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Surgical Asepsis: Pre-op
Rita Revak-Lutz
Introduction
Role of the Perioperative Nurse:
Umbrella term that describes care of client from the time decision is made to have the surgery, until discharge from the hospital
Introduction
Role of the Perioperative Nurse:
Four phases of operative experience: Pre-op:
Intraoperative:
Introduction
Role of the Perioperative Nurse:
Four phases of operative experience: Immediate post-operative:
Convalescent: Intermediate:
Extended:
Introduction
Common purposes of surgery
Diagnostic:
Exploratory:
Ablative:
Reconstructive
Introduction
Common purposes of surgery
Reconstructive:
Palliative
Introduction
Categories of Surgery: Emergent:
Urgent:
Elective:
Please review Lewis, Table 18- Suffixes describing surgical procedures
Operative Permit: client must sign a voluntary and
informed consent or permit for surgery
Protects patient Protects surgeon and hospital staff
Introduction: Legal Aspects of Surgery Introduction: Legal Aspects of Surgery
Informed Consent: active, shared decision-making
process between provider and recipient of care
Introduction: Legal Aspects of Surgery
Surgeonâs responsibility:
Ensure that client is giving informed consent Explanation of Surgical procedure Risks, including potential for death, need for blood transfusion Alternatives to surgery
Introduction: Legal Aspects of Surgery
Role of Nurse
Ensure consent is informed and voluntary Sound mind Not sedated Understands English Understands what the surgeon said Obtains and witnesses the patientâs signature Contact the physician and explain the need for additional information
Introduction: Legal Aspects of Surgery
Role of Student Nurse
MAY NOT witness consent Ensure pre-op meds are not given prior to consent Relay any questions that the client may have
Surgery as a Stressor
Surgery elicits the stress response (GAS)
Norepinephrine and Epinephrine released: Prepares us for âfight or flightâ Increased blood pressure Increased heart rate Bronchial dilatation Increased cardiac output Decreased peristalsis
Surgery as a Stressor
Surgery elicits the stress response (GAS) ACTH is released, which stimulates release of Cortisol and Aldosterone
Cortisol:
- Stimulates glucogenesis
- Increases protein breakdown:
- Increase anti-inflammatory response:
Increased platelets: promotes clotting of blood
Surgery as a Stressor
Surgery elicits the stress response (GAS)
Aldosterone
Surgery as a Stressor
Surgery elicits the stress response (GAS)
Posterior Pituitary releases anti-diuretic hormone (ADH)
Water Retention:
Surgery as a Stressor
Lowered defense against infection
First line against infection is violated Anti-inflammatory effect of cortisol
Disrupted vascular system
Disturbed organ function
Body image disturbance
Lifestyle Changes
Assessing Surgical Risk: Age
Very Young
Poorly developed lungs: less able to tolerate surgery as lungs have less range for stress: increased risk of pulmonary problems
Thin skin: Prone to breakdown Increased problems with healing
Assessing Surgical Risk: Age
Elderly Aeration: 30 % decrease in ventilatory function by age 60
Circulation
Assessing Surgical Risk: Age
Elderly
Renal:
Sensation
Assessing Surgical Risk: Age
Elderly
Sensation
Skin
Assessing Surgical Risk: Age
Elderly
Mobility
Nutrition
Assessing Surgical Risk: Nutrition
Obese Client: Excess adipose tissue and poor
blood supply
Prolonged Surgery
Prolonged excretion of anesthetic agent
Assessing Surgical Risk: Nutrition
Obese Client:
Reduced ventilatory function
Slower healing process
Assessing Surgical Risk: Nutrition
Underweight client: May lack needed vitamins and proteins Risk for poor wound healing and infection May be at risk for skin impairment with significance of bony prominences
Assessing Surgical Risk: Fluid and Electrolyte Balance
Adequate fluid and electrolyte balance is needed to
maintain blood volume and urinary output
Too little fluids
Electrolyte imbalance
Impact of Pre-existing Conditions on Surgical Risk
Bleeding disorders
Diabetes
Impact of Pre-existing Conditions on Surgical Risk
Heart disease
Fever
Impact of Pre-existing Conditions on Surgical Risk
Upper respiratory infection
Chronic respiratory disease
Impact of Pre-existing Conditions on Surgical Risk
Liver Disease
Immune Disorders
Renal Insufficiency
Pre-Operative Assessment: Physiological
Nursing Assessment and History: Nutrition
1. Height and Weight:
To determine drug doses Assess post-op fluid retention Admission weight is goal to be maintained after surgery
2. Serum Protein levels:
Assess healing potential
Pre-Operative Assessment: Physiological
Nursing Assessment and History: Respiratory
- History of smoking, any chronic lung diseases, or recent URI?
- Rate, Pattern
- Breath sounds
- Chest x-ray
- O2 sats
- Arterial blood gases as needed
Pre-Operative Assessment: Physiological Nursing Assessment and History: Cardiovascular
- History of cardiac disease: MIâs, CHF, Murmurs
- B/P
- Pulse: apical and peripheral
- Edema
- JVD
- Chest pain
- EKG
- Chest X-ray
- Capillary refill
Pre-Operative Assessment: Physiological
Nursing Assessment and History: Immunologic
1. Allergies: drugs, environmental, latex, tapes,
betadine
Allergy band and note prominently on chart
2. WBC: Acute infection
Pre-Operative Assessment: Physiological
Nursing Assessment and History: Drug therapy
1. What prescribed , OTC, and herbal drugs are
they currently taking?
2. Coumadin: what is PT/INR
3. Diuretics: can potentiate electrolyte imbalances
4. B/P, cardiac meds: can interact with anesthesia
and result in hypotension and bradycardia
5. Insulin
Pre-Operative Assessment: Physiological
Common Pre-op Screenings and Examinations
- CBC
- UA
- Chest X-Ray
- EKG
- Coagulation studies
- Electrolytes
- Serum Creatinine
- Type & Cross for blood Please review Lewis, Table 18-6 for rationales
Pre-Operative Assessment: Psychological
1. Anxiety
Look for cues of anxiety Physiological Behavioral Nurse can allay anxiety Therapeutic communication Determine source of anxiety Clear up misconceptions
Pre-Operative Assessment: Psychological
Fear: many causes for fear
Unknown: may be first surgery Pain and pain management Concern with body image/ change in image Death Anesthesia Disruption of life: having to be dependent on others
Pre-Operative Assessment: Psychological
Ability or inability to cope
Does client exhibit ability to problem-solve? How have they coped with past stressors? Have they had past surgeries? If so, what helped them cope at that time?
Pre-Operative Assessment: Psychological
Knowledge of the surgery, anesthesia, and their role
Does the client know what they need to know?
Support system
Do they have a support system?
What are the post-operative plans?
Pre-Operative Assessment: Sociocultural
Support System
Economic
Plans for convalescence
Nursing Diagnoses:
Knowledge Deficit
Regular or heavy meal
Light meal (toast and clear liquids)
Non-human milk, including baby formula
Breast Milk
Clear Liquids
Liquid and Food Intake Minimum Fasting Period
Nursing Diagnoses:
Knowledge Deficit
Pre-operative Medications
Instructions on what to do with routine, prescribed medications
A. Narcotics: Morphine, Demerol
A. Antiemetics: Reglan, Zofran
Nursing Diagnoses:
Knowledge Deficit
Pre-operative Medications
C. H2 Receptor antagonists: Tagamet,
Pepcid, Zantac
D. Benzodiazepines: Valium, Versed, Ativan
Nursing Diagnoses:
Knowledge Deficit
Pre-operative Medications
E. Anticholinergics: Atropine, scopolamine, glycopyrrolate
F. Bowel Preps: Enema, Magnesium Citrate,
Antibiotics, Low-residue Diet
Nursing Diagnoses:
Knowledge Deficit
Pre-operative Medications
G. Pre-operative antibiotics
Nursing Diagnoses:
Knowledge Deficit
Pre-Operative
- Surgical Permit
- Pre-op Screenings and Examinations
- Foley Catheter
- Pre-op diet and fluid restrictions
- Pre-op Medications
- Skin Prep Cleansing skin Clipping or shaving hair
- Family Support
Nursing Diagnoses:
Knowledge Deficit
Pre-Operative
- Surgical Permit
- Pre-op Screenings and Examinations
- Foley Catheter
- Pre-op diet and fluid restrictions
- Pre-op Medications
- Skin Prep
- Family Support Tell family when to arrive prior to surgery Direct them to appropriate waiting area Discuss how they will be contacted
Nursing Diagnoses:
Risk for Injury
1. Client preparation on surgical day
Make sure client voids prior to being given meds Double check that consent is signed prior to being given meds Give meds as ordered Ensure safety Siderails up Bed in low Call light
Nursing Diagnoses
Knowledge Deficit
Postoperative
- PACU âpost anesthesia care unitâ âRecovery Roomâ Will awaken there Frequent VS May feel cool/warm Family may be allowed in after you awaken, depending on your condition and whatâs going on in unit
Nursing Diagnoses
Knowledge Deficit
Postoperative
- Pain control Will have some type of pain medication ordered Ask for pain medication prior to pain becoming too severe May have PCA (Patient controlled analgesia) Basal infusion of narcotic, on demand extra
Nursing Diagnoses
Knowledge Deficit
Postoperative
- Tubes and drains Ask if surgeon has explained any drains or tubes post-op May have N/G tube (if GI surgery) May have drainage tubes Penrose Jackson-Pratt Hemovac
Nursing Diagnoses
Knowledge Deficit
Postoperative
- Respiratory exercises Coughing Incentive Spirometer Deep Breathing
Anesthesia
Increases lung secretions Causes respirations to be shallow
Secretions pool in lower airways
Nursing Diagnoses
Knowledge Deficit
Postoperative
5 Cardiovascular exercises Leg exercises Stimulates circulation by promoting venous return to heart Prevents thrombus formation Kozier Procedure 35- Dorsiflexion and plantar flexion of feet Knee flexion and extension Raising and lowering legs
Nursing Diagnoses
Knowledge Deficit
Postoperative
5 Cardiovascular exercises Antiemboli Stockings/ Sequential Compression Devices (Kozier Skills 37-2, 51-1) Facilitate venous return Improve arterial circulation to the feet and prevent edema DO NOT TAKE PLACE OF LEG EXERCISES: only facilitates muscle contraction
Nursing Diagnoses
Knowledge Deficit
Postoperative
6. Turning
Mobilizes respiratory secretions to dependent portions of the lungs Move q 1-2 hours while awake
