Perioperative Nursing

Definition of Surgery

Surgery is any procedure performed

on the human body that uses
instruments to alter tissue or organ
integrity.
integrity

Perioperative Nursing
Perioperative NursingNursing

connotes the delivery of patient

care in the preoperative,intraoperative, and
postoperative periods of the patients surgical experience
through the framework of the nursing process. The nurse
assesses the patient- collecting,organizing, and
prioritizing patient data; establishing nursing
diagnosis;identifies desired patient outcomes;develop
and implements a plan of care; and evaluates that care in
terms of outcomes achieved by the patient.

Perioperative Nursing
Phases
Preoperative phase

begins when the decision

to have surgery is made and ends when the
client is transferred to the OR table.
Intraoperative phase begins when the client
is transferred to the OR table and ends when
the client is admitted to the PACU.
Postoperative phase - begins with the
admission of the client to the PACU and ends
when the healing is complete.

Perioperative Nursing
Types of Surgery
Purpose/reasons

Degree of urgency necessity to preserve

the clients life, body part, or body function.
Degree of risk involved in surgical
procedure is affected by the clients age,
general health, nutritional status, use of
medications, and mental status.
Extent of surgery Simple and radical

Perioperative Nursing
Type of Surgery (Purpose)
Diagnostic-Allows
Diagnostic

to confirm or establishes diagnosis.

CorrectiveCorrective Excision or removal of diseased body part.
Reconstructive-Restore
function or appearance to
Reconstructive
traumatized or malfunctioning tissues.
Ablative Removes a diseased body parts
Palliative Relieves or reduces pain or symptoms of a
disease; it does not cure
Transplant Replaces malfunctioning structures
CosmeticCosmetic Performed to improve personal appearance.

Perioperative Nursing
Types of Surgery (Urgency)
Emergency- performed

immediately to preserve
function or the life of the client.
Elective is performed when surgical intervention
is the preferred treatment for a condition that is not
imminently life threatening or to improve the clients
life.
Urgent Necessary for client health to prevent
additional problem from developing; not necessarily
an emergency.
Required has to be performed at some point; can
be pre-scheduled.

Perioperative Nursing
Type of Surgery (Degree of Risk)
Major

involves a high degree of risk.

Minor normally involves little risk.
Age very young and elder clients are greater
surgical risks than children and adult.
General healthhealth surgery is least risky when the
clients general health is good.
Nutritional Status required for normal tissue repair.
Medications regular use of certain medications can
increase surgical risk.
Mental status disorder that affect cognitive
function

Perioperative Nursing
Surgical settings
Surgical suites
Ambulatory care setting
Clinics
Physician offices
Community setting
Homes

Perioperative Nursing
Surgical settings
Disadvantages

Less time for rapport

Less time to assess, evaluation, teach
Risk of potential complication post D/C.
Advantages of outpatient:
outpatient
Low cost
Low risk of infection
Less interruption of routine
Less than from work
Less stress

Preoperative Nursing
Consent
Nature and intention of the surgery
Name and qualifications of the person

performing the surgery.

Risks, including tissue damage, disfigurement,
or even death
Chances of success
Possible alternative measures
The right of the client to refuse consent or later
withdraw consent.

Preoperative Nursing
Assessment (Nursing History)
Current health status Allergies
Medications- list all current medications
Previous surgeries
Understanding of the surgical procedure and

anesthesia
Smoking
Alcohol and other-altering substances
Coping
Social resources
Cultural considerations

Preoperative Nursing Care

Physical assessment
Cardiovascular

system
Respiratory system
Renal system
Neurological system
Musculoskeletal system
Nutritional status
Gerontological considerations

Perioperative Nursing Care

Physical assessment/clinical manifestations

General surveysurvey

gestures and body movements

may reflect decreased energy or weakness
caused by illness.
Cardiovascular systemsystem alterations in cardiac
status are responsible for as many as 30% of
perioperative death.
Respiratory systemsystem a decline in ventilatory
function, assessed through breathing pattern
and chest excursion, may indicate a clients risk
for respiratory complications.

Perioperative Nursing Care

Physical assessment/clinical manifestations

Renal system-abnormal
system

renal function
can altered fluid and electrolyte balance
and decrease the excretion of preoperative
medications and anesthetic agents.
Neurologic systemsystem a clients LOC will
change as a result of general anesthesia
but should return to the preoperative LOC
after surgery.

Perioperative Nursing Care

Physical assessment/clinical manifestations

Musculoskeletal

systemsystem Deformities may interfere

with intraoperative and postoperative positioning.
Avoid positioning over an area where the the skin
shows signs of pressure over bony prominences.
Gastrointestinal systemsystem alteration in function
after surgery may result in decreased or absent
bowel sound and distention.
Head and NeckNeck the condition of oral mucous
membranes reveals the level of hydration.

Preoperative Nursing Care

Gerontological Considerations
Cardiovascular

Coronary flow decreases

Heart rate decreases
Response to stress decreases
Peripheral vascular decreases
Cardiac output decreases
Cardiac reserve decreases

Preoperative Nursing Care

Gerontological Considerations

Respiratory System

Static lung volumes decreases

Pulmonary static recoil decreases
Sensitivity of the airway receptors
decreases
Nervous system
Increased incidence of post.op. confusion.
Increased incidence of delirium
Increased sensitivity to anesthetic agents

Preoperative Nursing Care

Gerontological Considerations

Renal System

Renal blood flow

declines 1.5% per year. Renal clearance
reduced
Gastrointestinal Decreased intestinal
motility
Decreased liver blood flow
Delayed
gastric emptying

Preoperative Nursing Care

Gerontological Considerations

Musculoskeletal

Decreased mass, tone, strength

Decreased bone density
Integumentary

Decreased elasticity
Decreased lean body mass
Decreased subcutaneous fat

Preoperative Nursing Care

Psychosocial considerations
Level of anxiety
Coping ability
Support systems

Preoperative Nursing Care

Laboratory and diagnostic studies

Screening

tests depend on the condition of

the client and the nature of the surgery. If
test reveals severe problems the surgery
may be cancel until the condition is
stabilized.
Routine screening test-CBC,Blood
grouping
test
and X-match, Lytes, fasting blood sugar,
BUN & Creatinine, ALT,AST, and
bilirubin,Serum albumin, and Total protein,
Urinalysis, Chest X-ray,ECG

Preoperative Nursing Care

Common nursing diagnosis
Knowledge deficit
Anxiety
Risk for ineffective airway clearance
Fear related to
Disturbed sleep pattern
Anticipatory grieving related to

Preoperative Nursing Care

Preop. teaching
The education plan should begin with assessment,

including baseline knowledge of the patient and

family, readiness to learn,barriers to learning,
patient and family concern and learning styles and
preferences.
The content focuses on information that will
increase patients familiarity with procedural events.
This includes surgical experience (procedural), what
the pt. may experience (sensory) and what actions
may help decrease anxiety (behavioral).

Preoperative Nursing Care

Anxiety
The nurse must consider the pts family

and friends when planning

psychological support.
Empowering their sense of control.
Activities that decreasing anxiety are
deep breathing, relaxation exercises,
music therapy, massage and animalassisted therapy.
Use of medication to relieve anxiety .

Preoperative Nursing Care

Preanesthesia Management Physical Status Categories
ASA

1: Healthy patient with no disease

ASA 11: Mild systemic ds without fx limitations
ASA 111:Severe systemic ds associated with definite fx
limitations
ASA 1V: Severe systemic ds that is a constant threat to
life.
ASA V: Moribund pt. Who is not expected to survive
without the operation.
ASA V1: A declared brain-death whose organ are being
recovered for donor.
E: Emergency

Preoperative Nursing Care

Final Preparation for surgery
All personal belongings are identified

and secured.
Jewelry is usually removed.
Dentures are removed, labeled and
placed in a denture cup.
Pt. to verbally confirm the surgical
procedures and the surgical site. This
verification process is documented in
the medical record on the preop.
checklist.

Preoperative Nursing Care

Pre-op. medications

Prior to administering check permits

Purpose: Allay anxiety

Decrease pharyngeal secretionsDecrease gastric secretion.

Decrease side effects of anesthesia.
Induce amnesia

Preoperative Nursing Care

Medications
Sedatives/hypnotics-

Nembutal
Tranquilizers-Ativan, versed, valium
Opiate analgesics- Demerol, morphine
Anticholinergics-Atropine
sulfate,atarax
H2o blockers.- Tagamet, Zantac
Antiemetic- Reglan, Phenergan

Intraoperative Phase
Surgical Team

Surgeon
Anesthesiologist
Scrub Nurse
Circulating Nurse
OR techs

Intraoperative Nursing Care

Roles of team members
SurgeonSurgeon responsible for determining the

preoperative diagnosis, the choice and execution of

the surgical procedure, the explanation of the risks
and benefits, obtaining inform consent and the
postoperative management of the patients care.
Scrub nurse- (RN or Scrub tech)- preparation of
supplies and equipment on the sterile field;
maintenance of pt.s safety and integrity: observation
of the scrubbed team for breaks in the sterile fields;
provision of appropriate sterile instrumentation,
sutures, and supplies; sharps count.

Perioperative Nursing Care

Surgical team
Circulating Nurse - responsible for creating a

safe environment, managing the activities

outside the sterile field, providing nursing care to
the patient. Documenting intraoperative nursing
care and ensuring surgical specimens are
identified and place in the right media. In charge
of the instrument and sharps count and
communicating relevant information to individual
outside of the OR, such as family members.
members

Perioperative Nursing Care

Surgical team
Anesthesiologist and anesthetist-

anesthetizing the pt. providing

appropriate levels of pain relief,
monitoring the pts physiologic status
and providing the best operative
conditions for the surgeons.
Other personnel- pathologist,
radiologist, perfusionist, EVS personnel.

Perioperative Nursing Care

Surgical team
Nursing Roles:
Staff education
Client/family teaching
Support and reassurance
Advocacy
Control of the environment
Provision of resources
Maintenance of asepsis
Monitoring of physiologic and psychological
status

Intraoperative Nursing Care

Surgical asepsis

Ensure

sterility
Alert for breaks

Intraoperative Phase
Anesthesia
Greek word- anesthesis, meaning
negative sensation. Artificially induced
state of partial or total loss of sensation,
occurring with or without consciousness.

Blocks transmission of nerve impulses

Suppress reflexes
Promotes muscle relaxation
Controlled level of unconsciousness

Intraoperative Phase
Anesthesia
Factors influencing dosage and type:

1. Type

and duration of the procedure

2. Area of the body being operated on
3. Whether the procedure is an emergency
4. Options of management of post. Op. pain
5. How long it has been since the client ate,
had any liquids, or any medications
6. Client position for the surgical procedures

Intraoperative Phase
Types of Anesthesia
General-

method use when the surgery

requires that the patient be unconscious
and/or paralyzed.
A general anesthetic acts by blocking
awareness centers in the brain so that
amnesia (loss of memory), analgesia
(insensibility to pain), hypnosis (artificial
sleep), and relaxation (rendering a part of the
body less tense) occur.

Intraoperative Phase
Stages of General Anesthesia
Stage

1- Analgesia and sedation, relaxation

Stage 2- Excitement, delirium
Stage 3- Operative anesthesia, surgical
anesthesia
Stage 4- Danger

Intraoperative Phase

Complications of General Anesthesia

Overdose
Hypoventilation
Related to anesthetic agents
Malignant hyperthermia
Related to intubation

Intraoperative Phase
Local or Regional Anesthesia
Temporarily interrupts the transmission of
sensory nerve impulses from a specific area or
region.

Motor function may or may not be affected

Client does not lose consciousness
Gag reflex remains intact
Supplemented with sedatives, opioids, or
hypnotics

Types of Regional Anesthesia

Topical (surface)
Local
Nerve Block
Intravenous (Bier Block)
Spinal
Epidural (peridural)

Intraoperative Phase

Complications of Local/Regional
Anesthesia

Anaphylaxis
Administration technique
Systemic absorption
Overdosage

Spinal Anesthesia
Indications

-surgical procedures below the

diaphragm
-patients with cardiac or respiratory disease
Advantages -mental status monitoring -shorter
recovery
Disadvantages
-necessary extra expertise possible patient pain
Contraindications -coagulopathy -uncorrected
hypovolemia

Spinal Anesthesia
Involved

medications
-lidocaine
-bupivacaine
-tetracaine
Patient assessment
-continuous heart rate, rhythm, and
pulse oximetry monitoring
-level of anesthesia
-motor function and sensation return
monitoring

Spinal Anesthesia
Complications

-hypotension
-bradycardia
-urine retention
-postural puncture headache
-back pain

Spinal analgesia
Indications

-postoperative pain from

major surgery
Involved medications -lipid-soluble
drugs -preservative-free morphine
Monitoring recovery -respiratory
depression -urine depression pruritus
-nausea and vomiting

Examples of location for Spinal and

Epidural Anesthesia.

Nerve Block Sites

Intraoperative Phase
Conscious Sedation

Administration of IV sedative, hypnotic, and

opioid medications.

Produces a depressed level of consciousness

Retains ability to maintain a patent airway
Able to respond to verbal commands or
physical stimulation
Used for relatively short procedures

Postoperative Nursing Care

Nursing assessment in the PACU

Vital

signs- presence of artificial airway, 02

sat,BP,pulse, temperature.
LOC- ability to follow command, pupillary
response
Urinary output
Skin integrity
Pain
Condition of surgical wound
Presence of IV lines
Position of patient

Postoperative Nursing Care

Nursing Diagnosis

Ineffective

airway clearance- increased

secretions 2 to anesthesia, ineffective
cough, pain
Ineffective breathing pattern- anesthetic
and drug effects, incisional pain
Acute pain
Urinary retention
Risk for infection

Postoperative Phase
Assessment of the Postanesthesia Client

Airway
Vital signs
Cardiac monitoring
Peripheral vascular assessment
Level of consciousness (LOC)
Fluid and electrolytes
GI system
Integumentary system
Discomfort/pain

Perioperative Nursing Care

Postoperative Management

Maintain

a patent airway
Stabilize vital signs
Ensure patient safety
Provide pain
Recognize & manage complications

Postoperative Nursing Care

When caring for post-surgical patient, think of the
4 Ws

Wind:

prevent respiratory
complications
Wound: prevent infection
Water: monitor I & O
Walk: prevent thrombophlebitis

Postoperative Phase

Complications
Respiratory-

atelectasis, pulm. Embolus

Cardiovascular- venous thrombosis
Gastrointestinal-Hiccoughs, N/V,abd.
Distention, paralytic ileus, stress ulcer.
GU- urinary retention
Hemorrhage-slipping of a ligature(suture)
Wound infection Wound dehiscence and evisceration-

Dehiscence
Partial or complete separation of the

outer layer of the wound.

Possible causes:
Poor suturing technique
Distention
Excessive vomiting
Excessive coughing
Dehydration
Infection

Evisceration
Total

separation of the layers & protrusion of internal

organs or viscera through the open wound.
Causes: same as dehiscence
Treatment:
Call for help
Cover with sterile NS soaked gauze/towels
Keep moist
DO NOT ATTEMPTS TO REINSERT ORGANS.
Keep in supine position with knees/hips bent
Assessment/VS q 5 min. until MD arrive
Prepare for surgery.

Postoperative Phase

Postoperative Phase

Postoperative Nursing Care

Gerontologic considerations

Mental

status- attributed to medications,

pain, anxiety, depression.
Delirium- infection, malignancy, trauma,
MI, CHF, opioid use.
Dementia-sundowning-sleep
disturbances, lack of structure in the
afternoon or early morning, sleep apnea.