Nursing care of patients undergoing

surgery
(Perioperative Care)

Dr. Mohammad Alhawajreh

 Intended Learning Outcomes
• S.E.E.1.1: Apply knowledge of the purpose and components of a
perioperative nursing assessment
• S.E.E.1.2: Examine the ethical and safe nursing role and practices in the
physical, psychological, and educational preparation of the surgical patient.
• S.E.E.2.1: Analyze the components and purpose of the patient’s informed
consent for surgery.
• S.E.E.2.2: Prioritize the nursing responsibilities related to the perioperative
surgery preparation for the surgical patient, enhancing the safety of those
patients.
• PH.I.1.1: Distinguish the common purposes and settings of surgery.
• PH.I.1.2: Interpret the significance of data related to the preoperative
patient’s health status and operative risk.
• H.P.M.1: Apply knowledge of the purpose and components of a preoperative
nursing assessment.
 Intended Learning Outcomes
• H.P.M.1.1: Examine the nursing role in the physical, psychological, and
educational preparation of the surgical patient.
• H.P.M.1.2: Perform a comprehensive preoperative assessment to identify
pertinent health and surgical risk factors
• S.E.E.2: Prioritize the nursing responsibilities related to day-of-surgery
preparation for the surgical patient.
• PH.I.2: Recognize the purposes and types of common preoperative
medications.
• P.S.I.1: Describe considerations related to preoperative nursing care of older
adult patients, patients with obesity, and patients with disability
• G.H.E.2: Utilize the latest electronic health record systems used in healthcare
centers which include the data related to the preoperative patient’s health
status and operative risk
  Surgery

• Surgery: is the art and science of treating

diseases, injuries, and deformities by operation
and instrumentation.

• The total surgical episode is called the

perioperative period. This period includes:
• The time before surgery (preoperative period).
• The time spent during the actual surgical
procedure (intraoperative period).
• The period after the surgery is over
(postoperative period).
  Perioperative
• Preoperative phase: period of time from decision for
surgery until patient is transferred into operating room.

• Intraoperative phase: period of time from when patient

is transferred into operating room to admission to
postanesthesia care unit (PACU)

• Postoperative phase: period of time from when patient

is admitted to PACU to follow-up evaluation in clinical
setting or at home
 Surgeries Classification

• According to Reason/Purpose of surgery.

• According to Urgency
• According to Seriousness/Risk.
• Surgery Setting.
 According to Purpose/Reason of surgery

• Diagnostic (lymph node Biopsy, bronchoscopy)

• Curative (excision of tumor, Appendectomy)
• Palliative (relive pain or correct problem: insertion of
gastrostomy tube, create colostomy, cut a nerve root.
• Prevention (Mastectomy, removal of colon).
• Exploration (laparotomy)
• Plastic/ Cosmetic improvement (repair a burn scar).
 According to Seriousness (Degree of risk)

• Major:
Involves extensive reconstruction or alteration in
body parts; causes great risks.
• Minor:
Involves minimal alteration in body parts involves
minimal risk compared with major procedures.

Duration of surgery?!
 According to degree of urgency:
 According to Surgical Setting:

• Hospitals
• Inpatient surgery
• Ambulatory (outpatient) surgery
• Surgical procedure performed in same day
Usually require less than 3 -4 hours stay in PACU
not require an overnight hospital stay. E.g.
endoscopic procedures
• Clinics.
• Physician offices.
• Homes.
 Surgery Names
 Preoperative Care activities

• Nurses are responsible to ensure that the patient is

ready and prepared for surgery.
 Preoperative Care activities
• Assessment
• Physical
• Emotional
• previous anesthetic
• medical history
• health factors that affect
patients pre and post-
operatively
• Dx tests and procedures
• Education (post-op care)
• Consent form
• Preoperative preparations
  Informed Consent
• Voluntary
• Should be in writing
• necessary before non-emergent surgery can be
performed
• Emergency — surgeon may operate without pt
informed consent
• Protect patient and surgeon
• Nurse may ask patient to sign the form and may be
witness the signature
• Should be signed before pre op. medication
• Refusing surgical procedure is a person legal right
• Permission may be withdrawn at any time
  Informed Consent

• Physician/ Surgeon responsible for obtaining consent

and provide appropriate information
• Nurse may ask pt to sign the form and witness pt
signature
• Verify patient understanding (Informed) and
agreement to perform surgery (consent).
 Informed Consent

• Information should include:-

• Procedure
• Benefits
• Alternatives
• Possible risks
• Complications
• Additional information to take decision
 Informed Consent

Who sign consent form?

• Competent patients ( legal age at least 18 years of
age and mentally capable)
• Legally appointed representative of family may
consent if patient is
• Child
• Unconscious
• Mentally incompetent/ill
 Assessment of Health Factors

• Health history (interview)

• Physical examination
• Goal : identify risk factors that may lead to
complications
• Risk factors
• Heart disease ejection fraction
• DM
 Assessment of Health Factors

Nutritional & Fluid Status

• Malnourished client prone to poor tolerance of
anesthesia, infection, poor wound healing and
others
• Any nutrient deficiency and dehydration and
electrolytes disturbances should be corrected
before surgery
 Preoperative Assessment

• Drug or alcohol use

To be prepared for adverse reactions, such as
withdrawal, that may occur during surgery.
 Complimentary and herbal Meds
 Preoperative Assessment

Respiratory system
• Surgery may postponed if pt has resp infection
• Surgery may contraindicated when pt has
respiratory infection, COPD and Asthma.
• Smoking greater risk for complications, should
stopped 1-2 months before surgery
 Preoperative Assessment

Cardiovascular system
• Strict assessment of cardiac status to avoid
complications
• If patient has uncontrolled hypertension surgery
may be postponed until blood pressure controlled
 Preoperative Assessment

Hepatic & Renal Systems

• Any disorder of liver has an effect on anesthesia
metabolism
• Abnormal renal function can altered fluid and
electrolyte balance and ↓ excretion of preoperative
medications and anesthetic agents
• Surgery may contraindicated for patients with acute
kidney diseases
 Preoperative Assessment

Endocrine Function
• Pt assessed for hx of endocrine disorders
• Diabetic patients undergoing surgery are at risk for
hypo and hyper glycemia
• Blood glucose should be maintained at level less
than 200mg/dl
• Monitoring blood glucose before,during,and after
surgery
 Preoperative Assessment

Immune Function
• Allergies (drug and nondrug)
• Medications
• Foods
• Topical agents used to prepare skin for surgery,
and latex
  Preoperative Assessment
Mediations history
Drugs and herbal products.
Drug interaction with anesthesia.
Cardiac
Antihypertensive
Immunosupression
Seizure
Anticoagulation(Asprin)
Aspirin should be stopped at least 7-10 days before surgery
Endocrine (Insulin)
Ask patient about drug reaction
Drug allergies
 Preoperative Assessment
Psychosocial factors
• Anxiety
• Stress
• Fears (Loss of job, pain and bad experience, fear of
unknown and death,…)
• Hope
Nursing role
• Alleviating fear and anxiety
• Provide information
• Listen to patient
• Consultation with a social workers or a psychologist
or family members.
 Preoperative Nursing Interventions
• Preoperative Education
• Written/oral instructions
• Time of teaching : before surgery
• Surgical procedure
• Pre-op medication
• Deep-breathing, coughing exercise and
Spirometry (measuring of breath > lung function
test)
• Leg exercises
• Moving (Turning to side, Getting out of bed )
• Pain control (assessment and methods )
• Frequent change Positions & range of motion
• Presence of tubes, drains, monitoring devises.
Preoperative Education
Preoperative Education
Preoperative Education
  General Preoperative Nursing
Interventions
• Maintaining patient safety and protect him/ her
from injury (see chart 18-5)
• Managing Nutrition and Fluids
• Fluid and food restriction (NPO)
• Why? To prevent aspiration
• New recommendations for elective and healthy
people (not at risk) →clear fluids up to 2 hours
• Preparation bowel for surgery
• Enema (abdomen and pelvic surgery)
• Antibiotics(↓ intestinal flora)
• Skin preparations (cleaning, shower, shaving).
 Day of surgery
Immediate pre op Nursing Interventions (day of
surgery preparation)
• Wearing Gown (open in back) and ID band
• Jewelry, pins, nail polish removed
• Mouth inspected and denture removed
• Patient should void (before pre-op medications)
• Prevents involuntary elimination under anesthesia
or early postoperative recovery
• Administer pre-anesthesia medication Valium, Ativan,
Plasil, Atropine (PO, IV, IM, SC)
• Maintain preoperative records “checklist”
• Keep pt in bed with side rails raised
• Transporting patient to pre-surgical area
 Day of surgery preparation
Preoperative medications:
Purposes
• Sedation
• Amnesia.
• Reduce anxiety
• Reduce secretions
• ↓ pain.
• ↓ nausea and vomiting
• Oral medications given 60-90 min before patient
goes to OR unless otherwise ordered.
• These medications swallowed with minimal amount
of water.
NPO Before Surgery
Preop checklist
 Transportation to OR

• Nurse should ensure that patient is transported

safely.
• Nurse should prepare patient room for postop
arrival.
• Patient endorsement to OR staff.
 Electronic Healthcare System in Jordan

• In October 2009, Electronic Health Solutions

(EHS) launched its flagship program, Hakeem, the
first national initiative of its kind, to automate the
public healthcare sector in Jordan, under the
patronage of His Majesty King Abdullah II Bin Al
Hussein. The program aims to facilitate efficient,
high-quality healthcare in the Kingdom through
the nationwide implementation of an Electronic
Health Record solution (EHR). In effect,
physicians, pharmacists, medical technologists,
and other clinicians are able to electronically
access medical records of patients within
participating health facilities in Jordan simply by
entering the patient’s national ID number.
 Electronic Healthcare System in Jordan
• Benefits of Hakeem program
• For the patient
1. Hakeem program concentrates on preventive healthcare for the
patient through many features such as clinical reminders for
better management of chronic diseases as well as early
detection of illnesses which on the other hand decreases death
rates.
2. Create and sustain a patient-centric health record that can be
accessed from any automated institute in the public sector
across the Kingdom at any time.
3. Patient safety is a priority to Hakeem program where it provides
information that allows healthcare providers to examine their
patients' electronic health records using their national
identification number, these records include:
4. Current medications, possible allergies, and drug-drug
interaction alert to avoid giving the wrong medications.
 Electronic Healthcare System in Jordan
• Benefits of Hakeem program
• For the patient
1. Medical and surgical history including comprehensive procedural and
surgical reports.
2. Progress notes taken during the patient visits.
3. Electronic access to the patient’s lab results and x-rays.
4. Improving the patient's experience during receiving healthcare services
through:
5. Optimizing workflows, enhancing process mapping, and enabling a
platform for continuous process improvement in healthcare.
6. Reduce the need to visit specialty centers through a patient health
information exchange platform that allows doctors to access the patient's
electronic health record remotely thus evaluate and diagnose cases with
ease.
7. Enhance the quality of healthcare and ensure patient safety and privacy.
Reference:
https://ehs.com.jo/hakeem-program
 Electronic Healthcare System in Jordan
• Benefits of Hakeem program
• For the healthcare facility
• Elevate healthcare facilities standards to meet international standards.
• Reduction of operational costs in health institutes which will reduce the
overall healthcare cost as well as enhance the level of service provided
through:
• Reduction of waste of medications distributed in the country and lower
duplication in ordering medications.
• Elimination of x-ray prints and x-ray waste and lower patient/doctor exposure
to x-rays as well as improve the resolution of x-ray images and ability in
zooming in and out, thus easing the life of patients and doctors alike.
• Lowering of costs of laboratory tests and lower duplication in lab tests orders.
• Through the provision of preventive healthcare patients are treated more in
out-patient clinics than being admitted to hospitals, therefore, reducing the
overall cost of patient care.
• Patient workflow optimization through automating different procedures such
as appointments, Pharmacy, Radiology, and Lab.
Reference: https://ehs.com.jo/hakeem-program
 Electronic Healthcare System in Jordan
• Benefits of Hakeem program
• For the healthcare facility
• Creation of a comprehensive database of patients that will be made
available to authorized researchers for use in scientific studies, in addition,
to support decision-makers in setting health strategies and policies aiming
solely at improving healthcare delivery in Jordan.
• Hakeem program builds and provides instant and periodic reports that
support better decision-making.
• Develop and install hardware and network infrastructure in healthcare
facilities implementing the Hakeem program.
• Healthcare facilities will thus become more efficient and provide a better
patient experience, which will also enhance Jordan’s position as a
destination for medical tourism.
• Limiting mistakes among health and administration professionals.
• Creation of hundreds of job opportunities nationwide for qualified
Jordanians with expertise in the fields of health informatics and information
technology.
Reference:
https://ehs.com.jo/hakeem-program
 Thank you
Any Questions ?