Medical Surgical Nursing I
Unit III: Perioperative Care
Pre, Intra and Post operative
nursing care
Dr. J.C. HELEN SHAJI, Ph.D(N)
Asst.Prof of Medical Surgical Nursing
Caring for perioperative clients
Contents Outline
1. Objectives.
2. Introduction.
3. Phases of perioperative care.
4. Types of surgery.
5. Categories of surgery based on urgency.
6. Preoperative assessment.
7. Surgical risk factors.
8. Preoperative preparation.
9. Nursing diagnosis and intervention in preoperative phase.
10. Postoperative care.
11. Nursing diagnosis and intervention in postoperative
period.
12. Postoperative complications.
Caring for perioperative clients
Objectives:
At the end of this lecture, the student must be able to:
1. Differentiate the phases of perioperative care.
2. Define the types and categories of surgery.
3. Identify the preoperative assessments.
4. Develop a preoperative teaching plan.
5. Identify surgical risk factors.
6. Describe the preoperative preparation.
7. Discuss assessments needed in immediate and later postoperative
period.
8. Identify the postoperative complications.
What is meant by
perioperative?
Perioperative is a term used to
describe the entire span of surgery,
including what occurs before,
during, and after the actual
operation.
Phases of perioperative care
Preoperative:
begins with the decision to perform
surgery and continues until the client has reached the
operating area.
Intraoperative:
includes the entire
duration of the surgical procedure, until
transfer of the client to the recovery area.
Postoperative: begins with admission to the recovery area and
continues until the client receives a follow up evaluation at home, or is
discharged to a rehabilitation unit.
 INPATIENT SURGERY PROCEDURES ON A CLIENT WHO IS ADMITTED TO
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THE HOSPITAL.
OUTPATIENT SURGERYOPERATIVE PROCEDURES PERFORMED ON
CLIENTS WHO RETURN HOME THE SAME DAY.
LASER SURGERYOUTPATIENT SURGICAL PROCEDURES WITH THE
USE OF A LASER .
Types of surgery
•Diagnostic → Removal and study of tissue to make a
diagnosis.(Pathology)
•Exploratory → Most extensive means to involve
exploration of a body cavity or use of
scopes inserted though small incision.
•Curative → Removal or replacement of defective tissue
to restore function.(Joint)
•Palliative→ Relief of symptoms or enhancement of
function without cure. (Thiroidectomy)
•Cosmetic→ Correction of defects, improvement of
appearance, or change to a physical
feature.
Categories of
Surgery
Emergency
Urgent
Required
Elective
Optional
1. Optional surgery: decision rests with patient (eg, cosmetic surgery).
2. Elective surgery refers to procedures that scheduled at the client's
convenience (eg, cyst removal, repair of scars simple hernia or
vaginal repair).
3. Required surgery: is warranted for conditions necessitating
intervention within a few weeks (eg, cataract surgery, thyroid disorders).
4. Urgent surgery: is indicated for a problem requiring intervention
within 24 to 48 hours (eg, some cancers, acute gallbladder infection
and appendicitis, Kidney stones).
5. Emergency surgery: describes procedures that must be done
immediately to sustain life or maintain function (eg, repair of a
ruptured aortic aneurysm, gunshot, or knife wounds, extensive burns
, fractures skull, intestinal obstruction)
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CONDUCT A NURSING ASSESSMENT
PROVIDE PREOPERATIVE TEACHING
PERFORM METHODS OF PHYSICAL
PREPARATION
ADMINISTER MEDICATIONS
ASSIST WITH PSYCHOSOCIAL
PREPARATION
COMPLETE THE SURGICAL CHECKLIST
Assessment
•Client assessment varies depending on the urgency of the surgery.
•Time for preoperative assessment, nursing diagnosis, and evaluation of the
nursing management may be limited when a client is admitted for ambulatory
surgery or admitted shortly before surgery.
•Recognition of the client’s immediate preoperative needs is important.
•When the client is admitted, the nurse review preoperative instructions, such as
diet restriction, skin preparation, to ensure the client has followed them.
•The nurse immediately notifies the surgeon if the client has not carried out a
specific portion of the instruction.
Preoperative Assessment
I. Review preoperative laboratory and
diagnostic studies
II. Review the client’s health history and
preparation for surgery
:
III. Assess physical needs
IV. Assess psychological needs
V. Assess cultural needs
I. Review preoperative laboratory and diagnostic studies:
•Complete blood count.
•Blood type and cross match.
•Serum electrolytes.
•Urinalysis.
•Chest X-rays.
•Electrocardiogram.
•Other tests related to procedure or client’s medical condition, such
as: prothrombin time, partial thromboplastin time, blood urea
nitrogen, creatinine, and other radiographic studies.
II. Review the client’s health history and preparation for surgery:
•History of present illness and reason for surgery
•Past medical history
•Medical conditions (acute and chronic)
•Previous hospitalization and surgeries
•History of any past problem with anesthesia
•Allergies
•Present medications
•Substance use: alcohol, tobacco, street drugs
•Review of system
III. Assess physical needs:
•Ability to communicate
•Vital signs
•Level of consciousness
Confusion
Drowsiness
Unresponsiveness
•Weight and height
•Skin integrity
•Ability to move/ ambulate
•Level of exercise
•Prostheses
•Circulatory status
IV. Assess psychological needs:
•Emotional state
•Level of understanding of surgical procedure, preoperative and
postoperative instruction
•Coping strategies
•Support system
•Roles and responsibilities
V. Assess cultural needs:
•Language-need for interpreter
INFORMED CONSENT
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Before surgery, the client must sign a surgical consent form or
operative permit.
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Clients must sign a consent form for any procedure that requires
anesthesia and has risks of complications.
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If an adult client is confused, unconscious, a family member or
guardian must sign the consent form.
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If the client is younger than 18 years of age, a parent or legal
guardian must sign the consent form.
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In an emergency, the surgeon may have to operate without
consent, health care personnel, however, makes every effort to
obtain consent by telephone, or fax.
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Each nurse must be familiar with agency policies and state laws
regarding surgical consent forms.
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Clients must sign the consent form before receiving any
preoperative sedatives.
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The nurse is responsible for ensuring that all necessary parties
have signed the consent form and that it is in the client’s chart
before the client goes to the operating room (OR).
Teaching clients about their surgical procedure
and expectations before and after surgery is best
done during the preoperative period.
 Clients are more alert and free of pain at this
time.
 Clients and family members can better
participate in recovery if they know what to
expect.
 The nurse adapts instructions and expectations
to the client’s ability to understand.
 Information in a preoperative teaching plan
varies with the type of surgery and the length of
the hospitalization.
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Preoperative medication- when they are given
and their effects.
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Post operative pain control.
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Explanation and description of the post
anesthesia recovery room or post surgical area.
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Discussion of the frequency of assessing vital
signs and use of monitoring equipment.
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Explanation and demonstration deep breathing
and coughing exercises, use of incentive
spirometry, how to support the incision for
breathing exercises and moving, position
changes, and feet and leg exercises.
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Information about intravenous (IV) fluids and
other lines and tubes such as nasogastric tubes.
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Preoperative teaching time also gives the client
the chance to express any anxieties and fears
and for the nurse to provide explanations that
will help alleviate those fears.
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When clients are admitted for emergency
surgery, time for explanation is unavailable;
explanations will be more complete during the
postoperative period.
Deep breathing is a form of controlled ventilation that
opens and fills small air passages in the lungs to
prevent atelectasis and pneumonia.
 Coughing is a natural method of clearing secretions
from the airways.
 Leg exercises help promote circulation and reduce the
risk of forming a thrombus in the veins.
 Antiembolism stockings help prevent thrombi and
emboli by compressing superficial veins and capillaries
redirecting blood to larger and deeper veins, where it
flows more effectively toward the heart.
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ANTICHOLINERGICS: Glycopyrrolate (robinal)
decreases respiratory secretions.
 ANTIANXIETY: Lorazepam (ativan) reduces anxiety.
 HISTAMINE-2 RECEPTOR ANTAGONIST:
Cimetidine (tagamet) decreases gastric acidity and
volume.
 NARCOTICS: Demerol (meperidine) decreases the
amount of anesthesia needed to sedate the client.
 SEDATIVES: Midazolam (versed) promotes sleep or
conscious sedation and decrease anxiety.
 ANTIBIOTICS: Kanamycin (Kantrex) destroy enteric
microorganisms.
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History and physical examination.
 Name of procedure on surgical consent.
 Signed surgical consent.
 Laboratory results.
 Client is wearing an identification bracelet.
 Allergies have been identified.
 NPO.
 Skin preparation completed.
 Vital signs assessed.
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 Jewelry
removed.
 Dentures removed.
 Client is wearing a hospital gown and hair cover.
 Client has urinated.
 Location of IV site, type of intravenous solution,
rate of infusion is identified.
 The prescribed preoperative medication has been
given.
Surgical Risk Factors:
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Age → Very young – Elderly
Nutritional Status →Malnourished – Low weight –
Obese
Medical Problems →Acute and chronic respiratory
problems – Hypertension – Liver dysfunction – Renal
failure – Diabetes
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Physical Preparation.
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Skin preparation
Elimination
Food and fluids
Care of valuables
clothing/ grooming
Prostheses
Psychosocial Preparation.
 Careful preoperative teaching can reduce fear and
anxiety of the clients.
Nursing Diagnosis
• Anxiety related to results of surgery and
postoperative pain.
• Knowledge deficit related to preoperative
procedures and postoperative expectations.
INTRAOPERATIVE CARE
1. General Anesthesia (inhaled or intravenously)
refers to drug – induced depression of the central
nervous system that produces analgesia, amnesia
and unconsciousness (affects whole body).
2. Regional anesthesia is a form of local anesthesia
that suspends sensation and motion in body region
or part; the client remains awake. Continuous
monitoring is required in the event the block is not
totally effective and the client experiences pain or
reactions to blocking agents (e.g. nausea,
cardiovascular collapse). Regional anesthesia
differs in terms of location and size of the anatomic
area anesthetized and the volume and type of
anesthesia agent used.
3. Spinal Anesthesia is local anesthesia injected into
the subarachniod space at lumbar level to block
nerves and suspend sensation and motion to the
lower extremities, perineum, and lower abdomen.
4. Conduction Blocks suspend sensation and motion
on various groups of nerves such as epidural block
(i.e. anesthetic into space around the dura mater);
Para vertebral block (i.e. produces anesthesia of the
chest, abdominal wall and extremities) and Tran
sacral (caudal) block (i.e. anesthesia of the
perineum).
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Surgeon performs the surgical procedure and heads the surgical
team.
An anesthesiologist or anesthetist makes a preoperative assessment
to plan the type of anesthetic to be administered and to evaluate the
client's physical status.
Circulating nurse manages the operating room and protects the
patient’s safety and health by monitoring the activities of the surgical
team, checking the operating room conditions, and continually
assessing the patient for signs of injury and implementing
appropriate interventions. Verify consent, ensure cleanliness, proper
temperature, humidity, and lighting; the safe functioning of
equipments; and the availability of supplies and materials.
Scrubbing nurse setting up the sterile tables; preparing sutures, and
special equipments; and assisting the surgeon and the surgical
assistants during the procedure by anticipating the instruments that
will be required
- Scrub nurse and circulatory count all needles, sponges; and instruments used.
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Verifying consent
Coordinating the team
Ensuring cleanliness, proper temp., humidity
& lighting
Safe functioning of equipment
Availability of supplies and materials
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Performing a surgical hand scrub
Setting up the sterile tables
Preparing sutures, ligatures & special
equipment
Assisting the surgeon during the procedure
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Nausea and vomiting
Anaphylaxis
Hypoxia
Hypothermia
Malignant hyperthermia
Disseminated Intravascular Coagulopathy
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Physiologic status (LOC)
Psychosocial status (anxiety level, coping
mechanisms)
Physical status (surgical site, skin condition,
immobile joints)
POST OPERATIVE CARE
Postoperative Care:
Immediate postoperative period.
Initial Assessment
Airway patency
 Effectiveness of respiration
 Presence of artificial airways
 Mechanical ventilation, or supplemental oxygen
 Circulatory status, vital signs
 Wound condition, including dressings and drains
 Fluid balance, including IV fluids, output from catheters
and drains and ability to void
 Level of consciousness and pain
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Postoperative Care:
Later postoperative period
Ongoing Assessment
Respiratory function
 General condition
 Vital signs
 Cardiovascular function
 Fluid status
 Pain level
 Bowel and urinary elimination
 Dressings, tubes, drains, and IV lines
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When caring for post-surgical patient, think
of the “4 W’s”
1.
2.
3.
4.
Wind: prevent respiratory
complications
Wound: prevent infection
Water: monitor I & O
Walk: prevent thrombophlebitis
Nursing Diagnosis
• Risk for altered respiratory function related to
immobility, effects of anesthesia, analgesics and pain.
• Pain related to surgical incision and manipulation of
body structures.
• Altered Comfort (nausea and vomiting) related to
effects of anesthesia or side effects of narcotics.
• Risk for Infection related to break in skin integrity
(surgical incision, wound drainage devices).
• Activity Intolerance related to decreased mobility and
weakness secondary to anesthesia and surgery.
Nurse’s Responsibilities in Postoperative Phase
• Ensures a patent airway
• Helps maintain adequate circulation
• Prevents or assist with the treatment of shock
• Maintains proper position and function of
drain tubes and IV infusion
• Monitor for potential complications
Immediate Postoperative
Complications
1. Hemorrhage
2. Shock
3. Hypoxia
4. Aspiration
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CARE OF THE INCISION.
SIGNS OF COMPLICATIONS.
DRUGS FOR PAIN MANAGEMENT.
HOW TO SELF ADMINISTER PRESCRIBED
MEDICATIONS.
ACTIVITY LEVEL.
AMOUNT OF WEIGHT THAT CAN BE LIFTED.
DIET.
RETURN FOR A MEDICAL APPOINTMENT.