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Peri-operative Care


Nursing Fundamentals CHAPTER 27 Perioperative Care This is the care clients receive before, during and after surgery peri means around ... – PowerPoint PPT presentation

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Title: Peri-operative Care

Peri-operative Care
  • Nursing Fundamentals
  • CHAPTER 27

Perioperative Care
  • This is the care clients receive before, during
    and after surgery
  • peri means around.its around surgery
  • The current trend is to get pts in and then out
    the door, insurance doesnt want to pay and pts
    dont want to stay

Preoperative period
  • This is the time BEFORE
  • surgery.
  • This is when the family and
  • pt find out that surgery is
  • necessary
  • This is the time pts are taken to the O.R. As
    soon as the pt enters the O.R., preop is over
  • Preop can be long or quick depending on other
    surgeries, the Dr. and if there are any

Inpatient surgery
  • Procedures performed on clients and then they
    must be admitted and stay overnight
  • Generally, the nursing care postop, determines
    how long a pt will stay for

Outpatient surgery
  • Also called ambulatory surgery or same day
    surgery (SDS)
  • Pts usually have quick procedures performed and
    they may recover at home
  • SDS sites can be free standing buildings that
    either are or are not affiliated with a hospital

Outpatient surgery
  • Pt comes in
  • VS assessed, IV started
  • Pt taken in for procedure
  • Pt taken to area to recover
  • A few things must happen before pt can be D/Cd

D/C from SDS
  • Pt awakens and is alert
  • VSS
  • Pain and nausea are controlled
  • Oral fluids are retained
  • Pt voids sufficiently
  • D/C instructions and scripts are given
  • If pt has complications, pt is transferred to

  • Physician who administers chemical agents that
    temporarily eliminate sensation and pain

Nurse Anesthetist
  • Is a nurse specialist who administers anesthesia
    under the direction of a Physician

Types of Surgery According to Their Urgency
  • Optional
  • Elective
  • Required
  • Urgent
  • Emergency

Optional Surgery
  • Surgery is performed at the pts request
  • Example
  • cosmetic
  • surgery

Elective Surgery
  • Surgery is planned at the pts convenience
  • Failure to have the surgery, does NOT result in
  • Example surgery to remove a superficial cyst

Required Surgery
  • Surgery is necessary and should be done
    relatively promptly
  • Example removal of a cataract

Urgent Surgery
  • Surgery is required promptly, within 1-2 days if
    at all possible
  • Example Surgical removal of a malignant tumor

Emergency Surgery
  • Surgery is required IMMEDIATELY for survival
  • Example surgery to relieve an intestinal

Reasons for Surgery
  • Diagnostic
  • Exploratory
  • Curative
  • Palliative
  • Cosmetic

Diagnostic Surgery
  • Removal and study of tissue to make a diagnosis
  • Example breast biopsy or biopsy of skin lesion

Exploratory Surgery
  • More extensive means to diagnose a problem
  • Usually involves exploration of a body cavity or
    the use of scopes inserted through small
    incisions (laporoscopy)
  • Example exploration of abdomen for unexplained
    pain or to look at the appendix

Curative Surgery
  • Removal or replacement of defective tissue to
    restore function
  • Example Cholecystectomy, total hip replacement

Palliative Surgery
  • Relief of symptoms without a cure
  • Example resection of a tumor to relieve pressure
    and pain

Palliative Care Mission StatementHOSPICE
  • Hospice of the Western Reserve
  • provides palliative end-of-life
  • care, caregiver support and
  • bereavement services throughout Northern
    Ohio. In celebration of the individual worth of
    each life, we strive to relieve suffering,
    enhance comfort, promote quality of life, foster
    choice in end-of-life care and support effective

Cosmetic Surgery
  • Surgery to correct defects, improvement of
    appearance or change to a physical feature
  • Example Cleft lip repair, Rhinoplasty (nose
    job), breast implants

Types of Anesthesia
  • General anesthesia
  • Regional anesthesia

General Anesthesia
  • Eliminates all sensation and consciousness of or
    memory for the event. Acts on the CNS to produce
    loss of sensation, reflexes, and consciousness
  • Pt is watched closely for oxygenation and
    circulation, pt is intubated
  • Inhalants includes gas or volatile liquids
  • Injectables given as IV

Regional Anesthesia
  • Blocks sensation in an area
  • of skin and Sub Q tissue.
  • Pt does not loose consciousness
  • Advantage of a regional is that respiratory,
    cardiac and GI complications are minimized
  • Pt is watched for allergic reactions, changes in
    VS and toxic reactions
  • Anesthesized area must be protected from injury
    because they have no feeling (my block at pain
    mngmt, weak legs)

  • these include
  • Spinals eliminates sensation in lower
    extremities, abdomen and pelvis, this includes
    spinal epidurals
  • Local these block sensation in a circumscribed
    area of skin and sub Q tissue
  • Topical inhibits sensation in epithelial
    tissues such as skin and mucous membranes where
    the med is directly applied

Conscious Sedation
  • Refers to a state in which the pt is sedated and
    in a state of relaxation and emotional comfort
    but ARE NOT unconscious
  • Pt is free of pain, fear, anxiety and can
    tolerate unpleasant diagnostic and short
    therapeutic procedures such as endoscopies or
    bone marrow aspirations
  • Meds are administered IV
  • Nurse must watch pt carefully and use very good
    assessment skills

Reversal Meds
  • Meds to reverse the effects of those used for
    conscious sedation must be readily available in
    case pt becomes too sedated
  • Narcan antagonist for opiates or narcotics like
  • Romazicon reverses anti-anxiety drugs like

Laser Surgery
  • The acronym is
  • Light Amplification by the
  • Stimulated
  • Emission of Radiation
  • Laser converts a solid, gas, or liquid into
    light. When focused, the energy from the light
    is converted to heat, causing vaporization of
    tissue and coagulation of blood vessels

Examples of lasers
  • Carbon dioxide laser
  • Argon laser
  • Ruby laser

Advantages of laser surgery
  • Cost effective
  • Reduced need for general anesthesia
  • Smaller incisions
  • Minimal blood loss
  • Reduced swelling
  • Less pain
  • Less wound infections
  • Reduced scarring
  • Less recuperation time

Unique Safety Precautions
  • Laser technology requires unique safety
    precautions such as
  • Eye
  • Fire
  • Heat
  • Vapors

  • Depending on the type of laser used, goggles must
    be worn when lasers are being used
  • Contacts are not to be worn around laser surgery

Lasers produce heat
  • This can be volatile
  • Alcohol and acetone ARE NOT TO BE USED around
    lasers because of their flammability
  • Surgical instruments are coated in black to avoid
    absorbing scattered light that causes them to heat

Pts teeth
  • At times, pts teeth may be covered with plastic
    or a rubber mouth guard to shield metal fillings

What happens when a laser is used
  • The laser releases plume which is a substance
    composed of vaporized tissue, carbon dioxide and
  • Plume is accompanied by smoke, an offensive odor,
    and burning eyes for some people

  • It is bad to inhale plume
  • Airborne cells in the inhaled plume may contain
    viruses, possibly HIV therefore, high-efficiency
    respirator masks are to be worn

Informed Consent
  • Permission a client gives after an explanation of
    the risks, benefits and alternatives are told to
    the pt by the Dr.
  • This form is signed by the pt with a witness to
    the nurse present. This verifies that the pt
    didnt sign under duress

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Who else can sign
  • Power of attorney can sign the informed consent
  • If the pt can sign but is under the influence of
    any drug or alcohol, NO PROCEDURE CAN BE DONE.
    You cannot sign consent under the influence

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  • In a life-threatening emergency, a court may
    waive the need to obtain written or verbal
    consent from a pt who requires immediate surgery
    on the basis of substituted judgment

18 years old or younger
  • Must have parental consent
  • Emancipated adolescents minors who are regarded
    as living independently and who support
    themselves can sign their own consent form

Who is responsible
  • The nurse makes sure that this form gets
    completed BEFORE the pt receives any meds in
    preop area
  • If this has not been done, surgery may be with
    held until pt can sign for themselves

Preoperative Blood Donations
  • Pts can organize a visit to have pre-donated
    blood saved and used for surgery if needed
  • Autologus transfusion
  • If the blood is not needed, it is usually

Directed donors
  • Blood donors chosen from among the pts relatives
    or friends
  • If this blood is not used, it will be put back
    into the pool and used by whoever needs it

Preoperative care
  • Many tasks must be completed just a few hours
    before a pt goes to the O.R. these include
  • Nurse assessment
  • Preoperative reaching
  • Performing methods of physical preparation
  • Administration of meds
  • Assisting with psychosocial preparation
  • Completing the surgical checklist

Nursing Assessment
  • Nurses ask a lot of questions
  • Form is used and must be filled out completely
  • Info such as
  • Name DOB VS
  • Allergies L.M.P. Meds
  • NPO status past medical Hx

Pre-op teaching
  • Easier to teach a pt that is AO and hopefully
    not in pain
  • We teach about
  • Preop meds
  • Post-op pain control
  • Explanation of PACU (post anesthesia care unit -
  • Discussion of post-op care using meds and

Deep Breathing
  • We teach coughing and deep breathing to prevent
  • Atelectasis and pneumonia
  • We teach incentive
  • spirometry

Forced Cough
  • Remember that thick secretions accompany impaired
  • Teach pts to use a splint

Leg Exercises
  • Leg exercise promotes circulation
  • Prevents thrombus
  • Use of PAS stockings are EXTREMELY important
  • What is an emboli and why is it a bad thing

Physical Preparation
  • Skin prep
  • Elimination
  • Food and Fluids
  • Valuables
  • Surgical attire
  • prosthesis

Skin Preparation
  • Involves removing hair and cleansing the skin
    because these contain microorganisms that can be
    harmful to the pt in large amounts
  • Pts may be instructed to wash the surgical site
    to be the night before and the morning
    ofbetadine in a scrub brush form is given
  • All other cleaning of the skin will be done in
    the O.R.

  • The nurse may need to insert a foley catheter
    depending on the surgery type
  • Catheters can be inserted once the pt is asleep
  • Bowel preps can be ordered the night before,
    enemas can be given in preop area
  • Antibiotics can be ordered the day before and
    OCTOR on call to O.R., the nurse gives these 30
    minutes before pt is called to O.R

Foods and Fluids
  • It is common to have pts be NPO 8-10hrs before
    O.R. time
  • Many SDS allow clear liquids up to 3 or 4 hrs
    before surgery
  • The nurse encourages good nutrition such as
    protein and vitamin C needed for healing if she
    meets the pt preoperatively

  • The nurse tells the pt to leave valuables at home
  • Lockers are issued to pts
  • If a pt doesnt want to remove a wedding band,
    gauze is wrapped around the ring and tapes for

Surgical Attire
  • All pts are required to wear a gown to the OR
  • Children may leave their undergarments on for
  • Surgical cap is given to pts as they are going to
    the OR
  • Dr. may order surgical hose to be placed on pt
    before OR to prevent stasis
  • Makeup and hair décor is to be removed, no nail
    polish, one acrylic nail must be removed for
    pulse ox assessment

  • Pts should remove full and partial dentures to
    avoid damage to them during intubation
  • Unless anesthesia requests dentures to be left
    in, take them out and place them in denture cup

Pre-op meds
  • Anticholinergics Robinol, decreased respiratory
    secretions, dries mucous membranes, prevents
    vagal nerve stimulation during intubation
  • Anti-anxiety ativan reduces preop anxiety,
    causes slight sedation, slows motor activity, and
    promotes the induction of anesthesia

  • Sedatives such as versed promotes sleep or
    conscious sedation and decrease anxiety
  • Antibiotics gentamycin, zosyn, vancomycin
    prevent bacteria, used prophylactically

Psychosocial preparation
  • Preparing the pt emotionally, spiritually and
    physically is necessary
  • Anxiety and fear need to be calmed
  • Education is the best thing to teach about,
    leaving your pt educated decreases fear
  • Listening is important, call Chaplin or social
    work, allow pt time to express his thoughts or

Preop checklist
  • Use your facilitys form
  • Obtain a hx and physical
  • Be sure the pt knows exactly what he is having
    done, allow him to explain it to you
  • Obtain labs
  • Have pt sign surgical consent form
  • Be sure to get Dr. to complete risks and
    benefits, have pt sign it

  • Identify allergies, place allergy band on pt
  • Check to see if pt has NPO and ask for how long
  • Skin prep, VS, remove nail polish and dentures
  • Put pt in gown
  • Start IV
  • Administer prescribed pre-op med

Intraoperative period
  • Time in which pt is actually having surgery
  • Takes place in the OR

Receiving Room
  • Its the room where pt goes to be observed until
    the operating room and surgical team are ready
  • Meds can be given during this time

Operating Room
  • This is where the surgery takes place
  • Entire room is sterile and usually cold to
    prevent organisms from growing

Surgical Waiting Area
  • The room where family and friends await
    information about the pt and their surgery
  • It is staffed by volunteers who provide comfort,
    support and news about how the pt is doing
  • TV and snacks are also available

Postoperative Period
  • Begins after the operative procedure is completed
    and the pt is transported to an area to recover
    from anesthesia
  • This period ends when the pt leaves the PACU and
    goes to a nursing floor or when the pt goes home
    from SDS

  • Postanesthesia care unit is where pts are
    intensively monitored
  • Nurses in the PACU ensure the safe recovery of
    surgical pts from anesthesia

Immediate Postop care
  • This refers to the first 24 hrs after surgery
  • During this time, nurse monitor the pt for
    complications he or she recovers

Postoperative complications(10)
  • Airway occlusion d/t obstruction in airway
  • Hemorrhage control bleeding, give IVFs and
    replace blood
  • Shock d/t inadequate blood flow, place the pt
    in Trendelenburg position (legs up, head lower)
  • Pulmonary embolis obstruction of circulation
    through the lung as a result of a wedged blood
    clot that began as a thrombus

Postoperative complications(10)
  • Hypoxemia inadequate oxygenation of blood, the
    nurse gives O2
  • Paralytic ileus lack of bowel motility, nurse
    makes pt NPO, NGT inserted, IVFs given
  • Urinary retention inability to void, nurse
    inserts a catheter

Postoperative complications(10)
  • Wound infection pathogens at or beneath the
    incision nurse can cleanse incision with
    antimicrobial agents, administer antibiotics
  • Dehiscence separation of incision, nurse can
    reinforce wound edges with steri-strips or apply
    a binder
  • Evisceration protrusion of abdominal organs
    through separated wound, nurse covers wound with
    a wet dressing and calls Dr.

Initial post-op assessment
  • ABCs are always important
  • The nurse checks
  • LOC
  • VS
  • Effectiveness of respirations
  • Need for supplemental oxygen
  • Condition of the wound and dressing
  • Location of drains and fluid amount out in drains
  • IV rate, site
  • Level of pain
  • Presence of urinary catheter

Continuing post-op care
  • After surgery, the pt needs to resume eating and
    demonstrate adequate elimination, circulation and
    wound healing

Food and oral fluids
  • These are with held until pt is AO and has no
    N/V and has bowel sounds
  • Pts usually start on a clear diet then go to a
    soft diet
  • Is and Os are monitored

Venous Circulation
  • You need to move your pt around ASAP to prevent
    venous stasis, thrombus and clots
  • Application of PAS stockings ARE A MUST
  • Keeping legs uncrossed, drinking plenty of
    fluids, avoid long periods of sitting, encourage
    ambulation and not sitting

Wound Management
  • Nurses asses the condition of a wound and the
    characteristic of the drainage at least once a
    shift if not more
  • Nurses reinforce dressings if they become loose
    or saturated

Discharge Instructions
  • These directions are for
  • managing self-care and
  • medical follow-up

Common areas to address when discharging the
surgical pt
  • How to care for the incision site
  • Signs of complications to report
  • What medications to use to control pain
  • How to self-administer prescribed meds
  • When pre-surgical activity can be resumed
  • If and how much weight can be lifted
  • Which foods to consume or avoid
  • When and where to return for a f/u appointment
  • The nurse should give both verbal and written

NANDA Diagnoses
  • Deficient knowledge
  • Fear
  • Anxiety
  • Acute Pain
  • Impaired Skin Integrity
  • Risk for infection
  • Ineffective breathing pattern
  • Risk for impaired gas exchange

The End