Perioperative Nursing Care

PORTREITZ KMTC
Naom nyarangi
 Learning Outcomes

By the end of this unit the students will be able to:

• Describe physical layout of operating rooms.
• Demonstrate appropriate scrubbing and gowning
skills.
• Apply knowledge in assisting various operative
procedures.
• Apply nursing process in the management of
clients peri-operatively
Specific objectives

• List and discuss common purposes of surgery.

• List the components of preoperative assessment and
discuss the purposes and nursing responsibilities.
• List the components of preoperative patient preparation and
discuss the purposes and nursing responsibilities.
• List and discuss the potential complications of the
postoperative period and the preventative measures.
• Discuss nursing responsibilities related to the postoperative
care of patients.
 Peri-operative nursing
Definition;
• Perioperative nursing describes the wide
variety of nursing functions associated with the
patient’s surgical management. 
• Perioperative Nursing is the care of a client or
patient before, during, and after an operation.
• It is a specialized nursing area wherein a
registered nurse works as a team member of
other surgical health care professionals.
Perioperative nursing is used to describe the nursing
care provided in the total surgical experience of the
patient: preoperative, intra-operative and postoperative.

a.Preoperative Phase:
Extends from the time the client is admitted in the
surgical unit, to the time he/she is prepared for the
surgical procedure, until he is transported into the
operating room.
b. Intra-operative Phase;
• Extends from the time the client is admitted to the
Operating Room, to the time of administration of
anesthesia, surgical procedure is done, until he/she
is transported to the Recovery Room (RR)/PACU.

c. Postoperative Phase:
• Extends from the time the client is admitted to the
recovery room, to the time he is transported back in
to the surgical unit, discharged from the hospital,
until the follow-up care.
Reasons for surgery
• To cure an illness or disease by removing the
diseased tissue or organs.
• To visualize internal structures during diagnosis.
• To obtain tissue for examination.
• To prevent disease or injury.
• To improve appearance.
• To repair or remove traumatized tissue and
structures.
• To relieve symptoms or pain.
There are 4 Major Types of Pathologic Process Requiring
Surgical Intervention; (OPET)

• Obstruction – impairment to the flow of vital fluids

(blood, urine, CSF, bile)
• Perforation – rupture of an organ.
• Erosion – wearing off of a surface or membrane.
• Tumors – abnormal new growths.

Examples of pathologic process requiring surgery;

Hydrocephalus (Obstruction), Burn (Erosion), Benign
Prostatic Hyperplasia (Tumor), Cholelithiasis
(Obstruction), Intussusceptions (Obstruction), Perforation
(Ruptured Aneurysm).
Classifications of Surgical Procedures

There are different classifications of surgical

procedures
The class can be based on:

• Purpose
• Urgency
• Risk
 Based on Purpose
1. Diagnostic. These kind of surgeries are done to
determine cause of illness and/or make confirm a
diagnosis. Examples includes: biopsy, exploratory
laparotomy (explorelap)

2. Ablative/Curative. These kind of surgeries are

performed to remove a diseased part or organ.
Examples include: gastrectomy (partial or full
removal of stomach), thyroidectomy, and
appendectomy.
 Based on Purpose contd….
3. Palliative. To relieve symptoms without curing
the disease. These include: colostomy,
debridement of necrotic tissue.

4. Re-constructive. These includes skin graft,

plastic surgery, scar revisions. These are done to
restore function to traumatized or
malfunctioninig tissue and to improve self
concept.
 Based on Purpose contd….

5. Transplant. To replace organs or structures that are

diseased or malfunctioning.

6. Constructive. To restore function in congeinital

anomalies. Cleft palate repaire (palatoplasty),
closure of atrial-septal defect.
 Based on Purpose contd….

7. Exploratory. To estimate the extend of the

disease or confirmation of diagnosis. Examples:
Exploratory laparatomy, pelvic laparatomy.

8. Aesthetic. To improve on physical features that

are within normal range. Example: breast
augmentation.
Examples of the type of surgery according to purpose:
• Pap Smear (Diagnostic),
• Tonsillectomy (Curative),
• Nephrocapsulectomy (Curative),
• Osteoplasty (Curative/ Constructive),
• Perineorrhaphy (Curative/Reconstructive),
• Trachelorrhaphy (Curative/Constructive),
• Skin Grafting(Curative/ Reconstructive)
 Based on Urgency

1. Elective. These are kind of surgeries wherein they are

pre-planned.
Delay of surgery has no ill-effects.
These can be scheduled in advance based on the
client’s choice. 
Examples: tonsillectomy, hernia repair, cataract
extraction, mammoplasty, face lift, and cesarean
section.
 Based on Urgency contd..
2. Urgent. Surgeries that are necessary for the client’s
health, usually done within 24 to 48 hours. Examples:
Removal of gall bladder, amputation, colon resection,
coronary artery bypass, surgical removal of tumor

3. Emergent. Surgeries that must be done immediately to

preserve client’s life, body part of body function.
Examples: Control of hemorrhage, perforated ulcer,
intestinal obstruction, repair of trauma, tracheostomy
According To Degree Of Risk
1. Major Surgery – involves high risk / Greater Risk
for Infection – it’s Extensive or Prolonged - Large
amount of blood loss -Vital organ may be handled
or removed
2. Minor Surgery - Generally not prolonged - Leads
to few serious complication - Involves less risk
Common Terms

Perioperative Nursing:
• Includes the preoperative (before), intraoperative (during)
and postoperative (after) periods.
Preoperative period:
• This is an important time to address issues that may come
up during surgery (Screening)
o i.e. assess for bleeding problems, don't want to find out
that someone has a bleeding problem as they
exsanguinate on the operating table
• Also can teach patients and family about what to expect
before, during and after a procedure
o in an emergency, we can prepare the family if the patient
isn't alert
Further Descriptors of Surgery
Elective: Emergency:
• Carefully planned event • arises unexpectedly
• Advanced assessments • can also occur in a wide
are usually attained and variety of settings
pre-operative checks are o ER
in place o OR
o blood draws o Battlefield/Trauma
o physical exam scene
o other necessary studies • Needed within minutes to
• Can be scheduled in some hours
cases as an outpatient or Urgent:
in an ambulatory surgery • delay could be detrimental
center • usually within 24-48 hours
Types of Elective Admissions for
Surgery
Ambulatory Surgery:
• Usually outside a hospital setting
• Special prescreening
• Don't use in patient's with multiple problems
Same-Day Surgery:
• Outpatient, can be in the hospital
• Go home the day of the surgery
Early Hospital Admission:
• Patient comes in early (night before or earlier)
• Usually patients with complex medical issues, and increased
risk for poor surgical outcomes
 PREOPERATIVE PHASE
Goals:
• Assessing and correcting physiologic and psychologic
problems that may increase surgical risk.

• Giving the person and significant others complete

learning / teaching guidelines regarding surgery.

• Instructing and demonstrating exercises that will

benefits the person during postoperative period.

• Planning for discharge and any projected changes in

lifestyle due to surgery.
 POSTOPERATIVE CARE

Goals:
• Restore homeostasis and prevent complication
• Maintain adequate cardiovascular and tissue perfusion.
• Maintain adequate respiratory function.
• Maintain adequate nutrition and elimination.
• Maintain adequate fluid and electrolyte balance.
• Maintain adequate renal function.
• Promote adequate rest, comfort and safety.
• Promote adequate wound healing.
• Promote and maintain activity and mobility.
• Provide adequate psychological support.
Preoperative Nursing Assessment

1. Age
2. Allergies
3. Vital Sign Trend
4. Nutritional Status
5. Habits affecting tolerance to anesthesia
6. Presence of Infections
7. Use of drugs that are contraindicated prior to surgery
8. Physiological Status
9. Psychological state of the patient
Preoperative Nursing Assessment
Age:
•  Elderly are at risk
• >65 years of age
• obtain a detailed medical
history and health
assessment
• assess for sensory deficits
• assess for overall
functional status
• understand that there is a
decreased physiological
reserve
Allergies: 
• assess for known drug,
food and substance
allergies
• assess what the reaction
to the drug or substance is
(is it a true allergy, hives or
anaphylaxis?)
• allergies must be clearly
noted on the chart, and
other steps are usually
taken per
hospital/institutional
protocol
Preoperative Nursing Assessment

Vital Signs Trends:

• What is normal for that patient, and are V/S in the

preoperative period in line with the norms or deviating?
Preoperative Nursing Assessment

Nutritional Status:
• This can be a situation of deficit or excess
• assess for individuals who are prone to general nutritional
deficiencies:
o Aged
o Cancer patients
o Gastrointestinal problems
o Chronic illness/Chronic steriod use
o Alcoholics/Drug Addicts
• Also assess for excess (Obesity):
o Poor wound healing because of decreased blood supply
o Hard to access surgical site
o Decreased lung capacity
o Anesthesia meds are stored in fat cells
Preoperative Nursing Assessment

Habits affecting tolerance to anesthesia:

• Smoking:
o alters platelet function...hypercoagulable
o reduces the amount of functional hemoglobin
 carboxyhemoglobin
o cilia in the lung are damaged, more difficult to mobilize
secretions in the patient that smokes
o retards wound healing (especially because of the
decreased functional hemoglobin)
• Alcoholism:
o can have impaired liver function
o B-vitamin deficiencies
• Opioid Addiction
o have a high tolerance for pain meds
Preoperative Nursing Assessment

Presence of Infections:
• Biggest indicator is the presence of fever above 101
degrees F (38C)
• If infection is present, likely surgery will need to be delayed
because the risks to the patient are too great.
• Goal will be to find and treat the infection, and then
reattempt surgery once the infection is cleared
Preoperative Nursing Assessment

Use of drugs that are contraindicated prior to surgery:

• Drugs like aspirin, heparin, warfarin (Coumadin) should be
stopped prior to surgery
o affect bleeding time
 ASA is 2 weeks because of the permanent platelet
affects
 heparin, and low molecular weight heparins are usually
stopped 24 preop, unless there are problems with the
liver
 warfarin is usually 7 days, but the PT/INR is rechecked
either the day of or the day before the surgery to check
for bleeding
Preoperative Nursing Assessment
Use of drugs that are contraindicated prior to surgery:
• Current use of medications,
• Over the counter agents and herbal remedies should be
assessed and documented
• Some drugs/herbs can interact with the anesthesia
• Check about antihypertensives the morning of surgery
• Need to be clear about home meds (dose, frequency,
timing) so that any necessary meds are in the postoperative
order as per the MD
o can check with the MD if certain meds should be
restarted
• Want to reinforce that if the patient is to take meds the
morning of surgery, they should be taken with sips of water
Preoperative Nursing Assessment

Physiological Status: Psychological Status:

• Need to ensure as a
preoperative nurse that all
labs, xrays, EKGs and
necessary tests are done
and in the chart
• Need to notify the
physician if there is
anything abnormal,
shouldn't assume that
they've already seen it
• Common behaviors are
fear and anxiety
• fear = pt. knows what they
are scared of
• anxiety = don't tangibly
know what is scaring you
 ROUTINE PRE OPERATIVE SCREENING
TESTS
TEST RATIONALE

CBC RBC,Hgb,Hctareimportanttotheoxygencarryingc
apacityofblood.
WBC are indicator of immune function.
BLOOD GROUPING AND Determined in case blood transfusion is required
CROSSMATCHING
during or after surgery.

SERUM ELECTROLYTE To evaluate fluid and electrolyte status

PT, PTT Measure time required for clotting to occur.

FASTING BLOOD GLUCOSE High level may indicate undiagnosed DM

BUN / Creatinine Evaluate Renal Function

ALT/AST/LDH And Evaluate Liver Function

Bilirubin

Serum Albumin And Evaluate Nutritional Status

Total CHON

Urinalysis Determine Urine Composition

Chest Xray Evaluate Resp.Status/ Heart Size

ECG Identify preexisting cardiac problem

Preoperative Nursing Assessment

Psychological States:
Common Fears:
1. Fear of death
2. Fear of pain and discomfort
3. Fear of mutilation or alteration in body image
4. Fear of anesthesia
5. Fear of disruption of life functioning or patterns
6. Fear due to lack of knowledge regarding the proposed
surgery
7. Fear related to previous surgical expriences
8. Fear due to the influence of significant others
 
Remember, for our patients, surgery presents a major lack
of control. 
Preoperative Nursing Assessment

Psychological States:
Preoperative fear and anxiety can lead to:
1. Need for increased anesthesia
2. Need for increased postoperative pain management
3. Speed of recovery is decreased
 
 
Preoperative education of what to expect in clear, common
english can alleviate some fear and anxiety
 
Remember the role of HOPE for our patients, it is often the
most common coping strategy 
 Manifestation of Fears

• -anxiousness
• -bewilderment
• -anger
• -tendency to exaggerate
• -sad, evasive, tearful, clinging
• -inability to concentrate
• -short attention span
• -failure to carry out simple directions
 Nursing Intervention to Minimize Anxiety

• Explore client’s feeling

• Allow client’s to speak openly about fears/concern.

• Give accurate information regarding surgery (brief, direct to

the point and in simple terms)

• Give empathetic support

• Consider the person’s religious preference and arrange for

visit by a priest / minister as desired.
Patient Preparation for Surgery
1. Operative consent

2. Preoperative learning needs

3. Interventions the day or evening prior to surgery

4. Interventions the day of surgery

1. Operative Consent
This is part of the legal preparation for surgery.
Informed consent is an active, shared decision making process
between the provider and recipient of care. 
Purposes of informed consent:
•To ensure that the client understand the nature of the treatment
including the potential complications and disfigurement (explained
AMD)
•To indicate that the client’s decision was made without pressure.
•To protect the client against unauthorized procedure.
•To protect the surgeon and hospital against legal action by a client
who claims that an authorized procedure was performed.
Has 3 components to make it valid:

1. Adequate Disclosure of:

 The diagnosis,
 Nature and purpose of the proposed treatment,
 Probability of successful outcome,
 Risks and consequences of moving forward with treatment
or alternatives,
 The prognosis if treatment is not instituted, and
 If treatment is deviating from standard for their condition.
 Essential Elements of Informed Consent

• The diagnosis and explanation of the condition.

• A fair explanation of the procedure to be done and used and the

consequences.

• A description of alternative treatment or procedure.

• A description of the benefits to be expected.

• The prognosis, if the recommended care, procedure is refused.

 Informed Consent (cont):

2. Understanding and Comprehension of above:   this has to be

assessed before sedating medicines can be given (minors can't
give consent, severely mentally ill or severely developmentally
challenged).

3. Voluntary Consent:  Can't be coerced into going through with

a procedure. 

This consent can be revoked at any point leading up to a surgical

procedure.
Operative Consent

Who can give consent?

• The patient
• Next of kin (in order of kinship): Spouse, Adult Child,
Parent, Sibling
• Can be designated with a durable power of attorney in
case of medical incapacitation
Who has the legal responsiblity of obtaining consent?
The Physician
 
• The nurse is not legally required to obtain consent
• However, the nurse must make sure the consent was signed

• Nurse has a primary role as a patient advocate.

• Nurse can "witness" the consent, and sign it as such

• If the patient has questions that you can answer to clarify

things, you can do that
• If the patient continues to have questions, or there is a question
that they are not voluntarily giving consent, the doctor needs to
come and speak with them again.

• Very important that patient is consenting voluntarily and with

knowledge of the situation
What about emergency treatment?

 A true medical emergency may override the need to

obtain consent. 
 When medical care is needed to protect the life of an
individual, the next of kin/POA (Power of Attorney) can
give consent. 
 Also, if there is a known and available Advanced
Directive with healthcare decision making instructions,
that can be used to assist in justifying consent. (be sure
with country legal system and institution’s policy)  
 What about emergency treatment contd…?

 If the above are not available, and the doctor deems the
procedure necessary for life, the doctor can chart that it
was necessary, and go ahead with the procedure.

• The nurse may need to write up an incident report and

state that the emergency caused a deviation in the
normal policy to obtain consent on everyone
 Pre Operative Care

Physical Preparation
Before Surgery
• Correct any dietary deficiencies
• Reduce an obese person’s weight
• Correct fluid and electrolyte imbalances
• Restore adequate blood volume with BT
• Treat chronic diseases
• Halt or treat any infectious process
• Treat an alcoholic person with vitamin supplementation, IVF
or fluids if dehydrated
Patient preparation: 

• Preoperative learning needs

• Deep breathing (incentive spirometer),

• Coughing,
• Leg exercises,
• Ambulation
• Pain control and medications
• Cognitive control to decrease anxiety and enhance relaxation
(deep breathing)
• Recovery room orientation
• Probable postoperative therapies
• Directions for the family
Patient preparation:  interventions the day or evening
prior to the surgery

• Diet Restrictions
o Historical guidelines to prevent aspiration were NPO after
midnight the night before 
o Educating the patient about the reason for NPO status may
help with adherence

• Information of what to wear to the surgery

•  Patient will likely need to be there 1 to 2 hours prior to

scheduled procedure
Patient preparation:  interventions the day of surgery

This varies based on whether the person is inpatient or

outpatient.

• Encourage the patient to void (empty their bladder) before

they get any sedative medications
• Final preoperative teaching
• Final Assessment and communication of findings to MD
• Ensuring that all preoperative orders have been completed
• Check to chart to make sure that there is:
o A signed consent for the procedure
o Laboratory data, X ray reports, EKG
o Necessary consults
o Baseline vitals
o Nursing notes up until that point
Patient preparation:  interventions the day of surgery

• Remove any jewelry, hair pins, clothes (except gown)

• Remove contact lens
• No dentures or partial dentures
• If the hearing aides need to be removed, please note that on
the front of the chart.
o glasses or hearing aides need to be returned to the patient
as soon as possible after the procedure
• No makeup or dark nail polish
• Give any preoperative medications
• Note the time the patient leaves the floor
• ID band should be placed, or checked depending on patient
status, and an allergy band per institution protocol
Preoperative Checklist

 
Preoperative Medications
1) Benzodiazepines/Barbituates:  used for their sedative
and amnesic properties
2) Anticholinergics:  reduce secretions, and can reduce
cramping
3) Opioids:  decrease need for intraoperative analgesics and
decrease pain
4) Antiemetics:  decrease Nausea/Vomiting
5) Antibiotics: prevent infective endocarditis, or where
wound contamination is a risk (GI surgery) or where wound
infection would cause significant postoperative morbidity;
usually given IV
6) Eyedrops:  especially with eye surgery (lasik/laser,
cataract surgery)
Preoperative Medications

 
 INTRAOPERATIVE PHASE

Goals
• Asepsis
• Homeostasis
• Safe Administration of Anesthesia
• Hemostasis
 Intraoperative; Operating Area

A surgical suite/setting is a controlled environment designed to

minimize the spread of infectious organisms and allow a
smooth flow of patients, personnel, and the instruments and
equipment.

It has got three areas;

– Unrestricted Area: 
– Semi-restricted Area: 
– Restricted Area: 
Surgical Setting

1.Unrestricted Area

• Provides an entrance and exit from the surgical suite for

personnel, equipment and patient

• Street clothes are permitted in this area

• The area provides access to communication with personnel

within the suite and with personnel and patient’s families
outside the suite
Surgical Setting contd..

2. Semi-restricted Area

• Provides access to the procedure rooms and peripheral support

areas within the surgical suite.
• Personnel entering this area must be in proper operating room
attire
• Traffic control must be designed to prevent violation of this
area by unauthorized persons
• Peripheral support areas consists of: storage areas for clean and
sterile supplies, sterilization equipment and corridors leading to
procedure room
Surgical Setting contd..

3. Restricted Area

• Includes the procedure room where surgery is

performed and adjacent sub-sterile areas where the
scrub sinks and autoclaves are located

• Personnel working in this area must be in proper

operating room attire
The Surgical Team

• The Patient
• The Anesthesiologist or Anesthetist
• The Surgeon
• Scrub Nurse
• Circulating Nurse
• RNFA ( Registered Nurse First Assistant )
• Surgical Technologists
Surgeon

Responsibilities
• Primarily responsible for the preoperative medical
history and physical assessment.
• Performance of the operative procedure according to
the needs of the patients.
• The primary decision maker regarding surgical
technique to use during the procedure.
• May assist with positioning and propping the patient or
may delegate this task to other members of the team
First Assistant to the Surgeon

Responsibilities
• May be a resident (MO), intern , physician’s assistant or a peri
operative nurse.

• Assists with retracting, hemostasis, suturing and any other

tasks requested by the surgeon to facilitate speed while
maintaining quality during the procedure.
Anesthesiologist

Responsibilities
• Selects the anesthesia, administers it, intubates the
client if necessary, manages technical problems related
to the administration of anesthetic agents, and
supervises the client’s condition throughout the
surgical procedure.

• A physician who specializes in the administration and

monitoring of anesthesia while maintaining the overall
well-being of the patient.
Scrub Nurse
Responsibilities
• May be either a nurse or a surgical technician.
• Reviews anatomy, physiology and the surgical procedures.
• Assists with the preparation of the room.
• Scrubs, gowns and gloves self and other members of the surgical team.
• Prepares the instrument table and organizes sterile equipment for
functional use.
• Assists with the drapping procedure.
• Passes instruments to the surgeon and assistants by anticipating their
need.
• Counts sponges, needles and instruments.
• Monitor practices of aseptic technique in self and others.
• Keeps track of irrigations used for calculations of blood loss
Circulating Nurse
Very defined activities during surgery:

• Ensure all equipment is working properly.

• Guarantees sterility of instruments and supplies.
• Assists with positioning.
• Monitor the room and team members for breaks in the sterile
technique.
• Handles specimens.
• Coordinates activities with other departments, such as radiology
and pathology.
• Documents care provided.
• Minimizes conversation and traffic within the operating room
suite.
Other Nursing Roles

Nurse Anesthetist:
• Minimally masters prepared
• Perform many of the roles that an anesthesiology MD perform
• Manage patient pre-op. assessment, induction, maintenance,
and emergence from anesthesia
 Environmental Safety in surgical suite

1. The size of the procedure room

2. Temperature and humidity control

3. Ventilation and air exchange system

4. Electrical Safety

5. Communication System
 Environmental Safety in surgical suite contd..
a. Size of the Procedure Room
• Usually rectangular or square in shape
• 20 x 20 x 10ft. with a minimum floor space of 360 sq. ft
• Each procedure room must have the following equipment:
-Communication System
-Oxygen and vacuum outlets
-Mechanical ventilation assistance equipment
-Respiratory and Cardiac monitoring equipment
-X ray film illumination boxes
-Cardiac defibrillator
-High-efficiency particulate air filters
-Adequate room lighting
-Emergency lighting system
 Environmental Safety in surgical suite contd..

b. Temperature and Humidity Control

• The temperature in the procedure room should be maintained
between 20 -24 degrees C
• Humidity level between 50 -55 % at all times

c. Ventilation and Air Exchange System

• Air exchange in each procedure room should be at least 25 air
exchanges/ hour, and five of that should be fresh air.
• A high filtration particulate filter, working at 95% efficiency.
• Each procedure room should maintain positive pressure, which
forces old air out of the room and prevents air from
surrounding areas from entering into the procedure room
 Environmental Safety in surgical suite contd..

d. Electrical Safety
• Faulty wiring, excessive use of extension cords, poorly
maintained equipment and lack of current safety measures are
hazardous factors that must be constantly checked

• All electrical equipment, new/used, should be routinely checked

by qualified personnel.

• Equipment that fails to function at 100% efficiency should be

taken out of service immediately.
Perioperative asepsis/sterile technique

• It is the creation and maintenance of a sterile field, with the

patient's surgical incision at the center of the sterile field. 
Proper Technique for scrubbing into a surgical field:

1. Team members fingers and hands should be scrubbed first with

progression to the forearm and elbows.

2. The hands should be held away from the surgical attire.

3. The hands should be held up once clean so that no suds or

other bacteria can drift down onto the clean area

4. When waterless gels are used for asepsis, hands and forearms
are washed first thoroughly with soap and water, then dry
before putting on the gel

5. Then enter the surgical area and put on the surgical gown and
gloves
 ANESTHESIA
A state of “Narcosis”
• Anesthetics can produce muscle relaxation, block
transmission of pain nerve impulses and suppress reflexes.
• It can also temporary decrease memory retrieval and recall.
• The effects of anesthesia are monitored by considering the
following parameters:
• -Respiration
• -O2 saturation
• -CO2 levels
• -HR and BP
• -Urine output
Types of Anesthesia

1. General:  
Loss of sensation with the loss of consciousness, skeletal
muscle relaxation, possible impaired ventilatory and
cardiovascular function and elimination of the somatic,
autonomic, and endocrine responses, including coughing,
gagging, vomiting, and sympathetic nervous system responses.
General anesthesia contd…

• It is given IV, inhaled, or rectally

• It is the technique of choice when:
1.Surgical procedures require sig. skeletal muscle
relaxation, last for a long time, require awkward
positioning or control of respirations
2.Patient are extremely anxious
3.Refuse or have contraindications for local anesthesia
4.Are uncooperative (head injury, intoxication, youth,
emotional status, or cannot remain immobile)
Techniques used in General Anesthesia

a. Intravenous Anesthesia

• This is being administered intravenously and extremely rapid.

• Its effect will immediately take place after thirty minutes of
introduction.
• It prepares the client for smooth transition to the surgical
anesthesia.
b. Inhalation Anesthesia

• This comprises of volatile liquids or gas and oxygen.

• Administered through a mask or endotracheal tube.
Endotracheal Intubation

• This is a tube placed into the trachea once IV induction of

anesthesia occurs
• Allows for control of ventilation and airway protection
(specifically from aspiration)
• Complications:
o Sore throat/hoarseness
o Injury to the teeth
o Failure to intubate
o Laryngospasm, laryngeal edema

• Once the tube is placed, an ambu bag is attached and air is

instilled, the chest should rise and fall with the instillation of
air, and you should be able to hear breath sounds
Stages of GeneralAnesthesia

Stage 1: Onset / Induction.

Stage 2: Excitement / Delirium.
Stage 3: Surgical
Stage 4: Medullary / Stage of Danger
Types of Anesthesia contd….

2. Regional anesthesia 

This is the injection of a local anesthetic in or around a specific

nerve or group of nerves.
Reduce all painful sensation in one region of the body without
inducing unconsciousness.
Agents used are lidocaine and bupivacaine.
Techniques used in Regional Anesthesia:

a.Topical Anesthesia

• Applied directly to the skin and mucous membrane,

open skin surfaces, wounds and burns.
• Readily absorbed and act rapidly.
• Used topical agents are lidocaine and benzocaine.
b. Nerve blocks:  usually done for the palliation of pain
o celiac plexus block
o brachial plexus block

c. Spinal/Epidural Anesthetic:  injection of a local anesthetic

into either the subarachnoid space and CSF (spinal) or
epidural space (epidural)

i. Spinal blocks:  cause autonomic, sensory and motor

blockade, used for lower abdomen, perineal, groin, or
lower extremity
Agents used are procaine, tetracaine, lidocaine and
bupivacaine.
Can cause hypotension and vasodilatation, also spinal
headaches
ii. Epidural blocks:  anesthetic is given to the epidural space
Agents use are chloroprocaine, lidocaine and
bupivacaine.
lower incidence of headache

d. Peripheral Nerve Block: achieved by injecting a local

anesthetic to anesthetize the surgical site.
Agents use are chloroprocaine, lidocaine and bupivacaine
E. Intravenous Block ( Beir block )
• Often used for arm, wrist and hand procedure
• An occlusion tourniquet is applied to the extremity to prevent
infiltration and absorption of the injected IV agents beyond
the involved extremity.

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

G. Field Block Anesthesia

• The area proximal to a planned incision can be injected and
infiltrated with local anesthetic agents
Patient Positioning
• Critical part of every procedure and usually occurs once the
anesthesia has been administered.
• Needs to allow for accessibility of the surgical site,
administration of anesthesia, and maintenance of the
airway.
• Must take care to:
1.provide correct skeletal alignment
2.prevent undue pressure on nerves, skin over bony
prominences, and eyes
3.provide for adequate thoracic excursion
4.prevent occlusion of arteries and veins
5.provide some modesty
6.recognize and accommodate for previously assessed
skeletal deformities
Nursing Management

• Assessment
• Diagnosis
• Planning
• Intervention
• Evaluation
Complications and Discomforts of Anesthesia

• Hypoventilation -inadequate ventilatory support after

paralysis of respiratory muscles.
• Oral Trauma
• Malignant Hyperthermia -uncontrolled skeletal muscle
contraction
• Hypotension-due to preoperative hypovolemia or untoward
reactions to anesthetic agents.
• Cardiac Dysrhythmia -due to preexisting cardiovascular
compromise, electrolyte imbalance or untoward reaction to
anesthesia.
Complications of the Intraoperative
Period
Anaphylaxis:

• Most severe form of an allergic reaction, type I

hypersensitivity
• Clinical Manifestations can be masked by anesthesia
• Can be caused by any of the medications, inhaled, IV, or
by the compounds used in the tools of the surgery (iodine
allergy, latex allergy)
• Watch for hypotension, tachycardia, bronchospasm, and
pulmonary edema
Complications of the Intraoperative Period
Postoperative Hypothermia:
• get hypothermia up to 12 hours post surgery, 34.5C
• Direct effect of the anesthesia
• increased risk with longer surgeries
 
Postoperative Hyperthermia:  
• elevated temperatures:  38C or above 24-48 hours post
surgery
• results from inflammatory medications/cytokines that are
released in the post operative period to enhance healing 
Complications of the Intraoperative
Period
Malignant Hyperthermia:
• Rare metabolic disease in which affected period develop
hyperthermia with rigidity of skeletal muscles that can result
in death
o most often seen when Succinylcholine with inhalent drugs
are given together
• Autosomal dominant with varying levels of penetrance
• Thought to be a derangement of contol of intracellular
calcium, leading to muscle contracture, hyperthermia,
hypoxemia, lactic acidosis, and hemodynamic and cardiac
abnormalities
• Need to assess the patient and the family for any
untoward reactions to anesthesia
• Treatment is administration of dantrolene
Postoperative Nursing Care

1. Preparation for admitting the new postoperative patient

2. Initial assessment and interventions upon receiving the
patient
3. Selected data from the chart that is important
4. Post operative nursing assessments and interventions
Postoperative Nursing Care: 
Preparation
1. Have the postoperative bed ready, linens, extra pillows for
positioning
2. Have the appropriate equipment ready:
1.Suction, set up, tested and ready to hook up
2.antiembolism stockings, set up, tested and ready to hook
up
3.Oxygen hook up
4.if hip replacement, ensure you have the proper hip
abduction pillow
3. Emergency tray (airways, drugs, etc) depending on the type
of surgery
Proper Postoperative Positioning

 
Initial Assessment and Interventions
upon receiving the patient
1.  Level of consciousness and emotional state
 
2.  Move patient to the bed, placement and positioning,
attachment of equipment as needed
    a.  quick assessment of A (airway) B (breathing) C
(circulation)
    b.  proper positioning may be ordered based on the type of
surgery, if semiconscious, side lying with the head of the bed
flat, if fully conscious, semi fowlers (if not contraindicated)
 
3.  Safety Measures:  side rails up, brief assessment of
mentation
Initial Assessment and interventions
upon receiving the patient
4.  Review the postoperative plan of care with the recovery
room nurse to include orders:
• V/S, position, medications, IV fluids, NPO or type of oral
intake, activity, diagnostic tests needed, dressing changes,
etc...
 
5.  Emotional Support for the patient and the family

6.  Pain:  Assess pain per patient, and location

Initial assessment and interventions
upon receiving the patient
7.  Objective Data:
 
a.  Vital Signs (TPRBP) q 15min x 4, q 30 min x 4, q 1 hour x
4, then q 4 hours as indicated
    Can only move from 15 to 30min, and 30min to q1 hour
when the patient is stable
b.  Respiratory Status:  Patency of the airway, need for
suctioning if the patient can't move sections, depth of
respirations

C.  Neurological Status:  Level of consciousness, pupils, gag

and swallowing reflexes
Initial assessment and interventions
upon receiving the patient
    d.  Circulatory Status:  note the nailbeds (cap refill), lips,
buccal membranes, palms, and soles for pallor and duskiness
(cyanosis is usually first seen in the buccal membranes)

    e.  Dressing (s):  check the chart and see where they are,
and what they are comprised of.
    also check the chart for placement of any surgical drains
have been placed and where they exit

    f.  Drainage tubes:  are they free of kinks and draining
properly, check if the tubes need to be attached to suction,
check to ensure it is the proper amount of suction, assess type
and amount of drainage and know when to call the MD.
Initial assessment and interventions
upon receiving the patient
    g.  Urinary output:  if there is no foley, the patient must void
within 8-10 hours post-op, if not, notify the MD
        if there is a foley, there should be at least 500-700 cc in
the first 24 hours post surgery

    h.  Safety:  Side rails up, instruct the patient not to get out of
bed without help, ensure the call light and phone are within
reach, secure all tubes and lines properly to prevent
dislodgement and injury
        As the nurse, make sure to dangle the patient for 1-2
minutes the first time the patient gets up out of bed.

    i.  Proper positioning and comfort

    j.  Equipment
Selected data from the chart that is important

1. Surgeon's Orders
2. Surgical Notes and Anesthesia records
3. Recovery Room Summary
Postoperative nursing assessment and
interventions
1. Assessment of Risk Factors for postoperative
complications (will review later)
2. Promote comfort:  includes the relief of pain, the relief of
restlessness, relief of nausea and vomiting, relief of
abdominal distention, relief of hiccups.
3. Promote wound healing:  review wound healing from
earlier lectures...a properly approximated sutured or
stapled surgical wound is healing by primary intention,
how strong is the wound once the sutures are removed?
4. Care of tubes and drains
Postoperative nursing assessment and
intervention
5.  Ensuring optimal respiratory function:  Promote lung
expansion, deep breathing, coughing and use of the incentive
spirometer
    (Coughing is contraindicated in head and eye surgeries,
plastic surgery and hernia operations)

6.  Maintenance of Adequate Cardiovascular Function

 
7.  Maintenance of adequate F/E balance:  monitor for
abnormal electrolytes, monitor v/s, keep an accurate I&O
records, obtain laboratory specimens
Postoperative nursing assessment and
intervention
8.  Maintenance of nutritional balance:  NG tubes for 24-48
hours post GI surgery, post operative diet includes clear liquids
once bowel sounds return, advance the diet based on MD
orders and patient tolerance

9.  Return of Normal Urinary Function:  assess for bladder

pain and distention (palpation and percussion), assess urinary
output, Notify MD if no urine output 6-8 hours post surgery, If
patient continues on bed rest, assist the patient into the normal
voiding position as possible, provide for adequate privacy (as
much as possible)
Postoperative nursing assessment and
interventions
10.  Resumption of usual bowel elimination pattern:  assess
for abdominal distention, presence of bowel sounds, assist with
ambulation, provide ordered laxatives as needed, provide for
as much privacy as possible, assist in positioning patient in as
natural a position for stooling.

11.  Restoration of Mobility:  assess the patient for the ability

to ambulate, remember to dangle the patient before walking,
assess the patient before, during and after ambulating, work
with PT, provide for adequate pain medicines if needed prior to
ambulating.

12.  Reduction of anxiety and achievement of well-being

13.  Discharge Planning:  very teaching focused
Common postoperative complications

1. Hematological 1. Gastrointestinal
Hemorrhage i. Paralytic ileus
2. Respiratory ii. Constipation
i. Atelectasis 2. Neurological
ii. Pneumonia CVA/Stroke
iii. Pulmonary Embolism 3. Immunological
3. Cardiovascular Infection
i. Hypotension 4. Wound Healing
ii. Cardiac Dysrhythmias i. Dehiscence
iii. Venous Thrombosis ii. Eviserations
4. Urinary iii. Infection
i. Urinary Retention 5. Psychological
ii. Low urine production Body image problems
Common postoperative complications:

 
Common postoperative complications:
Hematologic
Hemorrhage:  
• Often related to ineffective vascular closure or alterations in
coagulation
• Observe for bleeding at the wound site/surgical dressing,
especially in the dependent areas
• Monitor the v/s closely (see previous slide), assess skin
closely, report any changes noted
• Assess LOC, and mentation (restlessness can indicate
altered cerebral perfusion)
Common postoperative complications:
Pulmonary
Atelectasis:
• Common cause of postoperative hypoxemia
• Retained secretions and decreased respiratory excursion
causes blockage of the alveoli
o once all the air trapped in the alveoli is absorbed, the
alveoli collapse
o hypotension and cardiac states can worsen this
• Assess for decreased lung sounds, decreased O2 sats
• Encourage deep breathing, incentive spirometry, coughing,
early mobilization
Common postoperative complications:
Pulmonary
Atelectasis:
 
Common postoperative complications:
Pulmonary
Pneumonia:
• Can be a sequela to the atelectasis, can occur from
aspiration
o increased risk post thoracic and abdominal surgery
• the atelectasis builds up, and increased secretions can
continue to block the airways
o microorganisms grow in the trapped secretions
• Proper positioning of patients can assist with this, as well as
q2 hour re-positioning
o ensure that respiratory effort is maximized
o O2 therapy as ordered/needed
o Antibiotics as ordered
• V/S and frequent lung sound assessment
• Cough, deep breathing
Common postoperative complications:
Pulmonary
Pulmonary Embolism:
• Caused by a thrombus that is dislodged from the peripheral
circulation, and then gets lodged in the pulmonary arterial
circulation
• See acute tachypnea, dyspnea, tachycardia, hypotension
and decreased O2 saturations
• Start O2 per MD, Anticoagulants as ordered,
cardiopulmonary support
• Preventing DVT is primary to preventing pulmonary emboli:
o Leg exercises
o Compression stockings/anticoagulants per MD
o Deep breathing, coughing
o Ambulate as soon as possible
Common postoperative complications:
Cardiovascular
Hypotension:
• Most common causes are unreplaced fluids during the
surgery and hemorrhage
• Secondary causes include MI, cardiac tamponade,
pulmonary emboli, or effects from the anesthesia drugs
• Show signs of hypoperfusion to the vital organs (heart,
brain, and kidneys)
• have clinical signs of disorientation, loss of consciousness,
chest pain, oliguria, and anuria
• Assess V/S, pulse Oxymeter, peripheral pulses, LOC and
report as necessary
• Assist physician with interventions aimed at correcting the
underlying cause of the hypotension
Common postoperative complications:
Cardiovascular
Cardiac Dysrhythmias:

• Usually stems from hypokalemia, hypoxemia, hypercarbia,

acid/base imbalances, underlying heart disease, and
circulatory instability.
• Need to assess V/S, compare peripheral pulse with the
heart sounds heard.
• Treatment involves resolving the underlying cause of the
dysrhythmia
Common postoperative complications:
Cardiovascular
Venous Thrombosis:
• Results from venous stasis (inactivity, body positioning,
pressure, dehydration)
• postoperative patients who are eldery or obese are at higher
risk of developing DVTs
• DVTs can embolize and travel to the lung and cause
pulmonary emboli
• Assess for swelling (usually unilateral) in the lower
extremities, redness and pain
• Provide passive ROM of the lower extremities, or encourage
active ROM if the patient is able
• Encourage early ambulation
• Apply compression stockings/sequential compression
devices and give anticoagulants as ordered.
Common posoperative complications:
Urinary
Urinary Retention:
• Can occur in the postoperative period because the
anesthesia can depress the nervous system, and impede
the sensation of bladder filling as well as interfere with the
ability to void.
• More likely to occur after lower abdominal or pelvic surgery
• Need to assess for urine output, both color and amount,
urine output should be 0.5ml/kg/hr, and the patient should
urinate within 6-8 hours of surgery
• Nurse should facillitate voiding by normal positioning of the
patient to void
• Provide privacy to void, running water, pouring warm water
over a female's perineum can assist with the ability to void,
and ambulating to the commode/toilet can help
Common postoperative complications:
Urinary
Low Urine Production:
• The diminished output of urine can be a manifestation of
renal failure and is less common 
• May result from renal ischemia from inadequate renal
perfusion or altered cardiovascular function
• Need to assess urine output, color and amount
• should be 0.5ml/kg/hr, if below that, palpate and percuss the
bladder for fullness and report to MD
Common postoperative complications:
Gastrointestinal
Paralytic Ileus:
• This is caused by bowel manipulation, anesthesia affects on
the bowel, immobility, and pain medicines
• Assess for bowel distention, bowel sounds, presence of
flatus, or stool, bowel sounds and nausea or vomiting
• Maintain NPO status is patient is showing signs of paralytic
ileus, teach patient the importance of the NPO status
• May need to place an NG tube if ordered by MD, and
manage per hospital protocol
Common postoperative complications:
Gastrointestinal
Constipation:
• Same causes as paralytic ileus
• Assess for bowel distention, bowel sounds, passage of
flatus, stool (color, caliber, form), assess bowel sounds,
assess for nausea and vomiting
• Early ambulation can assist with this
• Use of stool softeners, suppositories and enemas as
perscribed
o Harris flush for gas
o Molasses enemas, soap suds enemas, mineral oil
enemas
o positioning on the right side allows the gas to move up
the transverse colon and out the rectum
Common postoperative complications:
Neurological
CVA/Stroke:
• Can be the result of venous stasis and hypercoagulable
states
• Assess LOC, motor and strength, neuro exams, pupils
• Assist with early ambulation, prophylaxis for DVTs/venous
stasis
• Support the patient and the family
Common postoperative complications:
Immunologic
Infection:
• This is related to the altered skin integrity, inadequate
nutrition and fluid balance, presence of environmental
pathogens, invasive instrumentation, and immobility
• Assess for s/s of infection (wound, V/S)
• Provide clean or aspetic wound care (wounds and drains)
• Note the characteristics of drainage to determine infection
• Good pulmonary toilet
• Work with the dieticians to provide optimal nutrition for the
patients
Common postoperative complications:
Wound Healing
Dehisence:
• Separation and disruption of the previous joined wound
edges, may be preceeded by sudden discharge of pink,
brown, or clear drainage
• Often a complication of an infected wound, or from too much
pressure on a surgical wound (obesity, lifting, bending)
Eviseration:
• See dehisence but there is also protrusion of organs through
the wound opening
• Same risk factors
• Assess the wound frequently, note any changes in d/c or
approximation
• Teach the patient care of the wound and about
postoperative limitations
Common postoperative complications:
Wound Healing
Infection:
• This can be caused by altered skin integrity, altered
nutritional and fluid intake, presence of environmental
pathogens, invasive instrumentation, and immobility
• Assess the wound thoroughly:  Drainage,
approximation of wound edges, redness, tenderness,
etc.
• Teach care of the wound to the patient and the family
• Provide medically safe wound care based on orders
• Clean the wound appropriately
• Teach about postoperative limitations
Common postoperative complications:
Psychological
Body Image Problems:
• Any surgery has the potential to cause body image
disturbances
• Need to provide empathetic support
• Meet the patient where they are at...i.e. if they don't want to
look at their colostomy, that might not be the time to teach
colostomy care
• Support the family,
• provide social work referral where indicated
Thank you