NCM112 LECTURE

MEDICAL-SURGICAL NURSING

PERIOPERATIVE MANAGEMENT
TOPIC OUTLINE: 3. PALLATIVE
 Surgeries to relieve or reduce intensity of an
ALCON, MARY GRACE illness.
AQUINO, JVY MARIE
 It is not curative.
AZUTEN, ZYZA-ZHOLEY
BALLESTA, ERIKA  Examples:
BORJA, RIVERT JAMES o Colostomy
CARTUJANO, DAZLYNE o Nerve root resection
CASTERAL, EILEITHIA CHYAVANNA 4. RECONSTRUCTIVE
CORPUZ, MARK ANTHONY  Surgeries to restore function to traumatized or
DERY, JOHN BRYAN malfunctioning tissue or to improve self concept.
 Examples:
o Scar revision
I. PREOEPERATIVE/PERIANESTHESIA
o Plastic surgery
NURSING MANAGEMENT
o Internal fixation of a fracture
A. Surgical Classifications According to:
- Purpose/Reason o Breast reconstruction
- Urgency 5. TRANSPLANTATION
- Degree of Risk  Surgeries to replace organs or structures that are
- Extent diseased or malfunctioning.
B. Preparations for Surgery  Examples:
- Preoperative Assessment o Kidney, liver, and heart transplant.
- Informed Consent 6. CONSTRUCTIVE
- Preoperative Teachings
- Preoperative Medications  Surgeries to restore function in congenital
- Preoperative Checklist anomalies.
 Examples:
II. INTRAOPERATIVE NURSING o Cleft li repair
MANAGEMENT o Closure of atrial septal defect
A. The surgical team and their roles
B. The surgical environment URGENCY
C. Different surgical positions
D. Types of anesthesia 1. Elective Urgency
E. Potential intraoperative complications 2. Urgent Surgery
3. Emergency Surgery
III. POSTOPERATIVE NURSING
MANAGEMENT ELECTIVE URGENCY
A. Phases of postanesthesia care  It is a procedure that is pre-planned and based on
B. Postoperative complications the patients’ choice and availability of scheduling for
C. Postoperative pain management
the patient, surgeon, and the facility.
- Types of analgesics
- Other pain relief measures  Delay surgeon has no ill effects.
D. Kinds/Care of Drains  Examples:
o Hernia repair
o Cataract extraction
o Tonsillectomy
o Hip prosthesis
I. PREOPERATIVE/PERIANESTHESIA
NURSING MANAGEMENT URGENT SURGERY
 Must be done with in a reasonably short-time frame
A. SURGICAL CLASSIFICATIONS ACCORDING TO:
to preserve health.
PURPOSE/REASON  Usually done within 24 - 48 hours.
 Examples:
1. DIAGNOSTIC o Removal of gall bladder
 Surgeries to make or confirm a diagnosis. o Amputation
 Examples: o Appendectomy
o Biopsy
o Bronchoscopy EMERGENCY SURGERY
o Endoscopy  Must be done immediately to preserve life, a body
2. ABLATIVE part or function.
 Surgeries to remove a diseased body part.  Examples:
 Examples: o Control of hemorrhage
o Appendectomy o Repair of trauma, perforated
ulcers, intestinal obstruction.

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PERIOPERATIVE MANAGEMENT
DEGREE OF RISK
MAJOR SURGERY
 It involves a high degree of risk, for a variety of
reasons: It may be complicated or prolonged, large
losses of blood may occur, vital organs may be
involved, or postoperative complications may be
likely.
o Examples – organ transplant, open heart
surgery, removal of kidney, cesarean
section, joint replacement, full
hysterectomy, and bariatric surgeries,
including the gastric bypass.
MINOR SURGERY
 It involves little risk, produces few complications, and
is often performed in a “day surgery”.
o Example – breast biopsy, removal of
tonsils, knee surgery, cataract surgery,
dental restorations, circumcision, breast
biopsy, arthroscopy, laparoscopy, burn
excision, and debridement procedures
The degree of risk involved in a surgical procedure is
affected by the client’s age, general health, nutritional
status, use of medications, and mental status.
AGE
 Very young and elder clients are greater surgical
risks than children and adults.
 The physiologic response of an infant to surgery is
substantially different from an adult’s.
 The blood volume in an infant is small, and its fluid
reserves limited.
 The older adult often has fewer physiologic reserves
to meet the extra demands caused by surgery.
 The older adult may be poorly nourished, which can
impair healing.
GENERAL HEALTH
 Surgery is least risky when the client’s general health
is good.
 Common health problems that increase surgical risk
and may lead to the decision to postpone or cancel
surgery are malnutrition, cardiac conditions, blood
coagulation disorders, renal diseases, diabetes
mellitus, liver diseases, etc.
NUTRITIONAL STATUS
 Adequate nutrition is required for normal tissue
repair.
 Obesity contributes to postoperative complications
such as pneumonia, wound infection and wound
separation.
 Obese and underweight client are vulnerable to
pressure ulcer formation due to positioning required
for surgery.
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 A malnourished client is at risk for delayed wound
healing, wound infection and fluid and electrolyte
alterations.
MEDICATIONS
 The following medication can increase surgical risk:
 Anticoagulants increase blood coagulation time.
 Tranquilizers may interact with anesthetics,
increasing the risk of respiratory depression.
 Corticosteroids may interfere with wound healing and
increase the risk of infection.
 Diuretics may affect fluid and electrolyte balance.
MENTAL STATUS
 Clients with dementia may have difficulty
understanding proposed surgical procedures and
may respond unpredictably to anaesthetics.
 Extreme anxiety also increases surgical risk and
interferes with the client’s ability to process
information and respond appropriately to
instructions.
EXTENT
SIMPLE SURGERY
 Any surgeries that do not break past the surface
tissue or require a period of extended recovery
o Examples: laparoscopy, biopsy,
sutures.
RADICAL SURGERY
 also called radical dissection, is surgery that is more
extensive than "conservative" surgery.
 A surgery intended to remove both a tumor and any
metastases thereof, for diagnostic and/or treatment
purposes.
 It is opposed to for example palliative surgery which
is intended for symptom relief rather than complete
removal of cancer tissue
o Examples: radical prostatectomy,
pelvic lymph node dissection, and
transurethral resection of the
prostate.
MINIMALLY INVASIVE
 Surgery that is done using small incisions (cuts) and
few stitches.
 During minimally invasive surgery, one or more
small incisions may be made in the body.
TYPES OF MINIMALLY INVASIVE SURGERY
 ADVANCED LAPAROSCOPIC SURGERY
o The surgeon makes one or more small
incisions in the abdomen. Laparoscopic
procedures only require incisions that are ¼
to ½ inch long.
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o The surgeon inserts an instrument called a
laparoscope as well as other small, thin
surgical instruments through the incisions.
The laparoscope has a camera on it that
sends images to a monitor so the doctor
can visualize the surgical site.
o The procedure can also be
performed to: hysterectomy,
ladder support surgery,
yomectomy (fibroid removal),
gallbladder removal, astric bypass
or gastric sleeve surgery,
appendectomy, and hernia repair.
 VIDEO-ASSISTED THORACOSCOPIC SURGERY
(VATS)
 VATS is a type of minimally invasive
surgery that is used to diagnose and treat
conditions in the chest.
 During the procedure, an instrument called
a thoracoscope that has a tiny camera on it
is inserted into the chest through one or
more small incisions in the chest wall.
o The procedure can also be
performed to: biopsies to diagnose
lung cancer, mesothelioma, and
other chest cancers, lung surgery,
procedures to remove fluid or air
from around the lungs, surgery to
treat esophageal disorders, and
hiatal hernia repair.
 HYSTEROSCOPIC SURGERY
 Hysteroscopic surgery is a type of minimally
invasive surgery in which an instrument
called a hysteroscope is inserted through
the cervix into the uterus.
 During a hysteroscopic procedure, the
doctor can inspect the uterine cavity for
abnormalities such as fibroids or polyps.
They can also check the openings of the
fallopian tubes.
o The procedure can also be
performed to: biopsy the
endometrial lining, remove
endometrial or cervical polyps,
remove fibroids, open the fallopian
tubes, endometrial ablation, and
remove intrauterine scarring.
 VAGINAL SURGERY
 Vaginal access minimally invasive surgery
(VAMIS) is a type of minimally invasive
surgery that can be used for major
gynecologic surgery such as a
hysterectomy.
 This surgery requires no abdominal
incisions and has a lower risk of
complications than abdominal procedures.
o It is used to perform:
hysterectomy, uterine fibroid
debulking, pelvic mass removal,
BSN 3A | PBL GROUP 1
and procedures to treat
endometriosis.
 ROBOTIC SURGERY
 Robotic surgery is similar to laparoscopic
surgery and other types of minimally
invasive surgery because it uses small
incisions, a camera, and small surgical
instruments. However, robotic surgery is
more advanced and uses cameras that can
create a 3D color picture with 10x
magnification.
 Robotic surgery allows doctors to perform
many types of complex surgery with more
precision, control, and flexibility than other
methods.
o Examples: coronary artery
bypass, cutting away cancer
tissue from sensitive parts of the
body such as blood vessels,
nerves, or important body organs,
gallbladder removal, hip
replacement, and hysterectomy.
B. PREPARATIONS FOR SURGERY
PREOPERATIVE ASSESSMENT
 Preoperative assessment is a medical evaluation
that is conducted before a surgical procedure to
identify any co-morbidities that may lead to patient
complications during the surgery, anesthesia, or
post-operative period. The assessment usually
includes a history and physical examination focusing
on risk factors for cardiac, pulmonary, and infectious
complications. The goal of the preoperative
evaluation is to identify elements needed for
preoperative risk assessment and reduction. The
main goals of the preoperative evaluation are to
assess the patient's medical status and ability to
tolerate anesthesia for the planned procedure and
reduce perioperative morbidity and mortality. The
purpose of preoperative assessment is to identify
potential risks or complications associated with the
surgery and to develop a plan of care to optimize the
patient's outcome. Here are some of the essential
preoperative assessment components:
MEDICAL HISTORY
 Medical history is a crucial component of
preoperative assessment, as it provides valuable
information about the patient's overall health and any
underlying medical conditions that may impact the
surgery or anesthesia. Medical history includes
information about any past surgeries,
hospitalizations, allergies, and chronic medical
conditions such as diabetes, hypertension, or heart
disease. This information is important for the surgical
team to develop a plan of care that addresses the
patient's specific needs and minimizes any potential
risks or complications.
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PHYSICAL EXAMINATION
 The physical examination is another critical
component of the preoperative assessment, as it
helps to assess the patient's overall health,
identify any physical limitations or impairments
that may impact the surgery, and evaluate the
patient's vital signs, lung sounds, heart sounds,
and neurological function. The physical
examination is also an opportunity for the surgical
team to identify any potential surgical site infections
or skin issues that may need to be addressed prior
to the procedure.
LABORATORY TESTS
 Laboratory tests may be ordered to
evaluate the patient's blood count,
electrolyte levels, kidney and liver
function, and blood clotting ability.
These tests are important to identify any
potential risks or complications associated
with the surgery, such as bleeding disorders
or electrolyte imbalances. Depending on the
patient's medical history and the type of
surgery, other tests, such as a chest X-ray
or EKG, may also be ordered.
IMAGING STUDIES
 Imaging studies, such as X-rays, CT scans, or
MRIs, may be ordered to assess the area of the body
where the surgery will be performed. These studies
help to provide a detailed view of the surgical site and
can help the surgical team plan for the procedure and
identify any potential risks or complications.
MEDICATION REVIEW
 The patient's current medications should be
reviewed, including prescription medications,
over-the-counter medications, and herbal
supplements. Some medications may need to be
discontinued or adjusted prior to surgery, as they can
increase the risk of bleeding or interact with
anesthesia. It is important for patients to provide an
accurate list of all medications they are taking to
ensure that they receive safe and effective care.
ANESTHESIA ASSESSMENT
 The anesthesiologist will assess the patient's ability
to tolerate anesthesia and develop an anesthesia
plan based on the patient's medical history and
physical exam. This assessment is important to
ensure that the patient receives the appropriate type
and dosage of anesthesia and minimize the risk of
anesthesia-related complications.
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BASELINE FUNCTIONAL STATUS
 Patients should be assessed for their baseline
functional status to determine their ability to perform
daily activities following surgery and to plan for
postoperative care. This assessment helps the
surgical team plan for any necessary postoperative
physical therapy or rehabilitation and can also help
identify any potential issues related to the patient's
mobility or ability to care for themselves after
surgery.
BASELINE FUNCTIONAL STATUS
 Patients should be assessed for their baseline
functional status to determine their ability to perform
daily activities following surgery and to plan for
postoperative care. This assessment helps the
surgical team plan for any necessary postoperative
physical therapy or rehabilitation and can also help
identify any potential issues related to the patient's
mobility or ability to care for themselves after
surgery.
PSYCHOSOCIAL ASSESSMENT
 A psychosocial assessment may be performed to
identify any potential emotional or social factors that
may impact the patient's surgical outcome or
recovery. This assessment may include questions
about the patient's support system, coping
strategies, and mental health history, and can help
the surgical team develop a plan of care that
addresses the patient's emotional and social needs
as well as their medical needs.
INFORMED CONSENT
 Informed consent is the process in which a health
care provider educates a patient about the risks,
benefits, and alternatives of a given procedure or
intervention. The patient must be competent to make
a voluntary decision about whether to undergo the
procedure or intervention.
 Informed consent is both an ethical and legal
obligation of medical practitioners and originates
from the patient's right to direct what happens to their
body. Implicit in providing informed consent is an
assessment of the patient's understanding,
rendering an actual recommendation, and
documentation of the process.
 The Joint Commission requires documentation of all
the elements of informed consent "in a form,
progress notes or elsewhere in the record." The
following are the required elements for
documentation of the informed consent discussion:
(1) the nature of the procedure, (2) the risks and
benefits and the procedure, (3) reasonable
alternatives, (4) risks and benefits of alternatives,
and (5) assessment of the patient's
understanding of elements 1 through 4.
 Informed consent typically involves the following
components:
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o Disclosure: The person is provided with
information about the medical procedure,
including its purpose, potential risks and
benefits, and alternatives.
o Understanding: The person is given an
opportunity to ask questions and have the
information explained to them in a way that
they can understand.
o Voluntariness: The person is free to
decide whether or not to participate without
coercion or pressure.
o Capacity: The person must have the
capacity to make the decision, which
includes having the ability to understand the
information and appreciate the
consequences of the decision.
o Consent: The person must provide their
consent voluntarily, either through signing a
consent form or providing verbal consent.
WHY IS INFORMED CONSENT IMPORTANT?
 Consent codes and laws protect both caregivers and
care receivers. They help establish trust in your
caregiver while respecting your autonomy as a care
seeker. They help to prevent misunderstandings and
lapses in communication that could lead to you being
unhappy with the care that you receive. They make
sure that you understand what to expect, including
the chances of less-than-optimal outcomes.
MEDICAL PROCEDURES THAT REQUIRE INFORMED
CONSENT
 Treatment with high-risk medications, such as
opioids.
 Tests and medical interventions that go inside your
body, such as endoscopy.
 Childbirth interventions, such as forceps delivery or
episiotomy.
 Surgery.
NOTE: Overly detailed descriptions may increase anxiety in
 Biopsy.
some patients.
 Medical implants.
 Use of anesthesia.
 Use of radiation.
 Chemotherapy.
 Blood transfusions.
 Genetic testing.
 Clinical trials involving human research subjects
(including psychology research).
 Procedures involving medical students.
 Certain vaccines.
 Any transfer of your personal information.
EXCEPTIONS TO INFORMED CONSENT
 Several exceptions to the requirement for informed
consent include (1) the patient is incapacitated, (2)
life-threatening emergencies with inadequate
time to obtain consent, and (3) voluntary waived
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consent. If the patient's ability to make decisions is
questioned or unclear, an evaluation by a psychiatrist
to determine competency may be requested. A
situation may arise in which a patient cannot make
decisions independently but has not designated a
decision-maker. In this instance, the hierarchy of
decision-makers, which is determined by each
state's laws, must be sought to determine the next
legal surrogate decision-maker. If this is
unsuccessful, a legal guardian may need to be
appointed by the court.
CHILDREN AND INFORMED CONSENT
 Children (typically under 17) cannot provide informed
consent. As such, parents must permit treatments or
interventions. In this case, it is not termed "informed
consent" but "informed permission." An exception
to this rule is a legally emancipated child who may
provide informed consent for himself. Some, but not
all, examples of an emancipated minor include
minors who are (1) under 18 and married, (2)
serving in the military, (3) able to prove financial
independence or (4) mothers of children (married
or not). Legislation regarding minors and informed
consent is state based as well. It is important to
understand the state laws.
PREOPERATIVE TEACHINGS
 Initiated as soon as possible, and is individualized, with
consideration for any unique concerns or learning needs.
 Multiple education strategies should be used (verbal,
written, return demonstration), depending on the
patient’s need and abilities.
 The nurse or health care provider makes resources
available to patient education that includes:
 Written instructions
 Audio visual
 Online resources
 Telephone numbers
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.
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.
1. Practice in the same position you would assume in
bed after surgery: a semi-Fowler position, propped in
bed with the back and shoulders well supported with
pillows.
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PERIOPERATIVE MANAGEMENT
2. Feel the movement with your hands resting lightly on LEG EXERCISES
the front of the lower ribs and fingertips against the
lower chest. 1. Lie in a semi-Fowler position and perform the following
3. Breathe out gently and fully as the ribs sink down and simple exercises to improve circulation.
inward toward midline. 2. Bend your knee and raise your foot—hold it a few
4. Then take a deep breath through your nose and seconds, then extend the leg and lower it to the bed.
mouth, letting the abdomen rise as the lungs fill with 3. Do this five times with one leg and then repeat with the
air. other leg.
5. Hold this breath for a count of five. 4. Then trace circles with the feet by bending them down,
6. Exhale and let out all the air through your nose and in toward each other, up, and then out.
mouth. 5. Repeat these movements five times.
7. Repeat this exercise 15 times with a short rest after
each group of five.
8. Practice this twice a day preoperatively.

TURNING TO THE SIDE

1. Turn on your side with the uppermost leg flexed most

and supported on a pillow.
COUGHING
2. Grasp the side rail as an aid to maneuver to the side.
1. Lean forward slightly from a sitting position in bed, 3. Practice diaphragmatic breathing and coughing while
interlace your fingers together, and place your hands on your side.
across the incision site to act as a splint for support
GETTING OUT OF BED
when coughing
2. Breathe with the diaphragm as described under 1. Turn on your side.
“Diaphragmatic Breathing.” 2. Push yourself up with one hand as you swing your legs
3. With your mouth slightly open, breathe in fully. out of bed.
4. “Hack” out sharply for three short breaths.
5. Then, keeping your mouth open, take in a quick deep
breath and immediately give a strong cough once or
twice. This helps clear secretions from your chest. It
may cause some discomfort but will not harm your
incision.

NOTE: 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.
PREOPERATIVE MEDICATIONS
MOBILITY AND ACTIVE BODY MOVEMENT
 Appropriate preoperative medication management is
 The goals of promoting mobility postoperatively are to essential to ensure positive surgical outcomes and
improve circulation, prevent venous stasis, and promote prevent medication misadventures.
optimal respiratory function.  It is intended to reduce these stresses through anxiolytic
 The nurse explains the rationale for frequent position and sedative effects.
changes after surgery and then shows the patient how to
Common medications administered preoperatively:
turn from side to side and how to assume the lateral
position without causing pain or disrupting IV lines,  ANTIHYPERTENSIVE MEDICATIONS (Beta
drainage tubes, or other equipment. blockers, ARBs and ACE inhibitors, Diuretics)
 Exercise of the extremities includes extension and flexion  ANTICOAGULANT AND ANTIPLATELET
of the knee and hip joints (similar to bicycle riding while THERAPY (Vitamin K antagonists, Heparin)
lying on the side) unless contraindicated by type of surgical  PAIN MEDICATIONS (Analgesics)
procedure (e.g., hip replacement)

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PERIOPERATIVE MANAGEMENT
PREOPERATIVE CHECKLIST

GENERAL SURGERY PREPARATION

NUTRIENTS IMPORTANT FOR WOUND HEALING Preparations for surgery depend on your diagnosis. Your
physician will discuss with you how to prepare for your
surgery. However, if you will undergo general anesthesia, you
may be asked to do the following:

 Stop drinking and eating for a certain period of time

before the time of surgery
 Bathe or clean, and possibly shave the area to be
operated on
 Undergo various blood tests, X-rays,
electrocardiograms, or other procedures necessary
for surgery
 Sometimes a patient may be asked to take an enema
the evening before surgery, to empty the bowels.
Please check with your physician.
 Do not wear makeup the day of surgery
 Do not wear nail polish
 Do not wear your eye contacts
 Leave valuables and jewelry at home
 Advise the medical staff of dentures or other
prosthetic devices you may be wearing

Often, to make their experience more comfortable and

efficient, patients are advised to bring the following:

 Loose-fitting clothes to wear

 Social Security card number
 Insurance information
 Medicare or Medicaid card

II. INTRAOPERATIVE NURSING

MANAGEMENT

 The intraoperative experience has undergone many

changes and advances that make it safer and less
disturbing to patients. Even with these advances,
anesthesia and surgery still place the patient at risk
for several complications or adverse events.
Consciousness or full awareness, mobility,
protective biologic functions, and personal control
are totally or partially relinquished by the patient
when entering the operating room (OR). Staff from
the departments of anesthesia, nursing, and surgery
work collaboratively to implement professional
standards of care, to control iatrogenic and individual
risks, to prevent complications, and to promote high-
quality patient outcomes.

THE SURGICAL TEAM AND THEIR ROLES

 The surgical team consists of the patient, the

anesthesiologist (physician) or Certified registered
nurse anesthetist (CRNA), the surgeon, nurses,
surgical technicians, and registered nurse first
assistants (RNFAs) or certified surgical technologists
(assistants). The anesthesiologist or CRNA
administers the anesthetic agent (substance used to

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induce anesthesia) and monitors the patient’s
physical status throughout the surgery. The surgeon,
nurses, technicians, and assistants’ scrub and
perform the surgery. The person in the scrub role,
either a nurse or a surgical technician, provides
sterile instruments and supplies to the surgeon
during the procedure by anticipating the surgical
needs as the surgical case progresses. The
circulating nurse coordinates the care of the patient
in the OR. Care provided by the circulating nurse
includes planning for and assisting with patient
positioning, preparing the site for surgery, managing
surgical specimens, anticipating the needs of the
surgical team, documenting Intraoperative events,
and updating the plan of care. Collaboration of the
core surgical team using evidence-based practices
tailored to the specific case results in optimum
patient care and improved outcomes.
THE PATIENT
 As the patient enters the OR, they may feel either
relaxed and prepared or fearful and highly stressed.
These feelings depend to a large extent on the
amount and timing of preoperative sedation,
preoperative education, and the individual patient.
Fears about loss of control, the unknown, pain,
death, changes in body structure, appearance, or
function, and disruption of lifestyle all contribute to
anxiety. These fears can increase the amount of
anesthetic medication needed, the level of
postoperative pain, and overall recovery time. The
patient is subject to several risks. Infection, failure of
the surgery to relieve symptoms or correct a
deformity, temporary or permanent complications
related to the procedure or the anesthetic agent, and
death are uncommon but potential outcomes of the
surgical experience. In addition to fears and risks, the
patient undergoing sedation and anesthesia
temporarily loses both cognitive function and biologic
self-protective mechanisms. Loss of the sense of
pain, reflexes, and the ability to communicate
subjects the intraoperative patient to possible injury.
The OR nurse is the patient’s advocate while surgery
proceeds.
THE CIRCULATING NURSE
 The circulating nurse (or circulator), a qualified
registered nurse, works in collaboration with
surgeons, anesthesia providers, and other health
care providers to plan the best course of action for
each patient (Rothrock, 2019). In this leadership role,
the circulating nurse manages the OR and protects
the patient’s safety and health by monitoring the
activities of the surgical team, checking the OR
conditions, and continually assessing the patient for
signs of injury and implementing appropriate
interventions. A foremost responsibility includes
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verifying consent; if not obtained, surgery may not
commence. The team is coordinated by the
circulating nurse, who ensures cleanliness, proper
temperature, humidity, appropriate lighting, safe
function of equipment, and the availability of supplies
and materials. The circulating nurse monitors aseptic
practices to avoid breaks in technique while
coordinating the movement of related personnel
(medical, x-ray, and laboratory), as well as
implementing fire safety precautions. The circulating
nurse also monitors the patient and documents
specific activities throughout the operation to ensure
the patient’s safety and well-being.
THE SCRUB ROLE
 The registered nurse, licensed practical nurse, or
surgical technologist (or assistant) performs the
activities of the scrub role, including performing hand
hygiene; setting up the sterile equipment, tables, and
sterile field; preparing sutures, ligatures, and special
equipment (e.g., a laparoscope, which is a thin
endoscope inserted through a small incision into a
cavity or joint using fiber- optic technology to project
live images of structures onto a video monitor); and
assisting the surgeon and the surgical assistants
during the procedure by anticipating the instruments
and supplies that will be required, such as sponges,
drains, and other equipment. 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. Standards call for all
sponges used in surgery to be visible on x-ray and
for sponge counts to take place at the beginning of
surgery and twice at the end (when wound closure
begins and again as the skin is being closed). Tissue
specimens obtained during surgery are labeled by
the person in the scrub role.
THE SURGEON
 The surgeon performs the surgical procedure, heads
the surgical team, and is a licensed physician (MD or
DO), oral surgeon (DDS or DMD), or podiatrist
(DPM) who is specially trained and qualified.
Qualifications and training must adhere to The Joint
Commission standards, hospital standards, and local
and state admitting practices and procedures
(Rothrock, 2019).
THE REGISTERED NURSE FIRST ASSISTANT
 The registered nurse first assistant (RNFA) is
another member of the OR team. Although the scope
of practice of the RNFA depends on each state’s
nurse practice act, the RNFA practices under the
direct supervision of the surgeon. RNFA
responsibilities may include handling tissue,
providing exposure at the operative field, suturing,
and maintaining hemostasis (Rothrock, 2019). The
role requires a thorough understanding of anatomy
8
NCM112 LECTURE
MEDICAL-SURGICAL NURSING
PERIOPERATIVE MANAGEMENT
and physiology, tissue handling, and the principles of
surgical asepsis. The RNFA must be aware of the
objectives of the surgery, must have the knowledge
and ability to anticipate needs and to work as a
skilled member of a team, and must be able to handle
any emergency situation in the OR.
THE ANESTHESIOLOGIST AND CRNA
 An anesthesiologist is a physician specifically trained
in the art and science of anesthesiology. A certified
registered nurse anesthetist (CRNA) is a qualified
and specifically trained health care professional who
administers anesthetic agents, has graduated from
an accredited nurse anesthesia program, and has
passed examinations sponsored by the American
Association of Nurse Anesthetists. The
anesthesiologist or CRNA assesses the patient
before surgery, selects the anesthesia, administers
it, intubates the patient, if necessary, manages any
technical problems related to the administration of
the anesthetic agent, and supervises the patient’s
condition throughout the surgical procedure. Before
the patient enters the OR, often at preadmission
testing, the anesthesiologist or CRNA visits the
patient to perform an assessment, supply
information, and answer questions. The type of
anesthetic agent to be given, previous reactions to
anesthetic medications, and known anatomic
abnormalities that would make airway management
difficult are among topics addressed.
THE SURGICAL ENVIRONMENT
 surgical suite is behind double doors, and access is
limited to authorized, appropriately clad personnel.
 OPERATING ROOM
o restricted area where careful attention to
infection prevention is at the highest
standard
o Microbial contamination can occur in the
OR through:
 Airborne route
 Contact route
o has special air filtration devices
 to screen out contaminating
particles, dust & pollutants
o designed with laminar flow ventilation
 to circulate particles AWAY from
the patient and surgical field
 personnel MUST follow strict aseptic practices such
as:
o hand scrubbing
o machine and room cleaning
o sterile supply & instrumentation use
o limited movement
 reducing traffic & door openings
o to maintain optimal airflow with minimal
circulating particles and contaminants
 policies of this environment address issues such as:
o health of the staff
o cleanliness of rooms
o sterility of equipment and surfaces
BSN 3A | PBL GROUP 1
o processes fro scrubbing, gowning, and
gloving
o OR attire
 SURGICAL ENVIRONMENT
o Known for its stark appearance and cool
temperature
o IMPORTANT: maintain patient
normothermia
 Patient must be warmed starting in the preoperative
area throughout all perioperative phases
o Raising room temperature
o Using forced-air warming blankets
o Administering warmed irrigation and IV
solutons
 OR is situated in a location that is CENTRAL to all
supporting services
 2019 NATIONAL PATIENT SAFETY GOALS:
o Identify patients correctly
o Improve staff communication
o Use medicines safely
o Use alarms safely
o Prevent infection
o Identify patient safety risks
o Prevent mistakes in surgery
 Risk of fire in the OR
o Unique risk
o Due to three factors:
 Source of fuel
 Oxygen source
 Mechanism to ignite a fire
DIFFERENT SURGICAL POSITIONS
GOALS OF POSITIONING
 Providing adequate exposure
 Maintaining patient dignity
 Optimal ventilation & airway management
 Providing adequate access
 Avoiding poor perfusion
 Protecting fingers, toes, genitals
 Protecting muscles, nerves, bony prominences
SURGICAL POSITIONS
SUPINE (DORSAL RECUMBENT)
 Most commonly used surgical positon
 Common injuries related to the supine positon are
pressure ulcers on the occiput, scapulae, thoracic
vertebrae, elbows, sacrum, and heels
 Arms should either be secured at the sides or
extended on arm boards
 Safety strap should be placed across the thighs,
approximately 2 inches above the knees with a
sheet or blanket placed between the strap and the
patent’s skin
 Patent's heels should be elevated off the underlying
surface when possible
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 The supine positon is the most common surgical
position
 Includes abdominal surgeries and those that require
an anterior approach
 Head, neck, & most extremity surgeries as well as
most minimally invasive procedures, are done in the
supine position
 The head is supported by a headrest or pillow to
prevent stretching of neck muscles
 Arms may rest on padded arm boards or at the
patient’s side. When the arms are extended, arm
boards are positioned at less than a 90 angle from
the body and palms are supinated (facing upward)
to prevent ulnar and radial nerve compression
 When the arms are positioned at the patient’s sides,
the palms should rest against the patient and the
elbows should be padded and must not be flexed or
extend beyond the mattress. The arm is secured
with a draw sheet that extends above the elbows &
is secured under the patient.
 Take extra caution to be sure the sheet securing the
arm is not so tight that it will interfere with the blood
pressure cuff or intravenous line or compartment
syndrome exists with the arms tucked
 A small pillow may be placed under the luma
curvature to prevent the back strain that occurs
TRENDELENBURG
when parasspinal muscles are relaxed from
anesthetic and muscle-relaxant agents. An  Is a supine position in which the table is tilted head
anesthetized patient lying on the back for hours will down so that the patient’s head is lower than the
likely experience temporary lumbar pain without a feet
lumbar support.
 This position is used for providing additional
 The table strap is applied loosely at least 2 inches visualization of te lower abdomen and pelvis and is
above the knees to prevent hyperextension of the also indicated for patients who develop hypovolemic
knees. The strap should be secure, but not shock.
constricting, and should never be placed over a
 Patients having robot procedures are requently
bony prominence
placed in Trendelenburg position.
 Appropriate protective padding is placed at
 The patient is positioned supine with knees over the
pressure points. To prevent plantar flexion and
lower break in the table. All safety measures are
crushing injuries to the toes, the table must extend
initiated before the table is tilted. To help maintain
beyond the toes. A table extension may be required
this position, the lower part of the table may be
for all patients.
adjusted so that the patient’s legs are parallel with
 Pressure points at risk for skin injury in the supine the floor.
position include skin over body prominences:
 Take particular care when using shoulder braces
occiput, spinous processes, scapulae, styloid
because they pose a risk for brachial plexus injury
process of the ulna and radius (elbow), olecranon
unless they are positioned very carefully against the
process, sacrum, and calcaneus (heel). Skin
acromion and spinous process of the scapula
breakdown from pressure I s the most common on
 Check the position of the patient’s arm and hand to
the elbow, sacrum, and heel.
make certain that the elbow does not extend
 Nerves or nerve groups at risk include the brachial
beyond the table and the fingers are not too close to
plexus, radial, ulnar, median, common peroneal,
the lower break in the table where they might be
and tibial nerves
crushed when the table is adjusted.
 Vital capacity can be reduced because of restriction
 Before the table is titled into Trendelenburg
of posterior chest expansion. If the patient is
position, mayo stands, tables, and other
pregnant, a wedge may be placed under the
equipments are adjusted
patient’s right side to prevent hypotension caused
 All movements are done slowly to allow the body
by pressure from the uterus on the aorta and vena
enough time to adjust to the change in blood
cava.
volume, respiratory exchange, and displacement of
abdominal contents
 Before the procedure begins, ensure that the mayo
stand and other equipment are not touching the
patient

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 Respiratory & circulatory changes occur as a result
of redistribution of body mass. Abdominal contents
press against the diaphragm, limiting expansion and
decreasing the ventilation-perfusion ration.
 Trendelenburg position increases intrathoracic and
intracranial pressure. Because of these changes,
the patient should remain in Trendelenburg position
for as short time as possible.
REVERSE TRENDELENBURG
 In reverse Trendelenburg, the table is tilted feet
down. This position is used for head and neck
procedures and to provide visualization in
laparocscopic procedures in the upper abdomen.
 The patient’s feet should rest firmly on a padded
footboard, preventing the patient from sliding down
on the table.
 A pneumatic sequential compression device, elastic
bandages, or anti-embolectomy stockings prevent
pooling of blood in the legs
 Movement in and out of reverse Trendelenburg is
done slowly to allow sufficient time for the heart to
adjust to change in blood volume.
LITHOTOMY
 In lithotomy position, the patient is supine with the
legs elevated, abducted and supported in stirrups.
BSN 3A | PBL GROUP 1
The buttocks are even with the lower break in the
table
 This position is used primarily for procedures
involving the perineum region, pelvic organs, land
genitalia
 Arms are secured on padded armboards to prevent
crushing fingers and hands when the bottom
section of the table is lowered or raised, Armborad
should be positioned at an angle less than 90° to
the hody.
 Stirrups are attached securely to the table,
positioned according to the manufacturer’s
instructions, and adjusted to the length of the
patient’s legs to prevent pressure at the knees and
lumbar region of the spine.
 Various types of stirrups are available, and their
selection should be made carefully based on patient
size and the type and length of the surgical
procedure
 At-risk pressure points vary according to the type of
stirrups used. Pay particular attention to the femoral
epicondyle, tibial condyles, and lateral and medial
malleoli.
 Padding protects the legs from pressure from the
stirrup itself, and from external compression of
nerves. To prevent injury to the fernoral and
obrurator nerves, the inner thigh should be free of
pressure from the stirrup
 Although rare, compartment syndrome-
characterized by pain, muscle weakness, and loss
of sensation has been reported as a complication of
the lithotomy position (AORN, 2015, p. 572).
 To prevent hip dislocation or muscle strain from an
exaggerated range of motion, the legs are raised
and lowered slowly and simultaneously by wo
members of the surgical team. During leg elevation,
the foot is held in one hand and the lower part of the
log in the other hand. The legs are flexed slowly,
and the padded foot is secured in the stirrup.
 Padding may be placed under the sacrum to
prevent lumbosacral strain.
 After the legs are safely secured, the bottom section
of the table is lowered or removed.
 Following the procedure, the lower section of the
table is raised or replaced to align with the rest of
the table. 'The patient's legs are removed from the
stirrups simultaneously, extended fully to prevent
abduction of the hips, and lowered slowly onto the
table. The table strap is then applied.
 When the legs are lowered, 500 co 800 ml. of blood
is diverted from the visceral area co the extremities,
which can cause hypotension. Lowering the logs
slowly will prevent severe sudden hypotension.
 Lithotomy position can reduce respiratory efficiency
if pressure from the thighs on the abdomen and
pressure from the abdominal viscera on the
diaphragm restrict thoracic expansion. Lung tissue
becomes engorged with blood, and vital capacity
and tidal volume are decreased.
 lf nursing assessment suggests a limited range of
hip motion because of contractures, arthritis,
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NCM112 LECTURE
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PERIOPERATIVE MANAGEMENT
prosthesis, or another condition, the patient may be
placed in litothomy position while awake so the
patient can participate and ensure that the position
is comfortable.
SITTING, BEACH CHAIR
 Primarily used for shoulder surgery, often with the
beach-chair table attachment that allows half of the
backrest on the affected side to be removed for
improved access to the surgical site
 During breast reconstruction, the patient is
sometimes raised into the sitting position to assess
breast symmetry, and occasonaly the patient
remains in the sitting position for the remainder of
the surgery
 The sitting position has been used for certain
craniotomies and cervical laminectomy, but this is
rarely done, because the negative venous pressure
in the head & neck places these patients at risk for
air embolism that can be fatal. When done, a
central venous catheter with a Doppler ultrasound
flowmeter monitors the sitting patient. The Doppler
device is used to detect an air embolism, and the
central venous pressure line is used to extract the
air.
 The patient is initially positioned supine. The head
is supported in a secure headrest. The feet are
usually supported on a padded foot-rest. The foot of
the table is slowly lowered, flexing the knees and
pelvis. The upper portion of the table is raised to
BSN 3A | PBL GROUP 1
become the back-rest and the torso reaches an
upright position.
 The arms may be flexed at the elbows and rest on a
pillow on the patient’s lap or on an adjustable
padded platform in front of the patient. The arms
should not fall into a dependent position.
 Pressure points are similar to the supine position;
however, the operating table should have a well-
constructed, pressure-reducing pad because most
of the patient’s body weight rests on the ischial
tuberosities and the sacral nerve
 Additional padding will protect other pressure points
at increased risk for injury including the scapulae,
olecranon process, back of the knees, sacrum,
ischial tuberosities, and calcaneus.
SEMI-SITTING, SEMI-FOWLER’S, LAWN-CHAIR
POSITION
 The semi-fowler’s position is essentially a supine
position with the table adjusted to emulate a
lawnchair. The patient’s body is flexed at the pelvis
and knees. While the patient is in a reclining
position, the back of the table can be adjusted from
nearly flat to nearly sitting, depending upon the
procedure.
 With the back raised to different levels, this position
is used for nasopharyngeal, facial, neck, and breast
surgery
 A roll may be placed under the patient’s neck to
hyperextend the neck and provide better access to
the surgical site
PRONE
 In the prone position, the patient lies face down.
This exposure of the posterior body is used for
procedures of the spine, back, rectum, and the
posterior aspects of extremities
 The patient will either lie on a special table
engineered for prone positioning, or on a regular
table with a laminectomy frame (Wilson Frame) or
chest rolls. All of the necessary positioning
equipment must be collected and available prior to
intubation and transfer of the patient
 The anesthesia provider induces the patient on the
stretcher
 The stretcher height is raised slightly higher than
the operating table to facilitate moving the patient
from stretcher to table. The side rail closest to the
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PERIOPERATIVE MANAGEMENT
operating table is lowered, and the stretcher is  A small pillow or foam padding under the knees
positioned adjacent to the operating table and prevents pressure on the patellae.
locked  If the patient has a stoma, take precautions to
 Following intubation, the anesthesia provider prevent ischemic compression of the stoma against
secures the endotracheal tube to prevent the frame or chest rolls that can lead to tissue
dislocation and applies ointment to the eyes and necrosis and sloughing
tapes them shut to prevent corneal abrasion. The  Pedal pulses are assessed to assure circulation to
other side rail is lowered. The anesthesia provider the lower extremities
will indicate when the patient is ready to be moved
onto the operating room table
 A minimum of four persons is necessary to safely
turn the adult patient from a supine position on the
stretcher to a prone position on the operating table.
The anesthesia provider supports and manages the
head, one person supports and rotates the torso
while the person on the other side of the bed
positions the patient on the frame or chest rolls. The
MAYFIELD HEADREST (with Pins)
fourth person supports and moves the lower body
 All movement of the patient is done slowly and  If a Mayfield headrest is used, the surgeon will
gently to allow the body time to adjust to the change attach the head brace with pins to the patient after
in position. During turning, the patient’s arms and induction while the patient is still supine on the
hands are placed at the sides. The body is stretcher
maintained in anatomical alignment, and all team  After the patient has been placed in the prone
members work in concert to turn the patient in a position, the surgeon will hold the patient’s head in
single motion the brace while the nurse removes the head
 The patient is placed either on the pads on the attachment from the operating table and replaces it
special table specifically designed for chest, hips, with the Mayfield table attachment
and thighs or onto chest rolls or a laminectomy  The nurse will adjust the table attachment until it is
frame (e.g. Wilson frame) positioned lengthwise on aligned perfectly with the patient’s head, which the
the operating table from the acromioclavicular joint surgeon is holding in the desired position for
to the iliac crest. This positioning lifts the patient’s surgery. The nurse will then secure the headpiece
chest off the operating table and facilitates in place
respiratory expansion. Female breast and male
 The patient must never be repositioned on the table
genitalia must be arranged to avoid unnecessary
while the head brace is secured to the table
compression.
attachment
 Chest rolls that are too small or that are improperly
positioned can result in restricted lunge expansion.
Female breasts and male genitalia must be free and
not compressed.
 After the patient is supine, the arms are brought
down and forward in a normal range of motion and
placed on arm boards positioned next to the head.
The arms are flexed at the elbows with the hands
pronated (palms down) and elbows padded.
 The anesthesiologist either turns the patient’s head
to one side or places it in a headrest designed to
protect the airway, and then checks that the
KRASKE (JACKKNIFE) POSITION
patient’s eyes are closed to prevent corneal
abrasion and are free from pressure than can cause  Used for rectal procedures
permanent eye injury. The ears must be not folded  The patient is first placed in the prone position on
unnaturally. Neck and spine must be in good chest rolls with the hips over the center table joint.
alignment. Chest rolls are not necessary if the patient is
 A pillow under the ankles lifts the toes off the awake. The table if flexed to a 90 angle, causing the
mattress and prevents stretching of the anterior hips to be raised and the head & legs to be lowered
tibial nerve to prevent plantar flexion and foot drop.  All precautions appropriate for the prone position
 The table strap helps to hold the patient in position are applicable to the jackknife position
on the table. It is placed across the mid-thighs,  Venous pooling in the chest and feet can cause a
which are first covered with a sheet, pad, and/or a decrease in mean arterial blood pressure.
blanket to protect the skin. The strap should be at Restriction of diaphragm movement combined with
least 2 inches above the knees to promote increased blood volume in the lungs can cause a
superficial venous return. decrease in ventilation and cardiac output. Because

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PERIOPERATIVE MANAGEMENT
of its adverse effect on the respiratory and more than 90, because an angle greater than 90
circulatory systems, the jackknife position is can cause injury to the brachial plexus.
considered one of the most precarious surgical  For kidney procedures, it is important that the
positions. patient’s flank be positioned over the kidney
elevator (kidney rest) with the iliac crest just below
the table break. The table may be flexed at the
center break. The kidney rest is raised to provide
greater exposure of the area from the 12th rib to the
iliac crest. Kidney braces that fit over the kidney
elevator may be used to support and maintain the
patient in this position. These devices must always
be padded.
 Respiratory efficiency is affected by pressure from
the weight of the body on the lower chest. The
lower lung receives more blood from the right side
of the heart in the lateral position, so it has
LATERAL increased perfusion but less residual air because of
mediastinal compression and weight from
 In the lateral (or lateral decubitus) position, the abdominal contenct
patient lies on one side. In the right lateral position,  Circulation is compromised by pressure on
the patient lies on the right side for surgery on the abdominal vessels and pooling of blood in the lower
left side of the body. The reverse is true for the left extremities. In the right lateral position, compression
lateral position on the vena cava impairs venous return. If the
 The lateral position is used to access the thorax, kidney elevator is raised, addition pressure on
kidney, retroperitoneal space, and hip abdominal vessels can further compromise
 Often supported with a pegboard or beanbag circulation.
vacuum-positioning device  Injury of the eye or ear is a special concern with the
 The patient is induced in the supine position. A patient in the lateral position. The ear must life flat
team of four persons then lifts and turns the patient and the eyelid must be closed.
onto the nonoperative side. The patient is lifted in
the supine position toward the edge of the operative
side of the table then turned onto the side toward
the center of the table
 The anesthesia provider supports the head and
neck and guards the airway. The person standing
on the operative side lifts and supports the chest
and shoulders. The person on the patient’s other
side lifts and supports the hips, while the fourth
person supports and rotates the legs.
 The patient’s head is supported with a pillow or
headrest, and the body is checked for proper
alignment with the head in cervical alignment with
the spine.
 The lower leg is flexed. The lateral aspect of the
lower knee is well padded to prevent peroneal
nerve damage that might result in foot drop caused
by pressure from the fibula on the nerve. A pillow is
placed between the legs, and the upper leg is
extended. Feet and ankles are padded and
supported to prevent foot drop and pressure injuries
of the malleolus. The patient is secured with the
table strap or with wide tape applied across the
upper hip and fastened to the table.
 A small roll or padding is placed under the patient’s
lower axilla to relieve pressure on the chest and ROBOTIC POSITIONING
axial, to allow sufficient chest expansion, and to  Prior to draping, the patient’s positioning should
prevent compression of the brachial plexus by the be tested for sliding, limb impingement,
humeral head. The lower arm is slightly flexed and respiratory and circulatory problems.
placed on a padded arm board. The upper arm may  Periodic checks throughout the procedure to
assess for positional shifts are required. This is
rest on a padded elevated arm board or other
always dependent on the ability to access the
padded support. Take care not to abduct the arm

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PERIOPERATIVE MANAGEMENT
patient without compromising the surgical
procedure or sterile field.
 After the team docks the robot and periodically
throughout the procedure, safety checks should
be performed to ensure proper positioning of the
robotic arms and that they are not in contact with
the patient.
 Eye goggles can be used to protect the eyes
from the robotic arms, if they are going to be in
close proximity to the face.
POSITIONING THE MORBIDLY OBESE PATIENT
 BMI greater than 40
 OR bed must be capable of supporting patient’s
weight & must be wide enough to contain the
patient
 OBESITY causes respiratory issues & circulatory
issues.
 RESPIRATORY ISSUES:
o Airway compromise
o Difficult intubation
o Aspiration
o Hypoxia
o Intra-abdominal pressure
 CIRCULATORY ISSUES:
o Increased cardiac output
o Increased pressure on pulmonary artery
o Risk of inferior vena cava compression
 Safety trap must be long enough and wide
enough to secure the patient. Two safety straps
may be necessary – one for the upper portion of
the legs and one for the lower portion.
 Lifting devices should be used to transfer the
patient.
 SUPINE POSITION: may cause patient to have
difficulty breathing due to pressure of the viscera
of the diaphragm. A wedge should be placed
under the right flank to relieve pressure on the
vena cava.
 LITHOTOMY & TRENDELENBURG POSITION:
should be avoided because they may also cause
respiratory & circulatory compromise.
 PRONE POSITION: may cause pressure on the
diaphragm.
 SKIN BREAKDOWN: a challenge w/ obese
patients, because moisture and fluid from skin-
prep solutions may become trapped in tissue
folds.
TYPES OF ANESTHESIA
 General Anesthesia
 Multimodal Anesthesia
 Regional Anesthesia
 Moderate Sedation
 Local Anesthesia
GENERAL ANESTHESIA
 Anesthesia is a state of narcosis (severe central
nervous system depression produced by
pharmacologic agents), analgesia, relaxation, and
reflex loss.
FOUR (4) STAGES OF GENERAL ANESTHESIA
Stage I: beginning anesthesia.
 Dizziness and a feeling of detachment may be
experienced during induction.
 The patient may have a ringing, roaring, or buzzing
in the ears and, although still conscious, may sense
an inability to move the extremities easily. These
sensations can result in agitation.
 During this stage, noises are exaggerated; even low
voices or minor sounds seem loud and unreal.
Stage II: excitement.
 The excitement stage, characterized variously by
struggling, shouting, talking, singing, laughing, or
crying, is often avoided if IV anesthetic agents are
given smoothly and quickly.
 The pupils dilate, but they constrict if exposed to
light; the pulse rate is rapid; and respirations may be
irregular.
 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.
Stage III: surgical anesthesia.
 Surgical anesthesia is reached by administration of
anesthetic vapor or gas and supported by IV agents
as necessary.
 The patient is unconscious and lies quietly on the
table. The pupils are small but constrict when
exposed to light.
 Respirations are regular, the pulse rate and volume
are normal, and the skin is pink or slightly flushed.
Stage IV: medullary depression.
 This stage is reached if too much anesthesia has
been given.
 Respirations become shallow, the pulse is weak and
thready, and the pupils become widely dilated and no
longer constrict when exposed to light.
 Cyanosis develops and, without prompt intervention,
death rapidly follows.
 Inhalation: Inhaled anesthetic agents include
volatile liquid agents and gases. Volatile liquid
anesthetic agents produce anesthesia when their
vapors are inhaled.
 Gas anesthetic agents: are given by inhalation and
are always combined with oxygen. Nitrous oxide,
sevoflurane, and desflurane are the most commonly
used gas anesthetic agents.
 The vapor from inhalation anesthetic agents can be
given to the patient by several methods. The
inhalation anesthetic agent may be given through an
LMA —a flexible tube with an inflatable silicone ring
and cuff that can be inserted into the larynx.

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PERIOPERATIVE MANAGEMENT
 The endotracheal technique for administering
anesthetic medications consists of introducing a soft
rubber or plastic ET into the trachea, usually by
means of a laryngoscope. The ET may be inserted
through either the nose or mouth.
 Intravenous Administration- General anesthesia
can also be produced by the IV administration of
various anesthetic and analgesic agents, such as
barbiturates, benzodiazepines, nonbarbiturate
hypnotics, dissociative agents, and opioid agents.
ADVANTAGE OF IV ANESTHESIA
 the onset of anesthesia is pleasant; there is none of
the buzzing, roaring, or dizziness known to follow
administration of an inhalation anesthetic agent.
 The IV anesthetic agents are nonexplosive, require
little equipment, and are easy to administer.
 IV anesthesia is useful for short procedures but is
used less often for the longer procedures of
abdominal surgery. It is not indicated for those who
require intubation because of their susceptibility to
respiratory obstruction.
MULTIMODAL ANESTHESIA
 aims to reduce opioid requirements and associated
risks such as sedation, respiratory depression,
nausea, vomiting, and potential of overuse of
opioids.
 Multimodal anesthesia is a growing trend in the
enhanced recovery after surgery (ERAS) pathways,
as it decreases the risks of general anesthesia and
aids in opioid reduction strategies.
REGIONAL ANESTHESIA
 In regional anesthesia, an anesthetic agent is
injected around nerves so that the region supplied by
these nerves is anesthetized. The effect depends on
the type of nerve involved.
 The patient receiving regional anesthesia is awake
and aware of their surroundings unless medications
are given to produce mild sedation or to relieve
anxiety.
EPIDURAL ANESTHESIA
BSN 3A | PBL GROUP 1
 is achieved by injecting a local anesthetic agent into
the epidural space that surrounds the dura mater of
the spinal cord.
 Epidural anesthesia blocks sensory, motor, and
autonomic functions; it differs from spinal anesthesia
by the site of the injection and the amount of
anesthetic agent used.
 An advantage of epidural anesthesia is the absence
of headache that can result from spinal anesthesia.
SPINAL ANESTHESIA
 Spinal anesthesia is an extensive conduction nerve
block that is produced when a local anesthetic agent
is introduced into the subarachnoid space at the
lumbar level, usually between L4 and L5.
 It produces anesthesia of the lower extremities,
perineum, and lower abdomen. For the lumbar
puncture procedure, the patient usually lies on the
side in a knee–chest position.
 Headache may be an aftereffect of spinal
anesthesia. Several factors are related to the
incidence of headache: the size of the spinal needle
used, the leakage of fluid from the subarachnoid
space through the puncture site, and the patient’s
hydration status.
PERIPHERAL NERVE BLOCKS
 Peripheral nerve blocks (PNBs) are used in
conjunction with general or MAC anesthesia, or as a
stand-alone method. Instead of a single nerve being
targeted, a bundle of nerves is located via ultrasound
and injected with an anesthetic, opioid, or steroid.
Examples of common local conduction blocks
include:
o Brachial plexus block, which produces
anesthesia of the arm.
o Paravertebral anesthesia, which produces
anesthesia of the nervessupplying the chest,
abdominal wall, and extremities
o Transsacral (caudal) block, which produces
anesthesia of the perineum
o and, occasionally, the lower abdomen.
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.
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NCM112 LECTURE
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PERIOPERATIVE MANAGEMENT
 It is commonly used for many short-term surgical
procedures in hospitals and ambulatory care centers
(Rothrock, 2019).
 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 the patient’s comfort
during and cooperation with the procedures.
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.
LOCATION 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.
 LA is often given in combination with epinephrine.
Epinephrine constricts blood vessels, which prevents
rapid absorption of the anesthetic agent and thus
prolongs its local action and prevents seizures.
 The skin is prepared as for any surgical procedure,
and a small-gauge needle is used to inject a modest
amount of the anesthetic medication into the skin
layers. This produces blanching or a wheal.
Additional anesthetic medication is then injected into
the skin until an area surrounding the proposed
incision is anesthetized.
ADVANTAGES OF LA ARE AS FOLLOWS:
 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.
LOCAL ANESTHETIC SYSTEMIC TOXICITY
 is a potentially life-threatening event.
 LAST occurs when a bolus of LA is inadvertently
injected into peripheral tissue or venous or arterial
circulation during a PNB or spinal nerve block
procedure and is rapidly absorbed into systemic
circulation, resulting in cardiovascular or neurologic
collapse (Ferguson, Coogle, Leppert, et al., 2019).
SIGNS AND SYMPTOMS OF LAST ARE:
 Metallic taste
 Oral numbness
 Auditory changes
 Slurred speech
 Arrhythmias
 Seizure
 Respiratory arrest
BSN 3A | PBL GROUP 1
Hypoxemia and acidosis intensify the effects of
LAST. The nurse calls for help and maintains the
patient’s airway while administering 100% oxygen
and confirming IV access.
POTENTIAL INTRAOPERATIVE COMPLICATIONS
 The major potential intraoperative complications
include anesthesia awareness, nausea and
vomiting, anaphylaxis, hypoxia, hypothermia, and
malignant hyperthermia (MH). Targeted areas
include SSIs as well as cardiac, respiratory, and
venous thromboembolic complications (Joint
Commission, 2019).
ANESTHESIA AWARENESS
 It is important to discuss concerns about
intraoperative awareness with patients
preoperatively so that they realize that only general
anesthesia is meant to create a state of oblivion.
 Unintended intraoperative awareness refers to a
patient becoming cognizant of surgical interventions
while under general anesthesia and then recalling
the incident.
 Indications of the occurrence of anesthesia
awareness include an increase in the blood
pressure, rapid heart rate, and patient movement.
However, hemodynamic changes can be masked by
paralytic medication, beta-blockers, and calcium
channel blockers, thus the awareness may remain
undetected.
NAUSEA AND VOMITING
 Nausea and vomiting, or regurgitation, may affect
patients during the intraoperative period.
 The patient should be assessed preoperatively for
risk factors of PONV so that the surgical team can
formulate a plan for intraoperative prevention.
 Risk factors include female gender, age less than 50
years, history of PONV, and opioid administration.
 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.
 Suction is used to remove saliva and vomited gastric
contents. In some cases, the anesthesiologist or
CRNA administers antiemetics preoperatively or
intraoperatively to counteract possible aspiration.
 Patients may be given citric acid and sodium citrate,
a clear, nonparticulate antacid to increase gastric
fluid pH or a histamine-2 (H2) receptor antagonist
such as cimetidine, or famotidine to decrease gastric
acid production.
ANAPHYLAXIS
 An anaphylactic reaction can occur in response to
many medications, latex, or other substances. The
reaction may be immediate or delayed. Anaphylaxis
can be a life-threatening reaction.
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NCM112 LECTURE
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PERIOPERATIVE MANAGEMENT
 Latex allergy—the sensitivity to natural rubber latex
products—has become more prevalent, creating the
need for alert responsiveness among health care
professionals.
 If patients state that they have allergies to latex, even
if they are wearing latex in their clothing, treatment
must be latex free.
 In the OR, many products are latex free with the
notable exception of softer latex catheters. Surgical
cases should use latex-free gloves in anticipation of
a possible allergy, and if no allergy is present, then
personnel can switch to other gloves after the case
starts if desired.
 The nurse must be alert to the possibility and
observe the patient for changes in vital signs and
symptoms of anaphylaxis when these products are
used.
 In the OR, the team should remove potential
causative agents promptly—within 3 minutes or
less—of becoming aware of an anaphylactic
reaction.
 The surgical team should be aware of the importance
of prompt intervention to prevent cardiovascular and
respiratory collapse (Seifert, 2017).
HYPOXIA AND OTHER RESPIRATORY COMPLICATIONS
 Inadequate ventilation, occlusion of the airway,
inadvertent intubation of the esophagus, and hypoxia
are significant potential complications associated
with general anesthesia.
 Respiratory depression caused by anesthetic
agents, aspiration of respiratory tract secretions or
vomitus, and the patient’s position on the operating
table can compromise the exchange of gases.
 In addition to these dangers, asphyxia caused by
foreign bodies in the mouth; spasm of the vocal
cords; relaxation of the tongue; or aspiration of
vomitus, saliva, or blood can occur.
 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.
 Peripheral perfusion is checked frequently, and
capnography readings are monitored continuously.
Capnography provides instantaneous information
about carbon dioxide production, pulmonary
perfusion, and respiratory patterns that detect
hypoventilation and apnea.
HYPOTHERMIA
 During anesthesia, the patient’s temperature may
fall. Glucose metabolism is reduced, and as a result,
metabolic acidosis may develop. This condition is
called hypothermia and is indicated by a core body
temperature that is lower than normal (36.6°C [98°F]
or less).
 Risks of intraoperative hypothermia:
o Cardiovascular events
o SSIs
o Bleeding
o Delayed arousal from anesthesia
BSN 3A | PBL GROUP 1
 Unintended hypothermia may occur as a result of
a low temperature in the OR, infusion of cold fluids,
inhalation of cold gases, open body wounds or
cavities, decreased muscle activity, advanced age,
or the pharmaceutical agents used (e.g.,
vasodilators, phenothiazines, general anesthetic
medications).
 If hypothermia is intentional, the goal is:
o Safe return to normal body temperature.
o Environmental temperature in the OR can
temporarily be set at 25° to 26.6°C (78° to 80°F).
o IV and irrigating fluids are warmed to 37°C
(98.6°F).
o Wet gowns and drapes are removed promptly
and replaced with dry materials, because wet
materials promote heat loss.
o Warm air blankets and thermal blankets can
also be used on the areas not exposed for
surgery, and minimizing the area of the patient
that is exposed will help maintain core
temperature.
o Conscientious monitoring of core temperature,
urinary output, ECG, blood pressure, arterial
blood gas levels, and serum electrolyte levels is
required.
MALIGNANT HYPERTHERMIA
 Malignant hyperthermia is a rare inherited muscle
disorder that is chemically induced by anesthetic
agents (Rothrock, 2019).
 MH occurs because of a genetic autosomal dominant
disorder involving a mutation on the ryanodine
receptor that causes an atypical increase in release
of calcium in muscle cells (Mullins, 2018).
 Susceptible people include those with strong and
bulky muscles, a history of muscle cramps or muscle
weakness and unexplained temperature elevation,
and an unexplained death of a family member during
surgery that was accompanied by a febrile response
(Ho, Carvalho, Sun, et al., 2018).
PATHOPHYSIOLOGY
 The pathophysiology of MH is related to a
hypermetabolic condition that involves altered
mechanisms of calcium function in skeletal muscle
cells. This disruption of calcium causes clinical
symptoms of hypermetabolism, which in turn
increases muscle contraction (rigidity) and causes
hyperthermia and subsequent damage to the central
nervous system.
CLINICAL MANIFESTATIONS
 Cardiovascular, respiratory, and abnormal
musculoskeletal activity.
 Tachycardia (heart rate greater than 150 bpm) may
be an early sign.
 Sympathetic nervous stimulation also leads to
ventricular arrhythmia, hypotension, decreased
cardiac output, oliguria, and, later, cardiac arrest.
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NCM112 LECTURE
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PERIOPERATIVE MANAGEMENT
 Hypercapnia, an increase in carbon dioxide (CO2),
may be an early respiratory sign.
 Abnormal transport of calcium, rigidity or tetanuslike
movements occur, often in the jaw.
 Generalized muscle rigidity is one of the earliest
signs.
 The rise in temperature is actually a late sign that
develops rapidly; body temperature can increase 1°
to 2°C (2° to 4°F) every 5 minutes, and core body
temperature can exceed 42°C (107°F).
MEDICAL MANAGEMENT
 Goals of treatment are to decrease metabolism,
reverse metabolic and respiratory acidosis, correct
arrhythmias, decrease body temperature, provide
oxygen and nutrition to tissues, and correct
electrolyte imbalance.
 Use of dantrolene has lowered mortality rates to 10%
in current practice (Ho et al., 2018).
 Anesthesia and surgery should be postponed.
However, if end-tidal CO2 monitoring and dantrolene
sodium are available and the anesthesiologist is
experienced in managing MH, the surgery may
continue using a different anesthetic agent (Barash
et al., 2017).
NURSING MANAGEMENT
 Although MH is uncommon, the nurse must identify
patients at risk, recognize the signs and symptoms,
have the appropriate medication and equipment
available, and be knowledgeable about the protocol
to follow. Preparation and early intervention may be
lifesaving for the patient.
III. POSTOPERATIVE NURSING MANAGEMENT
 Postoperative period extend from the time the
patient leaves the operating room (OR) until the last
follow up with the surgeon.
 Postanesthia care unit (PACU) is located adjacent
to the OR suite.
PHASES OF POSTANESTHESIA CARE
 In some hospitals and ambulatory surgical centers,
postanesthesia care is divided into two phases
(Rothrock, 2019).
o PHASE 1 PACU - used during the
immediate phase, intensive nursing is
provided. It has monitoring and staffing
ratios equivalent to the ICU.
o PHASE II PACU - the patient is prepared
for transfer for an inpatient nursing unit, an
extended care setting, or discharge.
ADMITTING THE PATIENT TO THE POSTANESTHESIA
CARE UNIT (PACU)
 Transferring the postoperative patient from
the OR to the PACU is the responsibility of
the anesthesiologist or certified
BSN 3A | PBL GROUP 1
registered nurse anesthetist (CRNA) and
other licensed member of the OR team.
 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.
 SPECIAL CONSIDERATIONS (POTA)
o Prevent further strain on the
incision (the patient is positioned
so that they are not lying on and
obstructing drains or drainage
tubes
o Orthostatic hypotension may
occur when a patient is moved too
quickly from one position to
another, move the patient slowly
and carefully
o The soiled gown is removed and
replaced with a dry gown as soon
as the patient is placed on the
stretcher or bed
o A lightweight blanket or a forced
air warming blanket is used to
cover the patient
NURSING MANAGEMENT IN THE POSTANESTHESIA
CARE UNIT (PACU)
 Assessing the Patient
o The nurse performs frequent, basic
assessments of every postoperative
patient. These assessments include airway,
level of consciousness, cardiac, respiratory,
wound, and pain.
 Maintaining a Patent Airway
o Primary objective in post-op period is to
maintain ventilation, prevent hypoxemia
and hypercapnia
o Administering supplemental oxygen as
prescribed, and the nurse assesses RR and
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NCM112 LECTURE
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PERIOPERATIVE MANAGEMENT
depth, ease of respirations, O2sat, and o To ensure patient safety and recovery,
breath sounds. expert patient education and discharge
 Maintaining Cardiovascular Stability planning are necessary.
o The nurse assesses the patient's level of  Discharge Preparation
conciousness; vital signs; cardiac rhythm; o The px and caregiver are informed about
skin temperature, color, and moisture; and expected outcomes and immediate post-op
urine output. changes anticipate
o Assess the patency of all IV lines. o The nurse provides written instructions and
 Relieving Pain and Anxiety prescriptions are given to the px
o The nurse monitors the patient's o Schedule follow up appointments and
physiologic status, manages pain, and contact information for the hospital and
provides psychological suppport in an effort surgeon's office are provided.
to relieve the patient's fears and concerns.
o Opioid analgesic medications are given
mostly by IV in the PACU. IV opioids
provide immediate pain relief and are short-
acting
o Consider providing nonpharmacologic,
emotional,and psychological support to the
patient. These include massage,
acupuncture, heat/cold packs, relaxation
and breathing techniques, guided imagery,
and soothing music.
 Controlling Nausea and Vomiting
o 30% to 50% of surgical patients experience
postoperative nausea and vomiting
(PONV).
o Studies suggests that nonpharmacologic POSTOPERATIVE COMPLICATIONS
measures, such as aromatheraphy, may
HYPOTENSION AND SHOCK
be effective for PONV prevention and
treatment (Asay, et al., 2019).
 Results from blood loss, hypoventilation, position
 Gerontologic Considerations
changes, pooling of blood in the extremities, or side
o The older patient is transferred from the OR
effects of medications and anesthetics
table to the bed or stretcher slowly and
 Hypovolemic is the most common type of shock in
gently.
the post-op setting.
o Frequent monitoring on blood pressure and
 S/S are pallor; cool, moist skin; rapid breathing;
ventilation
cyanosis of the lips, gums, and tongue; rapid, weak,
o Older adults are more susceptible to
thready pulse; narrowing pulse pressure; LB
hypothermia, so special attention is given to
pressure; concentrated urine.
keeping the px warm.
HEMORRHAGE
 Bariatric Considerations
o Patients with obesity are seen in the PACU  An uncommon yet serious complication of surgery
for a wide variety of conditions, and so that can present insidiously or emergently at any time
properly sized blood pressure cuffs, gowns, in the immediate post-op period up to several days
transfer devices, and wheelchairs may be after surgery.
needed for the recovery and transitioning  S/S are hypotension; rapid, thready pulse;
care. disorientation; restlessness; oliguria; and cold, pale
 Determining Readiness for PACU Discharge skin.
o Indicators of recovery include stable blood  Determining the cause of hemorrhage includes
pressure, adequate respiratory function and assessing the surgical site and incision for bleeding.
adequate O2sat level compared with
baseline. HYPERTENSION AND ARRYTHMIAS
o The Aldrete score is used to determine the
patient's general condition and readiness  Common in the immediate post-op period secondary
for transfer from the PACU. to sympathetic nervous system stimulation from pain,
hypoxia, or bladder distention. Arrhythmiasare
PREPARING THE POSTOPERATIVE PATIENT FOR associated with electrolyte imbalance, altered
DIRECT DISCHARGE respiratory function, pain, hypothermia, stress, and
anesthetic agents.
 Promoting Home, Community-Based, and
Transitional Care

BSN 3A | PBL GROUP 1 20

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

PERIOPERATIVE MANAGEMENT
POSTOPERATIVE PAIN MANAGEMENT
 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
RELIEVING PAIN AND ANXIETY
 The nurse in the PACU monitors the patient’s physiologic
status, manages pain, and provides psychological
support in an effort to relieve the patient’s fears and
concerns.
 The nurse checks the medical record for special needs
and concerns of the patient
 Opioid analgesic medications are given mostly by IV in
the PACU
 IV opioids provide immediate pain relief and are short
acting, thus minimizing the potential for drug interactions
or prolonged respiratory depression while anesthetics are
still active in the patient’s system
PAIN
 The American Pain Society (APS) (2008) defines
pain as “an unpleasant sensory and emotional
experience associated with actual or potential
tissue damage, or described in terms of such
damage”
 This definition describes pain as a complex
phenomenon that can impact a person’s
psychosocial, emotional, and physical functioning.
The clinical definition of pain reinforces that pain
is a highly personal and subjective experience:
“Pain is whatever the experiencing person says it
is, existing whenever he says it does”
periodically —called breakthrough pain (BTP)—or
endure acute pain from repetitive painful
procedures during cancer treatment
Nociceptive (physiologic) pain refers to the normal
functioning of physiologic systems that leads to the
perception of noxious stimuli (tissue injury) as being painful
[NOTE: Nociceptive (physiologic) pain refers to the normal
functioning of physiologic systems that leads to the
perception of noxious stimuli (tissue injury) as being painful]
 Nociception includes specific processes:
transduction, transmission, Nociception includes
specific processes: transduction, transmission,
Neuropathic (pathophysiologic) pain is pathologic and
results from abnormal processing of sensory input by the
nervous system as a result of damage to the peripheral or
central nervous system (CNS) or both.
NOTE: Patients may have a combination of nociceptive and
neuropathic pain. For example, a patient may have
nociceptive pain as a result of tumor growth and also report
radiating sharp and shooting neuropathic pain if the tumor
is pressing against a nerve plexus. Sickle cell disease pain
is usually a combination of nociceptive pain from the
clumping of sickled cells and resulting perfusion deficits,
and neuropathic pain from nerve ischemia

EFFECTS OF PAIN
 Pain affects individuals of every age, sex, race,
and socioeconomic class
 It is the primary reason people seek health care
and one of the most common conditions that
nurses treat. Unrelieved pain has the potential to
affect every system in the body and cause
numerous harmful effects, some of which may last
a person’s lifetime

TYPES AND CATEGORIES OF PAIN
 Acute pain differs from chronic pain primarily in
its duration. For example, tissue damage as a
result of surgery, trauma, or burns produces acute
pain, which is expected to have a relatively short
duration and resolve with normal healing.
 Chronic pain is subcategorized as being of
cancer or noncancer origin and can be time limited
(e.g., may resolve within months) or persist
throughout the course of a person’s life. Examples
of noncancer pain include peripheral neuropathy
from diabetes, back or neck pain after injury, and
osteoarthritis pain from joint degeneration.
 Some conditions can produce both acute and
chronic pain. For example, some patients with
cancer have continuous chronic pain and also
experience acute exacerbations of pain
NOTE: Pain is better classified by its inferred pathology as
being either nociceptive pain or neuropathic pain
PHARMACOLOGIC PAIN MANAGEMENT: MULTIMODAL
ANALGESIA
 The recommended approach for the treatment of all
types of pain in all age groups is called multimodal
analgesia
 A multimodal regimen combines drugs with different
underlying mechanisms, which allows lower doses of
each of the drugs in the treatment plan, reducing the
potential for each to produce adverse effects.
Furthermore, multimodal analgesia can result in
comparable or greater pain relief than can be
achieved with any single analgesic agent.

BSN 3A | PBL GROUP 1 21

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PERIOPERATIVE MANAGEMENT
ROUTE OF ADMINISTRATION
 oral route is the preferred route of analgesic
administration and should be used whenever feasible
because it is generally the least expensive, best tolerated,
and easiest to administer
 When the oral route is not possible, such as in patients
who cannot swallow or are NPO (nothing by mouth) or
nauseated, other routes of administration are used. For
example, patients with cancer pain who are unable to
swallow may take analgesic agents by the transdermal,
rectal, or subcutaneous route of administration.
 In the immediate postoperative period, the intravenous
(IV) route is the first-line route of administration for
analgesic delivery, and patients are transitioned to the
oral route as tolerated.
 The rectal route of analgesic administration is an
alternative route when oral or IV analgesic agents are not
an option (e.g., for palliative purposes during end-of-life
care)
 The rectum allows passive diffusion of medications and
absorption into the systemic circulation.
 The rectal route is contraindicated in patients who are
neutropenic or thrombocytopenic because of potential
rectal bleeding. Diarrhea, perianal abscess or fistula, and
abdominoperineal resection are also relative
contraindications
 The topical route of administration is used for both acute
and chronic pain. For example, the nonopioid diclofenac
is available in patch and gel formulations for application
directly over painful areas.
PATIENT-CONTROLLED ANALGESIA
 Patient-controlled analgesia (PCA) is an interactive
method of pain management that allows patients to
treat their pain by self-administering doses of
analgesic agents. It is used to manage all types of
pain by multiple routes of administration, including
oral, IV, subcutaneous, epidural, and
ANALGESIC AGENTS
 Analgesic agents are categorized into three main
groups:
o nonopioid analgesic agents, which
include acetaminophen and NSAIDs;
o opioid analgesic agents, which include,
among others, morphine, hydromorphone,
fentanyl, and oxycodone
o adjuvant analgesic agents (sometimes
referred to as coanalgesic agents).
NOTE: The adjuvant analgesic agents comprise the largest
group and include various agents with unique and widely
differing mechanisms of action. Examples are local
anesthetics, some anticonvulsants, and some
antidepressants
BSN 3A | PBL GROUP 1
TYPES OF ANALGESICS
NON-OPOIOD ANALGESIC AGENTS
Acetaminophen and NSAIDs comprise the group of nonopioid
analgesic agents
INDICATIONS AND ADMINISTRATION
 Nonopioids are flexible analgesic agents used for a
wide variety of painful conditions. They are
appropriate alone for mild to some moderate
nociceptive pain (e.g., from surgery, trauma, or
osteoarthritis) and are added to opioids, local
anesthetics, and/or anticonvulsants as part of a
multimodal analgesic regimen for more severe
nociceptive pain
 Acetaminophen and an NSAID may be given
concomitantly, and there is no need for staggered
doses. Unless contraindicated, all surgical patients
should routinely be given acetaminophen and an
NSAID in scheduled doses throughout the
postoperative course, preferably initiated
preoperatively
 The nonopioids are often combined in a single tablet
with opioids, such as oxycodone (Percocet) or
hydrocodone (Vicodin, Lortab), and are very popular
for the treatment of mild to moderate acute pain.
They are the most common choice after invasive
pain management therapies are discontinued and for
pain treatment after hospital discharge and dental
surgery when an opioid is prescribed.
NOTE: Many people with persistent pain also take a
combination nonopioid–opioid analgesic agent; however, it is
important to remember that these combination drugs are not
appropriate for severe pain of any type because the maximum
daily dose of the nonopioid limits the escalation of the opioid
dose
 Acetaminophen is versatile in that it can be given by
multiple routes of administration, including oral, rectal,
and IV. Oral acetaminophen has a long history of
safety in recommended doses in all age groups. It is
a useful addition to multimodal treatment plans for
postoperative pain
 IV acetaminophen (Ofirmev) is approved for the
treatment of pain and fever and is given by a 15-
minute infusion in single or repeated doses. NOTE: It
may be given alone for mild to moderate pain or in
combination with opioid analgesic agents for more
severe pain and has been shown to be well tolerated
and to produce a significant opioid dose-sparing effect
and superior pain relief compared with placebo.
 Recommended dosing is 1000 mg every 6 hours for a
maximum of 4000 mg in patients weighing more than
50 kg, and 15 mg/kg every 6 hours in patients
weighing less than 50 kg. Repeated doses for up to 5
days have been shown to be safe and well tolerated
 NSAID group is the availability of a wide variety of
agents for administration via noninvasive routes.
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NCM112 LECTURE
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PERIOPERATIVE MANAGEMENT
Ibuprofen, naproxen, and celecoxib are the most
widely used oral NSAIDs in the United States.
 When rectal formulations are unavailable, an intact
oral tablet may be given rectally by inserting the tablet,
or a crushed tablet in a gelatin capsule, into the
rectum. The rectal route may require higher doses
than oral route to achieve similar analgesic effects
 Diclofenac can be prescribed in patch and gel form
for topical administration, and an intranasal patient-
controlled formulation of ketorolac (Sprix) has been
approved for the treatment of postoperative pain.
 IV formulations of ketorolac (Toradol) and
ibuprofen (Caldolor) are available for acute pain
treatment. Both have been shown to produce
excellent analgesia alone for moderate nociceptive
pain and significant opioid dose-sparing effects when
given as part of a multimodal analgesia plan for more
severe nociceptive pain
ADVERSE EFFECTS OF NONOPIOD ANALGESIC
AGENTS
 Acetaminophen is widely considered one of the
safest and best tolerated analgesic agents Its most
serious complication is hepatotoxicity (liver damage)
as a result of overdose. In the healthy adult, a
maximum daily dose below 4000 mg is rarely
associated with liver toxicity. NOTES: Acetaminophen
does not increase bleeding time and has a low
incidence of gastrointestinal (GI) adverse effects,
making it the analgesic agent of choice in many
individuals with comorbidities.
 NSAIDs have considerably more adverse effects than
acetaminophen, with gastric toxicity and ulceration
being the most common. The primary underlying
mechanism of NSAID-induced gastric ulceration is the
inhibition of COX-1, which leads to a reduction in GI-
protective prostaglandins. GI adverse effects are also
related to the dose and duration of NSAID therapy; the
higher the NSAID dose and the longer the duration of
NSAID use, the higher the risk of GI toxicity.
NOTE: A principle of nonopioid analgesic use is to
administer the lowest dose for the shortest time
necessary
OPIOD ANALGESIC AGENTS
 “Although it is often used, the term narcotic is
considered obsolete and inaccurate when discussing
the use of opioids for pain management, in part
because it is a term used loosely by law enforcement
and the media to refer to various substances of
potential abuse, which include opioids as well as
cocaine and other illicit substances.”
 Legally, controlled substances classified as narcotics
include opioids, cocaine, and others. The preferred
term is opioid analgesics when discussing these
agents in the context of pain management patients
prefer the term pain medications or pain medicine.
BSN 3A | PBL GROUP 1
TWO MAJOR GROUPS:
(1) mu agonist opioids (also called morphinelike
drugs)
 The mu agonist opioids comprise the larger of the
two groups and include morphine, hydromorphone,
hydrocodone, fentanyl, oxycodone, and methadone,
among others. The agonist–antagonist opioids
include buprenorphine (Buprenex, Butrans),
nalbuphine (Nubain), and butorphanol (Stadol).
 Opioid analgesic agents exert their effects by
interacting with opioid receptor sites located
throughout the body, including in the peripheral
tissues, GI system, and CNS; they are abundant in
the dorsal horn of the spinal cord.
 There are three major classes of opioid receptor sites
involved in analgesia: the mu, delta, and kappa.
 When an opioid binds to the opioid receptor sites, it
produces analgesia as well as unwanted effects,
such as constipation, nausea, sedation, and
respiratory depression.
 The opioid analgesic agents that are designated as
first line (e.g., morphine, hydromorphone, fentanyl,
and oxycodone) belong to the mu opioid agonist
class because they bind primarily to the mu-type
opioid receptors.
(2) agonist– antagonist opioids.
 The agonist–antagonist opioids are designated as
“mixed” because they bind to more than one opioid
receptor site. NOTE: They should be avoided in
patients receiving long-term mu opioid therapy
because their use may trigger severe pain and
opioid withdrawal syndrome characterized by
rhinitis, abdominal cramping, nausea, agitation, and
restlessness.
 Antagonists (e.g., naloxone, naltrexone) are drugs
that also bind to opioid receptors but produce no
analgesia. If an antagonist is present, it competes
with opioid molecules for binding sites on the opioid
receptors and has the potential to block analgesia
and other effects. Antagonists are used most often
to reverse adverse effects, such as respiratory
depression
ADMINISTRATION
 Many factors are considered when determining the
appropriate opioid analgesic agent for the patient with
pain. These include the unique characteristics of the
various opioids and patient factors, such as pain intensity,
age, coexisting disease, current drug regimen and
potential drug interactions, prior treatment outcomes, and
patient preference. In all cases a multimodal approach
that may rely on the selection of appropriate analgesic
agents from the nonopioid, opioid, and adjuvant analgesic
agent groups is recommended to manage all types of
pain
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NCM112 LECTURE
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PERIOPERATIVE MANAGEMENT
USE OF OPIODS TREATMENT OF ADVERSE EFFECTS

 Perform a comprehensive assessment that addresses  Be aware of the prevalence and impact of opioid adverse
pain, comorbidities, and functional status. effects.
 Develop an individualized treatment plan that includes  Remember that most opioid adverse effects are dose
specific goals related to pain intensity, activities dependent; always consider decreasing the opioid dose
(function/quality of life), and adverse effects (e.g., pain as a method of treating or eliminating an adverse effect;
intensity rating of 3 on a 0–10 numerical rating scale to adding nonopioid analgesic agents for additive analgesia
ambulate accompanied by minimal or no sedation). facilitates this approach.
 Use multimodal analgesia (e.g., add acetaminophen and  Use a preventive approach in the management of
NSAID; anticonvulsant in patients at risk for persistent constipation, including for patients receiving short-term
postsurgical pain). opioid treatment.
 Assess for presence preoperatively of underlying  Prevent respiratory depression by monitoring sedation
persistent pain in surgical patients and optimize its levels and respiratory status frequently and decreasing
treatment. the opioid dose as soon as increased sedation is
 Consider preemptive analgesic agents before surgery, detected.
particularly for those at risk for severe postoperative pain
or a persistent postsurgical Pain syndrome. MONITORING
 Provide analgesic agents prior to all painful procedures.
 Drug selection  Continually and consistently evaluate the plan on the
basis of the specific goals identified at the outset and
o Consider diagnosis, condition, or surgical procedure,
current or expected pain intensity, age, presence of assess pain intensity, adverse effects, and activity
levels.
major organ dysfunction or failure, and presence of
coexisting disease.  Make necessary modifications to treatment plan to
o Consider pharmacologic issues (e.g., accumulation maintain efficacy and safety.
of metabolites and effects of concurrent drugs). NOTE: Equianalgesia. The term equianalgesia means
o Consider prior treatment outcomes and patient approximately “equal analgesia.” An equianalgesic chart
preference. provides a list of doses of analgesic agents, both oral and
o Be aware of available routes of administration (oral, parenteral (IV, subcutaneous, and intramuscular), that are
transdermal, rectal, intranasal, IV subcutaneous, approximately equal to each other in ability to provide pain
perineural, intraspinal) and formulations (e.g., short relief.
acting, modified release).
o Be aware of cost differences. Formulation Terminology. The terms short acting,
 Route of administration immediate release, and normal release have been used
o Use least invasive route possible. interchangeably to describe oral opioids that have an onset of
o Consider convenience and patient’s ability to action of approximately 30 minutes and a relatively short
adhere to the regimen. duration of 3 to 4 hours.
o Consider staff’s (or patient’s or caregiver’s)
ability to monitor and provide care required.
 Dosing and titration
o Consider previous dosing requirement and
relative analgesic potencies when initiating
therapy.
o Use equianalgesic dose chart to determine
starting dose with consideration of patient’s
current status (e.g., sedation and respiratory
status) and comorbidities (e.g., medical frailty),
and then titrate until adequate analgesia is
achieved or dose-limiting adverse effects are
encountered.
o Use appropriate dosing schedule (e.g., around-
the-clock for continuous pain; PRN for
intermittent pain).
o When dose is safe but additional analgesia is
desired, titrate upward as prescribed by 25% for
slight increase, 50% for moderate increase, and
100% for considerable increase in analgesia ADDICTION, PHYSICAL DEPENDENCE, AND
o Provide supplemental doses for breakthrough TOLERANCE
pain; consider PCA if appropriate.
 Physical dependence is a normal response that
occurs with repeated administration of the opioid for
2 or more weeks and cannot be equated with

BSN 3A | PBL GROUP 1 24

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PERIOPERATIVE MANAGEMENT
addictive disease. It is manifested by the occurrence
of withdrawal symptoms when the opioid is suddenly
stopped or rapidly reduced or an antagonist such as
naloxone is given. Withdrawal symptoms may be
suppressed by the natural, gradual reduction of the
opioid as pain decreases or by gradual, systematic
reduction, referred to as tapering.
 Tolerance is also a normal response that occurs with
regular administration of an opioid and consists of a
decrease in one or more effects of the opioid (e.g.,
decreased analgesia, sedation, or respiratory
depression). It cannot be equated with addictive
disease. Tolerance to analgesia usually occurs in the
first days to 2 weeks of opioid therapy but is
uncommon after that. It may be treated with
increases in dose. However, disease progression,
not tolerance to analgesia, appears to be the reason
for most dose escalations.
 Opioid addiction, or addictive disease, is a chronic,
relapsing, treatable neurologic disease The
development and characteristics of addiction are
influenced by genetic, psychosocial, and
environmental factors. No single cause of addiction,
such as taking an opioid for pain relief, has been
found. It is characterized by behaviors that include
one or more of the following: impaired control over
drug use, compulsive use, continued use despite
harm, and craving to use the opioid for effects other
than pain relief.
OPIOID NAÏVE VERSUS OPIOID TOLERANT.
 Patients are often characterized as being either
opioid naïve or opioid tolerant. Whereas an opioid
naïve individual has not recently taken enough opioid
on a regular basis to become tolerant to the effects
of an opioid, an opioid tolerant individual has taken
an opioid long enough at doses high enough to
develop tolerance to many of the effects, including
analgesia and sedation.
OPIOD-INDUCED HYPERALGESIA
 means increased sensitivity to pain. Opioid-induced
hyperalgesia (OIH) is a paradoxical situation in which
increasing doses of opioid result in increasing
sensitivity to pain
SELECTED OPIOID ANALGESIC AGENTS
 Morphine is the standard against which all other
opioid drugs are compared. It is the most widely used
opioid worldwide, particularly for cancer pain, and its
use is established by extensive research and clinical
experience.
 It is available in a wide variety of short-acting and
modified-release oral formulations and is given by
multiple routes of administration.
 It was the first drug to be given intraspinally and
remains a first-line choice for long-term intraspinal
analgesia.
 Morphine is a hydrophilic drug (readily absorbed in
aqueous solution), which accounts for its slow onset
BSN 3A | PBL GROUP 1
and long duration of action when compared with
other opioid analgesic agents relevant metabolites.
 Hydromorphone (Dilaudid) is less hydrophilic than
morphine but less lipophilic than fentanyl, which
contributes to an onset and duration of action that is
intermediate between morphine and fentanyl. The
drug is often used as an alternative to morphine,
especially for acute pain because the two drugs
produce similar analgesia and have comparable
adverse effect profiles
 Oxycodone is available in the United States for
administration by the oral route only and is used to
treat all types of pain. In combination with
acetaminophen or ibuprofen, it is appropriate for mild
to some moderate pain. Single-entity short-acting
(OxyIR) and modified-release (OxyContin)
oxycodone formulations are used most often for
moderate to severe cancer pain and in some patients
with moderate to severe noncancer pain
 Hydrocodone is available only in combination with
nonopioids (e.g., with acetaminophen in Vicodin or
Lortab), which limits its use to the treatment of mild
to some moderate pain
 Methadone (Dolophine) is a unique opioid analgesic
agent that may have advantages over other opioids
in carefully selected patients.
 In addition to being a mu opioid, it is an antagonist at
the NMDA receptor site and thus has the potential to
produce analgesic effects as a second- or third-line
option for some neuropathic pain states.
 It may be used as an alternative when it is necessary
to switch a patient to a new opioid because of
inadequate analgesia or unacceptable adverse
effects.
DUAL-MECHANISM ANALGESIC AGENTS
 The dual-mechanism analgesic agents tramadol
(Ultram) and tapentadol (Nucynta) bind weakly to the
mu opioid receptor site and block the reuptake
(resorption) of the inhibitory neurotransmitters
serotonin and/or norepinephrine at central synapses
in the spinal cord and brain stem of the modulatory
descending pain pathway
 Tramadol is used for both acute and chronic pain
and is available in oral short-acting and modified-
release (Ultram ER) formulations, including a short-
acting tablet in combination with acetaminophen
(Ultracet).
 It has demonstrated good efficacy for the
treatment of neuropathic pain. The drug can
lower seizure threshold and interact with other
drugs that block the reuptake of serotonin, such
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NCM112 LECTURE
MEDICAL-SURGICAL NURSING
PERIOPERATIVE MANAGEMENT
as the SSRIs, putting the patient at risk for
serotonin syndrome, characterized by agitation,
diarrhea, heart and blood pressure changes,
and loss of coordination
 Tapentadol (Nucynta) is available in short-acting
and modified-release oral formulations. The drug has
been shown to produce dose-dependent analgesia
comparable to oxycodone.
OPIOIDS TO AVOID
 Codeine is a prodrug, which means it is
pharmacologically inactive when given. It must be
metabolized to morphine for the patient to experience
pain relief.
 Meperidine (Demerol) has either been removed from or
severely restricted on hospital formularies for the
treatment of pain in an effort to improve patient safety A
major drawback to the use of meperidine is its active
metabolite, normeperidine, which is a CNS stimulant and
can cause delirium, irritability, tremors, myoclonus, and
generalized seizures.
 Propoxyphene (Darvon) and propoxyphene plus
acetaminophen (Darvocet) were prescribed for many
years for mild to moderate pain but were withdrawn from
the U.S. market in 2010
ADVERSE EFFECTS OF OPIOID ANALGESIC AGENTS
 The most common adverse effects of opioids are
constipation, nausea, vomiting, pruritus,
hypotension, and sedation. Respiratory depression,
while less common, is the most serious and feared
of the opioid
ADJUVANT ANALGESIC AGENTS
 The adjuvant analgesic agents comprise the largest
group of analgesic agents, which is diverse and
offers many options.
LOCAL ANESTHETICS
 Local anesthetics have a long history of safe and
effective use for all types of pain management.
 Local anesthetics are sodium channel blockers that
affect the formation and propagation of action
potentials. Injectable and topical local anesthetics
are commonly
used for procedural pain treatment.
 Local anesthetics are added to opioid analgesic
agents and other agents to be given intraspinally for
the treatment of both acute and chronic pain.
 They are also infused for continuous peripheral
nerve blocks, primarily after surgery. The lidocaine
patch 5% (Lidoderm) is placed directly over or
adjacent
 The drug produces minimal systemic absorption and
adverse effects. The patch is left in place for 12 hours
and then removed for 12 hours (12 hours on, 12
hours off regimen).
BSN 3A | PBL GROUP 1
ANTICONVULSANTS
 The anticonvulsants gabapentin (Neurontin) and
pregabalin (Lyrica) are first-line analgesic agents for
neuropathic pain and are increasingly being added
to postoperative pain treatment plans to address the
neuropathic component of surgical pain
 Although further research is needed, their addition
has been shown to improve analgesia, allow lower
doses of other analgesic agents, and help prevent
persistent neuropathic postsurgical pain syndromes,
such as phantom limb, postthoracotomy, posthernia,
and postmastectomy pain
 They are also effective in improving the acute pain
associated with burn injuries as well as reducing the
potential for subsequent neuropathic pain.
 Analgesic anticonvulsant therapy is initiated with low
doses and titration according to patient response.
Primary adverse effects of anticonvulsants are
sedation and dizziness, which are usually transient
and most notable during the titration phase of
treatment
ANTIDEPRESSANTS
 Antidepressant adjuvant analgesic agents are
divided into two major groups: the tricyclic
antidepressants (TCAs) and the serotonin and
norepinephrine reuptake inhibitors (SNRIs).
Evidence-based guidelines recommend the TCAs
 desipramine (Norpramin) and nortriptyline (Aventyl,
Pamelor) and the SNRIs duloxetine (Cymbalta) and
venlafaxine (Effexor) as first-line options for
neuropathic pain treatment.
KETAMINE
 Ketamine (Ketalar) is a dissociative anesthetic with
dose-dependent analgesic, sedative, and amnestic
properties
 As an NMDA antagonist, it blocks the binding of
glutamate at the NMDA receptors and thus prevents
the transmission of pain to the brain via the
ascending pathway
 At high doses, the drug can produce psychomimetic
effects (e.g., hallucinations, dreamlike feelings);
however, these are minimized when low doses are
given
 A benefit of the drug is that it does not produce
respiratory depression.
 Ketamine is given most often by the IV route but can
also be given by the oral, rectal, intranasal, and
subcutaneous routes.
 Epidural ketamine is not approved for use in the
United States. Ketamine has been used for the
treatment of persistent neuropathic pain, but its
adverse effect profile makes it less favorable than
other analgesic agents for long-term therapy. It is,
however, increasingly used as a third-line analgesic
agent for refractory acute pain
26
NCM112 LECTURE
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PERIOPERATIVE MANAGEMENT
NOTE:
Opioid Analgesic Medications. Opioid analgesic agents are
commonly prescribed for pain and immediate postoperative
restlessness. A preventive approach, rather than an “as
needed” (PRN) approach, is more effective in relieving pain.
With a preventive approach, the medication is given at
prescribed intervals rather than when the pain becomes
severe or unbearable.
Patient-Controlled Analgesia. The goal is pain prevention
rather than sporadic pain control. Patients recover more
quickly when adequate pain relief measures are used, and
PCA permits patients to administer their own pain medication
when needed. Most patients are candidates for PCA. The two
requirements for PCA are an understanding of the need
to self-dose and the physical ability to self-dose.
Epidural Infusions and Intrapleural Anesthesia. Epidural
infusions are used with caution in chest procedures because
the analgesic may ascend along the spinal cord and affect
respiration. Intrapleural anesthesia involves the administration
of a local anesthetic by a catheter between the parietal and
visceral pleura. It provides sensory anesthesia without
affecting motor function to the intercostal muscles. This
anesthesia allows more effective coughing and deep
breathing in conditions such as cholecystectomy, renal
surgery, and rib fractures, in which pain in the thoracic region
would interfere with these exercises.
A local opioid or a combination anesthetic (opioid plus local
anesthetic agent) is used in the epidural infusion.
USE OF PLACEBOS
 A placebo is defined as any medication or procedure,
including surgery, that produces an effect in a patient
because of its implicit or explicit intent and not
because of its specific physical or chemical
properties
 A saline injection is one example of a placebo.
Administration of a medication at a known
subtherapeutic dose (e.g., 0.10 mg of morphine in an
adult) is also considered a placebo.
 Placebos are appropriately used as controls in
research evaluating the effects of a new medication.
The new drug is compared with the effects of a
placebo and must show more favorable effects than
placebos to warrant further investigation or
marketing of the drug
 When a person responds to a placebo in accordance
with its intent, it is called a positive placebo response
NON PHARMACOLOGIC METHODS OF PAIN
MANAGEMENT
 Most individuals use self-management strategies to
deal with their health issues and promote well-being.
 Nonpharmacologic measures, such as guided
imagery, music, and the implementation of healing
touch, have been successful clinical adjuncts used to
decrease pain and anxiety. Changing the patient’s
position, using distraction, applying cool washcloths
to the face, and providing back massage may be
BSN 3A | PBL GROUP 1
useful in relieving general discomfort temporarily,
promoting relaxation, and rendering medication
more effective when it is given
OTHER PAIN RELIEF MEASURES
 Other Pain Relief Measures. For pain that is difficult
to control, a subcutaneous pain management system
may be used. In this system, a nylon catheter is
inserted at the site of the affected area. The catheter
is attached to a pump that delivers a continuous
amount of local anesthetic at a specific amount
determined and prescribed by the primary provider
KINDS/CARE OF DRAINS
DRAINS
o tubes that exit the peri-incisional area,
either into a portable wound suction device
(closed) or into the dressings (open).
o to allow the escape of fluids that could
otherwise serve as a culture medium for
bacteria.
INDICATIONS
 to help eliminate dead space
 to evacuate existing accumulation of fluid, to
remove pus, blood, serous exudates, chyle or bile
 to prevent the potential accumulation of fluid
 decrease infection rate
CLASSIFICATION
 OPEN vs CLOSED systems
 ACTIVE vs PASSIVE
1. OPEN DRAINS
 Include corrugated ribber or plastic sheets
 Drain fluid collects in gauze pad or stoma bag
 They increase the risk of infection
 E.g. penrose drain
2. CLOSED DRAINS
 Consist of tubes draining intoa bag or bottle
 They include chest and abdominal drains
 The risk of infection is reduced
 E.g. Jackson-pratt drain
3. ACTIVE DRAINS
 Are maintained under suction
 Can be under low or high pressure
 Closed (Jackson-Pratt, hemovac drain)
 Open (sump drain)
 ADVANTAGES:
o Keep wound dry, efficient fluid removal
o Can be placed anywhere
o Prevent bacterial ascension
o Allows evaluation of volume & nature of
fluid
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NCM112 LECTURE
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PERIOPERATIVE MANAGEMENT
HEMOVAC DRAIN

 DISADVANTAGES:  A fine tube with many holes at the end, which is

o High negative pressure may injure tissue attached to an evacuated glass bottle providing
o Drain clogged by tissue suction
 Used to drain blood under the skin
4. PASSIVE DRAINS
 Have no suction PIGTAIL DRAIN
 Drains by means of pressure differentials, overflow,
and gravity between body cavities & the exterior  Used to remove unwanted body fluids from an
 Closed (NGT, Foleys catheter, T-tube) organ, duct or abscess.
 Open (Penrose drain, conjugated drain)  Are inserted under strict radiological guidance to
 ADVANTAGES: ensure correct positioning
o Allow evaluation of volume & nature of  A sterile, thin, long, universal catheter with a locking
fluid tip that forms a pigtail shape
o Prevent bacterial ascension  The tip of the pigtail has sevral holes which facilitate
o Eliminate dead space the drainage process
 DISADVANTAGES:  Inserted through the skin by a radiologist
o Gravity dependent affects location of drain  Inserted to allow urine to drain directly from a
o Drain easily cogged kidney

PENROSE DRAIN (Open Drain)

 Soft & flexible

 Doesn’t have a collection device
 Empties intro absorptive dressing material
 Promotes drainage passively
 Drainage moving from area of greater pressure in
the wound or surgical site to the area of less
pressure
 A sterile, large pin is often attached to the outer
portion to prevent the drain from slipping back into
the incised area
 The drain acts like a straw to pull fluids out of the
TYPES OF DRAINS wound & release them outside the body

DAVOL DRAIN
JACKSON-PRATT DRAIN
 Has a rubber bulb on top of the drain that acts as
 Used to remove fluids that build up in an area of the
pump to inflate the balloon in the drainage bottle
body after surgery
 To re-establish suction, squeeze the rubber bulb
 Is a bulb-shaped device connected to a tube
with a continuous pumping motion until the balloon
 One end of the tube is placed inside the body
in the drainage bottle is completely inflated
during surgery
 Quickly replace the plug in the drain before the
 The other end comes out through a small cut in the
balloon deflates
skin
 The inflated balloon inside the drainage bottle
 The bulb is connected to this end
creates the suction
 Used as negative pressure vacuum, which also
collects fluid T-TUBE
 Removes fluid by creating suction in the tube. The
bulb is squeezed flat and connected to the tube that  Consisting of a stem & a cross head
sticks out of your body. The bulb expands as it fills  Placed in to the common bile duct while the stem is
with fluid. connected to a small pouch
 COMMON USES:  Used as temporary post-operative drainage of
o Abdominal surgery common bile duct
o Breast surgery  Sometimes used in ureteric problems
o Mastectomy
o Thoracic surgery CHEST TUBE (Close Drain)

 Used to drain haemothorax, pneumothorax, pleural

effusion, chylothorax, & empyema
 Put in the pleural space in the 4th intercostal space
above the upper border of the rib below

BSN 3A | PBL GROUP 1 28

NCM112 LECTURE
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PERIOPERATIVE MANAGEMENT
 ADULT MALE: 28-32 Fr of the outline are recorded on the dressing
 ADULT FEMALE: 28 Fr so that increased drainage can be easily
 CHILD: 18 Fr seen
 NEWBORN: 12-14 Fr o Increasing amounts of fresh blood on the
dressing should be reported immediately

CARING FOR SURGICAL DRAINS

 In portable wound suction, the use of gentle,

constant suction enhances drainage of these fluids
and collapses the skin flaps against the underlying
tissue, thus removing “dead space.”
 Wound vacuum-assisted closure (VAC) devices
o used on open wounds allowed to heal on
their own.
o a foam dressing that uses negative
pressure suction at the wound surface
o removes debris while promoting
granulation tissue growth and blood flow
o placed intraoperatively and the foam
dressing is changed periodically as the
wound shrinks in size
o amount, pressure, and color of drainage
should be assessed and recorded.
o Patients should be assessed for pain as
nerve endings may grow into the sponge
as tissue regrows.
o amount of bloody drainage on the surgical
dressing is assessed frequently
o Spots of drainage on the dressings are
outlined with a pen, and the date and time

BSN 3A | PBL GROUP 1 29