PREOPERATIVE NURSING

Types of Surgery

 Surgical procedures are commonly group

according to:

 1. Purpose
 2. Degree of Urgency
 3. Degree of Risk
 Purpose
 1. Diagnostic – confirms or establishes a
diagnosis
Ex. Biopsy

 2. Pallative- Relieves or reduces pain or

symtoms of a disease, it does not
cure.
Ex. Resection of nerve roots
Purpose
 3. Ablative- removes a diseased body part
Ex. Removal of gallbladder(cholecystectomy)

 4. Constructive- restores function or appearance

that has been lost or reduced
Ex. Breast implant

 5. Transplant- replaces malfunctioning structures

Ex. Hip replacement, Kidney transplant
 Degree of Urgency
 1. Emergency surgery
- Is performed immediately to preserve function or the
life of the client
- Ex. Control of internal hemorrhage or repair a
fracture

 2. Elective surgery
-is performed when surgical intervention is the
preferred treatment for a condition that is not
imminently life threatening or improve the client’s
life.
Degree of Risk
 1. Major surgery- involves a high degree of risk
to the client.

- May be complicated or prolonged

- Large losses of blood may occur
- Vital organs may be involve
Ex. Organ transplant , open heart surgery, removal
of a kidney.
Degree of Risk

 2. Minor Surgery- normally involves little risk,

produces few complications and often
performed in a “day surgery”

Ex. Breast biopsy, removal of tonsils, knee

surgery
Phases of Peri-operative
period
 PRE- operative phase

 INTRA- operative phase

 POST- operative phase

PRE-Operative Phase
 Begins when the decision to have
surgery is made and ends when the
client is transferred to the operating
table
INTRA-Operative Phase

 Begins when the client is transferred

to the operating table and ends
when the client is admitted to the
post-anesthesia care unit
Post-operative Phase

 Begins with the admission of the

client to the PACU and ends when
healing is complete
Activities in the
PREOPERATIVE PHASE
 Assessing the client
 Ensure consent is signed
 Obtain nursing history, PE and lab exam
 Identifying potential or actual health
problems
 Providing pre-operative teaching
 Physical preparation
 Preoperative Medications
Assessing the client
NUTRITION
 Review the physician’s orders regarding the NPO
status before surgery
 Solid foods and liquids usually are withheld for 6 to
8 hours before general anesthesia and for 3 hours
before surgery with local anesthesia to avoid
aspiration
 Prepare to initiate an IV line and administer IV fluids
as prescribed
ELIMINATION
 If the client is to have intestinal or abdominal
surgery, an enema or laxative or both may be
prescribed the night before surgery
 The client should void immediately before surgery
 Prepare to insert a Foley catheter if ordered
 If Foley catheter is in place, it should be emptied
immediately before surgery, and the nurse should
document the amount and characteristics of the
urine
 Consent
 The surgeon is responsible for obtaining the
consent for surgery
 No sedation should be administered before
SIGNING the consent
 The nurse may serve as witness
 Minors may need a parent or legal guardian to
sign the consent form
 Older clients may need a legal guardian to sign
the consent form
PREOPERATIVE CLIENT TEACHING
 Inform the client about what to expect post-
operatively
 Inform the client to notify the nurse if the client
experiences any pain post-operatively and that pain
medication will be prescribed to be given as the
client requests
 Inform the client that requesting a narcotic after
surgery will not make the client a drug addict
 Demonstrate the use of a client-controlled
analgesia pump if its use is prescribed
 PREORATIVE CLIENT TEACHING

 Instruct the client to use non-invasive pain relief

techniques such as relaxation, distraction
techniques, and guided imagery before the pain
occurs and as soon as the pain is noticed

 Instruct the client not to smoke for at least 12-

24 hours before surgery
 Instruct the client in deep breathing and
coughing techniques, use of incentive
spirometry, and the importance of performing
the techniques post-operatively to prevent the
development of pneumonia and atelectasis

 Instruct the client in the leg and foot exercises to

prevent venous stasis of blood and facilitate
venous return.

 Instruct client how to splint an incision and to

turn and reposition
 Physical Preparation
 Skin preparation- the goal is to decrease bacteria
without compromising skin integrity.

 Prostheses- removes full or partial dentures

 Attire/Grooming- remove all make-up and nail

polish

 Care of valuables
Pre-op psychological
preparation
 Be alert to the client’s anxiety level
 Answer questions or concerns
 Allow time for privacy
 Pre-operative medications
Pre-op Drugs Example Purpose
Anti-anxiety Diazepam To decrease nervousness
Promote relaxation
Anti- Atropine Decreases secretions
cholinergic Prevent bradycardia
Muscle Succinylcholine To promote muscle
relaxant relaxation
Anti-emetic Promethazine To prevent nausea and
vomiting

Antibiotic Cephalosporin To prevent infection

 Pre-operative medications
Pre-op Drugs Example Purpose

Analgesics Meperidine To decrease pain and

decrease anesthetic dose

Anti-histamine Diphenhydramine To decrease occurrence

of allergy

H-2 Cimetidine To decrease gastric fluid

antagonist and acidity
 Pre-operative screening test
CBC Determine Hgb and Hct, infection
Blood type Determined in case of blood transfusion
Serum Evaluates the fluid and electrolyte
electrolytes status
FBS Evaluates diabetes mellitus
BUN, Creatinine Assess the renal function
ALT, AST, Evaluates the liver function
Bilirubin
Serum albumin Evaluates nutritional status
CXR and ECG Respiratory and Cardiac status
SURGICAL AREA

 Unrestricted zone- where street clothes are

allowed
 Semi-Restricted zone- scrub suit and caps
 Restricted zone- scrub clothes, shoe covers,
caps and mask are worn.
SURGICAL ASESPSIS

 Prevents contamination of surgical wounds

 It is the foundation of preventing surgical site
infection
Basic Guidelines for
Maintaining Surgical
Asepsis
 All material in contact with the surgical wound
and used within the sterile field must be sterile.
 Gowns of the surgical team are considered
sterile in front from the chest to the level of the
sterile field
 Sterile drapes are used to create a sterile field
 Items should be dispensed to a sterile field by
methods that preserve the sterility of the items
and the integrity of the sterile field.
 The mov’t of the surgical team are from sterile
to sterile areas and from unsterile to unsterile
areas
 Movement around a sterile field must not cause
contamination of the field
 Whenever a sterile barrier is breached, the area
is considered contaminated
 Every sterile field should be constantly
monitored and maintained.
Health Hazard Asso. With
the Surgical Env’t
 Laser Risks
 Exposure to Blood and Body fluids
 Latex Allergy
Functions of the nurse during OR
procedure
SCRUB NURSE Assists the surgeon
Maintains sterility
Handles instruments
Drapes patient
Counts sponges
Wears sterile gown, gloves
CIRCULATING Assists the Scrub nurse
NURSE Positions the patient for
surgery
Positions any equipments
Intra-operative phase
interventions
 Determine the type of surgery and
anesthesia used
 Position client appropriately for surgery
 Assist the surgeon as circulating or scrub
nurse
 Maintain the sterility of the surgical field
 Monitor for developing complications
 Physical Status
Classification System
 P1- A normally healthy patient
 P2- A patient w/ mild systemic dse.
 P3- A patient with severe systemic dse. That is
not incapacitating.
 P4- A patient with an incapacitating systemic
dse. That is a constant threat to life
 P5- A moribund patient who is not expected to
survive for 24 hrs. with or without operation
Objectives of Anesthesia
 To render the patient free of pain during the
operative procedure.

 To promote a relaxed state of mind and sense

of security in the patient
 Types of Anesthesia
 General anesthesia-
 Loss of all sensation and
consciousness

 Regional or Local anesthesia

 Loss of sensation in ONE area with
consciousness present
GENERAL Anesthesia
 Protective reflexes are lost
 Amnesia, analgesia and hypnosis
occur
 Administered in two ways:
 Inhalational – liquid ( ether, halothane,
isoflurane, enflurane)
- Gases ( nitrous oxide,
cyclopropane)
 Intravenous-brevital, surital, Penthotal
 4 Levels of Sedation and
Anesthesia
 Mild Sedation
 Is a drug-induced state during which the patient can
respond normally to verbal command.
 Ventilatory and Cardiovascular function are not affected
 Moderate Sedation
 Form of anesthesia that may be produced intravenously
 Depressed level of consciousness that does not impair the
patient’s ability to maintain a patent airway and to
respond appropriately to physical stimulation and verbal
command.
 Midazolam (Versed) and Diazepam (Valium) used
frequently for IV sedation
  Narcotic antagonist Naloxone (Narcan)
 Deep Sedation
 Drug-induced state during which a patient cannot be
easily aroused but can respond purposefully after
repeated stimulation
 N20- the most commonly used GAS anesthetic
 Anesthesia-
 State of narcosis (severe CNS depression produced
by pharmacologic agents), analgesia, relaxation and
reflex loss.
Stages I: Beginning of
Anesthesia
 Dizziness
 Feeling of detachment
 Ringing, roaring or buzzing in the ears
 Conscious
 Sense an ability to move the extremities easily
 Noises are exaggerated
 Low voices or minor sounds seem loud and
unreal
Stage II: Excitement

 Chrac. Variously by struggling, shouting,

talking, singing, laughing or crying
 Pupils dilated but reacts to light
 PR rapid
 RR irregular
 Uncontrolled movement of the patient during
this stage
Stage III: Surgical
Anesthesia (surgery is
permitted)

 Unconscious and lies quietly on the table

 Pupils are small but reacts to light
 PR and RR regular
 Skin is pink or slightly flushed
Stage IV: Medullary
depression
 Due to too much anesthesia has been
administered
 Respi. Shallow
 Pulse weak and thready
 Pupils dilated
 Cyanosis develops
 Death rapidly follows
 REGIONAL Anesthesia
TOPICAL Applied directly on the skin

INFILTRATION Injected into a specific area of

skin
NERVE BLOCK Injected around a nerve

SPINAL Low spinal anesthesia

Subarachnoid
EPIDURAL Epidural space is injected with
anesthesia
Potential Intraoperative
Complication
 Nausea and Vomiting
 Anaphylaxis
 Hypoxia and other Respiratory complication
 Hypothermia
 Malignant hyperthermia
 DIC
Dismissal of the client
from PACU
5 Parameters

1. Activity- can move 4 extremities

2. Respiration- can deep breath and cough
3. Circulation- less than 20 to more than 20
beats of preanesthetic level
4. Consciousness- fully awake
5. Color- pink
Position Patient during
Surgery
Abdominal surgeries Supine

Bladder surgery Slightly trendelenburg

Perineal surgery Lithotomy

Brain surgery Semi-fowler’s

Spinal cord surgeries Prone mostly

Lumbar puncture Side lying, flexed body

Postoperative care

 Objective:
- To assist the patient in recovering from
operation and from the effects of the
anesthetic agent as quickly, safely and
comfortably as possible.
 POST Operative
Interventions
 Maintain patent airway
 Monitor vital signs and note for early
manifestations of complications
 Monitor level of consciousness
 Maintain on PROPER position
 NPO until fully awake, with passage of
flatus and (+) gag reflex
 POST Operative
Interventions
 Monitor the patency of the drainage
 Maintain intake and output monitoring
 Care of the tubes, drains and wound
 Ensure safety by side rails up
 Pain medication given as ordered
 Measures to PREVENT post-op
Complications
Post-operative
interventions
PAIN MANAGEMENT
 Pain is usually greatest during the 12-36
hours after surgery
 Narcotic analgesics and NSAIDS may be
prescribed together for the early period of
surgery
 Provide back rub, massage, diversional
activities, position changes
Post operative
interventions
POSITIONING
 Clients who have spinal anesthesia is
usually placed FLAT on bed for 8-12 hours
 Unconscious client is placed side lying to
drain secretions
 Other positions are utilized BASED on the
type of surgery
Post-operative Interventions
Some Examples of Position Post
Op
Mastectomy Semi-fowlers’, affected
arm elevated
Thyroidectomy Semi fowlers’ , head
midline
Hemorrhoidectomy Semi-prone, side-lying

Laryngectomy Fowler’s

Pneumonectomy Lateral, affected side

Lobectomy Lateral, unaffected

side
 Post-operative Interventions
Some Examples of Position Post
Op
Aneurysmal repair Fowler’s 45 degrees
(abdomen)
Amputation of lower Flat, with stump
extremities elevated with pillow
Cataract surgery Fowler’s 45 degrees

Supratentorial Folwers’
craniotomy
Infratentorial Flat on bed, supine
craniotomy
Spina bifida repair Prone
 Post-operative
Interventions
 Deep breathing and coughing
exercises Q2 hours  to remove
secretions
 Leg exercises Q 2 hours  to promote
circulation
 Ambulation ASAP prevents
respiratory, circulatory, urinary and
gastrointestinal complications
 Post-operative
Interventions
 Hydration after NPO to maintain
fluid balance
 Suction, either gastro or respiratory
to relieve distention, to remove respi
secretions
 Diet progressive, usually given when
bowel sounds and gag reflex return
Wound Care

 Inspect dressing hourly

 Change dressing daily
 Inspect for signs of infection
redness, swelling, purulent exudate
 Maintain wound drainage
Diet

 NPO usually immediately after surgery

 Progressive diet

 Assess the return of the bowel sounds

Liquid Diet Vs Soft diet
Clear liquid Full liquid Soft diet
Coffee Clear liquid PLUS: All CL and FL
Tea Milk/Milk prod plus:
Carbonated Vegetable juices Meat
drink Cream, butter Vegetables
Bouillon Yogurt Fruits
Clear fruit Puddings Breads and
juice cereals
Custard
Popsicle Pureed foods
Ice cream and
Gelatin sherbet
Hard candy
Urinary Elimination

 Offer bedpans
 Allow patient to stand at the bedside
commode if allowed
 Report to surgeon if NO URINE output
noted within 8 hours post-op
Post operative complications
Atelectasis Collapsed Assess breath
alveoli due to sounds
secretions Repositioning
Deep breathing
and coughing
Pneumonia Inflammation Chest physio
of alveoli Suctioning
Ambulation
Thrombophlebitis Inflammation Leg exercises
of the veins Monitor for
swelling
Elevated
extremities
Post-operative Complications
Hypovolemic Loss of Shock position
Shock circulatory Determine cause and
fluid volume prevent bleeding
O2, IVF

Urinary Involuntary Encourage ambulation

retention accumulation Provide privacy
of urine Pour warm water
Catheterize
Pulmonary Embolus Notify physician
embolism blocking the Administer O2w
lung blood
flow
Post-operative complications
Constipation Infrequent High fiber diet
passage of Increased fluid
stool Ambulation

Paralytic ileus Absent bowel Encourage

sound ambulation
NPO until
peristalsis returns
Wound Occurs about Daily wound
infection 3 days after dressing
surgery Antibiotics
Maintain drain
Post-operative complications
Wound Separation of Cover the wound
dehiscence wound edges at with sterile normal
the suture line saline dressing
Place in low-
Fowler’s
Notify MD
Wound Protrusion of Cover the wound
evisceration the internal with saline pad
organs and Place in low-
tissues through fowler’s
wound Notify MD
To emphasize

 The over-all goal of nursing care during the

PRE-OPERATIVE phase is to prepare the
patient mentally and physically for the
surgery
To emphasize

 The over-all goal of nursing care during the

INTRA-OPERATIVE phase is to maintain
client safety
To emphasize

 The over-all goals of nursing care during the

POST-OPERATIVE phase are to promote
healing and comfort, restore the highest
possible wellness and prevent associated
risk