Perioperative Nursing.pdf

PERIOPERATIVE NURSING gastrostomy tube may be inserted to It is a term used to describe the compensate for the inability to nursing care provided in the total swallow food) surgical experience of the patient. The periope...

PERIOPERATIVE NURSING gastrostomy tube may be inserted to It is a term used to describe the compensate for the inability to nursing care provided in the total swallow food) surgical experience of the patient. The perioperative period consists CLASSIFICATION OF SURGERY of three phases; that begin and end at (According to the degree of urgency) a particular point in the sequence of O-E-R-U-E events in the surgical experience. 1. Optional- Decision rests with the patient, Surgery is scheduled Preoperative phase completely at the preference of the begins when the decision to proceed patient (eg, cosmetic surgery). with surgical intervention is made 2. Elective- Patient should have and ends with the transfer of the surgery, The approximate time of patient onto the operating room (OR) surgery is at the convenience of the table.c patient; failure to have surgery 1s not catastrophic (eg, a superficial cyst) Intraoperative phase 3. Required- Patient needs to have begins when the patient is transferred surgery, The condition requires onto the OR table and ends with surgery within a few weeks (eg, eye admission to the PACU (Post cataract). Anesthesia Care Unit). 4. Urgent- Patient requires prompts attention, The surgical problem Postoperative phase requires attention within 24 to 48 begins with the admission of the hours (eg, cancer) patient in the PACU and ends with a 5. Emergency- The situation requires follow-up evaluation in the clinical immediate surgical attention without setting or home. delay (eg, intestinal obstruction and shotgun wound) SURGICAL CLASSIFICATION D-C-R-R-P INFORMED CONSENT 1. Diagnostic- (eg, biopsy, exploratory (Operative ermit) laparotomy) Informed consent is the patient's 2. Curative- (eg, excision of a tumor or autonomous decision about whether an inflamed appendix) to undergo a surgical procedure. It is 3. Reparative- (eg, multiple wound the process of informing the patient repair) and family about the surgical 4. Reconstructive or cosmetic- (eg, procedure: that is, the risks and mammoplasty or facelift) possible complications of surgery 5. Palliative- (eg, to relieve pain or and anesthesia. Consent is obtained correct a problem- for instance, a  by the surgeon. This is a legal An offer to answer questions about requirement. procedure Purposes Instructions that the patient withdraw To ensure that the patient consent understands the nature of the A statement informing the patient if treatment, including potential the protocol differs from customary complications. proc To indicate that the patient's decision was made without pressure. Patient Able to Comprehend To protect the patient against If the patient is non-English unauthorized procedure is performed speaking, it is necessary to provide on the correct consent (write and verbal) in a To protect the surgical team and language that is understandable to hospital against legal action by a the client. A trained medical patient who claims that an interpreter may be consulted. unauthorized procedure was Alternative formats of performed. communication (e.g., Br large print, sign interpreter) may be needed if the patient has a disability t affects vision or hearing. Questions must be answered to facilitate comprehensive material is confusing. PRE-OPERATIVE ASSESSMENT -The goal of the pre-operative period is for the patient to be as healthy as possible. PRE meaning Before. ✓ Consent ✓ Health history is obtained ✓ Nutritional and fluid status ✓ Dentition Informed Subject ✓ Alcohol and drug use Informed consent should be in writing. It ✓ Respiratory status should contain the following: ✓ Cardiovascular status Explanation of procedure and its ✓ Hepatic, Renal and endocrine risks function Description of benefits and ✓ Previous medication used alternatives ✓ Psychosocial Factors ✓ Spiritual and Cultural Belief  - Specific recommendations depend Pre-operative Nursing Interventions on the age of the patient and the type -Providing Patient Teaching of food (ex. Adult is advised to fast ❖ Deep Breathing, Coughing and for hours after eating fatty food) Incentive Spirometry ❖ Bowel Preparation ✓ Demonstrates how to take deep, slow Enemas are not commonly breath and how to exhale slowly prescribed preoperatively unless the ✓ Instruct the patient to breathe deeply, patient is undergoing abdominal or exhale through the mouth, take a pelvic surgery short breath, and cough from deep in Allow satisfactory visualization of the lungs the surgical site and to prevent ✓ Demonstrates how to use an trauma to the intestine or incentive spirometer contamination of the peritoneum by fecal material ❖ Mobility and Active Body Cleansing enema or laxatives may be Movement prescribed evening before the Patient should be taught that early surgery and may be repeated the and frequent ambulation, exercise of morning of surgery the extremities and frequent change of position immediately ❖ Skin Preparation postoperative as tolerated will help Goal is to decrease bacteria without to prevent complications. injuring the skin. ❖ Pain Management ❖ Cognitive Coping Strategies Patient is instructed to take the - Cognitive strategies may be medication as frequently as useful for relieving tension, prescribed during the initial overcoming anxiety, postoperative period for pain relief decreasing fear, and achieving relaxation. ❖ Reducing Anxiety and Imagery: The patient concentrates Decreasing Fear on a pleasant experience or restful Assists the patient to identify coping scene. strategies that he or she has Distraction: The patient thinks of an previously decrease fear. enjoyable story or recites a favorite poem or song. ❖ Managing Nutrition and Fluids Optimistic self-recitation: The - NPO overnight or longer to prevent patient recites optimistic thoughts ("I aspiration know all will go well").  Music: The patient listens to ❖ Transfer the patient to the holding soothing music (an easy-to- area/presurgical suite 30-60 minutes administer, inexpensive, noninvasive anesthetic agent is administered. intervention). PREOPERATIVE MEDICATION ❖ respecting cultural, spiritual and ❖ Reduce anxiety religious belief ❖ Promote relaxation Identifying and showing respect. The ❖ Reduce pharyngeal secretions responses should be recognized as ❖ Prevent laryngospasm normal. ❖ Inhibit gastric secretion ❖ Decrease amount of anesthetic ❖ maintaining patient safety needed for induction and maintenance of anesthesia IMMEDIATE PRE-OP NURSING INTRA-OPERATIVE ASSESSMENT INTERVENTION The goal of Intra-operative period is ❖ Assist the patient in changing patient safety and sterile hospital gown environment. intra meaning Present ❖ Cover the head completely with cap ❖ Inspect the mount, dentures and plates are removed THE SURGICAL TEAM C-S-S-A ❖ Remove all jewelries/body piercing ❖ If the patient objects in removing ❖ Circulating Nurse wedding ring, secure it with tape Main responsibilities include: ❖ All valuable articles are given to ✓ Verifying consent family members or labeled it clearly ✓ Coordinating the team and stay in a safe and secured place ✓ Ensuring cleanliness according to hospital policy ✓ Proper temperature and humidity ❖ Patient should void first before going ✓ Lighting and safe function of to OR equipment and the availability of ❖ If preanesthetic medication is supplies and materials. administered, the patient is kept in The circulating nurse bed w rails raised monitors aseptic practices to ❖ The completed chart (with the avoid breaks in technique preoperative checklist and while coordinating the verification accompanies the patient movement of related to the OR with the surgical consent personnel (medical, x-ray, form attached laboratory reports and and laboratory) as well as nurse's records implementing fire safety precautions.  Responsible for ensuring that any technical problems the second verification of the related to the administration surgical procedure and site of the anesthetic agents, and takes place is documented. supervises the patient's condition throughout the ❖ Scrub Nurse surgical procedure. Performs surgical hand scrub During surgery, the Setting up the sterile tables anesthesiologist monitors the Preparing sutures, ligatures, patient's blood pressure, and special equipment (eg, pulse, and respirations as laparoscope) well as the electrocardiogram Assisting the surgeon and the (ECG), blood oxygen surgical assistants during the saturation Level, tidal procedure by anticipating the volume, blood gas level, instruments and supplies that blood ph, alveolar gas will be require such as concentrations, and body sponges, drains, and other temperature. equipment Scrub nurse and the circulator count all needles, sponges, ANESTHESIA and instruments to be sure A state of narcosis (severe central they are accounted for and nervous system depression produced not retained as a foreign body by pharmacologic agents), analgesia, in the patient. relaxation, and reflex loss. ❖ Surgeon TYPES OF ANESTHESIA Performs the surgical procedure, heads the surgical 1. GENERAL ANESTHESIA team and is specially trained reversible consisting of and qualified complete loss of consciousness that provides Has the ultimate analgesia, muscle relaxation, responsibility for performing and sedation, Protective the surgery in an effective reflexes are lost. and safe manner ❖ Inhalation ❖ Anesthesiologist Inhaled anesthetic agents include volatile liquid agents Assesses the patient before and gases. surgery, selects anesthesia, administers it, intubates patient if necessary, manages  Volatile liquid: anesthetic Because of uncontrolled movement agents produce anesthesia of the patient, restraints are H-E-I-S-D when their vapors are inhaled necessary ✓ Halothane (Fluothane) ✓ Enflurane (Ethrane) ❖ Stage 3 (Surgical Anesthesia) ✓ Isoflurane (Forane) Patient is unconscious and lies ✓ Sevoflurane (Ultrane) quietly ✓ Desflurane (Suprane) Pupils are small but reactive to light Respirations are regular, the pulse ❖ Intravenous Administration and volume are normal General anesthesia can also Skin is pink or slightly flushed be produced by the IV administration of various ❖ Stage 4 (Medullary substances, such as: Depression/Danger) B-B-N-D-O Barbiturates Too much anesthesia has been Benzodiazepines administered Non-barbiturate hypnotics Shallow respiration, weak and thread Dissociative agents pulse Opioid agents Widely dilated pupils Endotracheal tube Death may occur Laryngeal Mask Airway If this stage develops, discontinue anesthesia and initiate respiratory STAGES OF GENERAL ANESTHESIA and circulatory support ❖ Stage 1 (Beginning Anesthesia/Induction) 2. REGIONAL ANESTHESIA Feeling of detachment Anesthetic agents are injected Drowsy/dizziness around nerves so that the Hallucination occurs region supplied by these Close 0.R doors nerves is anesthetized. Ringing, roaring or buzzing in the Patient receiving regional ears anesthesia is awake and Keep quiet because exaggerated aware of his or her noises are heard by the patient surroundings unless Standby to assist the client medications are given to produce mild sedation or to ❖ Stage 2 (Excitement/Delirium) relieve anxiety. Pupils are dilated, pulse rate are rapid, and may have irregular Epidural Anesthesia respiration Achieved by injecting a local anesthetic agent into the epidural  space that surrounds the dura mater anesthetic agent into the tissues at of the spinal cord the planned incision site. Advantage absence of headache Disadvantage: greater technical challenge of introducing the anesthetic agents into the epidural rather than the subarachnoid space Spinal Anesthesia Extensive conduction nerve block that is produced when a local anesthetic agent is introduced into the subarachnoid space at the lumbar level, usually between L4 and L5. It produces anesthesia of the lower extremities, perineum, and lower abdomen Moderate sedation Previously referred to as conscious sedation, is form of anesthesia that involves the IV administration of sedative or analgesic medications to reduce patient's anxiety and to control pain during diagnostic or therapeutic procedures Monitored anesthesia care (MAC) Also referred to as monitored sedation, is moderate sedation administered by an anesthesiologist or anesthetist who must be prepared and qualified to convert to general anesthesia if necessary 3. LOCAL ANESTHESIA- Injection of a solution containing the