Medical Surgical

Nursing
PERIOPERATIVE NURSING
By : ho ho lidres
 DEFINITION OF TERMS
 SURGERY -It is the branch of medicine
concerned with diseases and conditions
which require or are amenable to
operative procedures. Surgery is the
work done by a surgeon.
-"Surgery can involve
cutting, abrading, suturing, laser or
otherwise physically changing body
tissues and organs."
 SURGEON - A physician who treats
disease, injury, or deformity by operative
or manual methods. A medical doctor
specialized in the removal of organs,
masses and tumors and in doing other
procedures using a knife (scalpel)
 STERILE - free from living germs or
microorganisms; aseptic: sterile surgical
instruments.
 ASEPSIS - The state of being free of
pathogenic microorganisms.
- The process of removing
pathogenic microorganisms or protecting
against infection by such organisms.
 SEPSIS - a toxic condition resulting from the
spread of bacteria or their toxic products
from a focus of infection; especially : 
septicemia
 SEPSIS - is a severe illness caused by
overwhelming infection of the bloodstream by
toxin-producing bacteria.
- is caused by bacterial infection that
can originate anywhere in the body.
 DISINFECTANT - any chemical agent used
chiefly on inanimate objects to destroy or
inhibit the growth of harmful organisms.
 ANTISEPTICS - is a substance that prevents or
arrests the growth or action of microorganisms
either by inhibiting their activity or by destroying
them. The term is used especially for preparations
applied topically to living tissue
 STERILIZATION
-the destruction of all living microorganisms, as
pathogenic bacteria, vegetative forms, and spores.
 BACTERIOSTATIC -Capable of inhibiting the growth
or reproduction of bacteria.
- An agent, such as a chemical or biological
material, that inhibits bacterial growth.
 BACTERICIDAL - Capable of killing bacteria.
 BACTERIOCIDES - is a substance that kills bacteria
.Bactericides are either disinfectants, antiseptics
or antibiotics.
 PREFIXES & SUFFIXES
 Prefixes & Suffixes can explain the type of
procedure the client will undergo:
 PREFIXES

 Supra – above ; beyond

 Ortho – joint
 Chole – bile or gall
 Cysto – bladder
 Encephalo- brain
 Entero – intestine
 Hystero – uterus
 Mast – breast
 Meningo – membrane; meninges
 Myo – muscle
 Nephro – kidney
 Neuro – nerve
 Oophor - ovary
 Pneumo – lungs
 Pyelo – kidney pelvis
 Salphingo – fallopian tube
 Thoraco – chest
 Viscero – organ esp. abdomen
 SUFFIXES
 Oma – tumor ; swelling
 Ectomy – removal of an organ or gland
 Rhapy – suturing or stitching of a part or
an organ
 Scopy – looking into
 Ostomy – making an opening or a stoma
 Otomy – cutting into
 Plasty – to repair or restore
 Cele – tumor ; hernia ; swelling
 Itis – inflammation of
 PERIOPERATIVE
NURSING
 SURGERY – a branch of Medicine
that encompasses preoperative
care, intraoperative judgement &
management, & postoperative
care of patients.
 OPERATION – an invasive modality
of treatment.
 PERIOPERATIVE
NURSING
 DEFINITION:
 a.k.a : OPERATING ROOM NURSING

 The identification of physiological &

sociological needs of the client, & the
implementation of an individualized program
of nursing care in order to restore or maintain
the health & welfare of the patient before,
during & after surgical intervention.
 PERIOPERATIVE
NURSING
 PHILOSOPHY :
 To give service that aims to
provide comprehensive
support physically, morally,
psychologically, spiritually, &
socially to a patient
undergoing surgery.
 PERIOPERATIVE
NURSING
 GOALS :
1.To provide safe, supportive &
comprehensive care.
2.To assist the surgeon by
functioning effectively as a
member of the surgical team.
3.To create & maintain an
aseptic / sterile environment.
 PERIOPERATIVE
NURSING
 Fundamental purposes of the O.R. :
 It is a place. . .

1.To correlate theory & practice.

2.To develop skills in assisting the

surgeon in the operation.
3.To create a suitable sterile field for
surgical procedures to prevent
complications.
Perioperative Patient-
Focused Model
 Period of time that constitutes the surgical experience.
Includes three phases:
 Preoperative phase: the period of time from the decision for
surgery until the patient is transferred into the operating room.
 Intraoperative phase: the period of time from when the patient
is transferred to the operating room to the admission to
postanesthesia care unit (PACU).
 Postoperative phase: the period of time that begins with
admission to the PACU and ends with follow-up evaluation in the
clinical setting or at home
 CLASSIFICATIONS

OF SURGERY
According to Urgency :
1) EMERGENT – pt. requires immediate
attention ; disorder maybe life- threatening.
> indications for surgery : without delay.
> examples : Severe bleeding, extensive
burns, bladder or intestinal obstruction,
fractured skull, gunshot or stab wounds.
 CLASSIFICATIONS
OF SURGERY
2) URGENT – pt. requires prompt
attention.
> indications for surgery : within
24-30 hours.
> examples : Acute gallbladder
infection
Kidney / Ureteral
stones
 CLASSIFICATIONS
OF SURGERY
3) REQUIRED – pt. needs to have
surgery.
> indications for surgery: plan
within few weeks or months.
> examples : Prostatic
hyperplasia without bladder
obstruction, Thyroid disorders,
Cataracts.
 CLASSIFICATIONS
OF SURGERY
4) ELECTIVE – pt should have
surgery.
> indications for surgery:
Failure to have surgery not
catastrophic.
> examples : Repair of scars
Simple hernia
Vaginal repair
 CLASSIFICATIONS
OF SURGERY
5) OPTIONAL – decision rests with
pt.
> indications for surgery :
Personal preference
> examples : Cosmetic surgery
 CLASSIFICATIONS
OF SURGERY
 Accdg. To Degree Of Risk :
 MAJOR – high degree of risk :

>maybe complicated / prolonged,

large losses of blood may occur, vital
organs maybe involved, post-op
complications may be likely.
>ex. Organ transplant
Open heart surgery
Removal of a kidney
 CLASSIFICATIONS
OF SURGERY
 MINOR – little risk with few
complications.
- often performed in a
“day surgery”.
> examples: Breast biopsy
Tonsillectomy
Knee surgery
 CLASSIFICATIONS
OF SURGERY
 Accdg. To Purpose :
1. DIAGNOSTIC – verifies suspected diagnosis

- ex. Biopsy
2. EXPLORATORY – estimates the extent of the
disease or injury.
- Ex. Explore laparotomy
3. CURATIVE – removes or repairs damaged
tissues .
 CLASSIFICATIONS
OF SURGERY
4. ABLATIVE – removing diseased organ that
can’t wait anymore.
- emergency surgery.
5. PALLIATIVE – relieves symptoms but does not
cure the underlying disease process.
6. RECONSTRUCTIVE – partial or complete
restoration of a damaged organ/tissue to
bring back the original appearance &
function.(mammoplasty, face-lift)
7. CONSTRUCTIVE – repairing the damaged
tissue or congenitally defective organ.
(multiple wound repair)
 Accdg. To Location :
1. INTERNAL – inside the body .
Ex. Hysterectomy
2. EXTERNAL – outside the body .
Ex. Skin grafting
 FOUR BASIC PATHOLOGIC CONDITIONS
THAT REQUIRE SURGERY:
1) OBSTRUCTION – a blockage ; are dangerous
because they block the flow of blood, air,
CSF, urine & bile through the body.
2) PERFORATION – is a rupture of the organ,
artery or bleb.
3) EROSION – break in the continuity of
tissue surface. It can be caused by
irritation, infection, ulceration or
inflammation. It can damage the
walls of blood vessels resulting in
serious bleeding.
4) TUMORS – abnormal growth of tissue
that serves no physiologic function
in the body.
 THE SURGICAL RISK
PATIENTS
 Extremes of age ( very young & very old )
 Extremes of weight (emaciation, obesity)
 Dehydrated pts.
 Nutritional deficits
 Pts. with severe trauma or injury, infection/sepsis
 Pts. with cardiovascular disease
 Endocrine dysfunction (diabetes mellitus)
 Hypertensive & hypotensive pts.
 Hypovolemia
 Hepatic disease
 Preexisting mental or physical
disability
 PROBLEMS THAT MAY ARISE IN SURGERY:
1. Surgical risk pts – probability of
morbidity or mortality following
surgery.
2. Pain

3. Hemorrhage

4. Infection

5. UTI
 PHASES OF O.R. NURSING :
I. PREOPERATIVE PHASE
 The rendering of nursing care to
the surgical client as soon as he
is admitted & the decision to
undergo surgery is made.
 It ends on the time the client is
transferred to the O.R.
 NURSING ACTIVITIES :
 Assessment of the client (baseline evaluation of the pt.
before the day of surgery-interview)
 Identification of potential/actual health problems.

 PREADMISSION TESTING- ensure necessary tests have

been performed
 Pre-op teaching involving client & support persons.
 Day of surgery :
 pt. teaching reviewed

 informed consent confirmed

 pt.’s identity & surgical site verified

 IVF started.
 PREPARATION FOR
SURGERY
 Psychological Support :
a) Assess client’s fears, anxieties, support
systems & patterns of coping.
b) Establish trusting relationship with
client & significant others.
c) Explain routine procedures, encourage
verbalization of fears & allow client to
ask questions.
d) Demonstrate confidence in
surgeon & staff.
e) Provide for spiritual care if
appropriate.
 PREOPERATIVE
TEACHING
 Frequently done on an outpatient basis.
 Assess client’s level of understanding of
surgical procedure & its implications.
 Answer questions, clarify & reinforce
explanations given by the surgeon.
 Explain routine pre- & post-op procedures
& any special equipment to be used.
 PREOPERATIVE
 TEACHING
Preoperative experience
 Preoperative medication
 Breathing exercises, coughing, incentive spirometer
 Leg exercises
 Position changes and movement
 Pain management
 Reducing anxiety and fear, support of coping
 Special considerations related to outpatient surgery
Diaphragmatic Breathing
and Splinting When
Coughing
Leg Exercises and Foot
Exercises
 Preoperative Nursing
Interventions
 PHYSICAL PREPARATIONS:
 Patient safety is a primary concern.
 Obtain history of past medical conditions, surgical
procedures, dietary restrictions & medications.
 Perform baseline head-to-toe assessment, including
VS, height & weight.
 Ensure that diagnostic procedures pertinent to
surgery are performed as ordered:
1. CBC
2. Electrolytes
3. PT/PTT (Prothrombin
Time;Partial thromboplastin
time)
4. Urinalysis
5. ECG
6. Blood typing & crossmatch
 NPO- to prevent aspiration
 Bowel prep and skin prep
- cleansing enema or laxative
before surgery to allow
satisfactory visualization of the
surgical site.
- goal of pre-op skin prep is to
decrease bacteria without injuring
the skin.
 Immediate preoperative preparation
 Complete checklist and chart
 Hospital gown, voiding, removal of dentures,
jewelry, contacts, etc.
 Preoperative medication

 Transporting the pt. to the Presurgical

area about 30 to 60 minutes before
anesthetics is to be given.
 Attend to family needs
 LEGAL PREPARATION:
 Surgeon obtains operative permit
(informed consent)
1. Surgical procedures, alternatives ,
possible complications & disfigurements or
removal of body parts are explained.
2. It is part of the nurse’s role as client
advocate to confirm that the client
understands information given.
 INFORMED CONSENT is necessary in the
ff. Circumstances:
 Invasive procedures, such as surgical
incisions, biopsy, cystoscopy or
paracentesis.
 Procedures requiring sedation or
anesthesia
 A non-surgical procedure, such as
arteriography
 Procedures involving radiation
 Adult client (over 18 y/o) signs own permit
unless unconcious or mentally
incompetent.
1. If unable to sign, relative (spouse or next
of kin) or guardian will sign.
2. In an emergency, permission via
telephone or telegram is acceptable; have
a 2nd listener on phone when telephone
permission is given
3. Consents are not needed for
emergency care if all 4 of the ff.
criteria are met:
a. There is an immediate threat to life.
b. Experts agree that it is an emergency.
c. Client is unable to consent.
d. A legally authorized person cannot be
reached.
 Minors (under 18 y/o) must have
consent signed by an adult (i.e.
Parent or legal guardian)
 Emancipated minor (married or
independently earning his or her
own living)may sign his/ her own
consent.
 Witness to informed consent may
be a nurse, another M.D., clerk or
any other authorized person.
 The nurse witnessing informed
consent, specifies whether
witnessing explanation of surgery
or just signature of the client.
 PREOPERATIVE
MEDICATIONS
 PURPOSES:
1. To relieve fear & anxiety.

2. To reduce dose needed for

induction & maintenance of
anesthesia.
3. To prevent reflex bradycardia that
happens during induction of
anesthesia.
4. To minimize oral secretions.
PREOPERATIVE
MEDICATIONS
II. INTRAOPERATIVE PHASE
 Giving nursing care to client
undergoing surgery.
 It starts from the time the pt.
was admitted to the O.R. ,
during operation until it ends &
transferred to the PACU.
 NURSING ACTIVITIES:
 Activities providing for pt’s safety.

 Maintenance of aseptic environment.

 Ensuring proper function of equipments.

 Providing surgeons with specific

instruments & supplies for surgical field.
 Completing documentation.

 Positioning pts.

 Acting as scrub/circulating nurse.

Members of the Surgical
Team
 Patient
 Anesthesiologist
or anesthetist
 Surgeon

 Nurses (Scrub &

Circulating)
 Surgical
technologists
SCRUB TEAM @ WORK
 PATIENT – the most important member of the
surgical team. May feel relaxed & prepared,
or fearful & highly stressed.
- is also subject to several risks.
 OPERATING SURGEON – pre-op dx & care.
- performance of operation.
- post-op mgt & care
- assumes all responsibility for all medical
acts of judgement & mgt.
 SURGEON & ASSISTANTS – scrub & perform
the surgery.
 REGISTERED NURSE 1ST ASST. – practices
under the direct supervision of the
surgeon. (handling tissue, suturing,
maintaining hemostasis)
 ANESTHESIOLOGIST /
 NURSE ANESTHETIST – administers the
anesthetic agent & monitors the pt’s
physical status throughout the surgery.
 SCRUB NURSE – provides sterile instruments &
supplies to the surgeon during the procedure.
- performs surgical hand scrub.
 CIRCULATING NURSE – coordinates the care of the
pt. in the O.R.
- care provided includes assisting with pt.
positioning , skin prep, managing surgical
specimens & documenting intraoperative events.
 SCRUB NURSE
 CIRCULATING
NURSE
                                                                                                                   
 Prevention of Infection
 The surgical environment – stark
appearance & cool temperature. Located
central to all supporting services.
 Unrestricted zone – where street clothes are
allowed.
 Semirestricted zone- where attire consists of
scrub clothes & caps.
 Restricted zone- where scrub clothes, shoe
covers, caps & masks are worn.
THE OPERATING ROOM
 Basic Guidelines for
Surgical Asepsis
 All materials in contact with the wound and
within the sterile field must be sterile.
 Gowns are sterile in the front from chest to the
level of the sterile field, and sleeves from 2
inches above the elbow to the cuff.
 Only the top of a draped table is considered
sterile. During draping, the drape is held well
above the area and is placed from front to back.
 Basic Guidelines for
Surgical Asepsis
 Items are dispensed by methods to preserve sterility.
 Movements of the surgical team are from sterile to
sterile and from unsterile to sterile only.
 Movement around the sterile field must not cause
contamination of the field. At least a 1-foot distance
from the sterile field must be maintained.
 Basic Guidelines for
Surgical Asepsis
 Whenever a sterile barrier is breached, the
area is considered contaminated.
 Every sterile field is constantly maintained
and monitored. Items of doubtful sterility
are considered unsterile.
 Sterile fields are prepared as close as
possible to time of use.
 SURGICAL ASEPTIC
TECHNIQUE
 BEFORE AN OPERATION, it is necessary to
sterilize and keep sterile all instruments,
materials, and supplies that come in contact
with the surgical site. Every item handled by
the surgeon and the surgeon's assistants
must be sterile. The patient's skin and the
hands of the members of the surgical team
must be thoroughly scrubbed, prepared, and
kept as aseptic as possible.
 DURING THE OPERATION, the surgeon, surgeon's
assistants, and the scrub nurses must wear sterile
gowns and gloves and must not touch anything
that is not sterile.
 Maintaining sterile technique is a cooperative
responsibility of the entire surgical team.
 Each member must develop a surgical
conscience, a willingness to supervise and be
supervised by others regarding the adherence to
standards.
 BASIC PRINCIPLES OF
SURGICAL ASEPSIS
 All personnel assigned to the
operating room must practice good
personal hygiene. This includes daily
bathing and clothing change.
 Those personnel having colds, sore
throats, open sores, and/or other
infections should not be permitted in
the operating room.
 Operating room attire (which includes scrub suits,
gowns, head coverings, and face masks) should not
be worn outside the operating room suite. If such
occurs, change all attire before re-entering the clean
area. (The operating room and adjacent supporting
areas are classified as "clean areas.")
 All members of the surgical team having direct
contact with the surgical site must perform the
surgical hand scrub before the operation.
 All materials and instruments used in
contact with the site must be sterile.
 · The gowns worn by surgeons and scrub
corpsmen are considered sterile from
shoulder to waist (in the front only),
including the gown sleeves.
 · If sterile surgical gloves are torn,
punctured, or have touched an unsterile
surface or item, they are considered
contaminated.
 The safest, most practical method of sterilization
for most articles is steam under pressure.
 · Label all prepared, packaged, and sterilized items
with an expiration date.
 · Use articles packaged and sterilized in cotton
muslin wrappers within 28 calendar days.
 Use articles sterilized in cotton muslin wrappers
and sealed in plastic within 180 calendar days
 Unsterile articles must not come in
contact with sterile articles.
 Make sure the patient's skin is as
clean as possible before a surgical
procedure.
 Take every precaution to prevent
contamination of sterile areas or
supplies by airborne organisms.
 HANDLING STERILE
ARTICLES
 When you are changing a dressing, removing
sutures, or preparing the patient for a surgical
procedure, it will be necessary to establish a
sterile field from which to work. The field should
be established on a stable, clean, flat, dry
surface.
 An article is either sterile or unsterile; there is no
in-between. If there is doubt about the sterility of
an item, consider it unsterile
 Any time the sterility of a field has
been compromised, replace the
contaminated field and setup.
 Do not open sterile articles until they
are ready for use.
 Do not leave sterile articles
unattended once they are opened and
placed on a sterile field.
 Do not return sterile articles to a container
once they have been removed from the
container.
 Never reach over a sterile field.
 When pouring sterile solutions into sterile
containers or basins, do not touch the
sterile container with the solution bottle.
Once opened and first poured, use bottles
of liquid entirely. If any liquid is left in the
bottle, discard it.
 Never use an outdated article.
Unwrap it, inspect it, and, if
reusable, rewrap it in a new
wrapper for sterilization.
SURGICAL HAND SCRUB
 PURPOSE: To reduce resident and
transient skin flora (bacteria) to a
minimum.
 Proper hand scrubbing and the
wearing of sterile gloves and a
sterile gown provide the patient
with the best possible barrier
against pathogenic bacteria in the
environment and against bacteria
from the surgical team.
1. Before beginning the hand scrub, don a
surgical cap or hood that covers all hair, both
head and facial, and a disposable mask
covering your nose and mouth.
2. Using approximately 6 ml of antiseptic
detergent and running water, lather your hands
and arms to 2 inches above the elbow. Leave
detergent on your arms and do not rinse.
3. Under running water, clean your fingernails and
cuticles, using a nail cleaner.
4. Starting with your fingertips, rinse each hand and
arm by passing them through the running water.
Always keep your hands above the level of your
elbows.
5. From a sterile container, take a sterile brush and
dispense approximately 6 ml of antiseptic
detergent onto the brush and begin scrubbing your
hands and arms.
6. Begin with the fingertips. Bring your thumb and
fingertips together and, using the brush, scrub
across the fingertips using 30 strokes.
7. Now scrub all four surface planes of the thumb and
all surfaces of each finger, including the webbed
space between the fingers, using 20 strokes for
each surface area.
8. Scrub the palm and back of the hand in a circular
motion, using 20 strokes each.
9. Visually divide your forearm into two parts, lower
and upper. Scrub all surfaces of each division 20
strokes each, beginning at the wrist and
progressing to the elbow
10. Scrub the elbow in a circular motion using 20
strokes.
11. Scrub in a circular motion all surfaces to
approximately 2 inches above the elbow.
12. Do not rinse this arm when you have finished
scrubbing. Rinse only the brush.
13. Pass the rinsed brush to the scrubbed hand and
begin scrubbing your other hand and arm, using
the same procedure outlined above
14. Drop the brush into the sink when you are
finished.
15. Rinse both hands and arms, keeping your hands
above the level of your elbows, and allow water
to drain off the elbows.
16. When rinsing, do not touch anything with your
scrubbed hands and arms.
17. The total scrub procedure must include all
anatomical surfaces from the fingertips to
approximately 2 inches above the elbow.
18. Dry your hands with a sterile towel.
Do not allow the towel to touch
anything other than your scrubbed
hands and arms.
19. Between operations, follow the
same hand- scrub procedure.
 Gowning and Gloving
 GOWNING
 1. Dry one hand and arm, starting with the hand and ending
at the elbow, with one end of the towel. Dry the other hand
and arm with the opposite end of the towel. Drop the towel.
 2. Pick up the gown in such a manner that hands touch only
the inside surface at the neck and shoulder seams.
 3. Allow the gown to unfold downward in front of you.
 GLOVING
 1. Pick up one glove by the cuff using your
thumb and index finger.
 2. Touching only the cuff, pull the glove
onto one hand and anchor the cuff over
your thumb.
 3. Slip your gloved fingers under the cuff of
the other glove. Pull the glove over your
fingers and hand, using a stretching side-
to-side motion.
 4. Anchor the cuff on your thumb. With
your fingers still under the cuff, pull the
cuff up and away from your hand and over
the knitted cuff of the gown.
 5. Repeat the preceding step to glove your
other hand.
 6. The gloving process is complete.
 To gown and glove the surgeon,
follow these steps:
1. Pick up a gown from the sterile
linen pack. Step back from the
sterile field and let the gown
unfold in front of you. Hold the
gown at the shoulder seams with
the gown sleeves facing you.
 2. Offer the gown to the surgeon. Once the surgeon's
arms are in the sleeves, let go of the gown. Be
careful not to touch anything but the sterile gown.
The circulator will tie the gown.
 3. Pick up the right glove. With the thumb of the
glove facing the surgeon, place your fingers and
thumbs of both hands in the cuff of the glove and
stretch it outward, making a circle of the cuff. Offer
the glove to the surgeon. Be careful that the
surgeon's bare hand does not touch your gloved
hands. (Repeat for left hand)
 TYPES OF ANESTHESIA
 ANESTHESIA - is a state of narcosis,
analgesia, relaxation & reflex loss.
 involves the use of medications
that block pain sensations
(analgesia) during surgery and
other medical procedures.
 Anesthesia also reduces many of
your body's normal
stress reactions to surgery.
 TYPES OF ANESTHESIA
 I. General Anesthesia
 II. Local Anesthesia
 III. Regional Anesthesia
 IV. Moderate Sedation
 V. Monitored Anesthesia Care
 GENERAL ANESTHESIA
 I. GENERAL ANESTHESIA - affects your
entire body and renders you
unconscious.
 The patient would be completely
unaware and not feel pain during the
surgery or procedure.
 Also causes forgetfulness (amnesia)
and relaxation of the muscles
throughout your body.
 Suppresses many of your body’s normal
automatic functions, such as those that
control breathing, heartbeat, circulation
of the blood (such as blood pressure),
movements of the digestive system, and
throat reflexes such as swallowing,
coughing, or gagging that prevent foreign
material from being inhaled into your lungs
(aspiration)
 Monitoring of the heart, breathing,
blood pressure, and other vital
functions is important. An
endotracheal (ET) tube or a
laryngeal mask airway is usually
used to give an inhalant anesthetic
and oxygen, control and assist
breathing. An ET tube is used to
prevent aspiration.
 General anesthesia is commonly begun
(induced) with
intravenous (IV) anesthetics, but
inhalation agents also may be used.
Once you are unconscious, anesthesia
may be maintained with an inhalant
anesthetic alone, with a combination of
intravenous anesthetics, or a
combination of the two.
 STAGES OF GENERAL
ANESTHESIA
 STAGE I – BEGINNING ANESTHESIA
STAGE I – BEGINNING ANESTHESIA
 Warmth, dizziness , & feeling of detachment.

 Ringing, roaring or buzzing in the ears.

 Still conscious but may sense inability to move the

extremities easily.
 Noises are exaggerated – even low voices or minor
sounds seem loud & unreal.
 Unnecessary noises & motions should be avoided.
 STAGE II – EXCITEMENT
 Struggling, shouting ,talking, singing,
laughing or crying – (avoided if given
smoothly & quickly)
 Pupils dilate ( but contract if exposed to
light)
 PR rapid & RR irregular.

 Restraining the patient may be possible.

 STAGE III – SURGICAL ANESTHESIA
 Reached by continuous administration
of anesthetic vapor or gas.
 Pt. is unconscious & lies quietly.

 Pupils are small but contract when

exposed to light
 RR regular, PR & volume WNL, skin
pink/flushed
 STAGE IV – MEDULLARY DEPRESSION
 Reached when too much anesthesia has
been administered.
 Respirations shallow, pulse weak &
thready .
 Pupils widely dilated & no longer
contract when exposed to light.
 CYANOSIS develops & w/o prompt
intervention  DEATH
 Anesthetic is discontinued
immediately.
 Circulatory support initiated.
 REGIONAL ANESTHESIA
 REGIONAL ANESTHESIA involves
injection of a local anesthetic (numbing
agent) around major nerves or the
spinal cord to block pain from a larger
but still limited part of the body. TYPES
:
 1. EPIDURAL
 2. SPINAL
 3. LOCAL CONDUCTION BLOCKS
 EPIDURAL ANESTHESIA
 commonly used conduction block
 Injecting a local anesthetic into the epidural
space that surrounds the dura matter of the SC.
 Blocks sensory, motor & autonomic functions.
 Doses are much higher than spinal because
epidural anesthetic does not make direct contact
w/ the SC or nerve roots.
 ADVANTAGE: absence of headache
 DISADVANTAGE: greater technical
challenge of introducing the anesthesia
in the epidural space.
 If (+) accidental puncture of the dura
happens & the anesthetic travels
toward the head  HIGH SPINAL
ANESTHESIA  SEVERE HYPOTENSION ,
RESPIRATORY DEPRESSION  ARREST
 SPINAL ANESTHESIA
 Local anesthetic is introduced @ the
lumbar level between L4 & L5.
 Produces anesthesia of lower
extremities, perineum & lower
abdomen.
 Lumbar puncture done  knee –chest
position
 As soon as the injection has been made
 position pt on his back
 PERIPHERAL NERVE BLOCKS. A local anesthetic is
injected near a specific nerve or group of nerves to
block pain from the area of the body supplied by the
nerve. Nerve blocks are most commonly used for
procedures on the hands, arms, feet, legs, or face.
 Brachial plexus block- arm
 Paravertebral anesthesia- chest, abdo wall & ext.
 Transacral (Caudal) block- peineum,lower abdomen
 LOCAL ANESTHESIA
 LOCAL ANESTHESIA involves injection of
a local anesthetic (numbing agent)
directly into the surgical area to block
pain sensations. It is used only for minor
procedures on a limited part of the body.
You may remain awake, though you will
likely receive medicine to help you relax
or sleep during the surgery
 Often administered in combination with
Epinephrine.
 ADVANTAGES :
 Simple, economical, non-explosive
 Equipment needed is minimal
 Post-op recovery is brief
 Undesirable effects of Gen.
Anesthesia are avoided.
 Ideal for short & superficial surgical
procedures.
 Intraoperative
Complications
 Nausea and vomiting
 Anaphylaxis
 Hypoxia and respiratory complications
 Hypothermia
 Malignant hyperthermia
 Disseminated intravascular
coagulation (DIC)
Potential Adverse Effects
of Surgery and
Anesthesia
 Allergic reactions and drug toxicity or reactions

 Cardiac dysrhythmias
 CNS changes and oversedation or
undersedation
 Trauma: laryngeal, oral, nerve, and skin,
including burns
 Hypotension
 Thrombosis
 Gerontologic
Considerations
 Elderly patients are at increased risk for
complications due to surgery and anesthesia
because of:
 Increased likelihood of coexisting conditions.
 Aging heart and pulmonary systems.

 Decreased homeostatic mechanisms.

 Changes in responses to drugs and anesthetic

agents due to aging changes such as decreased
renal function, and changes in body composition
of fat and water.
 Nursing Goals for the
Patient in the
Intraoperative Period
 Reducing anxiety
 Preventing positioning injuries
 Maintaining patient safety
 Maintaining the patient's dignity
 Avoiding complications
 Laparotomy Position,
Trendelenburg Position, Lithotomy
Position, and Sidelying Position
for Kidney Surgery
 Protecting the Patient
from Injury
 Patient identification
 Correct informed consent
 Verification of records of health
history and exam
 Results of diagnostic tests
 Allergies (include latex allergy)
 Monitoring and modifying the
physical environment
 Safety measures such as grounding
of equipment, restraints, and not
leaving a sedated patient
 Verification and accessibility of blood
III. POSTOPERATIVE PHASE
 Begins with the admission of
the client to PACU & ends with
discharge of client from
hospital or facility providing
continuity of care.
 Post-Anesthesia Care
Unit
 The PACU environment
 Beds and other equipment
 Three phases:
 Phase I
 Phase II

 Phase III
 Nursing Management in
the PACU
 Provide care for the patient until he/she
has recovered from the effects of
anesthesia.
 Patient has resumption of motor and
sensory function, is oriented, has stable
VS, and shows no evidence of hemorrhage
or other complications of surgery.
 Frequent skilled assessment of the patient
is vital
 Responsibilities of the
PACU Nurse
 Review pertinent information and baseline
assessment upon admission to the unit.
 Assessments include airway and respirations,
cardiovascular function, surgical site, function of
the central nervous system; also assess IVs and all
tubes and equipment.
 Reassess VS and patient status every 15 minutes
or more frequently as needed.
 Provide report and transfer the patient to another
unit or discharge the patient to home.
 Outpatient
Surgery/Direct Discharge
 Discharge planning and discharge assessment

 Provide written and verbal instructions regarding

follow-up care, complications, wound care, activity,
medications, and diet.

 Give prescriptions and phone numbers. Discuss actions

to take if complications occur.
 Outpatient
Surgery/Direct Discharge
 Give instructions to the patient and a
responsible adult who will accompany the
patient.

 Patients are not to drive home or be

discharged to home alone. Sedation and
anesthesia may cloud memory and judgment
and affect ability.
 Maintaining a Patent
Airway
 A primary consideration: necessary to maintain
ventilation and oxygenation!
 Provide supplemental oxygen as indicated.
 Assess breathing by placing hand near face to feel
movement of air.
 Keep head of bed elevated 15-30o unless
contraindicated.
 May require suctioning.
 If vomiting occurs, turn patient to the side
Head and Jaw Positioning
to Open Airway
 Use of Oral Airway
Note: Do not remove oral airway until
evidence of gag reflex returns