1 Perioperative Nursing

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PERIOPERATIVE NURSING
Nursing care takes place immediately:
Before
During
After surgery.
A nurse act as independent cIinician and a member of a heaIth
care team during perioperative nursing.
Coals of erloperaLlve nurslng
1o asslsL cllenLs and Lhelr slgnlflcanL oLhers Lhrough
Lhe surglcal eplsode
1o help promoLe poslLlve ouLcomes
1o help cllenLs achleve Lhelr opLlmal level of funcLlon
and wellness afLer surgery
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1reoperaLlve hase (surglcal unlL Lo C8)
Lhe perlod when Lhe cllenL ls admlLLed ln Lhe surglcal unlL Lo Lhe perlod he ls
prepared physlcally psychosoclally splrlLually and legally prepared for Lhe surglcal
procedure unLll he ls LransporLed lnLo Lhe operaLlng room
2 lnLraoperaLlve hase (C8ACu)
Lhe perlod Lhe cllenL ls admlLLed Lo Lhe C8 Lhe Llme of admlnlsLraLlon of
anesLhesla surglcal procedure ls done recovery room or posL anesLhesla care
unlL
3 osLoperaLlve hase (ACulCLLCWu)
Lhe perlod recovery room/ACu LransporLed back lnLo Lhe surglcal unlL
dlscharged from Lhe hosplLal unLll Lhe followup care
Surglcal ClasslflcaLlons
According to Purpose
1. Aesthetic (cosmetic)
mprovement of physical
features that are within
the "normal range.
Ex. Breast augmentation
2. Constructive
Repair of congenitally
defective body part.
Ex. Cleft lip and cleft
palate
3. Curative
Removal or repair of damaged
or diseased tissue or organs (ex
hysterectomy).
Mostly done with definite cancer
diagnosis
Operations are conducted to
remove or destroy cancerous
tissues
Su8ClCAL CLASSlllCA1lCn
4. Diagnostic
Done when a specific diagnosis
is not possible using
noninvasive or simple biopsy
techniques.
Done for discovery or
confirmation of a dx
Ex. Breast biopsy
According to purpose
5. Exploratory
Estimation of the extent
of the disease or
confirmation of a dx
Ex. Exploratory
laparotomy
According to purpose
6. Palliative
Relief of symptoms but
without cure of
underlying disases
Ex. Colostomy
. Reconstructive
Partial or complete restoration
of a body part
Ex. Total joint replacement
According to Degree of Risk
Major Surgery
nvolves a high degree of risk since these surgeries may be
complicated or prolonged, hemorrhage may occur, vital organs
may be involved, or postoperative complications are likely to
appear.
Minor Surgery
nvolve little risks
Produces fewer complications
Often performed in "day surgery
Performed in the OPD
According to Urgency
1. Emergent
Must not be delayed
Almost always life-threatening
Patient requires immediate attention
Ex. Fractured skull, gunshot or stab wounds, extensive burns
2. Urgent
Pt requires prompt attention
ndicated within 24-30 hrs
Ex. Acute gallbladder infection, kidney stones
3. Required
Pt needs to undergo surgery but could be planned within a few weeks or months
Ex cataracts, thyroid disorders
4. Elective
Client should have surgery
However, failure to have surgery does not end in catastrophic consequences
Ex. Vaginal repair, repair of scars
5. Optional
The decision to undergo these types of surgeries rest solely on the personal preference of the client
Cosmetic surgeries
8LCL8A1lvL PASL
8LCL8A1lvL PASL
Preoperative Assessment
To be included in the preop assessment:
1. Medical/health hx
Review past medical hx
To determine operative risk
Previous surgery and experience with anesthesia
Untoward reactions to anesthesia
Hypethermia, prolonged n/v
These do not hinder surgery, but need to change the type of anesthetics
used
MLulCAL PlS1C8?
Serious llness or Trauma
A - AIIergy
Medications, chemicals, latex
All should be reported before the beginning of surgery
B - BIeeding tendencies
use of meds that daunt cIotting (aspirin, heparin/warfarin)
C - Cortisone (AL rlsk for adrenal lnsufflclency)
- iabetes meIIitus
Other condition that requires strict blood glucose control that known to delay wound healing
E - EmboIi
1 Uncontro||ed 1hyro|d D|sease
CveracLlve rlsk of 1hyroLoxlcosls
underacLlve rlsk of resplraLory depresslon
MLulCAL PlS1C8?
AIcohoI, recreationaI drug or nicotine use
ndicate potential problem with anesthesia or analgesic administration
and risk for withdrawal complications
Alcohol/drugs can cause withdrawal
Tobacco/drug reduces hemoglobin levels making less oxygen available
for tissues
Smokers are at high risk for thrombus formation (due to
hypercoagulability secondary to nicotine use
MLulCAL PlS1C8?
Current iscomforts
With preexisting painful conditions may require alternative methods of pain reduction
while under NPO
Chronic iIIness
llness that require consideration when positioning
Arthritis of the neck/back
Advanced age
Older clients have specific perioperative needs
Medication hx
OTC may increase operative risk
Ask if they are taking and brought them in the hospital
Medication dosages and administration schedules should be noted in the chart
S?CPCLCClCAL Px
Client's cultural beliefs and practices
Client's emotional reaction towards the whole
surgical experience
AbiIity to toIerate perioperative stress
Physiologic stress like pain, tissue damage, anesthesia, blood
loss, fever and immbilization
LifestyIe habits and sociaI hx
PhysicaI examination
Must be done prior to operation
To identify present health status and to have baseline info
To identify problems and to develop appropriate outcome goals
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resence of paLhologlc or cardlac condlLlons
lncrease operaLlve rlsks and could lead Lo decrease Llssue
perfuslon wlLh lmpalrmenL of surglcal heallng
Anglna pecLorls
Cccurrence of Ml ln Lhe lasL 6 mos
unconLrolled Pn
PearL fallure
erlpheral vascular dlsease
CA8ulCvASCuLA8
Document the ff observations:
SOB on minor exertion
HPN
Heart murmurs or S3 gallops
Chest pain
CA8ulCvASCuLA8
Dx and lab studies done to measure cardiovascular
function
a. ECG, esp for cients over 40 yrs
b. hemoglobin, hct and serum electrolytes
8LSl8A1C8?
1 Chronlc lung condlLlons
lncrease operaLlve rlsks
lmpalr gas exchange ln Lhe alveoll
predlsposlng Lo posLoperaLlve pulmonary compllcaLlons
a Lmphysema
b AsLhma
c 8ronchlLls
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2. Assessment of pulmonary conditions must include:
a. Examining for presence of SOB
b. Wheezing
c. Clubbed fingernails
d. Chest pain
e. Cyanosis
f. Coughing with expectoration of copious or purulent mucous
g. Obtain hx of smoking and respiratory allergies
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3. Diagnostic and lab studies to measure respiratory
function:
a. CXR
b. pulse oximetry
c. ABG (arterial blood gas) analysis
d. Pulmonary function test
MuSCuLCSkLLL1AL
1 Assess for hx of Lhe ff dlsorders LhaL may affecL
surglcal poslLlonlng and posLop supporL
a arLhrlLls
b fracLures
c conLracLures
d [olnL ln[ury
e musculoskeleLal lmpalrmenL
2 L LhaL may reveal problems wlLh [olnL moblllLy or
deformlLles LhaL may lnLerfere wlLh operaLlve
poslLlonlng
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Cl condlLlons LhaL may be assoclaLed wlLh poor
surglcal ouLcomes
Severe malnuLrlLlon
rolonged nausea and vomlLlng
Ceneral assessmenL of Lhe Cl funcLlonlng should
be done esp for abdomlnal surgery
ln1LCuMLn1A8?
The skin must be assessed preoperatively to be able to establish
baseline data for comparisons postoperatively.
The following should be documented and reported if observed
during assessment:
1. Lesions
2. Pressure ulcers
3. Necrotic skin tissue
4. Skin turgor
5. Erythema
6. Discoloration of the skin
. Tattoos and body piercing
8LnAL
adequaLe renal funcLlon ls necessary Lo ellmlnaLe proLeln wasLes Lo preserve fluld and
elecLrolyLe balance and Lo remove anesLheLlc agenLs
1 8enal and relaLed renal dlsorders LhaL may affecL Lhe ouLcome of Lhe surgery are Lhe followlng
a Advanced renal lnsufflclency
b AcuLe nephrlLls
c 8enlgn prosLaLlc hyperLrophy
2 Assess renal sLaLus by asklng abouL voldlng paLLerns
MonlLor fluld and elecLrolyLe balance by recordlng lnLake and ouLpuL LhroughouL Lhe perloperaLlve phases
3 common preoperaLlve LesLs done Lo deLermlne Lhe sLaLus of renal funcLlon
8lood urea nlLrogen (8un)
serum creaLlnlne
urlnalysls are Lhe
Liver Function Assessment
1. Cirrhosis of the liver increases client's surgical risk since an
impaired liver cannot detoxify medications and anesthetic agents
2. Hx of alcoholism or other substance abuse require carefuI
assessment of the Iiver function before surgery.
3. A high caIorie diet or hyperaIimentation may be ordered during
preop and postop phases
to correct problems of malnourished and debilitated clients with liver
disease
Cognitive and Neurologic Assessment
1. Assess for serious neurologic conditions such as:
- uncontrolled epilepsy
- severe Parkinson's disease
- that may increase surgical risk.
2. Assess the following through thorough physical assessment and interview to obtain baseline data:
a. Severe headache
b. Frequent dizziness
c. Light-headedness
d. Ringing in the ears
e. Unsteady gait
l unequal puplls
g PlsLory of selzures
h neurologlc funcLlons (le reflex response of exLremlLles sensory reflexes and cerebral responses)
l CrlenLaLlon Lo Llme person and place
Lndocrlne AssessmenL
1. Diabetes mellitus (DM)
- most common pre-existing endocrine disorder.
- puts client at high risk for poor wound healing and increased risk of postoperative
infections.
Constant monitoring and control of blood glucose should be done all throughout the
perioperative period.
2. Thyroid functioning may also be assessed preoperatively.
Thyroid replacement is usually continued during the perioperative period.
Additional Assessments
1. Age
a. Physiologic changes normal to aging clients and presence of certain
diseases may adversely affect surgical outcomes.
b. Surgical risks including:
Malnutrition
Anemia
Dehydration
Atherosclerosis
Chronic obstructive
Pulmonary disease
Diabetes mellitus
Cerebrovascular changes
Peripheral vascular disease
may increase due to chronic conditions commonly found to elderly clients.
2 aln
lmporLanL physlologlc lndlcaLor LhaL necesslLaLes careful
monlLorlng
CllenLs should be asked wheLher Lhey are experlenclng
any paln prlor Lo any surglcal procedure
lf paln ls presenL Lhorough assessmenL should be done
Lo ldenLlfy Lhe cause of Lhe paln
3. Nutrition
- nutritional status is directly related to intraoperative success and
postop recovery.
- Assessment includes:
- acquiring a diet history
- observing general appearance
- laboratory/diagnostic testing
- comparing current weight with ideal
body weight.
4. Fluid and electrolyte balanc e
- Proper assessment of actual and potential fluid
imbalances
- Fluid volume deficits such as hypovolemia or hypervolemia predispose a client
to complications during and after surgery.
- Electrolyte imbalances also increase operative risk
- Preoperative laboratory results should be checked
to determine whether serum sodium, potassium, calcium, and magnesium
concentrations are within normal levels.
lnfecLlon and lmmunlLy
a Any preexlsLlng lnfecLlon can adversely affecL surglcal ouLcomes slnce bacLerla
may be released ln Lhe blood sLream durlng surgery
b Any posslble exposure Lo communlcable dlseases presence of skln leslons or
manlfesLaLlons of an lnfecLlon (eg coughlng sore LhroaL or fever) should be
properly documenLed durlng preoperaLlve assessmenL
c lf exlsLlng lnfecLlon greaLly lncreases surglcal rlsks reschedullng Lhe surgery may
be necessary
. HematoIogic conditions
a. History of bleeding or diagnosis of pathologic condition such as
hemophilia or sickle cell anemia
b. Bruising, excessive bleeding following dental extractions, or severe
epistaxis
c. Hepatic or renal disease
d. Use of anticoagulants, aspirin or other non steroidal anti-inflammatory drugs
e. Abnormal bleeding time, prothrombin time, or platelet count
lnformed ConsenL
A legal documenL LhaL slgnlfles LhaL Lhe cllenL has been Lold abouL and
undersLands all aspecLs of as speclflc lnvaslve procedure
Cuards Lhe cllenL agalnsL unwanLed lnvaslve procedures
roLecLs Lhe healLh care faclllLy and healLh care professlonals when Lhe cllenL
denles undersLandlng abouL Lhe procedure
hyslclan's responslblllLy Lo provlde approprlaLe lnformaLlon
nurse's duLy Lo ask Lhe cllenL Lo slgn Lhe consenL form and may be a wlLness Lo
Lhe cllenL's slgnaLure
nformed consent is a must in the following
circumstances:
1. nvasive procedures
- surgical incision
- a biopsy
- cystoscopy
- paracentesis)
2. Procedures requiring sedation and/or anesthesia
3. A nonsurgical procedure
- arteriography that carries more than slight risk to the client
4. Procedures involving radiation
CrlLerla for valld lnformed ConsenL
volunLary ConsenL
valld consenL musL be freely glven wlLhouL
coerclon
lncompeLenL CllenL
noL auLonomous
cannoL glve or wlLhhold consenL
menLally reLarded menLally lll comaLose
nformed Sub[ect
lnformed consenL should be ln wrlLlng and should conLaln Lhe followlng
1 LxplanaLlon of procedure and lLs rlsks
2 uescrlpLlon of beneflLs and alLernaLlves
3 An offer Lo answer quesLlons abouL procedures
4 A sLaLemenL lnformlng Lhe cllenL lf Lhe proLocols dlffer from cusLomary
procedures
CllenL Able Lo Comprehend
lnformaLlon musL be wrlLLen and dellvered ln
language undersLandable Lo Lhe cllenL
CuesLlons musL be answered Lo faclllLaLe
comprehenslon lf maLerlal ls confuslng
reoperaLlve 1eachlng
u8CSL
1o ensure a poslLlve surglcal experlence for
Lhe cllenL
helps Lo allevlaLe Lhe cllenL's fear and
anxleLy regardlng Lhe surgery
ComponenLs of reoperaLlve 1eachlng
Sensory lnformaLlon
addresses Lhe slghLs sounds and
omblooce of tbe opetotloq too
Jlscoss wbot tbe clleot sboolJ expect
to see beot ooJ feel wbeo be/sbe
ls ttoosfetteJ to tbe opetotloq toom
ooJ oo tbe opetotloq toom toble
sychosoclal lnformaLlon
addresses Lhe coplng ablllLles and Lhe worrles of Lhe cllenL and Lhe
famlly
1o allevlaLe Lhe cllenL and famlly's worrles and fears Lhe nurse
LogeLher wlLh Lhe help of a soclal worker or a counselor should
address quesLlons such as Lhe followlng
1 WhaL lf l dle?
2 Pow could we pay for Lhe operaLlon?
3 Who wlll Lake care of my chlldren whlle l'm here?
rocedural lnformaLlon
whaL wlll happen all LhroughouL Lhe
perloperaLlve perlod lncludlng Lhe
dlscharge phase
All Lhe lnformaLlon LhaL Lhe cllenL wanLs
Lo know regardlng Lhe cllenL care should
be addressed
1he nurse o/so provides instruction for the
fo//owinq
1 ueep breaLhlng
2 Coughlng
3 1urnlng
4 AmbulaLlng
aln conLrol
reoperaLlve nurslng ulagnoses
ueflclL knowledge relaLed Lo unfamlllar
surglcal experlence
AnxleLy/fear relaLed Lo paln deaLh
dlsflguremenL or Lhe unknown
reoperaLlve nurslng Care
1 reparaLlon of Lhe skln
a shower/baLhlng Lhe nlghL before a scheduled surgery as per
lnsLlLuLlonal pollcy
b Clean Lhe slLe wlLh soap and waLer or anLlmlcroblal soluLlon Lo
dlmlnlsh Lhe # of mlcrobes on Lhe skln
2 Clean Lhe area before Lhe surgery
3 addlng on bony promlnences Lo prevenL Lrauma ln Lhe skln
durlng Lransfer
4 1he gasLrolnLesLlnal LracL ls prepared Lhe nlghL before Lhe
surgery Lo
8educe Lhe posslblllLy of vomlLlng and asplraLlon
8educe Lhe rlsk of posslble bowel obsLrucLlon
Allow vlsuallzaLlon of Lhe lnLesLlne durlng bowel surgery
revenL conLamlnaLlon from fecal
maLerlal ln Lhe lnLesLlnal LracL durlng bowel or abdomlnal
surgery
reparaLlons for Lhe gasLrolnLesLlnal LracL lnclude Lhe followlng
a 8esLrlcLlng food and fluld 810 hrs before Lhe operaLlons
b AdmlnlsLerlng enema as needed
reparaLlons for Lhe gasLrolnLesLlnal LracL lnclude Lhe followlng
estr|ct|ng food and f|u|d 810 hrs before the operat|ons
1 Lxplaln Lhe reason for resLrlcLlon
2 8emove food and waLer from bedslde aL mldnlghL
3 lace nC" slgns on Lhe door and bed
4 Mark Lhe care plan or Lhe kardex wlLh nC"
lnform Lhe dleL and nuLrlLlon depL and famlly abouL Lhe sLaLus
6 lf Lhe cllenL has been lnsLrucLed Lo Lake lmpL meds orally
1 Allow only small slps of waLer
2 Lxplaln why Lhls permlsslon ls permlsslble
3 uocumenL Lhe med and amounL of fluld Laken ln Lhe charL
AdmlnlsLerlng enema as needed
1 Lspeclally operaLlon ln gasLrolnLesLlnal LracL perlanal
area and pelvlc cavlLy
2 May be done aL home or admlnlsLered by Lhe nurse ln
Lhe hosplLal
3 8owel cleanslng ln Lhe mornlng before Lhe surgery may be
done as prescrlbed
Preoperative Preparation ImmediateIy
Before Surgery
1 All known allergles are recorded and an allergy wrlsLband ls presenL
2 vlLals slgns are checked and recorded
3 1he ldenLlflcaLlon band ls presenL and correcL
4 1he consenL formed ls slgned and Lhe surglcal procedure ls llsLed correcLly
Skln preparaLlon ls compleLed lf ordered preoperaLlvely
6 Any speclal orders are compleLed (enema lv llne)
1he cllenL has noL eaLen or had flulds by mouLh for Lhe lasL elghL
hours
8 1he cllenL has [usL volded
9 Cral hyglene or oLher physlcal/hyglene care ls compleLed
10 1he presence of denLures brldgework or oLher prosLheses ls
noLed
11 SLorage ls arranged and documenLed for valuables accordlng Lo
healLh care faclllLy pollcy
Before Surgery
Before Surgery
12 1he cllenL has removed [ewelry
13 1he perloperaLlve nurse ls noLlfled abouL Lhe presence of a
hearlng ald
14 1he cllenL ls wearlng a hosplLal gown and proLecLlve cap
1 Makeup ls removed
16 reoperaLlve medlcaLlons are glven
1 1ransfer Lhe cllenL from bed Lo a sLreLcher
ln18ACL8A1lvL PASL
Members of Lhe Surglcal 1eam
Croup of hlghly Lralned professlonals who coordlnaLe Lhelr
efforLs Lo ensure Lhe welfare and safeLy of Lhe cllenL
Members of Lhe Surglcal 1eam
1 Surgeon
PLAu
2 Second Surgeon or a Speclally 1ralned nurse
3 AnesLheslologlsL
AllevlaLes paln
romoLes relaxaLlon wlLh medlcaLlons
MalnLaln alrway
Lnsure adequaLe gas exchange
MonlLors clrculaLlon and resplraLlon
LsLlmaLes blood and fluld loss
lnfuses blood and flulds
MalnLalns hemodynamlc sLablllLy
AlerLs surgeon lmmedlaLely Lo any compllcaLlons
4 erloperaLlve nurses
8oles of Lhe erloperaLlve nurse
l ClrculaLory nurse
1 AssessmenL of cllenL preoperaLlvely
2 lannlng for opLlmal care durlng Lhe surglcal lnLervenLlon
3 CoordlnaLlng all personnel wlLhln Lhe operaLlng room
4 uelegaLlng and monlLorlng unllcensed personnel
MonlLorlng responslble cosL compllance assoclaLed wlLh operaLlng
room procedures
|rcu|atory Nurse
6 Lnsurlng all equlpmenL are worklng properly
CuaranLeelng sLerlllLy of equlpmenL and supplles
8 AsslsLlng wlLh poslLlonlng
9 erformlng surglcal skln preparaLlon
10 MonlLorlng Lhe room and Leam members for breaks ln sLerlle
Lechnlque
8oles of Lhe erloperaLlve nurse
|rcu|atory Nurse
11 AsslsLlng anesLhesla personnel wlLh lnducLlon and physlologlc monlLorlng
12 Pandllng speclmens
13 CoordlnaLlng acLlvlLles wlLh oLher deparLmenLs such as radlology and
paLhology
14 uocumenLlng care provlded
1 Mlnlmlzlng conversaLlon and Lrafflc wlLhln Lhe operaLlng room sulLe
II. Scrub Nurse
RN or Surgical Technician
Duties:
1. Gathering all necessary equipment for the procedure
2. Preparing all supplies and instruments using sterile technique
3. Maintaining sterility within the sterile field during surgery
4. Handling instruments and supplies during surgery
. Scrub Nurse
5. Cleaning up after the case
6. Maintains an accurate count of sponges, sharps, and instruments on the sterile
field and counts the same materials with the circulating nurse before and after
the surgery
eg|stered Nurse I|rst Ass|stant (NIA)
new role of perloperaLlve nurses
1
sL
asslsLanLs (Lo Lhe surgeon) ln place of a 2
nd
or asslsLlng physlclan
AddlLlonal Speclallzed educaLlon
MusL work wlLh surgeon and are noL lndependenL pracLlLloners
1 rovldlng exposure of Lhe surglcal area
2 uslng lnsLrumenLs Lo hold and cuL
3 8eLracLlng and handllng Llssues
4 rovldlng homeosLasls
SuLurlng
I ert|f|ed eg|stered Nurse Anesthet|st (NA)
8n wlLh mlnlmum of addlLlonal 2 yrs educaLlon speclallzlng ln Lhe
anesLhesla admlnlsLraLlon
8Sn + 12 yrs ln lCu
Work under Lhe dlrecLlon of anesLheslologlsL
I Manager
LxLenslve experlence addlLlonal educaLlon ln mgL
8eqL 8Sn degree Mn
C1PL8 nAMLS cllnlcal nurslng dlrecLor/ C8 manager
I Lducator
Any 8n alLhough usually wlLh MSn experlenced perloperaLlve
nurses
I ase Manager
LxLenslve experlence
AblllLy Lo communlcaLe
knowledge of Lhe LoLal surglcal eplsode from home before
surgery Lo home care needs afLer surgery
Su8ClCAL Lnvl8CnMLn1
Su8ClCAL Lnvl8CnMLn1
ulvlslon of Surglcal Area
3 zones (decrease mlcrobes clrculaLlng ln Lhe C8
1 UNLS11LD 2CNL
SLreeL cloLhes or dlrLy (noL sLerlle) cloLhlng are allowed
SLMLS11LD 2CNL
ALLlre conslsLs of scrub cloLhes and cap
LS11LD 2CNL
Scrub cloLhes shoe covers caps and masks are worn
LlghL 8aslc rlnclple of AsepLlc
1echnlque
Eight Basic PrincipIe of Aseptic
Technique
1. All materials in contact with the surgical wound and used within the sterile field must
be sterile.
2. Gowns of the surgical team are considered sterile in front from the chest to the level
of the sterile filed.
SIeeves are steriIe from 2 inches above the eIbow to the stockinette cuff
3. Sterile drapes are used to create sterile field.
ONLY the top surface of drape tabIe is steriIe
4. tems should be dispensed to a sterile field by methods that preserve the sterility of
the items and the integrity of the sterile field.
Edges are considered UNSTERILE
5. The movements of the surgical team are from sterile to sterile areas and from unsterile
to unsterile areas.
6. Movement around the sterile filed must not cause contamination of the field.
. Whenever the sterile barrier is breeched, the area must be considered contaminated.
8. Every sterile field should be constantly monitored and maintained.
DOUBTFUL STERLTY ARE
CONSDERED
UNSTERILE
Eight Basic PrincipIe of Aseptic
Technique
Surglcal Pand Washlng (Scrubblng)
9urpose of Surg|ca| nand Wash|ng
1 1o remove debrls and LranslenL mlcroorganlsms
2 1o reduce Lhe resldenL mlcroorganlsms
3 1o lnhlblL rapld rebound growLh of mlcroorganlsms
Surglcal Pand Washlng (Scrubblng)
m|n surg|ca| scrub ls Lhe recommended
lengLh of Llme for surglcal hand washlng by
Lhe
Assoc|at|on of Cperat|ng oom Nurses (ACN)
To perform the surgicaI hand washing (scrubbing):
Su8ClCAL A11l8L
Surglcal ALLlre
SemlresLrlcLed and resLrlcLed zones wlLhln LradlLlonal C8 sulLes
requlres personnel Lo wear speclal surglcal aLLlre
Wearlng surglcal aLLlre helps
prevenL Lransmlsslon of mlcrobes from personnel Lo cllenLs
ConslsL of
Scrub gowns
na|r cover|ngs
Masks
9rotect|ve eyewear
Shoe covers
9LSCNAL 9C1L1IL LU9MLN1
The foIIowing are principIes that shouId be observed when
donning surgicaI attire:
1 Surglcal aLLlre should be worn only wlLhln Lhe surglcal slLe
2 lf ln case Lhere ls a need Lo wear Lhe aLLlre ouLslde Lhe semlresLrlcLed and
resLrlcLed zones of Lhe C8 lL should be covered or changed before reenLerlng
Lhe area
3 Clean scrub sulL should be worn wlLhln Lhe surglcal envlronmenL
1C CN1AN 8A1LAL SnLDDNG ICM 1nCAk AND A8DCMNAL SkN
4 lf a Lwoplece scrub sulL ls worn (panLs and Lop) Lhe Lop musL be secured aL Lhe
walsL Lucked lnLo Lhe panLs or flL close Lo Lhe body
Scrub sulLs should be changed dally or whenever Lhey become vlslbly solled
or weL
6 Sleeves of scrub sulLs should be shorL enough Lo allow for surglcal hand
washlng Lo Lwo lnches above Lhe elbow
All head and faclal halr lncludlng sldeburns and neckllnes should be
covered by a clean lowllnL surglcal haL or hood when one ls ln Lhe seml
resLrlcLed/resLrlcLed zones
8 1he surglcal haL or hood should be Lhe flrsL plece of Lhe C8 aLLlre LhaL ls
donned
1C 9LILN1 nA ICM CLLL1NG CN 1nL SU8 LC1nLS
9 Shoe covers may be worn lnslde Lhe C8 for sanlLaLlon purposes
10All shoe covers should be removed upon leavlng Lhe resLrlcLed zones and
a new palr should be worn when reLurnlng Lo Lhe C8
11Masks musL be worn ln speclfled resLrlcLed areas of Lhe surglcal sulLe
12Masks are worn Lo fllLer organlsms from Lhe exhaled alr
13A mask should be secured over Lhe nose along Lhe sldes of Lhe face and
under Lhe chln Lo prevenL venLlng or escape of alr
14Surglcal masks should be changed beLween procedures and should be
allowed Lo hang around ln Lhe neck
1use of double masks ls unaccepLable for lL becomes a barrler raLher Lhan a
fllLer
16roLecLlve eyewear (goggles wlLh solld slde shlelds or chlnlengLh face
shleld) ls worn Lo reduce Lhe lncldence of conLamlnaLlon of mucous
membranes whenever conLamlnaLlon can be anLlclpaLed as a resulL of
splashes sprays or splaLLers of blood dropleLs
1!ewelry should noL be worn ln Lhe surglcal sulLes
18SLerlle gown and gloves are donned uslng Lhe
closed meLhod when a scrub nurse enLers Lhe
operaLlng room
19Cloves should flL properly Lo ensure ease of
handllng of Lhe C8 lnsLrumenLs and supplles
20CompleLe surglcal hand washlng (scrubblng) should
be performed before donnlng sLerlle gown and
gloves
Surglcal uraplng
Surglcal uraplng
the practice of covering a client and the surrounding areas with
sterile barriers to create and maintain a sterile field during a surgical
procedure.
Sterile surgical drapes protect the client from infection by preventing
microbes from making their way into the skin opening created during
surgery.
2 responsibilities of scrub nurse:
1. to provide the correct drapes for a specific surgical procedure
2. to assist surgeons during draping
ClrculaLlng nurse
Cbserve for breaks ln sLerlle Lechnlques so LhaL
correcLlve measures should be Laken by Lhe
surglcal Leam
Surglcal uraplng
8aslc rlnclples of uraplng
1 so|ate
lsolaLe dlrLy area" from clean area
Accompllshed by uslng lmpermeable drape made from a plasLlc
maLerlals
8arr|er
rovldes an lmpermeable layer musL have plasLlc fllm Lo prevenL
sLrlkeLhrough
Ster||e I|e|d
Achleved Lhru sLerlle presenLaLlon of drape and asepLlc appllcaLlon
Lechnlque
lf drape ls noL lmpermeable addlLlonal lmpermeable layer should be
added
. SteriIe Surface
skin cannot be sterilized, it is necessary to apply an incise drape to
create a sterile surface. Only an incise drape can create a sterile
surface
5. Equipment Cover
Sterile drapes cover nonsterile equipment or organize equipment used
on the sterile field.
To protect client from equipment
To protect and prolong life of equipment
. FIuid ControI
8aslc rlnclples of uraplng
Four LeveIs of Sedation
1. MNMAL Sedation
Drug-induced state during the client can't respond normally to verbal command
2. MODERATE Sedation
May be administered thru V
Depressed level of consciousness that does not impair the client's ability to maintain
patent airway
To respond appropriately to physical stimulation and verbal command
3. DEEP Sedation
Client can not be easily aroused or respond purposefully after repeated stimulation
SEATION & ANESTHESIA
FOUR LeveIs of Anesthesia
SLage l 8eglnnlng AnesLhesla (CnseL)
SLage ll LxclLemenL
SLage lll Surglcal AnesLhesla
SLage lv Medullary uepresslon
LLvLLS Cl AnLS1PLSlA
Stage I: Beginning Anesthesia (Onset)
START: during anesthetic
administration
END: during loss of consciousness
Client may be drowsy/dizzy with possible auditory or visual
hallucinations.
Nursing Intervention:
Close the OR door
Avoid unnecessary noises or motions when anesthesia begins
Stand by to assist client
Stage Lxc|tement
S1A81 durlng loss of consclousness
Lnu loss of eyelld reflexes
1here ls lncrease auLonomlc acLlvlLy lrregular breaLhlng
and may sLruggle
Nurs|ng ntervent|on
AsslsL anesLh ln resLralnlng Lhe cllenL
1ouch Lhe cllenL only for purpose of resLralnL
Stage Surg|ca| Anesthes|a
S1A81 loss of eyelld reflexes
Lnu loss of mosL reflexes ls presenL and Lhere ls depresslon
of vlLal funcLlons
CllenL ls unCCnSClCuS relaxed muscles bllnk and gag reflexes
are absenL
Nurs|ng ntervent|on
8egln preparaLlon for surgery only when anesLheLlsL lndlcaLes
sLage lll has been reached and cllenL ls breaLhlng well wlLh
sLable v/s
Stage IV: MeduIIary epression
START: functions are excessively depressed
END: indicates respiratory and circulatory failure.
The client is not breathing; the heartbeat may or may not be
present.
ursing Intervention:
If arrest occurs, respond immediately to assist in
establishing airway;
provide cardiac arrest tray, drugs, syringes , long needles;
Assist surgeon with closed or open cardiac massage.
1 ntravenous Anesthes|a
nha|at|on Anesthes|a
Types of GeneraI Anesthesia
1ypes of Ceneral AnesLhesla
1 ntravenous Anesthes|a
8apld lnducLlon
unconsclousness occurs 30 sec afLer Lhe admlnlsLraLlon
romoLes rapld LranslLlon from consclous Lo surglcal
anesLhesla sLage
repare cllenL for a smooLh LranslLlon Lo Lhe surglcal
anesLhesla sLage slnce lv anesLheLlcs has calmlng effecLs
Lx 1h|openta| sod|um and ketam|ne
2. InhaIation Anesthesia
A mixture of volatile liquid or gas and oxygen is used.
ease of administration and elimination through the respiratory system.
Usually used to maintain the client in stage anesthesia following induction.
Mixture is given through mask or an endotracheal tube (ET tube is inserted once
the client is paralyzed and unconscious).
Commonly used inhalation anesthetics are haIothane and isofIurane
nitrous oxide = commonly used gas anesthetic
1ypes of Ceneral AnesLhesla
Types of RegionaI Anesthesia
1. Spinal Anesthesia
2. Epidural Anesthesia
3. Topical Anesthesia
4. Local nfiltration Anesthesia
5. Filed Block Anesthesia
6. Peripheral Nerve Block Anesthesia
. SpinaI Anesthesia
used for surgical procedures involving the lower half of the body;
any procedure performed below the level of the diaphragm (e.g., hysterectomy,
appendectomy)
Anesthetic technique of choice for older adults
Benefits:
relative safety;
excellent lower-body muscle relaxation,
absence of the effect of unconsciousness.
does not require emptying of the stomach.
achieved by injecting local anesthetics into the subarachnoid space.
2. EpiduraI Anesthesia
Epidural block is achieved by introduction of an anesthetic agent into
the epidural space (entered by a needle at a thoracic, lumbar, sacral,
or caudal interspace).
Provide a blockage of the autonomic nerves and hypotension can
result.
Respiratory muscles are affected, respiratory depression or paralysis
may occur if the level of block is too high.
Caudal Anesthesia
produced by injection of the local anesthetic into the caudal or sacral canal. This
is a variation of epidural anesthesia. This method is commonly used with obstetric
clients.
1op|ca| Anesthes|a
agenLs may be applled dlrecLly on Lhe area Lo be
desenslLlzed
May come ln a form of a soluLlon an olnLmenL cream or
powder
a shorLacLlng anesLhesla LhaL can block perlpheral nerve
endlngs ln Lhe mucous membranes of Lhe vaglna recLum
nasopharynx and mouLh
Loca| nf||trat|on Anesthes|a
lnvolves Lhe ln[ecLlon of an anesLheLlc agenL lnLo Lhe
skln and subcuLaneous Llssue of Lhe area Lo be
anesLheLlzed
lldocalne (xylocalne)
block only Lhe perlpheral nerves around Lhe area of
lnclslon
I|||ed 8|ock Anesthes|a
ln[ecLed and lnfllLraLed lnLo Lhe area proxlmal Lo
Lhe planned lnclslon
block forms a barrler beLween Lhe lnclslon and
Lhe nervous sysLem
9er|phera| Nerve 8|ock Anesthes|a
AnesLheLlzes nerves or nerve plexus raLher Lhan all
Lhe local nerves anesLheLlzed by a flled block
Commonly used drugs ||doca|ne bup|vaca|ne and
mep|vaca|ne
N1AC9LA1IL NUSNG
AL
1 oslLlon Lhe CllenL
Conslder cllenL's
SlLe of operaLlon
Age
Slze of cllenL
1ypes of anesLheLlc used
aln normally experlenced by Lhe cllenL on movemenL
oslLlon musL
noL hlnder resplraLlon/clrculaLlon
noL apply excesslve pressure Lo skln surfaces
noL llmlL surglcal exposure
Maintaining Safety and Preventing Injury
Surgical Positions
a. Dorsal Recumbent (supine)
Commonly used for CABG,
hernia repair, mastectomy, bowel
resection
b. Trendelenburg
Permits displacement of intestines
into upper abdomen
Often sued during surgery of lower
abdomen or pelvis
c. Lithotomy
Exposes perineal and rectal areas
Vaginal repair, D&C, rectal surgery
d. Prone
Cervical spine
Posterior fossa craniotomy
Back, rectal and posterior leg
e. Lateral
kldney chesL or hlp surgery
9rov|de Lqu|pment Safety
CounLlng of needles sponges and lnsLrumenLs are performed by
Lhe clrculaLlng nurse and Lhe scrub nurse musL be done
a before Lhe lnlLlal lnclslon
b durlng Lhe surgery
c lmmedlaLely before Lhe lnclslon ls closed
A flnal correcL counL ls announced Lo Lhe surgeon and charLed on
Lhe lnLraoperaLlve charL
Ma|nta|n Surg|ca| Aseps|s
Lnsure Lhe sLerlllLy of supplles and equlpmenL
Lnsure all members of surglcal Leam use sLerlle
Lechnlque Lo mlnlmlze posLop lnfecLlons
8e an advocaLe ln malnLalnlng sLerlle surglcal
envlronmenL
4 AsslsLlng wlLh Wound Closure
AnLlclpaLe Lhe Lype of closure needed and obLaln Lhe supplles
necessary for wound closure
lf a surglcal draln ls used assess wheLher Lhe dralnage ls flowlng
freely Lhrough Lhe sysLem
MonlLorlng of Lhe draln's paLency and Lhe characLerlsLlc of Lhe
dralnage ls conLlnued when Lhe cllenL ls Lransferred ouL of Lhe
operaLlve area
5. Monitoring
Monitor body temperature and watch out for signs of hypothermia.
Offer a blanket to the client immediately upon transfer to the operating
room bed.
Report the lowest core body temperature to the postoperative nurse
when transferring the client after surgery.
Thermal blankets may be provided
V solutions can be warmed to assist maintaining warm body temperature
MonlLor for mallgnanL hyperLhermla a geneLlc dlsorder characLerlzed by
unconLrolled skeleLal muscle conLracLlon leadlng Lo poLenLlally faLal
hyperLhermla
a 1hls condlLlon can occur 30 mlnuLes of anesLhesla lnducLlon or several hours afLer surgery
b lnlLlal manlfesLaLlon ls lncreased endLldal carbon dloxlde [aw muscle rlgldlLy cardlac
dysrhyLhmlas and a hypermeLabollc sLaLe caused by anesLheLlc agenLs (succlnylchollne)
MonlLor for resplraLory and cardlac arresL AlLhough an arresL ls a rare
occurrence everyone lnslde Lhe operaLlng room should know where Lhe
crash carL ls kepL so lmmedlaLe managemenL could be admlnlsLered
MonlLor for unconLrolled hemorrhage and secondary allerglc reacLlons from
drugs and laLex
Documentat|on
clrculaLlng nurse records every evenL and acLlon ln Lhe operaLlng
room
lnformaLlon abouL Lhe followlng ls endorsed Lo Lhe
posLoperaLlve nurse upon cllenL Lransfer
1 uralns Lubes or oLher devlces remalnlng on Lhe cllenL afLer Lhe
surglcal procedure
2 1ype of closure and dresslng used
Mov|ng and 1ransport|ng the ||ent
wlpe off excess blood skln preparaLlon and debrls from Lhe cllenL's skln before movlng and
LransporLlng Lhe cllenL
uL on a clean gown and blankeL
Lnsure LhaL enough personnel are presenL for movlng or Lransferrlng a cllenL posLoperaLlvely
Lo prevenL ln[urles
Avold rapld movemenLs when changlng Lhe cllenL's poslLlon
Cradually move Lhe cllenLs from Lhe operaLlng room Lable Lo Lhe sLreLcher
8e careful noL Lo caLch klnk or dlslodge lv or caLheLer Lublng dralns or oLher equlpmenL
durlng Lransfer
Avold rough handllng whlch may damage fraglle skln
9CS1C9LA1IL 9nASL
9CS1C9LA1IL 9nASL
1 lnlLlal perlod of Llme for recovery from anesLhesla durlng whlch Lhe
cllenL ls monlLored closely by posLanesLhesla nurses
2 1lme from dlscharge from Lhe posLanesLhesla care unlL (ACu) Lo
Lhe flrsL day or so afLer surgery whlle Lhe cllenL ls recoverlng from
Lhe effecLs of Lhe surgery and ls beglnnlng Lo ambulaLe
3 Lhe Llme of heallng whlch may lasL for a few weeks monLhs or
even years afLer surgery
osLAnesLhesla Care unlL (ACu)
GOAL:
To assist an uncomplicated return
to safe physiologic function after
an anesthetic procedure by
providing safe, knowledgeable,
individualized nursing care for
clients and their family members in
the immediate post-anesthesia
phase.
mmediate Assessment
Supporting vital physiologic functions until the
effect of anesthetic agents abate.
Proper positioning of a sedated, unconscious
or semiconscious client ensuring airway
patency.
osLAnesLhesla Care unlL (ACu)
Review client's record noting the
following:
1. Anesthesia record for V medications and blood received
during surgery
2. Any unanticipated complications
3. Significant preoperative findings
4. Presence of tubes, drains, and types of wound closure
5. Length of time the client was in surgery
MMEDATE: Perform an assessment which
includes the following:
1 A|rway
a aLency
b resence of Lubes and resplraLory asslsLance
devlce
8reath|ng
a 8esplraLlon raLe and depLh
b resence of bllaLeral breaLh sounds sLrldor wheezes
hoarseness or
decreased breaLh sounds
c 8eLurn of gag reflex
MMEDATE: Perform an assessment which
includes the following:
. CircuIation
a. Pulse, BP, skin color, pulse oximeter
b. ECG tracing if attached
c. Wound status and dressings
d. Slight increase in the heart rate
may be normal due to stress response
after surgery
. Others
a. Level of consciousness
b. Muscle strength
c. Ability to follow commands
d. V infusions, dressings, drains, and
special
equipments; tubes and drains that must be
attached to containers or suction
e. Reddened or bruised areas on the skin
unrelated to surgery
f. Temperature
nitial Nursing Diagnoses
. Ineffective airway cIearance reIated to effects of anesthesia.
2. Impaired gas exchange reIated to ventiIation-perfusion imbaIance.
. AItered tissue perfusion reIated to hypotension postoperativeIy.
. Risk for aItered body temperature reIated to medications , sedation, and cooI environment.
5. Risk for fIuid voIume deficit reIated to bIood Ioss, food and fIuid deprivation, vomiting, and
indweIIing tubes.
. Pain reIated to surgicaI incision and tissue trauma.
7. Impaired skin integrity reIated to invasive procedure, immobiIization, and aItered metaboIic and
circuIatory state.
8. Risk for injury reIated to sensory dysfunction and physicaI environment.
9. Sensory aIterations reIated to effects of medications and anesthesia.
nurslng Care ln Lhe ACu
Protect the Airway
1. by positioning the head of a minimally responsive client to the side with the chin extended forward
to prevent respiratory obstruction.
2. Suctioning is administered to a client who is unable to clear mucus or vomitus from the throat.
3. Place an oral or nasal airway, as necessary, to help maintain patency and control the tongue.
4. Observe for the development of laryngospasm as manifested by crowing respirations in an
extubated client.
NTERVENTONS:
1, immediately ventilate the client by face mask, securing a tight fit over the mouth and nose.
2. Remove irritating stimulus to the airway
3. if >1min, may require muscle relaxant (succinylcholine) to relax the muscles of the larynx
6. Administer prescribed medications as needed.
. Administer oxygen using the appropriate method for delivery as prescribed.
8. Hook the client on a pulse oximeter to monitor tissue oxygenation.
Ma|nta|n Norma| 8|ood 9ressure
1 MonlLor for a slgnlflcanL drop ln Lhe blood pressure accompanled by
lncreased hearL raLe whlch may lndlcaLe hemorrhage clrculaLory fallure or fluld
shlfLs
2 MonlLor for a decrease ln blood pressure whlch may lndlcaLe LhaL Lhe
anesLhesla ls wearlng off or LhaL Lhe cllenL may be experlenclng severe paln
3 Measure pressure every flve mlnuLes for 1 mlnuLes Lo deLermlne Lhe
lnconslsLency ln Lhe cllenL's blood pressure
4 Cbserve for manlfesLaLlons of shock (Lachycardla resLlessness and
apprehenslons cold molsL pale or cyanoLlc skln)
5. Provide the following interventions if the client appears to be going into shock:
a. Administer oxygen or increase the rate of delivery
b. Raise the client's legs above the level of the heart
c. ncrease the rate of V fluids, unless contraindicated
d. Notify the anesthetist and the surgeon
e. Provide medications as ordered
f. Continue to assess the client and his/her response to interventions
6. Watch out for older clients with history of hypertension who
may exhibit hypertensive episodes after the stress of the surgery.
. f blood pressure rises above the baseline, consult with the
anesthetist or the surgeon and administer antihypertensive
medication as ordered.
8. f sinus tachycardia happens,
Treat the underlying cause (anxiety, pain, hypovolemia, hypoxia)
Betablockers may be given
9. f sinus bradycardia happens,
Treat the cause (vagal stimulation, hypoxemia, hypothermia, high spinal anesthesia,
certain anesthetic drug
Atropine is the drug of choice
Monitor for the Return of Consciousness
1. Assess level of orientation by asking the client his/her name.
2. Orient the client to place, date and time.
3. Monitor for postoperative delirium which usually happens to clients
who undergo open heart surgery.
Assess for Return of Sensation and Motion
1. Monitor the client carefully for return of sensation as the anesthetic
wears off.
2. Check for return of motion to the extremities by asking client to
wiggle his/her toes (this may be delayed if client had spinal
anesthesia).
Assess for normoLhermla
1 MonlLor for v/s every 1 mlnuLes unLll v/s are sLable or more ofLen lf
Lhese are unsLable
2 MonlLor aL leasL 1 hr unLll Lhey are dlscharged from ACu
3 When admlnlsLerlng measures Lo warm Lhe cllenL consLanL LemperaLure
monlLorlng should be done
Lo prevenL from overwarmlng causlng excesslve vasodllaLlon whlch can
cause fluld shlfLs and a decrease ln 8
Assess Perfusion
1. Assess skin color, warmth and turgor
2. Observe for development of shock which could be manifested by:
a. Dusky, pale, cold, moist skin
b. Significantly decreased blood pressure
c. Cyanotic lips, nails, and skin
d. Low oxygen saturation
e. Low levels of hemoglobin
Assess the SurgicaI Site
1. Check the dressing over the surgical incision frequently.
2. Note the color, type, and amount of drainage if dressing is soiled.
3. Support dressing but do not change or open it without a physician's order.
4. f seepage is observed, draw an outline of the dressing and note date
and time this is observed. Estimate amount of seepage if oozing
continues.
5. f bleeding is suspected and not visibly seen, inspect under the
operated extremity or under the back for signs of leakage.
Promote FIuid and EIectroIyte BaIance
1. ntake and output should be assessed hourly.
2. Monitor all parenteral fluids (e.g., V fluids, medications , blood products , nutritional
support, and colloidal infusions)
to ensure proper amount of fluids are being infused.
3. Upon admission of the client to the PACU, check the amount of solution in the V
fluid including the rate of infusion.
4. Check that all types of delivery systems and lines the client has (e.g., pumps,
infusion machines, monitoring machines , V lines, central venous lines, and arterial
lines) are patent and functioning.
5. Check insertion sites for redness, soreness, and swelling which may
indicate infiltration.
6. Note medications that have been added to solutions . This ensures
that the required dilution of fluid and the next dose of medication are
available to prevent lapses in administration.
. Avoid fluid overload through careful monitoring and prompt
administration of required parenteral fluids.
8. f an indwelling catheter is present, document the amount of output
and compare it with the amount of intake via V fluids.
Manage rainage Systems
1. Constantly monitor drainage tubes such as T tube, gastric tube,
urinary catheter, or wound drains.
2. Ensure that the drainage tubes are attached to their respective
drainage systems, patent, and draining freely.
3. Check that there are no kinks and occlusions on the tubes.
4. Document the amount and characters of drainage on a regular
schedule.
5. Compare the type, amount, and characteristic of drainage with
those expected for the surgical nursing.
Promote Comfort
1. Assess the client's level of pain carefully and regularly.
2. Provide appropriate pain relief/reduction while not overmedicating.
Maintain Safety
1. Side rails must be raised at all times to protect the client from falling out of the bed.
2. Ass ist the client in maintaining circulation and relieving skin pressure by proper body
alignment and frequent repositioning.
3. Check postoperative equipment prior to receiving clients in the PACU to ensure that
they are working properly.
POSTOPERATVE NURSNG CARE
LsLabllsh Lhe osLoperaLlve Coals by ev|s|ng and
Lxpand|ng the 9ostoperat|ve
Nurs|ng are 9|an
1 Assess Lhe osLoperaLlve CllenL
2 Assess 8esplraLory SLaLus
3 Assess ClrculaLlon
4 Assess neurologlc SLaLus
MonlLor Lhe Wound
6 MonlLor lnLravenous Llnes
. Monitor Drainage Tubes
8. Promote Comfort
9. Reduce Nausea and Vomiting
10. Discharge nstructions and Care
Assess Respiratory Status
1. Assess for patent airway.
2. Observe the client and assess the breathing pattern at rest.
3. Listen to breath sounds; breath respirations should be unlabored and quiet.
4. Observe for clinical manifestations of hypoxia which include confusion, restlessness,
pale skin, pulse oximetry readings below 90%, and cool skin temperature.
5. Be aware of the major complications following surgery such as decreased lung
expansion, atelectasis, or aspiration of retained secretions.
6. Assess the lungs by auscultating all the lobes of the lungs, as well as rate and rhythm
of respirations.
. Assist client in incentive spirometry to increase lung expansion and keep alveoli open.
Best results are achieved when HOB is elevated 45-90 degrees
8. Monitor changes in temperature. A body temperature greater than 3.C in the first
24 hours of surgery is frequently caused by atelectasis.
Assess CircuIation
1. Assess vital signs, skin color, and temperature according to institutional
policy.
2. Evaluate extremities for weakness, circulation, and numbness.
3. Assess bony prominences for deep tissue injuries, which may look like
bruises.
4. Encourage early ambulation and leg exercises to prevent formation of
thrombus.
5. Place client in dorsal recumbent position to provide comfort and
decreases strain on the incision.
6. Be alert when client complains of pain in the extremity, unilateral edema,
or warmth in the calf which may indicate thrombus formation.
Assess neurologlc SLaLus
1 Ass ess Lhe cllenL for level of consclousness orlenLaLlon and remalnlng effecLs
of anesLhesla on Lhe flrsL 24 hours prlor Lo surgery
2 Lnsure cllenLs LhaL lmpalred cognlLlon afLer surgery ls Lemporary
3 laclllLaLe recovery by promoLlng cognlLlve acLlvlLy repeaLlng lnsLrucLlons
ofLen lf necessary havlng paLlence wlLh cllenLs and fosLerlng hope
4 uocumenL changes ln condlLlon every shlfL noLlfy Lhe physlclan
lmmedlaLely lf a decrease ln Lhe cllenL's cognlLlon ls observed
8e aware LhaL obese cllenLs may have a delayed reLurn of consclousness afLer
anesLheLlc procedures
Monitor the Wound
1. Assess the dressing, amount, and character of any drainage present.
2. Be attentive to the method of wound care the surgeon prefers. Most surgeons
prefer to do the first dressing change.
3. f the wound is closed and healing by first intention, dressings on the wound may
be minimal and the client may be allowed to shower after 24 hours.
4. f the wound healing is to be by second or third intention, then it is left open to
heal from the fascia to the skin, and requires special wound handling.
5. Measures such as wound packing, dressing, drains, or ostomy bags are included in
the wound care depending on wound size, location, and drainage from the wound.
6. Measure and record the amount of drainage every shift for comparison with earlier
assessments to guide potential care plan changes.
. Assess the client's willingness to look at the wounds. Do not force the client to look
at the wounds if he/she is not yet ready
Body image is altered in response to surgery
thus specific interventions should be directed
towards restoration of the client's body image.
1. Show acceptance of the client's appearance.
2. Assist the client in verbalizing feelings about
the postoperative appearance and the reactions of
others.
SlCnS Cl WCunu lnlLC1lCnS
usually appear 34 days posLop
1 8edness beyond Lhe lnclslon llne
2 Ldema LhaL remalns afLer lnlLlal swelllng
3 lncreaslng paln
4 lncreaslng dralnage LhaL someLlmes become purulenL
lever
6 Malalse
Anorexla
8 LeukocyLosls
noLlfy Lhe surgeon of any suspecLed wound lnfecLlon
Wound culLure may be ordered
Wound uehlscence
8e alerL for wound dehlscence
uehlscence ls an openlng of a skln wound lL
should be LreaLed as open wounds
1 kepL clean wlLh appllcaLlon of packlng or dresslngs
2 Allowed Lo heal by secondary or LerLlary lnLenLlon
Wound LvlceraLlon
a condlLlon whereln Lhe abdomlnal wounds become lnfecLed and
Lhe abdomlnal lnclslon opens Lhe fascla or lnLernal organs may be
vlslble
1 uo noL aLLempL Lo replace Lhe organs
2 Cover Lhe wound wlLh sLerlle dresslngs molsLened wlLh normal
sallne
3 MonlLor cllenL's vlLal slgns and keep Lhe cllenL as calmas
posslble
4 noLlfy Lhe physlclan lmmedlaLely
8educe nausea and vomlLlng
osLoperaLlve nausea and vomlLlng (Cnv) do noL occur frequenLly
MedlcaLlons LhaL are used Lo c onLrol Cnv
1 AnLlchollnerglcs and hlsLamlne Lype 1 recepLor anLagonlsLs
reduce exclLablllLy of Lhe labyrlnLh recepLors
2 AnLldopamlnerglc drugs
depresses Lhe chemorecepLor Lrlgger zone
3 CasLrolnLesLlnal anLlspasmodlcs
promoLe forward perlsLalLlc movemenL
Cnv has also been conLrolled by acupuncLure
ulscharge lnsLrucLlons and Care
Discharge nstructions and Care
Ensure that the client and a family member or caregiver have information and skills
needed for continuous recovery.
Teach skills (e.g., wound care) over a period of days, with enough time for
questions,demonstration, and return demonstration.
Provide information about home care in writing to the client and family members.
Provide a printed form filled out with specific postoperative information, such as
instructions on medications and wound care, an appointment for the next clinic visit,
names and contact numbers for emergencies and further questions.
f collaboration with other health care workers (e.g., social services, home nurses, or
rehabilitation centers) is needed, proper endorsement should be done.
Craded 8eclLaLlon
Mlss nervous nellle
Mlss n ls scheduled for a colon resecLlon A recenL blopsy of a
polyp revealed a mallgnancy uurlng your preadmlsslon
lnLervlew Mlss n ls Learful and keeps saylng l hope Lhls won'L
be llke lL was when my dad had colon surgery" l'm so afrald l
wlll dle [usL llke he dld"
WhaL are Mlss n's psychosoclal needs?
Pow wlll you meeL Lhose needs?
lnLraoperaLlve Case SLudy
O 1he cllenL a 62yearold secreLary has enLered Lhe surglcal sulLe
abouL 30 mlnuLes afLer she has recelved aLroplne and mldazolam for
preoperaLlve medlcaLlon 1he C8 schedule llsLs LhaL she ls
scheduled Lo have a vaglnal hysLerecLomy ln addlLlon Lhe
preoperaLlve hlsLory lndlcaLes LhaL she smokes Lhree packs of
clgareLLes per day and drlnks Lhree cans of beer each day When
you ask her whaL klnd of surgery she ls havlng Loday her response ls
l am golng Lo have a hemorrholdecLomy" ?ou ask her lf she means
hysLerecLomy and she responds Well lL ls some klnd of operaLlon
'down Lhere'"
WhaL Should ?ou uo?
WhaL addlLlonal quesLlons should you ask Lhls cllenL?
WhaL should you do wlLh Lhe lnformaLlon?
WhaL effecL lf any wlll her hlsLory of smoklng and drlnklng
have on her surglcal experlence?
1he Case ConLlnues
1he cllenL demonsLraLes undersLandlng of Lhe surglcal procedure and Lhe
Leam proceeds wlLh Lhe planned vaglnal hysLerecLomy 1he cllenL welghs
96 pounds
ln whaL poslLlon should you place Lhls cllenL for Lhe surglcal procedure?
WhaL areas on Lhls cllenL are mosL llkely Lo be ln[ured as a resulL of poor
poslLlonlng or lnadequaLe paddlng?
WhaL are Lhe nurslng responslblllLles relaLed Lo skln lnLegrlLy?
8un uown
erloperaLlve nurslng
hases
reoperaLlve
lnLraoperaLlve
osLoperaLlve
1lme
Surglcal unlL Lo C8
C8ACu
ACulCLLCWu
ConsenL
lf pL ls sedaLed
ConsenL should be from Lhe famlly member and
wlLnessed by 2 persons
AnxleLy before Surgery
verlfy pL's undersLandlng abouL Lhe upcomlng
surgery
Clarlfy cerLaln vague ldeas
uo healLh Leachlng
Drugs that p|ace c||ents at r|sk dur|ng per|operat|ve
per|od
Asp|r|n
lncrease bleedlng durlng surgery
Ant|depressant
May lower 8 durlng anesLhesla
eg serLrallne (ZolofL)
Ant|cho||nerg|cs
Stero|ds
rlsk for adrenal lnsufflclency)
NSAD
lncrease Lhe rlsk of sLress ulcers and dlsplace oLher drugs from blood proLelns
eg lbuprofen
Ant|hypertens|ves
1ranqu|||zers
D|uret|cs
Drugs conta|n|ng brom|de
Can accumulaLe ln Lhe body and can produce manlfesLaLlons of demenLla
eg ulphenhydramlne (Somlnex)
PealLh 1eachlng
nurse
reoperaLlve Leachlng should lnclude
LducaLlng Lhe cllenL abouL Lhe anLlclpaLed posLoperaLlve
nurslng lnLervenLlons lncludlng Lurnlng coughlng deep
breaLhlng and leg exerclse
Mus
reoperaLlve Leachlng lnclude
8lsks of compllcaLlons
roposed surglcal procedures
AnesLheLlc cholces

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