1. Interventions for Preoperative Clients
Francisco Felix

2. Perioperative Nursing Definition of Surgery
Surgery is any procedure performed on the human body that uses instruments to alter tissue or organ integrity.

3. Purposes of Surgery Diagnostic Curative Restorative
Palliative surgery, which makes the client more comfortable
Cosmetic surgery, which reconstructs the skin and underlying structures
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4. Perioperative Nursing Types of Surgery
Degree of urgency – necessity to preserve the client’s life, body part, or body function.
Degree of risk – involved in surgical procedure is affected by the client’s age, general health, nutritional status, use of medications, and mental status.
Extent of surgery – Simple and radical

5. Perioperative Nursing Types of Surgery (Urgency)
Emergency- performed immediately to preserve function or the life of the client.
Elective – is performed when surgical intervention is the preferred treatment for a condition that is not imminently life threatening or to improve the client’s life.
Urgent – Necessary for client’ health to prevent additional problem from developing; not necessarily an emergency.
Required – has to be performed at some point; can be pre-scheduled.

6. Perioperative Nursing Type of Surgery (Degree of Risk)
Major – involves a high degree of risk.
Minor – normally involves little risk.
Age – very young and elder clients are greater surgical risks than children and adult.
General health- surgery is least risky when the client’s general health is good.
Nutritional Status – required for normal tissue repair.
Medications – regular use of certain medications can increase surgical risk.
Mental status – disorder that affect cognitive function

7. Perioperative Nursing Surgical settings
Surgical suites
Ambulatory care setting
Clinics
Physician offices
Community setting
Homes

8. Perioperative Nursing Surgical settings
Disadvantages Less time for rapport Less time to assess, evaluation, teach Risk of potential complication post D/C.
Advantages of outpatient: Low cost Low risk of infection Less interruption of routine Less than from work Less stress

9. Collaborative Management Assessment
History and data collection
Age
Drugs and substance use
Medical history, including cardiac and pulmonary histories
Previous surgery and anesthesia
Blood donations
Discharge planning

10. Physical Assessment/Clinical Manifestations
Obtain baseline vital signs.
Focus on problem areas identified by the client’s history on all body systems affected by the surgical procedure.
Report any abnormal assessment findings to the surgeon and to anesthesiology personnel.
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11. System Assessment Cardiovascular system Respiratory system
Renal/urinary system
Neurologic system
Musculoskeletal system
Nutritional status
Psychosocial assessment
Gerontological Considerations

12. Preoperative Nursing Care Psychosocial considerations
Level of anxiety
Coping ability
Support systems

13. Preoperative Nursing Care Gerontological Considerations
Cardiovascular Coronary flow decreases Heart rate decreases Response to stress decreases Peripheral vascular decreases Cardiac output decreases Cardiac reserve decreases

14. Preoperative Nursing Care Gerontological Considerations
Respiratory System
Static lung volumes decreases
Pulmonary static recoil decreases
Sensitivity of the airway receptors decreases
Nervous system
Increased incidence of post.op. confusion.
Increased incidence of delirium
Increased sensitivity to anesthetic agents

15. Preoperative Nursing Care Gerontological Considerations
Renal System Renal blood flow declines 1.5% per year. Renal clearance reduced
Gastrointestinal Decreased intestinal motility
Decreased liver blood flow Delayed gastric emptying

16. Preoperative Nursing Care Gerontological Considerations
Musculoskeletal Decreased mass, tone, strength Decreased bone density
Integumentary Decreased elasticity Decreased lean body mass Decreased subcutaneous fat

17. Laboratory Assessment
Urinalysis
Blood type and crossmatch
Complete blood count or hemoglobin level and hematocrit
Clotting studies
Electrolyte levels
Serum creatinine level
Pregnancy test
Chest x-ray examination
Electrocardiogram

18. Preoperative Nursing Consent
Nature and intention of the surgery
Name and qualifications of the person performing the surgery.
Risks, including tissue damage, disfigurement, or even death
Chances of success
Possible alternative measures
The right of the client to refuse consent or later withdraw consent.

19. Deficient Knowledge Interventions
Informed consent
The surgeon is responsible for obtaining signed consent before sedation is given and surgery is performed.
The nurse’s role is to clarify facts presented by the physician and dispel myths that the client or family may have about surgery.

20. Implementing Dietary Restrictions
Client is given nothing by mouth (NPO) for 6 to 8 hours before surgery.
NPO status decreases the risk for aspiration.
Failure to adhere can result in cancellation of surgery or increase the risk for aspiration during or after surgery.
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21. Administering Regularly Scheduled Medications
Consult the medical physician and anesthesia provider for instructions about drugs, such as those taken for diabetes, cardiac disease, glaucoma, regularly scheduled anticonvulsants, antihypertensives, anticoagulants, antidepressants, or corticosteroids.

22. Intestinal Preparation
Bowel or intestinal preparations are performed to prevent injury to the colon and to reduce the number of intestinal bacteria.
Enema or laxative may be ordered by the physician.

23. Skin Preparation
The skin is the body’s first line of defense against infection; a break in the barrier increases the risk for infection.
Shower using antiseptic solution.
Shaving as a procedure before surgery is viewed as controversial.

24. Preparing the Client
Possible placement of tubes, drains, and vascular access devices
Teaching about postoperative procedures and exercises:
Breathing exercises, incentive spirometry, coughing and splinting
(Continued)

25. Preparing the Client (Continued)
Leg procedures and exercises, antiembolism stockings and elastic wraps, early ambulation, and range-of-motion exercises

26. Anxiety Interventions
Preoperative teaching
Encouraging communication
Promoting rest
Using distraction
Teaching family and significant others

27. Preoperative Nursing Care Anxiety
The nurse must consider the pt’s family and friends when planning psychological support.
Empowering their sense of control. Activities that decreasing anxiety are deep breathing, relaxation exercises, music therapy, massage and animal-assisted therapy.
Use of medication to relieve anxiety.

28. Preoperative Chart Review
Ensure all documentation, preoperative procedures, and orders are complete.
Check the surgical consent form and others for completeness.
Document allergies.
Document height and weight.
(Continued)

29. Preoperative Chart Review (Continued)
Ensure results of all laboratory and diagnostic tests are on the chart.
Document and report any abnormal results.
Report special needs and concerns.

30. Preop Client Prep
Client should remove most clothing and wear a hospital gown.
Valuables should remain with family member or be locked up.
Tape rings in place if they can’t be removed.
Remove all pierced jewelry.
(Continued)

31. Preop Client Prep (Continued)
Client wears an identification band.
Dentures, prosthetic devices, hearing aids, contact lenses, fingernail polish, and artificial nails must be removed.

32. Preoperative Medication
Reduce anxiety.
Promote relaxation.
Reduce pharyngeal secretions.
Prevent laryngospasm.
Inhibit gastric secretion.
Decrease amount of anesthetic needed for induction and maintenance of anesthesia.

33. Preoperative Nursing Care Medications
Sedatives/hypnotics- Nembutal
Tranquilizers-Ativan, versed, valium
Opiate analgesics- Demerol, morphine
Anticholinergics-Atropine sulfate,atarax
H2o blockers.- Tagamet, Zantac
Antiemetic- Reglan, Phenergan

35. Preoperative Nursing Care Preanesthesia Management Physical Status Categories
ASA 1: Healthy patient with no disease
ASA 11: Mild systemic ds without fx limitations
ASA 111:Severe systemic ds associated with definite fx limitations
ASA 1V: Severe systemic ds that is a constant threat to life.
ASA V: Moribund pt. Who is not expected to survive without the operation.
ASA V1: A declared brain-death whose organ are being recovered for donor.
E: Emergency

36. Members of the Surgical Team
Surgeon
Surgical assistant
Anesthesiologist
Certified registered nurse anesthetist
Holding area nurse
Circulating nurse
Scrub nurse
Surgical technologist
Operating room technician

37. Perioperative Nursing Care Surgical team
Nursing Roles:
Staff education
Client/family teaching
Support and reassurance
Advocacy
Control of the environment
Provision of resources
Maintenance of asepsis
Monitoring of physiologic and psychological status

38. Environment of the Operating Room
Preparation of the surgical suite and team safety
Layout
Health and hygiene of the surgical team
Surgical attire
Surgical scrub

39. Intraoperative Nursing Care Surgical asepsis
Ensure sterility
Alert for breaks

40. Intraoperative Phase Anesthesia
Greek word- anesthesis, meaning “negative sensation.” Artificially induced state of partial or total loss of sensation, occurring with or without consciousness.
Blocks transmission of nerve impulses
Suppress reflexes
Promotes muscle relaxation
Controlled level of unconsciousness

41. Anesthesia
Induced state of partial or total loss of sensation, occurring with or without loss of consciousness
Used to block nerve impulse transmission, suppress reflexes, promote muscle relaxation, and, in some instances, achieve a controlled level of unconsciousness
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42. General Anesthesia
Reversible loss of consciousness is induced by inhibiting neuronal impulses in several areas of the central nervous system.
State can be achieved by a single agent or a combination of agents.
Central nervous system is depressed, resulting in analgesia, amnesia, and unconsciousness, with loss of muscle tone and reflexes.
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43. Stages of General Anesthesia
Stage 1: analgesia
Stage 2: excitement
Stage 3: operative
Stage 4: danger

44. Administration of General Anesthesia
Inhalation: intake and excretion of anesthetic gas or vapor to the lungs through a mask
Intravenous injection: barbiturates, ketamine, and propofol through the blood
Adjuncts to general anesthetic agents: hypnotics, opioid analgesics, neuromuscular blocking agents

45. Balanced Anesthesia
Combination of intravenous drugs and inhalation agents used to obtain specific effects
Combination used to provide hypnosis, amnesia, analgesia, muscle relaxation, and reduced reflexes with minimal disturbance of physiologic function
(Continued)

46. Balanced Anesthesia (Continued)
Example: thiopental for induction, nitrous oxide for amnesia, morphine for analgesia, and pancuronium for muscle relaxation

47. Complications from General Anesthesia
Malignant hyperthermia: possible treatment with dantrolene
Overdose
Unrecognized hypoventilation
Complications of specific anesthetic agents
Complications of intubation
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48. Local or Regional Anesthesia
Sensory nerve impulse transmission from a specific body area or region is briefly disrupted.
Motor function may be affected.
Client remains conscious and able to follow instructions.
Gag and cough reflexes remain intact.
Sedatives, opioid analgesics, or hypnotics are often used as supplements to reduce anxiety.
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49. Local Anesthesia Topical anesthesia Local infiltration
Regional anesthesia
Field block
Nerve block
Spinal anesthesia
Epidural anesthesia

50. Complications of Local or Regional Anesthesia
Anaphylaxis
Incorrect delivery technique
Systemic absorption
Overdosage
(Continued)

51. Complications of Local or Regional Anesthesia (Continued)
Assess for central nervous system stimulation, central nervous system and cardiac depression, restlessness, excitement, incoherent speech, headache, blurred vision, metallic taste, nausea and vomiting, tremors, seizures, increased pulse, respirations, and blood pressure.

52. Treatment of Complications
Establish an open airway.
Give oxygen.
Notify the surgeon.
Fast-acting barbiturate is usual treatment.
If toxic reaction is untreated, unconsciousness, hypotension, apnea, cardiac arrest, and death may result.

53. Conscious Sedation
IV delivery of sedative, hypnotic, and opioid drugs reduces the level of consciousness but allows the client to maintain a patent airway and to respond to verbal commands.
Diazepam, midazolam, meperidine, fentanyl, alfentanil, and morphine sulphate are the most commonly used drugs.
(Continued)

54. Conscious Sedation (Continued)
Nursing assessment of airway, level of consciousness, oxygen saturation, electrocardiographic status, and vital signs are monitored every 15 to 30 minutes.

55. Collaborative Management
Assessment
Medical record review
Allergies and previous reactions to anesthesia or transfusions
Autologous blood transfusion
Laboratory and diagnostic test results
Medical history and physical examination findings

56. Risk for Perioperative Positioning Injury
Interventions include:
Proper body position
Risk for pressure ulcer formation
Prevention of obstruction of circulation, respiration, and nerve conduction

57. Impaired Skin Integrity and Impaired Tissue Integrity
Interventions include:
Plastic adhesive drape
Skin closures, sutures and staples, nonabsorbable sutures
Insertion of drains
Application of dressing
Transfer of client from the operating room table to a stretcher

58. Potential for Hypoventilation
Continuous monitoring of:
Breathing
Circulation
Cardiac rhythms
Blood pressure and heart rate
Continuous presence of an anesthesia provider

59. Interventions for Postoperative Clients
Francisco Felix

60. PACU Recovery Room
Purpose is to provide ongoing evaluation and stabilization of clients to anticipate, prevent, and treat complications after surgery.
PACU is usually located close to the surgical suite.
The PACU nurse is skilled in the care of clients with multiple medical and surgical problems that can occur following a surgical procedure.
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61. Collaborative Management
Assessment
Physical assessment and clinical manifestations
Assess respiration.
Examine surgical area for bleeding
Monitor vital signs.
Assess for readiness to discharge once criteria have been met.

62. Respiratory System Airway assessment Breath sounds
Other respiratory assessments

63. Cardiovascular Assessment
Vital signs
Cardiac monitoring
Peripheral vascular assessment

64. Neurologic System Cerebral functioning
Motor and sensory assessment important after epidural or spinal anesthesia
Motor function: simple commands; client to move extremities
Return of sympathetic nervous system tone: gradually elevate head and monitor for hypotension

65. Fluid, Electrolyte, and Acid-Base Balance
Check fluid and electrolyte balance.
Make hydration assessment.
Intravenous fluid intake should be recorded.
Assess acid-base balance.
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66. Renal/Urinary System
The effects of drugs, anesthetic agents, or manipulation during surgery can cause urine retention.
Assess for bladder distention.
Consider other sources of output such as sweat, vomitus, or diarrhea stools.
Report a urine output of < 30 mL/hr.

67. Gastrointestinal System
Nausea and vomiting are common reactions after surgery.
Peristalsis may be delayed because of long anesthesia time, the amount of bowel handling during surgery, and opioid analgesic use.
Clients who have abdominal surgery often have decreased peristalsis for at least 24 hours.

68. Nasogastric Tube Drainage
Tube may be inserted during surgery to decompress and drain the stomach, to promote gastrointestinal rest, to allow the lower gastrointestinal tract to heal, to provide an enteral feeding route, to monitor any gastric bleeding, and to prevent intestinal obstruction.
(Continued)

69. Nasogastric Tube Drainage (Continued)
Assess drained material every 8 hours.
Do not move or irrigate the tube after gastric surgery without an order from the surgeon.
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70. Skin Assessment Normal wound healing
Ineffective wound healing: can be seen most often between the 5th and 10th days after surgery
Dehiscence: a partial or complete separation of the outer wound layers, sometimes described as a “splitting open of the wound.”
(Continued)
S&P

71. Skin Assessment (Continued)
Evisceration: a total separation of all wound layers and protrusion of internal organs through the open wound.
Dressings and drains, including casts and plastic bandages, must be assessed for bleeding or other drainage on admission to the PACU and hourly thereafter.

73. Postoperative Phase

74. Discomfort/Pain Assessment
Client almost always has pain or discomfort after surgery.
Pain assessment is started by the postanesthesia care unit nurse.
Pain usually reaches its peak the second day after surgery, when the client is more awake, more active, and the anesthetic agents and drugs given during surgery have been excreted.

75. Impaired Gas Exchange Interventions include: Airway maintenance
Positioning the client in a side-lying position or turning his or her head to the side to prevent aspiration
Encouraging breathing exercises
Encouraging mobilization as soon as possible to help remove secretions and promote lung expansion
S&P

76. Impaired Skin Integrity
Interventions include:
Nursing assessment of the surgical area
Dressings: first dressing change usually performed by surgeon
Drains: provide an exit route for air, blood, and bile as well as help prevent deep infections and abscess formation during healing
(Continued)
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77. Impaired Skin Integrity (Continued)
Drug therapy including antibiotics and irrigations are used to treat wound infection.
Surgical management is required for wound opening.

78. Acute Pain Interventions include: Drug therapy
Complementary and alternative therapies such as:
Positioning
Massage
Relaxation and diversion techniques

79. Potential for Hypoxemia
Interventions include:
Maintenance of airway patency and breathing pattern
Prevention of hypothermia
Maintenance of oxygen therapy as prescribed

80. Health Teaching Prevention of infection Dressing care Nutrition
Pain medication management
Progressive increase in activity level
Use of proper body mechanics
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