MEDICOSURGICAL NURSING

MR. CLOVER EYONG

TOP-UP BSC
THE PREOPERATIVE PHASE

 The Pre-Operative phase begins with the decision that surgical intervention is necessary
and ends when the patient is transferred to the operating room table.
 Patients are admitted to the health care facility for surgical intervention from a variety of
situations and in various physical conditions.
 The nurse is responsible for completion of preoperative forms, implementing doctor's
orders for preoperative care, and documentation of all nursing measures.
Goals

Although the physician is responsible for explaining the surgical procedure to the patient, the
patient may ask the nurse questions about the surgery. There may be specific learning needs
about the surgery that the patient and support persons should know. A nursing care plan and a
teaching plan should be carried out. During this phase, emphasis is placed on:

 Assessing and correcting physiological and psychological problems that may

increase surgical risk.
 Giving the patient and significant others complete learning and teaching
guidelines regarding the surgery.
 Instructing and demonstrating exercises that will benefit the patient
postoperatively.
 Planning for discharge and any projected changes in lifestyle due to the surgery.
Physiologic Assessment
Before any treatment is initiated, a health history is obtained and a physical examination is
performed during which vital signs are noted and a data base is establish for future
comparisons.

The following are the physiologic assessments necessary during the preoperative phase:

 Age
 Obtain a health history and perform a physical examination to establish vital signs
and a database for future comparisons.
 Assess patient’s usual level of functioning and typical daily activities to assist in
patient’s care and recovery or rehabilitation plans.
 Assess mouth for dental caries, dentures, and partial plates. Decayed teeth or
dental prostheses may become dislodged during intubation for anesthetic delivery
and occlude the airway.
 Nutritional status and needs – determined by measuring the patient’s height and
weight, triceps skinfold, upper arm circumference, serum protein levels and
nitrogen balance. Obesity greatly increases the risk and severity of complications
associated with surgery.
 Fluid and Electrolyte Imbalance – Dehydration, hypovolemia and electrolyte
imbalances should be carefully assessed and documented.
 Infection
 Drug and alcohol use – the acutely intoxicated person is susceptible to injury.
 Respiratory status – patients with pre-existing pulmonary problems are evaluated
by means pulmonary function studies and blood gas analysis to note the extent of
respiratory insufficiency. The goal for potential surgical patient us to have an
optimum respiratory function. Surgery is usually contraindicated for a patient who
has a respiratory infection.
 Cardiovascular status – cardiovascular diseases increases the risk of
complications. Depending on the severity of symptoms, surgery may be deferred
until medical treatment can be instituted to improve the patient’s condition.
  Hepatic and renal function – surgery is contraindicated in patients with acute
nephritis, acute renal insufficiency with oliguria or anuria, or other acute renal
problems. Any disorder of the liver on the other hand, can have an effect on how
an anesthetic is metabolized.
 Presence of trauma
 Endocrine function – diabetes, corticosteroid intake, amount
of insulin administered
 Immunologic function – existence of allergies, previous allergic reactions,
sensitivities to certain medications, past adverse reactions to certain drugs,
immunosuppression
 Previous medication therapy – It is essential that the patient’s medication
history be assessed by the nurse and anesthesiologist. The following are the
medications that cause particular concern during the upcoming surgery:
 Adrenal corticosteroids – not to be discontinued abruptly before the surgery. Once
discontinued suddenly, cardiovascular collapse may result for patients who are taking
steroids for a long time. A bolus of steroid is then administered IV immediately
before and after surgery.
 Diuretics – thiazide diuretics may cause excessive respiratory depression during
the anesthesia administration.
 Phenothiazines – these medications may increase the hypotensive action of
anesthetics.
 Antidepressants – MAOIs increase the hypotensive effects of anesthetics.
 Tranquilizers – medications such as barbiturates, diazepam and chlordiazepoxide may
cause an increase anxiety, tension and even seizures if withdrawn suddenly.
 Insulin – when a diabetic person is undergoing surgery, interaction between
anesthetics and insulin must be considered.
 Antibiotics – “Mycin” drugs such as neomycin, kanamycin, and less frequently
streptomycin may present problems when combined with curariform muscle relaxant.
As a result nerve transmission is interrupted and apnea due to respiratory paralysis
develops.
Gerontologic Considerations

 Monitor older patients undergoing surgery for subtle clues that indicate
underlying problems since elder patients have less physiologic reserve than
younger patients.
 Monitor also elderly patients for dehydration, hypovolemia, and electrolyte
imbalances.
Nursing Diagnosis

The following are possible nursing diagnosis during the preoperative phase:

 Anxiety related to the surgical experience (anesthesia, pain) and the outcome of
surgery
 Risk for Ineffective Therapeutic Management Regiment related to deficient
knowledge of preoperative procedures and protocols and postoperative
expectations
 Fear related to perceived threat of the surgical procedure and separation from
support system
 Deficient Knowledge related to the surgical process
Diagnostic Tests

These diagnostic tests may be carried out during the perioperative phase:

 Blood analyses such as complete blood count, sedimentation rate, c-reactive

protein, serum protein electrophoresis with immunofixation, calcium, alkaline
phosphatase, and chemistry profile
 X-ray studies
 MRI and CT scans (with or without myelography)
 Electrodiagnostic studies
 Bone scan
 Endoscopies
 Tissue biopsies
  Stool studies
 Urine studies
When the patient has been determined to be an appropriate candidate for surgery, and has
elected to proceed with surgical intervention, the pre-operative assessment phase begins.

The purpose of pre-operative assessment is to reduce the morbidity of surgery, increase

quality of intraoperative care, reduce costs associated with surgery, and return the patient to
optimal functioning as soon as possible.

Psychological Assessment

Psychological nursing assessment during the preoperative period:

 Fear of the unknown

 Fear of death
 Fear of anesthesia
 Concerns about loss of work, time, job and support from the family
 Concerns on threat of permanent incapacity
 Spiritual beliefs
 Cultural values and beliefs
 Fear of pain
Psychological Nursing Interventions

1. Explore the client’s fears, worries and concerns.

2. Encourage patient verbalization of feelings.
3. Provide information that helps to allay fears and concerns of the patient.
4. Give empathetic support.
Informed consent

 Reinforce information provided by surgeon.

 Notify physician if patient needs additional information to make his or her
decision.
  Ascertain that the consent form has been signed before administering
psychoactive premedication. Informed consent is required for invasive
procedures, such as incisional, biopsy, cystoscopy, or paracentesis; procedures
requiring sedation and/or anesthesia; nonsurgical procedures that pose more than
slight risk to the patient (arteriography); and procedures involving radiation.
 Arrange for a responsible family member or legal guardian to be available to give
consent when the patient is a minor or is unconscious or incompetent (an
emancipated minor [married or independently earning own living] may sign his or
her own surgical consent form).
 Place the signed consent form in a prominent place on the patient’s chart.
An informed consent is necessary to be signed by the patient before the surgery. The
following are the purposes of an informed consent:

 Protects the patient against unsanctioned surgery.

 Protects the surgeon and hospital against legal action by a client who claims that
an unauthorized procedure was performed.
 To ensure that the client understands the nature of his or her treatment including
the possible complications and disfigurement.
 To indicate that the client’s decision was made without force or pressure.
Criteria for a Valid Informed Consent

 Consent voluntarily given. Valid consent must be freely given without coercion.
 For incompetent subjects, those who are NOT autonomous and cannot give or
withhold consent, permission is required from a responsible family member who
could either be apparent or a legal guardian. Minors (below 18 years of age),
unconscious, mentally retarded, psychologically incapacitated fall under the
incompetent subjects.
 The consent should be in writing and should contain the following:
 Procedure explanation and the risks involved
 Description of benefits and alternatives
 An offer to answer questions about the procedure
  Statement that emphasizes that the client may withdraw the consent
 The information in the consent must be written and be delivered in language that a
client can comprehend.
 Should be obtained before sedation.
Nursing Interventions

Reducing Anxiety and Fear

 Provide psychosocial support.

 Be a good listener, be empathetic, and provide information that helps alleviate
concerns.
 During preliminary contacts, give the patient opportunities to ask questions and to
become acquainted with those who might be providing care during and after
surgery.
 Acknowledge patient concerns or worries about impending surgery by listening
and communicating therapeutically.
 Explore any fears with patient, and arrange for the assistance of other health
professionals if required.
 Teach patient cognitive strategies that may be useful for relieving tension,
overcoming anxiety, and achieving relaxation, including imagery, distraction, or
optimistic affirmations.
Managing Nutrition and Fluids

 Provide nutritional support as ordered to correct any nutrient deficiency before

surgery to provide enough protein for tissue repair.
 Instruct patient that oral intake of food or water should be withheld 8 to 10 hours
before the operation (most common), unless physician allows clear fluids up to 3
to 4 hours before surgery.
 Inform patient that a light meal may be permitted on the preceding evening when
surgery is scheduled in the morning, or provide a soft breakfast, if prescribed,
when surgery is scheduled to take place after noon and does not involve any part
of the GI tract.
  In dehydrated patients, and especially in older patients, encourage fluids by
mouth, as ordered, before surgery, and administer fluids intravenously as ordered.
 Monitor the patient with a history of chronic alcoholism for malnutrition and
other systemic problems that increase the surgical risk as well as for
alcohol withdrawal (delirium tremens up to 72 hours after alcohol withdrawal).
Promoting Optimal Respiratory and Cardiovascular Status

 Urge patient to stop smoking 2 months before surgery (or at least 24 hours
before).
 Teach patient breathing exercises and how to use an incentive spirometer if
indicated.
 Assess patient with underlying respiratory disease (eg, asthma, chronic
obstructive pulmonary disease [COPD]) carefully for current threats to pulmonary
status; assess patient’s use of medications that may affect postoperative recovery.
 In the patient with cardiovascular disease, avoid sudden changes of position,
prolonged immobilization, hypotension or hypoxia, and overloading of the
circulatory system with fluids or blood.
Supporting Hepatic and Renal Function

 If patient has a disorder of the liver, carefully assess various liver function tests
and acid–base status.
 Frequently monitor blood glucose levels of the patient with diabetes before,
during, and after surgery.
 Report the use of steroid medications for any purpose by the patient during the
preceding year to the anesthesiologist and surgeon.
Monitor patient for signs of adrenal insufficiency.

 Assess patients with uncontrolled thyroid disorders for a history of thyrotoxicosis

(with hyperthyroid disorders) or respiratory failure (with hypothyroid disorders).
Promoting Mobility and Active Body Movement
  Explain the rationale for frequent position changes after surgery (to improve
circulation, prevent venous stasis, and promote optimal respiratory function) and
show patient how to turn from side to side and assume the lateral position without
causing pain or disrupting IV lines, drainage tubes, or other apparatus.
 Discuss any special position patient will need to maintain after surgery (eg,
adduction or elevation of an extremity) and the importance of maintaining as
much mobility as possible despite restrictions.
 Instruct patient in exercises of the extremities, including extension and flexion of
the knee and hip joints (similar to bicycle riding while lying on the side); foot
rotation (tracing the largest possible circle with the great toe); and range of
motion of the elbow and shoulder.
 Use proper body mechanics, and instruct patient to do the same. Maintain
patient’s body in proper alignment when patient is placed in any position.
Respecting Spiritual and Cultural Beliefs

 Help patient obtain spiritual help if he or she requests it; respect and support the
beliefs of each patient.
 Ask if the patient’s spiritual adviser knows about the impending surgery.
 When assessing pain, remember that some cultural groups are unaccustomed to
expressing feelings openly. Individuals from some cultural groups may not make
direct eye contact with others; this lack of eye contact is not avoidance or a lack
of interest but a sign of respect.
 Listen carefully to patient, especially when obtaining the history. Correct use of
communication and interviewing skills can help the nurse acquire invaluable
information and insight. Remain unhurried, understanding, and caring.
Providing Preoperative Patient Education

 Teach each patient as an individual, with consideration for any unique concerns or
learning needs.
 Begin teaching as soon as possible, starting in the physician’s office and
continuing during the pre admission visit, when diagnostic tests are being
performed, through arrival in the operating room.
  Space instruction over a period of time to allow patient to assimilate information
and ask questions.
 Combine teaching sessions with various preparation proce-dures to allow for an
easy flow of information. Include descriptions of the procedures and explanations
of the sensations the patient will experience.
 During the preadmission visit, arrange for the patient to meet and ask questions of
the perianesthesia nurse, view audiovisuals, and review written materials. Provide
a telephone number for patient to call if questions arise closer to the date of
surgery.
 Reinforce information about the possible need for a ventilator and the presence of
drainage tubes or other types of equipment to help the patient adjust during
the postoperative period.
 Inform the patient when family and friends will be able to visit after surgery and
that a spiritual advisor will be available if desired.
Teaching the Ambulatory Surgical Patient

 For the same day or ambulatory surgical patient, teach about discharge and
follow-up home care. Education can be provided by a videotape, over the
telephone, or during a group meeting, night classes, preadmission testing, or the
preoperative interview.
 Answer questions and describe what to expect.
 Tell the patient when and where to report, what to bring (insurance card, list of
medications and allergies), what to leave at home (jewelry, watch, medications,
contact lenses), and what to wear (loose-fitting, comfortable clothes; flat shoes).
 During the last preoperative phone call, remind the patient not to eat or drink as
directed; brushing teeth is permitted, but no fluids should be swallowed.
Teaching Deep Breathing and Coughing Exercises

 Teach the patient how to promote optimal lung expansion and consequent blood
oxygenation after anesthesia by assuming a sitting position, taking deep and slow
breaths (maximal sustained inspiration), and exhaling slowly.
  Demonstrate how patient can splint the incision line to minimize pressure and
control pain (if there will be a thoracic or abdominal incision).
 Inform patient that medications are available to relieve pain and that they should
be taken regularly for pain relief to enable effective deepbreathing and
coughing exercises.
Explaining Pain Management

 Instruct patient to take medications as frequently as prescribed during the initial

postoperative period for pain relief.
 Discuss the use of oral analgesic agents with patient before surgery, and assess
patient’s interest and willingness to participate in pain relief methods.
 Instruct patient in the use of a pain rating scale to promote postoperative pain
management.
Preparing the Bowel for Surgery

 If ordered preoperatively, administer or instruct the patient to take the antibiotic

and a cleansing enema or laxative the evening before surgery and repeat it the
morning of surgery.
 Have the patient use the toilet or bedside commode rather than the bedpan for
evacuation of the enema, unless the patient’s condition presents some
contraindication.
Preparing Patient for Surgery

 Instruct patient to use detergent–germicide for several days at home (if the
surgery is not an emergency).
 If hair is to be removed, remove it immediately before the operation using electric
clippers.
 Dress patient in a hospital gown that is left untied and open in the back.
 Cover patient’s hair completely with a disposable paper cap; if patient has long
hair, it may be braided; hairpins are removed.
 Inspect patient’s mouth and remove dentures or plates.
Remove jewelry, including wedding rings
  If patient objects, securely fasten the ring with tape.
 Give all articles of value, including dentures and prosthetic devices, to family
members, or if needed label articles clearly with patient’s name and store in a safe
place according to agency policy.
 Assist patients (except those with urologic disorders) to void immediately before
going to the operating room.
 Administer preanesthetic medication as ordered, and keep the patient in bed with
the side rails raised. Observe patient for any untoward reaction to the medications.
Keep the immediate surroundings quiet to promote relaxation.
Transporting Patient to Operating Room

 Send the completed chart with patient to operating room; attach surgical consent
form and all laboratory reports and nurses’ records, noting any unusual last
minute observations that may have a bearing on the anesthesia or surgery at
the front of the chart in a prominent place.
 Take the patient to the preoperative holding area, and keep the area quiet,
avoiding unpleasant sounds or conversation.
Attending to Special Needs of Older Patients

 Assess the older patient for dehydration, constipation, and malnutrition; report if
present.
 Maintain a safe environment for the older patient with sensory limitations such as
impaired vision or hearing and reduced tactile sensitivity.
 Initiate protective measures for the older patient with arthritis, which may affect
mobility and comfort. Use adequate padding for tender areas. Move patient
slowly and protect bony prominences from prolonged pressure. Provide
gentle massage to promote circulation.
 Take added precautions when moving an elderly patient because decreased
perspiration leads to dry, itchy, fragile skin that is easily abraded.
 Apply a lightweight cotton blanket as a cover when the elderly patient is moved to
and from the operating room, because decreased subcutaneous fat makes older
people more susceptible to temperature changes.
  Provide the elderly patient with an opportunity to express fears; this enables
patient to gain some peace of mind and a sense of being understood
Attending to the Family’s Needs

 Assist the family to the surgical waiting room, where the surgeon may meet the
family after surgery.
 Reassure the family they should not judge the seriousness of an operation by the
length of time the patient is in the operating room.
 Inform those waiting to see the patient after surgery that the patient may have
certain equipment or devices in place (ie, IV lines, indwelling urinary
catheter, nasogastric tube, suction bottles, oxygen lines, monitoring equipment,
and blood transfusion lines).
 When the patient returns to the room, provide explanations regarding the frequent
postoperative observations.
Spiritual Considerations

 Help patient obtain spiritual help if he or she requests it; respect and support the
beliefs of each patient.
 Ask if the patient’s spiritual adviser knows about the impending surgery.
 When assessing pain, remember that some cultural groups are unaccustomed to
expressing feelings openly. Individuals from some cultural groups may not make
direct eye contact with others; this lack of eye contact is not avoidance or a lack
of interest but a sign of respect.
 Listen carefully to patient, especially when obtaining the history. Correct use of
communication and interviewing skills can help the nurse acquire invaluable
information and insight. Remain unhurried, understanding, and caring.

Nursing Implications

The following nursing implications are related to preparing a patient for surgery.
Prepare the patient's chart which should include:
 Space for the patient's identification.
 A checklist for pertinent clinical records.
 A space for recording the most current set of vital signs taken prior to preoperative
medications. o A space to indicate allergies. o A space to document all preoperative
nursing measures.
 A space to document any comment that indicates something very special about this
particular patient (for example, removal of prosthesis, patient hard of hearing).
 A space for signature of release by the registered nurse when all actions are completed.

Completion of Requests for Anesthesia

Complete any request for administration of anesthesia.

• The patient must sign in the presence of a witness, to consent for the surgical
procedure.

• The witness is attesting to the patient's signature, not to the patient's understanding of
the surgical risks.
• If the adult patient is unconscious, semiconscious, or is not mentally competent, the
consent form may be signed by a family member or legal guardian.
• If the patient is a minor (usually under the age of 18), the consent form is signed by a
parent or legal guardian.
• A minor who lives away from home and is self-supporting is considered emancipated
and he may sign.
• Be familiar with the age of consent for the state in which the health care facility is
located and with legal implications when a person other than the patient signs the
consent form.
• Legal consent forms must be signed prior to administration of preoperative medication
or any type of mind-altering medication or the document is not legally binding.

Implement Doctors Orders for Pre-Operative Care

• Implement doctor's orders for preoperative care as follows.

 • If ordered, administer an enema.

• The enema cleanses the colon of fecal material, which reduces the possibility of
wound contamination during surgery.
• If ordered, assure that the operative site skin prep (shave) is done.

• An operating room technician or other designated person will clean and shave a wide
area surrounding the planned site for the incision.
• (This may be done in the operating room immediately before surgery).

• The skin prep frees the skin of hair and microorganisms as much as possible, thus
decreasing the possibility of them entering the wound via the skin surface during
surgery.

Doctors Direction for Pre-Operative Diet

• The doctor will give specific directions concerning withholding food and fluid before
surgery.
• Assure that the order is followed.

• Typically, the patient may eat solid food until supper, but can have nothing by mouth
(NPO) beginning at midnight before surgery.
• Place the NPO sign outside the patient's room. Instruct the patient of the importance
and the reason for being NPO.
• Remove the water pitcher and the drinking glass.

• Clearly mark the diet roster.

• If ordered, administer a sedative.

• The evening before surgery a hypnotic drug, such as flurazepam hydrochloride

(Dalmane®) may be given so that the patient can get a good night's sleep.

Patient Preparation before Surgery

 • The following outlines the patient hygiene preparation procedure prior to the surgical
experience:
• Assist the patient with personal hygiene and related preoperative care.

• The evening before surgery, the patient should take a bath or shower, and shampoo
hair to remove excess body dirt and oils. The warm water will also help to relax the
patient.
• Sometimes plain soap and water are used for cleansing the skin, but a topical
antiseptic may be used.
Patients Personal Effects

• Remove all makeup and nail polish.

• Numerous areas (face, lips, oral mucosa, and nail beds) must be observ ed for
evidence of cyanosis.
• Makeup and nail polish hide true coloration.
• The patient may wear a wedding band to surgery, but it must be secure d with tape and
gauze wrapping.
• Do not wrap tightly; circulation may be impaired.

• Jewelry and other valuables should be removed for safe keeping.

• Do not leave valuables in the bedside stand or store in the narcotics container.
• Chart what has been done with the valuables

• If possible, send these items home with a relative until the patient has need of them.
Patient Briefing regarding Planned Surgery

Provide the patient with information concerning surgery and include the following
information:
 The risks and benefits of surgery. o The likely outcome if surgery is not performed. o The
alternative methods of treatment by his doctor.
 o The nurse can also help the patient cope with the upcoming surgery by taking the
time to listen to the patient and others who are concerned about his/her well
being, and answering other questions. This can be facilitated by:
 Explaining each preoperative nursing measure.
 Providing an opportunity for the patient to express his feelings. o Asking about spiritual
needs and whether he/she wishes to see a Chaplain.
Surgery Briefing to Family members

• Provide family members with information concerning their role the morning of the
surgery.
• Give them the surgical waiting room location, and the probable time that they can visit
the patient after surgery.
• Explain the rationale for the patient's stay in the recovery room.

Inform them of any machines or tubes that may be attached to the patient following
surgery.
Patient Pre-Operative Morning Care

• Provide Preoperative morning care for the patient as follows:

• Awake the patient early enough to complete morning care.

• Give him a clean hospital gown and the necessary toiletries.

• The patient should have another shower or bath using a topical antiseptic, such as
povidone-iodine.
• The skin cannot be made completely sterile, but the number of microorganisms on it
can be substantially reduced.
• If the surgery is extensive, it may be several days before the patient has another
shower or "real" bath.
• The patient should have complete mouth care before surgery.

• A clean mouth provides comfort for the patient and prevents aspiration of small food
particles that may be left in the mouth.
• Instruct the patient not to chew gum.
Other Pre-Operative Patient Care Activities

• Remove prostheses: Assist the patient or provide privacy so that the patient can
remove any prostheses.
• These includes artificial limbs, artificial eyes, contact lenses, eyeglasses, dentures, or
other removable oral appliances.
• Place small items in a container and label them with the patient's name and room
number.
• Dentures are usually left at the bedside.

• Record vital signs.

• Obtain and record the patient's temperature, pulse, respiration, and blood pressure
before the preoperative medication is administered.

Allow the patient time to complete any last minute personal measures and visit with
the family.
Surgical Check List

• Recheck surgical check list. If ordered, administer preoperative medications.

• Pre-op medications are usually ordered by the anesthesiologist, and administered
about 30 to 60 minutes before the patient is taken to the operating room. The
medications may be ordered given at a scheduled time or on call (the operating room
will call and tell you when to give the medications).
• The medications may consist of one, two, or three drugs: a narcotic or sedative; a drug
to decrease secretions in the mouth, nose, throat, and bronchi; and an antiemetic.
• Have the patient void before administering the medications. Explain to the patient the
effects experienced following administration of the medications (drowsiness, extreme
dry mouth).
• Instruct the patient to remain in bed. Raise the side rails on the bed and place the call
bell within easy reach. Assist the operating room technician. The patient is usually
transported to the operating room on a wheeled litter, or gurney.
 • The technician should cover the patient with a clean sheet or cotton blanket. Assist the
technician to position the patient on the litter. See that the patient is comfortable, and
that the restraint is fastened to prevent him from falling off the litter.
In Holding Area

 Assess patient’s status, baseline pain and nutritional status.

 Review chart.
 Identifies patient.
 Verifies surgical site and marks site per institutional policy.
 Establishes intravenous line.
 Administers medication 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.

Documentation of Nursing Measures

• All necessary information should be recorded on the chart before the patient leaves the
nursing unit.
• Check the patient's identification band to be sure the right patient is being taken to
surgery.
Check the consent form to be sure that it is correctly signed and witnessed.
• "Sign out" the patient in the nurse's notes.

• Include the date, the time, the event, and your observations on the status of the patient.

INTRAOPERATIVE PHASE

 The Intraoperative phase is the period during which the patient is undergoing surgery in
the operating room. It ends when the patient is transferred to the post-anesthesia recovery
room.
  Throughout the surgical experience the nurse functions as the patient’s chief advocate.
The nurse’s care and concern extend from the time the patient is prepared for and
instructed about the forthcoming surgical procedure to the immediate preoperative period
and into the operative phase and recovery from anesthesia. The patient needs the security
of knowing that someone is providing protection during the procedure and while he is
anesthetized because surgery is usually a stressful experience.
Goals

1. Promote the principle of asepsis asepsis.

2. Homeostasis
3. Safe administration of anesthesia
4. Hemostasis

The Surgical Team

Key Members:
The Intraoperative phase begins when the patient is received in the surgical area and lasts
until the patient is transferred to the recovery area. Although the surgeon has the most
important role in this phase, there are five key members of the surgical team which are as
follows:

 The Surgeon
 The Anesthesiologist
 The Scrub Nurse
 The Circulating Nurse

The Surgeon

The surgeon is the leader of the surgical team. The surgeon is ultimately responsible for
performing the surgery effectively and safely; however, he is dependent upon other members of
the team for the patient's emotional wellbeing and physiologic monitoring.
Anesthesiologist

Anesthesiologist/Anesthetist: An anesthesiologist is a physician trained in the administration

of anesthetics.
An anesthetist is a registered professional nurse trained to administer anesthetics.

The responsibilities of the anesthesiologist or anesthetist include:

 Providing a smooth induction of the patient's anesthesia in order to prevent pain.

 Maintaining satisfactory degrees of relaxation of the patient for the duration of the
surgical procedure.
 Continuous monitoring of the physiologic status of the patient for the duration of the
surgical procedure.
 Continuous monitoring of the physiologic status of the patient to include oxygen
exchange, systemic circulation, neurologic status, and vital signs.
 Advising the surgeon of impending complications and independently intervening as
necessary.

Scrub Nurse

 Scrub Nurse/Assistant: The scrub nurse or scrub assistant is a nurse or surgical technician
who prepares the surgical set-up, maintains surgical asepsis while draping and handling
instruments, and assists the surgeon by passing instruments, sutures, and supplies.
 The scrub nurse must have extensive knowledge of all instruments and how they are
used.
 The scrub nurse or assistant wears sterile gown, cap, mask, and gloves.

Circulating Nurse

 Circulating Nurse: The circulating nurse is a professional registered nurse who is liaison
between scrubbed personnel and those outside of the operating room.
 The circulating nurse is free to respond to request from the surgeon, anesthesiologist or
anesthetist, obtain supplies, deliver supplies to the sterile field, and carry out the nursing
care plan.
 The circulating nurse does not scrub or wear sterile gloves or a sterile gown.

Other responsibilities include:

 Initial assessment of the patient on admission to the operating room, helping monitoring
the patient.
 Assisting the surgeon and scrub nurse to don sterile gowns and gloves.
 Anticipating the need for equipment, instruments, medications, and blood components,
opening packages so that the scrub nurse can remove the sterile supplies, preparing
labels, and arranging for transfer of specimens to the laboratory for analysis.
 Saving all used and discarded gauze sponges, and at the end of the operation, counting
the number of sponges, instruments, and needles used during the operation to prevent the
accidental loss of an item in the wound.

Major Classifications of Anesthetic Agents

There are three major classifications of anesthetic agents:

 General Anesthetic
 Regional Anesthetic
 Local Anesthetic

A general anesthetic produces loss of consciousness and thus affects the total person.
When the patient is given drugs to produce central nervous system depression, it is termed
general anesthesia.
Characteristics of General Anesthetic

 It produces analgesia.
 It produces complete loss of consciousness.
 It provides a degree of muscle relaxation.
 It dulls reflexes.
 It is safe and has minimal side effects.

General anesthesia is used for major head and neck surgery, intracranial surgery, thoracic
surgery, upper abdominal surgery, and surgery of the upper and lower extremities.

Phases of General Anesthesia

There are three phases of general anesthesia as follows:

 Induction: rendering the patient unconscious, begins with administration of the anesthetic
agent and continues until the patient is ready for the incision.

 Maintenance (surgical anesthesia) begins with the initial incision and continues until near
completion of the procedure.

 Emergence: Begins when the patient starts to come out from under the effects of the
anesthesia and usually ends when the patient leaves the operating room.

Routes of Administration of a General Anesthetic Agents

 Rectal (which is not used much in today's medical practices)

 Intravenous infusion
 Inhalation

No single anesthetic meets the criteria for an ideal general anesthetic.

A Regional or Block Anesthetic Agent

o A regional or block anesthetic agent causes loss of sensation in a large region of the body.
o The patient remains awake but loses sensation in the specific region anesthetized. In some
instances, reflexes are lost also.
o When an anesthetic agent is injected near a nerve or nerve pathway, it is termed regional
anesthesia.
o Regional anesthesia may be accomplished by nerve blocks, or subdural or epidural
blocks. Nerve blocks are done by injecting a local anesthetic around a nerve trunk
supplying the area of surgery such as the jaw, face, and extremities.
o Subdural blocks are used to provide spinal anesthesia. The injection of an anesthetic,
through a lumbar puncture, into the cerebrospinal fluid in the subarachnoid space causes
sensory, motor and autonomic blockage, and is used for surgery of the lower abdomen,
perineum, and lower extremities.
o Side effects of spinal anesthesia include headache, hypotension, and urinary retention.
o For epidural block, the agent is injected through the lumbar interspace into the epidural
space, that is, outside the spinal canal.

Local anesthesia
Local Anesthesia is administration of an anesthetic agent directly into the tissues.
It may be applied topically to skin surfaces and the mucous membranes in the nasopharynx,
mouth, vagina, or rectum or injected intradermally into the tissue.

Impact of the Anesthetic Agent

 Depending on its classification, Anesthesia produces states such as narcosis (loss of

consciousness), analgesia (insensibility to pain), loss of reflexes, and relaxation.
 General Anesthesia produces all of these responses.
 Regional Anesthesia does not cause narcosis, but does result in analgesia and reflex loss.
 Local anesthesia results in loss of sensation in a small area of tissue.

The choice of route and the type of anesthesia is primarily made by the anesthetist or
anesthesiologist after discussion with the patient.

Factors which effect the selection of the Anesthetic Agent

 The type of surgery.
 The location and type of anesthetic agent required.
 The anticipated length of the procedure.
 The patient's condition.
 The patient's age.
 The patient's previous experiences with anesthesia.

 The available equipment. o Preferences of the anesthesiologist or

anesthetist and the patient.

 The skill of the anesthesiologist or anesthetist.

Factors considered when selecting the Anesthetic Agent

 Smoking and drinking habits of the patient

 Medications the patient is taking
 Presence of disease

Impact of medication on the Anesthetic Agent

 Patients may be taking medication for conditions unrelated to the surgery, and are
unaware of the potential for adverse reactions of these medications with anesthetic
agents.
 Because some medications interact adversely with other medications and with anesthetic
agents, preoperative assessment should include a thorough medication history.
 Medications, whether prescribed or over-the-counter, can affect the patient's reaction to
the anesthetic agent, increase the effects of the anesthesia, and increase the risk from the
stress of surgery.
 Medication is usually withheld when the patient goes to surgery; but some specific
medications are given even then.
 For example, patients with cardiovascular problems or diabetes mellitus may continue to
receive their prescribed medications.
 Nursing Assessment

The following are nursing assessment after anesthesia:

1. Monitoring vital signs.

2. Observe patient and record the time when motion and sensation of the legs and
the toes return.
Side Effects

1. Some numbness or reduced feeling in part of your body (local anesthesia)

2. Nausea and vomiting.
3. A mild drop in body temperature.
How do anesthesiologists determine the type of anesthesia to be used?

The type of anesthesia the anesthesiologist chooses depends on many factors. These include the
procedure the client is having and his or her current health.

Positioning

The nurse should have an idea which patient position is required for a certain surgical procedure
to be performed. There are lots of factors to consider in positioning the patient which includes
the following:

1. Patient should be in a comfortable position as possible whether he or she is awake

or asleep.
2. The operative area must be adequately exposed.
3. The vascular supply should not be obstructed by an awkward position or undue
pressure on a part.
4. There should be no interference with the patient’s respiration as a result of
pressure of the arms on the chest or constriction of the neck or chest caused by a
gown.
 5. The nerves of the client must be protected from undue pressure. Serious injury or
paralysis may result from improper positioning of the arms, hands, legs or feet.
6. Shoulder braces must be well padded to prevent irreparable nerve injury.
7. Patient safety must be observed at all times.
8. In case of excitement, the patient needs gentle restraint before induction.
Nursing Responsibilities

Here are the nursing responsibilities during intraoperative phase:

1. Safety is the highest priority.

2. Simultaneous placement of feet. This is to prevent dislocation of hip.
3. Always apply knee strap.
4. Arms should not be more than 90°
5. Prepare and apply cautery pad. Cautery is used to stop bleeding.

The Recovery Room

 The Recovery Room is defined as a specific nursing unit, which accommodates patients
who have undergone major or minor surgery.
 Following the operation, the patient is carefully moved from the operating table to a
wheeled stretcher or bed and transferred to the recovery room.
 The patient usually remains in the recovery room until he begins to respond to stimuli.
 The postoperative phase lasts from the patient's admission to the recovery room through
the complete recovery from surgery.

Nursing Function for Patient Care in the Recovery Room

 To relieve the patient's discomfort.

 Pain is usually greatest for 12 to 36 hours after surgery, decreasing on the second and
third post-op day.
 Analgesics are usually administered every 4 hours the first day.
  Tension increases pain perception and responses, thus analgesics are most effective if
given before the patient's pain becomes severe.
 Analgesics may be administered in patient controlled infusions.

The Recovery Room Complications

 Early detection of complications. Most people recover from surgery without incident.
 Complications or problems are relatively rare, but the recovery room nurse must be aware
of the possibility and clinical signs of complications.
 Prevention of complications. Complications that should be prevented in the recovery
room are respiratory distress and hypovolemic shock.

The Recovery Room and Intensive Care

 The difference between the recovery room and surgical intensive care are as follows:
 The recovery room staff supports patients for a few hours until they have recovered from
anesthesia.
 The surgical intensive care staff supports patients for a prolonged stay, which may last 24
hours or longer.

THE POSTOPERATIVE PHASE

The postoperative phase of the surgical experience extends from the time the client is
transferred to the recovery room or postanesthesia care unit (PACU) to the moment he or she is
transported back to the surgical unit, discharged from the hospital until the follow-up care.

Goals

During the postoperative period, reestablishing the patient’s physiologic

balance, pain management and prevention of complications should be the focus of the nursing
care. To do these it is crucial that the nurse perform careful assessment and immediate
intervention in assisting the patient to optimal function quickly, safely and comfortably as
possible.

1. Maintaining adequate body system functions.

2. Restoring body homeostasis.
3. Pain and discomfort alleviation.
4. Preventing postoperative complications.
5. Promoting adequate discharge planning and health teaching.

The mnemonic “POSTOPERATIVE” may also be helpful:

 P – Preventing and/or relieving complications

 O – Optimal respiratory function
 S – Support: psychosocial well-being
 T – Tissue perfusion and cardiovascular status maintenance
 O – Observing and maintaining adequate fluid intake
 P – Promoting adequate nutrition and elimination
 A – Adequate fluid and electrolyte balance
 R – Renal function maintenance
 E – Encouraging activity and mobility within limits
 T – Thorough wound care for adequate wound healing
 I – Infection Control
 V – Vigilant to manifestations of anxiety and promoting ways of relieving it
 E – Eliminating environmental hazards and promoting client safety

To PACU

Patient Care during Immediate Postoperative Phase: Transferring the Patient to RR or PACU

Patient Assessment
Special consideration to the patient’s incision site, vascular status and exposure should be
implemented by the nurse when transferring the patient from the operating room to the
postanethesia care unit (PACU) or postanesthesia recovery room (PARR). Every time the patient
is moved, the nurse should first consider the location of the surgical incision to prevent further
strain on the sutures. If the patient comes out of the operating room with drainage tubes, position
should be adjusted in order to prevent obstruction on the drains.

1. Assess air exchange status and note patient’s skin color

2. Verify patient identity. The nurse must also know the type of operative procedure
performed and the name of the surgeon responsible for the operation.
3. Neurologic status assessment. Level of consciousness (LOC) assessment and Glasgow
Coma Scale (GCS) are helpful in determining the neurologic status of the patient.
4. Cardiovascular status assessment. This is done by determining the patient’s vital signs in
the immediate postoperative period and skin temperature.
5. Operative site examination. Dressings should be checked.
Positioning

Moving a patient from one position to another may result to serious arterial hypotension. This
occurs when a patient is moved from a lithotomy to a horizontal position, from a lateral to
a supine position, prone to supine position and even when a patient is transferred to the stretcher.
Hence, it is very important that patients are moved slowly and carefully during the immediate
postoperative phase.

Promoting Patient Safety

When transferred to the stretcher, the patient should be covered with blankets and secured with
straps above the knees and elbows. These straps anchor the blankets at the same time restrain the
patient should he or she pass through a stage of excitement while recovering from anesthesia. To
protect the patient from falls, side rails should be raised.

Safety checks when transferring the patient from OR to RR:

  S – Securing restraints for I.V. fluids and blood transfusion.
 A – Assist the patient to a position appropriate for him on her based on the
location of incision site and presence of drainage tubes.
 F – Fall precaution implementation by making sure the side rails are raised and
restraints are secured well.
 E – Eliminating possible sources of injuries and accidents when moving the
patient from the OR to RR or PACU.
Postoperative Nursing Care

Airway

 Keep airway in place until the patient is fully awake and tries to eject it. The
airway is allowed to remain in place while the client is unconscious to keep the
passage open and prevents the tongue from falling back. When the tongue falls
back, airway passage obstruction will result. Return of pharyngeal reflex, noted
when the patient regains consciousness, may cause the patient to gag and vomit
when the airway is not removed when the patient is awake.
 Suction secretions as needed.
Breathing

 B – Bilateral lung auscultation frequently.

 R – Rest and place the patient in a lateral position with the neck extended, if not
contraindicated, and the arm supported with a pillow. This position promotes
chest expansion and facilitates breathing and ventilation.
 E – Encourage the patient to take deep breaths. This aerates the lung fully and
prevents hypostatic pneumonia.
 A – Assess and periodically evaluate the patient’s orientation to name or
command. Cerebral function alteration is highly suggestive of impaired oxygen
delivery.
 T – Turn the patient every 1 to 2 hours to facilitate breathing and ventilation.
 H – Humidified oxygen administration. During exhalation, heat and moisture are
normally lost, thus oxygen humidification is necessary. Aside from that, secretion
 removal is facilitated when kept moist through the moisture of the inhaled air.
Also, dehydrated patients have irritated respiratory passages thus, it is very
important make sure that the inhaled oxygen is humidified.

Post-Operative Respiratory Care

• Reinforce the deep breathing exercises the patient was taught

preoperatively.
• Deep breathing exercises hyperventilate the alveoli and prevent their collapse, improve
lung expansion and volume, help to expel anesthetic gases and mucus, and facilitate
oxygenation of tissues.
o Exhale gently and completely.

o Inhale through the nose gently and completely.

o Hold his breath and mentally count to three.

o Exhale as completely as possible through pursed lips as if to whistle.
o Repeat these steps three times every hour while awake.

Post-Operative Respiratory Care - Coughing

Coughing, in conjunction with deep breathing, helps to remove retained mucus from the
respiratory tract.
 Coughing is painful for the postoperative patient.

 While in a semi-Fowler's position, the patient should support the incision with a pillow or
folded bath blanket and follow these guidelines for effective coughing:
 Inhale and exhale deeply and slowly through the nose three times.

 Take a deep breath and hold it for 3 seconds.

 Give two or three "hacking" coughs while exhaling with the mouth open and the tongue
out.
 Take a deep breath with the mouth open.
  Cough deeply once or twice.

 Take another deep breath.

 Repeat these steps every 2 hours while awake.

Post-Operative Respiratory Care - Breathing Apparatus

 An Incentive Spirometer may be ordered to help increase lung volume, inflation of

alveoli, and facilitate venous return.
 Most patients learn to use this device and can carry out the procedure without a nurse in
attendance.
 Monitor the patient from time to time to motivate them to use the spirometer and to be
sure that they use it correctly.
 While in an upright position, the patient should take two or three normal breaths, then
insert the spirometer's mouthpiece into his mouth.
 Inhale through the mouth and hold the breath for 3 to 5 seconds.
 Exhale slowly and fully.

 Repeat this sequence 10 times during each waking hour for the first 5 post-op days.
 Do not use the spirometer immediately before or after meals.

Circulation

 Obtain patient’s vital signs as ordered and report any abnormalities.

 Monitor intake and output closely.
 Recognize early symptoms of shock or hemorrhage such as cold extremities,
decreased urine output – less than 30 ml/hr, slow capillary refill – greater than 3 seconds,
dropping blood pressure, narrowing pulse pressure, tachycardia – increased heart rate.
 Venous return from the legs slows during surgery and may actually decrease in some
surgical positions.
 With circulatory stasis of the legs, thrombophlebitis and emboli are potential
complications of surgery.
  Venous return is increased by flexion and contraction of the leg muscles. To prevent
thrombophlebitis, instruct the patient to exercise the legs while on bedrest.
Post-Operative Cardiovascular Procedure

 Leg exercises are easier if the patient is in a supine position with the head of the bed
slightly raised to relax abdominal muscles.
 Leg exercises should be individualized using the following guidelines;
 Flex and extend the knees, pressing the backs of the knees down toward the mattress on
extension.
 Alternately, point the toes toward the chin (dorsiflex) and toward the foot of the bed
(plantar flex); then, make a circle with the toes.
 Raise and lower each leg, keeping the leg straight.
 Repeat leg exercises every 1 to 2 hours.
 Post-Operative Cardiovascular Support
 Ambulate the patient as ordered. (See also separate Nursing Course Module on Patient
Ambulating).
 Provide physical support for the first attempts.
 Have the patient dangle the legs at the bedside before ambulation.
 Monitor the patient's blood pressure while he dangles.
 If the patient is hypotensive or experiences dizziness while dangling, do not ambulate.
 Report this event to the supervisor.

Thermoregulation

 Hourly temperature assessment to detect hypothermia or hyperthermia.

 Report temperature abnormalities to the physician.
 Monitor the patient for postanethesia shivering or PAS. This is noted in
hypothermic patients, about 30 to 45 minutes after admission to the PACU. PAS
represents a heat-gain mechanism and relates to regaining the thermal balance.
 Provide a therapeutic environment with proper temperature and humidity. Warm
blankets should be provided when the patient is cold.
Fluid Volume
  Assess and evaluate patient’s skin color and turgor, mental status and body
temperature.
 Monitor and recognize evidence of fluid and electrolyte imbalances such
as nausea and vomiting and body weakness.
 Monitor intake and output closely.
 Recognize signs of fluid imbalances. HYPOVOLEMIA: decreased blood
pressure, decreased urine output, increased pulse rate, increased respiration rate,
and decreased central venous pressure (CVP). HYPERVOLEMIA: increased
blood pressure and CVP, changes in lung sounds such as presence of crackles in
the base of both lungs and changes in heart sounds such as the presence of S3
gallop.
Safety

 Avoid nerve damage and muscle strain by properly supporting and padding
pressure areas.
 Frequent dressing examination for possible constriction.
 Raise the side rails to prevent the patient from falling.
 Protect the extremity where IV fluids are inserted to prevent possible needle
dislodge.
 Make sure that bed wheels are locked.
GI Function and Nutrition

 If in place, maintain nasogastric tube and monitor patency and drainage.

 Provide symptomatic therapy, including antiemetic medications for nausea and
vomiting.
 Administer phenothiazine medications as prescribed for severe, persistent
hiccups.
 Assist patient to return to normal dietary intake gradually at a pace set by patient
(liquids first, then soft foods, such as gelatin, junket, custard, milk, and creamed
soups, are added gradually, then solid food).
  Remember that paralytic ileus and intestinal obstruction are potential
postoperative complications that occur more frequently in patients undergoing
intestinal or abdominal surgery.
 Arrange for patient to consult with the dietitian to plan appealing, high-protein
meals that provide sufficient fiber, calories, and vitamins.
 Instruct patient to take multivitamins, iron, and vitamin C supplements
postoperatively if prescribed

Post-Operative Gastrointestinal System Procedure

 Inactivity and altered fluid and food intake during the perioperative period alter
gastrointestinal activities.
 Nausea and vomiting may result from an accumulation of stomach contents before
peristalsis returns or from manipulation of organs during the surgical procedure if the
patient had abdominal surgery.
 Report to the supervisor if the patient complains of abdominal distention.
 Ask the patient if he has passed gas since returning from surgery.
 Auscultate for bowel sounds. Report your assessment to the supervisor, and document
in nursing notes.
 Assess abdominal distention, especially if bowel sounds are not audible or are high-
pitched, indicating an absence of peristalsis.
 Provide a privacy so that the patient will feel comfortable expelling gas.

Gastrointestinal System - Measures and Checks

• Encourage food and fluid intake when the patient in no longer NPO.

• Ambulate the patient to assist peristalsis and help relieve gas pain, which is a common
postoperative discomfort.
• Instruct the patient to tell you of his first bowel movement following surgery. Record the
bowel movement on the intake and output (I&O) sheet.
• If nursing measures are not effective, the doctor may order medication or an enema to
facilitate peristalsis and relieve distention.
 • A last measure may require the insertion of a nasogastric or rectal tube.

• Document nursing measures and the results in the nursing notes.

Comfort

 Observe and assess behavioral and physiologic manifestations of pain.

 Administer medications for pain and document its efficacy.
 Assist the patient to a comfortable position.
Drainage

 Presence of drainage, need to connect tubes to a specific drainage system,

presence and condition of dressings
Skin Integrity

 Record the amount and type of wound drainage.

 Regularly inspect dressings and reinforce them if necessary.
 Proper wound care as needed.
 Perform hand washing before and after contact with the patient.
 Turn the patient to sides every 1 to 2 hours.
 Maintain the patient’s good body alignment.

Integumentary System

Follow doctor's orders for wound care, wound irrigations and cultures.
 In addition to assessment of the surgical wound, you should evaluate the patient's general
condition and laboratory test results.
 If the patient complains of increased or constant pain from the wound, or if wound edges are
swollen or there is purulent drainage, further assessment should be made and your findings
reported and documented.
 Generalized malaise, increased pain, anorexia, and an elevated body temperature and pulse
rate are indicators of infection.
 Important laboratory data include an elevated white blood cell count and the causative
organism if a wound culture is done.
 Staples or sutures are usually removed by the doctor using sterile technique.
 After the staples or sutures are removed, the doctor may apply SteriStrip® to the wound to
give support as it continues to heal.
Procedure for Applying a Patient Dressing

 At some time, most wounds are covered with a dressing and you may be responsible for
changing the dressing. The following outlines the approach to Patient dressing:
 First, gather needed supplies. Items may be packaged individually or all necessary items
may be in a sterile dressing tray.
 Some surgical units have special dressing carts, with agents needed to clean the wound,
and materials to cover and secure the dressing.
 Next, prepare the patient for the dressing change by explaining what will be done,
providing privacy for the procedure, and assisting the patient to a position that is
comfortable for him and for you.
 Finally, use appropriate aseptic techniques when changing the dressing and follow
precautions for contact with blood and body fluids.
 The most common cause of nosocomial infections is carelessness in observing medical
and surgical asepsis when changing dressings.
 It is especially important to wash hands thoroughly before and after changing dressings
and to follow the US Centers for Disease Control (CDC) guidelines.
 Methods of Caring for Wounds
 The basic objective of wound care is to promote tissue repair and regeneration, so that
skin integrity is restores.
 There are two methods of caring for wounds:
 The Open Method, in which no dressing is used to cover the wound
 The Closed Method, in which a dressing is applied.

Dressings have advantages and disadvantages.

Advantages. Dressings absorb drainage, protect the wound from injury and contamination, and
provide physical, psychological, and aesthetic comfort for the patient.
Disadvantages. Dressings can rub or stick to the wound, causing superficial injury.
Dressings create a warm, damp, and dark environment conducive to the growth of organisms and
resultant infection.

Contact with Blood and Body Fluids

Precautions for Contact with Blood and Body Fluids:

 Wear gloves when touching blood, body fluids containing visible blood, an open wound,
or non-intact skin of all clients and when handling items or surfaces soiled with blood or
body fluids.
 Wash hands thoroughly after removing gloves and if contaminated with blood or with
body fluids that contain visible blood.
 Take precautions to prevent injuries by needles, sharp instruments, or sharp devices.
 Do not give direct client care if you have open or weeping lesions or dermatitis.
 If procedures commonly cause droplets or splashing of blood or body fluids to which
universal precautions apply, wear gloves, a surgical mask, and protective eyewear, as
appropriate.

Assessing and Managing Voluntary Voiding

 Assess for bladder distention and urge to void on patient’s arrival in the unit and
frequently thereafter (patient should void within 8 hours of surgery).
 Obtain order for catheterization before the end of the 8-hour time limit if patient
has an urge to void and cannot, or if the bladder is distended and no urge is felt or
patient cannot void.
 Initiate methods to encourage the patient to void (eg, letting water run, applying
heat to perineum).
 Warm the bedpan to reduce discomfort and automatic tightening of muscles and
urethral sphincter.
 Assist patient who complains of not being able to use the bedpan to use a
commode or stand or sit to void (males), unless contraindicated.
  Take safeguards to prevent the patient from falling or fainting due to loss of
coordination from medications or orthostatic hypotension.
 Note the amount of urine voided (report less than 30 mL/h) and palpate the
suprapubic area for distention or tenderness, or use a portable ultrasound device to
assess residual volume.
 Continue intermittent catheterization every 4 to 6 hours until patient can void
spontaneously and postvoid residual is less than 100 mL.

Post-Operative Urinary System Procedure

• Urinary System. Patients who have had abdominal surgery, particularly in the lower
abdominal and pelvic regions, often have difficulty urinating after surgery.
• The sensation of needing to urinate may temporarily decrease from operative trauma in
the region near the bladder.
• The fear of pain may cause the patient to feel tense and have difficulty urinating.
• If the patient does not have a catheter, and has not voided within eight hours after return
to the nursing unit, report this event to the supervisor.
• Palpate the patient's bladder for distention and assess the patient's response.
• The area over the bladder may feel rounder and slightly cooler than the rest of the
abdomen.
• The patient may tell you that he feels a sense of fullness and urgency.

Additional post-operative Urinary System patient support is as follows:

• Assist the patient to void.

• Assist the patient to the bathroom or provide privacy.

• Position the patient comfortably on the bedpan or offer the urinal.

• Measure and record urine output.

• If the first urine voided following surgery is less than 30 cc, notify the supervisor.
 • If there is blood or other abnormal content in the urine, or the patient complains of pain
when voiding, report this to the supervisor.
Follow nursing unit standing operating procedures (SOP) for infection control, when
caring for the patient with a Foley catheter.

Encouraging Activity

 Encourage most surgical patients to ambulate as soon as possible.

 Remind patient of the importance of early mobility in preventing complications
(helps overcome fears).
 Anticipate and avoid orthostatic hypotension (postural hypotension: 20-mm Hg
fall in systolic blood pressure or 10-mm Hg fall in diastolic blood pressure,
weakness, dizziness, and fainting)
 Assess patient’s feelings of dizziness and his or her blood pressure first in the
supine position, after patient sits up, again after patient stands, and 2 to 3 minutes
later.
 Assist patient to change position gradually. If patient becomes dizzy, return to
supine position and delay getting out of bed for several hours.
 When patient gets out of bed, remain at patient’s side to give physical support and
encouragement.
 Take care not to tire patient.
 Initiate and encourage patient to perform bed exercises to improve circulation
(range of motion to arms, hands and fingers, feet, and legs; leg flexion and leg
lifting; abdominal and gluteal contraction).
 Encourage frequent position changes early in the postoperative period to stimulate
circulation. Avoid positions that compromise venous return (raising the knee or
placing a pillow under the knees, sitting for long periods, and dangling the legs
with pressure at the back of the knees).
 Apply antiembolism stockings, and assist patient in early ambulation. Check
postoperative activity orders before get-ting patient out of bed. Then have patient
 sit on the edge of bed for a few minutes initially; advance to ambulation
as tolerated
Gerontologic Considerations

Elderly patients continue to be at increased risk for postoperative complications. Age-related

physiologic changes in respiratory, cardiovascular, and renal function and the
increased incidence of comorbid conditions demand skilled assessment to detect early signs of
deterioration. Anesthetics and opioids can cause confusion in the older adult, and altered
pharmacokinetics results in delayed excretion and prolonged respiratory depressive effects.
Careful monitoring of electrolyte, hemoglobin, and hematocrit levels and urine output is essential
because the older adult is less able to correct and compensate for fluid and electrolyte
imbalances. Elderly patients may need frequent reminders and demonstrations to participate in
care effectively.

 Maintain physical activity while patient is confused. Physical deterioration can

worsen delirium and place patient at increased risk for other complications.
 Avoid restraints, because they can also worsen confusion. If possible, family or
staff member is asked to sit with patient instead.
 Administer haloperidol (Haldol) or lorazepam (Ativan) as ordered during
episodes of acute confusion; discontinue these medications as soon as possible to
avoid side effects.
 Assist the older postoperative patient in early and progressive ambulation to
prevent the development of problems such as pneumonia, altered bowel
function, DVT, weakness, and functional decline; avoid sitting positions that
promote venous stasis in the lower extremities.
 Provide assistance to keep patient from bumping into objects and falling. A
physical therapy referral may be indicated to promote safe, regular exercise for
the older adult.
 Provide easy access to call bell and commode; prompt void-ing to prevent urinary
incontinence.
  Provide extensive discharge planning to coordinate both professional and family
care providers; the nurse, social worker, or nurse case manager may institute the
plan for continuing care.
Evaluation

Patients in PACU are evaluated to determine the client’s discharge from the unit. The following
are the expected outcomes in PACU:

1. Patient breathing easily.

2. Clear lung sounds on auscultation.
3. Stable vital signs.
4. Stable body temperature with minimal chills or shivering.
5. No signs of fluid volume imbalance as evidenced by an equal intake and output.
6. Tolerable or minimized pain, as reported by the patient.
7. Intact wound edges without drainage.
8. Raised side rails.
9. Appropriate patient position.
10. Maintained quiet and therapeutic environment.
To Surgical Unit

Patient Care during Immediate Postoperative Phase: Transferring the Patient from RR to the
Surgical Unit

To determine the patient’s readiness for discharge from the PACU or RR certain criteria must be
met. The parameters used for discharge from RR are the following:

1. Uncompromised cardiopulmonary status

2. Stable vital signs
3. Adequate urine output – at least 30 ml/ hour
4. Orientation to time, date and place
5. Satisfactory response to commands
6. Minimal pain
 7. Absence or controlled nausea and vomiting
8. Pulse oximetry readings of adequate oxygen saturation
9. Satisfactory response to commands
10. Movement of extremities after regional anesthesia
Most hospitals use a scoring system to assess the general condition of patient in RR or PACU.
Observation and evaluation of the patient’s physical signs is based on a set of objective criteria.

The evaluation guide used is a modification of the APGAR scoring system used for newborns.
Through this, a more objective assessment of the patient’s physical condition is guaranteed while
recovering the RR or PACU.

The perfect possible score in this modified APGAR scoring system is 10. To be discharge from
RR or PACU the patient is required to have at least 7 to 8 points.

Patients with score less than 7 must remain in RR or PACU until their condition improves. Areas
of assessment in PACU or RR evaluation guide are:

1. Respiration – ability to breathe deeply and cough.

2. Circulation – systolic arterial pressure >80% of preanesthetic level
3. Consciousness Level – verbally responds to questions or oriented to location
4. Color – normal skin color and appearance: pinkish skin and mucus
5. Muscle activity – moves spontaneously or on command

Postoperative Nursing Implications:

 The nursing process is used throughout the Peri-operative period to provide the
patient with individualized care and the knowledge and ability for self-care following
disposition.
  Surgical intervention often alters physical appearance and normal physiological
functions and may threaten the patients psychological security.
 Some surgical patients react to the loss of a body part as to a death.
 Any or all of these may lead to alterations in the patient's self-concept and body
image.
 Be aware of the patient's needs and establish interventions that will support his
strengths and effective coping skills.
General Post-Operative Monitoring and Observation
 Monitor vital signs as ordered.
 Administer analgesics as ordered.

 Report lowered blood pressure and increased pulse to supervisor (hypovolemic shock).
 Report elevated temperature and rapid/weak pulse immediately to supervisor (infection).
 Procedure to Administering Post-Operative Patient Medication

 Apply all nursing implications related to the patient receiving analgesics whether narcotic
or non-narcotic, to include the following:
 Check each medication order against the doctor's order.

 Prepare the medications (check labels, accurately calculate dosages, observe proper
asepsis techniques with needles and syringes).
 Check the patient's identification wristband to ensure positive identification before
administering medications.

Nursing Implications related to Post-Operative Patient Medication

 Apply all nursing implications related to the patient receiving analgesics whether narcotic or
non-narcotic, to include the following:
 Administer the medications: Offer each drug separately if administering more than one drug
at the same time.
 Remain with the patient and see that the medication is taken.
 Never leave medications at the bedside for the patient to take later.
 Document the medications given as soon as possible.