PERIOPERATIVE NURSING

REY VINCENT H. LABADAN, RN
EARL KRISTOFFER L. PIRANTE, RN

PERIOPERATIVE PATIENTFOCUSED MODEL

Patient

PERIOPERATIVE NURSING: GENERAL CONSIDERATION
Conditions Requiring Surgery: a. Obstruction or blockage (Impairment to the flow of vital fluids) b. Perforation or rupture of an organ c. Erosion or wearing away of the surface of a tissue d. Tumors or abnormal growth

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

Constructive: repair of a congenitally defective organ. orchidopexy d. Ablative: removal of diseased organs. cheiloplasty.PERIOPERATIVE NURSING: GENERAL CONSIDERATION c. Palliative: to relieve pain.g. plastic surgery after burns iii. Reconstructive: partial or complete restoration of a damaged organ. Types of Curative Surgery: i. e. -orrhaphy. relieve distressing S/Sx According to Degree of Risk to Client: a. Major surgery b. (-ectomy) e. Minor surgery .g. hysterectomy ii. appendectomy. (-plasty.g. -pexy) e.

described as “one-day surgery” or outpatient surgery  Leads to few serious complications  Involves less risk.g. e. e. cyst removal . Major surgery: High degree of risk  Prolonged intraoperative period  Large amount of blood loss  Extensive. Minor surgery: Lesser degree of risk to the client  Generally not prolonged. liver biopsy b.PERIOPERATIVE NURSING: GENERAL CONSIDERATION Criteria: a. g. vital organs may be handled or removed  Great risk of complications.

rhinoplasty. liposuction. e. mammoplasty . e. cholecystectomy. gunshot wound. e.PERIOPERATIVE NURSING: GENERAL CONSIDERATION According to Urgency: a. Optional: surgery that a client requests. Emergency: must be performed immediately without delay. Elective: should be performed for the client’s well being but which is not absolutely necessary. Required: necessary for the well-being of the client.g. vaginal repair.g. e. g.g. b. severe bleeding. repair of scar e. usually within weeks to months. thyriodectomy d. e. Imperative or Urgent: must be performed as soon as possible within 24 – 48 hours.g. cataract extraction. simple hernia. appendectomy c.

Physical and Mental Condition of the Client  Age: premature babies and elderly persons are at risk  Nutritional status: malnourished and obese are at risk  State of fluid and electrolytes balance: dehydration and hypovolemia predispose a person to complications  General health: infectious process increase operative risk  Mental health  Economic and occupational status .PERIOPERATIVE NURSING: GENERAL CONSIDERATION Factors that Affect the Estimation of Surgical Risk a.

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

PERIOPERATIVE NURSING: GENERAL CONSIDERATION c. Nurses. The Extent of the Disease d. Resources and Preparation of the Surgeon. The Magnitude of the Required Operation e. and the Hospital .

removal) Colostomy Phlebotomy Rinoplasty Herniorrhaphy Endoscopy Cholecystectomy .PERIOPERATIVE NURSING: GENERAL CONSIDERATION Suffixes Related to Surgery: -ostomy -otomy -plasty -orrhaphy -oscopy -ectomy (make artificial opening) (cut into or incision) (plastic repair) (suturing. repair) (visual examination) (excision.

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

PERIOPERATIVE NURSING: PHASES OF PERIOPERATIVE NURSING a. Intra-Operative Phase: begins with the client is received in the OR and ends with his admission to the PARR or PACU c. Pre-Operative Phase: begins with the decision to perform surgery and ends with the client’s transfer to the operating room table b. Post-Operative Phase: begins with the client is admitted to PARR or PACU and extends through follow-up home or clinic evaluation .

PERIOPERATIVE NURSING: THE PERIOPERATIVE TEAM The Surgeon An Anesthesiologist or Nurse Anesthetist Makes the preoperative assessment to plan for the type of anesthesia to be administered and to evaluate the client’s status The Professional Registered OR Nurse Makes preoperative assessment and documents the perioperative client care plan (Scrub. PACU Nurse) . Circulating.

The Scrub Nurse Responsible for scrubbing for surgery. including setting up sterile tables and equipment and assisting the surgeon and surgical technicians during the surgical procedure c. The Circulating Nurse Manages the OR and protects the safety and health needs of the client by monitoring the activities of the members of the surgical team and monitoring the conditions in the OR b. is oriented. and shows no evidence of hemorrhage . has stable vital signs.PERIOPERATIVE NURSING: THE PERIOPERATIVE TEAM a. The PACU Nurse Responsible for caring for the client until the client has recovered from the effects of anesthesia.

a specific hand washing technique used by operating room personnel designed to reduce microorganisms in the hands and arms. Surgical scrub. Maintain general cleanliness in surgical suite d. is done for the length of time designed by hospital policy . Maintain surgical asepsis: activities designed to keep sites free from the presence of microorganisms throughout the procedure Personnel: a. Check package sterilization expiration date to verify sterility c.PERIOPERATIVE NURSING: PRINCIPLES OF PERIOPERATIVE ASEPSIS General: a. Keep sterile supplies dry and unopened b. Personnel with signs of illness should not report to work b.

PERIOPERATIVE NURSING: PRINCIPLES OF PERIOPERATIVE ASEPSIS Surgical Scrub i. Keep the finger nails short and well-trimmed v. Remove all rings and watches iii. then using a second towel to dry the second hand . Clean all areas of skin on the hands and arms in sequence starting at the hands and ending at the elbows x. Clean fingernails with a nail stick under running water vi. Use liquid soaps to prevent the spread of organisms iv. A scrub brush facilitates the removal of microorganisms ix. After rinsing.or foot-operated faucet allows the water to be turned on and off without the use of the hands ii. drying first one arm from the hand to the elbow. A sensor-controlled or knee. Hold the hands higher than the elbows throughout the hand washing procedure so that run-off goes to the elbows vii. Allows the cleanest part of the arms to be the hands viii. dry the hands with paper towels.

Keep drapes dry and out of contact with nonsterile objects e. Create a sterile field using sterile drapes b. Drape equipment prior to use d. Check expiration dates for sterility b. Utilize sterile technique while adding or removing supplies from sterile fields Sterile Supplies and Solutions: a. Use the sterile field to place sterile supplies where they will be available during the procedure c. “Lip” the solution after initial use by pouring a small amount of liquid out of the bottle into a waste container to cleanse the bottle lip . Don’t use solutions that were opened prior to current use c.PERIOPERATIVE NURSING: PRINCIPLES OF PERIOPERATIVE ASEPSIS Maintaining a Sterile Field (a microorganism-free area): a.

blood and body substance isolation) 2. Sterile objects become unsterile when touched by unsterile objects 4. All items used in the sterile field must be sterile 3. Sterile objects can become unsterile by prolonged exposure to air-born organism 6. The skin can not be sterilized and is unsterile  All personnel must perform a surgical scrub . OR personnel must practice strict Standard Precautions (i.PERIOPERATIVE NURSING: PRINCIPLES OF SURGICAL ASEPSIS 1.. Sterile items that are out of vision sterile or below the waist level of the nurse are considered unsterile 5.e.

gloves. Masks must be worn at all times in the OR for the purpose of minimizing air-borne contamination and must be changed between operations or more often. All OR personnel are required to wear specific. with the goal of “shedding” the outside environment. and specific shoe covers b. clean attire. OR personnel must wear a sterile gown. Any personnel who harbors pathogenic organisms must report themselves unable to be in the OR to protect the client from outside pathogens . if necessary 8. Hair must be completely cover c.PERIOPERATIVE NURSING: PRINCIPLES OF SURGICAL ASEPSIS 7.  Specific clothing requirements are prescribed and standardized for all ORs: a.

Scrubbed personnel wearing sterile attire should touch only sterile items 10.  Contact with unsterile objects at any point renders a sterile area contaminated. 11. Sterile supplies are unwrapped and delivered by the circulator following specific standard protocol so as not to cause contamination . Sterile gowns and sterile drapes have defined borders for sterility.  Sterile surfaces or articles may touch other sterile surfaces or articles and remain sterile.PERIOPERATIVE NURSING: PRINCIPLES OF SURGICAL ASEPSIS 9. The circulator and unsterile personnel must stay at the periphery of the of the sterile operating area to keep the sterile area free from contamination 12.

PERIOPERATIVE NURSING: PRINCIPLES OF SURGICAL ASEPSIS 13. in some cases. The utmost caution and vigilance must be used when handling sterile fluids to prevent splashing or spillage 14. Anything that is used for one client must be discarded or. resterilized .

PERIOPERATIVE NURSING: PREOPERATIVE PHASE  Begins at the time of decision for surgery and ends when the client is transferred to the OR  This period is used to physically and psychologically prepare the client for surgery  The nurse plays a major role in client teaching and in relieving the client’s and the family’s anxieties .

Planning for discharge and any projected changes in lifestyle due to surgery . Giving the person and significant others complete learning/ teaching guidelines regarding surgery c. Instructing and demonstrating exercises that will benefits the person during post-op period d.PERIOPERATIVE NURSING: PREOPERATIVE PHASE Goals: a. Assessing and correcting physiologic and psychologic problems that might increase surgical risk b.

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

clinging  Inability to concentrate  Short attention span  Failure to carry out simple directions  Dazed .PERIOPERATIVE NURSING: PREOPERATIVE PHASE Manifestations of Fears:  Anxiousness  Confusion  Anger  Tendency to exaggerate  Sad. tearful. evasive.

support systems. and patterns of coping Establish trusting relationship with client and significant others Explain routine procedures. encourage verbalization of fears. anxieties.PERIOPERATIVE NURSING: PREOPERATIVE PHASE Nursing Interventions to Minimize Anxiety:    Assess client’s fears. and allow client to ask questions   Demonstrate confidence in surgeon and staff Provide for spiritual care if appropriate .

surgical consent  This is to protect the surgeon and the hospital against claims that unauthorized surgery has been performed and that the patient was unaware of the potential risks of complications involved  Protects the client from undergoing unauthorized surgery . operative permit.PERIOPERATIVE NURSING: PREOPERATIVE PHASE Legal aspect: “Informed Consent”.

The Surgeon obtains operative permit or informed consent:  Surgical procedure.g. relative. (spouse or next of kin) or guardian will sign . Informed consent is necessary for each operation performed. or removal of body parts are explained Note: It is part of the nurse’s role as a client advocate to confirm that the client understands information given. alternatives. thoracentesis c. disfigurements. e. possible complications. Adult client (over 18 years of age) signs own permit unless unconscious or mentally incompetent  If unable to sign. b. however minor  It is also necessary for major diagnostic procedures where major body cavity is entered.PERIOPERATIVE NURSING: PREOPERATIVE PHASE a.

permission via the telephone is acceptable.PERIOPERATIVE NURSING: PREOPERATIVE PHASE  In an emergency. There is an immediate threat to life ii. A legally authorized person cannot be reached . have a second listener on phone when telephone permission being given Consents are not needed for emergency care if all four of the following criteria are met: i. Client is unable to consent iv. Experts agree that it is an emergency iii.

College student living away from home. Minors (under 18) must have consent signed by an adult (i. Any pregnant female or anybody who has given birth e. If nurse witnesses informed consent.e. ii. In military service. or authorized person f.PERIOPERATIVE NURSING: PREOPERATIVE PHASE d. iv. parent or legal guardian). other physician. iii. Witness to informed consent may be nurse. An emancipated minor may sign own consent: i. clerk. specify whether witnessing explanation of surgery or just signature of client . Married.

crossmatching. and other environmental products such as latex  All allergies are reported anesthesia and surgical personnel before the beginning of surgery  If allergy exist. CBC. dietary restrictions. Cardiovascular preparation: ECG. chemicals. Respiratory preparation: chest x-ray b. PT/PTT (prothrombin time. Renal preparation: urinalysis Obtain history of past medical conditions. and medications: A – Allergy to medications. blood typing.PERIOPERATIVE NURSING: PREOPERATIVE PHASE Physiologic Preparation Prior to Surgery: a. allergies. serum electrolytes c. partial thromboplastin time). an allergy band must be placed in the client’s arm immediately .

and warfarin sodium. previous embolic events ( such as lower leg blood clots) may recur because of prolonged immobility . a condition that not only requires strict control of blood glucose levels but also known to delay wound healing E – Emboli. heparin. such as aspirin.PERIOPERATIVE NURSING: PREOPERATIVE PHASE B – Bleeding tendencies or the use of medications that deter clotting.  Herbal medications may also increase bleeding time or mask potential blood-related problems C – Cortisone and steroid use D – Diabetes mellitus.

clarify and reinforce explanations given by surgeon Explain routine pre and post procedures and any special equipment to be used Deep breathing exercises: use of diaphragmatic and abdominal breathing .PERIOPERATIVE NURSING: PREOPERATIVE PHASE Instructional and Preventive Aspects:   Frequently done on an out-client basis Assess the client’s level of understanding of surgical procedure and its implications    Answer questions.

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

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PERIOPERATIVE NURSING: PREOPERATIVE PHASE
Physical Preparation On the Night of the Surgery: a. Preparing the client’s skin: shave against the grain of the hair shaft to ensure clean and close shave b. Preparing the GIT:  NPO after midnight  Administration of enema may be necessary  Insertion of gastric or intestinal tubes Preparing for Anesthesia  Promoting rest and sleep: use of drugs ∞ Barbiturates: Secobarbital Na, Pentobarbital Na ∞ Non barbiturates: chloral hydrate, Flurazepam Note: given after all pre-op treatments have been completed.

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

To reduce the amount of anesthesia to be given iv. Pre-Operative Medications: Generally administered 60-90 min before induction of anesthesia Purpose: i. To decrease the flow of pharyngeal secretions iii. To allay anxiety: the primary reason for pre-operative medications ii. Sedative:  Given to decrease client’s anxiety to lower BP and PR  Reduce the amount of general anesthesia: an overdose can result to respiratory depression ∞ e.PERIOPERATIVE NURSING: PREOPERATIVE PHASE b. Phenobarbital . To create amnesia for the events that precedes surgery Types of Pre-Operative Medications: 1.g.

5 . Morphine sulfate 8-15 mg SC 1 hour prior to preoperative.g. Tranquilizer:  Lowers the client’s anxiety level ∞ e. *Can cause vomiting. respiratory depression and postural hypotension . Narcotic analgesia:  Given to reduce patients to reduce anxiety and to reduce the amount of narcotics given during surgery ∞ e.25 mg IM 1-2 hours prior to surgery 3.PERIOPERATIVE NURSING: PREOPERATIVE PHASE 2.g. Thorazine 12.

3-0. Recording: all final preparation and emotional response before surgery should be noted down d.g. Atropine sulfate 0. *Woolen or synthetic blankets must never be sent to the OR because they are source of static electricity . * An overdose can result to severe tachycardia c. Transportation to the OR.6 mg IM 45 min before surgery.PERIOPERATIVE NURSING: PREOPERATIVE PHASE 4. Vagolytic or drying agents:  To reduce the amount of tracheobronchial secretions which can clog the pulmonary tree and result in atelectasis and pneumonia ∞ e.

post operative care and potential body image change . physical preparation for surgery.PERIOPERATIVE NURSING: PREOPERATIVE PHASE Nursing Diagnosis for Preoperative Client  Anxiety related to lack of knowledge about preoperative routines.

PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE  Begins the moment the patient is anesthetized and ends when the last stitch or dressing is in place  Anesthesia – A state or narcosis. relaxation and reflex loss (severe central nervous system [CNS] depression produced by pharmacologic agent) . analgesia.

shouting. roaring. & feeling of detachment may be experienced  Ringing. irregular RR  Patient restrain might be necessary . or buzzing in the ears  Inability to move extremities  Surrounding noise is exaggerated  Still conscious b. laughing or crying may be experienced  Pupils dilate but PERRLA.PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE Four Stages of Anesthesia: a. dizziness. Stage I: Onset [Beginning of Anesthesia]  Patient breath in the anesthetic mixture  Warmth. singing. Stage II: Excitement  Struggling. rapid PR.

without prompt intervention death may ensue . Stage IV: Danger Stage [Medullary Depression]  Reached when to much anesthesia has been administered  Respiration shallow. pupils dilate  Cyanosis develops. skin pink and flushed  Patient is unconscious d. PR normal. pulse weak.PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE c. Stage III: Surgical Anesthesia  Continued administration of anesthetic agent  RR.

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

cyclopropane . Inhalation Anesthesia Advantage: prevention of pain and anxiety Disadvantage: circulatory and respiratory depression * Highly inflammable and explosive Safety rules:  Do not wear slips. gas anesthetic: e.g. nitrous oxide. wool.g. volatile liquid: halothane. ether. nylons. amnesia. e. or any material which can set-off sparks  No smoking 12 hours after the operation  Do not wear shoes that are not conductive  Do not rise bed materials that are not conductive.PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE Types of Anesthesia: a. General Anesthesia: a state of analgesia. and unconsciousness characterized by the loss of reflexes and muscle tone i.

PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE ii. Ketamine ( Ketalar).g. Used commonly in minor procedure Advantage:  Rapid pleasant induction  Absence of explosive hazards  Low incidence of nausea and vomiting Disadvantage:  Laryngeal spasm and bronchospasm  Hypotension  Respiratory arrest. e. Intravenous Anesthesia: usually employed as an induction prior to administration of the more potent inhalation anesthetic agents. Fentanyl ( Innovar) . Thiopental Na (Pentothal Na).

Local anesthesia. Lidocaine (Xylocaine) . Procaine. e. Saddle block for vaginal delivery iv. lidocaine ii.g. e.g.PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE b. Infiltration anesthesia  Nerve block  Epidural block  Caudal block  Pudendal block iii. Topical anesthesia: e.g. Regional Anesthesia: it is the injection or application of a local anesthetic agent to produce a loss of painful sensation in only one region of the body and does not result to unconsciousness i. Spinal anesthesia.

PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE c. Hypothermia: it refers to the deliberate reduction of the patient’s body temperature between 28°-30° C  Uses: Heart surgery.g. Curarine chloride (Curare) ii. Specialized Methods of Producing Anesthesia: i. Surgery on large vessels supplying major organs . Pancuronium bromide (Pavulon). e. Muscle relaxants: it is a neuromuscular blocking agent used to provide muscle relaxation  Use: for endotracheal intubation. Brain surgery.

PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE Methods:  Ice water immersion  Ice bags  Cooling blanket Complications:  Cardiac arrest  Respiratory depression .

mastectomy  Prone: spine surgery. rectal surgery  Trendelenburg  Reverse Trendelenburg  Lithotomy position  Lateral position: kidney and chest surgery  Others: for thyroidectomy.head hyperextended . explore lap.PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE Positioning the Client: Commonly Used Operative Positions  Supine: hernia repair. cholecystectomy.

PERIOPERATIVE NURSING: POSTOPERATIVE PHASE Post Anesthetic Care Nursing Responsibilities: a. Maintenance of pulmonary ventilation:  Position the client to side lying or semi-prone position to prevent aspiration  Oropharyngeal or nasopharyngeal airway: * Is left in place following administration of general anesthetic until pharyngeal reflexes have returned •It is only removed as soon as the client begins to awaken and has regained the cough and swallowing reflexes All clients should received O2 at least until they are conscious and are able to take deep breaths on command  .

Hypotension Causes: ∞ Jarring the client during transport while moving client from the OR to his bed ∞ Reaction to drug and anesthesia ∞ Loss of blood and other body fluids ∞ Cardiac arrhythmias and cardiac failure ∞ Inadequate ventilation ∞ Pain . and should be administered until shivering has ceased b.PERIOPERATIVE NURSING: POSTOPERATIVE PHASE  Shivering of the client must be avoided to prevent an increase in O2. Maintenance of circulation:  Most common cardiovascular complications: i.

Procainamide c.PERIOPERATIVE NURSING: POSTOPERATIVE PHASE ii. Hypercapnea Interventions: O2 therapy. Drug administration: Lidocaine. Cardiac arrhythmias Causes: Hypoxemia. Protection from injury and promotion of comfort  Provide side rails  Turning frequently and placed in good body alignment to prevent nerve damage from pressure  Administration of narcotic analgesics to relieve incisional pain  Post-operative dose usually reduced to half the dose the patient will be taking after fully recovered from anesthesia .

Respiration – able to breath effortlessly and deeply. Color – pink (lips). Activity – able to move four extremities voluntarily on command b.PERIOPERATIVE NURSING: POSTOPERATIVE PHASE Dismissal of Client from Recovery Room: Modified Aldrete Score for Anesthesia Recovery Criteria The Five Physiological Parameters: a. Consciousness – fully awake. oriented to time. and cough freely c. Circulation – BP is (+ 20%) or (. place and person e.20%) of pre-anesthetic level d. for blacks: tongue .

20%-40% of pre-anesthetic level  BP +/.20% of pre-anesthetic level  BP +/.PERIOPERATIVE NURSING: POSTOPERATIVE PHASE Modified Aldrete Score AREA OF ASSESSMENT Muscle activity  Ability to move all extremities  Ability to move 2 extremities  Unable to control any extremity  Ability to breath deeply and cough  Limited respiratory effort (dyspnea)  No spontaneous effort  BP +/.50% pre-anesthetic level Point Score 1 hour 2 hours 3 hours Respiration Circulation Consciousness Level O2 Saturation  Fully awake  Arousable on calling  Not responding  Unable to maintain O2 sat >92% on room air  Needs O2 inhalation to maintain O2 sat >90%  O2 sat <90% even with O2 supplement 2 1 0 2 1 0 2 1 0 2 1 0 2 1 0 Total Points Required for discharge from PACU: 7-8 .

Respiratory Complications: atelectasis and pneumonia  Suspected when ever there is a sudden rise of temperature 24-48 hours after surgery  Collapse of the alveoli is highly susceptible to infection: pneumonia .PERIOPERATIVE NURSING: POSTOPERATIVE PHASE Postoperative Care  Begins when the client returns from the recovery room or surgical suite to the nursing unit and ends when the client is discharged  It is directed toward prevention of complication and postoperative discomfort Post-Operative Complications a.

Measures to prevent pooling of secretions:  Frequent changing of position  High fowler’s position  Moving out of bed ii. Measures to liquefy and remove secretions:  Increase oral fluid intake  Breathing moist air .PERIOPERATIVE NURSING: POSTOPERATIVE PHASE  Occurs usually in high abdominal surgery when prolonged inhalation anesthesia has been necessary and vomiting has occurred during the operation or while the patient is recovered from anesthesia NURSING MANAGEMENT: i.

Other measures to increase pulmonary ventilation  Blow bottle exercise  Rebreathing tubes: increase CO2 stimulates the respiratory center to increase the depth of breathing thus increasing the amount of inspired air  IPPB: intermittent positive pressure breathing apparatus .PERIOPERATIVE NURSING: POSTOPERATIVE PHASE   Deep breathing followed by coughing Administer analgesics before coughing is attempted after thoracic and abdominal surgery Splint operative area with draw sheet or towel to promote comfort while coughing  iii.

Circulatory Complication: venous stasis  Causes of venous stasis − Muscular inactivity − Respiratory and circulatory depression − Increased pressure on blood vessels due to tight dressing − Intestinal distention − Prolonged maintenance of sitting Contributing factors for venous stasis: • Obesity • CV disease • Debility • Malnutrition • Old age .PERIOPERATIVE NURSING: POSTOPERATIVE PHASE b.

PERIOPERATIVE NURSING: POSTOPERATIVE PHASE Most common circulatory complications:  Phlebothrombosis  Thrombophlebitis NURSING MANAGEMENT:  Limbs must never be massaged for a post-op client  If possible. . client should lie on his abdomen for 30 min several time a day to prevent pooling of blood in the pelvic cavity  Do not allow the client to stand unless pulse has returned close to baseline to prevent orthostatic hypotension  Wear elastic bandages or stockings when in bed and when walking for the first time.

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

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

or eating food or drinking water before peristalsis returns.PERIOPERATIVE NURSING: POSTOPERATIVE PHASE d. Complications of Surgery i. GIT complications: Paralytic ileus: Cessation of peristalsis due to excessive handling of GI organs NURSING MANAGEMENT: NPO until peristalsis has returned as evidenced by auscultation of bowel sounds or by passing out of flatus Vomiting: usually the effect of certain anesthetics on the stomach. Psychologic factors also contribute to vomiting NURSING MANAGEMENT:  Position the client on the side to prevent aspiration .

give ice chips. Prochiorperasine dimaleate (Compazine)  Abdominal distention: results from the accumulation of nonabsorbable gas in the intestine Causes:  Reaction to the handling of the bowel during surgery  Swallowing of air during recovery from anesthesia  Passage of gases from the blood stream to the atonic portion of the bowel . or eating small frequent amounts of dry foods thus relieving nausea Administer anti-emetic drugs as ordered: Trimethobenzamide Hcl (Tigan).PERIOPERATIVE NURSING: POSTOPERATIVE PHASE  When vomiting has subsided. sips of ginger ale or hot tea.

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

perspiration. hyperventilation. GUT Complications  Return of urinary function: usually after 6-8 hours − First voiding may not be more than 200 ml. and increased secretion of ADH . vomiting.PERIOPERATIVE NURSING: POSTOPERATIVE PHASE Constipation: due to decreased food intake and inactivity  Regular bowel movement will return 3-4 days after surgery when resumption of regular diet and adequate fluid intake and ambulation ii. and total out put may not be more than 1500ml − Due to the loss of fluids during surgery.

done by sterile technique .PERIOPERATIVE NURSING: POSTOPERATIVE PHASE Complication: urinary retention Causes:  Prolonged recumbent position  Nervous tension  Effect of anesthetics interfering with bladder sensation and the ability to void  Use of narcotics that reduce the sensation of bladder distention  Pain at the surgical site and on movement  Urinary tract infection Management: − Instruct the client to empty the bladder completely during voiding − Catheterize if needed.

irritation of the diaphragm. Post-operative Discomforts i.PERIOPERATIVE NURSING: POSTOPERATIVE PHASE f. peritonitis and uremia causing a reflex or stimulation of the phrenic nerve Management: − Paper bag blowing. Singultus  Brought about by the distention of the stomach. CO2 inhalation: 5% CO2 and 95% O2 x 5 minutes every hour . Post-operative pain  Narcotics can be given every 3-4 hours during the first 48 hours post-operatively for severe pain without danger of addiction ii.

Hemorrhage from the wound  Most likely to occur within the first 48 hours post-op or as late as 6th-7th post-op day Causes:  Hemorrhage occurring soon after operation: mechanical dislodging of a blood clot or caused by the reestablished blood flow through the vessel  Hemorrhage after few days: Sloughing off of blood clot or of a tissue  Infection . Wound Complications:  Sutures are usually removed about 5th-7th day post-op with the exception of wire retention sutures placed deep in the muscles and removed 14-21 days after surgery i.PERIOPERATIVE NURSING: POSTOPERATIVE PHASE g.

low grade fever. and the wound becomes painful and swollen. There maybe purulent drainage on the dressing . moist skin ii.PERIOPERATIVE NURSING: POSTOPERATIVE PHASE Assessment:  Bright red blood  Decreased BP  Increased PR and RR  Restlessness  Pallor  Weakness  Cold. Infection  Cause: streptococcus and staphylococcus  Assessment: 3-6 days after surgery.

and remain quiet until the surgeon arrives  Protruding viscera should be covered warm. pink drainage Management:  Position the client to low Fowler’s position  Instruct the client not to cough. sterile.PERIOPERATIVE NURSING: POSTOPERATIVE PHASE iii. Dehiscence and Evisceration Dehiscence or wound disruption: Refers to a partial-tocomplete separation of the wound edges Evisceration: Refers to protrusion of the abdominal viscera through the incision and onto the abdominal wall Assessment:  Complain of a “giving” sensation in the incision  Sudden. sneeze. eat or drink. profuse leakage of fluid from the incision  The dressing is saturated with clear. saline dressing .

make sure a responsible adult takes the client home . which has become common. dietary management. symptoms to report. medication administration. typically increases client teaching needs  Be sure to provide information about wound care.PERIOPERATIVE NURSING: POSTOPERATIVE PHASE Discharge Instructions:  Early discharge. and follow-up care  A client recovering from same-day surgery in an outpatient surgical unit must be in stable condition before discharge  This client must not drive home. activity restrictions.

PERIOPERATIVE NURSING: References  Textbook of Medical Surgical Nursing 7th Edition by Joyce Black  Brunner and Suddarth’s Textbook of Medical Surgical Nursing 11th Edition by Suzanne Smeltzer  Berry & Kohn’s Operating Room Technique 10th edition by Nancymarie Philips  The Lippincott Manual of Nursing Practice 7th Edition by Sandra Nettina  Mastering Medical-Surgical Nursing 2nd edition by Josie Udan  NCLEX-RN Review Materials .

Daghang Salamat! Nagpaka-hero tungod ug alang kaninyo… Hahaayyy…pastilan… .

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