Week 3 Perioperative Concepts and Wound Care

Perioperative Concepts and
Wound care
Week 3
BSN214: Adult Medical Surgical Nursing 1
Theory
Semester 1, 21-22
10/19/2021
BSN214: Adult Medical Surgical Nursing Theory 1
Perioperative Concepts and Nursing
Management
Intended Learning Outcomes
At the end of this week, students will be able to:
• Define the three phases of perioperative patient care.

• Discuss different classifications of surgery.
• Describe a comprehensive perioperative assessment to identify
surgical risk factors.
• Identify health factors that affect patient preoperatively.
• Identify legal and ethical consideration related to obtaining informed
consent for surgery.
10/19/2021
Perioperative Phases
The perioperative period consists of 3

phases:
 Preoperative: begins when decision to proceed with

surgical intervention is made & ends with the transfer
of the pt onto the OR table.
 Intraoperative: begins when pt is transferred onto
the OR table & ends with admission to the Post-
Anesthesia Care Unit PACU.
 Post operative: begins with admission to the PACU
& ends with the follow up evaluation in the clinical
setting or home.
10/19/2021
BSN214: Adult Medical Surgical Nursing Theory
Surgical Classifications
Surgery may be classified according to the purpose:

 Diagnostic: determine the origin of the presenting
symptom. (e.g, biopsy, exploratory laparotomy)
 Curative: Repair or removal of diseased organ
(e.g, appendectomy, excision of a tumor)
 Palliative: to relieve pain or correct a problem.(e.g,
colostomy, gastrostomy tube)
 Cosmetic: (e.g, mammoplasty or scar repair
 Transplant: (e.g kidney transplant)
10/19/2021
Surgical Classifications
Surgery may be classified according to the urgency:
 Emergent: requiring immediate attention, without delay
(Stab wound, severe bleeding)
 Urgent: requiring prompt attention within 24–30 hrs (Acute
gall bladder infection).
 Required: pt needs surgery, planned within few weeks or
months (eg cataract removal)
 Elective: Patient should have surgery, failure to have it not
disastrous (Simple hernia).
 Optional: Decision rests with patient, personal preferences
(eg cosmetic surgery)
10/19/2021
Classification according to seriousness
• Classification according to Seriousness:

Major
• Performed in a surgical suite (OR).
• Under General or regional anaesthesia
• May involve risk to life.
Minor
• Little risk to life
• Can be performed in Surgical Clinics,
• or outpatient surgery units
• Under Local anaesthetic and sedation
• Client concerns still present.
10/19/2021 SUBTILE 2 : MAIN TITLE 6
Classification according to procedure
• (Potter & Perry, 2009)

• Ectomy: Excision or removal of (Appendectomy)
• Orrhaphy: Repair or suture of (Herniorrhaphy)
• Ostomy: Creation an opening into (Gastrostomy)
• Otomy: cutting into or incision (tracheotomy)
• Plasty: formation or plastic (synthetic) repair
(Mammoplasty)
• Scopy: looking into (Endoscopy)
• (Lewis, Heitkemper, Dirksen, Bucher &

Some surgeries named from surgeon
eg Keller’ s excision arthroplasty which is a type of orthopaedic

surgery started by William L. Keller
•
It is done under general anaesthesia and it involves making a
small incision (cut) over the joint in the big toe, removal of a
small portion of the bone and replacement of the removed
bone with soft tissue to create a “false joint”.

Preoperative phase: preoperative assessment
• Why is a comprehensive assessment needed

before surgery?*
• To address risk factors that may lead to postoperative
complications which affect the length of hospital stay and costs.
• Before any surgery is initiated, the following
should be obtained:
 Health history & history of allergies
 Physical examination and vital signs
assessment
 Diagnostic and laboratory tests (blood tests
& x-ray)
 Consent forms
10/19/2021
Preoperative nursing assessment
1- Nutritional and fluid status:

Nutritional needs may be determined by measurement of
BMI and waist circumstances.
 Any Nutritional deficiency, such as malnutrition should be
corrected to provide adequate protein for tissue repair (see
table 18-2, p.431).
Dehydration, hypovolemia, and electrolyte imbalances can
lead to significant problems in elderly or pt with comorbid
med-surgical problems.
10/19/2021
2- Dentition:
 The condition of the mouth (dental caries, dentures,
and partial plates) are significant to anesthesiologist. Why?*
3- Drug or Alcohol Use:
Nurse who is obtaining pt’s health history needs to ask frank
questions about abusing alcohol or drugs with patience &
nonjudgmental attitude.
Surgery is postponed “ if possible” for Intoxicated people
(why?), if it is urgent local, or regional block anesthesia is used.
(Alcohol increases the risk of post surgical bleeding thus delays
wound healing, It increases the risk of infection at surgical site
and also impairs liver function and metabolism of anaesthetic
agents )
10/19/2021
Alcohol withdrawal syndrome (ie, delirium)

may be anticipated between 48-72hrs after
alcohol withdrawal and is associated with high
mortality rate when it occurs postoperatively
due to possible cardiac dysrhythmia, and increased
bleeding tendency.
4- Respiratory Status:
Surgery is usually postponed if pt has a
respiratory infection. Why?*
10/19/2021
Pt with underlying respiratory disease (asthma,
COPD) are assessed carefully for current threats to
pulmonary status.
Pt who smoke are urged to stop 4-8 wks before surgery
to reduce pulmonary and wound healing complications.
5- Cardiovascular status: If the pt has uncontrolled
hypertension, surgery maybe postponed until the BP is
under control.
Surgical treatment can be modified to meet the cardiac
tolerance of the patient*.
10/19/2021
6- Hepatic & Renal Function:

 Preoperative improvement in liver function is a
goal because it has an effect on how anesthetic
agents are metabolized, acute liver disease is
associated with a high surgical mortality rate.
Surgery is contraindicated if a pt has acute

nephritis, acute renal insufficiency with oliguria or
anuria (Why?*) exception include lifesaving
surgeries. (Which assessment of liver and
kidney functions should be included)?
10/19/2021
6- Endocrine function: pt with diabetes mellitus are at risk for:

 Hypoglycemia: during anesthesia or post-op from inadequate
carbohydrates or excessive insulin.
Hyperglycemia: from stress, which can ↑risk of wound infection.
Strict glycemic control (80-110mg/dl) leads to better outcomes.
Frequent monitoring of blood glucose level is important before,
during, and after surgery.
10/19/2021
7- Immune function: It is important to determine the presence of

allergies, sensitivity for medication, contrast agent, blood
transfusion, any food products.
Pts who are immunosupressed (??) are highly susceptible to

infection, great care is taken to ensure strict asepsis.
8- Previous medication use: Nurse must assess &

document the pt’s prescribed medications, OTC medications
(ie,aspirin), & herbal agents because
of possible adverse interactions.
10/19/2021
Positive outcomes of pre operative teaching
• Decreased perception of pain

(Effective pain management)
• Increased adherence to treatment
• Decreased post operative
complications
• Decreased duration of hospitalization
• Reduced fear and anxiety
10/19/2021
Preoperative Interventions
• Informed consent
• Health Promotion Activities:
Physical preparation:
 Maintenance of normal fluid and
electrolyte balance
Reduction of risk of infection
Manage incontinence: Interferential Therapy(IFC)
Promotion of rest and comfort
Keep the patient NPO
10/19/2021
Preoperative Patient Teaching
Leg exercises:
• Routine except for leg surgery, prevent DVT.
Deep breathing, coughing
• Prevents atelectasis and pneumonia
• Use incentive spirometer and mark their
preoperative measurement (hold breath 3-5
seconds, mouthpiece removed, blow out, repeat 3-5
times then cough)
• Use pillow to support incision
Positioning, Turning, dangling, and early ambulation
• Allow lung secretions to drain into bronchi to be
coughed up and exercises legs to help prevent
thrombus.
10/19/2021
Preoperative Interventions
Preparation on the day of surgery
• Hygiene, prepare surgical site
• Hair & cosmetics
• Removal of prostheses
• Safeguarding valuables
• Preparing the bowel and bladder(enemas, catheters,
fasting of the patient)
• Vital signs
• Documentation and preoperative checklist (see next
slide)
• Performing special procedures if needed.
• Administering preoperative medication
• Confirming proper site for the procedure
10/19/2021
Preoperative chacklist

Admission to the operating room
• Stretcher locked for transfer on

OR bed
• Fastening a strap around the
client
• Keep on explaining
• Provide Privacy
10/19/2021
Intraoperative nursing
10/19/2021
Nurses’ roles
• Scrub nurse
• Circulating nurse
10/19/2021
Scrub Nurse
1. Assist the surgeon during the surgery by passing the

instruments, suture and supplies.
2. Maintain surgical asepsis while draping and handling
instruments.
3. The scrub nurse must have extensive knowledge of
all instruments and how they are used. wears sterile
gown, cap, mask, and gloves.
4. Count the instruments, and the gauze with the
circulating nurse.
10/19/2021
Circulating Nurse
1. Assesses the client on admission to the operating

room.
2. Helps to position the client on the operating table.
3. Helps with monitoring devices. She does not wear
sterile gloves or gown.
4. Responds to request from the surgeon, or
anesthesiologist to obtain additional supplies and
delivers them to the sterile field.
5. Counts the number of instruments, needles, and
gauze sponges used during the surgery to prevent the
accidental loss of an item in the wound.
10/19/2021
Postoperative Care
10/19/2021
Postoperative Care
• Postoperative period carries high risk of morbidity and
mortality after any type of anesthesia
• Responsibility of the anesthesia provider to provide care
while patient recovers from effects of anesthesia.
• Constant monitoring of patient is critical—temperature,
pulse, blood pressure, respiration rate and any signs of
continuing blood loss.
• All postoperative patients should be cared in a recovery
ward well equipped with drugs, supplies and trained staff.
10/19/2021
Monitoring in Recovery Area (PACU)
Follow the ABCD of postoperative
care: Initial Phase
• Airway
• Does the patient control his/her own
breathing?
• Check for any obstructions of the airway
• Breathing
• Note the rate and depth of respiration.
• Is there any sign of hypoxia?
10/19/2021
Monitoring in Recovery Area (PACU)
• Circulation
• Check pulse and blood pressure.
• Check for peripheral circulation
• Is the patient bleeding? If yes, inform the surgeon
• Does the patient need fluid replacement?
10/19/2021
Monitoring in Recovery Area
• Drugs
• Is the patient in excessive pain? Consider additional drugs for pain management
• Is nausea and/or vomiting severe? Consider anti-emetics
• Consider providing sedation, if required
• Is the patient restless, confused and agitated?
Look for a cause
10/19/2021
Transferring the Patient to the Ward
Determining readiness for discharge from the

recovery area:
• Stable vital signs
• Orientation to person, place, events and time
• Uncompromised pulmonary function
• Pulse Oximetry indicating adequate oxygen saturation
• Urine output at least 30 ml/hour
• Nausea and vomiting absent or under control
• Minimal pain
• No bleeding
10/19/2021
• Does the patient have a good color when breathing?
• Is the patient able to cough and maintain a clear airway?
• Is there any evidence for airway obstruction or laryngeal spasm?
• Can the patient lift her/his head from the bed for at least 3 seconds?
• Are the patient’s pulse rate and blood pressure stable?
• Are the hands and feet well perfused and warm?
• Is there a good urine output?
• Is the patient’s pain controlled, and have necessary analgesics and
fluids been prescribed?

Postoperative Nursing Care
• Assess vital signs frequently:

Every 15 minutes until stable
Then every half hour for 2 hours
Every hour for 4 hours then every 4 hours for 24-48
hours
• Assess and maintaining respiratory
function.
• Assess Circulation: peripheral pulse and
ECG.
• Preventing Circulatory complications
10/19/2021
Postoperative Nursing Care
• Maintain Fluid and Electrolyte

Balance
• Assess Neurological Function: LOC,
Sensory and Motor status
• Assess Skin Integrity and condition of
the wound
• Promoting wound healing
• Genitourinary function: Intake &
Output (I &O)
• Promoting urinary elimination
10/19/2021
Post operative care
• Assess Gastrointestinal Function: N & V.

• Promote normal bowel elimination
• Comfort & client expectation
• Assess pain level and promote pain
control
• Achieving rest and comfort
• Maintaining and enhancing self concept
10/19/2021
Laboratory and diagnostic tests
Complete blood count

Rationale: Anemia, immune status, infection.
Electrolytes
Rationale : metabolic status, renal function, diuretic side
effect.
PT, PTT, INR, platelets count
Rationale: Coagulation status
Blood Types and cross match
Rationale: blood availability for transfusion
Blood glucose
Rationale: metabolic status, DM
10/19/2021
Blood urea nitrogen, creatinine.

Rationale: renal function
Liver function test
Rationale: liver status (ALT (liver damage) AST (liver damage but can
also be produced from damage in other organs such as the heart and
the kidneys))
Serum albumin
Rationale: Nutritional status
HCG
Rationale: pregnancy
ECG
Rationale: cardiac disease, dysrhythmias, electrolyte imbalance
(Hyponatremia, hyperkalemia, calcium and magnesium imbalances).
10/19/2021
Chest X – ray
Rational: pulmonary disorders, cardiac enlargement,
heart failure .
Pulmonary function test
Rational: pulmonary status
ABG, pulse oximetry
Rational: ventilation and metabolic function,
oxygenation status.
Urinalysis
Rational: renal status, dehydration, urinary tract
infection (UTI).
10/19/2021
Leg Exercise
1- 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.
10/19/2021
Leg Exercise
2- Flex knee, raise foot in air and hold this position for 2-3
seconds, Have client extend the leg and lower it to bed.
3- Alternate dorsiflexion (toward head of bed) and plantar
flexion (toward bottom of bed) of the feet.
4- Instructed client to make circles with the ankle moving first to
the left and then to the right
10/19/2021
Deep breathing (diaphragmatic) exercises.
• Assist client to semi-fowler or
high fowler.
• Instruct client to place palms of

hands across from each other
down on the border of your rib
cage.
• Ask him to inhale slowly and

deeply through the nose and
pushing abdomen against
hands.
10/19/2021
Deep breathing (diaphragmatic)
exercises.
• Ask the client to take slow, deep
breath and hold for count 3, and
then slowly exhale through
mouth as if blowing out a
candle. (Pursed lips).
• Repeat breath exercise 3-5

times, Client is instructed to
take 10 slow, deep breaths
every 2 hours while awake
10/19/2021
Using Incentive spirometry
• IS assists the client in deep
breathing and encourage the
patients to achieve their normal
inspiratory capacity.
• It is most often used following

abdominal and thoracic surgery to
help to reduce the incidence of post
operative pulmonary atelectasis.
10/19/2021
How to use the Incentive Spirometry
• Perform Hand Hygiene.
• Position client in semi-fowler position.
• Instruct client to place lips completely over
mouth piece.
• Instruct client to take a slow deep breath like
pulling through a straw, when maximum
inspiration is reached,
• client should hold breath for 2-5 seconds
and then exhale slowly.
10/19/2021
Teach controlled Coughing
• Explain the importance of
maintaining an upright
position. To enhance thorax
and abdominal expansion.
• Ask the client to take two

deep, slow breaths inhaling
through nose and exhaling
through pursed lips.
• Inhale deeply a third time, and

hold breath to count of 3.
Cough fully for two to three
consecutive coughs without
inhaling between coughs.
10/19/2021
Teach controlled Coughing
• Show the client how to
support the incision by
placing the palms of the
hands on either side of
incision site or directly over
the incision site, holding the
palm of one hand over the
other.
• Show the client how to splint

the abdomen with clinched
hands and a firmly rolled
pillow held against abdomen.
10/19/2021
Anxiety
• Mild anxiety increases alertness, increases the ability to

learn, and increases the ability to adjust to one’s
environment and increases the ability to adjust to several
simultaneous stressors.
• High levels of anxiety can prevent successful preoperative

adaptation and can negatively influence postoperative
recovery.
10/19/2021
S& S of stress:
1- Shortness of Breath
2- Shallow breathing
3- Activity intolerance
4- Tiredness and muscle

tension
10/19/2021
How would you prevent and reduce
anxiety and stress?
10/19/2021
Decreasing Anxiety and stress
• Music therapy
• Meeting spiritual needs
• Preoperative teaching
• Knowing ahead of time about equipment attached to
patient
10/19/2021
WOUND CARE

Wound
= type of injury in which
 The skin is torn, cut, or punctured (an open wound), or
 where blunt force trauma causes a contusion (a closed wound).
• According to level of contamination a wound can be classified as
1. Clean wound: no organisms
2. Contaminated wound: pathogenic organisms
3. Infected wound: pathogenic organisms present with signs of infection, where it
looks yellow, oozing pus, having pain and redness.
4. Colonized wound: chronic one and there are a number of organisms present and
very difficult to heal as in a bedsore.
10/19/2021
Classification of Open wound
• Incisions or incised wounds: caused by a clean, sharp-edged object
such as a knife or razor.
• Lacerations: irregular tear-like wounds caused by some blunt
trauma.
• Abrasions : caused by a sliding fall onto a rough surface.
• Avulsions: amputation
• Puncture wounds: nail or needle.
• Penetration wounds: knife entering and coming out from the skin.
• Gunshot wounds: caused by a bullet
10/19/2021
10/19/2021
Classification of Closed Wound
• Hematomas, also called a blood tumor, caused by damage

to a blood vessel:
• petechiae, purpura, and ecchymosis.
• Crush injury, caused by a great or extreme amount of

force applied over a long period of time.
10/19/2021 NRS 2101 / Nursing Clients with Medical-Surgical Conditions
56
WOUND HEALING
• Wounds heal by different mechanisms depending on the

condition of the wound.
• healing occurs in three phases:

• First-intention
• Second intention
• Third-intention wound healing
10/19/2021 NRS 2101 / Nursing Clients with Medical-Surgical Conditions
57
Wound Healing Mechanisms:
First-Intention Healing
• Wounds made aseptically with a

minimum of tissue destruction
• Properly closed heal with little tissue
reaction by first intention (primary
union)
• Granulation tissue is not visible
• Scar formation is minimal
• Covered with a dry sterile dressing.
10/19/2021
Second-Intention Healing
(granulation)
• Occurs in infected wounds (abscess)
or in wounds in which the edges
have not been approximated.
• Drainage tube or gauze packing is
inserted into the abscess pocket to
allow drainage to escape easily
10/19/2021
Third-Intention Healing (secondary
• Used for deep wounds that either
suture)
have not been sutured early or
break down
• Resutured later, thus bringing
together two apposing
granulation surfaces.
• Results in a deeper and wider
scar.
• Packed postoperatively with
moist gauze and covered with a
dry sterile dressing.
10/19/2021
Assessment of the Surgical Wound
• Inspection for approximation of wound edges

• Integrity of sutures or staples
• Redness, discoloration, warmth, swelling
• Unusual tenderness, or drainage.
• Reaction to tape or trauma from tight bandages.
10/19/2021
CARING FOR SURGICAL DRAINS
• Drains are tubes that exit the peri-

incisional area, either into a portable
wound suction device (closed) or into
the dressings (open).
• Types of wound drains include the
• Penrose
• Hemovac
• Jackson-Pratt
For more information on drains, click link below
Penrose Drain, JP Drain, and Hemovac

Drain by Hailey Martin (prezi.com)
10/19/2021
CARING FOR SURGICAL DRAINS
• You should record the following:

– Output (drainage)
– The amount of bloody drainage on the surgical dressing
– Spots of drainage on the dressings are outlined with a pen
– Date and time
• Report to the physician immediately if:

– Excessive amounts
– Increasing amounts of fresh blood on the dressing
10/19/2021
CHANGING THE DRESSING
Dressing is applied for one or more of the following reasons:

• To provide a proper environment for wound healing
• To absorb drainage
• To splint or immobilize the wound
• To protect the wound and new epithelial tissue from mechanical injury
• To protect the wound from bacterial contamination and from soiling by
feces, vomitus, and urine
• To promote hemostasis
• To provide mental and physical comfort for the patient.
10/19/2021
CHANGING THE DRESSING
• Performed at a suitable time

• Privacy is provided
• Avoid referring to the incision as a scar because the term
may have negative connotations for the patient.
• Assurance is given that the incision will shrink as it heals
and that the redness will fade.
• Dressings are never touched by ungloved hands
10/19/2021
Perioperative Concepts and Nursing
Management
References
• Potter and Perry (2010). Clinical Nursing Skills and Techniques.
Mosby (7 th ed.)
• Potter and Perry (2008). Fundamental’s of Nursing (7 th ed.)
• Smeltzer, S.C., Bare, B.G., Hinkle, J.L., Cheever, K.H. (2010).

Brunner & Suddarth’s textbook of medical-surgical nursing (12th ed.).
Philadelphia: Lippincott Williams & Wilkins.
10/19/2021

Week 3 Perioperative Concepts and Wound Care

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Perioperative Concepts and

At the end of this week, students will be able to:

• Define the three phases of perioperative patient care.

The perioperative period consists of 3

 Preoperative: begins when decision to proceed with

Surgery may be classified according to the purpose:

• Classification according to Seriousness:

• (Potter & Perry, 2009)

• (Lewis, Heitkemper, Dirksen, Bucher &

10/19/2021 SUBTILE 2 : MAIN TITLE 7

eg Keller’ s excision arthroplasty which is a type of orthopaedic

10/19/2021 SUBTILE 2 : MAIN TITLE 8

• Why is a comprehensive assessment needed

1- Nutritional and fluid status:

Alcohol withdrawal syndrome (ie, delirium)

6- Hepatic & Renal Function:

Surgery is contraindicated if a pt has acute

6- Endocrine function: pt with diabetes mellitus are at risk for:

7- Immune function: It is important to determine the presence of

Pts who are immunosupressed (??) are highly susceptible to

8- Previous medication use: Nurse must assess &

• Decreased perception of pain

10/19/2021 SUBTILE 2 : MAIN TITLE 21

• Stretcher locked for transfer on

1. Assist the surgeon during the surgery by passing the

1. Assesses the client on admission to the operating

• Check for peripheral circulation

• Is the patient bleeding? If yes, inform the surgeon

• Does the patient need fluid replacement?

Determining readiness for discharge from the

10/19/2021 SUBTILE 2 : MAIN TITLE 33

• Assess vital signs frequently:

• Maintain Fluid and Electrolyte

• Assess Gastrointestinal Function: N & V.

Complete blood count

Blood urea nitrogen, creatinine.

• Instruct client to place palms of

• Ask him to inhale slowly and

• Repeat breath exercise 3-5

• It is most often used following

• Ask the client to take two

• Inhale deeply a third time, and

• Show the client how to splint

• Mild anxiety increases alertness, increases the ability to

• High levels of anxiety can prevent successful preoperative

4- Tiredness and muscle

10/19/2021 SUBTILE 2 : MAIN TITLE 52

• Hematomas, also called a blood tumor, caused by damage

• Crush injury, caused by a great or extreme amount of

10/19/2021 NRS 2101 / Nursing Clients with Medical-Surgical Conditions

• Wounds heal by different mechanisms depending on the

• healing occurs in three phases:

10/19/2021 NRS 2101 / Nursing Clients with Medical-Surgical Conditions

• Wounds made aseptically with a

• Inspection for approximation of wound edges

• Drains are tubes that exit the peri-

For more information on drains, click link below

Penrose Drain, JP Drain, and Hemovac

• You should record the following:

• Report to the physician immediately if:

Dressing is applied for one or more of the following reasons:

• Performed at a suitable time

• Potter and Perry (2008). Fundamental’s of Nursing (7 th ed.)