PERIOPERATIVE

NURSING
OBJECTIVES

PREOPERATIVE PHASE INTRAOPERATIVE POSTOPERATIVE

 PREOPERATIVE SCREENING  TYPES OF ANESTHESIA  - POST ANESTHETIC PHASE /

TEST  DIAGNOSIS RECOVERY SCORING
 DIAGNOSIS  SKIN PREP  - POST OP PROBLEMS
 PREOPERATIVE INSTRUCTION  POSITIONING  - DIAGNOSIS
 PREOP CHECKLIST  - WOUND CARE
 MEDICATIONS
• Perioperative nursing is the delivery of nursing care through the
framework of the nursing process. It also includes collaborating with
members of the health care team, making nursing referrals, and
delegating and supervising nursing care.
• Outpatient procedures do not require an overnight hospital stay. The
client goes to the outpatient site the day of surgery, has the
procedure, and leaves the same day.
• Degree of Urgency
• Emergent – requires immediate
attention (without delay)
• Urgent – requires prompt attention
(within 24-30 hours)
• Required – needed to have surgery
(plan within few weeks or months)
• Elective – should have surgery (not
having surgery is not catastrophic)
• Optional – decision rest with patient
(personal preference)

• Degree of Risk
• Major - organ transplant, open heart
surgery, and removal of a kidney
• Minor - breast biopsy, removal of
tonsils, and cataract extraction.
• MEDICATIONS
• CORTICOSTEROIDS (Prednisone)
• DIURETICS (Hydrochlorothiazide)
• TRANQUILIZERS (Diazepam)
• ANTICOAGULANTS (Warfarin)
• OPIODS
INFORMED CONSENT
• The patients autonomous decision about whether to undergo a
surgical procedure.
• Necessary to protect the patient from unsanctioned surgery and
protect the surgeon from claims of unauthorized operation.
• Surgeon responsibility is to provide a clear and simple explanation of
the surgery prior to patient giving consent.
• Nurse responsibility is to witness the signing of consent. Clarifies the
information provided by the surgeon and ascertain that prior to
signing the patient is not under the influence of medication that affect
judgement.
INFORMED CONSENT
• VOLUNTARY CONSENT
• Freely given without coercion
• At least 18 yo (unless an emancipated minor)
• Obtained by physician, witnessed by professional staff member

• INCOMPETENT PATIENT – (legal definition) individual who is NOT autonomous and cannot give
or withhold consent (cognitively impaired, mentally ill, or neurologically incapacitated)

• INFORMED SUBJECT – should be in writing, containing:

• Explanation and risk of procedure
• Benefits and alternatives
• An offer to answer questions about procedure
• Instructions that the patient may withdraw consent
• A statement informing the patient if the protocol differs from customary procedures
• PATIENT ABLE TO COMPREHEND
• Non English speaking must provide consent in a language that is understandable
• Alternative formats of communication (braille, sign interpreter) with vision/hearing problems
• Questions must be answered to facilitate comprehension
PREOPERATIVE PHASE
• Preoperative assessment includes collecting and reviewing physical,
psychological, and social client data to determine the client’s needs throughout
the three perioperative phases.
• Preoperatively, the nurse performs a brief but complete physical assessment,
paying particular attention to systems that could affect the client’s response to
anesthesia or surgery.
• A brief or “mini” mental status examination provides valuable baseline data for
evaluating the client’s mental status and alertness after surgery.
• The surgeon and/or anesthesiologist orders preoperative diagnostic tests.
Abnormalities may warrant treatment prior to surgery. The nurse’s responsibility
is to check the orders carefully, to see that they are carried out, and to ensure
that the results are obtained and in the client’s record prior to surgery
PREOP ASSESSMENT DATA
• CURRENT HEALTH STATUS
• ALLERGIES
• MEDICATIONS
• PREVIOUS SURGERIES
• MENTAL STATUS
• UNDERSTANDING OF THE SURGICAL PROCEDURE AND ANESTHESIA
• SMOKING
• ALCOHOL
• COPING
• SOCIAL RESOURCES
• CULTURAL AND SPIRITUAL CONSIDERATIONS
ROUTINE PREOP SCREENING TESTS
• Complete blood count
• Blood grouping and crossmatching
• Serum electrolytes (Na, K, Ca, Mg, Cl, HCO3)
• Fasting Blood Glucose
• BUN and Creatinine
• ALT, AST, LDH, and Bilirubin
• Serum albumin and total protein
• Urinalysis
• Chest x-ray
• ECG (>40 years old and with preexisting cardiac conditions
• Pregnancy (childbearing age)
PREOP DIAGNOSIS
• Deficient Knowledge related to
• A lack of education about the perioperative process
• A lack of exposure to the specific perioperative experience.
• Anxiety related to
• Effects of surgery on ability to function in usual roles Outcome of exploratory surgery for
malignancy
• Risk of death
• Loss of control during anesthesia or waking up during anesthesia
• Perceived inadequate postoperative analgesia
• Change in health status and/or body image.
• Grieving related to
• Perceived loss of body part associated with planned surgery
• Ineffective Coping related to
• Lack of clear outcomes of surgery
• Unresolved past negative experience with surgery
PLANNING
• The overall goal in the preoperative period is to ensure that the client
is mentally and physically prepared for surgery.
• Planning should involve the client, the family, and/or significant
others.
• The perioperative nurse usually does preoperative care planning and
teaching interventions on an outpatient basis.
PEROPERATIVE TEACHING
• GOAL: Reduce clients anxiety and postoperative complications and
increase satisfaction with the surgical experience.
• Purpose: to facilitates clients successful and early return to work and
other activities of daily living.
• Four dimension:
• INFORMATION (WHAT, WHEN HOW)
• PSYCHOLOGICAL SUPPORT TO REDUCE ANXIETY
• THE ROLE OF THE CLIENT AND SUPPORT PEOPLE
• SKILL TRAINING
PREOP MEDICATION
• SEDATIVES AND TRANQUILIZERS – Lorazepam (Ativan)
• NARCOTIC ANALGESICS – morphine
• ANTICHOLINERGICS – atropine, scopolamine
• ANTIEMETICS AGENTS – Metoclopramide (Plasil); ondansetron
(Zofran)
• ANTIHISTAMINES – Ranitidine (Zantac); cimetidine (Tagamet)
INTRAOPERATIVE PHASE
• Classification of Anesthesia
• GENERAL - acts by blocking awareness centers in the brain so that amnesia
(loss of memory), analgesia (insensibility to pain), hypnosis (artificial sleep),
and relaxation (rendering a part of the body less tense) occur.
• REGIONAL - the temporary interruption of the transmission of nerve impulses
to and from a specific area or region of the body.
• Topical - applied directly to the skin and mucous membranes, open skin surfaces,
wounds, and burns.
• Local - injected into a specific area and is used for minor surgical procedures such as
suturing a small wound or performing a biopsy.
• Nerve Block - anesthetic agent is injected into and around a nerve or small nerve group
that supplies sensation to a small area of the body.
• Spinal - agent is injected via lumbar puncture into the subarachnoid space in between L2
and S1.
• Epidural - injection of an anesthetic agent into the epidural space, the area inside the
spinal column but outside the dura mater.
INTRAOPERATIVE ASSESSMENT
• On the day of surgery, client’s family members are escorted to a surgical holding
area.
• Nurse confirms the client’s identity and assesses the client’s physical and emotional
status. The nurse verifies the information on the preoperative checklist and
evaluates the client’s knowledge about the surgery and events to follow.
• client’s response to preoperative medications is assessed, as well as the placement
and patency of tubes such as IV lines, nasogastric tubes, and urinary catheters.
• Assessment continues throughout surgery, monitoring patient VS, ECG, and oxygen
saturation, Fluid intake and urinary output, blood loss.
• Continual assessment is necessary to rapidly identify adverse responses to surgery
or anesthesia and intervene promptly to prevent complicati
PERIOP DIAGNOSIS
• Risk for Aspiration
• Ineffective Protection
• Impaired Skin Integrity
• Risk for Perioperative Positioning Injury
• Risk for Imbalanced Body Temperature
• Ineffective Peripheral Tissue Perfusion
• Risk for Deficient Fluid Volume.
PERIOP PLANNING
• The overall goals of care in the intraoperative period are to maintain the
client’s safety and to maintain homeostasis. These can be achieved thru:
• Position the client appropriately for surgery.
• Perform preoperative skin preparation.
• Assist in preparing and maintaining the sterile field.
• Open and dispense sterile supplies during surgery.
• Provide medications and solutions for the sterile field.
• Monitor and maintain a safe, aseptic environment.
• Manage catheters, tubes, drains, and specimens.
• Perform sponge, sharp, and instrument counts.
• Document nursing care provided and the client’s response to interventions.
• Circulating nurse - coordinates activities and manages client care by
continually assessing client safety (e.g., client positioning) and by
monitoring aseptic practice and the environment (e.g., temperature,
humidity, and lighting).
• Scrub nurse role is to assist the surgeons by controlling bleeding,
using instruments, handling and cutting tissues, and suturing during
the procedure
SKIN PREPARATION
• Surgical skin preparation involves cleaning the surgical site, removing
hair only if necessary, and applying an antimicrobial agent.
• Purpose: reduce the risk of surgical site infections (SSIs), the most
common type of health care–associated infection in the surgical
population.
• Procedure:
• Clean the surgical site and surrounding areas by washing the surgical site
before applying an antimicrobial agent.
• Remove hair from the surgical site only when necessary.
• Prepare the surgical site and surrounding area with an antimicrobial agent.
POSITIONING
• Beckett (2010) states that inadequate padding and incorrect positioning
can cause serious injury and long-term disability.
• The client’s position should provide:
• • Optimal visualization of and access to the surgical site
• Optimal access to IV lines and monitoring devices
• Protection of the client from harm (anatomic and physiological considerations).
• Straps maintain positions on the operating table, and body prominences
are frequently padded.
• should consider normal joint range of motion and good body alignment.
POST OPERATIVE PHASE
• Recovery of surgical clients who required anesthesia is performed in the PACU or RR
by certified PACU nurses.
• The PACU nurse uses criteria developed by the anesthesia department to evaluate
client readiness for discharge from the PACU.
• Clients are usually discharged from the PACU when:
• They are conscious and oriented.
• They are able to maintain a clear airway and deep breathe and cough freely.
• Vital signs have been stable or consistent with preoperative vital signs for at least 30 minutes.
• Protective reflexes (e.g., gag, swallowing) are active.
• They are able to move all extremities.
• Intake and urinary output is adequate.
• They are afebrile or a febrile condition has been attended to.
• Dressings are dry and intact; there is no overt drainage.
POSTOP ASSESSMENT
• In the nursing unit, nurse conduct initial assessment and carry out doctors STAT orders at
the same time.
• The nurse consults the surgeon’s postoperative orders to learn the following:
• Food and fluids permitted by mouth
• IV solutions and IV medications
• Position in bed
• Medications ordered (e.g., analgesics, antibiotics)
• Laboratory tests
• Intake and output, which in some agencies are monitored for all postoperative clients
• Activity permitted, including ambulation
• The nurse also checks the PACU record for the following data:
• Operation performed
• Presence and location of any drains
• Anesthetic used
• Postoperative diagnosis
• Estimated blood loss
• Medications administered in the PACU
Initial Assessment
• Level of Consciousness
• Vital Signs
• Skin color and temperature
• Comfort
• Fluid balance
• Dressing and bedclothes
• Drains and tubes

• Note: Document the client’s time of arrival and all assessments

POSTOP DIAGNOSIS
• Acute Pain
• Risk for Infection
• Risk for Injury
• Risk for Deficient Fluid Volume
• Ineffective Airway Clearance
• Ineffective Breathing Pattern
• Delayed Surgical Recovery
• Disturbed Body Image
POST OF MANAGEMENT
• Nursing interventions designed to promote client recovery and prevent
complications include
• pain management,
• appropriate positioning,
• incentive spirometry and deep-breathing and coughing exercises,
• leg exercises,
• early ambulation,
• adequate hydration,
• promoting urinary and gastrointestinal function,
• diet,
• suction maintenance, and
• wound care
Wound Care
• nurse assesses the wound for appearance, size, drainage, swelling, pain, and
the status of a drain or tubes.
• APPEARANCE - Inspect color of wound and surrounding area and approximation of
wound edges.
• SIZE - Note size and location of dehiscence, if present.
• DRAINAGE - Observe location, color, consistency, odor, and degree of saturation of
dressings. Note number of gauzes saturated or diameter of drainage on gauze.
• SWELLING - Observe the amount of swelling; minimal to moderate swelling is normal in
early stages of wound healing.
• PAIN - Expect severe to moderate postoperative pain for 3 to 5 days; persistent severe
pain or sudden onset of severe pain may indicate internal hemorrhaging or infection.
• DRAINS AND TUBES - Inspect drain security and placement, amount and character of
drainage, and functioning of collecting apparatus, if present
END