NUR 425 Module 1
Perioperative Cycle
Classifications for surgery:
Degree of urgency
 Emergency—performed immediately to preserve function or life (internal
bleeding)
 Elective—preferred treatment, but not life threatening, but may threaten life
or well-being, or improve life (total hip)
Degree of risk
 Major—high degree of risk…complicated or prolonged, major blood loss,
vital organ involvement, or high risk for post-op complications likely from
the surgery (open heart)
 Minor—few complications…. outpatient
Purposes
 Diagnostic—confirms or establishes a diagnosis (lung biopsy,
bronchoscopy)
 Palliative—relieves or reduces pain or symptoms of disease, it does not cure
(resection of a brain tumor…. may not get it all, but relieves symptoms of
headache)
 Reconstructive/Restorative—restores function or appearance that has been
lost or reduced (breast implant)
 Ablative—removes a diseased body part (colectomy)
 Procurement for Transplant—replaces malfunctioning structures
 Cosmetic—personal appearance (rhinoplasty)
Informed consent: agreement by the client to accept a course of treatment or
procedure after being provided complete info regarding the treatment/procedure
(risks of procedure and risks of not doing procedure)
 Responsibility to obtain the consent is to the person performing the
procedure
 Based on autonomy---some cultures (group perspective—American Indian,
Amish)
3 major elements of informed consent:
 Given voluntarily
 Consent given by individual with the capacity and competence to understand
 Client given enough info to be the ultimate decision maker
Competency of individual—
 If given sufficient info, can make decisions
 Over 18 who is conscious and oriented---if sedated—not considered
functionally competent
o 3 groups cannot give consent:
o Minors—must get from parent or guardian---unless married, pregnant,
parent, member of the military, emancipated
o Unconscious—obtain from the closest adult relative….in lifethreatening ER—law agrees to implied consent
o Mentally ill judged by professionals as being incompetent
Physician Role
 Nature of and reason for surgery
 Available options and risks
 Risk of the surgical procedure
 Name and qualifications of surgeon
 Right to refuse
Nurse’s Role:
 Nurse not responsible for explaining the surgical procedure, but may witness
signature…When the nurse signs the form it is noted:
o Client gave consent voluntarily
o Signature is authentic
o Client is competent to give consent
What’s included:
 Description of procedure and alternative therapies
 Underlying disease process and its course
 Names and qualifications of person performing procedure
 Risks and frequency of occurrence
 Explanation patient has right to refuse or stop treatment
 Explanation of expected outcome, recovery, rehab plan, and course
Pre-operative Phase—Goal—ensure client is mentally and physically prepared
Identifying issues that increase surgical risk:
Age:
 Neonates and infants—blood volume small, reserves limited—risk of
volume depletion resulting in inadequate oxygen of body tissues, immature
temp regulation—risk of hypothermia during surgery…..also risk of
metabolizing and eliminating meds and resist infection, small airway!!--leading to hypoxia, bronchospasm
 Toddlers—fear separation, bodily mutilation, death—include parents as
much as possible, play is an effective teaching tool
 Older adult—changes in liver and kidney function, decreased thirst, poorly
nourished preop—impairs healing, dementia, and chronic illness
General health:
 Sometimes, IV antibiotics pre-op
 Current status, current meds, smoking alcohol history,
immunocompromised??
 CV disease— (thrombocytopenia, HF, MI, dysrhythmias, --increase
hemorrhage, shock, hypotension, DVT, etc.)
 Respiratory—pneumonia, emphysema—respiratory depression, post-op
pneumonia
 Kidney/liver—excretion of drugs, altered metabolism, etc
 Endocrine—DM--infection
Nutrition:
 Needed for tissue repair—at least 1500Kcal/day
 Obesity—pneumonia, wound infections, and wound separation (dehiscence,
evisceration)—increased risk by decrease ventilation and cardiac
function…leading to embolism, atelectasis, pneumonia (most common)
 Malnourished—delayed healing, infection, fluid/electrolytes problems
Meds:
 Anticoagulants—alter clotting, increase risk of hemorrhage…. stop 48h
prior
 Tranquilizers—interact with anesthetics, increase hypotension effects
 Corticosteroids—risk for infection
 Diuretics—fluid/electrolytes
 Antibiotics— (especially mycins) potentiate anesthetic agents—respiratory
paralysis
 Beta-Blockers—reduce cardiac contraction with anesthesia…lead to
bradycardia, decrease BP
 Herbs—affect platelet activity—ginger, gingko, ginseng
 Oral diabetic agents---metformin—react with dyes---kidney failure
Mental status:
 Ability to understand pre-op/post-op teaching
Also assess:
Allergies
Smoking—great risk for pulmonary complications—increase thickness of mucous
Coping/support systems
Cultural spiritual considerations—pain management
Alcohol/substance abuse—may need higher anesthetic dose—often
malnourished—delayed wound healing and watch for alcohol withdrawal
Pre-op Nursing Diagnoses:
 Knowledge deficit
 Anxiety
 Disturbed sleep pattern
 Anticipatory grieving
 Ineffective coping
Pre-op check list:
 ID bracelet
 Consent forms
 H/P
 Blood type/cross
 Blood tests—CBC, chemistry, pregnancy test
 Urinalysis
 Chest Xray/EKG
 Voiding—no underwear
 Vitals
 Make-up/nail polish/dentures/jewelry
 NPO—why: ---changing—light meal—6 hours before or heavier meal 8
hours before
 Bowel prep—if bowel surgery, foley during or—keep bladder empty
Nurse’s role preop—
 ensure tests are explained to patient
 results on the char
 reporting of abnormal results to physician!!!
 Allowing client to verbalize fears
 Empathy/caring
 Answering common questions about surgery
Pre-op teaching:
Moving, leg exercises, C/DB (IS), skin preparation (decreased risk of post-op
wound infection), general timetable, needs for pain meds
Pre-op meds:
Sedatives/antianxiety--Bensodiazipines—midazolam (versed)—reduce anxiety and
ease induction
Narcotic analgesics—sublimaze (fentanyl) sedation
Anticholinergics—atropine, glycopyrrolate (robinul)—reduce secretions
PPI- Protonix
Safety Protocols: JCAHO—
Pre-op verification—person, procedure, site, “time-out”—final verification
Intraoperative Phase: admission to surgical department to transfer to
recovery room
Anesthesia:
 General: loss of all sensation and consciousness…. all protective reflexes
are lost (gag and cough, block awareness centers in the brain (loss of
memory, analgesia, hypnosis, relaxation)
o Administered by gases and/or IV
o Disadvantage—depresses respiratory and circulatory system—
endotracheal tube in place (sore throat post-op), rectal thermometers
(hypothermia post-op),
 Regional: interruption of nerve transmission, anesthetic agent injected
around nerve pathway around operative site, but remains conscious, but
client often sedated—useful for older adults in reducing post-op pain, bowel
dysfunction, length of hospital stays
o nerve block—around a nerve trunk…. duration depends on anesthetic
drug
o spinal anesthesia—requires lumbar puncture—subarachnoid
space…can be used for lower abdomen, perineum, and legs (sensation
distal to administration with decreased motion…must assess for return
of sensation----side effects—hypotension, headache, urinary
retention),
o Caudal (caudal canal in the sacrum)—used for lower extremities or
perineum
o Epidural—intervertebral spaces—lumbar region…also thoracic and
cervical regions
 Local (topical)—loss of sensation at desired site used on mucous
membranes, open skin, wounds, burns...(lidocaine) inhibits nerve conduction
until diffuses in circulation…topical,
 Conscious sedation—minimal depression of LOC…, short term, minimally
invasive procedures…but amnesia, pain relief, stable vitals, rapid
recovery…patient retains ability to maintain patent airway and respond
appropriately to commands verbally or tactile ---use Versed (midazolam)
and fentanyl---endoscopies
Goal—maintain client safety and homeostasis…
 proper positioning, skin preparation
 maintaining sterile field
 monitoring aseptic environment
 managing tubes
 sharp, sponge, instrument counts
 documentation
Intraoperative Nursing Diagnoses
 Risk for:
o Aspiration
o Ineffective protection
o Impaired skin integrity
o Perioperative positioning injury
o Impaired body temperature
o Impaired tissue perfusion
o Deficient fluid volume
Postoperative Phase:
Goals: promote comfort and healing, restoration to wellness, prevention of
associated risks
 Communication from OR staff— “hand off” report from OR nurse…meds,
complications, special concerns, EBL
Immediate post anesthesia phase:
 airway, oxygen saturation, ventilation, CV status—respiratory obstruction—
most common PACU emergency
 vitals—hypotension—anesthetic agents, preop meds, position changes,
blood loss, peripheral blood pooling
 hypothermia
 LOC—unconscious, responds to touch/sounds, drowsiness, awake but not
alert, awake and alert, protective reflexes, move extremities,
 Skin color, fluid status
 Operative site
 Patency of tubes
 Comfort—proper positioning—side…. if spinal—keep client flat; suction as
needed until cough and swallowing
Gagging, cough swallowing—client awakening. ---watch for aspiration
return of reflexes—squeezing hands, moving legs
Shivering common
Restless—assess need for pain medication
Vitals!!!—assessing for shock!!!!!
 Hypovolemia—due to fluid/blood loss—tachycardia, <30mL urine/h,
hypotension
 Hemorrhage—overt bleeding, increase in pain, distention, swelling around
wound
 Hypovolemic shock—weak pulse, dyspnea, tachypnea, restlessness,
hypotension, decrease urine, cool, clammy skin, thirst, pallor
Post-op complications!!!!
PC: pneumonia, atelectasis (24—48 hours), urinary retention, phlebitis, emboli,
paralytic ileus, infection
Nursing care:
 Pain—will be discussed next
 Breathing—prevention of atelectasis—incentive spirometer
 Replacement of fluids/electrolytes (especially if NPO) ---and
nausea/vomiting (side effects of some pain meds) and until peristalsis
returns—watch for overload in the elderly—especially 24—48 hours
 Maintain of glucose levels—to prevent infection
Wound/surgical site assessment:
 Physician usually changes the original dressing
 Dressing observed and reinforced
 Call physician if excessive drainage
 Assess for healing/infection/exudate/approximation/
 Drainage tubes—JP, Hemovac
 Staples, retaining sutures
 Dehiscence/evisceration????
 Need for NG suctioning and nursing care…. why???
Psychological needs: depression??
Standards of post-op care:
 Coughing/deep breathing
 Ambulation
 Monitoring for immediate complications
 Decreasing factors which can lead to infection and other complications
Comparison of exercise and Immobility on systems:
Musculoskeletal:
Exercise:
– Maintain size, shape, tone, and strength of muscles (including the
heart muscle)
– Nourish joints
– Increase joint flexibility, stability, and ROM
– Maintain bone density and strength
Immobility:
 Osteoporosis- demineralization of bones…. regardless of amount of Ca in a
person’s diet—unneeded calcium will only add very large amounts of
calcium excreted leading to renal calculi –pathological fractures
 Atrophy—decrease muscle size, decrease function, movement, strength,
endurance, and coordination
 Contractures—permanent shortening (foot drop)—unable to do full ROM
 Stiffness and pain in joints—ankylosis—collagen at the joints become
immobile—calcium deposits causing pain
 Decubiti—pressure—decrease blood supply—diminished nutrition to area—
ischemia and necrosis
Nursing care:
 maintain alignment—trochanter roll—prevents external rotation of the hip—
when hip aligned correctly—patella faces directly upward
 maintain joints in functional position, footboard, do not put pillows under
knees!!!!! Hand rolls—maintain thumb in slight adduction and in
opposition to fingers…do not use wash cloths…don’t maintain enough
adduction
 position change—use trapeze bar
 ROM—all should be active…passive begins when ability to move joint is
lost---move just to the point of resistance, should not cause pain, do not
force beyond capacity, repeat each movement 5x during a session
Cardiovascular:
Exercise:
– Increases HR, strength of contraction, and blood supply to the heart
and muscles
– Mediates harmful effects of stress
Immobility
 Decreased cardiac reserve—imbalance of sympathetic over cholinergic
activity resulting in increased heart rate—decreases ability to respond to
demands even with little activity—will get tachycardic even with little
activity—increased workload of the heart…. when lying—there is increased
volume of circulating blood…as there is decreased in vascular
resistance…causing increase in CO and stroke volume
 Increased use of Valsalva—holding breath and straining against a closed
glottis…. causes pressure on large veins in thorax interfering with blood
flow to the heart and coronary arteries…. when exhales…surge of blood
flows to the heart leading to arrhythmias—exhale when moving in bed,
instead of inhale
 Orthostatic hypotension—decreased automatic vasoconstriction of the blood
vessels in the lower half of the body upon changing positions…causing
blood to pool in extremities and BP drops…cerebral perfusion is
decreased…lightheaded…causing heart rate to increase (drop in 15mmHg
for systolic and/or 10mmHg for diastolic
 Venous vasodilation and stasis—no skeletal muscle contraction to promote
the flow of blood back to the heart…. dependent pooling of blood
 Dependent edema—when venous pressure is great…. some of the serous
part of the blood is forced out of the vessel into interstitial spaces
 Thrombus formation—due to impaired circ back to the heart,
hypercoagulability of blood, injury to the blood vessel wall---symptoms
(tenderness, redness, warmth, and/or swelling of the legs) …. emboli—when
it travels in the general circ…. may block pulmonary circ…PE
Circ:
 Hemorrhage: decrease BP, elevated/weak pulse, cold/clammy skin,
increase resp, restlessness, decrease urine output
 Hypovolemic shock same as hemorrhage
 Thrombophlebitis—swelling, achy/cramp pain, vein feels hard, sensitive
to touch
 Thrombus—localized tenderness, swollen calf >3cm from other, pitting
edema, decrease pulse below thrombus
 Emboli—depends on where it lodges
Nursing care:
 exhale when moving in bed—discourages Valsalva
 passive/active ROM
 prevent constipation
 dangling
 prevent DVT—heparin subQ, SCD’s (35—45 mmHg pressure), TEDS
(promote venous return…need to remove and change), measure calf for
size, avoid crossing legs, pillows under knees, massaging legs
Respiratory:
Exercise:
– Increase ventilation and oxygen intake improving gas exchange
– Prevents pooling of secretions in the bronchi and bronchioles
Immobility:
 Decreased respiratory movement—anything that creates intraabdominal
pressure will prevent normal descent of the diaphragm and limit
inspiration, abdominal organs push against diaphragm…. decrease ability
to full expansion of the lungs….rarely sighs…..causing decreased vital
capacity….and also, decrease muscle strength to breathe….also
decreased respiratory centers if on sedatives, narcotics,
 Pooling of secretions—normally expelled by posture and coughing….
pool by gravity…predisposes to respiratory acidosis (hypoxemia) leading
to decrease oxygen to the tissues (hypoxia)
 Atelectasis—distribution of the mucus in bronchi increases when
supine…blocked bronchiole with pooled secretions causes collapse of
lobe or entire lung
 Hydrostatic pneumonia—growth of bacteria in pooled secretions—
impairs oxygen/carbon dioxide exchange…. especially bad with heavy
smokers
Respiratory:
 Atelectasis—increase resp, dyspnea, fever, crackles, productive
cough
 Pneumonia—fever, chills, productive cough, chest pain, mucous,
dyspnea
 Hypoxemia—confusion, restlessness, dyspnea, high or low HR,
diaphoresis, cyanosis
 PE—dyspnea, chest pain, cyanosis, elevated HR, hypotension
Nursing care:
 observation of resp. function, routinely cough/deep breathe q1—2hour, yawn q1h, incentive spirometer, teach deep breathing using
abdominal muscles,
Metabolic System:
Exercise:
– Elevates the metabolic rate
– Decreases serum triglycerides and cholesterol
– Stabilizes blood sugar and make cells more responsive to insulin
Immobility:
 Disruption of normal metabolic functioning—decreased BMR—due
to decreased energy requirements. (Decreased thyroid hormone
needed), altering metabolism of CHO, fats, proteins, causing
fluid/electrolyte and calcium imbalances, GI disturbances
 Negative Nitrogen balance and anorexia--Deficiency of calories and
protein with decreased appetite 2ndary to immobility (normally—
body is constantly synthesizing proteins and breaking them down into
amino acids for energy)..when immobile—the client’s body often
excretes more nitrogen (end product of amino acid breakdown) then it
ingests in proteins---negative nitrogen balance…leading to weight
loss, decreased muscle mass, weakness from tissue catabolism
(anabolism—protein synthesis…..catabolism—protein breakdown)
 Negative Calcium balance--Calcium resorption (loss) from
bones…causes release of calcium into the blood…normally kidneys
excrete the calcium…if unable to respond lead to hypercalcemia
Nursing care:
 increase fluid intake
 protein nutrition—Vit C…replace protein stores, Vit B complex—
skin integrity and wound healing
 passive/active ROM
Urinary system:
Exercise:
– Promotes blood flow to the kidneys causing body wastes to be
excreted more effectively
– Prevents stasis (stagnation) of urine in the bladder
Immobility:
 Stasis—gravity helps to empty----renal pelvis will fill with urine before it is
pushed into the ureters when horizontal.
 Calculi—due to bone resorption, excreting a larger amount of calcium
begins within 2 days of bedrest…. urine becomes more alkaline and calcium
salts crystallized—can injure the mucosal lining of the urinary tract and
make it more susceptible to infection urinary output decreases about 5th or
6th day, becoming more concentrated
 Urinary retention, incontinence—due to decreased muscle tone—does not
completely empty. ---if sensation is not heeded, the bladder distends and
with extensive stretching of the detrusor muscle, the sensation is no longer
felt…. may lead to back pressure and damage to the kidney nephron
(overflow incontinence)
 UTI—Escherichia coli due to static urine
Nursing care:
 Active/passive ROM, periodic check for distention…crede,
 fluid intake, (2000—3000 mL/day)
 acid-ash diet (limited amount of calcium…acid residue (cereal, meat,
poultry, fish),
 limit catheterization
GU:
 Retention—inability to void, restless (6—8 hours after surgery)
 UTI—dysuria, itching, Abd. Pain, fever, cloudy, WBC and leukocyte
esterase positive
GI:
Exercise:
– Improves the appetite
– Increases GI tract tone
– Facilitates peristalsis
Immobility:
 Anorexia—prolonged negative nitrogen balance suffers from anorexia….
further contributes to malnutrition…prolonging the disease process
 Stress—have continued stimulation of parasympathetic nervous system
leading to dyspepsia, gastric stasis, distention, diarrhea, or constipation
 Constipation—diminished expulsive power, loss of defecation reflex…need
to increase intraabdominal pressure for defecation…generalized
weakening….not able to assist with elimination leading to retention and
incomplete evacuation…if fail to defecate….reflexes become progressively
less and less strong over a period of time…develop fecal impactions and
mechanical bowel obstruction (SYMPTOMS OF CONSTIPATION:
headache, anorexia, distention, malaise, vertigo, pain in buttocks and
sacrum) …..earliest symptom of an impaction: frequent passage of liquid
material around the impacted stool.
 Pathologic conditions—from the straining of stool and excessive use of
Valsalva –CVA, hemorrhoids, ulcers, rectal prolapsed, heart block, death
Nursing care:
 prevention of constipation…obtain history of elimination habits,
(peristalsis occurs most often following meals…. strongest following
breakfast., stool softeners, …. discourage use of laxatives and enemas
GI
 paralytic ileus—decrease peristalsis
 Abdominal distention—increase girth, tympany on percussion, fullness,
gas pains
 N/V
Integumentary system:
 Reduced skin turgor—shifts of body fluids…affects dermis especially in
dependent parts of the body…leading to elasticity
 Pressure ulcers—impeded circulation and decreased nutrients to the
areas
Psychosocial
Exercise:
– Elevates mood
– Relieves stress and anxiety
– Improves quality of sleep for most individuals
– Positive effects on decision-making and problem-solving processes,
planning, and paying attention
– Induces cells in the brain to strengthen and build neuronal connections
Immobility:
 Behavioral changes—hostility, giddiness, fear, anxiety
 Coping—sleep-wake alterations, depressed due to role and self-concept
changes, withdrawal, have decreased stimuli—causing perception of time
changes
 Developmental changes—
 Infants/Toddlers/Preschoolers—delay of child’s gross motor skills,
intellectual development, musculoskeletal development
 Adolescents—alters growth patterns, behind peers in gaining independence,
social isolation
 Adults—all physiological systems are at risk, role changes
 Older adults—loss of total bone mass, increased dependence---need to
encourage to do as much as they can.
Nursing Care:
 Incorporate play for children—puzzles (helps with fine motor),
reading—cognitive development
 Clocks, calendars for older people—to increase sensory stimuli
Skin:
 Infection—warm, red, tender, fever/chills, purulent, (3—6 days after
surgery)
 Dehiscence—6—8 days after OR
 Evisceration—6—8 days after OR
NANDA Diagnoses:
 Activity Intolerance
 Impaired physical mobility
 Sedentary lifestyle
 Risk for Disuse Syndrome
Mobility can also be the etiology for nursing diagnoses