1. Perioperative Nursing Care

2. I. Types of Surgery
A. Diagnostic - determination of presence and/or extent of
pathology, ex. lymph node biopsy
B. Therapeutic - curative. Elimination/repair of pathology, ex.
appendectomy
C. Palliative - relieve or alleviate without curing, ex. g-
tube placement
D. Preventive - stop another problem from happening
ex. suspicious mole
E. Cosmetic - optional. Decision rests with patient.
Other Types
Emergency - required immediately. May be life threatening
Elective - should operate, not catastrophic -ectomy: removal
-otomy: incision
-plasty: change shape
-oscopy: look

3. II. Preoperative Nursing
Assessment
A. Age
B. Allergies
C. Vital sign trend
D. Nutritional status
E. Habits affecting tolerance to anesthesia
– drug & alcohol use
– smoking: 6x risk increase

5. II. Preoperative Nursing Assessment
F. Presence of infections
G. Use of drugs that are contraindicated prior to
surgery
Everything! Including OTC herbal supplements, etc.
H. Physiological status / labs
Full H&P by physician
I. Psychological state of the patient

10. III. Patient preparation
A. Operative consent. Nurse is advocate. 3 conditions:
• adequate disclosure of Dx, nature & purpose of Rx, risks &
consequences
• must demonstrate clear understanding & comprehension of
information
• must be given voluntarily
Informed consent: active shared decision making process between provider and
patient. Protects all involved. Responsibility of surgeon to have it signed.
Contains anticipated procedures, other procedures that might need to be done, and
anything that can happen to the patient, including death.
Patient must be of legal age or parent/guardian responsible. Must be signed
voluntarily, never through coercion.

11. Informed consent

12. B. Preoperative learning needs
Individualized for pt’s needs.
Common needs:
• Deep breathing and coughing
• Turning and active body movement
• Pain control and medications
– Educate pt. on notifying nurse if pain occurs.
• Tubes, drains, dressings, other devices to expect
(SEDs, TEDs, IS, etc.)
• Cognitive control – psychosocial aspects.
Explain rationale, too.

13. Teaching splinting the incision
During TCDB, etc. to maintain incision integrity Teaching – PCA pump

14. C. Interventions the day/evening prior
to surgery
• Intake restrictions
– NPO after midnight
– Although, evidence that pt. can have clear liquids up to 2
hours before surgery
• Cleansing enema or laxative night before (bowel
preps)
– For purpose of preventing defecation during surgery,
promoting intestinal deflation in case of surgical site local to
bowels
• Skin prep
– Ex. hot shower before surgery & additional skin prep in OR

15. D. Interventions the day of surgery
• NPO
• May receive preanesthetic medication
• Skin prep
• Jewelry removed or taped
– Defibrillation or cauterization will cause burns
• Void right before going to surgery
• Preoperative check list

16. Preoperative check list

17. IV. Intraoperative nursing considerations
A. Nursing roles
1. Circulating RN - manages OR room. Nonsterile
activities. Protects safety & health needs of patient by
monitoring all activities of members of surgical team &
conditions of OR.
2. Scrub RN
• Sterile activities
• Scrub for surgery
• Set up sterile table, prepare sutures, special equipment
• Assist surgeon during procedure - anticipate needs
• Ensure equipment/instrument count with circulating RN

18. B. Perioperative asepsis
• Main priority of surgery - prevent patient problems
• Includes protecting patient from infection
1. All materials in sterile field must be sterile
2. Sterile items in contact with non-sterile items are contaminated
3. Remove contaminated items immediately
4. Sterile team members wear sterile gowns
5. Keep wide margin between sterile & non-sterile field
6. Tables sterile only at tabletop level
7. Edges of sterile package contaminated once package is
opened
8. Bacteria travel on airborne particles
9. Bacteria travel by capillary action through moist fabrics
11. Bacteria harbor on patients and team members’ hair, skin, and

19. • Preparation of a sterile fieldz
Sterile clothing is worn in the OR Preparation of a sterile field

20. An OR suite

21. C. Types of anesthesia
Factors to consider in anesthetics:
• current health status and history
• emotional stability
• factors relating to operative procedure

22. C. Types of anesthesia
• General - loss of sensation with loss of
consciousness
• Local - loss of sensation without loss of
consciousness
• Conscious sedation - minimally depressed LOC,
twilight sleep
• Regional - loss of sensation without loss of
consciousness when specific nerve is blocked, ex.
spinal anesthetic

23. 1. General Anesthesia
• IV Anesthesia
Anesthesia induction
• Inhalation Agents
• Adjuncts to General Anesthesia
– Muscle relaxation & reflex control
– Relieve pain & anxiety
– Amnesia, LOC
• Begin with IV induction of short acting barbiturate

24. 2. Regional Anesthesia
• Suspends sensation in parts of body
• Injected around nerves so area supplied
by nerves is anesthetized
• Effect depends on type of nerve involved
• Spinal anesthesia
• Epidural block

25. Spinal and Epidural Anesthesia

26. D. Patient positioning
Depends on surgery & condition of pt.
• correct skeletal alignment
• undue pressure on nerves, skin over bony
prominences, eyes
• adequate thoracic excursion
• occlusion of arteries and veins
• modestly in exposure
• recognize and respect individual needs

27. Operative positions

28. E. Temperature alterations
during interoperative period
May be intentional. May be caused by:
• low temp in OR
• infusion of cold fluid
• inhalation of cold gases
• open body wounds or cavities
• decreased muscle activity
• advanced age
• drugs used (vasodilators)
Malignant hyperthermia – hypermetabolic condition of very high temperatures
associated with muscle rigidity in the skeletal muscles. Occurs in some people
exposed to certain anesthetics. Can lead to cardiac dysrhythmia. Mortality rate >50%

29. V. Postoperative care
A. Preparation for admitting the new
postoperative patients
B. Initial assessment and interventions
upon receiving the patient
C. Selected data from the chart that is of
importance

30. D. Post operative nursing
assessment and concerns
• Ineffective airway clearance
• Pain & other postoperative discomforts
• Risk for altered body temperature
• Risk for injury related to postanesthesia
• Altered nutrition – less than body requirements
• Altered urinary elimination
• Constipation
• Impaired physical mobility
Anesthetic into body through inhalation, out through expiration. Encourage deep
breaths immediately to expel post-op.

31. Post-operative position

32. Postoperative Care
Preparing for post-operative patient
Initial Assessment and Interventions
Selecting important data from chart
General post-op assessment & interventions

33. Preparing for Post-operative
Patient
Is there 02 in the room?
IV or PCA pumps/poles?
Pt arriving by bed or gurney?
Does the patient need suction?
Is traction required?
Are tracheostomy supplies needed?
Is the nurse’s assistant prepared?

34. Initial Assessment & Interventions
LOC: Alert and oriented
Comfort: Pain, nausea, pruritus
Vital Signs: All especially respirations
Wound: Incision
Drains: Color, amount, location(s)
Support equipment:
Compression & Sequential stockings
CPM PCA IV 02
NOTE: Nursing Care Plan
Table 20-1 in Lewis
Dressing: drainage, mark with pen and date to monitor for bleeding

35. Selecting Important Data from
the Patient’s Chart
Doctor’s orders
History & Physical (H&P)
Allergies
Pre-op vital signs
Pre-op medications
Pre-op lab levels

36. General Post-op
Assessment & Interventions
Continue with initial Assessment then…
Pain management
Ambulate or ROM (per MD orders)
Cough, deep breath & Incentive Spirometer
Incisions and drains
Antibiotic therapy
Anti-DVT/PE interventions

37. Potential Postoperative
Complications
Hematological Respiratory
Cardiovascular Urinary
Gastrointestinal Neurological
Immunological Wound
Psychological

38. Potential Postoperative
Complications
Hematological
Hemorrhage:
S/S: External: Surgical site
(dressing, drains, linens)
Internal: tenderness, swelling
B/P changes, CBC levels.
Symptoms of hypovolemia

39. Potential Postoperative
Complications
Respiratory
Atelectasis: Collapse of alveoli
Pneumonia: Fluid infiltration
Pulmonary embolism: DVT moved to lung
Prevention: Deep breath, cough &
Incentive spirometer, hydrations,
antibiotics, anti-embolism
interventions & Rxs

40. Postoperative Atelectasis

41. Potential Postoperative
Complications
Cardiovascular
Hypotension: Hypovolemic: Hemorrhage,
dehydration, due to NPO status, poor IV access
Cardiac dysrhythmias: Due to dehydration,
previous condition, anesthesia,
electrolyte imbalance.
Deep Vein Thrombosis
Prevention: Assessment & intervention,
hydration, continue previous meds.

42. Potential Postoperative
Complications
Thromboembolism: DVT/PE
#1 cause of mortality in Post-op &
Hospitalized patients
200,000-600,000 cases annually
60,000-200,000 die annually
(APHA, 2003)

43. Potential Postoperative
Complications
Thromboembolism Continued…
Causes: Dehydration,immobility, vascular
manipulation or injury, hormones
& birth control, history of DVT
S/S: Redness, swelling, pain, chest
pain, SOB, dyspnea
Prevention: Turn, cough, deep breath, ROM,
ambulation, hydration, exercises
antiembolism & sequential
stockings and anticoagulants

44. Assessing for Homan’s sign

45. Post-operative Leg Exercises

46. Potential Postoperative
Complications
Urinary
Urinary retention: (bladder related)
S/S: Tenderness, low or no output,
distension, incontinence.
Low urine output: (renal) < 30mL/hr rule
Causes: Anesthesia, anticholinergic and
narcotics, dehydration, position,
ARF or CRF.

47. Palpation for bladder distention

48. Potential Postoperative
Complications
Gastrointestinal
Paralytic ileus:
Causes: Intestinal manipulation, narcotics,
premature introduction of food
Tx: NG tube to suction, NPO
Constipation:
Causes: Narcotics, NPO, dehydration,
inactivity, previous hx.
Tx: Hydration, ambulation, stool softeners
and/or fiber.

49. Potential Postoperative
Complications
Neurological
CVA or stroke:
Causes: DVT
Prevention: Same as DVT/PE
Narcosis or “narcotized state”
Causes: Opiod Naïve, anesthesia,
narcotic overload.
Sensory changes: peripheral and urinary

50. Potential Postoperative
Complications
Immunological
Infection:
Signs & Symptoms:
Assessment: Fever, tenderness, redness,
swelling, drainage color changes or c/o
“feeling lousy.”
Lab: Elevated WBCs
Prevention:
Aseptic technique when handling wounds,
dressings and drains.

51. Jackson-Pratt Drain

52. Hemovac Drain

53. Cleaning a Drain Site
Penrose drain

54. Cleaning a Wound Site

55. Montgomery Ties

56. Potential Postoperative
Complications
Wound
Dehiscence: Spontaneous opening of incision
Evisceration: Escape of Organs
Infection: Invasion of organisms w/ potential
of causing disease
Prevention: Hand washing, assessment, aseptic
technique, binder, splinting and patient teaching.

57. Dehiscence and Eviseration

58. Abdominal Binder

59. Splinting Methods

60. Surgical wound classifications

61. Potential Postoperative
Complications
Psychological:
Body image Problems: Scarring, drains,
amputation, ostomy.
Pain Management:
• Pre-op pain vs. post-op pain
• Chronic pain vs. acute pain