Peri-operative

Nursing Care
53081 SN2123

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Learning Outcomes (pre-operation)
n Define different phases of perioperative period.
n Describe the classification for surgical procedure based on
degree of urgency, degree of risk and purpose.
n Identify essential aspects of preoperative assessment.
n Give examples of pertinent nursing diagnoses for surgical
clients.
n Identify nursing responsibilities in planning and prioritizing of
preoperative nursing care.
n Describe essential aspects of preparing a client for surgery,
including informed consent and skin preparation.
n Describe essential preoperative teaching, including pain
control, moving, leg exercises, and coughing and deep-
breathing exercises.
n Name three types of medication that may be prescribed
preoperatively, and the desired effects of each.
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Learning Outcomes (intra- and post-
operation)
n State the priorities in a patient’s preparation for emergency
surgery.
n Compare various types of anesthesia.
n Identify essential nursing assessments and interventions
during the immediate postanesthetic phase.
n Demonstrate ongoing nursing assessments and
interventions for the postoperative nursing care.
n Identify potential postoperative complications and describe
nursing interventions to prevent them.
n State five possible causes of cardiac arrest following
surgery.
n State six elements of the discharge plan.
n Evaluate the effectiveness of postoperative nursing
interventions.

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Terms
Perioperative nursing
¨ Total surgical episode, which includes: pre-
operative care, intra-operative care and post-
operative care
n Pre-operative phase
¨ Time before the surgery
n Intra-operative phase
¨ Actual time of the surgery to transfer into Post-
anesthesia care unit (PACU)
n Post-operative phase
¨ Time after the surgery is completed

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Classification for Surgical Procedure
1. Degree of urgency
¢ Emergency surgery
¢ Urgent surgery
¢ Elective surgery
2. Degree of risk
¢ Major surgery
¢ Minor surgery
3. Purpose
¢ Diagnostic / exploratory
¢ Palliative
¢ Ablative
¢ Constructive
¢ Reconstructive
¢ Transplant 5
Preoperative assessment
Surgical risk factors:
n Age
n General health
n Nutritional status
n Medication history
n Mental status
n Personal habits & lifestyle
n Patient / family emotional health
n Economic / occupational status

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Preoperative Assessments
(cont.)
n Physical examination
¨ Cardiovascular and respiratory
¨ Musculoskeletal and skin
¨ Gastrointestinal, renal, and liver
¨ Cognitive and neurologic
¨ Endocrine

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Preoperative Assessments
(cont.)
n Additional assessments
¨ Age
¨ Pain
¨ Fluid and electrolyte balance
¨ Infection, immunity and hematologic function
¨ Nutritional status

n Educational assessments
¨ Knowledge deficit

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 Preoperative Nursing Diagnoses

n Deficient knowledge r/t unfamiliar surgical

experience
n Anxiety and/or Fear r/t pain, death,
disfigurement, or the unknown
n Disturbed Sleep Pattern r/t hospital routines, or
psychological stress
n Anticipatory grieving r/t perceived loss of body
parts associated with surgery
n Ineffective coping r/t conflicting values, lack of
clear outcomes of surgery, or unresolved past
negative experience with surgery

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Anxiety and/or Fear r/t pain, death,
disfigurement, or the unknown
n Care of anxiety and fear
¨ Providing adequate information
¨ Allow the patients to ask questions and
express feelings
¨ Empathetic to patient
¨ Reassure patient being with him/her in all
three periods
¨ Refer to other support group if there is long-
term effect of the operation

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Preoperative nursing
responsibilities
n Legal – informed consent
n Physiological care
n Psychological care
n Nutritional care
n Rest and sleep
n Client’s valuables and prostheses
n Pre-op teaching
n Preparing skin
n Preparing GI Tract
n Care on the day of surgery
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Informed consent
n Needed for each invasive procedure
n Written with the procedure to be done
n Client must understand its risks and
benefits
n Physician obtains consent prior to
medication administration
n Competent adults to sign the operative
permit

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Nursing priorities
Priorities in care are identified:
n to establish baseline data for
intraoperative and postoperative
comparison
n to promote patient’s
understanding of the surgical
experience
n to complete the necessary surgical
preparations
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Nursing priorities
(1) Baseline data
1. Establishing baseline data
2. Medical records
3. Nursing history – any former
hospitalization experience
4. Physical assessment – essential to include
the organ system to be involved in surgical
procedure

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Nursing priorities
(2) Promote patient understanding of the
surgical experience
n Psychological preparation for surgery and the
recovery phase
n Coughing and deep breathing; incisional
splinting; incentive spirometer
n Leg and ankle exercises; anti-embolism
stockings; turning; early ambulation
n Medication for pain relief (PCA, injection)
n Equipment
¨ Tubes and drains
¨ Intravenous infusion devices
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Nursing priorities
(3) Pre-surgical preparation procedures
n Complete preoperative checklist
n Diet modification – NPO after midnight
n Bowel preparation- enema or Golytely
n Skin preparation (optional) – shower the
night before, or shaving before PTCA
(percutanerous transluminal coronary
angioplasty)
¨ Hair that enters a surgical wound can
introduce microbes associated with
postoperative wound infection
¨ Hair may prevent adequate contact of
electrodes e.g. ECG ; Electrocautery
grounding pad
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Hair removal procedure
1. Place a towel in position to absorb fluid
and to contain loose hair
2. Wear gloves and apply soap to area to
be shaved
3. Hold the skin taut between thumb and
forefinger (no dry shave)
4. Shave in the direction of hair growth
5. Dispose used razor in the sharps box
6. Use second towel dry site
7. Dispose of gloves
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Pre-operative teaching
n Pain control: reassure the patient that pain can be
controlled with medications, PCA through epidural or IV
route.
n Ambulation
n Turning to prevent pressure ulcer and venous stasis
n Facilitate venous return to the heart to prevent
thrombophlebitis and clot formation.
n Deep breathing
¨ Expand collapsed alveoli
¨ Prevent postoperative pneumonia
¨ Faster clearance of inhalation agents from the body
n Coughing
¨ Remove secretion from the bronchi and larger airways
Extremity exercises
n Equipment
¨ Tubes and drains
¨ Intravenous infusion devices 18
Preparing the gastrointestinal tract
¨ To empty gastrointerstinal tract
n Reduce the possibility of vomiting and
aspiration
n Reduce the risk of possible bowel obstruction

n Allow visualization of the intestine in bowel

operation
n To prevent contamination from fecal maters
during bowel and abdominal surgery
¨ By enemas and bowel cleansing
¨ By restricting food and fluids (Nil by mouth/ Nil
per oral)

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Preparing the Client on the Day
of Surgery
Same-day surgery issues
n instruct the patient one day before
surgery àClarification of questions
n Empty bladder
n Wearing operational gown, protective cap
and stocking
n Checking to determine: ID band, consent
form signed, fasting, all patient record, all
diagnostic results available, vital signs,
removal of dentures, jewelry …… etc 20
Recheck Pre-op checklist
n Give pre-medications on call to OT à for
induction
¨ Prophylactic antibiotics – administered on call
before surgery so they reach peak action by the
time anesthesia is induced
¨ Combined narcotic and tranquilizer to relieve anxiety
and reduce pain (e.g. morphine, valium)
¨ Anticholinergic agent to reduce respiratory tract and
oral pharyngeal secretions (e.g. atropine sulfate)
n Transferred to surgery on stretcher or trolley.
n Prepare room/bed for postoperative care
n Care for significant others
¨ Explain surgery, equipments
¨ Give reassurance 21
Emergency OT Preparation
Procedures
Although there is insufficient time for a complete
health history or physical assessment, it is
essential to determine the following system
status before anesthesia is induced:
n cardiac, respiratory, and renal functions
n Any known allergies
n When the last food was eaten
n Obtain legal consent
n State indications of urgent operation with 2
doctors’ signatures if patient can’t give
consent 22
Intraoperative – anesthesia (1)
n General anesthesia (GA)
¨ IV or inhaled
¨ Block pain stimulus at the cerebral cortex
and induce depression of CNS
¨ Produce analgesia, unconsciousness, loss of
reflexes and muscle tone
¨ Reverse effect by metabolic change,
elimination from the body, or by
pharmacologic means
¨ Affecting the neurologic, respiratory and
cardiovascular systems

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 Intraoperative – anesthesia (2)
Regional anesthesia
¨ Types: spinal, and epidural
(through at thoracic,
lumbar, sacral or caudal
interspace) anesthesia
¨ block the pain stimulus
along the spinal cord
¨ A loss of painful sensation,
but remain conscious
¨ Sedative agent to produce
drowsiness (conscious
sedation) 24
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Intraoperative – anesthesia (3)
n Local infiltration anesthesia
¨ e.g. Lignocaine to skin or SC tissues
n Topical anesthesia
¨ e.g. apply gel or ointment directly to
numb an area
¨ Short term: block the peripheral nerve
endings in the mucous membrane of
vaginal and rectum; spray the
nasopharynx and mouth area
(endoscopic examination)
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Intraoperative care (4)
n Maintain safety and prevent injury
¨ Positioning
n Dorsal recumbent
n Lithotomy
n Trendelenburg
n Lateral
¨ Equipment safety
¨ Maintain surgical asepsis
¨ Assist with wound closure
¨ Monitor pt’s condition & assist in emergencies

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Intraoperative care (5)
n Monitoring
¨ Monitoring body temperature
¨ Monitoring for emergencies
n Malignant hyperthermia

¨ Uncontrolled skeletal muscle contraction

leading to potentially fetal hyperthermia (43C)
¨ Triggering agents: a combination of
succinylcholine chloride (Anectine) and
halothane (inhalation agents)
n Cardiopulmonary arrest

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Post-op summary from OT
Check postoperative record for
n Operative diagnosis & procedure
performed
n Anesthetic used
n Postoperative diagnosis
n Amount of blood loss & any blood
transfusion?
n Medications administered in recovery
room
n Any specimens sent?
n Any complications?
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Post-anesthesia care in
recovery room
n Immediate assessments in post-anesthesia
care unit (recovery room)
¨ Airway, breathing, circulation, level of consciousness
n Nursing diagnoses
¨ Risk for injury
¨ Hypothermia
¨ Altered comfort (pain)
¨ Risk for aspiration
¨ Disturbed thought processes

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Postoperative nursing care
Priorities (1)
1. Monitor the patient’s postoperative
condition
n Airway clearance
n Vital signs stability
n Promote comfort: easing postoperative pain
n Inspect surgical site outer dressing
n Return of sensation, movement of extremities,
and conscious level

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Postoperative nursing care
Priorities (2)
2. Promote ventilation, circulation, wound
healing, and comfort
n Assess for perfusion: through assessment of skin
color (pallor or cyanosis), skin warmth and turgor
n Promote fluid and electrolyte balance
¨ Ensure correct amount and type of IV fluid to be infused
¨ Monitor intake and output
¨ Hourly monitor of IV therapy
n Maintain drainage systems (Tubes and lines)
¨ Suction available, color, amount of the drainage
¨ Patent tube and no occlusion of drainage system
n Positioning
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Postoperative nursing care
Priorities (3)
3. Promote the patient’s participation in
postoperative care
n Prepare for discharge planning (progressive to
normal and then vigorous activities)
n Provide psychological support for patient and
family
n Maintain safety

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Postop care: observe for potential
complications
1. Adequate cardiovascular function/ tissue
perfusion à(hemorrhage, hypovolemic
shock)
2. Maintain adequate respiratory function
à(atelectasis, pneumonia, hypoxia,
pulmonary embolism)
3. Maintain GI function à(nausea and
vomiting, abdominal distension, paralytic
ileus, constipation, bowel obstruction)
4. Maintain fluid and electrolyte balance
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Postop care: observe for potential
complications (cont’d)
5. Maintain renal function à (urinary retention,
urinary infection)
6. Promote rest, comfort, and safety à (fall)
7. Promote wound healing à (wound infection,
dehiscence, evisceration)
8. Promote early ambulation à (thrombus
formation, embolus, thrombophlebitis)
9. Psychological care à (postoperative depression)
10. Planning home care in preparing for discharge
à (progress from mild to normally active
activities) 35
Potential postoperative
complications - Respiratory
n Occlusion of the pharynx by the tongue
n Inability of the patient to remove
secretions from the airway
n Aspiration of secretions or vomitus
n Edema of the airway

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Signs of
respiratory obstruction
n Noisy, irregular respirations
n Pallor or cyanosis
n Restlessness
n Anxiety
n Use of accessory muscles for
breathing
n Rapid, irregular pulse
n Frequent sighing
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Potential postoperative
complications - shock
n Result from massive hemorrhage, peripheral
vascular shutdown, or cardiac insufficiency
n Signs of shock or hemorrhage include:
¨ Cold, clammy skin
¨ Increases in pulse and respiratory rates
¨ Decreases in blood pressure
¨ Thirst
¨ Restlessness

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Potential postoperative complications
– cardiac arrest
n May result from:
¨ Hypoxia
¨ Respiratory obstruction
¨ Cardiac insufficiency
¨ Fluid and electrolyte imbalances
¨ Reaction to the anesthesia

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Patient’s participation in the
postoperative care:
Discharge planning
n Frequency of prescribed treatments such as
wound care
n Activity limitations
n Diet modifications
n Use of prescribed medications
n Signs and symptoms that should be reported
n Follow up visit / home health support

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