OUR LADY OF GUADALUPE COLLEGES

COLLEGE OF NURSING
NCM 123: Course Enhancement
PERIOPERATIVE NURSING

PERIOPERATIVE NURSING SURGERY ACCORDING TO URGENCY

● Care rendered to surgical patients before, during, Classification Indication Examples
and after surgery. EMERGENT w/o delay Severe bleeding
● CLIENTS FOR SURGERY: anyone (womb to tomb) Stat, Bladder or
● INDICATIONS: OPET life-threatening. Intestinal
○ Obstruction (Informed consent Obstruction
○ Perforation (rupture) not needed) Fractured skull
○ Erosion (wounds/cuts) Gunshot or stab
○ Tumor wounds
Extensive burns
URGENT Within Closed fractures
NOTE! Pt requires prompt 24-30 hrs Infected wound
Do not discard any specimen in the operating room. attention. exploration/irrig
(Consent) ation
SURGERY vs SURGICAL PROCEDURE REQUIRED Within a Prostatic
SURGERY SURGICAL PROCEDURE Pt need to have few weeks hyperplasia
the surgery. or months Thyroid
It is a branch of Includes incisions and disorders
medicine that deals with sutures Cataracts
the removal or repair of ELECTIVE Failure to Repair of scars
organs through surgical Pt should have the have Simple hernia
procedures. surgery surgery not Vaginal repair
catastrophic
OPTIONAL Personal Cosmetic
SURGICAL CLASSIFICATIONS Decision rests with preference surgery
SURGERY ACCORDING TO PURPOSE the pt
Type Purpose
DIAGNOSTIC ● To diagnose PHASES OF PERIOPERATIVE NURSING
● To determine the extent of ● From the decision to
organ involvement proceed with surgical
● The surgeon can remove/repair PREOPERATIVE intervention to the transfer
EXPLORATORY any organ based on the of the patient onto the
damage inflicted on it even operating room (OR) bed.
without the patient’s ● From transfer to the OR
consent. INTRAOPERATIVE bed to admission to the
CURATIVE ● To cure PACU.
Ablative ● Removal of organ to cure the ● From admission to the
disease PACU to follow-up
Reconstructive ● Repair of a previously POSTOPERATIVE
evaluation in the clinical
damaged organ setting or home.
Constructive ● Repair of congenital anomalies
(ex. Cleft lip repair)
MINIMALLY INVASIVE SURGERY (MIS)
● To relieve pain and signs and ● Procedures that use specialized instruments
PALLIATIVE
symptoms inserted into the body either through natural
orifices or through small incisions.
SURGERY ACCORDING TO DEGREE OF RISK ● ADVANTAGE: Shorter recovery time.
Type Purpose
● Greater risk and can be fatal PRE ADMISSION TESTING (PAT)
● Involves vital organs ● Incentives to reduce hospital stay costs have
MAJOR ● Great blood loss can occur resulted in diagnostic pre-admission testing
● Prolonged duration (PAT) and preoperative preparation prior to
● Pt is under general anesthesia admission.
● Lesser risk ● During the PAT visit, patients learn what to
● Lesser blood loss expect on the day of surgery and receive
MINOR ● Does not involve vital organs answers to questions they may have.
● Shorter duration
● Pt is under local anesthesia
AMBULATORY SURGERY
● OUTPATIENT, SAME-DAY or SHORT-STAY NOTE!
surgery The preoperative phase is the best time to
● Laparoscopic and minimally invasive surgery conduct teachings because the patient is not yet
● Admission to an inpatient hospital setting for less suffering from pain.
than 24 hours
● Requires Preadmission Testing (PAT)
PSYCHOLOGICAL PREPARATION
● Admitted in preoperative holding area of the
Operating Room and stays in the Post-Anesthesia
Care Unit (PACU) prior to discharge. CAUSES OF FEAR
1. Fear of pain
Nursing Responsibilities 2. Fear of death
1. Nurses must quickly and comprehensively assess 3. Fear of anesthesia, vulnerability while
and anticipate the needs of the patient at the unconscious.
same time. 4. Fear of disturbance of body image.
2. Begin planning for discharge and follow-up home 5. Worry of loss of finances, employment, social,
care. and family roles.
3. Make sure that the patient and family understand
that the patient will first go to the preoperative MANIFESTATIONS OF FEAR:
area before going to the OR and then spend 1. Anxiousness
some time in the PACU before discharge. 2. Confusion
3. Anger
4. Tendency to exaggerate
PREOPERATIVE NURSING
5. Dazed
● BEFORE SURGERY
6. Short attention span
● Begins at the time of decision for surgery and
7. Inability to concentrate
ends when the client is transferred to the OR
● Used to prepare the patient PHYSICALLY and
PSYCHOLOGICALLY for the surgery. NOTE!
● MAJOR ROLE OF THE NURSE: client teaching and The most devastating fear of surgical clients is the
relieving the client’s and the family’s anxieties. FEAR OF THE UNKNOWN – not having the
knowledge of what will happen to them
NOTE!
Nursing Role
Psychological preparation is more important to
● Educate the patient on what to expect about
prioritize. Because a patient who is fearful and
the surgery.
anxious about the surgical procedure usually has
● Do not make the patient’s fear worse.
abnormal vital signs.

The patient cannot be allowed to undergo surgery if Nursing Interventions: Fear

the vital signs are erratic. Ensure that the patient is ● BE A THERAPEUTIC COMMUNICATOR
emotionally and mentally stable before the surgery
1. MOST IMPORTANT: The best way to relieve fear
and anxiety is to allow the patient to verbalize
Major Role of the Nurse in the Preoperative Phase:
their fears
● Client teaching in relaxing the client and family’s
a. Utilize open-ended questions (what are
anxiety.
your fears? What are your concerns? Would
you like to tell me more about it? Would you
GOALS OF CARE:
like to express your anxiety? What makes
1. Assessing and correcting physiologic and
you anxious?)
psychologic problems that might increase surgical
risks (complications)
b. AVOID FALSE REASSURANCE (Do not
a. Thorough head-to-toe assessment and all
worry, everything is going to be okay, your
body systems are reviewed.
doctor is the best, nothing bad will happen to
you) because this prevents addressing the
Ex. If the patient is dehydrated, it should be corrected
patient’s fear. No one knows what will
first through IV therapy. The patient cannot be
happen to the patient no matter how minor
dehydrated before surgery because blood during the
the procedure, there is still the possibility
operation can cause hypovolemic shock and severe
of complications.
fluid loss.
2. Assess client’s fears, anxieties, support systems
2. Giving the person and significant others complete
and patterns of coping
learning/ teaching guidelines regarding surgery
3. Provide emotional support
3. Instructing and demonstrating exercises that will
4. Establish a trusting relationship
benefit the person during post-op period
5. Provide spiritual care if applicable
4. Planning for discharge and any projected changes
6. Explain routine procedures and allow the client
in lifestyle due to surgery
to ask questions
 LEGAL ASPECTS OF SURGERY
NOTE!
The consent is not valid if the patient does not
NOTE! understand the procedure even if they have
ALL invasive procedures require informed consent. already signed it
Such consent will protect the patient’s RIGHT FOR
AUTONOMY and respect their RIGHT TO REFUSE If the patient did not understand the explanation,
ask the physician to repeat the explanation. The
nurse is not allowed to tell the patient that they
INFORMED CONSENT are wrong. (“Let me clarify it to your physician, I’ll
● The document signed by the patient that they call your surgeon if you want to discuss this matter”)
agree to undergo such a procedure.
● Serves as the protection for the patient and
surgical team. 5. It must be signed before the patient receives
sedation
SURGICAL CONSENT a. For instance, if the patient has already been
● Operative permit sedated first without signing the consent, you
● A document describing that the client has FULL must still ask the patient to sign but this time
KNOWLEDGE of the instructions of the EXACT after the patient wakes up. You still have to
SURGICAL PROCEDURE to be performed and wait for the effects of the anesthesia to wear
HAS GIVEN PERMISSION to have the procedure off.
on them. 6. Must be signed at least a day before the surgery
● SURGEON: responsible for explaining everything
about the procedure (alternatives, complications,
etc) NOTE!
If the patient is blind, deaf, or does not have a
common language with the nurse there should be
NOTE! an interpreter, brail etc…
What if there is really a need to remove another
body part aside from what the patient has If the patient really wasn’t able to sign, just put an
known from the consent? There will be a need for “x” mark and then state the reason why (for
another consent and this time from the relatives. documentation in the patient’s chart). In doing this,
ensure that you have a witness.

TAHBSO - Total Abdominal Hysterectomy Bilateral

Salpingo-Oophorectomy (removal of the uterus, NOTE!
fallopian tube, and ovaries) Consent is not needed for emergencies if all the
criteria are met:
TAHUSO - Total Abdominal Hysterectomy 1. There is an immediate threat to life.
Unilateral Salpingo-Oophorectomy (removal of the 2. A legally authorized person cannot be reached
uterus, fallopian tube, and ovaries) (relatives are not around)
● REJECT, because the site must be 3. Experts agree that it is an emergency (the
specified (left or right) surgical team will be protected with the
principle of BENEFICENCE (do good))

VALID SURGICAL CONSENT

1. Consent should be be FREELY GIVEN without PREOPERATIVE PREPARATIONS
COERCION (not forced, threatened, sedated) ASSESSMENT
2. Patient must be MENTALLY COMPETENT(capable 1. ALLERGIES: Drugs, Food, and Latex
of judgment, stable mental condition) and of LEGAL a. Aside from allergies to medication, assess for
AGE (18yrs of age) allergies in iodine (iodine-rich food: seafood).
a. If minor or mentally incompetent, parents, If there are any, inform the OR nurse so that
legal guardian, spouse, or relative next of they will not use iodine-based antiseptic (skin
kin should be the ones to sign. prep). Assess also for latex allergy, so that
3. EMANCIPATED MINORS (minors who are married) the surgical team will use latex-free gloves.
can sign their own consent. 2. DENTITION
4. It should be witnessed by the nurse or another a. Prevents risk for aspiration
doctor. b. Check for loose tooth
a. Ensure that the patients understand the 3. DRUG OR ALCOHOL ABUSE
procedure before signing the consent. (Then a. Ask the patient if they are drinking alcoholic
attach to chart, before surgery) substances (patient may manifest withdrawal
b. Encourage the patient to ask questions symptoms or DELIRIUM TREMENS 48hrs after
regarding the surgery their last intake of alcohol.
b. Ask the patient if they are taking
medications other than the prescribed ones.
Explain to them that such medication can affect
the surgery
4. NUTRITIONAL AND FLUID STATUS
a. Undernourished - lack of protein, poor NOTE!
healing, poor immune response. STEROIDS - Don’t stop abruptly!
b. Overnourished (Obese) - difficult to move in ● Stopping abruptly causes the adrenal gland to
the OR, difficult to position (respiratory stop producing steroids and can cause
problems can occur), prone to wound Hypotension
DEHISCENCE (bumubuka yung tahi) and
EVISCERATION (protrusion of organs) ANTICOAGULANT
5. RESPIRATORY STATUS ● Anticoagulants can cause bleeding. It should
a. Ask the patient if they smoke. (If yes, they be stopped completely 2 days before surgery.
need to stop 4-8 weeks before the surgery or if
immediate 24hrs before the surgery.
All diagnostic examinations should be completed
6. HEPATIC AND RENAL FUNCTION
before surgery which include:
a. Check for liver disease. (Liver disease can
a. Chest X-ray
cause toxicity to anesthesia and affect clotting
b. ECG
factors).
c. Complete Blood Count (CBC)
7. ENDOCRINE FUNCTION
d. Coagulation studies
a. Stress causes Hyperglycemia
e. Urinalysis
b. Hypoglycemia occurs when Pt receives
anesthesia
PRE OP TEACHINGS
8. IMMUNE FUNCTION
a. Risk for infection 1. Assess the client’s level of understanding of surgical
procedure and its implications.
2. Answer questions, clarify and reinforce explanations
PREVIOUS MEDICATION USE
given by the surgeon
Effects of Interactions with
Agents 3. Explain routine pre and post-procedures and any
Anesthesia / Surgery
special equipment to be used
Corticosteroids Cardiovascular collapse may 4. Demonstrate exercises that prevents
Prednisone occur if discontinued suddenly postoperative complications
(Deltasone) a. Deep breathing / Diaphragmatic breathing
Diuretics Respiratory depression may b. Coughing
Hydrochlorothiazide occur with anesthesia use c. Incentive Spirometry
(HydroDIURIL) d. Leg Exercises
Phenothiazines Increases hypotensive effects e. Turning to Side
Chlorpromazine of anesthesia
(Thorazine)
Anxiety, tension and seizures PREOP TEACHINGS EXERCISES
Tranquilizers 1. Deep Breathing/ Diaphragmatic Breathing
may occur when withdrawn
Diazepam(Valium) ● To promote lung expansion.
suddenly
Intravenous insulin may be ● Repeat 3-5x.
Insulin needed to regulate blood 2. Incentive Spirometry
glucose level during surgery ● Alternative for deep breathing.
Antibiotics Risk for respiratory paralysis ● A device that will expand your lungs by
Erythromycin when combined with muscle helping you breathe more deeply and fully.
(Ery-Tab) relaxant 3. Coughing
Anticoagulants Increases the risk of bleeding ● To expectorate secretions and prevent
Warfarin during the intraoperative and pneumonia.
(Coumadin) postoperative period ● Surgeries Contraindicated for Coughing
○ EYE SURGERY - Coughing can
Intravenous administration is
increase intraocular pressure.
Antiseizure Agents needed to prevent seizure
○ BRAIN SURGERY - Coughing can
during surgery
cause increased intracranial
Thyroid Hormone Intravenous administration
pressure.
Levothyroxine may be needed during the
○ SPINE SURGERY - Coughing causes
sodium postoperative period to
intraspinal pressure.
(Levothroid) maintain thyroid levels
Chronic use may alter 4. Leg Exercise
Opioids
response to analgesic ● Promote venous return and prevent venous
stasis.
5. Turning to side
● Prevent stasis of secretions in the lungs.

6. Getting out of bed

● Get out of bed slowly. First sit up, dangle
your legs, and sit on the side of the bed,
then stand up slowly. (Prevent orthostatic
hypotension)
 COMMON PREOP MEDICATIONS
PHYSICAL PREPARATION SEDATIVE AND ● Secobarbital
THE DAY BEFORE THE SURGERY TRANQUILIZERS ● Diazepam (Valium)
1. NOTHING PER OREM (NPO) ● Morphine
● To prevent aspiration. NARCOTIC
● Meperidine HCl
● NPO for 6-8 hrs only, not more than 8 hrs. ANALGESICS
(Demerol)
(Prone to dehydration) ● Atropine sulfate
● Oral medications and smoking are included. ANTICHOLINERGICS
● Scopolamine
HISTAMINE-RECEPTOR ● Cimetidine (Tagamet)
2. BOWEL PREPARATION ANTAGONISTS
● Cleansing enema or laxatives.
● Prevent contamination and pooling of fecal SAFETY PROTOCOLS
material in the abdomen which causes ● Joint Commission on Accreditation of
distention. Healthcare Organizations (JCAHO)
● NEOMYCIN SULFATE – Antibiotic that ● 2003 Universal Protocol for Preventing Wrong
decreases normal flora in the GI Site, Wrong Procedure, Wrong Person Surgery
● 2009 National Patient Safety Goals
3. SKIN PREPARATION
Universal Protocol for Preventing Wrong Site,
THE DAY OF THE SURGERY Wrong Procedure, Wrong Person Surgery
● Hospital gown is worn that is left untied and open ● Preoperative verification process
in the back ● Marking the operative site in an unambiguous
● Braid long hair and remove hair pins manner
● Provide oral care ● “Time Out”
● Inspect the mouth and remove dentures or plates
● Remove eyeglasses and prosthetic devices 2009 National Patient Safety Goals
● If able, allow the patient to take a bath and ● Improve the accuracy of patient identification
hygiene care. ● Improve effectiveness of communication among
● Remove pins or hair pins. (Prevent head caregivers
puncture) ● Improve safety of using medications
● Oral Care (Prevent contamination) ● Reduce the risk of health care-associated
● Remove makeup, nail polish and jewelry. infections
(Makeup masks true skin color, and nail bed is ● Accurately and completely reconcile medications
used to detect cyanosis caused by low oxygen across continuum of care
levels) ● Reduce the risk of patient harm resulting from
● Obtain baseline vital signs falls
● Complete pre op checklist. ● Reduce the risk of influenza and pneumococcal
● Administer pre op medications as ordered disease in institutionalized older adults
● Reduce the risk of surgical fires
PREANESTHETIC MEDICATION ● Implement applicable National Patient Safety
● PREOP MEDICATION Goals and associated requirements by
● Usually given 30 to 45 minutes before the patient components and practitioner sites
is transported to the OR or “On call to OR” ● Encourage patient’s active involvement in their
● Given in the holding area of the OR for own care as a patient safety strategy
ambulatory surgery ● Prevent health care-associated pressure ulcers
Identify safety risks inherent in the organization’s
PURPOSES OF PREOP MEDICATIONS patient population
● To allay fear and anxiety ● Improve recognition and response to changes in a
● To produce some amnesia patient’s condition
● To reduce reflex irritability
● To raise the pain threshold Patient Transport to the Operating Room
● To lower the body metabolism ● The patient is transferred to the holding area or
● To decrease respiratory and mouth secretions presurgical suite in a bed or a stretcher about 30
to 60 minutes before the anesthetic is given
Nursing Responsibilities: Before Administration of ● The stretcher should be comfortable with a small
Preop Medication pillow and sufficient blankets
● Check for drug allergy ● Ensure safety during transport
● Ensure the surgical consent has been signed
● Instruct the patient to void
● Obtain the baseline vital signs

After the Administration of Preop Medication

● Instruct the patient to stay in bed
● Raise the side rails up to ensure safety
 ● PRIORITY: Respiratory and cardiovascular function
INTRAOPERATIVE NURSING may be impaired.
● Begins from admission to OR and ends in admission
to the PACU STAGES OF GENERAL ANESTHESIA
● HIGHEST PRIORITY: Upon entry to the OR, ● START: Induction or anesthesia
verification of the client’s identity using two-patient administration
identifiers must be done. ● END: Loss of consciousness
● The circulating nurse should check the surgical ● Characterized by: patient feeling
consent and ensure the correct surgical procedure dizzy, drowsy, and feeling of
for the patient. STAGE 1: detachment
● UTMOST CONCERN: Patient’s safety, when the ONSET ● Noises are exaggerated that
patient is in the intraoperative phase. INDUCTION even low voices or minor sounds
seem loud and unreal
SURGICAL SAFETY CHECKLIST (JCI)
● Done before anesthesia NURSING RESPONSIBILITY
● Provide a quiet environment for
Tasks: Verification of smooth induction.
1. Patient’s Identity ● START: Loss of consciousness
2. Surgical Site and Consent ● END: Loss of certain reflexes.
SIGN IN ● Characterized by struggling,
3. Surgical Risks (allergy, airway, and
blood loss) shouting, talking or crying.
4. Anesthesia ● The patient can move and talk.
5. Equipments ● Involuntary manifestations
6. Medications include rapid pulse, irregular
STAGE 2:
● Done before skin incision respiration, and pupil dilation.
EXCITEMENT
DELIRIUM
Tasks: Final verification of NURSING RESPONSIBILITY
TIME OUT 1. Patient’s Identity ● Ensure safety
2. Identity and Role of the surgical ● Prevent injury or fall
team ● Help restrain the patient when
3. Surgical Procedure necessary
● Done before the patient leaves the ● Apply cricoid pressure in the case
operating room of vomiting to prevent aspiration.
● Patient achieved generalized
SIGN OUT Tasks: Confirmation of insensibility and is noted to be
1. Surgical Procedure ready for surgery.
2. Completion of Instrument Count ● Characterized by patient being
3. Specimen Labeling unconscious, lies quietly, the
pupils are small, respirations are
ANESTHESIA AND SEDATION STAGE 3: regular and pulse rate is normal,
ANESTHESIA:
SURGICAL muscles are relaxed and the skin
ANESTHESIA is pink or slightly flushed.
● A state of narcosis (severe central nervous
system depression produced by pharmacologic
agents), analgesia, relaxation and reflex loss. NURSING RESPONSIBILITY
● MAY BE: ● Prepare the patient for the
○ Partial or Complete loss of sensation surgical procedure by performing
○ With or without loss of consciousness catheterization, positioning, skin
preparation and draping.
SEDATION ● Occurs when too much
● Diminishes physical and mental responses at anesthesia is administered – can
lower dosages but does not affect consciousness. cause respiratory depression.
● Characterized by shallow
MAJOR TYPES OF ANESTHESIA respiration, weak and thready
1. General Anesthesia pulse and pupils are widely
2. Regional Anesthesia dilated. If it remained
3. Moderate Sedation or Moderate Anesthesia Care unrecognized, cyanosis develops
(MAC) STAGE 4: and death rapidly follow.
4. Local Anesthesia MEDULLARY ● Immediate interventions by the
DEPRESSION anesthesiologist includes
GENERAL ANESTHESIA discontinuing anesthesia, initiating
respiratory and circulatory support
● Complete loss of sensation or pain with loss of
and administering stimulants
consciousness.
and/or narcotic antagonist.
● Pain is controlled by general insensibility.
● Patients are not arousable, not even to painful
NURSING RESPONSIBILITY
stimuli.
● Prepare for possible
resuscitation.
 METHODS OF GA ADMINISTRATION REGIONAL ANESTHESIA
● Partial loss of sensation without loss of
consciousness.
Anesthesia induction (initiation) begins with IV ● The anesthetic agent is injected around nerves
anesthesia and is then maintained at the desired so that the region supplied by these nerves is
stage by inhalation methods, achieving a smooth anesthetized.
transition and eliminating the obvious stages of ● Reflexes may be lost or diminished in the area that
anesthesia. All are given in combination with is anesthetized since sensory and motor functions
oxygen and usually nitrous oxide as well. are impaired.

TYPES OF REGIONAL ANESTHESIA

INHALATION
1. Local Conduction Blocks or Regional Blocks
● Use of gas or volatile liquid anesthetic agents 2. Subarachnoid Block (SAB) or Spinal Anesthesia
that produce anesthesia when the vapors are 3. Epidural Block or Epidural Anesthesia
inhaled.
● Act on the cerebral centers to produce loss of
LOCAL CONDUCTION BLOCKS
consciousness and sensation.
● Also known as nerve blocks or regional blocks
● When discontinued, the vapor or gas is eliminated
● Involves administration of anesthetic agent on a
through the lungs.
group of nerves at a given point causing loss of
● CAN BE GIVEN THROUGH: Laryngeal Mask
sensation to the region supplied by these nerves.
Airway (LMA) or Endotracheal Technique (ETT)

COMMON LOCAL CONDUCTION BLOCKS ARE

COMMONLY USED INHALATION AGENTS
● Nitrous Oxide Gas
1. BRACHIAL PLEXUS BLOCK – produces
● Sevoflurane (Sevorane / Ultrane)
anesthesia of the arm.
● Halothane (Fluothane)
● Enflurane (Ethrane)
2. PARAVERTEBRAL ANESTHESIA – produces
● Desflurane (Suprane)
anesthesia of the nerves supplying the chest,
● Isoflurane (Forane)
abdominal wall, and extremities.

INTRAVENOUS 3. TRANSSACRAL (CAUDAL) BLOCK –

● PURPOSE: To induce or maintain anesthesia and produces anesthesia of the perineum and,
may be used in combination with inhalation occasionally, the lower abdomen.
anesthetic agents or solely given.
SUBARACHNOID BLOCK / SPINAL ANESTHESIA
ADVANTAGES
● The local anesthetic agent is introduced into the
1. Pleasant induction
subarachnoid space at the lumbar level.
2. Duration of action is brief
● It produces anesthesia of the lower extremities,
3. Patient awakens with little nausea and vomiting
perineum, and lower abdomen.
4. Nonexplosive and easy to administer.

The spread of the anesthetic agent and the level of

COMMONLY USED IV AGENTS
anesthesia depends on the amount of agent
● Propofol (Diprivan)
injected, the speed with which it is injected, the
● Thiopental sodium (Pentothal)
positioning of the patient after the injection, and
● Diazepam (Valium)
the specific gravity of the agent.
● Ketamine (Ketalar)
● Etomidate (Amidate)
● Midazolam (Versed)
VARIATIONS OF SPINAL ANESTHESIA
IV NEUROMUSCULAR BLOCKERS (MUSCLE 1. HIGH-SPINAL – involves anesthesia that
RELAXANTS) extends from the 4th intercostal space down to
● Used to relaxed muscles in abdominal, thoracic toes. To achieve a higher level of block, the
and eye surgeries, facilitate intubation, treat patient is placed immediately in a slight
laryngospasm and assist in mechanical Trendelenburg position after anesthesia
ventilation. induction.

2. MID-SPINAL – produces anesthesia from point

COMMONLY USED MUSCLE RELAXANTS
midway of the xiphoid process down to toes.
● Succinylcholine
● Atracurium besylate (Tracrium)
3. LOW-SPINAL – produces anesthesia from the
● Rocuronium (Zemuron)
umbilicus down to toes.
● Pancuronium (Pavulon)
 EPIDURAL BLOCK OR EPIDURAL ANESTHESIA
SPINAL HEADACHE
● Achieved by injecting a local anesthetic agent into
the epidural space that surrounds the dura mater of
● CAUSE: leakage of CSF at the puncture site
the spinal cord.
● OTHER FACTORS: Size of the spinal needle
● It differs from spinal anesthesia by the site of the
used and hydration status of the patient.
injection and the amount of anesthetic agent used.
● CHARACTERISTICS: A headache that worsens
● Epidural doses are much higher because the
in an upright position and is relieved when the
epidural anesthetic agent does not make direct
patient lies flat on bed.
contact with the spinal cord or nerve roots; but
● PREVENTION: Place the patient flat on bed
usually of lesser concentration compared to spinal
(without pillow) for 6 to 8 hours and keeping
anesthesia.
the patient well-hydrated.
ADVANTAGE vs Spinal Anesthesia
1. Absence of headache because there is no CSF
leak. COMMONLY USED REGIONAL ANESTHETICS
2. Free from post-op pain when the epidural ● Bupivacaine (Marcaine, Sersorcaine),
catheter is used to administer opioid analgesic ● Tetracaine (Pontocaine)
post-operatively. ● Procaine (Novocaine).

ADMINISTRATION OF SPINAL AND EPIDURAL MODERATE SEDATION / MONITORED

ANESTHESIA ANESTHESIA CARE
● Formerly called conscious sedation
● POSITION: Lateral knee-chest position (also ● PURPOSE: Done to reduce patient anxiety and
known as C-position, fetal or shrimp position) to control pain during a short surgical procedure.
provide space for the insertion of the needle ● The patient’s level of consciousness is depressed to
in the lumbar area usually between L3 and L4 moderate level while allowing patient’s comfort and
or between L4 and L5. cooperation during the procedure.
● The site of needle insertion prevents damage to
the spinal cord that terminates in L2. ADVANTAGES
● Sterile technique is ensured through skin 1. Patent airway is maintained
preparation and the use of sterile articles. 2. Protective airway reflexes and ability of the patient
● A local anesthesia is injected prior to the insertion to respond to verbal and physical stimuli are also
of the spinal needle. maintained

LOCAL ANESTHESIA
EFFECTS OF SPINAL AND EPIDURAL ANESTHESIA ● Injection of solution containing the anesthetic agent
into the tissues at the surgical site.
1. AUTONOMIC NERVE BLOCK (sympathetic ● Commonly used local anesthetic agent is Lidocaine
block) that cause vasodilating effects leading to a (Xylocaine).
transient hypotensive state. ● It may also be combined with other regional
anesthesia.
2. SENSORY NERVE BLOCK produces loss of
sensation (anesthesia). ADVANTAGES:
1. Simple, economical and nonexplosive
3. MOTOR NERVE BLOCK produces loss of 2. Postoperative recovery is brief
mobility (paralysis) 3. Ideal for short and minor surgical procedures
4. No undesirable effects compared to other types of
anesthesia
SIDE EFFECTS
SPINAL EPIDURAL
1. Hypotension 1. Hypotension EPINEPHRINE
2. Nausea and vomiting 2. Nausea and vomiting
3. Headache 3. Bradycardia An adrenergic agent can be used in combination
(post-anesthesia 4. Chilling or shivering with local anesthesia with the purpose of
headache or spinal 5. Urinary retention prolonging the effect of local anesthesia.
headache)
Epinephrine causes vasoconstriction thereby
preventing rapid absorption of the anesthetic
agent.
 SURGICAL POSITIONING Nursing Interventions
1. PURPOSE: To maintain body alignment and to 1. Place the patient in lateral position and turn the
expose the surgical site. head to the side.
2. UTMOST NURSING CONSIDERATION: prevent 2. Provide emesis basis to collect vomitus.
positioning injury while ensuring accessibility of the 3. Suction as needed.
surgical site.
ANAPHYLAXIS
● A severe and can be a life-threatening
QUALIFICATIONS OF A GOOD POSITION hypersensitivity reaction.
● Can occur in response to any medications, latex and
1. Free respiration. Respiration should not be other substances.
impeded by pressure of arms on the chest or ● The reaction may be immediate or delayed.
constricting gown.
2. Free circulation. Check for constricting straps Manifestations:
that can impede circulation. 1. Urticaria, hives, itching, flushed or pale skin
3. Hands and feet should be properly supported. 2. Hypotension
Improper positioning of the arms, hands, legs or 3. Rapid and weak pulse
feet can cause serious injury or paralysis. When 4. Wheezes and constriction of airway that can lead
the arms and hands are allowed to dangle at to asphyxia.
the sides, it can lead to brachial nerve
damage. Nursing Interventions:
4. Nerves must be protected from undue pressure. 1. Assess for allergy to any medication, food, latex
5. There should be no undue post-op discomfort. and other substances.
6. The operative field must be accessible and 2. For patients with latex allergy, all procedures
adequately exposed. should be latex-free (use of latex-free gloves and
catheters).
3. For allergy to iodine, replaced iodine-based
MANAGEMENT OF POTENTIAL INTRAOPERATIVE
antiseptic with alcohol-based antiseptic for
COMPLICATIONS
disinfection and skin preparations.
1. Anesthesia awareness
2. Nausea and vomiting
HYPOXIA AND OTHER RESPIRATORY
3. Anaphylaxis
COMPLICATIONS
4. Hypoxia and other respiratory complications
5. Hypothermia Potential Complications Associated with GA
6. Malignant hyperthermia 1. Inadequate ventilation
2. Occlusion of the airway
3. Inadvertent intubation of the esophagus
ANESTHESIA AWARENESS
4. Hypoxia
● A condition where a patient is partially awake and 5. Aspiration of vomitus and patient’s position during
cognizant of surgical interventions while under surgery may further cause respiratory problems.
general anesthesia and then recalling the incident.
Nursing Interventions
Manifestations: 1. Monitor patient’s respiratory status such as noting
1. An increase in blood pressure respiratory rate and oxygen saturation levels are
2. Rapid heart rate crucial for early detection of hypoxia.
3. Patient movement 2. Ensure patent airway and oxygen administration
are interventions to correct hypoxia.
Preventive Measures
1. Premedication with amnesic agents
HYPOTHERMIA
2. Avoidance of muscle paralytics except when
essential ● A condition when the core body temperature
drops below 36.6 degrees celsius.
● Prolonged hypothermia can lead to a reduced
NAUSEA AND VOMITING
glucose metabolism and subsequent metabolic
● Can be secondary to side effects of anesthesia acidosis.
and muscle relaxants. ● In some cases, hypothermia is intentional but safe
● Aspiration of vomitus is the consequence of nausea and gradual return to normal body temperature must
and vomiting that may lead to severe complications be promoted.
like severe bronchial spasms, wheezing,
pneumonitis, and pulmonary edema that can Causes of hypothermia during surgery are:
cause extreme hypoxia. 1. Low temperature in the OR
2. Infusion of cold fluids (for washing or irrigation)
Preventive Measures 3. Open body wounds or cavities
● Ondansetron (Zofran) and Metoclopramide 4. Decreased muscle activity
(Plasil) preoperatively or intraoperatively. 5. Old age
6. Medications such as vasodilators, phenothiazines,
general anesthetic agents
Nursing Interventions
1. OR environmental temperature should be set at POST OPERATIVE NURSING
25-26 degrees Celsius ● PACU → Surgical Floor → Discharge & Follow up
2. IV and irrigating fluids are warmed to 37 degrees Visit
Celsius
3. Wet gowns and drapes are removed promptly and PHASES OF POST-ANESTHESIA CARE (4-6hrs)
replaced with dry materials PHASE I PACU Immediate Recovery Phase
4. Use of warm air blankets and thermal blankets PHASE II PACU Preparation for self-care
5. Minimizing exposure of body parts
Step-down / Sit-up / Progressive
6. Conscientious monitoring of core temperature
PHASE III PACU Care Units
Preparation for discharge
MALIGNANT HYPERTHERMIA
● A rare inherited muscle disorder that is chemically ENDORSEMENT FROM OR TO PACU
induced by anesthetic agents (halothane, enflurane,
isoflurane) and muscle relaxants (succinylcholine). ● Patient’s name, age, gender
● It is a hypermetabolic condition that involves ● Room number
altered mechanisms of calcium function in ● Operation done and surgeon (for CS include gender
skeletal muscles causing persistent muscle of baby)
contraction (rigidity). ● Anesthesia and anesthesiologist
● Incidence is 1 in 50,000-100,000 adult but has a ● Contraptions
high mortality rate of 70%. ● Medications given at OR
● It usually manifests about 10 to 20 minutes after ● Latest VS
anesthesia induction, but can also occur 24 hours ● OR intake and output
after surgery. ● Blood transfusions, x-ray plates and specimen
● Post-op orders
Risk Factors
1. Having strong and bulky muscles NURSING MANAGEMENT IN THE PACU
2. A history of muscle cramps or muscle weakness ● HIGHEST PRIORITY: Maintain patent airway
3. Unexplained temperature elevation
4. An unexplained death of a family member during SIGNS OF AIRWAY OCCLUSION
surgery with febrile response 1. Choking
2. Noisy and irregular breathing
Manifestations 3. Decreased oxygen saturation levels
1. Early signs are tachycardia (heart rate of 150 4. Cyanosis
bpm), hypercapnia (increase in carbon dioxide)
and generalized muscle rigidity (tetanus-like WAYS TO PROMOTE AIRWAY
movements). 1. Lateral position with the head of the bed elevated
2. Sympathetic stimulation leads to ventricular 15 to 30 degrees
dysrhythmia, hypotension, decreased cardiac 2. Turn head to the side Use of hard/rubber plastic
output and oliguria. airway
3. A rapid increase in body temperature of 1 to 2
degrees Celsius every 5 minutes, reaching ASSESSING THE PATIENT
greater than 42 degrees Celsius is a late sign. ● Monitoring the VITAL SIGNS
4. Cardiac arrest and death may ensue secondary to ○ Every 15 minutes for the first hour
life-threatening dysrhythmias and acidotic state. ○ Every 30 minutes for the next 2 hours
○ Hourly for the next 4 hours or until stable
Medical Management ● Monitoring oxygen saturation
1. Prompt discontinuation of anesthesia ● Assess the surgical site and wound drainage
administration. systems
2. Administration of Dantrolene sodium (Dantrium), a ● Assess the level of consciousness, orientation
muscle relaxant and the drug of choice for and ability to move extremity
malignant hyperthermia. ● Measure urine output hourly
3. Sodium bicarbonate can be administered to ● Pain assessment
reverse metabolic and respiratory acidosis.
4. Oxygen administration SIGNS OF HEMORRHAGE
5. Correct electrolyte imbalance 1. Restlessness and disorientation
2. Hypotension
Nursing Interventions 3. Rapid, thready pulse
1. Identify patients at risks 4. Oliguria
2. Recognize the signs and symptoms 5. Cold, pale skin
3. Have the appropriate medication and equipment 6. A systolic BP of less than 90mmHg is
available considered immediately reportable
4. Monitor core body temperature and end-tidal CO2
5. Perform interventions to decrease the body
temperature such as tepid sponge bath
6. Prepare for possible resuscitation
NURSING INTERVENTIONS
1. Relieving pain and anxiety MANAGING VOIDING
2. Controlling nausea and vomiting 1. The patient is expected to void within 8 hours after
3. Determining readiness for discharge from the surgery
PACU 2. The patient must void 6 to 8 hours after the removal
of the catheter
RECEIVING THE PATIENT IN THE SURGICAL FLOOR 3. Relieve urinary retention
● Admit the patient to the unit
● Review post-op orders MAINTAINING A SAFE ENVIRONMENT
○ Verify post-op position 1. Put the side rails up The bed should be in the low
○ Verify post-op medications position
○ Verify type of diet 2. Assist in ambulation
● Perform initial assessment 3. Assess level of consciousness and orientation
● Attend to patient’s immediate needs
POST-OP COMPLICATIONS
POST-OP NURSING INTERVENTIONS 1. Hemorrhage
PREVENTING RESPIRATORY COMPLICATIONS 2. Hypovolemic Shock
1. Encourage the patient to perform deep breathing 3. Thrombophlebitis
and coughing exercises 4. Atelectasis
2. Use of incentive spirometer 5. Pneumonia
3. Turning to sides and early ambulation 6. Pulmonary Embolism
4. The patient is encouraged to be out of bed as soon 7. Urinary Retention
as possible. 8. Paralytic Ileus
9. Abdominal
RELIEVING PAIN 10. Gas Pain
1. Administer analgesics as ordered 11. Wound Infection
2. Be cautious with the administration of Opioid 12. Wound Dehiscence
analgesics 13. Wound Evisceration
3. Teach patient how to splint the wound
Non-pharmacological pain management

ENCOURAGING ACTIVITY
1. Check doctor’s order regarding positioning and
activity
2. Gradual position change is advised
3. Bed exercises: Arm exercises Leg and foot
exercises
4. Abdominal and gluteal setting exercises

CARING FOR WOUNDS

1. Assists in change of dressing observing strict
aseptic technique
2. Assess the amount of bloody drainage frequently
3. Assess for signs of infection
4. Promote wound healing

MAINTAINING NORMAL BODY TEMPERATURE

1. The room is maintained at a comfortable
temperature
2. Blankets are provided to prevent chilling
3. Assess for presence of fever

MANAGING GASTROINTESTINAL FUNCTION

1. Assess for return of peristalsis
2. Presence of bowel sounds
3. Passage of flatus
4. Progression of diet NPO → Liquids → Soft foods
→ DAT

PROMOTING BOWEL FUNCTION

1. Early ambulation
2. Increase oral fluids
3. High fiber diet
4. Laxatives as ordered