PERIOPERATIVE NURSING

REY VINCENT H. LABADAN, RN

EARL KRISTOFFER L. PIRANTE, RN

PERIOPERATIVE PATIENTFOCUSED MODEL

Patient

PERIOPERATIVE NURSING: GENERAL CONSIDERATION

Conditions Requiring Surgery: a. Obstruction or blockage (Impairment to the flow of vital fluids) b. Perforation or rupture of an organ c. Erosion or wearing away of the surface of a tissue d. Tumors or abnormal growth

Categories of Surgical Procedures: According to Purpose: a. Diagnostic: to verify suspected diagnosis, e.g. biopsy b. Exploratory: to estimate the extent of the disease, e.g. exploratory laparotomy c. Curative: to remove or repair damaged or diseased organs or tissues

PERIOPERATIVE NURSING: GENERAL CONSIDERATION

c. Types of Curative Surgery: i. Ablative: removal of diseased organs. (-ectomy) e.g. appendectomy, hysterectomy ii. Reconstructive: partial or complete restoration of a damaged organ, e.g. plastic surgery after burns iii. Constructive: repair of a congenitally defective organ, (-plasty, -orrhaphy, -pexy) e.g. cheiloplasty, orchidopexy d. Palliative: to relieve pain, relieve distressing S/Sx According to Degree of Risk to Client: a. Major surgery b. Minor surgery

PERIOPERATIVE NURSING: GENERAL CONSIDERATION

Criteria: a. Major surgery: High degree of risk Prolonged intraoperative period Large amount of blood loss Extensive, vital organs may be handled or removed Great risk of complications, e. g. liver biopsy

b. Minor surgery: Lesser degree of risk to the client Generally not prolonged; described as one-day surgery or outpatient surgery Leads to few serious complications Involves less risk, e.g. cyst removal

PERIOPERATIVE NURSING: GENERAL CONSIDERATION

According to Urgency: a. Emergency: must be performed immediately without delay, e.g. gunshot wound, severe bleeding, b. Imperative or Urgent: must be performed as soon as possible within 24 48 hours, e.g. appendectomy c. Required: necessary for the well-being of the client, usually within weeks to months, e. g. cholecystectomy, cataract extraction, thyriodectomy d. Elective: should be performed for the clients well being but which is not absolutely necessary, e.g. simple hernia, vaginal repair, repair of scar e. Optional: surgery that a client requests, e.g. rhinoplasty, liposuction, mammoplasty

PERIOPERATIVE NURSING: GENERAL CONSIDERATION

Factors that Affect the Estimation of Surgical Risk a. Physical and Mental Condition of the Client Age: premature babies and elderly persons are at risk Nutritional status: malnourished and obese are at risk State of fluid and electrolytes balance: dehydration and hypovolemia predispose a person to complications General health: infectious process increase operative risk Mental health Economic and occupational status

PERIOPERATIVE NURSING: GENERAL CONSIDERATION

b. Types of drugs taken regularly: i. Steroids: may improve the bodys ability to response to the stress of anesthesia and surgery ii. Anticoagulants and salicylates: may increase bleeding during surgery iii. Antibiotics: maybe incompatible with or potentiate anesthetic agents iv. Tranquilizers: potentiate the effect of narcotics and can cause hypotension v. Antihypertensives: may predispose to shock by the combined effect of blood pressure reduction and anesthetic vasodilation vi. Diuretics: may increase potassium loss vii. Alcohol: will place the surgical client at risk when used chronically

PERIOPERATIVE NURSING: GENERAL CONSIDERATION

c. The Extent of the Disease

d. The Magnitude of the Required Operation

e. Resources and Preparation of the Surgeon, Nurses, and the Hospital

PERIOPERATIVE NURSING: GENERAL CONSIDERATION

Suffixes Related to Surgery: -ostomy -otomy -plasty -orrhaphy -oscopy -ectomy (make artificial opening) (cut into or incision) (plastic repair) (suturing; repair) (visual examination) (excision; removal) Colostomy Phlebotomy Rinoplasty Herniorrhaphy Endoscopy Cholecystectomy

PERIOPERATIVE NURSING: PHASES OF PERIOPERATIVE NURSING

Because clients experience varying degrees of anxiety and deficient knowledge related to surgery, careful planning by the nurse can help ensure a positive outcome. Encompasses a clients total surgical experience, including preoperative, intra-operative, and postoperative phases Refers to activities performed by the professional nurse during these phases.

PERIOPERATIVE NURSING: PHASES OF PERIOPERATIVE NURSING

a. Pre-Operative Phase: begins with the decision to perform surgery and ends with the clients transfer to the operating room table b. Intra-Operative Phase: begins with the client is received in the OR and ends with his admission to the PARR or PACU

c. Post-Operative Phase: begins with the client is admitted to PARR or PACU and extends through follow-up home or clinic evaluation

PERIOPERATIVE NURSING: THE PERIOPERATIVE TEAM

The Surgeon An Anesthesiologist or Nurse Anesthetist Makes the preoperative assessment to plan for the type of anesthesia to be administered and to evaluate the clients status The Professional Registered OR Nurse Makes preoperative assessment and documents the perioperative client care plan (Scrub, Circulating, PACU Nurse)

PERIOPERATIVE NURSING: THE PERIOPERATIVE TEAM

a. The Circulating Nurse Manages the OR and protects the safety and health needs of the client by monitoring the activities of the members of the surgical team and monitoring the conditions in the OR b. The Scrub Nurse Responsible for scrubbing for surgery, including setting up sterile tables and equipment and assisting the surgeon and surgical technicians during the surgical procedure c. The PACU Nurse Responsible for caring for the client until the client has recovered from the effects of anesthesia, is oriented, has stable vital signs, and shows no evidence of hemorrhage

PERIOPERATIVE NURSING: PRINCIPLES OF PERIOPERATIVE ASEPSIS

General: a. Keep sterile supplies dry and unopened b. Check package sterilization expiration date to verify sterility c. Maintain general cleanliness in surgical suite d. Maintain surgical asepsis: activities designed to keep sites free from the presence of microorganisms throughout the procedure Personnel: a. Personnel with signs of illness should not report to work b. Surgical scrub, a specific hand washing technique used by operating room personnel designed to reduce microorganisms in the hands and arms, is done for the length of time designed by hospital policy

PERIOPERATIVE NURSING: PRINCIPLES OF PERIOPERATIVE ASEPSIS

Surgical Scrub i. A sensor-controlled or knee- or foot-operated faucet allows the water to be turned on and off without the use of the hands ii. Remove all rings and watches iii. Use liquid soaps to prevent the spread of organisms iv. Keep the finger nails short and well-trimmed v. Clean fingernails with a nail stick under running water vi. Hold the hands higher than the elbows throughout the hand washing procedure so that run-off goes to the elbows vii. Allows the cleanest part of the arms to be the hands viii. A scrub brush facilitates the removal of microorganisms ix. Clean all areas of skin on the hands and arms in sequence starting at the hands and ending at the elbows x. After rinsing, dry the hands with paper towels, drying first one arm from the hand to the elbow, then using a second towel to dry the second hand

PERIOPERATIVE NURSING: PRINCIPLES OF PERIOPERATIVE ASEPSIS

Maintaining a Sterile Field (a microorganism-free area): a. Create a sterile field using sterile drapes b. Use the sterile field to place sterile supplies where they will be available during the procedure c. Drape equipment prior to use d. Keep drapes dry and out of contact with nonsterile objects e. Utilize sterile technique while adding or removing supplies from sterile fields Sterile Supplies and Solutions: a. Check expiration dates for sterility b. Dont use solutions that were opened prior to current use c. Lip the solution after initial use by pouring a small amount of liquid out of the bottle into a waste container to cleanse the bottle lip

PERIOPERATIVE NURSING: PRINCIPLES OF SURGICAL ASEPSIS

1. OR personnel must practice strict Standard Precautions (i.e., blood and body substance isolation) 2. All items used in the sterile field must be sterile 3. Sterile objects become unsterile when touched by unsterile objects 4. Sterile items that are out of vision sterile or below the waist level of the nurse are considered unsterile 5. Sterile objects can become unsterile by prolonged exposure to air-born organism 6. The skin can not be sterilized and is unsterile All personnel must perform a surgical scrub

PERIOPERATIVE NURSING: PRINCIPLES OF SURGICAL ASEPSIS

7. All OR personnel are required to wear specific, clean attire, with the goal of shedding the outside environment. Specific clothing requirements are prescribed and standardized for all ORs: a. OR personnel must wear a sterile gown, gloves, and specific shoe covers b. Hair must be completely cover c. Masks must be worn at all times in the OR for the purpose of minimizing air-borne contamination and must be changed between operations or more often, if necessary 8. Any personnel who harbors pathogenic organisms must report themselves unable to be in the OR to protect the client from outside pathogens

PERIOPERATIVE NURSING: PRINCIPLES OF SURGICAL ASEPSIS

9. Scrubbed personnel wearing sterile attire should touch only sterile items 10. Sterile gowns and sterile drapes have defined borders for sterility. Sterile surfaces or articles may touch other sterile surfaces or articles and remain sterile. Contact with unsterile objects at any point renders a sterile area contaminated. 11. The circulator and unsterile personnel must stay at the periphery of the of the sterile operating area to keep the sterile area free from contamination 12. Sterile supplies are unwrapped and delivered by the circulator following specific standard protocol so as not to cause contamination

PERIOPERATIVE NURSING: PRINCIPLES OF SURGICAL ASEPSIS

13. The utmost caution and vigilance must be used when handling sterile fluids to prevent splashing or spillage 14. Anything that is used for one client must be discarded or, in some cases, resterilized

PERIOPERATIVE NURSING: PREOPERATIVE PHASE

Begins at the time of decision for surgery and ends when the client is transferred to the OR This period is used to physically and psychologically prepare the client for surgery

The nurse plays a major role in client teaching and in relieving the clients and the familys anxieties

PERIOPERATIVE NURSING: PREOPERATIVE PHASE

Goals: a. Assessing and correcting physiologic and psychologic problems that might increase surgical risk b. Giving the person and significant others complete learning/ teaching guidelines regarding surgery

c. Instructing and demonstrating exercises that will benefits the person during post-op period
d. Planning for discharge and any projected changes in lifestyle due to surgery

PERIOPERATIVE NURSING: PREOPERATIVE PHASE

Psychologic Preparation for Surgery Preparation for hospital admission: includes explanation of the procedure to be done, probable outcome, expected duration of hospitalization, cost, length of absence from work, and residual effects

Causes of Fears: Fear of the unknown Fear of anesthesia, vulnerability while unconscious Fear of pain Fear of death Fear of disturbance of body image Worries: loss of finances, employment, social and family roles

PERIOPERATIVE NURSING: PREOPERATIVE PHASE

Manifestations of Fears: Anxiousness Confusion Anger Tendency to exaggerate Sad, evasive, tearful, clinging Inability to concentrate Short attention span Failure to carry out simple directions Dazed

PERIOPERATIVE NURSING: PREOPERATIVE PHASE

Nursing Interventions to Minimize Anxiety: Assess clients fears, anxieties, support systems, and patterns of coping Establish trusting relationship with client and significant others Explain routine procedures, encourage verbalization of fears, and allow client to ask questions

Demonstrate confidence in surgeon and staff

Provide for spiritual care if appropriate

PERIOPERATIVE NURSING: PREOPERATIVE PHASE

Legal aspect: Informed Consent, operative permit, surgical consent

This is to protect the surgeon and the hospital against claims that unauthorized surgery has been performed and that the patient was unaware of the potential risks of complications involved Protects the client from undergoing unauthorized surgery

PERIOPERATIVE NURSING: PREOPERATIVE PHASE

a. The Surgeon obtains operative permit or informed consent: Surgical procedure, alternatives, possible complications, disfigurements, or removal of body parts are explained Note: It is part of the nurses role as a client advocate to confirm that the client understands information given. b. Informed consent is necessary for each operation performed, however minor It is also necessary for major diagnostic procedures where major body cavity is entered, e.g. thoracentesis

c. Adult client (over 18 years of age) signs own permit unless unconscious or mentally incompetent If unable to sign, relative, (spouse or next of kin) or guardian will sign

PERIOPERATIVE NURSING: PREOPERATIVE PHASE

In an emergency, permission via the telephone is acceptable; have a second listener on phone when telephone permission being given

Consents are not needed for emergency care if all four of the following criteria are met: i. There is an immediate threat to life ii. Experts agree that it is an emergency iii. Client is unable to consent iv. A legally authorized person cannot be reached

PERIOPERATIVE NURSING: PREOPERATIVE PHASE

d. Minors (under 18) must have consent signed by an adult (i.e. parent or legal guardian). An emancipated minor may sign own consent: i. Married, ii. College student living away from home, iii. In military service, iv. Any pregnant female or anybody who has given birth e. Witness to informed consent may be nurse, other physician, clerk, or authorized person

f. If nurse witnesses informed consent, specify whether witnessing explanation of surgery or just signature of client

PERIOPERATIVE NURSING: PREOPERATIVE PHASE

Physiologic Preparation Prior to Surgery: a. Respiratory preparation: chest x-ray b. Cardiovascular preparation: ECG, CBC, blood typing, crossmatching, PT/PTT (prothrombin time, partial thromboplastin time), serum electrolytes c. Renal preparation: urinalysis

Obtain history of past medical conditions, allergies, dietary restrictions, and medications: A Allergy to medications, chemicals, and other environmental products such as latex All allergies are reported anesthesia and surgical personnel before the beginning of surgery If allergy exist, an allergy band must be placed in the clients arm immediately

PERIOPERATIVE NURSING: PREOPERATIVE PHASE

B Bleeding tendencies or the use of medications that deter clotting, such as aspirin, heparin, and warfarin sodium. Herbal medications may also increase bleeding time or mask potential blood-related problems C Cortisone and steroid use

D Diabetes mellitus, a condition that not only requires strict control of blood glucose levels but also known to delay wound healing E Emboli; previous embolic events ( such as lower leg blood clots) may recur because of prolonged immobility

PERIOPERATIVE NURSING: PREOPERATIVE PHASE

Instructional and Preventive Aspects: Frequently done on an out-client basis Assess the clients level of understanding of surgical procedure and its implications

Answer questions, clarify and reinforce explanations given by surgeon

Explain routine pre and post procedures and any special equipment to be used Deep breathing exercises: use of diaphragmatic and abdominal breathing

PERIOPERATIVE NURSING: PREOPERATIVE PHASE

Coughing exercise: deep breath, exhale through the mouth, and then follow with a short breath while coughing; splint thoracic and abdominal incision to minimize pain Turning exercise: every 1-2 hours post-operative Extremity exercise: prevents circulatory problems and post operative gas pains or flatus Assure that pain medications will be available post-op

PERIOPERATIVE NURSING: PREOPERATIVE PHASE

Physical Preparation On the Night of the Surgery: a. Preparing the clients skin: shave against the grain of the hair shaft to ensure clean and close shave b. Preparing the GIT: NPO after midnight Administration of enema may be necessary Insertion of gastric or intestinal tubes Preparing for Anesthesia Promoting rest and sleep: use of drugs Barbiturates: Secobarbital Na, Pentobarbital Na Non barbiturates: chloral hydrate, Flurazepam Note: given after all pre-op treatments have been completed.

PERIOPERATIVE NURSING: PREOPERATIVE PHASE

On the Day of Operation: a. Early morning care: about 1 hour before the pre-operative medication schedule Vital signs taken and recorded promptly Patient changes into hospital gown that is left untied and open at the back Braid long hair and remove hair pin Provide oral hygiene Prosthetic devices, eyeglasses, dentures removed Remove jewelries Remove nail polish Patient should void immediately before going to the OR Make sure that the patient has not taken food for the last 10 hours by asking the client Urinary catheterization may be performed in the OR

PERIOPERATIVE NURSING: PREOPERATIVE PHASE

b. Pre-Operative Medications: Generally administered 60-90 min before induction of anesthesia Purpose: i. To allay anxiety: the primary reason for pre-operative medications ii. To decrease the flow of pharyngeal secretions iii. To reduce the amount of anesthesia to be given iv. To create amnesia for the events that precedes surgery Types of Pre-Operative Medications: 1. Sedative: Given to decrease clients anxiety to lower BP and PR Reduce the amount of general anesthesia: an overdose can result to respiratory depression e.g. Phenobarbital

PERIOPERATIVE NURSING: PREOPERATIVE PHASE

2. Tranquilizer: Lowers the clients anxiety level e.g. Thorazine 12.5 - 25 mg IM 1-2 hours prior to surgery 3. Narcotic analgesia: Given to reduce patients to reduce anxiety and to reduce the amount of narcotics given during surgery e.g. Morphine sulfate 8-15 mg SC 1 hour prior to preoperative; *Can cause vomiting, respiratory depression and postural hypotension

PERIOPERATIVE NURSING: PREOPERATIVE PHASE

4. Vagolytic or drying agents: To reduce the amount of tracheobronchial secretions which can clog the pulmonary tree and result in atelectasis and pneumonia e.g. Atropine sulfate 0.3-0.6 mg IM 45 min before surgery; * An overdose can result to severe tachycardia c. Recording: all final preparation and emotional response before surgery should be noted down

d. Transportation to the OR, *Woolen or synthetic blankets must never be sent to the OR because they are source of static electricity

PERIOPERATIVE NURSING: PREOPERATIVE PHASE

Nursing Diagnosis for Preoperative Client Anxiety related to lack of knowledge about preoperative routines, physical preparation for surgery, post operative care and potential body image change

PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE

Begins the moment the patient is anesthetized and ends when the last stitch or dressing is in place Anesthesia A state or narcosis, analgesia, relaxation and reflex loss (severe central nervous system [CNS] depression produced by pharmacologic agent)

PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE

Four Stages of Anesthesia: a. Stage I: Onset [Beginning of Anesthesia] Patient breath in the anesthetic mixture Warmth, dizziness, & feeling of detachment may be experienced Ringing, roaring, or buzzing in the ears Inability to move extremities Surrounding noise is exaggerated Still conscious b. Stage II: Excitement Struggling, shouting, singing, laughing or crying may be experienced Pupils dilate but PERRLA, rapid PR, irregular RR Patient restrain might be necessary

PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE

c. Stage III: Surgical Anesthesia Continued administration of anesthetic agent RR, PR normal, skin pink and flushed Patient is unconscious

d. Stage IV: Danger Stage [Medullary Depression] Reached when to much anesthesia has been administered Respiration shallow, pulse weak, pupils dilate Cyanosis develops, without prompt intervention death may ensue

PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE

Stages of Anesthesia, summary:
Stage Onset Start-point End-point Anesthetic Loss of administration consciousness Physical Reactions Client maybe drowsy, or dizzy Possible auditory and visual hallucinations Increase in autonomic activity Irregular breathing Client may struggle Nursing Interventions Close operating room doors, keep room quiet Stand by to assist the client

Loss of eyelid Excitement Loss of consciousness reflexes

Remain quietly at clients side Assist anesthetist, as needed

Surgical Loss of eyelid Loss of most Client is unconscious Begin preparation (if indicated) only reflexes Muscles are relaxed when anesthesia indicates stage III Anesthesia reflexes Depression of vital No blink or gag reflexes has been reached and client is functions breathing well, with stable vital signs Danger (Death) Functions excessively depressed Respiratory and circulatory failure Client is not breathing If arrest occurs, respond immediately A heartbeat may or may to assist in establishing airway, provide cardiac arrest tray, drugs not be present syringes, long needles Assist surgeon with closed or open cardiac massage

PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE

Types of Anesthesia: a. General Anesthesia: a state of analgesia, amnesia, and unconsciousness characterized by the loss of reflexes and muscle tone i. Inhalation Anesthesia Advantage: prevention of pain and anxiety Disadvantage: circulatory and respiratory depression * Highly inflammable and explosive
Safety rules: Do not wear slips, nylons, wool, or any material which can set-off sparks No smoking 12 hours after the operation Do not wear shoes that are not conductive Do not rise bed materials that are not conductive, e.g. volatile liquid: halothane, ether; gas anesthetic: e.g. nitrous oxide, cyclopropane

PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE

ii. Intravenous Anesthesia: usually employed as an induction prior to administration of the more potent inhalation anesthetic agents. Used commonly in minor procedure Advantage: Rapid pleasant induction Absence of explosive hazards Low incidence of nausea and vomiting Disadvantage: Laryngeal spasm and bronchospasm Hypotension Respiratory arrest, e.g. Thiopental Na (Pentothal Na), Ketamine ( Ketalar), Fentanyl ( Innovar)

PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE

b. Regional Anesthesia: it is the injection or application of a local anesthetic agent to produce a loss of painful sensation in only one region of the body and does not result to unconsciousness i. Topical anesthesia: e.g. lidocaine

ii. Infiltration anesthesia Nerve block Epidural block Caudal block Pudendal block iii. Spinal anesthesia, e.g. Saddle block for vaginal delivery iv. Local anesthesia, e.g. Procaine, Lidocaine (Xylocaine)

PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE

c. Specialized Methods of Producing Anesthesia: i. Muscle relaxants: it is a neuromuscular blocking agent used to provide muscle relaxation Use: for endotracheal intubation, e.g. Pancuronium bromide (Pavulon), Curarine chloride (Curare)

ii. Hypothermia: it refers to the deliberate reduction of the patients body temperature between 28-30 C Uses: Heart surgery, Brain surgery, Surgery on large vessels supplying major organs

PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE

Methods: Ice water immersion Ice bags Cooling blanket Complications: Cardiac arrest Respiratory depression

PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE

Positioning the Client: Commonly Used Operative Positions Supine: hernia repair, explore lap, cholecystectomy, mastectomy Prone: spine surgery, rectal surgery Trendelenburg Reverse Trendelenburg Lithotomy position Lateral position: kidney and chest surgery Others: for thyroidectomy- head hyperextended

PERIOPERATIVE NURSING: POSTOPERATIVE PHASE

Post Anesthetic Care Nursing Responsibilities: a. Maintenance of pulmonary ventilation: Position the client to side lying or semi-prone position to prevent aspiration Oropharyngeal or nasopharyngeal airway: * Is left in place following administration of general anesthetic until pharyngeal reflexes have returned It is only removed as soon as the client begins to awaken and has regained the cough and swallowing reflexes All clients should received O2 at least until they are conscious and are able to take deep breaths on command

PERIOPERATIVE NURSING: POSTOPERATIVE PHASE

Shivering of the client must be avoided to prevent an increase in O2, and should be administered until shivering has ceased

b. Maintenance of circulation: Most common cardiovascular complications: i. Hypotension Causes: Jarring the client during transport while moving client from the OR to his bed Reaction to drug and anesthesia Loss of blood and other body fluids Cardiac arrhythmias and cardiac failure Inadequate ventilation Pain

PERIOPERATIVE NURSING: POSTOPERATIVE PHASE

ii. Cardiac arrhythmias Causes: Hypoxemia, Hypercapnea Interventions: O2 therapy, Drug administration: Lidocaine, Procainamide

c. Protection from injury and promotion of comfort Provide side rails Turning frequently and placed in good body alignment to prevent nerve damage from pressure Administration of narcotic analgesics to relieve incisional pain Post-operative dose usually reduced to half the dose the patient will be taking after fully recovered from anesthesia

PERIOPERATIVE NURSING: POSTOPERATIVE PHASE

Dismissal of Client from Recovery Room: Modified Aldrete Score for Anesthesia Recovery Criteria

The Five Physiological Parameters: a. Activity able to move four extremities voluntarily on command b. Respiration able to breath effortlessly and deeply, and cough freely c. Circulation BP is (+ 20%) or (- 20%) of pre-anesthetic level d. Consciousness fully awake, oriented to time, place and person e. Color pink (lips), for blacks: tongue

PERIOPERATIVE NURSING: POSTOPERATIVE PHASE

Modified Aldrete Score
AREA OF ASSESSMENT Muscle activity Ability to move all extremities Ability to move 2 extremities Unable to control any extremity Ability to breath deeply and cough Limited respiratory effort (dyspnea) No spontaneous effort BP +/- 20% of pre-anesthetic level BP +/- 20%-40% of pre-anesthetic level BP +/- 50% pre-anesthetic level Fully awake Arousable on calling Not responding Unable to maintain O2 sat >92% on room air Needs O2 inhalation to maintain O2 sat >90% O2 sat <90% even with O2 supplement
Point Score 1 hour 2 hours 3 hours

Respiration

Circulation

Consciousness Level O2 Saturation

2 1 0 2 1 0 2 1 0 2 1 0 2 1 0

Total Points
Required for discharge from PACU: 7-8

PERIOPERATIVE NURSING: POSTOPERATIVE PHASE

Postoperative Care Begins when the client returns from the recovery room or surgical suite to the nursing unit and ends when the client is discharged It is directed toward prevention of complication and postoperative discomfort Post-Operative Complications a. Respiratory Complications: atelectasis and pneumonia Suspected when ever there is a sudden rise of temperature 24-48 hours after surgery Collapse of the alveoli is highly susceptible to infection: pneumonia

PERIOPERATIVE NURSING: POSTOPERATIVE PHASE

Occurs usually in high abdominal surgery when prolonged inhalation anesthesia has been necessary and vomiting has occurred during the operation or while the patient is recovered from anesthesia NURSING MANAGEMENT: i. Measures to prevent pooling of secretions: Frequent changing of position High fowlers position Moving out of bed

ii. Measures to liquefy and remove secretions: Increase oral fluid intake Breathing moist air

PERIOPERATIVE NURSING: POSTOPERATIVE PHASE

Deep breathing followed by coughing Administer analgesics before coughing is attempted after thoracic and abdominal surgery Splint operative area with draw sheet or towel to promote comfort while coughing

iii. Other measures to increase pulmonary ventilation Blow bottle exercise Rebreathing tubes: increase CO2 stimulates the respiratory center to increase the depth of breathing thus increasing the amount of inspired air IPPB: intermittent positive pressure breathing apparatus

PERIOPERATIVE NURSING: POSTOPERATIVE PHASE

b. Circulatory Complication: venous stasis Causes of venous stasis Muscular inactivity Respiratory and circulatory depression Increased pressure on blood vessels due to tight dressing Intestinal distention Prolonged maintenance of sitting Contributing factors for venous stasis: Obesity CV disease Debility Malnutrition Old age

PERIOPERATIVE NURSING: POSTOPERATIVE PHASE

Most common circulatory complications: Phlebothrombosis Thrombophlebitis NURSING MANAGEMENT: Limbs must never be massaged for a post-op client If possible, client should lie on his abdomen for 30 min several time a day to prevent pooling of blood in the pelvic cavity Do not allow the client to stand unless pulse has returned close to baseline to prevent orthostatic hypotension Wear elastic bandages or stockings when in bed and when walking for the first time.

PERIOPERATIVE NURSING: POSTOPERATIVE PHASE

c. Fluids and Electrolytes Imbalance: Causes: Blood loss Increased insensible fluid loss through the skin; After surgery through vomiting, from copious wound drainage, and from the tube drainage as in NGT Since surgery is a stressor, there is an increased production of ADH for the first 12-24 hours following surgery resulting to fluid retention by the kidney The potential for over hydration therefore exists since fluids being given IV may exceed fluid output by the kidney

PERIOPERATIVE NURSING: POSTOPERATIVE PHASE

Electrolyte Imbalance: Particularly Na and K imbalance as a result of blood loss Stress of surgery increases adrenal hormonal activity resulting to increased aldosterone and glucocorticoids, resulting in sodium reabsorption by the kidney And as Na is reabsorbed, K coming from tissue breakdown is excreted Action: IV of D5W alternate with D5NSS or half strength NSS to prevent Na excess

PERIOPERATIVE NURSING: POSTOPERATIVE PHASE

d. Complications of Surgery i. GIT complications: Paralytic ileus: Cessation of peristalsis due to excessive handling of GI organs NURSING MANAGEMENT: NPO until peristalsis has returned as evidenced by auscultation of bowel sounds or by passing out of flatus Vomiting: usually the effect of certain anesthetics on the stomach, or eating food or drinking water before peristalsis returns. Psychologic factors also contribute to vomiting NURSING MANAGEMENT: Position the client on the side to prevent aspiration

PERIOPERATIVE NURSING: POSTOPERATIVE PHASE

When vomiting has subsided, give ice chips, sips of ginger ale or hot tea, or eating small frequent amounts of dry foods thus relieving nausea Administer anti-emetic drugs as ordered: Trimethobenzamide Hcl (Tigan); Prochiorperasine dimaleate (Compazine)

Abdominal distention: results from the accumulation of nonabsorbable gas in the intestine Causes: Reaction to the handling of the bowel during surgery Swallowing of air during recovery from anesthesia Passage of gases from the blood stream to the atonic portion of the bowel

PERIOPERATIVE NURSING: POSTOPERATIVE PHASE

Gas pains: results from contraction of the unaffected portion of the bowel in order to move accumulated gas in the intestinal tract Management: Aspiration of fluid or gas: with the insertion of an NGT Ambulation: stimulates the return of peristalsis and the expulsion of flatus Enema Rectal tube insertion: inserted just passed the anal sphincter and removal after approximately 20 minutes Adult: 2-4 inches, children: 1-3 inches Prolonged stimulation of the anal sphincter may cause loss of neuromuscular response, and pressure necrosis of the mucous surface

PERIOPERATIVE NURSING: POSTOPERATIVE PHASE

Constipation: due to decreased food intake and inactivity Regular bowel movement will return 3-4 days after surgery when resumption of regular diet and adequate fluid intake and ambulation ii. GUT Complications Return of urinary function: usually after 6-8 hours First voiding may not be more than 200 ml, and total out put may not be more than 1500ml Due to the loss of fluids during surgery, perspiration, hyperventilation, vomiting, and increased secretion of ADH

PERIOPERATIVE NURSING: POSTOPERATIVE PHASE

Complication: urinary retention Causes: Prolonged recumbent position Nervous tension Effect of anesthetics interfering with bladder sensation and the ability to void Use of narcotics that reduce the sensation of bladder distention Pain at the surgical site and on movement Urinary tract infection Management: Instruct the client to empty the bladder completely during voiding Catheterize if needed, done by sterile technique

PERIOPERATIVE NURSING: POSTOPERATIVE PHASE

f. Post-operative Discomforts i. Post-operative pain Narcotics can be given every 3-4 hours during the first 48 hours post-operatively for severe pain without danger of addiction ii. Singultus Brought about by the distention of the stomach, irritation of the diaphragm, peritonitis and uremia causing a reflex or stimulation of the phrenic nerve Management: Paper bag blowing; CO2 inhalation: 5% CO2 and 95% O2 x 5 minutes every hour

PERIOPERATIVE NURSING: POSTOPERATIVE PHASE

g. Wound Complications: Sutures are usually removed about 5th-7th day post-op with the exception of wire retention sutures placed deep in the muscles and removed 14-21 days after surgery i. Hemorrhage from the wound Most likely to occur within the first 48 hours post-op or as late as 6th-7th post-op day Causes: Hemorrhage occurring soon after operation: mechanical dislodging of a blood clot or caused by the reestablished blood flow through the vessel Hemorrhage after few days: Sloughing off of blood clot or of a tissue Infection

PERIOPERATIVE NURSING: POSTOPERATIVE PHASE

Assessment: Bright red blood Decreased BP Increased PR and RR Restlessness Pallor Weakness Cold, moist skin ii. Infection Cause: streptococcus and staphylococcus Assessment: 3-6 days after surgery, low grade fever, and the wound becomes painful and swollen. There maybe purulent drainage on the dressing

PERIOPERATIVE NURSING: POSTOPERATIVE PHASE

iii. Dehiscence and Evisceration Dehiscence or wound disruption: Refers to a partial-tocomplete separation of the wound edges Evisceration: Refers to protrusion of the abdominal viscera through the incision and onto the abdominal wall Assessment: Complain of a giving sensation in the incision Sudden, profuse leakage of fluid from the incision The dressing is saturated with clear, pink drainage Management: Position the client to low Fowlers position Instruct the client not to cough, sneeze, eat or drink, and remain quiet until the surgeon arrives Protruding viscera should be covered warm, sterile, saline dressing

PERIOPERATIVE NURSING: POSTOPERATIVE PHASE

Discharge Instructions: Early discharge, which has become common, typically increases client teaching needs Be sure to provide information about wound care, activity restrictions, dietary management, medication administration, symptoms to report, and follow-up care A client recovering from same-day surgery in an outpatient surgical unit must be in stable condition before discharge This client must not drive home, make sure a responsible adult takes the client home

PERIOPERATIVE NURSING: References

Textbook of Medical Surgical Nursing 7th Edition by Joyce Black Brunner and Suddarths Textbook of Medical Surgical Nursing 11th Edition by Suzanne Smeltzer Berry & Kohns Operating Room Technique 10th edition by Nancymarie Philips The Lippincott Manual of Nursing Practice 7th Edition by Sandra Nettina

Mastering Medical-Surgical Nursing 2nd edition by Josie Udan

NCLEX-RN Review Materials

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