This document outlines preoperative, intraoperative, and postoperative nursing care for surgical patients. It discusses the nursing assessment process including health history, physical exam, and psychosocial evaluation. Key parts of the nursing management are preoperative teaching, informed consent, preparing patients for surgery, and providing care in the operating room, PACU, and postoperative units. Potential postoperative complications are reviewed for multiple body systems along with the corresponding nursing care.

1. Preoperative Care Paulette Hamner RN, MSN NUR 1213

2. Surgery Art and science of treating diseases, injuries, and deformities by operation and instrumentation

3. Surgery Performed for Diagnosis Cure Palliation Prevention Exploration Cosmetic improvement

4. Surgical Settings Inpatient Same day admission Ambulatory (outpatient) Usually less than 3 to 4 hours in PACU

5. Patient Interview Check documented information prior to interview Avoids repetition Occurs in advance or on day of surgery

6. Patient Interview Purpose Obtain health information Determine expectations Provide and clarify information on procedure Assess emotional state and readiness

7. Nursing Assessment Overall goal Identify risk factors Plan care to ensure patient safety

8. Nursing Assessment Goals Determine psychological status to reinforce coping strategies Determine psychological factors of procedure contributing to risks

9. Nursing Assessment Goals Establish baseline data Identify medications and herbs taken that may affect surgical outcome Identify, document, and communicate results of laboratory/diagnostic tests

10. Nursing Assessment Goals Identify cultural and ethnic factors that may affect surgical experience Determine receipt of adequate information from surgeon in order to sign informed consent

11. Nursing Assessment Psychosocial assessment Excessive stress response can be magnified and recovery affected

12. Nursing Assessment Influencing factors Age Past experience Current health Socioeconomic status

13. Nursing Assessment Use common language Use translators if needed Decreases level of anxiety Communicate all concerns to surgical team

14. Nursing Assessment Anxiety can impair cognition, decision making, and coping abilities Lack of knowledge Unrealistic expectations Information lessens anxiety

15. Nursing Assessment Anxiety may arise from conflict with interventions (i.e., blood transfusions) and religious/cultural beliefs Identify beliefs and discuss with surgeon and operative staff

16. Nursing Assessment Fears Death or disability May prompt postponement Influence outcome Pain Consult with ACP Reassure drugs will be available

17. Nursing Assessment Fears Mutilation/alteration in body image Assess concerns nonjudgmentally Anesthesia ACP for consult Assess malignant hyperthermia risk

18. Nursing Assessment Fears Disruption of life functioning Range from fear of permanent disability to temporary loss Include family and financial concerns Consultations PRN

19. Nursing Assessment Hope May be strongest positive coping mechanism Never deny or minimize Assess and support

20. Nursing Assessment Health history Diagnosed medical conditions Previous surgeries and problems Menstrual/obstetric history

21. Nursing Assessment Health history Familial diseases Conditions Reactions/problems to anesthesia (patient or family)

22. Nursing Assessment Current medications Prescription and OTC Herbs Vitamins Recreational Drugs Alcohol Tobacco

23. Nursing Assessment Allergies (drug and nondrug) Screen areas: Risk factors Contact urticaria Aerosol reactions History of reactions suggesting latex allergy

24. Nursing Assessment Cardiovascular system Report Problems for effective monitoring Use of cardiac drugs Presence of pacemaker/MI

25. Nursing Assessment Cardiovascular system Vitals recorded preoperatively for baseline Bleeding/clotting times Laboratory reports Possible prophylactic antibiotics

26. Nursing Assessment Respiratory system Inquire about recent airway infections Procedure could be cancelled because of increased risk of laryngo/bronchospasm or decreased SaO2

27. Nursing Assessment Respiratory system History of dyspnea, coughing, or hemoptysis reported to operative team COPD or asthma High risk for atelectasis and hypoxemia

28. Nursing Assessment Respiratory system Smokers should be encouraged to quit 6 weeks before procedure Decreases risk of complications Greater years and number of packs = greater risk

29. Nursing Assessment Nervous system Evaluation of neurologic functioning Vision or hearing loss can influence results

30. Nursing Assessment Nervous system Cognitive function Assess or correct any deficits before surgery Durable power of attorney for health care should be obtained if deficits cannot be corrected

31. Nursing Assessment Nervous system Cognitive function Postoperative delirium (falsely labeled senility or dementia) can occur with dehydration, hypothermia, and adjunctive medications

32. Nursing Assessment Urinary system History of urinary or renal diseases Renal dysfunction contributes to F and E imbalances Increased risk of infection Impaired wound healing Altered response to drugs and their elimination

33. Nursing Assessment Urinary system Renal function tests Note problems voiding and inform operative team

34. Nursing Assessment Integumentary system History of skin and musculoskeletal problems History of pressure ulcers Extra padding during procedure Affect postoperative healing

35. Nursing Assessment Musculoskeletal system Identify joints affected with arthritis Mobility restrictions may affect positioning and ambulation Bring mobility aids to surgery

36. Nursing Assessment Musculoskeletal system Report problems affecting neck or lumbar spine to ACP Can affect airway management and anesthesia delivery

37. Nursing Assessment Endocrine system Patients with diabetes mellitus especially at risk for: Hypo/hyperglycemia Ketosis Cardiovascular alterations Delayed wound healing Infection

38. Nursing Assessment Endocrine system Patients with diabetes mellitus Serum glucose tests morning of surgery (baseline) Clarify with physician or ACP if usual dose of insulin is taken

39. Nursing Assessment Endocrine system Patients with thyroid dysfunction Hyper/hypothyroidism are surgical risk due to altered metabolic rate Verify with ACP about giving medications

40. Nursing Assessment Endocrine system Patients with Addison’s disease Abruptly stopping replacement corticosteroids could cause addisonian crisis Stress of surgery may require increased dose of corticosteroids

41. Nursing Assessment Immune system Patients with history of compromised immune system or use of immunosuppressive drugs can have Delayed wound healing Increased risk for infection

42. Nursing Assessment Fluid and electrolyte status Vomiting, diarrhea, or difficulty swallowing can cause imbalance Identify drugs that alter status Diuretics Evaluate serum electrolyte levels

43. Nursing Assessment Fluid and electrolyte status NPO status May require additional fluids and electrolytes prior to surgery if dehydration occurs

44. Nursing Assessment Nutritional status Obesity Stresses cardiac and pulmonary systems Increased risk of wound dehiscence and infection Slower recovery from anesthesia Slower wound healing

45. Nursing Assessment Nutritional status Provide extra padding to underweight patients to prevent pressure ulcers Identify dietary habits that may affect recovery (i.e., caffeine)

46. Nursing Assessment: Exam Findings enable ACP to rate patient for anesthesia administration Indicator of perioperative risk and overall outcome

47. Nursing Assessment: Exam Document relevant findings and report to perioperative team Obtain and evaluate results of laboratory tests Monitor blood glucose for diabetics

48. Nursing Management Preoperative teaching Patient has right to know what to expect and how to participate Increases patient satisfaction Reduces fear, anxiety, stress, pain, and vomiting

49. Nursing Management Preoperative teaching Limited time available Address needs of highest priority Include information focused on safety Provide written material

50. Nursing Management Preoperative teaching Several days before surgery Observe and listen to determine amount of teaching for each session Anxiety and fear can hinder learning Give priority to patient’s concerns

51. Nursing Management Preoperative teaching Must be documented and reported to postoperative nurses Avoid duplication of information Assess learning

52. Nursing Management Preoperative teaching Teach deep breathing, coughing, and moving for postop Inform if tubes, drains, monitoring devices, or special equipment will be used postop

53. Nursing Management Preoperative teaching Basic information before arrival Time and place Fluid and food restrictions Need for enema Need for shower

54. Nursing Management Legal preparation All required forms are signed and in chart Informed consent Blood transfusions Advance directives Power of attorney

55. Nursing Management Consent for surgery Informed consent must include Adequate disclosure Understanding and comprehension Voluntarily given consent

56. Nursing Management Surgeon responsible for obtaining consent Nurse may obtain and witness signature Verify patient has understanding Permission may be withdrawn at any time

57. Nursing Management Consent for surgery Medical emergency may override need for consent

58. Nursing Management Legally appointed representative of family may consent if patient is Child Unconscious Mentally incompetent

59. Nursing Management Day-of-surgery preparation Final preoperative teaching Assessment and report of pertinent findings Verify signed consent

60. Nursing Management Day-of-surgery preparation Labs History and physical examination Baseline vitals Consultation records Nurse’s notes

61. Nursing Management Day-of-surgery preparation Patient should not wear any cosmetics Observation of skin color is important Remove nail polish for pulse oximeter

62. Nursing Management Day-of-surgery preparation Valuables returned to family member or locked up Dentures, contacts, prostheses are removed Identification and allergy bands on wrist

63. Nursing Management Void before surgery Prevents involuntary elimination under anesthesia or early postoperative recovery Before medication administration

64. Nursing Management:Intraoperative Care

65. Physical Environment Department Layout Holding Area Operating Room

66. Surgical Team Registered Nurse Licensed Practical Nurse and Surgical Technician Surgeon and Assistant Registered Nurse First Assistant Anesthesia Care Provider

67. Nursing Management: Patient Before Surgery Psychosocial Assessment Physical Assessment Chart Review Admitting the Patient

68. Nursing Management: Patient During Surgery Room Preparation Transferring the Patient Scrubbing, Gowning, and Gloving Basic Aseptic Technique Assisting the Anesthesia Care Provider

69. Nursing Management: Patient During Surgery (cont.) Positioning the Patient Preparing the Surgical Site Safety Considerations Patient After Surgery

70. Classification of Anesthesia General Anesthesia Intravenous Induction Agents Inhalation Agents

71. Classification of Anesthesia General Anesthesia (cont.) Adjuncts to General Anesthesia Opioids Benzodiazepines Neuromuscular blocking agents Antiemetics Dissociative Anesthesia

72. Classification of Anesthesia (cont.) Local Anesthesia Methods of Administration Spinal and epidural anesthesia Additional Anesthesia Considerations

73. Gerontologic Considerations: Patient During Surgery

74. Catastrophic Eventsin the Operating Room Anaphylactic Reactions Malignant Hyperthermia

75. Postoperative Care in the Postanesthesia Care Unit (cont.) Potential Alterations in Cardiovascular Function Etiology

76. Nursing Management:Cardiovascular Complications Nursing Assessment Nursing Diagnoses Nursing Implementation

77. Postoperative Care in the Postanesthesia Care Unit (cont.) Potential Alterations in Neurologic Function Etiology

78. Nursing Management:Neurologic Complications Nursing Assessment Nursing Diagnoses Nursing Implementation

79. Postoperative Care in the Postanesthesia Care Unit (cont.) Pain and Discomfort Etiology

80. Nursing Management: Pain Nursing Assessment Nursing Diagnoses Nursing Implementation

81. Postoperative Care in the Postanesthesia Care Unit (cont.) Hypotherma Etiology

82. Nursing Management: Hypothermia Nursing Assessment Nursing Diagnoses Nursing Implementation

83. Postoperative Care in the Postanesthesia Care Unit (cont.) Nausea and Vomiting Etiology

84. Nursing Management:Nausea and Vomiting Nursing Assessment Nursing Diagnoses Nursing Implementation

85. Postoperative Care in the Postanesthesia Care Unit (cont.) Surgical-Specific Care of the Patient in the PACU Discharge from the PACU Ambulatory Surgery Discharge

86. Care of the Postoperative Patient on the Clinical Unit Potential Alterations in Respiratory Function Etiology

87. Nursing Management:Respiratory Complications Nursing Assessment Etiology Nursing Diagnoses Nursing Implementation

88. Nursing Management:Cardiovascular Complications Nursing Assessment Etiology Nursing Diagnoses Nursing Implementation

89. Nursing Management:Urinary Complications Nursing Assessment Nursing Diagnoses Nursing Implementation

90. Nursing Management:Gastrointestinal Complications Nursing Assessment Etiology Nursing Diagnoses Nursing Implementation

91. Nursing Management:Surgical Wounds Nursing Assessment Etiology Nursing Diagnoses Nursing Implementation

92. Nursing Management:Psychologic Function Nursing Diagnoses Etiology Nursing Implementation

93. Care of the Postoperative Patienton the Clinical Unit (cont.) Planning for Discharge and Follow-Up Care