INTRODUCTION TO MEDICAL SURGICAL NURSING I injury, or improve functional

status ex. Cleft lip/Palate

PERIOPERATIVE NURSING OF SCIENCE AND ARTS d. Palliative
OF NURSING IN THE CASE OF PREOPERATIVE i. Performed to relieve symptoms
PATIENTS w/o the intent of care, the pain
Patient focus - model used n periop NSG composed of 4 on the extent of cancer.
DOMAINS ii. It caters most cancer; colon
● Patient Safety cancer - removes only the
● Health System obstruction in the colon but not
● Physiologic Responses cure
● Behavioral Responses e. Ablative
i. Performed to enclose tissue that
Major Types of Pathologic Processes inquiring may contribute to patients
intervention (OPET) existing medical condition
1. Obstruction - impairment to the flood of vital ii. Ex. sleep apnea w/ tonsillitis -
fluids i.e. CSF, blood urine, bile/colon requires tonsillectomy to clear
2. Perforation - rupture of an organ if not the path for airway.
addressed can lead to sepsis or hemorrhage i.e iii. It can be removal of excess
ruptured appendicitis fluids in the body ex.
3. Erosion - wearing off of a surface or membrane Arthrocentesis
i.e burns that require skin grafting f. Cosmetic
4. Tumors - abnormal new growths that can be i. Performed for aesthetic
benign or malignant i.e neck tumor purposes
3. ACCORDING TO ANATOMIC SITE
CLASSIFICATION OF SURGICAL PROCEDURES: a. By location of body systems, Usually a
1. ACCORDING TO DEGREE OF RISK specialization ex. Neuro - brain, Cardio -
a. Major operation heart, GenSurg, etc.
i. Involves higher % of risks, 4. ACCORDING TO URGENCY
involves vital organs a. Elective
ii. Amount of blood loss, i. Planned, non-essential or for
general/spine anesthesia survival, has time to prepare
b. Minor operation ii. Ex. scar repair, vaginal repair,
i. Less risks, lesser time, lesser simple hernia
complications b. Urgent
ii. Usually done in cases of i. Unplanned, performed w/i
lacerations or trauma 24-48hrs
iii. Uses Local anesthesia ii. Ex. hysterectomy, acute
● Use of Regional anesthesia can be used in gallbladder, infection of the
either operations kidney/ureteral stones)
2. ACCORDING TO PURPOSE c. Emergency
a. Diagnostic i. To be done immediately to
i. To determine the cause of save/preserve life or limb
symptoms or origin of Problems ii. Ex. Trauma, GSW/SW, skull
ex. Fine needle aspiration fracture, appendectomy
biopsies - used to diagnose d. Planned-Required (a subcategory of
malignant/benign tumors elective)
b. Curative i. Requires surgery, necessary for
i. To resolve the problem by well-being. Planned w/in weeks
recovering the involved tissue or months
ex. Appendectomy - removal of Ex. BPH w/o obstruction (if
the appendix obstruction occurs it becomes
c. Reconstructive urgent) - it causes problems on
i. Performed to correct the urination
abnormality/deformity, repair
 Ex. Thyroid surgery - it cannot ● Goal: Ensure well functioning CV
be performed to someone with system to meet oxygen, fluid and
hyperthyroidism, it needs to be nutritional needs during peri-op period​
scheduled when the thyroid is at ● Assess history of CV disorders​
optimal size. 4. HEPATIC AND RENAL FUNCTION ​
e. Optional Goal: ​
i. Decision of the patient, usually ● Optimal function of liver and urinary
requested by personal system​
preference, ex. Cosmetic ● Liver impt. for metabolism of anesthetic
surgery. drugs​
● Assess Kidney Function ​
SURGICAL RISKS 5. ENDOCRINE FUNCTION​
General Risk Factors Goal: ​
1. Obesity ● Optimal function of Endocrine System​
2. Fluid, Electrolyte, and Nutritional Problems ● Control DM and Thyroid problem​
3. Presence of disease/s 6. IMMUNE FUNCTION ​
4. Concurrent or prior pharmacotherapy Goal: ​
Effects of Surgery to the Client ● Determine existence of allergies,
1. Stress response in elicited including nature of previous allergic
2. Defense against infection is lowered reactions and other Immune disorders.​
3. Vascular system in disrupted 7. PREVIOUS MEDICATION USE​
4. Organ functions are disturbed ● Obtain medication history - prevent drug
5. Body image may be disturbed interactions​
6. Lifestyle may change ● potent drugs (Narcotics, CNS
Depressants, Steroids)​
I. PRE-OPERATIVE PHASE ● OTC (Cough medications, Aspirin)​
Starts at the admission of the client, upto the preparation
of the client physically, psychosocially, spiritually, and Psychological Factors
legality of the procedure. ● All patients have some type of emotional
reaction before any surgical procedure​
Goals of Pre-op Phase ● Pre-op fears may be anticipatory response to an
1. Assessing and correcting physiologic and experience patient views as threat to:​
psychologic problems that might increase ○ customary role in life​
surgical risk. ○ body integrity​
2. Giving a person and significant others complete ○ life itself ​
learning/teaching guidelines regarding surgery. ○ Psychological distress directly
3. Instructive and demonstration exercises that will influences body functioning​
benefit person during post-op period ○ imperative to identify patient’s anxiety
4. Planning for discharge and any projected
charges in lifestyle due to surgery. Causes of Fears of the Pre-op client​
1. Fear of the unknown​
PHYSIOLOGIC ASSESSMENT 2. Fear of anesthesia, vulnerability while
↑ (-) Factors = ↑ risk ​ unconscious​
a. Health History​ 3. Fear of pain​
b. Physical examination (Cephalo caudal) ​ 4. Fear of death​
c. Laboratory and Diagnostic Examinations 5. Fear of disturbance of body image ​
6. Threat of permanent incapacity​
1. NUTRITIONAL AND FLUID STATUS​ 7. Worries loss of finances, employment, social
● Optimum nutrition​ and family roles​
2. RESPIRATORY STATUS​ 8. Fear r/t to previous experience with the health
● Goal: optimal respiratory function​ care system​
● Smokers: urged to stop 2 mos. Before
surgery Physical Preparations
3. CARDIOVASCULAR STATUS​ Before Surgery
 1. CORRECT ALL NEGATIVE FACTORS BASED ● require the patient to remove dentures
ON PHYSIOLOGIC ASSESSMENT​ 7. offer spiritual support - pray w/
2. TEACHING PRE-OP EXERCISES ​ patient(regardless of religion)
● Diaphragmatic breathing​ 8. accomplish preop care checklist
● health teaching, instructions, post-op 9. have client void before pre-op meds
care, etc. because the patient may not
be able to understand or comprehend INFORMED CONSENT
after surgery due to pain, anesthetics. Operative permit/surgical consent/anesthesia consent
● atelectasis, coughing exercises - using Purpose:
of pillow or abdominal binder 1. ensure that the client understand the nature of
● includes the diet the treatment incl potential complication and
● hypostatic pneumonia - pooling of disfigurement
secretions in the lower airways due to 2. indicate the the client decision was made w/o
immobility pressure
3. FULL BATH TO REDUCE MICROORGANISM​ ● the patient should not be other the
● includes shaving - if not applies influence of any medication that may
antiseptic affect independent decision-making
4. PREPARING G.I. TRACT​ 3. protect client against unauthorized procedure
● NPO; ENEMAS AS REQUIRED​ 4. protect the surgeon and hospital against legal
● depends on what part of the colon would action by the client who claims that an
be operated unauthorized procedure was performed.
● admin of laxative to clear the GI tract ● patient can redact the informed consent,
5. PREPARING FOR ANESTHESIA​ before the operation. explain the
● Avoid alcohol and cigarette smoking at consequences.
least 24 H before sx.​ ● minors and independently incapable, the
6. REST AND SLEEP​ guardian or the doctor can provide the
● May administer sedatives as ordered consent

Day of the Surgery NUrsing Consideration

1. MORNING BATH/ MOUTHWASH → if possible​ 1. doctors explain the procedure, nurses may ask
2. PROVIDE CLEAN GOWN always → remove patient to sign and witness patient's signature
underwear​ 2. if a patient needs additional inf. to make their
3. REMOVE HAIR PINS, BRAID LONG HAIRS, decision. the nurse notifies about this - if the
COVER HAIR W/ CAP​ nurse is knowledgeable enough.
4. REMOVE DENTURES, FOREIGN MATERIALS 3. the nurse ascertains that the consent has been
(gum), COLORED NAILS, HEARING AID, signed before any psychoactive medication was
CONTACT LENS​ administered.
5. WEDDING RING → REMOVE AND TIE WITH ● Consent not valid if obtained under the
GAUZE AND FASTEN AROUND THE WRIST influence of medications that can
influence and affect judgment and
Preoperative Medications decision making​
Day of the Surgery 4. act as a patient's advocate
*removal or jewelry, dentures, nail polish, wearing of ● No patient should be urged or coerced
gown before transport to OR to sign an operative permit against their
1. baseline v/s 1hr prior to transport - it should be will ​
in normal levels ● Refusing to undergo any surgical
2. check chart (doc's orders/lab results) - if cp procedure is a PATIENT’S LEGAL
clearance granted RIGHT AND PRIVILEGE​
3. check id band, perform skin prep - right patient, ● NURSE MUST DOCUMENT REFUSAL
make it state their name AND INFORM SURGEON ASAP so that
4. check for special orders other arrangements can be made. ​
5. enema, ngt, iv line, blood reservation HOW TO PREVENT WRONG SITE, WRONG
6. check npo - 6-8hrs npo prior to surgery PROCEDURE, WRONG SURGERY
● fasting the night before the surgery 1. preop patient verification
 ● Ask patient’s name, state patient’s name, check ● Can be a source of infection​
w/ the records (at least 2 of the ff.)​ 2. Always wear a mask when approaching a sterile area​
a. Door​ ● Avoid contamination​
3. A surgical attire must be worn by all members​
b. Headboard​
● Scrub suit, cap/ hood covering hair, OR shoes, mask​
c. Bracelet​
4. The scrub suit does not make the hands and forearms
d. Chart​ sterile​
e. Identification system​ ● Only reduces microbes Medical asepsis​
2. site marking 5. All articles to be sterilized should be clean and free from
3. time out foreign particles, hair, dust, dirt or discharge​
● brief conference of the medical team - discuss 6. All articles must be sterile before it comes in contact with a
the assessment, procedure, and outcome sterile surface​
7. Dressings and supplies once removed from the sterile
container are considered contaminated​
KISS - KEEP IT SHORT AND IS SIMPLE
8. IF IN DOUBT AS TO THE STERILITY OF ANY ARTICLE,
*answer only what the patient is asked
IT SHOULD BE CONSIDERED UNSTERILE ​
9. Edges of anything that encloses sterile contents are
II. INTRAOPERATIVE NURSING considered unsterile ​
Starts - when patient is transferred to the OR table 10. Table are considered sterile at table level only ​
Ends - admission to the PACU/RR ● Lines which falls over the side the table should be
discarded​
● Sutures which falls over the side the table should be
Client Needs
cut off at table height or discarded completely​
● emotional well being
11. Sterile packages should have identification​
● safety ● Sterile and unsterile articles should not be stored
● positioning together​
● maintenance of sepsis 12. Wet areas are to be considered contaminated​
● controlling surgical environment ● Moisture may cause contamination​
● Remedy contamination​
Nursing Responsibilities ● Damp area cover​
1. reviewing patient's record for completeness and ● Draping over dry areas only​
● Petroleum/ Lubricating jelly place on towel or sponge​
accuracy
13. Sterile drapes or towel clips should not be removed once
2. ensuring proper identification of the client
they are placed​
3. client safety 14. Infected tissues or purulent fluid are considered
4. providing support contaminated​
5. deal with patient's fears and concerns 15. Contents of the L. Intestines and rectum are
contaminated​
ASEPSIS - Free from microbes that can cause disease​ 16. Equipment should not be transferred from one case to
- waist-down and back is considered is another after initial incision has been made​
unsterile ● Nothing from the table can be used on another case
or placed w/ sterile articles not coming from the same
- ensure secured wearing of head cap,
case​
masks, ppe, etc
17. Gowns are considered sterile only from the waist to the
- do not touch anything once sterile shoulder level​
- autoclave - used to sterile material to be 18. Items dropped below waist level are considered unsterile
used for procedure and discarded​
● MEDICAL ASEPSIS​ 19. Keep hands in sight and at or above waist level​
→Reduction in the number of microbes​ 20. Arms are never folded perspiration in the axillary region
● SURGICAL ASEPSIS​ 21. Sterile members touch only sterile items or areas; Unsterile
→Virtually remove microbes including spores​ members touch only unsterile items or areas​
22. Sterile member should allow a wide margin of safety when
● DISINFECTION ​
passing unsterile areas​
→For inanimate objects (Instruments)​
23. Unsterile members avoid reaching over a sterile field;
● ANTISEPTIC​ Sterile members avoid reaching over an unsterile field​
→For animate objects, persons, animals ​ 24. All personnel should face sterile areas.​
When passing other persons, use back to back or front to front
PRINCIPLES OF ASEPSIS technique​
1. Anyone w/ an open wound, cold, infection should not 25. Sterile members turn their back to a non-sterile person or
participate in surgery​ area when passing ​
26. SKIN CANNOT BE STERILIZED.​ ● best suited for surgery of the head, neck, and
It should be made clean as possible​ upper torso​
27. Nurses and doctors must not touch the outside of the gown ● depth of anesthesia is monitored by observing
and glove with their hands​
changes in RR, O2 saturation, tidal CO2, CR,
28. The knife used for the initial incision must be discarded​
Urine output and BP
29. Change glove immediate if it gets a hole in it​
30. Wrappers on sterile packages should be of double STAGES OF GEN. ANESTHESIA
thickness and sufficient size A. Onset (administration to loss of consciousness)
Assessment:
4 Simple Rules on Aseptic Technique ● Drowsy and Dizziness
1. know what's sterile ● Auditory/Visual Hallucinations
2. know what is unsterile Nursing Cons:
3. keep the two apart ● Close OR doors, Silence, Stand by for
4. remedy contamination immediately assistance
● SYDEX AND STERILLIUM B. Excitement (Loss of consciousness to Loss of
Surgical Conscience eyelid reflex)
→involves a concept of self-inspection coupled with a Assessment:
moral obligation, involving both scientific and intellectual ● Increased autonomic activity
honesty ● Irregular breathing
→it is self regulation in practice according to a deep ● Struggling
personal commitment to the highest value Nursing Cons:
● Remain quiet @ client’s side
MEMBERS OF THE SURGICAL TEAM ● Assist Anesthesiologist
A. SCRUBBED STERILE TEAM C. Surgical Anesthesia (Loss of eyelid reflexes to
1. surgeon - leader Depression of Vital Functions)
2. assistant surgeon - assisting doctor Assessment:
3. scrub nurse - instrument nurse; tallies the ● Unconscious; relaxed muscles
equipment used, logs every procedure done and ● Negative blink and gag reflex
what equipment were used - cutting time, knife, Nursing Cons:
at what time, etc. before the closing of the ● Prep for intubation
equipment used will be tallied again. ● SELLICK MANEUVER
B. UNSCRUBBED STERILE TEAM ○ Application of pressure in the
1. anesthesiologist - trained; nurse anesthetist - cricoid cartilage
assists ○ Closes airway and prevents
2. circulating nurse - manager and overseer aspiration of gastric contents
3. pathologist - pathology specialist D. Medullary Depression/Death (Depression of
4. internist - cardiopulmonary medicine specialist Vital Functions to Cardio-resp failure/arrest)
5. x-ray technician/medical technologies - performs Assessment:
radiologic-diagnostic procedure while px is on ● No spontaneous respiration; no
OR heartbeat
Nursing Cons:
ANESTHESIA IN SURGERY ● Assist in est. airway; Do CPR
→artificially induced state of partial or total loss of ● Provide emergency cardiac drugs
sensation, occurring w/ or w.o loss of consciousness
purpose of which is to produce muscle relaxation, block TYPES OF GENERAL ANESTHESIA
transmission of nerve impulse suppress reflexes, and 1. INTRAVENOUS - promotes rapid induction and
cause loss of consciousness transition from the conscious stage to the
surgical anesthesia stage
CLASSIFICATION OF ANESTHESIA a. Thiopentalsodium(WEAK)
GENERAL ANESTHESIA - Short acting - rapid
● a drug induced depression of the cns that is unconsciousness
revered either by metabolic elimination in the - Cannot be mixed with others
body or by pharmacologic means - naloxone b. Fentanyl Citrate(POTENT opioid)
● blocks pain stimulus at the cerebral cortex​ - CNS dprs, calming analgesic
and reduced motor activity
 - cannot be used for patient with Agent:​
IOP, ICOP, COPD & the elderly ● Succinylcholine
c. Ketamine HCL (Dissociative Amnesia)
- Sedation, amnesia, immobility, MALIGNANT HYPERTHERMIA(41-42C)
analgesia and - uncontrolled skeletal muscle contraction
unresponsiveness to pain leading to potentially fatal hyperthermia​
- Used for elderly and the young - Chemically induced by anesthetic agents ​
d. Propofol(Emulsion sedative) Risk Factors
- Induction and maintenance - Strong, bulky muscles, History of muscle
cramps, muscle weakness​
- Rapid unconsciousness and
Management:
minimal excitation
● Stop the triggering event​
- Antiemetic effects
● Cool the body → ↓ body temperature → ↓
- Allergic hx SHOULD BE
metabolism​
CONSIDERED
○ increase in temp, the head is always
protected, in male; the scrotal area is
2. INHALATION - volatile liquids or gasses
also protected to prevent
a. Ether(OLDEST)
sterility(destruction of sperm)
- Deep and prolonged
● Reverse Metabolic and Resp. Acidosis →
- CV complications(rare)
NaHCO3​
- Very explosive
○ pyruvate to lactate to lactic acid =
b. Nitrous Oxide(LOW POTENCY)
acidosis, treatment is NaHCO3(sodium
- Little to no effect on BP
bicarbonate should be base) - should be
- No muscle relaxant property
inserted to the central vessel to prevent
c. Isoflurane(HIGH POTENCY)
- Profound vasodilation acid burn
- Causes mod. ↓ in BP;​ ○ sodium bicarbonate is an acid out of the
- Causes large ↓ in RR;​ blood vessel, but baking soda is also
d. Sevoflurane(HIGH POTENCY) sodium bicarbonate at a lower acid rate
- Weak analgesic effect ● Provide O2 and nutrition to tissue, correct
- Rapid induction and excretion electrolyte imbalance​
- Malignant hyperthermia ○ have appropriate medications like O2,
anti-seizures
Muscle Relaxants ● Administer DANTROLENE Na → skeletal
- blocks transmission of nerve impulse to muscle muscle relaxant ​
fibers Nursing Cons:
- IV an facilitates intubation; relaxes muscle ● No screening test for this d/o​
laryngospasms for controlled ventilation ● Determine family history ​
1. Non - depolarizing ● If w/ (+) history → USE GENERAL
→ Prevent Ach from Binding to receptors on ANESTHESIA ONLY IF ABSOLUTELY
Muscle plate​ NECESSARY​
→ Blocks Depolarization​ ● Monitor client closely​
→be cautious with patients w/ neuromuscular ● Recognize early symptoms ​
problems which will worsen current condition ● Have appropriate medications and equipment
Agents: available​
● Atracurium Besylate, Vecuronium bromide
Antidote:​ REGIONAL ANESTHESIA
● Neostigmine - painful sensation in only one region of the body
and does not result in unconsciousness​
2. Depolarizing - Use of sedative agents and epinephrine
→ Depolarizing agent That prolongs 1. Epidural Anesthesia
depolarization of muscle end plate - Introduction of an anesthetic agent into
→maintain and secure patency of the airway the epidural space (→ NO CSF)​
→resuscitation at the bedside - Use of needles in the spine spaces
 - Causes autonomic blockade​ - A nerve block anesthetizes individual
- Blocks sensory, motor and autonomic nerves or nerve plexuses rather than all
fxn.​ the local nerves anesthetized by a field
- Maybe administered as a single dose or block​
intermittently through an epidural Agents: Lidocaine, Bupiacaine, Mepivacaine​
catheter​ 5. Caudal Anesthesia/Trans-Sacral
Agents:​Pontocaine, Tetracaine, Bupivacaine​, - caudal or sacral canal​
Morphine, ​Butorphanol Tartrate ​ - Variation of epidural anesthesia​
- Produces anesthesia of the perineum
2. Spinal Anesthesia and lower abdomen ​
- local anesthetics into the subarachnoid - → OB cases​
space​
- Very fast onset → combines with 6. Intravenous Regional Block Anes./Bier’s
CSF​(10-20mins) Block
- **when the anesthesia mixes - Regional anesthesia of a limb​
with the csf spinal headache - Achieved by injecting an agent into a
occurs, it can be prevented with vein of the limb to be anesthetized​
the use of pillows, proper - Placing a pneumatic tourniquet over the
hydration anesthetized area​
- **FAST to assess stroke due to - Used for short procedures on the
dehydration; fast drip 500-800 extremities ​
- **modified trendelenburg - Agents: Lidocaine
positioning of the extremities
ADVANTAGES:
- **can be used for clients with
- Better airway control​
full stomach but can still
- Fewer Respiratory complications.​
aspirate but can be prevented
- Agents are easily metabolized and
- Within minutes of induction → loss of
excreted by the body.​
sensation and paralysis of toes, feet,
- Consciousness is sustained and patient
legs, abdomen​
cooperation secured ​
- Relatively safe, does not cloud
consciousness, can be used to clients
DISADVANTAGES:
with full stomach
- State of consciousness may cause
Agents: Bupivacaine, pontocaine & tetracaine
anxiety.​
Complications and Discomforts
- Lack of Flexibility.​
- Hypotension​
- Short time duration​
- Nausea/vomiting​
- False security.​
- Spinal headache​
- Drugs employed can caused systemic
- Respiratory paralysis
depression​

3. Nerve Block
LOCAL ANESTHESIA
- Anesthetic is injected into or around a
ADVANTAGES
nerve that innervates the operative site
- Simple, economical and non-explosive.
Field Block Anes.
- The area proximal to the incision is
- Equipment needed is minimal.​
injected and infiltrated with local - Post-operative recovery is brief.​
anesthetics, thereby forming a barrier - Undesirable effects of GA are avoided.​
between the incision and the nervous - It is ideal for short and superficial surgical
system​ procedures
Agents: Lidocaine*, bupivacaine, mepivacaine,
tetracaine* 1. Topical Anesthesia
4. Peripheral Nerve Block Anesthesia - Directly applied to the area
- short acting- peripheral nerve endings
 - Use for rectal exams, dental procedure, - hernia repair, bowel resection,
bronchoscopy mastectomy​
- Cocaine b. Trendelenburg
- 4-10% solution commonly used - Head is lower that abdomen;
- Highly Toxic displaces the intestines
- Used in the eyes, mucous membrane of - sx. of the lower abdomen or
mouth, nose, and urethra pelvis, OB GYNE procedures​
2. Local Infiltration c. Dorsal Lithotomy
- Skin and SUBQ - Both thighs ove a stirrup;
- block s peripheral nerve area of exposes perineal and rectal
incision(45mins-3hrs) areas
- Aspirate first - vaginal repairs, D&C, rectal
Complications: surgeries​
→ CV collapse, ​ d. Laminectomy
→ Convulsions​ - Prone position
→ Anaphylactic Reaction - sx. Procedures involving the
Agents: Lidocaine, Epinephrine - Causes local spine and back​
B.V. to constrict → delaying absorption of anesthetic e. Lateral
- Placed on their L or R
OTHER TYPE OF ANESTHETIC
- kidney, chest or hip surgery
1. Acupuncture
- Insertion of needles into specific
2. Prevent Client Heat Loss
acupuncture points along channels
(meridian) that run throughout the - Keep patient warm w/o causing
body​ vasodilation = bleeding
- Gate theory ​ - Maintain temp
- Stimulates larger sensory nerve - Regulate humidity - inhibits bacterial
fibers that carry non-pain impulses ​ growth
- Endorphins release theory ​ 3. Assisting with surgical wound closure
- Triggers the release of endorphins ​ - Sutures, staples, skin closure strips,
- Endogenous polypeptides with
retention sutures, zipper like devices​
analgesic properties​
- Apply sterile dressing and secure​
2. Cryothermia
- Proper suturing
- Refrigeration anesthesia​
- Low surface temperature reduces Types of Sutures
pain​ a. Cutting/traumatic
- Surgical site is treated with ice b. Round/atraumatic
before sx. c. Absorbable - e.g Catgut(chromic/plain),
3. Hypnoanesthesia vicryl, PDS
- use of hypnosis ​ d. Non-absorbable - Becomes encapsulated
- altered state of consciousness in by tissues and remains unless removed. E.g.
w/c the person experiences a silk, prolene, nylon, polyester ​
heightened state of consciousness​
- Hypnosis alleviates pain thru 4. Assessing Drainage
relaxation, suggestion and intense - A drain is placed in the incision to drain
concentration ​
blood, serum and debris from the
TECHNIQUES:​
operative site​
1. Symptom Suppression​
2. Symptom Substitution​ - May delay wound healing and promote
3. Time distortion ​ infection​
● OB and Dental Sx. ​ - Drains may be free draining, attached to
- suction, or self contained drainage with
Nursing Interventions during Intra-op Phase suction​
1. Assisting with positioning - Nurse must ensure that the drainage is
Surgical Positions free flowing thru the system​
a. Surgical Recumbent - Drains are removed when drainage is
- Flat on the table reduced to insignificant amount
 5. Maintaining Surgical Asepsis
6. Makes inventory of material used during Immediate Post-op Assessment and Intervention
operation Immediate Baseline Assessment
7. Ensure proper functioning of equipements 1. Assess airway patency and support as needed.​
8. Transporting the client to PACU/RR, the 2. Applied humidified O2 via face mask or nasal
surgical nurse endorses patient to the RR cannula.​
nurse 3. Monitor and record VS.BP, O2 saturation, Heart
rate, strength and regularity Respiratory rate and
Nursing Responsibilities depth skin color and temperature​
1. Dress the client in a clean gown​ 4. Assess client’s LOC, muscle strength and ability
2. Assist transfer to a stretcher, place side rails up.​ to follow commands.​
3. Avoid undue exposure during transfer​ 5. Observes the client’s IVF infusions, dressings,
4. Place warm blanket over patient to prevent heat drains and special equipment.​
loss, Respiratory infection and shock​ 6. Remains at the client’s bedside, continuing close
5. Avoid rough handling which may strain sutures observation of the client’s condition.​
and convey lack of concern for client’s comfort
and feelings​ Assessment for immediate Post-operative
6. Avoid hurried movements and rapid changes in Complications
position. 1. AIRWAY OBSTRUCTION​
Causes:​
III. POST OPERATIVE PHASE ● Collection of mucus and vomitus in the
Starts - patient in PACU back of the throat​
Ends - complete recovery and healed ● Aspiration​
Nursing Goal - Return the px in optimal level of 2. CARDIOVASCULAR COMPLICATIONS​
functioning ● Cardiac Dysrhythmias, HPN, hpn, ​
3. COMPLICATIONS INVOLVING RENAL
2 PHASES FUNCTION AND FLUID
1. Immediate post-anesthesia and post operative ● Electrolyte Balance, Secretion of ADH
period and aldosterone​
- First few hours after surgery, when client 4. PAIN
is recovering from effects of anesthesia ● Monitor for s/sx of pain​
very critical period for the client 5. OTHER COMPLICATIONS
2. Last post-operative period time for healing and ● Diabetic patients
preventing complications may last weeks or
months after surgery DISCHARGE FROM PACU
● Length of stay in the PACU should be
Goal of PACU/RR nurse - To assist the client in determined in a case to case basis​
returning to a safe physiologic level after an anesthetic ● Most common tool in determining discharge
by providing safe, knowledgeable, individualized nursing from the PACU​
care to clients and their families in the immediate → ALDRETE’S SCORING BY
post-anesthesia phase ANESTHESIOLOGIST​
Common Post-operative Orders Post-operative Nursing in the Surgical Unit
● NPO until fully alert, then ice chips as tolerated. → Client is returned to the clinical unit for complete
Advance diet as tolerated.​ recovery​
● Suction prn​ → PACU/ RR nurse accompanies patient to the Clinical
● Complete current IV then discontinue if pt. unit and makes a detailed endorsement of the patient
tolerating fluids.​ case to the receiving Clinical Unit nurse.​
● Compazine 5 mg prn for nausea and vomiting​
● Morphine Sulfate 10 mg IM every 3-4 hours prn​ ASSESSMENT ON THE CLINICAL UNIT​
● Accurate intake and output​ 1. Respiratory Status ​
● T,C, and DB every 2 hours​ ● assess for patent airway​
● Hemoglobin and hematocrit in a.m. ​ 2. Cardiovascular Status ​
● Catheter if patient can’t void in 8 – 10 hours​ ● Assess VS, skin color, degree of
● Reinforce dressing prn​ moistness, abnormal pulse​
 3. Neurologic Status​ POST-OPERATIVE SHOCK
● Assess LOC ​ 1. Hypovolemic Shock​- can be caused by two
4. Surgical Wound​ factors:
● Assess the dressing and any drainage ● depleting water, or (treatment: IV saline)
present​ ● depleting blood
● Measure and record area of drainage ​ product/hemorrhage(treatment: if
5. Intravenous Lines​ hemorrhage-blood product/transfusion; if
● Assess for patency, type of fluid, and not blood product causing-vasopressin,
regulation​ sometime vasopressin is not enough it is
6. Drainage Tube and other contraptions​
caused by neurologic shock)
● Attach to gravity drainage or suction​
● colloid - histidine/albumin; bigger
● Record amount of drainage​
molecules, retains in the blood vessels;
7. Position​
!!!could cause kidney damage
● Promote ventilation and prevent pain​
● crystalloid - IV fluid/PNSS; smaller
8. Pain​
molecules
● Assess for pain (degree and tolerance)​
● Initiate comfort measures​ 2. Septic Shock ​- vasogenic; infection in the
​ circulation; loosens the circulation
ESTABLISHMENT OF POST-OPERATIVE GOALS​ 3. Cardiogenic Shock ​- myocadiac infraction,
● post operative care plan dysrhythmias, arrhythmias; impaired circulation
● assessment of client needs and problems - 4. Anaphylactic Shock ​- allergic reactions,
supports the diagnosis transfusions
● appropriate nursing interventions - once 5. Transfusion Reaction ​
problems are identified ● negative blood product are precious,
negative cannot be transfused with
GOAL 1: RESTORE HOMEOSTASIS AND PREVENT negative
COMPLICATIONS - ABCs ● MACROSET TRANSFUSION FOR
● restoring normal balance, and help prevent PLATELETS - HAS CLOTTING FACTOR
complications - ABCs ● BT SET FOR TRANSFUSION FOR BLOOD
● post-op complications - lingering effect of - HAS FILTRATION
anesthesia ● NURSING RESPONSIBILITY FOR BLOOD
● arising any untoward event w/in 30 days after TRANSFUSION
surgery a. Crossmatch
● complication may result directly from the b. blood product required
surgical procedure or c. EXPIRATION DATE OF THE
● maybe a consequence of the condition being BLOOD
treated ● SHELF LIFE OF BLOOD - RBC 104DAYS;
can develop: BLOOD PRODUCT 120 DAYS
1. directly in the wound ● we don't transfuse expired blood product
2. in organs bordering the operative site or far or old blood - it will induce cardiac arrest
remove from it due to potassium levels increase upon
3. body cavities death of cells
4. as a result of the client's medical history ● pre transfusion cons: take note serum
● parameters in removing drainage from levels(potassium levels)
wound: clear output, no complains ● post transfusion medication: furosemide
● in bph - removing of cytolysis, no blood, - eliminates unnecessary potassium
no problems in urination 6. Pulmonary Embolism ​- obstructive shock, blood
● post catheter intervention - bladder circulation is depressed
exercise 7. Adrenal Failure ​- history of steroid use; exogenous
● less than 50cc/24hrs in thrice in a row - supply of steroids - causes adrenal glands to atrophy
it can be absorbed, but more than that is due to inactivity
infectious
GOAL 2: MAINTAIN AND PROMOTE ADEQUATE AIRWAY 2. Atelectasis - Closure or collapse of an alveoli in
AND RESPIRATORY FUNCTION sections of a lung; monotonous breathing
SIGNS and SYMPTOMS of Pulmonary Complications ● TESTS: X-RAYS
1. ↑ Temperature ​ ● PREVENTION: mobilization, breathing
2. Tachycardia ​ exercises
3. Restlessness ​ ● INTERVENTION: incentive spirometry,
4. Dyspnea ​ suctioning
5. Hemoptysis​- common signs of ptb, can be 3. Pneumonia - Acute infection causing
trauma or tumor; laboratory diagnosis; afb - acid inflammation of lung tissue​; increase temp,
fast bacilli - first thing in the morning sputum 3x respi, pulse; crackles and dullness caused by
6. Pulmonary edema​- emergency; difficulty in consolidation
oxygen exchange CAUSES OF POST-OP RESPIRATORY ACIDOSIS -
7. Altered breath sounds​ inadequate exchange of oxygen, retained carbon dioxide
8. Thick viscous sputum​ 1. Narcotics
9. Chest pain - pleurisy 2. Post-op pain, and bulky uncomfortable dressings​
3. Abdominal distention ​
CAUSES of PULMONARY COMPLICATIONS 4. Surgery with high incision​
1. Pre-existing respiratory problems, not resolved 5. Post-op Respiratory complications​
during pre-op period.​
2. Respiratory infection ff. surgery​ GOAL 3: MAINTAIN ADEQUATE CARDIAC FUNCTION
3. Use of anesthetics, ET, Oxygen​ AND PROMOTE TISSUE PERFUSION
4. Aspiration of vomitus​ MOST COMMON POST-OP CARDIAC PROBLEMS
5. Prolonged immobility of client on the OR table 1. Thrombophlebitis - Thrombus of the peripheral
during sx.​ veins (calf veins) develops in the pressure
6. History of Smoking​ wall/venous stasis; 7-14days
7. Respiratory disease prior to sx.​ SIGNS: homan signs; redness, swelling,
8. Depressive effects of many narcotics on the tenderness
cough reflex​ PREVENTIONS: ambulation, mobility/leg
9. Collapse of the lung during sx. Or inadequate exercise, anit-embolic stocking, hydration, low
reexpansion of the lung tissue following surgery​ dose - molecular wt; heparin for high risk
10. Severe post-op pain​ patients(IV/SM)
11. Surgery with high abdominal or chest incision ​ 2. Myocardial Infarction/Cardiac Arrest - Occurs
12. Extreme debilitation and old age​ during the 1st 72 after surgery; history of cardiac
13. Prolonged post-op immobility ​ problems, dysrhythmias
PREVENTION: Cardiac monitor in post-op
3. Blood loss/Hemorrhage
SIGNS: decrease urine output, lab results
decreased cbc
RESPIRATORY COMPLICATION INTERVENTION: plasma expander, transfusion
1. pulmonary embolism - Obstruction of the GOAL 4:
pulmonary artery or its branches by a thrombus NORMAL FLUID AND ELECTROLYTE ADJUSTMENT 1ST
that originates somewhere in the body or R side 3-4 DAYS post SURGERY
of the heart​ 1. Renal retention of H2O and Na​
● Blood, air, fart, amniotic fluid 2. Expansion of ECF in excess of Na and Cl​
● risk factors: venous stasis - prolonged 3. A transient ↓ in ECF Na and Cl​
immobility 4. ↑ in K excretion​
● TESTS: pulmonary angiography, 5. ↓ in Hct - dilution
ventilation perfusion scanning, chest
x-ray NORMAL FLUID AND ELECTROLYTE ADJUSTMENT 5th -
● TREATMENT: thrombolytic agent, 7th DAYS post SURGERY​
admin/anticipate or prepare of 100% O2 1. Diuresis​- increased urine output
2. Return of ECF volume to normal​
 3. Serum Na level returns to normal​ 3. Clients can self-administer small amounts of
4. Reduction of K concentration in urine - returning analgesia, sparing them the difficult cycles of
to blood cells escalating pain and heavy sedation.​
​
CAUSES OF POST-OP DEHYDRATION AND FACTS ABOUT PCA:​
ELECTROLYTE DEFICITS:​ → PCA pump is provided with safety measures to prevent
1. Failure to replace deficits existing before surgery​ overdosing​
2. Inadequate replacement of post-operative losses​ 1. After administration, there is a pre set time during
3. Excessive postoperative losses which the machine will not deliver more
4. Diaphoresis,​ medication​; also gives placebo effect
5. Hyperventilation​ 2. POST-OP CLIENTS DO NOT OVERMEDICATE
6. Wound drainage/ GIT drainage THEMSELVES​
7. Diarrhea
8. Diuresis​ Clients using PCA:​
9. Vomiting​ 1. Use less medication​
2. Are able to ambulate earlier​
CAUSES OF POST-OP FLUID OVERLOAD:​ 3. Recover pulmonary function sooner , as a result
1. Administration of excessive amounts of IVF​ of increased activity levels​
2. Over replacement of post-operative losses
3. Inadequate renal function with low urine output​ PCA SETTINGS
1. PCA Programmed Settings:​
GOAL 5: PROMOTE COMFORT AND REST 2 .Flow rate (dosage)​
- reduce the intensity of pain; promote mobility and fast 3. Flow type (continuous or intermittent)​
recovery 4. Number of milligrams per dose​

FACTORS R/T HIGH INCIDENCE AND INTENSITY OF Device records:​

POST-OP PAIN:​ 1. Number of injection attempts​
1. Type of anesthesia used​ 2. Number of injections actually given​
2. High levels of anxiety​ 3. A low battery​
3. Lengthy and extensive surgical procedures​ 4. Error in the system set-up​
4. Poor state of mental health​ 5. Little or no remaining infusion​
6. An unauthorized entry into the system​
NURSING ASSESSMENT FOR PAIN PRIOR TO 7. Occlusion or excessive pressure in the line​
ADMINISTRATION OF ANALGESICS:​
1. HPN OR hpn​ NURSING RESPONSIBILITY:​
2. Pressure points beneath a cast, splint or dressing​ 1. Assess IV catheter patency​
3. Distended bladder​- cause increased blood 2. Administer narcotics routinely during the 1st 24
pressure; encourage px to urinate hours​
4. Abdominal distention and flatulence​ 3. Employ other methods of pain management to
complement PCA​
PATIENT CONTROLLED ANALGESIA(PCA)
→ Use of a PCA system device which allows client to self
administer post-op analgesia​ GOAL 6: PROMOTE ADEQUATE NUTRITION AND
ELIMINATION
ADVANTAGES OF PCA:​ → Normal Diet​
1. Clients, who are expert on their own pain, can promotes early return of GIT function, aids in wound
monitor and meet their own analgesia need.​ healing and psychologically healthy for patient.​
rescue dose; novae - respiratory assessment
beforehand PARAMETERS FOR RESUMING DIET​
2. PCA allows a constant blood levels of analgesics​ 1. (+) bowel sounds​
2. Abdomen is soft and palpable​
3. Diet not contraindicated after surgery​
 ● Abdominal Sx.​ 1. Location of incision​- skin fold are susceptible to
● NGT​ infection
● Nutritional support with 2. Type of surgical closure ​- clean, dirty, etc.
hyperalimentation​ 3. Nutritional Status​- TPAG=total protein and a/g
ratio
DIETARY REGIMEN POST SURGERY​ 4. Presence of Disease​- diabetes, liver prob,
1. Clear Liquids​ pathologic disease
● Water, broth, tea with lemon and sugar​ 5. Presence of infection​- SSI
2. General Liquids​ 6. Presence of drains and dressings​
● Broth, fruit juices, soup​
3. Soft Diet​ TYPES OF HEALING​
● Soup, noodles, jello, toast, cornstarch 1. PRIMARY​
puddings, vegetables, fruits​ ● Occurs in most sx. Incision​
4. Full Diet​ ● Scar tissue laid down across a clean
● Diet as tolerated ​ wound; edges in close apposition​
● Incision is clean straight line with all
NURSING CONSIDERATIONS:​​ layers of the wound well approximated
1. Record immediate abdominal movement​ ○ ​macrophages, neutrophils -
2. Record any bowel movement post-op​ cleans the wounds
● Bowel function impaired by:​ ○ 7 days removal of sutures, 12
● Immobility​ days total healing
● Anesthesia​ 2. SECONDARY​
● Manipulation of abdominal organs​ ● Occurs when the edges of the wound
● Use of pain medications​ cannot be well approximated​, wound is
3. Ensure proper intake of nutritional requirements enlarged
post-op​ ○ tissue granulation - forms the
4. Address post-op GIT discomfort and render base and fills missing tissues
appropriate interventions.​ ○ keloid formation - abnormality in
5. Prevent complications​ the collagen synthesis
3. TERTIARY​“DELAYED PRIMARY CLOSURE”​
POST-OP GIT DISCOMFORTS​ ● Delayed apposition of edges after
1. Nausea and Vomiting​ infection subsides and wound
2. Thirst​ granulates​
3. Constipation and Abdominal cramps​ ● inflammatory process that delays the
4. Abdominal Distention​ closure

POST-OPERATIVE COMPLICATIONS​ PHASES OF WOUND HEALING​

1. HICCUPS/ SINGULTUS​ 1. VASCULAR RESPONSE PHASE​
- Produced by involuntary contraction of ● HEMOSTASIS - starts immediately after
the diaphragm and rapid closure of the injury, clotting cascade
glottis​ 2. INFLAMMATORY PHASE​
2. STRESS ULCER​ ● 3-6 days; vasodilation, sequential migration of
- Result of physiologic stress in patients wbc in wound site
undergoing surgery ​ ● increase neutrophils, macrophages, eosinophils,
3. PARALYTIC ILEUS ​ basophils, lymphocytes, chemmediators, kemins,
- A post-op complication that occur when cytokinins
a portion of the bowel stops normal 3. PROLIFERATIVE PHASE/ FIBROPLASIA​
peristalsis ​ ● 4 - 21days after surgery
● fibroblasts are predominant; collagen
GOAL 7: PROMOTE WOUND HEALING synthesis(vit c)
FACTORS AFFECTING WOUND HEALING:​ ● angiogenesis - creation of new
capillaries; wound contraction
 4. REMODELING/ MATURATION PHASE​ 5. Pseudomonas Aeruginosa ​
● 1year
● equilibrium with collagen and COMMON WOUND HEALING COMPLICATIONS​
degradation 1. Wound Dehiscence​
2. Evisceration​- usual in abdominal operations
CLASSIFICATION OF OPERATIVE WOUNDS​
1. CLASS I – CLEAN​ PREVENTION:​
● Elective, primarily closed, and undrained​ 1. Splinting wound during vigorous coughing or
● non traumatic injuries, uninfected, no movement​
inflammations, did not open and major cavities or 2. Preventing wound infection​
organs, aseptic 3. Adequate nutrition and hydration​
2. CLASS II – CLEAN CONTAMINATED​ 4. Use of binder or abdominal supports​
● Resp. G.I. and G.U. tracts entered under ● MGT:​
controlled conditions and w/o unusual ● ‘E’ closure of wound​
contamination
● non-ruptured appendicitis; no leakage NURSING RESPONSIBILITY
3. CLASS III – CONTAMINATED​ 1. Remain calm​
● Open fresh traumatic wound​ 2. Place patient in bed in semi-fowler’s position
● immediately brought to the hospital with knees slightly bent.​
4. CLASS IV – DIRTY AND INFECTED​ 3. Call for help, remain with patient.​
● Traumatic wound w/ retained dead tissue, foreign 4. Inform doctor ASAP.
bodies.​ ● OR, anesthesiologist
● delayed ambulation, perforated colon, presence 5. Cover any protruding coils of intestine with
of infection(pus, foul odor) sterile dressings moistened with sterile saline
solution​
NURSING ASSESSMENT TO PROMOTE WOUND ● clean towel wet with nss or salt-water
HEALING​ solution, if gauze not available - to
1. Assess wound for signs of infection.​(pus, foul maintain viability of organ
odor, redness, inflammation, bleeding) 6. Moisten towels and dressings with sterile saline
2. Observe the wound for edema, bleeding and frequently.​
color.​ 7. Monitor VS closely.​
3. Observe the wound for approximation of the 8. Provide emotional reassurance.​
suture line.​ 9. Inform OR personnel and surgeon.​
4. Monitor drains and assess the color, consistency, 10. Set up Intravenous equipment and prepare
and amount of discharge​ patient for surgery.​
● open-line incase for administration for
PREDISPOSING FACTORS FOR WOUND INFECTION​ emergency medications
1. Obesity​
2. Advanced age​ COMPLICATION OF WOUND HEALING
3. Debilitation​ 1. Hemorrhage​
4. Lengthy and complicated operations ​ 2. Infection​
5. Therapy with steroids, anticancer medications, 3. Dehiscence​
irradiation ​ 4. Evisceration​
6. Presence of other disease​ 5. Fistula​- abnormal connection of tissues, blood
7. Failure to maintain asepsis​ vessels or organs; usually occurs in the anus
8. Preoperative organ rupture/ Sepsis​
GOAL 8:
CAUSATIVE AGENTS:​ PREVENTION OF COMPLICATIONS R/T IMMOBILITY​
1. Staphylococcus Aureus ​ 1. Encourage client to move around in bed.​
2. Escherichia Coli​ 2. Encourage client to cough and deep breathily.​
3. Proteus vulgaris​ 3. Flex ankles and legs.​
4. Aerobacter aerogens​ 4. Encourage early ambulation.​
 5. Allow client to assume personal care as soon as
possible to promote early movement.​

Goal 9: PROVIDE ADEQUATE EMOTIONAL SUPPORT

AND FOSTER POSITIVE BODY IMAGE​
→ NURSING CONSIDERATIONS:​
1. Provide psychological support​
2. Draw client and significant others into
discussions of anticipated changes post-op.​
3. Encourage verbalization of feelings.​
4. Provide empathetic listening.​
5. Provide reassurance that the grieving process is
normal and will pass in no time.​
6. Arrange support groups and community referrals
for the client and significant others.​

Goal 10: PLAN FOR DISCHARGE​

1. Wound care - one stroke, apply pressure on the
sutures esp after bathing
2. Activity restrictions​
3. Dietary instructions​
4. Post-operative medications instructions​
5. Personal hygiene​
6. Follow-up appointment​- important to evaluate
the patients progression