Download Philippine Nurse Licensure Review

Medical Surgical Nursing
PERIOPERATIVE NURSING
By : Lowell P. Bautista, RN
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
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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

1.
2.
3.
GOALS :
To provide safe, supportive &
comprehensive care.
To assist the surgeon by functioning
effectively as a member of the surgical
team.
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 followup evaluation in the clinical setting or at home


1)
CLASSIFICATIONS
OF SURGERY
According to Urgency :
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

1.
2.
3.
Accdg. To Purpose :
DIAGNOSTIC – verifies suspected diagnosis
- ex. Biopsy
EXPLORATORY – estimates the extent of
the disease or injury.
- Ex. Explore laparotomy
CURATIVE – removes or repairs damaged
tissues .
CLASSIFICATIONS
OF SURGERY
4.
5.
6.
ABLATIVE – removing diseased organ
that can’t wait anymore.
- emergency surgery.
PALLIATIVE – relieves symptoms but
does not cure the underlying disease
process.
RECONSTRUCTIVE – partial or complete
restoration of a damaged organ/tissue to
bring back the original appearance &
function.(mammoplasty, face-lift)
7.

1.
2.
CONSTRUCTIVE – repairing the
damaged tissue or congenitally defective
organ. (multiple wound repair)
Accdg. To Location :
INTERNAL – inside the body .
Ex. Hysterectomy
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)
4)
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.
TUMORS – abnormal growth of tissue that
serves no physiologic function in the body.
THE SURGICAL RISK
PATIENTS

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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)
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Hypertensive & hypotensive pts.
Hypovolemia
Hepatic disease
Preexisting mental or physical disability

1.
2.
3.
4.
5.
PROBLEMS THAT MAY ARISE IN
SURGERY:
Surgical risk pts – probability of morbidity
or mortality following surgery.
Pain
Hemorrhage
Infection
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)
e)
Demonstrate confidence in surgeon & staff.
Provide for spiritual care if appropriate.
PREOPERATIVE TEACHING

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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
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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
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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.
2.
3.
4.
5.
6.
CBC
Electrolytes
PT/PTT (Prothrombin Time;Partial
thromboplastin time)
Urinalysis
ECG
Blood typing & crossmatch

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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
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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.
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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

1.
2.
Adult client (over 18 y/o) signs own permit
unless unconcious or mentally incompetent.
If unable to sign, relative (spouse or next of
kin) or guardian will sign.
In an emergency, permission via telephone
or telegram is acceptable; have a 2nd
listener on phone when telephone
permission is given
3.
a.
b.
c.
d.
Consents are not needed for emergency
care if all 4 of the ff. criteria are met:
There is an immediate threat to life.
Experts agree that it is an emergency.
Client is unable to consent.
A legally authorized person cannot be
reached.

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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

1.
2.
3.
4.
PURPOSES:
To relieve fear & anxiety.
To reduce dose needed for induction &
maintenance of anesthesia.
To prevent reflex bradycardia that happens
during induction of anesthesia.
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.

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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

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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


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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 1foot distance from the sterile field must be
maintained.
Basic Guidelines for Surgical
Asepsis


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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.

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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.

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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.
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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

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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

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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

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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.
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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.
2.
3.
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.
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.
Under running water, clean your fingernails and
cuticles, using a nail cleaner.
4.
5.
6.
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.
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.
Begin with the fingertips. Bring your thumb
and fingertips together and, using the brush,
scrub across the fingertips using 30 strokes.
7.
8.
9.
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.
Scrub the palm and back of the hand in a
circular motion, using 20 strokes each.
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.
11.
12.
13.
Scrub the elbow in a circular motion using 20
strokes.
Scrub in a circular motion all surfaces to
approximately 2 inches above the elbow.
Do not rinse this arm when you have finished
scrubbing. Rinse only the brush.
Pass the rinsed brush to the scrubbed hand
and begin scrubbing your other hand and arm,
using the same procedure outlined above
14.
15.
16.
17.
Drop the brush into the sink when you are
finished.
Rinse both hands and arms, keeping your
hands above the level of your elbows, and
allow water to drain off the elbows.
When rinsing, do not touch anything with your
scrubbed hands and arms.
The total scrub procedure must include all
anatomical surfaces from the fingertips to
approximately 2 inches above the elbow.
18.
19.
Dry your hands with a sterile towel. Do not
allow the towel to touch anything other than
your scrubbed hands and arms.
Between operations, follow the same handscrub procedure.
Gowning and Gloving
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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.

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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-toside 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

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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
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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.
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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
 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.
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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.
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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
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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.
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REGIONAL ANESTHESIA
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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
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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.
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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
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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
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LOCAL ANESTHESIA
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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.
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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
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Nausea and vomiting
Anaphylaxis
Hypoxia and respiratory complications
Hypothermia
Malignant hyperthermia
Disseminated intravascular coagulation (DIC)
Potential Adverse Effects of
Surgery and Anesthesia
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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.
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Nursing Goals for the Patient in
the Intraoperative Period
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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
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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
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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
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The PACU environment
Beds and other equipment
Three phases:
Phase I
 Phase II
 Phase III
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Nursing Management in the
PACU
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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
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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
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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