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 Art & science
of treating diseases, injuries, & deformities by
operation & instrumentation
Perioperative nursing
is an umbrella term that groups several nursing roles,
all dealing with patients undergoing surgery.
Three Phases:
1.Pre-operative nursing care:
Before the patient goes to surgery.
2. Intra-operative nursing care
While the patient is in surgery
3. Post-operative nursing care
After the patient is done from surgery
CLASSIFICATION OF SURGERY

PURPOSE

URGENCY

RISK

EXTENT
 CLASSIFICATION OF SURGERY
ACCORDING TO PURPOSE
= to determine the origin &
cause of a disorder or the cell type for cancer
ex: Biopsy
= estimation of the extent of disease
or confirmation of a diagnosis.
ex: Exploratory Laparatomy
= to relieve symptoms of a disease process,
but does not cure
Ex: Colostomy
=done to enhance appearance and to
correct body parts
Ex:Rhinoplasty, Blepharoplasty
 Classification:

a. Ablative = Includes removal of an organ .

ex.:appendECTOMY (suffix)

b. Constructive=e.g., cheiloPLASTY, orchidoPEXY

c. Reconstructive=e.g., Total joint replacement

ACCORDING TO URGENCY
1. Emergent- patient requires immediate
attention, life theatening condition
▪ e.g., gunshot or stab wound, severe bleeding

2. Urgent- patient needspromt treatment

▪ performed as soon as client is stable & infection is under
control;
▪ e.g., appendectomy, intestinal obstruction

3. Required- patient needs to have surgery

▪ Client should have surgery;
▪ e.g., Cataracts, Simple Hernia

4. Elective- patient should have surgery

e.g., Revision of Scars, Vaginal Repair
5. Optional= rest on
patients declaration
e.g., Cosmetic surgery
ACCORDING TO DEGREE OF RISK

1. Major- high risk ,extensive.

Prolonged large amount of blood
loss; vital organ maybe handled
or removed
Ex. Cholecystectomy
Nephrectomy

2. Minor – less risk not prolonged,

few complication.
Ex: Removal of skin lesion
D&C
ACCORDING TO EXTENT OF SURGERY

1. Simple
▪ e.g., Simple or Partial Mastectomy
ACCORDING TO EXTENT OF SURGERY
2. Radical
e.g., Radical Mastectomy, Radical
Hysterectomy
Common Surgical Suffixes..
-ectomy: removal of an organ or gland.
ex: appendectomy

- otomy: cutting into an organ or tissue

ex: cardiotomy

- ostomy: providing an opening (stoma)

ex: colostomy

-plasty: restoration of a lost part or piece of

tissue
- ex: blepharoplasty
- scopy:examination of an organ by viewing
ex: bronchoscopy

-centesis: puncture to aspirate

ex: thoracentesis

-orrhaphy: repair of
ex: herniorrhaphy

-pexy: to fix or suture in place

ex: proctopexy
Preoperative Care
Sedation should not be administered to the client before
he or she signs the consent
The patient should personally sign the consent unless
she/he:

1. MINOR
2. EMANCIPATED MINOR
3. ILLITERATE

A MINOR WHO IS THE PARENT OF AN INFANT OR

CHILD WHO IS HAVING A PROCEDURE -
he or she may sign for his/her child

Blind:- May sign his own consent with 2 witnessess

3 required consents before surgery
Surgery Consent
Anesthesia Consent
Blood Transfusion Consent
Chest Physiotherapy
 PREOPERATIVE MEDICATIONS
45-70 min.pre op, any delay report to surgeon.

DRUG GROUP DOSE & ACTION/ NSG. IMPLICATION

USES
ROUTE

Benzodia Decrease Monitor

zipines 5-20mg
Diazepam- PO anxiety respiratory
Valium and depression,
produce hypotension,
Lorazepam- 1-4mg
Ativan IM,IV sedation, drowsiness
Induce and lack of
amnesia coordination
OPIOID ANALGESICS: Decreased anxiety, Respiratory
Morphine 5-15 mg IM,IV provide analgesia, depression, nausea,
allow reduced vomiting, orthostatic
50-150mg anesthetic dose hypotension and
Meperidine IM,IV pruritus
(Demerol)

H2 receptor Reduce gastric

antagonists:
Monitor for
Cimetidine (Tagamet) 300mg IV,IM acid volume & confusion, &
Ranitidine(Zantac) concentration dizziness in
Famotidine(Pepcid) 30 mg IV,IM older adults
20 mg IV

Monitor for
sedation &
Antiemetics: Enhance gastric
extrapyramidal
Metoclopramide
10mg IV emptying reaction(involuntar
(Reglan) Tranquilizer y movement,
muscle tone
Droperidol 2.5-10mg IM changes &
(Inapsine) abnormal posture).
Anticholinergics: Reduce oral & Monitor for
At SO4 0.4-o.5mg IM,IV respiratory confusion,
secretions to restlessness ,
Scopolamine 0.4-0.6mg IM,IV decrease risk of tachycardia. Prepare
aspiration, vomiting client to expect a dry
& laryngospasm. mouth.

Antibiotics: Prevents surgical Skin test, watch

Cefazoline 1-2g IV 30 min-2hr site from out for allergy
preop infections. and proper
Vancomycin 1 g IV Lower risk of mortality referral.
Clindamycin 600-900mg IV in elderly clients.

Gastric acid pump Suppresses gastric Monitor for

inhibitors: 15-60mg PO acid secretion dizziness,
Lansoprazole headache, rash or
(Prevacid) 20-40mgPO thirst
Omeprazole
(Prilosec)
 Psychosocial Preparation
• Assess client's anxiety level

• Address client's questions and

concerns regarding surgery

• Give client privacy to prepare

psychologically for surgery
• Tell the client that he or she will feel
drowsy shortly after the medications are
administered

• After administering the preoperative

medications, keep the client in bed with
the side rails up and place the call bell
next to the client

• Instruct the client not to get out of bed and

to call for assistance if needed
INTRAOPERATIVE
PERIOD
Arrival in the Operating Room

• When the client arrives in the

operating room, the operating-room
nurse will check the identification
bracelet against the client's verbal
response
 Key words of OR practiced are:
1. Caring 3. Discipline
2. Conscience 4. Technique

SURGICAL CONSCIENCE – “Surgical Golden Rule”

“Do unto the patient as you would have others
do unto you.”
Surgical Conscience
➢One’s inner voice for the conscientious practice of
asepsis & sterile technique @ all times.
Surgical Safety Checklist – it is a tool for the
relevant clinical teams to improve the safety of
surgery by reducing deaths and complications.
 
STERILIZATION
• complete destruction of microorganism.
• - complete sterilization of instruments and
equipments is used in the surgical practice.
 ANESTHESIA
➢ “Negative Sensation”

PURPOSES:
1. Block nerve impulse transmission
2. Promote muscle relaxation
3. Achieve a controlled level of unconsciousness
 TYPES OF ANESTHESIA

1. GENERAL ANESTHESIA
➢ Depresses CNS resulting:
♠ amnesia ♠ unconsciousness
♠ analgesia ♠ loss of muscle tone &
reflexes
STAGES OF GENERAL ANESTHESIA

STAGE I – STAGE OF INDUCTION

Nursing Action:
▪ Close OR doors & keep room quiet
▪ Standby the client & assist if necessary
STAGE II – STAGE OF EXCITEMENT

NURSING ACTION:
▪ Restrain client if needed
▪ Remain at client’s side
▪ Be quiet & alert
▪ Assist anesthesiologist if needed
STAGE III – SURGICAL ANESTHESIA &
RELAXATION

NURSING ACTION:
▪ Begin final prep – client is under control
STAGE IV – DANGER STAGE

➢ Vital
functions are to depressed
➢ Respiratory failure & possible cardiac arrest

NURSING ACTION:
▪ Be ready to resuscitate
ADMINISTRATION OF GENERAL
ANESTHESIA
1. INHALATION

a. GASEOUS AGENTS – Nitrous oxide

b. VOLATILE AGENTS – Liquid agent vaporized
for inhalation
➢ cause shivering after surgery – effect on
hypothalamus
 2. INTRAVENOUS INJECTION

a. BARBITURATES – mild sedation to deep loss of

consciousness.

b. KETAMINE (KETALAR) – dissociative anesthetic

agent.

c. PROPOFOL (DIPRIVAN)
3. ADJUNCTS TO GENERAL ANESTHESIA

a. HYPNOTICS
a. Midazolam or Diazepam (Benzodiazepines)

b. OPIOID ANALGESICS

➢ MSO4, Demerol, Sublimaze

c. NEUROMUSCULAR BLOCKING AGENTS

➢Used to relax the jaw & vocal cords

immediately after induction so that the ET can
be placed.

➢Tracium, Anectine
 REGIONAL ANESTHESIA
❑ Produces a loss of painful sensation in only
one region of the body.

1. TOPICAL ANESTHESIA

2. LOCAL INFILTRATION ANESTHESIA

3. NERVE BLOCK
– injection of the local anesthetic agent into or
around a nerve or group of nerves in the
involved area.
NERVE BLOCK

➢ Radial,
Medial & Ulnar nerve (elbow, wrist,
hands, & fingers)
NERVE BLOCK
➢ Brachial plexus (upper arm)
4. SPINAL ANESTHESIA – injecting an
anesthetic agent into the CSF on the
subarachnoid space.
➢Lower abdominal & pelvic surgery
Spinal anesthesia
5. EPIDURAL ANESTHESIA -Anesthetic agent
injected into the epidural space.
• Spinal needles
Epidural anesthesia set
NURSE’S ROLE IN THE DELIVERY OF
ANESTHESIA:

1. Assisting the anesthesia provider

2. Observing for breaks in the sterile technique

3. Providing emotional support for the client

4. Staying with the client
5. Offering information & reassurance
6. Positioning the client comfortable & safely
asepsis

Defined as absence of infectious or decrease

producing microorganism
ASEPTIC techniques

GOAL:
❑ PREVENT SURGICAL INFECTIONS
❑ MINIMIZES LENGTH OF RECOVERY FROM
SURGERY
❑ PREVENTS TRANSFER OF MICROORGANISM
INTO BODY TISSUES
TWO TYPES OF ASEPSIS

1. MEDICAL ASEPSIS- reduce the number

& transfer of pathogens.

2. SURGICAL ASEPSIS-renders & keep

objects & areas free from microorganism
STERILE TECHNIQUE IS REQUIRED IN
THE FF.:

❑ ALL SURGICAL PROCEDURES

❑ ALL PROCEDURES THAT INVADE THE BLOOD

STREAM
❑ COMPLEX DRESSING AND WOUND CARE
❑ TUBE INSERTIONS
❑ CARE OF HIGH RISK GROUPS OF PATIENTS
 TWO TYPES OF microorganism
THAT INHIBITS THE SKIN
• TRANSIENT- ACQUIRED BY DIRECT CONTACT

• RESIDENT-BELOW THE SKIN SURFACES

2 process used in removing
microorganism
• 1. mechanical
• 2. chemical
12 PRINCIPLES OF SURGICAL
ASEPSIS/ASEPTIC TECHNIQUE
12 PRINCIPLES OF SURGICAL
ASEPSIS/ASEPTIC TECHNIQUE

1. Only sterile items are used within the sterile field.

2. Sterile gowns are considered sterile only in front,
from shoulder to the level of the sterile field and at
sleeves from 2 inches above the elbow to the cuff.
3. Tables are sterile only up to the table level.
4. Sterile persons touch only sterile items or areas; unsterile
person touch only unsterile items or areas.
5. Unsterile persons avoid reaching over a sterile field;
Sterile persons avoid leaning over unsterile area.
6. The edges of anything that encloses sterile content are
considered unsterile.
7. Sterile areas are continuously kept in view. In passing
always face the sterile field.
8. Sterile persons keep well within sterile areas. Unsterile
persons avoid sterile areas.
9. Sterile persons keep contact with sterile areas to a
minimum.
10. When in doubt, consider it unsterile.
11. Moisture causes contamination.
12. Microorganisms must be kept to an irreducible
minimum
POSITIONING
 POSITIONING
PUTTING CIENT IN PROPER BODY ALIGNMENT TO
EXPOSE THE OPERATIVE SITE OR AREA.

• QUALIFICATION OF A GOOD POSITION:

1. free respiration
2. Free circulation
3. No pressure on nerve
4. hand or feet properly supported
5. No undue postoperative discomfort
6. accessible operative site
Sutures and stiches

• Sutures
stitches
ligature
Classification of suture

1. Absorbable

surgical gut/cutgut - made from sheep

intestine (ex.Plain/Chromic)
Plain
Chromic – used for tissues, such as the
muscle and peritoneum that require
longer added support ( 10-20 days )
collagen

• made from deep flexor tendon

of cattle
plain=absorb in 5-10 days
synthetic – Dexon/Vicryl
• Non-absorbable

Example: silk, cotton, nylon, stainless

steel wires, tevdek, ti-cron and
metal clips
silk
Ti cron
Stainless steel wires
Metal clips
 5 LAYERS OF THE ABDOMEN

1. skin
2. subcutaneous
3. fascia
4. muscle
5. peritoneum
 e nt s
st r um
a l I n
ur gi c
S

Surgical instruments are designed to provide the

tools the surgeon needs for each maneuver
four basic categories of instruments:

Cutting and Dissecting

Clamping and Occluding
Grasping and Holding
Retracting and Exposing
SURGICAL INSTRUMENTATION

❑CUTTING & DISSECTING

❑CLAMPING & OCCLUDING
❑GRASPING & HOLDING
❑EXPOSING & RETRACTING
SPONGES
Diff. types of sponges

• O.S. (operating sponge)

• -Blue Radiopaque Element for Easy
Recognition Under X-Ray
Square Pack
Rolled Gauze
• Cherries
Peanuts..
Cottonoids..
SPONGE, SHARPS, & INSTRUMENT COUNTS

ACCOUNTABILITY
❑Isa professional responsibility that rests
primarily on the scrub nurse & the circulator.
COUNTING PROCEDURES
❑Isa method of accounting for items put on the
sterile table for use during the surgical
procedure.
 Sponge and Instrument Count

Before
Before closure closure of
of peritoneum skin

Before surgery
“ DOCTORS ALL SPONGES,
SHARPS AND INSTRUMENTS
CHECKED , COUNTED AND
COMPLETE”
DRAINS – is placed in a separate small incision
parallel to the operative incisions to drain blood &
serum from the operative site.
POSTOPERATIVE
PERIOD
UPON RECEIVING:

1. AIRWAY PATENCY/POSITION
SAFELY/STABLE
Unconscious adult

Preferred position

2. ENDORSEMENT – verbal detailed report of

events from OR.
Incentive Spirometer
  Splinting

 Coughing

✓To expel secretions, keep lungs clear,

allow full aeration, prevent pneumonia &
atelectasis
• Early Ambulation

• ROME – prevent joint rigidity & muscle

contracture
POSTOPERATIVE NURSING CARE

ASSESSMENT
1. ASSESS RESPIRATORY STATUS
Patent airway ♠ HYPOXIA

2. ASSESS CIRCULATION

3. ASSESS NEUROLOGIC STATUS

4. MONITOR WOUND

a. Assess dressing amount & charac. Drainage,

wound appearance

c. Measure drainage – drains, ostomy bag

d. Wound dressing
❖ DEHISCENCE & EVISCERATION

5. MONITOR IV LINES
 6. MONITOR DRAINAGE TUBES

• Drainage tube to suction/gravity drain

• Note amt, color, consistency of drainage

NGT – removal of intestinal secretion, monitor GI

bleeding
7. PROMOTE COMFORT
• Pain meds
Oral – reassess after 30 minutes
IV – reassess after 5-10 minutes

8. REDUCE NAUSEA & VOMITING

Atelectasis and Pneumonia
• Collapse of the alveoli with retained mucous
secretions

Assessment
• Dyspnea, increased respiratory rate, productive
cough, chest pain
• Crackles over involved lung area
• Increased temperature
Interventions

1. Reposition client every 1 to 2 hours;

encourage deep breathing, coughing, and
use of the incentive spirometer
2. Encourage fluid intake
3. Encourage early ambulation
4. Perform suctioning to clear secretions
if client is unable to cough
Hypoxia
Assessment:

Restlessness
• Dyspnea
• Diaphoresis
• Cyanosis
Interventions
• Monitor client for signs of hypoxia
• Monitor lung sounds and pulse oximetry
• Administer oxygen as prescribed
Pulmonary Embolism

Assessment:

• Dyspnea
• Sudden, sharp chest or upper-abdominal
pain
• Cyanosis
• Tachycardia and tachypnea
• Anxiety
Interventions:

• Notifysurgeon immediately
• Monitor vital signs
• Administer oxygen and medications

as prescribed
Hemorrhage and Shock

Assessment:

• Restlessness
• Weak, rapid pulse
• Hypotension
• Tachypnea
• Cool, clammy skin
• Reduced urine output
Interventions:

• Put pressure on site of bleeding & elevate legs

• Notify surgeon immediately
• Adm. intravenous fluids , oxygen & blood as
prescribed
• Monitor LOC, vital signs, and intake & output
• Prepare client for surgery, if necessary
 Thrombophlebitis

Assessment:

• Vein inflammation
• Aching or cramping pain
• Vein feels hard and cordlike and is tender to
touch 
• Increased temperature
• Homans' sign
 Interventions

1. ROME every 2H

2. Monitor legs for swelling, inflammation, pain,

tenderness, venous distention, & cyanosis
 
 Interventions
3. Elevate leg 30° w/o placing any pressure on
popliteal area

4. use antiembolism stockings, as prescribed

5. Administer heparin sodium or warfarin

sodium (Coumadin), as prescribed
 
 Urine Retention
Assessment:

• Inability
to void
• Restlessness and diaphoresis

• Lower-abdominal pain & a distended bladder

• On percussion, bladder sounds like a drum

Paralytic Ileus

Assessment:

• Nausea & vomiting immediately after surgery

• Abdominal distention
• Absence of bowel sounds, bowel movement,
or flatus
 Interventions for urine retention
1. Monitor client for voiding and assess for
distended bladder
2. Encourage fluid intake
3. Assist client in voiding by helping him or
her stand
4. Pour warm water over the perineum
5. Catheterize client as prescribed
Interventions

• Keep client from eating or drinking until

bowel sounds return; administer intravenous
fluids as prescribed

• Encourage walking

• Administer medications, as prescribed 

Constipation

Assessment:
Abdominal distention
Absence of bowel movements
Anorexia, headache, and nausea
Interventions
• Encourage fluid intake up to 3000 mL/ day, unless
contraindicated

• Encourage early ambulation

• Encourage consumption of fiber-rich foods, unless

contraindicated

• Administer stool softeners and laxatives as

prescribed

• Provide privacy and adequate time for elimination

Wound Infection

Assessment:

• Fever and chills

• Warm, tender, painful, inflamed incision site

• Edematous skin at incision and tight skin sutures

• Increased white blood cell count

Interventions:

1. Monitor client’s temperature

2.Monitor incision site for approximation of

suture line, edema, or bleeding, signs of
infection
Interventions:

3. Maintain patency of drains and assess

drainage amount, color, and consistency

4. Change dressing as prescribed; maintain

asepsis

5. Administer antibiotics as prescribed

Wound Dehiscence

Assessment:

• Increased drainage
• Opened wound edges
• Appearance of
underlying tissues
through the wound
Interventions
• Place the client in low Fowler's position with
the knees bent

• Notify surgeon immediately 

• Cover wound with a sterile normal saline

dressing
EVISCERATION

• Preceded gush of serosanguinous drainage

Interventions
• cover wound sterile NS dressing

• Monitor V/S

• Keep client as calm as possible

• Notify surgeon
Criteria for Client Discharge:

• Client is alert and oriented

• Client has voided

• Client has no respiratory distress

• Client can walk, swallow, and cough

• Client tolerates a small amount of fluid and

food
Criteria for Client Discharge :

• Pain is minimal

• Client is not vomiting

• Bleeding from incision site, if any, is minimal

• A responsible adult is available to drive the

client home

• The surgeon has signed a release form

Discharge Teaching

• Provide written instructions to client and

family regarding specifics of care

• Instruct client & family about possible

postoperative complications
 Discharge Teaching

• Instruct client to call surgeon, ambulatory

center, or emergency department if
postoperative problems occur

• Instruct client to keep follow-up appointments

with surgeon
• Demonstrate care of incision & how to change
dressing , provide extra dressings for home
use

• Instruct client on importance of returning to

surgeon's office for follow-up
• Instruct client that sutures are usually
removed in surgeon's office 7 to 10 days after
surgery

• Inform client that staples are removed 7-14

days after surgery & that skin may become
slightly reddened when they are ready to be
removed
• Instruct client on use of medications: purpose,
doses, administration, side effects

• Instruct client on diet and remind him or her to

drink six to eight glasses of liquid a day
•
• Instruct client on activity levels; tell him or her to
resume normal activities gradually

• Instruct client to avoid lifting for 6 weeks (or as

prescribed by the surgeon) if a major surgical
procedure has been performed
• Instruct client with an abdominal incision not to
lift anything weighing 10 pounds or more (or as
prescribed by surgeon)

• Instruct client on signs and symptoms of

complications and when to call surgeon

Generally client can return to work in 6 to 8 weeks,

as prescribed by surgeon