PERI-OPERATIVE NURSING

UNIVERISTY OF NORTH FLORIDA

SCHOOL OF NURSING
M. Catherine Hough, PhD, RN, Associate Professor
Linda K. Connelly, ARNP, MSN, CNOR
Introduction to Perioperative Nursing

Phases of Perioperative Care

Pre Operative - begins with the patients decision to have

surgery, ends with entry into the operating room

Intra Operative - begins with entry into the operating room and
ends with admission to the recovery room

Post Operative - begins with admission to recovery room, and

ends with discharge from care (varies but usually 6 weeks post
op) by physician
PERIOPERATIVE NURSING
Informed Consent
 Pre-Operative

Responsibilities of Operating Room Nurse:

Patient Assessment

Physical Problems

Emotional Aspects

Understanding of surgery/consent

Legal requirements for chart completion

Read and interpret lab results

PeriOperative Teaching
 PREOPERATIVE NURSING
CONSIDERATIONS
COMPLETE PHYSICAL ASSESSMENT
Physical & psychological needs
Medical & surgical history
Completion of required documents

DETERMINE READINESS & MODE OF

TRANSPORTATION TO OR

ACCESS HEALTH CARE TEAM AVAILABILITY

Surgeon
Anesthesia personnel
Circulating nurse
Scrub person
Other personnel
 PRE-OP MEDS
Pharmacologic preparation as necessary &
psychological support
Facilitates induction of anesthesia & reduces
anesthetic requirement
Determinants of drug choice
Age
Weight
Level of anxiety
Drug allergies
Inpatient/outpatient
Timing of administration
 PREOPERATIVE NURSING
CONSIDERATIONS
COMPLETE PHYSICAL ASSESSMENT
Physical & psychological needs
Medical & surgical history
Completion of required documents

DETERMINE READINESS & MODE OF

TRANSPORTATION TO OR

ACCESS HEALTH CARE TEAM AVAILABILITY

Surgeon
Anesthesia personnel
Circulating nurse
Scrub person
Other personnel
Intra-Operative

Provide for quiet environment during induction

Assist during intubation
Observe aseptic technique
Safe operation of equipment (lasers, electrosurgery unit)
Position patient safely - CV, nervous, respiratory system
Document events, patient care given,
Provide all supplies, equipment, to team during surgery
Provide for a safe transfer to recovery room
Unsterile Team Member - Circulating Nurse

Responsible for nursing care in the operating room

Responsible for the organization of the workload
Responsible for the maintenance of policy and
procedures
Responsible for signing and documentation
The Circulating Nurse is the professional staff
member in the operating room, representing the
patient (Patient Advocate) and the hospital
administration
Surgical Nurse 1889
A level head & keen eyes, ever watchful for all
that may be required, a mind not easily
irritated or confused, combined with the facility
of keeping out of the way & still being of the
greatest help..Thoroughness, speed,
gentleness especially fit the surgical nurse.

(Asepsis for the Nurse, Clemons, 1889)

1945
Discussion of the role of the OR Nurse
In charge of the operating room, taking care of the
needs of the room assigned to her. It is her
responsibility to watch the aseptic technique of her
team.

A surgery nurse must have many good qualities; but

first of all, she must be conscientious of sterile
technique. Speed & efficiency are of no avail if a
surgical wound breaks down due to an infection
received in the OR.

Crawford, 1945
 SCRUB PERSON

May be a: Duties:
Usually confined to

RN the intraoperative
phase of the
LPN
patients surgical
Surgical Tech experience, may also
be involved in
gathering surgical
supplies &
equipment
SCRUB NURSE
The nurse who is the immediate
assistant to the surgeon is often called
the scrub or sterile nurse. She first
scrubs her hands and arms the required
length of time, puts on sterile gown &
gloves, and handles only sterile
material.

Crawford 1945
SCENARIO #1
A. Smith, RN & D Jones, RN are assigned to scrub &
circulate for a 0800 gastrostomy on WW, a 79 year
old emaciated male. Since his hospitalization 3 days
ago, he has managed to remove his IV and NG tube
several times. Consequently he has been restrained
even on the stretcher during his transport to the OR.
His medical DX is chronic alcoholism with dementia.
WW seems to acknowledge D Joness presence with
a half glance, however he will not respond to the
anesthesia providers questions. WW is supported
on the stretcher in a semi-flowers position with
several pillows. Further assessment reveals that WW
has contractures of his hips and knees.
SURGICAL POSITIONING
Facilitated through the nursing process
Patients body must remain in physiologic alignment

Dependent Upon:
The surgical procedure
Exposure at the surgical field
Surgeons preference and idiosyncrasies
Patients condition

Special Considerations:
Geriatric patients
Obese patients
Malnourished patients
 SURGICAL POSITIONING
EQUIPMENT

Pillow or headrest Padded Shoulder

Arm boards braces
Safety belt/strap Stirrups (candy canes,
Allen, or knee)
Footboard
Laminectomy Frame
Padding
Gel pads
Olympic vac pac
Egg crate (suction beanbag)
Donut rolls 3 adhesive tape
Foam
POSITIONING DEVICES
SCENARIO #2
WH is a 36 year old black male who had been scheduled
for a hemorrhoidectomy on an outpatient basis. He is 5
11tall and weighs 250 lbs. His HBG is low (12g/dL)
secondary to rectal bleeding. WH has a HX of asthma
since age 5. He has episodes of difficulty breathing
6X/year, treated with an inhaler at the time of each
episode. He does not smoke; ETOH 2 glasses of beer per
week. WHs current BP is 138/96, which he controls by
taking a daily antihypertensive med. WH is a high school
teacher. He spends most of his days standing and
occasionally sitting. His evenings and weekend are spent
working on a masters degree in education. He does not
participate in a regular exercise program.
SETTINGS:

Ambulatory Surgery - In and Out in same

day
Pre-op teaching
T&A, Cyst removal, D&C, Cataract removal
with lens implants, Biopsy
Heart cath
scopes
SETTINGS

Same Day General Surgery - Admitted to

inpatient unit or special same day surgery unit
Pre-Op teaching prior to day of
surgery
Nurses especially trained in Pre-Op

assessment (Hysterectomy, Lap

Chole, Appendectomy, Mastectomy,
C-Section)
SETTINGS

Main OR Surgery - Patient admitted to hospital prior

to surgery OR DAY OF SURGERY

Prep and assessment and teaching done in

hospital
Patient stays @ least overnight, and rehab
begins before discharge
Major heart surgery such as CABGs, Bowel
Resections, Large tumor removal or Brain
surgery
PURPOSE of SURGERY
Diagnostic - Determines cause of symptoms (Exploratory
laparotomy and biopsy)
Curative - Removal of diseased part (Appendectomy, Ovarian
Cyst, Cancerous Tumors)
Restorative or Reconstructive - Strengthens a weakened part
(Herniorrhaphy or cervical rings) rejoins disconnected areas
(orthopedic surgeries), corrects deformities, (MVR, joint
replacement, etc)
Palliative - Relieves symptoms without curing (some lower back
surgeries, tumorectomies)
Cosmetic - Repairing a burn scar or changing breast shape,
altering physical appearance
Patients @ High risk for Complications

Smokers UTI
Obese Diabetes
Chronic Lung Diseases Poor Nutritional Status
Elderly Dehydration
HTN Heart Disease
Thoracic or Abdominal Self-fulfilling Prophecy
Surgeries Inhalant Anesthesia
Immobilizing Surgery
 PREVENTING COMPLICATIONS

DVT, UTI, Aspiration,

Wound Infection, Shock, Constipation

Identify those @ risk

Provide adequate hydration/nutrition
NPO after MN
Leg exercises
Breathing exercises and IS
I&O
Preventing Complications

Splint Incision to cough

Anticoagulant Therapy - Heparin
Ambulate and OOB to BRP - ASAP
Discourage smoking
Fluid and fiber ASAP, laxatives. Enemas
Clean Hands
Instruct in proper wound care
Sterile bowel prep and skin prep
Sleep/Rest
PREPPING THE PATIENT

TEACHING
Name and purpose of the surgery
NPO after MN and why early awakening, shower,
remove all jewelry, makeup, etc
Anesthesia, Cold Room, Smells, Drowsy Feeling
Recovery Room
Post-op care - TCDB, leg exercises, pain
management, DVT< OOB ASAP
Begin discharge planning
 WAYS TO DECREASE ANXIETY

COMMUNICATION
Early teaching and counseling
Diversional activities
Encourage family support
Encourage verbalization of fears/loss of control
Deep breathing, medications, imagery, music
 Ways to Decrease Anxiety

Spiritual support (communion, bible reading,

prayers, rituals, chants)
Inform family where to wait, buy food,
bathroom, phone, overnight and visiting
policy
Possible use of sedative or tranquilizer or
PRN medications
Dolls/favorite toy for children
 NURSING ASSESSMENT

Assessment Data Base - vital signs, weight,

height
Review of Systems
Past history of illnesses (i.e. HTN, pneumonia)
that may predispose client to complications
Past experience with hospitalization or surgery
Allergies to medications or foods, tapes, surgical
scrubs
 Nursing Assessment

Intellectual ability to understand teaching

Language differences, social, spiritual or cultural
considerations, anxiety level
Labs: CBC; U/A; Chemistry (electrolytes:
K,CL,NA,CA,BS,BUN,Creatine), total bilirubin,
albumin, alkaline phosphatase, SGOT, HCO3, HIV,
Pregnancy
Other: Chest X-Ray, EKG if > 40 years old
 PRE-OP NURSING DIAGNOSES

Knowledge Deficit R/T Unfamiliar Planned or

Unplanned Surgery

Ineffective individual or family coping R/T Unfamiliar

Planned or Unplanned Surgery

Anticipatory Grieving R/T Potential for Loss of Life or

Body Part
NURSING RESPONSIBLITIES

Informed Consent Form/Patient Advocacy

Secure personal belongings: Dentures, glasses,
rings, money
Administration of pre-op medications on call to
OR - i.e. Demerol, Valium, Atropine
Complete Pre-op Checklist @ clinical site -
remove hair pins, loose teeth, dentures, nail
polish, bath, urinate, NPO, VS taken within 15
minutes of going to OR, Ted Hose or compression
devices
 NURSING RESPONSIBLITIES ...

Report anything of note that needs to be brought to the attention

of the anesthesiologist, surgeon, or OR nurse
low potassium,
fever,
arrthymias,
loose teeth,
chest pain, or
anything unusual
Assure patient has ID bracelet on; Send current chart and any
old medical records with the patient;
EVALUATE patients level of understanding, physical stability,
emotionally prepared, fulfilled hospital pre-op policies
 TYPES OF SURGERY

MAJOR -- Present a real threat to life

MINOR -- Present little threat to life

NOTE: **** All patients consider their

surgery a major thing ****
 BLOODLESS SURGERY
a term that has evolved in the medical
literature to refer to a perioperative team
approach to avoid allogeneic transfusions
and improve patient outcomes

utilizing combinations of the numerous blood

conservation techniques and transfusion
alternatives available
BENEFITS OF BLOODLESS SURGERY

Decreased costs Promotes better quality

Less risk for blood patient care
contamination for At times decreased
patients death rate
Reduce risk of post op Can decrease time
fevers and infections spent in ICU
usually associated with
blood transfusions
Catastrophic Events in the OR

Anticipated:
Anticipated
Cardiac Arrest in an unstable patient

Massive Blood Loss - during trauma surgery

Loss of ability to ventilate a patient

Catastrophic Events in OR ...

Unanticipated:
Latex Allergy Reaction - reactions can range from
urticaria to anaphylaxis

Maligant Hyperthermia - rare, life-threatening

disorder that can be triggered by anesthesia drugs -
Is an autosomal dominant trait
 Peri-Operative Standards of Care (example)

All Policy & Procedures of the medical and surgical nursing division
will be followed.
Patients shall ALWAYS wear a legible identification band
Operative permit(s) must be signed and witnessed according to
hospital policy, The procedure documented on the operative permit
MUST MATCH what is scheduled on the OR schedule
The history and physical shall be completed according to policy and
be part of the medical record prior to surgery
All ordered lab work shall be collected and results placed in the
medical record in accordance with the physicians orders
Dentures, hairpins, jewelry, wigs, contact lenses, nail polish, make-up
and prosthesis shall be removed as requested by the physician
Any jewelry not removed shall be secured with tape and documented
as such
 Peri-Operative Standards of Care

Pre-operative skin prep shall be done without abrading, cutting or

irritating the patients skin
Patient privacy shall be provided at all times
Any pre-operative drainage tubes shall be placed without tissue trauma
and be completed utilizing sterile techniques when indicated
All IV infusions shall be monitored to maintain the appropriate flow rate
and type of solution and remain patent without signs of inflammation or
swelling
The patient shall be provided emotional and educational support to
reduce pre-operative anxiety
The patients shall be provided a safe and normothermic environment in
the pre-op waiting area
The patient shall be transferred safely to the OR table and safety straps
appropriately applied
 Expected Outcomes:
Demonstrate knowledge of physiologic & psychological
responses to surgical intervention
Absence of infection
Maintenance of skin integrity
Freedom from injury R/T positioning, equipment
Maintenance of fluid and electrolyte balance
Satisfaction with pain relief
Participation in the rehab process
 AORN a tradition of excellence

Formally organized between 1949 1954

A professional organization of periOperative

registered nurses whose mission is to provide quality
patient care by providing its members with education,
standards, services and representation.

Membership 340 chapters, 12 specialty assemblies,

25 state councils and 41,000 members
PERIOPERATIVE NURSING

If you or your family came

through surgery in good shape,
thank a perioperative nurse.
 If someone listens, or stretches out a
hand, or whispers a kind word of
encouragement, or attempts to
understand a lonely person, extraordinary
things begin to happen

Loretta Gizarlis (1920)

American writer and educator