1. Timby/Smith: Introductory Medical-Surgical Nursing, 10/e
Chapter 14: Peri-Operative Care

2. Preoperative Care
Surgery, no matter how minor, causes stress and poses risks for complication
Many variables, such as the procedure performed, age of the client and co- existing medical conditions determine the care a client needs before, during and after surgery

3. Perioperative Care Introduction Describes entire span of surgery
Three phases: Preoperative, intra- operative, and postoperative
REVIEW:
Reasons for Surgery: Table 14-1 pg 145
Categories for Surgery: Table 14-2 pg 145

4. Perioperative Care Preoperative Care
Client’s immediate preoperative needs
REVIEW: Preoperative Assessment, Box pg 146
Preparation for surgery
Assessment:
*Urgency of the surgery: if not emergency, perform H&P
*Risk for complications: Table 14-3 pg 147
*Review preoperative instructions

5. Question
Is the following statement true or false?
There are three phases to the perioperative process.

6. Answer
True.
There are three phases to the perioperative process: Preoperative, Intraoperative, and Postoperative phases.

7. Preoperative Care
Non-emergency surgery: Perform history and physical examination; Assess client’s understanding, postoperative expectations, and ability to participate in recovery
Client’s: Cultural needs, privacy, and presence of family members; Feelings related to disposal of body parts and blood transfusions
Emergency surgical procedures

8. Preoperative Care Surgical Consent (pg 146) Necessary
Invasive procedures; Anesthesia
Sign before preoperative medications; Adult witness to signature
Purpose: Client understands procedural risks and benefits
Family member or guardian may sign consent form; Agency policies

9. Question
Is the following statement true or false?
The proper time to get a client’s signature on a surgical consent is prior to administration of preoperative medications.

10. Answer
True.
The proper time to get a client’s signature on a surgical consent is prior to administration of preoperative medications. After the medication has been administered, the client is considered “under the influence” and not legally competent to sign legal papers.

11. Preoperative Teaching
Preoperative period:
Surgery procedure expectations – Pre/Post Op
Clients are alert and free of pain
Better participation in recovery
Instruct at client’s comprehension level
Preoperative medications: Purpose; Effects
Postoperative pain control
Describe postanesthesia recovery room

12. Preoperative Teaching
Preoperative Period (Cont’d)
Discuss monitoring equipment; Assessment frequency
Explain, demonstrate: Cough and deep breathing; Leg exercises
Instruct re: IV fluids; Tubes
Provide explanations: Help alleviate client anxieties, fears
Preoperative Preparation
Includes physical, psychosocial preparation
REVIEW: Gerontologic Considerations, pg 148

13. Preoperative Preparation
Physical Preparation, pg
Skin preparation: Decrease bacteria; Maintain skin integrity
Elimination: Insert indwelling urinary catheter; Cleansing enema or laxative prn
Food, fluids: Restrictions before surgery; Nutrients for healing process
Care of valuables; Eyeglasses, contacts
Denture removal; Other prosthetics

14. Preoperative Preparation
Physical Preparation (Cont’d)
Preoperative Medications, pg 149
Anticholinergics
Antianxiolytics
Histamine-2 receptor antagonists
Narcotics
Sedatives; Tranquilizers
REVIEW: Drug Therapy Table 14-1, pg 150
Nursing Process for Preoperative Care, pg

15. Preoperative Preparation
Preoperative Medications
Before administering, check
Client ID bracelet; Drug allergies
Review medication effects
Post-administration instructions
Measure vital signs; Client to void
Confirm surgical consent signature

16. Preoperative Preparation
Psychosocial Preparation, pg 149
Emotionally; Spiritually
Begin when surgery scheduled
Preoperative teaching, listening, and explaining: Reduces fear and anxiety
Anxious clients: Poor surgical response; Prone to complications
Assess methods for coping; Religious faith

17. Preoperative Checklist
Record all necessary information
Checklist
Assessment; Preoperative medications
IV; Preoperative preparations; Chart
Other information; All signature(s)
Universal protocol: Right client has the right procedure at the right site; REFER to Box 14-3, pg 151

18. Intraoperative Care Begins: Client on operating table
Surgical team responsible for client’s care
Anesthesia
General, regional, or local anesthesia
Procedural sedation: Ambulatory surgery
General Anesthesia: Produces loss of sensation, reflexes, and consciousness
Administration

19. Intraoperative Care General Anesthesia (Cont’d)
Four stages: Induction; Excitement; Surgical anesthesia; Medullary depression (to be avoided)
Induction: Dizziness; Detachment; Temporary heightened sense of awareness; Unable to move extremities
Airway: Secured with endotracheal tube

20. Intraoperative Care General Anesthesia (Cont’d)
Excitement: Uncontrolled movements
Prevention: Anesthesia administration
Surgical anesthesia: Client unconscious
Medullary depression: Excessive anesthesia; Death can occur
Shallow respirations; Weak pulse; Pupils widely dilated, unresponsive to light
Closely monitor client

21. Question
Is the following statement true or false?
Medullary depression is the state of general anesthesia with the most effective drug effects.

22. Answer
False.
Medullary depression is a dangerous condition of excessive anesthesia which should be avoided at all times.

23. Intraoperative Care Regional Anesthesia: Client remains conscious
Blocks conduction of specific nerve impulses
Loss of sensation; Decreased mobility
Types of regional anesthesia: Local; Spinal; Conduction blocks
Advantage: Less risk for complications
Monitor: Allergic reactions; Vital sign changes; Toxic reactions
Protect anesthetized areas
REVIEW: Table 14-4 pg 152

24. Ambulatory Care Introduction Outpatient Settings Ambulatory Surgery
Same day, outpatient surgery
Increase in the number of ambulatory surgical procedures: Advances in surgical techniques; Methods of anesthesia; Changes in Medicare provisions
Criteria for ambulatory surgery
REVIEW: Gerontologic Considerations, pg 153

25. Ambulatory Care
Procedural Sedation, pg 153
Outpatient diagnostic, short therapeutic procedures: Clients sedated - not unconscious
Sedation; Analgesia; Procedural sedation
Presedation evaluation
History of adverse reactions to sedatives?
Age and weight

26. Ambulatory Care
Procedural Sedation, con’t pg 153
Sedative Medications
Assess effects; Side effects
Reversal drugs
REVIEW: Drug Therapy Table , pg 154

27. Ambulatory Care Procedural Sedation (Cont’d)
Three Phases of Sedation Process
Monitor: Adverse effects; Complications of procedure; Late sedation
Discharge and Teaching
Determining stability of client condition
Discharge instructions

28. Surgical Team
Anesthesiologist or anesthetist; Surgeon; Assistants; Intraoperative nurses
Anesthesiologist Responsibilities
Administer anesthesia; Monitor client
Assess client pre-op; Write preoperative medication orders; Inform client of anesthesia options; Explain surgical risks
Anesthetists: Not sterile member of surgical team

29. Surgical Team Anesthetist Responsibilities
Medical doctor; Dentist; CRNA: Administers limited types of anesthesia
Anesthesiologist (physician) supervises the anesthetist
Surgeon Responsibilities
Determines the surgical procedure required; Obtains client consent; Performs procedure; Follow-ups

30. Surgical Team Intraoperative Nurses Scrub Nurse and Circulating Nurse
Scrub nurse responsibilities: Handing instruments to surgeon and assistants; Prepare sutures; Receive specimens; Count sponges, needles
Circulating nurse responsibilities: Obtain, open wrapped sterile equipment; Supply equipment before, during surgery; Keep records; Adjust lights

31. Operating Room Environment
Isolated; Restricted access
Filtered air; Positive pressure maintained
Three designated zones: Unrestricted zone; Semi-restricted zone; Restricted zone
Efficient design; Stainless steel furniture
Temperature < 70ºF
Specific OR attire: Decreases microbial growth
REVIEW: Box 14-5 Operating Rm Attire, pg 155

32. Nursing Management, Intraoperative
Routine tasks performed
Other factors: Type of surgery; Anesthesia; Client age; Condition; Complications
Asepsis in the OR; Surgical asepsis: Prevents surgical wound contamination
Maintain client safety, protection during surgery
Assessment of client: Vital signs; LOC; Physical condition; Catheters, tubes
REVIEW: Stop, Think, Respond 14-2, pg 155

33. Postoperative Care, pg 157 Immediate Postoperative Period
Client safety; Critical considerations; Observation, monitoring
Initial assessment
Respiratory status; circulatory status, intake and output, LOC, and pain
Major responsibility: Client’s PACU stay
Prevent potential post-op complications
Hemorrhage; Shock; Hypoxia; Aspiration (pg )
REVIEW: Gerontologic Considerations, pg 157

34. Postoperative Care REVIEW: Aldrete Scale, Table 14-5 pg 157
Later Postoperative Period
Begins: Client arrival in hospital room
Ongoing assessments (pg ):
a) Respiration
b) Circulation
c) Pain Management
d) Fluids & Nutrition
e) Skin Integrity & Wound Healing
f) Activity
g) Bowel & Urinary Elimination

35. Postoperative Care Potential Postoperative Complications
Respiratory: atelectasis, pneumonia, pulmonary embolism, aspiration
Cardiovascular: shock, thrombophlebitis
Urinary: acute urine retention, urinary tract infection
Neurologic: delirium, stroke
Gastrointestinal: constipation, paralytic ileus, bowel obstruction
Functional: weakness, fatigue, functional decline
Wound: infection, dehiscence, evisceration, delayed healing, hemorrhage, hematoma
REVIEW: Box 14-8, pg 164

37. Postoperative Care
Fig pg 160

38. Postoperative Care
Fig pg 161

39. Postoperative Care
A. Dehiscence
B. Evisceration
Fig pg 162

40. Postoperative Care Postoperative Care con’t Client and Family Teaching
REVIEW: Nursing Guideline 14-1, pg 159
REVIEW: Nutrition Notes 14-1, pg 160
Client and Family Teaching
Explain prescribed treatment regimen
REVIEW: Client & Family Teaching 14-1 pg 163
REVIEW: Client & Family Teaching 14-2 pg 164
Determine specific client needs: Supervised home care; Supplies; Dietary needs; DME

41. REVIEW: Standards of Care, pg 165 - 167
Postoperative Care
Nursing Management
REVIEW: Standards of Care, pg

42. End Of Chapter