Objectives of Perioperative Nursing

 To apply nursing process to nursing actions in the OR

 To promote an understanding of the patients total surgical experience by demonstrating the ability
to assess physiologic, psychologic and sociologic patients needs

Objectives….
 To assist with the management of anxiety by assessing their needs for psychologic and
physiologic needs support
 To recognize effects of preoperative medication, anesthesia, positioning on the operating table,
site of incision and operative procedure as the basis for planning the patients post-operative recovery and
rehabilitation.
Phases of Perioperative Surgery
 Pre-operative - form decision for surgical intervention to transfer to OR.

 Intra-operative – from OR to RR

 Post operative – from RR to ward

OR TEAM
 STERILE TEAM
 Operating Surgeon
 Assistants to the Surgeon
 Scrub Nurse

 UNSTERILE TEAM
 Anesthesiologist
 Circulating Nurse
Surgical Conscience
“ Do unto the patient as you would have others do unto you”
Purposes of Surgery
 To preserve LIFE
 To maintain dynamic bodily equilibrium
 To undergo diagnostic procedures
 To prevent infection and to promote healing
 To obtain comfort and to ensure the ability to earn a living

Types of Conditions Requiring Surgery

 Obstruction
 Perforation

 Erosion

 Tumors
Surgical Risks
 General Risk Factors
 Age
 Fluid, Electrolyte and nutritional problems
 Obesity
 Presence of diseases
 Concurrent or prior pharmacotheraphy

Surgical Risks
 Other factors
 Nature of condition
 Location of the condition
 Magnitude and urgency of the surgical procedure
 Mental attitude of the person toward surgery
 Caliber of the professional staff and health care.

Classification of Surgery

 Major – extensive surgery that involves serious risk and complication as it involves major organ.

 Minor – surgery that involves minimal complications and minimal blood loss.

Types of Surgery
 Optional – at the preference of patient,surgery not needed.
(e.g. Cosmetic surgery, liposuction)
 Elective – at the convenience of patient as failure to have surgery is not catastrophic.
(excision of superficial cyst)

 Planned/Required – within a few weeks as surgery is important

(e.g. cataract extraction)
 Urgent/Imperative – within 24 to 48 hours
(e.g. cancer surgery)
 Emergency – immediately without delay to maintain life or organ, remove damage, stop bleeding.
 Diagnostic – to confirm a diagnosis
(e.g. excision of biopsy)

 Exploratory – to estimate the extent of the disease and confirm diagnosis as well. (e.g. Ex-Lap)

 Curative

 Ablative – removal of diseased organ (hysterectomy)

 Curative – repair of congenital defects (repair if cleft lip/palate)

 Reconstructive – restoration of damaged organ. (episiorrhapy)

 Palliative – relieves symptoms but does not cure the disease. ( rhizotomy and
chordotomy, myringotomy)

Focus on Preoperative Care Surgery

• Art and science of treating diseases, injuries, and deformities by operation and instrumentation
Surgery
• Performed for
– Diagnosis
– Cure
– Palliation
– Prevention
– Exploration
– Cosmetic improvement
Surgical Settings
• Inpatient
– Same day admission

• Ambulatory (outpatient)
– Usually less than 3 to 4 hours in PACU

Patient Interview
• Check documented information prior to interview
– Avoids repetition

• Occurs in advance or on day of surgery

Patient Interview
• Purpose
– Obtain health information
– Determine expectations
– Provide and clarify information on procedure
– Assess emotional state and readiness
Nursing Assessment
• Overall goal
– Identify risk factors
– Plan care to ensure patient safety
Nursing Assessment Goals
• Determine psychological status to reinforce coping strategies

• Determine psychological factors of procedure contributing to risks

Nursing Assessment Goals
• Establish baseline data

• Identify medications and herbs taken that may affect surgical outcome

• Identify, document, and communicate results of laboratory/diagnostic tests

Nursing Assessment Goals
• Identify cultural and ethnic factors that may affect surgical experience

• Determine receipt of adequate information from surgeon in order to sign informed consent
Nursing Assessment
• Psychosocial assessment
– Excessive stress response can be magnified and recovery affected
Nursing Assessment
• Influencing factors
– Age
– Past experience
– Current health
– Socioeconomic status

Nursing Assessment
• Use common language

• Use translators if needed

– Decreases level of anxiety

• Communicate all concerns to surgical team

Nursing Assessment
• Anxiety can impair cognition, decision making, and coping abilities
– Lack of knowledge
– Unrealistic expectations
– Information lessens anxiety
Nursing Assessment
• Anxiety may arise from conflict with interventions (i.e., blood transfusions) and religious/cultural
beliefs
– Identify beliefs and discuss with surgeon and operative staff
Nursing Assessment
• Fears
– Death or disability
• May prompt postponement
• Influence outcome
– Pain
• Consult with ACP
• Reassure drugs will be available
Nursing Assessment
• Fears
– Mutilation/alteration in body image
• Assess concerns nonjudgmental
– Anesthesia
• ACP for consult
• Assess malignant hyperthermia risk

Nursing Assessment
• Fears
– Disruption of life functioning
• Range from fear of permanent disability to temporary loss
• Include family and financial concerns
• Consultations PRN

Nursing Assessment
• Hope
– May be strongest positive coping mechanism
• Never deny or minimize
– Assess and support
Nursing Assessment
• Health history
– Diagnosed medical conditions
– Previous surgeries and problems
– Menstrual/obstetric history

Nursing Assessment
• Health history
– Familial diseases
• Conditions
– Reactions/problems to anesthesia (patient or family)
Nursing Assessment
• Current medications
– Prescription and OTC
– Herbs
– Vitamins
– Recreational
• Drugs
• Alcohol
• Tobacco
Nursing Assessment
• Allergies (drug and nondrug)

• Screen areas:
– Risk factors
– Contact urticaria
– Aerosol reactions
– History of reactions suggesting latex allergy

Nursing Assessment
• Cardiovascular system
– Report
• Problems for effective monitoring
• Use of cardiac drugs
• Presence of pacemaker/MI

Nursing Assessment
• Cardiovascular system
– Vitals recorded preoperatively for baseline
– Bleeding/clotting times
– Laboratory reports
– Possible prophylactic antibiotics
Nursing Assessment
• Respiratory system
– Inquire about recent airway infections
• Procedure could be cancelled because of increased risk of laryngo/bronchospasm or decreased
SaO2
Nursing Assessment
• Respiratory system
– History of dyspnea, coughing, or hemoptysis reported to operative team
– COPD or asthma
• High risk for atelectasis and hypoxemia
Nursing Assessment
• Respiratory system
– Smokers should be encouraged to quit 6 weeks before procedure
• Decreases risk of complications
• Greater years and number of packs = greater risk

Nursing Assessment
• Nervous system
– Evaluation of neurologic functioning
• Vision or hearing loss can influence results
Nursing Assessment
• Nervous system
– Cognitive function
• Assess or correct any deficits before surgery
• Durable power of attorney for health care should be obtained if deficits cannot be corrected
Nursing Assessment
• Nervous system
– Cognitive function
• Postoperative delirium (falsely labeled senility or dementia) can occur with dehydration,
hypothermia, and adjunctive medications
Nursing Assessment
• Urinary system
– History of urinary or renal diseases
– Renal dysfunction contributes to
• F and E imbalances
• Increased risk of infection
• Impaired wound healing
• Altered response to drugs and their elimination
Nursing Assessment
• Urinary system
– Renal function tests
– Note problems voiding and inform operative team
Nursing Assessment
• Integumentary system
– History of skin and musculoskeletal problems
– History of pressure ulcers
• Extra padding during procedure
• Affect postoperative healing
Nursing Assessment
• Musculoskeletal system
– Identify joints affected with arthritis
– Mobility restrictions may affect positioning and ambulation
– Bring mobility aids to surgery

Nursing Assessment
• Musculoskeletal system
– Report problems affecting neck or lumbar spine to ACP
• Can affect airway management and anesthesia delivery
Nursing Assessment
• Endocrine system
– Patients with diabetes mellitus especially at risk for:
• Hypo/hyperglycemia
• Ketosis
• Cardiovascular alterations
• Delayed wound healing
• Infection
Nursing Assessment
• Endocrine system
– Patients with diabetes mellitus
• Serum glucose tests morning of surgery (baseline)
• Clarify with physician or ACP if usual dose of insulin is taken
Nursing Assessment
• Endocrine system
– Patients with thyroid dysfunction
• Hyper/hypothyroidism are surgical risk due to altered metabolic rate
• Verify with ACP about giving medications
Nursing Assessment
• Endocrine system
– Patients with Addison’s disease
• Abruptly stopping replacement corticosteroids could cause addisonian crisis
• Stress of surgery may require increased dose of corticosteroids
Nursing Assessment
• Immune system
– Patients with history of compromised immune system or use of immunosuppressive drugs can
have
• Delayed wound healing
• Increased risk for infection
Nursing Assessment
• Fluid and electrolyte status
– Vomiting, diarrhea, or difficulty swallowing can cause imbalance
– Identify drugs that alter status
• Diuretics
– Evaluate serum electrolyte levels
Nursing Assessment
• Fluid and electrolyte status
– NPO status
• May require additional fluids and electrolytes prior to surgery if dehydration occurs
Nursing Assessment
• Nutritional status
– Obesity
• Stresses cardiac and pulmonary systems
• Increased risk of wound dehiscence and infection
• Slower recovery from anesthesia
• Slower wound healing
Nursing Assessment
• Nutritional status
– Provide extra padding to underweight patients to prevent pressure ulcers
– Identify dietary habits that may affect recovery (i.e., caffeine)
Nursing Assessment: Exam
• Findings enable ACP to rate patient for anesthesia administration
– Indicator of perioperative risk and overall outcome
Nursing Assessment: Exam
• Document relevant findings and report to perioperative team

• Obtain and evaluate results of laboratory tests

• Monitor blood glucose for diabetics

Nursing Management
• Preoperative teaching
– Patient has right to know what to expect and how to participate
• Increases patient satisfaction
• Reduces fear, anxiety, stress, pain, and vomiting

Nursing Management
• Preoperative teaching
– Limited time available
• Address needs of highest priority
• Include information focused on safety
• Provide written material
Nursing Management
• Preoperative teaching
– Several days before surgery
• Observe and listen to determine amount of teaching for each session
• Anxiety and fear can hinder learning
• Give priority to patient’s concerns

Nursing Management
• Preoperative teaching
– Must be documented and reported to postoperative nurses
• Avoid duplication of information
• Assess learning
Nursing Management
• Preoperative teaching
– Teach deep breathing, coughing, and moving for postop
– Inform if tubes, drains, monitoring devices, or special equipment will be used postop

Nursing Management
• Preoperative teaching
– Basic information before arrival
• Time and place
• Fluid and food restrictions
• Need for enema
• Need for shower
Nursing Management
• Legal preparation
– All required forms are signed and in chart
• Informed consent
• Blood transfusions
• Advance directives
• Power of attorney
Nursing Management
• Consent for surgery
– Informed consent must include
• Adequate disclosure
• Understanding and comprehension
• Voluntarily given consent
Nursing Management
• Surgeon responsible for obtaining consent
– Nurse may obtain and witness signature
– Verify patient has understanding
– Permission may be withdrawn at any time
Nursing Management
• Consent for surgery
– Medical emergency may override need for consent
Nursing Management
• Legally appointed representative of family may consent if patient is
– Child
– Unconscious
– Mentally incompetent
Nursing Management
• Day-of-surgery preparation
– Final preoperative teaching
– Assessment and report of pertinent findings
– Verify signed consent
Nursing Management
• Day-of-surgery preparation
– Labs
– History and physical examination
– Baseline vitals
– Consultation records
– Nurse’s notes

Nursing Management
• Day-of-surgery preparation
– Patient should not wear any cosmetics
• Observation of skin color is important
• Remove nail polish for pulse oximeter

Nursing Management
• Day-of-surgery preparation
– Valuables returned to family member or locked up
– Dentures, contacts, prostheses are removed
– Identification and allergy bands on wrist
Nursing Management
• Void before surgery
– Prevents involuntary elimination under anesthesia or early postoperative recovery
– Before medication administration

Intraoperative Phase
Members of the Surgical Team
• Surgeon
• Surgical assistant
• Anesthesiologist
• Certified registered nurse anesthetist
• Holding area nurse
• Circulating nurse
• Scrub nurse
• Surgical technologist
• Operating room technician
Environment of the Operating Room
• Preparation of the surgical suite and team safety
• Layout
• Health and hygiene of the surgical team
• Surgical attire
• Surgical scrub
Anesthesia
• Induced state of partial or total loss of sensation, occurring with or without loss of consciousness
• Used to block nerve impulse transmission, suppress reflexes, promote muscle relaxation, and, in
some instances, achieve a controlled level of unconsciousness
General Anesthesia
• Reversible loss of consciousness is induced by inhibiting neuronal impulses in several areas of the
central nervous system.
• State can be achieved by a single agent or a combination of agents.
• Central nervous system is depressed, resulting in analgesia, amnesia, and unconsciousness, with
loss of muscle tone and reflexes.
Stages of General Anesthesia
• Stage 1: analgesia
• Stage 2: excitement
• Stage 3: operative
• Stage 4: danger
Administration of General Anesthesia
• Inhalation: intake and excretion of anesthetic gas or vapor to the lungs through a mask
• Intravenous injection: barbiturates, ketamine, and propofol through the blood
• Adjuncts to general anesthetic agents: hypnotics, opioid analgesics, neuromuscular blocking
agents
Balanced Anesthesia
• Combination of intravenous drugs and inhalation agents used to obtain specific effects
• Combination used to provide hypnosis, amnesia, analgesia, muscle relaxation, and reduced
reflexes with minimal disturbance of physiologic function

(Continued)
Balanced Anesthesia (Continued)
• Example: thiopental for induction, nitrous oxide for amnesia, morphine for analgesia, and
pancuronium for muscle relaxation

Complications from General Anesthesia

• Malignant hyperthermia: possible treatment with dantrolene
• Overdose
• Unrecognized hypoventilation
• Complications of specific anesthetic agents
• Complications of intubation
Local or Regional Anesthesia
• Sensory nerve impulse transmission from a specific body area or region is briefly disrupted.
• Motor function may be affected.
• Client remains conscious and able to follow instructions.
• Gag and cough reflexes remain intact.
• Sedatives, opioid analgesics, or hypnotics are often used as supplements to reduce anxiety.
Local Anesthesia
• Topical anesthesia
• Local infiltration
• Regional anesthesia
– Field block
– Nerve block
– Spinal anesthesia
– Epidural anesthesia
Epidural Anesthesia
Complications of Local or Regional Anesthesia
• Anaphylaxis
• Incorrect delivery technique
• Systemic absorption
• Overdosage

Complications of Local or Regional Anesthesia (Continued)

• Assess for central nervous system stimulation, central nervous system and cardiac depression,
restlessness, excitement, incoherent speech, headache, blurred vision, metallic taste, nausea and vomiting,
tremors, seizures, increased pulse, respirations, and blood pressure.
Treatment of Complications
• Establish an open airway.
• Give oxygen.
• Notify the surgeon.
• Fast-acting barbiturate is usual treatment.
• If toxic reaction is untreated, unconsciousness, hypotension, apnea, cardiac arrest, and death may
result.
Conscious Sedation
• IV delivery of sedative, hypnotic, and opioid drugs reduces the level of consciousness but allows
the client to maintain a patent airway and to respond to verbal commands.
• Diazepam, midazolam, meperidine, fentanyl, alfentanil, and morphine sulphate are the most
commonly used drugs.
(Continued)
Conscious Sedation (Continued)
• Nursing assessment of airway, level of consciousness, oxygen saturation, electrocardiographic
status, and vital signs are monitored every 15 to 30 minutes.

Collaborative Management
• Assessment
• Medical record review
• Allergies and previous reactions to anesthesia or transfusions
• Autologous blood transfusion
• Laboratory and diagnostic test results
• Medical history and physical examination findings
Risk for Perioperative Positioning Injury
Interventions include:
• Proper body position
• Risk for pressure ulcer formation
• Prevention of obstruction of circulation, respiration, and nerve conduction
Impaired Skin Integrity and Impaired Tissue Integrity
Interventions include:
• Plastic adhesive drape
• Skin closures, sutures and staples, nonabsorbable sutures
• Insertion of drains
• Application of dressing
• Transfer of client from the operating room table to a stretcher
Potential for Hypoventilation
• Continuous monitoring of:
– Breathing
– Circulation
– Cardiac rhythms
– Blood pressure and heart rate
• Continuous presence of an anesthesia provider

Interventions for Postoperative Clients

PACU Recovery Room
• Purpose is to provide ongoing evaluation and stabilization of clients to anticipate, prevent, and
treat complications after surgery.
• PACU is usually located close to the surgical suite.
• The PACU nurse is skilled in the care of clients with multiple medical and surgical problems that
can occur following a surgical procedure.
Collaborative Management
• Assessment
• Physical assessment and clinical manifestations
– Assess respiration.
– Examine surgical area for bleeding
– Monitor vital signs.
– Assess for readiness to discharge once criteria have been met.
Respiratory System
• Airway assessment
• Breath sounds
• Other respiratory assessments
Cardiovascular Assessment
• Vital signs
• Cardiac monitoring
• Peripheral vascular assessment
Neurologic System
• Cerebral functioning
• Motor and sensory assessment important after epidural or spinal anesthesia
– Motor function: simple commands; client to move extremities
– Return of sympathetic nervous system tone: gradually elevate head and monitor for hypotension
Fluid, Electrolyte, and Acid-Base Balance
• Check fluid and electrolyte balance.
• Make hydration assessment.
• Intravenous fluid intake should be recorded.
• Assess acid-base balance.
Renal/Urinary System
• The effects of drugs, anesthetic agents, or manipulation during surgery can cause urine retention.
• Assess for bladder distention.
• Consider other sources of output such as sweat, vomitus, or diarrhea stools.
• Report a urine output of < 30 mL/hr.
Gastrointestinal System
• Nausea and vomiting are common reactions after surgery.
• Peristalsis may be delayed because of long anesthesia time, the amount of bowel handling during
surgery, and opioid analgesic use.
• Clients who have abdominal surgery often have decreased peristalsis for at least 24 hours.
Nasogastric Tube Drainage
• Tube may be inserted during surgery to decompress and drain the stomach, to promote
gastrointestinal rest, to allow the lower gastrointestinal tract to heal, to provide an enteral feeding route, to
monitor any gastric bleeding, and to prevent intestinal obstruction.

(Continued)
Nasogastric Tube Drainage (Continued)
• Assess drained material every 8 hours.
• Do not move or irrigate the tube after gastric surgery without an order from the surgeon.

Skin Assessment
• Normal wound healing
• Ineffective wound healing: can be seen most often between the 5th and 10th days after surgery
– Dehiscence: a partial or complete separation of the outer wound layers, sometimes described as a
“splitting open of the wound.”
(Continued)
Skin Assessment (Continued)
– Evisceration: a total separation of all wound layers and protrusion of internal organs through the
open wound.
• Dressings and drains, including casts and plastic bandages, must be assessed for bleeding or other
drainage on admission to the PACU and hourly thereafter.

Discomfort/Pain Assessment
• Client almost always has pain or discomfort after surgery.
• Pain assessment is started by the postanesthesia care unit nurse.
• Pain usually reaches its peak the second day after surgery, when the client is more awake, more
active, and the anesthetic agents and drugs given during surgery have been excreted.
Active ROM Exercises
Impaired Gas Exchange
Interventions include:
• Airway maintenance
• Positioning the client in a side-lying position or turning his or her head to the side to prevent
aspiration
• Encouraging breathing exercises
• Encouraging mobilization as soon as possible to help remove secretions and promote lung
expansion
Impaired Skin Integrity
Interventions include:
• Nursing assessment of the surgical area
• Dressings: first dressing change usually performed by surgeon
• Drains: provide an exit route for air, blood, and bile as well as help prevent deep infections and
abscess formation during healing
(Continued)
Impaired Skin Integrity (Continued)
• Drug therapy including antibiotics and irrigations are used to treat wound infection.
• Surgical management is required for wound opening.

Acute Pain
Interventions include:
• Drug therapy
• Complementary and alternative therapies such as:
– Positioning
– Massage
– Relaxation and diversion techniques
Potential for Hypoxemia
Interventions include:
• Maintenance of airway patency and breathing pattern
• Prevention of hypothermia
• Maintenance of oxygen therapy as prescribed
Health Teaching
• Prevention of infection
• Dressing care
• Nutrition
• Pain medication management
• Progressive increase in activity level
• Use of proper body mechanics