Introduction to Perioperative Nursing

Learning Objectives:

At the end of this session student will be able to:

1. Explain categories of surgical procedure.

2. Identify the patient at risk of complication during perioperative nursing.

3. Define the three phases of perioperative management.

Perioperative Nursing

Introduction to perioperative nursing.

1. Categories of surgical procedures.

a) Purpose

b) Magnitude of surgery

c) Urgency

2.Definitions.

a) Perioperative nursing

b) Preoperative phase

c) Intraoperative phase

d) Postoperative phase

Perioperative Nursing

Outline:

1. Categories of surgical procedures.

a) Purpose

b) Magnitude of surgery

c) Urgency
I) Categories of surgical procedures.

 Surgery may be performed for various reasons. A surgical procedure may

be:

 Diagnostic (eg, biopsy or exploratory laparotomy).

 Curative (eg, excision of a tumor or an inflamed appendix)
 Reparative (eg, multiple wound repair).
 Constructive: repairs a congenitally defective organ. (Plastic surgery for
cleft palate).

 Cosmetic (eg, mammoplasty or a facelift).

 Reconstructive: restoration of damaged organ or tissue to its original
appearance and function.

 Palliative (eg, to relieve pain or correct a problem; for instance, a

gastrostomy tube may be inserted to compensate for the inability to

swallow food).

 Surgery may also be classified according to the degree of urgency

involved:

 Emergent, urgent, required, elective, and optional.

 Surgery according to magnitude of surgery:

 Major surgery: Extensive prolonged and involve a significant loss of blood

involves greatest risk of complication.

 Minor surgery: Not prolonged, leads to few complications and involve less
risk.

II) Definitions:

 Perioperative Nursing:

• All nursing functions associated with the patient's

surgical experience.
 • "Perioperative" Incorporates the three phases of the

surgical experience (Preoperative, Intraoperative and

postoperative.)

 Preoperative phase:

Begins when the decision for surgical intervention is made and

ends with the transfer of the patient to operating room table.

 Intraoperative phase:
Begins when the patient is admitted or transferred to the surgery

department and end when he is admitted to the recovery area.

 Postoperative phase:

Begins with the admission of the patient to the recovery area and

ends with a follow up evaluation in the clinical setting.

 Preoperative Nursing

I- Learning objectives:-

At the end of this part the student:

⇒ Explain the content of the physiological and psychological assessment

of the preoperative client.

⇒ Identify appropriate common NANDA nursing diagnosis and planning for

the preoperative phase.

⇒ Plan the expected outcomes when prepare the client for surgery.

⇒ Describe the appropriate preoperative patient teaching.

⇒ Discuss preoperative nursing intervention.

⇒ Document the physical and psychological preparation of the

preoperative patient (i.e. writing patient care plan and recording).

Nursing Process for Preoperative Patient

I) Preoperative Assessment:

The overall goal in the preoperative period is for the patient to have as

many positive health factors as possible. Before any surgical treatment is

initiated,

1. A health history is obtained,

2. A physical examination is performed during which vital

signs are noted, and a database is established for future

comparisons.

3. Blood tests, x-rays, and other diagnostic tests are

prescribed.

1) Nutritional and Fluid Status:

• Optimal nutrition is an essential factor in promoting healing and resisting

infection and other surgical complications.

 • Assessment of a patient’s nutritional status (fluid& food) provides
information on obesity, under nutrition, weight loss, malnutrition,

deficiencies in specific nutrients, and metabolic abnormalities.

• Assessment includes weight, total serum protein (plasma proteins such

as albumin, transferring, prealbuimin, hemoglobin, blood urea nitrogen,

blood sugar level, minerals and vitamins levels).

2) Drug or Alcohol Abuse:

• People who abuse drugs or alcohol frequently deny or attempt to hide it.

The nurse who is obtaining the patient’s health history needs to ask frank

questions with patience, care, and a nonjudgmental attitude.

• Because acutely intoxicated persons are susceptible to injury, surgery is

postponed in these patients if possible.

• If emergency surgery is required, local, spinal, or regional block

anesthesia is used for minor surgery.

3) Respiratory Status:

• The goal for potential surgical patients is optimal respiratory function.

• Respiratory pattern must be assessed (rate, quality, abnormalities as

dyspnea, cough, sputum …etc.).

• Plain chest x-ray.

• Patients who smoke are urged to stop 2 months before surgery, although

many do not do so.

4) Cardiovascular Status:

• The goal in preparing any patient for surgery is to ensure a well

functioning cardiovascular system to meet the oxygen, fluid, and

nutritional needs of the perioperative period.

 • Assess heart beat (rate, rhythm, quality,etc.), blood pressure, ECG

• Because cardiovascular disease increases the risk for complications,

patients with these conditions require greater-than-usual

diligence/carefulness during all phases of nursing management and care.

5) Hepatic and Renal Function:

• The presurgical goal is optimal function of the liver and urinary systems
so that medications, anesthetic agents, body wastes, and toxins are

adequately processed and removed from the body.

• Careful assessment is made with the help of various liver function tests

(ALT, AST, PT, PTT, INR, etc).

• Because the kidneys are involved in excreting anesthetic drugs and their

metabolites and because acid–base status and metabolism are also

important considerations in anesthesia administration, kidney function

tests should be done (blood urea, creatinine, creatinine clearance, urine

analysis, etc).

6) Endocrine Function:

• Frequent monitoring of blood glucose levels is important before, during,

and after surgery.

• Patients who have received corticosteroids are at risk for adrenal

insufficiency. Therefore, the use of corticosteroids for any purpose must

be reported to the anesthesiologist or anesthetist and surgeon.

• Patients with uncontrolled thyroid disorders are at risk for thyrotoxicosis

(with hyperthyroid disorders) and respiratory failure (with hypothyroid

disorders).
7) Previous Medication Use:
• A medication history is obtained because of the possible effects of

medications on the patient’s perianesthesia course and the possibility of

drug interactions.

• Any medication is documented, including over-the-counter (OTC)

preparations and herbal agents and the frequency with which they are

used.
8) Immune Function:

• An important function of the preoperative assessment is to determine the

existence of allergies, including the nature of previous allergic reactions.

• It is especially important to identify and document any sensitivity to

medications and past adverse reactions to these agents.

9) Psychosocial Factors:

• All patients have some type of emotional reaction (fear& anxiety) before

any surgical procedure, be it obvious or hidden.

• For example, preoperative anxiety may be an anticipatory response to an

experience the patient views as a threat to his or her customary role in

life, pain, body integrity, or life itself.

• Concerns about loss of work time, loss of job, increased responsibilities or

burden on family members, and the threat of permanent incapacity further

contribute to the emotional strain created by the prospect of surgery.

10) Spiritual and Cultural Beliefs:

• Spiritual beliefs play an important role in how people cope with fear and

anxiety. Regardless of the patient’s religious affiliation/attachment,

spiritual beliefs can be as therapeutic as medication.

Asking if the patient’s spiritual advisor knows about the impending surgery

is a caring, nonthreatening approach.

Preoperative Teaching:

Nurses have long recognized the value of preoperative instruction.

Multiple teaching strategies should be used (eg, verbal, written, return

demonstration), depending on the patient’s needs and abilities.

1) Deep-breathing, coughing, and incentive spirometers:

• One goal of preoperative nursing care is to teach the patient how to

promote optimal lung expansion and consequent blood oxygenation after

anesthesia.

• The patient assumes a sitting position to enhance lung expansion. The

nurse also demonstrates how to use an incentive spirometer, a device that

provides measurement and feedback related to breathing effectiveness.

• In addition to enhancing respiration, the deep breathing may help the

patient to relax.

2) Mobility and active body movement:

• The goals of promoting mobility postoperatively are to improve

circulation, prevent venous stasis, and promote optimal respiratory

function.

• The nurse explains the rationale for frequent position changes after

surgery and then shows the patient how to turn from side to side and how

to assume the lateral position without causing pain or disrupting

intravenous lines, drainage tubes, or other equipment.

• Any special position the individual patient will need to maintain after

surgery according to site of operation (eg, adduction or elevation of an

extremity) is discussed, as is the importance of maintaining as much

mobility as possible despite restrictions.

3) Pain management:

• An assessment should include a determination between acute and chronic

pain so that the patient may differentiate postoperative pain from a

chronic condition.

• The patient is instructed in use of a pain intensity rating scale to promote

effective postoperative pain management.

II) Preoperative Nursing Interventions:

Preoperative Psychosocial Interventions:

1) Reducing preoperative fear& anxiety:

• Cognitive strategies (distraction, deep breathing, and imagination) useful

for reducing anxiety in addition to these strategies.

• Music therapy is an easy-to-administer, inexpensive, noninvasive

intervention that can reduce anxiety in the perioperative patient.

• Spiritual advisor (a clergy man) will be available if desired.

• Provide explanations or printed information about health care facility

routines& visiting hours& meal time.

• Explain the procedures involved in the upcoming surgery to allay the

Person’s anxiety. (Complete idea of what the pre, intra& post operative

course entails).

• Explain all nursing care and any possible discomfort that may result as a

consequence of nursing intervention.

• Allow the person to take the lead in asking questions. (Give only as much

information as the person wishes to know).

• Introduce the person who is to undergo a major surgical procedure to

people who have successfully recovered from this operation.

• Arrange occupational therapy for people who are facing an extended

operative period.

General Preoperative Physiological Interventions:

1) Managing nutrition and fluids:

• The major purpose of withholding food and fluid before surgery is to

prevent aspiration.
 • Recent review of this practice by the American Society of

Anesthesiologists has resulted in new recommendations for persons

undergoing elective surgery who are otherwise healthy. The

recommendations depend on the age of the patient and type of food eaten.

For example, adults are advised to fast for 8 hours after eating fatty food

and 4 hours after ingesting milk products.

• Generally fasting period is ranged from 10 to 12 hours preoperatively.

• Correct any dietary deficiencies.

• Reduce an obese person’s weight.

• Correct fluid & electrolyte imbalance.

• For gastrointestinal surgeries, the patient may live on fluids only for 3

days preoperatively.

2) Promoting rest& sleep:

Measure to reduce preoperative sleeplessness and restlessness

include:

• A well - ventilated room,

• Comfortable , clean bed,

• Back massage,

• Warm beverage (if fluids are not contraindicated).

• On the night before surgery sleeping medication.

3) Preparing the bowel for surgery:

• Enemas are not commonly ordered preoperatively unless the patient is

undergoing abdominal or pelvic surgery.

• In this case, a cleansing enema or laxative may be prescribed the evening

before surgery and may be repeated the morning of surgery.

 • The goals of this preparation are to allow satisfactory visualization of the
surgical site and to prevent trauma to the intestine or contamination of the

peritoneum by feces.

• Gastrointestinal tube sometimes is inserted the evening before or the

morning of surgery to remove gastric or intestinal contents (for people

undergoing major abdominal or intestinal tract surgery).

4) Preparing the skin:

• The goal of preoperative skin preparation is to decrease bacteria without

injuring the skin.

• If the surgery is not performed as an emergency, the patient may be

instructed to use a soap containing a detergent-germicide to cleanse the

skin area for several days before surgery to reduce the number of skin

organisms.

• If hair must be removed, electric clippers are used for safe hair removal

immediately before the operation.

• Preventing SSIs Surgical Site Infections: Recommendations for preventing

SSIs consist of four components:

o The appropriate use of prophylactic antibiotics.

o The use of appropriate hair removal methods.

o Glucose control in patients undergoing major

surgery.

o Normothermia in patients undergoing colon surgery.

Immediate Preoperative Nursing Interventions:

1. The patient changes into a hospital gown that is left untied and open in

the back.
2. The patient with long hair may braid it, remove hairpins, and cover the

head completely with a disposable paper cap.

3. The mouth is inspected, and dentures or plates are removed. If left in the

mouth, these items could easily fall to the back of the throat during

induction of anesthesia and cause respiratory obstruction.

4. Jewelry is not worn to the operating room; wedding rings and jewelry of

body piercings should be removed to prevent injury. If a patient objects to

removing a ring, some institutions allow the ring to be securely fastened

to the finger with tape.

5. All patients (except those with urologic disorders) should void

immediately before going to the operating room to promote continence

during low abdominal surgery and to make abdominal organs more

accessible. Urinary catheterization is performed in the operating room as

necessary. Measure amount of urine (if indicated).

6. Ask if the person has any questions or concerns.

7. Continue to assess for the signs of anxiety.

8. Record the vital signs:

oMaintaining normal body temperature: Hypothermia has been

associated with various complications following surgery, including

impaired wound healing, cardiac events, and infection.

oMaintaining the patient's normal body temperature (Normothermia) or

actively warming him in the OR can improve his chances of avoiding

SSI.

oImmediate postoperative Normothermia is defined in this quality

initiative as a body temperature of 96.8°F to 100.4°F (36°C to 38°C)

within the first hour after leaving the OR and currently includes only

patients having colorectal surgery.

9. Check the identification band.

 10. Complete skin preparation

11. Check for and carry out special orders (administering enema, inserting

NGT, starting IV line)

12. Verify that the person has not eaten for the last 8 hours.

13. Remove colored nail polish.

IV- Evaluation: Expected outcomes:

1. Anxiety is relieved:

oTells family / significant other he is looking forward to having problem

correct.

oQueries anesthesiologist about concerns related to types of anesthesia

and induction

oVerbalizes an understanding of the pre-anesthetic medication and

general anesthesia.

oQueries staff about last-minute concerns

o Verbalizes relief about hospital bills and other costs after talking with

social worker, when appropriate

oRequests visit with member of clergy when appropriate

o Relaxes quietly after being visited by health team member.

2. Prepares for surgical intervention:

oParticipate willingly in preoperative preparation

oDemonstrates and describes exercises he is expected to perform

postoperatively.

oReviews information about postoperative care.

oAccepts preanesthetic medication

oRemains in bed

oRelaxes during transportation to operating unit.

oState rational for use of side rails.

Informed Consent:
• Voluntary and written informed consent from the patient is necessary
before nonemergent surgery can be performed.

• Written consent protects the patient from unsanctioned surgery and

protects the surgeon from claims of an unauthorized operation.

• Informed consent should involve answering the following patient

questions:

o What do you plan to do t me?

o Why do you want to do this procedure?

o Are there any alternatives to this plan?

o What things should I worry about?

o What are the greatest risks or the worst thing that could happen?
• The nurse may ask the patient to sign the form and may witness the

patient’s signature. It is the physician’s responsibility to provide

appropriate information.

• Before the patient signs the consent form, the surgeon must provide a

clear and simple explanation of what the surgery will entail.

• Contents documented about informed consent should include but are not

limited to the following:

o Who will be performing the procedure, including any residents, interns,

or first assistants.

o Each surgical procedure to be performed, including secondary

procedures.

o Any procedure for which an anesthetic is administered.

o Procedures involving entrance into the body via an incision, puncture, or

natural orifice.

o Any hazardous therapy, such as irradiation or chemotherapy.

• Validation of consent:
o The patient should sign the consent unless he or she is a minor/young, is

unconscious or mentally incompetent, or in is a life-threatening situation

o A consent document should contain the patient's name in full, the

patient and authorized witness (es), and the date of signature.

o The patient giving consent for treatment should be of legal age and

mentally competent.