Perioperative Concepts and Nursing Management.pptx

CFGHVGH

1. Perioperative Concepts and Nursing Management Prepared by Dr/ Sabah nazeh Associated prof of medical surgical department

2. Outlines Introduction Preoperative phase Definition Preoperative Nursing Management Intra operative phase The Surgical Team Role of Scrub nurse Role of circulating nurse Postoperative phase Postoperative care Post Operative Complication

3. Introduction Perioperative nursing is a term used to describe the nursing care provided during the total surgical experience of the patient: preoperative, intraoperative , and postoperative.

4. Preoperative phase —from the time the decision is made for surgical intervention to the transfer of the patient to the operating room. Intraoperative phase —from the time the patient is received in the operating room until admitted to the post anesthesia care unit (PACU). Postoperative phase —from the time of admission to the PACU to the follow-up evaluation.

5. Preoperative phase Definition: Preoperative care is the preparation and management of a patient prior to surgery. It includes both physical and psychological preparation.

6. Preoperative Nursing Management: Informed consent: The physician must explain the risks and benefits of the surgery, along with other treatment options, It is important that the patient understands everything he or she has been told.

7. Patient Education: Tell patients how long they should be NPO (nothing by mouth) Inform the patient about what will be done during the surgery, how long is the procedure, and where the incision will be. Teaching deep breathing and coughing exercises and practice splinting the incision.

8. Compression stockings on their legs to prevent blood clots until they start ambulating. Encouraging mobility and active body movement. e.g. Turning (change position), foot and leg exercise. Explaining pain management.

9. Physical preparation: Complete medical history and physical exam: Including the patient's surgical and anesthesia background Laboratory tests: CBC, electrolytes, prothrombin time, urinalysis, electrocardiogram (EKG) and chest X- ray.

10. Managing nutrition and fluids. A fasting period of 8 hours or more is recommended to prevent aspiration. Clear fluids (water) may be given up to 4 hours before surgery depending on facility protocols.

11. Preparing the bowel for surgery. Enema is not commonly ordered, unless the patient is undergoing abdomen or pelvic surgery. e.g. (cleansing enema, laxative).

12. Preparing the skin. The goal of preoperative skin preparation is to decrease bacteria. Scrubbing with a special soap, or possibly hair removal from the surgical area.

13. Psychological preparation: Patients are often fearful or anxious about having surgery. It is often helpful for them to express their concerns to health care workers. In some cases, the procedure may be postponed until the patient feels more secure.

14. Immediate preoperative nursing intervention: Administering preanesthetic medication. Maintaining the preoperative record. E.g. Final checklist, consent form, identification.

15. Intra operative care: The Surgical Team Surgeon – leader of the surgical team anesthetist – provides smooth induction of the patient’s anesthesia in order to prevent  pain Scrub Nurse or Assistant  Circulating Nurse

16. The " scrub nurse " passes instruments, supplies, and suture to the surgeon during the procedure.  While the unsterile " circulating nurse " will provide for the safety and comfort of the surgical patient and will be alert to the needs of the other members of the surgical team. 

17. Role of Scrub nurse: Both the scrub nurse and circulating nurse assist with opening the sterile supplies needed for the surgical procedure.  The scrub nurse opens his/her gown and gloves last, preferably on a separate field and proceeds to perform the surgical scrub.    The scrub nurse and circulating nurse perform a sponge, needle, and instrument count before the initial incision is made.

18. Following the surgical scrub, the surgeon enters the operating room and is gowned by the scrub nurse.  The surgeon then preps the patient's skin with an antiseptic solution.  If performed on the abdominal area, the umbilicus is prepped last. 

19. Draping of the patient follows, according to procedure and the surgeon's preference.  The scrub nurse should know the draping routine and have all necessary drapes ready in proper order. When the surgery is ready to begin,  the scrub nurse passes the skin knife to the surgeon, The surgeon and first assistant hold the skin taut as the incision is made.

20. The scrub nurse assists by observing the operative procedure and passing the appropriate instruments to the surgeon and first assistant.  A sponge, needle, and instrument count is performed at the beginning of closure. 

21. Once the needle is returned to the scrub nurse, it is placed in the needle counter The final sponge, needle, and instrument count is performed during the skin closure by the scrub and circulating nurses. The scrub nurse removes his/her gown and gloves after all contact with soiled instruments and supplies is completed.

22. Role of circulating nurse: Prior to opening the first case of the day, flat surfaces and overhead lights are cleaned with a damp cloth moistened with high level disinfectant. The circulating nurse obtains the patient's x-rays if necessary and checks on any blood products that may have been ordered.

23. Positioning is performed two persons.  A safety strap is placed 2-3 inches above the patient's knees and the patient's arms are placed on arm boards.  Monitoring devices such as BP cuff, ECG pads, and pulse oximeter are placed on the patient by the circulating nurse

24. The circulating nurse may insert a Foley catheter, exposes the operative site, and performs the skin prep.  The circulator activates the overhead spot lights then move into position over the operative field. Circulating nurse sponge and suction blood from the operative site.

25. The circulating nurse should retrieve the used sponges from the kick bucket by using a sponge stick or his/her gloved hand, should be placed in a clear sponge counting bag. The anesthesia personnel and the surgeon will need to view the sponges to determine the patient's estimated blood loss (EBL).

26. The circulating nurse maintains communication with other areas of the operating room suite and may be responsible for sending for the next patient.  The circulating nurse is also responsible for correctly labeling and caring for the surgical specimen. 

27.  If a sponge drops on the floor, the circulating nurse removes the sponge using an instrument or gloved hand and wipes the area immediately with a hospital grade disinfectant. The surgeon will apply the dressing.  When the anesthesia personnel give permission, the patient is moved to the recovery room bed. 

28. All sharps are placed in an appropriate sharp's container. All linen is placed in an impervious bag and sent to the laundry to be washed. Cleaning of the room is next.  Walls are not considered contaminated and require no cleaning unless they have been splashed with blood. 

29. Postoperative care: Postoperative care is the management of a patient after surgery. This includes care given during the immediate postoperative period, both in the operating room and postanesthesia care unit (PACU), as well as during the days following surgery.

30. Post anesthesia care unit: Assessment of the patient's airway Patency, vital signs , and level of consciousness are the first priorities upon admission to the PACU, Then assessment of: - Surgical site (intact dressings with no signs of overt bleeding) - Patency (proper opening) of drainage tubes/drains.

31. Patency /rate of intravenous (IV) fluids. Circulation/sensation in extremities after vascular or orthopedic surgery - Pain status. - Nausea/vomiting. -Body temperature (hypothermia/hyperthermia)

32. First 24 hours Vital signs, respiratory status, pain status, the incision, and any drainage tubes should be monitored every one to two hours for at least the first eight hours. Body temperature must be monitored, since patients are often hypothermic after surgery.

33. Respiratory status should be assessed frequently, including auscultation of lung sounds, and presence of an adequate cough. Respiratory exercises (coughing, deep breathing, and incentive spirometry) every two hours.

34. Controlling pain, so the patient is able to perform deep breathing and coughing exercises, able to turn in bed, sit up and walk. Patient should splint any chest and abdominal incisions with a pillow to decrease the pain caused by coughing and moving. Fluid intake and urine output should be monitored every one to two hours .

35. The patient should be turned every two hours, at least be sitting on the edge of the bed by eight hours after surgery, unless contraindicated. Patients will have compression devices on their legs until they are able to move. Patients should be kept NPO (nothing by mouth) if ordered by the surgeon, at least until their cough and gag reflexes have returned. Patients often have a dry mouth following surgery; can be relieved with oral sponges dipped in ice water.

36. After 24 hours : Vital signs can be monitored every four to eight hours if the patient is stable. The incision and dressing should be monitored for the amount of drainage and signs of infection ( eg , increasing pain, erythema , drainage) . The surgeon may order a dressing change during the first postoperative day. A drain tube, if present, must be monitored for quantity and quality of the fluid collected.

37. Bowel sounds are monitored, and the patient's diet gradually increased as tolerated, depending on the type of surgery and the physician's orders . . Monitor patient for any evidence of potential complications, such as leg edema, redness, and pain ( deep vein thrombosis ), shortness of breath ( pulmonary embolism) , or ( intestinal obstruction ). Respiratory exercises are still be performed every two hours.

38. Post Operative Complication: Shock: Is the response of the body to a decrease in the circulating volume of blood, tissue perfusion impaired, cellular hypoxia and death. 2- Hemorrhage: Is the escape of blood from a blood vessel. 3- Deep vein thrombosis (DVT): Occur in pelvic vein or in lower extremities, and it’s common after hip surgery. 4-pneumonia : Due to accumulation of secretions. 5- Paralytic ileus .