PERIOPERATIVE NURSING

- Is a nursing specialty that works with patients who are having operative or other
invasive procedures.
- Perioperative nurses works closely with surgeons, anesthesiologist, and surgical
technologists.

PERIOPERATIVE PERIOD
- is the time period describing the duration of a patients surgical procedure; this
commonly includes ward admission, surgery and recovery.

WHY PATIENT’S COME TO THE OPERATING ROOM;

 To preserve life
 To maintain dynamic bodily equilibrium
 To undergo diagnostic procedures
 To prevent infection and to promote healing
 To obtain comfort and to ensure the ability to earn a living

HISTORICAL BACKGROUND

1900- Patients were admitted 4-5 days before the procedure

1930- 1 day before the procedure
- nursing leaders advocated the importance of both the physiologic preparation of
the surgical patient.
1940- Surgeons recognize the value of early ambulation
1960- Nursing research studies validated a link between pre-op preparation and
post-op recovery.

SURGICAL
- medical treatment or procedure that involves operation on or manipulations of the
patients.

3 ACTIVITIES ARE DIRECTED TOWARDS PROVIDING CONTINUITY OF

CARE THROUGH:

1. PREOPERATICE ASSESSMENT AND PREPARATION

2. INTRAOPERATIVE INTERVENTION AND
3. POSTOPERATIVE EVALUATION

PREOPERATIVE PHASE
- is the time period between the decision to have surgery and the beginning of the
surgical procedure
Purpose: an attempt to bring the patient to his/her best possible physical status.

INTRAOPERATIVE PHASE
- start from the transfer to the operating table and ends with the client is transfer to
Post Anesthesia Care Unit(PACU) OR Recovery Room (RR).

POSTOPERATIVE PHASE
- from the transfer of the patient to PACU or RR until the healing is complete.
-until the last follow-up visit with the surgeon.
SURGICAL OPERATION

Preoperative Phase Assessment Preparation

Intraoperative Phase Anesthesia Surgery

Postoperative Phase Postoperative Care Follow-up

As the resource person must be;consistent, concise, and organize.

TYPES OF SURGERY

ACCORDING TO PURPOSE
1. Diagnostic- confirms or establishes a diagnosus
Ex. Biopsy of breast mass
2. Palliative- relieves or reduces pain or symptoms of a disease, it does not cure.
Ex. Pelvic exenteration/evisceration
3. Ablative- removes a disease body part
Ex. Cholecystectomy( removal of gallbladder)
4. Constructive- restore function or appearance that has been lost or reduced.
Ex. Breast implant
5. Transplant- replace malfunctioning structure
Ex. Hip replacement
6. Cosmetic- nose lifting/face lifting

ACCORDING TO URGENCY
1. Elective- surgical intervention is not essential or necessary but it is usually the
choice of the patient (schedule)
Ex. Removal of cyst
2. Urgent Surgery- surgical intervention is necessary for client’s health and may
present additional problems from developing (as soon as possible)
Ex. Hysterectomy
3. Emergency- done immediately to save life
Ex. Abdominal ambulatory
ACCORDING TO DEGREE OF RISK

1. Major- involves a high degree of risk

- if may be prolonged or complicated, with a possibility of loss of large
amount of blood, vital organs involve.
Ex. Organ transplant
2. Minor- normally involves little risk and produces few complications.
Ex. Breast biopsy & circumcision

FACTORS INFLUENCING THE DEGREE OF RISK

1. Age
2. General Health
3. Nutritional Status
4. Medication
5. Mental Status
Hemoglobin: female- 12.1 to 15.1 gm/DL
Male- 13.8 to 17.2 gm/DL
Management: Preoperative Phase

A. Assessment and Nursing Diagnosis

A.1 Nursing History
- Current Health Status
- Previous Surgery and Experiences with Anesthesia
- Mental Status
- Allergies
- Medications
-Alcohol, recreation drugs use/nicotine
-Understanding of the surgical procedure
-lifestyle habits
-social resources
-spiritual and cultural beliefs
a.2 Screening Test
- CBC
- Blood typing and cross-matchinh
-serum electrolytes
- fasting blood glucose
- creatinine and blood urea nitrogen (kidney function)
- ALT (alamin, transminase test)
- serum albumin and total protein
- urinalysis
- chest x-ray
- ECG
a.3 Common Nursing Diagnosis
- knowledge deficit
- fear related to:
- surgical procedures
- prognosis
- disturbed sleep pattern
B. Planning and Implementation
B.1 Preoperative (Informed Consent)
Goal: client is mentally and physically prepared
- valid informed consent
- voluntary consent
- informed subject
- patient able to comprehend
B.2 Preoperative Teaching
- during the preoperative visit, the OR nurse supplements instruction by other
nursing team members and give information unique to the patient specific operation.
- the OR nurse teaches patients how to assist and encourage them to participate in
their own postoperative recovery.
We are going to teach patients:
- information, including what will happen, when and what the client will
experience, such as expected sensation and discomfort.
- Psychosocial support to reduce anxiety
- the roles of the client and support people in preoperative preparation, the
surgical and postoperative phase.
- skill training
B.3 Physical Preparation
- skin preparation
Goal: decrease bacteria without injuring the skin
- bowel preparation and elimination
 Enema/laxative use
Goal: allow satisfaction visualization of the surgical site
 Peristalsis often doesn’t return until 24-48 hours after surgery
 Retention Catheter
Goal: to empty the bladder and prevent unintentional injury

NUTRITION AND FLUIDS

-NPO goal: Prevent aspiration

-REST AND SLEEP
Goal: help the client manage stress related to surgery
- PROSTHESES
Goal: to prevent aspiration and any other unintended injury
- DENTRUES - EYEGLASSES
-CONTACT LENS - ARTIFICIAL LIMB
SPECIAL ORDERS
- interaction of NGT
- preparation of other materials
VITAL SIGNS
Goal: continuous monitoring to detect deviations from the baseline

PRE-OP MEDS
- to allay pre-op anxiety
- produces dull awareness of the OR environment
- decrease secretion in the respiratory tract
- counteract undesirable effects of some anesthetics
- diminishes vagal nerve effects on the heart
- raise the pain threshold
- given 45-60 minutes prior to induction

1. Narcotics
a) Nalbuphine
b) Demerol
c) Tramadol
d) Morphine
e) Stadol
2. Sedative/Antihistaminics
a) Diphenhydramine- benadryl
b) Promothazine-Phenegran
3. Antisialagogue/Anticholinergic
a) Atropine
4. Antimetic
a) Metoclopramide-Plasil

PREOPERATIVE: CHECKLIST
1. Establish baseline evaluation of the patient by carrying out a pre-op interview
and examination.
2. Ensuring that necessary test have been or will be done
3. Pre-admission test
4. Written instructions
-NPO- 8 hours before surgery
- Maintenance meds
- Skin/hair
- Nails-unpolished
- Jewelry & valuables
5. Informed consent: documented
6. Nurse interview/ anesthesia assessment
- All patients should have an understanding of the risks and alternatives to
the type of anesthetic to be administered
7. Additional specific orders
- bowel preparation
- bedtime sedation/sleep
8. On the day of surgery:
- patient teaching is reviewed
- patients identity is ascertained
- surgical site verified
- informed consent confirmed
9. IV infusion started and checked
ASSESSMENT

1. What type of surgery

2. Time of surgery
3. Name of surgeon
4. Preoperative order
5. Agency’s practice for pre- op care
6. Verify if client has complete medical history
7. Physical examination done
8. Consent signed

MOVING
1. Show the client ways to turn in bed and out of bed
- instruct a client who will have a right abdominal incision or a right sided chest
incision to turn to the left side of the bed and sit as follows:
 Flex the knees
 Splint the wound
 Assist patient

INTRAOPERATIVE PHASE
- start from the transfer to the operating table and ends with the client is transfer
to Post Anesthesia Care Unit(PACU) OR Recovery Room (RR).
Activities:
- a variety of specialized procedure
Goal: - provide patient safety
- maintain aseptic environment
- ensuring proper functions of equipment
- provide surgeon with specific instruments and supplies

SURGICAL TEAM
1. Patient
2. Surgeon
3. Registered Nurse First Assistant
4. Anesthesiologist
5. Circulating Nurse
6. Scrub Nurse (instrument nurse)
7. OR Tech

There are two types of OR team according to the functions of its members.

STERILE TEAM MEMBERS

1. Surgeon
2. Assistant to the surgeon
3. Scrub person ( either a registered nurse or surgical technologist)

UNSTERILE TEAM MEMBERS

1. Anesthesiologist
2. Ciruclator
3. Biomedical technicians, radiology technicians or other staff that might be needed
to set up and operate specialized equipment or devices essential in monitoring the
patient during a surgical operation.

OPERATING ROOM TEAM: STERILE PERSONNEL

The members of the OR sterile team will do the following things:
1. Performs surgical hand washing (arms are included)
2. Don sterile gowns and gloves
3. Enter the sterile field
4. Handles sterile items only
5. Functions only within a limited area (sterile field)
6. Wear mask.

OPERATING SURGEON
Responsibilities of a surgeon:
1. Preoperative siagnosis and care of the patient
2. Performance of the surgical procedure
3. Postoperative management of care
ASSISTANTS TO SURGEON
Responsibilities of a surgeon’s assistant:
1. Help maintain the visibility of the surgical site
2. Control bleeding
3. Close wounds
4. Apply dressings
5. Handles tissues
6. Uses instruments

SCRUB PERSON
- the responsibility of a scrub person is to maintain the integrity, safety and
efficiency of the sterile field throughout the surgical procedure.

SCRUB NURSE
- Works directly with the surgeon within the sterile field by passing instruments,
sponges and other items needed during the surgical procedure.

OPERATING ROOM TEAM: UNSTERILE MEMBERS

The unsterile operating room members are not allowed to enter the sterile field to
prevent contamination.
The responsibilities of the members of this team are the following:
1. Handles supplies and equipment that are considered unsterile
2. Touches unsterile surfaces only.
3. Keep the sterile team supplied with supplies handled aseptically.
4. Give direct pateint care
5. Assist the sterile team member’s need with strict observation of avoiding contact
to the sterile field.
6. Handles other requirements arising during the surgical procedure.

RESPONSIBILITIES OF AN ANESTHESIOLOGIST OR ANESTHETIST

1. Choice and application of appropriate agents.
2. Choice and application of suitable techniques of administration.
3. Monitoring of phsyiologic function.
4. Maintenance of fluid and electrolyte balance
5. Blood replacement
6. Helps in minimizing the hazards of shock, fire and electrocution
7. Use and interpret correctly a wide variety of monitoring devices
8. Overseeing the positioning and movement of patients.
9. Oversee the postanesthesia care unit (PACU) to provide resuscitative care until
the patient has regained vital functions.

CIRCULATOR/CIRCULATING NURSE
Responsibilities of a circulator:
1. Monitor and coordinate all activities within the room.
2. Manage the care required for each patient.
3. Provides assistance to any member of the OR team with strict observation to avoid
a break in sterility.
4. Creates and maintains a safe and comfortable environment for the patient through
the implementation of aseptic technique.
CIRCULATING NURSE
- The duties of the circulating nurse are carried out outside the sterile area
- Manages all the necessary care inside the surgery room
- Assisting the team in maintaining and creating a comfortable, safe environment
for the patient.
-Observe the team from a wide perspective.

CIRCULATING NURSE SHOULD SAY THIS:

EX.“Goodmorning Dr. La Paz ( Surgeon). Dr. Descendario (Asssitant
Surgeon), Dr. Jugador (Anesthesiologist) and rest of the surgical team, the 1st
(2nd, 3rd and final) counting of the sponges, instruments and needle/s is
complete.”

TYPES OF ANESTHESIA
Anesthesia is classified as :
- General
- Regional

GENERAL ANESTHESIA
- is the loss of all sensation and consciousness
-protective reflexes such as cough and gag reflex are lost.
- A general anesthetic acts by blocking awareness centers in the brain so that:
 Amnesia (loss of memory)
 Analgesia ( insensibility to pain)
 Hypnosis ( artificial sleep), and
 Relaxation ( rendering a part of the body less tense) occur

REGIONAL ANESTHESIA
- is the temporary interruption of the transmission of nerve impulses to and from
a specific are or region of the body.
- the client loses sensation in an area of the body but remains conscious.
TECHNIQUES USED:
1. Topical (surface) anesthesia
2. Local anesthesia
3. Nerve block
4. Spinal anesthesia is also referred to as a subarachnoid block (SAB)
5. Epidural (peridural) anesthesia
STAGE DURATION PHYSICAL NURSING
REACTIONS INTERVENTIONS
Onsent Anesthetic administartion to Drowsiness/Dizziness - Close opertaing room
loss of consciousness Auditory and Visual doors
Hallucinations -keep room quiet
-standby to assist client
Excitement Loss of consciousness to loss of Increase in autonomic - remain quiet at client’s
eyelid reflexes activity, Irregular side
breathing, client may - assist anaethetist if
struggle necessary
Surgical Loss of eyelid reflexes to loss Unconsciousness, -Begin preparation only
Anesthesia of most reflexes and depression relaxation of muscles, when anaesthetist indicate
of vital function diminished gag and stage 3has been reached
blink reflexes
Danger Depression ofvital function to Client is not breathing, - if arrest occurs, assist
respiratory and circulatory heatbet mayor may not immediately in
failure be present establishing airway,
provide cardiac arrest
tray, drugs, syringes, long
needles, closed or open
cardiac massage
PATEINT POSITIONING IN THE OR
Guidelines for positioning the client during Surgery:

1. Explain why the position and restraints are necessary

2. Preserve the client’s dignity and avoid undue exposure
3. Place restraining straps 2 inches above the knees.
4. Pressure points and bony prominence are padded.
5. Position the client to obtain or maintain adequate respiratory exchange and
vascular circulation.
6. Avoid pressure on the chest and on the body parts such as the female breast and
male genitalia.
7. Do not allow the client’s extremity to dangle over the sides of the table
8. When using an arm board, do not abduct the upper extremity more than 90 degree.
9. Be certain the client;s ankles are not crossed when in prone position.
10. Always move both lower extremities at the same time when putting them uo in
stirrups and when lowering.
11. Monitor the total position throughout the surgery.
COMMON POSITIONING PADS