Chapter two

perioperative care
Learning objectives
• Define the three phases of perioperative management.
• Explain principle of surgical asepsis
• Demonstrate the nursing tasks required to manage the patient in the
preoperative phase.
• Identify roles of operating room team members.
• Identify different patient operative position.
• Discuss post-operative nursing management post-operative complication.

Definitions
Surgery It Is the use of instruments during an operation to treat injuries,
diseases, and deformities
Perioperative nursing:
All nursing function associated with the patient surgical experience.
Perioperative; incorporates the three phases of the surgical experience which
include :- .Preoperative, Intraoperative and Postoperative.
1-Preoperative phase: begins when the decision for surgical intervention is
made and ends with the transfer of the patient to operating room table.
2-Intraoperative phase: begins when the patient is admitted or transferred to
the operating room and end when he is admitted to the recovery area.
3-Postoperative phase; begins with admission of the patient to the recovery
area and end with follow up evaluation in clinical sitting
CLASSIFICATION OF SURGERY
Surgical procedures are classified according to
• Urgency .
• Purpose .
• Extent
• Risk factors are also taken into consideration.

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ACCORDING TO URGENCY

• Emergent: Patient requires immediate attention to maintain life, disorder

may be life threatening. e.g., sever bleeding, gunshot, skull fracture.
• Urgent/ Imperative: Patient requires prompt attention within 24 – 30/48
hours. e.g acute gallbladder infection.
• Required/ Planned: Patient needs to have surgery; plan within a few
weeks or months. e.g., thyroid disorder, cataract.
• Elective: Patient should have surgery, failure to have surgery not
catastrophic, planned/scheduled with no time requirements. e.g., repaired
of scare, simple hernia.
• Optional: Decision rests with patient at the preference of patient. e.g.,
cosmetic surgery.
ACCORDING TO PURPOSE

• Aesthetic: Requested by patient for improvement.

• Diagnostic: To obtain tissue samples, make an incision, or use a scope to
make a diagnosis. e.g., biopsy.
• Exploratory: Confirmation or measurement of extent of condition.
• Preventive: Removal of tissue before it causes a problem.
• Curative (Ablative): Removal of diseased or abnormal tissue. e.g
exclusion of tumor or an inflamed appendix.
• Reconstructive: Correction of defects of body parts
• Palliative: to relieve pain or correct problems.
ACCORDING TO EXTENT

• Major: Extensive surgery that involves serious risk and complications, as

it involves major organ such as heart.
• Minor - Involves minimal complications & blood loss

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Risk factors are also taken into consideration.

1- Nutritional and Fluid Status

• Patient have obesity, weight loss, malnutrition, deficiencies in specific
nutrients, metabolic abnormalities high risk for surgical complication.
Nutritional deficiency should be corrected before surgery.
• Nutrients important for wound healing are: protein, carbohydrates and
fats, water, vitamin C, vitamin B complex, vitamin A, vitamin K,
magnesium, copper, zinc
2-Hypovolemia, dehydration or electrolyte imbalance.
3-Infection and sepsis
4-Toxic conditions.
5 -immunological abnormalities.
6-Drug or Alcohol Use
7 -Age: very young people and elderly patient.
8 -Presence of disease such as pulmonary disease, cardiovascular disease
(hypertension) endocrine (DM) and Pregnancy.
9-Concurrent or prior pharmacotherapy: Medication history for Example,
should be stop aspirin 7-10 days before surgery.
preoperative Phase

Pre-Operative Nursing Management:

a. Assessment:

[Link] Assessment and Care because the patient has fears from
anesthesia, pain, death, fear of disturbance on Body image. etc.
2 .Physiologic nursing assessment: Personal data such as (age, sex), presence of
pain, nutritional status (obesity or malnutrition), fluid and electrolyte balance ,
presence of infection and any disease.

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Nursing diagnosis:

• Anxiety related to fear of the unknown or surgical experience (anesthesia,

pain) and outcome of surgery.
• Knowledge deficit regarding preoperative procedure.
Patient out come:

• Relieve anxiety and increase knowledge regarding procedure and include

in surgical regimen.
Nursing preparation:

• Explain procedure to the patient about surgery.

• Explain all nursing care and any possible discomfort to promote faster
recovery
• Allow the patient ask any question about surgery and answer it.
• Introduce the person who undergoing the major surgery to the patient
who have successfully recovered from these operations.
Legal aspect:

• Any one undergoing surgery must sign an operative permit to protect the
patient from unwanted surgical procedure and protect the health care staff
from legal action.
• Defined as written informed consent (permission obtained from a patient
to perform a specific test or procedure) should be taken before surgery
Physiologic aspect:
Before the date of surgery:
• Correct any dietary deficiencies.
• Reduce an obsess person weight
• Correct fluid and electrolyte imbalance.
• Restore adequate blood volume with blood transfusion.
• Treat chronic disease

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 • Cure infectious disease
• Ensuring that necessary tests have been or will be performed such as liver
function, blood glucose level, ECG, X-ray, Blood grouping and matching,
PT, PTT etc.
Pre-operative teaching

• Instructing and demonstrating exercises that will benefits the person

during postoperative period such as deep breathing, coughing to promote
optimal lung expansion and respiratory function.
• turning and moving, foot and leg exercise to improve circulation and
prevent venous stasis.
• Planning for discharge and any projected changes in lifestyle due to
surgery
Preparing the Person Before Surgery
Preparing the skin :
• Have full bath to reduce microorganisms in the skin without injury the
skin and shaved hair from area of surgery.
Preparing the GI tract
• NPO after midnight; cleansing enema as required if the patient
undergoing abdominal or pelvis surgery .
Preparing for anesthesia
• Visit done by anesthetist complete respiratory, neurological and
cardiovascular examination
• Avoid alcohol and cigarette smoking for at least 24 hours before surgery.
Promoting rest and sleep
Measures to reduce preoperative sleeplessness and restlessness include:
• A well – ventilated room.
• Comfortable, clean bed.
• Back rub.

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 • Warm fluid (if the fluid is not contraindication)
• Administer sedatives as ordered on the night before surgery.
Preparing the Person on the Day of Surgery
• Early morning care
• Awaken one hour before preoperative medications
• Morning bath, mouth wash
• Provide clean gown
• Remove hairpins, link long hairs, cover hair with cap.
• Remove dentures, foreign materials (chewing gum), colored nail polish,
hearing aid, contact lens
• Take baseline vital signs before preoperative medication
• Check ID band and skin preparation
• Check for special orders – enema, GI tube insertion, IV line
• Check NPO
• Have client void before preoperative medication.
• Continue to support emotionally.
• Accomplish “preoperative care checklist.”
Pre operation checklist day of surgery
• Preoperative Medications/ Pre anesthetic Drugs such as:
• Narcotics such as: Morphine sulfate and Meperidine (Demerol)
• Analgesia; enhancement of postoperative pain relief
• Antianxiety and sedative hypnotics such as Diazepam (Valium) is
Sedation and anxiety reduction.
• Antiemetic: such as (Zofran): to Control nausea and vomiting; may be
effective into the postoperative period
• H2 antagonist: such as Ranitidine (Zantac)
• And Famotidine (Pepcid(
• To Reduction of acidic gastric secretions in case aspiration occurs.

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 • Antibiotic: such as Cefazolin and Ampicillin. to prevent the postoperative
infection.
• Anticholinergic: such as Atropine sulfate
• lead to Secretion reduction
Intraoperative Phase

Begins when the client is transferred onto the OR table and ends with admission
to the recovery room.
Nursing activities during intraoperative include :
• Providing safety and maintaining an aseptic environment
• Ensure proper functioning of equipment
• Providing the surgeon with specific instruments and supplies for the
surgical field.
• Proper documentation
The Surgical Team
• Patient
• Surgeon
• assistance surgeon
• scrub nurse
• circulatory nurse
• anesthesiologist
The circulating nurse: protects the patient’s safety and health by
1. Monitoring the activities of the surgical team.
2. Checking the OR conditions
3. Continually assessing the patient for signs of injury and implementing
appropriate interventions.
4. Monitors aseptic practices to avoid breaks in technique.

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 5. verifying consent, coordinating the team, and ensuring cleanliness, proper
temperature, humidity, lighting, safe function of equipment, and the
availability of supplies and materials.
6. Arranges sterile and non-sterile equipment and open sterile equipment to
scrub nurse.
7. Sends for client at proper time.
8. Confirms the client allergies.
9. Checks medical record for completeness.
[Link] the patient on the room table in accordance with type of
operation.
[Link] sponge, needle and instruments with scrub nurse before surgery
Role Of the Scrub Nurse:
1. Performs a surgical hand scrub and wear sterile gown and gloves.
2. Setting up the sterile tables and maintain sterile field
3. Prepares sutures, ligatures, and special equipment.
4. Assist with surgical draping of the client.
5. Observe progress of surgical procedure
6. Hands surgeon instrument, sponges and necessary supplies during
procedure.
7. The scrub nurse and the circulatory nurse count all needles, sponges and
instruments to ensure not retained as foreign body in the patient.
Important positions During Surgery
• Dorsal Recumbent: for hernia repair, mastectomy, bowel resection
• Trendelenburg: for lower abdomen, pelvic surgeries.
• Lithotomy: for vaginal repairs, D and C, rectal surgery
• Prone: for spinal surgeries, laminectomy
• Lateral: for kidney, chest, hip surgeries

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Potential adverse effect of surgery and anesthesia to the patient
1. Allergic reaction.
2. Cardiac dysrhythmia from adverse effect of anesthetic agents.
3. Stress response is elicited
4. Central nervous system agitation, seizures and respiratory arrest.
5. Defense against infection is lowered
6. Organ functions are disturbed
7. Body image may be disturbed
8. Lifestyles may change
Principles Of Surgical Asepsis
1. Moisture causes contamination because microorganism travel more easily
through moist environment.
2. Never assume that an object is sterile should be ensure that it is labeled as
sterile.
3. Always face the sterile field because objects that are out of the line of
vision may be accidently contaminated.
4. Sterile articles may touch only sterile articles or surfaces because
anything considered unsterile transfer microorganisms to the sterile object
it touches
5. Sterile equipment or areas must be kept above the waist and on top of the
sterile field .
6. Prevent unnecessary traffic and air currents around the sterile area.
7. Open, unused sterile articles are no longer sterile after the procedure.
8. A person who is considered sterile who becomes contaminated must
reestablish sterility.
9. surgical technique is a team effort

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 Anesthesia

is a state of narcosis (sever central nervous system depression produced by

pharmacological agent)
Types of Anesthesia
General, Regional, Epidural, Local.
Potential intraoperative complication
• Nausea and vomiting.
• Anaphylaxis: occurs when the patient contact with foreign substance.
• Hypoxia and other respiratory complication.
• Hypothermia; during anesthesia, the patient temperature may fall.
Glucose metabolism is reduced and as a result, metabolic acidosis.
• Malignant hyperthermia: is rare inherited muscle disorder that is
chemically induced by anesthetic agent.
Postoperative Phase
Extends from the time the client is admitted to the recovery room, to the time he
is transported back into the surgical unit, discharged from the hospital, until the
follow-up care.
Goals:
• Maintain adequate body system functions
• Restore homeostasis
• Alleviate pain and discomfort
• Prevent postoperative complications
• Ensure adequate discharge planning and teaching
Admission to post anesthesia care unit (PACU)
Goal:
• To promote safe recovery from anesthesia
• Administer oxygen by nasal cannula or mask as ordered

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 • Continuous monitoring is done for ECG, pulse oximetry, and bp
measurements
• Assess surgical site and dressing
• Check for patency of catheter, drains and tubes
• Measure vital signs every 5 to 15 minutes
• Provide warming blanket.
Phases of post anesthesia care unite (PACU)
• In phase I PACU: used during immediate recovery phase, intensive
nursing care is provided.
• In phase II PACU: the patient is prepared for self-care or care in the
hospital or an extended care setting.
• In phase III PACU: the patient prepared for discharged.
• Post anesthetic care (phase I)
The nurse who admits patient to the post anesthetic care unit (PACU)
Nursing management in the post anesthesia care unit
Systematic assessment is essential during the post-operative period to detect
quickly any complications and to individualize nursing care that promote
optimal recovery from the surgery.
Assessment in the immediate postoperative period (phase I PACU): -
1-Respiratory assessment- :
• Check airway potency and monitor respiratory rate and depth.
• Auscultate breath sound. inspect skin color.
• Observe chest expansion.
2-Cardiac assessment- :
• Monitor blood pressure and heart rate and rhythm at least every 15 min. the
first hour, every 30 min. the next 2 hours, every hour for 4 hrs, and finally,
every 4 hrs for the first 24 hrs assess EC.G.

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3 -Neuralgic assessment- :
• Check papillary response.
• Monitor muscle strength to determine muscle relaxant reversal.
4 -surgical site assessment- :
• Monitor for drainage (color, amount, and consistency(
• Observe for hemorrhage or hematoma formation.
5-Pain management- :
• -Assess for both subjective and objective and objective manifestations
of pain.
• Administer analgesics as prescribed.
6-Renal function assessment- :
• Monitor amounts of urinary output for clients with indwelling catheter (at
least 30 ml/hr)
• For clients without a urinary catheter, palpate and per cuss for bladder
distension or scan with portable bladder ultrasound.
7-Intravenous fluids- :
• Asses type amount of solution, flow rate, security and potency of tubing,
and infusion site.
Phase II: Nursing intervention the immediate post-operative period: -
1-Ensure maintenance of patent airway and adequate respiratory function
through:
• Lateral position with neck extended (recovery position)
• Keep airway in place until fully awake
• Suction secretions
• Encourage deep breathing
• Administer humidified oxygen as ordered

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2 .Maintaining cardiovascular stability through:
Manifestations
• Apprehension, restlessness, thirst, cold, moist, pale skin
• Deep rapid respiration, low body temperature
• Low blood pressure, low hemoglobin
• Progressive weakness.
Management: Check vital signs
• Administering I V fluids, blood and blood products and medication that
elevate blood pressure.
• Administer oxygen therapy.
• Administer Vitamin K as ordered
• Pressure dressings
3 .Relieving pain and anxiety :
• Monitor physiological status .
• Manage pain and discomfort by administer opioid administer by IV.
• Provides psychological support to relieve the patient fears and anxiety.
4 .Controlling nausea and vomiting.
• a. The nurse should administer antiemetic drugs at the patient first report
of nausea to control the problems
• Determined readiness for discharge from PACU to surgical unit
according to
Parameters for Discharge from Recovery Room to surgical word which
include:
• Activity: able to move spontaneously or on commands.
• Respiration: ability to breathe deeply and cough.
• Circulation: BP is within +/-20 mmHg of the preop level.
• Consciousness: fully awake and responsive.
• O2 saturation: Able to maintain o2 sat more than 95 % on room air.

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Phases III: Preparing the postoperative patient for direct discharge:
2-3 days after surgery (discharge planning/teaching) about:
• Self-care activities
• Activity limitation or introlence
• Diet and medications
• Complications
• Referrals, follow-up check up
Postoperative Complications
1 -Femoral phlebitis/ deep thrombophlebitis
Manifestations
• Pain, Redness, Swelling, Heat/warmth, Positive Homan’s sign.
Nursing Interventions (prevention)
• Hydrate adequately to prevent hemoconcentration
• Encourage leg exercises and ambulate early
• Avoid any restricting devices that can constrict and impair circulation
Nursing Interventions (Active)
• Bed rest, elevate the affected leg with pillow support
• Wear ant embolic support hose from the toes to the groin
• Avoid massage on the calf of the leg
• Initiate anticoagulant therapy as ordered
2-Pulmonary complications such as atelectasis, bronchitis, bronchopneumonia
and lobar pneumonia.
Nursing Interventions
• Reinforce deep breathing, coughing, and turning exercises to enhance the
respiratory function.
• Encourage early ambulation
• use Incentive spirometry

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3-Intestinal obstruction
Manifestations
• Intermittent, sharp, colicky abdominal pains
• Nausea and vomiting
• Abdominal distention
• Diarrhea (incomplete obstruction), no bowel movement (complete)
• Return flow of enema is clear.
Nursing Interventions
• NGT insertion
• Administer electrolyte/ IV as ordered
• Prepare for possible surgical intervention
4- Wound infections
Causes
• Staphylococcus aureus, E- coli ,Anaerobic bacteria.
Clinical manifestations
• Redness, swelling, pain, warmth
• Pus or other discharge on the wound
• Foul smell from the wound
• Elevated temperature; chills and Tender lymph nodes
• Rule of thumb to determined infection:
• Fever within first 24 hours – pulmonary infection
• Within 48 hours – urinary tract infection
• Within 72 hours – wound infection
Preventive interventions
• Strict aseptic technique
• Wound care
• Keep unit clean
• Maintain hand washing.

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 • Antibiotic therapy as ordered
Nursing interventions
• Apply abdominal binders can provide support and guard against
dehiscence.
• Encourage proper nutrition (high protein, vitamin C)
• Stay with client, have someone call for the doctor
• Keep in bed rest
• Supine or Semi-Fowler’s position, bend knees to decrease pressure.
• Cover exposed intestine with sterile, moist saline dressing
• Reassure, keep him/her quiet and relaxed
• Prepare for surgery and repair of wound

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 Students’ self-assessment
➢ multiple-choice questions (MCQs) about the phases of operative care:
1- Which phase includes the actual surgical procedure?
a) Preadmission testing
b) Intraoperative phase
c) Postoperative phase
d) None of the above
2- What is the primary purpose of maintaining NPO for 6 to 8 hours
before surgery?
a) To prevent malnutrition
b) To prevent electrolyte imbalance
c) To prevent aspiration pneumonia
d) To prevent intestinal obstruction
3- Which position is commonly used for patients undergoing abdominal
surgery?
a) Supine
b) Trendelenburg
c) Fowler's position
d) None of the above
4- Which factor ensures the validity of informed written consent?
a) The patient is of legal age with a proper mental disposition
b) If the patient is a child, secure consent from the parents or legal guardian
c) The consent is secured before administration of preoperative medications
d) If the patient is unable to write, the nurse signs the consent for the patient
5- Which phase involves the actual surgical procedure?
a) Preadmission testing
b) Intraoperative phase
c) Postoperative phase
d) None of the above

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