Peri-operative Nursing

Perioperative Nursing
is used to describe the nursing care provided in the total surgical experience of a patient.

= The provision of nursing care by an RN preoperatively, intraoperatively, and postoperatively to a patient undergoing an operative or invasive procedure

Areas in Which Perioperative Nursing Is Practiced

Hospital operating rooms Interventional radiology suites Cardiac catheterization labs Endoscopy suites Ambulatory surgery centers Trauma centers Pediatric specialty hospitals Physician offices

Nursing Roles in the OR

Circulating Nurse Scrub person RN first assistant (RNFA) Perioperative educator Specialty team leader Perioperative manager

Surgical Attire
Gowns Gloves Masks Hair covering Protective eyewear

Goals of Patient Safety

Provide safe patient care

Knowledge of procedure Ensure the correct patient, correct site, correct level, and correct procedure Knowledge of positioning Adhere to safe medication administration guidelines Perform surgical counts

Provide a safe environment

Adhere to asepsis Promote coordinated and effective communication

Phases of Peri-operative period

PRE- operative phase

INTRA- operative phase

POST- operative phase

PRE-Operative Phase
Begins when the decision to have surgery is made and ends when the client is transferred to the operating table

INTRA-Operative Phase
Begins when the client is transferred to the operating table and ends when the client is admitted to the post-anesthesia unit

Post-operative Phase
Begins with the admission of the client to the PACU and ends when healing is complete

Conditions requiring Surgery:

Perforation = rupture of an organ, artery or bleb Tumor = abnormal growth Obstruction or Blockage Erosion = wearing away of a surface of a tissue

TYPES of SURGERY
According to PURPOSE

According to degree of URGENCY

According to degree of RISK

According to PURPOSE
Diagnostic Palliative To verify a suspected diagnosis Ex. biopsy Relieves or reduces pain or symptoms Removes a diseased body part Ex. Nephrectomy
Restores function or appearance; repair of a congenitally defective organ ex. Cleft palate

Ablative
Constructive Transplant

Replaces malfunctioning structures ex. Heart transplant

Reconstructive partial or complete restoration of a damaged organ Exploratory to estimate extent of a disease

Ex. Exploratory Laparotomy

According to degree of urgency

Emergency surgery Preserves function or life Performed immediately

Elective surgery

Performed when condition is not imminently life threatening

According to degree of RISK

Major Surgery Involves high degree of risk Complicated or prolonged

Minor Surgery

Involves low risk Produces few complications Performed as day surgery

Classification I. Emergent life threatening II Urgent or imperative III. Required or planned IV. Elective V. Optional

Indication for surgery Without delay 24-30 hrs

examples trauma AP, Cholecystitis

Plan within Cataracts, weeks or month thyroid No emergency Personal preference CS, hernia Cosmetic surgery

Other types of Surgery

PROPHYLACTIC Prevents a more PREVENTATIVE serious condition from developing

INPATIENT SURGERY

OUTPATIENT SURGERY

Client has been in the hospital prior to the decision to have a surgery Client enters the hospital to have surgery done

Surgical Risk
Extremes of age premature baby & elderly persons Nutritional Status malnourished & obese at risk General health infectious process increase operative risk State of fluid and electrolyte balance dehydration & hypovolemia predispose a client to post op complications Economic & occupational status Co-morbid conditions Concurrent medications types of drugs taken regularly anticoagulants can cause hemorrhage; antibiotics can combine with the anesthesia Mental health The extent of the disease The magnitude of the required operation Resources and preparation of the surgeon, nurses and hospital

PRE OP PREPARATIONS

Activities in the Pre-op

Assessing the clients Identifying potential or actual health problems Planning specific care Providing pre-operative teaching Ensure consent is signed

Pre-operative Interventions
Obtain nursing history, PE and lab exam Provide pre-operative teaching as to the nature of surgery, what to expect and ways to manage post-operative discomforts Perform physical preparations- shaving, hygiene, enema, NPO, medications

Informed Consent
The surgeon is responsible for obtaining the consent for surgery No sedation should be administered before SIGNING the consent The nurse may serve as witness This is to protect the surgeon and hospital against a claim that an unauthorized surgery was performed & patient is aware of potential risk of complications This is also to protect the patient in undergoing unauthorized surgery

INFORMED CONSENT
EMANCIPATED MINORS
- below legal age of 18 but who is living independently from parents or those who are already living in with partners and with children of their own

Physiologic Preparation
Respiratory preparation includes xray order by the surgeon Cardiovascular preparation ex. ECG ( blood test eg. CBC, Hgb,Hct etc) Renal preparation routine urinalysis

Pre-op nutrition
Assess order for NPO Solid foods are withheld for about 8 hours before general anesthesia WATER can be given up to 4 hours prior to surgery

Pre-op elimination
Laxatives, enemas or both may be prescribed the night before surgery Have the client void immediately BEFORE transferring them to the OR Foley catheter may be inserted as ordered

Pre-op hygiene
Bath the night before surgery with antiseptic soap Shaving of the skin is usually done in the OR Removal of jewelry and nail polish, contact lenses, hearing aids, dentures

Pre-op psychological preparation

Preparation for hospital admission includes explanation of procedure to be done, probable outcome, expected duration of hospitalization, cost, length of absence from work and residual effects Be alert to the clients anxiety level Answer questions or concerns Allow time for privacy Pre-operative visits

Preparing the skin Administering Preanesthetic medications Transporting the patient to the presurgical area

Pre-operative medications
Pre-op Drugs Example

Purpose
To decrease nervousness Promote relaxation Decreases secretions Prevent bradycardia To promote muscle relaxation To prevent nausea and vomiting

Anti-anxiety Diazepam Anticholinergic; vagolytic Muscle relaxant Anti-emetic Antibiotic Atropine

Succinylcholine

Promethazine

Cephalosporin To prevent infection

Pre-operative medications
Pre-op Drugs Example

Purpose
To decrease pain and decrease anesthetic dose

Analgesics

Meperidine

Anti-histamine Diphenhydramine To decrease occurrence of allergy

H-2 antagonist

Cimetidine

To decrease gastric fluid and acidity

Pre-operative screening test

CBC Blood type Determine Hgb and Hct, infection Determined in case of blood transfusion

Serum electrolytes FBS

BUN, Creatinine

Evaluates the fluid and electrolyte status Evaluates diabetes mellitus

Assess the renal function

ALT, AST, Bilirubin Evaluates the liver function Serum albumin CXR and ECG Evaluates nutritional status Respiratory and Cardiac status

Pre-operative teaching
Leg exercises To stimulate blood circulation in the extremities to prevent thrombophlebitis

Deep breathing and Coughing Exercises

To facilitate lung aeration and secretion mobilization to prevent atelectasis and hypostatic pneumonia
Done every two to four hours

Positioning and Ambulation

To circulation, stimulate respiration, decrease stasis of gas

Instructional and Preventive aspects

Note: The best time to instruct the client is relatively close to the time of the surgery DBE use of diaphragmatic abdominal breathing. Done 5-10 times every hour in post op period Coughing exercises deep breathe, exhale through the mouth then follow with short breaths while coughing. SPLINT thoracic & abdominal incision to minimize pain. Turning exercises every 1-2 hours post op Extremity exercises prevents circulatory problems & post-op gas pains or flatus.

Terminologies
Analgesia decrease pain Analgesic drug to reduce pain Anesthesia loss of sensation Anesthetic drug that produces local or general loss of sensitivity Induction start from anesthetic administration until pt. loses consciousness Narcosis loss of consciousness

OK ARE YOU READY SIR FOR YOUR OPERATION?

Activities during the Intra-op

Assisting the surgeon as scrub nurse and circulating nurse

Intra-operative phase interventions

Determine the type of surgery and anesthesia used Position client appropriately for surgery Assist the surgeon as circulating or scrub nurse Maintain the sterility of the surgical field Monitor for developing complications

Principles of Sterile Technique

Principles of Sterile Technique

Sterile field The patient is the center of the sterile field, which includes the: areas of the patient the operating table and furniture covered with sterile drapes and the personnel wearing the OR attire. Strict adherence to sound principles of sterile technique and recommended practices is mandatory for the safety of the patient. This adherence reflects ones surgical conscience.

Principles remain the same; it is the degree of adherence to them that varies.
The principles of sterile technique are applied in the following: 1. Preparation for operation by sterilization of necessary materials and supplies 2. Preparation of the operating team to handle sterile supplies and intimately contact wound 3. Creation and maintenance of the sterile field, including the preparation and draping of the patient, to prevent contamination of the surgical wound 4. Maintenance of sterility and asepsis throughout the operative procedure 5. Terminal sterilization and disinfection at the conclusion of the operation

The sterile technique is the basis of modern surgery. A. Sterile persons have scrubbed and are gowned and gloved; Unsterile persons have not. Persons who are sterile touch only sterile articles. Persons who are not sterile touch only unsterile articles. All supplies for the sterile team members reach them by means of the circulating nurse, through the medium of sterile forceps or wrappers on sterile packages.

B. Only sterile items are used within the sterile field. Some items such as linen, sponges, or basins may be obtained from the stock supply of sterile packages. Others, such as instruments, may be sterilized immediately preceding the operation and removed directly from the sterilizer to the sterile table. Every person who dispenses a sterile article must be sure of its sterility and of its remaining sterile until used. Proper packaging, sterilizing, and handling should provide such assurance.

If you are in doubt about the sterility of anything, consider it not sterile. Known or potentially contaminated items must not be transferred to the sterile field, for example: 1. If sterile package is found in the nonsterile workroom 2. If uncertain about actual timing or operation of sterilizer: Items processed in a suspect load are considered unsterile. 3. If unsterile person comes into close contact with a sterile table and vice-versa 4. If sterile table or unwrapped sterile items are not under constant observation; if a sterile table or sterile articles are left unguarded and uncovered for more than 30 minutes 5. If sterile package falls to the floor, it must then be discarded.

C. Gowns are considered sterile only from the waist to shoulder level in front, and the sleeves. When wearing a gown, consider only the area you can see down to the waist as the sterile area. The following practices must be observed:

1. Sterile persons keep hands in sight and at or above waist level. 2. Hands are kept away from the face. Elbows are kept close to sides. Hands are never folded under arms because of perspiration in the axillary region.

3. Changing table levels is avoided. If sterile person must stand on a platform to reach the operative field, the area of the gown below waist must not brush against sterile tables or draped areas. 4. Items dropped below waist level are considered unsterile and must be discarded. eg, when picking up a gown, if the top of the gown drops below waist level, it is discarded.

D. Tables are sterile only at table level.

1. Only the top of a sterile draped table is considered sterile. Edges and sides of drape extending below the table level are considered unsterile. 2. Anything falling over or extending over table edge, such as sutures are considered unsterile and are discarded. Scrub nurse does not touch the part hanging below table level. 3. In unfolding sterile drape, the part that drops below table surface is not brought back up to table level.

E. Persons who are sterile touch only sterile items or areas. Persons who are not sterile touch only unsterile items or areas. 1. Sterile team members maintain contact with sterile field by means of gowns and gloves. 2. Nonsterile circulating nurse does not directly come into contact with the sterile field. 3. Supplies for sterile team members reach them by means of the circulating nurse who opens wrapper on sterile packages.

F. Unsterile persons avoid reaching over a sterile field. Sterile persons avoid leaning over an unsterile area.

1.

2. 3. 4. 5.

The scrub nurse sets basin or glasses to be filled at the edge of the sterile table. The circulating nurse stands near the edge of the table to fill them. The circulating nurse stands at a distance from the sterile field to adjust the light over it. The surgeon turns away from the sterile field to have perspiration mopped from his brow. The sterile nurse drapes a nonsterile table toward self first to protect gown. The circulating nurse, using sterile forceps, drapes a table away from her first.

G. Edges of anything that encloses sterile contents are considered unsterile. ex: the edges of wrappers on sterile packages, caps on solution bottles and test tube covers 1. 2. 3. 4. Sterile persons lift contents from packages by reaching down and lifting them straight up, holding elbows high. Steam reaches only the area within the gasket of a sterilizer. Instrument trays should not touch the edge of the sterilizer outside the gasket. The circulating nurse peels the cover of a solution bottle or test tube, the edge of the cover never touches the lip. If the instruments are boiled, the tray must not touch the edge of the sterilizer when lifting it out.

H. Sterile field is created as close as possible to time of use. Degree of contamination is proportionate to length of time sterile items are uncovered and exposed to the environment.

1. Sterile tables are set up just prior to the operation. 2. It is difficult to uncover a table of sterile contents without contamination. Covering sterile tables for later use is not recommended.

I. Sterile areas are continuously kept in view. Inadvertent contamination of sterile areas must be readily visible.

1. Sterile persons face sterile areas. 2. When sterile packs are opened in a room, or a sterile field is set up, someone must remain in the room.

J. Sterile persons keep well within the sterile area. Allow a wide margin of safety when passing unsterile areas and follow these rules: 1. Sterile persons stand back at a safe distance from the operating table when draping the patient. 2. Sterile persons pass each other back to back. 3. Sterile person turns back to nonsterile person or area when passing. 4. Sterile person faces sterile area to pass it.

5. 6.

7.

Sterile person asks nonsterile individual to step aside rather than risk contamination. Sterile persons stay within and around a sterile field. They do not walk around or go outside the room. Movement within and around a sterile area is kept to a minimum to avoid contamination of sterile items or persons.

K. Sterile persons keep contact with sterile areas to a minimum. 1. Sterile persons do not lean on sterile tables and on the draped patient. Sitting or leaning against a nonsterile surface is a break in technique. If the sterile team sits to operate, they do so without proximity to nonsterile areas.

2.

L. Unsterile persons avoid sterile areas. A wide margin of safety must be maintained when passing sterile areas. 1. 2. 3. 4. Unsterile persons maintain at least one foot distance from any area of the sterile field. Unsterile persons face and observe a sterile area when passing it to be sure they do not touch it. Unsterile persons never walk between two sterile areas, eg, between sterile instrument tables. Circulating nurse restricts to a minimum activity near sterile field.

M. Destruction of the integrity of microbial barriers results in contamination. The integrity of a sterile package or sterile drape is destroyed by perforation, puncture or strike-through (soaking of moisture through unsterile layers to sterile layers or vice versa- may transport bacteria to sterile area). To ensure sterility: 1. Sterile packages are laid on dry surfaces. 2. If sterile packages become damp or wet, it is resterilized or discarded. A package is considered nonsterile if any of it comes in contact with moisture.

3. Drapes are placed on a dry field. 4. If solution soaks through sterile drape to nonsterile area, the wet area is covered with impervious sterile drape or towels. 5. Packages wrapped in muslin or paper are permitted to cool after removal from the sterilizer to avoid steam condensation and resultant contamination. 6. Sterile areas are stored in clean dry areas. 7. Sterile packages are handled with clean dry hands. 8. Undue pressure on sterile pack is avoided to prevent forcing sterile air out and pulling unsterile air into the pack.

N. Microorganisms must be kept to an irreducible minimum. Perfect asepsis in the operative field is the ideal. Although all the microorganisms cannot be eliminated, this does not obviate the necessity for sterile technique. It is generally agreed that: 1. Skin cannot be sterilized. Skin is a potential source of contamination in every operation.

a.

b.

c.

All possible means are used to prevent entrance of microorganisms into wound. Preventive measures include: Transient and resident flora are removed from skin around operative site of patient and the hands and arms of sterile team members by mechanical washing and chemical antiseptics. (shaved and scrubbed) Gowning and gloving of operating team is accomplished without contamination of sterile exterior of gowns and gloves. (without touching with their bare hands) Sterile gloved hands do not directly touch skin and then deeper tissues.

d. e. f. g. h.

If glove is pricked or punctured by a needle or instrument, glove is changed immediately. Needle or instrument is discarded from sterile field. In draping, all the skin area is covered except the site of incision. All operators scrub their hands and arms. Operators scrub between cases to remove bacteria that may have emerged from the pores with perspiration under the gloves. The knife used for the skin incision is placed in a specimen basin which thereafter is considered contaminated.

2. Some areas cannot be scrubbed. When the operative field includes the mouth, nose, throat or anus, the number of microorganisms is great. Various parts of the body, such as the GIT and the vagina, usually are resistant to infection from flora that normally inhabit these parts. The following steps may be taken to reduce the number of microorganisms present in these areas and to prevent scattering them: a. Surgeon makes an effort to use a sponge only once, then discards it.

b.

The GIT , especially the colon, is contaminated. Measures are taken to prevent spreading this contamination. - gastric route when possible - cautery when cutting across a lumen - colostomy is walled off from the operative site when possible - antibiotics given preoperatively - septic routine clean-up after procedure on the colon

3. Infected areas are grossly contaminated. The team avoids spreading the contamination. 4. Air is contaminated by dust and droplets. Examples of control measures: - Masks are worn over the nose and mouth.(fit snugly) - Talking is kept to minimum. - Sneezing and coughing are avoided. - Doors from corridors into the OR are kept closed. - Floors are wet-mopped, not dry-swept as dust may float in the air for a long time. - OR attire is not worn outside the surgery suite. - Wash hands before and after the care of each client.

SUMMARY
Principles of Sterile Techniques 1. Sterile surface touching sterile surface means sterile. 2. Sterile surface touching un-sterile surface becomes contaminated. 3. When there is doubt about the sterility of any item, it must be considered not sterile. 4. Reaching across or above sterile with bare hands or arms or other non-sterile item must be avoided.

5. Sterile materials must kept dry; moisture transmits microorganism and contaminated.
6. Coughing, sneezing or unnecessary talking near or over a sterile field must be avoided. 7. When wearing sterile gloves, hands must be kept in sight, away from un-sterile objects and above waist level. 8. The wrapper of a sterile pack must be opened, away from the body, the distal flap first, the lateral flaps next, and the proximal flap toward the body last, thus it unnecessary to reach over the sterile field.

9. The sterile zone is confined to the tabletop or to above waist level. Anything that hangs, falls, or touches below these levels is considered contaminated. 10.Any area of 1 inch or so surrounding the outer edge of the sterile field must be considered unsterile.

11.The sterile field must be kept in sight at all times. Do not turn your back on it or leave. If you do, you cannot be sure that it is still sterile. 12.The floor must be recognized as the most grossly contaminated area. Clean or sterile items that fall on the floor should be discarded or decontaminated.

SEDATION
MINIMAL SEDATION MODERATE SEDATION DEEP SEDATION ANESTHESIA

LEVEL OF ANESTHESIA: Minimal sedation - drug induced state in which a patient can respond normally in verbal commands - cognitive function and coordination may be impaired Moderate sedation - depressed level of consciousness that does not impair ability to maintain a patent airway - calm, sedate a patient combined with analgesic - Midazolam/Diazepam

Deep Sedation - deep sedation is a drug induced state in which a patient cannot easily be aroused but can respond purposefully after repeated stimulation. - inhaled or intravenously - Volatile anesthetic (halothane, Isoflurane) - Gas anesthetic (Nitrous oxide)

ANESTHESIA
means the absence of sensation.

state of narcosis (severe CNS depression produced by pharmacological agents), analgesia, relaxation and reflex loss loses the ability to maintain ventilatory function and require assistance in maintaining a patent airway. Cardiovascular function may be affected as well

Types of Anesthesia
General anesthesia

Loss of all sensation and consciousness State of analgesia, amnesia & unconsciousness characterized by loss of reflexes & muscle tone

Regional or Local anesthesia

Loss of sensation in ONE area with consciousness present

Types of Regional Anesthesia

1.Topical anesthesia applied directly on the skin ex. Lidocaine ( emla); cocaine 2. Infiltration Anesthesia injected into a specific area of the skin Types: 1. Nerve block injected around a nerve 2. Epidural Block injected into the epidural space 3. Caudal block 4. Pudendal block 5. Spinal subarachnoid low spinal anesthesia

3. Spinal anesthesia
Saddle block ( used in vaginal delivery)

4. Local anesthesia

Ex. Procaine ( novocaine) Cocaine ( tetracaine) Lidocaine ( xylocaine)

Safety rules:

Do not wear slips, nylons, wool or any material which can set off sparks Do not allow cautery to be used Do not touch the vicinity of the breathing area to prevent sparks Do not wear shoes that are not conductive Do not use bed materials that are not conductive. Examples: Volatile liquid halothane, ether Gas anesthetic nitrous oxide, cyclopopane

Methods of Anesthesia Administration Inhalation Intravenous Regional Anesthesia Conduction and spinal anesthesia Local Infiltration

REGIONAL Anesthesia
TOPICAL INFILTRATION

Applied directly on the skin Injected into a specific area of skin

NERVE BLOCK
SPINAL Subarachnoid

Injected around a nerve

Low spinal anesthesia

EPIDURAL

Epidural space is injected with anesthesia

GENERAL ANESTHESIA
the patient is unconscious and does not see, hear, or feel anything. It provides pain relief, muscle relaxation, and amnesia so you don't remember the details of your surgery.

GENERAL Anesthesia
Administered in two ways: Inhalational ADV. = for prevention of pain & anxiety DISADV = circulatory & respiratory depression

Intravenous

G A: INHALATIONAL ADMINISTRATION

G A: INTRAVENOUS ADMINISTRATION

G A: HALOTHANE
is a powerful anesthetic and can easily be overadministered. Advantages: pleasant odor Disadvantages: little pain relief (combined with other agents to control pain) Adverse reactions:

cardiac dysrhythmia Hepatotoxicity

G A: ENFLURANE (ETHRANE)
is less potent and results in a more rapid onset of anesthesia and faster awakening than halothane. Adverse reaction: Increases ICP and the risk of seizure (contraindicated among patients with seizure disorders)

G A: ISOFLURANE (FORANE)
is not toxic to the liver but can cause some cardiac irregularities. Isofluorane is often used in combination with intravenous anesthetics for anesthesia induction. Awakening from anesthesia is faster than it is with halothane and enfluorane.

G A: SEVOFLURANE
Does not cause cardiac arrhythmias and coughing that is why this is replacing halothane for induction of pediatric clients

this agent is rapidly eliminated and allows rapid awakening

NITROUS OXIDE (LAUGHING GAS)

is a weak anesthetic and is used with other agents, such as thiopental, to produce surgical anesthesia. It has the fastest induction and recovery and is the safest because it does not slow breathing or blood flow to the brain. Adverse effect: it diffuses rapidly into aircontaining cavities and can result in a collapsed lung (pneumothorax) or lower the oxygen contents of tissues (hypoxia).

Intravenous Anesthesia:- usually employed as an induction prior to administration of the more potent inhalation anesthetic agents. Commonly used in minor operations. Advantages: 1. rapid pleasant induction 2. Absence of explosive hazards 3. Low incidence of N&V Disadvantages: 1. Laryngeal spasm & bronchospasm 2. Hypotension 3. Respiratory arrest Examples: 1. Thiopental sodium ( Pentothal Na) 2. Ketamine ( ketalar) 3. Fentanyl ( Innovar) 4. Mtethohexital ( Brevital)

POST- G A Effects
Headache vision problems, including blurred
or double vision

shivering or trembling muscle pain dizziness, lightheadedness, or faintness drowsiness mood or mental changes nausea or vomiting sore throat nightmares or unusual dreams

Potential adverse effects of anesthesia Myocardial depression, bradycardia Anaphylaxis CNS agitation, seizures, respiratory arrest Oversedation or under sedation Agitation and disorientation Hypothermia Hypotension Malignant hyperthermia

PRECAUTION
A complete medical history including a history of allergies in family members, is an important precaution. Patients may have a potentially fatal allergic response to anesthesia known as malignant hyperthermia (a muscular disorder induced by anesthesia), even if there is no previous personal history of reaction. WARNING SIGN: TACHYCARDIA

Discharge Instructions post- GA

Do not consume alcohol Do not drive a car or operate heavy machinery Do not sign any legal documents Do not make any important decisions Someone should stay with you at least for the first 24 hours after your surgery.

Establishing AIRWAY PATENCY: ENDOTRACHEAL INTUBATION

LARYNGOSCOPE

PURPOSES OF GENERAL ANESTHESIA pain relief (analgesia) blocking memory of the procedure (amnesia) producing unconsciousness inhibiting normal protective body reflexes to make surgery safe and easier to perform relaxing the muscles of the body

Stages of General Anesthesia

Stage I (Stage of Induction ;Beginning Anesthesia or Analgesia) - patient may be still conscious, sense inability to move extremities - noises are exaggerrated -NI: avoid unnecessary noises or motions - sensation of pain is not lost

Stage II: Delirium or Excitement - Characterized by struggling, shouting, talking, crying. - pupils dilate, rapid pulse and irregular RR - restrain the patient - extends from loss of consciousness to loss of eyelid reflexes - increased muscle tone, irregular respiration, REM Stage III: Stage of Surgical Anesthesia - extends from loss of eyelid reflexes to cessation of respiratory effort - reflexes absent - Surgical anesthesia is reached - pt unconscious and lies quietly - respirations are regular and CR - may be maintained in hours if properly given

Stage IV: Stage of Medullary Depression; Respiratory Paralysis; Toxic Stage - stage is reached when too much anesthesia is given - RR become shallow, pulse is weak and thready, pupils widely dilated - Without proper treatment death will follow - Discontinue anesthetic abruptly

INTRASPINAL ANAESTHESIA
best reserved for operations below the umbilicus e.g. appendectomy, hernia repairs, gynaecological and urological operations and any operation on the perineum or genitalia. 1. epidural 2. intrathecal (subarachnoid)

INTRASPINAL ANESTHESIA
TETRACAINE

EPIDURAL ANESTHESIA

INTRATHECAL (SUBARACHNOID)

Patient Positioning
Provides optimal visualization Provides optimal access for assessing and maintaining anesthesia and function Protects patient from harm

Position Patient during Surgery

Abdominal surgeries Bladder surgery Perineal surgery Brain surgery Spinal cord surgeries Lumbar puncture Supine Slightly trendelenburg Lithotomy Semi-fowlers Prone mostly Side lying, flexed body

Supine for hernia repair, explore lap, cholecystectomy, mastectomy Prone for back and rectal surgery, ( Note: after surgery, the patient will be returned to the supine position. This should be done gradually and slowly to adjust cardiovascular system to change in position. Rapid turning can cause a drop in BP. Lateral position used in kidney & chest surgery Lithotomy thighs & legs are flexed at right angles & then simultaneously placed in a stirrup.

Positions for Surgery

Supine/ Dorsal usual position for induction of general anesthesia and for entering the major body cavities Modified Trendelenburg used for lower abdominal surgery and some lower extremity surgery Reverse Modified Trendelenburg used for upper abdominal, neck and face surgery Lithotomy used in operation requiring perineal approach Prone used in surgery on the posterior part of the body Lateral used for operation on the kidneys, lungs or hips Modified Fowlers sitting position; used mostly in neurosurgery Modified jacknife for rectal surgery

Operating Room Team direct patient care team The team is likely a symphony orchestra Each person is an integral entity in harmony with his colleagues 1. THE STERILE TEAM 2. THE UNSTERILE TEAM

The Sterile Team

Operating surgeon Assistants to the surgeon Scrub person They:

scrub their hands and arms Don sterile gloves and gown Enter the sterile field (all items for the surgical procedure are sterilized)

Unsterile team: Anesthesiologist Circulating nurse Technician They:

Dont enter the sterile field Function outside of it Maintain sterile technique

SCRUB OUT !!!

Scrub duties

Scrub duties
Perform surgical hand scrub. Gown and glove using closed glove technique. Re-gown and glove when breaks in technique occur. Assist the 1st scrub in setting up case (back table, mayo stand and O.R. basins). Arrange instruments and supplies (back table, mayo stand and O.R.). Count needles, instruments and sponges. Check instruments for proper functions. Prepare irrigating solution. Draw medications properly. Gown and glove surgeon and assistant. Assist with draping.

Scrub duties
Prepare electric cautery, suction and light handles for proper use. Prepare necessary sutures. Pass instruments to surgeon and assistant. Retract, sponge, and suction during case as necessary. Proper identification and handling of specimen. Prepare instruments for decontamination at completion of case. Dispose of sharps properly. Discard soiled drapes and trash properly. Transport soiled drapes and trash properly. Anticipate the surgeon and assistant needs. Anticipate the operative procedure needs. Help apply wound dressing.

Circulating Responsibilities

Circulating Responsibilities
Clean operating room prior to case. Gather all supplies, instruments and equipment necessary for case. Arrange O.R. furniture properly. Open and flip sterile supplies for the surgical procedure. Assist with IV therapy. Assist the anesthesiologist. Assist with the skin preparation. Tie gowns of the scrub nurse and surgeon.

Circulating Responsibilities
Provide scrub personnel with sitting stools and foot stools as necessary. Turn and help adjust lights as necessary. Supply the scrub nurse with necessary supplies. Receive and label specimen properly. Log and deliver specimen to pathology properly. Help apply wound dressing. Pull case for following procedure.

SPONGE AND INSTRUMENT COUNTS

It is essential to keep track of the materials being used in the operating room and during any complicated procedure in order to avoid inadvertent disposal or the potentially disastrous loss of sponges and instruments in the wound. It is standard practice to count supplies (instruments, needles, screws and sponges): Before beginning a case Before final closure On completing the procedure

The aim is to ensure that materials are not left behind or lost. Pay special attention to small items and sponges. Create and make copies of a standard list of equipment for use as a checklist to check equipment as it is set up for the case and then as counts are completed during the case. Include space for suture material and other consumables added during the case.

When trays are created with the instruments for a specific case, such as a Caesarean section, also make a checklist of the instruments included in that tray for future reference.

Abdominal Surgical Incisions

Paramedian vertical incision ( rarely used intestinal problems) Longitudinal midline ( middle laparotomy) begins at the level of the xiphoid to the supra pubic region ( for gastrectomy & intestinal ressection) Right Subcostal (Kochers) from epigastric area and extends laterally & obliquely below the lower margin biliary, spleen and liver

Bilateral subcostal Mercedes Benz or Chevron incision liver transplant Mc Burney for appendectomy Rocky Davis for appendectomy Pfannenstiel pelvic procedures, hysterectomy or CS Inguinal inguinal herniorrhaphy

A. ABDOMINAL SURGERY 1. Abdominal Laparotomy 2. Herniorrhaphy 3. Cholecystectomy 4. Pancreaticoduodenectomy (Whipples) 5. Pancreatectomy 6. Splenectomy 7. Bariatric Surgery

B. BREAST SURGERY 1. Mastectomy 2. Breast Biopsy 3. Mammoplasty 4. Breast Augmentation, Breast Repair, Breast Lifting

C. OBSTETRIC & GYNECOLOGIC SURGERY 1. D & C 2. Vaginal/Abdominal Hysterectomy 3. Perineorrhaphy 4. Salphingo-Oophorectomy 5. Tuboplasty of the Fallopian tubes 6. Ceasarian Section low transverse, classical, Pfannensteil (bikini cut)

D. GENITOURINARY SURGERY 1. Circumcision 2. Vasectomy 3. Orchiectomy 4. Cystectomy 5. Transurethral Resection of the Prostate/Bladder (TURP/TURB) 6. Nephrectomy 7. Ureterolithotomy 8. Pyelolithotomy

PACU- Post-Anesthesia Care/Recovery Unit

Immediate and continuous assessment every 15 minutes initially Check airway patency, vital signs, surgical site, drain, recovery from anesthesia, pain control, fluid status, postop orders When stable, discharge to hospital room or home

1.

2.

3.

Activities in the POST-op

Assessing responses to surgery Performing interventions to promote healing Prevent complications Planning for home-care Assist the client to achieve optimal recovery

POST Operative Interventions

Maintain patent airway Monitor vital signs and note for early manifestations of complications Monitor level of consciousness Maintain on PROPER position NPO until fully awake, with passage of flatus and (+) gag reflex

POST Operative Interventions

Monitor the patency of the drainage Maintain intake and output monitoring Care of the tubes, drains and wound Ensure safety by side rails up Pain medication given as ordered Measures to PREVENT post-op Complications

Post-operative interventions
PAIN MANAGEMENT Pain is usually greatest during the 1236 hours after surgery Narcotic analgesics and NSAIDS may be prescribed together for the early period of surgery Provide back rub, massage, diversional activities, position changes

Post operative interventions

POSITIONING Clients who have spinal anesthesia is usually placed FLAT on bed for 8-12 hours Unconscious client is placed side lying to drain secretions Other positions are utilized BASED on the type of surgery

Post-operative Interventions Some Examples of Position Post Op

Mastectomy Thyroidectomy Hemorrhoidectomy Laryngectomy Pneumonectomy Lobectomy Semi-fowlers, affected arm elevated Semi fowlers , head midline Semi-prone, side-lying Fowlers Lateral, affected side Lateral, unaffected side

Post-operative Interventions Some Examples of Position Post Op

Aneurysmal repair (abdomen) Amputation of lower extremities Cataract surgery Supratentorial craniotomy Infratentorial craniotomy Spina bifida repair Fowlers 45 degrees Flat, with stump elevated with pillow Fowlers 45 degrees Fowlers Flat on bed, supine Prone

Tonsillectomy prone or side lying

PARAMETERS to consider before discharging a postop patient from PACU: 1. ACTIVITY can move all 4 extremities 2. RESPIRATION can deep breath and cough 3. CIRCULATION 4. CONSCIOUSNESS fully awake 5. COLOR - pink

Post-operative Interventions
Deep breathing and coughing exercises Q2-4 hours to remove secretions Leg exercises Q 2 hours to promote circulation Ambulation ASAP prevents respiratory, circulatory, urinary and gastrointestinal complications

Post-operative Interventions
Hydration after NPO to maintain fluid balance Suction, either gastro or respiratory to relieve distention, to remove respi secretions Diet progressive, usually given when bowel sounds and gag reflex return

Wound Care
Inspect dressing hourly Change dressing daily Inspect for signs of infection redness, swelling, purulent exudate Maintain wound drainage

Diet
NPO usually immediately after surgery Progressive diet

Assess the return of the bowel sounds

Liquid Diet Vs Soft diet

Clear liquid Coffee Tea Carbonated drink Bouillon Clear fruit juice Popsicle Gelatin Hard candy Full liquid Clear liquid PLUS: Milk/Milk prod Vegetable juices Cream, butter Yogurt Puddings Custard Ice cream and sherbet Soft diet All CL and FL plus: Meat Vegetables Fruits Breads and cereals Pureed foods

Urinary Elimination
Offer bedpans Allow patient to stand at the bedside commode if allowed Report to surgeon if NO URINE output noted within 8 hours post-op

CPT
Chest Physiotherapy Chest physiotherapy is based on the fact that mucus can be knocked or shaken form the walls of the airways and helped to drain from the lungs. The usual SEQUENCE is as followsPOSITIONING, Percussion, Vibration, and removal of secretions by SUCTIONING or Coughing followed lastly by oral hygiene

Chest Physiotherapy

Incentive Spirometry
This operates on the principle that spontaneous sustained maximal inspiration is most beneficial to the lungs and has virtually no adverse effects. The incentive spirometer measures roughly the inspired volume and offers the incentive of measuring progress

Incentive Spirometry

SPLINTING WHILE COUGHING

SPLINTING WHILE COUGHING

LEG EXERCISES

POSTMASTECTOMY EXERCISES

POSTMASTECTOMY EXERCISES

POSTMASTECTOMY EXERCISES

POSTMASTECTOMY EXERCISES

Post operative complications

Atelectasis
Assess breath Collapsed alveoli due to sounds Repositioning secretions

Pneumonia

Inflammation of alveoli

Deep breathing and coughing Chest physio Suctioning Ambulation

Thrombophlebitis Inflammation of the veins

Leg exercises Monitor for swelling Elevated extremities

ATELECTASIS

PNEUMONIA

DEEP VENOUS THROMBOSIS

*HOMANS SIGN

DEEP VENOUS THROMBOSIS

(+)HOMANS SIGN

EMBOLUS: MIGRATION OF A CLOT

Post-operative Complications
Hypovolemic Loss of Shock circulatory fluid volume
Shock position Determine cause and prevent bleeding O2, IVF
Encourage ambulation Provide privacy Pour warm water Catheterize

Urinary retention

Involuntary accumulation of urine

Pulmonary embolism

Embolus blocking the lung blood flow

Notify physician Administer O2w

HYPOVOLEMIC SHOCK
MODIFIED TRENDELENBURG

Post-operative complications
Constipation Infrequent passage of stool
High fiber diet Increased fluid Ambulation

Paralytic ileus Absent bowel Encourage ambulation sound Wound infection

NPO until peristalsis returns Occurs about Daily wound dressing 3 days after Antibiotics surgery Maintain drain

WOUND DISRUPTION

Post-operative complications
Wound dehiscence
Cover the wound Separation of wound edges at with sterile normal the suture line saline dressing Place in lowFowlers Notify MD

Wound evisceration

Cover the wound Protrusion of with saline pad the internal Place in loworgans and tissues through fowlers Notify MD wound

Wound dehiscence

Wound DEHISCENCE

Wound evisceration

INCISIONAL HERNIA

INCISIONAL HERNIA

INCISIONAL HERNIA

WOUND HEALING
PRIMARY INTENTION

SECONDARY INTENTION

TERTIARY INTENTION

To emphasize
The over-all goal of nursing care during the PRE-OPERATIVE phase is to prepare the patient mentally and physically for the surgery

To emphasize
The over-all goal of nursing care during the INTRA-OPERATIVE phase is to maintain client safety

To emphasize
The over-all goals of nursing care during the POST-OPERATIVE phase are to promote healing and comfort, restore the highest possible wellness and prevent associated risk