PERIOPERATIVE NURSING MANAGEMENT

1. DEFINITION OF TERMS:

a. Perioperative Nursing -period of time that constitutes the surgical instrument; includes the
pre-operative intra-operative and postoperative phases of nursing care.

- term used to describe the entire span of surgery.

b. Preoperative Nursing- begin with the decision to perform surgery and continuous until the
client reaches the opening area.

c. IntraOperative Nursing- includes the entire procedure until transfer of the client to recovery
room.

d. Postoperative Nursing- begins with admission to the recovery area and continuous until the
client receives a follow up evaluation at home or a discharge to a rehabilitation unit.

2. SURGICAL CLASSIFICATION:

a. Based on Reasons/Purpose

a.1 Diagnostic -removal and study of tissue to make a diagnosis.

a.2 Exploratory -most extensive means to diagnosis a problem; usually involves

exploratory of a baby cavity or use of scopes, inserted through small incision.

a.3 Curative -removal or replacement of defective tissue to restore function.

a.4 Palliative -relief of symptoms or enhancement of function w/o cure.

a.5 Cosmetic -Correction of defects, improvements of appearance or change to a physical

feature.

b. Based on Urgency

b.1 Emergent-patients require immediate attention; disorder may be life-threatening.

b.2 Urgent-patient requires prompt attention.

b.3 Required-patients need to have surgery.

b.4 Elective-patient should have surgery.

b.5 Optional-decision rests with patient.

3. PREPARATION FOR SURGERY

a. Informed Consent

a.1 Definition -informed consent from the patient is necessary before none emergent
surgery can be performed.

a.2 Criteria For Valid Informed Consent

-The surgeon is responsible for obtaining the consent for surgery.

-Minors may need a parent or legal guardian to sign the consent form.
-Older client may need a legal guardian to sign the consent form.
 -Persons younger than 18 years old living away from home and supporting themselves
are regarded as emancipated minor and can sign their own consent form.
-The nurse may witness the client signing the operative permits, but the nurse must be
sure that the client has understood the surgeon’s explanation of the surgery.
-The nurse needs to document the witnessing of the signing of the operative permits,
after the client acknowledges understanding the procedure.

b. Factors that Affects the Patients Preoperatively:

*Nutritional and fluid status:

-Drugs or alcohol use

-Respiratory status
-Cardiovascular status
-Hepatic and renal function
-Endocrine function
-Immune function
-Previous medication use
-Psychosocial factors
-Spiritual and cultural beliefs

c. Factors for Possible Surgical Complication:

-Hypovolemia
-Dehydration or electrolyte imbalance
-Nutritional deficits
-Extremes of age
-Extremes of weight
-Infection and sepsis
-Toxic condition
-Immunologic abnormalities
-Pulmonary disease
~Obstructive disease
~Restrictive disorder
~Respiratory infection
-Renal or urinary tract disease
~Decreased renal function
~Urinary tract infection
~Obstruction
-Pregnancy
~Diminished maternal physiologic reserve
-Cardiovascular disease
~Coronary artery disease or previous myocardial infarction
~Cardiac failure
~Dysrhythmias
~Hypertension
~Prosthetic heart valve
~Thromboembolism
~Hemorrhagic disorder
~Cerebrovascular disease

-Endocrine dysfunction

~Cirrhosis
 ~Hepatitis

-Pre-existing mental or physical disability

d. Nutrients That Are Imporatant To Wound Healing

NUTRIENT RATIONALE POSSIBLE DEFICIENCY

OUTCOME
Protein -To allow collagen -Collagen deposition leading
deposition and wound to impaired/ daelayed
healing to occur wound healing
-Decreased skin wound
strength

-Impaired wound healing

Arginine (Amino Acid) -To provide necessary
substrate for collagen
synthesis and nitric oxide
(crucial for wound
healing) at wound site
-To increase wound
strength and collagen
deposition
-To stimulate T- cell
response
-Associated with a variety
of essential reactions of
intermediary metabolism -Signs and symptoms of
Carbohydrates And Fats -Primary source of energy protein deficiency due to use
in the body and of protein to meet energy
consequently in the wound requirements
healing process -Extensive weight loss
-To meet the demand for
increased essential fatty
acids needed for cellular
function after an injury
-To spare protein
-To restore normal weight
-Signs, symptoms, and
Water -To replace fluid loss complication of
through vomiting, dehydration, such as poor
hemorrhage, exudates, skin turgor, dry mucous
fever, drainage, dieresis membrane, oliguria, anuria,
-To maintain hemeostasis weight loss, increased pulse
rate, decreased central
nervous pressure

-Impaired/ delayed wound

healing related to impaired
Vitamin C -Important for capillary collagen formation and
formation, tissue increased capillary fragility
synthesis, and wound and permeability
healing through collagen -Increased risk of infection
formation related to decreased
antibodies
-Needed for antibody
healing -Decreased enzymes
available for energy
metabolism.
Vitamin B Complex -Indirect role in wound
 healing through their
influence on host
resistance.

-Impaired/delayed wound
healing related to decreased
collagen synthesis; impaired
Vitamn A -Increased inflammatory immune function.
response in wounds, reduce -Increased risk of infection.
anti-inflammatory effects of
corticosteroids on wound -Prolonged prothrombin
healing. time.
-Hematomas contributing to
impaired healing and
Vitamin K -Important for blood predisposition to wound
clotting. infections.
-Impaired intestinal
synthesis associated with -Impaired/delayed wound
the use of antibiotics. healing (impaired collagen
production)

Magnesium -Essential cofactor for

many enzymes that are
involved in the process of
protein synthesis and -Impaired wound healing .
wound repair.

Copper -Required cofactor in the

development of -Impaired immune response.
connective tissue.

Zinc -Involved DNA synthesis,

protein synthesis, cellular
proliferation needed for
wound healing
-Essentiall to immune
function.

e. Medication to the Surgical Experience of the Patient

AGENT( Generic and Trade example) Effects of Medication

Corticosteroids -Cardiovascular collapse can occur if
Prednisone (Deltasone) discontinue suddenly. Therefore, a bolus of
corticosteroids maybe administered
intravenously immediately before and after
surgery.
Diuretics
Hydrochlorothiazide (HydroDIURIL) -During anaesthesia, may cause excessive
respiratory depression resulting from an
associated electrolyte imbalance
Phenothiazines
Chlorpromazine (Thorazine) -May increase the hypotensive action of
anesthetics
Tranquilizers
Diazepam (Valium) -May cause anxiety, tension,and even
seizures if withdrawn suddenly.

Insulin -Interaction between anesthetics and insulin

must be considered when a patient with
 diabetes is undergoing surgery. Intravenous
insulin may need to be administered to keep
the blood glucose within the normal range

Antibiotics -When combined with a curariform muscle

Erythromycin (Ery- Tab) relaxant. Nerve transmission is interrupted
and apnea from respiratory paralysis may
result

Anticoagulants -Can increase the risk for bleeding during

Warfarin (Coumadin) intraoperative and postoperative period;
should be discontinued in anticipation of
elective surgery the patient should stop
taking an anticoagulant, depending on the
type of planned procedure and the medical
condition of the patient.

Antiseizure Medication -Intravenous administration of medication

Monoamine oxidase (MAO) inhibitors may be needed to keep the patient seizure
Phenelzine sulphate (Nardil) free in the intraoperative and postoperative
periods.

Thyroid Hormone -May increase the hypotensive action of

Levothyroxine sodium(levothyroid) anesthetic

-Intravenous administration may be needed

during postoperative period to maintain
thyroid levels.

f. Preoperative Nursing Intervention

f.1 Preoperative Teaching

-Inform the client not to hesitate to request pain medication when needed.
-Inform the client that requesting a narcotic after surgery will not make the client a drug
addict.
-The client is instructed not to smoke for at least 12 hours before the surgery
-Instruct the client in deep breathing and coughing techniques, the use of incentive
spironometry, and the importance of performing the techniques postoperatively to
prevent the development of pneumonia and atelectasis.
-Instruct the client in the leg and foot exercise to prevent venous stasis blood and to
facilitate venous blood return
-Instruct the client how to splint an incision and to turn and reposition.

f.2 When Do We Teach The Patient About Preoperative Teaching

-The nurse should guide the patient through the experience and allow ample time for
questions.
-For some patients, overly detailed description increase anxiety; the nurse should be
sensitive to this and provide less detail.
-Preoperative teaching includes instruction in breathing and leg exercise used to prevent
postoperative complication such as pneumonia and deep vein thrombosis.
f.3 Topics We Need To Teach The Patient And Brieftly Discuss The Procedure

f.3.1 Exercise

-Leg and Hip Exercises

1. Instruct the client to press the back of the knees against the bed, and then to
relax knees. This contracts and relaxes the thigh and calf muscles to prevent
thrombus formation.
2. Instruct the client to rotate each foot in a circle at least ten times an hour.
3. Have the client flex the knee and thigh, straighten the leg up in the air,
and hold for 5 seconds before lowering, performing the exercise ten times
per day.

-Coughing and Deep-breathing Exercises

1. Instruct the client that a sitting position gives the best lung expansion for
coughing and deep-breathing exercises.
2. Instruct the client to breathe deeply 3X, inhaling in the nostrils and
exhaling through the mouth.
3. Instruct the client that the third breath should be held for 3 seconds, then
the client should forcefully cough out 3X.
4. The client should perform this perform this exercise every 2 hours.

-Splinting Incision

1. If the surgical incision is a abdominal or thoracic, instruct the client to place a

pillow, or one hand with the other hand on top, over the incisional area.
2. During the deep-breathing and coughing, the client presses gently against the
incisional area to splint and support.

-Incentive Spirometry

1. Instruct the client to assume a sitting position.

2. Instruct the client that lips need to cover the mouth piece completely.
3. Instruct the client to inhale slowly and maintain a constant flow through the
unit.
4. When maximal inspiration is reached, the client should hold the breath for
2-3 seconds and then exhale slowly.
5. Instruct the client that the number of breaths should not exceed 12 breaths
per minute.

f.3.2 Pain Management

-Teaching pain communication skill and pain management before surgery

may result in greater pain relief during the early post operative period.
-A pain intensity scale should be introduced and explained to the patient to
promote more effective postoperative pain management.
-Preoperative patient teaching also needs to include the difference between acute
and chronic pain, so that the patient is prepared to differentiate acute
postoperative pain from chronic condition such as back pain.
-Post operatively medications are administered to relieved pain and maintain
comfort without increasing the risk of inadequate air exercise.
 -The patient is instructed to take medication as frequently as prescribed during
the initial post operative period for pain relief.
 The patient who is expected to go home will likely receive oral analgesics agent.

f.3.3 Cognitive Coping Stategies

-cognitive strategies may be useful for relieving tension, overcoming

anxiety,decreasing fear, and achieving relaxation.
a. Imagery-the patient concentrates on a pleasant experience or restful scene.
b. Distraction-The patient thinks of an enjoyable story or recites a favourite poem
or song.
c. Optimistic Self Recitation-the patients recites optimistic thoughts (“i know all
will go well”).

f.3.4 Psychosocial Intervention

a. Reducing Preoperative Anxiety

-Cognitive strategies useful for reducing anxiety. In addition to these

strategies, music therapy is an easy to administer, in-expensive, non
invasive intervention that can reduce anxiety on the pre operative phase.

b. Decreased Fear

-The nurse should assist the patient to identify coping strategies that he or
she has previously use to decreased fear, the patient benefits from
knowing when family and friends will be able to visit after surgery and
that spiritual advisor will be available if desired.

c. Respecting Cultural, Spiritual and Religious Beliefs

-Include identifying and showing respect for cultural, spiritual, and

religious beliefs.

f.4 General Preoperative Nursing Intervention

a. Maintain Patient Safety

-Protecting patient from injury is one of the major roles of the preoperative nurse.

b. Managing Nutrition and Fluids

-The major of withholding food and fluid before surgery is to prevent aspiration
until recently fluid and food were restricted preoperatively overnight and often
longer.
-The goals these pre operations are to allow satisfactory visualization of the
surgical site to prevent trauma to the intestine or contamination of the perineum
by feces.

c. Preparing The Skin

-The goal of pre operation is to decreased bacteria without injuring the skin. If
the surgery is hot 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 organism; this preparation may
be carried out at home. Generally, hair is not remove preoperatively unless the
 hair at or around the incision site is likely to interfere with the operation. If hair
must be electric clippers are use for safe hair removal immediately before
operation.

IMMEDIATE PREOPERATIVE NURSING PHASE

 The patient with long hair may braid it, remove hairpins, and cover the
head completely with a disposable paper cap.
-The mouth is inspected, and dentures or plates are removed. If left in the
mouth, these items could easily fall to back of the throat during induction
of anesthesia and cause respiratory obstruction.
-Jewelry is not worn in the OR; wedding rings and jewelry of body
piercings should be removed to prevent injury.

f. Expected Patient Outcome In The Preoperative Nursing Phase

a. Relief of Anxiety- evidenced when the patient
-Discusses with the anaesthesiologist, anesthetist, or nurse anesthetist
concerns related to types of anesthesia and induction
-Verbalizes an understanding of the preanesthetic medication and general
anesthesia
-Discusses last- minute concerns with the nurse or physician
-Discusses the financial concerns with the social worker, when appropriate
-Relaxes visit with spiritual advisor when appropriate
-Relaxes quietly after being visited by health care team members
b. Decreased Fear- evidenced when the patient
-Discusses fears with health care professionals or a spiritual advisor, or
both
-Verbalizes an understanding of any expected bodily changes, including
xpected duration of bodily changes
c. Understanding of the Surgical Intervention- evidenced when the patient
-Participates in preoperative preparation
-Demonstrates and describes exercises he or she is expected to
perform postoperatively
-Reviews information about postoperative care
-Accepts preanesthetic medication, if prescribed
-Remains in bed once premedicated
-Relaxes during transportation to the OR or unit
-States rationale for use of side rails
-Discusses postoperative expectations
d. No Evidence of Preoperative Complications
 INTRAOPERATIVE NURSING MANAGEMENT

1. Members of the Surgical Team and their Functions

a. Anesthesiologist

-A physician who has completed 2 years completed 2 years of residency in

anesthesia
-Responsible for administering anesthesia t the client and for monitoring the
client during and after the surgical procedure

b. Anesthetist

-May be a medical doctor who administers anesthesia but has not completed a
residency in anesthesia, or a registered nurse (RN) who has completed an
accredited nurse anesthesia program and passed the certification examination

c. Surgeon

-Performs the surgical procedure and heads the surgical team

d. Surgical Assistant

- Classified as either first, second, or third assistants, the first assistant assists
in the surgical procedure and may be involved with the client’s preoperative
and postoperative care, he or she may be another physician, surgical resident,
or an RN who has appropriate approval and endorsement from the
AMERICAN OPERATING ROOM NURSES and AMERICAN COLLEGE
OF SURGEONS

e. Scrub Nurse

-Wears a sterile gown and gloves and assist the surgical team by handling the
instruments to the surgeon and assistants, preparing sutures, receiving
specimens for laboratory examination, and counting sponges and needles.

f. Circulating Nurse

-Wears OR attire but not a sterile gown. Responsible in opening and obtaining
wrapped sterile equipment and supplies before and during surgery, keeping
records, adjusting lights, receiving specimen for laboratory examination, and
coordinating activities of other personnel such as the pathologist and
radiology technician

2. Basic Guidelines for Maintaining Sugical Asepsis

-All materials in contact with the surgical wound or used within the sterile
field
must be sterile. Sterile surface or articles may touch other sterile surfaces or
articles and remain sterile; contact with unsterile objects any point renders sterile
is contaminated.
-Gowns of the surgical team are considered sterile in front from the chest to the
level of the sterile field. The sleeves are also considered sterile from 2 inches
above the elbow to the stockinette cuff.
-Sterile drapes are used to create a sterile field. Only the top surface of a draped
table is considered sterile. During draping of a table or patient, the sterile drape is
held well above the surface to be covered and is positioned from front to back.
 -Items are dispensed to a sterile field by method that preserve the sterility if the
items and the integrity of the sterile field. After a sterile package is opened, the
edges are considered unsterile. Sterile supplies, including solutions, are delivered
to a sterile field handed to a scrubbed person in such a way that the sterility of the
object or fluid remains intact.
-The movement of the surgical team are from sterile to sterile areas and from
unsterile to unsterile areas. Scrubbed persons and sterile items contact only sterile
areas; circulating nurses and unsterile items contact only unsterile areas.
-Movement around unsterile field must not cause contamination of the field.
Sterile areas must be kept in view during movement around the area. At least a 1
foot distance from the sterile field must be maintained to prevent inadvertent
contamination.
-Whenever a sterile barrier is breached, the area must be considered
contaminated. A tear or puncture of the drape permitting access to an unsterile.
Such a drape must be replaced.
-Every sterile field is constantly monitored and maintained. Items doubtful
sterility are considered unsterile. Sterile fields are prepared as close as possible to
the time of use.
-The routine administration of hyperoxia (high levels of oxygen) is not
recommended to reduce surgical site infections. In a study of 165 patients
undergoing general surgery, the rate surgical site of infection was higher in
patients who received 80% oxygen during surgery during than into those who
received 35% oxygen.

3. Types of Anesthesia
a. General anesthesia- administered IV or by inhalation.
b. Conscious sedation-one or more drug administered IV push.
c. Local anesthesia-administered topically or regionally

4. Stages Of General Anesthesia

a. Stage 1:onset
b. Stage 2:excitement
c. Stage 3:surgical anesthesia
d. Stage 4: danger

5. Potential Intraoperative Complication

a. Nausea and vomiting
b. Anaphylaxis
c. Hypoxia
d. Hypothermia
e. Malignant hyperthermia
f. Disseminated intravascular coagulophaty (DIC)

6. Common Positions of the Patients During Surgery

a. Patient in position on the operating table for a laparotomy.
b. Patient in trendelenburg position in operating table.
c. Patient in lithotomy position.
d. Patient leis on unaffected side for kidney surgery. table is spread apart to
provide space between the lower ribs and the pelvis.the upper leg is extended;
the lower leg is flex at the knee and the hips knee; a pillow is placed between
the legs.
 POST OPERATIVE NURSING MANAGEMENT

1. Post Anesthesia Care Unit

-It is also called recovery room or post anesthesia recovery room, is located
adjacent to the operating rooms suite.
-Is keep quiet, clean, and free of unnecessary equipment.
-Should also well ventilated.
-The PACU bed provides easy access to the patients, is safe and easily movable,
can readily be positioned to facilitated use of measures to counter act shock and
other complications.

2. Phases Of Postanesthesia Care

a. Phase I PACU

- Area designed for care of surgical patients immediately after surgery and
for patients whose condition warrants close monitoring

b. Phase II PACU

- Area designed for care of surgical patients who have been transferred from a
phase I PACU because their condition no longer requires the close
monitoring provided in a phase I PACU

c. Phase III PACU

- Setting in which the patient is cared for in the immediate postoperative

period and then prepared for discharge from the facility.

3. Nursing Care Management in Pacu

-The nursing management objectives for the patient in the PACU are to provide
care until the patient has recovered from the effects of anesthesia, is oriented, has
stable vital signs, and shows no evidence of hemorrhage or other complications.

4. Post Operative Nursing Intervention

-Give nothing by mouth

-Begin oral solids with small amounts o dry foods such as crackers

-Give carbonated beverages to relieve nausea

-Give frequent small feeding to prevent GI distention

-After episode of vomiting, provide adequate oral hydration and nutrition

-If patient is receiving parenteral fluids and electrolytes, observes for signs of

Infiltration. Maintain correct infusion flow rate and accurate intake and output record.

-Evaluate the patients emotional status

-Encourage patients to breathe deeply to facilitate elimination of anesthesia

-Support the wound during wretching and vomiting; turn head to the side to prevent
aspiration

-Discard vomitus and refresh patient-mouthwash

 -Offer chips of ice, sips of ginger or eating small amount of dry solid food.

-Administer anti emetics.

5. Phases of Wound Healing

-Inflammatory phase (also called lag or exudative)
-Proliferative phase (also called fibroblastic or connective tissue phase)
-Maturation phase (also called differentiation, resorptive, remodelling or plateau
phase)

6. Factors Affecting Wound Healing

-Age of the patient
-Handling of tissues
-Hemorrhage
-Hypovolemia
-Local factors
~edema
-Inadequate dressing equipment
~Too small
~Too tight
-Nutritional deficit
-Foreign bodies
-Oxygen deficit ( tissue oxygenation insufficient)
-Drainage accumulation
-Medication
~Corticosteroids
~Anticoagulants
~Broad- spectrum and specific antibodies
-Patient overactivity
-Systemic disorders
~Hemorrhagic shock
~Acidosis
~Hypoxia
~Renal failure
~Hepatic disease
~Sepsis
-Immunosuppressed state
-Wound stressors
~Vomiting
~Valsalva maneuver
~Heavy coughing
~Straining
7. Wound Drainage/ Indications

a. to redirect body fluids to allow time for a new suture line to heal

b. to drain collections of pus from the body cavities

c. to drain collections of fluid post-operatively

d. when haemostasis has not been achieved during surgery

8. Potential Post Operative Complications

 a. Deep Vein Thrombosis

-Orthopeidic patients having hip surgery, knee reconstruction, and other lower
extremity surgery
-Urologic patients having transurethral prostatectomy and older patients having
urologic surgery
-General surgical patients older than 40 years of age, those who are obese, those
with a malignancy. Those who have had prior deep vein thrombosis or
pulmonary embolism, and those undergoing extensive complicated surgical
procedures
-Gynaecologic patients older than 40 years of age with added risk factors
-Neurosurgical patients, similar to other surgical high risk groups

b. Pulmonary Complication

-Type of surgery- greater incidence after all forms of abdominal surgery when
compared with peripheral surgery
-Location of incision- the closer incision to the diaphragm, the higher the
incidence of pulmonary complications
-Preoperative respiratory problems
-Age- greater risk after age 40 than before 40
-Sepsis
-Obesity- weight greater than 110 % of ideal body weight
-Prolonged bed rest
-Duration of surgical procedure- more than 3 hours
-Aspiration
-Dehydration
-Malnutrition
-Hypotension and shock
-Immunosuppression

9. Wound Dehiscence And Wound Evisceration

a. Dehiscence - a surgical complication where the edges of a wound no longer meet. It is also
known as “wound separation.” A healthy, healing wound should be well-approximated, meaning
that the edges meet neatly and are held closely together by sutures, staples or another method of
closure. As an incision heals, the wound fills in with new tissue, called "granulation" or
"granulating tissue." This new tissue is not as strong as normal skin, as it is new and has not had
time to strengthen.

b. Evisceration- a rare but severe surgical complication where the surgical incision opens
(dehiscence) and the abdominal organs then protrude or come out of the incision (evisceration).
Evisceration is an emergency and should be treated as such. Evisceration can range from the less
severe, with the organs (usually abdominal) visible and slightly extending outside of the incision
to the very severe, where intestines may spill out of the incision.