Bonnie M. Wivell, MS, RN, CNS

Perioperative Nursing = care of patient during all phases of surgery◦ Preop◦ Intraop◦ Postop

Nurses play a major role in disease prevention, beginning with Florence Nightingale’s belief that the environment was a key factor in this prevention

1956 – Assoc. of OR Nurses (AORN)

1970s – the advent of Ambulatory Surgery Centers (ASC)

Opthalmic, GI, GYN, ENT, orthopedic, cosmetic/restorative

Benefits◦ Shorter operative times◦ Faster recovery times◦ Cost savings◦ Reduced Healthcare-associated infections◦ Laparoscopic procedures

Seriousness◦ Major◦ Minor

Urgency◦ Elective◦ Urgent◦ Emergency

Indicates level of nursing care required

Purpose◦ Diagnostic◦ Ablative◦ Palliative◦ Reconstructive/

Restorative◦ Procurement for

transplant◦ Constructive◦ Cosmetic

P1 = A normal healthy client P2 = A client with a mild systemic disease

(CV disease with minimal limitations) P3 = A client with a severe systemic

disease (DM, HTN, Obesity) P4 = A client with a severe systemic

disease that is a constant threat to life P5 = A moribund client who is not expected

to survive without the operation A client declared brain dead whose organs

are being removed for donor purpose

Provide valuable guidelines for perioperative management and evaluation of process and outcomes

Agency for Health Care Research and Quality (AHRQ)

AORN American Society of PeriAnesthesia Nurses

(ASPAN) American Society of Anesthesiologists (ASA)

Client admitted same day Imperative that you organize and verify

data obtained preoperatively Pt. may complete a self-report inventory for

pre-admission Physical exam, lab tests, EKG, and pt.

education occur prior to day of surgery

Nursing History Medical History

◦ History of past illnesses and surgeries◦ Primary reason for seeking medical care◦ Pre-existing illnesses can influence ability to

tolerate and recover from surgery

Age◦ Very young and old at risk due to anesthetics causing

vasodilation and heat loss◦ Potential for decreased blood volume◦ Very old less able to adapt to the stress of surgery

Nutrition◦ Requires at least 1500kcal/day to maintain energy

reserves◦ Increased protein, vitamins A and C, and zinc facilitate

wound healing Obesity

◦ Reduced ventilation and cardiac function◦ More at risk of Embolus, atelectasis and pneumonia

post-op

Obstructive Sleep Apnea Immunocompromise

◦ Increased risk of infection◦ Should wait 4-6 weeks after completion of RT

Fluid and Electrolyte Imbalance◦ Negative nitrogen balance and elevated glucose

can delay healing◦ Adrenocortical stress response –water and sodium

retained and K+ lost 2-5 days post-op Pregnancy

◦ Surgery done only on emergent or urgent basis

Assess ◦ Previous experience◦ Motion sickness◦ N/V associated with previous surgeries

Address fears Clarify concerns Understand pt./family knowledge,

expectations, and perceptions

Medication History Allergies

◦ Type of response important Smoking Habits

◦ Greater risk of post-op pulmonary complications Alcohol Ingestion and Substance Use and

Abuse◦ Can cause an adverse reaction to anesthetic

agents◦ Predisposed to bleeding disorders (potentially)◦ DTs

Support Sources Occupation – ability to return to work Preoperative Pain Assessment Review of Emotional Health

◦ Self-concept◦ Body image◦ Culture◦ Coping resources

Client Expectations

General survey◦ General appearance◦ Vital signs

Head and Neck◦ Note loose or capped teeth◦ Dentures to be removed prior to surgery

Integument◦ Susceptible to tears or pressure ulcers◦ Hydration status

Thorax and lungs◦ Atelectasis or moisture will be aggravated during

surgery Heart and vascular system

Abdomen◦ Size, shape, symmetry, and presence of distention

Neurological status◦ Gross motor function and strength important if

client to receive spinal anesthesia Diagnostic screening

◦ To screen for preexisting abnormalities◦ T & C if blood loss anticipated◦ Over age 40 or has heart disease, ECG and/or CXR◦ ABGs with preexisting lung disease◦ Glucose level if diabetic

Ineffective airway clearance Anxiety Fear Risk for deficient fluid volume Risk for perioperative-positioning injury Deficient knowledge Impaired physical mobility Nausea Acute pain Delayed surgical recovery

Pre-operative teaching plan◦ Include family

Goals and outcomes◦ Client is able to verbalize significance of

postoperative exercises Setting priorities

◦ Based on individual pt. needs Collaborative Care

Surgeon’s responsibility Placed in med record to go to OR with client

Health Promotion◦ Pre-op teaching◦ Client cites reasons for pre-op instructions and

exercises (see next slide)◦ Client states the time of surgery◦ Client states the post-op unit and location of the family

during surgery and recovery◦ Client discusses anticipated post-op monitoring and

therapies◦ Client describes surgical procedures and post-op

treatment◦ Client describes post-op activity resumption◦ Client verbalizes pain-relief measures◦ Client expresses feeling regarding surgery

Diaphragmatic breathing Incentive spirometry Turning, coughing, deep breathing Leg exercises Elastic stockings (TED hose and/or SCDs) Teach pre-op and have patient do return

demonstration to ensure understanding

Maintenance of normal fluid and electrolyte balance◦ NPO

6 hours after light meal 4 hours for breast milk Clear liquids 2-3 hours

Reduction of risk of surgical wound infection◦ Pre-op antibiotics◦ Skin prep◦ Shaving

Prevention of bowel and bladder incontinence◦ Bowel prep◦ Enemas till clear

Promotion of rest and comfort◦ Rest promotes healing◦ Medication may be given night before

Surgical checklist (see page 1388) Hygiene

◦ Oral rinse or brushing of teeth Hair and cosmetics

◦ No clips or pins◦ No makeup◦ No glasses/contacts

Removal of prosthesis◦ Hearing aides◦ Dentures/partials

Safeguarding valuables Preparing bowel and bladder

◦ Enema◦ Urinate◦ Placement of foley catheter

Vital signs Documentation Performing special procedures

◦ IV, NG (most often done in OR) Administer pre-op medications

Federal regulation enacted in Sept. 1998 mandates that all medical supplies contain a warning of latex content

Common sources of latex include gloves, IV tubing, syringes, rubber stoppers on bottles and vials, tape, disposable electrodes, ET tube cuffs, vent equipment

S/S of reaction◦ Local includes urticaria, flat or raised red patches,

bleeding eruptions◦ Rhinitis and/or rhinorrhea is common◦ Anaphylaxis

AANA has developed a protocol to provide safe, competent care to the client identified as being at risk for latex allergy

Joint Commission instituted Universal Protocol guidelines preventing such mishaps

Must be implemented whenever an invasive surgical procedure is to be performed no matter the location

3 principles◦ Preop verification ensuring all documents/studies

available◦ Marking of the operative site◦ “Time out” just before starting the procedure

Correct client, procedure, site, and any implants All members of team must participate

Usually done by an orderly Verify pt. with ID bracelet and chart to ensure

correct pt. is being transported (pt. may be drowsy from pre-meds)

Provide family an opportunity to visit prior to transport

Direct family to waiting area Prepare the bed and room for the client’s room

◦ VS equipment◦ Emesis basin◦ Clean gown◦ Washcloth, towel and facial tissues◦ IV pole◦ Suction equipment (if needed)◦ O2 equipment◦ Extra pillows and chux pads on bed

Circulating Nurse - Always an RN◦ Review of the pre-op assessment, establishing and

implementing the intraop plan of care, evaluating the care, and providing continuity of care postop.

◦ Assists with procedures as needed such as intubation, and blood administration

◦ Monitors sterile technique and a safe OR environment

◦ Assists the surgeon and surgical team by operating nonsterile equipment

◦ Provides additional supplies◦ Verifies sponge and instrument counts◦ Maintains accurate and complete written records

Scrub Nurse – Can be an RN, LPN or a surgical tech◦ Maintains a sterile field during the surgical

procedure◦ Assists with applying sterile drapes◦ Hands instruments and other sterile supplies to

surgeons◦ Counts the sponges and instruments

Preanesthesia Care Unit (PACU); Presurgical Care Unit (PSCU)

Explain process to pt. Verify appropriate data obtained Assess the client’s readiness Reinforce teaching Insert IV (18G) Apply BP cuff that will remain in place

throughout Review preop checklist Anesthesia assessment Cool environment so extra blankets may be

needed

Transfer via stretcher Safety strap applied once pt. is on OR table Continues reassurance may be needed as

surgical suite sights and sounds can be frightening

Assessment◦ Conduct a focused preop assessment to ensure

client is ready for surgery Nursing Diagnosis

◦ As before Planning

◦ Maintain skin integrity Implementation

Acute Care◦ Physical preparation◦ Introduction of anesthesia

General Regional Local Conscious sedation

◦ Positioning the client for surgery◦ Documentation of intraoperative care

Immediate postoperative recovery◦ It is the surgeon’s responsibility to describe the client’s

status, the results of surgery, and any complications that occurred

◦ “Hand off” communication Client’s care, treatment, and services Current condition Any recent or anticipated changes Anesthetics given IV fluids and blood products administered Special concerns (risk of hemorrhage, etc) Complications during surgery

◦ Nursing care focuses on monitoring and maintaining airway, respiratory, circulatory, and neurological status, and managing pain

Compare vital sign stability to preop data Body temp Good ventilatory function and oxygen status Orientation to surroundings Absence of complications Minimal pain and nausea Controlled wound drainage Adequate urine output Fluid and electrolyte balance Postanesthesia Recovery Scare (PARS) (pg.1394) If condition poor after 2-3 hours may need ICU

Phase II recovery which consists of a room equipped with medical recliners, side tables, and foot rests

Postanesthesia Recovery Score for Ambulatory Patients (PARSAP) (see pg. 1395)◦ Score of 18 or higher prior to discharge

Known OSA need to no longer at risk for respiratory depression prior to discharge

Postop Convalescence◦ Depends on type or extent of surgery, risk factors,

pain management, and postop complications

Airway and respiration Circulation Temperature control Fluid and electrolyte balance Neurological functions Skin integrity and condition of the wound

◦ Most surgeons prefer to change surgical dressings the first time so they can inspect the incisional area

◦ Assess is wound edges are well approximated◦ Normal glucose levels decreases incidence of wound

infection, decreases sepsis, and decreases mortality

GU function◦ May not regain voluntary control for 6-8 hours after

anesthesia◦ Urine output of 30-50 mL/hr should be expected

GI function◦ Nausea◦ Faint or absent bowel sounds◦ Inspect for distention◦ Paralytic ileus (a nonmechanical obstruction due to

lack of peristalsis)◦ Check bowel sounds q4h◦ 5-30 sounds per minute indicates peristalsis has

returned◦ Flatus◦ NG tube – assess patency and drainage (amt and color)

Comfort◦ Use of pain scale◦ Administer narcotics and evaluate effectiveness

Client expectations◦ Recovery progress◦ Pain control◦ Diet and activity ◦ Discharge to home

Typical postop orders (see pg. 1399) Goals and outcomes

◦ Client’s vitals will return to preop baseline◦ Client’s airway is patent and respirations are even

and unlabored Setting Priorities Collaborative Care

Health Promotion◦ Maintaining respiratory function

Breathing exercises IS Early ambulation

◦ Preventing Circulatory complications Leg exercises TEDS/SCDs Early ambulation

◦ Achieving rest and comfort

Acute Care◦ Temp regulation◦ Maintain neurological function◦ Maintaining fluid and electrolyte balance◦ Promoting normal bowel elimination and

adequate nutrition◦ Promoting urinary elimination◦ Promoting wound healing◦ Maintaining/enhancing self-concept

Respiratory System◦ Atelectasis◦ Pneumonia◦ Hypoxemia◦ Pulmonary embolism

Circulatory System◦ Hemorrhage◦ Hypovolemic shock◦ Thrombophlebitis◦ Thrombus◦ Embolus

GI System◦ Paralytic ileus◦ Adominal distention◦ Nausea and vomiting

GU System◦ Urinary retention◦ UTI

Integumentary system◦ Wound infection◦ Wound dehiscence◦ Wound evisceration◦ Skin breakdown