1. Perioperative concepts
and Nursing
Management

2. Introduction
Surgery is an invasive method of treatment which requires
physical and psychological stressors for both the patient and
family. The patient's recovery from a surgical procedure requires
skillful and knowledgeable nursing care.
All the phases of nursing process are used peri-operatively for
assessment, diagnosis and making appropriate plans and
providing intervention.

3. Perioperative Nursing
Perioperative Nursing which spans the entire surgical
experience, consists of three phases that begin and end at
particular points in sequence of surgical events.
Objectives:
● To provide quality and innovative perioperative nursing
care to patients that is professionally planned,
implemented and evaluated .

4. ● To provide a safe and therapeutic environment to the surgical
patient and a safe physical environment to the personnel.
● To promote excellence in knowledge and skills of all personnel
in order to facilitate the implementation of scientific and
technological advances in perioperative nursing.
● To offer the most effective and least invasive treatment options
to surgical patients much less invasive than traditional surgery
by ensuring optimal safe level in perioperative nursing services.

5. ● To serve as a clinical setting for experience of medical,
nursing and other paramedical interns and students as
well as training grounds for teaching and research.
● To keep the standards of perioperative nursing practice
evaluated and revised in accordance with the current
trends and evidence- based practice.
This 6 part process provide a systematic foundation for
assessing, diagnosis, identifying desired outcomes, planning
interventions, implementing care and evaluating the success
of plan .

6. The six components of nursing process are integrated into three
phases of patient's peri-operative experience:
● Pre-operative phase begins when the decision to proceed with
surgical procedure is made and ends with transfer of patient to
operating room.
● Intra-operative phase begins with the patient transferred to OR
bed and ends with admission to postanesthasia care
unit(PACU).
● Post-operative phase begins with admission of patient to PACU
and ends with follow up evaluation.

7. Pre-operative Nursing Care
Pre- operative preparation is vital for patient safety and is a
key nursing role. It begins with the decision making for taking
the surgical intervention to the transfer of patient to the
operating room. The goal in the phase is for the patient to be
as healthy as possible. And to assess for risk factors that may
contribute to postoperative complications and delay recovery.

8. 1. Psychological Support
Many factors contribute to anxiety in patients about to undergo
surgery, such as the anesthetic, the procedure itself and the
potential outcome of the surgery. To help reduce stress the nurse
should be able to read signs or body language of stress and
anxiety
Let someone sit with the patient before surgery
Suggest them to listen to music or other hobbies to distract
themselves.
2. Pre admission Assessment
Patients usually attend a Pre-Admission clinic which involves
medical history, nurses assessment, provision of written or verbal
information and tests.

9. 3. Admission to the Clinical Area
Identity band should be placed on the patient's dominant arm with printed
information.
The following risk assessments should be included, in line with local policy:
■ Pressure ulcer
■ Venous Thromboembolism (VTE)
■ Falls
■ Malnutrition screening
Baseline observations required and should be recorded are:
Blood pressure
Pulse
Respiration
Oxygen saturation

10. 4. Pre- operative teaching principles
Patient education on the importance of regular changes in position, deep
breathing and coughing, regular gentle leg exercises and early
mobilization to reduce the risk of complications such as chest infection,
deep-vein thrombosis and pulmonary embolism.
VTE prophylaxis-measure the patient for anti-embolism stockings, foot
impulse device or intermittent pneumatic compression device.
Discuss about anaesthesia and what to expect after surgery .

12. 5. Preparing the patient for theatre
a. Nutrition and hydration: clear fluids upto 2 hours and food upto 6 hours
before surgery post which , patient should be nil per orally (NPO)
b. Patient should shower with soap and water the evening before surgery
c. Hair around incision site should be removed.
d. Patient should be given hospital gown and all jewellery, dentures,
hearing aid should be removed.
e. Record vitals and check for allergies
f. Mark the surgery site
g. Check the identity band
6. Take the Informed Consent from the patient and/or family.
7. Transfer the patient to the theatre
8. Prepare the post op bed according to the needs of the patient.

13. Intra-operative Nursing Care
The intra-operative phase extends from the time the client is admitted to the
Operating Room, to the time of anesthesia administration, performance of the
surgical procedure and until the client is transported to the Recovery Room or
Post-anesthesia Care Unit (PACU).
Intra-operative nurses are responsible for planning and putting in practice
nursing interventions that minimize or make it possible to prevent complications
deriving from the anesthetic-surgical procedure, with a view to promote the
patient's safety, comfort and individuality.
Goals for Intra-Operative Care
1. Promote the principle of asepsis 2. Homeostasis 3. Safe administration of
anesthesia 4.Hemostasis

14. Nursing actions in the intra-operative setting
1. Check patient's identification.
2. Identify surgical site.
3. Verify Informed consent.
4.Verification of diagnostic test results
in the patient's medical record.
5. Communication and verification of
intra-operative information to members
of the surgical team during timeout
procedure.
6. Patient positioning according to
physiological principles
7. Skin assessment and reassessment.
8. Adherence to the principles of
asepsis.
9. Assurance equipment and supplies are
functioning properly.
10. Provisions of comfort measures and
supportive care to the patient, including
emotional and spiritual support, as
necessary.
11. Environmental monitoring and safety.
12. Physiological and psychological
monitoring of the patient, including
continued assessment of the patient status.
13 Obtain further diagnosis aid related to
changes in the patient's condition and/ or
re-assessment analysis.
14 Maintenance of safe environment.

15. PREPARATION OF OPERATING THEATRE
1. All sterile items to be used during an operative procedure will be opened in a manner so as
to avoid any possible contamination
2. All members of staff will be given training regarding the safe opening and of the equipment
3. Staff must check that the pack to be opened is intact
4. Any packaging that feels damp or contains moisture is not fit for use and must be discarded.
5. Expiry date of packaging must be checked
6. Any tray or package that has autoclave tape must be checked to ensure that the tape has
turned brown indicating the item has been through autoclaving process correctly.
Autoclave tape must be peeled up wards, care being taken not to tear the outer packaging
7. Trays must be opened in a manner whereby the unscrubbed circulating person does not lean
over any part of the sterile inner drapes.

16. 8. Items must not be dropped onto the scrub trolley without the scrub person's consent and
knowledge.
9. Items such as sutures must be presented to the scrub person from the edge of the sterile field.
10. Staplers and disposable pre-packaged items should have the paper peeled off the top of their
packaging, from the semi-peeled point, so as the scrub person can take the item from within the
sterile plastic packaging.
14. Prostheses and other implants must be opened according to the manufacturer's instructions and
must not be opened until both the surgeon and the scrub person have identified them as the required
item.
15. If staff touch or suspect they touched a sterile item, then it must be discarded and a fresh one
introduced.
16. Any sterility stickers or implant/prosthesis labels must be removed and placed in the patients
notes.

17. SURGICAL POSITIONING
Surgical positioning is the practice of placing a patient in a particular position during surgery.
The goal in selecting and adjusting a particular position is to maintain the patient's safety
while allowing access to the surgical site. Some common positions are supine position,
trendelenburg position, fracture table position, lithotomy position, Fowler's position, prone
position, lateral position, knee chest position, sim’s position.
● Patient should be in a comfortable position.
● The operative area should be well exposed.
● Any undue pressure should not be given to any part.
● There should be no interference with patient's respiration due to pressure.
● The nerves must be protected from undue pressure.
● Patient safety must be observed at all times.

18. Counting Procedure
A counting procedure is a method of accounting for items put on the sterile table for use
during the surgical procedure.Sponges, sharps and instruments should be counted for on
all surgical procedures three times in a surgical procedure:
1. First Count
The person who assembles and wraps items for sterilization will count them. In
commercially pre-packaged sterile items, the count is performed by the manufacturer.
2. Second Count
The scrub nurse and the circulator together count all items before the surgical procedure
begins and during the surgical procedure as each additional package is opened and
added to the sterile field. These initial counts provide the baseline for subsequent counts.
Any item initially placed in the wound is recorded. A useful method for counting is as
follows

19. Counting Procedure
3. Third Count
Counts are taken in three areas before the surgeon starts the closure of a body cavity
or a deep/large incision:
(i) Field count: Either the surgeon or the assistant assists the scrub nurse with the
surgical field count. Additional items are accounted for at this time.
(ii) Table count: The scrub nurse and the circulating nurse together count all items on
the Mayo stand and instrument table while surgeon and the assistant may be closing
the wound
(iii) Floor count: The circulating nurse counts sponges and any other items that have
been recovered from the floor or passed off the sterile field. These counts should be
verified by the scrub nurse.

20. Post-operative Nursing Care
Post-operative care is the management of patient after surgery. It
includes the care given during post operative period in the
operating room and post- anesthesia care unit and during the days
following the surgery.
The goal is to prevent infections, to promote healing, and to return
the patient to a state of health.
The extent of care depends on the individuals presurgical health,
type of surgery.

21. Assessment of Patient in Post-Anesthasia Care Unit
The amount of time spend in the PACU depends upon the length of
surgery, type of surgery, status of regional anaesthesia and the patient's
level of consciousness. Assessment of patient's airway patency, vital
signs , and level of consciousness are the first priorities.
The following is the list of other assessment categories:
1. Surgical site(intact dressing with no signs of overt bleeding)
2. Patency of drainage tubes/ drains
3. Body temperature (hypothermia/hyperthermia)

22. 4. Patency/ rate of IV fluids
5. Circulation/ sensation in the extremities after vascular or orthopaedic
surgery
6. Level of sensation after regional anaesthesia.
7. Pain status
8. Nausea/ Vomiting.

23. General Post operative Nursing Implications
1. Monitor vital signs as ordered.
2. Report elevated temperature and
rapid/ weak pulse
immediately(infection).
3. Report lowered blood pressure
and increased pulse (hypovolemic
shock).
4. Administer analgesic as
prescribed.
5. Apply nursing implications related
to patient receiving analgesic like :
check the medication order,
prepare medication, check
patient's identification, administer
the medication, document.
6. Administer IV fluids as prescribed.
Maintain and monitor all IV sites.
7. Participate with the health team in the
patient's nutrition therapy.
8. Maintain input - output chart.
9. Coordinate with the health team for
take home wound care supplies and
prescription for self administration.
10. Prepare the patient and the family for
disposition. Supply patient or family with
written instruction for: wound care,
medication, making out patient
appointment , and emergency.
11. Document the patient's disposition in
nurse's notes according to hospital policy.

24. General Post- Operative Complications
I) Immediate :
a) Primary hemorrhage- either starting during surgery or following post-
operative increase in blood pressure - repalce blood loss and may
require return to the operating theatre to re-explore the wound.
b) Basal atelectasis- minor lung collapse
c) Shock - blood loss, acute myocardial infarction, pulmonary embolism
d) Low urine output - inadequate fluid replacement intra-operatively
and post-operatively.

25. Ii) Early:
a) Acute confusion: exclude dehydration and sepsis.
b) Nausea and vomiting: analgesia or anaesthetic- related; paralytic ileus
c) Fever
d) Secondary hemorrhage: often as a result of infection
e) Pneumonia
f) Wound ar anastomosis dehiscence
g) DVT
h) Acute urinary retention
i) Urinary tract infection
j) Post- operative wound infection
k) Bowel obstruction
l) Paralytic ileus

26. III) Late:
a) Bowel obstruction due to fibrous adhesion
b) Incisional hernia
c) Persistent sinus
d) Recurrence of reason for surgery, e.g., malignancy
e) Keloid formation

27. Conclusion

28. Questions