The perioperative period consists of 3 phases:

❑ Preoperative: begins when decision to proceed with surgical intervention is made & ends with the transfer of
the pt onto the OR table - BEFORE SURGERY
❑ Intraoperative: begins when pt is transferred onto the OR table & ends with admission to the Post-
Anesthesia Care Unit PACU - DURING SURGERY

❑ Post operative: begins with admission to the PACU & ends with the follow up evaluation in the clinical setting
or home - AFTER SURGERY

Surgical Classifications
Its purpose :
❑ Diagnostic: determine the origin of the presenting symptom. (e.g, biopsy, exploratory laparotomy)

❑ Curative: Repair or removal of diseased organ

(e.g, appendectomy, excision of a tumor)

❑ Palliative: to relieve pain or correct a problem.(e.g, colostomy, gastrostomy tube)

❑ Cosmetic: (e.g, mammoplasty or scar repair

❑ Transplant: like kidney transplant

Its urgency:
❑ Emergent: requiring immediate attention, without delay (Stab wound, sever bleeding) - emergency
❑ Urgent: requiring prompt attention within 24–30 hr (Acute gall bladder infection) - not emergency but urgent
❑ Required: pt needs surgery, planned within few weeks or months (cataract) - is needed but can be delayed
❑ Elective: Patient should have surgery, failure to have it not disastrous (Simple hernia) - did not do , it is not a
disaster

❑ Optional: Decision rests with patient, personal preferences (cosmetic surgery) - as the patient wish

Preoperative phase: preoperative assessment

What is the reason of comprehensive assessment before the surgery !!!
Before any surgery initiated the followings should be obtained:

✓ Health history & history of allergies

✓ Physical examination and vital signs assessment

✓ Diagnostic and laboratory tests (blood tests & x-ray)

✓ Consent forms
 Preoperative nursing assessment :
1- Nutritional and fluid status:

➢ Nutritional needs may be determined by measurement of BMI and waist circumstances.

➢ Any Nutritional deficiency, such as malnutrition should be corrected

➢ Dehydration, hypovolemia, and electrolyte imbalances can lead to significant problems in elderly or pt with comorbid
med-surgical problems.
2- Dentition:

➢ The condition of the mouth (dental caries, dentures, and partial plates) are significant to anesthesiologist.
3- Drug or Alcohol Use:

➢ Nurse who is obtaining pt’s health history needs to ask frank - series questions about abusing alcohol or drugs
with patience & nonjudgmental attitude.
➢ Surgery is postponed “ if possible” for Intoxicated people (why?) if it is urgent local, or regional block anesthesia is
used.

4- Respiratory Status:
➢ Surgery is usually postponed if pt has a

respiratory infection. Why? - lung can’t breathe and healing and anesthesia
NOTE :

➢ Alcohol withdrawal syndrome (ie, delirium)

may be anticipated between 48-72hrs after

alcohol withdrawal and is associated with high

mortality rate when it occurs postoperatively

due to possible cardiac dysrhythmia, and increase

bleeding tendency.

5- Cardiovascular status: If the pt has uncontrolled hypertension, surgery maybe postponed until the BP is under
control.

➢ Surgical treatment can modified to meet the cardiac tolerance of the patient
NOTE :

➢ Pt with underlying respiratory disease (asthma, COPD) are assessed carefully for current threats to pulmonary
status.
➢ Pt who smoke are urged to stop 4-8 wks before surgery to reduce pulmonary and wound healing complications.

6- Hepatic & Renal Function:

➢ Preoperative improvement in liver function is a goal because it has an effect on how anesthetic agents are
metabolized, acute liver disease is associated with high surgical mortality rate.
➢ Surgery is contraindicated if a pt has acute nephritis, acute renal insufficiency with oliguria or anuria (Why?*) -
kidney used to excrete medication exception include lifesaving surgeries.

7- Endocrine function: pt with diabetes mellitus is at risk for:

➢ Hypoglycemia: during anesthesia or post-op from inadequate carbohydrates or excessive insulin.

➢ Hyperglycemia: from stress, which can ↑risk of wound infection.

➢ Strict glycemic control (80-110mg/dl) leads to better outcomes.

➢ Frequent monitoring of blood glucose level is important before, during, and after surgery.
7- Immune function: It is important to determine the presence of allergies, sensitivity for medication, contrast agent,
blood transfusion, any food products.

➢ Pts who are immunosupressed (??) are highly susceptible to infection, great care is taken to ensure strict asepsis.

8- Previous medication use:

Nurse must assess &

document the pt’s prescribed medications, OTC medications (ie,aspirin), & herbal agents because
of possible adverse interactions.

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Positive outcomes of pre operative teaching

• Decreased perception of pain
• Increased compliance with treatment
• Decreased post operative complications
• Decreased duration of hospitalization

• Reduced fear and anxiety

Preoperative Interventions
• Informed consent

• Health Promotion Activities:

Physical preparation:
✓ Maintenance of normal fluid and
electrolyte balance
✓ Reduction of risk of infection -aseptic teqnuique
✓ Manage incontinence: Interferential Therapy(IFC) - electrotherapy
✓ Promotion of rest and comfort
✓ Keep the patient NPO - nothing by mouth

Patient Teaching :
Leg exercises:
• Routine except for leg surgery, prevent DVT.
Deep breathing, coughing
• Prevents atelectasis and pneumonia
• Use incentive spirometer and mark their preoperative measurement (hold breath 3-5 seconds, mouthpiece removed,
blow out, repeat 3-5 times then cough)
• Use pillow to support incision
Turning, dangling, and early ambulation
• Allow lung secretions to drain into bronchi to be coughed up and exercises legs to help prevent thrombus.
 Deep breathing Technique :

Take a deep breath - inhale Exhale your breath out with pursed lips
‫كأنكم تشمون وررده‬ ‫كأنكم اطفون الشمعه‬

The second time you perform the same technique - the deep breath and blow with
pursed mouth

The Third technique is slightly different :-

Take a deep breath - inhale

‫كأنكم تشمون وررده‬
HOLD YOUR BREATH !!!

NOTE :
Repeat breath exercise 3-5
times, Client is instructed to take
10 slow, deep breaths every 2
hours while awake
LAST STEP = COOUGHH !
Preparation on the day of surgery
• Hygiene, prepare surgical site
• Hair & cosmetics
• Removal of prostheses
• Safeguarding valuables
• Preparing the bowel and bladder
• Vital signs
• Documentation and preoperative checklist
• Performing special procedures if needed.
• Administering preoperative medication
• Eliminating wrong site and wrong procedure surgery

Admission to the operating room

• Stretcher locked for transfer on OR bed
• Fastening a strap around the client

• Keep on explaining
• Provide Privacy

Intraoperative nursing
Nurses’ roles

Circulating nurse
SCRUB NURSE

1. Assesses the client on admission to the

operating room.
1. Assist the surgeon during the surgery
by passing the instruments, suture and 2. Helps to position the client on the operating
supplies. table.
2. Maintain surgical asepsis while 3. Helps with monitoring devices. She does not
draping and handling instruments. wear sterile gloves or gown.
3. The scrub nurse must have extensive 4. Responds to request from the surgeon, or
knowledge of all instruments and how anesthesiologist to obtain additional supplies
they are used. wears sterile gown, cap, and deliver it to the sterile field.
mask, and gloves.
4. Count the instruments, and the gauze 5. Counts the number of instruments, needles,
with the circulating nurse. and gauze sponges used during the surgery to
prevent the accidental loss of an item in the
wound.
Postoperative Care
• Postoperative period carries high risk of morbidity and mortality after any type of anesthesia

• Responsibility of the anesthesia provider to provide care while patient recovers from effects of anesthesia.
• Constant monitoring of patient is critical—temperature, pulse, blood pressure, respiration rate and any signs of
continuing blood loss.

• All postoperative patients should be cared in a recovery ward well equipped with drugs, supplies and trained staff.

Monitoring in Recovery Area (PACU)

Follow the ABCD of postoperative

care: Initial Phase
• Airway
• Does the patient control his/her own breathing?
• Check for any obstructions of the airway
• Breathing
• Note the rate and depth of respiration.
• Is there any sign of hypoxia?

• Circulation
• Check pulse and blood pressure.
• Check for peripheral circulation
• Is the patient bleeding? HR INCREASE , CO increase , If yes, inform
the surgeon
• Does the patient need fluid replacement?

Monitoring in Recovery Area

• Drugs
• Is the patient in excessive pain? Consider additional drugs for pain management
• Is nausea and/or vomiting severe? Consider anti-emetics
• Consider providing sedation, if required
• Is the patient restless, confused and agitated? - Look for a cause

Transferring the Patient to the Ward

Determining readiness for discharge from the
recovery area:
• Stable vital signs
• Orientation to person, place, events and time
• Uncompromised pulmonary function
• Pulse Oximetry indicating adequate oxygen saturation
• Urine output at least 30 ml/hour
• Nausea and vomiting absent or under control
• Minimal pain
• No bleeding
NOTE !!
Before sending the patient to the ward, make a quick assessment of the patient
Does the patient have a good color when breathing?
Is the patient able to cough and maintain a clear airway?
Is there any evidence for airway obstruction or laryngeal spasm?
Can the patient lift her/his head from the bed for at least 3 seconds?
Are the patient’s pulse rate and blood pressure stable?
Are the hands and feet well perfused and warm?
Is there a good urine output?
Is the patient’s pain controlled, and have necessary analgesics and fluids been prescribed?

Postoperative Nursing Care

• Assess vital signs frequently:
➢ Every 15 minutes until stable
➢ Then every half hour for 2 hours
➢ Every hour for 4 hours then every 4 hours for 24-48
➢ hours
• Assess and maintaining respiratory function.

• Assess Circulation: peripheral pulse and ECG.

• Preventing Circulatory complications

• Maintain Fluid and Electrolyte Balance

• Assess Neurological Function: LOC, Sensory and Motor status

• Assess Skin Integrity and condition of the wound

• Promoting wound healing

• Genitourinary function: Intake & Output (I &O)

• Promoting urinary elimination

Post operative care

• Assess Gastrointestinal Function: N & V.

• Promote normal bowel elimination

• Comfort & client expectation

• Assess pain level and promote pain control

• Achieving rest and comfort

• Maintaining and enhancing self concept

 Laboratory and diagnostic tests :
❖ Complete blood count
Rationale: Anemia, immune status, infection.
❖ Electrolytes
Rationale : metabolic status, renal function, diuretic side effect.
❖ PT, PTT, INR- PT & INR is test if taken warfarin ( vit K ) , PPT is test if taken Heparin ( prothrombin ), platelets
count
Rationale: Coagulation status
❖ Blood Types and cross match
Rationale: blood availability for transfusion
❖ Blood glucose
Rationale: metabolic status, DM

❖ Blood urea nitrogen ( not confirmed because can be changed by diet ) , creatinine.
Rationale: renal function
❖ Liver function test
Rationale: liver status
❖ Serum albumin
Rationale: Nutritional status
❖ HCG
Rationale: pregnancy
❖ ECG
Rationale: cardiac disease, dysrhythmias, electrolyte imbalance.
❖ Chest X – ray

Rational: pulmonary disorders, cardiac enlargement, heart failure .

❖ Pulmonary function test

Rational: pulmonary status

❖ ABG - PH , Paco2 , Hco3- , pulse oximetry

Rational: ventilation and metabolic function, oxygenation status.

❖ Urinalysis

Rational: renal status, dehydration, urinary tract infection (UTI).

Leg Exercise

1- Raise and lower the legs alternately from the surface of the bed. Flex the knee of the stable leg, and extend the knee of
the moving leg.

"
2- Flex knee, raise foot in air and hold this position for 2-3 seconds, Have client extend the leg and lower it to bed.
3- Alternate dorsiflexion (toward head of bed) and plantar flexion (toward bottom of bed) of the feet.
4- Instructed client to make circles with the ankle moving first to the left and then to the right

"
Using Incentive spirometry :
• IS assists the client in deep breathing and encourage the patients to achieve their
normal inspiratory capacity.
• It is most often use following abdominal and thoracic surgery to help to reduce the
incidence of post operative pulmonary atelectasis.
NOTE : Used 10 time every hour

How to use the Incentive Spirometry

• Perform Hand Hygiene.
• Position client in semi-fowler position.

• Instruct client to place lips completely over mouth piece.

• Instruct client to take a slow deep breath like pulling through a straw, when maximum inspiration is reached,

• client should hold breath for 2-5 seconds

and then exhale slowly through pears lips

Teach controlled Coughing

• Explain the importance of maintaining an upright position. To enhance thorax
and abdominal expansion.
• Ask the client to take two deep, slow breaths inhaling through nose and exhaling
through pursed lips.
• Inhale deeply a third time, and hold breath to count of 3. Cough fully for two to
three consecutive coughs without inhaling between coughs.

• Show the client how to support the incision by placing the palms of the hands on either
side of incision site or directly over the incision site, holding the palm of one hand over
the other.
• Show the client how to splint the abdomen with clinched hands and a firmly rolled pillow
held against abdomen.

Anxiety :
• Mild anxiety increases alertness, increases the ability to learn, and increases the ability to adjust to one’s environment
and increases the ability to adjust to several simultaneous stressors.

• High levels of anxiety can prevent successful preoperative adaptation and can negatively influence postoperative
recovery.

S& S of stress:
1- Shortness of Breath

2- Shallow breathing

3- Less energy for doing things

4- Tiredness and muscle tension

Decreasing Anxiety and stress :

• Music therapy

• Meeting spiritual needs

• Preoperative teaching

• Knowing a head of time about equipment attached to patient

Wound :
= type of injury in which
✓ The skin is torn, cut, or punctured (an open wound), or
✓ where blunt force trauma causes a contusion (a closed wound).
• According to level of contamination a wound can be classified as
1. Clean wound: no organisms
2. Contaminated wound: pathogenic organisms
3. Infected wound: pathogenic organisms present with signs of infection, where it looks yellow, oozing pus,
having pain and redness.
4. Colonized wound: chronic one and there are a number of organisms present and very difficult to heal as
in a bedsore.

Classification of Open wound :

Incisions or incised wounds: caused by a clean, sharp-edged
object such as a knife or razor.

• Lacerations: irregular tear-like wounds caused by some

blunt trauma.
• Abrasions : caused by a sliding fall onto a rough surface.

• Avulsions: amputation
• Puncture wounds: nail or needle.
• Penetration wounds: knife entering and coming out from the
skin.
• Gunshot wounds: caused by a bullet

Classification of Closed Wound

• Hematomas, also called a blood tumor, caused by damage to a blood vessel:

• petechiae, purpura, and ecchymosis.
•
• Crush injury, caused by a great or extreme amount of force applied over a long period of time.

WOUND HEALING :
• Wounds heal by different mechanisms depending on the condition of the wound.

•
• healing occurs in three phases:
• First-intention
• Second intention
• Third-intention wound healing
 Wound Healing Mechanisms:

First-Intention Healing Second-Intention Healing Third-Intention Healing

Wounds made aseptically with a (granulation) (secondary suture)
minimum of tissue destruction Occurs in infected wounds
(abscess) or in wounds in
• Properly closed heal with little • Used for deep wounds that
which the edges have not
tissue reaction by first intention either have not been sutured
(primary union) been approximated. early or break down
• Granulation tissue is not visible • Drainage tube or gauze • Resutured later, thus bringing
packing is inserted into the together two apposing
• Scar formation is minimal abscess pocket to allow granulation surfaces.
drainage to escape easily
• Covered with a dry sterile • Results in a deeper and wider
dressing. scar.
• Packed postoperatively with
moist gauze for the tissue and
covered with a dry sterile
" dressing.

"

"

"

"

Assessment of the Surgical Wound :

Inspection for approximation of wound edges

Integrity of sutures or staples
Redness, discoloration, warmth, swelling - infection
Unusual tenderness, or drainage.
Reaction to tape or trauma from tight bandages.
CARING FOR SURGICAL DRAINS :
• Drains are tubes that exit the peri-incisional area, either into a
portable wound suction device (closed) or into the dressings
(open).
• Types of wound drains include the
• Penrose
• Hemovac
• Jackson-Pratt

• You should record the following:

– Output (drainage)
– The amount of bloody drainage on the surgical dressing
– Spots of drainage on the dressings are outlined with a pen
– Date and time

• Report to the physician immediately if:

– Excessive amounts Hemovac
– Increasing amounts of fresh blood on the dressing

Dressing is applied for one or more of the following reasons:

• To provide a proper environment for wound healing
• To absorb drainage
• To splint or immobilize the wound
• To protect the wound and new epithelial tissue from mechanical injury
• To protect the wound from bacterial contamination and from soiling by feces, vomitus, and urine
• To promote hemostasis
• To provide mental and physical comfort for the patient.

• Performed at a suitable time

• Privacy is provided
• Avoid referring to the incision as a scar because the term may have negative connotations for the patient.
• Assurance is given that the incision will shrink as it heals and that the redness will fade.
• Dressings are never touched by ungloved hands