or lect

OBJECTIVES

On completion of this concept,

the student will be able to:

1. Define the three phases of the peri-

operative period.

2. Identify the causes of preoperative anxiety

and describe the nursing measures to

alleviate it.

3. Identify legal and ethical considerations

related to informed consent.

4. Develop a preoperative teaching plan

designed to promote the patient’s recovery

from anesthesia and surgery, thus preventing

postoperative complications.

5. Describe the interdisciplinary approach to

the care of the patient during surgery.

6. Describe the principles of surgical asepsis.

7. Identify adverse effects of surgery and

anesthesia.

8. Identify the use of the nursing process for

optimizing patient outcomes during the

intra-operative period.

9. Identify assessment parameters appropriate

for the early detection of postoperative

complications.

COURSE

OUTLINE

Preoperative Nursing Management

a. Peri-operative and Peri-anesthesia Nursing

b. Surgical Classifications

1. Emergency/Emergent surgery

2. Urgent

3. Required

4. Elective

5. Optional

c. Informed Consent

d. Psychosocial Nursing Assessment and

Interventions

1. Alleviating Fear

2. Respecting Spiritual and Cultural

Beliefs

e. General Physical Assessment

1. Nutritional Status – Nutrients

important for wound healing and

recovery

2. Drug and Alcohol use

3. Respiratory status

4. Cardiovascular status

5. Hepatic and Renal Function

6. Endocrine Function

7. Immunologic Function

8. Previous Medication Therapy

PATIENT EDUCATION

1. Deep Breathing and Coughing

Exercises

2. Mobility and Active Body Movement

3. Pain Management

4. Cognitive Coping Strategies

a. Imagery

b. Distraction

c. Optimistic Self-recitation

g. Preoperative Nursing Management

1. Managing Nutrition and Fluids

2. Preparing Bowel for Surgery

3. Preparing the skin

h. Immediate Preoperative Nursing

Interventions

1. Administering pre-anesthetic

medications

2. Maintaining the Preoperative Record

3. Transporting the patient to the

pre-surgical Suite

4. Attending to Family Needs

II Intraoperative Nursing Management

a. The Surgical Environment

1. Physical Layout of the O.R. suite

1. Location

2. Principles in Design

3. Exchange Areas

4. Peripheral Support Areas

5. Operating Room

b. Asepsis, Infection Control and

Principles of Sterile Technique

1. Surgical Conscience

2. Infection

a. Process of Infection

b. Classification of Infection

c. Factors Affecting Infection Rates

d. Classification of Operative Wounds

e. Sources of Contamination

f. Infection Control

g. Environmental Control

3. Principles of Sterile Technique

4. Methods of sterilization and

Disinfection

c. Surgical Scrub, Gowning and Gloving

1. The Surgical Scrub

2. Gowning and Gloving Techniques

The Surgical Team

a. Patient

b. Intraoperative Nurses

1. Circulating Nurse

2. Instrument Nurse

3. Division of Duties: Setup,

Procedure, Cleanup

c. Anesthesiologist and Anesthetist

d. Surgeon / Assistant Surgeon

The Surgical Experience

a. Anesthesia: an overview

b. Patients Positions on the Operating

table

c. Preparation of the Operative Site and

Draping

Potential Intra-operative Complications

a. Nausea and Vomiting

b. Hypoxia and other Respiratory

complications

c. Hypothermia

d. Malignant Hypothermia

Postoperative Nursing Management

The Postanesthesia Care Unit

a. Admitting Patient to the PACU

b. Nursing Mgt. in PACU

1. Assessing the patient

2. Maintaining patent airway

3. Maintaining Cardiovascular

stability

4. Relieving Pain and Anxiety

5. Determining readiness for

discharge from the post-anesthesia

care unit

b. The Hospitalized Postoperative Patient

a. Receiving the patient in the clinical unit

b. Nursing Management during the first

hours after surgery

1. Assessing and managing

ventilation

2. Assessing and managing

hemodynamics

3. Assessing and Managing Surgical Sites

4. Assessing and Managing Pain

5. Maintaining Normal Body Temperature

6. Assessing Mental Status

7. Assessing Neurovascular status

8. Assessing and Managing

Gastrointestinal Status

9. Assessing and Managing Voluntary

Voiding

10. Encouraging Mobility

11. Maintaining Safe Environment

12. Providing Emotional Support to

Patient and Family

c. The First Postoperative day to the day of

discharge

1. Relieving Pain

2. Preventing Respiratory Complications

3. Preventing Deep Vein Thrombosis

4. Encouraging Activity and Promoting

Self-care

5. Preventing wound infection and

providing wound care

a. Phases of wound healing

b. Factors affecting wound healing

c. Sterile dressing techniques

6. Managing wound complications

a. Hematoma

b. Wound Sepsis

c. Wound Dehiscence and

Evisceration

7. Resuming Oral intake and Promoting

Bowel Function

Peri-Operative

Nursing

Perioperative Nursing

Surgery – a branch of medicine that deals with

disease and trauma through surgical /

operative procedures.

History of Surgery:

- the earliest recorded sign of surgery was

found in ancient Egyptian papyri.

- they were for treatments of the back, chest ,

and shoulders.


- earliest known surgeon used a large amount

of tools like: knives, awls, drills, scissors,

saws, forceps, clamps, syringes, mirrors,

needles, cast, splints, & bandages

- surgery has been around since 3,000 B.C.

through today.

- among the first surgeons were battlefield

doctors in the Napoleonic Wars who were

primarily concerned with amputations.


- naval surgeons were often barber-surgeons,

who combined surgery with their main jobs

as barbers.

- history of surgery can be divided into three

eras: ancient, middle & modern

SUSHRUTA

The “Father of

surgery” and

inventor of Plastic

Surgery.

JOSEPH LISTER

The discoverer of

surgical sepsis and

Listerine named in

his honor.

ALFRED BLALOCK

The first modern

day successful

open heart

surgery in 1944.

CHRISTIAN BARNARD

The cardiac

surgeon who

first performed

the heart

transplantation

in 1967.

HARVEY CUSHING

Pioneer of brain

surgery.

GAVRIL ILIZAROV

Russian

orthopedic

surgeon who

invented the

procedure to

lengthen or

reshape limb

bones.


Perioperative Nursing – refers to the activities

performed by the professional nurse during

the client’s total surgical experience.

Perioperative period – encompasses a client’s

total surgical experience , including the

preoperative, intraoperative and

postoperative phases.

Phases of Peri-operative

Nursing

1. Preoperative Phase – begins with the

decision to perform surgery and ends with

the client’s transfer to the operating room

(O.R.).

2. Intraoperative Phase – begins when the

client is received in the O.R. and ends with

his admission to the post-anesthesia care

unit (PACU) / Recovery Room.

Phases of Peri-operative

Nursing

3. Postoperative Phase – begins when the

client is admitted to postanethesia care unit

and extends through follow-up home or clinic

evaluation.

Categories of Surgery based on Urgency:

1. Emergent / Emergency - patient requires

immediate attention, disorder may be life

threatening.

indication: without delay

examples: severe bleeding (gunshot or stab

wounds), bladder or intestinal obstruction,

fractured skull and extensive burns

2. Urgent – patient requires prompt attention.

indication: within 24-30 hours

examples: acute gallbladder infection, kidney

or ureteral stones, appendicitis

3. Required – patient needs to have surgery.

indication: plan within a few weeks or months

examples: prostatic hyperplasia (without

obstruction), thyroid disorders and cataracts

4. Elective – procedure performed by choice

indication: failure to have surgery not

essential

examples: repair of scars, hernia and vaginal

repair

5. Optional – decision rest with the patient.

indication: personal preference

example: cosmetic surgery

Classification of Surgery:

1. Diagnostic – e.g. biopsy or exploratory

laparotomy (Ex-Lap)

2. Curative – e.g. tumor excision & inflamed

vermiform appendix

Classification of Surgery

3. Reparative / Reconstructive– bringing back

to its normal functioning. Repair of damaged

organ.

4. Palliative – reduce intensity of

uncomfortable symptoms but not to produce

a cure.

Classification of

Surgery

a. Ablative – Involves removal of an organ.

(suffix used: “ectomy”) appendectomy

b. Constructive – Involves repair of

congenitally defective organ.

(suffixes used are “plasty”, “orrhapy”,

“pexy”) cheiloplasty & orchidopexy

c. Reconstructive – Involves repair of

damaged organ. (plastic surgery)

Classification of

Surgery

Categories of Surgery based on Magnitude/Extent:

A. Major Surgery

Criteria:

1. High risk 4. Large amount of blood loss

2. Extensive 5. Vital organs may be handled

3. Prolonged or be removed

B. Minor Surgery

Criteria:

1. Generally not prolonged

2. Leads to few serious complications

3. Involves less risk

Informed

Consent

Informed Consent – permission obtained from

a patient to perform a specific test or

procedure.

Criteria for a Valid Informed Consent:

1. Voluntary consent – valid consent must be

freely given without coercion.

2. Competent patient – individual who is

autonomous and can give or withhold

consent.

3. Patient able to comprehend – information

must be written and delivered in language

understandable to the patient.

4. Informed subject - consent must be in

writing & must contain the following:

a. Explanation of the procedure and its risk.

b. Description of benefits and alternatives.

c. Instructions that the patient may withdraw

consent.

d. A statement informing the patient if the

protocol differs from customary

procedure.

Informed Consent is necessary in the

following procedures:

1. Invasive procedures – surgical incision, a

biopsy, cystoscopy or paracentesis.

2. Procedures requiring sedation or anesthesia

3. Non-surgical procedure – arteriography,

lumbar puncture

4. Procedures involving radiation

Nursing Responsibilities:

1. The surgeon must provide a clear and

simple explanation of the surgical

procedure.

2. The nurse may ask the patient to sign the

consent form.

3. The nurse may witness the patient’s

signature.

4. If the patient needs additional information

about the procedure, nurse notifies the

surgeon.

5. The nurse ascertains that the consent form

has been signed before administering

psychoactive drugs.

6. If the patient is a minor, unconscious or

incompetent, permission must be obtained

from a responsible family member or legal

guardian.

7. An emancipated minor (married or

independently living or earning on his own)

may sign his own consent form.

8. No patient should be urged or coerced to

sign an operative permit.

9. In an emergency, a surgeon can operate

without the patient’s informed consent.

10. Refusing to undergo a surgical procedure

is a person’s legal right and privilege.

Preoperative

Phase

Preoperative Nursing Problems:

1. Anxiety related to the surgical experience

(anesthesia & pain) & outcome of surgery.

2. Fear related to perceived threat of the

surgical procedure and separation from

support system.

3. Knowledge deficit of preoperative

procedures and protocols and

postoperative expectations

Preoperative Nursing Management:

1. Teach deep-Breathing, Coughing and

Incentive Spirometer

2. Encourage mobility and active body

movement

3. Pain management – patient-controlled

analgesia (PCA), epidural catheter bolus or

infusion & patient controlled epidural

analgesia (PCEA)

4. Teach cognitive coping strategies

a. Imagery – patient concentrates on a

pleasant experience or restful scene.

b. Distraction – patient thinks of an enjoyable

story or recites a favorite poem or song.

PATIENT

CONTROLLED

ANALGESIA

PRE-OP NURSING

MANAGEMENT

Deep Breathing and Coughing Exercises

LEG and FOOT

EXERCISES

c. Optimistic self-recitation – patient recites

optimistic thoughts

(“I know all will go well”)

Instruction for Ambulatory Surgical patients:

a. Inform the patient the scheduled date and

time of the surgery and where to report.

b. Instruct what to bring

(insurance card, list of meds)

c. Instruct what to leave at home

(jewelry, watch )

d. Instruct what to wear (loose-fitting,

comfortable clothes & flat shoes)

e. Remind the patient not to eat or drink as

directed (fasting period of 8 hours or more

is recommended)

Preoperative Psychosocial Management:

1. Reducing Preoperative Anxiety

– music therapy

2. Decreasing Fear

3. Respecting Cultural, Spiritual and Religious

Beliefs

General Preoperative Nursing Management:

1. Managing Nutrition and Fluids

2. Preparing the Bowel for Surgery

3. Preparing the Skin

Immediate Preoperative Nursing Management:

1. Administering Pre-anesthetic Medication

2. Maintaining the Preoperative Record

3. Transporting the Patient to the Pre-surgical

Area

4. Attending to Family Needs

Nursing Evaluation:

1. Reports relief of anxiety

2. Reports that fear is decreased

3. Voices understanding of surgical

intervention

4. Shows no evidence of preoperative

complications

Intra-

operative

Phase

Surgical Environment

Physical Layout of the O.R. Suite:

1. Location – operating room is situated that is

central to all supporting services

(laboratory, radiology, pathology & central

supply room)

2. Principles in Design –

a. Exclusion of contamination from outside

the suite with sensible traffic patterns

within the suite.

b. Separation of clean areas from

contaminated areas within the suite.

3. Exchange Areas -

Surgical Area:

a. Unrestricted zone – street clothes are

allowed

b. Semi-restricted zone – Attire consist of

scrub clothes and caps

c. Restricted zone – scrub clothes, shoe

covers, caps and masks are worn

4. Peripheral Support Areas –

a. Central Administrative Control

b. Offices

c. Conference Room/Classroom

d. Laboratory / Radiology Services

e. Anesthesia Work & Storage Areas

f. Housekeeping Storage Areas

g. Utility Room

h. General Workroom

i. Storage Room

j. Sterile Supply Room

k. Instrument Room

l. Scrub Room

5. Operating Room – surgical suite is behind

double doors ( sliding doors, swing doors )

- Access is limited to authorized

personnel.

- External precautions include adhering

to principles of surgical asepsis.

- Strict control of the operating room

environment is required.

- OR has special air filtration devices to

screen out contaminating particles,

dust, and pollutants.

- Temperature, humidity & airflow

patterns are controlled.

Infection

Infection – is the product of the entrance,

growth, metabolic activities & patho-

physiologic effects of microorganism in

living tissues.

Three Stages of infection:

1. Invasion

2. Localization

3. Resolution leading to recovery

Infection

Process

Acute Bacterial Infection

(most common sepsis in surgical patients)

Wound infection begins 4th to 8th postoperative

Cellulitis pain, redness & swelling

(diffuse inflammatory process)

RBC’s, Leukocytes & Macrophages infiltrate the cells

(localization & containment of infecting microorganism)

Abscess / Pus formation

(suppuration)

If localization is inadequate

Spreading & extension occur causing regional infection

Microorganism & metabolic products carried into the lymphatic system

Lymphangitis

Failure of lymph nodes to hold infection

Uncontrolled cellulitis

Systemic infection occurs chills, fever, signs of toxicity

Septic Thrombophlebitis

Septic emboli in circulation

causing more infection and abscess in remote tissues

Elevates the patient’s metabolic rate 30% to 40% above average

(imposing stress on the body’s vital systems)

Body’s defenses still not able to overcome the infectious process

Septic shock

(Fever, restlessness, hypotension, hypoxia, cloudy sensorium, tachycadia)

rapid breathing, DIC, metabolic acidosis and oliguria

Death

Classification of

Infection

Classification of Infection:

1. Community-Acquired Infections – are

natural disease processes that developed

or were incubating before a patient’s

admission to the hospital or ambulatory

care facility.

2. Communicable Disease – Systemic

bacterial, viral or fungal infections may

be transmitted from one person to

another (HIV, hepatitis & Tuberculosis)

3. Spontaneous Infections – Localized

infections requiring surgical diagnosis and

or treatment for management or that occur

as adjuvants to medical therapy

(acute appendicitis, cholecystitis & bowel

perforation with peritonitis)

4. Nosocomial Infections – are hospital-

associated or acquired during the course of

health care of the patient.

Types of Nosocomial Infections:

1. Exogenous – infection is acquired from

sources outside the body

( personnel & environment )

2. Endogenous – infection develops from

sources within the body.

( abdominal sepsis caused from enteric flora

due to perforation )

Classification of Surgical Wounds:

1. Clean Wound

- No inflammation present

- Procedure under ideal O.R. conditions

- No break in sterile technique

- GIT, respiratory, genitourinary &

oropharyngeal cavity not entered

Infection rate: 1% to 5%

2. Clean-Contaminated Wound

- No inflammation or infection present

- Minor break in technique occurred

- Primary closure, wound drained

- GIT, respiratory, genitourinary tracts &

oropharyngeal cavity entered under

controlled conditions & no spillage &

contamination


3. Contaminated Wound

- Major break in technique occurred

- Open fresh traumatic of less than 4 hours

- Acute non purulent inflammation present

- Gross spillage/contamination from GIT

- Entrance to genitourinary or biliary tracts

with infected urine or bile present


4. Dirty and Infected Wound

- Organism present in surgical field before

procedure

- Perforated viscus

- Old traumatic wound of more than 4 hours

- Existing clinical infection: acute bacterial

inflammation encountered, with or without

purulence


Sources of

Contamination

1. Skin

2. Hair

3. Nasopharynx

4. Fomites

5. Air

6. Human Error

7. Cross Infection

STERILE / AUTOCLAVE TAPES

PREPARING A

STERILE FIELD

O.R. SCRUB SUIT

Surgical Team

The Surgical Team / Perioperative Team:

1. Circulating Nurse – also known as the

“circulator”

Responsibilities:

a. Manages the operating room

b. Protects patient’s safety and health by

monitoring the activities of the surgical

team.

Checks and verifies the consent form.

Ensure fire safety precautions,

cleanliness, proper temperature, humidity

and lighting of the O.R.

Monitors safe functioning of the

equipments.

Coordinates with the surgical / peri-

operative team and monitors aseptic

practices.

Documents O.R. surgical activities

3. Scrub Nurse – responsible for scrubbing for

the surgery.

Responsibilities:

a. Setting up sterile tables

b. Preparing sterile sutures, ligatures &

special equipments

c. Assisting the surgeon & assistant

surgeon, taking care tissue specimens

d. Count all needles, sponges & instruments

together with the circulating nurse

4. Surgeon – head of the surgical team

Responsibilities

a. Performs the surgical procedure

5. RN/INTERN/Co-Surgeon First Assistant –

practices under the supervision of the

surgeon

Responsibilities:

a. Suturing and handling of tissues

b. Providing exposure at the operative field

c. Providing homeostasis

6. Anesthesiologist – is a physician

specifically trained in the art and science of

anesthesiology.

- Anesthetist is a qualified health care

professional who administer anesthetics.

Responsibilities:

a. Interviews and assesses the patient

b. Select & administer appropriate

anesthesia

c. Monitors V/S, ECG, ABG & anesthesia

levels

7. Post Anesthesia Care Unit (PACU) Nurse –

responsible for caring for the patient until

the patient has recovered from the effects

of anesthesia.

Responsibilities:

a. Monitors V/S and post-operative

complications

(bleeding, respiratory distress etc)

b. Carry out postoperative orders

c. Refer any abnormalities to the physician

Anesthesia

Anesthesia – a state of narcosis, analgesia,

relaxation and loss of reflexes.

Levels of Sedation and Anesthesia:

1. Minimal sedation – is a drug-induced state

wherein patient can respond normally to

verbal command. Cognitive & coordination

is impaired but respiratory &

cardiovascular is not affected.

2. Moderate Sedation – a depressed level

of consciousness that does not impair

the patient’s ability to maintain patent

airway & respond to physical

stimulation and verbal commands, often

called

“ monitored anesthesia care”

( intravenous drugs: midazolam &

diazepam )

3. Deep sedation – is a drug induced

state which a patient cannot be

easily aroused but can respond

purposely after repeated

stimulation.

• Difference of deep sedation and

anesthesia is that the anesthetized

patient is not arousable.

Types of

Anesthesia

Types of Anesthesia:

1. General anesthesia – (inhaled or

intravenously) refers to drug-induced

depression of the central nervous system

that produces analgesia, amnesia and

unconsciousness.

volatile liquids – Halothane, Isofluorane,

methoxyflurane, enflurane

Tranquilizers and Sedative-

Hypnotics - Midazolam ( Midazolam )

Diazepam ( Valium )

Opioids - Morphine, Meperidine Hcl

( Demerol )

Neurolept Analgesics – Fentanyl

Dissociative Agent – Ketamine

( Ketalar )

Barbiturates – Thiopental Sodium

( Pentothal )

Methohexital Na ( Brevital )

Nonbarbiturates Hypnotics –

Propofol (Diprivan)

2. Regional Anesthesia

– is a form of local anesthesia that

suspends sensation and motion in a body

region or part, the patient is awake and

continuous monitoring is required.

3. Spinal Anesthesia

– is a local anesthetic injected into the

subarachnoid space at the lumbar level to

block nerves and suspend sensation and

motion to the lower extremities, perineum

and lower abdomen.

4. Conduction Blocks – suspend sensation

and motion on various groups of nerves.

Types of conduction blocks:

a. Epidural block – anesthetic into space the

dura mater

b. Brachial plexus – produces anesthesia on

the arm

c. Paravertebral block – produces

anesthesia of the chest, abdominal wall &

ext.

d. Transacral (caudal) – anesthesia of the

perineum

General Anesthesia

Spinal Anesthesia

Local Anesthetics Agents

1. Lidocaine (xylocaine) – topical or injection

Advantages: Rapid, longer duration of action

compared with procaine & free from local

irritation effect

2. Bupivacaine (sensorcaine) – infiltration,

peripheral nerve block & epidural

Advantages: Duration is 2-3 times longer

than lidocaine

Local Anesthetics Agents

3. Procaine (Novocaine) – subcutaneously,

intramuscular, intravenously & spinal

Advantages: low toxicity & inexpensive

4. Tetracaine (Pontocaine) – topical,

infiltration & nerve block

Advantages: low toxicity & inexpensive

Stages of General Anesthesia:

Stage I Beginning anesthesia

– feeling of warmth, dizziness &

detachment may be experienced, unable to

move extremities easily, experiences

roaring, ringing & buzzing in the ears.

Stage II Excitement

– characterized by struggling, shouting,

laughing, crying, increased pulse and

irregular respirations. Pupils dilate but

contract to light.

Stages of Anesthesia

Stage III Surgical Anesthesia

– patient is unconscious and lies quietly

on the table, surgical procedure

begins. Pupils are small but contract

when exposed to light. Respirations

are regular, pulse rate normal, skin is

pink and slightly flushed.

Stages of Anesthesia

Stage IV Medullary Depression/Danger

– this stage is reached when too much

anesthesia has been administered.

Respiration is shallow, pulse is weak &

thready, pupils dilated & non-reactive,

cyanosis develops & without prompt

intervention death rapidly follows.

Types of Anesthesia

2. Regional Anesthesia – is a form of local

anesthesia that suspends sensation and

motion in a body region or part, the

patient is awake and continuous

monitoring is required.

3. Spinal Anesthesia – is a local anesthetic

injected into the subarachnoid space at

the lumbar level to block nerves and

suspend sensation and motion to the

lower extremities, perineum and lower

abdomen.

Intraoperative Complications

Potential Intraoperative Complications:

Nausea and Vomiting

– if it occurs, turn patient to side, the

head of the table is lowered and a basin

is provided to collect vomitus.

- Suction saliva and vomited gastric

contents.

- Administration of anti-emetics.

Anaphylaxis

– is a life threatening acute allergic

reaction that causes vasodilation,

hypotension and bronchial constriction.

- carefully observe the patient for

changes in V/S and symptoms of

anaphylaxis.

Hypoxia & other Respiratory Complications

– inadequate ventilation, occlusion of the

airway, inadvertent intubation of the

esophagus and hypoxia are potential problems

of general anesthesia

- Peripheral perfusion & pulse oximetry are

monitored continuously.

- Vigilant assessment of the patient’s

oxygenation status is a primary function of the

anesthesiologist or anesthetist or circulating

nurse.

Hypothermia – body temperature below 36.6

- caused by low temperature in OR, infusion of

cold fluids, inhalation of cold gases, open

body wounds, decreased muscle activity and

advanced age.

Malignant Hyperthermia

– is an inherited muscle disorder chemically

induced by anesthetic agent.

- Susceptible people include those with

strong and bulky muscles, a history of

muscle cramps or muscle weakness and

unexplained temperature elevation.

Pathophysiology of Malignant Hyperthermia

Halothane, Enflurane (GA gases), Succinylcholine (muscle relaxant),

Stress

Muscle cell activity

Muscles cells composed of inner fluid (sarcoplasm) and

Outer surrounding membrane

Calcium (essential factor in muscle contraction) is normally stored in

sarcoplasm

Nerve impulses stimulate the muscle

Calcium is released, allowing contraction to occur

Pumping action mechanism return calcium to the sac

so that muscle can relax

Pathophysiology of Malignant Hyperthermia

Malignant Hyperthermia, this mechanism is disrupted

Calcium ions accumulate causing clinical symptoms of

hypermetabolism

Increases muscle contraction (rigidity), hyperthermia

Damage to the Central Nervous system

Clinical Manifestation:

1. Tachycardia >150 beats/min. (earliest

sign)

2. Hypotension

3. Decreased cardiac output

4. Oliguria

5. Body temperature >40 Celsius (late sign)

6. Cardiac arrest

Medical Management:

1. Discontinuing the anesthesia and

surgery

2. Administration of a muscle relaxant

and Sodium Bicarbonate

3. Decrease body temperature

4. Correct electrolyte imbalance

Nursing Management:

- Identify patient’s at risk, recognize the

signs & symptoms, have appropriate

medications and equipment available.

Disseminated Intravascular

Coagulopathy

( DIC )

- is a life-threatening condition

characterized by thrombus

formation and depletion of

select coagulation proteins.

Patient Position on the Operating

Table:

1. Dorsal recumbent

– flat on the back, used for most

abdominal surgeries.

2. Trendelenberg position

- the head & body are lowered,

used for surgery on the lower

abdomen and pelvis.

3. Lithotomy position

– patient positioned at the back with

the legs and thighs flexed used for

perineal, rectal and vaginal

surgical procedures.

4. Sims or lateral position

– patient positioned on the non-

operative side, used for renal

surgery.

SUPINE

SITTING

LITHOTOMY

REVERSE

TRENDELENBERG

LATERAL

Preparation of the

Operative Site

-Skin preparation (skin prep) begins

before the patient arrive in the OR.

Purpose:

- is to render the surgical site as free as

possible from transient and resident

microorganisms, dirt, and skin oil so the

incision can be made through the skin

with minimal danger of infection from this

source.

DRAPING

Draping - is the procedure of covering the

patient and surrounding areas with a

sterile barrier to create and maintain an

adequate sterile field.

SURGICAL

INSTRUMENTS

Surgical Instruments

Important Nursing Consideration:

Surgical instruments are designed to

provide the tools the surgeon needs for its

maneuver, they are classified by their

functions whether small, short, long,

straight, curve, sharp or blunt. All surgical

instruments should be used for their

intended purposes only and should not be

abused.

Parts of the Surgical

Instrument

Finger Ring

Ratchets

Shank Boxlock/Hinge Joint

Tip

Jaws

Classification of Instruments:

1. Cutting and Dissecting – instruments that

have sharp edges, used to dissect,

incise, separate, cut and excise tissues.

Nursing Responsibilities:

1. These instruments should be kept

separate from other instruments.

2. Demand careful handling at all times.

Examples:

Scalpels, Blades, Scissors, Knives, Bone

cutters, Curettes and Biopsy forceps

2. Grasping and Holding

– instruments used to grasp or hold

tissues (soft or hard) during the

surgical operation.

Examples:

Thumb forceps, Tissue forceps, Allis

forceps, Babcock forceps, Tenaculum,

Bone holders

3. Clamping or Occluding – instruments

used to apply pressure or occluding blood

vessels to prevent bleeding.

Examples: Kelly/Clamps, Pean, Ochsner,

Vascular mixter

Mosquito Clamp Kelly / Clamp Vascular Mixter

4. Retracting or Exposing – instruments used

to pull aside tissues, muscles & other

structures for exposure of the surgical site.

Types:

a.) Handheld retractor

b.) Self-retaining retractor

Examples: Balfour, Army/Navy, Richardson,

Malleable, Hooks and Deaver

Army-Navy Balfour / Self-retaining

Deaver Richardson Double-ended Richardson

5. Suturing and stapling

– instruments used to close/suture

the tissues and other structures of

the operative site.

Examples: Needle holder, free

needles (round or cutting),

Atraumatic needle and staplers

Needle Holder Free Needles

Skin Stapler Atraumatic Suture Needle

6. Viewing Instruments

– used to view the operative site.

Examples: Speculum and

Endoscopes

Endoscopes

Vaginal Speculum

7. Suctioning and Aspirating

– instruments used to suction

blood and other body fluids on the

operative site.

Examples: Poole Suction, Cannula,

Trocar, Yankeur suction, Frazier

Suction

Yankeur Suction

Poole Suction

Frazier

8. Dilating and Probing

– dilating instruments are used to

enlarge orifice and ducts while a

probe is used to explore a

structure or to locate an

obstruction

Examples: Common bile duct

dilators, esophageal dilators,

Probes

Hegars Probes

Dilators

9. Accessory instruments

– used in addition to basic

instruments.

Examples: Towel clips, Bovie

pencil, Ruler

Towel Clips

Surgical Ruler

Cautery Pad

Cautery Cord

Bipolar Cautery TipKidney Basin

Key Points in handling the instrument:

1. Scrub person counts all instruments &

sharps with circulating nurse (before and

after) in the procedure.

2. Never pile the instruments on top of

each other.

3. Know the name & use of the

instrument.

4. Handle the instrument individually.

5. Hand the surgeon/asst. surgeon the

correct instrument.

6. Pass the instrument firmly & decisively.

7. Careful handling of sharp instruments

at all times.

Postoperative

Phase

Objective of Postoperative Period:

1. Maintain adequate body system

functions.

2. Restore homeostasis

3. Alleviate pain and discomfort

4. Prevent postoperative

complications

5. Ensure adequate discharge

planning and teaching

Post-Anesthesia Care Unit

Postanesthesia Care Unit (PACU)

– is located adjacent to the operating rooms,

patients under anesthesia are placed in this

unit for easy access to experienced, highly

skilled nurse, anesthesiologists, nurse

anesthetist, surgeons and special

equipments & medications.

- PACU is kept quiet, clean & free of

unnecessary equipments & well ventilated.

Phases of PACU:

1. Phase I PACU – used during the

immediate recovery phase and intensive

nursing care is provided

2. Phase II PACU – is reserved for patients

who requires less frequent observation

and less nursing care

- the patient is prepared for discharge.

Admitting Patient to PACU:

1. Anesthesiologist or anesthetist is

responsible in transferring the patient from

the O.R. to the PACU

2. Avoid unnecessary body exposure.

3. Avoid rough handling

4. Avoid hurried movement & rapid changes in

position

5. Nurse who admits patient to the PACU

reviews the following information:

a. Medical diagnosis and type of surgery

performed

b. Pertinent past medical history &

allergies

c. Patient’s age and general condition,

airway patency & vital signs

d. Anesthetics & other medication used in

the procedure

Nursing Management in the PACU:

Assessing the Patient

a. Appraise air exchanges status & note

skin color.

b. Verify & identify operative status &

surgeon.

c. Assess neurologic status (LOC)

d. Examine operative site & check

dressings

e. Perform safety checks

– good body alignment, side rails &

restraints for IVF & blood transfusion

f. Require briefing on problems

encountered in OR

Maintaining a Patent Airway

a. Lateral position with neck extended

b. Keep airway in place until fully awake

c. Suction secretions

d. encourage deep breathing

e. administer humidified oxygen as ordered

Maintaining Cardiovascular Stability

a. Monitor VS and report abnormalities

b. Observe signs & symptoms of shock and

hemorrhage

Classic signs/symptoms of shock:

1. Pallor

2. Cool & moist skin

3. Rapid Breathing

4. Cyanosis of the lips, gums & tongue

5. Rapid, weak, thready pulse

6. Decreasing pulse pressure

7. Hypotension & concentrated urine

c. Promote comfort & maintain safety

d. Continuous monitoring until patient is

completely out of anesthesia

e. Recognize & minimize factors that

may affect the patient in PACU.

Relieving Pain & Anxiety

a. Opioid analgesics administration

b. Allow family member to visit PACU

Controlling Nausea & Vomiting

a. Administration of anti-emetics

( metoclopramide (plasil), promethazine )

Determining Readiness for Discharge from

the PACU:

1. Stable vital signs

2. Orientation to person, place, events and time

3. Uncompromised pulmonary function

4. Pulse oximetry readings indicating adequate

blood oxygen saturation

5. Urine output at least 30 cc/hr

6. Nausea & vomiting absent or under control

7. Minimal pain

Modified Aldrete Scoring System –

determine the patient’s general

condition and readiness for transfer from

PACU, it allows more objective

assessment at regular interval.

Shock – response of the body to a

decrease in the circulating blood volume

which results to poor tissue perfusion &

inadequate tissue oxygenation (tissue

hypoxia)

1. Hemorrhage – copious escape of blood

from the blood vessel

Capillary: slow, generalized oozing

Venous: dark in color and bubble out

Arterial: spurts & is bright red in color

Clinical Manifestations:

1. Apprehension, restlessness, thirst,

cold, moist, pale skin

2. Deep & rapid RR, low body

temperature

3. Low cardiac output

Medical Management:

1. Vitamin K, Hemostan

2. Ligation bleeders, pressure dressing,

BT & IV fluids

2. Femoral Phlebitis / Deep

Thrombophlebitis – often occurs after

operation on the lower abdomen or during

the course of septic conditions as

ruptured ulcer or peritonitis.

Etiologic factors:

1. Injury: damage to vein

2. Hemorrhage

3. Prolonged immobility

4. Obesity / Debilitation


1. Pain

2. Redness

3. Swelling

4. Heat / warmth

5. Homan’s sign (cardinal sign)

Nursing Management:

(Active Intervention)

1. Bed rest, elevate affected leg with

pillow support

2. Wear anti-embolic support hose from

the toes to the groin

3. Avoid massage on the calf of the leg

4. Initiate anticoagulant therapy as

ordered

Preventions:

1. Hydrate adequately (to prevent

hemoconcentration)

2. Leg exercises and ambulate early

3. Avoid any restricting devices

4. Preventing use of bed rolls, knee

gatches, dangling over the side of the

bed with pressure on popliteal area

3. Wound Infections

Etiologic Factors:

a. Staphylococcus aureus

b. Escherichia coli

c. Proteus vulgaris

d. Pseudomonas aerogenosa

e. Anaerobic bacteria


1. Redness, swelling, pain, warmth

2. Pus or other discharges on the

wound

3. Foul smell from the wound

4. Elevated temperature, chills

5. Tender lymph nodes on the axilla or

groin

Rule of thumb

1. Fever 1st

24 hours – Pulmonary infection

2. Within 48 hours – Urinary Tract Infection

3. Within 72 hours – Wound Infection

Preventive Interventions:

1. Housekeeping cleanliness in the OR

2. Strict Aseptic Technique

3. Antibiotic therapy

4. Wound Complications

Kinds

1. Hemorrhage / Hematoma

2. Wound dehiscence – disruption in the

coaptation of wound edges

3. Wound Evisceration – dehiscence with

outpouching of abdominal organs

Nursing Management:

1. Apply abdominal binder

2. Encourage proper nutrition

3. Keep in Bed

4. Stay with client, have someone call M.D.

5. Cover exposed intestine with sterile, moist

saline dressing

6. Supine or semi-fowlers, bend knees to

relieve tension on abdominal muscle

5. Pulmonary Complications

– atelectasis, Brochitis, Bronchopneumonia,

Lobar pneumonia, Hypostatic pulmonary

congestion & pleurisy

Nursing Management:

1. Reinforce deep breathing, coughing,

turning exercises

2. Encourage early ambulation

3. Incentive spirometer

6. Intestinal Obstruction (3rd

– 5th

Postop day)

– Loop of intestine may kink due to

inflammatory adhesion

Clinical Manifestation:

1. Intermittent sharp, colicky abdominal

pains

2. Nausea and vomiting (fecaloid)

3. Abdominal distention, hiccups

4. Diarrhea, shock & death

Nursing Management:

1. NGT insertion

2. Administer electrolyte / IV as ordered

3. Prepare for possible surgical

intervention

7. Hiccups – intermittent spasms of the

diaphragm causing a sound “hic” that

result from the vibration of closed vocal

cords as air suddenly into the lungs

Etiologic Factor:

1. irritation of phrenic nerve between the

spinal cord and terminal ramifications on

undersurface of the diaphragm.

Nursing Management:

1. Remove the cause

2. NGT for abdominal distention

3. Hold breath while taking a large

swallow of water / Metoclopramide

administration

4. Breath in and out paper bag (CO2)

Promoting Home and Community-Based Care:

1. Teaching Patient’s self care

a. Give written instructions on medications,

medical check-ups, wound care, activity

& diet.

b. Provide the nurse and surgeon’s number

2. Continuing Care

a. Assess patient’s physical status (surgical

incision, respiratory, cardiovascular &

pain management)

3. Previous teachings is reinforced as

needed

4. Change the wound dressings,

monitor the drainage system &

administer medications

5. Patient reminded of the importance

of follow-up appointments.