Chapter 56 Preoperative and Postoperative Care 2013

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 56

Preoperative and Postoperative Care2013

Chapter 56

Preoperative and Postoperative Care2013


Perioperative CarePerioperative Care

• The time span that includes preparation for, the process of, and recovery from surgery

• Three phases of perioperative nursing care

– Preoperative: before surgery

– Intraoperative: in operating room (OR), post-anesthesia recovery (PAR), or post-anesthesia care unit (PACU)

– Postoperative: after surgery


Factors in Surgery: SettingsFactors in Surgery: Settings

• Types of surgery settings

– Acute-care facility

– Walk-in or ambulatory center


**Types of Surgery**Types of Surgery

• Optional/elective

• Required/nonelective

• Urgent/nonelective

• Emergency


Nursing Diagnosis for the Perioperative Client and Family Nursing Diagnosis for the Perioperative Client and Family

• Examples

– Fear

– Deficient Knowledge

– Anticipatory Grieving

– Disturbed Body Image

– Risk for Aspiration

– Ineffective Airway Clearance

– Pain


Nursing Diagnosis for the Perioperative Client and Family, cont.Nursing Diagnosis for the Perioperative Client and Family, cont.

• Examples, cont.

– Hyperthermia

– Hypothermia

– Altered Tissue Perfusion (cerebral, peripheral)

– Deficient Fluid Volume

– Impaired Tissue Integrity

– Impaired Skin Integrity

– Impaired Physical Mobility


Factors to Address when assessing clients for surgical riskFactors to Address when assessing clients for surgical risk• *Weight

• Age

• *Lifestyle factors

• Pre-existing physical disorders

• Physical activity status


Nursing Interventions Common to all Surgical ProceduresNursing Interventions Common to all Surgical Procedures

• Providing emotional support

– *previous surgeries may alter his/her response to surgery

• Preparing client physically for surgery

• Ensuring legal matters are carried out

• Ensuring preoperative tests completed

• Teaching

• Providing routine preoperative and postoperative care



SedationSedation

• Minimal

• Moderate

• Deep

• Conscious sedation


AnesthesiaAnesthesia

• Anesthesia

– The complete or partial loss of sensation

• Anesthetics

– Medications that induce anesthesia

• Anesthesiology

– Discipline of medicine that administers anesthetics


Anesthesia, cont.Anesthesia, cont.

• Anesthesiologist

– A physician trained in anesthesiology

• Nurse anesthetist

– Registered nurse trained in anesthesiology


Periop care in the older adultPeriop care in the older adult

• Watch for unexpected side effects to medications. Older clients may have a greater than expected reaction to medications, may react more quickly, or may react differently than expected


In Practice: Caring for the Client Who Is Receiving AnesthesiaIn Practice: Caring for the Client Who Is Receiving AnesthesiaRefer to Nursing Care Guidelines 56-1.

Make sure client is wearing an ID band and has been carefully identified by at least two staff persons!!

Check for allergies

Note any abnormal lab test results

After surgery using spinal anesthetics, keep the client flat until the anesthetic has worn off

*Observe for spinal headache, respiratory depression and movement of extremities

*Postop check all v/s, including pain, frequently as ordered, report any deviations

*observe carefully for signs of respiratory distress following use of neuromuscular blockers or any type of general anesthetic


Types of AnestheticsTypes of Anesthetics

• General anesthetics

– Used to suspend all body sensations

• Administered

– Intravenously

– Rectally

– By inhalation


Types of Anesthetics, cont.Types of Anesthetics, cont.– Regional anesthesia: Injection of anesthesia around

nerves to prevent sending pain signals to brain

• Spinal anesthesia: Injection of anesthesia into the subarachnoid space of the spinal cord

• 2nd lumbar vertebrae

• Loss of feeling and movement in lower extremities, lower abdomen and perineum

• Keep the client flat until the anesthetic has worn off (spinal headache)

• Observe for respiratory distress

• Conduction blocks: Injection of anesthesia into or near a nerve trunk


Key ConceptKey Concept

• Clients receiving a local anesthetic are often given some type of sedation as well.


Stages of General Anesthesia Stages of General Anesthesia • Analgesia/amnesia

– Reflexes present, HR normal, RR slower

• Dreams and excitement

– Active reflexes, tachycardia, irregular breathing, increased BP, pupils dilated

• Surgical anesthesia

– Four planes, ranging from light to deep

– Third or fourth plane best for most types of surgery

• Toxic or extreme medullary depression

– No reflexes, weak pulse



• **The client under general anesthesia is completely dependent on others; he or she cannot control the most basic of body functions, including breathing and maintenance of a patent airway.

• This person must be observed and monitored carefully at all times by specially trained anesthesia personnel.


Preoperative Nursing CarePreoperative Nursing Care

• Orders written by surgeon or anesthesiologist

• Teach client to carry out orders exactly

– *make sure they can see/hear; could interfere with teaching

• Provide emotional support

• *keep the heirarchy of basic human needs, in mind

– *consider needs-oxygen, food, water, elimination, sleep


Nursing AlertNursing Alert

• *In most instances, the client is instructed to stop taking

– Aspirin

– Ibuprofen (Motrin, Advil)

– Other NSAIDs

– Any specific agents affecting blood coagulation

• For at least 7 days before surgery to reduce the risk of excessive bleeding.


Nursing Alert, cont.Nursing Alert, cont.

• Certain herbal supplements are mild anticoagulants and can contribute to the risk of bleeding.

• These include camomile, cat’s claw, feverfew, garlic, ginger, ginkgo, ginseng, goldenseal, grape seed extract, green tea leaf, horse chestnut seed, and turmeric.

• The preoperative client usually is advised to stop taking herbal supplements as well.


In Practice: Organizing Preoperative Nursing CareIn Practice: Organizing Preoperative Nursing Care

• Refer to Nursing Care Guidelines 56-2.

• Preop care on area undergoing surgery

• Surgical preparation and shave is usually done in the OR*

• Ensure all specimens have been collected & sent to lab (usually done day before surgery)

• NPO, 8 hours before surgery

– Decreases risk for aspiration


Immediately Before OperationImmediately Before Operation

Record baseline v/s, assess pain

Assist them to void before going to the OR

Remove partial, complete dentures

Give preop. Meds as ordered

raise siderails and have client remain in bed, enc. Them to call for assistance if a BR is needed (offer bedpan prior to surgery



Nursing AlertNursing Alert• **Be sure the client has signed the operative permit before

giving give any pre-sedation medications.

• The client is not considered to be responsible after being medicated and cannot legally sign the operative permit.

• If the permit is not signed before medication is given, the surgery would most likely need to be postponed.

• Obtaining the client’s permission for surgery is the responsibility of the surgeon; the nurse double-checks to make sure this had been done.

• Remember the concept of informed consent—the client must understand what is being done and why.

• The client must be able to verbalize the type of surgery being done, and this statement must agree with the records and consent forms.

• If surgery must be cancelled for an error, such as the inappropriate or incorrect signing of the operative permit, this is considered a sentinel event and must be reported and investigated.



• Each step in preoperative preparation has a purpose.

• If any steps are omitted, the client’s safety becomes jeopardized.

• The client will perform many of these steps at home, when being admitted on the day of surgery.

• It is the nurse’s responsibility to interview the client to make sure all steps in the preoperative preparation have been completed.


Teaching the ClientTeaching the Client

• When preparing the client

– Organize teaching.

– Explain procedures.

– Demonstrate for the client.

– **Client returns demonstration

– Supervise client’s practice until client can perform it independently

– Reinforce successful behavior.

– Review procedure



• If a client will be on a ventilator or otherwise unable to speak after surgery, make arrangements for a communication system.

• Allow the client to practice this system preoperatively.

• Preoperative teaching is vital because clients go home so soon after surgery.

• Explain to the client and family where the family lounge is located. Make sure they know where to find food, coffee or soda, newspapers, computer access, and telephones.

• Suggest they bring along something to do while waiting.


AssessmentsAssessments

• Observation

• Physical examination and laboratory tests


PreparationPreparation

• Skin preparation– shave –if ordered

– scrub- if ordered

– do not shave scalps or cut hair-may be done in OR

– Reduces risk for infection

• Intestinal preparation– Enemas

– Go-lightely po

– NPO 8-10 hrs. prior to surgery



• The client may be asked to self-administer a small-volume enema or drink a liquid cathartic at home, if the admission to the healthcare facility is on the day of surgery.

• The client may need instruction in the use of the enema or the cathartic.

• Encourage the client and reassure that he or she will be able to do the procedure.

• Be sure the client has an escort if same-day surgery is being done.


Preoperative MedicationsPreoperative Medications

• Four types of preoperative medications

– Sedatives

– Antibiotics

– Narcotics

• Given to relax the client and to enhance the anesthesia’s effects

– Drying agents

• Atropine (may cause urinary retention)

– Route: Orally-make sure they can swallow



• Before giving any preoperative medications, make sure the client does not have any drug allergies and that the surgical permit has been signed, witnessed, and is on the client’s chart or electronic record.

• Make sure the client is wearing an allergy band, whether or not an allergy exists.

• In addition, make sure the client is wearing one or two facility ID ands and that all information is correct.

• Be sure to offer a bedpan or urinal to the client immediately before he or she is taken to the operating suite. The client should not get up to the bathroom at that time.



• To prevent errors, always be certain that the client is properly identified before transfer to the OR.

• No client should be allowed to go to the OR without an identification bracelet! This would cause the surgery to be cancelled. Some hospitals require an ID bracelet on both of the client’s wrists.

• The client must also be wearing an allergy band, stating existing allergies or stating that the client has no known allergies.

• If the client is a fall risk, a fall risk ID band is worn as well. Blood ID bands (two) also must be worn if the client will receive blood transfusions.

• The ID band of the client going to surgery must be checked by at least two people.


AssistantsAssistants

• Two basic categories of assistant

– Sterile assistant, aka scrub nurse, OR technician

– Circulating nurse


Post-anesthesia Care Unit (PACU) or Post-anesthesia Recovery Area (PAR)Post-anesthesia Care Unit (PACU) or Post-anesthesia Recovery Area (PAR)

• Articles that may be needed for care are located near the client’s unit in the PACU

– Breathing aids

– Circulatory aids

– Drugs

• Narcotics

• Sedatives

• Drugs for emergency situations


PACU or PAR, cont.PACU or PAR, cont.

• Articles that may be needed, cont.

– Other supplies

• Surgical dressings

• Sandbags

• Warmed blankets

• Extra pillows

• Various other items


TransportTransport

• Client transport to surgery

• Moving the client to the PACU

• Moving the client to the floor/unit



• Leave no client alone until he or she has fully regained consciousness.

• Check the physician’s orders and carry them out immediately.


Immediate Postoperative ComplicationsImmediate Postoperative Complications

• Observe the client postoperatively for immediate complications, for example

– Hemorrhage

– Shock

– Hypoxia

– hypothermia



Signs of ShockSigns of Shock

•Hypovolemic shock-monitor for jugular vein distention


Shock Shock

1. Call for help.

2. Control hemorrhage.

3. *Position the client flat with his or her feet elevated, unless contraindicated (modified/reverse Trendelenburg position-head down & feet up)

4. *Administer oxygen, as ordered.

5. Administer blood, plasma, or other parenteral fluids as ordered.

6. Anticipate that the physician may order vasopressor medications.

7. Observe the client very closely.


Hypoxia (Hypoxemia)Hypoxia (Hypoxemia)

• Reduction of oxygen in the tissues

• Measure oxygen saturation using a pulse oximeter

• Keep oxygen and suction equipment readily available for emergency use


HypothermiaHypothermia

• Low body temperature

• Signs and symptoms of postoperative hypothermia

– Temperature below 97.5° Fahrenheit (36.4° Celsius) rectally

– Shivering and “goose flesh” unrelieved by warm blankets

– Client complains of being extremely cold

– Confusion, disorientation, difficulty with speech


**Postoperative Discomforts **Postoperative Discomforts

• Pain

• Thirst

• Abdominal distention

• Nausea

• Urinary retention

• Constipation-d/t handling of the intestines during surgery

• Restlessness and sleeplessness



• If a client complains of distention or “gas pains,” do not give ice or allow the client to take fluid through a drinking straw.

• Rationale: These actions tend to add air to the bowel and increase gas.

• The postoperative client may be permitted to take a sitz bath, a warm shower, or a warm tub bath.

• This often facilitates voiding and defecation.


In Practice: Important Medications for Postoperative CareIn Practice: Important Medications for Postoperative Care

Refer to Important Medications 56-2.


Postop ComplicationPostop Complication

• Respiratory and circulatory complications

• GET OOB Day 1 (usually)

• Remember: Steroids delay wound healing!!


Respiratory ComplicationsRespiratory Complications

• Pneumonia

– Hypostatic-caused by immobility, lying on the back

– Inflammation of or accumulation of fluid in the lung

– Pneumonectomy- turn on that side and back only

• Atelectasis

– Collapse of air sacs in the lungs usually caused by mucus plugs that close the bronchi and may involve all or part of the lung

– S/s: cyanosis, RR and P increase, dyspnea, pain!


Respiratory Complications, cont.Respiratory Complications, cont.• Prevention of respiratory complications

– Respiratory exercises

– Treatments

• **Turning, coughing, and deep breathing (TCDB)

• Take a deep breath-hold for 2-5 seconds

• Do a double cough with mouth open

• Chest percussion

• Incentive spirometer

• Do 8-10 times at a time!


Respiratory Complications, cont.Respiratory Complications, cont.• *Splinting

– Grasp pillow or blanket and stretch it across the incision

– Sit upright and take deep breaths prior to coughing

– Use of a pillow or large towel to provide support along a suture line

Incentive spirometer

– A device used to promote full inflation and oxygenation of the lungs

– Forces the client to concentrate on inspirations while providing immediate feedback, aids deep breathing

– Should do 8-10 times each time this is used (q 1-2 hours while awake)


Circulatory ComplicationsCirculatory Complications

• Thrombophlebitis

– *Formation of a blood clot in a vein, with inflammation

– *Assessment

• Flex foot up toward knee (dorsiflexion) with the leg straight

• Pain behind knee on dorsiflexion known as positive Homans’ sign, indicating probable thrombophlebitis


Circulatory Complications, cont.Circulatory Complications, cont.

• Instruct client to remain in bed, report finding immediately

• Supportive measures

– Elevate affected part.

– Ted hose

– Anticoagulants as directed

– Avoid rubbing—may dislodge clot

– Apply warmth as directed.

– Rare cases, client maintained on strict bed rest


Embolus (Plural: Emboli)Embolus (Plural: Emboli)• Piece of a clot or thrombus that breaks off and enters the

person’s circulatory system, usually obstructing the blood flow in a smaller vessel

• Signs/symptoms dependent on location

Severe pain

Nausea and vomiting

Severe shock


Embolus (Plural: Emboli), cont.Embolus (Plural: Emboli), cont.

• *Pulmonary embolism

– Life-threatening—lodged in the small vessels of the lung

– Signs/symptoms

Difficult breathing

Sharp chest pain

Cough

– Can be rapidly fatal

Cyanosis

Rapid respirations and heart rate

Severe anxiety



• Embolisms often treated with immediate administration of medications that dissolve existing blood clots, thrombolytic agents

– Examples

• Alteplase (Activase)

• Streptokinase (Streptase)

• Urokinase (Abbokinase)



• Avoiding circulatory disorders

– Elastic stockings, elastic roller bandages, or antiembolytic (TED) stockings

– Sequential circulation devices (SCDs)

– Leg exercises every 2 hours

– Complete range-of-motion exercises every shift

– Ambulation as soon as possible after surgery


Other Postoperative ComplicationsOther Postoperative Complications

• Infection

– Temp elevation 2-3 days after surgery, severe pain, redness or swelling around an incision, or increased WBC count

– If temp goes up 24-48 hours after surgery-the infection is RESPIRATORY!



• An infection acquired in the hospital is known as a nosocomial infection.

• Because most postoperative clients return home soon after surgery, it is vital to instruct the client and family about signs and symptoms of an infection.

• They should be instructed to report any problems immediately.


Dehiscence and EviscerationDehiscence and Evisceration

• Dehiscence

– The splitting open or separation of the surgical incision

• Evisceration

– Incision opens enough so that abdominal organs (viscera) protrude

COVER PROTRUDING PARTS WITH STERILE LARGE ABDOMINAL PADS THAT ARE MOISTENED WITH STERILE SALINE!!



Compartmental SyndromeCompartmental Syndrome

• Compression of nerves and blood vessels which lead to impaired blood flow and muscle and nerve damage

– Caused by swelling in a compartment (inside each layer of fascia)

• S/s: severe pain without response to pain meds or elevation

• Tx: surgery-long incision into fascia to release building pressure, wounds are left open, may need skin grafts


Additional Supportive MeasuresAdditional Supportive Measures

• Providing adequate nutrition

– Obese-may have ineffective tissue perfusion s/p surgery

– Diabetes

– Underweight

– Vomiting

– Assist with menu selection



• In many cases, a nutritional drink, such as Boost or Ensure, is given with meals after surgery, to supplement solid foods.

• Many clients find that they are able to drink, even if it is difficult to take solids.


Additional Supportive MeasuresAdditional Supportive Measures

• Irrigating wounds

• Changing dressings

– *Surgeon usually does the first dressing

• Reinforcing dressings

• Removing sutures and staples

– Sutures = stitches

• Thread used to hold an incision together while it heals


Additional Supportive Measures, cont.Additional Supportive Measures, cont.

• Providing IV therapy

– Venous access lock

• Catheter used to maintain an open route to a client’s venous system to give fluids and/or medications

• Removal or discontinuance of the venous access lock is the same as for an IV.



• The client who is having surgery needs not only physical preparation but also kind and gentle emotional support.

• The nurse is in a unique position to provide that support.

• Remember that the client’s family caregivers are vital members of the healthcare team because they will be assisting the client when he or she goes home. They need careful instruction and support because the client will be doing most of the recuperation at home.

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Chapter 56 Preoperative and Postoperative Care 2013

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