312 OR - Preoperative and Intraoperative Phase (1).pdf

Perioperative nursing – Preoperative and Intraoperative Phase J.A.K.E NCMB 312 RLE PERIOPERATIVE NURSING a) Ablative. Involves removal of an orga...

Perioperative nursing – Preoperative and Intraoperative Phase J.A.K.E NCMB 312 RLE PERIOPERATIVE NURSING a) Ablative. Involves removal of an organ. Suffix used is The Perioperative Period “ectomy.” E.g. Appendectomy – removal of the Perioperative period is divided into three phases namely: appendix; Hysterectomy – removal of the uterus; preoperative phase Oophorectomy – removal of the ovary; Mastectomy – intraoperative phase and removal of the breast; Pneumonectomy – removal of a postoperative phase lung; Tonsillectomy – removal of tonsils; Preoperative Phase Cholecystectomy – removal of the gall bladder. - This extends from the time the client is admitted to the b) Constructive. Involves repair of congenitally defective surgical unit, to the time he/she is prepared physically, organ. Suffixes used are “plasty,” “orrhaphy,” “pexy.” psychosocially, spiritually and legally for the surgical E.g. Cheiloplasty – repair of cleft lip; Uranoplasty procedure, until he/she is transported into the operating – repair of cleft palate; Herniorrhaphy – repair of room. hernia; Orchidopexy – repair of undescended testes. c) Reconstructive. Involves repair of damaged organ. E.g. plastic surgery after severe burns, scar revision. 4) Palliative – To relieve distressing signs and symptoms, not necessarily to cure the disease. E.g., colostomy, debridement of necrotic tissues, resection of nerve roots According to DEGREE OF RISK/ MAGNITUDE/ EXTENT 1) Major Surgery – The criteria for major surgery are as follows: Involves high risk of morbidity or mortality Intraoperative Phase It is extensive and prolonged. Involves a considerable - Extends from the time the client is admitted to the period of time operating room, to the time of administration of It may involve large amount of blood loss anesthesia, surgical procedure is done, until he/she is Vital organs are manipulated or removed transported to the recovery room (RR) / post-anesthesia Involves great risk of occurrence of complications care unit (PACU) E.g., craniotomy; open heart surgery; Postoperative Phase pneumonectomy; total abdominal hysterectomy with - extends from the time the client is admitted to the bilateral salpingo oophorectomy (TAHBSO). recovery room, to the time he is transported back into the 2) Minor surgery surgical unit, discharged from the hospital, until the follow The procedure is not prolonged. - up care. Involves lesser risk. Does not usually involve serious complications. Preoperative Phase E.g., appendectomy, tonsillectomy, blepharoplasty - the time the patient is prepared physically, psychosocially, (repair of eyelids). spiritually and legally for the surgical procedure According to URGENCY The Four Types of Conditions Requiring Surgery: 1) Emergency. The surgery should be done immediately to 1) Obstruction – Imairment to the flow of vital fluids, like save the client’s life or limb. E.g., emergency blood, urine, bile, CSF hysterectomy due to ruptured uterus; emergency 2) Perforation – Rupture of an organ, ruptured appendix, amputation of a limb due to crushing injury; emergency ruptured uterus appendectomy due to acute appendicitis. 3) Erosion – Wearing off of a surface or membrane, e.g. 2) Imperative. The procedure should be done within 24 to 48 peptic ulcer hours. E.g., profusely bleeding peptic ulcer, evacuation of 4) Tumors – Abnormal new growth, breast tumor, bone blood clots from the brain. tumor, lung tumor, brain tumor. 3) Planned Required. The procedure is necessary for the Classification of Surgical Procedures well – being of the client. However, it may be scheduled According to PURPOSE weeks or months. E.g., tonsillectomy, thyroidectomy, 1) Diagnostic – To confirm the presence of a disease cataract extraction. condition, e.g. biopsy. 4) Elective. The procedure is not absolutely necessary for 2) Exploratory – To determine the extent of the disease survival. Delay or omission will not cause adverse effect. condition, e.g., exploratory laparotomy (exploration of E.g., removal of simple, non – toxic goiter. the abdominal cavity and abdominal organs) 5) Optional. The procedure is requested by the client. It is 3) Curative – To treat the disease condition. The different usually for aesthetic purposes. E.g., rhinoplasty (repair of types of curative surgeries are as follows: the nose); blepharoplasty (repair of the eyelids). PP & IP 1 of 9 J.A.K.E Perioperative nursing – Preoperative and Intraoperative Phase 312 RLE Surgical risk patient: Tendency to exaggerate Extremes of age (very young & very old) Sad, evasiveness, tearfulness, and clinging behavior Extremes of weight (emaciation & obesity) Inability to concentrate Dehydrated patients with severe trauma or injury Short attention span Nutritional deficits Failure to carry out simple directions Patients with severe trauma or injury, infection/ sepsis Dazed appearance Patients with cardiovascular disease The nurse may implement the following nursing interventions Patients with endocrine dysfunction (DM) to minimize anxiety: Hypertensive and hypotensive patients Explore the client’s feelings Hypovolemia Allow client’s to speak openly about fears and Hepatic disease concerns. Preexisting mental of physical disability Give accurate information regarding surgery. GOALS of Nsg Care During Preop: Provide empathetic support. Accept individual’s Assessing and correcting physiologic and psychologic reactions to the surgical experience. problems that might increase surgical risk. Consider the person’s cultural and religious Instructing and demonstrating exercises that will benefit preferences. Arrange for visit by chaplain/priest/ the person during postoperative period. minister/religious adviser as desired by the patient Planning for discharge and any projected changes in and his family. lifestyle due to surgery. Informed Consent Preoperative Nursing Assessment - The Legal Aspects of Surgical Interventions: Written Physiologic Assessment of the Client Undergoing Surgery Informed Consent/ Operative Permit/ Surgical Permit The physical preparations of the patient before surgery include - The PURPOSES of the written informed consent are as the following: follows: 1) Correcting any dietary deficiencies. 1) To ensure that the client understands the nature of 2) Reducing an obese person’s weight, as time permits. the treatment including the potential complications 3) Correcting fluid and electrolyte imbalances. and disfigurement. These are explained by the 4) Restoring adequate blood volume with blood surgeon. transfusion. 2) To indicate that the client’s decision was made 5) Treating chronic diseases – DM, heart disease, renal without pressure. insufficiency, bleeding disorders. 3) To protect the client against unauthorized procedure. 6) Treating any infectious process 4) To protect the surgeon and the hospital against legal 7) Treating an alcoholic person with vitamin action by a client who claims that an unauthorized supplementation, IV fluids or oral fluids, if dehydrated. procedure was performed. - The circumstances requiring written informed consent are Psychosocial Assessment of the Client Undergoing as follows: Surgery 1) Any surgical procedure where scalpel, scissors, The common causes of fears of the preoperative client are as suture, hemostats of electrocoagulation may be used follows: 2) Any invasive procedure, or procedure that involves 1) Fear of the unknown. This is the greatest fear of most entry into a body cavity. E.g. paracentesis, patients undergoing surgery. bronchoscopy, cystoscopy, colonoscopy, 2) Fear of anesthesia. Many patients fear their proctosigmoidoscopy. vulnerability while unconscious. They also fear the 3) Any procedure that involves general anesthesia, local potential complications of anesthesia including death. infiltration anesthesia or regional block anesthesia 3) Fear of pain. Patients fear the agony, suffering, or - The requisites for validity of written informed consent are distress that may result from the surgical procedure as follows: especially postop wound and from contraptions. Written permit/ consent is best and is legally 4) Fear of death. This is due to the risk of complications acceptable. of anesthesia and the surgical procedure, itself. Patient’s signature is obtained with the client’s 5) Fear of disturbance of body image. For example, loss complete understanding of what is to occur. of limb, loss of reproductive organs, alteration in Adults sign their own consent unless he/she is bowel and bladder elimination, cause disturbance of physically and mentally incapacitated. a person’s body image. If the patient is a child or minor (below 18 years old), 6) Fear and worries from loss of finances, employment, the parent or legal guardian will sign the consent. social and family roles. The nurse should assess the client for manifestations of fear Consent is obtained before sedation. that include the following: The patient is not under the influence of drugs or Anxiousness alcohol & is secured without pressure or duress or threat. Anger PP & IP 2 of 9 J.A.K.E Perioperative nursing – Preoperative and Intraoperative Phase 312 RLE Signature of witness is required. The nurse, physician overnight. Shaving should be done in the direction of or other authorized persons may sign as witness hair growth. NURSING PRIORITY: The consent/permit should be 2) Preparing the Gastrointestinal Tract signed before the client receives preoperative - Preparation of the bowel for intestinal surgery to medications prevent escape of bacteria and sepsis includes the In an emergency, permission via telephone is following: acceptable. The physician should document the Cathartics and enemas. nature of the emergency situation. Oral antimicrobials to reduce bacterial flora. Emancipated minors are allowed to sign without Enemas “until clear” the evening before surgery. written consent. (Emancipated minors are those who No more than three enemas should be given to are married, those who live on their own or financially prevent fluid – electrolyte imbalances. independent from their parents. This is applicable in NPO for 6 hours before surgery. Patients having the U.S. only.) morning surgery are kept NPO from midnight. Preparation of the patient before surgery includes Clear fluids, like water may be given up to 4 hours EXERCISES that will prevent postoperative complications. before surgery if ordered to help client swallow Deep breathing and coughing exercises. To promote medications adequate lung expansion and ventilation, and expel 3) Preparing for Anesthesia mucous secretions. - The patient should avoid alcohol and cigarette Incentive spirometry. To enhance deep inspiration and smoking for at least 24 hours before surgery. This can promote maximum lung expansion help reduce potential complications of anesthesia. Turning exercises. To promote adequate lung expansion, 4) Promoting Rest and Sleep promote circulation, and prevent pressure sores. - Provide comfort measures, e.g. clean gown and linens, Foot and leg exercises. Flexion and extension exercises of correct room temperature, subdued lighting, back rub. the lower extremities promote circulation; prevent venous Administer sedative as ordered. stasis, thereby preventing thrombophlebitis. When preparing the patient on the day of surgery, the nurse should include the following: 1) Awaken the patient, one hour before preoperative medications. 2) Provide morning bath and mouth wash. 3) Provide clean gown. 4) Remove hairpins, braid long hairs, cover hair with cap. 5) Remove dentures, foreign materials (chewing gum) from patient’s mouth. 6) Remove colored nail polish, hearing aid, contact lens, jewelries. If the patient refuses to remove the wedding ring, tie it with gauze and fasten around the wrist. 7) Take baseline vital signs before administration of preop medications. 8) Check patient identification (ID) band and area of “skin prep” as applicable. 9) Check for special orders, e.g. enema, gastrointestinal tube insertion, IV line. Ensure that these orders are carried out. 10) Check if NPO is maintained. 11) Have client void before administration of preop medications. Some preop medications may cause hypotension and increase risk for falls. For patient safety, put up side rails, put call light within patient’s reach, and instruct patient to ask for help if he/she needs to void. 12) Continue to support the patient emotionally. Anxiety level Preparation of the patient the evening before the surgery may be high at this time. include the following: 13) Accomplish the “Preop Care Checklist”. 1) Preparing the skin 14) BEST PRACTICE: If surgery will be done to a body part - It is ideal for the patient to bathe or shower, using a which is present on both sides of the body, e.g., eyes, ears, bacteriostatic soap to reduce microorganisms in the arms, breasts, legs, practice “TIME OUT” to check if the skin right patient is sent for surgery. Avoid SENTINEL EVENT - Shaving should be performed as close to the related to surgery of the wrong body part. operative time as possible. Hair grows again, PP & IP 3 of 9 J.A.K.E Perioperative nursing – Preoperative and Intraoperative Phase 312 RLE Preoperative Medications/ Preanesthetic Drugs Purposes: To facilitate the administration of any anesthetic. To minimize respiratory tract secretions and changes in heart rate. To relax the client and reduce anxiety Types of Preop Medications: 1) Opiates – morphine (Roxanol) and meperidine (Demerol) are given to relax the patient and potentiate anesthesia. 2) Anticholinergics – atropine sulfate, scopolamine, and glycopyrrolate (Robinul) are given to reduce respiratory tract secretions and to prevent severe reflex slowing of the heart during anesthesia. 3) Barbiturates/ Tranquilizers – Phenobarbital (Nembutal) and other hypnotic agents are given the night before surgery to help ensure a restful night’s sleep. 4) Prophylactic antibiotic - administered just before or during surgery when bacterial contamination is expected; ideally before skin incision is made BEST PRACTICE: Preanesthetic medications should be given exactly the time they are prescribed. If given too early, the maximum potency will have passed before it is needed; if given too late, the action will not have began before anesthesia is started. When transporting the patient to the operating room, promote safety. Care of the patient’s family includes the following: 1) Directing the family to the proper visiting room or waiting lounge. 2) Informing them that they will be contacted by the surgeon immediately. 3) Explaining reason for long interval of waiting. This is due to anesthesia preparation, skin prep, surgical procedure and recovery room/post anesthesia care unit stay. This action helps prevent unnecessary anxiety by the family. 4) Explaining what to expect during the postoperative period, e.g., IV fluids, blood transfusions, oxygen therapy, tubes and other contraptions Preop checklist day of surgery Preoperative education completed Informed consent signed NPO – Bowel prepo Skin prep – shower or bath in antimicrobial soap Documentation/ checklist of valuables Voided prior to transfer Preop meds – given and charted Side rails up after preop bed in low position Hospital gown Allergy band ID band Dentures, eyeglasses, hearing aids, contacts – left in place or removed Makeup and nail polish removed Vital signs before transfer Preoplab work on chart, surgeon notified abnormal values Medication: history, MAR on char, HER/ EMR up to date, high alert meds noted. PP & IP 4 of 9