Perioperative Nursing

A. Preoperative period 1. Begins with decision to perform surgery and ends when client enters operating room; the surgery may be inpatient or outpatient 2. Types of surgery a. purpose i. diagnostic ii. curative iii. transplant iv. palliative v. cosmetic b. urgency of surgery i. elective: performed on basis of client's choice, not essential for health ii. urgent: necessary for client's health iii. emergency: must be done immediately to save client's life c. seriousness i. minor: minimally alters body parts, with less risk ii. major: extensively reconstructs or alters body parts; greater risk 3. Medical conditions that increase the risk of surgery a. bleeding disorders b. heart disease c. diabetes mellitus d. upper respiratory infection e. liver disease f. chronic respiratory disease g. immunological disorders h. drug abuse 4. Pre-anesthetic medications a. sedatives-hypnotics b. narcotics c. anticholinergics d. tranquilizers/antianxiety agents e. H2-receptor antagonists 5. Nursing interventions during preoperative period a. provide psychological support b. explain the procedures surrounding the surgery c. teach client i. type of surgery to be performed ii. deep breathing and coughing iii. post-op incisional splinting iv. comfort measures to be used post-operatively v. movement vi. elimination d. obtain baseline vital signs e. administer pre-anesthetic medications as ordered f. administer prophylactic antibiotics if ordered g. remove nail polish and makeup h. help client to empty bladder i. check client's identification bracelet j. provide for client safety k. remove any dentures or prostheses l. check that pre-op permit (informed consent) has been signed and appropriate lab work is documented m. check for allergies n. ensure that right site protocol is in use Intraoperative period 1. Surgery usually takes place in operating suite 2. Anesthesia, general

B.

a. b.

c.

d.

drug-induced analgesia, amnesia, muscle relaxation, and unconsciousness stages: i. induction: start of anesthetic administration, client becomes drowsy and loses consciousness ii. excitement: muscles become tense and almost spasmodic iii. swallowing and vomiting reflexes remain, may breathe irregularly iv. surgical anesthesia: I. muscle relaxation occurs II. breathing becomes regular III. vital functions and reflexes are depressed IV. operation begins v. complete respiratory depression types of anesthetic agents i. inhalation: gas and liquid: nitrous oxide, cyclopropane halothane, enflurane, ether, methoxyflurane ii. intravenous agents: methohexital, sodium thiopental iii. dissociative agents: (no loss of consciousness) ketamine iv. neuroleptics: fentanyl citrate with droperidol adjuncts to general anesthesia:

3. Complication of general anesthesia: malignant hyperthermia a. rapid progressive rise in body temperature b. fatal if not treated c. findings i. tachycardia ii. tachypnea iii. unstable blood pressure iv. diaphoresis (sweating) v. muscle rigidity d. thought to be caused by alteration of calcium-storing properties of muscle-cell membrane e. familial tendency f. treatment - dantrolene (Dantrium): skeletal muscle relaxant

g. nursing interventions in malignant hyperthermia i. administer medications as ordered ii. teach client to wear MedicAlert jewelry 4. Nursing interventions during the intraoperative period a. ensure right site protocol is in use b. provide emotional support during anesthesia induction c. provide for client safety during procedure d. position the client as ordered by procedure e. maintain surgical asepsis f. monitor for electrical hazards g. monitor client for effects of heat loss during surgery h. immediately after surgical drapes are removed, apply warm blankets Principles of Surgical Asepsis 1. A sterile object remains sterile only when touched by another sterile object. Sterile touching sterile remains sterile. Sterile touching clean becomes contaminated. Sterile touching contaminated becomes contaminated. Sterile touching questionable is contaminated. Only sterile objects may be placed on a sterile field. 2. A sterile object or field out of range of vision, or an object held below a person's waist, is contaminated. 3. Never turn your back on a sterile field. 4. A sterile object or field becomes contaminated by prolonged exposure to air. 5. When a sterile surface comes in contact with a wet, contaminated surface, the object or field becomes contaminated by capillary action. 6. Always hold your hands above the level of your elbows. 7. The edges of a sterile field or container are considered contaminated.

C. Postoperative period I: recovery and discharge home 1. Anesthesia recovery period - may range from a few hours to 23 hours a. surgical recovery: priority nursing interventions

b. recovery complications and how to react: c. provide emotional support and reorientation d. assist with notifying the family that the surgery is complete and of the general condition of the client

2. Post recovery: for clients discharged to home a. discharge criteria include these nine achievements i. adequate respiratory function ii. intact gag reflex iii. ability to deep breathe and cough iv. stable vital signs v. normal level of consciousness and muscle strength vi. ability to ambulate with assistance vii. ability to retain oral fluids viii. ability to urinate ix. ability to care for incision and any drainage tubes x. flatus/bowel sounds all 4 quadrants of abdomen b. instruct clients in eight areas i. medications and side effects ii. care of incision iii. care of any drainage apparatus iv. any required treatments v. findings of infection vi. activity progression or limitation vii. special dietary restrictions viii. when to contact the physician D. Postoperative period II: transfer to a medical-surgical unit 1. Acute pain management a. temporary pain occurring after a body injury i. disappears when injury is healed ii. monitor location, severity, quality, progression and alleviation of pain iii. administer pain medications as ordered (information about pain medications can be found in Pharmacological and Parenteral Therapies) iv. provide noninvasive pain relief measures as ordered massage

distraction relaxation hypnosis v. assist with invasive pain relief measures as ordered acupuncture nerve blocks 2. Other postoperative care a. provide restful environment b. encourage the client to turn, breathe deeply and cough c. encourage the client to change position every hour d. assist the client out of bed, an order is required following neck and back surgery e. change dressing as needed f. use sterile technique g. observe and record amount, color, odor of drainage on dressing h. observe incision for intactness, findings of infection i. assist with ADLs as indicated j. ambulate client, may require physical therapy in some facilities k. teach client to splint incision during coughing wound care importance of progressive activity medications and side effects findings of infection

b. monitorTYPES OF PAIN for complications A. Superficial 1. Arises from local tissues 2. Usually related to a nerve ending disturbance 3. Localized; usually described as constant, sharp, tingling or throbbing B. Visceral 1. Arises from somatic structures 2. Deep pain; may be dull or aching C. Referred - Pain felt in another area separate from source of pain D. Central 1. Caused by injury to central nervous system 2. Very intense pain; burning CLASSIFICATIONS OF SURGICAL WOUNDS RELATIVE TO RISK OF INFECTION The higher the class, the higher the risk: a class IV wound carries much more risk than a class I. A. Class I (clean wound) 1. No break in sterile technique 2. No inflammation encountered 3. GI, Respiratory or GU tract not entered B. Class II (clean-contaminated wound) 1. GI, GU or respiratory tract entered with no spillage of contents 2. Minor breaks in technique 3. Operations involving the biliary tract, appendix, vagina, and oropharynx C. Class III (contaminated wound) 1. Acute inflammation without pus 2. Spillage from a hollow viscus occurs 3. Trauma from a clean source D. Class IV (dirty) 1. Pus or a perforated viscus 2. Trauma from a dirty source 3. Organism causing infection present before surgery 4. Surgical variables that increase risk of infection 5. Prolonged preoperative hospital stay 6. Body location of surgery 7. Surgical technique: delayed wound closure, excess blood loss, presence of drain, improper suture tension 8. Presence of bacteria at closure

3. Complications a. wound complications i. dehiscence: complete separation of wound edges or ii. evisceration: wound edges separate; viscera protrude cause: obesity; malnutrition; too much coughing/straining cover with gauze soaked in sterile saline and report immediately keep client in flat position iii. infection b. circulatory complications: thrombosis and embolism c. fluid and electrolyte imbalance d. urinary retention i. finding: inability to void ii. causes include trauma to the bladder or its nerve supply during surgery, edema around bladder neck; reflex spasm due to drugs; spinal or epidural anesthesia iii. interventions encourage ambulation run water so client can hear sound pour warm water over perineum warm bath catheterization if indicated

HIGH RISK GROUPS FOR POST-OP INFECTIONS 1. 2. 3. 4. 5. 6. 7. 8. 9. Impaired immunologic system Extremes of age Diabetes mellitus Corticosteroid therapy Chemotherapy Infection elsewhere in the body Malnutrition Presence of staphylococcus aureus on client Contaminated environment where injury or trauma occurred

e. paralytic ileus i. diminished or absent peristalsis ii. caused by stress response to surgery and anesthesia, trauma or manipulation of abdominal contents, electrolyte imbalance, anesthetics and pain medications, wound infections and immobility iii. occurs to some degree following all abdominal surgeries iv. bowel sounds return gradually over several days v. findings decreased or absent bowel sounds abdominal distention

f.

feeling of fullness interventions withhold fluids until presence of bowel sounds encourage ambulation nasogastric decompression if ordered vii. return of peristalsis signaled by presence of bowel sounds, flatus or bowel movement nausea and vomiting i. caused by anesthetics and analgesics, gastric distention, surgical manipulation, pain, electrolyte imbalance ii. interventions limit oral intake administer antiemetics as tolerated measure drainage observe color, amount and odor of drainage progress client food intake: begin with clear liquids and progress to full diet as tolerated record intake and output

vi.

Wound drain 1. 2. Removal of wound drainage Types a. closed drain i. drain attached to collection system ii. uses vacuum to draw drainage into system iii. example: Jackson-Pratt, Hemovac iv. specific nursing interventions I. maintain patency of drain II. empty collection system and reactivate suction device III. record amount and characteristics of drainage IV. asepsis V. standard precautions b. open drain i. removes drainage from wound, deposits it on skin surface ii. example: Penrose drain iii. safety pin usually attached to outside end of drain iv. specific nursing interventions v. prevent inadvertent removal of drain I. protect skin II. record characteristics of drainage III. asepsis IV. standard precautions vi. protect skin surface from irritating effects of drainage vii. wound vacuum I. removes and collects infectious material from wound II. computer controlled III. requires a seal at wound site with pressure distributing wound packing IV. client may be discharged with device

Dressings, compresses, bandages, irrigation 1. Uses of dressings a. promote healing by absorbing drainage and debriding a wound

b. c. d. e. f. g. 2.

protect wound from contamination promote thermal insulation of wound protect wound from further injury prevent the spread of microorganisms control bleeding comfort

Types of dressing for simple wounds a. most of these are changed daily or more frequently

3. Types of dressing for complicated wounds: a. most of these remain on wound over a few days

4. Nursing interventions a. explain procedure to client b. maintain standard precautions c. change dressing as ordered according to institutional procedure d. maintain asepsis e. make sure dressing is secure f. document i. type and amount of drainage ii. presence of drains iii. condition of wound g. observe for signs of infection h. watch moist dressings for growth of yeast i. weigh dressing if ordered j. teach client i. type and purpose of dressing ii. how to change dressing if change required after discharge iii. findings of wound healing iv. findings of complications, e.g. infection 5. Compresses a. moistened piece of gauze dressing b. may be warm or cool c. uses i. improve circulation

ii. reduce edema iii. promote consolidation of pus d. nursing interventions i. explain procedure to client ii. change warm compresses frequently or apply aquathermic pad to maintain temperature 6. Bandages and binders a. made of gauze, elastic knit or webbing, muslin or flannel b. uses i. provide extra protection ii. create pressure over body part iii. immobilize body part iv. support a wound v. reduce or prevent edema vi. secure dressings c. bandage types i. circular ii. spiral iii. spiral reverse iv. figure eight v. recurrent d. binder types (illustration ) i. abdominal ii. T binder iii. breast e. nursing interventions i. explain procedure to client ii. ensure that bandage or binder is not constrictive iii. tell client to report any discomfort with bandage or binder iv. replace soiled bandages and binders

7. Slings a. supports arm with muscular sprain or fracture b. may be commercially made or home made c. nursing interventions i. explain procedure to client ii. support affected extremity while applying sling iii. place sling outside normal clothing 8. Irrigation a. flushing with solution b. uses i. to remove foreign matter or exudate ii. to ensure patency of drainage tubing iii. involves instilling a solution and withdrawing that solution c. types i. urinary ii. wound iii. nasogastric/gastrostomy/jejunostomy iv. arterial line v. ostomy vi. ear vii. vagina (douche) viii. colonic (enema) ix. central line or peripheral IV x. bladder