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Caring for Perioperative Clients

Reasons for Surgery


Diagnostic
Exploratory
Curative
Palliative
Cosmetic

Categories of Surgery Based on Urgency


Classification
Emergency
Urgent
Required
Elective
Optional
Examples
Gunshot wound
Fractured hip
Cataracts
Revision of scars
Cosmetic surgery

Perioperative Phases
Preoperative
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
Medications
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
barriers
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
Allergies
Present / Recent medications

2. First step in Pre-op Physical


Assessment is: Identify the
Patient
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


Age
Very young or old (Extremes)
Nutritional status
Malnourished
Obese
Hydration
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
person
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
procedure
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
Surgicalprocedure
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
TEACH
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


Site

Medication administration

Nutritional restrictions
Physical Preparation of Patient
Continued….
Elimination

Care of valuables

Attire/grooming

Physical Preparation of Patient


Skinpreparation
Food and fluids

Preoperative Medications
6. Preoperative Medications
Purpose: is for the patient comfort and reduced risk of
complications
Types:
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
SURGERY CAN and WILL BE DELAYED IF NOT COMPLETED =
unhappy surgeon
This is a safety tool for Peri-operative team and the scrub
nurse should review it
Preoperative Checklist
Assessment
Preoperative medications
IV
Preoperative preparations
Chart
Signatures
Intraoperative
Includes the entire surgical procedure until transfer of the
patient to the recovery area

Surgical Team
Anesthesiologist
Anesthetist
Surgeon
Surgical assistants
Scrub nurse
Circulating nurse

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

Regional

Local

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
sedation
Surgical Asepsis
Possible Intraoperative Complications
Infection
Fluid volume excess or deficit
Injury related to positioning
Hypothermia
Malignant Hyperthermia

Postoperative
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
PACU or RECOVERY ROOM
Recovery Position
Side-lying position is used until the patient is awake from anesthesia
Positioning
Semi-Fowlers position is usually used after a patient is awake from
anesthesia
Initial Postoperative Assessment
Airway patency
Circulatory status
Wound / Dressing condition
Fluid balance
LOC
Pain
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.
Pain
Thefastest-acting route for pain medication is parenteral
administration
Postoperative Complications
Hemorrhage
Shock
Hypoxia
Aspiration

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


Respiration
Reinforce deep breathing
Prevent atelectasis
Circulation
BP
Syncope
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
Ambulates
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
Analgesics
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
Redness
Warmth
Swelling
Tenderness
Discoloration
Drainage

Wound Complications
Most likely 7-10 days after surgery
Dehiscence
Evisceration

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

Later Postoperative Assessments


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

Later Postoperative Assessments


Urinary Elimination
Voids8 hours after surgery
Catheter
Psychosocial Care
Opportunity to verbalize
Counseling
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
Diagnoses: