PERIOPERATIVE NURSING
Learning objectives: Discuss surgery and identify the different classification of surgical procedures Recognize several diagnostic tests used in the perioperative period Identify medications and anesthetics used for the surgical client and describe nursing considerations for them Classify appropriate nursing care for the client in the preoperative, intraoperative, and postoperative phases of perioperative nursing Identify the members of the surgical team and discuss functions of each Discuss different kinds of methods of sterilization Define anesthesia and ascertain its different stages and classification Identify and differentiate the 3 main zones of the OR Identify and organize different instruments, sutures and other equipment used during surgery Be familiar with the WHOs Surgical Safety Checklist and find out how it is being utilized by the surgical team
Terms to Remember Surgical conscience - an individual's inner awareness of aseptic principals and adherence to aseptic technique in all situations; professional honesty. Asepsis - absence of pathogens Modes of Contamination - ways by which infecting organisms are transmitted to sterile objects Surgical Scrub - process of reducing the number of microorganisms from the hands and arms to a safe level before participating in an operative procedure. Sterile - free of all microorganisms Transient Flora - organisms present on the epidermis which have been picked up through contact with other objects Infection - invasion of the body by disease producing microorganisms and the reaction of the tissues of their presence and their toxins Strike - Through Contamination - transmission of microorganisms to a sterile field by moisture that has penetrated the sterile barrier Normal Flora - bacterial population peculiar to a particular body location; made up of transient and resident flora Contamination - to introduce microorganisms to a sterile field
SURGERY An ancient medical specialty that uses operative manual and instrumental techniques It involves cutting and dissection of tissues to diagnose of treat illness, injury, deformity Although it is a medical treatment, a nurse assumes an active role in caring for the client before, during and after it
Classification of Surgery 1. According to purpose Classification Diagnostic Ablative Definition To determine or confirm a diagnosis To remove diseased tissue, organ or extremity Build tissue/organ that are congenitally absent Rebuilding of a damaged tissue or organ To alleviate the symptoms only To replace organs/tissue to restore function Excision biopsy, gastroscopy Appendectomy, hysterectomy, amputation Examples
Constructive
Cleft lip/palate repair
Reconstructive Palliative Transplant
Skin grafting after a burn, total/partial joint replacement Bowel resection in a client with terminal cancer Heart, corneal, liver, kidney transplant
Amputation - involves cutting off a body part, usually a limb or digit Replantation - involves reattaching a severed body part Cosmetic - done to improve the appearance of an otherwise normal structure
2. According to Degree of risks Classifica tion Minor Definition Examples
Minimal physical assault with minimal risk Recovery time is short Most often done as an outpatient basis Complications are rare Shorter time of procedure
Hernia repairs Appendectomy Dilatation and curettage Removal of skin lesions
Major
Extensive physical assault and/or serious risk Recovery time is lengthy Often involves a stay in the hospital, or even in the ICU Involves vital organs Higher risks for complications Longer time of surgery/procedure
Organ transplantation Exploratory laparotomy Cataract extraction Open heart surgeries Total abdominal hysterectomy
3. According to Urgency Classification Emergent Definition Must be done without delay. Must be performed immediately Patient needs prompt attention. Must be done within 24-30 hours Patient needs to have surgery. Plan within few weeks or months Patient should have surgery. Failure to have surgery not catastrophic Decision to have surgery depends on the client Examples Severe bleeding, ruptured aneurysm
Urgent
Acute gallbladder infection, kidney/ureteral stones
Required
Cataracts, thyroid disorders, BPH
Elective
Simple hernia repair, repair of vagina or skin scars
Optional
Cosmetic surgery
4. According to Body Parts / Clients Involved Neurosurgery Pediatric surgery Obstetrics and Gynaecology Opthalmology ENT-HNS Thoracic surgery Cardiac surgery Gastrointestinal surgery Colorectal surgery Orthopedics Hand surgery Spine surgery Vascular surgery Urology
5. According to Degree of Invasiveness Minimally invasive surgery - involves smaller outer incision(s) to insert miniaturized instruments within a body cavity or structure. (ex: laparoscopic surgery, angioplasty) Open surgical procedure - requires a large incision to access the area of interest.
6. According to Equipment used Laser surgery - involves use of a laser for cutting tissue instead of a scalpel or similar surgical instruments. Microsurgery - involves the use of an operating microscope for the surgeon to see small structures. Robotic Surgery - makes use of a surgical robot to control the instrumentation under the direction of the surgeon. Laparoscopic surgery - involves smaller outer incision(s) to insert miniaturized instruments within a body cavity or structure.
7. According to the Length of Stay in a Healthcare Facility Ambulatory Sugery client is discharged generally the same day as the surgery is performed
Inpatient Surgical Care - client is admitted to the hospital setting for surgical care
Perioperative nursing
It includes a wide variety of nursing functions associated with the patients surgical experience It addresses the nursing roles relevant to three phases of surgical experience: o Preoperative o Intraoperative o Postoperative Each phase begins and ends at a particular point in the sequence of events that constitutes the surgical experience
Association of periOperative Registered Nurses (AORN) AORN is a non-profit membership association that represents the interests of more than 160,000 perioperative nurses by providing nursing education, standards, and clinical practice resources
Perioperative Nursing in the Philippines
Operating Room Nurses of the Philippines (ORNAP) LIFE PURPOSE: To promote the highest professional standard of Perioperative Nursing in the Philippines
ORNAP was founded on 1973 through the efforts of the OR Nurse Supervisors in Metro Manila, led by Mrs. Consuelo Gomez Arabit, Dr. Antonio Oposa (president of the Philippine College of Surgeons) and Johnson & Johnson (Phils.), Inc. Mrs. Consuelo Gomez Arabit considered as the Mother of Modern Perioperative Nursing in the Philippines The Consuelo Gomez - Arabit Award for Excellence in Perioperative Nursing was named after her
Preoperative Phase
The period of time that begins when the decision to proceed with surgical intervention is made, and ends with the transfer of the client onto the OR table
Nursing Activities during Preoperative Phase 1. Pre-admission Testing a. b. c. d. e. f. Initiates initial preoperative assessment Initiates teaching appropriate to patient needs Involves family in interview Verifies completion of preoperative testing Verifies understanding of surgeon specific preoperative orders Assesses patients needs for postoperative care
2. Admission to the Surgical Unit a. Completes preoperative assessment b. Assesses for risks for postoperative complications c. Reports unexpected findings or any deviations from normal d. Verifies that that operative consent has been signed e. Coordinates patient teaching with other nursing staff f. Reinforces previous teaching g. Answers patients and familys queries h. Develops a plan of care
3. In the Holding Area a. Assesses clients status, baseline pain and nutritional status b. Reviews chart c. Identifies patient d. Verifies surgical site and marks site per institutional policy e. Administers medications as prescribed f. Takes measures to ensure patient comfort g. Provides psychological support
INFORMED CONSENT VOLUNTARY CONSENT Valid consent must be freely given, without any coercion The client can personally sign the consent if he/she is of legal age and mentally capable INCOMPETENT PATIENT an individual who is not autonomous and cannot give or withhold consent (minors, cognitively impaired, mentally ill or neurologically incapacitated An Informed Consent should be in writing, and should contain the following: Explanation of the procedure and its risks Description of benefits and alternatives An offer to answer questions about the procedure Instructions that the patient may withdraw consent A statement informing the client if the protocol differs from clients customs and beliefs / customary procedure
Preoperative Medications Antibiotics (Cephalosporins) Benzodiazepines - Midazolam (Versed) - Diazepam (Valium) - Lorazepam (Ativan) Antiemetics - Metoclopramide (Reglan) - Droperidol (Inapsine) Opioid Analgesics - Morphine (Morphine) - Fentanyl (Sublimaze) - Oxycodone (Roxicodone) - Hydrocodone (Vicodin) - Meperidine (Demerol)
- Codeine - Tramadol (Ultram)
Non-opioid Analgesics / Antacids - Sodium citrate (Bicitra) H2 Receptor Antagonists - Cimetidine (Tagamet) - Famotidine (Pepcid) - Ranitidine (Zantac) Gastric Acid Pump Inhibitors - Lansopazole (Prevacid) - Omeprazole (Prilosec) Anticholinergics - Atropine Sulfate - Scopolamine
Laboratory Tests for Perioperative Assessment Test Hgb / Hct WBC Platelet Urinalysis CO2 (K+) (Na+) (Cl-) PT / PTT Significance of Increased Values DHN, polycythemia vera Infectious/inflammatory processes, leukemia Malignancies, polycythemia vera Varied Emphysema, chronic bronchitis, asthma Kidney dysfunction, DHN Kidney dysfunction Kidney dysfunction Defect in Mechanism for blood clotting, anticoagulant therapy, side effect of other drugs affecting clotting time Significance of Decreased Values excessive blood loss, anemia Immune deficiencies Clotting deficiency disorders Varied Metabolic acidosis, hyperventilation Side effects of diuretics, vomiting vomiting Side effects of diuretics, vomiting
Hypercoagulability of the blood may lead to thrombus f
Other Common Diagnostic Procedures done Preoperatively Chest X-ray X-ray of the affected part of the body MRI CT Scan ECG Ultrasonography
INTRAOPERATIVE PHASE
The period of time from when the patient is transferred to the operating room table to when he/she is admitted to the Postanesthesia Care Unit (PACU)
Three Main Zones of the Operating Room UNRESTRICTED ZONE area in the OR that interfaces with other departments. Common street/casual clothes are allowed here. It includes dressing area, quarters, reception and holding area SEMIRESTRICTED ZONE scrub attire is now required here. Includes the Central Sterile Supply Department (CSSD) RESTRICTED ZONE scrub attire, together with surgical masks, shoe covers, and caps are now required inside this area. Includes the main OR and sterile areas
THE SURGICAL TEAM 1. THE CLIENT The center / focus of the team is on the client him/herself He/she is subject to several risks, infection, and temporary and permanent complications 2. SURGEON He/she performs the surgical procedure and heads the surgical team As the head of the team, he is responsible for all medical actions and judgments
3. ASSISTANT SURGEON Works closely with the surgeon in performing the procedure Their number varies according to the complexity of the procedure Performs such duties as: exposing the operative site, retracting nearby tissue, sponging, suctioning blood, ligating bleeders, suturing, or helping suture the surgical wound 4. ANESTHESIOLOGIST Relieves the surgeons responsibility for the clients general well being, thus, allowing the surgeon to focus on the general aspects of the procedure Evaluates the client preoperatively, administers appropriate anesthesia, or other required medications, Tranfuses blood or other blood products, infuses IV fluids, continuously monitors clients physiological status Alerts the surgeon to developing problems Supervises clients recovery in the PACU 5. SCRUB NURSE Performs the surgical hand scrub Sets up sterile tables Prepares instruments, sutures, ligatures and other equipment needed Assisting the surgeon and assistant/s during the procedure, by anticipating the instruments and supplies being required Counts all needles, sponges and needles, together with the circulator Labels tissue specimen obtained during surgery 6. CIRCULATING NURSE Manages the OR and protects the clients safety and health by monitoring the activities of other members of the surgical team Verifies the consent, coordinates with the team, Ensuring proper cleanliness, temperature, humidity, and lighting inside the OR Monitors aseptic technique to avoid breaks
Other Functions of a Circulator Before an operation Checks all equipment for proper functioning such as cautery machine, suction machine, OR light and OR table Make sure theater is clean Arrange furniture according to use Place a clean sheet, arm board (arm strap) and a pillow on the OR table Provide a clean kick bucket and pail Collect necessary stock and equipment Turn on aircon unit Help scrub nurse with setting up the theater Assist with counts and records During the Induction of Anesthesia Turn on OR light Assist the anesthesiologist in positioning the patient Assist the patient in assuming the position for anesthesia Anticipate the anesthesiologists needs If spinal anesthesia is contemplated: Place the patient in quasi fetal position and provide pillow Perform lumbar preparation aseptically Anticipate anesthesiologists needs After the patient is anesthetized Reposition the patient per anesthesiologists instruction Attached anesthesia screen and place the patients arm on the arm boards Apply restraints on the patient Expose the area for skin preparation Catheterize the patient as indicated by the anesthesiologist Perform skin preparation During Operation Remain in theater throughout operation Focus the OR light every now and then Connect suction, etc. Position kick buckets on the operating side Replenishes and records sponge/ sutures Ensure the theater door remain closed and patient s dignity is upheld Watch out for any break in aseptic technique End of Operation Assist with final sponge and instruments count Signs the theater register Ensures specimen are properly labeled and signed After an Operation Hands dressing to the scrub nurse Helps remove and dispose of drapes Helps to prepare the patient for the recovery room Assist the scrub nurse, taking the instrumentations to the service (washroom)
Other Members of the Surgical Team 1. The Registered Nurse First Assistant (RNFA) -They practice under direct supervision of the surgeon -Their responsibilities may include handling and cutting tissues, providing exposure of operative field, suctioning and suturing 2. Certified Registered Nurse Anesthetist (CRNA) - a nurse who specializes in the administration of anesthesia - an advanced practice registered nurse (APRN) who has acquired graduate-level education and board certification in anesthesia. the
The Surgical Environment Must be stark in appearance and have a cool temperature Behind double doors Access is only limited to authorized personnel Situated in a central location Should have special air filtration devices to screen out contaminants, dusts and air pollutants Principles of Aseptic Technique Patient is the center of the sterile field Draped tables are sterile only at table height Sterile persons keep within sterile areas A sterile field is created as close as possible to the time of use Sterile areas are continuously kept in view Microorganisms must be kept to an irreducible minimum Destruction of the integrity of a sterile field results in contamination As a sterile package is opened, the EDGE of the wrapper are considered UNSTERILE UNSTERILE persons avoid sterile areas Persons that are sterile touch only STERILE items or areas; persons who are NOT STERILE touch only UNSTERILE items or areas. When youre in DOUBT, THROW it out!
Health Hazards inside a Surgical Environment Laser risks Electric Fires Electrocution Exposure to blood and body fluids Latex allergy Radiation Pricks/ Needlestick injuries Foreign bodies left inside the clients cavity Exposure to chemicals
Surgical Scrub Scrubbing that includes hands and forearms should be done every procedure and take at least 5-10 minutes. Anatomical Stroke method Purpose: Remove dirt, skin oils and transient microorganisms from hands and forearms Increase client safety by reducing microorganisms on the surgical personnel Leave an antimicrobial residue on the skin, to inhibit growth of microbes for several hours
Gloving Avoid contact of sterile gloves with ungloved hands Never let the fingers extend beyond the stockinette (close) Touch only the cuff of the glove with ungloved hand (open) If contamination occurs during either procedure, both gown and gloves must be discarded Removing Gloves 1. Remove gloves carefully to prevent splattering. 2. Grab the outside wrist of one glove with your other hand. Turn glove inside out as you remove it. 3. Drop the inverted glove into the other hand and slide your bare finger under the second glove to invert it and trap the first glove inside. Surgical Counts Sponge counts should occur as follows: (1) Prior to the skin incision (2) When closure of peritoneum is initiated or any first layer of a cavity or (3) When closure of fascia is initiated or layer before subcutaneous (4) As soon as skin closure is initiated Instances in which additional sponge counts should occur include: (1) Intraoperative additions of sponges (2) Change in circulator The initial count should be recorded on the count sheet by the circulator as reference to ensure a sponge is not retained. Intraoperative additions of sponges should be recorded on the count sheet and added to the initial count.
Draping The procedure of covering a patient and surrounding areas with a sterile barrier to create and maintain a sterile field during a surgical procedure Its purpose is to eliminate the passage of microorganisms between sterile and non-sterile areas
Skin Preparation Usually includes shaving on the skin of the proposed incision site (depends on the order of the surgeon) Shaving is more often performed in the surgical unit Also includes cleansing the area of incision site with a prescribed antimicrobial Additional skin cleansing before bringing the client into OR can also be done in the surgical unit. Patient Positioning Proper position of the clients while on the OR table exposes the operative site and provides access for anesthesia administration It is also imperative to prevent injury on the part of the client Improper positioning can lead to muscle and joint injuries, as well as nerve damage Common Surgical Positions Supine Lithotomy Prone Semisitting Lateral/lateral chest Jacknife
Common Surgical Instruments 1. 2. 3. 4. 5. 6. 7. 8. 9. Clamping instruments (Kelly hemostatic, mixter, mosquito,) Grasping instruments (allis, babcock) Forceps (adson, DeBakey) Orthopedic instruments (bone rongeurs, bone saw, gigli) Dilators (Hegars) Needle holders Probing instruments (grooved director) Cutting instruments (mayo curved & straight, metzenbaum, scalpel) Retractors Self-retaining (gelpi, weitlaner, balfour) Non-self retaining (deaver, Richardson, army-navy)
Surgical Needles CLASSIFICATION 1. By the Shaft 1. Straight used generally on the skin 2. circle (internal organs) 3. 3/8 circle (skin, plastic surgery) 2. By the Eye a. Traumatic with eye present (needs threading) b. Atraumatic needle and suture in one unit
3. By the Point a. Cutting (used on tough tissues) b. Round (commonly used in internal organs) c. Tapercut, reversed cutting d. Blunt tip SUTURE A medical device used to hold body tissues together after an injury or surgery. It generally consists of a needle with an attached length of thread. 2 Main Classifications of Sutures ABSORBABLE Biological catgut, plain gut Synthetic polyglycolic acid (Vicryl, Monocryl, Prolene) NON-ABSORBABLE Silk, nylon, cotton Colors of packages of sutures Vicryl VIOLET Chromic / Catgut BROWN Plain Gut YELLOW Prolene BLUE Monocryl RED Silk BLUE
Sterilization 1. Moist Heat 1. Steam under pressure (autoclave). Usually operated at 250F at 15 psi for 45 minutes 1 hour 2. Dry-heat (hot-air oven) operating temperature: 310-338 degrees F 2. Ethylene Oxide (EO) Gas - used to sterilize objects sensitive to temperatures greater than 60 C and / or radiation such as plastics, optics and electrics. 3. Chemical/Liquid Sterilants (glutaraldehyde solution)
The Surgical Experience ANESTHESIA Meant the condition of having sensation (including the feeling of pain) blocked or temporarily taken away. It is a pharmacologically induced and reversible state of amnesia, analgesia, loss of responsiveness, loss of skeletal muscle reflexes or decreased fight-or-flight response, or all simultaneously. This allows patients to undergo surgery and other procedures without the distress and pain they would otherwise experience.
4 Stages of Anesthesia Stage 1 Beginning Anesthesia As the client breathes in the anesthetic mixture, dizziness and a feeling of detachment may be experienced The client may have roaring, ringing and buzzing in the ears During this stage, noises are exaggerated Unnecessary noises and motions must be avoided during this stage Stage 2 - Excitement Characterized variously by struggling, shouting, talking, laughing or crying, is often avoided if the anesthetic is administered smoothly and quickly The pupils dilate rapid pulse rate Irregular respirations Uncontrolled movements Stage 3 Surgical Anesthesia Reached through continuous administration of anesthetic vapor or gas Client is unconscious and lies quietly on the table Small pupils, contract when expose to light Regular pulse rate and respirations Pink or slightly flushed skin This stage may be maintained for several hours Stage 4 Medullary Depression Reached when too much anesthesia is administered Shallow respirations Weak, thready pulse Widely dilated pupils Without prompt intervention, death rapidly follows
Physical Status Classification System Used to describe patients general status and identify potential risks during surgery P1 A normal healthy client P2 a client with mild systemic disease, without functional limitations P3 a client with severe systemic disease associated with functional limitations P4 a client with an incapacitating systemic disease that is a constant threat to life P5 a moribund client who is not expected to survive for 24 hours with or without operation P6 client is brain dead and is being prepared as an organ donor
Types of Anesthesia GENERAL ANESTHESIA - a medically induced coma and loss of protective reflexes resulting from the administration of one or more general anaesthetic agents.
- A variety of medications may be administered, with the overall aim of ensuring hypnosis, amnesia, analgesia, relaxation of skeletal muscles, and loss of control of reflexes of the autonomic nervous system. Types of General Anesthesia Inhalation (Halothane, Isoflurane, Sevoflurane, Desflurane) Intravenous (Ketamine, Propofol, Thiopental Na) Regional Anesthesia anaesthesia affecting only a large part of the body, such as a limb or the lower half of the body. It can be in form of Epidural, Spinal (L4-L5) or combination of both Common regional anesthetics include: Bupivacaine (sensorcaine), Tetracaine (pontocaine), Procaine (novocaine) Local Anesthesia Direct injection of the anesthetic into the tissue of the planned incision site Lidocaine (Xylocaine ) is the most common local anesthetic Its advantages include: Simple, economical Equipment needed is minimal Post-operative recovery is brief Ideal for short and superficial surgical procedures Other Medications Used Intraoperatively Opioid analgesics Morphine sulfate, fentanyl, demerol, Depolarizing Muscle Relaxants succinylcholine (anectine) Nondepolarizing Muscle Relaxants - Atracurium (tracrium), Rocuronium (zemuron), Vecuronium (norcuron), Pancuronium
The World Health Organizations Surgical Safety Checklist
The checklist identifies three phases of an operation, each corresponding to a specific period in the normal flow of work: Before the induction of anaesthesia (sign in), before the incision of the skin (time out) and before the patient leaves the operating room (sign out). In each phase, a checklist coordinator must confirm that the surgery team has completed the listed tasks before it proceeds with the operation.
Potential Intraoperative Complications Nausea and Vomiting Anaphylaxis Hypoxia Hypothermia Malignant Hyperthermia Disseminated Intravascular Coagulation
Nursing Interventions Reduce Anxiety Protect from injury Prevent positioning injury Serve as patients advocate Monitor for further complications
POSTOPERATIVE PHASE Begins with the admission of the patient into the PACU, and ends after a follow-up evaluation in the clinical setting or home
Postanesthesia Care Unit Located adjacent to OR Designed to provide care for patients recovering from anesthesia, whether it be general anesthesia, regional anesthesia, or local anesthesia. Must be kept quiet, clean and free of unnecessary equipment TRANSFERRING OF PATIENT TO PACU IS RESPONSIBILITY OF THE ANESTHESIOLOGIST/ANESTHETIST
Phases of Postanesthesia care Phase I PACU intensive nursing care is provided Phase II PACU client is prepared for self-care and care in the hospital or extended care setting Phase III PACU client is ready for discharge from PACU Nursing Management in the PACU Assess the Patient Maintain a patent airway Maintain cardiovascular stability Relieve pain and anxiety Controlling nausea and vomiting
Indicators for Discharge from PACU o o o o o o o Stable V/S Orientation to time, place and person Uncompromised pulmonary function Pulse oximetry readings indicating adequate blood O2 saturation Urine output of 30 ml/hour Absent nausea and vomiting, or under control Minimal pain
STAGES OF WOUND HEALING STAGE I (surgery-day 2) inflammatory process occurs to prepare surrounding tissues for healing STAGE II (day 3-14) fewer WBCs present, collagen tissue forms STAGE III (day 15-week 6) collagen tissues continue to strengthen the wound STAGE IV (several months-1 year) as wound tissue constricts, the scar becomes flat, smaller and white
Wound Collection Devices HEMOVAC JACKSON PRATT PENROSE
Immediate Postoperative Nursing Interventions Assess breathing, and administer supplemental O2 if prescribed Monitor V/S Note skin warmth, moisture or color Assess surgical site, and wound drainage system Assess LOC, orientation, ability to move extremities Assess pain level and characteristics Assess IV sites for patency Assess urine output Reinforce the need to begin DBCE and leg exercises Administer analgesics as prescribed Position patient to enhance comfort, safety and lung expansion
Common Postoperative Complications CARDIOVASCULAR shock, hemorrhage, deep vein thrombosis, pulmonary embolism RESPIRATORY pneumonia, atelectasis, WOUND COMPLICATIONS dehiscence, eviscreration, wound infection ELIMINATION constipation, urinary retention SPINAL HEADACHE MALIGNANT HYPERTHERMIA
