Perioperative Nursing Management

Perioperative period = the period of time that constitutes the surgical experience.
➢ Phases:
1. Preoperative phase = period of time when the decision for surgical intervention is made up to
when the patient is transferred to the operating room table.
2. Intraoperative phase = period of time from when the patient is transferred to the operating
room table up to when he or she is admitted to the postanesthesia care unit (PACU).
3. Postoperative phase = period of time that begins with the admission of the patient to the PACU
and ends after a follow-up evaluation in the clinical setting or home.

Surgery = can be defined as the art and science of treating disease, injuries, and deformities by operation and
instrumentation.
➢ Conditions requiring surgery:
Types of Biopsy:
o Obstruction or blockage = blockage in the flow
of body fluids (blood, CSF, urine, bile)
a. Needle Aspiration Biopsy – the area is
o Perforation or rupture of an organ usually first numbed with local anesthesia
o Erosion or wearing away of surface of a tissue and a needle is attached to a syringe and
o Tumors or abnormal growthof tissue that then inserted into the cyst or tumor to be
serves no chronological function to the body investigated and cells are sucked out to be
examined cystologically.
➢ Categories of surgical procedure: b. Incisional Biopsy – section of a tissue is cut
o According to Purpose: away
1. Diagnostic = determination of the c. Endoscopic Biopsy – an endoscope is
passed into the organ to be investigated
presence and/or extent of pathology
and an attachment (cytologic
(e.g., lymph node biopsy, or
brush/forceps) is used to take a sample.
bronchoscopy) d. Open Biopsy – part of an operation usually
2. Curative = elimination or repair of under general anesthesia in which the
pathology (e.g., removal of a rupture surgeon opens a body cavity to reveal a
appendix, benign ovarian cyst, or diseased organ or tumor and removes a
excision of a tumor) tissue sample
3. Palliative = alleviation of symptoms
without cure (e.g., cutting a nerve root [rhizotomy] to remove symptoms of pain,
gastrostomy tube may be inserted to compensate for the inability to swallow food, or
creating a colostomy to bypass an inoperable bowel obstruction)
4. Preventive = examples include removal of a mole before it becomes malignant or
removal of the colon in a patient with familial polyposis to prevent cancer
5. Exploratory = surgical examination to determine the nature or extent of a disease (e.g.,
exploratory laparotomy)
6. Cosmetic/ reconstructive/ reparative = examples include repairing a burn scar,
mammoplasty, face lift, cheiloplasty)

o According to the Degree of Urgency:

1. Emergency surgery
- stat surgeries to: a) maintain life; b) save organ or limb function; c) stop bleeding or
hemorrhage; d) remove damaged organ or limb
- Examples: severe bleeding, bladder or intestinal obstruction, perforated ulcer, gunshot and
stab wounds, fractured skull
2. Imperative/ urgent surgery
- requires surgical intervention with 24-28 hours
- Examples: eroding cancer tumors, kidney stones, hemorrhoids, appendectomy
3. Planned/required surgery
- Necessary to the well-being of the client; surgical intervention is scheduled weeks or months
in advance
- Examples: cataract removal, tonsillectomy, laminectomy, thyroidectomy
4. Elective surgery
- delay or omission of surgery will have no adverse effect
- Examples: elective CS, simple hernia repair
5. Optional surgery
- surgery based on individual preferences
 - Examples: face lift, nose lift, Suffixes Describing Surgical Procedure:
breast augmentation, Suffix Meaning Examples
liposuction -ectomy Excision or removal - Appendectomy
-lysis Destruction of - Electrolysis
o According to the Degree of Risk -orrhaphy Repair or suture of - Herniorrhaphy
to Client: -oscopy Looking into; visual - Endoscopy
1. Major surgery = high examination of
degree of risk -ostomy Creation of opening into - Colostomy
-otomy Cutting into or incision of
- Tracheostomy
- Prolonged intraoperative
-plasty Repair or reconstruction of
- Mammoplasty
period
- Large amount of blood loss
- Extensive, vital organs may be handled or removed (e.g., liver biopsy, open heart surgery)
2. Minor surgery = lesser degree of risk to the client
- Generally not prolonged; described as “one-day surgery” or outpatient surgery or ambulatory
surgery
- Leads to few serious complications (e.g., cyst removal)

➢ General Risk Factors:

o AGE
o IMMOBILITY
o MALNUTRITION
o OBESITY
o EMERGENCIES REQUIRING SURGERY
o ENDOCRINE RELATED CONDITIONS

Preoperative Nursing Management

Preoperative Period
❑ This period is used to physically and psychologically prepare the client for surgery.
❑ The nurse plays a major role in client teaching and in relieving the client’s and the family’s anxieties.
❑ Goals:
➢ Assessing and correcting physiologic and psychologic problems that might increase surgical risk
➢ Giving the person and significant others complete learning/ teaching guidelines regarding surgery
➢ Instructing and demonstrating exercises that will benefits the person during post-op period
➢ Planning for discharge and any projected changes in lifestyle due to surgery

Nursing Assessments of the Preoperative Patient:

➢ Psychological Nursing Assessment:
1. Regression – person who regresses behaves in a more dependent and childlike manner
2. Denial – manifested by casual attitude towards the impending surgery
3. Intellectualization – discuss the illness or surgical condition rationally but without emotion. This
detached attitude temporarily protects them from reality.
Psychologic Preparation for Surgery
➢ Preparation for hospital admission: includes explanation of the procedure to be done, probable
outcome, expected duration of hospitalization, cost, length of absence from work, and residual effects

➢ Causes of Fears:
1. Fear of the unknown
2. Fear of anesthesia, vulnerability while unconscious
3. Fear of pain and discomfort
4. Fear of death
5. Fear of mutilation or disturbance of body image
6. Worries: loss of finances, employment, social and family roles

➢ Manifestations of Fears:
1. Anxiousness
2. Confusion
3. Anger
4. Tendency to exaggerate
5. Sad, evasive, tearful, clinging
 6. Inability to concentrate
7. Short attention span
8. Failure to carry out simple directions
9. Dazed

➢ Nursing Interventions to Minimize Anxiety:

1. Assess client’s fears, anxieties, support systems, and patterns of coping
2. Establish trusting relationship with client and significant others
3. Explain routine procedures, encourage verbalization of fears, and allow client to ask questions
4. Demonstrate confidence in surgeon and staff
5. Provide for spiritual care if appropriate

Components of Pre-op Teaching:

➢ Sensory Information – addresses the sights, sounds and feel of the operating room
➢ Process information – patients may not want specific details but desire the general flow of what is going
to happen. This information would include the patient’s transfer to the holding area, visits by the nurse
and ACP before transfer to the OR, and waking up in the PACU.
➢ Procedural Information – desired details are more specific. For example, this information would include
that an IV line will be started while patients are in the holding area and the surgeon may mark the
operative site with an indelible marker to verify site and side.

➢ Major Pre-op Exercises:

1. Deep Breathing Exercises – to help expand the lungs and prevent post-op pneumonia and
atelectasis; can be done with pursed lip breathing
▪ Use of incentive spirometry
2. Coughing Exercises – promote removal of chest secretions (sitting or supine)
3. Turning Exercises – to stimulate circulation every 1-2 hours
▪ to prevent pressure sores
4. Leg Exercises – to improve circulation (thrombophlebitis); facilitates venous return to the heart
5. Ambulation – helps to prevent many post-op complications
6. Pain control – use of pain scale, facial pain scale, patient controlled analgesia, and other
measures

Physiologic Preparation Prior to Surgery:

➢ Respiratory preparation: chest x-ray
➢ Cardiovascular preparation: ECG, CBC, blood typing, cross-matching, PT/PTT (prothrombin time, partial
thromboplastin time), serum electrolytes
➢ Renal preparation: urinalysis

➢ Obtain history of past medical conditions, allergies, dietary restrictions, and medications:
1. A – Allergy to medications, chemicals, and other environmental products such as latex
▪ All allergies are reported to the anesthesia and surgical personnel before the beginning
of surgery
▪ If allergy exist, an allergy band must be placed in the client’s arm immediately
2. B – Bleeding tendencies or the use of medications that deter clotting, such as aspirin, heparin,
and warfarin sodium.
▪ Herbal medications may also increase bleeding time or mask potential blood-related
problems
3. C – Cortisone and steroid use
4. D – Diabetes mellitus, a condition that not only requires strict control of blood glucose levels but
also known to delay wound healing
5. E – Emboli; previous embolic events (such as lower leg blood clots) may recur because of
prolonged immobility

Legal Preparation for Surgery:

➢ Informed consent – also known as operative permit; is an active, shared decision-making process
between the provider and the recipient of care.
1. Three conditions must be met for consent to be valid:
1. Adequate disclosure of the diagnosis; the nature and purpose of the proposed
treatment; the risks and consequences of the proposed treatment; the probability of a
 successful outcome; the availability, benefits, and risks of alternative treatments; and
the prognosis if treatment is not instituted.
2. Patient must demonstrate clear understanding and comprehension of the information
being provided before receiving sedating preoperative medications.
3. Recipient of care must give consent voluntarily.

2. Purposes of Informed Consent:

▪ To ensure that the patient understands the nature of the treatment including potential
complications
▪ To indicate that the person’s decision was made without pressure
▪ To protect the patient against unauthorized procedures
▪ To protect the surgeon and hospital against legal action by a patient who claims that an
unauthorized procedure was performed.

3. Nursing Responsibility while Patient is Consenting for the Procedure:

▪ Nurses are responsible for witnessing the patient’s signature on the consent form.
▪ Nurse can be patient advocate, verifying that the patient (or family member)
understands the information presented in the consent form, the implications of
consent, and that consent for surgery is truly voluntary.
✓ If the patient is unclear about the operative plans, the nurse must contact the
surgeon about the patient’s need for additional information.
✓ The patient must also be aware that consent, even when signed, can be
withdrawn at any time if the desire to give permission for the procedure
changes.
✓ If the patient is minor, is unconscious, or is mentally incompetent to sign the
permit, the written permission may be given by a legally appointed
representative or responsible family member.
✓ Physician may institute treatment without written consent on the following
situations:
❖ If true medical emergency is present that when immediate medical
treatment is needed to preserve life
❖ If the individual patient is incapable of giving consent
❖ If reaching the next of kin is not possible
Nurses must note in the chart documenting the medical
necessity of the procedure, and will usually need to complete an
incident report because it is an occurrence that is inconsistent
with routine facility operations.
In an emergency, permission via the telephone is acceptable;
have a second listener on phone when telephone permission
being given

Nursing Preparations the Evening before the Surgery:

➢ Preparing the skin – cleanse the skin and reduce the number of organisms on the skin and to eliminate
as far as possible the transference of such organisms into the incision site
➢ GIT preparation
1. NPO for 8-10 hours before the operation to reduce possibility of vomiting and aspiration during
anesthesia
2. Enema – ordered only for surgical procedure which involves the GIT, peri-anal and the pelvic
cavity
▪ PURPOSES:
✓ To reduce possibility of bowel obstructions
✓ Prevent risk for contamination from fecal material during bowel surgeries
✓ Provide adequate surgical site for visualization
▪ DO NOT ATTEMPT TO REPEAT ENEMA AFTER 3 TRIES. Rationale:
✓ It is physically tiring
✓ It can damage the rectum and bowel area
✓ It can cause fluid and electrolyte imbalance
3. Insertion of NGT – to remove gastric or intestinal content
➢ Preparing for Anesthesia
➢ Promoting rest and comfort
1. well-ventilated room
 2. comfortable, clean bed
3. back rub
4. warm beverages if not contraindicated
5. sleeping medications can be given as prescribed to ensure a good night sleep

Nursing Responsibility for the Early Morning Care:

➢ Verify the presence of a signed operative consent, laboratory data, history and examination report, a
record of any consultations, baseline vital signs, and nurse’s notes complete to that point.
➢ Check identification band to make sure it is legible, accurate and securely fastened to the person
➢ Verify the site and side of the anticipated surgery that may be marked with an indelible marker.
➢ If a skin prep is ordered, check that it has been completely, accurately and thoroughly carried out
➢ Check for and carry out any special orders such as administering enemas, inserting NG tube, starting an
IV line
➢ Verify that the person has not eaten for the last 8 hours.
➢ Ask the person to void. Measure and record amount of urine.
➢ Assist the person with oral hygiene if necessary.
➢ Have the patient remove jewelries
o If the patient prefers not to remove wedding ring, the ring can be taped securely to the finger to
prevent loss.
➢ If the patient wears a hearing aid, notify the O.R. nurse
➢ Assist the person in wearing hospital gowns, protective head caps, or face wraps, anti-embolic stockings
(helps to prevent venous stasis that can cause shock or thromboembolism)
➢ Remove colored nail polish. Patient’s nail bed is frequently checked for signs of hypoxia

Pre-Operative Medications:
➢ Generally administered 60-90 min before induction of anesthesia
➢ Purpose:
1. To allay anxiety: the primary reason for pre-operative medications
2. To decrease the flow of pharyngeal secretions
3. To reduce the amount of anesthesia to be given
4. To create amnesia for the events that precedes surgery
➢ Types of Pre-Operative Medications:
1. Sedative:
▪ Given to decrease client’s anxiety to lower BP and PR
▪ Reduce the amount of general anesthesia: an overdose can result to respiratory
depression
▪ e.g. Barbiturates (Phenobarbital)
▪ benzodiazepines (Diazepam [Valium], Midazolam [Versed])
2. Tranquilizer:
▪ Lowers the client’s anxiety level
▪ e.g. Thorazine 12.5 - 25 mg IM 1-2 hours prior to surgery

3. Narcotic analgesia:
▪ Given to patients to reduce anxiety and to reduce the amount of narcotics given during
surgery
▪ e.g. Morphine sulfate 8-15 mg SC 1 hour prior to preoperative; *Can cause vomiting,
respiratory depression and postural hypotension
4. Vagolytic or anticholinergic (drying agents):
▪ To reduce the amount of tracheobronchial secretions which can clog the pulmonary tree
and result in atelectasis and pneumonia
▪ e.g. Atropine sulfate 0.3-0.6 mg IM 45 min before surgery; * An overdose can result to
severe tachycardia

Transportation to the Operating Room

➢ The nurse should assist the patient in transferring from the hospital bed to the OR cart, and the side rails
of the cart are raised and secured.
➢ Ensure that the completed chart goes with the patient in the OR.
➢ Patients can ambulate ONLY when they have not received pre-operative medications.
 Intraoperative Nursing Management
Surgical suite
➢ Is a controlled environment designed to minimize the spread of infectious organisms.
➢ Divided into 3 distinct areas:
1. Unrestricted area = these areas typically include the points of entry for patients (e.g., holding
area), staff (e.g., locker rooms), and information (e.g., nursing station)
➢ Is the area where personnel in street clothes can interact with those in scrub clothing.
2. Semirestricted area = includes the peripheral support areas and corridors. Only authorized
personnel are allowed to have an access.
➢ All personnel in the semirestricted area must wear surgical attire and cover all head
3. Restricted area = all must wear surgical attire, cover all head, and masks
➢ This area can include OR, scrub sink areas

Holding area
➢ Is a special waiting area inside or adjacent to the surgical suite.
➢ The area where perioperative nurse makes the final identification and assessment before the patient is
transferred into the OR for surgery.
➢ Minor procedures can also be performed, such as inserting IVF, removing casts, and drug administration.

Operating room
➢ A restricted area, which is preferable to have the physical location adjacent to the PACU and the surgical
intensive care unit (SICU) and close proximity to anesthesia personnel.
➢ Methods used to prevent the transmission of infections
o Filter and controlled airflow in the ventilating system provide dust control.
o Positive air pressure in the rooms prevents air from entering the OR from the halls and
corridors.

Surgical Team
➢ STERILE TEAM
1. Surgeon – is the physician who performs the surgical procedure.
- Is responsible for the following:
1. Preoperative medical history and physical assessment, including the need for surgical
intervention, choice of surgical procedure, management of preoperative workup, and
discussion of the risks of and alternatives to surgical intervention.
2. Patient safety and management in the OR
3. Postoperative management of the patient
2. Assistant Surgeon
- Another surgeon who assists the chief surgeon in a) retracting/exposing the operative site; b)
hemostasis; c) suturing/wound closure
- Registered Nurse First Assistant (RNFA)
✓ This nurse works in collaboration with the surgeon to produce an optimal surgical
outcome for the patient.
✓ Must have a formal education about handling tissue, using instrument, providing
exposure to the surgical site, assisting with hemostasis, and suturing.
3. Scrub Nurse
- Prepares the sterile field/mayo tray, the instruments and other special equipment needed for
the surgery
- Passes the instruments to the surgeon
- Participates in surgical counting and specimen collection
- Surgical technologist= can perform the scrub function
✓ Have attended an associate degree program, a vocational training program, or a
hospital or military training program.

➢ UNSTERILE TEAM
1. Anesthesia care provider = is one who administers anesthetic drugs
a. Anesthesiologist = is a physician with specialty in anesthesiology
b. Nurse anesthetist = is a RN who has graduated from an accredited nurse anesthesia program
(minimally a master’s degree program) and successfully completed a national examination to
become a certified registered nurse anesthetist (CRNA).
 2. Circulating nurse Scope of Practice of Anesthesia Care
3. Biomedical Technician Provider:
- 2 year vocational course 1. Performing and documenting a
- Handles specialized equipment like preanesthetic assessment and evaluation.
endoscopes 2. Developing and implementing an
- Always involved in laparoscopic surgeries anesthestic plan.
3. Selecting and initiating the planned
anesthetic technique.
4. Ancillary/Paraprofessional
4. Selecting, obtaining, and administering
- Responsible in maintaining day to day
the anesthesia, adjuvant drugs, accessory
functioning of the O.R. drugs, and fluids.
- Best time to clean the O.R.: in between cases 5. Selecting, applying, and inserting
- Involved in sterilization and packaging of appropriate noninvasive and invasive
instruments monitoring devices.
6. Managing a patient’s airway and
Principles of Basic Aseptic Technique in the Operating Room pulmonary status.
1. All materials that enter the sterile field must be sterile. 7. Managing emergency and recovery from
2. If a sterile item comes in contact with an unsterile item, it is anesthesia.
8. Releasing or discharging patients from
contaminated.
anesthesia.
3. Contaminated items should be removed immediately from
9. Ordering, initiating, or modifying pain
the sterile field. relief therapy.
4. Sterile team members must wear only sterile gowns and 10. Responding to emergency situations by
gloves; once dressed for the procedure, they should providing airway management,
recognize that the only parts of the gown considered sterile administering emergency fluids, and/or
are the front from the chest to the table and the sleeves to 2 emergency drugs.
inches above the elbow.
5. A wide margin of safety must be maintained between the sterile and unsterile fields.
6. Tables are considered sterile only at tabletop level; items extending beneath this level are considered
contaminated.
7. The edges of the sterile package are considered contaminated once the package has been opened.
8. Bacteria travel on airborne particles and will enter the sterile field with excessive air movements and
currents.
9. Bacteria travel by capillary action through moist fabrics and contamination occurs.
10. Bacteria harbor on the patient’s and the team members’ hair, skin, and respiratory tracts and must be confined by
appropriate attire.

Intraoperative Activities of the Perioperative Nurse:

Circulating/Nonsterile Nurse Scrubbed/Sterile Nurse
• Assists with preparation of the room. • Assists with preparation of the
• Practices aseptic technique in all required activities. room.
• Monitors practices of aseptic technique in self and others. • Scrubs, gowns, and gloves self and
• Ensures that needed items are available and sterile (if required). other members of the surgical
• Checks mechanical and electrical equipment and environment factors. team.
• Identifies and admits the patient to the OR suite. • Prepares the instrument table and
• Assesses the patient’s physical and emotional status. organizes sterile equipment for
• Plans and coordinates the intraoperative nursing care. functional use.
• Checks the chart and related pertinent data. • Assist with the draping procedure.
• Assists with transferring the patient to the operating room bed. • Passes instruments to the surgeon
• Ensures patient safety in transferring and positioning the patient. and assistants by anticipating their
• Participates in insertion and application of monitoring devices. needs.
• Assists with the induction of anesthesia. • Counts sponges, needles, and
• Monitors the draping procedure. instruments.
• Documents intraoperative care. • Monitors practices of aseptic
• Records, labels, and sends to proper locations tissue specimens and technique in self and others.
cultures. • Keeps tract of irrigation solutions
• Measure blood and fluid loss. used for calculation of blood loss.
• Records amount of drug used during local anesthesia. • Reports amounts of local
anesthesia and epinephrine
• Coordinates all activities in the room with team members and other
solutions used by ACP and/or
health-related personnel and departments.
surgeon.
• Counts sponges, needles, and instruments.
• Participates actively in the process
• Accompanies patient to the postanesthesia recovery area.
of time-out, and sign out.
• Reports information relevant to the care of the patient to the recovery
area nurses.
• Initiates the sign in, time-out, and sign out.
Anesthesia = is the art and science of inducing narcosis (deep sleep), amnesia (memory loss), analgesia (loss of
sensation), relaxation of muscles and loss of reflexes.
➢ Four levels of sedation and analgesia:
o Minimal sedation = patient responds normally
o Moderate sedation/analgesia (conscious sedation) = patient is groggy, dizzy but still awake and
responding; airway and cardiovascular function is maintained
o Deep sedation/analgesia = the client is not easily aroused
o Anesthesia level = the patient requires assisted ventilation

➢ Classifications of Anesthesia:
1. General – loss of sensation with loss of consciousness; skeletal muscle relaxation; possible
impaired ventilatory and cardiovascular function
a. INDICATIONS:
- for surgeries which require skeletal muscle relaxation
- for patients who are extremely anxious and/or uncooperative
- for patients who refused or are contraindicated for local or regional anesthesia

b. Types:
i. Intravenous Agents – TIVA; given as a routine general anesthetic which induce a
pleasant sleep
ii. Inhalation Agents – uses volatile liquids administered with a vaporizer after mixed
with Oxygen and Nitrous Oxide (N2O); or the use of gas mixture delivered via
anesthesia breathing circuit (ABC)/apparatus with oxygen. It may be given through
ET or mask.
iii. ADJUNCTS – is added to IV regimen to achieve narcosis, amnesia, analgesia and
muscle relaxation.
a) Opioids – used for sedation and analgesia for pre-op; induction and
maintenance of anesthesia during intra-op; and for pain management for
post-op cases.
▪ Monitor patient for signs of respiratory depression
b) Benzodiazepines – sedative-hypnotic med used widely for amnesic effect or
as supplemental IV sedation during local and regional anesthesia (DOC:
Medazolam [Versed])
▪ Flumazenil (Romazicon) = is a specific benzodiazepine antagonist
that may be used to reverse marked benzodiazepine-induced
respiratory depression
c) Neuromuscular Blocking Agents – for facilitating endotracheal intubation
and provides total relaxation of skeletal muscles
▪ Succinylcholine (Quelicin)
d) Antiemetics – given for nausea and vomiting associated with anesthesia
(given prn)

c. Possible complications of general anesthesia:

i. Anaphylactic Reactions
 ii.Decreased GI and renal function
iii.Disturbed metabolic activities
iv. Convulsion
v. Lip, teeth and tongue injuries and vocal cord damage during intubation
vi. Severe respiratory and circulatory problems resulting from overdose of anesthetic
agents
vii. MALIGNANT HYPERTHERMIA - most serious and potentially fatal complication
a) S/sx:
▪ Unexplained tachycardia (earliest and most consistent sign)
▪ Tachypnea
▪ Cyanosis/Skin mottling
▪ Rigidity
▪ Metabolic and respiratory acidosis
▪ Unstable blood pressure
▪ Increased temperature (can rise 1-2oC within 5 min and can reach
as high as 43oC) with profuse sweating
b) Known agents that trigger MH:
▪ Halothane
▪ Isoflurane
▪ D-tubocurarine
▪ Enflurane
▪ Succinylcholine
▪ Gallamine
c) Management:
▪ Stop administration immediately (inhalation)
▪ Administer 100% oxygen
▪ Cooling with icepacks/cooling blankets
▪ Lavage with iced saline
▪ Restore acid-base balance
▪ Rapid IV infusion of Dantrolene – provides skeletal muscle
relaxation and retards the biochemical actions that cause muscle
contractions
2. Regional – loss of sensation to a region of the body without the loss of consciousness when a
specific nerve or group of nerves is blocked with the administration of local anesthesia
a. Administered into or around a specific nerve or group of nerves.
b. INDICATIONS:
i. Biopsies
ii. Endoscopy and surgeries involving GIT and GUT
c. Types:
i. Peripheral Nerve Block – A local anesthetic is injected near a specific nerve or group
of nerves to block pain from the area of the body innervated by the nerve. (usu. for
surgical procedures on hands, arms, legs, feet or face.
ii. Intravenous Nerve Block/Bier Block
iii. Spinal Anesthesia – injection of a local anesthesia into CSF found in the sub-
arachnoid space (usually between L4 and L5)
a) Produces autonomic, sensory and motor blockade (lower abdomen, groin,
perineum, lower extremities)
iv. Epidural Anesthesia – injection of local anesthesia into the epidural space producing
autonomic, sensory and motor blockade.
3. Local – involves injection of local anesthetic directly into the surgical area to block pain
sensations on a limited part of the body.
a. INDICATIONS:
i. For patients who are less and anxious
ii. For many ambulatory surgeries and surgeries that are performed in a short time
iii. Surgeries that does not require unconsciousness or extreme muscle relaxation

Postoperative Nursing Management

Post Anesthetic Care
Nursing Responsibilities:
 a. Maintenance of pulmonary ventilation:
▪ Position the client to side lying or semi-prone position to prevent aspiration
▪ Oropharyngeal or nasopharyngeal airway:
❖ Is left in place following administration of general anesthetic until pharyngeal reflexes
have returned
❖ It is only removed as soon as the client begins to awaken and has regained the cough
and swallowing reflexes
▪ All clients should receive O2 at least until they are conscious and are able to take deep breaths
on command
▪ Shivering of the client must be avoided to prevent an increase in O2, and should be
administered until shivering has ceased

b. Maintenance of circulation:
▪ Most common cardiovascular complications:
i. Hypotension
Causes:
∞ Jarring the client during transport while moving client from the OR
to his bed
∞ Reaction to drug and anesthesia
∞ Loss of blood and other body fluids
∞ Cardiac arrhythmias and cardiac failure
∞ Inadequate ventilation
∞ Pain
ii. Cardiac arrhythmias
Causes: Hypoxemia, Hypercapnea
Interventions: O2 therapy, Drug administration: Lidocaine, Procainamide

c. Protection from injury and promotion of comfort

▪ Provide side rails
▪ Turning frequently and placed in good body alignment to prevent nerve damage from pressure
▪ Administration of narcotic analgesics to relieve incisional pain
▪ Post-operative dose usually reduced to half the dose the patient will be taking after fully
recovered from anesthesia

Dismissal of Client from Recovery Room: Modified Aldrete Score for Anesthesia Recovery Criteria

The Five Physiological Parameters:

a. Activity – able to move four extremities voluntarily on command
b. Respiration – able to breath effortlessly and deeply, and cough freely
c. Circulation – BP is (+ 20%) or (- 20%) of pre-anesthetic level
d. Consciousness – fully awake, oriented to time, place and person
e. Color – pink (lips), for blacks: tongue

AREA OF ASSESSMENT Point Score 1 hour 2 hours 3 hours

Muscle ▪ Ability to move all extremities 2

activity ▪ Ability to move 2 extremities
▪ Unable to control any extremity 1

Respiration ▪ Ability to breath deeply and cough 2

▪ Limited respiratory effort (dyspnea)
▪ No spontaneous effort 1

Circulation ▪ BP +/- 20% of pre-anesthetic level 2

▪ BP +/- 20%-40% of pre-anesthetic level
▪ BP +/- 50% pre-anesthetic level 1

0
Consciousness ▪ Fully awake 2
Level ▪ Arousable on calling
▪ Not responding 1

O2 Saturation ▪ Unable to maintain O2 sat >92% on room 2

air
▪ Needs O2 inhalation to maintain O2 sat 1
>90%
▪ O2 sat <90% even with O2 supplement 0

Total Points

Required for discharge from PACU: 7-8

Postoperative Care
❑ Begins when the client returns from the recovery room or surgical suite to the nursing unit and ends
when the client is discharged
❑ It is directed toward prevention of complication and post-operative discomfort

Post-Operative Complications
a. Respiratory Complications: atelectasis and pneumonia
▪ Suspected whenever there is a sudden rise of temperature 24-48 hours after surgery
▪ Collapse of the alveoli is highly susceptible to infection: pneumonia
▪ Occurs usually in high abdominal surgery when prolonged inhalation anesthesia has been
necessary and vomiting has occurred during the operation or while the patient is recovered
from anesthesia
NURSING MANAGEMENT:
i. Measures to prevent pooling of secretions:
▪ Frequent changing of position
▪ High fowler’s position
▪ Moving out of bed
ii. Measures to liquefy and remove secretions:
▪ Increase oral fluid intake
▪ Breathing moist air
▪ Deep breathing followed by coughing
▪ Administer analgesics before coughing is attempted after thoracic and
abdominal surgery
▪ Splint operative area with draw sheet or towel to promote comfort while
coughing

iii. Other measures to increase pulmonary ventilation

▪ Blow bottle exercise
▪ Rebreathing tubes: increase CO2 stimulates the respiratory center to increase
the depth of breathing thus increasing the amount of inspired air
▪ IPPB: intermittent positive pressure breathing apparatus

b. Circulatory Complication: venous stasis

▪ Causes of venous stasis
− Muscular inactivity
− Respiratory and circulatory depression
− Increased pressure on blood vessels due to tight dressing
− Intestinal distention
− Prolonged maintenance of sitting
▪ Contributing factors for venous stasis:
• Obesity
• CV disease
• Debility
• Malnutrition
• Old age
▪ Most common circulatory complications:
▪ Phlebothrombosis
 ▪ Thrombophlebitis
NURSING MANAGEMENT:
▪ Limbs must never be massaged for a post-op client
▪ If possible, client should lie on his abdomen for 30 min several time a day to
prevent pooling of blood in the pelvic cavity
▪ Do not allow the client to stand unless pulse has returned close to baseline to
prevent orthostatic hypotension
▪ Wear elastic bandages or stockings when in bed and when walking for the first
time.

c. Fluids and Electrolytes Imbalance:

Causes:
▪ Blood loss
▪ Increased insensible fluid loss through the skin;
− After surgery through vomiting, from copious wound drainage, and
from the tube drainage as in NGT
▪ Since surgery is a stressor, there is an increased production of ADH for the first
12-24 hours following surgery resulting to fluid retention by the kidney
− The potential for over hydration therefore exists since fluids being given
IV may exceed fluid output by the kidney
Electrolyte Imbalance:
▪ Particularly Na and K imbalance as a result of blood loss
▪ Stress of surgery increases adrenal hormonal activity resulting to increased
aldosterone and glucocorticoids, resulting in sodium reabsorption by the kidney
▪ And as Na is reabsorbed, K coming from tissue breakdown is excreted
Action: IV of D5W alternate with D5NSS or half strength NSS to prevent Na excess

d. Complications of Surgery
i. GIT complications:
Paralytic ileus: Cessation of peristalsis due to excessive handling of GI organs
NURSING MANAGEMENT:
NPO until peristalsis has returned as evidenced by auscultation of bowel sounds or by passing out of
flatus

Vomiting: usually the effect of certain anesthetics on the stomach, or eating food or drinking water
before peristalsis returns. Psychologic factors also contribute to vomiting
NURSING MANAGEMENT:
▪ Position the client on the side to prevent aspiration
▪ When vomiting has subsided, give ice chips, sips of ginger ale or hot tea, or eating small
frequent amounts of dry foods thus relieving nausea
▪ Administer anti-emetic drugs as ordered: Trimethobenzamide Hcl (Tigan);
Prochlorperazine dimaleate (Compazine)

Abdominal distention: results from the accumulation of non-absorbable gas in the intestine
Causes:
▪ Reaction to the handling of the bowel during surgery
▪ Swallowing of air during recovery from anesthesia
▪ Passage of gases from the blood stream to the atonic portion of the bowel

Gas pains: results from contraction of the unaffected portion of the bowel in order to move
accumulated gas in the intestinal tract
Management:
▪ Aspiration of fluid or gas: with the insertion of an NGT
▪ Ambulation: stimulates the return of peristalsis and the expulsion of flatus
▪ Enema
− Rectal tube insertion: inserted just passed the anal sphincter and removal after
approximately 20 minutes
− Adult: 2-4 inches, children: 1-3 inches
− Prolonged stimulation of the anal sphincter may cause loss of
neuromuscular response, and pressure necrosis of the mucous
surface
 Constipation: due to decreased food intake and inactivity
▪ Regular bowel movement will return 3-4 days after surgery when resumption of regular
diet and adequate fluid intake and ambulation

ii. GUT Complications

▪ Return of urinary function: usually after 6-8 hours
− First voiding may not be more than 200 ml, and total output may not be more
than 1500ml
− Due to the loss of fluids during surgery, perspiration, hyperventilation, vomiting,
and increased secretion of ADH

Complication: urinary retention

Causes:
▪ Prolonged recumbent position
▪ Nervous tension
▪ Effect of anesthetics interfering with bladder sensation and the ability
to void
▪ Use of narcotics that reduce the sensation of bladder distention
▪ Pain at the surgical site and on movement
▪ Urinary tract infection
Management:
− Instruct the client to empty the bladder completely during voiding
− Catheterize if needed, done by sterile technique

f. Post-operative Discomforts
i. Post-operative pain
ii. Narcotics can be given every 3-4 hours during the first 48 hours post-operatively for severe pain
without danger of addiction

i.Singultus
▪ Brought about by the distention of the stomach, irritation of the diaphragm, peritonitis
and uremia causing a reflex or stimulation of the phrenic nerve
Management:
− Paper bag blowing; CO2 inhalation: 5% CO2 and 95% O2 x 5 minutes
every hour
g. Wound Complications:
▪ Sutures are usually removed about 5th-7th day post-op with the exception of wire retention
sutures placed deep in the muscles and removed 14-21 days after surgery
▪ Hemorrhage from the wound
▪ Most likely to occur within the first 48 hours post-op or as late as 6th-7th post-op day
Causes:
▪ Hemorrhage occurring soon after operation: mechanical dislodging of a blood
clot or caused by the reestablished blood flow through the vessel
▪ Hemorrhage after few days: Sloughing off of blood clot or of a tissue
▪ Infection
Assessment:
▪ Bright red blood
▪ Decreased BP
▪ Increased PR and RR
▪ Restlessness
▪ Pallor
▪ Weakness
▪ Cold, moist skin

iii. Infection
▪ Cause: streptococcus and staphylococcus
▪ Assessment: 3-6 days after surgery, low grade fever, and the wound becomes painful
and swollen. There may be purulent drainage on the dressing
 i. Dehiscence and Evisceration
Dehiscence or wound disruption: Refers to a partial-to-complete separation of the wound edges
Evisceration: Refers to protrusion of the abdominal viscera through the incision and onto the abdominal
wall
Assessment:
▪ Complain of a “giving” sensation in the incision
▪ Sudden, profuse leakage of fluid from the incision
▪ The dressing is saturated with clear, pink drainage
Management:
▪ Position the client to low Fowler’s position
▪ Instruct the client not to cough, sneeze, eat or drink, and remain quiet until the
surgeon arrives
▪ Protruding viscera should be covered warm, sterile, saline dressing

Discharge Instructions:
❑ Early discharge, which has become common, typically increases client teaching needs

❑ Be sure to provide information about wound care, activity restrictions, dietary management,
medication administration, symptoms to report, and follow-up care
❑ A client recovering from same-day surgery in an outpatient surgical unit must be in stable
condition before discharge
❑ This client must not drive home, make sure a responsible adult takes the client home