NCM 112 | Peri Operative Nursing
 Elective- For client’s well-being but not
 General Consideration
 Conditions Requiring Surgery
 Obstruction or Blockage
 Perforation or Rupture
 Erosion or Wearing 1of Tissue
 Tumors & Abnormal Growths
 Categories of Surgical Procedures
 According to Purpose
 Diagnostic- To Verify Suspected diagnosis
 E.g. Biopsy
 Explorative Surgery- to Estimate the extent of
the disease
 E.g. Exploratory Laparotomy
 Curative- To remove or repair damaged or
diseased organs or tissues
 Types:
 Ablative- Removal of diseased organs
 Reconstructive- Partial or complete
reconstruction
 Constructive- repair of congenitally
defective organ
 Palliative- To relieve pain or Distressing S/Sx
 Cosmetic
 According to Degree of Risk to Client
 Major Surgery
 High Degree of Risk
 Prolonged Intraoperative period
 Large amount of Blood Loss
 Extensive, vital organs may be handled or
removed
 Great risk of Complications
 Minor Surgery
 Lesser degree of Risk to Client
 Generally not prolonged
 One day Surgery/outpatient surgery
 Leads to few Serious Complications
 According to Urgency
 Emergency- Immediate without Delay
 Gunshot wound, severe bleeding
 Imperative / Urgent- ASAP within 24-48 hours
 Appendectomy
 Required- Weeks to months
 Cholecystectomy, thyroidectomy
absolutely necessary
 Simple hernia, vaginal repair
 Cosmetic- at clients Request
 Rhinoplasty
 Factors that affect estimation of Surgical Risk
 Physical & Mental Condition of Client
 Age
 Nutritional Status
 Fluid & Electrolyte Balance
 General Health
 Mental Health
 Economic & Occupational Status
 Types of drugs taken regularly
 Steroids: may improve the body’s ability to
response to the stress of anesthesia and surgery
 Anticoagulants and salicylates: may increase
bleeding during surgery
 Antibiotics: maybe incompatible with or
potentiate anesthetic agents
 Tranquilizers: potentiate the effect of narcotics
and can cause hypotension
 Antihypertensive: may predispose to shock by
the combined effect of blood pressure reduction
and anesthetic vasodilation
 Diuretics: may increase potassium loss
 Alcohol: will place the surgical client at risk
when used chronically
 Extent of the Disease
 Magnitude of Operation
 Resources and Preparation
RE Macanlalay
 Suffixes Related to Surgery
 -ostomy (make artificial opening) Colostomy
 -otomy (cut into or incision) Phlebotomy
 -plasty (plastic repair) Rinoplasty
 -orrhaphy (suturing; repair) Herniorrhaphy
 -oscopy (visual examination) Endoscopy
 -ectomy (excision; removal) Cholecystectomy
 Phases of Perioperative Nursing
 Pre-Operative Phase: begins with the decision to perform
surgery and ends with the client’s transfer to the operating
room table
 Intra-Operative Phase: begins with the client is received
in the OR and ends with his admission to the PARR or
PACU
 Post-Operative Phase: begins with the client is admitted
to PARR or PACU and extends through follow-up home
or clinic evaluation
 THE PERIOPERATIVE TEAM
 The Surgeon
 An Anesthesiologist or Nurse Anesthetist
 Makes the preoperative assessment to plan for the
type of anesthesia to be administered and to evaluate
the client’s status
 The Professional Registered OR Nurse
 Makes preoperative assessment and documents the
perioperative client care plan (Scrub, Circulating,
PACU Nurse)
 The Circulating Nurse
 Manages the OR and protects the safety
and health needs of the client by
monitoring the activities of the members
of the surgical team and monitoring the
conditions in the OR
 The Scrub Nurse
 Responsible for scrubbing for surgery,
including setting up sterile tables and
equipment and assisting the surgeon and
surgical technicians during the surgical
procedure
 The PACU Nurse
 Responsible for caring for the client until
the client has recovered from the effects of
anesthesia, is oriented, has stable vital
signs, and shows no evidence of
hemorrhage
 PRINCIPLES OF PERIOPERATIVE ASEPSIS
 General
 Keep sterile supplies dry and unopened
 Check package sterilization expiration date to verify
sterility
 Maintain general cleanliness in surgical suite
 Maintain surgical asepsis: activities designed to keep
sites free from the presence of microorganisms
throughout the procedure
 Personnel
 Personnel with signs of illness should not report to
work
 Surgical scrub, a specific hand washing technique
used by operating room personnel designed to
reduce microorganisms in the hands and arms, is
done for the length of time designed by hospital
policy
 Surgical Scrub
 A sensor-controlled or knee- or foot-operated faucet
allows the water to be turned on and off without the
use of the hands
 Remove all rings and watches
 Use liquid soaps to prevent the spread of organisms
 Keep the finger nails short and well-trimmed
 Clean fingernails with a nail stick under running
water
 Hold the hands higher than the elbows throughout
the hand washing procedure so that run-off goes to
the elbows
 Allows the cleanest part of the arms to be the hands
 A scrub brush facilitates the removal of
microorganisms
 Clean all areas of skin on the hands and arms in
sequence starting at the hands and ending at the
elbow
 After rinsing, dry the hands with paper towels,
drying first one arm from the hand to the elbow, then
using a second towel to dry the second hand
 Maintaining a Sterile Field
 Create a sterile field using sterile drapes
 Use the sterile field to place sterile supplies where
they will be available during the procedure
RE Macanlalay
  Drape equipment prior to use  Sad, evasive, tearful, clinging
 Keep drapes dry and out of contact with nonsterile  Inability to concentrate
objects  Short attention span
 Utilize sterile technique while adding or removing  Failure to carry out simple directions
supplies from sterile fields  Dazed
 Sterile Supplies and Solutions:  Consents are not needed for emergency care if all four of the
 Check expiration dates for sterility following criteria are met:
 Don’t use solutions that were opened prior to  There is an immediate threat to life
current use  Experts agree that it is an emergency
 “Lip” the solution after initial use by pouring a small  Client is unable to consent
amount of liquid out of the bottle into a waste  A legally authorized person cannot be reached
container to cleanse the bottle lip  Physiologic Preparation Prior to Surgery:
 Respiratory preparation: chest x-ray
 Cardiovascular preparation: ECG, CBC, blood typing,
cross-matching, PT/PTT (prothrombin time, partial
 PREOPERATIVE PHASE
thromboplastin time), serum electrolytes
 Begins at the time of decision for surgery and ends when
 Renal preparation: urinalysis
the client is transferred to the OR
 This period is used to physically and psychologically
prepare the Client for surgery
 The nurse plays a major role in client teaching and in
relieving the client’s and the family’s anxieties
 Goals:
 a. Assessing and correcting physiologic and
psychologic problems that might increase surgical
risk
 Giving the person and significant others complete
learning/ teaching guidelines regarding surgery
 Instructing and demonstrating exercises that will
benefits the person during post-op period
 Planning for discharge and any projected changes in
lifestyle due to surgery
 Causes of Fears:
 Fear of the unknown
 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
 Manifestations of Fears:
 Anxiousness
 Confusion
 Anger
 Tendency to exaggerate

RE Macanlalay
  A– Allergy to medications, chemicals, and other  Make sure that the patient has not taken food for the
environmental products such as latex last 10 hours by asking the client
 All allergies are reported to the anesthesiologies and
surgical personnel before the beginning of surgery
 If allergy exist, an allergy band must be placed in
 Types of Pre-Operative Medications:
the client’s arm immediately
 Sedative:
 B –Bleeding tendencies or the use of medications that
 Given to decrease client’s anxiety to lower BP and
deter clotting, such as aspirin, heparin, and warfarin
PR
sodium.
 Reduce the amount of general anesthesia: an
 Herbal medications may also increase bleeding time
overdose can result to respiratory depression
or mask potential blood- related problems
 e.g. Phenobarbital
 C – Cortisone and steroid use
 Tranquilizer:
 D – Diabetes mellitus, a condition that not only requires
 Lowers the client’s anxiety level
strict control of blood glucose levels but also known to
 e.g. Thorazine12.5 - 25 mg IM 1- 2 hours prior to
delay wound healing
surgery
 E – Emboli; previous embolic events ( such as lower leg
 Narcotic analgesia:
blood clots) may recur because of prolonged immobility
 Given to patients to reduce anxiety and to reduce the
amount of narcotics given during surgery
 e.g. Morphine sulfate 8-15- mg SC 1 hour prior to
 Physical Preparation On the Night of the Surgery: preoperative; *Can cause vomiting, respiratory
 Preparing the client’s skin: depression and postural hypotension
 shave against the grain of the hair shaft to ensure  Vagolytic or drying agents:
clean and close shave  To reduce the amount of tracheobronchial secretions
 Preparing the GIT: which can clog the pulmonary tree and result in
 NPO after midnight atelectasis and pneumonia
 Administration of enema may be necessary
 Insertion of gastric or intestinal tubes
 Preparing for Anesthesia
 Promoting rest and sleep: use of drugs
 Barbiturates: Secobarbital Na, Pentobarbital Na
 Non barbiturates: chloral hydrate, Flurazepam
 Physical Preparation On the Day of Operation:
 Early morning care: about 1 hour before the pre-operative
medication schedule
 Vital signs taken and recorded promptly
 Patient changes into hospital gown that is left untied
and open at the back
 Braid long hair and remove hair pin
 Provide oral hygiene
 Prosthetic devices, eyeglasses, dentures removed
 Remove jewelries
 Remove nail polish
 Patient should void immediately before going to the
OR

RE Macanlalay
 INTRAOPERATIVE PHASE  Four Stages of Anesthesia:
 Begins the moment the patient is anesthetized and ends  Stage I: Onset [Beginning of Anesthesia]
when the last stitch or dressing is in place  Patient breath in the anesthetic mixture
 Anesthesia  Warmth, dizziness, & feeling of detachment maybe
 A state or narcosis, analgesia, relaxation and reflex loss experienced
due to severe central nervous system [CNS] depression  Ringing, roaring, or buzzing in the ears
produced by pharmacologic agent.  Inability to move extremities
 ACTIVITIES DURING THE INTRA OP  Surrounding noise is exaggerated
 Provide patient safety,  Still conscious
 Maintain an aseptic environment  Stage II: Excitement
 Ensure proper function of the equipment's,  Struggling, shouting, singing, laughing or crying
 Position the client, may be experienced
 Emotional support,  Pupils dilate but PERRLA, rapid PR, irregular RR
 Assisting the surgeon as  Patient restrain might be necessary
 scrub nurse  Stage III: Surgical Anesthesia
 circulating nurse  Continued administration of anesthetic agent
 nurse assistant  RR, PR normal, skin pink and flushed
 Access Control  Patient is unconscious
 UNRESTRICTED AREA  Stage IV: Danger Stage [ Medullary Depression]
 Areas outside the theatre complex including control  Reached when too much anesthesia has been
point to monitor the entrance of patients, personnel, administered
visitors, etc.  Respiration shallow, pulse weak, pupils dilate
 SEMI - RESTRICTED AREA  Cyanosis develops, without prompt intervention
 Peripheral support areas within theatre complex, death may occur
includes corridors leading to operating rooms, work
areas) storage (etc.
 All persons must wear scrub attire which should be
made of low linting material that minimizes bacterial
shedding, comfortable, clean and provides a
professional appearance
 RESTRICTED AREA
 Includes operating rooms, scrub areas and anterooms
 Personnel must wear full surgical attire, hair
coverings, masks where open sterile supplies and
scrubbed persons are present
 Masks are worn to reduce the dispersal of microbial
droplets from the mouth and naso-pharynx of
personnel – high filtered
 Masks must cover the mouth and nose entirely, and
be tied securely to prevent venting
 Metal strip in the top hem of the masks produces a
firm contoured kit over the bridge of the nose

RE Macanlalay
 Types of Anesthesia:  Specialized Methods of Producing Anesthesia
 General Anesthesia: a state of analgesia, amnesia, and  Muscle relaxants
unconsciousness characterized by the loss of reflexes and  it is a neuromuscular blocking agent used to To
muscle tone provide muscle relaxation
 Inhalation Anesthesia  Used for endotracheal intubation
 Advantage: prevention of pain and anxiety  e.g. Pancuronium bromide (Pavulon), Curarine
 Disadvantage: circulatory and respiratory chloride (Curare)
depression  Hypothermia :
 * Highly inflammable and explosive  it refers to the deliberate reduction of the patient’s
 Safety rules: body temperature between 28-30C
 Do not wear slips, nylons, wool, or any  Uses: Heart surgery, Brain surgery, Surgery on large
material which can set-off sparks vessels supplying major organs
 No smoking 12 hours after the operation  Methods:
 Do not wear shoes that are not conductive  Ice water immersion
 Intravenous Anesthesia  Ice bags
 usually employed as an induction prior to  Cooling blanket
administration of the more potent inhalation  Complications:
anesthetic agents.  Cardiac arrest
 Used commonly in minor procedure  Respiratory depression
 Advantage:  Positioning the Client:
 Rapid pleasant induction  Commonly Used Operative Positions

 Absence of explosive hazards  Supine: : hernia repair, explorlap,

 Low incidence of nausea and vomiting cholecystectomy ,mastectomy

 Disadvantage:  Prone : spine surgery, rectal surgery

 Laryngeal spasm and bronchospasm  Trendelenburg

 Hypotension  Reverse Trendelenburg

 Respiratory arrest  Lithotomy position

 e.g. Thiopental Na pentothal(Pentothal  Lateral position: kidney and chest surgery

(Pentothalal Na), Ketamine (Ketalar), Fentanyl  Others: for Thyroidectomy-- head hyperextended

(Innovar)
 Regional Anesthesia: it is the injection or application of a
local anesthetic agent to produce a loss of painful
sensation in only one region of the body and does not
result to unconsciousness
 i. Topical anesthesia: e.g. lidocaine
 ii. Infiltration anesthesia
 Nerve block
 Epidural block
 Caudal block
 Pudendal block
 Spinal anesthesia
 e.g. Saddle block for vaginal delivery
 Local anesthesia
 e.g. Procaine, Lidocaine (Xylocaine)

RE Macanlalay
 Postoperative Phase  Post- -operative dose usually reduced to half the
 Post Anesthetic Care dose to be taken after fully recovered from
 Nursing Responsibilities: anesthesia
 Maintenance of pulmonary ventilation:  Dismissal of Client from Recovery Room: Modified
 Position the client to side lying or semi- Aldrete Score for Anesthesia Recovery Criteria
prone position to prevent aspiration  The Five Physiological Parameters:
 Oropharyngeal or nasopharyngeal airway:  Activity – able to move four extremities voluntarily
 Is left in place following administration of on command
general anesthetic until pharyngeal  Respiration – able to breath effortlessly and deeply,
reflexes have returned and cough freely
 it is only removed as soon as the client  Circulation – BP is (+ 20%) or (-- 20%) of pre-
begins to awaken and has regained the anesthetic level
cough and swallowing reflexes  Consciousness – fully awake, oriented to time, place,
 All clients should receive O2 at least until person
they are conscious and are able to take  Color– pink (lips)
deep breaths on command
 Shivering of the client must be avoided to
prevent an increase in O2, and should be
administered until shivering has ceased
 Maintenance of circulation
 Most common cardiovascular complications:
 Hypotension
 Causes:
 Jarring the client during transport
while moving client from the OR to
his bed
 Reaction to drug and anesthesia
 Loss of blood and other body fluids
 Cardiac arrhythmias and cardiac
failure
 Inadequate ventilation
 Pain

 Cardiac arrhythmias
 Causes: Hypoxemia, Hypercapnea
 Interventions: O2 therapy, Drug
administration: Lidocaine, Procainamide
 Protection from injury and promotion of comfort
 Provide side rails
 Turning frequently and placed in good body
alignment to prevent nerve damage from pressure
 Administration of narcotic analgesics to relieve
incisional pain

RE Macanlalay
 Postoperative Care
 Begins when the client returns from the recovery room or
surgical suite to the nursing unit and ends when the client
is discharged
 It is directed toward prevention of complication and post-
operative discomfort
 Post - Operative Complications
 Respiratory Complications: atelectasis and pneumonia
 Suspected whenever there is a sudden rise of
temperature 24-48 hours after surgery
 Collapse of the alveoli is highly susceptible to
infection
 Occurs usually in high abdominal surgery when
prolonged inhalation anesthesia has been necessary
and vomiting has occurred during the operation or
while the patient is recovered from anesthesia
 NURSING MANAGEMENT:
 Measures to prevent pooling of secretions:
 Frequent changing of position
 High fowler’s position
 Moving out of bed
 Measures to liquefy and remove secretions:
 Increase oral fluid intake
 Breathing moist air
 Deep breathing followed by coughing
 Administer analgesics before coughing is
attempted after thoracic and abdominal
surgery
 Splint operative area with draw sheet or
towel to promote comfort while coughing
 Other measures to increase pulmonary
ventilation
 Blow bottle exercise
 Rebreathing tubes: increase CO2
stimulates the respiratory center to
increase the depth of breathing thus
increasing the amount of inspired air.
 IPPB: intermittent positive pressure
breathing apparatus
 Circulatory Complication: venous stasis
 Causes of venous stasis
 Muscular inactivity
 Respiratory and circulatory depression
 Increased pressure on blood vessels due to tight
dressing − Intestinal distention
 Prolonged maintenance of sitting
 Contributing factors for venous stasis:
 Obesity
 CV disease
 Debility
 Malnutrition
 Old age
 Most common circulatory complications:
 Phlebothrombosis- blood clot in the vein
 Thrombophlebitis- inflammatory process
causing Blood clot to form and block more
veins
 Fluids and Electrolytes Imbalance:
 Causes:
 Blood loss
 Increased insensible fluid loss through the skin;
After surgery through vomiting, from copious
wound drainage, and from the tube drainage as
in NGT
 Since surgery is a stressor, there is an increased
production of ADH for the first 12- 24 hours
following Surgery resulting to fluid retention by
the kidney
 The potential for over hydration therefore exists
since fluids being given IV may exceed fluid
output by the kidney
 Electrolyte Imbalance :
 Particularly Na and K imbalance as a result of blood
loss
 Stress of surgery increases adrenal hormonal activity
resulting to increased aldosterone and
glucocorticoids , resulting in sodium reabsorption by
the kidney
 And as Na is reabsorbed, K coming from tissue
breakdown is excreted
RE Macanlalay
  Action : IV of D5W alternate with D5NSS or half  Adult: 2-4 inches, children: 1-3
strength NSS to prevent Na excess inches
 Complications of Surgery  Prolonged stimulation of the anal
 GIT complications: sphincter may cause loss of
 Paralytic ileus: Cessation of peristalsis due to neuromuscular response, and pressure
excessive handling of GI organs necrosis of the mucous surface
 NURSING MANAGEMENT:  Constipation : due to decreased food intake and
 NPO until peristalsis has returned as inactivity
evidenced by auscultation of bowel sounds  Regular bowel movement will return 3- days4
or by passing out of flatus after surgery when resumption of regular diet,
 Vomiting: usually the effect of certain anesthetics adequate fluid intake and ambulation
on the stomach, or eating food or drinking water
before peristalsis returns.
 Psychologic factors also contribute to vomiting
 NURSING MANAGEMENT:
 Position the client on the side to prevent
 GUT Complications
aspiration
 Return of urinary function : usually after 6-8 hours
 When vomiting has subsided, give ice chips,
 First voiding may not be more than 200 ml,
sips of ginger ale or hot tea, or eating small
And total output may not be more than 1500ml
frequent amounts of dry foods thus relieving
 Due to the loss of fluids during surgery,
nausea
perspiration, hyperventilation, vomiting, and
 Administer anti-emetic drugs as ordered:
increased secretion of ADH
 Trimethobenzamide Hcl (Tigan);
 Complication: urinary retention
Prochiorperasine dimaleate (Compazine)
 Causes:
 Abdominal distention: results from the accumulation
 Prolonged recumbent position
of nonabsorbable gas in the intestine
 Nervous tension
 Causes:
 Effect of anesthetics interfering with
 Reaction to the handling of the bowel
bladder sensation and the ability to
during surgery
void ▪ Use of narcotics that reduce the
 Swallowing of air during recovery from
sensation of bladder distention
anesthesia
 Pain at the surgical site and on
 Passage of gases from the blood stream to
movement
the atonic portion of the bowel
 Urinary tract infection
 Gas pains: results from contraction of the unaffected
 Management:
portion of the bowel in order to move accumulated
 Instruct the client to empty the bladder
gas in the intestinal tract
completely during voiding
 Management:
 Catheterize if needed, done by sterile
 Aspiration of fluid or gas: with the
technique
insertion of an NGT
 Postoperative Discomforts
 Ambulation: stimulates the return of
 Post -operative pain
peristalsis and the expulsion of flatus
 Narcotics can be given every 3-4 hours during the
 Enema
first 48 hours post -operatively for severe pain
 Rectal tube insertion: inserted just passed
without danger of addiction
the anal sphincter and removal after
 Singultus
approximately 20 minutes

RE Macanlalay
  Brought about by the distention of the stomach,
irritation of the diaphragm, peritonitis and uremia
causing a reflex or stimulation of the phrenic nerve  Assessment:

 Management:  Complain of a “giving” sensation in the incision

 Paper bag blowing; CO2 inhalation: 5% CO2  Sudden, profuse leakage of fluid from the

and 95% O2 x 5 minutes every hour incision

 Wound Complications:
 Sutures are usually removed about 5th-7th day post-op
with the exception of wire retention sutures placed deep
in the muscles and removed 14-21 days after surgery
 Hemorrhage from the wound
 Most likely to occur within the first 48 hours post-op
or as late as 6th-7th post op day
 Causes:
 Hemorrhage occurring soon after operation:
 The dressing is saturated with clear, pink
drainage
 Management:
 Position the client to low Fowler’s position
 Instruct the client not to cough, sneeze, eat or
drink, and remain quiet until the surgeon arrives
 Protruding viscera should be covered warm,
sterile, saline dressing
 Discharge Instructions:

mechanical dislodging of a blood clot or caused  Early discharge, which has become common, typically

by the reestablished blood flow through the increases Increases client teaching needs

vessel  Be sure to provide information about wound care, activity

 Hemorrhage after few days: Sloughing off of restrictions, dietary management, medication administration,

blood clot or of a tissue symptoms to report, and follow up care

 Infection  A client recovering from same day surgery in an

 Assessment: outpatient surgical Surgical unit must be in stable condition

 Bright red blood before discharge

 Decreased BP  This client must not drive home, make sure a responsible adult

 Increased PR and RR takes the client home

 Restlessness
 Pallor
 Weakness
 Cold, moist skin
 Infection
 Cause: streptococcus and staphylococcus
 Assessment: - 3-6 days after surgery, low grade
fever, and the wound becomes painful and swollen.
There may be purulent drainage on the dressing
 Dehiscence and Evisceration
 Dehiscence or wound disruption: Refers to a partial-
to-complete separation of the wound edges
 Evisceration: Refers to protrusion of the abdominal
viscera through the incision and onto the abdominal
wall

RE Macanlalay