THEATRE NURSING

BY: GACHUHI WANGARI

 Course outline
• Physical design of OT
 Surgical suite concept
 Departmental layout
• Perioperative nursing- phases,surgery, surgical
team,roles of perioperative nurses, instruments,
sutures, positions and anesthesia
• Preoperative nursing
• Intraoperative nursing
• Postoperative nursing
PHYSICAL DESIGN OF OPERATING
THEATRES
 INTRODUCTION
• Operating theatres are constructed with the aim of
providing safe therapeutic environment for the patient
undergoing surgical intervention.

• Specific rooms should be designated for performing

surgical/clinical procedures and for processing instruments
and other items.

• It is important to control traffic and activities in these areas

since the number of people and the amount of activity
influence the number of microorganisms that are present
and therefore influence the risk of infection.
• Traffic flow in the operating theatre should be unidirectional
and the theatre design plays an important role in controlling
traffic
 Considerations OT design
• Patient as the center point of a functioning OT
• Team
• Purpose of OT (investigative, diagnostic,
therapeutic and palliative)---
Type of hospital, patient turnover, size of the
hospital.
 ct
• Always consider bacteriologic, environmental
and geographical isolation
• Location
• Space
• Exit
• Ventilation,temp and lighting
• OT ( doors, floor, walls,o table, x-ray
illuminators, corridors, h2o, drainage)
 Factors to consider when designing an
operating theatre
• Geographical isolation within the hospital protected
from unauthorized persons.
• Bacteriologic isolation through specific practices,
attire, delivery, and disposal systems in order to
prevent cross contamination from other areas of the
hospital
• Centralizing equipments and supplies providing
immediate access to specific items needed for surgery
without leaving the protected area.
• Centralizing specialty personnel, since modern
surgery requires the combined efforts of many groups
to perform a variety of specialized tasks.
 Location of the Operating Theatre Suites

• Operating theatres may be located in either

purpose-built units or in converted hospital
accommodation.
• They should be separated from the main flow
of hospital traffic and from the main corridors;
• It should be easily accessible from surgical
wards and emergency rooms.
 Location of the Operating Theatre Suites

• The operating theatre should be zoned and

access to these zones should be under control
of OT personnel.
• Aseptic and clean areas should be separated
from the outer areas.
• Physical barriers may be needed in order to
restrict access and to maintain unidirectional
movement of air in converted theatre units.
 The surgical suite Concept

• THEATRE LAYOUT
• The overall floor plan of the surgical suite is
divided into three areas or zones, which are
directly or indirectly involved with the operative
procedure equipment, supplies, and personnel.
• For descriptive purposes the zones represent
the type of activities, dress code, or restriction
for that zone.
• Each person working within the suite must
abide by policies related to the zones.
 The Three - Zone Concept
1. The outer zone - The unrestricted area
• provides an entrance and exit from the surgical
suite for personnel, equipments and patients.
• Street clothes are permitted in this area, and the
area provides access to communicate with
personnel within and without the suite.
• This zone should contain:
 A main access door;
 An accessible area for the removal of waste;
 A sluice;
 Storage for medical and surgical supplies;
 An entrance to the changing facilities
 2.The clean or semi-restricted zone
• provides access to the procedure room and peripheral
support areas within the surgical unit.
• Personnel entering this area must be in proper theatre
attire.
• Traffic control must be designed to prevent violation of this
area by unauthorized personnel or persons improperly
attired for this zone.

• This zone contains:

• The sterile supplies store;
• An anesthetic room;
• A recovery area (PACU);
• A clean corridor;
• Rest rooms for the staff.
 3. Aseptic or restricted area

• This area should be restricted to the working

team.
• Staff working in this area should change into
theatre clothes, should wear masks and gowns,
and, where necessary, should wear sterile
gloves
• This area includes:
• The operating theatre;
• A scrub-up area;
• The sterile preparation room (preparation of
sterile surgical instruments and equipment)
 DEPARTMENTAL LAYOUT
1.Reception area- this the first part of theatre in
which the patient come in contact with.
• The area must create pleasant impression in order
to allay anxiety
• The area should be large enough in order to allow
patient to be transferred from ward stretcher to
theatre stretcher
• Facilities such as telephones and tables for
reception staff should be included
• Patient are admitted to theatre via this area and
checking of various requirement for patient is done
 Ct..

2.Holding area-it is a special area inside or

adjacent to surgical room. should be located near
reception area.
• Nurse makes final identification and assessment
before patient is transferred into the operating
room
• Minor procedures can also be performed i.e
inserting catheters, i.v lines
• It serves as admission, observation and discharge
area.
3.Scrub room- it is where scrubbing is done to
avoid splashing of water which may contaminate
the operating room
 4. Operating room
• Its a unique acute setting removed from other clinical
units. It is controlled geographically, bacteriologic ally and
environmentally
• It is restricted in terms of inflow and outflow of personnel
• Several methods have been used to prevent transmission
of infections i.e
– Dust collecting surfaces i.e open shelves are made of materials
that are resistant to corroding of strong disinfectants
• Temperatures are controlled at a range of 20-24 and
humidity at 30%-60%
• Communication system provides a means of delivery of
routine and emergency messages
 Ct..
5.Anaesthetic room
• Should be large enough to accommodate patient trolley,
anaesthetic machine and staff movement
• Lockable cupboards should be used to accommodate
scheduled and controlled drugs
• Piped o2, nitrous oxide should be incorporated in the design
6.Recovery room/ post anaesthetic care unit (PACU)- the goal
is to provide total nursing care to postoperative patient
• Staff must be vigilant have knowledge on post-operative and
post- anaesthesia complications
• Resuscitation equipment must be available
• General lighting, ventilation and must be efficient
• Hand washing facilities are essential
 Ct..
7.Theatre changing room- this is where surgeons
nurses and theatre staff change into theatre
gowns
8.Packing area- instruments are packed according to
their specification ready for sterilization
9.Stores- linens, stationeries and theatre supplies
are kept
10.Utility/sluice room- cleaning of equipments is
done and sorting of soiled gowns,
11.Lounge- located outside operating room. this
where surgeons, nursing staff ,anaesthetist and
students go to rest after the procedure
12.Sterilization room(CSSD
INTRODUCTION TO PERIOPERATIVE
NURSING
 Perioperative nursing
• Perioperative nursing involves caring for the
patient in the three phases of surgical
intervention i.e. Preoperatively ,
intraoperatively & post operatively.
Preoperative phase starts from the time the
patient is admitted for surgery until he/she is
taken to the induction room for anesthesia.
Intraoperative phase starts from induction room
until the patient is admitted to post anesthetic
care unit (PACU).
Post operative period begins from PACU until
patient is discharged home.
 Philosophy of perioperative nursing

• Perioperative nurses believe in;

• Provision of safe physical environment for
patient’s relatives and significant others
• Promoting cohesive multidisplinary team work
in providing perioperative care
• Providing quality perioperative care to all
patients regardless of their race creed and
social economic status.
 SURGERY
• It is defined as the art of science of treating diseases, injuries and
deformities by operations and instrumentations
• Classification of surgery
1. Elective
• Does not require urgent intervention, it is planned and
performed when patient chooses.
2. Urgent
• Necessary for patient’s health. Is indicated to prevent additional
health problems from occurring
3. Emergency
• Performed immediately to save the individual’s life or preserve
function of a body part
4. Required—Patient needs to have surgery, Plan within a few
weeks or month i.e Prostatic hyperplasia without bladder
obstruction, Cataracts
5. Optional—Decision rests with patient and it is a Personal
preferencei.e Cosmetic surgery
 Purpose of surgery

• Curative – elimination or cure of a pathology e.g appendicectomy

to remove inflamed appendix
• Diagnostic - determine presence and extent of the disease &
exploration or to obtain tissue biopsy for cytology,& x- laparatomy
• Reconstructive - skin grafting for deep burns
• Constructive – Restores function lost or reduced as result of
congenital anomalies e.g. Repair of cleft palate, closure of atrial-
septal defects
• Organ transplant e.g. kidney, heart, liver
• Cosmetic/esthetic- helps improve appearance e.g mammoplasty,
facelift.
• Palliative -Therapy designed to relieve or reduce intensity of
uncomfortable symptoms without cure
• Ablation Amputation or excision of any part of body or removal of
a growth or harmful substance e.g. Amputation, cholecystectomy
 Suffixes describing surgical procedure

• Suffix meaning example

• Ectomy excision/removal of hysterectomy
• Lysis destruction of electrolysis
• Oorhaphy repair of hernioraphy
• Ostomy create opening into colostomy
• Otomy cutting into tracheotomy
• Plasty reconstruction tympanoplasty, mammoplasty
 Members of the Surgical Team
• Surgeon the doctor who performs the surgery
• Surgical assistant- surgeon or specifically trained person to assist
during such procedures
• Anesthesiologist – doctor who administers anesthetic drugs to
enable surgery to be done
• Certified registered nurse anesthetist assist the anesthesiologist
during anesthesia administration and can also work independently
• Holding area nurse ;receiving area nurse who admits the surgical
patient into the theatre and monitors the patient in the waiting bay/
traffic-in
• Circulating nurse- assists the “sterile” members of the surgical team
during the procedure.
• Scrub nurse – the nurse who scrubs gowns and gloves aseptically to
assist the surgeon with patient care and instrumentation/
equipment
• Surgical technician/ Operating room technician; assists with the
technical work
 Roles of the perioperative nurses
• Receiving area / preanaesthetic nurse.
• Scrub nurse
• Anesthetic nurse
• Scrub nurse
• Circulating nurse
• Post anesthetic nurse
• Perioperative nurse manager
 Receiving nurse
• Responsible for the preparation of the holding bay. Ensures
working machines, availabilty of equipment, supplies, and
acessories.
• Receives verbal report from the ward nurse
• Positively identifies the patient using the theatre schedule, in-
patient number and the patient’s identification bracelet.
• Verifies patient preparation using the preoperative checklist
• Conducts a brief physical assessment on the to role out any
anomaly
• Ascertains informed consent and Confirms Investigations as
appropriate.
• Ascertains if premedication was given also Ensures preparation
specific to the surgical procedure is done
• Maintains interaction with the patient while allaying anxiety and
giving health education as appropriate.
• Communicates to the appropriate theatre that the patient is at the
waiting bay and hands over to anaesthetic nurse
 roles of Anaesthetic nurse
Before operation
• Must stay with the patient in an operating room and never leave him
alone
• Ensure the room is quiet until the patient is fully anaesthetised
• Assist the anaesthetist in administration of oxygen and endotracheal
tube inflation
During the procedure
• Give anaesthetist additional requirementsi,e I.V. Fluids
• Assist in taking and recording of vital signs
• Record any change in vital signs
• Monitor the flow of infusion or blood
After the procedure
• Give anaesthetist any additional requirements required in reversal of
anaesthesia
• Assist in removing the patient from operating table
• Accompanies the patient to recovery room
 roles of Scrub nurse
Before the procedure
• Check and select required set for the operation
• performing a surgical hand scrub
• setting up the sterile tables and arrange instruments
• preparing sutures, ligatures, and special equipment (such as a laparoscope)
• Count instruments, gauzes, sutures and ensure that they have been recorded on the
checking board
During procedure
• Assist surgeon in draping the patient,Act as surgeon assistant if the assistant is not
available
• assisting the surgeon and the surgical assistants during the procedure by
anticipating the instruments that will be required, such as sponges, drains, and
other equipment
• Account for instrument and gauzes at every stage of operation, Keep instruments as
clean as possible during procedure
During the closure.
Together with the circulator nurse they count all needles, sponges, and instruments
labels Tissue specimens obtained during surgery
Verify the intrabdominal or other cavity packing material have been removed
 roles of circulating nurse
• He or she manages the operating room and protects the patient’s safety and
health by monitoring the activities of the surgical team, checking the operating
room conditions and.
The main responsibilities include
• verifying consent, coordinating the team, and ensuring cleanliness, proper
temperature, humidity, and lighting; the safe functioning of equipment; and the
availability of supplies and materials.
• monitors aseptic practices to avoid breaks in technique.
• monitors the patient and documents specific activities throughout the operation
to ensure the patient’s safety and well-being.
• Assists sterile scrub person by providing and opening of sterile items
• Participates in insertion and application of monitoring devices
• Assist in positioning of the patient
• Helps in gowning of the sterile team
• Alert to anticipate needs of the sterile team i.e .adjusting operating light,
providing items required i.e sutures,sponges
• Monitor condition of the patient all times and report
for any changes
• Count sponges, sutures and instrument with scrub person
 Nurse administrator/ perioperative nurse manager
His/roles include
• Duty allocation
• Guides, leads and teaches others and help increase
knowledge in theatre nursing
• Ensure availability of resources
• Plan, monitor theatre activities at every level and evaluate
to ensure Completion of work has been attained
• Consultant in matters of sterility to prevent infection as
much as possible
• Develop theatre personnel the will and desire to
cooperate in daily activities
 Surgical attire
• These are specific prescribed clothes/dressing code
in the operating theatres.
• The clothes have been designed to protect both the
theatre personnel and the patient undergoing
surgery
• These clothes include caps, scrubs, masks and
footwear i.e. boots or scolls.
• Patients wear theatre gown, cap and socks
• During a surgical procedure, sterile gowns & gloves
are worn aseptically after a surgical scrub.
Surgical Scrub, Gowning, and Gloving
 Equipment used in theatre
• Use of prepaked sets simplifies the
preparation of instruments in surgery
Saves time for the staff
Prevents holding of the operation
Classification of sets
1) Specific sets
2) General sets
handling of equipment
• Inspect each instrument before and
after use to detect imperfections.
• Set aside damaged instruments and
send them for repair or replacement
promptly.
• Use instruments only for the purpose
for which they are designed.
• Handle instruments gently
• Provide protection for delicate
instruments
• Clean instruments meticulously.
• Keep oil away from instruments
• Give instruments regular
maintenance.
• Take inventory
• Rotate sterile instruments in order
to use item according to expiring
date
• Sterile packs may be stored up to
the expiry date
Classes of instrument by
function
1.Cutting instruments and
dissecting
2.Grasping or holding instruments
3.Hemostatic instruments.
4.Retractors
5.tissue unifying instruments and
materials: needle holders, surgical
needles, staplers, clips, 
 Instruments used for dissecting and cutting
• They have sharp edges. They are used to dissect, incise, separate or excise
tissue. They should be kept separate from other instruments.
• Examples
• Scalpels, knives, scissors
types of Scissors
• Blades may be straight, angled or curved.
• It may also be pointed or blunt at the tip
• To maintain the sharpness scissors should be used for intended purpose
Sutures scissorsUsed to cut sutures and supplies. have blunt points to avoid
cutting structures near the suture
Tissue /dissecting scissorsMost have sharp blades .curved or angled blade are
needed
mayo scissors- they are curved used to cut heavy tissues
Metzbaum(metz)- used to cut delicate tissues
Wire scissors- have short heavy blades. They are used to cut stainless steel
sutures
Dressing/bandage scissors- used to cut drains, dressing.
 ct
Bone cutters/ debulking tools
• They are suitable for cutting into or through a
bone and cartilages. They include chisel,
osteomes, gauges, rasps and files
Curette-
• tissue / bone is removed by scrapping
With sharp edge of the loop
 Grasping and holding

• Tissues should be grasped and held in a position so that the

surgeon can perform the desired manoeuvre without injuring
the surrounding tissue
• Dissecting forceps
• Smooth/thumb forceps- resemble tweezers.
• They have serrations at the tip used for grasping delicate
tissues
• Toothed forceps- have single tooth on one side that fits
perfectly between the teeth on the opposite side. Provide
firm hold on tough tissue i.e skin
 ct
• Allis forceps- each jaw curves slightly inward and
there is raw of teeth at the end
• Babecock- the end of jaw is rounded section and
fenestrated. Used in grasping delicate tissue
• cocker
• Tenaculums- curved or angled points at the end of
jaws. Penetrate tissues to grasp firmly
• Stone forceps- used to grasp calculi
• Bone holders used to stabilise the bone
 Clamping and occluding
• They are used to apply pressure. Mostly used for clamping blood vessels
i.e
• Haemostats/artery forceps- have either straight or curved jaws. Have
serrations that goes across the jaws.
• Crushing clamps- used to crash or clamp blood vessels
• Non-crashing clamps- used to occlude major blood vessels temporarily
which minimizes tissue trauma
Exposing and retracting
• They hold organs and tissues away from surgical site so that the surgeon
can see clearly and Can have room to operate
• EXAMPLES
• Handled retractors- they have a blade on handle. They are used in pairs
and are used by first and second assistant i.e
malleable- may bent to desired angle or length
Hooks- they are used to retract delicate tissues
• Self retaining retractors- holding device with two or more blades. Can be
inserted to spread the edges of an incision and hold them apart.
 ct,..
viewing
• Used for viewing interior body cavities, hollow
organs and structures and include
• speculum and endoscopies
Suctioning and aspirating
• Blood, body fluids and irrigating solutions may be
removed by mechanical suction or manual
aspiration
 Ct..
Suturing and stapling
Needle holder -Used to grasp and curved surgical needles. It
has short sturdy jaw
Staplers- they are bulky heavy instruments, used for
occluding blood vessels or hollow organ or connection of
organ. examples are- clip appliers, internal anastomosis
stapler
Powered instruments
• Used primarily for drilling, cutting, shaping and bevelling a
bone. they increase speed and decrease fatigue.
• Diathermy machine
• High frequency electric current generates enough heaat
to coagulate and destroy body tissues. Mainly used in
stopping bleeding in small blood vessels i.e repair of
detached retina and cauterize small warts
 suture

• A suture is an all-inclusive term for any

strand of materials used for tying up ends or
approximating tissue and holding them until
healing has taken place.
• Suturing material can be used for ligating
blood vessels, suturing or for traction
(ligature)
• A variety of suture materials are available
 Classification of sutures
1. Synthetic or natural from mammal collagen (biologic)
2. Absorbable or non absorbable:-
absorbable- they dissolve in the tissue after some time or digested
by tissue enzymes during the process of wound healing. Examples
include –
• Surgical gut- not treated with fluid or chemical to resist absorption
• Chromic gut- treated with chromium salt solution to resist
absorption for varying length of time. support wound for 14-21
days
Non- absorbable - are not absorbed.Not used in muscles or where
infection is present
example, silkworm gut, nylon, cotton, linen, Stainless steel,
polyester fiber, prolene suture
3.Monofilament or multifilament (strands)
 Selection of a suture material
• The appropriate suture is selected according
to a number of characteristics: whether it is
- absorbable or not,
- its breaking (tensile) strength, whether it is
monofilament or multifilament,
-its knot-tying abilities,
- and its reactivity
 Wound approximation technique
• Stitching
- interrupted
- continuous
- interlocking
• Stapples
• tapes
 Suture techniques
• Interrupted suture:-Each stitch is taken and tied
separately.
• Continuous sutures:-A series of stitches are taken
with one strand of material and tied only at the ends
of the suture line.
• Retention sutures:-Interrupted non absorbable
sutures are placed through tissue on each side of the
primary suture line and a short distance from it to
relieve tension on it.
• Purse-string suture:-A continuous suture is place
around a lumen and tightened, drawstring fashion, to
 Surgical needles

• The needle is either straight or curved. There

are different classes of needles include:
• Cutting needles, which have a sharp edge, cut a
crack as they pass, and are used on strong
tissues, for example, skin, tendon, muscles.
• Round bodied needles, which are round and
smooth, cause less damage and make a
puncture. They are used in delicate tissues and
organs. i.e blood vessels, nerves
 Positions used in surgery
• Supine
• Lateral
• prone
• Trendenburg
• Reverse trendlenburg
• Lithotomy
• Jacknife or Kraske position
 Anesthesia
• Temporary induced state of partial or total loss of
sensation, occurring with or without loss of
consciousness.
USES
1) Hypnosis
2) Analgesia
3) Muscle relaxation
4) Suppressed reflexes
 Factors to consider in the choice of anaesthesia

• Age, size and weight of the patient

• Physical, mental and emotional state of the patient
• Previous anaesthesia experience
• Anticipated procedure
• Position required
• Type and expected length of the procedure
• Presence of complicating systemic disease
• Preference of surgeon
 Phases of anaesthesia
• Induction- time period starting from premedication,
intiation of I.V.; application of monitors, initiation of
medication that renders the patient unconscious
• Maintenance phase-time period which surgical
procedure is performed
• Emergence- surgical procedure is completed and
patient is reversed to conscious state
 Types of anesthesia
• General
• Local
• regional
 General Anesthesia (GA)
•Reversible loss of consciousness is induced by
inhibiting neuronal impulses in several areas of
the CNS.
•State can be achieved by a single agent or a
combination of agents.
•CNS is depressed, resulting in analgesia,
amnesia, and unconsciousness, with the loss of
muscle tone and reflexes.
 INDICATIONS OF GENERAL ANAESTHESIA

• It is indicated in procedures that

 Take a long time
 Include significant blood loss
 Expose you to cold environment
 Affect your breathing i.e chest or upper abdominal
surgery
RISK FACTORS
 Heart problems, daily alcohol use, allergies to
medication ,smoking ,obesity
 Stages of general anaesthesia
Stage 1- onset anaesthesia
• Patient may experience dreams, visual auditory hallucinations, speech
become difficulty and incomprehensible
• Ringing in the ear and inability to move may be present
• Feeling of detachment may be experienced and voices exaggerated
Stage two- excitement phase
• There is increase in pulse rate and irregular rhythm
• Patient may shout ,laugh, sing and swear
• There is possibility of uncontrolled movement
Stage iii-surgical anaesthesia
• Reached by continuous admistration of anaesthesia
• Patient is unconscious and lies quietly on operating table
• VS are normal
Stage iv- reached when too much anaesthesia has been administered.
Respirations become shallow, pulse weak and thready, pupils are widely
dilated and no longer contract
• Without prompt intervention death occurs
 Administration of GA
•Inhalation: intake and excretion of anesthetic gas
or vapor to the lungs through a mask Inhalational
can volatile liquids or gases
•Intravenous injection: barbiturates, ketamine, and
propofol through the blood stream
•Adjuncts to general anesthesia agents: hypnotics,
opioid analgesics, neuromuscular blocking agents
 Types of volatile liquids

Halothane
• Used as wide spectrum for all types of surgery
• Commonly used in induction phase because it gives muscle
relaxation but little analgesic effect
• Has hypnotic effect
• Has low incidence of post-operative nausea and vomiting
• There is little laryngeal irritation
Disadvantages
• Potentially toxic to the liver and can cause hypothermia
• May produce hypotension and depression to cardiovascular
system
 ct
Ether- considered safest anaesthetic and Can be used for all
types of patients
Desflorane- non-inflamable, halogenated liquid with low
solubility. Used in induction and maintenance phase
• Didadvantages
• Respiratory irritation, laryngeal spasm, cough
Sevoflorane
• Used for induction and maintenance.
• Can cause proteinuria and glycosuria when used for long
procedures
 gases
Nitrous oxide- administered by facemask.
• Not powerful anaesthetic agent and can’t be used on its own for longer but
combined with o2 and other volatile liquids
Advantages
• Rapidly cleared from circulation
• Incidence of nausea and vomiting is minimal &Non-inflamable
• Useful with other agents for all types of surgery &Causes minimal physiologic
change
Disadvantages
• Cause bowel distension
• Increase intracranial pressure and produce hypoxia
• No muscle relaxation
• Can cause laryngospasm and excitement
• Weak anaesthesia
oxygenIncreases oxygen supply to tissues
• Cyclopropane- used for maintenance of anaesthesia in low concentration. may be
used for induction.

•
 Ct..

Opiod analgesics-they are given to produce analgesia and sedation

• They are used intra-operatively as supplemental agents or in combination
with oxygen to produce complete anaesthesia in short procedures and in
patient with little cardiovascular reserve
• Do not produce muscle relaxation
• Examples- morphine sulphate, alfentanail, sulfentanail
Muscle relaxants
• block the transmission of nerve impulses at the neuromuscular junction of
skeletal muscles.
• Muscle relaxants are used to relax muscles in abdominal and thoracic
surgery, facilitate smoother endotracheal intubation, treat laryngospasm,
and assist in mechanical ventilation.
They provide smoother working condition during the procedure. They are
classified as
• Depolarizing(short acting)- mainly used for intubation and can cause
bradycardia example suxamethonium(scoline)
• Non-depolarizing( long acting)- their action has to be reversed to revive the
patient i.e pancurionium, curare,flaxedil,atracrium
 barbiturates

I. Thiopentone- (3-5mg)causes sleep very quickly. Dose will depend with the
procedure being performed. used in induction phase
• Large doses can cause cardiovascular depression and apnea
II. Methohexitone- used as induction agent.
• Can’t be used without equipment of resuscitation and contraindicated in
epilepsy
III. Ketamine hydrochloride- can be given iv or IM
• Has analgesic effect and can be used alone in minor surgeries.
• mainly used in children and adults younger than 30
• Disadvantages-bad dreams,elevetatedbloodpressure,delirium, hallucinations
• Contraindications- hypertension, procedure involving tracheal bronchial
stimulation, increased ICP and previous CVA.
IV.PROPOFOL
 Ct..
• Drugs used to reverse general anaesthesia
• Neostigmine- Used in many cases in combination
with atropine
• Naloxene hydrochloride and flumazenil
Balanced anaesthesia
• Combination of intravenous drugs and inhalation
agents used to obtain specific effects
Combination used to provide hypnosis, amnesia,
analgesia, muscle relaxation, and reduced reflexes
with minimal disturbance of physiologic function
 Local or Regional Anesthesia
•Sensory nerve impulse transmission from a specific
body area of region is briefly disrupted
•Motor function may be affected
•Patient remains conscious and able to follow
instructions
•Gag and cough reflexes remain intact
•Sedatives, opioid analgesics, or hypnotics are often
used as supplements to reduce anxiety. E.g
Lignocaine, procaine hydrochloride, tetracaine
hydrochloride
1. Infiltrative
2. Nerve blocks
3. Topical anesthesia
4. Neural axial anesthesia
– Spinal
– epidural
 Spinal anaesthesia
• This is where a local anaesthetic agent is introduced into subarachnoid
space at the lumbar level usually betweenL4 andL5.
• It produces anaesthesia of regions from abdomen and below.
• Used for abdominal, pelvic, urologic procedures
• Preferred in patient with alcoholism, drug abuse and emergency surgery

complications
• Headache, nausea and vomiting
• Temporary parasthesia i.e numbness
• Transient/ permanent neurological sequale resulting from cord trauma
• Hypotension, urinary retention

Nursing management of pt on spinal anaesthesia

• Maintain a quiet environment
• Keep the patient lying flat
• Keep the patient well hydrated
Epidural anaesthesia
• The drug is injected in the dura mater space of
the spinal cord. It blocks sensory, motor and
autonomic function.
• Used for operations of the abdomen and
below.
• Used for postoperative pain management
• Three approaches used include, lumber,
thoracic and caudal
PERIOPERATIVE NURSING CARE
OF THE PATIENT

gachuhi
 PREOPERATIVE PHASE
• begins when the decision to proceed with surgical
intervention is made and ends with the transfer of
the patient onto the operating room table.
preoperative nursing activities
• Preadmission Testing
• Initiates initial preoperative assessment
• Initiates teaching appropriate to patient’s needs
• Involves family in interview
• Verifies completion of preoperative Testing
• Verifies understanding of surgeon specific
preoperative orders (eg, bowel preparation,
preoperative shower)
 Admission to Surgical Center or Unit
• Completes preoperative assessment
• Assesses for risks for postoperative complications
• Reports unexpected findings or any deviations from normal
• Verifies that operative consent has been signed
• Coordinates patient teaching with other nursing staff
• Reinforces previous teaching
• Answers patient’s and family’s questions
• Develops a plan of care
In the holding area
• Assesses patient’s status; baseline pain and nutritional status ; Reviews chart
&Identifies patient
• Verifies surgical site and marks site per institutional policy then Establishes
intravenous line
• Administers medications if prescribed
• Takes measures to ensure patient’s comfort n Provides psychological support
• Communicates patient’s emotional status to other appropriate members of
the health care team
 ASSESSMENT OF HEALTH FACTORS THAT AFFECT PATIENTS
PREOPERATIVELY
• The overall goal in the preoperative period is for the patient to
have as many positive health factors as possible. Every attempt is
made to stabilize those conditions that otherwise hinder a
smooth recovery.
Nutritional and Fluid Status
• Optimal nutrition is an essential factor in promoting healing and
resisting infection and other surgical complications. Assessment
of a patient’s nutritional status provides information on obesity,
under nutrition, weight loss, malnutrition, deficiencies in specific
nutrients, metabolic abnormalities, the effects of medications on
nutrition, and special problems of the hospitalized patient.
Dehydration, Hypovolemia, and electrolyte imbalances should be
corrected
 Ct..

Alcohol n drug use

• acutely intoxicated persons are susceptible to injury, surgery is
postponed in these patients if possible. If emergency surgery is
required, local, spinal, or regional block anesthesia is used for minor
surgery.
• The person with a history of chronic alcoholism often suffers from
malnutrition and other systemic problems that increase the surgical
risk.
• alcohol withdrawal delirium (delirium tremens) may be anticipated
up to 72 hours after alcohol withdrawal. Delirium tremens is
associated with a significant mortality rate when it occurs
postoperatively.
Respiratory problems
• surgery is usually postponed when the patient has a respiratory
infection. Patients with underlying respiratory disease (eg, asthma,
COPD) are assessed carefully for current threats to their pulmonary
status. Patients who smoke are urged to stop smoking at least 24
hours prior to surgery.
 ct..
Cardiovascular status
• The goal in preparing any patient for surgery is to ensure a well
functioning cardiovascular system to meet the oxygen, fluid, and
nutritional needs of the perioperative period. If patient has
uncontrolled hypertension, surgery may be postponed until the
blood pressure is under control.
Renal and hepatic function
• any disorder of the liver(acute liver ds) has an effect on how
anesthetic agents are metabolized .Careful assessment is made with
the help of various liver function tests

• Because the kidneys are involved in excreting anesthetic drugs and

their metabolites and because acid–base status and metabolism are
also important considerations in anesthesia administration, surgery
is contraindicated when a patient has acute nephritis, acute renal
insufficiency with oliguria or anuria, or other acute renal problems.
 Endocrine function
• The patient with diabetes who is undergoing surgery is at risk for
hypoglycemia and hyperglycemia.
• Frequent monitoring of blood glucose levels is important before, during,
and after surgery.
• Patients who have received corticosteroids are at risk for adrenal
insufficiency. Therefore, the use of corticosteroids for any purpose during
the preceding year must be reported to the anesthetist and surgeon.
Patients with uncontrolled thyroid disorders are at risk for thyrotoxicosis
(with hyperthyroid disorders) and respiratory failure (with hypothyroid
disorders) therefore patient is assessed for history of this disorders

Immune function
• Because patients who are immunosuppressed are highly susceptible to
infection, great care is taken to ensure strict asepsis.
• Determine presence of allergies, any sensitivity to medication and past
adverse reactions to agents
 Medication use

• History of medication use is obtained from each

patient. also their length, and effects to the patient.
examples are asprin, antibiotics,
• Corticosteroids, tranquilizers.
Spiritual beliefs - play an important role in how
people cope with fear and anxiety. Regardless of the
patient’s religious affiliation, spiritual beliefs can be as
therapeutic as medication.
• Every attempt must be made to help the patient obtain
the spiritual help that he or she requests
 General pre-operative care for all patients
• establishing a baseline evaluation of the patient which include: a)History
and physical exam to assess presence of any risk factors
b)Laboratory test based on clinical indicators or risk factors i.e.
full haemogram,BUN,blood glucose level, blood typing and cross
matching
c)diagnostic studies- chest x-ray, ultrasound, ct scan.
• Voluntary and written informed consent is obtained from the patient
before non emergent surgery can be performed.written consent protects
the patient from unsanctioned surgery and protects the surgeon from
claims of an unauthorized operation. Nurse and surgeon should provide
necessary information before it is signed
• The surgeon must also inform the patient of the benefits, alternatives,
possible risks, complications, disfigurement, disability, and removal of body
parts as well as what to expect in the early and late postoperative periods.
• Patient personally signs the consent if he is of legal age and mentally
capable.
• When the patient is a minor or unconscious or incompetent, permission
must be obtained from a responsible family member
 Criteria for Valid Informed Consent
Voluntary Consent
Valid consent must be freely given, without coercion.
Incompetent Patient : individual who is not autonomous and cannot
give or withhold consent (eg, individuals who are mentally retarded,
mentally ill, or comatose
Patient Able to Comprehend - Information must be written and
delivered in language understandable to the patient.
Questions must be answered to facilitate comprehension if
material is confusing.
Informed Subject Informed consent should be in writing and should contain
the following:
• Explanation of procedure and its risks
• Description of benefits and alternatives
• An offer to answer questions about procedure
• Instructions that the patient may withdraw consent
• A statement informing the patient if the protocol differs from customary
procedure.
 PREOPERATIVE TEACHING
• Each patient is taught as an individual, with consideration for
any unique concerns or needs;
• Teaching should go beyond descriptions of the procedure and
should include explanations of the sensations the patient will
experience. ideal day is on admission visit
1.Deep-Breathing, Coughing, and Incentive Spirometers
• goal is to teach the patient how to promote optimal lung expansion and
consequent blood oxygenation after anesthesia. The patient assumes a
sitting position to enhance lung expansion. The nurse then demonstrates
how to take a deep, slow breath and how to exhale slowly.

• If there will be a thoracic or abdominal incision, the nurse demonstrates

how the incision line can be splinted to minimize pressure and control
pain.
• The goal in promoting coughing is to mobilize secretions so they can be
removed
 2.Mobility and Active Body Movement

• The goals are to improve circulation, prevent venous stasis,

and promote optimal respiratory function.
• the nurse explains the rationale for frequent position changes
after surgery and then shows the patient how to turn from
side to side and how to assume the lateral position without
causing pain
• Exercises of the extremities include extension and flexion of
the knee and hip joints
3.pain
• Teach patient to differentiate chronic and acute postoperative
pain
• Teach patient to take pain medication as prescribed during
initial postoperative period
 4.Cognitive Coping Strategies
may be useful for relieving tension, overcoming anxiety,
decreasing fear, and achieving relaxation. Examples of
such strategies include
• Imagery—The patient concentrates on a pleasant
experience.
• Distraction—The patient thinks of an enjoyable story.
5.Preoperative psychosocial interventions
• Reducing Preoperative Anxiety-by use of preoperative teaching and music
therapy.
• Decreasing Fear
• During the preoperative assessment the nurse should assist the patient to
identify coping strategies that he or she has previously used to decrease
fear
• Respecting Cultural, Spiritual, and Religious Beliefs
--Psychosocial interventions include identifying and showing re- spect for
cultural, spiritual, and religious beliefs.
 GENERAL PREOPERATIVE NURSING INTERVENTIONS

• withholding food and fluid before surgery is to

prevent aspiration.pt is put on NPO midnight before
surgery.
• Preparing the Bowel for Surgery
• Enemas are not commonly ordered preoperatively
unless the patient is undergoing abdominal or pelvic
surgery. In this case, a cleansing enema or laxative
may be prescribed the evening before surgery and
may be repeated the morning of surgery. The goals of
this preparation are to allow satisfactory visualization
of the surgical site and to prevent trauma to the
intestine or contamination of the peritoneum by feces
 ct
• Skin preparation done to decrease bacteria on the surgical site
by cleansing with site with soap containing germicide and
shaving incase of hair
• IMMEDIATE PREOPERATIVE NURSING INTERVENTIONS
• Mouth is inspected for and denture, plates are removed.
• Patient with long hair should braid, cover completely with
disposable cap
Jewellery, wedding rings and bangles should be removed
Ensure urinary catheterization especially for those patient going
for urologic procedures
Maintaining preoperative checklist which contains critical
elements that need to be checked preoperatively
The completed chart accompanies the patient to the operating
room with the surgical consent form attached, along with all
laboratory reports and nurses’ records.
 Preoperative check list
• Patient’s name: ______________________________ Date: _________________
Height: _____________ Weight: ___________ Identification band present:
_________________________________________________________________________
___________ 2. Informed consent signed: ___________________ Special permits
signed: ______________________________________________ (Ex: Sterilization) 4.
History & physical examination report present: _________________________ Date:
_______________________________________ 5. Laboratory records
present:__________________________________________________________________
____________________ CBC: ___________________ Hgb: ____________________
Urinalysis: _____________________ Hct: __________________
• 6. Item Present Removed
• a. Natural teeth _________________ _________________ Dentures; upper, lower,
partial _________________ _________________ Bridge, fixed; crown
_________________ _________________ b. Contact lenses _________________
_________________ c. Other prostheses—type: _____________ _________________
_________________ d. Jewelry: Wedding band (taped/tied)` _________________
_________________ Rings _________________ _________________ Earrings: pierced,
clip-on _________________ _________________ Neck chains _________________
_________________ Any other body piercings _________________ _________________
e. Make-up _________________ _________________ Nail polish _________________
_________________ 7
 ct,..
• . Clothing a. Clean patient gown _________________ _________________ b. Cap
_________________ _________________ c. Sanitary pad, etc. _________________
_________________ 8. Family instructed where to wait?
_________________________________________________________________________
________ 9. Valuables secured?
_________________________________________________________________________
__________________ 10. Blood available? _________________ Ordered?
_____________ Where? ______________________________________________ 11.
Preanesthetic medication given:
_________________________________________________________________________
_______ Type _____________________ Time
• 12. Voided: __________________ Amount: ___________________ Time:
____________________ Catheter: ___________________ Mouth care given:
____________________________ 13. Vital signs: Temperature: _______________
Pulse: ______________ Resp: _______________ Blood Pressure: ___________ 14.
Special problems/precautions: (Allergies, deafness, etc.):
_____________________________________________________________ 15. Area of
skin preparation:
_________________________________________________________________________
______________ 16.
________________________________________________________________ Date:
_________________ Time:_______________ Signature: Nurse releasing patient
 ct
Administer prescribed preoperative medication
Which include
-benzodiazopinesi.e diazepam,
narcotics i.e morphine
Antiemetic i.e plasil
Antichollinergics i.e atropine
Histamine 2 receptor blocker, ranitidine
 INTRA-OPERATIVE PHASE
Period of time when the patient is transferred to the operating table to
when he/she is admitted to post-operative care unit (PACU)
PRINCIPLES OF SURGICAL ASEPSIS
Surgical asepsis prevents the contamination of surgical wounds.
It includes
• Sterile field should be created as close as possible to the time of use
• All surgical supplies, any instruments, needles, sutures, dressings,
gloves, covers, and solutions that may come in contact with the
surgical wound and exposed tissues, must be sterilized before use

• the surgeon, surgical assistants, and nurses prepared themselves by

scrubbing their hands and arms with antiseptic soap and water

• Surgical team members wear long-sleeved sterile gowns and gloves.

Head and hair are covered with a cap, and a mask is worn
 Ct..
• All equipment that comes into direct contact with the
patient must be sterile
• Edges of anything enclosing sterile content is
considered unsterile
• Contaminated items should be immediately be
removed fro the sterile field
• A wide margin of safety should be maintained between
unsterile and sterile field
• Tables are considered sterile only at the top level, items
extending beneath the level are considered unsterile
• Sterile person must keep within sterile fields
 Cont..Principles of asepsis and aseptic
techniques
• Handling and storage of sterile supplies
• Scrubbing, gowning and gloving
• Opening of the wrappers and sterile packs aseptically
• Creating a sterile field
• Handling sterile field
• safeguarding the sterile field
Refuse generation, handling and disposal
• Segregating refuse
• Linear bag color coding
• Handling of soiled swabs
• Handling of body fluids/ exudates and blood
 Skin preparation(prepping)

• It is done to render surgical site as free as possible

from transient and resident micro-organisms
Procedure
• Shave the surgical site
• The soapy antiseptic sponges are used to cleanse the
skin in a circular motion from incision site to
periphery
• Then clean the surgical site in a similar manner using
iodine or hibitine in 70% alcohol
 Draping of a patient
• The purpose is to maintain an adequate sterile field for
operation and avoid exposing the patient.
• scrub nurse gives the surgeon four towels to cover area above
the operation, sides and below.
Types of drapes
Green towels
• Fenestrated sheets- has an opening that is placed to expose
anatomic area where incision will be made i.e laparatomy
sheet, thyroid and perineal sheet
• Separate sheet-mainly used for small incision
• Stockinet- used to cover extremity
 Sponge sharps and instrument count
Purpose
• Patient and health personnel safety
• Inventory purpose(accountability)
• Infection control
• Ensures that instruments are not accidentally thrown away
• Prevents damage of the laundry equipments
Counting procedure
• Initial count-when the tray is assembled for sterilization
• Baseline count- during set up of a surgical procedure, done by
circulator and scrub nurse
• Closing count- count is taken in three areas
Before surgeon starts the closure. the areas include, field count,
table and floor
Final count (second closing count)- done to verify the count
 Scrubbing

•This is done to remove micro-organisms from the forearm and

arms by mechanical washing and chemical disinfections before
taking part in surgical procedure. This helps prevent the
possibility of the patient being contaminated by bacteria from the
hands and arms.
•Gowning procedure.
• Pick a gown and step back.
• 2. Hold the neck-band and let the bottom hem drop.
•3. Open the gown and slide both hands in through the arm holes.

•4. Do not touch the outside of the gown with your bare hands.
• 5. The Runner Nurse will first tie the neck and shoulder bands
then wristbands without touching the gown.
 Potential intra-operative complications
Nausea and vomiting
• If gagging occurs patient is turned to the side
• And head of the table is lowered
• Prevention- give anti-emetics and h2-receptor antagonist i.e cimetidine, ranitidine
• Complications- asthma, pneumonia, hypoxia
Anaphylaxis
• It may be related to medications(anaesthesia),latex or other substances
• Intra-operative nurse must be alert and observe patient for changes in vital signs
and symptoms
• She/he must be aware of the type of anaesthesia used
• During anaesthesia patient s temperature may fall,Glucose metabolism is reduced,
and as a result metabolic acidosis may develop.
• hypothermia
• hypothermia may occur as a result of a low temper- ature in the OR, infusion of
cold fluids, inhalation of cold gases, open body wounds or cavities, decreased
muscle activity, advanced age, or the pharmaceutical agents used (eg,
vasodilators, phenothiazines, general anesthetics).
• Hypothermia may also be intentionally induced in selected surgical procedures
(such as cardiac surgeries requiring cardiopulmonary bypass)
 Malignant hyperthermia
is an inherited muscle disorder chemically induced by anesthetic
agents. Occurs as a result of hyper metabolism condition in
skeletal muscles cells related to altered mechanism of calcium
function at cellular level that result in increased muscle
contraction
Signs and symptoms
Tachychardia,dsyrrthmia,decreased cardiac output,oliguria
and later cardiac arrest.Muscle rigidity, rise in temperature
Management
Recognize symptoms early and stop anaesthesia
Hyperventilate patient with 100% oxygen
Administer sodium bicarbonate
Continually monitor the patient
 Disseminated intravascular coagulopathy
• is a life-threatening condition characterized by
thrombus formation and depletion of select
coagulation proteins.
• The exact cause is unknown, but predisposing
factors include many conditions that may occur
with emergency surgery, such as massive
trauma, head injury, massive transfusion, liver or
kidney involvement, embolic events, or shock
Hypoxia and other respiratory related conditions
Contributing factors include respiratory
depression, aspiration of secretions and patient
position on operating table
 Post-operative phase

• Extend from the time period the patient leaves operating

room until last follow up visit with the surgeon
PACU- (recovery room).
• Area where post operative patient are monitored as they
recover from anaesthesia
• Phases of PACU/recovery room
• Phase 1- used during immediate recovery of the patient,
intensive nursing care is provided
• Phase II- Patient is prepared for self-care in the hospital or
extended care setting
• Phase III- patient prepared for discharge.
 postoperative nursing considerations
• Prepare the PACU
• Assess patient status and suitability for admission
in the PACU
• Monitor the patient
• Maintain nursing care and nursing documentation
• Assess readiness to the ward
• Inform ward
• Discharge patient
 Information in a handing over report

• Name of the patient and the age

• Surgical procedure
• Type of anaesthesia
• Vital signs if they are stable
• Any complications
• Estimated blood loss
• Any tubings,drains and support aids
• Preoperative conditionsi.e allergies, dm
• Consideration for immediate postoperative care i.e pain
management, ventilator setting
 nursing management in PACU

1.Assessing the Patient

• Frequent, skilled assessments of the blood oxygen saturation level,
pulse rate and regularity, depth and nature of respirations, skin
color, level of consciousness, and ability to respond to commands
are the cornerstones of nursing care in the PACU.
performs a baseline assessment.
• check the surgical site for drainage or hemorrhage and makes sure
that all drainage tubes and monitoring lines are connected and
functioning.
• vital signs are monitored and the patient’s general physical status
is assessed at least every 15 minutes.
• Patency of the airway and respiratory function are always
evaluated first, followed by assessment of cardiovascular function,
the condition of the surgical site, and function of the central
nervous system.
 2.Maintaining a Patent Airway
• The primary objective is to maintain pulmonary ventilation and
thus prevent hypoxemia and hypercapnia. Both can occur if the
airway is obstructed due to anesthesia causing muscle relaxation,
excessive secretions of mucus and vomitus.
Patency of airway is maintained by
• Administration of supplemental oxygen,
• Correct positioning of the patient
• Suctioning of secretions
• Monitor respiratory rate and depth, and breath sounds
3.Maintaining Cardiovascular Stability
• assess the patient’s vital signs; cardiac rhythm; skin temperature,
color, and moisture; and urine output.
• also assess the patency of all IV lines
• Monitor for cardiovascular complications which include
hypotension and shock, hemorrhage, hypertension, and
dysrhythmias.
 4.Relieving Pain and Anxiety
• Opioid analgesics are administered i.e pethidine,
morphine
• Put the patient in a comfortable position
• provides psychological support in an effort to relieve
the patient’s fears and concerns.
5.Controlling nausea and vomiting
• Intervene at first report of nausea and vomiting by
administering antiemetic and positioning patient
laterally to prevent aspiration
 measures are used to determine the patient’s
readiness for discharge from the PACU

• Stable vital signs

• Orientation to person, place, events, and time
• Uncompromised pulmonary function
• Pulse oximetry readings indicating adequate
blood oxygen saturation
• Urine output at least 30 mL/h
• Nausea and vomiting absent or under control
• Minimal pain
 General Principles in Postoperative Care

They include:
• Ensuring clear airway
• Supporting circulation
• Controlling bleeding
• Preventing infection
• Monitoring any complications
• Controlling pain
• Ensuring return of gastro intestinal motility
• Ensuring easy ambulation
• Preparing the patient for discharge and home-based care
 CT..
• Ensuring Clear Airway by placing the patient in
recovery position This allows secretions from the lungs
and mouth to drain out. Suck the secretions using a
suction machine if they are excessive.
• Supporting Circulation which is achieved through
adequate blood volume. You should maintain the
infusion running at the required rates.
• Controlling bleeding and wound care
• Monitor the wound for any signs of bleeding. Should this
occur, apply a firm dressing and inform the surgeon.
• Controlling Pain This is achieved by the administration
of pain relief drugs once the patient is conscious.
pethidine 50-100mg IM or morphine 10-15mg for adult.
correct positioning of the patient
 • Ensuring return of gastro intestinal motility
assess the return of gastric motility. This is
indicated by the return of bowel sounds and
passing of flatus. The patient should not take
food orally before this period is over.
• Monitor VS every 15 minutes for the first two
hours, followed by every 30 minutes for the
next two hours, then four hourly if they
appear to be stable
• Monitor for any complications i.e shock,
bleeding, infection
 ct
• Maintain sterility/aseptic technique on wound
dressing to prevent infection
• Ensuring Early Ambulation this will prevent deep
venous thrombosis, hypostatic pneumonia and quick
healing of the wound
• Monitor for urine output
• Encourage bed exercises which include arm, finger
and foot exercises
• On discharge provide teaching regarding wound care,
avoiding strenuous exercise, nutrition and follow up
clinic
 Post- operative complications
Respiratory
• Atelectasis ,Pneumonia ,Pulmonary embolism, Aspiration.
Neurologic- Delirium related to hypoxia, dehydration,
• Fluid and electrolyte imbalance, alcohol withdrawal,heart failure,
unrelieved pain .
Stroke
Wound- Infection, Dehiscence ,Evisceration Delayed healing ,Hemorrhage
,Hematoma
Gastrointestinal- Constipation Paralytic ileus,, Bowel obstruction
Cardiovascular
• Shock
• Thrombophlebitis
• Hypotension which results from blood loss, hypoventilation, position
changes, pooling of blood in the extrimities,effects of anaesthetics
• Deep vein thrombosis
• Hematoma
• Hypertension and dysrrthmia
Functional – Weakness, Fatigue ,Functional decline
 Medical legal issues in theatre

• Policies, rules and standard operating procedure

• The nurse is the patients custodian and advocate
• Swab and instrument count
• Patients safety
• Regarding specimen/exhibits
• Diathermy burns
• Patients under guard
• Respect for the patient
• Death on the table/ last offices
 Wound healing
Types of wound
Clean, clean- contaminated, contaminated
Dirty wound
Occurs in three phases
Inflammatory (exudative phase)
• Lasts 1-4 days. there is transient vasoconstriction followed by vasodilatation,
pain, swelling, redness and loss of function. Wound fills with exudate containing
wbc,plasma,protein and fibrin.
• Blood clot forms
Proliferative phase/granulation phase
• Occurs on 5th -20th day.fibroplast invade the wound, they synthesize and secrete
collagen and elastin. Granulation tissue forms
• There is proliferation of capillaries.
• Collagen fibres enlarge to produce scar and bind the edges together
Maturation phase/remodelling phase
• Occurs from 21 day to months and years.
• Fibroblast leave the wound. Collagen fibres are cross linked so that the binding is
strengthened
• To reduce scar size/lightening of the wound
 Factors affecting wound healing
• Age of patient –the older healing will take longer
• Handling of tissues-Rough handling causes injury and
delayed healing
• Hemorrhage-Accumulation of blood creates dead
spaces as well as dead cells that must be removed
• Local factors Edema- Reduces blood supply by
exerting increased interstitial pressure on vessels
• Foreign bodies retard healing
• Oxygen deficit
• Drainage accumulation
 Ct..
• Wound stressors i.e Heavy coughing ,Straining
Can cause tension to the wound
• Immunosuppressed state-Patient is more vulnerable to
bacterial and viral invasion; defense mechanisms are
impaired.
• Systemic disorders i.eRenal failure, Sepsis -These
depress cell functions that directly affect wound healing
• . Medicationsi.e Corticosteroids, Anticoagulants Broad-
spectrum and specific antibiotics
• Nutritional deficits i.e proteins
• Inadequate dressing technique –permits bacterial
invasion and contamination
 Nutrients important in wound healing
• Proteins-tissue repair and resistance to infection
• Restore blood volume and plasma protein
• Water- replaces fluid lost through
vomiting,haemorrhage,fever
• Vitamin c-important for capillary formation, tissue
synthesis and antibody formation
• Vitamin A –tissue synthesis
• Enhance resistance to infection
• Vitamin k- important for normal blood clotting
• Zinc-
• Protein synthesis,normal lymphocyte and phagocyte
response
Summary of Perioperative patient care
• Preoperative Phase
• Preadmission Testing
• 1. Initiates initial preoperative assessment
• 2. Initiates teaching appropriate to patient’s needs
• 3. Involves family in interview
• 4. Verifies completion of preoperative testing
• 5. Verifies understanding of surgeon-specific preoperative
orders (eg, bowel preparation, preoperative shower)
• 6. Assesses patient’s need for postoperative transportation
and care
 Admission to Surgical Center or Unit
• 1. Completes preoperative assessment
• 2. Assesses for risks for postoperative complications
• 3. Reports unexpected findings or any deviations from
normal
• 4. Verifies that operative consent has been signed
• 5. Coordinates patient teaching with other nursing staff
• 6. Reinforces previous teaching
• 7. Explains phases in perioperative period and expectations
• 8. Answers patient’s and family’s questions
• 9. Develops a plan of care
 In the Holding Area
• 1. Assesses patient’s status; baseline pain and nutritional status
• 2. Reviews chart
• 3. Identifies patient
• 4. Verifies surgical site and marks site per institutional policy
• 5. Establishes intravenous line
• 6. Administers medications if prescribed
• 7. Takes measures to ensure patient’s comfort
• 8. Provides psychological support
• 9. Communicates patient’s emotional status to other
appropriate members of the health care team
 Intraoperative Phase
Maintenance of Safety
• 1. Maintains aseptic, controlled environment
• 2. Effectively manages human resources, equipment, and supplies for
individualized patient care
• 3. Transfers patient to operating room bed or table
• 4. Positions the patient i.e functional alignment and exposure of
surgical site
• 5. Applies grounding device to patient
• 6. Ensures that the sponge, needle, and instrument counts are
correct
• 7. Completes intraoperative documentation
•  
 Physiologic Monitoring
• 1. Calculates effects on patient of excessive fluid loss or gain
• 2. Distinguishes normal from abnormal cardiopulmonary data
• 3. Reports changes in patient’s vital signs
• 4. Institutes measures to promote normothermia
•  
• Psychological Support (Before Induction and
When Patient is Conscious)
• 1. Provides emotional support to patient
• 2. Stands near or touches patient during procedures and
induction
• 3. Continues to assess patient’s emotional status
 Postoperative Phase
Transfer of Patient to Postanesthesia Care Unit 
1. Communicates intraoperative information
• Identifies patient by name
• States type of surgery performed
• Identifies type of anesthetic used
• Reports patient’s response to surgical procedure and
anesthesia
• Describes intraoperative factors (eg, insertion of drains or
catheters; administration of blood, analgesic agents, or other
medications during surgery; occurrence of unexpected events)
• Describes physical limitations
• Reports patient’s preoperative level of consciousness
• Communicates necessary equipment needs
• Communicates presence of family and/or significant others
 Postoperative Assessment Recovery Area
• 1. Determines patient’s immediate response to surgical
intervention
• 2. Monitors patient’s physiologic status
• 3. Assesses patient’s pain level and administers appropriate
pain relief
• 4. Maintains patient’s safety (airway, circulation, prevention
of injury)
• 5. Administers medications, fluid, and blood component
therapy, if prescribed
• 6. Provides oral fluids if prescribed for ambulatory surgery
patient
• 7. Assesses patient’s readiness for transfer to in-hospital unit
or for discharge home based on institutional policy
 Surgical Unit
1. Continues close monitoring of patient’s physical and psychological
response to surgical intervention
2. Assesses patient’s pain level and administers appropriate pain relief
measures
3. Provides teaching to patient during immediate recovery period
4. Assists patient in recovery and preparation for discharge home
5. Determines patient’s psychological status
6. Assists with discharge planning 
Home or Clinic
1. Provides follow-up care during office or clinic visit or by telephone
contact
2. Reinforces previous teaching and answers patient’s and family’s
questions about surgery and follow-up care
3. Assesses patient’s response to surgery and anesthesia and their
effects on body image and function
Determines family’s perception of surgery and its outcome