Med Surg Guide for Exam #3
Perioperative
Perioperative: concentrate mostly on Pre-op and post-op
• Pre-op: importance of getting a good history, medication reconciliation, what puts
someone at post-op risks (ex: diabetes and obese patient; at risk for poor wound
healing/wound issues), what medications may increase bleeding
• Intra-op: safety focus (not covering any anesthetics)
• Post-op: post-op care for the orthopedic patient (kind of intertwines with
musculoskeletal), prevention of DVT, prevention of pneumonia, getting patient up and
moving as quickly as possible, incentive spirometry, cough and deep breathing, remember
if they develop fever within the first 24-48 hours it usually is related to a respiratory
problem and if they have a wound infection, fever usually occurs at about 72 hours post-
op.
From lecture notes:
Peri-operative nursing care
Pre-OP: Goals for pre-op assessment (this assessment can begin a few days prior to when surgery is
scheduled and continue the day of surgery. It all depends on the situation):
• Patient's psychological status- look at coping strategies, how the patient is looking at
the surgery, what plan do they have in place, do they need a driver home, do they need
rehab, any negative past experiences, etc.
• Any past history that may increase operative risk factors (weight, PMHx, smoke,
allergies, what meds they take (prescription/OTC), make sure they haven't eaten
past midnight, etc.)
• To establish baseline (to compare pre-op to post-ob labs) CBC, type and cross,
electrolytes, make sure they are not taking a medicine like Coumadin (increased risk
of bleeding) have to stop a week prior to surgery
• ID and document surgical site and/or procedure
• Medications- both prescription and OTC (ASA)
• Identify cultural and ethnic factors (Jehovah Witness)
• Check level of knowledge of: procedure
Why is pre-operative teaching done? To increase patient satisfaction, decrease operative fear, anxiety
and stress, decrease development of complications (early ambulation to prevent constipation & control
pain before ambulating, coughing and deep breathing), decreased length of stay, decreased recovery
time, FOCUS IS ON PATIENT SAFETY, make sure to DOCUMENT all patient teaching. Remember the
nurse wants to get a complete history – very detailed – this should include areas like medication
history, surgical history- have they had problems with anesthesia before – or problems post op too.
Why do you want baseline -labs and vitals – this allows us to compare it to the post op numbers. Ask
about allergies. Legal consent: must be informed consent, patient must be of sound mind, it is the
physician’s responsibility (the RN can witness the signature and clarify information). It is not the role of
the nurse to explain the procedure (RN can clarify points). Make sure the form is accurate – signatures
in place. It is important to note that the consent is INFORMED. That means that the patient is of sound
mind and knows what it is going on. As a proxy, a family member can give consent for a patient that is
not able to consent for themselves (ex: a patient with dementia). It must be proved legally that the
person signing the informed consent is a proxy. The physician is responsible for the person who is
performing the
,procedure. The RN can witness and clarify information. If English is second language, must provide a
hospital interpreter for the patient (not a family member).
Pre-operative checklist: use this the day of surgery, goes through everything that you need to know
and make sure of: dentures out, contacts off, nail polish removed, ID band and allergy band are on,
client teaching has been completed, consent form signed, NPO, patient is in gown, no jewelry-bands
taped, voiding prior to transfer, vitals within 4 hours of surgery of 30 minutes after pre-op, make sure
preoperative lab work is on the chart, recognize abnormal lab values (notify physician right away), skin
prep, history of aspirin, antidepressant, steroid or NSAID use, pre-op medications given, side rails up
after pre-op. Common labs done- CBC, ELECTROLYTES, TYPE AND CROSS MATCH, BUN AND CREAT ,
PREGNANCY TEST (IF INDICATED), CLOTTING STUDIES – PTT, INR, - remember if they are on
anticoagulants they will be discontinued pre-op for a period of time.
During pre-op experience, we talk about identifying risk factors, and there are risk factors that patients
are going to have questions about (ex: what about infection, anemia, loss of volume-hypovolemia,
electrolyte imbalance, DVT), so do teaching involving those pieces. Teach them how to cough and deep
breathe and how to use incentive spirometry. Also looking for risk factors that could cause surgical
complications (Ex: if a person has chronic respiratory disease, that could potentially cause problems
postoperatively, smoking patients, or even patients with heart failure (fluids are given during surgery, so
may have to alter diuretics or monitor I&Os very carefully and auscultate breath sounds). Diabetes
patients are definitely at risk. They have elevated blood sugars, so the stress of surgery will increase the
blood sugar even more and they have increased risk of delayed healing. Obesity patients put more
pressure on the incision and are at increased risk for wound evisceration or dehiscence. Older adults
have potential for post-operative complications due to their age related changes. Patients should
understand that when they are on scheduled medications, they should be aware of the medications
that they should take and those that they should not. For example, the BLOOD THINNERS! Reinforce
post op teaching- Turn Cough and Deep Breathe – incentive spirometry – post op diet – usual recovery
plan- pain control – DVT prevention interventions- demonstrate splinting when coughing. If pre-op
teaching occurs prior to surgery ( say a week or two before ) – make sure patient understands what
medications they can take( e.g. holding aspirin for a week prior to surgery) , when they should be NPO,
refrain from smoking. Intra-OP: SAFETY is the focus!!!!!!! Go through several safety checks to make sure
that we have the right patient and the right procedure, etc. Safety includes transferring the patient,
positioning on the table, hazards of anesthesia (gasses are flammable)as well as just protecting the
patient from general surgery. Prevent complications – proper positioning – making sure the right
procedure is being done on the correct patient! Everybody has a role and it is to protect the patient.
Intra-op safety time-out- created by the safety organizations to protect patients.
• Other nursing activities:
o Room preparation: ensure privacy, prevention of infection, safety
o Transferring patient to the OR suite, safety measures when transferring patient
(LOOK IT UP)***
o Take a surgical time out: Before induction of anesthesia ask patient to
confirm name, birth date, operative procedure and site and consent.
Compare the hospital ID number with the patient's own ID band and chart.
• During surgery:
o Maintain sterile field
o Ensure sponge, instrument count is correct (make sure nothing is left inside)
o Position patient to ensure correct alignment
o Prevent chemical injury
o Safety with electrical equipment
, o Safely administering medications
o Monitoring vital signs
o Monitoring blood loss and urine output
ATI- has great summary of patient centered care, the labs done, and breaks up the responsibilities very
well, so it would be a great idea to look this up.
Post-op:
Will first discuss the PACU- where you provide care for the patient until the patient has
recovered from the effects of anesthesia. Purpose is to get the patient awake and see less and less of
the effects of anesthesia. Patient has resumption of motor and sensory function, is oriented, has stable
VS, shows no evidence of hemorrhage or other complications of surgery. It is vital to perform frequent
skilled assessment of patient. What occurs in the PACU: There is a scoring system used to assist the
nurse in determining when the patient is ready for transfer, the Aldrete score-monitors the recovery
from anesthesia (5 factors-, grades activity, consciousness, respirations, O2 sats and circulation
assessment (ACROC)). The patient is typically ready for discharge at about a score of 8-10. Patient will
have stable vital signs, able to breathe on own, no evidence of bleeding and return of reflexes (ex: gag).
There is minimal to absent nausea and vomiting, wound drainage is minimal to moderate and urine
output is also about 30 ml/hr or greater. PACU environment: Beds, other equipment; there are three
phases: Phase I, Phase II, and Phase III. The PACU nurse is always assessing the patient; airway,
circulation, vitals, positioning, stimulate pt. to wake them up from anesthesia. Assess airway (#1),
respirations, cardiovascular function, surgical site, function of CNS, IVs, all tubes and equipment (looking
at what is going in and coming out of the patient).
Reassess VS, patient status every 15 minutes or more frequently as needed. Assess how the patient is
waking up from anesthesia, assess n/v, pain, monitor I&O (how much urine is coming out), assess
wound dressing (for drainage) – LOC. Transfer report, to another unit or discharge patient to home.
Example interventions: If patient is complaining of nausea, turn the over on side to prevent aspiration. If
person is receiving supplemental oxygen (monitoring O2 sats) and when returning to the bedside the
patient is sound asleep, NAD, and the O2 sat is 88-89%. Stimulate the patient; make them take a good
deep breath and see if the sats return, before upping the oxygen.
The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function
and prevention of hypoxemia and hypercapnia. Importance of this: positioning (head of bed up),
listening to lung sounds, administering oxygen as needed, monitoring O2 sats continuously, looking at
circulation, checking mucus membranes, lips and nail beds for any signs of cyanosis, monitoring fluid
and electrolyte balances, frequent vital signs at least every 15 minutes, assess for movement, LOC, etc.
Discharge from the PACU: Direct discharge (going home directly from recovery room) planning
includes written and verbal instructions about medication, wound care, activity restrictions, diet
restrictions and complications (when to call the doctor; signs and symptoms of infection, signs of DVT,
etc.). They need someone to drive them home and make sure that the caregiver is there to listen to the
discharge instructions. If discharged to the unit, the patient should report with stable vital signs,
recovered from anesthesia (mostly) and the nurse should have given SBAR report to the receiving unit.
When the patient is coming to the unit, what do you do? Get room ready – IV pole and pump,
suction equipment, oxygen, emesis basin, tissues, etc. The nurses focus includes ventilation (airway),
Hemodynamic stability- check vitals q15m x 1 hr: then q30m x 2h, incisional pain, surgical site, nausea
and vomiting, neuro status and thermoregulation – check temp q4h x 24h. When the person comes
to the unit, the nursing process is what you follow.
, -Assessment is critical! Make sure that we start aggressively with the airway management, and that
means coughing and deep breathing at least every hour, incentive spirometer every 1-2 hours,
sometimes you can have the patient do it more frequently, especially if they are awake (it can’t hurt). –
-Turn and position the patient at least every 2 hours and get the patient moving as soon as possible.
Pain control is important and you do not want to let the pain get out of control (needs to be controlled
so patient will move and do cough and deep breathing, ambulation, etc.). Remember that if they have
an abdominal or sternal incision, we have to teach them how to splint the incision, to protect the
incision and provide some comfort while performing exercises.
-Check I&0’s, check bladder (if they had catheter, is the bladder distended), are they retaining urine?
(Bladder scanner if they are voiding small amounts). When was catheter discontinued? –
-Assess bowel sounds and maintain NPO if indicated. If NG tube is present, need to assess that as
well (make sure functioning and hooked up to correct amount of suction, etc.). Also know when
advancing diet, start with clear liquids and assess patient to see if they are tolerating it.
-Diet is usually advanced when bowel sounds are present and patient is passing gas. Want to include
interventions that prevent DVT (ambulation, SCDs, compression stockings), and watch incisions and
drains (drains should be emptied every shift and document the amount and type of drainage). Vitamin C
helps with wound healing.
How to prevent complications? ATI does a nice job summarizing complications. PREVENTION IS
KEY! Complications include:
▪ Pulmonary embolism: chest pain, dyspnea, increased resp rate, tachycardia,
increased anxiety, diaphoresis, decreased orientation, decreased blood pressure,
blood gas changes
▪ DVT: patient may be on a low-molecular weight heparin like a Lovenox, avoid pressure
behind the knee, or pillow or blanket because it can decrease blood flow and put
constriction on blood vessels. Avoid dangling legs for a long period of time and keep
the patient well hydrated.
▪ Hypovolemic shock: decreased urine, low BP, weak pulse, cool and clammy,
restlessness, increased bleeding, increased thirst, decreased CVP
▪ Infection: redness, purulent drainage, fever, tachycardia, leukocytosis; respiratory
infection occurs about 24-48 hours post op, and wound infection presents about 72
hours post op.
▪ Dehiscence: separation of incision
▪ Evisceration: evidence of bowel through incision and increase in pain; apply sterile
wet dressing on top of it and notifying the doctor stat and the patient will going to the
OR.
▪ Gastric dilation: nausea and vomiting, abdominal distention (can lead to dehiscence);
assess NG tube for patency
▪ Paralytic ileus: decreased bowel sounds, no stool or flatus, nausea, vomiting,
abdominal distention, abdominal tenderness (prevent with ambulation)
▪ Atelectasis: dyspnea, tachypnea, decreased breath sounds, asymmetrical chest
movement, tachycardia, increased restlessness
▪ Pneumonia: rapid respirations, shallow respirations, fever, wet breath sounds,
asymmetrical chest movement, productive cough, hypoxia, tachycardia,
leukocytosis,
▪ Urinary retention: Unable to void 8-10 hours post op, palpable bladder, frequent small
amount (voiding), pain suprapubic area
