*There are three other works by
this artist in the nursing
department.
Jose Perez 1992*
PERIOPERATIVE CARE
Ignatavicius, 6th edition/ Chapters 20-22
Jerry Carley, MSN, MA, RN, CNE
“Waking Up Is Hard to Do…”
http://www.youtube.com/watch?v=WOrjcLJ2IE0
Objectives
Differentiate between the types and purposes of surgery
Identify factors that increase the client’s risk for complications
during and immediately following surgery
Discuss a preoperative assessment of the client’s physical and
psychosocial status
Describe proper procedure for obtaining informed consent
Recognize client conditions that need to be communicated to the
surgical and postoperative teams
Describe and identify safe nursing interventions during the perioperative period
Objectives Intra-operative
Discuss interventions to reduce client and family anxiety
Describe the roles and responsibilities of intra-operative
personnel
Discuss nursing interventions to prevent skin breakdown for older
clients during surgery
Discuss complications from anesthesia
Explain specific problems related to positioning during surgical
procedures
Objectives for Postoperative
Describe the ongoing head-to-toe assessment of the
postoperative client
Prioritize nursing interventions for the client recovering from
surgery and anesthesia during the first 24 hours
Discuss the criteria for determining readiness of the client to be
discharged from the post anesthesia care unit (PACU)
Discuss wound complications after surgery
Key Terms
Preoperative
 Intra-operative
 Postoperative
 Atelectasis
 Anuria
 Dysuria
 Oliguria
 Adipose

Nosocomial
 Hypoxia
 Aspiration
 Homan’s sign
 Dehiscence
 Evisceration
 LOC

Preoperative Care
Preoperative care begins when the client is scheduled
for surgery, and ends at the time of transfer to preanesthesia care unit or O.R. Suite
Purposes of Surgery
Diagnostic: determine origin and cause
Curative: resolve a health problem
Restorative: improves client function
Palliative: relieve symptoms
Cosmetic: alter or enhance personal
appearance
Urgency of Surgery
Elective: planned and non-acute
Urgent: prompt intervention, life
threatening if delayed 24-48 hours
Emergent: immediate intervention, life
threatening
Degree of Risk
Minor:
procedure with
less risk; often
completed with local
anesthesia
Major:
procedure with
greater risk, longer,
more extensive than
minor
Collaborative Management
Assessment
History and data collection:
-age
-drugs and substance abuse
-medical history and current medications
-previous surgery and anesthesia (family
history)
-blood transfusions or donations
-Allergies
-discharge planning
Medical History
Chronic and acute illness can increase surgical
risk
-Cardiac: anesthesia and medical
complications: CAD, MI, angina,
hemodynamic changes
-Respiratory: pulmonary complications:
smoker, asthma, emphysema, pneumonia
Current Medications
Medications can adversely affect the outcome of surgery
-Antidysrhythmics
-Antihypertensive
-Corticosteroids
-Anticoagulants
-Antiseizure
-Antidiabetic
Remember herbs and over the counter drugs
(OTC’s) are important as are Nutraceuticals
Surgery and Anesthesia
Family and client’s history of reactions to
anesthesia medications!!!!!!!!
ALLERGIES
Previous blood transfusions: history of any
reactions are IMPORTANT!
Assessment
Complete Head to Toe Assessment (baseline)
Review all systems:
-Cardiovascular
-Respiratory
-Neurological
-Renal/Urinary
-Gastrointestinal
-Musculoskeletal
-Psychosocial
-SKIN
Vital Signs (baseline)
Assessment
Labs:
-CBC, electrolytes, coagulation studies, type
and screen, pregnancy test, UA
Radiographic:
-chest x-ray, CT scans, and MRI
Diagnostic:
-EKG and ultrasound
Nutritional Status: malnutrition & obesity
Nursing Diagnoses
Knowledge Deficit
Anxiety
Risk for infection
Risk for pain
Altered urinary elimination
Risk for impaired skin integrity
Powerlessness
Disturbed body image
Ineffective coping
Disturbed sleep pattern
Interventions
Education (Pre-op teaching)*
-informed consent
-dietary restrictions
-specific preparation (e.g., bowel prep)
-post op instructions: exercise, plans for pain
management, incentive spirometer, cough and
deep breathing, splinting abdomen
Ensure client understands surgery, outcomes
and what to expect
Informed Consent
Consent implies the client has been given
sufficient information to understand;
-the nature of and reason for surgery
-know the surgeon performing surgery and
others that may be present during procedure*
-all available options and risks
-risks of surgery and potential outcomes
-risk associated with anesthesia
Informed Consent
Physicians responsibility:
-inform patient of surgical details (reason,
options, & risk etc.)
-have document signed prior to sedation
being given
Nurses responsibility:
-ensure consent is signed by the patient
-acts as a witness to client’s signature
ONLY
Preparation for Surgery
Dietary restrictions:
-NPO for 6-8 hours*(exception for medications with sips of H2O)
-NO drinking, eating, or smoking
-to decrease risk of aspiration/atelectasis
Preparation for Surgery
Medication administration:
-May be altered or given with sip
of
water
-Notify MD if patient is on any
antihypertensive, anticoagulants,
antiseizure, antidepressants,
corticosteroids, or insulin
Preparation for Surgery
Intestinal prep:
-may be needed if client is having abdominal,
pelvic, perineal, perianal surgery
-reduces injury to colon
-decreases intestinal bacteria
Skin prep:
-first step to reduce risk of infection
-sometimes done in the operating room holding
area
Preparation for Surgery
Tubes:
-indwelling catheter: bladder empty and
monitor renal functioning
-nasogastric: decompress &/or empty
stomach
Vascular access:
-peripheral or central line
-allows administration of fluids
and medications
Preoperative Teaching
Prepare the client for post op period
-breathing exercises
-incentive spirometry
-coughing and deep breathing
-Leg procedures: TED, ace wraps, sequential
compression devices (SCD’s) **(PREVENTS
DVT) **
-Type & Crossmatch # units
-early ambulation
-ROM exercises
Preoperative Chart Review
Ensure completion
Pre-Operative Checklist
Documents: surgical & blood consent, &
anesthesia report
Orders: NPO, labs, x-rays, IV access, foley, NG
tube, IVF, and medications etc.
Pre-op procedures: EKG & ultrasound
Accurate ht and wt* must be obtained
Check procedure schedule
REPORT ANY PROBLEMS, NEEDS, or
CONCERNS
Client Pre-op Preparation
Client should be wearing only a gown: all
undergarments are removed (some exceptions)
Leave valuables at home or with family
Tape rings if they can not be removed
Remove dentures, partials, and plates
Remove all prosthetic devices
ID and allergy band on wrist
Blood Bands if applicable
? Nail polish ?
Preoperative Medication
Reduce anxiety
Promote relaxation
Reduce pharyngeal
secretions
Prevent
laryngospasms
inhibit gastric
secretions
Preoperative Medications
Sedatives (benzodiazepines)
Narcotic analgesics (opioid)
Anticholinergics (atropine)
Antiemetic agents
Antacids or H2 receptor blockers
IV’s
Blood products (only run with NS)
Antibiotics for surgical prophylaxis
Intra-operative
Members of surgical team include but not
limited to:
-surgeons
-surgical assistants
-anesthesiologist
-certified registered nurse anesthetist
-operating room technicians
-surgical technologist
-holding area nurses
-circulating nurse
-scrub nurse
Environment of Operating Room
Ways to reduce bacteria level:
-cool temperature
-limited traffic
-personnel wearing sterile & protective attire
-personnel uses surgical scrub
Anesthesia


Induces state of partial or total loss of sensation,
occurring with or without consciousness
Used to block nerve impulse transmission,
suppress reflexes, promote muscle relaxation, and
in some instances achieve a controlled level of
unconsciousness
Complications from Anesthesia
Cardiac arrest
Anaphylactic reactions
Malignant hyperthermia
Massive blood loss
Dysrhythmias
Aspiration
Overdose
Unrecognized hypoventilation
Complications with intubations
Intra-operative Nurse Responsibility





Monitor airway and client’s O2 saturation
Constant monitoring of heart rhythm, rate, and BP
Monitor temperature
Monitor IV access, drains, tubes, and catheters,
I&O
Assessment of sedation level and anesthesia
Intra-operative positioning
Risk for peri-operative
positioning injury related to
immobilization and effects of
anesthesia
Circulating nurse coordinates
positioning and modifies to
reduce the risk of skin,
nerve, joint damage and
muscle strain or stretching
Postoperative
PACU:
Post-anesthesia Care Unit:
-Purpose is to provide ongoing evaluation and
stabilization of the clients and to
anticipate, prevent, and treat complications
after surgery
-Discharge is based on stability of client
(recovery score)
Postoperative Assessment
Complete assessment of ALL systems
Examine surgical site for bleeding
Assess for readiness to discharge client after
criteria have been met
Measure I & O (especially urine output!!!)
Goals:
-return client to normal physiologic
functioning following anesthesia
-Maintain asepsis
-Manage pain
-Prevent post op complications
Postoperative Assessment

Post anesthesia stage, client must be
continually assessed for airway patency and
adequate ventilation
Respiratory Assessment
Patent AIRWAY and adequate GAS
EXCHANGE
Monitor breath sounds, rate, depth, oxygen
saturations and pattern
Rate less than 10/minute, anesthetic
depression or opioid induced
Inspect chest wall for accessory muscle
use, sternal retractions, and diaphramatic
breathing
Cardiovascular Assessment
Vital signs (at least) every 15 minutes until
stable*
Listen to heart sounds, assess rate, rhythm, and
quality
Assess for Dysrhythmias via continuous cardiac
monitoring
Observe for signs of bleeding, check site
frequently
Peripheral vascular assessment (age matters!)
Check pulses, color, temperature, sensation, and
capillary refill of all extremities (especially
lower extremities)
Neurological Assessment
o
o
o
o
o
o
Assess LOC:
-observe for lethargy, restlessness, irritability,
and test coherence and orientation
Motor and sensory:
-follow simple commands and moves all
extremities
-numbness and tingling
-sympathetic nervous system: gradually elevate
head and monitor for hypotension
Fluid and Electrolytes Balance




Check and evaluate fluid and electrolyte balance
Assess fluid volume: overload vs. deficit
Monitor I&O
Observe mucus membranes, skin turgor, texture,
drainage, and perspiration
Renal/Urinary System
Indwelling catheter monitor output, clarity,
color, and amount*
No indwelling catheter or removed: observe for
urinary retention (how?)
Urine output should be greater than 30cc/h or
200cc every 6 hours
Gastrointestinal Assessment
Assess for bowel sounds, flatus, tenderness, and
distention
Monitor S&S of nausea and vomiting
NPO until gag reflex is present, risk for
aspiration
Assess and monitor NG tube
-check placement and patency
-observe drainage, color, and amount
Nasogastric Tube
May be inserted prior or
during surgery to
decompress or drain stomach
or reduce risk or aspiration
-promote gastrointestinal
rest
-allow lower gastrointestinal
tract to heal
-provide enteral feeding or
medication
Skin Assessment
Assess surgical wound:
-surgical dressing remains for 24-48 hours
-MD will remove first dressing*
-observe for bleeding or drainage on dressing
Check skin for breakdown**
Monitor drains: color, amount, consistency, and
odors
Pain Assessment
Client almost always has pain after surgery:
-pain related to: incision, tissue
manipulation, drains, positioning, and tubes
Assess physical and emotional signs of pain
-increased pulse, BP, respiratory rate,
profuse sweating, restlessness, wincing,
moaning, and crying
Plan activity’s around pain management to
ensure patient has optimal pain relief during
activities
Laboratory Assessment
Electrolytes
CBC
Left-Shift
-early sign of infection
-increase in immature neutrophils
ABG’s
Urinalysis
Risk Factors for Postoperative Complications
Pre-existing heart, respiratory, neurological,
renal or blood disorders
Diabetes (BS greater than 80-110 mg/dl)
Steroid therapy
Obesity (BMI>30)
Poor nutrition
History of substance abuse
Immobility
Anemia
Hypovolemia
Coagulation defect
ETOH abuse/history
Postoperative Complications
Respiratory:
-Inadequate airway and /or poor ventilation
-Obstruction
-Hypoxia
-Pneumonia
-Aspiration
-Pulmonary edema
-Exacerbation of CHF
-Laryngospasms
Postoperative Complications
Cardiac / cardiovascular:
-Hypovolemic shock
-Dysrhythmias
-DVT
Postoperative Complications
Gastrointestinal:
-Wound dehiscence and evisceration
-Nausea and vomiting
-Paralytic Ileus
Postoperative Complications


Dehiscence: partial or complete separation
of the outer wound layers, sometimes
described as “splitting open of the wound”
Evisceration: total separation of all wound
layers and protrusion of internal organs
through the open wound
Postoperative Diagnosis
Impaired gas exchange
Impaired skin integrity
Acute pain
Postoperative Interventions
Airway maintenance
Coughing & deep breathing
Inspirometry
Positioning and mobilization
DVT prophylaxis
Wound and drain care
Drug therapy (pain medication administration)
Health Teaching
Prevention of infection (such as?)
Care and assessment of surgical wound *
Diet therapy
Pain management
Drug therapy
Progressive increase in
activity
Postoperative Evaluations
Attains and maintains adequate lung
expansion and respiratory function
Has complete wound healing without
complications
Has acceptable comfort levels after
surgery (what level of pain is acceptable?)
Home Management
Assess home environment
Determine client’s needs
Assist devices may be needed
Educate on postoperative concerns:
-assessment and care of wounds
-S&S of infection
-pain medication and side effects
-constipation prevention
“Conscious Sedation”—”Moderate Sedation”

See the Case Study