Preoperative Period
Classifications Based on Extent
- Decision to undergo operation to the transfer to OR
Conditions requiring surgery:
 Obstruction - affects hollow structures.
 Perforation – rupture of organ, artery or bleb.
 Erosion – break in continuity of tissue surface.
 Tumors – abnormal growth of tissue without purpose (?)
Classifications Based on Purpose:
1. Diagnostic – confirm diagnosis. (benign / malignant)
2. Exploratory – estimate extent of disease and confirm
diagnosis. (ex. Exploratory Laparotomy)
3. Curative – remove or repair damages of diseased
organ / tissue
Types of Curative Surgery:
a) Ablative Surgery – removal of diseased
organ.
b) Constructive Surgery – repair
congenitally defective organ by improving
function or appearance.
c) Reconstructive Surgery – partial or
complete restoration of damaged organ or
tissues to its original appearance or
function.
d) Palliative Surgery – relieves symptoms but
does not cure underlying cause / disease.
1. Major
- extensive, significant and serious risk with significant
loss of blood.
- Ex. Craniotomy, cesarean section, appendectomy.
2. Minor
- Ex. Dilatation and curettage, circumcision, wound
drainage and suturing.
Classification Based on Urgency
1. Emergency
- performed immediately to maintain life/organ; stop
hemorrhage and remove damaged organ.
- Ex. Fractured skull, gunshot or stab wounds.
2. Urgent (Imperative)
- Performed within 24 – 30 hrs.
- Ex. Kidney or ureteral stones.
3. Planned (Required)
- Important but may be scheduled weeks or months in
advance.
of - Ex. Cataracts, tonsillectomy.
4. Elective
- Scheduled in advance and does not involve medical
emergency.
- Ex. Repair of scars, simple hernia repair, vaginal repair.
5. Optional
- Done for preference, surgery is not needed.
- Ex. Cosmetic surgery.

Preparations the Day Before Surgery
I. History taking
- Should include marital status, religion, social status,
support group/significant other, and if member of
PhilHealth or has insurance.
II. Physical Assessment
- Includes laboratory results and should make sure that
patient is cardiopulmonary (CP) cleared.
- Family should secure 1 bag of patient’s blood type.
III. Informed Consent
- Patient’s autonomous decision on where to undergo
procedure based on nature of condition, treatment
options, and risks and benefits involved.
- Protects patient from unsanctioned surgery.
- Protects surgeon from claims of unauthorized
operation.
 Voluntary Consent
- Of legal age and mentally capable.
- Should not be coerced or urged to sign.
- If not capable/minor, family member or guardian must
sign for emergency situations
Important Information
 Previous surgery and experience with anesthesia.
 Any serious illnesses the client had
 Current symptoms or discomforts
 Chronic illnesses, such as arthritis, migraines, back pain
 Previous and current prescribed medications or use of
over-the-counter drugs
 Allergies and reactions,
 Any dietary restrictions
 Alcohol, nicotine, recreational drug use
 Occupation
 Religious affiliation
 Significant others
 Questions the client has about the surgery
Reinforce Health Teachings
 Deep breathing exercises – promote optimal lung expansion
and prevent postoperative pneumonia.
 Coughing exercises – proper breathing (?) to minimize
pressure and control pain at incision site.
 Leg exercises – prevent circulatory problems and promote
venous return to the heart.
- early ambulation and pain management.
 Turning to sides – prevent respiratory problems and prevent
bed sores.
*Reminders
- Remove nail polish to observe nail bed for hypoxia.
- Skin prep/cleansed and shaved as close to incision time.
- Jewelry and valuable belongings are given to watcher.
Night Before Surgery
- Give medications like sedatives as ordered.
 - Instruct patient to maintain NPO after midnight (inform  Vital signs assessed.
watchers) [no fluids, foods, tea, milk, water, juice]
- Do bowel preparations for cases of abdominal surgery
as indicated. [enema, laxative]
- Full bath if able or assist in going to the hosp. Chapel if
there’s any. Preoperative Medications
- NPO is maintained and that patient is CP cleared and  ANTIANXIETY
check also the availability of the ordered blood  HISTAMINE-2 RECEPTOR ANTAGONIST
- Allow the patient to void.  SEDATIVES
- Change pt. dress to OR gown, tie long hair and you may  ANTIBIOTICS
put a disposable cap.
- Dentures/false teeth are removed
- Check if jewelry is already removed
- Start IV line using big bore catheter

Preoperative Checklist

 must be filled completely with patient / significant

other’s signature.
 Obtain initial vital signs for baseline data.
 Endorse the patient to OR nurse one hour prior to
surgery including the chart.

-> Checklist:

 History and physical examination.

 Name of procedure on surgical consent.
 Signed surgical consent.
 Laboratory results.
 Client is wearing an identification bracelet.
 Allergies have been identified.
 NPO.
 Skin preparation completed.
Intraoperative Period
- OR to Post Anesthesia Ward

Operating Theater

- is a facility within a hospital where surgical operations are

carried out in an aseptic environment. Historically, the term
"operating theatre" referred to a non-sterile, tiered theater
or amphitheater in which students and other spectators
could watch surgeons perform surgery.

Electrosurgical Unit (ESU)

- Consists of a generator and a handpiece with one or more

electrodes. The device is controlled using a switch on the
handpiece or a foot switch.
- Can produce a variety of electrical waveforms. As these
waveforms change, so do the corresponding tissue effects. Nursing Responsibilities

Anesthesia Machine 1. Focuses on the client’s emotional well – being.

2. Focuses on physical factors such as:
- Device used to generate and mix a fresh gas flow of medical o Positioning and safety
gases and inhalational anesthetic agents for the purpose of o Maintaining asepsis
inducing and maintaining anesthesia. o Controlling the surgical
- dispenses the gases that are necessary to induce sleep and o Environment
prevent pain to animals during surgical procedures or other 3. Being the client’s advocate.
potentially painful manipulations. 4. Anticipating and guarding against potential complications
Kick Bucket

- Medical receptacle, usually made of stainless steel, which is

mounted on wheels.
Operating Room Attire supplies to the surgeon during the
operation, Maintains accurate
o A protective cap covering their hair
count of sponges, sharps, and
o Masks over their lower face, covering their mouths and
instruments on the sterile field and
noses count.
o Shades or glasses over their eyes o Assesses the client preoperatively
o Latex gloves on their hands o Plans for optimal care during the
o Long gowns surgical intervention
o Protective covers on their shoes o Coordinates all personnel within the
Surgical Team OR
o Ensures that all equipment works
- The surgical team is a group of highly trained and educated properly
professionals who coordinate their efforts to ensure the welfare and 4. CIRCULATING NURSE
safety of the client. o Assesses the client preoperatively
1. SURGEON: The head of the surgical team; Makes decision o Plans for optimal care during the surgical
about the surgical procedure. intervention
2. ASSISTANT SURGEON: Assist the surgeon; May be a second o Coordinates all personnel within the OR
surgeon or specially trained nurse. o Ensures that all equipment works properly
3. ANESTHESIOLOGIST / NURSE ANESTHETIST: Alleviates pain o Guaranteeing sterility of instruments and
and promotes relaxation with medications, maintains supplies
airway and ensures adequate gas exchange, Monitors o Assists with positioning
circulation and respiration. Estimates fluid and blood loss. o Performs surgical skin preparation
Administers medications and infuses blood and fluids to o Monitors the room and team members for
maintain hemodynamic stability. break in the sterile technique
- Alerts the surgeon to any complications o Assists anesthesia personnel with induction
o Organize surgical instruments, and physiologic monitoring
Prepares all supplies and o Handles specimens
instruments using aseptic o Coordinates activities with other
technique, Maintains sterility within departments
the sterile field during surgery, o Documents care provided
Hands appropriate instruments and
 o Minimizes conversation and traffic within o Exposes the perineal and rectal areas and is ideal
for vaginal repairs, dilatation and curettage, and
most types of rectal surgery.

IV. PRONE
o Commonly used for cervical spine, posterior fossa
craniotomy, back, rectal, and posterior leg surgery.
V. LATERAL
o Used for clients undergoing kidney, chest, or hip
surgery.

During Induction of Anesthesia

- Anesthesia – an artificially induced state of partial or total

loss of sensation with or without loss of consciousness.
Anesthesia agents can produce muscle relaxation, block
the OR suite transmission of nerve impulses, and suppress reflexes.

Skin Preparation 1. GENERAL ANESTHESIA

- Block pain stimulus at the cerebral cortex

- Induce depression of the CNS
Surgical Position
- Produce analgesia, amnesia, unconsciousness, and loss of
I. DORSAL RECUMBENT (SUPINE) reflexes and muscle tone
o Commonly used for coronary artery bypass grafting, - Affect the neurologic, respiratory, and cardiovascular
hernia repair, mastectomy or bowel resection. system
II. TRENDELENBURG - Best used for:
o Permits displacement of the intestines into the  Head
upper abdomen and is often used during surgery of  Neck
the lower abdomen or pelvis.  Upper torso and back
III. LITHOTOMY  For prolonged surgical procedures
  Or for use in clients who are unable to lie quietly for
a long period.
- BALANCE (NEUROLEPTIC) ANESTHESIA
o a method in administering general anesthesia.
o achieved by using a combination of an inhalation
agent, oxygen, an opioid, and a neuromuscular
blocking agent.
o Inhalation and IV route are the most common route
of administration.
- Neuromuscular Blocking Agent
o Administered by IV route and are given mainly to
facilitate intubation by easing laryngospasm and
relaxing muscles for controlled ventilation.
o classified as depolarizing and nondepolarizing
agents; Block the transmission of nerve impulses of
the muscle fibers.
o Ex. succinylcholine, tubocurarine, pancuronium, and
vecuronium.
 Types of General Anesthesia
o Intravenous
- Rapid induction (30s)
- Rapid transition from conscious state to
anesthesia stage.
- Smooth transition; act as calming agent.
- Ex. thiopental Na and ketamine
o Inhalation
- Mixture of volatile liquids or gas and oxygen
is used
- Ease of administration and elimination
through respiratory system.
- Maintain the client in stage III anesthesia
following induction; given via face
mask/endotracheal tube.
- Ex. Halothane and Isoflurane
2. REGIONAL ANESTHESIA
- Block the pain stimulus at its origin, along afferent neurons
or along the spinal cord.
- Does not result in unconsciousness
- the client will also receive sedative agents that produce
drowsiness.
 Types of Regional Anesthesia
o SPINAL ANESTHESIA
- Achieve by injecting local anesthetics into
the subarachnoid space.
- Autonomic nerve fibers (ANS) are affected
first, then the spinal anesthesia blocks the
following fibers in this order: touch, pain,
motor, pressure and proprioceptive fibers.
 Recovery is in reverse order.
- A sterile field is established with povidone-
iodine applied with three basic sponges; the
solution is applied starting from the
injection site moving outward in a circular
fashion.
- A fenestrated drape is applied, and using a
sterile gauze, wipe the iodine from the
injection site to avoid initiation into the
subarachnoid space. A skin wheal is raised
 with 2cc of 1% lidocaine using a 25G needle
to the selected space.
- Used for almost any type of major
procedure performed below the level of
the diaphragm.
- Within minutes of administration the client
experiences a loss of sensation and paralysis
of the toes, feet, legs, and then abdomen
- Lower risk than GA; may cause vasodilation,
and hypotension.
o EPIDURAL ANESTHESIA
- achieved by introduction of an anesthetic
agent into the epidural space.
- produces a blockade of the autonomic
nerves and hypotension; Respiratory
depression or paralysis may occur if level of
block is too high and the respiratory
muscles are affected.
- commonly placed in the low back (lumbar
region).
- Local anesthetics and narcotics given
epidurally via this catheter.
- May be used for 1 to 4 days post
operatively.
o CAUDAL ANESTHESIA
- injecting of the local anesthetic into the
caudal or sacral canal.
- commonly used with obstetric clients.
o TOPICAL ANESTHESIA
- Short acting form of anesthesia
- Can block peripheral nerve endings in the
mucous membranes.
- Agent may be a solution, an ointment, a gel,
a cream, or a powder.
o LOCAL INFILTRATION
- injection of an agent (xylocaine) into the
skin and subcutaneous tissue of the area to
be anesthetized.
- Must do aspiration before injecting;
cardiovascular collapse and convulsions
could occur.
o FIELD BLOCK ANESTHESIA
- Agent is injected proximal to planned
incision site.
- Forms a barrier between the incision and
the nervous system.
o PERIPHERAL NERVE BLOCK ANESTHESIA
- Anesthetizes individual nerves or nerve
plexuses.
- injects the anesthetic along the nerve
rather than into the nerve to decrease the
risk of nerve damage.
 - Surgeon infiltrates the surgical site with a local anesthetic
and the anesthesia provider supplements it with IV drugs to
provide sedation and systemic analgesia.
- Anesthesia providers monitors the client’s BP, HR, and RR
during the process.
- Local standby and anesthesia standby also refer to
monitored anesthesia.

POTENTIAL INTRAOPERATIVE COMPLICATIONS

 Nausea and Vomiting

 Anaphylaxis
 Hypoxia and other respiratory complications
 Hypothermia

MONITORED ANESTHESIA

- A planned procedure during which the patient undergoes

local anesthesia together with sedation and analgesia. 
 Stage Start-Point Endpoint Physical Reaction Nsg. Interventions

I. Onset Anesthetic administration Loss of consciousness Drowsy or dizzy, possible Close operating room
visual or auditory doors, keep room quiet,
hallucination stand by to assist the
client

II. Excitement Loss of consciousness Loss of eyelid reflexes Increase in autonomic Remain quiet at client’s
activity and irregular side assist anesthesiologist
breathing, client may as needed
struggle

III. Surgical Loss of eyelid reflexes Loss of most reflexes and Client is unconscious, Begin preparation when
anesthesia depression of vital signs muscles are relaxed, no the client is breathing well
blink or gag reflex with stable vital signs

IV. Medullary Functions excessively Respiratory and circulatory Client is not breathing, If arrest occurs, respond
Depression depressed failure heartbeat may or may not immediately to assist in
be present establishing airways and
other procedures

Postoperative Period
- Leaves OR to follow up visit with surgeon.
Stages of Postoperative Period replaced with lightweight blanket and warmed. Side rails
1. Immediate Stage are raised.
 Then the PACU nurse admits the patient a handover or
- in the PACU
endorsement is made by the Operating room Nurse.
- Routine post op care are done.
2. Intermediate Stage
Information during admission to PACU
- in the Ward
o Medical diagnosis and type of surgery performed
3. Extended Stage o Pertinent past medical history & allergies
- Hospital discharge to the time of follow- o Age, general condition, airway patency, vital signs
up/consultation o Anesthetics & medications used during the procedure
o Problems intraoperatively (e.g. Extensive hemorrhage,
The Post anesthesia Care Unit (PACU)
shock, cardiac arrest)
- Patient still under anesthesia or recovering from
o Fluid administered, blood loss, replacement fluids
anesthesia are placed
o Tubing, catheters, drains
- Located adjacent to the operating rooms for easy
o Specific instructions for notification (e.g. BP or heart
access to experienced, highly skilled nurses,
rate below or above a specified level)
anesthesiologists, surgeons, advanced monitoring
devices to check for hemodynamic, pulmonary
ROUNTINE POST OPERATIVE CARE
status.
o Patient first then chart
 Transferring the postoperative patient to the PACU is a big
responsibility of the anesthesiologist or anesthetist o Intravenous fluids
 Anesthesia provider remains at the head of the stretcher (to  check on the going IVF as well as the next IV to
maintain the airway) and a surgical team member remains follow.
at the opposite end. o Monitoring
 Patient is critically monitored for any reaction from  every 15 mins for the first 2 hours, then q 30
anesthesia. mins there after until the clients vital signs are
 Positioning and placement of the IV tubing, catheters and stable.
tubes. Any soiled, wet gowns is removed carefully and
o DVT prophylaxis (Deep Vein Thrombosis) Immediate Anesthetic Care (PACU)
 - A blood clot in the deep veins is a concern
o Respiratory Status
because it can cause life-threatening
- patent airway, suction PRN
complications.
o Cardiovascular
 A blood clot (thrombus) in the deep venous
- Regular, strong HR and stable BP (VS); peripheral
system of the leg becomes dangerous if a piece
pulses; Homan’s Sign.
of the blood clot breaks off or travels through
o Neurological
the blood stream, through the heart, and into
- level of consciousness; orientation, sensation
the pulmonary arteries forming a pulmonary
o Fluid and Electrolyte, Acid Base Balance
embolism. A person may not have signs or
o Airway
symptoms of a small pulmonary
embolism (blood clot in the lungs), but a large - Keep airway in place until the patient is fully awake
embolism can be fatal. and tries to eject it.
 Symptoms of DVT in leg include: - Return of pharyngeal reflex, noted when the patient
o Pain regains consciousness, may cause the patient to gag
and vomit when the airway is not removed when
o Swelling
the patient is awake.
o Warmth
- Suction secretions as needed.
o Tenderness
o Breathing
o Redness of the leg or arm
- B – Bilateral lung auscultation frequently.
o Wound care
- R – Rest and place the patient in a lateral position
 assess always the wound for bleeding.
with the neck extended, if not contraindicated, and
o Medication
the arm supported with a pillow. This position
 post op medications include antibiotics and pain
promotes chest expansion and facilitates breathing
reliever, especial attention with medication if
and ventilation.
client has other underlying chronic conditions.
- E – Encourage the patient to take deep breaths. This
o Investigations – focus on other diagnostic studies to be
aerates the lung fully and prevents
done like biopsy, ultrasound, other laboratory studies.
hypostatic pneumonia.
- A – Assess and periodically evaluate the patient’s
orientation to name or command. Cerebral function
 alteration is highly suggestive of impaired Elderly Care in Postoperative
oxygen delivery.
o Respiratory System
- T – Turn the patient if advised every 1 to 2 hours to
- diminished airway reflexes and cough.
facilitate breathing and ventilation.
o Cardiovascular
- H – Humidified oxygen administration.
- myocardium weakness.
During exhalation, heat and moisture are normally
o Hypothermia
lost, thus oxygen humidification is necessary. Aside
- less subcutaneous tissue, muscle, slow metabolic
from that, secretion removal is facilitated when
rate.
kept moist through the moisture of the inhaled air.
o Pain
Also, dehydrated patients have irritated respiratory
passages thus, it is very important make sure that - more intense, confusion, impaired circulation and
the inhaled oxygen is humidified. sensory.
o Circulation Gentle handling and positioning should be observed
because it can influence BP and ventilation
- Obtain patient’s vital signs as ordered and report
Special attention is given to keeping the patient warm
any abnormalities.
because the elderly are more susceptible to hypothermia.
- Monitor intake and output closely.
Post op confusion is common among elderly which
- Recognize early symptoms of shock or hemorrhage
aggravated by social isolation, restraints, and anesthetic
such as cold extremities, decreased urine output –
agents and pain relievers
less than 30 ml/hr., slow capillary refill – greater
Reorienting them and using smaller amounts of sedatives
than 3 seconds, dropping blood pressure, narrowing
and analgesics may help prevent confusion.
pulse pressure, tachycardia – increased heart rate.
Safety very important at all times.
Initial Post-Operative Assessments
Readiness for Discharge from PACU
o Vital signs
 Stable vital signs
o Effectiveness of respirations
 Normal LOC
o Presence or need for supplemental oxygen
- patient is oriented to : Time, person and place
o Location of drains and drainage characteristics
 Uncompromised lung function
o Location, type, and rate of intravenous fluid
- normal O2 saturation, nail beds, no abnormal lung
o Level of pain and need for analgesia
sounds, not cyanotic
o Presence of a urinary catheter and urine volume
 Urine output
- 30 ml per hour
 Nausea & vomiting controlled/absent
- Negative for N/V which can lead to F and E
imbalances
 Minimal pain
