PERIOPERATIVE

NURSING
 SURGERY
• It is a unique experience of a planned physical alteration encompassing
three phases: preoperative, intraoperative, and postoperative.
• These three phases are together referred to as perioperative period.
 PERIOPERATIVE NURSING
• It is the delivery of nursing care through the framework of the nursing
process.
• It also includes collaborating with members of the health care team,
making nursing referrals, and delegating and supervising nursing care.
• The perioperative nurses’ role is underscored by the nursing process and
all care activities inherent in that process regardless of the health care
setting in which it is operationalized.
 PREOPERATIVE PHASE
• It begins when the decision to have surgery is made and it ends when the
client is transferred to the operating table.
• The nursing activities associated with this phase include assessing the
client, identifying potential or actual health problems, planning specific
care based on the individual’s needs, and providing preoperative teaching
for the client, the family, and significant others.
 INTRAOPERATIVE PHASE
• It begins when the client is transferred to the operating table and ends when the
client is admitted to the post-anesthesia care unit (PACU), also called as post-
anesthetic room or recovery room (RR).
• The nursing activities related to this phase include a variety of specialized
procedures designed to create and maintain a safe therapeutic environment for the
client and the health care personnel.
• These activities include interventions that provide for the client’s safety, maintaining
an aseptic environment, ensuring proper functioning of equipment, and providing the
surgical team with the instruments and supplies needed during the procedure.
 POSTOPERATIVE PHASE
• It begins with the admission of the client to the post-anesthesia area and
ends when healing is complete.
• During this phase, nursing activities include assessing client’s response
(physiological and psychological) to surgery, performing interventions to
facilitate healing and prevent complications, teaching and providing
support to the client and support people, and planning for home care.
• The goal is to assist the client to achieve the most optimal health status
possible.
 TYPES OF SURGERY
Surgical procedures are commonly grouped according to:
a. Purpose
b. Degree of urgency
c. Degree of risk
 TYPES OF SURGERY ACCORDING TO
PURPOSE
1. Diagnostic – confirms or establishes a diagnosis; for example, biopsy of a mass in a
breast.
2. Palliative – relieves or reduces pain or symptoms of a disease; it does not cure; for
example, resection of nerve roots.
3. Ablative – removes a diseased body part; for example, removal of a gallbladder
(cholecystectomy).
4. Constructive – restores function or appearance that has been lost or reduced; for
example, cleft palate repair.
5. Transplant – replaces malfunctioning structures; for example, kidney transplant.
 TYPES OF SURGERY ACCORDING TO
DEGREE OF URGENCY
Surgery is classified by its urgency and necessity to preserve the client’s life, body part,
or body function.
1. Emergency surgery – is performed immediately to preserve function or the life of
the client. Surgeries to control internal hemorrhage or repair a fracture are examples.
2. Elective surgery – is performed when surgical intervention is the preferred treatment
for a condition that is not imminently life threatening (but may ultimately threaten
life or well-being), or to improve the client’s life. Examples include cholecystectomy
for chronic gallbladder disease, hip replacement surgery, and plastic surgery
procedures such as breast reduction.
 TYPES OF SURGERY ACCORDING TO
DEGREE OF RISK
1. Major surgery – involves a high degree of risk for a variety of reasons. It
may be complicated or prolonged, large losses of blood may occur, vital
organs may be involved, or post-operative complications may be likely.
Examples are organ transplant, open heart surgery, and removal of a
kidney.
2. Minor surgery – normally involves little risk, produces few
complications, and is often performed in an outpatient setting. Examples
are breast biopsy, removal of tonsils, and cataract extraction.
 TYPES OF SURGERY ACCORDING TO
DEGREE OF RISK
The degree of risk involved in a surgical procedure is affected by:
1. Age – neonates/infants and older clients are greater surgical risks than children
and adults. Age and developmental status affect a child’s ability to cope with the
physiological and psychological stresses of surgery. Neonates and infants have a
higher metabolic rate and a physiological makeup than adults. These differences
cause a substantially different response to a surgical procedure.
The older adult (65 years and older) often has fewer physiological reserves to
meet the extra demands caused by surgery. The physiological deficits of aging
increase the surgical risk for the older adult.
2. General Health – surgery is least risky when the client’s general health is
good. Any infection or pathophysiology increases the risk. It is important for
the nurse to assess the client for an upper respiratory tract infection, which
together with a general anesthetic can adversely affect respiratory function.
3. Nutritional status – adequate nutrition is required for normal tissue repair.
Surgery increases the body’s need for nutrients that help with the tissue
healing and prevention of infection required during the postoperative period.
Obesity and malnutrition increase surgical risk.
4. Obstructive Sleep Apnea (OSA) – it is a common condition caused by
partial or complete obstruction of the upper airway during sleep. Breathing
is briefly interrupted during sleep with periods of apnea lasting at least 10
seconds. Recent studies have shown that clients with OSA who undergo
surgery appear to be at increased risk for pulmonary complications.
5. Medications – the regular use of certain medications can increase surgical
risk. Consider these examples:
• Anticoagulants – increase blood coagulation time
• Tranquilizers – may interact with anesthetics, increasing the risk of
respiratory depression
• Corticosteroids – may interfere with wound healing and increase the risk of
infection
• Diuretics – may affect fluid and electrolyte balance
6. Mental status
 Disorders that affect cognitive function, such as mental illness, mental retardation, or
developmental delay, affect the client’s ability to understand and cope with the stresses of
surgery.
 Clients with dementia may have difficulty understanding proposed surgical procedures and
may respond unpredictably to anesthetics. Manifestations of dementia such as confusion,
disorientation, and agitation also may be aggravated by the change of environment in the
hospital, interfering with the client’s ability to cooperate with pre- and postoperative care.
 Extreme anxiety also increases surgical risk and interferes with the client’s ability to process
information and respond appropriately to instructions.
PREOPERATIVE
PHASE
 PREOPERATIVE CONSENT
INFORMED CONSENT
 It is required from the client or legal guardian prior to any surgical procedure.
 It implies that the client has been informed and involved in decisions affecting his or her health.
 The surgeon is responsible for obtaining the informed consent by providing the following information to
the client or legal guardian:
- the nature of and the reason for surgery
- all available options and the risks associated with each option
- the risks of the surgical procedure and its potential outcomes
- name and qualifications of the surgeon performing the procedure
- the right to refuse consent or later withdraw consent
INFORMED CONSENT
 It protects the client from incorrect/unwanted procedures and the surgeon and facility
from litigation related to unauthorized surgeries or uniformed clients
 This form becomes part of the client’s medical record and goes to the operating room
with the client.
 The nurse may witness the client’s signature on the consent form and ensures that the
consent form is signed, not to the fact that the client is informed. If the nurse assesses
that the client does not understand the procedure to be performed, the surgeon is
contacted and requested to speak with the client before surgery can proceed.
INFORMED CONSENT
It is only possible when the client understands the provided information,
that is, speaks the language and is conscious, mentally competent, and not
sedated.
It may not be given by a minor.
Nurses must be aware of their responsibilities regarding consent and of
the particular hospital’s policies.
 NURSING MANAGEMENT
ASSESSING
Preoperative assessment includes collecting and reviewing physical, psychological, and social client data to
determine the client’s needs throughout the three perioperative phases
Physical Assessment
Preoperatively, the nurse performs a brief but complete physical assessment, paying particular attention to systems
that could affect the client’s response to anesthesia and surgery. A brief mental status examination provides valuable
baseline data for evaluating the client’s mental status and alertness after surgery. It is also important to evaluate the
client’s ability to understand what is happening.
Screening Tests
The surgeon and/or anesthesiologist orders preoperative diagnostic tests. Abnormalities may warrant treatment prior
to surgery. The nurse’s responsibility is to check the orders carefully, to see that they are carried out, and to ensure
that the results are obtained and in the client’s record prior to surgery.
 NURSING MANAGEMENT
DIAGNOSING
NANDA International nursing diagnoses that may be appropriate for the preoperative client
include the following:
• Deficient Knowledge related to:
- A lack of education about the perioperative process
- A lack of exposure to the specific perioperative experience
• Grieving related to
- Perceived loss of body part associated with planned surgery
DIAGNOSING
• Anxiety related to
- Effects of surgery on ability to function in usual roles
- Outcome of exploratory surgery for malignancy
- Risk of death
- Loss of control during anesthesia or waking up during anesthesia
- Perceived inadequate postoperative analgesia
- Change in health status and/or body image.
DIAGNOSING
• Ineffective Coping related to
- Lack of clear outcomes of surgery
- unresolved past negative experience with surgery
PLANNING
The overall goal in the preoperative period is to ensure that the client is
mentally and physically prepared for surgery.
Planning should involve the client, the family, and/or significant others.
IMPLEMENTING
The major nursing activity to ensure that the client is prepared for surgery is preoperative
teaching
Preoperative Teaching
- is a vital part of nursing care that reduces client’s anxiety and post-operative
complications and increases their satisfaction with the surgical experience according to
studies.
- It also facilitates the client’s successful and early return to work and other activities of
daily living (ADLs).
Four dimensions of preoperative teaching have been identified as important to clients:
• Information including what will happen to the client, when, and what the client will experience, such as
expected sensations and discomfort. – the nurse needs to listen carefully and attentively to the client to identify
specific concerns and fears.
• Psychosocial support to reduce anxiety. – the nurse provides support by actively listening and providing
accurate information.
• The roles of the client and support people in preoperative preparation, the surgical procedure, and during
the postoperative phase. – understanding the client’s role during the perioperative experience increases the
client’s sense of control and reduces anxiety. This includes what will be expected of the client, desired
behaviors, self-care activities, and what the client can do to facilitate recovery.
• Skills training. – this includes moving, deep breathing, coughing, splinting incisions with the hands or a pillow,
and using an incentive spirometer.
Physical Preparation
It includes the following areas:
• Nutrition and Fluids – adequate hydration and nutrition promote healing.
Nurses need to identify and record any signs of malnutrition or fluid
imbalance. The order “NPO after midnight” has been a long-standing
tradition because it was believed that anesthetics depress gastrointestinal
functioning and there was a danger the client would vomit and aspirate
during the administration of a general anesthetic.
Physical Preparation
• Elimination – enemas before surgery are no longer routine, but cleansing
enemas may be ordered if bowel surgery is planned. The enemas help prevent
postoperative constipation and contamination of the surgical area. After
surgery involving intestines, peristalsis often does not return for 24 to 48 hours
• Hygiene – in some settings, clients are asked to bathe or shower the evening
or morning of surgery (or both). The purpose of hygienic measures is to
reduce the risk of wound infection by reducing the amount of bacteria on the
client’s skin.
Physical Preparation
• Medications - the anesthetist or anesthesiologist may order routinely taken medications to be held the day of
surgery.
• Sleep – nurses should do everything to help the client sleep the night before the surgery because adequate sleep
helps the client manage the stress of surgery and helps healing.
• Valuables – such as jewelry and money should be sent home with the client’s family or significant other.
• Prostheses –artificial body parts, such as partial or complete dentures, contact lenses, artificial eyes, and
artificial limbs and eyeglasses, wigs and false eyelashes must be removed before surgery.
• Skin preparation
• Temperature
• Vital signs
INTRAOPERATIVE
PHASE
 INTRAOPERATIVE PHASE
The intraoperative nurse uses the nursing process to design, coordinate, and
deliver care to meet the identified needs of clients whose protective reflexes
or self-care abilities are potentially compromised because they are having
operative or other invasive procedures.
 TYPES OF ANESTHESIA
GENERAL ANESTHESIA
 It is the loss of all sensation and consciousness.
 Protective reflexes such as cough and gag reflexes are lost
 Acts by blocking awareness centers in the brain so that amnesia (loss of memory), analgesia (insensibility to
pain), hypnosis (artificial sleep), and relaxation (rendering a part of the body less tense) occur.
 Usually administered by IV infusion or by inhalation of gases through a mask or through an endotracheal tube
inserted into the trachea.
 It has certain advantages because the client is unconscious rather than awake and anxious, respiration and
cardiac function are readily regulated.
 It can be adjusted to the length of the operation and the client’s age and physical status
 Its chief disadvantage is that it depresses the respiratory and circulatory systems
REGIONAL ANESTHESIA – It is the temporary interruption of the transmission of nerve impulses to
and from a specific area or region of the body. The client loses sensation in an area of the body but
remains conscious. Several techniques are used:
• Topical (surface) anesthesia – is applied directly to the skin and mucous membranes, open skin
surfaces, wounds and burns. The most commonly used are lidocaine and benzocaine. They are
readily absorbed and act rapidly.
• Local anesthesia (infiltration) – is injected into a specific area and is used for minor surgical
procedures such as suturing a small wound or performing biopsy. Lidocaine or Tetracaine 0.1% may
be used.
• A nerve block – is a technique in which the anesthetic agent is injected into and around a nerve or
small nerve group that supplies sensation to a small area of the body.
• Spinal anesthesia or subarachnoid block (SAB) – requires a lumbar
puncture through one of the interspaces between lumbar disc 2 (L2) and
the sacrum (S1). An anesthetic agent is injected into the subarachnoid
space surrounding the spinal cord. Spinal anesthesia is often categorized
as a low, mid, or high spinal. Low spinals (saddle or caudal blocks) are
primarily used for surgeries involving the perineal or rectal areas. Mid-
spinals (below the level of the umbilicus – T10) can be used for hernia
repairs or appendectomies, and high spinals (reaching the nipple line –
T4) can be used for surgeries such as cesarean sections.
• Epidural anesthesia – is an injection of an anesthetic agent into the
epidural space, the area inside the spinal column but outside the dura
mater.
CONSCIOUS SEDATION
 It may be used alone or in conjunction with regional anesthesia for some diagnostic tests
and surgical procedures.
 It refers to minimal depression of the level of consciousness such that the client retains
the ability to maintain a patent airway and respond appropriately to commands.
 It increases the client’s pain threshold and induces a degree of amnesia but allows for
prompt reversal of its effects and a rapid return to normal ADLs.
 Procedures such as endoscopies, incision and drainage of abscesses, and even balloon
angioplasty may be performed.