Pre-operative and Post-operative nursing management for Septoplasty and FESS

Septoplasty

is a corrective surgical procedure done to straighten the nasal septum, the partition between the two nasal cavities. Ideally, the septum should run down the center of the nose. When it deviates into one of the cavities, it narrows that cavity and impedes airflow. Often the inferior turbinate on the opposite side enlarges, which is termed compensatory hypertrophy. Deviations of the septum can lead to nasal obstruction. Most surgeries are completed in 60 minutes or less, not including recovery time.

Septoplasty

is a reconstructive plastic surgery procedure and is carried out under anaesthesia.

The surgery typically takes around 90 minutes and involves the surgeon making an incision in the septum lining to access the cartilage. Excess cartilage is then removed, and the surgeon may fix the septum in a central position with sutures.

Following septoplasty, the nasal cavities may be irrigated or packed, with gauze fixed beneath to collect blood. The excess bleeding typically stops after one to two days.

FESS• is the mainstay in the surgical treatment of sinusitis and nasal polyps,

including bacterial, fungal, recurrent acute, and chronic sinus problems. Ample research supports its record of safety and success.

• FESS is a relatively recent surgical procedure that uses nasal endoscopes (using Hopkins rod lens technology) through the nostrils to avoid cutting the skin. These endoscopes have diameters of 4mm (adult use) and 2.7mm (pediatric use) and come in varying angles of view from 0 degrees to 30, 45, 70, 90, and 120 degrees. They provide good illumination of the inside of the nasal cavity and sinuses.

• FESS came into existence because of pioneering work of Messerklinger and Stamberger (Graz, Austria.) Other surgeons have made additional contributions (first published in USA by Kennedy in 1985).[1]

• Preoperative Phase: The period of time from when decision for surgical intervention is made to when the patient is transferred to the operating room table.

• Postoperative Phase: Period of time that begins with the admission of the patient to the post anesthesia care unit and ends after follow-up evaluation in the clinical setting or home.

Pre-operative procedures

• The patient should not eat or drink for 6-8 hours before the surgery.

It is advisable to inform and check with the doctor about any regular medication being taken, if necessary they should be taken with a minimal sip of water. (No Juice or other liquids).

•Patient has to make sure that they do not take any medications containing Aspirin at least 5-7 days before the surgery.

If the patient is a smoker then he should stop smoking from the time the surgery has been decided. Smoke irritates the nasal passages and causes coughing that might result in bleeding for several days after the operation. It is also a contraindication for undergoing the surgery with General Anaesthesia.

• Routine tests done before the surgeries are

1. Blood tests2. X-Ray Chest (very important if patient over 45 yrs, smoker, or history of heart/lung disease)3. ECG

The patient is given a consent form, which would explain the procedure, the medication given and the risks involved.

Dentures, rings, chains, or any metal objects on the body should be removed and given to the relative or attendants.

If an over night stay is required in the hospital then the patient should take clothes for changing and toilet items.

If there are any allergies to drugs like penicillin, sulpha or any other drugs it must be informed to the doctor.

PREOPERATIVE PHASE

• The rendering of nursing care to the surgical client as soon as he is admitted & the decision to undergo surgery is made.

• It ends on the time the client is transferred to the O.R.

NURSING ACTIVITIES:

• Assessment of the client (baseline evaluation of the pt. before the day of surgery-interview)

• Identification of potential/actual health problems.

• PREADMISSION TESTING- ensure necessary tests have been performed

• Pre-op teaching involving client & support persons.

• Day of surgery :• patient teaching reviewed• informed consent confirmed• Patient’s identity & surgical site verified• IVF started.

PREPARATION FOR SURGERY

• Psychological Support :a) Assess client’s fears, anxieties, support

systems &patterns of coping.b) Establish trusting relationship with client &significant others.c) Explain routine procedures, encourage verbalization of fears & allow client to ask questions.

• d) Demonstrate confidence in surgeon & staff.

• e) Provide for spiritual care if appropriate.

PREOPERATIVE TEACHING

Frequently done on an outpatient basis.

• Assess client’s level of understanding of surgical procedure & its implications.

• Answer questions, clarify & reinforce explanations given by the surgeon.

• Explain routine pre-& post-op procedures & any special equipment to be used.

PREOPERATIVE TEACHING

• Preoperative experience• Preoperative medication• Breathing exercises, coughing, incentive spirometer• Leg exercises• Position changes and movement• Pain management• Reducing anxiety and fear, support of coping• Special considerations related to outpatient surgery

Preoperative Nursing Interventions

PHYSICAL PREPARATIONS:• Patient safety is a primary concern.• Obtain history of past medical conditions,

surgical procedures, dietary restrictions & medications.

• Perform baseline head-to-toe assessment, including VS, height & weight.

• Ensure that diagnostic procedures pertinent to surgery are performed as ordered

• 1 CBC• 2. Electrolytes• 3. PT/PTT (Prothrombin

Time;Partialthromboplastin time)• 4. Urinalysis• 5. ECG• 6.Blood typing & crossmatch

• NPO - to prevent aspiration• Bowel prep and skin prep- cleansing enema or laxative before surgery to allow satisfactory visualization of the surgical site.- goal of pre-op skin prep is to decrease bacteri awithout injuring the skin.

Immediate preoperative preparation

• Complete checklist and chart• Hospital gown, voiding, removal of dentures,

jewelry,contacts, etc.• Preoperative medication• Transporting the pt. to the Presurgical area about

30to 60 minutes before anesthetics is to be given.• Attend to family needs

LEGAL PREPARATION:

• Surgeon obtains operative permit (informed consent)

1. Surgical procedures, alternatives , possible complications & disfigurements or removal of body parts are explained.• 2. It is part of the nurse’s role as client

advocate to confirm that the client understands the information given.

INFORMED CONSENT

is necessary in the following circumstances:• Invasive procedures, such as

surgical incisions, biopsy, cystoscopy or paracentesis.

• Procedures requiring sedation or anesthesia• A non-surgical procedure, such as

arteriography• Procedures involving radiation

• Adult client (over18 y/o) signs own permit unless unconcious or mentally incompetent.

1. If unable to sign, relative (spouse or next of kin) or guardian will sign.2. In an emergency, permission via telephone or telegram is acceptable; have a 2nd• listener on phone when telephone

permission is given

3. Consents are not needed for emergency care if all 4 of the ff. criteria are met:a. There is an immediate threat to life.b. Experts agree that it is an emergency.c. Client is unable to consent.d. A legally authorized person cannot be reached.

• Minors (under 18 y/o) must have consent signed by an adult (i.e. Parent or legal guardian)

• Emancipated minor (married or independently earning his or her own living)may sign his/ her own consent.

• Witness to informed consent may be a nurse, another M.D., clerk or any other authorized person.

• The nurse witnessing informed consent, specifieswhether witnessing explanation of surgery or justsignature of the client.

PREOPERATIVE MEDICATIONS

PURPOSES:• 1. To relieve fear & anxiety.• 2. To reduce dose needed for induction &

maintenance of anesthesia.• 3. To prevent reflex bradycardiathat

happensduring induction of anesthesia.• 4. To minimize oral secretions.

Post-operative nursing interventions

• Begins with the admission of the client to PACU &ends with discharge of client from hospital orfacility providing continuity of care.

Nursing Management in the PACU

• Provide care for the patient until he/she has recovered from the effects of anesthesia.

• Patient has resumption of motor and sensory function, is oriented, has stable VS, and shows no evidence of hemorrhage or other complications of surgery.

• Frequent skilled assessment of the patient is vital

• Vital signs every 30 minutes for 1st 6 hours then after every hour

• Changing of external pack/moustache dressing every 3 hours or as needed

• Keep the patient in fowlers position 30-45 degrees to reduce bleeding

• Start mobilization after 4 hours• Advised the patient not to blow his/her nose

for 10 days

Responsibilities of the PACU Nurse

• Review pertinent information and baseline assessment upon admission to the unit.

• Assessments include airway and respirations, cardiovascular function, surgical site, function of the central nervous system; also assess IVs and all tubes and equipment.

• Reassess VS and patient status every 15 minutes or more frequently as needed.

• Provide report and transfer the patient to another unit or discharge the patient to home.

Outpatient Surgery/Direct Discharge

Discharge planning and discharge assessment

• Provide written and verbal instructions regardingfollow

• up care, complications, wound care, activity,medications, and diet.

• Give prescriptions and phone numbers. Discuss actions totake if complications occur.

• Give instructions to the patient and a responsible adult who will accompany the patient.

• Patients are not to drive home or be discharged to home alone. Sedation and anesthesia may cloud memory and judgment and affect ability