Michael Angelo Abubo, Biologist, RN, RM, MCN- C

Learning Objectives:
• a. b. c. d. e. At the end of the discussion, nursing students will be able to State different conditions requiring surgical interventions Classify surgical procedures according to purpose, degree of risk, urgency Describe the different risk factors to surgery and effects of surgery to client Design plan of care for a client during the pre, intra and post operative period Appreciate the knowledge, skills and attitudes necessary for providing quality care of clients undergoing surgery.

Perioperative Nursing
- Goal: assist clients and their families and significant others to achieve a level of wellness after the procedure Phases of surgery: • Pre-operative phase - begins with the decision to perform surgery and ends with the clients transfer to the operating room table • Intraoperative phase –begins when the client is received in the OR and ends with his admission to the PACU • Postoperative phase – admitted to PACU and extends through follow up home or clinic evaluation

Circulating Nurse • b. Nursing Aide .Q: The sterile nurse touch only sterile supplies and instruments. Anesthesiologist • c. Surgeon • d. who hands out these items by opening its outer cover? • a. When there is a need for sterile supply which is not in the sterile field.

Circulating Nurse .ANSWER: A.

prepares patient for surgery Physician: performs preop history and PE 2. assist during the procedure and maintains sterile surgical field First assistant: assist the surgeon during surgery . sterile table and suture.Surgical Team 1. Preop Team • Preop nurse: performs preop assessment. OR team Sterile Member Surgeon: performs surgery Scrub nurse: sets up special equipment.

If hair at the operative site is not shaved. Draped b. what should be done to make suturing easy and lessen chance of incision infection? a. Clipped d.Q: It is the responsibility of the pre-op nurse to do skin prep for patients undergoing surgery. Pulled c. Shampooed .

Q: Which of the following should be given highest priority when receiving patient in the OR? a. Assess level of consciousness b. Verify patient identification and informed consent c. Assess vital signs d. Check for jewelry, gown, manicure, and dentures

Surgical Team
Non sterile Members Anesthesiologist: administers anesthesia, monitors patient’s VS Circulating nurse: manages patient care, coordinates activities of OR personnel 3. Post operative Team • Post anesthesia nurse: care of patient in the post anesthesia care unit (PACU)

Surgical Environment
• 3 zones a. Unrestricted zone (street clothes) b. Semirestricted zone (attire consists of scrub clothes and caps c. Restricted zone (scrub clothes, shoe covers, caps and mask are worn)

Four Types of Conditions Requiring Surgery • OBSTRUCTION .Rupture of an organ .Impairment to the flow of vital fluids.g. ruptured appendicitis. e. ruptured uterus .e. blood. urine. CSF • PERFORATION .g. bile.

brain tumor .Four Types of Conditions Requiring Surgery • • - EROSION Wearing off of a surface or membrane e. lung tumor. ruptured uterus TUMORS Abnormal new growth e.g.g. bone tumor. breast tumor.

Optional Elective Required Urgent . c. b. d.A client having excess fat suctioned from the thighs for cosmetic reasons is an example of which category of surgery? a.

g. they are done totally at the client’s education Elective surgery refers to the procedures that are scheduled at the clients convenience (e.Answer: A • Rationale: Cosmetic surgeries by definition. cyst removal. repair of scars or simple hernia) . are most often optional.

Required surgery is warranted for conditions necessitating intervention within a few weeks (e. kidney stones) .g.g. cataract surgery. thyroid disorders) Urgent/Imperative Surgery is indicated for a problem requiring intervention within 24 to 48 hours (e. appendicitis. acute gallbladder infection. some cancers.

g. Diagnostics .Classification of Surgery A.To confirm the presence of a disease condition.g. According to its purpose 1. Ex-Lap . biopsy 2. e. Exploratory .Extent of the disease condition e.

According to its purpose 3. Constructive c. Ablative b. Reconstructive .Classification of Surgery A. Curative .To treat the disease condition 3 types a.

g. suffix used is “ectomy”) b. e. e. scar revision) . ABLATIVE (removal of an organ. RECONSTRUCTIVE (repair of damaged organ. e.g. plastic surgery after severe pains.g. CONSTRUCTIVE ( repair of congenitally defective organ.Types of Curative a. suffix used are “plasty”) c.

g. not necessarily to cure the disease) e. PALLIATIVE (to relieve distressing signs and symptoms. debridement of necrotic tissues. colostomy.4. resection of nerve roots) .

thyroidectomy) .g. catacract surgery. appendicitis) 3. Urgent /Imperative ( a problem requiring intervention within 24-48 hours. repair of ruptured aortic aneurysm. According to Urgency 1. Emergent (procedures must bone immediately to sustain functioning. extensive burns. Required (warranted for conditions necessitating intervention within a few weeks (e. gunshot or knife wounds.g.B. e. fractured of the skull) 2. e.g.

Elective (procedures that are schedule at the clients’ convenience . e. e. Optional (done totally at the clients discretion.B.g. cosmetic surgery) . According to Urgency 4. cyst removal. vaginal repair) 5.g.

open heart surgery. TAHBSO Criteria for major surgery. craniotomy.g. Involves great risk of occurrence of complications . 1. Large amount of blood loss 4.Degree of Risk/Magnititue/Extent a. High risk of morbidity/mortality 2. pneumonectomy. Major e. Extensive and prolonged 3.

g.Minor Surgery • E. appendectomy • Generally. the procedure is not prolonged • Does not usually involve serious complications .

d. Aging Obesity Fluid and Electrolyte Imbalance Presence of disease Medication taken . e.Who are at risk for surgery? a. b. c.

The ability of an organ to return to normal after a disturbance in its equilibrium .1. AGING • Older clients have less physiologic reserve than younger clients • Physiologic reserve .

2. Obesity • Increases difficulty in technical aspects of performing surgery • Wound dehiscence is greater • Increases likelihood of infection because of lessened resitance .

Poor Nutrition • Preoperative malnutrition greatly impairs wound healing • Increases risk of infection and shock .3.

causing shock and cardiac dysrhythmias . Fluid and Electrolyte Imbalances • Dehydration and electrolyte imbalances can have an adverse effect in terms of general anesthesia and the anticipated volume losses associated with surgery.4.

Presence of Disease • Many surgical procedures may be complicated in the presence of cardiovascular compromise • The client may experience dysrhythmias.5. shock. or cardiac arrest during surgery .

Presence of Diabetes Mellitus • Hyperglycemia is potentiated by increased cathecolamines and glucocorticoids due to surgical stress • Poor wound healing may be experienced by the diabetic client .6.

7. Presence of alcoholism • Alcoholism is usually accompanied by problems of malnutrition • Client may also have an increased tolerance to anesthetics .

Preoperative phase Goals: 1. Teach the client and the relatives regarding surgery .Assessing and correcting physiologic and psychologic problems that are surgical risk 2.

Instruct and demonstrate exercise that will benefit the person during postoperative period 4. Planning for discharge begins .Preoperative phase Goals: 3.

Basic Guidelines for Surgical Asepsis • All materials in contact with the wound and within the sterile field must be sterile. . and sleeves from 2 inches above the elbow to the cuff. • Gowns are sterile in the front from chest to the level of the sterile field.

During draping. the drape is held well above the area and is placed from front to back. . • Movements of the surgical team are from sterile to sterile and from unsterile to unsterile only. • Items are dispensed by methods to preserve sterility.Basic Guidelines for Surgical Asepsis • Only the top of a draped table is considered sterile.

the area is considered contaminated. • Whenever a sterile barrier is breached. .Basic Guidelines for Surgical Asepsis • Movement around the sterile field must not cause contamination of the field. At least a 1-foot distance from the sterile field must be maintained.

Basic Guidelines for Surgical Asepsis • Every sterile field is constantly maintained and monitored. • Sterile fields are prepared as close as possible to time of use. . Items of doubtful sterility are considered unsterile.

Informed consent • The surgeon who will perform surgery explains the procedure and the risks • Responsible for obtaining patient’s signature • Nurse: witness .Preoperative phase 1.

Circumstances requiring written consent are as follows: • Any surgical procedure where special. cystoscopy . local infiltration anesthesia or regional block anesthesisa • Any invasive procedure that involves entry into a body cavity e. suture. paracentesis. scissors.g. hemostats of electrocoagulation may be used • Any procedure that involves general anesthesia. bronchoscopy.

Patients’signature is obtained with the client’s complete understanding of what is to occur .Requisites for validity of written informed consent 1. Written permit/consent is best and legally practice 2.Adults sign their own consent unless he/she is physically and mentally incapacitated .

If the patient is a child or minor (below 18 years old), the parent or legal guardian will sign the consent 3. Consent is obtained before sedation 4. The patient is not under the influence of drugs or alcohol 5. Consent is secured without pressure or duress

6. Signature of witness is required 7. In an emergency, permission via telephone or telefax is acceptable - The physician should document the nature of the emergency situation 8. Emancipated minors are allowed to sign without written consent

• -

Emancipated minors Married Live on their own Financially independent from their parents (U.S. only)

Nursing Priority: The consent/permit should be signed before the clients receives preoperative medications

Restore adequate blood volume with BT b.Preoperative phase 2. accomplish the “preop checklist” p. 439 Brunner and . DBCT. colored nail polish g. Preparing the skin: full bath f. Teaching: incentive spirometry. VS before preop medication h. Treat any infectious process c. cleansing enemas e. remove dentures. foot and leg excercises d. turning. NPO. Physical preparation a.

Diaphragmatic Breathing and Splinting When Coughing .

Leg Exercises and Foot Exercises .


…practice “TIME OUT” to check if the right patient is sent for surgery . arms. e. legs. eyes. ears. breast.g.BEST PRACTICE • If surgery will be done to a body part which is present on both sides of the body.

Preparing for anesthesia • The patient should avoid alcohol and cigarette smoking for atleast 24 hours before surgery • This can help reduce potential complication .

Minimize respiratory tract secretions and changes in the heart rate 3. To relax the client and reduce anxiety .Preoperative MEDICATIONS • Purposes 1. Facilitate admnistration of any anesthetic 2.

To relax the patient and potentiate anesthesia .Types of Pre op Meds • Opiates -Morphine (Roxanol) & Meperidine (Demerol) .

Types of Pre op Meds • Anticholinergic Atropine SO4.Hypnotic agents are given the night before surgery to help ensure a restful night’s sleep . Scopolamine To reduce respiratory tract secretions To prevent severe reflex slowing of the heart during anesthesia • Barbiturates/Tranquilizers -Phenobarbital (Nembutal) .

Types of Pre op Meds • Prophylactic Antibiotic .Before or during surgery when bacterial contamination is expected .Ideally before skin incision is made .

action will not have began before anesthesia is started . the maximum potency will have passed before it is needed • If given too late.Best Practice • Preanesthetic medications should be given exactly at the time they are prescribed • If given too early.

Possible Diagnosis during Preop • • • • Anxiety Fear Knowledge Deficit Pain .

432 .Latex allergies p.Environmental control • Standard OR ventilation – 15 air exchanges/hr • Standard temp.Laser risks = smoke evacuators/ “warning signs” b.Exposure to blood/ body fluids = *“double gloving” c. – 20 – 24 C( 68-73 F) • Standard humidity – 30 – 60% Health Hazards in Environment : a.

3. 4. 2. Goals of Care Asepsis and Infection Control Homeostasis Safe Administration of Anesthesia Hemostasis Surgical Conscience – attention to specific principles during the perioperative period .Intraoperative Phase • 1.

alcohol and hexachlorophene) • Skin of the surgical team is scrubbed -Use a brush and nail cleaner or foam preaparation . using a depilatory • Disinfect the skin (povidone-iodine. clipping. trimming. chlorhexidine.Preparation during intraoperative • Shaving.

intervertebral space depends on location of procedure. Regional: reduce all painful sensation in one region of the body a.e. Spinal: anesthesia injected in subarachnoid space.Intraoperative Phase Types of anesthesia: 1. 17G or 18 G blunt-tipped needle is used. inhalation . General: total loss of consciousness and sensation .Per IV. nitrous oxide (blue tank) 2. spinal headache rare 3. Epidural:injection of anesthetic into the epidural space w/o puncturing the dura.g. spinal headache(flat on bed ) b. on 3rd or 4th lumbar space 25-26 G spinal needle SE: Hypotension and respiratory depression (monitor VS). Local .

Spinal anesthesia .


and subsequently the injected dose is larger. while it is approximately 5 minutes in a spinal.5 mL in a spinal. an indwelling catheter may be placed that avails for additional injections later. • In an epidural. or lumbar site. . • The onset of analgesia is approximately 15–30 minutes in an epidural. thoracic. while a spinal is almost always a one-shot only. while a spinal must be injected below L2 to avoid piercing the spinal cord. as sensory nerve fibres. being about 10–20 mL in epidural anaesthesia compared to 1. while a spinal more often does. • An epidural often does not cause as significant neuromuscular block unless specific local anaesthetics are used which block motor fibres as readily An epidural may be given at a cervical.5–3.Differences between Epidural and Spinal Anesthesia • The involved space is larger for an epidural.

Surgical procedure is started • Medullary/Depression: characterized by cardiac and respiratory depression. Due to anesthesia overdose. resuscitation must be done .Stages of anesthesia • Onset/Induction: from administration of anesthesia to time of loss of consciousness • Excitement/Delirium: from time of loss of consciousness to time of loss of lid reflex • Surgical: from loss of lid reflex to loss of most reflexes.

Complications • Nausea and Vomiting • Anaphylaxis • Hypothermia • Malignant Hyperthermia • Respiratory Paralysis • Neurologic Complications (paraplegia) .

always check for breath sounds if suspicious of aspiration 2. Nausea & vomiting – Intervention : turned to side/ HOB elevated/ offer basin for vomitus *Tx. Anaphylaxis – allergic reaction 3. Hypoxia – due to inadequate ventilation/ airway occlusion/ inadequate intubation of esophagus *Familiarize with the equipment .Anti-emetic .1.

Hypothermia ( <36. Malignant hyperthermia * rare inherited muscle disorder induced by anesthetics .6 C .“wet” drapes – changed immediately -hydrate -check OR temp/fluids 5.4. <98 F) *due to – COLD OR/gases/fluids/ GA/specific surgery such as Bypass surgery *Intervention.

Susceptible to Malignant Hyperthermia:  Bulky muscles  Hx of muscle cramps  Hx of muscle weakness  Hx of relatives unexplained death during surgery with febrile episode *Pathophysio: -altered mechanism of Calcium function (hypermetabolism) -muscle rigidity/ hyperthermia .

 Triggering factors : inhalation anesthetics & muscle relaxant ( succinylcholine)  Manifestation : initial – cardiac & musculoskeletal HR>150 . muscle rigidity Late .INC. temp* Medical management : GOAL – to DEC. metabolism/ to DEC. temp  STOP anesthesia  Hyperventilate with O2 100% .

– “unknown” *precipitating factors – massive trauma/transfusion/head injury/shock . Give Dantrolene Na ( muscle relaxant) + Na Bicarbonate  RN – s/sx monitoring  Nursing management : identify those at risks/ sign and symptom for specific PERIOD/ check availability of meds 6. DIC (disseminated intravascular coagulation) *thrombus in circulation + depletion of coagulation proteins *exact Mech.

during.SPINAL HEADACHE • . and after the procedure • Maintain flat on bed position 6 to 12 hours after procedure • Administer analgesics .Due to leakage of CSF form the spinal puncture needle • Ensure adequate hydration before.

Dorsal recumbent. and Side lying Position: . Trendelenburg Position. Lithotomy Position.

rectal surgery • Lateral . mastectomy • Trendelenburg – lower abdomen • Lithotomy .back.hernia. cholecystectomy. kidney surgery .lung. vaginal surgery • Prone .Positions during surgery… • Dorsal recumbent . spine.perineal. rectal. ex lap.

Immediate period -Admission to the client to recovery area 2. Intermediate Postoperative period .Transfer from PACU to the surgical unit to Day 1 post op .POST OPERATIVE Phase 1.

Immediate Post operative Phase • After the operation. patient is transferred to recovery room • Cover patient with blanket. • Siderails up • Critical period & VS taken 15 mins • Adrete Scoring – 7 to 8 points .

Criteria in Transferring Patients from RR to Room (intermediate period) • • • • • Stable VS (1hour) Intact swallow. cough & gag reflexes Patient is awake & can call for assistance No postop complications Patient with regional anesthesia regains motor & sensory functions .

oral fluids if tolerated/permitted. NGT. moistened gauze square over lips occasionally. hard candies.Expected Post operative Discomfort • Nausea and vomiting (antiemetic. rinse the mouth) . deep breathing) • Thirst (IVF.

then oral) . increase hydration.Expected Post operative Discomfort • Constipation and gas cramps (early ambulation. proper diet. assess bowel sounds. encourage non use of analgesia) • Post-operative pain (IV parenteral analgesic 2-4 days.

respiratory depression.Best Practices • The client who remains sedated due to analgesia is at risk for complications such as aspiration. atelectasis. falls and poor postoperative course • Promotion of client’s safety should be given priority . hypotension.

Nursing Interventions: • Return of patient to the unit • Unit nurse accompanies patient to room & facilitate transfer from the OR stretcher to room bed • Make initial assessment .q 4 for 24 – 48 hrs • Carry out interventions & post op orders .q 30 mins for 2 hrs .hourly for 4 hrs .q 15 mins until stable .

thirst. Hemorrhage – copious escape of blood from the blood vessel . moist.restlesstness. monitor I and O. cold. Shock: decrease in circulating blood volume due to hypoxia (have blood available if needed.Post-operative Complications 1.(assess possible site of bleeding) . pale skin . VS – hypotachytachy) 2.

Post-operative Complications 3. Deep vein thrombosis: (+) Homan sign (pain or cramps in the calf) • Elevate legs • Administer anticoagulant (heparin. warfarin) • Anti-embolic stockings .

purulent discharge • . Urinary difficulties: absence of voiding. catheterization 6.Administer antibiotic and wound irrigation .Obtain C/S • . redness (rubor). bladder distention • Encourage normal voiding. pain (dolor). incentive spirometry 5. Infection. Pulmonary complication • DBCT. heat (calor).Post-operative Complications 4.

Auscultate the four quadrants of the abdomen for 5 minutes before concluding that there is absence of bowel sounds . Intestinal Obstruction .7.

Wound complication: • Wound dehisence: wound breakdown • Wound evisceration: dehiscence + outpouching of abdominal organs • Cover exposed intestine with sterile moist saline dressing .8.




needles. used during the surgical procedure.Q. d. Evaluate the type of anesthesia appropriate for the surgical client . Assess the readiness of the client prior to surgery b. Which of the following role would be the responsibility of the scrub nurse? a. supplies. Ensure that the airway is adequate c. Account for the number of sponges.

While the surgeon performs the surgical procedure. Anaesthesiologist • d. Surgeon • c. Scrub Nurse • b.Q. The OR team performs distinct roles for one surgical procedure to be accomplished within a prescribed time frame and deliver a standard patient outcome. Circulating Nurse . who monitors the status of the client ? • a.

Immediate postoperative assessment Respiratory status Cardiovascular status Neurologic status . c. a. b.Care of the Client after surgery A.

Nursing Dx (post op) • • • • Fear Pain Anxiety Altered Body Image .

Nursing Interventions • • • • • Maintain a patent airway Maintaining cardiovascular stability Relieving pain and anxiety Controlling nausea and vomiting Discharge from PACU .


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