1. Preoperative and Postoperative Care
Chapter 56:
Preoperative and Postoperative Care

2. Perioperative Care
The time span that includes preparation for, the process of, and recovery from surgery
Three phases of perioperative nursing care
**Preoperative: before surgery
Intraoperative: in operating room (OR), post- anesthesia recovery (PAR), or post-anesthesia care unit (PACU)
Postoperative: after surgery

3. Factors in Surgery: Settings
Types of surgery settings
Acute-care facility
Walk-in or ambulatory center

4. Types of Surgery *Optional/elective Tubal ligation or vasectomy
Required/nonelective
Urgent/nonelective
Emergency

5. Nursing Considerations
Examples
Fear
Deficient Knowledge
Anticipatory Grieving
Disturbed Body Image
Risk for Aspiration
Ineffective Airway Clearance
Pain

6. Nursing Considerations
Examples, cont.
Hyperthermia
Hypothermia
Altered Tissue Perfusion (cerebral, peripheral)
Deficient Fluid Volume
Impaired Tissue Integrity
Impaired Skin Integrity
Impaired Physical Mobility

7. Factors to Address when assessing clients for surgical risk
*Weight and eating disorders
Age
Lifestyle factors
Pre-existing physical disorders
Physical activity status

8. Nursing Interventions Common to all Surgical Procedures
Providing emotional support
*previous surgeries may alter his/her response to surgery
Preparing client physically for surgery
Ensuring legal matters are carried out
Ensuring preoperative tests completed
Teaching
Providing routine preoperative and postoperative care

10. Sedation Minimal Moderate Depressed level of consciousness Deep
Conscious sedation

11. Anesthesia Anesthesia The complete or partial loss of sensation
Anesthetics
Medications that induce anesthesia
Anesthesiology
Discipline of medicine that administers anesthetics

12. Anesthesia, cont. Anesthesiologist
A physician trained in anesthesiology
Nurse anesthetist
Registered nurse trained in anesthesiology

13. Periop care in the older adult
Box 56-1
*Watch for unexpected side effects to medications. Older clients may have a greater than expected reaction to medications, may react more quickly, or may react differently than expected

14. In Practice: Caring for the Client Who Is Receiving Anesthesia
Refer to Nursing Care Guidelines 56-1.
Make sure client is wearing an ID band and has been carefully identified by at least two staff persons!!
Check for allergies
Note any abnormal lab test results
After surgery using spinal anesthetics, keep the client flat until the anesthetic has worn off
Observe for spinal headache, respiratory depression and movement of extremities
Postop check all v/s, including pain, frequently as ordered, report any deviations
observe carefully for signs of respiratory distress following use of neuromuscular blockers or any type of general anesthetic

15. Types of Anesthetics *General anesthetics
Used to block all body sensations
Administered
Intravenously
Rectally
By inhalation
*LOCAL
*disrupts sensation to specific body area or parts without causing unconsciousness

16. Types of Anesthetics, cont.
Regional anesthesia: Injection of anesthesia around nerves to prevent sending pain signals to brain
Spinal anesthesia: Injection of anesthesia into the subarachnoid space of the spinal cord
2nd lumbar vertebrae
Loss of feeling and movement in lower extremities, lower abdomen and perineum
Keep the client flat until the anesthetic has worn off (spinal headache)
Observe for respiratory distress
Conduction blocks: Injection of anesthesia into or near a nerve trunk

17. Stages of General Anesthesia
Analgesia/amnesia
Reflexes present, HR normal, RR slower
Dreams and excitement
Active reflexes, tachycardia, irregular breathing, increased BP, pupils dilated and divergent
Surgical anesthesia
Four planes, ranging from light to deep
Third or fourth plane best for most types of surgery
Toxic or extreme medullary depression
No reflexes, weak pulse

18. Key Concept
The client under general anesthesia is completely dependent on others; he or she cannot control the most basic of body functions, including breathing and maintenance of a patent airway.
This person must be observed and monitored carefully at all times by specially trained anesthesia personnel.

19. Preoperative Nursing Care
Orders written by surgeon or anesthesiologist
Teach client to carry out orders exactly
*make sure they can see/hear; could interfere with teaching
Provide emotional support
*keep the heirarchy of basic human needs, in mind
*consider needs-oxygen, food, water, elimination, sleep

20. Nursing Alert
*In most instances, the client is instructed to stop taking
Aspirin
Ibuprofen (Motrin, Advil)
Other NSAIDs
Herbal supplements*
These include camomile, cat’s claw, feverfew, garlic, ginger, ginkgo, ginseng, goldenseal, grape seed extract, green tea leaf, horse chestnut seed, and turmeric.
For at least 7-14 days before surgery to reduce the risk of excessive bleeding**

21. In Practice: Organizing Preoperative Nursing Care
Refer to Nursing Care Guidelines 56-2.
* **Be sure the client has signed the operative permit and it has been witnessed
Preop care on area undergoing surgery
Surgical preparation and shave is usually done in the OR*
*V/S for baseline
Ensure all specimens have been collected & sent to lab (usually done day before surgery)
*Assist the client to void immediately before going to the OR
*surgeon and client mark operative site
**NPO, 8 hours before surgery
Decreases risk for aspiration

22. Nursing Alert
**Be sure the client has signed the operative permit before giving give any pre-sedation medications.
The client is not considered to be responsible after being medicated and cannot legally sign the operative permit.
If the permit is not signed before medication is given, the surgery would most likely need to be postponed.
Obtaining the client’s permission for surgery is the responsibility of the surgeon; the nurse double-checks to make sure this had been done.
Remember the concept of informed consent—the client must understand what is being done and why.
The client must be able to verbalize the type of surgery being done, and this statement must agree with the records and consent forms.
If surgery must be cancelled for an error, such as the inappropriate or incorrect signing of the operative permit, this is considered a sentinel event and must be reported and investigated.

23. Key Concept Each step in preoperative preparation has a purpose.
If any steps are omitted, the client’s safety becomes jeopardized.
The client will perform many of these steps at home, when being admitted on the day of surgery.
It is the nurse’s responsibility to interview the client to make sure all steps in the preoperative preparation have been completed.
*remember Maslows heirarchy of needs!!

24. Teaching the Client When preparing the client *Organize teaching.
*Explain procedures.
*Demonstrate for the client.
**Client and/or family returns demonstration
To alleviate surgical fears:
ask client to discuss info known about surgery**

25. Key Concept
If a client will be on a ventilator or otherwise unable to speak after surgery, make arrangements for a communication system.
Allow the client to practice this system preoperatively.
Preoperative teaching is vital because clients go home so soon after surgery.
Explain to the client and family where the family lounge is located. Make sure they know where to find food, coffee or soda, newspapers, computer access, and telephones.
Suggest they bring along something to do while waiting.

26. Assessments
Observation
Physical examination and laboratory tests

27. Preparation Skin preparation Intestinal preparation shave –if ordered
scrub- if ordered
do not shave scalps or cut hair-may be done in OR
Reduces risk for infection
Intestinal preparation
Enemas
Go-lightely po
NPO 8-10 hrs. prior to surgery

28. Key Concept
The client may be asked to self-administer a small- volume enema or drink a liquid cathartic at home, if the admission to the healthcare facility is on the day of surgery.
The client may need instruction in the use of the enema or the cathartic.
Encourage the client and reassure that he or she will be able to do the procedure.
Be sure the client has an escort if same-day surgery is being done.

29. Preoperative Medications
Four types of preoperative medications
Sedatives
Usually ordered in the evening before surgery
One time order, helps stabilize BP and pulse
Antibiotics
Narcotics
*Given to relax the client and to enhance the anesthesia’s effects
*Drying agents
Atropine (may cause urinary retention)
Route: Orally-make sure they can swallow

30. Preoperative Medications in practice 56-1
Atropine
Inform client about a dry mouth, relieve with moistened cloth, ice chips, sips of water and hard candy
Report if dry mouth does not gradually resolve

31. Key Concept
Before giving any preoperative medications, make sure the client does not have any drug allergies and that the surgical permit has been signed, witnessed, and is on the client’s chart or electronic record.
Make sure the client is wearing an allergy band, whether or not an allergy exists.
In addition, make sure the client is wearing one or two facility ID ands and that all information is correct.
Be sure to offer a bedpan or urinal to the client immediately before he or she is taken to the operating suite. The client should not get up to the bathroom at that time.

32. Nursing Alert
To prevent errors, always be certain that the client is properly identified before transfer to the OR.
No client should be allowed to go to the OR without an identification bracelet! This would cause the surgery to be cancelled. Some hospitals require an ID bracelet on both of the client’s wrists.
The client must also be wearing an allergy band, stating existing allergies or stating that the client has no known allergies.
If the client is a fall risk, a fall risk ID band is worn as well. Blood ID bands (two) also must be worn if the client will receive blood transfusions.
*The ID band of the client going to surgery must be checked by at least two people and verified by the client/family

33. Intraoperative Nursing Care
Assistants
Two basic categories of assistant
Sterile assistant, aka scrub nurse, OR technician
Circulating nurse
“TIME OUT”*
allows surgical team to verbally verify their agreement about clients name, surgical procedure and site

34. Post-anesthesia Care Unit (PACU) or Post-anesthesia Recovery Area (PAR)
Articles that may be needed for care are located near the client’s unit in the PACU
*specific monitoring includes the basic ABC’s of life- airway, breathing and circulation (defib)
Drugs
Narcotics
Sedatives
Drugs for emergency situations

35. PACU or PAR, cont. Articles that may be needed, cont. Other supplies
Surgical dressings
Sandbags
Warmed blankets
Extra pillows
Various other items

36. Transport Client transport to surgery Moving the client to the PACU
Moving the client to the floor/unit

37. Nursing Alert
Leave no client alone until he or she has fully regained consciousness.
Check the physician’s orders and carry them out immediately.

38. Immediate Postoperative Complications
Observe the client postoperatively for immediate complications, for example
Hemorrhage
Shock
*most dangerous is circulatory or hypovolemic shock
Hypoxia
hypothermia

40. Hypovolemic shock-monitor for jugular vein distention
Signs of Shock
Hypovolemic shock-monitor for jugular vein distention

41. Shock Call for help. Control hemorrhage.
*Position the client flat with his or her feet elevated, unless contraindicated (modified/reverse Trendelenburg position-head down & feet up)
Administer oxygen, as ordered.
Administer blood, plasma, or other parenteral fluids as ordered.
Anticipate that the physician may order vasopressor medications.
Observe the client very closely.

42. Hypoxia (Hypoxemia) Reduction of oxygen in the tissues
Measure oxygen saturation using a pulse oximeter
Keep oxygen and suction equipment readily available for emergency use

43. Hypothermia Low body temperature
Signs and symptoms of postoperative hypothermia
Temperature below 97.5° Fahrenheit (36.4° Celsius) rectally
Shivering and “goose flesh” unrelieved by warm blankets
Client complains of being extremely cold
Confusion, disorientation, difficulty with speech

44. **Postoperative Discomforts
Pain
Thirst
Abdominal distention
Nausea
Urinary retention-min 30ml/hr, must void within 8 hours after surgery!!!!!!
Constipation-d/t handling of the intestines during surgery
Restlessness and sleeplessness

45. Key Concept
If a client complains of distention or “gas pains,” do not give ice or allow the client to take fluid through a drinking straw.
Rationale: These actions tend to add air to the bowel and increase gas.
The postoperative client may be permitted to take a sitz bath, a warm shower, or a warm tub bath.
This often facilitates voiding and defecation.

46. In Practice: Important Medications for Postoperative Care
Refer to Important Medications 56-2.

47. Postop Complication Respiratory and circulatory complications
GET OOB Day 1 (usually)
Remember: Steroids delay wound healing!!

48. Respiratory Complications
Pneumonia
Hypostatic-caused by immobility, lying on the back
Inflammation of or accumulation of fluid in the lung
Pneumonectomy- turn on that side and back only
*Atelectasis
Collapse of air sacs in the lungs usually caused by mucus plugs that close the bronchi and may involve all or part of the lung
S/s: cyanosis, RR and P increase, dyspnea, pain!
*O2 sat, set alarm for continuous monitoring

49. Respiratory Complications, cont.
Prevention of respiratory complications
Respiratory exercises
Treatments
**Turning, coughing, and deep breathing (TCDB)
Take a deep breath-hold for 2-5 seconds
Do a double cough with mouth open
Chest percussion

50. Respiratory Complications, cont.
*Splinting
Grasp pillow or blanket and stretch it across the incision
Sit upright and take deep breaths prior to coughing
Use of a pillow or large towel to provide support along a suture line

51. Nursing care guideline 56-3
*Incentive spirometer
A device used to promote full inflation and oxygenation of the lungs
Forces the client to concentrate on inspirations while providing immediate feedback, aids deep breathing
1. position upright
2. repeat 8-10 times each time this is used
3. instruct the client to repeat coughing or huffing after using the spirometer
4. breath in and out forcefully when using the spirometer

52. Circulatory Complications
Thrombophlebitis
*Formation of a blood clot in a vein, with inflammation
*Assessment
Flex foot up toward knee (dorsiflexion) with the leg straight
Pain behind knee on dorsiflexion known as positive Homans’ sign, indicating probable thrombophlebitis

53. Circulatory Complications, cont.
Instruct client to remain in bed, report finding immediately
Supportive measures
Elevate affected part.
Ted hose
Anticoagulants as directed
Avoid rubbing—may dislodge clot
Apply warmth as directed.
Rare cases, client maintained on strict bed rest

54. Embolus (Plural: Emboli)
Piece of a clot or thrombus that breaks off and enters the person’s circulatory system, usually obstructing the blood flow in a smaller vessel
Signs/symptoms dependent on location
Severe pain
Nausea and vomiting
Severe shock

55. Embolus (Plural: Emboli), cont.
*Pulmonary embolism
Life-threatening—lodged in the small vessels of the lung
Signs/symptoms
Difficult breathing
Sharp chest pain
Cough
Can be rapidly fatal
*ambulate soon after surgery!!
Cyanosis
Rapid respirations and heart rate
Severe anxiety

56. Embolus (Plural: Emboli), cont.
Embolisms often treated with immediate administration of medications that dissolve existing blood clots, thrombolytic agents
Examples
Alteplase (Activase)
Streptokinase (Streptase)
Urokinase (Abbokinase)

57. Embolus (Plural: Emboli), cont.
Avoiding circulatory disorders
Elastic stockings, elastic roller bandages, or antiembolytic (TED) stockings
Sequential circulation devices (SCDs)
Leg exercises every 2 hours
Complete range-of-motion exercises every shift
Ambulation as soon as possible after surgery

58. Other Postoperative Complications
Infection
Temp elevation 2-3 days after surgery, severe pain, redness or swelling around an incision, purulent drainage or increased WBC count
If temp goes up hours after surgery-the infection is RESPIRATORY!

59. Dehiscence and Evisceration
The splitting open or separation of the surgical incision
Evisceration
Incision opens enough so that abdominal organs (viscera) protrude
COVER PROTRUDING PARTS WITH STERILE LARGE ABDOMINAL PADS THAT ARE MOISTENED WITH STERILE SALINE!!

61. Compartmental Syndrome
Compression of nerves and blood vessels which lead to impaired blood flow and muscle and nerve damage
Caused by swelling in a compartment (inside each layer of fascia)
S/s: severe pain without response to pain meds or elevation
Tx: surgery-long incision into fascia to release building pressure, wounds are left open, may need skin grafts

62. Additional Supportive Measures
Providing adequate nutrition
Obese-may have ineffective tissue perfusion s/p surgery
Diabetes
Underweight
Vomiting
Assist with menu selection

63. Key Concept
In many cases, a nutritional drink, such as Boost or Ensure, is given with meals after surgery, to supplement solid foods.
Many clients find that they are able to drink, even if it is difficult to take solids.

64. Additional Supportive Measures
Irrigating wounds
Changing dressings
*Surgeon usually does the first dressing
Reinforcing dressings
Removing sutures and staples
Sutures = stitches
Thread used to hold an incision together while it heals

65. Additional Supportive Measures, cont.
Providing IV therapy
Venous access lock
Catheter used to maintain an open route to a client’s venous system to give fluids and/or medications
Removal or discontinuance of the venous access lock is the same as for an IV.