Peri Operative Nursing
Peri Operative Nursing
3 Phases
Pre Operative- Extends from the time the client is admitted in the
surgical unit, to the time he / she is prepared physically,
psychologically, spiritually and legally for the surgical procedure,
until the patient is transported into the operating room.
1
B. According to Degree of Risk (magnitude/extent)
C. According to Urgency
1. Emergency- To be done immediately to save life or limb.
2. Imperative- To be done within 24-48 hrs.
3. Planned Required- Necessary for well-being may be
scheduled weeks or months.
4. Elective- Not absolutely necessary for survival. Delay or
emissions may not cause adverse effect.
5. Optional- Requested by the client-usually for aesthetic
purposes.
6. Day (Ambulatory Surgery)- Done on out-patient basis.
PREOPERATIVE PHASE
Goals:
2
Assessing and correcting physiologic and psychological
problems that might increase surgical risk.
Giving the person and significant others complete learning /
teaching guidelines regarding the surgery.
Instructing and demonstrating exercises that will benefits the
person during post op period.
Planning for discharge and any projected changes in lifestyle
due to surgery.
3
G. Short attention upon
H. Failure to carry out simple directions
I. Dazed
A. Nursing Intervention to Minimize Anxiety
1. Explore client's feeling
2. Allow client's to speak openly about fears/ concerns
3. Give accurate information regarding surgery
4. Give empathetic support
5. Consider the person's religious preferences and arrange for
visit by priest / minister as desired.
C. Physical Preparations
A. Before Surgery
Correct any dietary deficiencies
Reduce an obese person's weight
Correct fluid and electrolyte imbalances
Restore adequate blood volume and blood transfusion
Treat chronic diseases- DM, heart disease, renal insufficiency
Halt or treat any infection's process
Treat an alcoholic person and vitamin supplementation, IVF's
or oral fluid if dehydrated.
4
2. Preparing the G.I tract
- NPO, cleaning enema as required.
3. Preparing for Anesthesia
- Avoid alcoholic and cigarette smoking for at least 24
hours before surgery.
4. Promoting rest and sleep
- Administer Sedatives as ordered.
G. Patient's family
– Direct proper visiting room
5
– Doctor informs family immediately after surgery
– Explain reason for long interval of waiting: anesthesia
prep, skin prep, surgical procedure, RR
– Explain what to expect post-op.
INTRAOPERATIVE PHASE
Anesthesia
- Absence of pain (An-without and Estesia-awareness or
feeling)
Purposes
Produces muscle relaxation
Block Transmission of nerve impulses
Suppress reflexes
Cause loss of consciousness.
Types of Anesthesia
A. General Anesthesia- Pain is controlled by general insensibility.
Total loss of consciousness
Produces amnesia
Analgesia
Interference with undesirable reflexes
Muscle relaxation
6
Action of General Anesthesia
- Association pathways are broken in the cerebral cortex to
produce more or less complete lack of sensory perception and
motor discharge. Unconsciousness is produced when the blood
circulation to the brain contains an adequate amount of the
Anesthetic.
A. Inhalation
- The anesthetic is inhaled and carried into the bloodstreams
by passing across the alveolar membrane into the pulmonary
circulatory, then into the general circulation and onto the tissues.
The volume and rate of respiration influence the amount of vapor
inspired. The agent’s uptake and elimination by pulmonary
ventilation makes this a controllable technique.
- It is a standard anesthesia used in most major surgeries
involving the upper abdomen, head, neck and thorax.
Advantages
Prevention of pain
Relaxation of the tissues
Alleviation of anxiety through producing a state of total
unconsciousness
Disadvantages
Circulatory and Respiratory depression
Certain of the gases of anxiety and liquids used are highly
flammable and explosive when mixed with air or oxygen.
7
except in cases of tonsillectomy in children
8
Can cause cardiac arrest and laryngospasm
No analgesic effect
Patient is restless and noisy.
B. Intravenous Anesthesia
When general anesthetic agent is administered IV, the patient
experiences a simple pleasant and extremely rapid reaction and
induction, unconsciousness generally occurs only 30 seconds
following the initial IV administration of the anesthetic agent. It is
sometimes given to relax a patient prior to the administration of
powerful and more harmful inhalation anesthetic agent.
Major Advantages
Rapid pleasant induction
Absence of explosive hazards
Slow incidence of post operative nausea and vomiting
Major Dangers Are:
Laryngospasm and Bronchospasm owing to excitement of
laryngeneal reflexes by drug.
Hypotension owing to depression of the vasomotor center in
the brain.
Respiratory arrest owing to drug over dosage which may also
result in cardiac arrest.
Examples
1. Thiopental Sodium (Pentothal Sodium)- most commonly used
Short procedures not requiring relaxation such as D and C and
I and D.
As a basal anesthetic
For control of convulsion
As adjunct to spinal or nitrous oxide
For hypnosis during regional anesthesia
2. Pentobarbital Sodium (Nembutal Sodium) and Seconbarbital
9
Sodium (Seconal Sodium)
D. Regional Anesthesia
- The purpose is to reduce all painful sensation in one region of
the body without inducing unconsciousness. The anesthetic agent is
deposited either open the surface to be anesthetized or upon a
particular nerve pathway that lies between the area to be incised
and operated upon and receptors of painful stimuli located within
the CNS. This procedure then blocks the transmission of painful
stimuli to the brain.
Advantages
Non explosive anesthetic agents
Use of minimal, simple equipment; economy
Avoids undesirable effects of general anesthesia; no loss of
consciousness.
Suitable for ambulatory pts; who recently ate (OB emergency),
minor procedures, for cases where it is necessary to have the
patient's cooperation.
Better airway control- pt. who is awake is better able to vomit
Fewer respiratory complications- pt can be able to cough and
breathe which prevents pooling of mucus into the bronchi.
Disadvantages:
10
Not practical for all types of surgery
There are individual variations in response to regional
anesthesia
Too rapid absorption of the drug into the blood (overdosage)
can cause severe potentially fatal reactions.
Anxiety and fear are not alleys pt continues to see and hear
throughout the procedure.
Lack of flexibility- difficult to use with small children, elderly
senile person and uncooperative patient
Drugs employed can cause systemic reactions.
“False Security”- incorrectly believed that it will not cause
respiratory or circulatory problems.
Contraindications:
Local infection for malignancy which may be carried to and
spread the adjacent tissue by needle injection
Septicemia- in a proximal nerve block, it may open a new
lymph channel that drains through the region causing new food and
local abscess formation from the perforation of small vessels and
exit of bacteria
Allergic sensitivity of patient to local drug.
Highly nervous, apprehensive patients, excitable patients
or those not viable to cooperate because of mental state or
age as among children.
11
2. Infiltration- injection of an anesthetic agent such as lidocaine
into the skin and subcutaneous tissue of the area to be incised.
Major Benefits
relatively safe method of anesthesia
provides excellent muscle relaxation
Does not cloud the client's consciousness or alertness.
Can be used for clients with full stomach.
12
nerve occurs drugs T position prior to block
shortly after
induction
Nausea & During Ephedrine
Vomiting abdominal Antiemetics
surgery owing oxygen
to traction
placed on
various
structures
within the
abdomen or
hypotension
Headache CSF leakage apply tight use every small
increase by abdominal spinal needle,
using large binder, increase IV fluids before
needle, poor fluids, & after, flat on
hydration analgesics, in bed 6-8 hrs post
severe cases- op
inject 10 ml of
patient’s blood
to plug hole
Respiratory Large amount/ Artificial avoid extreme T
Paralysis heavy respiration position
concentration
reaches upper
thoracic &
cervical cord
Neurologic unsterile strict sterile
Complications needles, technique,
eg: Paraplegia- syringes & preoperative
severe muscle anesthetic neurological
weakness in the meds exam
legs Preexisting
diseases-
multiple
sclerosis &
Spinal cord
injury
Stages of Anesthesia
1. Onset / Induction – extends from the administration of
anesthesia to the time of loss of consciousness
2. Excitement / Delirium – extends from the time of loss of
13
consciousness to the time of loss of lid reflex. It may be
characterized by shouting, struggling of the client.
3. Surgical – extends from the loss of lid reflex to the loss of
most reflexes. Surgical procedure is started.
4. Medullary / Stage of Danger – it is characterized by
respiratory/ cardiac depression or arrest. It is due to overdose of
anesthesia. Resuscitation must be done.
• The weight of the upper leg may cause peroneal nerve injury in
the down side leg. (Both legs must therefore be padded.)
Surgical Incisions:
• Butterfly – for craniotomy
• Limbal – for eye surgeries
• Halstead / Elliptical – for breast surgeries
• Abdominal – for abdominal surgeries
• Mc Burneys – for appendectomy
• Lumbotomy / Transverse – for kidney surgeries
15
Goals:
• Maintain adequate body system functions.
• Restore hemeostasis.
• Alleviate pain and discomfort.
• Prevent post operative complications.
• Ensure adequate discharge planning and teaching.
B. Interventions (RR)
Ensure maintenance of patent airway and adequate respiratory
function
• Lateral position while neck extended
• Keep oral airway in place until fully awake
• Suction secretions
• Encourage deep breathing
• Administer humidified oxygen as ordered
Assess status of circulatory system
• Monitor VS and report abnormalities
• Observe S/S of shock and hemorrhage
• Promote comfort and maintain safety
• Continuous, constant surveillance of the client until
he/she is completely out of anesthesia
• Recognize stress factors that may affect the client in RR
16
and minimize these factors.
17
• Self activities
• Activity limitation
• Diet and medications at home
• Possible complications
• Referrals, follow up check up
Postop Discomforts
• Nausea and vomiting
• Restlessness and sleeplessness
• Thirst
• Constipation
• Pain
2. HEMORRHAGE
Clinical Manifestations
Apprehension; restlessness; thirst; cold, moist, pale skin
Deep, rapid RR; low body temp
Low cardiac output
Low BP, low hgb
Circumoral pallor; spots before the eyes, ringing ears
Progressive weakness, then death ensues
Management
Vitamin K (aquamephyton), Hemostan
Ligation of bleeders
Pressure dressing
Blood transfusion, IV fluids
3. FEMORAL PHLEBITIS
- often occurs after operations on the lower abdomen or
during the course of septic conditions as ruptured ulcer or peritonitis
18
Causes:
• injury – damage vein
• hemorrhage
• prolonged immobility
• obesity / debilitation
Clinical Manifestations
• Pain
• Redness
• Swelling
• Heat/ warmth
• + Homan’s sign
Nursing Interventions
Prevention
• Hydrate adequately to prevent hemoconcentration.
• Encourage leg exercises and ambulate early.
• Avoid any restricting devices that can constrict and impair
circulation.
• Prevent use of bed rolls, knee gatches, dangling over the side
of the bed with pressure on popliteal area.
Active Intervention
• Bed rest, elevate the affected leg with pillow support.
• Wear antiembolic support hose from toes to the groin.
• Avoid massage on the calf of the leg.
• Initiate anticoagulant therapy as ordered.
4. PULMONARY COMPLICATIONS
Atelectasis
Bronchitis
Bronchopneumonia
Lobar pneumonia
Hypostatic pulmonary congestion
Pleurisy
Nursing Interventions
• Reinforce deep breathing, coughing, turning exercises (DBCT)
• Encourage early ambulation
• Incentive spirometry
5. URINARY DIFFICULTIES
19
Retention
• Occurs most frequently after operation of the rectum, anus,
vagina, lower abdomen
• Caused by spasm of the bladder sphincter
Incontinence
• (30-60 ml every 15-30 mins – over distended bladder –
overflow incontinence)
• Loss of tone of the bladder sphincter
• Nursing Intervention
Implement measures to induce voiding
Nursing Interventions
• NGT insertion
• Administer electrolyte/ IV as ordered
• Prepare for possible surgical intervention
7. HICCUPS
Nursing Interventions
Remove the cause e.g. abdominal distention (NGT Insertion)
Hold breath while taking a large swallow of water
Pressing on the eyeball through closed lids for several minutes
Breathe in and out on the paper bag (CO2)
20
Plasil (methochlorpramide) as ordered.
8. WOUND INFECTIONS
Causes:
• Staphylococcus aureus
• Escherichia coli
• Proteus vulgaris
• Pseudomonas aeroginosa
• Anerobic bacteria
Clinical Manifestations
• Redness, swelling, pain, warmth
• Pus or other discharge on the wound
• Elevated temperature; chills
• Tender lymph nodes on the axilla or groin closest to the wound
Rule of Thumb
• Fever 1st 24 hrs – pulmonary infection
• Within 48 hrs – UTI (urinary tract infection)
• Within 72 hrs – wound infection
Preventive Interventions
• Housekeeping cleanliness in the surgical environment
• STRICT ASEPTIC TECHNIQUES
• Wound care
• Antibiotic therapy
9. WOUND COMPLICATIONS
Kinds
• Hemorrhage/ Hematoma
• Wound Dehiscence – disruption in the coaptation of wound
edges (wound breakdown)
• Wound Evisceration- dehiscence + outpouching of abdominal
organs
Nursing Interventions
• Apply abdominal binders
• Encourage proper nutrition – high CHON, Vitamin C
• Stay with client, have someone call for a doctor
• Keep in bed rest
• Supine or semi-fowler’s position, bend knees to relieve tension
on abdominal muscles
21
• Cover exposed intestine with sterile, moist saline dressing
• Reassure, keep him/her quiet and relaxed
• Prepare for surgery and repair of wound
10. POSTOP PSYCHOLOGICAL DISTURBANCES
• DELIRIUM (Mental Aberration)
• ACS (Acute Confusional State)
Causes:
• Dehydration
• Insufficient oxygen
• Anemia
• Hypotension
• Hormonal imbalances
• Infection
• Trauma (especially in nervous patients)
Manifestations
• Poor memory
• Restlessness
• Inattentiveness
• Inappropriate behavior, wild excitement, hallucination,
delusions, depression
• Disoriented
• Sleep disturbances
Nursing Interventions
• Sedatives to keep the client quiet and comfortable
• Explain reasons for interventions
• Listen and talk to the client and significant others
• Provide physical comfort
• Treat the underlying cause
22