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 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). 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 Nursing used to describe the nursing are provided in the total surgical experience of the patient: preoperative, intraoperative and postoperative.
1

perioperative

perioperative

intraoperative

postoperative

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. Intraoperative 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 the RR/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.

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 nursingThe 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 spent during 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.

pre-operative care

DefinitionPreoperative periodperiod 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 surgical risk. Giving the person and significant others complete learning / teaching regarding surgery. Instructing and demonstrating exercises that will benefits the person during post operative period. 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, the patients 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 assessmentPreoperative Assessment is the clinical investigation that precedes anaesthesia for surgical or nonsurgical 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.

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 SURGERYobtaining 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 traumathis 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 UseThe 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.

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 DiscomfortsClients 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 IllnessesArthritis of the neck or back is considered in positioning the client during surgery or in extending the neck during intubation. Advanced AgeOlder clients have specific perioperative needs that should be identified preoperatively and considered in developing and maintaining a plan of care. Medication HistoryMany 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 HistoryKnowledge 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.

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 StressPhysiologic 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 homeostatic balance. 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 HabitsSedentary lifestyles can complicate the surgical course because of poor muscle tone, limited cardiac and respiratory reserves, and decreased stress response. Social HistoryAn 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 EXAMINATIONA 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 AssessmentsCardiovascular Assessment-

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 wound healing. 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 at home 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.

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 for comparison 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

10

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 clotting abnormalities.

Cognitive and Neurologic assessmentSerious 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 AssessmentsOther factors that may be considered during the planning of surgical intervention include a. age b. nutritional

11

c. fluid and electrolyte balance d. infection ,and e. hematologic condition a. AgeNormal 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. PainPain 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 statusNutritional 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-

12

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 ImmunityAny 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 FunctionClients 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-inflammatory drug(NSAIDs) Abnormal bleeding time, prothrombin time, or platelet count ESTIMATING MEDICAL RISK FOR SURGERYEach 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.
13

III.

The type of surgery to be performed also has some inherent risk. The types of operations by category are presented in: PURPOSE EXAMPLES CATEGORY Improvement of physical Breast augmentation Aesthetic features that are within the normal range Repair of a congenitally Cleft palate and cleft lip Constructive defective body part repair

Curative

Diagnostic Explorative

Emergent Palliative

Removal or repair of damaged or diseased tissue or organ Discovery or confirmation of a diagnosis Estimation of the extent of disease or confirmation of a diagnosis Life-saving Relief of symptoms but without cure underlying disease Partial or complete restoration of a body part Performed as soon as client is stable and infection is under control

Hysterectomy

Breast biopsy Exploratory laparotomy

Repair of traumatic punctured lung Colostomy

Reconstructive Urgent

Total joint replacement Appendectomy

IV.

IV.ANESTHESIA AND ANESTHETIC RISKThe 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 ANESTHESIOLOGISTS: status P1 definition A normal healthy patient CLASSIFICATIONS OF AMERICAN SOCIETY OF

Description and examples No physiologic, psycho logic, biochemical

14

P2

Patient with mild systemic disease

P3

A patient with severe systemic disease that limits activity, but is not incapacitating

P4 P5

A patient with severe systemic disease that is constant threat to life A moribund patient who is not expected to survive 24 hrs or without operation

Cardiovascular disease with minimal restriction on activity, hypertension, asthma, chronic bronchitis, obesity Cardiovascular or pulmonary disease that limits activity, severe diabetes with systemic complication, history of myocardial infarction, angina pectoris, or poorly controlled hypertension Severe cardiac,pulmonary, renal, hepatic or endocrine dysfunction 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 CBC

Blood grouping/ X matching Serum Electrolyte PT,PTT Fasting Blood Glucose BUN / Creatinine ALT/AST/LDH and Bilirubin Serum albumin and total CHON Urinalysis Chest X ray

Rationale RBC,Hgb,Hct are important to the oxygen carrying capacity of blood.WBC are indicator of immune function. Determined in case blood transfusion is required during or after surgery. To evaluate fluid and electrolyte status Measure time required for clotting to occurs High level may indicate undiagnosed DM Evaluate renal function Evaluate liver function Evaluate nutritional status Determine urine composition Evaluate respiratory status/ heart size

15

ECG

Identify preexisting cardiac problem.

VI. PSYHCHOLOGICAL ASSESSMENT OR NEEDS(PRE-OPERATIVE ANXIETY AND FEARAll 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 expectations 4) 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.

FearThe 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:

16

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:

17

 To ensure that the client understand the nature of the treatment including the complications 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.

Circumstances Requiring Consent: 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. Requisites of for Validity Informed Consent 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 legal guardian 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 desirable nurse, 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 TEACHINGInformation provided to the client before surgery should be geared to individual needs. This information can be Sensory Psychosocial
18

 Procedural Sensory 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 that warm blankets are available. o Clients may be given headphones and can choose from a variety of music types to help them relax 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 Spirometry 2) Deep Breathing Exercises 3) Coughing Exercises 4) Turning Exercises 5) Foot And Leg Exercises 6) Ambulating And 7) Pain Control Incentive SpirometryEncouraged to use incentive spirometer about 10 to 12 times per hour.

Deep inhalations expand alveoli, which prevents atelectasis and other pulmonary complication.
19

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; your upper 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 and shoulders well supported with pillows.

With your hands in a loosefist position, let them rest lightly 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 down and 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 all the air through your nose and mouth. Repeat this exercise 15 times with a short rest after each group of five. Practice this twice a day preoperative

Coughing Lean 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.
20

 Then, keeping your mouth open, take in a quick deep breath and immediately give a strong cough once or twice. This helps clear secretions from your chest. It may cause some discomfort but wont harm your incision. 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 to the 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, and then out Repeat these movements five Moving 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.

21

. 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.

22

 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 prevent many 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 get out bed after surgery.

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

23

 Teaching of proper methods of arising from bed to prevent pain and to minimize orthostatic hypotension 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.

24

 Explain the type of pain relief or reduction that will be used postoperatively. For example, some surgeons inject the surgical site with a long-acting local anesthetic before closing the wound so that 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, give instructions 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. During the immediate postoperative period, clients can receive medications orally, intravenously, intramuscularly or epidurally. Explain patient about cycle of pain to relieve anxiety.

25

26

Equipment Explain the equipment that will be used during the perioperative period. Depending on the type of surgery to be performed, various tubes, drains, and IV lines may be used. Discussion should focus on the purpose of specific pieces of equipment and how related to the surgery. The most common type of tube used during the intraoperative period is an indwelling urinary catheter and Nasogastric Tube are inserted in operating room to empty bladder and drain stomach content. Drains are inserted to promote evacuation of fluid from the dead space(tissue planes created during the operation) in the operative site. Hemovac and Jackson-Pratt drains are commonly used low-suction devices. IV infusions are usually started before surgery. The purpose of the infusion is to administer medication, fluids, and nutrient solution. IX PREOPERATIVE NURSING DIAGNOSESo Anxiety/fear related to threat of loss of body parts or unknown effects of surgery on usual functions and roles. o Fear related to anticipation of postoperative pain. o Knowledge Deficit (preoperative and postoperative routines/care) related to no prior experience. o Sleep Pattern Disturbance related to hospital routines, stress, and anxiety. o Anticipatory Grieving related to anticipated surgical loss of body part. X IMMEDIATE PREOPERATIVE NURSING CAREPhysical CarePreparation of the Skin: Explain shower and bathing protocols for the night before a planned surgical procedure. Usually the operative area is cleaned the night before surgery with soap and water or an antimicrobial solution to reduce the number of microbes on the skin. Hair Should be removed within 1-2 mm of the skin to avoid skin breakdown, use of electric clipper is preferable.

Preparation of the Gastrointestinal Tract: The gastrointestinal tract needs special preparation on the evening before surgery to 1) reduce the possibility of vomiting and aspiration. 2) to reduce the risk of possible bowel or abdominal surgery. 3) to allow visualization of the intestine during bowel surgery. 4) to prevent contamination from fecal material in the intestinal tract during bowel or abdominal surgery. Preparation involves restricting food and fluid, administering enemas as needed. If a client undergoing surgery is to receive a general anesthetic, foods and fluids are restricted for 8 to 10 hours before the operation. This restriction significantly reduces the
27

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 2 Clear Liquids 4 Breast Milk 6 Nonhuman Milk 6 Light Meal 8 Regular / Heavy Meals Preparing for Anesthesia - Avoid alcohol and cigarette smoking for at least 24 hours 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 orders enema, 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.
28

 Prevent nausea and vomiting. Commonly used Preoperative Meds. Tranquilizers & Sedatives * Midazolam * Diazepam (Valium ) * Lorazepam ( Ativan ) Reduce anxiety and induces sleep * Diphenhydramine Analgesics * Nalbuphine ( Nubain ) Anticholinergics * Atropine Sulfate Proton Pump Inhibitors * Omeprazole ( Losec ) * Famotidine

Relieve pain

Control secretions

Inhibits gastric acid production

Pre-Operative Check List

29

30

Transporting the Patient to the OR Adhere to the principle of maintaining the comfort and safety of the patient. Accompany OR attendants to the patients bedside for introduction and proper identification. Assist in transferring the patient from bed to stretcher. Complete the chart and preoperative checklist. Make sure that the patient arrive in the OR at the proper time.

Patients Family Direct to the proper waiting room. Tell the family that the surgeon will probably contact them immediately after the surgery. Explain reason for long interval of waiting: anesthesia prep, skin prep, surgical procedure, RR. Tell the family what to expect postoperative when they see the patient.

31

post-operative care

32

DefinitionPostoperative 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 monitoring and 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.

33

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

34

Risk for ineffective airway clearance Risk for infection Risk for injury Risk for deficient fluid volume Activity intolerance Self-care deficit: bathing/hygiene, dressing/grooming, toileting

Initial Nursing Interventions

Maintaining a Patent Airway 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 BP o 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 ) Maintaining Adequate Respiratory 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.

35

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 Fluid 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

Minimizing Complications of Skin Impairment Perform hand washing before and after contact with the patient Inspect 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 Comfort Assess pain by observing behavioral and physiologic manifestations. Administer analgesic and document efficacy. Position the patient to maximize comfort.

36

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 (RR Unit )
Baseline Assessment Respiratory Status Cardiovascular Status - VS - Color and Temperature of Skin Level of Consciousness Tubes - Drain - NGT - T-tube Goals: o o o o o o o o o o Restore homeostasis and prevent complication. Maintain adequate cardiovascular and tissue perfusion. Maintain adequate respiratory function. Maintain adequate nutrition and elimination. Maintain adequate fluid and electrolyte balance. Maintain adequate renal function. Promote adequate rest, comfort and safety. Promote adequate wound healing. Promote and maintain activity and mobility. Provide adequate psychological support. .

37

Wound Care Common dressing Irrigating a wound

The strips of tape should be placed at the ends of the dressing and must be sufficiently long and wide to secure the dressing. The tape should adhere to intact skin

38

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

39

Care Of Drainage Tube-

The following instructions will help you and/or your caregiver correctly perform adequate drain care: Be aware of the drain at all times, especially during periods of activity, and guard against pulling on the drain tubes. Keep the drain secured to your clothing by means of a drain clip or safety pin. Drain care is a clean procedure: wash your hands thoroughly with soap and warm water before performing drain care. Supplies do not need to be sterile. Empty the drain container into the measuring cup given to you prior to leaving the hospital twice a day (once in the morning and once in the evening). Measure and record the amount of fluid emptied (see instructions below). Try to empty the drain at the same time each day. Make sure there is always adequate suction in the drain system: the drain should remain concave or somewhat flat; it should not be fully inflated. Reinforce or change the dressing on the drain site as instructed by your surgeon or your nurse. Look at your dressing for any signs of leakage or increased spotting of blood.

Steps for Emptying your Jackson-Pratt Drain

1. Detach the drain from your clothing 2. Open the plastic plug of the bulb container. 3. Carefully pour the contents of the bulb into the measuring cup detach the drain from your clothing.

40

. 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 your grip 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 again or 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
41

42

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 Prevention Relieving 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.
43

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 Help Consult 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 saline solution 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 known as septicemia. The bacteria can cause irreversible damage to internal organs, leading to death.

44

45

46

47

Discharge planning must embrace physical, psychological and social aspects of individual patient care.This framework can then be used to develop guidelines for patient discharge following day surgery

Discharge process
Discharge criteria should be relevant to the aims and objectives of each individual unit. However, the following aspects must always be assessed when developing discharge criteria for both adult and paediatric patients, irrespective of who takes responsibility for this purpose. Physical criteria 48

 conscious level should be consistent with pre-operative state cardiovascular and respiratory assessments should be stable alimentary input and output assessment should be undertaken patients should be conscious and orientated pain, nausea and vomiting should be minimal and controlled wound site surgical bleeding should be minimal, i.e. not requiring a dressing change mobility of the patient patient should be able to walk at a pre-operative Psychological criteria information about the patients recovery at home in relation to their procedure, both verbal and written the patients and the parents/carers level of understanding should be checked follow-up appointments instructions should be given to the patient or their parent/carer check medication to take home has been provided parents/carers may need support and guidance on administration contact telephone numbers should be given to the patient or their parent/carer both for emergency and continuing care general practitioner letter should be given to the patient or their parent/carer, or it should be posted depending on unit policy support in the community is advised following day surgery as parents/carers can feel very anxious in the immediate post-operative period some areas are able to offer a next-day visit from a children's community nurse. Others may offer a telephone call either from the community team or the day unit dressing/surgical appliances should be provided as needed and guidance given on their use verbal and written information for the patient/child and parent/carer should be given and level of understanding checked. Social criteria suitable transport home should be arranged, not public transport home environment should be suitable for the patient following the procedure/surgery undertaken for example access to a telephone or lift if in a flat. If the patient is a child, check sleeping arrangements for example will they be sharing with a sibling?

49

 parent/carer arrangements should be made for taking time off work or arranging care of other children suitable general practitioner, community or childrens community nurse, health visitor or school nurse arrangements should be made.

50