Care Of Clients Requiring Surgery

PERIOPERATIVE NURSING
Objectives:

• Describe the various classifications of surgical

procedures
• Provide appropriate nursing care for the client in the
preoperative, intraoperative and postoperative phases of
perioperative nursing
• Utilize nursing process as a framework for providing
individualized care for the client undergoing surgery
3 Phases

Preoperative
Phase

• Begins when the decision

for surgery is made and
ends when the client is
transferred to the
operating room
 3 Phases

Intraoperative
Phase
• Begins with the client’s entry
into the operating room and
ends with admittance to the
post anesthesia care unit
(PACU)
 3 Phases

Postoperative
Phase
• Begins with the client’s
admittance to PACU and
ends with the client’s
complete recovery from
the surgical intervention
•Conditions Requiring Surgery
5 Major Types of Pathologic
Processes
1. Obstruction
• Primarily affects hollow structures and ducts
2. Perforation
• Rupture of an organ, artery, lumen
3. Erosion
• Break in the continuity of tissue surface
4. Tumor
• Abnormal growth of tissues that serve no physiologic function in the body
5. Obstetric complication
• Obstructed labor, malpresentation, macrosomia
Categories of Surgical
Procedure
According to Purpose

• Diagnostic Surgery
• Verify the presence of a disease condition
• Exploratory Surgery
• Determine the extent of the disease condition
• Curative Surgery
• To treat the disease condition
Diagnostic

Palliative
Exploratory Laparotomy
According to Purpose

• Palliative Surgery
• Relieve distressing signs and symptoms, not necessarily cure the
disease
• Restorative
• Performed to improved a client’s functional ability
• Cosmetic
• Performed to alter or enhanced personal appearance
Types of Curative Surgery

• Ablative
• Involves removal of an organ
• Constructive
• Involves repair of a congenitally defective organ,
improving its function or appearance
• Reconstructive
• Partial/complete restoration/ repair of a damaged
organ/tissue to its original appearance and
function
According to Urgency

• Elective
• Planned for correction of a nonacute problem
• Imperative/Urgent
• Requires prompt intervention; may be life threatening if treatment
is delayed more than 24 – 28 hours
According to Urgency

• Emergency
• Requires immediate intervention because of life threatening
consequences
• Planned/Required
• Necessary for well-being. May be scheduled weeks or months
• Optional
• Requested by the client
 According to the Degree of Risk
• Minor Surgery
• Procedure without significant risk, often done with local anesthesia
• Major Surgery
• Procedure pf greater risk, usually longer, and more extensive than a
minor procedure
Extent of Surgery

• Simple
• Only the most overtly affected areas involved in the surgery
• Radical
• Extensive surgery beyond the area obviously involved; is directed
at finding a root cause
Effects of Surgery to the Client

• Stress response is elicited

• Defense against infection is lowered

• Vascular system is disrupted

• Organ function are disturbed

• Lifestyles may changes

Surgical Risk Factor
• Age
• Presence of infection
• Nutritional Status/Nutritional Deficiency
• Obesity
• Dehydration/fluid and Electrolyte Imbalance
• General Health of Individual
• Alcoholism
PREOPERATIVE NURSING
Preoperative Phase
•Goals:
• Assessing and correcting physiologic and psychologic
problems that might increase surgical risk
• Giving the person complete learning/teaching
guidelines regarding surgery
• Instructing and demonstrating exercises that will
benefit the persons during post-op period
• Planning for discharge and any projected changes in
lifestyle due to surgery
Physiologic Assessment of the Client
Undergoing Surgery

• Age
• Presence of Pain
• Nutritional Status
• Fluid and Electrolyte Balance
• Infection
• Cardiovascular Function
• Pulmonary Function
• Renal Function
Physiologic Assessment of the Client
Undergoing Surgery

• Gastrointestinal Function
• Liver Function
• Endocrine Function
• Neurologic Function
• Hematologic Function
• Use of Medication
• Presence of trauma
Causes of Fears:
• Fear of the unknown
• Fear of anesthesia, vulnerability while unconscious
• Fear of pain
• Fear of death
• Fear of disturbance of body image
• Worries – loss of finances, employment, social &
family
Nursing Diagnosis

• Anxiety
• Knowledge deficit
• Fear
• Risk for injury
• Ineffective individual coping
 Nursing Intervention to Minimize
Anxiety

• Explore client’s feelings

• Allow client’s to speak openly about fear/concerns
• Give accurate information regarding surgery
• Give empathetic support
• Consider the person’s religious preferences and
arrange for visit by priest/minister as desired
Preparation for Surgery

•Informed Consent
(Operative
Permit/Surgical
Consent)
Purpose
• To ensure that the client understands the nature of the treatment
including the potential complications and disfigurement
• To indicate that the client’s decision was made without pressure
• To protect the client against unauthorized procedure
• To protect the surgeon & hospital against legal action by client
who claims that an unauthorized procedure was performed
PHYSICAL PREPARATION
Before the Surgery:
• Correct any dietary deficiencies
• Reduce an obese person’s weight
• Correct fluid and electrolyte imbalance
• Restore adequate blood volume with blood transfusion
Before the Surgery:

• Treat chronic disease – DM, heart disease, renal insufficiency

• Halt or treat any infectious process

• Treat an alcoholic person with vitamin supplementation, IVF’s or oral

fluids, if dehydrated
PATIENT EDUCATION

•Preoperative
Instructions to Prevent
Postoperative
Complications
Deep Breathing Exercises
(Diaphragmatic Breathing)

• In deep, diaphragmatic breathing, the diaphragm flattens during

inspiration, enlarging the chest cavity and expanding the lungs.

• Breathing exercises that are taught to client who are at risk for developing
pulmonary complications.

• E.g. atelectasis or pneumonia

Deep Breathing Exercises
Incentive Spirometry

• Is an other way to encourage the client to take a deep breaths.

•Purposes:
• To promote complete lung expansion
• To prevent pulmonary problems
Coughing & Splinting
• Coughing may be performed along with deep breathing every 1 – 2 hours
after surgery
Purposes:
• To expel secretions
• Keep the lungs clear
• Allow full aeration
• Prevent pneumonia and atelectasis
Coughing & Splinting
Splinting
•(e.g. holding) the incision area provide support, promotes a feeling of
security and reduces pain during coughing
Turning Exercises

• The client who are risk for

circulatory, respiratory, or
gastrointestinal dysfunction
following surgery are taught to
turn in bed
Leg, Ankle, & Foot Exercises
• Leg exercises are taught to the client who is at risk for developing
thrombophlebitis
Purposes
• To promote venous blood return from the extremities
• Promote cardiac output and reducing venous stasis
Leg, Ankle, & Foot Exercises
Preoperative Client
Preparation
Nursing Responsibilities
(a night before the surgery)
• Preparing the Skin

• Preparing the G.I. tract

• Preparing for Anesthesia

• Promoting Rest & Sleep

 Nursing Responsibilities
(the day of surgery)

• Remove hairpins and jewelry

• Complete skin or bowel preparation as ordered
• Insert an indwelling catheter, intravenous line, or nasogastric tube as
ordered
• Remove dentures, artificial eye and contact lenses
• Leave a hearing aid in place if the client cannot hear without it, notify
OR nurse
•Nursing Process:
Care Of the Patient in
the Preoperative Period
Assessment

• Physical Condition

• Results pt blood test, x-ray studies, and other diagnostic tests

• Nutritional and fluid status

• Medication use

• Psychological preparedness

• Special Consideration
Planning and Goals

•Major Goals

• Relief of preoperative anxiety

• Decreased fear
• Increased knowledge of perioperative expectations
• Absence of preoperative complications
INTRAOPERATIVE
NURSING
GOALS OF INTRAOPERATIVE CARE
• Asepsis

• Homeostasis

• Safe administration of Anesthesia

Positioning a Person for Surgery
• Factors to be consider
• Site of operation
• Age & size of person
• Type of anesthesia use
• Pain normally experience by the person upon movement
Positions during Surgery
• Dorsal Recumbent
• Hernia repair, mastectomy, bowel resection
• Trendelenburg
• Lower abdomen, pelvic surgery
• Lithotomy
• Vaginal repairs, D&C, rectal surgery, abdomino-
perineal resection
• Lateral
• Kidney, chest, hip surgery
 Standard Position
Supine

Trendelenburg, Reverse Trendelenburg Position

Kidney Position

Lateral Tilt Position

Chair/Sitting Position

Lithotomy,Gynecology,Urology
•Proctology Prone, Kneeling Position

Gallbladder, Thoracic Abdominal Position

Surgical Terminology

• Ectomy
• Removal of organ and gland
• Prectomy
• Removal of kidney
• Rrhaphy
• Suturing/stitching of part
Surgical Terminology

•Scopy
• Means looking into
• Ostomy
• Making an opening/stoma
•Otomy
• Cutting into
•Plasty
• Repair/restore
Surgical Incisions
•Butterfly
• For craniotomy
•Limbal
• For eye surgery
• Halstead/elliptical
• For breast surgery
•Abdominal
• For abdominal surgery
Surgical Incisions

• Mc Burneys
• For appendectomy
• Lumbotomy/transverse
• For kidney surgery
•Sedation
and
Anesthesia
Four Levels

•Minimal Sedation
• Is a drug-induced state during which the patient can respond
normally to verbal commands
Four Levels

•Moderate Sedation
• Is defined as a depressed level of consciousness that does not
impair the patient’s ability to maintain a patent airway and to
respond appropriately to physical stimulation and verbal command
Four Levels

•Deep Sedation
• Is a drug-induced state during which a patient cannot be easily
aroused but can respond purposefully after repeated stimulation
Four Levels

•Anesthesia
• Is a state of narcosis (severe CNS depression produced by
pharmacologic agent), analgesia, relaxation, and reflex loss.
• Is an induced state of partial or total loss of sensation, occurring
with or without loss of consciousness
Purposes of Anesthesia
• To block nerve impulse transmission
• Suppress reflexes
• Promote muscle relaxation
• In some cases, achieve a controlled level of consciousness
Complications from General
Anesthesia
• Malignant Hyperthermia
•Is an acute, life-threatening complication of
certain drugs used for general anesthesia
•Overdose
•Anesthesia overdose can occur if the
client’s metabolism and drug elimination
are slower than expected
•Nursing People During
Surgery
The Surgical Team

• Is a group of highly
trained individuals who
must work together as
a coordinated team for
the welfare & safety of
the person undergoing
surgery
Circulating Nurse

• Acts as a manager of the group

• Checks that all the equipment is working properly before the
surgery
• Prepares & autoclave instruments for surgery
• Perform skin preparation on the person if ordered
• Alerts team member on any break in sterile technique
Skin Preparation
Patient positioning is crucial prior to any surgical procedure.
This involves the surgeon, nurses and orderlies.
Scrub Nurse
•Participates directly
during operative
procedure
•Setting up the OR
 Scrub Nurse

•Prepare all the

materials needed
•Making certain that
the environment for
surgery is sterile
• Preparing and supplying surgical instrument to the surgeon
• Ensures & maintains surgical asepsis throughout the
entire surgical intervention
• Involves technical skills, manual dexterity, & in-depth
knowledge of the anatomic & mechanical aspects of a
particular surgery
• Handles sutures, instrument & other instrument
immediately adjacent to the sterile field
Potential Intraoperative
Complications
• Nausea & Vomiting
• Anaphylaxis
• Hypoxia and Other Respiratory Complications
• Hypothermia
• Malignant Hyperthermia
• Disseminated Intravascular Coagulopathy
•POSTOPERATIVE
NURSING
Goals

• Maintain adequate body system functions

• Restore homeostasis

• Alleviate pain and discomfort

• Prevent postoperative complications

• Ensure adequate discharge planning & teaching

 •Nursing Care of Patient
during the Immediate
Postoperative
•(immediate post anesthesia recovery
– RR)
Immediate Post Anesthesia Recovery – RR)
Nursing Care of Patient during the
Immediate Postoperative

• Transport of the client from the OR to RR

• Avoid exposure
• Avoid rough handling
• Avoid hurried movement and rapid changes in position
Nursing Diagnosis

• Ineffective breathing pattern r/t general anesthesia

• Ineffective airway clearance r/t absent or weak cough
• Risk for aspiration r/t vomiting
Nursing Interventions

Ensure maintenance of patent airway &

adequate respiratory function
• Lateral position with neck extended
• Keep airway in place until fully awake
• Suction secretions
• Encourage deep breathing
• Administer humidified oxygen as ordered
 •Transfer of the Patient
from PACU/RR to Surgical
Ward
Parameters for Discharge from RR

• Activity
• Able to obey commands (e.g. deep breathing,
coughing)
• Respiration
• Easy, noiseless breathing
• Circulation
• BP is within + or - 20 mmHg of the preoperative
level
• Consciousness
• Responsiveness
• Color
• Pinkish skin & mucus membrane
 •Nursing Care of the Client
during the Intermediate Post
Operative Period
(RR-Unit)
Baseline Assessment

• Respiratory status

• Cardiovascular Status

• v/s, color & temperature of skin

• LOC

• Tubes

• Drainage, NGT, T-tube

• Position
Goals

• Maintain adequate renal function

• Promote adequate rest, comfort & safety

• Promote adequate wound healing

• Promote & maintain activity & mobility

• Provide adequate psychological support

Causes of Airway Obstruction

• Mucous collection in the throat

• Aspirated mucus/vomitus
• Loss of swallowing reflex
• Loss of control of the muscles of the jaw and tongue
• Laryngospasm due to intubation
• Bronchospasm
Causes of Hypoventilation
• Medications
• Pain
• Chronic lung disease
• obesity
Signs & symptoms of Respiratory
Obstruction & Hypoventilation
• Restlessness
• Attempt to sit up & stand
• Fast, thready pulse (early sign)
• Air hunger
• Nausea, apprehension, confusion
• Cyanosis
• Stridor/snoring/wheezing
•Nursing Care of Clients
During the Extended
Postoperative Period
2-3 days after surgery (discharge
planning/teaching)

• Self care activities

• Activity limitation
• Diet & medications at home
• Possible complications
• Referrals, follow-up check-up
Postoperative Complications

•Shock
• Response of the body to a decrease in the circulating blood volume,
which results to poor tissue perfusion & inadequate tissue
oxygenation
Postoperative Complications

• Hemorrhage
• Copious escape of blood from the blood vessels
• Capillary
• Slow, generalized oozing
• Venous
• Dark in color & bubble out
• Arterial
• Bright red in color
Postoperative Complications

• Femoral Phlebitis/Deep
Thrombophlebitis
• Often occurs after operations on the lower abdomen or during the
course of septic conditions as ruptured ulcer or peritonitis
Nursing Interventions

• Prevention
• Hydrate adequately to prevent hemoconcentration
• Encourage leg exercise & ambulate early
• Avoid any restricting devices that can constrict & repair circulation
• Prevent use of bed rolls, knee gatches, dangling over the side of
the bed with pressure on popliteal area
Postoperative Complications

•Pulmonary Complications
• Atelectasis
• Bronchitis
• Bronchopneumonia
• Lobar pneumonia
• Hypostatic pulmonary congestion
• Pleurisy
 Most common respiratory
complications include:

• Pneumonia
• An inflammation of lung tissue, caused either by microbial infection or by foreign
substances in the lung which leads to an infection
• Atelectasis
• Is an incomplete expansion or collapse of the lung tissue resulting in inadequate
ventilation and retention of pulmonary secretions
Common Assessment Findings

•Pneumonia
• High fever
• Rapid pulse and respiration
• Chills (present initially)
• Productive cough (present depending on the type of pneumonia)
• Dyspnea
• Chest pain
• Crackles & wheezes
Nursing Care

• Obtain sputum specimens for culture & sensitivity

testing
• Position client with the head of the bed elevated
• Encourage the client to turn, cough, & perform
deep breathing exercises @ least q 2 hours
• Assist with incentive spirometry, intermittent
positive pressure breathing and/or nebulizer as
ordered
• Ambulate client
• Administer Oxygen
 Nursing Care

• Assess v/s, breath sounds, & general condition

• Maintain hydration to help liquefy pulmonary
secretions
• Administer antibiotics, expectorants, antipyretics and
analgesics as ordered
• Provide or assist with frequent oral hygiene
• Prevent spread of microoganism by teaching disposal of
tissues, covering mouth when coughing and good
handwashing technique
• Provide supportive measures for client and family
Common Assessment Findings

•Atelectasis
• Dyspnea
• Diminished breaths sound the affected area
• Anxiety
• Restlessness
• Crackles
• cyanosis
Nursing Care

• Positioning – head of bed elevated

• Administer O2
• Encourage coughing, turning, and deep breathing q 2 hours
• Ambulate (as condition permits)
• Assist with incentive spirometry
• Administer analgesics as ordered
• Promoting hydration
• Providing supportive measures