University of Pangasinan

PHINMA Education Network

College of Health Sciences

Perioperative Nursing
Management

AA Patient Recovering From Abdominal Surgery

Mr. Dickson, a 60-year-old smoker, was admitted to the surgical unit 5 hours
ago after colon resection for cancer. He is groggy but easily arousable. He can
move all extremities with equal strength, but feels better lying still. In the
last 4 hours, 125 mL of greenish material has drained from his nasogastric
tube, which is connected to low intermittent suction. His abdomen is
mildly distended; bowel sounds are absent. The large abdominal dressing
has a reconstitutable bulb drain with 30 mL of serosanguineous
drainage; the dressing’s minimal visible drainage has not increased in
several hours. A peripheral IV of D5W 12NS with 20 mEq of KCl is infusing
at 125 mL/h. Mr. Dickson has voided 600 mL of clear urine. Vital
signs are: Temp 97_F; HR 82, B/P 112/70; Resp 12 and shallow. Lung auscultation
reveals scattered crackles throughout and a weak cough. After a 50-mg
morphine injection, Mr. Dickson rates his pain at 3 (down from 7). He is reluctant
to use his incentive spirometer for fear of more pain

Nursing Classifications and Languages

NANDA NIC
Nursing Diagnosis Nursing Interventions
Return to functional baseline
status, stabilization of, or
improvement in:
RISK FOR IMPAIRED GAS RESPIRATORY ANXIETY CONTROL—
EXCHANGE—At risk for MONITORING— Personal actions
excess or Collection and analysis of to eliminate or reduce feelings
deficit in oxygenation and/or patient of apprehension and tension
carbon data to ensure airway patency from an unidentifiable source
dioxide elimination at the and adequate gas exchange
alveolar-capillary membrane
RISK FOR INEFFECTIVE COUGH ENHANCEMENT— RESPIRATORY STATUS:
 AIRWAY Promotion of deep inhalation GAS
CLEARANCE— At risk for by EXCHANGE— The alveolar
inability the patient with subsequent exchange of O2 and CO2 to
to clear secretions or generation maintain arterial blood gas
obstructions of high intrathoracic pressures concentrations
from the respiratory tract to and compression of
maintain a clear airway underlying
lung parenchyma for the
forceful expulsion of air
ACUTE PAIN— Unpleasant PAIN MANAGEMENT— PAIN LEVEL— Severity of
sensory Alleviation observed or reported pain
and emotional experience of pain or reduction in pain to
arising a
from actual or potential tissue level of comfort that is
damage or described in terms acceptable
of to the patient
such damage
IMPAIRED PHYSICAL TEACHING: PRESCRIBED MOBILITY— Ability to move
MOBILITY— ACTIVITY/EXERCISE— purposefully in own
Limitation in independent, Preparing a environment
purposeful patient to achieve and/or independently with or without
physical movement of maintain assistive device
the body or of one or more a prescribed level of activity
extremities

Learning Objectives

1. Define the three phases of perioperative patient care.

2. Describe a comprehensive preoperative assessment to
identify surgical risk factors.
3. Identify health factors that affect patients preoperatively.
4. Identify legal and ethical considerations related to obtaining
informed consent for surgery.
5. Describe preoperative nursing measures that decrease
the risk for infection and other postoperative complications.
6. Describe the immediate preoperative preparation of the
patient.
7. Develop a preoperative teaching plan designed to
promote the patient’s recovery from anesthesia and surgery,
thus preventing postoperative complications.

Glossary

ambulatory surgery: includes outpatient, same-day, or

short-stay surgery that does not require an overnight
hospital stay
informed consent: the patient’s autonomous decision
about whether to undergo a surgical procedure, based
on the nature of the condition, the treatment options,
and the risks and benefits involved
intraoperative phase: period of time that begins with
transfer of the patient to the operating room table and
continues until the patient is admitted to the postanesthesia
care unit
perioperative phase: period of time that constitutes the
surgical experience; includes the preoperative, intraoperative,
phases of nursing care
postoperative phase: period of time that begins with the
admission of the patient to the postanesthesia care unit
and ends after follow-up evaluation in the clinical setting
or home
preadmission testing: diagnostic testing performed
before admission to the hospital
preoperative phase: period of time from when the
decision for surgical intervention is made to when the
patient is transferred to the operating room table

Perioperative Nursing

3 phases
preoperative phase begins when the decision
to proceed with surgical intervention is made and ends with
the transfer of the patient onto the operating room (OR) table
intraoperative phase begins when the patient is
transferred onto the OR table and ends with admission to
the PACU.
Nursing duties *scrub nurse,
*circulating nurse
Postoperative phase begins with the admission of the patient to
the PACU and ends with a follow-up evaluation in the clinical
setting or home

Surgical Classifications
various reasons.
diagnostic (eg, biopsy, exploratory laparotomy),
curative (eg, excision of a tumor or an inflamed appendix)
reparative (eg, multiple wound repair)
reconstructive or cosmetic (eg, mammoplasty or a facelift)
palliative (eg, to relieve pain or correct a problem—for instance,
a gastrostomy tube may be inserted to compensate for
the inability to swallow food)
degree of urgency involved: emergent, urgent, required, elective, and
optional
Categories of Surgery based on Urgency

Classification Examples Indications for Surgery Examples

I. Emergent—Patient requires Without delay Severe bleeding
immediate Bladder or intestinal
attention; disorder may be life- obstruction
threatening Fractured skull
Gunshot or stab wounds
Extensive burns

II. Urgent—Patient requires Within 24–30 hours Acute gallbladder infection

prompt attention Kidney or ureteral stones

III. Required—Patient needs Plan within a few weeks or Prostatic hyperplasia without
to have surgery months bladder obstruction
Thyroid disorders
Cataracts
IV. Elective—Patient should Failure to have surgery not Repair of scars
have surgery catastrophic Simple hernia
Vaginal repair
V. Optional—Decision rests Personal preference Cosmetic surgery
with patient

Special Considerations During the Perioperative Period

Gerontologic Considerations
Patients Who Are Obese
Patients With Disabilities
Patients Undergoing Ambulatory Surgery
Patients Undergoing Emergency Surgery

Informed Consent
Informed consent is the patient’s autonomous decision aboutwhether to undergo a surgical
procedure. Voluntary and written informed consent from the patient is necessary before
nonemergent surgery can be performed in order to protect the patient from unsanctioned
surgery and protect the surgeon from claims of an unauthorized operation. Consent is a legal
mandate, but it also helps the patient to prepare psychologically, because it helps to ensure that
the patient understands the surgery to be performed.

The signed consent form is placed in a prominent

place on the patient’s chart and accompanies the patient
to the OR.

Voluntary Consent
Valid consent must be freely given, without coercion.
Patient must be at least 18 years of age (unless an emancipated
minor), consent must be obtained by a physician, and
patient’s signature must be witnessed by a professional
staff member.
Incompetent Patient
Legal definition: individual who is not autonomous and cannot
give or withhold consent (eg, individuals who are cognitively
impaired, mentally ill, or neurologically incapacitated).
Informed Subject
Informed consent should be in writing. It should contain the
following:
• Explanation of procedure and its risks
• Description of benefits and alternatives
• An offer to answer questions about procedure
• Instructions that the patient may withdraw consent
• A statement informing the patient if the protocol differs
from customary procedure
Patient Able to Comprehend
If the patient is non–English speaking, it is necessary to
provide consent (written and verbal) in a language that is
understandable to the client. A trained medical interpreter
may be consulted. Alternative formats of communication
(eg, Braille, large print, sign interpreter) may be needed if
the patient has a disability that affects vision or hearing.
Questions must be answered to facilitate comprehension if
material is confusing.

Risk Factors for Surgical

Complications
• Hypovolemia
• Dehydration or electrolyte imbalance
• Nutritional deficits
• Extremes of age (very young, very old)
• Extremes of weight (emaciation, obesity)
• Infection and sepsis
• Toxic conditions
• Immunologic abnormalities
• Pulmonary disease
• Obstructive disease
• Restrictive disorder
• Respiratory infection
• Renal or urinary tract disease
• Decreased renal function
• Urinary tract infection
• Obstruction
• Pregnancy
• Diminished maternal physiologic reserve
• Cardiovascular disease
• Coronary artery disease or previous myocardial
infarction
• Cardiac failure
• Dysrhythmias
• Hypertension
• Prosthetic heart valve
• Thromboembolism
• Hemorrhagic disorders
• Cerebrovascular disease
• Endocrine dysfunction
• Diabetes mellitus
• Adrenal disorders
• Thyroid malfunction
• Hepatic disease
• Cirrhosis
• Hepatitis
• Preexisting mental or physical disability

Nutritional and Fluid Status

Optimal nutrition is an essential factor in promoting healing
and resisting infection and other surgical complications.
Assessment of a patient’s nutritional status identifies
factors that can affect the patient’s surgical course, such as
obesity weight loss, malnutrition, deficiencies in specific
nutrients, metabolic abnormalities, and the effects of medications
on nutrition.

Dentition
The condition of the mouth is an important health factor to
assess. Dental caries, dentures, and partial plates are particularly
significant to the anesthesiologist or anesthetist, because
decayed teeth or dental prostheses may become dislodged
during intubation and occlude the airway.

Drug or Alcohol Use

People who abuse drugs or alcohol frequently deny or attempt
to hide it. In such situations, the nurse who is obtaining
the patient’s health history needs to ask frank questions
with patience, care, and a nonjudgmental attitude.

Cardiovascular Status
The goal in preparing any patient for surgery is to ensure a
well-functioning cardiovascular system to meet the oxygen,
fluid, and nutritional needs of the perioperative period. If
the patient has uncontrolled hypertension, surgery may be
postponed until the blood pressure is under control.

Hepatic and Renal Function

The presurgical goal is optimal function of the liver and urinary
systems so that medications, anesthetic agents, body
wastes, and toxins are adequately metabolized and removed
from the body.
Endocrine Function
The patient with diabetes who is undergoing surgery is at
risk for hypoglycemia and hyperglycemia. Hypoglycemia
may develop during anesthesia or postoperatively from inadequate
carbohydrates or excessive administration of insulin.

Immune Function
An important function of the preoperative assessment is to
determine the presence of allergies. It is especially important
to identify and document any sensitivity to medications and
past adverse reactions to these agents.

Previous Medication Use

A medication history is obtained because of the possible effects
of medications on the patient’s perioperative course,
including the possibility of drug interactions.
Because of possible adverse interactions, the nurse
must assess and document the patient’s use of prescription
medications, OTC medications (especially aspirin),
herbal agents, and the frequency with which medications
are used. The nurse must clearly communicate this
information to the anesthesiologist or anesthetist.

Psychosocial Factors
Most patients have some type of emotional reaction before
any surgical procedure, be it obvious or hidden, normal or
abnormal. Fears may be related to fear of the unknown or of
death, anesthesia, pain, complications, or cancer.

Spiritual and Cultural Beliefs

Spiritual beliefs play an important role in how people cope
with fear and anxiety. Regardless of the patient’s religious affiliation,
spiritual beliefs can be as therapeutic as medication.

Examples of medications with the potential to affect the Surgical Experience

Agent Effect of Interaction With Anesthetics

Corticosteroids Cardiovascular collapse can occur if
Prednisone (Deltasone) discontinued suddenly. Therefore, a bolus of
corticosteroid may
be administered intravenously immediately
before and after surgery.
Diuretics During anesthesia, may cause excessive
Hydrochlorothiazide (HydroDIURIL) respiratory depression resulting from an
associated electrolyte
imbalance
Phenothiazines May increase the hypotensive action of
Chlorpromazine (Thorazine) anesthetics
Tranquilizers May cause anxiety, tension, and even seizures
 Diazepam (Valium) if withdrawn suddenly
Insulin Interaction between anesthetics and insulin
must be considered when a patient with
diabetes is
undergoing surgery. Intravenous insulin may
need to be administered to keep the blood
glucose
within the normal range.
Antibiotics When combined with a curariform muscle
Erythromycin (Ery-Tab) relaxant, nerve transmission is interrupted and
apnea
from respiratory paralysis may result.
Anticoagulants an increase the risk of bleeding during the
Warfarin (Coumadin) C intraoperative and postoperative periods;
should be
discontinued in anticipation of elective surgery.
The surgeon will determine how long before
the
elective surgery the patient should stop taking
an anticoagulant, depending on the type of
planned procedure and the medical condition
of the patient.
Thyroid Hormone Intravenous administration may be needed
Levothyroxine sodium (Levothroid) during the postoperative period to maintain
thyroid levels.
Opioids Long-term use of opioids for chronic pain (6
mo or greater) in the preoperative period may
alter
the patient’s response to analgesic agents.

Nursing Assessments

Preoperative Family History Assessment

• Obtain a thorough assessment of personal and family history,
inquiring about prior problems with surgery or anesthesia
with specific attention to complications such as
fever, rigidity, dark urine, and unexpected reactions.
• Inquire about any history of musculoskeletal complaints,
history of heat intolerance, fevers of unknown origin, or
unusual drug reaction.
• Assess for family history of any sudden or unexplained
death, especially during participation in athletic events.

Patient Assessment
• Assess for subclinical muscle weakness.
• Assess for other physical features suggestive of an underlying
genetic condition, such as contractures, kyphoscoliosis,
sand pterygium with progressive weakness.
Management Issues Specific to Genetics
• Inquire whether DNA mutation or other genetic testing has
been performed on an affected family member.
• If indicated, refer for further genetic counseling and evaluation
so that family members can discuss inheritance, risk
to other family members, availability of diagnostic/genetic
testing.
• Offer appropriate genetics information and resources.
• Assess patient’s understanding of genetics information.
• Provide support to families with newly diagnosed
malignant hyperthermia.
• Participate in management and coordination of care of patients
with genetic conditions and individuals predisposed
to develop or pass on a genetic condition.

PATIENT EDUCATION
Preoperative Instructions to Prevent Postoperative Complications

Diaphragmatic Breathing
Diaphragmatic breathing refers to a flattening of the dome of
the diaphragm during inspiration, with resultant enlargement
of the upper abdomen as air rushes in. During expiration, the
abdominal muscles contract.
1. Practice in the same position you would assume in bed after
surgery: a semi-Fowler’s position, propped in bed with
the back and shoulders well supported with pillows.
2. With your hands resting lightly on the front of the lower
ribs, and fingertips against lower chest to feel the
movement.
3. Breathe out gently and fully as the ribs sink down and
inward toward midline.
4. Then take a deep breath through your nose and mouth,
letting the abdomen rise as the lungs fill with air.
5. Hold this breath for a count of five.
6. Exhale and let out all the air through your nose
and mouth.
7. Repeat this exercise 15 times with a short rest after each
group of five.
8. Practice this twice a day preoperatively.

Coughing
1. Lean forward slightly from a sitting position in bed, interlace
your fingers together, and place your hands across the incisional
site to act as a splintlike support when coughing.
2. Breathe with the diaphragm as described under
“Diaphragmatic Breathing.”
Splinting of chest when coughing
Diaphragmatic breathing
3. With your mouth slightly open, breathe in fully.
4. “Hack” out sharply for three short breaths.
5. Then, keeping your mouth open, take in a quick deep
breath and immediately give a strong cough once or
twice. This helps clear secretions from your chest.
It may cause some discomfort but will not harm your
incision.

Leg Exercises
1. Lie in a semi-Fowler’s position and perform the
following simple exercises to improve circulation.
2. Bend your knee and raise your foot—hold it a few
seconds, then extend the leg and lower it to the
bed.
3. Do this five times with one leg, then repeat with the other
leg.
4. Then trace circles with the feet by bending them down, in
toward each other, up, and then out.
5. Repeat these movements five times.

Turning to the Side

1. Turn on your side with the uppermost leg flexed most and
supported on a pillow.
2. Grasp the side rail as an aid to maneuver to the side.
3. Practice diaphragmatic breathing and coughing while on
your side.

Getting Out of Bed

1. Turn on your side.
2. Push yourself up with one hand as you swing your legs
out of bed.

Maintaining Patient Safety

Protecting patients from injury is one of the major roles of
the perioperative nurse.

2009 National Patient Safety Goals

• Improve the accuracy of patient identification
• Improve effectiveness of communication among
caregivers
• Improve safety of using medications
• Reduce the risk of health care–associated infections
• Accurately and completely reconcile medications across
continuum of care
• Reduce the risk of patient harm resulting from falls
• Reduce the risk of influenza and pneumococcal disease
in institutionalized older adults
• Reduce the risk of surgical fires
• Implement applicable National Patient Safety Goals and
associated requirements by components and practitioner
 sites
• Encourage patients’ active involvement in their own care
as a patient safety strategy
• Prevent health care–associated pressure ulcers (decubitus
ulcers)
• Identify safety risks inherent in the organization’s patient
population
• Improve recognition and response to changes in a
patient’s condition

Preparing the Skin

Immediate Preoperative Nursing

Interventions
Maintaining the Preoperative Record
Administering Preanesthetic Medication
Transporting the Patient to the Presurgical Area
Attending to Family Needs

Expected Patient Outcomes

Relief of anxiety, evidenced when the patient

• Discusses with the anesthesiologist, anesthetist,
or nurse anesthetist concerns related to types of anesthesia
and induction
• Verbalizes an understanding of the preanesthetic medication
and general anesthesia
• Discusses last-minute concerns with the nurse or
physician
• Discusses financial concerns with the social worker, when
appropriate
• Requests visit with spiritual advisor when appropriate
• Appears relaxed when visited by health care team members

Decreased fear, evidenced when the patient

• Discusses fears with health care professionals or a
spiritual advisor, or both
• Verbalizes an understanding of any expected bodily
, including expected duration of bodily changes

Understanding of the surgical intervention, evidenced

when the patient
• Participates in preoperative preparation
• Demonstrates and describes exercises he or she is
expected to perform postoperatively
• Reviews information about postoperative care
• Accepts preanesthetic medication, if prescribed
• Remains in bed once premedicated
• Relaxes during transportation to the OR or unit
• States rationale for use of side rails
• Discusses postoperative expectations

No evidence of preoperative complications

CRITICAL THINKING EXERCISES

1. During your preoperative assessment of your patient,
a 42-year-old female who is alert and oriented reports that
she is having her right breast removed for cancer. The OR
schedule indicates that she is having a left mastectomy
(breast removal). What preoperative assessments are indicated?
What nursing interventions are warranted?
What should your initial action be?

2. A morbidly obese 55-year-old patient with diabetes

and a history of high blood pressure who takes insulin, antihypertensive
medication, aspirin, and several herbal
supplements daily is scheduled for major abdominal surgery.
What preoperative assessments would be appropriate?
What instructions would you anticipate for the
patient regarding medications and their rationale? What
additional preoperative teaching should be undertaken
with this patient?

3. A patient is admitted to the same-day surgery

unit with a known allergy to latex. What resources would
you use to identify evidence-based practices during the
perioperative period? Identify the evidence for and the
criteria used to evaluate the strength of the evidence for
the practices identified for this patient.