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Caring for Perioperative Clients

Reasons for Surgery


Categories of Surgery Based on Urgency

Gunshot wound
Fractured hip
Revision of scars
Cosmetic surgery

Perioperative Phases
Begins with the decision to perform surgery and continues
until the client reaches the operating area

1. Preoperative Assessment
Review preoperative orders:
Preoperative lab & diagnostic studies
Nutritional restrictions
Client’shealth history
Assess physical needs
Assess psychological needs
Assess cultural needs
Check consents
Preoperative teaching needs
Review of Preoperative Orders
What lab work and diagnostic studies would you expect the
doctor to have ordered?
Client’s Health History
Use this time to evaluate the client for any stress, anxiety or cultural
History of present illness and reason for surgery
Review of body systems examining past
Medical History:
Medical conditions: acute and chronic
Previous hospitalizations
Any previous problems with anesthesia
Present / Recent medications

2. First step in Pre-op Physical

Assessment is: Identify the
Psychosocial Preparation
Preoperative Physical Assessment
Purpose is a screening tool to reduce the risks and complications of
surgery and anesthesia.
Perform a head to toe systems assessment:
Key areas of focus are: Eye disease; Cardiovascular; Neurological; Muscular;
Pulmonary; Liver; Kidney/Bladder; Endocrine; Blood Disorders; Gastrointestinal;
Habits; Prosthesis; Pregnant/Menses; Dental; Anesthesia History and Other
(Language Barrier, HOH; Hearing Aid; Arthritis/Gout).

Surgical Risk Factors

Very young or old (Extremes)
Nutritional status
Chronic Disease Process - asthma, diabetes, anemia or bleeding
tendencies, etc
Acute Disease Process – abnormal labs, vitals signs, current
infectious process
Substance abuse – smoker, drugs, ETOH
3. Consent is Necessary for:
Invasive procedures
Procedures requiring sedation and/or anesthesia
A nonsurgical procedure that carries more than slight risk to
the patient
Procedures involving radiation

Surgical Consent
Operative permit
Physician responsibility
Explain risk and benefits of surgery
Nurse may witness
Patient consents to operation
Patient understands explanation given by MD
Must be signed prior to giving pre-op sedatives
There are 3 elements of Informed Consent
1. Capacity

2. Comprehension

3. Voluntariness
Criteria for Valid Informed Consent
Always check facility policy and procedure first!
Must be voluntary without coercion
Signature of competent patient or LEGALLY authorized
Informed subject

Criteria for Signature

Firstcheck with agency policy and procedure, if not one
available check with supervisor
General rules:
The individual if >18 years of age
Spouse of individual or nearest relative
If <18 years of age parent or legal guardian
If mentally incompetent, legal guardian

Surgical Consent Key Point Summary

Must be signed preoperatively
Physician must be notified if the client had not understood the scheduled
If an adult is confused, unconscious, or not mentally competent, a family
member or guardian must sign
If the client is younger than 18 years of age, a parent or legal guardian must
sign the consent
Exception for emancipated minors
In an emergency, the surgeon may have to operate without consent
Clients must sign the consent form before receiving any preoperative
sedatives or medications
Consent Flow Chart
4. Preoperative Teaching
Expectations before and after surgery
NPO status
Preoperative medications
Postoperative pain control & exercises
Explanation and description of PACU
Discussion of the frequency of assessing vital signs and use of
monitoring equipment
What to expect postoperatively

Preoperative Teaching
T- Turn cough and deep breathe
E- Exercises to perform after surgery
A- Administration of medication for pain and nausea
C- Client concerns should be addressed
H-Healing of the wound

Key Points of Preoperative Teaching

Reduce patient anxiety
More likely to cough and deep breathe, move as directed,
and properly utilize pain medication
Decrease post procedure complications and reduce
recovery period

5. Physical Preparation of Patient


Medication administration

Nutritional restrictions
Physical Preparation of Patient

Care of valuables


Physical Preparation of Patient

Food and fluids

Preoperative Medications
6. Preoperative Medications
Purpose: is for the patient comfort and reduced risk of
Reduce mucous secretions
Reduce anxiety – aids in induction of anesthetic
Decrease gastric secretions
Sedatives – promote sleep
Antibiotics – destroy enteric microorganism

7. Preoperative Check List

Varies with facility, check agency policy and procedure
unhappy surgeon
This is a safety tool for Peri-operative team and the scrub
nurse should review it
Preoperative Checklist
Preoperative medications
Preoperative preparations
Includes the entire surgical procedure until transfer of the
patient to the recovery area

Surgical Team
Surgical assistants
Scrub nurse
Circulating nurse

The partial or complete loss of the sensation of pain with or
without the loss of consciousness
Types of Anesthesia



Conscious Sedations
General Anesthesia
Acts on the central nervous system to produce loss of
sensation, reflexes, and consciousness
Characterized by loss
of consciousness
Regional Anesthesia
Uses local anesthetics to block the conduction of nerve
impulses in a specific region
Loss of sensation and decreased mobility to the specific
anesthetized area
No LOC change unless sedation also given to promote
relaxation / reduce anxiety
Local Anesthesia
Loss of feeling or sensation in a small ‘local’ area

Conscious Sedation
Used for diagnostic or short procedures
The client is free of pain, fear, and anxiety and can tolerate
unpleasant procedures while maintaining independent
cardiorespiratory function and ability to respond to verbal commands
and tactile stimulation
Usually given IV push
LPNs may monitor the patient who is recovering from conscious
Surgical Asepsis
Possible Intraoperative Complications
Fluid volume excess or deficit
Injury related to positioning
Malignant Hyperthermia

Begins with admission to the recovery area and continues
until the client receives a follow-up evaluation at home or is
discharged to a rehabilitation unit
Recovery Position
Side-lying position is used until the patient is awake from anesthesia
Semi-Fowlers position is usually used after a patient is awake from
Initial Postoperative Assessment
Airway patency
Circulatory status
Wound / Dressing condition
Fluid balance
Check Settings of Equipment
Nursing Standards for Care of the
Postsurgical Client
Respiratory function is maintained
Circulatory function is maintained
Pain and discomfort are recognized and effectively treated
Client safety is maintained
Wound healing is promoted and wound management is provided
Complication potential is continuously assessed, and any complications are immediately and
effectively treated

Gastrointestinal function is maintained

Self-care and mobility are encouraged as appropriate
Psychosocial needs are recognized and effectively managed
Discharge instructions, including follow-up care and home health services, are provided

Using an incentive spirometer

Purpose- the purpose of incentive spirometry is for the
patient to achieve maximum ventilation. Maximum
ventilation is necessary to help prevent and reverse alveolar
collapse, which can cause atelectasis and pneumonitis.
Thefastest-acting route for pain medication is parenteral
Postoperative Complications

Resuming Oral Fluids After Surgery

Assess adequate LOC
Assess swallowing ability
Offer small sips
Clear liquids or ice chips
Antiemetics nausea and vomiting

Later Postoperative Assessments

Reinforce deep breathing
Prevent atelectasis
Turn or ambulate
Prevent thrombophlebitis and embolus

Prevention of Venous Stasis & Other

Circulatory Complications
Move legs, leg exercises
Do not place pillow under client’s knees or calves unless ordered
Avoid placing pressure on lower extremities-such as massaging and
crossing legs
Apply TED hose
Low-dose heparin
Adequate fluid intake - water

Nursing Observations for Thrombophlebitis

Check Homan’s sign with each assessment
Dorsiflex foot and evaluate if there is pain in the calf
Assess lower extremities for pain or redness
Later Postoperative Assessments
Pain Management
Fluids and Nutrition
IV fluids
Decreased peristalsis
Progress diet from clear liquids to regular

Later Postoperative Assessments

Skin integrity/wound healing
Approximation of the wound edges
Intactness of staples or sutures

Wound Complications
Most likely 7-10 days after surgery

Separation of wound edges without the protrusion of organs
Thewound completely separates and organs protrude
Emergent condition
Place sterile dressing moistened with NS-keep moist until surgery
Later Postoperative Assessments
Ambulate as soon as possible
Monitor for numbness with regional anesthesia

Later Postoperative Assessments

Bowel Elimination
Abdominal distention
Encourage ambulation
Presence of bowel sounds

Later Postoperative Assessments

Urinary Elimination
Voids8 hours after surgery
Psychosocial Care
Opportunity to verbalize
Support groups
Social services

Gerontologic Considerations for the

Surgical Patient
Anesthesia and medications may cause confusion
Respiratory depression may result from opioids
Risk of surgery increases with other health problems

Nursing Implications
Applicable Nursing