Perioperative Nursing
Perioperative Nursing
Perioperative Nursing
Nursing
Presented by: Alrene D. Balce, RM,
RN
Cherry May B. Olesco, RN
testicl
es
Peri - Operative Nursing
It is used to describe
the nursing care
provided in the total
surgical experience of
a patient.
The provision of
nursing care by an RN
preoperatively,
intraoperatively, and
postoperatively to a
patient undergoing an
operative or invasive
procedure
Areas in Which
Perioperative Nursing
Is Practiced
Hospital operating
rooms
Interventional
radiology suites
Cardiac
catheterization labs
Endoscopy suites
Ambulatory surgery
centers
Trauma centers
Pediatric specialty
Conditions Requiring
Surgery
Perforation - rupture of an organ, artery
or bleb
Obstruction - blockage
Erosion - wearing away of a
surface of a tissue
Tumor - abnormal growth
Categories of SURGERY
According
to :
üP URPOSE
üR ISK , DEGREE OF
üU RGENCY , DEGREE
OF
According to : P URPOSE
Diagnosti To verify a suspected
c diagnosis Ex. biopsy
Palliativ Relieves or reduces pain
e or symptoms
Ablative Removes a diseased body
part
Ex. Nephrectomy
According to : P URPOSE
Constructiv Restores function or
e appearance ; repair of a
congenitally defective
Transplant organ ex. Cleft palate
Replaces malfunctioning
structures ex. Heart
Explorato transplant
To estimate extent of a
ry disease
Ex. Exploratory
Laparotomy
According to : P URPOSE
Curati To remove or repair
ve damaged or diseased
organs or tissues
Types of Curative Surgery:
Ablative removal of diseased organs
e.g. nephrectomy, appendectomy
risk
Surger Complicated or prolonged
loss
Extensive: Vital organs
colectomy
According to : R ISK, DEGREE
OF
Minor Involves low risk
Produces few
Surger complications
described as “one-day
surgery” or outpatient
surgery
Ex: cyst removal
According to : U RGENCY,
DEGREE OF
Emergenc must be performed immediately
e.g. gunshot wound
y
of the Clien
a)Age: t
premature babies and elderly
persons are at risk
b)Nutritional status: malnourished and
obese are at risk
c)State of fluid and electrolytes balance:
dehydration and hypovolemia predispose
a person to complications
d)General health: infectious process
increase operative risk
e)Mental health
f) Economic and occupational status
03/06/11 16
Factors that Affects Surgical
Risk Estimation
1 . Physical and Mental Condition
of the Client
g) Types of drugs taken regularly:
1). Steroids - may improve the body’s
ability to response to the stress of
anesthesia and surgery
2). Anticoagulants and
salicylates - may increase
bleeding during surgery
3). Antibiotics - maybe incompatible
with or potentiate anesthetic agents
03 /06 /11 17
Factors that Affects Surgical
Risk Estimation
1 . Physical and Mental Condition
of the Client
g) Types of drugs taken regularly:
03/06/11 19
Phases of Peri - operative
period
re Operative
Operativ
Nursing
Pre-Operative Phase
Begins at the time of decision for
surgery and ends when the client
is transferred to the OR
03/06/11 22
Pre-Operative Phase
Goals:
Preoperative Client
03/06/11 25
Pre-Operative Phase
A.) PSYCHOLOGIC PREPARATION FOR SURGERY
2 . Nursing Diagnosis for
Preoperative Client
Causes of Fears:
üFear of the unknown
üFear of anesthesia, vulnerability
while unconscious
üFear of pain
üFear of death
üFear of disturbance of body image
üWorries: loss of finances,
employment, social and family roles
03/06/11 26
Pre-Operative Phase
A.) PSYCHOLOGIC PREPARATION FOR SURGERY
2 . Nursing Diagnosis for
Preoperative Client
Manifestations of Fears :
üAnxiousness and bewilderment
üAnger
üTendency to exaggerate
üSad, evasive, tearful, clinging
üInability to concentrate
üShort attention span
üFailure to carry out simple
directions
üDazed
03/06/11 27
Pre-Operative Phase
A.) PSYCHOLOGIC PREPARATION FOR SURGERY
3. Nursing Interventions to Minimize Anxiety
03/06/11 28
Pre-Operative Phase
A.) PSYCHOLOGIC PREPARATION FOR SURGERY
3. Nursing Interventions to Minimize Anxiety
03/06/11 30
Pre-Operative Phase
B .) LEGAL ASPECT : “ INFORMED CONSENT ”,
OPERATIVE PERMIT , SURGICAL CONSENT
2 .) Minor Patients
üIf the client is minor allow
the parents or the nearest
relative to sign the consent
for the procedure
üFor EMANCIPATED CLIENTS, they
are allowed to sign the consent
03/06/11 32
Pre-Operative Phase
B .) LEGAL ASPECT : “ INFORMED CONSENT ”,
OPERATIVE PERMIT , SURGICAL CONSENT
1 ) Respiratory preparation :
- chest x-ray
2 ) Cardiovascular preparation :
- ECG, CBC, blood typing, cross-
matching,
PT/PTT (prothrombin time, partial
thromboplastin time), serum
electrolytes
3 ) Renal preparation :
- Urinalysis
ü
03/06/11 35
Pre-Operative Phase
C .) PHYSIOLOGIC PREPARATION
03/06/11 38
Pre-Operative Phase
C .) PHYSIOLOGIC PREPARATION
D- Diabetes mellitus, a
condition that not only
requires strict control of
blood glucose levels but
also known to delay wound
healing
03/06/11 39
Pre-Operative Phase
C .) PHYSIOLOGIC PREPARATION
03/06/11 40
Pre-Operative Phase
D .) INSTRUCTIONAL AND PREVENTIVE
ASPECTS
üAssess the client’s level of
understanding of surgical
procedure and its implications
üAnswer questions, clarify and
reinforce explanations given by
surgeon
üExplain routine pre and post
procedures and any special
equipment to be used
üDeep breathing exercises: use of
diaphragmatic and abdominal
03/06/1 1 41
Pre-Operative Phase
D .) INSTRUCTIONAL AND PREVENTIVE
ASPECTS
üCoughing exercise: deep breath,
exhale through the mouth, and then
follow with a short breath while
coughing; splint thoracic and
abdominal incision to minimize pain
üTurning exercise: every 1-2 hours
post-operative
üAssure that pain medications will
be available post-op
03/06/11 42
Pre-Operative Phase
D .) INSTRUCTIONAL AND PREVENTIVE
ASPECTS
üExtremity exercise: prevents circulatory
problems and post operative gas pains or
flatus
03/06/11 43
Pre-Operative Phase
E .) PHYSICAL PREPARATION
On the night of the
surgery
1.Preparing the client’s skin: shave
against the grain of the hair
shaft to ensure clean and close
shave
03/06/11 44
Pre-Operative Phase
E .) PHYSICAL PREPARATION
On the night of the
surgery
2. Preparing the GIT:
-NPO after midnight
-Note: the age of the client should
be taken in to consideration
-Infants and children has a higher
metabolic rate than adult
-This makes it essential for the
child or infant to receive CHO
regularly to prevent acidosis
from occurring
03/06/11 45
Pre-Operative Phase
E .) PHYSICAL PREPARATION
On the night of the
surgery
3. Administration
of enema
4. Insertion of
gastric or
intestinal tubes
03/06/11 46
Pre-Operative Phase
E .) PHYSICAL PREPARATION
On the night of the
surgery
5 . Preparing for Anesthesia
üPromoting rest and sleep : use of
drugs
-Barbiturates: Secobarbital Na
(Seconal), Pentobarbital Na
(Nembutal)
-Non barbiturates: chloral hydrate,
Flurazepam (Dalmane)
-Note : given after all pre - op
treatments have been completed .
-If a second barbiturate is
needed , it must be given at
least 4 hours before the pre - op47
03/06/11
Pre-Operative Phase
E .) PHYSICAL PREPARATION
On the day of the surgery
* Early morning care: about 1 hour before
the pre-operative medication schedule
Transportation to the
OR
Woolen or synthetic blankets must never
be sent to the OR because they are
source of static electricity
03/06/11 54
Intra - Operative phase
Begins when the
client is transferred
to the operating
table and ends when
the client is
admitted to the post -
anesthesia unit
Surgical Attire
0Gowns
Gloves
Masks
Hair covering
Protective
eyewear
Intra Operative Nursing
A . ROLES OF PERIOPERATIVE
NURSES
Scrub Nurse
•Circulating Nurse
•Registered Nurse First
Assistant ( RNFA )
•Perioperative Educator
•OR Manager / Director
Intra Operative Nursing
A . ROLES OF PERIOPERATIVE
NURSES
üScrub Nurse
•Responsible for scrubbing for
surgery, including setting up
sterile tables and equipment and
assisting the surgeon and surgical
technicians during the surgical
procedure
•Gathering all equipment for the
procedure
Intra Operative Nursing
A . ROLES OF PERIOPERATIVE
NURSES
üScrub Nurse
•Preparing all supplies and
instruments using sterile
technique
•Maintaining sterility within the
sterile field during surgery
•Handling instruments and
supplies during surgery
Intra Operative Nursing
A . ROLES OF PERIOPERATIVE
NURSES
üScrub Nurse
NURSES
üCirculating Nurse
NURSES
üCirculating Nurse
NURSES
üCirculating Nurse
Assisting with
positioning
Performing with the
surgical skin
preparation
Intra Operative Nursing
A . ROLES OF PERIOPERATIVE
NURSES
üCirculating Nurse
NURSES
üCirculating Nurse
NURSES
üCirculating Nurse
Handling specimens
Documenting care provided
Intra Operative Nursing
A . ROLES OF PERIOPERATIVE
NURSES
üRN First Assistant
•Directly assists
surgeon
•Controls patient ’ s
bleeding
•Provides wound exposure
and suturing
Using instruments to hold
and cut
Intra Operative Nursing
A . ROLES OF PERIOPERATIVE
NURSES
üRN First Assistant
Retracting and handling the
tissue
•Involved in care
before ,
during , and after
surgery
Intra Operative Nursing
A . ROLES OF PERIOPERATIVE
NURSES
üPerioperative Educator
Responsible in giving
health teachings to
the client who will
undergo and already
undergone surgical
operation
Intra Operative Nursing
A . ROLES OF PERIOPERATIVE
NURSES
üOR Manager / Director
Makes preoperative
assessment and documents
the intra-operative client
care plan
Intra Operative Nursing
INTERVENTIONS :
üDetermine the type of
1. A sensor-
controlled or
knee- or foot-
operated faucet
allows the
water to be
turned on and
off without the
use of the
hands
Intra Operative Nursing
B . SURGICAL SCRUB
2) Remove all
rings and
watches
3) Use liquid
soaps to
prevent the
spread of
organisms
Intra Operative Nursing
B . SURGICAL SCRUB
4) Hold the hands
facilitates the
removal of
microorganisms
- Clean all areas of
skin on the hands
and arms in sequence
starting at the
hands and ending at
the elbows
Intra Operative Nursing
B . SURGICAL SCRUB
6) After rinsing,
TECHNIQUE
1. Sterile Technique
The patient is the
center of the
sterile field,
which includes the:
-areas of the
patient
-the operating
table
-furniture
covered with
sterile drapes
-the personnel
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
1. Sterile Technique
Strict adherence
to sound
principles of
sterile technique
and recommended
practices is
mandatory for the
safety of the
patient. This
adherence reflects
one’s surgical
conscience
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
2. Application
Preparation for
operation by
sterilization of
necessary materials
and supplies
Preparation of the
operating team to
handle sterile
supplies and
intimately contact
wound
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
2. Application
Creation and
maintenance of the
sterile field,
including the
preparation and
draping of the
patient, to prevent
contamination of the
surgical wound
Maintenance of
sterility and asepsis
throughout the
operative procedure
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
2. Application
Terminal
sterilization and
disinfection at the
conclusion of the
operation
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
1. Sterile persons have scrubbed
and are gowned and gloved ;
Unsterile persons have not . Persons
who are sterile touch only sterile
articles . Persons who are not
sterile touch only unsterile
articles
-All supplies
. for the sterile team
members reach them by means of the
circulating nurse, through the
medium of sterile forceps or
wrappers on sterile packages.
-
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
2 . Only sterile items are used
within the sterile field .
- Some items such as linen, sponges,
or basins may be obtained from the
stock supply of sterile packages.
Others, such as instruments, may be
sterilized immediately preceding the
operation and removed directly from
the sterilizer to the sterile table.
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
2 . Only sterile items are used
within the sterile field .
TECHNIQUE
2 . Only sterile items are used
within the sterile field .
-If you are in doubt about the
sterility of anything, consider it
not sterile. Known or potentially
contaminated items must not be
transferred to the sterile field,
for example:
1 . If sterile package is found in the
nonsterile workroom
2 . If uncertain about actual timing or
operation of sterilizer :
Items processed in a suspect load are
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
2 . Only sterile items are used
within the sterile field .
-If you are in doubt about the
sterility of anything, consider it
not sterile. Known or potentially
contaminated items must not be
transferred to the sterile field,
for example:
3 . If unsterile person comes into
close contact with a sterile
table and vice - versa
4 . If sterile package falls to
the floor , it must then be
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
2 . Only sterile items are used
within the sterile field .
-If you are in doubt about the
sterility of anything, consider it
not sterile. Known or potentially
contaminated items must not be
transferred to the sterile field,
for example:
5. If sterile table or unwrapped
sterile items are not under
constant observation ; if a sterile
table or sterile articles are
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
3 . Gowns are considered sterile
only from the waist to
shoulder level in front , and
the sleeves .
- Sterile persons keep hands in
sight and at or above waist level
- Hands are kept away from the face .
Elbows are kept close to sides .
Hands are never folded under arms
because of perspiration in the
axillary region
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
3 . Gowns are considered sterile
only from the waist to
shoulder level in front , and
the sleeves .
- Changing table levels is avoided .
If sterile person must stand on a
platform to reach the operative
field , the area of the gown below
waist must not brush against
sterile tables or draped areas
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
3 . Gowns are considered sterile
only from the waist to
shoulder level in front , and
the sleeves .
-Items dropped below waist level are
considered unsterile and must be
discarded .
Example : when picking up a gown ,
if the top of the gown drops
below waist level , it is discarded
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
4 . Tables are sterile only
at table level
-Only the top of a sterile draped
table is considered sterile .
Edges and sides of drape extending
below the table level are
considered unsterile
-Anything falling over or extending
over table edge , such as sutures
are considered unsterile and are
discarded . Scrub nurse does not
touch the part hanging below table
level
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
4 . Tables are sterile only
at table level
TECHNIQUE
5 . Persons who are sterile
touch only sterile items
TECHNIQUE
5 . Persons who are sterile
touch only sterile items
TECHNIQUE
5 . Persons who are sterile
touch only sterile items
TECHNIQUE
6 . Unsterile persons avoid
reaching over a sterile
TECHNIQUE
6 . Unsterile persons avoid
reaching over a sterile
TECHNIQUE
6 . Unsterile persons avoid
reaching over a sterile
TECHNIQUE
6 . Unsterile persons avoid
reaching over a sterile
TECHNIQUE
6 . Unsterile persons avoid
reaching over a sterile
TECHNIQUE
7. Edges of anything that
encloses sterile contents
are considered unsterile .
Ex : the edges of wrappers
on sterile packages , caps on
solution bottles and test
tube covers
- Sterile persons lift
contents from packages by
reaching down and lifting
them straight up , holding
elbows high
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
7. Edges of anything that
encloses sterile contents
are considered unsterile .
Ex : the edges of wrappers
on sterile packages , caps on
solution bottles and test
tube covers
- Steam reaches only the area
within the gasket of a
sterilizer. Instrument trays
should not touch the edge of
the sterilizer outside the
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
7. Edges of anything that
encloses sterile contents
are considered unsterile .
Ex : the edges of wrappers
on sterile packages , caps on
solution bottles and test
tube covers
- The circulating nurse peels
the cover of a solution
bottle or test tube , the
edge of the cover never
touches the lip
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
7. Edges of anything that
encloses sterile contents
are considered unsterile .
Ex : the edges of wrappers
on sterile packages , caps on
solution bottles and test
tube covers
- If the instruments are
boiled , the tray must not
touch the edge of the
sterilizer when lifting it
out
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
8 . Sterile field is created as
close as possible to time
of use
“ Degree of contamination
is proportionate to
length of time sterile
items are uncovered and
exposed to the
environment . ”
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
8 . Sterile field is created
as close as possible to
time of use
-Sterile tables are set up
just prior to the operation .
-It is difficult to uncover
a table of sterile contents
without contamination .
Covering sterile tables for
later use is not
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
9. Sterile areas are
continuously kept in view
TECHNIQUE
10 . Sterile persons keep
well within the sterile
area
-Sterile persons stand back
at a safe distance from the
operating table when
draping the patient .
-Sterile persons pass each
other back to back .
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
10 . Sterile persons keep
well within the sterile
area
-Sterile person turns back to
nonsterile person or area when
passing.
-Sterile person faces sterile area
to pass it.
-Sterile person asks nonsterile
individual to step aside rather
than risk contamination
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
10 . Sterile persons keep
well within the sterile
area
-Sterile persons stay within and
around a sterile field. They do
not walk around or go outside
the room.
-Movement within and around a
sterile area is kept to a
minimum to avoid contamination
of sterile items or persons
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
11 . Sterile persons keep
contact with sterile
areas to a minimum
-Sterile persons do not lean on
sterile tables and on the
draped patient.
-Sitting or leaning against a
nonsterile surface is a break
in technique. If the sterile
team sits to operate, they do so
without proximity to nonsterile
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
12 . Unsterile persons avoid
sterile areas .
TECHNIQUE
12 . Unsterile persons avoid
sterile areas .
TECHNIQUE
13 . Destruction of the
integrity of microbial
barriers results in
contamination
-Unsterile persons never walk
between two sterile areas,
eg, between sterile
instrument tables.
-Circulating nurse restricts
to a minimum activity near
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
13 . Destruction of the
integrity of microbial
barriers results in
contamination
The integrity of a sterile package
or sterile drape is destroyed by
perforation, puncture or strike-
through (soaking of moisture
through unsterile layers to
sterile layers or vice versa- may
transport bacteria to sterile
area). To ensure sterility:
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
13 . Destruction of the
integrity of microbial
barriers results in
contamination
-Sterile packages are laid on
dry surfaces.
-If sterile packages become damp
or wet, it is re-sterilized or
discarded. A package is
considered nonsterile if any
of it comes in contact with
moisture.
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
13 . Destruction of the
integrity of microbial
barriers results in
contamination
-Drapes are placed on a dry
field
-If solution soaks through
sterile drape to nonsterile
area, the wet area is covered
with impervious sterile drape
or towels
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
13 . Destruction of the
integrity of microbial
barriers results in
contamination
-Packages wrapped in muslin or
paper are permitted to cool
after removal from the
sterilizer to avoid steam
condensation and resultant
contamination
-Sterile areas are stored in
clean dry areas
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
13 . Destruction of the
integrity of microbial
barriers results in
contamination
-Sterile packages are handled
with clean dry hands
-Undue pressure on sterile
pack is avoided to prevent
forcing sterile air out and
pulling unsterile air into
the pack
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
14 . Microorganisms must be kept
to an irreducible minimum
Perfect asepsis in the
operative field is the
ideal . Although all the
microorganisms cannot be
eliminated , this does not
obviate the necessity for
sterile technique . It is
generally agreed that :
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
14 . Microorganisms must be kept
to an irreducible minimum
a . Skin cannot be
sterilized
- Skin is a potential source of
contamination in every operation.
- All possible means are used to
prevent entrance of microorganisms
into wound
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
14 . Microorganisms must be kept
to an irreducible minimum
b . Some areas cannot be
scrubbed
When the operative field
includes the mouth , nose , throat
or anus , the number of
microorganisms is great . Various
parts of the body , such as the
GIT and the vagina , usually are
resistant to infection from
Intra Operative Nursing
C . PRINCIPLES OF STERILE
TECHNIQUE
14 . Microorganisms must be kept
to an irreducible minimum
TECHNIQUE
14 . Microorganisms must be kept
to an irreducible minimum
d . Air is contaminated
by dust and
droplets .
Intra Operative Nursing
D . ANESTHESIA
1 . Levels of Anesthesia
( Sedation )
a. Minimal sedation
- drug induced state in
which a patient can
respond normally in verbal
commands cognitive
function and coordination
may be impaired
Intra Operative Nursing
D . ANESTHESIA
1 . Levels of Anesthesia
( Sedation )
b. Moderate sedation
- depressed level of
consciousness that does not
impair ability to maintain a
patent airway
- calm, sedate a patient
combined with analgesic
- Midazolam/Diazepam
Intra Operative Nursing
D . ANESTHESIA
1 . Levels of Anesthesia
Sedation
c. ( Deep )
Sedation
- deep sedation is a drug
induced state in which a
patient cannot easily be
aroused but can respond
purposefully after repeated
stimulation .
- inhaled or intravenously
- Volatile anesthetic ( halothane ,
Isoflurane )
Intra Operative Nursing
D . ANESTHESIA
2 . Stages of Anesthesia
Stage Start - End - point Physical Nursing
point reactions interventi
I. Anestheti Loss of Client Close
on
Onset c Consciousnes maybe operating
administr s drowsy , or room
ation dizzy doors ,
Possible keep room
auditory quiet
and Stand by
visual to assist
hallucinat the client
ion
Intra Operative Nursing
D . ANESTHESIA
2 . Stages of Anesthesia
Stage Start - End - Physical Nursing
point point reactions interventi
II . Loss of Loss of Increase Remain
on
Excitement consciousnes eyelid in quietly at
s reflexe autonomic client ’ s
s activity side
Irregular Assist
breathing anesthetis
Client t , as
may needed
struggle
Intra Operative Nursing
D . ANESTHESIA
2 . Stages of Anesthesia
Stage Start - End - Physical Nursing
point point reaction intervention
s
III . Surgical Loss of Loss of Client is Begin
eyelid most unconscio preparation
reflexes reflexes us ( if indicated )
anesthesia Depressio Muscles only when
n of are anesthesia
vital relaxed indicates
functions No blink stage III has
or gag been reached
reflexes and client is
breathing
well , with
stable vital
Intra Operative Nursing
D . ANESTHESIA
2 . Stages of Anesthesia
Stage Start - End - point Physical Nursing
point reaction intervention
s
IV . Functions Respirator Client is If arrest occurs ,
Danger excessive y and not respond
( death ) ly circulator breathing immediately to
depressed y failure A assist in
heartbeat establishing
may or may airway , provide
not be cardiac arrest
present tray , drugs
syringes , long
needles
Assist surgeon
with closed or
Intra Operative Nursing
D . ANESTHESIA
2 . Stages of Anesthesia
Stage Start - End - point Physical Nursing
point reaction intervention
s
IV . Functions Respirator Client is If arrest occurs ,
Danger excessive y and not respond
( death ) ly circulator breathing immediately to
depressed y failure A assist in
heartbeat establishing
may or may airway , provide
not be cardiac arrest
present tray , drugs
syringes , long
needles
Assist surgeon
with closed or
Intra Operative Nursing
D . ANESTHESIA
3 . Types of Anesthesia
a . General Anesthesia
-A state of analgesia , amnesia ,
and unconsciousness
characterized by the loss of
reflexes and muscle tone
-Administered by using a
combination of agents based on
the client's need with
consideration of the type of
surgery to be performed
Intra Operative Nursing
D . ANESTHESIA
1 . Types of GA
Administration
G A : INTRAVENOUS
ADMINISTRATION
üUsually employed as
an induction prior to
administration of the
more potent
inhalation anesthetic
agents .
üUsed commonly in minor
procedure
üDental extraction
üUnconsciousness
generally occurs 30
seconds after
administration
üRapid and smooth
transition from
G A : INTRAVENOUS
ADMINISTRATION
Advantage of
IV Anesthesia :
1.Rapid pleasant
induction
2.Absence of
explosive hazards
3.Low incidence of
nausea and vomiting
G A : INTRAVENOUS
ADMINISTRATION
Disadvantage of IV
Anesthesia :
1. Laryngeal spasm and
bronchospasm
2. Hypotension
3. Respiratory arrest
Examples:
Thiopental Na
(Pentothal Na)
Ketamine (Ketalar)
Fentanyl (Innovar)
G A : INHALATION
ADMINISTRATION
üA mixture of
volatile liquids or
gas and O2 is used
üUsually used to
maintain the client
in stage III
anesthesia
following induction
ü
üThe mixture is given
through a mask or
through an
endotracheal tube
which is inserted
once the client is
G A : INHALATION
ADMINISTRATION
Administration
by a mask :
üThe gases flow
into the mask via
a finely
calibrated
vaporizer that is
controlled by a
machine
G A : INHALATION
ADMINISTRATION
Administration
by ETT :
üThe gases flow
directly into
the client’s
tracheobronchial
tree, resulting
in a quick
response
G A : INHALATION
ADMINISTRATION
Advantage :
üEase of
administration
and elimination
through the
respiratory
system
üRapid onset
üPrevention of
pain and anxiety
G A : INHALATION
ADMINISTRATION
Disadvantage:
ücirculatory
and
respiratory
depression
* Highly flammable
and explosive
G A : INHALATION
ADMINISTRATION
Two commonly
used Inhalation
Anesthetics :
- Halothane
- Isoflurane
Commonly used
Gas Anesthetic :
- Nitrous oxide ( Blue
tank )
POST GA
EFFECT
Headache
vision problems ,
including blurred
or double vision
shivering or trembling
muscle pain
dizziness ,
lightheadedness , or
faintness
drowsiness
mood or mental changes
nausea or vomiting
sore throat
nightmares or unusual
dreams
Intra Operative Nursing
D . ANESTHESIA
3 . Types of Anesthesia
b . Regional Anesthesia
üIt is the injection or
application of a local
anesthetic agent to produce a
loss of painful sensation in
only one region of the body
üDoes not result to
unconsciousness
üBlocks the conduction of
impulses in the nerve fibers
Intra Operative Nursing
D . ANESTHESIA
Types of Regional
Anesthesia
R A : SPINAL
ADMINISTRATION
üOften the
anesthetic
technique of
choice of older
adults
üCan be used for
almost any type of
major procedure
performed below
the level of the
diaphragm
üCholecystec
R A : SPINAL
ADMINISTRATION
üSpinal Anesthesia is
achieved by injecting
local anesthetics into
the subarachnoid space
üPosition of client : genu -
pectal or knee - chest
position
üLevel of anesthesia :
Intervertebral space
between
üL2 and L3
üL3 and L4
üAutonomic nerve fibers
are affected first and
also the last to recover
COMPLICATIONS
OF SA :
üHypotension
üParalysis of
vasomotor nerves ,
occurring shortly
after induction
of anesthesia
üRapid IVF
administration
before the
block
üAdminister O2 by
inhalation
üTrendelenburg
COMPLICATIONS
OF SA :
üNausea and
vomiting
-Occurs mainly from
abdominal surgery
because of traction
placed on various
structures within
the abdomen or from
hypotension
-Drugs used :
antiemetics
COMPLICATIONS
OF SA :
üHeadache
-Can be extremely painful and
may last a week
-CSF , which cushions the brain ,
is lost through dural hole
-Leakage of fluid with loss of
cushioning effect is
increased by :
Use of large
spinal needle
Poor hydration
- Keep client flat 6 - 8 hours
postoperatively
COMPLICATIONS
OF SA :
üRespiratory
paralysis
-Occurs when drug
reaches upper
thoracic or
cervical spinal
levels in large
amounts or in
heavy
concentrations
-Do artificial
respiration
COMPLICATIONS
OF SA :
üNeurologic
complications :
-Paraplegia
-Severe muscle
weakness in legs
-Postoperative
paralysis may be due
to :
Unsterile needles ,
syringes and
anesthetic agent
Pre - existing diseases
of the CNS
Transient response to
anesthetics
ADVANTAGES OF
SA :
üRelatively safe
üExcellent
lower - body
muscle
relaxant
üAbsence of
effect on
consciousness
üDoe not require
empty stomach
R A : EPIDURAL
ADMINISTRATION
vIntroduction of
anesthetic agent into the
epidural space
vThe needle is carefully
positioned in the
epidural space without
penetrating the dura and
without entering the
subarachnoid space
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03/06/11 160
R A : EPIDURAL
ADMINISTRATION
vEpidural block produces a
blockade of the autonomic nerves
and can result to hypotension
v
vIf the level of block is too high
and respiratory muscles are
affected , respiratory depression
or paralysis may occur
v
vThe epidural space is generally
entered by a needle at a thoracic ,
lumbar , sacral , or caudal
interspace
R A : CAUDAL
ADMINISTRATION
vA variation of epidural
anesthesia
vProduced by injection
of the local
anesthetic into the
caudal or sacral canal
vThis method is commonly
used with obstetric
clients
R A : TOPICAL
ADMINISTRATION
vApplication of the
agent directly to the
skin , mucous membranes ,
or open surface to be
desensitized
vThe anesthetic may be
a solution , an
ointment , a gel , a
cream , or a powder
R A : TOPICAL
ADMINISTRATION
vA short - acting form of
anesthesia can block
peripheral nerve endings in
the mucous membranes of the
vagina , rectum , nasopharynx , and
mouth
v
vUsed in minor procedures :
rectal examination with
painful hemorrhoids , and
bronchoscopy
R A : TOPICAL
ADMINISTRATION
vCommonly used topical
anesthesia :
§Solution of 4 - 10 % cocaine
-For topical used only
primarily to
anesthetize the eye
and the mucous
membrane of nose ,
mouth , and urethra
-Highly toxic agent
R A : TOPICAL
ADMINISTRATION
Other topical anesthetic
agents :
-Tetracaine
-Procaine
-Mepivacaine
-Lidocaine ( Xylocaine )
R A : LOCAL INFILTRATION
ADMINISTRATION
üInvolves the injection of an
anesthetic agent into the skin
and subcutaneous tissue of the
area to be anesthesized
üBlocks the peripheral nerves
around the area of the incision
üDuring administration of the
agent , aspiration should be done
to ensure that the needle is not
in the blood vessel
üInadvertent intravenous
injection of the agent can
result to cardiovascular
collapse or convulsions
R A : FIELD BLOCK
ADMINISTRATION
The area proximal to a planned
incision can be injected and
infiltrated with local anesthetic
agents to produce field block .
The block forms a barrier between
the incision and the nervous system
A field block actually walls in the
area around the incision and
prevent transmission of sensory
impulses to the brain from that
area
R A : PERIPHERAL NERVE
BLOCK ADMINISTRATION
vAnesthetizes individual
nerves or nerve plexuses
Examples :
-Digital nerve block :
fingers
-Brachial plexus nerve
block : entire upper arm
-Intercostal nerve block :
chest or abdominal wall
R A : PERIPHERAL NERVE
BLOCK ADMINISTRATION
Injection of anesthetic agents
along the nerve rather done
into the nerve in an effort to
decrease the risk of nerve
damage
Agents commonly used : lidocaine ,
bupivacaine , and Mepivacaine
Epinephrine - containing agents
are not used for surgery
involving the extremities , like
below the wrist and ankle ,
R A : REGIONAL EXTREMITY
BLOCK ADMINISTRATION
( BIER BLOCK)
Regional anesthesia of a limb
can be achieved with an agent
when it is injected into a vein
of the limb to be anesthetized
perineal approach
Prone – used in surgery on the posterior
lungs or hips
Modified Fowler’s – sitting position; used
mostly in neurosurgery
Modified jacknife – for rectal surgery
Position Patient during
Surgery
Abdominal Supine
surgeries
Bladder surgery Slightly
trendelenburg
Perineal surgery Lithotomy
Brain surgery Semi - fowler ’ s
Spinal cord Prone mostly
surgeries
Lumbar puncture Side lying ,
flexed body
Abdominal Surgical
Incision
Paramedian vertical incision
( rarely used –
Longitudinal intestinal problems))
( middle laparotomy
Midline begins at the level of
Right Subcostal the
from xiphoid to the
epigastric area
( Kochers ) supra pubic region
and extends laterally &
for gastrectomy
(obliquely &
below the
intestinal
lower marginresection
– biliary) ,
spleen and liver
Abdominal Surgical
Incision
Bilateral liver transplant
subcostal –
Mc BurneyBenz or for appendectomy
Mercedes
Chevron incision
Rocky Davis for appendectomy
Pfannenstiel pelvic procedures,
hysterectomy or CS
Inguinal inguinal herniorrhaphy
Different Surgeries
According to Location
A . ABDOMINAL SURGERY
1 . Abdominal
Laparotomy
2 . Herniorrhaphy
3 . Cholecystectomy
4.
Pancreaticoduodenectom
y ( Whipple ’ s )
5 . Pancreatectomy
6 . Splenectomy
7 . Bariatric Surgery
Different Surgeries
According to Location
B . BREAST SURGERY
1 . Mastectomy
2 . Breast Biopsy
3 . Mammoplasty
4 . Breast
Augmentation ,
Breast Repair ,
Breast Lifting
Different Surgeries
According to Location
D . GENITOURINARY SURGERY
1 . Circumcision
2 . Vasectomy
3 . Orchiectomy
4 . Cystectomy
5 . Transurethral Resection
Home
PACU Nurse
Responsible for
caring for the
client until the
client :
well lighted
Multiple electrical outlets and at
POSTANESTHESIA CARE
UNIT
Equipment
1.Pulse oximetry (SpO2)
2.Electrocardiogram (ECG)
3.Automated noninvasive
blood pressure (NIBP)
monitors
4.Capnography
5.Temperature
6.Air warming device,
POSTANESTHESIA CARE UNIT
Emergency Equipment
1.Oxygen cannulas
2.Masks
3.Oral and nasal airways
4.Laryngoscopes , ndotracheal tubes,
laryngeal mask airways, and self-
inflating bags for ventilation
5.Defibrillation device
6.Tracheostomy, chest tube, and
vascular cutdown trays
POSTANESTHESIA CARE UNIT
Respiratory therapy
equipment
1.Continuous positive
airway pressure (CPAP)
2.Ventilators
3.Bronchoscope
POSTANESTHESIA CARE UNIT
Staffing
Home
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CARE OF THE PATIENT
TRANSPORT FROM THE OPERATING
ROOM
This period is usually complicated by
All patients should be taken to the
PACU on a bed or trolley that can
be placed in either:
Post-Operative Phase
1) Maintenance of Pulmonary
Ventilation:
Position the client to
side lying or semi-
prone position to
prevent aspiration
03/06/11 206
Post-Operative Phase
Oropharyngeal or
nasopharyngeal airway:
Is left in place following administration
of general anesthetic until
pharyngeal reflexes have returned
Causes:
vLoss of blood and other
body fluids
vCardiac arrhythmias and
cardiac failure
vInadequate ventilation
vPain
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Post-Operative Phase
b) Cardiac arrhythmias
Causes:
Hypoxemia
Hypercapnea
Interventions:
O2 therapy
Drug administration:
Lidocaine
Procainamide (Pronestyl)
03/06/11 211
Post-Operative Phase
3) Protection from injury
Parameters:
1. Activity
2. Respiration
3. Circulation
03/06/11 213
Post Anesthesia Care Unit
After
Point Score 1 hour 2 hours 3 hours
Area of assessment
Muscle activity:
2
Moves spontaneously or on command
1
Ability to move all extremities
0
Ability to move 2 extremities
Respiration: 2
Unable to control any extremity
Ability to breath deeply and cough
1
0
Limited respiratory effort (dyspnea and
splinting)
No spontaneous effort
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P o st A n e sth e sia C a re U n it
M O D IF IE D A L D R E T E S C O R E
After
Point Score 1 hour 2 hours 3 hours
Area of assessment
2
Circulation:
BP +/- 20% of pre-anesthetic level
1
0
BP +/- 20%-40% of pre-anesthetic level
Consciousness Level: 2
BP +/- 50% pre-anesthetic level
Fully awake
1
0
Arousable on calling
Not responding
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P o st A n e sth e sia C a re U n it
M O D IF IE D A L D R E T E S C O R E
After
Point Score 1 hour 2 hours 3 hours
Area of assessment
2
O2 Saturation:
Unable to maintain O2 sat >92% on room air
1
0
Needs O2 inhalation to maintain O2 sat >90%
03/06/11 216
CARE OF THE PATIENT
ROUTINE RECOVERY
a)Airway patency, vital signs, and
oxygenation should be checked
immediately on arrival
b)Blood pressure, pulse rate, and
respiratory rate measurements are
routinely made at least every 5 min
for 15 min or until stable, and every
15 min thereafter
c)Pulse oximetry should be monitored
continuously
d)Neuromuscular function should be
assessed clinically
OT
PACU
Ward
Home
Post - operative interventions
PAIN MANAGEMENT
Post - operative interventions
POSITIONING
vClients who have spinal
anesthesia is usually
placed FLAT on bed for
8 - 12 hours
vUnconscious client is
placed side lying to
drain secretions
vOther positions are
utilized BASED on the
Post - operative interventions
Deep
breathing
and coughing
exercises
Q2 - 4 hours
0 to remove
secretions
Post - operative interventions
§ Leg exercises
Q 2 hours 0
to promote
circulation
§ Ambulation
ASAP0
prevents
respiratory ,
circulatory ,
urinary and
gastrointest
inal
Post - operative
interventions
§ Hydration after
NPO to
maintain fluid
balance
§ Suction, either
gastro or
respiratory
to relieve
distention, to
remove respi
secretions
Liquid Diet VS Soft diet
Clear liquid Full liquid Soft diet
Coffee Clear liquid PLUS: All CL and FL
Tea Milk/Milk prod plus:
Carbonated Vegetable juices Meat
drink Cream, butter Vegetables
Bouillon Yogurt Fruits
Clear fruit Puddings Breads and
juice Custard cereals
Popsicle Ice cream and Pureed foods
Gelatin sherbet
Hard candy
wound drainage
Hemovac
Jackson-Pratt
Penrose drain
T-tube
Salem Sump
tube
Chest Physiotherapy
Chest Physiotherapy
Chest physiotherapy is based on the
coughing
Pneumonia Inflammation Chest physio
Thrombophlebitis Inflammation
of alveoli
Leg exercises
Suctioning
extremities
ATELECTASIS
PNEUMONIA
DEEP VENOUS THROMBOSIS
*HOMAN’S SIGN
EMBOLUS: MIGRATION OF A
CLOT
Post-operative Complications
Hypovolemic Loss of Shock position
Determine cause and
Shock circulatory
prevent bleeding
fluid volume O2, IVF
of urine Catheterize
MODIFIED TRENDELENBURG
Post-operative complications
Constipation Infrequent High fiber diet
Increased fluid
passage of Ambulation
stool
sound ambulation
NPO until
peristalsis returns
Wound Occurs about 3 Daily wound
Fowler’s
Notify MD