Asia pacific college of advanced

College
studies of nursing
A.H. Banzon St. Ibayo, City of Balanga, Bataan

PERIOPERATIVE NURSING
- connotes the delivery of patient care in the pre-operative, intra-operative, and post-operative
periods of the patient’s surgical experience through the framework of the nursing process.
- The nurse assesses the patient by collecting, organizing, and prioritizing patient data;
establishing nursing diagnosis; identifies desired patient outcomes; develops and implements a
plan of care; and evaluates that care in terms of outcomes achieved by the patient.

Phases:
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.
Examples: Hydrocephalus - Obstruction, Burn – Erosion, Benign Prostatic Hyperplasia - Tumor
Cholelithiasis – Obstruction, Intussusception - Obstruction, Ruptured Aneurysm – Perforation
Classification of Surgical Procedure
A. According to PURPOSE:

a. Diagnostic – to establish the presence of a disease condition. ( e.g biopsy )

b. Exploratory – to determine the extent of disease
condition (e.g Ex-Lap)
c. Curative – to treat the disease condition.
➢ Ablative – removal of an organ “ectomy”
➢ Constructive – repair of congenitally defective
organ “plasty,oorhaphy,pexy”
➢ Reconstructive – repair of damage organ
d. Palliative – to relieve distressing sign and
symptoms, not necessarily to cure the disease.

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 B. According to URGENCY

C. According to DEGREE OF RISK

a. Major Surgery
- High risk / Greater Risk for Infection
- Extensive
- Prolonged
- Large amount of blood loss
-Vital organ may be handled or removed
b. 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 patient’s 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
ｷ Teeth extraction ｷ Circumcision ｷ Vasectomy ｷ Cyst removal ｷ Tubal ligation
Surgical Risk
a. Obesity
b. Poor Nutrition
c. Fluid and Electrolyte Imbalances
d. Age
e. Presence of Disease (Cardiovascular dse., DM, Respiratory dse.)
f. Concurrent or Prior Pharmacotherapy
g. 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

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 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
a. General survey- gestures and body movements may reflect decreased energy or
weakness caused by illness.
b. Cardiovascular system- alterations in cardiac status are responsible for as many as 30%
of perioperative death.
c. Respiratory system- a decline in ventilatory function, assessed through breathing pattern
and chest excursion, may indicate a client’s risk for respiratory complications.
d. Renal system- abnormal renal function can alter fluid and electrolyte balance and
decrease the excretion of preoperative medications and anesthetic agents.
e. Neurologic system- a client’s LOC will change as a result of general anesthesia but
should return to the preoperative LOC after surgery.
f. Musculoskeletal system - Deformities may interfere with intraoperative and
postoperative positioning. Avoid positioning over an area where the skin shows signs of
pressure over bony prominences.
g. Gastrointestinal system- alteration in function after surgery may result in decreased or
absent bowel sound and distention.
h. Head and Neck- the condition of oral mucous membranes reveals the level of hydration.
i. Gerontological Considerations
a. Physical
➢ Cardiovascular
- Coronary flow decreases
- Heart rate decreases
- Response to stress decreases
- Peripheral vascular decreases
- Cardiac output decreases
➢ Respiratory System
- Static lung volumes decrease
- Pulmonary static recoil decreases
- Sensitivity of the airway receptors decreases
➢ Nervous system
- Increased incidence of post.op. confusion.
- Increased incidence of delirium
- Increased sensitivity to anesthetic agents
➢ Renal System
- Renal blood flow declines 1.5% per year.
- Renal clearance reduced
➢ Gastrointestinal
- Decreased intestinal motility
- Decreased liver blood flow
- Delayed gastric emptying
➢ Musculoskeletal
- Decreased mass, tone, strength
- Decreased bone density
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 ➢ Integumentary
- Decreased elasticity
- Decreased lean body mass
- Decreased subcutaneous fat
b. Psychosocial considerations
- Level of anxiety Level of anxiety
- Coping ability Coping ability
- Support system
Routine Preoperative Screening Test

Psychosocial Assessment and Care

Causes of Fears of the Preoperative Clients
a. Fear of Unknown ( Anxiety )
b. Fear of Anesthesia
c. Fear of Pain
d. Fear of Death
e. Fear of disturbance on Body image
f. 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
1. Explore client’s feeling
2. Allow client’s to speak openly about fears/concern.
3. Give accurate information regarding surgery (brief, direct to the point and in simple
terms)
4. Give empathetic support
5. Consider the person’s religious preference and arrange for visit by a priest / minister as
desired.
Pre-anesthesia Management Physical Status Categories
ASA 1: Healthy patient with no disease
ASA 11: Mild systemic ds without fx limitations
ASA 111: Severe systemic ds associated with definite fx limitations
ASA 1V: Severe systemic ds that is a constant threat to life.
ASA V: Moribund pt. Who is not expected to survive without the operation.
ASA V1: A declared brain-death whose organ are being recovered for donor.
E: Emergency

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INFORMED CONSENT
Purposes:
a. To ensure that the client understand the nature of the treatment including the potential
complications and disfigurement (explained by AMD)
b. To indicate that the client’s decision was made without pressure.
c. To protect the client against unauthorized procedure.
d. To protect the surgeon and hospital against legal action by a client who claims that an
authorized procedure was performed.
Circumstances Requiring Consent
a. Any surgical procedure where scalpel, scissors, suture, hemostats of electrocoagulation
may be used.
b. Entrance into body cavity.
c. Radiologic procedures, particularly if a contrast material is required.
d. General anesthesia, local infiltration and regional block.
Essential Elements of Informed Consent
1. The diagnosis and explanation of the condition.
2. A fair explanation of the procedure to be done and used and the consequences.
3. A description of alternative treatment or procedure.
4. A description of the benefits to be expected.
5. The prognosis, if the recommended care, procedure is refused.
Requisites for Validity of Informed Consent ｷ

a. Written permission is best and legally accepted. ｷ

b. Signature is obtained with the client’s complete understanding of what to occur. - adult
sign their own operative permit -obtained before sedation
c. 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
d. For mentally ill and unconscious patient, consent must be taken from the parents or legal
guardian
e. If the patient is unable to write, an “X” is accepted if there is a witness to his mark
f. Secured without pressure and threat
g. A witness is desirable – nurse, physician or authorized persons.
h. 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.)
Pre- Operative Care
Physical Preparation
Before Surgery
a. Correct any dietary deficiencies
b. Reduce an obese person’s weight
c. Correct fluid and electrolyte imbalances
d. Restore adequate blood volume with BT
e. Treat chronic diseases Halt or treat any infectious process
f. Treat an alcoholic person with vit. supplementation, IVF or fluids if dehydrated

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Pre - Operative Teaching
Incentive Spirometer, Diaphragmatic Breathing. Coughing, Splinting, Turning,
Foot and Leg Exercise, Early Ambulation

A. Incentive Spirometry
ﾘ Encouraged to use incentive spirometer about 10 to 12
times per hour.
ﾘ Deep inhalations expand alveoli, which prevents
atelectasis and other pulmonary complication.
ﾘ There is less pain with inspiratory concentration than
with expiratory concentration

B. Diaphragmatic Breathing
ﾘ 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.
ﾘ In a semi-Fowlers position, with your hands loosefist, allow to rest lightly on the front of lower
ribs.
ﾘ Breathe out gently and fully as the ribs sink down and inward toward midline.
ﾘ Then take a deep breath through the nose and mouth, letting the abdomen rise as the lungs fill
with air.
ﾘ Hold breath for a count of 5.
ﾘ Exhale and let out all the air through your nose and mouth.
ﾘ Repeat this exercise 15 times with a short rest after each group of 5.

C. Coughing and Splinting

ﾘ Promotes removal of chest secretions.
ﾘ Interlace his fingers and place hands over the proposed incision site, this will act as a splint
and will not harm the incision.
ﾘ Lean forward slightly while sitting in bed.
ﾘ Breath, using diaphragm ﾘ Inhale fully with the mouth slightly open.
ﾘ Let out 3-4 sharp hacks.
ﾘ With mouth open, take in a deep breath and quickly give 1-2 strong coughs.

D. Turning
ﾘ Promotes removal of chest secretions.
ﾘ Interlace his fingers and place hands over the proposed incision site, this will act as a splint
and will not harm the incision.
ﾘ Lean forward slightly while sitting in bed.
ﾘ Breath, using diaphragm
ﾘ Inhale fully with the mouth slightly open.
ﾘ Let out 3-4 sharp hacks.
ﾘ With mouth open, take in a deep breath and quickly give 1-2 strong coughs.

E. Foot and Leg Exercise

ﾘ Moving the legs improves circulation and muscle tone.
ﾘ 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.
ﾘ Repeat above about 5 times with one leg and then with the other. Repeat the set 5 times every
3-5 hours.
ﾘ Then have the patient lie on one side and exercise the legs by pretending to pedal a bicycle.
ﾘ For foot exercise, trace a complete circle with the great toe.

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Preparing the Patient the Evening Before Surgery
a. 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.
b. Preparing the G.I tract
- NPO, cleansing enema as required
c. Preparing for Anesthesia
- Avoid alcohol and cigarette smoking for at least 24 hours before surgery.
d. Promoting rest and sleep
-Administer sedatives as ordered

ASA (American Society of Anesthesiologists) Guidelines for Preoperative Fasting

Preparing the Person on the Day Of Surgery

Early A.M Care
a. Awaken 1 hour before preop
medications
b. Morning bath, mouth wash
c. Provide clean gown
d. Remove hairpins, braid long hair, cover
hair with cap if available.
e. Remove dentures, colored nail polish,
hearing aid, contact lenses, jewelries.
f. Take baseline vital sign before preop
medication.
g. Check ID band, skin prep Check for
special orders – enema, IV line
h. Check NPO Have client void before
preop medication
i. Continue to support emotionally
Accomplished “preop care checklist

Pre-Operative Medications
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.

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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 patient’s 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 arrives in the OR at the proper time.
Patient’s 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

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Operative Site Identification

INTRAOPERATIVE PHASE
Goals
➢ Asepsis
➢ Homeostasis
➢ Safe Administration of Anesthesia
➢ Hemostasis
Surgical Setting
• 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 patient’s families outside the suite
• 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 consist 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 sub sterile areas where
the scrub sinks and autoclaves are located
- personnel working in this area must be in proper operating room attire
RMC Operating Room Set Up

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Environmental Safety
• The size of the procedure room
• Temperature and humidity control
• Ventilation and air exchange system
• Electrical Safety
• Communication System

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
• Each procedure room must have the following equipment:
- Communication System - Oxygen and vacuum outlets - Mechanical ventilation assistance
equipment - Respiratory and Cardiac monitoring equipment - X ray film illumination boxes -
Cardiac defibrillator - High-efficiency particulate air filters -Adequate room lighting -
Emergency lighting system
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.
• Each procedure room should maintain 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
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.

The Surgical Team

- The Patient
- The Anesthesiologist or Anesthetist
- The Surgeon
- Scrub Nurse
- Circulating Nurse
- RNFA ( Reg.Nurse First Assistant )
- Surgical Technologists

a. 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

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b. First Assistant to the Surgeon
➢ May be a resident, intern, physician’s 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.

c. Anesthesiologist
➢ Selects the anesthesia, administers it, intubates the client
if necessary, manages technical problems related to the
administration of anesthetic agents, and supervises the
client’s 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.

d. 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 draping 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

e. 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.

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Very defined activities during surgery:
a. Ensure all equipment is working properly.
b. Guarantees sterility of instruments and supplies.
c. Assists with positioning.
d. Monitor the room and team members for breaks in the sterile technique.
e. Handles specimens.
f. Coordinates activities with other departments, such as radiology and pathology.
g. Documents care provided.
h. Minimizes conversation and traffic within the operating room suite.

Medical vs. Surgical Asepsis

Principles of Surgical Asepsis (Sterile Technique)

- 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 person’s 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)

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Common Surgical Incision
Incision Site
Butterfly, Limbal, Halstead / Elliptical, Subcostal, Paramedian, Transverse, Rectus, McBurney
Pfannenstiel, Lumbotomy

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Position During Surgery

a. Supine (Dorsal Recumbent)

-Abdominal, extremity, vascular, chest, neck, facial, ear breast surgery
Positioning Techniques
• Patient lies flat on back with arms either extended on arm boards or placed along side of body.
• Small padding placed under patient’s head, neck and under knees
• Vulnerable pressure points should be padded.
• Safety strap applied 2 in. above knees.
• Eyes should be protected by using eye patch and ointment.

b. Prone Position
- Surgeries involving posterior surface of the body (spine, neck, buttocks and lower extremities)
Positioning Techniques
• Chest rolls or bolster are placed on operating table prior to positioning
• Foam head rest, head turned to side or facing downward
• Patient’s arms are rotated to the padded arm boards that face head, bringing them through their
normal range of motion.
• Padding for knees and pillow for lower extremities to prevent toes from touching mattress.
• Safety strap applied 2 in. above the knees

c. Trendelenburg Position
- Surgeries involving lower abdomen, pelvic organ when there is a need to tilt abdominal viscera
away from the pelvic area.
Positioning Techniques
• Patient is supine with head lower than feet.
• Shoulder braces should not be used as they may cause damage brachial plexus.
• When patient is returned to supine position, care must be taken move leg section slowly, then
the entire table to level position.
• Modification of this position can be used for hypovolemic shock.
• Extremity position and safety strap are the same as for supine.

d. Reverse Trendelenburg Position

- Upper abdominal, head, neck and facial surgery
Positioning Technique
• Patient is supine with head higher than feet.
• Small pillow under neck and knees.
• Well - padded footboard should be used to prevent slippage to foot of the table.
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• Anti embolic hose should be used if position is to be maintained for an extended period of time.
• Patient should be returned slowly to supine position.

e. Lithotomy
- Perineal, vaginal, rectal surgeries; combined abdominal vaginal procedure
Positioning Techniques
• Patient is placed in supine position with buttocks near lower break in the table (sacrum should
be well padded)
• Feet are placed in stirrups, stirrups height should not be excessively high or low, but even on
both sides.
• Knee brace must not compress vascular structures or nerves in the popliteal space.
• Pressure from metal stirrups against upper inner aspect of thigh and calf should be avoided.
• Legs should be raised and lowered slowly and simultaneously (may require two people)

f. Modified Fowler (Sitting Position)

- Otorhinology (ear and nose), neurosurgery
Positioning Techniques
• Patient is supine, positioned over the upper break in the table
• Backrest is elevated, knees flexed
•Arms rest on pillow, placed in lap; safety strap 2 in. above the knees.
• Slow movement in and out of position must be used to prevent drastic changes in blood volume
movement. • Anti embolic hose should be used to assist venous return.
• When using special neurologic headrest, eyes must be protected.

g. Jack Knife Position

- Rectal procedures, sigmoidoscopy and colonoscopy
Positioning Techniques
• Table is flexed at center break
•All precautions taken with prone position are taken with Jack knife position.
• Table strap applied over thighs

ANESTHESIA
- Greek word- anesthesis, meaning “negative sensation.”
- Artificially induced state of partial or total loss of sensation, occurring with or without
consciousness.
- 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 levels
- HR and BP
- Urine output

Factors influencing dosage and type:

1. Type and duration of the procedure
2. Area of the body being operated on
3. Whether the procedure is an emergency
4. Options of management of post. Op. pain
5. How long it has been since the client ate, had any liquids, or any medications
6. Client position for the surgical procedure

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 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.

Techniques used in General Anesthesia

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

B. Inhalation Anesthesia
ｷ This comprises of volatile liquids or
gas and oxygen.
ｷ Administered through a mask or
endotracheal tube.

Stages of General Anesthesia

1: Onset / Induction. ﾘ Stage

2: Excitement / Delirium. ﾘ Stage

3: Surgical ﾘ Stage
4: Medullary / Stage of Danger

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.

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Techniques used in Regional Anesthesia:
A. Topical Anesthesia
ｷ applied directly to the skin and mucous
membrane, open skin surfaces, wounds and
burns.
ｷ readily absorbed and act rapidly
ｷ used topical agents are lidocaine and
benzocaine.

B. Spinal Anesthesia (Subarachnoid

block)
ｷ local anesthetic is injected through lumbar
puncture, between L2 and S1
ｷ anesthetic agent is injected into
subarachnoid 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
ｷ agents used are procaine, tetracaine,
lidocaine and bupivacaine.

C. Epidural Anesthesia
ｷ achieved by injecting local anesthetic into epidural space by way of a lumbar
puncture. ｷ result similar to spinal analgesia
ｷ agents use are chloroprocaine, lidocaine and bupivacaine.

D. Peripheral Nerve Block

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

E. Intravenous Block (Beir block)

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

F. Caudal Anesthesia
ｷ Is produced by injection of the local anesthetic into the caudal or sacral canal

G. Field Block Anesthesia

ｷ the area proximal to a planned incision can be injected and infiltrated with local
anesthetic agents.

Complications and Discomforts of Anesthesia

a. Hypoventilation - inadequate ventilatory support after paralysis of respiratory
muscles.
b. Oral Trauma
c. Malignant Hyperthermia - uncontrolled skeletal muscle contraction
d. Hypotension - due to preoperative hypovolemia or untoward reactions to anesthetic
agents.
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 e. Cardiac Dysrhythmia - due to preexisting cardiovascular compromise, electrolyte
imbalance or untoward reaction to anesthesia.
f. Hypothermia - due to exposure to a cool ambient OR environment and loss of
thermoregulation capacity from anesthesia.
g. Peripheral Nerve Damage - due to improper positioning of patient or use of restraints.
h. Nausea and Vomiting
i. Headache
j. Spinal Anesthesia Complications - hypotension -bradycardia -urine retention -
postural puncture headache -back pain

POSTOPERATIVE CARE
Goals:
a. Restore homeostasis and prevent complication
b. Maintain adequate cardiovascular and tissue perfusion.
c. Maintain adequate respiratory function. Maintain adequate nutrition and elimination.
d. Maintain adequate fluid and electrolyte balance.
e. Maintain adequate renal function.
f. Promote adequate rest, comfort and safety.
g. Promote adequate wound healing.
h. Promote and maintain activity and mobility.
i. Provide adequate psychological support.
PACU CARE
Transport of client from OR to RR
- avoid exposure
- avoid rough handling
- avoid hurried movement and rapid changes in position.

Initial Nursing Assessment

a. Verify patient’s identity, operative procedure and the surgeon who performed the
procedure.
b. Evaluate the following sign and verify their level of stability with the anesthesiologist:
- Respiratory status
- Circulatory status
- Pulses
- Temperature
- Oxygen Saturation level
- Hemodynamic values
c. Determine swallowing and gag reflex, LOC and patient’s response to stimuli.
d. Evaluate lines, tubes, or drains, estimate blood loss, condition of wound, medication
used, transfusions and output.
e. Evaluate the patient’s level of comfort and safety.
f. Perform safety check; side rails up and restraints are properly in placed.
g. Evaluate activity status, movement of extremities.
h. Review the health care provider’s orders.

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Initial Nursing Interventions
1. Maintaining a Patent Airway
ﾘ Allow the airway (ET tube) to remain in place until the patient begins to waken and is trying to
eject the airway.
ﾘ The airway keeps the passage open and prevents the tongue from falling backward and
obstructing the air passages.
ﾘ Aspirate excessive secretions when they are heard in the nasopharynx and oropharynx.

2. Assessing Status of Circulatory System

ﾘ Take VS per protocol, until patient is well stabilized.
ﾘ Monitor intake and output closely.
ﾘ 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)

3. Maintaining Adequate Respiratory Function

ﾘ Place the patient in lateral position with neck extended (if not contraindicated) and upper arm
supported on a pillow.
ﾘ Turn the patient every 1 to 2 hours to facilitate breathing and ventilation.
ﾘ Encourage the patient to take deep breaths, use an incentive spirometer.
ﾘ Assess lung fields frequently by auscultation.
ﾘ Periodically evaluate the patient’s orientation – response to name and command.
Note: Alterations in cerebral function may suggest impaired O2 delivery.

4. Assessing Thermoregulatory Status

ﾘ Monitor temperature per protocol to be alert for malignant hyperthermia or to detect
hypothermia.
ﾘ Report a temperature over 37.8 C or under 36.1 C
ﾘ Monitor for post-anesthesia shivering, 30-45 minutes after admission to the PACU.
ﾘ Provide a therapeutic environment with proper temperature and humidity.

5. Maintaining Adequate Fluid Volume

ﾘ Administer I.V solutions as ordered.
ﾘ Monitor evidence of F&E imbalance such as N&V
ﾘ Evaluate mental status, skin color and turgor
ﾘ 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
ﾘ Monitor I&O

6. Minimizing Complications of Skin Impairment

ﾘ Perform handwashing before and after contact with the patient
ﾘ Inspect dressings routinely and reinforce them if necessary.
ﾘ Record the amount and type of wound drainage.
ﾘ Turn patient frequently and maintain good body alignment.

7. Maintaining Safety
ﾘ Keep the side rails up until the patient is fully awake.
ﾘ Protect the extremity into which I.V fluids are running so needle will not become accidentally
dislodged.
ﾘ Avoid nerve damage and muscle strain by properly supporting and padding pressure areas.

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ﾘ 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.
ﾘ Check dressing for constriction
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
Nursing Care of the Client During the Intermediate Postop Period (RR – Unit)
Baseline Assessment
a. Respiratory Status
b. Cardiovascular Status- VS - Color and Temperature of Skin
c. Level of Consciousness
d. Tubes - Drain - NGT - T-tube
e. Position
Immediate Post-Op Assessment and Interventions

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Common Post-Operative Orders
- NPO until fully alert, then ice chips as tolerated. Advance diet as tolerated.
- Suction prn
- Complete current IV then discontinue if pt. tolerating fluids.
- Compazine 5 mg prn for nausea and vomiting
- Morphine Sulfate 10 mg IM every 3-4 hours prn
- Accurate intake and output
- T, C, and DB every 2 hours
- Hemoglobin and hematocrit in a.m.
- Catheter if patient can’t void in 8 – 10 hours
- Reinforce dressing prn

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Commonly Used Wound Dressing

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POST OPERATIVE COMPLICATIONS

Complications
- Respiratory- Atelectasis, Pulmonary Embolus
- Cardiovascular- Venous Thrombosis
- Gastrointestinal- Hiccoughs, N/V, abdominal distention, Paralytic Ileus, Stress Ulcer.
- GU- Urinary Retention
- Hemorrhage-slipping of a ligature(suture)
- Wound infection
- Wound dehiscence and evisceration
Dehiscence
- Partial or complete separation of the outer layer of the wound.
Possible causes: Poor suturing technique, Distention, Excessive vomiting, Excessive
coughing, Dehydration, Infection

Evisceration
- Total separation of the layers & protrusion of
internal organs or viscera through the open wound.
Causes: same as dehiscence
Treatment:
a. Call for help
b. Cover with sterile NS soaked gauze/towels
c. Keep moist DO NOT ATTEMPTS TO
REINSERT ORGANS.
d. Keep in supine position with knees/hips bent
e. Assessment/VS q 5 min. until MD arrive
f. Prepare for surgery.

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