Perioperative Nursing

Care
Objectives
• List and discuss common purposes

of surgery. ​• List the components of

preoperative assessment and discuss

​
the purposes and nursing

responsibilities. ​• List the components

of preoperative patient preparation and

discuss the purposes and nursing

responsibilities. ​• List and discuss the

potential complications of the
postoperative period and the

preventative measures. ​• Discuss

nursing responsibilities related to the

postoperative
care of patients.
Common Terms
Perioperative Nursing: ​• Includes the

preoperative (before), intraoperative

(during)
and postoperative (after) periods.
Preoperative period: ​• This is an

important time to address issues that

may come
up during surgery (Screening)

o ​i.e. assess for bleeding problems,

don't want to find out

that someone has a bleeding problem
as they exsanguinate on the operating

table ​• Also can teach patients and

family about what to expect

before, during and after a procedure

o ​in an emergency, we can prepare

the family if the patient
isn't alert
Types of Surgeries
1. Diagnostic 2. Therapeutic 3.
Palliative 4. Preventive 5. Cosmetic
Types of Surgeries
Diagnostic: ​• Determination of the
presence and or extent of the

pathology ​• ​i.e. lymph node bx,

bronchoscopy, exploratory
laparatomy

Therapeutic: ​• Elimination or repair of

 the pathology
​ ​• ​Removal of the

appendix
when it's inflammed, removal of a
localized cancer
Types of Surgeries
Palliative: ​• Alleviation of symptoms

without curing the underlying disease ​•

Rhizotomy (cutting of a nerve

​ root)
to decrease pain, colostomy
placement to bypass an obstructing
colon tumor

Preventative: ​• Surgery to remove

tissue that
​ has the potential to become
pathologic (may not already express a

pathologic problem) ​• ​Total

Colectomy in patients
​ with FAP

Types of Surgeries
Cosmetic: ​• The surgery is preformed

for aesthetic reasons • ​Repair of

scars from burns or injuries, minor

cleft palate
repairs, face lifts, breast
augmentation
Further Descriptors of
Surgery
Elective: ​• Carefully planned event •

Advanced assessments are​ usually

attained and pre-operative checks are
in place

o ​blood draws o​ ​physical exam o​

other necessary studies • Can be

scheduled in some cases

​ as an
outpatient or in an ambulatory surgery
center

Emergency: ​• arises unexpectedly •

can also occur in a wide
variety of settings

​ ​OR o​ ​Battlefield/Trauma
o ​ER o

scene ​• Needed within minutes to

hours ​Urgent: ​• delay could be

detrimental • usually within 24-48

hours
Types of Elective
Admissions for Surgery
Ambulatory Surgery: ​• Usually
outside a hospital setting • Special

prescreening • Don't use in patient's

with multiple problems Same-Day

​
Surgery: ​• Outpatient, can be in the

hospital • Go home the day of the

surgery Early
​ Hospital Admission: ​•

Patient comes in early (night before or

earlier) • Usually patients with complex

medical issues, and increased

risk for poor surgical outcomes
TABLE ​18​-​1
Suffixes ​Describing Surgical ​Procedures

Suffix

-​ectomy ​-​lysis ​-​orrhaphy ​-​oscopy ​-​ostomy ​-​otomy

-​plasty
Meaning

Excision ​or removal ​of ​Destruction ​of ​Repair ​or ​suture

of ​Looking ​into ​Creation o ​ f ​opening ​into ​Cutting ​into ​or
incision ​of ​Repair ​or ​reconstruction ​of
Example ​Appendectomy ​Electrolysis ​Herniorrhaphy
Endoscopy ​Colostomy ​Tracheotomy ​Mammoplasty
Copyright ​© ​2007 ​by ​Mosby​, ​Inc​.,​ ​an ​affiliate o
​ f ​Elsevier ​Inc​.

Preoperative Nursing
Assessment
1. Age 2. Allergies 3. Vital Sign Trend
4. Nutritional Status 5. Habits affecting
tolerance to anesthesia 6. Presence of
Infections 7. Use of drugs that are
contraindicated prior to surgery 8.
Physiological Status 9. Psychological
state of the patient
Preoperative Nursing
Assessment
Age: ​• Elderly are at risk • >65 years of

age • obtain a detailed medical

history and health assessment ​•

assess for sensory deficits • assess for

overall functional
​ status ​• understand
that there is a decreased
​ physiological
reserve

Allergies: ​• assess for known drug,

food and substance allergies ​• assess

what the reaction

to the drug or substance is (is it a true

allergy, hives or anaphylaxis?) ​•

allergies must be clearly noted

​ on the
chart, and other steps are usually
taken per hospital/institutional protocol
Preoperative Nursing
Assessment
Vital Signs Trends: ​• What is normal

for that patient,

​ and are V/S in the
preoperative period in line with the
norms or deviating?
Preoperative Nursing
Assessment
Nutritional Status: ​• This can be a

situation of deficit or excess • assess

for individuals who are prone to

general nutritional
deficiencies:
o ​Aged o
​ ​Cancer patients o​

Gastrointestinal problems o​ ​Chronic

illness/Chronic steriod use ​o

Alcoholics/Drug Addicts ​• Also assess

for excess (Obesity):

o ​Poor wound healing because of

decreased blood supply o​ ​Hard to

access surgical site o​ ​Decreased lung

capacity o​ ​Anesthesia meds are

stored in fat cells

Preoperative Nursing
Assessment
Habits affecting tolerance to

anesthesia: ​• Smoking:

o ​alters platelet

function...hypercoagulable o​ ​reduces

the amount of functional hemoglobin ■

carboxyhemoglobin o​ ​cilia in the lung

are damaged, more difficult to mobilize

secretions in the patient that smokes ​o
retards wound healing (especially
because of the decreased functional
hemoglobin) ​• Alcoholism: o​ ​can have

impaired liver function o​ ​B-vitamin

deficiencies • Opioid Addiction

o ​have a high tolerance for pain meds
Preoperative Nursing
Assessment
Presence of Infections: ​• Biggest

indicator is the presence of fever

above 101 degrees

​ F (38C) ​• If

infection is present, likely surgery will

need to be delayed because
​ the risks

to the patient are too great. ​• Goal will

be to find and treat the infection, and

then
reattempt surgery once the infection is
cleared
Preoperative Nursing
Assessment
Use of drugs that are

contraindicated prior to surgery: ​•

Drugs like aspirin, heparin, warfarin

(Coumadin) should be
stopped prior to surgery

o ​affect bleeding time ■ ASA is 2

weeks because of the permanent

platelet
affects ​■ heparin, and low molecular

weight heparins are usually stopped

​
24 preop, unless there are problems

with the liver ​■ warfarin is usually 7

days, but the PT/INR is rechecked

either the day of or the day before the
surgery to check for bleeding
Preoperative Nursing
Assessment
Use of drugs that are

contraindicated prior to surgery: ​•

current use of medications, over the

counter agents and herbal

​ remedies

should be assessed and documented ​•

some drugs/herbs can interact with the

anesthesia • check about

antihypertensives the morning of

surgery • need to be clear about home

meds (dose, frequency, timing) so

​ that
any necessary meds are in the
postoperative order as per the MD
o ​can check with the MD if certain

meds should be restarted ​• want to

reinforce that if the patient is to take

meds the
morning of surgery, they should be
taken with sips of water
Preoperative Nursing
Assessment
Physiological Status: ​• Need to

ensure as a
preoperative nurse that all labs, xrays,
EKGs and necessary tests are done

and in the chart ​• Need to notify the

physician if there is anything abnormal,
shouldn't assume that they've already
seen it

Psychological Status: ​• Common

behaviors are fear

​ and anxiety ​• fear =

pt. knows what they are

​ scared of ​•

anxiety = don't tangibly

know what is scaring you
Preoperative Nursing
Assessment
Psychological States: Common

Fears: ​– Fear of death – Fear of pain

and discomfort – Fear of mutilation or

alteration in body image – Fear of

anesthesia – Fear of disruption of life

functioning or patterns – Fear due to

lack of knowledge regarding the

proposed surgery
​ ​– Fear related to
previous surgical expriences – Fear

due to the influence of significant

others
Remember, for our patients, surgery
presents a major lack of control.
Preoperative Nursing
Assessment
Psychological States: Preoperative
fear and anxiety can lead to:
1. Need for increased anesthesia 2.
Need for increased postoperative pain
management 3. Speed of recovery is
decreased
Preoperative education of what to
expect in clear, common english
can alleviate some fear and anxiety
Remember the role of HOPE for our
patients, it is often the most
common coping strategy
Patient Preparation for
Surgery
1. Operative consent 2. Preoperative
learning needs 3. Interventions the day
or evening prior to surgery 4.
Interventions the day of surgery
Operative Consent
This is part of the legal preparation for
surgery.
Informed consent: ​an active, shared
decision making process between the
provider and recipient of care. Has 3
components to make it valid:
1. Adequate Disclosure: ​of the
diagnosis, nature and purpose
of the proposed treatment, probability
of successful outcome, risks and
consequences of moving forward with
treatment or alternatives, the
prognosis if treatment is not instituted,
and if treatment is deviating from
standard for their condition. ​2.
Understanding and Comprehension of
above: ​this has to
be assessed before sedating meds
can be given (minors can't give
consent, severely mentally ill or
severely developmentally challenged).
Operative Consent
Informed Consent (cont):
3. ​Voluntary Consent: ​Can't be
coerced into going through with a
procedure. This consent can be
revoked at any point leading up to a
surgical procedure. ​Who can give

consent? ​• the patient • next of kin (in

order of kinship): Spouse, Adult Child,

Parent,
Sibling

o ​Can be designated with a durable

power of attorney in
case of medical incapacitation
Who has the legal
responsiblity of
obtaining consent?
The Physician
• The nurse is not legally required to

obtain consent ​• however, the nurse

must make sure the consent was

signed o​ ​nurse has a primary role as

a patient advocate. ​• nurse can

"witness" the consent, and sign it as

such • if the patient has questions that

you can answer to clarify things,

​ you

can do that ​• if the patient continues to

have questions, or there is a

question that they are not voluntarily
giving consent, the doctor needs to

come and speak with them again. ​•

Very important that patient is

consenting voluntarily and

with knowledge of the situation
What about emergency
treatment?
A true medical emergency may
override the need to obtain consent.
When medical care is needed to
protect the life of an individual, the
next of kin/POA (Power of Attorney)
can give consent. Also, if there is a
known and available Advanced
Directive with healthcare decision
making instructions, that can be
used to assist in justifying consent.
If they are not available, and the
doctor deems the procedure
necessary for life, the doctor can
chart that it was necessary, and go
ahead with the procedure. ​• The

nurse may need to write up an incident

report and state

that the emergency caused a deviation
in the normal policy to obtain consent
on everyone.
Patient preparation:
preoperative learning
needs
• Deep breathing (incentive
spirometer), coughing, leg exercises,

ambulation ​• Pain control and

medications • Cognitive control to

decrease anxiety and enhance

relaxation (deep breathing) ​• Recovery

room orientation • Probable

postoperative therapies • Directions for

the family
Essential ​Gastrocnemius ​(​calf​)
pumping
NNNNNNNN​N
www
www​.​WIN

Quadriceps ​(​thigh​) ​setting

Desirable ​Foot ​circles

Hip ​and ​knee ​movements

www

Copyright ​© ​2007 ​by ​Masby​, ​Inc​., ​an ​affiliate ​of

Elsevier ​Inc​.
Copyright ​© ​2007 ​by ​Mosby​, ​Inc​.​, ​an ​affiliate ​of ​Elsevier
Inc​.
TABLE ​PA​TIENT A ​ ND F​ AMILY ​TEACHING ​GUIDE
18​-​7 ​Preoperative ​Preparation
Sensory ​Information
• ​Holding ​area ​may ​be ​noisy​.
Drugs ​and ​cleaning ​solutions ​may ​be ​smelled​.
Operating ​room ​(​OR​) ​can b
​ e ​cold​; ​warm ​blankets ​are
available​.
• ​Talking ​may ​be ​heard ​in ​the O
​ R ​but ​may ​be ​distorted ​because ​of
masks​. ​Questions ​should ​be ​asked ​if something ​is ​not
understood​. ​OR ​bed ​will ​be ​narro​w​. ​A ​safety ​strap ​will ​be
applied ​over ​the ​knees​. ​Lights ​in ​the ​OR ​may ​be ​very ​bright​.
Monitoring ​machines ​(​ticking ​and ​pinging ​noi​ses) ​may ​be
heard ​when ​awake​. T​ heir ​purpose ​is ​to ​monitor ​and ​ensure
safety​.
P​r​ocedural ​Information
What ​to ​bring ​and ​what ​type ​of ​clothing ​to ​wear ​to ​the
ambulatory ​surgery ​center​. ​Any ​changes ​in ​time ​of ​surgery​.
Fluid ​and ​food ​restrictions​. ​Physical ​preparation ​required ​(​e​.​g​.​,
bowel ​or ​skin ​preparation​)​. ​Purpose ​of ​frequent ​vital ​signs
assessment​. ​Pain ​control ​and ​other ​comfort ​measures​. W ​ hy
turning​, ​coughing​, ​and ​deep ​breathing ​postoperatively ​is
important​; ​practice ​sessions n ​ eed ​to ​be ​done ​preoperatively​.
Insertion ​of ​intravenous ​lines​. ​Procedure ​for ​anesthesia ​administration​.
Expect ​surgical ​site ​and​/​or ​side ​to ​be ​marked ​with ​indelible i​ nk ​or
marker​.
Process ​Information ​Information ​A​bou​t ​General ​Flow ​of​
Surge​ry
Admission ​area​. ​Preoperative ​holding ​area​, ​OR​, ​and ​recovery
area​. ​Families ​can ​usually ​stay ​in ​holding ​area ​until
surgery​. ​Families ​may ​be ​able ​to ​enter ​recovery ​area ​as
soon ​as ​patient ​is ​awake​. ​Identification ​of ​any ​technology ​that
may ​be ​present ​on ​awakening​,
such ​as ​monitors ​and ​central ​lines​. ​Where ​Families ​Can ​Wait
during ​Surgery
Patient ​and ​family ​members ​need ​to ​be ​encouraged ​to
verbalize ​concerns​. ​OR ​staff ​will ​notify ​family ​when ​surgery ​is
com​pleted​. ​Surgeon ​will ​usually ​talk ​with ​family ​following
surgery​.
Copyright ​© ​2007 ​by ​Mosby​, ​Inc​.,​ ​an ​affiliate o
​ f ​Elsevier ​Inc​.

Patient preparation:
interventions the day or
evening prior to the
surgery
• Diet Restrictions
o ​Historical guidelines to prevent
aspiration were NPO after

midnight the night before ​o ​Educating

the patient about the reason for NPO

status may
​ help with adherence ​•

Information of what to wear to the

surgery • Patient will likely need to be

there 1 to 2 hours prior to

scheduled procedure
TABL​E ​18​-​8 ​Preoperative Fasting
Recommendations​*

Minimum ​Fasting ​Liquid and Food Intake

Period ​(​hr​) ​Clear ​liquids ​(​e​.​g​.​, ​water​, ​clear ​t​e​a​, ​black
co​f​fee​, ​carbonated ​beverages​, ​and ​fruit
juice ​without ​pulp​) ​Breast ​milk ​Nonhuman ​milk​,
including ​infant ​formula ​Light ​meal ​(​e​.​g​.​, ​toast ​and ​clear
liquids​) ​Regular ​or ​heavy ​meal ​(​may ​include ​fried
or ​fatty ​food​, meat​)

Source​: ​Practice ​guidelines ​for ​preoperative ​fasting a​ nd

the ​use ​of ​pharmacologic ​agents ​to ​reduce ​the ​risk ​of
pulmonary ​aspiration​: a​ pplication ​to ​healthy ​patients u​ n
dergoing ​elective ​procedures​: ​a ​report ​by ​the ​American
Society ​of ​Anesthesiologists​. ​Available at
www​.​asahq.​ o
​ rg​/​publications A ​ ndServices​/​N​P​O.​ p
​ df.​
*​For ​healthy patients ​of ​all ​ages ​undergoing ​elective
surgery ​(​excluding ​women ​in ​labor​)​.
Copyright ​© ​2007 ​by ​Mosby​, ​Inc​.,​ ​an ​affiliate o
​ f ​Elsevier ​Inc​.

Patient preparation:
interventions the day of
surgery
This varies based on whether the

person is inpatient or outpatient. ​•

Encourage the patient to void (empty

their bladder) before they

​ get any

sedative medications ​• Final

preoperative teaching • Final

Assessment and communication of

findings to MD • Ensuring that all

preoperative orders have been

completed • Check to chart to make

sure that there is:

o ​a signed consent for the procedure ​o

laboratory data, Xray reports, EKG o​

H&P, and necessary consults o​

Baseline vitals o​ ​Nursing notes up until

that point
Patient preparation:
interventions the day of
surgery
• Remove any jewerly, hair pins,
clothes (except gown)
o ​May be able to wear a wedding band

taped firmly to the finger ​• Remove

contact lens • No dentures or partial

dentures • If the hearing aides need to

be removed, please not that on

the front of the chart.
o ​glassesor hearing aides need to be
returned to the patient as soon as

possible after the procedure ​• No

makeup or dark nail polish • Give any

preoperative medications • Note the

time the patient leaves the floor • ID

band should be placed, or checked

depending on patient
status, and an allergy band per
institution protocol
Preoperative Checklist
Preoperative
Medications
• Benzodiazepines/Barbituates: used
for their sedative and amnesic

properties ​• Anticholinergics: reduce

secretions, and can reduce cramping

​ ​•

Opioids: decrease need for

intraoperative analgesics and

decrease pain ​• Antiemetics: decrease

N/V • Antibiotics: to prevent infective

endocarditis, or where
wound contamination is a risk (GI
surgery) or where wound infection
would cause significant postoperative

morbidity ​o ​usually given IV •

Eyedrops: especially with eye surgery

(lasik, cataract
surgery)
Preoperative
Medications
Intraoperative Nursing
Issues
• Nursing roles

o ​Circulating nurse ​o ​Scrub RN •

 Perioperative asepsis • Types of

anesthesia
o ​General o
​ ​Regional • Patient

positioning • Temperature alterations

during the intraoperative period

Nursing Roles
Circulating Nurse: ​• Deal with the

management of
​ unsterile activities in
the operating area ​• Document the the

nursing
care of the patient

​ ​interventions
o ​assessments o ​•

movement of unsterile
items out of the surgical suite

o ​labelingand
transporting specimens

Scrub Nurse: ​• Is gowned and gloved

and able
​ to handle and pass sterile

items into the sterile surgical field ​•

"Boss" of the sterile field • Assists with

the actual procedure

​ to varying
degrees
TABLE ​19​-​1​| ​Intraoperative ​Activities
of ​the ​Perioperative ​Nurse
Circulating​/​Nonsterile ​Activities
Reviews ​anatomy​, ​physiology​, ​and ​the ​surgical ​procedure​. ​. ​Assists ​with ​preparing ​the
room​. ​. ​Prac​t​ices ​aseptic ​technique in ​all ​required ​activities​.
Monitors ​prac​tices ​of ​a​sep​tic ​technique ​in ​self ​and ​others​.
Ensures ​that ​needed ​items ​are ​available ​and ​steri​le ​(​if ​required​)​. ​. ​Checks ​mechanical
and ​electrical ​equipment and ​environmental
factors​. ​Identifies ​and ​admits ​the ​p​a​tient ​to ​the ​OR ​suite​. ​A​ss​esses ​the ​patient​'​s ​physical ​and
emotional ​status​. ​Plans ​and c
​ oordinates ​the ​intraoperative ​nursing ​care​. ​Checks ​the
chart ​and ​relates ​pertinent ​data​. ​Admits ​the ​patient ​to ​the ​operating ​room ​suite​.
A​ssists ​with ​transferring ​the ​patient ​to ​the ​operating ​room ​bed​.
• ​Ensures ​patient ​safety ​in ​transferring ​and ​positioning ​the ​p​atient​.
Participates ​in ​insertion ​and ​appli​c​ation ​of ​monitoring ​devices​. ​Assists ​with ​the
​ onitors ​the ​draping ​procedure​. ​Documents ​intraoperative
induction ​of ​a​n​esthesia​. M
​ ecords​, ​labels​, ​and s
care​. R ​ ends ​to ​proper ​locations ​tissue ​specimens ​and
cultures
Measures ​blood ​and ​fluid ​loss​.
• ​Records ​amount ​of ​drugs ​used ​during ​local ​anesthesia​.
Coordinates ​all ​activities ​in ​the ​room ​wi​th ​team ​members ​and ​other ​health​-​related
personnel ​and ​departments​. ​Counts ​spo​n​ges​, ​needles​, ​and ​instruments​.
Accompanies ​the ​patient ​to ​the ​postanesthesia recovery ​area​. ​Reports ​information
relevant ​to ​t​he ​care ​of ​the ​patient ​to ​the ​recov
ery ​area ​nurses​.

S​crubbed​/​Sterile ​Activities
Reviews ​anatomy​, ​physiology​, ​and ​the ​sur​gical ​procedure​. ​A​ssists ​with ​preparation ​of ​the
​ ther ​members ​of ​the ​surgical ​team​. ​Prepares
room​. ​Scrubs​, ​go​wns​, ​and ​gloves ​self ​and o
the ​instrument ​table ​and ​organizes ​sterile ​equipment ​for ​functional
use​. ​Assists ​with ​the ​draping ​procedure​. ​Passes ​instruments ​to ​the ​surgeon ​and assistants
by ​anticipating ​their ​needs​. ​Counts ​sponges​, ​needles​, ​and ​instrumen​ts​.​.​. ​Monitors ​practices
​ eeps ​track ​of ​irrigation ​solutions ​used ​for
of ​aseptic ​technique ​in ​self ​and ​others​. K
cal​c​ulation ​of ​blood
loss​.
• ​Reports ​amounts ​of ​local ​an​esthesia ​and ​epinephrine solutions
used ​by ​ACP ​and​/​or ​surgeon​.
ACP ​Anesthesia ​care ​provider​.
Copyright ​© ​2007 ​by ​Mosby​, ​Inc​.​, ​an ​affiliate ​of ​Elsevier ​Inc​.

Other Nursing Roles

Registered Nurse First Assistant: ​•

Work in collaboration with the surgeon

to ensure excellent patient

​ outcomes ​•

Specialized training and certification •

Handle tissue specimens, use

instruments, provide
exposure to the surgical site, assist
with hemostatis and suturing ​Nurse

Anesthetist: ​• minimally masters

prepared • Perform many of the roles

that an anesthesiology MD preform

​ ​•

manage patient preop assessment,

induction, maintenance,
and emergence from anesthesia
TABLE 19​-​2 ​Examples ​of ​Nursing ​Activities
Surrounding ​the ​Surgical ​Experience
A​fter
Before ​Asses​sment ​Home​/​Cl​ inic​/​Holdi​ng ​Ar​ea ​Initiates ​preoperative
assessment ​Plans ​teaching ​methods ​appropriate ​to ​patient​'​s
​ nit ​Completes ​preoperative
needs ​Involves ​family ​in ​interview ​Surgical
U
assessment ​Coordinates ​patient ​teaching with ​other ​nursing

staff ​Develops ​a ​plan ​of ​care ​Surgical ​Suite ​Identifies ​patient ​Verifies
surgical ​site ​Assesses ​patient​'​s ​level ​of ​consciousness​, ​s​ki​n
integrity​, ​mobility​, ​emotional ​status​, ​and
​ lanning ​Determines ​a ​plan ​of ​care ​that ​incorporates
functional ​limitations ​Reviews ​chart P
and
respects ​the ​patient​'​s ​value ​system​, ​lifestyle​, ​ethnicity​, ​and ​culture​; ​care ​plan ​reflects ​the
patient​'​s ​level ​of ​function ​and ​ability ​during
the ​perioperative ​period ​Ensures ​all s​ upplies ​and ​equipment ​needed ​for
surgery ​are ​available​, f​ unctioning ​properly​, ​and ​sterile​, ​if ​appropriate
During ​Implementation ​Maintenance ​of ​Safety ​Ensures ​the ​integrity ​of
the ​sterile ​field ​Ensures ​that ​the ​sponge​, ​needle​, ​and ​instrument
counts ​are ​correct ​Positions ​the ​patient t​ o ​ensure ​correct ​align
ment​, ​exposure ​of ​surgical ​site​, ​and p
​ reven
tion ​of ​injury ​Prevents ​chemical ​injury ​from ​prepping ​solu
tions​, ​pharmaceuticals​, ​etc​. ​Ensures ​safe ​use ​of ​electrical ​equipment​, ​lasers​,
and ​radiation ​Safely ​administers ​appropriate ​medications ​Monitoring ​of
Physical ​Status ​Monitors ​and ​reports ​changes ​in ​patient​'​s ​vital
signs ​Monitors ​blood ​loss ​Monitors ​urine ​output ​as ​applicable ​Monitoring ​of
Psychologic ​Status ​Provides ​emotional ​support ​to ​patient S
​ tands ​near ​or
touches patient ​during ​proce
dures ​and ​induction ​Ensures ​the p
​ atient​'​s ​right ​to ​privacy ​is
maintained ​Communicates ​patient​'​s ​emotional ​status ​to
other ​appropriate ​members ​of ​the ​health ​care ​team
Evaluation
Postanesthesia​/​Discharge ​Area ​Determines ​patient​'​s ​i​mmediate ​response ​to ​sur
gical ​intervention ​Monitors ​vital signs ​Safely ​administers ​appropriate
medications ​Surgical ​Unit ​Evaluates ​effectiveness ​of ​nursing ​care ​in ​the
OR ​using ​patient ​outcome ​criteria ​Determines ​patient​'​s ​level ​of ​satisfaction ​with
care ​given ​during ​perioperative ​period ​Evaluates ​products ​used ​on ​patient ​in
the ​OR ​Determines ​patient​'​s ​psychologic ​status ​Assists ​with ​discharge ​planning
​ linic ​Seeks ​patient​'​s ​perception ​of ​surgery ​in ​terms ​of
Home​/C
the effects ​of ​anesthetic ​agents​, ​impact ​on
body ​image​, ​immobilization ​Determines ​family​'​s ​perceptions ​of ​surgery
OR​. ​Operating ​room
Copyright ​© ​2007 ​by ​Mosby​, ​Inc​.​, ​an ​affiliate ​of ​Elsevier ​Inc​.

What's in the Operating

Area?
A surgical suite is a controlled
environment designed to minimize
the spread of infectious organisms
and allow a smooth flow of patients,
personnel, and the instruments and

equipment. ​• ​Unrestricted Area:

where personnel in street clothes can

interact with those in scrubs ​•

Semirestricted Area: ​peripheral

support areas and

corridors, all individuals need to be
surgical scrubs and cover their hair

(both facial and on their head) ​•

Restricted Area: ​Masks must be worn

with above surgical

attire, includes the OR, sinks, and the
clean core
Copyright ​© ​2007 ​by ​Mosby​, ​Inc​.​, ​an ​affiliate ​of ​Elsevier ​Inc​.

What does
Perioperative asepsis
mean? ​It is the creation and
maintenance of a sterile field, with
the patient's surgical incision at the
center of the sterile field.
Proper Technique for
scrubbing in to a
surgical field:
1. Team members fingers and hands
should be scrubbed first
with progression to the forearm and
elbows. 2. The hands should be held
away from the surgical attire. 3. The
hands should be held up once clean
so that no suds or
other bacteria can drift down onto the
clean area 4. When waterless gels are
used for asepsis, you should first wash
you hands and forearms thoroughly
with soap and water, then dry before
putting on the gel 5. Then you can
enter the surgical area and put on the
surgical
gown and gloves
(​Courtesy ​The ​Methodist ​Hospital ​Houston​, ​Tex​. ​Photograph ​by ​Donna ​Dahms​, ​RN​,
CNOR​)

Types of Anesthesia
General: ​Loss of sensation with the
loss of consciousness, skeletal muscle
relaxation, possible impaired
ventilatory and cardiovascular function
and elimination of the somatic,
autonomic, and endocrine responses,
including coughing, gagging, vomiting,
and sympathetic nervous system

responses. ​• given IV, inhaled, or

rectally • Technique of choice when:

1.surgical procedures require sig.
skeletal muscle relaxation, last for a
long time, require awkward positioning
or control of respirations 2.patient are
extremely anxious 3.refuse or have
contraindications for local anesthesia
4.are uncooperative (head injury,
intoxication, youth,
emotional status, or cannot remain
immobile)
Endotracheal Intubation
• This is a tube placed into the trachea
once IV induction of anesthesia occurs

• Allows for control of ventilation and

airway protection (specifically

​ from

aspiration) ​• Complications: o​ ​Sore

throat/hoarseness o​ ​injury to the teeth

o ​failure to intubate ​o ​laryngospasm,

laryngeal edema ​• Once the tube is

placed, an ambu bag is attached and

air is instilled,
​ the chest should rise
and fall with the instillation of air, and
you should be able to hear breath
sounds
Types of Anesthesia
Regional: ​This is the injection of a
local anesthetic in or around a specific

nerve or group of nerves ​• ​Nerve

blocks: ​usually done for the palliation

of pain
o ​celiac plexus block ​o b
​ rachial plexus
block ​• ​Spinal/Epidural Anesthetic:

injection of a local anesthetic

into either the subarachnoid space and
CSF (spinal) or epidural space
(epidural)

o ​Spinal blocks: cause autonomic,

sensory and motor

blockade, used for lower abdomen,

perineal, groin, or lower extremity ​■

can cause hypotension and

vasodilation, also spinal

headaches ​o ​Epidural blocks:
anesthetic is given to the epidural

space ■ lower incidence of headache

Spinal
cord
Dura

Dura

B
S1

Sagittal ​section
(​From ​Rothrock ​JC​: ​Ale​xand​er​'​s Care ​of ​the ​Patient ​Sugery​, ​ed ​13​, ​St​. ​Louis​, ​2007​, ​Mosby​.​)

Types of Anesthesia
Local Anesthesia: ​Usually a topical or
injectable agent that provides sensory
blockade to a certain area
Topical: ​lidocaine spray at the dentist,
EMLA Cream for dermatologic
procedures
Injectables: ​Subcutaneous lidocaine
or nerve blocks used at the dentist
Patient Positioning
• Critical part of every procedure and
usually occurs once the anesthesia

has been administered. ​• Needs to

allow for accessibility of the surgical

site,
administration of anesthesia, and

maintenance of the airway. ​• Must take

care to: • provide correct skeletal

alignment • prevent undue pressure on

nerves, skin over bony
prominences, and eyes ​• provide for

adequate thoracic excursion • prevent

occlusion of arteries and veins •

provide some modesty • recognize and

accommodate for previously assessed

skeletal deformities
Patient Positioning
Greatest care must be taken to

prevent injury, because: ​• anesthesia

has blocked the nerve impulses

o ​the patient can't complain that they

have pain or
discomfort ​o ​can cause: ■ muscle

strain ■ joint damage ■ pressure ulcers

■ nerve damage • Need to also pay

attention to the pooling of blood due to

vasodilation, can cause central
hypotension
Patient Positioning
1. Supine 2. Prone 3. Trendelenberg 4.
Lateral 5. Kidney 6. Lithotomy 7.
Jackknife 8. Sitting
Complications of the
Intraoperative Period
Anaphylaxis: ​• Most severe form of

an allergic reaction, type I

hypersensitivity ​• Clinical

Manifestations can be masked by

anesthesia • Can be caused by any of

the medications, inhaled, IV, or by

the compounds used in the tools of the

surgery (iodine allergy, latex allergy) ​•

 Watch for hypotension, tachycardia,

bronchospasm, and
pulmonary edema
Complications of the
Intraoperative Period
Postoperative Hypothermia: ​• get

hypothermia up to 12 hours post

surgery, 34.5C • Direct effect of the

anesthesia • increased risk with longer

surgeries
 Postoperative Hyperthermia: ​•

elevated temperatures: 38C or above

24-48 hours post surgery

​ ​• results from

inflammatory medications/cytokines

that are released

​ in the post operative
period to enhance healing
Complications of the
Intraoperative Period
Malignant Hyperthermia: ​• Rare

metabolic disease in which affected

period develop
hyperthermia with rigidity of skeletal
muscles that can result in death

o ​most often seen when

Succinylcholine with inhalent drugs are

​
given together ​• Autosomal dominant

with varying levels of penetrance •

Thought to be a derangement of contol

of intracellular calcium,
​ leading to
muscle contracture, hyperthermia,
hypoxemia, lactic acidosis, and
hemodynamic and cardiac
abnormalities ​• ​Need to assess the

patient and the family for any

untoward reactions to anesthesia ​•

Treatment is administration of

dantrolene
Postoperative Nursing
Care
1. Preparation for admitting the new
postoperative patient 2. Initial
assessment and interventions upon
receiving the
patient 3. Selected data from the chart
that is important 4. Post operative
nursing assessments and interventions
Postoperative Nursing
Care: Preparation
1. Have the postoperative bed ready,
linens, extra pillows for
positioning 2. Have the appropriate
equipment ready:
1.Suction, set up, tested and ready to
hook up 2.antiembolism stockings, set
up, tested and ready to hook
up 3.Oxygen hook up 4.if hip
replacement, ensure you have the
proper hip
abduction pillow 3. Emergency tray
(airways, drugs, etc) depending on the
type
of surgery
Proper Postoperative
Positioning
Initial Assessment and
Interventions upon
receiving the patient
1. Level of consciousness and
emotional state
2. Move patient to the bed, placement
and positioning, attachment of
equipment as needed
a. quick assessment of A (airway) B
(breathing) C (circulation)
b. proper positioning may be ordered
based on the type of surgery, if
semiconscious, side lying with the
head of the bed flat, if fully conscious,
semi fowlers (if not contraindicated)
3. Safety Measures: side rails up, brief
assessment of mentation
Initial Assessment and
interventions upon
receiving the patient
4. Review the postoperative plan of
care with the recovery room nurse to

include orders: ​• V/S, position,

medications, IV fluids, NPO or type of

oral
intake, activity, diagnostic tests
needed, dressing changes, etc...
5. Emotional Support for the patient
and the family
6. Pain: Assess pain per patient, and
location
TABLE ​20​-​2 ​Postanesthesia ​A​dmission ​Report

General ​Information
Patient ​name ​Age ​Anesthesia ​care ​provider ​Surgeon
Surgical ​procedure ​Patient ​History
• ​Indication ​for ​surgery
• ​Medical ​history​, ​medications​, ​allergies
Intraoperative Management
• ​Anesthetic ​medications
• ​Other ​medications ​received p
​ reoperatively ​or
intraoperatively
Blood ​loss
Fluid ​replacement ​totals​, ​including ​blood ​transfusions
 • ​Urine ​output ​Intraoperative ​Course
• ​Unexpected ​anesthetic ​events ​or ​reactions
​ nexpected ​surgical ​events
• U
• V​ ital ​signs ​and ​monitoring ​tre​n​ds
• ​Results ​of ​intraoperative ​laboratory ​tests
Copyright ​© ​2007 ​by ​Mosby​, ​Inc.​, ​an ​affiliate ​of ​Elsevier ​Inc​.

TABLE ​2​0​-​30 ​Initia​l ​Postanesthesia ​Care

Unit ​Assessment

Airway
• ​Patency
• ​Oral ​or ​nasal ​airway
Endotracheal ​tube ​Breathing
• ​Respiratory rate ​and ​quality
Auscultated ​breath ​sounds
Pulse ​oximetry
• ​Supplemental oxygen ​Circulation
ECG ​monitoring​-​rate ​and ​rhythm
• ​Blood pressure
• ​Temperature ​and ​color ​of ​skin
​ eripheral ​pulses ​Neurologi​c
• P
• L​ evel ​of ​consciousness
• ​Orientation
• ​Sensory ​and ​motor ​status ​Genitourinary
• ​Intake ​(​fluids​, ​irrigations​)
• ​Output ​(​urine​, ​drains​) ​Surgical ​Site
• ​Dressings​/​drainage ​Pain
• ​Incision
Other

ECG,​ ​Electrocardiogram​.
Copyright ​© ​2007 ​by ​Mosby​, ​Inc​.​, ​an ​affiliate ​of Elsevier I​ nc​.

Initial assessment and

interventions upon
receiving the patient
7. ​Objective Data:
a. Vital Signs (TPRBP) q 15min x 4, q
30 min x 4, q 1 hour x 4, then q 4
hours as indicated
Can only move from 15 to 30min,
and 30min to q1 hour when the
patient is stable
b. Respiratory Status: Patency of the
airway, need for suctioning if the
patient can't move sections, depth of
respirations
C. Neurological Status: Level of
consciousness, pupils, gag and
swallowing reflexes
Initial assessment and
interventions upon
receiving the patient
d. Circulatory Status: note the nailbeds
(cap refill), lips, buccal membranes,
palms, and soles for pallor and
duskiness (cyanosis is usually first
seen in the buccal membranes)
e. Dressing (s): check the chart and
see where they are, and what they are
comprised of
also check the chart for placement of
any surgical drains have been placed
and where they exit
f. Drainage tubes: are they free of
kinks and draining properly, check if
the tubes need to be attached to
suction, check to ensure it is the
proper amount of suction, assess type
and amount of drainage and know
when to call the MD.
Initial assessment and
interventions upon
receiving the patient
g. Urinary output: if there is no foley,
the patient must void within 8-10 hours
post-op, if not, notify the MD
if there is a foley, there should be at
least 500-700 cc in the first 24 hours
post surgery
h. Safety: Side rails up, instruct the
patient not to get out of bed without
help, ensure the call light and phone
are within reach, secure all tubes and
lines properly to prevent dislodgement
and injury
As the nurse, make sure to dangle the
patient for 1-2 minutes the first time
the patient gets up out of bed.
i. Proper positioning and comfort j.
Equipment
Selected data from the
chart that is important
1. Surgeon's Orders 2. Surgical Notes
and Anesthesia records 3. Recovery
Room Summary
Postoperative nursing
assessment and
interventions
1. Assessment of Risk Factors for
postoperative
complications ​(will review later) ​2.
Promote comfort: ​includes the relief
of pain, the relief of
restlessness, relief of nausea and
vomiting, relief of abdominal distention,
relief of hiccups. ​3. Promote wound
healing: ​review wound healing from
earlier lectures...a properly
approximated sutured or stapled
surgical wound is healing by primary
intention, how strong is the wound
once the sutures are removed? ​4.
Care of tubes and drains
Postoperative nursing
assessment and
intervention
5. ​Ensuring optimal respiratory
function: ​Promote lung expansion,
deep breathing, coughing and use of
the incentive spirometer
(Coughing is contraindicated in head
and eye surgeries, plastic surgery and
hernia operations)
6. ​Maintenance of Adequate
Cardiovascular Function
7. Maintenance of adequate F/E
balance: ​monitor for abnormal
electrolytes, monitor v/s, keep an
accurate I&O records​, ​obtain
laboratory specimens
Postoperative nursing
assessment and
intervention
8. Maintenance of nutritional
balance: ​NG tubes for 24-48 hours
post GI surgery, post operative diet
includes clear liquids once bowel
sounds return, advance the diet based
on MD orders and patient tolerance
9. Return of Normal Urinary
Function: ​assess for bladder pain and
distention (palpation and percussion),
assess urinary output, Notify MD if no
urine output 6-8 hours post surgery, If
patient continues on bed rest, assist
the patient into the normal voiding
position as possible, provide for
adequate privacy (as much as
possible)
Postoperative nursing
assessment and
interventions
10. Resumption of usual bowel
elimination pattern: ​assess for
abdominal distention, presence of
bowel sounds, assist with ambulation,
provide ordered laxatives as needed,
provide for as much privacy as
possible, assist in positioning patient in
as natural a position for stooling.
11. Restoration of Mobility: ​assess
the patient for the ability to ambulate,
remember to dangle the patient before
walking, assess the patient before,
during and after ambulating, work with
PT, provide for adequate pain
medicines if needed prior to
ambulating.
12. Reduction of anxiety and
achievement of well-being 13.
Discharge Planning: ​very teaching
focused
Common postoperative
complications
• Hematological ​o H
​ emorrhage ​•

Respiratory o​ ​Atelectasis o​

Pneumonia o​ ​Pulmonary Embolism •

Cardiovascular
o H ​ C
​ ypotension o ​ ardiac
Dysrhythmias ​o ​Venous Thrombosis •

Urinary o​ ​Urinary Retention o​ ​Low

urine production
• Gastrointestinal

o ​Paralytic ileus ​o ​Constipation •

Neurological o​ ​CVA/Stroke •

Immunological o​ ​Infection • Wound

Healing
​ ​Eviserations o​
o ​Dehiscence o

Infection • Psychological
o ​Body image problems
Common postoperative
complications:
Common postoperative
complications:
Hematologic
Hemorrhage: ​• Often related to

ineffective vascular closure or

alterations in coagulation
​ ​• Observe for

bleeding at the wound site/surgical

dressing, especially
​ in the dependent

areas ​• monitor the v/s closely (see

previous slide), follow the H/H closely,

​
assess skin closely, report any

changes noted ​• assess LOC, and

mentation (restlessness can indicate

altered cerebral perfusion)
Common postoperative
complications:
Pulmonary
Atelectasis: ​• Common cause of
postoperative hypoxemia • Retained

secretions and decreased respiratory

excursion
causes blockage of the alveoli

o ​once all the air trapped in the alveoli

is absorbed, the
alveoli collapse ​o ​hypotension and

cardiac states can worsen this •

Assess for decreased lung sounds,

decreased O2 sats • Encourage deep

breathing, incentive spirometry,

coughing,
early mobilization
Common postoperative
complications:
Pulmonary
Atelectasis:
Common postoperative
complications:
Pulmonary
Pneumonia: ​• Can be a sequela to the
atelectasis, can occur from
aspiration ​o ​increased risk post

thoracic and abdominal surgery • the

atelectasis builds up, and increased

secretions can
continue to block the airways ​o

microorganisms grow in the trapped

secretions • Proper positioning of

patients can assist with this, as well as

q2 hour re-positioning

o ​ensure that respiratory effort is

maximized o​ ​O2 therapy as

ordered/needed o​ ​Antibiotics as

ordered • V/S and frequent lung sound

assessment • Cough, IS, deep

breathing
Common postoperative
complications:
Pulmonary
Pulmonary Embolism: ​• Caused by a

thrombus that is dislodged from the

peripheral circulation,
​ and then gets
lodged in the pulmonary arterial

circulation ​• See acute tachypnea,

dyspnea, tachycardia, hypotension

and decreased O2 saturations ​• ​Start

O2 per MD, Anticoagulants as

ordered, cardiopulmonary
​ support ​•

Preventing DVT is primary to

preventing pulmonary emboli:

o ​Leg exercises o​ ​Compression
stockings/anticoagulants per MD o​

Deep breathing, coughing, IS (move

the air in the lungs

and move the blood) ​o ​Ambulate as

soon as possible
Common postoperative
complications:
Cardiovascular
Hypotension: ​• Most common causes

are unreplaced fluids during the

surgery and hemorrhage ​• Secondary

causes include MI, cardiac

tamponade, pulmonary
​ emboli, or

effects from the anesthesia drugs ​•

Show signs of hypoperfusion to the

vital organs (heart, brain,

​ and kidneys)

• have clinical signs of disorientation,

loss of consciousness, chest

​ pain,

oliguria, and anuria ​• Assess V/S,

pulse Ox, peripheral pulses, LOC and

report as necessary
​ ​• Assist physician

with interventions aimed at correcting

the
underlying cause of the hypotension