notes for perioperative nursing

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    Perioperative Nursing

    Definition of Terms

    Surgery is any procedure performed on the human

    body that uses instruments to alter tissue or organ integrity.

    SURGEON - A physician who treats disease, injury, or deformity by

    operative or manual methods.

    *A medical doctor specialized in the removal of organs, masses

    and tumors and in doing other procedures using a knife (scalpel)

    STERILE- free from living germs or microorganisms; aseptic: sterile

    surgical instrumentsASEPSIS - The state of being free of pathogenic microorganisms.

    SEPSIS -a toxic condition resulting from the spread of bacteria or

    their toxic products from a focus of infection

    DISINFECTANT- any chemical agent used chiefly on inanimate

    objects to destroy or inhibit the growth of harmful organisms.

    ANTISEPTICS- is a substance that prevents or arrests the growth

    or action of microorganisms either by inhibiting their activity or by

    destroying them.

    STERILIZATION

    -the destruction of all living microorganisms, as pathogenic

    bacteria, vegetative forms, and spores.

    BACTERIOSTATIC-Capable of inhibiting the growth or

    reproductionofbacteria.

    BACTERICIDAL- Capable of killingbacteria.BACTERIOCIDES- is a substance that killsbacteria.Bactericides

    are eitherdisinfectants,antisepticsorantibiotics

    Prefixes and Suffixes

    PREFIXES

    Supraabove ; beyond

    Orthojoint

    Cholebile or gall

    Cystobladder

    Encephalo- brain

    Enterointestine

    Hystero uterus

    Mastbreast

    Meningomembrane; meninges

    Myomuscle

    Nephrokidney

    Neuronerve

    Oophorovary

    Pneumolungs

    Pyelokidney pelvis

    Salphingofallopian tube

    Thoracochest

    Visceroorgan esp. abdomen

    SUFFIXES

    Omatumor ; swelling

    Ectomyremoval of an organ or gland

    Rhapysuturing or stitching of a part or an organ

    Scopylooking into

    Ostomymaking an opening or a stoma

    Otomycutting into

    Plastyto repair or restore

    Celetumor ; hernia ; swelling

    Itisinflammation of

    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.

    Phases

    Preoperative phasebegins when the decision to havesurgery is made and ends when the client is transferred to

    the OR table.

    Intraoperative phasebegins when the client istransferred to the OR table and ends when the client is

    admitted to the PACU.

    Postoperative phasebegins with the admission of theclient to the PACU and ends when the healing is complete.

    Fundamental purposes of the O.R. :

    It is a place. . .

    To correlate theory & practice. To develop skills in assisting the surgeon in the

    operation.

    To create a suitable sterile field for surgicalprocedures to prevent complications.

    Perioperative NursingPurpose/reasons

    Degree of urgencynecessity to preserve the clients life, body

    part, or body function.

    Degree of riskinvolved in surgical procedure is affected by the

    clients age, general health, nutritional status, use of medications,

    and mental status.

    Extent of surgerySimple and radical

    CLASSIFICATIONS OF SURGERY

    According to Urgency :

    EMERGENTpatient requires immediate attention ; disorder maybe

    life- threatening.

    URGENTpatient requires prompt attention.

    > indications for surgery : within 24-30 hours.

    REQUIREDpatient needs to have surgery.

    > indications for surgery: plan within few weeks or months.

    ELECTIVEpatient should have surgery.

    > indications for surgery: Failure to have surgery is not

    catastrophic.

    OPTIONALdecision rests with pt.

    > indications for surgery : Personal preference

    Accdg. To Degree Of Risk :

    MAJORhigh degree of risk :

    >maybe complicated / prolonged, large losses of blood may occur,

    vital organs maybe involved, post-op complications may be likely.

    MINORlittle risk with few complications.

    - often performed in a day surgery.

    Accdg. To Purpose :

    DIAGNOSTICverifies suspected diagnosis

    EXPLORATORYestimates the extent of the disease or injury.

    CURATIVEremoves or repairs damaged tissues .ABLATIVEremoving diseased organ that cant wait anymore.

    - emergency surgery.

    PALLIATIVErelieves symptoms but does not cure the underlying

    disease process.

    RECONSTRUCTIVE partial or complete restoration of a damaged

    organ/tissue to bring back the original appearance & function.

    CONSTRUCTIVE repairing the damaged tissue or congenitally

    defective organ.

    Accdg. To Location :

    INTERNALinside the body . Ex. Hysterectomy

    EXTERNALoutside the body .Ex. Skin grafting

    http://www.medterms.com/script/main/art.asp?ArticleKey=5315http://www.medterms.com/script/main/art.asp?ArticleKey=5315http://www.medterms.com/script/main/art.asp?ArticleKey=13954http://www.medterms.com/script/main/art.asp?ArticleKey=13954http://www.medterms.com/script/main/art.asp?ArticleKey=13954http://cancerweb.ncl.ac.uk/cgi-bin/omd?bacteriahttp://cancerweb.ncl.ac.uk/cgi-bin/omd?bacteriahttp://cancerweb.ncl.ac.uk/cgi-bin/omd?bacteriahttp://en.wikipedia.org/wiki/Bacteriumhttp://en.wikipedia.org/wiki/Bacteriumhttp://en.wikipedia.org/wiki/Bacteriumhttp://en.wikipedia.org/wiki/Disinfectanthttp://en.wikipedia.org/wiki/Disinfectanthttp://en.wikipedia.org/wiki/Disinfectanthttp://en.wikipedia.org/wiki/Antiseptichttp://en.wikipedia.org/wiki/Antiseptichttp://en.wikipedia.org/wiki/Antiseptichttp://en.wikipedia.org/wiki/Antibiotichttp://en.wikipedia.org/wiki/Antibiotichttp://en.wikipedia.org/wiki/Antibiotichttp://en.wikipedia.org/wiki/Antibiotichttp://en.wikipedia.org/wiki/Antiseptichttp://en.wikipedia.org/wiki/Disinfectanthttp://en.wikipedia.org/wiki/Bacteriumhttp://cancerweb.ncl.ac.uk/cgi-bin/omd?bacteriahttp://www.medterms.com/script/main/art.asp?ArticleKey=13954http://www.medterms.com/script/main/art.asp?ArticleKey=5315
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    FOUR BASIC PATHOLOGIC CONDITIONS THAT REQUIRE

    SURGERY (OPET):

    OBSTRUCTIONa blockage ; are dangerous because they block

    the flow of blood, air, CSF, urine & bile through the body.

    PERFORATIONis a rupture of the organ, artery or bleb.

    EROSIONbreak in the continuity of tissue surface. It can damage

    the walls of blood vessels resulting in serious bleeding.

    TUMORSabnormal growth of tissue that serves no physiologic

    function in the body.

    Who are the the SURGICAL RISK PATIENTS?

    *Extremes of age ( very young & very old )

    *Extremes of weight (emaciation, obesity)

    *Dehydrated pts.

    *Nutritional deficits

    *Pts. with severe trauma or injury, infection/sepsis

    *Pts. with cardiovascular disease

    *Endocrine dysfunction (diabetes mellitus)

    *Hypertensive & hypotensive pts.

    *Hypovolemia

    *Hepatic disease

    *Pre-existing mental or physical disability

    PROBLEMS THAT MAY ARISE IN SURGERY:

    Surgical risk ptsprobability of mortality Pain Hemorrhage Infection UTI

    PHASES OF O.R. NURSING :

    PREOPERATIVE PHASE

    The rendering of nursing care to the surgical client as soonas he is admitted & the decision to undergo surgery is

    made.

    It ends on the time the client is transferred to the O.R.NURSING ACTIVITIES :

    Assessment of the client Identification of potential/actual health problems. Pre-op teaching involving client & support persons.

    Day of surgery :

    pt. teaching reviewed informed consent confirmed pt.s identity & surgical site verified IVF started.

    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

    PREPARATION FOR SURGERY

    Psychological Support :- Assess clients fears, anxieties, support systems & patterns

    of coping.

    - Establish trusting relationship with client & significantothers.

    - Explain routine procedures, encourage verbalization offears & allow client to ask questions.

    - Demonstrate confidence in surgeon & staff.- Provide for spiritual care if appropriate.

    PREOPERATIVE TEACHING

    - Assess clients level of understanding of surgical procedure& its implications.

    - >Answer questions, clarify & reinforce explanations givenby the surgeon.

    - Explain routine pre- & post-op procedures & any specialequipment to be used.

    PREOPERATIVE TEACHING

    - Preoperative experience- Preoperative medication- Breathing exercises, coughing, incentive spirometer- Leg exercises- Position changes and movement- Pain management- Reducing anxiety and fear, support of coping- Special considerations related to outpatient surgery- Diaphragmatic Breathing and Splinting When Coughing- Leg Exercises and Foot Exercises-

    Preoperative Nursing Interventions

    PHYSICAL PREPARATIONS:

    - Obtain history of past medical conditions, surgicalprocedures, dietary restrictions & medications.

    - Perform baseline head-to-toe assessment, including VS,height & weight.

    - Ensure that diagnostic procedures pertinent to surgery areperformed as ordered

    - NPO- Bowel prep- Skin prep- Immediate preoperative preparation- Transporting the pt. to the pre-surgical area about 30 to 60

    minutes before anesthetics is to be given.- Attend to family needs

    LEGAL PREPARATION:

    - Surgeon obtains operative permit (informed consent)- Surgical procedures, alternatives , possible complications &

    disfigurements or removal of body parts are explained.

    - It is part of the nurses role as client advocate to confirmthat the client understands information given.

    INFORMED CONSENT is necessary in the ff. Circumstances:

    - Invasive procedures- Procedures requiring sedation or anesthesia- A non-surgical procedure- Procedures involving radiation- Adult client (over 18 y/o) signs own permit unless

    unconcious or mentally incompetent.- Consents are not needed for emergency care if all 4 of theff. criteria are met:

    - There is an immediate threat to life.- Experts agree that it is an emergency.- Client is unable to consent.- A legally authorized person cannot be reached.

    *Minors (under 18 y/o) must have consent signed by an adult (i.e.

    Parent or legal guardian)

    PREOPERATIVE MEDICATIONS

    PURPOSES: To relieve fear & anxiety. To reduce dose needed for induction & maintenance of

    anesthesia.

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    To prevent reflex bradycardia that happens duringinduction of anesthesia.

    To minimize oral secretions.INTRAOPERATIVE PHASE

    Giving nursing care to client undergoing surgery. It starts from the time the pt. was admitted to the O.R. ,

    during operation until it ends & transferred to the PACU.

    NURSING ACTIVITIES:

    Activities providing for pts safety. Maintenance of aseptic environment. Ensuring proper function of equipments. Providing surgeons with specific instruments & supplies for

    surgical field. Completing documentation. Positioning pts. Acting as scrub/circulating nurse.

    Members of the Surgical Team

    Patient Anesthesiologist or anesthetist Surgeon Nurses (Scrub & Circulating) Surgical technologists

    PATIENT

    - the most important member of the surgical team. May feelrelaxed & prepared, or fearful & highly stressed.

    - is also subject to several r isks.OPERATING SURGEON

    - pre-op dx & care.- performance of operation.- post-op mgt & care- assumes all responsibility for all medical acts of judgement

    & mgt.

    SURGEON & ASSISTANTS

    - scrub & perform the surgery.REGISTERED NURSE 1STASST.

    - practices under the direct supervision of the surgeon.(handling tissue, suturing, maintaining hemostasis)

    ANESTHESIOLOGIST / NURSE ANESTHETIST

    - administers the anesthetic agent & monitors the ptsphysical status throughout the surgery.

    SCRUB NURSE

    - provides sterile instruments & supplies to the surgeonduring the procedure.

    - performs surgical hand scrub.CIRCULATING NURSE

    - coordinates the care of the pt. in the O.R.- care provided includes assisting with pt. positioning , skin

    prep, managing surgical specimens & documenting

    intraoperative events.

    Prevention of Infection

    The surgical environment- stark appearance & cool temperature. Located

    central to all supporting services.

    Unrestricted zone- where street clothes are allowed.

    Semirestricted zone- where attire consists of scrub clothes & caps.

    Restricted zone- where scrub clothes, shoe covers, caps & masks

    are worn.

    THE OPERATING ROOM

    Basic Guidelines for Surgical Asepsis

    - All materials in contact with the wound and within thesterile field must be sterile.

    - Gowns are sterile in the front from chest to the level ofthe sterile field, and sleeves from 2 inches above theelbow to the cuff.

    - Only the top of a draped table is considered sterile.During draping, the drape is held well above the area andis placed from front to back.

    - Items are dispensed by methods to preserve sterility.- Movements of the surgical team are from sterile to sterile

    and from unsterile to sterile only.- Movement around the sterile field must not cause

    contamination of the field. At least a 1-foot distance fromthe sterile field must be maintained.

    - Whenever a sterile barrier is breached, the area isconsidered contaminated.

    -

    Every sterile field is constantly maintained and monitored.Items of doubtful sterility are considered unsterile.- Sterile fields are prepared as close as possible to time of

    use.

    SURGICAL ASEPTIC TECHNIQUE

    BEFORE AN OPERATION, it is necessary to sterilize andkeep sterile all instruments, materials, and supplies that

    come in contact with the surgical site. Every item handled

    by the surgeon and the surgeon's assistants must be

    sterile. The patient's skin and the hands of the members of

    the surgical team must be thoroughly scrubbed, prepared,

    and kept as aseptic as possible.

    DURING THE OPERATION, the surgeon, surgeon'sassistants, and the scrub nurses must wear sterile gowns

    and gloves and must not touch anything that is not sterile.

    Maintaining sterile technique is a cooperative responsibility

    of the entire surgical team.

    - Each member must develop a surgical conscience,awillingness to supervise and be supervised by others regarding

    the adherence to standards.

    Intraoperative Nursing Care Roles of team members

    Surgeon

    responsible for determining the preoperative diagnosis, thechoice and execution of the surgical procedure, the

    explanation of the risks and benefits, obtaining inform

    consent and the postoperative management of the patients

    care.Scrub nurse

    (RN or Scrub tech)- preparation of supplies and equipmenton 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

    Circulating Nurse

    responsible for creating a safe environment, managing theactivities 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

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    and communicating relevant information to individual

    outside of the OR, such as family members.

    Anesthesiologist and anesthetist

    anesthetizing the pt. providing appropriate levels of painrelief, monitoring the pts physiologic status and providing

    the best operative conditions for the surgeons.

    Other personnel- pathologist, radiologist, perfusionist, EVS personnel.

    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 Ensure sterility Alert for breaks

    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

    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

    Intraoperative Phase Types of Anesthesia

    General

    - method use when the surgery requires that the patient beunconscious and/or paralyzed.

    - A general anesthetic acts by blocking awareness centers inthe 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.

    Stages of General Anesthesia

    Stage 1- Analgesia and sedation, relaxation

    Stage 2- Excitement, delirium

    Stage 3- Operative anesthesia, surgical anesthesia

    Stage 4- Danger

    Complications of General Anesthesia Overdose Hypoventilation Related to anesthetic agents Malignant hyperthermia Related to intubation

    Local or Regional Anesthesia

    Temporarily interrupts the transmission of sensory nerveimpulses 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

    Types of Regional Anesthesia

    Topical (surface) Local Nerve Block Intravenous (Bier Block) Spinal Epidural (peridural)

    Complications of Local/Regional Anesthesia

    Anaphylaxis Administration technique Systemic absorption Overdosage

    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

    Involved medications

    -lidocaine-bupivacaine-tetracaine

    Patient assessment

    -continuous heart rate, rhythm, and pulse oximetry monitoring-level of anesthesia-motor function and sensation return monitoring

    Complications

    -hypotension-bradycardia-urine retention-postural puncture headache-back pain

    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

    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

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