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PERI-OPERATIVE NURSING
UNIVERISTY OF NORTH FLORIDA
SCHOOL OF NURSING
M. Catherine Hough, PhD, RN, Associate Professor
Linda K. Connelly, ARNP, MSN, CNOR
Introduction to Perioperative Nursing
Phases of Perioperative Care
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Pre Operative - begins with the patient’s decision to have
surgery, ends with entry into the operating room
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Intra Operative - begins with entry into the operating room and
ends with admission to the recovery room
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Post Operative - begins with admission to recovery room, and
ends with discharge from care (varies but usually 6 weeks post
op) by physician
PERIOPERATIVE NURSING
Informed Consent
Pre-Operative
Responsibilities of Operating Room Nurse:
 Patient Assessment
 Physical Problems
 Emotional Aspects
 Understanding of surgery/consent
 Legal requirements for chart completion
 Read and interpret lab results
 PeriOperative Teaching
PREOPERATIVE NURSING
CONSIDERATIONS
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COMPLETE PHYSICAL ASSESSMENT
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Physical & psychological needs
Medical & surgical history
Completion of required documents
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DETERMINE READINESS & MODE OF
TRANSPORTATION TO OR
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ACCESS HEALTH CARE TEAM AVAILABILITY
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Surgeon
Anesthesia personnel
Circulating nurse
Scrub person
Other personnel
PRE-OP MEDS
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Pharmacologic preparation as necessary &
psychological support
Facilitates induction of anesthesia & reduces
anesthetic requirement
Determinants of drug choice
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Age
Weight
Level of anxiety
Drug allergies
Inpatient/outpatient
Timing of administration
PREOPERATIVE NURSING
CONSIDERATIONS
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COMPLETE PHYSICAL ASSESSMENT
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Physical & psychological needs
Medical & surgical history
Completion of required documents
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DETERMINE READINESS & MODE OF
TRANSPORTATION TO OR
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ACCESS HEALTH CARE TEAM AVAILABILITY
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Surgeon
Anesthesia personnel
Circulating nurse
Scrub person
Other personnel
Intra-Operative
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Provide for quiet environment during induction
Assist during intubation
Observe aseptic technique
Safe operation of equipment (lasers, electrosurgery unit)
Position patient safely - CV, nervous, respiratory system
Document events, patient care given,
Provide all supplies, equipment, to team during surgery
Provide for a safe transfer to recovery room
Unsterile Team Member - Circulating Nurse
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Responsible for nursing care in the operating room
Responsible for the organization of the workload
Responsible for the maintenance of policy and
procedures
Responsible for signing and documentation
The Circulating Nurse is the professional staff
member in the operating room, representing the
patient (Patient Advocate) and the hospital
administration
Surgical Nurse 1889
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A level head & keen eyes, ever watchful for
all that may be required, a mind not easily
irritated or confused, combined with the
facility of keeping out of the way & still being
of the greatest help……..Thoroughness,
speed, gentleness especially fit the surgical
nurse.
(Asepsis for the Nurse, Clemons, 1889)
1945
Discussion of the role of the OR Nurse
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“In charge of the operating room, taking care of the
needs of the room assigned to her. It is her
responsibility to watch the aseptic technique of her
team.”
“A surgery nurse must have many good qualities; but
first of all, she must be conscientious of sterile
technique. Speed & efficiency are of no avail if a
surgical wound breaks down due to an infection
received in the OR. “
Crawford, 1945
SCRUB PERSON
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May be a:
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RN
LPN
Surgical Tech
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Duties:
 Usually confined to
the intraoperative
phase of the
patient’s surgical
experience, may also
be involved in
gathering surgical
supplies &
equipment
SCRUB NURSE
“ The nurse who is the immediate
assistant to the surgeon is often called
the “scrub” or “sterile” nurse. She first
scrubs her hands and arms the required
length of time, puts on sterile gown &
gloves, and handles only sterile
material.”
Crawford 1945
SCENARIO #1
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A. Smith, RN & D Jones, RN are assigned to scrub &
circulate for a 0800 gastrostomy on WW, a 79 year
old emaciated male. Since his hospitalization 3 days
ago, he has managed to remove his IV and NG tube
several times. Consequently he has been restrained
even on the stretcher during his transport to the OR.
His medical DX is chronic alcoholism with dementia.
WW seems to acknowledge D Jones’s presence with
a half glance, however he will not respond to the
anesthesia provider’s questions. WW is supported
on the stretcher in a semi-flower’s position with
several pillows. Further assessment reveals that WW
has contractures of his hips and knees.
SURGICAL POSITIONING
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Facilitated through the nursing process
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Patient’s body must remain in physiologic alignment
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Dependent Upon:
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The surgical procedure
Exposure at the surgical field
Surgeon’s preference and idiosyncrasies
Patient’s condition
Special Considerations:
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Geriatric patients
Obese patients
Malnourished patients
SURGICAL POSITIONING
EQUIPMENT
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Pillow or headrest
Arm boards
Safety belt/strap
Footboard
Padding
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Gel pads
Egg crate
Donut rolls
Foam
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Padded Shoulder
braces
Stirrups (candy canes,
Allen, or knee)
Laminectomy Frame
Olympic vac pac
(suction beanbag)
3” adhesive tape
POSITIONING DEVICES
SCENARIO #2
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WH is a 36 year old black male who had been
scheduled for a hemorrhoidectomy on an outpatient
basis. He is 5’ 11”tall and weighs 250 lbs. His HBG is
low (12g/dL) secondary to rectal bleeding. WH has a
HX of asthma since age 5. He has episodes of
difficulty breathing 6X/year, treated with an inhaler at
the time of each episode. He does not smoke; ETOH
2 glasses of beer per week. WH’s current BP is
138/96, which he controls by taking a daily
antihypertensive med. WH is a high school teacher.
He spends most of his days standing and
occasionally sitting. His evenings and weekend are
spent working on a master’s degree in education. He
does not participate in a regular exercise program.
SETTINGS:
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Ambulatory Surgery - In and Out in same
day
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Pre-op teaching
T&A, Cyst removal, D&C, Cataract removal
with lens implants, Biopsy
Heart cath
scopes
SETTINGS…
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Same Day General Surgery - Admitted to
inpatient unit or special same day surgery unit
Pre-Op teaching prior to day of
surgery
 Nurses especially trained in Pre-Op
assessment (Hysterectomy, Lap
Chole, Appendectomy,
Mastectomy, C-Section)
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SETTINGS …
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Main OR Surgery - Patient admitted to hospital prior
to surgery OR DAY OF SURGERY
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Prep and assessment and teaching done in
hospital
Patient stays @ least overnight, and rehab
begins before discharge
Major heart surgery such as CABG’s, Bowel
Resections, Large tumor removal or Brain
surgery
PURPOSE of SURGERY
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Diagnostic - Determines cause of symptoms (Exploratory
laparotomy and biopsy)
Curative - Removal of diseased part (Appendectomy, Ovarian
Cyst, Cancerous Tumors)
Restorative or Reconstructive - Strengthens a weakened part
(Herniorrhaphy or cervical rings) rejoins disconnected areas
(orthopedic surgeries), corrects deformities, (MVR, joint
replacement, etc)
Palliative - Relieves symptoms without curing (some lower back
surgeries, tumorectomies)
Cosmetic - Repairing a burn scar or changing breast shape,
altering physical appearance
Patients @ High risk for Complications
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Smokers
Obese
Chronic Lung Diseases
Elderly
HTN
Thoracic or Abdominal
Surgeries
Immobilizing Surgery
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UTI
Diabetes
Poor Nutritional Status
Dehydration
Heart Disease
Self-fulfilling Prophecy
Inhalant Anesthesia
PREVENTING COMPLICATIONS
DVT, UTI, Aspiration,
Wound Infection, Shock, Constipation
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Identify those @ risk
Provide adequate hydration/nutrition
NPO after MN
Leg exercises
Breathing exercises and IS
I&O
Preventing Complications…
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Splint Incision to cough
Anticoagulant Therapy - Heparin
Ambulate and OOB to BRP - ASAP
Discourage smoking
Fluid and fiber ASAP, laxatives. Enemas
Clean Hands
Instruct in proper wound care
Sterile bowel prep and skin prep
Sleep/Rest
PREPPING THE PATIENT
TEACHING
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Name and purpose of the surgery
NPO after MN and why early awakening, shower,
remove all jewelry, makeup, etc
Anesthesia, Cold Room, Smells, Drowsy Feeling
Recovery Room
Post-op care - TCDB, leg exercises, pain
management, DVT< OOB ASAP
Begin discharge planning
WAYS TO DECREASE ANXIETY
COMMUNICATION
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Early teaching and counseling
Diversional activities
Encourage family support
Encourage verbalization of fears/loss of control
Deep breathing, medications, imagery, music
Ways to Decrease Anxiety…
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Spiritual support (communion, bible reading,
prayers, rituals, chants)
Inform family where to wait, buy food,
bathroom, phone, overnight and visiting
policy
Possible use of sedative or tranquilizer or
PRN medications
Dolls/favorite toy for children
NURSING ASSESSMENT
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Assessment Data Base - vital signs, weight,
height
Review of Systems
Past history of illnesses (i.e. HTN,
pneumonia) that may predispose client to
complications
Past experience with hospitalization or
surgery
Allergies to medications or foods, tapes,
surgical scrubs
Nursing Assessment…
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Intellectual ability to understand teaching
Language differences, social, spiritual or cultural
considerations, anxiety level
Labs: CBC; U/A; Chemistry (electrolytes:
K,CL,NA,CA,BS,BUN,Creatine), total bilirubin,
albumin, alkaline phosphatase, SGOT, HCO3, HIV,
Pregnancy
Other: Chest X-Ray, EKG if > 40 years old
PRE-OP NURSING DIAGNOSES
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Knowledge Deficit R/T Unfamiliar Planned or
Unplanned Surgery
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Ineffective individual or family coping R/T Unfamiliar
Planned or Unplanned Surgery
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Anticipatory Grieving R/T Potential for Loss of Life or
Body Part
NURSING RESPONSIBLITIES
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Informed Consent Form/Patient Advocacy
Secure personal belongings: Dentures, glasses,
rings, money
Administration of pre-op medications on call to
OR - i.e. Demerol, Valium, Atropine
Complete Pre-op Checklist @ clinical site remove hair pins, loose teeth, dentures, nail
polish, bath, urinate, NPO, VS taken within 15
minutes of going to OR, Ted Hose or compression
devices
NURSING RESPONSIBLITIES ...
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Report anything of note that needs to be brought to the attention
of the anesthesiologist, surgeon, or OR nurse
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low potassium,
fever,
arrthymias,
loose teeth,
chest pain, or
anything unusual
Assure patient has ID bracelet on; Send current chart and any
old medical records with the patient;
EVALUATE patients level of understanding, physical stability,
emotionally prepared, fulfilled hospital pre-op policies
TYPES OF SURGERY
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MAJOR -- Present a real threat to life
MINOR -- Present little threat to life
NOTE: **** All patients consider their
surgery a major thing ****
BLOODLESS SURGERY
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a term that has evolved in the medical
literature to refer to a perioperative team
approach to avoid allogeneic transfusions
and improve patient outcomes
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utilizing combinations of the numerous blood
conservation techniques and transfusion
alternatives available
BENEFITS OF BLOODLESS SURGERY
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Decreased costs
Less risk for blood
contamination for
patients
Reduce risk of post op
fevers and infections
usually associated with
blood transfusions
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Promotes better quality
patient care
At times decreased
death rate
Can decrease time
spent in ICU
Catastrophic Events in the OR
Anticipated:
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Cardiac Arrest in an unstable patient
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Massive Blood Loss - during trauma surgery
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Loss of ability to ventilate a patient
Catastrophic Events in OR ...
Unanticipated:
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Latex Allergy Reaction - reactions can range from
urticaria to anaphylaxis
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Maligant Hyperthermia - rare, life-threatening
disorder that can be triggered by anesthesia drugs Is an autosomal dominant trait
Peri-Operative Standards of Care (example)
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All Policy & Procedures of the medical and surgical nursing division
will be followed.
Patients shall ALWAYS wear a legible identification band
Operative permit(s) must be signed and witnessed according to
hospital policy, The procedure documented on the operative permit
MUST MATCH what is scheduled on the OR schedule
The history and physical shall be completed according to policy and
be part of the medical record prior to surgery
All ordered lab work shall be collected and results placed in the
medical record in accordance with the physician’s orders
Dentures, hairpins, jewelry, wigs, contact lenses, nail polish, make-up
and prosthesis shall be removed as requested by the physician
Any jewelry not removed shall be secured with tape and documented
as such
Peri-Operative Standards of Care …
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Pre-operative skin prep shall be done without abrading, cutting or
irritating the patient’s skin
Patient privacy shall be provided at all times
Any pre-operative drainage tubes shall be placed without tissue trauma
and be completed utilizing sterile techniques when indicated
All IV infusions shall be monitored to maintain the appropriate flow rate
and type of solution and remain patent without signs of inflammation or
swelling
The patient shall be provided emotional and educational support to
reduce pre-operative anxiety
The patients shall be provided a safe and normothermic environment in
the pre-op waiting area
The patient shall be transferred safely to the OR table and safety straps
appropriately applied
Expected Outcomes:
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Demonstrate knowledge of physiologic &
psychological responses to surgical
intervention
Absence of infection
Maintenance of skin integrity
Freedom from injury R/T positioning,
equipment
Maintenance of fluid and electrolyte balance
Satisfaction with pain relief
Participation in the rehab process
AORN a tradition of excellence
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Formally organized between 1949 – 1954
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A professional organization of periOperative
registered nurses whose mission is to provide quality
patient care by providing its members with education,
standards, services and representation.
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Membership 340 chapters, 12 specialty assemblies,
25 state councils and 41,000 members
PERIOPERATIVE NURSING
If you or your family came
through surgery in good shape,
thank a perioperative nurse.
If someone listens, or stretches out a
hand, or whispers a kind word of
encouragement, or attempts to
understand a lonely person, extraordinary
things begin to happen
Loretta Gizarlis (1920)
American writer and educator