Perioperatif Nursing PDF

Perioperative Nursing
Care
Objectives
• List and discuss common purposes
of surgery. • List the components of
preoperative assessment and discuss

the purposes and nursing
responsibilities. • List the components
of preoperative patient preparation and

discuss the purposes and nursing
responsibilities. • List and discuss the

potential complications of the
postoperative period and the
preventative measures. • Discuss
nursing responsibilities related to the
postoperative
care of patients.
Common Terms
Perioperative Nursing: • Includes the
preoperative (before), intraoperative
(during)
and postoperative (after) periods.
Preoperative period: • This is an
important time to address issues that
may come
up during surgery (Screening)
o i.e. assess for bleeding problems,
don't want to find out

that someone has a bleeding problem
as they exsanguinate on the operating
table • Also can teach patients and
family about what to expect

before, during and after a procedure
o in an emergency, we can prepare

the family if the patient
isn't alert
Types of Surgeries
1. Diagnostic 2. Therapeutic 3.
Palliative 4. Preventive 5. Cosmetic
Types of Surgeries
Diagnostic: • Determination of the
presence and or extent of the
pathology • i.e. lymph node bx,

bronchoscopy, exploratory
laparatomy
Therapeutic: • Elimination or repair of

the pathology
• Removal of the
appendix
when it's inflammed, removal of a
localized cancer
Types of Surgeries
Palliative: • Alleviation of symptoms
without curing the underlying disease •
Rhizotomy (cutting of a nerve

root)
to decrease pain, colostomy
placement to bypass an obstructing
colon tumor
Preventative: • Surgery to remove

tissue that
has the potential to become
pathologic (may not already express a
pathologic problem) • Total
Colectomy in patients
with FAP
Types of Surgeries
Cosmetic: • The surgery is preformed
for aesthetic reasons • Repair of
scars from burns or injuries, minor
cleft palate
repairs, face lifts, breast
augmentation
Further Descriptors of
Surgery
Elective: • Carefully planned event •
Advanced assessments are usually

attained and pre-operative checks are
in place
o blood draws o physical exam o
other necessary studies • Can be
scheduled in some cases

as an
outpatient or in an ambulatory surgery
center
Emergency: • arises unexpectedly •

can also occur in a wide
variety of settings
OR o Battlefield/Trauma
o ER o
scene • Needed within minutes to
hours Urgent: • delay could be
detrimental • usually within 24-48
hours
Types of Elective
Admissions for Surgery
Ambulatory Surgery: • Usually
outside a hospital setting • Special
prescreening • Don't use in patient's
with multiple problems Same-Day

Surgery: • Outpatient, can be in the
hospital • Go home the day of the
surgery Early
Hospital Admission: •
Patient comes in early (night before or
earlier) • Usually patients with complex
medical issues, and increased

risk for poor surgical outcomes
TABLE 18-1
Suffixes Describing Surgical Procedures
Suffix
-ectomy -lysis -orrhaphy -oscopy -ostomy -otomy

-plasty
Meaning
Excision or removal of Destruction of Repair or suture

of Looking into Creation o f opening into Cutting into or
incision of Repair or reconstruction of
Example Appendectomy Electrolysis Herniorrhaphy
Endoscopy Colostomy Tracheotomy Mammoplasty
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f Elsevier Inc.
Preoperative Nursing
Assessment
1. Age 2. Allergies 3. Vital Sign Trend
4. Nutritional Status 5. Habits affecting
tolerance to anesthesia 6. Presence of
Infections 7. Use of drugs that are
contraindicated prior to surgery 8.
Physiological Status 9. Psychological
state of the patient
Assessment
Age: • Elderly are at risk • >65 years of
age • obtain a detailed medical

history and health assessment •
assess for sensory deficits • assess for
overall functional
status • understand
that there is a decreased
physiological
reserve
Allergies: • assess for known drug,
food and substance allergies • assess
what the reaction

to the drug or substance is (is it a true
allergy, hives or anaphylaxis?) •
allergies must be clearly noted

on the
chart, and other steps are usually
taken per hospital/institutional protocol
Assessment
Vital Signs Trends: • What is normal
for that patient,

and are V/S in the
preoperative period in line with the
norms or deviating?
Assessment
Nutritional Status: • This can be a
situation of deficit or excess • assess
for individuals who are prone to
general nutritional
deficiencies:
o Aged o
Cancer patients o
Gastrointestinal problems o Chronic

illness/Chronic steriod use o
Alcoholics/Drug Addicts • Also assess
for excess (Obesity):

o Poor wound healing because of
decreased blood supply o Hard to
access surgical site o Decreased lung
capacity o Anesthesia meds are
stored in fat cells

Assessment
Habits affecting tolerance to
anesthesia: • Smoking:
o alters platelet
function...hypercoagulable o reduces
the amount of functional hemoglobin ■
carboxyhemoglobin o cilia in the lung
are damaged, more difficult to mobilize

secretions in the patient that smokes o
retards wound healing (especially
because of the decreased functional
hemoglobin) • Alcoholism: o can have
impaired liver function o B-vitamin
deficiencies • Opioid Addiction

o have a high tolerance for pain meds
Assessment
Presence of Infections: • Biggest
indicator is the presence of fever
above 101 degrees

F (38C) • If
infection is present, likely surgery will

need to be delayed because
the risks
to the patient are too great. • Goal will
be to find and treat the infection, and
then
reattempt surgery once the infection is
cleared
Assessment
Use of drugs that are
contraindicated prior to surgery: •
Drugs like aspirin, heparin, warfarin

(Coumadin) should be
stopped prior to surgery
o affect bleeding time ■ ASA is 2
weeks because of the permanent
platelet
affects ■ heparin, and low molecular
weight heparins are usually stopped

24 preop, unless there are problems
with the liver ■ warfarin is usually 7
days, but the PT/INR is rechecked

either the day of or the day before the
surgery to check for bleeding
Assessment
Use of drugs that are
contraindicated prior to surgery: •
current use of medications, over the
counter agents and herbal

remedies
should be assessed and documented •
some drugs/herbs can interact with the
anesthesia • check about
antihypertensives the morning of

surgery • need to be clear about home
meds (dose, frequency, timing) so

that
any necessary meds are in the
postoperative order as per the MD
o can check with the MD if certain
meds should be restarted • want to
reinforce that if the patient is to take
meds the
morning of surgery, they should be
taken with sips of water
Assessment
Physiological Status: • Need to
ensure as a
preoperative nurse that all labs, xrays,
EKGs and necessary tests are done
and in the chart • Need to notify the

physician if there is anything abnormal,
shouldn't assume that they've already
seen it
Psychological Status: • Common
behaviors are fear

and anxiety • fear =
pt. knows what they are

scared of •
anxiety = don't tangibly

know what is scaring you
Assessment
Psychological States: Common
Fears: – Fear of death – Fear of pain
and discomfort – Fear of mutilation or
alteration in body image – Fear of
anesthesia – Fear of disruption of life
functioning or patterns – Fear due to
lack of knowledge regarding the
proposed surgery
– Fear related to
previous surgical expriences – Fear
due to the influence of significant
others
Remember, for our patients, surgery
presents a major lack of control.
Assessment
Psychological States: Preoperative
fear and anxiety can lead to:
1. Need for increased anesthesia 2.
Need for increased postoperative pain
management 3. Speed of recovery is
decreased
Preoperative education of what to
expect in clear, common english
can alleviate some fear and anxiety
Remember the role of HOPE for our
patients, it is often the most
common coping strategy
Patient Preparation for
Surgery
1. Operative consent 2. Preoperative
learning needs 3. Interventions the day
or evening prior to surgery 4.
Interventions the day of surgery
Operative Consent
This is part of the legal preparation for
surgery.
Informed consent: an active, shared
decision making process between the
provider and recipient of care. Has 3
components to make it valid:
1. Adequate Disclosure: of the
diagnosis, nature and purpose
of the proposed treatment, probability
of successful outcome, risks and
consequences of moving forward with
treatment or alternatives, the
prognosis if treatment is not instituted,
and if treatment is deviating from
standard for their condition. 2.
Understanding and Comprehension of
above: this has to
be assessed before sedating meds
can be given (minors can't give
consent, severely mentally ill or
severely developmentally challenged).
Operative Consent
Informed Consent (cont):
3. Voluntary Consent: Can't be
coerced into going through with a
procedure. This consent can be
revoked at any point leading up to a
surgical procedure. Who can give
consent? • the patient • next of kin (in
order of kinship): Spouse, Adult Child,
Parent,
Sibling
o Can be designated with a durable

power of attorney in
case of medical incapacitation
Who has the legal
responsiblity of
obtaining consent?
The Physician
• The nurse is not legally required to
obtain consent • however, the nurse
must make sure the consent was
signed o nurse has a primary role as
a patient advocate. • nurse can

"witness" the consent, and sign it as
such • if the patient has questions that
you can answer to clarify things,

you
can do that • if the patient continues to
have questions, or there is a

question that they are not voluntarily
giving consent, the doctor needs to
come and speak with them again. •
Very important that patient is
consenting voluntarily and

with knowledge of the situation
What about emergency
treatment?
A true medical emergency may
override the need to obtain consent.
When medical care is needed to
protect the life of an individual, the
next of kin/POA (Power of Attorney)
can give consent. Also, if there is a
known and available Advanced
Directive with healthcare decision
making instructions, that can be
used to assist in justifying consent.
If they are not available, and the
doctor deems the procedure
necessary for life, the doctor can
chart that it was necessary, and go
ahead with the procedure. • The
nurse may need to write up an incident
report and state

that the emergency caused a deviation
in the normal policy to obtain consent
on everyone.
Patient preparation:
preoperative learning
needs
• Deep breathing (incentive
spirometer), coughing, leg exercises,
ambulation • Pain control and

medications • Cognitive control to
decrease anxiety and enhance

relaxation (deep breathing) • Recovery
room orientation • Probable
postoperative therapies • Directions for
the family
Essential Gastrocnemius (calf)
pumping
NNNNNNNNN
www
www.WIN
Quadriceps (thigh) setting

Desirable Foot circles
Hip and knee movements
www
Copyright © 2007 by Masby, Inc., an affiliate of

Elsevier Inc.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier
Inc.
TABLE PATIENT A ND F AMILY TEACHING GUIDE
18-7 Preoperative Preparation
Sensory Information
• Holding area may be noisy.
Drugs and cleaning solutions may be smelled.
Operating room (OR) can b
e cold; warm blankets are
available.
• Talking may be heard in the O
R but may be distorted because of
masks. Questions should be asked if something is not
understood. OR bed will be narrow. A safety strap will be
applied over the knees. Lights in the OR may be very bright.
Monitoring machines (ticking and pinging noises) may be
heard when awake. T heir purpose is to monitor and ensure
safety.
Procedural Information
What to bring and what type of clothing to wear to the
ambulatory surgery center. Any changes in time of surgery.
Fluid and food restrictions. Physical preparation required (e.g.,
bowel or skin preparation). Purpose of frequent vital signs
assessment. Pain control and other comfort measures. W hy
turning, coughing, and deep breathing postoperatively is
important; practice sessions n eed to be done preoperatively.
Insertion of intravenous lines. Procedure for anesthesia administration.
Expect surgical site and/or side to be marked with indelible i nk or
marker.
Process Information Information About General Flow of
Surgery
Admission area. Preoperative holding area, OR, and recovery
area. Families can usually stay in holding area until
surgery. Families may be able to enter recovery area as
soon as patient is awake. Identification of any technology that
may be present on awakening,
such as monitors and central lines. Where Families Can Wait
during Surgery
Patient and family members need to be encouraged to
verbalize concerns. OR staff will notify family when surgery is
completed. Surgeon will usually talk with family following
surgery.
f Elsevier Inc.
interventions the day or
evening prior to the
surgery
• Diet Restrictions
o Historical guidelines to prevent
aspiration were NPO after
midnight the night before o Educating
the patient about the reason for NPO

status may
help with adherence •
Information of what to wear to the
surgery • Patient will likely need to be
there 1 to 2 hours prior to

scheduled procedure
TABLE 18-8 Preoperative Fasting
Recommendations*
Minimum Fasting Liquid and Food Intake

Period (hr) Clear liquids (e.g., water, clear tea, black
coffee, carbonated beverages, and fruit
juice without pulp) Breast milk Nonhuman milk,
including infant formula Light meal (e.g., toast and clear
liquids) Regular or heavy meal (may include fried
or fatty food, meat)
Source: Practice guidelines for preoperative fasting a nd

the use of pharmacologic agents to reduce the risk of
pulmonary aspiration: a pplication to healthy patients u n
dergoing elective procedures: a report by the American
Society of Anesthesiologists. Available at
www.asahq. o
rg/publications A ndServices/NPO. p
df.
*For healthy patients of all ages undergoing elective
surgery (excluding women in labor).
f Elsevier Inc.
interventions the day of
surgery
This varies based on whether the
person is inpatient or outpatient. •
Encourage the patient to void (empty
their bladder) before they

get any
sedative medications • Final

preoperative teaching • Final
Assessment and communication of
findings to MD • Ensuring that all
preoperative orders have been
completed • Check to chart to make
sure that there is:

o a signed consent for the procedure o
laboratory data, Xray reports, EKG o
H&P, and necessary consults o
Baseline vitals o Nursing notes up until

that point
interventions the day of
surgery
• Remove any jewerly, hair pins,
clothes (except gown)
o May be able to wear a wedding band
taped firmly to the finger • Remove
contact lens • No dentures or partial
dentures • If the hearing aides need to
be removed, please not that on

the front of the chart.
o glassesor hearing aides need to be
returned to the patient as soon as
possible after the procedure • No
makeup or dark nail polish • Give any
preoperative medications • Note the
time the patient leaves the floor • ID
band should be placed, or checked
depending on patient
status, and an allergy band per
institution protocol
Preoperative Checklist
Preoperative
Medications
• Benzodiazepines/Barbituates: used
for their sedative and amnesic
properties • Anticholinergics: reduce
secretions, and can reduce cramping

•
Opioids: decrease need for
intraoperative analgesics and

decrease pain • Antiemetics: decrease
N/V • Antibiotics: to prevent infective
endocarditis, or where
wound contamination is a risk (GI
surgery) or where wound infection
would cause significant postoperative
morbidity o usually given IV •
Eyedrops: especially with eye surgery
(lasik, cataract
surgery)
Preoperative
Medications
Intraoperative Nursing
Issues
• Nursing roles
o Circulating nurse o Scrub RN •

Perioperative asepsis • Types of
anesthesia
o General o
Regional • Patient
positioning • Temperature alterations
during the intraoperative period

Nursing Roles
Circulating Nurse: • Deal with the
management of
unsterile activities in
the operating area • Document the the
nursing
care of the patient
interventions
o assessments o •
movement of unsterile
items out of the surgical suite
o labelingand
transporting specimens
Scrub Nurse: • Is gowned and gloved
and able
to handle and pass sterile
items into the sterile surgical field •
"Boss" of the sterile field • Assists with
the actual procedure

to varying
degrees
TABLE 19-1| Intraoperative Activities
of the Perioperative Nurse
Circulating/Nonsterile Activities
Reviews anatomy, physiology, and the surgical procedure. . Assists with preparing the
room. . Practices aseptic technique in all required activities.
Monitors practices of aseptic technique in self and others.
Ensures that needed items are available and sterile (if required). . Checks mechanical
and electrical equipment and environmental
factors. Identifies and admits the patient to the OR suite. Assesses the patient's physical and
emotional status. Plans and c
oordinates the intraoperative nursing care. Checks the
chart and relates pertinent data. Admits the patient to the operating room suite.
Assists with transferring the patient to the operating room bed.
• Ensures patient safety in transferring and positioning the patient.
Participates in insertion and application of monitoring devices. Assists with the
onitors the draping procedure. Documents intraoperative
induction of anesthesia. M
ecords, labels, and s
care. R ends to proper locations tissue specimens and
cultures
Measures blood and fluid loss.
• Records amount of drugs used during local anesthesia.
Coordinates all activities in the room with team members and other health-related
personnel and departments. Counts sponges, needles, and instruments.
Accompanies the patient to the postanesthesia recovery area. Reports information
relevant to the care of the patient to the recov
ery area nurses.
Scrubbed/Sterile Activities
Reviews anatomy, physiology, and the surgical procedure. Assists with preparation of the
ther members of the surgical team. Prepares
room. Scrubs, gowns, and gloves self and o
the instrument table and organizes sterile equipment for functional
use. Assists with the draping procedure. Passes instruments to the surgeon and assistants
by anticipating their needs. Counts sponges, needles, and instruments... Monitors practices
eeps track of irrigation solutions used for
of aseptic technique in self and others. K
calculation of blood
loss.
• Reports amounts of local anesthesia and epinephrine solutions
used by ACP and/or surgeon.
ACP Anesthesia care provider.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Other Nursing Roles

Registered Nurse First Assistant: •
Work in collaboration with the surgeon
to ensure excellent patient

outcomes •
Specialized training and certification •
Handle tissue specimens, use
instruments, provide
exposure to the surgical site, assist
with hemostatis and suturing Nurse
Anesthetist: • minimally masters

prepared • Perform many of the roles
that an anesthesiology MD preform

•
manage patient preop assessment,
induction, maintenance,
and emergence from anesthesia
TABLE 19-2 Examples of Nursing Activities
Surrounding the Surgical Experience
After
Before Assessment Home/Cl inic/Holding Area Initiates preoperative
assessment Plans teaching methods appropriate to patient's
nit Completes preoperative
needs Involves family in interview Surgical
U
assessment Coordinates patient teaching with other nursing
staff Develops a plan of care Surgical Suite Identifies patient Verifies
surgical site Assesses patient's level of consciousness, skin
integrity, mobility, emotional status, and
lanning Determines a plan of care that incorporates
functional limitations Reviews chart P
and
respects the patient's value system, lifestyle, ethnicity, and culture; care plan reflects the
patient's level of function and ability during
the perioperative period Ensures all s upplies and equipment needed for
surgery are available, f unctioning properly, and sterile, if appropriate
During Implementation Maintenance of Safety Ensures the integrity of
the sterile field Ensures that the sponge, needle, and instrument
counts are correct Positions the patient t o ensure correct align
ment, exposure of surgical site, and p
reven
tion of injury Prevents chemical injury from prepping solu
tions, pharmaceuticals, etc. Ensures safe use of electrical equipment, lasers,
and radiation Safely administers appropriate medications Monitoring of
Physical Status Monitors and reports changes in patient's vital
signs Monitors blood loss Monitors urine output as applicable Monitoring of
Psychologic Status Provides emotional support to patient S
tands near or
touches patient during proce
dures and induction Ensures the p
atient's right to privacy is
maintained Communicates patient's emotional status to
other appropriate members of the health care team
Evaluation
Postanesthesia/Discharge Area Determines patient's immediate response to sur
gical intervention Monitors vital signs Safely administers appropriate
medications Surgical Unit Evaluates effectiveness of nursing care in the
OR using patient outcome criteria Determines patient's level of satisfaction with
care given during perioperative period Evaluates products used on patient in
the OR Determines patient's psychologic status Assists with discharge planning
linic Seeks patient's perception of surgery in terms of
Home/C
the effects of anesthetic agents, impact on
body image, immobilization Determines family's perceptions of surgery
OR. Operating room
What's in the Operating

Area?
A surgical suite is a controlled
environment designed to minimize
the spread of infectious organisms
and allow a smooth flow of patients,
personnel, and the instruments and
equipment. • Unrestricted Area:
where personnel in street clothes can

interact with those in scrubs •
Semirestricted Area: peripheral
support areas and

corridors, all individuals need to be
surgical scrubs and cover their hair
(both facial and on their head) •
Restricted Area: Masks must be worn
with above surgical

attire, includes the OR, sinks, and the
clean core
What does
Perioperative asepsis
mean? It is the creation and
maintenance of a sterile field, with
the patient's surgical incision at the
center of the sterile field.
Proper Technique for
scrubbing in to a
surgical field:
1. Team members fingers and hands
should be scrubbed first
with progression to the forearm and
elbows. 2. The hands should be held
away from the surgical attire. 3. The
hands should be held up once clean
so that no suds or
other bacteria can drift down onto the
clean area 4. When waterless gels are
used for asepsis, you should first wash
you hands and forearms thoroughly
with soap and water, then dry before
putting on the gel 5. Then you can
enter the surgical area and put on the
surgical
gown and gloves
(Courtesy The Methodist Hospital Houston, Tex. Photograph by Donna Dahms, RN,
CNOR)
Types of Anesthesia
General: Loss of sensation with the
loss of consciousness, skeletal muscle
relaxation, possible impaired
ventilatory and cardiovascular function
and elimination of the somatic,
autonomic, and endocrine responses,
including coughing, gagging, vomiting,
and sympathetic nervous system
responses. • given IV, inhaled, or
rectally • Technique of choice when:

1.surgical procedures require sig.
skeletal muscle relaxation, last for a
long time, require awkward positioning
or control of respirations 2.patient are
extremely anxious 3.refuse or have
contraindications for local anesthesia
4.are uncooperative (head injury,
intoxication, youth,
emotional status, or cannot remain
immobile)
Endotracheal Intubation
• This is a tube placed into the trachea
once IV induction of anesthesia occurs
• Allows for control of ventilation and
airway protection (specifically

from
aspiration) • Complications: o Sore
throat/hoarseness o injury to the teeth

o failure to intubate o laryngospasm,
laryngeal edema • Once the tube is

placed, an ambu bag is attached and
air is instilled,
the chest should rise
and fall with the instillation of air, and
you should be able to hear breath
sounds
Types of Anesthesia
Regional: This is the injection of a
local anesthetic in or around a specific
nerve or group of nerves • Nerve
blocks: usually done for the palliation
of pain
o celiac plexus block o b
rachial plexus
block • Spinal/Epidural Anesthetic:
injection of a local anesthetic

into either the subarachnoid space and
CSF (spinal) or epidural space
(epidural)
o Spinal blocks: cause autonomic,
sensory and motor

blockade, used for lower abdomen,
perineal, groin, or lower extremity ■
can cause hypotension and
vasodilation, also spinal

headaches o Epidural blocks:
anesthetic is given to the epidural
space ■ lower incidence of headache

Spinal
cord
Dura
Dura
B
S1
Sagittal section
(From Rothrock JC: Alexander's Care of the Patient Sugery, ed 13, St. Louis, 2007, Mosby.)
Types of Anesthesia
Local Anesthesia: Usually a topical or
injectable agent that provides sensory
blockade to a certain area
Topical: lidocaine spray at the dentist,
EMLA Cream for dermatologic
procedures
Injectables: Subcutaneous lidocaine
or nerve blocks used at the dentist
Patient Positioning
• Critical part of every procedure and
usually occurs once the anesthesia
has been administered. • Needs to
allow for accessibility of the surgical
site,
administration of anesthesia, and
maintenance of the airway. • Must take
care to: • provide correct skeletal
alignment • prevent undue pressure on

nerves, skin over bony
prominences, and eyes • provide for
adequate thoracic excursion • prevent
occlusion of arteries and veins •
provide some modesty • recognize and
accommodate for previously assessed

skeletal deformities
Patient Positioning
Greatest care must be taken to
prevent injury, because: • anesthesia
has blocked the nerve impulses

o the patient can't complain that they
have pain or
discomfort o can cause: ■ muscle
strain ■ joint damage ■ pressure ulcers
■ nerve damage • Need to also pay
attention to the pooling of blood due to

vasodilation, can cause central
hypotension
Patient Positioning
1. Supine 2. Prone 3. Trendelenberg 4.
Lateral 5. Kidney 6. Lithotomy 7.
Jackknife 8. Sitting
Complications of the
Intraoperative Period
Anaphylaxis: • Most severe form of
an allergic reaction, type I

hypersensitivity • Clinical
Manifestations can be masked by
anesthesia • Can be caused by any of
the medications, inhaled, IV, or by

the compounds used in the tools of the
surgery (iodine allergy, latex allergy) •

Watch for hypotension, tachycardia,
bronchospasm, and
pulmonary edema
Postoperative Hypothermia: • get
hypothermia up to 12 hours post
surgery, 34.5C • Direct effect of the
anesthesia • increased risk with longer
surgeries
Postoperative Hyperthermia: •
elevated temperatures: 38C or above
24-48 hours post surgery

• results from
inflammatory medications/cytokines
that are released

in the post operative
period to enhance healing
Malignant Hyperthermia: • Rare
metabolic disease in which affected

period develop
hyperthermia with rigidity of skeletal
muscles that can result in death
o most often seen when
Succinylcholine with inhalent drugs are

given together • Autosomal dominant
with varying levels of penetrance •
Thought to be a derangement of contol
of intracellular calcium,
leading to
muscle contracture, hyperthermia,
hypoxemia, lactic acidosis, and
hemodynamic and cardiac
abnormalities • Need to assess the
patient and the family for any

untoward reactions to anesthesia •
Treatment is administration of
dantrolene
Postoperative Nursing
Care
1. Preparation for admitting the new
postoperative patient 2. Initial
assessment and interventions upon
receiving the
patient 3. Selected data from the chart
that is important 4. Post operative
nursing assessments and interventions
Postoperative Nursing
Care: Preparation
1. Have the postoperative bed ready,
linens, extra pillows for
positioning 2. Have the appropriate
equipment ready:
1.Suction, set up, tested and ready to
hook up 2.antiembolism stockings, set
up, tested and ready to hook
up 3.Oxygen hook up 4.if hip
replacement, ensure you have the
proper hip
abduction pillow 3. Emergency tray
(airways, drugs, etc) depending on the
type
of surgery
Proper Postoperative
Positioning
Initial Assessment and
Interventions upon
receiving the patient
1. Level of consciousness and
emotional state
2. Move patient to the bed, placement
and positioning, attachment of
equipment as needed
a. quick assessment of A (airway) B
(breathing) C (circulation)
b. proper positioning may be ordered
based on the type of surgery, if
semiconscious, side lying with the
head of the bed flat, if fully conscious,
semi fowlers (if not contraindicated)
3. Safety Measures: side rails up, brief
assessment of mentation
Initial Assessment and
interventions upon
4. Review the postoperative plan of
care with the recovery room nurse to
include orders: • V/S, position,
medications, IV fluids, NPO or type of

oral
intake, activity, diagnostic tests
needed, dressing changes, etc...
5. Emotional Support for the patient
and the family
6. Pain: Assess pain per patient, and
location
TABLE 20-2 Postanesthesia Admission Report
General Information
Patient name Age Anesthesia care provider Surgeon
Surgical procedure Patient History
• Indication for surgery
• Medical history, medications, allergies
Intraoperative Management
• Anesthetic medications
• Other medications received p
reoperatively or
intraoperatively
Blood loss
Fluid replacement totals, including blood transfusions
• Urine output Intraoperative Course
• Unexpected anesthetic events or reactions
nexpected surgical events
• U
• V ital signs and monitoring trends
• Results of intraoperative laboratory tests
TABLE 20-30 Initial Postanesthesia Care

Unit Assessment
Airway
• Patency
• Oral or nasal airway
Endotracheal tube Breathing
• Respiratory rate and quality
Auscultated breath sounds
Pulse oximetry
• Supplemental oxygen Circulation
ECG monitoring-rate and rhythm
• Blood pressure
• Temperature and color of skin
eripheral pulses Neurologic
• P
• L evel of consciousness
• Orientation
• Sensory and motor status Genitourinary
• Intake (fluids, irrigations)
• Output (urine, drains) Surgical Site
• Dressings/drainage Pain
• Incision
Other
ECG, Electrocardiogram.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier I nc.
Initial assessment and

interventions upon
7. Objective Data:
a. Vital Signs (TPRBP) q 15min x 4, q
30 min x 4, q 1 hour x 4, then q 4
hours as indicated
Can only move from 15 to 30min,
and 30min to q1 hour when the
patient is stable
b. Respiratory Status: Patency of the
airway, need for suctioning if the
patient can't move sections, depth of
respirations
C. Neurological Status: Level of
consciousness, pupils, gag and
swallowing reflexes
interventions upon
d. Circulatory Status: note the nailbeds
(cap refill), lips, buccal membranes,
palms, and soles for pallor and
duskiness (cyanosis is usually first
seen in the buccal membranes)
e. Dressing (s): check the chart and
see where they are, and what they are
comprised of
also check the chart for placement of
any surgical drains have been placed
and where they exit
f. Drainage tubes: are they free of
kinks and draining properly, check if
the tubes need to be attached to
suction, check to ensure it is the
proper amount of suction, assess type
and amount of drainage and know
when to call the MD.
interventions upon
g. Urinary output: if there is no foley,
the patient must void within 8-10 hours
post-op, if not, notify the MD
if there is a foley, there should be at
least 500-700 cc in the first 24 hours
post surgery
h. Safety: Side rails up, instruct the
patient not to get out of bed without
help, ensure the call light and phone
are within reach, secure all tubes and
lines properly to prevent dislodgement
and injury
As the nurse, make sure to dangle the
patient for 1-2 minutes the first time
the patient gets up out of bed.
i. Proper positioning and comfort j.
Equipment
Selected data from the
chart that is important
1. Surgeon's Orders 2. Surgical Notes
and Anesthesia records 3. Recovery
Room Summary
Postoperative nursing
assessment and
interventions
1. Assessment of Risk Factors for
postoperative
complications (will review later) 2.
Promote comfort: includes the relief
of pain, the relief of
restlessness, relief of nausea and
vomiting, relief of abdominal distention,
relief of hiccups. 3. Promote wound
healing: review wound healing from
earlier lectures...a properly
approximated sutured or stapled
surgical wound is healing by primary
intention, how strong is the wound
once the sutures are removed? 4.
Care of tubes and drains
assessment and
intervention
5. Ensuring optimal respiratory
function: Promote lung expansion,
deep breathing, coughing and use of
the incentive spirometer
(Coughing is contraindicated in head
and eye surgeries, plastic surgery and
hernia operations)
6. Maintenance of Adequate
Cardiovascular Function
7. Maintenance of adequate F/E
balance: monitor for abnormal
electrolytes, monitor v/s, keep an
accurate I&O records, obtain
laboratory specimens
assessment and
intervention
8. Maintenance of nutritional
balance: NG tubes for 24-48 hours
post GI surgery, post operative diet
includes clear liquids once bowel
sounds return, advance the diet based
on MD orders and patient tolerance
9. Return of Normal Urinary
Function: assess for bladder pain and
distention (palpation and percussion),
assess urinary output, Notify MD if no
urine output 6-8 hours post surgery, If
patient continues on bed rest, assist
the patient into the normal voiding
position as possible, provide for
adequate privacy (as much as
possible)
assessment and
interventions
10. Resumption of usual bowel
elimination pattern: assess for
abdominal distention, presence of
bowel sounds, assist with ambulation,
provide ordered laxatives as needed,
provide for as much privacy as
possible, assist in positioning patient in
as natural a position for stooling.
11. Restoration of Mobility: assess
the patient for the ability to ambulate,
remember to dangle the patient before
walking, assess the patient before,
during and after ambulating, work with
PT, provide for adequate pain
medicines if needed prior to
ambulating.
12. Reduction of anxiety and
achievement of well-being 13.
Discharge Planning: very teaching
focused
Common postoperative
complications
• Hematological o H
emorrhage •
Respiratory o Atelectasis o
Pneumonia o Pulmonary Embolism •
Cardiovascular
o H C
ypotension o ardiac
Dysrhythmias o Venous Thrombosis •
Urinary o Urinary Retention o Low
urine production
• Gastrointestinal
o Paralytic ileus o Constipation •
Neurological o CVA/Stroke •
Immunological o Infection • Wound
Healing
Eviserations o
o Dehiscence o
Infection • Psychological
o Body image problems
complications:
complications:
Hematologic
Hemorrhage: • Often related to
ineffective vascular closure or
alterations in coagulation
• Observe for
bleeding at the wound site/surgical

dressing, especially
in the dependent
areas • monitor the v/s closely (see
previous slide), follow the H/H closely,

assess skin closely, report any
changes noted • assess LOC, and
mentation (restlessness can indicate

altered cerebral perfusion)
complications:
Pulmonary
Atelectasis: • Common cause of
postoperative hypoxemia • Retained
secretions and decreased respiratory
excursion
causes blockage of the alveoli
o once all the air trapped in the alveoli
is absorbed, the
alveoli collapse o hypotension and
cardiac states can worsen this •
Assess for decreased lung sounds,
decreased O2 sats • Encourage deep

breathing, incentive spirometry,
coughing,
early mobilization
complications:
Pulmonary
Atelectasis:
complications:
Pulmonary
Pneumonia: • Can be a sequela to the
atelectasis, can occur from
aspiration o increased risk post
thoracic and abdominal surgery • the
atelectasis builds up, and increased
secretions can
continue to block the airways o
microorganisms grow in the trapped
secretions • Proper positioning of
patients can assist with this, as well as

q2 hour re-positioning
o ensure that respiratory effort is

maximized o O2 therapy as
ordered/needed o Antibiotics as
ordered • V/S and frequent lung sound
assessment • Cough, IS, deep
breathing
complications:
Pulmonary
Pulmonary Embolism: • Caused by a
thrombus that is dislodged from the

peripheral circulation,
and then gets
lodged in the pulmonary arterial
circulation • See acute tachypnea,
dyspnea, tachycardia, hypotension

and decreased O2 saturations • Start
O2 per MD, Anticoagulants as
ordered, cardiopulmonary
support •
Preventing DVT is primary to
preventing pulmonary emboli:

o Leg exercises o Compression
stockings/anticoagulants per MD o
Deep breathing, coughing, IS (move
the air in the lungs

and move the blood) o Ambulate as
soon as possible
complications:
Cardiovascular
Hypotension: • Most common causes
are unreplaced fluids during the

surgery and hemorrhage • Secondary
causes include MI, cardiac
tamponade, pulmonary
emboli, or
effects from the anesthesia drugs •
Show signs of hypoperfusion to the
vital organs (heart, brain,

and kidneys)
• have clinical signs of disorientation,
loss of consciousness, chest

pain,
oliguria, and anuria • Assess V/S,
pulse Ox, peripheral pulses, LOC and

report as necessary
• Assist physician
with interventions aimed at correcting
the
underlying cause of the hypotension

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Perioperative Nursing

of surgery. ​• List the components of

preoperative assessment and discuss

responsibilities. ​• List the components

of preoperative patient preparation and

responsibilities. ​• List and discuss the

preventative measures. ​• Discuss

nursing responsibilities related to the

preoperative (before), intraoperative

important time to address issues that

o ​i.e. assess for bleeding problems,

don't want to find out

table ​• Also can teach patients and

family about what to expect

o ​in an emergency, we can prepare

pathology ​• ​i.e. lymph node bx,

Therapeutic: ​• Elimination or repair of

without curing the underlying disease ​•

Rhizotomy (cutting of a nerve

Preventative: ​• Surgery to remove

pathologic problem) ​• ​Total

for aesthetic reasons • ​Repair of

scars from burns or injuries, minor

Advanced assessments are​ usually

o ​blood draws o​ ​physical exam o​

other necessary studies • Can be

scheduled in some cases

Emergency: ​• arises unexpectedly •

scene ​• Needed within minutes to

hours ​Urgent: ​• delay could be

detrimental • usually within 24-48

prescreening • Don't use in patient's

with multiple problems Same-Day

hospital • Go home the day of the

Patient comes in early (night before or

earlier) • Usually patients with complex

medical issues, and increased

-​ectomy ​-​lysis ​-​orrhaphy ​-​oscopy ​-​ostomy ​-​otomy

Excision ​or removal ​of ​Destruction ​of ​Repair ​or ​suture

age • obtain a detailed medical

assess for sensory deficits • assess for

Allergies: ​• assess for known drug,

food and substance allergies ​• assess

what the reaction

allergy, hives or anaphylaxis?) ​•

allergies must be clearly noted

for that patient,

situation of deficit or excess • assess

for individuals who are prone to

Gastrointestinal problems o​ ​Chronic

Alcoholics/Drug Addicts ​• Also assess

for excess (Obesity):

decreased blood supply o​ ​Hard to

access surgical site o​ ​Decreased lung

capacity o​ ​Anesthesia meds are

stored in fat cells

the amount of functional hemoglobin ■

carboxyhemoglobin o​ ​cilia in the lung

are damaged, more difficult to mobilize

impaired liver function o​ ​B-vitamin

deficiencies • Opioid Addiction

indicator is the presence of fever

above 101 degrees

of surgery. • List the components of

responsibilities. • List the components

responsibilities. • List and discuss the

preventative measures. • Discuss

o i.e. assess for bleeding problems,

table • Also can teach patients and

o in an emergency, we can prepare

pathology • i.e. lymph node bx,

Therapeutic: • Elimination or repair of

without curing the underlying disease •

Preventative: • Surgery to remove

pathologic problem) • Total

for aesthetic reasons • Repair of

Advanced assessments are usually

o blood draws o physical exam o

Emergency: • arises unexpectedly •

scene • Needed within minutes to

hours Urgent: • delay could be

-ectomy -lysis -orrhaphy -oscopy -ostomy -otomy

Excision or removal of Destruction of Repair or suture

Allergies: • assess for known drug,

food and substance allergies • assess

allergy, hives or anaphylaxis?) •

Gastrointestinal problems o Chronic

Alcoholics/Drug Addicts • Also assess

decreased blood supply o Hard to

access surgical site o Decreased lung

capacity o Anesthesia meds are

carboxyhemoglobin o cilia in the lung

impaired liver function o B-vitamin

to the patient are too great. • Goal will

contraindicated prior to surgery: •

o affect bleeding time ■ ASA is 2

with the liver ■ warfarin is usually 7

contraindicated prior to surgery: •

should be assessed and documented •

meds should be restarted • want to

and in the chart • Need to notify the

Psychological Status: • Common

Fears: – Fear of death – Fear of pain

consent? • the patient • next of kin (in

o Can be designated with a durable

obtain consent • however, the nurse

signed o nurse has a primary role as

a patient advocate. • nurse can

can do that • if the patient continues to

come and speak with them again. •

ambulation • Pain control and

Quadriceps (thigh) setting

Hip and knee movements

Copyright © 2007 by Masby, Inc., an affiliate of

midnight the night before o Educating

Minimum Fasting Liquid and Food Intake

Source: Practice guidelines for preoperative fasting a nd

person is inpatient or outpatient. •

sedative medications • Final