PERIOPERATIVE

NURSING
Surgery – refers to the treatment of injury, disease
or deformity through invasive operative methods.
Classification of Surgical Procedures:
A. Seriousness
1. Major
2. Minor
B. Urgency
1. Elective (breast reconstruction)
2. Urgent (gall bladder stone removal)
3. Emergency (control of internal hemorrhage)
C. Purpose
1. Diagnostic (breast mass biopsy)
2. Ablative (amputation)
3. Palliative (colostomy)
4. Reconstructive/restorative (scar)
5. Procurement for transplant (liver)
6. Constructive (repair of cleft palate)
7. Cosmetic (reshape the nose)
8. Curative (ruptured AP)
3 Phases of Perioperative Nursing:
1. Pre – operative phase – is the time during
the surgical experience beginning with the
client’s decision to have surgery and ending
with the transfer of the client to the
operating table.
- fear of the unknown is common at this
stage.
2. Intra – operative phase – is the time during
the surgical experience that begins when the
client is transferred to the operating room table
and ends when the client is admitted to the
post anesthesia care unit.
3. Post operative period – is the time during
the surgical experience that begins with the
end of the surgical procedure and lasts until
the client is discharged not just from the
hospital or institution, but from medical care
by the surgeon.
Pre - operative Assessment Considerations:
1. Age
> very young and very old clients are at risk
during surgery – declining physiological
status.
> Infant – normal body temperature must be
maintained.
> Shivering reflex is underdeveloped.
> anesthesia adds to the risk of hypothermia –
anesthetics can caused vasodilation and heat
loss.
2. Nutritional Status
> post – operative clients require at least 1500
kcal/day to maintain energy reserves.
> increase in CHON, vitamin A and Zinc to
facilitate healing.
> malnourished clients are more prone to poor
tolerance to anesthesia, negative nitrogen
balance, delayed poor clotting mechanism,
infection, poor wound healing, and a potential
for multiple organ failure.
3. Obesity/ Bariatrics
> increased surgical risks – reduces ventilatory and
cardiac function – HTN, CAD, DM are common to
bariatrics.
> post – operative complications: embolus,
atelectasis, pneumonia.
> susceptible to poor wound healing – because of
the structure of fatty tissues which contain a poor
blood supply; slow delivery of essential nutrients,
antibodies and enzymes needed for wound healing.
> often difficult to close surgical wound –
because of the thick adipose layer.
> at risk for dehiscence (opening of the suture
line).
4. Immunocompetence
> cancer patients: surgeon waits for 4 to 6
weeks (ideally) after completion of radiation
treatments before performing surgery –
chemotherapeutic agents, immunosuppressive
medications, etc., increase the risks for
infection.
5. Fluid and Electrolytes imbalances
> the body responds to surgery as a form of
trauma.
> adrenocortical stress response: Na and water
retention, and potassium is lost within the first
3 to 5 days post – operatively.
6. Pregnancy
> surgery is performed on pregnant clients
only on emergent or urgent basis.
> GA is administered with caution – GA
increase the risks for fetal death and pre – term
labor.
7. Previous Surgery
> client’s past experience with surgery can
influence physical and psychological
responses to a procedure.
8. Perception and understanding of surgery
> ethical dilemma: the client is misinformed or
unaware of the reason for surgery.
> nurse should confer with the physician if the
client has an in accurate perception of
knowledge of the surgical procedure before
the client is sent for surgery.
> determine whether the physician explained
routine pre – operative and post – operative
procedures.
> reinforce the client’s knowledge and
maintain accuracy and consistency.
9. Allergies
> allergies need to be delineated from
unpleasant side effects.
> Latex allergy – provide a latex free
environment.
10. Smoking habits
> smokers have increased amount and
thickness of mucus secretions.
> GA increases airway irritations and
stimulates pulmonary secretions which are
then retained as a result of reduction in ciliary
activity during anesthesia – Ineffective airway
clearance.
> nurse should emphasize the importance of
post – operative deep breathing and coughing.
11. Family Support
> it is best to have the client identify his/her
source of support.
> family presence should be encouraged.
> family members can become the client’s
coach, offering valuable support during the
post – operative period when the client’s
participation is vital.
12. Review of emotional health
> surgery is psychological stressful.
> nurse should assess the client’s feelings
about the surgery, self – concept, body image
and coping resources – to understand the
impact of surgery on a client’s and family’s
emotional health.
> explain that it is normal to have fears and
concerns.
client’s ability to share feelings partially
depends on the nurses willingness to listen.
The nurse should be supportive and clarify
misconceptions.
client feel powerless or loss of control –
attempt to determine the reason; assure client
of his/her right to ask questions and seek
information
Assess manifestations of anger and anxiety.
13. Self – concept
> assess and identify personal strengths and
weaknesses.
> poor self – concept hinders ability to adapt
to the stress of surgery and aggravates feelings
of guilt or inadequacy.
14. Body Image
> response is determined by culture, self –
concept, degree of self – esteem.
> nurse should encourage expression of
concerns about sexuality.
15. Coping Resources
> nurse must be aware of the responses; assist
in stress management; determine behaviors
that help resolve any tension and nervousness;
and identify sources of support.
16. Culture
> this refers to a system of beliefs that have
been developed over time and subsequently
been passed on through many generations. The
nurse should acquire knowledge regarding a
client’s cultural and ethnic heritage.
17. Client Expectations
> assess expectations
> nurse should provide accurate information
and clarify misconceptions.
PHYSICAL ASSESSMENT KEY POINTS:
1. Pre – operative vital signs – to establish
baseline data with which to compare
alteration that occur during and after
surgery.
2. Elevated temperature:
> a cause of concerns – if the client has
underlying infection, the surgeon may
choose to postpone the surgery until
infection has been treated.
> elevated body temperature also increases
the risk of fluid and electrolyte imbalance.
3. Dehydrated client – at risk for developing
serious fluid and electrolyte imbalance
intraoperatively.
4. Inspect the possibility of local and systemic
infection.
5. Jugular vein distention – at risk for
cardiovascular complications during surgery.
6. Loose or capped teeth:
> must be identified – they can become
dislodged during endotracheal intubation.
7. Dentures – must be removed.
8. Inspect the bony prominences of the skin –
prolonged surgery – increased risk of
pressure ulcers.
9. Older adults – high risk for alteration in the
skin integrity from positioning and sliding
on the OR table causing shear and pressure.
10. Wheezing in the airways – laryngeal
spasm (caused by certain anesthetics) – at
risk for further airway narrowing during
surgery and after extubation – inform the
physician.
11. Peripheral pulses are not palpable – use a
Doppler instrument for assessment of their
presence. Normal capillary refill time is 2
seconds.
12. Spinal anesthesia – causes temporary
paralysis of the lower extremities.
NURSING DIAGNOSIS:
1. Ineffective airway clearance
2. Anxiety
3. Risk for imbalance body temperature
4. Risk for injury
5. Impaired physical mobility
6. Risk for latex allergy response
7. Risk for infection
8. Acute pain
9. Impaired skin integrity
PLANNING:
1. Involve the client and the family in pre
operative instruction.
2. Provide therapies aimed at minimizing the
client’s fear or anxiety regarding surgery.
3. Plan therapies to reduce the surgical risks.
4. Consult with other health care provider.
IMPLEMENTATION:
Consent (18 to 65 yrs old) – this form
authorizes the attending physician and the
staff to render standard day to day treatment
or to perform generalized treatments.
Types of Consent:
1. General consent (admission) – is relied on
only for activities performed in routine care.
- as a nurse you must be knowledgeable
about the statements on the formed used in
their facility.
2. Informed consent – is a process not
necessarily a mere document, explanations
of the procedure, risks, benefits and
alternative therapy are made verbally to the
patients level of understanding.
- surgery cannot be ethically and legally
performed until client’s understands the
need for a procedure, the steps involved,
risks, expected results and alternative
therapy.
The following should be documented in an
informed consent:
1. Who will be performing the procedure, including
any residents, interns or first assist.
2. Each surgical procedure to be performed,
including secondary procedures.
3. Any procedure in which an anesthetic is
administered.
4. Procedure involving entrance into the body via an
incision, puncture and natural orifice.
5. Any hazardous therapy, such as radiation or
chemotherapy.
Responsibility for Informed consent before a
surgical procedure:
> Surgeon is responsible for obtaining the
consent and explaining the procedure.
> Nurse should ensure that the consent form
has been completed and placed in the clients
medical records.
Validation of the Consent:
1. Patient should be personally sign the consent
unless he or she is a minor, unconscious or
mentally incompetent or in a life threatening
situation.
2. The patient should not be under sedation
before he or she signs the consent.
3. The nurse needs to document the witnessing
of the signing of consent form, after the
client acknowledges understanding the
procedures.
Content of the Informed Consent:
1. Patient’s full name
2. Surgeon’s name and signature
3. Specific procedure
4. The witness name with signature
5. Date of signatures
If the patient is not capable of signing the
following should sign:
1. A minor – a parent or guardian should sign.
2. An emancipated minor – married or
independently earning a living, he or she
may sign.
3. A minor who is the parent of an infant or
child who is having a procedure, he or she
may sign for his or her child.
4. Illiterate – he or she may sign with an x
after which the witness writes, “Patient’s
mark” because illiteracy implies the inability
to read and write, the patient should indicate
an understanding of a verbal explanation.
5. Unconscious patient – a responsible relative
or guardian should sign.
6. Mentally incompetent – the legal guardian
should sign. In absence the legal guardian
court order maybe necessary to legalize the
procedure.
7. An adult or an emancipated minor – who is
mentally incapacitated by alcohol or chemical
substance, spouse or relative of legal age
should sign, but if the procedure if not urgent
wait until patient regain mental competence.
8. Emergency situation – no relatives at all
patient is alone.
- if with telephone number contact the
guardian or relative over the phone then 2
witness should monitor the call and sign the
form.
2. Pre-operative Client Teaching:
a. Inform the client what to expect post-
operatively.
b. Inform the client to notify the nurse if any
pain is experienced post-operatively and that
pain medication will be prescribed to be
given as the client requests.
c. Inform the client that requesting narcotic
after surgery will not make the client a drug
addict.
d. Demonstrate the use of a client controlled
analgesia pump if its use is prescribed.
e. Instruct the client to use the non-invasive
pain relief technique such as:
1. relaxation
2. distraction technique
3. guided imagery
f. The client should be instructed not to smoke
for at least 24 hrs before the surgery.
g. Instruct the client on the following:
1. Deep breathing and coughing exercises
a. Instruct the client that a sitting position
gives the best lung expansion for coughing
and deep breathing exercises.
b. Instruct the client to breath deeply three
times, inhaling through the nostrils and
exhaling slowly through pursed lips.
c. Instruct the client that the 3rd breath
should be held for 3 seconds; then the client
should cough deeply 3 times.
d. The client should perform this exercise
every 2 hours.
- this prevent development of pneumonia
and atelectasis.
2. Incentive Spirometry
a. Instruct the client to assume a sitting
position.
b. Instruct the client to place the mouth
tightly around the mouthpiece.
c. Instruct the client to inhale slowly to raise
and maintain the flow rate indicator between
600 and 900 marks.
 d. Instruct the client to hold the breath for 5
seconds, and then to exhale through purse
lips.
e. Instruct the client to repeat this process
10x every hour.
- To prevent the development of pneumonia and
atelectasis.
Leg and Foot exercises:
a. Gastrocnemius (calf ) pumping – instruct
the client to move both ankles by pointing
the toes up and then down.
b. Quadriceps (thigh) setting – instruct the
client to press the back of the knees against
the bed, and then to relax the knees; this
contracts and relaxes the thigh and calf
muscle to prevent thrombus formation.
- if pain is felt positive for homan’s sign
(deep vein thrombosis).
c. Foot circles – instruct the client to rotate each
foot in a circle.
d. Hip and knee movements – instruct the
clients to flex the knee and thigh and to
strengthen the leg and hold the position for 5
seconds before lowering (not performed if
the client is having abdominal surgery or if
the client has a back problem.
3. Instruct the client on how to splint an
incision and to turn and reposition
Splinting the incision:
a. If the surgical incision is abdominal or
thoracic, instruct the client to place a pillow,
or hand with the other hand on top, over the
incisional area.
b. During deep breathing and coughing, the
client presses gently against the incisional
area to splint or support it.
4. Instruct the client not to pull on any of the
invasive devices as they will be removed as
soon as possible.
3. Physical preparations:
 NPO – to keep the stomach to reduce the
risk of vomiting and aspiration.
 Patient is allowed to rinse the mouth with
mouth wash and brush the teeth immediately
prior to surgery provided that she/he will not
swallow the water.
Minimum Fasting Period:
1. 2 hrs – General liquid and clear liquids.
2. 4 hrs – breast milk
3. 6 hrs – non – human milk like infant
formula
4. 6 hrs – light meal
5. 8 hrs – regular or heavy meals
PREPARATION ON THE DAY OF
SURGERY:
1. Hygiene – a basic measures that provide
additional comfort before surgery.
2. Hair and cosmetics – hairpins, clips, wigs,
lipstick, powder, blush and nail polish
should be removed to expose normal skin
color.
3. Removal of Prostheses – removed all
prostheses including partial or complete
dentures, artificial limbs, artificial eyes and
hearing aids.
4. Safeguarding valuables – nurses should
give them to the family members or secure
them for housekeeping.
5. Preparing the bowel and bladder – client
should void before surgery, if unable note at
the pre – operative checklist.
> indwelling catheter – maybe placed if the
surgery is long or the incision is in the lower
abdomen.
6. Pre – operative Vital signs – if it is
abnormal surgery may be postponed.
7. Documentation – medical records, consent,
pre – operative checklist and nurses notes.
8. Pre – operative medications – warn the
clients to expect drowsiness and dry mouth.
Purposes of Pre – operative Medications:
1. Provide analgesia
2. Prevent nausea and vomiting
3. Promote sedation and amnesia
4. Decrease anesthesia requirements
5. Facilitate induction of anesthesia
6. Relieve apprehension and anxiety
7. Prevent autonomic reflex response
8. Decreased respiratory and gastrointestinal
secretions.
 Oral medications 60 to 90 minutes before
the patient goes to OR.
 IM and SC 30 to 60 minutes before the
arrival at the OR ( minimally 20 minutes)
 IV medications are usually administered to
the patient after arrival in the pre – operative
holding area or operating room.
9. Latex Sensitivity/ Allergy:
> Most persons that are at risk include those
with genetic predisposition to latex allergy,
clients with urogenital abnormalities or
spinal cord injury, clients with history of
multiple surgeries, health care providers and
workers who manufactures rubber products.
Manifestations:
Mild (Urticaria)
 rashes, irregularly – shaped skin eruptions
with varying sizes and shapes; eruptions
have reddened margins and pale centers.
 Flat or raised red patches to vesicular,
scaling or bleeding erruptions, acute
dermatitis and rhinitis.
Severe:
> Flat or raised red patches to vesicular, scaling
or bleeding erruptions, acute dermatitis and
rhinitis.
> Generalized urticaria, edema, bronchospasm,
mucus hypersecretions.
It is recommended that the client with latex
allergy be scheduled as the first case of the
day in the operating room.
THANK YOU…..