Preoperative and Postoperative Care Seminar

7/30/2019 Preoperative and Postoperative Care Seminar

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Introduction

Surgery can be defined as the art and science of treating diseases,injuries and deformities by

operation and instrumentation. The surgical procedure involves the interaction of the

patient,surgeon, and nurse. Surgery may be performed for any of the following purposes:

1. Diagnosis-determination of the presence and/or extent of pathology(e.g.,lymph node biopsy

or bronchoscopy)

2. Cure-elinination or repair of pathology (e.g,removal of the ruptured appendix or begnign

ovarian cyst)

3. Palliation-alleviation of symptoms without cure(e.g. cutting a nerve root {rhizotomy }to

remove symptoms of pain,or creating a colostomy to bypass an inoperable bowel

obstruction)

4. Prevention-examples include removal of a mole before it becomes malignant or removal ofthe colon in a patient with familial polyposis to prevent cancer.

5.Exploration-surgical examination to determine the nature or extent of a disease(e.g.laparotomy).

Cosmetic improvement-examples include repairing a burn scar or changing breast Surgery can be

defined as the art and science of treating diseases,injuries and deformities by operation and

instrumentation. The surgical procedure involves the interaction of the patient,surgeon, and nurse.

Surgery may be performed for any of the following purposes:

1. Diagnosis-determination of the presence and/or extent of pathology(e.g.,lymph node biopsy

or bronchoscopy)2. Cure-elinination or repair of pathology (e.g,removal of the ruptured appendix or begnign

ovarian cyst)

3. Palliation-alleviation of symptoms without cure(e.g. cutting a nerve root {rhizotomy }to

remove symptoms of pain,or creating a colostomy to bypass an inoperable bowel

obstruction)

4. Prevention-examples include removal of a mole before it becomes malignant or removal of

the colon in a patient with familial polyposis to prevent cancer.

5. Exploration-surgical examination to determine the nature or extent of a

disease(e.g.laparotomy).

6. Cosmetic shape.

Having surgery is a major event in any personslife. Clients faced with surgery want to

know that someone is there with them and will look out for them durig a time when they

may have no control or self-protective abilities. The perioperative nurse is the memberof the

surgical team to whom clients are most likely to look for advocacy.

Perioperative Nursingused to describe the nursing are provided in the total surgical

experience of the patient: preoperative, intraoperative and postoperative.


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Preoperative Phase, extends from the time the client is admitted in the surgical unit, to the time

he/she is prepared for the surgical procedure, until he is transported into the operating room.

I ntraoperative Phase, extends from the time the client is admitted to the OR, to the time of

administration of anesthesia, surgical procedure is done, until he/she is transported to theRR/PACU.

Postoperative Phase, extends from the time the client is the recovery room, to the time he is

transported back into the surgical unit, discharged from the hospital, until the follow-up care.

perioperative

intraoperative

perioperative

postoperative


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Basic concepts of perioperative nursing:

Nursing care of the perioperative client takes place immediately before, during, and

immediately after a surgical procedure.the goals of perioperative nursing practice are

To assist clients and their significant others through the surgical episode

To help promote positive outcomes

To help clients achieve their optimal level of function and wellness after surgery

Perioperative nursing-

The total surgical episode is called the perioperative period. This period in the health care

continuum includes the time before surgery, or the preoperative period, the time spentduring the actual surgical procedure, or intraoperative period , and the period after the

surgery is completed, or postoperative period.

A perioperative nurse is a registered nurse who uses the nursing process to design,plan, and

deliver care to meet the identified needs of a client whose protective reflexes or self-care

abilities are potentially compromised because of the operative procedures to be performed.

The professional practice of perioperative nursing is a based on the patient-focused model,which

consists of four domains-

Patient safety

Health system

Physiologic and behavioral responses

Perioperative nursing practice is directed toward helping patient and their families achieve a

level of wellness equal to or greater than threat which they had before the surgical or

invasive procedure.


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Definition-

Preoperative period-

period of time from when the decision for surgical intervention is made to when the patient is

made to when the patient is transferred to the operating room table.(Brunner and Suddarths)

Preoperative Period begins when the decision for surgical intervention is made.the scope of

nursing activities includes preoperative assessment of the patients physical,psycho logic, and

social states, and the implementation of nursing interventions. This phase ends when the patient is

safely transported to the operating room(OR) and transferred to the OR nurse for care.(Phipps)

Preoperative care:Goals

Assessing and correcting physiologic and psycho logic problems that may increase surgicalrisk.

Giving the person and significant others complete learning / teaching regarding surgery.

Instructing and demonstrating exercises that will benefits the person during post operativeperiod.

Planning for discharge and any projected changes in lifestyle due to surgery.

The scope of nursing activities during this time can include establishing a baseline evaluation of

the patient before the day of surgery by carrying out a preoperative interview(which includes not

only a physical but also an emotional assessment, previous anesthetic history, and identification of

known allergies or genetic problems that may affect the surgical outcome),ensuring that necessary

tests have been or will be performed(preadmission testing),arranging appropriate consultative

services, and providing preparatory education about recovery from anesthesia and postoperative

care. on the day of surgery, patient teaching is reviewed, thepatients identity and the surgical site

are verified, informed consent is confirmed, and an intravenous infusion is started. If the patient is

going home the same day, the availability of safe transport and the presence of an accompanying

responsible adult is verified. Depending on when the preadmission evaluation and testing were

done, the nursing actives on the day of surgery may be as basic as performing or updating the

preoperative patient assessment and addressing questions the patent or family may have.

Preoperative assessment-

Preoperative Assessment is the clinical investigation that precedes anaesthesia for surgical or non-

surgical procedures, and is the responsibility of the anaesthetist. The aims of preoperative

assessment are to reduce the risks associated with surgery and anaesthesia, to increase the quality

(thus decreasing the cost) of perioperative care, to restore the patient to the desired level of

function, and to obtain the patients informed consent for the anaesthetic procedure.


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Assessment is the first step in the nursing process and is designed to provide information that

enables the nurse and the client to plan for optimal postoperative outcomes. Preoperative

assessment includes the medical/health history , the psychosocial history, physical examination,

cognitive assessment and diagnostic testing.

I. REVIEW OF MEDICAL/HEALTH HISTORY BEFORE SURGERY-

obtaining a health history allows clients to explain their understanding of impending

surgery and to establish rapport with the nurse conducting the interview.

Reassurance by the nurse through this process may reduce anxiety in the client and

family members or significant others. the purpose of reviewing the past medical

history is to determine operative risk.

Previous Surgery And Experience With Anesthesia.

any untoward reactions to anesthesia (e.g high fever, intraoperative death of family

members, known malignant hyperthermia, prolonged nausea and vomiting)by the client or

anyone in the family must be reported to anesthesia personnel.these problems do not

preclude surgery but often require a change in the type of anesthetics used.

serious illness or trauma-

this information should cover anything that might influence the surgery and

recovery. an ABCDE mnemonic is often used to ascertain information:

A-Allergy to medications, chemicals, and other environmental products such as

latex.

All allergies are reported to anesthesia and surgical personnel before the beginning

of surgery. if allergies exists, an allergy band must be placed on the clients arm immediately.

B- Bleeding tendencies or the use of medications that deter clotting, such as aspirin, heparin, or

warfarin sodium.

C-Cortisone or steroid use.

D-Diabetes Mellitus, a condition that not only requires strict control of blood glucose levels but

is also known to delay wound healing.

E-Emboli; previous embolic events (such as lower leg blood clots)may recur because of

prolonged immobility.

Alcohol, Recreational Drug Or Nicotine Use-

The Use of drugs signals a potential problem with the administration of anesthesia or analgesia

and risk for withdrawal complications. Clients who use alcohol or drugs may experience

withdrawal manifestations while the drugs are withdrawn during the postoperative course.


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the abuse of tobacco or inhaled drugs reduces hemoglobin levels, making less oxygen available

for tissue repair. smokers may be more susceptible to thrombus(clot)formation because of the

hypercoagulability secondary to nicotine use. Clients are instructed to abstain from any

nicotine product for at least 1 week before surgery.

Current Discomforts-

Clients with pre-existing painful conditions may require alternate methods of pain reduction

while they are receiving nothing by mouth (NPO).

Clients who drink a considerable amount of caffeinated beverages such as coffee often

develop headaches related to their NPO status, when their caffeine intake ceases abruptly.

Without appropriate preoperative assessment, the headache may be misinterpreted as a surgical

problem.

Chronic Illnesses-

Arthritis of the neck or back is considered in positioning the client during surgery or in

extending the neck during intubation.

Advanced Age-

Older clients have specific perioperative needs that should be identified preoperatively and

considered in developing and maintaining a plan of care.

Medication History-

Many clients take prescription and over-the-counter(OTC)drugs that may increase operative risks.

ask the client whether these have been brought to the hospital. Dosage and administration schedules

for all medications should be noted on the chart. It is especially important to consider the effects of

drugs used for heart disease, hypertension, immune suppression , seizure control, anticoagulation,

and endocrine replacement. for examples, antihypertensive drugs may predispose the patient to

shock from the combined effect of the drug and the vasodilator effect of some anesthetic agents.

Use in common in many people ,but it inhibits platelet aggregation and may contribute to

postoperative bleeding complications. Surgeons often require that patients not tale any aspirin for at

least 2 weeks before surgery.

Psychological History-

Knowledge of cultural beliefs and practices is an important component of holistic nursing care.

Some cultures practice traditional health care as well as alternative and complementary practices that

may include use of candles, rituals and herbs.

Certain rituals are important to the client and should be respected by all members of the health care

team. For example, in some cultures, the family makes decisions regarding health care as a unit.


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In other cultures, the oldest woman makes all medical decisions. The nurse must be accepting of

each individuals beliefs and should play an active advocate role by supporting the client in any

manner possible.

Ability To Tolerate Perioperative Stress-

Physiologic stressors in the perioperative client include pain, tissue damage, blood loss, anesthesia,

fever, and immobilization.

The stressful stimuli imposed by surgery promote the physiologic stress response by combining

both psychological factors(such as anxiety and fear of the unknown)and physiologic

factors(including blood loss, anesthesia, pain and immobility).

The sympathetic nervous system is activated by any stressor. A persons age, physical condition,

and duration of the stress determine the success of the stress response in maintaining homeostaticbalance.

The nurse must be able to assess stress and plan and implement appropriate interventions to reduce

or treat complications related to stress in an effective manner.

Lifestyle Habits-

Sedentary lifestyles can complicate the surgical course because of poor muscle tone, limited cardiac

and respiratory reserves, and decreased stress response.

Social History-

An important component of a social history on a preoperative client is the support system.

identification of client occupation and physical and mental requirements for job performance also

provides important information that may prove useful for care planning.

II. PHYSICAL EXAMINATION-

A physical examination is performed on all persons undergoing surgery to identify the present

health status and to have baseline information for comparisons during and after surgery. These data

are used to determine nursing diagnoses or to identify problems and to develop pertinent outcomes

goals.

First, examine the part of the body that will be operated on first. next, complete a general systems

assessment. Systems to be assessed include cardiovascular, pulmonary, renal, musculoskeletal, skin,

and neurologic. Ask the client whether there are any particularly troublesome manifestations, and

include this information in the written assessment for further investigation.

Specific Body System Assessments-

Cardiovascular Assessment-


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Pathologic cardiac conditions or events that increase operative risk include angina pectoris,

the occurrence of Angina Pectoris,the occurrence of a myocardial infarction within the last 6

months, uncontrolled hypertension , Heart failure, and peripheral vascular disease. All the

cardiac conditions can lead to decreased tissue perfusion with impairment of surgical woundhealing.

Document shortness of breath on minor exertion, hypertension, heart murmurs or s3 gallops,

and chest pain. These manifestation may be present if the client is scheduled for heart or

vascular surgery, but they may make the ability to tolerate anesthesia and blood loss

questionable.

laboratory studies is measure the function of the cardiovascular system include an

electrocardiogram(ECG),especially for clients over 40 years of age,and determinations of

hemoglobin, hematocrit, and serum electrolytes.

Respiratory Assessment

Chronic lung conditions, such as emphysema, asthma, and bronchitis, increase operative

risk because these disorders impair gas exchange in the alveoli, predisposing the client to

postoperative pulmonary complications.

Assessment of pulmonary conditions includes examining for the presence of shortness of

breath, wheezing, clubbed fingers, chest pain, cyanosis, and coughing with expectoration of

copious or purulent mucus.

If client demonstrates any respiratory distress at the time of the assessment, notify the

surgeon before anesthesia is administered. Clients with severe respiratory disease are

usually managed preoperatively with aerosol therapy, postural drainage, and antibiotics.

Clients who smoke a strongly encouraged to stop smoking as early as possible before

surgery.

Laboratory studies performed before surgery to diagnose respiratory conditions include

chest radiography and pulse oximetry. Chest radiography(or x-rays) detects abnormalities, if

present, in the lungs, such as infections, collapsed alveoli or segments of the lung, tumors

fractures of the ribs and size of the heart.

Assess the presence of sleep apnea. If present, alert the surgery team and document it ,

including determination of whether the client uses an apnea assistance respiratory device athome and whether it will be continued postoperatively during hospitalization.

Musculoskeletal System-

A history of arthritis, fractures, contractures, joint injury, or musculoskeletal impairment is

an important factor in surgical positioning and postoperative support. The physical

examination should reveal any problems with operative positioning as well as with the

postoperative course.


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For example, if the preoperative assessment identifies arthritis of the neck and shoulder, the

circulating nurse can incorporate this information into the care plan. Hyperextension of the

arthritic neck during intubation for general anesthesia can cause postoperative pain and

discomfort unrelated to the surgery. The musculoskeletal system can be assessed through passive and active range of motion and

a history provided by the client, a family member, or the medical record. documentation of

impairment before the surgical procedure assists in the investigation of any impairment

postoperatively.

Gastrointestinal Assessment-

Gastrointestinal condition associated with poor surgical outcomes include severe

malnutrition and prolonged nausea and vomiting. The clients gastrointestinal system should

be assessed if the planned operation is in the abdominal area or if the general physical

examination reveals any abnormal data.

Because Opioid analgesics increase constipation, information about normal bowel patterns

can help to ensure that postoperative expectations for return of function are appropriate. A

client with a long history of constipation may have more difficulty postoperatively than that

experienced by a client with regular bowel function.

Skin Integrity Assessment-

Skin integrity must be assessed and documented preoperatively to establish a baseline forcomparison postoperatively. The operative site must be clear of any rashes, blisters, or

infectious processes.

Document and report lesions, pressure ulcers, necrotic skin tissue, skin turgor, or

discoloration of the skin, and the presence of external devices.

Note the size, color, and location of the skin impairment to determine whether the impaired

skin remains stable or worsens during and after the surgical procedure.

Tattoos and body piercing should also be noted. Incisions can be made through

tattoos, but the design may be altered afterward. Piercings may need to be removed, based on

the surgeons preference.

Renal Assessment-

Adequate renal function is necessary to eliminate protein wastes, to preserve fluid and

electrolyte balance, and to remove anesthetic agents. Important renal and related disorders

include advanced renal insufficiency, acute nephritis and benign prostatic hypertrophy.

Monitor fluid balance by recording intake and output throughout the surgical continuum.

The most common preoperative tests to assess renal function are determination of blood

urea nitrogen(BUN) and serum creatinine and urinalysis. BUN and serum creatinine levels


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indicate the ability of the kidney to excrete urea and protein wastes. Elevated levels may reflect

dehydration, impaired output, or renal failure.

Liver Function Assessment- Liver disease such as cirrhosis increases a clients surgical risk because an impaired liver cannot

detoxify medications and anesthetic agents.

Liver disease may be manifested by decreased albumin levels, leading to decreased

immunoglobulin and fibrinogen levels. Low albumin levels predispose the client to fluid shifts,

surgical wound infection, and effective coagulation.

Clients with a history of alcoholism or other substance abuse require a careful assessment of

liver function before surgery. Because a client with liver disease is often malnourished and

debilitated and may have clotting disorders, the surgeon generally orders a high-calorie diet or

hyper alimentation during the preoperative and postoperative periods and corrects clottingabnormalities.

Cognitive and Neurologic assessment-

Serious neurologic conditions, such as uncontrolled epilepsy or severe Parkinsons disease,

increase surgical risk.

Important preoperative neurologic abnormalities include severe headache, frequent dizziness,

light-headedness, ringing in the ears, unsteady gait ,unequal pupils, and a history of seizures.

Assessment of the clients orientation to time, place, and person can be accomplished by simple

questioning. To determine baseline neurologic function, include testing of cranial nerves, reflex

responses of the upper and lower extremities, sensory reflexes, and cerebral responses.

Endocrine Assessment-

Diabetes mellitus is the most common pre-existing endocrine path physiologic disorder. diabetes

mellitus predisposes the affected client to poor wound healing and increased risk of surgical wound

infection.

Thyroid functioning may also need to be assessed preoperatively. Thyroid hormone replacement

is usually continued throughout the perioperative period. Stopping thyroid medications may

precipitate hypothyroidism, with manifestations of hypotension, bradycardia, and hypothermia.

Additional Assessments-

Other factors that may be considered during the planning of surgical intervention include

a. age

b. nutritional


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c. fluid and electrolyte balance

d. infection ,and

e. hematologic condition

a. Age-

Normal physiologic changes that occur with aging, along with the increased presence of disease,

may adversely affect surgical outcomes. Chronic conditions commonly found in the older client that

may increase surgical risk include malnutrition, anemia ,dehydration, atherosclerosis, chronic

obstructive pulmonary disease(COPD),diabetes mellitus, cerebrovascular changes, and peripheral

vascular disease.

b.Pain-

Pain is an important physiologic indicator that must be carefully monitored.During the preoperative

nursing assessment, ask if the client is experiencing any pain. If pain is present, obtain a full

assessment of the pain.

Determine whether the pain is chronic and unrelated to the pathologic condition necessitating

surgery or whether it is acte and attributable to the need for the surgical procedure.

Be aware that although most operations increase p0ain, older adults who have undergone joint

replacement surgery often state that the postoperative pain is monor compared with the chronic pain

of a disintegrating joint.

c.Nutritional status-

Nutritional status(positive nitrogen balance) is directly related to intraoperative success and

postoperative recovery. The client who is well nourished preoperatively is better prepare to handle

surgical stress and to return to optimal health after surgery.

Improving nutrition is usually attended to in a clinic or physicians office weeks before surgery.

Assessment of nutritional status preoperatively includes obtaining a diet history, observing the

clients general appearance and laboratory diagnostic testing, and comparing current weight with

ideal body weight.

Protein-calorie malnutrition leads to delayed recovery, infection, and slow wound healing. Obesity

is also associated with poorer surgical outcomes. Adipose (fatty) tissue is less vascular and more

prone to postoperative infection, incisional hernias, and wound dehiscence or evisceration. The

surgeon may use and alternative closure method for a client with excess adipose tissue at or around

the incision.

Obesity decreases the efficiency of coughing and deep breathing. The pressure of the abdominal

contents on the diaphragm and lungs decreases expansion, which may lead to hypoventilation. An

obese client is more prone to postoperative immobility, which increases the risk of venous stasis

and deep vein thrombosis or pulmonary embolism.

d.Fluid And Electrolyte Balance-


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Fluid volume deficits(dehydration/hypovolemia or fluid volume excess/hypervolemia) predispose

a client to complications during and after surgery. Actual or potential fluid imbalance can be

assessed by evaluation of skin turgor. A coated tongue can also be a manifestation of fluid volume

deficit. A decrease in urine output or specific gravity is also diagnostic of decreased fluid volume.

Dehydration results from limited fluid intake, prolonged vomiting, diarrhea, or bleeding. Fluids

can be administered intravenously if dehydration is identified.

Electrolyte imbalances also increase operative risk. Preoperative laboratory results should be

checked to determine whether serum sodium, potassium, calcium, and magnesium concentrations

are within the normal range.

e. Infection and Immunity-

Any pre-existing infection can adversely affect surgical outcomes because bacteria may be released

into the bloodstream during surgery. Their release may lead to infection elsewhere in the body.

When the surgical site is near a lymph node or lymphatic vessel that is draining infectious material,

the likelihood of surgical infection increases.

An elevated white blood cell(WBC)count also suggests an infection and should be communicated

immediately to the surgical team. Because infection greatly increases surgical risk, it may be

necessary to reschedule elective surgery.

Steroid use also decreases the clients ability to fight infection; therefore the client taking steroids

should be assessed and monitored for immunosuppression.

f. Hematologic Function- Clients with blood coagulation disorders are at risk for hemorrhage and hypovolemic shock during

and after surgery. The following five factors should be assessed preoperatively to identify potential

hematologic problems:

A history of bleeding or a diagnosis of a pathologic condition such as hemophilia or

sickle cell anemia

Manifestations such as easy bruising, excessive bleeding following dental

extractions and razor nicks, and severe nosebleeds

Hepatic or renal disease

Use of anticoagulants, aspirin, or other non-steroidal anti-inflammatorydrug(NSAIDs)

Abnormal bleeding time, prothrombin time, or platelet count

III. ESTIMATING MEDICAL RISK FOR SURGERY-

Each surgeon determines the relative risk versus benefit from the operation for the specific client.

The surgeon presents a frank but optimistic discussion of risks of the procedure. Well-intentioned

friends and family may wish to shield the client from unpleasant facts. Although medical facts

may be unpleasant, it is imperative that the client have full and complete information before

consenting. Some clients (such as those with malnutrition or anemia) benefit from waiting for

surgery.


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The type of surgery to be performed also has some inherent risk. The types of operations by

category are presented in:

CATEGORY PURPOSE EXAMPLES

Aesthetic Improvement of physicalfeatures that are within the

normal range

Breast augmentation

Constructive Repair of a congenitally

defective body part

Cleft palate and cleft lip

repair

Curative Removal or repair of

damaged or diseased tissue

or organ

Hysterectomy

Diagnostic Discovery or confirmation of

a diagnosis

Breast biopsy

Explorative Estimation of the extent of

disease or confirmation of a

diagnosis

Exploratory laparotomy

Emergent Life-saving Repair of traumatic

punctured lung

Palliative Relief of symptoms but

without cure underlying

disease

Colostomy

Reconstructive Partial or complete

restoration of a body part

Total joint replacement

Urgent Performed as soon as clientis stable and infection is

under control

Appendectomy

IV.

IV.ANESTHESIA AND ANESTHETIC RISK-

The anesthesia care provider visits the client before surgery to perform a complete respiratory,cardiovascular, and neurologic examination. The clients general surgical risk(i.e., his or her ability

to withstand the surgery)is expressed according to the American Society Of Anesthesia(ASA)

grading system.

PHYSICAL STATUS CLASSIFICATIONS OF AMERICAN SOCIETY OF

ANESTHESIOLOGISTS:

status definition Description and examples

P1 A normal healthy patient No physiologic, psycho logic,biochemical


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P2 Patient with mild systemic disease Cardiovascular disease with minimal

restriction on activity, hypertension,

asthma, chronic bronchitis, obesity

P3 A patient with severe systemic disease

that limits activity, but is notincapacitating

Cardiovascular or pulmonary disease

that limits activity, severe diabeteswith systemic complication, history of

myocardial infarction, angina pectoris,

or poorly controlled hypertension

P4 A patient with severe systemic disease

that is constant threat to life

Severe cardiac,pulmonary, renal,

hepatic or endocrine dysfunction

P5 A moribund patient who is not expected

to survive 24 hrs or without operation

Surgery done as last recourse or

resuscitative effort, major multisystem

or cerebral trauma, ruptured aneurysm

or large pulmonary embolus

P6 A patient declared brain dead whose

organs are removed for donor purposes

V. ROUTINE PREOPERATIVE LABORATORY AND SCREENING TEST-

Test Rationale

CBC RBC,Hgb,Hct are important to the oxygen

carrying capacity of blood.WBC are

indicator of immune function.

Blood grouping/

X matching

Determined in case blood transfusion is

required during or after surgery.

Serum

Electrolyte

To evaluate fluid and electrolyte status

PT,PTT Measure time required for clotting to occurs

Fasting BloodGlucose

High level may indicate undiagnosed DM

BUN /

Creatinine

Evaluate renal function

ALT/AST/LDH

and Bilirubin

Evaluate liver function

Serum albumin

and total CHON

Evaluate nutritional status

Urinalysis Determine urine composition

Chest X ray Evaluate respiratory status/ heart size


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ECG Identify preexisting cardiac problem.

VI. PSYHCHOLOGICAL ASSESSMENT OR NEEDS(PRE-OPERATIVE ANXIETY AND

FEAR-

All clients are anxious and fearful of surgery. The extent to which a client fears surgery depends on

many factors, such as

1) how serious the operation is,

2) individual coping abilities

3) cultural expectations4) experiences with previous surgery

During the preoperative phase, clients also fear postoperative pain, the discovery of cancer, the loss

of an organ or limb, anesthesia, vulnerability while unconscious, the threat of loss of job or

financial security, loss of social and familial roles, disruption of lifestyle, separation from

significant others, and death.

Anxiety-

Anxiety can arise from lack of knowledge, which may range from not knowing what to expect

during the surgical experience to uncertainty about the outcome of surgery.

The potential of the unknown often contributes to anxiety when the surgery is for diagnostic

purposes. The patient may have totally unrealistic expectations of what surgery will be like, or

what it will accomplish.

This may be a result of past experience or the vicarious experiences provided by friends

stories and the mass media, especially television. The surgeon should be informed if the patient

requires any additional information or if anxiety seems excessive.

Fear-

The fear arises after hearing or reading about the risks during the informed consent process.Others fear are:

Fear of death:

If the nurse identifies a strong death fear, this concern must be communicated to the physician

immediately. A strong fear of impending death may prompt the physician to postpone the surgery

if the patient is convinced that it will lead to death. Attitude and emotional state influence the

stress response, and thus the surgical outcome.

Fear of pain and discomfort:


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If the fear appears extreme, the nurse should notify the anesthesia care provider(ACP) so that an

appropriate preoperative medication can be given. These medications provide an amnesic effect

so that the patient will not remember what occurs during the surgical episode.

Fear of mutilation or alteration in body image:

Whether the surgery is radical, such as amputation, or minor such as a bunion repair. The

presence of even a small scar on the body can be repulsive to some, and others fear keloid

development(overgrowth of a scar). The nurse must listen to and assess the patients concern

about this aspect of surgery with an open, non-judgmental attitude.

Fear of anesthesia :

Many patients fear losing control while under the imfluence of anesthesia. If these fears are

identified, the nurse should inform the ACP immediatelyso that he or she can talk further with

the patient. Some patients will ask the nurse I fit is safer to have general or spinal anesthesia. The

nurse should not recommend one or other, but should reassure the patient that both methods are

equally safe and suggest they talk further with the ACP.

Fear functioning or patterns of disruption of life:

Concerns about separation form family and about how spouse or children are managing are

common. Financial concerns may be related either to an anticipated loss of income or to the costs

of surgery

VII.INFORMED CONSENT-

Informed consent is an active, shared decision-making process between the provider and the

recipient of care. This process protects the patient, the surgeon,and the hospital and its employees.

Purposes:


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To ensure that the client understand the nature of the treatment including thecomplications and disfigurement.

To indicate that the clients decision was made without pressure.

To protect the client against unauthorized procedure. To protect the surgeon and hospital against legal action by a client who claims that an

authorized procedure was performed.

CircumstancesRequiringConsent: Any surgical procedure where scalpel, scissors, suture, hemostats of electrocoagulation may

be used.

Entrance into body cavity. Radiologic procedures, particularly if a contrast material is required.

General anesthesia, local infiltration and regional block.

Essential element of informed consent: The diagnosis and explanation of the condition. A fair explanation of the procedure to be done and the consequences. A description of alternative treatment or procedure. A description of the benefits to be expected. Material rights if any. The prognosis, if the recommended care, procedure is refused.

RequisitesofforValidity InformedConsent

Written permission is best and legally accepted. Signature is obtained with the clients complete Understanding of what to occurs.

- adult sign their own operative permit

- obtained before sedation

For minors, parents or someone standing in their behalf, gives the consent.Note: for a married emancipated minor parent consent is not needed anymore, spouse is

accepted

For mentally ill and unconscious patient, consent must be taken from the parents or legalguardian

If the patient is unable to write, an X is accepted if there is a witness to his mark Secured without pressure and threat

A witness is desirablenurse, physician or authorized persons. When an emergency situation exists, no consent is necessary because inaction at such time

may cause

greater injury. (permission via telephone/cellphone is accepted but must be signed 24hrs.)

VIII.PREOPERATIVE TEACHING-

Information provided to the client before surgery should be geared to individual needs. This

information can be

Sensory Psychosocial


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ProceduralSensory information addresses the sights, sounds, and feel of the operating room.

o Instruct the client that the operating room and skin preparation fluid will be cold but thatwarm blankets are available.

o Clients may be given headphones and can choose from a variety of music types to help themrelax and to reduce external noxious sounds in the operating room environment.

o If the client wears a hearing aid can remain in place during surgery.

Psychosocial information involves coping abilities and worries about family and similar concerns.

Typical questions the client may have include the following:

o What if I die?o Who is going to care for my children?o What if I become an invalid?o Who is going to earn enough money to care for my family?

You can provide answers if this information is available or arrange for others, such as a social

worker or a member of the clergy, to talk to the client.

Procedural information details activities during the preoperative period and postoperative care. It

includes information that the client needs to know and wants to know about is going to happen. If

you find that the client is unclear about what the operation entails, the physician must be notified.

You can elaborate on or clarify information regarding surgery.

The clients role in postoperative care is taught before surgery. The nurse provides instructions on :

1) Incentive Spirometry2) Deep Breathing Exercises

3) Coughing Exercises4) Turning Exercises5) Foot And Leg Exercises6) Ambulating And7) Pain Control

Incentive Spirometry-

Encouraged to use incentive spirometer about 10 to 12 times per hour.

Deep inhalations expand alveoli, which prevents atelectasis and other pulmonary complication.


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There is less pain with inspiratory concentration than with expiratory concentration.

Diaphragmatic breathing

Diaphragmatic breathing refers to a flattening of the dome of the diaphragm as you inhale; yourupper abdomen enlarges as air rushes in. During expiration, your abdominal

muscles contract.

Practice in the same position youd assume in bed after surgery:

A semi-Fowlers position, propped in bed with the back andshoulders well supported with pillows.

With your hands in a loosefist position, let them restlightly on the front of your lower ribs, with your fingertips

against your lower chest to feel the movement.

Breathe out gently and fully as your ribs sink downand inward toward the center of your chest.

Then take a deep breath through your nose and mouth,letting your abdomen rise as your lungs fill with air.

Hold this breath for a count of five.

Exhale and let out allthe air through your nose and mouth.

Repeat this exercise 15 times with a short rest after eachgroup of five.

Practice this twice a day preoperative

CoughingLean forward slightly from a sitting position in bed, lacing your fingers together, and putting your

hands across the incisional site to act as a splintlike support when coughing andpromotes

removal of chest secretions

Breathe with the diaphragm as described on the previous page.

With your mouth slightly open, breathe in fully. Hack out sharply for three short breaths.


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Then, keeping your mouth open, take in a quick deep breath and immediately give a strongcough once or twice. This helps clear secretions from your chest. It may cause some discomfort

but wont harm yourincision.

Leg And Foot Exercises

Lie in a semi-Fowlers position and perform the following simple exercises to improve circulation.

Bend your knee and raise your foothold it a few seconds, then extend your leg and lower it tothe bed.

Do this five times with one leg, then repeat with the other leg.

.

Then trace circles with your feet by bending them down, in toward each other, up, andthen out

Repeat these movements fiveMoving the legs improves circulation and muscletone.

Have the patient lie supine, instruct patient to bend a knee and raise the foot hold it a few

seconds and lower it to the bed.

Repeat above about 5 times with one leg and then with the other. Repeat the set 5 times every

3-5 hours.

Then have the patient lie on one side and exercise the legs by pretending to pedal a bicycle.For foot exercise, trace a complete circle with the great toe.


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.

Postoperative extremity exercise helps to prevent circulatory problems, such as thrombophebitis, by

facilitating venous return to the heart. The client is taught to flex and extend each joint, particularly

the hip, knee, and ankle-joints, while lying supine; the lower back is kept flat as the leg is lowered

and straightened.

Turning Excercise

Preoperative clients also need to practice turning from side to side, using the bedside rails to

assist movements.

Turning helps to prevent venous stasis, thrombophlebitis, pressure ulcer formation, and

respiratory complications.


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The client should be instructed to turn and reposition in bed every 1 to 2 hours during the

postoperative period.

Ambulation-

Ambulation should be encouraged whenever appropriate because it helps to preventmany post complications.

Clients are taught an appropriate ambulation schedule preoperatively so that they have an

idea of when they are allowed to get out of bed after an idea of when they are allowed to getout bed after surgery.

.

Teach the client to use the same splinting method for providing support to the incision that isused during coughing and deep breathing exercises to decrease pain on arising and sitting.


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Teaching of proper methods of arising from bed to prevent pain and to minimize orthostatichypotension is important

Pain Control-

Preoperatively, teaching the client how to communicate their level of pain to the caregiver. For,example, they can rate the intensity of a scale from 1 to 10, with 1 being no pain to 10 being the

most severe possible.


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Explain the type of pain relief or reduction that will be used postoperatively. For example, somesurgeons inject the surgical site with a long-acting local anesthetic before closing the wound sothat the client will not feel any pain in the site until the medication wear off.

Because the stress of surgery or side effects of anesthesia can effect memory temporarily, giveinstructions about taking the postoperative pain medication before surgery to both the client and

accompanying family members.

If the client is to be hospitalized after surgery, explain the type of pain medication used. Duringthe immediate postoperative period, clients can receive medications orally, intravenously,

intramuscularly or epidurally.

Explain patient about cycle of pain to relieve anxiety.


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possibility of aspiration of gastric contents, which may lead to pneumonia. Therefore clients

are assigned NPO status after midnight the night before surgery is scheduled.

ASA (American Society of Anesthesiologists) Guidelines for Preoperative Fasting

Liquid

Liquid and Food Intake Minimum Fasting Period

Clear Liquids 2

Breast Milk 4

Nonhuman Milk 6

Light Meal 6

Regular / Heavy Meals 8

Preparing for Anesthesia

- Avoid alcohol and cigarette smoking for at least 24hours before surgery. Promoting rest and sleep

- Administer sedatives as ordered

Preparing the Person on the Day Of Surgery

Early A.M Care

Awaken 1 hour before preoperative medications

Morning bath, mouth wash Provide clean gown

Remove hairpins, braid long hair, cover hair with cap

if available.

Remove dentures, colored nail polish, hearing aid,

contact lenses, jewelries.

Take baseline vital sign before preoperative medication

Check ID band, skin prep Check for special ordersenema, IV line Check NPO Have client void before preoperative medication Continue to support emotionally Accomplished preoperative care checklist

Preoperative Medication

Goals:

To aid in the administration of an anesthetics.

To minimize respiratory tract secretion and changes

in heart rate. To relax the patient and reduce anxiety.


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Prevent nausea and vomiting.

Commonly used Preoperative Meds.Tranquilizers & Sedatives

* Midazolam

* Diazepam (Valium )

* Lorazepam ( Ativan ) Reduce anxiety and induces sleep

* Diphenhydramine

Analgesics

* Nalbuphine ( Nubain ) Relieve pain

Anticholinergics

* Atropine Sulfate Control secretions

Proton Pump Inhibitors

* Omeprazole ( Losec ) Inhibits gastric acid production

* Famotidine

Pre-Operative Check List


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post-operative care


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Definition-

Postoperative period is period of time that begin with the admission of the patient to the PACU

and ends after a follow-up evaluation in the clinical setting or home setting.(Brunner and

Suddarths)

Postoperative period begin immediately after surgery and continues until the patient is discharged

from medical care.(Lewis)

The Post Anesthesia Care Unit

The Post Anesthesia Care Unit(PACU)also called the Post Anesthesia Recovery Room, is

located adjacent to the operating rooms. Patients still under anesthesia or recovering from

anesthesia are placed in this unit for easy access to experienced, highly skilled nurses,

anesthesiologists or anesthetist, surgeons, advanced hemodynamic and pulmonary monitoringand support, special equipment, and medications.

The PACU is kept quiet, clean, and free of unnecessary equipment. This area is painted in soft,

pleasing colors and has indirect lighting, a soundproof ceiling, equipment that controls or

eliminates noise(eg, plastic emesis basins, rubber bumpers on beds and tables) and isolated but

visible quarters for disruptive patients.

The PACU should also be well ventilated. These features benefit the patient by helping to

decrease anxiety and promote comfort. The PACU bed provides easy access to the patient, is

safe and easily movable, can be readily placed in position to facilitate use of measures to

counteract shock, and has features that facilitate care, such as intravenous(IV) poles, side rails,

wheel brakes, and chart storage rack.


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Goals:

Maintain adequate body system functions

Restore homeostasis

Alleviate pain and discomfort

Prevent postoperative complication

Ensure adequate discharge planning and teaching

Phases of Postanesthesia Care-

Phase I PACU, used during the immediate recovery phase, intensive nursing care is provided.

Phase II PACU, is reserved for patients who require less frequent observation and less nursing

care.In the phaseII unit, the patient is prepared for discharge.

Phase III PACU,ongoing care for patients needing extended observation and intervention after

phaseI or phaseII; preparing patient for self-care.

Initial Nursing Assessment

Verify patients identity, operative procedure and the surgeon who performed the procedure.

Evaluate the following sign and verify their level of stability with the anesthesiologist:

o Respiratory status

o Circulatory status

o Pulses

o Temperature

o Oxygen Saturation level

o Hemodynamic values

Determine swallowing and gag reflex , LOC and patients response to stimuli.

Evaluate lines, tubes, or drains, estimate blood loss, condition of wound, medication used,

transfusions and output. Evaluate the patients level of comfort and safety.

Perform safety check; side rails up and restraints are properly in placed.

Evaluate activity status, movement of extremities.

Review the health care providers orders.

Nursing Diagnoses

Impaired gas exchange

Impaired skin integrity

Acute pain


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Risk for ineffective airway clearance

Risk for infection

Risk for injury

Risk for deficient fluid volumeActivity intolerance

Self-care deficit: bathing/hygiene, dressing/grooming, toileting

Initial Nursing Interventions

Maintaining a Patent Air way

Allow the airway ( ET tube ) to remain in place until the patient begins to waken and is trying

to eject the airway.

The airway keeps the passage open and prevents the tongue from falling backward and

obstructing the air passage .Aspirate excessive secretions when they are heard in the nasopharynx and oropharynx.

Assessing Status of Circulatory System

Take VS per protocol, until patient is well stabilized.

Monitor intake and output closely.

Recognized early symptoms of shock or hemorrhage:

o cool extremities

o decreased urine output ( less than 30ml/hr )

o slow capillary refill ( greater than 3 sec. )

o lowered BPo narrowing pulse pressure

o increased heart rate

Initiate O2 therapy, to increase O2 availability from the blood.

Place the patient in shock position with his feet elevated ( unless contraindicated )

Maintaini ng Adequate Respir atory Function

Place the patient in lateral position with neck extended ( if not contraindicated ) and upper arm

supported on a pillow.

Turn the patient every 1 to 2 hours to facilitate breathing and ventilation.Encourage the patient to take deep breaths, use an incentive spirometer.

Assess lung fields frequently by auscultation.

Periodically evaluate the patients orientation response to name and command.

Note: Alterations in cerebral function may suggest impaired O2 delivery.

Administer humidified oxygen if required

Use mechanical ventilation to maintain adequate pulmonary ventilation if required.


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Assessing Thermoregulatory Status

Monitor temperature per protocol to be alert for malignant hyperthermia or to detect

hypothermia.

Report a temperature over 37.8 C or under 36.1 C

Monitor for post anesthesia shivering, 30-45 minutes after admission to the PACU.

Provide a therapeutic environment with proper temperature and humidity.

Maintaining Adequate F lu id Volume

Administer I.V solutions as ordered.

Monitor evidence of F&E imbalance such as N&V and weakness.

Evaluate mental status, skin color and turgor

Recognized signs of:

a. Hypovolemia

- decrease BP

- decrease urine output

- decreased CVP

- increased pulse

b. Hypervolemia

- increase BP

- changes in lung sounds (S3 gallop )

- increased CVP

Monitor I&O

Min imi zing Compli cations of Skin Impairment

Perform hand washing before and after contact with the patientInspect dressings routinely and reinforce them if necessary.

Record the amount and type of wound drainage.

Turn patient frequently and maintain good body alignment.

Maintaining Safety

Keep the side rails up until the patient is fully awake.

Protect the extremity into which I.V fluids are running so needle will not become accidentally

dislodged.

Avoid nerve damage and muscle strain by properly supporting and padding pressure areas.

Recognized that the patient may not be able to complain of injury such as the pricking of an

open safety pin or clamp that is exerting pressure.

Check dressing for constriction

Promoting Comfor t

Assess pain by observing behavioral and physiologic manifestations.

Administer analgesic and document efficacy.

Position the patient to maximize comfort.


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Parameter for Discharge from PACU/RR Activity. Able to obey commands

Respiratory. Easy, noiseless breathing

Circulation. BP within 20mmHg of preoperative level

Consciousness. Responsive

Color. Pinkish skin and mucus membrane

Nursing Care of the Client During the Intermediate

Postop Period (RRUnit )

Baseline Assessment

Respiratory Status

Cardiovascular Status

- VS

- Color and Temperature of Skin

Level of Consciousness

Tubes

- Drain

- NGT

- T-tube

Goals:

o Restore homeostasis and prevent complication.

o Maintain adequate cardiovascular and tissue perfusion.

o Maintain adequate respiratory function.

o Maintain adequate nutrition and elimination.

o Maintain adequate fluid and electrolyte balance.

o Maintain adequate renal function.

o Promote adequate rest, comfort and safety.

o Promote adequate wound healing.

o Promote and maintain activity and mobility.

o Provide adequate psychological support.

.


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Wound Care

Common dressing I r r igating a wound

i

The str ips of tape should be placed at the ends of the dressing and must be suf f icientl y

long and wide to secure the dressing. The tape should adhere to intact skin


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Cleaning Surgical Site

Cleaning from top to bottom starting at the center

Cleaning a wound outward from the incision

Cleaning around a Penrose drain site


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.4. Re-establish suction by squeezing the bulb in the palm of your hand until the inside walls

of the bulb touch. While maintaining pressure, replace the plug. Slowly release yourgrip to re-establish suction.

5. Measure and record the amount of drainage fluid on the record sheet as instructed.6. Note the nature of the drainage fluid (bloody, straw-colored, milky, etc.)7. Dispose of the drainage fluid in a toilet or rinse it down a sink.

Call your Physician if any of the Following Occurs:

The drainage has suddenly stopped or has increased significantly: the drainage amount

should decrease gradually.

There is a sudden change in the color of the drainage: the drainage should gradually

change from bloody to a straw-colored fluid. Call if the drainage becomes bloody againor changes to a milky white fluid.

There is an increase in redness or swelling around the insertion site of the drain. You are unable to keep the sides of the container compressed.

The drain has moved out of position or has come out.

Incision Supporting


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prevention of bed sore

BODY PRESSURE AREAS

Signs and Symptoms of Pressure Sore Development

Discoloration: In light-skinned people, the skin may turn red or dark purple. In dark-skinned

people the area may become darker than normal.

There may be a bad smell from the area

Redness or warmth around the sore

Swelling around the sore

Tenderness, pain around the sore

Thick yellow or green pus

Size of pressure sores are variable, they can go down into the muscle, or even to the bone. Further reduction in mobility

Pressure Sore PreventionRelieving pressure: Position must be changed on a regular basis, at least every two hours, and in the

very frail at least every hour.

Good Diet: A good and balanced diet contributes to healing, as well as avoiding severe nutritional

and weight loss

Skin Care: Keep the skin clean. Moisture should be minimized. Skin care products should be used

that moisturize the skin but do not make it wet or soggy.

Use continence aids if a person is unable to control their bladder or bowels. Pads, diapers, convenes

or catheterizing.


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Inspect the skin to see if any redness or breaks in the skin are developing.

Use products to relieve and treat pressure sores; airbeds, foam bed, bed and chair protectors, chair

products, continence aids can all contribute to avoiding of bed sores.

Getting Prompt HelpConsult a health professional for advice on how to avoid pressure sores and to find out about

appropriate products.

Alert a doctor or nurse immediately if you notice signs of infection. Signs and Symptoms include a

raised temperature, fever, chills, mental confusion or difficulty concentrating, rapid heartbeat,

weakness , increased pain. Antibiotics, IV hydration,

Treating Pressure Sores

Relieve pressure regularly: Hourly

Do not sit or lie on a pressure sore Use pillows or other similar positional products such as foam wedges to support, keep pressure

off an area and to encourage different positions.

Wheelchair users should try to keep as upright a position as possible

Cleaning a pressure sore: Pressure sores need to be kept clean and free from dead tissue. A salinesolution can be used and a dressing applied. The dressing should be renewed daily unless it is a

specialized dressing product, such as a hydrocolloid dressing, or a film dressing. Your doctor or

health care advisor will instruct you on the appropriate length of time.

Medical advice and intervention is advised to help in the assessment and treatment of pressure

sores. There is always a danger that a person who is malnourished and therefore has a less effective

immune system, may succumb to infection to the sore entering the blood stream, a condition knownas septicemia. The bacteria can cause irreversible damage to internal organs, leading to death.


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Discharge planning must embrace physical, psychological and social aspects of

individual patient care.This framework can then be used to develop guidelines forpatient discharge following day surgery

Discharge processDischarge criteria should be relevant to the aims and objectives of each individual unit.However, the following aspects must always be assessed when developing dischargecriteria for both adult and paediatric patients, irrespective of who takes responsibility

for this purpose.Physical criteria


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conscious level should be consistent with pre-operative statecardiovascular and respiratory assessments should be stablealimentaryinput and output assessment should be undertakenpatients should be conscious and orientatedpain, nausea and vomiting should be minimal and controlledwound sitesurgical bleeding should be minimal, i.e. not requiring a dressingchange

mobility of the patientpatient should be able to walk at a pre-operativePsychological criteria

information about the patients recovery at home in relation to their procedure, bothverbal and writtenthe patients and the parents/carers level of understandingshould be checked

follow-up appointmentsinstructions should be given to the patient or theirparent/carer

check medication to take home has been providedparents/carers may needsupport and guidance on administration

contact telephone numbers should be given to the patient or their parent/carer bothfor emergency and continuing care

general practitioner letter should be given to the patient or their parent/carer, or itshould be posted depending on unit policy

support in the community is advised followingday surgery as parents/carers can feel veryanxious in the immediate post-operative

period

some areas are able to offer a next-day visitfrom a children's community nurse. Othersmay offer a telephone call either from the

community team or the day unit

dressing/surgical appliances should beprovided as needed and guidance given ontheir use

verbal and written information for the

patient/child and parent/carer should be givenand level of understanding checked.

Social criteria

suitable transport home should be arranged,not public transport

home environment should be suitable for thepatient following the procedure/surgeryundertakenfor example access to atelephone or lift if in a flat. If the patient is achild, check sleeping arrangementsfor

example will they be sharing with a sibling?


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parent/carer arrangements should be made fortaking time off work or arranging care ofother children

suitable general practitioner, community or

childrens community nurse, health visitor orschool nurse arrangements should be made.

Preoperative and Postoperative Care Seminar

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