PERIOPERATIVE NURSING

Darren N.Constantino
Lecturer
Operating Room
Perioperative Nursing- preparing clients
and their families or significant others
physically, psychologically, emotionally,
and spiritually, for the entire course of
surgical experience.
PHASES OF PERIOPERATIVE NURSING
1. Pre-operative phase- begins when the
decision for surgical intervention is
made and ends with the transfer of the
patient to the operating room, bed/table
2. Intraoperative phase- begins when the
client is transfer to the OR table and ends
with the admission of the patient to the
post Anesthesia Care Unit (PACU).

3. Post-operative phase- begins with the

admission to PACU and ends with
resolution of the surgical sequelae.
Reasons for Surgical Intervention
1. To preserve life
2. To maintain dynamic bodily
equilibrium
3. To undergo diagnostic procedure
4. To prevent infection and promote
healing
5. To obtain comfort
6. To ensure the ability to earn a living
7. To restore or reconstruct a part of the
body that is congenitally malformed or
damaged by trauma or disease
8. To alter cosmetic appearance
Terms used:
Prefixes:
1. Supra- above/beyond
2. Athro- joint
3. Chole- bile/gall
4. Gastric-stomach
5. Encephalo- brain
6. Entero- intestinte
7. Myo-muscle
8. Nephro- kidneys
9. Neuro - nerve
10. Oophor -ovary
11. Salphingo - fallopian tube
12. Thoraco -chest
Suffixes:
1. itis- inflammation
2. ectomy- removal of an organ or gland;
i.e. nephrectomy
3. otomy- to make a cut into; i.e.
vagotomy
4. ostomy- to make a mouth or opening
into; i.e. ileostomy
Suffixes:
5. scopy- looking into; i.e. esophagoscopy
6. pexy- to sew up in position; i.e.
gastropexy
7. rrhaphy- to repair the defect; i.e.
herniorrhaphy
8. plasty- to improve by changing the
position of the tissue; i.e arthroplasty
 Asepsis- the absence of microorganisms
that cause disease

 Aseptic technique- the method by which

contamination with microorganisms is
prevented.

 Sterile- free of microorganism including

spores
 Sterile technique- the method by which
contamination with microorganism is
prevented to maintain sterility through
out the operative procedure.

 Sterile field- the area around the incision

site of introduction of any
instrumentation that has been prepared
for use of sterile supplies and equipment.
Includes all furniture covered with sterile
drapes and personnel who are properly
attired.
 Sterilization- the process by which all
pathogenic and non-pathogenic
microorganisms are killed including
spores.

 Sterilizer- the chamber or equipment

used to attain physical or chemical
sterilization. Also known as______?
Autoclave
 CATEGORIES OF SURGICAL
PROCEDURE
 Purpose
1. Diagnostic- to determine cause of
symptoms or confirm a diagnosis
2. Curative- removes diseased part
3. Restorative/Reconstructive- strengthens
weakened are, rejoins disconnected or
injured area or correct deformities
4. Palliative- relieves symptoms without
curing disease
5. Cosmetic- improves appearance
 EXTENT
1. Minor surgery- presents little risk to
life, involves minimal blood loss, few
serious complications, can be
performed in the surgeons clinic, OPD,
and ER.
2. Major surgery- extensive, involves
significant serious risk and
complications, moderate to excessive
blood loss, performed in the OR,
usually in a hospital setting.
 TYPES OF SURGERY
1. Optional surgery- surgery is scheduled
completely at the preference of he
patient. Non- catastrophic
2. Elective surgery- performed for the
persons well-being but is not absolutely
necessary
3. Planned/required surgery- intervention
is important but can be scheduled
several weeks/months in advance
4. Urgent- requires surgical attention within
24-30 hours.

5. Emergency surgery- requires immediate

surgical without delay so to preserve life,
maintain an organ and stop bleeding.
 PRE-OPERATIVE NURSING
MANAGEMENT
 Assessment- begins with the initial
contact between patient and nurse and
is ongoing throughout the period.
 Physical assessment
Reasons:
a. to obtain data for comparison during
the intra and post-op phase
b. to identify potential problems that may
require preventive nursing interventions
before surgery.
1. Age- infants, young children and older
adults have the lowest tolerance to
stressful effects of surgery.
2. Presence of pain
3. Nutritional status: 2 major problems
are: a. obesity b. nutritional deficiency
4. Fluid and Electrolyte Balance
5. Infection
6. Cardiovascular function
7. Pulmonary Function
8. Renal Function
9. GI function- client should be ask about
normal bowel functioning, so post-op
expectation for return of function are
appropriate.
10. Liver Function- an impaired liver is
unable to detoxify meds and anesthetic
agent or to metabolize carbohydrates,
fats and amino acids.
11. Endocrine function
12. Neurologic function
13. Hematologic Function- those with
blood coagulation disorders are at risk of
hemorrhage and hypovolemic shock
during and following surgery.
14. Use of medications- prescribed and
unprescribed meds taken should be noted
it might place a risk by increasing
coagulation time and interact
unfavorably with anesthetics
15. Presence of trauma
16. Health habits-
a. Smoker- has reduced level of Hgb
levels therefore less O2 available for
tissue repair.
b. Alcoholics- may experience withdrawal
symptoms during hospitalization could
lead to poor nutrition and unpredictable
reactions to anesthetic agents
c. HIV positive
 Psychological Aspect
1. Fear of surgical procedure, prognosis,
pain, anesthesia, loss of control,
disfigurement, loss of limb or organ,
threats to loss or financial security,
death
2. Sleep pattern disturbances r/t anxiety
3. Knowledge deficit
 Effect of surgery on clients
1. Stress response is activated
2. Resistance to infection is lowered due
to surgical incision
3. Vascular system is disturbed due to
severing of blood vessels and blood
loss
4. Organ function may be altered due to
manipulation
 Planning/implementation
1. Allow the client a time to ask questions about
procedures and surgery and post-op period
2. Provide a thorough explanation, printed info
about the health care facilities, routines,
visiting hours, mealtime, location of chapels
etc.
3. Explain the procedures involve in the
planned surgery
4. Determine the client’s level of understanding
of operative procedures to ascertain whether
signature on permit represents informed
consent.
5. Encourage nutritional assessment so that any
nutritional deficiencies can be corrected.
6. Provide essential info like NPO status, pre-op
procedures like enemas.
7. Teach patient the activities that will instituted
after surgery.
a. Diaphragmatic breathing
b. Incentive spirometry
Pre-op use- use to measure deep breaths while
exerting maximum efforts
Post-op-the patient is encouraged to use about 10-
12 times an hour to prevents atelectasis and
other pulmonary complication
c. Coughing-
d. Turning- should be done every 2 hours,
stimulates circulation, relieves pressure
areas and leg exercises
e. Post-op appearance like the presence of
tubes, drains , IVF infusion etc.
f. Pain control
g. Find out patients religious preference
h. Include patient’s family and significant
others in pre-op discussion
PATIENT’S HISTORY
A. Data gathered during a purposeful
history help detect problems that may
arise pre/intra/post operatively
B. Specific info to obtain pre-op history
concerns.
 Previous surgery and experience with
anesthesia
 Response of family members to
previous surgery and anesthesia
 If patient had any serious illness
 Previous and current medications
 Allergies
 Symptoms of discomfort
 Alcohol, nicotine, prohibited drug intake
 Symptoms or discomfort
 Occupation
 Religious affiliation
 Civil status
 Presence of chronic illness such as
arthritis migraine, back pain
 Whether patient had any question about
surgery
PHYSICAL EXAMINATION
 Performed on all clients undergoing
surgery to determine baseline data and
identify conditions that may interfere
with the administration of anesthesia or
produce post-op problems
 A complete PE is performed paying
attention to cardiac and respiratory
system
 Baseline VS are obtained
 Abnormal breath sounds are noted
 Determine/reveal any problems with
joint mobility, deformities that may
interfere with operative position of post
op course
 Special considerations on elderly patient
should include cardiac, respiratory, renal,
and musculoskeletal assessment
PRE-OP DIAGNOSTIC TEST
 Serum K-
 Serum Na
 Glucose (FBS)
 Creatinine
 BUN- to identify impaired liver, kidney
function or excessive protein or tissue
catabolism Hgb and Hct to determine
presence and extent of Anemia
 Prothrombin time- to identify deficiency
of coagulation factors
 Chest X-ray- to determine size and
contour of the heart, lungs and major
vessels
 ECG-
INFORMED CONSENT
 Provides a mechanism to protect a
patient right to self determination
regarding surgical intervention
 A legal permit or document ensuring
consent for the procedure
 Guards the patient against unwanted
invasive procedure
 Protect health care facility and health
care personnel/professionals
IC for surgical procedure
 The patient has the right to receive/
obtain full explanation and information
of the surgical procedure before signing
the permit
 The patient should understand all
relevant considerations like nature of
surgery, benefit risk, anesthesia,
complications and alternative treatments.
 A reasonable approach to IC should
answer the following patients question
1. What do you plan to do to me?
2. Why do you want to do this procedure?
3. What things should I worry about?
4. Are there any alternative to this plan?
5. What are the greatest risk or the worst
thing that would happen?
Validity of the IC
A. The patient giving consent must be of
legal age
B. The patient must sign before pre-med is
given before going to OR or other
treatment area, except in the life
threatening situation emergency
situations.
C. Must be given freely without coercion.
D. If the patient is:
1. A minor, a parent or legal guardian
must sign
2. An emancipated
minor/married/independently earning a
living he or she may sign
3. Illiterate, he or she may sign with an X
or thumb mark after which the witness
writes “patient’s mark”
4. Mentally incompetent, legal guardian
who may either be an individual or an
agency must sign
 A court of competent jurisdiction may
legalize the procedure in the absence of
the legal guardian
 A spouse or a reasonable relative may
sign for an adult or emancipated minor
who is under the influence of alcohol or
chemical substances
 A signed consent is legally regarded as
valid for as long as the patient still
consent for the procedure
 Institutional policy may vary
Consent in Emergency Situation
 In life- threatening emergency, consent is
derived but not essential
 For a minor, telegram or written
communication or by telephone maybe
accepted from legal guardian, responsible
relative
 In lieu of these methods, a written
consultation by 2 physicians other than
the surgeon can suffice until a relative
can sign
PHYSICAL PREPARATION
1. Preparing the skin
 The purpose of the skin prep is to render the
surgical site free microorganism, dirt and
skin oils.
 Mechanical cleaning-bathing patient prior to
surgery with antiseptic
 Hair removal
a. can injure skin, potential for infection
b. thick hair surrounding incision site must be
remove for they interfere with exposure, skin
closure or dressing and also prevent skin
contact
c. carried out per doctor’s order (pre-op unit
or in OR) close to scheduled time as possible
d. can be embarrassing procedure for the
patient, provide privacy by
draping/covering the patient
e. applying depletory creams or shaving
with a razor can remove hairs
Preparing the GI tract
 Done the night prior to surgery
a. Reduce the possibility of vomiting and
aspiration during anesthesia
b. Reduce possibility of bowel obstruction
c. Prevent from contamination from fecal
material during intestinal or bowel
surgery.
Preparation includes:
a. Restricting food and fluids (8-10 hours
before surgery)
b. Administration of enema as needed
c. Insertion of GI tubes when appropriate
Preparing for anesthesia
 Nurse anesthetist or an anesthesiologist
visits the patient before surgery for CP
clearance and neurological exam.
 Discusses type of anesthesia planned
 Fears concerning anesthesia are also
addressed.
Rest and Sleep- the night prior to surgery
the client must be:
1. Physically comfortable
2. Mentally at ease
3. Adequately sedated
Preparing the patient on the Day of Surgery
A. Early morning care- immediate pre-op
begins 1-2 hours before surgery. Pre-op
intervention includes:
1. Take and record VS
2. Check for skin prep as ordered
3. Check for ID band
4. Check and carry out all orders
5. Verify if NPO maintained
6. Ask the patient to void measure and
record
7. Assist with oral hygiene
8. Remove jewelries
9. Remove dentures/prosthesis
10. If wearing a hearing aid notify OR
nurse
11. Assist patient put on OR gown and caps
12. Remove nail polish and make ups
13. Continue to assess anxiety
B. Pre-op medications
 Prior to administration, check consent
and transfusion permit are correctly
signed and attached to chart.
Purpose: allay anxiety, decrease pharyngeal
secretions, reduce side effects of
anesthetic agents and create amnesia.
INTRA-OPERATIVE NURSING
 Nursing care focuses on the patients
emotional well-being and physical
factors
 At this time, the patient is identified by
the surgeon and anesthesiologist,
anesthetized, positioned, has the skin
prepared and is draped for surgery.
MEMBERS OF THE SURGICAL TEAM
 A group of highly trained individuals
who must work together as a coordinated
team for the welfare and safety of the
patient undergoing surgery.
The team is composed of the following:
A. Surgeon
 Heads the surgical team and makes the
major decision concerning the course of
surgery, such as whether to remove an
organ, amputate a limb or make radical
or extensive repairs.
B. Anesthesiologist
 Alleviates pain and promotes relaxation
with medication
a. Maintains clients airway
b. Ensure that the patient has an adequate
O2 and CO2 exchange
c. Infuse blood, fluids and medication to
maintain hemoglobin stability
d. Alert the surgeon immediately about
any complications
e. Monitor the patients circulation and
respiration
C. Circulating Nurse
 Acts as the manager of the operating
suite. Check equipment are working
before the surgery, ensures the sterility of
the instrument for the surgery, assist with
the positioning of the patient, perform
skin prep, assist the anesthesiologist with
monitoring vital signs and vital functions
such as urine output and blood loss,
coordinates with x-ray and pathology
Goals for preoperative medication
a. Anxiety
b. Sedation
c. Analgesia
d. Amnesia
e. Elevation of gastric fluid ph
f. Reduction of gastric fluid volume
g. Prophylaxis against allergic reaction
Low priority Goals for Preoperative
Premedication
a. Reduction of cardiac vagal activity
b. Facilitation of induction of anesthesia
c. Decrease anesthetic requirements
d. Postoperative analgesia
e. Prevention of postoperative nausea and
vomiting
 Is depressant preoperative
medication indicated?
NO YES
Less than 1 year of age Cardiac surgery
Elderly Cancer surgery
Most outpatient Most inpatient
Decreased LOC Regional anesthesia
Intracranial pathology
Severe chronic lung
disease
Hypovolemia
Common Preoperative Medications
1. Sedatives and Hypnotics (Pentobarbital
Na [Nembutal Na], Secobarbital Na
[Seconal Na], Chloral hydrate)
Interventions:
a. Monitor respiratory status- ?
b. Monitor level of anxiety- ?
2. Tranquilizers (Chlorpromazine HCl
[Thorazine], Hydroxyzine HCl
[Vistaril], Diazepam [Valium],
Promethazine HCl [Phenergan])
Interventions:
a. Maintain NPO – ?
b. Promote relaxation by dimming lights –
allows easier intubation and
visualization of surgical wound.
3. Narcotics (Meperidine HCl [Demerol],
Morphine sulfate, Hydromorphone HCl
[Dilaudid]
Nursing intervention:
a. Give deep IM – narcotics can be
irritating to SC and deep injection
provides increase effectiveness.
4. Anticholinergics (Atropine sulfate,
Glycopyrrolate [Robinul], Scopolamine
[Hyosine])
Nursing interventions:
a. Monitor BP and RR – can cause
palpitation and bradycardia with low
doses. Tachycardia with high doses.
b. Monitor hydration and maintain NPO
status – inhibit secretions before &
during surgery which could cause
aspiration, nausea,& vomiting
postoperatively.
ROLES AND RESPONSIBILITIES OF
THE Circulating Nurse
Before the operation
1. Checks that OR has been cleaned and
that the suction apparatus, diathermy
equipment, and the OR lights are in
working condition.
2. Ensure that the temp. and humidity
controls are correctly set.
3. Collects the necessary stocks and
equipment.
4. Ensures sterility of the instruments for
surgery.
5. Assist with positioning.
6. Performs the skin prep.
7. Prepares sterilized gowns and gowns for
the team and assist in tying gown.
8. Opens instruments and bowl packs and
other necessary equipment for the scrub
nurse.
9. Assist with the count and records the
count in display board.
During the Operation
1. Remains in OR all throughout.
2. Connects the diathermy and suction
leads to the appropriate machines.
3. Replenishes and record swabs, inst.,
and packs as requested.
4. Adheres strictly to local policy for
disposal of used swabs.
5. Ensures that all OR doors remain
closed.
6. Fills bowl with sterile H2O if required.
7. Places swabs collecting bowl/bucket
conveniently for the scrub nurse and the
surgical team.
8. Anticipates the requirements of the
surgical team.
9. Alert all team members of any break in
sterile technique.
10. Assist anesthetist with monitoring VS,
urine output, and blood loss and record
appropriately.
Before the end of the operation
1. Assist with the count and records. (final
count- done before the closure of the
skin, thus, inform the team that the
count is complete)
2. Prepares the wound dressing.
Completion of the operation
1. Hands the plaster to the scrub nurse.
2. Helps with the removal of the drapes
and preparation of client for transfer to
the PACU.
3. Removes specimen and labels properly.
4. Removes the inst. trolley and other
equip. to the dirty area.
Common Surgical Positions:
1. Dorsal recumbent – for abdominal
surgeries as in bowel surgery, chest
surgery, mastectomy
2. Trendelenburg – for lower abdominal
or pelvic surgery as the intestines are
displaced into the upper abdomen
3. Lithotomy – for vaginal and rectal
surgery
4. Laminectomy (?)– for spinal and back
surgery
5. Lateral position – for chest surgery on
one side, kidney or hip surgery
6. Prone – for spine and back surgery
7. Kraske or Jacknife – for hemorrhoid or
proctologic surgery
8. Reverse Trendelenburg – for gallbladder
surgery
Factors to consider in Preventing
Intraoperative Positioning Injury
1. The patient should be in a comfortable
position.
2. The operative field must be adequately
exposed.
3. Vascular supply should not be
obstructed.
4. Respiration should not be impeded.
5. Nerves must be protected from undue
pressure.
6. Precautions for safety particularly with
thin, elderly, or obese patient, or those
with physical deformity.
7. Patient needs gentle restraint before
induction in case of excitement.
D. SCRUB NURSE
Assist the surgeon during the procedure by
handling instruments, sutures, and other
supplies. It also maintain an accurate
count of sponges, sharp instruments in
the sterile field.
Roles and Responsibilities:
1. Checks the surgeon’s preference card
and collect the specialized equipment,
sutures, inst., and bowl sets.
2. Performs strict surgical hand scrubbing,
gowning and gloving-using an aseptic
technique.
3. Hands swabs inst., sutures as needed to
the surgeon and assistant.
4. Prepares on the working surface of the
following items: scalpel, forceps,
scissors, leads/tips, etc.
5. Hands diathermy lead and suction tubing to the
circulator for the attachment and checks the
cautery (use to burn or fuse small areas of body
tissue to destroy dead cells, prevent the spread
of infection, or seal tiny blood vessels to
minimize blood loss during surgery) setting
with the surgeon.
6. Keeps an accurate count of extra swabs,
needles, and inst. and ensures that they are
charted by the circulator.
7. Anticipates the needs of the surgeon by
continually observing the progress of the
operation.
Cautery Machine
Diathermy machine
Before the surgeon starts the incision
and suture or closes any cavity
1. Checks swabs, packs, inst., and needles
with the circulator in accordance with
the sponge count, inform the surgeon of
the findings and ensures that the
surgeon acknowledges the information.
2. Drape the trolleys, table, and bowl
stands with sterile drapes.
3. Checks the content of each inst. set
with the circulator & with the enclosed
contents list.
4. Collects from the circulator the sutures,
needles, and other necessary equipment
5. Checks and do initial count of swabs,
packs, inst. and needles with the
circulator and ensure that the initial
counts are charted and displayed.
6. Requests CN to double check clients
identity with name bands, case notes and
OR list.
7. Ensure with the circulator that the pt. is
positioned safely on the table.
At the start of the operation:
1. Hands the skin prep and sponge stick to
the surgeon.
2. Assists in applying and securing
drapes.
3. Position the trolleys and bowl stand.
At the end of the operation:
1. Checks with the circulator that
appropriate wound dressing is
available.
2. Carries out final count, informs surgeon
and ensures his acknowledgment and
that findings are charted.
3. Removes inst. from the blade handles
and disposes used blades and sharps in
the proper containers.
4. Collects the dressing from the
circulator and hand it to the surgeon.
5. Removes blade from the blade handle
and disposes used blades and sharps in
the proper containers.
6. Ensures that the area around the wound
dressings is clean and the pt’s gown and
sheets are clean and dry.
7. Covers the pt with clean sheet.
8. Transfers patient to the PACU.
Principles of Surgical Asepsis
1. Only sterile materials may be used
within a sterile field.
2. Gowns of scrubbed team members are
considered sterile in front, from
shoulders to waist levels and sleeves to
2 inches above the elbow.
3. Draped tables are considered to be
sterile on the top surfaces only.
4. Sterile surfaces should contact only
sterile areas.
5. Edge of any sterile package or counter
are considered unsterile.
6. Sterile field is created as closely as
possible to time of use.
7. Persons who are sterile touch only sterile
items or areas; persons who are not
sterile touch only unsterile items or areas.
Surgical Hand Wash
Hands are the major source of pathogenic
bacteria, thus, SHS is a MUST.
It reduces the number of microorganisms.
Takes 5 to 10 minutes and the hands are
held higher than the elbow for scrubbing
and rinsing.
Universal Precaution
Protection Barriers: Lessen the risk to
infection “Attire”
1. Scrub suit
2. Hand caps
3. Shoe covering, OR shoes
4. Mask
Sterile Draping
The purpose of draping is to create a sterile
field around the operative site.
The kinds of linens used as OR drapes are:
1. The towels, e.g. lap towel
2. Whole or half sheet
3. Fenestrated or slit drapes, e.g. eye
sheet, lap sheet
Patient Skin Prep
Begins with mechanical scrubbing at the
incision site in a circular motion to the
periphery.
At the periphery prep. sponge is considered
contaminated and is discarded- soiled
sponge is never brought back to the area.
Note: If it is a body orifice or an open
wound , it is based on the principle –
cleaning proceeds from CLEAN TO
DIRTY AREA.
SUTURES
Any strand of material used for ligating or
approximating tissue
Forms:
1. Ligature – material that is tied around
the blood vessels to occlude the lumen
2. Free tie- a single strand of material
handled to the surgeon/assistant to
ligate a vessel
3. Suture Ligature- a strand attach to the
needle before use.
4. Stick Tie – a strand attach to a forcep
Kinds of suture:
1. Absorbable - sterile strands prepared
from collagen derived from healthy
animals
2. Non-absorbable – strands of material
that effectively resist enzymatic
digestion or absorption of living
tissues.
Classification of Suture Materials:
1. Monofilament – a strand consisting of a
single threadlike structure
2. Microfilament – made of more than one
thread like structure together by
spinning, braiding, or twisting.
 NEEDLES
Surgical Needles – needed to carry the suture
material through the tissue with the least
amount of trauma
Parts of the needle:
1. Eye
2. Point
3. Body
 Needle Points
1. Cutting Needle
a. Conventional cutting needles
b. Reverse cutting needle
c. Side cutting needle
d. Trocar point
2. Taper point/ round needle
3. Blunt point
 Quality of a Surgical Needle
1. Strong
2. Rigid
3. Sharp
4. The same diameter as the suture material
5. Appropriate in size and shape for the type,
condition, and accessibility of the tissue to
be sutured
6. Free from corrosions or burns
Surgical Needles
Biopsy Needles
Anesthesia Needles
Suture Needles
 SURGICAL CONSCIENCE
Key words of OR practice
1. Caring
2. Conscience
3. Discipline
4. Technique
 SURGICAL CONSCIENCE
SC- may simply be stated as the Golden Rule
(?)
SC- involves a concept of self inspection
coupled with moral obligation
- it is one’s inner voice for conscientious
practice of asepsis and sterile technique at
all times.
SC- does not permit a person to excuse an
error but rather admit and rectify one.
3 ZONES OF THE OR
1. Unrestricted Area
 Provides an entrance to and exit from
OR
 Holding or admission area and PACU
 Dressing room, lounges, offices, and
storage rooms
2. Semi – restricted area
 Provides access to the procedure rooms
and peripheral support area within the
OR
 Proper OR attire is required to be worn
by all personnel
 Peripheral support consist of storage area
for clean and sterile supplies
 Areas and corridors leading to procedure
rooms and substerile utility areas
3. Restricted Area
 Procedure rooms in which surgery is
performed, and other substerile areas
where the scrub sink and autoclave is
located and preparation room
 Proper OR attire and surgical mask is
worn by all in this area for maximum
protection from possible contamination
ANESTHESIA
 Means absence of pain
 An artificially induced state of partial
or total loss of sensation occurring with
or without loss of consciousness
Purposes:
1. Produce muscle relaxation
2. Block transmission of nerve impulses
3. Suppress reflexes
4. Cause loss of consciousness
Phases of Anesthesia
1. Pre-induction – begins as soon as the
pt. is brought to procedure room and
ends immediately before the induction
of anesthesia
2. Induction – begins with the
introduction of anesthetic agents and
ends with introduction and stabilization
of the patient
Stages of General Anesthesia
Stage 1or Relaxation – begins when the
client’s being awake and includes the
gradual loss of consciousness during
which time analgesia occurs; Pt is
drowsy ® Close OR door
Stage 2 or Excitement – from total loss of
consciousness to the point of excitement,
with irregular breathing, and involuntary
limb movements ® Suctioning, more
sedatives
Stage 3 or Surgical Anesthesia – marked by
complete relaxation of jaw, regular
respiration, and loss of auditory and pain
sensation. ®Operation begins
Stage 4 or Danger – characterized by apnea
leading to CP arrest and death. ®Act
appropriately.
3. Maintenance Phase – starts when
stabilization is accomplished and ends
with reversal of anesthesia is initiated
near the procedure end.
4. Reversal or Extubation – begins with the
closure of the wound ends before pt is
transferred to the PACU
 Types of Anesthesia
A. General anesthesia- block the pain
stimulus at the cortex of the brain and
depress the CNS
 Methods of Administration
1. Inhalation – the most controlled method of
administration because intake and
elimination are accomplished primarily by
respirations. A mixture of volatile liquids
or gas and O2.
 Gaseous anesthetic –Nitrous oxide (blue
tank)
 Volatile gases – halothane; Ethrane
(liquid)
2. IV injection – provides a pleasant, rapid
and smooth dissipation of anesthetic agent.
The reversal and removal of this agent from
the circulation is not possible, and the safety
of the agent is directly related to the client’s
metabolism.
Examples: Thiopental Na (Penthotal),
Fentanyl citrate (Sublimaze), Fentany
citrate with droperidol (Innovar), Ketamine
(Ketalar; Ketaject)
3. Rectal installation – via rectal tube; rarely
used today
Example: Methohexital sodium (Brevital Na)
 Medications used as anesthesia adjuncts:
1. Barbiturates – often used for IV induction;
acting directly on the CNS, producing a
reaction from mild sedation to
unconsciousness
2. Narcotics- used to supplement inhalation
anesthesia
3. Neuromuscular blockers- used to provide
muscle relaxation and to facilitate passage
of an ET tube.
2 types:
a. Depolarizing agents
b. Non depolarizing
 Complications of General anesthesia
1. Minor comp. – broken or injured teeth,
trauma to vocal cords, injuries to lips and
tongue 2º to intubation, corneal abrasions
2. Hypotension
3. Malignant hyperthermia – rare and life-
threatening complication
 Malignant hyperthermia Sx:
a. Tachycardia
b. Continual increase in body temp. (which
can recur) during the post op period
c. Cyanosis
d. Hypotension
e. Muscle rigidity
f. Dark color of blood in the surgical wound
g. Arrhythmias
 Treatment
a. Immediate discontinuation of the surgery
b. Cooling of the pt. (admin. of iced IV
solutions)
c. Iced nasogastric gavage
d. Packing the client in ice
e. Dantrolene Na (Dantrium), steroids,
diuretics, and 100% O2
B. Balanced Anesthesia – the practice of
selecting drug combination based on the
client’s need and type of surgery and is
achieved with a combination of inhalant
agent, narcotic and muscle relaxant.
Example: barbiturate administered IV for
induction, nitrous oxide and morphine
for analgesia and relaxant
C. Local or Regional Anesthesia –
temporarily interrupts transmission of
nerve impulses to and from a specific
area or region; the client does not lose
consciousness in this type of anesthesia
Example of Surgical Procedures:
Breast biopsy, removal of superficial
growths, cataract extraction, hernia
repair, endoscopies of the GI tract,
respiratory & urinary tracts
Localized complications:
1. Edema
2. Inflammation
3. Abscess
4. Necrosis
5. Gangrene
Techniques used to administer anesthesia:
1. Topical anesthesia – applied directly to
the surface or area to be anesthetized;
forms: ointment or spray (Emla cream)
Procedures: for respiratory intubation or for
Dx tests, e.g. laryngoscopy,
bronchoscopy, cystoscopy
2. Local Infiltration – injection of an
anesthetic agent intracutaneously into the
tissue surrounding an incision, a wound,
or a lesion; blocks the peripheral nerve
stimulation at its origin
Commonly used during suturing of
superficial lacerations
3. Field block – series of injections around
the operative field; depresses the entire
sensory nervous system of a localized
area.
Used for: herniorrhaphy, dental
procedures, and plastic surgery
4. Nerve Block – injecting local anesthetic
agent into or around a nerve supplying
the involved area; interrupts sensory,
motor, or sympathetic transmission
Examples: Lidocaine (Xylocaine),
Bupivacaine (Marcain)
5. Spinal Anesthesia – injection of the
anesthetic agent into the subarachnoid
space at the level of L2-3 or L3-4. (?)
- Produces analgesia with relaxation,
effective for abdominal and pelvic
surgical procedures
2 Most Common S/E of Spinal Anesthesia:
1. Hypotension – preganglionic block of
the sympathetic fibers causing (?) and
reduction of venous return to the heart
Nursing Interventions:
 Monitor VS & peripheral circulation (?)
 Administer O2 and vasopressors
2. Spinal headache – during the 1st 24-48 H
after administration of the anesthetic; due
to incomplete seal of dura mater after the
removal of needle and leakage of CSF
into the epidural space, decreasing CSF
Prevention: Client lie flat in bed 6 to 12 H
post op & achieving adequate hydration
Nursing Intervention:
 Restrict client to bed rest
 Provide quiet, dark room
 Maintain hydration orally or IV
 Administer sedatives or analgesic as
ordered
POST-OP Nursing
-3rd and final phase of the surgical
experience
-Nursing plays a critical role in returning
the client to an optimal level of
functioning
Phases of Post-op Period
I. Immediate post-anesthesia & post-op
period
-first few hours after surgery when the
client is recovering from the effects of
anesthesia.
II. Later Post-op phase
-time for healing and preventing
complication
-last for weeks or months after surgery
 Transporting Client to the PACU
After the dressing is applied, clean the
client and change the client’s gown; after
which assist in the transfer of the client
to the stretcher.
There should be at least 4 personnel to help
transfer the clients
Cover the client and secure well for safety
On Admission to PACU:
1. Assess airway patency
2. Applies O2
3. Records VS
4. Assess LOC
5. Observe pt.’s IV infusions, dressing,
drains, and special equip. (cardiac
monitor, pulse oxymeter)
6. Continuous close observation of the
clients overall condition (P.E., lab
results)
Common Nursing Diagnoses:
o Impaired Gas Exchange R/T anesthesia;
o FVD R/T blood loss and loss of body
fluids
o High Risk for Injury R/T anesthesia;
intraoperative positioning
o Impaired skin integrity R/T surgical
wound
o Potential for infection R/T surgical
wound
o Fear R/T anesthesia
o Anxiety R/T anesthesia
o Powerlessness
o Decreased Cardiac Output R/T
anesthesia, decreased mobility and
venous pooling
o FVE R/T rapid fluid UV infusion
o Hypothermia R/T environmental
temperature changes; pre-op medications
o Ineffective breathing patterns
Criteria for D/C clients from PACU
 VS are stable; adequate respiratory &
circulatory function
 Client awake or easily aroused
 Post surgical complications (excessive
wound drainage, vomiting, fever, pain,
inadequate u.o.) are evaluated & under
control
 Those with regional anesthesia has motor
as well as partial sensory return to all
anesthesized areas.
 Common Postoperative Complications
and Interventions
1. Cardiovascular Complications
 Shock – Positioning; Blood
replacement and Fluid resuscitation
(Hypovolemic Shock); Ionotropic drugs
(Dopamine for cardiogenic shock)
 Hemorrhage – Apply pressure on
bleeding points; Apply P dressing on
bleeding area; Prepare for surgery
(internal bleeding); treat for shock
 Deep Vein Thrombosis – (pain, redness,
temp, [+] Homan’s sign)
 Administer anticoagulants and analgesics
(NSAID are not given along with
anticoagulants[?]); Monitor PT, PTT,
clotting time; Maintain on strict BR and
keep affected extremity at or above heart
level; Apply thigh high anti-embolic
stockings; or ace wraps; NEVER RUB
OR MASSAGE THE AREA!
 Pulmonary embolism – (mild to mod.
dyspnea, chest pain, diaphoresis, anxiety,
restlessness, tachycardia & tachypnea,
cough, cyanosis)
 Maintain on BR and keep HOB elevated;
O2 at 100%; IV fluids; administer as
prescribed anticoagulants; analgesics and
sedatives; frequent assessment
2. Respiratory Complications
 Pneumonia – (high fever, crackles,
wheezes, dyspnea, chills, productive
cough, sputum: yellowish-
staphylococcus; greenish- pseudomonas;
rusty- klebsiella)
 position HOB elevated; Obtain sputum
specimens for C&S; encourage to T, C &
DB; administer O2 as ordered; meds as
ordered- antibiotics, expectorants,
antipyretics, etc.; assist with IS, nebulizer
treatment; maintain hydration; Auscultate
breath sounds Q2 H and prn.
 Atelectasis- (absence of breath sounds)
 O2 therapy; HOB elevated; T, C, & DB;
ambulate as condition permits; Assist
with IS, IPPB, etc; Promote hydration;
Auscultate breath sounds Q2H and prn.
3. Complications Associated with
Elimination
 Urinary Retention – Assess bladder for
distention or if the client has not voided
for 6-8 hours after surgery; Monitor I&O;
Maintain IV fluids; Insert a straight
catheter or indwelling catheter as
ordered; Perform measures to promote
urinary elimination
 Abdominal Distention (Gas Pain) –
Rectal tube insertion; early ambulation;
Adequate fluid intake and increased fiber
in the diet
 Constipation – Assess for return of
normal peristalsis; Auscultate bowel
sounds; Determine passing out of flatus;
Early ambulation; Fluid intake of 2,500-
3,00 ml unless contraindicated; If no BM
by 3 to 4 days postop, a suppository or an
enema may be ordered
4. Wound Complications
 Infected Wound – Maintain medical
asepsis in wound care; Evaluate wound
discharge & condition of incision;
Maintain client’s hydration & nutritional
status; Culture wound prior to beginning
antibiotic therapy; Antibiotics as ordered
 Dehiscence – (opening of wound edges)
Reinforce wound with butterfly dressing;
Use binders when ambulating
 Evisceration- (wound edges part slowly;
sudden gush of profuse, pinkish serous
drainage)
 Cover wound with sterile dressing
moistened with NSS; Let client maintain
bed rest with knees bent; Prepare client
for emergency surgery
Positioning for specific conditions:
Appendicitis- if unruptured, any position
of comfort
- If ruptured, semi-fowler’s to prevent
the upward spread of infection
Bronchoscopy- semi-fowler’s post
procedure to prevent aspiration.
Cataract extraction- semi-fowler’s to
prevent edema at the operative site.
Cleft lip (cheiloplasty)- supine, to prevent
pressure on the suture line
Craniotomy- if supratentorial, semi-
fowler’s
- if infratentorial, flat to facilitate venous
drainage from the head
Hemorrhoidectomy- side-lying to prevent
pain
Hip surgery- keep the legs in abduction,
to prevent dislodge of the head of the
femur from the acetabulum
Laminectomy- keep the back as straight
as possible, to prevent twisting of the
spine
Laryngectomy- semi-fowler’s, to maintain
patent airway and minimize edema
Liver biopsy- right side-lying, post op, to
prevent bleeding
Lobectomy- semi-fowler’s to prevent
breathing
Lumbar puncture- lateral side-lying
during the procedure to facilitate entry
of needle between L3-L4
-Flat position, post op, to
prevent spinal headache
Mastectomy- elevate on pillow the
affected extremity, to prevent
lymphedema
Myelogram- if water based dye
(amipaque), elevate HOB, to prevent
upward dispersion of the dye.
- if oil based dye (pantopaque),
flat on bed to prevent leakage of CSF
Placenta Previa- sitting position to
minimize bleeding
Thoracentesis- fowler’s during the
procedure, to facilitate removal of fluids
from the chest wall
- after the procedure, any
position of comfort
Thyroidectomy- semi fowler’s and avoid
hyperflexion and hyperextension of the
neck to prevent tension on the suture line
Tonsillectomy- side-lying or prone, to
promote drainage secretion
Vein stripping- keep leg elevated, to
prevent venous stasis
END