Chapter 1

Perioperative Concepts And

Nursing Management

1
 PERIOPERATIVE & PERIANESTHESIA
NURSING
Perioperative care is the nursing care provided to a client
before, during, and after surgery.
PREOPERATIVE PERIOD
Begins when the decision for surgical intervention is
made and ends with the transference of the patient to
the operating room table.
 INPATIENT SURGERY-PROCEDURES ON A CLIENT WHO IS
ADMITTED TO THE HOSPITAL.
 OUTPATIENT SURGERY-OPERATIVE PROCEDURES PERFORMED
ON CLIENTS WHO RETURN HOME THE SAME DAY.
 LASER SURGERY-OUTPATIENT SURGICAL PROCEDURES WITH
THE USE OF A LASER .

2
INTRAOPERATIVE PERIOD
Begins when the patient is transferred onto the operating room
and ends with his admission to the postanesthesia recovery
room (PARR) or postanesthesia care unit (PACU).
POSTOPERATIVE PERIOD
Begins with the admission of the patient to the PACU or PARR
and ends with a follow –up evaluation in the clinical setting or
at home.
- The immediate postoperative period refers to the first 24 hours
after surgery.
- Nurses should monitor for complications.

3
 Surgical Classifications
1. Optional surgery: decision rests with patient (eg, cosmetic surgery).
2. Elective surgery refers to procedures that scheduled at the client's
convenience (eg, cyst removal, repair of scars simple hernia or
vaginal repair).
3. Required surgery: is warranted for conditions necessitating
intervention within a few weeks (eg, cataract surgery, thyroid disorders).
4. Urgent surgery: is indicated for a problem requiring intervention
within 24 to 48 hours (eg, some cancers, acute gallbladder infection
and appendicitis, Kidney stones).
5. Emergency surgery: describes procedures that must be done
immediately to sustain life or maintain function (eg, repair of a
ruptured aortic aneurysm, gunshot, or knife wounds, extensive burns
, fractures skull, intestinal obstruction)

4
 Informed Consent

 Information on the surgical procedure is provided by the

physician
 Explanation includes permission a client gives after an
explanation of the risks, benefits, and alternatives
 A signed form, witnessed by a nurse is evidence that consent
has been obtained
 If the client is mentally confused, unconscious, or mentally
incompetent, the client’s spouse, nearest blood relative, or
someone with durable power of attorney for the client’s health
care must sign the consent form.

5
 PREOPERATIVE NURSING CARE

 CONDUCT A NURSING ASSESSMENT

 PROVIDE PREOPERATIVE TEACHING
 PERFORM METHODS OF PHYSICAL
PREPARATION
 ADMINISTER MEDICATIONS
 ASSIST WITH PSYCHOSOCIAL PREPARATION
 COMPLETE THE SURGICAL CHECKLIST

6
SURGERY CHECKLIST

7
 RISK FACTORS THAT INCREASE
PERIOPERATIVE COMPLICATIONS
 EXTREMES IN AGE
 DEHYDRATION
 MALNUTRITION
 OBESITY
 SMOKING
 DIABETES
 CARDIOPULMONARY DISEASE
 DRUG AND ALCOHOL ABUSE
 BLEEDING TENDENCIES
 LOW HEMOGLOBIN AND RED CELLS
 PREGNANCY

8
 PREOPERATIVE TEACHING
 PREOPERATIVE MEDICATIONS: WHEN THEY ARE
GIVEN AND THEIR EFFECTS.
 POSTOPERATIVE PAIN CONTROL.
 EXPLANATION AND DESCRIPTION OF THE
POSTANESTHESIA RECOVERY ROOM OR
POSTSURGICAL AREA.
 DISCUSSION OF THE FREQUENCY OF ASSESSING
VITAL SIGNS AND USE OF MONITORING
EQUIPMENT.

9
DEEP BREATHING, COUGHING,
LEG EXERCISES
 Deep breathing is a form of controlled ventilation that opens
and fills small air passages in the lungs to prevent atelectasis
and pneumonia.
 Coughing is a natural method of clearing secretions from the
airways.
 Leg exercises help promote circulation and reduce the risk of
forming a thrombus in the veins.
 Antiembolism stockings help prevent thrombi and emboli by
compressing superficial veins and capillaries redirecting blood
to larger and deeper veins, where it flows more effectively
toward the heart.

10
DEEP BREATHING & COUGHING

11
LEGS EXERCISES

12
 PREOPERATIVE MEDICATIONS

 ANTICHOLINERGICS: Glycopyrrolate (robinal) decreases

respiratory secretions.
 ANTIANXIETY: Lorazepam (ativan) reduces anxiety.
 HISTAMINE-2 RECEPTOR ANTAGONIST: Cimetidine (tagamet)
decreases gastric acidity and volume.
 NARCOTICS: Demerol (meperidine) decreases the amount of
anesthesia needed to sedate the client.
 SEDATIVES: Midazolam (versed) promotes sleep or conscious
sedation and decrease anxiety.
 ANTIBIOTICS: Kanamycin (Kantrex) destroy enteric
microorganisms.

13
 PREOPERATIVE CHECKLIST
 History and physical examination.
 Name of procedure on surgical consent.
 Signed surgical consent.
 Laboratory results.
 Client is wearing an identification bracelet.
 Allergies have been identified.
 NPO.
 Skin preparation completed.
 Vital signs assessed.

14
 Jewelry removed.
 Dentures removed.
 Client is wearing a hospital gown and hair
cover.
 Client has urinated.
 Location of IV site, type of intravenous
solution, rate of infusion is identified.
 The prescribed preoperative medication has
been given.
15
 Types of anesthesia

1. General Anesthesia (inhaled or intravenously) refers to drug

– induced depression of the central nervous system that
produces analgesia, amnesia and unconsciousness (affects
whole body).
2. Regional anesthesia is a form of local anesthesia that
suspends sensation and motion in body region or part; the
client remains awake. Continuous monitoring is required in
the event the block is not totally effective and the client
experiences pain or reactions to blocking agents (e.g.
nausea, cardiovascular collapse). Regional anesthesia differs
in terms of location and size of the anatomic area
anesthetized and the volume and type of anesthesia agent
used.

16
3. Spinal Anesthesia is local anesthesia injected into the
subarachniod space at lumbar level to block nerves and
suspend sensation and motion to the lower extremities,
perineum, and lower abdomen.
4. Conduction Blocks suspend sensation and motion on
various groups of nerves such as epidural block (i.e.
anesthetic into space around the dura mater); Para vertebral
block (i.e. produces anesthesia of the chest, abdominal wall
and extremities) and Tran sacral (caudal) block (i.e.
anesthesia of the perineum).

17
SPINAL ANASTHESIA

18
 The perioperative team
 Surgeon performs the surgical procedure and heads the surgical
team.
 An anesthesiologist or anesthetist makes a preoperative assessment
to plan the type of anesthetic to be administered and to evaluate the
client's physical status.
 Circulating nurse manages the operating room and protects the
patient’s safety and health by monitoring the activities of the
surgical team, checking the operating room conditions, and
continually assessing the patient for signs of injury and
implementing appropriate interventions. Verify consent, ensure
cleanliness, proper temperature, humidity, and lightening; the safe
functioning of equipments; and the availability of supplies and
materials.
 Scrubbing nurse setting up the sterile tables; preparing sutures, and
special equipments; and assisting the surgeon and the surgical
assistants during the procedure by anticipating the instruments that
will be required
- Scrub nurse and circulator count all needles, sponges; and instruments used.

19
OPERATION POSITIONS

20
ENDOTRACHEAL INTUBATION

21
 INITIAL POSTOPERATIVE ASSESSMENTS

 Level of consciousness.
 Vital signs.
 Effectiveness of respirations.
 Presence or need for supplemental oxygen.
 Location of drains and drainage characteristics.
 Location, type, and rate of intravenous fluid.
 Level of pain and need for analgesia.
 Presence of a urinary catheter and urine volume.

22
 NURSING MANAGEMENT DURING
RECOVERY FROM SURGERY
 Preventing respiratory complications.
 Relieving pain.
 Encouraging activity.
 Promoting wound healing.
 Maintaining normal body temperature.
 Managing GI function.
 Nutrition.
 Resumption of urinary function.

23
POST OPERATIVE COMPLICATIONS

24
TYPES OF INCISIONS

25
CARE OF DRAIN

26
 DISCHARGE INSTRUCTIONS

 CARE OF THE INCISION.

 SIGNS OF COMPLICATIONS.
 DRUGS FOR PAIN MANAGEMENT.
 HOW TO SELF ADMINISTER PRESCRIBED
MEDICATIONS.
 ACTIVITY LEVEL.
 AMOUNT OF WEIGHT THAT CAN BE LIFTED.
 DIET.
 RETURN FOR A MEDICAL APPOINTMENT.

27
GERONTOLOGICAL CONSIDERATIONS
 Chronic medical problems increases risk of
complications.
 Sensory deprivation interferes with communication in the
operative period.
 Period of fluid restriction should be shortened before
surgery to prevent dehydration.
 Older adults needed instructions on care and
medications.
 Anticoagulant therapy increases the risk of bleeding.
 Carefully monitor cardiac status.
 A change in mental status is indicative of infection.

28