8/2/2019 Perioperative nsg
1/74
PERIOPERATIVENURSING
REY VINCENT H. LABADAN, RNEARL KRISTOFFER L. PIRANTE, RN
8/2/2019 Perioperative nsg
2/74
Patient
PERIOPERATIVE
PATIENT-
FOCUSED
MODEL
8/2/2019 Perioperative nsg
3/74
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
PERIOPERATIVE NURSING: GENERAL CONSIDERATION
8/2/2019 Perioperative nsg
4/74
c. Types of Curative Surgery:
i. Ablative: removal of diseased organs. (-ectomy) e.g.
appendectomy, hysterectomy
ii. Reconstructive: partial or complete restoration of a
damaged organ, e.g. plastic surgery after burns
iii. Constructive: repair of a congenitally defective organ,
(-plasty, -orrhaphy, -pexy) e.g. cheiloplasty, orchidopexy
d. Palliative: to relieve pain, relieve distressing S/Sx
According to Degree of Risk to Client:a. Major surgery
b. Minor surgery
PERIOPERATIVE NURSING: GENERAL CONSIDERATION
8/2/2019 Perioperative nsg
5/74
Criteria:
a. Major surgery: High degree of risk
Prolonged intraoperative period
Large amount of blood loss
Extensive, vital organs may be handled or removed
Great risk of complications, e. g. liver biopsy
b. Minor surgery: Lesser degree of risk to the client
Generally not prolonged; described as one-day
surgery or outpatient surgery
Leads to few serious complications Involves less risk, e.g. cyst removal
PERIOPERATIVE NURSING: GENERAL CONSIDERATION
8/2/2019 Perioperative nsg
6/74
According to Urgency:
a. Emergency: must be performed immediately without delay,
e.g. gunshot wound, severe bleeding,
b. Imperative or Urgent: must be performed as soon as possible
within 24 48 hours, e.g. appendectomy
c. Required: necessary for the well-being of the client, usually
within weeks to months, e. g. cholecystectomy, cataractextraction, thyriodectomy
d. Elective: should be performed for the clients well being but
which is not absolutely necessary, e.g. simple hernia, vaginal
repair, repair of scare. Optional: surgery that a client requests, e.g. rhinoplasty,
liposuction, mammoplasty
PERIOPERATIVE NURSING: GENERAL CONSIDERATION
8/2/2019 Perioperative nsg
7/74
Factors that Affect the Estimation of Surgical Risk
a. 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
8/2/2019 Perioperative nsg
8/74
b. Types of drugs taken regularly:
i. Steroids: may improve the bodys ability to response to
the stress of anesthesia and surgery
ii. Anticoagulants and salicylates: may increase bleeding
during surgery
iii. Antibiotics: maybe incompatible with or potentiate
anesthetic agentsiv. Tranquilizers: potentiate the effect of narcotics and can
cause hypotension
v. Antihypertensives: may predispose to shock by the
combined effect of blood pressure reduction andanesthetic vasodilation
vi. Diuretics: may increase potassium loss
vii. Alcohol: will place the surgical client at risk when used
chronically
PERIOPERATIVE NURSING: GENERAL CONSIDERATION
8/2/2019 Perioperative nsg
9/74
c. The Extent of the Disease
d. The Magnitude of the Required Operation
e. Resources and Preparation of the Surgeon, Nurses, and the
Hospital
PERIOPERATIVE NURSING: GENERAL CONSIDERATION
8/2/2019 Perioperative nsg
10/74
PERIOPERATIVE NURSING: GENERAL CONSIDERATION
Suffixes Related to Surgery:
-ostomy (make artificial opening) Colostomy
-otomy (cut into or incision) Phlebotomy
-plasty (plastic repair) Rinoplasty
-orrhaphy (suturing; repair) Herniorrhaphy
-oscopy (visual examination) Endoscopy-ectomy (excision; removal) Cholecystectomy
8/2/2019 Perioperative nsg
11/74
Because clients experience varying degrees of anxiety and
deficient knowledge related to surgery, careful planning by the
nurse can help ensure a positive outcome.
Encompasses a clients total surgical experience, including
preoperative, intra-operative, and postoperative phases
Refers to activities performed by the professional nurse during
these phases.
PERIOPERATIVE NURSING: PHASES OF PERIOPERATIVE NURSING
8/2/2019 Perioperative nsg
12/74
PERIOPERATIVE NURSING: PHASES OF PERIOPERATIVE NURSING
a. Pre-Operative Phase: begins with the decision to perform
surgery and ends with the clients transfer to the operating room
table
b. Intra-Operative Phase: begins with the client is received in the
OR and ends with his admission to the PARR or PACU
c. Post-Operative Phase: begins with the client is admitted to PARR
or PACU and extends through follow-up home or clinic
evaluation
8/2/2019 Perioperative nsg
13/74
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 clients status
The Professional Registered OR Nurse
Makes preoperative assessment and documents the perioperative
client care plan (Scrub, Circulating, PACU Nurse)
8/2/2019 Perioperative nsg
14/74
PERIOPERATIVE NURSING: THE PERIOPERATIVE TEAM
a. The Circulating Nurse
Manages the OR and protects the safety and health needs of the
client by monitoring the activities of the members of the
surgical team and monitoring the conditions in the OR
b. The Scrub Nurse
Responsible for scrubbing for surgery, including setting up steriletables and equipment and assisting the surgeon and surgical
technicians during the surgical procedure
c. The PACU NurseResponsible for caring for the client until the client has recovered
from the effects of anesthesia, is oriented, has stable vital signs,
and shows no evidence of hemorrhage
8/2/2019 Perioperative nsg
15/74
General:
a. Keep sterile supplies dry and unopened
b. Check package sterilization expiration date to verify sterility
c. Maintain general cleanliness in surgical suite
d. Maintain surgical asepsis: activities designed to keep sites
free from the presence of microorganisms throughout the
procedure
Personnel:
a. Personnel with signs of illness should not report to work
b. Surgical scrub, a specific hand washing technique used byoperating room personnel designed to reduce
microorganisms in the hands and arms, is done for the length
of time designed by hospital policy
PERIOPERATIVE NURSING: PRINCIPLES OF PERIOPERATIVE ASEPSIS
8/2/2019 Perioperative nsg
16/74
Surgical Scrub
i. A sensor-controlled or knee- or foot-operated faucet allows the
water to be turned on and off without the use of the handsii. Remove all rings and watches
iii. Use liquid soaps to prevent the spread of organisms
iv. Keep the finger nails short and well-trimmed
v. Clean fingernails with a nail stick under running water
vi. Hold the hands higher than the elbows throughout the handwashing procedure so that run-off goes to the elbows
vii. Allows the cleanest part of the arms to be the hands
viii. A scrub brush facilitates the removal of microorganisms
ix. Clean all areas of skin on the hands and arms in sequence starting
at the hands and ending at the elbowsx. After rinsing, dry the hands with paper towels, drying first one
arm from the hand to the elbow, then using a second towel to dry
the second hand
PERIOPERATIVE NURSING: PRINCIPLES OF PERIOPERATIVE ASEPSIS
8/2/2019 Perioperative nsg
17/74
PERIOPERATIVE NURSING: PRINCIPLES OF PERIOPERATIVE ASEPSIS
Maintaining a Sterile Field (a microorganism-free area):
a. Create a sterile field using sterile drapes
b. Use the sterile field to place sterile supplies where they will
be available during the procedure
c. Drape equipment prior to use
d. Keep drapes dry and out of contact with nonsterile objects
e. Utilize sterile technique while adding or removing suppliesfrom sterile fields
Sterile Supplies and Solutions:
a. Check expiration dates for sterilityb. Dont use solutions that were opened prior to current use
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
8/2/2019 Perioperative nsg
18/74
1. OR personnel must practice strict Standard Precautions (i.e.,
blood and body substance isolation)
2. All items used in the sterile field must be sterile
3. Sterile objects become unsterile when touched by unsterile
objects
4. Sterile items that are out of vision sterile or below the waist level
of the nurse are considered unsterile5. 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
PERIOPERATIVE NURSING: PRINCIPLES OF SURGICAL ASEPSIS
8/2/2019 Perioperative nsg
19/74
7. All OR personnel are required to wear specific, clean attire, with
the goal of shedding the outside environment.
Specific clothing requirements are prescribed and
standardized for all ORs:
a. OR personnel must wear a sterile gown, gloves, and
specific shoe covers
b. Hair must be completely coverc. 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,
if necessary8. Any personnel who harbors pathogenic organisms must report
themselves unable to be in the OR to protect the client from
outside pathogens
PERIOPERATIVE NURSING: PRINCIPLES OF SURGICAL ASEPSIS
8/2/2019 Perioperative nsg
20/74
9. Scrubbed personnel wearing sterile attire should touch only
sterile items
10. Sterile gowns and sterile drapes have defined borders for
sterility.
Sterile surfaces or articles may touch other sterile surfaces or
articles and remain sterile.
Contact with unsterile objects at any point renders a sterilearea contaminated.
11. The circulator and unsterile personnel must stay at the periphery
of the of the sterile operating area to keep the sterile area free
from contamination12. Sterile supplies are unwrapped and delivered by the circulator
following specific standard protocol so as not to cause
contamination
PERIOPERATIVE NURSING: PRINCIPLES OF SURGICAL ASEPSIS
8/2/2019 Perioperative nsg
21/74
PERIOPERATIVE NURSING: PRINCIPLES OF SURGICAL ASEPSIS
13. 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, in
some cases, resterilized
8/2/2019 Perioperative nsg
22/74
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 clients and the familys anxieties
PERIOPERATIVE NURSING: PREOPERATIVE PHASE
8/2/2019 Perioperative nsg
23/74
Goals:
a. Assessing and correcting physiologic and psychologic
problems that might increase surgical risk
b. 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. Planning for discharge and any projected changes in lifestyledue to surgery
PERIOPERATIVE NURSING: PREOPERATIVE PHASE
8/2/2019 Perioperative nsg
24/74
Psychologic Preparation for Surgery
Preparation for hospital admission: includes explanation of the
procedure to be done, probable outcome, expected duration of
hospitalization, cost, length of absence from work, and residual
effects
Causes of Fears:
Fear of the unknown
Fear of anesthesia, vulnerability while unconscious
Fear of pain
Fear of death
Fear of disturbance of body image
Worries: loss of finances, employment, social and family
roles
PERIOPERATIVE NURSING: PREOPERATIVE PHASE
8/2/2019 Perioperative nsg
25/74
Manifestations of Fears:
Anxiousness
Confusion
Anger
Tendency to exaggerate
Sad, evasive, tearful, clinging
Inability to concentrate Short attention span
Failure to carry out simple directions
Dazed
PERIOPERATIVE NURSING: PREOPERATIVE PHASE
8/2/2019 Perioperative nsg
26/74
Nursing Interventions to Minimize Anxiety:
Assess clients fears, anxieties, support systems, and
patterns of coping
Establish trusting relationship with client and significant
others
Explain routine procedures, encourage verbalization of
fears, and allow client to ask questions
Demonstrate confidence in surgeon and staff
Provide for spiritual care if appropriate
PERIOPERATIVE NURSING: PREOPERATIVE PHASE
8/2/2019 Perioperative nsg
27/74
Legal aspect: Informed Consent, operative permit, 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
PERIOPERATIVE NURSING: PREOPERATIVE PHASE
8/2/2019 Perioperative nsg
28/74
a. The Surgeon obtains operative permit or informed consent:
Surgical procedure, alternatives, possible complications,
disfigurements, or removal of body parts are explained
Note: It is part of the nurses role as a client advocate to
confirm that the client understands information given.
b. Informed consent is necessary for each operation performed,however minor
It is also necessary for major diagnostic procedures
where major body cavity is entered, e.g. thoracentesis
c. Adult client (over 18 years of age) signs own permit unless
unconscious or mentally incompetent
If unable to sign, relative, (spouse or next of kin) or
guardian will sign
PERIOPERATIVE NURSING: PREOPERATIVE PHASE
8/2/2019 Perioperative nsg
29/74
In an emergency, permission via the telephone is
acceptable; 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. There is an immediate threat to lifeii. Experts agree that it is an emergency
iii. Client is unable to consent
iv. A legally authorized person cannot be reached
PERIOPERATIVE NURSING: PREOPERATIVE PHASE
8/2/2019 Perioperative nsg
30/74
d. Minors (under 18) must have consent signed by an adult (i.e.
parent or legal guardian). An emancipated minormay sign own
consent:
i. Married,
ii. College student living away from home,
iii. In military service,
iv. Any pregnant female or anybody who has given birth
e. Witness to informed consent may be nurse, other physician,
clerk, or authorized person
f. If nurse witnesses informed consent, specify whether witnessing
explanation of surgery or just signature of client
PERIOPERATIVE NURSING: PREOPERATIVE PHASE
8/2/2019 Perioperative nsg
31/74
Physiologic Preparation Prior to Surgery:
a. Respiratory preparation: chest x-ray
b. Cardiovascular preparation: ECG, CBC, blood typing, cross-
matching, PT/PTT (prothrombin time, partial thromboplastin
time), serum electrolytes
c. Renal preparation: urinalysis
Obtain history of past medical conditions, allergies, dietary
restrictions, and medications:
A Allergy to medications, chemicals, and other environmental
products such as latex All allergies are reported anesthesia and surgical
personnel before the beginning of surgery
If allergy exist, an allergy band must be placed in the
clients arm immediately
PERIOPERATIVE NURSING: PREOPERATIVE PHASE
8/2/2019 Perioperative nsg
32/74
B Bleeding tendencies or the use of medications that deter
clotting, such as aspirin, heparin, and warfarin sodium.
Herbal medications may also increase bleeding time or
mask potential blood-related problems
C Cortisone and steroid use
D Diabetes mellitus, a condition that not only requires strict
control of blood glucose levels but also known to delay
wound healing
E Emboli; previous embolic events ( such as lower leg blood
clots) may recur because of prolonged immobility
PERIOPERATIVE NURSING: PREOPERATIVE PHASE
8/2/2019 Perioperative nsg
33/74
Instructional and Preventive Aspects:
Frequently done on an out-client basis
Assess the clients level of understanding of surgical
procedure and its implications
Answer questions, clarify and reinforce explanations given by
surgeon
Explain routine pre and post procedures and any specialequipment to be used
Deep breathing exercises: use of diaphragmatic and
abdominal breathing
PERIOPERATIVE NURSING: PREOPERATIVE PHASE
8/2/2019 Perioperative nsg
34/74
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 postoperative gas pains or flatus
Assure that pain medications will be available post-op
PERIOPERATIVE NURSING: PREOPERATIVE PHASE
8/2/2019 Perioperative nsg
35/74
Physical Preparation
On the Night of the Surgery:
a. Preparing the clients 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
8/2/2019 Perioperative nsg
36/74
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
PERIOPERATIVE NURSING: PREOPERATIVE PHASE
8/2/2019 Perioperative nsg
37/74
b. Pre-Operative Medications:
Generally administered 60-90 min before induction of anesthesia
Purpose:
i. To allay anxiety: the primary reason for pre-operative
medications
ii. To decrease the flow of pharyngeal secretions
iii. To reduce the amount of anesthesia to be giveniv. To create amnesia for the events that precedes surgery
Types of Pre-Operative Medications:
1. Sedative:
Given to decrease clients anxiety to lower BP and PR
Reduce the amount of general anesthesia: an
overdose can result to respiratory depression
e.g. Phenobarbital
PERIOPERATIVE NURSING: PREOPERATIVE PHASE
8/2/2019 Perioperative nsg
38/74
2. Tranquilizer:
Lowers the clients anxiety level
e.g. Thorazine 12.5 - 25 mg IM 1-2 hours prior to
surgery
3. Narcotic analgesia:
Given to reduce patients to reduce anxiety and toreduce the amount of narcotics given during surgery
e.g. Morphine sulfate 8-15 mg SC 1 hour prior to
preoperative; *Can cause vomiting, respiratory
depression and postural hypotension
PERIOPERATIVE NURSING: PREOPERATIVE PHASE
8/2/2019 Perioperative nsg
39/74
4. Vagolytic or drying agents:
To reduce the amount of tracheobronchial secretions
which can clog the pulmonary tree and result in
atelectasis and pneumonia
e.g. Atropine sulfate 0.3-0.6 mg IM 45 min before
surgery; * An overdose can result to severe
tachycardia
c. Recording: all final preparation and emotional response before
surgery should be noted down
d. Transportation to the OR, *Woolen or synthetic blankets must
never be sent to the OR because they are source of static
electricity
PERIOPERATIVE NURSING: PREOPERATIVE PHASE
8/2/2019 Perioperative nsg
40/74
PERIOPERATIVE NURSING: PREOPERATIVE PHASE
Nursing Diagnosis for Preoperative Client
Anxiety related to lack of knowledge about preoperative
routines, physical preparation for surgery, post operative care
and potential body image change
8/2/2019 Perioperative nsg
41/74
Begins the moment the patient is anesthetized and ends when
the last stitch or dressing is in place
Anesthesia A state or narcosis, analgesia, relaxation and reflex
loss (severe central nervous system [CNS] depression produced
by pharmacologic agent)
PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE
8/2/2019 Perioperative nsg
42/74
Four Stages of Anesthesia:
a. Stage I: Onset [Beginning of Anesthesia]
Patient breath in the anesthetic mixture
Warmth, dizziness, & feeling of detachment may be
experienced
Ringing, roaring, or buzzing in the ears
Inability to move extremities Surrounding noise is exaggerated
Still conscious
b. Stage II: Excitement
Struggling, shouting, singing, laughing or crying may be
experienced
Pupils dilate but PERRLA, rapid PR, irregular RR
Patient restrain might be necessary
PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE
8/2/2019 Perioperative nsg
43/74
c. Stage III: Surgical Anesthesia
Continued administration of anesthetic agent
RR, PR normal, skin pink and flushed
Patient is unconscious
d. Stage IV: Danger Stage [Medullary Depression]
Reached when to much anesthesia has been administered Respiration shallow, pulse weak, pupils dilate
Cyanosis develops, without prompt intervention death may
ensue
PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE
8/2/2019 Perioperative nsg
44/74
Stages of Anesthesia, summary:
Stage Start-point End-point Physical Reactions Nursing InterventionsOnset Anesthetic
administration Loss ofconsciousness Client maybe drowsy,or dizzy Possible auditory and
visual hallucinations
Close operating room doors, keep
room quiet
Stand by to assist the client
Excitement Loss of consciousness Loss of eyelidreflexes Increase in autonomicactivity
Irregular breathing Client may struggle
Remain quietly at clients side
Assist anesthetist, as needed
Surgical
Anesthesia Loss of eyelid reflexes Loss of mostreflexes Depression of vital
functions
Client is unconscious
Muscles are relaxed
No blink or gag reflexes Begin preparation (if indicated) only
when anesthesia indicates stage III
has been reached and client is
breathing well, with stable vital signsDanger
(Death) Functionsexcessively depressed
Respiratory and
circulatory failure Client is not breathing A heartbeat may or maynot be present
If arrest occurs, respond immediately
to assist in establishing airway,
provide cardiac arrest tray, drugs
syringes, long needles
Assist surgeon with closed or open
cardiac massage
PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE
8/2/2019 Perioperative nsg
45/74
Types of Anesthesia:
a. General Anesthesia: a state of analgesia, amnesia, and
unconsciousness characterized by the loss of reflexes and muscle
tone
i. Inhalation Anesthesia
Advantage: prevention of pain and anxiety
Disadvantage: circulatory and respiratory depression* Highly inflammable and explosive
Safety rules:
Do not wear slips, nylons, wool, 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, e.g. volatile
liquid: halothane, ether; gas anesthetic: e.g. nitrous oxide,
cyclopropane
PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE
8/2/2019 Perioperative nsg
46/74
ii. Intravenous Anesthesia: usually employed as an
induction prior to administration of the more potent
inhalation anesthetic agents. 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.g. Thiopental Na (Pentothal
Na), Ketamine ( Ketalar), Fentanyl ( Innovar)
PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE
PERIOPERATIVE NURSING INTRAOPERATIVE PHASE
8/2/2019 Perioperative nsg
47/74
PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE
b. Regional Anesthesia: it is the injection or application of a local
anesthetic agent to produce a loss of painful sensation in only
one region of the body and does not result to unconsciousness
i. Topical anesthesia: e.g. lidocaine
ii. Infiltration anesthesia Nerve block
Epidural block
Caudal block
Pudendal block
iii. Spinal anesthesia, e.g. Saddle block for vaginal delivery
iv. Local anesthesia, e.g. Procaine, Lidocaine (Xylocaine)
PERIOPERATIVE NURSING INTRAOPERATIVE PHASE
8/2/2019 Perioperative nsg
48/74
PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE
c. Specialized Methods of Producing Anesthesia:
i. Muscle relaxants: it is a neuromuscular blocking agent
used to provide muscle relaxation
Use: for endotracheal intubation, e.g.
Pancuronium bromide (Pavulon), Curarine
chloride (Curare)
ii. Hypothermia: it refers to the deliberate reduction of the
patients body temperature between 28-30 C
Uses: Heart surgery, Brain surgery, Surgery on
large vessels supplying major organs
PERIOPERATIVE NURSING INTRAOPERATIVE PHASE
8/2/2019 Perioperative nsg
49/74
Methods:
Ice water immersion
Ice bags
Cooling blanket
Complications:
Cardiac arrest
Respiratory depression
PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE
PERIOPERATIVE NURSING INTRAOPERATIVE PHASE
8/2/2019 Perioperative nsg
50/74
PERIOPERATIVE NURSING: INTRAOPERATIVE PHASE
Positioning the Client:
Commonly Used Operative Positions
Supine: hernia repair, explore lap, cholecystectomy,
mastectomy
Prone: spine surgery, rectal surgery
Trendelenburg
Reverse Trendelenburg Lithotomy position
Lateral position: kidney and chest surgery
Others: for thyroidectomy- head hyperextended
PERIOPERATIVE NURSING POSTOPERATIVE PHASE
8/2/2019 Perioperative nsg
51/74
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
PERIOPERATIVE NURSING POSTOPERATIVE PHASE
8/2/2019 Perioperative nsg
52/74
Shivering of the client must be avoided to prevent an
increase in O2, and should be administered until shivering
has ceased
b. Maintenance of circulation:
Most common cardiovascular complications:
i. HypotensionCauses:
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
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
PERIOPERATIVE NURSING POSTOPERATIVE PHASE
8/2/2019 Perioperative nsg
53/74
ii. Cardiac arrhythmias
Causes: Hypoxemia, Hypercapnea
Interventions: O2 therapy, Drug administration:Lidocaine, Procainamide
c. 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
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
8/2/2019 Perioperative nsg
54/74
Dismissal of Client from Recovery Room: Modified Aldrete Score
for Anesthesia Recovery Criteria
The Five Physiological Parameters:
a. Activity able to move four extremities voluntarily on
command
b. Respiration able to breath effortlessly and deeply, andcough freely
c. Circulation BP is (+ 20%) or (- 20%) of pre-anesthetic level
d. Consciousness fully awake, oriented to time, place and
person
e. Color pink (lips), for blacks: tongue
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
8/2/2019 Perioperative nsg
55/74
Modified Aldrete Score
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
AREA OF ASSESSMENT Point Score 1 hour 2 hours 3 hours
Muscle activity Ability to move all extremities Ability to move 2 extremities
Unable to control any extremity
21
0
Respiration Ability to breath deeply and cough
Limited respiratory effort (dyspnea)
No spontaneous effort
2
1
0
Circulation BP +/- 20% of pre-anesthetic level BP +/- 20%-40% of pre-anesthetic level
BP +/- 50% pre-anesthetic level
21
0
Consciousness
Level
Fully awake
Arousable on calling
Not responding
2
1
0
O2 Saturation
Unable to maintain O2 sat >92% on room air Needs O2 inhalation to maintain O2 sat >90%
O2 sat
8/2/2019 Perioperative nsg
56/74
Postoperative Care
Begins when the client returns from the recovery room orsurgical suite to the nursing unit and ends when the client is
discharged
It is directed toward prevention of complication and post-operative discomfort
Post-Operative Complications
a. 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
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
8/2/2019 Perioperative nsg
57/74
Occurs usually in high abdominal surgery when prolonged
inhalation anesthesia has been necessary and vomiting has
occurred during the operation or while the patient isrecovered from anesthesia
NURSING MANAGEMENT:
i. Measures to prevent pooling of secretions: Frequent changing of position
High fowlers position
Moving out of bed
ii. Measures to liquefy and remove secretions:
Increase oral fluid intake
Breathing moist air
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
8/2/2019 Perioperative nsg
58/74
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. 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
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
8/2/2019 Perioperative nsg
59/74
b. 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
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
8/2/2019 Perioperative nsg
60/74
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 30min 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.
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
8/2/2019 Perioperative nsg
61/74
c. Fluids and Electrolytes Imbalance:
Causes:
Blood loss Increased insensible fluid loss through the skin;
After surgery through vomiting, from copious
wound drainage, and from the tube drainage as in
NGT Since surgery is a stressor, there is an increased
production of ADH for the first 12-24 hours following
surgery resulting to fluid retention by the kidney
The potential for over hydration therefore exists
since fluids being given IV may exceed fluid
output by the kidney
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
8/2/2019 Perioperative nsg
62/74
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, resulting in sodium reabsorption by
the kidney And as Na is reabsorbed, K coming from tissue
breakdown is excreted
Action: IV of D5W alternate with D5NSS or half
strength NSS to prevent Na excess
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
8/2/2019 Perioperative nsg
63/74
d. Complications of Surgery
i. GIT complications:
Paralytic ileus: Cessation of peristalsis due to excessivehandling 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, or eating food or drinking water before peristalsis
returns. Psychologic factors also contribute to vomiting
NURSING MANAGEMENT:
Position the client on the side to prevent aspiration
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
8/2/2019 Perioperative nsg
64/74
When vomiting has subsided, give ice chips, sips of ginger
ale or hot tea, or eating small frequent amounts of dry
foods thus relieving nausea Administer anti-emetic drugs as ordered:
Trimethobenzamide Hcl (Tigan); Prochiorperasine
dimaleate (Compazine)
Abdominal distention: results from the accumulation of non-
absorbable gas in the intestine
Causes:
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
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
8/2/2019 Perioperative nsg
65/74
Gas pains: results from contraction of the unaffected portion
of the bowel in order to move accumulated gas in the
intestinal tractManagement:
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,
and pressure necrosis of the mucous surface
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
8/2/2019 Perioperative nsg
66/74
Constipation: due to decreased food intake and inactivity
Regular bowel movement will return 3-4 days after
surgery when resumption of regular diet and adequatefluid intake and ambulation
ii. GUT Complications
Return of urinary function: usually after 6-8 hours First voiding may not be more than 200 ml, and total
out put may not be more than 1500ml
Due to the loss of fluids during surgery, perspiration,
hyperventilation, vomiting, and increased secretion
of ADH
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
8/2/2019 Perioperative nsg
67/74
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 ofbladder 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, done by sterile technique
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
8/2/2019 Perioperative nsg
68/74
f. Post-operative Discomforts
i. Post-operative pain
Narcotics can be given every 3-4 hours during the first 48hours post-operatively for severe pain without danger of
addiction
ii. Singultus Brought about by the distention of the stomach,
irritation of the diaphragm, peritonitis and uremia
causing a reflex or stimulation of the phrenic nerve
Management:
Paper bag blowing; CO2 inhalation: 5% CO2 and 95%
O2 x 5 minutes every hour
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
8/2/2019 Perioperative nsg
69/74
g. Wound Complications:
Sutures are usually removed about 5th-7th day post-op with
the exception of wire retention sutures placed deep in themuscles and removed 14-21 days after surgery
i. Hemorrhage from the wound
Most likely to occur within the first 48 hours post-op or aslate 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
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
8/2/2019 Perioperative nsg
70/74
Assessment: Bright red blood
Decreased BP
Increased PR and RR
Restlessness
Pallor
Weakness Cold, moist skin
ii. Infection
Cause: streptococcus and staphylococcus
Assessment: 3-6 days after surgery, low grade fever, and
the wound becomes painful and swollen. There maybe
purulent drainage on the dressing
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
8/2/2019 Perioperative nsg
71/74
iii. Dehiscence and Evisceration
Dehiscenceor wound disruption: Refers to a partial-to-
complete separation of the wound edgesEvisceration: 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, profuse leakage of fluid from the incision
The dressing is saturated with clear, pink drainage
Management:
Position the client to low Fowlers position
Instruct the client not to cough, sneeze, eat or drink,
and remain quiet until the surgeon arrives
Protruding viscera should be covered warm, sterile,
saline dressing
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
8/2/2019 Perioperative nsg
72/74
Discharge Instructions:
Early discharge, which has become common, typicallyincreases client teaching needs
Be sure to provide information about wound care, activity
restrictions, dietary management, medicationadministration, symptoms to report, 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, make sure a responsible
adult takes the client home
PERIOPERATIVE NURSING: POSTOPERATIVE PHASE
PERIOPERATIVE NURSING: References
8/2/2019 Perioperative nsg
73/74
O U S G e e e ces
Textbook of Medical Surgical Nursing 7th Edition by Joyce Black
Brunner and Suddarths Textbook of Medical Surgical Nursing 11th
Edition by Suzanne Smeltzer
Berry & Kohns 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
h l !
8/2/2019 Perioperative nsg
74/74
Daghang Salamat!Nagpaka-hero tungod ug alang kaninyo Hahaayyypastilan