A. INTRODUCTION TO SURGERY 1.

Definition of Surgery
Surgery - Also called as operation, is any procedure performed on the human body that uses instruments to alter tissue or organ integrity. - It is also a unique experienced of a planned physical alteration encompassing three phases namely: preoperative, intraoperative, and postoperative. These three phases are together referred as the perioperative period.

2. Psychosocial Perspectives
All patients have some type of emotional reaction before any surgical procedure. Here are some psychosocial concerns when undergoing a surgery: - Anxiety the patient views as a threat to his or her customary role in life, body integrity, or life itself. Concerns about loss of work time, loss of job, increased responsibilities and threat of permanent incapacity. - Fears the patient about to undergo surgery faced with various fears such as: fear of unknown, death, anesthesia, pain or cancer. - Spiritual and cultural beliefs certain rituals are very important to the client should be respected by all members of the health care team. The family may make decisions regarding health care as a unit. The oldest woman makes all medical decision. Blood transfusion is forbidden in their religion. Patient from cultural groups are unaccustomed to expressing feeling openly. Intervention: Provide spiritual and emotional support Provide presence Listen empathically Encourage verbalization of feelings Supporting Religious practices

Provide relaxation techniques

Prepared by Emmanuelle H. Arana Referrence: Brunner, L. S., Suddarth, D. S., & Smeltzer, S. C. O. (2004). Brunner and Suddarths Textbook of Medical-Surgical Nursing (10th edition). Philadelphia: Lippincott Williams & Wilkins.

3. Classification of Surgery
Category Reasons for Surgery o Diagnostic Description Reason for Surgery

o Curative

o Restorative o Palliative

o Cosmetic

Performed to determine the Breast biopsy origin and cause of a disorder or Exploratory laparotomy the cell type for cancer Arthoroscopy Laparoscopic Performed to resolve a health cholecystectomy problem by repairing or Mastectomy removing the cause Hysterectomy Total knee replacement Performed to improve a clients Finger reimplantation functional ability Colostomy Performed to relieve symptoms Nerve root resection of a disease process, but does Tumor debulking not cure Ileostomy Liposuction Revision of scars Performed primarily to alter or Rhinoplasty enhance personal experience Blepharoplasty Planned for correction of a Cataract removal nonacute problem Hernia repair Hemorrhoidectomy Total Joint replacement Requires prompt intervention Intestinal obstruction Bladder obstruction Kidney or ureteral stones Bone fracture Eye injury Acute cholecystitis

Urgency of Surgery o Elective

o Urgent

o Emergent

Requires immediate intervention Gunshot or stab wound because of life-threatening Severe bleeding consequences Abdominal aortic aneurysm Compound fracture Appendectomy of Procedure without significant Incision and drainiage risk; often done with local Implantation and venous anesthesia access device Muscle biopsy Mitral valve replacement Procedure of greater risk, Pancreas transplant usually longer and more Lymph node dissection extensive than a minor procedure Only the most overtly affected areas involved in the surgery Extensive surgery beyond the area obviously involved; is directed at finding a root cause Description Simple/partial mastectomy Radical prostatectomy Radical Hysterectomy Reason for Surgery

Degree of Surgery o Minor

risk

o Major

Extent of Surgery o Simple o Radical

Category Reasons for Surgery o Diagnostic

o Curative

o Restorative o Palliative

o Cosmetic

Performed to determine the Breast biopsy origin and cause of a disorder or Exploratory laparotomy the cell type for cancer Arthoroscopy Laparoscopic Performed to resolve a health cholecystectomy problem by repairing or Mastectomy removing the cause Hysterectomy Total knee replacement Performed to improve a clients Finger reimplantation functional ability Colostomy Performed to relieve symptoms Nerve root resection of a disease process, but does Tumor debulking not cure Ileostomy Liposuction Revision of scars Performed primarily to alter or Rhinoplasty

enhance personal experience Urgency of Surgery o Elective

Blepharoplasty

o Urgent

o Emergent

Planned for correction of a Cataract removal nonacute problem Hernia repair Hemorrhoidectomy Total Joint replacement Requires prompt intervention Intestinal obstruction Bladder obstruction Kidney or ureteral stones Bone fracture Eye injury Acute cholecystitis Requires immediate intervention Gunshot or stab wound because of life-threatening Severe bleeding consequences Abdominal aortic aneurysm Compound fracture Appendectomy of Procedure without significant Incision and drainiage risk; often done with local Implantation and venous anesthesia access device Muscle biopsy Mitral valve replacement Procedure of greater risk, Pancreas transplant usually longer and more Lymph node dissection extensive than a minor procedure Only the most overtly affected Simple/partial mastectomy areas involved in the surgery Extensive surgery beyond the Radical prostatectomy area obviously involved; is Radical Hysterectomy directed at finding a root cause

Degree of Surgery o Minor

risk

o Major

Extent of Surgery o Simple o Radical

4. Types of Condition Requiring Surgery

1) Obstruction or blockage mainly affects arteries (e.g. the coronary or

cerebral arteries), tubes (e.g. bronchial and Eustachian tubes), and ducts (e.g. the cystic duct). Obstructions of passageways within the body are dangerous because they block the flow of such vital substances as blood, air, cerebrospinal fluid, urine, and bile. 2) Perforation is the rupture of an organ, artery or bleb. Examples of perforation are: perforated duodenal ulcer, ruptured bladder, and cerebral hemorrhage. Perforation is a dangerous event that usually calls for emergency surgery. 3) Erosion is the wearing away or eating away of the surface of a tissue as a result of continuous physical irritation, infection, ulceration, or inflammation. This process of erosion may wear away blood vessel walls, resulting in bleeding. Cancerous tumors, bladder stones, duodenal ulcers, and tuberculosis can all lead to the erosion of blood vessels and resultant bleeding. 4) Tumors are abnormal growths of tissues that form masses serving no physiologic function within the body, and that may be malignant. Tumors often grow very large before they are detected. A tumor may not initially produce symptoms, so patient may unknowingly neglect the condition and fail to seek medical advice. At times such neglect may be fatal. One of the most common methods of treating tumors is by surgical excision of the mass.
Prepared by: Faye Alexa Ponce Referrence: Medical-Surgical Nursing: Clinical Management for Positive Outcomes, 8th Edition By Joyce M. Black, PhD, RN, CPSN, CWCN, FAPWCA and Jane Hokanson Hawks, DNSc, RN, BC Medical Surgical Nursing - Workman

5. Surgical Positions And Draping

the most important nonsterile procedures in which the OR specialist assists because placement of the patient safeguards the patient and gives him comfort while enabling the medical officer Responsibility for Ordering the Patient's Position.

 The choice of position is made by the surgeon, with minor adjustments, if necessary, for the type of anesthesia and its administration Important considerations in positioning the patient include the following: 1) The type of surgery scheduled. The operative area must be accessible and easy to keep sterile, and the position must be conducive to speed and efficiency of the surgeon. 2) The type of anesthesia to be given. The patient's position must permit sufficient space for the necessary equipment. 3) Protection of patient's vital processes. The patient's vital processes must not be impaired because of his position for surgery. c. Equipment for Positioning. o Before he can effectively position patients, the specialist must familiarize himself in detail with the mechanism of the operating table he will use, as well as the table attachments and the various supplies used. 1) The operating table - differ among hospitals and among rooms in the same hospital -most of the tables consist of a rectangular metal top that rests upon a hydraulic, wheeled base -The table is designed for placement of the patient in many different positions, while enabling his body structures and his vital processes to be safeguarded no matter what his surgical position is.

Operating table.

2) Table attachments. All attachments used to secure the patient in the desired position must be adequately padded to prevent trauma. Fresh padding is used for each patient. (a) The anesthetist's screen is either a rectangular or a curved rod that keeps the sterile drapes off the patient's face and separates the sterile from the nonsterile field at the head of the table. Sterile drapes may be attached to intravenous (IV) standards on either side of the table rather than placed over the anesthetist's screen. (b) The leg strap is made of leather or heavy canvas and is covered with conductive rubber. Sometimes called a restraint strap, it is used to restrain the patient's legs during induction of anesthesia and for placement in many positions. (Lithotomy, paragraph 1-19, is an exception.) The strap must be tight enough to prevent movement, yet not so tight that it will interfere with circulation. (c) The patient's arms are usually restrained in the "lift sheet," a draw sheet that is placed across the operating table each time it is made up. The patient's arms should be tucked into the sheet before the anesthesia is started. Wristlets (leather cuffs) may also be used to secure the patient's hands and arms. (d) An armboard of metal or wood may be used in several instances, and it is slipped under the mattress or attached directly to the table. Uses of an arm board include the following: support an arm when an intra-venous infusion is employed; support the arm on the unaffected side when the patient is in the lateral position; serve as an operating table when the site of operation is the arm or hand; hold the arm away from the field when the patient's arm at his side would be in the way of the operative area; or to support the arms when the patient is too obese for the table and hold both his body and his arms. (e) Body rests are curved pieces of metal padded with foam rubber. These are placed in metal clamps on the sides of the table and slipped in from the table edge against the body to support and stabilize it in certain positions. (f) Kidney rests are wider than body rests, but are also curved metal pieces with grooved notches at the base. They are slipped in from the side of the table along the kidney elevator (bar) to fit snugly against the side of the patient, supporting his body during kidney surgery. (g) The metal footboard can be attached flat to increase the length of the table when necessary, or it may be placed at a 90-degree angle to the table and padded to support the feet in an upright position. The soles of the feet rest securely against it.

(h) Shoulder braces are of curved metal and are used to prevent the patient form slipping toward the head of the table while in certain surgical positions. (i) Stirrups are metal posts; they are placed one on each side of the table at the lower (foot end) break and are used to support the legs and feet when the perineal area is the site of operation. The knees and lower legs may rest on padded metal supports or the feet may hang in canvas straps attached to an upright bar. (j) The cerebellar headrest is a frame that supports the patient's head when he is in the prone position, and is used in spinal and posterior thoracic surgery. It is shaped to fit the face and has an opening for the nose and mouth. 3) Additional necessary supplies. (a) Pillows of various sizes are used to immobilize or to relieve pressure on a part. (b) The lift sheet is used to secure the patient's hands and arms during the operative procedure. (c) Sandbags in various sizes are used to immobilize a part. (d) Adhesive tape of various widths and lengths is used when the patient is placed in certain positions to stabilize the body. (e) Materials of foam rubber, sheet wadding, and cotton are used to pad attachments so that the patient will not be injured. (f) Extra sheets and towels are used for stabilization in certain positions. (4) Dressing the table. The table is routinely "dressed" or made up by covering the pad with a sheet doubled lengthwise and tucked in on the sides and ends. A lift sheet is placed across the center of the table; it is folded in quarters (fan folded). Folding it thus keeps the ends of the sheet from dangling down the side of the table, and enables the ends of the sheet to be moved without disturbing the rest of the lift sheet or the other linen on the table. The lift sheet facilitates moving and lifting the patient, and it is used to secure his arms at his sides. The leg-restraining strap is included in "dressing" the table. Principles Influencing Positioning. The patient should be told why he is being restrained, if he is awake. Unnecessary exposure of the patient should be avoided.

 The wheels of the operating table and the bed are always to be locked before the patient is moved. A sufficient number of personnel must be present to assist with positioning. At least two persons are required to place the patient in the surgical position desired. The patient is not to be touched or placed in position until the anesthetist indicates that it may be done. The patient's body alignment must be correctly maintained while he is being positioned. SUPINE POSITION (DORSAL RECUMBENT) This is the usual positionfor administering general anesthesia and for doing most surgery of the abdomen such as laparotomy, herniorrhaphy, and appendectomy. With slight modifications, it is also used for other types of surgery, such as surgery on the arms or legs.

Supine (dorsal recumbent) position. Modifications of the Supine Position. The most usual modified supine position is one in which the table is flexed slightly at both breaks. Sometimes the knees are flexed with a small pillow instead. A number of other modified positions are mentioned in this paragraph. When the position of the table is changed with the patient on his back, special precautions are necessary to protect him. (1) When the head is turned to one side or the other, it should be supported to keep the spine in alignment and secured in the desired position with a doughnut cushion, sandbag, or special headrest. (2) Pressure over bony prominences where nerves and blood vessels run superficially must be avoided. The eyes must be carefully guarded against pressure, and they must be protected as drapes are placed to prevent corneal irritation from textiles, solutions, and other foreign bodies. (3) For operations on the neck, the neck may be extended by placing a narrow support between the shoulder blades or by lowering the headpiece of

the table. There should be no gaps in the support of the neck in this position. A special screen that protects the face may be used in thyroid surgery. (4) For anterolateral incisions and for surgery on the shoulder or the chest, the patient's affected side may be elevated on rolls or pads. To prevent twisting of the spine, the full length of the body needs support that will keep the hips and shoulders in a plane. Body supports or straps in appropriate locations maintain the position and prevent rolling without interfering with the surgical approach. (5) An arm-board may be used to support the arm on the affected side. In some cases, both arms are supported on arm-boards. In a few cases, the arm may be bandaged to the ether screen, using specific precautions against nerve and circulatory disturbances. In many procedures, one arm is usually extended on an arm-board to administer intravenous therapy. One or both arms may be extended in radical mastectomy and other surgery on the upper extremity and chest regions. (6) The arm-board is padded to protect the skin and superficial tissues from pressure. The arm is extended at an angle less than 90 degrees to the table and level with the table. The arm-board is of the type that locks into position on the table to prevent inadvertent angle changes. Hyperabduction at the shoulder may cause both vascular and neural damage. Venous thrombosis may result when superficial veins are compressed by supports or straps or by the weight of body structures. The subclavian or axillary arteries may be occluded in abduction.

TRENDELENBURG POSITION The Trendelenburg position is used for operations on the bladder, prostate gland, colon, female reproductive system, or for any operation in which it is desirable to tilt the abdominal viscera away from the pelvic area for better exposure.

Trendelenburg position. Note that the knees are over the lower break in the table and shoulder braces are in place.

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Precautions. (1) The nerve supply to the upper extremities comes from the spinal cord, gathers at the brachial plexus and emerges under the muscles in front at the root of the neck, where the neck and shoulder join. It is very important to protect these nerves when using the Trendelenburg position. This is done by using adequate padding on the shoulder braces, and by placing the braces at the outer aspect of the shoulders over the acromion and spinous process of the scapula. (2) Careful positioning of the knees over the break is needed to prevent pressure in the popliteal space and safeguard the perineal nerve. Breaking the table at the knees takes some of the body weight off the shoulder braces and reduces pressure there. The legs are straightened before the patient is returned to a horizontal position. (3) While this is mainly the anesthetist's concern, you should also know that this position may result in respiratory distress. Modification of the Position. The Trendelenburg position is often mistakenly confused with shock position (extreme Trendelenburg position). The two are the same, except that in shock position, the table is straight (unbroken) at the knees so that the feet are higher than the head. REVERSE TRENDELENBURG POSITION The reverse Trendelenburg position may be used for surgery on the neck, such as thyroidectomy, and for certain abdominal surgery, such as liver or gallbladder operations.

Reverse position.

Trendelenburg

LATERAL KIDNEY POSITION The lateral kidney position is used for surgery on the kidney or the proximal third of the ureter.

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Right kidney position. Note the kidney strap across the hips for stabilizing the body and raised kidney elevator for hyperextending operative areas.

LATERAL CHEST POSITION The lateral chest position (is used for thoracoplasty, pneumonectomy, and lobectomy.

Right lateral position. Note the strap across the hips and body rest for stabilizing the body. Procedure. (1) Place the patient on his unaffected side with his back near the edge of the table. This requires two people: the anesthetist managing the head and shoulders, and the assistant moving the hips. (2) Place the upper leg straight with the patient's body, and flex the leg on the lower side. Place a pillow lengthwise between the legs. (3) Place a folded sheet or a small hard pillow under the patient so that it is immediately beneath the operative area. This relieves some of the pressure on the arm on the unaffected side and permits the free flow of any replacement fluids infused through the vessels of this arm. (4) Place a chest rest near the lumbar area, and another at the level of the axilla. (5) Bring the patient's arms and hands in front of him near his face and secure them. Secure the arm on the unaffected side to a padded arm board

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and the other arm rests on a pad as it hangs over the side of the table. This draws the scapula away from the operative area. (6) A pad or small pillow is used to align the head and neck. (7) Secure a strap over the hips. A second strap is sometimes used to stabilize the shoulder. (8) Tilt the table slightly, with the patient's head towards the floor if the patient needs postural drainage during surgery. If the patient's head is to be lowered, secure the mattress to the table to prevent it from slipping. LITHOTOMY POSITION The lithotomy position is used for surgery in the perineal area, such as drainage of rectal abscesses and perineal prostatectomies, and for gynecological surgery such as vaginal hysterectomy.

Lithotomy position. In the lithotomy position, the patient is on his back with the foot section of the table lowered to a right angle with the body of the table. Knees are flexed and the legs are on the outside of the metal posts with the feet supported by canvas straps. The buttocks are even with the table edge. d. Procedure. For the administration of anesthesia, the patient is placed in the supine position with buttocks at the edge of the knee break. In this position, the patient's legs will of course extend beyond the end of the table, but they will be supported by the extra basin stand, Mayo stand, or headrest. When the patient is anesthetized, the specialist and an "unsterile" assistant place the patient in position as follows:

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(1) Remove the leg restraint. (2) Fold the patient's arms and hands either across his upper abdomen or across his chest.. (3) Make sure the two stirrups are level, and at the proper height. Each of the two "unsterile" team members takes a position on either side of the patient at the foot end of the table. Each team member grasps a patient's leg near the knee with the other hand. The team members then flex the patient's legs and simultaneously lift them and place them in the padded stirrups. It is important that both legs be lifted at the same time to prevent injury to the patient. (4) Place the legs in the padded metal supports and secure the straps. To position the legs using canvas straps, bring the legs to the outside of the upright bars. Loop the strap once around the sole of the foot and once around the heel. Pad the bars with folded hand towels in the areas where they are touching the legs or where the legs may press against the bars. (5) Remove the basin stand or Mayo stand, if used. (6) Remove foot section of the table mattress and break and drop the foot of the table. (7) Pull the stirrups forward to extend slightly beyond the foot end of the table. Viewed from the side, the legs should form a "Z" shape with the angle of the buttocks. (8) Place the end of the Kelly pad (if one is used) in the kick bucket. This pad keeps the table dry under the patient during the surgical prep. The pad is removed after the prep and before the patient is draped. Precautions. This unnatural posture is fraught with danger and discomfort for the patient, and these hazards increase as the position is exaggerated for radical surgery. Extreme flexion of the thighs impairs respiratory function by increasing intraabdominal pressure. Gravity flow of blood from elevated legs causes blood to pool in the splanchnic region. Arms also require special care in lithotomy position. The hands should not extend along the sides, since they will reach below the break of the foot section of the table and be in danger of injury from manipulation of table parts. They may be folded loosely across the abdomen and supported by the folded gown or cover sheet, or one may be extended on an arm-board for infusion

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while the other is suspended from the anesthesia screen. Be sure they do not impede chest movement. PRONE POSITION The prone position is used for surgical procedures-major or minor-that are performed on the back, shoulders, neck, or back of the head. Placement of the patient in the prone position for minor surgery, using local anesthesia, differs in some respects with placement for general anesthesia.

Prone position. In the prone position, the patient lies on his abdomen. Note shoulder rolls under axillae and sides of chest to raise body weight from the chest to facilitate respiration. The patient is anesthetized and the endotracheal tube inserted in dorsal position. He is then turned to prone. JACKKNIFE (KRASKE) POSITION The jackknife (Kraske) position is used for surgery on the coccyx, buttocks, or rectum, particularly when the patient has had spinal anesthesia and there is no objection to his being placed either face downward or head low.

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Kraske position. Note that the hips are over the table break, and the table is flexed at a 90-degree angle. SITTING POSITION Included in surgery for which the patient sits upright are various operations on the nose and throat, as well as some plastic surgical procedures. The sitting position is described using the operating table as a chair.

Sitting position. Procedure. 1. 2. 3. 4. 5. 6. 7. Attach the footboard at a 90-degree angle to the table. Secure adhesive straps across the mattress for stabilization. Secure ends of lift sheet under the mattress. Break the table into a sitting position. Pad the footboard with a folded sheet. Assist the patient onto the table. Adjust and secure the leg strap. Adjust the footboard so that the feet are resting securely on it. 8. Place a sheet around the patient so that it reaches from the axilla to the iliac crest. Leave the arms free. Tie the sheet behind the table, using a square knot. 9. Place a pillow in the patient's lap to support his arms. The arms may then be restrained in the lift sheet.

POSITIONS FOR SPINAL ANESTHESIA

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a. Discussion. The patient may be in either a lying or a sitting position for the administration of spinal anesthesia. The position used will depend upon the condition of the patient and the preference of the anesthetist. b. Lying Position. Most subarachnoid blocks are given with the patient lying on his side.

Lying position for spinal anesthesia. This is the Sims position and is often referred to as the curled lateral position and is useful in establishment of subarachnoid and epidural anesthesia. c. Sitting Position.Sometimes, the anesthetist has reason to believe that, due to the condition of the patient, he may have difficulty in performing the lumbar puncture satisfactorily with the patient lying down. Faced with this type of situation, the anesthetist may order that the specialist place the patient in a sitting position.

Sitting position for spinal anesthesia. Prepared By: Marinela Mei C. Ayala
REFERENCE:

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Martin, J.T., M.D.; Positioning in Anesthesia and Surgery, ed. 2, Toledo, Ohio, 1987, W. B. Saunders Company.
Medical-Surgical Nursing Made Incredibly Easy! Lippincott Williams & Wilkins, 2008

Medical-Surgical Nursing: Clinical Management for Positive Outcomes, 8th Edition By Joyce M. Black, PhD, RN, CPSN, CWCN, FAPWCA and Jane Hokanson Hawks, DNSc, RN, BC Medical-Surgical Nursing: Patient-Centered Collaborative Care, Single Volume, 6e By Donna D. Ignatavicius MS,RN,ANEF and M. Linda Workman PhD,RN,FAAN

6. The Patients Response to Surgery

o Stress Response is elicited. Sympathoadrenomedullary response (SAMR or fight-or-flight response). Release of epinephrine and norepinephrine cause the following: a. Increased heart rate increases oxygen demand of the heart b. Vasoconstriction increases blood pressure and decreases blood flow to organs. Adrenocortical Stimulation a. Increased release of glucocorticoid increases blood glucose levels. Diabetic patients may experience hyperglycemia. b. Increased release of aldosterone causes retention of sodium and water. This causes elevation of blood pressure. o Defense against infection is lowered. Impairment of skin integrity due to surgical incision facilitates entry of microorganism into the body. Blood loss decreases protective cells in the body. o Vascular system is disrupted. Loss of red blood cells cause anemia. Therefore, there is decreased availability of oxygen to tissues. Loss of white blood cells cause lowered resistance to infection. Loss of platelets causes bleeding. o Organ Functions are distributed. Laryngectomy causes loss of voice. Total-abdominal hysterectomy and bi-lateral salpingo-oophorectomy results no inability to have pregnancy. o Body image may be disturbed.

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 Colostomy, mastectomy, prostatectomy, amputation of a limb are examples of surgeries that cause altered body image. Good body image enhances a persons self-esteem. o Lifestyles may change. Surgeries like open heart surgery , craniotomy, colostomy, amputation of a limb require some changes in the lifestyle of individuals.
Prepared by: Marinela Mei C. Ayala Reference: MEDICAL-SURGICAL NURSIGN CONCEPTS AND APPLICATION BY

UDAN

B. THE PERI-OPERATIVE CLIENT

Peri-operative Phase - period of time that constitutes surgical experience Phases: I. Preoperative Phase II. Intraoperative Phase III. Postoperative Phase

I. Preoperative Phase 1. Assessment Preoperative Assessment Data Current health status. Essential information includes general health status and the presence of any chronic diseases, such as diabetes or asthma, which may affect the clients response to surgery or anesthesia. Note any physical limitations that may affect the clients mobility or ability to communicate after surgery, as well as any prostheses such as hearing aids or contact lenses. Allergies. Include allergies to prescription and non-prescription drugs, food allergies, and allergies to tape, latex, soaps, or antiseptic agents. Some food allergies may indicate a potential reaction to drugs or substances used during surgery or diagnostic procedures Medications (including herbal supplements). List all current medications (prescribed and OTC). It may be vital to maintain a blood level of some medications throughout the surgical experience; others, such as anticoagulants or aspirin, increase the risks of surgery and anesthesia and need to be discontinued several days prior to surgery. It is important to include in the list any herbal remedies the client currently takes. Previous surgeries. Previous surgical experiences may influence the clients physical and psychologic responses to surgery or may reveal unexpected responses to anesthesia. Mental status. The clients mental status and ability to understand and respond appropriately can affect the entire perioperative experience. Note

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any developmental disabilities, mental illness, history of dementia, or excessive anxiety related to the procedure. Understanding of surgical procedure and anesthesia. The client should have a good understanding of the planned procedure and what to expect during and after surgery as well as the expected outcome of the procedure. Smoking. Smokers may have more difficulty clearing respiratory secretions after surgery, increasing the risk of postoperative complications such as pneumonia and atelectasis and delayed wound healing. Alcohol and other mind-altering substances. Use of substances that affect the central nervous system, liver, or other body systems can affect the clients response to anesthesia and surgery, and postoperative recovery. Coping. Clients with a healthy self-concept who have successfully employed appropriate coping mechanisms in the past are better able to deal with stressors associated with surgery. Social resources. Determine the availability of family or other caregivers as well as the clients social support network. These resources are important to the clients recovery, particularly for the client undergoing same-day or short-stay surgery. Cultural and spiritual considerations. Culture and spirituality influence the clients response to surgery; respecting cultural and spiritual beliefs and practices can reduce preoperative anxiety and improve recovery. Physical Assessment Complete set of VS; BP both arms/ht & wt Cardiovascular/peripheral vascular Respiratory system Renal/urinary system Neurologic system Musculoskeletal system Nutritional status Screening Tests UA (determines urine composition and possible abnormal components or infection) CBC (RBCs, Hgb, and Hct are important to the oxygen-carrying capacity of the blood; WBCs are an indicator of immune function) Blood grouping and cross-matching (determined in case blood transfusion is required during or after surgery) Serum electrolytes (to evaluate fluid and electrolyte status) ALT, AST, LDH, and bilirubin (to evaluate liver function) Fasting blood glucose (high levels may indicate undiagnosed diabetes mellitus) BUN and creatinine (to evaluate renal function) Serum albumin and total protein (to evaluate nutritional status) Chest x-ray (to evaluate respiratory status and heart size) ECG (to identify pre-existing cardiac problems or disease)

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 Pregnancy test (to identify if the client is pregnant) 2. Diagnosing Deficient knowledge related to -- lack of education about the perioperative process -- lack of exposure to the specific perioperative experience Anxiety related to -- effects of surgery on ability to function in usual roles -- outcome of exploratory surgery for malignancy -- risk of death -- loss of control during anesthesia or waking up during anesthesia -- perceived inadequate postoperative analgesia -- change in health status and/or body image Disturbed sleep pattern related to -- hospital routines -- psychologic stress

3. Planning Goal: to ensure that the client is mentally and physically prepared for surgery Preoperative Consent Nature and reason for surgery Name of person performing surgery and others who will be in OR during surgery Risks (of procedure and anesthesia) Possible alternative measures Right to refuse consent or later withdraw consent Nurse may witness; nurse signature witnesses that consent was signed by client (or designated person); if client doesnt understand, contact MD Client must be able to understand language, be conscious, mentally competent, and non-sedated (must sign before sedation) May sign with X witnessed by 2 people Minor may not give consent must get guardian consent

4. Implementing Preoperative teaching (reduces clients anxiety and postoperative complications and increases their satisfaction with the surgical experience) Physical Preparation Nutrition and fluids. Adequate hydration and nutrition promote healing. Nurses need to identify and record any signs of malnutrition or fluid imbalance. If the client is on intravenous fluids or on measured fluid intake, nurse must ensure that the fluid intake and output is accurately measured and recorded. Guidelines: ~ The consumption of clear liquids up to 2 hours before elective surgery requiring general, regional, or sedation-analgesia. ~ A light breakfast 6 hours before the procedure.

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~ A heavier meal 8 hours before surgery. Elimination. May need enema, Golytely, Mag Citrate Hygiene/skin preparation. No polish, gown only, no pins, no clips Medications - Sedatives and tranquilizers. Reduce anxiety and ease anesthetic induction (secobarbital and diazepam) - Narcotic analgesics. Provide client sedation and reduce the required amount of anesthetic (morphine and meperidine) - Anticholinergics. Reduce oral and pulmonary secretions and prevent laryngospasm (atropine, scopolamine, and glycopyrolate) - Histamine-receptor antihistamines. Reduce gastric fluid volume and gastric acidity (cimetidine and ranitidine) - Neuroleptanalgesic agents. Induce general calmness and sleepiness (Innovar) Rest and sleep. Nurses should do everything to help the client sleep the night before the surgery. Often a sedative is ordered. Adequate rest helps the client manage the stress of surgery and helps healing. Skills training CDB, splinting incision, IS, SCDs, TED hose, leg exercises, etc. -- Before proceeding to the OR Vital signs Height/weight Valuables/prosthesis remove everything; no dentures, contacts, glasses, etc. Pre-anesthetic medications Preop checklist -- Consent, nurses notes, med kardex, labs, xrays, VS -- ID band check -- Teaching -- Old chart -- Meds -- Voided 5. Evaluating Client states that he/she understands informed consent as it applies to surgery Complies with NPO before surgery Verbalizes understanding of pre op teaching Correctly demonstrates postop exercises CDB, IS, splinting, leg exercises

Prepared by: Charis Mae F. Dimaculangan References:

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Kozier, B., et. al. (2007). Fundamentals of Nursing (8th edition). Jurong, Singapore: Pearson Education. South Asia PTE Ltd. Brunner, L. S., Suddarth, D. S., & Smeltzer, S. C. O. (2004). Brunner and Suddarths Textbook of Medical-Surgical Nursing (10th edition). Philadelphia: Lippincott Williams & Wilkins.

Pre-operative medications The anesthesiologist may order routinely taken medications be held the day of surgery. However, prior to administering the medication, check the permits of the medication. Commonly used preoperative medications: o Anticholinergics to reduce oral and pulmonary secretions and prevent laryngospasm and prevent bradycardia Example: Atropine (Atropisol), scopolamine (Hyoscine) and glycopyrrolate (Robinul) o Anxiolytics to control anxiety, calming Example: Alprazolam (Xanax), Clonazepam (Klonipin), Diazepam (Valium), Lorazepam (Ativan) o Antihistamines provide sedations and antiemetic effects. Example: Hydroxizine (Vistaril), Diphenhydramine (Benadryl) o Barbiturates provide sedation without significant cardiopulmonary depression. Example: Secobarbital (Seconal), Pentobarbital (Nembutal) o H2 receptor antagonist reduce gastric acidity Example: Cimetidine (Tagamet), Ranitidine (Zantac) o Hypnotics Provide sedation and increase duration of sleep. Example: Temazepam (Restoril) o Neuroleptics Provide sedative, antiemetic, and anticonvulsant effects. Example: Droperidol (Inapsine), Innovar o Opiod Analgesic provides pain relief and sedation; induced anesthesia. Example: Fentanyl (Sublimaze), Meperidine (Demerol), Morphine o o o Medication that increases surgical risks: Antibiotics may potentiate the action of anesthetic agents. Anticoagulants and Aspirin increase risk for bleeding Antihypertensives - increase the risk for hypotension during surgery, may interact with anesthetic agents which cause bradycardia and impaired circulation o Antidysrhythmics may impair cardiac function during anesthesia. o Corticosteroids delays wound healing and increase risk for infection.

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o Diuretics Alter fluid and electrolyte balance o Opiods and Tranquilizers increase risk of respiratory depression o NSAIDs inhibit platelet aggregation, increasing risk Prepared by: Emmanuelle H. Arana Reference: Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th ed.) St. Louis: Mosby
Elsevier, 1029-1084. Sharp, T. (2001)

II. Intraoperative Operative Phase MEMBERS OF THE SURGICAL TEAM The surgical team is a unit providing the continuum of care beginning with preoperative care, and extending through perioperative (during the surgery) procedures, and postoperative recovery. The surgical team is also known as the operating room (OR) team is responsible for the well-being of a patient throughout the operation. This team should not only consider the patients privacy but will also promote safety measures for the patient. One way of promoting safety of patients inside the OR is by preventing infection from the incision that will be done. There are many members in an OR Team but they work together in unison and harmony to create a superb outcome. They coordinate their work with each other to have a successful operation. Classification of OR team There are two types of OR team according to the functions of its members. I. Sterile team members 1. Surgeon 2. Assistants to the surgeon 3. Scrub person (either a registered nurse or surgical technologist)
II.

Unsterile team members

1. Anesthesiologist 2. Circulator 3. Biomedical technicians, radiology technicians or other staff that might be needed to set up and operate specialized equipment or devices essential in monitoring the patient during a surgical operation I. Operating Room Team: Sterile Personnel

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The members of the OR sterile team will do the following things: 1. Perform surgical hand washing (arms are included). 2. Don sterile gowns and gloves. 3. Enter the sterile field. 4. Handles sterile items only. 5. Functions only within a limited area (sterile field). 6. Wear mask. A. Operating Surgeon The surgeon is a licensed physician (MD), osteopath (DO), oral surgeon (DDS or DMD), or podiatrist (DPM). This professional is especially trained and is qualified by knowledge and experience for the performance of a surgical operation. Responsibilities of a surgeon: 1. Preoperative diagnosis and care of the patient 2. Performance of the surgical procedure 3. Postoperative management of care B. Assistants to surgeon During a surgical procedure, the operating surgeon can have one or two assistants to perform specific tasks under his/her (operating surgeon) direction. The responsibilities of a surgeons assistant: 1. Help maintain the visibility of the surgical site 2. Control bleeding 3. Close wounds 4. Apply dressings 5. Handles tissues 6. Uses instruments

Types of Assistants to Surgeon: First Assistants could either be:

1. A qualified surgeon or resident in an accredited surgical education program. The first assistant should be capable of assuming the operating surgeons responsibility in cases of incapacitation or accidents. 2. Registered Nurse and surgical technologists that have a written hospital policy permitting the action.

Second Assistant could be a registered nurse or surgical technologist. These staff should be trained and they mar retract tissues and suction body fluids to help provide exposure of the surgical site. C. Scrub Person A scrub person could be the following: Registered Nurse

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Surgical technologist Licensed practical/vocational nurse The responsibility of a scrub person is to maintain the integrity, safety and efficiency of the sterile field throughout the surgical procedure (before, during and after). Maintains accurate count of all the surgical instruments.

II. Unsterile Operating Room Team The unsterile operating room members are not allowed to enter the sterile field to prevent contamination. The responsibilities of the members of this team are the following: Handle supplies and equipments that are considered unsterile. Touches unsterile surfaces only. Keep the sterile team supplied with supplies handled aseptically. Give direct patient care. Assist the sterile team members need with strict observation of avoiding contact to the sterile field. Handles other requirements arising during the surgical procedure. A. Anesthesiologist or Anesthetist Difference between an anesthesiologist and anesthetist: An anesthesiologist is a medical practitioner who is certified by a certain institution while an anesthetist could either be a qualified and licensed nurse, dentist or a physician who administers anesthetics. The anesthetist works under the supervision of an anesthesiologist or a surgeon when administering a drug or gas. Responsibilities of an anesthesiologist or anesthetist: 1. Choice and application of appropriate agents. 2. Choice and application of suitable techniques of administration. 3. Monitoring of physiologic function. 4. Maintenance of fluid and electrolyte balance. 5. Blood replacement. 6. Helps in minimizing the hazards of shock, fire and electrocution. 7. Use and interpret correctly a wide variety of monitoring devices. 8. Overseeing the positioning and movement of patients. 9. Oversee the postanesthesia care unit (PACU) to provide resuscitative care until the patient has regained vital functions. B. Circulator A circulator is preferably a registered nurse. However, in some cases a surgical technologist can perform the role of a circulator with the direct supervision from a registered nurse. Responsibilities of a circulator:

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1. Monitor and coordinate all activities within the room. 2. Manage the care required for each patient. 3. Provides assistance to any member of the OR team with strict observation to avoid a break in sterility. 4. Creates and maintains a safe and comfortable environment for the patient through theimplementation of aseptic technique. C. Others Biomedical technicians, radiology technicians or other staff that might be needed to set up and operate specialized equipment or devices essential in monitoring the patient during a surgical operation. As needed. Prepared by: Marinela Mei C. Ayala Reference: Medical Surgical Nursing by Luckman

ANESTHESIOLOGY -the branch of medicine which studies anesthesia and anesthetic ANESTHESIA "negative sensation" is an induced state of partial or total loss. Of sensation, or occurring with or without loss of consciousness. The purpose of anesthesia is to block nerve impulse transmission, suppress reflexes, promote muscle relaxation and achieve a controlled level of unconsciousness. it requires the skill of an anesthesiologist, a certified registered nurse anesthesiologist or another physician or an anesthesiologist's assistant.

Selection and dosage of anesthesia: o Type and duration of the procedure o Area of the body having surgery o Safety issues to reduce injury, such as airway management o Whether the procedure is an emergency o Options for management of pain after surgery o How long since it has been since the client ate, had any liquids, or any drugs o Client position needed for the surgical procedure Anesthesia can be induced in many ways: General or balanced anesthesia Local or regional anesthesia Hypnosis or hypoanesthesia

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 Cryothermia Acupuncture GENERAL ANESTHESIA -is a reversible loss of consciousness induced by inhibiting neuronal impulses in several areas of the central nervous system. -depresses the CNS, resulting in analgesia(pain relief or pain suppression), amnesia (memory loss of the surgery) and inconsciusness, with loss of muscle tone and reflexes. Speed of emergence (recovery from the anethesia) -depends on the type of anesthetic agent, the length of time the client is anesthesized, and whether a reversal agent is used. Administration of General Anesthesia Inhalation - easily controlled method of giving general anesthesia because intake and excretion of the agent occur mainly in the lungs. o Controlled respiration- uses a mechanical ventilator to automatically inflate the lungs. It is used after apnea is induced. o Assisted respiration- an endotracheal (ET) tube is used.

Inhalation anesthetic agents are: o gaseous agents- nitrous oxide is the most commonly used agent and is usually given with oxygen. o Volatile agents- liquid agents vaporized for inhalation. Intravenous Injection - injected through an IV line wherein the drug is diluted by the blood but is present At high levels in the brain, liver and kidneys to induce anesthesia. o Barbiturates- induce mild sedation to deep loss of consciousness o Ketamine- a dissociative anesthetic agent (one that promotes a feeling of separation or dissociation from the environment). o Profolol- short-acting anesthetic agent. Drug is eliminated rapidly, and the client becomes responsive within 8 minutes. Adjuncts to general anesthetic agents: Hypnotics- the benzodiazepines can be used for many effects. These drugs may be used during surgery along. with regional or local anesthesia. Opioid analgesics- used to enhance anesthesia include morphine sulfate, meperidine, fentanyl, and sufentanil. -It helps provide pain relief after surgery.

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Neuromuscular blocking agents -used to relax the jaw and vocal cords immediately after induction so that endotracheal tube can be placed. -It is used during surgery to provide continued muscle relaxation.

Two types: o Nondepolarizing o Depolarizing Balanced anesthesia -is a combination of IV drugs and inhalation agents used to obtain specific effects. A combination is used to provide hypnosis, amnesia, analgesia, muscle relaxation, and reduced reflexes with minimal disturbance of physiologic function. This method provides safe and controlled anesthetic delivery, especially for older and hugh risk clients. Steps in typical General Anesthesia Sedation- for clients who have not received an oral sedtaive, intravenous sedation is usually provided while still in the preoperative holding area. Common agents include midazolam or diazepam. Induction- important aspect of anesthesia. The client is given very short-acting medications to produce unconsciousness and a neuromuscular blocking agent, such as succinylcholine to cause paralysis. The clients's airway is intubated. Maintenance- The client can be positioned, prepped, and draped for the operation. Various medications, such as opioids, hypnotics, nitrous oxide and anesthetics are given to keep the client anesthesized during the various stages of operation. Emergence- the anesthetics are stopped and reversed sothat the client canemerge from anesthesia.

Complications from General Anesthesia Malignant hyperthermia- is an acute life-threatening complication of certain drugs used for general anesthesia. Onset of MH may occur immediately after induction of anesthesia several hours into the procedure, or rarely even after anesthetic has been terminated. Manifestations include tachycardia, dysrhythmias, muscle rigidity, hypotension, tachypnea, skin mottling, cyanosis and myoglobinuria. Overdose- can occur if the client's metabolism and drug elimination is slower tahn expected.

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Unrecognized hypoventilation- the respiratory system is most iften involved when the client has an anesthesia-induced complication. Failure to excahnge gases adequately can lead tocardiac arrest, oermanent brain damage and death. LOCAL OR REGIONAL ANESTHESIA - briefly disrupts sensory nerve impulse transmission from a specific body area or region. It is often supplemented with sedatives, opioid analgesics, or hypnotics to reduce anxiety or comfort. Local anesthesia- delivered topically and by local infiltration. Topical anesthesia- are applied directly to the area of skin or mucous membrane surface to be anesthesized. Often the anesthetic is an ointment or spray. Often used for respiratory intubation and for diagnostic procedures. Regional anesthesia- a type of anesthesia, may be used when: o General anesthesia cannot be used because of medical problem o The client has adverse reactions to general anethesia o The client has preference and choice o Pain managementafter surgery is enhanced by regional anesthesia

Types of Regional Anesthesia Field block - occurs with a series of injection around the operative field. - Injecting around a specific nerve or group of nerves depresses sensation at a local area. Used for chest procedures,, dental and plastic surgeries. Nerve block - occurs with the injection of local anesthetic agent into or around a nerve or group of nerves in the involved area. Itdisrupt sensory and motor impulse transmission. Spinal anesthesia - also called intrathecal block , occurs by injecting an anesthetic agent into the cerebrospinal fluid in thesubarachnoid space.this type of block inhibits the autonomic, sensory and motor nervous systems. Epidural anesthesia - the anesthetic agent is injected in the epidural space and the spinal cord areas are never entered. It is used for anorectal, vaginal, perineal, hip and lower extremity surgeries. Caudal anesthesia - also called saddle anesthesia or block is produced by injection of local anesthetic into the caudal or sacral canal.

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 Local infiltration - involves injection of an anesthetic agent such as lidocaine into the skin and subcutaneous tissue of the area to be anesthesized. Other methods of anesthesia or analgesia: Acupuncture- ancient chinese pain-killing technique that works by the insertion of long, thin needlesinto specific acupuncture points located on lines called meridians that connect anatomic sites on the body. Cryothermia- is the use of cold to induce anesthesia. Conscious Sedation -is the delivery of sedative, hypnotic and opioid druds to reduce the level of consciousness but allow the client to maintain a patent airway and to respond to verbal commands. The amnesia action is short and the client usually has a rapid return to activities of daily living. Complications of local or regional anesthesia: o related to client sensitivity to the anesthetic agent(anaphylaxis) , incorrect delivery technique, systemic absorption and overdosage. o cardiac arrest may occur as a rare complication of spinal anesthesia. o epinephrine is given to prevent cardiac arrest in clients in whom sudden, unexplained bradycardia develops. o local complications include edema and inflammation as early problems. Abscess formation, tissue necrosis, and or gangrene may occur later. The nurse's role in delivery if local or regional anesthesia consists of the following: o Assisting the anesthesia provider o Observing for breaks in sterile technique o Providing emotional support for the client o Staying with the client o Offering information and reassurance o Positioning the client comfortably and safely

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PRINCIPLES OF ASEPTIC TECHNIQUE

Principles Practices All objects in a sterile field o All articles sterilized appropriately by dry or moist heat, must be sterile chemicals, or radiation before use. o Always check a package containing a sterile object for intactness, dryness, and expiration date. Sterile articles can be stored for only a prescribed time: after that, they are considered unsterile. Any package that appears already open, torn, punctured or wet is considered unsterile. o Storage areas should be clean, dry, off the floor and way form the sinks. o Always check chemical indicators of sterilization before using a package. The indicator is often a tape used to fasten the package or contained inside the package. The indicator changes color during sterilization, indicating that contents have undergone a sterilization procedure. If the color change is not evident, the package is considered unsterile. Commercially prepared sterile packages may not have indicators but are marked with the sterile technique. Sterile objects become o Handle sterile objects that will touch open wounds or unsterile when touched by enter body cavities only with sterile forceps and sterile unsterile objects hand gloves. o Discard or resterilize objects that come into contact with unsterile objects. o Whenever the sterility of an object is questionable, assume the article is unsterile. Sterile items that are out of o Once left unattended, a sterile field is considered vision or below the waist or unsterile. table level are considered o Sterile objects are always kept in view. Nurses do not unsterile. turn their back on a sterile field. o Only the front part of the sterile gown, from shoulder to waist(or table height, whichever is higher) an the cuff of the sleeves to 2 inches above the elbows are considered sterile. o Always keep sterile gloved hands in sight and above waist table level; touch only objects that are sterile. o Sterile draped tables in the operating room or elsewhere are considered sterile only at surface level.

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Sterile objects can become unsterile by prolonged exposure to airborne microorganisms.

o o o o

o o

Fluids flow in the direction of gravity

Moisture that passes through a sterile object draws microorganisms from unsterile surfaces above or

Keep doors closed and traffic to a minimum in areas where a sterile procedure is being performed because moving air can carry dust and microorganisms. Keep areas in which sterile procedures are carried out as clean as possible by frequent damp cleaning with detergent and germicides to minimize contaminants in the area. Keep hair clean and short and enclose it in a net to prevent hair from falling on sterile objects. Microorganisms on the hair can make a sterile field unsterile. Wear surgical caps in operating rooms, delivery rooms and burn units. Refrain from sneezing or coughing over a sterile field. This can make it sterile because droplets containing microorganisms from the respiratory tract can travel 1 m(3 ft). Soma agencies recommend that masks covering the mouth an d the nose should be worm\n by anyone working in a sterile field or an open wound. Nurses with mild upper respiratory tract infections refrain from carrying of sterile procedures or wear masks. When working over a sterile field, keep talking to a minimum. Avert the head from the field if talking is necessary. To prevent microorganisms from falling over a sterile field, refrain from reaching over a sterile field unless sterile gloves are worn and refrain from moving unsterile objects over a sterile field. Unless gloves are worn, always hold wet forceps with the tips below the handles. When the tips are held higher than the handles, fluid can flow onto the handle and become contaminated by the hands. When the forceps are again pointed downward, the contaminated fluid flows back down and contaminates the tips. During a surgical handwash, hold the hands higher than the elbows to prevent contaminants from the forearms from reaching the hands. Sterile moisture proof barriers are used beneath sterile objiects. Liquids (sterile saline, or antiseptics) are frequently poured onto containers on sterile field. If the are spilled into the sterile field, the barrier keeps the

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below to the sterile surface by capillary action. The edges of a sterile field are considered unsterile.

o o o

o The skin cannot be sterilized and is unsterile. o o

liquid from seeping beneath it. Keep the sterile covers on the sterile equipment dry. Damp surfaces can attract microorganisms in the air. Replace sterile drapes that do not have a sterile barrier underneath when they become moist. A 2.5 cm (1in) margin at each edge of an opened drape is considered unsterile because the edges are in contact with unsterile surfaces. Place all sterile objects more than 2.5cm (1in) inside the edges of the sterile field. Use sterile gloves or sterile forceps to handle sterile items. Prior to surgical aseptic procedure, cleanse the hands to reduce the number of microorganisms. When a sterile object becomes unsterile, it does not necessarily change in appearance. The person who sees a sterile object become contaminated must corrector report the situation. Do not set up a sterile field ahead of time for future use.

Conscientiousness, alertness and honesty are essential qualities in maintaining surgical asepsis.

o o o

Prepared by: Faye Alexa Ponce Reference:

Medical-Surgical Nursing: Clinical Management for Positive Outcomes, 8th Edition By Joyce M. Black, PhD, RN, CPSN, CWCN, FAPWCA and Jane Hokanson Hawks, DNSc, RN, BC Medical Surgical Nursing - Workman

INTRAOPERATIVE NURSING RESPONSIBILITIES The nurse serves as the clients advocate during the operation by monitoring several aspects of the clients care. The nurse implements care individually designed for each client including the following: Identity the client It is important that each client should be identified before the beginning of any portion of surgical case. The arm band identifying the client is compared to the medical record. The surgical site which was marked and initialled by the surgeon is also compared to the planned operation.

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Position the client Explain to the client, in simple, understandable terms, why positions and restraints are necessary. Rationale: some clients feel that restraining straps are punitive. Some positions can be difficult or embarrassing. Preserve clients dignity and avoid undue exposure. Rationale: promotes a positive feeling that will encourage healing. Place restraining straps 2 inches above knees. Rationale: this is most secure position on operating bed. Avoids pressure injury from strap on bony prominence Nerves, muscles, pressure points and bony prominence are padded. Rationale: Prevents nerve and tissue damage; prevents pressure sores during long surgical procedures. Position client to obtain or maintain adequate respiratory exchange and vascular circulation. Rationale: ensures tissue perfusion and oxygenation, and minimizes pooling of blood, which prevents thrombus. Do not allow clients extremities to dangle along sides of table. Rationale: hands or feet can be unintentionally compressed against operating room bed by surgery team personnel as they lean over clients body. Impairment of circulation or nerve and muscles damage may result. Avoid excessive strain on clients muscle. Rationale: postoperative strain and discomfort may result Be certain that clients ankles are not crossed when in prone position Rationale: Circulation may be occluded Monitor total position throughout surgery. Rationale: client may remain one position for hours. Safety Almost everything in the operating room can be a source of injury if careful control is not exercised. Many procedures are in place to prevent accidents and injury.

o Preventing wrong site of surgery - The nurse or surgeon usually calls for time out before the first incision. This stops all members of the team from what they are doing and check that the client is correct, the body part, and all the details are correct.

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All plugs and wires are inspected for correct attachment; all equipments are checked if they are working properly and measures are taken to prevent burns to the client. Counting surgical supplies and equipments that could unintentionally be left inside the body, such as needles, sponges, gauzes and instrument. Usually performed by circulating nurse and scrub person at three different times. First, before the initial, second is during the surgery and third is immediately before closing the incision. Then the final count is being announced by the surgeon and charted.

o Maintain Surgical Asepsis - The nurse ensures the sterility of supplies and equipments. - If a suspected or actual outbreak in the sterile field occurs, the contaminated instruments and clothing are removed and replaced with new, sterile items. - The circulating nurse is not sterile and monitors the sterile filed to maintain sterility of supplies and personnel. o Monitor Body Temperature - The operating room temperature is maintained at 15o to 24o C. - The nurse should offer the client blanket immediately upon transfer to the operating room bed. - Hypothermia occurs if appropriate covering is not provided. - The nurse reports the lowest core body temperature after the surgery. - Cooling of body reduces the metabolic rate, which protects the brain and other organs during the surgical procedure. - Warm room is preferred for large body burns, for replantation and infants. o Monitor for Emergencies - The emergency crash cart should be in the operating room suite. - Emergency supplies of blood, using type O negative are required. Documentation The nurse documents every event and action in the operating room Information concerning drains, tubes, type of closure and dressing used is noted. Moving and Transporting the Client Avoid rapid movements when changing the clients position because it can predispose development of hypotension.

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Care must be taken not to catch, kink or dislodge IV catheter tubing, drains or other equipment during the transfer Avoid rough handling, which may damage fragile skin. Cover the client with warm blankets, secured with a safety belt and side rails are up.

Prepared by: Emmanuelle H. Arana Reference:

Medical-Surgical Nursing: Clinical Management for Positive Outcomes, 8th Edition By Joyce M. Black, PhD, RN, CPSN, CWCN, FAPWCA and Jane Hokanson Hawks, DNSc, RN, BC

III.

Postoperative Phase Third and final stage of the surgical process. It is divided into three stages: a. Immediate postoperative or post anesthesia recovery stage b. intermediate postoperative stage c. extended postoperative stage

NURSING CARE OF PEOPLE DURING THE IMMEDIATE POSTANESTHESIA RECOVERY STAGE *Transporting the person from the operating room to the recovery room or intensive care unit Following the operation, a member of the surgical team dresses the person in a clean gown, then assists the individual to a stretcher. But the personnel should strive to avoid the following problems: a. Exposure: may cause embarrassing and also predisposes the person to respiratory infections and shock. b. Rough Handling: may cause strain to the patient and conveys the feeling that the staff does not care for the patient. c. Hurried Movements and rapid position changes: this may predispose to hypotension.

The person is then moved or transferred to a bed or stretcher. The nurse must ensure safety of the patient. The nurse must be watchful to the effects of the

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anesthesia in some cases the patient is also accompanied by the surgeon or anesthesiologist. Some patients are transferred to the recovery room or PACU and others at the ICU.

POST-ANESTHESIA CARE UNIT Post Anaesthesia Care Unit (PACU) was introduced in 1923 and is the preferred location for the immediate recovery of the postoperative patient It is the unit where patients are temporarily admitted after any surgical; procedures. It is a vital part of hospitals and other medical facilities. It is normally attached to operating room suites, designed to provide care for patients recovering from anesthesia, whether it be general anesthesia, local or regional anesthesia such as epidurals and spinals. Close observation to the patient is done. The PACU nurse's priority of concerns when the patient arrives from the OR: assessment: VS, respiratory status, color, fluid intake, special equipment, dressing. Positioning of the head to side or lateral sims. Proper Positioning: A sedated and unconscious or semiconscious client must ensure proper airway patency. - extend the neck and thrust the jaw forward - for clients without devices: lateral sims position is the most preferred Rationale: this allows the tongue to freely fall forward and mucus and vomitus to drain from the mouth.

Assessment of the patient's airway patency (openness of the airway), vital signs , and level of consciousness are the first priorities upon admission to the PACU. The following is a list of other assessment categories:

surgical site (intact dressings with no signs of overt bleeding) patency (proper opening) of drainage tubes/drains body temperature (hypothermia/hyperthermia) patency/rate of intravenous (IV) fluids

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circulation/sensation in extremities after vascular or orthopedic surgery level of sensation after regional anesthesia pain status nausea/vomiting

Since the patient may still be sedated from anesthesia, safety is a primary goal. The patient's call light should be in the hand and side rails up. ALDRETE SCORING a measurement of recovery after anesthesia that includes gauging consciousness, activity, respiration, and blood pressure. scores the patient's mobility, respiratory status, circulation, consciousness, and pulse oximetry 1970; Aldrete proposed a scoring system to evaluate patient readiness for discharge from PACU 1995; Aldrete revised the scoring system

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Activity

Modified Aldrete Scoring Able to move four extremities voluntarily on command Able to move two extremities voluntarily on command Able to move no extremities voluntarily on command Able to breathe deeply and cough freely Dyspnea or limited breathing Apneic BP 20% of pre-anesthetic level BP20 49% of pre-anesthetic level BP50% of pre-anesthetic level

2 1 0 2 1 0 2 1 0

Respiration

Circulation

Pulse Rate Pulse20 beats of presedation rate Pulse50 to 21 beats of presedation rate Pulse>51 beats of presedation rate Consciousness Fully awake Arousable on calling Not responding 2 1 0 2 1 0

O2Saturation
Maintains baseline saturation on room air Needs O2 to maintain >90% saturation O2saturation<90% with O2 supplement 2 1 0

Surveillance Guidelines Score: Three (3) points below baseline Maintain 1:1 surveillance and q5 minute documentation of vital signs Score: Two (2) points below baseline *q 15 minutes surveillance and documentation of vital signs Score: One (1) point below baseline Q15-30 minutes urveillance and documentation of vital signs depending on patients condition (stable vs. unstable) Score: Equal to baseline (return to pre-procedure status) **Pre-discharge surveillance and documentation of vital signs

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Patients who receive reversal agents will require q 15 minute surveillance and documentation of vital signs for a minimum of two (2) hours post-reversal administration. *Patients with an Aldrete score of two (2) points or more below baseline must be referred to the physician responsible for the procedure for further evaluation. **Patients equal to baseline post-procedure will be discharged from the procedure area as in5.0 of the Sedation/Analgesia Policy The nurse needs to complete an initial assessment that includes the patients level of consciousness, vital signs, oxygen saturation, end tidal CO2 (if applicable), heart and breath sounds, surgical site and drainage devices, and IV access site so that any changes that occurred during transport can be identified immediately. Subsequently, a complete system assessment is performed and postoperative orders initiated. The report and assessment findings should be documented according to the institutions policies and procedures. Cardiopulmonary System: Maintenance of adequate gas exchange with adequate ventilation The patient should have unlabored, quiet respirations with adequate chest excursion a respiratory rate of 16 to 20 breaths per minute is normal for an adult (higher in children), but may be slower, particularly in a patient who has received opioids Patients should be encouraged to take deep breaths The respiratory function should be monitored, including oxygen saturation, and if available and appropriate, end-tidal carbon dioxide levels. Generally, an oxygen saturation level measured with a pulse oximeter should be higher than 92% to 94%, or the same as preoperative status. The cardiac output and perfusion should be assessed and monitored by checking arterial blood pressure for evidence of hypotension or hypertension postoperative blood pressure should be plus or minus 20% compared with the preoperative measurement heart rate and rhythm for signs of dysrhythmias skin color and temperature, and peripheral pulses for peripheral perfusion status fluid intake and output should be reviewed for indications of possible hypovolemia or hypervolemia, total fluids infused, including blood products compared with urinary output, estimated blood loss, and volume in surgical drains Peripheral edema or jugular venous distention should be noted. Numerous factors can alter cardiopulmonary function, including pain and residual anesthetic affects, and the underlying cause needs to be identified to effectively resolve the problem.

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Temperature: Hypothermia, a core temperature below 36 C, is a common, but adverse, side effect of anesthesia In the PACU, normothermic patients should continue to have an assessment of temperature at least hourly, assessment of thermal comfort and passive thermal care measures, such as a warmed blanket. Normothermic patients should have an application of forced-air warming and consideration of additional adjuvant measures such as warmed intravenous fluids and humidified warm oxygen.

PREPARED BY: Marinela Mei C. Ayala

RERENECES: MEDICAL SURGICAL NURSING BRUNNER AND SUDDHART, black and Workman Postoperative Care - procedure, recovery, blood, pain, complications, time, infection, medication, heart, nausea, rate, Definition, Purpose, Description, Preparation, Aftercare, Normal results http://www.surgeryencyclopedia.com/PaSt/Postoperative-Care.html#b#ixzz2BddJFhnT General Goals of Post-op Care Optimal respiratory function Relief of pain Optimal cardiovascular function Increased activity tolerance Unimpaired wound healing Maintenance of body temperature Maintenance of nutritional balance

Common Postoperative Complications A. Circulatory Hemorrhage Bleeding internally or externally Cause: Disruption of sutures, insecure ligation of blood vessels. Clinical signs: Rapid weak pulse, increasing respiratory rate, restlessness, lowered BP, cold clammy skin, thirst, pallor, reduced urine output. Preventive intervention: Early recognition of signs.

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Thrombus Blood clot attached to wall of vein or artery (most commonly the leg veins). Cause: Venous stasis; vein injury resulting from surgery of legs, pelvis, abdomen; factors causing increased blood coagulability (eg, use of estrogen) Clinical signs: Sudden chest pain, SOB, cyanosis, shock (tachycardia, low BP). Preventive Interventions: Early ambulation, leg exercises, antiemboli stockings, adequate fluid intake. Embolus Clot that has moved from its site of formation to another area of the body. Cause, Signs, Prevention: Same as thrombus.

B. Urinary Urinary retention Accumulation of urine in the bladder and inability of the bladder to empty itself. Cause: Depressed bladder muscle tone from narcotics & anesthetics; handling of tissues during surgery on adjacent organs (rectum, vagina). Clinical signs: Fluid intake larger than output; inability to void or frequent voiding of small amounts, bladder distention, suprapubic discomfort, restlessness. Preventive Intervention: Monitoring of fluid intake and output, interventions to facilitate voiding. Urinary tract infection Inflammation of the bladder. Cause: Immobilization and limited fluid intake. Clinical signs: Burning sensation when voiding, urgency, cloudy urine, lower abdominal pain: Preventive Intervention: Adequate fluid intake, early ambulation, early ambulation, good perineal hygiene.

C. Gastrointestinal Constipation Infrequent or no stool passage for abnormal length of time (eg, within 48 hours aftersolid diet started). Cause: Lack of dietary roughage, analgesics (decreased intestinal motility). Clinical signs: Absence of stool elimination, abdominal distention, and discomfort. Preventive Interventions: Adequate fluid intake, high-fiber diet, early ambulation. Nausea and vomiting Cause: Pain, abdominal distention, ingesting fluids or foods before return of peristalsis, certain medications,anxiety. Clinical signs: Complaints of feeling sick to the stomach, retching or gagging. Preventive Intervention: IV fluids until peristalsis returns; then clear fluids, full fluids and regular diet when peristalsis returns.

D. Wound Wound infection Inflammation and infection of incision or drain site. Cause: Poor aseptic technique; lab analysis of wound swab identifies causative microorganism. Clinical signs: Purulent exudates, redness, tenderness, elevated body temperature, wound odor.

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Nursing Management A. Assessing Level of Consciousness - Orientation to time, place, and person - Fully conscious but drowsy? - Reaction to verbal stimuli - Ability to move extremities Vital signs - Compare initial finding with Post-anesthetic Room data Skin color and temperature - Lips and nail beds (tissue perfusion) - Pale, cyanotic, cool, moist skin? (Circulatory problem) Fluid balance - Type and amount of IV fluids, flow rate, and infusion site - Fluid intake and output Position and safety - Appropriate position according to the physicians orders Dressings and bedclothes - Excessive bloody drainage on dressings or on bedclothes Pain and comfort level - Location and intensity of pain - Feeling warm and comfortable?

B. Nursing Interventions Appropriate client positioning - position as ordered - if otherwise, follow patients preference Appropriate client positioning- position as ordered- if otherwise, follow patients preference Encourage deep-breathing and coughing exercises - DBE helps remove mucus, which can form and remain in the lungs due to the effects of general anesthetic and analgesics (they depress the action of both cilia of the mucous membranes lining the respiratory tract and the respiratory center in the brain) - DBE prevents pneumonia by increasing lung expansion and preventing the accumulation of secretions - DBE also frequently initiates the coughing reflex; voluntary coughing in conjunction with deep breathing exercises facilitate the movement and expectoration of respiratory tract secretions Leg exercises - muscle contractions compress the veins, a cause of thrombus formation and subsequent thrombophlebitis and emboli - contractions also promote arterial blood flow Early ambulation

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- turning allows alternating maximum expansion of uppermost lung - early ambulation, as ordered, prevents respiratory, circulatory, urinary, and GI complications; it also prevents general muscle weakness Adequate hydration - IV infusions are given to balance loss of body fluids - sufficient fluids keep the respiratory mucous membranes and secretions moist, thus facilitating mucus expectoration during coughing - also, an adequate fluid balance will prevent dehydration and the resulting concentration of the blood that, along with venous stasis, is conducive to thrombus formation Diet - check clients postoperative diet ordered by the surgeon Promoting urinary elimination - ensure that fluid intake is adequate - determine whether client has any difficulties in voiding and asses for bladder distention Administering analgesics as ordered for pain - provide comfort measures to relax the client (rest periods) Wound care - clean, dry, intact? - change dressings, using sterile technique as required, when they are soiled with drainage or in accordance with the orders

References: Kozier, B., et. al. (2007). Fundamentals of Nursing (8th edition). Jurong, Singapore: Pearson Education. South Asia PTE Ltd. Brunner, L. S., Suddarth, D. S., & Smeltzer, S. C. O. (2004). Brunner and Suddarths Textbook of Medical-Surgical Nursing (10th edition). Philadelphia: Lippincott Williams & Wilkins.

Prepared by: Charis Mae F. Dimaculangan

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