Fundamentals of Nursing:
Standards & Practices, 2E
Chapter 30
Responding to
the Needs of the
Perioperative
Client
Perioperative Period
Perioperative refers to the management
and treatment of the client during the
three phases of surgery: preoperative,
intraoperative, and postoperative.
Preoperative refers to the time interval
that begins when the decision is made for
surgery until the client is transferred to the
operating room (OR).
Copyright 2002 by Delmar, a division of Thomson Learning
30-2
The intraoperative phase begins
when the client is transferred to the
OR and ends with the client transfer to
a postanesthesia care unit (PACU).
When the client leaves the OR and is
taken to a PACU, the postoperative
phase begins; this phase continues
until the client is discharged from the
care of the surgeon.
Copyright 2002 by Delmar, a division of Thomson Learning
30-3
Surgical Interventions
Surgeries are categorized according
to the degree of urgency (timely
intervention of surgery).
• Emergency surgery requires
immediate intervention to sustain life.
• Urgent surgery dictates intervention as
necessary to maintain health in
situations that are not life-threatening.
Copyright 2002 by Delmar, a division of Thomson Learning
30-4
• Elective surgery is usually performed
at a time convenient to the client.
Types of surgical procedures
•
•
•
•
•
Diagnostic/exploratory
Reconstructive
Curative
Palliative
Transplant
Copyright 2002 by Delmar, a division of Thomson Learning
30-5
Setting
Ambulatory care centers and physician
offices are the usual settings for minor
surgical procedures.
Outpatient surgery areas (one-day
surgery centers or free-standing
ambulatory clinics) provide the client and
physician with alternative services for
urgent and elective surgeries.
Copyright 2002 by Delmar, a division of Thomson Learning
30-6
Perioperative Management
of Care
Surgeon responsibilities
• Determine the need for the surgical
intervention.
• Determine the surgical setting in
collaboration with the client.
• Order diagnostic tests.
Copyright 2002 by Delmar, a division of Thomson Learning
30-7
• Obtain client’s consent for the surgical
procedure.
• Teach the client about the outcomes
and risks of the procedure.
• Explain and document evidence that
the client understands the nature of the
surgical procedure, the risk factors,
and expected outcomes of the surgery.
Copyright 2002 by Delmar, a division of Thomson Learning
30-8
Anesthesia provider responsibilities
• Obtain informed consent for anesthesia.
• Perform a preanesthesia evaluation that
includes a thorough history.
• Select anesthetic agents.
• Teach the client regarding the anesthetic
medications, their side effects, and risk
factors.
Copyright 2002 by Delmar, a division of Thomson Learning
30-9
• Perform intubation (the insertion of an
endotracheal tube into the bronchus
through the nose or mouth to ensure
an airway) and extubation (the
removal of an endotracheal tube).
Copyright 2002 by Delmar, a division of Thomson Learning
30-10
Nurse responsibilities
• Schedule the diagnostic tests.
• Verify that all the necessary documents
are on the client’s medical record.
• Report abnormal diagnostic results to
the surgeon.
• Prepare and teach the client.
Copyright 2002 by Delmar, a division of Thomson Learning
30-11
Anesthesia
Anesthesia means the absence of
pain
• General anesthesia
• Regional anesthesia
• Local anesthesia
Copyright 2002 by Delmar, a division of Thomson Learning
30-12
Preoperative Phase
Assessment
• Nursing history
 Medical history
 Medications
 Allergies
 Age-related considerations
Copyright 2002 by Delmar, a division of Thomson Learning
30-13
 Social and cultural considerations
 Spiritual considerations
 Psychosocial status
• Physical assessment
 General survey
 Head and neck
 Upper extremities
Copyright 2002 by Delmar, a division of Thomson Learning
30-14
 Anterior and posterior chest and abdomen
 Lower extremities
Nursing diagnosis
• Common nursing diagnoses for the
preoperative client are Deficient
Knowledge related to surgery, and
Anxiety and Fear.
Copyright 2002 by Delmar, a division of Thomson Learning
30-15
Outcome identification and planning
• The overall goal is to protect the client
from injury related to anesthesia and
surgery.
• Discharge planning considerations
include
 Psychosocial and spiritual support
systems and community resources
Copyright 2002 by Delmar, a division of Thomson Learning
30-16
 Financial aspects of the illness
 Degree of illness or disability
 Rehabilitation
 Preventive care
 Client teaching needs
Copyright 2002 by Delmar, a division of Thomson Learning
30-17
Implementation
• Surgical consent form
• Preoperative checklist
• Client teaching about interventions to
prevent postoperative complications
 Postoperative exercises
 Incentive spirometer
Copyright 2002 by Delmar, a division of Thomson Learning
30-18
 Antiembolism stockings
 Pneumatic compression device
 Continuous passive motion device
 Transcutaneous electrical nerve
stimulation unit (TENS)
 Patient-controlled analgesia pump
(PCA)
Copyright 2002 by Delmar, a division of Thomson Learning
30-19
• Physical preparation
 Skin preparation
 Nutrition
 Gastrointestinal preparation
 Nasogastric tube
 Bowel preparation
Copyright 2002 by Delmar, a division of Thomson Learning
30-20
 Urinary elimination
 Safety precautions
 Medications
Evaluation
• Preoperative evaluation focuses on the
client’s ability to verbalize and
demonstrate the exercises.
Copyright 2002 by Delmar, a division of Thomson Learning
30-21
• The evaluation of a client’s preoperative
preparation for surgery should include
understanding of the procedure,
verbalization and return demonstration of
postoperative exercises, and
postoperative expectations resulting from
the surgery.
• Documentation of preoperative activities
must be entered in the client’s record.
Copyright 2002 by Delmar, a division of Thomson Learning
30-22
Intraoperative Phase
Surgical environment
• Unrestricted zone
 Can enter in street clothes
 Receiving desk, locker rooms
• Semirestricted zone
 Surgical attire required
 Hallways, storage areas
Copyright 2002 by Delmar, a division of Thomson Learning
30-23
• Restricted zone
 Controlled and germ-free
 Scrub attire required
 OR and rooms where sterile instruments
are prepared
Copyright 2002 by Delmar, a division of Thomson Learning
30-24
Surgical team
•
•
•
•
•
Surgeon
Anesthesia provider
Surgical assistant
Scrub nurse or technician
Circulating nurse
Copyright 2002 by Delmar, a division of Thomson Learning
30-25
Occupational hazards
• There is a risk of exposure to harmful
pathogens.
• Latex allergies, needlesticks, eye
splashes, back injuries, and indoor
pollution are of particular concern.
• Precautions should be in place that are in
compliance with Occupational Safety and
Healthcare Administration (OSHA).
Copyright 2002 by Delmar, a division of Thomson Learning
30-26
Assessment
• Check the client’s identification band
and confirm the surgical site.
• Check for client alterations that can
affect positioning during the procedure.
• Make sure the OR bed is prepared to
receive the client and that accessories
are available for a specific position.
Copyright 2002 by Delmar, a division of Thomson Learning
30-27
Nursing diagnosis
• Common intraoperative nursing
diagnoses promote client comfort,
safety,and support during the surgical
procedure.
• Risk for perioperative positioning injury,
Risk for injury, Risk for infection,
Hypothermia.
Copyright 2002 by Delmar, a division of Thomson Learning
30-28
Outcome identification and planning
• Specific nursing care is planned to
encompass the surgeon’s specifications
for positioning and to alleviate or prevent
any individual client problem.
• Determine the appropriate mode of client
transfer, equipment and positioning aids,
as well as the need for ancillary
personnel to accomplish positioning .
Copyright 2002 by Delmar, a division of Thomson Learning
30-29
Interventions
•
•
•
•
•
•
Surgical asepsis
Skin preparation
Positioning and draping
Electrical hazards
Heat loss
Monitoring physiological functioning
Copyright 2002 by Delmar, a division of Thomson Learning
30-30
Evaluation
• Before the client is transferred to the
recovery room, the OR nurse
evaluates and documents achievement
of client outcomes.
• The nurse documents the specific data
on the OR record.
Copyright 2002 by Delmar, a division of Thomson Learning
30-31
Transfer to the PACU
• While the surgeon is closing the
incision, the OR nurse gives a
telephone report to a recovery room or
PACU nurse regarding the client’s
health status, surgical outcomes,
special equipment needs, and nursing
interventions.
Copyright 2002 by Delmar, a division of Thomson Learning
30-32
• The circulating nurse usually plans for
personnel and equipment needed to
safely transfer the client.
• The staff uses good body mechanics
and assistive devices to allow proper
weight distribution of the client (draw
sheets, body rollers).
Copyright 2002 by Delmar, a division of Thomson Learning
30-33
• The client is at high risk for injury related
to the effects of residual anesthesia. The
anesthetist stays with the client while the
OR nurse gives a report to the PACU
nurse.
• After giving report, the OR nurse
documents the time of discharge, method
and disposition of transfer, and a general
statement regarding the client’s status.
Copyright 2002 by Delmar, a division of Thomson Learning
30-34
Postoperative Phase
The primary goal of nursing care
during the immediate postoperative
phase is to maintain the “A-B-Cs”:
airway, breathing, and circulation.
Ongoing care is directed toward
restoring the client to the
preoperative health status.
Copyright 2002 by Delmar, a division of Thomson Learning
30-35
Assessment
• Following the initial assessment of the
client’s respiratory status, the nurse
performs a total assessment
 Airway and respiratory status
 Circulatory status
 Neurologic status
Copyright 2002 by Delmar, a division of Thomson Learning
30-36
 Fluid and metabolic status
 Level of discomfort or pain
 Wound management
Nursing diagnoses
• Ineffective airway clearance
• Ineffective breathing pattern
• Ineffective tissue perfusion
Copyright 2002 by Delmar, a division of Thomson Learning
30-37
• Deficient fluid volume
• Imbalanced nutrition: less than body
requirements
• Depending on the individual client’s
needs, other nursing diagnoses can be
included in the plan of care
Copyright 2002 by Delmar, a division of Thomson Learning
30-38
Outcome identification and planning
• Care planning is done in two parts immediate care rendered in the PACU
area and ongoing post-PACU care.
• Care is prioritized according to the type
of anesthesia and surgical
interventions.
Copyright 2002 by Delmar, a division of Thomson Learning
30-39
• After discharge, the nurse ensures that
the client is knowledgeable about
home care.
• For clients who are hospitalized
postoperatively, the nursing care plan
encompasses both inpatient and
discharge needs .
Copyright 2002 by Delmar, a division of Thomson Learning
30-40
Interventions
•
•
•
•
•
Maintaining respiratory status
Maintaining circulatory status
Maintaining neurologic status
Maintaining fluid and metabolic status
Managing pain
Copyright 2002 by Delmar, a division of Thomson Learning
30-41
Discharge from the PACU
• Specific client outcomes include
 The client is conscious, oriented, and can
move all extremities.
 The client demonstrates full return of
reflexes.
 The client can clear the airway and cough
effectively.
Copyright 2002 by Delmar, a division of Thomson Learning
30-42
 Vital signs have been stable or within
baseline ranges for 30 minutes.
 Intake and urinary output are adequate
to maintain the circulating blood
volume.
 The client is afebrile or a febrile
condition has been treated accordingly.
 Dressings are dry or have only minimal
drainage.
Copyright 2002 by Delmar, a division of Thomson Learning
30-43
Ongoing postoperative care
•
•
•
•
•
•
•
Ineffective airway clearance
Ineffective tissue perfusion
Deficient fluid volume
Imbalanced nutrition
Urinary retention
Pain
Risk for infection
Copyright 2002 by Delmar, a division of Thomson Learning
30-44
Evaluation
• Based on client-specific postoperative
nursing diagnoses and achievement of
outcomes
• The time frame for achieving the
outcomes can vary with the client’s
health status, surgical procedure, and
other factors such as age.
Copyright 2002 by Delmar, a division of Thomson Learning
30-45