Surgical Client

Perioperative nursing

Nursing care around the operation: before (pre-op), during (intra-op), and after (post-op) surgery

What does "peri" mean in perioperative?

"Around" (around the operation)

What does the relay-race analogy in perioperative care represent, and what is the "baton"?

Each phase hands the client to the next phase;

the baton is information.

Dropped baton = poor communication = client can be harmed

Baseline

The client's normal starting point (normal vital signs, alertness, etc.), recorded before surgery so changes can be recognized afterward

Why do nurses record baseline data before surgery?

So they can tell if anything changes afterward

Comorbidity

Another health condition the client already has (e.g., diabetes, COPD) besides the reason for surgery

Complication

A new problem that develops because of the surgery or recovery (e.g., infection, blood clot)

Surgical suite

The area that holds the operating rooms

Client vs. patient

The notes use "client" for the person receiving care;

"patient" is the same idea

Preoperative phase: starts when?

When the client decides to have surgery

Preoperative phase: ends when?

When the client is transferred to the surgical suite

Preoperative phase: nurse's main job

Assess, teach, make sure consent is done, find risks

Intraoperative phase: starts when?

When the client is in the surgical suite

Intraoperative phase: ends when?

When the client is admitted to the recovery room (PACU)

Intraoperative phase: nurse's main job

Keep the client safe, keep the area sterile, speak up (advocate) for the client

Postoperative phase: starts when?

When the client is admitted to the recovery room

Postoperative phase: ends when?

At the follow-up appointment

Postoperative phase: nurse's main job

Monitor, prevent and catch complications, manage pain, get the client moving

A client is being wheeled from the pre-op area into the operating room. Which phase just ended?

Preoperative phase (ends at transfer to the surgical suite)

A client has just been admitted to the PACU. Which phase has begun?

Postoperative phase (and the intraoperative phase has ended)

Exam wording alert: when does the preop phase begin?

The chapter intro says when the client decides to have surgery; the summary says at admission. Use your instructor's wording on exams

RN vs. PN: who performs the client assessment independently?

The RN

What is the PN's role in assessment?

Collects and reports client data and reports changes to the RN or provider

PN scope-of-practice rules vary by what?

By state; PN students follow their own state's rules

What are the nurse's three big jobs before surgery?

Assess the client, teach the client, and make sure informed consent is handled

What is the top priority in the preoperative phase, and why?

Assessment, because its purpose is client safety: finding anything that could make surgery riskier and recording baseline data

What does the preoperative assessment include?

Head-to-toe exam, review of medical history, and review of ordered lab and diagnostic tests

Besides assessing, what else does the nurse check about the planned procedure?

That the client understands the planned procedure;

applies the right identification bands (such as an allergy band) per facility policy

What is the goal of collecting the health history?

To spot comorbidities before surgery

What does the health history include?

Medical history, surgical history, allergies, current medications, and social history

Which body systems' conditions matter MOST for surgical risk?

Heart and lung conditions

Name the heart and lung conditions that can cause problems during surgery.

COPD, obstructive sleep apnea (OSA), asthma, coronary artery disease (CAD), congestive heart failure (CHF)

A client's history shows COPD and CHF. What should the nurse do with this information?

Pass it to the intraoperative team so they can add extra monitoring if needed

What should the nurse ask about surgical history?

• Past surgeries,

• how the client did with anesthesia,

• whether the client or any family member has had malignant hyperthermia

Malignant hyperthermia

A severe, potentially life-threatening reaction to certain anesthesia medications

A client says her brother had malignant hyperthermia during surgery. What is the nurse's best action?

Report it/communicate it to the surgical team so they can take preventive (prophylactic) steps

How should allergies be handled before surgery?

Record every allergy (medications and other substances like latex or foods) and make sure an allergy band is placed

What must be documented about medications?

Everything: prescriptions, over-the-counter drugs, and herbal supplements

What should the nurse do if a medication raises surgical risk?

Report it to the provider right away

Why do nurses check the last time a client took anticoagulants?

Blood thinners raise the risk of bleeding and may need to be stopped before surgery

A client taking warfarin is scheduled for surgery tomorrow. What should the nurse verify first?

The last time the client took the anticoagulant (and report it to the provider)

Why does recent tobacco use raise surgical risk?

Higher carbon monoxide levels in the blood and worse oxygen exchange

What risks does regular alcohol use add to surgery?

Bleeding, infection, heart problems, and a longer hospital stay

How should the nurse handle spiritual and cultural beliefs?

Ask about any requests tied to beliefs, record them, and provide culturally competent care (which improves quality and outcomes)

Why do spiritual beliefs matter in surgical care?

Many people use spiritual resources to cope with pain and stress

Which group may be reluctant to have surgery because of beliefs about how healing happens (book example)?

Some Buddhist clients

Which group often opposes medical treatment and may fear being forced into unwanted treatment (book example)?

Clients who practice Christian Science

High pre-op anxiety/stress is linked with what?

Poorer surgical outcomes

What communication style should the nurse use with an anxious pre-op client?

Empathetic, active listening, and clear communication

Purpose of the preoperative physical assessment

Find needs or problems and set a baseline; the nurse also notices the client's mental and emotional state

General survey: what is checked?

Vital signs

• BP, pulse, respirations, temperature, oxygen saturation, pain level)

overall appearance

• alertness, hygiene, distress)

height and weight

What should the nurse do with abnormal pre-op vital signs?

Document them and report to the provider

Pain assessment factors before surgery

Current pain, plus age, fear, anxiety, and type of surgery; pain control is planned before, during, and after surgery

Neurologic assessment: what is checked?

Alert and oriented to person, place, time, and situation; sensory problems; motor strength

Why is the pre-op neurologic baseline so important?

A change in mental status can be the first sign the client is getting worse

Head and neck assessment: what is checked?

Moisture and color of mucous membranes and gums (hydration); missing or broken teeth; past intubation problems; lymph nodes; nasal drainage

Why does the anesthesia provider need to know about teeth and airway issues?

They affect intubation and airway management

What can yellow or green nasal discharge or tender lymph nodes indicate?

Infection

Skin (integumentary) assessment: what is checked, and why?

Color, turgor (hydration clue), breakdown, lesions, edema, redness, pain;

it finds risk for pressure injuries during surgery

Lungs and thorax: what is checked?

Abnormal (adventitious) sounds, clubbing, use of accessory muscles

A client has wheezing before surgery. What may be needed before anesthesia?

A bronchodilator

Cardiovascular assessment: what is checked?

Heart sounds, rate and rhythm;

carotid artery;

capillary refill and pulses in all four limbs;

leg edema (baseline for circulation)

Gastrointestinal assessment: what should be done FIRST?

Have the client empty the bladder first

GI assessment: what is checked?

Contour, symmetry, distention;

bowel habits;

trouble swallowing, nausea, vomiting

Correct order of assessment techniques for MOST body systems

Inspection, palpation, percussion, auscultation

Correct order of assessment techniques for the ABDOMEN

Inspection, auscultation, palpation, percussion

Why is the abdomen auscultated before palpation?

Pressing on the belly can change bowel sounds

NCLEX-style: Which sequence is correct for an abdominal assessment? (A) palpation, inspection, auscultation, percussion (B) inspection, auscultation, palpation, percussion (C) inspection, palpation, percussion, auscultation (D) auscultation, percussion, inspection, palpation

B: inspection, auscultation, palpation, percussion

Name four goals of pain management after surgery.

• Relief of suffering,

• ability to move after surgery,

• shorter hospital stay,

• client satisfaction

Multimodal pain therapy

Several kinds of pain medicine that work in different ways, plus nonmedication methods (relaxation, massage)

Why use multimodal pain therapy?

It cuts the need for opioids and reduces side effects like nausea, constipation, and sedation

What items must be removed before surgery?

Dentures, piercings, and prosthetics

Informed consent

Formal permission, given with knowledge of the possible consequences and alternatives, by the client or legal representative, for care or a procedure

Who explains the procedure, reasons, risks, benefits, alternatives, and who will be present?

The provider (surgeon), NOT the nurse

Who checks that the client understands the procedure and answers the client's questions?

The provider

What is the nurse's role in informed consent?

Verify and witness that the client signed in their presence; confirm the client is of legal age and competent; notify the provider if the client still has questions or if the consent form does not match the scheduled procedure

A client asks the nurse, "What are the risks of this surgery?" before signing consent. What is the nurse's best action?

Notify the provider so they can explain; the nurse does not explain the surgery in place of the provider

The consent form lists a right knee arthroplasty but the schedule says left knee. What should the nurse do?

Notify the provider before surgery proceeds (consent does not match the scheduled procedure)

What must be true of how the client gives consent?

Voluntary, without pressure, with a chance to ask questions

The nurse witnesses consent. What exactly is the nurse witnessing?

That the client signed in the nurse's presence (not that the client understood the medical details)

Who can give consent if the client cannot?

The client's legal representative

What factors decide which pre-op tests are ordered?

Surgery type, existing conditions, age, and provider preference

Why are pre-op tests done?

To set a baseline and flag problems before surgery

Most common pre-op lab

Complete blood count (CBC)

What does a CBC show?

Fluid status, anemia, and infection

CMP or BMP (metabolic panels): what do they show?

Kidney function, liver function, electrolytes

Which pre-op test is used for clients with diabetes?

Fasting blood glucose or HbA1c

Coagulation studies

Check bleeding risk (depending on surgery and history)

Which diagnostic tests may be done for clients with heart or lung disease?

ECG, stress test, chest x-ray, pulmonary function testing, sleep study

Goals of perioperative client teaching

• Prepare the client,

• lower anxiety,

• help the client care for themselves after surgery, and

• support the family

How can good teaching affect hospital stays and costs?

It can shorten stays and cut costs

What should teaching be like, and when can it happen?

Individualized and evidence-based;

can happen weeks before surgery or right before it

Teach about the day of surgery: topics

Arrival time, where to check in, what to bring, visitor policy, expected length of stay

NPO

Nothing by mouth (client teaching: when to stop eating and drinking before surgery)

Skin preparation teaching

Client may need to wash with a special soap at home

Medication teaching before surgery

Which medications and supplements to stop

Tobacco and alcohol teaching

Benefits of quitting, with resources if needed

Post-op teaching topics

• What to expect right afterward;

• how pain will be rated and controlled (hospital and home);

• coughing and deep breathing (splinting, incentive spirometer);

• early mobility and activity restrictions

Splinting

Holding a pillow firmly over the incision when coughing or moving to reduce pain and support the incision

What tool keeps information flowing through every perioperative phase?

The AORN Comprehensive Surgical Checklist