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Periop Power Point
Periop Power Point
HERMAN F. ZOLETA
Perioperative Care
Support system
No sedation should be administered to the client before the client signs the
consent
Minors (clients under 18 years old) may need a parent or legal guardian to
sign the consent form
An emancipated minor is usually recognized as one who is not subject to
parental control:
Married minor
Older clients may need a legal guardian to sign the consent form
The nurse may witness the client’s signing of the
consent form, but the nurse must be sure that the
client has understood the surgeon’s explanation of
the surgery
The nurse needs to document the witnessing of the
signing of the consent form after the client
acknowledges understanding the procedure.
b. Nutrition
Review the physician’s orders regarding the NPO
status before surgery.
Withhold solid foods and liquids for 6 to 8 hours
before general anesthesia and 3 hours before
surgery with local anesthesia to avoid aspiration
Insert an IV line and administer IV fluids, if ordered.
Assess for allergies review the preop checklist to be sure that each item is
addressed before the client is transported to surgery
Ensured that informed consent forms have been signed for the operative
procedure, any blood transfusions, disposal of a limb or surgical
sterilization procedures
Ensure that a history and PE have been completed and documented in the
client’s record
Ensure that consultation requests have been completed and documented in
the client’s record
Ensure that the prescribed laboratory results are documented in the client’s
record
Ensure that the ECG and Chest X-ray reports are documented in the client’s
record
Ensure that the blood type, screen, type and crossmatch are
performed and documented in the client’s record
Remove jewelry, makeup, dentures, hairpins, nail polish
(depending on agency procedures), glasses and prostheses
Document that valuables have been given to the client’s
family members or locked in the hospital safe.
Document the last time the client ate or drank
Document the client voided before surgery
Document that the prescribed preop medication was given
Monitor and document the client’s vital signs
Preoperative medications
The anesthesiologist frequently orders preop meds.
Common preop meds include the following:
Anticholinergic,
↓ respiratory tract secretions
Dry mucous membranes
Interrupt vagal stimulation
Antianxiety drugs
Reduce preop anxiety
Slow motor activity
Promote induction of anesthesia
Histamine-2 receptor antagonist
↓ gastric acidity and volume
Narcotics
↓ the amount of anesthesia needed
Promote sleep
Sedatives
Promote sleep
↓ anxiety
Tranquilizers
Reduce nausea
Prevent emesis
IM
Inhaled
Rectal
inhalation/volatile liquids
considerations
1. ether Highly flammable
2. Halothane / flouthane Could decrease bp
Contraindicated in obstetrics
3. Methoxyflurane / penthrane Used during labor
Could cause hypotension
Contraindicated in renal disorders.
4. Enflurane / ethrane Can depress respiratory function.
Not to be used during labor because it
could suppress uterine contractions.
Contraindicated in clients with seizure
disorders.
5. Isoflurane / forane Could cause hypotension and respiratory
depression.
Not to be used during labor because it
could suppress uterine contractions.
6. Desflurane / suprane Could cause hypotension and
respiratory depression.
7. Sevoflurane / ultane Similar to isoflurane and desflurane, it
promotes rapid recovery after anesthetic
administration has ceased.
Inhalation / gas
considerations
1. Nitrous oxide / laughing gas Should be given with oxygen.
Has low potency
2. cyclopropane Highly flammable and explosive.
Seldom used.
intravenous
considerations
1.Ultrashort barbiturates
a. thiopental sodium / pentothal Keep client warm, shivering and tremors
may occur.
Can depress respiratory center, ventilator
assistance may be necessary.
b. methohexital sodium / brevital sodium Used for induction of anesthesia
An inhalation anesthesia usually follows.
c. thiamylal sodium / surital Used for induction of anesthesia and
anesthesia for electroshock therapy.
2. benzodiazepines
a. diazepam / valium For induction of anesthesia.
No analgesic effect.
b. midazolam / versed For induction of anesthesia and for
endoscopic procedures.
IV drug can cause conscious sedation.
Avoid if cardiopulmonary disorder is
present
3. others
a. Droperidol and Fentanyl / Innovar May cause hypotension and respiratory
depression.
b. Etomidate / Amidate Used for short – term surgery, or as
induction of anesthesia, or with general
anesthetic.
c. Ketamine hydrochloride / Ketalar It increases salivation, blood pressure and
heart rate.
Avoid with history of psychiatric disorders
d. Propofol / Diprivan May cause hypotension and respiratory
depression.
Pain can occur at the injection site; thus
may be mixed with a local anesthetic such
as lidocaine to decrease pain.
Local Anesthesia
Inhalation / Volatile Liquids
Considerations
1. Short – acting -1/2 – 1h
a. Chloroprocaine / Nesacaine For infiltration, caudal and epidural
anesthesia.
b. Procaine HCI For nerve block, infiltration, epidural and
spinal anesthesia.
Caution in use for clients allergic to
ester-type anesthetics.
2. Moderate – acting – 1-3 h
a. Lidocaine / xylocaine For nerve block, infiltration, caudal, and
epidural and spinal anesthesia.
b. Mepivacaine HCI / Carbocaine For nerve block, infiltration, caudal, and
HCI, Isocaine; Prolocaine epidural anesthesias.
May be used in dentistry.
c. Prilocaine HCI / Citanect For nerve block, infiltration, caudal, and
Four stages are used to describe the induction of
general anesthesia
Stage I. Induction or beginning
This short period is crucial for producing unconsciousness
The client experiences Dizziness
Detachment
Temporary heightened sense of awareness to noises and
movements
A sensation of “heavy” extremities and being unable to
move them
Inhaled or IV anesthetics are used to produce this phase
When the client becomes unconscious, his or her airway is secured with
endotracheal tube.
Stage II. Excitement
During this stage the client may:
Struggle
Shout
Talk
Sing
Laugh
Cry
anesthesia.
The client will have:
Shallow respirations
Weak pulse
Performing biopsy
Tooth extraction
Examples:
Procaine (Novocaine)
Lidocaine (Xylocaine)
Bupivacaine (Marcaine)
Dibucaine (Nupercaine)
2. Topical (surface) anesthesia is applied directly to the:
skin and mucous membrane
wounds
burns
Examples:
Xylocaine
Benzocaine
Examples:
Lidocaine (Xylocaine)
Mepivacaine (Carbocaine)
Bupivacaine (Marcaine)
4. Spinal anesthesia is also referred to as
subarachnoid block (SAB). It requires a lumbar
puncture through one of the interspaces between
lumbar disc L2 and the sacrum S1 but usually L4 and
L5.
An anesthetic agent is injected into the subarachnoid
space surrounding the spinal cord. Used for surgery
involving the abdomen, perineum and lower
extremities. Spinal anesthesia is often categorized
as a low, mid and high spinal.
Low spinals (saddle or caudal blocks) are primarily
used for surgeries involving the perineal or rectal
areas.
Mid spinals (below the level of the umbilicus – T10)
can be used for hernia repairs or appendectomy
High spinals (reaching the nipple line – T4) can be
used for surgeries such as cesarean sections.
5. Epidural (peridural) anesthesia is an injection of
an anesthetic agent into the epidural space,
the area inside the spinal column but outside the
dura mater. Anesthetics same as above;
opioids such as morphine or fenantyl may be added
to enhance the anesthetic effect and to provide
analgesia when the block has worn off.
2. Arrival in the OR
Is Guidelines to eliminate wrong site and wrong
procedure surgery
The nurse and surgeon ensure that the operative site
has been appropriately marked (the surgeon uses
indelible ink to mark the operative site)
Just before starting the surgical procedure, a time
out is conducted with all members of the operative
team present to identify the appropriate surgical
site again.
When the client arrives in the OR, the OR nurse will
verify identification bracelet with the client’s verbal
response and will review the client’s chart
The client’s chart will be checked for completeness and
reviewed for informed consent forms, history and PE
and allergic reaction information.
Physician’s orders will be verified and implemented
The IV line may be initiated at this time, if prescribed
The anesthesia team will administer the prescribed
anesthesia.
3. Possible Intraoperative Complications
- OR nurse assess the client continuously and protect the
client from potential complications, Including:
Infection
Strict aseptic technique is absolutely necessary before and during
surgery
Clients at risk for the retention of foreign objects in the wound.
Fluid volume
The anesthesiologist usually adds fluids to the IV lines, but the
circulating nurse may also perform this function.
If an indwelling catheter, the nurse measures urine output during
surgery.
Injury related to positioning
The OR staff positions the client on the OR table
according to the type of surgery.
Careful positioning and monitoring help to prevent
interruption of blood supply secondary to
prolonged pressure, nerve injury related to
pressure, postoperative hypotension, dependent
edema and joint injury related to poor body
alignment
Hypothermia
Client maybe at risk for hypothermia related to low
temperature in the OR, administration of cold IV
fluids, inhalations of cool gases, exposure of body
surfaces for the surgical procedure.
Malignant hyperthermia
Increase body temperature is response to anesthetic agent and response to stress
Symptoms include
- Tachycardia
- Tachypnea
- Cyanosis
- Fever
- Muscle rigidity
- Diaphoresis
- Mottled skin
-Hypotension
-Irregular heart rate
-↓ urine output
-Cardiac arrest
The circulating nurse closely monitors the client for
signs of hyperthermia
If the client’s temperature begins to rise rapidly,
anesthesia is discontinued and OR team implements
measures to correct physiologic problems, such as
fever or dysrhythmias.
Postoperative Care
i. Renal System
Assess the bladder for distention
Monitor patency of airway, verifying that the lungs are clear on auscultation or
describe sounds heard
Encourage deep breathing and coughing
b. Cardiovascular System
Monitor circulatory status, such as peripheral pulses, capillary refill and the absence
of edema, numbness, and tingling.
Encourage the use of antiembolism stockings, if prescribes, to promote venous return,
strengthen muscle tone, and prevent pooling of blood in the extremities.
c. Musculoskeletal system
Assess for range of motion in all extremities.
Maintain the NPO status until the gag reflex and peristalsis return.
When oral fluids are permitted, start with ice chips and water.
Ensure that the client advances to clear liquids and then to a regular
diet, as prescribed.
Assess for bowel sounds in all four quadrants.
Shock
Hemorrhage
Thrombophlebitis
Hypoxia
Urinary retention
Paralytic ileus
Wound dehiscence
Pneumonia and atelectasis
Wound evisceration
Pulmonary embolism
Wound infection
a. Pneumonia and Atelectasis
Definition:
Pneumonia: An inflammation of the alveoli caused by an infectious process
that may develop 3 to 5 days postoperatively as a result of infection,
aspiration and immobility.
Atelectasis: A collapse of the alveoli with retained mucous secretions; the most
common postoperative complication, usually occurring 1 to 2 days
postoperatively
1. Assessment
Assess for factors that may increase the risk of pneumonia and atelectasis.
Elevated temperature.
Cyanosis
Tachycardia
2. Interventions
Elevate temperature
Inability to void
Distended bladder
Hypertension
Abdominal distention
2. Interventions
Monitor temperature.
Monitor incision site for approximation of suture line, edema, or
bleeding, and signs of infection (REEDA: redness, erythema,
ecchymosis, drainage, approximation of the wound edges); notify the
physician if signs of wound infection as present.
Maintain patency of drains, and assess drainage amount, color, and
consistency.
Keep drain and tubes away from the incision line, and maintain
asepsis.
Change the dressing, as prescribed.
1. Assessment
Increased drainage
Opened wound edges
Appearance of underlying tissues through the wound
2. Interventions
Place the client in a low Fowler’s position with the knees
bent to prevent abdominal tension on an abdominal
suture line.
Cover the wound with a sterile normal saline dressing.
Notify the physician.
Prevent wound infection through strict asepsis.
Administer antiemetics as prescribed to prevent
vomiting and further strain on the abdominal incision.
Instruct the client to splint the abdominal incision when
coughing.
Wound Dehiscence and Evisceration
l. Wound Evisceration
Definition:
Wound evisceration is protrusion of the internal organs through an incision.
Evisceration is most common among obese clients, clients who have had
abdominal surgery, or those who have poor wound-healing ability.
Evisceration usually occurs 6 to 8 days after surgery.
1. Assessment
Discharge of serosanguineous fluid from a previously dried wound
Instruct the client not to drive for 24 hours after general anesthesia.
Instruct the client to cover the incision with plastic if showering is allowed.
Be sure the client is provided with a 48-hour supply of dressings for home
use.
Instruct the client on the importance of returning to the physician’s office for
follow-up.
Instruct the client that sutures usually are removed in the physician’s office 7
to 10 days after surgery.
Inform the client that staples are removed 7 to 14 days after surgery and
that the skin may become slightly reddened when they are ready to be
removed.
Types of Wound Healing
Steri-Strips may be applied to provide extra support after the sutures are removed.
Instruct the client on the use of medication, their purpose, dosages, administration,
and side effects.
Instruct the client on diet and to drink 6 to 8 glasses of liquid a day.
Instruct the client about activity levels and to resume normal activities gradually.
Instruct the client to avoid lifting for 6 weeks if a major surgical procedure was
performed.
Instruct the client with an abdominal incision not to lift anything weighing 10 Ibs or
more and not to engage in any activities that involve pushing or pulling.
The client usually can return to work in 6 to 8 weeks as prescribed by the physician.
Instruct the client about the signs and symptoms of complications and when to call a
physician.