NURSING SCIENCE

YNS20104

BCT
PRE AND POST OPERATIVE CARE

• Pre -operative Nursing Management

The preoperative phase begins when the decision to

proceed with surgical intervention is made and ends with
the transfer of the pt into the operating room table.
 Surgical classifications

1. Diagnostic ( biopsy)
2. Curative ( excision of tumor)
3. Reparative (multiple wound repair)
4. Reconstructive or cosmetic ( mamoplasty)
5. Palliative (relief pain or correct a problem)
According to degree of urgency
Emergent: require immediate attention without delay.

Urgent: require prompt attention within 24-30 hours.

Required: requires operation, plan hospital admission

within a few wks or months.

Elective: should be operated on, failure to have surgery

isn’t catastrophic.

Optional: the decision rests with the pt, depend on

personal preference
The patient’s major goals are:
Correction or treatment of physical problem

Relief of anxiety, worry and depression

Acceptance of and preparation for surgical interventions

Acceptance and tolerance of preansthetic medications

and agents.

Avoidance of injury, Nosocomial infections, and

complications.
The major nursing goals are to:
Assist the pt in understanding the physical and psychosocial
aspects of the surgical experience

Acquaint the pt and his family with the environment, protocol, and
expectations as surgery.

Teach the pt certain procedures that will help in reducing post

operative complications

Prepare the physically and psychologically for the operation

Collaborative with other members of the health team in

coordinating all preoperative procedures.
 Preparation for surgery
1. Informed Consent
Criteria for valid Informed consent:

Voluntary consent
Incompetent pt ( mentally retarded, mentally ill, or comatose)
Informed subject
Explanation
Description of risks and benefits
Answer questions about procedure
Instructions
Pt able to comprehend. (Information written in understandable
language.
 .
2. Assessment of health factors that affect pts
pre-operatively
 Assessment of Nutritional and fluid status.
 Respiratory status
 Cardiovascular status
 Assessment of hepatic and renal function
 Assessment of endocrine function
 Assessment of immunological function
 Assessment of effects of aging
 Assessment of prior drug therapy
 Assessment pts with disabilities
 3. Preoperative Nursing Interventions
The two goals of pre-operative care are:
To present the pt in the best possible physical and
psychosocial conditions for his operation

To initiate every effort that will eliminate or reduce post

operative discomforts and complications.

Nutrition and fluids:

Intestinal preparation
Preoperative skin preparation
 4. Pre-operative Teaching
The goal of preoperative teaching is to familiarize the pt
with the expected post operative outcomes such as:

Facilitation of recuperative period.

Attainment of a sense of well-being with minimal fear of
the unknown.
Decreased need for analgesics
Absence of complications
Decrease time for hospitalization
 When & What to teach:
Teaching sessions are combined with various
preparations to allow for an easy and timely flow of
information and allow time for questions.

Teaching should include description of the procedures

and include explanations of sensations of the pt’s will
experience.

The ideal timing or preoperative teaching isn’t on the day

of operation, but during the preadmission visit when
diagnostic tests are performed.
 Deep breathing and coughing:

Teaching the pt how to promote optimal lung expansion

and consequent bloody oxygenation after anesthesia.

The goal in promoting coughing is to mobilize secretions

so they can be removed .If the pt doesn’t cough
effectively, Atelectasis (lung collapse), pneumonia, and
other lung complications may occur.
 5. Pain Control and Management:
• Post operatively, medications are administered to relief
pain and maintain comfort without increasing the risks for
inadequate air exchange.

• Monitor - Pain score assessment

 6. Cognitive Coping Strategies:

Cognitive strategies may be useful for relieving tension,

overcoming anxiety.
Imagery: the pt can concentrates on a pleasant experience

 Distraction: thinks of an enjoyable story or song

 Optimal self-recitation: recites optimistic thoughts.
 7. Preoperative psychosocial interventions
 Reducing pre-operative anxiety

Cognitive strategies useful for reducing anxiety, music therapy

is an easy to administer, inexpensive, noninvasive
intervention

 Decreasing Fears

 Reflecting Cultural, Spiritual, and Religious Beliefs

Include identifying and showing respect for cultural, spiritual,

and religious beliefs, such as in pain control, or in blood
transfusion.
 Intra operative Nursing Management

 Artificial hypotension during operation:

To reduce bleeding at the operative site espicially in brain
surgery.

 Malignant hyperthermia:
Due to biochemical disturbances in skeletal muscle
involving calcium distribution. we use hypothermia blanket,
infusion of ice saline solution high concentration of oxygen,
and NaHCO3 to correct metabolic acidosis
 Positions on operating table:

Comfortable
Adequately exposed area
Circulation
Respiration free
Nerves is protected from undue pressure
Concern for obese, thin, old pt.
Gentle restrains.
 Positions:
Dorsal Recumbent position
Trendelenburg position
Lithotomy position
For kidney operation
For chest and abdominothoracic operation
Operation on the neck
Operation on the skull and brain.
Trendelenburg position
Dorsal Recumbent position
Lithotomy position
kidney operation
 Principles of perioperative asepsis:
1. Preoperative:
 Preoperative sterilization of surgical materials
 Placement of the operation room
 Scrubbing of health team
 Cleansing the patient’s skin with antiseptic agents
 Covering the rest of pt’s body with sterile drapes
2. Intraoperative:
Asepsis techniques in surgical practice
3. Post operative:
 Protect the wound from contamination by sterile
dressing
 Heat compresses at site of surgery
 Antimicrobial agents in infected wounds
 Post operative Nursing Management
goal is directed toward the reestablishment of the
patient’s physiological equilibrium and the prevention of
pain and complications.

Removing the patient from the operating table

The site of operation should be kept in mind every time.
Check positioning of the head ; extension, lying on
unaffected site ,
Check blood pressure; arterial hypotension
Remove the wet gown, keep the pt warm
 Recovery Room: should have
Wall and ceiling painted in soft, pleasing colors
Indirect lighting
Sound proof ceiling
Equipment that controls or eliminate noise
Isolated quarter for noisy pts.
Equipments:
( Breathing aids; oxygen, laryngoscope, tracheostomy
set, bronchial instruments, catheters, mechanical
ventilators, suction equipments, equipments for
circulatory needs blood pressure, parental infusions.
Surgical dressing materials, drugs especially emergency
drugs.)
The pt remains in this room until he has full recovery from
the anesthetic agents, stable blood pressure, good air
passage, and reasonable degree of consciousness.
 Goals of post operative nursing care:

1-
To assist the pt in maintaining optimum respiratory
function.
• Positioning
• Cleaning the airway
• Promoting lung expansion
• Rebreathing CO2
• Bed exercises.
 Deep- breathing exercises
 Arm exercises
 Hand and finger exercises
 Foot exercises
 Exercises to prepare pt for ambulatory activities
 Abdominal and gluteal contraction exercises
2-
To assist the cardiovascular status of the pt and
correct any deviation.

3-
To promote the comfort and safety of the pt
• Restlessness and discomfort
• Pain
4-
To promote hemostats through maintenance of fluid and
electrolyte balance, proper nutrition and elimination.

5-
To enhance wound healing and avoid or control infection.
Nosocomial infection
Invaded of skin and mucous membrane by tubes and catheters, by
the disease process
Effect of surgery and anesthesia reduce resistance of the body
 Organisms in the hospitals
Poor hand washing practices

 This can be reduced by:

Continuous health education about infection control
policy
Deep breathing exercise to prevent accumulation of
secretions
Sterilization of equipments
Antibiotics therapy
6-
To encourage activity through appropriate exercises,
ambulation and Rehabilitation
Positioning
Ambulation
 Ambulation increase respiratory exchange
 Prevent stasis of bronchial secretions
 Reduce distension
 Prevent thrombophlebitis
 Increase rate of wound healing
 Ambulation done gradually
7-
Psychosocial well-being of the pt and his family.
 Keep family in bed side for minutes
 Expression of feelings
 Participate in self care
 Attractive grooming

8-
Document all phases of nursing process and report data
 Any slight symptoms that can increase in severity
 Any progressive and steady change for the worse in the
general condition of the pt
 The pt's complaints
 Post operative discomfort
1- Vomiting- Aspiration

Insert NGT during surgery

Drugs e.g. antiemetics may cause hypotension and respiratory
depression
Prevent aspiration of vomitus
Turn the pt on his side lying position to provide effective
drainage from the throat
Clean mouth frequently to facilitate breathing
2-Abdominal distension
Loosing of normal peristalsis within 24-48 hours post operatively is
due to trauma in abdomen. he was swallowed mucous and
secretions during operation, so he needs to evacuate these things
.

3-Thirst. (atropine).

4- Hiccups.
It is produced by intermittent spasms of the diaphragm and
manifested by a coarse sound. The cause of diaphragmatic
spasm is any irritation in the phrenic nerve from its center in the
spinal cord.
 5-Constipation

It can be treated by simple enema, increased in diet (Constipation

has been described as a constant symptom of complete intestinal
obstruction)
(Cathartic drugs should never be given, except when prescribed by
the physician)
 6-Fecal Impaction
This complication as a result of neglect and never should occur.
So early ambulation, proper fluid and diet, enemas fairly effective.
It accompanied by abdominal discomfort, the pt represent that he
needs to defecate, but no relief.
Remove the impaction
 Enema of liquid petrolatum (oil enema)
 Gloved finger
 Injection of 30-60cc of H2O2 into the rectum
 7- Diarrhea
After operation diarrhea is rare. Fecal impaction is the main
cause:
Shock: Failure to provide adequate cellular oxygenation
accompanied by failure to remove the waste products of
metabolism.

Shock can be occurs with hemorrhage, trauma, burn, infection, and

heart disease, and from failure of the three aspects of circulation:
the heart pump, peripheral resistance, and blood volume , this
cause inadequate blood flow to vital organs or inability of the tissues
of these organs to utilize oxygen
 Classification of Shock:

1-Hypovolemic Shock:
• Cause by decreased fluid volume due to loss of blood,
plasma or water.
• Fluid volume usually decreased post surgery due to local
trauma to tissues and loss of blood and plasma from
circulation, which creates a decrease in the circulating
blood volume.
• It characterized by a fall in venous pressure, rise in
peripheral resistance and tachycardia.
2- Cardiogenic shock:

• It results from cardiac failure or an interference with heart

function,
(poor heart pump function, and causing diminished cardiac
output) as in MI, arrhythmias, tamponate, pulmonary embolism,
epidural or general anesthesia.
• The signs are increased pressure in the venous bed and an
increase in peripheral resistance.
3-Neurogenic shock:

• It occurs as a result of a failure of arterial resistance due to spinal

anesthesia, quadriplegia.
• It characterized by fall in blood pressure, increase heart activity to
maintain normal output (stroke volume); this helps in filling the
dilated vascular system.
4-Septic shock:

• It results from gram negative septicemia ( infection , peritonitis,

etc)
• The pt exhibit fever, rapid strong pulse, rapid respiration, and
normal or slightly decreased blood pressure, flushed , warm, dry
skin,then hypovolemia develops.
 Clinical manifestation
The classical signs of shock are :
• pallor ,
• cool ,
• moist skin,
• rapid breathing,
• ischemia to eyelids,
• lips, gums and tongue ,
• weak,
• thready pulse,
• small pulse pressure,
• low blood pressure.
Medical and nursing assessment of the pt with
shock
• The goal in initial assessment is to determine the cause of
volume loss and the status of the airway
Respiration: Hyperventilation is the early sign of septic
shock.
Skin: A cold, pale, moist skin is a sign of
vasoconstriction-hypovolmic shock. Warm, red skin
indicates septic or Neurogenic shock .
Pulse and blood pressure: If each 5-15 minutes interval
shows a fall in pulse and BP the indicate shock.
 Urinary output: an indwelling catheter is recommended,
a drop in renal artery pressure and flow produces renal
artery vasoconstriction and results decrease in filtration
and decreased in urinary output.
(Normal urine output= 50 cc per hour. An output 30cc
per minute= oliguria or unuria is a suggestive of
cardiac failure)
Central venous pressure: It has a value on the volume of
blood returning to the heart and the ability of the right
heart to propel blood. Average CVP is 5-12 cm water,
near zero indicate hypovolemia

Central venous pressure: It has a value on the volume of

blood returning to the heart and the ability of the right
heart to propel blood. Average CVP is 5-12 cm water,
near zero indicate hypovolemia
Arterial blood gases: an arterial pressure of oxygen
below 60 mm Hg indicates respiratory acidosis. A PCO2
over 45 mmHg indicated hypoventilation. In shock
PCO2 remain normal

Serum lactate: lactate elevation and oxygen dept, the

higher the lactate level, the greater the oxygen need.
Hematocrite: to determine the kind of fluid in
replacement. HCT over 55, plasma and normal saline
are given. HCT less than 20, blood is needed

Level of consciousness: alert in mild shock, to mental

cloudiness in moderate shock. Failure to react or stimuli
is irreversible shock.
Therapeutic and nursing management of shock:
Prevention:
Adequate preparation of pt physically.
Anticipation of complication
Preparation of special emergency equipments e.g. blood
studies, BP device, catheters, suction, oxygen, CVP line, IV,
defibrillator, solutions.
Decrease any operative trauma during surgery
Control pain
Thermal regulation after surgery
Control of blood loss, “ if the amount of blood loss exceeds
500 ml, replacement is usually indicated
Positioning “dorsal recumbent position to facilitate circulation.
Treatment:

The pt must kept warm, infusions of Ringer lactate is

started, placed in shock position, monitor respiratory and
circulatory status.

“The basic approach of treatment of shock is to determine

its cause and correct it if possible.”

1-Ensure adequacy of the airway.

2- Restore blood volume.
.
3-Administer vasodilators.
Vasopressors are not used for the pts in shock because
they have vasoconstriction in the microcirculation which
may cause irreversible damage to kidney, lungs, liver,
and GIT tissues.
Vasodilators are given to reduce peripheral resistance,
which decrease in turn the work of the heart and
increase cardiac output and tissue perfusion. They use
Nipride which stimulate cardiac contractibility and lower
peripheral resistance
4- Provide psychological support and minimize the pt's
energy expenditure.

5- Prevent complications:
Avoid peripheral and pulmonary edema due to fluid
overload from administering fluid faster than the body
can accommodate them.
Hemorrhage
Hemorrhage is classified as
1) primary, when it occurs at the time of the operation.

2) Intermediary, it occurs within the first few hours after an

operation.

3) Secondary, it occurs some time after the operation, as

result of slipping of a ligature because of infection.
Clinical manifestations:
It depends on the amount of blood lost and the rapidity of
its escape. Apprehensive and restless, and moves
continually
Thirsty, skin is cold, moist, and pale
Increase in pulse, fall in temperature, rapid and deep
respirations “gasping”
Decrease cardiac output
Fall of arterial and venous BP and Hb.
Palled lips and conjunctiva
Management:
Positioning in shock position
Administer morphine to keep pt quiet
Inspect wound for bleeding
Giving transfusion of blood and determine the
cause.
Giving fluids but not too rapid to avoid fluid
overload
Femoral Phlebitis or Thrombosis
Pathophysiology:
It occurs after operation upon lower abdomen or in the course
septic diseases e.g. peritonitis or ruptured ulcers. A mild to
severe inflammation of the vein in association with a clotting
of blood.

Complications occurred due to injury to the vein by tight

straps or leg holders at the time of operation. Pressure from
blanket-roll under the knees, concentration of blood due to
blood loss or dehydration.

The slowing of blood flow in the extremity leads to lowered

metabolism and depression of circulation after operation.
The first symptom is pain or cramps in the calf, followed
by swelling of the entire legs due to a soft edema that pits
easily on pressure, slight fever, chills and perspiration,
tenderness.

Phlebitis: indicate intravascular clotting without marked

inflammation of the veins. The clotting occurs on the calf.
The major sign is slight soreness of the calf.
Medical and nursing Management:
Preventive:
 Adequate administration of fluids after operation to
prevent blood concentration
 Leg exercises
 Elastic stockings
 Early ambulation to prevent stagnation of the blood in the
veins of the lower extremity.
 Low-dose of heparin prophylactically to prevent deep vein
thrombosis and major pulmonary embolism
 Avoid blanket-roll, pillow –rolls or any form of elevation
that can constrict vessels under the knees
2) Active treatment
Ligation of the femoral veins , to prevent pulmonary
embolism by eliminating the cause ( thrombi that could
become detached from femoral veins and circulate in
the blood)

Anticoagulant therapy. Heparin given IV by drip method

or SC to reduce the coagulability of the blood rapidly

Wrapping the legs from the toes to groin with elastic

stockings, these prevent swelling and stagnation of
venous blood in the legs and to relief pain with leg
elevation and legs exercises
Thank You