Peri-operative Nursing

Phases of Peri-operative period

PRE- operative phase

INTRA- operative phase

POST- operative phase

 PRE-Operative Phase
Begins when the decision to have
surgery is made and ends when
the client is transferred to the
operating table
 INTRA-Operative Phase
Begins when the client is
transferred to the operating table
and ends when the client is
admitted to the post-anesthesia
unit
 Post-operative Phase
Begins with the admission of the
client to the PACU and ends when
healing is complete
 Activities in the Pre-op
Assessing the clients
Identifying potential or actual health
problems
Planning specific care
Providing pre-operative teaching
Ensure consent is signed
 Consent
Surgeon - responsible for obtaining the
consent for surgery
No sedation should be administered
before SIGNING the consent
minor vs emancipated minor
Nurse- witness, documents signing
 TYPES of SURGERY
According to PURPOSE

According to degree of URGENCY

According to degree of RISK

 According to PURPOSE
Diagnostic Establishes a diagnosis

Palliative Relieves or reduces pain or

symptoms
Ablative Removes a diseased body
part
Constructive Restores function or
appearance
Transplant Replaces malfunctioning
structures
According to degree of urgency
Emergency Preserves function or life
surgery Performs immediately

Elective Performed when condition

surgery is not imminently life
threatening
 According to degree of RISK
Major Involves high degree of risk
Surgery Complicated or prolonged

Minor Involves low risk

Surgery Produces few complications
Performed as day surgery
Classification Indication for examples
surgery
I. Emergent Without delay trauma
life threatening
II Urgent 24-30 hrs AP,
Cholecystitis
III. Required Plan within Cataracts,
weeks or month thyroid
IV. Elective No emergency CS, hernia

V. Optional Personal Cosmetic

preference surgery
Health factors that affect preoperatively
Nutritional status
Drug or alcohol abuse
Respiratory status
Cardiovascular status
Hepatic and renal Factors
Endocrine Function
Immune function
Previous medication use
Psychosocial factors
Spiritual and cultural beliefs
 Surgical Risk
Extremes of age
Malnourished
Obese
Co-morbid conditions
Concurrent medications
 Pre-operative Interventions
Ensure signed consent form
Obtain nursing history, PE and lab exam
Provide pre-operative teaching (pain,
leg and foot exercises, splinting,
incentive spirometry)
Perform physical preparations- shaving,
hygiene, enema, NPO, medications
Pre-op exercises and teachings
leg and hip exercises
Deep breathing and Coughing Exercises
Splinting
Early ambulation
 Pre-op nutrition
Assess order for NPO
Solid foods are withheld for about 8
hours before general anesthesia
 Pre-op elimination
Laxatives, enemas or both may be
prescribed the night before surgery
Have the client void immediately
BEFORE transferring them to the OR
Foley catheter may be inserted as
ordered
 Pre-op hygiene
Bath the night before surgery with
antiseptic soap
Shaving of the skin is usually done in
the OR
Removal of jewelry and nail polish
Pre-op psychological preparation
Be alert to the client’s anxiety level
Answer questions or concerns
Allow time for privacy
Preparing the skin
Administering Preanesthetic medications
Transporting the patient to the presurgical
area
 Pre-operative medications
Pre-op Drugs Example Purpose
Anti-anxiety Diazepam To decrease nervousness
Promote relaxation
Anti- Atropine Decreases secretions
cholinergic Prevent bradycardia
Muscle Succinylcholine To promote muscle
relaxant relaxation
Anti-emetic Promethazine To prevent nausea and
vomiting

Antibiotic Cephalosporin To prevent infection

 Pre-operative medications
Pre-op Drugs Example Purpose

Analgesics Meperidine To decrease pain and

decrease anesthetic dose

Anti-histamine Diphenhydramine To decrease occurrence

of allergy

H-2 Cimetidine To decrease gastric fluid

antagonist and acidity
 Pre-operative screening test
CBC Determine Hgb and Hct, infection
Blood type Determined in case of blood transfusion
Serum Evaluates the fluid and electrolyte
electrolytes status
FBS Evaluates diabetes mellitus
BUN, Creatinine Assess the renal function
ALT, AST, Evaluates the liver function
Bilirubin
Serum albumin Evaluates nutritional status
CXR and ECG Respiratory and Cardiac status
 Pre-operative teaching
Leg exercises To stimulate blood circulation
in the extremities to prevent
thrombophlebitis

Deep breathing To facilitate lung aeration and

and Coughing secretion mobilization to
Exercises and prevent atelectasis and
splinting hypostatic pneumonia
Done every two to four hours

Positioning and To stimulate circulation, stimulate

Ambulation respiration, decrease stasis of
gas,stimulate peristlsis
Activities during the Intra-op
Assisting the surgeon as scrub nurse
and circulating nurse
 Intra-operative phase
interventions
Determine the type of surgery and
anesthesia used
Position client appropriately for
surgery
Assist the surgeon as circulating or
scrub nurse
Maintain the sterility of the surgical
field
Monitor for developing complications
 Basic Guidelines in Surgical Asepsis

All materials in contact with the surgical

wound and used within the sterile field
must be sterile.
Gowns are considered sterile in front from
the shoulder to the level of the sterile field
and the sleeves.
Sterile drape
Items should be dispensed to a sterile
field by methods that preserve the sterility
Movement of the surgical team are from
sterile to sterile and from unsterile to
unsterile area.
When a sterile barrier is breached, the
area , must be considered contaminated
 Anesthesia
General anesthesia
 Loss of all sensation and
consciousness

Regional or Local anesthesia

 Loss of sensation in ONE area
with consciousness present
 Minimal sedation
- drug induced state in which a patient can
respond normally in verbal commands
- cognitive function and coordination may be
impaired
Moderate sedation
- depressed level of consciousness that does not
impair ability to maintain a patent airway
- calm, sedate a patient combined with analgesic
- Midazolam/Diazepam
 Deep Sedation
- deep sedation is a drug induced state
which a patient cannot easily aroused but
can respond purposefully after repeated
stimulation.
- inhaled or intravenously
- Volatile anesthetic (halothane, Isoflurane)
- Gas anesthetic (Nitrous oxide)
 Stages
Stage I (Beginning Anesthesia)
- patient may have ringing, still conscious,
sense inability to move extremities
- noises are exagerrated
- avoid unnecessary noises or motions
 Stage II: Excitement
- Characterized by struggling, shouting,
talking, crying.
- pupils dilate, rapid pulse and irregular RR
- restrain the patient
Stage III
- Surgical anesthesia is reached
- pt unconscious and lies quietly
- respirations are regular and CR
- may be maintained in hours if properly
given
 Stage IV: Medullary Depression
- stage is reached when too much
anesthesia is given
- RR become shallow, pulse is weak and
thready, pupils widely dilated
- Without proper treatment death will follow
- Discontinue anesthetic abruptly
 state of narcosis (severe CNS depression
produced by pharmacological agents),
analgesia, relaxation and reflex loss
lose the ability to maintain ventilatory
function and require assistance in
maintaining a patent airway.
Cardiovascular function may be affected
as well
 Methods of Anesthesia Administration

Inhalation
Intravenous
Regional Anesthesia
Conduction and spinal anesthesia
Local Infiltration
 GENERAL Anesthesia
Protective reflexes are lost
Amnesia, analgesia and hypnosis
occur
Administered in two ways:

Inhalational

Intravenous
 REGIONAL Anesthesia
TOPICAL Applied directly on the skin

INFILTRATION Injected into a specific area of

skin
NERVE BLOCK Injected around a nerve

SPINAL Low spinal anesthesia

Subarachnoid
EPIDURAL Epidural space is injected with
anesthesia
 Potential adverse effects of anesthesia
Myocardial depression, bradycardia
Nausea and vomitting
anaphylaxis
CNS agitation, seizures, respiratory arrest
Oversedation or under sedation
Agitation and disorientation
Hypothermia
Hypotension
Malignant hyperthermia
 Patient Positioning
Provides optimal visualization

Provides optimal access for

assessing and maintaining
anesthesia and function

Protects patient from harm

 Position Patient during Surgery
Abdominal surgeries Supine

Bladder surgery Slightly trendelenburg

Perineal surgery Lithotomy

Brain surgery Semi-fowler’s

Spinal cord surgeries Prone mostly

Lumbar puncture Side lying, flexed body

SCRUB NURSE Assists the surgical team
Maintains sterility
Handles instruments,
prepares sutures,receives
specimen, counts
Drapes patient
Wears sterile gown, gloves

CIRCULATING Assists the Scrub

NURSE nurse,opens& obtains
instrument, keeps record,
adjust lights, receives
specimen,coordinates
Positions the patient for Sx
 surgical team
anesthesiologist
anesthetist
surgeon
assistants- 1st, 2nd, 3rd
intra-op nurses
 Quiz 1
1.This stage is referred to as surgical
anesthesia stage.
2. This stage Is characterized by
exaggerated noises.
3. This stage is met if the anesthesia given
exceeds the optimal dose
4. This stage is characterized by agitation
and increased VS
Match the following
5. Abdominal surgeries a. lithotomy
6. Bladder surgery b. prone
7.Perineal surgery c. semi-fowler’s
8. Brain surgery d. supine
9. Spinal cord surgeries e. modified sim’s
10. Lumbar puncture f. slightly trendelenburg
 Activities in the POST-op
Assessing responses to surgery
Performing interventions to promote
healing
Prevent complications
Planning for home-care
Assist the client to achieve optimal
recovery
POST Operative Interventions
Maintain patent airway
Monitor vital signs and note for early
manifestations of complications
Monitor level of consciousness
Maintain on PROPER position
NPO until fully awake, with passage
of flatus and (+) gag reflex
POST Operative Interventions
Monitor the patency of the drainage
Maintain intake and output
Monitor Temperature
Care of the tubes, drains and wound
Ensure safety by side rails up
Pain medication given as ordered
Measures to PREVENT post-op
Complications
 Post-operative interventions
PAIN MANAGEMENT
Pain is usually greatest during the 12-
36 hours after surgery
Narcotic analgesics and NSAIDS may
be prescribed together for the early
period of surgery
Provide back rub, massage, diversional
activities, position changes
 Post operative interventions
POSITIONING
Clients who have spinal anesthesia is
usually placed FLAT on bed for 8-12
hours
Unconscious client is placed side lying
to drain secretions
Other positions are utilized BASED on
the type of surgery
 Post-operative Interventions
Some Examples of Position Post Op
Mastectomy Semi-fowlers’, affected
arm elevated
Thyroidectomy Semi fowlers’ , head
midline
Hemorrhoidectomy Semi-prone, side-lying

Laryngectomy Fowler’s

Pneumonectomy Lateral, affected side

Lobectomy Lateral, unaffected

side
 Post-operative Interventions
Some Examples of Position Post Op
Aneurysmal repair Fowler’s 45 degrees
(abdomen)
Amputation of lower Flat, with stump
extremities elevated with pillow
Cataract surgery Fowler’s 45 degrees

Supratentorial 30- 40 degree head

craniotomy elevation
Infratentorial Flat on bed, supine
craniotomy
Spina bifida repair Prone
Post-operative Interventions
Deep breathing and coughing
exercises Q2-4 hours  to remove
secretions
Leg exercises Q 2 hours  to
promote circulation
Ambulation ASAP prevents
respiratory, circulatory, urinary
and gastrointestinal complications
Post-operative Interventions
Hydration after NPO to maintain
fluid balance
Suction, either gastro or
respiratory to relieve distention,
to remove respi secretions
Diet progressive, usually given
when bowel sounds and gag reflex
return
 Wound Care
Inspect dressing hourly
Change dressing daily
Inspect for signs of infection
redness, swelling, purulent
exudate
Maintain wound drainage
 Diet
NPO usually immediately after surgery
Progressive diet

Assess the return of the bowel sounds

 Liquid Diet Vs Soft diet
Clear liquid Full liquid Soft diet
Coffee Clear liquid PLUS: All CL and FL
Tea Milk/Milk prod plus:
Carbonated Vegetable juices Meat
drink Cream, butter Vegetables
Bouillon Yogurt Fruits
Clear fruit Puddings Breads and
juice Custard cereals
Popsicle Pureed foods
Ice cream and
Gelatin sherbet
Hard candy
 Urinary Elimination
Offer bedpans
Allow patient to stand at the bedside
commode if allowed
Report to surgeon if NO URINE output
noted within 8 hours post-op
 CPT
Chest Physiotherapy
Chest physiotherapy is based on the
fact that mucus can be knocked or
shaken form the walls of the airways
and helped to drain from the lungs.

The usual PVD SEQUENCE is as

follows- POSITIONING, Percussion,
Vibration, and removal of secretions
by SUCTIONING or Coughing
followed lastly by oral hygiene
 Incentive Spirometry
This operates on the principle that
spontaneous sustained maximal
inspiration is most beneficial to the
lungs and has virtually no adverse
effects.
The incentive spirometer measures
roughly the inspired volume and
offers the “incentive” of measuring
progress
 Post operative complications
Atelectasis Collapsed Assess breath
alveoli due to sounds
secretions Repositioning
Deep breathing
and coughing
Inflammation Chest physio
Pneumonia
of alveoli Suctioning
Ambulation
Thrombophlebitis Inflammation Leg exercises
of the veins Monitor for
swelling
Elevated
extremities
 Post-operative Complications
Hypovolemic Loss of Shock position
Shock circulatory Determine cause and
fluid volume prevent bleeding
O2, IVF

Urinary Involuntary Encourage ambulation

retention accumulation Provide privacy
of urine Pour warm water
Catheterize
Pulmonary Embolus Notify physician
embolism blocking the Administer O2
lung blood
flow
 Post-operative complications
Constipation Infrequent High fiber diet
passage of Increased fluid
stool Ambulation

Paralytic ileus Absent bowel Encourage

sound ambulation
NPO until
peristalsis returns
Wound Occurs about Daily wound
infection 3 days after dressing
surgery Antibiotics
Maintain drain
 Post-operative complications
Wound Separation of Cover the wound
dehiscence wound edges at with sterile normal
the suture line saline dressing
Place in low-
Fowler’s
Notify MD
Wound Protrusion of Cover the wound
evisceration the internal with saline pad
organs and Place in low-
tissues through fowler’s
wound Notify MD
 sutures
Absorbable Non-absorbable
Catgut Silk(silkworm larva)
Polyglycolic acid Polyester
Polyglyconate Nylon
Polyglactic acid Polypropylene
Polydiaxanone(180 d) (vascular)
Stainless steel
 Wound healing
Primary intention- edges of clean wound
are closed
Secondary intention- wound is allowed to
remain open and heal by granulation
Tertiary intention- wound is allowed to
remain open for some time and then
closed
 Suture techniques
Taper-point needle– round body, leaves
round hole (suturing of soft tissues other
than skin)
Conventional cutting needle- triangular
body (suturing of skin)
 stitches
Simple interrupted
Vertical mattress( far,far- near,near)-used for
difficult to approximate edges
Horizontal mattress stitch
Simple running stitch
Subcuticular stitch ( suture remains longer w/o
scar)
Pursestring suture– stitch which encircles a
tube( ex. Gastrostomy tube)
Stick tie
 quiz
1. What type of needle is used in closing
muscle and fascia?
A. Taper-point needle
B. round needle
C. Conventional cutting needle
D. traditional cutting needle
1. What type of needle is used in closing
skin?
A. Taper-point needle
B. round needle
C. Conventional cutting needle
D. traditional cutting needle
3. All of the following are examples of clear
liquid diet except
a. Carbonated drink
b. Bouillon
c. sherbet
d. Gelatin
4. All of the following are examples of
general liquid diet except
a. Osterized food
b. Milk/Milk prod
c. Vegetable juices
d. bouillon
5. This refers to the Separation of wound
edges at the suture line

c.Wound infection
d.Wound dehiscence
e.Wound evisceration
f. Wound apposition
6. Protrusion of the internal organs and
tissues through wound is called
b.Wound infection
c.Wound dehiscence
d.Wound evisceration
e.Wound apposition
 Match the following
7. Mastectomy a. Semi-fowlers’
8. Thyroidectomy b. Lateral, affected
side
9. Hemorrhoidectomy c. Lateral, unaffected
side
10. Laryngectomy d. prone
11. Pneumonectomy e. flat
12. segmentectomy
13. Amputation of lower extremities
14. Supratentorial craniotomy
15. Infratentorial craniotomy
 guidelines
1. Number of throws:
Silk-3
Gut-4
Vicryl, dexon- 4
Nylon polyester, polyprolene, PDS-6
2. Cutting the end:
Silk vessel ties- 1 to 2 mm
Abdominal fascia closure- 5 mm
Skin sutures, drain sutures- 5 to 10 mm
 Guidelines
3. when to remove:
Face- 3 to 5 days
Extremities- 7 days
Joints- 7 to 10 days
Back- 2 wks
Abdomen- 7 days
SURGICAL INSTRUMENTS
Surgical scalpel blades
 Shape:
Straight - The needle is straight and
usually has a cutting surface.
Half-curve or Ski - the needle is straight
and curves near the point.
Curved - The needle is formed in an arc of
1/4, 3/8, 1/2, or 5/8 of a circle
NEEDLES
SURGICAL BLADE HANDLE
Needle holder
 Sponge Forceps
Sponge forceps or sponge holding forceps
are often used in gynecological
procedures. They may be straight or
curved and have smooth or serrated jaws.
The jaws are rounded and provide an
atraumatic grip.
SPONGE FORCEP
 Dressing Forceps
Dressing forceps are also a type of tissue
forceps. They are used for dressing wounds and
pealing off the dressing. They have scissor-like
handles for grasping lint, drainage tubes, etc.
Dressing Tweezers may be curved or straight
tipped with serrated beak. In some cases it may
be smooth.
Dressing Forceps
 Suture Forceps
Needle holder forceps hold needles while
suturing. Suture Forcep is also called a needle
holder forceps. The typical needle holder has
two short, rather blunt, serrated beaks with a
groove in each beak. The grooves provide space
for the placement and retention of the needle. At
the end of the handles, there is a locking
mechanism that lets the secure the suture
needle in the correct position so as the needle
appears to be an extension of the needle holder.
The insert in the tip should be carbide steel, and
replaceable so that it can be changed when
required
Suture Forceps
 Surgical Hemostats
They are also called blood vessel forceps
and are used for controlling hemorrhage.
They are also called Hemostats. They look
like needle-holder forceps. The main
difference is that the beaks of the
hemostatic forceps are longer and more
slender.
Hemostatic forceps may have both curved and
straight tips or beaks, and there is a locking
device on the handle to keep them closed as
they are used as vessel clamps. They have
transverse serration on beak tips. They have a
box hinge and a locking mechanism by the
finger rings. all the hemostatic forceps are
designed to grab, hold, and crush
They are used for holding blood vessels,
and for blunt dissection. These forceps are
used in surgery to control hemorrhage by
clamping or constricting blood vessels. In
dental surgery, they are more used to
remove bits of bone chips or parts of
teeth, from the oral cavity during the tooth
removal.
Surgical Hemostats
 Towel Clamps
Towel-clamp forceps are used to maintain
surgical towels and drapes in the correct
position during an operation. They secure
drapes to the patients skin and may be
used for holding the tissue as well. They
are locking type forceps with curved ends.
The beak may be pointed or blunt and flat.
They may even overlap in closed position.
Towel Clamps
 Tubing Forceps
Also termed as vessel cannulation forceps
or tubing introducer forceps, they are
useful when a fine plastic tube/ micro
catheters have to be introduced into a
small blood vessel of almost equal size for
medication or diagnostic purposes .
The hollowed beak holds the tubing
without deforming it. The tip of the tubing
is directed exactly into the vessel opening
with a sturdy hand so as not to cause any
damage to the vessel from unwanted
movement.
Tubing Forceps
 Brain Forceps
Also called Obstetrical Forceps, they are Smoothly
shaped and curved, obstetrical forceps. The instrument
has two blades and a handle designed to aid in the
vaginal delivery of a baby.

Though there are many different kinds of brain forceps,

the most commonly used ones are thin metal curving
into a ring at its tip. This tip fastens the baby's head to
protect from damage during the delivery. The use of
these forceps is as safe /dangerous as any other surgical
tool or drug. They are used for saving babies' lives, when
delivery is prudent during fetal distress
Brain Forceps
 Grasping Forceps
Grasping forceps are used to remove stones
and retrieve foreign objects under direct vision.
These forceps are three pronged with hooked
tips. This typical design allows the objects to be
released easily. The hooks facilitates secure
grasping of both large and small objects. The
prong wires are rounded to allow atraumatic
manipulation. They can be easily passed
through the flexible endoscopes.
Grasping Forceps
 Mixter Forceps
Mixter forceps are the threading forceps
used for hemostatic purposes. Hemostatic
Forceps are used to wrap the thread
around the vessel to stop bleeding. Its
beak is such that it grips the thread well.
Mixter Forceps
 Mosquito Forceps
Mosquito forceps are used for more
delicate tissues. They are very fine and
small hemostats used during the surgery
to control the bleeding of finer vessels.
Mosquito Forceps
 Splinter Forceps

Splinter forceps are fine tipped forceps

used to remove the finest splinters from
the body. The may be curved or straight
and may also have an attached
magnifying glass for better vision. It is an
essential first aid instrument.
Splinter Forceps
 Tongue Forceps

Tongue forceps are sturdy tools used for

holding the tongue while piercing it. They
can be locked for a secure grip. They may
be slotted or the standard type. Once the
piercing is dome and the baebell is in
place, the forcep can be removed
Tongue Forceps
 Tilley's forceps
These are commonly called dressing or
packing forceps, and are generally used in
the nose. You are likely to use them to
pack noses and remove foreign bodies
Tilley's forceps
 tongue depressor
The wooden ones are disposable and also
the most common. Metallic instruments
can be used is more force is required.
There are different sizes of metallic tongue
depressor, and small ones can be used in
children or infants.
tongue depressor
 laryngeal mirror
It is used to see over the back of the
tongue and into the larynx
local anaestietic spray
otoscope
Allis Tissue Forcep
Tissue Forcep
SURGICAL SCISSOR –
STRAIGHT
SURGICAL SCISSOR -
CURVED
Bandage Scissor
Retractors
ARMY NAVY RETRACTOR
SENN Muller Retractor
MATHIEU Retractor
CRILE Retractor
Balfour Retractor Fenestrated end
Blades
TROCARS
PATTERSON Trocar
DUKE Trocar And Cannula
OCHSNER Trocars
UNIVERSAL Trocars
 OBSTETRICAL
INSTRUMENTS
SIMPSON Obstetrical Forceps
SIMPSON-LUIKART Obstetrical
Forceps
NAEGELE Obstetrical Forceps
Harrington Retractor
Deaver Retractors
Richardson Retractors
Malleable Ribbon
Balfour Retractor
Bladder Blade for Balfour Retractor
Goulet Retractor
Army Navy Retractors
Gelpi Perineal
Crile Hemostat
Kelly Hemostats
Allises
Babcocks
 Mayo Scissors
Curved and Straight
Metzenbaums "Mets"
Large and Medium
Debakey Tissue Forceps
Plain Tissue Forceps
Long and Short
Russian Tissue Forceps
Long and Short
Ferris Smith Tissue Forceps
Toothed Tissue Forceps
Long and Short
Adison Tissue Forceps
Toothed and Plain
#3 Knife Handles
Long n Short
Towel Clips
 Incision types
Kocher’s- right subcostal incision(
cholecytectomy)
Middle laparotomy
Mcburney’s( 1/3 fr ASIS)
Paramedian- lateral to linea alba(rarelu used)
Pfannenstiel’s- low transverse abdominal
incison
Transverse abdominal- used mainly in infants
and children or for splenectomy/hemicolectomy
Sternotomy- for heart procedures
Thoracotomy- 4th or 5th ICS, anterior or
posterior incision
Kidney transplant- lower quadrant, kidney
placed extraperitonealy
Liver transplant- chevron or mercedes-benz
incision
 To emphasize
The over-all goal of nursing care during
the PRE-OPERATIVE phase is to
prepare the patient mentally and
physically for the surgery
 To emphasize
The over-all goal of nursing care during
the INTRA-OPERATIVE phase is to
maintain client safety
 To emphasize
The over-all goals of nursing care
during the POST-OPERATIVE phase are
to promote healing and comfort,
restore the highest possible wellness
and prevent associated risk