PERI OPERATIVE NURSING
3 Phases
OR NURSING “Surgical Instrument Preparation
for surgery”
- 1875 - 1st lecture
- John Hopkins University in Baltimore
Highlights
- Request for chief OR nurse
- Ward Nurse – OR Nurse
- Dr. Joseph Bell “Specialized training”
- 1894 Dr. Hunter Robb – “ Team
concept
TEAM CONCEPT
Senior Nurse – scrub role
Junior Nurse - assist w/ dispensing sterile
supplies
Physician Assistant – an intern, trained to
assist the attending surgeon
1910 – Senior nurses – Circulating Nurses
1919 – Established OR Rotation
1933 – NLN – outlined a master curriculum plan
for advanced courses in OR theory and
technique
1940-1945 – War Years
- Emergence of Nursing Aides &
Orderlies
Medical Corpsmen - were trained and role of
nurses expanded to include giving anesthesia &
1st assistant during surgery
- Shift from general practitioners to
specialist began to emerge
1946-1960 – Post War changes
- Needed to train OR nurses became the
lowest priority of the NLN
- OR rotation was phased out
- 1949, OR rotation was eliminated from
the nursing curriculum
- OR nursing was no longer mandatory’
Emergence of OR Nursing as a specialty
1949 – Association of operating room nurses
(AORN) established
Edith Dee hall – founder of AORN
- Spearheaded OR nurses to form groups
to share knowledge, motivate
experienced OR nurses to teach the
neophytes and promote and benefit
professional OR nursing to a level of
specialization
Perioperative Nursing
1. Before (Peri)
2. During (Intra)
3. After (Post)
Nurse – act as independent clinician and a
member of a health care team during
perioperative nursing
Goals
- To assist client and their significant
other thru the surgical procedure
- To help promote positive outcomes
- To help clients achieve their optimal
level and wellness after surgery
Perioperative Period
1. Perioperative Phase (Surgical Unit to
OR)
- the period when the client is admitted in
the surgical unit, to the period he is
prepared physically, psychosocially,
spiritually and legally for the surgical
procedure, until he is transported into
the OR
2. Intraoperative Phase (OR – PACU)
- The period the client it admitted to the
OR > the time of administration of
anesthesia>surgical procedure is done
>recovery room or PACU (Post
anesthesia care unit)
3. Postoperative Phase (PACU – Follow
up)
- The period from recovery room/PACU >
transported back into the surgical unit>
discharged from the hospital, until the
follow up care
4 Major Types of Pathologic processes
requiring Surgical Intervention
1. Obstruction – impairment to the flow of
vital fluids (blood, urine, CSF, bile)
2. Perforation – rupture of an organ
3. Erosion – wearing off of a surface or
membrane
4. Tumors – abnormal new growths
Examples
Hydrocephalus – Obstruction
Burn – Erosion
BPH – Tumor
Cholelithiasis – Obstruction
Intussusception – Obstruction
Ruptured Aneurysm - Perforation
According to Purpose 4.Elective – patient should have surgery
1. Diagnosis- to establish the presence of Indication: Failure to have surgery not
a disease condition (eg biopsy) catastrophic
2. Explorative - to determine the extent of Ex. Repair of scar, Vaginal repair
disease condition (eg EX-Lap)
3. Curative – to treat the disease condition 5.Optional – pt’s decision
a. Ablative – removal of an organ Indication: Personal preference
“ectomy” Ex. Cosmetic Surgery
b. Constructive – repair of
congenitally defective organ Degree of Risk
“plasty, oorhaphy, pexy” 1. Major Surgery
c. Reconstructive- repair of a. High risk/ Greater risk for
damage organ infection
4. Pallative – to relieve distressing sign b. Extensive
and symptoms, not necessarily to cure c. Prolonged
the disease d. Large amount of blood loss
e. Vital organ may be handled or
Suffix Meaning Example removed
-ectomy Excision or Appendectomy 2. Minor Surgery
removal of a. Generally not prolonged
-lysis Destruction of Electrolysis b. Leads to few serious
-orrhaphy Repair or Herniorrhaphy complications
suture of c. Involves less risk
-oscopy Looking into Endoscopy
-ostomy Creation of Colostomy Ambulatory Surgery/ Same-day Surgery/
opening into Outpatient Surgery
-plasty Repair or Mammoplasty
reconstruction Advantages
of - Reduces length of hospital stayu and
cuts costs
Identify the type of surgery according to - Reduces stress for the pt
purpose: - Less incidence of hospital acquired
Pap smear – Diagnosis infection; minimal
Tonsillectomy – Curative – Ablative - Less time lost from work by the pt;
Nephrocapsulectomy – Curative – Ablative minimal disruptions on the pt’s activities
Osteoplasty – Curative – Reconstructive and family life
Perineorrhaphy – Curative – Reconstructive
Trachelorrhaphy – Curative – Constructive Disadvantages
Skingrafting – Curative – Reconstructive - Less time to assess the pt and perform
preoperative teaching
According to Urgency - Less time to establish rapport
1.Emergent – patient requires immediate - Less opportunity to assess for late
attention, life threatening postoperative complications
Indication: Without delay
Ex. Severe bleeding, gunshot/ stab wound, Ex. of Ambulatory Surgery
fractured skull Teeth extraction
Circumcision
2.Urgent/Imperative –patient requires prompt Vasectomy
attention Cyst Removal
Indication: within 24 – 30 hrs Tubal Ligation
Ex. Kidney/ ureteral stones

3.Required - patient needs to have surgery

Indication: Plan within a few weeks or months
Ex. Cataract, thyroid d/o
Surgical Risk 3. Cortisone (at risk for adrenal
- Obesity insufficiency)
- Poor Nutrition 4. DM – other condition that requires strict
- Fluid and electrolyte imbalances blood glucose control to delay wound
- Age healing
- Presence of disease (CVD, DM, Respi 5. Emboli
disease) 6. Uncontrolled Thyroid Disease
- Concurrent or prior pharmacology a. Overactive: risk of
- Other factors: Thyrotoxicosis
Nature of condition b. Underactive: risk of respiratory
Loc. Of the condition depression
Magnitude/urgency of the surgery
Mental attitude of the pt Alcohol, recreational drug or nicotine use
Caliber of health care team - Indicate potential problem w/ anesthesia
or analgesic administration and risk for
withdrawal complications
PREOPERATIVE PHASE - Alcohol/drugs can cause withdrawal
- Tobacco/ drug reduces hemoglobin
Goals levels making less O2 available for
-Assessing and correcting physiologic and tissues
psychological problems that may increase - Smokes are at high risk for thrombus
surgical risk formation (d/t hypercoagulability
-Giving the person and significant others secondary to nicotine use)
complete learning / teaching guidelines Current discomforts
regarding surgery - With preexisting painful conditions may
-Instructing and demonstrating exercises that require alternative methods of pain
will benefit the person during postop period reduction while under NPO
-Planningfor discharge and any projected Chronic Illness
changes in lifestyle d/t surgery - Illness that require consideration when
positioning
Preoperative Assessment - Arthritis of the neck/back
Advanced age
To be included in the preop assessment: - Older clients have specific perioperative
1. Medical/Health hx needs
a. Review past medical hx Medication hx
i. To determine operative - OTC may increase operative risk
risk - Ask if they are taking and brought them
b. Previous surgery and in the hospital
experience with anesthesia - Medication dosages and administration
i. Untoward reactions to schedules should be noted in the chart
anesthesia Psychological Hx
1. Hyperthermia - Client’s cultural beliefs and practices
2. Prolonged n/v - Client’s emotional reaction towards the
ii. These do not hinder whole surgical experience
surgery, but need to Ability to tolerate perioperative stress
change the type of - Physiologic stress like pain, tissue
anesthetics used damage, anesthesia, blood loss, fever
and immobilization
Medical History Lifestyle habits and social hx
Serious Illness or Trauma Physical Examination
- Must be done prior to operation
1. Allergy – medication, chemicals, latex - To identify present health status and to
a. All should be reported before have a baseline info
the beginning of the surgery - To identify problems and to develop
2. Bleeding tendencies – use of meds tjat appropriate outcome goals
daunt clotting (aspirin, heparin, warfarin)
Cardiovascular d. Joint injury
- Presence of pathologic or cardiac e. Musculoskeletal impairment
conditions
- Increase operative risk and could lead to PE that may reveal problems with joint mobility
decrease tissue perfusion with or deformities that may interfere with operative
impairment of surgical healing positioning
Ex
1. Angina pectoris Gastrointestinal
2. Occurrence of MI in the last 6 mos Gi conditions that may be associated with poor
3. Uncontrolled HPN surgical outcomes:
4. Heart failure - Severe malnutrition
5. Peripheral vascular disease - Prolonged nausea and vomiting
General assessment of the GiI functioning
Document the ff observations: should be done esp for abdominal surgery
- SOB in minor exertion
- HPN Integumentary
- Heart murmurs or S3 gallops The skin must be assessed preoperatively to be
- Chest pain able to establish baseline date for comparisons
postoperatively
Dx and lab studies done to measure
cardiovascular function The ff should be documented and reported if
a. ECG, esp for clients over 40 yrs observed during the assessment:
b. Hemoglobin, hct and serum electrolytes 1. Lesions
2. Pressure ulcers
Respiratory 3. Necrotic skin tissue
Chronic Lung conditions 4. Skin turgor
- Increase operative risk 5. Erythema
- Impair gas exchange in the alveoli 6. Discoloration of the skin
- Predisposing to postoperative 7. Tattoos and body piercing
pulmonary complications:
o Emphysema Renal
o Asthma Adequate renal function is necessary to
o Bronchitis eliminate protein wastes, to preserve fluid and
Assessment electrolyte balance, and to remove anesthetic
a. Examining presence ofSOB agents
b. Wheezing
c. Clubbing fingernails 1. Renal and related renal disorders that
d. Chest pain may affect the outcome of the surgery
e. Cyanosis are the ff:
f. Coughing w/ expectoration of copious or a. Advanced renal insufficiency
purulent mucous b. Acute nephritis
g. Obtain hx of smoking and respi allergies c. BPH
2. Assess renal status by asking about
Diagnostic and lab studies to measure voiding patterns
respiratory function: a. Monitor fluid and electrolyte
a. CXR balance by recording intake
b. Pulse oximetry and output thru the
c. ABG (arterial blood gas) analysis perioperative phases
d. Pulmonary function test 3. Common preoperative test done to
determine status of renal function
Musculoskeletal a. Blood Urea Nitrogen (BUN)
Asses for hx of the ff disorders that may affect b. Serum creatinine
surgical positioning and postop support: c. Urinalysis
a. Arthritis
b. Fractures
c. Contractures
Liver Function Assessment
1. Cirrhosis of the liver increases client’s
surgical risk since an impaired liver
cannot detoxify medications and
anesthetic agents
2. Hx of alcoholism or other substance
abuse require careful assessment of
the liver function before surgery
3. A high calorie diet or hyperalimentation
may be ordered during preop and
postop
a. To correct problem of
malnourished and debilitated
clients with liver disease
Cognitive and Neurological Assessment
1. Assess for serious neurologic condition
such as uncontrolled epilepsy, severe
Parkinsons disease, that may increase
surgical risk
2. Assess the following through physical
assessment and interview to obtain
baseline data; severe head ache,
frequent dizziness, light-headedness,
ringing in the ears, unsteady gait,
unequal pupils, hx of seizures and
orientation to time, person and place
Endocrine assessment
1. DM
a. Most common pre-existing
endocrine disorder
b. Puts clients at high risk for poor
wound healing and increased
risk of postoperative infections
c. Constant monitoring and control
of blood glucose should be
done all throughout the
perioperative period
2. Thyroid functioning may also be
assessed preoperatively
a. Thyroid replacement is usually
continued during the
perioperative period
Additional Assessments
1. Age
a. Physiologic changes normal to
aging clients and presence of
certain diseases may adversely
affect surgical outcomes
b. Surgical risks including:
i. Malnutrition
ii. Anemia
iii. Dehydration
iv. Atherosclerosis
v. COPD
vi. DM
vii. Cerebrovascular
changes
viii. Peripheral vascular
disease
c. May increased/t chronic
conditions commonly found to
elderly clients
2. Pain
a. Important physiologic indicator
that necessitates careful
monitoring
b. Clients should be asked
whether they are experiencing
any pain prior to any surgical
procedure
c. If pain is present, thorough
assessment should be done to
identify the cause of the pain
3. Nutrition – nutritional status is directly
related to intraoperative success and
post – op recovery
a. Acquiring a diet hx
b. Observing general appearance
c. Laboratory/diagnostic testing
d. Comparing current wt with ideal
bodywt
4. Fluid and Electrolyte Balance
a. Proper assessment of actual
and potential fluid imbalances
b. Fluid volume deficits such as
hypovolemia or hypervolemia
predispose a client to
complications during and after
surgery
c. Electrolyte imbalances also
increase operative risk
d. Preoperative lab results should
be checked to determine
whether serum Na, K, Ca, Mg
concentrations are within normal
levels
5. Infection and Immunity
a. Any preexisting infection can
adversely affect surgical
outcomes since bacteria may be
released in the blood stream
during surgery
b. Any possible exposure to
communicable diseases,
presence of skin lesions or
manifestations of an infection
(eg coughing, sore throat or
fever) should be properly
 documented during preoperative
assessment
c. If existing infection greatly
increases surgical risks,
rescheduling the surgery may
be necessary
6. Hematologic Conditions
a. History of bleeding or diagnosis
of pathologic condition such as
hemophilia or sickle cell anemia
b. Bruising, excessive bleeding
following dental extractions or
severe epistaxis
c. Hepatic or renal disease
d. Use of anticoagulants, aspirin or
other NSAIDS
e. Abnormal bleeding time,
prothrombin time or platelet
count
Informed Consent
- a legal document that signifies that the
client has been told about and
understands all aspects of a specific
invasive procedure
- guards the client against unwanted
invasive procedure
- Protects the health care facility and
health care professionals when the
client denies understanding about the
procedure
- Physicians responsibility to provide
appropriate information
- Nurses’ duty to ask the client to sign the
consent form and be a witness to the
client’s signature
Purposes:
a. To ensure that the client understand the
nature of the treatment including the
potential complications and
disfigurement (explained by AMD)
b. To indicate that the client’s decision was
made without pressure
c. To protect the client against
unauthorized procedure
d. To protect the surgeon and the hospital
against legal action by a client who
claims that an authorized procedure was
performed
Informed consent is a must in the ff
circumstance
1. Invasive procedures
a. Surgical incision
b. A biopsy
c. Cystoscopy
d. Paracentesis
2. Procedures requiring sedation and/or
anesthesia
3. A nonsurgical procedure
a. Arteriography that carries more
than slight risk to the client
4. Procedures involving radiation
Criteria for valid informed consent
Voluntary Consent
- Valid consent must be freely given,
without coercion
Incompetent Client
- Not autonomous
- Cannot give or withhold consent
- Mentally retarded, mentally ill, comatose
Informed Subject
- Informed consent should be in writing
and should contain the ff:
o Explanation of procedure and its
risks
o Description of benefits and
alternatives
o An offer to answer questions
about procedures
o A statement informing the client
if the protocols differ from
customary procedures
Client able to comprehend
- Information must be written and
delivered in language understandable
by the client
- Questions must be answered to
facilitate comprehension if material is
confusing
Preoperative Teaching
Purpose:
- To ensure a positive surgical experience
for the client
- Helps to alleviate the client’s fear and
anxiety regarding the surgery
Components of preoperative teaching
Sensory Information
- Addresses the sights, sounds and
ambiance of the operating room
- Discuss what the client should expect to
see, hear and feel when he/she is
 transferred to the OR and on the OR
table
Psychosocial Information
- Addresses the coping abilities and the
worries of the client and the family
- To alleviate the client and family’s
worries and fears, the nurse together
with the help of a social worker or a
counselor should address questions
such as the ff:
o What if I die?
o How could we pay for the
operation?
o Who will take care of my
children while im here?
Procedural Information
- What will happen all throughout the
perioperative period including the
discharge phase
- All the information that the client wants
to know regarding the client care should
be addressed
The nurse also provides instruction for the ff:
1. Deep breathing
2. Coughing
3. Turning
4. Ambulating
5. Pain control
Preoperative Nursing Diagnoses
- Deficit knowledge related to unfamiliar
surgical experience
- Anxiety/fear related to pain, death,
disfigurement or the unknown
Preoperative Nursing Care
1. Preparation of the skin
a. Shower/bathing the night before
the scheduled surgery as per
institutional policy
b. Clean site with soap and water
or antimicrobial solution to
diminish the # of microbes on
the skin
2. Clean the area before the surgery
3. Padding on bony prominences to
prevent trauma in the skin during
transfer
4. The GI tract is prepared the night before
the surgery
a. Reduce the possibility of
vomiting and aspiration
b. Reduce risk of possible bowel
obstruction
c. Allow visualization of intestine
during bowel surgery
d. Prevent contamination from
fecal material in the intestinal
tract during bowel or abdominal
surgery
Preparation for the GI must include
- Restricting food and fluid 8-10 hrs
before the operation
1. Explain the reason for res triction
2. Remove food and water from bedside at
midnight
3. Place NPO sign on the door and bed
4. Mark the care plan or the Kardex with
NPO
5. Inform the diet and nutrition dept and
family about the status
6. If the client has been instructed to take
impt meds orally
a. Allow only small sips of water
b. Explain why this permission is
permissible
c. Document the med and amount
of fluid taken in the chart
ASA (American Society of Anesthesiologist)
Guidelines for preoperative Fasting
Liquid and food intake Minimum fasting
period
Clear liquids 2
Breast milk 4
Nonhuman milk 6
Light meal 6
Regular/Heavy meal 8
Administering enemas needed
1. Especially operation in GI tract, perineal
area and pelvic cavity
2. May be done at home or administered
by the nurse in the hospital
3. Bowel cleansing in the morning before
the surgery may be done as prescribed
Preoperative preparation IMMEDIATELY before
surgery
1. All known allergies are recorded and an
allergy wristband is present
2. VS are checked and recorded
3. The identification band is present and
correct
4. The consent formed is signed and the
surgical procedure is listed correctly
5. Skin preparation is completed if ordered
preoperatively
 6. Any special orders are completed Patient’s Family
(enema, IV line) 1. Direct the proper waiting room
7. The client has not eaten or had fluids by 2. Tell the family that the surgeon will
mouth for the last eight hours probably contact them immediately after
8. The client has just avoided the surgery
9. Oral hygiene or other physical/hygiene 3. Explain reason for long interval of
care is completed waiting: anesthesia prep, surgical
10. The presence of dentures, bridgework procedure, RR.
or other prostheses is noted 4. Tell the family what to expect postop
11. Storage is arranged and documented for when they see the pt
valuables according to health care
facility policy
12. The client has removed jewelry
13. The perioperative nurse is notified about
the presence of a hearing aid
14. The client is wearing a hospital gown
and protective cap
15. Make up is removed
16. Preoperative medication are given
17. Transfer client from bed to stretcher

Preoperative Medications
Goals
1. To aid in the administration of an
anesthetics
2. To minimize respiratory tract secretion
and changes in the HR
3. To relax the pt and reduce anxiety

Commonly used preop Meds

Tranquilizers & Sedatives
1. Diazepam (Valium)
2. Midazolam
3. Lorazepam (Ativan)
4. Diphenhydramine
Analgesics
1. Nalbuphine (Nubain)
Anticholinergics
1. Altropine Sulfate
Proton pump Inhibitors
1. Omeprazole (Losec)
2. Famotidine

Transporting the pt to the OR

1. Adhere to the principle of maintaining
the comfort and safety of the pt
2. Accompany OR attendants to the pt’s
bedside for introduction and proper
identification
3. Assist in transferring the pt from bed to
stretcher
4. Complete the chart and preoperative
checklist
5. Make sure the pt arrive un the OR at the
proper time