Care For Perioperative Patient

Care for the
Perioperative Patient
NRS 380
Dr. Joanna Hernandez, DNP, RN, AGACNP-BC
Copyright 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
The Perioperative Period
Consists of 3 phases:
1.
Preoperative Period
2.
Intraoperative Period
3.
Postoperative Period
Important CBC
Laboratory Values
Hemoglobin (Hgb or Hb)
Males: 13.5 17.5gm/dL
Females: 12.0 15.5 gm/dL
Hematocrit (Hct) number of blood cells that are RBCs
Normally 3x the Hgb
Males: 38% - 50%
Females: 34.9% - 44.5%
Platelet count
150,000 300,000/mm3
White Blood Cell (WBC) Count
5,000 10,000/mm3
3
Care of Preoperative Patients
Preoperative Period
Begins when patient is scheduled for

surgery; ends at time of transfer to
surgical suite
Nurse functions as educator, advocate,
promoter of health and safety
Reasons for Surgery
Diagnostic
Curative
Improves patients functional ability
Palliative
Resolves health problem by repairing or removing cause
Restorative
Determines origin and cause of disorder
Relieves symptoms of disease process, but does not cure
Cosmetic
Alters/enhances personal appearance
Urgency, Degree of Risk,

and Extent of Surgery
Urgency:
Degree of risk:
Elective
Urgent
Emergent
Minor
Major
Extent:
Simple
Radical
Minimally invasive (MIS)
Anxiety Interventions
Preoperative teaching
Encourage communication
Promote rest
Use distraction
Teach family members
Preoperative Medications
Reduce anxiety (anxiolytics)

Promote relaxation (sedatives, hypnotics)
Reduce nasal and oral secretions
(anticholinergic agents)
Prevent laryngospasm
Reduce vagal-induced bradycardia
Inhibit gastric secretion (H2 histamine
blockers)
Decrease amount of anesthetic needed for
induction and maintenance (opioids)
Collaborative Management:
Assessment
History and data collection:
Age
Drugs, substance use
Allergies (food and medicine)
Medical history (including cardiac and pulmonary)
Complementary/alternative practices
Previous surgical procedures, anesthesia
Blood donations
Discharge planning
Smoking
10
Physical Assessment/
Clinical Manifestations
Obtain baseline vital signs

Focus on problem areas identified in
history; all body systems affected by
surgical procedure
Report abnormal assessment findings to
surgeon/anesthesiology personnel
11
System Assessment
Cardiovascular
Respiratory
CAD, MI within 6 months before surgery, angina,

hypertension, dysrhythmias
Chronic respiratory problems
Smoking increases carboxyhemoglobin blood level,
deceases oxygen delivery
Renal/Urinary
Kidney impairment inhibits drugs/anesthetic agent

excretion
12
System Assessment (Cont.)
Neurologic
Musculoskeletal
Nutritional status
Malnutrition and obesity increase surgical risk
Skin
Determine baseline
Assess level of consciousness (LOC), ability to follow
commands
Breakdown
Psychosocial
13
Laboratory Assessment
Urinalysis
Blood type and crossmatch
CBC or hemoglobin level and hematocrit
Clotting studies (PT, INR, aPTT)
Electrolyte levels
ABGs
Serum creatinine level
Pregnancy test
Chest x-ray
ECG
14
Informed Consent
Informed consent:
Surgeon obtains signed consent before sedation

and/or surgery
Nurse clarifies facts and dispels myths about surgery
Nurse not responsible for providing detailed
information about procedure!
Patients may sign with X

In emergency, telephone authorization is
acceptable
Special permits required for some
procedures
15
16
Implementing Dietary
Restrictions
NPO: Patient not to ingest anything by

mouth for 6 to 8 hours before surgery:
Decreases risk for aspiration

Give patients written/oral directions to stress
adherence
Surgery can be canceled if instructions not
followed
17
Administering Regularly
Scheduled Medications
Consult with physician and anesthesia

provider for instructions
Drugs for certain conditions often allowed
with a sip of water:
Cardiac disease
Respiratory disease
Seizures
Hypertension
18
Intestinal Preparation
Performed to prevent injury to colon; reduce

number of intestinal bacteria
Enema or laxative
Surgeon preference
19
Skin Preparation
Break in the skin increases risk for infection

Patient may be asked to shower using
antiseptic solution
Hair removal by electric clippers, depilatories
Shaving of hair creates risk for infection!
20
Common sites of skin

preparation
21
SCIP
Surgical Care Improvement Project (SCIP)
Also known as core measures
Prophylactic antibiotics
Catheter removal
VTE prophylaxis
22
Patients at Risk for VTE
Obese patients
Age 40 or older
History of cancer or decreased cardiac output
Decreased mobility, immobile, spinal cord injury
History of VTE, PE, varicose veins, edema
Oral contraceptives
Smoking
Hip fracture, total hip/knee surgery
23
External Pneumatic
Compression Devices
24
Preoperative Chart Review
Ensure all documentation, preoperative

procedures, orders are complete
Check surgical consent form and others for
completeness
Inform patient that area will be marked
before procedure begins
Document allergies, height, and weight
Ensure all laboratory and diagnostic test
results are in chart and abnormal results
noted
25
Preoperative Patient
Preparation
Remove most clothing; provide gown

Leave valuables with family or lock up
Tape rings in place if cannot be removed
Ensure patient is wearing ID band
Remove:
Dentures
Prosthetic devices
Hearing aids
Contact lenses
Fingernail polish
Artificial nails
All jewelry
26
Preoperative Education
Prevention of respiratory complications
Cough and deep breathe
Incentive spirometry
Cough and splinting
27
Older Adults: Changes of Aging

as Surgical Risk Factors
Decreased:
Cardiac output, peripheral circulation

Vital capacity, blood oxygenation
Blood flow to kidneys, glomerular filtration rate
Increased:
Blood pressure
Risk for skin damage, infection
Sensory deficits
Deformities related to osteoporosis/arthritis
28
Older Adults: Considerations for

Preoperative Care
Chronic illness
Malnutrition
Impaired self-care ability
Inadequate support systems
Stress from surgery/anesthesia
Cardiopulmonary complications after surgery
Mental status changes
Risk for falls
29
30
Care of
Intraoperative Patients
From Potter, P.A. & Perry, A.G. (2009). Fundamentals of Nursing. 7th Ed. St. Louis: Mosby.
31
Members of the Surgical Team
Surgeon and surgical assistant

Anesthesia providers
Holding area nurse
Circulating nurse
Scrub nurse
Surgical technologist
Specialty nurses
ORTs/surgical technologists may be used in
addition to nursing staff
32
Operating Room
A, from Patell, A., Whang, P., & Vaccaro, A. (2008). Overview of computer-assisted image-guided surgery of the spine. Seminars in
B, from Miller, R., & Pardo, M. (2011). Basics of anesthesia. 6th Ed. Philadelphia: Saunders.
Spine Surgery, 20(3), 186-194.
33
Minimally Invasive and

Robotic Surgery (MIS)
Now common practice
Preferred technique for

many surgery types,
including:
Cholecystectomy
Joint surgery
Cardiac surgery
Splenectomy
Spinal surgery
34
MIS Potential Injury
Mechanical trauma
Thermal injury
35
Environment of the Operating

Room
Preparation of surgical suite, team safety

Layout
Health and hygiene of surgical team
Surgical attire and scrub
Remember:
People are a source of bacteria in the surgical setting!
Special health care standards, dress are needed
Watch for nosocomial infections, identify source of

pathogens
36
Surgical Scrubbing
Broad-spectrum, surgical
antimicrobial solution
Vigorous rubbing that

creates friction used from
fingertips to elbow
Scrub continues for 3 to 5

min
37
Surgical Scrub, Gowning,

and Gloving
38
Anesthesia
Induced state of partial or total loss of

sensation, occurring with or without loss of
consciousness
Used to block nerve impulse transmission,
suppress reflexes, promote muscle relaxation,
achieve controlled level of unconsciousness (in
some cases)
39
General Anesthesia
Reversible loss of consciousness induced by

inhibiting neuronal impulses in several areas
of central nervous system (CNS)
Involves single or combination of agents
Depresses CNS, resulting in analgesia,
amnesia, and unconsciousness with loss of
muscle tone and reflexes
Administered via:
Inhalation
IV injection
Balanced anesthesia
40
Types of Anesthesia
Inhalation
Intravenous
Rapid and pleasant induction
Balanced
Reversible, most controlled
Can be used with older and high-risk populations
Regional or local
Gag and cough reflexes stay intact
Cannot control agent after administration

41
Four Stages of
General Anesthesia
Stage 1 Analgesia and sedation, relaxation

Stage 2 Excitement, delirium
Stage 3 Operative anesthesia, surgical
anesthesia
Stage 4 Danger
Emergence Recovery from anesthesia
42
Balanced Anesthesia
Combination of IV drugs and inhalation

agents used to obtain specific effects
Example: Thiopental for induction, nitrous
oxide for amnesia, morphine for analgesia,
pancuronium for muscle relaxation
43
Complications from
General Anesthesia
Malignant hyperthermia
Overdose
Unrecognized hypoventilation
Problems with specific anesthetic agents
Intubation problems
44
Malignant Hyperthermia
Acute, life-threatening complication
May be genetic
Begins with skeletal muscle exposed to specific

agent
Causes increased metabolism, calcium levels in

muscle cells
Leads to acidosis, high temperatures,

dysrhythmias
45
46
Clinical Manifestations of
Tachycardia
Skin mottling
Cyanosis
Myoglobinuria
Rise in end tidal carbon dioxide
Elevated temperature
47
Local Anesthesia
Briefly disrupts sensory nerve impulse

transmission from specific body area/region
Delivered topically and by local infiltration
Patient remains conscious, able to follow
instructions
48
Regional Anesthesia
Blocks multiple peripheral nerves in specific

body region
Field
Nerve
Spinal
Epidural
49
Spinal and Epidural Anesthesia
50
Complications of Local or
Regional Anesthesia
Anaphylaxis
Incorrect delivery technique
Systemic absorption
Overdose
Local complications
51
Treatment of Complications
Establish open airway

Give oxygen
Notify surgeon
Fast-acting barbiturate is usual treatment
Epinephrine for unexplained bradycardia
52
Moderate Sedation
IV delivery of sedative, hypnotic, opioid

drugs to reduce level of consciousness
Patient maintains patent airway, can respond
to verbal commands
Amnesia action is short
53
Collaborative Management
Assessment
Medical record review
Allergies and previous reactions to anesthesia
or transfusions
Autologous blood transfusion
Laboratory and diagnostic test results
Medical history and physical examination
findings
54
Common Surgical Positions
55
Potential for Injury
Interventions:
Proper body position

Prevent pressure ulcer formation
Prevent obstruction of circulation, respiration, nerve
conduction
56
Potential for Infection
Interventions:
Plastic adhesive drape

Skin closures, sutures and staples, nonabsorbable
sutures
Insertion of drains
Application of dressing
Patient transfer from OR table to stretcher
57
Common Skin Closures
58
Potential for Hypoventilation
Continuous monitoring of:
Breathing
Circulation
Cardiac rhythms
Blood pressure and heart rate
Continuous presence of anesthesia provider
59
Genetic/Genomic
Considerations
Overdose of anesthetic
From impaired elimination and metabolism
Must have accurate history, weight, height
Unrecognized hypoventilation
Anesthesia-induced complication
Can lead to cardiac arrest, permanent brain

damage, death
Intubation complications
60
Other Assessments
Patient verification
Advanced directive/DNR orders
Allergies
Previous anesthesia reactions
Laboratory/diagnostic test results
Physical examination
61
are of Postoperative Patients
From Frownfelter, D. & Dean, E. (2006). Cardiovascular and Pulmonary Physical Therapy. 5th Ed. St. Louis: Mosby.
62
Postoperative Period
Begins with completion of surgery and

transfer to PACU, ambulatory care unit, or
ICU
Phase 1: PACU, ICU, or ambulatory care unit
Phase 2: Preparing patient for step-down care
Phase 3: hospital unit or in home
Extended care environment
Surgical Care Improvement Project (SCIP)

measures established in the pre-operative
period are re-evaluated (Core Measures)
63
PACU Recovery Room
Ongoing evaluation and stabilization of

patients
To anticipate, prevent, and manage complications

after surgery
The Joint Commissions NPSGs require

circulating nurses and anesthesia providers to
give PACU nurses verbal hand-off reports
64
The PACU Nurse
Skilled in the care of patients with multiple

medical and surgical problems
In-depth knowledge of:
Anatomy and physiology
Anesthetic agents
Pharmacology
Pain management
Extubation
Able to make quick decisions
Works closely with anesthesiologist and surgeon
65
Potential Complications
Pneumonia
Shock
Cardiac arrest
Respiratory arrest
Clotting/VTE
GI bleed
66
Respiratory System Assessment
Patent airway, adequate gas exchange

Note artificial airway when applicable
Rate, pattern, depth of breathing
Breath sounds
Accessory muscle use
Snoring and stridor
Respiratory depression or hypoxemia
67
Types of Artificial Airways
68
69
Cardiovascular Assessment
Vital signs
Heart sounds
Cardiac monitoring
Peripheral vascular assessment
Monitor for VTE
70
Neurologic System
Cerebral functioning
Motor and sensory assessment after epidural or
spinal anesthesia
Glasgow Coma Scale
71
Fluid, Electrolyte, &

Acid-Base Balance
Intake and output (I&O)

Hydration status
IV fluids
Vomitus
Urine
Wound drainage
Nasogastric (NG) tube drainage
Acid-base balance
72
Renal/Urinary System
Check for urine retention

Consider other sources of output
Sweat
Vomitus
Diarrhea stools
Report urine output of <30 mL/hr
73
Gastrointestinal System
Postoperative nausea/vomiting common

30% of patients experience nausea or
vomiting after general anesthesia
Peristalsis may be delayed up to 24 hours
Monitor for bowel sounds
To reduce nausea/vomiting:
Ondansetron (Zofran)
Meclizine (Antivert, Dramamine)
Scopolomine patch
74
NG Tube Drainage
Inserted during surgery to:
Decompress and drain stomach

Promote GI rest
Allow lower GI tract to heal
Provide enteral feeding route
Monitor any gastric bleeding
Prevent intestinal obstruction
Assess drained material every 8 hr
75
Skin Assessment
Normal wound healing
Assess tissue integrity frequently
Impaired wound healing Seen most often

between 5 and 10 days after surgery
Dehiscence
Evisceration
76
Skin Assessment (Cont.)
77
Dressings and Drains
From Nouri, K. (2008). Complications in Dermatologic Surgery. St. Louis: Saunders.
78
Discomfort/Pain Assessment
Pain/discomfort expected after surgery

Physical and emotional signs of pain
Assess need for medication:
Consider type of surgery

Extent of surgery
Length of surgical procedure
79
Physical & Emotional

Signs of Acute Pain
Increased pulse and blood pressure

Increased respiratory rate
Profuse sweating
Restlessness
Confusion (older adults)
Wincing, moaning, crying
80
Laboratory Assessment
Analysis of electrolytes
CBC
Left-shift (bandemia)
Specimens for C&S

ABGs
Urine and renal laboratory tests
Procedure-specific labs
Glucose (diabetics)
Serum amylase (pancreatic surgery)
81
Potential for Hypoxemia
Highest incidence occurs on 2nd

postoperative day
Interventions:
Airway maintenance
Monitor (SpO2)
Semi-Fowlers position
Oxygen therapy, breathing exercises
Mobilization as soon as possible
82
Potential for Wound

Infection & Delayed Healing
Nursing assessment:
Dressings First change usually done by surgeon

Drains Provide exit route for air, blood, bile; help
prevent deep infections, abscess formation during
healing
Interventions
Drug therapy, irrigation to treat wound infection

Dbridement
Surgical management required for wound opening
83
Drains and Dressings
84
Pain Interventions
Drug therapy
Complementary and alternative therapies
Positioning
Massage
Relaxation/diversion techniques
85
Discharge from PACU
86
Community-Based Care
Home care management

Teaching for self management
Health care resources
87
88
Questions?
89

Care For Perioperative Patient

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Care For Perioperative Patient

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Care for the

The Perioperative Period

Hemoglobin (Hgb or Hb)

Males: 13.5 17.5gm/dL

Females: 12.0 15.5 gm/dL

Hematocrit (Hct) number of blood cells that are RBCs

Normally 3x the Hgb

Males: 38% - 50%

Females: 34.9% - 44.5%

White Blood Cell (WBC) Count

Care of Preoperative Patients

Begins when patient is scheduled for

Reasons for Surgery

Improves patients functional ability

Resolves health problem by repairing or removing cause

Determines origin and cause of disorder

Relieves symptoms of disease process, but does not cure

Alters/enhances personal appearance

Urgency, Degree of Risk,

Reduce anxiety (anxiolytics)

History and data collection:

Obtain baseline vital signs

CAD, MI within 6 months before surgery, angina,

Kidney impairment inhibits drugs/anesthetic agent

System Assessment (Cont.)

Malnutrition and obesity increase surgical risk

Surgeon obtains signed consent before sedation

Patients may sign with X

NPO: Patient not to ingest anything by

Decreases risk for aspiration

Consult with physician and anesthesia

Performed to prevent injury to colon; reduce

Break in the skin increases risk for infection

Common sites of skin

Surgical Care Improvement Project (SCIP)

Also known as core measures

Patients at Risk for VTE

Preoperative Chart Review

Ensure all documentation, preoperative

Remove most clothing; provide gown

Prevention of respiratory complications

Cough and deep breathe

Cough and splinting

Older Adults: Changes of Aging

Cardiac output, peripheral circulation

Older Adults: Considerations for

Members of the Surgical Team

Surgeon and surgical assistant

Spine Surgery, 20(3), 186-194.

Minimally Invasive and

Now common practice

Preferred technique for

MIS Potential Injury

Environment of the Operating

Preparation of surgical suite, team safety

People are a source of bacteria in the surgical setting!

Special health care standards, dress are needed

Watch for nosocomial infections, identify source of

Vigorous rubbing that

Scrub continues for 3 to 5

Surgical Scrub, Gowning,

Induced state of partial or total loss of

Reversible loss of consciousness induced by