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122 Cards in this Set

  • Front
  • Back
Ambulatory Surgery
- Includes outpatient (same-day) surgery that does not require an overnight hospital stay or short stay, with admission to an inpatient hospital setting for less than 24 hours
Informed Consent
The patient’s autonomous decision about whether to undergo a surgical procedure; based on the nature of the condition, the treatment options, and the risks and benefits involved
Physician/Surgeon is responsible for collecting this
Intraoperative Phase
Period of time from when the patient is transferred to the operating room table to when he or she is admitted to the postanesthesia care unit (PACU)
Perioperative Phase
Period of time that constitutes the surgical experience; includes the preoperative, intraoperative, and postoperative phases of nursing care
Postoperative Phase
Period of time that begins with the admission of the patient to the PACU and ends after a follow-up evaluation in the clinical setting or home
Preadmission testing (PAT)
Diagnostic testing performed before admission to the hospital
Preoperative Phase
Period of time from when the decision for surgical intervention is made to when the patient is transferred to the operating room table
What is the #1 concern when the patient is going into surgery?
Anxiety
Definition of Surgery
A branch of medicine concerned with diseases and trauma operative procedures (incision line/via orifice)
Preoperative Phase:
Preadmission Testing
- Initiates initial preoperative assessment
- Initiates teaching appropriate to patient’s needs
- Involves family in interview
- Verifies completion of preoperative testing
- Verifies understanding of surgeon-specific preoperative orders (bowel preparation, preoperative shower)
- Assesses patient’s need for postoperative transportation and care
Preoperative Phase:
Preadmission Testing:
Admission to Surgical Center or Unit
- Completes preoperative assessment
- Assesses for risk for postoperative complications
- Reports unexpected findings or any deviations from normal
- Verifies that operative consent has been signed
- Coordinates patient teaching with other nursing staff
- Reinforces previous teaching
- Explains phases in perioperative period and expectations
- Answers patient’s and family’s questions
- Develops a plan of care
Preoperative Phase:
Preadmission Testing:
Admission to Surgical Center or Unit
In the Holding Area
- Assesses the patient’s status, baseline pain and nutritional status
- Reviews chart
- Identifies patient
- Verifies surgical site and marks site per institutional policy
- Establishes intravenous line
- Administers medications if prescribed
- Takes measures to ensure patient’s comfort
- Provides psychological support
- Communicates patient’s emotional status to other appropriate members of health care team
A surgical procedure may be:
Diagnostic
Curative
Reparative/Restorative
Reconstructive or Cosmetic
Palliative
Transplant
Surgery may also be classified according to degree of urgency involved:
Emergent
Urgent
Required
Elective
Optional
Diagnostic Surgery
Biopsy, exploratory laparotomy
Curative Surgery
- Excision of a tumor or an inflamed appendix
- Localized treatment
Restorative/Reparative
- Multiple wound repair
- Hip Replacement
Cosmetic/Reconstructive Surgery
Mammoplasty or face-lift
Palliative Surgery
Relieve pain or correct a problem
Just taking care of the signs and symptoms
Transplant Surgery
Kidneys, hearts, lungs etc
Emergent Care
- Patient requires immediate attention; disorder may be life-threatening
- Without delay
- Severe bleeding, bladder or intestinal obstruction, fractured skull, gunshot or stab wounds, extensive burns
Urgent Care
- Patient requires prompt attention
- Within 24-30 hours
- Acute gallbladder infection, kidney or ureteral stones
Required Care
- Patient needs to have surgery
- Plan within a few weeks or months
- Prostatic hyperplasia w/o bladder obstruction, thyroid disorders, cataracts
Elective Care
- Patient should have surgery
- Failure to have surgery not catastrophic
- Repair of scars, simple hernia, vaginal repair
Optional Care
- Decision rests with patient
- Personal preference
- Cosmetic surgery
Types of Surgical Facilities
- Hospitals (Large & Small)
- Ambulatory Care
- Walk in Care
- Free-standing Surgical Centers
- On the corners of the streets
- Centracare
- Doctors Offices
Medications with Potential Affect Surgical Experience
Corticosteroids (Prednisone)
Diuretics (HCTZ)/B/P meds
Insulin
Anticoagulants
Thyroid Hormone (Levothyroid)
Informed Consent
- Voluntary and written, is necessary before nonemergent surgery
- It protects the patient from unsanctioned surgery and protects the surgeon
- It is the physician’s responsibility to provide appropriate information
- Nurse may ask patient to sign form and nurse can sign as a witness

- Before patient signs surgeon must provide a clear and simple explanation of what the surgery will entail, explain any benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and lat postoperative periods
- The consent needs to be signed before administering drugs

Voluntary Consent
Incompetent Patient
Informed Subject
Patient able to Comprehend
Informed Consent Signature Is Needed For:
- Invasive procedures, such as surgical incision, biopsy, cystoscopy, or paracentesis
- Procedures requiring sedation and/or anesthesia
- Nonsurgical procedure such as arteriography that carries more than a slight risk to the patient
- Procedures involving radiation
Assessment of Health Factors that Affect Patients Preoperatively
Nutritional and Fluid Status
Drug or Alcohol Use
Respiratory Status
Cardiovascular Status
Hepatic and Renal Function
Endocrine Function
Immune Function
Previous Medication Use
Spiritual and Cultural Beliefs
Gerontologic Surgery Considerations
- Elderly people frequently do not support symptoms
- Key predictors of perioperative complications in the elderly are the patient’s preoperative condition and level of functioning
- Arthritis is common in older people and may affect mobility, making it difficult for the patient to turn from one side to the other or ambulate without discomfort
- Protective measures include adequate padding for tender areas, moving the patient slowly, protecting bony prominences from prolonged pressure, and providing gentle massage to promote circulation
- The condition of the mouth is important to assess
- Dental caries, dentures, and partial plates are particularly significant to the anesthesiologist because they may become dislodged during intubation and occlude the airway
- Precautions are taken when moving an elderly person
- Older people are more susceptible to temperature changes
- Lightweight cotton blanket is an appropriate cover when an elderly patient is moved to and from the OR
- Following factors are critical:
- Skillful preoperative assessment and treatment
- Skillful anesthesia and surgery
- Meticulous and competent postoperative and postanesthesia management
Surgery Considerations For Patients Who Are Obese
- During surgery, fatty tissues are especially susceptible to infection
- Dehiscence (wound separation) and wound infections are more common
- Patients tend to have shallow respirations when supine
Surgery Considerations For Patients With Disabilities
- Special considerations for patients with mental or physical disabilities include the need for appropriate assistive devices, modifications in preoperative teaching, and additional assistance with and attention to positioning or transferring
- Assistive devices include hearing aids, eyeglasses, braces, prostheses, and other devices
- Ensuring the security of assistive devices is important
- Patient with a disability that affects body position (cerebral palsy, postpolio syndrome, other neuromuscular disorders) may need special positioning during surgery to prevent pain and injury
- Patients with respiratory problems related to a disability (multiple sclerosis, muscular dystrophy) may have difficulties unless the problems are made known to the anesthesiologist
Preoperative Nursing Interventions
- Preoperative Teaching
- Nursing Assessment
- Preoperative Psychosocial Interventions
- General Preoperative Nursing Interventions
- Bowel Preparation
- Skin Preparation
- Fluid &Nutrition Management
- Immediate Preoperative Nursing interventions
- Maintaining Records
- Administering Medications
- Transporting Patient to Presurgical Area
Preoperative Teaching
- Preoperative teaching is initiated as soon as possible
- Should start in the physician’s office or at the time of PAT and continue until the patient arrives in the OR
- Deep Breathing, Coughing, and Incentive Spirometry
- Mobility and Body Movement
Instruction for Patients Undergoing Ambulatory Surgery
- Preoperative teaching content should include:
- Answering questions and describing what to expect
- Tells the patient when and where to report
- What to bring (insurance card list of medications and allergies)
- What to leave at home (jewelry, watch, medications, contact lenses)
- What to wear (loose-fitting, comfortable clothes, flat shoes)
- During final preoperative telephone call, teaching is completed or reinforced as needed, last minute instructions are given
- Patient is reminded not to eat or drink as directed
General Preoperative Nursing Interventions
- Maintaining Patient Safety
- Managing Nutrition and Fluids
- Preparing the Bowel
- Preparing the Skin
- Immediate Preoperative Nursing Interventions
- Administering Pre-anesthetic Medication
- Maintaining the Preoperative Record
- Nurse completes the preoperative checklist
- Transporting the Patient to the Presurgical Area
- Attending to Family Needs
Anesthesia
A state of narcosis, analgesia, relaxation, and loss of reflexes
Anesthesiologist
Physician trained to deliver anesthesia and to monitor the patient’s condition during surgery
Anesthetic
The substance, such as a chemical or gas, used to induce anesthesia
Anesthetist
Health care professional, such as a nurse anesthetist, who is trained to deliver anesthesia and to monitor the patient’s condition during surgery
Circulating Nurse (Or circulator)
RN who coordinates and documents patient care in the operating room
Moderate Sedation
Use of sedation to depress the level of consciousness without altering the patient’s ability to maintain a patent airway and to respond to physical stimuli and verbal commands, previously referred to as conscious sedation
Monitored Anesthesia Care (MAC)
Moderate sedation administered by an anesthesiologist or anesthetist
Restricted Zone
Area in the operating room where scrub attire and surgical masks are required; includes operating room and sterile core areas
Scrub Role
RN, licensed practical nurse, or surgical technologist who scrubs and dons sterile surgical attire, prepares instruments and supplies, and hands instruments to the surgeon during the procedure
Semi-restricted Zone
- Area in the operating room where scrub attire is required; may include areas where surgical instruments are processed
Surgical Asepsis
Absence of microorganisms in the surgical environment to reduce the risk for infection
Unrestricted Zone
- Area in the operating room that interfaces with other departments; includes patient reception area and holding area
Surgical team consists of the:
Patient
Anesthesiologist or anesthetist
Surgeon
Nurses
Surgical technologists
Circulating Nurse
- Coordinates the care of the patient in the OR
- Advocate of the patient
- Makes sure there are no instruments left in the patient
- Includes assisting with:
- Patient positioning
- Preparing the patient’s skin for surgery
- Managing surgical specimens
- Documenting intraoperative events
Main responsibilities of Circulating Nurse include:
- Verifying consent
- Coordinating the team
- Ensuring cleanliness
- Proper temperature, humidity, lighting
- Safe function of equipment
- Availability of supplies and materials
- Monitors aseptic technique

- Is responsible for ensuring that the second verification of the surgical procedure and site takes place and is documented
- Referred to as a “surgical procedure pause” or “time-out” that takes place among the surgical team prior to incision
- Every member of the surgical team verifies the patient’s name, procedure, and surgical site using objective documentation and data before beginning the surgery
Scrub Role
- Activities include:
- Performing a surgical hand scrub
- Setting up the sterile tables
- Preparing sutures, ligatures, and special equipment (laparoscope)
- Assisting the surgeon and the surgical assistants
- Surgical incision is closed, the scrub person and the circulator count all needles, sponges, and instruments to be sure they are accounted for and not retained as a foreign body in the patient
- Standards call for all sponges to be visible on x-ray and for sponge counts to take place at the beginning of surgery and twice at the end
- Tissue specimens obtained during surgery are labeled by the scrub person and sent to the laboratory by the circulator
RN First Assistant
- Practices under direct supervision of the surgeon
- Responsibilities include:
- Handling tissue
- Providing exposure at the operative field
- Suturing
- Maintaining hemostasis
- Must be aware of the objectives of the surgery
- Must have knowledge and ability to anticipate needs and to work as skilled member of team
- Must be able to handle any emergency situation in the OR
During Surgery Monitor the Patient's:
Blood pressure
Pulse
Respirations
Electrocardiogram (ECG)
Blood oxygen saturation level
Tidal volume
Blood gas levels
Blood pH
Alveolar gas concentrations
Body temperature
ASA Physical Classification System
P1
- Normal healthy patient
- Ex: No systemic abnormality, localized infection without fever, benign tumor, hernia
P2
- Patient with mild systemic disease, without functional limitations
- Ex: Well controlled hypertension, diabetes mellitus, chronic bronchitis, obesity, age over 80 years
P3
- Patient with severe systemic disease associated with functional limitations
- Ex: Severe disease, compensated heart failure, myocardial infarction more than 6 months ago, angina pectoris, severe dysrhythmia, cirrhosis, poorly controlled diabetes or hypertension, ileus
P4
- Patient with an incapacitating systemic disease that is a constant threat to life
- Ex: Severe heart failure, myocardial infarction less than 6 months ago, severe respiratory failure, advanced liver or renal failure
P5
- Moribund patient who is not expected to survive for 24 hours with or without operation
- Ex: Unconscious patient with traumatic head injury and agonal respirations
P6
- Patient is brain dead and is being prepared as an organ donor
Surgical Environment
- To help decrease microbes the surgical area is divided into 3 zones:
- Unrestricted Zone
- Where street clothes are allowed
- Semi-restricted Zone
- Where attire consists of scrub clothes and caps
- Restricted Zone
- Where scrub clothes, shoe covers, caps and masks are worn
Basic Guidelines for Maintaining Surgical Asepsis
- All materials in contact with the surgical wound or used within the sterile field must be sterile
- Gowns of the surgical team are considered sterile in from from the chest to the level of the sterile field
- Sterile drapes are used to create a sterile field
- Only the top surface of a draped table is considered sterile
- Items are dispensed to a sterile field by methods that preserve the sterility of the items and the integrity of the sterile field
- The movements of the surgical team are from sterile to sterile areas and from unsterile to unsterile areas
- Movement around a sterile field must not cause contamination of the field
- At least 1 ft distance form the sterile field must be maintained to prevent inadvertent contamination
- Whenever a sterile barrier is breached the area must be considered contaminated
- Every sterile field is constantly monitored and maintained
- The routine administration of hyperoxia (high levels of oxygen) is NOT recommended to reduce surgical site infection
General Anesthesia Info and Stages
- Anesthesia is the state of narcosis (severe central nervous system depression produced by pharmacologic agents)
- Patients under general anesthesia are not arousable, not even to painful stimuli
- The lose the ability to maintain ventilatory function and require assistance in maintaining a patent airway
- Cardiovascular function may be impaired as well
- General anesthesia consists of 4 stages:
- Stage 1: Beginning anesthesia
- Patient breathes in anesthetic mixture, warmth, dizziness and a feeling of detachment may be experienced
- Noises are exaggerated
- Stage 2: Excitement
- Characterized variously by struggling, shouting, talking, singing, laughing, or crying is often avoided if the anesthetic is administered smoothly and quickly
- Pulse rate is rapid, and respirations may be irregular
- Stage 3: Surgical Anesthesia
- Patient is unconscious and lies quietly on the table
- Respirations are regular, pulse rate and volume are normal, skin is pink or slightly flushed
- Stage 4: Medullary Depression
- Reached when too much anesthesia has been administered
- Respirations become shallow
- Pulse is weak and thready
- Pupils become widely dilated and no longer contract when exposed to light
- Cyanosis develops followed quickly by death
General Anesthesia Inhalation Administration
- Inhales anesthetic agents include volatile liquid agents and gases
- All are administered with oxygen and usually with nitrous oxide as well
- Gas anesthetics are administered by inhalation and are always combined with oxygen
- Nitrous oxide is the most commonly used gas anesthetic agent
- The anesthetics enter the blood through the pulmonary capillaries and act on cerebral centers to produce loss of consciousness and sensation
- Gas is eliminated through the lungs
- Inhalation anesthetic may be administered through an LMA
- Flexible tube with an inflatable silicone ring and cuff that can be inserted into the larynx
- Endotracheal technique can be inserted through either the nose or mouth
- When in place the tube seals off the lungs from the esophagus so that, if the patient vomits, stomach contents do not enter the lungs
General Anesthesia IV Administration
- General anesthesia by IV of various substances:
- Barbiturates
- Benzodiazepines
- Nonbarbiturate hypnotics
- Dissociative agents
- Opioid agents
- Often used in combination with inhalation anesthetics or used alone
- They may also produce moderate sedation
- Advantage of IV is that the onset of anesthesia is pleasant
- There is no buzzing, roaring or dizziness known to follow administration by inhalation
- Low incidence of postoperative nausea and vomiting makes IV usedful in eye surgery
- Not indicated for children who have small veins or for those who require intubation because of their susceptibility to respiratory obstruction
- Disadvantage is thiopental (Pentothal) is its powerful respiratory depressant effect
Sneezing, coughing and laryngospasm are sometimes noted with its use
- IV neuromuscular blockers (muscle relaxants) block the transmission of nerve impulses in skeletal muscles
- Used to relax muscles in abdominal and thoracic surgery
- Relax eye muscles in eye surgery
- Facilitate endotracheal intubation
- Treat laryngospasm
- Assist in mechanical ventilation
Regional Anesthesia
- Regional anesthesia is a form of local anesthesia in which an anestetic agent is injected around nerves so that the area supplied by these nerves is anesthetized
- Local anesthetic blocks motor nerves least readily and sympathetic nerves most readily
- Anesthetic cannot be regarded as having worn off until all three systems (motor, sensory and autonomic) are no longer affected
- Patient is awake and aware of his or her surroundings
- Diagnosis must not be states aloud if the patient is not to know at this time
Epidural Anesthesia
- Commonly used conduction block, is achieved by injecting a local anesthetic into the epidural space that surrounds the dura mater of the spinal cord
- Epidural anesthesia blocks sensory, motor, and autonomic functions: it differs from spinal anesthesia by the site of the injection and the amount of the anesthetic agent used
- Doses are much higher because the epidural anesthetic does not make direct contact with the spinal cord or nerve roots
- An advantage is the absence of headache
- Disadvantage is the greater technical challenge of introducing the anesthetic into the epidural rather than the subarachnoid space
- If inadvertent puncture of the dura occurs, high spinal anesthesia can result, produce severe hypotension and respiratory depression and arrest
- Treatment of these complications includes airway support, IV fluids, and use of vasopressors
Spinal Anesthesia
- Is an extensive conduction nerve block that is produced when a local anesthetic is introduced into the subarachnoid space at the lumbar level, usually between L4-L5
- Produces anesthesia to lower extremities, perineum, and lower abdomen
- Patient usually lies on the side in a knee-chest position
- Sterile technique is used
- Once injection is made, patient lies on his back
- If relatively high level of block is sought, the head and shoulders are lowered
- Spread of anesthetic agent depend on:
- The amount of fluid injected
- The speed with which it is injected
- The positioning of the patient afterward
- The specific gravity of the agent
- If specific gravity is greater than the cerebrospinal fluid (CSP) the agent moves to dependent position of subarachnoid space
- If specific gravity is less than CSF than anesthetic moves away from dependent position
- Once injected anesthesia and paralysis affect the toes and perineum, then legs and abdomen
- If anesthetic reaches upper thoracic and cervical spinal cord in high concentrations, temporary partial or complete respiratory paralysis results
- Managed by mechanical ventilation until effect wears off
- Nausea, vomiting and pain may occur during surgery
- Simultaneous IV of thiopental and inhalation of nitrous oxide may prevent these reactions
- Several factors are related to incidence of headache:
- The size of spinal needle used
- Leakage of fluid from the subarachnoid space through the puncture site
- The patient’s hydration status
- Measures that increase cerebrospinal pressure are helpful in relieving headache
- Ex: quiet environment
- Patient lying flat
- Keeping patient well hydrated
- If it is a continuous spinal anesthesia the tip of the plastic catheter remains in the subarachnoid space

Moderate/Sedation/Analgesia
- Monitored anesthesia care (MAC) aka monitored sedation
- Administered by anesthetist that must be prepared and qualified to convert to general anesthesia if necessary
- MAC may be used for healthy patients undergoing relatively minor surgical procedures, critically ill patients who may be unable to tolerate anesthesia without extensive invasive monitoring and pharmacologic support
Local Anesthesia (Local Blocks)
- Infiltration anesthesia is the injection of a solution containing the local anesthetic into the tissues at the planned incision site
- Often is combined with local regional block
- Administered in combination with epinephrine
- Epinephrine constricts blood vessels which prevents rapid absorption of the anesthetic agent
- Rapid absorption into the bloodstream could cause seizures and also can be prevented
- Local anesthesia is the preferred method of choice in any surgical procedure
- Contraindications include high preoperative levels of anxiety
- The skin is prepared as for any surgical procedure
- Small gauge needle is used and inserts med into skin causing it to blanch or wheal (bump)
- The action of the agent is almost immediate
- Last 45 minutes - 3 hours
Potential Intraoperative Complications
Nausea and vomiting
Anaphylaxis
Hypoxia
Hypothermia
Malignant hyperthermia
Disseminated intravascular coagulopathy (DIC)
Nausea and Vomiting Complications
- If gagging occurs, the patient is turned to the side, the head of the table is lowered and a basin is provided to collect the vomitus
- Suction is used to remove saliva and vomited gastric contents
- If the patient aspirates vomitus, an asthma like attack with severe bronchial spasms and wheezing is triggered
- Pneumonitis and pulmonary edema can subsequently develop, leading to extreme hypoxia
- Patients may be given Bicitra, a clear nonparticulate antacid to increase gastric fluid pH or a histamine-2 (Zantac) or famotidine (Pepcid) to decrease gastric acid production
- Patient will get antiemetic and fluid replacement
Anaphylaxis Complications
- Medications are the most common cause of anaphylaxis
- The reaction may be immediate or delayed
- Anaphylaxis is a life-threatening acute allergic reaction
- Fibrin sealants are used in a variety of surgical procedures, and cyanoacrylate tissue adhesives are used to close wounds without the use of sutures
- Observe the patient for changes in vital signs and symptoms of anaphylaxis when these products are used

Hypoxia and Other Respiratory Complications
- Inadequate ventilation occlusion of the airway, inadvertent intubation of the esophagus, and hypoxia are significant potential complications associated with general anesthesia
- Respiratory depression caused by anesthetic agents, aspiration of respiratory tract secretions or vomitus, and the patient’s position on the operating table can compromise the exchange of gases
- Asphyxia caused by foreign bodies in the mouth, spasm of the vocal cords, relaxation of the tongue, or aspiration of vomitus, saliva, or blood can occur
- Vigilant monitoring of the patient’s oxygenation status is a primary function of the anesthesiologist or anesthetist and the circulating nurse
- Peripheral perfusion is checked frequently and pulse oximetry values are monitored continuously
- Want to prevent pneumonia at all cost!!
Hypothermia Complications
- During anesthesia, the patient’s temperature may fall
- Glucose metabolism is reduced, metabolic acidosis may develop
- Called hypothermia indicated by core body temperature that is lower than normal (36.6˚C (98˚F) or less)
- Hypothermia may also be intentionally induced in selected surgical procedures (cardiac surgeries requiring cardiopulmonary bypass) to reduce the patient’s metabolic rate and energy demands
- If hypothermia occurs the goal of intervention is to minimize or reverse the physiologic process
- Environmental temperature of OR can temporarily be set at 25˚-26.6˚C (78˚-80˚F)
- IV and irrigating fluids are warmed to 37˚C (98.6˚F)
- Wet gowns and drapes are removed promptly and replaced with dry materials
- Warming must be accomplished gradually, not rapidly
- Conscientious monitoring of:
- Core temperature
- Urinary output
- ECG
- Blood pressure
- Arterial blood gas levels
- Serum electrolyte levels is required
Malignant Hyperthermia Complications
- Is a rare inherited muscle disorder that is chemically induced by anesthetic agents
- Identification of patients at risk for malignant hyperthermia is imperative
- Susceptible people include those with strong and bulky muscles, history of muscle cramps or muscle weakness and unexplained temperature elevation, and an unexplained death of a family member during surgery that was accompanied by a febrile response
Pathophysiology of Malignant Hyperthermia
- Is related to a hypermetabolic condition in skeletal muscle cells that involves altered mechanisms of calcium function at the cellular level
- This disruption of calcium causes clinical symptoms of hypermetabolism, which in turn increases muscle contraction (rigidity) and causes hyperthermia and subsequent damage to the CNS
Clinical Manifestations of Malignant Hyperthermia
- Initial symptoms are related to cardiovascular and musculoskeletal activity
- Tachycardia (heart rate greater than 150 bpm) is often the earliest sign
- Sympathetic nervous stimulation leads to ventricular dysrhythmias, hypotension, decreased cardiac output, oliguria, and later cardiac arrest
- With abnormal transport of calcium, rigidity or tetanus-like movements occur, often in the jaw
- Rise in temperature is actually a late sign that develops rapidly
- Body can increase 1-2˚C (2-4˚F) every 5 minutes
- Core body temperature can reach or exceed 42˚C(104˚F)
Medical Management of Malignant Hyperthermia
- Recognizing symptoms early and discontinuing anesthesia prompty are imperative
- Goals of treatment are to:
- Decrease metabolism
- Reverse metabolic and respiratory acidosis
- Correct dysrhythmias
- Decrease body temperature
- Provide oxygen and nutrition to tissues
- Correct electrolyte imbalance
- As soon as the diagnosis is made, anesthesia and surgery are halted and patient is hyperventilated with 100% oxygen
- Dantrolen sodium (Dantrium) a skeletal muscle relaxant, and sodium bicarbonate are administered immediately
- Malignant hyperthermia usually manifests about 10-20 minutes after induction of anesthesia, it can also occur during the first 24 hours after surgery
Disseminated Intravascular Coagulation
- Aka Coagulopathy (DIC) is a life-threatening condition that is characterized by thrombus formation in the microcirculation and depletion of select coagulation proteins, causing hemorrhaging
- Exact cause is unknown but predicting factors include many conditions that may occur with emergency surgery:
- Massive trauma
- Head injury
- Massive transfusion
- Liver or kidney involvement
- Embolic events and shock
Laboratory/Diagnostic Assessments
- Hemoglobin/Hematocrit
- Electrolyte levels (Potassium)
- Clotting studies: PT, aPTT, INR
- Urinalysis
- Blood type and crossmatch
- Pregnancy test
- Chest xray
- TB
- Electrocardiogram
Nursing Interventions - Pre-Intraoperative
- Reducing Anxiety
- Preventing Intraoperative Positioning Injury
- Dorsal Recumbent Position
- The usual position for surgery
- One arm at side of table - palm down
- Other arm on arm board
- This position is used for most abdominal surgeries except for surgery of the gallbladder or pelvis
- Trendelenburg Position
- Used for surgery on the lower abdomen and pelvis to obtain good exposure by displacing the intestines into the upper abdomen
- Head and body are lowered and held in position by padded shoulder braces
- Lithotomy Position
- Used for nearly all perineal, rectal and vaginal surgical procedures
- Maintained by placing the feet in stirrups
- Sims or Lateral Position (Side Lying Position)
- Used for renal surgery
- Patient is placed on non-operative side with an air pillow 5-6 inches think under the loin or on a table with a kidney or back lift
- Positioned for a laparotomy
Surgical Attire
- OR attire includes close fitting cotton dresses, pantsuits, jumpsuits, and gowns
- Knitted cuffs on sleeves and pant legs, prevent organisms shed from the perineum, legs, and arms from being released into the immediate surroundings
- Masks are worn at all times in the restricted zone
- Masks are changed between patients and should not be worn outside the surgical department
- Masks cannot be worn around the neck hanging - must be on or off
- Headgear should completely cover the hair
- Shoe covers should be changed whenever they become wet, torn or soiled
Conscious sedation
- IV delivery of sedatives, hypnotics, opioids to reduce level of consciousness
- Patient can respond to verbal commands/physical stimulation
Reversal agents:
- Narcan (naloxone hydrochloride) for Narcotics - morphine

- Romazicon (flumazenil) for Benzodiazepines - Versed
First-intention Healing
Method of healing in which wound edges are surgically approximated and integumentary continuity is restored without granulation
Phase 1 PACU
Area designated for care of surgical patients immediately after surgery and for patients whose condition warrants close monitoring
Phase 2 PACU
Area designated for care of surgical patients who have been transferred from a phase 1 PACU because their condition no longer requires the close monitoring provided in phase 1 PACU
Phase 3 PACU
Setting in which the patient is cared for in the immediate postoperative period and then prepared for discharge from the facility
Postanesthesia Care Unit (PACU)
Area where postoperative patients are monitored as they recover from anesthesia; formerly referred to as the recovery room or postanesthesia recovery room
Second-Intention Healing
Method of healing in which wound edges are not surgically approximated and integumentary continuity is restored by the process known as granulation
Third-Intention Healing
- Method of healing in which surgical approximation of wound edges is delayed and integumentary continuity is restored by apposing areas of granulation
Communicates Intraoperative Information
- Identifies patient by name
- States type of surgery performed
- Identifies type of anesthetic used
- Reports patient’s response to surgical procedure and anesthesia
- Describes intraoperative factors (insertion of drains or catheters, administration of blood, analgesic agents, or other medications during surgery, occurrence of unexpected events)
- Describes physical limitations
- Reports patient’s preoperative level of consciousness
- Communicates necessary equipment needs
- Communicates presence of family and/or significant others
Postoperative Assessment Recovery Area Duties
- Determines patient’s immediate response to surgical intervention
- Monitor's patient’s physiologic status
- Assesses patient’s pain level and administers appropriate pain relief measures
- Maintains patient’s safety (airway, circulation, prevention of injury)
- Administers medications, fluid, and blood component therapy, if prescribed
- Provides oral fluids if prescribed for ambulatory surgery patient
- Assesses patient’s readiness for transfer to in-hospital unit or for discharge home based on institutional policy
Postanesthesia Care Unit (PACU)
- Also called the recovery room is located adjacent to the operating rooms suite
- PACU nurse provides frequent (every 15 minutes) monitoring of the patient’s:
- Pulse
- Electrocardiogram
- Respiratory rate
- Blood pressure
- Pulse oximetry value (blood oxygen level)
- Sometimes the end-tidal carbon dioxide (ETCO2) levels
Admitting the Patient to the PACU
- Transferring the postoperative patient from the OR to the PACU is the responsibility of the anesthesiologist or anesthetist
- The surgical incision is considered every time the postoperative patient is moved
- As soon as the patient is placed on the stretcher or bed, the soiled gown is removed and replaced with a dry gown
- Three side rails may be raised to prevent falls initially
Nursing Management in the PACU:
Assessing the Patient
- Blood oxygen saturation level
- Pulse rate and regularity
- Depth and nature of respirations
- Skin color
- Level of consciousness
- Ability to respond to commands are the cornerstones of nursing care in PACU
- The patient’s vital signs and general physical status are assessed at least every 15 minutes
- Patency of the airway and respiratory function are always evaluated first
- Followed by assessment of cardiovascular function, the condition of the surgical site and function of the CNS
Maintaining a Patent Airway
- Primary objective in the immediate postoperative period is to maintain pulmonary ventilation and thus preventing hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood)
- Relaxation extends to the muscles of the pharynx
- Hypopharyngeal obstruction
- When patient lies on his back the lower jaw and the tongue fall backward and the air passages become obstructed
- Signs of occlusion include choking, noisy and irregular respirations, decreased oxygen saturation scores and within minutes- a blue dusky color (cyanosis) of the skin
- Nurse needs to place the palm of the hand at the patient’s nose and mouth to feel the exhaled breath
- Treatment of hypopharngeal obstruction involves tilting the head back and pushing forward on the angle of the lower jaw as if to push the lower teeth in front of the upper teeth
- This maneuver pulls the tongue forward and opens the air passages
- Respiratory difficulty can also result from excessive secretion of mucus or aspiration of vomitus
- Turning the patient to one side allows the collected fluid to escape from the side of the mouth
- The head of the bed is elevated to 15-30˚ unless contraindicated
- A catheter can be passed into the nasopharynx or oropharynx safely to a distance of 6-8 inches
- Caution is necessary in suctioning the throat of a patient who has had a tonsilectomy or other oral or laryngeal surgery because of risk of bleeding and discomfort

Maintaining Cardiovascular Stability
The nurse assesses:

Patient’s mental status
Vital signs
Cardiac rhythm
Skin temperature, color and moisture
Urine output
Patency of all IV lines
Primary cardiovascular complications include:
Hypotension and shock
Hemorrhage
Hypertension
Dysrhythmias
Hypotension and Shock
- Hypotension can result from blood loss, hypoventilation, position changes, pooling of blood in the extremities or side effects of medications and anesthetics
- If the amount of blood loss exceeds 500 mL (especially if loss is rapid) replacement is usually indicated
- Shock
- Can result from hypovolemia and decreased intravascular volume
- Types of shock are classified as hypovolemic, cardiogenic, neurogenic, anaphylactic, septic shock
- Signs of shock:
- Pallor
- Cool moist skin
- Rapid breathing
- Cyanosis of the lips, gums, tongue
- Rapid, weak thready pulse
- Narrowing pulse pressure
- Low blood pressure
- Concentrated urine
- Hypovolemic Shock can be avoided largely by the timely administration of IV fluids, blood, blood products and medications that elevate blood pressure
- Volume replacement is the primary intervention for shock
- An infusion of lactated Ringer’s solution, 0.9% sodium chloride solution, colloids, or blood component therapy is initiated
- Oxygen is administered by nasa cannula, face mask, or mechanical ventilation
- Patient is placed flat in bed with legs elevated
- Respiratory rate, pulse rate, blood pressure, blood oxygen concentration, urinary output, level of consciousness, central venous pressure, pulmonary artery pressure, pulmonary capillary wedge pressure, cardiac output are monitored to provide information on the patient’s respiratory and cardiovascular status
Hemorrhage
- Is an uncommon yet serious complication of surgery that can result in death
- Blood loss is extreme, the patient is apprehensive, restless and thirsty
- Symptoms:
- Skin is cold, moist, and pale
- Pulse rate increases, temperature falls and respirations are rapid and deep, often of the gasping type spoken of as “air hunger”
- If untreated, cardiac output decreases, arterial and venous blood pressure and hemoglobin level fell rapidly, the lips and the conjunctivae become pale, spots appear before the eyes, a ringing is heard in the cars and the patient grows weaker but remains conscious until near death
- Transfusing blood or blood products and determining the cause of hemorrhage are the initial therapeutic measures
- The surgical site and incision should be inspected for bleeding
- If evident a sterile gauze and pressure dressing are applied
- Patient is placed in the shock position (flat on back at a 20˚ angle, knees kept straight)
Hypertension and Dysrhythmias
- Hypertension is common in the immediate postoperative period secondary to sympathetic nervous system stimulation from pain, hypoxia, or bladder distention
- Dysrhythmias are associated with electrolyte imbalance, altered respiratory function, pain, hypothermia, stress, and anesthetic agents
- Both hypertension and dysrhythmias are managed by treating the underlying causes
Controlling Nausea and Vomiting
- Nausea and vomiting are common issues in the PACU
- Medications such as:
- Metoclopramide (Reglan)
- Prochlorperazine (Compazine)
- Promethazine (Phenergan)
- Dimenhydrinate (Dramamine)
- Hydroxyzine (Vistaril, Atarax)
- Scopolamine (Transderm-Scop) are commonly prescribed
- It is important to evaluate the patient’s level of risk for postoperative nausea and vomiting (PONV)
- There are a range of treatments:
- No prophylactic antiemetics (for low-risk patients) to double and triple antiemetic combinations for patients at high risk for PONV
- High risk patients are:
- Females
- Nonsmokers
- Those with a history of PONV or motion sickness
- Patients undergoing surgical procedures lasting longer than 2 hours
- At the slightest indication of nausea, the patient is turned completely to one side to promote mouth drainage and prevent aspiration of vomitus which can cause asphyxiation and death
Determining Readiness for Discharge from PACU
- Indicators of recovery include:
- Stable blood pressure
- Adequate respiratory function
- Adequate oxygen saturation level compared with baseline
- Spontaneous movement or movement on command
- Orientation to person, place, time
- Uncompromised pulmonary function
- Pulse oximetry readings indicating adequate blood oxygen saturation
- Urine output at least 30mL/hour
- Nausea and vomiting absent or under control
- Minimal pain
- Many hospitals use a scoring system (Aldrete score) to determine the patient’s general condition and readiness for transfer from the PACU
- The patient’s physical signs are observed and evaluated by means of a scoring system based on a set of objective criteria
- A score of less than 7 must remain in PACU until their condition improves
Nursing Management After Surgery
- In the initial hours after admission to the clinical unit, adequate ventilation, hemodynamic stability, incisional pain, surgical site integrity, nausea and vomiting, neurologic status, and spontaneous voiding are primary concerns
- Pulse rate, blood pressure, and respiration rate are recorded at least every 15 minutes for first hour and every 30 minutes for the next 2 hours
- Temperature is monitored every 4 hours for the first 24 hours
- By next morning, patient should have begun their breathing and leg exercises, many will have dangled their legs and ambulated a little
- Many will have tolerated a light meal and had IV fluids discontinued
- Focus of care shifts
- Focus shifts to regaining independence with self-care and preparing for discharge
- Atelectasis, pneumonia, deep vein thrombosis, pulmonary embolism, bleeding, constipation, paralytic ileus, wound infection are ongoing threats for postoperative patient
Postoperative Nursing Assessment
- Respiratory status is important, because pulmonary complications are among the most frequent and serious problems encountered by the surgical patient
- Nurse observes for airway patency, watching for laryngeal edema
- Quality of respirations, including depth, rate, and sound are assessed regularly
- Chest auscultation verifies that breath sounds are normal (or abnormal) bilaterally, and the findings are documented as a baseline
- Shallow or rapid respirations may be caused by pain, constricting dressings, gastric dilation, abdominal distention or obesity
- The patient’s appearance, pulse, respirations, blood pressure, skin color (adequate or cyanotic) and skin temperature (cold and clammy, warm and moist, or warm and dry) are clues to cardiovascular function
- Nurse also assesses the patient’s mental status and level of consciousness, speech, and orientation and compares them with the preoperative baseline
- Change in mental status or postoperative restlessness may be related to anxiety, pain, or medications, it may also be a symptom of oxygen deficit or hemorrhage
- These serious causes must be investigated and excluded before other causes are pursued
- General discomfort may be relieved by administering the prescribed analgesics, changing the patient’s position frequently, and assessing and alleviating the cause of anxiety
Preventing Respiratory Complications
- Decreased mobility puts the patient at risk for common respiratory complications, particularly atelectasis, pneumonia, and hypoxemia
- Signs and symptoms include:
- Decreased breath sounds over affected area
- Crackles and cough
- Pneumonia is characterized by:
- Chills and fever
- Tachycardia
- Tachypnea
- Hypostatic pulmonary congestion caused by a weakened cardiovascular system that permits stagnation of secretions at lung bases, may develop
- Occurs most frequently in elderly patients who are not mobilized effectively
- Symptoms are often vague with perhaps slight elevation of temperature, pulse, and respiratory rate as well as cough
- Physical exam reveals dullness and crackles at the base of the lungs
Types of hypoxemia are subacute and episodic
- Subacute hypoxemia is a constant low level of oxygen saturation, although breathing appears normal
- Episodic hypoxemia develops suddenly and the patient may be at risk for cerebral dysfunction, myocardial ischemia, and cardiac arrest
- Patients who have undergone major surgery, are obese, or have preexisting pulmonary problems
- Hypoxemia can be detected by pulse oximetry which measure blood oxygen saturation
- Factors that may affect the accuracy of pulse oximetry readings include cold extremities, tremors, atrial fibrillation, acrylic nails, black or blue nail polish
First intention Healing
- Wounds made aseptically with a minimum of tissue destruction that are properly closed heal with little tissue tension reaction
- Granulation tissue is not visible and scar formation is minimal
Second Intention Healing
- Granulation occurs in infected wounds (abscess) or in wounds in which the edges have not been approximated
- Gauze packing is inserted into the abscess pocket to allow drainage to escape easily
- Healing is complete when skin cells (epithelium) grow over these granulations
- This method of repair is called healing by granulation, and it takes place whenever pus is formed or when loss of tissue has occurred for any reason
Third Intention Healing
- Secondary suture is used for deep wounds that either have not been sutured early or break down and are resutured later, thus bringing together two apposing granulation surfaces
- Results in a deeper and wider scar
- Wounds are packed postoperatively with moist gauze and covered with a dry sterile dressing
Narcotics
- Morphine and Dilatin (SP?) most commonly used
- Morphine with other stuff
- Given for any pain we might give them while they are still awake
Sedatives - Hypnotic
Relax the patient and calm them down
Anticholinergic
- It suppresses secretions
- GI tract
- Kidneys
- Must make sure patient has at least 30 ml/hr or may be going into acute renal failure
Amnesics
They don’t remember anything
Immediately report any of these signs of infection with the wound:
- Redness, marked swelling exceeding ½ inch from incision site, tenderness, or increased warmth around wound
- Red streaks in skin around wound
- Pus or discharge, foul odor
- Chills or temperature higher than 37.7˚C (100˚F)
Nasogastric tube inserted before surgery may remain in place until:
Full peristaltic activity (indicated by passage of flatus) has resumed
Managing Voiding
- The patient is expected to void within 8 hours after surgery (this includes the time spent in the PACU)
- If the patient cannot void in the specified time frame, the patient is catheterized and the catheter is removed after the bladder has emptied
- Straight intermittent catheterization is preferred
- Intermittent catheterization may be prescribed every 4-6 hours until the patient can void simultaneously and the post void residual is less than 100 mL
Maintaining a Safe Environment with the Bed etc
- During the immediate postoperative period you can have 3 side rails up, and the bed should be in the low position
- All objects the patient may need should be within reach, especially the call light
- Assessment includes having the patient move the hand or foot distal to the surgical site through a full range of motion, assessing all surfaces for intact sensation, and assessing peripheral pulses
Deep Vein Thrombosis Complications
- The first symptom of may be a pain or cramp in the calf
- Initial pain and tenderness may be followed by a painful swelling of the entire leg, often accompanied by a fever, chills, and diaphoresis
- It is important to avoid the use of blanket rolls, pillow rolls, or any form of elevation that can constrict vessels under the knees, even dangling
Infection (Wound Sepsis)
- Administration of supplemental oxygen during colorectal resection and for 2 hours postoperatively has been shown to reduce the incidence of postoperative infection
- Wound infection may not be evident until at least postoperative day 5
- Signs and symptoms of wound infection include increased pulse rate and temperature, and elevated white blood cell count, wound swelling, warmth, tenderness, or discharge, and incisional pain
- Staphylococcus Aureus accounts for many postoperative wound infections
Evisceration
- When the edges separate slowly, the intestines may protrude gradually or not at all, and the earliest sign may be a gush of bloody (serosanguineous) peritoneal fluid from the wound
- Patient may report that “something gave way”
- Causes pain and maybe associated with vomiting
Types of Drains
Penrose
T-Tube
Jackson-Pratt
Hemo-vac
Complication Prevention
Ambulation
Stress related to Surgery
General adaptation syndrome
Elevated BP, P, R
Skin cool and pale
Tendency for increased blood clotting