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1. Perioperative Concepts and Nursing
Management
Prepared by
Dr/ Sabah nazeh
Associated prof of medical surgical
department

2. Outlines
 Introduction
 Preoperative phase
 Definition
 Preoperative Nursing Management
 Intra operative phase
 The Surgical Team
 Role of Scrub nurse
 Role of circulating nurse
 Postoperative phase
 Postoperative care
 Post Operative Complication

3. Introduction
Perioperative nursing is a term used to describe
the nursing care provided during the total
surgical experience of the patient:
preoperative, intraoperative, and
postoperative.

4.  Preoperative phase—from the time the
decision is made for surgical intervention
to the transfer of the patient to the
operating room.
 Intraoperative phase—from the time the
patient is received in the operating room
until admitted to the post anesthesia care
unit (PACU).
 Postoperative phase—from the time of
admission to the PACU to the follow-up
evaluation.

5. Preoperative phase
Definition:
 Preoperative care is the preparation and
management of a patient prior to
surgery. It includes both physical and
psychological preparation.

6. Preoperative Nursing
Management:
 Informed consent:
The physician must explain the risks and
benefits of the surgery, along with other
treatment options, It is important that the
patient understands everything he or she
has been told.

7. Patient Education:
 Tell patients how long they should be
NPO (nothing by mouth)
 Inform the patient about what will be done
during the surgery, how long is the
procedure, and where the incision will be.
 Teaching deep breathing and coughing
exercises and practice splinting the
incision.

8.  Compression stockings on their legs to
prevent blood clots until they start
ambulating.
 Encouraging mobility and active body
movement. e.g. Turning (change
position), foot and leg exercise.
 Explaining pain management.

9. Physical preparation:
 Complete medical history and physical
exam:
 Including the patient's surgical and
anesthesia background
 Laboratory tests: CBC, electrolytes,
prothrombin time, urinalysis,
electrocardiogram (EKG) and chest X-

10. Managing nutrition and fluids.
 A fasting period of 8 hours or more is
recommended to prevent aspiration. Clear
fluids (water) may be given up to 4 hours
before surgery depending on facility
protocols.

11. Preparing the bowel for surgery.
 Enema is not commonly ordered, unless
the patient is undergoing abdomen or
pelvic surgery. e.g. (cleansing enema,
laxative).

12. Preparing the skin.
 The goal of preoperative skin preparation
is to decrease bacteria.
 Scrubbing with a special soap, or
possibly hair removal from the surgical
area.

13. Psychological preparation:
Patients are often fearful or anxious
about having surgery. It is often helpful
for them to express their concerns to
health care workers. In some cases, the
procedure may be postponed until the
patient feels more secure.

14. Immediate preoperative nursing
intervention:
 Administering preanesthetic medication.
 Maintaining the preoperative record.
E.g. Final checklist, consent form,
identification.

15. Intra operative care:
The Surgical Team
 Surgeon – leader of the surgical team
 anesthetist – provides smooth induction
of the patient’s anesthesia in order to
prevent pain
 Scrub Nurse or Assistant
 Circulating Nurse

16.  The "scrub nurse" passes instruments,
supplies, and suture to the surgeon
during the procedure. While the unsterile
"circulating nurse" will provide for the
safety and comfort of the surgical patient
and will be alert to the needs of the other
members of the surgical team.

18. Role of Scrub nurse:
 Both the scrub nurse and circulating nurse
assist with opening the sterile supplies needed
for the surgical procedure.
The scrub nurse opens his/her gown and
gloves last, preferably on a separate field and
proceeds to perform the surgical scrub.
The scrub nurse and circulating nurse perform
a sponge, needle, and instrument count
before the initial incision is made.

19.  Following the surgical scrub, the surgeon
enters the operating room and is gowned by
the scrub nurse.
 The surgeon then preps the patient's skin with
an antiseptic solution. If performed on the
abdominal area, the umbilicus is prepped
last.

20.  Draping of the patient follows, according to
procedure and the surgeon's
preference. The scrub nurse should know
the draping routine and have all necessary
drapes ready in proper order.
 When the surgery is ready to begin, the scrub
nurse passes the skin knife to the surgeon, The
surgeon and first assistant hold the skin taut as
the incision is made.

21.  The scrub nurse assists by observing the
operative procedure and passing the
appropriate instruments to the surgeon and
first assistant.
 A sponge, needle, and instrument count
is performed at the beginning of
closure.

22.  Once the needle is returned to the scrub
nurse, it is placed in the needle counter
 The final sponge, needle, and instrument
count is performed during the skin
closure by the scrub and circulating
nurses.
 The scrub nurse removes his/her gown
and gloves after all contact with soiled
instruments and supplies is completed.

23. Role of circulating nurse:
 Prior to opening the first case of the day, flat
surfaces and overhead lights are cleaned with
a damp cloth moistened with high level
disinfectant.
 The circulating nurse obtains the patient's x-
rays if necessary and checks on any blood
products that may have been ordered.

24.  Positioning is performed two persons. A
safety strap is placed 2-3 inches above the
patient's knees and the patient's arms are
placed on arm boards. Monitoring devices
such as BP cuff, ECG pads, and pulse
oximeter are placed on the patient by the
circulating nurse

25.  The circulating nurse may insert a
Foley catheter, exposes the operative
site, and performs the skin prep.
 The circulator activates the overhead
spot lights then move into position over
the operative field.
 Circulating nurse sponge and suction
blood from the operative site.

26.  The circulating nurse should retrieve the
used sponges from the kick bucket by
using a sponge stick or his/her gloved
hand, should be placed in a clear sponge
counting bag. The anesthesia personnel
and the surgeon will need to view the
sponges to determine the patient's
estimated blood loss (EBL).

27.  The circulating nurse maintains
communication with other areas of the
operating room suite and may be
responsible for sending for the next
patient.
 The circulating nurse is also responsible
for correctly labeling and caring for the
surgical specimen.

28.  If a sponge drops on the floor, the
circulating nurse removes the sponge
using an instrument or gloved hand and
wipes the area immediately with a
hospital grade disinfectant.
 The surgeon will apply the dressing.
 When the anesthesia personnel give
permission, the patient is moved to the
recovery room bed.

29.  All sharps are placed in an appropriate
sharp's container.
 All linen is placed in an impervious bag
and sent to the laundry to be washed.
 Cleaning of the room is next. Walls are
not considered contaminated and require
no cleaning unless they have been
splashed with blood.

30. Postoperative care:
 Postoperative care is the management
of a patient after surgery. This includes
care given during the immediate
postoperative period, both in the
operating room and postanesthesia
care unit (PACU), as well as during the
days following surgery.

31. Post anesthesia care unit:
 Assessment of the patient's airway
Patency, vital signs , and level of
consciousness are the first priorities
upon admission to the PACU, Then
assessment of:
 - Surgical site (intact dressings with no
signs of overt bleeding)
 - Patency (proper opening) of drainage

32.  Patency /rate of intravenous (IV) fluids.
 Circulation/sensation in extremities after
vascular or orthopedic surgery
 - Pain status.
 - Nausea/vomiting.
 -Body temperature
(hypothermia/hyperthermia)

33. First 24 hours
 Vital signs, respiratory status, pain
status, the incision, and any drainage
tubes should be monitored every one to
two hours for at least the first eight
hours.
 Body temperature must be monitored,
since patients are often hypothermic
after surgery.

34.  Respiratory status should be assessed
frequently, including auscultation of lung
sounds, and presence of an adequate
cough.
 Respiratory exercises (coughing, deep
breathing, and incentive spirometry) every
two hours.

35.  Controlling pain, so the patient is able to
perform deep breathing and coughing
exercises, able to turn in bed, sit up and
walk.
 Patient should splint any chest and
abdominal incisions with a pillow to
decrease the pain caused by coughing
and moving.
 Fluid intake and urine output should be
monitored every one to two hours.

36.  The patient should be turned every two
hours, at least be sitting on the edge of the
bed by eight hours after surgery, unless
contraindicated.
 Patients will have compression devices on
their legs until they are able to move.
 Patients should be kept NPO (nothing by
mouth) if ordered by the surgeon, at least
until their cough and gag reflexes have
returned.
 Patients often have a dry mouth following
surgery; can be relieved with oral sponges
dipped in ice water.

37. After 24 hours:
 Vital signs can be monitored every four to
eight hours if the patient is stable.
 The incision and dressing should be
monitored for the amount of drainage and
signs of infection (eg, increasing pain,
erythema, drainage) .
 The surgeon may order a dressing change
during the first postoperative day.
 A drain tube, if present, must be monitored
for quantity and quality of the fluid
collected.

38.  Bowel sounds are monitored, and the
patient's diet gradually increased as
tolerated, depending on the type of surgery
and the physician's orders ..
 Monitor patient for any evidence of
potential complications, such as leg
edema, redness, and pain (deep vein
thrombosis), shortness of breath
(pulmonary embolism), or (intestinal
obstruction).
 Respiratory exercises are still be

39. Post Operative Complication:
1) Shock:
Is the response of the body to a decrease
in the circulating volume of blood, tissue
perfusion impaired, cellular hypoxia and
death.
2- Hemorrhage:
Is the escape of blood from a blood vessel.
3- Deep vein thrombosis (DVT):
Occur in pelvic vein or in lower extremities,
and it’s common after hip surgery.
4-pneumonia :
Due to accumulation of secretions.