Pre & post operative nursing care

1. Advance nursing practice
presentation on
PRE &POST OPERATIVE nursing CARE
Presented by,
Ms. Flavia Dass
M.Sc Nsg 1st year
KIMS Hubli.

2. INTRODUCTION
 Surgery – can be defined as the art & science of
treating disease, injuries & deformities by
operation & instruments
The surgical procedures involves the interaction
of patients, surgeon, anesthesia care provider &
nurse.
Surgery may be performed for diagnosis, cure,
prevention, exploration or cosmetic
improvement.
 Regardless of what the surgery is, the nurse has a
vital role in preparing the patient for surgery,
caring for patient during surgery & facilitating the
patient recovery following surgery.

3. PRE OPERATIVE CARE
 It begins as soon as the surgeon makes a
diagnosis & decides that an operation is
necessary for the patient

4. INFORMED CONSENT
• Voluntary & written informed consent from
patient is necessary before non emergent
surgery can be performed.
• The nurse may ask the patient to sign the
form & may witness the patient's signature

5.  Criteria for valid informed consent
• Voluntary consent
consent must be freely given, without coercion.
• Incompetent patient
individual who is not autonomous & cannot give or
withhold consent
• Informed subject
informed consent should be in writing. It should
contain

6. Explanation of procedure & its risk
 Description of benefits & alternatives
An offer to answer questions about the procedure
Instructions that the patient may withdraw consent
Informing the patient if the protocols differ from
customary procedure

7. • Patient able to comprehend
 information must be delivered n written in language
understandable to the patient. Questions must be answered if
material is confusing
 many ethical principles are integral to informed consent
 before the patient signs the consent, the surgeon must
provide a clear explanation of the surgery.
 Informed consent is necessary in
invasive procedure, procedures needing sedative/ anesthesia,
non surgical procedure & radiation procedure.

8. • Patient personally signs the consent if he or
she is of legal age & mentally capable.
• When is patient is minor or unconscious or
incompetent permission must be obtained
from responsible family member or legal
guardian
• State regulations & agency policy must be
followed
• In emergency it may be necessary for the
surgeon to operate as a life saving measure
without patients consent
• Refusing to undergo a surgical procedure is a
persons legal right & privilege.

9. ASSESSMENT OF HEALTH FACTOR THAT
AFFECTS PATIENTS PRE - OPERATIVELY
• The overall goal in the pre- operative to have
as many positive health factors as possible
• Before any surgical treatment is initiated, a
health history, a physical examination and
data base is established
• Blood test , X-rays & other diagnostic test are
prescribed.

10. NUTRITIONAL & FLUID STATUS
• Optimal nutrition is an essential factor in
promoting healing & resisting infection & other
surgical complications
• Assess the patients nutritional status
• Nutritional needs maybe determine
by measurement of Body Mass Index
& waist circumference
• Any nutritional deficiency has to be corrected
• Additional time may be needed to correct fluid &
electrolyte deficits to promote best results

11. DRUG OR ALCOHOL USE
• People who abuse drugs or alcohol frequently
deny or attempt to hide it, in such situations,
the nurse who is obtaining the patients health
history needs to ask frank questions with
patience, care & non judgmental attitude.
• If emergency surgery is required, local, spinal
or regional block anesthesia is used for minor
surgery.

12. • Otherwise to prevent vomiting & potential
aspiration a NG tube is inserted
before administering general
anesthesia.
• The person with a history of chronic alcoholism
often suffers from malnutrition & other system
problems that increase the surgical risk.
• Additionally, alcohol withdrawal delirium may be
anticipated up to 72 hours after alcohol
withdrawal with a significant mortality rate when
it occurs post operatively.

13. RESPIRATORY STATUS
• The goal for potential surgical
patient is optimal respiratory function
• Breathing exercise & use of an incentive
spirometer is taught if indicated
• Respiratory disease patients are assessed
carefully
• Use of medications that may affect recovery is
also assessed.
• Patients who smoke are urged to stop 2 months
before or atleast 24hours preceding surgery.

14. CARDIOVASCULAR STATUS
• The goal is a well functioning cardiovascular system to
meet the oxygen, fluid & nutrition needs of the peri -
operative period.
• In case of uncontrolled HTN, surgery is postponed until
under control
• Because cardiovascular disease increase the risk for
complications, patients needs greater than usual
diligence during all phases of Nursing management.
• In case of severe symptoms, surgery
may be deferred until patients
condition is improved

15. HEPATIC & RENAL FUNCTION
• The liver is important in the
biotransformation of anesthetic
compounds. Therefore any
disorders of the liver has an effect
on how anesthetic agents are metabolized.
• Careful assessment is made with the help of
various Liver Function Test.
• Surgery is contraindicated in patients with acute
renal problems like acute nephritis.
• The surgery is performed as a life saving measure
or to improve the urinary function.

16. ENDOCRINE FUNCTION
• The patient with diabetes who is undergoing surgery is
at risk for hypoglycemia & hyperglycemia
• The goal is to maintain the blood glucose level to less
than 200mg/dl.
• Frequent monitoring of the blood glucose level is
important
• Patients who received corticosteroids are at risk for
adrenal insufficiency, its use should be reported to
anesthetist or surgeon.
• Thyroid disorders & respiratory failure is assessed.

17. IMMUNE FUNCTION
• Determining the existence of allergies & the
nature of previous allergic reactions is important.
• It is important to identify & document any
sensitivity & signs & symptoms produces by them
• Mildest symptoms & slightest temperature
elevation must be investigated
• Patients who immunosuppressed are highly
susceptible to infection, great care is taken to
ensure strict asepsis.

18. PREVIOUS MEDICATION
USE
• A medication history is obtained from patients to
avoid possibility of drug interaction
• Any medication used in the past is documented &
the frequency with which they are used
• Potent medications have effects on physiological
functions, interaction of such medications with
anesthetic agents can cause serious problem like
arterial hypertension

19. • The potential effects of prior medication
therapy are evaluated by the anesthesiologist
or anesthetist, who considers the length of
time the patient used medications, the
physical condition of the patient & the nature
of the proposed surgery.
• The information is noted in the patients chart
& conveyed to the anesthesiologist or
anesthetist or surgeon.

20. PSYCHOSOCIAL FACTORS
• All the patients have some type of emotional
reaction before any surgical procedure
• Psychological distress directly influences body
functioning
• Nurse should take a careful history about the
patients concerns that can have a bearing on
the course of the surgical experience
• The nurse must be empathetic, listen well &
provide information that helps alleviate
concerns

21. SPIRITUAL & CULTURAL BELIEFS
• Spiritual beliefs play an important role in coping
with fear & anxiety.
• Regardless of the patients religious affiliation,
spiritual belief can be as therapeutic as
medication
• The most valuable skill at the nurse’s disposal is
listening carefully to the patient, especially when
obtaining the history
• Invaluable information & insight may be gained
by engaging in conversation & using
communication & interviewing skills.

22. PRE OPERATIVE NURSING
INTERVENTION

23. PRE – OPERATIVE TEACHING
 Nurses have long recognized the value of pre –
operative instruction. It should be initiated as
soon as possible. It should be started in the
physician’s office & continue the patient
arrives in the operating room
 Each patient in taught as an individual
 Multiple teaching strategies should be used
depending on the patients need & abilities.

24. WHEN & WHAT TO TEACH
 Ideally, instruction is spaced over a period of time
to allow the patient to assimilate information &
ask questions as they arise
 Frequently teaching sessions are combined with
various preparation procedure to allow flow of
information
 Too many descriptive details
will increase their anxiety level
 During this visit, the patient can
meet & ask questions.

25. DEEP – BREATHING, COUGHING
& INCENTIVE SPIROMETERS
 One goal of pre- operative nursing care is to teach
the patient how to promote optimal lung
expansion & consequent blood oxygenation after
anesthesia
 The patient assumes a sitting position to enhance
lung expansion. The nurse then demonstrates
deep breathing exercise.
 The nurse also demonstrates how to use an
incentive spirometer.

26.  If there is thoracic or abdominal
incision, the nurse also demonstrates
how the incision line can be splinted
to minimize pressure & control pain
 The patient is informed that medications are
available to relieve pain & should be taken
regularly for pain relief so that effective deep
breathing n coughing exercise can be performed.
 If the patient does not cough effectively,
atelectasis, pneumonia etc may occur.

27. MOBILITY & ACTIVE BODY MOVEMENT
 Mobility is essential to improve circulation
prevent venous stasis & promote optimal
respiratory functions
 The nurse explains the rationale for frequent
position change after surgery
 Any special positions the individual patient will
need to maintain after surgery is discussed
 Exercise of the extremities should be performed
 The nurse should remember proper body
mechanics & to instruct the person the same

28. PAIN MANAGEMENT
 To asses & determine between acute & chronic
pain a pain scale is introduced & its use explained
to patient
 Post – operative, medications are administered to
relieve pain & maintain comfort
 Anticipated methods of administration of
analgesic agents for inpatients include patients
controlled analgesia(PCA), epidural catheter bolus
or infusion or patient – controlled epidural
analgesia ( PCEA)
 These are discussed with the patient before
surgery & the patient’s interest & willingness to
use those methods are assessed.

29. INSTRUCTION FOR AMBULATORY SURGICAL
PATIENTS
 Pre operative teaching content may be
presented in a group meeting, on a video tape
etc
 In additions to the questions & answers, the
nurse tells the patient when & where to
report, what to bring , what to leave home &
what to wear
 A fasting period of 8 hours or more after a
meal that includes fried or fatty foods or
meals

30. • The anesthesiologist or anesthetist may
restrict foods & floods for longer time
depending on the patients fluids status, age &
pulmonary status & nature of surgery to
prevent aspiration
• Fluid may be administered intravenously in
some patients to ensure an adequate fluid
volume when oral fluids are restricted

31. COGNITIVE COPING STRATEGIES
 Cognitive strategies may be useful for
relieving tension, overcoming anxiety,
decreasing fear & achieving relaxation
 Examples
• Imagery
• Distraction
• Optimistic self recitation

32. PRE OPERATIVE PSYCHOSOCIAL
INTERVENTION
 REDUCING PRE OPERATIVE ANXIETY
 Cognitive strategies are useful for reducing
anxiety in the pre – operative patient
 General pre- operative teaching will also help
decrease anxiety in many patient
 Knowing ahead of time about the possible
need for a ventilator, drainage tube or other
types of equipment will help decrease anxiety
in the post operative period

33.  DECREASING FEAR
 The nurse should assist the patient to
identify coping strategies that he or she has
previously used to decrease fear
 The patient benefits from knowing when
family & friends will be able to visit after
surgery
 Research suggests that hypnosis may be a
useful strategy for reducing fear & over
coming the anxiety associated with surgery.

34.  RESPECTING CULTURAL, SPIRITUAL & RELIGIOUS
BELIEFS
 Identifying & showing respect for cultural,
spiritual & religious beliefs
 The responses should be recognized as normal
for those patients & families & respected by peri
operative personals
 When patient declines blood transfusion for
religious reasons, the information needs to be
clearly identified, documented & communicated
to the appropriate personals

35. GENERAL PRE- OPERATIVE NURSING
INTERVENTION
MANAGING NUTRITION &
FLUIDS
 New recommendation are depends on the age n
type of food eaten
e.g. adults are advised to fast for 8 hours after
eating fatty food & 4 hours after ingesting milk
 Most patients are currently allowed clear liquids
up to 2 hours before an elective procedure

36.  PREPARING THE BOWEL FOR SURGERY
 Enemas are not commonly ordered unless the
patient is undergoing abdominal or pelvic
surgeries
 This preparation is to allow satisfactory
visualization of the surgical site & to prevent
trauma to the intestine or contamination of the
peritoneum by faces
 Additional antibiotics may be
prescribed to reduce intestinal
flora

37. PREPARING THE SKIN
 The goal of pre operative skin preparation is to
reduce bacteria without injuring the skin
 If the surgery is not an emergency , the patient is
instructed to use soap containing detergent –
germicide to clean the area days before OT
 Generally hair is not removed around the incision
site unless it is likely to interfere with surgery
 If the hair is removed, electric clippers are used
for safe hair removal

38.  ADMINISTERING PRE ANESTHETIC MEDICATIONS
 The use of pre anesthetic medication is minimal
with ambulatory or outpatient surgery
 If pre anesthetic drug is administered, the patient
is kept in bed with side rails raised because it
causes drowsiness
 During this time, the nurse observes the patient
for any untoward reaction to the medications
 It usually takes 15 to 20 minutes to prepare the
patient for operating room

39.  MAINTAINING THE PRE OPERATIVE RECORD
 A pre operative checklist
elements that needs to be
checked pre operatively
 The completed chart accompanies the patient to
the OT with the surgical consent form attached,
along with lab reports & nurses records
 Any unusual last minute observations are noted
at the front of the chart in prominent place

40.  TRANSPORTING THE PATIENT TO THR PRE –
SURGICAL AREA
 The patient is transferred to the holding area or
pre surgical suite about 30 to 60 minutes before
the anesthesia is given
 The stretcher should nr comfortable with
sufficient number of blankets to prevent chills in
air condition rooms
 The surrounding should be kept quiet
 Using a process to verify the patient
identification, surgical procedure & surgical site
maximizes patients safety

41. ATTENDING TO FAMILY NEEDS
 Most hospitals have a waiting room where the
family & significant others can wait
 This room may be equipped with comfortable
chairs, TV, telephone & facilities for light
refreshment
 After surgery, the surgeon may meet the
family in the waiting room & discuss the
outcome
 After surgery, the patient is taken to the post
anesthesia care unit ( PACU)

42.  Family members should be informed that the
patient might have certain equipment or
devices in place after the surgery
 The surgeon should provide explanations
regarding post operative observation that has
to be made

43. NURSING PROCESS
ASSESSMENT
Nursing assessment usually addresses the following
parameters
• Physical condition including respiratory, cardiac &
other major body system
• Results of blood test, x-rays studies etc
• Nutrition & fluid status
• Medication used
• Psychological preparedness for surgery
• Special considerations like gerontologic condition etc

44. DIAGNOSIS
Based on the assessment data, major pre –
operative nursing diagnoses of the surgical
patient may include
• Anxiety related to the surgical experience & the
outcome of surgery
• Fear related to perceived threat of the surgical
procedure & separation from support system
• Knowledge deficit of pre – operative procedure &
protocols & postoperative expectations

45.  COLLABORATIVE PROBLEMS/ POTENTIAL
COMPLICATIONS
Failure to identify & communicate pertinent
pre operative risk factor may lead to
complications.

46.  PLANNING AND GOALS
The major goals for the pre operative surgical
patient may include relief of pre operative
anxiety, decreased fear, increased knowledge
of peri operative expectations & absence of
pre operative complications.

47.  NURSING INTERVENTIONS
• Reducing pre operative anxiety
• Reducing fear
• Providing patient education
• Monitoring & managing potential
complication

48. EVALUATION
 Report relief of anxiety
• Discusses with anesthesiologist or anesthetist
concerns related to types of anesthesia &
induction
• Verbalizes an understanding of the pre-
anesthetic of the pre – anesthetic medication &
general anesthesia
• Discusses last minute concerns with nurse or
physician.

49. • Discusses financial concerns with social
workers, when appropriate
• Requests visits with member of clergy when
appropriate
• Relaxes quietly after being visited by health
care team members

50.  REPORTS THAT FEAR IS DECREASED
• Discusses fear with health care professionals
• Verbalizes an understanding of the location of
family members or significant others during
procedure

51.  VOICES UNDERSTANDING OF SURGICAL
INTERVENTION
• participates in pre operative preparations
• Demonstrates & describes exercises he or she is
expected to perform post operatively
• Reviews information about post operative care
• Accepts pre anesthetic medication
• Remains in bed once pre medicated
• Relaxes during transportation to OT
• Discusses post operative expectations

52. POST OPERATIVE CARE
1.IMMEDIATE POST OPERATIVE STAGE
It is described as the period of 1-4 hours
after surgery

53.  Respiratory system
• Monitor vital signs
• Monitor airways patency & adequate
ventilation
• Monitor for secretion
• Observe chest movement for symmetry & use
of accessory muscles
• Monitor oxygen administration
• Monitor pulse oxymetry
• Encourage deep breathing & coughing exercise
• Note rate, depth , quality of respirations &
breath sound

54.  Cardiovascular system
• Assess shin & check capillary refills
• Assess peripheral pulses
• Assess for peripheral edema
• Monitor bleeding
• Assess pulse for rate & rhythm
• Monitor for cardiac dysrrhythmias
• Assess for homan’s sign

55. Musculoskeletal system
• Assess the client for the movement of the
extremities
• Review physicians order regarding client
positioning & restriction
• Unless contraindicated place the patient in low
Fowler’s position after surgery to increase the
size of thorax for lung expansion
• Avoid positioning the client in a supine position
until pharyngeal reflexes have returned
• If the client is comatose or semi comatose,
position on side & keep an oral airway in place

56. NEUROLOGICSL SYSTEM
• Assess the level of consciousness
• Frequent periodic attempts to awaken the client
should continue till the client awaken
• Orient the client t the environment
• Speak in a soft tone, filter out extraneous noises
in the environment
• Maintain body temperature & prevent heat loss
by providing the client with warm blankets &
raising the room temperature as necessary

57.  TEMPERATURE CONTROL
• Monitor temperature
• Monitor for signs of hypothermia that result
from anesthesia, cool operating room etc
• Apply warm blankets & continue oxygen as
prescribed if the client is shivering

58. INTEGUMENTARY SYSTEM
• Assess surgical site, drains & wound dressings
• Monitor for & document any drainage or
bleeding from the surgical site
• Assess the skin for redness, abrasions or
breakdown that may have resulted from surgical
positioning

59. FLUID AND ELECTROLYTE IMBALANCE
• Monitor IV fluids administration as prescribed
• Record intake & output
• Monitor for signs of hypocalcaemia,
hyperglycemia & metabolic or respiratory
acidosis or alkalosis

60.  GASTRO INTESTINAL SYSTEM
• Monitor for nausea & vomiting
• Monitor patency of the NG tube if present
• Monitor for abdominal distension
• Monitor for return of bowel sounds

61. RENAL SYSTEM
• Assess the bladder for distension
• Monitor color, quality & quantity of urine if a
Foley’s catheter is present
• Expect the client to void 6-8 hours after the
surgery, depending on the anesthesia used

62.  PAIN MANAGEMENT
• Assess for pain
• Assess the type of anesthesia given & pre op
medications
• Enquire about the type & location of pain
• Ask the patient to rate the pain scale
• Administer pain medication
• Ensure the client with controlled analgesia pump
understands how to use it

63. 2. INTERMEDIATE POST OPERATIVE CARE
It is the period of 4-24 hours after surgery

64.  RESPIRATORY SYSTEM
• Monitor vital signs
• Monitor for patency of airway, verifying that
the lungs are clear
• Encourage deep breathing & coughing
• Continue the same assessment as during
immediate stage

65. CARDIOVASCULAR SYSTEM
• Monitor circulatory status such as peripheral
pulses, capillary refill & the absence of edema,
numbness & tingling
• Encourage use of the anti embolisms stocking,
if prescribed to promote venous return,
strengthen muscle tone & prevent pooling of
blood in the extremities

66. MUSCULOSKELETAL SYSTEM
• Assess for range of motion on all extremities
• Encourage ambulation, before ambulation
instruct the client to sit at the edge of the bed
with his or her feet supported to assume
balance
• If the client is unable to get out of bed, turn
the client every 1-2 hourly

67.  NEUROLOGICAL SYSTEM
• Assess level of consciousness
• Maintain orientation to the environment

68.  INTEGUMENTARY SYSTEM
• Assess surgical site & drains
• Monitor body temperature & wounds for infection
• Change dressings as prescribed
• Use abdominal binder
• Drains should be patent with minimal bleeding or
drainage
• Prepare to assist with removal of drains
• Turn the client to a side lying position
• Administer frequent oral care
• Maintain NPO status until gag reflex & peristalsis return
• Continue IV fluids as prescribed
• Assess bowel sound & monitor flatus & encourage
ambulation

69. RENAL SYSTEM
• Monitor urinary output
• If the client is not catheterized, the client is
expected to void within 6-8 hours post
operate , with at least 200ml

70. PAIN MANAGEMENT
• Assess for pain
• Assess the location of pain
• Ask the patient to rate the pain scale
• Enquire about effectiveness of the last pain
medication
• Administer pain medication, as prescribed

71. 3. EXTENDED POST OPERATIVE STAGE
This is the period of at least 1 to 4 days post
operatively

72. • Continue to assess and observe the client’s body
system during this stage
• Monitor for signs for infection
• Encourage active range of motion
• Continue to encourage ambulation
• Encourage the client to perform as many activities of
daily living as possible
• Diet which are rich in protein & vitamin C is advised

73. POST OPERATIVE COMPLICATIONS
 IMMMEDIATE
Bleeding
Shock
Atetectasis
Urine retension
hypoxia

74.  EARLY COMPLICATION
Pneumonia
Wound infection
Paralytic ileus
Wound dehiscence
Wound evisceration
Pulmonary embolism

75.  LATE COMPLICATION
Bowel obstruction
Constipation
Thrombophelibitis

76. PHARMACOLOGICAL MANAGEMENT OF SOME
COMPLICATIONS
HAEMORRHAGE
• Pressure should be provided at the site of
bleeding
• Blood & IV fluids should be administered as
prescribed

77. HYPOXIA
• Vital signs should be monitored
• The lung sound & pulse oxymetry should be
assessed
• Oxygen should be administered
as prescribed
• The breathing & coughing
exercise should be encouraged
• Turn & reposition the patient

78. PNEUMONIA & ATELECTASIS
• Encourage the client to do deep breathing
Exercise coughing & use of spirometer,
• Prescribe chest physiotherapy & postural
drainage
• Use suction to clear secretions, encourage
fluid intake & early ambulation
• Antibiotics can be given as doctor prescribed

79.  PULMONARY EMBOLISM
• It is a life threatening situation & requires
emergency action. Notify the physician in case
of emergency
• The vital sign should be monitored
• Administer oxygen & medications such as anti
coagulants as prescribed

80. SHOCK
• Initial focus on ABC
• Administer IV fluids, blood products
• Administer medications like crystalloid,
vasodilators, diuretics etc

81. WOUND INFECTION
• Incision site should be inspected
• Temperature should be monitored
• Dressing should be frequently changed
• Antibiotics to be administered

82. URINARY RETENSION
• It is caused by the effect of anesthesia or opoid
analgesia & appear after 6 to 8hours after surgery
• Voiding should be monitored
• Encourage ambulation & increased fluid intake
• Catheterize the client after all non invasive
technique have been attempted

83. CONSTIPATION
• Increased fluid intake upto
3000ml/day
• Early ambulation
• Consumption of fiber rich diet
• Laxatives & enemas can be used
• Bisacodyl tablets & suppositories, milk of magnesia
lactulose are the more potent drugs used
• Tegascrod can be used for management of chronic
constipation