2. PERIOPERATIVE NURSING
• Nursing care takes place immediately:
– Before
– During
– After surgery.
• A nurse act as independent clinician and a member of a health
care team during perioperative nursing.
3. Goals of Perioperative Nursing
• To assist clients and their significant others through
the surgical episode
• To help promote positive outcomes
• To help clients achieve their optimal level of function
and wellness after surgery
4.
5. PERIOPERATIVE PERIOD
1.Preoperative Phase (surgical unit to OR)
– the period when the client is admitted in the surgical unit, to the period he is
prepared physically, psychosocially, spiritually, and legally prepared for the surgical
procedure, until he is transported into the operating room.
2. Intraoperative Phase (OR-PACU)
– the period the client is admitted to the OR → the time of administration of
anesthesia → surgical procedure is done →recovery room or post anesthesia care
unit.
3. Postoperative Phase (PACU-FOLLOW-UP)
– the period recovery room/PACU →transported back into the surgical unit →
discharged from the hospital, until the follow-up care.
6. Surgical Classifications
• According to Purpose
1. Aesthetic (cosmetic)
– Improvement of physical
features that are within
the “normal range”.
– Ex. Breast augmentation
8. Surgical Classifications
According to Purpose
3. Curative
– Removal or repair of damaged
or diseased tissue or organs (ex
hysterectomy).
– Mostly done with definite cancer
diagnosis
– Operations are conducted to
remove or destroy cancerous
tissues
9. SURGICAL CLASSIFICATION
• According to Purpose
4. Diagnostic
– Done when a specific diagnosis
is not possible using
noninvasive or simple biopsy
techniques.
– Done for discovery or
confirmation of a dx
– Ex. Breast biopsy
10. SURGICAL CLASSIFICATION
According to purpose
5. Exploratory
– Estimation of the extent
of the disease or
confirmation of a dx
– Ex. Exploratory
laparotomy
13. Surgical Classifications
• According to Degree of Risk
• Major Surgery
– Involves a high degree of risk since these surgeries may be
complicated or prolonged, hemorrhage may occur, vital organs
may be involved, or postoperative complications are likely to
appear.
• Minor Surgery
– Involve little risks
– Produces fewer complications
– Often performed in “day surgery”
– Performed in the OPD
14. Surgical Classifications
• According to Urgency
1. Emergent
– Must not be delayed
– Almost always life-threatening
– Patient requires immediate attention
– Ex. Fractured skull, gunshot or stab wounds, extensive burns
2. Urgent
– Pt requires prompt attention
– Indicated within 24-30 hrs
– Ex. Acute gallbladder infection, kidney stones
3. Required
– Pt needs to undergo surgery but could be planned within a few weeks or months
– Ex cataracts, thyroid disorders
4. Elective
– Client should have surgery
– However, failure to have surgery does not end in catastrophic consequences
– Ex. Vaginal repair, repair of scars
5. Optional
– The decision to undergo these types of surgeries rest solely on the personal preference of the client
– Cosmetic surgeries
16. PREOPERATIVE PHASE
Preoperative Assessment
To be included in the preop assessment:
1. Medical/health hx
– Review past medical hx
• To determine operative risk
– Previous surgery and experience with anesthesia
• Untoward reactions to anesthesia
– Hypethermia, prolonged n/v
• These do not hinder surgery, but need to change the type of anesthetics
used
17. MEDICAL HISTORY
Serious Illness or Trauma
A – Allergy
– Medications, chemicals, latex
– All should be reported before the beginning of surgery
B – Bleeding tendencies
– use of meds that daunt clotting (aspirin, heparin/warfarin)
C – Cortisone (At risk for adrenal insufficiency)
D – Diabetes mellitus
– Other condition that requires strict blood glucose control that known to delay wound healing
E – Emboli
T - Uncontrolled Thyroid Disease
– Overactive: risk of Thyrotoxicosis
– Underactive: risk of respiratory depression
18. MEDICAL HISTORY
Alcohol, recreational drug or nicotine use
– Indicate potential problem with anesthesia or analgesic administration
and risk for withdrawal complications
– Alcohol/drugs can cause withdrawal
– Tobacco/drug reduces hemoglobin levels making less oxygen available
for tissues
– Smokers are at high risk for thrombus formation (due to
hypercoagulability secondary to nicotine use
19. MEDICAL HISTORY
Current Discomforts
– With preexisting painful conditions may require alternative methods of pain reduction
while under NPO
Chronic illness
– Illness that require consideration when positioning
– Arthritis of the neck/back
Advanced age
– Older clients have specific perioperative needs
Medication hx
– OTC may increase operative risk
– Ask if they are taking and brought them in the hospital
– Medication dosages and administration schedules should be noted in the chart
20. PSYCHOLOGICAL HX
• Client’s cultural beliefs and practices
• Client’s emotional reaction towards the whole
surgical experience
21. • Ability to tolerate perioperative stress
– Physiologic stress like pain, tissue damage, anesthesia, blood
loss, fever and immbilization
• Lifestyle habits and social hx
• Physical examination
– Must be done prior to operation
– To identify present health status and to have baseline info
– To identify problems and to develop appropriate outcome goals
23. CARDIOVASCULAR
• Presence of pathologic or cardiac conditions
• increase operative risks and could lead to decrease tissue
perfusion with impairment of surgical healing.
– Angina pectoris
– Occurrence of MI in the last 6 mos
– Uncontrolled HPN
– Heart failure
– Peripheral vascular disease
25. CARDIOVASCULAR
Dx and lab studies done to measure cardiovascular
function
a. ECG, esp for cients over 40 yrs
b. hemoglobin, hct and serum electrolytes
26. RESPIRATORY
1. Chronic lung conditions
- increase operative risks
- impair gas exchange in the alveoli
- predisposing to postoperative pulmonary complications:
a. Emphysema
b. Asthma
c. Bronchitis
27. RESPIRATORY
2. Assessment of pulmonary conditions must include:
a. Examining for presence of SOB
b. Wheezing
c. Clubbed fingernails
d. Chest pain
e. Cyanosis
f. Coughing with expectoration of copious or purulent mucous
g. Obtain hx of smoking and respiratory allergies
28. RESPIRATORY
3. Diagnostic and lab studies to measure respiratory
function:
a. CXR
b. pulse oximetry
c. ABG (arterial blood gas) analysis
d. Pulmonary function test
29. MUSCULOSKELETAL
1. Assess for hx of the ff disorders that may affect
surgical positioning and postop support:
a. arthritis
b. fractures
c. contractures
d. joint injury
e. musculoskeletal impairment
30. MUSCULOSKELETAL
2. PE that may reveal problems with joint mobility or
deformities that may interfere with operative
positioning
31. GASTROINTESTINAL
• GI conditions that may be associated with poor
surgical outcomes:
– Severe malnutrition
– Prolonged nausea and vomiting
• General assessment of the GI functioning should
be done esp for abdominal surgery
32. INTEGUMENTARY
• The skin must be assessed preoperatively to be able to establish
baseline data for comparisons postoperatively.
• The following should be documented and reported if observed
during assessment:
1. Lesions
2. Pressure ulcers
3. Necrotic skin tissue
4. Skin turgor
5. Erythema
6. Discoloration of the skin
7. Tattoos and body piercing
33. RENAL
• adequate renal function is necessary to eliminate protein wastes, to preserve fluid and
electrolyte balance, and to remove anesthetic agents.
1. Renal and related renal disorders that may affect the outcome of the surgery are the following:
a. Advanced renal insufficiency
b. Acute nephritis
c. Benign prostatic hypertrophy
2. Assess renal status by asking about voiding patterns.
– Monitor fluid and electrolyte balance by recording intake and output throughout the perioperative phases.
3. common preoperative tests done to determine the status of renal function
- Blood urea nitrogen (BUN)
- serum creatinine
- urinalysis are the
34. Liver Function Assessment
1. Cirrhosis of the liver increases client’s surgical risk since an
impaired liver cannot detoxify medications and anesthetic agents
2. Hx of alcoholism or other substance abuse require careful
assessment of the liver function before surgery.
3. A high calorie diet or hyperalimentation may be ordered during
preop and postop phases
– to correct problems of malnourished and debilitated clients with liver
disease
35. Cognitive and Neurologic Assessment
1. Assess for serious neurologic conditions such as:
- uncontrolled epilepsy
- severe Parkinson’s disease
- that may increase surgical risk.
2. Assess the following through thorough physical assessment and interview to obtain baseline data:
a. Severe headache
b. Frequent dizziness
c. Light-headedness
d. Ringing in the ears
e. Unsteady gait
F. Unequal pupils
g. History of seizures
h. Neurologic functions (i.e., reflex response of extremities, sensory reflexes, and cerebral responses)
i. Orientation to time, person and place
36. Endocrine Assessment
1. Diabetes mellitus (DM)
- most common pre-existing endocrine disorder.
- puts client at high risk for poor wound healing and increased risk of postoperative
infections.
Constant monitoring and control of blood glucose should be done all throughout the
perioperative period.
2. Thyroid functioning may also be assessed preoperatively.
Thyroid replacement is usually continued during the perioperative period.
37. Additional Assessments
1. Age
a. Physiologic changes normal to aging clients and presence of certain
diseases may adversely affect surgical outcomes.
b. Surgical risks including:
– Malnutrition
– Anemia
– Dehydration
– Atherosclerosis
– Chronic obstructive
– Pulmonary disease
– Diabetes mellitus
– Cerebrovascular changes
– Peripheral vascular disease
may increase due to chronic conditions commonly found to elderly clients.
38. 2. Pain
– important physiologic indicator that necessitates careful
monitoring.
– Clients should be asked whether they are experiencing
any pain prior to any surgical procedure.
– If pain is present, thorough assessment should be done
to identify the cause of the pain.
39. 3. Nutrition
- nutritional status is directly related to intraoperative success and
postop recovery.
- Assessment includes:
- acquiring a diet history
- observing general appearance
- laboratory/diagnostic testing
- comparing current weight with ideal
body weight.
40. 4. Fluid and electrolyte balanc e
- Proper assessment of actual and potential fluid
imbalances
- Fluid volume deficits such as hypovolemia or hypervolemia predispose a client
to complications during and after surgery.
- Electrolyte imbalances also increase operative risk
- Preoperative laboratory results should be checked
to determine whether serum sodium, potassium, calcium, and magnesium
concentrations are within normal levels.
41. 5. Infection and immunity
a. Any pre-existing infection can adversely affect surgical outcomes since bacteria
may be released in the blood stream during surgery.
b. Any possible exposure to communicable diseases, presence of skin lesions, or
manifestations of an infection (e.g., coughing, sore throat, or fever) should be
properly documented during preoperative assessment.
c. If existing infection greatly increases surgical risks, rescheduling the surgery may
be necessary.
42. 6. Hematologic conditions
a. History of bleeding or diagnosis of pathologic condition such as
hemophilia or sickle cell anemia
b. Bruising, excessive bleeding following dental extractions, or severe
epistaxis
c. Hepatic or renal disease
d. Use of anticoagulants, aspirin or other non steroidal anti-inflammatory drugs
e. Abnormal bleeding time, prothrombin time, or platelet count
43. Informed Consent
• A legal document that signifies that the client has been told about and
understands all aspects of as specific invasive procedure.
• Guards the client against unwanted invasive procedures
• Protects the health care facility and health care professionals when the client
denies understanding about the procedure
• Physician’s responsibility to provide appropriate information,
• Nurse’s duty to ask the client to sign the consent form, and may be a witness to
the client’s signature
44. Informed consent is a must in the following
circumstances:
1. Invasive procedures
- surgical incision
- a biopsy
- cystoscopy
- paracentesis)
2. Procedures requiring sedation and/or anesthesia
3. A nonsurgical procedure
- arteriography that carries more than slight risk to the client
4. Procedures involving radiation
45. Criteria for Valid Informed Consent
• Voluntary Consent
– valid consent must be freely given, without
coercion
• Incompetent Client
– not autonomous
– cannot give or withhold consent
– mentally retarded, mentally ill, comatose
46. Criteria for Valid Informed Consent
• Informed Subject
– informed consent should be in writing and should contain the following:
1. Explanation of procedure and its risks
2. Description of benefits and alternatives
3. An offer to answer questions about procedures
4. A statement informing the client if the protocols differ from customary
procedures
47. Criteria for Valid Informed Consent
• Client Able to Comprehend
– information must be written and delivered in
language understandable to the client.
– Questions must be answered to facilitate
comprehension if material is confusing.
48. Preoperative Teaching
PURPOSE:
• To ensure a positive surgical experience for
the client
• helps to alleviate the client’s fear and
anxiety regarding the surgery.
49. Components of Preoperative Teaching
• Sensory Information
– addresses the sights, sounds and
ambiance of the operating roo
– discuss what the client should expect
to see, hear, and feel when he/she
is transferred to the operating room
and on the operating room table.
50. Components of Preoperative Teaching
• Psychosocial Information
– addresses the coping abilities and the worries of the client and the
family.
– To alleviate the client and family’s worries and fears, the nurse
together with the help of a social worker or a counselor should
address questions such as the following:
1. What if I die?
2. How could we pay for the operation?
3. Who will take care of my children while I’m here?
51. Components of Preoperative Teaching
• Procedural Information
– what will happen all throughout the
perioperative period including the
discharge phase.
– All the information that the client wants
to know regarding the client care should
be addressed.
52. • The nurse also provides instruction for the
following:
1. Deep breathing
2. Coughing
3. Turning
4. Ambulating
5. Pain control
53. Preoperative Nursing Diagnoses
• Deficit knowledge related to unfamiliar
surgical experience.
• Anxiety/fear related to
pain, death, disfigurement, or the unknown
54. Preoperative Nursing Care
1. Preparation of the skin
a. shower/bathing the night before a scheduled surgery as per
institutional policy.
b. Clean the site with soap and water or antimicrobial solution to
diminish the # of microbes on the skin
2. Clean the area before the surgery
3. Padding on bony prominences to prevent trauma in the skin
during transfer
55. Preoperative Nursing Care
4. The gastrointestinal tract is prepared the night before the
surgery to:
– Reduce the possibility of vomiting and aspiration
– Reduce the risk of possible bowel obstruction
– Allow visualization of the intestine during bowel surgery
– Prevent contamination from fecal
material in the intestinal tract during bowel or abdominal
surgery
56. Preoperative Nursing Care
• Preparations for the gastrointestinal tract include the following:
a. Restricting food and fluid 8-10 hrs before the operations
b. Administering enema as needed
57. Preoperative Nursing Care
• Preparations for the gastrointestinal tract include the following:
– Restricting food and fluid 8-10 hrs before the operations
1. Explain the reason for restriction
2. Remove food and water from bedside at midnight
3. Place “NPO” signs on the door and bed
4. Mark the care plan or the Kardex with “NPO”
5. Inform the diet and nutrition dept and family about the status
6. If the client has been instructed to take impt meds orally:
1. Allow only small sips of water
2. Explain why this permission is permissible
3. Document the med and amount of fluid taken in the chart
58. Preoperative Nursing Care
• Administering enema as needed
1. Especially operation in gastrointestinal tract, perianal
area, and pelvic cavity.
2. May be done at home or administered by the nurse in
the hospital.
3. Bowel cleansing in the morning before the surgery may be
done as prescribed
59. Preoperative Preparation Immediately
Before Surgery
1. All known allergies are recorded and an allergy wristband is present.
2. Vitals signs are checked and recorded.
3. The identification band is present and correct.
4. The consent formed is signed and the surgical procedure is listed correctly.
5. Skin preparation is completed if ordered preoperatively.
6. Any special orders are completed (enema, IV line)
60. Preoperative Preparation Immediately
Before Surgery
7. The client has not eaten or had fluids by mouth for the last eight
hours.
8. The client has just voided.
9. Oral hygiene or other physical/hygiene care is completed.
10. The presence of dentures, bridgework, or other prostheses is
noted.
11. Storage is arranged and documented for valuables according to
health care facility policy.
61. Preoperative Preparation Immediately
Before Surgery
12. The client has removed jewelry.
13. The perioperative nurse is notified about the presence of a
hearing aid.
14. The client is wearing a hospital gown and protective cap.
15. Make-up is removed.
16. Preoperative medications are given.
17. Transfer the client from bed to a stretcher
63. Members of the Surgical Team
• Group of highly trained professionals who coordinate their
efforts to ensure the welfare and safety of the client
64. • Members of the Surgical Team
1. Surgeon
• HEAD
2. Second Surgeon or a Specially Trained Nurse
3. Anesthesiologist
• Alleviates pain
• Promotes relaxation with medications
• Maintain airway
• Ensure adequate gas exchange
• Monitors circulation and respiration
• Estimates blood and fluid loss
• Infuses blood and fluids
• Maintains hemodynamic stability
• Alerts surgeon immediately to any complications
4. Perioperative Nurses
65.
66. Roles of the Perioperative Nurse
I. Circulatory Nurse
1. Assessment of client preoperatively.
2. Planning for optimal care during the surgical intervention.
3. Coordinating all personnel within the operating room.
4. Delegating and monitoring unlicensed personnel.
5. Monitoring responsible cost compliance associated with operating
room procedures.
67. Roles of the Perioperative Nurse
• Circulatory Nurse
6. Ensuring all equipment are working properly
7. Guaranteeing sterility of equipment and supplies
8. Assisting with positioning
9. Performing surgical skin preparation
10. Monitoring the room and team members for breaks in sterile
technique
68. • Circulatory Nurse
11. Assisting anesthesia personnel with induction and physiologic monitoring
12. Handling specimens
13. Coordinating activities with other departments, such as radiology and
pathology
14. Documenting care provided
15. Minimizing conversation and traffic within the operating room suite
69. II. Scrub Nurse
– RN or Surgical Technician
– Duties:
1. Gathering all necessary equipment for the procedure
2. Preparing all supplies and instruments using sterile technique
3. Maintaining sterility within the sterile field during surgery
4. Handling instruments and supplies during surgery
70. II. Scrub Nurse
5. Cleaning up after the case
6. Maintains an accurate count of sponges, sharps, and instruments on the sterile
field and counts the same materials with the circulating nurse before and after
the surgery
71. III. Registered Nurse First Assistant (RNFA)
– New role of perioperative nurses
– 1st assistants (to the surgeon) in place of a 2nd or assisting physician
– Additional Specialized education
– Must work with surgeon and are not independent practitioners
1. Providing exposure of the surgical area
2. Using instruments to hold and cut
3. Retracting and handling tissues
4. Providing homeostasis
5. Suturing
72. IV. Certified Registered Nurse Anesthetist (CRNA)
– RN with minimum of additional 2 yrs education specializing in the
anesthesia administration
– BSN, + 1-2 yrs in ICU
– Work under the direction of anesthesiologist
V. Manager
– Extensive experience, additional education in mgt
– Reqt: BSN degree, MN
– OTHER NAMES: clinical nursing director/ OR manager
73. VI. Educator
– Any RN, although usually with MSN, experienced perioperative
nurses
VII. Case Manager
– Extensive experience
– Ability to communicate
– Knowledge of the total surgical episode from home before
surgery to home care needs after surgery
75. SURGICAL ENVIRONMENT
• Division of Surgical Area
– 3 zones (decrease microbes circulating in the OR
1. UNRESTRICTED ZONE
• Street clothes or dirty (not sterile) clothing are allowed
2. SEMI-RESTRICTED ZONE
• Attire consists of scrub clothes and cap
3. RESTRICTED ZONE
Scrub clothes, shoe covers, caps and masks are worn
77. Eight Basic Principle of Aseptic
Technique
1. All materials in contact with the surgical wound and used within the sterile field must
be sterile.
2. Gowns of the surgical team are considered sterile in front from the chest to the level
of the sterile filed.
– Sleeves are sterile from 2 inches above the elbow to the stockinette cuff
3. Sterile drapes are used to create sterile field.
– ONLY the top surface of drape table is sterile
4. Items should be dispensed to a sterile field by methods that preserve the sterility of
the items and the integrity of the sterile field.
– Edges are considered UNSTERILE
78. Eight Basic Principle of Aseptic
Technique
5. The movements of the surgical team are from sterile to sterile areas and from unsterile
to unsterile areas.
6. Movement around the sterile filed must not cause contamination of the field.
7. Whenever the sterile barrier is breeched, the area must be considered contaminated.
8. Every sterile field should be constantly monitored and maintained.
DOUBTFUL STERILITY ARE
CONSIDERED
UNSTERILE
79. Surgical Hand Washing (Scrubbing)
Purpose of Surgical Hand Washing
1. To remove debris and transient microorganisms.
2. To reduce the resident microorganisms
3. To inhibit rapid rebound growth of microorganisms
80. Surgical Hand Washing (Scrubbing)
2-3min surgical scrub is the recommended
length of time for surgical hand washing by
the
Association of Operating Room Nurses (AORN)
83. Surgical Attire
Semi-restricted and restricted zones within traditional OR suites
requires personnel to wear special surgical attire.
Wearing surgical attire helps
prevent transmission of microbes from personnel to clients.
Consist of:
– Scrub gowns
– Hair coverings
– Masks
– Protective eyewear
– Shoe covers
85. The following are principles that should be observed when
donning surgical attire:
1. Surgical attire should be worn only within the surgical site
2. If in case there is a need to wear the attire outside the semi-restricted and
restricted zones of the OR, it should be covered or changed before reentering
the area
3. Clean scrub suit should be worn within the surgical environment
– TO CONTAIN BACTERIAL SHEDDING FROM THORAX AND ABDOMINAL SKIN
4. If a two-piece scrub suit is worn (pants and top), the top must be secured at the
waist, tucked into the pants, or fit close to the body
86. The following are principles that should be observed when
donning surgical attire:
5. Scrub suits should be changed daily or whenever they become visibly soiled
or wet
6. Sleeves of scrub suits should be short enough to allow for surgical hand
washing to two inches above the elbow
7. All head and facial hair, including sideburns and necklines, should be
covered by a clean, low-lint surgical hat or hood when one is in the semi-
restricted/restricted zones
8. The surgical hat or hood should be the first piece of the OR attire that is
donned
– TO PREVENT HAIR FROM COLLECTING ON THE SCRUB CLOTHES
87. The following are principles that should be observed when
donning surgical attire:
9. Shoe covers may be worn inside the OR for sanitation purposes
10.All shoe covers should be removed upon leaving the restricted zones, and
a new pair should be worn when returning to the OR
11.Masks must be worn in specified restricted areas of the surgical suite
12.Masks are worn to filter organisms from the exhaled air
13.A mask should be secured over the nose, along the sides of the face, and
under the chin to prevent venting or escape of air
88. The following are principles that should be observed when
donning surgical attire:
14.Surgical masks should be changed between procedures and should be
allowed to hang around in the neck
15.Use of double masks is unacceptable for it becomes a barrier rather than a
filter
16.Protective eyewear (goggles with solid side shields, or chin-length face
shield) is worn to reduce the incidence of contamination of mucous
membranes whenever contamination can be anticipated as a result of
splashes, sprays or splatters of blood droplets
17.Jewelry should not be worn in the surgical suites
89. The following are principles that should be observed when
donning surgical attire:
18.Sterile gown and gloves are donned using the
closed method when a scrub nurse enters the
operating room
19.Gloves should fit properly to ensure ease of
handling of the OR instruments and supplies
20.Complete surgical hand washing (scrubbing) should
be performed before donning sterile gown and
gloves
91. Surgical Draping
• the practice of covering a client and the surrounding areas with
sterile barriers to create and maintain a sterile field during a surgical
procedure.
• Sterile surgical drapes protect the client from infection by preventing
microbes from making their way into the skin opening created during
surgery.
• 2 responsibilities of scrub nurse:
1. to provide the correct drapes for a specific surgical procedure
2. to assist surgeons during draping
92. Surgical Draping
• Circulating nurse
– Observe for breaks in sterile techniques so that
corrective measures should be taken by the
surgical team.
93. Basic Principles of Draping
1. Isolate
– Isolate “dirty area” from clean area
– Accomplished by using impermeable drape, made from a plastic
materials
2. Barrier
– Provides an impermeable layer, must have plastic film to prevent
strike-through
3. Sterile Field
– Achieved thru sterile presentation of drape and aseptic application
technique.
– If drape is not impermeable, additional impermeable layer should be
added.
94. Basic Principles of Draping
4. Sterile Surface
– skin cannot be sterilized, it is necessary to apply an incise drape to
create a sterile surface. Only an incise drape can create a sterile
surface
5. Equipment Cover
– Sterile drapes cover nonsterile equipment or organize equipment used
on the sterile field.
– To protect client from equipment
– To protect and prolong life of equipment
6. Fluid Control
95. SEDATION & ANESTHESIA
• Four Levels of Sedation
1. MINIMAL Sedation
– Drug-induced state during the client can’t respond normally to verbal command
2. MODERATE Sedation
– May be administered thru IV
– Depressed level of consciousness that does not impair the client’s ability to maintain
patent airway
– To respond appropriately to physical stimulation and verbal command
3. DEEP Sedation
– Client can not be easily aroused or respond purposefully after repeated stimulation
97. LEVELS OF ANESTHESIA
• Stage I: Beginning Anesthesia (Onset)
– START: during anesthetic
administration
– END: during loss of consciousness
– Client may be drowsy/dizzy with possible auditory or visual
hallucinations.
– Nursing Intervention:
– Close the OR door
– Avoid unnecessary noises or motions when anesthesia begins
– Stand by to assist client
98. LEVELS OF ANESTHESIA
• Stage II: Excitement
– START: during loss of consciousness
– END: loss of eyelid reflexes
– There is increase autonomic activity, irregular breathing
and may struggle.
– Nursing Intervention:
– Assist anesth in restraining the client
– Touch the client only for purpose of restraint.
99. LEVELS OF ANESTHESIA
• Stage III: Surgical Anesthesia
– START: loss of eyelid reflexes
– END: loss of most reflexes is present and there is depression
of vital functions
– Client is UNCONSCIOUS, relaxed muscles, blink and gag reflexes
are absent
– Nursing Intervention:
– Begin preparation for surgery only when anesthetist indicates
stage III has been reached and client is breathing well, with
stable v/s
100. LEVELS OF ANESTHESIA
• Stage IV: Medullary Depression
– START: functions are excessively depressed
– END: indicates respiratory and circulatory failure.
– The client is not breathing; the heartbeat may or may not be
present.
– Nursing Intervention:
– If arrest occurs, respond immediately to assist in
establishing airway;
– provide cardiac arrest tray, drugs, syringes , long needles;
– Assist surgeon with closed or open cardiac massage.
101. Types of General Anesthesia
1. Intravenous Anesthesia
2. Inhalation Anesthesia
102. Types of General Anesthesia
1. Intravenous Anesthesia
– Rapid induction
– Unconsciousness occurs 30 sec after the administration
– Promotes rapid transition from conscious to surgical
anesthesia stage
– Prepare client for a smooth transition to the surgical
anesthesia stage since IV anesthetics has calming effects.
– Ex. Thiopental sodium and ketamine
103. Types of General Anesthesia
2. Inhalation Anesthesia
– A mixture of volatile liquid or gas and oxygen is used.
– ease of administration and elimination through the respiratory system.
– Usually used to maintain the client in stage III anesthesia following induction.
– Mixture is given through mask or an endotracheal tube (ET tube is inserted once
the client is paralyzed and unconscious).
– Commonly used inhalation anesthetics are halothane and isoflurane
– nitrous oxide = commonly used gas anesthetic
105. Types of Regional Anesthesia
1. Spinal Anesthesia
• used for surgical procedures involving the lower half of the body;
• any procedure performed below the level of the diaphragm
(e.g., hysterectomy, appendectomy)
• Anesthetic technique of choice for older adults
• Benefits:
– relative safety;
– excellent lower-body muscle relaxation,
– absence of the effect of unconsciousness.
– does not require emptying of the stomach.
• achieved by injecting local anesthetics into the subarachnoid space.
106. Types of Regional Anesthesia
2. Epidural Anesthesia
• Epidural block is achieved by introduction of an anesthetic agent into
the epidural space (entered by a needle at a thoracic, lumbar, sacral,
or caudal interspace).
• Provide a blockage of the autonomic nerves and hypotension can
result.
• Respiratory muscles are affected, respiratory depression or paralysis
may occur if the level of block is too high.
• Caudal Anesthesia
– produced by injection of the local anesthetic into the caudal or sacral canal. This
is a variation of epidural anesthesia. This method is commonly used with obstetric
clients.
107. Types of Regional Anesthesia
3. Topical Anesthesia
– agents may be applied directly on the area to be
desensitized.
– May come in a form of a solution, an ointment, cream, or
powder.
– a short-acting anesthesia that can block peripheral nerve
endings in the mucous membranes of the vagina, rectum,
nasopharynx, and mouth.
108. Types of Regional Anesthesia
4. Local Infiltration Anesthesia
– involves the injection of an anesthetic agent into the
skin and subcutaneous tissue of the area to be
anesthetized.
– lidocaine (Xylocaine)
– block only the peripheral nerves around the area of
incision.
109. Types of Regional Anesthesia
5. Filled Block Anesthesia
– injected and infiltrated into the area proximal to
the planned incision
– block forms a barrier between the incision and
the nervous system.
110. Types of Regional Anesthesia
6. Peripheral Nerve Block Anesthesia
– Anesthetizes nerves or nerve plexus rather than all
the local nerves anesthetized by a filed block.
– Commonly used drugs lidocaine, bupivacaine, and
mepivacaine.
112. Maintaining Safety and Preventing Injury
1. Position the Client
• Consider client’s:
– Site of operation
– Age
– Size of client
– Types of anesthetic used
– Pain normally experienced by the client on movement
• Position must:
– Not hinder respiration/circulation,
– Not apply excessive pressure to skin surfaces
– Not limit surgical exposure
113. Maintaining Safety and Preventing Injury
• Surgical Positions
a. Dorsal Recumbent (supine) d. Prone
• Commonly used for CABG, – Cervical spine
hernia repair, mastectomy, bowel – Posterior fossa craniotomy
resection
– Back, rectal and posterior leg
b. Trendelenburg
• Permits displacement of intestines e. Lateral
into upper abdomen – Kidney, chest or hip surgery
• Often sued during surgery of lower
abdomen or pelvis
c. Lithotomy
• Exposes perineal and rectal areas
• Vaginal repair, D&C, rectal surgery
114. Maintaining Safety and Preventing Injury
2. Provide Equipment Safety
– Counting of needles, sponges, and instruments are performed by
the circulating nurse and the scrub nurse must be done:
a. before the initial incision
b. during the surgery
c. immediately before the incision is closed
– A final correct count is announced to the surgeon and charted on
the intraoperative chart.
115. Maintaining Safety and Preventing Injury
3. Maintain Surgical Asepsis
– Ensure the sterility of supplies and equipment.
– Ensure all members of surgical team use sterile
technique to minimize postop infections
– Be an advocate in maintaining sterile surgical
environment
116. Maintaining Safety and Preventing Injury
4. Assisting with Wound Closure
– Anticipate the type of closure needed and obtain the supplies
necessary for wound closure.
– If a surgical drain is used, assess whether the drainage is flowing
freely through the system.
– Monitoring of the drain’s patency and the characteristic of the
drainage is continued when the client is transferred out of the
operative area.
117. Maintaining Safety and Preventing Injury
5. Monitoring
• Monitor body temperature and watch out for signs of hypothermia.
• Offer a blanket to the client immediately upon transfer to the operating
room bed.
• Report the lowest core body temperature to the postoperative nurse
when transferring the client after surgery.
• Thermal blankets may be provided
• IV solutions can be warmed to assist maintaining warm body temperature
118. Maintaining Safety and Preventing Injury
• Monitor for malignant hyperthermia, a genetic disorder characterized by
uncontrolled skeletal muscle contraction leading to potentially fatal
hyperthermia.
a. This condition can occur 30 minutes of anesthesia induction or several hours after surgery.
b. Initial manifestation is increased end-tidal carbon dioxide, jaw muscle rigidity, cardiac
dysrhythmias , and a hypermetabolic state caused by anesthetic agents (succinylcholine).
• Monitor for respiratory and cardiac arrest. Although an arrest is a rare
occurrence, everyone inside the operating room should know where the
crash cart is kept so immediate management could be administered.
• Monitor for uncontrolled hemorrhage and secondary allergic reactions from
drugs and latex.
119. Documentation
• circulating nurse, records every event and action in the operating
room.
• Information about the following is endorsed to the
postoperative nurse upon client transfer:
1. Drains, tubes, or other devices remaining on the client after the
surgical procedure
2. Type of closure and dressing used
120. Moving and Transporting the Client
• wipe off excess blood, skin preparation, and debris from the client’s skin, before moving and
transporting the client
• Put on a clean gown and blanket.
• Ensure that enough personnel are present for moving or transferring a client postoperatively
to prevent injuries.
• Avoid rapid movements when changing the client’s position.
• Gradually move the clients from the operating room table to the stretcher.
• Be careful not to catch, kink, or dislodge IV or catheter tubing, drains, or other equipment
during transfer.
• Avoid rough handling, which may damage fragile skin.
122. POSTOPERATIVE PHASE
1. Initial period of time for recovery from anesthesia, during which the
client is monitored closely by post-anesthesia nurses.
2. Time from discharge from the post-anesthesia care unit (PACU) to
the first day or so after surgery while the client is recovering from
the effects of the surgery and is beginning to ambulate.
3. the time of healing, which may last for a few weeks, months, or
even years after surgery.
123. Post-Anesthesia Care Unit (PACU)
GOAL:
To assist an uncomplicated return
to safe physiologic function after
an anesthetic procedure by
providing safe, knowledgeable,
individualized nursing care for
clients and their family members in
the immediate post-anesthesia
phase.
124. Post-Anesthesia Care Unit (PACU)
• Immediate Assessment
– Supporting vital physiologic functions until the
effect of anesthetic agents abate.
– Proper positioning of a sedated, unconscious
or semiconscious client ensuring airway
patency.
125. Review client’s record noting the
following:
1. Anesthesia record for IV medications and blood received
during surgery
2. Any unanticipated complications
3. Significant preoperative findings
4. Presence of tubes, drains, and types of wound closure
5. Length of time the client was in surgery
126. IMMEDIATE: Perform an assessment which
includes the following:
1. Airway
a. Patency
b. Presence of tubes and respiratory assistance
device
2. Breathing
a. Respiration rate and depth
b. Presence of bilateral breath sounds, stridor, wheezes,
hoarseness , or
decreased breath sounds
c. Return of gag reflex
127. IMMEDIATE: Perform an assessment which
includes the following:
4. Others
3. Circulation
a. Level of consciousness
a. Pulse, BP, skin color, pulse oximeter
b. Muscle strength
b. ECG tracing if attached
c. Ability to follow commands
c. Wound status and dressings
d. IV infusions, dressings, drains, and
d. Slight increase in the heart rate – special
may be normal due to stress response equipments; tubes and drains that must be
after surgery attached to containers or suction
e. Reddened or bruised areas on the skin
unrelated to surgery
f. Temperature
128. Initial Nursing Diagnoses
1. Ineffective airway clearance related to effects of anesthesia.
2. Impaired gas exchange related to ventilation-perfusion imbalance.
3. Altered tissue perfusion related to hypotension postoperatively.
4. Risk for altered body temperature related to medications , sedation, and cool environment.
5. Risk for fluid volume deficit related to blood loss, food and fluid deprivation, vomiting, and
indwelling tubes.
6. Pain related to surgical incision and tissue trauma.
7. Impaired skin integrity related to invasive procedure, immobilization, and altered metabolic and
circulatory state.
8. Risk for injury related to sensory dysfunction and physical environment.
9. Sensory alterations related to effects of medications and anesthesia.
129. Nursing Care in the PACU
• Protect the Airway
1. by positioning the head of a minimally responsive client to the side with the chin extended forward
to prevent respiratory obstruction.
2. Suctioning is administered to a client who is unable to clear mucus or vomitus from the throat.
3. Place an oral or nasal airway, as necessary, to help maintain patency and control the tongue.
4. Observe for the development of laryngospasm as manifested by crowing respirations in an
extubated client.
INTERVENTIONS:
1, immediately ventilate the client by face mask, securing a tight fit over the mouth and nose.
2. Remove irritating stimulus to the airway
3. if >1min, may require muscle relaxant (succinylcholine) to relax the muscles of the larynx
6. Administer prescribed medications as needed.
7. Administer oxygen using the appropriate method for delivery as prescribed.
8. Hook the client on a pulse oximeter to monitor tissue oxygenation.
130. Nursing Care in the PACU
Maintain Normal Blood Pressure
1. Monitor for a significant drop in the blood pressure accompanied by
increased heart rate which may indicate hemorrhage, circulatory failure, or fluid
shifts.
2. Monitor for a decrease in blood pressure which may indicate that the
anesthesia is wearing off or that the client may be experiencing severe pain.
3. Measure pressure every five minutes for 15 minutes to determine the
inconsistency in the client’s blood pressure.
4. Observe for manifestations of shock (tachycardia, restlessness and
apprehensions, cold, moist, pale, or cyanotic skin)
131. Nursing Care in the PACU
5. Provide the following interventions if the client appears to be going into shock:
a. Administer oxygen or increase the rate of delivery
b. Raise the client’s legs above the level of the heart
c. Increase the rate of IV fluids, unless contraindicated
d. Notify the anesthetist and the surgeon
e. Provide medications as ordered
f. Continue to assess the client and his/her response to interventions
132. Nursing Care in the PACU
• 6. Watch out for older clients with history of hypertension who
may exhibit hypertensive episodes after the stress of the surgery.
• 7. If blood pressure rises above the baseline, consult with the
anesthetist or the surgeon and administer antihypertensive
medication as ordered.
• 8. If sinus tachycardia happens,
– Treat the underlying cause (anxiety, pain, hypovolemia, hypoxia)
– Betablockers may be given
• 9. If sinus bradycardia happens,
– Treat the cause (vagal stimulation, hypoxemia, hypothermia, high spinal anesthesia,
certain anesthetic drug
– Atropine is the drug of choice
133. Nursing Care in the PACU
Monitor for the Return of Consciousness
1. Assess level of orientation by asking the client his/her name.
2. Orient the client to place, date and time.
3. Monitor for postoperative delirium which usually happens to clients
who undergo open heart surgery.
134. Nursing Care in the PACU
Assess for Return of Sensation and Motion
1. Monitor the client carefully for return of sensation as the anesthetic
wears off.
2. Check for return of motion to the extremities by asking client to
wiggle his/her toes (this may be delayed if client had spinal
anesthesia).
135. Nursing Care in the PACU
• Assess for Normothermia
1. Monitor for v/s every 15 minutes until v/s are stable or more often if
these are unstable.
2. Monitor at least 1 hr until they are discharged from PACU
3. When administering measures to warm the client, constant temperature
monitoring should be done
- to prevent from overwarming causing excessive vasodilation, which can
cause fluid shifts and a decrease in BP
136. Nursing Care in the PACU
• Assess Perfusion
1. Assess skin color, warmth and turgor
2. Observe for development of shock which could be manifested by:
a. Dusky, pale, cold, moist skin
b. Significantly decreased blood pressure
c. Cyanotic lips, nails, and skin
d. Low oxygen saturation
e. Low levels of hemoglobin
137. Nursing Care in the PACU
Assess the Surgical Site
1. Check the dressing over the surgical incision frequently.
2. Note the color, type, and amount of drainage if dressing is soiled.
3. Support dressing but do not change or open it without a physician’s order.
4. If seepage is observed, draw an outline of the dressing and note date
and time this is observed. Estimate amount of seepage if oozing
continues.
5. If bleeding is suspected and not visibly seen, inspect under the
operated extremity or under the back for signs of leakage.
138. Nursing Care in the PACU
Promote Fluid and Electrolyte Balance
1. Intake and output should be assessed hourly.
2. Monitor all parenteral fluids (e.g., IV fluids, medications , blood products , nutritional
support, and colloidal infusions)
– to ensure proper amount of fluids are being infused.
3. Upon admission of the client to the PACU, check the amount of solution in the IV
fluid including the rate of infusion.
4. Check that all types of delivery systems and lines the client has (e.g., pumps,
infusion machines, monitoring machines , IV lines, central venous lines, and arterial
lines) are patent and functioning.
139. Nursing Care in the PACU
5. Check insertion sites for redness, soreness, and swelling which may
indicate infiltration.
6. Note medications that have been added to solutions . This ensures
that the required dilution of fluid and the next dose of medication are
available to prevent lapses in administration.
7. Avoid fluid overload through careful monitoring and prompt
administration of required parenteral fluids.
8. If an indwelling catheter is present, document the amount of output
and compare it with the amount of intake via IV fluids.
140. Nursing Care in the PACU
Manage Drainage Systems
1. Constantly monitor drainage tubes such as T tube, gastric tube,
urinary catheter, or wound drains.
2. Ensure that the drainage tubes are attached to their respective
drainage systems, patent, and draining freely.
3. Check that there are no kinks and occlusions on the tubes.
4. Document the amount and characters of drainage on a regular
schedule.
5. Compare the type, amount, and characteristic of drainage with
those expected for the surgical nursing.
141.
142. Nursing Care in the PACU
Promote Comfort
1. Assess the client’s level of pain carefully and regularly.
2. Provide appropriate pain relief/reduction while not overmedicating.
Maintain Safety
1. Side rails must be raised at all times to protect the client from falling out of the bed.
2. Ass ist the client in maintaining circulation and relieving skin pressure by proper body
alignment and frequent repositioning.
3. Check postoperative equipment prior to receiving clients in the PACU to ensure that
they are working properly.
143. POSTOPERATIVE NURSING CARE
Establish the Postoperative Goals by Revising and
Expanding the Postoperative
Nursing Care Plan
1. Assess the Postoperative Client
2. Assess Respiratory Status
3. Assess Circulation
4. Assess Neurologic Status
5. Monitor the Wound
6. Monitor Intravenous Lines
144. 7. Monitor Drainage Tubes
8. Promote Comfort
9. Reduce Nausea and Vomiting
10. Discharge Instructions and Care
145. Assess Respiratory Status
1. Assess for patent airway.
2. Observe the client and assess the breathing pattern at rest.
3. Listen to breath sounds; breath respirations should be unlabored and quiet.
4. Observe for clinical manifestations of hypoxia which include confusion, restlessness,
pale skin, pulse oximetry readings below 90%, and cool skin temperature.
5. Be aware of the major complications following surgery such as decreased lung
expansion, atelectasis, or aspiration of retained secretions.
6. Assess the lungs by auscultating all the lobes of the lungs, as well as rate and rhythm
of respirations.
7. Assist client in incentive spirometry to increase lung expansion and keep alveoli open.
Best results are achieved when HOB is elevated 45-90 degrees
8. Monitor changes in temperature. A body temperature greater than 37.7ºC in the first
24 hours of surgery is frequently caused by atelectasis.
146. Assess Circulation
1. Assess vital signs, skin color, and temperature according to institutional
policy.
2. Evaluate extremities for weakness, circulation, and numbness.
3. Assess bony prominences for deep tissue injuries, which may look like
bruises.
4. Encourage early ambulation and leg exercises to prevent formation of
thrombus.
5. Place client in dorsal recumbent position to provide comfort and
decreases strain on the incision.
6. Be alert when client complains of pain in the extremity, unilateral edema,
or warmth in the calf which may indicate thrombus formation.
147. • Assess Neurologic Status
• 1. Ass ess the client for level of consciousness, orientation, and remaining effects
of anesthesia on the first 24 hours prior to surgery.
• 2. Ensure clients that impaired cognition after surgery is temporary.
• 3. Facilitate recovery by promoting cognitive activity, repeating instructions
often if necessary, having patience with clients, and fostering hope.
• 4. Document changes in condition every shift. Notify the physician
immediately if a decrease in the client’s cognition is observed.
• 5. Be aware that obese clients may have a delayed return of consciousness after
anesthetic procedures.
148. Monitor the Wound
1. Assess the dressing, amount, and character of any drainage present.
2. Be attentive to the method of wound care the surgeon prefers. Most surgeons
prefer to do the first dressing change.
3. If the wound is closed and healing by first intention, dressings on the wound may
be minimal and the client may be allowed to shower after 24 hours.
4. If the wound healing is to be by second or third intention, then it is left open to
heal from the fascia to the skin, and requires special wound handling.
5. Measures such as wound packing, dressing, drains, or ostomy bags are included in
the wound care depending on wound size, location, and drainage from the wound.
6. Measure and record the amount of drainage every shift for comparison with earlier
assessments to guide potential care plan changes.
7. Assess the client’s willingness to look at the wounds. Do not force the client to look
at the wounds if he/she is not yet ready
149. • Body image is altered in response to surgery
thus specific interventions should be directed
towards restoration of the client’s body image.
1. Show acceptance of the client’s appearance.
2. Assist the client in verbalizing feelings about
the postoperative appearance and the reactions of
others.
150. SIGNS OF WOUND INFECTIONS
• Usually appear 3-4 days postop
1. Redness beyond the incision line
2. Edema that remains after initial swelling
3. Increasing pain
4. Increasing drainage that sometimes become purulent
5. Fever
6. Malaise
7. Anorexia
8. Leukocytosis
• Notify the surgeon of any suspected wound infection
• Wound culture may be ordered.
151. Wound Dehiscence
• Be alert for wound dehiscence.
• Dehiscence is an opening of a skin wound. It
should be treated as open wounds:
1. Kept clean with application of packing or dressings
2. Allowed to heal by secondary or tertiary intention
152. Wound Eviceration
• a condition wherein the abdominal wounds become infected and
the abdominal incision opens, the fascia or internal organs may be
visible.
• 1. Do not attempt to replace the organs.
• 2. Cover the wound with sterile dressings moistened with normal
saline.
• 3. Monitor client’s vital signs and keep the client as calmas
possible.
• 4. Notify the physician immediately.
153. Reduce Nausea and Vomiting
• Postoperative nausea and vomiting (PONV) do not occur frequently
Medications that are used to c ontrol PONV:
1. Anticholinergics and histamine type 1 receptor antagonists
– reduce excitability of the labyrinth receptors
2. Antidopaminergic drugs
– depresses the chemoreceptor trigger zone
3. Gastrointestinal antispasmodics
– promote forward peristaltic movement.
• PONV has also been controlled by acupuncture.
155. Discharge Instructions and Care
• Ensure that the client and a family member or caregiver have information and skills
needed for continuous recovery.
• Teach skills (e.g., wound care) over a period of days, with enough time for
questions,demonstration, and return demonstration.
• Provide information about home care in writing to the client and family members.
• Provide a printed form filled out with specific postoperative information, such as
instructions on medications and wound care, an appointment for the next clinic visit,
names and contact numbers for emergencies and further questions.
• If collaboration with other health care workers (e.g., social services, home nurses, or
rehabilitation centers) is needed, proper endorsement should be done.
157. Miss Nervous Nellie
• Miss N is scheduled for a colon resection. A recent biopsy of a
polyp revealed a malignancy. During your pre-admission
interview Miss N is tearful and keeps saying “I hope this won’t
be like it was when my dad had colon surgery.” “I’m so afraid I
will die just like he did.”
What are Miss N’s psychosocial needs?
How will you meet those needs?
158. Intraoperative Case Study
The client, a 62-year-old secretary, has entered the surgical suite
about 30 minutes after she has received atropine and midazolam for
preoperative medication. The OR schedule lists that she is
scheduled to have a vaginal hysterectomy. In addition, the
preoperative history indicates that she smokes three packs of
cigarettes per day and drinks three cans of beer each day. When
you ask her what kind of surgery she is having today, her response is
“I am going to have a hemorrhoidectomy.” You ask her if she means
hysterectomy and she responds, “Well, it is some kind of operation
‘down there’.”
159. What Should You Do?
• What additional questions should you ask this client?
• What should you do with the information?
• What effect, if any, will her history of smoking and drinking
have on her surgical experience?
160. The Case Continues
The client demonstrates understanding of the surgical procedure and the
team proceeds with the planned vaginal hysterectomy. The client weighs
96 pounds.
• In what position should you place this client for the surgical procedure?
• What areas on this client are most likely to be injured as a result of poor
positioning or inadequate padding?
• What are the nursing responsibilities related to skin integrity?
162. Perioperative Nursing
Phases: Time:
– Preoperative Surgical unit to OR
– Intraoperative OR-PACU
– Postoperative PACU-FOLLOW-UP
163. Consent
• if pt is sedated:
– Consent should be from the family member and
witnessed by 2 persons
164. Anxiety before Surgery
• Verify pt’s understanding about the upcoming
surgery
• Clarify certain vague ideas
• Do health teaching
165. Drugs that place clients at risk during perioperative
period
• Aspirin
– Increase bleeding during surgery
• Antidepressant
– May lower BP during anesthesia
– e.g. sertraline (Zoloft)
• Anticholinergics
• Steroids
– risk for adrenal insufficiency)
• NSAID
– Increase the risk of stress ulcers and displace other drugs from blood proteins
– e.g. ibuprofen
• Anti-hypertensives
• Tranquilizers
• Diuretics
• Drugs containing bromide
– Can accumulate in the body and can produce manifestations of dementia
– e.g. Diphenhydramine (Sominex)
166. Health Teaching
• Nurse:
– Preoperative teaching should include:
• Educating the client about the anticipated postoperative
nursing interventions including turning, coughing, deep
breathing and leg exercise.
• MDs
– Preoperative teaching include:
• Risks of complications
• Proposed surgical procedures
• Anesthetic choices
