Perioperative Nursing

Preoperative
Nursing
HISTORICAL PERSPECTIVE
HISTORY OF SURGERY
● Surgery is defined as the branch of medicine that involves
manual and operative procedures to correct deformities
and defects, repair injuries, and diagnose and treat certain
diseases.
● The Greek term kheirurgos signifies working by hand.
● Hippocrates, the founder of surgery, used wine or heated
water to clean wounds circa 450 BC.
● By AD 130-200, surgery became a specific medical
discipline and around this time Galen sterilized his
instruments before use.
● Morton's use of ether at Massachusetts General Hospital in
1846 signaled the advent of anesthesia.
HISTORY OF SURGERY
● Joseph Lister recommended using antiseptics like carbolic
acid sprays in surgery in 1867.
● Semmelweis and Lister's techniques weren't embraced until
the 1880s with aseptic technology.
● In the late 1890s, x-rays and surgical instruments were
discovered.
● Before 1900, most surgeries were on the abdomen. William and
Charles Mayo described 1000 abdominal surgeries in 1904.
● As thoracic, neurologic, and cardiovascular procedures were
added, surgical methods evolved. Throughout the 20th
century, innovations in anesthetic, surgery, and technology
have led to safer patient outcomes.
PERIOPERATIVE NURSING: PAST AND PRESENT
● Many surgeries were done at home in the

early 1900s.
● After a while, doctors began doing surgery
in private boarding houses that also
provided hotel and nursing services.
● By the 1920s and 1930s, most doctors were
associated with precise sponge and tool
counts, assisting surgeons. Nursing's
major job was technical aid to the surgeon.
Perioperative nursing refers to the nursing care that is
provided to a patient during the entirety of their surgical
procedure.
Perioperative Nursing Phases
● Preoperative phase
● Intraoperative phase
● Postoperative phase
The professional practice of perioperative

nursing is based on the patient-centered
approach which includes four domains:
- patient safety,
- the health system,
- physiologic responses
- behavioral responses
● The Association of periOperative Registered

Nurses (AORN) defines a perioperative nurse as
a registered nurse who sets a nursing plan and
coordinates and delivers care to patients
undergoing operative or other invasive
procedures.
● The AORN made perioperative nursing
explanations of the Code for Nurses by using
the American Nurses Association's (ANA) Code
for Nurses with Interpretive Statements.
In 2000, AORN members created the Perioperative Nursing

Data Set (PNDS), a set of standardized nursing
terminologies for the perioperative patient experience.
Clinical uses of the PNDS include:
- A framework for standardized documentation and

universal language
- The measurement and evaluation of patient care

outcomes
- A basis for perioperative nursing research
- Validation of the contributions of perioperative nurses

to patient outcomes
SURGICAL PROCEDURES
Most surgical procedures are named after the place and kind of operation.
Some operations are named after the inventor.
Surgery is characterized by:
- Degree of risk
- Purpose
- Anatomic site
- Timing or physical setting.
SURGICAL PROCEDURES
TYPE OF SURGERY
(DEGREE OF RISK)
The Degree of Risk associated with the surgical operation is categorized as either minor or
major
- Minor surgery is a straightforward procedure with a low mortality risk. Many minor
surgeries are performed with the use of local anesthesia, although general anesthesia may be
used.
- Major surgery is more invasive than minor surgery and may pose a threat to the patient's
life. Major surgical procedures are often conducted under general or regional anesthesia.
SURGICAL PROCEDURES
TYPE OF SURGERY
(EXTENT OF THE SURGICAL PROCEDURE)
The Extent of the Surgical Procedure may be minimally invasive, open, simple, or radical.
- Minimally Invasive Surgery is performed with fiberoptic endoscopes and does not
require large incisions. MIS uses smaller incisions, customized instrumentation, specialized
imaging, and robotics.
- Endoscopic procedures can be diagnostic or therapeutic and used alone or with open
techniques. Endoscopic procedures can be done in many anatomic areas. Endoscopes can be
introduced through natural body openings or porthole incisions that also allow surgical
instruments.
SURGICAL PROCEDURES (CONT…)
- Open procedures entail the typical opening of a bodily cavity to execute the surgery.
Because of the more comprehensive surgical technique, the patient may endure greater
postoperative discomfort and a longer recovery time. The extent and duration of the
procedure may also affect postoperative infection rates.
- Simple procedures are restricted to a particular anatomic site and don't involve
significant exposure and dissection.
- Radical procedures, generally linked with malignancies, require dissection of tissue

and structures beyond the operating site. In most cases, the surgeon removes lymph
nodes, muscle, and fascia that have been infiltrated by tumor.
COMMON SURGICAL SUFFIXES
> -ectonomy: Removal of an organ or gland
> -rrhaphy: Repair
> -ostonomy: Providing and opening (stoma)
> - otonomy: Cutting into
> - plasty: Formation or plastic repair
> - scopy: Looking into

Types of endoscopic, endoscopically assisted, and minimally invasive procedures
SURGICAL SPECIALTY PROCEDURE
GENERAL ADRENALECTOMY
MODIFIED WHIPPLE PROCEDURE
HERNIORRHAPHY
CHOLECYSTECTOMY
ORTHOPEDIC CARPAL TUNNEL RELEASE

DISKECTOMY
GYNECOLOGIC TUBAL LIGATION

HYSTEROSCOPY
Types of endoscopic, endoscopically assisted, and minimally invasive procedures
SURGICAL SPECIALTY PROCEDURE
EAR, NOSE, THROAT POLYPECTOMY

ETHMOIDECTOMY
UROLOGY PROSTATECTOMY
NEPHRECTOMY
CARDIOTHORACIC VALVE SURGERY

MEDIASTINOSCOPY
CORONARY ARTERY BYPASS
NEUROSURGICAL PITITUARY SURGERY

OPTIC NERVE DECOMPRESSION
SURGICAL PROCEDURES
TYPE OF SURGERY
(PURPOSE)
Surgical procedures may be classified according to their indications
Diagnostic procedure used to discover a problem's source.
Curative surgery removes diseased or unhealthy tissue.
Restorative or reconstructive surgery corrects deformities, repairs injuries, and improves

function.
SURGICAL PROCEDURES
TYPE OF SURGERY (cont…)
(PURPOSE)
Surgical procedures may be classified according to their indications
Palliative procedures alleviate symptoms without curing.
Ablative surgery removes tissue that may aggravate a patient's disease (e.g., an
orchiectomy performed for a patient with prostate cancer).
Cosmetic surgery is performed with the goal of improving one's appearance.

SURGICAL PROCEDURES
TYPE OF SURGERY
(ANATOMIC SITE)
There is also a method of classifying surgical procedures based on
the location of body parts or systems, such as cardiovascular
surgery, chest surgery, intestinal surgery, and neurologic surgery.
SURGICAL PROCEDURES
TYPE OF SURGERY
(TIMING OR PHYSICAL SETTING)
Elective- surgical procedures that are planned but nonessential
Urgent- procedures that are unplanned and require timely intervention, but do not pose an
immediate threat to life.
Emergent procedures- must be performed immediately to preserve life and limb.
Ambulatory surgery - does not require inpatient admission and may be performed with the patient
under general, local, or regional anesthesia. The patient is admitted to the facility on the day of
surgery, remains for postoperative care, and is discharged within 23 hours
SURGICAL PROCEDURES
TYPE OF SURGERY (cont…)
(TIMING OR PHYSICAL SETTING)
Terms associated with this type of admission include:
- to be admitted (TBA)
- same day admit (SDA)
- and to come in (TCI)

SPECIAL CONSIDERATIONS FOR PATIENTS IN SURGICAL SETTINGS
Neuroendocrine Response
❖ increase heart rate and blood pressure

❖ increased blood flow to the brain and vital organs
❖ decreased motility and blood flow to the gastrointestinal tract
❖ increased gastric acid production
❖ elevated blood glucose
❖ increased respiratory rate
❖ increased perspiration and piloerection
❖ dilation of pupils
❖ platelet aggregation
Psychologic Response
❖ Anxiety is a normal adaptive response to the stress of surgery

❖ Potential sources of anxiety include anticipation of impending surgery, pain and discomfort,
changes in body image or function, role changes, loss of control, family concerns, or potential
alterations in lifestyle.
❖ Physiologic manifestations of anxiety include increased pulse and respiratory rate, increased
blood pressure, abdominal distress, and increased urinary frequency
❖ Other fears have to do with the type, extent, and purpose of the surgery. Fears of pain,
disfigurement, disability, or death may be based on reality or on the experiences of others or
on a lack of information.
Sociologic Response
❖ Inability to work may be problem for both patient and family
❖ Job security and financial stress
❖ Family members often experience more anxiety than the patient
❖ Personal surgery and anesthetic experiences may affect family
perspective.
LEGAL AND ETHICAL ISSUES
Informed Consent
The informed consent process protects a

patient's right to self-determination and
autonomy regarding surgical intervention.
❖ The patient understands the nature of

the procedure and probable outcomes.
❖ The physician must tell the patient of
the risks and advantages of the surgery.
Perioperative Nurses’ Role
❖ Nurse assesses the patient's decision-making

capacity
❖ Confirms that the patient has been given the
necessary information to give informed
consent
❖ Clarifies any misconceptions
The AORN's explications of the ANA Code of

Ethics emphasize the nurse's ethical role to
check that the doctor has adequate permission
for surgery. In addition to the surgeon, the
anesthesia provider must disclose the risks and
advantages of any aesthetic agents or drugs
used during the treatment. The Joint
Commission on Accreditation of Healthcare
Organization (JCAHO) requires anesthesia
providers to get informed consent about
anesthesia hazards.
Advanced Directives
The Patient Self-Determination Act of 1991

(PSDA) compels healthcare practitioners to
notify patients of their decision-making
rights. Advance directives are created in
accordance with state law and enable a
person to designate treatment choices if he
or she cannot make autonomous health
care decisions.
Do-Not-Resuscitate Orders
A do-not-resuscitate order, or DNR order, is a doctor's

written instruction not to do CPR if a patient's
breathing stops or heart stops beating.
The AORN's policy statement on preoperative

treatment of patients with DNR orders is backed by
the PSDA, JCAHO, the ANA code for Nurses, and "A
patient's bill of rights." The AORN policy statement
states that "reconsideration of DNR decisions with
patients is a vital part of surgical treatment."
Nursing Management
of the Patient in the
Preoperative Period
ASSESSMENT
Patient assessment begins during the
initial contact between patient and
nurse and continues throughout the
perioperative period.
Health History
The nurse compiles a complete health history
to identify factors that may increase surgical
risk or contribute to postoperative
complications
The main goal of preoperative assessment:

“to identify individuals at risk for
intraoperative and postoperative
complications and implement
interventions to decrease risk and
improve surgical outcomes”
Assess for:
Ability to
Medications Herbs and Availability
Cultural and perform
and nutritional
Allergies substance supplements
religious of social ADLs
preferences support (functional
abuse use
assessment)
Actual
Presence of Previous knowledge
and Degree of
preexisting surgical and
Anxiety or systemic anesthetic
understanding Pain surgical
of
disease experience perioperative
risk
experience
Assess for:
Ability to
and nutritional
abuse use
assessment)
Actual
and Degree of
of
risk
experience
Assess for: ALLERGIES
The nurse should assess the patient for allergies to iodine,

medications, latex, cleaning solutions, and adhesive tapes. The
nurse should document the type of reaction in the patient’s record.
Assess for:
Medications Ability to
Herbs and Availability
and Cultural and perform
nutritional
abuse use
assessment)
Actual
and Degree of
of
risk
experience
Assess for: MEDICATIONS AND SUBSTANCE ABUSE
The nurse must collect data on the history of smoking, substance

use, and prescribed and over-the-counter (OTC) medications.
These substances may have potential adverse interactions with some
anesthetic agents that can increase risk for perioperative
complications.
Medications and Substance Abuse
Check for history of Reason Nursing Management
Smokers have increased risk for Inform patients about smoking

cardiopulmonary and wound cessation benefits and smoking
Smoking
complications as compared to cessation techniques during
nonsmokers. pre-admission interview.
Can alter effects of anesthetic and
Obtain an accurate history of
Drug & Alcohol Use analgesic agents, which requires
recreational drug use and history of
(Substance Abuse) adjustments of the recommended
alcohol consumption.
dosage.
Many prescription and OTC meds may Obtain an accurate and complete
Medication Use affect drug interactions, adverse side medication history (prescribed and OTC
(Prescribed & OTC) effects, anesthetic agent interactions meds), most importantly with older
or surgery reactions. adult patients.
Assess for:
Herbs and Ability to
Medications Availability
nutritional Cultural and perform
and
abuse use assessment)
Actual
and Degree of
of
risk
experience
Assess for: HERBS AND NUTRITIONAL SUPPLEMENTS
Herbs (botanicals/nutraceuticals/phytomedicines) are medicinal plants possessing
pharmacologic properties which is classified as dietary supplements rather than medications in
the United States.
In 1994, the Dietary Supplement Health and Education Act established regulations wherein
the FDA can restrict use of dietary supplement only if proven unsafe.
● Many consumers wrongly assume that all herbal products are safe and do not realize the
implications of their use, side effects and potential drug-herb interactions.
Therefore, the preoperative assessment must include specific questions regarding the
use of herbal products and other complementary and alternative therapies.
Herbs and Nutritional Supplements
● According to the American Society of Anesthesiologists (ASA), patients should

discontinue use of herbal medications at least 2 to 3 weeks before surgery.
● Some patients may still be taking herb medication at the time of surgery, therefore, the
perioperative nurse must know of the common names, actions, side effects, drug-herb
interactions, and perioperative implications of commonly used herbal products.
● The nurse should also ask about vitamin usage. Vitamin E may increase risk of
bleeding, particularly in patients taking anticoagulants.
Assess for:
Medications Herbs and Cultural and Ability to
Availability perform
and nutritional religious
Allergies substance supplements preferences
of social ADLs
support (functional
abuse use
assessment)
Actual
and Degree of
of
risk
experience
Assess for: CULTURAL AND RELIGIOUS PREFERENCES
Cultural and religious awareness can enhance the nurse’s
knowledge on how his patient and family may perceive the surgical
experience.
The nurse should arrange for an

Patient has language barrier
Culture interpreter to be present throughout
problems
the perioperative process.
The nurse should support the

Religion Patient is a Jehovah’s Witness patient’s refusal to receive blood
transfusions.
Assess for:
Ability to
and nutritional
abuse use
assessment)
Actual
and Degree of
of
risk
experience
Assess for: SOCIAL SUPPORT
Assessment of the patient’s social situation, family, and significant others is necessary to
coordinate postoperative care, discharge and follow-up care.
During the preoperative interview, the nurse should assess and evaluate for:
● the patient’s role in the family and social support network so the nurse can
assist them in coping up with the events to come.
● the patient’s financial status and insurance coverage because these factors
may have considerable implications for the immediate surgical intervention, hospitalization
and follow-up care.
Assess for:
Ability to
Medications Herbs and Availability perform
Cultural and
and nutritional
Allergies religious of social ADLs
substance supplements
use preferences support (functional
abuse
assessment)
Actual
and Degree of
of
risk
experience
Assess for: FUNCTIONAL ASSESSMENT
To assess ability to perform ADLs, the nurse can interview the patient or use a
standardized tool such as the
Sickness Impact Profile.
The nurse should assess potential discharge needs during preoperative

evaluation such as:
● If patient needs assistance with ADLs, a caregiver(s) should be identified

● If patient may experience change in role or loss of independence, patient and
family may be provided with counseling and support.
Assess for:
Ability to
and nutritional
abuse use
assessment)
Actual
and Degree of
of
risk
experience
Assess for: LEVEL OF ANXIETY
Anxiety is a common response to surgical intervention stressors.
It results to elevated levels of cortisol and adrenaline, but if
unmanaged or prolonged, would lead to:
● increased protein breakdown
● decreased wound healing
● increased risk of infection
● altered immune response
● fluid and electrolyte imbalances.
Assess for:
Ability to
and nutritional
abuse use
assessment)
Actual
and Degree of
of
experience risk
disease perioperative
experience
Assess for: MEDICAL HISTORY
The medical history should focus on pre-existing medical conditions that contribute to
increased perioperative risk.
The nurse should:

● obtain a complete and accurate family history to identify cardiac disease risk factors
● take a thorough review of systems to collect data on all body systems
● inquire about past hospitalizations and illnesses and collect data to determine presence
of any systemic or chronic disease
MEDICAL HISTORY
CARDIAC STATUS
Major Clinical Predictors to Identify Patients at Risk for
Perioperative Cardiac Complications:
● Angina
● History of myocardial infarction
● Congestive Heart Failure (CHF)
● Hypertension
● Symptomatic arrhythmias
Major Clinical Predictors to Identify Patients at Risk for Perioperative Cardiac Complications
ANGINA
● The health history must include questions about the:
- presence and severity of chest pain or angina at rest, during
physical activity and with exercise.
- history of excessive or unexplained fatigue, palpitations and
syncope.
● Patients with unstable angina should be referred for cardiac
clearance before surgery happens.
HISTORY OF MYOCARDIAL INFARCTION
● In the case of patient had history of myocardial infarction within
the past 6 months, surgery may be delayed or cancelled.
CONGESTIVE HEART FAILURE
● If the medication used to manage left-ventricular dysfunction is
digoxin, patient may be at risk for perioperative dysrhythmias. Patient
with dysrhythmias must be stabilized and controlled during the
preoperative period to reduce risk for surgical complications.
Major Clinical Predictors to Identify Patients at Risk for Perioperative Cardiac Complications
HYPERTENSION
● If patient with severe hypertension has been scheduled for an
elective surgery, surgery must be delayed until severe
hypertension is under control.
SYMPTOMATIC ARRHYTHMIAS
● The nurse must obtain data on the patient’s history of prosthetic
heart valves, valvular disease, cardiomyopathy, and bacterial
endocarditis.
● To prevent bacterial endocarditis, patients may need to take
antibiotics perioperatively.
MEDICAL HISTORY
PULMONARY STATUS
PERIOPERATIVE RISK FACTORS FOR
PULMONARY PULMONARY
COMPLICATIONS COMPLICATIONS
● Aspiration ● Smoking ● Type of surgery

● Pneumonia ● Advanced age
● Respiratory Failure ● Cough
● Bronchospasm ● Dyspnea
● Atelectasis ● COPD
● Hypoxemia ● Asthma
● Exacerbation of chronic lung ● Morbid Obesity
disease ● OSAHS
OBSTRUCTIVE SLEEP APNEA-HYPOPNEA SYNDROME (OSAHS)
- The nurse has to question the patient about history of sleeping problems or loud
snoring and to identify persons at risk.
- Additional monitoring and longer length of stay in the recovery room is required for
patients with known or suspected OSAHS.
- If the patient uses a continuous positive airway pressure device at home, he may be
asked to bring the machine on the day of surgery.
ASSESSMENT OF THE RESPIRATORY STATUS
- There must be questions about patient’s exercise intolerance, dyspnea on exertion,
unplanned dyspnea, cough, and increased sputum production.
- The nurse must assess the patient’s ability to climb the stairs and the number of stairs
that cause dyspnea.
MEDICAL HISTORY
RENAL STATUS
Kidney function decline can cause problems with the body’s

ability to excrete waste products, medications and anesthetic
agents.
During preoperative period, acute kidney failure (AKF) may

develop in patients who have preexisting renal insufficiency,
and even those without renal disease. Hypertension, sepsis,
and certain surgical procedures contribute to AKF, and
administration of nephrotoxic drugs or of contrast for
postoperative AKF.
MEDICAL HISTORY
HEPATIC STATUS
Important to assess because of the metabolic functions of the
liver.
Patients with liver dysfunction are at risk for:

● Hemorrhage ● Encephalopathy
● Altered pharmacokinetics ● Hepatitis
● Liver and kidney failure ● Infection
Elective surgery may be postponed if hepatic assessment

reveals acute, viral or alcoholic hepatitis or cirrhosis.
MEDICAL HISTORY
NEUROLOGIC STATUS
Perioperative stroke and delirium are the most common
neurologic complications.
Risk Factors for Perioperative Stroke:

● History of previous stroke or transient ischemic attack (TIA)
● Hypoperfusion
● Thromboembolism
● Carotid stenosis
● Aortic arch stenosis in older patients
● Recent myocardial infarction
● Atrial fibrillation
MEDICAL HISTORY
HEMATOLOGIC STATUS
Important to assess, most especially if the procedure has
expected blood loss.
The nurse must:

● Question the patient about history of anemia, bleeding
disorders and hematologic malignancies.
● Elicit a history of blood transfusions and any adverse
reactions to blood or blood products.
● Ask the patient if he did autologous donation.
● Obtain a thorough medication history, esp. meds that
inhibit platelet function.
● Consult with an anesthesiologist or surgeon if the
medications have to be discontinued before surgery.
MEDICAL HISTORY
ENDOCRINE FUNCTION
● The perioperative management of diabetes mellitus, a
common condition, is based on the type of diabetes and
treatment modality.
● Diabetic patients are at risk for delayed wound healing

and infection.
● Stabilization of blood glucose levels is the main goal of

managing patients in the perioperative period.
● Thyroid disorders are also common conditions that affect

outcomes of surgery of patients.
MEDICAL HISTORY
IMMUNOLOGIC STATUS
● Is important to assess because of the immune system’s

role in the body’s physiologic response to stress and
trauma.
● Decreased immune function leads to impaired wound

healing and infection.
● The nurse should question the patient about having

any history of risk factors for immunosuppression
such as cancer, diabetes mellitus, chemotherapy,
radio therapy, and long term steroid use.
MEDICAL HISTORY
NUTRITIONAL STATUS
Patients most likely to have deficits in their nutrition are older

adults and those who are chronically ill. The nurse must gather
data on patient’s nutritional status including:
● Any changes in appetite

● Fluctuations in weight
● Special dietary requirements
NUTRITIONAL STATUS
Malnourished patients
scheduled for
non-emergent surgery are
delayed and placed on
high-protein,
high-carbohydrate diet
before surgery and also
partnered with nutritional
supplements for at least
2 weeks before clinical
outcomes are improved.
Activity or exercise is also
required for protein
synthesis.
NUTRITIONAL STATUS
Obesity is often due to malnutrition from lack of appropriate

nutrient intake.
● Higher dose of anesthetic agents are required for
anesthesia maintenance.
● During surgery, vital signs fluctuation is common.
● During immediate postoperative period, obese patients
often need more assistance when turning, coughing and
deep breathing.
During the preoperative evaluation of obese patients, the nurse can
conduct a health teaching for the patient, providing information on:
● the benefits of maintaining an ideal body weight
● the benefits of following nutritional guidelines
● methods of weight reduction
Assess for:
Ability to
and nutritional
abuse use
assessment)
Actual
and Degree of
of
risk
experience
Assess for: SURGICAL AND ANESTHETIC HISTORY
Data on the patient’s previous surgical and anesthetic experience provides

information about reactions or complications to surgical procedures or
anesthetics.
The previous surgical experience of the patient’s family can also affect the
upcoming surgical event and influence physical and psychological responses to
the procedure.
Surgical and Anesthetic History
CHECK FOR NURSING INTERVENTIONS SIGNIFICANCE

● Ask about any problems with cervical
mobility, mouth opening, Having knowledge of the patient’s
Problems with airway dentures/loose teeth, and the previous problems with postoperative
maintenance and temporomandibular joint. nausea and vomiting can influence the
endotracheal intubation ● Assess for history of adverse reactions choice of anesthetic and analgesic
(such as nausea & vomiting) to medication.
anesthetic meds used perioperatively.
Helps to determine risk for serious
complications like malignant hyperthermia.
Patient’s anesthetic ● Elicit a family history of anesthetic
A positive family history may include
history complications.
sudden or unexplained death while patient
is under anesthesia.
If patient is prone to keloid formation,
Problems with incisions ● Question the patient for any problems
surgeon may inject corticosteroid to
and wound healing with incisions or wound healing.
reduce scar tissue formation.
Assess for:
Ability to
and nutritional
abuse use
assessment)
Actual
Presence of Previous knowledge and Degree of
preexisting surgical and understanding
Anxiety or systemic anesthetic of perioperative Pain surgical
disease experience experience risk
Assess for: PERCEPTION OF SURGICAL PROCEDURE
Knowing about the patient’s level of understanding of the surgical event is required before any
health teaching happens.
The nurse’s responsibilities:

● determine patient’s understanding of the proposed surgical procedure, postoperative
routine and expected outcomes.
● assess the patient’s informed consent
● clarify any misunderstandings and misconceptions, and if further information is
needed, refer the patient to the surgeon
Assess for:
Ability to
and nutritional
abuse use
assessment)
Actual
and Degree of
of
risk
experience
Assess for: PERCEPTION OF PAIN
All patients must have their pain assessed and properly managed.
● The nurse should perform a complete assessment for pain.

● The nurse must provide the patient with postoperative discharge pain
management instructions.
● The family should be included in the assessment and pain management
plan.
Preoperative pain assessment data will serve as a baseline data for

comparison of the patient’s postoperative pain level.
Assess for:
Ability to
and nutritional
abuse use
assessment)
Actual
Presence of Previous knowledge Degree
and of
understanding Pain
of surgical
experience
risk
Assess for: ASSESSMENT OF SURGICAL RISK
There are variables that influence patients’ responses throughout the entire
surgical experience, including age, the presence of chronic disease or
disabilities, impaired nutritional status, and type of surgical procedure.
VARIABLES TO ASSESS SURGICAL RISK
AGE AMERICAN SOCIETY OF

ANESTHESIOLOGISTS STATUS
Age affects surgical and Developed in 1963, the degree of risk
postoperative risk, complications and is determined based on the number
outcomes. Ages 30-40 experience and severity of preexisting medical
decrease of the functional capacity conditions. Higher ASA score means
of their organ system. increased risk of perioperative
complications and death.
PHYSICAL (P) STATUS CLASSIFICATIONS OF AMERICAN SOCIETY OF ANESTHESIOLOGISTS
Status Definition Description and Examples
No physiologic, psychologic, biochemical, or organic
P1 A normal healthy patient
disturbance
Cardiovascular disease with minimal restriction on
P2 A patient with mild systemic disease activity, hypertension, asthma, chronic bronchitis,
obesity or diabetes mellitus
Cardiovascular or pulmonary disease that limits activity;
A patient with severe systemic disease that severe diabetes with systemic complications; history of
P3
limits activity, but is not incapacitating myocardial infarction, angina pectoris, or poorly
controlled hypertension
A patient with severe systemic disease that is Severe cardiac, pulmonary, renal, hepatic, or endocrine
P4
constant threat to life dysfunction
Surgery done as last recourse or resuscitative effort;
A moribund patient who is not expected to
P5 major multisystem or cerebral trauma, ruptured
survive 24 hours with or without operation
aneurysm, or large pulmonary embolus
A patient declared brain dead whose organs
P6
are being removed for donor purposes
PHYSICAL
EXAMINATION
This is performed by the
preadmission staff (physician or
advanced practice nurse), anesthesia
provider, and nurse.
PHYSICAL EXAMINATION
● This focuses on the risk factors for cardiovascular, pulmonary
and infectious complications. Specifically, the patient is
evaluated for cardiopulmonary dysfunction.
● The patient’s functional capacity, specifically ability to do ADLs,

and the patient’s general mobility status is assessed.
● The airway, respiratory status (including lung auscultation), and

cardiovascular status is physically examined by the anesthesia
provider.
The nurse performs
Head-to-toe physical assessment
1. To obtain baseline data for

comparison during the intraoperative
and postoperative phases
2. To identify potential problems that

may require preventive nursing
interventions before surgery
● If patient has been hospitalized, the nurse must obtain the admission
history and its respective physical assessment.
● The nurse must assess and document preoperative vital signs.
● If in any case of any abnormalities in the patient’s physical assessment, the

nurse must document these and report to the attending surgeon and
anesthesiologist for further evaluation.
General survey
● Assess for Mood, Affect, Level of anxiety
● Functional status can be obtained by observing patient’s gait, ability to ambulate and
perform adls.
● Assess for use of any prostheses (artificial limbs or eyes, dentures, hearing aids)
CARDIOVASCULAR STATUS
● AUSCULTATE FOR HEART SOUNDS. NOTE FOR PRESENCE OF EXTRA SOUNDS, IRREGULAR RATE AND
RHYTHM OR ABNORMAL HEART MURMURS.
● AUSCULTATE THE CAROTIDS FOR BRUITS
● ASSESS FOR JUGULAR VENOUS DISTENTION AND EDEMA
● INSPECT AND PALPATE EXTREMITIES FOR PRESENCE AND QUALITY OF PERIPHERAL PULSES, CAPILLARY
REFILL, WARMTH, COLOR AND EDEMA.
RESPIRATORY STATUS (assess for)
● respiratory rate NEUROLOGIC STATUS (assess for)
● Effort ● Level of consciousness
● Rhythm ● Orientation
● Chest excursion ● Motor and sensory function
● Use of accessory muscles ● Vision, hearing and sensation
● Auscultation of breath sounds deficits/problems
● Pulse oximetry
musculoskeletal STATUS (assess for)
● Abnormalities in joint structure
and function
● Range of motion (rom)
INTEGUMENTARY STATUS (assess for) HYDRATION STATUS TO CHECK FOR
● SKIN INTEGRITY POTENTIAL ALTERATIONS IN FLUID VOLUME
● PRESENCE OF PRESSURE ULCERS BALANCE
● BREAKS IN THE SKIN (SIGNS OF HYDRATION)
● DECREASED SUBCUTANEOUS TISSUE ● NOT WITHIN IDEAL WEIGHT
● DECREASED MUSCLE TONE
NUTRITIONAL STATUS (assess for) ● LACK OF SUBCUTANEOUS TISSUE
● HEIGHT ● DRY AND FLAKY SKIN
● WEIGHT ● BRITTLE NAILS
● BODY MASS INDEX (BMI) ● DECREASED SKIN TURGOR
● LOOSE TEETH ● DRY MUCOUS MEMBRANES
● IMPROPERLY FIT DENTURES ● EDEMA
● POOR DENTITION ● ADVENTITIOUS BREATH SOUNDS
DIAGNOSTICS
Laboratory and diagnostic testing is
performed before patient is cleared
for surgery.
DIAGNOSTICS
Factors that determine the extent of laboratory testing:
● Age
● Physical condition
● Type of procedure and anesthetic
● Institutional requirements
DIAGNOSTICS 2. Chest Radiography
1. Electrocardiogram
Male patients over
40 years old and
female patients
over 50 years old
are required for
electrocardiogram
because of high
incidents of
coronary artery May be indicated for
disease. patients at high risk for
pulmonary complications.
COMMON PREOPERATIVE DIAGNOSTIC TESTS
Test Indications Possible Findings
Procedures with anticipated significant Baseline hematologic function
Complete blood count blood loss Anemia
with differential Chronic illness or disease Infection
History of infection Blood dyscrasias
Age over 60 years (age may vary with institutional Electrolyte imbalance
protocol) Acid-base imbalance
Basic metabolic panel
Cardiac disease Hydration status
(blood urea nitrogen,
Chronic disease Renal function
creatinine, chloride,
Renal disease Hepatic function
sodium and CO2)
Liver disease Hypoglycemia
Use of diuretics Hyperglycemia (with fasting glucose)
Coagulation studies
Bleeding disorders Baseline coagulation status
(prothrombin time,
Anticoagulant use Risk of perioperative bleeding
partial thromboplastin
Procedures with anticipated significant blood loss Response to anticoagulant therapy
time, international
Liver disease Liver disease
normalized ratio)
History of liver disease Hepatic function
Liver enzymes
History of current alcohol abuse
Women of childbearing years Pregnancy status
Beta-human chorionic Men over 40 years old Cardiac rhythm
gonadatropin 12-lead Women over 50 years old Dysrhythmias
electrocardiogram History of cardiac disease Ischemia
Abnormal cardiac examination Infarct
History of pulmonary disease Heart size
Thoracic surgical procedures Chronic obstructive pulmonary disease
Significant smoking history (per institutional Pneumonia
Chest radiograph
protocol) Structural abnormalities
Abnormal findings on auscultation Heart failure
Acute respiratory symptoms
Establish baseline pulmonary function Obstructive or restrictive lung disease
Evaluate or predict risk for perioperative
Pulmonary function complications
tests History of pulmonary disease
Significant smoking history (per institutional
policy)
Procedures involving instrumentation of urinary
Urinary tract infection
Urinalysis tract
Kidney disease
Urologic symptoms
DIAGNOSTICS
If surgical blood loss is expected, the patient’s
blood sample is sent for type and screen or type
and cross-matching so when transfusion is
needed during and after surgery, packed RBCs
are available for use.
In the case of elective surgery, the patient may
choose to do autologous donation. Hematocrit
level must be at least 34% and WBC must be
below 12,000/mm3. Donations must be 3 days
before surgery and blood can be used up to 36
days after donation.
NURSING DIAGNOSIS, OUTCOMES,
AND INTERVENTIONS
NURSING DIAGNOSIS: ANXIETY
OUTCOMES NURSING INTERVENTIONS
● Patient will describe techniques to ● Patient and family education

control anxiety (perioperative teaching)
● Report an increase in psychological ● Empowering patients by increasing their
comfort sense of control before surgery
● Verbalize an understanding of ● Teach activities such as deep breathing,
perioperative routines relaxation exercises, music therapy and
guided imagery
● Provide psychological support
NURSING DIAGNOSIS: RISK FOR INEFFECTIVE AIRWAY CLEARANCE
● Patient will demonstrate effective ● Teaching the necessity of deep breathing

coughing. and coughing exercises
● Demonstrate satisfactory performance of ● Use of an incentive spirometry device
postoperative respiratory exercises.
Deep Breathing and Coughing Exercise
Deep Breathing Coughing
1. Lie in semi-fowler’s or high Fowler’s

position with knees flexed to relax
abdomen and allow full chest expansion.
1. Breathe in as described previously.
2. Place hand lightly on the abdomen
2. Count to 3.
3. Breathe in slowly through the nose,
3. On “3” cough deeply three times.
letting chest expand and feeling
4. If unable to cough deeply, do repeat
abdomen rise against hand
“huff” coughs (forced expiration
4. Hold breath for 3 seconds
with glottis open)
5. Exhale slowly through pursed lips
6. Repeat deep breathing three times, then
cough.
NURSING DIAGNOSIS: RISK FOR INEFFECTIVE PERIPHERAL TISSUE PERFUSION
● Patient will verbalize knowledge of ● Promote adequate peripheral circulation

treatment regimen by using antiembolism hose, pneumatic
● Demonstrate correct performance of compression devices, doing leg
postoperative exercises. exercises, early ambulation, adequate
hydration and deep breathing.
Final Preparations for Surgery
● Patients belongings are ● Eyeglasses and prosthesis

identified and secured should be removed, labeled
● Patient needs to wear and placed in safe keeping
hospital gowns and remove ● Patients are allowed to wear
all personal clothing hearing aids to the surgical
● If patient is wearing nail suite to communicate with
polish or artificial nails, allow the surgical team throughout
one or more fingernails to be the perioperative period.
exposed for accurate ● Thoroughly review the
assessment of capillary refill medical record and operative
and pulse oximetry. consent
● Remove jewelries
Premedication
Purpose/s: Purpose/s:
● Decrease anxiety ● Decrease nausea

and provide and vomiting
sedation ● Relieve pain and
● Decrease secretion discomfort
of saliva and gastric
juices
● Decrease gastric
volume and acidity
Preoperative Checklist
Summarization of patient data and final preparation for surgery
Documentation
● Nurses reports, records (biopsychosocial assessment data,
preoperative teaching content, family’s responses. Vital
signs, medications, lab and diagnostic are part of patient’s
medical record
Legal Alert 🚨
JCAHO Universal Protocol for Preventing Wrong Site, Wrong Procedure, and
Wrong Person Surgery
Legal Alert 🚨
Preoperative Patient Verification
Confirm and verify the ff: Patient responses must match:
● Patient’s name on ID band ● Marked site

● Date of birth ● ID band
● Medical record number ● Consent forms
● Consent forms ● Radiologic examinations
● Availability of implant needed ● Scheduled procedure
● Availability of blood
● Radiologic examinations
Site Marking
● Site is marked with a permanent marker that is visible after the skin is prepped
and draped.
● Operating surgeon marks the site with his or her initials before the patient
enters the OR suite.
● Site is marked with patient participation (i.e., verbal confirmation or pointing)
● A patient has the right to refuse to mark the site. Each institution will determine
the policy for these situations.
COMMON
MEDICATIONS
Administered Before
Surgery
COMMON MEDICATIONS Administered Before Surgery
—cont’d

Perioperative Nursing

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Perioperative Nursing

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Preoperative

● Many surgeries were done at home in the

Perioperative Nursing Phases

The professional practice of perioperative

- the health system,

● The Association of periOperative Registered

In 2000, AORN members created the Perioperative Nursing

- A framework for standardized documentation and

- The measurement and evaluation of patient care

- A basis for perioperative nursing research

- Validation of the contributions of perioperative nurses

Surgery is characterized by:

(EXTENT OF THE SURGICAL PROCEDURE)

- Radical procedures, generally linked with malignancies, require dissection of tissue

> -ectonomy: Removal of an organ or gland

> -rrhaphy: Repair

> -ostonomy: Providing and opening (stoma)

> - otonomy: Cutting into

> - plasty: Formation or plastic repair

> - scopy: Looking into

SURGICAL SPECIALTY PROCEDURE

ORTHOPEDIC CARPAL TUNNEL RELEASE

GYNECOLOGIC TUBAL LIGATION

SURGICAL SPECIALTY PROCEDURE

EAR, NOSE, THROAT POLYPECTOMY

CARDIOTHORACIC VALVE SURGERY

NEUROSURGICAL PITITUARY SURGERY

Surgical procedures may be classified according to their indications

Diagnostic procedure used to discover a problem's source.

Curative surgery removes diseased or unhealthy tissue.

Restorative or reconstructive surgery corrects deformities, repairs injuries, and improves

Surgical procedures may be classified according to their indications

Palliative procedures alleviate symptoms without curing.

Cosmetic surgery is performed with the goal of improving one's appearance.

Emergent procedures- must be performed immediately to preserve life and limb.

(TIMING OR PHYSICAL SETTING)

Terms associated with this type of admission include:

- same day admit (SDA)

- and to come in (TCI)

❖ increase heart rate and blood pressure

❖ Anxiety is a normal adaptive response to the stress of surgery

The informed consent process protects a

❖ The patient understands the nature of

Perioperative Nurses’ Role

❖ Nurse assesses the patient's decision-making

The AORN's explications of the ANA Code of

The Patient Self-Determination Act of 1991

A do-not-resuscitate order, or DNR order, is a doctor's

The AORN's policy statement on preoperative

The main goal of preoperative assessment:

The nurse should assess the patient for allergies to iodine,

The nurse must collect data on the history of smoking, substance

Smokers have increased risk for Inform patients about smoking

● According to the American Society of Anesthesiologists (ASA), patients should

The nurse should arrange for an

The nurse should support the

Sickness Impact Profile.

The nurse should assess potential discharge needs during preoperative

● If patient needs assistance with ADLs, a caregiver(s) should be identified