PERIOPERATIVE NOTES

Perioperative Nursing
 Delivery of Nursing care in the different phases of client’s surgical experience.
 Underscored by the nursing process.
The Nursing Process:
 Assessment:
o Subjective: All data are coming from patient’s complaints.
o Objective: Observable by the nurses. (Lab results, vital signs, diagnostic test)
 Planning:
o Specific
o Measurable
o Attainable
o Realistic
o Time bounded.
 Intervention
o Nursing Responsibilities
o Priority Actions
 Evaluation
o Check if the objective is met.
Settings:
o In-patient services – it occurs in the hospital.
 In requires a minimum 24-hour observation
o Out-patient service – can be done in the following area:
 Physician’s clinic
 Hospital based ambulatory surgical clinics.
o OPD
Different Phases of Perioperative Nursing:
 Pre-op Phase: Patient is admitted from admission up to O.R endorsement.
o Focus: Patient -> Preparation
o Preparation:
 Physiologic Prep:
 CBC:
o Hbg: should be at least greater that 12g, if less than 12g you should have
procurement of blood products.
o HcT: Hydration status.
o WBC: Infection is concerned.
o Platelet: Bleeding tendencies
 Cardiopulmonary Clearance:
o 12-Led ECG:
o Chest X – Ray:
o Requirement to undergo CP Clearance:
o Greater than 40 years old
o (+) Comorbidity
 NPO: For at least 6 to 8 hours
 Bowel Preparation: If patient is going to undergo abdominal surgeries.
o 3 Days prior to OR – Regular diet but high in fiber
o 2 Days prior to OR – Soft diet, soups (clear)
 o 1 Day prior to OR – Liquid diet
o Enemas and Laxative.
 IV Antibiotics – Prophylaxis Purposes
o Therapeutic – (+) Confirm Infection (Thru lab and culture sensitivity)
o Empiric – (-) Confirmation, (+) Assessment of infection
 Aminoglycoside
 Antiprotozoal – Abdominal surgery
 Intravenous Line
o Diabetic – Glucose containing fluids – frequent glucose monitoring.
o Non-Diabetic – Single testing on glucose before NPO, or at the middle of
fasting time.
o Use Large Bore Needle
 Rapid fluid replacement
 Blood Transfusion
 Pulse Oximeter Usage
o Remove Nail Polish
 If gel polish, inform the receiving nurse or the physician.
o If cold extremities – use droplight.
o If exposed to sunlight – cover with blanket.
 Remove Dentures and Jewelries
o Prepare receiving logbook.
 Mental Preparation: Focus on Health Teaching
 2 Types of Health Teaching
o Process Information:
 Surgery Experience
 Time Related Events
 Medication
 Setup
o Procedural Information: What to expect during post-op period.
 DBE
 Coughing Exercises
 Incentive Spirometry
 Emotional Preparation:
 Who will inform the family? Nurse as a medium, but if asked in the board if the
relative can call directly to the surgeon via cellular phones, the answer is YES.
 Spiritual Preparation:
 Religious Belief
 Norms
 Tradition
 Culture
o Nursing Care in Pre-op Phase
 Client Identity:
 Review the patient’s chart:
o History
o Implanted devices
o Risk factors – social factors
o Possibility of pregnancy – LMP
o Allergies
  Consent:
o Legal age: 18 and above
o Free will and sound mind
o Vertical first in decision making.
o Responsibility of Nurse:
 Witness
 Verifier
 Verification of Client
o Identifier
 Stating the name
 ID Band
 Pre-op medication
 Anticholinergic
o Atropine Sulfate – Increased HR, Decrease secretion – prone to cardiac
arrythmia.
 Analgesia – Increases pain threshold.
 Sedative
o Mild tranquillizer
o Lessen the pain.
 Antihistamine
o Anticholinergic Effect
o Sedative Property
 Antibiotics – anti prophylaxis
 Health Teaching
 Intra – Operative Phase: In the OR (from ward) to PACU (Recovery Room)
o Categories of Surgery
 Reason
 Diagnostic – Removal of tissue or organ for diagnosis (Ex. Biopsy)
 Exploratory – Extensive way of diagnosis (Ex. ExTap, Scope Procedures)
 Curative – There is a removal of defective tissues, it resolves health problem (Ex.
“Ectomy”)
 Palliative – To relief the burden and for the comfortability of the patient, since
there’s no treatment modalities available (Ex. Amputation, Colostomy)
 Cosmetic:
o For beautification enhancement
o For Correction of defective organ or structure
o (Ex. “Plasty” (not all -plasty), SRA, Liposuction, Breast Augmentation)
 Time
 Emergency: Should be done immediately to save life. Requires immediate
intervention (Ex. Gunshot wound, stab wound)
 Urgency: Requires prompt intervention. Life threatening (Ex. Obstruction)
 Elective: These are the planned surgeries. Scheduled surgeries (Ex.
Uncomplicated CS, Cataract surgeries, hip/knee joint replacement)
 Risk
 Minor: Without significant risk
o Local Anesthesia
o 1 – 2 hours
o Ex. Incision and Drainage, Biopsy
  Major: Greater Risk
o General/Regional Anesthesia
o 2 – 4 hours
o Ex. Implants, Organ Transplant
 Extent
 Simple: Only the affected areas
 Radical: There is an extensive surgery beyond the area
o Operating Room Members:
 Surgeon
 Leader of the band
 Captain of the ship
 Assistant Surgeon
 Anesthesiologist
 Monitors the hemodynamic status.
 Identifies the amount of blood loss.
 Scrub Nurse
 Head of the Sterile Team
 One step ahead
 Circulating Nurse
 Coordinator of transaction inside the OR
 In-charge in counting of instrument
 Initiates the completeness of the checklist.
 Ancillary Members
 Pathologist
 Orderly/Transporter/Lifter
 Nursing Aide
o Phases of Operation
 Sign in Phase: There’s still no patient.
 Identification of the patient
 Identification of the procedure
 OR Suite (Must be prepared by the CN)
 Clarification regarding blood loss – blood products
 Verification that surgery checklist is complete.
 Time Out Phase: Patient comes into the OR and should be placed on OR Table directly.
 Introduction of patient
 Introduction of the members of the surgical team
 Concern of anesthesiologist
 Induction of anesthesia – Go signal to start.
 Completeness of the equipment
 Counting of instrument – closure of skin
 Sign Out Phase:
 Completeness of instrument
 Proper endorsement of specimen
 PACU
o Principles of Asepsis
 Asepsis – Absence of microorganism (Technique)
 Disinfection – Reduction of microorganism
  Contaminated – Soiled with microorganism.
 Infection – invasion of pathogen
 Sterile – Free from microorganism (Items)
o Sterile Items:
 Sterile to Sterile
 Unsterile can touch sterile items only if using a forceps.
o Sterile Field:
 Keep an eye always.
 Mayo Table: Primary Table
 Back Table: Secondary Table
 1 – 2 feet away from sterile field
 Hands above waist level
 Pouring of PNSS:
 Discard some solution.
o Traffic:
 Front to Front
 Back-to-Back
o Drape: MD’s role (Nurse: Assist)
o Gown:
 Unsterile Part: Below the waist, back elbow, above area, and above shoulders
o Gloves:
 If there is still a time – change.
 If there is no more time – double gloving.
o OR Lights:
 1 – 2 feet away from the sterile field
 Moist and Dry
o Sterilization Procedures:
 Physical Sterilization
 Autoclave: 121 to 123 Degree Celsius
 15 – 30 minutes
 Sharp is not allowed.
 Flash Sterilization
 132 Degree Celsius
 3 – 10 minutes
 Chemical Sterilization
 Ethylene Oxide
o Best Sterilization
o 16 – 18 Degree Celsius
 Plasma Hydrogen
o Best Sterilization for SHARPS
o Labelling of Sterilized Pack:
 Process Date
 Expiration Date
 Item
 Packer Name
 Processor
o Shell Life/Expiration of Sterile Item
 Time Related
  Autoclave – 2 weeks
 Sterrad – 1 month
 Ethylene Oxide – 2 months
 Event Related
 Sterile – as long as the package is intact.
 When to use:
o When OR cases are high
o Decreased manpower.
o Chemical Indicators
 Sterilization/Autoclave: White to Brown/Black
 Ethylene Oxide: Yellow to Blue
 Plasma Gas: Red/Maroon to Yellow/Gold
o Surgical Instrument
 Classification of Instruments
 Clamping/Hemostats – Forceps
 Retracting Instrument – Widen the vision of the affected area.
 Dissecting/Cutting Instrument – Metz, Mayo, Blade
 Suturing Instrument – Suture, Needle Holder
 Suture: These are the materials used to sew, stitch organ and bodies
 Ligature: Tie used to ligate blood vessels
 Types of Sutures:
 Natural – From Environment
 Synthetic – Refine Materials
 Absorbable – Naturally Dissolved
 Non-absorbable – When to comeback? After 1 week for the removal of sutures
o Anesthesia
 Factors in choosing anesthesia:
 Physical/Mental condition
 Age of the patient:
o Child – GA
o Adult – Based on the location of Surgery.
 Location
o Above the nipple – GA
o Below the nipple – Regional Anesthesia (Spinal, Epidural)
 Duration
o > 4 Hours – General Anesthesia
 Patient Preference
 Types of Anesthesia:
 General Anesthesia: By blocking awareness of the brain – (+) LOC.
o 4 Things happen post GA:
 Amnesia: Loss of recent memory
 Analgesic Effect: Insensible to pain
 Hypnosis: Artificial Sleep
 Relaxation: Body becomes less tensed
 Stages of Anesthesia:
o Induction Stage: From induction to LOC
 Drowsy/Dizzy
 Priority: Safety (Soft restraint)
  Nursing Intervention: Keep the room calm and quiet!
o Excitement Stage: From the period of LOC to loss of reflexes
 Breathing Pattern: Irregular
 Gag, Swallowing, and Corneal Reflex is diminished.
 Priority: Seizure precaution – More sensitive to external stimuli
o Surgical Anesthesia Stage: From the loss of reflexes to respiratory
paralysis.
 Breathing Pattern: Regular
 Best time for the surgery to start.
 Priority: Airway
o Stage of Danger: Increased amount of anesthesia given; Respiratory
Paralysis to Medullary Stimulation – Paralysis – Apnea – Cardiac
Pulmonary Arrest – Death.
 Administration of GA
o Inhalation of gases – Nitrous oxide
o Volatile agents: “ane” (Ex. Halothane, Enflurane, Isoflurane
 IV Infusion:
o Barbiturate: Thiopental Sodium
o Nonbarbiturates – Profofol
o Complication:
 Malignant Hyperthermia – Gene predisposition – reaction – GA
 Sign:
o Early Sign: Muscle rigidity upper jaw, chest area
o Late Sign: Fever
o Cola colored urine – secondary to bladder spasm
o Tachycardia
 Management:
o DOC: Dantrolene
o Supportive and Symptomatic approach
 Nursing Management:
o Assess for allergies.
o Resuscitation Equipment
o Position: Side Lying position
 Local Anesthesia:
o Uses:
 Dental Procedure
 Minor surgical procedure
o Type of Local Anesthesia:
 Topical LA: Ointment, Spray
 Inhibits the sensory conduction of pain after
administration.
 Uses:
o Prior to injection of regional anesthesia
o Prior to endotracheal intubation and diagnostic
procedure.
 Infiltration LA: Parenteral; given via SQ (Minor Surgery), IV (during
medical cases Ex. Cardiac Arrythmia), and IM
 Uses:
 o Uses of all topical
o Superficial lacerations
o Example: “cane” Ex. Lidocaine, Procaine, Etidocaine
o NEVER DO A SKIN TEST IF SQ ADMINISTRATION
o Only do a skin test – when IV administration – risk
for anaphylactic reaction if skin test is not done.
 Regional LA:
 Spinal Anesthesia vs Epidural Anesthesia
 Location:
o Subarachnoid Space (Spinal)
o Epidural Space (Epidural)
 MOA: Blocking of impulse (same)
 Effect: Lower extremities + groin + lower abdomen (Same)
 Types:
o Abdominal surgery (Spinal)
o Labor/Delivery (Epidural
 Complication
o Spinal headache: due to rapid movement of CSF to
brain – Increased ICP (headache)
 Management:
o Supine position for 6 – 8 hours
 Note: Labor/Delivery: May have 1 pillow
only.
o DOC: Paracetamol
 Complication
o Hypotension
 Anesthesia (Paralysis of vasomotor nerves)
 Blood loss – bleeding
o Management:
 O2 administration for vasodilator
 Hydration
 Transfusion
 Vasoactive drugs – norepinephrine
 Complication
o Bladder Retention/Urine Retention
 200 cc/urine – bladder rupture – bladder
atony – bleeding – hypotension –
hypovolemic shock
o Management:
 Bladder training: Clamp the catheter 2 -3
hours then release for 30 minutes.
 If there is urge to urinate < 3 hours release
for 30 mins then reclamp
 3 – 4 times urge to urinate prior to IFC
removal
 You should begin to void after removal of
IFC within 4 hours – straight catheter if px
 hasn’t urinated for 4 hours – or IFC
reinsertion.
 Post – Operative Phase: When patient is at the PACU until patient is Discharged.
 Within a year, a nurse is still bound to ethical responsibilities to the patient.
o Roles and Responsibilities:
 Respiratory Status:
 Assess the ability of the patient to expel airway.
 Position: Side Lying
 Suctioning
 Cardiovascular Status
 Pooling of blood – BP and HR
 Drainage – Bleeding (Amount and Color)
 Circulation – Check for pulse rate, color of extremities, capillary refill test (2 – 3
secs)
 Thermoregulatory Status
 Hypothermia
o Assess clothing for saturated areas.
o Blanket
 CNS Status
 Orient the patient.
 Protection of eye
 Protection of airway