CHAPTER 14

PERIOPERATIVE CARE

By Elias Ezo (BSc)

February /2018

Saturday, November 9,
Objectives:

At the end of this lecture, the student must be able to:

 Differentiate the phases of perioperative care.
 Define the types and categories of surgery.
 Identify the preoperative assessments.
 Develop a preoperative teaching plan.
 Identify surgical risk factors.
 Describe the preoperative preparation.
 Discuss assessments needed in immediate and later postoperative
period.
 Identify the postoperative complications.

Saturday, November 9,
 What is meant by
perioperative?

Perioperative is a term used to describe the

entire span of surgery, including what occurs
before, during, and after the actual operation.

Saturday, November 9,
 Phases of perioperative care

Preoperative: begins with the decision to perform

surgery and continues until the client has reached the
operating area.

Intraoperative: includes the entire

duration of the surgical procedure, until
transfer of the client to the recovery area.

Postoperative: begins with admission to the recovery area and

continues until the client receives a follow up evaluation at home, or is
discharged to a rehabilitation unit.

Saturday, November 9,
Saturday, November 9,
 Types of surgery

•Diagnostic → Removal and study of tissue to make a

diagnosis.(Pathology)
•Exploratory → Most extensive means to involve
exploration of a body cavity or use of scopes inserted though
small incision.
•Curative → Removal or replacement of defective tissue
to restore function.(Joint)
•Palliative→ Relief of symptoms or enhancement of
function without cure. (Thiroidectomy)
•Cosmetic→ Correction of defects, improvement of
appearance, or change to a physical feature.

Saturday, November 9,
 Perioperative care
According to degree of 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.

Saturday, November 9,
 Assessment

•Client assessment varies depending on the urgency of the surgery.

•Time for preoperative assessment, nursing diagnosis, and evaluation of the nursing
management may be limited when a client is admitted for ambulatory surgery or admitted
shortly before surgery.
•Recognition of the client’s immediate preoperative needs is important.
•When the client is admitted, the nurse review preoperative instructions, such as diet
restriction, skin preparation, to ensure the client has followed them.
•The nurse immediately notifies the surgeon if the client has not carried out a specific
portion of the instruction. Saturday, November 9,
 Preoperative Assessment

I. Review preoperative laboratory and

diagnostic studies

II. Review the client’s health history and

preparation for surgery
:

III. Assess physical needs

IV. Assess psychological needs

V. Assess cultural needs

Saturday, November 9,
I. Review preoperative laboratory and diagnostic studies:

• Complete blood count.

• Blood type and cross match.
• Serum electrolytes.
• Urinalysis.
• Chest X-rays.
• Electrocardiogram.
• Other tests related to procedure or client’s medical condition, such as:
prothrombin time, partial thromboplastin time, blood urea nitrogen, creatinine,
and other radiographic studies.

Saturday, November 9,
II. Review the client’s health history and preparation for surgery:
• History of present illness and reason for surgery
• Past medical history
• Medical conditions (acute and chronic)
• Previous hospitalization and surgeries
• History of any past problem with anesthesia
• Allergies
• Present medications
• Substance use: alcohol, tobacco
• Review of system

Saturday, November 9,
III. Assess physical needs:
• Ability to communicate
• Vital signs
• Level of consciousness
Confusion
Drowsiness
Unresponsiveness
• Weight and height
• Skin integrity
• Ability to move/ ambulate
• Level of exercise
• Prostheses
• Circulatory status

Saturday, November 9,
IV. Assess psychological needs:
• Emotional state
• Level of understanding of surgical procedure, preoperative and
postoperative instruction
• Coping strategies
• Support system
• Roles and responsibilities

V. Assess cultural needs:

• Language-need for interpreter

Saturday, November 9,
Surgical consent
 Before surgery, the client must sign a surgical consent
form or operative permit.
 Clients must sign a consent form for any procedure that
requires anesthesia and has risks of complications.
 If an adult client is confused, unconscious, a family
member or guardian must sign the consent form.
 If the client is younger than 18 years of age, a parent or
legal guardian must sign the consent form.
 In an emergency, the surgeon may have to operate without
consent, health care personnel, however, makes every
effort to obtain consent by telephone, or fax.
 Each nurse must be familiar with agency policies and state
laws regarding surgical consent forms.
 Clients must sign the consent form before receiving any
preoperative sedatives.
 The nurse is responsible for ensuring that all necessary
parties have signed the consent form and that it is in the
client’s chart before the client goes to the operating room
(OR).

Saturday, November 9,
 Preoperative Teaching

 Teaching clients about their surgical procedure and

expectations before and after surgery is best done
during the preoperative period.
 Clients are more alert and free of pain at this time.
 Clients and family members can better participate in
recovery if they know what to expect.
 The nurse adapts instructions and expectations to
the client’s ability to understand.
 Information in a preoperative teaching plan varies
with the type of surgery and the length of the
hospitalization.

Saturday, November 9,
Preoperative Teaching Plan Includes:

 Preoperative medication- when they are given and

their effects.
 Post operative pain control.
 Explanation and description of the post anesthesia
recovery room or post surgical area.
 Discussion of the frequency of assessing vital signs
and use of monitoring equipment.
 Explanation and demonstration deep breathing and
coughing exercises, use of incentive spirometry,
how to support the incision for breathing exercises
and moving, position changes, and feet and leg
exercises.

Saturday, November 9,
 Information about intravenous (IV) fluids and other
lines and tubes such as nasogastric tubes.
 Preoperative teaching time also gives the client the
chance to express any anxieties and fears and for
the nurse to provide explanations that will help
alleviate those fears.
 When clients are admitted for emergency surgery,
time for explanation is unavailable; explanations
will be more complete during the postoperative
period.

Saturday, November 9,
Surgical Risk Factors:

 Age → Very young – Elderly

 Nutritional Status →Malnourished – Low weight – Obese
 Medical Problems →Acute and chronic respiratory problems
– Hypertension – Liver dysfunction – Renal failure –
Diabetes

Saturday, November 9,
Saturday, November 9,
Preoperative Preparation:

 Physical Preparation.
◦ Skin preparation
◦ Elimination
◦ Food and fluids
◦ Care of valuables
◦ clothing/ grooming
◦ Prostheses
 Psychosocial Preparation.
◦ Careful preoperative teaching can reduce fear and
anxiety of the clients.

Saturday, November 9,
Postoperative Care:
Immediate postoperative period.

Initial Assessment
 Airway patency

 Effectiveness of respiration

 Presence of artificial airways

 Mechanical ventilation, or supplemental oxygen

 Circulatory status, vital signs

 Wound condition, including dressings and drains

 Fluid balance, including IV fluids, output from catheters and

drains and ability to void

 Level of consciousness and pain

Saturday, November 9,
Postoperative Care:
Later postoperative period
Ongoing Assessment
 Respiratory function

 General condition

 Vital signs

 Cardiovascular function

 Fluid status

 Pain level

 Bowel and urinary elimination

 Dressings, tubes, drains, and IV lines

Saturday, November 9,
Nurse’s Responsibilities in Postoperative
Phase

 Ensures a patent airway

 Helps maintain adequate circulation
 Prevents or assist with the treatment of shock
 Maintains proper position and function of drain tubes and IV
infusion
 Monitor for potential complications

Saturday, November 9,
Postoperative Complications

1. Hemorrhage
2. Shock
3. Hypoxia
4. Aspiration

Saturday, November 9,
 Basic areas of post operative assessment
 1. Respiration points
 * Ability to breath deeply & cough…………. 2
 * Limited respiratory effort (dyspnea) ………. 1
 * No spontaneous effort……………………….. 0

Saturday, November 9,
 2. Circulation/Systolic arterial pressure/
 - > 80% of pre anesthetic level ……………. 2
 - 50 – 80% of pre anesthetic level ………… 1
 - < 50% of pre anesthetic level …….…….. 0

Saturday, November 9,
3. Color
 - Normal skin color & appearance………… 2

 - Altered skin color & pallor………………… 1

 - Cyanosis………………………………………. 0

Saturday, November 9,
4. Muscle activity
 - ability to move all extremities……………. 2

 - ability to move two extremities………….. 1

 - unable to control any extremity…………. 0

 NB:- to discharge the pt from Recovery Room, the pt should

score 7 to 8 points

Saturday, November 9,
 TEACHING THE PATIENT
COUGHING AND DEEP BREATING
EXERCISE

Saturday, November 9,
 The coughing exercise is one of the best known and most
effective forms of chest physiotherapy. Coughing deeply
will help in clearing your lung after surgery. When you stay
in bed for a long time after surgery, you need to keep your
lungs active as if you are doing your daily activities.
 COUGHING – is a reflexive response to irritation in airways.
Or Is sudden explosive exhalation that pushes secretion up
ward

Saturday, November 9,
Function of cough:
 to help clear offending substance from the air ways.

 Serves as a warning signals’ to alert the cougher that the

airways are being assaulted by possibly harmful stimuli and

that steps s/d be taken to prevent further irritation.
Causes of cough- cough can be triggered by
 anything that enters the air way that does not normally

belong there Eg. Chemical substance or physical substance.

 Inflammation of the tissue by disease that results in

increase of histamine w/c irritates the air ways and triggers

a cough.

Saturday, November 9,
DEEP BREATHING-
 It is a condition in which there is more than the normal
amount of air entering and leaving the lungs
 is the alteration of active inhalation of air in to the lungs

through the mouth or nose with passive exhalation of air.

Indication
 Pts with infective air way clearance and excessive secretion

in the respiratory tracts

 Pts with infective breathing pattern

 Respiratory defect, hypoventilation

Saturday, November 9,
Coughing Technique

 Start with sitting on a chair with both feet on the floor. Lean
slightly forward. Relax.
 Fold your arms across your abdomen and breathe in slowly
through your nose. The power of the cough comes from
moving air.
 To exhale: lean forward, pressing your arms against your
abdomen. Slightly open mouth.
 Cough two to three times, short and sharp.
 Breathe in again by "sniffing" slowly through your nose.
This gentle breath prevents mucus from moving back down
your airways. Rest and repeat.
 The first cough loosens the mucus. The second and third
cough moves the mucus up and out.

Saturday, November 9,
Saturday, November 9,