MEDICAL-SURGICAL NURSING

Perioperative Nursing
PERIOPERATIVE OVERVIEW
INTRODUCTION
Perioperative nursing is a term used to describe the nursing care provided in the total surgical experience of the patient: preoperative, intraoperative,
and postoperative.
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 postanesthesia care unit (PACU).
Postoperative phase from the time of admission to the PACU to the follow-up evaluation
Types of Surgery

 Optional. Surgery is scheduled completely at the preference of the patient (eg, cosmetic surgery).
 Elective. The approximate time for surgery is at the convenience of the patient; failure to have surgery is not catastrophic (eg, a superficial
cyst).
 Required. The condition requires surgery within a few weeks (eg, eye cataract).
 Urgent. The surgical problem requires attention within 24 to 48 hours (eg, cancer).
 Emergency. The situation requires immediate surgical attention without delay (eg, intestinal obstruction).

AMBULATORY SURGERY

Ambulatory surgery (same-day surgery, outpatient surgery) is a common occurrence for certain types of procedures. The office nurse is in a key
position to assess patient status; plan perioperative experience; and monitor, instruct, and evaluate the patient.

1) Less time lost from work by the patient; minimal disruption of the patient's activities and family life

There

1
9 regions of the abdomen …

Top region:
 Right hypochondriac region / hypochondrium (RHC)
 Epigastric region (also known as epigastrium)
 Left hypochondriac region / hypochondrium (LHC)

Centre region:
 Right lumbar region
 Umbilical region
 Left lumbar region

Bottom region:
 Right iliac region / Right iliac fossa (RIF)
 Hypogastric region
 Left iliac region / Left iliac fossa (LIF)

2
 Each of the regions hold their own important organs:

 Right hypcochondrium – Small intestine, right kidney, gallbladder, liver

 Left hypochondrium – Pancreas, left kidney, colon, spleen
 Epigastrium – Adrenal glands, spleen, pancreas, duodenum, liver, stomach
 Right lumbar region – Right colon, liver, gallbladder
 Left lumbar region – Left kidney, descending colon
 Umbilical region – Duodenum, ileum, jejunum, umbilicus
 Right iliac fossa – Cecum, appendix
 Left iliac fossa – Sigmoid colon, descending colon
 Hypogastrium – Female reproductive organs, sigmoid colon, urinary bladder

4 Quadrants of the Abdomen

If three lines were too many and you wanted to break things down into two lines – four boxes or quadrants, rather than

nine, you can break them down into the following:

Right upper quadrant – This will be assessed by doctors for tenderness and also localised pain from organs such as the

gall bladder, liver, colon (hepatic flexure), duodenum, and the upper part of the pancreas. Pain and tenderness in this

area can be caused by conditions such as cholecystitis, hepatitis, and also the beginnings of a peptic ulcer.

Right lower quadrant – You will find the following organs here – female reproductive organs (right fallopian tube and

ovary), right ureterpenus, colon (upper portion), and the appendix. If you were suffering with appendicitis, for example, the

pain and tenderness would be localised to the right lower quadrant.

3
Left upper quadrant – Here you will find various parts of the colon – the bottom portion and splenic flexure, as well as

the adrenal gland and also the kidney (left portion), and you will also find the spleen and stomach, pancreas, and also a

part of the liver (left portion).

Left lower quadrant – Found beneath the umbilicus plane, you will find the left fallopian tube and ovary, and also the left

uterine tube in women here. In both sexes you will find the sigmoid and bottom section of the colon. If you have abdominal

pain, it is likely to come from the lower left quadrant, and it could be a sign of a number of conditions, including colitis,

ureteral colic, or diverticulitis. Pelvic inflammation (such as is found with pelvic inflammatory disease) and ovarian cysts

can also cause pain in this area, and even tumours associated with cancers, including colon and ovarian cancer.
Perioperative Nursing Practice- includes those activities performed by the registered nurse during the preoperative,
intraoperative and postoperative phase of the patients surgical experience. It encompasses the patient’s total experience
when surgical intervention is accepted as the treatment of choice.

Perioperative- refers to events during the entire surgical period, from preparation for surgery to recovery from the
temporary effects of surgery and anesthesia. This period is divided into preoperative, intraoperative and postoperative
phases.

Preoperative phase- starts when the patient is admitted to the surgical floor and prepare him physically, psychologically,
spiritually and legally for the surgical procedure until he is transported to the operating room.

Intraoperative phase- is when the patient is transferred to the operating room where he is anesthetized and undergoes
the scheduled surgical procedure.

Postoperative phase- is the time during which the patient is transferred to the recovery room/post anesthesia unit where
the nurse assist and observes the patient as he recovers from anesthesia and from the stress of surgery itself; to the time
he is transferred back to the surgical floor, discharged from the hospital until the follow-up care.

ESTIMATION OF SURGICAL RISKS

General Risks factors:

 Obesity
 Fluid and Electrolyte and Nutritional problems
 Presence of diseases
 Concurrent or prior pharmacotherapy

Other factors:
 Nature of condition
 Location of the condition
 Magnitude and urgency of the surgical procedure
 Mental attitude of the person toward surgery
 Caliber of the professional staff and health care facilities

The effects of surgery upon the patient:

 Stress response is elicited.
 Defense against infection is lowered.
 Vascular system is disrupted.
 Organ functions are disturbed.

4
  Body image may be disturbed.
 Lifestyle might change.
GENERAL CONSIDERATIONS:
a) Basic Types of Pathologic Conditions Requiring Surgery
 Obstruction
 Perforation
 Erosion
 Tumors
b) Major Categories of Surgical Procedures (according to:)
1) Purpose
 Diagnostic
 Curative
 Ablative
 Constructive
 Reconstructive
 Palliative
2) Degree of Risk
 Major Surgery
 Minor Surgery
3) Urgency
 Emergency – to be done immediately in order to;
 save the life of the patient
 save the function of an organ or limb
 removed a damaged organ or limb as necessary
 stop hemorrhage
 Imperative or Urgent
 Planned Required
 Elective
 Optional
 Day (ambulatory surgery)

PREOPERATIVE PHASE
 Goals
 Assessment & Correction of physiologic & psychological problems that may increase surgical risks.
 Giving the person & significant others complete learning/teaching guidelines regarding surgery.
 Instructing & demonstrating exercises that will benefit the person during the postoperative period.
 Planning for discharge & any projected changes in lifestyle due to surgery.
 Physiologic Assessment
 Age
 Presence of pain
 Nutritional Status
 Fluid & Electrolyte Balance
 Infection
 Cardiovascular Function
 Pulmonary Function
 Liver Function
 Gastrointestinal Function
 Liver Function
 Endocrine Function
 Neurologic Function
 Hematologic Function
5
  Use of Medication
 Presence of Trauma
 Psychosocial Assessment & Care
 Manifestations of Fear
 Anxiousness
 Bewilderment
 Anger
 Tendency to exaggerate
 Sad, evasive, tearful, clinging
 Inability to concentrate
 Short attention span
 Failure to carry out simple directions
 Nursing Interventions to Minimize Anxiety
 Explore patient’s feelings
 Allow patient to speak openly about fears/concerns
 Give accurate information regarding surgery
 Give empathetic support
 Consider the person’s religious preferences and arrange for visit priest/minister as desired
 Informed Consent (Operative Permit/Surgical Consent)
 Purposes:
 To ensure that the patient understands the nature of the treatment including the potential complications and
disfigurement.
 To indicate that the patient’s decision was made without pressure.
 To protect the client against unauthorized procedure.
 To protect the surgeon and the hospital against legal action by a client who claims that an unauthorized
procedure was performed.
 Circumstances Requiring a Permit
 Any surgical procedure where scalpel, scissors, suture, thermostats electro coagulation may be used.
 Entrance into a body cavity.
 General anesthesia, local infiltration, local anesthesia.
 Requisites for validity of informed consent
 Written permission is best and is legally acceptable.
 Signature is obtained with the client’s complete understanding of what is to occur.
 Secured without pressure.
 A witness is desirable.
 For minor (below 18 years old), unconscious, psychologically incapacitated, permission is required from
responsible family member (parent/legal guardian).

 Physical Preparation
 Before Surgery
 Correct any dietary deficiencies
 Reduce an obese person’s weight
 Correct fluid and electrolyte imbalances
 Restore adequate blood volume with blood transfusion
 Treat chronic diseases – DM, heart disease, renal insufficiency
 Halt or treat any infectious process
 Treat an alcoholic person with vitamin supplementation, IVF or oral fluids if dehydrated.
 Preparing the patient the evening before surgery
 Preparing the skin – have full bath to reduce microorganisms in the skin.
 Preparing the G.I. tract – NPO cleansing enema as required.
 Preparing for anesthesia – avoid alcohol and cigarette smoking for at least 24 hours before surgery.
 Promoting sleep – administer sedatives as ordered.

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 Preparing the patient on the day of surgery
Early Morning Care:
 Awaken one hour before preop medications
 Morning bath, mouth wash
 Provide clean gown
 Remove hairpins, braid long hairs, cover hair with cap
 Remove dentures, foreign materials, colored nail polish, hearing aid, contact lens, wedding ring – tie with
gauze and tie around the wrist.
 Check ID band, skin prep
 Check for special orders – enema, GI tube insertion, IV line
 Check NPO
 Have patient void before preop medication
 Check baseline V/S before preop medication
 Continue to support emotionally
 Accomplish “preop care checklist”
 Preoperative medication/preanestheic drugs
A. Goals:
1. To allay anxiety
2. To decrease the flow of pharyngeal secretions
3. Reduce the amount of anesthesia given
4. Create amnesia for the events that precede surgery.
B. Types of preoperative medications:
1. Tranquilizers
2. Sedatives
3. Analgesics
4. Anticholinergics
5. Histamine – H2 Receptor Antagonist
C. Recording – all final preparation and emotional responses before surgery are noted down.
 Transporting the patient to the Operating Room
 Patient’s Family
o Direct proper visiting room
o Doctor informs the family immediate after surgery
o Explain reason for long interval of waiting
o Explain what to expect postoperatively
*** Nursing Diagnosis for a Preoperative Patient***
Anxiety related to lack of knowledge about preoperative routines, physical preparations for surgery, postoperative
care and potential body image change.

INTRAOPERATIVE PHASE
 Goals

 Asepsis
 Homeostasis
 Safe administration of Anesthesia
 Hemostasis
 The Surgical team
 The surgeon
 The Anesthesiologist
 The Circulating Nurse
 The Scrub Nurse
 Direct Assistant to the Surgeon

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  Commonly Used Operative Positions
 Dorsal Recumbent (Supine
 Prone – for back and rectal surgery.
 Trendelenburg – head and body are flexed by “breaking the table”. This position permits displacement of
the intestines into the upper abdomen and is often used during surgery of the lower abdomen or pelvis.
 Reverse Trendelenburg – head is elevated and feet are lowered.
 Lithotomy This position exposes the perineal area and is ideal for perineal repairs, dilatation and
curretage and most abdomino-perineal resection. (APR)
 Lateral
 Laminectomy positions
Nursing Management:
 Explain purpose of the position.
 Avoid undue exposure.
 Strap the patient to prevent falls.
 Maintain adequate respiratory and circulatory function.
 Maintain good body alignment.

ASSISTING WITH SURGICAL WOUND CLOSURE

Skin closure (sutures) are used to approximate wound edges until wound healing is complete or to occlude the
lumen or a blood vessel. A contaminated wound may be left open or partially open.
The surgical wound is closed with:
 Sutures
 Staples
 Skin closure strips
 Retention sutures
 Zipper-like devices
After the incision is closed, a dressing is applied:
 To prevent wound contamination.
 Absorb drainage.
 To provide support for the incision.
If healing progresses without complications, the sutures, clips, and staples are usually removed after 7-10
days.
ASSESSING DRAINAGE
A drain is placed in the incision to drain blood, serum and debris from the operative site.
Drains may be free draining, attached to suction or self-contained drainage with suction.
Nursing Interventions:
 Maintenance of pulmonary ventilation (patent airway and adequate respiratory function)
 Position patient to lateral position with neck extended.
 Keep airway in place until fully awake.
 Suction secretions.
 Encourage deep breathing.
 Administer humidified oxygen as ordered.
 Maintenance of circulation
 Monitor vital signs and report abnormalities.
 Observe signs and symptoms of shock and hemorrhage.
 Promote comfort and maintain safety.
 Continuous constant surveillance of the patient until completely out of anesthesia.
 Recognize stress factors that may affect the patient and minimize these factor.

5 Physiologic Parameters in the Discharge of Patient from Recovery Room

 ACTIVITY- able to obey commands. Example: move four extremities voluntarily on commands, deep breathing,
coughing.

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  RESPIRATION- able to breath deeply and cough freely with easy and noiseless breathing.
 CIRCULATION- BP is within + 20 mmHg of the preoperative level.
 CONSCIOUSNESS – fully awake; responsive
 COLOR- pinkish skin and mucus membrane

POSTOPERATIVE PHASE
 Goals
 Maintain adequate body systems functions.
 Restore homeostasis.
 Alleviate pain and discomfort.
 Prevent postoperative complications.
 Ensure adequate discharge planning and teaching.
1. Post Anesthetic Care
Immediate post op (immediate post anesthesia recovery- RR) Assist patient in returning to safe
physiologic level by providing safe and individualized nursing care.
Transport of the patient from the OR to RR.
 Avoid exposure.
 Avoid rough handling.
 Avoid hurried movement and rapid changes in position.
a.) Get the baseline assessment of the patient.
 Appraise air exchange status and skin color.
 Verify identity, operative procedure and surgeon.
 Assess neuro status.
 Determine vital signs and skin temperature. (CV status)
 Examine operative site and check dressings.
 Perform safety checks.
o Position for good body alignment.
o Side rails.
o Restraints for IVF’s, blood transfusion
 Require briefing on problems encountered in OR.
2. Intermediate postop care
When the patient returns from RR to the surgical unit; directed towards prevention of complications and
postoperative discomforts.
 Initial assessment
 Respiratory Status.
 Cardiovascular status
 LOC ( Level of Consciousness)
 Tubes – Drainage, NGT, T-tube
 Position
 Ongoing Assessment, Goals and Interventions.
 Goals
 Restore homeostasis and prevent complications.
 Maintain adequate cardiovascular and tissue perfusion.
 Maintain adequate respiratory function.
Causes of airway obstruction:
 Mucus collection in the throat
 Aspirated mucus/vomitus
 Loss of swallowing reflex
 Loss of control of the muscles of the jaw and tongue.
 Laryngospasm due to intubation.
 Bronchospasm.

9
 Causes of hypoventilation:
 Medications
 Pain
 Chronic Lung Disease
 Obesity
Signs and Symptoms of Respiratory Obstruction and Hypoventilation
 Restlessness
 Attempt to sit up on bed
 Fast, thready pulse (early sign)
 Air hunger
 Nausea, apprehension, confusion
 Stridor/ snoring/ wheezing
 Cyanosis (late sign)
 Interventions
 Maintain adequate nutrition and elimination.
 Maintain adequate fluid and electrolyte balance.
 Maintain adequate renal function.
 Promote adequate rest, comfort and safety.
 Promote wound healing.
 Promote and maintain activity and mobility.
 Provide adequate psychological support.
3. Extended Postop Period
2-3 days after surgery
 Self care activities
 Activity Limitation
 Diet and Medication at Home
 Possible Complications
 Referrals, follow up check-up
Post Discomfort
 Nausea and Vomiting
 Restlessness and Sleeplessness
 Thirst
 Constipation
 Pain

POSTOPERATIVE COMPLICATIONS
SHOCK- response of the body to a decrease in the circulating blood volume, which results to poor tissue perfusion and
inadequate tissue oxygenation. (tissue hypoxia)
Impaired Tissue Metabolism

Cell/ Organ Death

HEMORRHAGE- the copious escape of blood from the blood vessel.
 Capillary- slow, generalized oozing
 Venous- dark in color and bubble out.
 Arterial – spurts and is bright red in color.
Clinical Manifestations:
 Apprehension
 Deep, rapid RR, low body temperature
 Low BP, Low Hgb
 Circumoral pallor, ringing in ears
 Progressive weakness, the death ensues

10
FEMORAL PHLEBITIS/ DEEP THROMBOPHLEBITIS- often occurs after operations on the lower abdomen or during the
course of septic conditions as ruptured ulcer or peritonitis.
Causes:
 Injury; damage to vein
 Hemorrhage
 Prolonged Immobility
 Obesity/ Debilitation
Clinical Manifestations:
 Pain
 Redness
 Swelling
 Heat/ warmth
 (+) homan’s sign
Nursing Interventions:
 Prevention
 Hydrate adequately to prevent hemoconcentration.
 Encourage leg exercises and ambulate early.
 Avoid any restricting devices that can constrict and impair circulation.
 Prevent use of bed rolls, knee gatches, dangling over the side of the bed with pressure on the popliteal
area.
 Active Interventions
 Bed rest, elevate the affected leg with pillow support.
 Wear anti embolic support from the toes to the groin.
 Avoid massage on the calf of the leg.
 Initiate anticoagulant therapy as ordered.
PULMONARY COMPLICATIONS
 Atelectasis
 Bronchitis
 Bronchopneumonia
 Lobar Pneumonia
 Hypostatic Pneumonia
 Pleurisy
Nursing Interventions:
 Reinforce deep breathing , coughing, turning exercises.
 Encourage early ambulation.
 Incentive spirometry.
URINARY DIFFICULTIES
 Retention- occurs most frequently after operation of the rectum, anus, vagina, lower abdomen, caused by the
spasm of the bladder sphincter.
 Incontinence – 30-60 ml every 15-30 minutes, the bladder is over distended, there is overflow incontinence
caused by loss of tone of the bladder sphincter.
Nursing Interventions: Implement measures to induce voiding.
INTESTINAL OBSTRUCTION- loop of intestine may kink due to inflammatory adhesions.
Clinical Manifestations:
 Intermittent sharp, colicky abdominal pains.
 Nausea and vomiting.
 Abdominal distention, hiccups
 Diarrhea (incomplete obstruction), No bowel movement (complete obstruction)
 Return flow of enema is clear.
 Shock, then death occurs.
Nursing Interventions:
11
  NGT insertion
 Administer electrolyte/IV as ordered.
 Prepare for possible surgical intervention.

HICCUPS- intermittent spasms of the diaphragm causing a sound (“hic”) that result from the vibration of closed vocal
cords as air rushes suddenly into the lungs------ caused by irritation of the phrenic nerve between the spinal cord and
terminal ramifications on the undersurface of the diaphragm.
Nursing Interventions:
 Remove the cause. e.g abdominal distention
 Hold breath by taking a large swallow of water.
 Pressing on the eyeball thru closed lids for several minutes.
 Breath in or out paper bag.
 Plasil as ordered.
WOUND INFECTIONS
Clinical Manifestations:
 Redness, swelling, pain, warmth
 Pus or other discharge on the wound.
 Foul smell from the wound.
 Elevated temperature, chills
 Tender lymph nodes on the axilla or groin closes to the wound.
Preventive Measures:
 Housekeeping cleanliness in the surgical environment.
 Strict aseptic techniques.
 Wound care.
 Antibiotic therapy

12
 MEDICAL-SURGICAL NURSING
Perioperative Nursing
PERIOPERATIVE OVERVIEW
INTRODUCTION
Perioperative nursing is a term used to describe the nursing care provided in the total surgical experience of the patient: preoperative, intraoperative,
and postoperative.
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 postanesthesia care unit (PACU).
Postoperative phase from the time of admission to the PACU to the follow-up evaluation
Types of Surgery

 Optional. Surgery is scheduled completely at the preference of the patient (eg, cosmetic surgery).
 Elective. The approximate time for surgery is at the convenience of the patient; failure to have surgery is not catastrophic (eg, a superficial
cyst).
 Required. The condition requires surgery within a few weeks (eg, eye cataract).
 Urgent. The surgical problem requires attention within 24 to 48 hours (eg, cancer).
 Emergency. The situation requires immediate surgical attention without delay (eg, intestinal obstruction).

AMBULATORY SURGERY

13
Ambulatory surgery (same-day surgery, outpatient surgery) is a common occurrence for certain types of procedures. The office nurse is in a key
position to assess patient status; plan perioperative experience; and monitor, instruct, and evaluate the patient.

2) Less time lost from work by the patient; minimal disruption of the patient's activities and family life

There

9 regions of the

abdomen …

Top region:
 Right hypochondriac region / hypochondrium (RHC)
 Epigastric region (also known as epigastrium)
 Left hypochondriac region / hypochondrium (LHC)

Centre region:
 Right lumbar region
 Umbilical region
 Left lumbar region

Bottom region:
 Right iliac region / Right iliac fossa (RIF)
 Hypogastric region
 Left iliac region / Left iliac fossa (LIF)
14
 Each of the regions hold their own important organs:

 Right hypcochondrium – Small intestine, right kidney, gallbladder, liver

 Left hypochondrium – Pancreas, left kidney, colon, spleen
 Epigastrium – Adrenal glands, spleen, pancreas, duodenum, liver, stomach
 Right lumbar region – Right colon, liver, gallbladder
 Left lumbar region – Left kidney, descending colon
 Umbilical region – Duodenum, ileum, jejunum, umbilicus
 Right iliac fossa – Cecum, appendix
 Left iliac fossa – Sigmoid colon, descending colon
 Hypogastrium – Female reproductive organs, sigmoid colon, urinary bladder

4 Quadrants of the Abdomen

If three lines were too many and you wanted to break things down into two lines – four boxes or quadrants, rather than

nine, you can break them down into the following:

15
Right upper quadrant – This will be assessed by doctors for tenderness and also localised pain from organs such as the

gall bladder, liver, colon (hepatic flexure), duodenum, and the upper part of the pancreas. Pain and tenderness in this

area can be caused by conditions such as cholecystitis, hepatitis, and also the beginnings of a peptic ulcer.

Right lower quadrant – You will find the following organs here – female reproductive organs (right fallopian tube and

ovary), right ureterpenus, colon (upper portion), and the appendix. If you were suffering with appendicitis, for example, the

pain and tenderness would be localised to the right lower quadrant.

Left upper quadrant – Here you will find various parts of the colon – the bottom portion and splenic flexure, as well as

the adrenal gland and also the kidney (left portion), and you will also find the spleen and stomach, pancreas, and also a

part of the liver (left portion).

Left lower quadrant – Found beneath the umbilicus plane, you will find the left fallopian tube and ovary, and also the left

uterine tube in women here. In both sexes you will find the sigmoid and bottom section of the colon. If you have abdominal

pain, it is likely to come from the lower left quadrant, and it could be a sign of a number of conditions, including colitis,

ureteral colic, or diverticulitis. Pelvic inflammation (such as is found with pelvic inflammatory disease) and ovarian cysts

can also cause pain in this area, and even tumours associated with cancers, including colon and ovarian cancer.
Perioperative Nursing Practice- includes those activities performed by the registered nurse during the preoperative,
intraoperative and postoperative phase of the patients surgical experience. It encompasses the patient’s total experience
when surgical intervention is accepted as the treatment of choice.

Perioperative- refers to events during the entire surgical period, from preparation for surgery to recovery from the
temporary effects of surgery and anesthesia. This period is divided into preoperative, intraoperative and postoperative
phases.

Preoperative phase- starts when the patient is admitted to the surgical floor and prepare him physically, psychologically,
spiritually and legally for the surgical procedure until he is transported to the operating room.

Intraoperative phase- is when the patient is transferred to the operating room where he is anesthetized and undergoes
the scheduled surgical procedure.

Postoperative phase- is the time during which the patient is transferred to the recovery room/post anesthesia unit where
the nurse assist and observes the patient as he recovers from anesthesia and from the stress of surgery itself; to the time
he is transferred back to the surgical floor, discharged from the hospital until the follow-up care.

ESTIMATION OF SURGICAL RISKS

General Risks factors:

Other factors:
 Nature of condition
 Location of the condition
 Magnitude and urgency of the surgical procedure
 Mental attitude of the person toward surgery
 Caliber of the professional staff and health care facilities

16
The effects of surgery upon the patient:
 Stress response is elicited.
 Defense against infection is lowered.
 Vascular system is disrupted.
 Organ functions are disturbed.
 Body image may be disturbed.
 Lifestyle might change.
GENERAL CONSIDERATIONS:
a) Basic Types of Pathologic Conditions Requiring Surgery
 Obstruction
 Perforation
 Erosion
 Tumors
b) Major Categories of Surgical Procedures (according to:)
1) Purpose
 Diagnostic
 Curative
 Ablative
 Constructive
 Reconstructive
 Palliative
2) Degree of Risk
 Major Surgery
 Minor Surgery
3) Urgency
 Emergency – to be done immediately in order to;
 save the life of the patient
 save the function of an organ or limb
 removed a damaged organ or limb as necessary
 stop hemorrhage
 Imperative or Urgent
 Planned Required
 Elective
 Optional
 Day (ambulatory surgery)

PREOPERATIVE PHASE
 Goals
 Assessment & Correction of physiologic & psychological problems that may increase surgical risks.
 Giving the person & significant others complete learning/teaching guidelines regarding surgery.
 Instructing & demonstrating exercises that will benefit the person during the postoperative period.
 Planning for discharge & any projected changes in lifestyle due to surgery.
 Physiologic Assessment
 Age
 Presence of pain
 Nutritional Status
 Fluid & Electrolyte Balance
 Infection
 Cardiovascular Function
 Pulmonary Function
17
  Liver Function
 Gastrointestinal Function
 Liver Function
 Endocrine Function
 Neurologic Function
 Hematologic Function
 Use of Medication
 Presence of Trauma
 Psychosocial Assessment & Care
 Manifestations of Fear
 Anxiousness
 Bewilderment
 Anger
 Tendency to exaggerate
 Sad, evasive, tearful, clinging
 Inability to concentrate
 Short attention span
 Failure to carry out simple directions
 Nursing Interventions to Minimize Anxiety
 Explore patient’s feelings
 Allow patient to speak openly about fears/concerns
 Give accurate information regarding surgery
 Give empathetic support
 Consider the person’s religious preferences and arrange for visit priest/minister as desired
 Informed Consent (Operative Permit/Surgical Consent)
 Purposes:
 To ensure that the patient understands the nature of the treatment including the potential complications and
disfigurement.
 To indicate that the patient’s decision was made without pressure.
 To protect the client against unauthorized procedure.
 To protect the surgeon and the hospital against legal action by a client who claims that an unauthorized
procedure was performed.
 Circumstances Requiring a Permit
 Any surgical procedure where scalpel, scissors, suture, thermostats electro coagulation may be used.
 Entrance into a body cavity.
 General anesthesia, local infiltration, local anesthesia.
 Requisites for validity of informed consent
 Written permission is best and is legally acceptable.
 Signature is obtained with the client’s complete understanding of what is to occur.
 Secured without pressure.
 A witness is desirable.
 For minor (below 18 years old), unconscious, psychologically incapacitated, permission is required from
responsible family member (parent/legal guardian).

 Physical Preparation
 Before Surgery
 Correct any dietary deficiencies
 Reduce an obese person’s weight
 Correct fluid and electrolyte imbalances
 Restore adequate blood volume with blood transfusion
 Treat chronic diseases – DM, heart disease, renal insufficiency
 Halt or treat any infectious process

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  Treat an alcoholic person with vitamin supplementation, IVF or oral fluids if dehydrated.
 Preparing the patient the evening before surgery
 Preparing the skin – have full bath to reduce microorganisms in the skin.
 Preparing the G.I. tract – NPO cleansing enema as required.
 Preparing for anesthesia – avoid alcohol and cigarette smoking for at least 24 hours before surgery.
 Promoting sleep – administer sedatives as ordered.
 Preparing the patient on the day of surgery
Early Morning Care:
 Awaken one hour before preop medications
 Morning bath, mouth wash
 Provide clean gown
 Remove hairpins, braid long hairs, cover hair with cap
 Remove dentures, foreign materials, colored nail polish, hearing aid, contact lens, wedding ring – tie with
gauze and tie around the wrist.
 Check ID band, skin prep
 Check for special orders – enema, GI tube insertion, IV line
 Check NPO
 Have patient void before preop medication
 Check baseline V/S before preop medication
 Continue to support emotionally
 Accomplish “preop care checklist”
 Preoperative medication/preanestheic drugs
D. Goals:
1. To allay anxiety
2. To decrease the flow of pharyngeal secretions
3. Reduce the amount of anesthesia given
4. Create amnesia for the events that precede surgery.
E. Types of preoperative medications:
1. Tranquilizers
2. Sedatives
3. Analgesics
4. Anticholinergics
5. Histamine – H2 Receptor Antagonist
F. Recording – all final preparation and emotional responses before surgery are noted down.
 Transporting the patient to the Operating Room
 Patient’s Family
o Direct proper visiting room
o Doctor informs the family immediate after surgery
o Explain reason for long interval of waiting
o Explain what to expect postoperatively
*** Nursing Diagnosis for a Preoperative Patient***
Anxiety related to lack of knowledge about preoperative routines, physical preparations for surgery, postoperative
care and potential body image change.

INTRAOPERATIVE PHASE
 Goals

 Asepsis
 Homeostasis
 Safe administration of Anesthesia
 Hemostasis

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  The Surgical team
 The surgeon
 The Anesthesiologist
 The Circulating Nurse
 The Scrub Nurse
 Direct Assistant to the Surgeon
 Commonly Used Operative Positions
----
Nursing Management:
 Explain purpose of the position.
 Avoid undue exposure.
 Strap the patient to prevent falls.
 Maintain adequate respiratory and circulatory function.
 Maintain good body alignment.

ASSISTING WITH SURGICAL WOUND CLOSURE

Skin closure (sutures) are used to approximate wound edges until wound healing is complete or to occlude the
lumen or a blood vessel. A contaminated wound may be left open or partially open.
The surgical wound is closed with:
 Sutures
 Staples
 Skin closure strips
 Retention sutures
 Zipper-like devices
After the incision is closed, a dressing is applied:
 To prevent wound contamination.
 Absorb drainage.
 To provide support for the incision.
If healing progresses without complications, the sutures, clips, and staples are usually removed after 7-10
days.
ASSESSING DRAINAGE
A drain is placed in the incision to drain blood, serum and debris from the operative site.
Drains may be free draining, attached to suction or self-contained drainage with suction.
Nursing Interventions:
 Maintenance of pulmonary ventilation (patent airway and adequate respiratory function)
 Position patient to lateral position with neck extended.
 Keep airway in place until fully awake.
 Suction secretions.
 Encourage deep breathing.
 Administer humidified oxygen as ordered.
 Maintenance of circulation
 Monitor vital signs and report abnormalities.
 Observe signs and symptoms of shock and hemorrhage.
 Promote comfort and maintain safety.
 Continuous constant surveillance of the patient until completely out of anesthesia.
 Recognize stress factors that may affect the patient and minimize these factor.

5 Physiologic Parameters in the Discharge of Patient from Recovery Room

 ACTIVITY- able to obey commands. Example: move four extremities voluntarily on commands, deep breathing,
coughing.
 RESPIRATION- able to breath deeply and cough freely with easy and noiseless breathing.
 CIRCULATION- BP is within + 20 mmHg of the preoperative level.

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  CONSCIOUSNESS – fully awake; responsive
 COLOR- pinkish skin and mucus membrane

POSTOPERATIVE PHASE
 Goals
 Maintain adequate body systems functions.
 Restore homeostasis.
 Alleviate pain and discomfort.
 Prevent postoperative complications.
 Ensure adequate discharge planning and teaching.
1. Post Anesthetic Care
Immediate post op (immediate post anesthesia recovery- RR) Assist patient in returning to safe
physiologic level by providing safe and individualized nursing care.
Transport of the patient from the OR to RR.
 Avoid exposure.
 Avoid rough handling.
 Avoid hurried movement and rapid changes in position.
b.) Get the baseline assessment of the patient.
 Appraise air exchange status and skin color.
 Verify identity, operative procedure and surgeon.
 Assess neuro status.
 Determine vital signs and skin temperature. (CV status)
 Examine operative site and check dressings.
 Perform safety checks.
o Position for good body alignment.
o Side rails.
o Restraints for IVF’s, blood transfusion
 Require briefing on problems encountered in OR.
2. Intermediate postop care
When the patient returns from RR to the surgical unit; directed towards prevention of complications and
postoperative discomforts.
 Initial assessment
 Respiratory Status.
 Cardiovascular status
 LOC ( Level of Consciousness)
 Tubes – Drainage, NGT, T-tube
 Position
 Ongoing Assessment, Goals and Interventions.
 Goals
 Restore homeostasis and prevent complications.
 Maintain adequate cardiovascular and tissue perfusion.
 Maintain adequate respiratory function.
Causes of airway obstruction:
 Mucus collection in the throat
 Aspirated mucus/vomitus
 Loss of swallowing reflex
 Loss of control of the muscles of the jaw and tongue.
 Laryngospasm due to intubation.
 Bronchospasm.
Causes of hypoventilation:
 Medications

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  Pain
 Chronic Lung Disease
 Obesity
Signs and Symptoms of Respiratory Obstruction and Hypoventilation
 Restlessness
 Attempt to sit up on bed
 Fast, thready pulse (early sign)
 Air hunger
 Nausea, apprehension, confusion
 Stridor/ snoring/ wheezing
 Cyanosis (late sign)
 Interventions
 Maintain adequate nutrition and elimination.
 Maintain adequate fluid and electrolyte balance.
 Maintain adequate renal function.
 Promote adequate rest, comfort and safety.
 Promote wound healing.
 Promote and maintain activity and mobility.
 Provide adequate psychological support.
3. Extended Postop Period
2-3 days after surgery
 Self care activities
 Activity Limitation
 Diet and Medication at Home
 Possible Complications
 Referrals, follow up check-up
Post Discomfort
 Nausea and Vomiting
 Restlessness and Sleeplessness
 Thirst
 Constipation
 Pain

POSTOPERATIVE COMPLICATIONS
SHOCK- response of the body to a decrease in the circulating blood volume, which results to poor tissue perfusion and
inadequate tissue oxygenation. (tissue hypoxia)
Impaired Tissue Metabolism

Cell/ Organ Death

HEMORRHAGE- the copious escape of blood from the blood vessel.
 Capillary- slow, generalized oozing
 Venous- dark in color and bubble out.
 Arterial – spurts and is bright red in color.
Clinical Manifestations:
 Apprehension
 Deep, rapid RR, low body temperature
 Low BP, Low Hgb
 Circumoral pallor, ringing in ears
 Progressive weakness, the death ensues

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FEMORAL PHLEBITIS/ DEEP THROMBOPHLEBITIS- often occurs after operations on the lower abdomen or during the
course of septic conditions as ruptured ulcer or peritonitis.
Causes:
 Injury; damage to vein
 Hemorrhage
 Prolonged Immobility
 Obesity/ Debilitation
Clinical Manifestations:
 Pain
 Redness
 Swelling
 Heat/ warmth
 (+) homan’s sign
Nursing Interventions:
 Prevention
 Hydrate adequately to prevent hemoconcentration.
 Encourage leg exercises and ambulate early.
 Avoid any restricting devices that can constrict and impair circulation.
 Prevent use of bed rolls, knee gatches, dangling over the side of the bed with pressure on the popliteal
area.
 Active Interventions
 Bed rest, elevate the affected leg with pillow support.
 Wear anti embolic support from the toes to the groin.
 Avoid massage on the calf of the leg.
 Initiate anticoagulant therapy as ordered.
PULMONARY COMPLICATIONS
 Atelectasis
 Bronchitis
 Bronchopneumonia
 Lobar Pneumonia
 Hypostatic Pneumonia
 Pleurisy
Nursing Interventions:
 Reinforce deep breathing , coughing, turning exercises.
 Encourage early ambulation.
 Incentive spirometry.
URINARY DIFFICULTIES
 Retention- occurs most frequently after operation of the rectum, anus, vagina, lower abdomen, caused by the
spasm of the bladder sphincter.
 Incontinence –
Nursing Interventions: Implement measures to induce voiding.
INTESTINAL OBSTRUCTION- loop of intestine may kink due to inflammatory adhesions.
Clinical Manifestations:
 Intermittent sharp, colicky abdominal pains.
 Nausea and vomiting.
 Abdominal distention, hiccups
 Diarrhea (incomplete obstruction), No bowel movement (complete obstruction)
 Return flow of enema is clear.
 Shock, then death occurs.
Nursing Interventions:
 NGT insertion
 Administer electrolyte/IV as ordered.
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  Prepare for possible surgical intervention.

HICCUPS- intermittent spasms of the diaphragm causing a sound (“hic”) that result from the vibration of closed vocal
cords as air rushes suddenly into the lungs------ caused by irritation of the phrenic nerve between the spinal cord and
terminal ramifications on the undersurface of the diaphragm.
Nursing Interventions:
 Remove the cause. e.g abdominal distention
 Hold breath by taking a large swallow of water.
 Pressing on the eyeball thru closed lids for several minutes.
 Breath in or out paper bag.
 Plasil as ordered.
WOUND INFECTIONS
Clinical Manifestations:
 Redness, swelling, pain, warmth
 Pus or other discharge on the wound.
 Foul smell from the wound.
 Elevated temperature, chills
 Tender lymph nodes on the axilla or groin closes to the wound.
Preventive Measures:
 Housekeeping cleanliness in the surgical environment.
 Strict aseptic techniques.
 Wound care.
 Antibiotic therapy

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