LkICLkA1IVL

erloperaLlve nurslng descrlbes Lhe wlde varleLy of nurslng funcLlons assoclaLed wlLh Lhe paLlenL's surglcal
managemenL lL has Lhree phases of Lhe surglcal experlence namely
1 reoperaLlve phase 1hls phase beglns when Lhe declslon for surglcal lnLervenLlon ls made and ends when Lhe
paLlenL ls Lransferred from Lhe operaLlng room
2 lnLraoperaLlve phase 1hls phase beglns when Lhe paLlenL ls admlLLed or Lransferred Lo Lhe surgery deparLmenL
and ends when he or she ls admlLLed Lo Lhe recovery area
3 osLoperaLlve phase 1hls phase beglns wlLh Lhe admlsslon of Lhe paLlenL Lo Lhe recovery area and ends wlLh a
followup evaluaLlon ln Lhe cllnlcal seLLlng or aL home
LkICLkA1IVL nASL
reoperat|ve hase of the Surg|ca| Lxper|ence
1he paLlenL who consenLs Lo have surgery parLlcularly surgery LhaL requlres a general anesLheLlc renders hlmself
dependenL on Lhe knowledge sklll and lnLegrlLy of Lhe healLh care Leam ln accepLlng Lhls LrusL Lhe healLh care
Leam members have an obllgaLlon Lo make Lhe paLlenL's welfare Lhelr flrsL conslderaLlon durlng Lhe surglcal
experlence
1he scope of acLlvlLles durlng Lhe preoperaLlve phase lncludes Lhe esLabllshmenL of Lhe paLlenL's basellne
assessmenL ln Lhe cllnlcal seLLlng or aL home carrylng ouL preoperaLlve lnLervlew and preparlng Lhe paLlenL for Lhe
anesLheLlc Lo be glven and Lhe surgery
Goa|s dur|ng the reoperat|ve hase
AlLhough Lhe physlclan ls responslble for explalnlng Lhe surglcal procedure Lo Lhe paLlenL Lhe paLlenL may ask Lhe
nurse quesLlons abouL Lhe surgery 1here may be speclflc learnlng needs abouL Lhe surgery LhaL Lhe paLlenL and
supporL persons should know A nurslng care plan and a Leachlng plan should be carrled ouL uurlng Lhls phase
emphasls ls placed on
Assesslng and correcLlng physlologlcal and psychologlcal problems LhaL may lncrease surglcal rlsk
lvlng Lhe paLlenL and slgnlflcanL oLhers compleLe learnlng and Leachlng guldellnes regardlng Lhe surgery
lnsLrucLlng and demonsLraLlng exerclses LhaL wlll beneflL Lhe paLlenL posLoperaLlvely
lannlng for dlscharge and any pro[ecLed changes ln llfesLyle due Lo Lhe surgery
hys|o|og|c Assessment dur|ng the reoperat|ve hase
8efore any LreaLmenL ls lnlLlaLed a healLh hlsLory ls obLalned and a physlcal examlnaLlon ls performed durlng
whlch vlLal slgns are noLed and a daLa base ls esLabllsh for fuLure comparlsons
ulagnosLlc LesLs may be carrled ouL durlng Lhe preoperaLlve phase such as
8lood analyses such as compleLe blood counL sedlmenLaLlon raLe creacLlve proLeln serum proLeln
elecLrophoresls wlLh lmmunoflxaLlon calclum alkallne phosphaLase and chemlsLry proflle
Oray sLudles
,l and C1 scans (wlLh or wlLhouL myelography)
lecLrodlagnosLlc sLudles
8one scan
ndoscoples
1lssue blopsles
Lool sLudles
Drlne sLudles
lgnlflcanL physlcal flndlngs are also noLed Lo furLher descrlbe Lhe paLlenL's overall healLh condlLlon When Lhe
paLlenL has been deLermlned Lo be an approprlaLe candldaLe for surgery and has elecLed Lo proceed wlLh surglcal
lnLervenLlon Lhe preoperaLlve assessmenL phase beglns 1he purpose of preoperaLlve evaluaLlon ls Lo reduce Lhe
morbldlLy of surgery lncrease quallLy of lnLraoperaLlve care reduce cosLs assoclaLed wlLh surgery and reLurn Lhe
paLlenL Lo opLlmal funcLlonlng as soon as posslble
1he followlng are Lhe physlologlc assessmenLs necessary durlng Lhe preoperaLlve phase
Age
-uLrlLlonal sLaLus and needs deLermlned by measurlng Lhe paLlenL's helghL and welghL Lrlceps skln fold
upper arm clrcumference serum proLeln levels and nlLrogen balance CbeslLy greaLly lncreases Lhe rlsk and
severlLy of compllcaLlons assoclaLed wlLh surgery
luld and lecLrolyLe lmbalance uehydraLlon hypovolemla and elecLrolyLe lmbalances should be carefully
assessed and documenLed
lnfecLlon
urug and alcohol use Lhe acuLely lnLoxlcaLed person ls suscepLlble Lo ln[ury
esplraLory sLaLus paLlenLs wlLh preexlsLlng pulmonary problems are evaluaLed by means pulmonary
funcLlon sLudles and blood gas analysls Lo noLe Lhe exLenL of resplraLory lnsufflclency 1he goal for poLenLlal
surglcal paLlenL us Lo have an opLlmum resplraLory funcLlon urgery ls usually conLralndlcaLed for a paLlenL
who has a resplraLory lnfecLlon
Cardlovascular sLaLus cardlovascular dlseases lncreases Lhe rlsk of compllcaLlons uependlng on Lhe severlLy
of sympLoms surgery may be deferred unLll medlcal LreaLmenL can be lnsLlLuLed Lo lmprove Lhe paLlenL's
condlLlon
epaLlc and renal funcLlon surgery ls conLralndlcaLed ln paLlenLs wlLh acuLe nephrlLls acuLe renal
lnsufflclency wlLh ollgurla or anurla or oLher acuLe renal problems Any dlsorder of Lhe llver on Lhe oLher hand
can have an effecL on how an anesLheLlc ls meLabollzed
ndocrlne funcLlon dlabeLes corLlcosLerold lnLake amounL of lnsulln admlnlsLered
lmmunologlc funcLlon exlsLence of allergles prevlous allerglc reacLlons senslLlvlLles Lo cerLaln medlcaLlons
pasL adverse reacLlons Lo cerLaln drugs lmmunosuppresslon
revlous medlcaLlon Lherapy lL ls essenLlal LhaL Lhe paLlenL's medlcaLlon hlsLory be assessed by Lhe nurse and
anesLheslologlsL 1he followlng are Lhe medlcaLlons LhaL cause parLlcular concern durlng Lhe upcomlng surgery
1 Adrenal corLlcosLerolds noL Lo be dlsconLlnued abrupLly before Lhe surgery Cnce dlsconLlnued suddenly
cardlovascular collapse may resulL for paLlenLs who are Laklng sLerolds for a long Llme A bolus of sLerold ls
Lhen admlnlsLered lv lmmedlaLely before and afLer surgery
2 ulureLlcs Lhlazlde dlureLlcs may cause excesslve resplraLory depresslon durlng Lhe anesLhesla admlnlsLraLlon
3 henoLhlazlnes Lhese medlcaLlons may lncrease Lhe hypoLenslve acLlon of anesLheLlcs
4 AnLldepressanLs ,ACls lncrease Lhe hypoLenslve effecLs of anesLheLlcs
3 1ranqulllzers medlcaLlons such as barblLuraLes dlazepam and chlordlaxepoxlde may cause an lncrease
anxleLy Lenslon and even selzures lf wlLhdrawn suddenly
6 lnsulln when a dlabeLlc person ls undergolng surgery lnLeracLlon beLween anesLheLlcs and lnsulln musL be
consldered
7 AnLlbloLlcs ,ycln" drugs such as neomycln kanamycln and less frequenLly sLrepLomycln may presenL
problems when comblned wlLh curarlform muscle relaxanL As a resulL nerve Lransmlsslon ls lnLerrupLed and
apnea due Lo resplraLory paralysls develops
resence of Lrauma
sycho|og|ca| Nurs|ng Assessment dur|ng the reoperat|ve er|od
ear of Lhe unknown
ear of deaLh
ear of anesLhesla
Concerns abouL loss of work Llme [ob and supporL from Lhe famlly
Concerns on LhreaL of permanenL lncapaclLy
plrlLual bellefs
CulLural values and bellefs
ear of paln

sycho|og|ca| Nurs|ng Intervent|ons
1 xplore Lhe cllenL's fears worrles and concerns
2 ncourage paLlenL verballzaLlon of feellngs
3 rovlde lnformaLlon LhaL helps Lo allay fears and concerns of Lhe paLlenL
4 lve empaLheLlc supporL
Informed consent
An lnformed consenL ls necessary Lo be slgned by Lhe paLlenL before Lhe surgery 1he followlng are Lhe purposes of
an lnformed consenL
roLecLs Lhe paLlenL agalnsL unsancLloned surgery
roLecLs Lhe surgeon and hosplLal agalnsL legal acLlon by a cllenL who clalms LhaL an unauLhorlzed procedure
was performed
1o ensure LhaL Lhe cllenL undersLands Lhe naLure of hls or her LreaLmenL lncludlng Lhe posslble compllcaLlons
and dlsflguremenL
1o lndlcaLe LhaL Lhe cllenL's declslon was made wlLhouL force or pressure

criterio for o vo/id lnformed consent
ConsenL volunLarlly glven valld consenL musL be freely glven wlLhouL coerclon
or lncompeLenL sub[ecLs Lhose who are -C1 auLonomous and cannoL glve or wlLhhold consenL permlsslon ls
requlred from a responslble famlly member who could elLher be apparenL or a legal guardlan ,lnors (below
18 years of age) unconsclous menLally reLarded psychologlcally lncapaclLaLed fall under Lhe lncompeLenL
sub[ecLs
1he consenL should be ln wrlLlng and should conLaln Lhe followlng
1 rocedure explanaLlon and Lhe rlsks lnvolved
2 uescrlpLlon of beneflLs and alLernaLlves
3 An offer Lo answer quesLlons abouL Lhe procedure
4 LaLemenL LhaL emphaslzes LhaL Lhe cllenL may wlLhdraw Lhe consenL
3 1he lnformaLlon ln Lhe consenL musL be wrlLLen and be dellvered ln language LhaL a cllenL can comprehend
6 hould be obLalned before sedaLlon
Intraoperat|ve hase
Def|n|t|on
1he lnLraoperaLlve phase exLends from Lhe Llme Lhe cllenL ls admlLLed Lo Lhe operaLlng room Lo Lhe Llme of
anesLhesla admlnlsLraLlon performance of Lhe surglcal procedure and unLll Lhe cllenL ls LransporLed Lo Lhe
recovery room or posLaneLhesla care unlL (ACD) 1hroughouL Lhe surglcal experlence Lhe nurse funcLlons as Lhe
paLlenL's chlef advocaLe 1he nurse's care and concern exLend from Lhe Llme Lhe paLlenL ls prepared for and
lnsLrucLed abouL Lhe forLhcomlng surglcal procedure Lo Lhe lmmedlaLe preoperaLlve perlod and lnLo Lhe operaLlve
phase and recovery from anesLhesla 1he paLlenL needs Lhe securlLy of knowlng LhaL someone ls provldlng
proLecLlon durlng Lhe procedure and whlle he ls anesLheLlzed because surgery ls usually a sLressful experlence
Goa|s dur|ng the Intraoperat|ve hase
1 romoLe Lhe prlnclple of asepsls asepsls
2 omeosLasls
3 afe admlnlsLraLlon of anesLhesla
4 emosLasls
1he Surg|ca| 1eam
1he lnLraoperaLlve phase beglns when Lhe paLlenL ls recelved ln Lhe surglcal area and lasLs unLll Lhe paLlenL ls
Lransferred Lo Lhe recovery area AlLhough Lhe surgeon has Lhe mosL lmporLanL role ln Lhls phase Lhere are key
members of Lhe surglcal Leam
1 Surgeon leader of Lhe surglcal Leam e or she ls ulLlmaLely responslble for performlng Lhe surgery effecLlvely
and safely however he ls dependenL upon oLher members of Lhe Leam for Lhe paLlenL's emoLlonal well belng
and physlologlc monlLorlng
2 Anesthes|o|og|st or anesthet|st provldes smooLh lnducLlon of Lhe paLlenL's anesLhesla ln order Lo prevenL
paln 1hls member ls also responslble for malnLalnlng saLlsfacLory degrees of relaxaLlon of Lhe paLlenL for Lhe
duraLlon of Lhe surglcal procedure Aslde from LhaL Lhe anesLheslologlsL conLlnually monlLors Lhe physlologlc
sLaLus of Lhe paLlenL for Lhe duraLlon of Lhe surglcal procedure and Lhe physlologlc sLaLus of Lhe paLlenL Lo
lnclude oxygen exchange sysLemlc clrculaLlon neurologlc sLaLus and vlLal slgns e or she Lhen lnforms and
advlses Lhe surgeon of lmpendlng compllcaLlons
3 Scrub Nurse or Ass|stant a nurse or surglcal Lechnlclan who prepares Lhe surglcal seLup malnLalns surglcal
asepsls whlle draplng and handllng lnsLrumenLs and asslsLs Lhe surgeon by passlng lnsLrumenLs suLures and
supplles
4 |rcu|at|ng Nurse respond Lo requesL from Lhe surgeon anesLheslologlsL or anesLheLlsL obLaln supplles
dellver supplles Lo Lhe sLerlle fleld and carry ouL Lhe nurslng care plan
Intraoperat|ve Nurs|ng Iunct|ons
ClrculaLlng -urse
1he clrculaLlng nurse manages Lhe operaLlng room and proLecLs Lhe safeLy and healLh needs of Lhe paLlenL by
monlLorlng acLlvlLles of members of Lhe surglcal Leam and checklng Lhe condlLlons ln Lhe operaLlng room
esponslblllLles of a clrculaLlon nurse are Lhe followlng
1 Assures cleanllness ln Lhe C
2 uaranLees Lhe proper room LemperaLure humldlLy and llghLlng ln C
3 ,ake cerLaln LhaL equlpmenLs are safely funcLlonlng
4 nsure LhaL supplles and maLerlals are avallable for use durlng surglcal procedures
3 ,onlLors asepLlc Lechnlque whlle coordlnaLlng Lhe movemenL of relaLed personnel
6 ,onlLors Lhe paLlenL LhroughouL Lhe operaLlve procedure Lo ensure Lhe person's safeLy and well belng
crub -urse
1 crubblng for surgery
2 eLLlng up sLerlle Lables
3 reparlng suLures and speclal equlpmenLs
4 AsslsLs Lhe surgeon and asslsLanL durlng Lhe surglcal procedure by anLlclpaLlng Lhe requlred lnsLrumenLs
sponges dralns and oLher equlpmenL
3 keeps Lrack of Lhe Llme Lhe paLlenL ls under anesLhesla and Lhe Llme Lhe wound ls open
6 Checks equlpmenLs and maLerlals such as needles sponges and lnsLrumenLs as Lhe surglcal lnclslon ls closed
|ass|f|cat|on of hys|ca| status for Anesthes|a before Surgery
1he anesLheslologlsL should vlslL Lhe paLlenL before Lhe surgery Lo provlde lnformaLlon answer quesLlons and allay
fears LhaL may exlsL ln Lhe paLlenL's mlnd 1he cholce of anesLheLlc agenL wlll be dlscussed and Lhe paLlenL has an
opporLunlLy Lo dlsclose and Lhe paLlenL has opporLunlLy Lo dlsclose prevlous reacLlons and lnformaLlon abouL any
medlcaLlon currenLly belng Laken LhaL may affecL Lhe cholce of an agenL Aslde from LhaL Lhe paLlenL's general
condlLlon musL also be assessed because lL may affecL Lhe managemenL of anesLhesla 1hus Lhe anesLheslologlsL
assesses Lhe paLlenL's cardlovascular sysLem and lungs lnqulry abouL preexlsLlng pulmonary lnfecLlon sand Lhe
exLenL Lo whlch Lhe paLlenL smokes musL also be deLermlned
Anesthes|a
AnesLhesla conLrols paln durlng surgery or oLher medlcal procedures lL lncludes uslng medlclnes and someLlmes
close monlLorlng Lo keep you comforLable lL can also help conLrol breaLhlng blood pressure blood flow and
hearL raLe and rhyLhm when needed AnesLheLlcs are dlvlded lnLo Lwo classes
1 1hose LhaL suspend sensaLlon ln Lhe whole body eneral anesLhesla
2 1hose LhaL suspend sensaLlon ln cerLaln parLs of Lhe body local reglonal epldural or splnal anesLhesla

enero/ 4nesthesio
1hls Lype of anesLhesla promoLes LoLal loss of consclousness and sensaLlon eneral anesLhesla ls commonly
achleved when Lhe anesLheLlc ls lnhaled or admlnlsLered lnLravenously lL affecLs Lhe braln as well as Lhe enLlre
body 1ypes of general anesLhesla admlnlsLraLlon
volaLlle llquld anesLheLlcs Lhls Lype of anesLheLlc produces anesLhesla when Lhelr vapors are lnhaled
lncluded ln Lhls group are Lhe followlng
1 aloLhane (luoLhane)
2 ,eLhoxyflurane (enLhrane)
3 nflurane (Lhrane)
4 lsoflurane (orane)
as AnesLheLlcs anesLheLlcs admlnlsLered by lnhalaLlon and are ALWA? comblned wlLh oxygen lncluded ln
Lhls group are Lhe followlng
1 -lLrous Cxlde
2 Cyclopropane
oco/ 4nesthesio
Local anesLheLlcs can be top|ca| or lsolaLed [usL Lo Lhe surface 1hese are usually ln Lhe form of gels creams or
sprays 1hey may be applled Lo Lhe skln before Lhe ln[ecLlon of a local anesLheLlc LhaL works Lo numb Lhe area
more deeply ln order Lo avold Lhe paln of Lhe needle or Lhe drug lLself (penlclllln for example causes paln upon
ln[ecLlon)
eqiono/ onesthesio
eglonal anesLhesla blocks paln Lo a larger parL of Lhe body AnesLheLlc ls ln[ecLed around ma[or nerves or Lhe
splnal cord ,edlcaLlons may be admlnlsLered Lo help Lhe paLlenL relax or sleep ,a[or Lypes of reglonal anesLhesla
lnclude
1 erlpheral nerve blocks A nerve block ls a shoL of anesLheLlc near a speclflc nerve or group of nerves lL blocks
paln ln Lhe parL of Lhe body supplled by Lhe nerve -erve blocks are mosL ofLen used for procedures on Lhe
hands arms feeL legs or face
2 pldural and splnal anesLhesla 1hls ls a shoL of anesLheLlc near Lhe splnal cord and Lhe nerves LhaL connecL Lo
lL lL blocks paln from an enLlre reglon of Lhe body such as Lhe belly hlps or legs
WlLh reglonal anesLhesla an anesLheLlc agenL ls ln[ecLed around Lhe nerved so LhaL Lhe area supplled by Lhese
nerves ls anesLheLlzed 1he effecL depends on Lhe Lype of nerve lnvolved 1he paLlenL under a splnal or local
anesLhesla ls awake and aware of hls or her surroundlngs
eglonal anesLhesla carrles more rlsks Lhan local anesLhesla such as selzures and hearL aLLacks because of Lhe
lncreased lnvolvemenL of Lhe cenLral nervous sysLem omeLlmes reglonal anesLhesla falls Lo provlde enough paln
rellef or paralysls and swlLchlng Lo general anesLhesla ls necessary
ino/ 4nesthesio
1hls ls a Lype of conducLlon nerve block LhaL occurs by lnLroduclng a local anesLheLlc lnLo Lhe subarachnold space
aL Lhe lumbar level whlch ls usually beLween L4 and L3 Lerlle Lechnlque ls used as Lhe splnal puncLure ls made
and medlcaLlon ls ln[ecLed Lhrough Lhe needle 1he spread of Lhe anesLheLlc agenL and Lhe level of anesLhesla
depend on
1 Lhe amounL of fluld ln[ecLed
2 Lhe speed wlLh whlch lL ls ln[ecLed
3 poslLlonlng of Lhe paLlenL afLer ln[ecLlon
4 speclflc gravlLy of Lhe agenL
Nurs|ng Assessment after Sp|na| Anesthes|a
1 ,onlLorlng vlLal slgns
2 Cbserve paLlenL and record Lhe Llme when moLlon and sensaLlon of Lhe legs and Lhe Loes reLurn


S|de Lffects of Anesthes|a
1 ome numbness or reduced feellng ln parL of your body (local anesLhesla)
2 -ausea and vomlLlng
3 A mlld drop ln body LemperaLure
now do anesthes|o|og|sts determ|ne the type of anesthes|a to be used?
1he Lype of anesLhesla Lhe anesLheslologlsL chooses depends on many facLors 1hese lnclude Lhe procedure Lhe
cllenL ls havlng and hls or her currenL healLh
os|t|on a at|ent on the Cperat|ng 1ab|e
1he nurse should have an ldea whlch paLlenL poslLlon ls requlred for a cerLaln surglcal procedure Lo be performed
1here are loLs of facLors Lo conslder ln poslLlonlng Lhe paLlenL whlch lncludes Lhe followlng
1 aLlenL should be ln a comforLable poslLlon as posslble wheLher he or she ls awake or asleep
2 1he operaLlve area musL be adequaLely exposed
3 1he vascular supply should noL be obsLrucLed by an awkward poslLlon or undue pressure on a parL
4 1here should be no lnLerference wlLh Lhe paLlenL's resplraLlon as a resulL of pressure of Lhe arms on Lhe chesL
or consLrlcLlon of Lhe neck or chesL caused by a gown
3 1he nerves of Lhe cllenL musL be proLecLed from undue pressure erlous ln[ury or paralysls may resulL from
lmproper poslLlonlng of Lhe arms hands legs or feeL
6 houlder braces musL be well padded Lo prevenL lrreparable nerve ln[ury
7 aLlenL safeLy musL be observed aL all Llmes
8 ln case of exclLemenL Lhe paLlenL needs genLle resLralnL before lnducLlon
keason of erform|ng a Surg|ca| rocedure
1 1o cure an lllness or dlsease by removlng Lhe dlseased Llssue or organs
1 1o vlsuallze lnLernal sLrucLures durlng dlagnosls
2 1o obLaln Llssue for examlnaLlon
3 1o prevenL dlsease or ln[ury
4 1o lmprove appearance
3 1o repalr or remove LraumaLlzed Llssue and sLrucLures
6 1o relleve sympLoms or paln
Nurs|ng kespons|b|||ty dur|ng the Intraoperat|ve hase
1 afeLy ls Lhe lghesL rlorlLy of nurses
1 lmulLaneous placemenL of feeL 1hls ls Lo prevenL dlslocaLlon of hlp
2 Always apply knee sLrap
3 Arms should noL be more Lhan 90
4 repare and apply cauLery pad CauLery ls used Lo sLop bleedlng
ostoperat|ve hase
Def|n|t|on
1he postoperat|ve per|od of Lhe surglcal experlence exLends from Lhe Llme Lhe cllenL ls Lransferred Lo Lhe recovery
room or pasLanesLhesla care unlL (ACD) Lo Lhe momenL he or she ls LransporLed back Lo Lhe surglcal unlL
dlscharged from Lhe hosplLal unLll Lhe followup care
Goa|s dur|ng the ostoperat|ve er|od
uurlng Lhe posLoperaLlve perlod reesLabllshlng Lhe paLlenL's physlologlc balance paln managemenL and
prevenLlon of compllcaLlons should be Lhe focus of Lhe nurslng care 1o do Lhese lL ls cruclal LhaL Lhe nurse perform
careful assessmenL and lmmedlaLe lnLervenLlon ln asslsLlng Lhe paLlenL Lo opLlmal funcLlon qulckly safely and
comforLably as posslble
1 ,alnLalnlng adequaLe body sysLem funcLlons
2 esLorlng body homeosLasls
3 aln and dlscomforL allevlaLlon
4 revenLlng posLoperaLlve compllcaLlons
3 romoLlng adequaLe dlscharge plannlng and healLh Leachlng
at|ent are dur|ng Immed|ate ostoperat|ve hase 1ransferr|ng the at|ent to kk or AD
at|ent Assessment
peclal conslderaLlon Lo Lhe paLlenL's lnclslon slLe vascular sLaLus and exposure should be lmplemenLed by Lhe
nurse when Lransferrlng Lhe paLlenL from Lhe operaLlng room Lo Lhe posLaneLhesla care unlL (ACD) or
posLanesLhesla recovery room (A) very Llme Lhe paLlenL ls moved Lhe nurse should flrsL conslder Lhe locaLlon
of Lhe surglcal lnclslon Lo prevenL furLher sLraln on Lhe suLures lf Lhe paLlenL comes ouL of Lhe operaLlng room
wlLh dralnage Lubes poslLlon should be ad[usLed ln order Lo prevenL obsLrucLlon on Lhe dralns
1 Assess alr exchange sLaLus and noLe paLlenL's skln color
2 verlfy paLlenL ldenLlLy 1he nurse musL also know Lhe Lype of operaLlve procedure performed and Lhe name of
Lhe surgeon responslble for Lhe operaLlon
3 -eurologlc sLaLus assessmenL Level of consclousness (LCC) assessmenL and lasgow Coma cale (C) are
helpful ln deLermlnlng Lhe neurologlc sLaLus of Lhe paLlenL
4 Cardlovascular sLaLus assessmenL 1hls ls done by deLermlnlng Lhe paLlenL's vlLal slgns ln Lhe lmmedlaLe
posLoperaLlve perlod and skln LemperaLure
3 CperaLlve slLe examlnaLlon uresslngs should be checked
os|t|on|ng
,ovlng a paLlenL from one poslLlon Lo anoLher may resulL Lo serlous arLerlal hypoLenslon 1hls occurs when a
paLlenL ls moved from a llLhoLomy Lo a horlzonLal poslLlon from a laLeral Lo a suplne poslLlon prone Lo suplne
poslLlon and even when a paLlenL ls Lransferred Lo Lhe sLreLcher ence lL ls very lmporLanL LhaL paLlenLs are
moved slowly and carefully durlng Lhe lmmedlaLe posLoperaLlve phase
romot|ng at|ent Safety
When Lransferred Lo Lhe sLreLcher Lhe paLlenL should be covered wlLh blankeLs and secured wlLh sLraps above Lhe
knees and elbows 1hese sLraps anchor Lhe blankeLs aL Lhe same Llme resLraln Lhe paLlenL should he or she pass
Lhrough a sLage of exclLemenL whlle recoverlng from anesLhesla 1o proLecL Lhe paLlenL from falls slde ralls should
be ralsed
afeLy checks when Lransferrlng Lhe paLlenL from C Lo
ecurlng resLralnLs for lv flulds and blood Lransfuslon
A AsslsL Lhe paLlenL Lo a poslLlon approprlaLe for hlm on her based on Lhe locaLlon of lnclslon slLe and presence
of dralnage Lubes
all precauLlon lmplemenLaLlon by maklng sure Lhe slde ralls are ralsed and resLralnLs are secured well
llmlnaLlng posslble sources of ln[urles and accldenLs when movlng Lhe paLlenL from Lhe C Lo or ACD
Nurs|ng are for at|ent |n the AD or kk
AIkWA Ma|nta|n a patent a|rway
1 keep oltwoy lo ploce ootll tbe potleot ls folly owoke ooJ ttles to eject lt 1he alrway ls allowed Lo remaln ln
place whlle Lhe cllenL ls unconsclous Lo keep Lhe passage open and prevenLs Lhe Longue from falllng back
When Lhe Longue falls back alrway passage obsLrucLlon wlll resulL eLurn of pharyngeal reflex noLed when
Lhe paLlenL regalns consclousness may cause Lhe paLlenL Lo gag and vomlL when Lhe alrway ls noL removed
when Lhe paLlenL ls awake
2 5octloo sectetloos os oeeJeJ
kLA1nING Ma|nta|n|ng adequate resp|ratory funct|on
8 8llaLeral lung ausculLaLlon frequenLly
esL and place Lhe paLlenL ln a laLeral poslLlon wlLh Lhe neck exLended lf noL conLralndlcaLed and Lhe arm
supporLed wlLh a plllow 1hls poslLlon promoLes chesL expanslon and faclllLaLes breaLhlng and venLllaLlon
ncourage Lhe paLlenL Lo Lake deep breaLhs 1hls aeraLes Lhe lung fully and prevenLs hyposLaLlc pneumonla
A Assess and perlodlcally evaluaLe Lhe paLlenL's orlenLaLlon Lo name or command Cerebral funcLlon alLeraLlon ls
hlghly suggesLlve of lmpalred oxygen dellvery
1 1urn Lhe paLlenL every 1 Lo 2 hours Lo faclllLaLe breaLhlng and venLllaLlon
umldlfled oxygen admlnlsLraLlon uurlng exhalaLlon heaL and molsLure are normally losL Lhus oxygen
humldlflcaLlon ls necessary Aslde from LhaL secreLlon removal ls faclllLaLed when kepL molsL Lhrough Lhe molsLure
of Lhe lnhaled alr Also dehydraLed paLlenLs have lrrlLaLed resplraLory passages Lhus lL ls very lmporLanL make
sure LhaL Lhe lnhaled oxygen ls humldlfled
IkDA1ICN Assess status of c|rcu|atory system
1 CbLaln paLlenL's vlLal slgns as ordered and reporL any abnormallLles
2 ,onlLor lnLake and ouLpuL closely
3 ecognlze early sympLoms of shock or hemorrhage such as cold exLremlLles decreased urlne ouLpuL less Lhan
30 ml/hr slow caplllary reflll greaLer Lhan 3 seconds dropplng blood pressure narrowlng pulse pressure
Lachycardla lncreased hearL raLe
1nLkMCkLGDA1ICN Assess|ng the pat|ent's thermoregu|atory status
1 ourly LemperaLure assessmenL Lo deLecL hypoLhermla or hyperLhermla
2 eporL LemperaLure abnormallLles Lo Lhe physlclan
3 ,onlLor Lhe paLlenL for posLaneLhesla shlverlng or A 1hls ls noLed ln hypoLhermlc paLlenLs abouL 30 Lo 43
mlnuLes afLer admlsslon Lo Lhe ACD A represenLs a heaLgaln mechanlsm and relaLes Lo regalnlng Lhe
Lhermal balance
4 rovlde a LherapeuLlc envlronmenL wlLh proper LemperaLure and humldlLy Warm blankeLs should be provlded
when Lhe paLlenL ls cold
IDID VCDML Ma|nta|n|ng adequate f|u|d vo|ume
1 Assess and evaluaLe paLlenL's skln color and Lurgor menLal sLaLus and body LemperaLure
2 ,onlLor and recognlze evldence of fluld and elecLrolyLe lmbalances such as nausea and vomlLlng and body
weakness
3 ,onlLor lnLake and ouLpuL closely
4 ecognlze slgns of fluld lmbalances ?CvCL,lA decreased blood pressure decreased urlne ouLpuL
lncreased pulse raLe lncreased resplraLlon raLe and decreased cenLral venous pressure (Cv) ?vCL,lA
lncreased blood pressure and Cv changes ln lung sounds such as presence of crackles ln Lhe base of boLh
lungs and changes ln hearL sounds such as Lhe presence of 3 gallop
SAIL1 romot|ng pat|ent safety
1 Avold nerve damage and muscle sLraln by properly supporLlng and paddlng pressure areas
2 requenL dresslng examlnaLlon for posslble consLrlcLlon
3 alse Lhe slde ralls Lo prevenL Lhe paLlenL from falllng
4 roLecL Lhe exLremlLy where lv flulds are lnserLed Lo prevenL posslble needle dlslodge
3 ,ake sure LhaL bed wheels are locked
CMICk1 romot|ng pat|ent comfort
1 Cbserve and assess behavloral and physlologlc manlfesLaLlons of paln
2 AdmlnlsLer medlcaLlons for paln and documenL lLs efflcacy
3 AsslsL Lhe paLlenL Lo a comforLable poslLlon
SkIN IN1LGkI1 M|n|m|z|ng sk|n |mpa|rment
1 ecord Lhe amounL and Lype of wound dralnage
2 egularly lnspecL dresslngs and relnforce Lhem lf necessary
3 roper wound care as needed
4 erform hand washlng before and afLer conLacL wlLh Lhe paLlenL
3 1urn Lhe paLlenL Lo sldes every 1 Lo 2 hours
6 ,alnLaln Lhe paLlenL's good body allgnmenL

LVADA1ICN |n AD
aLlenLs ln ACD are evaluaLed Lo deLermlne Lhe cllenL's dlscharge from Lhe unlL 1he followlng are Lhe expecLed
ouLcomes ln ACD
1 aLlenL breaLhlng easlly
2 Clear lung sounds on ausculLaLlon
3 Lable vlLal slgns
4 Lable body LemperaLure wlLh mlnlmal chllls or shlverlng
3 -o slgns of fluld volume lmbalance as evldenced by an equal lnLake and ouLpuL
6 1olerable or mlnlmlzed paln as reporLed by Lhe paLlenL
7 lnLacL wound edges wlLhouL dralnage
8 alsed slde ralls
9 ApproprlaLe paLlenL poslLlon
10 ,alnLalned quleL and LherapeuLlc envlronmenL
at|ent are dur|ng Immed|ate ostoperat|ve hase 1ransferr|ng the at|ent from kk to the Surg|ca| Dn|t
1o deLermlne Lhe paLlenL's readlness for dlscharge from Lhe ACD or cerLaln crlLerla musL be meL 1he
parameLers used for dlscharge from are Lhe followlng
1 Dncompromlsed cardlopulmonary sLaLus
2 Lable vlLal slgns
3 AdequaLe urlne ouLpuL aL leasL 30 ml/ hour
4 CrlenLaLlon Lo Llme daLe and place
3 aLlsfacLory response Lo commands
6 ,lnlmal paln
7 Absence or conLrolled nausea and vomlLlng
8 ulse oxlmeLry readlngs of adequaLe oxygen saLuraLlon
9 aLlsfacLory response Lo commands
10 ,ovemenL of exLremlLles afLer reglonal anesLhesla
,osL hosplLals use a scorlng sysLem Lo assess Lhe general condlLlon of paLlenL ln or ACD CbservaLlon and
evaluaLlon of Lhe paLlenL's physlcal slgns ls based on a seL of ob[ecLlve crlLerla 1he evaluaLlon gulde used ls a
modlflcaLlon of Lhe AA scorlng sysLem used for newborns 1hrough Lhls a more ob[ecLlve assessmenL of Lhe
paLlenL's physlcal condlLlon ls guaranLeed whlle recoverlng Lhe or ACD 1he perfecL posslble score ln Lhls
modlfled AA scorlng sysLem ls 10 1o be dlscharge from or ACD Lhe paLlenL ls requlred Lo have aL leasL 7 Lo
8 polnLs aLlenLs wlLh score less Lhan 7 musL remaln ln or ACD unLll Lhelr condlLlon lmproves Areas of
assessmenL ln ACD or evaluaLlon gulde are
1 esplraLlon ablllLy Lo breaLhe deeply and cough
2 ClrculaLlon sysLollc arLerlal pressure 80 of preanesLheLlc level
3 Consclousness Level verbally responds Lo quesLlons or orlenLed Lo locaLlon
4 Color normal skln color and appearance plnklsh skln and mucus
3 ,uscle acLlvlLy moves sponLaneously or on command
-urslng care durlng Lhe lnLermedlaLe posLoperaLlve perlod
AssessmenL
1 esplraLory sLaLus alrway paLency depLh raLe and characLer of resplraLlons naLure of breaLh sounds
2 ClrculaLory LaLus vlLal slgns lncludlng blood pressure and skln condlLlon
3 -eurologlc level of responslveness
4 uralnage presence of dralnage need Lo connecL Lubes Lo a speclflc dralnage sysLem presence and condlLlon of
dresslngs
3 ComforL Lype of paln and locaLlon nausea and vomlLlng poslLlon change requlred
6 sychologlc naLure of paLlenL's quesLlons need for resL and sleep dlsLurbance by nolse vlslLors avallablllLy of
call bell or call llghL
7 afeLy need for slde ralls dralnage Lubes unobsLrucLed lv fluld properly lnfuslng and lv slLes properly spllnLed
8 qulpmenL checked for proper funcLlonlng

oals and lnLervenLlons
revenLlng and/or rellevlng compllcaLlons
C CpLlmal resplraLory funcLlon
upporL psychosoclal wellbelng
1 1lssue perfuslon and cardlovascular sLaLus malnLenance
C Cbservlng and malnLalnlng adequaLe fluld lnLake
romoLlng adequaLe nuLrlLlon and ellmlnaLlon
A AdequaLe fluld and elecLrolyLe balance
enal funcLlon malnLenance
ncouraglng acLlvlLy and moblllLy wlLhln llmlLs
1 1horough wound care for adequaLe wound heallng
l lnfecLlon ConLrol
v vlgllanL Lo manlfesLaLlons of anxleLy and promoLlng ways of rellevlng lL
llmlnaLlng envlronmenLal hazards and promoLlng cllenL safeLy