PERIOPERATIVE NURSING

Mrs. Kathleen R. Parel, BSN, RN

PERIOPERATIVE NURSING

specialized area of nursing practice incorporates three phases of surgical procedure

SURGERY
Invasive medical

procedure performed to diagnose or treat illness, injury or deformity

Classification of surgical procedures

A. Procedure
1. Diagnostic - determine or confirm a diagnosis 2. Ablative remove diseased tissue, organ or extremity

Constructive build tissue /organs that are absent (congenital anomalies) 4. Reconstructive rebuild/restore organs/tissues that has been damaged
3.

5. Palliative alleviate symptoms of a disease ( not curative) 6. Transplant replace organs/tissue to restore function

7. Aesthetic - improvement of physical features that are within the normal range - otherwise known as cosmetic surgery

B. Risk factor
1.Minor minimal physical
assault with minimal risk 2.Major extensive physical assault and/or serious risk

C. Urgency
1. Elective suggested though no
foreseen ill effects if postponed 2. Urgent necessary to be performed within 1 to 2 days 3. Emergency performed immediately

Settings for Surgery

a.Inpatients b.Outpatients

3 Phases/Periods Preoperative Period Intraoperative Period Postoperative Period

Preoperative Period
- begins from the time
the decision for surgery until the client is transported to the operating room

Intraoperative Period
-

begins with the clients entry into the operating room and ends with admittance to postanesthesia care unit (PACU) or recovery room (RR)

Postoperative Period
-

begins with clients admittance to the PACU and ends with the clients recovery from surgical intervention

Preoperative Period
I.Preoperative Assessment

a. medical / health hx
1. Previous surgery and experience

2. Serious

illness/trauma

Allergy Bleeding tendencies Cortisone or Steroid use Diabetes Mellitus Emboli

3. Alcohol, Recreational Drug or

Nicotine Use 4. Current discomforts 5. Chronic Illnesses 6. Advanced Ages 7. Medication History

Psychological hx c. Ability to tolerate perioperative stress d. Lifestyle habits e. Social hx

b.

II. Physical Examination

Identify the present health status - Baseline information for comparisons during and after surgery
-

Specific Body System Assessments

1. Cardiovascular 2. Respiratory
3. Musculoskeletal 4. Gastrointestinal 5. Skin Integrity

6. Renal 7. Liver function 8. Cognitive & Neurologic 9. Endocrine

Additional Assessments
1. Age 2. Pain 3. Nutritional status 4. Fluid and electrolyte balance 5. Infection and immunity 6. Hematologic function

Preoperative Nursing Care

Preparation of the skin

shower and bathing shaving of operative site cleaning of operative site with soap and water or antimicrobial solution

Preparation of the Gastrointestinal tract

reduce vomiting & aspiration - reduce risk of bowel obstruction - allow visualization of the intestine during bowel surgery
-

prevent contamination from fecal material in the intestinal tract during bowel or abdominal surgery
-

foods and fluids are restricted for 8 10 hours before the operation - clients are assigned of nothing per orem(NPO) status

When client is on NPO:

explain the reason for the fluid and food restriction remove food and water from the bedside at midnight place NPO signs on the door and on the bed

 mark the care plan or Kardex with NPO inform the dietary & nutrition department about the clients NPO status

 inform other caretakers &

other family members that the client is NPO

Administration of important

medications orally taken with small sips of water especially cardiac drugs - digoxin

 Enemas are done as bowel

preparations for surgical procedures that involve the gastrointestinal tract, perianal or perineal areas and pelvic cavity

Nutritional Care
Malnourished Preoperatively encouragement of high CHO intake to increase energy

- high CHON intake to assist in wound healing

- vitamin supplement to
encourage healing

- vitamin C wound healing - vitamin K increase blood

clotting times

Components of Preoperative Teaching

Sensory information
sights, sounds, and feel of the operating room

Psychosocial information - coping abilities and worries about family and similar concerns

Procedural
- activities during the

preoperative period and postoperative care

Teaching of clients role

- Deep Breathing Exercises Coughing Exercises

 Turning Exercises

Extremity Exercises

Ambulation Pain control

Informed consent

legal document required for certain diagnostic procedures or therapeutic measures, including surgery

protects client, nurse, physician & health care facility

includes the ff:

need for the procedure in
relation to the diagnoses description and purpose of the proposed procedure

possible benefits and potential risks likelihood of a successful outcome

 alternative treatments

or procedures available likelihood of a successful outcome

 anticipated

risks should the procedure not be performed Physicians advice as to what is needed

right to refuse treatment or withdraw consent

securing of informed consent is done by the nurse who was present when the information was provided

adults who are unconscious

or mentally incompetent may have their informed consent signed by a surrogate, relative or legal guardian

children under legal age

may be obtained of informed consent through parents or legal guardian

Collaborative Care

Diagnostic tests
provide baseline data detect problems that may place the client at additional risk during & after surgery

- new trend toward shortened

hospitalization stays
- diagnostic studies and procedures - preadmission either a few days or within a week prior to elective surgery

hematologic studies
Hgb, hct cbc plt ct ABGs PT or PTT

blood chemistry
electrolytes
K+ Na+ Cl

Radiographic or Ultrasonographic
CXR

X-RAY of region of the body or extremity UTZ of specific region of the body

Other Dx Tests or Exams

ECG PFT UA

Preoperative Prep Immediately before surgery provision of a preoperative checklist administration of preoperative medications

Preoperative Medications
provide sedation reduce anxiety produce analgesia or amnesia increase comfort during preoperative procedures

reduce gastric acidity & volume increase gastric emptying decrease nausea & vomiting reduce incidence of aspiration

 has quick onset

short duration of action administered 40 70 minutes before

scheduled surgery administered either orally, parenterally

Classifications of Preanesthetic Medications

Sedatives and Tranquilizers Narcotics Antimuscarinics

Sedatives and Tranquilizers

A.Benzodiazepines B. Barbiturates C. Antiemetics/Antinauseants

Benzodiazepines
produce

excellent amnesia & mild sedation sufficient to reduce anxiety and fear - inhibitory effect on interneuronal transmission to sites in the CNS associated with anxiety & fear

1.DIAZEPAM Valium
- produces amnesia, sedation and muscle relaxation - lowers BT - causes less hypotension, bradycardia - facilitates awake intubation

2. LORAZEPAM Ativan
_

better amnesic effect when given orally than IM route

3. MIDAZOLAM Versed, Dormicum

- given IM for premedication or

slow IV infusion for conscious sedation - Short acting - Metabolized 4 6 hours - Causes respiratory depression

Barbiturates
prolonged duration of action given orally for sleep the before to help allay anxiety have hypnotic and sedative effect

SECOBARBITAL Seconal PENTOBARBITAL Nembutal PHENOBARBITAL

Antiemetics/ Antinauseants

minimize nausea and vomiting potentiate effects of narcotics

Promethazine hydrochloride

Phenergan sedation & side effects are secondary to interactions with other drugs on CNS

Hydroxyzine hydrochloride
combined

with a narcotic given IM drowsiness antihistaminic and anticholinergic actions

Droperidol
Inapsine given Im good sedative & antiemetic
action hypotension & tachycardia

Narcotics
natural alkaloids of opium opiates or opiods produce analgesia

raise the pain threshold & lower metabolic rate decrease alveolar ventilation & depress respiration

 circulatory depression &

hypotension stimulate & constrict smooth muscles nausea, vomiting & urinary retention

Morphine sulfate

prolonged duration of action , unless pt is in pain

mepereidine hydrochloride

given IM or SC short acting

Antimuscarinics
anticholinergics interfere with stimulation of the vagus nerve

Useful in prevention & tx of reflex slowing of the heart, which may occur intraoperatively with stimulation of the carotid sinus, intrathoracic manipulation or traction on intraabdominal viscera or extraocular muscles

prevent vagal mediated hypotension, cardiac dysrhythmias & bradycardia increases heart rate

bronchodilators & parasympathetic depressants inhibit mucus secretions dry mouth given IM

Atropine sulfate dry mouth and blurred vision

Glycopyrrolate (Robinul) longer duration of action

Reduces volume and acidity of gastric secretions elevating gastric pH less autonomic effect causes less tachycardia than atropine

Nursing Responsibilities in the administration of Premedications:

before administration of premedications, consent should be signed by the client because a legal consent cannot be given by a medicated adult

have the client to void prior to administration of premeds

after administration of premeds, bed should be placed in the lowest position and side rails raised

lower window shades, turn bright lights off

instruct client to

remain in trolley or stretcher to prevent occurrence of dizziness & premeds are likely to produce drowsiness

observe for side

effects of premeds given document all premeds given document all reactions to premeds