Lecture Notes on Perioperative Nursing

Prepared By: Mark Fredderick R Abejo R.N, MAN

According to URGENCY
Classification

MEDICAL AND SURGICAL NURSING

PERIOPERATIVE NURSING
Lecturer: Mark Fredderick R. Abejo RN, MAN
__________________________________________

PERIOPERATIVE
NURSING
Perioperative Nursing used to describe the nursing
care provided in the total surgical experience of the
patient: preoperative, intraoperative and postoperative.
Preoperative Phase, extends from the time the client is
admitted in the surgical unit, to the time he/she is
prepared for the surgical procedure, until he is
transported into the operating room.
Intraoperative Phase, extends from the time the client is
admitted to the OR, to the time of administration of
anesthesia, surgical procedure is done, until he/she is
transported to the RR/PACU.
Postoperative Phase, extends from the time the client is
admitted to the recovery room, to the time he is
transported back into the surgical unit, discharged from
the hospital, until the follow-up care.
4 Major Types of Pathologic Process Requiring
Surgical Intervention (OPET)
Obstruction impairment to the flow of vital fluids
(blood,urine,CSF,bile)
Perforation rupture of an organ.
Erosion wearing off of a surface or membrane.
Tumors abnormal new growths.

Classification of Surgical Procedure

According to PURPOSE:
Diagnostic to establish the presence of a disease
condition. ( e.g biopsy )
Exploratory to determine the extent of disease
condition ( e.g Ex-Lap )
Curative to treat the disease condition.
* Ablative removal of an organ
* Constructive repair of congenitally
defective organ.
* Reconstructive repair of damage organ
Palliative to relieve distressing sign and symptoms,
not necessarily to cure the disease.

MS Perioperative Nursing

Emergent patient
requires immediate
attention, life
threatening condition.
Urgent / Imperative
patient requires prompt
attention.
Required patient
needs to have surgery.
Elective patient
should have surgery.
Optional patients
decision.

Indication
for Surgery
Without
delay

Within 24 to
30 hours
Plan within a
few weeks or
months
Failure to
have surgery
not
catastrophic
Personal
preference

Examples
- severe
bleeding
- gunshot/
stab wounds
- Fractured
skull
- kidney /
ureteral
stones
- cataract
- thyroid d/o
- repair of
scar
- vaginal
repair
- cosmetic
surgery

According to DEGREE OF RISK

Major Surgery
- High risk / Greater Risk for Infection
- Extensive
- Prolonged
- Large amount of blood loss
- Vital organ may be handled or removed
Minor Surgery
- Generally not prolonged
- Leads to few serious complication
- Involves less risk
Ambulatory Surgery/ Same-day Surgery / Outpatient
Surgery
Advantages:
- Reduces length of hospital stay and cuts costs
- Reduces stress for the patient
- Less incidence of hospital acquired infection
- Less time lost from work by the patient; minimal
disruptions on the patients activities and family life.
Disadvantages:
- Less time to assess the patient and perform
preoperative teaching.
- Less time to establish rapport
- Less opportunity to assess for late postoperative
complication.
Example of Ambulatory Surgery
Teeth extraction
Circumcision
Vasectomy
Cyst removal
Tubal ligation
Surgical Risks
Obesity
Poor Nutrition
Fluid and Electrolyte Imbalances
Age

Abejo

Lecture Notes on Perioperative Nursing

Prepared By: Mark Fredderick R Abejo R.N, MAN

Presence of Disease (Cardiovascular dse., DM,

Respiratory dse. )
Concurrent or Prior Pharmacotherapy
other factors:
- nature of condition
- loc. of the condition
- magnitude / urgency of the surgery
- mental attitude of the patient
- caliber of the health care team

PREOPERATIVE PHASE
Goals
Assessing and correcting physiologic and
psychologic problems that may increase surgical risk.
Giving the person and significant others complete
learning / teaching guidelines regarding surgery.
Instructing and demonstrating exercises that will
benefits the person during postop period.
Planning for discharge and any projected changes in
lifestyle due to surgery.
Physiologic Assessment of the Client Undergoing
Surgery
Age
Presence of Pain
Nutritional & Fluid and Electrolyte Balance
Cardiovascular / Pulmonary Function
Renal Function
Gastrointestinal / Liver Function
Endocrine Function
Neurologic Function
Hematologic Function
Use of Medication
Presence of Trauma & Infection
Routine Preoperative Screening Test
Test
CBC

Blood grouping/
X matching
Serum
Electrolyte
PT,PTT
Fasting Blood
Glucose
BUN /
Creatinine
ALT/AST/LDH
and Bilirubin
Serum albumin
and total CHON
Urinalysis
Chest Xray
ECG

Rationale
RBC,Hgb,Hct are important to the
oxygen carrying capacity of blood.
WBC are indicator of immune
function.
Determined in case blood transfusion
is required during or after surgery.
To evaluate fluid and electrolyte
status
Measure time required for clotting to
occur.
High level may indicate undiagnosed
DM
Evaluate renal function
Evaluate liver function
Evaluate nutritional status
Determine urine composition
Evaluate resp.status/ heart size
Identify preexisting cardiac problem.

Psychosocial Assessment and Care

Causes of Fears of the Preoperative Clients
Fear of Unknown ( Anxiety )
Fear of Anesthesia
MS Perioperative Nursing

Fear of Pain
Fear of Death
Fear of disturbance on Body image
Worries loss of finances, employment, social and
family roles.
Manifestation of Fears
- anxiousness
- bewilderment
- anger
- tendency to exaggerate
- sad, evasive, tearful, clinging
- inability to concentrate
- short attention span
- failure to carry out simple directions
- dazed
Nursing Intervention to Minimize Anxiety
Explore clients feeling
Allow clients to speak openly about fears/concerns
Give accurate information regarding surgery
(brief, direct to the point and in simple terms)
Give empathetic support
Consider the persons religious preference and
arrange for visit by a priest / minister as desired.

INFORMED CONSENT

Purposes:
To ensure that the client understand the nature of
the treatment including the potential complications
and disfigurement
( explained by AMD )
To indicate that the clients decision was made
without pressure.
To protect the client against unauthorized
procedure.
To protect the surgeon and hospital against legal
action by a client who claims that an authorized
procedure was performed.
Circumstances Requiring Consent
Any surgical procedure where scalpel,
suture, hemostats of electrocoagulation
used.
Entrance into body cavity.
Radiologic procedures, particularly if a
material is required.
General anesthesia, local infiltration and
block.

scissors,
may be

contrast
regional

Essential Elements of Informed Consent

the diagnosis and explanation of the condition.
a fair explanation of the procedure to be done and
used and the consequences.
a description of alternative treatment or procedure.
a description of the benefits to be expected.
material rights if any.
the prognosis, if the recommended care, procedure
is refused.
Requisites for Validity of Informed Consent
Written permission is best and legally accepted.
Signature is obtained with the clients complete
understanding of what to occur.
Abejo

Lecture Notes on Perioperative Nursing

Prepared By: Mark Fredderick R Abejo R.N, MAN

- adult sign their own operative permit

- obtained before sedation
For minors, parents or someone standing in their
behalf, gives the consent.
Note: for a married emancipated minor parental
consent is not needed anymore, spouse is accepted
For mentally ill and unconscious patient, consent
must be taken from the parents or legal guardian
If the patient is unable to write, an X ia accepted
if there is a witness to his mark
Secured without pressure and threat
A witness is desirable nurse, physician or
authorized persons.
When an emergency situation exists, no consent is
necessary because inaction at such time may cause
greater injury. (permission via telephone/cellphone
is accepted but must be signed within 24hrs.)

PREOPERATIVE CARE

Physical Preparation
Before Surgery
Correct any dietary deficiencies
Reduce an obese persons weight
Correct fluid and electrolyte imbalances
Restore adequate blood volume with BT
Treat chronic diseases
Halt or treat any infectious process
Treat an alcoholic person with vit. supplementation,
IVF or fluids if dehydrated
Preoperative Teaching

Interlace his fingers and place hands over the

proposed incision site, this will act as a splint and
will not harm the incision.
Lean forward slightly while sitting in bed.
Breath, using diaphragm
Inhale fully with the mouth slightly open.
Let out 3-4 sharp hacks.
With mouth open, take in a deep breath and quickly
give 1-2 strong coughs.
Turning
Changing positions from back to side-lying (vice
versa ) stimulates circulation, encourages deeper
breathing and relieve pressure areas
Help the patient to move onto his side if assistance is
needed.
Place the uppermost leg in a more flexed position
than that of the lower leg and place a pillow
comfortably between the legs.
Make sure that the patient is turned from one side to
the back and onto the other side every 2 hours.
Foot and Leg Exercise
Moving the legs improves circulation and muscle
tone.
Have the patient lie supine, instruct patient to bend a
knee and raise the foot hold it a few seconds and
lower it to the bed.
Repeat above about 5 times with one leg and then
with the other. Repeat the set 5 times every 3-5
hours.
Then have the patient lie on one side and exercise the
legs by pretending to pedal a bicycle.
For foot exercise, trace a complete circle with the
great toe.
Turning to the Side
Turn on your side with the uppermost leg flexed most
and supported on a pillow.
Grasp the side rails as an aid to maneuver to the side.

Incentive Spirometry
Encouraged to use incentive spirometer about 10 to
12 times per hour.
Deep inhalations expand alveoli, which prevents
atelectasis and other pulmonary complication.
There is less pain with inspiratory concentration than
with expiratory concentration.
Diaphragmatic Breathing
Refers to a flattening of the dome of the diaphragm
during inspiration, with resultant enlargement of
upper abdomen as air rushes in. During expiration,
abdominal muscles contract.
In a semi-Fowlers position, with your hands loosefist, allow to rest lightly on the front of lower ribs.
Breathe out gently and fully as the ribs sink down and
inward toward midline.
Then take a deep breath through the nose and mouth,
letting the abdomen rise as the lungs fill with air.
Hold breath for a count of 5.
Exhale and let out all the air through your nose and
mouth.
Repeat this exercise 15 times with a short rest after
each group of 5.
Coughing
Promotes removal of chest secretions.

MS Perioperative Nursing

Abejo

Lecture Notes on Perioperative Nursing

Prepared By: Mark Fredderick R Abejo R.N, MAN

Preparing the Patient the Evening Before Surgery

Preparing the Skin
- have a full bath to reduce microorganisms in the
skin.
- hair should be removed within 1-2 mm of the skin
to avoid skin breakdown, use of electric clipper is
preferable.
Preparing the G.I tract
- NPO, cleansing enema as required

Check ID band, skin prep

Check for special orders enema, IV line
Check NPO
Have client void before preop medication
Continue to support emotionally
Accomplished preop care checklist

PREOPERATIVE MEDICATIONS
ASA (American Society of Anesthesiologists)
Guidelines for Preoperative Fasting
Liquid and Food Intake
Clear Liquids
Breast Milk
Nonhuman Milk
Light Meal
Regular / Heavy Meals

Minimum
Fasting Period
2
4
6
6
8

Preparing for Anesthesia

- Avoid alcohol and cigarette smoking for at least 24
hours before surgery.
Promoting rest and sleep
- Administer sedatives as ordered
Preparing the Person on the Day Of Surgery
Early A.M Care
Awaken 1 hour before preop medications
Morning bath, mouth wash
Provide clean gown
Remove hairpins, braid long hair, cover hair with cap
if available.
Remove dentures, colored nail polish, hearing aid,
contact lenses, jewelries.
Take baseline vital sign before preop medication.

MS Perioperative Nursing

Goals:
To aid in the administration of an anesthetics.
To minimize respiratory tract secretion and changes
in heart rate.
To relax the patient and reduce anxiety.
Commonly used Preop Meds.
Tranquilizers & Sedatives
* Midazolam
* Diazepam ( Valium )
* Lorazepam ( Ativan )
* Diphenhydramine
Analgesics
* Nalbuphine ( Nubain )
Anticholinergics
* Atropine Sulfate
Proton Pump Inhibitors
* Omeprazole ( Losec )
* Famotidine
Transporting the Patient to the OR
Adhere to the principle of maintaining the comfort
and safety of the patient.
Accompany OR attendants to the patients bedside
for introduction and proper identification.
Assist in transferring the patient from bed to
stretcher.
Complete the chart and preoperative checklist.
Make sure that the patient arrive in the OR at the
proper time.

Abejo

Lecture Notes on Perioperative Nursing

Prepared By: Mark Fredderick R Abejo R.N, MAN

Patients Family
Direct to the proper waiting room.
Tell the family that the surgeon will probably contact
them immediately after the surgery.
Explain reason for long interval of waiting:
anesthesia prep, skin prep, surgical procedure, RR.
Tell the family what to expect postop when they see
the patient

Electrical Safety
Faulty wiring, excessive use of extension cords,
poorly maintained equipment and lack of
current safety measures are just some of the
hazardous factors that must be constantly
checked
All electrical equipment new or used, should be
routinely checked by qualified personnel.
Equipment that fails to function at 100%
efficiency should be taken out of service
immediately.

Communication System

INTRAOPERATIVE PHASE
Goal:
Asepsis
Homeostasis
Safe Administration of Anesthesia
Hemostasis

Surgical Environment
Unrestricted Area
- provides an entrance and exit from the surgical suite
for personnel, equipment and patient
- street clothes are permitted in this area, and the area
provides access to communication with personnel within
the suite and with personnel and patients families
outside the suit.
Semi-restricted Area
- provides access to the procedure rooms and
peripheral support areas within the surgical suite.
- personnel entering this area must be in proper
operating room attire and traffic control must be
designed to prevent violation of this area by
unauthorized persons
- peripheral support areas consists of: storage areas
for clean and sterile supplies, sterilization equipment and
corridors leading to procedure room
Restricted Area
- includes the procedure room where surgery is
performed and adjacent substerile areas where the scrub
sinks and autoclaves are located
- personnel working in this area must be in proper
operating room attire

Environmental Safety

The size of the procedure room

Usually rectangular or square in shape
20 x 20 x 10 with a minimum floor space of
360 square feet

Temperature and humidity control

The temperature in the procedure room should
maintained between 68 F - 75 F ( 20 - 24
degrees C)
Humidity level between 50 - 55 % at all times

Ventilation and air exchange system

Air exchange in each procedure room should be
at least 25 air exchanges every hour, and five of
that should be fresh air.
A high filtration particulate filter, working at
95% efficiency is recommended.

MS Perioperative Nursing

Each procedure room should maintained with

positive pressure, which forces the old air out of
the room and prevents the air from surrounding
areas from entering into the procedure room

The Surgical Team

Surgeon
Primary responsible for the preoperative
medical history and physical assessment.
Performance of the operative procedure
according to the needs of the patients.
The primary decision maker regarding surgical
technique to use during the procedure.
May assist with positioning and prepping the
patient or may delegate this task to other
members of the team
Assistant Surgeon
May be a resident, intern , physicians assistant
or a perioperative nurse.
Assists with retracting, hemostasis, suturing and
any other tasks requested by the surgeon to
facilitate speed while maintaining quality
during the procedure.
Anesthesiologist
Selects the anesthesia, administers it, intubates
the client if necessary, manages technical
problems related to the administration of
anesthetic agents, and supervises the clients
condition throughout the surgical procedure.
A physician who specializes in the
administration and monitoring of anesthesia
while maintaining the overall well-being of the
patient.
Scrub Nurse
May be either a nurse or a surgical technician.
Reviews anatomy, physiology and the surgical
procedures.
Assists with the preparation of the room.
Scrubs, gowns and gloves self and other
members of the surgical team.
Prepares the instrument table and organizes
sterile equipment for functional use.
Assists with the drapping procedure.
Passes instruments to the surgeon and assistants
by anticipating their need.
Counts sponges, needles and instruments.
Monitor practices of aseptic technique in self
and others.
Keeps track of irrigations used for calculations
of blood loss
Abejo

Lecture Notes on Perioperative Nursing

Prepared By: Mark Fredderick R Abejo R.N, MAN

Circulating Nurse
Must be a registered nurse who, after additional
education and training, specialized in
perioperative nursing practice.
Responsible and accountable for all activities
occurring during a surgical procedure including
the management of personnel equipment,
supplies and the environment during a surgical
procedure.
Patient advocate, teacher, research consumer,
leader and a role model.
May be responsible for monitoring the patient
during local procedures if a second
perioperative nurse is not available.
Ensure all equipment is working properly.
Guarantees sterility of instruments and supplies.
Assists with positioning.
Monitor the room and team members for breaks
in the sterile technique.
Handles specimens.
Coordinates activities with other departments,
such as radiology and pathology.
Documents care provided.
Minimizes conversation and traffic within the
operating room suite.

Principles of Surgical Asepsis

Sterile object remains sterile only when touched by
another sterile object
Only sterile objects may be placed on a sterile field
A sterile object or field out of range of vision or an
object held below a persons waist is contaminated
When a sterile surface comes in contact with a wet,
contaminated surface, the sterile object or field
becomes contaminated by capillary action
Fluid flows in the direction of gravity
The edges of a sterile field or container are
considered to be contaminated (1 inch)
Medical Asepsis vs. Surgical Asepsis

Surgical Incisions
Incision Site
Butterfly
Limbal
Halstead / Elliptical
Subcostal
Paramedian

Transverse
Rectus

McBurney
Pfannenstiel
Lumbotomy

Type of Surgery
For craniotomy
For eye surgeries
For breast surgeries
Gallbladder and biliary tract
surgery
Right side gallbladder, biliary
tract
Left side - splenectomy
Gastrectomy
Right side small bowel
resection
Left side sigmoid colon
resection
Appendectomy
Gynecologic surgery
For kidney surgeries

Position During Surgery

Position
Type of Surgery
Dorsal Recumbent
Hernia repair, mastectomy,
bowel resection
Trendelenburg
Pelvic Surgeries
Lithotomy
Vaginal repair, D&C, rectal
surgery, APR
Prone
Spinal surgery, laminectomy
Lateral
Kidney, chest, hip surgery
Jack Knife Position
Rectal procedures,
sigmoidoscopy and colonosc
Reverse
Trendelenburg
Position

Upper abdominal, head, neck

and facial surgery

Explain the purpose of position

Avoid undue exposure
Strap the person to prevent falls
Maintain adequate respiratory and circulatory
functions.
Maintain good body alignment

ANESTHESIA

State of Narcosis
Anesthetics can produce muscle relaxation,
block transmission of pain nerve impulses and
suppress reflexes.
It can also temporary decrease memory
retrieval and recall.
The effects of anesthesia are monitored by considering
the following parameters:
- Respiration
- O2 saturation / CO2 level
- HR and BP
- Urine output
Types of Anesthesia
1. General Anesthesia
reversible state consisting of complete loss of
consciousness and sensation.
protective reflexes such as cough and gag are lost
provides analgesia, muscle relaxation and sedation.
produces amnesia and hypnosis.
MS Perioperative Nursing

Abejo

Lecture Notes on Perioperative Nursing

Prepared By: Mark Fredderick R Abejo R.N, MAN

Techniques used in General Anesthesia

A. Intravenous Anesthesia
This is being administered intravenously and
extremely rapid.
Its effect will immediately take place after thirty
minutes of introduction.
It prepares the client for smooth transition to the
surgical anesthesia.

E. Intravenous Block ( Beir block )

often used for arm,wrist and hand procedure
an occlusion tourniquet is applied to the extremity to
prevent infiltration and absorption of the injected IV
agents beyond the involved extremity.

B. Inhalation Anesthesia
This comprises of volatile liquids or gas and
oxygen.
Administered through a mask or endotracheal tube
2. Regional Anesthesia
temporary interruption of the transmission of nerve
impulses to and from specific area or region of the
body.
achieved by injecting local anesthetics in close
proximity to appropriate nerves.
reduce all painful sensation in one region of the body
without inducing unconsciousness.
agents used are lidocaine and bupivacaine.

Indicating a site for insertion of the lumber puncture

needle into the subarachnoid space of the spinal
canal.

Techniques used in Regional Anesthesia:

A. Topical Anesthesia
applied directly to the skin and mucous membrane,
open skin surfaces, wounds and burns.
readily absorbed and act rapidly
used topical agents are lidocaine and benzocaine.
B. Spinal Anesthesia ( Subarachnoid block )
local anesthetic is injected through lumbar puncture,
between L2 and S1
anesthetic agent is injected into subarachoid space
surrounding the spinal cord.
- Low spinal, for perineal/rectal areas
- Mid spinal T10 ( below level of umbilicus)
for hernia repair and appendectomy.
- High spinal T4 ( nipple line ), for CS
anesthetic block conduction in spinal nerve roots and
dorsal ganglia; paralysis and analgesia occur below
level of injection
agents used are procaine, tetracaine, lidocaine and
bupivacaine.
C. Epidural Anesthesia
achieved by injecting local anesthetic into epidural
space by way of a lumbar puncture.
result similar to spinal analgesia
agents use are chloroprocaine, lidocaine and
bupivacaine.

D. Peripheral Nerve Block

achieved by injecting a local anesthetic to anesthetize
the surgical site.
agents use are chloroprocaine, lidocaine and
bupivacaine.

MS Perioperative Nursing

F. Caudal Anesthesia
Is produced by injection of the local anesthetic into
the caudal or sacral canal
G. Field Block Anesthesia
The area proximal to a planned incision can be
injected and infiltrated with local anesthetic agents.
Stages of Anesthesia
Onset / Induction. Extends from the
administration of anesthesia to the time of loss
of consciousness.

Excitement / Delirium. Extends from the time

of loss of consciousness to the time of loss of
lid reflex. Increase in autonomic activity and
irregular breathing. It may be characterized by
shouting, struggling of the client.

Surgical. Extends from the loss of lid reflex to

the loss of most reflexes. surgical procedure is
started.

Medullary / Stage of Danger. It is

characterized by respiratory and cardiac
depression or arrest. It is due to overdose of
anesthesia. Resuscitation must be done.

Abejo

Lecture Notes on Perioperative Nursing

Prepared By: Mark Fredderick R Abejo R.N, MAN

Complication and Discomforts of Anesthesia

Hypoventilation - inadequate ventilatory support
after paralysis of respiratory muscles.
Oral Trauma
Malignant Hyperthermia
Hypotension - due to preoperative hypovolemia or
untoward reactions to anesthetic agents.
Cardiac Dysrhythmia - due to preexisting
cardiovascular compromise, electrolyte imbalance or
untoward reaction to anesthesia.
Hypothermia - due to exposure to a cool ambient
OR environment and loss of thermoregulation
capacity from anesthesia.
Peripheral Nerve Damage - due to improper
positioning of patient or use of restraints.
Nausea and Vomiting
Headache

MS Perioperative Nursing

POSTOPERATIVE PHASE
Goals:
Maintain adequate body system functions
Restore homeostasis
Alleviate pain and discomfort
Prevent postop complication
Ensure adequate discharge planning and teaching.

PACU CARE

Transport of client from OR to RR

avoid exposure
avoid rough handling
avoid hurried movement and rapid changes in
position.

Abejo

Lecture Notes on Perioperative Nursing

Prepared By: Mark Fredderick R Abejo R.N, MAN

Initial Nursing Assessment

Verify patients identity, operative procedure and the
surgeon who performed the procedure.
Evaluate the following sign and verify their level of
stability with the anesthesiologist:
- Respiratory status
- Circulatory status
- Pulses
- Temperature
- Oxygen Saturation level
- Hemodynamic values
Determine swallowing and gag reflex , LOC and
patients response to stimuli.
Evaluate lines, tubes, or drains, estimate blood loss,
condition of wound, medication used, transfusions and
output.
Evaluate the patients level of comfort and safety.
Perform safety check; side rails up and restraints are
properly in placed.
Evaluate activity status, movement of extremities.
Review the health care providers orders.
Initial Nursing Interventions
Maintaining a Patent Airway
Allow the airway ( ET tube ) to remain in place until
the patient begins to waken and is trying to eject the
airway.
The airway keeps the passage open and prevents the
tongue from falling backward and obstructing the air
passages.
Aspirate excessive secretions when they are heard in
the nasopharynx and oropharynx.
Assessing Status of Circulatory System
Take VS per protocol, until patient is well stabilized.
Monitor intake and output closely.
Recognized early symptoms of shock or hemorrhage:
- cool extremities
- decreased urine output ( less than 30ml/hr )
- slow capillary refill ( greater than 3 sec. )
- lowered BP
- narrowing pulse pressure
- increased heart rate
* initiate O2 therapy, to increase O2
availability from the blood.
* place the patient in shock position with his
feet elevated ( unless contraindicated )
Maintaining Adequate Respiratory Function
Place the patient in lateral position with neck
extended ( if not contraindicated ) and upper arm
supported on a pillow.
Turn the patient every 1 to 2 hours to facilitate
breathing and ventilation.
Encourage the patient to take deep breaths, use an
incentive spirometer.
Assess lung fields frequently by auscultation.
Periodically evaluate the patients orientation
response to name and command.
Note: Alterations in cerebral function may suggest
impaired O2 delivery.
Administer humidified oxygen if required.
MS Perioperative Nursing

Use mechanical ventilation to maintain adequate

pulmonary ventilation if required.
Assessing Thermoregulatory Status
Monitor temperature per protocol to be alert for
malignant hyperthermia or to detect hypothermia.
Report a temperature over 37.8 C or under 36.1 C
Monitor for postanesthesia shivering, 30-45 minutes
after admission to the PACU.
Provide a therapeutic environment with proper
temperature and humidity.
Maintaining Adequate Fluid Volume
Administer I.V solutions as ordered.
Monitor evidence of F&E imbalance such as N&V
and weakness.
Evaluate mental status, skin color and turgor
Recognized signs of:
a. Hypovolemia
- decrease BP
- decrease urine output
- decreased CVP
- increased pulse
b. Hypervolemia
- increase BP
- changes in lung sounds (S3 gallop )
- increased CVP
Monitor I&O
Minimizing Complications of Skin Impairment
Perform handwashing before and after contact with
the patient
Inspect dressings routinely and reinforce them if
necessary.
Record the amount and type of wound drainage.
Turn patient frequently and maintain good body
alignment.
Maintaining Safety
Keep the side rails up until the patient is fully awake.
Protect the extremity into which I.V fluids are
running so needle will not become accidentally
dislodged.
Avoid nerve damage and muscle strain by properly
supporting and padding pressure areas.
Recognized that the patient may not be able to
complain of injury such as the pricking of an open
safety pin or clamp that is exerting pressure.
Check dressing for constriction
Promoting Comfort
Assess pain by observing behavioral and physiologic
manifestations.
Administer analgesic and document efficacy.
Position the patient to maximize comfort.

Parameter for Discharge from PACU/RR

Activity. Able to obey commands
Respiratory. Easy, noiseless breathing
Circulation. BP within 20mmHg of preop level
Consciousness. Responsive
Color. Pinkish skin and mucus membrane

Abejo

Lecture Notes on Perioperative Nursing

Prepared By: Mark Fredderick R Abejo R.N, MAN

Nursing Care of the Client During the Intermediate

Postop Period (RR Unit )
Baseline Assessment
Respiratory Status
Cardiovascular Status
- VS
- Color and Temperature of Skin
Level of Consciousness
Tubes
- Drain
- NGT
- T-tube
Position

MS Perioperative Nursing

10

Goals:
o Restore homeostasis and prevent complication.
o Maintain adequate cardiovascular and tissue
perfusion.
o Maintain adequate respiratory function.
o Maintain adequate nutrition and elimination.
o Maintain adequate fluid and electrolyte balance.
o Maintain adequate renal function.
o Promote adequate rest, comfort and safety.
o Promote adequate wound healing.
o Promote and maintain activity and mobility.
o Provide adequate psychological support.

Abejo

Lecture Notes on Perioperative Nursing

Prepared By: Mark Fredderick R Abejo R.N, MAN

MS Perioperative Nursing

11

Abejo

STI Global City College of Nursing / QMMC Surgery Ward Exposure

Lecture Notes on Perioperative Nursing
Prepared By: Mark Fredderick R Abejo R.N
Clinical Instructor

12

WOUND CARE
Frequently used Dressing
Materials

Common dressing

Irrigating a wound

Montgomery Straps holding dressing

The strips of tape should be placed at the ends of

the dressing and must be sufficiently long and wide to
secure the dressing. The tape should adhere to intact skin.

Cleaning Surgical Site

Cleaning a wound outward

from the incision
Cleaning from top to bottom
Starting at the center

MS Perioperative Nursing

Cleaning around a
Penrose drain site

Abejo

STI Global City College of Nursing / QMMC Surgery Ward Exposure

Lecture Notes on Perioperative Nursing
Prepared By: Mark Fredderick R Abejo R.N
Clinical Instructor

13

INCISION SUPPORTING

BODY PRESSURE AREAS:

MS Perioperative Nursing

Abejo

STI Global City College of Nursing / QMMC Surgery Ward Exposure

Lecture Notes on Perioperative Nursing
Prepared By: Mark Fredderick R Abejo R.N
Clinical Instructor

14

POST OPERATIVE COMPLICATIONS

Problem

Description

Cause

Inflammation of the
lung parenchyma /
alveoli

Infection
Toxin / irritants
causing
inflammatory
process

Clinical Signs

Nursing Intervention

RESPIRATORY
Pneumonia

Infectious
Pneumonia

Cause by
streptococcus
pneumoniae /
Staphylococcus
aureus

Hypostatic
Pneumonia

Immobility
Impaired
ventilation

Aspiration
Pneumonia
Atelectasis

A condition in
which alveoli
collapsed and are
not ventilated

Aspiration of
gastric contents,
food
Mucous plugs
blocking bronchial
passageways
Inadequate lung
expansion
Immobility

Pulmonary
Embolism

Blood clot that has

moved to the lungs
and blocks a
pulmonary artery
and obstruct blood
flow to the lungs

Immobility
Use of oral
contraceptives
Coagulation
problem

- elevated temp.
- cough
- blood tinged
sputum
- dyspnea
- chest pain

Deep breathing exercises

Coughing exercise
Early ambulation

- Fever ( 1st 24
hours)
- Dyspnea
- Tachycardia
- Diaphoresis
- Pleural pain
- Dull or absent
lung sounds
- Dec. SaO2

Deep breathing exercises

Coughing exercise
Early ambulation

- Sudden chest
pain
- SOB
- Cyanosis
- Tachycardia
- Low BP

Turning
Ambulation
Anti embolic stockings
Compression devises
Prevent massaging the
lower extremities

- Tachycardia
- Dec. urine
output
- Dec. BP
- Cold, moist and
pale skin
- Deep, rapid RR
- Low temp
- Increase pain
- Inc. abd. girth
- Swelling or
bruising around
incision

Fluid and blood

replacement

CIRCULATION
Hypovolemia

Inadequate
circulating blood
volume

Hemorrhage

Internal or external
bleeding
Capillary slow
generalized oozing
Venous dark in
color and bubble out
Arterial spurts,
bright red in color

MS Perioperative Nursing

Hemorrhage
Fluid deficit

Disruption of
sutures
Insecure ligation of
blood vessels

Fluid and blood

replacement
Vit.k and hemostat
Ligation of bleeders
Pressure dressing

Abejo

STI Global City College of Nursing / QMMC Surgery Ward Exposure

Lecture Notes on Perioperative Nursing
Prepared By: Mark Fredderick R Abejo R.N
Clinical Instructor

15

Overt Bleeding
- Dressing
saturated with
bright blood
- Bright, freeflowing blood in
drains or tubes.
Thrombophlebitis

Thrombus

Embolus

URINARY
Urinary
Retention

Urinary
Incontinence
Urinary Tract
Infection

MS Perioperative Nursing

Inflammation of the
veins, usually of the
legs and associated
with a blood clot.

Slowed venous
blood flow due to
immobility or
prolonged sitting
Trauma to the vein
Increased blood
coagulability.

- Homans Sign
pain, discomfort in
calf when foot is
dorsiflexed
- Aching, cramping
pain
- Swollen, red and
hot to touch
- Vein feels hard
Arterial
- Pain
- Pallor on the
affected
extremities
- Dec./absent of
peripheral pulse

Blood clot attached

to wall of vein or
artery

Note:
Embolus in the
venous system
usually becomes a
pulmonary
embolus

Foreign body or clot

that has moved from
its site of formation
to another area of
the body

Broken IV catheter
Fat
Amniotic fluid

Inability to empty
the bladder, with
excessive
accumulation of
urine in the bladder

Depressed bladder
muscle tone from
narcotics and
anesthetics
Handling of tissue
during surgery on
adjacent organs
Spasm of the
bladder sphincter
Loss of tone of the
bladder sphincter

- Larger fluid
intake than output
- Inability to void
- Bladder
distention
- Suprapubic
discomfort
- Restlessness

Immobilization
Limited fluid
intake

- Fever ( 48 hours
postop)
- Burning sensation
when voiding
- Urgency
- Cloudy urine
- Lower abdominal
pain

Inability of the
bladder to hold
accumulated urine
Inflammation of the
bladder, ureters or
urethra

- 30 60 ml of
urine q 15-30 mins

Early ambulation
Anti embolic stocking
Encourage leg exercise
Hydrate adequately
Avoid any restricting
devices that impaired
circulation
Avoid massage on the
calf of the leg
Initiate anticoagulant
therapy

Careful maintenance of
IV catheters

Monitor I & O
Interventions to facilitate
voiding
Urinary Catheterization
as needed

Monitor I & O

Adequate fluid intake

Early ambulation
Aseptic catheterization as
needed
Good perineal hygiene

Abejo

STI Global City College of Nursing / QMMC Surgery Ward Exposure

Lecture Notes on Perioperative Nursing
Prepared By: Mark Fredderick R Abejo R.N
Clinical Instructor

16

GASTROINTESTINAL
Nausea and
Vomiting

Pain
Abdominal
distention
Ingestion of fluid
or food before the
return of peristalsis

- Complaints of
feeling sick to the
stomach
- Retching
- Gagging

- Abdominal
distention
- Absence of bowel
sound
- A sound
hic that result
from the vibration
of closed vocal
cords as air rushes
suddenly into the
lungs

IV fluids until peristalsis

returns
Progressive diet ( clear
liquid then full fluids, soft
then regular diet)
Anti emetics as ordered

Tympanities

Retention of gases
within the intestines

Slowed motility of
the intestines due to
effects of anesthesia

Hiccups

Intermittent spasms
of the diaphragm

Irritation of
phrenic nerve bet.
the spinal cord and
terminal
ramifications on
undersurface of the
diaphragm
Abdominal
distention

Intestinal
Obstruction
( 3rd-5th day
postop)

Kink loop of
intestines

Due to
inflammatory
adhesions

- Intermittent
sharp, colicky
abdominal pains
- Nausea &
Vomiting
- Abdominal
distention
- Hiccups
- No bowel
movement

NGT insertion as needed

Administered IVF as
ordered
Prepare for possible
surgery

Constipation

Infrequent or no
stool passage for
abnormal length of
time
( within 48 hours
after solid diet
started )
Lack of peristaltic
activity

Lack of dietary
roughage
Analgesics
Immobility

- Absence of stool
elimination
- Abdominal
distention
- Abdominal
discomfort

Adequate hydration
High fiber diet
Encourage early
ambulation

- Abdominal pain
- Abdominal
distention
- Constipation
- Absence of bowel
sounds

Encourage early
ambulation

Inflammation and
infection of incision
or drain site

Poor aseptic
techniques

- Fever ( 72 hours
postop)
- Redness, swelling
, pain and warmth
- Pus or discharge
on the wound site
- Foul smelling
discharge

Keep wound clean and

dry
Surgical aseptic technique
when changing dressing
Antibiotic therapy

Paralytic Ileus

WOUND
Wound Infection

MS Perioperative Nursing

Due to anesthetics
Immobility

Early ambulation
Avoid using straw
Provide ice chips
NGT insertion as needed
Hold breath while taking
a large swallow of water
Breath in and out on a
paper bag
Anti emetics as ordered

Abejo

STI Global City College of Nursing / QMMC Surgery Ward Exposure

Lecture Notes on Perioperative Nursing
Prepared By: Mark Fredderick R Abejo R.N
Clinical Instructor

Wound
Dehiscence

Wound
Evisceration

17

Separation of a
suture line before
the incision heals

Extrusion of internal
organ or tissues
through the incision

Malnutrition
emaciation/obesity
Excessive strain on
suture line
Poor circulation

- Increased incision
drainage
- Tissues
underlying skin
become visible

Apply abdominal binders

Encourage high protein
diet and Vit.C intake
Keep in bed rest

- Opening of
incision and visible
protrusion of
organs

Semi-Fowlers, bend
knees to relieve tension on
the abdominal muscles
Splinting on coughing
Cover exposed organ with
sterile , moist saline
dressing
Reassure, keep him/her
quite and relaxed
Prepare for surgery and
repair of wound

- Anorexia
- Tearfulness
- Withdrawal
- Rejection of
others
- Sleep
disturbances
- Poor memory
- Restlessness
- Inattentive
- Inappropriate
behavior
- Wild excitement
- Hallucination
- Delusions
- Disoriented
- Sleep
disturbances

Adequate rest
Physical activity
Opportunity to express
anger and other negative
feelings

PSYCHOLOGIC
Postoperative
Depression

Delirium / Acute
Confusional State

MS Perioperative Nursing

Altered Mood

Weakness
Surprise nature of
E surgery
News of
malignancy
Severely altered
body image
Dehydration
Insufficient
oxygenation
Anemia
Hypotension
Hormonal
Imbalances
Infection
Trauma

Sedatives to keep client

quite and comfortable
Explain reasons for
interventions
Listen and talk to the
client
Provide physical comfort

Abejo

STI Global City College of Nursing / QMMC Surgery Ward Exposure

Lecture Notes on Perioperative Nursing
Prepared By: Mark Fredderick R Abejo R.N
Clinical Instructor

18

STUDY HARD
GOD BLESS YOU
THANKS
Mark Fredderick R. Abejo R.N, M.A.N
Clinical Instructor

MS Perioperative Nursing

Abejo