Sophia Loraine D.

Jesura BSN-3D
Medical Surgical Nursing
3rd Year 1st Sem
S.Y 2020-2021

Perioperative nursing management

Preoperative phase
 Any client undergoing surgery today receives the benefit of advances surgical
techniques, anesthesia, pharmacology, medical devices, and many supportive
interventions.
Note:
 as techniques to performed surgery change with improved technology and expertise,
surgery becomes less invasive and thereby less debilitating not like the years before.
 With the advancement of technology, we now have several surgery where in the patient
would not develop complication and the patient can go even within or after the surgery.
Within 24 hours they can nor leave the hospital especially for those who is undergoing
the minimally invasive surgical procedure.
 Surgery often considered as a stressful and a complex event.
 Surgery is defined as an invasive surgical procedure performed to diagnose or to treat
illness, injury, or deformities. It is the art and science of treating diseases, injury and
deformities through operations or instrumentation.
 Any procedure performed in the human body with instruments involving: incision,
excision or transaction of various organs or part are and often is performed by surgeons
or doctors who have been trained and who has experienced in a variety of specialization.
 Modern technologies such as laser surgery, and endoscopic technology would cause a
lesser risk, lesser invasion, faster recovery, and reduce hospitalization or even an
ambulatory surgery wherein after the surgery the patient can go home after several hours.
 Another new area that is explored right now is the robotic surgery

Major types of problem/pathology processes that requires surgical

intervention:
 Perforation - this refers to the ruptures of an organ
 Obstruction - impairment to the flow of vital fluids such as blood, urine, CSF or bile.
 Tumor or mass - refers to the abnormal new growth within the body.
 Erosion - wearing off of a surface or a membrane

Categories of surgical procedures

1. According to purpose
■ Diagnostic - used to obtain tissue sample by making an incision or through a
scope(instrument wherein it is inserted into the body in order to make diagnosis). it is
referred to as Biopsy (very common in the medical surgical ward wherein the patient
would be admitted only for incision of a tissue or a sample for biopsy) e.g patient with
presence of cyst in the breast.
■ Ablative - also known as curative surgery. Removal of a disease or abnormal tissue
 such as in presence of a tumor or infected or inflamed appendix.
■ Reconstructive - performed primarily to reconstruct , to alter or to enhance personal
appearance.

■ Palliative - done to alleviate symptoms without curing the disease. (e.g rhizotomy -
cutting of the nerve root to relieve the pain of patient with trigeminal neuralgia.
Insertion of a gastric tube/gastrotomy tube - insertion of a tube directly to the
stomach of a client for person who has difficulty in swallowing)
■ Transplant - to replace an organ or a tissue to restore function such as heart
transplant, liver transplant and kidney transplant.

2. According to risk factor

■ Major - procedure of a greater risk.
- longer and more extensive.
e.g mitral valve replacement, or any heart operation or surgery, or
pancreas transplant.
■ Minor - procedure that has no surgical risk
- it can be done with local anesthesia
-e.g incision and drainage and muscle biopsy

3. According to urgency
■ Elective - planned and schedule and with no time requirement.
- e.g joint replacement, thin lesion removal or hernia repair(as long as
this wont cause to a possible death to the patient)
-however in Hernia repair the condition may require an emergency
surgery if it is classified as an strangulated type then this may cause an
urgent problem.
■ Urgent - needed within 24-30 hours
- e.g fractured repair, infected gallbladder
■ Emergency/STAT surgery - immediate surgery. It would need to save the life or
limb of the person.
-e.g ruptured appendix that cause perforation, rupture aortic
aneurysm, or traumatic limb amputation that would need to
save the limb of the client.
■ Optional - performed at the patients discretion
-e.g nose reconstruction, facelift or breast reconstruction

4. Extent of surgery
■ simple
■ radical

Surgical risk - the probability of possible death as a result from surgery.

Note:
 There are cases wherein the patient be considered as surgical risk that is why in every
institution they would often have a clearance from the doctor or from the primary health
care provider of the patient.
 For example is, if the patient has a heart condition or a lung condition the surgeon would
ask for a clearance from the cardiologist of from the respiratory consultant of the patient
before performing the surgical procedure in order to prevent this possible morbidity or
death that could be the result of surgery.
Perioperative period
■ preoperative
■ intraoperative
■ postoperative

➪ each phase includes a wide range of activities the nurse performs using the
nursing process.

 surgical settings
 inpatient surgery - the patient is admitted in the hospital for surgery
outpatient surgery - day surgery, ambulatory surgery
Advantages :
 Cause is decreased
 Reduce risk of hospital acquired infection(e.g nosocomial infection-patient who stayed in
the hospital for more than 5-7 days can acquire this)
 Less interruption of patient and family routine
 Possible time reduction from work or other responsibilities of the patient as well as the
significant others.
Disadvantages:
 Less time for the nurse to establish rapport
 Less time for the nurse to assess or evaluate and do the health teaching to the patient and
family
 Lack of opportunity to assess for possible complication after the surgery
 Less time for adequate pain control

HOWEVER, there were always an exception. Most often the doctor will not allow the
patient to be discharge from the recovery room even if it is an ambulatory surgery not until
that the patient have been cleared by the physician.

Assessment period here is performed within the recovery room.

 physician’s clinic or offices - where in the surgery is performed in the doctors clinic or
office. Minor surgery is performed
 Freestanding surgical centers - outpatient surgical center where patient can go for
surgery and the can go home right after the surgery.

PREOPERATIVE PHASE:

-Begins when the decision of the surgery is made and ends when the patient is
transferred to the OR.

 Preadmission Testing (pat)

Diagnostic studies
-ultrasound
 -endoscopy(if needed)
Laboratory test
X-rays

All of this test is performed before the patient is admitted.

➪ done to reduce hospital stay and contain cost
➪ initiates the nursing assessment process(only upon admission because we cannot
see the patients in preadmission testing only the doctor and person incharge with the
testing)

 Special considerations during the periop period

➪ Gerontologic(elderly)
 Less physiological reserve (care needs to be addressed accordingly)
 At risk for dehydration, constipation and malnutrition postoperatively
 Has sensory limitation (nurses must maintain a safe environment after the
operation)
 Perspire less that may lead to dry itchy skin where it would be fragile and at
risk for injury (risk for impaired skin integrity) take precaution in moving and
positioning our patient.
 Decrease subcutaneous fat that makes them susceptible to temperature
changes (do skillful preop assessment and treatment and observe meticulous
and competent post operative and postanesthesia management)
 They need more time and multiple explanation to understand and retain what
is being communicated to them.
 Educate patient about proper management and encourage good
communication to obtain a great postop pain relief to the client.
➪ Bariatrics (obese clients)
 Revolves around diagnosing treatment and managing patient who are obese.
 Greater than 30kg/m2
 At risk for complications because of surgery
 Dehiscense - opening up of surgical sight.
 More challenging to provide care to this patient because of excessive weight
and possible movement restriction.
 Increase cardiac workload and pulmonary complication because they usually
have shallow respiration when they are in supine and may also increase the
risk for hypoventilation postoperatively.
 Risk in difficulty in intubation because of several factor:
 Short thick neck
 Large tongue
 Recessed chin
 Redundant pharyngeal tissue
 These factors often associated with increase oxygen demands and decrease
pulmonary reserve.
 Preop assessment should look for these factors as well as the presence of
obstructive sleep apnea.
➪ Clients with disabilities
  This patients may need assisted devices such as eyeglasses, hearing aids,
prostheses, braces, and other devices.
 Hearing aids may be removed during surgery as advised by the doctor (verify
and confirm that the doctor really ordered for the removal of the hearing aid)
 if general anesthesia they WONT NEED HEARING AID
 Regional or local anesthesia THEY MIGHT NEED HEARING AID
 Modification in preop medication and additional assistant with an attention to
positioning and transferring is needed for client with disability that affects
body position such as:
 Cerebral palsy
 Post polio syndrome
 Other neuromuscular diseases
 They need special positioning during the surgery to prevent pain and injury.
 Disabled client may unable to sense painful positioning if their extremities are
incorrectly adjusted, or they may be unable to communicate their discomfort.
(ask and confirm from the patient whether they are comfortable with their
position.)
 Patient with respiratory problem related to disability (e.g multiple
sclerosis and muscle dystrophy) may experience difficulties unless the
problem are made known to the anesthesiologist so that adjustment may be
made.
 These factors needs to be clearly identified in the preop period and
communicated to appropriate personnel. (surgeon, anesthesiologist, attending
physician of the client and the nursing team)
➪ clients undergoing ambulatory surgery
 During the brief time the patient and family spend in the ambulatory
setting nurse must:
 Quickly and comprehensively assess and anticipate the needs of the
patient
 At the same time begin planning for discharge and follow-up home
care.(health teaching and discharge teaching)
 Nurse needs to be sure that the patient and the family understand that the
patient will first go to the preop holding area after the surgery before they
will sent home.
 Sometimes they allow the family to go with the patient after the surgery to
alleviate the anxiety of the family as well as the patient
➪ emergency surgery
 Unpredictable nature of trauma and emergency surgery posses unique
challenges throughout the perioperative pariod.
 Nurse should communicate with the patient and team members as calmly
and effectively as possible in these kind of situation.
 Factors that affects patients preparing to undergo surgery also apply to
patients undergoing emergency surgery, although usually in a very
condensed time frame.
 We need to have a quick visual survey of the patient to identify the sight
of the injury if the emergency is due to trauma.
 Patient who may have undergone traumatic experience , may need extra
 support and explanation of the surgery.
 For unconscious patient, informed consent and essential information, such
as pertinent past medical history and allergies, needs to be obtained from
the family, if one is available.
 If in this case like the patient is unconscious and we were not able to
gather vital information like the medical history, the doctor MAY NOT
ALLOW the patient to be send to surgery, not unless necessary, especially
if there is no consent. (in mission gina hulat ang significant other bfr
STAT surgery) THIS MAY BE DEPEND IN THE PROTOCOL OF
EACH HOSPITALS.

 informed consent
➪ the client’s autonomous decision about whether to undergo a surgical procedure.
➪ disclosure of the risk associated with the intended procedure on operation to the client.
Purpose:
 Ensure the patient understand the nature of the treatment including potential
complications, and disfigurement.
 Indicate that the client decision was made without pressure.
 Protect the patient against unauthorized surgery
 Protect the surgeon and the hospital against legal action by the client who claims that
unauthorized procedure was performed.
Who signs
 adults who are mentally capable sign their own operative permit(patient is fully
conscious, sane, no mental problem)
 for minor (below 18 yrs.), unconscious, psychologically
 Incapacitated, permission is required from responsible family
 Member (parent/ legal guardian).
 a witness is desirable – nurse, physician or other authorized persons.
 in an emergency, permission via telephone or telefax is acceptable.
 written permission is best and is legally acceptable.
 signature is obtained before sedation with the client's complete understanding of what is
to occur.
➪ md to obtain consent once surgery has been discussed with client.
➪ nurse can clarify any information that remains unclear after the
Md’s explanation of the procedure.

Responsibility of a circulating nurse

 When the doctor has already scheduled the patient for surgery, the first thing that should
be check is the informed consent whether it was signed by the patient or not.
The nurse may ask the patient to sign the consent form and witness the signature.

Who is responsible for this?

 It is the responsibility of the surgeon to provide a clear and simple explanation of what
the surgery will entail prior to the patient giving consent.
 Surgeon must also inform the client of the benefits, alternatives, possible risk,
complications, disfigurement, disability, and removal of body parts as well as what to
expect in the early and late postop periods.
 They also have to see to it that when they give the explanation to the client, the patient
should be FULLY CONSCIOUS and FULLY AWARE of the environment.
 In cases of a young children, the parents should be there when the surgeon is explaining
the purpose of the informed consent.

Who will be the witness?
 NURSE
If the doctor is no around when patient will sign the informed consent 2 NURSES could
witness or could stand as a witness.

 It should be signed before the patient is sedated especially for emergency surgery and if
the patient themselves will be the one to sign the consent. (so before giving preop meds
we should let the patient sign the consent)
 If the doctor already explained everything and the patient asked follow-up question you
need to reiterate what is the explanation of the doctor (it is very important as a nurse that
we should also be familiarized and understand the following possible surgical procedure
that is to be done to the client)
 During emergency, telephone, fax, or other electronic means are acceptable.
Informed consent is invalid if the patient signed it after administering preop
medications.

Provision of informed consent:

 The need for the procedure in relation to the diagnosis of the patient
 The description and the purpose of the surgery
 The benefits of the surgery to the patient
 The potential risk
 Possibility of successful outcome to the client
 Alternative treatment or procedure available that was given to the patient during the
surgery

Provision to be included in informed consent:

 Anticipated risk if procedure is not performed
 The advise about what is needed
 Patients right to refuse treatment or withdraw consent

Note:
 If the patient has already signed the consent, the patient still has the right to withdraw.
 If it is a planned procedure and if the patient change their mind they have also the right to
withdraw. Such information must be documented and relayed to the surgeon so that other
arrangement can be made.
 If patient has doubts and has not had an opportunity to investigate alternative treatments,
a second opinion may be request
 No patient should be urged or coerced to give informed consent.
 Refusing to undergo surgical procedure is a person’s legal right and privilege.

Circumstances where informed consent is necessary:

 Any surgical procedure where scalpel, scissors, suture, hemostats of electrocoagulation
 may be used.
 entrance into a body cavity – e.g. Paracentesis, bronchoscopy, crystocopy, colonoscopy,
proctosigmoidscopy.
 general anesthesia, local infiltration, regional block.
Consent form should be written in easily understandable words and concepts to facilitate the
consent process and should use other strategies and resources as needed to help the patient
understand the content.

Preoperative assessment:
Overall goal is to gather data in order to identify risk factors and plan care to ensure patients
safety throughout the surgical experience.
 Every attempt is made to assess for and address risk factors that may contribute to
postoperative complication and delay recovery.
 Before any surgical treatment is initiated,
 Health history is obtained
 Physical examination is performed
 Vital signs are noted
 Baseline is established for future comparisons
 Ask about any allergies and comorbid condition that could affect anesthesia
 Genetics consideration
 Asking patient about use of medication (herbal and other supplements provides
useful information)
 Activity and functional levels should be determined
 Asking about allergies to latex
 Allergies to kiwi, avocado, or banana, or cannot blow up balloons can be
associated with an allergy to latex.
 Latex allergy can manifest as a rash, asthma, or anaphylactic shock
 Be alert for signs of abuse
 Laboratory test and other diagnostic tests may be prescribed.

➪ nutritional and fluid status

• optimal nutrition- promotes healing and resisting infection and other surgical
complications.
 Assessment of the nutritional status could identify the general risk factor that can affect
the surgical course, such as:
 Obesity (wound infection, dehisence, delayed wound healing, pneumonia,
athelectasis, Thromboplibitis, cardiac problems and possible heart failure)
 Weight loss and Malnutrition (nutritional reserve may not be sufficient to allow
the body to respond satisfactorily that may lead to possible organ failure)
 During surgery the patient would have an increase in metabolic needs that
could not be meet if the patient is malnourished
 Deficiency in specific nutrients (should be corrected before surgery to provide
adequate protein for tissue repair)
 Metabolic abnormalities(e.g diabetic patient - need to have a good control of the
sugar level before surgery because they would be at risk for infection, delayed
wound healing and hypoglycemia in relation to their insulin intake.)
 Fluid and electrolytes (dehydration, hypovolemic, and electrolyte imbalance can
lead to significant problems in patient with comorbid medical condition or in
older patient that may cause possible cardiac arrhythmias)
 And the effects of medication on nutrition (may alter possible nutritional
requirements because there are some medications that may affect the nutritional
intake of the patient.)
 Smoking ( increase risk for possible complication, it is advise that if it is not an
emergency it is often advice that the patient should stop smoking for 3-4 weeks
before the scheduled operation.)

➢ nutrients important in wound healing - protein, vit. C, b complex, a & k, etc.

➪ dentition
 Condition of the mouth is an important health factor to assess (this might also
cause possible nutritional deficiency)
 dental caries, dentures and partial plates – are particularly significant to
anesthesiologist or anesthetist(decayed teeth or dental prostheses may become
dislodge during intubation and occlude the airway during the induction of
anesthesia)
 This is especially important to older patients as well as those who may not
regular dental care.
 Condition of the mouth is also important because any bodily infection, even
in the mouth, can be a source of postop infection.

➪ drug or alcohol use

 Ingestion even moderate amounts of alcohol prior to surgery can weaken
patient’s immune system and increase the likelihood of developing postop
complications.
 The use of elicit drugs and alcohol may impede the effectiveness of some
medications that includes the anesthesia
 History of alcohol abuse client may suffer from malnutrition and withdrawal
symptoms r/t significant mortality rate
 More than 2 drinks of alcohol per day 2 weeks prior to surgery would suffer
from complication longer hospital care and more days in ICU postoperatively.
 Acute intoxicated people are susceptible to injury (surgery may be postponed
if possible)
 If for emergency local, spinal, regional, block anesthesia is used for minor
surgery.
 In an emergency surgery to prevent vomiting and potential aspiration,
nasogastric tube is inserted before general anesthesia is given.

➪ respiratory status
 Patient is educated about breathing exercises and the use of incentive
spirometer, if indicated, to achieve optimal respiratory function prior to
surgery.
 optimal respiratory function is the goal for surgical client.
  in assessing pulmonary status, observe the client’s:
 Posture (tripod position - optimized the breathing of the patient)
 Fingers (for clubbing) (indication of hypoxia)
 Assess respiratory rate, depth and rhythm
 lung expansion
 Potential compromise of ventilation during all phases of surgical treatment
necessitates a proactive response to respiratory infection. (If found to be
positive in respiratory infection surgery is postponed for elective surgery)
 Clients with underlying respiratory disease such as:
 (asthma, copd) are assessed for current threats to their Pulmonary
status.
 Preop smoking cessation – 4 to 8 wks before surgery (can be effective
in changing smoking behavior and reducing the incidence of postop
complications.
 Patient who are smoking are at risk for slow wound healing, higher
incident of SSI, and complication that includes IVE and pneumonia.

➪ cardiovascular status
goal: Ensure a well functioning cardiovascular system to meet the oxygen, fluid and
nutritional needs of the perioperative period.
 patients preperation for surgical intervention includes ensuring that cardiovascular
system can support the oxygen, fluid, and nutritional needs of the perioperative
period.
 cardiovascular assessment - includes palpation of peripheral pulses and
auscultation of heart sounds for rate, regularity and abnormalities.
 postponing the surgery or modifying surgical treatment to meet cardiac
tolerance/needs of the client.
 if patient has an uncontrolled hypertension surgery may be postponed until the
blood pressure is under control.
E.g. Patient with obstruction of the descending colon and coronary artery disease, a
temporary simple colostomy may be performed rather than a more extensive colon
resection that would required a prolonged period of anesthesia.

➪ hepatic and renal function

presurgical goal: Optimal function of the liver and the urinary system so that
medications, anesthetic agents, body wastes, and toxins are adequately metabolized
and removal from the body.
 The liver, lungs and kidney are the routes for elimination of drugs and toxins.
 Liver is important in biotransformation of anesthetic compounds.
 Disorder of the liver may substantially affects how anesthetic agents are
metabolized.
 Acute liver disease is associated with high surgical mortality; preoperative
improvement in liver function is the goal.
nurse role: if the doctor has already ordered for liver function test (includes the ASD and
ALD) and renal function test(createnine very important and BUN) and you have notice
abnormalities result it is important to referred it to the surgeon and the attending
physician of the patient.
  Kidneys are involved in excreting anesthetic medication and their metabolites;
therefore, surgery is contraindicated if the patient has:
 Acute nephritis
 Acute renal insufficiency with oliguria or anuria
 Or, other acute renal problems
 Exception include surgeries performed as:
 life-saving measures
 Surgery to enable easier access for dialysis
 Those necessary to improve renal function(e.g obstructive uropathy or
hydronephrosis)

➪ endocrine functions
 diabetic patients - at risk for hypo/hyperglycemia
-Hypoglycemia - may develop during anesthesia or postoperatively from
inadequate carbohydrates(could be a result of the NPO status of the patient due to
surgery) or excessive administration of insulin.
-Hyperglycemia - can increase the risk of surgical wound infection, may result
from the stress surgery, which can trigger increased level of catecholamines.
Doctor must control the blood sugar first before scheduling the surgery not unless it is an
emergency surgery.
 Surgical risk in the patient with controlled diabetes is no greater than in patient
without diabetes (strict glycemic control leads to better outcomes)
 Frequent monitoring of capillary blood glucose level is important before, during,
and after surgery.
 clients receiving steroids – at risk for adrenal insufficiency (the use of
corticosteroids for ant purpose during preceding year must be reported to the anesthesiologist
and surgeon and the patient will be monitored for signs of adrenal insufficiency )
 Clients with uncontrolled thyroid disorders – at risk for
thyrotoxicosis/hyperthyroidism (increasing amount of thyroid hormone in the blood) or
hypothryroid disorders (risk for respiratory failure)
Note: if the patient is in thyroid crisis, watch out for severe elevation of the blood
pressure and heart rate including that hypothermia which could be fatal.
(EMERGENCY CONDITION)
 Patient with an associated history of thyroid disorder is assess preoperatively.

Note:
After surgery if super high gid ang glucose level we need to assess it every 30mins -
1hour.

➪ immune function
 Important function of preop assessment is to determine the presence of infection
or allergies.
 Routine laboratory test used to detect infection includes the white blood count
and urinalysis.
 it is important to identify and document any sensitivity to medications and past
adverse reactions.
  Patient is asked to identify any substances that precipitated previous allergic
reactions, including:
 Medications
Not allowed to take herbal supplements:
 Cardiac problems
 Kidney problems
 Blood transfusion
 Contrast agents
 Latex
 Food products
 and to describe the signs and symptoms produced by these
substances.
 immunosuppression – is common with corticosteroid therapy, organ
transplantation, radiation therapy, chemotherapy, and disorder
affecting immune system such as:
 Acquired immunodeficiency syndrome
 leukemia
 The mildest symptoms or slightest temperature elevation must be investigated.
(refer to the doctor immediately)
 Ensure strict asepsis.

➪ previous medication use

 Obtain medication history because of possible interaction.
 Any medication that patient is using or has used should be documented, including
 OTC preparation
-Aspirin - inhibits platelet aggregation should be prudently discontinued 7-10
days before surgery. (risk for bleeding)
 Herbal agents
 Frequency of use
 medications affecting surgery:
-Anticoagulant - given to patient with cardiac problems and has history of
hypertension (prevents clotting of blood and therefor prevents thrombus from
forming) clopidogrel is the best example maybe taken everyday as maintenance.
Should be stop 48 hours before surgery (risk for bleeding during and after surgery 24hrs -
2 days after surgery)
-Diuretics (furosemide) - promote urination to the client and if the patient is
having an increase amount of urination related to intake of diuretics (at risk for
not only for dehydration but also of electrolytes imbalance)
-antihypertensive -my cause possible hypotension.
 Calcium channel blockers (amlodipine)
 ACE inhibitors (Losartan)
-Antidepressant - cause possible hypotension
-Antibiotics - potentiate(enhance) the action of the anesthesia
-Corticosteroid - lead to inability of the patient to withstand stress and can cause
immune problems
-Insulin - risk of developing HYPOglycemia during the
operation.
 -Antidysrhythmic agents - patient with problems with the heart rhythms
(dysrythmias) that reduces cardiac contractility
-Herbal supplements - most often the patient wont tell that they are taking
herbal supplements. Taken without prescription. (some may interact with
anesthesia) best continued 2-3 weeks after surgery.
Common herbal examples:
 Ephedra - good for asthma, bronchitis (increases blood pressure
and causes irregular heart beat)
 Echinacea - taken for common cold, cough, bronchitis and other
respiratory infection. (increase effects of some meds use during the
anesthesia)
 Gingko biloba(contraindicated to patient taking seizure
medication)
 Ginger, Garlic, and Ginseng -prevents clot formation. (cause
severe bleeding)
 Kava-Kava - relaxant
 St. John’s wort and Camomile - prolongs the sedative effects of
anesthesia
 Feverfew - prevents clotting (bleeding)
 Saw palmetto - used for inlarge prostate gland, a diuretic and
urinary antiseptic and reduces the sexual drive (affects the
testosterone level)
 Black cohosh - use for menopuasal period

If patient is taking any if this herbal medication, imformed the doctor!!

Herbal preparations should be discontinued 2 to 3 weeks before surgery.

➪ psychological factors

 Causes of fears of the preop clients:

• fear of the unknown (they wont know what would happen to them or what is
happening during the surgery that is why the doctor should explain what
would be happening during the operation)
• fear of anesthesia, vulnerability while unconscious
• fear of pain
• fear of death
• fear of disturbance of body image
• worries – loss of finances, employment, social and
Family roles
 Preop anxiety – can be preemptive response to a treat to the patient’s role in life, a
permanent incapacity or body integrity, increased responsibilities or burden on family
members, or life itself.

Nursing interventions to minimize anxiety:

 explore client's feelings (build rapport, stay and converse)
 allow client's to speak openly about fears / concerns (when they are speaking about
their feelings DO NOT STOP THEM, make time to listen to them)
  give accurate information regarding surgery
 give empathetic support
 consider the person's religious preferences and arrange for visit by priest/ minister as
desired.

 Identification of anxiety using supportive guidance at every juncture of the periop

process helps ease anxiety.
 Psychological distress - directly influences the body functioning.
 Important outcome of psychosocial assessment – determine extent and role of the client’s
support network.

How each ppl expresses fear:

 Asking repeated questions
 May withdraw (look at cues that indicates fear in the patient)
 Avoiding communication by reading, watching tv, or talking about trivialities.

 The value and reliability of available support system is also assess.

 Assessing the patient’s readiness to learn and determining the best approach to maximize
comprehension - provide the basis for preop patient education.
 In cases which patients who are developmentally delayed and those cognitively impaired
the approached to patients education and consent should include the legal guardian.

➪ spiritual and cultural factors

 Spiritual beliefs play an important role in how people cope with fear and anxiety.
Regardless of religious affiliation, adhering to spiritual beliefs, can be therapeutic.
 Every attempt must be made to help patient obtain the spiritual support that he/she
requests.
 Nurse must show respect and support for a client’s cultural values and beliefs - to
facilitates rapport and trust

ASSESSMENT
 Identifying the ethnic group to which the patient relates and the custom and beliefs
the patient holds about illness and health care providers.
 When assessing pain some ethnics group are unaccustomed to expressing their
feelings openly with strangers and nurses should consider this pattern of
communication.
 Nurses should know that avoiding eye contact sometimes is not avoidance nor does
not reflect a lack of interest.
 Nurses should listen carefully to the patient and observe bodily language, esp in
obtaining history.

 diagnostic tests
 Test that may be performed before admission or during admission.
➪ complete blood count
 monitor the hgb and hct - would monitor the oxygenation, fluid volume
status and possible bleeding esp internal bleeding.
 Wbc - helps monitor for possible infection or inflammation
 ➪ electrolyte studies – k+, na+, cl- (incase of abnormal results need to refer
closely
➪ coagulation studies - monitor the clotting time and bleeding time
 prothrombin time (pt)
 partial Thromboplastin time (ptt)
➪ urinalysis - detect for presence of protein in the urine
➪ chest x-ray – especially in the elderly with risk
Factors related to heart and lung function
➪ ecg – routinely for 40 years old and above or have
Cardiovascular disease
➪ creatinine
➪ abg
➪ blood urea nitrogen (bun)
➪ glucose (fasting)

 analysis:
Common nursing diagnoses:
■ knowledge deficit r/t perioperative experience
■ anxiety
■ fear

 additional diagnoses:
► sleep pattern disturbance r/t fear of impending surgery
► ineffective individual coping
► anticipatory grieving (common to client who will have a surgery wherein there is
a removal of body part)
► body image disturbance

 Planning:
Expected outcome:
 Client will verbalized the understanding of the preparation fot the periop.

 for anxiety - the client will appear relaxed and will report that anxiety is reduced to a
manageable level.

 for fear - the client will demonstrate appropriate range of feeling and will verbalize
that fear has lessened.

 general preop nursing interventions:

 Providing patient teaching
 Each patients education is individualized.
 Multiple educational strategies should be used depending on patients needs and
abilities.
 It is initiated as soon as possible:
 Beginning in the physicians office
 Clinics
 Or at the time of PAT when diagnostic test are performed.
  Nurses should guide the patient through the experience and allow ample time for
questions.
 Telling patients that preop meds will cause relaxation before the operation is not
as effective because meds will act quickly and may result in lightheadedness,
dizziness, and drowsiness.
 Knowing what to expect helps the patient anticipate these reactions.
 Overly detailed description may increase anxiety in some patients; therefore,
nurses should be sensitive to this, by watching, listening and provide less detail
explanation.
➪ Components:
1. Sensory information – sights, sounds and “feel” of OR (reduces anxiety)
2. Psychosocial information – coping abilities and worries about family.
(promote comfort)
3. Procedural information – details during the preoperative period and
postoperative care. (
Example : During preop doctor ordered for an insertion of catheter you
need to:
 Explaining the purpose why you have to insert the catheter
 Why the doctor need to insert the catheter
 Expected outcome
 How/What will they feel during insertion
 Dos and Don’t

➪ Purpose:
 discussion, demonstration, and practice
 if clients must remain in bed it is important for them to turn, cough and deep
breath q 2 hours. (these are the necessary info to give PREOP and not after the
operation unless the surgery is a emergency surgery)

Deep breathing, coughing and incentive spirometry.

Deep breathing exercises - regardless of which type of breathing is used. The nurse
emphasizes the need to begin exercises early in the recovery phase and to continue
them 5 to 10 times every 1 to 2 hrs after surgery for at least the first 48 hrs.

 Goal: Educate the patient how to promote optimal lung expansion and
resulting blood oxygenation after anesthesia.
 Sitting position - enhance lung expansion
 Nurses should demonstrate how to take a deep breath, slow breath and how to
exhale slowly.
 After several times of practice:
 Patient is instructed to breathe deeply
 Exhale through the mouth
 Take a short breath
 Cough deeply in the lungs
Diaphragmatic breathing - flattening of the dome of the diaphragm during
inspiration with resultant to enlargement of the abdomen as air rushes in. During
expiration the abdominal muscle contracts( teach patient to inhale through nose and
 exhale through mouth)

Coughing exercises - removes retained secretions from bronchi and airways to

prevent possible infection (mobilize secretions so that they can be removed)
 Performed in conjunction with deep breathing every 1-2 hours
postoperatively.
 Goal: help breathing and to clear the lungs and the lower respiratory tract to
prevent the risk for pneumonia.
 Nurse and Respiratory therapist - also demonstrate how to use an incentive
spirometer, a device that provides measurement and feedback related to
breathing effectiveness.
 incentive spirometry - promote expansion of alveoli by guiding the client to
reach a predetermined level of lung inflation and strengthens respiratory
muscles
 If thoracic and abdominal incision is anticipated - nurse demonstrate how to
splint the incision to minimize pressure and control of pain.
 Splinting (placing the hands across the incision site) - acts as an effective
support when coughing.
-Patient should put the palms of both hands together, interlacing the
fingers snugly.
 Patient is informed that medications are available to relieve pain and should
be taken regularly for pain relief so that effective deep-breathing and cough
exercise can be performed comfortably.
 Deep-breathing before coughing stimulates cough reflex.

Note: if the patient does not cough effectively, atelectasis (collapse of the alveoli),
pneumonia, or other lung complications may occur.

Purpose:
• coughing is performed in conjunction with deep breathing every 1 to 2 hours
postoperatively.

Mobility and active body movement

Purpose:
- improve circulation, prevent venous stasis(preventing the formation of venous
thrombosis), and promote optimal respiratory function
Position changes:
-assist the client in position changes, but if the client is able to change position by
themselves we need to promote independency.
 Patient should be taught that early and frequent ambulation postoperatively, as tolerated,
helps prevent complications.
 Nurse responsibilities:
 needs to exaplain the rationale for frequent position changes.
 Shows how to turn from side to side
 How to assume a lateral position without causing pain or disrupting IV lines,
drainage tubes, or other equipment.
 Discussed the special position that needs to be maintain after surgery (adduction or
 elevation of extremities)
 Review the process before surgery (patient may be to uncomfortable or drowsy after
the surgery to absorb new information)
 Use of ted hose (prevent development of thromboembolism-deterrent)
Exercise of extremities (Preop)
 extension and flexion of knee and joints (unless contraindicated in surgeries such as
hip replacement.)
 Foot is rotated
 Elbows and shoulders are put through ROM
Note:
At first, patient is assisted and reminded to perform the exercise.
Later, patient is encourage to do them independently.
 Muscle tone is maintained (ambulation will be easier)
 Use proper body mechanics.

Pain management
 Should include differentiation between acute and chronic pain
 pain intensity scale - should be introduced and explained to the patient (promote more
effective postop pain management)
 Preop patient education also needs to include difference between acute and chronic pain
(promote preparedness for patient to differentiate acute postop pain from chronic
condition.
 Pain meds are given after surgey to relieve pain and maintain comfort without suppresing
respiratory function.
 Patient is instructed to take the meds frequently
Anticipated methods of administration of analgesic agents for inpatient includes:
 Patient-controlled analgesia
 Epidural catheter bolus or infusion
 Patient-controlled epidural analgesia.
 Patient going home = oral analgesia
Note: doctors are the one responsible for administering pain meds via epidural catheter.

cognitive coping strategies - useful for relieving tension, overcoming anxiety, decreasing
fear and achieving relaxation
imagery
distraction
optimistic self-recitation - motivates themselves
 music therapy