Maysan University / College of Nursing

Fundamental of Nursing Dep. 1th stage

MSN, Tabarek Abdul Sahib

Pre-Post-Operative Nursing Care

INTRODUCTION
Surgery is a unique experience of a planned physical alteration encompassing three
phases: preoperative, intraoperative, and postoperative.
These three phases are together referred to as the perioperative period.

PREOPERATIVE PHASE
1. The preoperative phase: begins when the decision to have surgery is made; it
ends when the client is transferred to the operating table.
The nursing activities associated with this phase include
 assessing the client
 identifying potential or actual health problems
 planning specific care based on the individual’s needs
 and providing preoperative teaching for the client, the family, and significant
others.
2. The intraoperative phase: begins when the client is transferred to the
operating table and ends when the client is admitted to the post-anesthesia
care unit (PACU), also called the post-anesthetic room or recovery room (RR).
The nursing activities related to this phase include a variety of specialized
procedures designed to create and maintain a safe therapeutic environment for the
client and the
health care personnel. These activities include
 interventions that provide for the client’s safety
 maintaining an aseptic environment
 ensuring proper functioning of equipment
 providing the surgical team with the instruments and supplies needed during the
procedure.
3. The postoperative phase: begins with the admission of the client to the post-
anesthesia area and ends when healing is complete.
During the postoperative phase, nursing activities include:
 Assessing the client’s response (physiological and psychological) to surgery
 Performing interventions to facilitate healing and prevent complications
 teaching and providing support to the client and support people
 planning for home care.
 The goal is to assist the client to achieve the most optimal health status possible.
TYPES OF SURGERY
Surgical procedures are commonly grouped according to:
a) Purpose Surgical procedures may be categorized according to their purpose

b) Degree of Urgency Surgery is classified by its urgency and necessity to

preserve the client’s life, body part, or body function.
 Emergency surgery is performed immediately to preserve function
or the life of the client. Surgeries to control internal hemorrhage or
repair a fracture are examples of emergency surgeries.
 Elective surgery is 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) Degree of Risk Surgery is also classified as major or minor according to the
degree of risk to the client.
 Major surgery 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.
Examples are organ transplant, open heart surgery, and removal of a
kidney.
 Minor surgery normally involves little risk, produces few complications,
and is often performed in an outpatient setting.
The degree of risk involved in a surgical procedure is affected by the client’s :
1. AGE Neonates/infants and older clients are greater surgical risks than children
and adults.
2. GENERAL HEALTH Surgery is least risky when the client’s general health is
good. Any infection or pathophysiology increases the risk. Common health
problems that increase surgical risk and may lead to the decision to postpone or
cancel surgery are listed in Box 37–2.
3. NUTRITIONAL STATUS: Adequate nutrition is required for normal tissue
repair. Surgery increases the body’s need for nutrients that help with the tissue
healing and prevention of infection required during the postoperative period.
Many vitamins and minerals are essential in wound healing (Table 37–1)

4. OBSTRUCTIVE SLEEP APNEA (OSA): is a common condition caused by

partial or complete obstruction of the upper airway during sleep. Breathing is
briefly interrupted during sleep with periods of apnea lasting at least 10 seconds.
5. MEDICATIONS: The regular use of certain medications can increase surgical
risk. Consider these examples:
-Anticoagulants increase blood coagulation time.
 -Tranquilizers may interact with anesthetics, increasing the risk of respiratory
depression.
6. MENTAL STATUS: Disorders that affect cognitive function, such as mental
illness, mental retardation, or developmental delay, affect the client’s ability to
understand and cope with the stresses of surgery. These clients also may require
medication such as anticonvulsants or antipsychotic drugs that can interact with
anesthetic and analgesic medications used during and after surgery.
PREOPERATIVE PHASE
Preoperative Consent Prior to any surgical procedure, informed consent is required
from the client or legal guardian. Informed consent implies that the client has been
informed and involved in decisions affecting his or her health. The surgeon is
responsible for obtaining the informed consent by providing the following
information to the client or legal guardian:
• The nature of and the reason for the surgery
• All available options and the risks associated with each option
• The risks of the surgical procedure and its potential outcomes
• Name and qualifications of the surgeon performing the procedure
• The right to refuse consent or later withdraw consent.
Nursing Management
1.Assessing: Preoperative assessment includes collecting and reviewing physical,
psychological, and social client data to determine the client’s needs throughout the
three perioperative phases. The client’s mobility and ability to function should also be
assessed in the preoperative phase. The perioperative nurse collects the data by
interviewing the client in the pre-surgical care unit or by telephone prior to the day of
surgery.
Physical Assessment
Current health status.
Allergies.
Medications.
Previous surgeries.
Mental status.
Understanding of the surgical procedure and anesthesia.
Smoking.
Obstructive sleep apnea (OSA).
Alcohol and other mind-altering substances.
Coping.
Social resources.
Cultural and spiritual considerations.
2.Diagnosing: Nursing diagnoses that may be appropriate for the preoperative client
include
 Deficient Knowledge related to
• A lack of education about the perioperative process
• A lack of exposure to the specific perioperative experience.
 Anxiety related to
• Effects of surgery on ability to function in usual roles
• Risk of death
• Loss of control during anesthesia or waking up during anesthesia
• Change in health status and/or body image.
3. Planning: The overall goal in the preoperative period is to ensure that the client is
mentally and physically prepared for surgery. Examples of nursing activities to meet
this goal are discussed in the Implementing section that follows. Planning should
involve the client, the family, and significant others.
4.Implementing: The major nursing activity to ensure that the client is prepared for
surgery is
Preoperative Teaching: Preoperative teaching is a vital part of nursing care reduces
clients’ anxiety, postoperative complications and increases their satisfaction with the
surgical experience, and facilitates the client’s successful and early return to work and
other activities of daily living (ADLs).
Preoperative teaching has been identified as
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.
3. The roles of the client and support people in preoperative preparation, the
surgical procedure, and during the postoperative phase.
4. Skills training
5. Provides support by actively listening and providing accurate information and
Instruction:
Explain the need for preoperative test.
Explain individual therapies order such as I.V therapy, insertion or urinary
catheter or nasogastric tube.
Explain the restricts food and oral fluid at least 8 hours before surgery.
Discuss the need to remove jewelry, makeup and all prostheses (eyeglasses,
hearing aid, denture.
Complete preoperative checklist.
Physical preparation.
Preoperative preparation includes the following areas.
 Nutrition and fluid:
Elimination:
Hygiene:
Medication:
Rest and sleep:
Valuables: such as jewelry and money should be labeled and placed in safe
keeping
prostheses: such as (partial or complete denture, lenses, artificial eye, artificial
limb.
Skin preparation: Is carried out during the intraoperative phase
Vital signs: assess and record vital signs for baseline data, report any abnormal
finding
5.Evaluating: The goals established during the planning phase are evaluated according
to specific desired outcomes, also established in that phase.
INTRAOPERATIVE PHASE
The intraoperative nurse uses the nursing process to design, coordinate, and deliver
care to meet the identified needs of clients whose protective reflexes or self-care
abilities are potentially compromised because they are having operative or other
invasive procedures.
Types of Anesthesia
Anesthetic agents usually are administered by an anesthesiologist or a certified
registered nurse anesthetist (CRNA). Anesthesia is classified as
general or regional: is the loss of all sensation and consciousness. Under general
anesthesia, protective reflexes such as cough and gag reflexes are lost. 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.
Regional anesthesia: is 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:
Topical (surface) anesthesia is applied directly to the skin and mucous
membranes, open skin surfaces, wounds, and burns. The most commonly used
topical agents are lidocaine (Xylocaine) and benzocaine.
Local anesthesia (infiltration) is injected into a specific area and is used for
minor surgical procedures such as suturing a small wound or performing a
biopsy. Lidocaine or tetracaine 0.1% may be used.
 A nerve block is a technique in which the anesthetic agent is injected into and
around a nerve or small nerve group that supplies sensation to a small area of the
body.
Spinal anesthesia is also referred to as a subarachnoid block (SAB). It requires
a lumbar puncture through one of the interspaces between lumbar disk 2 1L2 2
and the sacrum 1S1 2. An anesthetic agent is injected into the subarachnoid
space surrounding the spinal cord.
Epidural (peridural) anesthesia is an injection of an anesthetic agent into the
epidural space, the area inside the spinal column but outside the duramater.
NURSING MANAGEMENT
Assessing
On the day of surgery, after the client has been admitted to the hospital, the client’s
family members or significant others are escorted to a surgical holding area located
outside of the operating room. This area is also known as a presurgical care unit
(PSCU). The perioperative nurse confirms the client’s identity and assesses the client’s
physical and emotional status. The nurse verifies the information on the preoperative
checklist and evaluates the client’s knowledge about the surgery and events to follow.
Diagnosing
nursing diagnoses that may be appropriate for the intraoperative client include the
following:
• Risk for Aspiration
• Ineffective Protection
• Impaired Skin Integrity
• Risk for Perioperative Positioning Injury
Planning
The overall goals of care in the intraoperative period are to maintain the client’s safety
and to maintain homeostasis. Examples of nursing activities to achieve these goals
include the following:
• Assist in preparing and maintaining the sterile field.
• Open and dispense sterile supplies during surgery.
• Provide medications and solutions for the sterile field.
• Monitor and maintain a safe, aseptic environment.
• Manage catheters, tubes, drains, and specimens.
• Perform sponge, sharp, and instrument counts.
• Document nursing care provided and the client’s response to interventions.
Implementing
Intraoperative interventions are carried out by the circulating nurse, the scrub person,
and the registered nurse first assistant.
The 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).
The scrub person is usually an RN, LPN, or certified surgical technologist (CST).
They wear sterile gowns, gloves, caps, and eye protection. Their role is to assist the
surgeons.
Evaluating
The intraoperative nurse uses the goals developed during the planning stage (e.g.,
maintain client safety) and collects data to evaluate whether the desired outcomes have
been achieved.
Documentation
The intraoperative nurse documents the perioperative plan of care including
assessment, diagnosis, outcome identification, planning, implementation, and
evaluation.