Interventions for

Preoperative
Clients
Francisco Felix
Perioperative Nursing
Definition of Surgery

Surgery is any procedure

performed on the human body
that uses instruments to alter
tissue or organ integrity.
integrity
Purposes of Surgery

 Diagnostic
 Curative

 Restorative

 Palliative surgery, which makes the

client more comfortable
 Cosmetic surgery, which
reconstructs the skin and
underlying structures
 Perioperative Nursing
Types of Surgery

 Degree of urgency – necessity to preserve the

client’s life, body part, or body function.
 Degree of risk – involved in surgical
procedure is affected by the client’s age,
general health, nutritional status, use of
medications, and mental status.
 Extent of surgery – Simple and radical
 Perioperative Nursing
Types of Surgery (Urgency)
 Emergency- performed immediately to
preserve function or the life of the client.
 Elective – is performed when surgical
intervention is the preferred treatment for a
condition that is not imminently life
threatening or to improve the client’s life.
 Urgent – Necessary for client’ health to
prevent additional problem from
developing; not necessarily an emergency.
 Required – has to be performed at some
point; can be pre-scheduled.
 Perioperative Nursing
Type of Surgery (Degree of Risk)
 Major – involves a high degree of risk.
 Minor – normally involves little risk.
 Age – very young and elder clients are greater surgical
risks than children and adult.
 General health-
health surgery is least risky when the client’s
general health is good.
 Nutritional Status – required for normal tissue repair.
 Medications – regular use of certain medications can
increase surgical risk.
 Mental status – disorder that affect cognitive function
 Perioperative Nursing
Surgical settings
 Surgical suites
 Ambulatory care setting

 Clinics

 Physician offices

 Community setting

 Homes
 Perioperative Nursing
Surgical settings
 Disadvantages
Less time for rapport
Less time to assess, evaluation, teach
Risk of potential complication post D/C.
 Advantages of outpatient:
outpatient
Low cost
Low risk of infection
Less interruption of routine
Less than from work
Less stress
Collaborative Management
Assessment
 History and data collection
 Age
 Drugs and substance use
 Medical history, including cardiac
and pulmonary histories
 Previous surgery and anesthesia
 Blood donations
 Discharge planning
Physical Assessment/Clinical
Manifestations
 Obtain baseline vital signs.
 Focus on problem areas identified
by the client’s history on all body
systems affected by the surgical
procedure.
 Report any abnormal assessment
findings to the surgeon and to
anesthesiology personnel.
System Assessment

 Cardiovascular system
 Respiratory system
 Renal/urinary system
 Neurologic system
 Musculoskeletal system
 Nutritional status
 Psychosocial assessment
 Gerontological Considerations
 Preoperative Nursing Care
Psychosocial considerations
 Level of anxiety
 Coping ability

 Support systems
 Preoperative Nursing Care
Gerontological Considerations
 Cardiovascular
Coronary flow decreases
Heart rate decreases
Response to stress decreases
Peripheral vascular decreases
Cardiac output decreases
Cardiac reserve decreases
 Preoperative Nursing Care
Gerontological Considerations
 Respiratory System
Static lung volumes decreases
Pulmonary static recoil decreases
Sensitivity of the airway receptors decreases
 Nervous system

Increased incidence of post.op. confusion.

Increased incidence of delirium
Increased sensitivity to anesthetic agents
 Preoperative Nursing
Care
Gerontological Considerations
 Renal System
Renal blood flow declines 1.5% per
year. Renal clearance reduced
 Gastrointestinal
Decreased intestinal motility
Decreased liver blood flow
Delayed gastric emptying
 Preoperative Nursing
Care
Gerontological Considerations

 Musculoskeletal
Decreased mass, tone, strength
Decreased bone density
 Integumentary
Decreased elasticity
Decreased lean body mass
Decreased subcutaneous fat
 Laboratory Assessment
 Urinalysis
 Blood type and crossmatch
 Complete blood count or hemoglobin
level and hematocrit
 Clotting studies
 Electrolyte levels
 Serum creatinine level
 Pregnancy test
 Chest x-ray examination
 Electrocardiogram
 Preoperative Nursing
Consent
 Nature and intention of the surgery
 Name and qualifications of the person
performing the surgery.
 Risks, including tissue damage,
disfigurement, or even death
 Chances of success

 Possible alternative measures

 The right of the client to refuse consent or

later withdraw consent.
 Deficient Knowledge
Interventions
 Informed consent
 The surgeon is responsible for obtaining
signed consent before sedation is given and
surgery is performed.
 The nurse’s role is to clarify facts presented
by the physician and dispel myths that the
client or family may have about surgery.
Implementing Dietary
Restrictions
 Client is given nothing by mouth
(NPO) for 6 to 8 hours before
surgery.
 NPO status decreases the risk for
aspiration.
 Failure to adhere can result in
cancellation of surgery or increase
the risk for aspiration during or
after surgery.
Administering Regularly
Scheduled Medications
 Consult the medical physician and
anesthesia provider for
instructions about drugs, such as
those taken for diabetes, cardiac
disease, glaucoma, regularly
scheduled anticonvulsants,
antihypertensives, anticoagulants,
antidepressants, or corticosteroids.
Intestinal Preparation

 Bowel or intestinal preparations are

performed to prevent injury to the
colon and to reduce the number of
intestinal bacteria.
 Enema or laxative may be ordered
by the physician.
Skin Preparation

 The skin is the body’s first line of

defense against infection; a break
in the barrier increases the risk for
infection.
 Shower using antiseptic solution.

 Shaving as a procedure before

surgery is viewed as controversial.
Preparing the Client

 Possible placement of tubes,

drains, and vascular access
devices
 Teaching about postoperative
procedures and exercises:
 Breathingexercises, incentive
spirometry, coughing and splinting

(Continued)
Preparing the Client (Continued)

 Legprocedures and exercises,

antiembolism stockings and elastic
wraps, early ambulation, and range-
of-motion exercises
Anxiety Interventions

 Preoperative teaching
 Encouraging communication

 Promoting rest

 Using distraction

 Teaching family and significant

others
Preoperative Nursing Care
Anxiety
 The nurse must consider the pt’s
family and friends when planning
psychological support.
 Empowering their sense of control.
Activities that decreasing anxiety
are deep breathing, relaxation
exercises, music therapy, massage
and animal-assisted therapy.
 Use of medication to relieve
anxiety.
Preoperative Chart Review

 Ensure all documentation,

preoperative procedures, and
orders are complete.
 Check the surgical consent form
and others for completeness.
 Document allergies.

 Document height and weight.

(Continued)
Preoperative Chart Review
(Continued)

 Ensure results of all laboratory and

diagnostic tests are on the chart.
 Document and report any abnormal
results.
 Report special needs and
concerns.
Preop Client Prep

 Client should remove most clothing

and wear a hospital gown.
 Valuables should remain with
family member or be locked up.
 Tape rings in place if they can’t be
removed.
 Remove all pierced jewelry.
(Continued)
Preop Client Prep (Continued)

 Client wears an identification band.

 Dentures, prosthetic devices,
hearing aids, contact lenses,
fingernail polish, and artificial nails
must be removed.
Preoperative Medication

 Reduce anxiety.
 Promote relaxation.

 Reduce pharyngeal secretions.

 Prevent laryngospasm.

 Inhibit gastric secretion.

 Decrease amount of anesthetic

needed for induction and
maintenance of anesthesia.
Preoperative Nursing Care
Medications
 Sedatives/hypnotics- Nembutal
 Tranquilizers-Ativan, versed,
valium
 Opiate analgesics- Demerol,
morphine
 Anticholinergics-Atropine
sulfate,atarax
 H2o blockers.- Tagamet, Zantac

 Antiemetic- Reglan, Phenergan

 Preoperative Nursing Care
Preanesthesia Management Physical Status Categories
 ASA 1: Healthy patient with no disease
 ASA 11: Mild systemic ds without fx limitations

 ASA 111:Severe systemic ds associated with

definite fx limitations
 ASA 1V: Severe systemic ds that is a constant
threat to life.
 ASA V: Moribund pt. Who is not expected to
survive without the operation.
 ASA V1: A declared brain-death whose organ
are being recovered for donor.
Members of the Surgical Team
 Surgeon
 Surgical assistant
 Anesthesiologist
 Certified registered nurse anesthetist
 Holding area nurse
 Circulating nurse
 Scrub nurse
 Surgical technologist
 Operating room technician
 Perioperative Nursing Care
Surgical team
Nursing Roles:
Staff education
Client/family teaching
Support and reassurance
Advocacy
Control of the environment
Provision of resources
Maintenance of asepsis
Monitoring of physiologic and psychological
status
Environment of the
Operating Room
 Preparation of the surgical suite
and team safety
 Layout

 Health and hygiene of the surgical

team
 Surgical attire

 Surgical scrub
Intraoperative Nursing
Care
Surgical asepsis
 Ensure sterility

 Alert for breaks

 Intraoperative Phase
Anesthesia
 Greek word- anesthesis, meaning “negative
sensation.” Artificially induced state of partial or
total loss of sensation, occurring with or without
consciousness.

 Blocks transmission of nerve impulses

 Suppress reflexes
 Promotes muscle relaxation
 Controlled level of unconsciousness
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, and, in
some instances, achieve a
controlled level of
unconsciousness
 General Anesthesia
 Reversible loss of consciousness is
induced by inhibiting neuronal impulses in
several areas of the central nervous
system.
 State can be achieved by a single agent or
a combination of agents.
 Central nervous system is depressed,
resulting in analgesia, amnesia, and
unconsciousness, with loss of muscle
tone and reflexes.
Stages of General Anesthesia

 Stage 1: analgesia
 Stage 2: excitement

 Stage 3: operative

 Stage 4: danger
 Administration of General
Anesthesia
 Inhalation: intake and excretion of
anesthetic gas or vapor to the lungs
through a mask
 Intravenous injection: barbiturates,
ketamine, and propofol through the blood
 Adjuncts to general anesthetic agents:
hypnotics, opioid analgesics,
neuromuscular blocking agents
Balanced Anesthesia

 Combination of intravenous drugs

and inhalation agents used to
obtain specific effects
 Combination used to provide
hypnosis, amnesia, analgesia,
muscle relaxation, and reduced
reflexes with minimal disturbance
of physiologic function

(Continued)
Balanced Anesthesia (Continued)

 Example: thiopental for induction,

nitrous oxide for amnesia,
morphine for analgesia, and
pancuronium for muscle relaxation
Complications from General
Anesthesia
 Malignant hyperthermia: possible
treatment with dantrolene
 Overdose

 Unrecognized hypoventilation

 Complications of specific
anesthetic agents
 Complications of intubation
 Local or Regional Anesthesia
 Sensory nerve impulse transmission from a
specific body area or region is briefly
disrupted.
 Motor function may be affected.

 Client remains conscious and able to follow

instructions.
 Gag and cough reflexes remain intact.

 Sedatives, opioid analgesics, or hypnotics

are often used as supplements to reduce
anxiety.
 Local Anesthesia

 Topical anesthesia
 Local infiltration

 Regional anesthesia
 Fieldblock
 Nerve block
 Spinal anesthesia
 Epidural anesthesia
Complications of Local or
Regional Anesthesia
 Anaphylaxis
 Incorrect delivery technique
 Systemic absorption
 Overdosage

(Continued)
 Complications of Local or
Regional Anesthesia (Continued)
 Assess for central nervous system
stimulation, central nervous system
and cardiac depression, restlessness,
excitement, incoherent speech,
headache, blurred vision, metallic
taste, nausea and vomiting, tremors,
seizures, increased pulse, respirations,
and blood pressure.
Treatment of Complications

 Establish an open airway.

 Give oxygen.

 Notify the surgeon.

 Fast-acting barbiturate is usual

treatment.
 If toxic reaction is untreated,
unconsciousness, hypotension,
apnea, cardiac arrest, and death
may result.
 Conscious Sedation
 IV delivery of sedative, hypnotic, and
opioid drugs reduces the level of
consciousness but allows the client to
maintain a patent airway and to respond
to verbal commands.
 Diazepam, midazolam, meperidine,
fentanyl, alfentanil, and morphine
sulphate are the most commonly used
drugs.
(Continued)
Conscious Sedation (Continued)

 Nursing assessment of airway,

level of consciousness, oxygen
saturation, electrocardiographic
status, and vital signs are
monitored every 15 to 30 minutes.
 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
Risk for Perioperative
Positioning Injury
Interventions include:
 Proper body position

 Risk for pressure ulcer formation

 Prevention of obstruction of
circulation, respiration, and nerve
conduction
Impaired Skin Integrity and
Impaired Tissue Integrity
Interventions include:
 Plastic adhesive drape

 Skin closures, sutures and staples,

nonabsorbable sutures
 Insertion of drains

 Application of dressing

 Transfer of client from the

operating room table to a stretcher
Potential for Hypoventilation

 Continuous monitoring of:

 Breathing
 Circulation
 Cardiac rhythms
 Blood pressure and heart rate

 Continuous presence of an
anesthesia provider
Interventions for
Postoperative
Clients
Francisco Felix
 PACU Recovery Room
 Purpose is to provide ongoing
evaluation and stabilization of clients to
anticipate, prevent, and treat
complications after surgery.
 PACU is usually located close to the
surgical suite.
 The PACU nurse is skilled in the care of
clients with multiple medical and
surgical problems that can occur
following a surgical procedure.
Collaborative Management

 Assessment
 Physical assessment and clinical
manifestations
 Assess respiration.
 Examine surgical area for bleeding
 Monitor vital signs.
 Assess for readiness to discharge
once criteria have been met.
Respiratory System

 Airway assessment
 Breath sounds

 Other respiratory assessments

Cardiovascular Assessment

 Vital signs
 Cardiac monitoring

 Peripheral vascular assessment

 Neurologic System
 Cerebral functioning
 Motor and sensory assessment important
after epidural or spinal anesthesia
 Motor function: simple commands; client
to move extremities
 Return of sympathetic nervous system
tone: gradually elevate head and monitor
for hypotension
Fluid, Electrolyte, and Acid-
Base Balance
 Check fluid and electrolyte balance.
 Make hydration assessment.

 Intravenous fluid intake should be

recorded.
 Assess acid-base balance.
 Renal/Urinary System

 The effects of drugs, anesthetic agents,

or manipulation during surgery can
cause urine retention.
 Assess for bladder distention.

 Consider other sources of output such

as sweat, vomitus, or diarrhea stools.
 Report a urine output of < 30 mL/hr.
Gastrointestinal System

 Nausea and vomiting are common

reactions after surgery.
 Peristalsis may be delayed because
of long anesthesia time, the
amount of bowel handling during
surgery, and opioid analgesic use.
 Clients who have abdominal
surgery often have decreased
peristalsis for at least 24 hours.
 Nasogastric Tube Drainage
 Tube may be inserted during surgery to
decompress and drain the stomach, to
promote gastrointestinal rest, to allow
the lower gastrointestinal tract to heal,
to provide an enteral feeding route, to
monitor any gastric bleeding, and to
prevent intestinal obstruction.

(Continued)
Nasogastric Tube
Drainage (Continued)
 Assess drained material every 8
hours.
 Do not move or irrigate the tube
after gastric surgery without an
order from the surgeon.
 Skin Assessment
 Normal wound healing
 Ineffective wound healing: can be seen
most often between the 5th and 10th days
after surgery
 Dehiscence: a partial or complete
separation of the outer wound layers,
sometimes described as a “splitting open
of the wound.”
(Continued)
Skin Assessment (Continued)

 Evisceration: a total separation of

all wound layers and protrusion of
internal organs through the open
wound.
 Dressings and drains, including
casts and plastic bandages, must
be assessed for bleeding or other
drainage on admission to the PACU
and hourly thereafter.
Postoperative Phase
Discomfort/Pain Assessment
 Client almost always has pain or
discomfort after surgery.
 Pain assessment is started by the
postanesthesia care unit nurse.
 Pain usually reaches its peak the
second day after surgery, when the
client is more awake, more active,
and the anesthetic agents and
drugs given during surgery have
been excreted.
 Impaired Gas Exchange
Interventions include:
 Airway maintenance

 Positioning the client in a side-lying

position or turning his or her head to the
side to prevent aspiration
 Encouraging breathing exercises

 Encouraging mobilization as soon as

possible to help remove secretions and
promote lung expansion
 Impaired Skin Integrity
Interventions include:
 Nursing assessment of the surgical area

 Dressings: first dressing change usually

performed by surgeon
 Drains: provide an exit route for air, blood,
and bile as well as help prevent deep
infections and abscess formation during
healing
(Continued)
Impaired Skin Integrity
(Continued)

 Drug therapy including antibiotics

and irrigations are used to treat
wound infection.
 Surgical management is required
for wound opening.
Acute Pain

Interventions include:
 Drug therapy

 Complementary and alternative

therapies such as:
 Positioning
 Massage
 Relaxation and diversion
techniques
Potential for Hypoxemia

Interventions include:
 Maintenance of airway patency and
breathing pattern
 Prevention of hypothermia

 Maintenance of oxygen therapy as

prescribed
Health Teaching

 Prevention of infection
 Dressing care

 Nutrition

 Pain medication management

 Progressive increase in activity

level
 Use of proper body mechanics