Universidad de Sta.

Isabel
College of Health Sciences
Nursing Program

CONCEPTS IN THE CARE OF AT RISK AND

SICK ADULT CLIENTS

Cecilia A. Hidalgo, MAN, RN .

Clinical Instructor
 SELF-ASSESSMENT QUIZ

Instruction: Read each questions carefully.

Write your answer briefly on the lines
provided.
1. In your own understanding, what is
the definition of surgery?
2. What are the three phases of Perioperative
Care? Enumerate and explain each period briefly.
3. A client is scheduled for surgery in
the morning. Preoperative orders have
been written by the physician. What do
you think is the most important thing to
do prior to surgery?
 Surgery
Learning Module 1

Topic: Concepts in the Care of at Risk and Sick

Adult Clients

Course Code: NCM 112

Preoperative Phase
Learning Module 1.1
Learning Outcomes:
• Upon completion of this module you will be able to:
1. Classify surgical procedures according to purpose, degree of risk, and urgency.
2. Discuss the components and purpose of written informed consent for surgery.
3. Describe the physical environment of the operating room, holding area and
identify the functions of the members of the surgical team.
4. Discuss the different type of anesthesia as to classification, advantages,
disadvantages, techniques of administration, potential adverse effects and
nursing intervention
5. Discuss the nursing assessment and management of the postoperative patient
6. Identify the components of pre-discharge patient teaching for the post-
operative patient.
A. Basic Concepts / Terminologies
Perioperative Nursing Care refers to the
total span of nursing intervention, and the
role of the nurse during the phases of the
patient’s surgical intervention.
Surgical Intervention is a common
treatment for injury, disease of disorder, and
the surgeon intervenes in the disease process
by repairing, removing, or replacing body
tissues or organ.
Surgery is defined as the art and science of
treating diseases, injuries and deformities by
operation and instrumentation.

It is invasive because an incision is made into

the body o a part of the body is removed.
Perioperative Nursing Care is divided into
three phases: preoperative, intraoperative
and post operative phase.
PHASES OF PERIOPERATIVE NURSING CARE:
PERIOPERATIVE NURSING CARE:

1. PREOPERATIVE PHASE

• Begins with the decision that

surgical intervention is necessary
and ends when the patient is
transferred to the operating
room.
 PERIOPERATIVE NURSING CARE:
2. INTRAOPERATIVE PHASE

• Is the period during which the

patient is undergoing surgery
in the operating room.

• It ends when the patient is

transferred to the Post
Anesthesia Care Unit/ PACU.
 PERIOPERATIVE NURSING CARE:

POSTOPERATIVE PHASE

• Lasts from the patient’s

admission to the recovery
room through the complete
recovery from surgery.
Safe transport of patient to
PACU/ RR
B. Perioperative Nursing Phase
1. THE PREOPERATIVE PHASE

ADMITTED to the surgical unit

PREPARATION for surgery:

Physical, Psychological, Spiritual,
Legal

TRANSPORT to the Operating Room

 2. THE INTRAOPERATIVE PHASE
• PICTURE OF INTRAOPERATIVE ADMITTED to the OR

ANESTHESIA -- SURGERY

TRANSPORT to the Recovery Room

2. THE INTRAOPERATIVE PHASE
2. THE INTRAOPERATIVE PHASE
3. THE POSTOPERATIVE PHASE
3. THE POSTOPERATIVE PHASE
ADMITTED to the RR/ PACU

BACK TO WARD

DISCHARGE

FOLLOW UP CARE
SURGICAL INTERVENTION MAY BE REQUIRED
FOR THE FOLLOWING CONDITIONS: (OPET)
 SURGICAL INTERVENTION MAY BE REQUIRED
FOR THE FOLLOWING CONDITIONS: (OPET)
O - OBSTRUCTION
• Impairment to the flow of vital fluids like blood, bile, cerebrospinal fluid
(CSF).

• It impedes or prevents
passage or progress.
P - PERFORATION
Example: PERFORATION IN GI TRACT

Hole in Large intestine

(Bowel Perforation)

Leak

Peritonitis
(Inflamed inner abdominal wall)

Damage

Sepsis
 E - EROSION

- Rupture of an organ.
 T - TUMOR

- Abnormal growths

- A solid mass of tissue that forms when

abnormal cells group together.

- Can affect bones, skin, tissue, organs and

glands.

- Many tumors are not cancer (benign).

- Cancerous, or malignant, tumors can be life

threatening and require cancer treatment.
 PURPOSE DEGREE OF RISK/ URGENCY SURGICAL SETTING
MAGNITUDE/ EXTENT
1. Diagnostic 1. Major Surgery 1. Emergency 1. Inpatient Surgery

 To confirm the  Criteria:  Should be done  Patients who are to

presence of the  Involves high risk immediately be admitted a day
disease of morbidity & before or on the
mortality day of the surgery.
 Extensive &
prolonged
 May involve large
amount of blood
loss
 Vital organs are
manipulated or
removed
 Involves greater
risk of occurrence
of complications
 PURPOSE DEGREE OF RISK/ URGENCY SURGICAL SETTING
MAGNITUDE/ EXTENT
2. Exploratory 2. Minor Surgery 2. Imperative 2. Ambulatory
Surgery
 To determine the  Generally the  Should be done  Out patient
extent of the procedure is not within 24 – 48 surgery
disease condition prolonged. hours  Endoscopy,
removal of
 Involves lesser foreign body,
risk proctoscopy
 Monitored
 Does not usually Anesthesia Care
involve serious (MAC) or local
complications  Maybe admitted
in PACU
 PURPOSE DEGREE OF RISK/ URGENCY SURGICAL SETTING
MAGNITUDE/ EXTENT

3. Curative 3. Planned
To treat the disease required
condition
 ABLATIVE  Necessary for the
Removal of organ well-being of the
patient.
 CONSTRUCTIVE
Repair of  Scheduled by
congenitally weeks or month
defective organ

 RECONSTRUCTIVE
Repair of
damaged organ
 PURPOSE DEGREE OF RISK/ URGENCY SURGICAL SETTING
MAGNITUDE/ EXTENT
4. Palliative 4. Elective
 Relive distressing Necessary for survival
signs and symptoms, for survival.
not necessarily to
cure the symptoms Delay or omission will
not cause adverse
effect.
5. Preventive 5. Optional
• To inhibit Procedure is requested
transformation of by the patient.
precancerous lesion
or benign tumors Usually foe aesthetic
purposes.
6. Cosmetic
• Improvement
Terms Related to Perioperative Nursing:
 SUFFIX used “ectomy”
Appendectomy Removal of appendix
Hysterectomy Removal of uterus
Oophorectomy Removal of ovary
Mastectomy Removal of breast
Pneumonectomy Removal of lungs
Tonsillectomy Removal of tonsils
Cholecystectomy Removal of gallbladder
 SUFFIXES used “plasty”, “orrhapy”, “pexy”
Cheiloplasty Repair of cleft lip

Herniorrhaphy Repair of hernia

Orchidopexy Repair of undescended

testes

Uranoplasty Repair of cleft palate

 THE SURGICAL RISKS:
1. General Risk Factors:
 Aging
Obesity
Fluids and electrolyte imbalance/s
Presence of disease/s
Concurrent or prior pharmacotherapy
 THE SURGICAL RISKS:
2. Other Factors:
 Nature of the disease conditions
Location of the condition
Magnitude and urgency of the surgical procedure
Mental attitude of the person towards surgery
Caliber of the professional staff and health care facilities
GOALS OF CARE DURING THE PREOPERATIVE
PERIOD:
 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 benefit the

person during post-operative period

 Planning for discharge and any projected changes in lifestyle due to

surgery
GOALS OF CARE DURING THE PREOPERATIVE
PERIOD:
 PREOPERATIVE NUSRSING ASSESSMENT:
A. Physiologic Assessment of the Client undergoing Surgery

 Age
 Presence of Pain
 Fluid and Electrolyte Balance
 Infection
 Cardiovascular Function
 Pulmonary Function
 Renal Function
 PREOPERATIVE NUSRSING ASSESSMENT:
A. Physiologic Assessment of the Client undergoing Surgery

 Gastrointestinal
 Liver Function
 Endocrine Function
 Neurologic Function
 Use of Medication and allergies
 Presence of Trauma
 COMMONLY ORDERED PREOPERATIVE
DIAGNOSTIC TESTS:
1. Urinalysis - To assess renal status, hydration, urinary tract infection and disease

2. Chest X-ray - To assess pulmonary disorders, cardiac enlargement

3. Blood Studies - To assess anemia, immune system, infection

4. Electrolytes - To assess the metabolic status, renal function, diuretic side effects

5. ABG’s Oximetry - To assess oxygenation

6. PT, PTT, INR, Platelet Count - To assess bleeding tendencies

7. Blood Glucose - To assess metabolic status, DM

 COMMONLY ORDERED PREOPERATIVE
DIAGNOSTIC TESTS:
8. Creatinine
- To assess renal function
9. Blood Urea Nitrogen

10. Serum Albumin - To assess nutritional status

11. Electrocardiogram (ECG) - To assess cardiac disease, electrolyte abnormalities

12. Pulmonary function test - To assess pulmonary function

13. Liver function test - To assess liver function test

14. Blood Typing and cross - To assess blood availability and for transfusion
matching
15. HCG - To assess pregnancy
 PREOPERATIVE NURSING ASSESSMENT:
B. Psychosocial Assessment of the client undergoing Surgery

Surgery is a frightening event for majority of the patient

even when the procedure is relatively minor
Role: prepare patient psychologically to prepare them and
to assess the patient for potential stressors that could effect
outcomes of surgery.

Factors: Fears, anxiety and hope

 PREOPERATIVE NURSING ASSESSMENT:
B. Psychosocial Assessment of the client undergoing Surgery

 Most common causes of fears of patient for operation:

a. Fear of the unknown
b. Anesthesia
c. Pain
d. Death
e. Disturbance in body image
f. Loss of finances, employment, social and family roles
Legal Aspects of Surgical Interventions:
WRITTEN INFORMED CONSENT
 PURPOSE:

1. To ensure that patient understands the nature of the treatment

including the potential complications and disfigurement.
2. To indicate that the patient’s decision was made without
pressure.
3. To protect the patient against unauthorized procedure.
4. To protect the surgeon and the hospital against legal action by
the patient who claims that an unauthorized procedure was
performed.
 Circumstances requiring written informed
consent:
1. Any surgical procedure where scalpel, scissors, suture,
hemostats or electrocoagulation may be used.

2. Any invasive procedure, or procedure that involves entry into

the body.

3. Any procedure that involves general anesthesia, local

infiltration anesthesia, or regional block anesthesia.
 Requisites for validity of written informed
consent:
1. Written permit/ consent is best and is legally acceptable.
2. The physician is responsible for obtaining patient’s consent.
3. Patient’s signature is obtained with the patient’s complete
understanding of what is occur, what is the treatment to be
done and possible complications, alternative treatments, risk
and benefits of its option.
 Adult: Physically and mentally incapacitated
 Minor: the parent/ legal guardian
4. Consent is obtained before sedation.
5. The patient is not under the influence of drugs or alcohol.
 Requisites for validity of written informed
consent:
6. The consent is secured without pressure or duress.

7. Signature of witness is required. The nurse, physician or other authorized persons

may sign as witness.

8. In case of emergency, to preserve life or to prevent serious impairment to life, the

patient is capable of giving consent, the next of kin may give consent.
 If no next kin to sign – 2 physician signs the consent and makes the notation on the progress
notes.

9. Emancipated minors are allowed to sign written consent.

10. The patient is aware that consent, even when signed can be withdrawn at any time.
 NURSING MANAGEMENT:
(Physical Preparation)

1. Correcting any dietary deficiencies

2. Reducing an obese person’s weight, as time permits
3. Correcting fluid and electrolyte imbalances
4. Restoring adequate blood volume with blood transfusion
5. Treating chronic diseases (DM, Heart disease, Bleeding
disorders, renal insufficiency
6. Treating any infectious disease
7. Treating an alcoholic person
 NURSING MANAGEMENT:
(Preoperative Teaching)

1. Patient has the right to know what to expect and how to participate
effectively during the surgical experience
2. Preoperative teaching increases patient satisfaction and may reduce
postoperative fear, anxiety and stress
3. Teaching may also decrease complications, the duration of hospitalization
and the recovery time following discharge
4. In some surgical settings patient arrive on a short time before scheduled
surgery like in ambulatory surgery and patients who will be hospitalized
postoperatively
5. In some situations, the patient had been admitted several days before the
surgery for treatment of certain disease conditions
6. Preoperative teaching/ visit
Preparation of the patient the evening before
surgery:

1. Skin preparation

2. Preparing the gastrointestinal tract

3. Preparing for anesthesia

4. Promoting rest and sleep

 Preparation of the patient on the day of
surgery:

1. Preoperative medication
 Facilitates administration of anesthetic
 Minimizes respiratory tract secretion/ changes in heart rate
 Relax patient/ reduce anxiety
2. Bedside care
3. Proper OR attire
4. Baseline vital signs
5. Check special orders
6. Emphasize NPO and other instruction(s)
7. Preoperative checklist
Preparation of the patient on the day of
surgery:
 Types of Preoperative Medications:
1. Opiates - To relax the patient, potentiate anesthesia, and relive
(Morphine, Demerol, Fentanyl) discomfort
2. Anticholinergics - To reduce respiratory tract secretions and to prevent severe
(ATSO4) reflex slowing of the heart during anesthesia
3. Benzodiazepines - To induce sedation and help ensure a restful night sleep
(Midazolam, Diazepam, Lorazepam) - Reduce stress and anxiety
4. Antibiotics - Administered just before or during surgery when bacterial
(Cefazolin, Ceftriazone, Piptaz) infection is expected
- Ideally given before induction/ skin incision is made
5. Histamine (H2)- Receptor
Antagonist - To decrease acid secretions, increase gastric pH, and decrease
(Ranitidine, Famotidine, Cimetidine) gastric volume
6. Antiemetic - To prevent/ decrease nausea and vomiting, and increase
(Ondasetron, Metochlopramide gastric emptying
BEST PRACTICES:

1. Preanesthetic medications should be given exactly at the time

they are ordered
2. Premedication may be administered orally, IV, SC, or IM.
3. Oral medications are given 60-90 minutes before the patient
goes to the OR unless otherwise ordered – patient is on NPO
before surgery.
4. IM and SC injections are usually given 30-60 minutes before
transport to OR.
5. IV meds are usually administered after arrival in the pre-op
holding area or OR.
BEST PRACTICES:

6. The patient should be informed about expected effects of the

medications.
7. Instruct patient to void before the administration of pre-op
medicines.
8. Instruct the patient not to get up from bed after administration
of premedication since drowsiness or postural hypotension may
occur.
9. Place the call light system within reach.
10. Darken the room after administration of medication, to
enhance sedative effects.
PROTOCOLS WHEN TRANSPORTING PATIENT TO
THE OR:
1. Follow hospital protocols when transporting patient scheduled for
OR. For elective cases, wheel patient at least 30 - 45 minutes before
scheduled time.
2. Proper OR attire required.
3. Inform OR Triage nurse on duty about the wheeling of patient to
OR.
4. Ward nurse checks completeness of preoperative checklist. Bring
other materials/ medical supplies needed as ordered.
5. Ward nurse assists in transferring patient from hospital bed to
stretcher with side rails up. Never leave patient unattended.
6. During the transport, maintain patient’s privacy and safety. When
using elevator, head first and exit feet first.
CARE OF SIGNIFICANT OTHERS AFTER
TRANSPORT OF PATIENT FOR OR:
1. Direct patient’s relatives to the waiting area
2. Inform the family to wait for they will be contacted anytime
when needed and once surgery is completed
3. Explain the reason for long interval of waiting due to:
 Anesthesia Induction
 Skin Preparation
 Surgery
 PACU/ ICU stay
4. Orient the family what to expect during the post-operative
period
SPECIAL CONSIDERATIONS FOR THE
PREOPERATIVE OLDER ADULT PATIENT:
1. Emotional reactions to impending surgery and hospitalization is
often intense in older adults
2. Hospitalization may be viewed as physical decline and loss of
health, mobility, independence and finances. They may view
the hospital as a place to die
3. The risk associated with anesthesia and surgery increase in the
older patient. It is important to consider the physiologic health
status or condition of the patient in planning of care
4. The surgical risk in the older adult may be related to normal
physiologic aging and changes that compromise organ function
SPECIAL CONSIDERATIONS FOR THE
PREOPERATIVE OLDER ADULT PATIENT:
5. It is important that the nurse obtains a detailed history and
complete physical examination when preparing the older adults
for surgery. Pre-op lab tests, ECG and chest x-ray may be
required in planning the choice and technique for anesthesia
6. Family support is important consideration for the surgical older
adult
7. The nurse must assess and document the sensory function,
thought process and cognitive abilities of the surgical older
adult. Many adults have sensory impairment
SPECIAL CONSIDERATIONS FOR THE
PREOPERATIVE OLDER ADULT PATIENT:
8. A next kin or a legal representative of the patient must be
present to provide consent for surgery if the older adult is
unable to sign for himself or herself.

9. It is vey important for the nurse to be supportive and help the

older adult cope with the overall surgical experience
Intensive Practicum
“ They may forget your name
but …….
they will never forget
how you made them feel

Thank you!!!
 SELF-ASSESSMENT QUIZ

Instruction: Write “T” for true and “F” for

false and identify the word or group of words
that make it false.
1. Elective surgery is necessary but scheduled at
the convenience of the patient and health provider.
2. Based on the degree of risk it may be
performed in an out-patient clinic, same day
surgery setting, or in the operating suite of a
hospital is considered as major surgery.
3. Surgical procedures can be combine
with a several classifications and
descriptors.
4. Minor surgery requires
hospitalization, it is usually
prolonged, carries a higher degree of
risk, and involves major body organs.
5. Anxiety and worry use up energy that is
needed for healing of tissue during the
postoperative period.
6. Regardless of whether the surgery is
major or minor, elective or emergency,
it requires both physical and
psychological adaptation for the patient
and his family.
7. The anesthesiologist is responsible for
completion of preoperative forms,
implementing doctor’s order for
preoperative care, and documentation of
all nursing measures.
8. The patient must sign in the presence
of a witness, to consent for the
surgical procedure.
9. Legal consent forms must be signed
prior to administration of preoperative
medication or any type of mind-altering
medication or the document is not
legally binding.
10. Informed consent is not legal if the
patient is confused, unconscious,
sedated, mentally incompetent, or a
minor.