Adult Care Nursing I / Theory

Faculty of Nursing
First Semester
2021-2022
Lecture 3
Unit 4 – Chapters
17,18,19 :
Perioperative Concepts
and Nursing
Management
 Objectives:

1. Define the three phases of perioperative care.

2. Identify legal and ethical consideration related to obtaining
informed consent for surgery.
3. Describe the immediate preoperative preparation for the
patient.
4. Describe the interdisciplinary approach to the care of the
patient during surgery.
5. Describe the role of the nurse in ensuring patient safety
during the intraoperative period.
6. Describe the responsibilities of the post anesthesia care
nurse
7. Identify common postoperative problems and their
management.
 Surgical Classification

• Surgery can also be classified based upon its purpose

1. Diagnosis (a diagnostic procedure such as biopsy,
exploratory laparotomy, or laparoscopy).
2. Cure (e.g., excision of a tumor or an inflamed appendix).
3. Repair (e.g., multiple wound repair).
4. Reconstructive or cosmetic (e.g., mammoplasty,
facelift).
5. Palliative (to relieve pain or correct a problem—such as
debulking a tumor to achieve comfort, or removal of a
dysfunctional gallbladder).
6. Rehabilitative (e.g., total joint replacement surgery to
correct crippling pain)
 Surgical Classification
• Surgery can also be classified based upon the degree of urgency
involved: emergent, urgent, required, elective, and optional.
 Perioperative Nursing

• Perioperative Concept: Period of time that constitutes

the surgical experience; includes the preoperative,
intraoperative, & postoperative phases of nursing care
1. Preoperative Phase: begins when the decision to
proceed with surgical intervention is made & ends with
the transfer of the patient onto the operating room (OR)
bed.
2. Intraoperative Phase: begins when the patient is
transferred onto the OR bed & ends with admission to the
PACU (Post Anesthesia Care Unit).
3. Postoperative Phase: begins with the admission of the
patient to the PACU & ends with a follow-up evaluation in
the clinical setting or home.
 Phase One
Preoperative phase
Nursing Activities in the preoperative
phase
• Initiates initial preoperative assessment
• Initiates education appropriate to patient’s needs
• Verifies completion of preoperative diagnostic testing
• Verifies understanding of surgeon-specific preoperative
orders (e.g., bowel preparation, preoperative shower)
• Begins discharge planning by assessing patient’s need for
postoperative transportation and care
 Preoperative Assessment
 Health History & Physical Exam
 Vital signs (important for future comparisons)
 Nutritional, Fluid Status: important in promoting
healing and resisting infection and other complications
 E.g., obesity, malnutrition, dehydration,
hypovolemia & electrolyte imbalances
 Dentition (mouth condition); dental caries, dentures
& partial plates may become dislodged during
intubation and occlude the airway
 Hepatic, Renal Functions: important for anesthetic
agents metabolism and excretion
- Assess kidney & liver function tests
- Surgery is contraindicated with acute nephritis,
oliguria, anuria (except in lifesaving measures)
 Preoperative Assessment

 Respiratory Status; e.g. infections, resp. disorders,

smoking
 Surgery is usually postponed for elective cases if
the patient has a respiratory infection
 Smokers are urged to stop 30 days before
surgery to reduce complications (e.g. poor
wound healing, pneumonia)
 Cardiovascular Status is important to support
the oxygen, fluid, and nutritional needs
 Surgery may be postponed until the blood
pressure is under control
 Surgery can be modified to meet cardiac
tolerance of the patient
 Preoperative Assessment

 Endocrine Function:
 DM patients need frequent monitoring of blood
glucose. (at risk for hypoglycemia [from
inadequate carbohydrates or excessive
administration of insulin] & hyperglycemia [from
the stress of surgery])
 Patients receive corticosteroids at risk for adrenal
insufficiency
 Patients with uncontrolled thyroid disorders are at
risk for thyrotoxicosis (with hyperthyroidism) or
respiratory failure (with hypothyroidism).
 Immune Function: (allergies [e.g., Latex , food,
medications], infections [WBC count, urine analysis],
Immunosuppression [e.g. corticosteroid therapy, organ
transplantation, radiation therapy, chemotherapy)
 Preoperative Assessment

 Previous Medication Use:

 Aspirin: (common OTC medication) inhibits platelet
aggregation and increases risk for bleeding. Should be
discontinued 7 to 10 days before surgery.

 ,
 Preoperative Assessment

 Drug or Alcohol Use: Alcohol weaken the immune

system, alcohol withdrawal syndrome (i.e., delirium is
associated with a significant mortality 48-72 hrs
postoperatively).
• Spiritual and Cultural Beliefs: affect how patients
cope with fear and anxiety
– E.g., identify the ethnic group to which the patient
relates and his/her customs and beliefs
 Preoperative Assessment

Psychosocial Factors: Patients may have fear or anxiety

due to unknown, lack of control, possibility of death,
permanent incapacity, perceived threat to body integrity,
increased responsibility or burden on family members
– Prior surgical experience (self or others) affects
patients’ emotional reactions
– Assess extent and role of the patient’s support network
– Assess patient’s readiness to learn & determine the
best approach to comprehend which provides the basis
for preoperative patient education.
 Informed Consent
• Informed Consent is the patient’s autonomous decision
about whether to undergo a surgical procedure, based on
the nature of the condition, the treatment options, and the
risks and benefits involved.
• It is legal mandate; protects the patient from unsanctioned
surgery and protects the surgeon from claims of an
unauthorized operation. Should be placed in a prominent
place on the patient’s medical record and accompanies
the patient to the OR
• Should be in writing & voluntary (no coercion) before
nonemergent surgery
• The signed consent form The patient personally signs
the consent if of legal age (18 years & older) and mentally
capable (not cognitively impaired or mentally ill).
Permission is otherwise obtained from a surrogate.
 Informed Consent
 It is the surgeon’s responsibility to: provide a clear and
simple explanation of the surgery prior to the patient
giving consent (benefits, alternatives, complications,
disability, what to expect in the postoperative period
 The nurse clarifies the information provided, and if the
patient requests additional information, the nurse notifies
the physician.
• The nurse may witness the patient’s signature
• The nurse ascertains that the consent form has been
signed before administering psychoactive premedication
(invalid after psychoactive medications as they can affect
judgment and decision-making capacity)
• In an emergency the surgeon can operate without the
patients informed consent. However, every effort must be
made to contact the patient’s family (e.g., by phone, fax).
 Preoperative Nursing Interventions/
Patient Education
 Patient Education should be individualized (based on
patient’s needs) and initiated as soon as possible
 Should goes beyond descriptions of the procedure by
including explanations of the sensations the patient will
experience (overly detailed descriptions may increase
patient’s anxiety)
1- Diaphragmatic Breathing, coughing, incentive
spirometry
2- Mobility, active body movement
3- Pain management
4- Cognitive coping strategies
5- Instruction for patients undergoing ambulatory surgery
 Preoperative Nursing Interventions/
Patient Education
Diaphragmatic Breathing Exercise To promote optimal lung
expansion & prevent respiratory complications postoperatively. To
help the patient relax.
The patient assumes a semi-Fowler’s position, with the back and
shoulders well supported with pillows.
Feel the movement with your hands resting lightly on the front of
the lower ribs and fingertips against the lower chest. Breathe out
gently and fully as the ribs sink down and inward toward midline.
Then inhale deeply & slowly through the nostrils letting the
abdomen rise as the lungs fill with air.
Hold this breath for a count of five.
Exhale and let out all the air through your nose and mouth.
Repeat this exercise 15 times with a short rest after each group of
five. Practice this twice a day preoperatively.
Preoperative Nursing Interventions/
Patient Education
Preoperative Nursing Interventions/
Patient Education

Coughing Exercise: to mobilize secretions so that they

can be removed, & to prevent atelectasis, pneumonia.
– Lean forward slightly from a sitting position in bed
– Putting the palms of both hands together, interlacing
the fingers across the incision site to act as a splint
for support when coughing.
– After practicing Diaphragmatic Breathing (Deep
breathing before coughing stimulates the cough reflex)

– With mouth slightly open, breath in fully

– “Hack” out sharply for three short breaths.
– Keeping mouth open, take in a quick deep breath &
immediately give a strong cough once or twice.
Preoperative Nursing Interventions/
Patient Education
Incentive Spirometry provides feedback related to breathing
effectiveness as it measures the flow of air inhaled through a
mouthpiece.
• The nurse demonstrates how to use an incentive spirometer
Preoperative Nursing Interventions/
Patient Education
 Preoperative Nursing Interventions/
Patient Education
Mobility & Active Body Movement are important to
improve circulation, prevent venous stasis and promote
optimal respiratory function.
• The nurse explains the rationale for exercises, frequent
ambulation, position changes and after surgery
• The nurse shows the patient how to turn from side to
side or getting out of bed without causing pain or
disrupting IV lines or drainage tubes.
• Any special position the patient needs to maintain after
surgery is discussed, as is the importance of maintaining
as much mobility as possible despite restrictions.
Preoperative Nursing Interventions/
Patient Education
Mobility & Active Body Movement
Teach patient how to perform Leg Exercises postoperatively

• Lie in a semi-Fowler’s position

• Bend the knee & rise foot- hold it a few seconds, then extend
the leg & lower it to the bed.
• Do this five times with one leg & then repeat with the other
leg
Preoperative Nursing Interventions/
Patient Education

Mobility & Active Body Movement

Teach patient how to perform Foot Exercises (Postoperatively)

Trace circles with the feet by bending them down, in

toward each other, up & then out.
-Repeat these movements five times.
Preoperative Nursing Interventions/
Patient Education

Pain Management
• Pain intensity scale should be explained to promote
more effective post operative pain management.
•Postoperatively, medications are given to relieve pain
and maintain comfort without suppressing respiratory
function.
•The patient is instructed to take the medication as
frequently as prescribed during the initial
postoperative period for pain relief.
•After discharge to home patient will likely receive oral
analgesic agents.
Preoperative Nursing Interventions/
Patient Education
 Pain Intensity Scale
Preoperative Nursing Interventions/
Patient Education
4- Cognitive Coping Strategies are useful for
relieving tension and anxiety, decreasing fear &
achieving relaxation
 General Strategies Include:
Imagery: patient concentrate on a pleasant experience
or restful scene.
Distraction: patient thinks of an enjoyable story or
recites a favorite poem or song.
Optimistic self-recitation: patient recites optimistic
thoughts (“I know all will go well”).
Quran / Music: patient listens to Quran / soothing music
Preoperative Nursing Interventions/
Patient Education
For patients undergoing ambulatory surgery:
• Preoperative education is performed in the surgeons
office or by telephone contact.
• Compromise all previously discussed education
• Tells the patient what to bring (insurance card, list of medications)
What to leave at home (jewelry, watch, medications)
• What to wear (loose-fitting, comfortable cloths; flat shoes)
• Patient is reminded not to eat or drink for a specified period of
time preoperatively.
 General Preoperative Nursing Interventions

 Providing Psychosocial Interventions to reduce Anxiety,

& Fear
– Each patient should be acknowledged as an individual,
and each patient’s needs and desires must be assessed
– Discussion of the surgical experience (e.g., length, who
else will be present in the OR, and explanation of what
will happen may diminish the patient’s anxiety by
gaining a sense of control
– The patient benefits from knowing when family and
friends will be able to visit after surgery
– Respecting cultural, spiritual, religious Beliefs
 General Preoperative Nursing Interventions

Maintaining Patient Safety:

 Identify patients correctly, use medicines safely, use alarms
safely, Prevent infection, Prevent mistakes in surgery
protecting Patient from injury
Managing Nutrition, Fluids:
 The purpose of withholding food and fluid before surgery is to
prevent aspiration.
 Until recently, fluid and food were restricted preoperatively
overnight and often longer
 IV fluids may be administered
 General Preoperative Nursing Interventions
Preparing Bowel for abdominal or pelvic surgery:
• Cleansing enema or laxative may be prescribed on the
evening before surgery and morning of surgery to allow
satisfactory visualization of the surgical site and to prevent
trauma to the intestine or contamination of the peritoneum
by fecal material.
• Antibiotic may be prescribed to reduce intestinal flora
Preparing Skin: The goal is decrease bacteria without
injuring the skin
• Some surgical centers implement antiseptic skin cleansing
protocols (a soap containing detergent-germicide for several
days before surgery. the surgical site is typically marked by
the patient and the surgeon prior to the procedure
• Hair is not removed preoperatively unless the hair at or
around the incision site is likely to interfere with the
operation. Shaving is no longer recommended; clipping the
hair is evidence-based practice.
Immediate Preoperative Nursing Interventions

• Follow the Preoperative Checklist: gown, dentures

removal, jewelry, Void & bowel emptying, valuables stored in a
secure place

• Administering Preanesthetic Medication: (Having the

patient void prior to administering a premedication is necessary for
patient safety to prevent falls & injury)
 Sedatives or anxiolytics (they might be “on call to OR“ due to
delays in the OR). It usually administered in the preoperative
holding area and it takes 15 to 20 minutes to prepare the
patient for the OR.
 If given in the ward, the patient is kept in bed with the side
rails raised, because the medication can cause
lightheadedness or drowsiness, and the nurse should keep a
close eye on the patient (drowsiness may develop).

• Maintaining preoperative record

o Patient file, diagnostic test, consent form, and nurse’s notes
Immediate Preoperative Nursing Interventions
Preoperative Checklist
Immediate Preoperative Nursing
Interventions
 Transporting patient to presurgical area
o On a bed or stretcher 30-60 minutes before surgery or when
called
o Maintain comfort (use pillow and blanket)
o Avoid unpleasant sounds and conversation (can be
misinterpreted by sedated patient)
o Patient safety in the preoperative area is a priority. Use a
standard process to verify patient identity, the surgical
procedure, and the surgical site

 Attending to family needs

o Waiting areas (if available)
o Communicate with family members and reassure them
(especially if delays happen)
Special Considerations During Preoperative Period

 Elderly:
Older adult patients have less physiologic reserve than
younger patients because:
1. Cardiac reserves are lower; Renal and hepatic
functions are depressed; Gastrointestinal activity is
likely to be reduced; Respiratory compromise.
2. Decreased subcutaneous fat; more susceptible to
temperature changes.
3. May need more time and multiple explanations to
understand and retain what is communicated
restrictions.
Special Considerations During Preoperative Period

 Obesity (Bariatric Patients): obesity (BMI >

30kg/m2) are at increased risk as wound infection,
dehiscence (wound separation), hypoventilation when
supine, Sleep apnea.
 Disabilities (mental or physical): Patients with
disabilities may need assistive devices (e.g hearing
aids, eyeglasses), modifications in preoperative
education, & assistance with positioning or
transferring.
Special Considerations During Preoperative
Period

 Ambulatory surgery
patients with (outpatient, same
day, or short stay surgery that
does not require an overnight
hospital stay. [e.g.,
Cataract Surgery, breast
biopsy]
The nurse must quickly
and comprehensively:
 assess and anticipate
the needs of the patient
 begin planning for
discharge and follow-up
home care.
Special Considerations During Preoperative
Period
Emergency surgery (unplanned surgery and occur with
little time for preparation)
The nurse needs to:
 communicate with the patient and team members as calmly
and effectively as possible in these situations.

 Make a quick visual survey of the

patient to identify all sites of injury
in case of trauma.

• For the unconscious patient,

informed consent and essential
information, such as allergies, need
to be obtained from a family
member, if one is available.
Expected Outcomes from this phase

 Relief of anxiety
 Decreased fear
 Understanding of the surgical intervention