Pre-Operative Nursing Care Procedures PDF

Safe and comprehensive perioperative nursing care - July Ven Hernandez-Obrador, RN, MSN, JD*(eu)* - SURGERY - Is the use of instruments during an operation to treat injuries, diseases, and deformities. Is a stressful, complex event. The branch of medicine concerned with diseases a...

Safe and comprehensive perioperative nursing care - July Ven Hernandez-Obrador, RN, MSN, JD*(eu)* - SURGERY - Is the use of instruments during an operation to treat injuries, diseases, and deformities. Is a stressful, complex event. The branch of medicine concerned with diseases and trauma requiring operative procedures. - **Surgical procedures are named according to:** 1\. the involved body organ, part, or location and 2\. the suffix that describes what is done during the procedure Physicians who perform surgery include surgeons or other physicians trained to do certain surgical procedures. Examples: General Surgeon, Neurosurgeon, Orthopedic Surgeon, Pediatric Surgeon - **SURGICAL PROCEDURE SUFFIXES** - ectomy - Removal by cutting - orrhaphy - Suture of or repair - oscopy - Looking into - ostomy - Formation of a permanent artificial opening - otomy - Incision or cutting into - plasty - Formation or repair ** Emergent** \- Patient requires immediate attention; disorder may be life threatening; immediately without delay to maintain life or organ, remove damage, stop bleeding. **Urgent / Imperative** \- Patient requires prompt attention; within 24 -- 30/48 hours. - **Required / Planned** - Patient needs to have surgery; plan within a few weeks or months. - CLASSIFICATION OF SURGERY - **Elective** - Patient should have surgery; failure to have surgery not catastrophic; planned/scheduled with no time requirements. **Optional** \- Decision rests with patient; at the preference of patient. - ACCORDING TO PURPOSE - **Aesthetic** - Requested by patient for improvement. **Diagnostic** \- To obtain tissue samples, make an incision, or use a scope to make a diagnosis. **Exploratory** \- Confirmation or measurement of extent of condition. - ACCORDING TO PURPOSE - **Preventive** - Removal of tissue before it causes a problem. **Curative (Ablative)** - Removal of diseased or abnormal tissue. **Reconstructive** - Correction of defects of body parts ** Palliative** \- Alleviation of symptoms without curing disease. - ACCORDING TO EXTENT ** Major** - \- Extensive surgery that involves serious risk and complications, as it involves major organ, High risk, extensive, prolonged, large amount of blood loss, vital organs may be handled or removed, great risk of Complications. ** Minor** \- Involves minimal complications & blood loss, Generally not prolonged, leads to few serious complications, involves less risk. - PRINCIPLES OF SURGICAL ASEPSIS - **Moisture causes contamination** Prevent splashing of liquids in the sterile fields. Place wet objects on sterile, water-impermeable surfaces, such as sterile basin. - Rationale: microorganisms travel more easily through moist environment. When sterile surface becomes moist, microorganisms from the unsterile surface may be transmitted into the sterile surface. - 2\. **Never assume that an object is sterile** Ensure that it is labeled as sterile Always check the integrity of the packaging Always verify the expiration date on the package Whenever in doubt of the sterility of an object, consider it unsterile - Rationale: commercially prepared products are labeled as sterile on their packaging; special indicators are used to show that objects have completed their sterilization process; packages that are torn, punctured, or moist are considered unsterile. 3\. **Always face the sterile field** - Rationale: objects that are out of the line of vision may be inadvertently contaminated. **4. Sterile articles may touch only sterile articles or surfaces if they are to maintain their sterility** - Rationale: anything considered unsterile may transfer microorganisms to the sterile object it touches. **5. Sterile equipment or areas must be kept above the waist and on top of the sterile field** - Waist level is the limit of good visual field. Maximum visibility of all sterile objects prevents inadvertent contamination. **6. Prevent unnecessary traffic and air currents around the sterile area** Close doors Unfold drapes or wrappers properly Do not sneeze, cough, or talk excessively over the sterile field Do not reach across sterile fields Move around a sterile field to reach for an object, if necessary - Rationale: microorganisms cannot be completely excluded from the air; overreaching across sterile fields will render sterile objects unsterile. **7. Open, unused sterile articles are no longer sterile after the procedure** - Rationale: once protective wrapping have been removed, the article is being contaminated by air so, it must be discarded or sterilized before it is used; liquids opened during the procedure that remain in the container are also considered contaminated. **8. A person who is considered sterile who becomes contaminated must reestablish sterility** - Rationale: if a scrubbed person punctures the gloves or is contaminated by touching an unsterile object, he or she must change the contaminated articles; if a scrubbed person leaves the area of the sterile field, he or she must go through the procedure of rescrubbing, gowning, and gloving. 9\. Surgical technique is a team effort A collective and individual ‚sterile conscience‛ is the best method of enhancing sterile technique. - Rationale: staff members must rely on one another to maintain sterile technique; periodic review of procedures and infection control surveillance reports enhance everyone's sterile technique. - FOUR MAJOR TYPES OF PATHOLOGIC PROCESSES REQUIRING SURGICAL INTERVENTION (POET) - EFFECTS OF SURGERY TO THE CLIENT - Stress response is elicited - Defense against infection is lowered - Vascular system is disrupted - Organ functions are disturbed - Body image may be disturbed - Lifestyles may change - SURGICAL RISK FACTORS 1\. **Nutritional and Fluid Status** Optimal nutrition is an essential factor in promoting healing an resisting infection and other surgical complications. obesity, under nutrition, weight loss, malnutrition, deficiencies in specific nutrients, metabolic abnormalities, and the effects of medication on nutrition. Nutritional needs may be measured through BMI and waist circumference Nutritional deficiency should be corrected before surgery Nutrients important for wound healing are: protein, arginine, carbohydrates and fats water, vitamin C, vitamin B complex, vitamin A, vitamin K, magnesium, copper, zinc 2\. **Drug or Alcohol Use** - The person with a history of chronic alcoholism often suffers from malnutrition and other systemic problems that increase surgical risk. 3**. Age** - very young and very old 4\. **Presence of disease/s** Respiratory, Renal/urinary, Cardiovascular, Endocrine Hepatic. 5\. **Concurrent or prior pharmacotherapy** A medication history is obtained from each patient because of the possible effects of medications on the patient's perioperative course, including the possibility of drug interactions. Document all medications. Stop aspirin 7-10 days before surgery. Currently it is recommended that the use of herba lproducts be discontinued 2 to 3 weeks before surgery 6**. OTHER SURGICAL RISK FACTORS** Nature of condition Location of the condition Magnitude and urgency of the surgical procedure Mental attitude of the person toward surgery Caliber of the professional staff and health care facilities - THE SURGICAL TEAM 1\. **SURGEON** Head of the surgical team. Perform operative procedure safely and correctly. Visits the patient before anesthesia is inducted, if needed, assist in the positioning of the patient. Responsible for being certain that all team members are aware of what they need during the procedures and that all necessary equipment are available. If he/she is responsible to give the anesthesia (incases of local anesthesia), it will either be given before scrubbing or after the patient has been draped. - After the operation: surgeon secures the dressings - in place. - After the anesthesiologist gives his/her permission, - the surgeon should assist in moving the patient to - the stretcher to be brought to the Post Anesthesia - Care Unit (PACU). **2.ANESTHESIOLOGIST/ANESTHETIST** Person who gives the anesthesia to the patient. Must be properly attired in the operating room Responsible for making sure that all equipment and supplies necessary for the induction of anesthesia are available and then checks the patient and the chart for any last minute changes. Monitoring equipment such BP apparatus, cardiac monitor are attached to the patient. Helps position the patient. During the surgery: monitors the patient's vital signs, responsible for keeping the surgeon aware of the condition of the patient, he/she gives the fluids and blood transfusion needed during the operation. Responsible to inform the operating nurse of the time for the next patient to be pre medicated. Determines if the patient is to be brought to the PACU after surgery is completed. Usually checks the patient's airway or vital signs before moving the patient to PACU. **3. ASSISTANT SURGEON** Help the surgeon in any way possible. Must be properly attired. May help with the drapes and final placement of equipment and supplies. May close the incision and help with the dressing. ❖ In our hospital, the assistant surgeons are usually the residents. **4. CIRCULATING NURSE** He/she does not need to scrub, but a good hand washing technique should be done. In charge of the overall running of the OR before, during and after surgery. One of the most important duty: Sterility is maintained at all times. Preparing the operating room. Assisting the scrub nurse, especially during sponge count. Caring for the patient before and after the operation. Assisting the anesthesiologist. Positioning the patient and preparing the operative site. Assisting the scrub team before and during surgery. Caring for the patient after surgery. Cleaning the operating room after the surgery has been completed. **5. SCRUB NURSE** Must be properly attired, scrubbed, gowned and gloved. Assist the circulating nurse in the preparation of the operating room. Must familiarize itself with the procedure and supplies & equipment needed to avoid delay. Set up back table. Assist surgeon & assistant surgeon in their gowns and gloves. Drapes the operative site. Should anticipate the surgeon's needs. Wash the instruments. - THE SURGICAL ENVIRONMENT Known for its stark appearance and cool temperature. Access is limited to authorized personnel. The OR must be situated in a location that is central to all supporting services. The OR must have a specific air filtration devices to screen out contaminating particles, dust, and pollutants. ❖ The unrestricted zone (street clothes are allowed); the semi restricted zone (attire consists of scrub clothes and caps); and the restricted zone (scrub clothes, shoe covers, caps, and masks are worn) - Shirts and waist drawstrings should be tucked inside the pants. Wet or soiled garments should be changed. Masks are worn at all times at the restricted zone. Upper respiratory tract infections and skin infections in staff and patients. ources of pathogens and must be reported. - PERIOPERATIVE NURSING Nursing care given to surgical patients preoperatively, intraoperatively, and postoperatively by a registered nurse or a delegated professional person. PRE -- before INTRA -- during POST -- after - PERIOPERATIVE NURSING - PREOPERATIVE PHASE - Begins at the time of decision for surgery and ends when the client is transferred to the Operating Room - GOALS: a\. Assessing and correcting physiologic and physiologic problems that might increase surgical risk. b\. Giving the person and significant others complete learning/teaching guidelines regarding surgery. c\. Instructing and demonstrating exercises that will benefits the person during postoperative period. d\. Planning for discharge and any projected changes in lifestyle due to surgery. - PHYSIOLOGIC PREPARATION\ FOR THE SURGERY Preparation for hospital admission includes : - explanation of the procedure to be done, - Probable outcome, - expected duration of hospitalization, cost, length of absence from work, and residual effects. - CAUSE OF FEARS: - Fear of the unknown - Fear of Anesthesia, vulnerability while unconscious - Fear of pain - Fear of death - Fear of disturbance of body image - Worries: loss of finances, employment, social and family roles - [LEGAL ASPECT]:\ INFORMED CONSENT, OPERATIVE PERMIT, SURGICAL PERMIT - This is to protect the surgeon and the hospital against claims that unauthorized surgery has been performed and the patient was unaware of the potential risks of complications involved - Protects the client from undergoing unauthorized surgery The surgeon obtains operative permit or informed consent and provides information to the client or guardian. The nature and reason for the surgery All available options and the risk associated with each option The risk of the surgical procedure and its potential outcomes Name and qualifications of the surgeon performing the procedure. The right to refuse the consent or later withdraw consent. - NOTE: \- Nurse serves as a witness during the signing of the consent form Informed consent is necessary for each operation performed, however: It is also necessary for major diagnostic procedures where major body cavity is entered e.g. thoracentesis. Adult client over 18 years old signs own permit unless unconscious or mentally incompetent. If unable to sign relative or guardian will sign. - CONSENTS ARE NOT NEEDED FOR EMERGENCY - CASE IF ALL FOUR OF THE FOLLOWING CRITERIA ARE MET: a\. There is an immediate threat to life b\. Experts agree that it is an emergency c\. Client is unable to consent d\. A legally authorized person cannot be reached Minor (under 18) must have consent signed by an adult(i.e. parent, legal guardian). An emancipated guardian may sign own consent: Married College students living away from home In military service Any pregnant female or anybody who has givenphysician, clerk or authorized person If nurse witnesses informed consent, specify whether witnessing explanation of surgery or just signature of client. - PHYSIOLOGIC PREPARATION PRIOR TO SURGERY a\. Respiratory Preparation - Chest X-ray b\. Cardiovascular Preparation ECG, CBC, blood typing, cross-matching, - PT/PTT(prothrombin time, partial prothrombin time), serum electrolytes c\. Renal preparation Urinalysis - Obtain history of past medical conditions, allergies, dietary restrictions, and medications. ❖ **A** - Allergy to medications, chemicals and other environmental products (latex). All allergies are reported before the beginning of the surgery. If allergy exist, an allergy band must be placed in the clients arm immediately. ❖ **B** - Bleeding tendencies or the use of medications that defer clotting, such as aspirin, heparin, and warfarin sodium. Herbal medications may also increase bleeding time or mask potential blood-related problems. ❖ **C** - Cortisone and steroid use. ❖ **D** - Diabetes Mellitus, a condition that not only requires strict control of blood glucose levels but also known to delay wound healing. ❖ **E** - Emboli, previous embolic events such as lower leg blood clots may recur because of prolonged immobility. - Instructional and Preventive Aspects: - Coughing Exercise: deep breath, exhale through the mouth, and then follow with a short breath while coughing; splint thoracic and abdominal incision to minimize pain. - Turning exercise every 1-2 hours post-operative. - Extremity exercise-prevents circulatory problems and post operative gas pains or flatus. - Assure that pain medications will be available post--op. - PHYSICAL PREPARATION - **[On the Night of the Surgery]** - a\. Preparing the client's skin (follow hospital protocol): \- shave against the grain of the hair shaft to ensure clean and close shave - b\. Preparing the GIT: - \- NPO after midnight - \- Administration of enema(if necessary) - \- Insertion of gastric or intestinal tubes(if necessary - **[On the Day of Operation]** a\. Early morning care about 1 hour prior to the preoperative medication schedule \- Vital signs taken and recorded \- Patient changes into hospital gown that is left untied and open at the back \- Braid long hair and remove hair pin \- Provide oral hygiene \- Prosthetic devices, eyeglasses, dentures removed \- Remove jewelries \- Remove nail polish \- Patient should void immediately before going the OR \- Make sure that the patient has not taken food for the last 10 hours by asking the client b\. Pre-operative medications \- Generally administered 60-90 min. before induction of anesthesia - TYPES PRE-OPERATIVE MEDICATIONS 1\. Sedative Given to decrease clients anxiety to lower BP and PR Reduce the amount of general anesthesia: an overdose can result to respiratory depression 2\. Tranquilizer Lowers the client's anxiety level 3\. Narcotic Analgesics Given to patients to reduce anxiety and to reduce the amount of narcotics given during surgery 4\. Vagolytics or Drying Agents To reduce the amount of tracheobronchial secretions which can clog the pulmonary tree and result in atelectasis and pneumonia