• SURGERY – an invasive medical procedure performed to diagnose or treat illness, injury, or deformity. • OPERATION – for correction of deformities and defects, repair of injuries, diagnosis and cure disease processes, relief of suffering and prolongation of life. • PERIOPERATIVE NURSING – used to describe the nursing functions in the total surgical experience of the

3 Phases of Perioperative Nursing

PRE OPERATIVE PHASE : from the time the decision is made for surgical intervention to the transference of the patient to the operating room. INTRA OPERATIVE PHASE : from the time the patient is received in the operating room, to the time of administration of anesthesia, surgical procedure is done, until he is admitted in the recovery room/post anesthesia care unit. POST OPERATIVE PHASE – from the time of admission to the recovery room, to the time he is transported back to the surgical unit, discharged from the

2. 3. 4. 5. Obstruction Perforation Erosion Tumor





I. According to PURPOSE:
1. 2. 3. Diagnostic Exploratory Curative 3.1) Ablative 3.2) Constructive 3.3) Reconstructive 4. Palliative 5. Transplant

II. According to DEGREE of RISK (Magnitude / Extent):

3. Major 4. Minor

III. According to URGENCY:
1. 2. 3. 4. 5. Emergency Urgent / Imperative Elective Planned / Required Optional

Abruptio placenta, an emergency

VSD needs urgent surgery

Hair transplant – elective surgery

Required surgery for infected ulcer

Optional surgery for Siamese twins


1. Aging
Nsg. Implications: 2. Consider using lesser doses for desired effect. 3. Adjust nutritional intake to conform to higher protein and vitamin needs. 4. Anticipate problems from long standing chronic disorders such as diabetes, anemia, obesity, cardiovascular disorders,

2. Obesity
Nsg. Implications: 2. Promote weight reduction if time permits. 3. Monitor closely for wound, pulmonary, and cardiopulmonary complications postoperatively. 4. Encourage coughing, turning, and diaphragmatic breathing exercises and early ambulation.

Nsg. Implications: 2. Promote weight gain by providing well-balanced diet high in calories, protein and vitamin C. 3. Administer total parenteral nutrition intravenously, nutritional supplements and tube feedings as prescribed. 4. Daily weight and calorie counts also may be ordered.

4. Dehydration/Electrolyte Imbalance
Nsg. Implications: 2. Administer intravenous fluids as ordered. 3. Keep a detailed input and output record. 4. Monitor client for evidence of electrolyte imbalance (Na+, K+, Ca++, etc.).

5. Cardiovascular Disorders
Nsg. Implications: 2. Diligently monitor vital signs, especially pulse rate, regularity, and rhythm, and general condition of the client. 3. Closely monitor fluid intake (oral & parenteral) to prevent circulatory overload. 4. Assess skin color.

4. Assess for chest pain, lung congestion, and peripheral edema. 5. Observe for signs of hypoxia, and administer oxygen as ordered. 6. Early postoperative ambulation and leg exercises reduce the risk of vascular problems, such as thrombophlebitis and pulmonary embolism. 7. Encourage change of position but avoid sudden exertion.

6. Respiratory Disorders
Nsg. Implications: 2. Closely monitor respirations, pulse, and breath sounds. 3. Assess for hypoxia, dyspnea, lung congestion, and chest pain. 4. Encourage coughing, turning, and diaphragmatic breathing exercises and early postoperative ambulation.

4. Encourage client to quit smoking or at least to reduce the number of cigarettes smoked. 5. Patients with chronic pulmonary problems such as emphysema, bronchiectasis, etc. should be treated for several days postoperatively with bronchodilators, aerosol medications, and conscientious mouth care.

7. Diabetes Mellitus
Nsg. Implications: 2. Monitor the client closely for signs and symptoms of hypoglycemia and hyperglycemia. 3. Monitor blood glucose levels every 4 hrs. as ordered. 4. Administer insulin as prescribed. 5. Encourage intake of food at the designated meal and snack times.

8. Renal & Liver Dysfunction
Nsg. Implication: 2. Monitor for fluid volume overload, I & O, and response to medication. 3. Evaluate closely for drug side effects and evidence of acidosis or alkalosis.

9. Alcoholism
Nsg. Implications: 2. Monitor closely for signs of delirium tremens. 3. Encourage well – balanced diet. 4. Monitor for wound complications. 5. Administer supplemental nutrients parenterally as ordered.

10. Medications
A. Anticoagulants and Salicylates Nsg. Implications: 4. Monitor for bleeding. 5. Assess PTT / PT values.

B. Diuretics (particularly Thiazides) Nsg. Implications: 4. Monitor I & O and electrolytes. 5. Assess cardiovascular and respiratory status.

C. Antihypertensives (particularly Phenothiazines) Nsg. Implication: 3. Closely monitor blood pressure. D. Antidepressants (particularly MAO inhibitors) Nsg. Implication: • Closely monitor blood pressure. E. Antibiotics Nsg. Implication: • Monitor respirations.

1. 2. 3. Nature of the condition Location of the condition Magnitude and urgency of the surgical procedure 4. Mental attitude of the person toward the surgery 5. Caliber of the professional staff health care facilities.

Ectomy – removal of an organ or a gland Rrhaphy – repair Ostomy – providing an opening (stoma) Otomy – cutting into Plasty – formation or plastic repair Scopy – looking into

 TAHBSO – Total Abdominal Hysterectomy Bilateral Salphingo Oophorectomy  TURP – Transurethral Resection of the Prostate  TURBT – Transurethral Resection of the Bladder Tumor  STSG – Split Thicknes Skin Grafting  BKA – Below Knee Amputation

 AKA – Above Knee Amputation  ECCE w/ IOL – Extra Capsular Cataract Extraction w/ Intra-Ocular Lens Implantation  CHOLE w/ IOC – Cholecystectomy w/ Intra-operative Cholangiogram  D & C – Dilatationof the cervix & Curettage of the uterus  SMR – Submucous resection of the Nasal Septum  MRM – Modified Radical Mastectomy

 LCCS – Low Cervical Cesarean Section  LSTCS – Low Segment Transverse Cesarean Section  ORIF – Open Reduction Internal Fixation  BTL – Bilateral Tubal Ligation


 PSYCHOLOGICAL Fear • Manifestations: - Anxious - Bewilderment - Anger - Tendency to exaggerate - Sad, evasive, tearful, clinging - Inability to concentrate - Short attention span - Failure to carry out simple directions

Nsg. Interventions to minimize ANXIETY:
1. Explore client’s feelings. 2. Allow client to speak openly about fears / concerns. 3. Give empathetic support. 4. Consider the person’s religious preferences and arrange for visit by priest / minister as desired.

 LEGAL Considerations Informed Consent - (Operative Permit / Surgical Consent) - LEGAL document required for certain diagnostic procedures or therapeutic measures, including surgery.

1. To ensure that the client understands the nature of the treatment including the potential complications and disfigurement. 2. To indicate that the client’s decision was made without pressure. 3. To protect the client against unauthorized procedure. 4. To protect the surgeon and the hospital against legal action by a client who claims that an

Nursing Responsibilities:
1. Witnessing the exchange between the client and the surgeon. 2. Witnessing the client’s signature. 3. Establishing that the client really did understand.

3 Major Elements of Informed Consent
1. The consent must be given voluntarily. 2. The consent must be given to individual who have the capacity to understand. 3. The client must be given information to be the ultimate decision maker.

 PHYSIOLOGICAL a. Cardiovascular – ECG for patient aged 40 yrs. and above and those undergoing gen. anesthesia, or have cardiovascular disease. b. Hematologic – CBC, Hgb & Hct, WBC, PTT & PT, Platelet count. c. Respiratory – Chest x-ray, pulmonary function test / PFT. d. Metabolic – FBS, Electrolytes(K+,Na++, etc). e. Genitourinary – routine urine

 PHYSICAL: A. Teaching Post Op Exercises: 4. Deep breathing exercise (diaphragmatic) 5. Coughing exercise 6. Turning exercise 7. Leg, ankle, and foot exercise

B. Night Prior to Surgery:     Preparing the skin Preparing the GIT Preparing for anesthesia Promoting rest and sleep

C. On the Day of Surgery: 3. Early Am Care 4. Preoperative Medications / Preanesthetic Drugs - generally administered 6090minutes before induction of anesthesia.


Definition of Terms:
 Surgical Conscience – one’s inner voice for the conscientious practice of asepsis & sterile technique at all times.  Asepsis – absence of microorganism; freedom from infection; exclusion of microorganism.  Sterile – free of microorganism, including all spores.  Spores – inactive but visible sate of microorganism in the environment.  Sterilization – process by which all pathogenic microorganisms, including

3 Methods of Sterilization
1. Saturated Steam under Pressure e.g. autoclave 4. Gas Chemical Sterilization e.g. Sterrad 7. Liquid Chemical Sterilization - 2% activated aqueous glutaraldehyde solution ( e.g. cidex).

 Sterile Field – area around the site of incision into tissue or introduction of any instrumentation into the body orifice that has been prepared for use of sterile supplies and equipments including all furniture covered w/ sterile drapes and personnel who are properly attired.  Sterile Technique – method by which contamination w/ microorganism is prevented to maintain sterility throughout the operative procedure.

 Surgically Clean – mechanically cleansed but unsterile.  Disinfection – process of destroying all pathogenic microorganism except spore – bearing one.  Antiseptic – used on tissue and skin and the growth of endogenous bacteria.  Incision – the result of cutting into a body tissue using sharp instrument.

 Medical Asepsis – include all practices intended to confine a specific microorganism to a specific area limiting the new growth and spread of microorganism.  Surgical Asepsis (or sterile technique) – refers to those practices that keep an area or object free of all microorganisms including practices destroying all microorganisms and spores.

1. Only sterile items are used within the sterile field. 2. Gowns are considered sterile only from the waist to shoulder level in front and sleeves. 3. Tables are sterile only at table level. 4. Persons who are sterile touch only sterile items or areas; persons who are not sterile.

1. Unsterile persons avoid reaching over a sterile field; sterile persons avoid leaning over an unsterile area. 2. Edges of anything that encloses sterile contents are considered unsterile. 3. Sterile field is created as close as possible to time of use. 4. Sterile areas are continuously kept in view. 5. Sterile persons keep well within the

1. Sterile persons keep contact with sterile areas to a minimum. 2. Unsterile persons avoid sterile areas. 3. Destruction of integrity of microbial barriers results in contamination. 4. Microorganisms must be kept to an irreducible minimum.

1. 2. 3. 4. 5. 6. Surgeon Assistant to the surgeon Anesthesiologist Nurse anesthetist (CRNA) Circulating nurse Scrub nurse

Effects of Anesthesia: 3. 4. 5. 6. Analgesia Amnesia Hypnosis Muscle relaxation

Factors considered in choice of Anesthesia:
• Physical condition • Age • Presence of co-existing disease • Type, site, duration of surgery • Anesthesiologist’s preference • Patient’s preference

• General Anesthesia Types: a. Inhalation anesthesia - mask inhalation - endotracheal administration

b. Intravenous anesthesia

Stages of General Anesthesia:
2. 3. 4. 5. Onset / Analgesia / Induction Excitement or Delirium Surgical Excitement / Anesthesia Danger / Medullary


Regional Anasthesia Types: 3. Topical anesthesia 4. Infiltration anesthesia 5. Regional application Examples: - Nerve block - Intravenous regional extremity block anesthesia (Bier Block) w/ tourniquet - Spinal anesthesia / Intrathecal anesthesia

Complications & discomforts of Spinal Anesthesia: a. Hypotension b. Nausea & vomiting c. Headache d. Respiratory paralysis e. Neurologic complications 8. Epidural Anesthesia Ex. Cocaine, Novocaine, Xylocaine,Carbocaine

Specialized methods in producing anesthesia:
• Muscle relaxants • Hypothermia • Controlled Hypotension

1. 2. 3. 4. 5. 6. 7.

Hypoventilation Oral trauma Hypotension Cardiac dysrhythmia Hypothermia Peripheral nerve damage Malignant hyperpyrexia

Intraoperative (ANESTHESIA) Complications:

Surgical Incisions:
• Subcostal • Paramedian • Midline • Transverse • Mcburneys • Butterfly • Pfannenstiel • Limbal • Halstead / elliptical

Layers of the abdomen:
• Skin – monocryl 3/0 or 2/0, vicryl 4/0, safil 4/0, dexon 4/0, silk 3/0 • Subcutaneous – plain 2/0 • Fascia – vicryl 1 or 0, safil 1 or 0, dexon1 or 0 • Muscle • Peritoneum – chromic 2/0, monocryl 2/0 or 3/0

• Classification: 1. Absorbable 2. Non-absorbable • Types: 1. Atraumatic 2. Non-atraumatic

Surgical Needles
• Types: 1. Cutting 2. Round • Classification of surgical needles: 1. eye needle / free needle / nonatraumatic 2. eyeless / swaged needle /

1. Cutting ex. Metzenbaum (metz), mayo scissors, suture scissors, knife. 2. Grasping - divided in the following categories: hemostats occluding clamps graspers and holders forceps or pick – ups 3. Retracting 4. Accessory and ancillary


Counting and Reporting of SIN
• INITIAL COUNTING – before the procedure starts. • 1st counting – before the closure of peritoneum • 2nd counting – before the closure of fascia • 3rd counting – before closure of skin

• Immediate post-op nursing care: - avoid exposure - avoid rough handling - avoid hurried movement and rapid changes in position

• Appraise air exchange and note skin color • Verify identify, operative procedure, surgeon • Assess neurologic status (LOC) • Determine VS and skin temp (CV status) • Determine operative site and check dressing • Perform safety checks

1. Ensure maintenance of patent airway and adequate respiratory function. 2. Assess status of circulatory system. Common cardiovascular complication immediate postop: 5. Hypotension

• Activity extremities extremities 1 0 • Respiration deep breath 1 2 able to move 4 able to move 2 not able to move 2 able to cough &

dyspnea or limited

• Circulation 2 20% pre anesthesia 1 20-50% pre anesthesia 0 above 50% pre anesthesia • Consciousness 2 fully awake 1 rousable on calling 0 not responding • Color 2 pink 1 pale, dusky, blotchy

Parameters for discharge from RR
• Activity – score of 2; able to obey commands. • Respiration – score of 2; easy, noiseless breathing. • Circulation – 20 of pre anesthesia; BP is within +/-20 mmHg of the pre op level. • Consciousness – score of 2; responsive. • Color – score of 2; pinkish skin and

• Baseline assessment:  Respiratory status  Cardiovascular status  LOC  Tubes  Position

Nursing Care of the client during the intermediate post op period (RRunit)

• Goals: 2. Restore homeostasis and prevent complications. 3. Maintain adequate cardiovascular and tissue perfusion. 4. Maintain adequate respiratory function 5. Maintain adequate nutrition and elimination. 6. Maintain adequate fluid and electrolyte balance.

1. Maintain adequate renal function. 2. Promote adequate rest, comfort and safety. 3. Promote adequate wound healing. 4. Promote and maintain activity and mobility. 5. Provide adequate psychological support. Post op discomforts: 7. Nausea and vomiting 8. Pain 9. Thirst

• Self – care activities • Wound care activities • Activity limitations • Diet and medications at home • Possible complications • Referrals, follow – up check - up

Discharge Planning / Teaching 2 – 3 days after surgery:

 b. c. d. CIRCULATORY COMPLICATIONS: Shock Hemorrhage Thrombophlebitis / deep thrombophlebitis PULMONARY COMPLICATIONS Atelectasis Pneumonia

 g. h.

 URINARY DIFFICULTIES b. Urinary retention  GASTROINTESTINAL COMPLICATIONS e. Paralytic ileus f. Gas pain g. Intestinal obstruction h. Hiccups

 WOUND COMPLICATIONS b. Wound infections * Rule of thumb - fever 1st 24 hours post op - fever 48 hrs. post op - fever 48-72 hrs. post op - fever 72 hrs. post op h. Hemorrhage / Hematoma i. Wound dehiscence and evisceration

a. b. • -

Delirium ACS (Acute Confusional State) Causes: Dehydrartion Insufficient oxygenation Anemia Hypotension Hormonal imbalance Infection Trauma (esp. in nervous person)

Post Op Psychological Disturbances


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