Definition of Perioperative Nursing

The provision of nursing care by an RN

preoperatively, intraoperatively, and
postoperatively to a patient undergoing an
operative or invasive procedure.
 Areas in Which
Perioperative Nursing
Is Practiced
• Perioperative nursing is practiced in
– Hospital operating rooms
– Interventional radiology suites
– Cardiac catheterization labs
– Endoscopy suites
– Ambulatory surgery centers
– Trauma centers
– Pediatric specialty hospitals
– Physician offices
 Functions of the
Perioperative Nurse
• Advocate
• Protector
• Teacher
• Change agent
• Manager of patient care
Nursing Roles in the OR
– Circulating Nurse
– Scrub person
– RN first assistant (RNFA)
– Perioperative educator
– Specialty team leader
– Perioperative manager
 Surgical Attire
• Gowns
• Gloves
• Masks
• Hair covering
• Protective eyewear
• Surgical shoe covers
Goals of Patient Safety

• Provide safe patient care

– Knowledge of procedure
– Ensure the correct patient, correct site, correct level, and correct
procedure
– Knowledge of positioning
– Adhere to safe medication administration guidelines
– Perform surgical counts

• Provide a safe environment

– Adhere to asepsis
– Promote coordinated and effective communication
Phases of Perioperative period

• PRE- operative phase

• INTRA- operative phase

• POST- operative phase

 PRE-Operative Phase
• Begins when the decision to
have surgery is made and ends
when the client is transferred to
the operating table
INTRA-Operative Phase
• Begins when the client is
transferred to the operating table
and ends when the client is
admitted to the post-anesthesia
unit
Post-operative Phase
• Begins with the admission
of the client to the PACU
and ends when healing is
complete
 Activities in the Pre-op
• Assessing the clients
• Identifying potential or actual health
problems
• Planning specific care
• Providing pre-operative teaching
• Ensure consent is signed
 Consent
• The surgeon is responsible
for obtaining the consent
for surgery
• No sedation should be
administered before
SIGNING the consent
• The nurse may serve as
witness
Activities during the Intra-op

Assisting the surgeon

as scrub nurse and circulating nurse
 Activities in the POST-op
• Assessing responses to surgery
• Performing interventions to promote
healing
• Prevent complications
• Planning for home-care
• Assist the client to achieve optimal
recovery
 TYPES of SURGERY
• According to PURPOSE

• According to degree of
URGENCY

• According to degree of RISK

 According to PURPOSE
Diagnostic Establishes a diagnosis

Palliative Relieves or reduces pain or

symptoms
Ablative Removes a diseased body
part
Constructive Restores function or
appearance
Transplant Replaces malfunctioning
structures
 According to degree of urgency

Emergency Preserves function or life

surgery Performed immediately

Elective Performed when condition

surgery is not imminently life
threatening
 According to degree of RISK
Major Involves high degree of risk
Surgery Complicated or prolonged

Minor Involves low risk

Surgery Produces few complications
Performed as day surgery
Classification Indication for examples
surgery
I.Emergent Without delay trauma
life threatening
II Urgent 24-30 hrs AP,
Cholecystitis
III. Required Plan within Cataracts,
weeks or month thyroid
IV. Elective No emergency CS, hernia
V. Optional Personal Cosmetic
preference surgery
Health factors that affect preoperatively
• Nutritional status
• Drug or alcohol abuse
• Respiratory status
• Cardiovascular status
• Hepatic and renal Factors
• Endocrine Function
• Immune function
• Previous medication use
• Psychosocial factors
• Spiritual and cultural beliefs
 Surgical Risk
• Extremes of age
• Malnourished
• Obese
• Co-morbid conditions
• Concurrent medications
 Pre-operative Interventions
• Ensure signed consent form
• Obtain nursing history, PE and lab exam
• Provide pre-operative teaching as to the
nature of surgery, what to expect and
ways to manage post-operative
discomforts
• Perform physical preparations- shaving,
hygiene, enema, NPO, medications
 Pre-op nutrition
• Assess order for NPO
• Solid foods are withheld for
about 8 hours before general
anesthesia
Pre-op elimination
• Laxatives, enemas or both may
be prescribed the night before
surgery
• Have the client void
immediately BEFORE
transferring them to the OR
• Foley catheter may be inserted
as ordered
Pre-op hygiene
• Bathe the night before surgery with
antiseptic soap
• Shaving of the skin is usually done in
the OR
• Removal of jewelry and nail polish
Pre-op psychological
preparation
• Be alert to the client’s anxiety level
• Answer questions or concerns
• Allow time for privacy
• Preparing the skin
• Administering Preanesthetic
medications
• Transporting the patient to
the presurgical area
 Pre-operative medications
Pre-op Drugs Example Purpose
Anti-anxiety Diazepam To decrease nervousness
Promote relaxation
Anti- Atropine Decreases secretions
cholinergic Prevent bradycardia
Muscle Succinylcholine To promote muscle
relaxant relaxation
Anti-emetic Promethazine To prevent nausea and
vomiting

Antibiotic Cephalosporin To prevent infection

 Pre-operative medications

Pre-op Example Purpose

Drugs
Analgesics Meperidine To decrease pain and
decrease anesthetic
dose
Anti- Diphenhydramine To decrease
histamine occurrence of allergy

H-2 Cimetidine To decrease gastric

antagonist fluid and acidity
 Pre-operative screening test
CBC Determine Hgb and Hct, infection
Blood type Determined in case of blood
transfusion
Serum Evaluates the fluid and electrolyte
electrolytes status
FBS Evaluates diabetes mellitus
BUN, Creatinine Assess the renal function
ALT, AST, Evaluates the liver function
Bilirubin
Serum albumin Evaluates nutritional status
CXR and ECG Respiratory and Cardiac status
 Pre-operative teaching
Leg exercises To stimulate blood circulation
• Pre-operative teaching
in the extremities to prevent
thrombophlebitis

Deep breathing To facilitate lung aeration and

and Coughing secretion mobilization to
Exercises prevent atelectasis and
hypostatic pneumonia
Done every two to four hours
Positioning and To stimulate circulation,
Ambulation stimulate respiration, decrease
stasis of gas
 ARE YOU
READY FOR
YOUR
OPERATION?
 Intra-operative phase interventions
• Determine the type of surgery and
anesthesia used
• Position client appropriately for
surgery
• Assist the surgeon as circulating or
scrub nurse
• Maintain the sterility of the surgical
field
• Monitor for developing complications
 Basic Guidelines in Surgical Asepsis
• All materials in contact with the surgical
wound and used within the sterile field
must be sterile.
• Gowns are considered sterile in front from
the chest to the level of the sterile field.
• Sterile drape
• Items should be dispensed to a sterile
field by methods that preserve the sterility
• Movement of the surgical team
are from sterile to sterile and
from unsterile to unsterile area.
• When a sterile barrier is
breached, the area , must be
considered contaminated
PUT CAP AND
MASK FIRST
BEFORE
SCRUBBING
THIS IS HOW TO
SCRUB
 USE FOOT
PADDLE OR
ELBOW IN
OPENING OR
CLOSING FAUCET
AND SOAP
DISPENSER
ASSISTING IN
GLOVING
CIRCULATING
NURSE
ASSISTING
THE SCRUB
NURSE
• state of narcosis (severe
CNS depression produced
by pharmacological agents),
analgesia, relaxation and
reflex loss
• loses the ability to maintain
ventilatory function and
require assistance in
maintaining a patent airway.
• Cardiovascular function may
be affected as well
 Anesthesia
• General anesthesia
– Loss of all sensation and
consciousness

• Regional or Local anesthesia

– Loss of sensation in ONE area
with consciousness present
Minimal sedation

- drug induced state in which a

patient can respond normally in
verbal commands

- cognitive function and

coordination may be impaired
Moderate sedation

- depressed level of
consciousness that does not
impair ability to maintain a
patent airway

- calm, sedate a patient

combined with analgesic

- Midazolam/Diazepam
Deep Sedation
- a drug induced state in
which a patient cannot be
easily aroused but can
respond purposefully
after repeated stimulation
- inhaled or intravenous
- Volatile anesthetic
(halothane, Isoflurane)
- Gas anesthetic (Nitrous
oxide)
 Stages
• Stage I (Beginning Anesthesia)
- patient may have ringing, still conscious,
sense inability to move extremities
- noises are exaggerrated
- avoid unnecessary noises or motions
• Stage II: Excitement
- Characterized by struggling,
shouting, talking, crying.
- pupils dilate, rapid pulse and
irregular RR
- restrain the patient

• Stage III
- Surgical anesthesia is reached
- pt unconscious and lies quietly
- respirations are regular and CR
- may be maintained in hours if
properly given
• Stage IV: Medullary Depression
- stage is reached when too much
anesthesia is given
- RR becomes shallow, pulse is
weak and thready, pupils widely
dilated
- Without proper treatment death
will follow
- Discontinue anesthetic abruptly
Methods of Anesthesia Administration

• Inhalation
• Intravenous
• Regional Anesthesia
• Conduction and spinal anesthesia
• Local Infiltration
 GENERAL Anesthesia
• Protective reflexes are lost
• Amnesia, analgesia and hypnosis
occur
• Administered in two ways:
– Inhalational
– Intravenous
 REGIONAL Anesthesia

TOPICAL Applied directly on the skin

INFILTRATION Injected into a specific area

of skin
NERVE BLOCK Injected around a nerve

SPINAL Low spinal anesthesia

Subarachnoid
EPIDURAL Epidural space is injected
with anesthesia
 Potential adverse effects of anesthesia

• Myocardial depression, bradycardia

• Nausea and vomiting
• anaphylaxis
• CNS agitation, seizures, respiratory
arrest
• Oversedation or under sedation
• Agitation and disorientation
• Hypothermia
• Hypotension
• Malignant hyperthermia
 Patient Positioning
• Provides optimal visualization

• Provides optimal access for

assessing and maintaining
anesthesia and function

• Protects patient from harm

Position Patient during Surgery

Abdominal surgeries Supine

Bladder surgery Slightly trendelenburg

Perineal surgery Lithotomy

Brain surgery Semi-fowler’s

Spinal cord surgeries Prone mostly

Lumbar puncture Side lying, flexed body

Operating Room Team
direct patient care team
• The team is likely a symphony orchestra
• Each person is an integral entity in
harmony with his colleagues
5. THE STERILE TEAM
6. THE UNSTERILE TEAM
SCRUB OUT !!!
The Sterile Team
– Operating surgeon
– Assistants to the surgeon
– Scrub person
– They:
• scrub their hands and arms
• Don sterile gloves and gown
• Enter the sterile field (all items for the surgical
procedure are sterilized)
The Unsterile Team
– Anesthesiologist or anesthetist
– Circulating nurse
– Technicians
– They:
• Don’t enter the sterile field
• Function outside of it
• Maintain sterile technique
 Functions of the nurse during OR procedure

SCRUB NURSE •Assists the surgeon

•Maintains sterility
•Handles instruments
•Drapes patient
•Counts sponges
•Wears sterile gown, gloves
CIRCULATING •Assists the Scrub nurse
NURSE •Positions the patient for
surgery
• Positions any equipment
Scrub Nurse
– Maintain safety of the sterile field
– Knows the sterile and aseptic technique
– Prepares the instruments
– Assists the surgeon with the instruments
– PRIVATE SCRUB NURSE (employed by the
surgeon)
Circulating Nurse
– Monitors/coordinates all activities
– Controls the physical and emotional
atmosphere in the room
 POST Operative Interventions
• Maintain patent airway
• Monitor vital signs and note for
early manifestations of
complications
• Monitor level of consciousness
• Maintain on PROPER position
• NPO until fully awake, with passage
of flatus and (+) gag reflex
POST Operative Interventions
• Monitor the patency of the drainage
• Maintain intake and output monitoring
• Care of the tubes, drains and wound
• Ensure safety by side rails up
• Pain medication given as ordered
• Measures to PREVENT post-op
Complications
Post-operative interventions
PAIN MANAGEMENT
• Pain is usually greatest during the 12-
36 hours after surgery
• Narcotic analgesics and NSAIDS may
be prescribed together for the early
period of surgery
• Provide back rub, massage, diversional
activities, position changes
 Post operative interventions
POSITIONING
• Clients who have spinal anesthesia is
usually placed FLAT on bed for 8-12
hours
• Unconscious client is placed side lying
to drain secretions
• Other positions are utilized BASED on
the type of surgery
 Post-operative Interventions
Some Examples of Position Post Op

Mastectomy Semi-fowlers’, affected

arm elevated
Thyroidectomy Semi fowlers’, head
midline
Hemorrhoidectomy Semi-prone, side-lying

Laryngectomy Fowler’s

Pneumonectomy Lateral, affected side

Lobectomy Lateral, unaffected

side
 Post-operative Interventions
Some Examples of Position Post Op

Aneurysmal repair Fowler’s 45 degrees

(abdomen)
Amputation of lower Flat, with stump
extremities elevated with pillow
Cataract surgery Fowler’s 45 degrees

Supratentorial Fowlers’
craniotomy
Infratentorial Flat on bed, supine
craniotomy
Spina bifida repair Prone
Post-operative Interventions
• Deep breathing and coughing
exercises Q2-4 hours  to remove
secretions
• Leg exercises Q 2 hours  to
promote circulation
• Ambulation ASAP prevents
respiratory, circulatory, urinary and
gastrointestinal complications
Post-operative Interventions
• Hydration after NPO to maintain
fluid balance
• Suction, either gastro or respiratory
to relieve distention, to remove
respiratory secretions
• Diet progressive, usually given when
bowel sounds and gag reflex return
 Wound Care
• Inspect dressing hourly
• Change dressing daily
• Inspect for signs of infection
redness, swelling, purulent
exudate
• Maintain wound drainage
 Diet
• NPO usually immediately after surgery
• Progressive diet

• Assess the return of the bowel sounds

 Liquid Diet Vs Soft diet
Clear liquid Full liquid Soft diet
Coffee Clear liquid PLUS: All CL and FL
Tea Milk/Milk prod plus:
Carbonated Vegetable juices Meat
drink Cream, butter Vegetables
Bouillon Yogurt Fruits
Clear fruit Puddings Breads and
juice Custard cereals
Popsicle Pureed foods
Ice cream and
Gelatin sherbet
Hard candy
Urinary Elimination

• Offer bedpans
• Allow patient to stand at the bedside
commode if allowed
• Report to surgeon if NO URINE output
noted within 8 hours post-op
CPT
Chest Physiotherapy
• Chest physiotherapy is based on the
fact that mucus can be knocked or
shaken form the walls of the airways
and helped to drain from the lungs.
Chest Physiotherapy
Incentive Spirometry

• This operates on the principle that

spontaneous sustained maximal
inspiration is most beneficial to the
lungs and has virtually no adverse
effects.
• The incentive spirometer measures
roughly the inspired volume and offers
the “incentive” of measuring progress
Incentive Spirometry
 Post operative complications
Atelectasis Collapsed •Assess breath
alveoli due to sounds
secretions •Repositioning
•Deep breathing
and coughing
Inflammation •Chest physio
Pneumonia
of alveoli •Suctioning
•Ambulation
Thrombophlebitis Inflammation •Leg exercises
of the veins •Monitor for
swelling
•Elevated
extremities
 Post-operative Complications
Hypovolemic Loss of
Shock circulatory •Determine cause and
fluid volume prevent bleeding
•O2, IVF

Urinary Involuntary •Encourage ambulation

retention accumulation •Provide privacy
of urine •Pour warm water
•Catheterize
Pulmonary Embolus •Notify physician
embolism blocking the •Administer O2
lung blood
flow
Post-operative complications
Constipation Infrequent •High fiber diet
passage of •Increased fluid
stool •Ambulation
Paralytic ileus Absent bowel •Encourage
sound ambulation
•NPO until
peristalsis
returns
Wound Occurs about 3 •Daily wound
infection days after dressing
surgery •Antibiotics
•Maintain drain
Post-operative complications
Wound Separation of •Cover the wound
dehiscence wound edges with sterile
normal saline
at the suture
dressing
line
•Place in low-
Fowler’s
•Notify MD
Wound Protrusion of •Cover the wound
evisceration the internal with saline pad
organs and •Place in low-
tissues through fowler’s
•Notify MD
wound
Wound dehiscence
Wound evisceration
To emphasize
• The over-all goal of nursing care
during the PRE-OPERATIVE phase
is to prepare the patient mentally
and physically for the surgery
To emphasize
• The over-all goal of nursing care
during the INTRA-OPERATIVE
phase is to maintain client safety
To emphasize
• The over-all goals of nursing
care during the POST-
OPERATIVE phase are to
promote healing and comfort,
restore the highest possible
wellness and prevent
associated risk