PERIOPERATIVE

CARE
Care of Patients
Requiring Surgery
Perioperative Care
Learning Objectives
Define key terms.
Define the three phases
of perioperative care.
Describe the methods of
classifying a surgical
procedure and give an
example of each one.
Describe the different
types of anesthesia.
Utilize the nursing
process in the care of a
surgical patient.
Describe the nursing
intervention for each of
the three phases.
Perioperative Care
Learning Objectives-
continued
Identify factors and health
conditions that may
influence or alter the well-
being of an surgical
patient.
Describe the nurses’ legal
responsibilities in the
preparing the patient for
surgery.
Identify the appropriate
nursing care in assessing
and monitoring for
complications.
Utilize effective
communication techniques
in teaching client and
family about surgery.
Perioperative Care
Three Phases

Preoperative

Intraoperative

Postoperative
 Perioperative Care
Categories and Purposes

Reason/Purpose
Diagnostic, curative, restorative,
palliative, cosmetic
Degree of Urgency
urgent, elective, optional
Degree of Risk
major, minor
Anatomic location
Extent of surgery- minimal, open,
simple and radical
 Perioperative Care
Preoperative Phase-
Assessment

• Risk Factors
age, nutritional, health
status, fluid & electrolytes
imbalances, radiation,
cardiopulmonary,
chemotherapy, meds,
family history, prior
surgical experiences
(positive/negative), type
of surgery, location site
 Perioperative Care
Preoperative Phase- Assessment

• Nursing History
– past & present, meds, diet, allergies
(latex), personal habits, occupation,
finances, family support, knowledge of
surgery, attitude
• Physical Exam
• Diagnostic Tests
– CBC, electrolytes, creatinine, urinalysis,
x-ray exams, EKG, Blood Type, PTT, PT,
Platelet
– Blood donations
• Radiographic
• Bloodless Surgery/Discharge
 Perioperative Care
Preoperative Care

• Psychological Response
• Informed Consent - Nurse
witness
• Mentally competent
• If minor, a guardian, parent,
or court order will sign
permit; state will dictate
age.
• Sociological
Nursing Process –
Preoperative Care

• Assessment
– History, Physical Exam,
Lab/Radiology, Health
Status, Risk Factors, Meds
• Nursing Diagnosis
• Planning
– Goal statement
– EOC (expected outcome
criteria)
 Perioperative Care
Preoperative -Implementation

• Informed Consent • Vital Signs

• Nutrition/fluids – • Height/ Weight
IV ; NPO after MN • Special orders -
• Elimination (insert tubes,
-enemas, foley medications)
• Hygiene - skin • Promote Comfort -
scrub; remove nail Anti-anxiety meds
polish, hair pins, • Skin preparation
hospital gown
 Perioperative Care
Preoperative Nursing Care

• Pre-op Teaching
– leg and deep breathing exercises;
ROM exercises
– Moving patient ; coughing and
splinting
– Preoperative medications : when
they are given & their effects
– Postoperative pain control
– Explanation & description of
postanesthesia recovery room or
postsurgical area
– Discussion of the frequency assessing
V/S & use of monitoring equipments
Perioperative Care
Preoperative - Implementation

• Day of Surgery
complete pre-op checklist
sheet in medical record
VS
skin prep
removal of prosthetics, hair
pins, dentures
bowel and bladder prep
IV, NG Tube, ID band
pre-op medications.
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
Preoperative
Checklist
• 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
Perioperative Care
Pharmocology

• Purpose - facilitate
effective anesthetics,
minimize respiratory tract
secretions and relax,
reduce anxiety.

• Types - Opiates,
Anticholinergics,
Barbiturates, Prophylactic
antibiotics
Perioperative Care
Pharmocology
Hazardous to Surgery
• Certain antibiotics
• Anti-depressants
• Phenothiazines
• Diuretics
• Steriods
• Anticoagulants
INTRAOPERATIVE PERIOD

• Intraoperative period is the

time during which the
client undergoes surgery.
• Intraoperative period is in
the operating suite
– Receiving room - client is
observed until the surgical
team is ready
– Operating room - Where the
care and safety are in the
hands of the surgical team
 Perioperative Care
Intraoperative Care

• From the holding room to the

operating room and then to
recovery room.

• Implementation of anesthesia for

analgesic, sedative, and muscle
relaxant purposes as well as
control Autonomic Nervous
System.
• Surgeon, surgical assistant
– Surgical scrub, gowning, surgical asepsis
• Anesthesia
– Anesthesiologist, CRNA
• Holding Area Nurse
• Circulating Nurse
• Scrub Nurse/Surgical
Technologist (ORT’s)
• Specialist Nurse

Intraoperative Care Staff

What is a Perioperative
Nurse?

A perioperative
nurse is a nurse who
provides patient
care, manages,
teaches, and studies
the care of patients
undergoing operative
or other invasive
procedures.
What Does a
Perioperative Nurse
Do?
Provides specialized nursing
care to
patients before, during, and
after their
surgical and invasive procedures
Helps plan, implement, and
evaluate
treatment of the patient
Acts as a patient advocate for
patients
undergoing surgical and invasive
procedures
Works closely with all members
of the surgical team (Surgeon,
anesthesiologist, surgical
technologist, etc.)
Roles of Perioperative Nurses

• Scrub Nurse
• Circulating Nurse
• Registered Nurse First
Assistant (RNFA)
• Perioperative Educator
• OR Manager/Director
 Scrub Nurse

• Selects and handles instruments

and supplies used for surgery

• Works directly with surgeon

• In the sterile field

Circulating Nurse
• Manages the individual operating
room and care of the patient in
the OR

• Creates and maintains

comfortable,safe environment

• Helps all team members work

together

• Works in the OR in the area

outside the sterile field
RN First Assistant

• Directly assists surgeon

• Controls patient’s bleeding

• Provides wound exposure

and suturing

• Involved in care before,

during,and after surgery
 Perioperative Care
Preoperative -Anesthesia

• Types

– General

– Regional

– Local
Perioperative Care
Intraoperative Care

Common General Anesthetics

• Inhaled General Anesthetics
– Nitrous oxide, cyclopropane
• Inhaled liquid
– halothane, enflurane, isoflurane
• Intravenous Anesthetic
– Pentothal (thiopental)
 Perioperative Care
Nursing Concerns-Intraop

• Patent Airway
• Therapeutic Response to
Anesthesia
• Proper Positioning
• Maintain Surgical Asepsis
 Perioperative Care
Intraoperative Care-Complication

• Hypoventilation • Cardiac
dysrhythmia
• Oral Trauma -
endotracheal • Hypothermia
intubation
• Peripheral
• Hypotension nerve damage

• Malignant
hyperthermia
Perioperative Care
Intraoperative - Complications 2

• Malignant hyperthermia - due

to abnormal and excessive
intracellular collection of Ca+
resulting in hypermetabolism
and increased muscle
contraction.
• Signs and Symptoms - high
fever, tachycardia, muscle
rigidity, heart failure,
pseudotetany, and CNS
damage.
 Perioperative Care
Intraoperative Care

• Treatment of Malignant
Hyperthermia

– discontinue inhalent
anesthetic, Give Dantrium,
oxygen, dextrose 50%,
diuretic, antiarrhythmics,
sodium bicarbonate, and
hypothermic measures-cooling
blanket, iced IV saline or iced
saline lavage of stomach,
bladder, rectum.
 Perioperative Care
Adjunctive Anesthetic Agents

• Opioid analgesic • Anticholinergic

– Alfenta – Atropine,
– Demerol and scopolamine
Morphine
• Benzodiazepine • Sedative-hypnotic
– Valium, – Atarax, Vistaril,
Versed Seconal,
Nembutal
 Perioperative Care
Intraoperative-Drug Interaction

• Antihypertensives-
hypotension

• Beta-Blockers- myocardium
decreased

• Tetracycline--renal toxicity

• Enflurane - liver disease

lead to toxicity
 Perioperative Care
Anesthesia
• Local/Regional • Topical
– Epidural – Dermoplast
– Infltration (benzocaine)
– Nerve Block – cocaine
– Spinal – ethyl chloride
– Topical
• Anesthetic agents
– Xylocaine, Novocain,
carbocaine
 Perioperative Care
Anesthesia

• Geriatric concerns
• Address safety issues - sensory
decline
• Hepatic, cardiac respiratory and
renal decline
• Assess for preexisting problems
such as cardiac, renal, hepatic, or
respiratory.
Postoperative Care
 Learning
Objectives/Outcomes

• Define the time line for the

postoperative period.
• Describe nursing care
during the PACU.
• Describe nursing care
during the post operative
period.
• Identify proper technique in
care of surgical wounds.
• State complications in
wound healing.
 POSTOPERATIVE
PERIOD

• Postanesthesia care unit-

nurses ensure the safe
recovery of surgical clients
in which they are intensely
monitored
• The immediate
postoperative period refers
to the first 24 hours after
surgery
• Nurses should monitor for
complications
 Perioperative Care
Immediate Anesthetic
Care (PACU)

• Respiratory Status
- patent airway
• Cardiovascular
- regular, strong HR and
stable BP (VS); peripheral
pulses; Homan’s Sign
• Neurological
– level of consciousness;
orientation, sensation
• Fluid and Electrolyte, Acid
Base Balance
 Perioperative Care
Immediate Anesthetic Care

• Airway/breathing ex.
• VS, Pulses • Dressings
• IV • Drains/Tubes
• ABG’s • I&O; renal
• Pulse oximetry function
• Pupil Respond • Medications
• Level of conscious • Laboratory
work
• Safety
• Hemodynamics
• Position/ROM
• Comfort
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
Post – Operative Care
Nutrition

• Clear Liquids
• Full Liquids
• Soft
• Regular
Nursing Care Post Op
Physical Assessment
(continued)

• Renal Function
• Gastrointestinal
• Dressings
• Pain
• Thermoregulation
Perioperative Care
Elderly Care in Postop

• Respiratory • Hypothermia
System – less
– diminished subcutaneous
airway tissue,
reflexes and muscle, slow
cough metabolic
• Cardiovascular rate
– myocardium • Pain
weakness – more intense,
confusion,
impaired
circulation
and sensory
 Perioperative Care
Complications in Postop

• Hypotension • Immobility with

• Dysrhythmia skin integrity
• Venous • Urinary
Thrombosis retention
• Pulmonary • Urinary tract
Embolism infection
• Hiccoughs • Wound
infection,
• Adbominal
dehiscence,
distention -
hemorrhage
paralytic ileus
evisceration,
 Perioperative Care
Postop Care

• Psychological
– Anxiety
– Altered body image
– Finances, Family
responsibility
– Future changes
PERIOPERATIVE CARE
Postoperative Care

• Postoperative Care
– Same care as immediate
anesthetic care
– Decrease frequency of
vital signs to every 4
hours, IV’s will be
discontinued in time,
increase ADL, decrease
in breathing exercises
and breathing
treatments, advance
diet.
– Recovery Period - 4 to 6
weeks
 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
NURSING IMPLICATIONS:
NURSING DIAGNOSES

• DEFICIENT KNOWLEDGE
• FEAR
• ACUTE PAIN
• IMPAIRED SKIN INTEGRITY
• RISK FOR INFECTION
• RISK FOR DEFICIENT FLUID
VOLUME
• INEFFECTIVE BREATHING
PATTERN
• INEFFECTIVE AIRWAY
CLEARANCE
• RISK FOR IMPAIRED GAS
EXCHANGE
• DISTURBED BODY IMAGE
• RISK FOR INEFFECTIVE
THERAPEUTIC REGIMEN
MANAGEMENT
 Perioperative Care
Discharge Plans
• Patient/Family Education and
Psychosocial Support is throughout.
– Return MD Visit
– Dressing Care and Comfort
– Optimum respiratory,circulatory
function, diet, meds(antibiotics,
analgesic)
– Adequate hydration and body
temperature
– Adequate renal function, safety in
ADL
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
 PERIOPERATIVE CARE
Summary

• Specific Nursing Duties for

each phase:
– Preoperative, Intraoperative,
Postoperative

• Throughout Perioperative
Care, the nurse will always:
– Monitor patient’s response to
therapeutic regime, prevent
complications, patient
education and promote
optimum well-being