PRE AND POST –OPERATIVE NURSING CARE.pptx

NURSING FOUNDATION:PRE AND POST OPP CARE

1. PRE AND POST –OPERATIVE NURSING CARE

2. Surgery can be defined as the art and science of treatment.  Most surgical procedures are performed in a hospital operating room, although many simpler procedures are carried out in surgical centers and ambulatory surgical units. Surgical procedures are commonly grouped according to the: (A) Purpose Diagnostic Palliative Ablative Reconstructive or cosmetic Transplant or corrective Curative Repairative Restorative

3. B) Degrees of Urgency Emergency Surgery - Immediate - Urgent  Elective Surgery - Required - Recommended -Optional (C) Degree of risk involved Major Surgery Minor Surgery

4. Types of Surgery Main Features According to Purpose Diagnosis: This is an operation in which the diagnosis is unknown and so it confirms or establishes diagnosis.  e.g., exploratory laparotomy in which the abdomen is opened to seek the cause of symptoms or biopsy of a mass in the breast.  Palliative: This is an operation in which symptoms are relieved, but the basic cause remains and so does not cure the disease.  e.g., resection of nerve root, or insertion of gastrostomy tube to compensate for the inability to swallow. ).

5.   Ablative: This is an operation in which the diseased body part is removed.  e.g., removal of gall bladder (Cholecystectomy Reconstructive or Cosmetic : This is an operation which is done to restore function or restore appearance that has been lost or reduced, e.g., mammoplasty, breast implant, face lift etc.  Repair of cleft lip and cleft palate 

6. Transplant or Corrective: This is an operation in which deformities are corrected and malfunctioning structure are re-placed.  e.g., hip replacement, replacement of the mitral valve. Curative: This is an operation in which complete cure is assured by removing the diseased part or organ e.g.  removal of an inflamed appendix, total excision of a tumor mass   .  

7. - Repairative : This is an operation in which repair of damaged or injured part is done.  e.g., suturing multiple wounds. - Restorative : This is an operation involving strengthening of weakened area.  e.g., herniorrhaphy.  - Preventive: Operation is performed to prevent the disease.  removal of mole to prevent it turn into malignant

8. Degree of Urgency Emergency: In this, pre-operative period is very short, because of the life threatening situation.  e.g., acute appendicitis.  Therefore minimum preparation can be done in the pre-operative period.  (a) Immediate: Surgery is performed immediately to preserve (without delay) function or save life of the client.  e.g., ruptured aortic aneurysm, gunshot wound, epidural hematoma, acute appendicitis (b) Urgent: Client requires prompt attention.  Surgery is performed within 24 to 48 hours.  e.g.  ureteral calculi, bleeding uterine fibroids, obstructed duodenal ulcer. 

9. Elective or Planned: Surgery is performed when surgical intervention is the preferred treatment for a condition that is most immediately life threatening (but may ultimately threaten life on well being)   Or to improve clients life.  Time for surgery is fixed with the mutual consent of the surgeon and the patient.  There will be enough time left for the pre-operative care to be given to the patient. 

10. a) Required : Surgery is required within weeks or months.  eg cataract extraction, benign prostatic hypertrophy chronic cholecystitis.  (b)Recommended: Client should be operated upon.  Failure to surgery is not catastrophic.e,g haemorrhoids , rectocele, cystocele, simple hernia (c) Optional or Cosmetic : Decision rest with the client and is the personal preference of the client.  Plastic surgery procedure e.g., face lift. 

11. Degree of Risk Major Surgery: This involves a high degree of risk to the client, for a variety of reasons.  It may be complicated, prolonged, there may be heavy loss of blood, vital organs may be involved, post operative complications are likely, operation may involve large surface area of ​​the  body.eg ., open heart surgery, organ transplant, removal of a kidney etc.  Minor Surgery: This normally involves little risk, produces few complications and usually involves a small area of ​​the body.  e.g., breast biopsy, tonsillectomy.  The degree of risk involved in the surgical procedures depends on the client's age, general health, nutritional status, use of medications, mental status, etc. 

12.   Suffixes Describing Surgical Procedures Ectomy = Excision or removal of eg:Myomectomy Lysis = Destruction of eg : Electrolysis Orrhaphy = Repair or suture of eg :Colporrhaphy Ostomy=Creation of opening into eg : Colostomy Otomy =Cutting into or incision of eg:Tracheotomy Plasty =Repair or reconstruction of eg , Tympanoplasty

13. The surgical experience is a unique one and involves three phases: 1. Pre-operative phase 2. Intra-operative phase 3. Post-operative phase.   These three phases together are referred to as peri-operative period. 

14. Pre-Operative Phase is the period between the decision to do the surgery and the client being shifted to the operation table.  The nursing activities during this phase includes: ( i ) Assessment of the client.  (ii) Identification of health problems -both actual and potential.  (iii) Plan of care based on individual health needs.  (iv) Preoperative health teaching of the client and supportive people.  (v) Actual preparation of the client for surgery (physical, psychological, social etc.)

15.  Intra-Operative Phase : It is the period from the time the client shifted to the operating table, and later admitted to the post anaesthesia care unit or recovery room.  The nursing activities during this phase include all the specialized procedures designed ate a safe therapeutic environment for the client. 

16. Post-Operative Phase is the period between the admission of the client to the recovery room until the healing is complete.  The nursing activities during this phase include.   ( i ) Assessment of the clients response to surgery.  (Physical and Psychological).  (ii) Care to promote healing process.  (iii) Activities to prevent complications.   (iv) Health teaching and postoperative exercises.  (v) Planning for home care.

17. Pre-operative Care of Patients (In General) Pre-operative care of the patient begins as soon as the surgeon makes a diagnosis and decides that an operation is necessary for the patient.  1. Psychological Preparation Discuss with the patient to give full information about the surgery, such as: Type of surgery - Consequence of surgery (if it is done and if it is not done) - The problems to be faced (disabilities expected) Expected duration of hospitalization Expected time of resuming duty (if employed) Cost of surgery Treatment/investigations done before surgery and its purpose Necessary arrangements to be made about the family, financial matters, work, hospitalization, etc.  

18. 2. Eradicate Fear of Operation from the Patient Allow the patient to ask questions and clear all his doubts from her.  Introduce the patient to someone who had similar surgeries and have been successfully recovered from the symptoms.  Explain what happens during anaesthesia Explain how to get rid of pain after surgery.  Tell the patient when he can have meals

19. Answer all questions asked by the patient in a language he can understand, so that the patient will have confidence to undergo surgery.  Let the patient see the persons, places and equipment involved in his operation.  Always start the procedures with an explanation, so that it will inspire confidence in the medical team.  The patient has to feel that he will be safe in the hands of the competent people during surgery.  For many patients, their admission to the hospital is a first experience in their lives.  In such a situation, the nurse should make them feel at home by eradicating their fear.

20. 3. Meet the Spiritual Needs of the Patient -Help the patient to meet the ministers of his religion, if requested by the patient.  4. Obtain informed Consent Obtain the consent from the patient/guardian for each operation after explaining the nature of the operation and anesthesia.  - Never compel the patient/guardian to give their consent.  Explain the complications that may occur when the patient is under anesthesia.  - The language used in the consent form should be understood by the patient/guardian, who gives the signature.  Obtain consent for major diagnostic procedure.

21. Build up the General Health of the Patient and Correction of the Disease Process for Speedy Recovery Assist the doctor to carry out a thorough physical examination from head to foot to assess the physical health of the patient.  - Ask the patient appropriate questions to obtain past and present medical history in order to exclude anaemia , jaundice, diabetes, asthma, lung infections, hypertension, heart dis- eases, bleeding tendencies, mental diseases, drug reactions, blood transfusions, previous operations, etc.  - Carry out the investigations that the doctor ordered, such as;  Blood for Hb, TC, DC, ESR, blood urea, blood sugar, BT.  CT, HIV, VDRL grouping and typing etc.  Urine for albumin, sugar, microscopic examination. 

22. Collect all the baseline data - temperature, pulse rate, respiration, blood pressure, ECG, X-ray chest etc.  Further investigations may be carried out that are specific the nature of the operation e.g., Intravenous pyelography kidney operations. - Arrange for the blood donors.  - Fluids may be administered if the patient is dehydrated. Patients with chronic obstructive pulmonary disease (COPD) will have pulmonary function tests done before they undergo the general anaesthesia .  Diet may be adjusted to correct under weight\over weight of the patient. 

23. 6. Pre-operative Teaching - Stop smoking (if the patient is a smoker) - Maintain personal hygiene Deep breathing and coughing exercises to prevent chest complications.  - Active and passive exercises of the limbs to prevent postoperative thrombus (blood clot) due to venous stasis.  - Postural drainage to prevent pulmonary complications, e.g.  COPD.  - Control of visitors to prevent cross infection. 

24. 7. Surgical Preparation of the Skin 8. Preparation of the Patient on the Evening before Operation Remove all jewellery and hand over them to the relatives.  Remove the lipstick and nail polish etc.  if the patient wa using.  Get the orders from the physician for immediate pre-operative preparation.  These orders cancel all previous ones.  If the patient was taking some drugs regularly, such as  insulin, steroids, hormones, digitalis preparations (card drugs)., ask the physician how to administer them.  Shave the part to be operated. 

25. After shaving the area, ask the patient to have a bath and dress in clean clothes Paint the area using a safe antiseptic, eg , Mercurochrome Enema is ordered on the evening when the the gastro-intestinal system/pelvic/perineal/and surgery involves areas.  perianal areas A light diet in the evening before the day of surgery and fasing after midnight (6 to 8 hours prior to surgery) is advised to prevent vomiting and aspiration of the food materials into the lungs during general anaesthesia . 

26. A tranquillizer like diazepam may be ordered by the doctor and it is given at bedtime to the patient to ensure good sleep at night before the day of surgery.  The patient should be reassured to prevent anxiety and fear of operation.  Note : The preparation of the patient for surgery varies according to the types of operation and the surgeon's preferences.  Therefore ask the surgeon for specific orders. 

27. 9. Preparation of the Patient on the Day of Surgery Help the patient to go to toilet and for the mouth care.  Remove hair pins, clips, ornaments, false teeth etc.  Comb the hair and tie them with a ribbon.  Remind the patient and his relatives about the fasting before surgery.  If there is a delay for the operation, ask the surgeon/ anaesthetist about the fluids (drinks) that can be given to the patient. 

28. Check the orders for the bowel preparation.  Some doctors may prefer to give an enema and a bowel wash on the morning of operation to empty the bowels, if the operation is on the bowels.  Repeated enemas and bowel wash tire the patient, upset the electrolyte balance and irritate the rectal and bowel mucosa.  Clean the operation site with soap and water thoroughly, dry the area with a clean towel, and paint the area with mercurochrome or any other antiseptics that will not damage the skin.  Cover the operation site with a sterile towel, and fix it by means of binder\bandages. 

29. Introduce a naso -gastric tube, urinary catheter etc.  if ordered by the surgeon.  Always reassure the patient by giving appropriate explanations and take all the precautions.  Stop all medications, unless specially ordered by the surgeon.  If oral medicines are to be given/give them with a minimum amount of water. 

30. 10. Sending the Patient to Operating Room Administer the pre-medications to the patient one hour before surgery.  These are the drugs that reduce anxiety in the patient, and provide a smoother induction Before giving the pre-medications, check the vital signs of the patient such as blood pressure, temperature, pulse, res.  pirates etc.  Record the vital signs in the patient's charts as baseline data. 

31. Change the patient's dress and put on hospital gown, Write the patient's name, age, ward, bed number, diagnosis hospital number etc.  on an identification card and fasten t onto the dress or on the arm to prevent mistaken identity.   Ask the patient to void just before sending the patient to the operating room.  Transfer the patient onto a patient trolley and cover him with clean sheets to prevent draught.   Never leave the patient alone on a trolley without any person near-by to prevent falls and injuries.

32.   Always send the patient's charts with all reports, such as lab reports/medication charts/X-ray/ECG reports/and other investigations done on the patient.  Check the consent form for the operation and anesthesia.  Always send the patient with an attendant up to the operation theater.  It is preferable to have a female attendant to accompany the female patient.  Always entrust the patient to someone who will take responsibility for the patient while he is in the operation theater.  

33. NURSING DIAGNOSIS OF THE PRE-OPERATIVE CLIENT 1.Anxiety related to lack of knowledge about pre-operative routines and post-operative care.  2. Fear related to effect of surgery and ability to function in usual roles.  3. Fear related to the risk of death.   4. Anxiety related to the outcome of exploratory surgery for malignancy.  5. Fear related to loss of control during anesthesia or waking up during anesthesia.  6. Anxiety related to the perceived inadequate postoperative analgesia. 

34. 7. Sleep pattern disturbance related to hospital routines and psychological stress 8. Anticipatory grieving related to perceived loss of body part associated with planned surgery.  9. Ineffective individual coping related to conflicting values ​​(e.g., need for blood transfusion verses the religious values ​​for Jehovah's witness).  10. Ineffective individual coping related to lack of clear out-come of surgery.  11. Ineffective individual coping related to unresolved past negative experience with surgery.  

35. Intra-operative Care When a client arrives in the operating room three groups of personnel are involved in the care.  1. The anesthetic team 2. The surgical team 3. The operating room nurses Intra-operative nurses are responsible for the safety and well being of the patient, the co-ordination of the operating room per- sonnel and activities of the circulating nurse and the scrub nurse. 

36. Intra Operative Nursing Functions (A) The Circulating Activities include assuring cleanliness, proper temperature, humidity and lighting, the safe functioning of the equipment and the availability of the supplies and materials.  The circulating nurse also monitors the aseptic practices of the related personnel (Medical, X-ray and Laboratory) besides monitoring the safety of the patient throughout the surgical procedure, ( B) The Scrub Activities includes scrubbing for surgery, setting up the sterile tables, preparing sutures, ligatures and special equipments and assisting surgeons during the procedure.