NUR 312
1st sem | AY 2023-2024
Topic: TEXTBOOK OF MED-SURG NURSING (UNIT 4)
Author: BRUNNER AND SUDDARTH’S
PREOPERATIVE NURSING MANAGEMENT
Perioperative Nursing
Many patients enter the hospital 90 minutes prior to
surgery and have necessary medical assessments and analyses
preceding the surgical intervention. The surgery is followed by a
limited recovery period in the postanesthesia care unit (PACU).
Traumatic and emergency surgery most often results in prolonged
hospital stays. Patients who are acutely ill or undergoing major
surgery and patients with concurrent medical disorders may require
supportive supplementary care from other medical disciplines,
which can be coordinated more easily within the hospital setting.
The high acuity level of surgical inpatients and the greater
complexity of procedures have placed greater demands on the
practice of nursing in this setting.
Phases of Perioperative Nursing Care
1. Preoperative Phase- begins when the decision to proceed
with surgical intervention is made and ends with the transfer
of the patient onto the operating room (OR) bed
2. Intraoperative Phase- begins when the patient is transferred
onto the OR bed and ends with admission to the PACU.
•
Intraoperative Nursing Responsibilities involves acting as
scrub nurse, circulating nurse, or registered nurse first
assistant.
3. Postoperative Phase- begins with the admission of the
patient to the PACU and ends with a follow-up evaluation in
the clinical setting or home
Domains of conceptual model of patient care (AORN)
•
Safety
•
Physiologic Response
•
Behavioral responses
•
Health care systems
•
Note:
o The first three domains reflect phenomena of
concern to perioperative nurses and are
composed of nursing diagnoses, interventions,
and outcomes.
o The fourth domain—the health care system—
consists of structural data elements and focuses
on clinical processes and outcomes.
Surgical Classifications (Surgery may be perform for several reason)
a. Diagnostic- Surgery done to verify certain diagnosis.
Example is Breast Biopsy and Exploratory Laparotomy
o Exploratory Laparotomy- Surgery done to
estimate the disease and maybe done to
confirm a diagnosis.
b. Curative- Remove or repair damage, disease, or
congenitally malformed organs or tissues. Example is
Excision of Tumor and Inflamed appendix.
c. Reparative- repairs congenitally defective organs, thus
improving its function and appearance. Example is multiple
wound repair
d. Ablative Surgery- Involves removing deceased organs
e. Reconstructive or Cosmetic- Example is mammoplasty or a
facelift.
f. Palliative- Done to relieve symptoms but does not cure the
disease
g.
Restorative- To restore the functioning of the damage
organs/tissues
Categories of Surgery Based on Urgency
a. Emergent- Patient required immediate attention, order
maybe life-threatening and should be without delay.
Examples are Severe Bleeding, Fractured skull, gunshot,
stab wound, extensive burn, internal obstruction
b. Urgent- Patient requires prompt attention and must be
done in 24-30 hrs. Example is Acute bladder infection,
kidney or urethral stone.
c. Required- Patient needs to have surgery and surgery is plan
within few weeks or months. Example is Prostatic
Hyperplasia without bladder obstruction, Thyroid disorder,
and Cataracts
d. Elective- Patient should have the surgery and failure to have
surgery is not catastrophic. It includes repair of scars, simple
hernia, vaginal repair.
e. Optional- Decision rests with the patient and is considered
to be a personal preference. Example would be cosmetic
surgery.
Gerontologic Considerations
Because the older patient may have greater perioperative risks, the
following factors are critical:
1. skillful preoperative assessment and treatment
2. proficient anesthesia and surgical care
3. meticulous
and
competent
postoperative
and
postanesthesia management
Bariatric Patients
•
Bariatrics is a specialty that revolves around diagnosing,
treating, and managing patients who are obese.
•
Obesity is defined as a body mass index of greater than
30 kg/m2
•
Wound infections are more common in patients that are
obese
•
The patient with obesity tends to have shallow
respirations when supine, increasing the risk of
hypoventilation
and
postoperative
pulmonary
complications.
Patients with Disabilities
•
Special considerations for patients with mental or
physical disabilities include the need for appropriate
assistive devices, modifications in preoperative
education, and additional assistance with and attention
to positioning or transferring.
•
People who are hearing impaired may need and are
entitled by law to a sign interpreter or some alternative
communication system perioperatively.
•
These needs must be identified in the preoperative
evaluation and clearly communicated to personnel.
Patients Undergoing Ambulatory Surgery
•
Ambulatory surgery includes outpatient, same-day, or
short-stay surgery not requiring admission for an
overnight hospital stay but may entail observation in a
hospital setting for 23 hours or less.
•
The nurse needs to be sure that the patient and family
understand that the patient will first go to the
preoperative holding area before going to the OR for the
surgical procedure and then will spend some time in the
PACU before being discharged home with the family
member later that day.
PADUA, JAKE DONELY P.
BSN 3-1 (THIRD YEAR)
NUR 312
1st sem | AY 2023-2024
Topic: TEXTBOOK OF MED-SURG NURSING (UNIT 4)
Author: BRUNNER AND SUDDARTH’S
Patients Undergoing Emergency Surgery
•
Emergency surgeries are unplanned and occur with little
time for preparation of the patient or the perioperative
team.
•
Factors that affect patients preparing to undergo surgery
also apply to patients undergoing emergency surgery,
although usually in a very condensed time frame.
•
A quick visual survey of the patient is essential to identify
all sites of injury if the emergency surgery is due to
trauma
Informed Consent
•
is the patient’s autonomous decision about whether to
undergo a surgical procedure.
•
Voluntary and written informed consent from the patient
is necessary before nonemergent surgery can be
performed to protect the patient from unsanctioned
surgery and protect the surgeon from claims of an
unauthorized operation or battery.
•
The nurse may ask the patient to sign the consent form
and witness the signature
•
it is the surgeon’s responsibility to provide a clear and
simple explanation of what the surgery will entail prior to
the patient giving consent.
o The surgeon must also inform the patient of the
benefits,
alternatives,
possible
risks,
complications, disfigurement, disability, and
removal of body parts as well as what to expect
in the early and late postoperative periods.
•
The nurse ascertains that the consent form has been
signed before administering psychoactive premedication
•
The patient personally signs the consent if of legal age
and mentally capable.
o Permission is otherwise obtained from a
surrogate, who most often is a responsible
family member (preferably next of kin) or legal
guardian.
Many ethical principles are integral to informed consent. Informed
consent is necessary in the following circumstances:
•
Invasive procedures, such as a surgical incision, a biopsy,
a cystoscopy, or paracentesis
•
Procedures requiring sedation and/or anesthesia (see
Chapter 18 for a discussion of anesthesia)
•
A nonsurgical procedure, such as an arteriography, that
carries more than a slight risk to the patient
•
Procedures involving radiation
•
Blood product administration
Valid Informed Consent
•
Valid consent must be freely given, without coercion.
Patient must be at least 18 years of age
•
a physician must obtain consent, and a professional staff
member must witness patient’s signature.
Preoperative Assessment
•
The goal in the preoperative period is for the patient to
be as healthy as possible.
•
A plan of action is designed so that potential
complications are averted.
•
Latex, the milky fluid from the rubber tree, is found in
many everyday products, and repeated exposure may
•
cause some people to develop the allergy as an immune
response to the protein
Health care providers also should be alert for signs of
abuse, which can occur at any age, in either sex, and in
any socioeconomic, ethnic, and cultural group.
Nutritional and Fluid Status
•
Optimal nutrition is an essential factor in promoting
healing and resisting infection and other surgical
complications.
•
Nutritional needs may be determined by measurement of
body mass index and waist circumference.
•
Any nutritional deficiency should be corrected before
surgery to provide adequate protein for tissue repair.
•
The depletion of fluids and electrolytes following bowel
preparation, especially when combined with prolonged
fasting, can result in dehydration and chemical
imbalances, even among healthy surgical patients.
Dentition
•
The condition of the mouth is an important health factor
to assess.
•
Dental caries, dentures, and partial plates are particularly
significant to the anesthesiologist or CRNA, because
decayed teeth or dental prostheses may become
dislodged during intubation and occlude the airway
•
The condition of the mouth is also important because any
bodily infection, even in the mouth, can be a source of
postoperative infection.
Drug or Alcohol Use
•
Ingesting even moderate amounts of alcohol prior to
surgery can weaken a patient’s immune system and
increase the likelihood of developing postoperative
complications
•
If emergency surgery is required, local, spinal, or regional
block anesthesia is used for minor surgery
•
The person with a history of alcohol abuse often suffers
from malnutrition and other systemic problems or
metabolic imbalances that increase surgical risk.
Psychosocial Factors
•
The nurse anticipates that most patients have emotional
reactions prior to surgery—obvious or veiled, normal or
abnormal.
•
Fear may be related to the unknown, lack of control, or
of death and may be influenced by anesthesia, pain,
complications, cancer, or prior surgical experience.
•
People express fear in different ways.
Important outcomes
•
The value and reliability of available support systems are
assessed.
•
Assessing the patient’s readiness to learn and
determining the best approach to maximize
comprehension
•
Usual level of functioning
Spiritual and Cultural Beliefs
•
Spiritual beliefs play an important role in how people
cope with fear and anxiety.
•
Regardless of the patient’s religious affiliation, adhering
to spiritual beliefs can be therapeutic
PADUA, JAKE DONELY P.
BSN 3-1 (THIRD YEAR)
NUR 312
1st sem | AY 2023-2024
•
•
•
•
•
Topic: TEXTBOOK OF MED-SURG NURSING (UNIT 4)
Author: BRUNNER AND SUDDARTH’S
Asking whether the patient’s spiritual advisor knows
about the impending surgery is a caring, nonthreatening
approach.
Showing respect for a patient’s cultural values and
beliefs facilitates rapport and trust.
Certain ethnic groups are unaccustomed to expressing
feelings openly with strangers and nurses need to
consider this pattern of communication when assessing
pain.
In some cultural groups, it is seen as impolite to make
direct eye contact with others and doing so is seen as
disrespectful.
Perhaps the most valuable skill at the nurse’s disposal is
listening carefully to the patient and observing body
language, especially when obtaining the history.
Preoperative Teaching
1. Deep Breathing, Coughing, and Incentive Spirometry
educate the patient how to promote optimal lung
expansion and resulting blood oxygenation after
anesthesia.
The patient assumes a sitting position to enhance lung
expansion.
The nurse then demonstrates how to take a deep, slow
breath and how to exhale slowly.
After practicing deep breathing several times, the
patient is instructed to breathe deeply, exhale through
the mouth, take a short breath, and cough deeply in
the lungs
Splinting or placing the hands across the incision site
acts as an effective support when coughing.
The goal in promoting coughing is to mobilize
secretions so that they can be removed.
2. Mobility and Active Body Movement
The goals of promoting mobility postoperatively are to
improve circulation, prevent venous stasis, and
promote optimal respiratory function.
The nurse explains the rationale for frequent position
changes after surgery and then shows the patient how
to turn from side to side and how to assume the lateral
position without causing pain or disrupting
intravenous (IV) lines, drainage tubes, or other
equipment.
Exercise of the extremities includes extension and
flexion of the knee and hip joints (similar to bicycle
riding while lying on the side) unless contraindicated
by type of surgical procedure (e.g., hip replacement).
The nurse should remember to use proper body
mechanics and to instruct the patient to do the same.
3.
Pain Management
A pain assessment should include differentiation
between acute and chronic pain.
A pain intensity scale should be introduced and
explained to the patient to promote more effective
postoperative pain management.
patient is prepared to differentiate acute
postoperative pain from a chronic condition such as
back pain.
Postoperatively, medications are given to relieve pain
and maintain comfort without suppressing respiratory
function
Preoperative Instructions to Prevent Postoperative
Complications
4.
o Diaphragmatic Breathing
o Coughing
o Leg Exercises
o Turning to the Side
o Getting Out of Bed
Cognitive Coping Strategies
Cognitive strategies may be useful for relieving
tension, overcoming anxiety, decreasing fear, and
achieving relaxation
o Imagery: The patient concentrates on a
pleasant experience or restful scene.
o Distraction: The patient thinks of an
enjoyable story or recites a favorite poem or
song.
o Optimistic self-recitation: The patient recites
optimistic thoughts (“I know all will go well
”).
o Music: The patient listens to soothing music
(an
easy-to-administer,
inexpensive,
noninvasive intervention).
Providing Psychosocial Interventions
1. Reducing Anxiety and Decreasing Fear
Nurses must introduce themselves, giving their title
and a brief synopsis of their professional role and
background.
The nurse assists the patient to identify coping
strategies that he or she has previously used to
decrease fear
Discussions with the patient to help determine the
source of fears can help with expression of concerns.
Knowing ahead of time about the possible need for a
ventilator, drainage tubes, or other types of equipment
helps decrease anxiety related to the postoperative
period.
2.
Respecting Cultural, Spiritual, and Religious Beliefs
Psychosocial interventions include identifying and
showing respect for cultural, spiritual, and religious
beliefs
These responses should be recognized as normal for
those patients and families and should be respected by
perioperative personnel.
If patients decline blood transfusions for religious
reasons (Jehovah’s Witnesses), this information
needs to be clearly identified in the preoperative
period, documented, and communicated to the
appropriate personnel.
3.
Maintaining Patient Safety
Protecting patients from injury is one of the major
roles of the perioperative nurse.
These apply to hospitals as well as to ambulatory
surgery centers and office-based surgery facilities
Managing Nutrition and Fluids
The purpose of withholding food and fluid before
surgery is to prevent aspiration.
Until recently, fluid and food were restricted
preoperatively overnight and often longer.
Specific recommendations depend on the age of the
patient and the type of food eaten.
Preparing the Bowel
4.
5.
PADUA, JAKE DONELY P.
BSN 3-1 (THIRD YEAR)
NUR 312
1st sem | AY 2023-2024
Topic: TEXTBOOK OF MED-SURG NURSING (UNIT 4)
Author: BRUNNER AND SUDDARTH’S
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6.
Enemas are not commonly prescribed preoperatively
unless the patient is undergoing abdominal or pelvic
surgery.
The goals of this preparation are to allow satisfactory
visualization of the surgical site and to prevent trauma
to the intestine or contamination of the peritoneum by
fecal material.
Unless the condition of the patient presents some
contraindication, the toilet or bedside commode,
rather than the bedpan, is used for evacuating the
enema if the patient is hospitalized during this time.
Preparing the Skin
The goal of preoperative skin preparation is to
decrease bacteria without injuring the skin.
If the surgery is not performed as an emergency, most
health care facilities and ambulatory surgical centers
have implemented antiseptic skin cleansing protocols.
Generally, hair is not removed preoperatively unless
the hair at or around the incision site is likely to
interfere with the operation.
To ensure the correct site, the surgical site is typically
marked by the patient and the surgeon prior to the
procedure.
Immediate Preoperative Nursing Interventions
1. Administering Preanesthetic Medication
The use of preanesthetic medication is minimal with
ambulatory or outpatient surgery
If prescribed, it is usually given in the preoperative
holding area.
During this time, the nurse observes the patient for
any untoward reaction to the medications.
In these situations, the preoperative medication is
prescribed “on call to OR.”
It usually takes 15 to 20 minutes to prepare the patient
for the OR.
2. Maintaining the Preoperative Record
Preoperative checklists contain critical elements that
must be checked and verified preoperatively
The nurse completes the preoperative checklist (see
Fig. 17-2). The completed medical record (with the
preoperative checklist and verification form)
accompanies the patient to the OR with the surgical
consent form attached, along with all laboratory
reports and nurses’ records.
3. Transporting the Patient to the Presurgical Area
The patient is brought to the holding area or
presurgical suite about 30 to 60 minutes before the
anesthetic is to be given.
The patient is taken to the preoperative holding area,
greeted by name, and positioned comfortably on the
stretcher or bed.
Patient safety in the preoperative area is a priority.
References
▢
Suzanne
C.
Smeltzer,
Brenda
G.
Bare. Brunner & Suddarth's Textbook of Medical-Surgical
Nursing. Philadelphia :Lippincott, 2000.
INTRAOPERATIVE NURSING MANAGEMENT
The intraoperative experience has undergone many
changes and advances that make it safer and less disturbing to
patients. Even with these advances, anesthesia and surgery still
place the patient at risk for several complications or adverse events.
Consciousness or full awareness, mobility, protective biologic
functions, and personal control are totally or partially relinquished
by the patient when entering the operating room (OR). Staff from
the departments of anesthesia, nursing, and surgery work
collaboratively to implement professional standards of care, to
control iatrogenic and individual risks, to prevent complications, and
to promote high-quality patient outcomes.
Surgical Team
•
The surgical team consists of the:
o patient,
o the anesthesiologist (physician) or certified
registered nurse anesthetist (CRNA),
o the surgeon,
o nurses,
o surgical technicians, and
o registered nurse first assistants (RFNAs) or
certified surgical technologists (assistants).
•
The anesthesiologist or CRNA administers the anesthetic
agent (substance used to induce anesthesia) and
monitors the patient’s physical status throughout the
surgery.
•
The surgeon, nurses, technicians, and assistants scrub
and perform the surgery.
•
The person in the scrub role, either a nurse or a surgical
technician, provides sterile instruments and supplies to
the surgeon during the procedure by anticipating the
surgical needs as the surgical case progresses.
•
The circulating nurse coordinates the care of the patient
in the OR.
A. Patient
•
These feelings depend to a large extent on the amount
and timing of preoperative sedation, preoperative
education, and the individual patient.
•
Fears about loss of control, the unknown, pain, death,
changes in body structure, appearance, or function, and
disruption of lifestyle all contribute to anxiety.
•
The patient is subject to several risks.
•
Infection, failure of the surgery to relieve symptoms or
correct a deformity, temporary or permanent
complications related to the procedure or the anesthetic
agent, and death are uncommon but potential outcomes
of the surgical experience
B. Circulating Nurse
•
The circulating nurse (or circulator), a qualified registered
nurse, works in collaboration with surgeons, anesthesia
providers, and other health care providers to plan the
best course of action for each patient
•
In this leadership role, the circulating nurse manages the
OR and protects the patient’s safety and health by
monitoring the activities of the surgical team, checking
the OR conditions, and continually assessing the patient
for signs of injury and implementing appropriate
interventions
•
The team is coordinated by the circulating nurse, who
ensures cleanliness, proper temperature, humidity,
PADUA, JAKE DONELY P.
BSN 3-1 (THIRD YEAR)
NUR 312
1st sem | AY 2023-2024
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D.
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E.
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Topic: TEXTBOOK OF MED-SURG NURSING (UNIT 4)
Author: BRUNNER AND SUDDARTH’S
appropriate lighting, safe function of equipment, and the
availability of supplies and materials.
The circulating nurse monitors aseptic practices to avoid
breaks in technique while coordinating the movement of
related personnel (medical, x-ray, and laboratory), as well
as implementing fire safety precautions (Seifert,
Peterson, & Graham, 2015).
In addition, the circulating nurse is responsible for
ensuring that the second verification of the surgical
procedure and site takes place and is documented
Scrub Role
The registered nurse, licensed practical nurse, or surgical
technologist (or assistant) performs the activities of the
scrub role, including performing hand hygiene; setting up
the sterile equipment, tables and sterile field; preparing
sutures, ligatures, and special equipment
and assisting the surgeon and the surgical assistants
during the procedure by anticipating the instruments and
supplies that will be required, such as sponges, drains,
and other equipment.
scrub person and the circulating nurse count all needles,
sponges, and instruments to be sure that they are
accounted for and not retained as a foreign body in the
patient
Tissue specimens obtained during surgery are labeled by
the person in the scrub role and sent to the laboratory by
the circulating nurse.
Surgeon
The surgeon performs the surgical procedure, heads the
surgical team, and is a licensed physician (MD or DO), oral
surgeon (DDS or DMD), or podiatrist (DPM) who is
specially trained and qualified.
The Registered Nurse First Assistant
The registered nurse first assistant (RNFA) is another
member of the OR team.
RNFA responsibilities may include handling tissue,
providing exposure at the operative field, suturing, and
maintaining hemostasis
The RNFA must be aware of the objectives of the
surgery, must have the knowledge and ability to
anticipate needs and to work as a skilled member of a
team, and must be able to handle any emergency
situation in the OR.
The Anesthesiologist and CRNA
An anesthesiologist is a physician specifically trained in
the art and science of anesthesiology.
A CRNA is a qualified and specifically trained health care
professional who administers anesthetic agents, has
graduated from an accredited nurse anesthesia master’
s program, and has passed examinations sponsored by
the American Association of Nurse Anesthetists.
The anesthesiologist or CRNA assesses the patient
before surgery, selects the anesthesia, administers it,
intubates the patient if necessary, manages any technical
problems related to the administration of the anesthetic
agent, and supervises the patient’s condition
throughout the surgical procedure.
Before the patient enters the OR, often at preadmission
testing, the anesthesiologist or CRNA visits the patient to
perform an assessment, supply information, and answer
questions.
When the patient arrives in the OR, the anesthesiologist
or CRNA reassesses the patient’s physical condition
immediately prior to initiating anesthesia.
•
The anesthetic agent is given, and the patient’s airway
is maintained through an intranasal intubation (if the
surgeon is using an oral approach to surgery), intubation
with an endotracheal tube (ETT), or a laryngeal mask
airway (LMA).
The Surgical Environment
•
The surgical environment is known for its stark
appearance and cool temperature.
•
The surgical suite is behind double doors, and access is
limited to authorized, appropriately clad personnel.
•
Precautions include adherence to principles of surgical
asepsis; strict control of the OR environment is required,
including use of laminar airflow rooms as indicated for the
surgical procedure, and decreasing noise as well as the
number of operating theater door openings
•
the cleanliness of the rooms; the sterility of equipment
and surfaces; processes for scrubbing, gowning, and
gloving; and OR attire
•
Warming the patient, which may begin in the
preoperative phase of surgery, is continued or initiated
during the perioperative stage
•
To provide the best possible conditions for surgery, the
OR is situated in a location that is central to all supporting
services
•
To help decrease microbes, the surgical area is divided
into three zones:
o the unrestricted zone, where street clothes are
allowed; the
o semirestricted zone, where attire consists of
scrub clothes and caps; and
o the restricted zone, where scrub clothes, shoe
covers, caps, and masks are worn.
•
The surgeons and other surgical team members wear
additional sterile clothing and protective devices during
surgery.
•
Masks are worn at all times in the restricted zone of the
OR.
o Masks should fit tightly; should cover the nose
and mouth completely; and should not interfere
with breathing, speech, or vision.
o Masks must be adjusted to prevent venting
from the sides. Disposable masks have a
filtration efficiency exceeding 95%.
o Masks are changed between patients and
should not be worn outside the surgical
department.
•
Headgear should completely cover the hair (head and
neckline, including beard) so that hair, bobby pins, clips,
and particles of dandruff or dust do not fall on the sterile
field.
Principles of Surgical Asepsis
•
Surgical asepsis prevents the contamination of surgical
wounds.
•
All surgical supplies, instruments, needles, sutures,
dressings, gloves, covers, and solutions that may come in
contact with the surgical wound or exposed tissues must
be sterilized before use
•
Traditionally, the surgeon, surgical assistants, and nurses
prepared themselves by scrubbing their hands and arms
with antiseptic soap and water
•
Surgical team members wear long-sleeved, sterile gowns
and gloves.
PADUA, JAKE DONELY P.
BSN 3-1 (THIRD YEAR)
NUR 312
1st sem | AY 2023-2024
•
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Topic: TEXTBOOK OF MED-SURG NURSING (UNIT 4)
Author: BRUNNER AND SUDDARTH’S
Head and hair are covered with a cap, and a mask is worn
over the nose and mouth to minimize the possibility that
bacteria from the upper respiratory tract will enter the
wound.
During surgery, only personnel who have scrubbed,
gloved, and gowned touch sterilized objects.
An area of the patient’s skin larger than that requiring
exposure during the surgery is meticulously cleansed, and
an antiseptic solution is applied
Basic Guidelines for Maintaining Surgical Asepsis
•
All materials in contact with the surgical wound or used
within the sterile field must be sterile. Sterile surfaces or
articles may touch other sterile surfaces or articles and
remain sterile; contact with unsterile objects at any point
renders a sterile area contaminated.
•
Gowns of the surgical team are considered sterile in front
from the chest to the level of the sterile field. The sleeves
are also considered sterile from 2 in above the elbow to
the stockinette cuff.
•
Sterile drapes are used to create a sterile field (see Fig.
18-2). Only the top surface of a draped table is
considered sterile. During draping of a table or patient,
the sterile drape is held well above the surface to be
covered and is positioned from front to back.
•
Items are dispensed to a sterile field by methods that
preserve the sterility of the items and the integrity of the
sterile field. After a sterile package is opened, the edges
are considered unsterile. Sterile supplies, including
solutions, are delivered to a sterile field or handed to a
scrubbed person in such a way that the sterility of the
object or fluid remains intact.
•
The movements of the surgical team are from sterile to
sterile areas and from unsterile to unsterile areas.
Scrubbed people and sterile items contact only sterile
areas; circulating nurses and unsterile items contact only
unsterile areas.
•
Movement around a sterile field must not cause
contamination of the field. Sterile areas must be kept in
view during movement around the area. At least a 1-ft
distance from the sterile field must be maintained to
prevent inadvertent contamination.
•
Whenever a sterile barrier is breached, the area must be
considered contaminated. A tear or puncture of the drape
permitting access to an unsterile surface underneath
renders the area unsterile. Such a drape must be
replaced.
•
Every sterile field is constantly monitored and
maintained. Items of doubtful sterility are considered
unsterile. Sterile fields are prepared as close as possible
to the time of use.
•
The routine administration of hyperoxia (high levels of
oxygen) is not recommended to reduce surgical site
infections.
The Surgical Experience
a. General Anesthesia
Anesthesia is a state of narcosis (severe central
nervous
system
depression
produced
by
pharmacologic agents), analgesia, relaxation, and
reflex loss.
Patients under general anesthesia are not arousable,
not even to painful stimuli.
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General anesthesia consists of four stages, each
associated with specific clinical manifestations:
o Stage I: beginning anesthesia. Dizziness and a
feeling of detachment may be experienced
during induction. The patient may have a
ringing, roaring, or buzzing in the ears and,
although still conscious, may sense an
inability to move the extremities easily.
These sensations can result in agitation.
During this stage, noises are exaggerated;
even low voices or minor sounds seem loud
and unreal. For these reasons, unnecessary
noises and motions are avoided when
anesthesia begins.
o Stage II: excitement. The excitement stage,
characterized variously by struggling,
shouting, talking, singing, laughing, or crying,
is often avoided if IV anesthetic agents are
given smoothly and quickly. The pupils dilate,
but they constrict if exposed to light; the
pulse rate is rapid, and respirations may be
irregular.
o Stage III: surgical anesthesia. Surgical
anesthesia is reached by administration of
anesthetic vapor or gas and supported by IV
agents as necessary. The patient is
unconscious and lies quietly on the table. The
pupils are small but constrict when exposed
to light. With proper administration of the
anesthetic agent, this stage may be
maintained for hours in one of several planes,
ranging from light (1) to deep (4), depending
on the depth of anesthesia needed.
o Stage IV: medullary depression. This stage is
reached if too much anesthesia has been
given. Respirations become shallow, the
pulse is weak and thready, and the pupils
become widely dilated and no longer
constrict when exposed to light.
When opioid agents (narcotics) and neuromuscular
blockers (relaxants) are given, several of the stages are
absent.
During smooth administration of an anesthetic agent,
there is no sharp division between stages.
The responses of the pupils, the blood pressure, and
the respiratory and cardiac rates are among the most
reliable guides to the patient’s condition.
Anesthetic medications produce anesthesia because
they are delivered to the brain at a high partial
pressure that enables them to cross the blood–brain
barrier.
Inhalation
•
Inhaled anesthetic agents include volatile liquid agents
and gases.
•
Gas anesthetic agents are given by inhalation and are
always combined with oxygen. Nitrous oxide is the most
commonly used gas anesthetic agent.
•
When inhaled, the anesthetic agents enter the blood
through the pulmonary capillaries and act on cerebral
centers to produce loss of consciousness and sensation.
PADUA, JAKE DONELY P.
BSN 3-1 (THIRD YEAR)
NUR 312
1st sem | AY 2023-2024
Topic: TEXTBOOK OF MED-SURG NURSING (UNIT 4)
Author: BRUNNER AND SUDDARTH’S
Intravenous Administration
•
General anesthesia can also be produced by the IV
administration of various anesthetic and analgesic agents,
such as barbiturates, benzodiazepines, nonbarbiturate
hypnotics, dissociative agents, and opioid agents.
•
An advantage of IV anesthesia is that the onset of
anesthesia is pleasant; there is none of the buzzing,
roaring, or dizziness known to follow administration of an
inhalation anesthetic agent.
•
The IV anesthetic agents are nonexplosive, require little
equipment, and are easy to administer.
•
IV anesthesia is useful for short procedures but is used
less often for the longer procedures of abdominal
surgery. It is not indicated for those who require
intubation because of their susceptibility to respiratory
obstruction.
✓ Regional Anesthesia
➢ It is a form of local anesthesia in which an
anesthetic agent is injected around nerves
so that the area supplied by these nerves
is anesthetized.
➢ The effect depends on the type of nerve
involved
➢ These are agents that will block the nerve
impulse at its origin along afferent neurons
and along the spinal cords.
➢ An anesthetic cannot be regarded as
having worn off until all motor, sensory,
and autonomic are no longer affected.
➢ Patient is awake
➢ Nurse must avoid careless conversation,
unnecessary noise, and unpleasant odors.
➢ Provide a quiet environment
✓ Conduction Blocks and Spinal Anesthesia
➢ This may be subarachnoid block , epidural
block, and spinal anesthesia
➢ Commonly used for CS, hysterectomy,
appendectomy, or any abdominal surgery
or amputation
➢ Injection of local anesthetic is into the
spinal canal in the space surrounding the
dura mater.
➢ Epidural Anesthetic will block sensory,
motor, and autonomic functions.
➢ Advantage
•
Absence of headache
➢ Disadvantage
•
It is a challenge to introduce the
anesthetic into the epidural
rather than in the subarachnoid
space.
•
If inadverted injection to the
subarachnoid, instead of epidural
mod, then the anesthetic agent
will travel towards the head and
high spinal anesthesia can result.
This will produce a severe
hypotension and respiratory
depression and possible arrest.
•
Treatment of this complication
o Airway support
o IV fluid
o Use of vasopressor
➢
➢
➢
➢
➢
➢
➢
➢
Other type of nerve blocks include
•
Brachial plexus block which will
produce anesthesia in the arms
•
Paravertebral anesthesia which
produces anesthesia of the nerve
supply in the chest, abdominal
wall, and extremities
•
Transtracheal or caudal block
which produces anesthesia of te
perineum and occasionally on
lower abdomen
Spinal Anesthesia
•
It provides regions of anesthesia
from the abdomen to the toes
•
It is a type of extensive
conduction nerve block that is
produced when a local anesthetic
is
introduced
into
the
subarachnoid space and lumbar
level.
•
Usually used is L4 and L5
•
Spread of anesthetic agent and
level of anesthesia will depend on
the amount of the fluid injected.
The speed with which it is
injected, the positioning of the
patient after the injection, and
the specific gravity of the agent
•
Assist the anesthesiologist to
position the patient in a knee
chest position
General agents used for conduction blocks and
spinal anesthesia
•
Procaine
•
Tetracaine
•
Pontocaine
•
Lidocaine or Xylocaine
•
Bupivacaine
After a few minutes after induction of spinal
anesthetic, the anesthesia will have paralysis
effect on toes, perineum, and gradually the legs
and abdomen. If it reaches the upper thoracic and
cervical spinal cord, it means high concentration
and temporary partial or complete respiratory
paralysis will be the result
If respiratory muscles paralysis occurs, it is
managed through mechanical ventilation until
the effect of anesthetic on the respiratory nerves
have worn off
Nausea, vomiting and pain may occur during
surgery when spinal anesthesia is used so as a
rule this reaction will resolve from the
manipulation of various structures particularly
with those abdominal cavity
Headache is the after effect of spinal anesthesia
and there are several factors that are involve
such as the size of the spinal needle used, the
leakage of fluid from the subarachnoid space
through the puncture site and the patient’s
hydration status
Measures that increases the Cerebrospinal
pressure is very helpful in relieving headache
such as keeping the patient lying lfat and
PADUA, JAKE DONELY P.
BSN 3-1 (THIRD YEAR)
NUR 312
1st sem | AY 2023-2024
Topic: TEXTBOOK OF MED-SURG NURSING (UNIT 4)
Author: BRUNNER AND SUDDARTH’S
producing quiet environment and hydrate the
patient
➢ For continuous spinal anesthesia, continuous
epidural anesthesia (CEA) where a catheter is
inserted into the epidural space and it will remain
in the subarachnoid space during the surgical
procedure so that more anesthetics may be
injected as needed. This technique will allow
greater control of the dosage but there is greater
potential for post anesthetic headache because
of the large gauge needle used.
✓ Local Infiltration Anesthesia
➢ Advantage:
•
It is simple, economical and it is nonexplosive
•
The equipment needed is minimal
•
Post- operative recovery is brief
•
Undesirable effect of general anesthesia
are avoided
•
It is ideal for short superficial surgical
procedure
•
Anesthetic agent is injected into a specific
area at the operative site and it will
interfere with impulses from the CNS to
the operative site while the tissues are
being manipulated
➢ Often administered with epinephrine
because epinephrine constricts blood
vessel which prevents rapid absorption of
anesthetic agents and prolong its local
action.
➢ If rapid absorption of the anesthetic agents
into the bloodstream will cause a seizure
and it will be prevented
➢ Local anesthesia is the anesthesia of
choice in any surgical procedure
➢ Contraindication
•
High Preoperative Level of Anxiety – because surgery with
local anesthesia will increase anxiety
➢ Skin is prepared for any surgical procedure and a small
gauge needle is used to inject modest amount of the
anesthetic into the skin layers.
➢ This will produce wheal and additional anesthetic is then
injected in the until an area the length of the proposed
incision is anesthetized.
➢ The action of the agent is almost immediate and the
surgery will begin as soon as the injection is completed
➢ Local anesthesia will lasts 45 minutes to 3 hours depending
on the anesthetic and the use of epinephrine.
✓
✓
✓
✓
✓
-
-
-
-
-
-
Most Common Incision Site
Kocher Incision
Also known as subcostal incision
Incision on the right side of the abdomen
Used for open exposure of gallbladder and biliary tree
Incision is inferior and parallel to subcostal margin
Associated with slight increase in pain during the postoperative phase due to the severing of the rectus muscle
Midline Incision
✓ Also known as laparotomy incision or celiotomy
✓ Most traditional
✓ Sizes may vary depending on the type of
procedure to be performed
✓ Generally provides the beast visualization and
intraabdominal access commonly used in
exploratory procedure and trauma
McBurney Incison
✓ Grid iron incision
✓ Provides good exposure for performing open
appendectomy and is made obliquely at the
mcburney point
✓ 2/3 from the umbilicus to the anterior superior
iliac spine
✓ This is for appendectomy
Battle Incision
✓ Battle-jalaquier-kammerer-lennander Incision
✓ It is a lower right paramedian incision but placed
more laterally than the standard paramedian
incision
✓ It is suitable for dealing for acute appendicitis and
pathologist in the right lower quadrant of the
abdomen
Lanz Incision
✓ Rocky Davis Incision
✓ Similar to grid iron incision and is useful for open
appendectomy
✓ It is made in the mcburneys point with the same
anatomical layers as well as the blood supply
✓ Horizontal incision
Paramedian Incision
✓ Lateral or Medial Paramedian
✓ It is a surgical incision especially of the abdominal
wall close to the midline
Transverse Incision
✓ Clam shell incision
✓ It is a large transverse incision that spans across
the entire chest wall and also known as bilateral
thoracotomy and is used during massive chest
PADUA, JAKE DONELY P.
BSN 3-1 (THIRD YEAR)
NUR 312
1st sem | AY 2023-2024
-
-
Topic: TEXTBOOK OF MED-SURG NURSING (UNIT 4)
Author: BRUNNER AND SUDDARTH’S
trauma, lung transplant, or resection of tumors in
the chest
✓ This incision extends through the sternum
between the 4th and 5th ribs bilaterally and
extends to the mid-axillary line
Rutherford Morrison Incision
✓ For the access of the sigmoid colon and pelvis
particularly used if the midline very scared from
previous surgery
Pfannenstiel Incision
✓ Low transverse Incision or Kerr Incision or Bikini
Cut
✓ Transverse lower abdominal incision that is made
superior pubic ridge
✓ This approach is most frequently used for
urologic orthopedic, pelvic, and cesarean section
✓ It limits the exposure beyond the pelvis and the
blood supply is inferior epigastric branches and
superficial epigastric
-
Intra-operative Care
1. Protect the patient from any injury – skin care during
transfer place and maintain comfortable position and it has
to be padded as required. Used safety devices such as side
rails and safety straps.
2. Protect from infection hazards – use only sterilize packs
and instruments
3. Preparation and coordination of the circulating for smooth
procedure – assisting and scrubbing functions
✓ Counting of sponges
✓ Serving of instruments
✓ Ensure and provide warm fluid, adequate lighting
and keep things easily accessible
4. Monitor physiologic responses
✓ For GA, it will be the anesthesiologist who will
monitor
✓ For LA, it will be nurses who will monitor
✓ Maintain accurate and complete documentation
Potential Intraoperative Complications
Nausea and Vomiting
✓ Regurgitation
✓ May affect the patient during the intraoperative
period
✓ If it occurs with gaging, the patient is turned to
the side and the head of the head of the table
used is lowered and a basin is provided to collect
vomitus
✓ Suction is used to remove saliva and vomited
gastric contents
✓ Anesthesiologist may administer anti-emetics
preoperatively or intraoperatively ton counteract
possible aspiration
✓ If the patient has an aspiration of the vomitus,
there is an asthma like attack with severe
bronchial spasm and wheezing
✓ Pneumonitis and Pulmonary edema can
subsequently develop leading to extreme hypoxia
✓ Increasing medical attention is paid to silent
regurgitation of gastric contents which occurs
more frequently than previously realized
Anaphylaxis
The nurse must be aware of the type and method
of the anesthesia used as well as the specific
agents
✓ Anaphylactic reaction can occur in response to
many medications or latex or other substances
✓ Reaction may be immediate or delayed
✓ Anaphylaxis is life-threatening and acute allergic
reaction that causes vasodilation, hypotension,
and bronchial constrictions
✓ Some surgical procedures uses fibrin sealants,
this sealants have been implicated in allergic
reaction and anaphylactic. Although this reactions
are rare, the nurse should be alert to the
possibility and observe the patient for changes in
VS and symptoms of anaphylaxis when this
products are used
Hypoxia and other respiratory complications
✓ Inadequate ventilation, occlusion of the airways,
inadvertent intubation of the esophagus, and
hypoxia are significant potential problems of GA
✓ There are many factors contributing to
inadequate ventilation
✓ Respiratory depression can be caused by
anesthetic agents, aspiration of the respiratory
tract secretion or the vomitus, and the patient’s
position on the operating table can compromise
the exchange of gases
✓ In addition to those dangers, asphyxia which is
caused by foreign in the mouth, spasm of the
vocal cords, relaxation of the tongue, or aspiration
of the vomitus, saliva, or blood.
✓ Since brain damage occurs if there is hypoxia,
nurses should be more vigilant in assessing the
patient’s oxygenation status
✓ Primary function of the anesthesiologist,
anesthetist, and circulating nurse are to assess the
oxygenation
✓ Peripheral perfusion is checked frequently and
pulse
oximetry
values
are
monitored
continuously.
Hypothermia
✓ It is during anesthesia where the patient’s
temperature may fall
✓ Glucose metabolism is reduced and as a result
metabolic acidosis may develop
✓ This is called hypothermia and it is indicated by a
core body temperature blow normal 36.6 or lower
✓ Inadverted hypothermia may occur as a result of
a lower temperature in the OR, infusion of cold
fluids, inhalation of cold gases, open body wound
or cavities, decrease muscle activity, advanced
age, or pharmaceutical agents such as
vasodilators, phenothiazines, and GA
✓ Hypothermia may be intentionally induced in
selected surgical procedures such as cardiac
surgeries that requires cardiopulmonary bypass to
reduce the patient’s metabolic rate
✓ If it is unintentional hypothermia, main
intervention is to minimize or reverse the
physiologic process
✓ If it is intentional, goal is the safe return of the
normal body temperature. Environmental
temperature in the OR can be temporarily set to
25 degree to 26.6 degree Celsius and then
✓
-
PADUA, JAKE DONELY P.
BSN 3-1 (THIRD YEAR)
NUR 312
1st sem | AY 2023-2024
-
✓
Topic: TEXTBOOK OF MED-SURG NURSING (UNIT 4)
Author: BRUNNER AND SUDDARTH’S
intravenous and irrigation fluids will be warmed.
Wet gowns and drapes has to be remove
promptly and replaced with dry material
✓ Warming must be accomplish gradually and not
rapidly
✓ Consensus monitoring of core temperature,
urinary output, ECG, BP, ABG level, and serum
electrolyte level is required
Malignant hyperthermia
✓ An inherited muscle disorder chemically induced
by anesthetic agents
✓ Identifying patient at risk for malignant
hyperthermia is imperative. Susceptible patients
includes those with strong and bulky muscles,
history of muscles cramps or muscle weakness or
unexplained
temperature
elevation,
and
unexplained death of a family member during
surgery that was accompanied by a febrile
response.
✓ Brief Pathophysiology:
➢ During the anesthesia, the potent agent
such as inhalation anesthetics and
muscles relaxants may trigger the
symptoms of malignant hyperthermia
plus the stress and some medications
such as sympathomimetic, theophylline,
aminophylline,
anti-cholinergic
and
cardiac glycosides can induce or intensify
the reaction.
➢ It is related to muscle cell activity
➢ Calcium and essential factor in muscle
contraction is normally stored in sacs in
the sarcoplasm. So when nerve impulses
stimulate the muscles, calcium is released
allowing contraction to occur. Pumping
mechanism returns calcium to the sacs so
that the muscle can relax.
✓
This mechanism is disrupted. Calcuim ions are
not returned and they accumulate causing clinical
symptoms of hypermetabolism which in turn
increases muscle contraction or rigidity,
hyperthermia, and damage to CNS.
✓ Initial symptoms are related to cardiovascular
and musculoskeletal activity
➢ Tachycardia – above 150 bpm; earliest sign
➢ Sympathetic nervous stimulation – leads to
ventricular dysrhythmia, hypotension, decrease
cardiac output, oliguria, and cardiac arrest
➢ With the abnormal transfer of calcium, rigidity
or tetanus like movement may occur often in
the jaw
➢ Rise in temperature – late sign that develops
rapidly and the body temperature can increase
1 to 2 degrees Celsius every 5 mins. The
temperature can exceed 40 degree Celsius in a
very short time
Medical Management
➢ Recognize the symptoms as early as
possible and discontinue the anesthesia
promptly and imperative
➢ Goal of treatment is to decrease
metabolism, reverse metabolic and
respiratory acidosis.
Correct dysrhythmia, decrease body
temperature, provide oxygen and nutrition
to tissues
➢ Correct electrolyte imbalance
➢ Treatment protocol should be posted in
the OR or be readily available in a
malignant hyperthermia cart
➢ Usually presents about 10 to 20 minutes
after the induction of anesthesia, it can
also occur in the first 24 hours after
surgery
➢ As
soon
diagnosis
is
made,
anesthesiologist and surgeon will halt the
procedure
and
the
patient
is
hyperventilated with 100% oxygen
➢ Dantrolene sodium is skeletal muscle
relaxant and sodium bicarbonate are
administered continuously
➢ Continued monitoring of all parameters
are necessary to evaluate the patient’s
status.
Nursing Management
➢ Nurse must identify the patient at risk and
recognize the signs and symptoms.
➢ Have the appropriate medication and
equipment available
➢ Be knowledgeable about the protocol to
follow
Disseminated Intravascular Coagulopathy
It Is a life-threatening condition characterized by a
thrombus formation and the depletion of select
coagulation proteins
Predisposing Factors includes many conditions that may
occur with emergency surgery such massive trauma, head
injury, massive transfusion, liver or kidney involvement,
embolic events or shock.
➢
✓
✓
✓
PADUA, JAKE DONELY P.
BSN 3-1 (THIRD YEAR)
NUR 312
1st sem | AY 2023-2024
Topic: TEXTBOOK OF MED-SURG NURSING (UNIT 4)
Author: BRUNNER AND SUDDARTH’S
POSTOPERATIVE NURSING MANAGEMENT
Post-operative Period
● From the operating room to the recovery room or post
anesthesia care unit. In order for the patient to recover
from anesthesia and the stress of the surgery.
● Final phase of the entire surgical process
● Most often the PACU or RR is located adjacently to the
operating room
● Patients who have undergone surgery are placed in the
PACU or RR, so that the highly skilled nurses can easily
access if there is a complication with the anesthesia and
can call immediately the anesthesiologist or anesthetist,
surgeons and advanced hemodynamic and pulmonary
monitoring and support
● There are special equipment and medication in the PACU
● The PACU is usually kept quiet, clean free of unnecessary
equipment. This area is painted in soft, pleasing colors and
has indirect lighting, it is also a sound proof ceiling and
equipment that controls or eliminate noise such as plastic
and basin, rubber bumpers on beds and tables are placed in
the RR.
● It is isolated but visible quarters for disruptive patients
● The PACU should also be well-ventilated and these
features will benefit the patient by helping to decrease
anxiety and to promote comfort
● The PACU bed provides easy access to the patient, it is safe
and easily movable, it can be readily placed in position to
facilitate the use of measure to counter act shock and has
the features that facilitate care such as IV poles, side rails,
wheel breaks and a chart storage wrap.
PHASES OF POSTANESTHESIA CARE
● Phase I PACU – it used during the immediate recovery
phase, so intensive nursing care is provided
● Phase 2 PACU – is reserved for patients who requires less
frequent observation and less nursing care. The patient is
now prepared for discharge, so recliners rather than
stretchers or beds are standard in many phase II units.
Which also be referred as step down or sit up or
progressive care unit. Patient may remain in phase II PACU
unit for as long as 4 to 6 hours depending from the type of
surgery and any pre-existing conditions of the patient
● Phase 3 PACU- the patient is prepared for discharge.
● In facilities without separate Phase I and Phase II unit, the
patient will stay on the PACU and may be discharge home
directly from the PACU
● Both Phase I and Phase II PACU nurses have special skills:
● Phase I PACU Nurse – will provide frequent care, every 15
minutes monitoring patient’s pulse, electrocardiogram,
respiratory rate, blood pressure and pulse oximeter value
(the blood oxygen level) and in some cases they check the
end tidal carbon dioxide levels and the patient’s airway may
become obstructed because of the latent effect of the
recent anesthesia and the PACU nurse must be prepared in
the air intubation and handling other emergencies that may
occur
● Phase II PACU Nurse – must possess strong clinical
assessment and patient teaching skills
Admitting the Patient to the Postanesthesia Care Unit
•
Transferring the postoperative patient from the OR to the
PACU is the responsibility of the anesthesiologist or certified
registered nurse anesthetist (CRNA) and other licensed
members of the OR team.
•
the anesthesia provider remains at the head of the stretcher
(to maintain the airway), and a surgical team member remains
at the opposite end.
•
The surgical incision is considered every time the
postoperative patient is moved; many wounds are closed
under considerable tension, and every effort is made to
prevent further strain on the incision.
•
Orthostatic hypotension may occur when a patient is moved
too quickly from one position to another
•
As soon as the patient is placed on the stretcher or bed, the
soiled gown is removed and replaced with a dry gown.
•
The nurse who admits the patient to the PACU reviews
essential information with the anesthesiologist or CRNA and
the circulating nurse.
•
The nursing management objectives for the patient in the
PACU are to provide care until the patient has recovered from
the effects of anesthesia
•
Frequent, skilled assessments of the patient’s airway,
respiratory function, cardiovascular function, skin color, level
of consciousness, and ability to respond to commands are the
cornerstones of nursing care in the PACU.
•
Vital signs are observed and recorded, as well as level of
consciousness. The nurse performs and documents a baseline
assessment, then checks the surgical site for drainage or
hemorrhage and makes sure that all drainage tubes and
monitoring lines are connected and functioning.
•
After the initial assessment, vital signs are monitored and the
patient’s general physical status is assessed and
documented at least every 15 minutes.
Maintaining a Patent Airway
•
The primary objective in the immediate postoperative period
is to maintain ventilation and thus prevent hypoxemia
(reduced oxygen in the blood) and hypercapnia (excess carbon
dioxide in the blood).
o Both can occur if the airway is obstructed and ventilation
is reduced (hypoventilation).
•
Patients who have experienced prolonged anesthesia usually
are unconscious, with all muscles relaxed.
•
When the patient lies on their back, the lower jaw and the
tongue fall backward and the air passages become obstructed
(hypopharyngeal obstruction)
•
Signs of occlusion
o choking; noisy and irregular respirations
o decreased oxygen saturation scores;
o within minutes, a blue, dusky color (cyanosis) of the skin
•
Because movement of the thorax and the diaphragm does not
necessarily indicate that the patient is breathing, the nurse
needs to place the palm of the hand at the patient’s nose
and mouth to feel the exhaled breath.
•
The anesthesiologist or CRNA may leave a hard rubber or
plastic airway in the patient’s mouth to maintain a patent
airway
•
The nurse assists in initiating the use of the ventilator as well
as the weaning and extubation processes
•
Some patients, particularly those who have had extensive or
lengthy surgical procedures, may be transferred from the OR
directly to the intensive care unit (ICU) or from the PACU to
PADUA, JAKE DONELY P.
BSN 3-1 (THIRD YEAR)
NUR 312
1st sem | AY 2023-2024
•
•
Topic: TEXTBOOK OF MED-SURG NURSING (UNIT 4)
Author: BRUNNER AND SUDDARTH’S
the ICU while still intubated and receiving mechanical
ventilation.
If the teeth are clenched, the mouth may be opened manually
but cautiously with a padded tongue depressor. The head of
the bed is elevated 15 to 30 degrees unless contraindicated,
and the patient is closely monitored to maintain the airway as
well as to minimize the risk of aspiration.
Mucus or vomitus obstructing the pharynx or the trachea is
suctioned with a pharyngeal suction tip or a nasal catheter
introduced into the nasopharynx or oropharynx to a distance
of 15 to 20 cm (6 to 8 in).
•
It can present insidiously or emergently at any time in the
immediate postoperative period or up to several days after
surgery
The patient presents with hypotension; rapid, thready pulse;
disorientation; restlessness; oliguria; and cold, pale skin.
The early phase of shock will manifest in feelings of
apprehension, decreased cardiac output, and vascular
resistance.
Breathing becomes labored, and “air hunger” will be
exhibited; the patient will feel cold (hypothermia) and may
experience tinnitus.
Transfusing blood or blood products and determining the
cause of hemorrhage are the initial therapeutic measures.
The surgical site and incision should always be inspected for
bleeding.
If hemorrhage is suspected but cannot be visualized, the
patient may be taken back to the OR for emergency
exploration of the surgical site.
•
•
•
•
Maintaining Cardiovascular Stability
•
To monitor cardiovascular stability, the nurse assesses the
patient’s level of consciousness; vital signs; cardiac rhythm;
skin temperature, color, and moisture; and urine output.
•
The primary cardiovascular complications seen in the PACU
include hypotension and shock, hemorrhage, hypertension,
and dysrhythmias.
•
In patients who are critically ill, have significant comorbidity,
or have undergone riskier procedures, additional monitoring
may have been done in the OR and will continue in the PACU
Hypotension and Shock
•
Hypotension can result from blood loss, hypoventilation,
position changes, pooling of blood in the extremities, or side
effects of medications and anesthetics.
•
If the amount of blood loss exceeds 500 mL (especially if the
loss is rapid), replacement is usually indicated.
•
Shock, which is one of the most serious postoperative
complications, can result from hypovolemia and decreased
intravascular volume (Gallagher & Vacchiano, 2014).
o Types of shock are classified as hypovolemic, cardiogenic,
neurogenic, anaphylactic, and septic.
o The classic signs of hypovolemic shock (the most common
type of shock) are pallor; cool, moist skin; rapid breathing;
cyanosis of the lips, gums, and tongue; rapid, weak,
thready pulse; narrowing pulse pressure; low blood
pressure; and concentrated urine.
o Hypovolemic shock can be avoided largely by the timely
administration of IV fluids, blood, blood products, and
medications that elevate blood pressure.
▪
The primary intervention for hypovolemic shock is
volume replacement, with an infusion of lactated
Ringer solution, 0.9% sodium chloride solution,
colloids, or blood component therapy
▪
Oxygen is given by nasal cannula, facemask, or
mechanical ventilation. If fluid administration fails to
reverse hypovolemic shock, then various cardiac,
vasodilator, and corticosteroid medications may be
prescribed to improve cardiac function and reduce
peripheral vascular resistance.
•
The patient is placed flat with the legs elevated, usually with
a pillow. Respiratory rate, pulse rate, blood pressure, blood
oxygen concentration, urinary output, and level of
consciousness are monitored to provide information on the
patient’s respiratory and cardiovascular status.
•
Other factors can contribute to hemodynamic instability, such
as body temperature and pain
Hemorrhage
•
Hemorrhage is an uncommon yet serious complication of
surgery that can result in hypovolemic shock and death.
•
•
Hypertension and Dysrhythmias
•
Hypertension is common in the immediate postoperative
period secondary to sympathetic nervous system stimulation
from pain, hypoxia, or bladder distention.
•
Dysrhythmias are associated with electrolyte imbalance,
altered respiratory function, pain, hypothermia, stress, and
anesthetic agents.
Relieving Pain and Anxiety
•
The nurse in the PACU monitors the patient’s physiologic
status, manages pain, and provides psychological support in
an effort to relieve the patient’s fears and concerns.
•
IV opioids provide immediate pain relief and are short acting,
thus minimizing the potential for drug interactions or
prolonged respiratory depression while anesthetics are still
active in the patient’s system
Controlling Nausea and Vomiting
•
Nausea and vomiting occur in about 10% of patients in the
PACU.
•
Many medications are available to control postoperative
nausea and vomiting (PONV) without over-sedating the
patient; they are commonly given during surgery as well as in
the PACU
Determining Readiness for Postanesthesia Care Unit Discharge
•
A patient remains in the PACU until fully recovered from the
anesthetic agent.
•
Indicators of recovery include stable blood pressure, adequate
•
respiratory function, and adequate oxygen saturation level
compared with baseline.
Post Anesthesia Care Unit Assessment & Grading Tool) –
⮚ also known Aldrete’s Scoring System
⮚ 10 is the perfect score
⮚ Will be used as a tool for discharging patients
⮚ 8 and above score – can be discharged
⮚ 7 and below – do not discharge; monitor the patient and
observe or for any signs and then slow detoxification of the
anesthesia
●
Activity – determine the number of the extremities the
person can be able to move voluntarily or on command
o Criteria to follow:
PADUA, JAKE DONELY P.
BSN 3-1 (THIRD YEAR)
NUR 312
1st sem | AY 2023-2024
Topic: TEXTBOOK OF MED-SURG NURSING (UNIT 4)
Author: BRUNNER AND SUDDARTH’S
2 – patient is able to move all the extremities
1 – the patient is able to one extremity
0 – the patient wasn’t able to move extremity at
all
Respiration – determine the patient’s ability to breathe and
cough
o 2 – can breathe deeply and cough freely
o 1 – dyspneic and limited breathe
o 0 – apneic and
Circulation – determine the person’s present blood
pressure based from his/her preoperative blood pressure
o 2 - the BP is equal to 20 mmHg to the pre-op level
o 1 – equivalent to 20-50 mmHg
o 0 – equal to 50 and above mmHg
Consciousness – determine person’s level of consciousness
o 2 – fully awake
o 1 – drowsy, can be awaken up if called
o 0 – no response
Color – determine skin color
o 2 – normal or pinkish
o 1 – pale
o 0 – jaundice or cyanotic
o
o
o
●
●
●
●
Preparing the Postoperative Patient for Direct Discharge
•
Ambulatory surgical centers frequently have a step-down
PACU similar to a phase II PACU.
•
Patients seen in this type of unit are usually healthy, and the
plan is to discharge them directly to home.
•
Prior to discharge, the patient will require verbal and written
instructions and information about follow-up care.
Promoting Home, Community-Based, and Transitional Care
•
To ensure patient safety and recovery, expert patient
education and discharge planning are necessary when a
patient undergoes same-day or ambulatory surgery
•
Alternative formats (e.g., large print, Braille) of instructions or
the use of a sign language interpreter may be required to
ensure patient and family understanding.
•
Although recovery time varies depending on the type and
extent of surgery and the patient’s overall condition,
instructions usually advise limited activity for 24 to 48 hours.
•
During this time, the patient should not drive a vehicle, drink
alcoholic beverages, or perform tasks that require high levels
of energy or skill.
•
Patients are cautioned not to make important decisions at this
time because the medications, anesthesia, and surgery may
affect their decision-making ability.
•
Although most patients who undergo ambulatory surgery
recover quickly and without complications, some patients
require referral for some type of continuing or transitional
care.
o Nursing interventions may include changing surgical
dressings, monitoring the patency of a drainage system, or
administering medications.
o The patient and family are reminded about the importance
of keeping follow-up appointments with the surgeon.
o Follow-up phone calls from the nurse are also used to
assess the patient’s progress and to answer any
questions.
Care of the Hospitalized Postoperative Patient
•
Most surgeries are now performed in ambulatory care
centers, but there are unanticipated transfers of some
patients for hospitalization (Allison & George, 2014).
•
•
•
However, the majority of surgical patients who require
hospital stays are trauma patients, acutely ill patients, patients
undergoing major surgery, patients who require emergency
surgery, and patients with a concurrent medical disorder.
Seriously ill patients and those who have undergone major
cardiovascular, pulmonary, or neurologic surgery may be
admitted to specialized ICUs for close monitoring and
advanced interventions and support.
Patients admitted to the clinical unit for postoperative care
have multiple needs and stay for a short period of time.
Receiving the Patient in the Clinical Unit
•
The patient’s room is readied by assembling the necessary
equipment and supplies: IV pumps, drainage receptacle
holder, suction equipment, oxygen, emesis basin, tissues,
disposable pads, blankets, and postoperative documentation
forms.
•
Usually, the surgeon speaks to the family after surgery and
relates the general condition of the patient.
Nursing Management After Surgery
•
During the first 24 hours after surgery, nursing care of the
hospitalized patient on the medical-surgical unit involves
continuing to help the patient recover from the effects of
anesthesia
•
The pulse rate, blood pressure, and respiration rate are
recorded at least every 15 minutes for the first hour and every
30 minutes for the next 2 hours.
•
Patients usually begin to return to their usual state of health
several hours after surgery or after awaking the next morning.
•
Although pain may still be intense, many patients feel more
alert, less nauseous, and less anxious.
PREVENTING RESPIRATORY COMPLICATIONS
•
Respiratory depressive effects of opioid medications,
decreased lung expansion secondary to pain, and decreased
mobility combine to put the patient at risk for respiratory
complications, particularly atelectasis (alveolar collapse;
incomplete expansion of the lung), pneumonia, and
hypoxemia (Rothrock, 2014).
•
Atelectasis remains a risk for the patient who is not moving
well or ambulating or who is not performing deep breathing
and coughing exercises or using an incentive spirometer.
•
Hypostatic pulmonary congestion, caused by a weakened
cardiovascular system that permits stagnation of secretions at
lung bases, may develop; this condition occurs most
frequently in older patients who are not mobilized effectively
•
The types of hypoxemia that can affect postoperative patients
are subacute and episodic.
•
To clear secretions and prevent pneumonia, the nurse
encourages the patient to turn frequently, take deep breaths,
cough, and use the incentive spirometer at least every 2
hours.
•
Coughing is contraindicated in patients who have head
injuries or who have undergone intracranial surgery (because
of the risk for increasing intracranial pressure), as well as in
patients who have undergone eye surgery (because of the risk
for increasing intraocular pressure) or plastic surgery (because
of the risk for increasing tension on delicate tissues).
RELIEVING PAIN
•
Most patients experience some pain after a surgical
procedure. Complete absence of pain in the area of the
surgical incision may not occur for a few weeks, depending on
PADUA, JAKE DONELY P.
BSN 3-1 (THIRD YEAR)
NUR 312
1st sem | AY 2023-2024
•
•
•
Topic: TEXTBOOK OF MED-SURG NURSING (UNIT 4)
Author: BRUNNER AND SUDDARTH’S
the site and nature of the surgery, but the intensity of
postoperative pain gradually subsides on subsequent days.
Many factors (motivational, affective, cognitive, emotional,
and cultural) influence the pain experience (Rodriguez, 2015).
The degree and severity of postoperative pain and the patient
’s tolerance for pain depend on the incision site, the nature
of the surgical procedure, the extent of surgical trauma, the
type of anesthesia, and the route of administration.
Intense pain stimulates the stress response, which adversely
affects the cardiac and immune systems. When pain impulses
are transmitted, both muscle tension and local
vasoconstriction increase, further stimulating pain receptors.
PROMOTING CARDIAC OUTPUT
•
Although most patients do not hemorrhage or go into shock,
changes in circulating volume, the stress of surgery, and the
effects of medications and preoperative preparations all
affect cardiovascular function.
•
IV fluid replacement may be prescribed for up to 24 hours
after surgery or until the patient is stable and tolerating oral
fluids.
ENCOURAGING ACTIVITY
•
Early ambulation has a significant effect on recovery and the
prevention of complications (e.g., atelectasis, hypostatic
pneumonia, gastrointestinal [GI] discomfort, circulatory
problems) (Rothrock, 2014).
•
When a patient gets out of bed for the first time, orthostatic
hypotension, also called postural hypotension, is a concern.
Orthostatic hypotension is an abnormal drop in blood
pressure that occurs as the patient changes from a supine to
a standing position.
•
To assist the postoperative patient in getting out of bed for
the first time after surgery, the nurse:
o 1. Helps the patient move gradually from the lying position
to the sitting position by raising the head of the bed and
encourages the patient to splint the incision when
applicable.
o 2. Positions the patient completely upright (sitting) and
turned so that both legs are hanging over the edge of the
bed.
o 3. Helps the patient stand beside the bed.
•
Whether or not the patient can ambulate early in the
postoperative period, bed exercises are encouraged to
improve circulation. Bed exercises consist of the following:
o Arm exercises (full range of motion, with specific attention
to abduction and external rotation of the shoulder)
o Hand and finger exercises
o Foot exercises to prevent VTE, footdrop, and toe
deformities and to aid in maintaining good circulation
o Leg flexion and leg-lifting exercises to prepare the patient
for ambulation
o Abdominal and gluteal contraction exercises
WOUND HEALING
•
First-Intention Healing Wounds- made aseptically with a
minimum of tissue destruction that are properly closed heal
with little tissue reaction by first intention (primary union).
When wounds heal by first-intention healing, granulation
tissue is not visible and scar formation is minimal.
Postoperatively, many of these wounds are covered with a dry
sterile dressing. If a cyanoacrylate tissue adhesive (LiquiBand)
has been used to close the incision without sutures, a dressing
is contraindicated.
•
•
Second-intention healing (granulation) occurs in infected
wounds (abscess) or in wounds in which the edges have not
been approximated. When an abscess is incised, it collapses
partly, but the dead and dying cells forming its walls are still
being released into the cavity. For this reason, a drainage tube
or gauze packing is inserted into the abscess pocket to allow
drainage to escape easily.
Third-intention healing (secondary suture) is used for deep
wounds that either have not been sutured early or break
down and are resutured later, thus bringing together two
opposing granulation surfaces. This results in a deeper and
wider scar. These wounds are also packed postoperatively
with moist gauze and covered with a dry sterile dressing.
CARING FOR WOUNDS
•
Wound Healing. Wounds heal by different mechanisms,
depending on the condition of the wound. Surgical wound
healing may occur in three ways, by first-intention, secondintention, and third-intention wound healing
•
Caring for Surgical Drains. Nursing interventions to promote
wound healing also include management of surgical drains.
Drains are tubes that exit the peri-incisional area, either into
a portable wound suction device (closed) or into the dressings
(open). The principle involved is to allow the escape of fluids
that could otherwise serve as a culture medium for bacteria.
Types of wound drains include the Penrose, Hemovac, and
Jackson-Pratt drains
•
Changing the Dressing. Although the first postoperative
dressing is usually changed by a member of the surgical team,
subsequent dressing changes in the immediate postoperative
period are usually performed by the nurse. A dressing is
applied to a wound for one or more of the following reasons:
o (1) to provide a proper environment for wound healing;
o (2) to absorb drainage;
o (3) to splint or immobilize the wound;
o (4) to protect the wound and new epithelial tissue from
mechanical injury;
o (5) to protect the wound from bacterial contamination and
from soiling by feces, vomitus, and urine;
o (6) to promote hemostasis, as in a pressure dressing; and
o (7) to provide mental and physical comfort for the patient.
MAINTAINING NORMAL BODY TEMPERATURE
•
The patient is still at risk for malignant hyperthermia and
hypothermia in the postoperative period.
•
Efforts are made to identify malignant hyperthermia and to
treat it early and promptly
•
Hypothermia management, begun in the intraoperative
period, extends into the postoperative period to prevent
significant nitrogen loss and catabolism
MANAGING GASTROINTESTINAL FUNCTION AND RESUMING
NUTRITION
•
Discomfort of the GI tract (nausea, vomiting, and hiccups) and
resumption of oral intake are issues for the patient and affect
their outcome following surgery.
•
If the risk of vomiting is high due to the nature of surgery, a
nasogastric tube is inserted preoperatively and remains in
place throughout the surgery and the immediate
postoperative period.
•
Hiccups, produced by intermittent spasms of the diaphragm
secondary to irritation of the phrenic nerve, can occur after
surgery
PADUA, JAKE DONELY P.
BSN 3-1 (THIRD YEAR)
NUR 312
1st sem | AY 2023-2024
Topic: TEXTBOOK OF MED-SURG NURSING (UNIT 4)
Author: BRUNNER AND SUDDARTH’S
PROMOTING BOWEL FUNCTION
•
Constipation can occur after surgery as a minor or a serious
complication.
•
Decreased mobility, decreased oral intake, and opioid
analgesic medications can contribute to difficulty having a
bowel movement.
•
The nurse should assess the abdomen for distention and the
presence and frequency of bowel sounds. If the patient does
not have a bowel movement by the second or third
postoperative day, the primary provider should be notified
and a laxative or other test or intervention may be needed.
MANAGING VOIDING
•
Urinary retention after surgery can occur for various reasons.
•
Anesthetics, anticholinergic agents, and opioids interfere with
the perception of bladder fullness and the urge to void and
inhibit the ability to initiate voiding and completely empty the
bladder.
•
Bladder distention and the urge to void should be assessed at
the time of the patient’s arrival on the unit and frequently
thereafter. The patient is expected to void within 8 hours after
surgery
•
The bedpan should be warm; a cold bedpan causes discomfort
and automatic tightening of muscles
•
If the patient has not voided within the specified time frame,
an ultrasound bladder scan or bladder ultrasonography is
performed to check for urinary retention
•
Even if the patient voids, the bladder may not necessarily be
empty.
•
•
deep body tissues to pathogens in the environment places the
patient at risk for infection of the surgical site, and a
potentially life-threatening complication such as infection can
increase the length of hospital stay, costs of care, and risk of
further complications.
Wound Dehiscence and Evisceration. Wound dehiscence
(disruption of surgical incision or wound) and evisceration
(protrusion of wound contents) are serious surgical
complications (see Fig. 19-6). Dehiscence and evisceration are
especially serious when they involve abdominal incisions or
wounds. These complications result from sutures giving way,
from infection, or, more frequently, from marked distention or
strenuous cough. They may also occur because of increasing
age, anemia, poor nutritional status, obesity, malignancy,
diabetes, the use of steroids, and other factors in patients
undergoing abdominal surgery (Meiner, 2014).
Continuing and Transitional Care. Community-based and
transitional care services are frequently necessary after
surgery. Older patients, patients who live alone, patients
without family support, and patients with preexisting chronic
illness or disabilities are often in greatest need. Planning for
discharge involves arranging for necessary services early in
the acute care hospitalization for wound care, drain
management, catheter care, infusion therapy, and physical or
occupational therapy. The home, community-based, or
transitional care nurse coordinates these activities and
services.
MAINTAINING A SAFE ENVIRONMENT
•
During the immediate postoperative period, the patient
recovering from anesthesia should have three side rails up,
and the bed should be in the low position.
•
The nurse assesses the patient’s level of consciousness and
orientation and determines whether the patient can resume
wearing assistive devices as needed
•
Vascular surgeries, such as replacement of sections of
diseased peripheral arteries or insertion of an arteriovenous
graft, put the patient at risk for thrombus formation at the
surgical site and subsequent ischemia of tissues distal to the
thrombus.
MANAGING POTENTIAL COMPLICATIONS
•
Venous
Thromboembolism.
Serious
potential
VTE
complications of surgery include DVT and PE (Rothrock,
2014). Prophylactic treatment is common for patients at high
risk for VTE. Dehydration, low cardiac output, blood pooling
in the extremities, and bed rest add to the risk of thrombosis
formation. The first symptom of DVT may be a pain or cramp
in the calf although many patients are asymptomatic. Initial
pain and tenderness may be followed by a painful swelling of
the entire leg, often accompanied by fever, chills, and
diaphoresis
•
Hematoma. At times, concealed bleeding occurs beneath the
skin at the surgical site. This hemorrhage usually stops
spontaneously but results in clot (hematoma) formation within
the wound. If the clot is small, it will be absorbed and need not
be treated. If the clot is large, the wound usually bulges
somewhat, and healing will be delayed unless the clot is
removed.
•
Infection (Wound Sepsis). The creation of a surgical wound
disrupts the integrity of the skin, bypassing the body’s
primary defense and protection against infection. Exposure of
PADUA, JAKE DONELY P.
BSN 3-1 (THIRD YEAR)