equal to or greater than that which they OBJECTIVES:

PERIOPERATIVE NURSING
PHASES
- The provision of nursing care by an RN
preoperatively, intraoperatively, and
postoperatively to a patient undergoing
an operative or invasive procedure
PHILOSOPHY
- To provide comprehensive support
physically, morally, psychological,
spiritually, and socially to a patient
undergoing surgery
GOAL
- Is to assist clients and their significant
others to achieve a level of wellness
had prior to the procedure
1. Preoperative phase
- Begins with decision to perform
surgery and ends when client in OR
2. Intraoperative phase
- Begins with the entry into OR and
ends when client is in recovery
room
3. Postoperative recovery
- Intermediate – post anesthesia care
unit (PACU)
- Ongoing- begins with return to
clinical unit
- Ends at discharge form facility
 Prepare the patient mentally
 Physically prepare assist with recovery
o Process begins on admission
o Process ends when recovery is
complete
PURPOSES
It is a place…
1. To correlate theory and practice
2. To develop skills in assisting the surgeon
in the operation
3. To create a suitable sterile field for
surgical procedures to prevent
complications
AREAS IN WHICH PREOPERATIVE NURSING IS
PRACTICED:

1. Hospital operating rooms 4. Endoscopy suites 6. Trauma canters

2. Intervention radiology suites 7. Pediatric specialty hospitals
3. Cardiac catheterization labs 5. Ambulatory surgery center 8. Physician offices

FUNCTIONS OF THE PREOP NURSE

 Advocate  Teacher  Management of patient care
 Protector  Change agent
procedures. Surgery is the work done by
SURGERY a surgeon
- It is the branch of medicine concerned - Surgery can involve cutting abrading, PREFIXES AND SUFFIXES
with diseases and conditions which suturing, laser or otherwise physically Prefixes:
require or are amenable to operative changing body tissues and organs
 Supra – above; beyond  Entero – intestine  Nephron – kidney
 Ortho – joint  Hystero – uterus  Neuro – nerve
 Chole – bile or gall  Mast – breast  Oophor – ovary
 Cysto – bladder  Meningo – membrane; meninges  Pneumo – lungs
 Encephalo – brain  Myo – muscle  Phylo – kiney pelvis
  Salphingo – fallopian tube
Suffixes
 Oma – tumor; swelling
 Ectomy – removal of an organ or gland
 Rrhaphy – suturing or stitching of a part
or an organ
 Scopy – looking into
 Ostomy – making an opening or a
stoma
 Plasty – to repair or restore
 Cele – tumor; hernia; swelling;
inflammation of
SURGIAL TERMINOLOGIES
Surgical Roots
1. Angio – related to blood vessels
Plasty – replacement
Angioplasty – repair of obstructed
arteries common sites: coronary,
femoral, iliac, popliteal, arteries
2. Arth – related to a joint
e. surgical remodeling of a joint
3. Bi – two
Ex. Bilateral oophorectomy
4. Colpo – related to the vagina
Rrhappy- suture
e. colpoperreniorrhaphy – flower
arrangement; an operation to repair
tears in the vagina and surrounding
tissues
5. Encephala – brain
 Thoraco – chest
e. encephalopathy – various diseases
that affect the functioning of the brain
6. Hepat – liver
Ectomy – removal
e. hepatectomy – liver removal
7. Hyster – uterus
Ex. Hysteroctomy
8. Lapar – abdominal cavity
Octomy – surgical incision
Ex. Laparotomy – surgical incision into
the abdominal cavity
9. Lobo – lobe (brain or lungs)
Lobotomy – surgical; operation of
interrupting the pathways of white
nerve fibers within the brain
Lobectomy – surgical removal of a lobe
of an organ
10. Mammo/masto – breast
Mammoplasty – plastic surgery of the
breast in order to alter their shapes
11. Myo – muscle tissues
Myotomy – dissection or surgical
division of a muscle
12. Nepro- related to the kidney
Nephrectomy- surgical removal of a
kidneys
13. Oophor- related to the ovary
 Viscero – organ esp. abdomen
Oophorectomy- surgical removal of an
ovary
14. Orchid- related to the testicle
Orchidectomy- surgical removal of the
testis
15. Vas- related to the vas deferens
Vasectomy-surgical removal of the vas
deferens
4 Basic Pathological Conditions that Require
Surgery
Obstruction- a blockage; are dangerous
because they block the flow of blood, air, CSF,
urine and bile through the body.
Perforation- is a rupture of the organ, artery or
vein.
Erosion- break in the continuity of tissue
surface; it can be caused by irritation, infection,
ulceration or inflammation
Tumors- abnormal growth of tissue that serves
no pathologic function in the body
Major Category of Surgery
According to purpose
1. Diagnostic surgery
 To confirm a diagnosis
 Involve a procedure to visualize the
suspected unhealthy tissue
 Endoscopy, excision, biopsy
 2. Exploratory surgery
 To estimate the extent of the
disease and to conform diagnosis
 Exploratory laparotomy (ExLap)
3. Ablative surgery
 To restore malfunctioning tissue
 Removal of disease organ
 Hysterectomy, appendectomy,
amputation
4. Re-constructive surgery
 To restore the form and function of
the body
 Repair of congenital defects
 Repairs of cleft lip or palate-
Cheiloplasty
 Improve appearance or
replacement of damaged tissues
 Cosmetics surgery
 Repair of cleft lip palate
 Women who have breast implants
 Episiorrhapy
 Internal fixation of fracture
5. Cosmetic surgery
 To improve appearance; not attain
perfection
 Rhinoplasty
6. Palliative surgery
 Relieves symptom but does not
cure the disease
 Rhizotomy
 Myringotomy
According to degree of risk and management
Major surgery- involves extensive
reconstruction or alteration in the body parts;
great risks to well being
e.g. Hysterectomy, CS,
mastectomy
Minor surgery- Involves minimal
alteration in body parts
e.g. Cataract extraction, D and
C, Tooth Extraction, Circumcision, Skin Grafting
According to Urgency
1. Emergency
 Requires immediate attention
without delay
 Control of hemorrhage
 Tracheostomy
2. Urgent
 Surgical problem requires attention
within 24-48 hours
 Removal of malignant tumor
 Excision of cancerous tumor
 Removal of gallbladder stones
 Vascular repair of obstruction artery
Extent of surgery
1. Simple- only the most overtly affected
areas involved in the surgery. E.g.
simple/partial mastectomy
2. Radical- extensive surgery beyond the
area obviously involved, is directed at
finding a root cause. E.g. Radical
Hysterectomy, Radical Mastectomy
Surgical Settings: Ambulatory/Outpatient
Advantage of Outpatient:
- Low cost
- Low risk of infection
- Less interruption of routine
- Less time from work
- Less stress
- Usually elective
- Surgery causes minimal pain
- Patient accepts the idea of outpatient
surgery
- Does not require intensive post-surgery
- Can follow discharge instructions
Disadvantages:
- Less time for rapport
- Less time to assess, evaluate, teach
- Risk of potential complication
Make a collage of basic instruments – ortho
instruments,
Make a scrapbook – surgical rules, methods of
sterilization
Nursing Assessment
1. History
- Collecting information about the client
to determine surgical risk factors
- To establish rapport
- May reduce anxiety in the client and
family member
Past medical history
1. Previous surgery and experience with
anesthesia- Any untoward reactions to
anesthesia
2. Serious illness/trauma
 A- Allergy  Sedentary lifestyle- complicate the - Notify surgeon and anesthesiologist
B- Bleeding tendencies surgical course via poor muscle - Chest radiology
C- Cortisone tone, limited cardiac and - Pulse oximetry
D- DM respiratory reserves and decrease C. Musculoskeletal
E- Emboli stress response  History of fracture,
3. Alcohol or Nicotine use  Active lifestyle- post-op compliance contractures, joint
 Use of drugs signals potential 11. Social history injury, musculoskeletal
problem with the administration of  support system; occupation impairment factors in
anesthesia and risk for withdrawal surgical positioning
PHYSICAL EXAMINATION
complications  Arthritis of the neck and
 Smoker- damage lung tissue; must  to identify present health status shoulder
abstain from any nicotine product  baseline information for  Can be assessed thru
for at least 1 week prior to surgery comparison during and after passive and active ROM
 Nicotine- potent vasoconstrictor surgery and history taking
4. Current discomforts  perform a complete physical D. Gastrointestinal
 With pre-existing painful conditions examination  Should be properly
5. Chronic Illness  in trauma and emergency cases, assessed
 Consider in positioning the client examination is brief; examine part  Obtain information
during intubation and operation of the body that will be operated about normal patterns
6. Advance age  assess cognition- responses and  Anesthesia and
 Older clients have specific movement analgesics cause:
perioperative needs that should be o Prolonged
identified preoperatively SPECIFIC BODY SYSTEM ASSESSMENT
nausea and
7. Medication history  Physiologic preparations vomiting
 OTC drugs may increase operative A. Cardiovascular – All cardiac o Constipation
skills conditions can lead to E. Skin integrity
8. Psychological history decreased tissue perfusion  Document and report
 Knowledge of culture beliefs and Angina pectoris, MI, lesions, pressure ulcers
practices are components of holistic Uncontrolled HPN, Heart Failure and necrotic skin and
care B. Respiratory presence of eternal
 Certain rituals should be respected  Chronic Lung conditions- Increase device
9. Ability to tolerate pre-op stress operative risk; impair gas exchange  Note the size, color,
 Physiologic stressors include pain, Emphysema and location of the skin
tissue damage, blood loss, Asthma impairment
anesthesia fever and immobilization Bronchitis
10. Lifestyle - Ask about smoking habit; respiratory
allergies and infection
  Any alteration in skin and anesthetics predisposes to poor
integrity that can occur agents wound healing and
intraoperatively o Cannot infection
F. Renal functions metabolize o Thyroid
 Adequate renal CHO, fats, and hormone
function is necessary to amino acids replacement –
eliminate protein o Often continues
wastes, t preserve FE malnourished, throughout the
balance and to remove debilitated, and Perioperative
anesthetic agents with clotting period
 To access renal status disorders  Hypoth
o Ask about yroidis
voiding H. Cognitive and Neurologic m
patterns assessment  Cardiac
o Monitor FE  Surgical risks: arrest
balance o Uncontrolled
Preoperative Diagnostic Tests
o BUN (blood epilepsy
urea nitrogen), o Severe Tests Normal Purposes
serum headache Ranges
creatinine, o Frequent Serum 3.5-5.0 To identify
urinalysis – dizziness potassium mEq/L hyperkalemia or
most common o Light- hypokalemia
preop tests headedness Serum 1.36-1.45 To identify
G. Liver functions assessment o Tinnitus - sodium mEq/L hypernatremia,
hyponatremia,
 Client with liver disease o Unsteady gait
dehydration, or
must be assessed o Unequal pupils
overhydration
properly  Assess cognition –
Serum 96-106 To identify
o Cirrhosis orientation to time, chloride mEq/L hyperchloremia,
o History of place, and person, hypochloremia,
alcoholism cognition, or metabolic
o Increase alkalosis
surgical risk due Glucose 60-100 To identify
to impaired mg/dl hypoglycemia
liver or
I. Endocrine hyperglycemia
o Cannot detoxify
medications  DM – most common
endocrine DO;
 Creatinine 0.7-1.4 To identify  Underlying disease process and  Witness to informed consent
mg/dl acute or chronic its natural course maybe a nurse, another M.D.,
renal diseae  Name and qualifications of a clerk or any other authorized
Blood urea 10-20 To identify person performing procedure person
nitrogen mg/dl impaired liver  Explanation of risks and how  The nurse witnessing informed
(BUN) or kidney
often they occur consent, specifies whether
function or
 Explanation that patient has the witnessing explanation of
excessive
right to refuse treatment or surgery or just signature of the
protein or
tissue withdraw consent client
catabolism  Patient must be 18 years old to  Surgeon obtains operative
hemoglobin Female: To identify the sign own consent or be an permit (informed consent)
12.0-15.0 presence and emancipated minor o Surgical procedure,
g/dl extent of  Patients sign for dependent alternatives possible
Male: 13.0- anemia children as legally responsible complications and
17.0 g/dl  Patient must be deemed disfigurements or
Hematocrit Female: To identify the competent to sign own consent removal of body parts
36%-45% presence and are explained
 Patient must be alert and
Male: 39%- extent of o It is part of the nurse’s
oriented; consent may not be
51% anemia role as client advocate
signed by patient after receiving
narcotics or sedatives to confirm that the
 Not necessary if there is threat client understands
to life and legally authorized information given
person is unavailable  Informed consent for surgery
 Consent are NOT needed for and blood transfusions
emergency care if all of the FF o Adequate disclosure of
PREOP RESPONSIBILITIES diagnosis-purpose,
criteria are met:
1. Informed consent risks, and consequences
o There is an immediate it
 Patient signs consent id of legal of treatment,
is an emergency
age probability of success,
o There is an immediate
 Family member signs permit if prognosis if not
threat to life
patient is a minor instituted
o Client is unable to
 Family member signs permit if consent o Understanding and
patient is incapacitated o A legally authorized comprehension –
 Signed permit is part of person cannot be patient must be drug
patient’s chart reached free prior to signing a
 Description of procedure and consent
alternative therapies
 o Consent given
voluntarily – patient
must not be ….
o Part of legal prep for
surgery
o Active, shared decision-
making process
between provider and
recipient of care
o Protects patient,
surgeon, hospital and
its employees
o Nurses role: advocate,
witness, appropriate
person signs
2. Physical preparation
3. Preparing the client on the day of
surgery
PREOP CHART REVIEW
- Ensure all documentation, preoperative
procedures, and orders are complete
- Check the surgical consent form and
other for completeness
- Document allergies …
- Ensure results of all lab and diagnostic
tests any AB results
- Report special needs and concern
SPECIAL CONSIDERATIONS:
 Obese patients
- An obese client Is more
susceptible to postop
complications, obesity
 Elderly
 Pediatric IMPLEMETING DIETARY RESTRICITONS
 Malnourished patients
- Client is given nothing by mouth NPO
for 6-8 hrs. before surgery
o NPO status – risk for aspiration
PREOP TEACHING o Failure to adhere
 Postop experience  Cancellation of surgery
 Preop medication  Increase the risk for
 Breathing exercises, coughing, incentive aspiration
spirometry
 Splinting abdomen while coughing
PREOP NUTRITIONAL CARE
 Understands NPO stat
PREOP INSTRUCTIONS  Remove water and check room at meal
times
 Discuss procedure and postop  On clear liquid diet prior to surgery
instructions  Enemas and laxatives
 Teach about special equipment
 Teach turn, cough and deep breathing PREPARING THE CLIENT
 Teach leg exercises  Possible placement of tubes, drains, and
 Teach patient to splint incision with vascular devices
small pillow  Teaching about postop procedures and
exercises
 Allow patent to verbalize feelings about
surgery o Breathing exercise
o Incentive spirometry
 Good preoperative instructions prevent
fewer complications o Coughing and splinting
 Leg procedures and exercises
 Antiembolism stockings and elastic
wraps
PREOP PREP
 Early ambulation
Intestinal Preparation  ROM exercises
 Bowel or intestinal prep are performed
to prevent injury to the colon and to
reduce the number of intestinal NURSE ALERT!
bacteria – enema, laxative  Vigorous coughing is discouraged after
some types of surgeries
o Hernia repair
 o Brain surgeries
o Eye surgeries
o Eye surgeries
o Ear
SKIN PREP
 Skin
 Shower using antiseptic solution
 Shaving
 Caution: check allergies
 If patient needs to have surgical areas
shaved this is done in or right before
surgery-less likely to develop infection
due to shaving
o Current practice is not shave
patient unless hair interferes
with surgical site
o Use sharp disposable razor
o Strokes should be with the grain
of hair
o Nicking and scraping may
become sites of infection
DAY OF SURGERY
 Allow patient to rest on day of surgery
 Family should come 1 hr. before surgery
 Allow patient for personal hygiene
 Answer patient’s/family questions
 Monitor VS and report AB
 Assess surgical sites
 Document preop baseline status of
patient
PREOP CLIENT PREP
 Client should remove most clothing and o To reduce dose needed for
wear a hospital gown induction and maintenance
 Valuables should remain with family o To prevent reflex bradycardia
member or be locked up that happens during induction
 Tape rings in place if they can’t be of anesthesia
removed o To minimize oral secretions
 Remove all pieces of jewelry  Sedatives hypnotics/tranquilizers
 Client ears an identification band o Decrees anxiety
 Dentures, prosthetic devices, hearing o Provide sedation
aids, contact lenses, fingernail polish, o Nembutal (pentobarbital
and artificial nails must be removed sodium)
o Vistaril (hydroxyzine)
o Valium (diazepam)
IMMEDIATE PREOP PREP o Phenergan (promethazine)
o Versed (midazolam)
 Complete checklist and chart  Narcotics
 Hospital gown, voiding removal of o Relieve pain/discomfort
dentures, jewelry, contact, etc. o Demerol
 Preop meds o MS
 Transporting the client to the o Dilaudid
presurgical area about 30-60 min before o Fentanyl
anesthetics is to be given o Check respiratory depression
 Attend to family needs  Anticholinergics
o Decrease secretion of saliva and
gastric juices
PREOP MEDS o Prevent bradycardia
 Atropine sulfate
 Reduce anxiety  Robinul
 Promote relaxation  Scopolamine
 Reduce pharyngeal secretions o Check BP and HR
 Prevent laryngospasm o Dry mouth, drowsiness, urinary
 Inhibit gastric secretion consistency
 Decrease amount of anesthesia needed  Antiulcer (histamine h2 antagonist)
for induction ad maintenance of o Prevent aspiration pneumonitis
anesthesia  Ranitidine (zanact)
 PURPOSES:  Cimetidine (Tagamet)
o T relieve fear and anxiety  Famotidine (Pepcid)
  Antiemetics
o Increase gastric emptying
o Decrease n/v
 Metoclopramide
(reglan)
 Droperidol (inapsine)
PREOP PREP – NANDAS
1. Anxiety r/t to unknown
2. Risk for injury
3. Knowledge deficit
PREOP NURSING CARE
1. Anxiety
 The nurse must consider the
patient’s family and friends
when planning psychological
support
 Empowering their sense of
control
FORM THAT LISTS REQUIREMENTS TO BE
 Activities that decrease anxiety
ACERTAIN BEFORE PATIENT GOES TO
are deep breathing, relaxation
OPERATING ROOM
exercises, music therapy,
message and animal-assisted
therapy
 Use of meds to relieve anxiety
 INTERVENTIONS
o Preop teaching
o Encourage
communication
o Promoting rest
o Using distraction
o Teaching family and  Patient allergies
significant others
2. Preanesthetic Management Physical
Status Categories
 ASA/P 1: healthy patient with
no disease
 ASA/P 11: mild systemic ds
without fix limitations
 ASA/P 111: severe systemic ds
associated with definite
functions limitation
 ASA/P 1V: moribund – a patient
who is not expected to service
w/out operation
 ASA/P V1: a declaration brain-
death whose organ are being
recovered for donor
 E: emergencies
 Documents diagnostic tests are
complete
 Documents pre-op medication given
 Documents VS
 Documents safety data
o ID band in place; 2 identifiers
o Jewelry removed
 Last void
 Dentures removed
 Informed consent verifies