Perioperative Nursing

Definition of Surgery

Surgery is any procedure performed on

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

● Perioperative Nursing- 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 client’s life, body part, or body
function.
● Degree of risk – involved in surgical
procedure is affected by the client’s 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 to confirm or establishes
diagnosis.
● Corrective- Excision or removal of diseased
body part.
● Reconstructive-Restore function or appearance to
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
● Cosmetic- 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 client’s 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 health- surgery is least risky when the
client’s 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:
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 survey- gestures and body movements

may reflect decreased energy or weakness
caused by illness.
● Cardiovascular system- alterations in cardiac
status are responsible for as many as 30% of
perioperative death.
● Respiratory system- a decline in ventilatory
function, assessed through breathing pattern
and chest excursion, may indicate a client’s risk
for respiratory complications.
Perioperative Nursing Care
Physical assessment/clinical manifestations

● Renal system-abnormal renal function

can altered fluid and electrolyte balance
and decrease the excretion of
preoperative medications and anesthetic
agents.
● Neurologic system- a client’s 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 system- 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 system- alteration in function
after surgery may result in decreased or
absent bowel sound and distention.
● Head and Neck- 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 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 patient’s 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 pt’s
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 animal- assisted 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 secretions-
Decrease 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

● Surgeon-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 patient’s
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.
 Perioperative Nursing Care
Surgical team

● Anesthesiologist and anesthetist-

anesthetizing the pt. providing
appropriate levels of pain relief,
monitoring the pt’s 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 W’s”

● 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.