Bulauitan MEDICAL SURGICAL NURSING
PERIOPERATIVE NURSING CARE
MANAGEMENT
INTRODUCTION
• Surgery, whether elective, or emergent, is
a stressful, complex event. Even healthy
clients having outpatient surgery may
experience unanticipated complications
during otherwise benign procedure
• Surgery is the art and science of treating
diseases, injuries, and deformities by
operation and instrumentation
• Physicians who perform surgeries include
surgeons or other physicians trained to
do certain surgical procedures
• As technics to perform surgery change
with improved technology and expertise,
surgery becomes less invasive and
thereby less debilitating.
• The increased use of Minimal Invasive
Surgery (MIS) enables many surgery to
be performed on an outpatient basis
• Laser and scope technology continue to
lead newer procedures that offer less risk,
less invasion, faster recovery and
reduced hospitalization, or ambulatory
surgery
• Research during best practices —>
Improved outcomes in all areas of the
periop experience
• Newer diagnostic and intervention
devices being developed such as the
Gamma knife (tumor resection); Robotics
and other types of MIS
1
MAJOR TYPES OF PATHOLOGIC
PROCESSES REQUIRING SURGICAL
INTERVENTION
‣ Perforation: rupture of an organ
‣ Obstruction: impairment to the flow of vital
fluids - e.g. blood, urine, CSF, bile
‣ Erosion: wearing off a surface or
membrane
‣ Tumors: abnormal new growths
DIFFERENT CATEGORIES OF
SURGERIES
‣ According to purpose…
- Diagnostic: to obtain tissue samples,
make an incision or use a scope to
make a diagnosis - e.g. biopsy
- Ablative or Curative: removal of
disease or abnormal tissues - e.g.
inflamed appendix, tumor benign cyst
- Cosmetic/Aesthetic: performed
primarily to alter and/or enhance
personal appearance - e.g. liposuction,
revision of scar, blepharoplasty
- Exploratory: conformation or
measurement of extent of condition -
e.g. exploratory laparotomy
- Preventive: removal of tissue before it
causes a problem - e.g. mole or polyp
removal
- Restorative: performed to improve a
client’s functional ability - e.g. total knee
replacement
- Palliative: alleviation of symptoms
without curing the disease - e.g.
Rhizotomy cuts, nerve root to relieve
pain); gastrostomy tube insertion of
swallowing problem
Bulauitan MEDICAL SURGICAL NURSING 2

- Transplant: to replace organs/tissue to

restore function - e.g. heart, lung, liver,
kidney transplant
‣ According to risk of surgery…
- Major: procedure of greater risk,
usually longer and more extensive than
a minor procedure. - e.g. mitral valve
replacement; pancreas transplant
- Minor: procedure without significant
risk; often done with local anesthesia -
e.g. I & D(insertion and drainage);
muscle biopsy
‣ According to extent of Surgery…
- Simple: only the most overtly affected
areas involved in the surgery - e.g.
Simple/partial mastectomy
- Radical: extensive surgery beyond the
area obviously involved, is directed at
finding a root cause - e.g. radial
prostatectomy
- MIS: Minimal Invasive Surgery
‣ According to urgency
- Elective: planned/scheduled, with no
time requirement - e.g. Hernia repair,
joint replacement, skin lesion removal
- Urgent: surgery is needed within 24-30
hrs - e.g. Infected gallbladder
- Emergent: immediate surgery needed
to save life or limb - e.g. Ruptured aortic
aneurysm or Appendix; Traumatic limp
amputation
PERIOPERATIVE PERIOD
• Encompasses the patient’s total surgical
episode
‣ Phases: Preoperative Phase >
Intraoperative Phase > Postoperative
Phase
• Each phase includes a wide range of
activities the nurse performs using the
nursing process.
‣ Surgical Settings
✓ Inpatient Surgery
✓ Outpatient Surgery - Day Surgery,
Ambulatory Surgery
✓ Physician’s Clinic or Offices
✓ Freestanding Surgical Centers
‣ Surgical Risk: the probability of morbidity
or death from surgery
‣ Preadmission Testing:
- Done to reduce hospital stay and
contain cost
- Initiates the nursing assessment
process
‣ Special Considerations During the
Periop Period
✓ Gerontologic
✓ Obese Clients
✓ Clients with disabilities
✓ Clients undergoing ambulatory surgery
✓ Emergency surgery
Bulauitan MEDICAL SURGICAL NURSING 3

‣ Nurse can clarify any information that

PREOPERATIVE PHASE
remains unclear after the MD’s explanation
of the procedure
Informed Consent: ‣ Nurse’s Role: witness the client signing of
The client’s autonomous decision about the consent form after the client
whether to undergo a surgical procedure acknowledges
‣ Purpose:
- to ensure that the client Circumstances Where the Informed
understands the nature of the Consent is Necessary
treatment including the potential
complications na disfigurement
‣ Any surgical procedure where scalpel,
- to indicate that the client’s decision
scissors, suture, hemostats, or
was made without pressure
electrocoagulation may be used
- to protect the client against
‣ Entrance into a body cavity
unauthorized procedure
- e.g Paracentesis, bronchoscopy,
- to protect eh surgeon and hospital
cystocopy, colonscopy,
agains legal action by a client who
proctosigmoidoscopy
claims an unauthorized procedure
‣ General anesthesia, local infiltration,
was performed
regional block

Who Signs:
Preoperative Assessment

‣ Adults who are mentally capable sign

‣ Nutritional and Fluid Status:
their own operative permit
- Optimal Nutrition: Promotes healing
‣ For minor (below 18yrs), unconscious,
and resisting infection and other
psychologically incapacitated,
surgical complications
permission is required from responsible
‣ General Risk Factors:
family member parent/legal guardian
- Obesity
‣ A witness is desirable
- Fluid, electrolyte and nutritional
‣ Nurse, physician, or other
problems
authorized persons
- Age
‣ In a emergency, permission via
- Smoking
telephone or telefax is acceptable
- Presence of disease/s
‣ Written permission is best and is legally
- Concurrent or prior pharmacotherapy
acceptable
‣ Nutrient Important in Wound Healing:
‣ Signature is obtained before sedation
- Protein: helps body repair damaged
with the client’s complete understanding
tissues
of what is to occur
- Vitamin C: form new collagen
- Vitamin B Complex: (B1, B2, B3)
• MD to obtain consent once surgery has
metabolize carbohydrates
been discussed with client
- Vitamin A & K, etc.
- A: control inflammatory
response
Bulauitan MEDICAL SURGICAL NURSING
‣ Dentition:
- Dental caries, dentures and partial
plates: are particularly significant to
anesthesiologist or anesthetist
‣ Drug or Alcohol use:
- Client may suffer from malnutrition and
withdrawal symptoms R/T significant
mortality rate
‣ Respiratory Status:
- Optimal respiratory function is the goal
for surgical client
- In assessing pulmonary status, observe
the client’s:
✓Posture
✓Fingers (f or clubbing)
✓Respiratory Rate, depth and rhythm
✓Lung expansion
- If client has respiratory infection surgery
is postponed
- Clients with under lying respiratory
problems (asthma, COPD) are assess
for current threats to their pulmonary
status
- Preop Smoking Cessation: 4-8 weeks
before surgery
‣ Cardiovascular Status:
- Cardiovascular assessment:
✓Palpation of peripheral pulses
✓Auscultation of heart sound for rate,
regularity and abnormalities
➡ Presurgical Goal: Ensure a well
functioning CV system to meet the
oxygen, fluid and nutritional needs of
the perioperative period
- Postponing the surgery or modifying the
surgical treatment to met cardiac
tolerance/needs of the client
4
‣ Hepatic and Renal Function:
- Presurgical Goal: Optimal function of
the liver and urinary system so that
medications, anesthetic agents, body
wastes, and toxins are adequately
metabolized and removed from the
body
‣ Endocrine Functions:
- Diabetic Patients: At risk for Hyp/
Hyperglycemia
- Clients receiving steroids: at risk for
adrenal insufficiency
- Clients with uncontrolled thyroid
disorders:
- at risk for thyrotoxicosis
(Hyperthyroid Disorders) respiratory
failure (hypothyroid disorders)
✓ Assess clients for history of above
orders
‣ Immune Function:
- Determine the presence of allergies
- Immunosuppresion: is common with
corticosteroid therapy, renal
transplantation, radiotherapy, and
chemotherapy and disorders affecting
the immune system such as AIDS and
leukemia
- Ensure strict asepsis
‣ On Herbal Preparations
- Most commonly used are Ephedra;
Echinacea; Garlic; Gingko biloba;
Ginseng; Kava Kava; St. John’s word;
Licorice Extract and Valerian
Bulauitan MEDICAL SURGICAL NURSING 5

Herb Effects Medication Affects

Gingko biloba, Alters clotting

Garlic, Ginger and Prevent clot formation Anticoagulants *DC 48H before
Ginseng surgery*

CI to those taking meds Diuretics Electrolyte Imbalance

Gingko biloba
for seizure
Antihypertensive Hypotention
Anti-Depressant
St. Johns Wort *prolong sedative effects Antidepressants Hypotension
of anesthesia*
Potentiates action of
Antibiotics
Relaxant anesthetic
Kava-Kava *prolong sedative effects
Inability to withstand
of anesthesia* Corticosteroids
stress
Chamomile Sedative effect
Insulin
impairs clotting, used for
Feverfew reduces cardiac
migraine headaches Antidysrhythmics
contractibility
used for enlarged interacts with
prostate gland, diuretic Herbal Supplements
anesthetics
and urinary antiseptic,
Saw Palmetto
reduces sexual drive
(affects testosterone) CI: ‣ Psychological Factors:
Hormonal Therapies
- Causes of Fears of the preop clients
Tx: Menopausal • Fear of the unknown
Symptoms
✓ Herbal Preparations:
• Fear of anesthesia, vulnerablility
Black Cohosh while unconscious
should be DC
2-3wks before • Fear of pain
surgery
• Fear of death
‣ Previous Medication Use: • Fear of disturbance of body image
- Obtain medication history - Worries.. loss of
- Medications affecting surgery: • finances
• employment,
• social and family roles

- Preop Anxiety - Nursing

Interventions to Minimize Anxiety:
• Explore client’s feelings
• Allow client’s to speak openly about
fears/concerns
• Give accurate information regarding
surgery
• Give empathetic support
• Consider the person’s religious
preferences and arrange for visit by
priest/minister as desired
Bulauitan MEDICAL SURGICAL NURSING 6

- Important Outcome of Psychosocial - Anticipatory Grieving

Assessment: - Body Image Disturbance
• determine extent and role of the
client’s support network
Planning - Expected Outcomes: Examples

‣ Spiritual and Cultural Factors

- Spiritual beliefs play an important role in ‣ For Knowledge Deficit:
how people cope with fear and anxiety - The client will verbalize understanding
- Showing respect for a client’s cultural of the preparations for the perioperative
values and beliefs facilitates rapport experience
and trust ‣ For Anxiety:
- The client will appear relaxed and will
report that anxiety is reduced to a
Diagnostic Testing
manageable level
‣ For Fear:
‣ Complete Blood Count - The client will demonstrate appropriate
- WBC, RBC range of feeling and will verbalize that
‣ Electrolyte Studies fear has lessened
- K+, Na+, Cl-
‣ Coagulation Studies
GENERAL Preop Nursing Interventions
- Prothrombin Time (PT)
- Partial Thromboplastin Time
‣ Urinalysis ‣ Providing Patient Teaching:
‣ Chest X-Ray: Components
- especially in the elderly with risk factors 1. Sensory Information:
related to heart and lung function • Sights, Sounds and “Feel” of the
‣ Creatinine OR
‣ ABG 2. Psychosocial Information
‣ Blood Urea Nitrogen (BUN) • coping abilities and worries about
‣ Albumin family
‣ ECG: routinely for 40+ yr old or have 3. Procedural Information
cardiovascular disease • details during the preoperative
period and postoperative care
✴Purpose:
Analysis: Nursing Diagnoses
• Discussion, demonstration, and
practice
‣ Common Diseases • If client must remain in bed it is
- Knowledge Deficit R/T perioperative important for them to turn,
experience cough and deep breathe q 2hrs
- Anxiety
- Fear
‣ Additional Diagnoses
- Sleep Pattern Disturbance R/T Fear of
Impending Surgery
- Ineffective Individual Coping
Bulauitan MEDICAL SURGICAL NURSING 7

‣ Deep Breathing, Coughing And

Incentive Spirometry -
- Deep Breathing Exercises:
• regardless of which type of
breathing use used the nurse
emphasizes the need to begin
exercises early in the recovery
phase and to continue them 5-10x
every 1-2hrs for at least the first
48hrs
- Coughing Exercises:
• removes retained secretions from
bronchi and airways
• Purpose
• Coughing is performed in
conjunction with deep breathing
every 1-2hrs postoperatively
๏ Splinting
- Incentive Spirometry:
• Promote expansion of alveoli by
guiding the client to reach a
predetermined level of lung inflation
strengthens respiratory muscles
Preparing the client for Tubes, drains and
vascular access
‣ Instruction for Clients undergoing
Ambulatory Surgery
- Verbal and written instructions be
provided
- Outcomes and complications
- Limiting activities
- Referral for home care
- Followup care
Providing Psychosocial Interventions
‣ Reducing anxiety and decreasing fear
- Assist client identify coping strategies
- Discuss regarding post-op routines,
tubes and equipment
‣ Respecting cultural, spiritual, and
religious belief
Maintaining Patient Safety

‣ Mobility and Active Body Movement ‣ Protecting clients from injury

- Purpose: improve circulation, prevent ‣ side rails
venous stasis, and promote optimal
respiratory function Managing Nutrition and Fluids
• Position Changes
• Exercise of extremities
‣ Purpose
• Ambulation
‣ On NPO
• Use of TED hose
‣ Some alterations in the client’s usual
medication schedule
‣ Pain Management

‣ Cognitive Coping Strategies -

- useful for relieving tension, overcoming
anxiety, decreasing fear and achieving
relaxation
• Imagery
• Distraction
• Optimistic Self-Recitation
• Music Therapy
Bulauitan MEDICAL SURGICAL NURSING 8

Preparing the Bowel Administering Preanesthetic Medications

‣ Goals
‣ Purpose of bowel or GI prep - To facilitate the administration of any
- For clients undergoing abdominal or pelvic anesthetic
surgery, a cleansing enema or laxative may - To minimize respiratory tract and
be prescribed the evening before surgery, secretions
and maybe repeated the morning of - To relax the client and reduce anxiety
surgery changes in heart rate

Preparing the Skin Commonly Used Pre-op Medications

Medication Action Example

‣ Purpose of skin prep
Tranquilizer decrease anxiety Diazepam (Valium)
- Instruct client to use germicidal and apprehension Droperidol
detergent (Inapsine)

Sedatives diminishes physical - Hydroxyzine

and mental (Vistaril;Atarax)
IMMEDIATE Preop Nursing Interventions responses at lower - Promethazine
dosages of certain HCl (Phenergan)
CNS depressants - Secobarbital
but does not effect Sodium (Seconal
‣ Awaken early for preparation consciousness Sodium)
- Pentobarbital
‣ Nurse make assessments Sodium
‣ Client to remove all clothing, hair covered (Nembutal
Sodium)
‣ Anti-embolism stockings or ace bandages ‣
are applied
Hypnotics produces a form of Lozepam
‣ Remove all jewelries: tape wedding bands “natural” sleep
‣ Religious emblems may be pinned or Anxiolytics used to treat Midazolam HCl
securely fastened to client’s gown anxiety and (Versed)
insomnia
‣ Client wears an ID band
Opioid relieve pain - Morphine Sulfate
‣ Dentures, including partial dental plates Analgesics - Fentanyl Citrate
‣ All prosthetic devices are removed (Sublimaze)
‣ Hear aids, may be taken out after - Meperidine
(Demerol)
anesthesia has been administered
- Hydromorphone
‣ Hairpins and clips, wigs and toupees are
Anticholinergi control secretions, - Atropine Sulfate
removed cs (reduce the rigidity - Glycopyrrolate
‣ Removal of fingernail polish: the policy of and some of the (Robinul)
the facility is followed tremors
characteristic of
‣ The nurse asks the client to empty his or
Parkinsonism)
her bladder
H2 Receptors inhibits HCl acid - Cimetidine
‣ Measurement of VS before the Antagonist production (Tagamet)
administration of preop meds and transfer - Rantidine
of the client to the surgical suite (Zantac)

Rapid - Metaclopramide
Emptying of (Reglan
Stomach
Bulauitan MEDICAL SURGICAL NURSING 9

‣ “On call to OR”

Expected Patient Outcomes
- there is no schedule time to take
medication to the OR.
‣ The nurse evaluates the care of the Preop
‣ Nursing care after administering Meds client according to the identified Nursing
Diagnoses
‣ It may include the following: The Client Will
Maintaining the Preop Record
- Verbalizes understanding of the
informed consent as it applies to
‣ Complete chart and checklist surgery
‣ Review chart to ensure that all - States an understanding of the preop
documentation, preop procedures, and dietary restrictions
orders are completed - Verbalizes understanding of and the
‣ Report special needs, concerns and reason for bowel prep
instruction (Advanced Directives) to the
surgical team

Transporting the client to the Presurgical

Area

‣ Most clients are transferred to the surgical

suite on a stretch with the sider rails up, or
the client is transferred in bed.
‣ The client, along with the signed consent
form, completed preoperative checklist, and
chart are transported to the surgical suite

Attending to the Family Needs

‣ Direct client’s family to the waiting room

‣ Teach family about the surgery, schedule or
any changes, Intraop and Postop
procedures
Bulauitan MEDICAL SURGICAL NURSING 10

THE SURGICAL TEAM

Circulating Nurse

‣ Surgeon
‣ Core member of the surgical team
‣ Surgical Assistant
‣ Maintains coordination of all team members
‣ Anesthesiologist
‣ Maintains client advocate role
‣ Circulating Nurse
‣ Managing nursing care and coordinating
‣ Scrub Nurse
needs of surgical team
‣ Oversees physical aspects of the OR,
Surgeon including equipment
‣ Assists in transfer and positioning
‣ Skin prep, ensures no break in the sterile
‣ Perform procedure, head of the surgical
technique
team
‣ Anticipate needs of team
‣ Responsible for all medical actions and
judgments
Scrub Nurse

Surgical Assistant
‣ Technical skills, manual dexterity, in-depth
knowledge of the anatomic and mechanical
‣ Works closely with surgeon in performing
aspects of surgery
operation, can either be a physician, nurse,
‣ Organizes surgical equipment and hands
physician’s assistant or other trained
the surgeon appropriate instruments
personnel
required for operation
‣ Duties:
‣ Prepares and preserves sterile field
- Exposing operative site
- Retracting nearby tissue
- Sponging Behind the Scenes
- Suctioning the wound
- Ligating bleeding vessels
‣ Radiologist Technologist
- Suturing or helping suture the surgical
‣ Anesthesia Technician
wound
‣ Nursing Technician
‣ Transport Team
Anesthesiologist ‣ Environmental Services

‣ Evaluates client preoperatively

‣ Administers anesthesia and other required
medications
‣ Transfuses blood and other blood products
‣ Infuses IV
‣ Continuously monitor client’s status
‣ Alerts surgeon of developing problem and
treat them as they arise
‣ Supervises client’s recovery
Bulauitan MEDICAL SURGICAL NURSING
The Surgical Environment
‣ Three Areas of the Surgical Suite
- Unrestricted: street clothes and
scrubs, holding area and staff area
- Semi-Restricted: surgical attire
required, corridors and support area
- Restricted: full surgical gear, OR
rooms
‣ Surgical Suite: is arranged so that cross
contamination is prevented from clean to
sterile areas.
‣ Surgical Attire:
- scrub suit, shoe covers, cap or hood to
cover hair
‣ Sterile Attire:
- scrub suit, shoe covers, cap or hood to
cover hair, gown, gloves and mask
‣ Surgical Scrub:
- performed to render hands and arms as
clean as possible in preparation for the
procedure
- Purpose: of the Surgical Scrub
• Removes dirt, skin oils and transient
microorganisms from hands and
forearm
• Increase client safety by reducing
microorganisms on surgical
personnel
• Leave an antimicrobial residue on
the skin to inhibit growth of
microbes for several hours
‣ Principal of Surgical Asepsis
- Only sterile materials may be used
within a sterile field
- Gowns of scrubbed team members are
considered sterile in front, from
11
shoulders to waist levels and sleeves to
two inches above the elbow
- Draped tables are considered to be
sterile on the top surfaces only
- Sterile surfaces should contact only
sterile areas
- Edge of any sterile package or counter
are considered unsterile
• Caps of bottle or a sterile solution
are considered contaminated once
the cap is removed
- Non-sterile items should not cross over
a sterile field
- There should be no talking, laughing,
coughing, or sneezing across a sterile
field
- Personnel with colds should avoid
working while ill or apply a double mask
- Edges of sterile areas or fields
(generally the outer inch) are not
considered sterile
- When pouring fluids, only the lip and
inner cap of the pouring container is
considered sterile, the pouring
container should not touch the receiving
container, and splashing should be
avoided
- Tears in barriers and expired
sterilization dates are considered break
in sterility
- Contaminated items must be removed
immediately from the sterile field
- An important principle of aseptic
technique is that fluid (a potential mode
of pathogen transmission) flows in the
direction of gravity
• With this in mind, hands are held
below elbows during the surgical
scrub and above elbows following
the surgical scrub
- Only areas that can be seen by the
clinician are considered sterile (i.e., the
back of the clinician is not sterile.
Bulauitan MEDICAL SURGICAL NURSING 12

3. Lithotomy: exposes perineal and

Preparing the Client
‣ Final Skin Preparation
- The skin prep begins at the proposed
incision line and proceeds to the
periphery of the area involved
- Remember, a soiled sponge is never
brought back over a scrubbed area
rectal areas; vaginal repairs, D and C,
rectal surgery, APR
(abdominoperineal resection); 18%
decreased vital lung capacity of the
lungs
4. Prone: used for spinal surgeries,
laminectomy

‣ Positions and Use 5. Lateral: used for kidney, chest, hip

surgeries

- The final responsibility for the positioning 6. Semisitting Position: for surgeries
of the client- shared by the circulating on thyroid and neck areas
nurse, the MD and the anesthesiologist
7. Jackknife: used for proctologic
‣ Factors to Consider when Positioning surgeries (removal of hemorrhoids)
the Client and some spinal surgeries;
1. Site of the operation - 12% decreased vital capacity of
2. Age and size of the client the lungs
3. Type of anesthetic used
4. Pain normally experienced by the
client upon movement Equipment Used for Proper Positioning
5. The ability of the client to move
1. Straps
‣ The Positing of the Client Must Not 2. Wrist Restrains
1. Compromise circulation 3. Arm Boards
2. Cause pressure points from bony 4. Donuts
prominences 5. Sandbags or Rolls
3. Restrict ventilation due to pressure on 6. Stirrups
the upper thorax
4. Cover the operative site
Gowning and Gloving

‣ Positions During Surgery

1. Supine: used for hernia repair, ‣ Methods of Gloving
mastectomy, bowel resection, 1. Open
coronary artery bypass 2. Closed
3. Offering
2. Trendelenburg: used for lower
abdomen, pelvic surgeries permits
displacement of the intestines into the
upper abdomen
Bulauitan MEDICAL SURGICAL NURSING 13

‣ Subcuticular or Buried
Sterile Draping
‣ Running Closure

‣ Purpose: to keep equipment sterile

The Surgical Experience
‣ Kinds of linens:
- Towels
- Whole or half sheets ‣ During the surgical procedure, the client will
- Fenestrated or slit drapes need sedation, anesthesia, or some
combination of these

Instruments and Sutures

Anesthesia

‣ Instruments are classified according to

‣ From the Greek word Anesthesis meaning
their use during surgery
“negative sensation:
- Cutting: scalpel, knife, scissors
‣ Produces unconsciousness, analgesia,
- Grasping and Holding: Allis, tissue
reflex loss and muscle relaxation during
forceps
surgery
- Clamping and Occluding: hemostats
- Viewing: speculums, retractors,
endoscopic instruments
- Suturing and Stapling: needle holders
and needles; staplers
- Suctioning, irrigating and aspirating
- Dialating and Probing
- Measuring: calipers
- Accessory: mallet, bone drills,
screwdrivers
- Exposing and retracting: retractors
- Needles

Types of Suture Materials

‣ What are the different types of
‣ Absorbable sutures: Anesthesia?
- Chromic, Plain, Vicryl - General Anesthesia
‣ Nonabsorbable sutures: - Regional Anesthesia
- Silk, Cotton, Nylon - Combined General and Epidural
Anesthesia
Common Skin Closure Suturing Methods - Monitored Anesthesia Care with
Conscious Sedation

‣ Plain: Interrupted
- Single Interrupted Closure
‣ Mattress: Continuous
- Horizontal Mattress
- Vertical Mattress
Bulauitan MEDICAL SURGICAL NURSING
General Anesthesia
Stages of Anesthesia:
a. Stage I: Onset/Induction
‣ Administration of anesthesia to the
time of loss of consciousness
✴ Nursing Intervention
- Close operating room doors and
control traffic in and out of room
- Position client securely with
safety belts
- Maintain minimal discussion in
the OR
b. Stage II: Excitement/delirium
‣ Loss of consciousness to the time
of loss of lid reflex characterized by
shouting, talking, singing, laughing,
or crying, struggling of the client.
✴ Nursing Intervention
- Shield client from extra noice
and physical stimuli
- Protect the client’s extremities
- Assist anesthesia personnel as
needed. Stay with the client
c. Stage III: Surgical
‣ Loss of lid reflex to the loss of most
reflexes surgical procedure is
started
✴ Nursing Intervention
- Assist anesthesia personnel with
intubation of client in position for
surgery
- Prep the clients skin in area of
operative site
d. Stage IV: Medullary/Stage of
danger
‣ Characterized by cardiac/respiratory
depression or arrest due to
overdose of anesthesia,
resuscitation must be done
14
✴Nursing Intervention
- Prepare for and assist in
treatment of cardiovascular and/
or pulmonary arrest
- Document in record
General Anesthesia
‣ Total loss of consciousness and sensation
‣ Produces amnesia
‣ Methods of administration
- Intravenous
- Inhalation
- Combination of IV and Inhalation
Intravenous Agents
‣ These medications may be given to induce
or maintain anesthesia. Although they are
often used in combination with inhalation
anesthetic agents, they may be used alone.
they may also be used to produce
moderate sedation.
‣ Advantage:
‣ Onset is pleasant, none of the
buzzing, roaring, or dizziness known
to follow administration of an
inhalation anesthetic.
‣ The duration of action is brief, and
the patient awakens with little
nausea or vomiting
‣ Thiopental sodium (Pentothal) commonly
called “Sodium penthotal” (Class:
Barbiturate)
‣ Diprivan (Propofol - Milk of amnesia)
• Rapid acting
• Monitor vital signs
• Respirator depression
Bulauitan MEDICAL SURGICAL NURSING 15

Inhalation Agents Complications of General Anesthesia

‣ Inhalation: most controllable method; ‣ Minor complications

lungs act as passageway for entrance & ‣ Hypotension
exit of agent
‣ Mask, Endotracheal tube (ETT) or ‣ Malignant Hyperthermia:
Laryngeal managed airway (LMA) - acute, life-threatening complication of
certain drugs
‣ Gas agent: ✓Symptoms:
Agent Notes • Tachycardia
• Continual increase in body temp -
Nitrous Oxide - Must be given with
which can recur - during the post-
O2
- Require assistance operative period
to mechanical • Cyanosis
ventilation • Hypotension
- Frequently shiver
- Taken in & excreted • Muscle rigidity
via lungs • Dark color of blood in the surgical
wound
‣ Volatile Liquids
• Arryhythmias
- Examples:
✓Treatment:
Agent Notes • Immediate discontinuation of the
Halothane surgery
• Cooling of the patient
Ethrane
(administration of iced IV solutions
Isoflurane • Iced nasogastric gavage
Desflurane
• Packing the client in ice
• Medication Administered
Sevoflurane simultaneously* :
‣ Adjuncts to General Anesthesia ❖ Dantrolene Sodium (Dantrium)
❖ Steroids
Agent Drug Notes
❖ Diuretics
Hypnotics Versed, also used for ❖ 100% O2 to induce
Valium conscious
hyperventilation
sedation

Opioid Morphine, causes Other Complications from General

Analgesics Demerol respiratory
depression Anesthesia

Neuromuscular Pavulon, causes

Blocking Succinycholine muscle ‣ Malignant Hyperthermia: possible tx with
paralysis
Dantrolene
‣ Overdose
‣ Unrecognized hypoventilation
‣ Complications of specific anesthetic agents
‣ Complications of intubation
‣ Anesthesia Awareness
Bulauitan MEDICAL SURGICAL NURSING 16

- Cuff inflated only 2-hrs

Regional Anesthesia
‣ Medication is instead around the nerve and
blocks the transmission of nerve impulses
‣ Produces analgesia, relaxation and
reduced reflexes
‣ Client is awake and conscious but does not
perceive pain
Technics of Administration
‣ Topical: cocaine
solution, lidocaine
(xylocaine),
benzocaine
‣ Local Nerve
Infiltration: lidocaine
or tetracaine is
injected around a
local nerve to
depress nerve stimulation, used in skin or
muscle biopsy
‣ Nerve block: injecting
anesthetic at the nerve
trunk to produce lack of
sensation over an area
(extremity)
‣ Field block: area
proximal to a planned
incision is injected/infiltrated
with anesthetic block forms
a barrier btw incisions and
the nervous system
‣ IV Regional “bier block”: regional
anesthesia of a limb where lidocaine is
injected into the vein of the limb to be
anesthetized
- Pneumatic dual-cuff tourniquet: is
applied preventing the agent from
circulating beyond the area undergoing
the procedure
increments
- Used in procedures of
the extremities with
short duration
‣ Spinal Anesthesia: injecting local
anesthetics into the subarachnoid space
- Autonomic nerve fibers are affected first
and also last to recover
- Spinal anesthesia blocks fibers in
this order:
Touch > Pain > Motor > Pressure >
Proprioceptive Fibers
- Recovery in reverse order!
Proprioceptive Fibers > Pressure >
Motor > Pain > Touch
- Used in surgeries of the lower
abdomen, perineum and lower
extremities
✴ Leakage of CSF from needle
insertion site causes reduced CSF
pressure and post op headaches
- Anesthesia: starts from tip of Xiphoid
process to toes
- Risks:
• loss of vasomotor tone
• “Spinal Headache”
• Infection (meningitis)
• Rising anesthesia above diaphragm
- Example of anesthetics
• Procaine (novocaine)
• Tetracaine (pontocaine)
• Lidocaine (xylocaine)
• Mepidivacaine (carbocaine)
• Bupivacaine (marcaine)
✓ Nursing care after:
- Keep flat
- Monitor VS & offer fluids when
appropriate
Bulauitan MEDICAL SURGICAL NURSING 17

‣ Complications and Discomforts of vomiting, tremors, seizures, increased

Spinal Anesthesia: pulse, respirations, and blood pressure
• Hypotension
• Nausea/Vomiting Treatment of Complications
• Headache
• Respiratory paralysis
‣ Establish an open airway
• Neurologic complications
‣ Give O2
(paraplegia, sever muscle
‣ Notify the surgeon
weakness of the legs
‣ Fast-acting barbiturate is usual treatment
‣ If toxic reaction is untreated,
‣ Epidural Anesthesia
unconsciousness, hypotension, apnea,
-Local anesthesia agents injected into
cardiac arrest, and death may result
the epidural space outside the dura
mater of the spinal cord
Moderate (Conscious Sedation)
-Used for surgeries of the abdomen
and lower extremities
-Injected into epidural space rather ‣ Reduce intensity of pain w/o loss of
than subarachnoid fluid (usually defensive reflexes
safer) ‣ Usually a combination of opioid analgesic
-Used for OR & OB and sedative-hypnotics
-Epidural catheter can be held in ‣ May be administered by credentialed RN
place for postop pain management ‣ Expect clients to be sleepy but arousable
(PCA) ‣ Just because his eyes are closed
doesn’t mean he’s asleep
Regional Anesthetic Risks
Balance Anesthesia

‣ Anaphylaxis (allergy)
‣ Incorrect administration technique
‣ Systemic absorption of medication
‣ infection
Complication of Local or Regional
Anesthesia
‣ Start with Pentothal or Propofol
‣ Add in some Nitrous oxide for amnesia
‣ Use inhalation agent such as Halothane
‣ Stir in a little opiate-Morphine, Fentanyl, for
postop analgesia
‣ To top if off Pavulon, a neuromuscular
blocker, for additional muscular relaxation

‣ Anaphylaxis
‣ Incorrect Delivery Technique
‣ Systemic Absorption
‣ Overdoseage
‣ Assess for Central Nervous System
stimulation, central nervous system and
cardiac depression, restlessness,
excitement, incoherent speech, headache,
blurred vision, metallic taste, nausea and
Bulauitan MEDICAL SURGICAL NURSING
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 adequate personnel to
help transfer the client - at least 4 ppl
‣ Cover client and secure well for safety
‣ The Anesthesiologist and Circulation Nurse
accompanies the client to the PACU
Practices to Avoid
‣ Overexposure of the client
‣ Rough handling
‣ Hurried movements and sudden changes in
position
‣ Hurried movements and sudden changes in
position
Documentation
‣ A review of the client’s chart is done in the
holding area by the Circulating Nurse
Patient-Centered Collaborative Care
1. Assessment:
- On arrival to the surgical suite (OR), the
client is placed in the holding area. The
circulating nurse meets the client,
identifying him/herself
- As the nurse who will be with the client
during surgery and continuous to do
the following:
• Verifies the client’s identity
• Assess the client’s emotional and
physical status
• Confirms the information on the
preop checklist and performs chart
review
18
- Rapidly assess the client’s status,
giving particular attention to any factors
that would increase the surgical risk
- Continuous assessment during the
client’s transfer to the or table, induction
of anesthesia and draping
- Ongoing assessment during the
surgical procedure
- Monitoring of equipment needed to
maintain the client’s safety
2. Analysis - Nursing Diagnosis
‣ Common Diagnosis:
- High risk for injury r/t
Anesthesia;Intra-operative
Positioning
- Impaired skin integrity r/t surgical
wound
- Impaired gas exchange r/t
anesthesia
- Fluid volume Deficit r/t blood loss
and loss of body fluids during
surgery
- Potential for infection r/t Surgical
wound
- Fear r/t Anesthesia
- Anxiety r/t Anesthesia
- Powerlessness r/t Anesthesia
3. Planning - Expected Outcomes
‣ Depending on the nursing diagnoses,
the objective(s) will be that the client will
- Be free of injury resulting from
anesthesia, position, etc
- Experience minimal skin impairment
and contamination as a result of the
surgery
- Maintain adequate respiratory
function throughout the surgical
procedure, AEB..
- Maintain adequate cardiac output,
AEB…
- Manifest decreased signs of Fear/
Anxiety/Powerlessness AEB
- Be hydrated adequately without
evidence of excess fluid AEB
Bulauitan MEDICAL SURGICAL NURSING 19

4. Implementation and questions are understood by the

‣ General Intraoperative Nursing client
Interventions: It may include the - Older adult clients have more risks for
following: hypothermia, so warming blankets may
a. Admitting the client to the OR area be needed when transporting into and
b. Transferring and positioning client out of the OR
for surgery
c. Skin cleansing and final prep
d. Draping
e. Assisting in anesthesia
f. Maintaining surgical asepsis

Nursing Care During Surgery

‣ Provide emotional care

‣ Assist with client positioning
‣ Maintaining surgical asepsis
‣ Monitoring malignant hyperthermia
‣ Assisting with surgical wound closure
‣ Assessing the drainage
5. Evaluation
‣ On the basis of the identified common/
additional nursing diagnoses, the nurse
evaluates the care of the intraop client

Special Consideration
for the Older Adults

‣ Complications that Older Adults are at

risk:
- Hypotension
- Hypothermia
- Hypoxemia
- Postop Arthritic Joint Pains
- Pressure Sore Formation
- Fear and Disorientation

‣ Meeting the Needs of the Elderly

- The older client is more susceptible to
rxn from anesthesia
- Communication abilities are often
lessened in the older adults, so the
nurse must ensure all conversations
Bulauitan MEDICAL SURGICAL NURSING
POSTOPERATIVE PHASE
‣ PACU/RECOVER ROOM
- “Post Anesthesia Care Unit”
- Purpose: is to provide ongoing
evaluation and stabilization of clients to
anticipate, prevent, and treat
complications after surgery
- usually located close to surgical suite
- Nurse is skilled in the care of clients
with multiple medical and surgical
problems that can occur following a
surgical procedure
‣ Standards of PACU
1. All patients who have received
general anesthesia, regional
anesthesia, or monitored anesthesia
care should receive post-anesthesia
management
2. Patient should be transported to the
PACU by a member of the anesthesia
care team that is knowledgeable
about the patient’s condition
3. Upon arrival int the PACU, the patient
should be re-evaluated and a verbal
report should be provided to the nurse
4. The patient shall be evaluated
continually in the PACU
5. A physician is responsible for
discharge of the patient
Phases of Postanesthesia Care
‣ Phase I PACU - care given immediately
after patient is transferred to PACU
‣ Phase II PACU - (Step down or
progressive care unit) care begins when
patient condition is stable, no long requires
intensive monitoring
‣ Phase III PACU - prepares to be
discharged from facility
20
Equipment to Prepare for Monitoring
Postop Clients
‣ BP Monitoring Equipment
‣ Cardiac Monitor
‣ IV Equipment
‣ Suction Equipment
‣ Supplies to support respiration - O2
‣ Medications, such as narcotics,
antihypertensive drugs, etc
‣ Emesis basin, mouth wipes
‣ Urinals and bedpans
‣ Warmed blankets
‣ Emergency Cart
Data bout the Client to be Obtained from
the Anesthesiologist Or Nurse should
include:
‣ Current medical diagnosis
‣ Surgical Procedure performed - what & why
‣ Anesthetic agent administered and other
medications given in the OR
‣ Complications during surgery, the type, and
the treatment done
‣ Fluids - EBL (Estimated Blood Loss) and
total administered; total output
‣ Pertinent pre-op problems - physical and
psychologic
Nursing Management in the PACU
‣ Objectives:
- Provide care until the client has
recovered from the effects of
anesthesia
- Is oriented
- Has stable vital signs
- Shows no evidence of hemorrhage or
other complications
Bulauitan MEDICAL SURGICAL NURSING 21

1. Assessing the Patient Maintaining a Patent Airway

‣ A postoperative head-to-toe ‣ Objectives:

assessment includes but may not be - Maintain ventilation
limited to the following - Prevent hypoxemia and hypercapnea
- General appearance • Hypopharyngeal obstruction
- Vital signs • Use of airways
- Lvl of Consciousness • Head positioning
- Emotional Status
- Quantity of Respirations Maintaining Cardiovascular Stability
- Skin color & Temp
- Discomfort/pain
‣ Assess the client’s mental status, VS,
- Nausea/Vomiting
cardiac rhythm; skin temperature, color and
- Type of IV fluids and flow rate
moisture; and urine output; CVP; PAP;
- Dressing site and drains (penrose
arterial lines, if in place
drain, T-tube); presence of closed
‣ Primary cardiovascular complications seen
suction drains, such as Hemovac,
in the PACU include; hypotension and
Vacu-Drain; Jackson Pratt
shock; hemorrhage; hypertension and
- Drainage on the dressing and/or bed
dysrhythmias
linen
- Urinary output (catheter or ability to
‣ Hypotension and Shock
urinate)
- Hypotension can result from:
- Ability to move all extremities
• Blood loss
• Hypoventilation
‣ How often should VS be assess?
• Position changes
- After initial assessment, VS are
• Pooling of blood in the extremities
monitored and the patient’s
• Side effects of medications and
geneTral physical status is
anesthetics
assessed and documented at least
- Shock: most serious postop
q15min (Eg. VS q 15 x4, q 30 x4, q
complications secondary to
H x4, q 2H x4, Q 4h for 1-2 days)
hypovolemia and decreased
intravascular volume
‣ Postoperative Laboratory
- Serum electrolytes
- Serum glucose
- CBC
- ABG
- Urine specific gravity
‣ The administration of the client’s
postop analgesic requirements is a top
priority