Perioperative Nursing Phases

Definition of Terms  Preoperative phase – begins when the decision to have

Surgery is any procedure performed on the human body
that uses instruments to alter tissue or organ integrity.
SURGEON - A physician who treats disease, injury, or deformity by
operative or manual methods.
*A medical doctor specialized in the removal of organs, masses
and tumors and in doing other procedures using a knife (scalpel)
STERILE - free from living germs or microorganisms; aseptic: sterile
surgical instruments
ASEPSIS - The state of being free of pathogenic microorganisms.
SEPSIS - a toxic condition resulting from the spread of bacteria or
their toxic products from a focus of infection
DISINFECTANT- any chemical agent used chiefly on inanimate
objects to destroy or inhibit the growth of harmful organisms.
ANTISEPTICS - is a substance that prevents or arrests the growth
or action of microorganisms either by inhibiting their activity or by
destroying them.
STERILIZATION
-the destruction of all living microorganisms, as pathogenic
bacteria, vegetative forms, and spores.
BACTERIOSTATIC -Capable of inhibiting the growth or
reproduction of bacteria.
BACTERICIDAL - Capable of killing bacteria.
BACTERIOCIDES - is a substance that kills bacteria .Bactericides
are either disinfectants, antiseptics or antibiotics
surgery is made and ends when the client is transferred to
the OR table.
 Intraoperative phase – begins when the client is
transferred to the OR table and ends when the client is
admitted to the PACU.
 Postoperative phase – begins with the admission of the
client to the PACU and ends when the healing is complete.
Fundamental purposes of the O.R. :
It is a place. . .
 To correlate theory & practice.
 To develop skills in assisting the surgeon in the
operation.
 To create a suitable sterile field for surgical
procedures to prevent complications.
Perioperative Nursing
Purpose/reasons
Degree of urgency – necessity to preserve the client’s life, body
part, or body function.
Degree of risk – involved in surgical procedure is affected by the
client’s age, general health, nutritional status, use of medications,
and mental status.
Extent of surgery – Simple and radical

Prefixes and Suffixes CLASSIFICATIONS OF SURGERY

PREFIXES According to Urgency :
Supra – above ; beyond EMERGENT – patient requires immediate attention ; disorder maybe
Ortho – joint life- threatening.
Chole –bile or gall URGENT – patient requires prompt attention.
Cysto – bladder > indications for surgery : within 24-30 hours.
Encephalo- brain REQUIRED – patient needs to have surgery.
Entero – intestine > indications for surgery: plan within few weeks or months.
Hystero – uterus ELECTIVE – patient should have surgery.
Mast – breast > indications for surgery: Failure to have surgery is not
Meningo – membrane; meninges catastrophic.
Myo – muscle OPTIONAL – decision rests with pt.
Nephro – kidney > indications for surgery : Personal preference
Neuro – nerve
Oophor – ovary Accdg. To Degree Of Risk :
Pneumo – lungs MAJOR – high degree of risk :
Pyelo – kidney pelvis >maybe complicated / prolonged, large losses of blood may occur,
Salphingo – fallopian tube vital organs maybe involved, post-op complications may be likely.
Thoraco – chest MINOR – little risk with few complications.
Viscero – organ esp. abdomen - often performed in a “day surgery”.
SUFFIXES Accdg. To Purpose :
Oma – tumor ; swelling DIAGNOSTIC – verifies suspected diagnosis
Ectomy –removal of an organ or gland EXPLORATORY – estimates the extent of the disease or injury.
Rhapy – suturing or stitching of a part or an organ CURATIVE – removes or repairs damaged tissues .
Scopy – looking into ABLATIVE – removing diseased organ that can’t wait anymore.
Ostomy – making an opening or a stoma - emergency surgery.
Otomy – cutting into PALLIATIVE – relieves symptoms but does not cure the underlying
Plasty – to repair or restore disease process.
Cele – tumor ; hernia ; swelling RECONSTRUCTIVE – partial or complete restoration of a damaged
Itis – inflammation of organ/tissue to bring back the original appearance & function.
CONSTRUCTIVE – repairing the damaged tissue or congenitally
Perioperative Nursing defective organ.
Perioperative Nursing- connotes the delivery of patient care in the
preoperative,intraoperative, and postoperative periods of the patients Accdg. To Location :
surgical experience through the framework of the nursing process. INTERNAL – inside the body . Ex. Hysterectomy
EXTERNAL – outside the body .Ex. Skin grafting
FOUR BASIC PATHOLOGIC CONDITIONS THAT REQUIRE - Explain routine procedures, encourage verbalization of
SURGERY (OPET): fears & allow client to ask questions.
OBSTRUCTION – a blockage ; are dangerous because they block - Demonstrate confidence in surgeon & staff.
the flow of blood, air, CSF, urine & bile through the body. - Provide for spiritual care if appropriate.
PERFORATION – is a rupture of the organ, artery or bleb.
EROSION – break in the continuity of tissue surface. It can damage PREOPERATIVE TEACHING
the walls of blood vessels resulting in serious bleeding. - Assess client’s level of understanding of surgical procedure
TUMORS – abnormal growth of tissue that serves no physiologic & its implications.
function in the body. - >Answer questions, clarify & reinforce explanations given
by the surgeon.
Who are the the SURGICAL RISK PATIENTS? - Explain routine pre- & post-op procedures & any special
*Extremes of age ( very young & very old ) equipment to be used.
*Extremes of weight (emaciation, obesity)
*Dehydrated pts. PREOPERATIVE TEACHING
*Nutritional deficits - Preoperative experience
*Pts. with severe trauma or injury, infection/sepsis - Preoperative medication
*Pts. with cardiovascular disease - Breathing exercises, coughing, incentive spirometer
- Leg exercises
*Endocrine dysfunction (diabetes mellitus)
- Position changes and movement
*Hypertensive & hypotensive pts. - Pain management
*Hypovolemia - Reducing anxiety and fear, support of coping
*Hepatic disease - Special considerations related to outpatient surgery
*Pre-existing mental or physical disability - Diaphragmatic Breathing and Splinting When Coughing
PROBLEMS THAT MAY ARISE IN SURGERY: - Leg Exercises and Foot Exercises
 Surgical risk pts – probability of mortality - Preoperative Nursing Interventions
 Pain
PHYSICAL PREPARATIONS:
 Hemorrhage
- Obtain history of past medical conditions, surgical
 Infection
procedures, dietary restrictions & medications.
 UTI - Perform baseline head-to-toe assessment, including VS,
height & weight.
PHASES OF O.R. NURSING : - Ensure that diagnostic procedures pertinent to surgery are
PREOPERATIVE PHASE performed as ordered
 The rendering of nursing care to the surgical client as soon - NPO
- Bowel prep
as he is admitted & the decision to undergo surgery is
- Skin prep
made.
- Immediate preoperative preparation
 It ends on the time the client is transferred to the O.R. - Transporting the pt. to the pre-surgical area about 30 to 60
minutes before anesthetics is to be given.
NURSING ACTIVITIES : - Attend to family needs
 Assessment of the client
 Identification of potential/actual health problems. LEGAL PREPARATION:
 Pre-op teaching involving client & support persons. - Surgeon obtains operative permit (informed consent)
Day of surgery : - Surgical procedures, alternatives , possible complications &
 pt. teaching reviewed disfigurements or removal of body parts are explained.
 informed consent confirmed - It is part of the nurse’s role as client advocate to confirm
 pt.’s identity & surgical site verified that the client understands information given.
 IVF started.
INFORMED CONSENT is necessary in the ff. Circumstances:
Assessment (Nursing History) - Invasive procedures
- Current health status- - Procedures requiring sedation or anesthesia
- A non-surgical procedure
- Allergies
- Procedures involving radiation
- Medications- list all current medications - Adult client (over 18 y/o) signs own permit unless
- Previous surgeries unconcious or mentally incompetent.
- Understanding of the surgical procedure and anesthesia - Consents are not needed for emergency care if all 4 of the
- Smoking ff. criteria are met:
- Alcohol and other-altering substances - There is an immediate threat to life.
- Coping - Experts agree that it is an emergency.
- Client is unable to consent.
- Social resources
- A legally authorized person cannot be reached.
- Cultural considerations *Minors (under 18 y/o) must have consent signed by an adult (i.e.
Parent or legal guardian)
PREPARATION FOR SURGERY
 Psychological Support : PREOPERATIVE MEDICATIONS
- Assess client’s fears, anxieties, support systems & patterns PURPOSES:
of coping.  To relieve fear & anxiety.
- Establish trusting relationship with client & significant  To reduce dose needed for induction & maintenance of
others. anesthesia.
  To prevent reflex bradycardia that happens during  Semirestricted zone
induction of anesthesia. - where attire consists of scrub clothes & caps.
 To minimize oral secretions.  Restricted zone
- where scrub clothes, shoe covers, caps & masks
INTRAOPERATIVE PHASE
are worn.
 Giving nursing care to client undergoing surgery.
 It starts from the time the pt. was admitted to the O.R. ,
THE OPERATING ROOM
during operation until it ends & transferred to the PACU.
Basic Guidelines for Surgical Asepsis

NURSING ACTIVITIES: - All materials in contact with the wound and within the
 Activities providing for pt’s safety. sterile field must be sterile.
 Maintenance of aseptic environment. - Gowns are sterile in the front from chest to the level of
 Ensuring proper function of equipments. the sterile field, and sleeves from 2 inches above the
 Providing surgeons with specific instruments & supplies for elbow to the cuff.
surgical field. - Only the top of a draped table is considered sterile.
 Completing documentation. During draping, the drape is held well above the area and
 Positioning pts. is placed from front to back.
 Acting as scrub/circulating nurse. - Items are dispensed by methods to preserve sterility.
- Movements of the surgical team are from sterile to sterile
Members of the Surgical Team and from unsterile to sterile only.
 Patient - Movement around the sterile field must not cause
 Anesthesiologist or anesthetist contamination of the field. At least a 1-foot distance from
 Surgeon the sterile field must be maintained.
 Nurses (Scrub & Circulating) - Whenever a sterile barrier is breached, the area is
 Surgical technologists considered contaminated.
- Every sterile field is constantly maintained and monitored.
Items of doubtful sterility are considered unsterile.
PATIENT
- Sterile fields are prepared as close as possible to time of
- the most important member of the surgical team. May feel use.
relaxed & prepared, or fearful & highly stressed.
- is also subject to several risks. SURGICAL ASEPTIC TECHNIQUE
 BEFORE AN OPERATION, it is necessary to sterilize and
OPERATING SURGEON keep sterile all instruments, materials, and supplies that
- pre-op dx & care. come in contact with the surgical site. Every item handled
- performance of operation. by the surgeon and the surgeon's assistants must be
- post-op mgt & care sterile. The patient's skin and the hands of the members of
- assumes all responsibility for all medical acts of judgement the surgical team must be thoroughly scrubbed, prepared,
& mgt. and kept as aseptic as possible.
 DURING THE OPERATION, the surgeon, surgeon's
SURGEON & ASSISTANTS assistants, and the scrub nurses must wear sterile gowns
- scrub & perform the surgery. and gloves and must not touch anything that is not sterile.
Maintaining sterile technique is a cooperative responsibility of
REGISTERED NURSE 1ST ASST. the entire surgical team.
- practices under the direct supervision of the surgeon. - Each member must develop a surgical conscience, a
(handling tissue, suturing, maintaining hemostasis) willingness to supervise and be supervised by others regarding
the adherence to standards.
ANESTHESIOLOGIST / NURSE ANESTHETIST
- administers the anesthetic agent & monitors the pt’s Intraoperative Nursing Care Roles of team members
physical status throughout the surgery. Surgeon
 responsible for determining the preoperative diagnosis, the
SCRUB NURSE choice and execution of the surgical procedure, the
- provides sterile instruments & supplies to the surgeon explanation of the risks and benefits, obtaining inform
during the procedure. consent and the postoperative management of the patient’s
- performs surgical hand scrub. care.
Scrub nurse
CIRCULATING NURSE  (RN or Scrub tech)- preparation of supplies and equipment
- coordinates the care of the pt. in the O.R. on the sterile field; maintenance of pt.s safety and
- care provided includes assisting with pt. positioning , skin integrity: observation of the scrubbed team for breaks in
prep, managing surgical specimens & documenting the sterile fields; provision of appropriate sterile
intraoperative events. instrumentation, sutures, and supplies; sharps count

Prevention of Infection Circulating Nurse

 The surgical environment
- stark appearance & cool temperature. Located
central to all supporting services.
 Unrestricted zone
- where street clothes are allowed.
 responsible for creating a safe environment, managing the
activities outside the sterile field, providing nursing care to
the patient. Documenting intraoperative nursing care and
ensuring surgical specimens are identified and place in the
right media. In charge of the instrument and sharps count
 and communicating relevant information to individual Types of Regional Anesthesia
outside of the OR, such as family members.  Topical (surface)
Anesthesiologist and anesthetist  Local
 anesthetizing the pt. providing appropriate levels of pain  Nerve Block
 Intravenous (Bier Block)
relief, monitoring the pt’s physiologic status and providing
 Spinal
the best operative conditions for the surgeons.
 Epidural (peridural)
Other personnel- pathologist, radiologist, perfusionist, EVS personnel.
Complications of Local/Regional Anesthesia
Nursing Roles:  Anaphylaxis
 Staff education  Administration technique
 Client/family teaching  Systemic absorption
 Support and reassurance  Overdosage
 Advocacy
 Control of the environment Spinal Anesthesia
 Provision of resources
Indications
 Maintenance of asepsis
-surgical procedures below the diaphragm
 Monitoring of physiologic and psychological status
-patients with cardiac or respiratory disease
 Ensure sterility
 Alert for breaks
Advantages
Intraoperative Phase Anesthesia -mental status monitoring
- Greek word- anesthesis, meaning “negative sensation.” -shorter recovery
Artificially induced state of partial or total loss of sensation,
Disadvantages
occurring with or without consciousness.
-necessary extra expertise
- Blocks transmission of nerve impulses
-possible patient pain
- Suppress reflexes
- Promotes muscle relaxation Contraindications
- Controlled level of unconsciousness -coagulopathy
Factors influencing dosage and type: -uncorrected hypovolemia
- Type and duration of the procedure
- Area of the body being operated on Involved medications
- Whether the procedure is an emergency -lidocaine
- Options of management of post. Op. Pain -bupivacaine
- How long it has been since the client ate, had any liquids, or -tetracaine
any medications
Patient assessment
-continuous heart rate, rhythm, and pulse oximetry monitoring
Intraoperative Phase Types of Anesthesia
-level of anesthesia
General -motor function and sensation return monitoring
- method use when the surgery requires that the patient be
unconscious and/or paralyzed. Complications
- A general anesthetic acts by blocking awareness centers in -hypotension
the brain so that amnesia (loss of memory), analgesia -bradycardia
(insensibility to pain), hypnosis (artificial sleep), and -urine retention
relaxation (rendering a part of the body less tense) occur. -postural puncture headache
-back pain
Stages of General Anesthesia
Spinal analgesia
Stage 1- Analgesia and sedation, relaxation
Indications
Stage 2- Excitement, delirium
-postoperative pain from major surgery
Stage 3- Operative anesthesia, surgical anesthesia
Stage 4- Danger
Involved medications
-lipid-soluble drugs
-preservative-free morphine
 Complications of General Anesthesia
 Overdose Monitoring recovery
 Hypoventilation -respiratory depression
 Related to anesthetic agents -urine depression
 Malignant hyperthermia -pruritus
 Related to intubation -nausea and vomiting

Local or Regional Anesthesia Conscious Sedation

 Temporarily interrupts the transmission of sensory nerve
impulses from a specific area or region.
 Motor function may or may not be affected
 Client does not lose consciousness
 Gag reflex remains intact
 Supplemented with sedatives, opioids, or hypnotics
Administration of IV sedative, hypnotic, and opioid
medications.
- Produces a depressed level of consciousness
- Retains ability to maintain a patent airway
- Able to respond to verbal commands or physical stimulation
- Used for relatively short procedures
Postoperative Nursing Care  Treatment:
Nursing assessment in the PACU  Call for help
 Vital signs- presence of artificial airway, 02 sat,BP,pulse,  Cover with sterile NS soaked
temperature. gauze/towels
 LOC- ability to follow command, pupillary response  Keep moist
 Urinary output  DO NOT ATTEMPT TO REINSERT
 Skin integrity ORGANS.
 Pain  Keep in supine position with knees/hips
 Condition of surgical wound bent
 Presence of IV lines  Assessment/VS q 5 min. until MD
 Position of patient arrive
 Prepare for surgery.
Nursing Diagnosis
 Ineffective airway clearance- increased secretions 2 to Gerontologic considerations
anesthesia, ineffective cough, pain  Mental status- attributed to medications, pain, anxiety,
 Ineffective breathing pattern- anesthetic and drug effects, depression.
incisional pain  Delirium- infection, malignancy, trauma, MI, CHF, opioid
 Acute pain use.
 Urinary retention
 Dementia-sundowning-sleep disturbances, lack of structure
 Risk for infection
in the afternoon or early morning, sleep apnea.
Assessment of the Postanesthesia Client
 Airway
 Vital signs
 Cardiac monitoring
 Peripheral vascular assessment
 Level of consciousness (LOC)
 Fluid and electrolytes
 GI system
 Integumentary system
 Discomfort/pain

Postoperative Management
 Maintain a patent airway
 Stabilize vital signs
 Ensure patient safety
 Provide pain relief
 Recognize & manage complications

When caring for post-surgical patient, think of the “4 W’s”

 Wind: prevent respiratory complications
 Wound: prevent infection
 Water: monitor I & O
 Walk: prevent thrombophlebitis

Complications
 Respiratory- atelectasis, pulm. Embolus
 Cardiovascular- venous thrombosis
 Gastrointestinal-Hiccoughs, N/V,abd. Distention, paralytic
ileus, stress ulcer.
 GU- urinary retention
 Hemorrhage-slipping of a ligature(suture)
 Wound infection-
 Wound dehiscence and evisceration-

Dehiscence
 Partial or complete separation of the outer layer of the
wound.
Possible causes:
 Poor suturing technique
 Distention
 Excessive vomiting
 Excessive coughing
 Dehydration
 Infection

Evisceration
 Total separation of the layers & protrusion of internal
organs or viscera through the open wound.
Causes: same as dehiscence