Perioperative Nursing Care

The Perioperative Nursing
Care
1
Surgical Concepts
A. Terms
1. Surgery – a branch of medicine that treats
diseases by manual operative procedure that
encompasses pre-operative care intraoperative
judgment and management, and post-operative
care of clients
2. Perioperative Nursing Management – refers to
activities performed by nurses during the pre,
intra, and post- operative phases through the
framework of the nursing process.
2
Surgical Concepts
B. Goals of Surgery
1. For diagnosis
2. For preservation of life
3. For maintenance of dynamic bodily
equilibrium
4. For prevention of infection and
promotion of healing
5. For alleviation of discomforts
6. For correction of deformities and defects
3
Surgical Concepts
C. Conditions That Require Surgery

1. Obstruction
2. Perforation
3. Erosion
4. Tumor
4
Surgical Concepts
D. Major Categories of Surgery

1. According to Purpose
a. Diagnostic
a.1 Biopsy
a.2 Endoscopy
5
Surgical Concepts

b. Curative
b.1 Ablative
b.2 Reconstructive
b.3 Constructive
6
Surgical Concepts

c. Exploratory
d. Restorative
e. Palliative
f. Cosmetic/Reconstructive
7
Surgical Concepts

2. According to Urgency
a. Emergency
b. Imperative
c. Planned/Required
d. Elective
e. Optional
8
Surgical Concepts

3. According to Extent/Magnitude/
Degree of Risk
a. Major
b. Minor
9
The Pre-operative Nursing Care
10
I. Assessment
A. Health History
1. Biographical Data
2. Chief Complaint
3. Present Health Concerns or Illness
4. Past Health History
5. Family History
6. Patient Profile
11
Assessment
B. Pre-operative Assessment
1. Physical Assessment
a. Nutritional and fluid status
b. Cardiovascular status
c. Respiratory status
12
Assessment
2. Pre-surgical Screening Tests
a. Chest X-ray
b. ECG
c. Electrolytes level
d. Urinalysis
e. Blood studies
13
Assessment
3. Health Factors
a. Hepatic, renal, and endocrine
functions
b. Immune functions
c. Psychosocial factors
d. Spiritual and cultural beliefs
14
II. Analysis
Potential Nursing Diagnoses
1. Anticipatory grieving related to perceived loss
of normal body image
2. Anxiety related to the surgical experience and
outcome of surgery
3. Fear related to perceived threat of the surgical
procedure and separation from support systems
4. Knowledge deficit of pre-operative procedures
and protocols and post- operative expectations
15
III. Planning and Implementation
A. Physiological Preparation for Surgery
1. Managing nutrition and fluids
a. Correct dietary deficiencies
b. Correct fluid and electrolyte
imbalance
c. Restore adequate blood volume
16
A. Physiological Preparation for Surgery

2. Managing infection
a. Treat existing infection
b. Prevent possible infection
3. Managing existing systemic
disorders
17
B. Psychosocial Preparation for Surgery
Reducing Pre-Operative Anxiety/Fear
a. Promote positive coping strategies
a.1. Imagery
a.2. Distraction
a.3. Optimistic self-recitation
b. Provide pre-operative teaching
c. Provide opportunity for visits from
family and friends
18
Principles of Pre-operative
Teaching and Learning
1. Maintain uniformity and accurateness of content.
2. Supply what is necessary.
3. Use simple terms.
4. Do not overwhelm with information.
5. Provide chance for patient to ask questions.
6. Check patient for comprehension.
7. Repeat if necessary.
8. Use appropriate teaching strategies.
9. Involve significant others.
19
Pre-operative Teaching
1. Deep-breathing, coughing, and

Incentive Spirometer
2. Mobility and Active Body Movement
3. Pain Management
4. Cognitive Coping Strategies
20
Exercises
1. Deep breathing
• Expands the lungs
• Prevents post-operative pneumonia and
atelectasis
2. Coughing
• Helps clear airway of secretions
3. Incentive spirometry
• Expands the lungs
• Provides a visual feedback to patients
21
Exercises
Mobility and Active Body Movement
Purposes:
a. Promotes circulation
b. Prevents circulation stasis which may lead
to thrombus formation
1. Leg Exercises
2. Turning-to-sides Exercises
3. Getting-Out-of-Bed Exercises
22
C. Spiritual Preparation for Surgery
Respecting spiritual and Religious Beliefs
a. Provide time for prayer
b. Arrange for visit from a spiritual
adviser/clergyman as desired
c. Take into consideration
religious beliefs in the operative
care
23
D. Securing Consent for Surgery
Rationale for Securing Informed Consent
a. Patient’s protection from
unsanctioned surgery
b. Doctor’s protection against claims of
unauthorized operation
24
Criteria for a Valid Informed Consent
a. It is done voluntarily.
b. It is made by a competent person.
c. Subject is informed.
d. Information must be written or
delivered in a language
understandable to the subject.
25
Criteria for a Valid Informed Consent
e. It should be in writing and should contain the following:
1. Explanation of the procedure and its risks

2. Description of the benefits and alternatives
3. An offer to answer questions about the surgery
4. Instructions that the consent may be
withdrawn
5. A statement informing the patient if protocol
differs from the customary procedure
26
Preparing the Patient on the
Eve of Surgery
A. Preparing the skin
- helps reduce the possibility of infection
by minimizing the number of
microorganisms through chemical and
mechanical means
1. Washing
2. Scrubbing
3. Shaving
27
Eve of the Surgery
B. Preparing the GI tract
a. Reduces the possibility of vomiting and
aspiration
b. Reduces the possibility of bowel
obstruction
c. Prevents contamination from fecal material
1. Food and water restriction

2. Enema administration
28
Eve of Surgery
1. Food and Water Restriction
Guidelines for NPO
a. Explain the reason for the restriction.
b. Remove food and water at bedside.
c. Place an NPO tag on door and on bedside.
d. Mark cardex with NPO.
e. Inform dietician.
f. Inform other health team members of the restriction.
29
Eve of Surgery
2. Enema Administration
Purposes:
a. Reduces possibility of fecal impaction
b. Prevents colon injury/trauma
c. Provides adequate surgical site
visualization
30
Eve of Surgery
C. Preparing for Anesthesia
Reduces or totally removes any fear
and anxiety to anesthesia
*The anesthesiologist visits the client and
assesses client’s cardiovascular and
neurological functioning.
31
Day of Surgery
A. Immediate Pre-operative Nursing
Interventions
1. Administering Pre-Anesthetic
Medication
Purposes:
a. to allay anxiety
b. to decrease pharyngeal secretions
c. to reduce amount of anesthetics
d. to create amnesia prior to surgery
32
Day of Surgery
2. Maintaining the Pre-operative Record
a. Attachment of consent, clearance,
lab reports, nurse’s records
b. Maintenance of NPO status
c. Changing of gown and wearing of
cap, etc
d. Removal of dentures, jewelry, nail
polish and other accessory devices
33
Day of Surgery
3. Transporting Patient to the
Pre-surgical Area
a. Provision of a comfortable
stretcher
b. Provision of sufficient number
of blankets
c. Provision of safety measures
d. Proper identification of surgical patient
e. Proper greeting of patient
f. Provision of a quiet environment
34
The Intra-operative Nursing
Care
35
I. Assessment
1. Identification of surgical client

2. Assessment of client’s status
a. physiological
b. psychological
c. physical
3. Verification of the information
in the pre-operative checklist
36
II. Analysis
1. Anxiety related to expressed concerns due to
surgery
2. Risk for perioperative injury related to
environmental conditions in the OR
3. Risk for injury related to anesthesia and
surgery
4. Disturbed sensory perception related
to general anesthesia
5. Risk for fluid volume deficit related
to bleeding
37
1. Reducing anxiety
a. Introduce yourself.
b. Address patient by name warmly and
frequently.
c. Provide explanations.
d. Encourage questions and answer
them.
e. Provide comfort measures
38
2. Preventing Intraoperative Positioning
Injury
Factors to Consider in Positioning
a. The patient should be in as comfortable
position as possible, whether asleep or awake.
b. The operative field must be adequately
exposed.
c. An awkward position, undue pressure on a
body part, or use of stirrups or traction, should not
obstruct the vascular supply.
39
2. Preventing Intraoperative Positioning
Injury
Factors to Consider in Positioning
d. Respiration should not be impeded by pressure
of arms on the chest or by a gown that
constricts the neck or chest.
e. Nerves must be protected from undue pressure.
Improper positioning of the arms, legs, or feet
may cause serious injury or paralysis.
f. Precautions for patient’s safety must be
observed.
g. The patient needs gentle restraint before
induction in case of excitement
40
Surgical Positions
1. Dorsal Recumbent/Supine
• Flat on bed
• One arm is positioned at the side of the
table, with the hand placed palm down;
the other hand is carefully positioned on
an armboard
• Used for most abdominal surgery
41
Surgical Positions
2. Trendelenburg
• Flat on bed but head and body are
lowered
• The patient is held in position by padded
shoulder braces.
• Used for surgery on lower abdomen and
pelvis to obtain good exposure by
displacing the intestines into the upper
abdomen
42
Surgical Positions
3. Lithotomy
• Flat on back with legs and thighs flexed
• Position is maintained by placing stirrups.
• Used for nearly all perineal, rectal, and
vaginal surgical procedures
43
Surgical Positions
4. Sims or Lateral
• Patient is placed on non-operative side
with air pillow 12.5 – 15 cm thick under
the loin; the upper leg extended; the
lower leg is flexed at the knee
• Used for kidney, chest, and hip surgery
44
Surgical Positions
5. Prone
• Face-down position
• Head is turned to one side
• Used in back and spine surgery
6. Other positions
• Jackknife
• Thyroidectomy
45
3. Protecting the Patient From Injury

a. Verifying information
b. Checking chart for completeness
c. Maintaining surgical asepsis
d. Maintaining an optimal
environment
46
Verifying information/Checking of Chart for
Completeness
• Correct patient and the planned surgical
procedure and type of anesthesia
• Correct informed surgical consent, with
patient’s signature
• Completed records for health history and
physical examinations
• Results of diagnostic studies
• Allergies (including latex)
47
Maintaining Surgical Asepsis
Basic Principles of Aseptic Technique
1. Only sterile items are used within the sterile field.
Practices:
a. Obtain materials from a stock of sterile
packages.
b. Ensure and maintain the sterility of sterile
articles.
c. If in doubt about the sterility of anything,
consider it not sterile.
48
2. Sterile persons are gowned and gloved.
Practices:
a. Self-gowning and gloving should be done from a
separate sterile surface.
b. Stockinette cuffs of the gown are enclosed beneath
sterile gloves.
c. Sterile persons keep their hands in sight at all times and
at or above the waist level or sterile field.
d. Hands are kept away from face and are never folded
under arms.
e. Sterile persons are aware of the height of team
members in relation to each other and the sterile field.
49
3. Tables are sterile only at the table level.
Practices:
a. Only the top of a sterile table is considered sterile and
the edges and sides of the drape extending below the
the table level are considered unsterile.
b. Anything falling and extending over the edge is unsterile
and should not be brought back up to the table level.
50
4. Sterile persons touch only sterile items or areas;
unsterile persons touch only unsterile items.
Practices:
a. Sterile team members maintain contact with the
sterile field by means of sterile gowns and gloves.
b. Unsterile circulator does not directly contact the
sterile field.
51
5. Unsterile persons avoid reaching over sterile field,
sterile persons avoid leaning over unsterile area.
Practices:
a. In pouring solutions into a sterile basin the circulator directs
only the lip of the bottle over the basin to avoid reaching over
the sterile area.
b. The circulator stands at a distance from the sterile field to
adjust the light.
c. Surgeon turns away from the sterile field to have perspiration removed
from brow.
d. Scrub person stands back from the unsterile table when draping it.
52
6. Edges of anything that encloses sterile are considered
unsterile.
Practices:
a. In opening sterile packages, the circulator opens the top flap away
from self, then turns the side under. Ends of the flaps secured in the
hand so they don’t dangle loosely.
b. Sterile person lifts contents from packages by reaching down and
lifting them straight up, holding their elbows high.
c. Flaps on peel-open packages should be pulled back, not torn, to
expose the sterile contents. Contents should be flipped or lifted
upward and no permitted to slide over edges.
d. Before pouring sterile solution to a sterile basin pour some amount
into the waste receptacle to clean the lid of the bottle.
53
7. Sterile field is created as close as possible to
time of use.
Practice:
a. Sterile tables are set up just before surgical
procedure.
It is virtually impossible to uncover a table of sterile contents
without contamination. Covering sterile tables for later use is
not recommended.
54
8. Sterile areas are continuously kept in view.
Practices:
a. Sterile persons face the sterile area.
b. When sterile packs are open in a room or a
sterile field is set up, someone must remain in
the room to maintain vigilance. Sterility cannot
be ensured without direct observation.
55
9. Sterile persons keep well within sterile area.
Practices:
a. Sterile persons stand back at a safe distance from the table when
draping the patient.
b. Sterile persons pass each other at a 360-degree turn
c. Sterile persons turns back to an unsterile person or area and faces a
sterile area when passing.
d. Sterile person asks an unsterile individual to step aside.
e. Sterile persons stay within the sterile field. They do not walk around
or go outside the room.
f. Movement within and around the sterile area is kept to a minimum.
56
10. Sterile persons keep contact with sterile
areas to minimum.
Practices:
a. Sterile persons do not lean on sterile tables or on
the draped of the patient.
b. Sitting or leaning against an unsterile surface is a
break in technique. If the sterile team sits to operate,
the members do so without proximity to unsterile
areas.
57
11. Unsterile persons avoid sterile areas.
Practices:
a. Unsterile persons maintain a distance of at least 1 foot
(30 cm) from any area of the sterile field.
b. Unsterile persons face and observe a sterile area when
passing it to be sure they do not touch it.
c. Unsterile persons never walk between two sterile areas
d. Circulator restricts to a minimum all activity near the sterile
field.
58
Maintaining an Optimal Environment
• Assess for nonroutine medications, blood components,
instrument and other equipment and supplies
• Determine the following:
a. readiness of the room
b. completeness of the physical setup
c. completeness of the instruments
• Employ injury-preventing measures
a. safety straps
b. proper transferring/positioning
c. proper positioning of grounding pad
59
4. Monitoring and Managing Potential
Complications
a. Being alert to and reporting changes in
vital signs, nausea and vomiting,
anaphylaxis, hypoxia and hypothermia, and
assisting in their management
b. Maintaining asepsis
c. Preventing infection
60
Stages of Anesthesia
Stage I: Beginning Anesthesia
• Warmth, dizziness, feeling of detachment may be
experienced
• Ringing , roaring, or buzzing in the ears may be
experienced. Noise is exaggerated.
• Though conscious, client may find it difficult to
move extremities easily
NURSING RESPONSIBILITIES:
a. Close OR doors
b. Keep room quiet
61
Stage II: Excitement
• Characterized variously by struggling, shouting,
talking, singing, laughing, or crying
• Respirations are irregular.
• Pulse rate is rapid
• Pupils may dilate
NURSING RESPONSIBILITY:
Assist in restraining the client.
62
Stage III: Surgical Anesthesia
• Anesthesia is completely established
• Patient is unconscious and lies quietly on the
table.
• Respirations are regular; pulse rate and volume
are normal.
NURSING RESPONSIBILITIES:
a. Assist in positioning the patient.
b. Begin skin prep
c. Prepare operative site
d. Observe for signs and symptoms
63
Stage IV: Medullary Depression
• Reached only when too much anesthesia has
been administered.
• Respirations become shallow; pulse is weak and
thready, and the pupils become widely dilated.
• Cyanosis may be observed, death may follow if
without prompt treatment.
NURSING REPONSIBILITIES:
a. Assist in CPR
b. Provide emergency equipment
c. Establish airway
64
Responsibilities of A Scrub Nurse
1. Performing surgical hand scrub
2. Setting up the sterile tables
3. Preparing sutures, ligatures, and special
instruments
4. Assisting the surgeon and the surgical assistants during
the procedure by anticipating the instruments that will be
required
5. Counting all sponges, needles, and instruments to be
sure they are all accounted for and not retained as a foreign
body in the patient (together with the circulating nurse)
6. Collecting and labeling of tissue specimen
65
Responsibilities of A Circulating Nurse
1. Verifying consent
2. Coordinating the team
3. Ensuring the following:
a. cleanliness
b. proper temperature, humidity, and lighting
c. safe functioning of equipment
d. availability of supplies
4. Monitoring aseptic practices
5. Monitoring the patient and documenting specific
activities
66
The Post-operative Nursing Care
67
I. Assessment
Nursing Management in the PACU
Assessing the patient
a. Respiratory status
 Rate
 Depth
 Sound
68
I. Assessment
b. Cardiovascular status
 Pulse (rate, rhythm, quality)
 Blood pressure
 Skin (temperature, color, moistness)
 Urine output
 Bleeding
 Mental status
69
I. Assessment
c. Pain
 Level
 Characteristics
 Patient’s appearance
 Changes in vital signs
70
I. Assessment
A – Airway E – Elimination
B – Breathing F – Fluids
C – Circulatory F - Food
C – Consciousness S – Safety/comfort
D – Dressing
D – Drainage
D – Drugs
71
II. Analysis
1. Risk for ineffective airway clearance
related to:
a. depressed respiratory function
b. pain
c. bed rest
2. Acute pain related to surgical incision
3. Decreased cardiac output related
to hemorrhage
72
II. Analysis
3. Activity intolerance related to:
a. generalized weakness secondary to
surgery
b. pain
4. Impaired skin integrity related to surgical
incisions and drains
5. Risk for imbalanced nutrition related to:
a. decreased intake
b. increased need for nutrients 2⁰ to surgery
73
II. Analysis
6. Risk for constipation related to:
a. effects of medication
b. surgery
c. dietary change
d. immobility
7. Risk for urinary retention related to anesthetic
agents
8. Risk for injury related to
a. surgery
b. anesthetic agents
74
II. Analysis
9. Anxiety related to surgery
10. Disturbed body image related to surgery
11. Risk for ineffective therapeutic regimen related to
insufficient knowledge about:
a. wound care
b. dietary restriction
c. activity recommendations
d. medications
e. follow-up care
f. signs and symptoms of complications
75
1. Preventing Respiratory Complications

a. Deep-breathing exercises
b. Coughing exercises
c. Incentive spirometry
d. Turning exercises
e. Ambulation
76
2. Relieving Pain
a. Opioid analgesics
b. Patient-Controlled Analgesia
c. Epidural/Intrathecal Infusions and
Intrapleural Anesthesia
d. Other Pain Relief Measures
77
2. Promoting Cardiac Output

a. IV therapy
b. Leg exercises/Positioning
c. Early ambulation
d. Intake and output monitoring
78
3. Encouraging Activity
a. Arm exercises
b. Hand and finger exercises
c. Foot exercises
d. Leg exercises
79
4. Managing Gastrointestinal Function

and Resuming Nutrition
a. Turning exercises
b. Ambulation
c. Nutrition
80
5. Promoting Bowel Function

a. Early ambulation
b. Dietary intake
c. Stool softeners
6. Managing Voiding
a. Encourage independent voiding
b. Catheterization
81
7. Maintaining a Safe Environment

a. Safety measures
b. Special positioning
c. Assessment of level of
consciousness and orientation
82
8. Managing Potential Complications

a. Deep vein thrombosis
b. Hematoma
c. Infection
d. Wound dehiscence and Evisceration
83
IV. Evaluation
84

Perioperative Nursing Care

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The Perioperative Nursing

C. Conditions That Require Surgery

D. Major Categories of Surgery

D. Major Categories of Surgery

D. Major Categories of Surgery

D. Major Categories of Surgery

D. Major Categories of Surgery

A. Physiological Preparation for Surgery

1. Deep-breathing, coughing, and

2. Mobility and Active Body Movement

4. Cognitive Coping Strategies

1. Explanation of the procedure and its risks

1. Food and water restriction

1. Identification of surgical client

3. Protecting the Patient From Injury

1. Preventing Respiratory Complications

2. Promoting Cardiac Output

4. Managing Gastrointestinal Function

5. Promoting Bowel Function

7. Maintaining a Safe Environment

8. Managing Potential Complications

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