10. Peri-operative care (2 hrs).pptx

PERI-OPERATIVE CARE
By Ame Mehadi(BSc, MSc in EMCCN)

Phases of the Surgical Experience
 The perioperative period
begins when the patient is informed of the need for surgery,
includes the surgical procedure and recovery, and continues until the
patient resumes his or her usual activities.
 The surgical experience can be segregated into three phases:
1) preoperative,
2) intraoperative, and
3) postoperative.
 The word “perioperative” is used to encompass all three phases.
 The perioperative nurse provides nursing care during all three
phases.

PREOPERATIVE PHASE
 begins when the patient, or someone acting on the patient’s behalf,
is informed of the need for surgery and makes the decision to have
the procedure.
 ends when the patient is transferred to the OR bed.
 is the period that is used to physically and psychologically prepare the
patient for surgery.
 The length of the preoperative period varies.
 For the patient whose surgery is elective, the period may be lengthy.

PREOPERATIVE PHASE
 Extends from the time the client is a admitted in the surgical unit, to the
time he/she is prepared physically, psychosocially, spiritually, and legally
for the surgical procedure, until he is transported into the OR.
 Begins when the decision to proceed with surgical intervention is made
and ends with the transfer of the patient onto the OR table.
 involves establishing a baseline evaluation of the patient before surgery by
carrying out a preoperative interview.
 ensuring that necessary tests have been or will be performed.
 arranging appropriate consultations; and providing education about
recovery from anesthesia and postoperative care.
 On the day of surgery, patient teaching is reviewed, the patient’s identity
and surgical site are verified, informed consent is confirmed, and an IV
infusion is started.

PHYSIOLOGIC ASS’T OF THE CLIENT UNDERGOING
SURGERY
 Age
 Presence of pain
 Nutritional status
 Fluid and electrolyte balance
 Infection
 Cardiovascular function
 Pulmonary function
 Renal function
 Gastrointestinal function
 Liver function
 Endocrine function
 Hematologic function
 Use of medication
 Presence of trauma

PSYCHOSOCIAL ASSESSMENT AND CARE
 Causes of fears of the preoperative
clients
Fear of the unknown
Fear of anesthesia, vulnerability
while unconscious
Fear of pain
Fear of death
Fear of disturbance of body image
Worries – loss of finances,
employment, social and family roles
Manifestations of fears
Anxiousness
Bewilderment
Anger
Tendency to exaggerate
Sad, evasive, tearful, clinging
Inability to concentrate
Short attention span
Failure to carry out simple
directions
Dazed

INTERVENTIONS TO MINIMIZE ANXIETY
 Explore client’s feelings
 Assist client to identify coping strategies that he or she has previously
used to decrease fear
 Allow client to speak openly about fears/concerns
 Give accurate information regarding surgery
 Give empathetic support
 Consider the person’s religious preferences and arrange visit by
priest/minister as desired
 Music therapy

PHYSICAL PREPARATION
 Before Surgery
 Correct any dietary deficiencies
 Reduce an obese person’s weight
 Correct fluid and electrolyte imbalances
 Restore adequate blood volume with blood transfusion
 Treat chronic diseases
 Halt or treat any infectious process
 Treat an alcoholic person with vitamin supplementation, IVF’s or oral
fluids if dehydrated

TEACHING PREOPERATIVE EXERCISES
 Deep breathing exercises
Practice in the same position client would assume in bed after surgery
Allow hands in a loose fist position to rest lightly on the front of the
lower ribs with your finger tips against lower chest to feel the movement
Breathe out gently and fully as the ribs sink down and inward toward
midline
Take a deep breath your nose and mouth, letting the abdomen rise as
the lungs fill with air
Hold this breath for a count of five
Exhale and let out all the air through your nose and mouth
Repeat this exercise 15 times with a short rest after each group of five
Practice twice daily preoperatively

Incentive spirometry
Let client sit upright, at 45 degrees minimum
Take two normal breaths.
Place mouthpiece of spirometer in mouth
Inhale until target, designated by spirometer
light or rising ball, is reached, and hold breath for
3 to 5 seconds
Exhale completely
Perform 10 sets of breaths each hour

Coughing exercises
Have client sit up and lean forward
Show client how to splint incision with hands, pillow, or
blanket
Have client inhale and exhale deeply three times through
mouth
Have client take in deep breath and cough out the breath
forcefully with three short coughs using diaphragmatic muscles.
Take in quick deep breath through mouth, cough deeply, and
deep breathe

Turning exercises
Turn on your side with the uppermost leg
flexed most and supported on a pillow
Grasp the side rail as an aid to maneuver to
the side
Practice diaphragmatic breathing and
coughing while on your side

Foot and leg exercises
Lie in a semi-Fowler’s position
Bend your knee and raise your foot – hold it
a few seconds, then extend the leg and lower
it to the bed
Do this five times with each leg
Then trace circles with the feet by bending
them down, in toward each other, up, and
then out

PREPARING THE PERSON BEFORE
SURGERY
 Preparing the skin
Have full bath to reduce microorganisms in the skin
 Preparing the GI tract
NPO; cleansing enema as required
 Preparing for anesthesia
Avoid alcohol and cigarette smoking for at least 24 hours before
surgery
 Promoting rest and sleep
Administer sedatives as ordered

PREPARING THE PERSON ON THE DAY OF SURGERY
Early morning care
Awaken one hour before preoperative medications
Morning bath, mouth wash
Provide clean gown
Remove hairpins, braid long hairs, cover hair with cap
Remove dentures, foreign materials (chewing gum), colored nail
polish, hearing aid, contact lens

PREPARING THE PERSON ON THE DAY OF SURGERY
 Baseline vital signs before preoperative medication
 Check ID band and skin preparation
 Check for special orders – enema, GI tube insertion, IV line
 Check NPO
 Have client void before preoperative medication
 Continue to support emotionally
 Accomplish “preoperative care checklist”

PREOPERATIVE PREPARATION (SURGICAL HYGIENE
AND SHORN)
 INTRODUCTION:
The surgical infection is that takes place during the 30 days
following the intervention or 1 year following of implant.
It is causes significant morbidity and mortality.
The majority of infections is produced by the contamination of the
incision by microorganisms of the own skin.
 OBJECTIVES:
to achieve a reduction in the bacterial contamination of the tissues
of the patient.
Guaranteeing the security of the sick person in the whole process.

PREOPERATIVE PREPARATION
 Revising the clinical record of the patient
 Asks the possible allergies.
 Verifying fasting (6hr before the surgery it must not
insert solids nor liquid ) for risk of bronchial-aspiration.
 Withdrawing jewels, piercing, prosthesis (footsore,
dental prosthesis, earphones…)
 Registering vital constants in preoperative sheet
 Verifying the correct identification of the patient.
 Securing that the prepared area is wide enough to
include the surgical area and a margin that permits
manipulate the skin.

PREPARATION OF THE SURGICAL AREA
 Asepsis of the skin and the mucous membranes before carrying out in the act
surgical.
 Guaranteeing the asepsis of the surgical area and it minimizes the risk of
infection
 DESCRIPTION MATERIAL X OF THE SAME THING
Sterile capsule
Nippers of apprehension
Sterile gauzes
Beat gloves +
Antiseptic solution according to the field to prepare: dyed alcoholic clorhexidina
to the 2 % or iodized povidone ( hope that withers ).
* the clorhexidina cannot use: umbilical cord; surgical open wounds with
exposition of visceras; ophthalmological in the inside of the eye; and to carry out
intra-abdominal washes.

PREPARATION OF THE SURGICAL AREA
 INDICATOR
Sick persons with constancy of the clinical record of the register of
the used solution.
Register of infirmary of the surgical area of the used antiseptic
solution, the spotted area and any incidence in report to the
procedure.
Register of sheets of injuries in the surgical area, compliments in
the case of allergic reaction in the used solution as antiseptic.

PREOPERATIVE MEDICATIONS/PREANESTHETIC DRUGS
Purpose
To facilitate the administration of any anesthetic
To minimize respiratory tract secretions and
changes in heart rate
To relax the client and reduce anxiety

PREOPERATIVE MEDICATIONS/PREANESTHETIC
DRUGS
Narcotics
Morphine sulfate
Fentanyl (Sublimaze)
Meperidine (Demerol)
Analgesia; enhancement of
postoperative pain relief
Antianxiety and sedative
hypnotics
Diazepam (Valium)
Hydroxyzine hcl (Vistaril)
Lorazepam (Ativan)
Midazolam (Versed)
Phenobarnital sodium
Sedation; anxiety reduction

Anticholinergic
Atropine sulfate
Scopolamine hydrobromide
Secretion reduction
Antiemetic
Ondansetron (Zofran)
Metoclopramide (Reglan)
Promethazine hcl (Phenergan)
Control nausea and vomiting;
may be effective into the
postoperative period.
H2 antagonist
Cimetidine (Tagamet)
Ranitidine (Zantac)
Famotidine (Pepcid)
Reduction of acidic gastric
secretions in case aspiration
occurs
Antibiotic
Cefazolin (Ancef)
Ampicillin (Omnipen
Prevention of postoperative
infection.

Preoperative Phase
 For the patient whose surgery is urgent, the period is brief; the
patient may have no awareness of this period.
 Diagnostic studies and medical regimens are initiated in the
preoperative period.
 Information obtained from preoperative assessment and interview is
used to prepare a plan of care for the patient.
 Nursing activities in the pre op phase are directed toward patient
support, teaching, and preparation for the procedure.

Pre OP check list
 Discuss each item on the checklist, and provide an evidence based
rationale for its importance.
 Consent answers
Legal requirement >Informed consent
Written consent should be obtained identifying that the subject
has received and understood:-
The procedure offered
Reasonable alternatives to the procedure
Possible benefits of the procedure to the patient
Risks, inconveniences, and discomforts of the procedure
Answers to all patient's questions

Preoperative Assessment
I. Review preoperative laboratory and diagnostic studies
II. Review the client’s health history and preparation for surgery:
III. Assess physical needs
IV. Assess psychological needs
V. Assess cultural needs

 Age
 Allergies
 Vital Sign Trend
 Nutritional Status
 Habits affecting tolerance to anesthesia
 Presence of Infections
 Use of drugs that are contraindicated prior to surgery
 Physiological Status
 Psychological state of the patient

 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

I. Review preoperative laboratory and diagnostic studies:
Complete blood count.
Blood type and cross match.
Serum electrolytes.
Urinalysis.
Chest X-rays.
Electrocardiogram.
Other tests related to procedure or client’s medical condition, such
as: prothrombin time, partial thromboplastin time, blood urea
nitrogen, creatinine, and other radiographic studies.

II. Review the client’s health history and preparation for surgery:
History
History of present illness and reason for surgery
Medical conditions (acute and chronic)
Past medical history
History of any past problem with anesthesia
Previous hospitalization and surgeries
Allergies
Present medications
Substance use: alcohol, tobacco, street drugs
Review of system

III. Assess physical needs:
Physical assessment (physiological measurement)
Identification of risk factors for the patient/client
Ability to communicate
Vital signs
Level of consciousness
Confusion
Drowsiness
Unresponsiveness
Weight and height
Skin integrity
Ability to move/ ambulate
Level of exercise
Prostheses
Circulatory status

IV. Assess psychological needs:
Emotional state
Level of understanding of surgical procedure, preoperative and
postoperative instruction
Coping strategies
Support system
Roles and responsibilities
V. Assess cultural needs:
Language-need for interpreter

Surgical consent
 Before surgery, the client must sign a surgical consent
form or operative permit.
 Clients must sign a consent form for any procedure that
requires anesthesia and has risks of complications.
 If an adult client is confused, unconscious, a family
member or guardian must sign the consent form.
 If the client is younger than 18 years of age, a parent or
legal guardian must sign the consent form.

Surgical consent
 In an emergency, the surgeon may have to operate without
consent, health care personnel, however, makes every effort
to obtain consent by telephone, or fax.
 Each nurse must be familiar with agency policies and state
laws regarding surgical consent forms.
 Clients must sign the consent form before receiving any
preoperative sedatives.
 The nurse is responsible for ensuring that all necessary parties
have signed the consent form and that it is in the client’s chart
before the client goes to the operating room (OR).

Preoperative Teaching
 Teaching clients about their surgical procedure and
expectations before and after surgery is best done during the
preoperative period.
 Clients are more alert and free of pain at this time.
 Clients and family members can better participate in recovery
if they know what to expect.
 The nurse adapts instructions and expectations to the client’s
ability to understand.
 Information in a preoperative teaching plan varies with the
type of surgery and the length of the hospitalization.

 Preoperative Teaching Plan Includes:
Preoperative medication- when they are given and their effects.
Post operative pain control.
Explanation and description of the post anesthesia recovery room
or post surgical area.
Discussion of the frequency of assessing vital signs and use of
monitoring equipment.
Explanation and demonstration deep breathing and coughing
exercises, use of incentive spirometry, how to support the incision for
breathing exercises and moving, position changes, and feet and leg
exercises.

 Preoperative Teaching Plan Includes:
Information about IV fluids and other lines and tubes such as NG-
tubes.
Preop teaching time also gives the client the chance to express any
anxieties and fears and for the nurse to provide explanations that will
help alleviate those fears.
When clients are admitted for emergency surgery, time for
explanation is unavailable; explanations will be more complete
during the postoperative period.

Preoperative Preparation:
 Physical Preparation.
 Skin preparation
 Elimination
 Food and fluids
 Care of valuables
 Clothing/grooming
 Prostheses
 Psychosocial Preparation.
 Careful preoperative teaching can reduce fear and anxiety
of the clients.

Responsibilities Before surgery
 Ensuring the OR has the proper equipment, any positioning devices,
and the OR table is in correct position, anesthesia circuit and suction is
hooked up, BAIR warmer and sequential compression devices (SCD’s)
are readily available
 Counting sharps and sponges (instruments if needed) with the scrub
person
 Pulling medications such as local and antibiotics
 Reviewing the patient’s chart to ensure the history and physical is
within 30 days, the surgical consent has been signed within 60 days,
and the day of surgery note has been entered by the surgeon.

Preop Interview
It is the nurses responsibility to interview the patient preoperatively
and verify identity, surgical procedure, marked if surgery consist of
laterality (i.e. right or left), allergies, if they are on a beta blocker that
it has been taken within the past 24 hours, any metal implanted in the
body, and the last time they had anything to eat or drink, they do not
have anything on that can be removed (i.e. dentures, jewelry etc.)
The patient has spoken with both the surgeon and anesthesiologist
and they have no questions before taking them back to the OR.

Circulating role
 coordinates the care of the patient,
 serves as the patient’s advocate throughout the intraoperative experience, and
 has responsibility for managing and implementing activities outside the sterile field.
 Activities are directed toward assuring patient safety and achieving desired patient outcomes.
 The nursing process is used as a framework for these activities.
 Examples of activities performed by the perioperative nurse in the circulating role include the following:
Providing emotional support to the patient prior to the induction of anesthesia
Performing ongoing patient assessment
Formulating a nursing diagnosis
Developing and implementing a plan of care
Documenting patient care
Evaluating patient outcomes
Teaching patient and family
Obtaining appropriate surgical supplies and equipment
Creating and maintaining a safe environment
Administering drugs
Implementing and enforcing policies and procedures that contribute to patient safety, such as surgical checklists, “time-out”
protocols, surgical counts for instruments, sponges, and sharps, as well as performing equipment checks
Preparing and disposing of specimens
Communicating relevant information to other team members and to the patient’s family

Circulating role
 In the operating room
Assisting the anesthesiologist with hooking the patient up to monitors, administering
oxygen and intubating the patient
Positioning the patient, hooking up the BAIR warmer, SCDs, cautery pad if needed,
prepping the surgical site
Tying up the scrub techs and surgeon
Hooking up equipment cords needed on the sterile field
Conducting a Time Out that verifies
the correct patient,
surgical procedure,
laterality,
allergies,
 available blood products if needed,
DVT prophylaxis,
implants/special equipment in the room and
any concerns

Circulating role
During surgery
Charting
Opening needed supplies to the sterile
field
Getting additional supplies
Assisting the anesthesiologist as
needed
Handling specimens and cultures
Performing first and final counts with
the scrub tech during closing if
applicable
After surgery
Calling postop/PACU to alert them
of our arrival
Transferring patient onto stretcher
Assisting anesthesiologist as needed
with emerging the patient from
anesthesia, any complications,
extubating etc.
Helping to transfer patient to
postop/PACU

INTRAOPERATIVE PHASE
 begins when the patient is transferred to the OR bed and
 ends with transfer to the PACU or another area where immediate
postsurgical recovery care is given.
 During the intraoperative period,
the patient is monitored, anesthetized, prepped, and draped, and
the procedure is performed.
 Your activities in the intraoperative period center on:
patient safety,
facilitation of the procedure,
prevention of infection, and
satisfactory physiologic response to anesthesia and surgical intervention.

 Maintenance of Safety
Maintains aseptic, controlled env’t
Effectively manages human resources, equipment, and supplies for
individualized patient care
Transfers patient to operating room bed or table
Positions patient based on functional alignment and expo-sure of
surgical site
Applies grounding device to patient
Ensures that the sponge, needle, and instrument counts are correct
Completes intraoperative documentation.

 Physiologic Monitoring
Calculates effects on patient of excessive fluid loss or gain
Distinguishes normal from abnormal cardiopulmonary data
Reports changes in patient’s vital signs
Institutes measures to promote normothermia
 Psychological Support (Before Induction and When Patient is
Conscious)
Provides emotional support to patient
Stands near or touches patient during procedures and induction
Continues to assess patient’s emotional status

Potential INTRA OP Complications
 The surgical patient is subject to several risks.
 Potential intra op cxns include
nausea and vomiting,
anaphylaxis,
hypoxia,
hypothermia, and
malignant hyperthermia.
 Targeted areas include surgical site infections, as well as cardiac,
respiratory, and venous thromboembolic complications.

Patient transfer
 Enough personnel are available to
undertake the transfer.
 The anaesthetist supervises and protects
the head, neck and airway.
 The patient is rolled and a sliding board
(arrow) is placed under the patient and
undersheet or canvas, which will allow the
patient to slide across to the bed in a
controlled fashion.
 Care is being taken by all of the team
members to protect the whole patient.

POSTOPERATIVE PHASE
 begins with the patient’s transfer to the recovery unit and
 ends with the resolution of surgical sequelae.
 may be either brief or extensive, and
 most commonly ends outside the facility where the surgery was
performed.
 For patients who will remain in the hospital for an extended stay, the
perioperative nurse may not provide care beyond patient transfer to
the PACU, where postanesthesia care nurses assume responsibility for
the patient.

POSTOPERATIVE PHASE
 Activities in the immediate postoperative phase center on
support of the patient’s physiologic systems.
 In the later stages of recovery, much of the focus is on
reinforcing the essential information that the patient and other
caregivers require in preparation for discharge.

Immediate postoperative period
 Initial Assessment
Level of consciousness
Airway patency
Presence of artificial airways
Respiratory status
Effectiveness of respiration
Mechanical ventilation, or supplemental oxygen therapy
Cardiovascular status
Circulatory status, vital signs
Central nervous system (effects of anaesthesia)
Fluid balance, including IV fluids, output from catheters and drains and ability to void
Pain relief/comfort/general condition
Vital signs
Wound condition, including dressings and drains/Skin integrity

Later postoperative period
 Ongoing Assessment
 Respiratory function
 General condition
 Vital signs
 Cardiovascular function
 Fluid status
 Pain level
 Bowel and urinary elimination
 Dressings, tubes, drains, and IV lines

Later postoperative period
 Long-term postoperative care is predominately concerned with
preventing complications and returning the patient/client to a state
whereby they can retake control over their own lives and lifestyle.
 The focus can be determined by using the identified factors to assess;
plan; implement and evaluate the nursing care given.

Your Responsibilities in Post op Phase
Ensures a patent airway
Helps maintain adequate circulation
Prevents or assist with the treatment of shack
Maintains proper position and function of drain tubes
and IV infusion
Monitor for potential complications

ASSISTING THE CLIENT WITH POSTOP EXERCISES
General Guidelines
Remember that the postop client will be better able to
perform these exercises if he or she learns them during the
preop period.
Wear gloves for these procedures if the client has any
open drainage.
Explain procedures to the client before you assist with
them.
Document all procedures and results.

ASSISTING THE CLIENT WITH POSTOP
EXERCISES
 Splinting an Incision
Holding a pillow or a folded bath blanket and pulling
it tightly against the incision splints the incisional area.
Assist the client to hold the splint for the first few
post op days.
Hold it from behind or press firmly on the front.
Do this as the client coughs.
it helps to make coughing or deep breathing more
comfortable,
it promotes better oxygenation,
it relieves pressure on the abd suture line and thus,
it relieves pain.

 Turning, Coughing, and Deep Breathing (TCDB)
Instruct the client to take a deep breath, hold it for 2
to 5 seconds, and then do a strong double-cough (or
“hack out” three short coughs) with the mouth open.
Holding a deep breath allows air to reach the lung’s
most severely deflated areas.
The double-cough maneuver helps the client to
mobilize and remove secretions.
Repeat this process several times each hour,
especially for the first few Post-OP days and while the
client remains bedridden.

ASSISTING THE CLIENT WITH POSTOP
EXERCISES
 Huffing
Teach the client to take a deep abdominal breath and then
force air out in several short, quick breaths.
The client should then take a second, deeper breath and force
it out in short, panting movements.
The client should then take an even deeper third breath and
exhale it quickly in a strong huff.
helps to loosen more secretions than just coughing.

Using the Incentive Spirometer
The client can observe her progress by
watching the diaphragm rise in the tube.
should be rptd 5 to 10 times every hour.

 Leg Exercises
 Suture and Staple Removal
Pull on the side next to the knot, to
prevent pulling the knot through the wound.
This might violently open the suture line
and would be more painful

 RECEIVING THE CLIENT FROM PACU
Measure V/S at least Q15min for the first
hour, and gradually less often as the client’s
condition stabilizes.

Roles of the Perioperative Nurse
Educator role
 Support and reassurance
 Patient advocacy
 Control of the env’t
 Maintaining of asepsis
 Monitoring of the patient
 Collaboration and consultation
 Those of manager/director role
 Clinical practitioner
 e.g., scrub, circulator, clinical specialist, registered first assistant,
 Researcher.

 Patient ass’t before, during, and after surgery
 Patient and family teaching
 Patient and family support and reassurance
 Patient advocacy
 Performing as scrub or circulating during surgery
 Control of the env’t
 Efficient provision of resources
 Coordination of activities related to patient care
 Communication, collaboration, and consultation with other healthcare
team members
 Maintenance of asepsis
 Ongoing monitoring of the patient’s physiological and psychological status
 Supervision of ancillary personnel

 Additional responsibilities that promote personal and professional growth
and contribute to the profession of perioperative nursing include, but are
not limited to, the following:
Participation in professional organization activities
Participation in research activities that support the profession of
perioperative nursing
Exploration and validation of current and future practice
Participation in continuing education programs to enhance personal
knowledge and to promote the profession of perioperative nursing
Functioning as a role model for nursing students and perioperative
nursing colleagues.
Mentoring, precepting, and instructing other perioperative nurses

Scrub person
 works primarily with instruments and equipment.
 The scrub person has the following responsibilities:
Selecting instruments, equipment, and other supplies appropriate
for the surgery
Preparing the sterile field and setting up the sterile table(s) with
instruments and other sterile supplies needed for the procedure
Scrubbing, and then donning a gown and gloves
Maintaining the integrity and sterility of the sterile field throughout
the procedure

Scrub person
Having knowledge of the procedure and anticipating the surgeon’s
needs throughout the procedure
Providing instruments, sutures, and supplies to the surgeon in an
appropriate and timely manner
Preparing sterile dressings
Implementing procedures that contribute to patient safety (e.g.,
surgical counts for instruments, sponges, and sharps)
Cleaning and preparing instruments for terminal sterilization

Roles of the Perioperative Nurse Midwife
 Perioperatively function in various roles, including those of
manager/director,
clinical practitioner,
e.g.,
scrub nurse midwife,
circulating nurse midwife,
clinical nurse midwife specialist,
registered nurse midwife first assistant [RNFA],
educator, and
researcher.

Roles of the Perioperative Nurse Midwife
 In these roles, your perioperative responsibilities include, but are not limited to, the
following:
Patient assessment before, during, and after surgery
Patient and family teaching
Patient and family support and reassurance
Patient advocacy
Performing as scrub or circulating nurse during surgery
Control of the environment
Efficient provision of resources
Coordination of activities related to patient care
Communication, collaboration, and consultation with other healthcare team
members.
Maintenance of asepsis
Ongoing monitoring of the patient’s physiological and psychological status
Supervision of ancillary personnel

Complications related to central venous
cannulation
 Line-related sepsis
 Trauma to tricuspid and pulmonary valves
 Arrhythmias
 Perforation of cardiac chambers
 Pulmonary artery rupture
 Pulmonary infarction
 Pulmonary embolism

Postoperative Phase
 extends from the time the patient leaves the OR until the last follow-
up visit with the surgeon.
 may be as short as 1 week or as long as several months.
 During the post op period, nursing care focuses on
reestablishing the patient’s physiologic equilibrium,
alleviating pain, preventing complications, and
teaching the patient self-care.
 Careful assessment and immediate intervention assist the patient in
returning to optimal function quickly, safely, and as comfortably as possible.
 Ongoing care in the community through home care, clinic visits, office visits,
or telephone follow-up facilitates an uncomplicated recovery.

Transfer from Theatre
 The nurse receiving the client from the OR needs the following
information:
Medical diagnosis and surgical procedure done
Past medical hx and allergies
Age, general condition
Airway status, current vital signs
Anesthetic agents and medications given during surgery
Any pathology found and if so, have family members been informed
Amount of fluid and blood lost and administered
Any tubes, catheters
Any other pertinent information needed to care for the client

Transfer from Theatre
 Patients are usually admitted to ICU for a
number of reasons:
Post-operative ventilation and respiratory
optimization
Hemodynamic monitoring
Sedation and analgesia

Transfer of Patient to PACU
 Communicates intraoperative information
Identifies patient by name
States type of surgery performed
Identifies type and amounts of anesthetic and analgesic agents used
Reports patient’s vital signs and response to surgical procedure and
anesthesia
Describes intraoperative factors (eg, insertion of drains or catheters,
administration of blood, medications during surgery, or occurrence of
unexpected events)
Describes physical limitations
Reports patient’s preoperative level of consciousness
Communicates necessary equipment needs
Communicates presence of family or significant others

ADMITTING THE PATIENT TO THE PACU
 Transferring the post op patient from OR to PACU is
the responsibility of the anesthesiologist or anesthetist.
 During transport from the OR to the PACU,
the anesthesia provider remains at the head of the stretcher (to
maintain the airway), and
a surgical team member remains at the opposite end.
 Transporting the patient involves special consideration of
the incision site,
potential vascular changes, and
exposure.

 The surgical incision is considered every time the postoperative patient is
moved; many wounds are closed under considerable tension, and every
effort is made to prevent further strain on the incision.
 The patient is positioned so that he or she is not lying on and obstructing
drains or drainage tubes.
 Serious orthostatic hypotension may occur when a patient is moved from
one position to another (e.g., from a lithotomy position to a horizontal
position or from a lateral to a supine position), so the patient must be
moved slowly and carefully.
 As soon as the patient is placed on the stretcher or bed, the soiled gown is
re-moved and replaced with a dry gown.
 The patient is covered with lightweight blankets and warmed.
 The side rails are raised to guard against falls.

 The nurse who admits the patient to the PACU reviews the following information
with the anesthesiologist or anesthetist:
Medical diagnosis and type of surgery performed
Pertinent past medical history and allergies
Patient’s age and general condition, airway patency, vital signs
Anesthetics and other medications used during the procedure
e.g., opioids and other analgesic agents, muscle relax-ants, antibiotic agents
Any problems that occurred in the OR that might influence post op care
e.g., extensive hemorrhage, shock, cardiac arrest
Pathology encountered
Fluid administered, estimated blood loss and replacement fluids
Any tubing, drains, catheters, or other supportive aids
Specific information about which the surgeon, anesthesiologist, or anesthetist
wishes to be notified (eg, BP or HR below or above a specified level)

POSTANESTHESIA CARE
 Postanesthesia Care is provided in PACU or recovery room(RR)
 The postanesthesia care unit (PACU)
is located adjacent to the OR, kept quiet, clean, and free of
unnecessary equipment.
should also be well ventilated.
 Patients still under anesthesia or recovering from anesthesia are
placed in this unit for easy access to experienced, highly skilled
nurses, anesthesiologists or anesthetists, surgeons, advanced
hemodynamic and pulmonary monitoring and support, special
equipment, and medications.

POSTANESTHESIA CARE
 The postanesthesia care unit (PACU)
is painted in soft, pleasing colors and
has indirect lighting, a soundproof ceiling,
has equipment that controls or eliminates noise (e.g., plastic
emesis basins, rubber bumpers on beds and tables), and
isolated but visible quarters for disruptive patients.
 These features benefit the patient by helping to decrease anxiety and
promote comfort.
 The PACU bed provides easy access to the patient, is safe and easily
movable, can be readily placed in position to facilitate use of
measures to counteract shock, and has features that facilitate care,
such as IV poles, side rails, wheel brakes, and a chart storage rack.

PHASES OF POSTANESTHESIA CARE
 Postanesthesia care in some hospitals and ambulatory surgical centers is
divided into two phases.
 In the phase I PACU,
used during the immediate recovery phase, intensive nursing care is
provided.
The phase I PACU nurse provides frequent (Q15 minutes) monitoring of the
patient’s pulse, ECG, RR, BP, and pulse oximeter value (blood O2 level).
In some cases, end-tidal CO2(ETCO2) levels are monitored as well.
The patient’s airway may become obstructed because of the latent effects
of recent anesthesia, and the PACU nurse must be prepared to assist in
reintubation and in handling other emergencies that may occur.

 The phase II PACU
is reserved for patients who require less frequent observation and less
nursing care.
In the phase II unit, the patient is prepared for discharge.
Recliners rather than stretchers or beds are standard in many phase II
units, which may also be referred to as
step-down,
sit-up, or
progressive care units.
Patients may remain in a phase II PACU unit for as long as 4 to 6 hrs,
depending on
the type of surgery and
any preexisting conditions of the patient.
The nurse in the phase II PACU must possess strong clinical assessment
and patient teaching skills.

 Both phase I and phase II PACU nurses have special skills.
 In facilities without separate phase I and phase II units, the patient
remains in the PACU and may be discharged home directly from this
unit.

POSTANESTHESIA CARE……
 Objectives are to provide care for the patient in PACU until the
patient:
has recovered from the effects of anesthesia
e.g., until resumption of motor and sensory functions,
is oriented,
has stable vital signs, and
shows no evidence of hemorrhage or other complications.

Post-operative Assessment
 the cornerstones of nursing care in the PACU are Frequent, skilled ass’ts of
the blood O2 saturation level,
pulse rate and regularity,
depth and nature of respirations,
skin color,
Level of consciousness, and
ability to respond to commands
 The nurse performs a baseline ass’t, then checks the surgical site for drainage or
hemorrhage and makes sure that all drainage tubes and monitoring lines are
connected and functioning.

Initial post-operative assessment
 airway potency/presence of artificial airways
 effectiveness of respirations
 mechanical ventilation/or supplemental O2
 circulatory status
 vital signs
 wound condition including dressings and drains
 fluid balance, including
IV fluids,
output from catheters and drains.
 level of consciousness
 pain

Post-operative Assessment
 After the initial ass’t, V/S are monitored and the patient’s general physical status
is assessed at least Q15 minutes.
 Patency of the airway and respiratory function are always evaluated first,
followed by ass’t of
cardiovascular function,
the condition of the surgical site, and
function of the CNS.
 The nurse needs to be aware of any pertinent information from the patient’s
history that may be significant
e.g., patient is hard of hearing,
has a history of seizures,
has diabetes, or
is allergic to certain medications or to latex.

Major responsibilities
 Ensure patent airway
 Maintain adequate circulation
 Prevent and assist with the treatment of shock
 Maintain proper position and function of drains, tubes and IV
infusions; and monitor for potential cxns.

Airways & Breathing
 The airway should be examined to exclude any obstruction.
 Monitoring of breathing
observing for bilateral chest movements and
observing for ventilation effort
rate, depth, accessory muscle use) and
observing for ventilation efficacy
breath sounds using a stethoscope,
signs of cyanosis, and
oxygen saturation.

Maintaining a Patent Airway
 The primary objective in the immediate post op period is
to maintain pulmonary ventilation and
to prevent hypoxemia and hypercapnia.
• Both can occur if the airway is obstructed and ventilation is reduced (hypoventilation).
 Besides checking the physician’s orders for and administering supplemental O2,
the nurse assesses
RR and depth,
ease of respirations,
O2 saturation, and
breath sounds.
 When the patient lies on his or her back, the lower jaw and the tongue fall
backward and the air passages become obstructed.
 This is called hypopharyngeal obstruction.

Maintaining a Patent Airway
 Signs of occlusion include
choking,
noisy and irregular respirations,
decreased O2 saturation scores, and
within minutes a blue, dusky color (cyanosis) of the skin.
 Respiratory difficulty can also result from
excessive secretion of mucus or
aspiration of vomitus.
 Turning the patient to one side
allows the collected fluid to escape from the side of the mouth.
to prevent aspiration, If vomiting occurs
 Elevation of head of the bed 15 to 30 degrees unless contraindicated
to maintain the airway as well as to minimize the risk of aspiration.
 Suctioning
If mucus or vomitus obstructing the pharynx or the trachea
nasopharynx or oropharynx
Catheter can passed safely to a distance of 15 to 20 cm.

Monitoring Oxygenations
 Pulse Oximetry
Measurement of arterial O2 saturation (SaO2) is important in the acutely ill.
Allows measurement of the oxygenated hgb in arterial blood.
PR and arterial hgb O2 saturation (SaO2) are continuously displayed.
 Blood Gas Analysis
gives more information on respiratory function than pulse oximetry as it
measures:
PaCO2 (partial pressure of arterial CO2).
PaO2 (partial pressure of arterial O2).
SaO2 (saturation of hgb by O2).
Four main groups of results that are routinely analyzed on most samples are:
pH
Respiratory function (oxygen, CO2, saturation).
Metabolic measures (bicarbonate, base excess).
Electrolytes and metabolites.

Maintaining Cardiovascular Stability
 To monitor cardiovascular stability, the assesses the patient’s
mental status; vital signs; cardiac rhythm;
skin temperature, color, and moisture; and
urine output.
 CVP, PAP, and arterial lines are monitored if the patient’s condition
requires such assessment.
 the patency of all IV lines.
 The primary cardiovascular cxns seen in the PACU include
hypotension and shock,
hemorrhage, hypertension, and
dysrhythmias.

Hemodynamic Monitoring
 Clinical hemodynamic ass’t is informative and easy to perform.
 Simple and versatile clinical parameters include:
BP, HR, RR
fluid balance, conscious level,
capillary refill and peripheral cyanosis.
 The RR is the most sensitive indicator of underlying circulatory dysfunction.
 ECG
Used in the form of continuous monitoring on a screen by the bedside or a
single 12-lead ECG.
ECG is an essential part of cardiovascular ass’t in the critically ill.
Abnormalities of heart rhythm may cause or result from circulatory shock.
Evidence of myocardial ischemia, electrolyte imbalance, drug toxicity and
other metabolic disturbances may also be detected.

Hemodynamic Monitoring……
 Fluid Balance
Accurate measurement and monitoring of fluid balance over a 24-hr
period, includes;
Correct administration, documentation and prescription of fluids and fluid types;
being aware of electrolyte levels and the correct administration of replacement
elements.
Accurate measurement of urine output and fluid loss through drain sites and
observation of wounds.
Observing V/S for changes that may indicate internal haemorrhage.
 Non-invasive blood pressure (NIBP)
Is usually measured with automated equipment.
Knowledge of the BP does not give information about blood flow or
tissue perfusion to other organ systems (e.g. kidney, gut, brain).
It does, however, give important information about the level of
circulatory

Hemodynamic Monitoring……
 Invasive monitoring of arterial pressure
Used when a continuous reading of BP is required.
allows early recognition of hemodynamic changes, especially in an unstable patient, as well as
enabling rpted blood sampling for analysis of ABG.
provides accurate and reliable data.
 Invasive monitoring of CVP
CVP is the most common parameter to be monitored invasively.
The CVP is usually measured in the superior vena cava.
The purpose of measuring CVP is
to obtain an estimate of the volume status (right-sided preload).
However right-sided heart pressures do not always equate with left-sided pressures, especially in
the critically ill.
Therefore, the CVP may not provide a reliable index of left-ventricular preload, which is the main
determinant of CO.
 Monitoring of cardiac output
is recommended to
ensure optimal fluid resuscitation and
guide the choice of inotropic and vasoactive drugs.

Determining Readiness for Discharge from
PACU
 A patient remains in the PACU until he or she has fully recovered
from the anesthetic agent.
 Indicators of recovery include
stable BP,
adequate respiratory function,
adequate O2 saturation level compared with baseline, and
spontaneous mov’t or mov’t on command.

Determining Readiness for Discharge from
PACU
 Usually the following measures are used to determine the patient’s
readiness for discharge from the PACU:
Stable vital signs
Orientation to person, place, events, and time
Uncompromised pulmonary function
Pulse ox readings indicating adequate blood oxygen saturation
Urine output at least 30 mL/h
Nausea and vomiting absent or under control
Minimal pain

Determining Readiness for Discharge from PACU
 Many hospitals use a scoring system (e.g., Aldrete score) to determine the
patient’s general condition and readiness for transfer from the PACU.
 Throughout the recovery period, the patient’s physical signs are observed
and evaluated by means of a scoring system based on a set of objective
criteria.
 This evaluation guide, a modification of the Apgar scoring system used for
evaluating newborns, allows a more objective ass’t of the patient’s
condition in the PACU.
 The patient is assessed at regular intervals (eg, every 15 or 30 minutes),
and the score is totaled on the ass’t record.
 Patients with a score lower than 7 must remain in the PACU until their
condition improves or they are transferred to ICU, depending on their pre
op baseline scores.

Determining Readiness for Discharge from PACU
 The patient is discharged from the phase I PACU by
the anesthesiologist or anesthetist to
the critical care unit,
the medical-surgical unit,
the phase II PACU, or
home with a responsible family member.
 Patients being discharged directly to home require verbal and written
instructions and information about follow-up care.

Areas of Assessment
 Respiration point score
Ability to breathe deeply and cough---------2
Limited respiratory effort (dyspnea )---------1
No, spontaneous effort -----------------------0
 Circulation: SAP point score
> 80% of pre anesthetic level-------------2
50% of pre anesthetic level --------------1
< 50% of pre anesthetic level ----------0
 Color:- point score
Normal skin color and appearance--------- 2
Altered skin color: place---------------------- 1
Cyanosis--------------------------------------- 0
 Muscle activity point score
Ability to move all extremities ----------2
Ability to move two extremities ---------1
Unable to control any extremity---------0
 Consciousness level
Fully awake----------2
Arousable on calling----------1
Not responding----------0
 O2 saturation
Able to maintain o2 sat >90% on room air----------2
Need O2 inhalation to maintain O2 sat>90%----------1
O2 sat <90% even O2 supplementation----------0
 Total: required for discharge from recovery room:
 7-8:- points
103

Areas of Assessment Point
score
Up on
admission
After
1hr 2 hr 3 hr
Muscle activity
Move spontaneously or on command:
Ability to move all extremities
Ability to move two extremities
Unable to control any extremity
2
1
0
Respiration
Ability to breathe deeply and cough
Limited respiratory effort (dyspnea or splinting)
No, spontaneous effort
2
1
0
Circulation
BP±20% of pre anesthetic level
BP±20-49% of pre anesthetic level
BP±50% of pre anesthetic level
2
1
0

Areas of Assessment Point
score
Up on
admissi
on
After
1hr 2 hr 3 hr
Color:
Normal skin color and appearance
Altered skin color: place
Cyanosis
2
1
0
Consciousness level
Fully awake
Arousable on calling
Not responding
2
1
0
O2 saturation
Able to maintain o2 sat >90% on room air
Need O2 inhalation to maintain O2 sat>90%
O2 sat <90% even O2 supplementation
2
1
0
Totals

Postoperative Complications
 Common post operative complications
 Respiratory complications
Airway obstruction, chest infection
Hypoxia
Aspiration
 Cardiovascular complications
shock, haemorrhage, DVT, PE
 Gastrointestinal
vomiting, constipation, paralytic ileus, retention of urine
 Wound infection
 Delirium

HYPOTENSION AND SHOCK
Hypotension can result from
blood loss,
hypoventilation,
position changes,
pooling of blood in the
extremities, or
side effects of medications and
anesthetics;
the most common cause is loss of
circulating volume through blood
and plasma loss.
 If the amount of blood loss exceeds
500 mL (especially if the loss is rapid),
replacement is usually indicated.
Shock
one of the most serious postop cxns,
can result from hypovolemia.
may be described as inadequate cellular
oxygenation accompanied by the inability
to excrete waste products of metabolism.
Hypovolemic shock is char’zed by
a fall in venous pressure,
a rise in peripheral resistance, and
tachycardia.
Neurogenic shock,
a less common in the surgical patient,
occurs as a result of decreased arterial
resistance caused by spinal anesthesia.
It is char’zed by a fall in blood

Risk Factors for Postoperative Complications
 Risk Factors for post op DVT
Orthopedic patients having
hip surgery, knee reconstruction, and other lower extremity surgery
Urologic patients having
transurethral prostatectomy, and older patients having urologic surgery
General surgical patients
Age of over 40 years, Obesity, Malignancy,
prior DVT or pulmonary embolism, or
extensive, complicated surgical procedures
Gynecology (and obstetric) patients
Age of over 40 years with added risk factors
varicose veins, previous venous thrombosis, infection, malignancy, obesity

Risk Factors for Postoperative Complications
 Risk Factors for post op Pulmonary Complications
Type of surgery—greater incidence after all forms of abdominal surgery
when compared with peripheral surgery
Location of incision—the closer the incision to the diaphragm, the higher
the incidence of pulmonary complications
Preoperative respiratory problems
Age—greater risk after age 40 than before age 40
Sepsis, Aspiration
Obesity—weight greater than 110% of ideal body weight
Prolonged bed rest
Duration of surgical procedure—more than 3 hrs
DHN, Hypotension and shock
Malnutrition, Immunosuppression

Causes of Postoperative Delirium
 Fluid and electrolyte imbalance
 DHN
 Hypoxia
 Hypercarbia
 Acid–base disturbance
 Infection
urinary tract,
wound,
respiratory
 Medications
anticholinergics,
benzodiazepines,
CNS depressants
 Unrelieved pain
 Blood loss
 Decreased CO
 Cerebral hypoxia
 Heart failure
 AMI
 Hypothermia or hyperthermia
 Unfamiliar surroundings and sensory
deprivation
 Emergent surgery
 Alcohol withdrawal
 Urinary retention
 Fecal impaction

Expected patient outcomes may include:
 1. Maintains optimal respiratory function
a. Performs deep-breathing exercises
b. Displays clear breath sounds
c. Uses incentive spirometer as prescribed
d. Splints incisional site when coughing to reduce pain
 2. Indicates that pain is decreased in intensity
 3. Exercises and ambulates as prescribed
a. Alternates periods of rest and activity
b. Progressively increases ambulation
c. Resumes normal activities within prescribed time frame
d. Performs activities related to self-care
 4. Wound heals without complication

Expected patient outcomes may include:
 5. Maintains body temperature within normal limits
 6. Resumes oral intake
a. Reports absence of nausea and vomiting
b. Takes at least 75% of usual diet
c. Is free of abdominal distress and gas pains
d. Exhibits normal bowel sounds
 7. Reports resumption of usual bowel elimination pattern
 8. Resumes usual voiding pattern
 9. Is free of injury
 10. Exhibits decreased anxiety
 11. Acquires knowledge and skills necessary to manage therapeutic
regimen
 12. Experiences no complications

 Discuss common post operative cxns and how would you detect and
prevent these cxns?
 Example
Respiratory
Cardiovascular
Gastrointestinal
Genitourinary
Wound

The PACU contains special equipment, to deal with any
post op emergency.

Articles that may be needed for care are located
near the client’s unit in the PACU:
Breathing aids:
Oxygen, suction equipment,
nasal and oral airways,
pulse oximeter,
mechanical breathing bag or other
resuscitation equipment, and
emergency equipment such as a
laryngoscope,
otoscope,
ophthalmoscope,
tracheostomy set, or
endotracheal tube
 Circulatory aids and related medications:
BP and pulse monitor,
stethoscope,
IV solution and pumps,
tourniquets,
syringes and needles,
cardiac monitor,
cardiac arrest equipment,
cardiac drugs,
medications to counteract narcotic
overdose,
respiratory stimulants,
the defibrillator and a backboard for
CPR

Articles that may be needed for care are
located near the client’s unit in the PACU:
 Drugs: Narcotics, sedatives, and drugs for emergency situations
 Other supplies:
Surgical dressings, sandbags, warmed blankets, extra pillows, and
various other items.
A crash cart is also available.
Special equipment for a particular client, such as a traction setup or
back brace, is also present.

KEY POINTS
 Preoperative teaching is the first line of defense against postop Cxns.
 Teaching also helps clients to feel more at ease during this stressful
time.
 Surgery may need to be cancelled if the client has a cold or other
illness, or if the client is extremely apprehensive.
 Before giving any pre- or post op medication, always check the client
for drug and/or latex allergies.
 All permits must be signed before any pre op medications are given.
 Use of narcotics and sedatives can cause serious side effects.
 Watch carefully for these side effects, especially respiratory
depression.

KEY POINTS
 Early postoperative cxns include
 hemorrhage,
 hypotension and shock,
 hypoxia and hypoxemia,
 hypothermia, and
 neurologic complications.
 Be alert for early indications of these cxns and
respond to them quickly.
 Post op discomforts may include
 pain,
 thirst,
 abdominal distention,
 nausea,
 urinary retention,
 constipation,
 restlessness, and
 sleeplessness.
 Try to anticipate client needs and take
appropriate steps to prevent or alleviate
these discomforts.
 Other later post op Cxns include
circulatory complications, such as
thrombophlebitis and/or DVT,
infection, and
dehiscence or evisceration.
 The nurse must report signs of any of these
cxns immediately.
 Pulmonary hygiene is extremely important in
the prevention of later post op respiratory
cxns.
 Early post op mobility helps to decrease the
possibility of respiratory or circulatory cxns.

Preoperative Phase
Preadmission Testing (PAT)
Initiates initial preoperative assessment
Initiates teaching appropriate to
patient’s needs
Involves family in interview
Verifies completion of preoperative
diagnostic testing.
Verifies understanding of surgeon-
specific preoperative orders (eg, bowel
preparation, preoperative shower)
Discusses and reviews advanced
directive document
Begins discharge planning by assessing
patient’s need for postoperative
transportation and care.
In the Holding Area
Assesses patient’s status, baseline
pain, and nutritional status
Reviews chart
Identifies patient
Verifies surgical site and marks site per
institutional policy
Establishes intravenous line
Administers medications if prescribed
Takes measures to ensure patient’s
comfort
Provides psychological support
Communicates patient’s emotional
status to other appropriate members
of the health care team.

Postoperative Phase
Postoperative Assessment Recovery Area
Determines patient’s immediate response to surgical intervention
Monitors patient’s vital signs and physiologic status
Assesses patient’s pain level and administers appropriate pain relief
measures
Maintains patient’s safety (airway, circulation, prevention of injury)
Administers medications, fluid, and blood component therapy, if
prescribed
Provides oral fluids if prescribed for ambulatory surgery patient
Assesses patient’s readiness for transfer to in-hospital unit or for
discharge home based on institutional policy (e.g., Alderete score)

10. Peri-operative care (2 hrs).pptx

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