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.
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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.
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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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