & HCV

Assessment of client psychological condition

The psychological condition of a client can have

stronger influence than does the physical condition, Encourage the client to express their feelings and fears about the surgery and receiving anesthesia Observe the client for nonverbal clues indicating anxiety To reduce the anxiety explain the client what will be happening throughout the surgical experience

Psychosocial health assessment

Cultural beliefs can influence persons perception of

surgery The client should be provided the opportunity to express their spiritual values and beliefs Patient education

Purpose of pre operative teaching To answer questions and concerns about the surgery To ascertain the needs or desire for additional information To provide information in a manner of conductive to learning

General instructions
Preoperatively the patient will be instructed in the

following postoperative activities this will allows a chance for practice and familiarity Incentive spirometry Coughing Turning Foot and leg exercises

Physical preparation
Identifying the client and verifying the operative

procedure Preparing the operative site Checking and recording the vitals Assisting in bath and gowning Verifying allergies and reordered NPO Identifying sensory defects of the client

PHARMACOLOGICAL ASPECTS IN PREOPERATIVE

Preoperative medications Opiates- such as morphine(ROXONOL)and meperidine are given to relax the patient and potentiate the anesthesia Anticholernegics - atropine, glycopyrolate given to reduce primary top reduce respiratory tract secretions and to prevent severe reflexes slowing of heart doing the anesthesia Barbiturate/ tranquilizers given in the night for a peaceful sleep Prophylactic antibiotics _ administered just before the surgery ST skin test

Final check list

Identification and verification

Review of patient record

Consent form Patient preparation

Transporting patient to operation room

Preoperative medicines Psychological support to patients family

2) INTRA OPERATIVE PHASE

Sterile Members 1) Surgeon First assistant (physician or registered nurse who assist surgeon in performing homeostasis, tissue retraction and wound closure Scrub nurse ( An LP/VN/RN or a surgical technologist who preparers and maintains integetery safety and efficiency of sterile fields throughout the operation Nonsterile members Anesthesia provider Circulating nurse R N responsibility for management of personal, equipment supplies, environment and communication throughout the procedure

 Sterile field

Asepsis
Elements of aseptic techniques Sterile gowns and glows Sterile drapes Sterilization of items used in sterile tables

Intraoperative nursing care

1. 2. 3. 4. 5.

6.

Risk of infection related to invasive procedure and exposure to pathogens Risk of injury related to possibility of positioning during surgery Risk of injury related to foreign bodies in adversely left in the wound Risk of injury related to chemical physical and electrical hazards Risk of impaired tissue integrity Risk of alteration in fluid electrolyte balance related to abnormal blood loss and NPO status

Anesthesia
Conscious sedation

general anesthesia Four stages

Induction Maintenance Emergence Recovery

Regional anesthesia Local Nerve block Spinal or epidural

 Local anesthesia

Consists of local volume of fluid is administered in the skin for minimal procedures it will become the patient senseless for sometime E.g. xylocine, lignocane, loxicard bupivaccine Spinal anesthesia Local anesthesia is injected to lumbar or intrathecal space. Anesthesia blocks conduction in spinal nerve roots and dorsal ganglia, paralysis and analgesia occur below the level of injection. Agents used procaine, tetracaine, lidocine, and bupivacaine Epidural anesthesia Achieved by injecting the local anesthesia in to the epidural space by the way of lumbar puncture Agents used are chloroprocaine, lidocaine and bupivacine Peripheral nerve block Achieved by injecting a local anesthesia or anesthetize n to the surgical site

Complications
Hypo ventilation

Inadequate ventilator support to the after paralyzing of respiratory muscles and ensuring coma Oral trauma Broken teeth, oropharyngeal or laryngeal trauma due to difficult intubation Hypotension Due to the blood loss or effect of anesthesia Cardiac dysarythemia Due to the pre exposing cardio vascular compromise electrolyte imbalance, or untoward reactions to anesthetic agents Hypothermia

Due to the exposure to the cool atmosphere in the Operation Theater and table Due to loss of thermoregulation capability due to anesthetic agents

Peripheral nerve damages

Due to the improper positioning of the patient Malignant hyperthermia

Malignant hyperthermia
This is a rare reaction to anesthetic agents like

enflurane, fluroxene, and halothane Such drugs like theophylline, aminophylline, epinerphine, and digoxin Inherited muscle disorder (muscle dystrophy) or a history clinical manifestations

Tachycardia Pseudotetany Muscle rigidity High fever Cyanosis Heart failure CNS damage

management
Discontinue the inhalant anesthesia

Dantroline (dantrium) + oxygen + dextrose 50,

diuretics, antiarrhythics, sodium bi carbonate, and hypothermic measures (cooling blanket, iced saline solution, iced saline lavage of stomach, bladder, or rectum

Nursing process
Interventions Safety Advocacy Verification Counting instruments sponges needles

Evaluation Expected Unexpected Documented Informing client family Surgical waiting room Ongoing update by OR team

3) POSTOPERATIVE PHASE

 ensure the continuity of care from Intraoperative phase to the

immediate postoperative phase in circulating nurse anestheologist or nurse anesthesia with a through report to PACU nurse IT include

Type of surgery performed & Intraoperative complications Type of anesthesia Drains and type of dressing No of suturing & type Presence of ET tube and type of oxygen to be administered Presence of lines and locations (central, peripheral, arterial line) Catheterization & tubes Administration of colloids blood crystalloids and electrolyte balance Drug allergies Preexisting medical conditions Post op investigations

Nursing assessment
Before receiving the patients itself the nurse should

ensure his/her unit should ready to receive the patient Checklist

Functioning of oxygen and ventilator Functioning of suction apparatus Cardiac monitor should be ready or not I V access are prepared Check for a crash cart

Assessment after receiving patient

Verify the patient identity

The operative procedure and the surgeon who

performed the procedure Evaluate the following signs and verify their level of stability with the anestheolgist

Respiratory status (airway) Breathing Circulation Temperature, pulse, respiration Oxygen saturation of the blood Hemodynamic status

 Determine the swallowing gag reflexes and LOC

including patients response to stimuli Evaluate lines, tubes, drains, estimated blood loss condition of wound (open closed packed ) Medications used , infusions, including the transfusions, and output) Evaluate the level of consciousness and comfort and safety measures such as pain protective reflexes Perform safety checks to verify that side rails are in placed and restrains are properly applied Evaluate activity status, movements extremities Revise physician orders

Nursing diagnosis
Ineffective airway clearance related to effect of anesthesia Impaired gas exchange related to ventilation perforation

imbalance Ineffective tissue perforation related to cardiopulmonary (hypertension) Risk of imbalanced body temperature related to medications sedation and cool environment Risk of fluid imbalance related to related to blood loss NPO status and vomiting and indwelling tubes Pain related to surgery incision and trauma Risk of injury related to sensory dysfunction and physical environment Disturbed sensory participation related to effects of medications and anesthesia

Evaluation or expected outcomes

Breath easily

Lung sound clear

Vital signs stable Thermoregulation stable

Intake output balance

Report of adequate pain control Wound edges intact without drainage

Position comfortably and carefully

Quiet reassuring environment maintained

Post operative complications

Nausea vomiting Pain Constipation and gas cramps Thirst Shock Hemorrhage Deep vein thrombosis Pulmonary embolism Urinary retention Intestinal obstruction Hiccups Wound infection Wound dehiscence and evisceration Psychological disturbances

Depression
Delirium

NAUSEA AND VOMITING

Causes Occurs due to the

complication of in halation anesthesia Result from an accumulation of fluids in stomach before peristaltic movements return Due to the abdominal distention Psychological induction Adverse effects of opiods

THIRST
Inhibitions of secretions by preoperative medications like glycopyrolate fluid loss, blood loss, dehydration due to the NBM

CONSTIPATION AND GAS CRAMPS

trauma and

manipulation of the bowel during the surgery local inflammation, peritonitis, abscess long standby bowel problem this may leads bowel impaction

PAIN
This is the most important and common symptoms in which patients exhibits a

feeling of distress stimulation of or trauma to certain nerve ending as a result causing pain Management Reduce the anxiety due to anticipation of pain Teach the patient about pain management Review analagics with patient and reassure the relief with available quickly Establish a trusting relationship with the patient Pharmacological management Parental analgesia for 2-4 days initially and later the dose decreased to oral analgesic The nurses responsibility to make ensure the drug is given safely and assessed efficiency Other type of pain management Patient controlled analgesia Epidural analgesia

SHOCK
It is a response of the body to a decrease in circulatory

volume of blood, tissue perforation is impaired culminating eventually in the cellular hypoxia and death Management

Arrange and transfusion of blood if necessary Accurately measure any blood loss and monitor all fluid intake and output Anticipitate the progression of symptoms in earliest manifestation Monitor vital signs as per institutional policy until they are stable

HEMORRHAGE
Hemorrhage is a copious escape of blood from a blood

vessel Classified as 1) general 2) according to blood vessel 3) according to location

General
Primary occurs in the time of operation Intermediately with in the first few hours of the operation after the surgery immediately after the blood pressure comes normal Secondary occurs some times after the surgery due to ligatures slip from the blood vessel and erosion of the blood vessel

According to blood vessel

Capillary slow general oozing from the capillaries Venous - bleeding in dark color blood Artery bleeding that sprats and bright red in colour

According to location
External - visible bleeding present in surface Internal (concealed)- bleeding cannot seen

DEEP VEIN THROMBOSIS

DVT occurs in the pelvic

veins and deep vein of lower extremities in post operative patients most common in hip surgeries and abdominal surgeries

PULMONARY COMPLICATIONS
Atelectasis-incomplete expansion of the lungs or a

portion of lung with in 48 hours of the surgery Aspiration caused by the inhalation of foods or gastric contents or blood to the trachea bronchial system Pneumonia this is a inflammatory response in which cellular materials replaces alveolar gases Pulmonary embolism caused by the obstruction of one or more arterioles by an embolous originating in some ware in the venous system

 URINARY RETENTION INTESTINAL OBSTRUCTION Bowel obstructs result in partial or complete

impairment to forward flow of intestinal contents HICCUPS Due to intermittent spasm of diaphragm causing hic that resulting from vibration of closed vocal cord as air rushes suddenly in to the lungs WOUND INFECTION It is the second most nosocomial infections the infection may limited to the surgicial site 60% to 80% or affect systematically w

WOUND DEHISCENCE & EVISCERATION

Due to the inadequate

sutures or excessively tight sutures the rupture of skin and abdominal organs are protududed out through the ruptured skin

WOUND CARE (DRESSING)

The management of the wound is done by the

physician or his assistant by strict sterile and aseptic techniques Purpose

To protect the wound from the infection To splint or immobilize the wound To protect the wound from mechanical injury To prevent contamination To absorbe drainage To inhibit or kill microorganisms by using dressing with antiseptic r anti microbial properties

Drains
The drains are the tubes

that kept collecting the discharges from in wound or surgical site Purpose

Drains are placed only when abnormal fluid collection is present or expected Collection of fluids that cause harmful to the wound

PATIENT EDUCATION
Before the discharge of the patient he should

thoroughly teach the techniques of wound care Report immediately to the health care provider if the following signs will occur Reduces or marked swelling surrounding the tissues Pus or usual discharge Chills or fever more than 100 Keep suture line clean and neat never vigorously rub near the incision site

POST OPERATIVE DISCHARGE INSTRUCTION

Rest and activity eating sleeping wound healing bowels bathing clothing driving bending and lifting

SUMMARY