Perioperative Concepts and Nursing Management PDF

Perioperative concepts and Nursing management  Intended Learning Outcomes (ILOs) At the end of this lecture the students will be able to :  Know the different types of surgeries  Recognize the surgical risk factors  Discuss & apply the nursing roles in the different distinct...

Perioperative concepts and Nursing management  Intended Learning Outcomes (ILOs) At the end of this lecture the students will be able to :  Know the different types of surgeries  Recognize the surgical risk factors  Discuss & apply the nursing roles in the different distinct phases of surgery (preoperative , intraoperative & postoperative )  Recognize & apply concept related health teaching to be used during preoperative patient’s teaching.  Discuss the pharmacological aspects of preoperative medication  Predict& differentiate between the postoperative discomfort and complications.  Formulate a comprehensive care plan to be used & apply for patient undergoing surgical procedure.  Out lines  Perioperative overview(types of surgery , surgical risk factors )  Preoperative care (informed consent , patient education, patient preparation ,preoperative medication & transferring the patient to surgery )  Intra-operative care ( common types of anesthetics technique, intraoperative complication)  Post operative (initial assessment , intervention , postoperative discomfort and complications ) Perioperative overview  Introductory information : Perioperative nursing is a term used to describe the nursing care provided in the total surgical experiences of the patient It include : Preoperative phase : begins with the time the decision is made for surgical intervention to the transfer of the patient to the operating room. Intraoperative phase : started from the time the patient is received in the operating room till admitted to recovery room Postoperative phase : from the time of admission to the recovery room to the follow up home /clinic evaluation Types of Surgery According to Extent: A. Minor surgery: Simple operations not considered a risk to life. B. Major surgery: Important and serious operations involving a risk to life.  Types of surgery according to urgency  Optional – Surgery : is scheduled completely at the preference of the patient e.g. cosmetic surgery  Elective – The approximate time for surgery is at the convenience of the patient of patient , failure to have surgery is not catastrophic e.g. superficial cyst  Required –The condition requires surgery within a few weeks e.g. eye cataract  Urgent surgery : The surgical problem requires attention within 24-48 hours  Emergency surgery : Situation requires immediate surgical attention without delay  Types of Surgery According to Purpose: 1. Diagnostic: To determine cause of symptoms. Examples: Biopsy, Exploratory Laparotomy 2. Curative/Ablative: To remove diseased tissue. Example: Appendectomy. 3. Cosmetic: To improve appearance. Example:--Rhinoplasty 7 4. Restorative - Examples: a. To strengthen weakened areas: Herniorrhaphy b. To correct deformities: Repair of cleft lip 5. PalLiative: To relieve symptoms without curing disease.  Example: Sympathectomy 8  Surgical Risk Factors ‫نسجة الدهنية وانشقاق‬C‫شاركة في الجوانب الفنية للجراحة )تصبح الخياطة صعبة بسبب ا‬-‫ زيادة الصعوبة ا‬ ‫حشاء‬C‫الجروح وا‬  Obesity -------- danger : ‫قاومة‬-‫سؤولية عن العدوى بسبب انخفاض ا‬-‫ زيادة ا‬.‫بكر‬-‫شي ا‬-‫سؤولية عن ا‬-‫ تقليل ا‬ Increase difficulty involved in technical aspects of surgery (suturing become difficult because of fatty tissues , wound dehiscence and evisceration Increase liability to infection because of lessened resistance Decrease liability to early ambulation.  Poor nutrition ------danger : Preoperative malnutrition greatly impaired wound healing. Increase liability to infection.  Fluid &electrolytes imbalance ------danger : Dehydration and electrolytes imbalance can have adverse effects in terms off general anesthesia and the anticipated volume loss with surgery. Surgical Risk Factors  Aging ----- danger Potential for injury is greater in the aged ‫صابة أكبر لدى كبار السن‬0‫احتمال ا‬ Be aware that the cumulative effect of medication is greater in the older ‫ كن على علم بأن التأثير التراكمي‬ persons..‫دوية أكبر لدى كبار السن‬A‫ل‬ Note the medication as morphine and barbiturates in the usual dosages my B‫ورف‬E‫حظ الدواء على أنه ا‬J causes confusion , disorientation & respiratory depression. ‫عتادة التي‬E‫والباربيتورات بالجرعات ا‬ ‫كتئاب‬J‫رتباك وا‬J‫رتباك وا‬J‫يسببها ا‬  Presence of CVD------danger.‫التنفسي‬ Many surgical problems may be complicated in the presence of cardiovascular  Presence of Diabetes Mellitus -----danger Hyperglycemia is potentiated by increase catecholamine and glucocorticoids due to surgical stress. ‫يتم تعزيز ارتفاع السكر في الدم عن طريق زيادة‬ ‫جهاد‬0‫ والجلوكوكورتيكويدات بسبب ا‬B‫م‬J‫الكاتيكو‬.‫الجراحي‬ Surgical Risk Factors  Presence of Alcoholism -----danger Additional problem of malnutrition may be present in the presurgical patient with alcoholism. The tolerance of to anesthesia may be increased The presence of liver disorders may present also with alcoholism.  Presence of pulmonary and upper respiratory disease ----danger Chronic pulmonary illness may contribute to hypoventilation leading to pneumonia and atelectasis. Preoperative assessment 12  Assessment of health factors that affect patients preoperatively ‫تقييم العوامل الصحية التي تؤثر‬ 1- Nutritional and Fluid Status ‫رضى قبل الجراحة‬9‫على ا‬ 2- Drug or Alcohol Use 3- Respiratory Status surgery is usually postponed when the patient has a respiratory infection. ‫عادة ما يتم تأجيل الجراحة عندما يكون‬.‫ريض مصابا بعدوى في الجهاز التنفسي‬9‫ا‬  Patients who smoke are urged to stop 2 months before surgery although many do not do so. 13 Assessment of health factors that affect patients ‫تقييم العوامل الصحية التي تؤثر‬ ‫رضى قبل الجراحة‬9‫على ا‬ 4- Cardiovascular Status  Ensuring a well functioning cardiovascular system to meet the oxygen, fluid, and nutritional needs of the perioperative period.  If the patient has uncontrolled hypertension, surgery may be postponed until the blood pressure is under control. 14  Assessment of health factors that affect patients ‫الصحية التي تؤثر‬ ‫تقييم العوامل‬ 5- Hepatic and Renal Function: ‫رضى قبل الجراحة‬9‫على ا‬  optimal function of the liver and urinary systems is needed as medications, anesthetic agents, body wastes, and toxins are processed and removed from the body. ‫ثلى للكبد والجهاز البولي‬9‫هناك حاجة إلى الوظيفة ا‬ ‫دوية وعوامل التخدير ونفايات‬O‫حيث تتم معالجة ا‬ Endocrine Function.‫الجسم والسموم وإزالتها من الجسم‬  The patient with diabetes who is undergoing surgery is at risk for hypoglycemia and hyperglycemia. which may increase the risk for ‫صاب بمرض السكري الذي يخضع لعملية جراحية‬9‫ريض ا‬9‫ا‬ surgical wound infection..‫معرض لخطر نقص السكر في الدم وارتفاع السكر في الدم‬.‫صابة بعدوى الجروح الجراحية‬e‫مما قد يزيد من خطر ا‬  Frequent monitoring of blood glucose ‫وأثناء‬ levels is important before, ‫ستويات الجلوكوز في الدم مهمة قبل‬9 ‫تكررة‬9‫راقبة ا‬9‫ ا‬ during, and after surgery. 15.‫وبعد الجراحة‬  ‫تقييم العوامل الصحية التي تؤثر‬ 7- Immune Function ‫رضى قبل الجراحة‬9‫على ا‬  An important function of the preoperative assessment is to determine the existence of allergies, including the nature of previous allergic ‫تحديد‬ reactions. ‫همة لتقييم ما قبل الجراحة في‬9‫تتمثل الوظيفة ا‬.‫ بما في ذلك طبيعة الحساسية السابقة‬،‫وجود الحساسية‬  Because patients who are immunosuppressed are highly susceptible to infection, great care is taken to ensure strict asepsis. ‫ناعة عرضة‬9‫رضى الذين يعانون من كبت ا‬9‫ن ا‬V ‫ نظرا‬ ‫ يتم توخي الحذر الشديد لضمان التعقيم‬،‫للغاية للعدوى‬ 8- previous medication use.‫الصارم‬  A medication history is obtained any medication the patient is using or has used in the past is documented, including herbal agents and the frequency with which they are used. ‫ريض أو استخدمه في‬9‫يتم الحصول على تاريخ الدواء أي دواء يستخدمه ا‬ 9- Psychosocial Factors ‫ بما في ذلك العوامل العشبية وتكرار استخدامها‬،‫اضي يتم توثيقه‬9‫ا‬ 16 I- Preoperative care  Informed consent  Preoperative patient education  Patient’s preparation  Preoperative medication  Transferring the patient to surgery  Informed Consent An informed consent is the process of informing the patient about the surgical procedure and obtaining consent from him.It is a legal requirement. Purposes of Informed Consent :  To ensure that the patient understands the nature of the treatment including potential complications  To indicate that the patient’s decision was made without pressure.  To protect the patient against the unauthorized procedures ,and to ensure that the procedure is performed on the correct body part.  To protect the surgeon and the hospital against legal action by a patient or his family. Preoperative patient education  Is a vital component of the surgical experience , it may be offered through conversation , discussion , the use of audiovisual materials , demonstration and re-demonstration.  It may be initiated before hospitalization to minimize anxiety , promote full recovery and decrease postoperative complications and discomfort.  The preoperative nurse can assess the patient’s knowledge base and use this information in developing a plan for an uneventful perioperative period Components of preoperative patient’s education ‫التنفس الحجابي‬ ‫هذه طريقة للتنفس يتم فيها تسطيح قبة الحجاب الحاجز‬  Diaphragmatic breathing : ‫ت البطن العليا‬E‫ مما يؤدي إلى تضخم عض‬،‫لهام‬R‫أثناء ا‬.‫ وتعتبر تقنية استرخاء فعالة‬،‫واسترخاء الحجاب الحاجز‬ This is a mode of breathing in which the dome of the diaphragm is flattened during inspiration , resulting in enlargement of the upper abdominal muscle and the diaphragm relax , It is considered as an effective relaxation technique.  Incentive Spirometry : :‫قياس التنفس الحافز‬ Preoperatively , the patient uses a spirometer to measure deep breathing ( inspired air ) while exerting maximum effort. The preoperative measurement becomes the goal to be achieved as possible postoperative. ‫ يستخدم ا]ريض مقياس التنفس لقياس التنفس العميق )الهواء‬،‫قبل الجراحة‬ ‫ يصبح القياس قبل الجراحة هو الهدف الذي يجب‬.‫ا]لهم( مع بذل أقصى جهد‬.‫تحقيقه بعد العملية الجراحية‬ Components of preoperative patient’s education  Coughing : Coughing promotes the removal of chest secretions, So teaching the patient coughing exercise will help in avoidance of serious problem post operatively.  Turning : Changing position from back to side –lying ( and vice versa ) stimulates circulation , encourage deeper breathing and relive pressure area.  Foot & Leg Exercise : Moving legs improves circulation , muscle tone & prevent stasis of the blood Patient’s preparation  Skin preparation :.‫مراض‬%‫ وبعضها مسبب ل‬،‫قيمة‬5‫عادة ما يؤوي جلد ا?نسان النباتات البكتيرية العابرة وا‬  Human skin normally harbors transient and resident bacterial flora , some of them are pathogenic.  Skin can’t be sterilized without destroying skin cells  Friction enhancing the action of detergent antiseptic, but for patient’s safety it must be avoided in many cases.  It is ideal for the patient to bathe or shower using bacteriostatic soap on the day of surgery.  If requested, shaving should be performed as close to the operative time as possible. The longer the interval between the shave and operation ,the higher the incidence of postoperative wound infection. Preparation of GIT ‫معاء‬%‫يعد إعداد الوعاء أمرا ضروريا لجراحة ا‬  Preparation of the bowl is imperative for intestinal surgery because escaping bacteria can invade adjacent tissue and cause sepsis.  Cathartics and enema remove gross collection of stool  Oral antimicrobial agents (neomycin ) suppress the colon’s potent microflora  Enema until clear are prescribed the evening the night before surgery.No more than 3 enemas should be given because of the adverse effect of fluid &electrolytes disturbances.  Solid food is withheld from the patient for 6 hours before surgery. Patient having morning surgery is kept NPO overnight. Water can be given 4 hours before surgery to help the patient swallow medications if ordered.  Immediate preoperative nursing interventions  The patient changes into a hospital gown that is left untied and open in the back.  remove hairpins, and cover the head completely with a disposable paper cap.  The mouth is inspected, and dentures or plates are removed.  Jewelry is not worn to the operating room; wedding rings and jewelry should be removed.  All articles of value, including assistive devices, dentures, glasses, and prosthetic devices, are given to family members or are labeled clearly with the patient’s name and stored in a safe place according to the institution’s policy.  All patients (except those with urologic disorders) should void immediately before going to the operating room to promote continence during low abdominal surgery and to 24 make abdominal organs more accessible.  5- Administering Preanesthetic.‫نتظار قبل الجراحة‬3‫عادة ما يتم إعطاؤه في منطقة ا‬ ‫ للحصول على تأثير إضافي أو تآزري بحيث‬،‫ جرعة من ا@دوية قبل التخدير للحد من القلق‬ Medication ‫يمكن أن يكون الحث سلسا وسريعا وتخفيف ا@لم‬ ‫ والديازيبام‬a‫ ا@سيبرومازين وا@تروب‬:‫ أمثلة على عوامل ما قبل التخدير هي‬ ‫ريض في السرير مع رفع القضبان‬e‫ يتم إبقاء ا‬،‫ إذا تم إعطاء دواء ما قبل التخدير‬  It is usually administered in the preoperative holding area..‫الجانبية @ن الدواء يمكن أن يسبب الدوار أو النعاس‬  Pupose of preanethestic medications to reduce anxiety, to obtain an additive or synergistic effect so that induction could be smooth and rapid and to relieve from pain  Examples of preanesthetic agents are: Acepromazine, atropine, and diazepam  If a preanesthetic medication is administered, the patient is kept in bed with the side rails raised because the medication can cause lightheadedness or drowsiness.  The nurse can have the medication ready to give and administer it as soon as a call is received from the operating room staff. 25  Transporting the Patient to the Presurgical Area  The patient is transferred to the holding area or presurgical suite in a bed or on a stretcher about 30 to 60 minutes before the anesthetic is to be given.  The stretcher should be as comfortable as possible, with a sufficient number of blankets to prevent chilling in air-conditioned rooms. A small head pillow is usually provided.  The surrounding area should be kept quiet if the preoperative medication is to have maximal effect.  Unpleasant sounds or conversation should be avoided.  Patient safety in the preoperative area is a priority. 26 8- The patient's significant others or family are provided with the following information: 1. Where to wait until the patient returns to the ward. 2. Availability of cafeteria, prayer room, etc. 3. Expected time of client's return to ward. Surgery may be delayed if the previous surgery took longer than anticipated. 4. Visit by surgeon after the surgery (if this Is the hospital policy). 5. What to expect when the patient returns from surgery: condition, special equipment, tubes, 27 etc