The PREOPERATIVE PHASE extends from the time the client is admitted to the surgical unit, to the time

he/she is
prepared physically, psychosocially, spiritually and legally for the surgical procedure, until he/she is transported
into the operating room.

ADMISSION to the Surgical Unit

Preparation for Surgery:

Physical, Psychosocial, Spiritual, Legal

Transport to Operating Room(OR)

The INTRAOPERATIVE PHASE extends from the time the client is admitted to the operating room,
to the time of administration of anesthesia, surgical procedure is done, until he/she is transported
to the recovery room (RR) / postanesthesia unit (PACU).

ADMISSION to the OR

ANESTHESIA SURGERY

Recovery Room / PACU

The POSTOPERATIVE PHASE extends from the time the client is admitted to the recovery room, to the time he is
transported back into the surgical unit, discharged from the hospital, until the follow-up care.

ADMISSION to the RR/PACU

Back to the Surgical Unit

Follow-up Care
Intraoperative Nursing Care
Goals of Care During Intraoperative Period
Asepsis and Infection Control
Homeostasis
Safe Administration of Anesthesia
Homostasis
Surgical conscience
Preparation for Surgery
Definition
The intraoperative phase extends from the time the client is admitted to the operating room, to the time of anesthesia administration,
performance of the surgical procedure and until the client is transported to the recovery room or postanesthesia care unit (PACU).
Throughout the surgical experience the nurse functions as the patients chief advocate. The nurses care and concern extend from the time the
patient is prepared for and instructed about the forthcoming surgical procedure to the immediate preoperative period and into the operative
phase and recovery from anesthesia. The patient needs the security of knowing that someone is providing protection during the procedure and
while he is anesthetized because surgery is usually a stressful experience.

Goals
Promote the principle of asepsis asepsis.
Homeostasis
Safe administration of anesthesia
Hemostasis

The Surgical Team

The intraoperative phase begins when the patient is received in the surgical area and lasts until the patient is transferred to the recovery
area. Although the surgeon has the most important role in this phase, there are key members of the surgical team.
1. Surgeon leader of the surgical team. He or she is ultimately responsible for performing the surgery effectively and safely; however, he
is dependent upon other members of the team for the patients emotional well being and physiologic monitoring.
2. Anesthesiologist or anesthetist provides smooth induction of the patients anesthesia in order to prevent pain. This member is also
responsible for maintaining satisfactory degrees of relaxation of the patient for the duration of the surgical procedure. Aside from that,
the anesthesiologist continually monitors the physiologic status of the patient for the duration of the surgical procedure and the
physiologic status of the patient to include oxygen exchange, systemic circulation, neurologic status, and vital signs. He or she then
informs and advises the surgeon of impending complications.
3. Scrub Nurse or Assistant a nurse or surgical technician who prepares the surgical set-up, maintains surgical asepsis while draping and
handling instruments, and assists the surgeon by passing instruments, sutures, and supplies.
4. Circulating Nurse respond to request from the surgeon, anesthesiologist or anesthetist, obtain supplies, deliver supplies to the sterile
field, and carry out the nursing care plan.
Scrub Nurse

The scrub nurse assists the surgeon during the

whole procedure by anticipating the required
instruments and setting up the sterile table. The
responsibilities of the scrub nurse are:
1. Scrubbing for surgery.
2. Setting up sterile tables.
3. Preparing sutures and special equipments.
4. Assists the surgeon and assistant during the
surgical procedure by anticipating the
required instruments, sponges, drains and
other equipment.
5. Keeps track of the time the patient is under
anesthesia and the time the wound is open.
6. Checks equipments and materials such as
needles, sponges and instruments as the
surgical incision is closed.
Circulating Nurse

The circulating nurse manages the operating room

and protects the safety and health needs of the
patient by monitoring activities of members of the
surgical team and checking the conditions in the
operating room. Responsibilities of a circulation
nurse are the following:
1. Assures cleanliness in the OR.
2. Guarantees the proper room temperature,
humidity and lighting in OR.
3. Make certain that equipments are safely
functioning.
4. Ensure that supplies and materials are
available for use during surgical procedures.
5. Monitors aseptic technique while coordinating
the movement of related personnel.
6. Monitors the patient throughout the operative
procedure to ensure the persons safety and
well being.
In the practice
of medicine (especially surgery and dentistry), anesthesia or an
aesthesia (from the Greek ", anesthisia" meaning "no
feeling") is a state of temporary induced loss of sensation or
awareness. It may include analgesia (relief from or prevention
of pain), paralysis (muscle relaxation), amnesia (loss of
memory), or unconsciousness.
At the Massachusetts General Hospital, Boston, Massachusets, on
October 16, 1846, for the first time in history a group of reputable
physicians were given convincing proof that, by inhaling ether vapor, a
patient could safely be made insensible to the pain of a surgical
operation. Over the ages, seemingly, pain had been considered so
inevitably a part of life that had to be endured that attempts to
alleviate it were sporadic and unconvincing. Primitive man resented
pain as an invisible demon that could, in some unexplainable way,
take possession of his body. Charms of weird variety were worn as
guard against the demon's entrance or, once enthroned, he might be
exorcised by fright or magical incantations.
However, from time immemorial, mankind has sought palliatives to
heal or soothe his pain. Probably in his search for food he early
learned that many vegetable substances have hypnotic and analgesic
effects when chewed, or burnt and the fumes inhaled. That this
knowledge was used for the relief of pain as civilization progressed is
evidenced by many references found in the literature of ancient Greece
and Rome, of China, Assyria, and Egypt, and throughout the early
Christian era. Notable among the substances used were henbane and
the root of the mandrakehyoscin; seed of the white poppy-opium;
leaves of the coca tree-cocaine; and the fumes of burning hemp-
Oriental hashish. There are many recipes for the preparation of
elaborate combinations of these and other vegetable substances,
which are to be imbibed or inhaled by patients prior to imperative
surgical operations, such as amputation of diseased or injured limbs,
trephination, removal o'f bladder stone, etc. Alcoholic beverages of
sorts seem to have antedated recorded history, and their hypnotic
effects were noted and used for the relief of pain. But crude drugs of all A patient under the effects of anesthetic drugs is referred
kinds have many side actions, often harmful and dangerous; their to as being anesthetized.
general effect is unpredictable and specific effect definitely beyond
control. Not until the active principle of opium-morphine-was
Anesthesia enables the painless performance of medical
discovered by the German chemist, Friederich W. Sertiirner,2 in 1806, procedures that would cause severe or intolerable pain
could this most valuable narcotic drug be used with reasonable safety. to an unanesthetized patient. Three broad categories of
He named the alkaloid morphium, after the Greek god of dreams,
Morpheus. By his invention of the hollow needle in 1853, Dr. Alex ander
anaesthesia exist:
Wood of Edinburgh blazed the trail for the modern hypodermic
injection of this drug.
 Classification of Physical Status for Anesthesia Before Surgery
The anesthesiologist should visit the patient before the surgery to provide information, answer questions and allay fears that may exist in the
patients mind.
The choice of anesthetic agent will be discussed and the patient has an opportunity to disclose and the patient has opportunity to disclose
previous reactions and information about any medication currently being taken that may affect the choice of an agent. Aside from that, the
patients general condition must also be assessed because it may affect the management of anesthesia. Thus, the anesthesiologist assesses the
patients cardiovascular system and lungs.
Inquiry about preexisting pulmonary infection sand the extent to which the patient smokes must also be determined. The classification of a
clients physical status for anesthesia beforesurgery is summarized below.

Classification of Physical Status for Anesthesia Before Surgery

Classification Description Example

Good No organic disease; no systemic disturbance Uncomplicated hernias,fracture

Fair Mild to moderate systemic disturbance Mild cardiac (I and II) disease, mild diabetes

Poor Severe systemic disturbance Poorly controlled diabetes, pulmonary

complications, moderate cardiac (III)
disease
Serious Systemic disease threatening life Severe renal disease, severe cardiac disease
(IV), decompensation
Moribund Little chance of survival but submitting to Massive pulmonaryembolus, ruptured
operation in desperation abdominal aneurysm with profound shock
Emergency Any of the above whensurgery is performed An uncomplicated hernia that is now
in an emergency situation strangulated and associated with nausea
and vomiting.

Source: Brunner and Suddarths Medical-Surgical Nursing by Smeltzer and Bare

Anesthesia
Anesthesia controls pain during surgery or other medical procedures. It includes using medicines, and sometimes close monitoring,
to keep you comfortable. It can also help control breathing, blood pressure, blood flow, and heart rate and rhythm, when needed.
Anesthetics are divided into two classes:
Those that suspend sensation in the whole body General anesthesia
Those that suspend sensation in certain parts of the body local, regional, epidural or spinal anesthesia

General Anesthesia
This type of anesthesia promotes total loss of consciousness and sensation. General anesthesia is commonly achieved when
the anesthetic is inhaled or administered intravenously. It affects the brain as well as the entire body. Types of general
anesthesia administration:
Volatile liquid anesthetics this type of anesthetic produces anesthesia when their vapors are inhaled. Included in this
group are the following:
Halothane (Fluothane)
Methoxyflurane (Penthrane)
Enflurane (Ethrane)
Isoflurane (Forane)
 Cocaine Volatile agents are specially formulated organic liquids that evaporate readily into
vapors, and are given by inhalation for induction and/or maintenance of general
General anesthetics anesthesia. Nitrous oxide and xenon are gases at room temperature rather than
liquids, so they are not considered volatile agents. The ideal anesthetic vapor or gas
should be non-flammable, non-explosive, and lipid-soluble. It should possess low
Inhaled agents blood gas solubility, have no end-organ (heart, liver, kidney) toxicity or side-effects,
should not be metabolized, and should not be an irritant to the respiratory pathways
of the patient.
No anaesthetic agent currently in use meets all these requirements, nor can any
Desflurane anaesthetic agent be considered safe. There are inherent risks and drug interactions
Enflurane that are specific to each and every patient.The agents in widespread current use
are isoflurane,desflurane, sevoflurane, and nitrous oxide. Nitrous oxide is a
Halothane common adjuvant gas, making it one of the most long-lived drugs still in current use.
Isoflurane Because of its low potency, it cannot produce anesthesia on its own but is frequently
Methoxyflurane combined with other agents. Halothane, an agent introduced in the 1950s, has been
almost completely replaced in modern anesthesia practice by newer agents because of
Nitrous oxide its shortcomings. Partly because of its side effects, enflurane never gained widespread
Sevoflurane popularity.
Xenon (rarely used) In theory, any inhaled anesthetic agent can be used for induction of general anesthesia.
However, most of the halogenated anesthetics are irritating to the airway, perhaps
leading to coughing, laryngospasm and overall difficult inductions. For this reason, the
most frequently used agent for inhalational induction is sevoflurane. All of the volatile
agents can be used alone or in combination with other medications to maintain
anesthesia (nitrous oxide is not potent enough to be used as a sole agent).
Volatile agents are frequently compared in terms of potency, which is inversely
proportional to the minimum alveolar concentration. Potency is directly related to
lipid solubility. This is known as the Meyer-Overton hypothesis. However, certain
pharmacokinetic properties of volatile agents have become another point of
comparison. Most important of those properties is known as the blood/gas partition
coefficient. This concept refers to the relative solubility of a given agent in blood.
Those agents with a lower blood solubility (i.e., a lower bloodgas partition
coefficient; e.g., desflurane) give the anesthesia provider greater rapidity in titrating
the depth of anesthesia, and permit a more rapid emergence from the anesthetic state
upon discontinuing their administration. In fact, newer volatile agents (e.g.,
sevoflurane, desflurane) have been popular not due to their potency (minimum
alveolar concentration), but due to their versatility for a faster emergence from
anesthesia, thanks to their lower bloodgas partition coefficient.
Intravenous opioid analgesic agents
While opioids can produce unconsciousness, they do so unreliably and with significant side effects. So, while they are rarely used to
induce anesthesia, they are frequently used along with other agents such as intravenous non-opioid anesthetics or inhalational
anesthetics. Furthermore, they are used to relieve pain of patients before, during, or after surgery. The following opioids have short
onset and duration of action and are frequently used during general anesthesia:

Alfentanil
Fentanyl
Remifentanil
Sufentanil, which is not available in Australia.

The following agents have longer onset and duration of action and are frequently used for post-operative
pain relief:
Buprenorphine
Butorphanol
Diamorphine, also known as heroin, not available for use as an analgesic in any country but the UK.
Hydromorphone
Levorphanol
Pethidine, also called meperidine in North America.
Methadone
Morphine
Nalbuphine
Oxycodone, not available intravenously in U.S.
Oxymorphone
Pentazocine
 The two barbiturates mentioned above, thiopental and methohexital, are ultra-short-
acting, and are used to induce and maintain anesthesia. However, though they
produce unconsciousness, they provide no analgesia (pain relief) and must be used
with other agents. Benzodiazepines can be used for sedation before or after surgery
and can be used to induce and maintain general anesthesia. When benzodiazepines
Intravenous agents (non-opioid) are used to induce general anesthesia, midazolam is preferred. Benzodiazepines are
While there are many drugs that can be used also used for sedation during procedures that do not require general anesthesia. Like
intravenously to produce anesthesia or sedation, barbiturates, benzodiazepines have no pain-relieving properties. Propofol is one of
the most common are: the most commonly used intravenous drugs employed to induce and maintain
general anesthesia. It can also be used for sedation during procedures or in
the ICU. Like the other agents mentioned above, it renders patients unconscious
Barbiturates without producing pain relief. Because of its favorable physiological effects,
Amobarbital (trade name: "etomidate has been primarily used in sick patients". Ketamine is infrequently used
Amytal) in anesthesia because of the unpleasant experiences that sometimes occur on
emergence from anesthesia, which include "vivid dreaming, extracorporeal
Methohexital (trade name: experiences, and illusions. However, like etomidate it is frequently used in
Brevital) emergency settings and with sick patients because it produces fewer adverse
Thiamylal (trade name: physiological effects.[5] Unlike the intravenous anesthetic drugs previously
mentioned, ketamine produces profound pain relief, even in doses lower than those
Surital) that induce general anesthesia.[5] Also unlike the other anesthetic agents in this
Thiopental (trade name: section, patients who receive ketamine alone appear to be in a cataleptic state,
Penthothal, referred to unlike other states of anesthesia that resemble normal sleep. Ketamine-anesthetized
patients have profound analgesia but keep their eyes open and maintain many
as thiopentone in the UK)
reflexes.
Benzodiazepines Neonatal and infant neurotoxicity concerns
Diazepam Concerns have been raised as to the safety of general anesthetics, in
particular ketamine and isoflurane in neonates and young children due to
Lorazepam significant neurodegeneration. The risk of neurodegeneration is increased in
Midazolam combination of these agents with nitrous oxide and benzodiazepines such as
midazolam. This has led to the FDA and other bodies to take steps to investigate
Etomidate
these concerns. These concerns have arisen from animal studies involving rats and
Ketamine non-human primates. Research has found that anesthetics which enhance GABA or
Propofol block NMDA can precipitate neuronal cell death in these animals. The developing
central nervous system is most vulnerable to these potential neurotoxic effects
during the last trimester of pregnancy and shortly after birth. Melatonin, a free
oxygen radical scavenger and indirect antioxidant is known to reduce the toxicity of
a range of drugs has been found in a rat study to reduce the neurotoxicity of
anesthetic agents to the early developing brain. Recent research in animals has
found that all sedatives and anesthetics cause extensive neurodegeneration in the
developing brain. There is also some evidence in humans that surgery and exposure
to anesthetics in the early developmental stages causes persisting learning deficits.
Muscle relaxants
Muscle relaxants do not render patients unconscious or relieve pain. Instead, they are sometimes used after a patient is rendered
unconscious (induction of anesthesia) to facilitate intubation or surgery by paralyzing skeletal muscle.

Depolarizing muscle relaxants

Succinylcholine (also known as suxamethonium in the UK, New Zealand, Australia and other countries,
"Celokurin" or "celo" for short in Europe)
Decamethonium
Non-depolarizing muscle relaxants
Short acting
Mivacurium
Rapacuronium
Intermediate acting
Atracurium
Cisatracurium
Rocuronium
Vecuronium
Long acting
Alcuronium
Doxacurium
Gallamine
Metocurine
Pancuronium
Pipecuronium
Tubocurarine
Adverse effects
Depolarizing Muscle Relaxants i.e. Suxamethonium

Hyperkalemia A small rise of 0.5 mmol/l occurs normally, this is of little consequence unless
potassium is already raised such as in renal failure
Hyperkalemia Exaggerated potassium release in burn patients (occurs from 24 hours after injury,
lasting for up to 2 years), neuromuscular disease and paralyzed (quadraplegic, paraplegic) patients. The
mechanism is reported to be through upregulation ofacetylcholine receptors in those patient
populations with increased efflux of potassium from inside muscle cells. May cause life-threatening
arrhythmia
Muscle aches, commoner in young muscular patients who mobilize soon after surgery
Bradycardia, especially if repeat doses are given
Malignant hyperthermia, a potentially life-threatening condition in susceptible patients
Suxamethonium Apnea, a rare genetic condition leading to prolonged duration of neuromuscular
blockade, this can range from 20 minutes to a number of hours. Not dangerous as long as it is recognized
and the patient remains intubated and sedated, there is the potential for awareness if this does not
occur.
Anaphylaxis
Non-depolarizing Muscle Relaxants
Histamine release e.g. Atracurium & Mivacurium
Anaphylaxis
Another potentially disturbing complication where neuromuscular blockade is employed is 'anesthesia
awareness'. In this situation, patients paralyzed may awaken during their anesthesia, due to an inappropriate
decrease in the level of drugs providing sedation and/or pain relief. If this fact is missed by the anesthesia
provider, the patient may be aware of their surroundings, but be incapable of moving or communicating that
fact. Neurological monitors are increasingly available that may help decrease the incidence of awareness.
Most of these monitors use proprietary algorithms monitoring brain activity via evoked potentials. Despite
the widespread marketing of these devices many case reports exist in which awareness under anesthesia has
occurred despite apparently adequate anesthesia as measured by the neurologic monitor.
Intravenous reversal agents

Flumazenil, reverses the effects of benzodiazepines

Naloxone, reverses the effects of opioids
Neostigmine, helps reverse the effects of non-depolarizing muscle relaxants
Sugammadex, new agent that is designed to bind Rocuronium therefore terminating its action

Gas Anesthetics anesthetics administered by inhalation and are ALWAYS combined with oxygen. Included in
this group are the following:
Nitrous Oxide
Cyclopropane
Stages
General anesthesia consists of four stages, each of which presents a definite group of signs and
symptoms.

Stage I: Onset or Induction or Beginning anesthesia.

This stage extends from the administration of anesthesia to the time of loss of consciousness. The patient may have a
ringing, roaring or buzzing in the ears and though still conscious, is aware of being unable to move the extremities
easily. Low voices or minor sounds appear distressingly loud and unreal during this stage.
Stage II: Excitement or Delirium.
Stage II extends from the time of loss of consciousness to the time of loss of lid reflex. This stage is characterized by
struggling, shouting, talking, singing, laughing or even crying. However, these things may be avoided if the anesthetic
is administered smoothly and quickly. The pupils become dilated but contract if exposed to light. Pulse rate is rapid
and respirations are irregular.
Stage III: Surgical Anesthesia
This stage extends from the loss of lid reflex to the loss of most reflexes. It is reached by continued administration of the
vapor or gas. The patient now is unconscious and is lying quietly on the table. Respirations are regular and the pulse
rate is normal.
Stage IV: Overdosage or Medullary or Stage of Danger.
This stage is reached when too much anesthesia has been administered. It is characterized by respiratory or
cardiac depression or arrest. Respirations become shallow, the pulse is weak and thread and the pupils are widely
dilated and no longer contract when exposed to light. Cyanosis develops afterwards and death follows rapidly unless
prompt action is taken. To prevent death, immediate discontinuation of anesthetic should be done and respiratory and
circulatory support is necessary
Local Anesthesia
Local anesthetics can be topical, or isolated just to the surface. These are usually in the form of gels, creams or sprays. They may be
applied to the skin before the injection of a local anesthetic that works to numb the area more deeply, in order to avoid the pain of
the needle or the drug itself (penicillin, for example, causes pain upon injection).

Each of the local anesthetics have the suffix "-caine" in their names.
procaine
amethocaine
lidocaine (also known as lignocaine)
prilocaine
bupivacaine
levobupivacaine
ropivacaine
mepivacaine
dibucaine
cocaine
Local anesthetics are agents that prevent transmission of nerve impulses without causing unconsciousness. They act by binding to
fast sodium channels from within (in an open state). Local anesthetics can be either ester- or amide-based.
Ester local anesthetics (e.g., procaine, amethocaine, cocaine, benzocaine, tetracaine) are generally unstable in solution and fast-
acting, and allergic reactions are common.
Amide local anesthetics (e.g., lidocaine, prilocaine, bupivicaine, levobupivacaine, ropivacaine, mepivacaine, dibucaine
and etidocaine) are generally heat-stable, with a long shelf life (around 2 years). They have a slower onset and longer half-life
than ester anesthetics, and are usually racemic mixtures, with the exception of levobupivacaine (which is S(-) -bupivacaine) and
ropivacaine (S(-)-ropivacaine). These agents are generally used within regional and epidural or spinal techniques, due to their
longer duration of action, which provides adequate analgesia for surgery, labor, and symptomatic relief.
Only preservative-free local anesthetic agents may be injected intrathecally.
Pethidine also has local anesthetic properties, in addition to its opioid effects.
 Regional anesthesia
Regional anesthesia blocks pain to a larger part of the
body. Anesthetic is injected around major nerves or
the spinal cord. Medications may be administered to
help the patient relax or sleep. Major types of regional
anesthesia include:

Peripheral nerve blocks.

A nerve block is a shot of anesthetic near a specific

nerve or group of nerves. It blocks pain in the part of
the body supplied by the nerve. Nerve blocks are most
often used for procedures on the hands, arms, feet,
legs, or face.

Epidural and spinal anesthesia.

This is a shot of anesthetic near the spinal cord and

thenerves that connect to it. It blocks pain from an
entire region of the body, such as the belly, hips, or
legs.

Epidural Anesthesia involves the injection of a local anesthetic, usually

with a narcotic, into the epidural space, through either a needle or
catheter. The epidural space is outside of the spinal cord. This type of
anesthesia is commonly used in labor and delivery and for procedures of
the lower extremities.

With regional anesthesia, an anesthetic agent is injected around the

nerved so that the area supplied by these nerves is anesthetized. The
effect depends on the type of nerve involved. The patient under a spinal
or local anesthesia is awake and aware of his or her surroundings.
Regional anesthesia carries more risks than local anesthesia, such as
seizures and heart attacks, because of the increased involvement of the
central nervous system. Sometimes regional anesthesia fails to provide
enough pain relief or paralysis, and switching to general anesthesia is
necessary.
Spinal Anesthesia
This is a type of conduction nerve block
that occurs by introducing a local
anesthetic into the subarachnoid space
at the lumbar level which is usually
between L4 and L5. Sterile technique is
used as the spinal puncture is made and
medication is injected through the
needle. The spread of the anesthetic
agent and the level of anesthesia
depend on:

-the amount of fluid injected

-the speed with which it is injected

-positioning of the patient after

injection

-specific gravity of the agent

Spinal Anesthesia also involves the injection of a local anesthetic,

with or without a narcotic, into the fluid that surrounds the spinal
cord. This type of anesthesia is commonly used for genitourinary
procedures, cesarean sections and procedures of the lower
extremities.
Nursing Assessment
The following are nursing assessment after anesthesia:

Monitoring vital signs.

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

Side Effects

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

Nausea and vomiting.

A mild drop in body temperature.

How do anesthesiologists determine the type of anesthesia to be used?
The type of anesthesia the anesthesiologist chooses depends on many factors. These include the procedure the
client is having and his or her current health.

Positioning
The nurse should have an idea which patient position is required for a certain surgical procedure to be performed.
There are lots of factors to consider in positioning the patient which includes the following:
1. Patient should be in a comfortable position as possible whether he or she is awake or asleep.
2. The operative area must be adequately exposed.
3. The vascular supply should not be obstructed by an awkward position or undue pressure on a part.
4. There should be no interference with the patients respiration as a result of pressure of the arms on the chest
or constriction of the neck or chest caused by a gown.
5. The nerves of the client must be protected from undue pressure. Serious injury or paralysis may result from
improper positioning of the arms, hands, legs or feet.
6. Shoulder braces must be well padded to prevent irreparable nerve injury.
7. Patient safety must be observed at all times.
8. In case of excitement, the patient needs gentle restraint before induction.
Nursing Responsibilities
Here are the nursing responsibilities during intraoperative phase:

Safety is the highest priority.

Simultaneous placement of feet. This is to prevent dislocation of hip.
Always apply knee strap.
Arms should not be more than 90
Prepare and apply cautery pad. Cautery is used to stop bleeding.
What is the name of this machine?
Positioning the Client for Surgery
Supine position
The most common surgical position. The patient lies with back flat on operating
room bed.
Trendelenburg position
Same as supine position but the upper torso is lowered.
Reverse Trendelenburg position
Same as supine but upper torso is raised and legs are lowered
Fracture Table Position
For hip fracture surgery. Upper torso is in supine position with unaffected leg
raised. Affected leg is extended with no lower support. The leg is strapped at
the ankle and there is padding in the groin to keep pressure on the leg and hip.
Lithotomy position
Used for gynecological, anal, and urological procedures. Upper torso is placed
in the supine position, legs are raised and secured, arms are extended.
Fowler's position
Begins with patient in supine position. Upper torso is slowly raised to a 90
degree position.
Semi-Fowlers position
Lower torso is in supine position and the upper torso is bent at a nearly 85
degree position. The patient's head is secured by a restraint.
Prone position
Patient lies with stomach on the bed. Abdomen can be raised off the bed.
Jackknife position
Also called the Kraske position. Patient's abdomen lies flat on the bed. The bed
is scissored so the hip is lifted and the legs and head are low.
Knee-chest position
Similar to the jackknife except the legs are bent at the knee at a 90 degree
angle.
Lateral position
Also called the side-lying position, it is like the jackknife except the patient is on
his or her side. Other similar positions are Lateral chest and Lateral kidney.
Lloyd-Davies position
It is a medical term referring to a common position for surgical procedures
involving the pelvis and lower abdomen. The majority of colorectal and pelvic
surgery is conducted with the patient in the Lloyd-Davis position
Kidney position
The kidney position is much like the lateral position except the patient's
abdomen is placed over a lift in the operating table that bends the body to
allow access to the retroperitoneal space. A kidney rest is placed under the
patient at the location of the lift.
Sims' position
The Sims' position is a variation of the left lateral position. The patient is usually
awake and helps with the positioning. The patient will roll to his or her left side.
Keeping the left leg straight, the patient will slide the left hip back and bend the
right leg. This position allows access to the anus.
Postoperative Complications
Circulatory Problems

1. Shock It can be often prevented by attention to fluid balance and the

administration of blood or blood substitutes during and after surgery. There are
several causes of shock, although it usually occurs as the result of a combination
of two or more factors.
Categories of shock:
1. Hematogenic cause by blood loss
2. Neurogenic caused by vasodilatation and reflex inhibition of the heart
brought about by an insult to the nervous system.
3. Cardiogenic results from cardiac failure or an interference with heart
functions and inmyocardial infarction or coronary thrombosis.
4. Vasogenic caused by diffuse vasodilation; blood circulates poorly through
dilated vessels and is not as available to the vital centers (pools in the small
vessels and viscera); may occur in anaphylaxis
5. Toxic or bacteremic thought to be cause by toxic fact that enters the
bloodstream from infection
6. Psychic results from extreme pain, deep fear, or sudden severe emotional
disturbance
Signs and Symptoms of Shock:

The person in shock appears nervous and apprehensive at first, but later
become apathetic.

The skin is cold and moist, and the lips are somewhat cyanotic.

The pulse is rapid and thready, respirations are rapid and shallow, and the
temperature subnormal.

The blood pressure begins to fall.

Treatment of Shock:
o Treatment of shock, defends on the type of shock and the cause.
o The primary treatment of hematogenic shock is restoration of blood volume.
o Primary treatments for other types of shock might include the following:
1. Checking of the airway and theadministration of oxygen,
2. Checking or changing the patients position to relieve pain or assist
the airway.
3. Attention to urinary volume and medication.
o Some of the drugs commonly used to treat shock are:
1. Ephedrine
2. Phenylephrine (Neo-synephrine)
3. Isoproterenol (Isuprel)
4. Atropine
Recovery and Convalescence:
When signs and symptoms of shocks are noted immediately and
treatment is initiated promptly, recovery is usually rapid. The
prognosis becomes more guarded if treatment is delayed.
Therefore prompt and intelligent recognition of the early
manifestations of shock is important.
2. Hemorrhage Hemorrhage may be either evident (can be seen) or concealed
(cannot be seen). Primary hemorrhage occurs at the time of surgery,
intermediate hemorrhage occurs within the first few hours of surgery and
secondary hemorrhage occurs some time after surgery.
Symptoms of Hemorrhage:
o The patient is apprehensive, restless and thirsty.
o The skin is cold, moist and pale; his temperature falls.
o The pulse rate increases and respirations become rapid and deep.
o As hemorrhaging continues the blood pressure continues to fall, and the
patients lips and conjunctivae become pallid.
o He will see spots before his eyes and hear ringing in his ears.
o The patient is weak but conscious.
Treatment of Hemorrhage:
o The surgeon must be notified immediately and emergency measures are
instituted until he arrives.
o The patient should be given oxygen, and the rate of intravenous drip should be
increased.
o His feet should be elevated, if possible.
o Blood pressure should be checked again.
3. Femoral phlebitis or thrombosis Phlebitis or thrombosis occurs most
frequently after operation on the lower abdomen or in the course of severe
septic diseases, such as peritonitis and ruptured ulcer. The condition can be
caused by several factors, including:
a. Injury to the vein by tight straps or leg holders at the time of surgery.
b. Blanket roll under the knees.
c. Concentration of blood by loss of fluid or dehydration.
d. Slowing of the blood flow in the extremity due to a lowered metabolism and
depression of the circulation after operation.
Signs and Symptoms of phlebitis or thrombosis:
o The primary symptom of phlebitis or thrombosis is pain in the calf of the leg
with swelling occurring within 1 to 2 days.
o The patient often ha a slight fever, sometimes with chills and sweat.
Treatment of phlebitis or thrombosis:
o The best treatment of femoral phlebitis or thrombosis is prevention. This is
done by administration of adequate fluids after surgery to prevent
concentration of blood, leg exercise and bandaging the legs with elastic
bandages or antiembolic stockings as necessary.
o Blanket rolls or pillow rolls should not be placed under the knees.
o Early ambulation is also important in preventing phlebitis and thrombosis
because it prevents the stagnation of blood in the veins of the lower
extremities.
o If ordered, intermittent positive pressure breathing (IPPB) therapy may also be
beneficial.
o Active treatment of phlebitis or thrombosis includes ligature or removal of the
affected veins and the administration of heparin.
Pulmonary Complications
Pulmonary complications are the most serious and most common post-
operative complications. They may be avoided in large measure by careful
preoperative observation and teaching and by taking every precaution during
and after surgery.
It is well known that those patients who have a respiratory disease at the time
of surgery are more likely to develop pulmonary complications post-operatively.
Therefore only emergency surgery should be performed on a patient with a
respiratory disease.
Predisposing causes of pulmonary complications include:
o Preoperative trauma
o Infections of the mouth, nose and throat.
o Irritating effect of the anesthetic, especially either on the respiratory mucous
membranes, with a resultant increase in mucus secretion
o Aspirations of vomitus.
o Shallow respirations after the operation because of the pain.
o History of heavy smoking or chronic respiratory diseases.
o Obesity, debilitation, age (very old or very young)
o Smoke inhalation.
1. Atelectasis when the mucous plug closes one of the bronchi entirely, there
is a collapse of the pulmonary tissue beyond the point.

Signs and Symptoms of Atelectasis:

If the lung tissue is involved, the patient will demonstrate the following:
a. Marked dyspnea
b. Cyanosis
c. Prostration and pleural pain (usually referred to lower chest)
d. Fever (common)
e. Tachycardia
f. Anxiety
g. Labored respiration
Treatment of Atelectasis:
o Treatment involved removal of fluid or air by needle aspiration and sedation.
o The incidence of postoperative pulmonary atelectasis has been reduced
significantly as a result of the more conservative and judicious use of
preoperative and postoperative sedation and by early ambulation of
postoperative patients.
o Other pulmonary complications that may occur later in the postoperative
period are bronchitis, pneumonia, hypostatic pulmonary congestion, pleurisy,
and pulmonary embolism.
Urinary Complications

1. Urinary Retention may occur following any operation, but it occurs most
frequently after operations on the rectum, anus, vagina or lower abdomen. The
cause is thought to be a spasm of the bladder sphincter. Treatment depends on
the individual patient but may include diuretics or increasing intravenous fluids.

2. Urinary In continence is a frequent complication in the aged.