LEOPOLDO G. CASTILLO, MAN, Ed.D.

NCM 103A CONCEPT

Perioperative Nursing
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Objectives
• Given relevant questions, the students
will:
– Define related terminologies in
surgery
– Describe the 3 phases of surgical
experiences
– Identify surgical classification
– Differentiate conditions requiring
surgery
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Objectives

• Given relevant questions, the students

will:
– Explain effects of surgery to the
patient
– Identify the risk factors
– Discuss responsibilities of the
surgical team to the patient during
peri-operative phase.
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Objectives
– Enumerate the members of the surgical
team in the intra-operative phase
• Differentiate the 2 intra-operative nurses
during surgery
• Enumerate positions assumed by the
patient during surgery
• Discuss responsibilities of nurses during
surgery
• Differentiate types of anesthesia & stages
• Recognize the possible complications of
anesthesia
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Objectives

• Given relevant questions, the students

will:
– Identify members of the team in post-
operative phase
– Discuss responsibilities of the nurse to the
patient in the post operative phase
– Identify post-operative complications and
discuss measures to prevent their
recurrence
– Discuss classification of wounds
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Three Phases of Perioperative Period

• Postoperative — lasts from admission to recovery
room to complete recovery from surgery.
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Postoperative Nursing Care

•Divided into 2 stages:

– Immediate care (usually provided at
PACU)

– Ongoing postoperative care (from return

to the unit through convalescence period)
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Postoperative Assessments
• A – irway • D – ressing
• B – reathing • D – rainage
• C - irculation • D – rugs
• C - onsciousness • E – limination
• C - omfort/Safety • F – luids
• F - oods
 LEOPOLDO G. CASTILLO, MAN, Ed.D.
Post-anesthetic Recovery Score
Post-anesthetic Recovery Score in 15 30 45 hrs out
Activity 4 extremities 2 2 2 2 2 2
.
Able to move voluntarily 2 extremities 4 1 1 1 1 1
or on command 0 extremity 0 0 0 0 0 0
Respiration Able to deep breath & cough freely 2 2 2 2 2 2
Dyspnea shallow or limited breathing 1 1 1 1 1 1
Apneic 0 0 0 0 0 0
Circulation 20 mm of pre-anesthesia level 2 2 2 2 2 2
20-50 mm of pre-anesthesia level 1 1 1 1 1 1
50 mm of pre-anesthesia level 0 0 0 0 0 0
Consciousness Fully awake 2 2 2 2 2 2
Arousable on calling 1 1 1 1 1 1
Not responding 0 0 0 0 0 0
Color Normal 2 2 2 2 2 2
Pale, dusky, blotchy, jaundiced, other 1 1 1 1 1 1
Cyanotic 0 0 0 0 0 0
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Postoperative Assessments
• ALDRETE’S SCORING: Five
Physiological Parameters
1. Activity
2. Respiration
3. Circulation
4. Consciousness
5. Color
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Postoperative Assessments
• ALDRETE’S SCORING: Muscle
Activity
Area of Assessment Point 1 2 3
Score hour hours hours

Ability to move all 2

extremities
Ability to move 2 1
extremities
Unable to control any 0
extremity
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Postoperative Assessments
• ALDRETE’S SCORING: Respiration
Area of Assessment Point 1 2 3
Score hour hours hours

Ability to breath deeply 2

and cough

Limited respiratory effort 1

No spontaneous effort 0
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Postoperative Assessments
• ALDRETE’S SCORING: Circulation
Area of Assessment Point 1 2 3
Score hour hours hours

BP +/- 20% of pre- 2

anesthetic level
BP +/- 20%-40% of pre- 1
anesthetic level
BP +/- 50% of pre- 0
anesthetic level
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Postoperative Assessments
• ALDRETE’S SCORING:
Consciousness Level
Area of Assessment Point 1 2 3
Score hour hours hours

Fully awake 2

Arousal on calling 1

Not responding 0
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Postoperative Assessments
• ALDRETE’S SCORING: Oxygen
Saturation (O2 Sat)
Area of Assessment Point 1 2 3
Score hour hours hours

Unable to maintain O2 2
92% on room air
Needs O2 inhalation to 1
maintain O2 sat 90%
O2 sat less than 90% 0
even with O2 supplement
LEOPOLDO G. CASTILLO, MAN, Ed.D

Required for
Discharge from
PACU
Score of 7-8
LEOPOLDO G. CASTILLO, MAN, Ed.D

POST OPERATIVE
ASSESSMENTS
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Post-operative Assessments
1. Respiratory Status: Assessment
– Respiratory rate, rhythm & depth
– Patency of airway & Presence of oral airway
– Breath sounds
– Use of accessory muscles
– Skin color
– Ability to cough
– ABG’s & Oxygen Saturation
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Post-operative Assessments
• Respiratory Status: Interventions
– Position patient on side to prevent
aspiration.
– Suction artificial airways and oral
cavity as necessary.
– Ask patient to perform respiratory
exercises
– Administer oxygen as ordered.
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Post-operative Assessments
2. Circulatory Status: Assessment
– HR, BP & urine output
– Skin color, Skin temperature, capillary refill and
edema
– Heart sounds & peripheral pulses
– Homan’s sign
– Changes in VS symbolizing shock
– Type, amount, color, odor & character of
drainage from tubes, drains, catheters or
incision.
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Post-operative Assessments
• Circulatory Status: Interventions
– Check under patent for pooling of
blood.
– Check dressings, tubes, drains, and
catheters for blood.
– Monitor changes in HR and BP.
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Post-operative Assessments
3. Thermoregulatory Status:
– Assessment
•Body temperature
•Shivering
– Interventions
•Apply warming blankets
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Post-operative Assessments
4. CNS Status: Assessment
– Level of consciousness (LOC)
– Mental status
– Movement and sensation in extremities
– Presence of gags and corneal reflexes
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Post-operative Assessments
• CNS Status: Interventions
– Orient patient to PACU environment
– Protect eyes if corneal reflex is
absent
– Protect airway if gag reflex is
absent.
 LEOPOLDO G. CASTILLO, MAN, Ed.D

Post-operative Assessments

5. Wound Status: Types of Wound

Healing
– First Intention (Primary Union)
• Clean incision, early suture, hairline scar
– Secondary Intention (Granulation)
• Gaping irregular wound, granulation, epithelium
grows over scar
– Third Intention (Secondary Suture)
• Wound, granulation, closure with wide scar
 LEOPOLDO G. CASTILLO, MAN, Ed.D

Classifications of Surgical Wounds

• Clean Wound

• Clean-Contaminated Wound

• Contaminated Wound

• Dirty and Infected Wound

 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Wound Drainage
LEOPOLDO G. CASTILLO, MAN, Ed.D
 LEOPOLDO G. CASTILLO, MAN, Ed.D

Types of Dressings

• Dry to Dry - trap necrotic debris &

exudates

• Wet to Dry – softens debris as it dries

• Wet to Damp - wound debridement

• Wet to Wet – moisture dilute exudates

 LEOPOLDO G. CASTILLO, MAN, Ed.D

Assessment of Dressings
• Warmth, swelling, tenderness or pain around
incision
• Type, amount, color, and character of
drainage on dressings
• Amount, consistency, color of drainage
• Drains and tubes and be sure they are
intact, patent and properly connected to
drainage systems
 LEOPOLDO G. CASTILLO, MAN, Ed.D

Interventions

•Reinforce dressings as
necessary
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Post-operative Assessments
6. Urinary Status:
– Assessment
• Bladder distention
• Amount, color, odor, and character of
urine from foley catheter if present

– Interventions
• Catheterize if necessary
• Notify MD if UO is less than 30cc/hr
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Post-operative Assessments
7. Gastrointestinal Status: Assessment
– Abdominal distention
– N&V
– Bowel sounds
– Passage of flatus
– Type, amount, color and character of
drainage from NGT if present
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Post-operative Assessments
8. F & E Status: Assessment
– I&O
– Color and appearance of mucus
membranes
– Skin turgor, tenting and texture
– Status of IVF’s, type, amount and flow
rate
LEOPOLDO G. CASTILLO, MAN, Ed.D

POST OPERATIVE
COMPLICATIONS
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

1. Wound Infection
• Predisposing Factors
– Obesity, DM, malnutrition, elderly, lower resistance to
infection, steroids and immunosuppressive agents
• Assessment Findings
– Redness, tenderness, drainage, heat in incision
area and fever.
• Nursing Interventions
– Obtain C&S of wound drainage (S. Aureus –common
cultured)
– Perform cleansing and irrigation of wound as ordered
– Administer antibiotics therapy as ordered.
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Wound Dehiscence & Evisceration

•Predisposing Factors
– Wound infection

– Faulty wound closure

– Severe abdominal stretching

 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Wound Dehiscence
•Opening of wound edges
•Interventions
– Apply steri-strips to incision
– Notify the attending physician
– Promote wound healing
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Wound Evisceration
• Protrusion of loops of bowel through
incision, usually accompanied by sudden
escape of profuse, pink serous drainage.
• Interventions:
– Place patient on supine position
– Cover protruding intestinal loops with moist NSS
– Notify attending physician
– Check vital signs
– Start IV line if needed
– Prepare client for OR for surgical closure of wound
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

2. Elevated Body Temperature

• Predisposing Factors
– Infection
– Dehydration
– Response to stress & trauma
– Prolonged hypotension
– Transfusion reaction
– Respiratory congestion
– thrombophlebitis
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Elevated Body Temperature (cont.)

• Assessment Findings
– Temperature elevated above 99.5⁰F
(37.5 ⁰C)
– Elevated pulse and respiratory rates
– Diaphoresis
– Lethargy
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Elevated Body Temperature (cont.)

• Nursing Interventions
– Tepid sponge bath (TSB) or cooling sponge
bath
– Increasing fluid intakes
– Antipyretics as ordered
 LEOPOLDO G. CASTILLO, MAN, Ed.D.
Causes of Post-operative Fever
Etiology Onset Fever Type Intervention Complications

.
Atelectasis Within 24 Low grade Cough, deep Pneumonia
hours breath
Dehydration 2-3 days Varies IV/p.o. fluids Renal &
respiratory
Wound 3-5 days Varies Antibiotics Sepsis &
Infection wound
dehiscence
UTI 5-8 days Low grade Antibiotics Sepsis

Thrombo- 7-14 varies OOB, TED Pulm.

phlebitis days hose, heparin Embolism
Loss of limb,
sepsis
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

3. Urinary Retention
• Major Clinical Manifestations
– Little or no output or frequent small
amounts
– Palpably distended bladder
– Restlessness
– Discomfort
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Urinary Retention (cont.)

• Treatment
– Measures to promote voiding (privacy,
running water, sitting patient up, or
ambulation as necessary)

– Catheterization is above methods fail.

 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Urinary Retention (cont.)

• Preventive Nursing Interventions
– Adequate hydration

– Early Ambulation
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

4. Urinary Tract Infection (UTI)

• Major Clinical Manifestations
– Mild fever
– Dysuria
– Hematuria
– Body malaise
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Urinary Tract Infection (cont.)

• Treatment

– Adequate hydration

– Maintenance of good bladder drainage

– Antibiotics on basis of urine culture

and sensitivity
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Urinary Tract Infection (cont.)

• Preventive Nursing Interventions
– Encourage fluid intake

– Early ambulation

– Avoid catheterization or remove within 2

days
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

5. Pneumonia
• Major Clinical Manifestations
– Increased body temperature
– Chills
– Productive cough of purulent or rusty
sputum & increased secretions
– Crackles/Wheezes
– Dyspnea & tachypnea
– Chest pain
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Pneumonia (cont.)
• Treatment
– Promote full aeration of lungs by positioning in
semi-fowler’s position
– Administer oxygen as ordered
– Maintain fluid status
– Chest physiotherapy
– Administer antibiotics on basis of sputum C&S
– Administer expectorants & analgesics as
ordered
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Pneumonia (cont.)
• Preventive Nursing Interventions
– Turn, coughing and deep breathing exercise

– Frequent position changes

– Early ambulation
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

6. Atelectasis
• Major Clinical Manifestations
– Decreased lung sound over affected area
– Dyspnea
– Cyanosis
– Restlessness
– Apprehension
– Fever
– tachypnea
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Atelectasis (cont.)
• Treatment
– Position in semi-fowler’s or fowler’s
– Maintain hydration
– Suctioning
– Chest physiotherapy
– Administer oxygen as ordered
– Administer analgesics as ordered
– Administer bronchodilators and mucolytic via
nebulizer
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Atelectasis (cont.)
• Preventive Nursing Interventions
– Early ambulation

– Turn. Cough and deep breathing exercise

– Incentive spirometry
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

7. Pulmonary Embolism
• Major Clinical Manifestations
– Dyspnea
– Sudden severe chest pain or tightness
– Cough/hemoptysis
– Pallor or cyanosis
– Increased respirations
– Tachycardia or Bradycardia
– Hypotension
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Pulmonary Embolism(cont.)
• Treatment
– Maintain bedrest with HOB in semi-fowler’s
– Maintain fluid balance
– Contact MD stat
– Administer oxygen as ordered
– Administer analgesics as ordered
– Administer anticoagulants as ordered
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Pulmonary Embolism (cont.)

• Preventive Nursing Interventions
– Passive and active ROM exercises to legs

– Antiembolic stocking

– Low-dose of heparin administration if

predisposing factors present

– Early ambulation
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

8. Paralytic Ileus
• Major Clinical Manifestations
– Absent of bowel sounds

– No passage of flatus or feces

– Abdominal distention
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Paralytic Ileus (cont.)

• Treatment
– Nasogastric suction
– IV fluids
– Rectal tube
– ambulate
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Paralytic Ileus (cont.)

• Preventive Nursing Interventions

– Early ambulation

– Abdominal tightening exercises

– Keep NPO if inactive bowel sounds

 LEOPOLDO G. CASTILLO, MAN, Ed.D.

9. Hypovolemic Shock
• Major Clinical Manifestations
– Decreased blood pressure
– Cold, clammy skin
– Weak, rapid thready pulse
– Deep, rapid respirations
– Decreased urine output
– Thirst
– Apprehensions and restlessness
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Hypovolemic Shock (cont.)

• Treatment
– Position flat with legs elevated in 45
degrees
– Place extra covering to maintain warmth
– Administer oxygen as ordered
– Administer fluid resuscitation as well as
whole blood or its components as ordered
– Prepare for OR
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

10. Thrombophlebitis
• Major Clinical Manifestations
– Pain and cramping in the calf of the
involved extremity
– redness., swelling in the affected area of
the involved extremity
– Increased temperature of the involved
extremity
– Increased diameter of the involved
extremity
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Thrombophlebitis (cont.)
• Treatment
– Measure bilateral calf or thigh
circumference.
– Elevate affected extremity to heart level
– Maintain bedrest
– Apply moist heat on affected extremity as
ordered
– Administer analgesics and anticoagulants as
ordered.
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Thrombophlebitis (cont.)
• Preventive Nursing Interventions

– Antiembolic stockings or sequential

pneumatic compressions stockings

– Post-operative leg exercises

– Avoid ambulation
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

11. Hematoma
• Major Clinical Manifestations
– Active bleeding
– Elevation and discoloration of wound
edges
• Treatment
– If small, may reabsorb; otherwise
surgical evacuation
 LEOPOLDO G. CASTILLO, MAN, Ed.D.

Outcomes for the Surgical Patient

• Be free from injury and adverse effects
• Be free from infection
• Maintain fluid and electrolyte balance; skin
integrity
• Demonstrate understanding of physiologic and
psychological responses to surgery
• Participate in rehabilitation process
LEOPOLDO G. CASTILLO, MAN, Ed. D.

THANK YOU