Perioperative Nursing PDF

PERIOPERATIVE NURSING Copyright © 2008 Lippincott Williams & Wilkins. Copyright © 2008 Lippincott Williams & Wilkins. PERIOPERATIVE NURSING – used to describe the nursing care provided in the total surgical experience of the patient: a. preoperative b. intraoperative c. postoperative....

PERIOPERATIVE NURSING Copyright © 2008 Lippincott Williams & Wilkins. Copyright © 2008 Lippincott Williams & Wilkins. PERIOPERATIVE NURSING – used to describe the nursing care provided in the total surgical experience of the patient: a. preoperative b. intraoperative c. postoperative. Copyright © 2008 Lippincott Williams & Wilkins. Preoperative Phase extends from the time the client is admitted in the surgical unit, to the time he/she is prepared for the surgical procedure, until he is transported into the operating room. Copyright © 2008 Lippincott Williams & Wilkins. Intraoperative Phase extends from the time the client is admitted to the OR, to the time of administration of anesthesia, surgical procedure is done, until he/she is transported to the RR/PACU. Copyright © 2008 Lippincott Williams & Wilkins. Postoperative Phase extends from the time the client is admitted to the recovery room, to the time he is transported back into the surgical unit, discharged from the hospital, until the follow-up care. Copyright © 2008 Lippincott Williams & Wilkins. 4 Major Types of Pathologic Process Requiring Surgical Intervention (OPET) Obstruction – impairment to the flow of vital fluids (blood,urine,CSF,bile) Perforation – rupture of an organ. Erosion – wearing off of a surface or membrane. Tumors – abnormal new growths. Copyright © 2008 Lippincott Williams & Wilkins. Identify the type of pathologic process requiring surgery Hydrocephalus Obstruction Burn Erosion Benign Prostatic Hyperplasia Tumor Cholelithiasis Obstruction Intussusception Obstruction Perforation Ruptured Aneurysm Copyright © 2008 Lippincott Williams & Wilkins. Classification of Surgical Procedure Copyright © 2008 Lippincott Williams & Wilkins. According to PURPOSE: Diagnostic – to establish the presence of a disease condition. ( e.g biopsy ) Exploratory – to determine the extent of disease condition ( e.g Ex-Lap ) Copyright © 2008 Lippincott Williams & Wilkins.  Curative – to treat the disease condition. * Ablative – removal of an organ “ectomy” * Constructive – repair of congenitally defective organ “plasty,oorhaphy,pexy” * Reconstructive – repair of damage organ Palliative – to relieve distressing sign and symptoms, not necessarily to cure the disease. Copyright © 2008 Lippincott Williams & Wilkins. Identify the type of surgery according to purpose: Pap Smear Diagnostic Tonsilectomy Curative - Ablative Nephrocapsulectomy Curative - Ablative Osteoplasty Curative - Constructive Perineorrhaphy Curative - Reconstructive Trachelorrhaphy Curative - Constructive Curative - Reconstructive Skin Grafting Copyright © 2008 Lippincott Williams & Wilkins.  According to URGENCY Classification Indication for Surgery Examples Emergent – patient requires - severe bleeding immediate attention, life threatening condition. Without delay - gunshot/ stab wounds - Fractured skull Urgent / Imperative – patient Within 24 to 30 hours - kidney / ureteral stones requires prompt attention. Required – patient Plan within a few weeks - cataract or months needs to have surgery. - thyroid d/o Elective – patient should have Failure to have surgery - repair of scar surgery. not catastrophic - vaginal repair Optional – patient’s decision. Personal preference - cosmetic surgery Copyright © 2008 Lippincott Williams & Wilkins. According to DEGREE OF RISK Major Surgery - High risk / Greater Risk for Infection - Extensive - Prolonged - Large amount of blood loss -Vital organ may be handled or removed Minor Surgery - Generally not prolonged - Leads to few serious complication - Involves less risk Copyright © 2008 Lippincott Williams & Wilkins. Ambulatory Surgery/ Same-day Surgery / Outpatient Surgery Advantages: - Reduces length of hospital stay and cuts costs - Reduces stress for the patient - Less incidence of hospital acquired infection - Less time lost from work by the patient; minimal disruptions on the patient’s activities and family life. Copyright © 2008 Lippincott Williams & Wilkins. Disadvantages: - Less time to assess the patient and perform preoperative teaching. - Less time to establish rapport - Less opportunity to assess for late postoperative complication. Copyright © 2008 Lippincott Williams & Wilkins. Example of Ambulatory Surgery ｷ Teeth extraction ｷ Circumcision ｷ Vasectomy ｷ Cyst removal ｷ Tubal ligation Copyright © 2008 Lippincott Williams & Wilkins. Surgical Risk ｷ Obesity ｷ Poor Nutrition ｷ Fluid and Electrolyte Imbalances ｷ Age ｷ Presence of Disease (Cardiovascular dse., DM, Respiratory dse. ) ｷ Concurrent or Prior Pharmacotherapy ｷ other factors: - nature of condition - loc. of the condition - magnitude / urgency of the surgery - mental attitude of the patient - caliber of the health care team Copyright © 2008 Lippincott Williams & Wilkins. PREOPERATIVE PHASE Copyright © 2008 Lippincott Williams & Wilkins. Goals ｷ Assessing and correcting physiologic and psychologic problems that may increase surgical risk. ｷ Giving the person and significant others complete learning / teaching guidelines regarding surgery. ｷ Instructing and demonstrating exercises that will benefits the person during postop period. ｷ Planning for discharge and any projected changes in lifestyle due to surgery. Copyright © 2008 Lippincott Williams & Wilkins. Physiologic Assessment of the Client Undergoing Surgery ｷ Presence of Pain ｷ Nutritional & Fluid and Electrolyte Balance ｷ Cardiovascular / Pulmonary Function ｷ Renal Function ｷ Gastrointestinal / Liver Function ｷ Endocrine Function ｷ Neurologic Function ｷ Hematologic Function ｷ Use of Medication ｷ Presence of Trauma & Infection Copyright © 2008 Lippincott Williams & Wilkins. Routine Preoperative Screening Test Test Rationale CBC RBC,Hgb,Hct are important to the oxygen carrying capacity of blood. WBC are indicator of immune function. Blood grouping/ X Determined in case blood transfusion is matching required during or after surgery. Serum Electrolyte To evaluate fluid and electrolyte status PT,PTT Measure time required for clotting to occur. Fasting Blood High level may indicate undiagnosed DM Glucose Copyright © 2008 Lippincott Williams & Wilkins. BUN / Creatinine Evaluate renal function ALT/AST/LDH Evaluate liver function and Bilirubin Serum albumin Evaluate nutritional status and total CHON Urinalysis Determine urine composition Chest Xray Evaluate resp.status/ heart size ECG Identify preexisting cardiac problem. Copyright © 2008 Lippincott Williams & Wilkins. Psychosocial Assessment and Care Causes of Fears of the Preoperative Clients ｷ Fear of Unknown ( Anxiety ) ｷ Fear of Anesthesia ｷ Fear of Pain ｷ Fear of Death ｷ Fear of disturbance on Body image ｷ Worries – loss of finances, employment, social and family roles. Copyright © 2008 Lippincott Williams & Wilkins. Manifestation of Fears - anxiousness - bewilderment - anger - tendency to exaggerate - sad, evasive, tearful, clinging - inability to concentrate - short attention span - failure to carry out simple directions - dazed Copyright © 2008 Lippincott Williams & Wilkins. Nursing Intervention to Minimize Anxiety ｷ Explore client’s feeling ｷ Allow client’s to speak openly about fears/concern. ｷ Give accurate information regarding surgery (brief, direct to the point and in simple terms) ｷ Give empathetic support ｷ Consider the person’s religious preference and arrange for visit by a priest / minister as desired. Copyright © 2008 Lippincott Williams & Wilkins. INFORMED CONSENT Copyright © 2008 Lippincott Williams & Wilkins. Copyright © 2008 Lippincott Williams & Wilkins. Purposes: To ensure that the client understand the nature of the treatment including the potential complications and disfigurement ( explained by AMD ) To indicate that the client’s decision was made without pressure. To protect the client against unauthorized procedure. To protect the surgeon and hospital against legal action by a client who claims that an authorized procedure was performed. Copyright © 2008 Lippincott Williams & Wilkins. Circumstances Requiring Consent Any surgical procedure where scalpel, scissors, suture, hemostats of electrocoagulation may be used. Entrance into body cavity. Radiologic procedures, particularly if a contrast material is required. General anesthesia, local infiltration and regional block. Copyright © 2008 Lippincott Williams & Wilkins. Essential Elements of Informed Consent ｷ The diagnosis and explanation of the condition. ｷ A fair explanation of the procedure to be done and used and the consequences. ｷ A description of alternative treatment or procedure. ｷ A description of the benefits to be expected. ｷ The prognosis, if the recommended care, procedure is refused. Copyright © 2008 Lippincott Williams & Wilkins. Requisites for Validity of Informed Consent ｷ Written permission is best and legally accepted. ｷ Signature is obtained with the client’s complete understanding of what to occur. - adult sign their own operative permit -obtained before sedation ｷ For minors, parents or someone standing in their behalf, gives the consent. Note: for a married emancipated minor parental consent is not needed anymore, spouse is accepted ｷ For mentally ill and unconscious patient, consent must be taken from the parents or legal guardian Copyright © 2008 Lippincott Williams & Wilkins. ｷ If the patient is unable to write, an “X” is accepted if there is a witness to his mark Secured without pressure and threat A witness is desirable – nurse, physician or authorized persons. When an emergency situation exists, no consent is necessary because inaction at such time may cause greater injury. (permission via telephone/cellphone is accepted but must be signed within 24hrs.) Copyright © 2008 Lippincott Williams & Wilkins. Pre Operative Care Copyright © 2008 Lippincott Williams & Wilkins. Physical Preparation Before Surgery Correct any dietary deficiencies Reduce an obese person’s weight Correct fluid and electrolyte imbalances Restore adequate blood volume with BT Treat chronic diseases Halt or treat any infectious process Treat an alcoholic person with vit. supplementation, IVF or fluids if dehydrated Copyright © 2008 Lippincott Williams & Wilkins. Pre Operative Teaching Incentive Spirometer Diaphragmatic Breathing Coughing Splinting Turning Foot and Leg Exercise Early Ambulation Copyright © 2008 Lippincott Williams & Wilkins. Incentive Spirometer Copyright © 2008 Lippincott Williams & Wilkins. ﾘ Encouraged to use incentive spirometer about 10 to 12 times per hour. ﾘ Deep inhalations expand alveoli, which prevents atelectasis and other pulmonary complication. ﾘ There is less pain with inspiratory concentration than with expiratory concentration. Copyright © 2008 Lippincott Williams & Wilkins. Diaphragmatic Breathing ﾘ Refers to a flattening of the dome of the diaphragm during inspiration, with resultant enlargement of upper abdomen as air rushes in. During expiration, abdominal muscles contract. ﾘ In a semi-Fowlers position, with your hands loose- fist, allow to rest lightly on the front of lower ribs. ﾘ Breathe out gently and fully as the ribs sink down and inward toward midline. Copyright © 2008 Lippincott Williams & Wilkins. ﾘ Then take a deep breath through the nose and mouth, letting the abdomen rise as the lungs fill with air. ﾘ Hold breath for a count of 5. ﾘ Exhale and let out all the air through your nose and mouth. ﾘ Repeat this exercise 15 times with a short rest after each group of 5. Copyright © 2008 Lippincott Williams & Wilkins. Coughing and Splinting Quic kTime™ and a dec ompress or are needed to see this picture. Copyright © 2008 Lippincott Williams & Wilkins. ﾘ Promotes removal of chest secretions. ﾘ Interlace his fingers and place hands over the proposed incision site, this will act as a splint and will not harm the incision. ﾘ Lean forward slightly while sitting in bed. ﾘ Breath, using diaphragm ﾘ Inhale fully with the mouth slightly open. ﾘ Let out 3-4 sharp hacks. ﾘ With mouth open, take in a deep breath and quickly give 1-2 strong coughs. Copyright © 2008 Lippincott Williams & Wilkins. Turning ﾘ Promotes removal of chest secretions. ﾘ Interlace his fingers and place hands over the proposed incision site, this will act as a splint and will not harm the incision. ﾘ Lean forward slightly while sitting in bed. ﾘ Breath, using diaphragm ﾘ Inhale fully with the mouth slightly open. ﾘ Let out 3-4 sharp hacks. ﾘ With mouth open, take in a deep breath and quickly give 1-2 strong coughs. Copyright © 2008 Lippincott Williams & Wilkins. Foot and Leg Exercise ﾘ Moving the legs improves circulation and muscle tone. ﾘ Have the patient lie supine, instruct patient to bend a knee and raise the foot – hold it a few seconds and lower it to the bed. ﾘ Repeat above about 5 times with one leg and then with the other. Repeat the set 5 times every 3-5 hours. ﾘ Then have the patient lie on one side and exercise the legs by pretending to pedal a bicycle. ﾘ For foot exercise, trace a complete circle with the great toe. Copyright © 2008 Lippincott Williams & Wilkins. Preparing the Patient the Evening Before Surgery v Preparing the Skin - have a full bath to reduce microorganisms in the skin. - hair should be removed within 1-2 mm of the skin to avoid skin breakdown, use of electric clipper is preferable. v Preparing the G.I tract - NPO, cleansing enema as required v Preparing for Anesthesia - Avoid alcohol and cigarette smoking for at least 24 hours before surgery. v Promoting rest and sleep - Administer sedatives as ordered Copyright © 2008 Lippincott Williams & Wilkins. ASA (American Society of Anesthesiologists) Guidelines for Preoperative Fasting Liquid and Food Intake Minimum Fasting Period Clear Liquids 2 Breast Milk 4 Nonhuman Milk 6 Light Meal 6 Regular / Heavy Meals 8 Copyright © 2008 Lippincott Williams & Wilkins. Preparing the Person on the Day Of Surgery Early A.M Care Awaken 1 hour before preop medications Morning bath, mouth wash Provide clean gown Remove hairpins, braid long hair, cover hair with cap if available. Remove dentures, colored nail polish, hearing aid, contact lenses, jewelries. Take baseline vital sign before preop medication. Check ID band, skin prep Check for special orders – enema, IV line Check NPO Have client void before preop medication Continue to support emotionally Accomplished “preop care checklist Copyright © 2008 Lippincott Williams & Wilkins. Copyright © 2008 Lippincott Williams & Wilkins. Copyright © 2008 Lippincott Williams & Wilkins. Pre Operative Medications Copyright © 2008 Lippincott Williams & Wilkins. PREOPERATIVE MEDICATIONS Goals: To aid in the administration of an anesthetics. To minimize respiratory tract secretion and changes in heart rate. To relax the patient and reduce anxiety. Copyright © 2008 Lippincott Williams & Wilkins. Commonly used Preop Meds. - Tranquilizers & Sedatives * Midazolam * Diazepam ( Valium ) * Lorazepam ( Ativan ) * Diphenhydramine - Analgesics * Nalbuphine ( Nubain ) - Anticholinergics * Atropine Sulfate - Proton Pump Inhibitors * Omeprazole ( Losec ) * Famotidine Copyright © 2008 Lippincott Williams & Wilkins. Transporting the Patient to the OR Adhere to the principle of maintaining the comfort and safety of the patient. Accompany OR attendants to the patient’s bedside for introduction and proper identification. Assist in transferring the patient from bed to stretcher. Complete the chart and preoperative checklist. Make sure that the patient arrive in the OR at the proper time. Copyright © 2008 Lippincott Williams & Wilkins. Patient’s Family Direct to the proper waiting room. Tell the family that the surgeon will probably contact them immediately after the surgery. Explain reason for long interval of waiting: anesthesia prep, skin prep, surgical procedure, RR. Tell the family what to expect postop when they see the patient Copyright © 2008 Lippincott Williams & Wilkins. Copyright © 2008 Lippincott Williams & Wilkins. Operative Site Identification Copyright © 2008 Lippincott Williams & Wilkins. Copyright © 2008 Lippincott Williams & Wilkins. INTRAOPERATIVE PHASE Copyright © 2008 Lippincott Williams & Wilkins. Goals ｷ Asepsis ｷ Homeostasis ｷ Safe Administration of Anesthesia ｷ Hemostasis Copyright © 2008 Lippincott Williams & Wilkins. Surgical Setting Unrestricted Area - provides an entrance and exit from the surgical suite for personnel, equipment and patient - street clothes are permitted in this area, and the area provides access to communication with personnel within the suite and with personnel and patient’s families outside the suite Copyright © 2008 Lippincott Williams & Wilkins. Surgical Setting Semi-restricted Area - provides access to the procedure rooms and peripheral support areas within the surgical suite. - personnel entering this area must be in proper operating room attire and traffic control must be designed to prevent violation of this area by unauthorized persons - peripheral support areas consists of: storage areas for clean and sterile supplies, sterilization equipment and corridors leading to procedure room Copyright © 2008 Lippincott Williams & Wilkins. Surgical Setting Restricted Area - includes the procedure room where surgery is performed and adjacent substerile areas where the scrub sinks and autoclaves are located - personnel working in this area must be in proper operating room attire Copyright © 2008 Lippincott Williams & Wilkins. RMC Operating Room Set Up Anesthesia Department Recovery OR Suite Room Scrubbing/Washing Area Storage OR Suite Nurse Station OR Suite MD/ Nurses Dressing Room OR Suite Main Entrance OR Supervisor Office Lounge Copyright © 2008 Lippincott Williams & Wilkins. QMMC Operating Room Set Up OR OR Suite Suite Scrubbing / Washing Scrubbing / Washing Area Area OR OR Suite Suite Nurses Storage/Supplies Station Recovery Room Dressing Room OR Manager Room Receiving Area Lounge Copyright © 2008 Lippincott Williams & Wilkins. Environmental Safety The size of the procedure room Temperature and humidity control Ventilation and air exchange system Electrical Safety Communication System Copyright © 2008 Lippincott Williams & Wilkins. Size of the Procedure Room Usually rectangular or square in shape 20 x 20 x 10 with a minimum floor space of 360 square feet Each procedure room must have the following equipment: - Communication System - Oxygen and vacuum outlets - Mechanical ventilation assistance equipment - Respiratory and Cardiac monitoring equipment - X ray film illumination boxes - Cardiac defibrillator - High-efficiency particulate air filters - Adequate room lighting - Emergency lighting system Copyright © 2008 Lippincott Williams & Wilkins. Temperature and Humidity Control The temperature in the procedure room should maintained between 68 F - 75 F ( 20 - 24 degrees C) Humidity level between 50 - 55 % at all times Copyright © 2008 Lippincott Williams & Wilkins. Ventilation and Air Exchange System Air exchange in each procedure room should be at least 25 air exchanges every hour, and five of that should be fresh air. A high filtration particulate filter, working at 95% efficiency is recommended. Each procedure room should maintained with positive pressure, which forces the old air out of the room and prevents the air from surrounding areas from entering into the procedure room Copyright © 2008 Lippincott Williams & Wilkins. Electrical Safety Faulty wiring, excessive use of extension cords, poorly maintained equipment and lack of current safety measures are just some of the hazardous factors that must be constantly checked All electrical equipment new or used, should be routinely checked by qualified personnel. Equipment that fails to function at 100% efficiency should be taken out of service immediately. Copyright © 2008 Lippincott Williams & Wilkins. The Surgical Team ｷ The Patient ｷ The Anesthesiologist or Anesthetist ｷ The Surgeon ｷ Scrub Nurse ｷ Circulating Nurse ｷ RNFA ( Reg.Nurse First Assistant ) ｷ Surgical Technologists Copyright © 2008 Lippincott Williams & Wilkins. Surgeon Copyright © 2008 Lippincott Williams & Wilkins. Responsibilities Primary responsible for the preoperative medical history and physical assessment. Performance of the operative procedure according to the needs of the patients. The primary decision maker regarding surgical technique to use during the procedure. May assist with positioning and prepping the patient or may delegate this task to other members of the team Copyright © 2008 Lippincott Williams & Wilkins. First Assistant to the Surgeon Copyright © 2008 Lippincott Williams & Wilkins. Responsibilities May be a resident, intern , physician’s assistant or a perioperative nurse. Assists with retracting, hemostasis, suturing and any other tasks requested by the surgeon to facilitate speed while maintaining quality during the procedure. Copyright © 2008 Lippincott Williams & Wilkins. Anesthesiologist Copyright © 2008 Lippincott Williams & Wilkins.  Responsibilities Selects the anesthesia, administers it, intubates the client if necessary, manages technical problems related to the administration of anesthetic agents, and supervises the client’s condition throughout the surgical procedure. A physician who specializes in the administration and monitoring of anesthesia while maintaining the overall well-being of the patient. Copyright © 2008 Lippincott Williams & Wilkins. Scrub Nurse Copyright © 2008 Lippincott Williams & Wilkins. Responsibilities May be either a nurse or a surgical technician. Reviews anatomy, physiology and the surgical procedures. Assists with the preparation of the room. Scrubs, gowns and gloves self and other members of the surgical team. Prepares the instrument table and organizes sterile equipment for functional use. Assists with the drapping procedure. Passes instruments to the surgeon and assistants by anticipating their need. Counts sponges, needles and instruments. Monitor practices of aseptic technique in self and others. Keeps track of irrigations used for calculations of blood loss Copyright © 2008 Lippincott Williams & Wilkins. Circulating Nurse Copyright © 2008 Lippincott Williams & Wilkins. Responsibilities Must be a registered nurse who, after additional education and training, specialized in perioperative nursing practice. Responsible and accountable for all activities occurring during a surgical procedure including the management of personnel equipment, supplies and the environment during a surgical procedure. Patient advocate, teacher, research consumer, leader and a role model. May be responsible for monitoring the patient during local procedures if a second perioperative nurse is not available. Copyright © 2008 Lippincott Williams & Wilkins. Very defined activities during surgery: Ensure all equipment is working properly. Guarantees sterility of instruments and supplies. Assists with positioning. Monitor the room and team members for breaks in the sterile technique. Handles specimens. Coordinates activities with other departments, such as radiology and pathology. Documents care provided. Minimizes conversation and traffic within the operating room suite. Copyright © 2008 Lippincott Williams & Wilkins. Medical vs. Surgical Asepsis Copyright © 2008 Lippincott Williams & Wilkins. Principles of Surgical Asepsis (Sterile Technique) Sterile object remains sterile only when touched by another sterile object Only sterile objects may be placed on a sterile field A sterile object or field out of range of vision or an object held below a person’s waist is contaminated Copyright © 2008 Lippincott Williams & Wilkins. Principles of Surgical Asepsis (Sterile Technique) When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action Fluid flows in the direction of gravity The edges of a sterile field or container are considered to be contaminated (1 inch) Copyright © 2008 Lippincott Williams & Wilkins. Common Surgical Incision Incision Site Butterfly Limbal Halstead / Elliptical Subcostal Paramedian Transverse Rectus McBurney Pfannenstiel Lumbotomy Copyright © 2008 Lippincott Williams & Wilkins. Position During Surgery Supine ( Dorsal Recumbent ) - Abdominal,extremity,vascular,chest,neck,facial,ear breast surgery Positioning Techniques Patient lies flat on back with arms either extended on arm boards or placed along side of body. Small padding placed under patient’s head,neck and under knees Vulnerable pressure points should be padded. Safety strap applied 2 in. above knees. Eyes should be protected by using eye patch and ointment. Copyright © 2008 Lippincott Williams & Wilkins.  Prone Position - Surgeries involving posterior surface of the body ( spine, neck,buttocks and lower extremities ) Positioning Techniques Chest rolls or bolster are placed on operating table prior to positioning Foam head rest, head turned to side or facing downward Patient’s arms are rotated to the padded armboards that face head, bringing them through their normal range of motion. Padding for knees and pillow for lower extremities to prevent toes from touching mattress. Safety strap applied 2 in. above the knees Copyright © 2008 Lippincott Williams & Wilkins. Trendelenburg Position - Surgeries involving lower abdomen, pelvic organ when there is a need to tilt abdominal viscera away from the pelvic area. Positioning Techniques Patient is supine with head lower than feet. Shoulder braces should not be used as they may cause damage brachial plexus. When patient is returned to supine position, care must be taken move leg section slowly, then the entire table to level position. Modification of this position can be used for hypovolemic shock. Extremity position and safety strap are the same as for supine. Copyright © 2008 Lippincott Williams & Wilkins. Reverse Trendelenburg Position - Upper abdominal, head, neck and facial surgery Positioning Technique Patient is supine with head higher than feet. Small pillow under neck and knees. Well - padded footboard should be used to prevent slippage to foot of the table. Anti embolic hose should be used if position is to be maintained for an extended period of time. Patient should be returned slowly to supine position. Copyright © 2008 Lippincott Williams & Wilkins.  Lithotomy - Perineal, vaginal, rectal surgeries; combined abdominal vaginal procedure Positioning Techniques Patient is placed in supine position with buttocks near lower break in the table ( sacrum are should be well padded ) Feet are placed in stirrups, stirrups height should not be excessively high or low, but even on both sides. Knee brace must not compress vascular structures or nerves in the popliteal space. Pressure from metal stirrups against upper inner aspect of thigh and calf should be avoided. Legs should be raised and lowered slowly and simultaneously ( may require two people ) Copyright © 2008 Lippincott Williams & Wilkins.  Modified Fowler ( Sitting Position ) - Otorhinology (ear and nose ), neurosurgery Positioning Techniques Patient is supine, positioned over the upper break in the table Backrest is elevated, knees flexed Arms rest on pillow, placed in lap; safety strap 2 in. above the knees. Slow movement in and out of position must be used to prevent drastic changes in blood volume movement. Anti embolic hose should be used to assist venous return. When using special neurologic headrest, eyes must be protected. Copyright © 2008 Lippincott Williams & Wilkins. Jack Knife Position - Rectal procedures, sigmoidoscopy and colonoscopy Positioning Techniques Table is flexed at center break All precautions taken with prone position are taken with Jack knife position. Table strap applied over thighs Copyright © 2008 Lippincott Williams & Wilkins. ANESTHESIA Copyright © 2008 Lippincott Williams & Wilkins.  State of “Narcosis” Anesthetics can produce muscle relaxation, block transmission of pain nerve impulses and suppress reflexes. It can also temporary decrease memory retrieval and recall. The effects of anesthesia are monitored by considering the following parameters: - Respiration - O2 saturation - CO2 levels - HR and BP - Urine output Copyright © 2008 Lippincott Williams & Wilkins. Types of Anesthesia 1. General Anesthesia ｷ reversible state consisting of complete loss of consciousness and sensation. ｷ protective reflexes such as cough and gag are lost ｷ provides analgesia, muscle relaxation and sedation. ｷ produces amnesia and hypnosis. Copyright © 2008 Lippincott Williams & Wilkins. Techniques used in General Anesthesia A. Intravenous Anesthesia ｷ This is being administered intravenously and extremely rapid. ｷ Its effect will immediately take place after thirty minutes of introduction. ｷ It prepares the client for smooth transition to the surgical anesthesia. B. Inhalation Anesthesia ｷ This comprises of volatile liquids or gas and oxygen. ｷ Administered through a mask or endotracheal tube. Copyright © 2008 Lippincott Williams & Wilkins. Stages of General Anesthesia ﾘ Stage 1: Onset / Induction. ﾘ Stage 2: Excitement / Delirium. ﾘ Stage 3: Surgical ﾘ Stage 4: Medullary / Stage of Danger Copyright © 2008 Lippincott Williams & Wilkins. 2. Regional Anesthesia ｷ temporary interruption of the transmission of nerve impulses to and from specific area or region of the body. ｷ achieved by injecting local anesthetics in close proximity to appropriate nerves. ｷ reduce all painful sensation in one region of the body without inducing unconsciousness. ｷ agents used are lidocaine and bupivacaine. Copyright © 2008 Lippincott Williams & Wilkins. Techniques used in Regional Anesthesia: A. Topical Anesthesia ｷ applied directly to the skin and mucous membrane, open skin surfaces, wounds and burns. ｷ readily absorbed and act rapidly ｷ used topical agents are lidocaine and benzocaine. Copyright © 2008 Lippincott Williams & Wilkins. B. Spinal Anesthesia ( Subarachnoid block ) ｷ local anesthetic is injected through lumbar puncture, between L2 and S1 ｷ anesthetic agent is injected into subarachoid space surrounding the spinal cord. - Low spinal, for perineal/rectal areas - Mid spinal T10 ( below level of umbilicus) for hernia repair and appendectomy. -High spinal T4 ( nipple line ), for CS ｷ agents used are procaine, tetracaine, lidocaine and bupivacaine. Copyright © 2008 Lippincott Williams & Wilkins. Copyright © 2008 Lippincott Williams & Wilkins. C. Epidural Anesthesia ｷ achieved by injecting local anesthetic into epidural space by way of a lumbar puncture. ｷ result similar to spinal analgesia ｷ agents use are chloroprocaine, lidocaine and bupivacaine. D. Peripheral Nerve Block ｷ achieved by injecting a local anesthetic to anesthetize the surgical site. ｷ agents use are chloroprocaine, lidocaine and bupivacaine. Copyright © 2008 Lippincott Williams & Wilkins. E. Intravenous Block ( Beir block ) ｷ often used for arm,wrist and hand procedure ｷ an occlusion tourniquet is applied to the extremity to prevent infiltration and absorption of the injected IV agents beyond the involved extremity. F. Caudal Anesthesia ｷ Is produced by injection of the local anesthetic into the caudal or sacral canal G. Field Block Anesthesia ｷ The area proximal to a planned incision can be injected and infiltrated with local anesthetic agents. Copyright © 2008 Lippincott Williams & Wilkins. Nursing Management Assessment Diagnosis Planning Intervention Evaluation Copyright © 2008 Lippincott Williams & Wilkins. Complications and Discomforts of Anesthesia ｷ Hypoventilation - inadequate ventilatory support after paralysis of respiratory muscles. ｷ Oral Trauma ｷ Malignant Hyperthermia - uncontrolled skeletal muscle contraction ｷ Hypotension - due to preoperative hypovolemia or untoward reactions to anesthetic agents. ｷ Cardiac Dysrhythmia - due to preexisting cardiovascular compromise, electrolyte imbalance or untoward reaction to anesthesia. Copyright © 2008 Lippincott Williams & Wilkins. ｷ Hypothermia - due to exposure to a cool ambient OR environment and loss of thermoregulation capacity from anesthesia. ｷ Peripheral Nerve Damage - due to improper positioning of patient or use of restraints. ｷ Nausea and Vomiting ｷ Headache Copyright © 2008 Lippincott Williams & Wilkins. Practice Question A female client, 23 years old was admitted for the first time at the QMMC, she was diagnosed to have ruptured appendicitis. She was scheduled to have emergency Ex-Lap under general anesthesia. 1. Pre-op instructions to the client would include the following EXCEPT: a. deep breathing and coughing exercise b. explaining the procedure c. turning to the side d. foot and leg exercise Copyright © 2008 Lippincott Williams & Wilkins. Answer: B. Explaining the procedure. Rationale: Explaining the treatment, procedure, and outcome is done by the attending physician Copyright © 2008 Lippincott Williams & Wilkins. 2. During the induction of anesthesia, what is your nursing priority action? a. secure informed consent b. maintain the OR room quite and close the door c. stay with the patient and assess for possible anesthesia complication d. assist the physician in preparing the OR table Copyright © 2008 Lippincott Williams & Wilkins. Answer: B. Rationale: During the 1st stage of general anesthesia ( onset or Induction stage ), noises are exaggerated. For this reason Unnecessary noises and motions are avoided. Copyright © 2008 Lippincott Williams & Wilkins. POSTOPERATIVE CARE Copyright © 2008 Lippincott Williams & Wilkins. Goals: Restore homeostasis and prevent complication Maintain adequate cardiovascular and tissue perfusion. Maintain adequate respiratory function. Maintain adequate nutrition and elimination. Maintain adequate fluid and electrolyte balance. Maintain adequate renal function. Promote adequate rest, comfort and safety. Promote adequate wound healing. Promote and maintain activity and mobility. Provide adequate psychological support. Copyright © 2008 Lippincott Williams & Wilkins.  PACU CARE Transport of client from OR to RR ｷ avoid exposure ｷ avoid rough handling ｷ avoid hurried movement and rapid changes in position. Copyright © 2008 Lippincott Williams & Wilkins. Initial Nursing Assessment ｷ Verify patient’s identity, operative procedure and the surgeon who performed the procedure. ｷ Evaluate the following sign and verify their level of stability with the anesthesiologist: - Respiratory status - Circulatory status - Pulses - Temperature - Oxygen Saturation level - Hemodynamic values ｷ Determine swallowing and gag reflex , LOC and patients response to stimuli. Copyright © 2008 Lippincott Williams & Wilkins. ｷ Evaluate lines, tubes, or drains, estimate blood loss, condition of wound, medication used, transfusions and output. ｷ Evaluate the patient’s level of comfort and safety. ｷ Perform safety check; side rails up and restraints are properly in placed. ｷ Evaluate activity status, movement of extremities. ｷ Review the health care provider’s orders. Copyright © 2008 Lippincott Williams & Wilkins. Initial Nursing Interventions Copyright © 2008 Lippincott Williams & Wilkins. Maintaining a Patent Airway ﾘ Allow the airway ( ET tube ) to remain in place until the patient begins to waken and is trying to eject the airway. ﾘ The airway keeps the passage open and prevents the tongue from falling backward and obstructing the air passages. ﾘ Aspirate excessive secretions when they are heard in the nasopharynx and oropharynx. Copyright © 2008 Lippincott Williams & Wilkins. Assessing Status of Circulatory System ﾘ Take VS per protocol, until patient is well stabilized. ﾘ Monitor intake and output closely. ﾘ Recognized early symptoms of shock or hemorrhage: - cool extremities - decreased urine output ( less than 30ml/hr ) - slow capillary refill ( greater than 3 sec. ) - lowered BP - narrowing pulse pressure - increased heart rate * initiate O2 therapy, to increase O2 availability from the blood. * place the patient in shock position with his feet elevated ( unless contraindicated ) Copyright © 2008 Lippincott Williams & Wilkins. Maintaining Adequate Respiratory Function ﾘ Place the patient in lateral position with neck extended ( if not contraindicated ) and upper arm supported on a pillow. ﾘ Turn the patient every 1 to 2 hours to facilitate breathing and ventilation. ﾘ Encourage the patient to take deep breaths, use an incentive spirometer. ﾘ Assess lung fields frequently by auscultation. ﾘ Periodically evaluate the patient’s orientation – response to name and command. Note: Alterations in cerebral function may suggest impaired O2 delivery. Copyright © 2008 Lippincott Williams & Wilkins. Assessing Thermoregulatory Status ﾘ Monitor temperature per protocol to be alert for malignant hyperthermia or to detect hypothermia. ﾘ Report a temperature over 37.8 C or under 36.1 C ﾘ Monitor for postanesthesia shivering, 30-45 minutes after admission to the PACU. ﾘ Provide a therapeutic environment with proper temperature and humidity. Copyright © 2008 Lippincott Williams & Wilkins. Maintaining Adequate Fluid Volume ﾘ Administer I.V solutions as ordered. ﾘ Monitor evidence of F&E imbalance such as N&V ﾘ Evaluate mental status, skin color and turgor ﾘ Recognized signs of: a. Hypovolemia - decrease BP - decrease urine output - decreased CVP - increased pulse b. Hypervolemia - increase BP - changes in lung sounds (S3 gallop ) - increased CVP ﾘ Monitor I&O Copyright © 2008 Lippincott Williams & Wilkins. Minimizing Complications of Skin Impairment ﾘ Perform handwashing before and after contact with the patient ﾘ Inspect dressings routinely and reinforce them if necessary. ﾘ Record the amount and type of wound drainage. ﾘ Turn patient frequently and maintain good body alignment. Copyright © 2008 Lippincott Williams & Wilkins. Maintaining Safety ﾘ Keep the side rails up until the patient is fully awake. ﾘ Protect the extremity into which I.V fluids are running so needle will not become accidentally dislodged. ﾘ Avoid nerve damage and muscle strain by properly supporting and padding pressure areas. ﾘ Recognized that the patient may not be able to complain of injury such as the pricking of an open safety pin or clamp that is exerting pressure. ﾘ Check dressing for constriction Copyright © 2008 Lippincott Williams & Wilkins. Parameter for Discharge from PACU/RR ｷ Activity. Able to obey commands ｷ Respiratory. Easy, noiseless breathing ｷ Circulation. BP within 20mmHg of preop level ｷ Consciousness. Responsive ｷ Color. Pinkish skin and mucus membrane Copyright © 2008 Lippincott Williams & Wilkins. Nursing Care of the Client During the Intermediate Postop Period (RR – Unit ) Baseline Assessment Respiratory Status Cardiovascular Status - VS - Color and Temperature of Skin Level of Consciousness Tubes - Drain - NGT - T-tube Position Copyright © 2008 Lippincott Williams & Wilkins. Immediate Post-Op Assessment and Interventions Areas of Concern Intervention Neurological Status Assess LOC– response to name Return of swallow and gag reflex Fluid and Electrolyte Intake and Output Balance IV Fluids Dressing, Tubes, Drains Color, consistency and amount of drainage Pain May need 1/2 to 1/3 less analgesia in recover room Safety and Comfort Side rails Warmth Aseptic Technique Copyright © 2008 Lippincott Williams & Wilkins.  Areas of Concern Intervention Respiratory ASSESS !!! Position on Side Keep Airway in Oxygen Cardiovascular ASSESS !!! Watch for: Post-op hypotension; cardiac arrest; hemorrhage Signs of Hemorrhage: ↑ pulse and respiratory rate; restlessness; ↓ blood pressure; cold, clammy skin; thirst; pallor Copyright © 2008 Lippincott Williams & Wilkins. Copyright © 2008 Lippincott Williams & Wilkins. Common Post-Operative Orders NPO until fully alert, then ice chips as tolerated. Advance diet as tolerated. Suction prn Complete current IV then discontinue if pt. tolerating fluids. Compazine 5 mg prn for nausea and vomiting Morphine Sulfate 10 mg IM every 3-4 hours prn Copyright © 2008 Lippincott Williams & Wilkins. Common Post-Operative Orders Accurate intake and output T,C, and DB every 2 hours Hemoglobin and hematocrit in a.m. Catheter if patient can’t void in 8 – 10 hours Reinforce dressing prn Copyright © 2008 Lippincott Williams & Wilkins. Copyright © 2008 Lippincott Williams & Wilkins. Copyright © 2008 Lippincott Williams & Wilkins. WOUND CARE Commonly Used Wound Dressing Copyright © 2008 Lippincott Williams & Wilkins. Copyright © 2008 Lippincott Williams & Wilkins. The strips of tape should be placed at the ends of the dressing and must be sufficiently long and wide to secure the dressing. The tape should adhere to intact skin. Copyright © 2008 Lippincott Williams & Wilkins. Cleaning Surgical Site Cleaning from top Cleaning a wound outward Cleaning around to bottom, starting at the from the incision Penrose drain site center Copyright © 2008 Lippincott Williams & Wilkins. Wound Irrigation Copyright © 2008 Lippincott Williams & Wilkins. Incision Support Copyright © 2008 Lippincott Williams & Wilkins. Body Pressure Areas Copyright © 2008 Lippincott Williams & Wilkins. POST OPERATIVE COMPLICATIONS Copyright © 2008 Lippincott Williams & Wilkins. Copyright © 2008 Lippincott Williams & Wilkins. A client has returned from surgery with a fine, reddened rash noted around the area where Betadine prep had been applied prior to surgery. Nursing documentation in the chart should include a. The time and circumstances under which the rash was noted. b. The explanation given to the client and family of the reason for the rash. c. Notation on an allergy list and notification of the doctor. d. The need for application of corticosteroid cream to decrease inflammation. Copyright © 2008 Lippincott Williams & Wilkins. C Suspected reaction to drugs should be reported to the doctor and noted on list of possible allergies Copyright © 2008 Lippincott Williams & Wilkins. A 41-year-old woman was brought to the emergency room by two police officers after she had been standing barefoot in the rain for more than two hours. The police officers report that the woman had to be restrained after she resisted and became agitated. The intake nurse's FIRST action should be to: a. Complete a physical examination. b. Maintain a safe environment. c. Ascertain the client's mental status. d. Orient the client to place and time. Copyright © 2008 Lippincott Williams & Wilkins. B implementation; major priority of the nurse is to provide and maintain safety for the client who is unable to provide for herself; safe environment will generate trust and rapport; will decrease resistance to doing preliminary physical exam, which includes orienting client and doing a mental status exam Copyright © 2008 Lippincott Williams & Wilkins. The nurse is preparing to insert a Foley catheter into a patient. It would be MOST important for the nurse to take which of the following actions? a. Place all supplies close to the edge of the table. b. Keep the field holding the supplies in front of the nurse. c. Set up the field below the nurse's waist level. d. Add only clean supplies to the field. Copyright © 2008 Lippincott Williams & Wilkins. B represents the best technique for a sterile field Copyright © 2008 Lippincott Williams & Wilkins. A nurse instructs a preoperative client in the proper use of an incentive spirometer. Postoperative assessment of the effectiveness of its use is determined if the client exhibits: a. Coughing b. Shallow breaths c. Wheezing in one lung field d. Unilateral chest expansion Copyright © 2008 Lippincott Williams & Wilkins. A Incentive devices have many desired and positive effects. Incentive devices provide the stimulus for a spontaneous deep breath. Spontaneous deep breathing, using the sustained maximal inspiration concept, reduces atelectasis, opens airways, stimulates coughing, and actively encourages individual participation in recovery. Shallow breaths, wheezing, and unilateral chest expansion would indicate that the incentive spirometry was not effective. Wheezing indicates narrowing or obstruction of the airway, and unilateral chest expansion could indicate atelectasis. Copyright © 2008 Lippincott Williams & Wilkins.