Perioperative Nugrsing

Perioperative Nursing Definition of SurgeryDefinition of Surgery

Surgery is any procedure performed Surgery is any procedure performed on the human body that uses on the human body that uses instruments to alter tissue or organ instruments to alter tissue or organ integrityintegrity.

Perioperative Nursing

Perioperative NursingPerioperative Nursing- connotes the delivery of patient care in the preoperative,intraoperative, and postoperativepostoperative periods of the patients surgical experience through the framework of the nursing process. The nurse assesses the patient- collecting,organizing, and prioritizing patient data; establishing nursing diagnosis;identifies desired patient outcomes;develop and implements a plan of care; and evaluates that care in terms of outcomes achieved by the patient.

Perioperative Nursing Phases

Preoperative phase – Preoperative phase – begins when the decision begins when the decision to have surgery is made and ends when the to have surgery is made and ends when the client is transferred to the OR table.client is transferred to the OR table.

Intraoperative phase – Intraoperative phase – begins when the client begins when the client is transferred to the OR table and ends when is transferred to the OR table and ends when the client is admitted to the PACU.the client is admitted to the PACU.

Postoperative phase - Postoperative phase - begins with the begins with the admission of the client to the PACU and ends admission of the client to the PACU and ends when the healing is complete.when the healing is complete.

Perioperative Nursing Types of SurgeryTypes of Surgery

Purpose/reasonsPurpose/reasons - Degree of urgencyDegree of urgency – necessity to preserve

the client’s life, body part, or body function.Degree of riskDegree of risk – involved in surgical

procedure is affected by the client’s age, general health, nutritional status, use of medications, and mental status.

Extent of surgeryExtent of surgery – Simple and radical

Perioperative Nursing Type of Surgery (Purpose)Type of Surgery (Purpose)

DiagnosticDiagnostic-Allows to confirm or establishes diagnosis. CorrectiveCorrective- Excision or removal of diseased body part. ReconstructiveReconstructive-Restore function or appearance to

traumatized or malfunctioning tissues. AblativeAblative – Removes a diseased body parts PalliativePalliative – Relieves or reduces pain or symptoms of a

disease; it does not cure TransplantTransplant – Replaces malfunctioning structures CosmeticCosmetic- Performed to improve personal appearance.

Perioperative Nursing Types of Surgery (Urgency)Types of Surgery (Urgency)

Emergency-Emergency- performed immediately to preserve function or the life of the client.

Elective Elective – is performed when surgical intervention is the preferred treatment for a condition that is not imminently life threatening or to improve the client’s life.

UrgentUrgent – Necessary for client’ health to prevent additional problem from developing; not necessarily an emergency.

Required Required – has to be performed at some point; can be pre-scheduled.

Perioperative NursingType of Surgery (Degree of Risk)Type of Surgery (Degree of Risk)

MajorMajor – involves a high degree of risk. MinorMinor – normally involves little risk. Age Age – very young and elder clients are greater

surgical risks than children and adult. General healthGeneral health- surgery is least risky when the

client’s general health is good. Nutritional StatusNutritional Status – required for normal tissue repair. MedicationsMedications – regular use of certain medications can

increase surgical risk. Mental statusMental status – disorder that affect cognitive

function

Perioperative Nursing Surgical settingsSurgical settingsSurgical suitesSurgical suitesAmbulatory care settingAmbulatory care settingClinicsClinicsPhysician officesPhysician officesCommunity settingCommunity settingHomesHomes

Perioperative Nursing Surgical settingsSurgical settings DisadvantagesDisadvantages

Less time for rapportLess time to assess, evaluation, teachRisk of potential complication post D/C.

Advantages of outpatientAdvantages of outpatient:Low costLow risk of infectionLess interruption of routineLess than from workLess stress

Preoperative Nursing Consent Consent

Nature and intention of the surgeryNature and intention of the surgery Name and qualifications of the person Name and qualifications of the person

performing the surgery.performing the surgery. Risks, including tissue damage, disfigurement, Risks, including tissue damage, disfigurement,

or even deathor even death Chances of successChances of success Possible alternative measuresPossible alternative measures The right of the client to refuse consent or later The right of the client to refuse consent or later

withdraw consent.withdraw consent.

Preoperative Nursing Assessment (Nursing History)Assessment (Nursing History)

Current health status-Current health status- AllergiesAllergies Medications- list all current medicationsMedications- list all current medications Previous surgeriesPrevious surgeries Understanding of the surgical procedure and Understanding of the surgical procedure and

anesthesiaanesthesia SmokingSmoking Alcohol and other-altering substancesAlcohol and other-altering substances CopingCoping Social resourcesSocial resources Cultural considerationsCultural considerations

Preoperative Nursing Care Physical assessmentPhysical assessment

Cardiovascular systemCardiovascular systemRespiratory systemRespiratory systemRenal systemRenal systemNeurological systemNeurological systemMusculoskeletal systemMusculoskeletal systemNutritional statusNutritional statusGerontological considerationsGerontological considerations

Perioperative Nursing CarePhysical assessment/clinical manifestationsPhysical assessment/clinical manifestations

General surveyGeneral survey- gestures and body movements may reflect decreased energy or weakness caused by illness.

Cardiovascular systemCardiovascular system- alterations in cardiac status are responsible for as many as 30% of perioperative death.

Respiratory systemRespiratory system- a decline in ventilatory function, assessed through breathing pattern and chest excursion, may indicate a client’s risk for respiratory complications.


Renal systemRenal system-abnormal renal function can altered fluid and electrolyte balance and decrease the excretion of preoperative medications and anesthetic agents.

Neurologic systemNeurologic system- a client’s LOC will change as a result of general anesthesia but should return to the preoperative LOC after surgery.


MusculoskeletalMusculoskeletal systemsystem- Deformities may interfere with intraoperative and postoperative positioning. Avoid positioning over an area where the the skin shows signs of pressure over bony prominences.

Gastrointestinal systemGastrointestinal system- alteration in function after surgery may result in decreased or absent bowel sound and distention.

Head and NeckHead and Neck- the condition of oral mucous membranes reveals the level of hydration.

Preoperative Nursing Care Gerontological ConsiderationsGerontological ConsiderationsCardiovascularCardiovascular

Coronary flow decreasesCoronary flow decreasesHeart rate decreasesHeart rate decreasesResponse to stress decreasesResponse to stress decreasesPeripheral vascular decreasesPeripheral vascular decreasesCardiac output decreasesCardiac output decreasesCardiac reserve decreasesCardiac reserve decreases

Preoperative Nursing Care Gerontological ConsiderationsGerontological Considerations

Respiratory SystemRespiratory SystemStatic lung volumes decreasesPulmonary static recoil decreases

Sensitivity of the airway receptors decreases

Nervous systemNervous systemIncreased incidence of post.op. confusion.Increased incidence of deliriumIncreased sensitivity to anesthetic agents


Renal SystemRenal System Renal blood flow declines 1.5% per year. Renal clearance reduced

GastrointestinalGastrointestinal Decreased intestinal motilityDecreased liver blood flow Delayed gastric emptying


MusculoskeletalMusculoskeletalDecreased mass, tone, strengthDecreased bone density

IntegumentaryIntegumentaryDecreased elasticityDecreased lean body massDecreased subcutaneous fat

Preoperative Nursing Care Psychosocial considerationsPsychosocial considerationsLevel of anxietyLevel of anxietyCoping abilityCoping abilitySupport systemsSupport systems

Preoperative Nursing Care Laboratory and diagnostic studiesLaboratory and diagnostic studies

Screening tests depend on the condition of the client and the nature of the surgery. If test reveals severe problems the surgery may be cancel until the condition is stabilized.

Routine screening testRoutine screening test-CBC,Blood grouping and X-match, Lytes, fasting blood sugar, BUN & Creatinine, ALT,AST, and bilirubin,Serum albumin, and Total protein, Urinalysis, Chest X-ray,ECG

Preoperative Nursing Care Common nursing diagnosisCommon nursing diagnosisKnowledge deficitKnowledge deficitAnxietyAnxietyRisk for ineffective airway clearanceRisk for ineffective airway clearanceFear related toFear related toDisturbed sleep patternDisturbed sleep patternAnticipatory grieving related toAnticipatory grieving related to

Preoperative Nursing CarePreoperative Nursing Care Preop. teachingPreop. teaching

The education plan should begin with assessment, The education plan should begin with assessment, including baseline knowledge of the patient and including baseline knowledge of the patient and family, readiness to learn,barriers to learning, family, readiness to learn,barriers to learning, patient and family concern and learning styles and patient and family concern and learning styles and preferences.preferences.

The content focuses on information that will The content focuses on information that will increase patient’s familiarity with procedural events. increase patient’s familiarity with procedural events. This includes surgical experience (procedural), This includes surgical experience (procedural), what the pt. may experience (sensory) and what what the pt. may experience (sensory) and what actions may help decrease anxiety (behavioral).actions may help decrease anxiety (behavioral).

Preoperative Nursing CarePreoperative Nursing Care AnxietyAnxietyThe nurse must consider the pt’s family The nurse must consider the pt’s family

and friends when planning and friends when planning psychological support. psychological support.

Empowering their sense of control. Empowering their sense of control. Activities that decreasing anxiety are Activities that decreasing anxiety are deep breathing, relaxation exercises, deep breathing, relaxation exercises, music therapy, massage and animal-music therapy, massage and animal-assisted therapy.assisted therapy.

Use of medication to relieve anxietyUse of medication to relieve anxiety..

Preoperative Nursing CarePreanesthesia Management Physical Status Categories

ASA 1: Healthy patient with no disease ASA 11: Mild systemic ds without fx limitations ASA 111:Severe systemic ds associated with definite fx

limitations ASA 1V: Severe systemic ds that is a constant threat to

life. ASA V: Moribund pt. Who is not expected to survive

without the operation. ASA V1: A declared brain-death whose organ are being

recovered for donor. E: Emergency

Preoperative Nursing CarePreoperative Nursing CareFinal Preparation for surgeryFinal Preparation for surgeryAll personal belongings are identified All personal belongings are identified

and secured.and secured.Jewelry is usually removed.Jewelry is usually removed.Dentures are removed, labeled and Dentures are removed, labeled and

placed in a denture cup.placed in a denture cup.Pt. to verbally confirm the surgical Pt. to verbally confirm the surgical

procedures and the surgical site. This procedures and the surgical site. This verification process is documented in verification process is documented in the medical record on the preop. the medical record on the preop. checklistchecklist.

Preoperative Nursing CarePreoperative Nursing Care Pre-op. medicationsPre-op. medications

Prior to administering – check permitsPrior to administering – check permitsPurpose: Allay anxietyPurpose: Allay anxiety Decrease Decrease

pharyngeal secretions- pharyngeal secretions- Decrease gastric secretion.Decrease gastric secretion.Decrease side effects of anesthesia.Decrease side effects of anesthesia.

Induce amnesiaInduce amnesia

Preoperative Nursing CarePreoperative Nursing Care MedicationsMedicationsSedatives/hypnotics- NembutalTranquilizers-Ativan, versed, valiumOpiate analgesics- Demerol, morphineAnticholinergics-Atropine

sulfate,ataraxH2o blockers.- Tagamet, ZantacAntiemetic- Reglan, Phenergan

Intraoperative Phase Surgical TeamSurgical Team

SurgeonSurgeonAnesthesiologistAnesthesiologistScrub NurseScrub NurseCirculating NurseCirculating NurseOR techsOR techs

Intraoperative Nursing CareIntraoperative Nursing Care Roles of team membersRoles of team members

SurgeonSurgeon-responsible for determining the responsible for determining the preoperative diagnosis, the choice and execution of preoperative diagnosis, the choice and execution of the surgical procedure, the explanation of the risks the surgical procedure, the explanation of the risks and benefits, obtaining inform consent and the and benefits, obtaining inform consent and the postoperative management of the patient’s care.postoperative management of the patient’s care.

Scrub nurse-Scrub nurse- (RN or Scrub tech)- preparation of (RN or Scrub tech)- preparation of supplies and equipment on the sterile field; supplies and equipment on the sterile field; maintenance of pt.s safety and integrity: observation maintenance of pt.s safety and integrity: observation of the scrubbed team for breaks in the sterile fields; of the scrubbed team for breaks in the sterile fields; provision of appropriate sterile instrumentation, provision of appropriate sterile instrumentation, sutures, and supplies; sharps countsutures, and supplies; sharps count..

Perioperative Nursing CarePerioperative Nursing CareSurgical teamSurgical team

Circulating NurseCirculating Nurse - responsible for creating a responsible for creating a safe environment, managing the activities safe environment, managing the activities outside the sterile field, providing nursing care to outside the sterile field, providing nursing care to the patient. Documenting intraoperative nursing the patient. Documenting intraoperative nursing care and ensuring surgical specimens are care and ensuring surgical specimens are identified and place in the right media. In charge identified and place in the right media. In charge of the instrument and sharps count and of the instrument and sharps count and communicating relevant information to individual communicating relevant information to individual outside of the OR, such as family membersoutside of the OR, such as family members.

Perioperative Nursing CarePerioperative Nursing CareSurgical teamSurgical team

Anesthesiologist and anesthetist-Anesthesiologist and anesthetist- anesthetizing the pt. providing anesthetizing the pt. providing appropriate levels of pain relief, appropriate levels of pain relief, monitoring the pt’s physiologic status monitoring the pt’s physiologic status and providing the best operative and providing the best operative conditions for the surgeons.conditions for the surgeons.

Other personnel- pathologist, radiologist, perfusionist, EVS personnel.

Perioperative Nursing Care Surgical teamSurgical team

Nursing Roles:Nursing Roles:Staff educationStaff educationClient/family teachingClient/family teachingSupport and reassuranceSupport and reassuranceAdvocacyAdvocacyControl of the environmentControl of the environmentProvision of resourcesProvision of resourcesMaintenance of asepsisMaintenance of asepsisMonitoring of physiologic and psychological Monitoring of physiologic and psychological

statusstatus

Intraoperative Nursing Care Surgical asepsis

Ensure sterilityAlert for breaks

Intraoperative Phase AnesthesiaAnesthesia

Greek word- anesthesis, meaning “negative sensation.” Artificially induced state of partial or total loss of sensation, occurring with or without consciousness.

Blocks transmission of nerve impulses Suppress reflexes Promotes muscle relaxation Controlled level of unconsciousness

Intraoperative PhaseIntraoperative Phase AnesthesiaAnesthesia Factors influencing dosage and typeFactors influencing dosage and type: :

1. Type and duration of the procedure2. Area of the body being operated on3. Whether the procedure is an emergency4. Options of management of post. Op. pain5. How long it has been since the client ate,

had any liquids, or any medications6. Client position for the surgical procedures

Intraoperative Phase Types of AnesthesiaTypes of Anesthesia

General- method use when the surgery requires that the patient be unconscious and/or paralyzed.

A general anesthetic 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.

Intraoperative Phase Stages of General AnesthesiaStages of General Anesthesia

Stage 1- Analgesia and sedation, relaxationStage 2- Excitement, deliriumStage 3- Operative anesthesia, surgical

anesthesiaStage 4- Danger

Intraoperative PhaseIntraoperative Phase

Complications of General AnesthesiaComplications of General Anesthesia Overdose Hypoventilation Related to anesthetic agents Malignant hyperthermia Related to intubation


Local or Regional AnesthesiaLocal or Regional AnesthesiaTemporarily interrupts the transmission of sensory nerve impulses from a specific area or region.

Motor function may or may not be affected Client does not lose consciousness Gag reflex remains intact Supplemented with sedatives, opioids, or

hypnotics

Types of Regional AnesthesiaTypes of Regional Anesthesia

Topical (surface)Topical (surface)LocalLocalNerve BlockNerve BlockIntravenous (Bier Block)Intravenous (Bier Block)SpinalSpinalEpidural (periduralEpidural (peridural)


Complications of Local/Regional Complications of Local/Regional AnesthesiaAnesthesia Anaphylaxis Administration technique Systemic absorption Overdosage

Spinal Anesthesia Indications -surgical procedures below the

diaphragm-patients with cardiac or respiratory disease

Advantages -mental status monitoring -shorter recovery

Disadvantages -necessary extra expertise -possible patient pain

Contraindications -coagulopathy -uncorrected hypovolemia

Spinal Anesthesia

Involved medications -lidocaine -bupivacaine -tetracaine

Patient assessment -continuous heart rate, rhythm, and pulse oximetry monitoring -level of anesthesia -motor function and sensation return monitoring

Spinal Anesthesia

Complications-hypotension-bradycardia-urine retention-postural puncture headache-back pain

Spinal analgesiaIndications

-postoperative pain from major surgery

Involved medications-lipid-soluble drugs-preservative-free morphine

Monitoring recovery-respiratory depression-urine depression-pruritus-nausea and vomiting

Examples of location for Spinal and Examples of location for Spinal and Epidural Anesthesia.Epidural Anesthesia.

Nerve Block SitesNerve Block Sites


Conscious SedationConscious SedationAdministration of IV sedative, hypnotic, and Administration of IV sedative, hypnotic, and

opioid medicationsopioid medications..

Produces a depressed level of consciousness

Retains ability to maintain a patent airway Able to respond to verbal commands or

physical stimulation Used for relatively short procedures

Postoperative Nursing CarePostoperative Nursing CareNursing assessment in the PACUNursing assessment in the PACU

Vital signs- presence of artificial airway, 02 sat,BP,pulse, temperature.

LOC- ability to follow command, pupillary response

Urinary output Skin integrity Pain Condition of surgical wound Presence of IV lines Position of patient

Postoperative Nursing CarePostoperative Nursing CareNursing DiagnosisNursing Diagnosis

Ineffective airway clearance- increased secretions 2 to anesthesia, ineffective cough, pain

Ineffective breathing pattern- anesthetic and drug effects, incisional pain

Acute painUrinary retentionRisk for infection

Postoperative PhasePostoperative Phase

Assessment of the Postanesthesia ClientAssessment of the Postanesthesia Client AirwayAirway Vital signsVital signs Cardiac monitoringCardiac monitoring Peripheral vascular assessmentPeripheral vascular assessment Level of consciousness (LOC)Level of consciousness (LOC) Fluid and electrolytesFluid and electrolytes GI systemGI system Integumentary systemIntegumentary system Discomfort/painDiscomfort/pain

Perioperative Nursing Care Postoperative ManagementPostoperative Management

Maintain a patent airwayStabilize vital signsEnsure patient safetyProvide painRecognize & manage complications

Postoperative Nursing CareWhen caring for post-surgical patient, think of the When caring for post-surgical patient, think of the “4 W’s“4 W’s””

Wind: prevent respiratory complications

Wound: prevent infectionWater: monitor I & OWalk: prevent thrombophlebitis

Postoperative PhasePostoperative Phase ComplicationsComplications Respiratory- atelectasis, pulm. Embolus Cardiovascular- venous thrombosis Gastrointestinal-Hiccoughs, N/V,abd.

Distention, paralytic ileus, stress ulcer. GU- urinary retention Hemorrhage-slipping of a ligature(suture) Wound infection- Wound dehiscence and evisceration-

DehiscenceDehiscencePartial or complete separation of the Partial or complete separation of the

outer layer of the wound.outer layer of the wound.Possible causes:Possible causes:

Poor suturing techniquePoor suturing techniqueDistentionDistentionExcessive vomitingExcessive vomitingExcessive coughingExcessive coughingDehydrationDehydrationInfectionInfection

EviscerationEvisceration Total separation of the layers & protrusion of internal

organs or viscera through the open wound. Causes: same as dehiscence Treatment:

Call for helpCover with sterile NS soaked gauze/towelsKeep moistDO NOT ATTEMPTS TO REINSERT ORGANS.Keep in supine position with knees/hips bentAssessment/VS q 5 min. until MD arrivePrepare for surgery.

Postoperative Phase

Postoperative Phase

Postoperative Nursing CarePostoperative Nursing CareGerontologic considerationsGerontologic considerations

Mental status- attributed to medications, pain, anxiety, depression.

Delirium- infection, malignancy, trauma, MI, CHF, opioid use.

Dementia-sundowning-sleep disturbances, lack of structure in the afternoon or early morning, sleep apnea.

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Perioperative Nugrsing