1. FUNDAMENTALS
of
NURSING:
special lecture on
Perioperative Nursing
Prepared by: Ronivin Garcia Pagtakhan, RN, MAN (c)
2. Perioperative Nursing
– a clinical specialty, refers to the role of the
nurse during the preoperative (before
surgery), intraoperative (during surgery)
and post operative (after surgery) phases
of the client’s surgical experience
3. What are the different types of
surgery?
- Severity/ Risk
- Urgency
- Reason
5. major surgery
These are surgeries of the head, neck, chest, and
abdomen.
The recovery time can be lengthy and may involve a
stay in intensive care or several days in the hospital.
There is a higher risk of complications after such
surgeries.
Types of major surgery may include:
removal of brain tumors
correction of bone malformations of the skull and face
repair of congenital heart disease, transplantation of
organs, and repair of intestinal malformations
correction of spinal abnormalities and treatment of injuries
sustained from major blunt trauma
correction of problems in fetal development of the lungs,
intestines, diaphragm, or anus.
6.
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17.
18.
19. minor surgery
The recovery time is short and patient return to their
usual activities rapidly.
These surgeries are most often done as an
outpatient
Complications from these types of surgeries are
rare.
Examples of the most common types of minor
surgeries may include, but are not limited to, the
following:
placement of ear tubes
hernia repairs
correction of bone fractures
removal of skin lesions
biopsy of growths
23. ACCORDING TO DEGREE OF
URGENCY
Emergent – life-threatening – without
delay
Severe bleeding
Urgent – prompt attention – 24-30 hrs
Cholecystitis
Required – needs – weeks-months
Cataract
Elective – should be, not catastrophic
Scar repair
Optional – personal reference
cosmetic
24. Biopsy is the removal of a piece of
tissue from an organ or other part of the
body for microscopic examination to
confirm or establish a diagnosis,
estimate prognosis, or follow the course
of a disease.
Curative surgery is the removal of the
entire tumor. Even after curative
surgery, you may still be given
chemotherapy or radiation to kill micro-
metastases. Micro-metastases are
cancer cells that may still be in the body
but cannot be detected by current
technology.
25.
26.
27. Cryosurgery involves the use of liquid nitrogen
or a very cold probe to freeze cancer cells.
Debulking surgery is when the entire cancer
cannot be removed without serious damage to
the body so the surgeon takes out only that
portion of the tumor that can be removed
safely. The rest of the tumor may be killed with
radiation therapy or chemotherapy.
Electrosurgery uses an electrical current to
destroy cancer cells.
Laser surgery is surgery in which a beam of light
is used instead of a scalpel.
Mohs surgery is the removal of skin cancer by
shaving off one layer at a time. The
dermatologist (skin doctor) looks at each layer
under a microscope. When the layers look
normal (no cancer) the surgeon stops removing
skin.
45. Prophylactic surgery
to prevent cancer when there is a good
chance that a particular body tissue will
become cancerous in the future.
Palliative surgery
does not treat the underlying disease but is
done to control symptoms of cancer, such
as pain.
Restorative or reconstructive surgery
commonly called plastic surgery
restores the function and appearance of an
area after a previous surgery.
46. Staging surgery
determine the extent of the cancer, or how
large it is and how much it has spread
throughout the body. This is very important,
as it will determine the course of treatment.
Ablative
Removal of a diseased organ
47. Surgery is affected by:
age
general health
nutrition
medications
mental status
51. PHYSICAL PREPARATION - Preoperative
checklist
Nutrition and hydration
Consumption of clear liquids up to 2 hours
before elective surgery requiring general
anesthesia.
Fasting for 4 hours prior to surgery after
ingesting milk products
Eating a light breakfast 6 hours before the
procedure
A heavier meal 8 hours before surgery
Fasting for 8 hours prior to surgery after eating
fatty foods
52. Elimination
Catheter insertion, Enema
Rest and Sleep
Hygiene
Bath ,Remove cosmetics, Remove all hairpins and
clips, OR gown
Medication
Discontinued, Preop meds
53. Personal valuables and prosthesis
Care of belongings, Remove all body prostheses
Special orders
NGT, insulin, etc
Special skin preparation
PREOPERATIVE TEACHING
proper timing
PAINMANAGEMENT
PHYSICAL ACTIVITIES
DBE , Coughing exercises , Leg exercises,
Turning in bed
EMOTIONAL SUPPORT
54. PREOP CHECKLIST
CONSENT
HEALTH TEACHING (SPEC. POST OP
PROCEDURES)
LAB TESTS,ECG,X-RAY
SKIN PREP
BOWEL PREP
IV’S
NPO
PREOP MEDS,SEDATION AND ANTIBIOTICS
REMOVAL OF DENTURES,NAILPOLISH AND
JEWELRY
NUTRITION-TPN OR ENTERAL FEEDINGS PREOP
55. INFORMED CONSENT
protects the patient from unsanctioned
surgery and protects the surgeon from
claims of an unauthorized operation
nurse may ask patient to sign the form
and witness the patient’s signature
the physician provides appropriate
information:
flow of surgery
alternatives
possible risks, complications, disfigurement
what to expect early and late post op
56. Indications of Informed Consent
invasive procedure/ surgery
use of anesthesia
nonsurgical by there might be slight risk
involves radiation
Criteria of Informed Consent
Consent voluntarily given (without
coercion)
Competent subject
64. Appendectomy
An appendectomy is the surgical
removal of the appendix, a small tube
that branches off the large intestine, to
treat acute appendicitis. Appendicitis is
the acute inflammation of this tube due
to infection.
65.
66.
67.
68.
69. Breast biopsy
A biopsy is a diagnostic test involving
the removal of tissue or cells for
examination under a microscope. This
procedure is also used to remove
abnormal breast tissue. A biopsy may
be performed using a hollow needle to
extract tissue (needle aspiration), or a
lump may be partially or completely
removed (lumpectomy) for examination
and/or treatment.
70.
71.
72.
73.
74. carotid endarterectomy
Carotid endarterectomy is a
surgical procedure to remove
blockage from carotid arteries, the
arteries located in the neck that
supply blood to the brain. Left
untreated, a blocked carotid artery
can lead to a stroke.
75.
76.
77.
78.
79. cataract surgery
Cataracts cloud the normally clear lens
of the eyes. Cataract surgery involves
the removal of the cloudy contents with
ultrasound waves. In some cases, the
entire lens is removed.
80.
81.
82.
83.
84.
85.
86. cesarean section
Cesarean section (also called a c-section) is the
surgical delivery of a baby by an incision through the
mother's abdomen and uterus. This procedure is
performed when physicians determine it a safer
alternative than a vaginal delivery for the mother,
baby, or both.
87.
88.
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90.
91.
92.
93. cholecystectomy
A cholecystectomy is surgery to remove
the gallbladder (a pear-shaped sac near
the right lobe of the liver that holds bile).
A gallbladder may need to be removed
if the organ is prone to troublesome
gallstones, if it is infected, or becomes
cancerous.
94.
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103.
104.
105. coronary artery bypass surgery
Most commonly referred to as simply "bypass
surgery," this surgery is often performed in
people who have angina (chest pain) and
coronary artery disease (where plaque has
built up in the arteries). Bypass surgery
consists of grafting veins or arteries from the
aorta (a major artery that carries blood from
the heart to the rest of the body) to the
coronary artery, bypassing areas that are
blocked. Veins are usually taken from the leg.
117. debridement of wound, burn, or infection
Debridement involves the surgical removal of
foreign material and/or dead, damaged, or
infected tissue from a wound or burn. By
removing the diseased or dead tissue,
healthy tissue is exposed to allow for more
effective healing.
118.
119.
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124.
125.
126.
127. dilation and curettage (Also called D
& C.)
A D&C is a minor operation in which the
cervix is dilated (expanded) so that the
cervical canal and uterine lining can be
scraped with a curette (spoon-shaped
instrument).
128.
129. free skin graft
A skin graft involves detching healthy skin
from one part of the body to repair areas of
lost or damaged skin in another part of the
body. Skin grafts are often performed as a
result of burns, injury, or surgical removal
of diseased skin. They are most often
performed when the area is too large to be
repaired by stitching or natural healing.
130.
131.
132.
133.
134. hemorrhoidectomy
A hemorrhoidectomy is the surgical
removal of hemorrhoids, distended
veins in the lower rectum or anus.
135.
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138.
139.
140.
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142.
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144.
145.
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147.
148. hysterectomy
A hysterectomy is the surgical removal of a
woman's uterus. This may be performed either
through an abdominal incision or vaginally.
hysteroscopy
Hysteroscopy is a surgical procedure used to
help diagnose and treat many uterine disorders.
The hysteroscope (a viewing instrument inserted
through the vagina for a visual examination of the
canal of the cervix and the interior of the uterus)
can transmit an image of the uterine canal and
cavity to a television screen.
149.
150.
151.
152.
153. mastectomy
A mastectomy is the removal of all or
part of the breast. Mastectomies are
usually performed to treat breast
cancer.
There are several types of mastectomies,
including the following:
partial
(segmental) mastectomy,
involves the removal of the breast
cancer and a larger portion of the
normal breast tissue around the breast
cancer.
154. total (or simple) mastectomy, in which
the surgeon removes the entire breast,
including the nipple, the areola (the
colored, circular area around the nipple),
and most of the overlying skin, and may
also remove some of the lymph nodes
under the arm, also called the axillary
lymph glands.
155. modified radical mastectomy, in
which the surgeon removes the entire
breast (including the nipple, the areola,
and the overlying skin), some of the
lymph nodes under the arm, and the
lining over the chest muscles. In some
cases, part of the chest wall muscles is
also removed.
156. radical mastectomy, involves removal of the
entire breast (including the nipple, the areola,
and the overlying skin), the lymph nodes
under the arm, and the chest muscles.
157.
158.
159.
160.
161. partial colectomy
A partial colectomy is the removal of
part of the large intestine (colon) which
may be performed to treat cancer of the
colon or long-term ulcerative colitis.
162.
163.
164. prostatectomy
The surgical removal of all or part of the
prostate gland, the sex gland in men
that surrounds the neck of the bladder
and urethra - the tube that carries urine
away from the bladder. This may be
performed for an enlarged prostate,
benign prostatic hyperplasia (BPH), or if
cancerous.
174. tonsillectomy
The surgical removal of one or both
tonsils. Tonsils are located at the back
of the mouth and help fight infections.
175. INTRAOPERATIVE PHASE
begins with the admission of the client
to the surgical area and ends when the
client is transferred to the recovery
area.
176. INTRA-OPERATIVE CARE
MAINTAIN SURGICAL ASEPSIS, MONITOR CLIENT
STATUS,, APPROPRIATE GROUNDING DEVICES,
FLUID BALANCE AND SPONGE/INSTRUMENT
COUNT
SCRUB NURSE – HANDLES EQUIPMENT ,
MATERIALS TO THE SURGEON, SPONGE
AND INSTRUMENT COUNT
( STERILE)
CIRCULATING NURSE- ENSURES ADEQUACY
OF SUPPLIES, SKIN PREP ,
DOCUMENTATION , HANDLES STERILE
EQUIPMENTS BY FORCEPS
177. The OPERATING ROOM
freefrom contaminating particles, dusts,
pollutants, radiation, noise
ZONES
Unrestricted – street clothes are allowed
Semi-restricted – scrubs, shoe covers,
cap and mask
Restricted zone
178.
179. SURGICAL SKIN PREPARATION
Cleaning, shaving, applying antimicrobials
POSITIONING
Performed after anesthesia is given
Provide correct position for the specific
procedure
Protect bony prominences
Avoid strain or injury to muscles, bones
and joints
Protect the skin – lift rather than pull or roll
the client into position
181. OTHER RESPONSIBILITIES
Draping
Assist in preparing and maintaining the sterile
field
Open sterile packages during surgery
Provide meds and solutions for the sterile field
Monitor and maintain sterile environment
Manage catheters, tubes, drains and
specimens
Perform sponge, instrument and sharp counts
Document care provided and client responses
Transferring of client to RR
Endorsement
182.
183.
184. THE SURGICAL EXPERIENCE
ANESTHESIA
stateof narcosis (severe CNS depression)
Analgesia, relaxation, reflex loss
General Anesthesia – inhaled, most
common
Volatile liquid agents – vapors
Halothane, enflurane, isoflurane, sevoflurane
Gas anesthetics – with oxygen, N2O
185. IV ANESTHESIA
Barbiturates, benzodiazepines, non-barbiturates
Opioids
used for induction (initiation) or mainstream
used to produce conscious sedation
Advantages Contraindications
onset is pleasant children
non-explosive powerful
easy to administer respiratory
decreased nausea
depressant
and vomiting
186. CONSCIOUS SEDATION
depression of LOC without impairment of
the patient’s ability to maintain a patent
airway and to respond to physical
stimulation and verbal command
Medazolam (Versed), Diazepam
first dose is given by the physician
succeeding doses – RN, Nurse-anesthetist
WOF: dysrhythmias, CNS, Respi
depression
O2, resuscitation, pulse oximetry, cont.
ECG, VS
Adjunctive Agents : Neuromuscular
blockers – purified curare
187. REGIONAL ANESTHESIA
form of local anesthesia
anesthetic agent is injected around nerves
so that the area supplied is anesthetized
188. SPINAL ANESTHESIA
extensive conduction nerve block
local anesthetic agent into subarachnoid
space at the lumbar level (L4, L5)
lower extremities, perineum, lower
abdomen
knee-chest position, place supine after
injection
if high level block, head and shoulders are
lowered
anesthesia and paralysis of toes, perineum
then legs and abdomen
may also reach upper thoracic and cervical
spine resp paralysis
189. CONDUCTION BLOCKS
Epidural anesthesia
injection of local anesthetic into the spinal
canal in the space around the dura mater
higher dose than spinal
no headache
disadvantage: epidural space vs.
subarachnoid space
190. Brachial plexus
arm
Paravertebral anesthesia
chest, abdominal wall, extremities
Transsacral (caudal)
perineum, lower abdomen
Local Infiltration Anesthesia
Advantages – simple, economical,
nonexplosive, minimal equipment, postop
recovery is shortened, no GA side effects,
short superficial surgical procedures
191. TAKE NOTE: Anesthesia
Halothane-respiratory and cardiovascular
depression-monitor VS, open IV site-ABC’s
prevent aspiration
Nitrous Oxide- Hypotension and nausea and
vomiting- adequate O2
IV thiopental Na- decreased BP , respiratory
depression, laryngospasm- ABC
spinal and saddle – hypotension and HA-
increased OFI
conduction block/epidural block- hypotension
and respiratory depression-HA not experienced
local – excitability and hypersensitivity;no
epinephrine on fingers
192. STAGES OF ANESTHESIA
STAGE 1. BEGINNING ANESTHESIA,
analgesia, sedation and relaxation
warmth, dizziness, feeling of
detachment
ringing, roaring, buzzing in ears
aware of being unable to move the
extremities noises are exaggerated
193. STAGE 2. EXCITEMENT, DELIRIUM
struggling, shouting, talking, singing,
laughing, crying – decreased if
anesthesia is given quickly and
smoothly
pupil dilates but constricts if with light
PR rapid, RR irregular
Vomiting
Restraining
194. STAGE
3. SURGICAL ANESTHESIA,
OPERATIVE ANESTHESIA
unconscious
pupils – small but reactive
RR irregular, PR normal
Skin – pink, flushed
No hearing
195. STAGE
4. MEDULLARY
DEPRESSION, DANGER
if
anesthesia is too much
RR shallow
Pulse weak, thready
Pupils – widely dilated, non reactive
Cyanosis death
202. Suture
medical device use to hold skin, internal
organs, blood vessels and all other
tissues of the human body together
after they have been severed by injury,
incision or surgery.
203. Assessment of the suture line:
Stitched too tight or too loose
Too many or too few stitches
Suture holes not equidistant for the edges so
that the bite is not uneven, or uneven spacing
between sutures
Inversion or eversion of tissue edges
Edges of tissue overlapping and heaped on
each other.
204. Types of stitch:
Simple interrupted suture
Inserted singly through each side of the
wound and tied with a surgeon’s knot. Several
of these may be used at short intervals ( 4—
8mm apart) to close large wounds and share
tension. Easy to keep clean, can be replaced
singly and will evert edges of the flap.
205.
206. Horizontal mattress suture
Evert the mucosal or skin margins,
thereby bringing greater areas of raw
tissue into contact. Useful for closing
wounds over bony deficiencies such as
oro-antral fistulae or cyst cavities.
207.
208.
209.
210. Vertical mattress suture
Specially designed for use in the skin.
Pass through at two levels:
(i) Deep—provides
support and adduction of wound surface
(ii) Superficial—draw
edges together and evert them
211. Vertical Mattress is a suture technique
most commonly used in anatomic
locations which tend to invert, such as
the posterior aspect of the neck or the
palm of the hand.
This type of suture is good for deep
lacerations, instead of combining two
layers of deep and superficial sutures.
212.
213.
214. Continuous suture
Disadvantaged that if they cut out at
one point the whole suture will slacken.
Advantage—only two knots present.
¨ Simple continuous— applies pull on
the wound obliquely
¨ Continuous blanket stitch—more firm
and stable. Gives traction on the wound
edges at right angles to the wound
¨ Purse string suture—useful as a deep
suture for wounds of the skin of the
face.
215. Suture sizes:
defined by the United States
Pharmacopeia (U.S.P.).
Sutures were originally manufactured
ranging in size from #1 to #6, with #1
being the smallest.
Modern sutures range from #5 (heavy
braided suture for orthopedics) to #11-0
(fine monofilament suture for
ophthalmics).
216. Types of Suture Material
Plain catgut
Absorbable biological suture material.
taken from bovine intestines.
absorbed by enzymatic degradation.
217. Chromic
Absorbable biological suture material.
taken from bovine intestines.
offers roughly twice the stitch-holding time of
plain catgut.
absorbed by enzymatic degradation.
Note– catgut is no longer used in the UK for
human surgery.
220. Indication
Plain catgut Chromic Polyglycolic Polydioxanone
acid (P.G.A.) (PDS)
-all surgical -all surgical Subcutaneou - combination of
procedures procedures s, an absorbable
- for tissues - for intracutaneo suture
regenerating tissues that us closures, - extended
faster are regenerate abdominal wound support
involved. faster. and thoracic is desirable,
- General surgeries pediatric
closure, cardiovascular
ophthalmic, surgery,
orthopedics, ophthalmic
obstetrics/gyne surgery
, GI
221.
222.
223.
224. Removal of Sutures
facial wounds 3–5 days
scalp wound 7–10 days
trunk of the body 7–10 days.
limbs 10–14 days
joints 14 days
225. Others….
Tissue adhesives
topical cyanoacrylate adhesives ("liquid
stitches"), combination or alternative to, sutures
in wound closure.
adhesive is liquid exposed to water/water-
containing substances/tissue cures
(polymerizes) forms a flexible film that bonds
to the underlying surface.
act as a barrier to microbial penetration as long
as the adhesive film remains intact.
Contraindications: near eyes and a mild
learning curve on correct usage.
226. Antimicrobial sutures
sutures coated with antimicrobial
substances to reduce the chances of wound
infection.
228. Malignant Hyperthermia
d/tanesthetic agents, muscle relaxants,
syphatomimetics, theo/aminophylline,
anticholinergic, cardiac glycosides
Risks: bulky, strong muscles, muscle cramps,
weakness
CM: tachycardia, SNS stimulation
(vent.dysrhythmias, hypotension, dec CO, oliguria,
cardiac arrest, tetany-like movements, increased
temperature 1 degree every 15 minutes
Mgt: critical assessment 10-20 mins post induction
or 24 hrs postop; stop anesthesia, surgery; 100%
oxygen; DANTROLENE Na – muscle relaxant,
NaHCO3
229. POSTOPERATIVE PHASE
begins with the admission of the client
to the PACU and ends when healing is
complete
PHASE I – Immediate postoperative care,
intensive nursing care
PHASE II – Ongoing postoperative care
Step down, Sit up or Progressive Care Unit
– 4-6 hours
230. NURSING RESPONSIBILITIES
ASSESSMENT
Respiratory Status
Airway patency, O2 sat, Effectiveness of ventilation
Cardiovascular Status
BP, All pulses, Color, skin temp, edema , Urine
output
CNS
LOC, Orientation, Reflexes, Ability to move
extremities
Fluid Status
IVF, Urine output, Wound drainage, Drainage from
catheters, tubes and drains, Skin turgor, edema, VS
231. Status of wound
Dressing and drainage
Pain
Nausea and Vomiting
Keep all lines patent
Assure that monitors and equipments are
functioning
Positioning
Help arouse and orient the client
Facilitate oxygenation
Treat hypotension
Provide for safety AND comfort
232. Readiness for Discharge from PACU
uncompromised pulmonary function
pulse oximetry ok
stable VS
oriented
U/O > 30cc/hr
N/V under control
Minimal pain
234. Assess and Manage Hemodynamic
stability
Shock and hemorrhage
WOF dec BP 90 mmHg, dec, 5 mmHg q
15mins
IVF
FVE
I&O
Venous stasis – d/t dehydration,
immobility, pressure on legs DVT
(Homan’s sign, pain swelling on calf, fever,
chills, diaphoresis) = leg exercises,
antiembolism stocking, early ambulation,
low dose heparin
235. Assess and Manage the Surgical Site
WOF bleeding, dressing, drains
Hematoma
Infection after 5 days, wound dehiscence
and evisceration
Assess and Manage Pain
Maintain body temperature
Assess Mental status and NVS
LOC, speech, orientation
Assess GI function
N/V, hiccups, NGT, Antiemetics,
phenothiazine
Liquid - clear liquid soft solid food
236. Assess and manage voluntary voiding
Urinary retention
Void within 8 hours post surgery non
catheter interventions catheter
Encourage Activity
Earlyambulation
Bed exercises
Maintain safe environment
Provide emotional support to the patient
and family
237. POST-OPERATIVE COMPLICATIONS
SHOCK
PARALYTIC ILEUS
ATELECTASIS AND PNEUMONIA - 2ND DAY
EMBOLISM- 2ND DAY
WOUND INFECTION-3-5D
DEHISCENCE AND EVISCERATION-5-6D
PSYCHOSIS
CARDIOVASCULAR COMPROMISE
URINARY RETENTION-8-12H
URINARY INFECTION -5-8 D
DVT-6-14 DAYS-1 YEAR
238. POST-OPERATIVE CARE
POST OP- MONITOR VS
Q15X4;Q30X2;Q1HX2 THEN PRN
MONITOR I AND O , K LEVEL , CVP, BOWEL
SOUNDS, BREATH SOUNDS AND LOC
RESPIRATORY PHYSIOTHERAPY,TCBD
INCENTIVE SPIROMETRY-20 SECS INHALATION
ENCOURAGE AMBULATION
REFER IF UNABLE TO VOID IN 8 HOURS
APPLY TED HOSE AND PNEUMATIC
COMPRESSION DEVICE,CHECK FOR HOMAN’S
SIGN
241. TYPES OF DRESSINGS
DRY TO DRY – TRAP NECROTIC DEBRIS
AND EXUDATE
WET TO DRY ( SALINE AND ANTI
MICROBIAL SOLUTION – SOFTEN DEBRIS
AS IT DRIES, DILUTE EXUDATE
WET TO DAMP – WOUND DEBRIDED IF
GAUZE REMOVED( VARIATION @
DRYING)
WET TO WET – KEEP MOIST – WOUND
BATHED – MOISTURE DILUTES VISCIOUS
EXUDATE
242. pressure ulcer dressings
drygauze stage II-IV
tegaderm film/ hydrocolloid – SI - SII
Absorptive Dressing III
Hydrogel – II - III
243. SURGICAL DRAINS
PENROSE – OPEN ENDS
CLOSED WOUND DRAINAGE ( SUCTION) –
DECREASE ENTRY OF MICROBES-
HEMOVAC / JACK PRATT TO RESERVOIR
D/C 3-7 DAYS POST – OP
