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1
Discuss various types of surgery according to the purpose, degree of urgency,
and degree of risk.
Concepts for Lecture
1. Surgery is classified by its urgency and necessity to preserve the
client’s life, body part, or body function. Emergency surgery is
performed immediately to preserve function or the life of the client
may be likely (for example, open heart surgery). Minor surgery nor-
mally involves little risk, produces few complications, and is often
performed on an outpatient basis (for example, breast biopsy).
Surgical procedures have various purposes. A diagnostic proce-
dure confirms or establishes a diagnosis (for example, breast
L
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2
Describe the phases of the perioperative period.
Concepts for Lecture
1. Surgery is a unique experience of a planned physical alteration
encompassing three phases: preoperative, intraoperative, and postop-
erative.
The preoperative phase begins when the decision to have sur-
gery is made and ends when the client is transferred to the operating
C
HAPTER
37
PERIOPERATIVE NURSING
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Have the students discuss the following state-
ment: Surgery is never “minor” for a client.
S
UGGESTIONS FOR
C
LINICAL
A
CTIVITIES
• Have the students classify the type and pur-
pose of surgery for various clients on the sur-
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Discuss the implications of same-day surgery
on the preoperative phase.
• Discuss the implications of early discharge on
the postoperative phase.
S
UGGESTIONS FOR
C
LINICAL
A
CTIVITIES
• Have each student follow a client through the
three phases of the perioperative period.
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Using the nursing diagnosis book required by
CHAPTER 37 / Perioperative Nursing 271
this phase include a variety of specialized procedures designed to
create and maintain a safe therapeutic environment for the client and
the health care personnel. The activities include providing for the
client’s safety, maintaining an aseptic environment, ensuring proper
L
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3
Identify essential aspects of preoperative assessment.
Concepts for Lecture
1. Preoperative assessment includes collecting and reviewing physical,
psychological, and social client data to determine the client’s needs
2. A brief but complete physical assessment pays particular attention to
systems that could affect the client’s response to anesthesia and
surgery. It also includes a brief “mini” mental status. Respiratory,
cardiovascular, and other systems (gastrointestinal, genitourinary,
and musculoskeletal) are examined to provide baseline data.
L
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4
Give examples of pertinent nursing diagnoses for surgical clients.
Concepts for Lecture
1. Nursing diagnoses that may be appropriate for the preoperative
2. Nursing diagnoses that may be appropriate for the intraoperative
3.
Nursing diagnoses that may be appropriate for the postoperative client
include Acute Pain; Risk for Infection; Risk for Injury; Risk for Deficient
Fluid Volume; Ineffective Airway Clearance; Ineffective Breathing
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Discuss the importance of the preoperative
consent form and responsibilities of the
surgeon and nurse in relationship to obtaining
consent.
• Present a list of clients and type of surgery
each is scheduled to have. Ask the students to
identify the physical assessment that should be
pare and contrast the nursing interventions
required for each client.
the school or facility, have the students review
the defining characteristics, etiology, or risk
factors for each diagnosis.
• Provide the students with several case studies.
Ask them to develop nursing diagnoses related
to the specific perioperative phase in each case
study and to document the defining character-
istics, etiology, or risk factors.
postoperative phase. Compare and contrast
plans in postconference.
for the assessment.
272 CHAPTER 37 / Perioperative Nursing
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5
Identify nursing responsibilities in planning perioperative nursing care.
Concepts for Lecture
1. The overall goal in the preoperative period is to ensure that the client
is mentally and physically prepared for surgery. Planning should
involve the client, the client’s family, and significant others. Exam-
ples of nursing activities to achieve these goals include preoperative
2. The overall goals of care in the intraoperative period are to maintain
the client’s safety and to maintain homeostasis. Examples of nursing
activities to achieve these goals include positioning the client appro-
3.
Overall goals in postoperative period include promotion of comfort and
healing; restoration of the highest possible level of wellness; and preven-
tion of associated risks. Postoperative care planning and discharge plan-
L
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6
Describe essential preoperative teaching, including pain assessment and
management, moving, leg exercises, and coughing and deep-breathing exer-
cises.
Concepts for Lecture
1. Four dimensions of preoperative teaching have been identified as
important to clients: information including what will happen to the
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Invite a nurse educator from a hospital operat-
ing room to discuss current trends in
perioperative nursing. Ask the nurse to discuss
such issues as the qualifications of each
member of the surgical team and beliefs about
skin preparation.
S
UGGESTIONS FOR
C
LINICAL
A
CTIVITIES
•
Have the students participate in preoperative
teaching.
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UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Have pairs of students role-play preoperative
teaching for a client who is scheduled for
abdominal surgery.
2. Preoperative teaching includes instruction about preoperative and
postoperative regimens.
Preoperative regimen teaching includes need for preoperative
testing; discuss bowel preparation if necessary, skin preparation,
preoperative medications, specific preoperative therapies, visit by
3. The purposes for performing each of these skills include the
following:
Moving: to promote venous return, mobilize secretions, stimu-
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7
Describe essential aspects of preparing a client for surgery.
Concepts for Lecture
1. Physical preparation includes the following: nutrition and fluids,
elimination, hygiene, medications, rest, care of valuables and pros-
theses, special orders, vital signs, safety protocols, and surgical skin
revised guidelines.
Enemas prior to surgery are no longer routine but may be
S
UGGESTIONS FOR
C
LINICAL
A
CTIVITIES
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Discuss the importance of reviewing the plan
for postoperative analgesia with the client and
family prior to surgery.
medications that are given “on call” or at a scheduled time prior to
surgery.
To promote rest and sleep, a sedative may be ordered the night
before surgery. The nurse should do everything possible to help the
client sleep.
volves three steps: The first step is client verification at the time sur-
gery is scheduled, during admission, and whenever the client is
transferred to another caregiver. The second step involves marking
of the operative site in an unambiguous manner. The third step is
called “time–out.” The surgical team takes a time-out to conduct a
L
EARNING
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8
Compare various types of anesthesia.
Concepts for Lecture
2. General anesthesia is the loss of all sensation and consciousness.
Protective reflexes such as cough and gag reflexes are lost. General
3.
Regional anesthesia is the temporary interruption of the transmission of
nerve impulses to and from a specific area or region of the body. The
client loses sensation in an area of the body but remains conscious. Tech-
niques include the following: topical or surface (applied directly to the
skin and mucous membranes, open skin surfaces, wounds, and burns);
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Discuss different types of anesthesia and have
the students identify the nursing implications
of each.
• Invite a panel of nurse anesthetists to discuss
CHAPTER 37 / Perioperative Nursing 275
nous block or Bier block (used most often for procedures involving the
arm, wrist, and hand; an occlusion tourniquet is applied to the extremity
L
EARNING
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9
Identify essential nursing assessments and interventions during the immediate
postanesthetic phase.
Concepts for Lecture
1. Essential nursing assessments during the immediate postanesthetic
phase include adequacy of airway; oxygen saturation; adequacy of
2.
Interventions include positioning the client on the side, with the face
slightly down; elevating the upper arm on a pillow; suctioning as needed
L
EARNING
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10
Demonstrate ongoing nursing assessments and interventions for the postoper-
ative client.
Concepts for Lecture
1. As soon as the client returns to the nursing unit, the nurse conducts
an initial assessment. The sequence of assessment varies with the
situation.
The nurse consults the surgeon’s postoperative orders for the
2. Nursing interventions designed to promote client recovery and pre-
vent complications include pain management, appropriate position-
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Discuss nursing responsibilities and interven-
tions for clients who experience complications
in the immediate postanesthesia phase.
S
UGGESTIONS FOR
C
LINICAL
A
CTIVITIES
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Discuss postoperative analgesic administra-
tion, including the various routes.
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UGGESTIONS FOR
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LINICAL
A
CTIVITIES
•
Have the students review the agency’s policies
and procedures for routine preoperative prepara-
tion and postoperative care. Review the agency’s
276 CHAPTER 37 / Perioperative Nursing
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11
Identify potential postoperative complications and describe nursing interven-
tions to prevent them.
Concepts for Lecture
1. Potential postoperative problems and preventive nursing interven-
tions include pneumonia (deep breathe, cough; moving in bed, early
ambulation); atelectasis (deep, breathe, cough, moving in bed, early
L
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12
Verbalize the steps used in:
a. Teaching moving, leg exercises, deep breathing, and coughing
b. Applying antiembolic stockings
Concepts for Lecture
ESSENTIAL/
CRITICAL
ELEMENT?
COMPETENCY
DEMONSTRATED?
Yes
No
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Provide the students with case studies of
clients who are experiencing postoperative
complications. Have the students identify the
problem and related nursing responsibilities
and interventions. Also ask them to identify
interventions to prevent the complications, if
possible.
S
UGGESTIONS FOR
C
LINICAL
A
CTIVITIES
CHAPTER 37 / Perioperative Nursing 277
ESSENTIAL/
CRITICAL
ELEMENT?
SKILL 37–2: APPLYING ANTIEMBOLIC STOCKINGS
COMPETENCY
DEMONSTRATED?
Yes
No
1. Introduced self and verified client’s identity.
2. Explained procedure to client and discussed how results will be
used.
3. Gathered appropriate equipment.
tion control procedures.
5. Provided for client privacy.
278 CHAPTER 37 / Perioperative Nursing
6. Selected appropriate time to apply stockings.
out of bed.
b. Assisted client who had been ambulating to lie down and el-
evate legs for 15 to 30 minutes before applying stockings.
a. Applied stockings in morning, if possible, before client gets
7. Prepared client.
a. Assisted client to lying position in bed.
8. Applied the stockings:
a. Reached inside the stocking from the top, grasped the heel,
and turned upper portion of the stocking inside out so the
foot portion was inside the stocking leg.
the toes and placed the toe and heel portions of the stocking
appropriately.
c. Grasped the loose portion of the stocking at the ankle and
gently pulled the stocking over the leg, turning it right side
out in the process.
d. Inspected the client’s leg and stocking and smoothed out any
folds or creases.
b. Asked the client to point the toes. Positioned the stocking on
ESSENTIAL/
CRITICAL
ELEMENT?
SKILL 37–3: MANAGING GASTROINTESTINAL SUCTION
COMPETENCY
DEMONSTRATED?
Yes
No
1. Introduced self and verified client’s identity.
2. Explained procedure to client and discussed how results will be
used.
3. Gathered appropriate equipment.
4. Performed hand hygiene and observed other appropriate infection
control procedures.
5. Provided for client privacy.
Initiating Suction
6. Positioned client appropriately.
a. Assisted client to semi-Fowler’s position, if not contraindicat-
ed.
7. Confirmed that the tube is in the stomach:
a. Applied clean gloves.
placement:
c. Removed and discarded gloves. Performed hand hygiene.
b. Checked agency protocol for preferred methods to verify
8. Set and checked the suction.
9. Established gastric suction.
10. Assessed the drainage. Observed amount, color, odor, and con-
sistency of drainage.
Maintaining Suction
11. Assessed the client and the suction system regularly.
b. Inspected suction system for patency of system and tightness
a. Assessed the client every 30 minutes until system was running
12. Relieved blockages if present.
a. Applied clean gloves.
b. Checked suction equipment.
e. Irrigated nasogastric tube as per agency protocol.
f. Removed and discarded gloves. Performed hand hygiene.
13. Prevented reflux into the vent lumen of a Salem sump tube:
a. Placed the vent tubing higher than the client’s stomach.
b. Kept the drainage collection container higher than the level of
c. Kept the drainage lumen free of particulate matter.
14. Ensured client comfort:
a. Cleaned the client’s nostrils as needed.
15. Changed drainage receptacle according to agency policy.
Irrigating a Gastrointestinal Tube
16. Prepared the client and equipment:
a. Placed moisture-resistant pad under end of GI tube.
b. Turned off suction.
c. Applied clean gloves.
e. Determined that tube is in the stomach.
17. Irrigated the tube.
18. Reestablished suction.
ESSENTIAL/
CRITICAL
ELEMENT?
37–4: CLEANING A SUTURED WOUND AND CHANGING
A DRESSING ON A WOUND WITH A DRAIN
COMPETENCY
DEMONSTRATED?
Yes
No
1. Introduced self and verified client’s identity.
2. Explained procedure to client and discussed how results will be
used.
3. Gathered appropriate equipment.
4. Performed hand hygiene and observed other appropriate infection
5. Provided for client privacy.
6. Removed binders and tape.
7. Removed and disposed of soiled dressings appropriately:
a. Applied clean disposable gloves and removed the outer ab-
dominal dressing or surgipad.
b. Lifted the outer dressing so the underside was away from the
client’s face.
touching the outside of bag.
d. Removed the under dressing, taking care not to dislodge any
drains.
lected on the dressings.
f. Discarded the soiled dressings in the bag.
g. Removed and discarded gloves in moisture-proof bag. Per-
formed hand hygiene.
c. Placed the soiled dressing in the moisture-proof bag without
8. Set up the sterile supplies:
nique.
c. Opened the sterile cleaning solution and poured it over the
gauze sponges in the plastic container.
d. Applied sterile gloves.
a. Opened the sterile dressing set and used surgical aseptic tech-
9. Cleaned the wound if indicated.
moistened with cleaning solution.
ter use.
a. Cleaned wound using gloved hands or forceps and gauze swabs
10. Applied dressings to drain site and the incision.
a. Placed a precut 4 × 4 gauze snugly around the drain.
and below the drain, depending on the client’s usual position.
L
EARNING
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13
Evaluate the effectiveness of perioperative nursing interventions.
Concepts for Lecture
1. Using the goals established during the pre-, intra-, and postoperative
phases, the nurse collects data to evaluate whether the identified
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Provide the students with case studies of
clients in various perioperative phases with
nursing diagnoses already identified. Ask the
students to develop appropriate goals/desired
outcomes that will be used for evaluation.
CHAPTER 37 / Perioperative Nursing 281
For example, if the outcome “Pain control” is not met, questions
to be considered include:
• What is the client’s perception of the problem?
L
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14
Recognize when it is appropriate to delegate infection control skills to unli-
censed assistive personnel.
Concepts for Lecture
1. Preoperative teaching is conducted by the nurse and is not delegated
2. The role of the circulating nurse may not be delegated to a UAP or
licensed vocational/practical nurse (LVN/LPN) (Association of
Operating Room Nurses [AORN], 2011). The
scrub person
is usually
3. Managing gastrointestinal suction requires application of knowledge
4.
Cleaning a newly sutured wound, especially one with a drain, requires
application of knowledge, problem solving, and aseptic technique. As a
L
EARNING
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15
Demonstrate appropriate documentation and reporting of perioperative skills.
Concepts for Lecture
1. Document the preoperative teaching and all assessments. Some
agencies may have a preoperative teaching flow sheet. Check agency
2. The nurse completes the agency’s preoperative checklist following
appropriate documenting procedures. It is essential that all pertinent
3. In the preoperative phase the nurse assesses and documents vital
4. Document nursing care provided and the client’s response to
interventions.
5. The intraoperative nurse documents the perioperative plan of care,
6. Postoperatively, document the client’s time of arrival to the unit and
7.
When documenting suture removal, document the number of sutures