Perioperative Phases
• Pre-operative
• Intra-operative
• Post-operative

  Describe each of these stages?

  What are the essential nursing competencies for
  each phase?
  (Nursing Responsibilities: Chart 18-1, p. 482-483)
Operative Classifications   Operative Categories
• Diagnostic                • Emergent
• Curative                  • Urgent
• Reparative                • Required
• Reconstructive/cosmetic   • Elective
• Palliative                • Optional

                            (Table 18-1, p. 485)
          Ambulatory Surgery
How is ambulatory surgery defined?

What is the goal of ambulatory surgery?

What are the nursing responsibilities associated
 with ambulatory surgery?
               Pre-operative Phase
• PAT (blood tests, x-rays, other diagnostics)
• Teaching
• Knowledge of Risk Factors for Complications
 (Chart 18-3, p. 486)
      Important Things to Consider
• Stop ASA 7-10 days before surgery
• Stop herbals 2-3 weeks before surgery
• Encourage no smoking for 4-8 weeks before surgery;
  stop smoking at least 24 hours before surgery
• Monitor immunocompromised patient closely for s/s of
  infection before surgery
• Surgery contraindicated if acute renal problems
• Control hypertension prior to surgery if possible
• Obesity increases risk and severity of complications
           Specific Considerations
• Diabetes Mellitus:
  – At risk for hyperglycemia or hypoglycemia
• Long-term corticosteroid use:
  – At risk for adrenal insufficiency
• Uncontrolled Thyroid Disease
  – Overactive: risk of Thyrotoxicosis
  – Underactive: risk of respiratory depression
    Considerations for the Elderly
• Increased risk for complications
  – Less physiologic reserves
• “Hazards. . . are proportional to the # and
  severity of c0-existing health problems and
  the nature and duration of the operative
  procedure.” (p. 491)
         Pre-Operative Teaching
• Reinforce physician’s explanations and
• Discuss what to expect
• Instruct in breathing and leg exercises
• Demonstrate splinting of abdomen (if appropriate)
• Explain rationale for frequent position
• Discuss pain management
• Discuss cognitive coping strategies
           Miss Nervous Nellie
• Miss N is scheduled for a colon resection. A
  recent biopsy of a polyp revealed a
  malignancy. During your pre-admission
  interview Miss N is tearful and keeps saying “I
  hope this won’t be like it was when my dad
  had colon surgery.” “I’m so afraid I will die just
  like he did.”
  What are Miss N’s psychosocial needs?

  How will you meet those needs?
                Pre-Operative Care
General                               Immediate

• Protect from injury                 • Gown
   – 7 patient safety goals (JCAHO)   • Cap (braid long hair, no hairpins)
• Manage nutrition and fluids         • Remove dentures/plates
   – NPO                              • No jewelry
• Prepare bowel (if appropriate)      • Void immediately before
• Prepare skin (if appropriate)         transport
                                      • Cover with bath blanket
                                      • Administer preanesthetic
                                        medication if ordered
Responsibilities related to the Medical
• Complete pre-operative check list
• Place surgical consent form in plain view
• Send entire medical record (chart) to surgery
  with patient
  – Includes current MAR
            Informed Consent
• What is it?

• When is it necessary?

• Who can sign?

• What is the responsibility of the nurse?

• What are the legal implications?
    Holding Area Responsibilities
• Initiation of verification form
• Pre-anesthesia medication if ordered
• Foley catheter if ordered

Note: Entire peri-operative team should be
 involved in verification process (correct
 patient, correct site, etc)

  Why is the verification process so important?
              Family Needs
• Explain where to wait
• Surgeon will talk to them after surgey
• Never judge seriousness by length of time
  patient in surgery (keep family updated)
• Prepare them for what they will see post-op
• Explain post-op protocol and routines
        Intraoperative Phase
An interdisciplinary approach to intraoperative
care is essential.

Who makes up the interdisciplinary team?

What are the responsibilities of team
         Microbe Management
• Controlled Environment
  What measures are implemented to control the
    surgical environment?
  Discuss the use of zones to decrease mibcrobes.

• Surgical Asepsis
  List the basic principles of aseptic technique.
         Intraoperative Case Study
 The client, a 62-year-old secretary, has entered the
  surgical suite about 30 minutes after she has received
  atropine and midazolam for preoperative medication.
  The OR schedule lists that she is scheduled to have a
  vaginal hysterectomy. In addition, the preoperative
  history indicates that she smokes three packs of
  cigarettes per day and drinks three cans of beer each
  day. When you ask her what kind of surgery she is
  having today, her response is “I am going to have a
  hemorrhoidectomy.” You ask her if she means
  hysterectomy and she responds, “Well, it is some kind
  of operation ‘down there’.”
         What Should You Do?

• What additional questions should you ask this

• What should you do with the information?

• What effect, if any, will her history of smoking
  and drinking have on her surgical experience?
           The Case Continues
The client demonstrates understanding of the
  surgical procedure and the team proceeds
  with the planned vaginal hysterectomy. The
  client weighs 96 pounds.

• In what position should you place this client
  for the surgical procedure?
• What areas on this client are most likely to be
  injured as a result of poor positioning or
  inadequate padding?
  Health Hazards Associated with
       Surgical Environment
• Laser Risks
• Exposure to blood and body fluids
• Latex allergy
             Types of Anesthesia
• General
  – 4 stages
• Regional
  – Epidural
  – Spinal
  – Local conduction block
• Moderate Sedation/Analgesia
• Monitored Anesthesia Care
• Local Anesthesia
Potential Intraoperative Complications
 Nausea and vomiting
 Anaphylaxis
 Respiratory complications
   Inadequate ventilation, airway occlusion, intubation of the
    esophagus, and hypoxia
 Hypothermia
 Malignant hyperthermia
 Disseminated Intravascular Coagulation

What are measures to prevent or treat these
      Postoperative Pain Control

• What is the definition of Pain?

• As nurses, what do we need to remember
  about the pain experience?

• What is the key reason to control
  postoperative pain?
            Opioid Analgesics
• Commonly prescribed for postoperative pain
  and immediate postoperative restlessness.

• Why would this drug be effective for

• By what route will this drug be adminstered?
     Patient Controlled Analgesia
• What is a nursing responsibility with PCA?

• What is the benefits of self administration of

• What are the two requirements for use of
            Epidural Infusions
• What is an epidural infusion?

• Why would an epidural infusion be used?

• When must epidural infusions be used
        Intrapleural Anesthesia
• What does intrapleural administration mean?

• What are the benefits to intrapleural
    Other Pain Relief Measures
• Subcutaneous Pain Management Systems

• Nonpharmacologic Measures
      Postoperative Care: PACU

• What is the goal of PACU care?

• What does PACU care entail?
       Immediate General Floor
         Postoperative Care
• What is included in the immediate post-
  operative care of the individual?

• How often should vital signs be assessed?

• What other assessments are needed?

• What should you do if the systolic pressure is
• < 90 mm HG?
  Post 24 hour Postoperative Care

• How does the focus of care shift after the first
  24 postoperative hours?

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