PERIOPERATIVE NURSING

o Mammoplasty
PERIOPERATIVE NURSING o Facelift
• Palliative – to relieve or correct a problem
o Debulking
PERIOPERATIVE NURSING PHASES: o Removal of dysfunctional organ
(e.g., gallbladder)
• Used to describe nursing care provided in
• Rehabilitative
the total surgical experience of the patient,
o Total joint replacement surgery to
which span the entire experience, consists
correct crippling pain or progression
of three phases that begin and end at points
of degenerative osteoarthritis.
in the sequence of surgical experience
events:

o Preoperative phase – begins when CATEGORIES OF SURGERY on URGENCY:

the decision to proceed with surgical 1. Emergent – patient requires immediate
intervention is made and ends with attention; disorder may be life-threatening.
the transfer of the patient onto the a. Indications – without delay.
operating room (OR) bed. b. Examples –
o Intraoperative phase – begins i. Severe bleeding
when the patient is transferred onto ii. Bladder or intestinal
the OR bed and ends with the obstruction
admission to the PACU. iii. Fractured skull
iv. Gunshot or stab wounds
Nursing responsibilities: v. Extensive burns
▪ Scrub nurse – assist the 2. Urgent – patient requires prompt attention.
surgeon during operation. a. Indication – within 24-30 hours.
▪ Circulating nurse – ensures b. Examples –
that all surgical supplies are i. Acute gallbladder infection
correctly and promptly ii. Kidney or ureteral stones
provided. 3. Required – patient needs to have surgery.
▪ RN first assistant a. Indication – plan within a few weeks
or months.
o Postoperative phase – begins with b. Examples –
the admission of the patient to the i. Prostatic hyperplasia without
PACU and ends with a follow-up bladder obstruction
evaluation in the clinical or home ii. Thyroid disorders.
setting. iii. Cataracts.
4. Elective – patient should have surgery.
SURGICAL CLASSIFICATIONS BASED ON: a. Indication – failure to have surgery
not catastrophic.
• Diagnosis b. Examples –
o Biopsy i. Repair of scars.
o Exploratory laparotomy ii. Simple hernia.
o Laparoscopy iii. Vaginal repair.
• Cure – excision of a tumor or an inflamed 5. Optional – decision rests with patient.
appendix. a. Indication – personal preference.
o Appendectomy b. Examples –
• Repair i. Cosmetic surgery.
o Multiple wound repair
• Reconstructive or cosmetic
PERIOPERATIVE NURSING
SURGERY ACCORDING TO DEGREE OF RISK:
• Major surgery –
o High risk/greater risk for infection
o Extensive
o Prolonged
o Large amount of blood loss
o Vital organ may be handled or
removed
• Minor surgery –
o Generally, not prolonged
o Leads to few serious complication
SPECIAL CONSIDERATIONS:
1. During the Perioperative Period
a. If the surgical patient is currently
using beta-blockers, particular
attention is given to ensure timely
administration of the beta-blocker
and appropriate monitoring of vital
signs.
b. If the patient has not taken the usual
dosage of this medication, the
anesthesiologist or certified
registered nurse anesthetist (CRNA)
must evaluate whether it should be
administered prior to surgery or
during the perioperative period.
c. The nurse in the perioperative area
needs to be alert for appropriate
preoperative prescriptions aimed at
preventing VTE (venous
thromboembolism) and SSI (surgical
site infections).
2. Gerontology
a. Have less physiologic reserve (i.e.,
the ability of an organ to return to
normal after a disturbance in its
equilibrium.
b. Respiratory and cardiac
complications are the leading
causes of postoperative morbidity
and mortality in older adults.
c. Cardiac reserves are lower, renal,
and hepatic functions are
depressed, and GI activity is likely to
be reduced.
3. Critical Factors for Older Patients
a. Skillful preoperative assessment and
treatment.
b. Proficient anesthesia and surgical
care, and
c. Meticulous and competent
postoperative and post anesthesia
management.
PREOPERATIVE PHASE:
ACTIVITIES IN THE PERIOPERATIVE PHASES
OF CARE:
Preadmission Testing –
1. Initiates initial preoperative assessment.
2. Initiates education appropriate to patient’s
needs.
3. Involves family in interview.
4. Verifies completion of preoperative
diagnostic testing.
5. Verifies understanding of surgeon-specific
preoperative orders (e.g., bowel
preparation, preoperative shower).
6. Discusses and reviews advance directive
document.
7. Begins discharge planning by assessing
patient’s need for postoperative
transportation and care.
Admission to Surgical Center –
1. Completes preoperative assessment.
2. Assesses for risks for postoperative
complications.
3. Reports unexpected findings or any
deviations from normal.
4. Verifies that operative consent has been
signed.
5. Coordinates patient education and plan of
care with nursing staff and other health
team members.
6. Reinforces previous education.
7. Explains phases in perioperative period and
expectations.
8. Answer patient’s and family’s questions.
In the Holding Area –
1. Identifies patient.
PERIOPERATIVE NURSING
2. Assesses patient’s status, baseline pain,
and nutritional status.
3. Reviews medical record.
4. Verifies surgical site and that it has been
marked per institutional policy.
5. Establishes IV line.
6. Administers medication if prescribed.
7. Take measures to ensure patient’s comfort.
8. Provides psychological support.
9. Communicates patient’s emotional status to
other appropriate members of the
healthcare team.
SPECIAL CONSIDERATIONS:
1. Bariatric Patients
a. Specialty that revolves around
diagnosing, treating, and managing
patients who are obese.
b. Obesity increases the risk and
severity of complications associated
with surgery.
c. The patient with obesity tends to
have shallow respirations when
supine, increasing the risk of
hypoventilation and postoperative
pulmonary complications.
d. Physical characteristics found in
patients who are obese impede
intubation, such as short thick necks,
large tongues, recessed chins, and
redundant pharyngeal tissue.
e. Preoperative assessment looks for
these characteristics as well as the
presence of obstructive sleep apnea.
i. Treated with continuous
positive airway pressure
(CPAP).
ii. The use of CPAP should be
incorporated throughout the
perioperative period.
2. Patients With Disabilities
a. Hearing impaired may need and are
entitled by law to a sign interpreter
or some alternative communication
system perioperatively.
b. If the patient relies on signing or
speech (lip) reading and their
eyeglasses or contact lenses are
removed or the health care staff
wears surgical masks, an alternative
method of communication will be
needed.
c. Patients with respiratory problems
related to a disability (e.g., multiple
sclerosis, muscular dystrophy) may
experience difficulties unless the
problems are made known to the
anesthesiologist or CRNA and
adjustments.
3. Patients Undergoing Ambulatory
Surgery
a. Ambulatory Surgery/ Same-day
Surgery / Outpatient Surgery 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.
Advantages –
i. Reduced length of hospital
stays and cut costs.
ii. Reduces stress for the
patient.
iii. Less incidence of hospital
acquired infection.
iv. Less time lost from work by
the patient.
Disadvantages –
v. Less time to assess the
patient and perform
preoperative teaching.
vi. Less time to establish
rapport.
vii. Less opportunity to assess
for late postoperative
complication.
4. Patients Undergoing Emergency Surgery
a. Emergency surgeries are unplanned
and occur with little time for
preparation of the patient or the
perioperative team.
PERIOPERATIVE NURSING
b. The patient, who may have
undergone traumatic experience,
may need extra support and
explanation of the surgery.
c. For the unconscious patient,
informed consent, and essential
information, such as pertinent past
medical history and allergies, need
to be obtained from a family
member, if one is available.
INFORMED CONSENT:
• 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.
Surgeon Responsibility –
• Provide a clear and simple explanation of
what the surgery will entail prior to the
patient giving consent.
• Inform the patient of the benefits.
• Alternatives
• Possible risks
• Complications
• Disfigurement
• Disability
• Removal of body parts
• As well as what to expect in the early and
late postoperative periods.
Quality and Safety Nursing Alert – the signed
consent form is placed in a prominent place on
the patient’s medical record and accompanies
the patient to the OR.
Nurse Responsibility –
• Clarifies the information provided, and
• If the patient requests additional
information, the nurse notifies the physician
• The nurse ascertains that the consent form
has been signed before administering
psychoactive premedication, because
consent is not valid if it is obtained while the
patient is under the influence of medications
that can affect judgement and decision-
making capacity.
Informed Consent Is Necessary in The
Following –
• Invasive procedures, such as a surgical
incision, a biopsy, a cystoscopy, or
paracentesis.
• Procedures requiring sedation and/or
anesthesia.
• A nonsurgical procedure, such as an
arteriography, that carries more than a slight
risk to the patient.
• Procedures involving radiation.
• Blood product administration.
In getting the consent, remember that –
• The patient personally signs the consent if
of legal age and mentally capable.
• Permission is otherwise obtained from a
surrogate, who most often is a responsible
family member (preferably next of kin) or
legal guardian.
• In an emergency, it may be necessary for
the surgeon to operate as a lifesaving
measure without the patient’s informed
consent.
• However, every effort must be made to
contact the patient’s family. In such a
situation, contact can be made by
telephone, fax, or other electronic means
and consent obtained.
• If the patient has doubts and has not had
the opportunity to investigate alternative
treatments, a second opinion may be
requested.
• No patient must be urged or coerced to give
informed consent.
• Refusing to undergo a surgical procedure is
a person’s legal right and privilege.
• Consent forms should be written in easily
understandable words and concepts to
facilitate the consent process and should
use other strategies and resources as
needed to help the patient understand the
content.
• Asking patients to describe in their own
words the surgery they are about to have
PERIOPERATIVE NURSING
promotes nurses’ understanding of patients’
comprehension.
Valid Informed Consent –
1. Voluntary consent – must be freely given
without coercion. Patient must be at least 18
years of age (unless an emancipated
minor), a physician must obtain consent,
and a professional staff member must
witness patient’s signature.
2. Incompetent patient – an individual who is
not autonomous and cannot give or withhold
consent (e.g., individuals who are
cognitively impaired, mentally ill, or
neurologically incapacitated).
Informed Subject –
Informed consent should be in writing. It should
contain the following:
• Explanation of procedure and its risks.
• Description of benefits and alternatives.
• An offer to answer questions about the
procedure.
• Instructions that the patient may withdraw
consent.
• A statement informing the patient if the
protocol differs from customary procedure.
Patient Able to Comprehend –
postoperative complications and delay
recovery.
Activities –
• A health history is obtained.
• Physical exam is performed.
• Vital signs are noted, and a baseline is
established for future comparisons.
• Allergies must be asked.
• Used of other OTC medications, including
herbal and other supplements.
Latex Allergy
• If a patient states that he or she is allergic to
kiwi, avocado, or banana, or cannot blow up
balloons, there may be an association with
an allergy to latex.
• Can manifest as a rash, asthma, or
anaphylactic shock.
Routine Preoperative Screening Test –

• If the patient is non-English speaking, it is

necessary to provide consent (written and
verbal) in a language that is understandable
to the client. A trained medical interpreter
may be consulted.
• Alternative formats of communication (e.g.,
Braille, large print, sign interpreter) may be
needed if the patient has a disability that
affects vision or hearing.
• Questions must be answered to facilitated
comprehension if material is confusing.

PREOPERATIVE ASSESSMENT
Goal –
• The goal in the preoperative period is for the
patient to be as healthy as possible.
• Every attempt is made to assess for and
address risk factors that may contribute to
Nutritional And Fluid Status –
• Optimal nutrition is an essential factor in
promoting healing and resisting infection
and other surgical complications.
PERIOPERATIVE NURSING
• Assessment of a patient’s nutritional status;
obesity, weight loss, malnutrition,
deficiencies in specific nutrients, metabolic
abnormalities, and the effects of
medications on nutrition.
• 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.
• Assessment of a patient’s hydration status
is also essential.
• Dehydration, hypovolemia, and electrolyte
imbalances can lead to significant problems
in patients with comorbid medical conditions
or in older adults.
Dentition –
• 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.
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
complication.
• In an emergency, to prevent vomiting and
potential aspiration, a nasogastric tube is
inserted before general anesthesia is given.
Nurse Responsibility –
o The nurse who is obtaining the
patient’s health history needs to ask
frank questions with patience, care,
and a nonjudgmental attitude.
o Such questions should include
asking whether the patient has had
two drinks per day or more on a
regular basis in the 2 weeks prior to
surgery.
Respiratory Status –
• The patient is educated about breathing
exercises and the use of an incentive
spirometer, if indicated, to achieve optimal
respiratory function prior to surgery.
• Patients who smoke are urged to stop 30
days before surgery to significantly reduce
pulmonary and wound healing
complications.
• Patients who smoke are more likely to
experience poor wound healing, a higher
incidence of SSI, and complications that
include VTE and pneumonia.
Cardiovascular Status –
• If the patient has uncontrolled hypertension,
surgery may be postponed until the blood
pressure is under control.
• Surgical treatment can be modified to meet
the cardiac tolerance of the patient.
Hepatic And Renal Function –
• The presurgical goal is optimal function of
the liver and urinary systems so that
medications, anesthetic agents, body
wastes, and toxins are adequately
metabolized and removed from the body.
• The liver, lungs, and kidneys are the routes
for elimination of drugs and toxins.
• The liver is important in the
biotransformation of anesthetic compounds.
• Disorders of the liver may substantially
affect how anesthetic agents are
metabolized.
• Acute liver disease is associated with high
surgical mortality; preoperative
improvement in liver function is a goal.
• The kidneys are involved in excreting
anesthetic medications and their
metabolites; therefore, surgery is
contraindicated if a patient has acute
nephritis, acute renal insufficiency with
oliguria or anuria, or other acute renal
problem.
PERIOPERATIVE NURSING
Endocrine Function –

• The patient with diabetes who is undergoing

surgery is at risk for both hypoglycemia and
hyperglycemia.
• Hypoglycemia may develop during
anesthesia or postoperatively from
inadequate carbohydrates or excessive
administration of insulin.
• Hyperglycemia, can increase the risk of
surgical wound infection, may result from
the stress of surgery, which can trigger
increased levels of catecholamine.
• Strict glycemic control (80 to 110 mg/dL) o Patients with uncontrolled thyroid
leads to better outcomes. disorders are at risk for
thyrotoxicosis (with hyperthyroid
Nurse Responsibility – disorders) or respiratory failure (with
o Frequent monitoring of blood hypothyroid disorders).
glucose levels is important before, o The patient with an associated
during, and after surgery. history of a thyroid disorder is
o Patients who have received assessed preoperatively.
corticosteroids are at risk for adrenal
insufficiency.

Immune Function –

• An important function of the preoperative

o The use of corticosteroids for any
purpose during the preceding year
must be reported to the
anesthesiologist or CRNA and
surgeon.
o The patient is monitored for signs of
adrenal insufficiency.
assessment is to determine the presence of
infection or allergies.
• Routine laboratory tests used to detect
infection include the white blood count
(WBC) and the urinalysis.
• Surgery may be postponed in the presence
of infection.
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 –
o The unknown,
PERIOPERATIVE NURSING
o Lack of control,
o Death
• May be influenced by anesthesia, pain,
complications, cancer, or prior surgical
experience.
• Manifestations of fears –
o Anxiousness
o Bewilderment
o Anger
o Tendency to exaggerate
o Sad, evasive, tearful, clinging
o Inability to concentrate
o Short attention span
o Failure to carry out simple directions
o Dazed
• Nursing intervention to minimize anxiety –
o Explore client’s feeling.
o Allow client to speak openly about
fears/concern.
o Give accurate information regarding
surgery (brief, direct to the point and
in simple terms).
o Give empathic support.
o Consider the person’s religious
preference and arrange for visit by a
priest/minister as desired.
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.
• Showing respect for a patient’s cultural
values and beliefs facilitates rapport and
trust.
PREOPERATIVE NURSING INTERVENTIONS:
• Providing Patient Education – initiated as
soon as possible.
o Beginning in the physician’s office.
o In the clinic, or
o At the time of PAT (pre-admission
testing) when diagnostic tests are
performed.
Instruction is spaced over a period to allow
the patient to assimilate information and ask
questions as they arise.
DEEP BREATHING, COUGHING, AND
INCENTIVE SPIROMETRY –
• One goal of preoperative nursing care is to
educate the patient how to promote optimal
lung expansion and resulting blood
oxygenation after anesthesia.
• 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.
• The nurse or respiratory therapist also
demonstrates how to use an incentive
spirometer, a device that provides
measurement and feedback related to
breathing effectiveness.
• In addition to enhancing respiration, these
exercises may help the patient relax.
Coughing and Splinting –
• If a thoracic or abdominal incision is
anticipated, the nurse demonstrates how to
splint the incision to minimize pressure and
control pain.
• The patient is informed that medications are
available to relieve pain and should be
taken regularly for pain relief so that
effective deep- breathing and coughing
exercises can be performed comfortably.
• The goal in promoting coughing is to
mobilize secretions so that they can be
removed. Deep breathing before coughing
stimulates the cough reflex.
• If the patient does not cough effectively,
atelectasis (collapse of the alveoli),
pneumonia, or other lung complications may
occur.
Coughing –
1. Lean forward slightly from a sitting position
in bed, interlace your fingers together, and
place your hands across the incision site to
act as a splint for support when breathing.
PERIOPERATIVE NURSING
2. Breathe with the diaphragm as described
under “Diaphragmatic Breathing”.
3. With your mouth slightly open, breathe in
fully.
4. “Hack” out sharply for three short breaths.
5. Then, keeping your mouth open, take in
quick deep breath and immediately give a
strong cough once or twice. This helps clear
secretions from your chest. It may cause
discomfort but will not harm your incision.
Diaphragmatic Breathing – refers to a flattening
of the dome of the diaphragm during inspiration,
with resultant enlargement of the upper abdomen
as air rushes in. During expiration, the abdominal
muscles contract.
1. Practice in the same position you would
assume in bed after surgery: a semi-
Fowler’s position, dropped in bed with the
back and shoulders well supported with
pillows.
2. Feel movement with your hands resting
slightly on the front of the lower ribs and
fingertips against the lower chest.
3. Breathe out gently and fully as the ribs sink
down and inward toward midline.
4. Then take a deep breath through your nose
and mouth, letting the abdomen rise as the
lings fill with air.
5. Hold this breath for a count of five.
6. Exhale and let out all the air through your
nose and mouth.
7. Repeat this exercise 15 times with a short
rest after each group of five.
8. Practice this twice a day preoperatively.
MOBILITY AND ACTIVE BODY MOVEMENT:
• Improve circulation.
• Prevent venous stasis, and
• Promote optimal respiratory function.
Patient should be taught that early and frequent
ambulation postoperatively, as tolerated, will help
prevent complications.
Nursing Responsibilities –
• 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.
Turning to the Side –
1. Turn on your side with the uppermost leg
flexed most and supported on a pillow.
2. Grasp the side rail as an aide to maneuver
to the side.
3. Practice diaphragmatic breathing and
coughing while on your side.
Exercise of the extremities includes
extension and flexion of the knee and hip
joints (like bicycle riding while lying on the
side) unless contraindicated by type of
surgical procedure (e.g., hip replacement).
At first, the patient is assisted and reminded
to perform these exercises.
Later, the patient is encouraged to do them
independently.
Muscle tone is maintained so that
ambulation will be easier.
The nurse should remember to use proper
body mechanics and to instruct the patient
to do the same.
Leg Exercises –
1. Lie in a semi-Fowler’s position and perform
the following simple exercises to improve
circulation.
2. Bend your knee and raise your foot – hold it
a few seconds. Then extend the leg and
lower it to the bed.
3. Do this five times with one leg and then
repeat with other leg.
PERIOPERATIVE NURSING
4. Then trace circles with the feet by bending
them down, in toward each other, up, and
then out.
5. Repeat these movements five times.
Getting out of Bed –
1. Turn on your side.
2. Push yourself up with one hand as you
swing your legs out of bed.
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.
COGNITIVE COPING STRATEGIES:
Cognitive strategies may be useful for relieving
tension, overcoming anxiety, decreasing fear, and
achieving relaxation.
Strategies include –
• Imagery – patient concentrates on a
pleasant experience or restful scene.
• Distraction – patient thinks of an enjoyable
story or recites a favorite poem or song.
• Optimistic self-recitation – patient recites
optimistic thoughts (“I know all will go well”).
• Music – patient listens to soothing music
(an easy-to-administer, inexpensive,
noninvasive intervention).
PREPARING THE PATIENT, THE EVENING
BEFORE SURGERY:
• Preparing the Skin –
o Have a full bath to reduce
microorganisms in the skin.
o Hair should be removed within 1-2
mm of the skin to avoid skin
breakdown; use of electric clipper is
preferable.
• Preparing the GI tract –
o NPO, cleansing enema as required.
• Preparing for Anesthesia –
o Avoid alcohol and cigarette smoking
for at least 24 hours before surgery.
• Promoting rest and sleep –
o Administer sedatives as ordered.
PREPARING THE PERSON ON THE DAY OF
SURGERY:
• Early AM Care –
o Awaken 1 hour before preop
medications.
o Morning bath, mouth wash.
o Provide clean gown.
o Remove hairpins, braid long hair,
cover hair with cap if available.
o Remove dentures, colored nail
polish, hearing aid, contact lenses,
jewelries.
o Take baseline vital signs before
preop medication.
o Check ID band, skin prep.
o Check special orders – enema, IV
line.
o Check NPO.
o Have client void before preop
medication.
o Continue support emotionally.
o Accomplished “preop care checklist”.
ADMINISTERING PREANESTHETIC
MEDICATION:
Preoperative Medications –
• Goals –
o To aid in the administration of an
anesthetics.
o To minimize respiratory tract
secretion and changes in heart rate.
o To relax the patient and reduce
anxiety.
• Nurse Responsibilities –
o If a preanesthetic medication is
given, the patient is kept in bed with
the side rails raised, because the
medication can cause
lightheadedness or drowsiness.
PERIOPERATIVE NURSING
oDuring this time, the nurse observes
the patient for any untoward reaction
to the medications.
o The immediate surroundings are
kept quiet to promote relaxation, and
some facilities use soft classical
music.
o The preoperative medication is
prescribed “on call to OR.
• Commonly used Preop Meds –
o Tranquilizers and Sedatives –
▪ Midazolam
▪ Diazepam (valium)
▪ Lorazepam (Ativan)
▪ Diphenhydramine
o Analgesics –
▪ Nalbuphine (Nubain)
o Anticholinergics –
▪ Atropine Sulfate
o Proton Pump Inhibitors –
▪ Omeprazole (Losec)
▪ Famotidine
IMMEDIATE PREOPERATIVE NURSING
INTERVENTIONS:
MAINTAINING THE PREOPERATIVE RECORD:
• The nurse completes the preoperative
checklist.
• 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.
• Any unusual last-minute observations that
may have a bearing on anesthesia or
surgery are noted prominently at the front of
the medical record.
TRANSPORTING THE PATIENT TO THE
PRESURGICAL AREA:
• The patient is brought to the holding area or
pre-surgical 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.
• The surrounding area should be kept quiet if
the preoperative medication is to have
maximal effect.
• Unpleasant sounds or conversation should
be avoided because a sedated patient may
misinterpret them.
TRANSPORTING THE PATIENT TO THE OR:
• Adhere to the principle of maintaining the
comfort and safety of the patient.
• Accompany OR attendants to the patient’s
bedside for introduction and proper
identification.
• Assist in transferring the patient from bed to
stretcher.
• Complete the chart and preoperative
checklist.
• Make sure that the patient arrives in the OR
at the proper time.
Patient’s Family –
• Direct to the proper waiting room.
PERIOPERATIVE NURSING
• Tell the family that the surgeon will probably o Relaxes during transportation to the
contact them immediately after the surgery. operating room or unit.
• Explain reason for long interval of waiting: o States rationale for use of side rails.
anesthesia prep, skin prep, surgical o Discusses postoperative
procedure, RR. expectations.
• Tell the family what to expect postop when
they see the patient.

EXPECTED PATIENT ACTIVITIES IN THE

PREOPERATIVE PHASE OF CARE:

• Relief of anxiety, evidenced when the

patient:
o Discusses with the anesthesiologist,
or CRNA concerns related to types
of anesthesia and induction.
o Verbalizes an understanding of the
preanesthetic medication and
general anesthesia.
o Discusses last-minute concerns with
the nurse or physician.
o Discusses financial concerns with
the social worker, when appropriate.
o Requests visit with spiritual advisor,
when appropriate.
o Appears relaxed when visited by
health care team members.
• Decreased fear, evidenced when the
patient:
o Discusses fears with healthcare
professionals or a spiritual advisor,
or both.
o Verbalizes an understanding of any
expected bodily changes, including
expected duration of bodily changes.
• Understanding of the surgical
intervention, evidenced when the INTRAOPERATIVE PHASE
patient:
o Participates in preoperative
Maintenance of Safety –
preparations as appropriate (i.e.,
bowel preparation, shower). 1. Maintains specific aseptic, controlled
o Demonstrates and describes environment.
exercises that he or she is expected 2. Effectively manages human resources,
to perform postoperatively. equipment, and supplies for individualized
o Reviews information about patient care.
postoperative care. 3. Transfers patient to operating room bed or
o Accepts preanesthetic medication, if table.
prescribed. 4. Positions patient based on functional
o Remains in bed once premedicated. alignment and exposure of surgical site.
PERIOPERATIVE NURSING
5. Applies grounding device to patient.
6. Ensures that the sponge, needle, and
instrument counts are correct.
7. Completes intraoperative documentation.
Physiologic Monitoring –
1. Calculates effects on patient of excessive
fluid loss or gain.
2. Distinguishes normal from abnormal
cardiopulmonary data.
3. Reports changes in patient’s vital signs.
4. Institutes measures to promote
normothermia.
Psychological Support (Before Induction and
When Patient is Conscious) –
1. Provides emotional support to patient.
2. Stands near or touches patient during
procedures and induction.
3. Continues to assess patient’s emotional
status.
Goals –
• Asepsis
• Homeostasis
• Safe administration of anesthesia
• Hemostasis
THE SURGICAL TEAM:
• Patient
o The patient is subject to several
risks.
o 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.
• Anesthesiologist
o Selects the anesthesia, administers
it, intubates the client, if necessary,
manages technical problems related
to the administration of anesthetic
agents, and supervises the client’s
condition throughout the surgical
procedure.
o A physician who specializes in the
administration and monitoring of
anesthesia while maintaining the
overall well-being of the patient.
• Certified registered nurse anesthetist
(CRNA) –
o 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.
• Surgeon
o Primary responsible for the
preoperative medical history and
physical assessment.
o Performance of the operative
procedure according to the needs of
the patients.
o The primary decision maker
regarding surgical technique to use
during the procedure.
o May assist with position and
prepping the patient and may
delegate this task to other members
of the team.
• Nurses
o Scrub Nurse
▪ May be either a nurse or a
surgical technician.
▪ Review anatomy and
physiology and the surgical
procedures.
▪ Assists with the preparation
of the room.
▪ Scrubs, gowns, and gloves
self, and other members of
the surgical team.
▪ Prepares the instrument table
and organizes sterile
equipment for functional use.
▪ Assist with the draping
procedures.
PERIOPERATIVE NURSING
▪ Passes instruments to the
surgeon and assistants by
anticipating their need.
▪ Count sponges, needles, and
instruments.
▪ Monitor practices of aseptic
technique in self and others.
▪ Keeps track of irrigation used
for calculations of blood loss.
o Circulating Nurse
▪ Must be a RN who, after
additional education and
training, specialized in
perioperative nursing
practice.
▪ Responsible and
accountable for all activities
occurring during a
o RN
▪ May be a resident, intern,
physician’s assistant or a
perioperative nurse.
▪ Assisting with retractions.
• Surgical technicians
• Registered nurse first assistants (RFNA)
o Another member of the operating
room staff.
o Practices under the direct
supervision of the surgeon.
o Responsibilities may include:
▪ Handling tissue
▪ Providing exposure at the
operative field
▪ Suturing, and
▪ Providing hemostasis
o The entire process requires
thorough understanding of anatomy
and physiology, tissue handling, and
the principles of surgical asepsis.
• Certified surgical technologists
(assistants)
SURGICAL SAFETY CHECKLIST:
1. Before Induction of Anesthesia – with at
least nurse and anesthetist:
a. Has the patient confirmed his/her
identity, site, procedure, and
consent.
b. Is this site marked?
c. Is the anesthesia machine and
medication check complete?
d. Is the pulse oximeter on the patient
and functioning?
e. Does the patient have –
i. Allergy
ii. Difficult airway or aspiration
risk
iii. Risk of >500 ml blood loss
(7ml/kg in children)?
2. Before skin incision – with nurse,
anesthetist, and surgeon:
a. Confirm team members have
introduced themselves by name and
role.
b. Confirm the patient’s name,
procedure, and where the incision
will be made.
c. Has antibiotic prophylaxis been
given within the last 60 minutes.
d. Anticipated critical events
i. To surgeon
1. What are the critical
or non-routine steps?
2. How long will the
case take?
3. What is the
anticipated blood
loss?
ii. To anesthetist
1. Are there any patient-
specific concerns?
iii. To nursing team
1. Has sterility (including
indicator results) been
confirmed?
2. Are there equipment
issues or any
concerns?
e. Is essential imaging displayed?
3. Before patient leaves operating room –
with nurse, anesthetist, and surgeon:
a. Nurse verbally confirms
i. The name of the procedure.
ii. Completion of instrument,
sponge, and needle counts.
iii. Specimen labelling (read
specimen labels aloud,
including patient name).
PERIOPERATIVE NURSING
iv. Whether there are any
equipment problems to be
addressed.
b. To surgeon, anesthetist, and nurse:
i. What are the key concerns
for recovery and
management of this patient?
THE SURGICAL ENVIRONMENT:
The surgical is divided into three zones:
1. Unrestricted Zone – where street
clothes are allowed:
a. Provides an entrance and exit
from the surgical suite for
personnel, equipment, and
patient.
b. Street clothes are permitted in
this area, and the area provides
access to communication with
personnel within the suite and
with personnel and patient’s
families outside the suite.
2. Semi-restricted Zone – where attire
consists of scrub, clothes, and caps:
a. Provides access to the
procedure rooms and peripheral
support areas within the surgical
suite.
b. Personnel entering this area
must be in proper operating
room attire and traffic control
must be designed to prevent
violation of this area by
unauthorized persons.
c. Peripheral support areas consist
of:
i. Storage areas for clean
and sterile supplies,
ii. Sterilization equipment
and corridors leading to
procedure room.
3. Restricted Zone – where scrub clothes,
shoe covers, caps, and masks are worn:
a. Includes the procedure room
where surgery is performed and
adjacent sub sterile areas where
the scrub sinks and autoclaves
are located.
b. Personnel working in this area
must be in proper operating
room attire.
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 meet the surgical wound
or exposed tissues must be sterilized before
use.
• Surgical team members wear long-sleeved,
sterile gowns and gloves. 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.
Medical vs. Surgical Asepsis –
• Medical Asepsis –
o Reduces number of pathogens.
o Referred to as “clean technique.”
o Used in administration of:
▪ Medications
▪ Enemas
▪ Tube feedings
▪ Daily hygiene
o Example is handwashing.
• Surgical Asepsis –
o Eliminates all pathogens.
o Referred to as “sterile technique.”
o Used in:
▪ Dressing changes.
▪ Catheterizations.
▪ Surgical procedures.
PRINCIPLES OF SURGICAL ASEPSIS (STERILE
TECHNIQUE):
• Sterile object remains sterile only when
touched by another sterile object.
• Only sterile objects may be placed on a
sterile field.
PERIOPERATIVE NURSING
• A sterile object or field out of range of vision
or an object held below a person’s waist is
contaminated.
• When a sterile surface meets a wet,
contaminated surface, the sterile object or
field becomes contaminated by capillary
action.
• Fluid flows in the direction of gravity.
• The edges of a sterile field or container are
contaminated (1 inch).
ENVIRONMENTAL CONTROLS:
• Floors and horizontal surfaces are cleaned
between cases with detergent, soap, and
water or a detergent-germicide.
• Sterilized equipment is inspected regularly
to ensure optimal operation and
performance.
• Airborne bacteria are a concern. To
decrease the number of bacteria in the air,
standard OR ventilation provides 15 air
exchanges per hour, at least 3 of which are
fresh air.
• Systems with high-efficiency particulate air
(HEPA) filters are needed to remove
particles larger than 0.3 μm.
• A room temperature of 20°C to 24°C (68°F
to 73°F), humidity between 30% and 60%,
and positive pressure relative to adjacent
areas are maintained
VENTILATION AND AIR EXCHANGE SYSTEM:
• A high filtration particulate filter, working at
95% efficiency is recommended.
• Each procedure room should be maintained
with positive pressure, which forces the old
air out of the room and prevents the air from
surrounding areas from entering the
procedure room.
THE SURGICAL EXPERIENCE:
• During the surgical procedure, the patient
will need sedation, anesthesia, or some
combination of these.
• ANESTHESIA - State of “Narcosis” (severe
central nervous system depression
produced by pharmacologic agents),
analgesia, relaxation, and reflex loss.
o Anesthetics can produce muscle
relaxation, block transmission of
pain nerve impulses and suppress
reflexes. • It can also temporary
decrease memory retrieval and
recall.
• The effects of anesthesia are monitored by
considering the following parameters:
o Respiration
o O2 saturation
o CO2 levels
o HR and BP
o Urine output
TYPES OF ANESTHESIA AND SEDATION:
General Anesthesia (inhalation, IV) –
Effects:
• Patients under general anesthesia are not
arousable, not even to painful stimuli.
• Lose the ability to maintain ventilatory
function and require assistance in
maintaining a patent airway.
Anesthesia Awareness:
• Phenomenon of patients being partially
awake while under general anesthesia
• Patients at greatest risk of anesthesia
awareness are:
o Cardiac patients,
o Obstetric patients, and
o Major trauma patients.
Stages of General Anesthesia:
1. Stage 1: Beginning Anesthesia –
a. Dizziness and a feeling of
detachment may be experienced
during induction.
b. 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.
PERIOPERATIVE NURSING
c. These sensations can result in
agitation.
d. During this stage, noises are
exaggerated; even low voices or
minor sounds seem loud and unreal.
e. For these reasons, unnecessary
noises and motions are avoided
when anesthesia begins.
2. Stage 2: Excitement –
a. 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.
b. The pupils dilate, but they constrict if
exposed to light; the pulse rate is
rapid, and respirations may be
irregular.
c. Because of the possibility of
uncontrolled movements of the
patient during this stage, the
anesthesiologist or CRNA must
always be assisted by someone
ready to help restrain the patient or
to apply cricoid pressure in the case
of vomiting to prevent aspiration.
3. Stage 3: Surgical Anesthesia –
a. Surgical anesthesia is reached by
administration of anesthetic vapor or
gas and supported by IV agents as
necessary.
b. The patient is unconscious and lies
quietly on the table.
c. The pupils are small but constrict
when exposed to light. Respirations
are regular, the pulse rate and
volume are normal, and the skin is
pink or slightly flushed.
d. 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.
4. Stage 4: Medullary Depression –
a. This stage is reached if too much
anesthesia has been given.
b. Respirations become shallow, the
pulse is weak and thready, and the
pupils become widely dilated and no
longer constrict when exposed to
light.
c. Cyanosis develops and, without
prompt intervention, death rapidly
follows.
d. If this stage develops, the anesthetic
agent is discontinued immediately,
and respiratory and circulatory
support is initiated to prevent death.
Techniques Used in General Anesthesia –
1. Intravenous Anesthesia –
a. This is being administered
intravenously and extremely rapid.
b. Its effect will immediately take place
after thirty minutes of introduction.
c. It prepares the client for smooth
transition to the surgical anesthesia.
2. Inhalation Anesthesia –
a. This comprises of volatile liquids or
gas and oxygen.
b. Administered through a mask or
endotracheal tube.
c. Nitrous oxide is the most used gas
anesthetic agent.
Regional Anesthesia (Epidural, Spinal, And
Local Conduction Blocks) –
Effects –
• An anesthetic agent is injected around
nerves so that the region supplied by these
nerves is anesthetized.
• Patient receiving regional anesthesia is
awake and aware of their surroundings
unless medications are given to produce
mild sedation or to relieve anxiety.
Nurse Responsibilities –
• The health care team must avoid careless
conversation, unnecessary noise, and
unpleasant odors; these may be noticed by
the patient in the OR and may contribute to
a negative response to the surgical
experience.
• A quiet environment is therapeutic.
PERIOPERATIVE NURSING
• The diagnosis must not be stated aloud if
the patient is not to know it at this time
Types –
• Epidural Anesthesia –
o Achieved by injecting a local
anesthetic agent into the epidural
space that surrounds the dura mater
of the spinal cord.
o Blocks sensory, motor, and
autonomic functions; it differs from
spinal anesthesia by the site of the
injection and the amount of
anesthetic agent used.
o Epidural doses are much higher
because the epidural anesthetic
agent does not make direct contact
with the spinal cord or nerve roots
o An advantage of epidural anesthesia
is the absence of headache that can
result from spinal anesthesia.
o A disadvantage is the greater
technical challenge of introducing
the anesthetic agent into the
epidural space rather than the
subarachnoid space.
• Spinal Anesthesia –
o Local anesthetic agent is introduced
into the subarachnoid space at the
lumbar level, usually between L4
and L5.
Moderate Sedation (Monitored Anesthesia Care
[MAC]) –
Effects –
o Anesthesia of the lower extremities,
perineum, and lower abdomen.
o For the lumbar puncture procedure,
the patient usually lies on the side in
a knee–chest position.
o Sterile technique is used as a spinal
puncture is made and the
medication is injected through the
needle.
o As soon as the injection has been
made, the patient is positioned on
their back.
o If a relatively high level of block is
sought, the head and shoulders are
lowered.
o A few minutes after induction of a
spinal anesthetic agent, anesthesia
and paralysis affect the toes and
perineum and then gradually the
legs and abdomen.
o Nausea, vomiting, and pain may
occur during surgery when spinal
anesthesia is used.
o Headache may be an aftereffect of
spinal anesthesia.
o Measures that increase
cerebrospinal pressure are helpful in
relieving headache.
o These include maintaining a quiet
environment, keeping the patient
lying flat, and keeping the patient
well hydrated

• Moderate sedation, previously referred to as

conscious sedation, is a form of anesthesia
that involves the IV administration of
sedatives or analgesic medications to
reduce patient anxiety and control pain
during diagnostic or therapeutic procedures.
• For specific short-term surgical procedures
in hospitals and ambulatory care centers.
• The goal is to depress a patient’s level of
consciousness to a moderate level to
enable surgical, diagnostic, or therapeutic
procedures to be performed while ensuring
PERIOPERATIVE NURSING
the patient’s comfort during and cooperation
with the procedures.
Nurse Responsibilities –
• The patient receiving moderate sedation is
never left alone and is closely monitored by
a physician or nurse who is knowledgeable
and skilled in detecting dysrhythmias,
administering oxygen, and performing
resuscitation.
• The continual assessment of the patient’s
vital signs, level of consciousness, and
cardiac and respiratory function is an
essential component of moderate sedation.
• Pulse oximetry, a continuous ECG monitor,
and frequent measurement of vital signs are
used to monitor the patient.
Monitored Anesthesia Care –
• Monitored anesthesia care (MAC), also
referred to as monitored sedation, is
moderate sedation given by an
anesthesiologist or CRNA who must be
prepared and qualified to convert to general
anesthesia if necessary.
• MAC may be used for healthy patients
undergoing relatively minor surgical
procedures and for some critically ill
patients who may be unable to tolerate
anesthesia without extensive invasive
monitoring and pharmacologic support.
Local Anesthesia –
Effects –
• Local anesthesia is the injection of a
solution containing the anesthetic agent into
the tissues at the planned incision site.
• Often it is combined with a local regional
block by injecting around the nerves
immediately supplying the area.
• It is given directly to the surgical field, and
the circulating nurse observes and monitors
the patient for possible side effects.
• Local anesthesia is often given in
combination with epinephrine.
Advantages –
• It is simple, economical, and nonexplosive.
• Equipment needed is minimal.
• Postoperative recovery is brief.
• Undesirable effects of general anesthesia
are avoided.
• It is ideal for short and minor surgical
procedures.
POTENTIAL INTRAOPERATIVE
COMPLICATIONS:
The surgical patient is subject to several risks.
Potential intraoperative complications include:
1. Anesthesia awareness
a. Refers to a patient becoming
cognizant of surgical interventions
while under general anesthesia and
then recalling the incident.
b. Indications of the occurrence of
anesthesia awareness include:
i. an increase in the blood
pressure,
ii. rapid heart rate, and
iii. patient movement.
c. However, hemodynamic changes
can be masked by paralytic
medication, beta-blockers, and
calcium channel blockers, thus the
awareness may remain undetected.
2. Nausea and vomiting
a. Nausea and vomiting, or
regurgitation, may affect patients
during the intraoperative period.
b. If gagging occurs, the patient is
turned to the side, the head of the
table is lowered, and a basin is
provided to collect the vomitus.
c. Suction is used to remove saliva and
vomited gastric contents.
3. Anaphylaxis
a. An anaphylactic reaction can occur
in response to many medications,
latex, or other substances.
b. The reaction may be immediate or
delayed.
c. Anaphylaxis can be a life-
threatening reaction.
PERIOPERATIVE NURSING
4. Hypoxia and other Respiratory
Complications
a. Associated potential complication
with General Anesthesia:
i. Inadequate ventilation,
ii. Occlusion of the airway,
iii. Inadvertent intubation of the
esophagus, and
iv. Hypoxia
b. Nurse Responsibilities:
i. Brain damage from hypoxia
occurs within minutes;
therefore, vigilant monitoring
of the patient’s oxygenation
status is a primary function of
the anesthesiologist or CRNA
and the circulating nurse.
ii. Peripheral perfusion is
checked frequently, and
pulse oximetry values are
monitored continuously.
used on the areas not
exposed for surgery, and
minimizing the area of the
patient that is exposed will
help maintain core
temperature.
v. Whatever methods are used
to rewarm the patient,
warming must be
accomplished gradually, not
rapidly.
vi. Conscientious monitoring of
core temperature, urinary
output, ECG, blood pressure,
arterial blood gas levels, and
serum electrolyte levels is
required.
6. Malignant hyperthermia.
PATIENT POSITION:

5. Hypothermia 1. The dorsal recumbent position, usual

a. Patient’s temperature may fall. position for surgery. This position is used for
b. Glucose metabolism is reduced, and most abdominal surgeries, except for
as a result, metabolic acidosis may surgery of the gallbladder or pelvis.
develop.
c. A core body temperature that is
lower than normal (36.6°C [98°F] or
less).
d. Unintentional hypothermia needs to
be avoided. If it occurs, it must be
minimized or reversed.
e. If hypothermia is intentional, the goal 2. The Trendelenburg position usually is used
is safe return to normal body for surgery on the lower abdomen and
temperature. pelvis to obtain good exposure by displacing
f. Nurse Responsibilities: the intestines into the upper abdomen.
i. Environmental temperature in
the OR can temporarily be
set at 25°C to 26.6°C (78°F
to 80°F).
ii. IV and irrigating fluids are
warmed to 37°C (98.6°F).
iii. Wet gowns and drapes are
removed promptly and
replaced with dry materials,
3. The lithotomy position is used for nearly all
because wet materials
perineal, rectal, and vaginal surgical
promote heat loss.
procedures.
iv. Warm air blankets and
thermal blankets can also be
PERIOPERATIVE NURSING
4. The Sims or lateral position is used for renal
surgery.
POSTOPERATIVE NURSING
MANAGEMENT
• Extends from the time the patient leaves the
operating room (OR) until the last follow-up
visit with the surgeon.
• May be short as a day or two or several
months.
• Careful assessment and immediate
intervention assist the patient in returning to
optimal function quickly, safely, and as
comfortable as possible.
• Ongoing care in the community through
home care, clinic visits, office visits, or
telephone follow-up facilitates an
uncomplicated recovery.
IMMEDIATE POSTOPERATIVE NURSING
INTERVENTIONS:
1. Assess breathing and administer
supplemental oxygen, if prescribed.
a. Provides baseline and helps identify
signs and symptoms of respiratory
distress.
2. Monitor vital signs and note skin warmth,
moisture, and color.
a. Baseline data and identifies signs
and symptoms of shock.
3. Assess the surgical site and wound
drainage systems. Connect all drainage
tubes to gravity or suction as indicated.
a. Baseline data and identifies signs
and symptoms of hemorrhage.
4. Assess level of consciousness, orientation,
and ability to move extremities.
a. Provides baseline and help identify
signs and symptoms of neurologic
complications.
5. Assess pain level; pain characteristics
(location, quality); and timing, type, and
route of administration of the last dose of
analgesic.
a. Baseline for current pain level and
assesses effectiveness of pain
management strategies.
6. Administer analgesic medications as
prescribed and assess their effectiveness in
relieving pain.
a. Helps decrease pain.
7. Place the call light, emesis basin, ice chips
(if swallowed), and bedpan or urinal within
reach.
a. Provides comfort and safety.
8. Position the patient to enhance comfort,
safety, and during lung expansion.
a. Promotes safety and reduces risks
for postoperative complications.
9. Assess IV sites for patency and infusions for
correct rate and solution.
a. Helps detect phlebitis and prevents
errors in rate and solution type.
10. Assess urine output in closed drainage
system or use bladder scanner to detect
distention.
a. Baseline and identifies signs of
urinary retention.
11. Reinforce the need to begin deep breathing
and leg exercises.
a. Prevent complications related to
immobility (e.g., atelectasis, VTE).
PERIOPERATIVE NURSING
12. Provide information to the patient and
family.
a. Decrease the patient’s and family’s
anxiety.
CARE OF THE PATIENT IN THE PACU:
• Post-anesthesia care unit (PACU),
formerly referred to as the recovery room or
post-anesthesia recovery room, located
adjacent to the OR suite.
• Patients still under anesthesia or recovering
from anesthesia are placed in this unit for
easy access to experienced, highly skilled
nurses, anesthesia providers, surgeons,
advanced hemodynamic and pulmonary
monitoring and support, special equipment,
and medications
Phases of Post-anesthesia Care –
1. Phase I PACU – intensive nursing care is
provided during the immediate recovery
phase.
2. Phase II PACU – the patient is prepared for
self-care or an extended care setting.
3. Phase III PACU – the patient is prepared
for discharge.
Patients may remain in a PACU for as long as 4
to 6 hours, depending on the type of surgery
and any preexisting conditions or comorbidities.
Admitting the Patient to the Post-anesthesia
Care Unit –
• During Transport from the OR to the PACU,
the anesthesia provider remains at the head
of the stretcher (to maintain the airway), and
a surgical team member remains at the
opposite end.
Nursing Management in the Post-anesthesia
Care Unit –
The nursing management objectives for the patient
in the PACU are:
• To provide care until the patient –
• Has recovered from the effects of
anesthesia (e.g., until resumption of motor
and sensory functions),
• Is oriented,
• Has stable vital signs, and
• Shows no evidence of hemorrhage or other
complications.
POSTOPERATIVE PHASE ACTIVITIES:
Transfer of Patient to PACU –
1. Communicates intraoperative
information –
a. Identifies patient by name.
b. States type of surgery performed.
c. Identifies type and amounts of
anesthetic and analgesic agents
used.
d. Reports patient’s vital signs and
response to surgical procedure and
anesthesia.
e. Describes intraoperative factors
(e.g., insertion of drains or catheters,
administration of blood, medications
during surgery, or occurrence of
unexpected events).
f. Describes physical limitations.
g. Reports patient’s preoperative level
of consciousness.
h. Communicates necessary
equipment needs.
i. Communicates presence of family or
significant others.
Postoperative Assessment Recovery Area –
1. Determines patient’s immediate response to
surgical intervention.
2. Monitor patient’s vital signs and physiologic
status.
3. Assesses patent’s pain level and
administers appropriate pain-relief
measures.
4. Maintains patient’s safety (airway,
circulation, prevention of injury).
5. Administers medications, fluid, and blood
component therapy, if prescribed.
6. Provides oral fluids if prescribed for
ambulatory surgery patient.
7. Assesses patient’s readiness for transfer to
in-hospital unit or for discharge home based
on institutional policy.
PERIOPERATIVE NURSING
ASSESSING THE PATIENT:
Assessments of the patient’s –
• Airway
• Respiratory function
• Cardiovascular function
• Skin color
• Level of consciousness
• Ability to respond to commands.
Initial Nursing Assessment –
• Verify patient’ s identity, operative
procedure and the surgeon who performed
the procedure.
• Evaluate the following sign and verify their
level of stability with the anesthesiologist:
o Respiratory status
o Circulatory status
o Pulses
o Temperature
o Oxygen saturation level
o Hemodynamic values
• Determine swallowing and gag reflex, LOC
and patient’s response to stimuli.
• Evaluate lines, tubes, or drains, estimate
blood loss, condition of wound, medication
used, transfusions and output.
• Checks any intravenous (IV) fluids with the
goal of maintaining a euvolemic state.
• Evaluate the patient’s level of comfort and
safety.
• Perform safety check; side rails up and
restraints are properly in placed.
• Evaluate activity status, movement of
extremities.
• Review the health care provider’s orders.
The nurse assesses –
• RR and depth
• Ease of respiration
• Oxygen saturation
• Breath sounds
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 called
hypopharyngeal obstruction.
Signs of occlusion include –
• Choking
• Noisy and irregular respirations
• Decreased oxygen saturation scores, and
within minutes, cyanosis.
How to maintain patent airway?
1. Nurse needs to place the palm of the hand
at the patient’s nose and mouth to feel the
exhaled breath.
2. Because movement of the thorax and the
diaphragm does not necessarily indicate
that the patient is breathing the
anesthesiologist or CRNA may leave a hard
rubber or plastic airway in the patient’s
mouth to maintain a patent airway.

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 Such a device should not be removed until
blood). signs such as gagging indicate that reflex
action is returning.
PERIOPERATIVE NURSING
3. Allow the airway (ET tube) to remain in • Classic signs of hypovolemic shock (the
place until the patient begins to waken and most common type of shock) are –
is trying to eject the airway. o Pallor
4. The airway keeps the passage open and o Cool, moist skin
prevents the tongue from falling backward o Rapid breathing
and obstructing the air passages. o Cyanosis of the lips, gums, and
5. Aspirate excessive secretions when they tongue
are heard in the nasopharynx and o Rapid, weak, thready pulse
oropharynx. o Narrowing pulse pressure
o Low blood pressure
o concentrated urine.
MAINTAINING CARDIOVASCULAR STABILITY: • Hypovolemic shock can be avoided largely
by the timely administration of –
The nurse assesses – o IV fluids
• Level of consciousness o Blood
• Vital signs o Blood products
• Cardiac rhythm o Medications that elevate blood
pressure
• Skin temperature, color, and moisture
• The primary intervention for hypovolemic
• Urine output
shock is volume replacement, with an
• Patency of all IV lines
infusion of lactated Ringer solution, 0.9%
sodium chloride solution, colloids, or blood
component therapy.
The primary cardiovascular complications seen
in the PACU include – Hemorrhage

Hypotension • Hemorrhage is an uncommon yet serious

complication of surgery that can result in
• Can result from – hypovolemic shock and death.
o Blood loss • The patient presents with –
o Hypoventilation o Hypotension
o Position changes o Rapid, thready pulse
o Pooling of blood in the extremities o Disorientation
o Side effects of medications and o Restlessness
anesthetics o Oliguria
• If the amount of blood loss exceeds 500 mL o Cold, pale skin
(especially if the loss is rapid), replacement • Types –
is usually indicated. o Classification – Time Frame:
Shock ▪ Primary – occurs at the time
of surgery.
• One of the most serious postoperative ▪ Intermediary – occurs during
complications. the first few hours after
• Can result from – surgery when the rise of BP
o Hypovolemia to tis normal level dislodges
o Decreased intravascular volume insecure clots from untied
• Types – vessels.
o Hypovolemic (most common) ▪ Secondary – may occur
o Cardiogenic sometime after surgery if a
o Neurogenic suture slips because a blood
o Anaphylactic vessel was not securely tied,
o Septic
PERIOPERATIVE NURSING
became infected, or was Hypertension and Dysrhythmias –
eroded by a drainage tube.
o Classification – Type of Vessel: • Hypertension is common in the immediate
▪ Capillary – slow, general postoperative period secondary to
ooze. sympathetic nervous system stimulation
▪ Venous – darkly-colored from pain, hypoxia, or bladder distention.
blood flows quickly. • Dysrhythmias are associated with
▪ Arterial – blood is bright red electrolyte imbalance, altered respiratory
and appears in spurts with function, pain, hypothermia, stress, and
each heartbeat. anesthetic agents.
o Classification – Visibility: • Both hypertension and dysrhythmias are
▪ Evident – on the surface and managed by treating the underlying causes.
can be seen.
▪ Concealed – in a body cavity
and cannot be seen. IMMEDIATE POST-OP ASSESSMENT AND
• The early phase of shock will manifest in – INTERVENTIONS:
o Feelings of apprehension,
o Decreased cardiac output, and
o Vascular resistance.
o Breathing becomes labored, and “air
hunger” will be exhibited.
o 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 patient is placed in the shock position
(flat on back; legs elevated at a 20-degree
angle; knees kept straight).

• If hemorrhage is suspected but cannot be

visualized, the patient may be taken back to
the OR for emergency exploration of the
surgical site.
PERIOPERATIVE NURSING
COMMON POST-OP ORDERS:
• NPO until fully alert, then ice chips as
tolerated. Advance diet as tolerated.
• Suction prn
• Complete current IV then discontinue if pt.
tolerating fluids.
• Compazine 5 mg prn for nausea and
vomiting
• Morphine Sulfate 10 mg IM every 3-4 hours
pr
• Accurate intake and output
• Coughing, and Deep Breathing every 2
hours
• Hemoglobin and hematocrit in a.m.
• Catheter if patient can’t void in 8 – 10 hours
• Reinforce dressing pr
DETERMINING READINESS FOR
POSTANESTHESIA CARE UNIT DISCHARGE:
• A patient remains in the PACU until fully
recovered from the anesthetic agent.
• Indicators of recovery include –
o Stable blood pressure,
o Adequate respiratory function, and
o Adequate oxygen saturation level
compared with
o Baseline
• The Aldrete score is usually between 7 and
10 before discharge from the PACU.
• Patients with a score of less than 7 must
remain in the PACU until their condition
improves or until they are transferred to an
ICU, depending on their preoperative
baseline score.
PREPARING THE POSTOPERATIVE PATIENT
FOR DIRECT DISCHARGE:
• Ambulatory surgical centers frequently have
a step-down PACU like 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.
• A translator may be required if the patient
and family members do not understand
English.
Home or Clinic –
1. Provides follow-up care during office or
clinic visit or by telephone contact.
2. Reinforces previous education and answers
patient’s and family’s questions about
surgery and follow-up care.
PERIOPERATIVE NURSING
3. Assesses patient’s response to surgery and Surgical Nursing Unit –
anesthesia and their effects on body image
1. Continues close monitoring of patient’s
and function.
physical and psychological response to
4. Determines family’s perception of surgery
surgical intervention.
and its outcome IV.
2. Assesses patient’s pain level and
administers appropriate pain-relief
measures.
DISCHARGE PREPARATION:
3. Provides education to patient during
• The patient and caregiver (e.g., family immediate recovery period.
member, friend) are informed about 4. Assists patient in recovery and preparation
expected outcomes and immediate for discharge home.
postoperative changes anticipated. 5. Determines patient’s psychological status.
• The nurse provides Written instructions 6. Assists with discharge planning.
covering each of those points.
• Prescriptions are given to the patient.
• The nursing unit or surgeon’s telephone
number is provided, and the patient and
caregiver are encouraged to call with
questions and to schedule follow-up
appointments.
Patient Advice –

• Limited activity for 24 to 48 hours.

• During this time, the patient should not –
o Drive a vehicle,
o Drink alcoholic beverages, or
o Perform tasks that require high
levels of energy or skill.
• Fluids may be consumed as desired and
smaller than normal amounts may be eaten
at mealtime.
• Patients are cautioned not to make
important decisions at this time because the
medications, anesthesia, and surgery may
affect their decision-making ability.
Receiving the Patient in the Clinical Unit –

• The patient’s room is readied by assembling

the necessary equipment and supplies:
o IV pumps,
o Drainage receptacle holder,
o Suction equipment,
o Oxygen,
o Emesis basin,
o Tissues,
o Disposable pads,
o Blankets, and
o Postoperative documentation forms