responding to the needs of the perioperative client

Responding to the Needs of thePerioperative Client

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COMPETENCIES

1. Discuss the three phases of the perioperative experience in relation to the client’s expected outcomes and the major functional roles ofthe nurse.

2. Assess the physiological, psychological, social, cultural, spiritual, and age-related aspects of the perioperative client’s health status.

3. Recognize sociocultural and ethical factors that affect decision making in planning care with the perioperative client.

4. Demonstrate an awareness of age-related functions and values whenassessing and teaching clients.

5. Plan, implement, and evaluate the nursing care outcomes for perioperative clients in various health care settings.

6. Document nursing interventions that achieve the individualized expected outcomes for perioperative clients.

7. Describe essential components of discharge teaching for the perioperative client.

Life’s not just living, it’s living in health.—Guterman (1960)

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742 UNIT VI Diagnostic and Therapeutic Interventions

Perioperative refers to the management and treat-ment of the client during the three phases of surgery:preoperative, intraoperative, and postoperative. Thethree perioperative phases are designated by time inter-vals, interventions, and settings, using the word roots ofpre—before; intra—during, and post—after. Preop-erative (before surgery) refers to the time interval thatbegins when the decision is made for surgery until theclient is transferred to the operating room (OR). The intraoperative (during surgery) phase begins whenthe client is transferred to the OR and ends with clienttransfer to a postanesthesia care unit (PACU). When theclient leaves the OR and is taken to a PACU, the post-operative (after surgery) phase begins; this phase con-tinues until the client is discharged from the care of thesurgeon.

Changes have occurred in perioperative services as aresult of advances in technology (such as lasers) andlimited resources such as cost-containment measures inhealth care. These changes have challenged health careproviders to be more responsive and cost-effective indelivering perioperative services.

Surgery is a major source of a hospital’s income.Although major surgical interventions still occur in thehospital setting, the 1980s introduced a trend to per-form surgery in ambulatory settings. Many of the serv-ices of the hospital’s perioperative departments are nowperformed in outpatient settings. This change has had apositive impact on decreasing health care costs relatedto surgery. At the same time, health care providers arechallenged to work in greater collaboration to decreasethe client’s length of stay in the hospital, increase satis-faction with the services, and prevent complications.

Ambulatory surgery clinics (free-standing facilities)also began in the 1980s as an outgrowth of federally reg-ulated reforms from the Health Care FinancingAdministration (HCFA). HCFA’s goal in health carereform was to decrease inpatient costs of services.Except for inpatient hospitalization, ambulatory surgeryclinics provide all the services offered by hospitals.

In 1989, HCFA developed a listing of urgent and elective surgeries that require preauthorization forMedicare clients. Preauthorization means the surgerymust be approved before surgery is performed toensure that Medicare and other third-party payers willreimburse the facility for incurred surgical costs.

SURGICAL INTERVENTIONS

Surgery is performed to correct an anatomical or physi-ological defect or to provide therapeutic interventions.Surgeries are categorized according to the degree ofurgency (timely intervention of surgery):

1. Emergency surgery requires immediate interventionto sustain life.

2. Urgent surgery dictates intervention as necessary tomaintain health in situations that are not life-threat-ening.

3. Elective surgery is usually performed at a time con-venient to the client, with the delay presenting nophysiological harm.

Once the degree of urgency is established, the reasonfor performing the surgical intervention is categorizedaccording to the expected outcome (see Table 30-1).

K E YT E R M S

anesthesiaarthroplastycontinuous passive motion

(CPM) deviceCullen’s signextubationincentive spirometersintraoperative

intubationlock-out intervalmalignant hyperthermiapatient-controlled analgesia

(PCA)perioperativepneumatic compression

device

postoperativepreoperativepulse oximetertranscutaneous electrical

nerve stimulation (TENS)urgency

TABLE 30-1Surgical Interventions Based on Expected Outcomes

Intervention Expected Outcome

Diagnostic/exploratory Determine the origin of presenting symptoms and extent of a disease process (e.g., biopsy)

Reconstructive Correct a disease process or improve cosmetic appearance (e.g., arthroplasty and rhinoplasty)

Curative Repair or remove a diseased organ or restore normal physiologicfunctioning (e.g., amputation or aneurysm repair)

Palliative Decrease the spread of the disease process to prolong life or to alleviate pain (e.g., colostomy or partial tumor removal)

Transplant Remove diseased tissue or organ and replace with functioning tissue or organ (e.g., kidney)

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CHAPTER 30 Responding to the Needs of the Perioperative Client 743

In a true emergency, saving the client’s life is the pri-mary goal. Stat blood work, including a type and cross-match, is performed while the client and the operatingroom are prepared for the surgery. Urgent and electivesurgeries allow the client and physician time to discussthe setting and scheduling of the surgery.

SETTING

Ambulatory care centers and physician offices are theusual settings for minor surgical procedures, such asremoval of skin lesions and laparoscopy for inspectionand biopsy. Outpatient surgery areas (one-day surgerycenters or free-standing ambulatory clinics) provide theclient and physician with alternative services for urgentand elective surgeries.

Outpatient surgical units focus on the needs of theclient and strive to expedite the rendering of serviceswith a preadmission visit. Preauthorization documentsfor Medicare or third-party insurance payers should beprocessed and approved before the preadmission visit.

During the preadmission visit, the nurse and anes-thetist perform the preoperative assessment and initiateteaching. Diagnostic tests are performed in the outpa-tient surgical unit as opposed to the traditional processof having a client go to the various hospital departmentsfor testing. Performing diagnostic testing in this fashionpromotes a sense of caring for the client’s needs anddecreases the preadmission time.

On the day of surgery, clients who have been pread-mitted go directly to an outpatient surgical unit, wherethey are prepared for surgery. Family members areencouraged to remain with the client while the clientawaits transfer to the operative area.

Perioperative care is initiated for the hospitalized clientwhen the decision is made for surgery. The client isreassessed and the nurse collaborates with the client inplanning the care. Client and family teaching is begun assoon as possible to allow time to reinforce the teaching.

Preparing a client for a surgical procedure requiresthe collaboration of many professionals. Specific roleresponsibilities focus on assessment, client and familyteaching, and interventions to promote client achieve-ment of expected outcomes.

PERIOPERATIVE MANAGEMENT OF CARE

Effective perioperative management is directed by a mul-tidisciplinary team in accordance with recognized stan-dards of care and individualized expected clientoutcomes. Institutional protocol, which defines how pro-cedures will be performed, is initiated in the preoperativephase and continues throughout the othe phases.

Each member of the health care team (surgeon,anesthetist, and nurse) has a specific role and responsi-

bility toward the perioperative client. Collaborationbetween all health care providers is essential in plan-ning client care. “Collaboration means that people withdifferent areas of expertise are working as equals todefine issues, design solutions, and achieve high qualityoutcome” (Rubenfeld & Scheffer, 1999, p. 352).

Surgeon ResponsibilitiesPhysicians are credentialed by health care facilities toperform surgery. The surgeon is the primary physicianthe nurse communicates with regarding client careneeds. Before surgery, the surgeon:

• Determines the need for the surgical intervention onthe basis of the client’s medical diagnosis and findingsfrom the medical history and physical examination

• Determines the surgical setting in collaboration withthe client

• Orders diagnostic tests only if directly correlated tothe procedure or client diagnosis (see the accompa-nying display)

• Obtains client’s consent for the surgical procedure• Teaches the client about the outcomes and risks of

the procedure

A major role function of the surgeon is explaining and doc-umenting evidence that the client understands the nature of the sur-gical procedure, the risk factors, and expected outcomes of the surgery.This is done with a surgical consent form, the client’s writtenpermission to allow the surgeon to provide surgery. Manystates, through statutory provisions, require physicians toperform and document client teaching. Once the clientdemonstrates understanding, the client signs the form, giv-ing permission for the specific surgical intervention.

Anesthesia Provider ResponsibilitiesThe anesthesia provider (anesthesiologist or certifiedregistered nurse anesthetist) actively participates ineach perioperative phase. The main role of the

COMMON DIAGNOSTIC TESTS

• Urinalysis• Complete blood count (CBC)• Prothrombin time (PT) and partial thromboplastin

time (PTT): Clients with known or suspected coagu-lation defects or to establish baseline information

• Chemistry profile: Clients with diseases that can alterelectrolytes

• Electrocardiogram (ECG)• Human immunodeficiency virus (HIV) testing: In

accordance with agency policy• Chest x-ray films: Clients over age 60 years, smokers,

or those scheduled for general anesthesia

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anesthesia provider is to ensure client safety relative tothe administration of anesthesia. The anesthesiaprovider:

• Obtains informed consent for anesthesia services• Performs a preanesthesia evaluation that includes a

thorough history, such as complications from previ-ous anesthesia, and physical examination (AmericanAssociation of Nurse Anesthetists [AANA], 1999a)

• Selects anesthetic agents• Teaches the client regarding the anesthetic medica-

tions, their side effects, and risk factors• Performs intubation (the insertion of an endotra-

cheal tube into the bronchus through the nose ormouth to ensure an airway) and extubation (theremoval of an endotracheal tube)

Most surgical procedures have predetermined anes-thetic agents based on policy; if there is a variance fromthe norm, the anesthetist seeks agreement with the sur-geon. The decision to use particular anesthetic agents isbased on the client’s health status, the surgical proce-dure, and anticipated duration of the surgery.

During the client interview, the anesthesiologistinquires about previous anesthesia experiences that canplace the client at risk such as connective tissue abnor-malities that suggest the presence of the autosomaldominant malignant hyperthermia (MH) gene.Malignant hyperthermia is a potentially lethal syndromecaused by a hypermetabolic state that is precipitated bythe administration of certain anesthetic agents, forexample, succinylcholine. When appropriate and feasi-ble, medical records from previous surgeries arereviewed as part of the preanesthesia examination.

Nurse ResponsibilitiesThe Association of periOperative Registered Nurses(AORN), formerly called the Association of OperatingRoom Nurses, promotes quality client care through thedevelopment of guidelines and standards of nursingpractice. AORN has also developed the PerioperativeNursing Data Set (PNDS) to standardize nursing termi-nology regarding the perioperative client experiencefrom preadmission until discharge to promote evidence-based practice. The PNDS is the first nursinglanguage developed by a specialty organization that hasbeen recognized by the American Nurses Association.

Perioperative nurses perform critical functions thatvary with specific surgical procedures and the uniqueneeds of individual clients to achieve positive client out-comes (Parker, Mimick, & Kee, 1999). Rubenfeld andScheffer (1999) identified three guiding principles forimplementing care based on professional standards:maintain client safety; provide effective care; and pro-vide care as efficiently as possible. These principles areincorporated into each phase of the perioperative stan-dards of nursing practice.

The nurse coordinates the client’s care in a timelyfashion to ensure safety and avoid surgical delays.Activities include:

• Scheduling the diagnostic tests• Verifying that all the necessary documents (e.g.,

signed consent form) are on the client’s medicalrecord

• Reporting abnormal diagnostic results to the sur-geon. Depending on the test results, treatment maybe instituted to correct any abnormalities or the sur-gery may be canceled

A major part of the nurse’s time is spent in preparingand teaching the client. Preoperative teaching is struc-tured to provide planned educational activities topresurgical clients or family (significant others) accord-ing to assessed anxiety and fear levels, as discussed laterin this chapter.

As technology becomes more sophisticated andhealth care resources become more limited, ethicalissues have become more complex (Schroeter, 1999).Ethical dilemmas are inherent in perioperative nursingsuch as lack of respect for the client’s dignity, withhold-ing information or lying to clients, inadequate consents,incompetent health care providers, and do-not-resuscitate(DNR) orders. These issues have implications for the management of care in perioperative settings.Schroeter (1999) studied the aspects of informed con-sent and the impaired or incompetent colleague in theperioperative practice setting, and determined thatperioperative nurses can accurately identify ethical situ-ations occurring in the environment and that the major-ity of the participants reported that they would takeaction. The ethical competency of perioperative nursesis paramount to ensure that safe, competent, and ethi-cal care is provided to all surgical clients.

ANESTHESIA

Anesthesia means the absence of pain. Anestheticagents render a person insensible to pain during surgi-cal, obstetric, and therapeutic or diagnostic procedures.Anesthesia requires a balancing of several agents to pro-vide sedation, analgesia, muscle relaxation, and anes-thesia for procedures of varying complexity. The typesof anesthesia and their effects are listed in Table 30-2.

General AnesthesiaGeneral anesthesia refers to the drug-induced state ofanalgesia, amnesia, muscle relaxation, and uncon-sciousness. General anesthesia represents a criticalexperience for surgical clients. The needs of theseclients require that perioperative nurses possess knowl-edge of the basic principles of general anesthesia.

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The common routes for administering general anes-thetics are inhalation and parenteral; other routes usedless frequently are oral and rectal. Inhalation agents areadministered in the form of gases or as vapors ofvolatile liquids through an anesthesia delivery systemand a face mask or endotracheal tube. Commonly usedinhalation agents that can produce all of the elementsof general anesthesia are listed in the accompanyingdisplay; these agents are absorbed by the lungs. Nitrousoxide (compressed gas) is both absorbed and elimi-nated by the lungs, whereas the percentage of volatileliquids varies in their excretion between the lungs andkidneys.

Although anesthesia is administered parenterally, ittakes several intravenous drugs to produce all of the ele-ments of general anesthesia. Injectable agents used forinduction or maintenance of anesthesia are from one ofthe following drug classifications: barbiturates, benzodi-azepines, narcotics, and neuromuscular blockingagents. See the accompanying display for commondrugs for each of these classifications.

TABLE 30-2Effects of Anesthetic Agents

Type of Anesthesia Effects

General anesthesia Expected result Total unconscious state, placement of a tube into the tracheaTechnique Intravenous injection or inhalationRisks Mouth or throat pain, hoarseness, injury to mouth or teeth, awareness

under anesthesia, injury to blood vessels, aspiration, pneumonia

Regional Anesthesia

Spinal or epidural Expected result Temporary decreased sensation or loss of feeling and movement to lower analgesic/anesthesia part of the body

Technique Drug injected through a needle or catheter placed either directly into the spinal canal (spinal or subarachnoid) or immediately outside the spinal canal (epidural)

Risks Headache, backache, buzzing in the ears, convulsions, infection, persistent weakness, numbness, residual pain, injury to blood vessels, completespinal

Major/minor nerve block Expected result Temporary loss of feeling or movement of a specific limb or areaTechnique Drug injected near multiple nerves or a plexus (major) or into or around a

nerve or small nerve group (minor) providing loss of sensation to the area of the procedure

Risks Infection, convulsions, weakness, persistent numbness, residual pain, injury to blood vessels

Intravenous regional anesthesia Expected results Temporary loss of feeling and movement of an extremityTechnique Drug injected into veins of arms or leg while using a tourniquetRisks Infection, convulsions, persistent numbness, residual pain, injury to

blood vessels

(Adapted with permission from the American Association of Nurse Anesthetists. [1999b]. Informed consent in anesthesia. Park Ridge, IL: Author.)

INHALATION GENERALANESTHETIC AGENTS

Volatile Liquids

• Halothane (Fluothane, Somnothane)• Methoxyflurane (Penthrane)• Enflurane (Ethrane)• Isoflurane (Forane)

COMMON INTRAVENOUS AGENTSUSED FOR GENERAL ANESTHESIA

• Barbiturates: methohexital sodium, thiamylal sodium,thiopental sodium

• Benzodiazepines: diazepam and midazolam• Narcotics: alfentanil hydrochloride, fentanyl, and

sufentanil citrate• Neuromuscular blocking agents: atracurium bresylate,

doxicurium chloride, gallamine triethiodide, meto-curine iodide, mivacurium chloride, pancuronium bro-mide, pipecuronium bromide, succinylcholine chloride,tubocurarine chloride, and vecuronium bromide

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Barbiturates provide a rapid induction of short dura-tion and are therefore used for invasive diagnostic andobstetric procedures and minor surgery. When barbitu-rates are contraindicated, other short-acting agents areused: ketamine or a nonbarbiturate drug (etomidate orpropofol). Neuromuscular blocking agents producemuscle relaxation required for select surgical proce-dures; these drugs vary in their duration of action.

The client’s individualized plan for balanced anesthe-sia may involve the concurrent or sequential use of manyagents. For instance, thoracic muscle relaxation that isrequired for lung surgery can be provided by intravenousadministration of a neuromuscular blocking agent.During the surgery, various types of vapors and gases mayalso be administered with oxygen to provide anesthesia.For abdominal surgery, muscle relaxation can be achievedby injecting a local anesthetic into the cerebrospinal fluid;after the abdominal anesthesia level is established, a short-acting barbiturate may be infused to provide general anes-thesia during the surgical procedure.

Although the incidence of drug toxicity in anesthesia israre, clients need to be informed about these inherentrisk factors. General anesthetic agents can induce anaphy-lactic reactions; the incidence is 1:4,500, with a mortalityrate of 6%, according to Khrais and Ouellette (1995).

Regional AnesthesiaThe increased use of balanced anesthesia for surgicalprocedures has made it increasingly important for peri-operative nurses to be knowledgeable about regionaland local anesthetic agents. Regional anesthesia blocksnerve impulse conduction to a specific area or region ofthe body to decrease intractable pain or to produce ananesthetic field without the loss of consciousness.

An analgesic/anesthesic state is obtained by injectinga local anesthetic solution along a specific nerve path(see the accompanying display for a list of commonlyused local anesthetic agents). Regional anesthesia canbe administered with or without sedation (refer to Table30-2 for the various techniques used in administeringregional anesthesia).

Local AnesthesiaLocal anesthesia refers to use of an anesthetic agent thatdisrupts sensation at the nerve endings. The two tech-niques used for administering local anesthesia are topi-cal and infiltration. Topical anesthesia is the directapplication of local anesthetics to tissues in the form ofointments, lotions, solutions, or sprays. After the use oforal anesthetic solutions (e.g., viscous lidocaine), fluidsand foods must be withheld until the gag reflex returns.

Infiltrate anesthesia refers to intradermal, subcutaneous,or submucosal injection to provide a circumscribed area ofanesthesia. This technique provides a local nerve block thatis used for suturing lacerations or extracting teeth.

PREOPERATIVE PHASE

The primary goal of preoperative nursing care is to placethe client in the best possible condition for surgerythrough careful assessment and thorough preparation.Assessment of the client’s status before surgery establishesbaseline data to direct interventions throughout the peri-operative phases. Each member of the health care teamhas identified functions relating to the assessment of theclient’s physiological, psychological, social, cultural, andspiritual status. The findings from the client’s assessment mustbe documented throughout the surgical experience.

AssessmentAssessment of the perioperative client includes a nursinghistory and physical examination. A complete assessmentis performed on the outpatient client during the pread-mission visit. On the day of surgery, the nurse conducts afocused assessment to ensure current, accurate data.

During the assessment process, the nurse evaluatesthe client’s level of anxiety and fear. Bulechek andMcClosky (1995) describe these feelings:

• Anxiety is a vague, uneasy feeling whose source isoften nonspecific or unknown to the client.

• Fear is a feeling of dread related to an identifiablesource that the client validates.

Anxiety also has well-defined physiological changes, suchas an increased heart rate, clammy hands, muscular ten-sion (especially in the neck muscles), and behavioral man-ifestations, such as rapid speech and irritability.

Nursing HistoryThe perioperative nursing history provides informationrelative to factors that can increase a client’s risk or influ-ence the expected surgical outcomes. Pertinent data areobtained from the client interview: medical historyincluding family history of anesthesia complications(malignant hypertension); medications; allergies; age-related factors; social, cultural, and spiritual concerns;and psychologic status. See Chapter 6 for more details.

COMMONLY USED LOCALANESTHETIC AGENTS

• Bupivacaine hydrochloride (Marcaine, Sensorcaine)• Chloroprocaine (Nesacaine, Nesacaine MPF)• Etidocaine hydrochloride (Duranest)• Lidocaine hydrochloride (Xylocaine)• Mepivacaine hydrochloride (Carbocaine, Polocaine)• Procaine hydrochloride (Novocain)• Tetracaine hydrochloride (Pontocaine)

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Nurses should conduct the interview in a quiet room,free from background noise. Many elderly clients havesome degree of high-tone hearing loss (Eiseman, 1996),so it is necessary to speak in a strong, clear voice.

Clients who have difficulty comprehending the surgi-cal procedure should have a responsible family memberpresent during the interview. A third person can helpclarify precisely what the nurse said and can interpretsuch instructions to other family members.

Medical HistoryThe nurse reviews the client’s medical record. The sur-geon’s history and physical findings provide pertinentdata regarding the reasons for surgery. If the client waspreviously hospitalized, the nurse obtains the previousmedical records to have available on the nursing unit.Hospitalization records are reviewed to gain an overviewof the client’s health status because preexisting medicalconditions can increase the client’s surgical risks.

During the interview, the nurse questions the clientregarding past illnesses and the main reason for seekingsurgical treatment. The client is asked to describe priorsurgeries and their dates. Any complications from a pre-vious surgery or anesthesia should be recorded.

It is important to note if the client has had priorblood transfusions or reactions. At this time the nursecan ascertain whether the client has objections to receiv-ing blood or blood products or has made arrangementsfor blood replacement. Some clients prefer to donatetheir own blood in advance so that it can be held inreserve if the need for it arises during surgery. Familymembers or friends may also donate blood to decreasethe cost to the client.

MedicationsDuring the nursing history, the nurse needs to assessexactly what drugs the client has been taking. Theclient’s response to questions about the use of alcohol,tobacco, “street drugs,” prescription, over-the-counterdrugs, and herbs should be documented because thesesubstances have surgical implications.

Certain prescription drugs (antihypertensives, tran-quilizers, steroids, and diuretics) can increase theclient’s anesthesia risks. Clients with chronic diseasesare likely to be taking numerous medications that cancause complications during the perioperative period(see the accompanying display).

HerbsQuestion clients regarding their use of herbal productsand supplements as part of the preoperative assessment.Certain herbal products and supplements may place theclient at risk if taken before surgery such as Ephedrasinica (Chinese ephedra or Ma Huang), St. John’s wort,and Feverfew.

Ephedra can produce the same side effects ofephedrine such as increased blood pressure and heartrate, insomnia and anxiety. St. John’s wort is used widelyas a mild to moderate antidepressant because of its abil-ity to inhibit monoamine oxidase (MAO). MAOinhibitors may interact with various types of anestheticagents. Feverfew inhibits platelet aggregation and mayaffect the client’s clotting time.

Although some herbal products may place the clientat risk during surgery, other herbs such as Bromelain canreduce healing time and pain following various surgicalprocedures. Bromelain is obtained from the pineappleplant and refers to a group of sulfur-containing enzymesthat digest protein (proteolytic enzymes or proteases).Murray (1995) addresses a double-blind study of personsundergoing oral surgery; bromelain reduced edema,inflammation, and pain when taken preoperatively.

AllergiesAllergies and sensitivities to foods, drugs, or other sub-stances should be documented on the assessmentrecord. Of special importance is questioning the clientabout allergies to iodine. Povidone-iodine, a commonantiseptic, is used to prepare the skin for surgery. Thenurse places a note regarding the client’s allergies on thefront of the chart to alert perioperative team members.

Age-Related ConsiderationsAge-related considerations are critical aspects of assess-ment (Eiseman, 1996). The client’s age and develop-mental stage can influence the ability to cope withsurgery. Age-related factors can also influence existinghealth care problems and the client’s response to sur-gery. For instance, infants are at risk during surgicalinterventions because their physiological functions areimmature. The infant’s ability to respond to stress is alsoaltered.

Morbidity and mortality rates for surgical clients overthe age of 90 are much higher than for those in the 70to 75 age group (Hogstel, 2001). Older clients may befearful of death, especially if this is their first hospital-ization or surgery. The risk of surgery for many olderclients is complicated by chronic disease processes;more than 100,000 clients over 65 years of age die

DRUGS THAT PLACESURGICAL CLIENTS AT RISK

• Aspirin: May increase bleeding• Antidepressants: May lower blood pressure during

anesthesia• Bromide in medications (e.g., Sominex): Can accu-

mulate and produce signs and symptoms of dementia• Drugs with anticholinergic effects: Increase the

potential for confusion• Steroids: Suppress immunity• Nonsteroidal anti-inflammatory medications:

Increase the risk of stress ulcers and displace otherdrugs from blood proteins

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postoperatively each year (Corey-Plett, 1995). Age-related risk factors for the older adult should beassessed on an individual basis. Hogstel (2001) contendsthat age should no longer be a major factor in decidingwhether or not surgery should be performed to prolonglife or to provide comfort for elderly clients. When eld-erly clients are adequately prepared for a noncompli-cated surgical procedure, they can tolerate many typesof surgeries as well as younger clients (Cory-Plett, 1995;Hogstel, 2001). However, studies have shown that, whenelderly clients are subjected to emergency surgeries orlong, complicated surgeries, their decreased ability toadapt to physical and psychological stress may have anegative surgical outcome (Eiseman, 1996). Since 50%of all emergency surgeries are on clients over 65 years ofage (Eiseman, 1996), nurses need to provide psycholog-ical support to assist the elderly client in coping with thestress of surgery.

Social and Cultural ConsiderationsData relative to the client’s social and cultural orienta-tion are incorporated into care. These data assist thenurse in selecting appropriate teaching methods. Manyfacilities provide interpreters to prevent language frombeing a communication barrier.

Cultural beliefs can influence a client’s perception ofsurgery. Listen to a client’s concerns expressed duringthe interview. Surgeries that cause changes in bodyimage can alter self-esteem. The client may worry aboutbeing sexually attractive or active after surgery. Thenurse may initiate discussion regarding sexual outcomesof surgery; encourage the client to verbalize fears inorder to increase adaptive coping.

Spiritual ConsiderationsClients must be provided the opportunity to expresstheir spiritual values and beliefs. Religious beliefs arediscussed and incorporated into the client’s plan ofcare. A client may ask to see a member of the clergybefore surgery. The beliefs of the client should berespected. The client has the right to refuse certain

types of interventions. For example, some religions donot allow the administration of blood products as treat-ment. When the client indicates that religious beliefsprevent blood administration, the health care teamshould identify alternative methods of treatment anddiscuss these with the client during the preoperativephase. Collaborating with the client preoperativelyhelps prevent ethical dilemmas from arising during theother perioperative phases in the event that the clientloses a large quantity of blood.

Psychosocial StatusA psychosocial evaluation is conducted with the clientand family by assessing their degree of understandingand anxiety regarding the surgical procedure (see theaccompanying display). Assess the client’s knowledge ofthe surgical procedure and the expected surgical out-comes. It is important that the client express agreementwith the surgical plan of care.

Physical AssessmentThe nurse assesses the client’s physiological health sta-tus by performing either a partial or a complete physicalexamination. The decision to conduct a partial or com-plete physical depends on the client’s health status rela-tive to the surgical procedure, the setting, and theamount of time available to gather pertinent data.

The nurse in an outpatient setting, on the day of sur-gery, usually performs a partial examination. Theclient’s medical record should be reviewed to ensurethat a complete nursing physical was conducted duringthe preadmission visit. The nurse should focus onobtaining pertinent assessment data to establish base-line parameters for prioritizing the client’s care. Theclient’s neurologic assessment is integrated throughoutthe interview and physical examination.

T H I N K A B O U T I TT H I N K A B O U T I TResponding to Client Altered Self-Image

As a student nurse, how can you assist the client inverbalizing fears about alterations in body image that havesexual implications? A 30-year-old woman is admitted forremoval of a cancerous breast. Her mother died at age 30from breast cancer. The client has been married for 5years and has a 3-week-old infant. Her husband is with her.You have to admit and interview the client for the nursinghistory. How would you approach the medical diagnosis?Would you feel comfortable helping this client verbalizeher fears?

ASSESSMENT QUESTIONS:PSYCHOSOCIAL STATUS

• Why are you having surgery?• When did this problem start?• What do you think caused this problem?• Has this caused any problems with your relationships

with others?• Has your problem prevented you from working?• Are you able to take care of your own needs?• Are you experiencing any discomfort or pain?• What are you expecting from this surgery?• Is there anything that you do not understand regard-

ing your surgery?• Are you worried about anything?• Will someone be available to assist you when you

return home?

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General SurveyObserve the client’s condition starting with the initialcontact. For instance, if the client walks into the unit,observe and note the client’s gait; note if assistance isneeded with ambulation. Does the client need assis-tance when transferred to a bed? When shaking theclient’s hand, note the strength and sensation of the hand grasp and the skin temperature. Coldness of thehand may indicate impaired circulation.

During the interview, assess the level of consciousnessand orientation. Does the client respond appropriatelyto your questions? Observe for signs of hearing impair-ment or loss of vision. Note if the client is wearingglasses.

Head and NeckWhile talking with the client, assess if eye contact ismaintained. Note the color of the sclera and inspect fordrainage from the eyes. Inspect the general condition ofthe scalp, noting alopecia or seborrheic dermatitis.Inspect the oral cavity, check for any loose teeth, andassess the tongue and mucous membranes (note colorand moisture). Observe the client’s lips and tongue(especially if client has a history of cardiac disease).Note if the client has dentures.

Inspect the neck and verify the strength of thecarotid pulses, one at a time; palpate jugular veins fordistension. If the client is a child or has cancer, palpatethe cervical lymph nodes. Assess for range of motion.

Upper ExtremitiesPalpate the client’s brachial and radial pulses bilaterally;note the rate and character of each pulse. Check thecapillary refill. Assess the skin; note the temperature,texture, and integrity. Assess for range of motion.

Anterior and Posterior Chest and AbdomenInspect and palpate the chest wall, noting the breathingpattern and expansion of the chest wall. Auscultateheart sounds and listen to anterior and posterior breathsounds; note crackles, gurgles, or wheezing.

Inspect the abdomen for distension and listen forbowel sounds in all four quadrants. Palpate the abdomenfor rigidity, enlarged organs, or rebound tenderness.

Lower ExtremitiesAssess the length and position of each leg. Palpate thebilateral strength of femoral, popliteal, and pedalpulses, noting the rate and character of each pulse.Assess the skin; note the temperature, texture, integrity,and the presence of edema. Check the capillary refill.Inspect the bony prominences of the ankles and feet.Assess for strength and sensation by having the clientbend the leg and push the foot against your hand. Assessfor range of motion. Clients scheduled for spinal anes-thesia should be assessed for gross motor function andstrength.

The nurse documents on the medical record andcommunicates to the health care team all significantassessment data. This information establishes baselineparameters to direct decision making throughout theperioperative phases.

Diagnosis The nurse formulates nursing diagnoses based on ananalysis of assessment data and the nature of surgery.Physical assessment findings are compared againstdiagnostic test results; for example, cardiovascularfindings are analyzed with blood chemistry and ECGresults.

N U R S I N G A L E R TSpinal AnesthesiaSpinal anesthesia causes temporary paralysis of the lowerextremities. Preoperative weakness or impaired movementof the lower extremities should be reported to nursescaring for clients recovering from spinal anesthesia;postoperatively this report prevents the recovery nursefrom making the wrong decisions when full motor functionfails to return.

ASSESSMENT

Mrs. Broussard, 69, was admitted to an outpatientsurgical unit for a total hip replacement (arthro-plasty). The surgeon explained the surgical proce-dure during her last office visit. Preauthorizationhas been granted for the surgery. Diagnostic test-ing, a comprehensive history and physical exami-nation, and postoperative exercise instructionswere performed during the preadmission visit.Mrs. Broussard has been suffering for 10 years withchronic degenerative arthritis. She has experi-enced increasing pain and loss of mobility in herleft hip for the past 6 months.

• In collecting data from Mrs. Broussard duringthe focused assessment, what types of informa-tion are essential for the development of a planof care for her on the day of surgery?

• Which baseline data should be obtained fromMrs. Broussard during the partial physical exam-ination?

• What further data should be collected at thistime?

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Selection of the most appropriate nursing diagnosisshould focus on the specific perioperative phase (seethe accompanying display). The diagnosis may be perti-nent to all three perioperative phases or to one or morephases.

For instance, as described in the Nursing ProcessHighlight, Mrs. Broussard is experiencing pain that iscaused from the degenerative changes in the hip joint asa result of arthritis. Although the surgeon will removethe diseased joint, Mrs. Broussard will continue to expe-rience pain. In fact, the pain may worsen for severalweeks postoperatively (Barrows, 1995). The most appro-priate diagnosis for Mrs. Broussard is Pain.Preoperatively, the pain is related to the degeneration ofthe hip joint; postoperatively, the pain is related toswelling at the surgery site.

Common nursing diagnoses for the preoperativeclient are Deficient Knowledge related to the surgery,Anxiety, and Fear. Clients and families view the perioper-ative experience differently on the basis of prior experi-ences and coping skills (Bulechek & McCloskey, 1995).Some clients are threatened; others consider the expe-rience to be a challenge. Some clients are highly anx-ious, whereas others experience a moderate degree ofanxiety. Besides the primary threat of surgery, clientsalso have to deal with separation from family and loss ofindependence.

Associated nursing diagnoses address the client’s pre-existing health condition. For instance, an associateddiagnosis for Mrs. Broussard is Impaired Physical Mobilityrelated to musculoskeletal impairment. This nursingdiagnosis would be initiated preoperatively andthroughout the perioperative experience.

Outcome Identificationand Planning The nurse develops goals with client-focused expectedoutcomes based on relevant nursing diagnoses. Nursescollaborate with other health care team members andthe client in establishing the goals and outcomes. Theoverall goal is to protect the client from injury related toanesthesia and surgery. The plan of care directs theselection of specific nursing interventions that promotethe client’s achievement of expected outcomes, forexample, client teaching.

The current health care system challenges the peri-operative nurse to be responsive to surgical clients whomay enter and exit the health care setting at variouspoints and with different experiences (Bulechek &McCloskey, 1995). Some clients are admitted to the hos-pital the day of surgery, some the evening before; somehave surgery as an outpatient. Some clients with generalanesthesia may be discharged the day of surgery.

Discharge planning needs are incorporated into theplan of care on admission. The following considerationsare included in discharge planning:

• Psychosocial and spiritual support systems and com-munity resources

• Financial aspects of the illness • The degree of illness or disability• Rehabilitation• Preventive care • Client teaching needs

Some clients need the services of a home health agencyon discharge. The perioperative nurse usually coordi-nates home care with the social worker.

ImplementationPreparing the client for surgery requires the nurse toperform multiple interventions within specific time con-straints. However, the nurse must remain responsive tothe client’s needs, demonstrating a caring attitude (seeFigure 30-1). Documentation tools are available to assistthe nurse in providing safe, timely preoperative care(e.g., the consent form and preoperative checklist).Active planning and intervention are necessary toreduce the risk for complications (Eliopoulos, 1999).

Surgical Consent FormAlthough surgeons are responsible for obtaininginformed consent, nurses should verify that consent hasbeen obtained before treatment begins. Consent isgiven only for the extent of action documented on theinformed consent. Nurses can identify problems withconsent when the client:

• Cannot explain the procedure or identify the risks• Signed the form more than 30 days before surgery• Had an unauthorized person sign the consent form• Did not sign the consent form

Figure 30-1 The nurse prepares a client for surgery. While thenurse was performing preoperative assessment, the client demon-strated pain through facial expression. What implications might theclient’s pain have on the surgery? What actions should the nursetake, considering the potential effects on the client’s perioperativeexperience?

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The nurse should notify the surgeon in the event thatany problems with consent are identified.

If the surgeon proceeds without appropriate consent,nursing administration should be notified and thenurse should make personal notations outside the med-ical record. This practice protects the nurse should thesituation be brought to court. If the client reverses adecision and decides against surgery, the nurse is obli-gated to inform the surgeon in order to preventunwanted treatment.

Preoperative ChecklistA checklist is a form that allows the nurse to insert acheckmark (√) beside symptoms or to fill in one or twowords in answer to a cue or a question. Although somevariations exist in how agencies format the preoperativechecklist, the forms usually have similar content.Nursing activities are usually designated by time inter-vals: “night before surgery” and “day of surgery.” Timedesignations help to prevent surgical delays that canincrease the client’s anxiety and the agency’s costs.Table 30-3 presents a sample preoperative checklist.

Although clients in outpatient settings arrive the dayof surgery, the nurse prepares the client’s medicalrecord the day before for necessary documentation asitemized in Table 30-3. This preparation ensures thatassessment, diagnostic tests, and teaching were done onthe preadmission visit and allows time to obtain missinginformation and to assess the need for reinforcement orreevaluation as necessary.

On the day of surgery, the nurse focuses on the imme-diate physical interventions to prepare the client for surgery. While admitting and preparing the client for sur-gery, the nurse uses this time to encourage the client to

PERIOPERATIVE NURSING DIAGNOSES

Preoperative Phase

Deficient Knowledge related to:

• Nature and purpose of the surgical procedure• Preoperative preparation to decrease postoperative

risks

Anxiety related to:

• Deficient knowledge of a new experience• Inherent risk factors of the surgical procedure and

anesthesia

Fear related to:

• The unknown• Effects of surgery on economic and employment status

Intraoperative Phase

Risk for Perioperative Positioning Injury related to:

• Sensory/perceptual disturbances due to anesthesia• Edema

Risk for Injury related to:

• Physical (equipment or sponge count)• Environmental• Positional

Risk for Infection related to:

• Invasive procedure• Imbalanced nutrition

Hypothermia related to:

• Exposure to cool environment• Decreased metabolic rate

Postoperative Phase

Ineffective Airway Clearance related to:

• Anesthesia (diminished cough reflex)• Increased pulmonary congestion

Ineffective Breathing Pattern related to:

• Pain• Decreased energy/fatigue

Ineffective Tissue Perfusion (Cardiopulmonary) related to:

• Anesthesia• Position or immobility

Deficient Fluid Volume related to:

• Active fluid volume loss• Inadequate fluid intake

Imbalanced Nutrition: Less Than Body Requirements relatedto:

• Anesthesia• Surgical manipulation of intestines

(continues)

PERIOPERATIVE NURSING DIAGNOSES (continued)

Urinary Retention related to:

• Anesthesia• Surgical manipulation of the bladder

Acute Pain related to:

• Surgical incision

Risk for Infection related to:

• Impaired skin integrity from surgical wound• Deficient knowledge of wound or drainage tube care

Situational Low Self-Esteem related to:

• Altered body image, effects of surgery• Dependence on others during recuperation from

surgery

(From North American Nursing Diagnosis Association. [2001].Nursing diagnoses: Definitions & classification. 2001–2002. Philadelphia:Author.)

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TABLE 30-3Preoperative Checklist

CK Comments Nurse(✓ ) CK (✓ )

COMPLETE NIGHT BEFORE SURGERY

List allergies

Procedure scheduled

Surgical permit signed/witnessed

History/physical on chart and/or dictated

Pre-anesthetic evaluation done

Able to state type and purpose of surgery

Demonstrates ability to perform: Deep breathing, turning and coughing exercises

Leg exercises

PM care with shower or bath given

Nail polish removed and make-up removed

Old chart requested and obtained

Type and crossmatch for ____units of blood

Blood consent signed and witnessed

Lab work a. CBC ______ b. UA ____

Tonsillectomy and Adenoidectomy patients: a. __PTT b. ____PT c. ____Platelets

If ordered by MD: a. EKG ______ b. Chest X-ray ______

Add other lab work ordered (specify)

Notify surgeon of abnormal lab work

New progress note and physician order sheet on chart

Weight

NPO after midnight (if applicable)

Signature of Nurse __________________________________ Date __________

COMPLETE DAY OF SURGERY

Jewelry removed and secured with responsible party

Dental prosthesis and contact lenses removed

Hospital gown/cap on and undergarments removed

Voided on call to surgery

Indwelling catheter ordered and inserted

Tampon removed

Identiband and/or bloodband on/checked for accuracy

Time ______ Pulse ______ Resp ______ B/P ________ Temp. ______

Pre-op medicine given Medication __________________ Time ____ AM PM

Siderails up and bed to lowest level

Patient instructed not to get out of bed without nursing assistance

Addressograph plate/MAR’s on chart

VS 30 minutes after preop (if remains on unit)

BP ______ P ______ R ______ T ______

Old chart sent to surgery per request

Surgical prep done and checked

To surgery Time ________ Via ________

Signature of Nurse __________________________________________________ Date __________________Holding Room Nurse Signature ______________________________________ Date __________________

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verbalize any concerns. Allowance should be made forfamily members or significant others to remain with theclient as the client awaits transfer to the operating room.

Client TeachingMost clients view surgery as a threatening and anxiety-provoking event (Bulechek & McCloskey, 1995). Clientteaching reduces anxiety. The risks of surgical compli-cations are decreased when the client knows what toexpect and receives instruction in postoperative exer-cises (Lindeman & Van Aernam, 1971).

Teaching the client and family members (significantothers) is the responsibility of the multidisciplinary team.The nurse verifies that the client or family member is ableto describe, in his or her own words, the reason for the sur-gery, what will be done during the surgical procedure, theside effects of the anesthetic agents, and the possible com-plications of both the surgery and the anesthesia.

The nurse plays a major role in relieving the client’sanxiety by facilitating communication between physi-cians and the client and family and by reinforcing teach-ing regarding preoperative care. The client’s familyshould be involved in the teaching sessions. Table 30-4presents an overview to perioperative teaching activitieswith the client’s expected outcomes.

Teaching aids (videotapes and pamphlets) areresources for client instruction during the perioperativeprocesses. The nurse selects teaching materials based onthe client’s ability to read and understand. The nurse pro-vides accurate, consistent information throughout theteaching process. The teaching aids must reinforce the

verbal instructions of the nurse, anesthetist, and surgeon.Informational materials should explain what will happenin each of the perioperative areas (such as the holdingarea) to foster client cooperation. Refer to Chapter 13 foradditional information on client teaching.

Types of Surgical IncisionsNurses need to be knowledgeable about common surgicalincisions to reinforce the surgeon’s teaching and toanswer the client’s questions. Two main factors governincisions: direction and location. Incisions may be vertical,horizontal, transverse, or oblique. Figure 30-2 illustratesand describes the location of common surgical incisions.

Postoperative Exercise InstructionAs early as 1941, nurses were challenged to participatein preoperative instruction (Bulechek & McCloskey,1995). In 1983, Leventhal and his colleagues suggestedthat the effectiveness of existing preoperative instruc-tion could be increased by assisting clients to assumeself-regulation after surgery.

Preoperative teaching of postoperative exercises pre-pares the client physically and emotionally for the impend-ing surgery (Bulechek & McCloskey, 1995; Eiseman, 1996).Language barriers, identified during assessment, are con-sidered when teaching the client. The goal of instruction isto have the client demonstrate the performance of exer-cises while verbalizing why the exercises are used during thepostoperative phase (Procedure 30-1).

Clients may experience their worst postoperative painwhile coughing, deep breathing, and exercising. Clientswith abdominal or chest surgery may avoid using muscles

TABLE 30-4Preoperative Teaching Interventions and Expected Client Outcomes

Intervention Expected Client Outcomes

Preparation activities The client can: • Describe in own terms the purpose, risk factors, and outcomes of surgery and anesthesia. • Explain restrictions on food the evening before, identifying the time frame (6–8 hr)

when no food and drink are allowed by mouth, NPO • Explain the meaning and purpose of skin and bowel preps. • Identify medications to be taken or omitted the day of surgery. • Describe activities that will occur in each perioperative area: holding area, fluids will be

started in a vein; position on the operating room table; stay in recovery until awake,then be transferred to an intensive care unit.

Postoperative exercise instructions • Demonstrate on two consecutive occasions postoperative exercises: deep breathing, coughing and pillow splinting, turning and proper body alignment; leg and foot exercises; and out-of-bed transfers.

Proper application and usage of • For example, demonstrate proper use of incentive spirometer, application of TED hose, medical devices and self-medicating pain infusion pump.

Physical or environmental • Demonstrate knowledge of the rehabilitation process: daily physical therapy for 2 changes following surgery weeks and a home health nurse for 10 days to administer prophylactic antibiotics and

to monitor and refill the patient-controlled analgesia pump.

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in the affected areas to take deep breaths or to cougheffectively. Deep breathing and coughing facilitateremoval of accumulated pulmonary secretions. Certainanesthetic agents depress the central nervous system,causing some clients to experience shallow respirations.Inhaled gases and oxygen have a direct drying effect onthe respiratory mucosa, which increases the viscosity ofmucus, making the secretions difficult to raise withcoughing. These factors place the client at risk for respi-ratory complications (see the accompanying display).

To prevent respiratory complications, the nurse teachesclients to use a breathing technique in which the clientturns, coughs, and deep breathes to achieve sustained max-

A. Sternal Split Begins at the top of the sternum and extends downward to the sternal notch. Heart

B. Oblique Subcostal Begins in the epigastric area and extends laterally and obliquely below the lower costal margin.

C. Upper Vertical Begins below the sternal notch and distally around the umbilicus. Stomach, Duodenum, Pancreas

D. Thoracoabdominal Begins midway between the xiphoid process and the umbilicus and extends Thorax, Heartacross the seventh or eighth intercostal space, to the midscapular line.

E. McBurney Begins below the umbilicus, goes through McBurney's point, and extends Appendixtoward the right flank.

F. Lower Vertical Begins below the umbilicus, downward toward the symphysis pubis. Bladder, Uterus Midline

G. Pfannenstiel Begins 1.5 inches above the symphysis pubis with a curved transverse Uterus, Fallopian tubes, cut across the lower abdomen. Ovaries

Midline

Right side: Gallbladder, BiliaryLeft side: Spleen

INCISION LOCATION ORGAN

A

B

C D

EF

G

Figure 30-2 Common Surgical Incisions

COMMON RESPIRATORYCOMPLICATIONS AFTER SURGERY AND ANESTHESIA

• Pulmonary embolism: A blood clot that has movedto the lungs, causing pulmonary obstruction

• Atelectasis: Decreased ventilation caused from thepooling of secretions in dependent areas of thebronchiole

• Pneumonia: Inflammation of lung tissue• Hypoxemia: Lowered oxygen level in the blood

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Equipment

Educational materials PillowTissues Nonsterile gloves Disposable volume-oriented incentive spirometer

PROCEDURE 30-1Postoperative Exercise Instruction

Action

1. Wash hands and organize equipment.

2. Check the client’s identification band.

3. Place client in a sitting position.

4. Demonstrate deep breathing exercise.

5. Have the client return demonstrate deepbreathing:

• Place one hand on abdomen (umbilical area)during inhalation.

• Expand the abdomen and rib cage on inspiration.

• Inhale slowly and evenly through your noseuntil you achieve maximum chest expansion.

• Hold breath for 2 to 3 seconds.

• Slowly exhale through your mouth until maxi-mum chest contraction has been achieved.

• Repeat the exercise three or four times; allowclient to rest.

6. The nurse demonstrates splinting and coughing.

7. Don gloves.

8. Keep the client in a sitting position, headslightly flexed, shoulders relaxed and slightlyforward, and feet supported on the floor.

9. Have the client return demonstrate splintingand coughing:

• Have the client slowly raise head and sniff the air.

• Have the client slowly bend forward andexhale slowly through pursed lips.

• Repeat breathing two to three times.

• When the client is ready to cough, have clientplace a folded pillow against the abdomen;

Rationale

1. Reduces transmission of microorganisms andpromotes efficiency.

2. Facilitates proper identification of client.

3. Promotes full chest expansion.

4. Shows the client how to breathe deeply.

5. Fosters learning.

• Exerts counterpressure during inhalation.

• Promotes maximum chest expansion.

• Maintains full expansion of the alveoli.

• Increases the pressure, preventing immediatecollapse of the alveoli.

• Promotes maximum chest contraction.

• Enforces learning.

6. Shows the client how to raise mucus secretionsfrom the tracheobronchial tree.

7. Reduces transmission of microorganisms.

8. Promotes full expansion of chest cage and useof accessory muscles to produce a deep, pro-ductive cough.

9. Fosters learning.

• Increases the amount of air and helps to aer-ate the base of the lungs.

• Dries the tracheal mucosa as air flows over it;there is a slight increase in the carbon diox-ide level, which stimulates deeper breathing.

• Loosens mucus plugs and moves secretions tothe main bronchus.

• Elevates the diaphragm and expels air in amore forceful cough; supports the abdominal

(continues)

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PROCEDURE 30-1Postoperative Exercise Instruction (continued)

Action

have the client grasp the pillow against theabdomen with clasped hands (see Figure 30-3).

• Have client take a deep breath and begincoughing immediately after inspiration iscompleted by bending forward slightly andproducing a series of soft, staccato coughs.

• Have a tissue ready.

10. Instruct the client on the use of an incentivespirometer (see Figure 30-4). Have the client:

• Hold a volume-oriented incentive spirometerupright.

Rationale

muscles and reduces pain when coughing ifthe client has an abdominal incision.

• Removes secretions from the main bronchus.

• Provides a tissue for sputum disposal.

10. Reinflates the alveoli and removes mucus secretions.

• Promotes proper functioning of the device.

(continues)

Figure 30-3 Splinting

Figure 30-4 Incentive Spirometer

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Action

• Take a normal breath and exhale, then seallips tightly around the mouthpiece; take aslow, deep breath to elevate the balls in theplastic tube, hold the inspiration for at least 3 seconds.

• The client simultaneously measures theamount of inspired air volume on the cali-brated plastic tube.

• Remove the mouthpiece, exhale normally.

• Take several normal breaths.

• Repeat the procedure four to five times.

• Have the client cough after the incentiveeffort; repeat Step 9. Have a tissue ready.

• Have client clean mouthpiece under runningwater and place in clean container (dispos-able mouthpiece changed every 24 hours).

11. The nurse explains leg and foot exercises(Figure 30-5).

Rationale

• Allows for greater lung expansion; holdingthe inspiration increases the pressure, pre-venting immediate collapse of the alveoli.

• Encourages the client to do respiratory exercises.

• Allows normal expiration.

• Provides client the opportunity to relax.

• Encourages sustained maximal inspirationand loosens secretions.

• Facilitates removal of secretions.

• Prevents transmission of microorganisms.

11. Elicits client cooperation.

(continues)

Figure 30-5 Leg Exercises

C.

B.

A.

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Action

12. Instruct client to return demonstrate in bed:

• Have the client, with heels on bed, push thetoes of both feet toward the foot of the beduntil the calf muscles tighten; then relax feet.Pull the toes toward the chin, until calf musclestighten; then relax feet (see Figure 30-5A).

• With heels on bed, lift and circle both ankles,first to the right and then to the left; repeatthree times, relax.

• Flex and extend each knee alternately, slidingfoot up along the bed; relax (see Figure 30-5B, C).

13. The nurse shows the client how to turn in bedand get out of bed.

14. Instruct the client who will have a left-sidedabdominal or chest incision to turn to the rightside of bed and sit up as follows:

• Flex the knees.

• With the right hand splint the incision withhand or small pillow.

• Turn toward right side by pushing with theleft foot and grasping the shoulder of thenurse or partial foot rail of the bed with theleft hand.

• Raise up to a sitting position on the side ofthe bed by using the left arm and hand topush down against the mattress (see Figure30-6).

Rationale

12. Fosters learning of how to improve venousblood return:

• Causes contraction and relaxation of the calfmuscles.

• Causes contraction and relaxation of thequadriceps muscles.

• Causes contraction and relaxation of thequadriceps muscles.

13. Elicits client cooperation.

14. Fosters learning how to turn and get out of bedwithout putting pressure on the incision line.

(continues)Figure 30-6 Out-of-Bed Transfers

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imum inspiration (SMI). SMI promotes the reinflation ofthe alveoli and the removal of mucus secretions.

Several devices help encourage clients to perform SMIexercises. The breathing devices, called incentive spirom-eters, measure the client’s ventilatory volume and pro-vide the user with a tangible reward for generating anadequate respiratory flow. Devices range from simpletypes, a Ping-Pong ball in a plastic tube, to sophisticatedmodels (see Figure 30-4). When the client takes a deepbreath, the ball moves upward and the amount of air ismeasured, making the results visible to the client.

Turning, deep breathing, coughing, and usingspirometry prevent respiratory complications by:

• Promoting pulmonary circulation• Promoting the exchange of gases by increasing lung

compliance• Facilitating the removal of mucus secretions from the

tracheobronchial tree

Postoperatively the client is encouraged to move in bedand perform leg exercises as explained in Procedure 30-1. These exercises assist in preventing circulatorycomplications that can arise from anesthetic agents thatdepress the metabolic and heart rates; see the accompa-nying display. Early ambulation also increases respira-tory function and the return of peristalsis.

Other DevicesBesides exercises, other devices are used to preventpostoperative circulatory complications, namely,antiembolism stockings and pneumatic compression.Another device, continuous passive motion (CPM),

increases range of motion for immobilized clients aftersurgery. The CPM device also stimulates healing of artic-ular cartilage by reducing swelling and adhesions.

Pain is managed with devices such as transcutaneouselectrical nerve stimulation (TENS) and patient-con-trolled analgesia (PCA). The client needs to beinformed about the use of such devices preoperativelyto promote achievement of postoperative pain out-comes. All medical devices require a physician’s order.

Antiembolism StockingsAntiembolism stockings are elastic hose that compressleg veins to facilitate the return of venous blood.Depending on the surgical site, these stockings can beapplied either preoperatively (e.g., abdominal surgery)or postoperatively (e.g., cardiac catheterization).

Elastic stockings are available in a variety of lengths,colors, and sizes to accommodate specific needs. Onetype of hose goes from the foot to the knee; anothertype goes from the foot to midthigh. Some stockingshave partial openings on the foot to expose either thetoes or heel so that the nurse can assess circulation.

The physician usually specifies the size and style ofthe hose and the frequency of application. If the physi-cian does not indicate the size, the nurse uses a tape tomeasure the circumference of the calf and thigh andthe length of the client’s leg from the heel to the glutealfurrow. Stockings are removed for 20 to 30 minutesthree times a day to allow for assessment and hygieniccare. Assessment should include inspection for redness,palpation for tenderness or increased temperature, andtesting for Homans’ sign.


Action

15. Reverse instructions (use left side instead ofright) for the client with a right-sided incisionaccording to step 14.

16. Instruct clients with orthopedic surgery (e.g.,hip surgery) how to use a trapeze bar.

Rationale

15. Same as step 14.

16. Facilitates movement in bed without puttingpressure on a leg or hip joint.

COMMON CIRCULATORYCOMPLICATIONS AFTER SURGERY AND ANESTHESIA

• Thrombophlebitis: Inflammation of a vein with theformation of a blood clot

• Thrombus: A blood clot in the circulatory system• Embolus: A blood clot or air that moves in the circu-

latory system from its place of origin

N U R S I N G T I PClient Safety

Instruct the client with antiembolism stockings towear slippers or shoes to avoid slipping.

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Pneumatic Compression DeviceA pneumatic compression device provides intermittent com-pression cycles to the veins of the extremities to promote cir-culation. The device consists of either vinyl surgical sleevesthat slide over each calf or Velcro-secured vinyl compressionhoses that are applied under the thigh and leg with a knee-opening site that is placed over each popliteal area (seeFigure 30-7). Both types of vinyl appliances have tube con-nectors that attach to an air pump machine. Observe theclient applying the stockings, connecting the tubes to the airpump, and setting the correct pressure.

The air pump has an on-off switch and a dial to setthe desired pressure. Turning on the pump initiatescompression cycles, which cause the vinyl sleeves toautomatically inflate and deflate. The nurse assesses thecirculation to the extremities and placement of thestockings every 2 to 3 hours. The stockings are removedthree times a day for 20- to 30-minute intervals to allowfor hygiene care. Instruct the client on how to clean thevinyl stockings by disconnecting the stockings from theair pump and wiping off with tepid, soapy water.

Continuous Passive Motion DeviceThe continuous passive motion (CPM) device increasesrange of motion and stimulates healing of the articularcartilage by decreasing swelling and the formation ofadhesions. It is used for clients with a nursing diagnosisof either Impaired Physical Mobility related to the surgicalintervention or Altered Tissue Perfusion related to surgicalintervention and immobility. The goal is to increase tol-erance to the CPM device. The expected client outcomeis to maintain maximum mobility of the joint.

Before initiating CPM, the nurse:

• Assesses the client’s neurovascular status (skin colorand temperature, pulses, capillary refill, sensation,and movement) of the extremity

• Applies the disposable soft goods to the CPM deviceaccording to the manufacturer’s instructions

Sleeve containingthree chambers

First chamberinflated

Pump

Figure 30-7 Pneumatic Compressed Device

• Wash hands and obtain the stockings, makingsure the type and size are correct.

• Check the client’s identification band.• Show the client the stockings and explain the

procedure to elicit cooperation. Make surethe client knows that the stockings are to beremoved routinely and washed daily accord-ing to package directions.

• Provide for privacy. The client should be in acomfortable position to observe your tech-nique while you apply one of the stockings.

• Wash, rinse, and dry the legs; stockings shouldonly be applied to clean, dry skin.

• Talcum powder can be applied to the feet andlegs to allow the stocking to move more easilyover the skin.

• Turn the stocking inside out, except the footportion.

• Place the foot of the stocking over the client’stoes and on the foot; with your nondominanthand supporting the client’s ankle, use yourdominant hand to pull the heel pocket overthe client’s heel (see Figure 30-8).

• Slide the stocking up the leg, straightening asyou apply; make sure that kinks and wrinklesare smoothed out to provide even pressure.

• Knee-length stockings should end 1 inch (2.5cm) below the knees.

• If the stocking goes to midthigh, have the clientflex the knee while you pull the stocking over theknee and thigh; the stocking should be 1 to 3inches (2.5 to 7.5 cm) from the groin.

• The top of the stockings should not be foldedover because additional constriction can occur.

• Have the client apply the other stocking, andassess the client’s learning.

• Document client learning.

NURSING CHECKLISTApplication of Antiembolism Stockings

✓

Figure 30-8 When applying antiembolism stockings, sup-port client’s ankle while pulling stocking up.

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• Sets the machine to provide the degree of flexionand extension according to the physician’s orders(e.g., 0° extension and 35° flexion)

• Adjusts the speed to control movement

When the device is readied, the client is positioned inthe middle of the bed to accommodate the CPM unit.The nurse places the client’s legs in the padded CPMdevice, making sure that the knees are at the hingedjoint of the machine. The nurse measures the angle offlexion with a goniometer when the device has reachedits greatest height. The client is taught how to operatethe “go/stop” button and is instructed to report any dis-comfort or pain that occurs with motion.

Transcutaneous ElectricalNerve Stimulation UnitA transcutaneous electrical nerve stimulation (TENS) unitcontrols pain by delivering electrical impulses to nerve end-ings that block the passage of pain signals from entering the

dorsal spinal root. The TENS unit is effective in reducingpain and the amount of pain medication required to main-tain comfort after surgery. The unit consists of a transmitter,lead wires, and electrodes (see Figure 30-9).

Patient-Controlled Analgesia PumpThe patient-controlled analgesia (PCA) pump is a devicethat allows the client to control the delivery of intravenousor subcutaneous pain medication in a safe, effective man-ner. The client self-regulates the delivery of the medica-tion. Several different types of PCA devices are available;the manufacturers provide instructions for setting up theinfusion pump. The pain medication is contained withinan infusion pump and set according to the physician’sorder: type and concentration of pain medication, load-ing dosage, and lock-out interval (minimum time allowedbetween doses for the client to self-medicate).

Before initiating the PCA pump, the nurse assessesthe client’s level of consciousness, orientation, readingability, and ability to learn and comprehend. PCA isused most frequently in adolescents and adults. Familymembers are also taught how to recognize the signs ofdrug overdose in home-bound clients. Instruct theclient on the PCA unit:

• To self-administer the medication as needed • That the amount of the drug the machine delivers

within a particular time frame is regulated to preventoverdose

• On the use of the control button

The advantages of a PCA unit are rapid pain relief,increased client satisfaction, and often the use of lessmedication than with the traditional intramuscular anal-gesia method.

Physical PreparationNursing activities related to the physical preparation ofthe client must be performed. These nursing functionsare individualized to the client’s needs as determined byhealth status and the type of surgical procedure sched-uled. Activities such as restricting fluids, bowel prepara-tion, or the removal of nail polish are done the eveningbefore, regardless of the setting. Other activities occurthe day of surgery in various perioperative settings.

Skin PreparationThe skin and hair follicles harbor microorganisms thatcan contaminate a surgical wound. The skin around theoperative site is prepared to reduce the number oforganisms present and to inhibit rebound growth.Preparation of the skin to reduce contamination of thesurgical wound occurs in two phases. The eveningbefore or the day of surgery, the client washes the areainvolved in the surgical procedure with an antimicrobialsoap. The client is usually instructed to wash the surgi-cal area vigorously several times to decrease the chanceof wound infection.Figure 30-9 Transcutaneous Electrical Nerve Stimulation (TENS) Unit

• Place electrodes on the skin in the area ofpain (e.g., on both sides of an incision).

• Connect the lead wires to the electrodes andportable battery-powered transmitter.

• Turn on and regulate for comfort by working withone lead at a time, beginning with a zero setting.

• Gradually increase the level of stimulation untilthe client feels discomfort, indicating that maxi-mum stimulation has been achieved to blockpain sensation; then reduce the volume slightlyto prevent continued contraction of muscles.

• Repeat the same process with the other lead;this time allow the client to perform theactions.

• Ensure that the client knows to apply the elec-trodes to clean, unbroken skin.

NURSING CHECKLISTInstructing the Client onthe Use of the TENS Device

✓

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Most agencies follow the recommendation of theCenters for Disease Control and Prevention (CDC) andthe Association of periOperative Registered Nursesregarding the second phase. During the second phase,the skin is surgically prepared by removing hair in theoperative site. The CDC and AORN recommend that thisbe done in the operating room. Shaving with a razor maycause cuts and nicks in the skin that promote the growthof microorganisms; therefore, performing this functionimmediately before surgery in the operating room, whichis basically a controlled and germ-free environment,reduces the risk of wound contamination. Methods usedto prep the skin are discussed in the intraoperative phase.

NutritionNutrition and fluid considerations are determined by theclient’s health status and the nature of the surgical proce-dure and anesthesia. Clients scheduled for surgical proce-dures requiring only local anesthetic agents may be alloweda light breakfast or clear liquids the day of surgery. However,clients scheduled for regional or general anesthesia areinstructed not to eat or drink (NPO) for 6 to 8 hours beforesurgery. Restricting food and fluids decreases the risk of aspi-ration of gastric contents into the lungs during anesthesia.

Clients at risk for dehydration are infants, the elderly,those with preexisting nutritional imbalances, and thosehaving surgical procedures that cause extensive loss ofblood and other body fluids. These clients are usually givenintravenous fluids preoperatively to maintain fluid and elec-trolyte balances. Measurement of intake and output allowsthe nurse to monitor the client’s fluid and electrolyte status.

Gastrointestinal PreparationGastrointestinal surgeries usually require special proce-dures to prepare the stomach or intestines.

Nasogastric Tube Some clients may require a naso-gastric tube to facilitate stomach decompression to pre-vent postoperative abdominal distension. Insertion of anasogastric tube causes client discomfort and canincrease apprehension regarding surgery; therefore, thetube is usually inserted during the intraoperative phasewhen the client is under anesthesia. Inform clients thatthe tube can cause irritation to the nasal mucosa and mayresult in a sore throat.

Bowel Preparation The surgeon prescribes thetype of bowel preparation on the basis of the surgicalprocedure. Enemas and laxatives are not routinelyadministered unless the client is having abdominal sur-gery. Intestinal surgeries require a bowel preparation tocleanse the intestines of fecal material by administeringeither a cathartic or enema to empty the bowel.Antibiotics are given to reduce the bacterial content.Cleansing the bowel is necessary because surgicalmanipulation of the intestines interrupts normal peri-stalsis. Also, incision of any portion of the gastrointesti-nal tract places the client at risk for peritonitis if fecalmaterial enters the abdominal cavity.

The client is usually instructed to eat a light meal theevening before, avoiding high-fat foods, and is given alaxative. The morning of surgery, enemas may be given.If the surgeon orders “enemas until clear” (no fecalreturn), refer to the agency’s policy. Administering ene-mas until clear can place the NPO client at risk for fluidand electrolyte imbalances. The client’s stress responsemay already be compromised by the fear of surgery;administering repeated enemas may further decreasethe client’s coping mechanisms.

Urinary EliminationThe client is instructed to void before receiving the pre-operative medication or being transferred to the oper-ating room. The bladder needs to be empty to preventdistension and incontinence during the surgery.

Some surgeries can require continuous decompressionof the bladder; the operating room nurse usually inserts aFoley catheter before or during surgery. See Chapter 39 fordetails on catheterization. If this occurs, the client shouldbe informed about the catheter and how long the catheterwill be left in place. Inform the client that a Foley cathetercauses a sensation of pressure and an urge to urinate.

Safety PrecautionsOutpatient clients are instructed to leave their jewelryat home and to avoid the use of makeup the day of sur-gery for safety reasons. Jewelry and other metal objectscan cause burns when electrocautery is used duringsurgery. Rings can compromise circulation. Hairpinscan injure the scalp when the head is positioned foranesthesia. Makeup and nail polish can interfere withthe practitioner’s assessment of oxygenation.

Unnecessary prosthetic devices should also be left athome to prevent client injury or loss. Outpatient areashave limited space to secure valuables. Contact lensesshould always be removed and stored before surgery toavoid corneal ulceration and displacement. Partial den-tures and other orthodontic devices must be removed toprevent displacement into the throat during anesthesia.

If the client feels helpless without certain devices, suchas glasses and hearing aids, it should be documented on

T H I N K A B O U T I TT H I N K A B O U T I TNursing Intervention

What should a nurse do if a client refuses a treatment?You are caring for a 16-year-old boy who was in anautomobile accident and is scheduled for bladder surgery.The parents are present for perioperative teaching. Youexplain what will happen during the surgical procedureand that the boy will have a catheter after surgery. The boygets upset, saying he does not want a tube. What type ofage-related teaching materials might you use in thissituation?

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the preoperative checklist that the client is wearing suchdevices. The operating room nurse removes such devicesimmediately before or after anesthesia induction.

Hospitalized clients are usually instructed to give theirvaluables to a family member before surgery. Otherwisethese items are removed from the client’s room andplaced in a safe area according to hospital policy. Thenurse documents on the preoperative checklist the dis-position of valuables and prosthetic devices.

MedicationsEfforts are made to continue routine medicationsthroughout the perioperative experience. The physicianinstructs outpatient clients on which medications to takethe day of surgery. The nurse is responsible the day of sur-gery to document which medications were taken and tonotify the surgeon when drugs were omitted.

Clients scheduled to receive only local anesthesia areusually instructed to wait until after the procedure to taketheir medications unless there may be a time delay thatcould have a negative effect on the client. The followingmedications that increase a client’s risk are withheld:

• Anticoagulants, ibuprofen, and aspirin: May increaseblood loss. Clients routinely taking oral anticoagu-lants are given subcutaneous heparin to ensureprompt reversal with intravenous protamine sulfateshould the need arise; oral anticoagulants are notreversed by protamine sulfate.

• Monoamine oxidase inhibitors: May interact withanesthetic agents and are discontinued 2 weeksbefore surgery.

• Aminoglycosides: Potentiate the effect of neuromus-cular blockers.

• Oral hypoglycemic agents: Are continued until theevening before surgery except for chlorpropamide,which is discontinued 48 hours before surgery; to preventintraoperative fluctuations in blood sugar, an intravenousinfusion of glucose and insulin is begun before surgery.

The medication dosage can be adjusted preoperativelyfor certain drugs. For instance, corticosteroid therapyshould be continued when clients have been maintainedon the drug for 2 months or more; the dose to be giventhe day of surgery depends on the client’s daily therapy.

Medications to reduce anxiety and facilitate theinduction of anesthesia are administered as prescribed.To prevent client discomfort with traditional intramus-cular preanesthetic injections, facilities with a “holdingarea” use this setting to initiate intravenous therapy andadminister the pre-anesthetic drugs intravenously.

EvaluationEvaluation of actual and expected outcomes of the peri-operative client is done over the three phases.Preoperative evaluation focuses on the client’s ability toverbalize and demonstrate the exercises. The outcome

is evaluated when the client successfully performs theexercises after surgery. Measurement of the client’s abil-ity to perform postoperative exercises should first beassessed during the teaching session and again an hourlater to evaluate learning. If the client needs coaching toperform the exercises, reinforce teaching until theclient demonstrates the exercises appropriately.

Assessment of the client’s knowledge regarding thenature, purpose, and risks of the surgical procedure ismeasured preoperatively. Likewise, the nurse listens tothe client’s comments and monitors physiological indi-cators (e.g., vital signs) to measure fears and anxietiesregarding the surgery.

The evaluation of a client’s preoperative preparationfor surgery should include understanding of the proce-dure, verbalization and return demonstration of post-operative exercises, and postoperative expectationsresulting from the surgery. Refer to the accompanyingNursing Process Highlight to understand how the nurseevaluates achievement of client expected outcomes.

DocumentationDocumentation of preoperative activities must beentered in the client’s medical record on the appropri-ate forms. The preoperative checklist is used to docu-ment accurate completion of preoperative activities.Documentation on this form means that all aspects ofcare have been performed as ordered. When the oper-ating room (OR) personnel come to transfer the client,the preoperative nurse signs the checklist, entering thetime and mode of transportation to the OR (e.g., bystretcher).

EVALUATION

In evaluating the nursing care of Mrs. Broussard duringthe preoperative phase of her total hip replacementsurgery, the following questions should be considered:

• What methods can be used to determine whetherMrs. Broussard understands the events that willoccur during the surgery?

• What postoperative exercises should Mrs. Broussardbe asked to demonstrate for the evaluation of herability to perform these measures?

• What types of information should Mrs. Broussard beable to share about the postoperative course oftreatment?

• What methods can be implemented to elicit Mrs.Broussard’s concern or anxiety about the surgeryitself or the expectations for her recovery?

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INTRAOPERATIVE PHASE

The intraoperative phase begins when the client is trans-ferred to the OR and ends with the client’s dischargefrom the OR. The goal of nursing care during this phaseis to ensure client safety. Maintaining a safe environ-ment includes protecting the client from injury, infec-tion, and complications arising from anesthetic agents,hazards, and the surgical procedure (see the accompa-nying Research Focus).

Surgical EnvironmentThe surgical area usually consists of three zones: unre-stricted, semirestricted, and restricted. The unrestrictedarea is designed for personnel to enter in street clothes:receiving desk, holding area, and locker rooms. Surgicalattire (scrub clothes, disposable shoe covers, and caps)is required in the semirestricted and restricted zones.Hallways and storage areas constitute the semirestrictedarea. Restricted zones (controlled and germ-free areas)include the OR and rooms where sterile instruments areprepared.

Holding AreaThe holding area is a unit where the surgical team pre-pares the client for surgery (Figure 30-10). The anes-thetist usually starts the intravenous infusion andadministers the preoperative intravenous medication.The nurse confirms that aspects of care on the preoper-ative checklist have been performed. A family memberis usually encouraged to remain with the client while theclient awaits transfer to the OR.

Surgical TeamThe surgical team consists of the surgeon, anesthetist,OR nurses, surgical assistants, and other members of thehealth care team. The roles and responsibilities of the

RESEARCHFOCUS

Title of Study“Clinical Decision-Making Process in PerioperativeNursing”

AuthorsParker, C., Minick, P., & Kee, C.

PurposeThe purpose of this phenomenological study was toreveal the processes of clinical decision-making byexpert perioperative nurses.

MethodsSix expert nurses from five different hospitals in alarge southern metropolitan area participated in thestudy. Expert nurses were defined as having workeda minimum of 5 years and considered themselves tobe expert circulating nurses in the OR. Based on aninterview guide, the participants were asked todescribe any perioperative clinical situation in whichthey intervened on the patient’s behalf and affectedthe patient’s outcome by doing so. The interviewswere transcribed verbatim; data were loaded into asoftware program to categorize, sort, and managethe data.

FindingsThe predominant pattern contributing to the clinicaldecision-making process among the expert nurseswas “seeing the big picture: engendered throughcaring.” Multiple decisions were identified withineach nurse’s practice, and within each decision, cer-tain characteristics were identified and categorizedinto themes. Data analysis identified three themesas requisite for expert clinical decision-making: con-necting with patients; advocating for patients; andembodied knowing.

ImplicationsThis study demonstrates that positive patient out-comes depend on the ability of the perioperativenurse to integrate all nursing knowledge, make rapiddecisions, and constantly advocate for the patient.These data also suggest that nurses and nursing stu-dents would both benefit if personal care experienceswere shared so that the taken-for-granted knowledgeof clinical practice could be examined and caringpractices could be made explicit.

Parker, C., Minick, P., & Kee, C. (1999). Clinical decision-makingprocess in perioperative nursing. AORN Journal, 70(1), 45–62.

Figure 30-10 Holding Area. What is this nurse doing to prepare thisclient for surgery?

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surgeon and anesthetist have already been discussed.The OR team usually consists of:

• Surgeon: Scrubbed and in surgical attire to performthe surgery

• Anesthesia provider: Masked and in clean scrub attireto administer the anesthesia

• Surgical assistant (first assistant): Can be anotherphysician, a nurse, or physician’s assistant (PA) who isscrubbed, in sterile attire, and assists the surgeon toligate, suction, and suture

• Scrub nurse or technician: Scrubbed and in sterile attire;prepares the instrument tray and passes the instruments,sponges, needles, and sutures to the surgeon

• Circulating nurse: In clean scrub attire and mask;obtains supplies, delivers materials, pours solutions,handles specimens, positions the client and surgicaldrapes, and disposes of soiled items

Both the scrub and circulating nurses are responsiblefor counting the number of used instruments, needles,and sponges. Before the surgeon closes the incision,these items are counted to ensure that nothing is beingleft in the operative site.

Occupational HazardsPerioperative personnel are at risk of exposure to harmfulpathogens and other dangers. Dangers of a particular con-cern to perioperative nurses are latex allergies, needle-sticks, eye splashes, back injuries, and indoor pollution.Precautions should be in place that are in compliance withOccupational Safety and Healthcare Administration(OSHA) standards regarding blood-borne pathogens,medical waste and hazards materials, including personalprotection devices, disposal of needles and syringes, andcontaminated supplies. See Chapter 31 for a complete dis-cussion of latex allergy and OSHA’s standards.

Health care agencies need to have a process in placeto document compliance with OSHA requirements.Akdumann (1999) studied the compliance of OR per-sonnel with universal precautions during surgical pro-cedures in four subspecialties: orthopedic, gynecologic,cardiothoracic, and general surgery. Personnel wereinformed in advance about data collection regardingthe use of protective equipment. The study revealedthat only 39% of the personnel wore protective goggles,5% wore face shields, 32% wore regular glasses, andnearly one-fourth wore no eye protection. Althoughdouble-gloving was higher in orthopedics than otherareas, only 28% of the observed personnel double-gloved. A 22% rate of exposure was observed during 76cases with three percutaneous injuries (two scalpel, oneneedle-stick) and 14 cutaneous blood and bodily fluidexposures. The study proposed the need for consistenttraining in and reinforcement of OSHA’s guidelines.

Slattery (1998) refers to the hospital environment as a“chemical soup” and addresses the agents that compro-

mise the quality of indoor air. Pollution in the OR iscaused by fumes from high levels of disinfectants, surgi-cal smoke from tissue being cut, vaporized, or coagu-lated, and waste gases from anesthetic agents.Disinfectants such as glutaraldehyde used to sterilizeinstruments are not regulated, and the fumes may causeserious respiratory and dermatologic problems. ORnurses are also at risk with respect to laser plume or sur-gical smoke, which can lead to respiratory problems,burning, watery eyes, nausea, and viral contaminationand regrowth. To decrease the exposure to these dan-gerous pollutants, agencies should have policies in placethat require clients and personnel to wear high-filtrationmasks and to provide the rooms with smoke evacuators.

AssessmentThe first activity of assessment for the OR nurse is tocheck the client’s identification band and confirm thesurgical site. Agency protocol and standards of carefrom the AORN establish the focus areas of assessmentfor the client and the environment.

Assessment of proper positioning to ensure comfortand safety includes:

• Checking for client alterations that can affect posi-tioning during the procedure, such as previous skele-tal or joint surgery, presence of a joint or vascularprothesis, poor nutrition, and skin integrity

• Making sure the OR bed is prepared to receive theclient: for example, warming mattress on bed, properorientation of bed, bed wheels locked

• Ensuring that accessories are clean and readily avail-able for a specific position: for example, Wilsonframe, chest rolls, pillows, headrest

Throughout the surgical procedure, the nurse assessesfor pressure areas of the extremities, joints, or any bodysurface; skin discoloration; and temperature. Wheneverthe client’s position is changed during surgery, the nursereassesses for signs of circulatory impairment from posi-tioning and equipment in contact with the skin.

Nursing DiagnosesCommon intraoperative nursing diagnoses promoteclient comfort, safety, and support during the surgicalprocedure. See the previous display of nursing diagnosesin the section on Perioperative Nursing Diagnoses.

Outcome Identificationand PlanningThe focus of intraoperative care planning is on nursingactivities that promote the client’s achievement of expectedintraoperative outcomes (see the accompanying display).

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These outcomes are directed at placing the client in a safeenvironment free from injury. The OR team monitors theclient throughout the surgical procedure for complications.

Specific nursing care is planned to encompass the sur-geon’s specifications for positioning and to alleviate orprevent any individual client problem. Surgeons havepreference cards that identify the type of equipment andinstruments for various surgical procedures (e.g., indica-tions and use of electrical equipment). Planning alsoinvolves determining the appropriate mode of clienttransfer, determining equipment and positioning aids, ordetermining the need for ancillary personnel to accom-

plish the positioning. The plan of care should be individ-ualized to include needs relative to the client’s health sta-tus such as diabetes, malnourishment, or paralysis.

InterventionsNursing interventions are selected to facilitate caringand to achieve the expected outcomes, such as theclient is free from infection 72 hours postoperatively.Because anesthesia inhibits the client’s ability to protectself, the OR staff implements surgical asepsis, safe posi-tioning, and other interventions that promote clientsafety (e.g., the client is never left unattended).

Nursing care includes communication skills to reducethe client’s anxiety. The OR staff communicates a caring atti-tude, functioning under the assumption that anesthetizedclients will be able to recall comments made during surgery.

Surgical AsepsisSurgical asepsis is used to decrease the client’s risk foran infection. Surgical asepsis refers to handwashing,wearing surgical attire, handling sterile instruments andequipment, and establishing and maintaining sterilefields. The sterile field is free of microorganisms andonly sterile items can be placed inside the field. SeeChapter 31 for a complete discussion of surgical asepsis.

Surgical handwashing is performed to remove soiland microorganisms from the skin. The skin on thehands and arms should be intact (free of lesions).Agency policy determines how the scrub is to be per-formed (e.g., method and timing).

Once the scrub nurse is properly attired for surgery,strict adherence to aseptic principles guides all actions. Thehands and arms are held above the waist at all times. Onlyattire from the waist to the gown’s collar and the anteriorsurface of the sleeves is considered sterile. The scrub nursesets up the instrument table, using sterile drapes and instru-ments. Only the tops of instrument tables are consideredsterile. Items placed within a sterile field are opened, dis-pensed, and transferred using technique to maintain theitem’s sterility. Soiled or contaminated articles are removedimmediately from the room by the circulating nurse.

Skin PreparationSkin preparation (prep) is performed to decrease the riskfor infection by reducing the resident microbial count onthe skin and inhibiting rebound growth of microbes whenthe skin is incised during surgery. The second phase of thesurgical skin preparation is usually done by OR personnelbefore surgery to prevent the growth of microorganisms.

Guidelines for when and where the skin is to beprepped for the surgical procedure differ according toagency policy, surgeon’s preference, and incision site. Thepreference card usually indicates the type of preparation.The OR nurse ensures that the operative site is clean.

The skin preparation should comply with the CDCrecommendations to avoid unnecessary hair removal

T H I N K A B O U T I TT H I N K A B O U T I TNursing Care and Client Populations

What options are available to nurses who have personalobjections to caring for certain client populations?

A Special Committee on Ethics of the AORN conducteda study to elicit the acquired immunodeficiency syndrome(AIDS)-related knowledge, attitudes, and practices ofperioperative nurses. The findings revealed that:

Nurses continue to be reluctant to provide care to HIV-positive patients if given a choice. Sixty percent ofperioperative nurse respondents said they “somewhatagreed” or “strongly agreed” with this sentimentcompared with 62% of the respondents in the originalstudy. One AORN respondent said, “I don’t believeanyone should be legally required to care for any patientwith any illness/disease (Reeder, Hamlet, Killen, King, &Uruburu, 1994, p. 456).

What is your reaction to the AORN respondent? Read theAmerican Nurses Association Code of Ethics in reviewingyour own values toward HIV-positive clients.

COMMON INTRAOPERATIVECLIENT OUTCOMES

• The client demonstrates knowledge related to thephysical environment and surgical intervention.

• The client’s needs are met while in a dependentstate from the anesthesia.

• The client is maintained in a safe germ-free environ-ment during the surgical procedure.

• The client is free from infection 72 hours postoperatively.

• The client’s skin integrity is maintained by properpositioning on the operating room table.

• The client is maintained in proper body alignmentto prevent injury from positioning.

• The client is free from injury related to exposurefrom heat loss.

• The client is free from injury related to chemical,electrical, and physical hazards.

• The client’s fluid and electrolyte balance is maintained.

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and to shave immediately before an operation. Haircan be removed by clipping, depilatory, and shavingwith a razor. A dry shave refers to the removal of hairby clipping or the use of a depilatory. Shaving with arazor and a warm, antiseptic solution is often called awet shave. Figure 30-11 designates the body surfaces tobe prepared for surgical procedures involving thehead, neck, ear, and upper thorax. Preparation of theupper extremities, chest, and abdomen are illustratedin Figure 30-12.

A.

B. C.

D.

E. F.

Figure 30-11 Preparation of the Head for Surgery: A.–C. Head for aCraniotomy; D. Neck for Otological Surgery; E., F. Upper Thorax forThyroidectomy

Figure 30-12 Surgical Preparation of Upper Extremities and Trunkfor Surgery, Anterior and Posterior Views

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When performing a skin prep, the nurse should pro-vide the client with an explanation of the procedure,privacy, comfort, and safety. Common agents for prep-ping the skin include povidone-iodine, chlorhexidine,alcohol, and hexachlorophene. If the client has anyadverse reactions to the prep, the nature of the reactionshould be documented and the physician notified.

Positioning and DrapingThe surgical client is usually sedated or anesthetizedand therefore is unable to communicate any discomfort.Proper positioning ensures client comfort and safety,preserves vascular supply, and prevents neuromusculardamage to tissue. At the same time, positioning also pro-vides access to the surgical site, airway, intravenous lines,and all monitoring devices.

All sharp surfaces in contact with the client’s skin arepadded to prevent injury from positioning. Bony promi-nences (e.g., sacrum and heels) are padded to avoidexcessive pressure on these points. The nurse ensuresthat skin surfaces are insulated from metal bed attach-ments (e.g., padded arm boards, headrest, stirrups).Appropriate devices are made available to supportextremities to prevent compression of vital structures,such as the ulnar nerve or Achilles tendons.

The circulating nurse ensures that at least four per-sons are available for positioning clients under generalanesthesia. Restraints (or belts) are available to securethe client to the operating bed; sufficient soft padding isused to maintain anatomical alignment of the head andneck with the spine.

Once the client is positioned properly and the sitehas been prepped, the circulating nurse applies the ster-ile drapes. OR drapes are designed to expose specificoperative sites. The staff keeps the sterile drapes dry andin place.

Electrical HazardsDuring surgery the client can be exposed to an electricalsurgical generator (electrocautery device to eliminatebleeding and reduce contamination). Electricity cannotflow unless a circuit is complete; thus, electricity intro-duced into the body has to find a pathway back to thegenerator. A ground pad is provided for that purpose.

Proper grounding technique is essential for the safeand effective use of the generator. The circulating nurseensures that the selected ground site is free of skinfolds,

scar tissue, erythema, skin lesions, or bony protuber-ances. The site should be as close as possible to the oper-ative area. Throughout the surgery, the circulatingnurse inspects the ground pad site for any unusual skindiscoloration, burns, or skin reaction.

Lasers provide another method for cutting and coag-ulating tissue during the surgical procedure. Lasersdeliver high energy-beams directly onto the tissue andreduce tissue damage and scarring that can inhibit heal-ing. To prevent injury to the skin and eyes, the staff andconscious clients wear special high-filtration maskswhen the laser produces smoke.

Heat LossInjury from hypothermia is prevented by measuresimplemented to minimize heat loss. During surgery,body heat is lost by positioning on a cold OR table (con-duction); administration of cold gases (convection);exposure of large operative sites, such as thoracic andabdominal areas (evaporation); and exposure to coldOR temperatures (radiation). Anesthetic agents canalso alter thermoregulation and lower metabolism.Body temperature is maintained by applying warmingmattresses or warmed blankets, warming and humidify-ing inhaled gases, warming irrigating and intravenoussolutions, and increasing room temperature when theclient is exposed, for example, for skin preparation andpositioning.

Monitoring PhysiologicalFunctioningAfter intubation and induction of anesthesia, the clientis monitored for:

• Ventilation and circulation• ECG and oxygen analyzer alterations• Fluid intake, urinary output, and calculated blood

loss• Behavioral changes• Body temperature• Diagnostic testing (collection of specimens and cul-

tures, x-rays and fluoroscopy)• Placement of medical devices (ground pad, position

support, drains, catheters, implants, packings, anddressings)

These measures assist in identifying and correcting anyserious problems before they can result in client injury.

EvaluationBefore the client is transferred to the recovery room,the OR nurse evaluates and documents achievement ofclient outcomes. Evaluation is based on reassessmentfindings of the client during and after surgery. Thenurse documents the specific data on the OR record,

N U R S I N G A L E R TChemical BurnsAfter the skin preparation, remove all solution that haspooled under the client; chemical skin burns can resultfrom prolonged exposure to antiseptic solutions.

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which usually reflects AORN standards of intraopera-tive care and other direct care issues pertinent to clientoutcomes.

Transfer to Postanesthesia Care UnitWhile the surgeon is closing the incision, the OR nursegives a telephone report to a recovery room or PACUnurse regarding the client’s health status, surgical out-comes, special equipment needs, and nursing interven-tions. This information allows the PACU staff time toprepare to receive the client.

Planning for personnel and equipment needed tosafely transfer the client is usually handled by the circu-lating nurse. Moving the semianesthetized client fromthe OR table to the PACU stretcher for transportrequires coordinated effort of at least four persons.Assurance is made that a sufficient number of staff areavailable to move the client while maintaining properbody alignment and preventing the dislodgement of anytubes, drains, or monitoring devices.

Safety measures are implemented to prevent injury toboth client and staff members. The staff uses good bodymechanics and assistive devices, such as draw sheets orbody rollers, to allow proper weight distribution of theclient. The stretcher wheels are locked to prevent move-ment. The client is always lifted from the table, asopposed to being dragged or pulled with draw sheets, toprevent skin irritation or shearing. The nurse appliesstretcher belts (restraints) prior to transport. Also, thehead of the stretcher is elevated, side rails are raised,and the placement of tubes and drains is confirmed.

Once on the stretcher, the client is quickly trans-ported by a nurse and anesthetist to the PACU. Theclient at this time is at high risk for injury related to theeffects of residual anesthesia: airway distress, vomitingand aspiration, and circulatory alterations. The anes-thetist stays with the client while the OR nurse gives areport to the PACU nurse assigned to the client. Thereport should include all pertinent anesthesia and sur-gery information (refer to the Nursing Checklist).

After giving the report, the OR nurse documents thetime of discharge, method and disposition of transfer,and a general statement regarding the client’s status.The client usually remains on the same PACU stretcherthroughout the stay in the unit.

POSTOPERATIVE PHASE

The primary goal of nursing care during the immediatepostoperative phase is to maintain the “A-B-Cs”: airway,breathing, and circulation. Ongoing care is directedtoward restoring the client to the preoperative healthstatus. Clients receiving local anesthetics, without seda-tion, are usually transferred to the outpatient ambula-tory care setting for observation while awaitingdischarge. Their postoperative care is usually nonemer-gent in nature and is discussed later in the section titledOngoing Postoperative Care.

General anesthesia requires intubation. Extubation isperformed by the anesthetist before the client leaves theOR or in the PACU when assessment data confirm ade-quate gas perfusion. Clients with heart and other majorsurgeries are not extubated immediately. The endotra-cheal tube is usually removed on the first postoperativeday. Intubated clients are usually transferred to inten-sive care units for 2 or 3 days.

AssessmentFollowing the initial assessment of the client’s respira-tory status, the nurse performs a total assessment (seeTable 30-5). The postoperative nursing care protocol,based on AORN’s standards of care, is initiated. Theprotocol identifies those areas requiring immediateassessment and reassessment as discussed in Table 30-5.Focused assessment is performed relative to the surgicalprocedure as discussed in the Nursing ProcessHighlight.

Nursing DiagnosisRefer to the earlier display of perioperative nursingdiagnoses. Clients with preexisting conditions, identi-fied during the preoperative period, will continue torequire special nursing care. Depending on the individ-ual client’s needs, other nursing diagnoses can beincluded in the plan of care.

• Brief history of client’s health status: preexist-ing conditions and medical diagnoses requir-ing surgery

• Baseline and OR vital signs• Results of diagnostic testing (e.g., blood gases) • Administration of anesthetic agents and other

medications • Estimated blood loss• Total volume of output from all tubes and

drains• Total volume of infused intravenous fluids

and blood products • Presence and status of devices (e.g., tubes,

drains, antiembolism hose)• Any other problems treated during the sur-

gery or other special nursing interventions

NURSING CHECKLISTPreparing the PostanesthesiaReport

✓

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Some surgeries have unpleasant outcomes. The loss ofan extremity or other body part or function can cause theclient and family to experience ineffective coping. Thesesituations require compassion and consideration to assistthose involved to work through and express their feel-ings. Support needs to be given not only to the client butalso to the family. Physical healing can occur before emo-tional or spiritual healing does. Learning to cope with aloss sometimes extends beyond the postoperative phase.See Chapters 11 and 21 for more information.

Outcome Identificationand PlanningPlanning the care for postanesthesia clients addressesthe development of nursing interventions to achieve theclient’s expected outcomes during recovery from anes-thesia and surgery. Care planning is done in two parts:immediate care rendered in the PACU area and ongo-ing post-PACU care. Nursing care in PACU usually lasts1 to 3 hours and is directed toward returning the clientto a safe physiological level of functioning after anes-thesia. Care is prioritized according to the type of anes-thesia and surgical interventions through the assistanceof appropriate agency protocols (e.g., care of the clientfollowing extubation).

ASSESSMENT

During surgery Mrs. Broussard was placed in a lat-eral position and given a general anesthetic. She wasextubated before leaving OR with an oral airway inplace on arrival to PACU. Following assessment andmanagement of the “A-B-Cs” the nurse assessed:alignment of the left hip; the client’s level of pain;incision dressing for drainage, inspecting posteri-orly where drainage can pool; and circulatory,motor, and sensory status below the site of surgery.

• What immediate assessment parameters mustthe nurse address to ascertain the status of thepostoperative client?

• What priority areas must the nurse assess?• What measures should be implemented to deter-

mine the client’s level of pain?• What are the nurse’s priorities when inspecting

the incision?• What signs or manifestations should the nurse

be alert for regarding the incision?

TABLE 30-5Initial Postoperative Assessment: Normal and Abnormal Findings

Area of Assessment Normal Findings Abnormal Findings

Airway and Respiratory Status The client is able to: • Upper airway obstruction: • Adequacy of airway and return of gag, • Expel an oral airway; gag reflex has stridor, retractions, asymmetrical

cough, and swallowing reflexes returned chest movement • Type of artificial airway • Breathe deeply and cough freely with • Laryngospasm: high-pitched • Rate, rhythm, and depth of respirations normal rate for age, even, without use squeaky sounds • Symmetry of chest wall movements and of accessory muscles, and chest wall • Dyspnea: shortness of breath or

use of accessory muscles symmetry; breath sounds present in difficulty in breathing • Breath sounds all lobes; mucous membranes pink • Diminished breath sounds, • Color of mucous membranes • Pulse oximeter reading between 95% wheezing, rales, or rhonchi • Pulse oximeter readings and 100% • Residual neuromuscular blockage: • Amount and method of oxygen • If awake, demonstrates proper use of weak inspiratory effort, inability to

administration incentive spirometer lift head, or inadequate muscle • If awake, ability to deep breathe and strength

cough

Circulatory Status The client has: • Hypotension: BP <20 mm of• Apical and peripheral pulses • Normal apical rate and peripheral baseline; rapid, weak pulse; nail • Blood pressure (BP) pulses beds bluish; capillary refill >3 • Nail bed and skin color and • BP within 20 mm of baseline seconds

temperature measurements • Hemorrhage/hypovolemic shock: • Capillary refill • Pink nail beds; skin warm and dry rapid, weak pulse; increasing • Homans’ sign • Capillary refill <3 seconds respirations; restlessness; Monitoring devices: • Negative Homans’ sign hypotension; cold, clammy skin; • Cardiac monitor (ECG) • Normal ECG rhythm pallor; urinary output <30 ml/hr

(continues)

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After discharge from PACU, the nurse ensures thatthe client is knowledgeable about home care. Post-PACU care is begun for outpatients in the ambulatorysetting. The nursing interventions reinforce client safetyand teaching for discharge. For clients who are hospi-talized postoperatively, the nursing care plan encom-passes both inpatient and discharge needs.

InterventionsCare in the recovery unit is directed by standards of careand protocols. These tools assist the nurse in determin-ing the most effective interventions for specific clientpopulations, type of anesthesia, and surgical procedure.Postoperative nursing interventions are based on assess-ment and reassessment findings.

Safety measures are initiated immediately on arrivalinto the recovery unit (see Figure 30-13). Intubatedclients require the constant attendance of a nurse at thebedside. The head of the stretcher is maintained in ahigh Fowler’s position. Stretcher belts and side rails areleft in place from transfer; wheels on the stretcher arelocked. Lifesaving equipment is at the client’s bedside.

Maintaining Respiratory StatusOn arrival to the recovery area the client is placed onhigh-humidity oxygen and attached to a pulse oximeter(sensor device to measure the oxygen saturation level ofthe blood). The client is at risk for ineffective breathingpatterns resulting from the anesthesia. At least every 15minutes the nurse monitors the reading on the pulse

TABLE 30-5 (continued)Initial Postoperative Assessment: Normal and Abnormal Findings

Area of Assessment Normal Findings Abnormal Findings

• Pressure readings (arterial blood • Positive Homans’ sign (calf pain pressure or central venous pressure) present on dorsiflexion of foot)

• ECG pattern: dysrhythmias; signs of cardiac ischemia

Neurologic Status The client: Glasgow Coma Scale <15 indicates • Level of consciousness (Glasgow • Spontaneously opens eyes some alteration in consciousness; a

Coma Scale) • Is orientated score of 7 is considered coma• Eye opening • Obeys commands (Glasgow Coma • Verbal response Scale of 15, highest rating)• Motor response

Fluid and Metabolic Status Fluid intake balanced with total output, • Signs of deficient fluid volume (thirst, • Intake and output electrolytes within normal limits, poor skin turgor, low-grade • Palpate for bladder distention considering replacement of blood volume temperature, tachycardia, • Patency of intravenous (IV) infusion lost during surgery: respirations ≥30, a 10–15 mm

(type, rate, and amount) • IV fluids infusing per surgeon’s order decrease in systolic blood pressure, • Signs of dehydration (skin integrity and • Absence of bladder distension slow venous filling, urinary output

turgor) or overload (edema) • Good skin turgor <25 ml/hr) • Patency, amount, and character of • Absence of edema • Bright red blood on operative

drainage (catheters, drains, or tubes) • Drains and other tubing patent and intact dressing • Inspect operative dressing (type, color • Dressing dry and intact • Signs of excess fluid volume

and amount of drainage) • Bowel tones faint or absent during the (increased central venous pressure • Auscultate for bowel tones in all four immediate recovery phase and edema, pulmonary or

quadrants and inspect for • Absence of nausea and vomiting peripheral) abdominal distension

Level of Discomfort or Pain Client free from pain Pain not relieved by analgesia• Location, intensity, and duration • Type, amount of analgesia

administered and client’s response

Wound Management Dressing dry and intact Clot dislodged: bright red drainage • Inspect the dressing on the dressing• Note type and amount of drainage • If drainage is present, reassess in

15-minute intervals

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oximeter along with respirations. A patent airway can bemaintained with an endotracheal tube, nasal or oral air-ways, and suctioning when needed. See Chapter 32 fora complete discussion of airway devices.

If the client is extubated and experiences difficulty inbreathing, reestablish the upper airway: bring the chinforward, hyperextend the neck, and turn the head tothe side. If the obstruction is unrelieved, insert either anasal or an oral airway and suction. If these measuresfail to relieve the obstruction, notify the anesthetist. Theanesthetist is responsible for treating any physiologicalimpairments related to anesthesia.

The nurse tapes the endotracheal tube on intubatedclients to ensure proper placement. The client is main-tained in a high Fowler’s position to optimize breathingand lung expansion, unless contraindicated. Bronchialsecretions are removed by suctioning the intubatedclient. Suctioning is performed on the basis of assess-ment findings:

• Rhonchi (low-pitched gurgling sounds in large airways)• Low-pitched, musical wheezes despite bronchodila-

tor therapy• Increased peak airway pressure in clients receiving

mechanical ventilation

The lungs are usually hyperinflated and hyperoxy-genated before, between, and after suctioning to pre-vent hypoxemia and cardiac dysrhythmias. The nurseobserves the ECG monitor while suctioning to observefor signs of hypoxemia.

Hypoxemia can be caused by inadequate lung venti-lation from the depressant effects of anesthesia or nar-cotics. The PACU client is at risk for hypoxemia fromthe effects of general anesthesia, which reduces theinspiratory effort, and the presence of pain, whichreduces ventilatory effort. Older or obese clients areespecially vulnerable to postoperative hypoxemia(McCaffigan, 1996).

The early symptoms of hypoxemia are drowsinessand confusion. These symptoms are usually present in

PACU clients recovering from anesthesia. A blood oxy-gen level measurement less than 95% is an indication ofhypoxemia.

ExtubationThe agency’s protocol is implemented to determine theparameters for extubation, such as the client being ableto lift the head for 5 seconds and produce strong bilat-eral hand grasps. The nurse obtains a tidal volume, neg-ative inspiratory force, and vital capacity (if the clientcan cooperate) before extubation. See Chapter 32 forfurther discussion. The anesthetist is notified when theoxygen saturation percent is within safe limits to allowextubation.

The nurse confirms the presence of bilateral breathsounds immediately before and after extubation by aus-cultation. The procedure is explained to elicit clientcooperation and to allay anxiety. Before extubation, thepharynx and trachea are suctioned. The client isinstructed to inhale deeply while the anesthetist deflatesthe cuff and removes the endotracheal tube at maximallung inflation to encourage initial gas flux outward,allowing the forceful exhaling of secretions.

The client is placed immediately on humidified oxy-gen for at least 30 minutes and monitored with a pulseoximeter for an hour after extubation. Ventilation ismaintained by encouraging deep breathing, coughing,turning, and taking deep breaths every 5 to 10 minutes.

Maintaining Circulatory StatusThe client is monitored carefully for the signs ofhypotension (Table 30-5), which can occur from themyocardial depressant effects of residual anesthesia orhypovolemia. The cardiac monitor displays the client’sheart rhythm; it is used to detect and treat tachycardia,bradycardia, dysrhythmias, and cardiac ischemia.

Hypovolemic shock (marked reduction in circulatingblood volume) is caused from hemorrhage. The symp-toms of hemorrhage are presented in Table 30-5. Arapid pulse rate can indicate pain, bleeding, dehydra-tion, or shock. Impaired capillary refill indicates inade-quate tissue perfusion to extremities.

Passive range of motion and the application ofantiembolism hose or other devices promote circulationof the intubated or semiconscious client. Postoperativeleg exercises are begun as soon as the client recoversfrom the effects of anesthesia. These measures preventcirculatory complications such as thrombophlebitis,thrombus, and embolus formation.

Maintaining Neurologic StatusMonitoring the client’s level of consciousness is done inrelation to how the airway is maintained:

• The unconscious client with an absence of the coughand gag reflex will have an endotracheal tube or airway.

Figure 30-13 Postanesthesia Care Unit (PACU). What is the mostessential action the nurse should implement with the client in thissituation?

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• The semiconscious client with partial return of allreflexes will have an oral or nasal airway.

• The conscious client with full return of all reflexes willbreathe without assistance from an artificial airway.

The Glasgow Coma Scale is used to measure the client’slevel of response. See Chapter 36 for a description ofthe Glasgow Coma Scale.

The nurse monitors clients who had spinal anesthesiafor return of reflexes, sensation, and movement ofextremities below the level of anesthesia. Extremitiesare assessed for color, temperature, and pedal pulses.

Nursing care of clients with spinal anesthesiaincludes the prevention of a postspinal headache. Thepostspinal headache is thought to be caused by theleakage of cerebrospinal fluid from the puncture site inthe dura. Measures to prevent a headache include strictbed rest for 24 to 48 hours, adequate hydration withintravenous saline, and injection of 5 to 20 ml autolo-gous blood into the epidural space at the puncture site.

Maintaining Fluidand Metabolic StatusDuring the immediate postoperative phase, gastroin-testinal and genitourinary assessment and interventionsare considered from a fluid and metabolic perspective.The client is maintained on intravenous infusions asprescribed by the surgeon. The goal of intravenous ther-apy is to maintain the circulating fluid volume. Infusionsites are inspected for patency immediately when theclient arrives in the PACU. Frequent inspection of thesesites is necessary throughout recovery; intravenousaccess must be maintained in the event of complications(e.g., hemorrhage) that warrant emergency administra-tion of intravenous fluids or medications. Secretionsfrom tubes, drains, and the incision site are measured todetermine output. The client’s total output is comparedagainst the volume of intravenous replacement fluids.

After surgery, the muscle tone of the bladder is com-promised by analgesic or anesthetic agents. Assess forbladder distension by palpating the contour of thelower abdomen for a rounded mass above the symphysispubis. When clients cannot void within 8 hours, the sur-geon is notified for an order to catheterize. If the clienthas a Foley catheter, it should flow freely with urine.

Postoperative nausea and vomiting can be caused bymultiple factors. Anesthetic agents and opiates can stim-ulate the chemoreceptors of the inner ear and the vomit-ing center in the brain. Deficient fluid volume, electrolyteimbalances, drugs, and general anesthesia by mask tech-nique can also cause nausea and vomiting. Nausea andvomiting are treated with antiemetics.

Anesthetic agents can decrease peristalsis, resultingin diminished or absent bowel tones. Manipulation ofthe intestines further decreases the loss of bowel tones.The nurse auscultates for bowel tones and inspects forabdominal distension. A nasogastric tube is usually inplace for clients with abdominal surgery and clients atrisk for nausea and vomiting postoperatively.

With abdominal surgery, the nurse also monitors forabdominal distension to detect internal hemorrhage.Cullen’s sign (a bluish discoloration around the umbili-cus in postoperative clients) can indicate intra-abdomi-nal or perineal bleeding.

Clients are kept on an NPO status until the gag reflexreturns, they are free from nausea, and the presence ofbowel tones is detected. Certain drugs (analgesic/anes-thetic agents) have a drying effect on the oral mucousmembranes. Dehydration from loss of body fluids alsocauses dryness and thirst. Oral hygiene is performedfrequently to promote comfort and prevent infections.

Managing Pain Nurses assess for pain by allowing the client to rate theintensity of pain. Studies comparing nurses’ and clients’ rat-ings of pain have found little similarity between the two(Pasero, 1996). One study compared the pain ratings of 119postoperative clients and their nurses. The ratings matchedonly 35% of the time; nurses underassessed pain in 45% ofthe cases and overassessed pain in 20% of the cases.

Pain management is monitored and treated by intra-venous narcotics in titrated doses until the client is fully con-scious. Once the client is fully conscious, pain is managedaccording to physician order: PCA, continuous epiduralanesthesia, intravenous or intramuscular injection, TENS.

The nurse should institute comfort measures such assplinting the incision line and positional changes todecrease the client’s pain repsonse. Besides incisionalpain, the client can experience pain for other reasons,such as positioning during surgery, presence of tubes(endotracheal, nasogastric, chest, or Foley), and tightdressings or casts. Skin care and back rubs are done topromote comfort and circulation.

The Agency for Health Care Policy and Research(AHRQ) has clinically relevant practice guidelines forthe management of postoperative pain. Three interdis-ciplinary panels, chaired by nurses, developed guide-lines to inform the public on pain management:

• The provider should anticipate the pain.• It is least therapeutic to be medicated when in pain.• There are alternatives to pharmacologic manage-

ment of pain.

N U R S I N G A L E R TAbdominal DistensionWhen clients with abdominal surgery develop abdominaldistension, inspect the tape over the incision dressing;tension on the tape can cause disruption of skin integrity(irritation and blisters). This can also increase the client’srisk for a wound infection.

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Relaxation techniques, distraction, environmentalmanipulation, massage, and positioning are optionaltherapies. See Chapter 14 for additional information oncomplementary therapies for pain management.

Evaluation and Dischargefrom the PACUThe anesthetist is responsible for releasing the clientfrom the PACU. Agencies have specific standards of carethat have to be met before discharge. These standardsaddress achievement of specific client outcomes withinherent parameters for evaluation, such as:

• The client is conscious, oriented, and can move allextremities.

• The client demonstrates full return of reflexes.• The client can clear the airway and cough effectively.• Vital signs have been stable or within baseline ranges

for 30 minutes.• Intake and urinary output are adequate to maintain

the circulating blood volume.• The client is afebrile, or a febrile condition has been

treated accordingly.• Dressings are dry or have only minimal drainage.

The surgeon manages the client’s treatment throughoutthe remainder of the postoperative phase.

Ongoing Postoperative CareThe postoperative phase continues until the client isreleased from the surgeon’s care. The primary goal dur-ing this phase is to restore physiological functioning,promote healing, and prevent complications. When theclient is discharged from the PACU, the client goeseither directly to an inpatient hospital bed or to the out-patient ambulatory unit for observation. The surgeonwill later decide whether to admit the client to an inpa-

tient 24-hour observation room or to discharge theclient. When clients are discharged to their residence,they often require the services of a home health nurseto assist with their postoperative care. The home healthnurse will continue to assess and provide necessary careuntil the client achieves the expected outcomes.

Postoperative nursing care after discharge is basedon the nursing diagnoses and expected outcomes thatstill have not been met (see the accompanying display).Clients who are discharged without the services of ahome health agency assume their own care or have afamily member or significant other serve as the careprovider. In this situation, specific written dischargeinstructions are explained to the client or care provider.

Ineffective Airway ClearanceIneffective Airway Clearance during this phase can resultfrom a diminished cough reflex or increased pulmonarycongestion. The nurse monitors skin color and respira-tory rate and depth and auscultates breath sounds todetermine the adequacy of oxygenation and to identifycomplications (e.g., atelectasis). Deep breathing andcoughing and the use of the incentive spirometer arecontinued until the client demonstrates achievement ofrespiratory outcomes.

Ineffective Tissue PerfusionIneffective Tissue Perfusion (Cardiopulmonary) related to inad-equate circulation is a possible nursing diagnosis. Thenurse monitors pulse rate and quality, blood pressure, skinand nail bed color and condition, and temperature forindications of decreased oxygenation at the cellular level.Capillary refill and peripheral pulses are checked for ade-quate circulation to the extremities. The nurse monitorsthe lower extremities for signs of superficial vein throm-bosis (local warmth, swelling, pain, redness) and deepvein thrombosis (a positive Homans’ sign).

Postoperative leg exercises are performed until theclient is able to ambulate and resume activities of dailyliving. Antiembolism hose are usually worn until theclient returns for the first office visit. At that time thesurgeon assesses the need to continue use of the hose.

Other devices, pneumatic compression, and CPM aremaintained according to the physician’s order. Clientsare encouraged to ambulate while these devices are inplace to promote respiratory, circulatory, and gastroin-testinal functions. The CPM device is used until signs ofincision swelling have decreased, healing is evident, andrange of motion is achieved.

Deficient Fluid VolumeDeficient Fluid Volume can be related to active fluid volumeloss, inadequate fluid intake from being NPO, or nauseaand vomiting. The client is monitored for intake and out-put that includes secretions from drainage tubes, drains,and dressings. If oral fluids are restricted, the client is

DISCHARGE TEACHING

Client Expected Outcomes

Before discharge, the client can:

• List the symptoms to be reported to the physician onoccurrence.

• Describe limitations in activity.• Explain dietary limitations.• Explain the meaning and purpose of medications. • Explain potential food or drug interactions.• Describe the use of Standard Precautions as appropriate.• Demonstrate aseptic technique in changing dressings.• Demonstrate use or application of prescribed med-

ical devices (identify appropriate device).

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maintained on intravenous infusions as ordered by thesurgeon. The nurse monitors the patency of the intra-venous line, observes for signs of infiltration, and recordsthe amount and type of fluids infused. The nurse assessesfor signs of dehydration or fluid overload. See Chapter 37for a discussion of fluid balance.

Home health clients with continuous intravenous ther-apy are maintained on an infusion pump. The caregiveris taught how to add infusions to the line under steriletechnique. The home health nurse visits the client dailyto assess for intravenous patency. A nurse is usually on call24 hours for clients receiving continuous infusions.

Imbalanced NutritionImbalanced Nutrition: Less Than Body Requirements is usu-ally related to anesthesia or surgical manipulation of theintestines. Until peristalsis returns and nausea,anorexia, or vomiting subsides, the client is maintainedon intravenous therapy to maintain fluid and electrolytebalance. Nasogastric tube drainage is measured, andcolor and consistency are documented. See Chapter 38for more information.

Clients with abdominal surgery can take up to 2 to 3days or longer for return of normal gastrointestinalfunction. The nurse auscultates the abdomen for gur-gling and rumbling sounds in all four quadrants to indi-cate return of peristalsis. Early ambulation promotes thereturn of peristalsis. When bowel tones return and nau-sea subsides, the client’s diet is progressive: first icechips, then clear to full liquids; if tolerated, the diet isprogressed to soft or regular. Some clients are on a reg-ular diet within hours after surgery. See Chapter 38 fora discussion of types of modified diets.

Urinary RetentionUrinary Retention is related to anesthesia or surgicalmanipulation that causes temporary loss of bladdertone. Efforts are made to promote urination (e.g., maleclients are more prone to void if they can stand). If theclient does not void within 8 hours after surgery, assessfor bladder distension and notify the surgeon. The sur-geon can order a straight or Foley catheter. Clients mustvoid before they can be released from the ambulatory setting.

Acute PainPosition changes and splinting are continued to relievepain. Clients can be discharged to home with a PCApump. Before discharge the nurse ensures that theclient is able to correctly self-administer using the PCA.Efforts are made to provide adequate rest by schedulingprocedures that do not interfere with sleep.

Risk for InfectionThe client with a surgical incision is at risk for infection.Wound healing begins as early as 2 hours after surgery.

The nurse ensures that the dressing is clean, dry, andintact; dressings promote rapid re-epithelialization andprotect against infection. Various types of dressings areused: conventional absorbent nonocclusive, semiocclu-sive hydroactive, and occlusive hydrocolloid.

In a study of 250 heart surgery clients, Wikblad andAnderson (1995) found that hydroactive dressings werenot as effective as occlusive hydrocolloid and absorbentnonocclusive dressings in preventing wound infections.Hydroactive dressings were difficult to remove andpainful to the client. An earlier study by Bolton and vanRijswijk (1991) showed that epithelialization can bedelayed by repeated trauma or removal of dressings thathave aggressive adhesives.

Nurses use Standard Precautions when caring forclients and sterile technique when changing a dressing.The incision line is assessed when the nurse changes thedressing. For some clients, the surgeon usually ordersprophylactic antibiotics and removes any catheters ordrains as soon as possible to prevent an infection. If theclient were to develop a deep wound infection, it couldnecessitate prosthesis removal.

To monitor for signs of an infection, the nurse notes thetype and amount of drainage on the dressing and the stageof wound healing. Vital signs are measured, recorded, andanalyzed against laboratory results, especially the whiteblood cell count and differential. The client is taught tocare for the wound and to observe for the complications ofwound healing: hemorrhage, hematoma formation, infec-tion, dehiscence, and evisceration. See Chapter 35 for adiscussion of these complications.

• The client’s respiratory function has returnedto baseline level within 1 week after surgery asdemonstrated by respirations 16 to 20/minute,deep and regular, skin color pink, lungs soundsclear on auscultation; oxygen saturation greaterthan 95%.

• The client’s cardiopulmonary function hasreturned to baseline level within 1 week aftersurgery as demonstrated by: blood pressurewith 10 to 20 mm Hg of baseline measurement;absence of dysrhythmias; pulse rate 60 to 90beats per minute; skin pink, warm, and dry; cap-illary refill less than 3 seconds; peripheralpulses present; negative Homans’ sign; outputis within 500 ml of intake.

• The client is free from signs of a wound infec-tion within 72 hours after surgery as demon-strated by: afebrile; pulse and respirations atbaseline level; sutures intact; incision line with-out swelling, redness, or purulent exudate; scabsloughing.

NURSING CHECKLISTPostoperative Documentation✓

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EvaluationEvaluation is based on client-specific postoperative nurs-ing diagnoses and achievement of outcomes. The timeframe for the client’s achieving the outcomes can varywith the client’s health status, surgical procedure, andother factors, such as age. The nurse documentsachievement of outcome criteria data (see the NursingChecklist on the previous page).

K E Y C O N C E P T S

• The major role of nursing functions in caring for theperioperative client is to foster the achievement ofexpected outcomes of care.

• Outpatient surgical clinics decrease the client’slength of stay in the hospital and health care costs.

• Management of the perioperative client occurs invarious health care settings.

• Effective perioperative management is directed by amultidisciplinary team on the basis of recognizedstandards of care, protocols, and individualizedexpected client outcomes.

• Assessment of the client’s status before surgery estab-lishes baseline data to direct interventions through-out the perioperative phases.

• Interventions of the health care team focus ondecreasing the perioperative client’s risks for compli-cations.

• Documentation of the client’s response to interven-tions and achievement of expected outcomes pro-vides the framework for evaluation.

• Coordination of discharge care begins in the preop-erative phase and is reinforced throughout the othertwo phases.

C R I T I C A L T H I N K I N G A C T I V I T I E S

1. Mrs. G is a 45-year-old wife and mother who needsan emergency hysterectomy; however, she has nohealth insurance. Where should Mrs. G seek surgi-cal intervention? With emergency surgery there islittle time for client teaching. How does the nursehandle this challenge? What type of supportshould the family receive?

2. An 11-year-old child is hospitalized for surgicalrepair of an ankle injury. The child lives with a sin-gle parent, a 5-year-old brother, and a 3-year-oldsister. What age-related considerations need to beincorporated into planning the discharge care ofthe child, keeping in mind the implications on thefamily unit?

3. Mr. S is an 86-year-old inpatient client scheduledfor heart surgery. The evening before surgery herequests the sacrament of Anointing of the Sick.What nursing activities should the nurse institute?

4. Although the primary activity of perioperativenursing is client-centered care, nurses must alsohave an awareness of inherent “cost” challenges.Discuss how nurses can have a positive or negativeimpact on health care costs related to surgery.

5. You are working the evening shift on a surgicalunit. You assess a client on his second postopera-tive day; he is receiving morphine, 2 to 4 mg/hr,with a PCA pump. He has had 17 mg morphineduring the past 6.5 hours. During your assessmentyou observe that he is nodding and unable to tellyou the day of the week, his color is pale, the vitalsigns are: T-37°C, P-94, R-12, BP 144/92. Whatnursing actions should you initiate to determine ifthe client’s symptoms are caused from a lack ofsleep, the morphine, or hypoxemia?

6. Identify the ongoing postoperative nursing diag-noses, expected outcomes, interventions, and eval-uation criteria in planning the discharge care forMrs. Broussard from the hospital the second post-operative day.

W E B R E S O U R C E S

Agency for Health Care Policy and Research (AHRQ)www.ahrq.gov

Association of periOperative Registered Nurseswww.aorn.org

Occupational Safety & Health Administration, U.S.Department of Laborwww.osha.gov

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responding to the needs of the perioperative client

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