Peri-operative

patient care

By Mahlet Temesgen (BSc,MSc)

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Session objectives

• Define terms which is related with ORT

• Discuss the role of nurses in the Perioperative

patient care

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INTRODUCTION
• Surgery : is any procedure performed on the human
body that uses instruments to alter tissue integrity

• Types of surgery

1. Purpose
• Diagnostic: allows to confirm or establish Dx.
• Ablation: excision or removal of diseased body part
• Palliative: reduces intensity of disease symptoms,
Will not produce cure
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INTRODUCTION
• Reconstructive: restores function or appearance to
traumatized or malfunctioning tissue
• Transplant: replaces malfunctioning organs or
structures
• Constructive: restores function lost or reduced as
result of congenital anomalies
• Cosmetic : performed to improve personal
appearance
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INTRODUCTION

2. Urgency
• Elective: when surgical intervention is the
preferred t/t for the con.
• Urgent: necessary for patient’s health to prevent
additional problem.
• Emergency: must be done immediately to save
life or preserve function
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INTRODUCTION

3. Seriousness
• Major: extensive reconstruction of or
alteration in body parts
• Minor: Minimal alteration in body parts

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Definition

• Peri-operative nursing care: the delivery of care in

pre, intra, and postoperative periods of the pts surgical
experience through the framework of nursing process.
• Peri-operative phase: period of time that constitutes
the surgical experience; includes the preoperative,
intraoperative, and postoperative phases of nursing care.

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Preoperative phase

• Begins when the decision to proceed with surgical

intervention is made and ends with the transfer of
the patient onto the operating room (OR) bed

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Preoperative phase

Role of nurse in the preoperative phase

• Preoperative assessment

• Obtaining informed consent

• Preoperative teaching

• Physical preparation

• Psychological preparation

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Preoperative phase

1. Preoperative assessment
I. History
• HPI
• Comorbidity
• Substance use
• Allergies
• Current medication
• Review of systems
• PHI
• Previous hospitalization and surgeries
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Preoperative phase
II. Examination
• V/S
• Presence of infection
• Nutritional status(deficit/excess)
III. Review preoperative lab & dx studies
• order only when clinically indicated
• Need to notify physician if there is any thing
abnormal
IV. Assess for psychological state.
• fear and anxiety.

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Preoperative phase

• Preoperative fear and anxiety can lead to

• Need for increased anesthesia
• Need for increased postoperative pain
management
• Speed of recovery is decreased

• Preoperative education of what to expect in clear

language can alleviate some fear and anxiety.
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 Preoperative phase
2. Obtaining informed consent
• Informed consent: informed consent is the patient’s
autonomous decision about whether to undergo a
surgical procedure.

Has 3 components to make it valid

1.Adequate disclosure

2.Abel to understanding and comprehension

3.Voluntary and written

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Preoperative phase
Who can give consent?

• The patient

• The parents or legal guardians

Who has the legal responsibility of obtaining

consent?

• The physician

• The nurse must make sure the consent was signed

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Preoperative phase

3. Preoperative teaching

• About their surgical procedures and expectation

• Varies with the type of surgery and the length of

hospitalization.

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Preoperative phase
Preoperative teaching plan includes:

• Preoperative medication

• Postoperative pain control

• Deep breathing and coughing exercises, ambulation &

leg exercises

• Use of incentive spirometry

• Position changes

• Probable Postoperative therapies.

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Preoperative phase

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Preoperative phase

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Preoperative phase

4. Physical preparation

1. Diet restriction:

• evening prior to surgery

• to prevent aspiration

• “NPO after midnight”

• Maintenance fluid

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Preoperative phase

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Preoperative phase

2. Bowel and bladder elimination

• Enemas may be ordered: to prevent contamination

• Foley catheter may be ordered: to prevent injury to

the bladder

3. Hygiene

• Clients are asked to shower the evening or

morning of surgery

• To reduce the risk of wound

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Preoperative phase
• Nails should be trimmed and free of polish

• All cosmetics should be removed

4. Preoperative medications (may be ordered)

Prior to going to the OR

• Antiemetics

• Anticholinergics

• Sedatives

• antibiotics
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Preoperative phase
5. Sleep

• The nurse should help the client to sleep the night

before surgery.

6. Care of valuables and prostheses

• Jewelry, hairpins, wedding rings should be removed

• All prostheses(artificial body parts) such as dentures,

contact lenses, artificial limbs &eye glass, wigs, false
eyelashes must be removed
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Preoperative phase
7. Special orders

• The nurse checks the surgeons order for special

requirements(NG tube, medications)

8. Safety protocols

• Identifying the pt. &surgery to be performed

• Surgical site marking

9. Vital signs

The nurse assess and document VS for baseline data.

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Preoperative phase

5. Psychological preparation

Reducing Anxiety and Decreasing Fear

• Careful preoperative teaching

• Cognitive control

• Relaxation(deep breathing)

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Preoperative phase

Expected Patient Activities

• Relief of anxiety

• Decreased fear

• Understanding of the surgical intervention

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Preoperative phase
Preoperative preparation immediately before surgery

Patient should be seen by both the surgeon and the

anesthetist before any pre-medication is given

• Patient’s name(identification)

• Condition

• Consent – mark side

• All investigations available

• Sepsis

• Pre-existing complicationsmahlet.t
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Preoperative phase

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Intraoperative phase
• Begins when the client is transferred to the OR table and
ends when the client is admitted to the PACU.

Surgical team

• Surgeon

• Ass Surgeon

• Anesthetist

• Scrub nurse

• Circulating nurse

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OR techs mahlet.t 29
Intraoperative phase

• Nurses role

• Surgical asepsis

• Induction of anesthesia

• Skin preparation (prepping)

• Surgical draping

• Counting

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Intraoperative phase

Nurses role

1. Scrub nurse

• Is gowned and gloved

• Handle & pass sterile items into the sterile filed and the surgeon

• Boss of the sterile filed

• Assist the actual procedure to varying degree

• Surgical counting

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Intraoperative phase

2. Circulating nurse

• Deal with the mang’t of unsterile activities in the OR

• Document the nursing care of the pt

• Mov’t of unsterile items out of the surgical suite

• Labeling &transporting specimens

• Surgical counting
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Intraoperative phase

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Intraoperative phase

To help decrease microbes, the surgical area is divided

into three zones:

• The unrestricted zone: where street clothes are allowed

• The semi restricted zone: where attire consists of scrub

clothes and caps

• The restricted zone: where scrub clothes, shoe covers,

caps, and masks are worn

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Intraoperative phase

Principles of Surgical Asepsis

• It is the creation and maintenance of a sterile filed

• All practitioners involved in the intraoperative phase have a

responsibility to provide and maintain a safe environment

• The risk of wound infection can be minimized by strict theatre

discipline

• Scrubbing

• Gowning

• Gloving

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Intraoperative phase

Principles of Surgical Asepsis

• All materials used within the sterile field must be sterile

• Sterile item may touch other sterile item and remain

sterile; contact with unsterile objects make it
contaminated.

• Gowns of the surgical team are considered sterile in front

from the chest to table level and the sleeves 2in above the
elbow.

• Only the top surface of a draped table is considered sterile.

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Intraoperative phase

• Staff who are ‘scrubbed up’ only touch sterile

items or areas. Staff who are not ‘scrubbed up’
only touch unsterile items or areas.

• Movement around a sterile field must not cause

contamination of the field

• Items of doubtful sterility are considered unsterile .

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Intraoperative phase
Induction of anesthesia

Before the patient is anaesthetized

the patient is once again checked

• Pt’s name and identity label

• Operation with the patient

• Dentures should be removed and rings taped

• consent form

• Preoperative antibiotics should be given.

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Intraoperative phase

SKIN PREPARATION (PREPPING)

• to reduce the microbial count on the patient’s skin

• ‘pre-prep’ phase: Cleaning with soaps and water

Skin preparation solution

Alcohol-based solutions =skin is intact

Aqueous solutions=open wound

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Intraoperative phase

Preparing the patient’s skin (‘prepping’)

• Performed by staff who are scrubbed up

• Work from the incision site outwards

• Repeat at least twice

• Clean heavily contaminated areas last and then

discard the prep sponge

• Remove excessive prep solution with a dry swab

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Intraoperative phase

Solutions

1. Chlorhexidine gluconate

• Effective for more than 4 hours

• Effective in G+ve and G-ve bacteria, some viruses

• Moderate activity against the tubercle bacillus.

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Intraoperative phase

2. Iodine

• Not sustained for more than 4 hours.

• Highly bactericidal, fungicidal and viricidal.

• Some activity against bacterial spores

• Good activity against the tubercle bacillus.

• Penetrate cell walls to produce anti-microbial effects.

• May be irritating to the skin

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Intraoperative phase

3. Alcohols

• Highly effective, rapidly acting

• Effective in G+ve and G-ve bacteria, fungi, viruses

and tubercle bacilli,

• not sporicidal.

• inexpensive

• Most widely used skin antiseptics

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Intraoperative phase

Surgical draping

• Covering with sterile barrier material, ‘drapes’, the area

immediately surrounding the operative site

Purpose

• To create and maintain sterile field

• Resist penetration of microscopic particles and moisture

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Intraoperative phase

Counting

Sponge, Sharp, and Instrument Count

Items are counted before and after use

• For personnel safety

• infection control, and

• inventory purposes.
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Intraoperative phase

Consequences will be:

• Formation of an abscess

• Development of fistula

• Foreign body reaction

• Sometimes difficult and costly to diagnose

• Removal requires major surgery

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Intraoperative phase

Counting procedure is made three times

A. First Count: who wraps items for sterilization

B. Second Count: the scrub nurse and the circulator

together count all items before the procedure and
during the procedure as each additional package is
opened

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Intraoperative phase

C. Third Count

Counts are taken in three areas before the

surgeon starts the closure of a body cavity or a
deep/large incision

1. Field Count.

2. Table Count.

3. Floor Count.
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Postoperative care

• Begins with the admission of the patient to the

PACU and ends with a follow –up evaluation in the
clinical setting or at home.

• The immediate postoperative period refers to the

first 24 hours after surgery.

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Postoperative care
Includes

• V/S- presence of artificial airways, oxygen saturation ,

temperature, pulse, BP.

• LOC

• Urine output

• Pain

• Presence of Iv line

• Condition of wound

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Postoperative care

Postoperative management

• Maintain a patent airway

• Stabilize V/S

• Provide pain medication

• Recognize and manage complication

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Postoperative care

Think of the 4 W’S

• Wind: prevent respiratory complication

• Wound: prevent wound infection

• Water: monitor I &O

• Walk: prevent thrombophlebitis

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Postoperative care

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Postoperative care

The Recovery Room

• Patients after surgery will be admitted to the recovery room (RR)

after their operation.

Causes of death within the first 24 hours

• Obstruction of airway

• Laryngospasm

• Hemorrhage

• Cardiac arrest, and

• Inappropriate administration of medications

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 Thank you

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