FUNDAMENTALS OF NURSING

Week 7 - Perioperative Nursing; Activity and Exercise

Perioperative Nursing
I. Definition of Terms
A. Perioperative Nursing - the delivery of nursing care through the framework of the
nursing process during the perioperative period
B. Preoperative Phase - begins when the decision to have surgery is made; it ends
when the client is transferred to the operating table.
C. Intraoperative Phase - begins when the client is transferred to the operating table
and ends when the client is admitted to the postanesthesia care unit (PACU),
also called the postanesthetic room or recovery room (RR)
D. Postoperative Phase - begins with the admission of the client to the
postanesthesia area and ends when healing is complete
II. Types of Surgery
A. According to Purpose
1. Diagnostic - confirms or establishes a diagnosis; for example, biopsy of a
mass in a breast.
2. Palliative - relieves or reduces pain or symptoms of a disease; it does not
cure; for example, resection of nerve roots.
3. Ablative - removes a diseased body part; for example, removal of a
gallbladder (cholecystectomy).
4. Constructive - restores function or appearance that has been lost or
reduced; for example, cleft palate repair.
5. Transplant - replaces malfunctioning structures; for example, kidney
transplant.
B. According to Degree of Urgency
1. Emergency - performed immediately to preserve function or the life of the
client.
2. Elective - performed when surgical intervention is the preferred treatment
for a condition that is not imminently life threatening (but may ultimately
threaten life or wellbeing), or to improve the client’s life.
C. According to Degree of Risk
1. Major - involves a high degree of risk, for a variety of reasons: It may be
complicated or prolonged, large losses of blood may occur, vital organs
may be involved, or postoperative complications may be likely.
2. Minor - involves little risk, produces few complications, and is often
performed in an outpatient setting.
III. Preoperative Phase
A. Preoperative Consent
1. Prior to any surgical procedure, informed consent is required from the
client or legal guardian.
2. Informed consent implies that the client has been informed and involved
in decisions affecting his or her health.
 3. Although the surgeon maintains legal responsibility for ensuring that the
client has given informed consent, the nurse may witness the client’s
signature on the consent form.
B. Preoperative Teaching
1. Information, including what will happen to the client, when, and what the
client will experience, such as expected sensations and discomfort.
2. Psychosocial support to reduce anxiety.The nurse provides support by
actively listening and providing accurate information.
3. The roles of the client and support people in preoperative preparation, the
surgical procedure, and during the postoperative phase. Understanding
his or her role during the perioperative experience increases the client’s
sense of control and reduces anxiety.
4. Skills training. This includes moving, deep breathing, coughing, etc.
Moving, Leg Exercises, Deep Breathing and Coughing - https://youtu.be/flIV8c38zDE 1. Show
the client ways to turn in bed and to get out of bed. Instruct a client who will have a right
abdominal incision or a right-sided chest incision to turn to the left side of the bed and sit up
as follows:
a. Flex the knees.
b. Splint the wound by holding the left arm and hand or a small pillow against the
incision.
c. Turn to the left while pushing with the right foot and grasping a partial side rail on
the left side of the bed with the right hand.
d. Come to a sitting position on the side of the bed by using the right arm and hand
to push down against the mattress and swinging the feet over the edge of the
bed.
e. Teach a client with a left abdominal or left-sided chest incision to perform the
same procedure but splint with the right arm and turn to the right.
2. Teach the client the following three leg exercises:
a. Alternate dorsiflexion and plantar flexion of the feet.
b. Flex and extend the knees, and press the backs of the knees into the bed while
dorsiflexing the feet.
c. Raise and lower the legs alternately from the surface of the bed. Flex the knee of
the stable leg and extend the knee of the moving leg.
3. Demonstrate deep-breathing (diaphragmatic) exercises as follows:
a. Place your hands palms down on the border of your rib cage, and inhale slowly
and evenly through the nose until the greatest chest expansion is achieved. b.
Hold your breath for 2 to 3 seconds.
c. Then exhale slowly through the mouth.
d. Continue exhalation until maximum chest contraction has been achieved.
4. Help the client perform deep-breathing exercises.
a. Ask the client to assume a sitting position.
b. Place the palms of your hands on the border of the client’s rib cage to assess
respiratory depth.
c. Ask the client to perform deep breathing
5. Instruct the client to cough voluntarily after five deep inhalations.
 a. Ask the client to inhale deeply, hold the breath for a few seconds, and then cough
once or twice.
b. Ensure that the client coughs deeply and does not just clear the throat. 6. If the
incision will be painful when the client coughs, demonstrate techniques to splint the
abdomen.
a. Show the client how to support the incision by placing the palms of the hands on
either side of the incision site or directly over the incision site, holding the palm
of one hand over the other.
b. Show the client how to splint the abdomen with clasped hands and a pillow firmly
held against the client’s abdomen.
7. Instruct the client to start the exercises as soon after surgery as possible. Encourage
clients to carry out deep breathing and coughing at least every 2 hours, taking a
minimum of five breaths at each session.
C. Physical Preparation
1. Nutrition and fluids
2. Elimination
3. Hygiene
4. Medications
5. Sleep
6. Prostheses
7. Special orders
8. Skin preparation
9. Vital Signs
10. Safety protocols
11. Antiembolic stockings
Applying Antiembolic Stockings - https://youtu.be/zARySfecmYc
1. Apply stockings in the morning, if possible, before the client gets out of bed. Assist the
client who has been ambulating to lie down and elevate the legs for 15 to 30 minutes
before applying the stockings.
2. Assist the client to a lying position in bed. Wash and dry the legs as needed.
3. Apply the stockings.
a. Reach inside the stocking from the top, and grasping the heel, turn the upper
portion of the stocking inside out so the foot portion is inside the stocking leg. b. Ask
the client to point the toes, then position the stocking on the client’s foot. With the
heel of the stocking down and stretching each side of the stocking, ease the
stocking over the toes taking care to place the toe and heel portions of the stocking
appropriately.
c. Grasp the loose portion of the stocking at the ankle and gently pull the stocking
over the leg, turning it right side out in the process. If applying thigh-length
stockings, stretch them over the knee until the top is below the gluteal fold.
4. Inspect the client’s leg and stocking, smoothing any folds or creases. Ensure that the
stocking is not rolled down or bunched at the top or ankle. Ensure that the stocking is
distributed evenly and that the heel is properly centered in the heel pockets.
IV. Intraoperative Phase
A. Types of Anesthesia
 1. General - the loss of all sensation and consciousness. A general
anesthetic acts by blocking awareness centers in the brain so that
amnesia (loss of memory), analgesia (insensibility to pain), hypnosis
(artificial sleep), and relaxation (rendering a part of the body less tense)
occur.
2. Regional - the temporary interruption of the transmission of nerve
impulses to and from a specific area or region of the body. The client
loses sensation in an area of the body but remains conscious. Several
techniques are used:
a) Topical (surface) - applied directly to the skin and mucous
membranes, open skin surfaces, wounds, and burns.
b) Local - injected into a specific area and is used for minor surgical
procedures such as suturing a small wound or performing a
biopsy.
c) Nerve block - the anesthetic agent is injected into and around a
nerve or small nerve group that supplies sensation to a small area
of the body.
d) Spinal (subarachnoid) - an anesthetic agent is injected into the
subarachnoid space surrounding the spinal cord.
e) Epidural (peridural) - injection of an anesthetic agent into the
epidural space, the area inside the spinal column but outside the
dura mater.
3. **Conscious sedation - minimal depression of the level of consciousness
such that the client retains the ability to maintain a patent airway and
respond appropriately to commands.
B. Circulating Nurse vs Scrub Nurse
1. Circulating Nurse - coordinates activities and manages client care by
continually assessing client safety (e.g., client positioning) and by
monitoring aseptic practice and the environment (e.g., temperature,
humidity, and lighting).
2. Scrub Nurse - wear sterile gowns, gloves, caps, and eye protection. Their
role is to assist the surgeons.
3. BOTH the circulating nurse and the scrub person are responsible for
accounting for all sponges, needles, and instruments at the close of
surgery. This precaution prevents foreign bodies from being left inside the
client.
C. Surgical Skin Preparation
1. Clean the surgical site and surrounding areas.
2. Remove hair from the surgical site only when necessary, for example, if it
interferes with the surgical procedure.
3. Prepare the surgical site and surrounding area with an antimicrobial agent
when indicated.
D. Positioning
1. Positioning is performed after anesthesia is induced and before surgical
 draping of the client.
2. The position of the client during a surgical procedure is essential to the
maintenance of client safety.
3. The client’s position should provide:
a) Optimal visualization of and access to the surgical site
b) Optimal access to IV lines and monitoring devices
c) Protection of the client from harm (anatomic and physiological
considerations)
4. The position should consider normal joint range of motion and good body
alignment, thereby avoiding strain or injury to muscles, bones, and
ligaments.
5. The most common position for a client during a surgical procedure is the
supine position.
a) This position provides approaches to the cranial, thoracic, and
peritoneal body cavities as well as to all four extremities and the
perineum.
b) Proper body alignment and padding of potential pressure areas
are essential to preventing client risk for injury during surgery.
V. Postoperative Phase
A. Immediate Postanesthetic Phase - recovery of surgical clients who required
anesthesia is performed in the PACU (Post-Anesthesia Care Unit) or RR
(Recovery Room)
1. Clinical Assessment
a) Adequacy of airway
b) Oxygen saturation
c) Adequacy of ventilation
d) Cardiovascular status
e) Level of consciousness:
f) Presence of protective reflexes (e.g., gag, cough)
g) Activity, ability to move extremities
h) Skin color (pink, pale, dusky, blotchy, cyanotic, jaundiced)
i) Fluid status:
j) Condition of operative site
k) Patency of and character and amount of drainage from catheters,
tubes, and drains
l) Discomfort (i.e., pain) (type, location, and severity), nausea,
vomiting
m) Safety (i.e., necessity for side rails, call bell within reach)
B. Ongoing Care of Postoperatiive Client
1. Pain management
2. Positioning
3. Deep breathing
4. Deep breathing and coughing exercises
5. Leg exercises
 6. Moving and ambulation
7. Hydration
8. Urinary and gastrointestinal functions
9. Diet
10. Suction
11. Wound care and wound drains
Cleaning a Sutured Wound and Changing a Dressing -
https://youtu.be/otHmSV8nC9s 1. Prepare the equipment.
2. Perform hand hygiene.
3. Remove binders and tape.
4. Apply clean gloves and remove the outer abdominal dressing or surgipad. 5. Lift the
outer dressing so that the underside is away from the client’s face. 6. Place the soiled
dressing in the moisture-proof bag without touching the outside of the bag.
7. Remove the underdressings, taking care not to dislodge any drains. If the gauze sticks to
the drain, support the drain with one hand and remove the gauze with the other. 8. Assess
the location, type (color, consistency), and odor of wound drainage, and the number of
gauzes saturated or the diameter of drainage collected on the dressings. 9. Discard the
soiled dressings in the bag as before.
10. Remove and discard gloves in the moisture-proof bag.
11. Perform hand hygiene.
12. Open the sterile dressing set, using surgical aseptic technique.
13. Place the sterile drape beside the wound.
14. Open the sterile cleaning solution and pour it over the gauze sponges in the
plastic container.
15. Apply sterile gloves.
16. Clean the wound, using your gloved hands or forceps and gauze swabs moistened
with a cleaning solution.
17. Use a separate swab for each stroke and discard each swab after
use. 18. Clean as many times as necessary to remove the drainage.
19. Dry the surrounding skin with dry gauze swabs as required. Do not dry the incision
or wound itself.
20. Apply dressings to the drain site and the incision. Place a precut 4×4 gauze snugly
around the drain, or open a 4×4 gauze to 4×8 in., fold it lengthwise to 2×8 in., and place
it around the drain so that the ends overlap.
21. Apply the final surgipad. Remove and discard gloves.
22. Secure the dressing with tape or ties.
23. Perform hand hygiene.
C. Home Care
1. Maintaining comfort
a) Instruct the client to use pain medications as ordered, not allowing
pain to become severe before taking the prescribed dose
b) Discuss the importance of gradually resuming activities, avoiding
overexertion
c) Teach the client to use nonpharmacologic measures to help
 manage pain, such as conscious relaxation, distraction,
meditation, or visualization.
d) Instruct the client to contact the primary care provider if pain
increases after a period of decreasing discomfort
2. Promoting healing
a) Emphasize the importance of hygiene and hand washing to
prevent infections.
b) Instruct the client to report promptly to the primary care provider
any increasing redness, swelling, pain, or discharge from the
incision or drain sites.
c) Discuss the importance of keeping follow-up appointments to
monitor healing and recovery after surgery
3. Restoring wellness
a) Discuss the relationship of increasing activities to restoring
wellness and promoting a sense of well-being.
b) Emphasize the importance of adequate rest for healing and
immune function.

Activity and Exercise

● At the 2005–2006 North American Nursing Diagnosis Association (NANDA) Conference,
the diagnosis Sedentary Lifestyle was approved, underscoring the role of exercise and
activity as an essential component of health.
● Activity-exercise pattern - refers to a person’s routine of exercise, activity, leisure, and
recreation.
● Mobility - the ability to move freely, easily, rhythmically, and purposefully in the
environment
I. Normal Movement
A. Alignment and posture
B. Joint mobility
C. Balance
D. Coordinated movements
II. Factors Affecting Alignment and Activity
A. Growth and development
B. Nutrition
C. Personal values and attitudes
D. External factors
E. Prescribed limitations
III. Exercise
A. Types of Exercise
1. Isotonic (dynamic) - those in which the muscle shortens to produce
muscle contraction and active movement
2. Isometric (static or setting) - those in which muscle contraction occurs
without moving the joint (muscle length does not change)
3. Isokinetic (resistive) - involve muscle contraction or tension against
 resistance
4. Aerobic - activity during which the amount of oxygen taken into the body
is greater than that used to perform the activity
5. Anaerobic - activity in which the muscles cannot draw out enough oxygen
from the bloodstream, and anaerobic pathways are used to provide
additional energy for a short time
IV. Body mechanics - the efficient, coordinated, and safe use of the body to move objects
and carry out the ADLs
A. Lifting - nurses should not lift more than 35 pounds without assistance from
proper equipment and/or other individuals
B. Pulling and pushing - when pulling or pushing an object, a person maintains
balance with least effort when the base of support is increased in the direction in
which the movement is to be produced or opposed
C. Pivoting - a technique in which the body is turned in a way that avoids twisting of
the spine
V. Positioning Clients
A. Make sure the mattress is firm and level yet has enough give to fill in and support
natural body curvatures.
B. Ensure that the bed is clean and dry.
C. Place support devices in specified areas according to the client’s position. D.
Avoid placing one body part, particularly one with bony prominences, directly on top
of another body part.
E. Avoid friction and shearing.
F. Plan a systematic 24-hour schedule for position changes.
G. Always obtain information from the client to determine which position is most
comfortable and appropriate.
1. Fowler’s position
2. Orthopneic position
3. Dorsal recumbent position
4. Prone position
5. Lateral position
6. Sim’s position
Moving a Client Up in Bed - https://youtu.be/2T2HtI16GGc
1. Adjust the head of the bed to a flat position or as low as the client can tolerate.
2. Raise the bed to a height appropriate for personnel safety
3. Lock the wheels on the bed and raise the rail on the side of the bed opposite you.
4. Remove all pillows, then place one against the head of the bed.
5. For the client who is able to reposition without assistance:
a. Stand by and instruct the client to move self.
b. Encourage the client to reach up and grasp the upper side rails with both hands,
bend knees, and push off with the feet and pull up with the arms
simultaneously.
c. Ask if a positioning device is needed.
6. For the client who is partially able to assist:
 a. Use a friction-reducing device and two assistants.
b. Ask the client to flex the hips and knees and position the feet so that they can be
used effectively for pushing.
c. Place the client’s arms across the chest. Ask the client to flex the neck during the
move and keep the head off the bed surface.
d. Use the friction-reducing device and assistants to move client up in bed. Ask the
client to push on the count of three.
Turning a Client in Bed - https://youtu.be/NotoJXPhQlo
1. Adjust the head of the bed to a flat position or as low as the client can tolerate.
2. Raise the bed to a height appropriate for personnel safety.
3. Lock the wheels on the bed.
4. Move the client closer to the side of the bed opposite the side the client will face when
turned.
5. While standing on the side of the bed nearest the client, place the client’s near arm
across the chest. Abduct the client’s far shoulder slightly from the side of the body and
externally rotate the shoulder.
6. Place the client’s near ankle and foot across the far ankle and foot. 7. Roll the client to
the lateral position. The second person(s) standing on the opposite side of the bed helps roll
the client from the other side.
8. Place one hand on the client’s far hip and the other hand on the client’s far shoulder.
9. Position the client on his or her side with arms and legs positioned and supported
properly.
Logrolling a Client - https://youtu.be/lAoFqO5fbHI
1. Position yourselves and the client appropriately before the move.
2. Place the client’s arms across the chest.
3. Pull the client to the side of the bed.
4. Use a friction-reducing device to facilitate logrolling.
a. First, stand with another nurse on the same side of the bed.
b. Assume a broad stance with one foot forward, and grasp the rolled edge of the
friction-reducing device.
c. On a signal, pull the client toward both of you.
5. One person moves to the other side of the bed, and places supportive devices for the
client when turned.
6. Place a pillow where it will support the client’s head after the turn.
7. Place one or two pillows between the client’s legs to support the upper leg when the
client is turned.
8. Go to the other side of the bed (farthest from the client), and assume a stable stance.
9. Reaching over the client, grasp the friction-reducing device, and roll the client toward
you.
10. The second nurse (behind the client) helps turn the client and provides pillow supports
to ensure good alignment in the lateral position.
11. Support the client’s head, back, and upper and lower extremities with pillows.
12. Raise the side rails and place the call bell within the client’s
reach. Assisting a Client to Sit on the Side of the Bed (Dangling)
1. Assist the client to a lateral position facing you, using an assistive device depending on
 client assistance needs.
2. Raise the head of the bed slowly to its highest position.
3. Position the client’s feet and lower legs at the edge of the bed.
4. Stand beside the client’s hips and face the far corner of the bottom of the bed. 5.
Move the client to a sitting position, using an assistive device depending on client
assistance needs.
a. Place the arm nearest to the head of the bed under the client’s shoulders and the
other arm over both of the client’s thighs near the knees.
b. Pivot on the balls of your feet in the desired direction facing the foot of the bed
while pulling the client’s feet and legs off the bed.
Transferring Between Bed and Chair - https://youtu.be/pDa75MNGpWY 1.
Place the wheelchair parallel to the bed and as close to the bed as possible. 2.
Ask the client to:
a. Move forward and sit on the edge of the bed (or surface on which the client is
sitting) with feet placed flat on the floor.
b. Place the client’s hands on the bed surface (or available stable area) so that the
client can push while standing.
3. Stand directly in front of the client and to the side requiring the most support. 4. Assist
the client to stand, and then move together toward the wheelchair or sitting area to which
you wish to transfer the client.
a. Support the client in an upright standing position for a few moments. b. Together,
pivot on your foot farthest from the chair, or take a few steps toward the wheelchair,
bed, chair, commode, or car seat.
5. Assist the client to sit. Move the wheelchair forward or have the client back up to the
wheelchair (or desired seating area) and place the legs against the seat. 6. Ensure
client safety.
Assisting a Client to Ambulate - https://youtu.be/fuY9_rGmJPA
1. Prepare the client for ambulation.
a. Have the client sit up in bed for at least 1 minute prior to preparing to dangle legs.
b. Assist the client to sit on the edge of the bed and allow dangling for at least 1
minute.
c. Assist the client to stand by the side of the bed for at least 1 minute until he or
she feels secure.
2. Encourage the client to ambulate independently if he or she is able, but walk beside the
client’s weak side, if appropriate.
3. Encourage the client to assume a normal walking stance and gait as much as possible.
Client Teaching: Using Walkers - https://youtu.be/GzTp6Xy6ako
1. When maximum support is required:
a. Move the walker ahead about 15 cm (6 in.) while your body weight is borne by
both legs.
b. Then move the right foot up to the walker while your body weight is borne by the
left leg and both arms.
c. Next, move the left foot up to the right foot while your body weight is borne by the
right leg and both arms.
2. If one leg is weaker than the other:
 a. Move the walker and the weak leg ahead together about 15 cm (6 in.) while your
weight is borne by the stronger leg.
b. Then move the stronger leg ahead while your weight is borne by the affected leg
and both arms.
Client Teaching: Using Crutches - https://youtu.be/ElZkPye4WtA
1. Four-point alternate gait:
a. Move the right crutch ahead a suitable distance, such as 10 to 15 cm (4 to 6 in.).
b. Move the left front foot forward, preferably to the level of the left crutch. c. Move
the left crutch forward.
d. Move the right foot forward.
2. Three-point gait:
a. Move both crutches and the weaker leg forward.
b. Move the stronger leg forward.
3. Two-point alternate gait:
a. Move the left crutch and the right foot forward together.
b. Move the right crutch and the left foot ahead together.
4. Swing-To gait:
a. Move both crutches ahead together.
b. Lift body weight by the arms and swing to the crutches.
5. Swing-through gait:
a. Move both crutches forward together.
b. Lift body weight by the arms and swing through and beyond the crutch.
6. Going Up Stairs:
a. Assume the tripod position at the bottom of the stairs.
b. Transfer the body weight to the crutches and move the unaffected leg onto the
step
c. Transfer the body weight to the unaffected leg on the step and move the crutches
and affected leg up to the step. The affected leg is always supported by the
crutches.
d. Repeat steps 2 and 3 until the client reaches the top of the stairs.
7. Going Down Stairs:
a. Assume the tripod position at the top of the stairs.
b. Shift the body weight to the unaffected leg, and move the crutches and affected
leg down onto the next step
c. Transfer the body weight to the crutches, and move the unaffected leg to that
step. The affected leg is always supported by the crutches.
d. Repeat steps 2 and 3 until the client reaches the bottom of the stairs.