NURSING FOUNDATION:PRE AND POST OPP CARE

1. PRE AND POST –OPERATIVE
NURSING CARE

2. Surgery can be defined as the art and science of treatment. Most surgical
procedures are performed in a hospital operating room, although many simpler
procedures are carried out in surgical centers and ambulatory surgical units.
Surgical procedures are commonly grouped according to the:
(A) Purpose
• Diagnostic
• Palliative
• Ablative
• Reconstructive or cosmetic
• Transplant or corrective
• Curative
• Repairative
• Restorative

3. B) Degrees of Urgency
• Emergency Surgery
- Immediate
- Urgent
• Elective Surgery
- Required
- Recommended
-Optional
(C) Degree of risk involved
- Major Surgery
- Minor Surgery

4. Types of Surgery Main Features
According to Purpose
- Diagnosis: This is an operation in which the diagnosis is unknown and
so it confirms or establishes diagnosis. e.g., exploratory laparotomy in
which the abdomen is opened to seek the cause of symptoms or biopsy
of a mass in the breast.
- Palliative: This is an operation in which symptoms are relieved, but the
basic cause remains and so does not cure the disease. e.g., resection
of nerve root, or insertion of gastrostomy tube to compensate for the
inability to swallow. ).

5. - Ablative: This is an operation in which the diseased body part is
removed. e.g., removal of gall bladder (Cholecystectomy
- Reconstructive or Cosmetic : This is an operation which is done to
restore function or restore appearance that has been lost or reduced,
e.g., mammoplasty, breast implant, face lift etc. Repair of cleft lip and
cleft palate

6. - Transplant or Corrective: This is an operation in which deformities are
corrected and malfunctioning structure are re-placed. e.g., hip replacement,
replacement of the mitral valve.
- Curative: This is an operation in which complete cure is assured by
removing the diseased part or organ e.g. removal of an inflamed appendix,
total excision of a tumor mass
.

7. - Repairative: This is an operation in which repair of damaged or
injured part is done. e.g., suturing multiple wounds.
- Restorative : This is an operation involving strengthening of weakened
area. e.g., herniorrhaphy.
- Preventive: Operation is performed to prevent the disease. removal of
mole to prevent it turn into malignant

8. Degree of Urgency
Emergency:
In this, pre-operative period is very short, because of the life threatening
situation. e.g., acute appendicitis.
Therefore minimum preparation can be done in the pre-operative period.
(a) Immediate:
Surgery is performed immediately to preserve (without delay) function or
save life of the client. e.g., ruptured aortic aneurysm, gunshot wound,
epidural hematoma, acute appendicitis
(b) Urgent:
Client requires prompt attention. Surgery is performed within 24 to 48
hours. e.g. ureteral calculi, bleeding uterine fibroids, obstructed duodenal
ulcer.

9. Elective or Planned:
Surgery is performed when surgical intervention is the preferred treatment
for a condition that is most immediately life threatening (but may ultimately
threaten life on well being) Or to improve clients life.
Time for surgery is fixed with the mutual consent of the surgeon and the
patient. There will be enough time left for the pre-operative care to be
given to the patient.

10. a) Required : Surgery is required within weeks or months. eg cataract
extraction, benign prostatic hypertrophy chronic cholecystitis.
(b)Recommended: Client should be operated upon. Failure to surgery is
not catastrophic.e,g haemorrhoids, rectocele, cystocele, simple hernia
(c) Optional or Cosmetic : Decision rest with the client and is the
personal preference of the client. Plastic surgery procedure e.g., face
lift.

11. Degree of Risk
• Major Surgery: This involves a high degree of risk to the client, for a
variety of reasons. It may be complicated, prolonged, there may be
heavy loss of blood, vital organs may be involved, post operative
complications are likely, operation may involve large surface area
of ​​the body.eg., open heart surgery, organ transplant, removal of a
kidney etc.
• Minor Surgery: This normally involves little risk, produces few
complications and usually involves a small area of ​​the body. e.g., breast
biopsy, tonsillectomy.
The degree of risk involved in the surgical procedures depends on the
client's age, general health, nutritional status, use of medications, mental
status, etc.

12. Suffixes Describing Surgical Procedures
• Ectomy = Excision or removal of eg:Myomectomy
• Lysis = Destruction of eg: Electrolysis
• Orrhaphy= Repair or suture of eg:Colporrhaphy
• Ostomy=Creation of opening into eg: Colostomy
• Otomy =Cutting into or incision of eg:Tracheotomy
• Plasty =Repair or reconstruction of eg , Tympanoplasty

13. The surgical experience is a unique one and involves three phases:
1. Pre-operative phase
2. Intra-operative phase
3. Post-operative phase.
These three phases together are referred to as peri-operative period.

14. Pre-Operative Phase is the period between the decision to do the
surgery and the client being shifted to the operation table. The nursing
activities during this phase includes:
(i) Assessment of the client.
(ii) Identification of health problems -both actual and potential.
(iii) Plan of care based on individual health needs.
(iv) Preoperative health teaching of the client and supportive people.
(v) Actual preparation of the client for surgery (physical, psychological,
social etc.)

15. Intra-Operative Phase :
It is the period from the time the client shifted to the operating table, and
later admitted to the post anaesthesia care unit or recovery room.
The nursing activities during this phase include all the specialized
procedures designed ate a safe therapeutic environment for the client.

16. Post-Operative Phase is the period between the admission of the client
to the recovery room until the healing is complete. The nursing activities
during this phase include.
• (i) Assessment of the clients response to surgery. (Physical and
Psychological).
• (ii) Care to promote healing process.
• (iii) Activities to prevent complications.
• (iv) Health teaching and postoperative exercises.
• (v) Planning for home care.

17. Pre-operative Care of Patients (In General)
• Pre-operative care of the patient begins as soon as the surgeon makes a
diagnosis and decides that an operation is necessary for the patient.
1. Psychological Preparation
Discuss with the patient to give full information about the surgery, such as:
• Type of surgery
• - Consequence of surgery (if it is done and if it is not done)
• - The problems to be faced (disabilities expected)
• Expected duration of hospitalization
• Expected time of resuming duty (if employed)
• Cost of surgery
• Treatment/investigations done before surgery and its purpose
• Necessary arrangements to be made about the family, financial matters, work,
hospitalization, etc.
•

18. 2. Eradicate Fear of Operation from the Patient
• Allow the patient to ask questions and clear all his doubts from her.
• Introduce the patient to someone who had similar surgeries and have
been successfully recovered from the symptoms.
• Explain what happens during anaesthesia
• Explain how to get rid of pain after surgery.
- Tell the patient when he can have meals

19. - Answer all questions asked by the patient in a language he can
understand, so that the patient will have confidence to undergo
surgery.
- Let the patient see the persons, places and equipment involved in his
operation.
- Always start the procedures with an explanation, so that it will inspire
confidence in the medical team. The patient has to feel that he will be
safe in the hands of the competent people during surgery.
- For many patients, their admission to the hospital is a first experience
in their lives. In such a situation, the nurse should make them feel at
home by eradicating their fear.

20. 3. Meet the Spiritual Needs of the Patient
• -Help the patient to meet the ministers of his religion, if requested by
the patient.
4. Obtain informed Consent
- Obtain the consent from the patient/guardian for each operation
after explaining the nature of the operation and anesthesia.
- Never compel the patient/guardian to give their consent. Explain
the complications that may occur when the patient is under
anesthesia.
- The language used in the consent form should be understood by the
patient/guardian, who gives the signature. Obtain consent for major
diagnostic procedure.

21. Build up the General Health of the Patient and Correction of the Disease
Process for Speedy Recovery
- Assist the doctor to carry out a thorough physical examination from
head to foot to assess the physical health of the patient.
- Ask the patient appropriate questions to obtain past and present
medical history in order to exclude anaemia, jaundice, diabetes, asthma,
lung infections, hypertension, heart dis- eases, bleeding tendencies,
mental diseases, drug reactions, blood transfusions, previous operations,
etc.
- Carry out the investigations that the doctor ordered, such as; Blood for
Hb, TC, DC, ESR, blood urea, blood sugar, BT. CT, HIV, VDRL grouping
and typing etc. Urine for albumin, sugar, microscopic examination.

22. - Collect all the baseline data - temperature, pulse rate, respiration, blood
pressure, ECG, X-ray chest etc.
Further investigations may be carried out that are specific the nature of the
operation e.g., Intravenous pyelography kidney operations.
- Arrange for the blood donors.
- Fluids may be administered if the patient is dehydrated.
Patients with chronic obstructive pulmonary disease (COPD) will have
pulmonary function tests done before they undergo the general
anaesthesia. Diet may be adjusted to correct under weightover weight of
the patient.

23. 6. Pre-operative Teaching
- Stop smoking (if the patient is a smoker)
- Maintain personal hygiene
- Deep breathing and coughing exercises to prevent chest
complications.
- Active and passive exercises of the limbs to prevent postoperative
thrombus (blood clot) due to venous stasis.
- Postural drainage to prevent pulmonary complications,
e.g. COPD. - Control of visitors to prevent cross infection.

24. 7. Surgical Preparation of the Skin
8. Preparation of the Patient on the Evening before Operation
- Remove all jewellery and hand over them to the relatives.
- Remove the lipstick and nail polish etc. if the patient wa using.
- Get the orders from the physician for immediate pre-operative
preparation. These orders cancel all previous ones.
- If the patient was taking some drugs regularly, such as insulin, steroids,
hormones, digitalis preparations (card drugs)., ask the physician how to
administer them.
- Shave the part to be operated.

25. - After shaving the area, ask the patient to have a bath and dress in
clean clothes
- Paint the area using a safe antiseptic, eg, Mercurochrome
- Enema is ordered on the evening when the the gastro-intestinal
system/pelvic/perineal/and surgery involves areas. perianal areas
- A light diet in the evening before the day of surgery and fasing after
midnight (6 to 8 hours prior to surgery) is advised to prevent vomiting
and aspiration of the food materials into the lungs during general
anaesthesia.

26. - A tranquillizer like diazepam may be ordered by the doctor and it is
given at bedtime to the patient to ensure good sleep at night before
the day of surgery.
- The patient should be reassured to prevent anxiety and fear of
operation.
- Note : The preparation of the patient for surgery varies according to
the types of operation and the surgeon's preferences. Therefore ask
the surgeon for specific orders.

27. 9. Preparation of the Patient on the Day of Surgery
• Help the patient to go to toilet and for the mouth care.
Remove hair pins, clips, ornaments, false teeth etc.
• Comb the hair and tie them with a ribbon.
• Remind the patient and his relatives about the fasting before
surgery. If there is a delay for the operation, ask the
surgeon/anaesthetist about the fluids (drinks) that can be given to
the patient.

28. • Check the orders for the bowel preparation.
Some doctors may prefer to give an enema and a bowel wash on the
morning of operation to empty the bowels, if the operation is on the
bowels. Repeated enemas and bowel wash tire the patient, upset the
electrolyte balance and irritate the rectal and bowel mucosa.
• Clean the operation site with soap and water thoroughly, dry the area with
a clean towel, and paint the area with mercurochrome or any other
antiseptics that will not damage the skin. Cover the operation site with a
sterile towel, and fix it by means of binderbandages.

29. • Introduce a naso-gastric tube, urinary catheter etc. if ordered by the
surgeon. Always reassure the patient by giving appropriate explanations
and take all the precautions.
• Stop all medications, unless specially ordered by the surgeon. If oral
medicines are to be given/give them with a minimum amount of water.

30. 10. Sending the Patient to Operating Room
• Administer the pre-medications to the patient one hour before
surgery. These are the drugs that reduce anxiety in the patient, and
provide a smoother induction
• Before giving the pre-medications, check the vital signs of the patient
such as blood pressure, temperature, pulse, res. pirates etc. Record
the vital signs in the patient's charts as baseline data.

31. • Change the patient's dress and put on hospital gown, Write the
patient's name, age, ward, bed number, diagnosis hospital number
etc. on an identification card and fasten t onto the dress or on the arm
to prevent mistaken identity.
• Ask the patient to void just before sending the patient to the operating
room.
• Transfer the patient onto a patient trolley and cover him with clean
sheets to prevent draught.
• Never leave the patient alone on a trolley without any person near-by
to prevent falls and injuries.

32. • Always send the patient's charts with all reports, such as lab
reports/medication charts/X-ray/ECG reports/and other investigations
done on the patient. Check the consent form for the operation and
anesthesia.
• Always send the patient with an attendant up to the operation
theater. It is preferable to have a female attendant to accompany the
female patient.
• Always entrust the patient to someone who will take responsibility for
the patient while he is in the operation theater.

33. NURSING DIAGNOSIS OF THE PRE-OPERATIVE CLIENT
1.Anxiety related to lack of knowledge about pre-operative routines and
post-operative care.
2. Fear related to effect of surgery and ability to function in usual roles.
3. Fear related to the risk of death.
4. Anxiety related to the outcome of exploratory surgery for
malignancy.
5. Fear related to loss of control during anesthesia or waking up during
anesthesia.
6. Anxiety related to the perceived inadequate postoperative
analgesia.

34. 7. Sleep pattern disturbance related to hospital routines and psychological
stress
8. Anticipatory grieving related to perceived loss of body part associated with
planned surgery.
9. Ineffective individual coping related to conflicting values ​​(e.g., need for blood
transfusion verses the religious values ​​for Jehovah's witness).
10. Ineffective individual coping related to lack of clear out-come of surgery.
11. Ineffective individual coping related to unresolved past negative experience
with surgery.

35. Intra-operative Care
When a client arrives in the operating room three groups of personnel are
involved in the care.
1. The anesthetic team
2. The surgical team
3. The operating room nurses
Intra-operative nurses are responsible for the safety and well being of the
patient, the co-ordination of the operating room per- sonnel and activities
of the circulating nurse and the scrub nurse.

36. Intra Operative Nursing Functions
(A) The Circulating Activities include assuring cleanliness, proper
temperature, humidity and lighting, the safe functioning of the equipment and
the availability of the supplies and materials.
The circulating nurse also monitors the aseptic practices of the related
personnel (Medical, X-ray and Laboratory) besides monitoring the safety of
the patient throughout the surgical procedure,
(B) The Scrub Activities includes scrubbing for surgery, setting up the sterile
tables, preparing sutures, ligatures and special equipments and assisting
surgeons during the procedure.

37. Nursing Diagnosis of
Intra Operative Clients
1. Potential for risk of aspiration
related to the position used for
surgery and anaesthesia.
2. Potential for risk of perioperative
positioning injury related to improper
positioning and inadequate support while
positioning.
4. Potential for altered tissue perfusion related
to anesthetic drugs5.
5. Potential for risk of fluid volume deficit
related to loss of fluid during surgery.
6. Potential for risk of altered body
temperature related to:
• (a) Lowered room temperature of theater
operation.
• (b) Infusion of cold fluids.
• (c) Inhalation of cold gases
• (d) Decreased muscle activity
• (e)Advanced age
• (f) Use of pharmaceutical agents.

38. POST OPERATIVE CARE
1.PREPARATION OF POST ANESTHETIC BED & RECEPTION OFTHE
PATIENT
• Prepare bed for the patient
•There should be adequate number of people to transfer the
patient
• Received patient without disturbing the devices attached
to the patient
• Check operation site for the bleeding or any discharge.

39. • Keep the patient well covered and comfortable
• Never leave the patient alone
• Observe the patient for swallowing reflex. If not present
keep the patient in a sideling position to prevent the
tongue falling back and obstructing the airway
• Check the doctor’s order

40. 2. CARE OFTHE PATIENT WHO IS UNDERTHE EFFECTS OF
ANAESTHESIA
• Patient needs close and diligent observation until the patient fully
recover from anaesthesia.This will help to detect the early signs of
complications after surgery and the nurse will be able to respond
immediately.
• A noisy breathing is indicative of airway obstruction that can occur due
to the tongue falling back and obstructing the pharynx, or fluid collected
in the airway passages or fluids aspirated into the lungs. Apply suction
immediately, send call the surgeon and the anaesthetist.

41. • Keep the patient in a suitable position that will be helpful to drain out
the vomitus, blood and secretions collected in the mouth and will
prevent them aspirating into the lungs.This position is maintained until
protective reflexes are returned.
•The oro-pharyngeal airway left in the mouth of the patient should be
removed as soon as the patient has regained the cough and swallowing
reflexes
• Excessive secretions in the mouth or anywhere in the respiratory
passage can lead to airway obstruction. It should be sucked out. If intra-
tracheal suctioning is necessary, always use sterile technique.

42. • If the patient is cyanosed, administer oxygen inhalation. At the same
time, find out the cause and remove the cause. prolonged oxygen
therapy should be guided by arterial blood as determinations
• A weak thready pulse with a significant fall in blood pressure may
indicate circulatory failure. It may also indicate loss from the body.The
surgeon and the anaesthetist should be informed.
• In order to prevent injury from falls from bed, put the rails on the
bed.Till the patient recover from the effects of anaesthesia, the nurse
should not leave the patient Alone

43. • Patient recovering from anaesthesia may ask for
drinking water Unless the patient has fully regained the
swallowing reflex, drinking water may choke the patient;
it should not be given.
• As the patient is recovering from the effects of
anaesthesia, the patient may become restless due to the
discomfort caused by the presence of those devices
attached to the patient, such as i.v. sets, urinary
catheters, drainage tubes etc.

44. The nurse should help the patient by giving adequate
explanations
• Keep the family informed of the successful completion of
surgery, transfer of the patient from the operating room to
recovery room etc.These information will reduce their anxiety.
• If possible, allow the relatives to meet surgeon to clear their
doubts.

45. 3. OBSERVATIONOFTHE PATIENT INTHE POST OPERATIVE PERIOD
• Close and diligent observation by the nurses are important to detect complications
in the early stages, and thus, save the patient.
• On the first post operative day the patient needs close and frequent observations :
e.g., the vital signs are checked every 15 minutes or more frequently
The main points that should be observed are :
•Vital signs—blood pressure, pulse rate, respiratory rate, skin colour, skin
temperature.
• Intake and output — I.V. fluids, oral fluids taken by the patient, naso- gastric
aspiration, wound drainage, blood loss.
• Abdominal girth in patients with abdominal distension.
•

46. Urinary output - time and amount.
• Bowel movements.
• Signs of hypo/ hypervolaemia.
• Any breathing difficulties.
• Pain over the calf muscles.
• Operation site for bleeding, drainage
• Any specific observation as told by the surgeon and according to the operation done.

47. 3.CARE OF WOUND
• Check Dressing
• Dressing should be regular
• Skin care
• Infection control
• Proper diet

48. 4.DIET OFTHE PATIENT
• All patients, except patients who had abdominal surgery, may
start the normal diet, if desired so, on the first day. Remember to
exclude nausea and vomiting due to the effect of anaesthesia.
• Patient who had abdominal surgery, but did not involve the
intestine or stomach, can have the clear fluids on the day after the
surgery.
• Gradually, it can change into soft diet and then normal diet.

49. • Patients who are with specific diseases, for
which they scare taking special diets, should
continue to observe the control of their diet as
ordered by the doctor (e.g., a diabetic patient)
• Remember, the patients who had undergone
any type of surgery need a diet rich in vitamins
and minerals.

50. 6. POST OPERATIVE HEALTHTEACHING
All patients need health teaching according to the education at background of
the patient.
Teach the patient following points
• Maintenance of personal hygiene.
• Diet that is allowed for the patient; any control on the diet.
• Ambulation; activities that are permitted, as well as restricted.
• Any adjustments to be made in the occupation of the patient.

51. • Any drugs to be taken post operatively; the side effects and
precautions
. • Date on which the patient may resume duty.
• Learning of any particular procedure to be carried out
postoperatively, e.g., care of the colostomy. When the patient is
unable to perform the procedure, teach the patient's relatives.
• Future treatment that may be needed for the patient in any
other hospital e.g., radiation therapy for cancer patients.

52. NURSING DIAGNOSIS OF POST OPERATIVE CLIENTS
a Ineffective airway clearance related to effects of medications and
anaesthetic agents.
b Ineffective breathing pattern related to pain, surgical incision and
medications.
c Risk for altered body temperature, hypothermia — related to the use of
drugs, infusion of cold fluids, inhalation of cold gases etc.
d Risk for injury related to post anaesthetic status.
e Pain related to surgical incision and reflex muscle spasm.

53. f.Altered nutrition, less than body requirements.
q Risk for fluid volume deficit related to loss of fluid during surgery and inadequate
intake of fluid after surgery.
h. Nausea and vomiting related to gastrointestinal distension medication, anaesthetic
effect and stimulation of vomiting centre or chemoreceptor's trigger zone.
i. Risk for infection related to surgical incision, inadequate nutrition and fluid intake,
presence of environmental pathogens, invasive catheter and immobility.
j. Altered urinary elimination related to decreased activity, effects of medication and
reduced intake of fluid.