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PERIOPERATIVE
NURSING CARE
By
Purwaningsih
Surgery
• The treatment of injury, disease, or
deformity through invasive operative
methods.
• Surgery is a unique experience, with
no two clients responding alike to
similar operations.
From a Client’s Experiences Point
• Surgery is a major stressor for all
clients.
• Anxiety and fear are normal.
• Fear of the unknown is the most
prevalent fear prior to surgery and is
the fear that is the easiest for the
nurse to help the client overcome.
Type of Surgery
• Seriousness: Degree of risk
Major- Involves extensive reconstruction or
alteration in body parts;poses great risks.
Minor- Involves minimal alteration in body
parts;often
designed
to
correct
deformities;involves minimal risk compared with
major procedures.
Types of Surgery
• Urgency: reason for procedure:
Elective-Performed on the basis of client’s choice; not essential and may
not necessary for health.
Urgent- Necessary for client’ health,may prevent additional problem from
developing (e.g. tissue destruction);not necessarily emergency.
Emergent- Must be done immediately to save life or preserve function of
body part.
Required- Has to performed at some point;can be pre-scheduled.
Types of Surgery
• Diagnostic-Allows to confirm diagnosis.
• Corrective- Excision or removal of diseased body
part.
• Reconstructive-Restore function or appearance to
traumatized or malfunctioning tissues.
Types of Surgery
• Procurement for transplant- Removal of
organs and/or tissues from a person
pronounced brain death for transplantation
into another person.
• Constructive- Restores function lost or
reduced as result of congenital anomalies.
• Cosmetic- Performed to improve personal
appearance.
Types of Surgery
• Extent of surgery :
Simple- Only the most overtly affected areas
involved in the surgery.
Radical- Extensive surgery beyond the area
obviously involved; is directed at finding a root
cause.
Location: Based on the area of the body on which
the surgery occurs (e.g abdominal, heart surgery).
Informed Consent
• A legal form signed by the client and
witnessed by another person that
grants permission to the client’s
physician to perform the procedure
described by the physician.
Informed Consent is Required
WHEN:
• Anesthesia is used.
• Procedure is considered invasive.
• Procedure is nonsurgical but has more than a
slight risk of complications.
• When radiation or therapy is used.
Informed Consent
• What is it?
• When is it necessary?
• Who can sign?
• What is the responsibility of the nurse?
• What are the legal implications?
What is Perioperative Nursing?
• Three Phases:
• Preoperative (Preop)
• Intraoperative (Intraop)
• Postoperative (Postop)
Preoperative Phase
• Begins when the client is scheduled
for surgery and ends at the time of
transfer to the surgical suite
• 3-6 months
• 30 days
• 7 days
• Day before
Nursing Process in Pre-op Phase
Preoperative Surgical Phase
• Assessment:
Nursing History-key elements that pertains to the
surgical client’s risks and needs. Information
concerning about advance directives. Ask if the
patient has a durable power of attorney for health
care and a living will.
Medical History- includes past illnesses and the
primary reason for seeking medical care.
Preoperative Surgical Phase
Previous surgeries- past experience with surgery
can reveal potential physical and psychological
responses to procedure and alert you to special
needs and risk factors. Complications such as
anaphylaxis or malignant hyperthermia.
Medication History- any medications that might
predispose to surgical complications.
Preoperative Surgical Phase
Allergies- to medications, topical agents used to prepare
the skin for surgery, and latex can create significant
risks.
Smoking Habits – greater risks for complications.
Alcohol and Controlled Substance Use and abuse- to be
prepared for adverse reactions, such as withdrawal, that
may occur during surgery.
Client Expectations- to identify the client’s and family
perceptions and expectations regarding surgery and
health care providers.
Preoperative Surgical Phase
Family Support- determine the extent of the client’s support
from family members or friends.
Occupation- surgery may result in physical alterations that
hinder or prevent a person from returning from work.
Feeling- surgery causes anxiety and a feeling of loss of control
for most clients.
Cultural and Spiritual Factors- cultural differences in the use of
both verbal and nonverbal communication require you to
validate interpretation of cues with the client and family.
Preoperative Surgical Phase
Coping Resources- assessment of a client’s
feeling and self-concept helps to reveal
whether the client has the ability to cope with
the stress of surgery.
Body image-surgical removal of a diseased
tissue often leaves permanent disfigurement
or alteration in body function.
Laboratory 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.
Common Preoperative Laboratory
Tests
• Hemoglobin and
hematocrit (Hgb and
Hct)
• White blood cell count
(WBC)
• Blood typing and cross
matching (screening)
• Serum electrolytes
• Prothrombin time (PT)
and partial
thromboplastin time
(PTT)
• Bilirubin
• Liver enzymes
• Urine analysis
• Blood urea nitrogen
(BUN) and creatinine
Nursing Diagnosis
• Deficient knowledge r/t lack of exposure
• Anxiety r/t threat of a change in health status
or fear of unknown
• Disturbed sleep patterns r/t internal sensory
alteration (illness & anxiety)
• Ineffective coping r/t impending surgery
• Disturbed body image r/t anticipated changes
Nursing Diagnosis
• Disabled family coping r/t temporary family
disorganization and role changes
• Powerlessness r/t health care environment,
loss of independence and loss of control of
one’s body
Nursing Process in Pre-op Phase
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Planning:
Correction of any abnormal labs
Blood donations
Bloodless surgery
Nutrition
Pain Management
Surgery Classes
Discharge planning
Nursing Process Pre-op Phase
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Implementation:
Explain purpose of planned procedure
Asking questions
Adhering to NPO status
Stating understanding of preop preparations
Demonstrating correct use of
exercises/techniques to prevent complications
Interventions
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Ensuring informed consent
Client self-determination
Implementing dietary restrictions
Administration of medications
Intestinal preparation
Skin preparation
Vascular access
Pre-operative Teaching
• Tubes, drains, additional vascular access
• Post-op procedures
• Post-op exercises: breathing exercises,
incentive spirometry, coughing & splinting, leg
procedures and exercises
• Early Ambulation
• Range of Motion exercises (ROM)
Preoperative Chart Review
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Pre-op check list:
Surgical informed consent
Anesthesia informed consent
Blood transfusion consent
Site verification checklist
Lab results-report abnormal lab values
Current vital signs
Special Needs
Preoperative Client Preparation
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Clothing removed/don patient gown
Jewelry removed including body any piercing
Prosthesis: dentures, wigs, limbs
Aides: hearing, glasses, cane
Arm bands: identification, code status, blood
bracelet, fall risk status bracelet
• Misc: contact lenses, hairpins
• Nail polish, artificial nails
Preoperative Client Preparation
• Empty bladder
• Pre-operative medications
• Safe transfer to surgical suite
Pre-Operative Teaching
• Reinforce physician’s explanations and
instructions
• Discuss what to expect
• Instruct in breathing and leg exercises
• Demonstrate splinting of abdomen (if appropriate)
• Explain rationale for frequent position changes
• Discuss pain management
• Discuss cognitive coping strategies
– Imagery, distraction, optimistic self-recitation
Collaborative Management:
Assessment & Planning
• Client interview
– Correct person for the correct procedure
with correct preparation on the correct
anatomy
• Risk for perioperative positioning injury
– Lacks normal defense mechanisms
– Size, age skin integrity
• Potential for hypoventilation
• Potential for hemodynamic shifts
– Blood loss
Purposes of Preoperative Teaching
• To answer questions and concerns about
surgery.
• To ascertain client’s present knowledge of the
intended surgery.
• To ascertain the need or desire for additional
information.
• To provide information in a manner most
conducive to learning.
Physical Preparation
• Identifying the client and verifying the operative
procedure.
• Preparing operative site.
• Checking client’s vital signs.
• Assisting in putting on hospital gown, cap, and, if
ordered, antiembolic hose.
• Verifying allergies.
• Verifying NPO (nothing by mouth) status.
• Identifying any sensory deficits in the client.
Members of Sterile
Surgical Team
• Surgeon.
• First assistant (Physician or RN who assists surgeon in
performing hemostasis, tissue retraction, and wound
closure).
• Scrub nurse (an LP/VN, RN, or surgical technologist
who prepares and maintains integrity, safety, and
efficiency of the sterile field throughout the
operation).
Sterile Field
• The area surrounding the client and the
surgical site that is free from all
microorganisms.
Non-Sterile Members of the
Surgical Team
• Anesthesia provider.
• Circulating nurse (an RN responsible for management
of personnel, equipment, supplies, environment, and
communication throughout a surgical procedure).
Family Needs
• Explain where to wait
• Surgeon will talk to them after surgey
• Never judge seriousness by length of time
patient in surgery (keep family updated)
• Prepare them for what they will see post-op
• Explain post-op protocol and routines
Responsibilities related to the Medical
Record
• Complete pre-operative check list
• Place surgical consent form in plain view
• Send entire medical record (chart) to surgery
with patient
Evaluation:
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Safety
Health promotion & maintenance
Psychosocial integrity
Physiological Integrity
Variables Affecting Surgical Status
• Age
• Nutritional status
• Fluid and electrolyte
status
• Respiratory status
• Medications
• Cardiovascular status
• Renal and hepatic
status
• Neurological,
musculoskeletal, and
integumentary status
• Endocrine and
immunological status
Disease/Medication
Specific Considerations
• Diabetes Mellitus:
– At risk for hyperglycemia or hypoglycemia
• Long-term corticosteroid use:
– At risk for adrenal insufficiency
• Uncontrolled Thyroid Disease
– Overactive: risk of Thyrotoxicosis
– Underactive: risk of respiratory depression