perioperative nursing

1. PERIOPERATIVE NURSING

2. PERI OPERATIVE NURSING
Definition
It is defined as delivery of patient care during preoperative ,intraoperative and post-operative
period.
Objectives of perioperative Nursing
To provide nursing care according to nursing process.
To promote the understanding of the patient’s total surgical experience ,ability to cope up with
physiologic, psychologic and sociological needs of the patient.
To provide basic knowledge related to body image and pain related to intraoperative procedure.
Assist the patient to relieve anxiety preoperatively.
To help patients understand the effects of anesthesia, medications and the procedures for early
recovery.
To become an effective communicator with the patients to relieve anxiety, tension related to
procedures.

3. Phases of Perioperative

4. Classification of Surgery
a) Based on purpose
Diagnostic :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, insertion of gastrostomy tube to compensate for the inability to
swallow.
Ablative/ curative: This is an operation in which the diseased body part is removed and complete
cure is ensured . e.g., removal of inflamed appendix (appendectomy), total excision of a tumour
mass.
Restorative/ reconstructive: 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 ,repair of
cleft lip and cleft palate etc.
Transplant / corrective : This is an operation in which deformities are corrected and
malfunctioning structure are replaced. e.g., hip replacement, replacement of the mitral valve.
Cosmetic : To improve the appearance. eg: rhinoplasty

5. b) Based on urgency
 Emergency surgery: Surgery is performed immediately to preserve function or save life
of the client. e.g., extensive burn, gunshot wound, acute appendicitis. Client requires
prompt attention. In this, pre-operative period is very short, because of the life
threatening situation. Therefore minimum preparation can be done in the pre-operative
period.
Urgent surgery :Surgery is performed within 24 to 48 hours. e.g. ureteral calculi, bleeding
uterine fibroids, acute gall bladder infection.
Elective surgery : Surgery is performed when surgical intervention is the preferred
treatment for a condition ,but not serious. Time for surgery is fixed with the mutual
consent of the surgeon and the patient. There is enough time left for the pre-operative
care for the patient. Surgery is required within weeks or months. Eg: cataract extraction,
tonsillectomy.

6. c) Based on degree of risk and seriousness
 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.e.g., 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., tooth extraction, tonsillectomy.
Suffixes Describing Surgical Procedures
Ectomy = Excision or removal of e.g., appendectomy
Lysis = Destruction of e.g., Electrolysis
Orrhaphy = Repair or suture of e.g., Colporrhaphy
Ostomy = Creation of opening into e.g., Colostomy
Plasty = Repair or reconstruction of e.g., Tympanoplasty

7. PREOPERATIVE CARE
Preoperative phase begins with the decision to have surgery
and ends with the patient transferred to operating room. The care during this
phase include:
a) Psychological preparation.
For many patients, their admission, to the hospital and surgery is a first
experience in their life. It is the nurses responsibility to eradicate fear of operation
from the patient.
Discuss with the patient and give full information about the surgery like type of
surgery , consequence of surgery, problems to be expected, duration in hospital,
expected time of resuming duty, cost of surgery, the investigations done before
surgery and its purpose.
Allow the patient to ask questions and clear all his doubts.
Introduce the patient to someone who had similar surgeries and have been
successfully recovered from the symptoms.

8.  Explain what happens during anesthesia explain how to get rid of pain after
surgery.
Explain post operative equipments , like tubes, drains and intravenous infusion
devices.
Tell the patient when he can have meals after surgery.
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 person's places and equipment involved in his operation.
In case of children, allow them to carry favorite toys on the day of surgery.

9. Provide preoperative teaching on the following :
 stop smoking and alcohol at least 2-3 weeks prior to
surgery
Maintain personal hygiene
 NPO from 12 midnight to avoid aspiration
 withhold aspirin ( enhances bleeding tendency)
 control number of visitors
 modification of diet
 post operative exercises

11. Incentive spirometry
•Encourage patient to use incentive spirometer about 10 to 12
times per hour.
• Deep inhalations expand alveoli, which prevents atelectasis
and other pulmonary complication.

12. Diaphragmatic Breathing
• In a semi-Fowlers position, with your hands loose- fist, allow to rest
lightly on the front of lower ribs.
• Breathe out gently and fully as the ribs sink down and inward toward
midline.
• Then take a deep breath through the nose and mouth, letting the
abdomen rise as the lungs fill with air.
• Hold breath for a count of 5.
• Exhale and let out all the air through your nose and mouth.
• Repeat this exercise 15 times with a short rest after each group of 5.

13. Coughing and Splinting
• Promotes removal of chest secretions.
• Interlace the fingers and place hands over the proposed incision
site, this will act as a splint and will not harm the incision.
• Lean forward slightly while sitting in bed.
• Breath, using diaphragm
• Inhale fully with the mouth slightly open. Let out 3-4 sharp hacks.
• With mouth open, take in a deep breath and quickly give 1-2 strong
cough

14. Foot and Leg Exercise
• Moving the legs improves circulation and muscle tone.
• Have the patient lie supine, instruct patient to bend a knee and raise
the foot – hold it a few seconds and lower it to the bed.
• Repeat above about 5 times with one leg and then with the other.
• Repeat the set 5 times every 3-5 hours.
• Then have the patient lie on one side and exercise the legs by
pretending to pedal a bicycle.
• For foot exercise, trace a complete circle with the great toe.

15. b) Legal preparation.
 Obtain informed/legal consent from patient or guardian or family
after explaining the nature of surgery and anesthesia.
Never compel the patient to give consent.
The language which is used to explain, should be simple and
understood by the patient and family.
Obtain consent for major diagnostic procedures.
Explain the complications that may occur when the patient is under
anesthesia.
 The child’s parent or legal guardian must sign for children under the
legal age.

16. c) Physical preparation.
Shaving and cleaning the skin with antiseptic solutions to
avoid risk of developing complications. (in case of children,
shaving should be avoided.)
Observe the skin for any rashes, cuts or irritation
In case of spinal anesthesia, shaving is done on lumbar
region
Provide thorough bath on the previous day of surgery

17. d) Spiritual preparation.
 Help patients to practice their beliefs and practices
according to their religion.
 It helps decrease fear, anxiety, and promote the hope of
recovery.

18. e) Physiological preparation.
 Head to foot examination to assess the general condition of the
patient.
 Ask for past medical history, past surgical history, any previous blood
transfusion, any diseases like diabetes, hypertension ,tuberculosis or
any other communicable disease, previous and present medication,
any allergies, dietary restrictions, alcohol or nicotine usage, smoking
habit, occupation, any prosthesis, any chronic illness .
 Carry out the investigations such as blood for hemoglobin ,TC, DC,
ESR, Blood urea, blood sugar, BT, CT, HIV, VDRL test , blood
grouping.
 Urine is tested for albumin ,sugar and microscopic examination.
 Collect all the baseline data like temperature, pulse, respiration and
blood pressure.

19. Chest X-ray and lung studies to assess the lung function.
ECG to assess the cardiac function.
 Renal studies, urinary output to assess the kidney functions.
 Arrange for blood donors or blood in case of emergency.
 In case of dehydration, start IV fluids
 Diet must be adjusted to correct, overweight or underweight.
 Ask the patient to provide the list of drugs ,vitamins, herbal
medications and food supplements.
 Check for latex allergy.

20. f) 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 was using
Get the orders from the physician for immediate pre-operative
preparation.
If the patient was taking some drugs regularly, such as, Insulin,
steroids, hormones, digitalis preparations (cardiac drugs), ask the
physician how to administer them.
Shave the part to be operated
After shaving the area, ask the patient to have a thorough bath and
dress in clean clothes
Paint the area using a safe antiseptic, e.g.. Mercurochrome

21.  Enema is ordered on the evening when the surgery involves the gastro-
intestinal system/pelvic/perineal/and perianal areas.
 A light diet in the evening before the day of surgery and fasting 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.
 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.
 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.

22. g) 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 delay for the operation, ask the surgeon/ anaesthetist about
the fluids (drinks) that can be given to the patient.
 Check the orders for the bowel preparation. Some doctors 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.

23. Clean the operation site with soap and water thoroughly, dry the
area with clean towel, and paint the area with antiseptics that will
not damage the skin. Cover the operation site with a sterile towel,
and fix it by means of binderbandages.
 Introduce a naso-gastric tube, urinary catheter etc. if ordered by
the surgeon.
 Stop all medications, unless specially ordered by the surgeon. If
oral medicines are to be given/give them with minimum amount
of water.

24. h) 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 of anaesthesia.
 Before giving the pre medications, check the vital signs of
the patient such as blood pressure, temperature, pulse,
respirations etc. Record the vital signs in the patient's charts
as baseline data.
 Change the patient's dress and put on hospital gown.

25. Write the patient's name, age, ward, bed number, diagnosis
,hospital number etc. on a identification card and fasten it
onto the dress or on the arm to prevent mistaken identity.
 Ask the patient to void just before sending the patient to
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 nearby to prevent falls and injuries.

26. 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 anaesthesia.
 Always send the patient with an attendant up to the
operation theatre. It is preferable to have female attendant to
accompany the female patient.
Always entrust the patient to someone who will take
responsibility of the patient while he is in the operation
theatre.

27. INTRA OPERATIVE NURSING
The term intraoperative face refers to the time during the
surgery within the operation theater.
Surgical team.
Surgeon: Leader of surgical team responsible for performing
surgery safely
Anesthetist-
 Physician trained in giving anesthesia (It helps reduce pain,
maintain relaxation).
He monitor physiological status of patient during surgery, monitor
the oxygen status, Systemic circulation, Vital Signs, neurologic
status and respiratory status, cardiovascular status.

28. Scrub nurse - The scrub nurse is the one who prepares the sterilized
instruments and equipments ready for the surgery and assist the
surgeon during surgery.
 Must wear PPE
maintain surgical asepsis while draping and handling instruments
assist surgeon in surgery , passage of correct instruments and
suturing.
Handle sterile equipments.

29. Have extensive care of all instruments.
Set up the operation room table prior to surgery.
Count all sponges, instruments ,needle during surgery. After
surgery, she counts all instruments, sponges and inform the
surgeon.
 Preparing suture ,ligature

30. Circulating nurse.
She is a professional registered nurse who does not scrub, who
helps the scrub nurse, free to move about to assist all other scrub
personnel
She is a link between the scrub personal and outside of operation
room.
She obtains and deliver supplies to sterile field and carries out
nursing activities.
 Receive the patient, check the patient's identity with name band,
case paper and operating list

31. Assist in positioning of the patient on the operating table.
She monitors the patient.
She check for the function of the equipments.
She ensures proper cleanliness, temperature ,humidity, lighting ,function of
equipments availability of supplies etc.
She's responsible for charting and recording.
 She assist the surgeon and scrub nurse.
 Assist in tying gowns for the surgeons, scrub nurse, anesthesiologist etc.

32. Open sterile instruments and bowl packs and other necessary equipment's for
scrubbed nurse
She checks the stock of drugs, instruments and equipments. Eg: Swabs,
specimen jars, sterile water, sterilized gowns and gloves for the team
Receive specimen for laboratory test and label it.
Help with the removal of drapes and preparation of the patient for return to the
recovery room.
Remove the instruments trolley and other equipments to the cleaning room after
surgery.
Ensure that the theater is cleaned and prepared for the next case.

33. Perioperative nursing care
 Obtain data from patient and patient record (rule out any risk factor)
 Positioning the patient for the surgery
 Providing emotional care by reducing anxiety
 Maintain safety of the patient
 Maintaining surgical asepsis
 Preventing hypothermia
 Assisting surgeon in surgery
 assisting with wound closure
 continuous monitoring of the patient

34. • POSTOPERATIVE NURSING CARE
 Immediately after the surgery , the patient is shifted to Immediate Postoperative Care in
Recovery Room (RR) or Postanesthesia Care Unit (PACU)
The goal of the postoperative phase
 the patient's return, as quickly as possible, to an optimal level of functioning from the
effect of anesthesia and traumatic effects of surgery
promote wound healing
prevent complications.
Much of the nursing care in the immediate postanesthetic period depends on the surgical
procedure performed and type of anesthesia given.

35. • Personnel in Postanesthesia Care Unit
Adequate personnel should be available to monitor patients and to provide appropriate
care as needed.
PACU nurses should demonstrated competency in:
 Physical assessment (e.g. heart and lung sounds)
Management of physiologic emergencies (e.g. airway, hemorrhage, cardiac arrest)
Additional competency in basic life support (BLS) and advanced cardiac life support
(ACLS).

36. • Admission to Postanesthesia Care Unit
The circulatory nurse should call the PACU nurse before the patient leaves the operation
room to give the estimated time of arrival in the PACU and to advise of a need to have any
special life support equipment on standby for immediate use.
 The patient is accompanied to the recovery room or PACU by the anesthesiologist and
another member of the operation team.
The surgeons discuss the result of the surgery with the family immediately after surgery
and also visit the patient to describe the findings and to provide reassurance.
As the patient enters the PACU, his or her immediate physiological and psychological
status is reported to PACU nurse and any emergency life support equipment such as a
ventilator is connected if required.

37. The PACU nurse connects electrocardiography electrodes, attaches a pulse
oximetry lead, and place a blood pressure cuff on the patient( cardiac monitor)
The recovery room nurse assesses the patient's status, obtains a report and
begins recording the recovery room notes.

38. • Postoperative Report and General Nursing Care for All Patients in Recovery
Room
The postoperative report will vary according to the type of anesthesia and the
surgical procedure, the anesthesiologist and the surgeon preference and the
policy and procedures.
The main emphasis is placed on the needs of the patient in the immediate
postoperative period which includes
• Maintain pulmonary ventilation
• Circulation
• Fluid and electrolyte balance
• Prevent injury
• Promotes comfort

39. Preparing recovery room to receive patient
The patient's room is prepared to facilitate patient transfer and monitoring.
Adequate number of people should be present to transfer the patient without disturbing
the functioning of the devices attached to the patient.
Make an open surgical bed to facilitate easy transfer of the patient.
Provide sufficient covers/blanket (patient may feel cold).
Clear passageway to the bed.
Provide necessary equipment
IV Stand
 Sphygmomanometer/BP apparatus and stethoscope

40. Thermometer
Kidney/emesis basin
Suction cylinder/or centralized oxygen with nasal cannula or mask.
 Ensure proper functioning of cardiac monitor and other devices
 Any special equipment as required

41. Immediate post operative Phase
Immediate postoperative phase is the first few hours after surgery when
the client is recovering from the effect of anesthesia.
 Quickly observe the functioning of all devices and make sure they are in
functioning order.
Assess airway patency and support as needed, and assess for the presence of
hoarseness, cramp, stridor, wheezes , decreased breath sounds or noisy
breathing
Applies humidified oxygen via nasal cannula or facemask
Record vital signs (blood pressure, heart rate, strength and regularity, respiratory
rate and depth, oxygen saturation, skin color, and temperature)
Assess the client's level of consciousness, muscle strength and ability to follow
commands

42. Observe the client's IV infusions, dressings, drains and special equipment.
Connect all the tubings ( IV infusion, cardiac monitor)
Keep the patient in a suitable position that will be helpful to drain out the vomitus,
blood, secretions collected.( side lying). If spinal anesthesia – foot end slightly elevated
check the operation site for bleeding, discharge , etc, if drainage tubes are fitted.
Observe the patient for swallowing and coughing reflex
 Keep the patient well covered to prevent draught
The nurse receives verbal report regarding surgery in detail, i.e. type of surgery, time
of incision, patient's condition during surgery, type of anesthesia, sedative, any
untoward incident happened and everything about surgery and documents the reliable
and retainable information for further care.
 Record intake and output, amount of drain, nasogastric aspiration, vitals
 carry out other doctors orders

43. • Post operative care
Maintaining airway patency:
Airway obstruction (indicated by noisy breathing) is usually caused by falling
back of the relaxed tongue against the pharynx, secretions or other fluids
collecting in the pharynx, trachea or bronchial tree.
 Positioning - side-lying or semi prone position with the head tilted back (if not
contraindicated) and the jaw supported forward.
Artificial airway - Allow metal, plastic or rubber airway to remain in place until the
patient begins to waken and is trying to eject the airway. Some patients may
return from the OR with an endotracheal tube.
Removal of secretion - Oropharyngeal suction is usually done. Tracheal
suctioning may be indicated.
 Encourage body position changes at least every 2 hours( avoid pooling of
secretion)

44. Maintaining adequate ventilation:
 Oxygen therapy-Oxygen is administered by nasal cannula,
disposable facemask, endotracheal or tracheostomy tube, if one is in
place.
Breathing exercises--Deep breathing exercises are started as soon
as the patient is fully conscious and able to follow instructions.
Use additional ventilator maneuvers, such as incentive spirometer,
for person at risk for pulmonary complications


45.  Maintaining circulation
 Vital signs- Blood pressure, pulse and respiration are usually taken as follows.
Every 15 minutes until stable or for at least 1 hour
Every half an hour for 2 hours
Every 4 hours, until ordered otherwise.
 Hypotension and cardiac dysarrhythmia are the most common cardiovascular
complication in the immediate postanesthetic period, early detection and management of
these complications depends on frequent assessment of the patient's vital signs.
 Administer IV fluids to maintain the fluid status
 Provide elastic stocking for person at risk( avoid thrombophlebitis)
 Encourage bed exercise and ambulation within prescribed limits.
Instruct patient to elevate legs when sitting, unless contraindicated
Avoid postoperative leg massage.


46. Promoting Normal Temperature
Monitor for signs of hypothermia: Persistent low body temperature, shivering and
patient reporting of feeling cold, cold extremities
Use of warming methods: warm blankets are usually applied.

47. Maintaining Fluid Balance
Careful monitoring of intravenous fluids and output( urine, drainage and stoma) are
important to ensure adequacy of fluid replacement and prevention of fluid
overload.(Intake output chart)
Fluid excess- may occur from large volume of fluids replaced by intravenous fluids when
kidney function is inadequate, at evidence by oliguria.
 Monitor intake and output until patient is taking, oral fluids equal to at least 1200 ml
output.
Monitor intravenous fluid flow to provide required fluids.
Encourage oral fluid, once the swallowing reflex is regained and unless contraindicated
by the patient's condition or type of surgery
 Preventing Injury
 To prevent falls - side rails on the structure or bed are raised, until the patient is fully
awake.

48. Relieving Pain –
 Assess and record the patient's perception of pain.
Observe for restlessness, immobility, grimacing, increased sweating, tachycardia, pallor,
anxiety and hypertension, all of which can be associated with increased pain.
Good pain relief is essential for physical and psychological recovery.
Postoperative pain management in the recovery room is usually under the direction of
the anesthesiologist.
Pethidine is usually given by intramuscular injection as ordered.

49. Promoting psychological comfort.
 The immediate postanesthetic period is often frightening to the patient.
Psychological support is very important for physical and emotional well-
being.
 Good psychological support usually results in faster recovery from
anesthesia, fewer complications and less incisional pain.
 Frequent orientation to place and reassurance of not being alone, done
while patient is awakening from anesthesia
Inform the patient that operation is over and recovery from anesthesia is
satisfactory.
Patient positioned for comfort and to facilitate ventilation/breathing once
observations are stable, assist the patient to sit upright in the bed well
supported by pillows, unless contraindicated.

50. Observe:
• Breath sounds are clear.
• Respiratory rate is 12-20 breaths per minute and regular.
• Oxygen saturation levels are within normal limits.
• Blood pressure and temperature return to the patient's usual level.
• Skin is warm and dry.
• Pulse is regular
• Sleep is quiet and face is relaxed.

51. Maintain Nutrition
Teach the patient to select foods high in protein and vitamin C to encourage wound healing.
 When oral intake is permitted, encourage fresh fruits to supply needed potassium
If the patient complains of nausea, administer antiemetics as prescribed and monitor their effect.
 Provide a vomit bowl, tissue and mouth wash in case the patient needs to vomit.
Record Urine Output
Anesthesia can affect bladder muscle tone and cause difficulty with micturition.
 Note when the patient has passed urine, and the volume.
Observe for bladder distention and inform medical staff if the patient does not pass urine within 8
hours of surgery if uncomfortable.
If the patient has difficulty in passing urine, try conservative measures sitting on a commode or
toilet, running the tap, and relaxation techniques, unless contraindicated,
Catheterize if other options are unsuccessful.

52. • Discharge from Recovery Room
Criteria for discharging patient from recovery room
Vital signs are stable and indicate normal respiratory and circulatory function.
Patient is awake or easily aroused and can call assistance when in need.
Post surgical complications have been thoroughly evaluated and are under control.
After anesthesia, all sensory and physiological functions have returned to normal.
Transfer of Patient to Clinical Unit/Ward
When a patient is considered fit for transfer to the ward, the recovery nurse should give
the ward nurse a full account of the patient's condition during surgery and recovery. The
ward nurse should ensure that the patient is fit for transfer and that the notes for the
operative procedure have been completed.

53. • Patient Assessment on Return from Recovery Room
1. Patient is asked for symptoms of discomfort.
2. Respiratory status.
a. Patency of airway