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1. PRE
OPERATIVE
NURSING
CARE

2. Surgical Classifications
Surgery may be performed for various reasons.
1. Diagnostic (eg, biopsy or exploratory
laparotomy).
2. Curative (eg, excision of a tumor or an
inflamed appendix)
3. Reconstructive or cosmetic (eg,
mammoplasty or a facelift)
4. Palliative (eg, rhizotomy to relieve pain )

3. CLASSIFICATION INDICATIONS FOR SURGERY
EXAMPLES
I. Emergent—Patient requires immediate attention; disorder
may be life-threatening.done without delay.eg.,Severe
bleeding,Bladder or intestinal obstruction,Fractured skull,
II. Urgent—Patient requires prompt attention. Within 24–30 hr.
Acute gallbladder infection. Kidney or ureteral stones
III. Required—Patient needs to have surgery. Plan within a few
weeks or months. Prostatic hyperplasia without bladder
obstruction ,Thyroid disorders, Cataracts
IV. Elective—Patient should have surgery. Failure to have
surgery not catastrophic. Repair of scars, Simple hernia,
Vaginal repair
V. Optional—Decision rests with patient.Personal preference
Cosmetic surgery

4.  DEGREE OF RISK
 Major
 Minor
 ANATOMICAL LOCATION
 Abdominal
 Thoracic
 Neurological
 Cardiac
 Renal
 EXTENT OF SURGERY
 Minimal
 Open
 Radical
 Open

5. Perioperative and perianesthesia nursing addresses
the nursing roles relevant to the three phases of
the surgical experience:
preoperative, intraoperative, and postoperative.
 The preoperative phase begins when the
decision to proceed with surgical intervention is
made and ends with the transfer of the patient onto
the operating room table.
 The intraoperative phase begins when the
patient is transferred onto the operating room
table and ends when he or sheis admitted to the
postanesthesia care unit (PACU)

6.  The postoperative phase begins with
the admission of the patient to the
PACU and ends with a follow-up
evaluation in the clinical setting or at
home.

7.  Preoperative Phase
1. Initiates initial preoperative assessment
2. Initiates teaching appropriate to patient’s
needs
3. Involves family in interview
4. Verifies completion of preoperative testing
5. Verifies understanding of preoperative orders
(eg, bowel preparation, preoperative shower)

8. In the Holding Area
1. Assesses patient’s status; baseline pain
and nutritional status
2. Identifies patient
3. Verifies surgical site
4. Takes measures to ensure patient’s
comfort
5. Provides psychological support

9.  preoperative interview (which include
physical, emotional assessment, previous
anesthetic history, allergies or genetic
problems
 Ensure that Necessary tests performed,
 Arranging appropriate consulative
services,

10. Pre operative assessment
 History taking
Past medical conditions, HTN, epilepsy, bronchial
asthma, tuberculosis, cardiac diseases
Drug therapy: steroids, antibiotics, antihypertensives,
anti diabetic drugs,antiepileptics.
ALLERGIES
Previous hospitalization, surgeries, ?
Ill habits ?
Women: menstural history

11.  ASSESSMENT
Nutritional & fluid status
Drug & alcohol use
Respiratory status
Cardiovascular status
Hepatic & renal function
Endocrine function
Immune function
Concurrent or prior pharmacotherapy

12. NUTRITIONAL & FLUID
STATUS
 Optimal nutrition required ; promote healing ,
resisting infection & surgical
complication.
 Assess for obesity, under nutrition,
weight loss, malnutrition, metabolic
abnormalities & effects of medication.
 Nutrients needed for wound healing;
Vit A ,C ,K ,iron ,zinc .
 Assess for dehydration, hypovolemia &
electrolyte imbalances.

13. DRUG & ALCOHOL USE
 Acutely intoxicated persons ;
susceptible to injury.
 For emergency surgery, local,
spinal, block anesthesia is used
 To prevent vomiting & aspiration,
a nasogastric tube is inserted, before
administering general anesthesia

14. RESPIRATORY STATUS
 Goal ; optimal respiratory function.
 Patients are taught breathing
exercises & use of incentive
spirometer.
 Surgery postponed if respiratory
infection present
 Assess for current threats to
pulmonary status in patients with
chronic pulmonary diseases.
 Urge smokers to stop before two
months or at least 24 hours prior to surgery.

15. CARDIOVASCULAR STATUS
 Well functioning CVS meets
oxygen, fluid & nutritional needs
of perioperative patient.
 Surgery postponed if patient has
uncontrolled hypertension.
 Greater than usual diligence
required for cardiac patients

16. HEPATIC & RENAL
FUNCTION
 Medications, anesthetic agents,
body wastes & toxins are processed
& excreted through the kidneys.
 Liver ; biotransformation of
anesthetic compounds
 Careful assessments through
LFT & RFT
 Surgery contraindicated in renal
patients unless its a life saving measure

17. ENDOCRINE FUNCTION
 Patients at risk are
Diabetics
With Thyroid disorders
 Goal is to maintain blood glucose less
than 200 mg/dl
 Maintain optimal thyroid levels

18. IMMUNE FUNCTION
 Existence of allergies
 Sensitivity to medications
 Any past adverse reactions to ; latex ,food,
blood transfusions
 Immunosuppression ; corticosteroid
therapy, transplantations , AIDS ,
leukemia.
 Slightest temperature elevation is
investigated.

19. Concurrent /Prior Medication
 Interaction of some drugs with anesthesia can
lead to hypotension & circulatory collapse
 Nurse informs physician if patient is on
 Certain antibiotics
 Antidepressants ; MAOI
 phenothiazines
 Diuretics
 Steroids
 Anti coagulants ;warfarin / coumadin
 Self prescribed OTC drugs ; aspirin
 Herbal medicines

20. PSYCHOSOCIAL FACTORS
 Assess type of emotional reaction before surgery
 Fear is related to
 Fear of the unknown
 Anesthesia
 Pain
 Complications
 Death
 Threat to customary role in life
 Permanent incapacity
 Being a burden on family members
 Determine best approach to increase
comprehension

21. SPECIAL CONSIDERATIONS
 AMBULATORY SURGERY PATIENT
 Brief time
 Quick & comprehensive assessment
 Anticipate patient’s needs
 Plan for discharge & follow up care
 ELDERLY PATIENT
 May have chronic illness
 Less physiologic reserve
 Low cardiac reserve
 Renal & hepatic functions are depressed
 Reduced gastrointestinal activity
 Dehydration, constipation & malnutrition
 Sensory limitation
 Presence of dentures
 Arthritis

22. Risk factors
 Hypovolemia
 Dehydration or electrolyte imbalance
 Nutritional deficits
 Extremes of age (very young, very old)
 Extremes of weight (emaciation, obesity)
 Infection and sepsis
 Toxic conditions
 Immunologic abnormalities
 Pulmonary disease
 Respiratory infection

23.  Renal or urinary tract disease
 Decreased renal function
 Urinary tract infection
 Obstruction
 Pregnancy
 Diminished maternal physiologic reserve
 Cardiovascular disease
 Coronary artery disease or previous myocardial
infarction
 Cardiac failure
 Dysrhythmias
 Hypertension
 Prosthetic heart valve

24.  Endocrine dysfunction
 Diabetes mellitus
 Adrenal disorders
 Thyroid malfunction
 Hepatic disease
 Cirrhosis
 Hepatitis
 Preexisting mental or physical disability

25. Physical examination
 Diagnostic procedures
Electrolytes: k, Na
Creatinine
BUN
Hb
Prothrombin time
Crossmatch

26. Psychosocial assessment
Age
Past experience and stress
Current health and socio economic status
Reducing preoperative anxiety
Cognitive strategies useful for reducing anxiety, music
therapy is an easy to administer, inexpensive,
noninvasive intervention
 Decreasing Fears
 Reflecting Cultural, Spiritual, and Religious Beliefs
Include identifying and showing respect for cultural,
spiritual, and religious beliefs, such as in pain control, or
in blood transfusion.

27. PREOPERATIVE NURSING
INTERVENTIONS
PREVIOUS DAY PREPARATION
o Implementing dietary restriction
o Intestinal preparation
o Skin preparation
o Teaching postoperative exercises
o Importance of early ambulation
ON THE OF SURGERY
o Preoperative chart review
o Preoperative client preparation
o Preparative medication

28. INFORMED CONSENT
• Voluntary and written informed consent from the
patient is necessary before non emergent surgery
can be performed.
• Such written consent protects the patient from
unsanctioned surgery and protects the surgeon
from claims of an unauthorized operation.
• In the best interests of all parties concerned, sound
medical, ethical, and legal principles are followed.
The nurse may ask the patient to sign the form and
may witness the patient’s signature. It is the
physician’s responsibility to provide appropriate
information.

29. o Before the patient signs the consent form, the
surgeon must provide a clear and simple
explanation of what the surgery is
o The surgeon must also inform the patient of the
benefits,alternatives, possible risks,
complications, disfigurement,disability, and
removal of body parts as well as what to expect
in the early and late postoperative periods.
o Nurse ensures that the consent form has been
signed before administering psychoactive
premedication

30. Criteria for Valid Informed Consent
1.Valid consent must be freely given, without coercion.
2.Individual who are mentally retarded, mentally ill, or comatose
cannot give consent
3. Subject should be informed
Informed consent should be in writing. It should contain the
following:
• Explanation of procedure and its risks
• Description of benefits and alternatives
• An offer to answer questions about procedure
• Instructions that the patient may withdraw consent
• A statement informing the patient if the protocol differs from
customary procedure
4.Information must be written and delivered in language
understandable to the patient. Questions must be answered
to facilitate comprehension if material is confusing.

31. 5. When the patient is a minor or unconscious or
incompetent, permission must be obtained from a
responsible family member (preferably next of kin)
or legal guardian.
6. In emergency, it may be necessary for the
surgeon to operate as a lifesaving measure
without the patient’s informed consent. Everyeffort,
however, must be made to contact the patient’s
family.
7. Refusing to undergo a surgical procedure is a
person’s legal right and privilege.

32. Informed consent is necessary in the following
circumstances:
• Invasive procedures, such as a surgical incision, a
biopsy, a cystoscopy, or paracentesis
• Procedures requiring sedation and/or anesthesia
A nonsurgical procedure, such as an
arteriography, that carries more than slight risk to
the patient
• Procedures involving radiation

33. To summarize
Criteria for valid Informed consent:
 Voluntary consent
 Incompetent pt ( mentally retarded, mentally ill, or
comatose)
 Informed subject
 Explanation
 Description of risks and benefits
 Answer questions about procedure
 Instructions
 Pt able to comprehend. (Information written in
understandable language.

34. The two goals of preoperative care are:
To present the pt in the best possible physical and
psychosocial conditions for his operation
To initiate every effort that will eliminate or reduce
post operative discomforts and complications.

35. The goal of preoperative teaching is to familiarize
the pt with the expected post operative
outcomes such as:
 Facilitation of recuperative period.
 Attainment of a sense of well-being with
minimal fear of the unknown.
 Decreased need for analgesics
 Absence of complications
 Decrease time for hospitalization

36. Pre operative teaching
Teaching should be spaced over a period
of time
Deep breathing and coughing exercises to
promote lung expansion and to remove
secretions
Spirometry to improve the vital capacity of
lungs

37. Mobility and active body movements help
to improve circulation, prevent Venous
stasis and promote optimal respiratory
function
Pain management-Post operatively,
medications are administered to relief pain
and maintain comfort without increasing
the risks for inadequate air exchange.

38.  Coping strategies to relieve tension and anxiety
( imagery, distraction)
may be useful for relieving tension, overcoming
anxiety
 Imagery: the pt can concentrates on a pleasant
experience
 Distraction: thinks of an enjoyable story or song
 Optimal self-recitation: recites optimistic
thoughts.

39.  Npo status 8 to 10 hrs before surgery
 Bowel preparation to allow visualization of
the site and to prevent trauma and
contamination of peritoneum by feces
 Skin preparation to decrease the bacteria

40. Nursing diagnosis
Major preoperative nursing diagnoses of the
surgical patient may include the following:
• Anxiety related to the surgical experience
(anesthesia, pain)
and the outcome of surgery
• Fear related to perceived threat of the surgical
procedure
and separation from support system
• Knowledge deficit of preoperative procedures
and protocols
and postoperative expectations

41. NURSING MEASURES
 Provide adequate padding for
tender areas.
 Move patient slowly.
 Protect bony prominences
from prolonged pressure.
 Provide gentle massage to
promote circulation.
 A light weight cotton blanket is used as a cover
while moving an elderly patient