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Introduction to Perioperative Nursing Phases of Perioperative Care Pre Operative - begins with the patient’s decision to have surgery, ends with entry into the operating room Intra Operative - begins with entry into the operating room and ends with admission to the recovery room Post Operative - begins with admission to recovery room, and ends with discharge from care (varies but usually 6 weeks post op) by physician


Informed Consent

Pre-Operative Responsibilities of Operating Room Nurse: Patient Assessment Physical Problems Emotional Aspects Understanding of surgery/consent Legal requirements for chart completion Read and interpret lab results PeriOperative Teaching

PREOPERATIVE NURSING CONSIDERATIONS COMPLETE PHYSICAL ASSESSMENT Physical & psychological needs Medical & surgical history Completion of required documents DETERMINE READINESS & MODE OF TRANSPORTATION TO OR ACCESS HEALTH CARE TEAM AVAILABILITY Surgeon Anesthesia personnel Circulating nurse Scrub person Other personnel

PRE-OP MEDS Pharmacologic preparation as necessary & psychological support Facilitates induction of anesthesia & reduces anesthetic requirement Determinants of drug choice Age Weight Level of anxiety Drug allergies Inpatient/outpatient Timing of administration

PREOPERATIVE NURSING CONSIDERATIONS COMPLETE PHYSICAL ASSESSMENT Physical & psychological needs Medical & surgical history Completion of required documents DETERMINE READINESS & MODE OF TRANSPORTATION TO OR ACCESS HEALTH CARE TEAM AVAILABILITY Surgeon Anesthesia personnel Circulating nurse Scrub person Other personnel

Intra-Operative Provide for quiet environment during induction Assist during intubation Observe aseptic technique Safe operation of equipment (lasers, electrosurgery unit) Position patient safely - CV, nervous, respiratory system Document events, patient care given, Provide all supplies, equipment, to team during surgery Provide for a safe transfer to recovery room

Unsterile Team Member - Circulating Nurse Responsible for nursing care in the operating room Responsible for the organization of the workload Responsible for the maintenance of policy and procedures Responsible for signing and documentation The Circulating Nurse is the professional staff member in the operating room, representing the patient (Patient Advocate) and the hospital administration

Surgical Nurse 1889 A level head & keen eyes, ever watchful for all that may be required, a mind not easily irritated or confused, combined with the facility of keeping out of the way & still being of the greatest help .Thoroughness, speed, gentleness especially fit the surgical nurse. (Asepsis for the Nurse, Clemons, 1889)

1945 Discussion of the role of the OR Nurse “In charge of the operating room, taking care of the needs of the room assigned to her. It is her responsibility to watch the aseptic technique of her team.” “A surgery nurse must have many good qualities; but first of all, she must be conscientious of sterile technique. Speed & efficiency are of no avail if a surgical wound breaks down due to an infection received in the OR. “ Crawford, 1945

SCRUB PERSON May be a: RN LPN Surgical Tech Duties: Usually confined to the intraoperative phase of the patient’s surgical experience, may also be involved in gathering surgical supplies & equipment

SCRUB NURSE “ The nurse who is the immediate assistant to the surgeon is often called the “scrub” or “sterile” nurse. She first scrubs her hands and arms the required length of time, puts on sterile gown & gloves, and handles only sterile material.” Crawford 1945

SCENARIO #1 A. Smith, RN & D Jones, RN are assigned to scrub & circulate for a 0800 gastrostomy on WW, a 79 year old emaciated male. Since his hospitalization 3 days ago, he has managed to remove his IV and NG tube several times. Consequently he has been restrained even on the stretcher during his transport to the OR. His medical DX is chronic alcoholism with dementia. WW seems to acknowledge D Jones’s presence with a half glance, however he will not respond to the anesthesia provider’s questions. WW is supported on the stretcher in a semi-flower’s position with several pillows. Further assessment reveals that WW has contractures of his hips and knees.

SURGICAL POSITIONING Facilitated through the nursing process Patient’s body must remain in physiologic alignment Dependent Upon: The surgical procedure Exposure at the surgical field Surgeon’s preference and idiosyncrasies Patient’s condition Special Considerations: Geriatric patients Obese patients Malnourished patients

SURGICAL POSITIONING EQUIPMENT Pillow or headrest Arm boards Safety belt/strap Footboard Padding Gel pads Egg crate Donut rolls Foam Padded Shoulder braces Stirrups (candy canes, Allen, or knee) Laminectomy Frame Olympic vac pac (suction beanbag) 3” adhesive tape


SCENARIO #2 WH is a 36 year old black male who had been scheduled for a hemorrhoidectomy on an outpatient basis. He is 5’ 11”tall and weighs 250 lbs. His HBG is low (12g/dL) secondary to rectal bleeding. WH has a HX of asthma since age 5. He has episodes of difficulty breathing 6X/year, treated with an inhaler at the time of each episode. He does not smoke; ETOH 2 glasses of beer per week. WH’s current BP is 138/96, which he controls by taking a daily antihypertensive med. WH is a high school teacher. He spends most of his days standing and occasionally sitting. His evenings and weekend are spent working on a master’s degree in education. He does not participate in a regular exercise program.

SETTINGS: Ambulatory Surgery - In and Out in same day Pre-op teaching T&A, Cyst removal, D&C, Cataract removal with lens implants, Biopsy Heart cath scopes

SETTINGS Same Day General Surgery - Admitted to inpatient unit or special same day surgery unit Pre-Op teaching prior to day of surgery Nurses especially trained in Pre-Op assessment (Hysterectomy, Lap Chole, Appendectomy, Mastectomy, C-Section)

SETTINGS Main OR Surgery - Patient admitted to hospital prior to surgery OR DAY OF SURGERY Prep and assessment and teaching done in hospital Patient stays @ least overnight, and rehab begins before discharge Major heart surgery such as CABG’s, Bowel Resections, Large tumor removal or Brain surgery

PURPOSE of SURGERY Diagnostic - Determines cause of symptoms (Exploratory laparotomy and biopsy) Curative - Removal of diseased part (Appendectomy, Ovarian Cyst, Cancerous Tumors) Restorative or Reconstructive - Strengthens a weakened part (Herniorrhaphy or cervical rings) rejoins disconnected areas (orthopedic surgeries), corrects deformities, (MVR, joint replacement, etc) Palliative - Relieves symptoms without curing (some lower back surgeries, tumorectomies) Cosmetic - Repairing a burn scar or changing breast shape, altering physical appearance

Patients @ High risk for Complications Smokers Obese Chronic Lung Diseases Elderly HTN Thoracic or Abdominal Surgeries Immobilizing Surgery UTI Diabetes Poor Nutritional Status Dehydration Heart Disease Self-fulfilling Prophecy Inhalant Anesthesia

PREVENTING COMPLICATIONS DVT, UTI, Aspiration, Wound Infection, Shock, Constipation Identify those @ risk Provide adequate hydration/nutrition NPO after MN Leg exercises Breathing exercises and IS I&O

Preventing Complications Splint Incision to cough Anticoagulant Therapy - Heparin Ambulate and OOB to BRP - ASAP Discourage smoking Fluid and fiber ASAP, laxatives. Enemas Clean Hands Instruct in proper wound care Sterile bowel prep and skin prep Sleep/Rest

PREPPING THE PATIENT TEACHING Name and purpose of the surgery NPO after MN and why early awakening, shower, remove all jewelry, makeup, etc Anesthesia, Cold Room, Smells, Drowsy Feeling Recovery Room Post-op care - TCDB, leg exercises, pain management, DVT OOB ASAP Begin discharge planning

WAYS TO DECREASE ANXIETY COMMUNICATION Early teaching and counseling Diversional activities Encourage family support Encourage verbalization of fears/loss of control Deep breathing, medications, imagery, music

Ways to Decrease Anxiety Spiritual support (communion, bible reading, prayers, rituals, chants) Inform family where to wait, buy food, bathroom, phone, overnight and visiting policy Possible use of sedative or tranquilizer or PRN medications Dolls/favorite toy for children

NURSING ASSESSMENT Assessment Data Base - vital signs, weight, height Review of Systems Past history of illnesses (i.e. HTN, pneumonia) that may predispose client to complications Past experience with hospitalization or surgery Allergies to medications or foods, tapes, surgical scrubs

Nursing Assessment Intellectual ability to understand teaching Language differences, social, spiritual or cultural considerations, anxiety level Labs: CBC; U/A; Chemistry (electrolytes: K,CL,NA,CA,BS,BUN,Creatine), total bilirubin, albumin, alkaline phosphatase, SGOT, HCO3, HIV, Pregnancy Other: Chest X-Ray, EKG if 40 years old

PRE-OP NURSING DIAGNOSES Knowledge Deficit R/T Unfamiliar Planned or Unplanned Surgery Ineffective individual or family coping R/T Unfamiliar Planned or Unplanned Surgery Anticipatory Grieving R/T Potential for Loss of Life or Body Part

NURSING RESPONSIBLITIES Informed Consent Form/Patient Advocacy Secure personal belongings: Dentures, glasses, rings, money Administration of pre-op medications on call to OR - i.e. Demerol, Valium, Atropine Complete Pre-op Checklist @ clinical site remove hair pins, loose teeth, dentures, nail polish, bath, urinate, NPO, VS taken within 15 minutes of going to OR, Ted Hose or compression devices

NURSING RESPONSIBLITIES . Report anything of note that needs to be brought to the attention of the anesthesiologist, surgeon, or OR nurse low potassium, fever, arrthymias, loose teeth, chest pain, or anything unusual Assure patient has ID bracelet on; Send current chart and any old medical records with the patient; EVALUATE patients level of understanding, physical stability, emotionally prepared, fulfilled hospital pre-op policies

TYPES OF SURGERY MAJOR -- Present a real threat to life MINOR -- Present little threat to life NOTE: **** All patients consider their surgery a major thing ****

BLOODLESS SURGERY a term that has evolved in the medical literature to refer to a perioperative team approach to avoid allogeneic transfusions and improve patient outcomes utilizing combinations of the numerous blood conservation techniques and transfusion alternatives available

BENEFITS OF BLOODLESS SURGERY Decreased costs Less risk for blood contamination for patients Reduce risk of post op fevers and infections usually associated with blood transfusions Promotes better quality patient care At times decreased death rate Can decrease time spent in ICU

Catastrophic Events in the OR Anticipated: Anticipated Cardiac Arrest in an unstable patient Massive Blood Loss - during trauma surgery Loss of ability to ventilate a patient

Catastrophic Events in OR . Unanticipated: Latex Allergy Reaction - reactions can range from urticaria to anaphylaxis Maligant Hyperthermia - rare, life-threatening disorder that can be triggered by anesthesia drugs Is an autosomal dominant trait

Peri-Operative Standards of Care (example) All Policy & Procedures of the medical and surgical nursing division will be followed. Patients shall ALWAYS wear a legible identification band Operative permit(s) must be signed and witnessed according to hospital policy, The procedure documented on the operative permit MUST MATCH what is scheduled on the OR schedule The history and physical shall be completed according to policy and be part of the medical record prior to surgery All ordered lab work shall be collected and results placed in the medical record in accordance with the physician’s orders Dentures, hairpins, jewelry, wigs, contact lenses, nail polish, make-up and prosthesis shall be removed as requested by the physician Any jewelry not removed shall be secured with tape and documented as such

Peri-Operative Standards of Care Pre-operative skin prep shall be done without abrading, cutting or irritating the patient’s skin Patient privacy shall be provided at all times Any pre-operative drainage tubes shall be placed without tissue trauma and be completed utilizing sterile techniques when indicated All IV infusions shall be monitored to maintain the appropriate flow rate and type of solution and remain patent without signs of inflammation or swelling The patient shall be provided emotional and educational support to reduce pre-operative anxiety The patients shall be provided a safe and normothermic environment in the pre-op waiting area The patient shall be transferred safely to the OR table and safety straps appropriately applied

Expected Outcomes: Demonstrate knowledge of physiologic & psychological responses to surgical intervention Absence of infection Maintenance of skin integrity Freedom from injury R/T positioning, equipment Maintenance of fluid and electrolyte balance Satisfaction with pain relief Participation in the rehab process

AORN a tradition of excellence Formally organized between 1949 – 1954 A professional organization of periOperative registered nurses whose mission is to provide quality patient care by providing its members with education, standards, services and representation. Membership 340 chapters, 12 specialty assemblies, 25 state councils and 41,000 members

PERIOPERATIVE NURSING If you or your family came through surgery in good shape, thank a perioperative nurse.

If someone listens, or stretches out a hand, or whispers a kind word of encouragement, or attempts to understand a lonely person, extraordinary things begin to happen Loretta Gizarlis (1920) American writer and educator

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