Peri- Operative Nursing

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•Peri- Operative Nursing
Description- including pre-operative, intra-operative and post-operative care.
Aim - To increase the success of the surgery.
Pre-Operative Nursing Care-
It is a nursing care that applying before the any procedure.
Informed Consent-
The surgeon/doctors are responsible for obtaining the consent for surgery. (NORCET-2021

Nurses are not responsible for signing the consent form, they are only verifying the consent
that consent were taken or not but the nurses may witness the client's signing of the
consent form and the nurses also must be ensure that the client has understood the
surgeon's explanation of the surgery.
Minors or <18 years may need a parent or legal guardian to sign the consent form,
but some time minors consent also required, is called Assent. (Bhopal AIIMS-2018)

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Older clients may also need a legal guardian to sign the consent form.
Psychiatry clients have a right to refuse treatment until a court has legally determined that they are unable to make
decisions for themselves.
Sedation should not be administered to the client before taking the consent.

Preparation of Surgical Site-

 Clean the surgical site with a mild antiseptic or antibacterial soap the night before surgery,
or as per ordered.

 Shave the operative site, as per ordered.

Elimination- enema should be given before the night of surgery for bowel preparation.

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• Pre-Operative Client Education-

• Full explanation about the procedure & its consequence,

• Explained about post-operative pain management options

• Explained about breathing, coughing and incentive spirometry, splinting technique when coughing to prevent pain.

• Explained about any invasive devices that may be after operation such as NG tubes, Foleys, ERT tubes etc. Explained
about post-operative exercises.

• Psychological support to the client & family.

• Pre-Operative Checklist-
Ensure consent taken or not.
Ensure the client is wearing an identification band.
Assess for allergies
Review the checklist before sending the client to the OT.
Ensure all ordered pre-operative medications given such as antibiotics (usually it should be
given 1 hours prior to operation/skin incision). (BHU & Bhatinda AIIMS-2018)
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Ensure all history & physical examination completed & documented in client's record.
Ensure that ECG & chest x-ray are taken and that attached to client's records.
Ensure the blood types, cross match performed and documented.
Before sending the client to OT, all jewelleries, makeup, dentures, hairpins, nail polish, glasses and prosthetics
should be removed & hand overed to patient's relative.
Document that all valuables such as jewelleries given to the guardians.
Document that the client voided before surgery.
Monitor & document the client's vital signs before sending the client to OT.
Should be followed surgical check list to prevent any surgical errors.

• Drugs To Be Withheld Before Surgery-

Aspirin 7 days prior to surgery
Warfarin 4 days prior to surgery
Clopidogrel 4 days prior to surgery
Anti-diabetic on the day of operation
Heparin 6 hrs prior to surgery
Diuretics 1 day prior to surgery
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• Drug to be continued-

Digoxin
Anti-hypertensive
Anti-arrhythmic

• Intra-Operative Nursing Care-

• It begins when the client Arrival in the operative room and end when the client leaving from the operation theatre-

• Nursing Care by OT Nurse After Receiving The Patient

• When the client arrives in the operative room, the OT nurse will verify the consent and,
history, allergic conditions & identification bracelet, with the client's verbal response.

• Check the file for name of the patient

• Confirm the operation - Site, Side and Diagnosis

• Confirm about one relative along with the patient.

• Check OT clothes 6
• Drug to be continued-
Digoxin
Anti-hypertensive
Anti-arrhythmic
• Intra-Operative Nursing Care-
• It begins when the client Arrival in the operative room and end when the client leaving from the operation
theatre-

• Nursing Care by OT Nurse After Receiving The Patient

• When the client arrives in the operative room, the OT nurse will verify the consent and,
history, allergic conditions & identification bracelet, with the client's verbal response.
• Check the file for name of the patient
• Confirm the operation - Site, Side and Diagnosis
• Confirm about one relative along with the patient.
• Check OT clothes
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• Confirm part preparation done or not.

• Confirm blood if arranged previously, depending on the surgery

• In the OT the OT nurse and surgeon ensure and reconfirm that the operative site has been appropriately marked.

• Just before starting the surgical procedure, a Time-Out is conducted with all members of the operative team.

• Doctors orders will be verified & implemented.

• Other Intra-Operative Nursing Care-

Maintain safety of the client

Maintain aseptic environment or technique Position the client in correct alignment & drape
for surgery.
Ensure that instrument counts are correct.
Apply monitoring devices as needed. Insert urinary catheter if needed
Maintain complete documentation.
Support to the client during anaesthesia introduction.
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• Scrub Nurse

1.Scrub nurse is gowned and gloved and able to handle and pass sterile items into the sterile surgical field to the
surgeon. It is also known as 'Boss' of the sterile field.
2.Assist with the actual procedure to the surgeon.

• Circulating Nurse

Deal with the management of unsterile activities in the operating area.

Nursing care of the client including assessment & interventions.
Movement of unsterile items out of the surgical field such as labelling & transportation of
specimen.

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• Classic Stages of Anaesthesia

• Stage-1: Analgesia Stage

• In this stage after administration of anaesthetic drugs client become drowsy, loss of consciousness, amnesia
decreased awareness of pain and euphoria like clinical features occurred

• Stage-2: Disinhibition Stage

• It is also known as stage of excitement, muscle become tense, breathing may be irregular, delirium,

• excitement, combative behaviour and incontinence

• Stage-3: Surgical Anaesthesia

• This is stage of operation, operation begins in this stage, in which reflexes are depressed,
unconscious, no pain reflexes, regular or normal respiration and BP is maintained., decreased
eye movement.

• Stage-4: Medullary Depression

• Respiratory & cardiovascular depression, requiring ventilation and pharmacologic support

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Ideal temperature for OT-23-25°C and Humidity 30-40% should be maintained.

• Post-Operative Nursing Care-

• This type of care starts after operation of the client and end at discharge of the client. Post-operative care divided
into three stages-

• Immediate post-operative stage- First 1 to 4 hours after surgery. (NORCET-2020)

• Intermediate postoperative stage-4 to 24 hours after surgery.

• Extended post-operative stage-1 to 4 days after surgery.

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 • Immediate Post-Operative Nursing Care-

• Maintain Airway & Respiration-

• Position-head turn on side & neck slightly extended to prevent aspiration and accumulation of mucous secretions.

• Suction the artificial airway & oral cavity as needed to remove secretion.

• Monitor saturation and administer oxygen according to SPO, saturation.

• Monitor all vital signs every 5 minutes initially in immediate post-operative stage later every 15 minutes up to
stabilization
• Keep artificial airway at bedsides until gag reflexes return.
• Suction airway before extubation to clear secretions as per needed
• Assess respiration status & distress after extubation such as restlessness, confusion,
dyspnoea, stridor, decreased oxygen saturation and inability to expectorate
• Monitor breath sounds, RR, depth & rhythm, pulse oximeter, behaviour and colour of
mucous membranes.
• Encourage coughing & deep breathing to prevent atelectasis. (most common respiratory
post-operative complication)
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• Promote Circulation-
• Monitor heart rate, rhythm and blood pressure every minutes initially then later every 15 minutes. 5

• Monitor peripheral circulation by identifying colour, temperature, presence of pulses, capillary refill within 3 seconds
(it may not be helpful if client's circulation is compromised such as in fracture of extremity.

• Monitor for sign & symptoms of haemorrhage by assessing blood pressure, pulse rate, amount of drainage, frequent
swallowing, if any finding noted then immediately inform to on duty doctor.

• Apply SCD (Sequential Compressive Devices) anti- embolism stocking and anti-coagulants

and early ambulation if permitted to prevent thromboembolism.

• Monitor neurologic status by checking the LOC, papillary & gag reflexes, motor & sensory

status of extremities.

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• Wound care-

• Identify the location & size of the wound, colour, odour, amount & consistency of drainage.

• Types of wound drainage- (GMCH, AIIMS, PGI JIPMER 2018,19,20)

• 1. Sanguineous Drainage- Bright red colour, indicate active bleeding

• 2. Serosanguineous Drainage- Pale, red, watery of clear & red fluids

• 3. Serious Drainage-Clear watery plasma

• 4. Purulent Drainage- Thick yellow, green or brown colour, indicate infection.

• Care of The Drains & Tubes-

• Maintain patency of tubing such as gravity, negative pressure.

• Attach tubing to appropriate collection containers.

• Maintain negative pressure in portable wound drainage system.

• Empty the drainage bags when half full and should be compress before closing port except
abdominal drainage. Maintain surgical asepsis to prevent infection.
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• Fluids & Electrolytes Needs-

Maintain IV therapy as per ordered.

Record intake & output.
Monitor for electrolytes imbalances.

• Comfort & Emotional Needs-

Assess presence & characteristics of pains such as location, intensity, duration,

precipitating factors and effectiveness of pain therapy.
To give pain killers as per ordered. Call the client by name.
Instruct to client that how to use PCA pump.

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• Intermediate & Late Post-operative Nursing Care-

• Protect form injury

Change the position at least every 2 hours to prevent bed sore.

Encourage deep breathing & coughing and incentive spirometry to prevent atelectasis or hypostatic pneumonia,
auscultate the lower lobe of the lungs for diminished breath sound, which may indicate atelectasis.
Encourage for early ambulation & exercise to prevents thromboembolism, phlebitis, paralytic ileus and venous stasis.
Maintain patency of tubing to promote drainage and reduce pressure on suture line.

 Follow surgical aseptic technique while changing dressing, or when emptying tubing to
prevent infection. Before starts by orally check gag reflex by sips of water
 Maintain hydration and closely monitor Intake & Output for fluids status of the body.
 Usually within 8-12 hours after surgery client may voided, if not voids then a catheter may be
inserted.

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Offer high fiber diet, more fluids and exercises to prevent constipation.
Observe for abdominal distension, it indicates paralytic ileus.
Regulate IV therapy to prevent overload or circulatory collapse.
Encourage to use of splinting on incision site when coughing, sneezing, moving or turning to prevent tension on
suture line.
Position as required or depend on the type of surgery.
Provide emotional support.
After operation encourage Protein diet to growth tissues & Vita-C and Zink to healing the wound.

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• Priority Nursing Actions in Post-Operative Period

Maintain patent airway- administer oxygen & position of the neck slightly extended with side lateral (first priority)
Assess all vital parameters including pulse oximeter. (second priority)
Assess Level of consciousness LOC (third priority)
Assess for haemorrhage or bleeding
Assess urinary output
Tubes for patency & drainage for characteristics
Assess potential or presence of complications.

• Post-Operative Complications-

• Pneumonia-

Pneumonia is the inflammation & consolidation of the lung parenchyma.

It may develop after 3-5 days post-operatively due to infection, aspiration and immobility.

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• Atelectasis-

Most common post-operative complication.

It is collapsed or airless state of the lungs that may be the result of airway obstruction caused by immobility, lack of deep breathing
after surgery.
It is usually occurs after 1 to 2 days post-operatively.

• Signs & Symptoms-

 Dyspnoea & increased respiratory rate

 Crackles & elevated temperature
 Productive cough & chest pain
 Diminished breath sounds on affected site, usually seen in atelectasis.
• Nursing Care-

Assess lungs & breaths sounds.

Reposition the client every 2 hours
Encourage the client for deep breathing & coughing and use of spirometry.
Provide chest physiotherapy & postural drainage.
Do suction as per needed Provide adequate hydration to liquify secretions.
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• Hypoxemia-
It is inadequate oxygen concentration in arterial blood.
It occurs due to anaesthetic medicines that may suppress respiratory centre and cause hypoxaemia.
• Signs & Symptoms-
Restlessness- early sign of hypoxaemia in unconscious & conscious client. (NORCET-2020)
Dyspnoea, sweating, tachycardia & hypertension Cyanosis- late sign of hypoxaemia, in both clients
conscious & unconscious client.

• Nursing Care-

Frequently assess Spo2, level or oxygen saturation (first priority)

Administer oxygen
Inform to on duty doctor
Monitor lungs sound

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• Pulmonary Embolism-

• In which a thrombus dislodged usually from operative site and become embolus. An embolus blocking
the pulmonary artery and disturbing blood flow to one or more lobes of the lungs.

• Signs & Symptoms-

Sudden dyspnoea, sudden sharp chest or upper abdominal pain.

Cyanosis, tachycardia & low blood pressure.

• Nursing Care-

Immediately place the client in semi fowler or fowler position. (first priority)
Administer oxygen (second priority)
Inform to on duty doctor immediately (third priority)
Monitor all vital parameters including oxygen saturation.

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• Haemorrhage-

• It is the loss of the large amount of the blood (external or internal).

• Signs & Symptoms-

Restlessness, weak & rapid pulse

Hypotension & tachycardia
Cool & clammy skin
Decreased urine output.

• Nursing Care-

Provide pressure to the site of bleeding (first priority) Inform to doctor (second priority)
Provide oxygen therapy as per order
To give IV fluids, colloids and blood products or as per ordered.

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• Hypovolaemic Shock

• It is large volume of circulatory blood lost, which usually is caused by haemorrhage.

• Signs & Symptoms-

• 1. Restlessness, weak & rapid pulse

• 2. Hypotension & tachycardia

• 3. Cool & clammy skin 4. Decreased urine output.

• Nursing Care-

If shock developed then elevate the foot end of the bed or foot of the client if permitted,
(first priority)
Inform to doctor immediately (second priority)
Determine and treat the cause of the shock
Other nursing care same as haemorrhage.

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• Thrombophlebitis-
• It is an inflammation of the vein, cause by clot formation.
• Signs & Symptoms-
Vein inflammation
Aching & cramping pain
Veins feel hard & cord like & tender to touch
Elevated temperature.

• Nursing Care-

Monitor the legs for sign of inflammation, pain, tenderness, venous distension, and cyanosis,
if present then inform to doctor immediately.
Elevate the extremity 30° without allowing any pressure on the popliteal fossa.
Apply SCD devices & stockings.
Do not allow to the client dangle the legs.
Encourage early ambulation
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• Paralytic ileus-
• It is failure of appropriate forward movement of bowel contents.
• This condition may occurs as a result of anaesthetic medications or manipulation of the bowel during
surgical procedure.

• Signs & Symptoms-

Vomiting post-operatively that may contain brown colour.
Abdominal distension
Absence of bowel sounds, bowel movements & flatus.
Nursing Care-
Non-surgical treatment of choice for paralytic ileus- Bowel decompression by
insertion of a nasogastric tube attached to intermittent or constant suction.
Surgical intervention may be required if decompression is not effective.
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• Wound Infection-

• Most common cause- Poor aseptic technique.

• Precipitating factor-Poor sugar control in DM clients. Infection occurs usually 3-6 days post-operatively.

• Signs & Symptoms- (NORCET-2021, S-I)

Fever & chills and elevated WBCs. Warm, tender, painful and inflamed incision site.
Oedematous skin at the insertion and tight skin sutures.

• Nursing Care-

• Maintain aseptic technique & To give antibiotics as per order.

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• Wound Dehiscence-
• It is separation of wound edge at the suture line
• It is usually occurs 6-10 days after surgery.
• Wound Evisceration-
 separation of wound edge with protrusion of internal organ through an incision.
 usually occurs 6-8 days after surgery.
 most common in obese & pregnant clients, who had abdominal surgery, who have poor wound healing ability.
 Wound evisceration is the surgical emergency

If it occurs then place the client in supine or low fowler position with knee bent to prevent
abdominal pressure on suture line. (1 priority) (AIIMS Delhi, GMCH)
Cover the wound with sterile towel moistened with normal saline (2 priority) (AIIMS GMCH,
PGI, JIPMER)
Then immediately inform to doctor
Be calm and stay with the client & assess all vitals

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