Adult Care Nursing I / Theory

Faculty of Nursing
First Semester
2021-2022

Lecture 4
Perioperative Concepts
Intra & post operative
Nursing Management
Members of the Surgical Team & Roles
Patient
– The intraoperative patient is susceptible to injury because
of loss of the sense of pain, reflexes, and the ability to
communicate. Thus, the OR nurse is the patient’s advocate
while surgery proceed.
– As advocates, intraoperative nurses monitor factors that
have the potential to cause injury, such as patient position,
equipment malfunction, and environmental hazards.
– Nurses also protect the patient’s dignity, privacy, rights
and interests while the patient is under anesthesia.
Members of the Surgical Team & Roles
Anesthesiologist

Assesses the patient before surgery, selects the anesthesia,

administers it, intubates the patient if necessary, manages
any technical problems related to the administration of the
anesthetic agent, and supervises the patient’s condition
throughout the surgical procedure.
Surgeon
 Performs the surgical procedure, heads the surgical
team.
Circulating Nurse (circulator)
A qualified registered nurse, works in collaboration with surgeons,
anesthesia providers, and other health care providers to plan the best
course of action for each patient
Members of the Surgical Team & Roles
Circulating Nurse (circulator)
 Manages the OR and protects the patient’s safety and health
by monitoring the activities of the surgical team, checking the
OR conditions, and continually assessing the patient for signs
of injury and implementing appropriate interventions. For
example:
I. Verifying consent
II. Planning for and assisting with patient positioning,
preparing the site for surgery, managing surgical
specimens, anticipating the needs of the surgical team.
III.Documenting intraoperative events
IV. Ensures cleanliness, proper temperature, humidity,
appropriate lighting, safe function of equipment, and the
availability of supplies and materials.
V. Monitors aseptic practices
VI. Implementing fire safety precautions
Members of the Surgical Team & Roles

Scrub Role
 Performing hand hygiene; setting up and preparing the sterile
equipment and supplies, tables and sterile field; preparing sutures,
ligatures.

 As the surgical incision is closed, the scrub person and the

circulating nurse count all needles, sponges, and instruments to be
sure that they are accounted for and not retained as a foreign body in
the patient
 Surgical Environment

• The surgical suite is behind double doors, and Unnecessary

personnel and physical movement may be restricted to
minimize risk of infection.
• Precautions include adherence to principles of surgical
asepsis; decreasing noise.
• The OR has special air filtration devices to screen out
contaminating particles, dust, and pollutants
• Room temperature between 20 to 24 0C (68°F to 73°F),
humidity between 30% and 60%.
• To help decrease microbes, the surgical area is divided into
three zones.
1. Unrestricted zone: area in the operating room that
interfaces with other departments; includes patient
reception area and holding area. (Street clothes are
allowed)
 Surgical Environment

2. Semirestricted zone: area in the operating room where

scrub attire is required; may include areas where surgical
instruments are processed. (Scrub clothes and caps are
worn)
3. Restricted zone: area in the operating room where scrub
attire and surgical masks are required; includes operating
room and sterile core areas. (where scrub clothes, shoe
covers, caps, and masks are worn. Masks are worn at all
times).
Surgical Environment/ Principles of
Surgical Asepsis
• Surgical Asepsis: Absence of microorganisms in
the surgical environment to reduce the risk of
infection and prevents the contamination of surgical
wounds.
 All equipment that comes into direct contact with the
patient must be sterilized before their use.
 All materials in contact with the surgical wound or
used within the sterile field must be sterile.
 Gowns of the surgical team are considered sterile in
front from the chest to the level of the sterile field.
The sleeves are also considered sterile from 2 in
above the elbow to the stockinette cuff.
 Sterile areas must be kept in view during movement
around the area.
Surgical Environment/ Principles of
Surgical Asepsis

 Sterile drapes are used to create a sterile field. Only

the top surface of a draped table is considered sterile.
 After a sterile package is opened, the edges are
considered unsterile.
 Sterile items, including solutions, are dispensed to a
sterile field by methods that preserve their sterility and
the integrity of the sterile field.
 Items of doubtful sterility are considered unsterile.
 Sterile fields are prepared as close as possible to the
time of use.
Surgical Environment/ Principles of
Surgical Asepsis

Figure 18-2: Proper draping exposes only the surgical site,

which decreases the risk of infection
Surgical Environment/ Principles of
Surgical Asepsis

 The movements of the surgical team are from sterile to

sterile areas and from unsterile to unsterile areas.
 Scrubbed people and sterile items contact only sterile
areas; circulating nurses and unsterile items contact
only unsterile areas.
 Movement around a sterile field must not cause
contamination of the field.
 At least a 1-ft distance from the sterile field must be
maintained to prevent inadvertent contamination.
 Whenever a sterile barrier is breached, the area must
be considered contaminated.
Types of Anesthesia
General Anesthesia
– Is a state of narcosis (severe CNS depression produced
by pharmacologic agents) which leads to
unconsciousness, analgesia, muscle relaxation, and
reflex loss.
– Patients lose the ability to maintain ventilatory
function, require assistance in maintaining a patent
airway and their cardiovascular function may be
impaired
– When possible, the anesthesia induction (initiation)
begins with IV anesthesia and is then maintained at the
desired stage by inhalation methods
Types of Anesthesia
Regional Anesthesia
– An anesthetic agent is injected around nerves so that
the region supplied by these nerves is anesthetized
– The patient is awake and aware of their surroundings
unless medications are given to produce mild sedation
or to relieve anxiety (thus avoid careless conversation
& noise to prevent negative surgical experience).
– Includes epidural anesthesia, spinal anesthesia &local
conduction blocks
– Epidural Anesthesia: Achieved by injecting a local
anesthetic agent into the epidural space. An advantage
is the absence of headache. A disadvantage is the
greater technical challenge (puncturing the dura may
cause cardiac & resp. depression [managed by airway
support, IV fluids, and the use of vasopressors])
 Types of Anesthesia
Regional Anesthesia (cont.)
– Spinal Anesthesia:
• Achieved by injecting a local anesthetic agent into the
subarachnoid space at the lumbar level (usually
between L4 and L5).
• It produces anesthesia of the lower extremities,
perineum, and lower abdomen.
• A disadvantage is headache which is linked with the
spinal needle size, leakage of CSF from the
subarachnoid space through the puncture site, and the
patient’s hydration status. (measures to decrease
headache: maintaining a quiet environment, keeping
the patient lying flat, and hydration).
– Local Conduction Blocks (nerve blocks):
• E.g., Brachial plexus block, which produces anesthesia
of the arm
 Types of Anesthesia
Local anesthesia
– Is the injection of the anesthetic agent into the tissues at
the planned incision site.
– It is ideal for short and minor surgical procedures.
– Advantages: simple, economical, need of equipment is
minimal, & brief postoperative recovery.
– A contraindication is high preoperative levels of anxiety.
– Impractical for some surgical procedures ((e.g., breast
reconstruction) because of the number of injections and
the high amount of anesthetic medication that would be
required (toxic).
Types of anesthesia
 Intraoperative Complications
Anesthesia awareness (rare)
Infection:
Nausea, vomiting: Turn pt to
side, suction, antiemetics • Follow aseptic
(aspiration causes bronchial technique for
spasm) prevention

Anaphylaxis:
• severe allergic reaction in Hypoxia, & respiratory.
response to medications, latex, or Depression:
others.
– May occur sec. to
• S&S: diffuse erythema, anesthesia, position
bronchospasm, dysrhythmias, on OR table. Thus
and hypotension. monitor the pt.
closely for S&S
• Management: DC the causative
agent, medications & fluids to
restore vascular tone, CPR.
 Intraoperative Complications

Malignant hyperthermia: Hypothermia:

 a rare (inherited), life
threatening hypermetabolic • Core body temp. < 36.6.
condition • Occurs Sec. to OR
 Can be induced by anesthetic environment, IV fluids,
agents. vasodilation, exposed
body. May lead to M.
 Symptoms: increase body acidosis.
temp (late sign) by 1°C to
2°C every 5 minutes (core • Management: Gradual
temperature can exceed rewarming by removal of
42°C), generalized muscle
wet gowns and drapes,
rigidity, tachycardia,
hypotension, oliguria, & use of thermal blankets,
hypercapnia, cardiac arrest. warming Iv fluids, reset
OR temp.
 Management: early
recognition of symptoms, DC
anesthesia promptly
 Nursing Process: Interventions
• Reducing anxiety
– E.g., the circulating nurse may assist to
decrease anxiety during induction by using
guided imagery, talking about the patient’s
favorite place in a soft voice and using eye
contact
• Reducing latex exposure
– Early identification of latex allergy, reporting
patient’s allergy to other health care providers.
(in most ORs, there are few latex items currently
in use but hospital materials managers need to
take responsibility for identifying the latex
content in items used by patients and health
care personnel)
 Nursing Process: Interventions

• Preventing injuries and maintaining safety

– Place the patient in comfortable and proper a position.
(Many surgical procedures require awkward anatomical for
prolonged time which compress arteries, press on nerves
and bony prominences, & impede respiration)

– Using safety straps and side rails and not leaving the
sedated patient unattended. Extra cautions for older
adults, thin or obese patients, and anyone with a
physical deformity.
– Verifying and information and checking the medical
record for completeness (e.g. patient identification,
allergies, correct informed consent, health history,
results of Dx tests)
Nursing Process: Interventions
– Safe blood, fluid, & medication administration
– Set up the OR environment (room temperature
and humidity, humidity, equipment in working
order[e.g. suction])
– Maintaining surgical asepsis
• Monitoring, managing potential complications
• Serving as patient advocate
– Minimizing the clinical, dehumanizing aspects of
being a surgical patient by making sure that the
patient is treated as a person, respecting cultural
and spiritual values, providing physical privacy, and
maintaining confidentiality
Phase three: Postoperative Nursing
Management
 Postoperative phase

• The postoperative period extends from the time the

patient leaves the OR until the last follow-up visit with the
surgeon.
• May be as short as a day or two or as long as several
months
• Nursing care in this phase focuses on reestablishing the
patient’s physiologic equilibrium, alleviating pain,
preventing complications, and educating the patient about
self-care
 Postanesthesia Care Unit (Recovery)

• Post anesthesia care unit or recovery room is located

adjacent to the OR.
• Transferring the postoperative patient from the OR to
PACU is the responsibility of the anesthesiologist
• The anesthesiologist remains at the head of streacher (to
maintain the airway), surgical team member remains at
the opposite end (give attention to surgical incision site,
drainage tubes.
• Transporting the patient involves special consideration of
the incision site, potential vascular changes (orthostatic
hypotension may occur with quick position change). Raise
the side rails to prevent falls.
 Postanesthesia Care Unit (Recovery)

 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

 The nurse Provide care for patient until patient has

recovered from effects of anesthesia (resumption of
motor and sensory function, oriented, Stable VS, no
evidence of hemorrhage or other complications of
surgery)
 Nursing Management in PACU
Assessing the Patient
• Assess airway, respiratory function, cardiovascular
function, VS (Q 15 min), skin color, level of
consciousness, and ability to respond to commands
• Assess surgical site for drainage or hemorrhage. Makes
sure that all drainage tubes and monitoring lines are
connected and functioning.
• Verifyis that medications currently infused are at the
correct dosage and rate.
 Nursing Management in the PACU

Maintaining a Patent Airway

• Patients undergone prolonged anesthesia usually are
unconscious, with all muscles relaxed. (relaxation
extends to the muscles of the pharynx causing
hypopharyngeal obstruction)
• Signs of hypopharyngeal obstruction: choking; noisy
and irregular respirations; decreased oxygen
saturation, cyanosis of the skin.
• Head tilt a jaw positioning to open Airway
 Nursing Management in the PACU

Maintaining a Patent Airway

Use of oral Airway to maintain patient air way.

Do not remove oral airway until evidence of gag reflex returns.
 Nursing Management in the PACU

Maintaining a Patent Airway

• Keep head of bed elevated 15 to 30 degrees unless
contraindicated
• Pt may require suctioning, If vomiting occurs, turn
patient to side
– Caution is necessary in suctioning the throat of a
patient who has had a tonsillectomy or other
oral or laryngeal surgery because of the risk of
bleeding and discomfort.
 Nursing Management in the PACU

Maintaining Cardiovascular Stability

• Assess vital signs; cardiac rhythm; skin

temperature, color, moisture; and urine output.

• Assesse the patency of all IV lines.

• The primary cardiovascular complications in the

PACU: hypotension and shock, hemorrhage,
hypertension, and dysrhythmias.
 Nursing Management in the PACU

Maintaining Cardiovascular Stability/

hypotension and shock
• Causes: blood loss, hypoventilation, position
changes, pooling of blood in the extremities, or side
effects of medications and anesthetics.
• Signs: pallor, cool & moist skin, rapid respirations,
cyanosis, rapid, weak pulse, low BP, concentrated
urine.
• Prevention & management: administration of IV
fluids (Ringer solution, 0.9% sodium chloride
solution, colloids), blood products, and medications
to elevate BP.
 Nursing Management in the PACU
Maintaining Cardiovascular Stability/
Hemorrhage
• Signs: low BP, rapid, thready pulse; disorientation;
restlessness; oliguria; and cold, pale skin, drop in
hemoglobin & HCT levels, shock and death
• If the amount of blood loss exceeds 500 mL (especially if
the loss is rapid), replacement is usually indicated
• If bleeding is evident, a sterile gauze pad and a pressure
dressing are applied, and the site of the bleeding is
elevated to heart level if possible. 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.
 Nursing Management in the PACU
Maintaining Cardiovascular Stability/
Hypertension and Dysrhythmias
Causes: Hypertension Rt SNS stimulation from pain,
bladder distension & hypoxia. Dysrhythmias Rt
electrolyte imbalance, altered respiratory function,
pain, hypothermia, stress, and anesthetic agents.
Management: treating the underlying causes.

Relieving Pain and Anxiety

Assess patient comfort, Control of environment (
quiet, low lights, noise level), Administer analgesics as
indicated; usually short-acting opioids by IV route
• Family visit , dealing with family anxiety
 Nursing Management in the PACU

Controlling Nausea and Vomiting

• Intervene at first indication of nausea, medications,

deep breathing.

•
 Nursing Management in the PACU

Determining Readiness for PACU

Discharge

• Patient remains in the PACU until fully recovered

from the anesthetic agent. (Indicators of recovery:
stable BP, adequate respiratory function, and
adequate oxygen saturation level compared with
baseline.
Preparing the Postoperative Patient for
Direct Discharge From PACU

• Provide written, verbal instructions regarding follow-up

care, complications, wound care, activity, medications,
diet
• Give prescriptions, phone numbers
• Discuss actions to take if complications occur
• Give instructions to patient, responsible adult who will
accompany patient
• Patients are not to drive home or be discharge to home
alone as Sedation & anesthesia may cloud memory,
judgment
 Nursing Management in the surgical Unit

• Goals: continuing to help patient recover from anesthesia by

frequent assessment of physiologic status, monitoring for
complications, managing pain, and helping pt achieve
independence with self-care.
• The pulse rate, blood pressure, and respiration rate are
recorded at least every 15 minutes for the first hour and every
30 minutes for the next 2 hours. Thereafter, they are
measured less frequently if they remain stable
• Managing ventilation: observe for airway patency & quality
of respirations, pulse oximetry, breath sounds. Encourage
deep breathing and coughing exercises, and incentive
spirometry. (note; coughing is contraindicated in patients who
have head injuries (elevates ICP), undergone eye surgery
(elevates IOP) or plastic surgery (increase tension on delicate
tissues).
 Nursing Care of the Postoperative pt in the
Surgical Unit
• Promoting CO:
– Assess for signs of hemorrhage and shock, I & O,
fluid and electrolyte balance
– IV fluid replacement may be prescribed for up to 24
hours after surgery or until the patient is stable and
tolerating oral fluids (avoid hypervolemia).
– Report oliguria (hourly outputs should not be < 0.5
mL/kg/h).
– Leg exercises and frequent position changes
stimulate circulation (Venous stasis from
dehydration, immobility, and pressure on leg veins
during surgery put the patient at risk for VTE )
• Assessing and managing pain (assess pain & consider
pharmacologic & non pharmacologic measures)
 Nursing Care of the Postoperative pt in the
Surgical Unit
• Encouraging activity (ambulation, bed exercises)
– Ambulation reduces postoperative complications (e.g.,
atelectasis, pneumonia, GI distention, thromboembolic
events)
– Postoperative activity orders are checked before the
patient is assisted to get out of bed
– Pt may develop orthostatic hypotension When getting
out of bed time (S & S: a decrease of 20 mm Hg in SPB
or decrease of 10 mm Hg in DPB, dizziness, and fainting)
– Bed exercises (exercises for Arm, Hand and finger, Foot,
Leg). One way to increase the patient’s activity is to
performing as much routine hygiene care as possible!
 Nursing Care of the Postoperative pt in the
Surgical Unit
• Wound Healing and dressing changing.
• Nursing interventions affect wound healing (nutrition, glycemic
control, cleanliness, rest, and position).

• Dressing helps in healing, absorbing drainage, splinting or

immobilizing the wound, promoting physical & mental comfort

– Note; first dressing is usually done by the surgeon

• Ongoing assessment of the surgical site (immediately report any

signs of infection: redness, marked swelling, tenderness; or
increased warmth around wound, red streaks in skin near wound,
pus or discharge, foul odor, chills or temperature > 37.7°C).

• Follow correct dressing procedure and consider time and privacy

 Nursing Care of the Postoperative pt in the
Surgical Unit
• Caring for Surgical Drains
– Drains allow the escape of fluids that could otherwise
serve as a culture medium for bacteria.
– Assess the amount of bloody drainage on the surgical
dressing. Excessive amounts of drainage should be
reported.
 Spots of drainage on the dressings are outlined with a pen,
and the date and time of the outline are recorded on the
dressing for monitoring

• .
 Nursing Care of the Postoperative pt in
the Surgical Unit
• Managing GI function and resuming nutrition

– Pt may have NG in place (due to the nature of surgery)

– Pt may develop hiccups (rt intermittent spasms of the

diaphragm secondary to irritation of the phrenic nerve
[e.g., by a distended abdomen, or uremia).

• Persistent hiccups may cause vomiting, exhaustion, and

wound dehiscence, should be reported

– Pt may develop distention (sec. to gas accumulation, loss

of normal peristalsis, manipulation of the abdominal organs
during surgery), prevented by exercise, ambulation
 Nursing Care of the Postoperative pt in
the Surgical Unit
• Managing GI function and resuming nutrition

– Once nausea subsided and the patient is fully awake, the

sooner he/ she can tolerate a usual diet.

– The return to normal dietary intake should proceed at a

pace set by the patient (Clear liquids, soft foods [e.g,
gelatin, custard] then solid food). Bowel sounds are
documented so that diet progression can occur.

– Constipation may occur sec to decreased mobility,

decreased oral intake, and opioid analgesic medications.
Early ambulation, improved dietary intake, and a stool
softener (if prescribed) promote bowel elimination
 Nursing Care of the Postoperative pt in
the Surgical Unit
• Assessing and managing voluntary voiding
 Urinary retention can occur because of anesthesia, pain
(secondary to abdominal, pelvic or hip surgery), difficult to use
the bedpan or urinal in the recumbent position
 Assess bladder distention, encourage the patient to void (e.g.,
letting water run, applying heat to the perineum, warm
bedpan, use a commode or a toilet)
 If the patient has not voided within the specified time frame,
an ultrasound bladder scan is performed to check for urinary
retention. The patient is catheterized. straight intermittent
catheterization is preferred over indwelling catheterization
because the risk of infection
 Intermittent catheterization may be prescribed every 4 to 6
hours until the patient can void spontaneously and the
postvoid residual is less than 50 mL.
 Nursing Care of the Postoperative pt in
the Surgical Unit
• Maintaining a safe environment

• Three side rails up, bed in the low position, wearing assistive
devices as needed (e.g., eyeglasses, hearing aid). All objects the
patient may need should be within reach (e.g. call light). The
patient is instructed to ask for assistance with any activity.

• Providing emotional support

Providing reassurance and information (hospital routines and what

to expect , purpose of nursing assessments and interventions),
acknowledging family members’ concerns and accepting and
encouraging their participation in the patient’s care
 Expected patient outcomes

• Maintains optimal respiratory function

• Indicates that pain is decreased in intensity
• Increases activity as prescribed
• Wound heals without complication
• Maintains body temperature within normal limits
• Resumes oral intake, Reports resumption of usual bowel
elimination pattern
• Resumes usual voiding pattern
• Is free of injury, Exhibits decreased anxiety, Acquires
knowledge and skills necessary to manage regimen after
discharge, Experiences no complications