GODE HEALTH

SCIENCE COLLEGE

SOMALI REGIONAL STATE

BUREAU OF TECHNICAL AND VOCATIONAL
EDUCATION AND TRAINING
GODE, SOMALI, ETHIOPIA

COMPREHENSIVE NURSING LEVEL IV

LEARNING GUIDE 5
Unit of Competence: Provide Care in the Pre / Post and
Intra Operative Nursing

Module Title: Providing Care in the Pre / Post and Intra

Operative Nursing

LG Code: HLT CON4 MO2 LO5

TTLM Code: HLT CON4 TTLM 0812v1

LO5: Evaluate the effectiveness of nursing interventions

and planned care in pre/ post and intra operative
environment
 Instruction Sheet Learning Guide 5
This learning guide is developed to provide you the necessary information
regarding the
following content coverage and topics;
 Preoperative nursing care
 Intra operative nursing care
 Postoperative nursing care
This guide will also assist you to attain the learning outcome stated in the
cover page.
Specifically, upon completion of this Learning Guide, you will be able to
 identify the different procedures that will involve in preoperative phase
 enumerate and apply the steps of different procedures under intra operative
phase based on the international standard
 perform the preoperative, intra operative and postoperative nursing care
 observe and put into practice the Occupational Health and Safety (OHS) and
Kaizen.
Learning Activities
1. Read the specific objectives of this Learning Guide.
2. Read the information written in the “Information Sheets 5”
3. Accomplish the “Self-check”
4. Submit your accomplished Self-check. This will form part of your training
portfolio.
5. Read Operation Sheets and try to understand the procedures discussed.
Practice and master each operation.
6. Do the “Lap test” (if you are ready) and show your output to your teacher.
Your teacher will evaluate your output either satisfactory or unsatisfactory.
 INFORMATION SHEET #5 Perform clinical nursing actions that are appropriate to
the care of pre/post and intra operative clients

Surgical Team
Sterile
 Surgeon
 Scrub Nurse
Non sterile
 Anesthesiologist
 Circulating Nurse
 OR techs
Division of duties
Surgeon-responsible for determining the preoperative diagnosis, the choice and execution of the surgical
procedure, the
explanation of the risks and benefits, obtaining inform consent and the postoperative management of the
patient’s care
Scrub nurses duties
The nurse who is the immediate assistant to the surgeon is often called the “scrub” or “sterile” nurse. She
first scrubs her
hands and arms the required length of time, puts on sterile gown & gloves, and handles only sterile
material.”
-Scrub nurse- (RN or Scrub tech)- preparation of supplies and equipment on the sterile field;
 maintenance of pt.s safety and integrity:
 observation of the scrubbed team for breaks in the sterile fields;
 provision of appropriate sterile instrumentation, sutures, and supplies; sharps count.
-Usually confined to the intraoperative phase of the patient’s surgical experience, may also be involved in
gathering surgical
supplies & equipment
Duties of Anesthesiologist and anesthetist
 anesthetizing the pt.
 providing appropriate levels of pain relief,
 monitoring the pt’s physiologic status and providing the best operative conditions for the
surgeons.
Other personnel- pathologist, radiologist, perfusionist, EVS personnel
Circulatory nurse duties
 responsible for creating a safe environment,
 managing the activities outside the sterile field,
 providing nursing care to the patient.
 Documenting intraoperative nursing care and ensuring surgical specimens are identified and
place in the
right media.
4
 In charge of the instrument and sharps count and communicating relevant information to
individual
outside of the OR, such as family members.

. OR nurse
OR nurses
– Holding area nurse
– Circulating nurse
– Scrub nurse (& surgical tech)
– Specialty nurses
Responsibilities of Operating Room Nurse:
 Patient Assessment
 Physical Problems
 Emotional Aspects
 Understanding of surgery/consent
 Legal requirements for chart completion
 Read and interpret lab results
 Peri Operative Teaching
Preliminary preparation
 All personal belongings are identified and secured.
 Jewelry is usually removed.
 Dentures are removed, labeled and placed in a denture cup.
 Pt. to verbally confirm the surgical procedures and the surgical site. This verification
process is documented in the medical record on the preop. checklist.

Intra operative Phase

Intra Operative - begins with entry into the operating room and ends
with admission to the recovery room
Assessment
Assessment during the perioperative period includes identifying and reviewing the
patient’s record for completeness, thus ensuring the patient’s identify. The
emotional and physical status of the client must also be assessed. Emotional status
includes dealing with the patient’s fears and the concerns of a frightened or
agitated client. A relaxed patient undergoes anesthetic induction easier compared
to a tense one. Aside for emotional assessment, it is also important to assess the
health-illness level of the patient, level of consciousness, anxiety level, verbal
communication, and coping. It is important that a baseline data for vital signs is
obtained and the pre-surgical examination results are reviewed. Information in the
preoperative checklist needs to the rechecked and verified. This is important to
confirm that all the items on the checklist have been done or prepared.
Analysis
The client may encounter several problems during the course of the intraoperative
period. No problem is ever too small to be addressed. These potential problems
include but may not be limited to the following:

A. Hypothermia related to decreased metabolic rate and exposure to cold environment

B. Impaired skin integrity related to mechanical trauma to the tissues secondary to surgical
incision
C. Impaired gas exchange related to depressed respiratory function secondary
to anesthetic effect
D. Fear related to the threat of loss of a body part or death
E. Anxiety related to lack of information on the surgical procedure
F. Fluid volume deficit related to massive blood loss secondary to surgical procedure
During the analysis stage, the nurse must also anticipate the possible complications that may
arise after the surgery which includes the following:
A. nausea and vomiting
B. anaphylaxis
C. hypoxia
D. unintentional hypothermia
E. malignant hyperthermia
F. disseminate intravascular coagulation
G. infection
Plan/ Implementation
Every surgical procedure is manned by a surgical team. However, the members of
the surgical team vary depending on the type of surgical procedure to be
performed.
The surgical team is a group of highly trained and educated individuals who must
work together as a coordinated team for the safety of the client undergoing
operative and other invasive procedures.
The surgical team is composed of the Surgeon, Anesthesiologist, circulating nurse,
scrub nurse, and the Registered-nurse first assistant.
The surgeon is performs the surgical procedure and heads the surgical team.
He/She is a licensed physician, osteopath, oral surgeon, or a podiatrist, who is
specially trained and qualified. The surgeon makes the major decisions concerning
the course of surgery, such as whether to remove an organ, amputate a limb, or
make radical or extensive repairs. It is expected that the surgeon be alert at all
times to reports from the anesthesia provider concerning the changing physiologic
needs of the client undergoing the stress of surgery.
The anesthesiologist or the nurse-anesthetist is the member of the surgical team who
is responsible for alleviating the pain and promoting relaxation with medications. It is
the anesthesiologist’s/nurse-anesthetist’s duty to maintain the client’s airway;
ensuring that the client has an adequate gas exchange. It is also his/her duty to
infuse blood, fluids, and medications to maintain hemodynamic stability. Aside from
that, he/she should monitor the circulation and respiration of the surgical patients.
The anesthesiologist or nurse-anesthetist should alert the surgeon immediately on any
complications the patient is developing.
The person responsible for ensuring that all equipment is working properly before the
procedure is the circulating nurse. This member of the surgical team is unsterile. It is
also his/her duty to ensure the sterility of the instruments for surgery, assist in the
positioning of the client, perform a skin preparation on the client, alert the members
of the surgical team to any break in the sterile techniques, assist the anesthesiologist
in monitoring the patient’s vital signs and functions (like urine output and blood loss),
send tissue specimens to the laboratory, coordinate activities with other
departments such as X-ray and pathology, document the care provided, and
ensure that staff traffic and conversation are kept to a minimum. The circulating
nurse holds the responsibility of promoting smooth and safe function in the operating
suite by bringing needed supplies and medications to the operating table. It is also
expected that the circulating nurse assist in the sponge, sharps, and instruments
count. Removing unneeded items or specimens from the sterile field is part of the
circulating nurse’s duty.
The scrub nurse is a sterile member of the surgical team. He/ She perform the
surgical hand scrub prior to the procedure. It is his/her duty to set up the sterile
tables and prepare the sutures, ligatures, and special equipment.
It is expected of him/her to assist the surgeon and the surgical assistants during the
procedure by anticipating the instruments that will be required. After the incision is
closed, the scrub person and circulating nurse count all needles, sponges, and
instruments to be sure they are accounted for and not retained as a foreign body in
the patient. The scrub nurse also is responsible for labeling the tissue specimens
obtained during surgery.
The Registered-Nurse First Assistant is the person responsible for handling tissue,
providing exposure at the operative field, suturing, and providing homeostasis. This
member of the surgical team requires a thorough understanding of the anatomy
and physiology, tissue handling, and the principles of surgical asepsis. He/She needs
to be aware of the objectives of the surgery and needs to have the knowledge and
ability to anticipate needs. Aside from that, he/ she needs to be able to handle any
emergency situation in the O.R.
 Pillow or headrest
 Arm boards
 Safety belt/strap
 Footboard
 Padding
 Gel pads
 Egg crate
 Donut rolls
 Foam
 Padded Shoulder braces
 Stirrups (candy canes, Allen, or knee)
 Laminectomy Frame
  Olympic vac pac (suction beanbag)
 3” adhesive tape
Common Surgical Positions
Positioning during surgery is important to expose the operative site and gives access
for anesthesia administration. Different kinds of surgeries require different kinds of
positions.
1. The dorsal recumbent position (supine) is used for many abdominal surgeries (like in
colostomy and hernioraphy) as well as for some thoracic surgeries (like open heart
surgery), and some surgeries on the extremities. One disadvantage of this position is the
excessive pressure on the posterior bony prominences (back of head, scapulae, sacrum,
and heels). It is important that these areas are padded with soft materials.
2. The semi-sitting position is commonly used on surgeries on the thyroid and neck areas.
This type of position may lead to postural hypotension and venous pooling in the legs. It
may promote skin breakdown on the buttocks. Sciatic nerve injury is possible. A soft
padding must be used to prevent nerve compression.
3. The prone-position is commonly used for spinal fusion and removal of hemorrhoids.
This position causes pressure on the face, knees, thighs, anterior ankles, and toes. Bony
prominences must be padded and the feet must be supported under the ankles. To
promote optimum respiratory function, raise the client’s chest and abdomen and support
with padding. Corneal abrasions may occur if the eyes are not closed or are insufficiently
padded.
4. The Lateral chest position is used for some thoracic surgery as well as hip replacements.
This kind of position may cause excessive pressure on the body prominences on the side
on which the client is positioned. Ensure adequate padding and support, especially on the
downside arm. The weight of the upper leg may cause perineal nerve injury on the
downside leg. Both legs must therefore be padded.
5. The lithotomy position is used in gynecologic, perineal, or rectal surgeries. This position
causes an 18% decrease (from standing point) in vital capacity of the lungs. It is thus
important to monitor the respiration and assess for hypoxia and dyspnea. The lithotomy
position can lead to joint damage, perineal nerve damage, and damage to peripheral blood
vessels. To avoid injury, ensure adequate padding and manipulate both legs into the
stirrups simultaneously.
6. The jackknife position is used for proctologic surgeries, such as removal of hemorrhoids
and for some spinal surgeries. This position causes 12% decrease (from standing point) in
vital capacity of the lungs. Monitor respiration and assess for hypoxia and dyspnea. In
this position, the greatest pressure is felt at the bends of the knees, as well as at the
ankles. Padding of the chest and knees helps prevent skin breakdown.
Anesthesia
Anesthesia literally means “without feeling.” It is an artificially induced state of partial or total
loss of sensation, with or without loss of consciousness. Sedation and anesthesia, upon induction,
have four levels. These levels are the following: minimal sedation, moderate sedation, deep
sedation, and anesthesia. When administer, anesthesia produces muscle relaxation, blocks
transmission of nerve impulses, and suppresses reflexes. For the patient, the anesthetic
experience consists of having an intravenous line inserted, receiving a sedating agent prior to
induction with an anesthetic agent, losing consciousness, being intubated, and receiving a
combination of anesthetic agents.
Variables: Essential in Administering Anesthetic Agent for surgical use
The anesthetic agents chosen for a surgical procedure depend on many variables
including:
A. age and physical condition of the client
B. type, location, and duration of the surgery
C. degree of technical intricacy of the surgery
D. previous anesthetic history
E. personal preference, expertise, and judgment of the anesthesiologist

Levels of Sedation
1. In minimal sedation, the patient can respond normally to verbal commands. In this level,
the cognitive function and coordination may be impaired, but ventilatory and
cardiovascular functions are not affected.
2. Moderate sedation is the level wherein there is depressed level of consciousness that
does not impair the patient’s ability to maintain a patent airway and respond
appropriately to physical stimulations and verbal commands. The goal of moderate
sedation is a calm, tranquil, amnesic patient who, when sedation is combined with
analgesic agents, is relatively pain-free during the procedure but able to maintain
protective reflexes.
3. In deep sedation, the patient cannot be easily aroused but can respond purposefully after
repeated stimulation. Anesthesia is the state of narcosis (severe CNS depression produced
by pharmacologic agents), analgesia, relaxation, and reflex loss. Patients under General
Anesthesia are not arousable, even to painful stimuli. They lose the ability to maintain
ventilatory function and require assistance in maintaining a patent airway. Cardiovascular
functions may be impaired as well.
Stages of General Anesthesia
1. Beginning Anesthesia
As the patient breathes in he anesthetic mixture, warmth, dizziness, and feeling of detachment
may be experienced. The patient may have a ringing, roaring, or buzzing in the ears, and though
still conscious may sense an inability to move the extremities easily. During this stage, noises are
exaggerated; even low voices or minor sounds seem loud and unreal. For this reason, the nurse
avoids unnecessary noises or motions when anesthesia begins.
2. Excitement
In this stage, the client may demonstrate struggling, shouting, talking, singing, and laughing.
This is often avoided if the anesthetic is administered smoothly and quickly. The pupils dilate,
but contract if exposed to light. The pulse rate is rapid and respirations may be irregular.
3. Surgical Anesthesia
This stage is reached by continued administration of the anesthetic vapor or gas. The patient is
unconscious and lies quietly on the table. The pupils are small but contract when exposed to
light. Respirations are regular, the pulse rate and volume are normal, and the skin is pink or
slightly flushed.
With proper administration of anesthetic, this stage maybe maintained for hours in one of several
planes, ranging from light to deep, depending on the depth of anesthesia needed.
4. Medullary Depression
This occurs when too much anesthesia has been administered. Respiration becomes shallow, the
pulse is weak and thready, and the pupils become widely dilated and no longer contract when
exposed to light. Cyanosis follows and without prompt intervention, death rapidly follows. If this
stage develops, the anesthetic is discontinued immediately and respiratory and circulatory
support is initiated to prevent death.
Major Classifications of Anesthesia
Anesthesia may be classified as general or regional.
1. General Anesthesia
General anesthesia blocks pain stimulus at the cerebral cortex. This is a druginduced depression
of the Central Nervous System that is reversed either by metabolic elimination in the body or by
pharmacologic means. General Anesthesia agents produce analgesia, amnesia, and
unconsciousness, characterized by loss of reflexes and muscle tone.
The goal of general anesthesia is the total loss of consciousness and sensation.
It aims to produce amnesia by blocking awareness centers in the brain. This is most commonly
given intravenously, by inhalation, rectally, or orally,
2. Regional Anesthesia
Regional anesthesia blocks pains stimulus at its origin, along efferent neurons,
along the spinal cord. Unlike general anesthesia, regional anesthesia produces a
loss of painful sensation in only one region of the body and does not result
unconsciousness. The client may receive sedative agents that produce drowsiness.
The goal of regional anesthesia is to reduce all painful sensations in one region of the
body without inducing unconsciousness. Those that block transmission of nerve
impulses at their origin are administered topically and through local infiltration. Those
that block transmission along the afferent neurons are given as field block, nerve
block, or IV regional. Spinal and epidural blocks prevent transmission of nerve
impulses along spinal cord.
Types of General Anesthesia
1. Intravenous anesthesia
It is rapid and usually sets in 30 seconds after initial administration. This is the
most commonly used type of general anesthesia. Examples of these are Thiopental
Sodium and Ketamine. There is no antagonist for Ketamine but it metabolizes
quickly. It is important to alert the PACU as to the use of this drug due to its
hallugenic properties.
2. Inhalation anesthesia
Itis a mixture of volatile liquids/ gas and oxygen. This is given through mask or
endotracheal tube. One advantage of this type of anesthesia is because of itease
of administration and elimination through the respiration system. Example of this is
Halothane and Isoflurane (volatile liquid) and nitrous oxide (gas anesthetic).
Rectal anesthesia
It is given via the rectal tube. This is useful in children or when facial surgery
makes it difficult to maintain airway. IV or liquid inhalation agents are instilled to the
rectum. The drug is absorbed in the rectal mucosa and delivered to the CNS via the
circulatory system. An example of this is Methohexital Sodium.
Types of Regional Anesthesia
1. Topical anesthesia
It is directly applied to the area to be desensitized. This comes in the form of
solution, ointment, gel, cream, and powder. Topical anesthesia blocks peripheral
nerve endings in the mucous membrane of the vagina, rectum, nasopharynx, and
mouth. An example of this is cocaine, lidocaine, procaine, tetracaine,
mepevacaine, and bupivacaine.
Local infiltration involves the injection of an anesthetic agent, such as lidocaine, into
the skin and tissue of the area to be incised.
Local anesthesia blocks only the peripheral nerves around the area of the incision.
Field block is done by injecting or infiltrating the area proximal to the site of
incision with local anesthetics thereby, forming a barrier between the incision and
the nervous system. A field block actually walls in the area around the incision and
thereby prevents transmission of sensory impulses to the brain from that area.
In peripheral nerve blocks, the individual nerves or nerve plexuses are
anesthetized rather than all the local nerves. Nerves most commonly blocked are
those in the same brachial plexus and the same intercostals, sciatic, and femoral
nerves.
2. Spinal anesthesia
It is achieved by injecting certain local anesthetics into the subarachnoid space.
Automatic nerve fibers are the first to be affected by spinal anesthesia and the last
to recover. Following automatic blockage, spinal anesthesia locks the following
fibers in this order: touch, pain, motor, pressure, and proprioceptive fibers. Recovery
is in reverse order. This is commonly used for procedures performed below the level
of the diaphragm. The benefits of using spinal anesthesia are the following:
-relatively safe
-provides excellent muscle relaxation
-does not cloud the client’s consciousness or alertness
-can be used for client’s with a full stomach because they will be awake to
maintain their airways if they vomit
After the anesthesia has worn off, the patient should be asked to wiggle their toes.
3. Epidural anesthesia
It is achieved by introducing an anesthetic agent into the epidural space by
a needle at the thoracic, lumbar, sacral, or caudal interspaces. The needle is
carefully positioned in the epidural space, without penetrating the dura and
entering the subarachnoid space. When the needle is properly positioned, the
cerebrospinal fluid cannot be aspirated. This type of anesthesia produces
autonomic blockage. Hypotension and respiratory depression/ paralysis may occur
if the level of the block is too high and affects respiratory muscles.
4. Caudal anesthesia
It is produced by injecting the local anesthetic into the caudal or sacral canal.
This is a variation of epidural anesthesia commonly used in Obstetrics clients.
5. Intravenous Regional (Extremity) Block Anesthesia
It is the production of anesthesia in a limb and can be achieved through an
agent such as lidocaine, which is injected into a vein of the limb to be operated. A
pneumatic dual cuff tourniquet is applied to the anesthesia area to prevent the
lidocaine from circulating beyond the area undergoing the procedure.
Intraoperative Nursing Care
Intraoperative nurses see the client immediately before surgery, either in the
holding area or in an admission unit. An initial, brief assessment is completed by the
intraoperative nurse. Intraoperative nursing care plans incorporates safety,
monitoring of the client, and control of operative resources along with
considerations of the individual needs of each client.
1. Maintaining safety and Preventing Injury
Safety is a major consideration in the perioperative nursing. Using data
gathered from the perioperative assessment, the nurse implements care individually
designed for each client. This care includes positiong, controlling equipment and
supplies, maintaining surgical asepsis, monitoring the physiologic status, and
monitoring for potential emergencies.
2. Positioning the Client
The perioperative nurse understands the various operative positions as well as
the physiologic changes that occur when a patient is placed in a specific position.
The position must not hinder respiration or circulation, must no apply excessive
pressure to OR table, there are general guidelines to promote safety. Most clients
feel stiff and sore after a long surgical procedure and may actually complain of the
effects of positioning.
3. Providing Equipment Safety
Almost everything in the OR can be a source of injury if careful control is not
exercised. Every action is designated to prevent accidents. These procedures
include counting surgical supplies and equipment that could inadvertently be left
inside the surgical incision, such as needles, sponges, and instruments. Counts are
performed by two people, usually the circulating nurse and the scrub person, at
three different times: before the initial incision, during the surgery, and before the
incision is closed. A final correct count is announced to the surgeon and charted on
the intraoperative chart.
Electrical safety is also controlled during surgery. All plugs nd wires are
inspected for correct attachment; all equipment is checked to ensure that it is in
working order; and measures are taken to prevent electrical burns to the client.
4. Maintaining Surgical Asepsis
The perioperative nurse ensures the sterility of supplies and equipment. All
members of the health care team use sterile technique. If a suspected or actual
break in the sterile field occurs, the contaminated instruments and clothing are
removed and replaced with new, sterile items. Members of the surgical team who
are in the sterile area are those actively performing or assisting in the surgical
procedure.
The nurse is the advocate of the client in maintaining a sterile surgical
environment.
5. Assisting with Wound Closure
After final counts are completed, the nurse anticipates the type of wound
closure needed and obtains the supplies for the surgical team. The surgical wound
may be closed with sutures, staples, or other materials or maybe left open to heal by
secondary intention.
6. Monitoring Body Temperature
Hypothermia can occur easily in the OR. The OR is maintained at a standard
cool level of 60° to 75° Fahrenheit. Humidity is regulated at 50% to 60%.
Temperature control is set to allow optimal performance of the surgical team
members, who must wear layers of clothing, and to inhibit bacterial growth. The
client can become cold in the OR if appropriate is not provided. Heat is lost from
the skin and from the area open for surgery. When tissues that are not covered with
skin are exposed to the air, heat loss is greater than normal. The client should be
kept as warm as possible to minimize heat loss without causing vasodilation, which
may cause more bleeding.
7. Monitoring for Emergencies
The perioperative nurse must be alert for potential emergencies. When these
occur, knowledge, instant decision-making, & critical thinking are essential, as is
speed in performing needed skills. Although almost any imaginable emergency can
occur during an operation, the most common are malignant hyperthermia, cardiac
or respiratory arrest, uncontrollable hemorrhage, and drug or allergic reactions.
Malignant hyperthermia is a genetic disorder characterized by uncontrolled
skeletal muscle contraction leading to potentially fatal hyperthermia. It occurs in
predisposed clients when they receive a combination of succinyl choline and
inhalation agents. Unless the triggering event is stopped and the body is cooled,
death is the result. Datrolene is a medication that can be used to treat malignant
hyperthermia. It is also used to decrease muscle rigidity.
Cardiac and Respiratory Arrest rarely occur in the OR. But if ever they occur,
the same emergency procedures should be carried out as elsewhere.
Allergic reactions should not occur if an adequate history is taken. However,
some clients do not recall an allergy; in other cases, the allergy is identified only with
the occurrence of a second allergic reaction to the triggering agent during surgery.
8. Documentation of the Intraoperative Care
The intraoperative nurse documents every event and action in the OR.
Information concerning any drains, tubes, or other devices remaining in the client on
completion of the surgical procedure, as well as the type of closure and dressing
used, is given to the post-operative nurse upon transfer.
9. Moving and Transporting the Client
On the completion of the operation, a member of the surgical team wipes off
any excess blood, skin preparation, and debris from the client’s skin and outs a clean
gown and blanket on the client. There should always be enough personnel for
moving or transferring a patient to prevent injuries. Avoid rapid movements when
changing the client’s position because it can predispose the development of
hypotension. In particular, move the client gradually from whatever surgical
procedure was used onto the transportation cart. During emergence from
anesthesia, the client is prone to nausea, confusion, and hypotension. Care must be
taken not to catch, kink, or dislodge the IV or catheter tubing, drains, or other
equipment during the transfer. After being placed on the stretcher, the client is
covered with warm blanket and secured with a safety belt. Make sure that the side
rails are up to ensure the client’s safety in case the client becomes agitated during
transport from the OR.

Post-Operative Phase
A. Immediate Care in Post-Anesthesia Care Unit (PACU)
Immediate Post Anesthesia Care begins when the client has been transferred from
the operating room to the PACU. The PACU is usually located adjacent to the
operating rooms. The basic design consists of a large open room divided into
individual patient care spaces. The Registered nurses in the PACU have an in-depth
knowledge of anesthetic agents and patient responses to these agents, pain
management techniques, surgical procedures, and potential complications. The
circulating nurse informs the PACU of the patient’s estimated time of arrival in the
unit and also of any special care needs or equipment required. A report is given

when the patient is admitted to the unit, The PACU Nurse’s responsibilities include
the following:
1. Maintaining pulmonary ventilation
Ensure that the airway is patent. All clients receive oxygen, usually at the rate of 60
% / 6L, although clients with COPD will receive no more than 20% / 2L. In the
immediate post-operative period, the head of a minimally responsive client may be
turned to the side and the head extended forward to prevent respiratory
obstruction. The client who is unable to clear mucus or vomits from the throat
requires suctioning immediately. Some clients are intubated and ventilated. They
require close monitoring and suctioning as needed.
Manifestations of pulmonary complications include:
 increase temperature
 restlessness
 dyspnea
 tachycardia
 hemoptysis
 pulmonary edema
 altered breath sounds
 thick viscous sputum (with chest pain, if the client has pneumonia),
Pulmonary problem typically develop in the first 18 hours after surgery.
2. Maintenance of circulation
Common cardiovascular complications include arrhythmias, hypertension and
hypotension resulting in shock. When assessing a client for post-op cardiovascular
complications remember that a slight increase in a client’s heart rate after surgery
may be normal. However, a significant increase or decrease from baseline or the
development of new dysrhythmias requires observation.
When a client appears to be going into shock, the PACU nurse:
 Applies oxygen or increase the rate of delivery
 Raises the client’s legs above the level of the heart.
 Increases the rate of IV fluids unless contraindicated.
 Notifies the anesthesia provided and surgeon.
 Administers medication or additional fluid volume as ordered and
 Continues assessment on a one-to-one basis

3. Promotion of Comfort

Being comfortable and free from pain enables a client to progress more quickly and
more easily through the post-op period.
Factors related to high incidence and intensity of post-operative pain include the
type of anesthesia used, high levels of anxiety, extensive and prolonged surgical
procedures, and poor state of mental health.
Nursing measures that help alleviate pain include the following:
i. Comfort measures, such as changing the client’s position, straightening bed linen,
giving a back rub and lotion, and applying a cool cloth to the hands and face.
ii. Administration of narcotics, such as morphine, meperidine, and codeine; narcotics
are used primarily during the first 24 to 72 hours after surgery.
4. Protection from Injury
Place great emphasis on patient’s safety until the patient is fully awake, or has
complete return of sensation after regional blocks. The unconscious patient must be
protected from falling and injury as a result of improper positioning. Side rails should
be maintained in the upright position. The patient call light should be within close
reach and interventions to prevent falls should be implemented.
Post-operative care
1. Assessment
The PACU nurse should regularly assess for the following:
1. V/S and Color and temperature of skin
This is important to determine the response to the surgical procedure and to detect
significant changes.
2. Level of consciousness
The client may require repeated orientation to time, place, and person if the client
is disoriented.
3. Comfort
Assess client’s pain, emotional support; because the client is in a vulnerable and
dependent position.
4. Time of arrival
After major surgery, the nurse generally assess the client every 15 minutes during the
first hour and if the client is stable, after 30 minutes for the next 2 hours, and then
every hour during the subsequent hours. Assessment is then carried out every 4
hours, if ordered by the doctor.
18
2. Analysis
The following are possible Nursing Diagnoses for the Post-operative client:
1. Acute pain related to mechanical trauma to the skin secondary to surgical procedure,
intraoperative positioning
2. Risk for activity intolerance related to bed rests, increased metabolic demands of surgery
3. Risk for infection related to break in the integrity of the skin secondary to surgical
procedures , iatrogenic factors, intrinsic factors
4. Risk for Imbalanced Fluid Volume
5. Delayed surgical recovery
6. Ineffective airway clearance related to increased secretions secondary to anesthesia,
ineffective cough, airway obstruction, pain, improper positioning.
7. Ineffective breathing pattern related to anesthetic and drug effect, incisional pain,
recumbent position, constrictive dressing.
3. Plan/Implementation
3.1. Preventing Post-op complication
a. Respiratory
Most common respiratory complications are atelectasis, pneumonia and
pulmonary embolus. The majority of post-op respiratory complications are the
result of anesthesia and poor post-op pain control.
It is important to assess for signs and symptoms of these complications:
Atelectasis: Dyspnea, fever, chills, productive cough, and pleuritic chest pain
Pulmonary embolism: tachypnea, anxiety, tachycardia, dyspnea, pleuritic
chest pain, cyanosis, and hypoxia.
b. Cardiovascular
The most common cardiovascular complication is Venous thrombosis which is the
formation of clots in the veins of the pelvis and lower extremities impair circulation.
Ambulation and mobility promote return of venous blood to the heart and
prevention of venous stasis.
c. Gastrointestinal
Hiccoughs are produced by involuntary contraction of the diaphragm and rapid
closure of the glottis. These usually resolve in a few hours
Nausea and Vomiting is common after general anesthesia. This occurs in 25% to
30% of surgical patients
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Abdominal Distention results in accumulation of non-absorbable gas in the
intestines caused by manipulating the bowel during surgery. This usually persists
until normal bowel tone and peristalsis resumes.
d. Urinary
The patient will usually experience inability to void (urinary retention)over a 6 to 8
hours period post-operatively. This usually resolves within 48 hours.
e. Wound
Wound infection is one of the most common causes of wound complication. As
nurses, it is part of our primary duty to prevent the occurrence of such.
Preventing wound infection:
i. Excessive body cavity exposure and decreased body defense mechanisms
are among the contributing factors to post-operative would infection.
ii. Understanding the principles of standard precautions wound healing, and
wound care is imperative when caring for the surgical patient.
Wound Dehiscence and Evisceration are among the most common wound
complications. Wound dehiscence is the partial to complete separation of
surgical incision. Meanwhile, evisceration is the protrusion of an internal organ
through the incision and onto the skin
3.2 Post-op Discomforts
Acute Postoperative Pain is always expected after surgery. It is neither realistic nor
practical to eliminate post-operative pain completely. Nevertheless, the client
should receive substantial relief from control of this discomfort.
Controlling post-operative pain not only promotes comfort but also facilitates
coughing, turning, deep breathing exercises, earlier ambulation, and decreased
length of hospitalization, resulting in fewer post-op complications and therefore
reducing health care cost.

Self Check 5 Written Test

Name: _____________________________ ________Date: _____________

Time started: _______________________ Time finished: _______________

Instructions: Multiple Choice: Encircle the letter of your answer.

1. In postoperative care, the nurse should regularly conduct assessment for the following
except:
A. V/S, Color and temperature of skin
B. Level of consciousness
C. Time of arrival
D. effect of anesthesia
2. All should be done by the nurse when a client appears to be going into shock, except:
A. Maintain the rate of oxygen to flow for 2-3 liters per minute
B. Increases the rate of IV fluids unless contraindicated.
C. Notifies the anesthesia provided and surgeon.
D. Administers medication or additional fluid volume as ordered
3. Manifestations of pulmonary complications include:
A. decrease temperature, bradycardia and pale
B. pulmonary edema, altered breath sounds and elevated temperature
C. diarrhea, whooping cough and skin warm to touch
D. apnea, fever and restlessness
4. It is known as the most common cardiovascular complication and it is with the formation of
clots in the veins of the pelvis and lower extremities that impaired circulation.
A. Embolism
B. Malfunction of clotting factor
C. Venous thrombosis
D. Pneumothorax
5. PACU means:
A. Post Anesthesia Care Unit
B. Pre Anesthesia Care Unit
C. Post Advance Cardiac Unit
D. Pre Advance Cardiac Unit

Note: Satisfactory rating above - 3 points Unsatisfactory below- 3 points

You can ask you teacher for the copy of the correct answers.

Operation Sheet ARTERIAL BLOOD PRESSURE

I. PURPOSE: To measure force of blood against arterial walls for comparison with
accepted normal values while causing no trauma to the patient.
II. CONDITION/SITUATIONS
Patient is scheduled for operation. The nurse should take the vital signs
specifically blood pressure.
III. EQUIPMENT AND MATERIALS
Tray with:
 Sphygmomanometer (blood pressure apparatus)
 Stethoscope
 Jar of alcoholized cotton
 Waste receptacle
IV. PROCEDURE:
1. Explain the procedure to the client.
2. Gather all equipment.
3. Wash hands.
4. Position the patient comfortably.
5. Expose the area of the brachial artery by removing garments or move a sleeve, if it
is too tight, above the area where the cuff will be placed.
6. Wrap the cuff around the patient’s arm with the lower edge about 1-2 inches above the
inner aspect of the elbow.
7. Perform preliminary palpatory determination of systolic pressure.
7.1 palpate the brachial artery with the middle 3 finger tips on the medial aspect of the
anticubital fossa.
7.2 close the valve on the pump by turning the knob clockwise.
7.3 inflate the cuff (while continuing to palpate the artery) until you can no longer feel
the brachial pulse.
7.4 deflate the cuff and wait 15 seconds.
8. With the ear attachment in place (stethoscope).
9. Place the diaphragm of the stethoscope over the patient’s brachial pulse again.
10. Pump up the cuff until the sphygmomanometer registers about 30 mmHg above the patient
where the Brachial pulse disappears.
11. Release the valve on the cuff carefully so that the pressure decreases at the rate of 2-3 mmHg
per second.
12. Note the point on the gauge at which there is an appearance of the first faint, but clear sound,
which slowly increase in intensity.
13. Continue to release air in the cuff evenly and note for the diastolic pressure.
14. Deflate the cuff to zero. If there is doubt about any of the pressures, wait 30 – 60
seconds, then repeat the measure.
15. Remove the stethoscope from your ears and the cuff from the patient’s arm.
16. Record appropriate findings.
V. PRECAUTIONS
Be careful in using mercuric sphygmomanometer.
VI. QUALITY CRITERIA
1. Use appropriate equipment in taking blood pressure.
2. Place patient in ideal postion.
Operation Sheet CLEANING A WOUND AND APPLYING A STERILE
 DRESSING

I. PURPOSE: To provide oxygen delivery via nasal cannula, nasal catheter, face
mask
II. CONDITION/SITUATIONS:
Patient is now in his room 24 hours after surgery. The nurse should adminiter
oxygen as per doctor’s order.
III. EQUIPMENT AND MATERIALS:
 cotton balls soaked with hydrogen peroxide
 cotton balls soaked with betadine
 dry cotton balls
 sterile gauze or (OS) 4 x4
 plaster
 dressing set
 sterile gloves
 waste receptacle
IV. PROCEDURE:
1. Review the physician’s order for wound care of the nursing plan of care related
to wound care.
2. Gather the necessary materials.
3. Identify the patient. Explain the procedure to the patient. Inquire about any
known allergies, specifically related to the products being used for wound care.
4. Perform hand washing.
5. Close door or curtain. Place the bed at an appropriate and comfortable working
height.
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6. Place a waste receptacle or bag at a convenient location for use during the
procedure.
7. Assist patient to comfortable position that provides easy access to wound care
area. Use a bath blanket to cover any exposed area other than the wound. If
necessary, place a waterproof pad under the wound site.
8. Check the positions of drains, tubes or other adjuncts before removing the
dressing. Put on the clean disposable gloves and loosen tape on the dressings.
If necessary, use an adhesive remover to help get the tape off.
9. Carefully remove the soiled dressings. If any part of the dressing sticks to the
underlying skin, use small amounts of sterile saline to help loosen and remove.
Do not reach over the wound.
10. After removing the dressing, note the presence, amount, type, color, and odor
of any drainage on the dressings. Place soiled dressing in the appropriate
waste receptacle. Remove your gloves and dispose of in appropriate waste
receptacle.
11. Inspect the wound site for appearance and drainage. Assess if any pain is
present. Check the sutures, steri-strips, staples, and drains or tubes. Note any
problems to include in your documentation.
12. Using sterile technique, prepare a sterile work area and open the needed
supplies.
13. Open the sterile cleaning solution. Depending on the amount of cleaning
needed, the solution might be poured directly over gauze sponges for small
cleaning jobs or in a basin for more complex or lager cleaning.
14. Put on sterile gloves.
15. Clean the wound. If needed, use sterile forceps to clean the area. Clean the
wound from top to bottom and from center to outside. Following this pattern,
use gauze for each wipe, placing the used gauze in the waste receptacle. Do
not touch any surface with the gloves or forceps.
16. If a drain is in use, clean around the drain using a circular motion. Wipe from
the center toward the outside. Use the gauze a single time and then dispose
of it.
17. Once the wound is cleansed, dry the area using a gauze sponge in the same
manner. Apply ointment or any other treatments if ordered.
18. Apply the layer of dry sterile over the wound. Forceps may be used to apply
the dressing.
19. Place a second layer of gauze over the wound site.
20. Apply a surgi-pad dressing over the gauze at the site as the outermost layer of
the dressing.
21. Remove and discard sterile gloves. It is often easier to apply the items used to
secure the dressing in place when working without gloves. Apply tape to
secure the dressings.
22. After securing the dressing label dressing with date and time, remove all
remaining equipment, place the patient in a position of comfort with side rails
up and bed in the lowest position, and perform hand hygiene.
23. Record the procedure, wound assessment, and the patient’s reaction to the
procedure according to institution’s guidelines.
24. Check all wound dressings every shift. More frequent checks may be needed
if the wound is more complex or dressings become saturated quickly.
V. PRECAUTIONS:
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Observe sterile technique in performing wound dressing.
VI. QUALITY CRITERIA:
1. Perform proper steps in wound dressing.
JOB SHEET Perioperative Nursing Care
Preoperative Patient Care:
1. Identify patients for whom surgery is a greater risk:
a. Very young or elderly patients
b. Obese or malnourished patients
c. Patients with fluid and electrolyte imbalances
d. Patients in poor general health from chronic diseases and infectious processes
e. Patient taking certain medication (ie, anticoagulants, antibiotics, diuretics,
depressants, steroids)
f. Patients who are extremely anxious
2. Review nursing data base, history and physical examination. Check that baseline
data are recorded; report those that are abnormal.
3. Check that diagnostic testing has been completed and results are available;
identify and report abnormal results.
4. Promote optimal nutritional and hydration status.
5. Identify learning needs of patient and family.
6. Conduct preoperative teaching regarding coughing and deep- breathing exercises
with splinting if necessary.
7. Conduct preoperative teaching regarding respiratory therapy regimens, such as
incentive spirometry.
8. Conduct preoperative teaching regarding pain management after surgery.
9. Conduct preoperative teaching regarding leg exercises.
10. Provide preoperative teaching regarding early ambulation and turning in bed.
11. Provide preoperative teaching regarding postoperative equipment and monitoring
devices.
12. Provide preoperative teaching regarding home care requirements.
13. Document findings and instructions given
Day Before Surgery
14. Provide emotional support. Answer questions realistically. Provide with spiritual
guidance if requested. Include family when possible.
15. Follow preoperative fluid and food restrictions.
16. Prepare for elimination needs during and after surgery.
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17. Attend to patient’s special hygiene needs (eg, use of antiseptic cleaning agents to
prepare surgical site).
18. Provide for adequate rest.
Day of Surgery
19. Check that proper identification band is on patient.
20. Check that preoperative consent forms are signed, witnessed, and correct; that
advanced directives are in the medical record (as applicable); and that the medical
record is in order.
21. Check the vital signs. Notify physician of any pertinent changes (eg, rise or drop
in blood pressure, elevated temperature, cough, symptoms of infection).
22. Provide hygiene and oral care. Remind patient of food and fluid restrictions and
time when oral intake is restricted for surgery.
23. Continue nutritional and hydration preparation.
24. Remove cosmetics, jewelry, nail polish, and prostheses (eg, contact lenses, false
eyelashes, dentures). Assess for loose teeth.
25. Place valuables in appropriate area. Hospital safe is not appropriate place for
valuables. They should not be placed in narcotics drawer.
26. Have patient empty bladder and bowel before surgery.
27. Attend to any special preoperative orders.
28. Complete preoperative checklist and record patient’s preoperative preparation.
29. Administer preoperative medication as prescribed by physician/anesthesia
provider.
30. Raise the side rails of the bed; place the bed in the lowest position. Instruct the
patient to remain in bed or on the stretcher. If necessary, a safety restraint may
be used.
31. Help move the patient from the bed to the transport stretcher if necessary.
Reconfirm patient identification and ensure that all preoperative events and
measures are documented.
32. After the patient leaves for the operating room, prepare the room and bed for
postoperative care. Anticipate any necessary equipment based on the type of
surgery and the patient’s history.
Intraoperative Patient Care:
1. Providing for patients safety and well-being
2. Maintaining an aseptic environment.
3. Perform surgical handwashing.
4. Wear sterile gown.
5. Don surgical gloves.
6. Ensuring proper function of equipment
7. Providing the surgeon with specific instruments and supplies for the surgical field
8. Completing appropriate documentation
9. Providing emotional support like providing information and realistic reassurance
10. Assisting in positioning the patient on the OR table
11. Acting as scrub nurse, circulating nurse, and RN first assistant
Postoperative Patient Care:
26
1. Upon return from PACU, obtain report from PACU nurse and review the operating
room and PACU data. Check patient’s identification. Perform hand hygiene.
Place patient in safe position (semi-or high Fowler’s or side lying). Note level of
consciousness.
2. Monitor and record vital signs frequently. Assessment order may vary, but usual
frequency includes taking vital signs every 15 minutes the first hour, every 30
mins. The next 2 hours, every hour for 4 hours, and finally, every 4 hours.
3. Provide for warmth, using blankets as necessary. Assess skin color and
condition.
4. Check dressings for color, and amount of drainage. Feel under patient for
bleeding.
5. Verify that all tubes and drains are patient and equipment is operative. Note
amount of drainage in collection device.
6. Maintain intravenous infusion at correct rate.
7. Provide for a safe environment. Keep bed in low position with side rails up. Have
call bell within patient’s reach.
8. Relieve pain by administering medications ordered by physician. Check record to
verify if analgesic medication was administered in PACU.
9. Record assessments and interventions on chart.
Ongoing Care
10. Promote optimal respiratory function.
a. Encourage coughing and deep breathing.
b. Perform incentive spirometry.
c. Encourage early ambulation.
d. Assist when frequent position change.
e. Administer oxygen as ordered.
11. Maintain adequate circulation.
a. Assist with frequent position changes.
b. Encourage early ambulation.
c. Apply antiembolic stockings or pneumatic compression devices if ordered by
physicians.
d. Assist with leg and range-of-motion exercises if not contraindicated.
12. Assess urinary elimination status.
a. Promote voiding by offering bedpan at regular intervals.
b. Monitor catheter drainage if present.
c. Measure intake and output
13. Promote optimal nutrition status and return of gastrointestinal function.
a. Assess for return of peristalsis.
b. Assist with diet progression.
c. Encourage fluid intake.
d. Monitor intake.
e. Medicate for nausea and vomiting as ordered by physician.
14. Promote wound healing by using surgical asepsis. Assess condition of wound and
any drainage.
15. Provide for rest and comfort.
16. Provide emotional support and spiritual support.
17. Document findings and intervention used.
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References:
Smith, P. E., LeBon, M.Taylor’s Clinical Nursing Skills: A Nursing Process Approach.
Lippincott Williams & Wilkins.
Procedural Manual, University of Cebu.