KEPERAWATAN

PERIOPERATIF

Kuswantoro Rusca Putra, S.Kp.M.Kep

PENDAHULUAN
Perioperatif
:
Praoperatif,
Intraoperatif,
Pascaoperatif
Praoperatif Peran keperawatan perioperatif
dimulai ketika keputusan untuk intervensi bedah
dibuat & berakhir ketika pasien dikirim ke meja
operasi
Intraoperatif dimulai ketika pasien masuk ke
kamar bedah & berakhir saat pasien dipindahkan ke
ruang pemulihan
Pascaoperatif dimulai masuknya pasien ke ruang
pemulihan & berakhir dengan evaluasi tindak lanjut
pada tatanan klinik atau rumah

CLASSIFICATION OF SURGICAL PROCEDURES

Based on Urgency
Classification

Purpose

Examples

Elective

To remove or repair a body part

To restore function
To improve health
To improve self-concept

Tonsillectomy, hernia
repair, cataract extraction
and lens implantation,
hemorrhoidectomy

Urgent

To remove or repair a body part

To preserve or restore health
To prevent further tissue
damage

Removal of gallbladder,
coronary artery bypass,
surgical removal of a
malignant tumor, colon
resection, amputation

Emergency To preserve life (plus purposes

listed above)

Control of hemorrhage;
repair of trauma,perforated
ulcer,intestinal obstruction;
tracheostomy

CLASSIFICATION OF SURGICAL PROCEDURES

Based on Purpose
Classification

Purpose

Examples

Diagnostic

To make or confirm a
diagnosis

Ablative

To remove a diseased Appendectomy,

thyroidectomy,
body part

Breast
biopsy,
bronchoscopy,
laparotomy

gastrectomy,
amputation

Palliative

colon

laparoscopy,
exploratory
subtotal
partial
resection,

Colostomy,
dbridement
To relieve or reduce
intensity of an illness; necrotic tissue
is not curative

of

CLASSIFICATION OF SURGICAL PROCEDURES

Based on Purpose
Classification

Purpose

Reconstruc To restore function to

tive
traumatized or
malfunctioning tissue
To improve self
concept
Transplant To replace organs or
ation
structures that are
diseased or
malfunctioning

Examples
Scar revision, plastic surgery, skin
graft, internal
fixation of a fracture, breast
reconstruction
Kidney, liver, cornea, heart, joints

Constructi To restore function in Cleft palate repair, closure of atrial

ve
congenital anomalies septal defect

Endoscopic thoracoscopy

Effects of Anesthetic Agents

TYPE OF
ANESTHESIA

EXPECTED RESULT

RISKS

General
Total unconscious
anesthesia state, placement of a
tube into the trachea

Mouth or throat pain,

hoarseness, injury to mouth
or teeth, awareness under
anesthesia, injury to blood
vessels, aspiration, pneumonia

Spinal or Temporary decreased

epidural
sensation or loss of
analgesic/
feeling and
anesthesia movement to lower
(with and part of the body
without
sedation)

Headache, backache, buzzing

in the ears, convulsions,
infection, persistent weakness,
numbness, residual pain, injury
to blood vessels

Effects of Anesthetic Agents

TYPE OF
ANESTHESIA

EXPECTED RESULT

Major/minor Temporary loss of

nerve block feeling or
(with
and movement of a
without
specific limb or
sedation)
area
Intravenous Temporary loss of
regional
feeling and/or
anesthesia
movement of an
(with
and extremity
without
sedation)

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

Effects of Anesthetic Agents

TYPE OF
ANESTHESIA

Local
anesthesia

EXPECTED RESULT

Reduced pain

RISKS

Increase anxiety
Occasional
allergic
reaction

Injection sites for spinal and epidural anesthesia

Cross-section of injection sites for peripheral nerve, epidural and spinal blocks.

INHALATION GENERAL ANESTHETIC AGENTS

Halothane (Fluothane, Somnothane)

Methoxyflurane (Penthrane)
Enflurane (Ethrane)
Isoflurane (Forane)

COMMON INTRAVENOUS AGENTS

USED FOR GENERAL ANESTHESIA
Barbiturates: methohexital sodium, thiamylal sodium,
thiopental sodium propofol

Benzodiazepines: diazepam and midazolam

Narcotics: alfentanil hydrochloride, fentanyl, and sufentanil
citrate

Neuromuscular blocking agents: atracurium besylate,

doxacurium chloride, gallamine triethiodide, metocurine
iodide, mivacurium chloride, pancuronium bromide,
pipecuronium
bromide,
succinylcholine
chloride,
tubocurarine chloride, and vecuronium bromide

COMMONLY USED LOCAL ANESTHETIC AGENTS

Bupivacaine hydrochloride (Marcaine, Sensor-caine)

Chloroprocaine (Nesacaine, Nesacaine-MPF)
Etidocaine hydrochloride (Duranest)
Lidocaine hydrochloride (Xylocaine)
Mepivacaine hydrochloride (Carbocaine, Polo-caine)
Procaine hydrochloride (Novocain)
Tetracaine hydrochloride (Pontocaine)

PREOPERATIVE
PHASE
Kuswantoro Rusca Putra, S.Kp.M.Kep

Assessment
O Nursing History
O Medical History
O Medications (Herbs, Allergies)
O Age-Related Considerations
O Social and Cultural Considerations

O Spiritual Considerations
O Psychosocial Status
O Physical Assessment

DRUGS THAT PLACE SURGICAL

CLIENTS AT RISK
O Aspirin: May increase bleeding
O Antidepressants: May lower blood pressure dur-

O
O
O

ing anesthesia
Bromide in medications (e.g., Sominex): Can
accumulate 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
other drugs from blood proteins

ASSESSMENT QUESTIONS:
PSYCHOSOCIAL STATUS
O Why are you having surgery?
O When did this problem start?

O What do you think caused this problem?

O Has this caused any problems with your

relationships with others?

O Has your problem prevented you from
working?
O Are you able to take care of your own needs?

ASSESSMENT QUESTIONS:
PSYCHOSOCIAL STATUS
O Are you experiencing any discomfort or pain?
O What are you expecting from this surgery?

O Is there anything that you do not understand

regarding your surgery?

O Are you worried about anything?
O Will someone be available to assist you when
you return home?

FOCUS ON THE OLDER ADULT

NURSING INTERVENTIONS TO ADDRESS

AGE-RELATED INCREASED SURGICAL RISK

Age Related Changes

Cardiovascular
Decreased cardiac output,
stroke volume and cardiac
reserve
Decreased
peripheral
circulation
Increased vascular rigidity

Nursing Interventions
Obtain and record baseline vital
signs.
Assess peripheral pulses.
Teach leg exercises, turning, and
ambulating.
Document normal activity levels
and tolerance of fatigue.
Monitor fluid administration rate.
Allow sufficient time for effects of
medications to occur.

FOCUS ON THE OLDER ADULT

NURSING INTERVENTIONS TO ADDRESS

AGE-RELATED INCREASED SURGICAL RISK

Age Related Changes

Respiratory
Reduced vital capacity

Nursing Interventions

Obtain and record baseline

respiratory depth and rate.
Diminished cough reflex
Teach coughing and deep
Decreased oxygenation of
breathing exercises.
blood
Teach use of incentive
Decreased chest expansion
spirometer.
and strength of intercostal Assess color of skin.
muscles and diaphragm
Explain use of pulse
oximeter for monitoring
postoperative oxygenation.

FOCUS ON THE OLDER ADULT

NURSING INTERVENTIONS TO ADDRESS

AGE-RELATED INCREASED SURGICAL RISK

Age Related Changes

Nursing Interventions

Central Nervous System

Decreased reaction time and Orient to surroundings.
coordination
Institute safety measures,
Reduced short term memory
such as keeping
Sensory deficits
environment clear of clutter
Decreased thermoregulation
and using a night light.
ability
Allow additional time for
teaching.
Use appropriate measures
to conserve body heat.

FOCUS ON THE OLDER ADULT

NURSING INTERVENTIONS TO ADDRESS

AGE-RELATED INCREASED SURGICAL RISK

Age Related Changes

Renal
Decreased renal blood flow
Reduced bladder capacity

Nursing Interventions
Monitor amount and times
of voiding.
Monitor fluid and electrolyte
status.
Maintain and record intake
and output.

FOCUS ON THE OLDER ADULT

NURSING INTERVENTIONS TO ADDRESS

AGE-RELATED INCREASED SURGICAL RISK

Age Related Changes

Nursing Interventions

Gastrointestinal
Increased gastric pH
Obtain baseline weight.
Prolonged gastric emptying Monitor nutritional status
time
(weight, laboratory data).
Decreased hepatic blood flow, Observe for prolonged
liver mass, and enzyme
effects of medications.
function

FOCUS ON THE OLDER ADULT

NURSING INTERVENTIONS TO ADDRESS

AGE-RELATED INCREASED SURGICAL RISK

Age Related Changes

Nursing Interventions

Integumentary
Decreased vascularity
Assess skin status.
Decreased skin moisture and Monitor fluid status.
elasticity
Pad and protect bony
Decreased subcutaneous fat
prominences.
Monitor skin for pressure
areas.
Use minimal amounts of
tape on dressings and
intravenous sites

FOCUSED ASSESSMENT GUIDE

PREOPERATIVE PHYSICAL ASSESSMENT

Factors to Assess

Questions and Approaches

General survey

Note general state of health.

Note body posture and stature.
Take and record vital signs.

Skin

Inspect skin for color,

characteristics, and location
and appearance of lesions.
Assess skin over bony
prominences.
Palpate skin turgor.

FOCUSED ASSESSMENT GUIDE

PREOPERATIVE PHYSICAL ASSESSMENT

Factors to Assess
Chest and lungs

Cardiovascular system

Questions and Approaches

Observe chest excursion and
diameter and shape of thorax.
Auscultate breath sounds.
Palpate for any pain or tenderness.
Inspect for jugular vein distention.
Auscultate apical rate, rhythm, and
character.
Auscultate heart sounds.
Assess for peripheral edema.
Palpate character of peripheral
pulses.

FOCUSED ASSESSMENT GUIDE

PREOPERATIVE PHYSICAL ASSESSMENT

Factors to Assess

Questions and Approaches

Abdomen

Ask time of last bowel movement.

Inspect abdominal contour.
Auscultate bowel sounds.

Neurologic system

Note orientation, level of

consciousness, awareness, and
speech.
Assess reflexes.
Assess motor and sensory ability.
Assess visual and hearing ability.

FOCUSED ASSESSMENT GUIDE

PREOPERATIVE PHYSICAL ASSESSMENT

Factors to Assess
Musculoskeletal
system

Questions and Approaches

Inspect and note joint range of
motion.
Palpate muscle strength.
Assess ability to ambulate.

Examples of NANDA Nursing Diagnoses

NURSING DIAGNOSIS

Nursing
Diagnoses
Grieving

Related Factors
Any condition that is
perceived as a
potential loss, such as
physical ability and
appearance following
surgery

Sample Defining
Characteristics
Verbalizations of
distress at the
potential loss
Denial of the
potential loss
Altered eating
habits, sleep
patterns, activity
level, and/or libido

Examples of NANDA Nursing Diagnoses

NURSING DIAGNOSIS

Nursing
Diagnoses
Anxiety

Related Factors

Sample Defining
Characteristics

Any condition that is

perceived as a threat or
danger, such as effects
of surgery on ability to
carry out family roles
and responsibilities.
Any condition that is
perceived as a danger,
such as the possibility
of dying while under
anesthesia

Restlessness, poor eye

contact, fidgeting, quivering
voice, hand tremor
Increased pulse and
respirations
Abdominal pain, sweating,
dry mouth, fatigue, nausea,
urinary frequency
Preoccupation,
forgetfulness, decreased
attention span
Verbalizations of distress,
worry, being afraid

Examples of NANDA Nursing Diagnoses

NURSING DIAGNOSIS

Nursing
Diagnoses
Risk
Infection

Related Factors

for Any condition that

interferes with normal
inflammatory healing
process

Sample Defining
Characteristics
Risk Factors
Obesity
Aging
Immunosuppression
Malnutrition

Outcome Identification
and Planning
Specific appropriate outcomes include that the
patient:
O Is physically and emotionally prepared for
surgery
O Demonstrates turning, coughing, and deepbreathing exercises
O Verbalizes understanding of postoperative
pain management
O Maintains fluid intake and nutritional balance
to meet needs

Implementing
Preparing the patient psychologically through

communicating
Preparing the patient psychologically through
teaching
Teaching about surgical events and
sensations
Teaching about pain management
Teaching about physical activities (Deep
Breathing, Coughing, Incentive Spirometry,
Leg Exercises, Turning in Bed)

Implementing
Preparing the Patient Physically

Hygiene and skin preparation

Elimination
Nutrition and fluids
Rest and sleep

COMMON CIRCULATORY
COMPLICATIONS AFTER SURGERY
AND ANESTHESIA
Thrombophlebitis: Inflammation of a vein with

the formation of a blood clot

Thrombus: A blood clot in the circulatory
system
Embolus: A blood clot or air that moves in the
circulatory system from its place of origin

COMMON RESPIRATORY
COMPLICATIONS AFTER SURGERY
AND ANESTHESIA
Pulmonary embolism: A blood clot that has

moved to the lungs, causing pulmonary

obstruction
Atelectasis: Decreased ventilation caused by
the pooling of secretions in dependent areas
of the bronchiole
Pneumonia: Inflammation of lung tissue
Hypoxemia: Lowered oxygen level in the blood

INTRAOPERATIVE
PHASE

The Surgical Team

O The Circulating Nurse
O The Scrub Role
O The Surgeon

O The Anesthesiologist and Anesthetist

The Surgical Environment

To help decrease microbes, the surgical area is
divided into three zones :
the unrestricted zone, where street clothes are
allowed
the semirestricted zone, where attire consists of
scrub clothes and caps
the restricted zone, where scrub clothes, shoe
covers, caps, and masks are worn

Peraturan Dasar Asepsis Bedah

Umum
Permukaan atau benda steril dapat bersentuhan
dengan permukaan atau benda lain yang steril
dan tetap steril
Jika terdapat keraguan tentang sterilitas pada
perlengkapan atau area, maka dianggap tidak
steril atau terkontaminasi
Apapun yang steril untuk satu pasien dapat
digunakan hanya pada pasien ini.

Peraturan Dasar Asepsis Bedah

Personel
Personel yang scrub tetap dalam area prosedur bedah
Hanya sebagian kecil dari tubuh individu scrub
dianggap steril : dari bagian depan pinggang sampai
daerah bahu, lengan bawah dan sarung tangan
Pada beberapa ruang operasi, suatu pelindung
khusus yang menutupi gaun dipakai memperluas
area steril
Perawat instrumentasi & semua personel yang tidak
scrub tetap berada pada jarak aman untuk
menghindari kontaminasi di area steril

Peraturan Dasar Asepsis Bedah

Penutup/Draping
Selama menutup meja atau pasien, penutup steril
dipegang dg baik di atas permukaan yang akan
ditutup dan diposisikan dari depan ke belakang
Hanya bagian atas dari pasien atau meja yang
dianggap steril, penutup yg menggantung
melewati pinggir meja tidak steril
Penutup steril tetap dijaga dalam posisinya dg
menggunakan penjepit/perekat agar tidak
berubah selama prosedur bedah

Peraturan Dasar Asepsis Bedah

Pelayanan peralatan steril
Pak
peralatan dibungkus atau dikemas
sedemikian rupa sehingga mudah untuk dibuka
tanpa resiko mengkontaminasi lainnya
Peralatan steril, termasuk larutan, disorongkan ke
bidang steril/diberikan ke orang yg berscrub
sedemikian
rupa
sehingga
kesterilan
benda/cairan terjaga

Peraturan Dasar Asepsis Bedah

Pelayanan peralatan steril
Tepian pembungkus yg membungkus peralatan
steril atau bagian bibir botol terluar yang
mengandung larutan tidak dianggap steril
Lengan tidak steril perawat instrumentasi tidak
boleh menjulur di atas area steril. Alat steril akan
dijatuhkan ke atas bidang steril, dengan jarak
yang wajar dari pinggir area steril

Peraturan Dasar Asepsis Bedah

Larutan
Larutan steril dituangkan dari tempat yang cukup
tinggi untuk mencegah sentuhan tidak disengaja
pada basin atau mangkuk wadah steril, tetapi
tidak terlalu tinggi sehingga menyebabkan
cipratan (bila permukaan steril menjadi basah,
maka dianggap terkontaminasi)

Assessment
O Nurses in surgical scrub attire identify the

surgical patient, assess the patients

emotional and physical status, and verify the
information on the preoperative checklist
including assessment data, lab reports, and
consents for surgery and blood transfusion.

Assessment
O They may also carry out required immediate

preoperative care, including performing skin

preparation, starting IV fluids, placing
sequential compression devices to prevent
deep vein thrombosis (DVT), determining pain
level, assuring patient and family, providing
comfort, and giving preoperative medications.
The patients response to the procedures is
assessed, and the events of surgery are
explained

Examples of NANDA Nursing Diagnoses

NURSING DIAGNOSIS

Nursing
Diagnoses
Risk
for
Imbalanced
Fluid
Volume

Related Factors
Hemorrhage
Failure of
regulatory
mechanisms

Sample Defining
Characteristics
Increased pulse
rate with
decreased
volume
Decreased blood
pressure

Examples of NANDA Nursing Diagnoses

NURSING DIAGNOSIS

Nursing
Diagnoses
Risk
for
Perioperative
Positioning
Injury

Related Factors
Any lengthy
surgical
procedure
requiring special
intraoperative
positioning

Sample Defining
Characteristics
Risk Factors
Aging
Obesity
Anesthesia, with
resulting
sensory/perceptual
alterations
Emaciation

Outcome Identification
and Planning
Some expected outcomes are that the patient
will:
Remain free of neuromuscular injury
Remain free from wrong site, wrong side, wrong
procedure surgery
Maintain fluid and electrolyte balance
Maintain skin integrity (other than for the
incision)
Have symmetric breathing patterns

Outcome Identification
and Planning
Some expected outcomes are that the patient
will:
Be free of injury from burns, retained foreign
objects (inaccurate count of supplies), and
medication errors
Remain free from surgical site infection
Maintain normothermia

Implementing
Positioning

Draping
Documenting
Transferring to the Postanesthesia Care Unit

Positions on the operating table

Patient in position on the operating table for a laparotomy.

Note the strap above the knees.

Positions on the operating table

Patient in Trendelenburg position on operating table.

Note padded shoulder braces in place. Be sure that
brace does not press on brachial plexus.

Positions on the operating table

Patient in lithotomy position.

Note that the hips extend over the edge of the table.

Positions on the operating table

Patient lies on unaffected side for kidney surgery.

Table is spread apart to provide space between the lower ribs
and the pelvis. The upper leg is extended; the lower leg is flexed
at the knee and hip joints; a pillow is placed between the legs

Preparation of the Head for Surgery: AC. Head for a Craniotomy

D. Neck for Otological Surgery; E., F. Upper Thorax for Thyroidectomy

Surgical Preparation of Upper Extremities and Trunk for Surgery, Anterior

and Posterior Views

Surgical Preparation of Upper Extremities and Trunk for Surgery, Anterior

and Posterior Views

Surgical Preparation of Upper Extremities and Trunk for Surgery, Anterior

and Posterior Views

PASCAOPERATIVE
PHASE

Immediate Postoperative
Assessment and Care
O Respiratory Status
O Cardiovascular Status
O Central Nervous System Status
O Fluid Status
O Wound Status
O Pain Management
O General Condition

The nursing process for ongoing

postoperative care
O Respiratory Status
O Cardiovascular Status
O Central Nervous System Status
O Fluid Status
O Wound Status
O Pain Management
O General Condition

POSTOPERATIVE ASSESSMENTS AND

INTERVENTIONS ON RETURN TO THE UNIT

Factors to
Assess

Assessments and Interventions

Vital signs and Temperature, blood pressure, pulse and

oxygen saturation respiratory rates; oxygen saturation
Note, report, and document deviations from
preoperative and PACU data as well as
symptoms of complications.
Color
and Skin color (pallor, cyanosis), skin temperature,
temperature
of and diaphoresis
skin
Level
of Orientation to time, place, and person
consciousness
Reaction to stimuli and ability to
extremities

move

POSTOPERATIVE ASSESSMENTS AND

INTERVENTIONS ON RETURN TO THE UNIT

Factors to
Assess

Assessments and Interventions

Intravenous fluids Type and amount of solution, flow rate, security

and patency of tubing
Infusion site
Surgical site

Position
safety

Dressing and dependent areas for drainage (color,

amount, consistency)
Drains and tubes; be sure they are intact, patent,
and properly connected to drainage systems

and Place the patient in an ordered position, or

If the patient is not fully conscious, place in the
side-lying position.
Elevate the side rails and place the bed in low
position.

POSTOPERATIVE ASSESSMENTS AND

INTERVENTIONS ON RETURN TO THE UNIT

Factors to
Assess

Assessments and Interventions

Other tubes

Assess indwelling urinary catheter, gastrointestinal suction,

and others for drainage, patency, and amount of output.
Be sure dependent drainage bags are hanging properly and
suction drainage is attached and functioning.
If oxygen is ordered, ensure placement of ordered
application and flow rate.

Comfort

Assess pain (location, duration, intensity) and determine

whether analgesics were given in the PACU.
Assess for nausea and vomiting.
Cover the patient with a blanket.
Reorient to the room as necessary.
Allow family members to remain with the patient after the
initial assessment is completed.

Examples of NANDA Nursing Diagnoses

NURSING DIAGNOSIS

Nursing
Diagnoses
Risk
Infection

Related Factors

for Any condition that

interferes with
normal
inflammatory
healing process
or provides an
entry for infectious
agents

Sample Defining
Characteristics
Risk Factors
Obesity
Aging
Immunosuppression
Malnutrition
Presence of incision
Decreased ability to cough,
deep breathe, use incentive
spirometer
Presence of drains, tubes,
and catheters
Insertion site for intravenous
therapy

Examples of NANDA Nursing Diagnoses

NURSING DIAGNOSIS

Nursing
Diagnoses
Disturbed
Body Image

Related Factors

Sample Defining
Characteristics

Any condition that

causes confusion
in the mental image
of oneself,
including surgical
incision, removal
of body part, and
inability to use
body as one did
before surgery

Verbalization of altered view

of ones body in
appearance, structure, or
function
Refusal to look at incision
or area of surgical
treatment
Actual change in ones body
from surgery or trauma
Actual missing body part
Verbalizations of negative
feelings about body

Examples of NANDA Nursing Diagnoses

NURSING DIAGNOSIS

Nursing
Diagnoses
Acute Pain

Related Factors

Sample Defining
Characteristics

Any condition that Rating pain as severe on a

scale of 1 to 10 (i.e., as a
causes actual
9)
tissue damage,
Positioning or guarding self
such as the surgical to avoid pain
incision
Inability to sleep
Loss of appetite
Diaphoresis, changes in
vital signs, dilated pupils
Moaning, crying, sighing

Examples of NANDA Nursing Diagnoses

NURSING DIAGNOSIS

Nursing
Diagnoses
Urinary
Retention

Related Factors

Sample Defining
Characteristics

Any condition that

causes incomplete
emptying of the
bladder, such as
neurologic effects
of anesthesia

Urine not eliminated for

more than 8 hours
Distended, palpable
bladder
Small, frequent voiding
Residual urine

Outcome Identification
and Planning
The patient will:
Carry out leg exercises every 2 to 4 hours.
Deep breathe and cough effectively every 2 hours.
Verbalize decreasing levels of pain.
Have a balanced intake and output.
Regain normal bowel and bladder elimination.
Exhibit a healing surgical incision.
Remain free of infection.
Verbalize any concerns about appearance of
wound.
Verbalize and demonstrate wound self-care.

Implementing
Preventing Cardiovascular Complications
Hemorrhage
Shock
Thrombophlebitis
Preventing Respiratory Complications
Pulmonary embolus
Pneumonia
Atelectasis

Implementing
Preventing Surgical Site Complications
Infection, dehiscence (wound closure
separation), and evisceration (protrusion of
intra-abdominal organs)
Preventing Respiratory Complications
Promoting a Return to Health
Elimination needs
Fluid and nutrition needs
Comfort and rest needs