Reduction of Risk Potential

Perioperative Nursing

A. Preoperative period

1. Begins with decision to perform surgery and ends when client enters operating room; the surgery may be inpatient or outpatient

2. Types of surgery

a. purpose

i. diagnostic

ii. curative

iii. transplant

iv. palliative

v. cosmetic

b. urgency of surgery

i. elective: performed on basis of client's choice, not essential for health

ii. urgent: necessary for client's health

iii. emergency: must be done immediately to save client's life

c. seriousness

i. minor: minimally alters body parts, with less risk

ii. major: extensively reconstructs or alters body parts; greater risk

3. Medical conditions that increase the risk of surgery

a. bleeding disorders

b. heart disease

c. diabetes mellitus

d. upper respiratory infection

e. liver disease

f. chronic respiratory disease

g. immunological disorders

h. drug abuse

4. Pre-anesthetic medications

a. sedatives-hypnotics

b. narcotics

c. anticholinergics

d. tranquilizers/antianxiety agents

e. H2-receptor antagonists

5. Nursing interventions during preoperative period

a. provide psychological support

b. explain the procedures surrounding the surgery

c. teach client

i. type of surgery to be performed

ii. deep breathing and coughing

iii. post-op incisional splinting

iv. comfort measures to be used post-operatively

v. movement

vi. elimination

d. obtain baseline vital signs

e. administer pre-anesthetic medications as ordered

f. administer prophylactic antibiotics if ordered

g. remove nail polish and makeup

h. help client to empty bladder

i. check client's identification bracelet

j. provide for client safety

k. remove any dentures or prostheses

l. check that pre-op permit (informed consent) has been signed and appropriate lab work is documented

m. check for allergies

n. ensure that right site protocol is in use

B. Intraoperative period

1. Surgery usually takes place in operating suite

2. Anesthesia, general

a. drug-induced analgesia, amnesia, muscle relaxation, and unconsciousness

b. stages:

i. induction: start of anesthetic administration, client becomes drowsy and loses consciousness

ii. excitement: muscles become tense and almost spasmodic

iii. swallowing and vomiting reflexes remain, may breathe irregularly

iv. surgical anesthesia:

I. muscle relaxation occurs

II. breathing becomes regular

III. vital functions and reflexes are depressed

IV. operation begins

v. complete respiratory depression

c. types of anesthetic agents

i. inhalation: gas and liquid: nitrous oxide, cyclopropane halothane, enflurane, ether, methoxyflurane

ii. intravenous agents: methohexital, sodium thiopental

iii. dissociative agents: (no loss of consciousness) ketamine

iv. neuroleptics: fentanyl citrate with droperidol

d. adjuncts to general anesthesia:

3. Complication of general anesthesia: malignant hyperthermia

a. rapid progressive rise in body temperature

b. fatal if not treated

c. findings

i. tachycardia

ii. tachypnea

iii. unstable blood pressure

iv. diaphoresis (sweating)

v. muscle rigidity

d. thought to be caused by alteration of calcium-storing properties of muscle-cell membrane

e. familial tendency

f. treatment - dantrolene (Dantrium): skeletal muscle relaxant

g. nursing interventions in malignant hyperthermia

i. administer medications as ordered

ii. teach client to wear MedicAlert jewelry

4. Nursing interventions during the intraoperative period

a. ensure right site protocol is in use

b. provide emotional support during anesthesia induction

c. provide for client safety during procedure

d. position the client as ordered by procedure

e. maintain surgical asepsisf. monitor for electrical hazards

g. monitor client for effects of heat loss during surgery

h. immediately after surgical drapes are removed, apply warm blankets

C. Postoperative period I: recovery and discharge home

1. Anesthesia recovery period - may range from a few hours to 23 hours

a. surgical recovery: priority nursing interventions

b. recovery complications and how to react:

c. provide emotional support and reorientation

d. assist with notifying the family that the surgery is complete and of the general condition of the client

2. Post recovery: for clients discharged to home

a. discharge criteria include these nine achievements

i. adequate respiratory function

ii. intact gag reflex

iii. ability to deep breathe and cough

iv. stable vital signs

v. normal level of consciousness and muscle strength

vi. ability to ambulate with assistance

vii. ability to retain oral fluids

viii. ability to urinate

ix. ability to care for incision and any drainage tubes

x. flatus/bowel sounds all 4 quadrants of abdomen

b. instruct clients in eight areas

i. medications and side effects

ii. care of incision

iii. care of any drainage apparatus

iv. any required treatments

v. findings of infection

vi. activity progression or limitation

vii. special dietary restrictions

viii. when to contact the physician

D. Postoperative period II: transfer to a medical-surgical unit

1. Acute pain management

a. temporary pain occurring after a body injury

i. disappears when injury is healed

ii. monitor location, severity, quality, progression and alleviation of pain

iii. administer pain medications as ordered (information about pain medications can be found in Pharmacological and Parenteral Therapies)

iv. provide noninvasive pain relief measures as ordered

massage

distraction

relaxation

hypnosis

v. assist with invasive pain relief measures as ordered

acupuncture

nerve blocks

2. Other postoperative care

a. provide restful environment

b. encourage the client to turn, breathe deeply and cough

c. encourage the client to change position every hour

d. assist the client out of bed, an order is required following neck and back surgery

e. change dressing as needed

f. use sterile technique

g. observe and record amount, color, odor of drainage on dressing

h. observe incision for intactness, findings of infection

i. assist with ADLs as indicated

j. ambulate client, may require physical therapy in some facilities

k. teach client

to splint incision during coughing

wound care

importance of progressive activity

medications and side effects

findings of infection

monitor for complications

3. Complications

a. wound complications

i. dehiscence: complete separation of wound edges or

ii. evisceration: wound edges separate; viscera protrude

cause: obesity; malnutrition; too much coughing/straining

cover with gauze soaked in sterile saline and report immediately

keep client in flat position

iii. infection

b. circulatory complications: thrombosis and embolism

c. fluid and electrolyte imbalance

d. urinary retention

i. finding: inability to void

ii. causes include trauma to the bladder or its nerve supply during surgery, edema around bladder neck; reflex spasm due to drugs; spinal or epidural anesthesia

iii. interventions

encourage ambulation

run water so client can hear sound

pour warm water over perineum

warm bath

catheterization if indicated

e. paralytic ileus

i. diminished or absent peristalsis

ii. caused by stress response to surgery and anesthesia, trauma or manipulation of abdominal contents, electrolyte imbalance, anesthetics and pain medications, wound infections and immobility

iii. occurs to some degree following all abdominal surgeries

iv. bowel sounds return gradually over several days

v. findings

decreased or absent bowel sounds

abdominal distention

feeling of fullness

vi. interventions

withhold fluids until presence of bowel sounds

encourage ambulation

nasogastric decompression if ordered

vii. return of peristalsis signaled by presence of bowel sounds, flatus or bowel movement

f. nausea and vomiting

i. caused by anesthetics and analgesics, gastric distention, surgical manipulation, pain, electrolyte imbalance

ii. interventions

limit oral intake

administer antiemetics as tolerated

measure drainage

observe color, amount and odor of drainage

progress client food intake: begin with clear liquids and progress to full diet as tolerated

record intake and output Wound drain

1. Removal of wound drainage

2. Types

a. closed drain

i. drain attached to collection system

ii. uses vacuum to draw drainage into system

iii. example: Jackson-Pratt, Hemovac

iv. specific nursing interventions

I. maintain patency of drain

II. empty collection system and reactivate suction device

III. record amount and characteristics of drainage

IV. asepsis

V. standard precautions

b. open drain

i. removes drainage from wound, deposits it on skin surface

ii. example: Penrose drain

iii. safety pin usually attached to outside end of drain

iv. specific nursing interventions

v. prevent inadvertent removal of drain

I. protect skin

II. record characteristics of drainage

III. asepsis

IV. standard precautions

vi. protect skin surface from irritating effects of drainage

vii. wound vacuum

I. removes and collects infectious material from wound

II. computer controlled

III. requires a seal at wound site with pressure distributing wound packing

IV. client may be discharged with device

Dressings, compresses, bandages, irrigation

1. Uses of dressings

a. promote healing by absorbing drainage and debriding a wound

b. protect wound from contamination

c. promote thermal insulation of wound

d. protect wound from further injury

e. prevent the spread of microorganisms

f. control bleeding

g. comfort

2. Types of dressing for simple wounds

a. most of these are changed daily or more frequently

3. Types of dressing for complicated wounds:

a. most of these remain on wound over a few days 4. Nursing interventions

a. explain procedure to client

b. maintain standard precautions

c. change dressing as ordered according to institutional procedure

d. maintain asepsis

e. make sure dressing is secure

f. document

i. type and amount of drainage

ii. presence of drains

iii. condition of wound

g. observe for signs of infection

h. watch moist dressings for growth of yeast

i. weigh dressing if ordered

j. teach client

i. type and purpose of dressing

ii. how to change dressing if change required after discharge

iii. findings of wound healing

iv. findings of complications, e.g. infection

5. Compresses

a. moistened piece of gauze dressing

b. may be warm or cool

c. uses

i. improve circulation

ii. reduce edema

iii. promote consolidation of pus

d. nursing interventions

i. explain procedure to client

ii. change warm compresses frequently or apply aquathermic pad to maintain temperature

6. Bandages and binders

a. made of gauze, elastic knit or webbing, muslin or flannel

b. uses

i. provide extra protection

ii. create pressure over body part

iii. immobilize body part

iv. support a wound

v. reduce or prevent edema

vi. secure dressings

c. bandage types

i. circular

ii. spiral

iii. spiral reverse

iv. figure eight

v. recurrent

d. binder types (illustration )

i. abdominal

ii. T binder

iii. breast

e. nursing interventions

i. explain procedure to client

ii. ensure that bandage or binder is not constrictive

iii. tell client to report any discomfort with bandage or binder

iv. replace soiled bandages and binders

7. Slings

a. supports arm with muscular sprain or fracture

b. may be commercially made or home made

c. nursing interventions

i. explain procedure to client

ii. support affected extremity while applying sling

iii. place sling outside normal clothing

8. Irrigation

a. flushing with solution

b. uses

i. to remove foreign matter or exudate

ii. to ensure patency of drainage tubing

iii. involves instilling a solution and withdrawing that solution

c. types

i. urinary

ii. wound

iii. nasogastric/gastrostomy/jejunostomy

iv. arterial line

v. ostomy

vi. ear

vii. vagina (douche)

viii. colonic (enema)

ix. central line or peripheral IV

x. bladder

Principles of Surgical Asepsis

A sterile object remains sterile only when touched by another sterile object.

Sterile touching sterile remains sterile.

Sterile touching clean becomes contaminated.

Sterile touching contaminated becomes contaminated.

Sterile touching questionable is contaminated.

Only sterile objects may be placed on a sterile field.

A sterile object or field out of range of vision, or an object held below a person's waist, is contaminated.

Never turn your back on a sterile field.

A sterile object or field becomes contaminated by prolonged exposure to air.

When a sterile surface comes in contact with a wet, contaminated surface, the object or field becomes contaminated by capillary action.

Always hold your hands above the level of your elbows.

The edges of a sterile field or container are considered contaminated.

TYPES OF PAIN

Superficial

Arises from local tissues

Usually related to a nerve ending disturbance

Localized; usually described as constant, sharp, tingling or throbbing

Visceral

Arises from somatic structures

Deep pain; may be dull or aching

Referred - Pain felt in another area separate from source of pain

Central

Caused by injury to central nervous system

Very intense pain; burning

CLASSIFICATIONS OF SURGICAL WOUNDS RELATIVE TO RISK OF INFECTION

The higher the class, the higher the risk: a class IV wound carries much more risk than a class I.

Class I (clean wound)

No break in sterile technique

No inflammation encountered

GI, Respiratory or GU tract not entered

Class II (clean-contaminated wound)

GI, GU or respiratory tract entered with no spillage of contents

Minor breaks in technique

Operations involving the biliary tract, appendix, vagina, and oropharynx

Class III (contaminated wound)

Acute inflammation without pus

Spillage from a hollow viscus occurs

Trauma from a clean source

Class IV (dirty)

Pus or a perforated viscus

Trauma from a dirty source

Organism causing infection present before surgery

Surgical variables that increase risk of infection

Prolonged preoperative hospital stay

Body location of surgery

Surgical technique: delayed wound closure, excess blood loss, presence of drain, improper suture tension

Presence of bacteria at closure

HIGH RISK GROUPS FOR POST-OP INFECTIONS

Impaired immunologic system

Extremes of age

Diabetes mellitus

Corticosteroid therapy

Chemotherapy

Infection elsewhere in the body

Malnutrition

Presence of staphylococcus aureus on client

Contaminated environment where injury or trauma occurred