PERIOPERATIVE NURSING

PROF. EJ FLAMINIANO

SUFFIXES:
1. ECTOMY- removal
- Craniectomy: $-bone bank PRIORITY: SAFETY!!
₱- abdomen
HL- return immediately (corticosteroids)
- MASTECTOMY: PRIORITY: Elevate
- APPENDECTOMY: curative/prophylactic
: Laparoscopic (less invasive)
2. OTOMY- creation of an opening
- Craniotomy: supra (head elevation)
Intra (flat on bed)
- Palliative (lessen CSF)
- Fasciotomy: compartment syndrome
- Tracheotomy ➡ Tracheostomy
3. OSTOMY- maintenance of an opening
- Through tube or stoma
- Stoma: red and moist – normal
: dry – dehydration
: pale – cyanosis
: black– necrosis
: pus – infection
4. CENTESIS- aspiration
Arthrocentesis – synovial fluid aspiration
Amniocentesis - amniotic fluid aspiration
5. CLASIS- to break
Thrombolytics ➡thrombolytics
- streptokinase, retavase, eminase (kinds of thrombolytics)
6. PLASTY- molding
ANGIOPLASTY ➔ balloon, stent
7. PLEXY- fixation of an organ
AORTOPEXY: fixation away the trachea; prevent tracheal compression
NEPHROPEXY: suturing back of normal of nephron/kidney to prevent post-renal failure
8. RHAPY- suturing; episiorrhaphy

OR SET UP:

PHASES: SURGERY

 PRE-OPERATIVE: surgical unit ➔ semi- restricted

 INTRA-OPERATIVE: restricted ➔ restricted
 POST-OP: semi-restricted (PACU) ➔ surgical unit ➔ home
PRE-OP ELEMENTS:

1. CONSENT- surgeon explains the procedure

- It has to be understood by the client
- 18 years old and above
- 17 years old above- should be signed by parents/ guardians
- It has to be witnessed by the nurse
- Tentative consent- 2 witnesses (nurse)
2. NUTRITION- NPO depends on the anesthesia
a. General anesthesia: 6-8hrs
b. Spinal anesthesia: 6-8hrs
c. Local anesthesia: 3hrs
- IVF as ordered – replacement, access for medications
- MALNUTRITION: TPN as ordered
3. ELIMINATION- void; immediately before surgery
- Fooley catheter ➔ to decrease fluids in the bladder
- Laxative (to loosen stools)
- Enema
4. SKIN PREPARATION- cleanse the surgical site with soap and water
- Clip hair as much as possible
- Ø shave – it should be the last option
5. PRE- OPERATIVE TECHNIQUES- ↑ awareness to expect on post-op
S-plint (↑intra-abdominal pressure) with hand or pillows; coughing, sneezing, repositioning
P- ain: analgesics
A- Telectasis: : coughing techniques; Position: lean forward
D- evices : invasive (NGT, IV LINE, fooley catheter, drains)
E- xercises

COUGHING EXERCISES:

DBE INCENTIVE SPIROMOTER

Inhale: nose Inhale: 600-900; mouth
Exhale: mouth (pursed-lip: maximize O2) Exhale: mouth (pursed-lip: maximize O2)
Hold: 3 seconds Hold: 5 seconds
Repeat: 3x/hr Repeat: 10x/hr

DRAINS:

OPEN CLOSED
OPEN OPEN
⬇ ⬇
↑ risk of infection ↓ risk of infection
⬇ ⬇
OS- collection Bulb- collection
⬇ ⬇
Penrose Drain Jackson Pratt Drain

EXERCISE:

1. CALF-PUMPING: doris-flexion-extension
- Prepare for ambulation
- Gastroenemics exercise
2. FOOT CIRCLES: rotate the foot
3. QUADRICEPS STILT: hyperextended the knee
4. HIP AND KNEE EXERCISE: flex the hip 90’ and flex the knee 90’

PRE-OP CHECKLIST GUIDELINES:

- Done by the nurse
D- entures, hairpins, glasses – removed
I – nformed consent (signed)
A- Ssement of allergies (Latex): if there is latex allergy- delay the surgery
 M- onitor VS: Baseline
O-bserve accuracy ➔ blood typing, cross-matching
N- ote physical exam/ history of ASA: STOP; Corticosteroids: continue until the day of the surgery
D- o last voiding; pre-op medications
S- ecure belongings

INTRA-OP: OR/OR SUITE/ OR-THEATRE

1. STERILE FIELD
- Absence of microorganisms
- Aseptic technique
- Observe barriers: packs (inside-sterile)
Gloves (outside-sterile) thumb out
Gowns (outside-sterile)
2. SURGICAL TEAM: sterile
- Surgeon (head)
- 1st assist (resident)
- Scrub nurse
NON- sterile
- Anesthesiology
- Circulating nurse (OR MANAGER)
- Radiologist
3. UNIVERSAL PRECAUTION: to avoid mistakes
- Markings (indelible ink)
- For bilateral organs
- Sign in phase – should be done!
PHASES OF OPERATION:
1. SIGN IN: before induction (UP)
2. TIME OUT: before incision (INTRO)
3. SIGN OUT: closure of the skin (orders post-op)

PRINCIPLES OF STERILE TECHNIQUE:

 Sterile to sterile; unsterile to unsterile
 Confirm sterility: check the expiry date
o General: 96 weeks; dry
: OR TYPE (auto-clave tape): chemical indicator; no stripes: unsterile
 Opening: open package close to the time of use: 15-20 minutes
- 1st: top flap (away)
- 2nd: side flaps (L/R)
- 3rd: bottom (towards self)
 when it doubt: DISCARD ➔ unsterile
 sterile: table ➔ sleeves ➔ shoulders
 1 inch: 2-5 cm: edge of the mayo table (unsterile); center: sterile
 No coughing, no sneezing, no laughing, no excessive talking
 Always face the sterile field: back to back, front to front
 Dropping of instruments
- 1 armlength
- 6-8 inches far
 Lid of the bottle: unsterile; sterile: fluid inside the bottle
 Pouring: 1 armlength
- 4-6 inches
 Honesty: if breech of sterility occurs

COUNTING OF INSTRUMENTS:
- Instruments, sponges, needles
- Count audibly and singly
- REP-IPSA-LIQUOR: acaptain ship: ALL IS ACOUNTABLE
- 3x should count – initial (before incision), 2nd (before closure of the cavity), final (before skin closure)
POST-OP:
- Monitor VS; q15, 30 minutes, q 1hr
- Q15: 1st hr
- Q30: 2nd-3rd hr
- Q1hr: 4th-5th hr
- TOTAL: 7HRS
NURSING CONSIDERATIONS:
IMMIDIATE INTERMIDDIATE EXTENDED

1-4 hrs 4-24 hrs 1-4 days

Change dressing (minimal
INCISION Report active bleeding WOF: signs of infection
bleeding)
(+) peristaltic movement:
NUTRITION NPO ⬆ protein/ ⬆ vitamins
FEEDING

URINE OUTPUT (-) Urine output 30cc/hr Normal urine output

AES: Anti embolic stockings ROME (range of motion

DVT (Deep Vein Thrombosis) Report for + Homan’s sign
when going up exercises)

EXERCISE Dorsi-flex-extension Supported ambulation Intermediate ambulation

COMPLICATIONS:
1. HYPOXIA: ↓ O2; insert oropharyngeal airway: to maintain patency of the airway
- Failure to put OPA in the patient
- Allergies(latex)
- Paleness
- Numbness
- Tingled sensation
- Coolness
- Restlessness: initial sign
MGT:
- O2: 2L/MIN
- Refer to the doctor
- Antihistamine as ordered
- Intubation
2. PULMONARY EMBOLISM: thrombus → massage → lungs
s/sx: hemoptysis
- Dyspnea
- Petechial rash: chest and neck
MGT: O2: 2L/min; administer heparin
3. ATELECTASIS: lung collapse caused by anesthesia
S/SX: - diminished breath sounds
- ↓ O2
- Hypoxia
- Secretions
- Productive cough
- Pneumonia
- Coughing technique
- DBE
- Incentive spirometer
MGT: antibiotic as ordered
4. HEMMORHAGE: loss of significant amounts of blood: 5,000/cc
CAUSE: lengthy surgeries
S/SX: hypotension - paleness -tingling sensation
Tachypnea INITIAL SX - coolness
Tachycardia -numbness
MGT: apply pressure to stop the bleeding
- Refer to physician
- IVF (isotonic) → BT
5. SHOCK: loss of vital process
CAUSE: hemmorhage, allergies, infection
LATE SIGN: Hypotension, bradycardia, bradypnea
INITIA SX: hypotension - paleness -tingling sensation
Tachypnea - coolness
Tachycardia -numbness
MGT: - elevate lower extrimities
- Refer to doctor
- IVF (isotonic) → BT
 6. CONSTIPATION 7. PARALYTIC

- Absence of feces - Absence of peristaltic movement

- With feeding - NPO
- Hypoactive bowel sounds - Absence of bowel sounds
- Absent of BS - Hypoactive bowel sounds
- Abdominal distention - Abdominal distention
- Caused by anesthesia - Caused by anesthesia
MGT: high fiber diet MGT: NGT: decompress stomach
Laxatives as ordered Prokinetics as ordered (suppository)

8. THROMBOPHLEBITIS
- Inflammation of blood vessels
- PAIN
- (+) Homan’s sign
- Fever
DISTAL: paleness, numbness, coolness, tingling sensation
MGT:
- Elevate lower extremities without popliteal pressure
- Avoid dangling of feet
- Apply anti embolic as ordered
- Anti coagulants – Heparin
- Analgesics
- Antipyretics (fever)
- Thrombolytics

9. DEHISENCE 10. EVISCERATION

- Separation of wound edges - Protusion of wound edges
- Underlying tissues - Loops of bowel
- INITIAL SIGN: popping sound - INITIAL SIGN: popping sound
6-8 days after surgery 6-8 days after surgery
Increase intra-abdominal
pressure
MGT:
C-over (SSS: sterile saline solution)
L-ow fowler’s with knees flexed (relaxes abdominal organ)
O- observe signs of shock
V-omitting: anti emetics as ordered
E- ducate (Ø heavy lifting more than 10 pounds)
S-plint