Keperawatan Perioperatif: Reni Prima Gusty, S.KP, M.Kes
Keperawatan Perioperatif: Reni Prima Gusty, S.KP, M.Kes
Keperawatan Perioperatif: Reni Prima Gusty, S.KP, M.Kes
“PERIOPERATIF”
Suatu istilah gabungan yang
mencakup tiga fase pengalaman
pembedahan: praoperatif
intraoperatif, dan pascaoperatif.
Meet the Patient
The experience
of surgery is a
routine event for
everyone
involved EXCEPT
for the patient!
Special Situations
Developmental Considerations:
• Infants and Older adults are at
greater risk from surgery than are
children and young or middle
adults
• The infant has lower total blood
volume which puts it at risk for
dehydration and increased oxygen
needs during surgery
• The infant has difficulty maintaining
body temperature, making
• The infant has a lower GFR and creatinine clearance
which leads to slower metabolism of drugs
• The infant also has an immature liver, which may
cause the effects of muscle relaxants and narcotics to
be longer
• The older adult also has a decrease in metabolism and
renal functioning which puts them at risk for
anesthesia complications
• The older adult may also have prolonged or altered
wound healing
• Chronic illnesses are more common in older adults
Medical History
• Provides information about past and
current illnesses
• Pathologic changes increases surgical
risk and post-op complications (i.e.
diabetes, heart disease, respiratory,
etc)
• Provides a data base for individualized
assessments and interventions
Medications
• Certain medications may interfere
with anesthesia or put client’s at
risk for bleeding; therefore, it is
important to obtain information
about:
• Prescribed medications
• Over-the-Counter medications
• Herbals or other dietary supplements
Specific medications that cause increased
surgical risk:
• Anticoagulants (may cause hemorrhaging)
• Diuretics (may cause electrolyte imbalances)
• Tranquilizers (increased hypotensive effects
with anesthesia)
• Adrenal steroids (withdrawal may cause
cardiovascular collapse)
• Antibiotics (mycins interfere with muscle
relaxants)
• Insulin
• Anticonvulsants
Previous Surgery
• Physical implications
• Positioning changes
• Adaptations to anesthesia
• Complications
• Malignant hyperthermia
• Latex allergy
• Pneumonia
• Thrombophlebitis
• Surgical site infection
• Past experiences with surgery
• Pain management
• Negative feelings
• Perceptions and knowledge of
surgical procedure
• Aids with care planning for surgery
• Patient and family teaching
• Meeting patient and family psychosocial
needs
• Discharge preparation
Nutrition and Nutritional Status of Client
• Malnutrition:
• increased risk for poor wound healing
• Increased risk for wound infection
• Obesity:
• Increased risk for respiratory, cardiovascular, and
gastrointestinal problems (GERD)
• Fatty tissue has a poor blood supply causing
possible increased risk for infection and possible
delayed wound healing
• Disruption in integrity of wound
(evisceration/dehiscence)
Alcohol, Drug Use, or Nicotine Use
• These client’s may require increased doses of
anesthesia and post-op analgesics
• Illicit drugs may interfere with anesthetic agents
• Smokers are at increased risk for respiratory
complications after surgery (difficulty in clearing
respiratory passages due to mucous collection
after anesthesia)
• Smoking compromises wound healing by
constricting blood vessels, impairing blood flow
to the tissues.
Occupation
• May be delay in return to work or work-related
activities
• Financial Stressors
Activities of Daily Living
• Exercise (a patient with established exercise
program has improved cardiovascular,
respiratory, metabolic, and musculoskeletal
functioning)
• Rest (Rest and sleep are essential to physical
and emotional adaptation and recovery from the
stress of surgery)
• Sleep habits
Coping Patterns
• Psychological
• Dealing with stress and anxiety (fear about physical
attractiveness, social relationships, lifestyle and
sexuality)
• Displays of stress: anger, hostility, withdrawal, apathy,
confrontation and questioning
• Sociocultural (family cultural beliefs and
backgrounds) c/o pain
• Spiritual (prayer, other rituals, faith in a higher power,
visits from spiritual leaders)
Support Systems
• Family (the patient benefits from knowing when family
and friends can visit after surgery)
• Friends
The Nursing Process in Pre-Operative Client
Care
Nursing Diagnoses
Planning Interventions
Implementation
Outcomes identification
***Planning for the entire perioperative
period is done in the preoperative phase
and includes expected outcomes that are
discussed and mutually agreed on by the
nurse, the patient, and the family***
Pre-Operative Teaching
• Timing is a significant consideration: teaching too far
in advance of surgery or when the patient is anxious
is less effective
• Information to teach client in Preoperative Phase:
• Exercises and physical activities (Cough, Turn, Deep
Breath, incentive spirometry, and leg exercises) q 2 hours
• Unless contraindicated (head injuries and eye surgery – No
coughing)
• Pain management (PRN orders, timing to ask, incision
splinting) Assess q 2 hours; relaxation and alternative
methods
• Visit by anesthesiologist
• Physical Preparation (NPO, sleep meds, pre-op checklist)
• Visitors and waiting room
• Transported to OR by stretcher
Pre-Operative Checklist (example p. 417
Brunner) Day of surgery:
• Consent forms signed and witnessed
• Advance directives are in the medical record
• Perform Hand Hygiene
• Check Vital Signs (*notify physician of any
pertinent changes – rise or drop in bp, increased
temp, cough, or symptoms of infection*)
• Provide hygiene and oral care
• Remind client of NPO status
• Instruct patient to remove all clothing and
underwear and don hospital gown
• Ask patient to remove cosmetics and jewelry
including body piercing, nail polish, and prostheses
(false eye lashes, contact lenses, dentures, etc)
• If possible give valuables to the family member or if
not lock them in hospital safe
• Have patient empty bladder and bowel before surgery
• Complete Pre-Op orders
• Administer Preoperative medications as prescribed by
anesthesiologist/physician
• Sedatives
• Anitcholinergics
• Narcotic analgesics
• Neuroleptanalgesic agents
• Histamine receptor antihistaminics
• Raise side rails; place bed in low position
• Instruct patient to remain in bed or stretcher
• Help move pt from bed to stretcher
• Reconfirm patient Identification
• Ensure that all pre-op events and measures are documented
• Tell family where pt will be taken after surgery and location
of waiting rooms
• After the pt leaves the room set up room for pt’s return from
OR
• Explain holding area (keep area as quiet as possible)
• Explain OR suite and what to expect
• Positioning
• Draping
• Documentation (verify pt identification, surgical procedure and
surgical site)
• PACU
Surgery Specific Care
Immediate Care
• PACU (ensures pt is stable before
transfer to floor)
Ongoing Post-operative care
• Sent to Critical Care (unstable or
special needs)
• Return to medical floor
Ongoing Postoperative
Care
Assessing – post-op checklist or flow sheet, initial
assessment, post-op physician orders Diagnosing –
Actual problems or risk for
Outcome Identification and Planning – continue
plan of care identified in pre-operative phase;
specific outcomes are individualized based on risk
factors, the surgical procedure, and the patient’s
unique needs
• Carry out leg exercised q 2-4 hours
• T, C, and DB q 2 hours
• Have decreased pain levels
• Regain bowel and bladder elimination
• Have well-healed surgical incision
• Remain free of infection
• Verbalize concerns about appearance of wound
• Verbalize and demonstrate wound self-care
Detailed Assessment
Respiratory
Cardiovascular
Fluid Status
Nutrition
Elimination
Activity
Wound Healing
Respiratory
Pulmonary
assessment
data
TCDB
• C/I: CHI, eye sx
O2 therapy
The real reason dinosaurs
IPPB became extinct.
I.S.
Cardiovascular
Leg exercises
Avoiding venous
statsis
ICD/hose
Fluid Status
Hydration status
data
Drainage amts
vital signs
daily weights!
IV therapy
Blood therapy
Nutrition
NPO status
Progression of
diet
check bowel
sounds
Urinary output
• retention?!!
• Dehydration
• Catheter is the
last resort!
Bowel activity
• bowel sounds
• flatus
Ambulation!!!!
Activity
OOB ASAP!!
• Usually within 24
hrs
Psychological
impact
Needs
encouragement!
Physiology of Wound
Healing
Inflammatory Stage
• “insult”
Proliferative Stage
• reinforcemen/framework
Maturation Stage
• “settling in”
Wound Healing:
First Intention
Scar formation is minimal
Properly closed
Heal with little tissue reaction
Wound Healing:
Second Intention
Wound is left open to granulate
Resultant in scar formation
“Healing by granulation”
Wound Healing:
Third Intention
Two opposing granulation surfaces
are brought together
Scar is deeper and wider
“Delayed closure”
Factors Affecting
Wound Healing
Age Oxygen deficit
Hemorrhage Drainage
Hypovolemia Medications
Local Factors Systemic
Nutritional Disorders
Deficits Wound Stressors
Post-op Pain Control
What is pain?
Factors affecting pain
Administration
• Preventative Approach
• PRN vs ATC
• Routes of Administration
• Intramuscular
• Intravenous
• PCA pump/Epidural lines
Post-op Pain Control