1. Perioperative Nursing & Teaching
Carol J. McFadyen, RN, PhD
Modified by Sarah Jean Cooper RN, MN

2. Objectives – Student will be able to
Describe legal requirements for informed consent
Identify risk factors for surgery
Identify assessments and care needed for surgical client
Identify factors to consider in developing a teaching plan
Discuss the operative process

3. Objective 1: Concept of Perioperative Nursing
Covers all aspects of surgical care
Preoperative -Preparation for surgery
Intraoperative -Surgery and recovery from anesthesia
Postoperative-Recovery from surgery to discharge
Surgery = invasive procedure
Perioperative covers all areas
most areas different nurses in each area
requires coordination and good communication

4. Perioperative Nursing
Surgery classified by setting, urgency
Table 49-1, p shows classifications
Usually ambulatory and elective
Goal = provision of safe, effective care
Most will be ambulatory and elective
Some areas client admitted preop and preparation completed
transferred to OR and return to unit after PACU

5. Objective 2: Informed Consent
Legal Requirement for invasive procedure (Figure 17-1 in “Iggy”shows example)
Surgeon provides information
Benefits
Risks
Alternatives
Others only witness signature
Notify surgeon if client confused or needs more information
Informed means client is able to understand and has sufficient info to make a decision.
Info often provided in office when decision for surgery made
Form may be signed in office or upon admit
note area for surgeon’s signature
Assure client understands what is to happen
Notify surgeon if client appears unclear or has additional questions
In general, do not provide information. May be found to invalidate consent

6. Informed Consent Special Considerations Client with dementia Minors
Implied Consent
Life threatening
Telephone
Does not speak English
Person with power of Attorney (POA) may sign
Difficult if no POA and client confused at times
Other family members may be consulted
Parents must sign for minors unless life threatening
child, even adolescent, can agree to surgery but not consent
Implied consent = measures taken to save life in emergency
document efforts to reach family members
Telephone consent requires two witnesses
both listen on telephone and identify selves to consenter
Use interpreter if does not speak English
best if understand medical terms and are not member of family
students may be asked to serve in this capacity

7. Objective 3: Preparation of Client for Surgery- Assessment
Health History
Screening for Risk Factors
Obtaining base line information
Physical Examination (Table 49-7 p1217)
Identify fears and concerns
Any alteration in physiologic status
Increase risk of complications either intraoperative or post operative
infection
anesthesia complications
metabolism and excretion of drugs

8. Risk Factors Table 49-3, 49-4, p. 1214 Aging
Increases risk of other diseases
Medical Conditions
Respiratory and Cardiac most critical
Medication Use
List all medications used by client
Table , p. 1214
Adverse reactions and interactions

9. Nursing Diagnosis Anxiety Use therapeutic communication to elicit
Listen for experience with unusual occurrence
Explain common occurrences and procedures
Use a calm, unhurried approach
Form often used
Watch carefully for nonverbal cues to information
expand if abnormal data obtained.
Assess for non verbal cues to anxiety
Recognize that most people are anxious but level varies
if anxiety high, use short simple statements that are to the point
young child fears separation from parents
induction of anesthesia may be started with parents present, security object may go to surgery
Physical may be completed by physician
Assess for condition that may interfere during surgery
joint problems, skin condition
previous unexpected occurrences in surgery for client or others

10. Nursing Diagnosis Anticipatory Grieving Knowledge Deficit
Listen for unusual concerns
Knowledge Deficit
Assess what client knows by asking him to describe what he has been told and what previous surgical experiences he has had
Form often used
Watch carefully for nonverbal cues to information
expand if abnormal data obtained.
Assess for non verbal cues to anxiety
Recognize that most people are anxious but level varies
if anxiety high, use short simple statements that are to the point
Anticipatory grieving also common
fear of dying or changes in body image
young child fears separation from parents
induction of anesthesia may be started with parents present, security object may go to surgery
Physical may be completed by physician
Assess for condition that may interfere during surgery
joint problems, skin condition
previous unexpected occurrences in surgery for client or others

11. Preoperative Preparation
Laboratory/Diagnostic Studies - Box 49-2, p. 1218
Complete Blood Count (CBC)
Hemoglobin and hematocrit (Hgb & Hct) – oxygen carrying capacity
White blood cell count (WBC) – infection
Clotting capacity
Prothrombin (PT) or partial thromboplastin time (PTT)
Urinalysis – bladder & kidney
Not all completed for every surgery
May be completed prior to admit
nurses role = assure reports are on chart prior to review by anesthesiologist
review – notify surgeon if abnormal

12. Preoperative Preparation
Laboratory and diagnostic studies (cont.)
Chest X-ray
Respiratory status
Electrocardiogram
Cardiac function
Fasting Glucose Level
Diabetic
Chest X-ray if concerns re: problems
EKG often completed if client over age 50 to R/O cardiac problems
Fasting blood glucose or glucoscan for diabetic
other care for diabetic discussed during diabetic section

13. Preoperative Physical Preparation
NPO after midnight or for specific period
Inform client and remove pitcher
Post sign on door
Skin preparation
Shower with antibacterial soap
Shaving controversial (usually done in pre-op area)
Additional cleansing for some
Remove contact lenses, glasses, jewelry
Void prior to preoperative medications
Instruct client to increase fluids day prior to surgery if possible
Child NPO for less time depending on age
infant may be NPO for 4 hours
Shaving increase risk of skin infection due to microscopic breaks in skin
May use depilatory agent
Put valuables in safe place where they can be found
leave hearing aid in place until anesthesia begun

14. Preoperative Documentation
Preoperative Checklist (Box 49-4, p.1224, Figure p 258 in “Iggy”
Assessment & Vital Signs
Informed consent
Reports of diagnostic/laboratory tests
Medications given that AM
Procedures completed
Checklist used to assure all common procedures and needed documentation completed
nurse responsible for completing checklist
Determine if scheduled medications should be given am of surgery
oral with sip of water
Foley usually inserted in surgery after induction of anesthesia

15. Objective 4: Develop a plan for providing age appropriate pre-operative teaching
Prevention is an important nursing role and function
Early discharge to home requires client/family to possess knowledge for self-care management
Client has a right to receive understandable information

16. Age Appropriate Teaching Nrsg Dx = Knowledge Deficit
Common Learning Needs–Knowledge re:
Events and sensations perioperatively
Use language client understands and can comprehend
Pain Management
Availability
Physical Exercises and importance of completing
Turn, deep breathing, leg exercises
Describe preoperative preparation and diagnostic testing
Time teaching to appropriate time for child
toddler-preschool = right before surgery
school age adolescent = when surgery scheduled
Avoid term sleep – preschool may fear going to sleep
discuss “special sleep”
Books or printed materials helpful
Explaining reason for activities elicits client cooperation
assure will have adequate pain relief to complete activities
Do Not indicate will be pain free -

17. Factors Affecting Client Teaching
Literacy level & Language spoken
Reading level
Level of Education
Health knowledge & Beliefs
Age & Developmental level
Adult education
Self directed – motivation
Practical, purposeful – readiness to learn
What is education level of person
What is occupation?

18. Factors that Inhibit Learning (Barriers)
Pain, fatigue
Acute illness
Self image, perception
Timing/environmental issues
Cultural issues
Language client does not understand (jargon,spoken language, perceptual issues)

19. Teaching Plan –Outcome Oriented
First assess current knowledge level
Learning Objectives – describes the intended result of learning
Performance, what will the client be able to do?
Condition, when will the client be able to do?
Criterion, how well will the client perform

20. Teaching Methods Active participation important One on One
Discussion – keep it simple
Printed materials
AV presentations
Demonstration
Role playing – works well with children
One on One
Group teaching
Formal Class or Informal opportunity

21. Evaluation of Learning/Documentation
Measurable criteria
Client must do something to document learning
“Identify symptoms to report”
“Describe cause of disease and prognosis”
“Return demonstration of skill/procedure”
Documentation
Specifics of what was taught
What client knows or can do

22. Teaching Activity Checklist
Perform Needs Assessment
Identify special needs
Determine preferred learning style
Establish readiness to learn
Establish priorities
Identify goal
Compose measurable objectives

23. Teaching Activity Checklist
Determine method of presentation
Identify required materials
Formulate plan
Control distracting environmental factors
Establish a caring, concerned atmosphere
Evaluate effectiveness of teaching. Was stated outcome achieved?

24. Group Activity
Meet in groups of 4-5 and identify one pre-operative or post-operative teaching need.
Identify how you would assess?
Write a measurable goal/outcome.
Develop a plan for teaching. Include content (what will be taught) and method
State how you will know that learning has taken place

25. Objective 5: Discuss Medications administered during the Perioperative Period
Sedatives/hypnotics
Anticholinergics
H2 anatagonists
Antiemetics
Analgesics

26. Sedatives/Hypnotics (Barbiturates & Benzodiazepines)
Action: Depresses the CNS
TE: Relief of anxiety,sedation,amnesia
Potentiate action of opiod analgesics
Interventions:
Monitor vital signs especially Respiratory rate and BP
Evaluate : reduction in anxiety, drowsiness/resting
Examples: Valium, Ativan, Phenergan
Antidote is Flumazenil - Romazicon

27. Anticholenergics
Action: Inhibits action of acetylchloline at postganglionic sites located in smooth muscle, secretory glands, and the CNS
TE: Decreases GI & Respiratory secretions (prevents aspiration during surgery)
Interventions: Monitor Monitor VS, I&O and urinary output (may cause retention)
Evaluation: Decreased secretions in OR, client has dry mouth
Examples: Robinul, Atropine

28. Antiulcer Agents -H2 Antagonists
Action: Inhibits gastric acid secretion
TE: Decreased secretion of gastric acid
Interventions: Monitor for complaints of epigastric pain, in elderly watch for confusion, several drug interactions, timing of drug is important
Evaluation: decreased epigastric pain after eating
Examples: Ranitidine, Famotidine,Cimetidine

29. Antiemetics (Phenothiazines)
Action:Depresses the chemoreceptor trigger zone in the CNS
TE: Diminished nausea a & vomiting
Interventions: Give deep IM, slowly. Assess VS and for drowsiness. May cause decreased BP on standing
Evaluation: Decreased nausea and vomiting

30. Antiemetics – Reglan (Metoclopaminde)
Action:Blocks dopamine receptors in chemoreceptor trigger zone of the CNS. Stimulates motility of upper GI tract and gastric emptying
TE: Decreased nausea & vomiting
Interventions: Give before meals (30min) monitor for excessive drowsiness, extrapyramidal symptoms
Evaluation: decreased nausea and/or vomiting

31. Opiod analgesics (may be combined with ASA or Tylenol)
Action:Bind to CNS receptors. Alters perception of and response to painful stimuli while producing generalized CNS depression
TE: Decrease in severity of moderate pain
Interventions: Assess VS (P&R), level of sedation, Administer on regular basis for best pain relief. Give before pain becomes severe. Constipation is frequent side effect
Evaluation: Relief of pain (<3/10)
Examples: Lortab, Vicodin, Percodan,Perocet

32. Objective 6: Describe the role of team members during surgery
Team members (Figure 18-5,6 in Iggy)
Sterile = wear gown, gloves plus cap, mask
Surgeon – Responsible for client during surgery
Assistant – may be specially trained registered nurse
Scrub Technician – passes instruments, monitors sterility
Unsterile = wears cap and mask
Circulating Nurse – coordinates care (Figure 18-3 shows)
Anesthesiologist/CRNA = Monitors client status
Sterile members of team complete surgical scrub (see pictures for examples)
don sterile gown, gloves in room
scrub tech may be in room preparing prior to your entrance
DO NOT touch tables or objects covered in blue
Circulating nurse = RN, coordinates care, advocates for client, gets needed supplies, documents events, counts sponges instruments with scrub nurse and documents
follow circulating nurses directions re: where to stand

33. Objective 7: Health Promotion and Prevention during Surgery
Risk for Perioperative positioning injury
Figure 49-7, p shows positions
Loss of pain sensation
Pad pressure points
Avoid pressure on nerves
Assess skin integrity before and after
Maintain anatomic position of joints
Involuntary movements may increase stress
Need to be particularly conscious of elderly or emaciated client
client may need to be in position for extended period
prolonged pressure on nerves can lead to permanent damage to nerves
Use belts to stabilize extremities, particularly arms

34. Measures to Maintain Health-Intraoperative Care
Risk for Injury
Falls
Side rails up
Belts
Teach to not get up post medication
Burns
Proper grounding of equipment
Retained foreign objects
Accurate sponge counts
Client may be awake but unsteady on feet or have diminished judgement
Loss of protective pain reflex places client at risk
All team members responsible to monitor instruments and
circulating nurse and scrub nurse count sponges and needles prior to surgery and at times during surgery. Count must agree.

35. Intraoperative Care- Measures to Maintain Health
Risk for Infection
Caps, mask, clothing
Skin Preparation
Draping
Surgical asepsis maintained
All personnel have responsibility to reduce risk
put on mask prior to entering operating room
cap to cover all hair
Skin preparation = responsibility of circulating nurse
needs to be aware of skin allergies
Avoid touching any areas that are draped (blue in color)
Surgical scrub gowns, gloves, and sterile instruments
anything below waist and on back considered unsterile

36. Types of Anesthesia
General -Medication given by Intravenous or inhalation routes
Can be used for all ages and surgeries
Intravenous for Induction
May be given in SDS for young child
Agents rapidly excreted and action reversed
Causes cardiac and respiratory depression
Keep noise to a minimum during induction
Circulating nurse assists anesthesiologist with induction and intubation
Client returns to consciousness through same stages
may lead to respiratory arrest or larnygospasm
monitor client closely after removal of ET tube and until awake and responsive
Figure 18-9, p. 270 shows ET tube in place

37. Types of Anesthesia
Anesthesia = partial or complete loss of sensation with or without loss of consciousness
Local –used for small areas – infiltration or topical
Regional – several types
Medication instilled around or into the nerves blocks nerve transmission (Figure 49-2, p. 1212)
Client awake during procedure, does not perceive pain
Disadvantages = hypotension, spinal headache
Local = suturing lacerations, some dental
no monitoring due to lack of systemic effect
Regional requires anesthesiologist to initiate
CRNA may monitor
client must be able to cooperate so not for child or confused
May be used for client with respiratory or cardiac problems
can not be used for thoracic or cardiac surgery
Hypotension lessened by hydration or vasoconstrictors
vessels dilate in area under anesthesia
Headache due to leakage of spinal fluid
may do blood patch

38. Intraoperative Care Types of Anesthesia Concious Sedation
Used for diagnostic procedures
Medication given by IV push
Midazolan hydrochloride (Versed)
Meperidine given for analgesia
Nurse monitors client
Airway, vital signs, O2 Saturation
Client sleepy but arouses
Does not remember details of procedure
Will review conscious sedation next quarter
used for endoscopy
also used in ER

39. Four Phases of Anesthesia (See Table 18-2, p 270 “Iggy”)
Stage 1 Induction to loss of consciousness – vulnerable to noise
Stage 2 Excitement -starts with loss of consciousness and ends with loss of eyelid reflex – vulnerable to noise & injury
Stage 3 Operative – relaxation to loss of hearing, sensation to pain lost
Stage 4 Extreme depression of functions leads to death if not reversed
Stage 1 – be quiet, do not talk over client, can overstimulate and make process unpleasant and dangerous

40. Anesthetic Agents (Table 18-3 & 18-4 p271-72 “Iggy”
Agents used are dependent on client’s physical condition and nature of surgery(Length of procedure, age of client etc)
PACU & OR RN’s must be knowledgeable about side effects of each agent used in anesthesia in order to protect the client and assist in recovery
A balance of agents are used to induce relaxation, analgesia, amnesia etc.

41. Objective 8: Describe Assessments to Identify and Respond to Potential Anesthesia Complications (PACU)
Monitored by PACU RN
Airway, may have laryngospasm when extubated
Vital Signs
LOC – respond to command or stimuli
Bleeding
Pain
Vital signs, particularly BP, P closely monitored(may use automatic monitor ) may also use EKG monitor
First hour after surgery = critical period for return to normal physiologic status – assessments every 5 to 15 minutes and documented
may use form
Airway priority till extubated and normal respiratory rate established
may need reminders to breath or to breath deeply
Discharge from PACU when meet criteria
usually stable VS, arouseable or awake, gag – swallow present, pain control

42. Objective 9: Develop a nursing care plan to restore health for the post surgical client
Postoperative assessment for Complications
Impaired Gas Exchange/Ineffective Breathing Pattern
Risk for Infection
Fluid Volume Deficit
Alteration in Nutrition:Less than body requirements (nausea & vomiting, NPO)
Alteration in Elimination
Pain
Altered Tissue Perfusion
Risk for injury/Body Image Disturbance
Review nursing process handout

43. Focused Assessment of Post-operative Client
Immediate post-op client on unit
Airway (patent, O2??, breath sounds Resp)
Cardiovascular (BP, Pulse & Temp)
LOC (establish)
Dressings, Tubes/drains (check)
IV fluids/status (rate, solution, site)
Skin Integrity & positioning (condition)
Comfort Level (pain, nausea, last med)
Safety – side rails, call light
New orders
Frequent checks q 15 min x1 hour then q 30 min x2-hours, then q 1 hr times 4 hours, then q 4 hours
Report from PACU RN
Read notes – blood loss, fluids in OR, length of surgery/anesthetic, problems??

44. Focused Post Surgery Shift Assessment Activity
Form into groups of 4-5
Draw a picture of assigned client or problem
Identify assessments and rationale for assessments for the client
Identify interventions/rationale to prevent complications, promote health
Report to class

45. Postoperative Care Special Considerations Elderly
Recovery slower
Interventions to prevent complications need to be scrupulous
May be more sensitive to medications
Confusion
Respiratory depression
Monitor closely for post op infection
Need to pay particular attention to respiratory status
encourage/ insist on deep breathing, coughing and use of incentive spirometer to set level q1h
ambulate when ordered
Monitor for confusion and respiratory depression with pain meds
Immune system function slower and decreased
UTI if foley inserted

46. Postoperative Care Special Considerations – Children
Use of FACES scale for assessment of pain
Watch for non verbal behaviors indicating pain in younger
Medicate prior to painful procedures
Encourage parents to stay with child/assist with care
Be sure security objects available
Illness/hospitalization may result in < coping
Provide age appropriate diversion
Explain procedures to child in age appropriate terms
Prepare child if procedure hurts
Praise for accomplishments
Children usually recover rapidly
Younger children often unable to verbalize pain until acute
play can be used to work through feelings particularly for preschool
Behaviors indicating Developmental level may decrease with hospitalization or illness
Toddler/preschooler right before procedure
can cry or yell but need to help by holding still
restraint = helping child to hold still
reinforce often that painful procedures are not punishment
Praise child for what they did accomplish