Preoperative Period Classifications Based on Extent

1. Major
- Decision to undergo operation to the transfer to OR
- extensive, significant and serious risk with significant loss
of blood.
Conditions requiring surgery: - Ex. Craniotomy, cesarean section, appendectomy.
2. Minor
• Obstruction - affects hollow structures.
- Ex. Dilatation and curettage, circumcision, wound
• Perforation – rupture of organ, artery or bleb. drainage and suturing.
• Erosion – break in continuity of tissue surface.
• Tumors – abnormal growth of tissue without purpose (?) Classification Based on Urgency

Classifications Based on Purpose: 1. Emergency

- performed immediately to maintain life/organ; stop
1. Diagnostic – confirm diagnosis. (benign / malignant) hemorrhage and remove damaged organ.
2. Exploratory – estimate extent of disease and confirm - Ex. Fractured skull, gunshot or stab wounds.
2. Urgent (Imperative)
diagnosis. (ex. Exploratory Laparotomy)
- Performed within 24 – 30 hrs.
3. Curative – remove or repair damages of diseased - Ex. Kidney or ureteral stones.
organ / tissue 3. Planned (Required)
- Important but may be scheduled weeks or months in
Types of Curative Surgery: advance.
a) Ablative Surgery – removal of diseased - Ex. Cataracts, tonsillectomy.
organ. 4. Elective
b) Constructive Surgery – repair of congenitally - Scheduled in advance and does not involve medical
defective organ by improving function or emergency.
appearance. - Ex. Repair of scars, simple hernia repair, vaginal repair.
c) Reconstructive Surgery – partial or complete 5. Optional
restoration of damaged organ or tissues to - Done for preference, surgery is not needed.
its original appearance or function. - Ex. Cosmetic surgery.
d) Palliative Surgery – relieves symptoms but
does not cure underlying cause / disease.
Preparations the Day Before Surgery • Alcohol, nicotine, recreational drug use
• Occupation
I. History taking
• Religious affiliation
- Should include marital status, religion, social status,
• Significant others
support group/significant other, and if member of
PhilHealth or has insurance. • Questions the client has about the surgery
II. Physical Assessment Reinforce Health Teachings
- Includes laboratory results and should make sure that
patient is cardiopulmonary (CP) cleared. • Deep breathing exercises – promote optimal lung expansion
- Family should secure 1 bag of patient’s blood type. and prevent postoperative pneumonia.
III. Informed Consent • Coughing exercises – proper breathing (?) to minimize
- Patient’s autonomous decision on where to undergo pressure and control pain at incision site.
procedure based on nature of condition, treatment • Leg exercises – prevent circulatory problems and promote
options, and risks and benefits involved. venous return to the heart.
- Protects patient from unsanctioned surgery.
- early ambulation and pain management.
- Protects surgeon from claims of unauthorized operation.
• Turning to sides – prevent respiratory problems and prevent
• Voluntary Consent bed sores.
- Of legal age and mentally capable.
- Should not be coerced or urged to sign.
*Reminders
- If not capable/minor, family member or guardian must
sign for emergency situations - Remove nail polish to observe nail bed for hypoxia.
- Skin prep/cleansed and shaved as close to incision time.
Important Information
- Jewelry and valuable belongings are given to watcher.
• Previous surgery and experience with anesthesia.
Night Before Surgery
• Any serious illnesses the client had
• Current symptoms or discomforts - Give medications like sedatives as ordered.
• Chronic illnesses, such as arthritis, migraines, back pain - Instruct patient to maintain NPO after midnight (inform
• Previous and current prescribed medications or use of watchers) [no fluids, foods, tea, milk, water, juice]
over-the-counter drugs - Do bowel preparations for cases of abdominal surgery as
• Allergies and reactions, indicated. [enema, laxative]
• Any dietary restrictions
 - Full bath if able or assist in going to the hosp. Chapel if Preoperative Medications
there’s any.
• ANTIANXIETY
- NPO is maintained and that patient is CP cleared and
check also the availability of the ordered blood • HISTAMINE-2 RECEPTOR ANTAGONIST
- Allow the patient to void. • SEDATIVES
- Change pt. dress to OR gown, tie long hair and you may • ANTIBIOTICS
put a disposable cap.
- Dentures/false teeth are removed
- Check if jewelry is already removed
- Start IV line using big bore catheter

Preoperative Checklist

• must be filled completely with patient / significant

other’s signature.
• Obtain initial vital signs for baseline data.
• Endorse the patient to OR nurse one hour prior to
surgery including the chart.

-> Checklist:

• History and physical examination.

• Name of procedure on surgical consent.
• Signed surgical consent.
• Laboratory results.
• Client is wearing an identification bracelet.
• Allergies have been identified.
• NPO.
• Skin preparation completed.
• Vital signs assessed.
Intraoperative Period
- OR to Post Anesthesia Ward

Operating Theater

- is a facility within a hospital where surgical operations are

carried out in an aseptic environment. Historically, the term
"operating theatre" referred to a non-sterile, tiered theater
or amphitheater in which students and other spectators
could watch surgeons perform surgery.

Electrosurgical Unit (ESU)

- Consists of a generator and a handpiece with one or more

electrodes. The device is controlled using a switch on the
handpiece or a foot switch.
- Can produce a variety of electrical waveforms. As these
waveforms change, so do the corresponding tissue effects. Nursing Responsibilities

Anesthesia Machine 1. Focuses on the client’s emotional well – being.

2. Focuses on physical factors such as:
- Device used to generate and mix a fresh gas flow of medical o Positioning and safety
gases and inhalational anesthetic agents for the purpose of o Maintaining asepsis
inducing and maintaining anesthesia. o Controlling the surgical
- dispenses the gases that are necessary to induce sleep and o Environment
prevent pain to animals during surgical procedures or other 3. Being the client’s advocate.
potentially painful manipulations. 4. Anticipating and guarding against potential complications
Kick Bucket

- Medical receptacle, usually made of stainless steel, which is

mounted on wheels.
Operating Room Attire operation, Maintains accurate
count of sponges, sharps, and
o A protective cap covering their hair
instruments on the sterile field and
o Masks over their lower face, covering their mouths and
count.
noses
o Assesses the client preoperatively
o Shades or glasses over their eyes
o Plans for optimal care during the
o Latex gloves on their hands
surgical intervention
o Long gowns
o Coordinates all personnel within the
o Protective covers on their shoes
OR
Surgical Team o Ensures that all equipment works
properly
- The surgical team is a group of highly trained and educated 4. CIRCULATING NURSE
professionals who coordinate their efforts to ensure the welfare and o Assesses the client preoperatively
safety of the client. o Plans for optimal care during the surgical
1. SURGEON: The head of the surgical team; Makes decision intervention
about the surgical procedure. o Coordinates all personnel within the OR
2. ASSISTANT SURGEON: Assist the surgeon; May be a second o Ensures that all equipment works properly
surgeon or specially trained nurse. o Guaranteeing sterility of instruments and
3. ANESTHESIOLOGIST / NURSE ANESTHETIST: Alleviates pain supplies
and promotes relaxation with medications, maintains airway o Assists with positioning
and ensures adequate gas exchange, Monitors circulation o Performs surgical skin preparation
and respiration. Estimates fluid and blood loss. Administers o Monitors the room and team members for
medications and infuses blood and fluids to maintain break in the sterile technique
hemodynamic stability. o Assists anesthesia personnel with induction
- Alerts the surgeon to any complications and physiologic monitoring
o Organize surgical instruments, o Handles specimens
Prepares all supplies and o Coordinates activities with other
instruments using aseptic departments
technique, Maintains sterility within o Documents care provided
the sterile field during surgery, o Minimizes conversation and traffic within
Hands appropriate instruments and the OR suite
supplies to the surgeon during the
Skin Preparation IV. PRONE
o Commonly used for cervical spine, posterior fossa
craniotomy, back, rectal, and posterior leg surgery.
V. LATERAL
o Used for clients undergoing kidney, chest, or hip
surgery.

During Induction of Anesthesia

- Anesthesia – an artificially induced state of partial or total

loss of sensation with or without loss of consciousness.
Anesthesia agents can produce muscle relaxation, block
transmission of nerve impulses, and suppress reflexes.

1. GENERAL ANESTHESIA

- Block pain stimulus at the cerebral cortex

- Induce depression of the CNS
Surgical Position - Produce analgesia, amnesia, unconsciousness, and loss of
reflexes and muscle tone
I. DORSAL RECUMBENT (SUPINE) - Affect the neurologic, respiratory, and cardiovascular system
o Commonly used for coronary artery bypass grafting, - Best used for:
hernia repair, mastectomy or bowel resection. ➢ Head
II. TRENDELENBURG ➢ Neck
o Permits displacement of the intestines into the ➢ Upper torso and back
upper abdomen and is often used during surgery of ➢ For prolonged surgical procedures
the lower abdomen or pelvis. ➢ Or for use in clients who are unable to lie quietly for
III. LITHOTOMY a long period.
o Exposes the perineal and rectal areas and is ideal for
vaginal repairs, dilatation and curettage, and most
types of rectal surgery.
- BALANCE (NEUROLEPTIC) ANESTHESIA 2. REGIONAL ANESTHESIA
o a method in administering general anesthesia.
- Block the pain stimulus at its origin, along afferent neurons
o achieved by using a combination of an inhalation
or along the spinal cord.
agent, oxygen, an opioid, and a neuromuscular
- Does not result in unconsciousness
blocking agent.
- the client will also receive sedative agents that produce
o Inhalation and IV route are the most common route
drowsiness.
of administration.
- Neuromuscular Blocking Agent
➢ Types of Regional Anesthesia
o Administered by IV route and are given mainly to
o SPINAL ANESTHESIA
facilitate intubation by easing laryngospasm and
- Achieve by injecting local anesthetics into
relaxing muscles for controlled ventilation.
the subarachnoid space.
o classified as depolarizing and nondepolarizing
- Autonomic nerve fibers (ANS) are affected
agents; Block the transmission of nerve impulses of
first, then the spinal anesthesia blocks the
the muscle fibers.
following fibers in this order: touch, pain,
o Ex. succinylcholine, tubocurarine, pancuronium, and
motor, pressure and proprioceptive fibers.
vecuronium.
• Recovery is in reverse order.
➢ Types of General Anesthesia
- A sterile field is established with povidone-
o Intravenous
iodine applied with three basic sponges; the
- Rapid induction (30s)
solution is applied starting from the injection
- Rapid transition from conscious state to
site moving outward in a circular fashion.
anesthesia stage.
- A fenestrated drape is applied, and using a
- Smooth transition; act as calming agent.
sterile gauze, wipe the iodine from the
- Ex. thiopental Na and ketamine
injection site to avoid initiation into the
o Inhalation
subarachnoid space. A skin wheal is raised
- Mixture of volatile liquids or gas and oxygen
with 2cc of 1% lidocaine using a 25G needle
is used
to the selected space.
- Ease of administration and elimination
- Used for almost any type of major
through respiratory system.
procedure performed below the level of the
- Maintain the client in stage III anesthesia
diaphragm.
following induction; given via face
mask/endotracheal tube.
- Ex. Halothane and Isoflurane
 - Within minutes of administration the client o LOCAL INFILTRATION
experiences a loss of sensation and paralysis - injection of an agent (xylocaine) into the skin
of the toes, feet, legs, and then abdomen and subcutaneous tissue of the area to be
- Lower risk than GA; may cause vasodilation, anesthetized.
and hypotension. - Must do aspiration before injecting;
cardiovascular collapse and convulsions
o EPIDURAL ANESTHESIA could occur.
- achieved by introduction of an anesthetic o FIELD BLOCK ANESTHESIA
agent into the epidural space. - Agent is injected proximal to planned
- produces a blockade of the autonomic incision site.
nerves and hypotension; Respiratory - Forms a barrier between the incision and the
depression or paralysis may occur if level of nervous system.
block is too high and the respiratory muscles o PERIPHERAL NERVE BLOCK ANESTHESIA
are affected. - Anesthetizes individual nerves or nerve
- commonly placed in the low back (lumbar plexuses.
region). - injects the anesthetic along the nerve rather
- Local anesthetics and narcotics given than into the nerve to decrease the risk of
epidurally via this catheter. nerve damage.
- May be used for 1 to 4 days post operatively.
o CAUDAL ANESTHESIA
- injecting of the local anesthetic into the
caudal or sacral canal.
- commonly used with obstetric clients.
o TOPICAL ANESTHESIA
- Short acting form of anesthesia
- Can block peripheral nerve endings in the
mucous membranes.
- Agent may be a solution, an ointment, a gel,
a cream, or a powder.
MONITORED ANESTHESIA

- A planned procedure during which the patient undergoes

local anesthesia together with sedation and analgesia.
- Surgeon infiltrates the surgical site with a local anesthetic
and the anesthesia provider supplements it with IV drugs to
provide sedation and systemic analgesia.
- Anesthesia providers monitors the client’s BP, HR, and RR
during the process.
- Local standby and anesthesia standby also refer to
monitored anesthesia.

POTENTIAL INTRAOPERATIVE COMPLICATIONS

➢ Nausea and Vomiting

➢ Anaphylaxis
➢ Hypoxia and other respiratory complications
➢ Hypothermia
 Stage Start-Point Endpoint Physical Reaction Nsg. Interventions

I. Onset Anesthetic administration Loss of consciousness Drowsy or dizzy, possible Close operating room
visual or auditory doors, keep room quiet,
hallucination stand by to assist the
client

II. Excitement Loss of consciousness Loss of eyelid reflexes Increase in autonomic Remain quiet at client’s
activity and irregular side assist
breathing, client may anesthesiologist as
struggle needed

III. Surgical Loss of eyelid reflexes Loss of most reflexes and Client is unconscious, Begin preparation when
anesthesia depression of vital signs muscles are relaxed, no the client is breathing well
blink or gag reflex with stable vital signs

IV. Medullary Functions excessively Respiratory and circulatory Client is not breathing, If arrest occurs, respond
Depression depressed failure heartbeat may or may not immediately to assist in
be present establishing airways and
other procedures
Postoperative Period • Positioning and placement of the IV tubing, catheters and
tubes. Any soiled, wet gowns is removed carefully and
- Leaves OR to follow up visit with surgeon. replaced with lightweight blanket and warmed. Side rails are
Stages of Postoperative Period raised.
• Then the PACU nurse admits the patient a handover or
1. Immediate Stage
endorsement is made by the Operating room Nurse.
- in the PACU
- Routine post op care are done.
Information during admission to PACU
2. Intermediate Stage
o Medical diagnosis and type of surgery performed
- in the Ward o Pertinent past medical history & allergies
3. Extended Stage o Age, general condition, airway patency, vital signs
- Hospital discharge to the time of follow- o Anesthetics & medications used during the procedure
o Problems intraoperatively (e.g. Extensive hemorrhage,
up/consultation shock, cardiac arrest)
The Post anesthesia Care Unit (PACU) o Fluid administered, blood loss, replacement fluids
- Patient still under anesthesia or recovering from o Tubing, catheters, drains
anesthesia are placed o Specific instructions for notification (e.g. BP or heart rate
- Located adjacent to the operating rooms for easy below or above a specified level)
access to experienced, highly skilled nurses,
anesthesiologists, surgeons, advanced monitoring ROUNTINE POST OPERATIVE CARE
devices to check for hemodynamic, pulmonary o Patient first then chart
status. o Intravenous fluids
• Transferring the postoperative patient to the PACU is a big ▪ check on the going IVF as well as the next IV to
responsibility of the anesthesiologist or anesthetist follow.
• Anesthesia provider remains at the head of the stretcher (to o Monitoring
maintain the airway) and a surgical team member remains at ▪ every 15 mins for the first 2 hours, then q 30 mins
the opposite end. there after until the clients vital signs are stable.
• Patient is critically monitored for any reaction from
anesthesia.
o DVT prophylaxis (Deep Vein Thrombosis) Immediate Anesthetic Care (PACU)
▪ - A blood clot in the deep veins is a concern
o Respiratory Status
because it can cause life-threatening
- patent airway, suction PRN
complications.
o Cardiovascular
▪ A blood clot (thrombus) in the deep venous
- Regular, strong HR and stable BP (VS); peripheral
system of the leg becomes dangerous if a piece
pulses; Homan’s Sign.
of the blood clot breaks off or travels through the
o Neurological
blood stream, through the heart, and into the
- level of consciousness; orientation, sensation
pulmonary arteries forming a pulmonary
o Fluid and Electrolyte, Acid Base Balance
embolism. A person may not have signs or
o Airway
symptoms of a small pulmonary
- Keep airway in place until the patient is fully awake
embolism (blood clot in the lungs), but a large
and tries to eject it.
embolism can be fatal.
- Return of pharyngeal reflex, noted when the patient
▪ Symptoms of DVT in leg include:
regains consciousness, may cause the patient to gag
o Pain
and vomit when the airway is not removed when the
o Swelling
patient is awake.
o Warmth
- Suction secretions as needed.
o Tenderness
o Breathing
o Redness of the leg or arm
- B – Bilateral lung auscultation frequently.
o Wound care
- R – Rest and place the patient in a lateral position
▪ assess always the wound for bleeding.
with the neck extended, if not contraindicated, and
o Medication
the arm supported with a pillow. This position
▪ post op medications include antibiotics and pain
promotes chest expansion and facilitates breathing
reliever, especial attention with medication if
and ventilation.
client has other underlying chronic conditions.
- E – Encourage the patient to take deep breaths. This
o Investigations – focus on other diagnostic studies to be
aerates the lung fully and prevents
done like biopsy, ultrasound, other laboratory studies.
hypostatic pneumonia.
- A – Assess and periodically evaluate the patient’s
orientation to name or command. Cerebral function
 alteration is highly suggestive of impaired Elderly Care in Postoperative
oxygen delivery.
o Respiratory System
- T – Turn the patient if advised every 1 to 2 hours to
- diminished airway reflexes and cough.
facilitate breathing and ventilation.
o Cardiovascular
- H – Humidified oxygen administration.
- myocardium weakness.
During exhalation, heat and moisture are normally
o Hypothermia
lost, thus oxygen humidification is necessary. Aside
- less subcutaneous tissue, muscle, slow metabolic
from that, secretion removal is facilitated when kept
rate.
moist through the moisture of the inhaled air. Also,
o Pain
dehydrated patients have irritated respiratory
- more intense, confusion, impaired circulation and
passages thus, it is very important make sure that the
sensory.
inhaled oxygen is humidified.
Gentle handling and positioning should be observed because
o Circulation
it can influence BP and ventilation
- Obtain patient’s vital signs as ordered and report any
Special attention is given to keeping the patient warm
abnormalities.
because the elderly are more susceptible to hypothermia.
- Monitor intake and output closely.
Post op confusion is common among elderly which
- Recognize early symptoms of shock or hemorrhage
aggravated by social isolation, restraints, and anesthetic
such as cold extremities, decreased urine output –
agents and pain relievers
less than 30 ml/hr., slow capillary refill – greater than
Reorienting them and using smaller amounts of sedatives
3 seconds, dropping blood pressure, narrowing pulse
and analgesics may help prevent confusion.
pressure, tachycardia – increased heart rate.
Safety very important at all times.
Initial Post-Operative Assessments
Readiness for Discharge from PACU
o Vital signs
• Stable vital signs
o Effectiveness of respirations
• Normal LOC
o Presence or need for supplemental oxygen
- patient is oriented to : Time, person and place
o Location of drains and drainage characteristics
• Uncompromised lung function
o Location, type, and rate of intravenous fluid
- normal O2 saturation, nail beds, no abnormal lung
o Level of pain and need for analgesia
sounds, not cyanotic
o Presence of a urinary catheter and urine volume
• Urine output
- 30 ml per hour
• Nausea & vomiting controlled/absent
- Negative for N/V which can lead to F and E
imbalances
• Minimal pain
•