INTRODUCTION TO PERIOPERATIVE NURSING

The Surgical Experience

Surgery: Is a branch of medical practice that treats injuries, diseases, and deformities by
the physical removal, repair or readjustment of organs and tissues, often involving cutting in
to the body. eg cardiac surgery
Or. The treatment of injuries or disease in people or animals by cutting open the body and
removing or repairing the damaged part.
Surgery is classified as major or minor based on the degree of risk for the patient.

Surgery may be classified as elective, meaning that it is necessary but scheduled at the
convenience of the patient and the health care provider or it can be classified as emergency,
demanding immediate surgical intervention.

Regardless of whether the surgery is major or minor, elective or emergency, it requires both
physical and psychosocial adaptation for the patient and his family and is an important
event in a person's life.

Types of Surgery

Minor surgery is brief, carries a low risk, and results in few complications. It may be
performed in an outpatient clinic, same-day surgery setting, or in the operating suite of a
hospital.

Major surgery requires hospitalization, is usually prolonged, carries a higher degree of risk,
involves major body organs or life-threatening situations, and has the potential of
postoperative complications.

Classification of Surgical Procedures

Surgical intervention may be for one or more reasons. The following descriptors classify
surgical procedures by purpose:

Ablative - removal of a diseased organ or structure (e.g., appendectomy).

Diagnostic - removal and examination of tissue (e.g., biopsy).

Constructive - repair a congenitally malformed organ or tissue. (e.g., harelip; cleft palate
repair). Surgical procedures usually combine several classifications and descriptors. For
example, a trauma patient may require major, reconstructive, emergency surgery.

One or more of the following may cause the patient psychological stress;

Reconstructive - repair or restoration of an organ or structure (e.g., colostomy; rhinoplasty,

cosmetic improvement).

Palliative - relief of pain (for example, rhizotomy--interruption of the nerve root between
the ganglion and the spinal cord).

Transplant - transfer an organ or tissue from one body part to another, or from one person
to another, to replace a diseased structure, to restore function, or to change appearance
(for example, kidney, heart transplant; skin graft).

Impact of Surgical Intervention on the Patient

Surgery produces physical stress relative to the extent of the surgery and the injury to the
tissue involved.

The physical stress of surgery is greatly magnified by the psychological stress.

Anxiety and worry use up energy that is needed for healing of tissue during the
postoperative period.

Unconsciousness and not knowing or being able to control what is happening.

One or more of the following may cause the patient psychological stress;

 Pain o Loss of a body part

 Fear of death
 Separation from family and friends.
 The effects of surgery on his lifestyle at home and at work.
 Exposure of his body to strangers.

Note

Regardless of the risk, any surgery that imposes physical and psychological stress is rarely
considered "minor" by the patient.
Perioperative Nursing
Definition
Perioperative Nursing connotes the delivery of patients care in the preoperative phase,
intraoperative periods and the postoperative periods of the patient’s surgical experience
through the frame work of the nursing process.

Phases of Perioperative Nursing

There are three phases of perioperative nursing:
Pre-Operative Phase: Begins when the decision to have surgery is made and ends when the
client is transferred to the OR table.
Intra-Operative Phase: Begins when the client is transferred to the OR table and ends when
the client is admitted to the PACU.
Post-Operative Phase: Begins with the admission of the client to the PACU and ends when
healing is complete.

Pre-Operative Phase
Definition: Begins when the decision to have surgery is made and ends when the client is
transferred to the OR table.
the patient who consents to have surgery, particularly surgery that require general
anesthesia, renders him/her self-dependent on the knowledge, skills and integrity of health
care team.
In accepting this trust, the health care team, have an obligation to make the patient’s
welfare their first consideration during the surgical experience
The scope of activities during the preoperative phase includes the establishment of the
patient’s baseline assessment in the clinical setting or at home, carrying out preoperative
interviews and preparing the patient for the anesthetics to be given and for the surgery
itself.

Goals during the preoperative phase

Although the physician is responsible for explaining the surgical procedure to the patient,
the patient may ask the nurse questions about the surgery
There may be specific learning needs about the surgery that the patient and support
persons should know.
A nursing care plan and teaching plan should be carried out. During this phase, emphasis
should be placed on:
 Assessing and correcting physiological and psychological problems that may increase
surgical risks
  Giving the patient and significant others complete learning and teaching guidelines
regarding the surgery
 Instructing and demonstrating exercises that will benefit the patient postoperatively
 Planning for discharge and any projected changes in the lifestyle due to the surgery

Physiologic assessment during the preoperative phase

Before any treatment is initiated, a health history is obtained and physical examination is
performed during which vital signs are noted and data base is established for future
comparisons.
Diagnostic tests may be carried out during the preoperative phase such as:
1. Blood analysis such as:
 Complete blood count (CBC)
 Erythrocyte sedimentation rate (ESR)
 C-Reactive Protein (CRP)
 Serum protein electrophoresis with immunofixation, calcium, alkaline phosphatase,
and chemistry profile
2. X-ray studies
3. MRI and CT scans (with or without myelography)
4. Electro diagnostic studies
5. Bone scan
6. Endoscopies
7. Tissue biopsies
8. Stool studies
9. Urine tests
10. Blood grouping and cross-matching
11. Screening for infectious diseases
Significant physical findings are also noted to further describe the patient’s overall health
condition
When the patient has been determined to be an appropriate candidate for surgery, and has
elected to proceed with surgical interventions, the preoperative assessment phase begins.
The purpose of preoperative evaluation is to reduce the morbidity of surgery, increase
quality of intraoperative care, reduce costs associated with surgery, and return the patient
to optimal functioning as soon as possible.
The following are physiologic assessment necessary during the preoperative phase:
1. Age
2. Nutritional status and needs. This is determined by measuring the patient’s height, and
weight, triceps skin fold, upper arm circumference, serum protein levels and nitrogen
balance. Obesity greatly increases the risk and severity of complications associated with
surgery. Check for NPO status, progression of diet, assessing bowel sounds.
3. Fluid and Electrolyte Imbalance. Dehydration, hypovolemia and electrolyte imbalance
should be carefully assessed and documented.
4. Infection
5. Drug and Alcohol use. The acutely intoxicated person is susceptible to injury. Alcohol
contributes to malnutrition, and affects patient’s response to anesthetics
6. Respiratory status: patients with preexisting pulmonary problems are evaluated by
means of pulmonary function studies and blood gas analysis to note the extent of
respiratory insufficiency. The goal of potential surgical patient is to have an optimum
respiratory function. Surgery is usually contraindicated for a patient who has respiratory
infection.
7. Cardiovascular Status. Cardiovascular disease increases risk of complications. Depending
on the severity of symptoms, surgery may be deferred until medical treatment can be
instituted to improve the patient’s condition.
8. Hepatic and Renal function. Surgery is contraindicated in patients with acute nephritis,
acute renal insufficiency with oliguria or anuria, or other acute renal problems
Any disorder of the liver on the other hand, may have an effect on how anesthetics will be
metabolized.
9. Endocrine function. Diabetes, corticosteroid intake, amount of insulin administered
10. Immunologic function. Existence of allergy, previous allergic reaction, sensitivity to
certain medications, past adverse reactions to certain drugs, immunosuppression.
11. Previous medication therapy. It is essential that the patient’s medication history be
assessed by the nurse and the anesthesiologist. The following are medications that cause
particular concern during the upcoming surgery.
i. Adrenal corticosteroids. Not to be discontinued abruptly before the surgery. Once
discontinued abruptly, or suddenly, cardiovascular collapse may occur for patients
who are taking steroids for long time. A bolus of steroids is then administered IV
immediately before and after surgery.
ii. Diuretics. Thiazide diuretics may cause excessive respiratory depression during
anesthetics administration.
iii. Phenothiazine. These medications may increase the hypotensive action of
anesthetics
iv. Anti-depressants. Increases the hypotensive effects of anesthetics
 v. Tranquilizers. Medications such as barbiturates, diazepam, and chlordiaxepoxide
may cause an increased anxiety, tension and even seizures if withdrawn suddenly.
vi. Insulin. When diabetic person is undergoing surgery, interaction between
anesthetics and insulin must be considered.
vii. Antibiotic. “mycin” drugs such as neomycin, kanamycin, and less frequently
streptomycin may present problems when combined with muscle relaxants. As a
result, nerve transmission is interrupted and apnea due to respiratory paralysis
develops.
12. Dentition.

Psychological Nursing Assessment During the Preoperative Period

Fear of the unknown
Fear of death
Fear of anesthesia
Concerns about loss of work, time, job and support from the family
Concerns on threats of permanent incapacity
Spiritual beliefs
Cultural values and beliefs
Fear of pain

Psychological Nursing Interventions

 Explore the clients fears, worries and concerns
 Encourage the client to verbalize his/her feelings about the surgical procedure
 Provide information that helps to allay fears and concerns of the patient
 Give empathetic support

Preoperative Nursing Interventions

The nursing interventions in the preoperative period include the following below:
1. Patient’s education/teachings
 Teaching deep breathing and coughing exercise
 Encouraging mobility and active body movement eg. Turning (changing position),
foot and leg exercise
 Explaining pain management
 Teaching cognitive coping strategies
2. Providing psychological interventions
 Reducing anxiety and decreasing fear
 Respecting cultural, spiritual, and religious beliefs
3. Maintaining patients’ safety
o Identify the patient correctly
o Improve staff communications
 o Use medicines correctly
o Identify patients’ safety risks
o Prevents mistakes in surgery

4. Managing nutrition and fluids

 Withholding food and fluids before surgery to prevents aspiration

 Fast the patient for at least 8 hours
5. Preparing the bowel for surgery.

 Enema is not commonly ordered, unless the patient is undergoing abdomen or pelvic
surgery e.g., cleansing enema and laxatives may be used.
6. Preparation of the skin.
o The goal of preoperative skin preparation is to decrease bacteria without injuring the
skin.
o Activities in preoperative skin preparation include, shaving hair on the surgical site,
washing the patient’s skin.
7. Preparing the bladder. Inserting and indwelling urinary catheter prior to surgery. Monitor
input and output postoperatively.
Immediate Preoperative Nursing Interventions
1. Administer pre-anesthetic medications
2. Maintaining the preoperative record eg. Final checklist, consent form, patient
identification.
3. Transporting the patient to the operation room
4. Attending to the family needs