Perioperative nsg

8/2/2019 Perioperative nsg

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PERIOPERATIVENURSING

REY VINCENT H. LABADAN, RNEARL KRISTOFFER L. PIRANTE, RN


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Patient

PERIOPERATIVE

PATIENT-

FOCUSED

MODEL


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Conditions Requiring Surgery:

a. Obstruction or blockage (Impairment to the flow of vital

fluids)

b. Perforation or rupture of an organ

c. Erosion or wearing away of the surface of a tissue

d. Tumors or abnormal growth

Categories of Surgical Procedures:

According to Purpose:

a. Diagnostic: to verify suspected diagnosis, e.g. biopsy

b. Exploratory: to estimate the extent of the disease, e.g.exploratory laparotomy

c. Curative: to remove or repair damaged or diseased organs or

tissues

PERIOPERATIVE NURSING: GENERAL CONSIDERATION


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c. Types of Curative Surgery:

i. Ablative: removal of diseased organs. (-ectomy) e.g.

appendectomy, hysterectomy

ii. Reconstructive: partial or complete restoration of a

damaged organ, e.g. plastic surgery after burns

iii. Constructive: repair of a congenitally defective organ,

(-plasty, -orrhaphy, -pexy) e.g. cheiloplasty, orchidopexy

d. Palliative: to relieve pain, relieve distressing S/Sx

According to Degree of Risk to Client:a. Major surgery

b. Minor surgery



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Criteria:

a. Major surgery: High degree of risk

Prolonged intraoperative period

Large amount of blood loss

Extensive, vital organs may be handled or removed

Great risk of complications, e. g. liver biopsy

b. Minor surgery: Lesser degree of risk to the client

Generally not prolonged; described as one-day

surgery or outpatient surgery

Leads to few serious complications Involves less risk, e.g. cyst removal



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According to Urgency:

a. Emergency: must be performed immediately without delay,

e.g. gunshot wound, severe bleeding,

b. Imperative or Urgent: must be performed as soon as possible

within 24 48 hours, e.g. appendectomy

c. Required: necessary for the well-being of the client, usually

within weeks to months, e. g. cholecystectomy, cataractextraction, thyriodectomy

d. Elective: should be performed for the clients well being but

which is not absolutely necessary, e.g. simple hernia, vaginal

repair, repair of scare. Optional: surgery that a client requests, e.g. rhinoplasty,

liposuction, mammoplasty



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Factors that Affect the Estimation of Surgical Risk

a. Physical and Mental Condition of the Client

Age: premature babies and elderly persons are at risk

Nutritional status: malnourished and obese are at risk

State of fluid and electrolytes balance: dehydration and

hypovolemia predispose a person to complications General health: infectious process increase operative risk

Mental health

Economic and occupational status



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b. Types of drugs taken regularly:

i. Steroids: may improve the bodys ability to response to

the stress of anesthesia and surgery

ii. Anticoagulants and salicylates: may increase bleeding

during surgery

iii. Antibiotics: maybe incompatible with or potentiate

anesthetic agentsiv. Tranquilizers: potentiate the effect of narcotics and can

cause hypotension

v. Antihypertensives: may predispose to shock by the

combined effect of blood pressure reduction andanesthetic vasodilation

vi. Diuretics: may increase potassium loss

vii. Alcohol: will place the surgical client at risk when used

chronically



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c. The Extent of the Disease

d. The Magnitude of the Required Operation

e. Resources and Preparation of the Surgeon, Nurses, and the

Hospital



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Suffixes Related to Surgery:

-ostomy (make artificial opening) Colostomy

-otomy (cut into or incision) Phlebotomy

-plasty (plastic repair) Rinoplasty

-orrhaphy (suturing; repair) Herniorrhaphy

-oscopy (visual examination) Endoscopy-ectomy (excision; removal) Cholecystectomy


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Because clients experience varying degrees of anxiety and

deficient knowledge related to surgery, careful planning by the

nurse can help ensure a positive outcome.

Encompasses a clients total surgical experience, including

preoperative, intra-operative, and postoperative phases

Refers to activities performed by the professional nurse during

these phases.

PERIOPERATIVE NURSING: PHASES OF PERIOPERATIVE NURSING


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PERIOPERATIVE NURSING: PHASES OF PERIOPERATIVE NURSING

a. Pre-Operative Phase: begins with the decision to perform

surgery and ends with the clients transfer to the operating room

table

b. Intra-Operative Phase: begins with the client is received in the

OR and ends with his admission to the PARR or PACU

c. Post-Operative Phase: begins with the client is admitted to PARR

or PACU and extends through follow-up home or clinic

evaluation


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PERIOPERATIVE NURSING: THE PERIOPERATIVE TEAM

The Surgeon

An Anesthesiologist or Nurse Anesthetist

Makes the preoperative assessment to plan for the type of

anesthesia to be administered and to evaluate the clients status

The Professional Registered OR Nurse

Makes preoperative assessment and documents the perioperative

client care plan (Scrub, Circulating, PACU Nurse)


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PERIOPERATIVE NURSING: THE PERIOPERATIVE TEAM

a. The Circulating Nurse

Manages the OR and protects the safety and health needs of the

client by monitoring the activities of the members of the

surgical team and monitoring the conditions in the OR

b. The Scrub Nurse

Responsible for scrubbing for surgery, including setting up steriletables and equipment and assisting the surgeon and surgical

technicians during the surgical procedure

c. The PACU NurseResponsible for caring for the client until the client has recovered

from the effects of anesthesia, is oriented, has stable vital signs,

and shows no evidence of hemorrhage


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General:

a. Keep sterile supplies dry and unopened

b. Check package sterilization expiration date to verify sterility

c. Maintain general cleanliness in surgical suite

d. Maintain surgical asepsis: activities designed to keep sites

free from the presence of microorganisms throughout the

procedure

Personnel:

a. Personnel with signs of illness should not report to work

b. Surgical scrub, a specific hand washing technique used byoperating room personnel designed to reduce

microorganisms in the hands and arms, is done for the length

of time designed by hospital policy

PERIOPERATIVE NURSING: PRINCIPLES OF PERIOPERATIVE ASEPSIS


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Surgical Scrub

i. A sensor-controlled or knee- or foot-operated faucet allows the

water to be turned on and off without the use of the handsii. Remove all rings and watches

iii. Use liquid soaps to prevent the spread of organisms

iv. Keep the finger nails short and well-trimmed

v. Clean fingernails with a nail stick under running water

vi. Hold the hands higher than the elbows throughout the handwashing procedure so that run-off goes to the elbows

vii. Allows the cleanest part of the arms to be the hands

viii. A scrub brush facilitates the removal of microorganisms

ix. Clean all areas of skin on the hands and arms in sequence starting

at the hands and ending at the elbowsx. After rinsing, dry the hands with paper towels, drying first one

arm from the hand to the elbow, then using a second towel to dry

the second hand



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Maintaining a Sterile Field (a microorganism-free area):

a. Create a sterile field using sterile drapes

b. Use the sterile field to place sterile supplies where they will

be available during the procedure

c. Drape equipment prior to use

d. Keep drapes dry and out of contact with nonsterile objects

e. Utilize sterile technique while adding or removing suppliesfrom sterile fields

Sterile Supplies and Solutions:

a. Check expiration dates for sterilityb. Dont use solutions that were opened prior to current use

c. Lip the solution after initial use by pouring a small amount

of liquid out of the bottle into a waste container to cleanse

the bottle lip


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1. OR personnel must practice strict Standard Precautions (i.e.,

blood and body substance isolation)

2. All items used in the sterile field must be sterile

3. Sterile objects become unsterile when touched by unsterile

objects

4. Sterile items that are out of vision sterile or below the waist level

of the nurse are considered unsterile5. Sterile objects can become unsterile by prolonged exposure to

air-born organism

6. The skin can not be sterilized and is unsterile

All personnel must perform a surgical scrub

PERIOPERATIVE NURSING: PRINCIPLES OF SURGICAL ASEPSIS


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7. All OR personnel are required to wear specific, clean attire, with

the goal of shedding the outside environment.

Specific clothing requirements are prescribed and

standardized for all ORs:

a. OR personnel must wear a sterile gown, gloves, and

specific shoe covers

b. Hair must be completely coverc. Masks must be worn at all times in the OR for the

purpose of minimizing air-borne contamination and

must be changed between operations or more often,

if necessary8. Any personnel who harbors pathogenic organisms must report

themselves unable to be in the OR to protect the client from

outside pathogens



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9. Scrubbed personnel wearing sterile attire should touch only

sterile items

10. Sterile gowns and sterile drapes have defined borders for

sterility.

Sterile surfaces or articles may touch other sterile surfaces or

articles and remain sterile.

Contact with unsterile objects at any point renders a sterilearea contaminated.

11. The circulator and unsterile personnel must stay at the periphery

of the of the sterile operating area to keep the sterile area free

from contamination12. Sterile supplies are unwrapped and delivered by the circulator

following specific standard protocol so as not to cause

contamination



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13. The utmost caution and vigilance must be used when handling

sterile fluids to prevent splashing or spillage

14. Anything that is used for one client must be discarded or, in

some cases, resterilized


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Begins at the time of decision for surgery and ends when the

client is transferred to the OR

This period is used to physically and psychologically prepare the

client for surgery

The nurse plays a major role in client teaching and in relieving

the clients and the familys anxieties

PERIOPERATIVE NURSING: PREOPERATIVE PHASE


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Goals:

a. Assessing and correcting physiologic and psychologic

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 post-op period

d. Planning for discharge and any projected changes in lifestyledue to surgery



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Psychologic Preparation for 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

Causes 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



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Manifestations of Fears:

Anxiousness

Confusion

Anger

Tendency to exaggerate

Sad, evasive, tearful, clinging

Inability to concentrate Short attention span

Failure to carry out simple directions

Dazed



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Nursing Interventions to Minimize Anxiety:

Assess clients fears, anxieties, support systems, and

patterns of coping

Establish trusting relationship with client and significant

others

Explain routine procedures, encourage verbalization of

fears, and allow client to ask questions

Demonstrate confidence in surgeon and staff

Provide for spiritual care if appropriate



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Legal aspect: Informed Consent, operative permit, surgical

consent

This is to protect the surgeon and the hospital against claims that

unauthorized surgery has been performed and that the patient

was unaware of the potential risks of complications involved

Protects the client from undergoing unauthorized surgery



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a. The Surgeon obtains operative permit or informed consent:

Surgical procedure, alternatives, possible complications,

disfigurements, or removal of body parts are explained

Note: It is part of the nurses role as a client advocate to

confirm that the client understands information given.

b. Informed consent is necessary for each operation performed,however minor

It is also necessary for major diagnostic procedures

where major body cavity is entered, e.g. thoracentesis

c. Adult client (over 18 years of age) signs own permit unless

unconscious or mentally incompetent

If unable to sign, relative, (spouse or next of kin) or

guardian will sign



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In an emergency, permission via the telephone is

acceptable; have a second listener on phone when

telephone permission being given

Consents are not needed for emergency care if all four of the

following criteria are met:

i. There is an immediate threat to lifeii. Experts agree that it is an emergency

iii. Client is unable to consent

iv. A legally authorized person cannot be reached



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d. Minors (under 18) must have consent signed by an adult (i.e.

parent or legal guardian). An emancipated minormay sign own

consent:

i. Married,

ii. College student living away from home,

iii. In military service,

iv. Any pregnant female or anybody who has given birth

e. Witness to informed consent may be nurse, other physician,

clerk, or authorized person

f. If nurse witnesses informed consent, specify whether witnessing

explanation of surgery or just signature of client



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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 thromboplastin

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 such as latex All allergies are reported anesthesia and surgical

personnel before the beginning of surgery

If allergy exist, an allergy band must be placed in the

clients arm immediately



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B Bleeding tendencies or the use of medications that deter

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



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Instructional and Preventive Aspects:

Frequently done on an out-client basis

Assess the clients level of understanding of surgical

procedure and its implications

Answer questions, clarify and reinforce explanations given by

surgeon

Explain routine pre and post procedures and any specialequipment to be used

Deep breathing exercises: use of diaphragmatic and

abdominal breathing



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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 postoperative gas pains or flatus

Assure that pain medications will be available post-op



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Physical Preparation

On the Night of the Surgery:

a. Preparing the clients skin: shave against the grain of the hair

shaft to ensure clean and close shave

b. Preparing the GIT:

NPO after midnight Administration of enema may be necessary

Insertion of gastric or intestinal tubes

Preparing for Anesthesia

Promoting rest and sleep: use of drugs

Barbiturates: Secobarbital Na, Pentobarbital Na

Non barbiturates: chloral hydrate, Flurazepam

Note: given after all pre-op treatments have been

completed.



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On the Day of Operation:

a. Early morning care: about 1 hour before the pre-operative

medication schedule

Vital signs taken and recorded promptly

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 to the OR

Make sure that the patient has not taken food for the

last 10 hours by asking the client

Urinary catheterization may be performed in the OR



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b. Pre-Operative Medications:

Generally administered 60-90 min before induction of anesthesia

Purpose:

i. To allay anxiety: the primary reason for pre-operative

medications

ii. To decrease the flow of pharyngeal secretions

iii. To reduce the amount of anesthesia to be giveniv. To create amnesia for the events that precedes surgery

Types of 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

e.g. Phenobarbital



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2. Tranquilizer:

Lowers the clients anxiety level

e.g. Thorazine 12.5 - 25 mg IM 1-2 hours prior to

surgery

3. Narcotic analgesia:

Given to reduce patients to reduce anxiety and toreduce the amount of narcotics given during surgery

e.g. Morphine sulfate 8-15 mg SC 1 hour prior to

preoperative; *Can cause vomiting, respiratory

depression and postural hypotension



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4. Vagolytic or drying agents:

To reduce the amount of tracheobronchial secretions

which can clog the pulmonary tree and result in

atelectasis and pneumonia

e.g. Atropine sulfate 0.3-0.6 mg IM 45 min before

surgery; * An overdose can result to severe

tachycardia

c. Recording: all final preparation and emotional response before

surgery should be noted down

d. Transportation to the OR, *Woolen or synthetic blankets must

never be sent to the OR because they are source of static

electricity



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Nursing Diagnosis for Preoperative Client

Anxiety related to lack of knowledge about preoperative

routines, physical preparation for surgery, post operative care

and potential body image change


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Begins the moment the patient is anesthetized and ends when

the last stitch or dressing is in place

Anesthesia A state or narcosis, analgesia, relaxation and reflex

loss (severe central nervous system [CNS] depression produced

by pharmacologic agent)

PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE


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Four Stages of Anesthesia:

a. Stage I: Onset [Beginning of Anesthesia]

Patient breath in the anesthetic mixture

Warmth, dizziness, & feeling of detachment may be

experienced

Ringing, roaring, or buzzing in the ears

Inability to move extremities Surrounding noise is exaggerated

Still conscious

b. Stage II: Excitement

Struggling, shouting, singing, laughing or crying may be

experienced

Pupils dilate but PERRLA, rapid PR, irregular RR

Patient restrain might be necessary



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c. Stage III: Surgical Anesthesia

Continued administration of anesthetic agent

RR, PR normal, skin pink and flushed

Patient is unconscious

d. Stage IV: Danger Stage [Medullary Depression]

Reached when to much anesthesia has been administered Respiration shallow, pulse weak, pupils dilate

Cyanosis develops, without prompt intervention death may

ensue



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Stages of Anesthesia, summary:

Stage Start-point End-point Physical Reactions Nursing InterventionsOnset Anesthetic

administration Loss ofconsciousness Client maybe drowsy,or dizzy Possible auditory and

visual hallucinations

Close operating room doors, keep

room quiet

Stand by to assist the client

Excitement Loss of consciousness Loss of eyelidreflexes Increase in autonomicactivity

Irregular breathing Client may struggle

Remain quietly at clients side

Assist anesthetist, as needed

Surgical

Anesthesia Loss of eyelid reflexes Loss of mostreflexes Depression of vital

functions

Client is unconscious

Muscles are relaxed

No blink or gag reflexes Begin preparation (if indicated) only

when anesthesia indicates stage III

has been reached and client is

breathing well, with stable vital signsDanger

(Death) Functionsexcessively depressed

Respiratory and

circulatory failure Client is not breathing A heartbeat may or maynot be present

If arrest occurs, respond immediately

to assist in establishing airway,

provide cardiac arrest tray, drugs

syringes, long needles

Assist surgeon with closed or open

cardiac massage



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Types of Anesthesia:

a. General Anesthesia: a state of analgesia, amnesia, and

unconsciousness characterized by the loss of reflexes and muscle

tone

i. Inhalation Anesthesia

Advantage: prevention of pain and anxiety

Disadvantage: circulatory and respiratory depression* Highly inflammable and explosive

Safety rules:

Do not wear slips, nylons, wool, or any material which can set-off

sparks

No smoking 12 hours after the operation Do not wear shoes that are not conductive

Do not rise bed materials that are not conductive, e.g. volatile

liquid: halothane, ether; gas anesthetic: e.g. nitrous oxide,

cyclopropane



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ii. Intravenous Anesthesia: usually employed as an

induction prior to administration of the more potent

inhalation anesthetic agents. Used commonly in minor

procedure

Advantage:

Rapid pleasant induction

Absence of explosive hazards Low incidence of nausea and vomiting

Disadvantage:

Laryngeal spasm and bronchospasm

Hypotension

Respiratory arrest, e.g. Thiopental Na (Pentothal

Na), Ketamine ( Ketalar), Fentanyl ( Innovar)


PERIOPERATIVE NURSING INTRAOPERATIVE PHASE


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b. Regional Anesthesia: it is the injection or application of a local

anesthetic agent to produce a loss of painful sensation in only

one region of the body and does not result to unconsciousness

i. Topical anesthesia: e.g. lidocaine

ii. Infiltration anesthesia Nerve block

Epidural block

Caudal block

Pudendal block

iii. Spinal anesthesia, e.g. Saddle block for vaginal delivery

iv. Local anesthesia, e.g. Procaine, Lidocaine (Xylocaine)



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c. Specialized Methods of Producing Anesthesia:

i. Muscle relaxants: it is a neuromuscular blocking agent

used to provide muscle relaxation

Use: for endotracheal intubation, e.g.

Pancuronium bromide (Pavulon), Curarine

chloride (Curare)

ii. Hypothermia: it refers to the deliberate reduction of the

patients body temperature between 28-30 C

Uses: Heart surgery, Brain surgery, Surgery on

large vessels supplying major organs



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Methods:

Ice water immersion

Ice bags

Cooling blanket

Complications:

Cardiac arrest

Respiratory depression




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Positioning the Client:

Commonly Used Operative Positions

Supine: hernia repair, explore lap, cholecystectomy,

mastectomy

Prone: spine surgery, rectal surgery

Trendelenburg

Reverse Trendelenburg Lithotomy position

Lateral position: kidney and chest surgery

Others: for thyroidectomy- head hyperextended

PERIOPERATIVE NURSING POSTOPERATIVE PHASE


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PERIOPERATIVE NURSING: POSTOPERATIVE PHASE

Post Anesthetic Care

Nursing Responsibilities:

a. Maintenance of pulmonary ventilation:

Position the client to side lying or semi-prone position to

prevent aspiration

Oropharyngeal or nasopharyngeal airway:* Is left in place following administration of general

anesthetic until pharyngeal reflexes have returned

It is only removed as soon as the client begins to awaken

and has regained the cough and swallowing reflexes

All clients should received O2 at least until they are conscious

and are able to take deep breaths on command



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Shivering of the client must be avoided to prevent an

increase in O2, and should be administered until shivering

has ceased

b. Maintenance of circulation:

Most common cardiovascular complications:

i. HypotensionCauses:

Jarring the client during transport while

moving client from the OR to his bed

Reaction to drug and anesthesia

Loss of blood and other body fluids

Cardiac arrhythmias and cardiac failure

Inadequate ventilation

Pain




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ii. Cardiac arrhythmias

Causes: Hypoxemia, Hypercapnea

Interventions: O2 therapy, Drug administration:Lidocaine, Procainamide

c. Protection from injury and promotion of comfort

Provide side rails Turning frequently and placed in good body alignment to

prevent nerve damage from pressure

Administration of narcotic analgesics to relieve incisional

pain

Post-operative dose usually reduced to half the dose the

patient will be taking after fully recovered from anesthesia




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Dismissal of Client from Recovery Room: Modified Aldrete Score

for Anesthesia Recovery Criteria

The Five Physiological Parameters:

a. Activity able to move four extremities voluntarily on

command

b. Respiration able to breath effortlessly and deeply, andcough freely

c. Circulation BP is (+ 20%) or (- 20%) of pre-anesthetic level

d. Consciousness fully awake, oriented to time, place and

person

e. Color pink (lips), for blacks: tongue




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Modified Aldrete Score


AREA OF ASSESSMENT Point Score 1 hour 2 hours 3 hours

Muscle activity Ability to move all extremities Ability to move 2 extremities

Unable to control any extremity

21

0

Respiration Ability to breath deeply and cough

Limited respiratory effort (dyspnea)

No spontaneous effort

2

1

0

Circulation BP +/- 20% of pre-anesthetic level BP +/- 20%-40% of pre-anesthetic level

BP +/- 50% pre-anesthetic level

21

0

Consciousness

Level

Fully awake

Arousable on calling

Not responding

2

1

0

O2 Saturation

Unable to maintain O2 sat >92% on room air Needs O2 inhalation to maintain O2 sat >90%

O2 sat


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Postoperative Care

Begins when the client returns from the recovery room orsurgical suite to the nursing unit and ends when the client is

discharged

It is directed toward prevention of complication and post-operative discomfort

Post-Operative Complications

a. Respiratory Complications: atelectasis and pneumonia

Suspected when ever there is a sudden rise of temperature

24-48 hours after surgery

Collapse of the alveoli is highly susceptible to infection:

pneumonia




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Occurs usually in high abdominal surgery when prolonged

inhalation anesthesia has been necessary and vomiting has

occurred during the operation or while the patient isrecovered from anesthesia

NURSING MANAGEMENT:

i. Measures to prevent pooling of secretions: Frequent changing of position

High fowlers position

Moving out of bed

ii. Measures to liquefy and remove secretions:

Increase oral fluid intake

Breathing moist air




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Deep breathing followed by coughing

Administer analgesics before coughing is attempted after

thoracic and abdominal surgery Splint operative area with draw sheet or towel to

promote comfort while coughing

iii. Other measures to increase pulmonary ventilation Blow bottle exercise

Rebreathing tubes: increase CO2 stimulates the

respiratory center to increase the depth of breathing thus

increasing the amount of inspired air

IPPB: intermittent positive pressure breathing apparatus




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b. Circulatory Complication: venous stasis

Causes of venous stasis

Muscular inactivity Respiratory and circulatory depression

Increased pressure on blood vessels due to tight dressing

Intestinal distention

Prolonged maintenance of sitting

Contributing factors for venous stasis:

Obesity

CV disease

Debility

Malnutrition

Old age




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Most common circulatory complications:

Phlebothrombosis

Thrombophlebitis

NURSING MANAGEMENT:

Limbs must never be massaged for a post-op client

If possible, client should lie on his abdomen for 30min several time a day to prevent pooling of blood in

the pelvic cavity

Do not allow the client to stand unless pulse has

returned close to baseline to prevent orthostatic

hypotension

Wear elastic bandages or stockings when in bed and

when walking for the first time.




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c. Fluids and Electrolytes Imbalance:

Causes:

Blood loss Increased insensible fluid loss through the skin;

After surgery through vomiting, from copious

wound drainage, and from the tube drainage as in

NGT Since surgery is a stressor, there is an increased

production of ADH for the first 12-24 hours following

surgery resulting to fluid retention by the kidney

The potential for over hydration therefore exists

since fluids being given IV may exceed fluid

output by the kidney




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Electrolyte Imbalance:

Particularly Na and K imbalance as a result of blood

loss Stress of surgery increases adrenal hormonal activity

resulting to increased aldosterone and

glucocorticoids, resulting in sodium reabsorption by

the kidney And as Na is reabsorbed, K coming from tissue

breakdown is excreted

Action: IV of D5W alternate with D5NSS or half

strength NSS to prevent Na excess




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d. Complications of Surgery

i. GIT complications:

Paralytic ileus: Cessation of peristalsis due to excessivehandling of GI organs

NURSING MANAGEMENT:

NPO until peristalsis has returned as evidenced by

auscultation of bowel sounds or by passing out of flatus

Vomiting: usually the effect of certain anesthetics on the

stomach, or eating food or drinking water before peristalsis

returns. Psychologic factors also contribute to vomiting

NURSING MANAGEMENT:

Position the client on the side to prevent aspiration




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When vomiting has subsided, give ice chips, sips of ginger

ale or hot tea, or eating small frequent amounts of dry

foods thus relieving nausea Administer anti-emetic drugs as ordered:

Trimethobenzamide Hcl (Tigan); Prochiorperasine

dimaleate (Compazine)

Abdominal distention: results from the accumulation of non-

absorbable gas in the intestine

Causes:

Reaction to the handling of the bowel during surgery

Swallowing of air during recovery from anesthesia

Passage of gases from the blood stream to the atonic

portion of the bowel




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Gas pains: results from contraction of the unaffected portion

of the bowel in order to move accumulated gas in the

intestinal tractManagement:

Aspiration of fluid or gas: with the insertion of an NGT

Ambulation: stimulates the return of peristalsis and the

expulsion of flatus Enema

Rectal tube insertion: inserted just passed the anal

sphincter and removal after approximately 20

minutes

Adult: 2-4 inches, children: 1-3 inches

Prolonged stimulation of the anal sphincter

may cause loss of neuromuscular response,

and pressure necrosis of the mucous surface




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Constipation: due to decreased food intake and inactivity

Regular bowel movement will return 3-4 days after

surgery when resumption of regular diet and adequatefluid intake and ambulation

ii. GUT Complications

Return of urinary function: usually after 6-8 hours First voiding may not be more than 200 ml, and total

out put may not be more than 1500ml

Due to the loss of fluids during surgery, perspiration,

hyperventilation, vomiting, and increased secretion

of ADH




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Complication: urinary retention

Causes:

Prolonged recumbent position Nervous tension

Effect of anesthetics interfering with bladder

sensation and the ability to void

Use of narcotics that reduce the sensation ofbladder distention

Pain at the surgical site and on movement

Urinary tract infection

Management:

Instruct the client to empty the bladder completely

during voiding

Catheterize if needed, done by sterile technique




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f. Post-operative Discomforts

i. Post-operative pain

Narcotics can be given every 3-4 hours during the first 48hours post-operatively for severe pain without danger of

addiction

ii. Singultus Brought about by the distention of the stomach,

irritation of the diaphragm, peritonitis and uremia

causing a reflex or stimulation of the phrenic nerve

Management:

Paper bag blowing; CO2 inhalation: 5% CO2 and 95%

O2 x 5 minutes every hour




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g. Wound Complications:

Sutures are usually removed about 5th-7th day post-op with

the exception of wire retention sutures placed deep in themuscles and removed 14-21 days after surgery

i. Hemorrhage from the wound

Most likely to occur within the first 48 hours post-op or aslate as 6th-7th post-op day

Causes:

Hemorrhage occurring soon after operation:

mechanical dislodging of a blood clot or caused by

the reestablished blood flow through the vessel

Hemorrhage after few days: Sloughing off of blood

clot or of a tissue

Infection




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Assessment: Bright red blood

Decreased BP

Increased PR and RR

Restlessness

Pallor

Weakness Cold, moist skin

ii. Infection

Cause: streptococcus and staphylococcus

Assessment: 3-6 days after surgery, low grade fever, and

the wound becomes painful and swollen. There maybe

purulent drainage on the dressing




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iii. Dehiscence and Evisceration

Dehiscenceor wound disruption: Refers to a partial-to-

complete separation of the wound edgesEvisceration: Refers to protrusion of the abdominal viscera

through the incision and onto the abdominal wall

Assessment:

Complain of a giving sensation in the incision Sudden, profuse leakage of fluid from the incision

The dressing is saturated with clear, pink drainage

Management:

Position the client to low Fowlers position

Instruct the client not to cough, sneeze, eat or drink,

and remain quiet until the surgeon arrives

Protruding viscera should be covered warm, sterile,

saline dressing




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Discharge Instructions:

Early discharge, which has become common, typicallyincreases client teaching needs

Be sure to provide information about wound care, activity

restrictions, dietary management, medicationadministration, symptoms to report, and follow-up care

A client recovering from same-day surgery in an outpatient

surgical unit must be in stable condition before discharge

This client must not drive home, make sure a responsible

adult takes the client home


PERIOPERATIVE NURSING: References


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O U S G e e e ces

Textbook of Medical Surgical Nursing 7th Edition by Joyce Black

Brunner and Suddarths Textbook of Medical Surgical Nursing 11th

Edition by Suzanne Smeltzer

Berry & Kohns Operating Room Technique 10th edition by Nancymarie

Philips

The Lippincott Manual of Nursing Practice 7th Edition by Sandra

Nettina

Mastering Medical-Surgical Nursing 2nd edition by Josie Udan

NCLEX-RN Review Materials

h l !


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Daghang Salamat!Nagpaka-hero tungod ug alang kaninyo Hahaayyypastilan

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Perioperative nsg