PERIOPERATIVE NURSING SURGERY

• The branch of medicine that deals with the diagnosis and treatment of surgery,
deformity or disease by manual or instrumental means.

Perioperative Period
• The period of time that constitutes the surgical experience

TERMINOLOGIES:
• Surgery - the branch of medicine that encompasses preoperative care, intra operative
judgment and management and postoperative care of patients.
Operation a surgical procedure done for correction of deformities and defects, repair of
injury, diagnosis, and cure of disease processes, relief of suffering and prolong action
life.
o Asepsis/ Sterile - the absence of microorganism
o Bactericidal - an agent that is destructive to bacteria
o Obstructions - impairmerit to the flow of vital fluids
o Erosions - wearing off of a surface or membrane
Tumors
 abnormal cell growth of tissue that serves no physiologic function in the body

Factors that affect Outcomes of Surgery:

1. Malnutrition
2. Obesity
3. Presence of disease such as : Cardiac problem,
URTI, Renal diseases, DM, Liver Diseases
4. Age
5. Concurrent or prior pharmacotherapy - anticoagulant (heparin, warfarin) or
chemo therapy
6. Nature of the condition
7. Location of the condition (affected organ or system)
8. Magnitude and extent of surgical procedure ( how far within the body)
9. Mental attitude of the person toward surgery (psychological preparedness)
10. Caliber of the professional staff and health care facilities

Effects of Surgery:
o Lifestyles may change
o Organ functions may be disturbed
o Vascular system is disrupted
Derense against infection is lowered
o Stress response is elicited
PHASES
o Preoperative Period - begins when the decision to proceed is made and ends
with the transfer of patient into the OR table.

o Intraoperative - begins when the patient is transferred to the OR table and ends
with the admission to the PACU

o Post-operative - begins with the admission of patient to the PACU and ends with
follow-up evaluation in the clinical setting or home.

PERIOPERATIVE NURSING: GENERAL CONSIDERATION

Conditions Requiring Surgery:
 Obstruction or blockage (Impairment to the flow of vital fluids) e.g.
ureterolithotomy
 Perforation or rupture of an organ- e. g. aneurysm
 Erosion or wearing away of the surface of a tissue- e. g. pressure ulcer, burn
 Tumors or abnormal growth- e.g. myoma

Categories of Surgical Procedures:

According to Purpose:
a. Diagnostic: to verify suspected diagnosis, e.g. biopsy
b. Exploratory: to estimate the extent of the disease, e.g. exploratory laparotomy
c. Curative: to remove or repair damaged or diseased organs or tissues

Types of Curative Surgery:

i. Ablative: removal of diseased organs. (-ectomy) e.g. appendectomy, hysterectomy
il. Reconstructive: partial or complete restoration of a damaged organ, e.g.
plastic surgery after burns
Constructive: repair of a congenitally defective organ, (-plasty, -orrhaphy, -pexy) e.g.
cheiloplasty, orchidopexy
d. Palliative: to relieve pain, relieve distressing S/Sx

According to Degree of Risk to Client:

a. Maior surgery
b. Minor surgery

According to Urgency:
1. Emergency: must be performed immediately without delay, e.g. gunshot
wound, severe bleeding,

2. Imperative or Urgent: must be performed as soon as possible within 24 - 48

hours, e.g. appendectomy

3. Required: necessary for the well-being of the client, usually within weeks to
months, e. g. cholecystectomy, cataract extraction, thyroidectomy

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 4. Elective: should be performed for the client's well being but which is not
absolutely necessary, e.g. simple hernia, vaginal repair, repair of scar e. .

5. Optional: surgery that a client requests, e.g. rhinoplasty, liposuction,

mammoplasty

Criteria:
a. Major surgery:
High degree of risk
 Prolonged intraoperative period
 Large amount of blood loss
 Extensive, vital organs may be handled or removed
 Great risk of complications, i.e. liver biopsy

b. Minor surgery:
Lesser degree of risk to the client
 Generally not prolonged; described as "one-day surgery" or outpatient surgery
 Leads to few serious complications
 Involves less risk, e.g. cyst removal

Factors that Affect the Estimation of Surgical Risk

a. Physical and Mental Condition of the Client
o Age: premature babies and elderly persons are at risk
o Nutritional status: malnourished and obese are at risk
o State of fluid and electrolytes balance: dehydration and hypovolemia predispose
a person to complications
o General health: infectious process increase operative risk
o Mental health
o Endocrine function
o Hepatic/ renal disease
o Cardiovascular functioning
o Economic and occupational status

b. Types of drugs/substances taken regularly:

i. Steroids: may improve the body's ability to response to the stress of anesthesia and
surgery
ii. Anticoagulants and salicylates: may increase bleeding during
surgery
iii. Antibiotics: maybe incompatible with or potentiate anesthetic
agents
iv. Tranquilizers: potentiate the effect of narcotics and can cause
hypotension
Antihypertensives: may predispose to shock by the combined effect of blood pressure
reduction and anesthetic vasodilation
vi. Diuretics: may increase potassium loss
vil- Alcohol: will place the surgical client at risk when used chronically

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Factors that Affect the Estimation of Surgical Risk...
1. The Extent of the Disease- degree of spread
2. The Magnitude of the Required Operation
3. Resources and Preparation of the Surgeon, Nurses, and the Hospital

Disease/Medication
Specific Considerations
o Diabetes Mellitus:
- At risk for hyperglycemia or hypoglycemia
o Long-term corticosteroid use:
- At risk for adrenal insufficiency
o Uncontrolled Thyroid Disease
o Overactive: risk of Thyrotoxicosis
o Underactive: risk of respiratory depression

PHASES OF PERIOPERATIVE NURSING

o Because clients experience varying degrees of anxiety and deficient knowledge
related to surgery, careful planning by the nurse can help ensure a positive
outcome.
o Encompasses a client's total surgical experience, including preoperative, intra-
operative, and postoperative phases
o Refers to activities performed by the professional nurse during these phases.

PREOPERATIVE PHASE
Psychologic Preparation for Surgery
o Preparation for hospital admission includes explanation of the

Psychologic Preparation for Surgery

o Preparation for hospital admission includes explanation of the procedure to be
done, probable outcome, expected duration of hospitalization, cost, length of
absence from work, and residual effects
Causes of Fears:
o Fear of the unknown
o Fear of anesthesia, vulnerability while unconscious
o Fear of pain
o Fear of death
o Fear of disturbance of body image
o Worries: loss of finances, employment, social and family roles

INFORMED CONSENT
a. The Surgeon obtains operative permit or informed consent:
• Surgical procedure, alternatives, possible complications, disfigurements, or removal of
body parts are explained

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Note: It is part of the nurse's role as a client advocate to confirm that the client
understands information given.

b. Informed consent is necessary for each operation performed, however minor

• It is also necessary for major diagnostic procedures where major body cavity is
entered, e.g. thoracentesis

C. Adult client (over 18 years of age) signs own permit unless unconscious or mentally
incompetent
• If unable to sign, relative, (spouse or next of kin) or guardian will sign or may use
thumbprint if unable to sign

o In an emergency, permission via the telephone is acceptable; have a second

listener on phone when telephone permission being given
o No sedation should be administered to the client before he/she signs the consent

Consents are not needed for emergency care if all four of the following criteria are met:
i. There is an immediate threat to life ii. Experts agree that it is an emergency iii. Client
is unable to consent
iv. A legally authorized person cannot be reached
d. Minors (under 18) must have consent signed by an adult (i.e. parent or legal
guardian). An emancipated minor may sign own consent:
i. Married,
ii. College student living away from home, iii. In military service,
iv. Any pregnant female or anybody who has given birth
1. Witness to informed consent may be nurse, other physician, clerk, or authorized
person
2. If nurse witnesses informed consent, specify whether witnessing explanation of
surgery or just signature of client

PREOPERATIVE
• Goals:
1. Assessing and correcting physiologic and psychologic problems that might
increase surgical risk
2. Giving the person and significant others complete learning/ teaching guidelines
regarding surgery
3. Instructing and demonstrating exercises that will benefits the person during post-
op period
4. Planning for discharge and any projected changes in lifestyle due to surgery

Manifestations of Fears:
o Anxiousness
o Confusion
o Anger
o Tendency to exaggerate
o Sad, evasive, tearful, clinging

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 o Inability to concentrate
o Short attention span
Failure to carry out simple directions
Dazed

Nursing Interventions to Minimize Anxiety:

 Assess client's fears, anxieties, support systems, and patterns of coping
 Establish trusting relationship with client and significant others
 Explain routine procedures, encourage verbalization of fears, and allow client to
ask questions
 Demonstrate confidence in surgeon and staff
 Provide for spiritual care if appropriate

Physiologic Preparation Prior to Surgery:

1. Respiratory preparation: chest x-ray
2. Cardiovascular preparation: ECG, CBC, blood typing, cross-matching, PT/PTT
(prothrombin time, partial thromboplastin time), serum electrolytes
3. Renal preparation: urinalysis
4. CP Clearance → 18-35 y.o.

Obtain history of past medical conditions, allergies, dietary restrictions, and

medications:
A - Allergy to medications, chemicals, and other environmental products such as latex
o All allergies are reported to the anesthesiologist and surgical. personnel before
the beginning of surgery
o If allergy exist, an allergy band must be plat's arm immediately

B - Bleeding tendencies or the use of medications that deter clotting, such as aspirin,
heparin, and warfarin sodium.
• Herbal medications (garlic, ginseng) may also increase bleeding time or mask
potential blood-related problems
1. Cortisone and steroid use
2. Diabetes mellitus, a condition that not only requires strict control of blood glucose
levels but also known to delay wound healing
-Emboli; previous embolic events ( such as lowe. may recur because of prolonged
immobility
clots)

Instructional and Preventive Aspects:

o Frequently done on an out-client basis
o Assess the client's level of understanding of surgical procedure and its
implications
o Answer questions, clarify and reinforce explanations given by surgeon
o Explain routine pre and post procedures and any special equipment to be used
o Deep breathing exercises: use of diaphrar abdominal breathing

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 o Coughing exercise: deep breath, exhale through the mouth, and then follow with
a short breath while coughing; splint thoracic and abdominal incision to minimize
pain
o Turning exercise: every 1-2 hours post-operative
o Extremity exercise: prevents circulatory problems and post operative gas pains
or flatus
Assure that pain medications will be available post-op

Incentive spirometery
Positive Effects:
1. provides stimulus for a spontaneous deep breath
2. reduces atelectasis-opens airways
3. stimulates coughing
4. encourage active individual participation in recovery

Physical Preparation
On the Night of the Surgery:
1. Preparing the client's skin: shave against the grain of the hair shaft to ensure
clean and close shave
2. Preparing the Gastro intestinal tract:
o NPO after midnight
o Administration of enema may be necessary
o Insertion of gastric or intestinal tubes (Enemas)
Preparing for Anesthesia
o Promoting rest and sleep: use of drugs
Barbiturates: Secobarbital Na, Pentobarbital Na
∞ Non barbiturates: chloral hydrate, Flurazepam
Note: given after all pre-op treatments have been completed.

On the Day of Operation: a.

Early morning care: about 1 hour before the pre-operative medication schedule
Vital signs taken and recorded promptly
Patient changes into hospital gown that is left untied and open at the back
o Braid long hair and remove hair pin
o Provide oral hygiene
Prosthetic devices, eyeglasses, dentures removed
Remove jewelries
Remove nail polish
Patient should void immediately before going to the
OR
o Make sure that the patient has not taken food for the last 10 hours by asking the
client
Urinary catheterization may be performed in the OR

b. Pre-Operative Medications:
Generally administered 60-90 min before induction of anesthesia
Purpose:
To allay anxiety: the primary reason for pre-operative medications

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To decrease the flow of pharyngeal secretions iii. To reduce the amount of anesthesia
to be given iv. To create amnesia for the events that precedes surgery

Types of Pre-Operative Medications:

1. Sedative:
o Given to decrease client's anxiety to lower BP and PR
o Reduce the amount of general anesthesia: an overdose can result to respiratory
depression
∞ e.g. Phenobarbital

2. Tranquilizer:
• Lowers the client's anxiety level
00 e.g. Thorazine 12.5 - 25 mg IM 1-2 hours prior to surgery

3. Narcotic analgesia:
• Given to reduce patients anxiety and to reduce the amount of narcotics given during
surgery
∞ e.g. Morphine sulfate 8-15 mg SC 1 hour prior to preoperative; *Can cause vomiting,
respiratory depression and postural hypotension

4. Vagolytic or drying agents:

To reduce the amount of tracheobronchial secretions which can clog the pulmonary tree
and result in atelectasis and pneumonia
∞ e.g. Atropine sulfate 0.3-0.6 mg IM 45 min before surgery; * An overdose can result to
severe tachycardia
Recording: all final preparation and emotional response before surgery should be noted
down
d. Transportation to the OR, *Wool or synthetic blankets must never be sent to the OR
because they are source of static electricity

Nursing Diagnosis for Preoperative Client

• Anxiety related to lack of knowledge about preoperative routines, physical preparation
for surgery, post operative care and potential body image change

Holding Ares
o Initiation of verification form
o Pre-anesthesia medication if ordered
o Foley catheter if ordered
Note: Entire peri-operative team should be involved in verification process
(correct patient, correct site, etc)
Why is the verification process so important?

Fan
o Explain where to wait
o Surgeon will talk to them after surgey
o Never judge seriousness by length of time patient is in surgery (keep family
updated)
o Prepare them for what they will see post-op

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 o Explain post-op protocol and routines

PERIOPERATIVE NURSING: THE PERIOPERATIVE

TEAM
The Surgeon
An Anesthesiologist or Nurse
Anesthetist
The Professional Registered OR Nurse

• Makes the preoperative

assessment to plan for the type of anesthesia to be
administered and to evaluate
the clients status
• Makes preoperative assessment
and documents the
perioperative client care plan (Scrub, Circulating, PACU Nurse)

a. The Circulating Nurse

Manages the OR and protects the safety and health needs of the client by monitoring
the activities of the members of the surgical team and monitoring the conditions in the
OR
 Sets up the Operating room
 Ensures that necessary supplies and equipment are readily available, safe and
functional patient endorsement
- ASSIStS
Assists in the transterring of clientin the OR bed
 Positions patient in the OR bed
 Performs surgical skin preparation
 Opens and dispenses additional needed supplies/medications during surgery
 Manages catheters, tubes, drains and specimens
 Reviews the results of any diagnostic tests or lab studies
 Ensures that the surgical team maintains sterile technique and a sterile field.
 Monitors traffic in the OR
 Manages the flow of information to and from the surgical team members
scrubbed at the field
 Manages personnel, equipment, supplies and the environment during surder
 Periorms, sharps, sponge and instrument count at appropriate time
 Documents all care, events, findings and patient's responses intra-op
 Dressing of wound and drainage
 Care of the tissue specimen

b. The Scrub Nurse

Responsible for scrubbing for surgery, including setting up sterile tables and equipment
and assisting the surgeon and surgical technicians during the surgical procedure
 Performs scrubbing, gowning and gloving
 Prepares sterile field for scheduled/emergency surgery
 Assiste wi
th instrumentation, sponges and suture presentation

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  Anticipate needs for surgical team
 Performs, sharps, sponge, and instrument count
 Prepares sterile dressing w/c will be applied when surgery is completed
 Aftercare of instruments and other materials
 Care of tissue specimen

c. The PACU Nurse

Responsible for caring for the client until the client has recovered from the effects of
anesthesia, is oriented, has stable vital signs, and shows no evidence of hemorrhage

Health Hazards Associated with Surgical

Environment
o Laser Risks
o Exposure to blood and body fluids
Later allergy

Potential Intraoperative Complications

o Nausea and vomiting
o Anaphylaxis
o Respiratory complications
o Inadequate ventilation, airway occlusion, intubation of the esophagus, and
hypoxia
o Hypothermia
o Malignant hyperthermia
o Disseminated Intravascular Coagulation

INTRAOPERATIVE PHASE
Transmission based precautions should be used in addition to standard precautions for
patients who are known or suspected to be infected with highly transmissible
pathogens.
1. Airborne precautions examples: rubeola, varicella, tuberculosis
 respiratory protection to be worn by susceptible persons
 placing surgical mask on patient during transport; elective surgical procedures on
TB patients should be delayed until patient is no longer infectious.

2.Droplet precautions-
examples: diphtheria, pertussis, influenza, mumps
 wearing a mask when within 3 feet from patients
 positioning patients at a distance of at least 3 feet from other patients

3. Contact Precautions
 wearing gloves when caring for patients/coming in contact with items that may
contain high concentrations of microbes.
 wearing gowns when it is anticipated that clothing will have substantial contact
with patients/items in any environment

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  precautions are maintained during transport;
adequately cleaning and disinfecting patient care equipment and items before
use w/ each patient.

ANESTHESIA
Begins the moment the patient is anesthetized and ends when the last stitch or dressing
is in place
Anesthesia - A state or narcosis, analgesia, relaxation and reflex loss (severe central
nervous system [CNS] depression produced by pharmacologic agent)

INTRAOPERATIVE PHASE
Types of Anesthesia:

а. General Anesthesia: a state of analgesia, amnesia, and unconsciousness

characterized by the loss of reflexes and muscle tone
Inhalation Anesthesia
Advantage: prevention of pain and anxiety
Disadvantage: circulatory and respiratory depression
* Highly flammable and explosive
Safety rules:
o Do not wear nylons, wool, or any material which can set-off sparks
o No smoking 12 hours after the operation
o Do not wear shoes that are not conductive
o Do not use bed materials that are not conductive, e.g. volatile liquid: halothane,
ether; gas anesthetic (nitrous oxide, cyclopropane)

Inhalation Anesthesia
Volatile agents
1. Halothane
 safe to use; producing rapid smooth induction; non-flammable, non-explosive,
 Very potent-seldom causes nausea & vomiting; non-irritating to mucous
membranes; excellent bronchodilator
 Hepatotoxic
 Decreases BP
 -causes malignant hyperthermia- high temperature in the body can damage
organ and death.

2. Forane(Isoflourane)
 Provides rapid induction, rapid emergence
 Low incidence of nausea & vomiting
 Does not stimulate excessive secretions

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  Non-hepatotoxic/non-nephrotoxic
 Excellent choice for neurosurgery
 Not recommended for children under 2 years of age due to longen airway
irritation

3. Enflurane
 Has similar effects to halothane
 Muscle relaxation is stronger
 Hepatotoxicity is not a problem
 Induces electroencephalographic changes causing seizure.

Four Stages of General Anesthesia:

a. Stage l: Onset Beginning of Anesthesial
o Patient breath in the anesthetic mixture
o Warmth, dizziness, & feeling of detachment may be experienced
o Ringing, roaring, or buzzing in the ears
o Inability to move extremities
o Surrounding noise is exaggerated
o Still conscious

b. Stage Il: Excitement

o Struggling, shouting, singing, laughing or crying may be experienced
o Pupils dilate but PERRLA, rapid PR, irregular RR
o Patient restrain might be necessary

c. Stage III: Surgical Anesthesia

Continued administration of anesthetic agent
RR, PR normal, skin pink and flushed
• Patient is unconscious

d. Stage IV: Danger Stage [Medullary Depression]

Reached when to much anesthesia has been administered
• Respiration shallow, pulse weak, pupils dilate
Cyanosis develops, without prompt intervention death may ensue

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Stages of Anesthesia, summary:
Stage End-point Physical Reactions Nursing Interventions
Start-point
Onset • Loss of eyelid • Loss of consciousness quiet
• Anesthetic reflexes • Increase • Client maybe drowsy, • Stand by to assist the client
• administration in autonomic or •Close operating • Remain quietly at client's
Excitement • room doors, keep room side
Loss of dizzy • Assist anesthetist, as
• • Possible auditory and needed
consciousness visual hallucinations
activity
• Irregular breathing
• Client may struggle
Surgical • Loss of eyelid • • Muscles are relaxed • Begin preparation (if
Anesthesia • Loss of most • No blink or gag indicated) only when
reflexes reflexes • Client is reflexes anesthesia indicates stage Ill
unconscious has been reached and client
• Depression of is breathing well, with stable
vital vital signs
functions
Danger • Respiratory and • Client is not breathing • If arrest occurs, respond
• Functions circulatory failure • A heartbeat may or immediately to assist in
(Death) may not be present establishing airway, provide
excessively cardiac arrest tray, drugs
• depressed syringes, long needles
• Assist surgeon with closed
or open cardiac massage

COMPLICATIONS of General Anesthesia;

1. Aspiration
2. Oral trauma
3. Hypoventilation
4. Cardiac dysrythmias
5. Hypothermia
6. Malignant Hyperthermia

II. Intravenous Anesthesia: usually employed as an induction prior to administration of

the more potent inhalation anesthetic agents.

Used commonly in minor procedure Advantage:

o Rapid pleasant induction
o Absence of explosive hazards
o Low incidence of nausea and vomiting

Disadvantage:
o Laryngeal spasm and bronchospasm

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 o Hypotension
Respiratory arrest, e.g. Thiopental Na (Pentothal Na), Ketamine ( Ketalar),
Fentanyl (Innovar)

b. Regional Anesthesia: it is the injection or application of a local anesthetic agent

to produce a loss of painful sensation in only one region of the body and does not
result to unconsciousness

I. Topical anesthesia: e.g. lidocaine spray ii. Infiltration anesthesia

* Nerve block- Anesthetic is injected around a nerve that supplies sensation to a small
area of the body

Intravenous block- IV injection of a local agent and the use of an occlusion tourniquet

Pudendal block - IV injection of a local agent into the pudendal nerve

iii. Spinal anesthesia, e.g. Saddle block for vaginal delivery

iv. Epidural block - Injecting local anesthetic into epidural ace by way of a lumbar
puncture

v. Local anesthesia, e.g. Procaine, Lidocaine (Xylocaine)

COMPLICATIONS of Spinal Anesthesia:

1. Hypotension - due to vasodilation
2. Nausea and vomiting - v Gl motility
3. Urinary retention - delayed return of sensation since micturition reflex is located
in the sacral area
4. Post spinal headache - prevented by positioning the client on supine 6-8 hours
post SA

c. Specialized Methods of Producing Anesthesia:

i. Muscle relaxants: it is a neuromuscular blocking agent used to provide muscle
relaxation
• Use: for endotracheal intubation, e.g.
Pancuronium bromide (Pavulon), Curarine chloride (Curare)

ii. Hypothermia: it refers to the deliberate reduction of the patient's body temperature
between 28°-30° C
Uses: Heart surgery, Brain surgery, Surgery on large vessels supplying major organs

Methods used for Hypothermia Anesthesia:

o Ice water immersion
o Ice bags

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 o Cooling blanket

Complications:
o Cardiac arrest
o Respiratory depression

Positioning: A Team Concept

5 Factors to be considered when positioning a surgical patient:

1. Anatomy involved with the procedure
2. Surgical Approach/surgeon's preference
3. Patient comfort
4. Patient and staff safety
5. Respiratory and circulatory freedom

Supine: hernia repair

cholecystectomy, mastectomy, Abdominale
Extremity Vascular, ChestNeck,
Facial Ear, Breast

Lithotomy position
 Perineal/vaginal
o Combined
→ abdominal/vaginal

Tondelerburg Praiton
个个Kraske (Jacknife)
RectalProcedures: C
- Sigmoidoscopy

POSTOPERATIVE PHASE
3 Stages
1. Immediate Stage - 1-4hrs after surgery
2. Intermediate Stage - 4-24 hours after surgery
3. Extended Stage - 1- 4days after surgery/ last follow-up visit with the attending
physician

Post Anesthetic Care

Nursing Responsibilities:
a. Maintenance of pulmonary ventilation:
Position the client to side lying or semi-prone position to prevent aspiration
o Assess rate & depth of respiration

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 o Oropharyngeal or nasopharyngeal airway:
* Is left in place following administration of general anesthetic until pharyngeal reflexes
have returned
o It is only removed as soon as the client begins to awaken and has regained the
cough, gag & swallowing reflexes
o All clients should received 02 at least until they are conscious and are able to
take deep breaths on command
o Assess breath sounds & need for suction

• Shivering of the client must be avoided to prevent an increase in 02, and should be
administered until shivering has ceased

b.Maintenance of circulation:
Most common cardiovascular complications:
Hypotension

Causes:
∞ Jarring the client during transport while moving client from the OR to his bed
∞ Reaction to drug and anesthesia
∞ Loss of blood and other body fluids
∞ Cardiac arrhythmias and cardiac failure
∞ Inadequate ventilation
∞ Pain

ii. Cardiac arrhythmias

Causes: Hypoxemia, Hypercapnea
Interventions: 02 therapy, Drug administration:
Lidocaine, Procainamide

c. Protection from injury and promotion of comfort

o Provide side rails
o Turning frequently and placed in good body alignment to prevent nerve damage
from pressure
o Administration of narcotic analgesics to relieve incisional pain
Post-operative dose is usually reduced to half the dose after the patient fully
recovers from anesthesia

Dismissal of Client from Recovery Room: Modified Aldrete Score for Anesthesia
Recovery Criteria

The Five Physiological Parameters:

1. Activity - able to move four extremities voluntarily on command
2. Respiration - able to breath effortlessly and deeply, and cough freely
3. Circulation - BP is (+ 20%) or (- 20%) of pre-anesthetic level
4. Consciousness - fully awake, oriented to time, place and person

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 5. Color - pink (lips), for blacks: tongue

Transferring the patient from the PACU

Transfer Criteria: Patient coming out of General Anesthesia
1. Vital signs are stable for at least 30mins and are within normal range
2. Patient is breathing easily
3. Reflexes has returned to normal
4. Patient is responsive and oriented to time and place
5. Sensation is restored and circulation is intact
6. Reflexes has returned
7. Vital signs have stabilized for at least 30mins
8. Adequate urine output
9. Control of pain
10. Control or absence of vomiting

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Postoperative Care
 Begins when the client returns from the recovery room or surgical suite to the
nursing unit and ends when the client is discharged
• It is directed toward prevention of complication and postoperative
discomfort
 Post-Operative Complications
• Respiratory Complications: atelectasis and pneumonia
• Suspected when ever there is a sudden rise of temperature
 24-48 hours after surgery
 Collapse of the alveoli is highly susceptible to infection: pneumonia
 Occurs usually in high abdominal surgery when prolonged inhalation anesthesia
has been necessary and vomiting has occurred during the operation or while the
patient is recovering from anesthesia

NURSING MANAGEMENT: i.
Measures to prevent pooling of secretions:
Frequent changing of position
o High fowler's position
o Moving out of bed

ii. Measures to liquefy and remove secretions:

• Increase oral fluid intake
• Breathing moist air
o Deep breathing followed by coughing
o Administer analgesics before coughing is attempted after thoracic and abdominal
surgery
o Splint operative area with draw sheet or towel to promote comfort while coughing

ill. Other measures to increase pulmonary ventilation

o Blow bottle exercise
o Rebreathing tubes: increase CO2 stimulates the respiratory center to increase
the depth of breathing thus increasing the amount of inspired air
IPPB: intermittent positive pressure breathing apparatus

Most common circulatory complications:

o Phlebothrombosis
o Thrombophlebitis (7-14 days post-op)

NURSING MANAGEMENT:
o Limbs must never be massaged for a post-op client
o Assess skin and capillary refill
o Assess for vein inflammation, if vein feels hard & cordlike & is tender to touch
o Assess for signs of peripheral edema
o Do not allow the client to stand unless pulse has returned close to baseline to
prevent orthostatic hypotension
o If possible, client should lie on his abdomen for 30 min several time a day to
prevent pooling of blood in the pelvic cavity

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 o Wear elastic bandages or stockings (AES) when in bed and when walking for the
first time.

c. Fluids and Electrolytes Imbalance:

Causes:
o Blood loss
o Increased insensible fluid loss through the skin;
- After surgery through vomiting, from copious wound drainage, and from
the tube drainage as in NGT
o Since surgery is a stressor, there is an increased production of ADH for the first
12-24 hours following surgery resulting to fluid retention by the kidney
- The potential for over hydration therefore exists since fluids being given IV
may exceed fluid output by the kidney

Electrolyte Imbalance:
• Particularly Na and K imbalance as a result of blood loss
o Stress of surgery increases adrenal hormonal activity resulting to increased
aldosterone and glucocorticoids, resulting in sodium reabsorption by the kidney
o And as Na is reabsorbed, K coming from tissue breakdown is excreted
Action: IV of D5W alternate with D5NSS or half strength NSS to prevent Na
excess

d. Complications of Surgery
i. GIT complications:
Paralytic ileus: Cessation of peristalsis due to excessive handling of GI organs

NURSING MANAGEMENT:
NO until peristalsis has returned as evidenced by auscultation of bowel sounds or by
passing out of flatus
Vomiting: usually the effect of certain anesthetics on the stomach, or eating food or
drinking water before peristalsis returns. Psychologic factors also contribute to vomiting

• Position the client on the side to prevent aspiration

• When vomiting has subsided, give ice chips, sips of ginger ale or hot tea, or eating
small frequent amounts of dry foods thus relieving nausea
• Administer anti-emetic drugs as ordered:
Trimethobenzamide Hcl (Tigan); Prochiorperasine
dimaleate (Compazine)

Abdominal distention: results from the accumulation of non-absorbable gas in the

intestine
Causes:
o Reaction to the handling of the bowel during surgery
o Swallowing of air during recovery from anesthesia
o Passage of gases from the blood stream to the a tonic portion of the bowel

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Gas pains: results from contraction of the unaffected portion of the bowel in order to
move accumulated gas in the intestinal tract
Management:
o Aspiration of fluid or gas: with the insertion of an NGT
o Ambulation: stimulates the return of peristalsis and the expulsion of flatus
o Enema
-Rectal tube insertion: inserted just passed the anal sphincter and removal after
approximately 20 minutes
- Adult: 2-4 inches, children: 1-3 inches
- Prolonged stimulation of the anal sphincter may cause loss of neuromuscular
response, and pressure necrosis of the mucous surface

Constipation: due to decreased food intake and inactivity

• Regular bowel movement will return 3-4 days after surgery when resumption of regular
diet and adequate fluid intake and ambulation

ii. GUT Complications

o Return of urinary function: usually after 6-8 hours
 First voiding may not be more than 200 ml, and total out put may not be more
than 1500ml
 Due to the loss of fluids during surgery, perspiration, hyperventilation, vomiting,
and increased secretion of ADH

Complication: urinary retention

Causes:
• Prolonged recumbent position
o Nervous tension
o Effect of anesthetics interfering with bladder sensation and the ability to void
o Use of narcotics that reduce the sensation of bladder distention
o Pain at the surgical site and on movement
 Assess for bladder distention/ Monitor | & O accurately

Urinary tract infection

Management:
 Instruct the client to empty the bladder completely during voiding
 Catheterize if needed, done by sterile technique

f. Post-operative Discomforts i.
Post-operative pain
• Narcotics can be given every 3-4 hours during the first 48 hours post-operatively for
severe pain without danger of addiction
Singultus

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Brought about by the distention of the stomach, irritation of the diaphragm, peritonitis
and uremia causing a reflex or stimulation of the phrenic nerve Management:
Paper bag blowing; CO2 inhalation: 5% CO2 and 95% 02 x 5 minutes every hour

g. Wound Complications:
Sutures are usually removed about 5th. 7th day post-op with the exception of wire
retention sutures placed deep in the muscles and removed 14-21 days after surgery

i. Hemorrhage from the wound

o Most likely to occur within the first 48 hours post-op or as late as 6th- 7th post-op
day
Causes:
o Hemorrhage occurring soon after operation: mechanical dislodging of a blood
clot or caused by the reestablished blood flow through the vessel
o Hemorrhage after few days: Sloughing off of blood clot or of a tissue
o Infection

Assessment:
o Bright red blood
o Decreased BP & UO
o Increased PR and RR
o Restlessness
o Pallor
o Weakness
o Cold, moist skin

ii. Infection
o Cause: streptococcus and staphylococcus
o Assessment: 3-6 days after surgery, low grade fever, and the wound becomes
painful and swollen. There maybe purulent drainage on the dressing

iii. Dehiscence and Evisceration

Dehiscence or wound disruption: Refers to a partial-to-complete separation of the
wound edges
Evisceration: Refers to protrusion of the abdominal viscera through the incision and
onto the abdominal wall
Assessment:
o Complain of a "giving" sensation in the incision
o Sudden, profuse leakage of fluid from the incision
o The dressing is saturated with clear, pink drainage

Management:
o Position the client to low Fowler's position
o Instruct the client not to cough, sneeze, eat or drink, and remain quiet until the
surgeon arrives

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 o Protruding viscera should be covered warm, sterile, saline dressing

DRAINS
 are placed in wounds only when abnormal fluid collections
 are present/expected
 are placed near the incision site
 In compartments that are intolerant to fluid accumulation
 In areas with large blood supply
 In infected draining wounds
 areas that have sustained large superficial tissue dissection
 greatest amount is expected during the first 24 hrs
 are removed when amount of drainage decreases

Types of Drains
... By Gravity
1. Penrose7-14 days
2. T-tube
T-tube in common bile duct
Cystic duct fiod off
Hepatic duct

By Mechanical
1. Jackson-Pratt
2. Hemovac

Nutrition
o Clear Liquids
o Full Liquids
o Soft
o Regular

Types of Wound Healing:

1. First Intention Healing
 Wounds are made aseptic by minor debridement and irrigation
 with a minimum tissue damage and tissue reaction
 Wound edges are properly approximated with suture
 Granulation tissue is not visible/scar formation minimal

2. Secondary Intention Healing

 Wounds are left open to heal spontaneously or surgically closed at a later date
 Examples include burns, traumatic injuries, ulcers and suppurative infected
wounds
 Cavity of the wound fills with a red, soft, sensitive tissue(granulation tissue),
which bleeds easily, a scar eventually forms.

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  In infected wounds, drainage may be accomplished by use of special dressings
and drains.
 Produces deeper wider scar

Discharge Instructions:
o Early discharge, which has become common, typically increases client teaching
needs
o Be sure to provide information about wound care, activity restrictions, dietary
management, medication administration, symptoms to report, and follow-up care
o A client recovering from same-day surgery in an outpatient surgical unit must be
in stable condition before discharge
This client must not drive home, make sure a responsible adult takes the client
home
o Proper wound dressing
o Diet
o Follow-up visit for removal of sutures in 7-10 days, for removal of staples 7-14
days
o Activity: NO heavy lifting for 6 weeks (>10lbs)
o Return to work in 6-8 weeks
o Instruct how to assess signs & symptoms of complications

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