PERIOPERATIVE CARE & PREOPERATIVE PHASE

Perioperative includes:

Before (pre-operative) surgery

o Decision to have to OR
During (intra-operative) surgery
o OR to recovery room
After (post-operative) surgery
o From recovery room to complete recovery from surgery

Classification of Surgical procedure: (see attachment)

Consent for surgery

Persons agreement to allow something to happen

Protects patient, physician, institution
Must be in understandable terms
Is a legal document
o Consents are not legal if the patient is a minor, is confused,
sedated or imcompetent
Pt can withdraw consent at any time, even if in OR

Consent consist of:

Name and qualification (MD, RN) of person performing procedure
Steps involved in the procedure
Risks of the procedure
Alternatives to procedure
Expected results of the procedure
Effects of not having the surgery
Person responsible for obtaining:
Person performing procedure gets consent
Nurses role:
Nurses witnesses the signature
Document consent on file
Psychological preparation for surgery

Nurse is responsible for providing information to the patient

Communication guidelines:
o anxiety can be reduced & recovery can be enhanced by the
nurse actions
1

o allow the patient to verbalize their fears & concerns.

o Need to have active listening skills & non-verbal communication
(50-60%)
o touch can be used & be prepared for common questions about
surgery
o be careful about therapeutic false reassurance
Teaching post-operative activities:

It is best done in the pre-op phase; it is the nurse responsibility

Surgical events and sensation

Informing the patient about the events that takes place decreases
post-op complications.
When the patient is informed before surgery, they are more likely to
comply after with the care.
Inform patient about:
o When surgery is schedule
o How long it will last
o Sensation to expect during the post-op phase
o How they are going to wake up - dry mouth.
o It takes 5-7 days to get general anesthesia out of the body.

Pain management

Need to be told ahead of time how the pain is going to be managed

Patient has to request for the med if on PRN dosing.
It is a major concern for patients:
o Incisional pain really hurts so be mindful with the pain med.
o Immediately after surg - IV form of pain med for a couple of
days
o Once they are taking in food they are switched to oral pain med.
o Addiction is not the issue, pain is
o It helps them to do post-op activities.
o Inform the patient the length of time it will take before the drug
starts to work

Physical activities (TCDB)

Teaching them about the activities that they are going to need to
perform after surgery
Have patient understand that the activities will speed up their
recovery.
They are designed to reduce the possibility of complications
2

o Deep breathing
Cough reflex decreases after surgery, mucus accumulates
10 deep breathing with the incentive spirometer is a cycle.
Every 2 hrs
Respirations are less effective because of
anesthesia, pain medicine & incisional pain.
o Cough
o Inhale 3 times then hold breath to the count of 3
o Cough fully for 2-3 coughs without inhaling between
coughs
help remove mucus
o Push all air out of lungs
o 2-3 times q2hrs
o Avoid with eye, intracranial, or spinal surgery because of
potential to increase intraocular or intracranial pressure
o Leg exercises
o Venous return to the leg is slow
o Some surgical positioning decreases venous return
o There is circulatory stasis in the lower extremities
(Virchows triad)
thrombophlebitis & emboli.
o Teach leg exercises that encourage flexion & contraction
o Dorsiflex, plantar-flexion, circular motion
o No crossing of legs because it acts like a tourniquet
o Inform the patient that we dont massage the legs.
Turning in bed (repositioning)
o Improves venous return, respiratory function,
o Helps GI peristalsis and skin integrity.
o The patient needs to be informed on this during pre-op
teaching & performed every 2hr post-op.

Physical preparation
Preparation varies depending on the type of surgery
Pre-operative check list:

To ensure that the patient is ready for surgery

If unprepared document reason
3

Allergies are also noted there.

Pre-operative screening tests:

EKG, chest x-rays, lab works
(H&H links to anesthesia)
o need to be done before going into surgery
o PTT, PT, INR, UA
Pre-operative physical exam:
Health and physical needs to be signed off by the doctor
Hygiene and skin preparation
Intact skin is the bodys best defense
Skin prep done ahead of time - minimize the risk of infection
o Betadine or antibacterial solution
Patient must be clean
o Shaving is done in OR or holding area

Elimination
Void before surgery and taking pre-op medication
Empting the bowel is not considered routine for surgery
Unless that is the surgical site.
Foley catheter is placed for long procedures
Nutrition and fluids
NPO 8hrs before surgery to prevent aspiration & vomiting
If oral meds are given, give with 30ml of water
This needs to be explained to patient & family
Sleep and Rest
Want the patient to be well rested from natural defense
DNRS ARE SUSPENDED ONCE GOING INTO SURGERY- it is protocol

Intra-operative Nursing Care

Day of surgery:
Assessment
Verify pre-op check list
4

Pre-op skin care

Start IVs
Obtain Vital signs before giving pre-op med
o Give pre-op meds
o 30 mins 1 hr before procedure
Remove all clothing including underwear and pants
o all muscles relax so it is easier to clean up if theres no clothing
o Put on OR gown
o Remove hair pins and jewelry (may create sparks)
o Dentures may be removed or ordered by anesthesiologist to
leave in because of better mask fit
o Leave in hearing aids
o Identify patient and operative site several times
o Maintain safe environment
o Dont allow patient out of bed after pre-op meds
o Assist in transfer to stretcher
o Prepare room for pts return (equipment, oxygen, BP cuff,
thermometer special mattress)

During surgery

Scrub nurses
o hands the instrument to the surgeon (technical skill)
Circulating nurse:
o (professional role) responsible for patient safety
o prep, positioning, watching personnel, communication,
documentation,
o transporting patient to the recovery room & reporting off to the
RN.
Classification of Anesthesia

Anesthesia Produces:
Narcosis: loss of consciousness
Analgesia: loss of pain
Relaxation
Loss of reflexes
Types of Anesthesia
General anesthesia
5

Entire body is sedated/unconscious

Can be given by inhalation route (most common)
IV, rectally, orally (not often)

Stages of inhalation:
First

phase
Breath in
Patient feels warm
Detached, numb, dizzy, ringing in the ear
Person is conscious & noises are exaggerated

Second Phase (excitement phase)

Uncontrolled movements
o shrugging, talking, laughing,
Will have exaggerated reflexes
There is a reaction to noise & touch.
Third Phase
Unconscious, pupils are constricted
Face is expression less,
Pulse is strong, respirations full & regular
BP drops slightly, temp.
This stage can be maintained for hours.

Fourth Phase (overdose)

undesirable stage
Either too much anesthesia - undesirable reaction to it.
It could result in respiratory arrest & paralysis of the diaghram
vaso-motor collapse
Regional anesthesia:

Injected or applied topically near the nerve

It inhibits the transmission of sensory stimuli to the CNS
The loss of sensation to a specific area of the body

Local infiltration:
Injecting locally around the site

Nerve blocks:
When the anesthetic is injected into the nerve - area of surgery
o Dental work
o Jaw, Face
o Extremities
o Spinal, epidurals
o Surgery of lower abdomen, perineum, lower extremities
o Post op care similar to lumbar puncture
Conscious sedation:
routinely used for procedures that do not require complete
anesthesia but rather a depressed level of consciousness
retains a patent airway
adequately ventilation able to respond to verbal stimuli/light tactile
stimulation.

Post-operative phase
Two Phases of Post-Operative
Immediate phase

Recovery room, post anesthesia care unit

1-2 hrs
The emphasis of the assessment will be on any complications from
anesthesia/surgery

On-going post-op care:

It last from the floor through covalence, could be from 1-2yrs

Post-operative assessment
Continuous and on-going assessments include:

Vital signs every 10-15mins more often if necessary

o priority on the pre-op check list is the V.S
The post-op phase would use that as a baseline for comparison

Respiratory status:
Done by monitoring the respiratory rate, rhythm, depth
Observing skin color, pulse oximeter.
7

Respiratory obstruction is the most common recovery room

complication
o The tongue
1st sign of the tongue blocking the airway is snoring,
suctioning
Giving O2 also maintains a good airway & the tissues are
being oxygenated.
o Secretion accumulation:
o during the procedure secretions accumulate down the
tracheal bronchial tree which can also cause a respiratory
obstruction
Laryngospasm (contraction)
spasming of the larynx due to irritation from the
intubation tube.

Laryngoedema (swelling)
happens from irritation from the tube
Vomiting:
occurs from drugs, eating, and anesthesia.
The positioning is neck extended & head to the side.
Once the patient is reactive then they are raised to a
fowlers position.
Cardio-vascular status:
vital signs, pulse, BP, skin color & the wound (dressing)
CNS status:
Reflexes return in the reverse order of how they were lost.
The last thing that happened was being unconscious, so that is the first
thing that comes back and then responding to touch & sounds.
Fluid status:
Check skin turgor
Assess vital signs
Pay close attention to urinary output
o urinary drainage post diuresis
o increased amt and well diluted
o increased IV fluids given during operation
Nausea and vomiting
o car sick people & obese people are more prone
Wound condition
Look at the amount, color, the consistency of drainage
8

check the drains to make sure they are not dislodge & whats coming
out of them

General condition:
If the patient is having pain:
o condition is stabilized , medicine is given
With some anesthetic when the patient is having pain
o their BP goes down
Patients come out of the OR cold
o warming the patient stimulates them & gets rid of anesthesia.
o The new warm blanket always goes next to the patients skin.
For physical safety:
o position the patient properly & use the side rails.
o Gather all the equipment once it is known that the patient is
coming back to the floor.

Initial assessment on post-op unit

Vital signs
Color and temperature of skin
LOC:
o they should be oriented by the time they make it to the floor
o moving extremities
IV fluids
o might have to change tubing & regulate the fluid
o check the infusion site
Wound
o look at the wound, look under the dependent areas
o along with tubes & drains
Other tubes:
o check Foley, NG
o IV, drainage tube
Level of comfort
o PQRST, nausea & vomiting, also warmth
o reorient to the room & call bell
Psycho-social needs
o allow the family to visit the patient

Post-op complications in the elderly

Skin:
vascularity of the skin & loss of collagen in the older adult
poor wound healing post-op
9

Respiratory:
lung capacities
Elasticity weaken
o intercostal muscles & respiratory clearance
leads to ineffective cough, shallow breathing
risk for pneumonia & atelectasis
Cardiovascular:
cardiac output, blood flow
also contributes to delayed wound healing,
the risk of DVT & an altered response to infection
often masked because of no febrile response & no signs in the WBC
count
GI:

intestinal absorption of nutrients

peristalsis, and loss of elasticity of abdominal muscle
dehydration & malnutrition
delayed wound healing
paralytic ileus is more common

Renal:
glomerual filtration, concentrating ability of the kidneys
leads to prolong drug metabolism & clearance
have to be more concerned about drug levels & how long its going to
take them to clear the anesthetic
Hepatic:
blood flow) also leads to prolong drug metabolism & clearance
Immune:
immune response, formation of antibodies & lymphocytes
leads to slow inflammatory response
delayed fever, delayed wound healing & risk for infection
Cardio-vascular complications

Assess & document vital signs

Cover to prevent chilling
Monitor I & O, maintain the fluid balance
Monitor the rate & type of IV fluids
Check skin turgor & hydration.
10

Monitor the color & consistency of wound drainage

Implement leg exercises
Turning every 2hrs
Assist with ambulation
Place Teds & SCDs
Give anticoagulants.
Assess & record Holmans sign (once positive stop/DVT)
o avoid positioning that would impede venous return.

Hemorrhage/hypovolemic shock:

The blood could be pooling in the bed/ the patient.

Assessment:
o 1st sign is restlessness & anxiety
o frank bleeding, BP, tachycardic
o cold clammy skin, weak tready pulse,
o urinary output (cause BP is trying to rise)
o thirsty.
Primary care
o stopping the bleeding, apply pressure on the site
o prepare to for the return to surgery
o shock position raise the legs 20-30
o prepare to give fluids & blood (whole), give O2.
o Dont put in trendelenburg position
because all the blood will run to the brain & we need it at
the heart
o puts pressure of the diaphragm on the respiratory, if the patient
is elderly the intracranial pressure will .

Thrombophlebitis:
An inflammation of the vein associated with clot formation most
commonly seen in the lower extremities of post-op patients.
Assessment:
Pain
cramping in the affected site
redness, swelling of the calf & thigh
temperature, + Holmans sign
Primary care
Prevent the clot from breaking loose
Prevent further clot formation
11

Give anticoagulants
bed rest, Teds
elevate the affected extremity to heart level
no leg massage
give analgesic, use external heat if ordered
measure it to see if its getting better/worse

Pulmonary embolus:

A dislodged clot that has gone into the lungs

It is a cardiovascular problems
o because it is within the vascular system it affects gas exchange.
Assessment:
dyspnea, chest pain (not crushing but sharp)
cough
cyanosis (late sign)
rapid respirations, tachycardia & anxiety
Primary care:
Stabilize the cardiovascular & respiratory function
Prevent the further formation of emboli.
Bed rest (semi- fowler)
Maintain fluid balance
Give O2, administer anticoagulants, pain meds
Monitor V.S & general condition
Avoid valsalva

Pulmonary complications
Nursing interventions:
Monitor Vital signs
Implement deep breathing
coughing, incentive spirometer every 2hrs
Ambulate as ordered
Maintain hydration (best expectorant)
Monitor the responses to narcotics
Avoid positions that ventilation (head of bed 30, neck extended)

12

Pneumonia
Inflammation of the alveoli
o it occurs post-op as a result of aspiration and infection
depressed cough reflexes
secretions
dehydration & immobility
Assessment:
temperature (unless elderly), chills
production cough, purulent sputum, crackles/ ronchi
dyspnea, chest pain,
Primary care
To treat the infection, maintain the respiratory status
prevent the spread of microorganisms.
Promote full expansion of the lungs
semi-fowler
Give O2, fluid, nutrition & antibiotics.
May get expectorants/analgesic
cough and deep breath, oral hygiene
dispose of tissue with sputum & ensure resting comfort
Atelectasis
Incomplete expansion/collapsing of the alveoli
retained mucus it involves a portion of the lungs
results in poor gas exchange.
Assessment

breath sound over the affected area

dyspnea, cyanosis, crackles
restlessness, apprehension
Primary care:
Ensuring oxygenation to the tissues to prevent further collapsing
Expanding lung tissue. Same care as pneumonia

Preventing wound complications

Assessment:
RNs focus is to prevent infection with good sterile technique
early detection & promoting healing.
An elevation in temperature will signal an infection,
13

Maintain hydration
Maintain nutritional status:
High in protein (tissue healing), calories, carbohydrate, vitamins
Meeting elimination needs
Urinary elimination:
Can be altered by anesthesia
o retention, stasis & with foley an infection
Monitor I & O
Normal position to void
Assessment
o Check for distention:
o If patient has voided within 8hr/ small amounts frequently
o Maintain IV fluids
o Privacy for elimination
o Catheterization: if ordered
Bowel elimination
Can be altered by anesthesia/ manipulation during procedure
Abdominal gas increase.
Assessment
Assess for bowel sound every 4hrs
keep NPO until sound return
start on clear liquid diet
Ambulation:
As soon as possible, it maintains muscle strength
High fiber foods
along with good hydrations
Privacy:
Respond to the 1st urge
Use of:
o Colon tube: to let the gas out has a plastic bag
o Suppositories
o Enemas: return flow enema for gas
o Laxatives

14

Meeting fluid and electrolyte needs

Monitor I & O and IV fluids

Assess hydration
Assess the electrolytes
Oral hygiene
Progress diet as tolerated
o assess to make sure there is a gag reflex
o 1st (tongue blade)
Provide environment conducive to eating
Sit up for meals
Family participation in meals

Meeting comfort & rest needs

Decrease nausea and vomiting:

have all the unpleasant odors out the room
oral hygiene
small frequent meal
maintain bowel elimination
give nausea meds
Relieve thirst
o oral hygiene
Manage pain
o keep on assessing for pain
Facilitate comfort and rest:
o re-enforce pre-op teaching

Facilitate coping with alterations

Physical appearance: keep in mind it not just a face

Normal physiologic function
Self-concept
Body Image

15