Perioperative Nursing

PERIOPERATIVE NURSING

* Perioperative nursing includes those activities performed by the nurse in the preoperative, intraoperative and postoperative phases of surgery.

* Surgery refers to surgical operation or procedure, especially one involving the removal or replacement of a diseased organ or tissue. It is a planned alteration that encompasses three phases collectively called the perioperative period.

* Perioperative nurses are registered nurses who work in hospital surgical departments and ambulatory surgery units; they work closely with the surgical patients, significant others, and other health care professionals throughout the perioperative period.

Perioperative and perianesthesia nursing addresses the nursing roles relevant to the three phases of the surgical experience: preoperative, intraoperative, and postoperative.

1. Preoperative phase - begins when the decision to proceed with surgical intervention is made

and ends with the transfer of the patient onto the operating room table.
2. Intraoperative phase - begins when the patient is transferred onto the operating room table and

ends when he or she is admitted to the postanesthesia care unit (PACU).
3. Postoperative phase - begins with the admission of the patient to the PACU and ends with a

follow-up evaluation in the clinical setting or at home.

SURGICAL CLASSIFICATION

I. reason for the surgery

a. diagnostic - performed to determine the origin and cause of a disorder or the cell type of a cancer

e.g., breast biopsy, exploratory laparotomy

b. curative - performed to resolve a health problem by repairing or removing the cause

e.g., cholelithiasis, mastectomy, hysterectomy

c. restorative - performed to improve a patient's functional ability

e.g., total knee replacement, finger reimplantation

d. palliative - performed to relieve symptoms of a disease process, but does not cure

e.g., colostomy, nerve root resection, tumor debulking, ileostomy

e. cosmetic - performed primarily to alter or enhance a person's appearance

e.g., revision of scars, liposuction, rhinoplasty, blepharoplasty

II. urgency of surgery

a. elective - planned for correction of a nonacute problem

e.g., cataract removal, hernia repair, total joint replacement

b. urgent - requires prompt intervention; or may be life-threatening if treatment delayed

e.g., intestinal obstruction, bladder obstruction, kidney or urethral stones

c. emergency - requires immediate intervention because of life-threatening consequences

e.g., gunshot wound, stab wound, severe bleeding

III. degree of risk of surgery

a. minor surgery (low degree of risk) - procedure without significant risk, often done with local anesthesia

e.g., incision and drainage, muscle biopsy

b. major surgery (high degree of risk) - procedure of greater risk, usually longer and more extensive than a minor procedure

e.g., mitral valve replacement (MVR), pancreas implant, lymph node dissection

IV. extent of surgery

a. simple - only the most overtly affected areas involved in the surgery

e.g., simple or partial mastectomy

b. radical - extensive surgery beyond the area obviously involved; is directed at finding a root cause

e.g., radical mastectomy or prostatectomy

EFFECTS OF SURGERY ON THE CLIENT

Physical Effects

Stress response (neuroendocrine response) is activated.

Resistance to infection is lowered due to surgical incision.

Vascular system is disturbed due to severing of blood vessels and blood loss.

Organ function may be altered due to manipulation.

Psychologic Effects
Common fears: pain, anesthesia, loss of control, disfigurement, separation from loved ones,

alterations in roles or life-style

Diagnosis

NURSING DIAGNOSES

Based on the assessment data, major preoperative nursing diagnoses of the surgical patient

may include the following:

Anxiety related to the surgical experience (anesthesia, pain) and the outcome of surgery
Fear related to perceived threat of the surgical procedure and separation from support system
Knowledge deficit of preoperative procedures and protocols and postoperative expectations

FACTORS INFLUENCING SURGICAL RISK

Age: very young and elderly are at increased risk.

Nutrition: malnutrition and obesity increase risk of complications.

Fluid and electrolyte balance: dehydration, hypovolemia, and electrolyte imbalances can pose problems during surgery.

General health status: infection, cardiovascular disease, pulmonary problems, liver dysfunction, renal insufficiency, or metabolic disorders create increased risk.

Medications

Anticoagulants (including aspirin and NSAIDS) predispose to hemorrhage; discontinue 2 weeks before surgery.

Tranquilizers (e.g., phenothiazines) may cause hypotension and potentiate shock.

Antibiotics: aminoglycosides may intensify neuromuscular blockade of anesthesia with resultant respiratory paralysis.

Diuretics: may cause electrolyte imbalances.

Antihypertensives: can cause hypotension and contribute to shock.

Long-term steroid therapy: causes adrenocortical suppression; may need increased dosage during perioperative period.

Type of surgery planned: major surgery (e.g., thoractomy) poses greater risk than minor surgery (e.g., dental extraction).

Psychologic status of client: excessive fear or anxiety may have adverse effect on surgery.

PREOPERATIVE PERIOD

Psychologic Support

Assess client's fears, anxieties, support systems, and patterns of coping.
Establish trusting relationship with client and significant other
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.

Preoperative Teaching

Frequently done on an outpatient basis.
Assess client's level of understanding of surgical procedure and its implications.
Answer questions, clarify and reinforce explanations given by surgeon.
Explain routine pre- and post-op procedures and any special equipment to be used.
Teach coughing and deep-breathing exercises, splinting of incision, turning side to side in bed, and leg exercises; explain their importance in preventing complications; provide opportunity for return demonstration.
Assure client that pain medication will be available post-op.

Physical Preparation

   1. Obtain history of past medical conditions, surgical procedures, allergies, dietary restrictions,
   and medications.
   2. Perform baseline head-to-toe assessment, including vital signs, height, and weight.
   3. Ensure that diagnostic procedures are performed as ordered: common tests are
   a. CBC (complete blood count)
   b. Electrolytes
   c. PT/PTT (prothrombin time; partial thromboplastin time)
   d. Urinalysis
   e. ECG (electrocardiogram)
   f. Type and crossmatch

4. Prepare client's skin.

a. Shower with antibacterial soap to cleanse skin if ordered; client may do this at home the

night before surgery if outpatient admission.

b. Skin prep if ordered: shave or clip hairs and cleanse appropriate areas to reduce bacteria on

skin and minimize chance of infection.

5. Administer enema if ordered (usually for surgery on GI tract, gynecologic surgery).

6. Promote adequate rest and sleep.

a. Provide back rub, clean linens.
b. Administer bedtime sedation.

7. Instruct client to remain NPO after midnight to prevent vomiting and aspiration during surgery.

Legal Responsibilities

1. Surgeon obtains operative permit (informed consent).

a. Surgical procedure, alternatives, possible complications, disfigurements, or removal of body

parts are explained.

b. It is part of the nurse's role as client advocate to confirm that the client understands

information given.

2. Informed consent is necessary for each operation performed, however minor. It is also

necessary for major diagnostic procedures, e.g., bronchoscopy, thoracentesis, etc., where a

major body cavity is entered.
3. Adult client (over 18 years of age) signs own permit unless unconscious or mentally

incompetent.
a. If unable to sign, relative (spouse or next of kin) or guardian will sign.

b. In an emergency, permission via telephone or telegram is acceptable; have a second listener

   on phone when telephone permission being given.
   c. Consents are not needed for emergency care if all four of the following criteria are met.
   1. There is an immediate threat to life.
   2. Experts agree that it is an emergency.
   3. Client is unable to consent.
   4. A legally authorized person cannot be reached.

4. Minors (under 18) must have consent signed by an adult (i.e., parent or legal guardian). An

emancipated minor (married, college student living away from home, in military service) may

   sign own consent.
   5. Witness to informed consent may be nurse, another physician, clerk, or other authorized person.
   6. If nurse witnesses informed consent, specify whether witnessing explanation of surgery or just

signature of client.

Preparation Immediately Before Surgery

1. Obtain baseline vital signs; report any elevated temperature.

   2. Provide oral hygiene and remove dentures.
   3. Remove client's clothing and dress in clean gown.
   4. Remove nail polish, cosmetics, hair pins, prostheses.
   5. Instruct client to empty bladder.
   6. Check identification band.
   7. Administer pre-op medications as ordered.
   a. Narcotic analgesics (meperidine [Demerol], morphine sulfate) relax client, reduce anxiety,

and enhance effectiveness of general anesthesia.
b. Sedatives (secobarbital sodium [Seconal]), sodium pentobarbital [Nembutal] decrease

anxiety and promote relaxation and sleep.
c. Anticholinergics (atropine sulfate, scopolamine [Hyoscine]) and glycopyrrolate (Robinul)

decrease tracheobronchial secretions to minimize danger of aspirating secretions in lungs,

decrease vagal response to inhibit undesirable effects of general anesthesia (bradycardia).
d. Droperidol, fentanyl or a combination may be ordered; should not be given with sedatives

because of danger of respiratory depression; also helpful in control of postoperative nausea

and vomiting.

8. Elevate side rails and provide quiet environment.
9. Prepare client's chart for OR including operative permit and complete pre-op check list.

PATIENT’S EDUCATION

A. Preoperative Instructions to Prevent Postoperative Complication

1. Diaphragmatic Breathing - refers to a flattening of the dome of the diaphragm during

inspiration, with resultant enlargement of the upper abdomen as air rushes in. During expiration,

the abdominal muscles contract.

2. Splinting when coughing

3. Leg Exercises

4. Turning to side
5. Getting out of bed

B. Pain Management

Cognitive Coping Strategies

Cognitive strategies may be useful for relieving tension, overcoming anxiety, decreasing fear, and

achieving relaxation. Examples of such strategies include the following:

Imagery—The patient concentrates on a pleasant experience or restful scene.
Distraction—The patient thinks of an enjoyable story or recites a favorite poem or song.
Optimistic self-recitation—The patient recites optimistic thoughts (“I know all will go well”).

C. Preoperative Psychosocial Interventions

1. Reducing preoperative anxiety

2. Decreasing fear

3. Respecting Cultural, Spiritual, and Religious Beliefs

D. General Preoperative Nursing Intervention

1. Managing Nutrition and Fluids

2. Preparing the Bowel for Surgery

3. Preparing the skin

E. Immediate Preoperative Nursing Interventions

INTRAOPERATIVE PERIOD

12 PRINCIPLES OF OR TECHNIQUE

All articles in the operating room are previously sterilized.
Persons who are sterile touch only sterile articles, persons who are unsterile touch only unsterile articles.
If in doubt of sterility of something, consider it unsterile.
Non-sterile persons avoid reaching over sterile field, sterile persons avoid leaning over unsterile field.
Tables are sterile only at table level.
Gowns are considered sterile only from waist to shoulder level, in front and on the sleeves.
Edge of anything that encloses sterile articles is considered unsterile
Sterile persons keep well within the sterile area.
Non-sterile persons keep away from sterile area.
Sterile persons keep in contact with sterile areas in a minimum.
Moisture may cause contamination
When bacteria cannot be eliminated from a field, they must be kept at an irreversible minimum.

SURGICAL CONSCIENCE – inner voice that tells us what is right or wrong.

Ø Should be present to every member of the surgical team.

Inner voice for the conscientious practice of asepsis and sterile technique at all times.

A surgical conscience is the foundation for the practice of strict asepsis and sterile technique.

SURGICAL SCRUB – it is the process of removing as many microorganisms as possible from the hands

and arms by mechanical washing and chemical asepsis before participating in an operation

Skin and nails should be kept clean

Fingernails should not reach beyond the fingertip to avoid glove puncture

Fingernail polish should not be worn.

No artificial nails allowed.

ASEPSIS – absence of any infectious agents and therefore it is aimed at eliminating microorganisms

present in the surgical environment including harmless microorganisms living in the body

surface or within.

MEDICAL ASEPSIS – prevention of pathogenic microorganism to spread

SURGICAL ASEPSIS – prevention of microorganisms to enter the patient

PREP. IMMEDIATELY BEFORE SCRUB:

Inspect hands for cuts and abrasions. Skin integrity of hands and forearms should be intact.
Remove all finger jewelry
Be sure all hair is covered by headgear
Adjust disposable mask snugly and comfortably over nose and mouth

OR TEAM

STERILE TEAM – team members scrub their hands and arms, don sterile gown and gloves, and enter the sterile field.

STERILE FIELD – area in the OR that immediately surrounds and is especially prepared for the

patient. All the items in the sterile field needed for surgical procedure are sterilized, which are

the processes by which all living microorganisms are killed.

   a. Operating surgeon
   b. Assistant to the surgeon
   c. Scrub nurse

UNSTERILE TEAM

a. Anesthesiologist

ANESTHESIA

General Anesthesia

     A. General information
          1. Drug-induced depression of CNS; produces decreased muscle reflex activity and loss of
              consciousness.
          2. Balanced anesthesia: combination of several anesthetic drugs to provide smooth induction,
              appropriate depth and duration of anesthesia, sufficient muscle relaxation, and minimal
              complications.

     B. Stages of general anesthesia: induction, excitement, surgical anesthesia, and danger stage.
     C. Agents for general anesthesia
          1. Inhalation agents
               a. Gas anesthetics
                    1. nitrous oxide: induction agent; component of balanced anesthesia; used alone for
                        short procedures; always given in combination with oxygen
                    2. cyclopropane: obstetric anesthesia; clients with cardiovascular complications; highly
                        flammable and explosive

               b. Liquid anesthetics
                    1. halothane (Fluothane): widely used; rapid induction, low incidence of post-op nausea
                        and vomiting; may cause bradycardia and hypotension; contraindicated in clients with
                        liver disease.
                    2. enflurane (Ethrane): effects similar to halothane, but muscle relaxation is stronger and
                        hepatotoxicity not a problem; use cautiously in clients with cardiac disease.
                    3. methoxyflurane (Penthrane): very potent agent with slow onset and recovery;
                        circulatory depression at high concentrations; associated with liver and kidney
                        damage; rarely used.
                    4. isoflurane (Forane): rapid induction and recovery; potentiates muscle relaxants;
                        causes profound respiratory depression; monitor respirations carefully.

          2. IV anesthetics: used primarily as induction agents; produce rapid, smooth induction; may be
              used alone in short procedures such as dental extractions.
               a. Common IV anesthetics: methohexital (Brevital), sodium thiopental (Pentathol)
               b. Disadvantages: poor relaxation; respiratory and myocardial depression in high doses;
                   bronchospasm, laryngospasm; hypotension, respiratory depression

          3. Dissociative agents: produce state of profound analgesia, amnesia, and lack of awareness
              without loss of consciousness; used alone in short surgical and diagnostic procedures or for
              induction prior to administration of more potent general anesthetics.
               a. Agent: ketamine (Ketalar)
               b. Side effects: tachycardia, hypertension, respiratory depression, hallucinations, delirium
               c. Precautions: decrease verbal, tactile, and visual stimulation during recovery period

          4. Neuroleptics: produce state of neuroleptic analgesia characterized by reduced motor activity,
              decreased anxiety, and analgesia without loss of consciousness; used alone for short
              surgical and diagnostic procedures, as premedication or in combination with other
              anesthetics for longer anesthesia.
               a. Agent: fentanyl citrate with droperidol (Innovar)
               b. Side effects: hypotension, bradycardia, respiratory depression, skeletal muscle rigidity,
                   twitching
               c. Precautions: reduce narcotic doses by 1/2 to 1/3 for at least 8 hours postanesthesia as
                   ordered to prevent respiratory depression.

D. Adjuncts to general anesthesia: neuromuscular blocking agents: used with general anesthetics
to enhance skeletal muscle relaxation.

Agents: gallamine (Flaxedil), pancuronium (Pavulon), succinylcholine (Anectine), tubocurarine, atracurium besylate (Tubarine), vecuronium bromide (Norcuron)

Precaution: monitor client's respirations for at least 1 hour after drug's effect has worn off.

TABLE 4.12 Stages of Anesthesia

Stage	From	To	Client Status
Stage I (induction)	Beginning administration of anesthetic agent	Loss of consciousness	May appear euphoric, drowsy, dizzy.
Stage II (delirium or excitement)	Loss of consciousness	Relaxation	Breathing irregular; may appear excited; very susceptible to external stimuli.
Stage III (surgical anesthesia)	Relaxation	Loss of reflexes and depression of vital functions	Regular breathing pattern; corneal reflexes absent; pupillary constriction.
Stage IV (danger stage)	Vital functions depressed	Respiratory arrest; possible cardiac arrest	No respirations; absent or minimal heartbeat; dilated pupils

Regional Anesthesia

General information (see also Table 4.13).

Produces loss of painful sensation in one area of the body; does not produce loss of consciousness.

Uses: biopsies, excision of moles and cysts, endoscopies, surgery on extremities; childbirth

Agents: lidocaine (Xylocaine), procaine (Novocain), tetracaine (Pontocaine)

TABLE 4.13 Regional Anesthesia

Types	Method
Topical	Cream, spray, drops, or ointment applied externally, directly to area to be anesthetized.
Local infiltration	Injected into subcutaneous tissue of block surgical area
Field block	Area surrounding the surgical site injected with anesthetic.
Nerve block	Injection into a nerve plexus to anesthetize part of body.
Spinal	Anesthetic introduced into subarachnoid space of spinal cord producing anesthesia below level of diaphragm.
Epidural	Anesthetic injected extradurally to produce anesthesia below level of diaphragm; used in obstetrics.
Caudal	Variation of epidural block; produces anesthesia of perineum and occasionally lower abdomen; commonly used in obstetrics.
Saddle block	Similar to spinal, but anesthetized area is more limited; commonly used in obstetrics.

a. Circulating nurse
b. Others – med tech, rad tech, transport aides

DUTIES OF A SCRUB NURSE

A. Before the surgeon arrives

     1. Do a complete scrub according to accepted practice
     2. Gown and glove
     3. Drape tables as necessary
     4. Drape mayo stand
     5. Count and arrange the instruments on instrument table. Count sponges and count instruments,

needles and sharps.

6. Arrange the instruments on the mayo stand making and opening initial incisions

Instruments are classified as:

               a. Cutting or dissecting – knives and scissors
               b. Grasping and holding – tissue and thumb forceps
               c. Clamping and occluding – hemostatic forceps and clamps
               d. Exposing – retractors
               e. Suturing – needle holders

     7. Put blades on knife handles (Scalpel)
               Blade holder # 3 – blade # 10,11,12,15
               Blade holder # 4 – blade # 20 and above

     8. Prepare sutures in the sequence in which the surgeon will use them
               Free Ties – use to ligate blood vessels if not they can also use the cautery machine.

LAYERS OF ABDOMEN

               1. Peritoneum
               2. Muscle
               3. Anterior fascia
               4. Subcutaneous
               5. Skin

     9. Count surgical needles with circulating nurse
     10. Count all sponges with circulating nurse. Circulating nurse immediately records it

counts before the start of the operation
counts before the surgeon starts closure of a body cavity or deep or large incision

          a. Table count – scrub nurse and CN count all items in the instrument table and mayo stand
          b. Floor count – CN counts sponges and other items that are recovered from the floor
          c. Field count – CN totals floor and table count. Then inform surgeon if sponge count is correct

counts all over again before subcuticular closure. If sponges are intentionally retained for packing or instrument remains with the patient, this should be documented in the patient chart

INCORRECT COUNT
1. Entire count is repeated immediately

2. CN looks at trash receptacles, under furniture, linen hamper or throughout the room

3. SN looks over drapes and under items on table and mayo stand
4. Surgeon rechecks field and wound

5. CN should call HN to check the count

6. X-ray must be taken before the patient leaves OR whenever a sponge or instrument

count is incorrect

7. CN makes an incident report.

B. After Surgeon and Assistants Scrub

     1. Gown and glove the surgeons and assistants as soon as they enter the room
     2. Assist in draping the patient accdg. to the routine procedure
     3. Bring mayo table into position after draping is completed. Position the table at right angle to
         operating table

C. During the Operation

      1. Hand skin knife to surgeon and hemostat to assistant. When handling knife, hold the handle
          blade down and pointed toward your wrist NEVER toward the surgeon
      2. Watch field and anticipated the needs of the surgeon. Keep one step ahead of him in offering
          instruments, sutures, or sponges. Notify CN quietly for supplies not in the table
    3. Pass instruments in a positive manner. When surgeon extends the hand, instruments should be

slapped firmly into the palm in proper position for use.

          Hemostat – bleeding
          Scissors – need to cut tissues
          Mayo scissors – cut sutures

keep instruments clean as possible wipe blood with moist sponge
return instruments to mayo stand promptly after use

4. Save all tissue specimen

Never use a large clamp for all small specimens. It may crash.
Put in a specimen bottle, basin wrapper or towel NEVER in a sponge. Tell CN what specimen it is if not sure asks MD.

5. Maintain sterile technique. Watch for any breaks

D. During Closure

     1. Count sponges, needles, instruments with CN when surgeon begins closure of the wound
     2. Clear off mayo stand as time permits leaving a knife handle with blade, tissue forcep, scissors,
         4 hemostat and 2 allis forceps
     3. Have a damp sponge ready to wash blood from the area surrounding the incision as soon as
         skin closure is completed.
     4. Have betadine, dressings and plaster ready