Keperawatan Perioperatif

Reni Prima Gusty,S.Kp,M.Kes

 KEPERAWATAN PERIOPERATIF:

“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

 Patients who require surgical

intervention and nursing care
enter the healthcare settings in
a variety of situations:
• Planned elective procedures
• Emergency procedures
• Treatment of trauma
The Nurse is responsible
for:
 Identifying factors that affect the risk for
the surgical procedure
• Assessing physical needs (hearing
impaired, visually impaired, chronic
illness, etc)
• Assessing psychosocial needs of patient
and family
• Establishing a plan of care based on
appropriate nursing diagnoses
• Meet patient needs
• Facilitate recovery
 Health History

 The health history identifies risk

factors and strengths in the client’s
physical and psychosocial status
 The health history helps the Nurse to
INDIVIDUALIZE the preoperative
assessment
 Helps to ensure interventions to
maintain pt safety
 Important Components of the
Client’s Health History

 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

 Postoperative Uniquities and

“worries”
Postoperative Phase:
Plan of Care
 Postoperative Nursing
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

 Initial hours post-op

• Ensure adequate ventilation
• Ensure hemodynamic stability
• Assess for incision pain
• Assess surgical site integrity
• Assess and tx N & V
• Assess neurologic status
• Assess cognitive status
• 51% of older adults experience post-op confusion
and delirium
 Vital Signs Post-Op
• P, bp, and RR are evaluated every
15 minutes X 1 hour, and if stable,
then every 30 minutes for the next
2 hours.
• Temp is evaluated and recorded
every 4 hours for the first 24 hours.
 Implementation – nursing care to
prevent post-op complications,
promote a return to health, and
facilitate coping with alterations,
and further to keep family informed
about need for frequent assessments
and presence of necessary
equipment to appropriately monitor
patient.
 Preventing post-op cardiovascular complications
 Hemorrhage (monitoring wound drainage, and
output)
 Shock (hypovolemic shock) (monitor output & vital
signs) and replenish fluid loss (adequate intake)
 Thrombophlebitis (venous stasis in legs/clot
formation – applying TED hose, CPMs, leg
exercises, early ambulation, and anticoagulant
medications as ordered, and prevent knee gatch
(constriction of blood vessels which impede
circulation)
 Pulmonary embolism (dislodged blood clot or
foreign substance that travels to the pulmonary
vessels)
 • Hypertension -- is common in the
immediate postoperative period
secondary to sympathetic nervous
system stimulation from pain, hypoxia, or
bladder distention
• Dysrhythmias are associated with
electrolyte imbalance, altered respiratory
function, pain, hypothermia, stress, and
anesthetic agents
• *Both are managed by treating the
underlying causes*
 Preventing Respiratory Complications
• Pneumonia (aspiration, depressed cough reflex,
increased secretions from anesthesia,
dehydration and immobilization)
• Increased temp, chills, a productive cough with
rusty or purulent sputum, crackles, wheezes,
dyspnea, and chest pain
• Atelectasis (incomplete expansion or collapse of
alveoli with retained mucus, involving a portion
of lung and resulting in poor gas exchange
• Decreased lung sounds over affected area,
dyspnea, cyanosis, crackles, restlessness, and
apprehension
 Ways to Prevent Respiratory
Complications:
• HOB in Semi-Fowler’s position
• Administering Oxygen Therapy as
needed
• Administering analgesics for pain
• Use of incentive spirometry (deep
breathing)
• Coughing while splinting
 Nursing Assessments and Interventions to
meet Elimination needs:
• Bowel elimination:
• Auscultate for peristalsis q 4 hours
• Assess abdominal distention, especially if bowel
sounds are not audible or high-pitched– indicates
possible paralytic ileus – which is absence of
intestinal peristalsis
• Assist movement in bed and ambulation to relieve
gas pain
• Maintain privacy while pt is on bedpan or bedside
commode
• Administer suppositories, enemas, or medications
such as stool softeners as prescribed
• Urinary Elimination
• Monitor I’s and O’s
• Assist in normal positioning of ct for voiding
• Assess for bladder distention if ct has not
voided within 8 hours post-op or has been
voiding less than 50 cc/hr
• Report results to physician
• Maintain IV infusion fluid infusion rates
• Encourage PO fluid intake when prescribed
• Provide ct privacy
• Initiate urinary catheterization if ordered
• Prevention of Urinary Tract Infections
 Wound Care
• Monitor wound for dehiscence and evisceration
(p.458 Brunner)
• Manage drains and document output
• Monitor wound and dressing for infectious
drainage or excessive bleeding
• Usually, the first dressing change done
postoperatively is done by the surgical team
• Subsequent dressing changes are usually done by
the nurse
• The nurse will instruct and teach patient and
family members how to perform dressing changes
for post d/c.
 Home Care and
Discharge Needs
Discharge Planning Needs:
Prescriptions
Discharge summary with prescribed medications and time
schedule
Teaching self-care
Referrals
Physical Therapy
Home Health Needs
Wound Care
Follow-up appointments (i.e. to remove sutures or staples)
Occupational Therapy
Special home equipment needs (bed wheelchair, crutches,
splints, etc.)
Case Management
 System Assessments

 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

“Okay, Williams, we’ll vote…

 Cardiac how many here say the
assessment heart has four
data chambers?”

 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

 Feedings “The Nurse says a trip-o’-loomin’

 TPN cow-filler is feeding Grandma.
It has three loops--one for breakfast,
one for lunch, and one for dinner!”
 Elimination

 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

 Common Pain Medication

• Demerol
• Morphine
• Dilaudid
• Stadol
• NSAIDs

 Side Effects of Pain medication*

SELAMAT
BELAJAR