PERIOPERATIVE

Clinical Instructor: Keith C. Lambojon, RN

does not cure.
PERIOPERATIVE NURSING
- Example:
- Used to describe the nursing care provided in the total o Colostomy
surgical experience of the patient o Debridement of necrotic tissue
- Has 3 phases: o Rhizotomy
TRANSPLANT
PHASES START END - To replace organs or structure that are diseased or
malfunctioning.
PREOPERATIVE Decision of Transport to OR - WOF: Risk of rejection
patient to o Signs:
have surgery ▪ High HR, BP
is made ▪ Febrile
(signed
▪ Anuria (common) or oliguria
informed
consent) ▪ Elevated WBC
o To prevent rejection, administer:
INTRAOPERATIVE OR table Transport to ▪ Immunosuppressant or steroids
PACU • AT RISK for infection.
• Restrict visitors
POSTOPERATIVE Admission to Wound is - Examples:
PACU completely o Kidney transplant
healed o Corneal transplant
o Liver transplant

AESTHETIC
- To improve physical features that are NORMAL. -
TYPES OF SURGERY Examples:
ACCORDING TO PURPOSE o Rhinoplasty
DIAGNOSTIC
- To confirm and establish diagnosis. ACCORDING TO DEGREE OF URGENCY
- Examples: EMERGENT
o Biopsy - Requires IMMEDIATE action.
o Exploratory laparotomy - Without any delay
- May be life-threatening.
EXPLORATORY - Performed immediately to preserve life
- To know the EXTENT of the disease. - Examples:
- Examples: o Skull fractures
o Exploratory laparotomy o Intestinal obstruction
o Pelvic laparotomy ▪ Inguinal hernia
▪ Adenocarcinoma
RECONSTRUCTIVE ▪ Adhesions
- To restore function of TRAUMA or malfunctioning tissue and o Internal hemorrhage
to improve self-concept.
o Extensive burns
- Examples:
o Skin graft (commonly in inner thigh) o Fracture
o Plastic revision ▪ Chest fracture = impaired bleeding
pattern
o Scar revision
o Perforated ulcer
CONSTRUCTIVE
- To repair CONGENITAL ANOMALIES URGENT
- Example: - Requires a PROMPT attention.
- Indication: should be done within 24-48 hours. -
o Cheiloplasty (cleft lip)
Examples:
o Palatoplasty (cleft palata) o Cholecystectomy
o Closure of atrial septal defect o Appendectomy
o Colon resection
CURATIVE / ABLATIVE
o Amputation
- To remove DISEASED body part.
- Usually ends with “-ectomy” ▪ DM foot
- Examples:
o Thyroidectomy
o Gastrectomy
REQUIRED
o Appendectomy - NEEDS to have surgery.
- Indication: plans within a few weeks or months. o Patient
PALLIATIVE has an illness where it can be managed through medication.
- To relieve or reduce pain or symptom of a disease. - It However, it still
 needs surgery as it affects quality of life. o Thyroid disorders
- Examples:
o Prostatic hyperplasia ELECTIVE
- SHOULD have the surgery.
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PSALM 23
▪ Spine surgeries ▪ Digit (hands and feet)
- Indications: failure to have surgery is not catastrophic.
- Risk factors are reduced.
- Delay or omission will not cause adverse effect. - - Assess for airway and allergy
Examples: - Expected blood loss
o Tonsillectomy 🡺 repeated tonsilitis 🡺 RHD o
Hernia repair TIME OUT
o Cataract extraction - Before the procedure or skin incision
- OR team introduce themselves
OPTIONAL - Check identifier of patient including the procedure and
- Rests with the patient or PATIENT PREFERENCE - site marking
Examples: - Antibiotic within 60 minutes
o Cosmetic surgery - Critical events (discussed by surgeon and
o Circumcision anesthesiologist)
- Imaging (common in brain, internal, and fracture
ACCORDING TO DEGREE OF RISK surgeries)
MAJOR
- Blood loss: > 500 ml SIGN OUT
- Prolonged time: > 2 hours - Before patient leaves OR
o WOF: potassium count 🡺 hyperkalemia - Confirm the name of procedure.
- Prone for complications - Count (instruments and sponge)
- Involves major body organs - Specimen.
- Examples:
o Cataract surgery
o Kidney transplant
o Cesarean
o Lap chole

MINOR
- Day surgery or ambulatory
- Little to no complications
- Local anesthesia
- Examples:
o Circumcision
o Incision or excision biopsies

PREFIXES OR SUFFIXES
o Contraindication:
▪ Neonates = permanent
- Checks anesthesia machine and medication -
Pulse oximeter
• Supra-: above or beyond • Ortho-: joint • Salphingo-: fallopian tube PREOPERATIVE PHASE
• Chole-: bile or gall • Cysto-: bladder • Thoraco-: chest
• Encephalo-: brain • Entero-: intestine • Viscero-: organ especially in the abdomen - Refers to the time interval that begins when
• Hystero-: uterus • -oma: tumor or swelling the decision for surgical intervention is made
• Mast-: breast • -ectomy: removal of an organ or gland until the client is transported to the OR.
• Meningo-: meninges or membranes • -rhapy: suturing or stitching • Focus: preparation of the patient
• Myo-: muscles • -scopy: looking into • Goal: best possible physical and emotional
• Nephro-: kidney • -ostomy: making an opening or stoma condition for surgery
• Neuro-: nerve • -otomy: cutting into
• Oophor-: ovaries • -plasty: to repair or restore
• Pneumo-: lungs • -itis: inflammation • -cele: tumor; swelling;
hernia

SURGICAL SAFETY CHECKLIST surgeon and the procedure is written on the site) o When it
SIGN IN involves the:
- Before induction of anesthesia ▪ Laterality
- Validate identity and consent INFORMED CONSENT
- Site marking –– done by the surgeon (usually initials of the - It is required.
 - Proof that client has been informed and decided on his or - The healthcare provider (HCP) should obtain the consent.
her health. - Valid only for 24 hours.

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PSALM 23

Before obtaining the informed consent, the surgeon or HCP 3. Mental status examination
should provide the following information to the client: 1. Nature of a. Ask the name and date of birth of the patient
and the reason for the surgery b. To determine if the patient is competent enough
2. Available options and its risks. to sign informed consent
3. Risk and benefits
4. Name and qualifications of performing the procedure. 5. 4. Cardiovascular and Pulmonary
Right to refuse or withdraw. a. Respiratory depression

Role of Nurse 5. Endocrine and Renal

• Witness the client’s signature. a. If diabetic = poor wound healing
• Ensure that client is competent and signing voluntarily. • b. If patient has CKD = cannot excrete anesthesia =
Discuss and review the document. STAT HD
o The document should not have any erasures,
abbreviations. 6. Gastrointestinal
o Should contain the: a. Common complication: constipation
▪ Complete name of the patient, HCP,
and the procedure. 7. Neurologic
▪ Date of birth of the patient a. Determine if the patient has any paralysis or
weakness.
Procedures that need informed consent: 8. Integumentary
1. Radiation a. No nail polish, dentures, and make up
2. Invasive procedures
3. Anesthesia with sedation DIAGNOSTICS
1. Complete Blood Count (CBC)
Who can give informed consent: a. Postpone surgery if:
1. At least 18 years old i. Low Hgb
2. Conscious, coherent and mentally competent 3. ii. Elevated
Voluntarily iii. Low WBC (immunosuppressed or
4. Emancipated minors viral infection
a. <18 years old with spouse, children, pregnant or iv. Low platelet 🡺 bleeding
special power of attorney v. High platelet 🡺 clotting
2. Serum and Electrolytes
Who cannot give consent: 3. Creatinine and Bun
1. Minors a. To determine kidney function
2. Unconscious 4. AST, ALT, LDH, Bilirubin
3. Mentally ill person a. To determine coagulation and drug metabolism
5. FBS
!! If the patient is illiterate, they are not allowed to give consent a. Normal blood sugar prior surgery should be within
immediately !! 80-110 mg/dL to prevent complications
6. Chest Xray
What if I cannot give an informed consent: 7. Urinalysis
1. Spouse a. To determine renal function
2. Son or daughter of legal age 8. Coagulation studies (PT, PTT, bleeding and clotting time)
3. Either of the parents (priority: mother) a. High = bleeding
4. Brother or sister of legal age b. Low = clotting
5. Guardian or next of kin 9. ECG
10. CT Scan, MRI, PET Scan
Consents are not needed for emergency care if all 4 are met: 11. ABG
1. Immediate threat to life 12. Pregnancy test
2. Emergency a. If patient is pregnant, check FHR before and after
3. Client is unable to consent. the surgery.
4. A legally authorized person cannot be reached. 13. Other radiologic studies

PHYSICAL ASSESSMENT PSYCHOLOGICAL ASSESSMENT

- Baseline assessment 1. Fear of unknown
2. Fear of death
1. Height and weight 3. Fear of anesthesia
a. For anesthesia medications 4. Concern on threat of permanent incapacity
5. Loss of work, time, job and support
2. Vital signs 6. Spiritual beliefs
a. BP: +/- 20 in PACU 7. Cultural values and beliefs
8. Fear of pain
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PSALM 23

OTHER ASSESSMENT 1. Use of medications depression

g. Liver disease d. Heart diseases
i. High risk for bleeding i. Cardiac arrest
a. Over the counter medications e. Obstructive sleep apnea
b. Herbal medications f. Upper respiratory tract infection
2. Presence of trauma 1. Vitamin K IV to control
a. Internal hemorrhage bleeding
b. Further need for surgical management h. Fever
3. Previous surgeries i. Infection
a. Effect of anesthesia to the patient i. Chronic respiratory diseases (COPD, asthma)
b. Removed organs j. Immunological disorders (SLE, HIV, AIDS, cancer)
c. To identify precaution that should be done to the i. Anemic
patient ii. Low WBC
4. Social resources (support group and financial) 5. iii. Poor wound healing
Contraptions of the patient iv. High risk for infection
a. Porta Cath (usually in cancer patients) k. Renal diseases
b. AV graft i. High Creatinine, potassium
c. AV fistula ii. Congestion
d. Stent and pacemakers (interaction with cautery) 9. Medications that can increased risk for surgery a.
6. Smoking history Antibiotics
a. Stop 4-8 weeks before surgery to prevent i. Potentiate action of anesthesia
respiratory and wound healing complications b. Anticholinergics
b. Withheld at least 24 hours prior surgery i. Tachycardia, confusion, hypomotility
c. Smoking cessation c. Anticoagulants, antiplatelets, thrombolytics
7. Allergies i. Anticoagulants = prevent clot;
a. Food allergies withhold for 7 days
i. Related to latex 1. Heparin IV
1. Banana 2. Warfarin PO
2. Tomato 3. Enoxaparin SQ
3. Kiwi ii. Antiplatelet = prevent platelet
4. Plum formation or aggregation
5. Avocado 1. Aspirin
6. Strawberry 2. Clopidogrel
7. Passionfruit iii. Thrombolytics = to prevent clot;
b. Medication allergies withhold for 24 hours or 7 days
c. Latex allergies 1. Urokinase
2. Streptokinase
! SKIN TEST ! 3. Alteplase
d. Anticonvulsants
i. Lower the dose to prevent seizure
- Goal: to provide a medication that the client requires e. Antidepressants
for allergy testing and TB screening i. Inhibit reuptake of catecholamines
(epi and norepi)
Assessment ii. Higher BP
1. Measure the area of redness and induration in mm f. Antidysrhythmic, Antihypertensive
at largest diameter and document findings. i. Impairs cardiac contractility
2. Swelling ii. Decrease HR, BP
3. Rashes g. Diuretics
i. Furosemide = ototoxic
h. Herbal substances
i. Gingko biloba = blood thinning effect
8. Medical conditions that has high risk for surgery a. i. Insulin
Bleeding disorders
i. Thrombocytopenia 🡺 blood NURSING DIAGNOSIS
products 🡺 fresh frozen plasma or " Deficient knowledge related to lack of education about the
platelet con perioperative process.
ii. Hemophilia ○ FAQs
b. Diabetes mellitus ○ Preparation
i. Infection " Anxiety related to effects of surgery on ability to function
ii. Poor wound healing in usual roles.
iii. Clotting ○ FAQs
c. Chronic pain ○ Elevated HR
i. Higher dose of opioids = respiratory ○ Frequent urination
○ Uncontrolled movements
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PSALM 23

" Grieving related to perceived loss of body part associated

DEEP BREATHING EXERCISES
with planned surgery.
○ Crying ! !
○ Aloof
○ DABDA
" Ineffective coping related to lack of clear outcomes of
surgery.
○ No idea on postop preparations

⇒ Include the following:

PLANNING OR IMPLEMENTATION

• Diagnostics (same as diagnostics see page 3) •

Medications
• Exercises
• Incentive spirometry
• Skin preparation
• Pain management
• Elimination
• Psychosocial preparation
• Embolic stockings
• Diet

PREOP MEDICATIONS
• Sedatives and tranquilizers
o Anxiolytics
# Lorazepam
• Narcotic analgesics
o Opioids = for pain and sedation
# Morphine
• Anticholinergics = to decrease respiratory secretion to
prevent aspiration
# Atropine
• Antiemetic
# Metoclopramide (Plasil/Reglan)
# Ondansetron (Onsia/Zofran)
• Histamine-receptor antihistamines = decrease gastric
content
# Ranitidine
# Famotidine
• Proton pump inhibitors
# Omeprazole
# Pantoprazole
# Esomeprazole
# Lansoprazole
• Analgesics
# Paracetamol

Prior to giving the medication

1. Know identifiers
2. Validate the ID band
3. Allow to urinate or defecate

After giving the medication: SAFETY

1. Side rails up
2. Companion
3. Call button beside the patient

EXERCISES
• Deep breathing and coughing (DBCE) to enhance lung
expansion and mobilize secretions, thereby preventing
atelectasis.
 lowering.
- Perform this every 1-2 hours. ▪ Not performed if client is/has:
• Having abdominal surgery
STEPS
1. Sitting position gives the best lung expansion for • Back problem
coughing and DBE. • Early ambulation to:
2. Instruct to breathe deeply 3x, inhaling through the o Promote venous return.
nostrils and exhaling through pursed lips. o Enhance lung expansion and mobilize secretions.
3. Instruct the client that the 3rd breath should be held o Stimulate GI motility.
for 3 secs; then the client should cough deeply • Splinting incision
3x. o If it is abdominal or thoracic, instruct the client to
place a pillow, or 1 hand with the other hand
on top over the incisional area 🡺 during
DBCE, the client presses.
• Leg exercises to promote venous return, thereby
INCENTIVE SPIROMETRY
preventing thrombophlebitis and thrombus formation. o
! !
Gastrocnemius (calf) pumping
▪ Instruct the client to move both
ankles by pointing the toes up and - Measures the inhalation of the patient
then down.
o Quadriceps (thigh) setting STEPS
1. Assume sitting or upright position.
▪ Instruct the client to press the back
2. Place the mouth tightly around the mouthpiece.
of the knees against the bed and the 3. Inhale slowly to raise and maintain the flow
relax the knees. rate. a. 600-900 or more
▪ This contracts and relaxes the thigh 4. Hold the breath for 5 secs and then to exhale
and calf muscles to prevent through pursed lips.
thrombus formation. 5. Instruct to repat this process 10x every (waking) hour.
o Foot circles
▪ Instruct the client to rotate each foot
in a circle.
o Hip and knee movements
SKIN PREPARATION
▪ Instruct the client to flex the knee • Mild antiseptic or antibacterial soap (chlorhexidine wash)
and thigh and to straighten the leg, • Bath or shower the evening or morning of surgery to reduce
holding the position for 5 secs before risk of wound infection

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PSALM 23

• Trimming or clipping of the hair may be done in the 1. Cleansing –– to remove feces.
operative area 2. Carminative –– to expel flatus.
3. Oil retention –– to soften the feces and to lubricate the
ELIMINATION rectum and anal canal 🡺 facilitate passage of feces. 4.
• Enema, laxatives or both can be given depending to Return-flow –– to expel flatus.
physician’s orders 5. Fleet –– uses a salt called sodium phosphate to keep
• Enemas before surgery are no longer routine. o water in the intestines.
However, it is done during:
▪ Bowel surgeries ANTI-EMBOLIC STOCKINGS
▪ Colonoscopy - Purpose:
▪ Colostomy insertion ✅ To facilitate venous return from the lower
• Upon the administration of enema, the client should extremities
position in left lateral position ✅ To prevent venous stasis and DVT
o To facilitates the flow of solution (due to ✅ To reduce peripheral edema
anatomical position) by gravity into the
sigmoid and descending colon, which are on DIET
the left side. • Always review the surgeon’s prescriptions regarding the
o Having the right leg acutely flexed provides for NPO status during the surgery
adequate exposure of the anus. o Clear liquids: at least 2 hours prior surgery
o Breast milk: at least 4 hours prior surgery
Laxatives
o Light meals (anything that has no meat): at least
6 hours prior surgery
▪ Bread
# Lactulose (Duphalac, Lilac)
▪ Fruits
# Bisacodyl (Dulcolax, Correctal) ▪ Vegetables
# Senna (Senakot) o Heavy meals: at least 8 hours prior surgery
# Mineral and castor oil
CONTRAPTIONS
Types of enemas • Nasogastric tube
 • Indwelling catheter (FC) - Effect:
• Epidural catheters o Analgesia
• Wound drains o Amnesia
• Arterial line o Unconsciousness
• Intravenous lines o Loss of reflexes and muscle tone
• Oxygen support
• Subclavian or intrajugular line - Chief disadvantage: respiratory and cardiac depression
• Jackson-Pratt drains
• Blake-drain " Ineffective protection
• Penrose drain ○ Prone to aspiration, fall, and injury

PSYCHOSOCIAL PREPARATION Conscious sedation

• Inform the client about what to expect postoperatively. • - Depress consciousness but maintains airway and
Level of anxiety ventilation.
• Answer any questions of concerns that the client may have - Usually used during MRI, CT, spinal and regional
regarding surgery. anesthesia
• Psychosocial support. - Examples:
# Midazolam
INTRAOPERATIVE PHASE # Ketamine
# Fentanyl
- Goal:
o Asepsis REGIONAL ANESTHESIA
- Temporary interruption of the transmission of nerve
▪ Responsible: scrub nurse and impulses to and from a SPECIFIC AREA or REGION of
surgeon the body.
o Homeostasis: stable VS
▪ Responsible: anesthesiologist ①Topical Anesthesia
o Safe administration of anesthesia - Usually applied to skin and mucous membranes. -
▪ Responsible: anesthesiologist Effect will be felt after 15 minutes.
o Hemostasis: no bleeding and intact suture - Open skin surfaces, wounds, and burns
▪ Responsible: surgeon - Usually used during neonatal circumcision.
- Examples:
TYPES OF ANESTHESIA # Lidocaine
GENERAL ANESTHESIA # Benzocaine

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PSALM 23

②Local Anesthesia subarachnoid space surrounding the spinal cord.

- Infiltration - Complications:
- Injected to a specific area % Nausea and vomiting
- It may be characterized by shouting, struggling of the % Hypotension
client. & IV fluids
' Increased autonomic activity
- Used for the minor surgical procedure such as suturing a % Spinal Headache
small wound or performing biopsy. & Flat on bed for 6-8 hours
- Examples: % Respiratory paralysis
# Lidocaine % Neurologic complications
# Tetracaine
⑤Epidural Anesthesia
- Anesthetic agent in the epidural space that surrounds the
dura mater of the spinal cord.
③Nerve Block - Advantage: Absence of headache.
- Injected to the nerve or small nerve group that supplies - Disadvantage: Greater technical challenge of introducing the
small area of the body. anesthetic agents into the epidural rather than the
- Examples: subarachnoid space.
# Brachial plexus – arms - Medications given in epidural catheter: opioids and
anesthetic medications
# Facial nerve
# Morphine
# Pudendal block
# Fentanyl

④ Spinal Anesthesia # Oxycodone

- AKA Subarachnoid block & Ensure that the catheter is completely removed.
- Requires lumbar puncture through on of the interspaces ▪ Blue tip signifies the complete
between lumbar disk and the sacrum. - Injected to removal of epidural catheter.
STAGES OF ANESTHESIA NURSING DIAGNOSIS
STAGE 1: BEGINNING / ONSET / INDUCTION " Risk for aspiration
- Extends from administration of anesthesia to the time of loss " Risk for injury
of consciousness. " Ineffective protection
- Close OR doors " Risk for imbalanced body temperature
# Propofol
" Impaired skin integrity
' Dizziness, drowsy, hallucination " Ineffective peripheral tissue perfusion
' Feeling of detachment " Risk for deficient fluid volume
' Ringing, roaring or buzzing in the ears
SURGICAL TEAM
STAGE 2: EXCITEMENT / DELIRIUM OPERATING SURGEON
- Extends from the time of loss of consciousness by the time - Head of the surgical team; Captain of the ship -
of loss of lid reflex. Ultimate responsible in performing the procedure
' Dilated pupils
' Rapid pulse rate ANESTHESIOLOGIST
' Irregular and increased RR - Assess the patient before the procedure.
- Supervises the patient throughout the procedure - Monitor
' Uncontrolled movement
VS, ECG, blood oxygen saturation, urinary output, and blood
& Use safety straps on both arms and thigh area.
loss.
STAGE 3: SURGICAL CIRCULATING NURSE
- Extends from the loss of lid reflex of most reflexes. -
- Coordinates all personnel in the OR
Surgical procedure is started.
- Monitors responsible cost compliance associated with OR
' Unconscious and lies quietly procedures
' VS are within normal limits - Ensure all equipment are working properly.
' Constricted pupils - Guaranteeing sterility of instruments and supplies. -
Assisting with positioning.
STAGE 4: MEDULLARY DEPRESSION / DANGER - Too much - Performing surgical skin preparation.
anesthesia had been administered. & If this stage develops, - Handling specimens.
discontinue anesthesia and initiate respiratory and circulatory - Assisting anesthesia personnel.
support. - Monitors the room and team members for breanks in sterile
' Widely dilated pupils technique.
' Shallow respiration, weak and thready pulse ' - Coordinating activities with other departments. -
Death Documenting care provided
' Respiratory or cardiac depression or arrest - Minimizing conversation and traffic within the OR suite

SCRUB NURSE

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PSALM 23

- Gathering of equipment and supplies. 2. Sterile surfaces or articles may touch other sterile surfaces
- Prepares all supplies and instruments using sterile or articles remain sterile 🡺 STERILE to STERILE.
technique. 3. CONTACT WITH UNSTERILE OBJECTS at any point
- Maintains sterility during surgery. renders a sterile area CONTAMINATED.
- Handles supplies and instruments during surgery. - 4. Gowns of the surgical team are considered sterile in front
Performs after care form the CHEST TO THE LEVEL OF THE STERILE
- Keep accurate count of sponges, sharps, and instruments FIELD.
during surgery, 5. The sleeves are also considered from 2 inches above the
elbow to the stockinette of the cuff.
ZONES 6. Sterile drapes are used to create a sterile field. a. Only the
UNRESTRICTED ZONE top surface of a draped table is considered sterile.
- Can wear street clothes 7. After a sterile package is opened, the edges are
considered unsterile.
- Patient reception area and holding attire
8. The movements of the surgical team are from sterile to
- Area in the OR that interfaces with other department.
sterile areas only.
9. Sterile areas must be kept in view during movement
SEMI-RESTRICTED ZONE around the area.
- Scrub clothes and caps are required 10. Whenever a sterile barrier is breached, the area must be
- May include areas where surgical instruments are considered contaminated.
processed. 11. A tear or puncture of the drape permitting access to an
unsterile surface underneath renders the area unsterile.
RESTRICTED ZONE 12. Items of doubtful sterility are considered unsterile.
- Scrub clothes, shoe cover, caps, and masks are worn. -
Operating theater and sterile core area 🡺 sterile gown and
POSTOPERATIVE PHASE
gloves

SURGICAL ASEPTIC TECHNIQUE - Goal:

1. All materials in contact with surgical wound or used within o Return homeostasis.
the STERILE FIELD MUST BE STERILE. o Maintain adequate body system function.
 o Alleviate pain and discomfort. CARDIAC STATUS
o Prevent postop complications. • Skin color, pulses, and capillary refill
o Ensure discharge planning and teaching. • Absence of edema, numbness or tingling
ASSESSMENT • Hypertension and hypotension
Assess the following in order: • Cardiac dysrhythmias
1. Airway o Most common: sinus bradycardia
2. Oxygen saturation and ventilation • Encourage the use of anti-embolic stockings, sequential
3. Cardio status compression device.
4. Level of consciousness o To promote venous return.
5. Cough and gag reflex o Strengthen muscle tone.
6. Ability to move extremities o Prevent pooling of blood in the extremities.
7. Fluid status
8. Postoperative site LEVEL OF CONSCIOUSNESS
9. Drains • Make a frequent periodic attempts to awaken the client until
10. Pain and safety the client awakens.

AIRWAY ABILITY TO MOVE EXTREMITIES

• Assess for breath sounds • One of the discharge criteria
• Wheezing, stridor (infant), crowing, crackles (fluid overload)
or rhonchi FLUID STATUS
• Monitor for the secretions • IV fluid administration
• Avoid positioning the client in supine position and moderate • Record intake and output
high back rest • Monitor for signs of fluid and electrolyte imbalances
• Always ensure lateral position (side-lying)
POSTOPERATIVE SITE AND DRAINS
OXYGEN SATURATION AND VENTILATION • Assess for the surgical site, drains and wound dressing •
• Observe for the chest movement for symmetry • Hook to Record I&O
continuous pulse oximeter and oxygen support • DBE o Always ensure that JP drain is in negative
( WOF: respiratory distress, atelectasis, or respiratory pressure
complications. o Drain the drains qshift or as needed.
o first sign: 'ALOC o
• Low fowler’s • Monitor for signs of fluid and electrolyte imbalance
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PSALM 23

BP is within +/- 20 mmHg preoperative level

• Consciousness 🡺 responsive
Serous • Clear or straw colored. • Color 🡺 pinkish skin and mucous membrane
• Occurs as a normal part of the
healing !! Score of ≥ 9 = safe discharge from PACU !!

Serosanguineous • Pink colored due to the presence of

a small amount of blood cells
mixed with serous drainage.
• Occurs as a normal part of the
healing process.

Purulent • Yellow, gray, or green drainage

due to infection in the wound

Sanguineous • Red drainage from trauma to blood

vessel.
• May occur with wound cleansing or
other trauma to wound bed.
• Abnormal in wounds.

Hemorrhage • Frank blood from a leaking blood

vessel.
• May require emergency treatment
to control bleeding.
• Abnormal wound exudate.

CRITERIA IN DISCHARING TO PACU

• Activity 🡺 able to obey commands such as DBE •
Respiration 🡺 easy and noiseless breathing • Circulation 🡺
 SNS/PNS SNS PNS

Vital signs Increased Within normal

limits

Physiologic Physiologic Psychologic

or
Psychologic

Visible Yes No
symptoms?

PAIN MANAGEMENT
Pain
- 5th vital sign; always subjective
- An unpleasant sensory and emotional experience
associated with, or resembling that associated with,
actual or potential tissue damage.
TERMS
TYPES OF PAIN: LOCATION • Pain threshold –– is the least amount of stimuli that is
① REFERRED PAIN needed for a person to label a sensation as pain. • Pain
- Pain that appears or arise in different areas of the body. tolerance –– is the maximum of painful stimuli that a person
is willing to withstand or to endure.
② VISCERAL PAIN
- Pain arising from organs or hollow visceral or perceived PAIN ASSESMENT
area in a remote area. P What are the factors that precipitated
(Precipitatin the pain? What are you doing?;
TYPES OF PAIN: DURATION g/ WHAT
Provoking)
Acute Chronic
Q Crashing? Throbbing? Burning?
Duration < 6 mos > 6 mos (Quality) Tingling?

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PSALM 23

(Timing)
R Where is the pain? Does it
(Radiation) radiate?; WHERE

S Pain scale; HOW 0 NO PAIN

(Severity) 1
2 MILD PAIN
T How long? Intermittent?; WHEN 3
4
 5 MODERATE PAIN
6 Onset 1-2 days after 3-5 days after
7 surgery surgery
8
SEVERE PAIN 9 Dyspnea and increased respiratory rate,
10 crackles, elevated body temperature,
productive cough and chest pain
PATIENT CONTROLLED ANALGESIA (PCA)
- Allows the patient to control the administration of their own
medication within predetermined safety limits - A PCA pump is
electronically controlled by a timing device
- The pump delivers a preset amount of medication. - It HYPOXEMIA
permits the patient to administer continuous infusion of - Inadequate concentration of oxygen in the blood - Can be
medication (basal rates) safely and to administer extra due to shallow breathing caused by anesthesia
medication (bolus doses / rescue rate) with episodes of
increased pain or painful activities Clinical Manifestations
- The time can be programmed to prevent additional doses ' Restlessness –– first sign
from being administered until a specified time period has ' Dyspnea
elapsed (lock-out time). ' Diaphoresis
- Even if the patient pushes the button multiple times in a
' Tachycardia, tachypnea
rapid succession, no additional doses are released. (
Always watch out for respiratory depression and pruritus.
Late signs
Mild Moderate Severe ' Cyanosis
' Low pulse oximetry reading
# Paracetamol #Hydrocodon # Fentanyl
# Aspirin e # Hydromorp Nursing Intervention: Atelectasis, Pneumonia, and
# Ibuprofen #Codeine hone # Hypoxemia
Oxycodone & Administer oxygen as ordered.
# Indomethaci #Tramadol
& DBE and coughing
n # Morphine
& Use of incentive spirometry
# Ketorolac # Oxymorp
& Turning and early ambulation
# Celecoxib hone #
& Notify MD
Methadone
WOUND INFECTION
S2 requiring ––
- Onset: 3-6 days
yellow RX;
regulated
Cause or Risk Factors
1. Poor aseptic technique
2. Contaminated wound prior surgery
3. Diabetes mellitus
COMPLICATIONS 4. Immunoccompromised
!! BEST WAY TO PREVENT COMPLICATIONS: EARLY
AMBULATION !! Clinical Manifestations
' Fever and chills
ATELETASIS ' Warm, tender, painful and inflamed site
- Collapsed or airless state ' Edematous site
- Caused by: ' Elevated WBC
o Accumulated secretions
o Failure to DBE Management
o Failure to ambulate & Administer antibiotics
& Monitor VS
PNEUMONIA & Assess wound drainage
- Inflammation of the alveoli caused by infectious process. & Maintain asepsis, change dressing, and perform from
- Caused by: wound irrigation
o Infection
& Monitor for signs of infection
o Aspiration
' Redness
o Immobility
' Ecchymosis
ATELECTASIS PNEUMONIA ' Drainage
' Approximation

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YOU ARE GOING TO MAKE IT: TRUST ME.
PSALM 23

HEMORRHAGE
- Loss of large amount of blood externally and internally in a Clinical Manifestations
short period of time. ' Restlessness
 ' Weak and rapid pulse - Abnormal infrequent passage of stool
' Hypotension, tachypnea - Failure to pass stool within 48 hours
' Absence of BM
' Cool, clammy skin
' Abdominal distention
' Reduced urine output.
' Anorexia, headache, and nausea
Nursing Intervention Nursing Intervention
& Pressure to the site of the bleeding & Ambulation
& Administer Vitamin K and Tranexamic acid (Hemostan) & Increased OFI
& Administer oxygen as needed & High fiber diet
& Blood transfusion and IV fluids & Stool softeners and laxative
& Notify MD ○ Stool softeners: Castor and mineral oil
○ Laxative: Dulcolax, lactulose
WOUND DEHISCENCE
- Is the separation of the wound edges at the suture line - PARALYTIC ILEUS
Usually occurs 6-8 days after surgery. - No forward movement of bowel contents
- Due to anesthesia or bowel surgery
WOUND EVISCERATION
- Is the protrusion of the internal organs through an incision. Clinical Manifestations
- Usually occurs 6-8 days after surgery ' Vomiting
' Abdominal distention
!! Evisceration is most common among obese clients who have ' No bowel sound, BM, or flatus
had abdominal surgery !!
Nursing Intervention
Nursing Intervention: Dehiscence and Evisceration & NPO status
& Splint & Maintain NGT
& Ambulation
Evisceration & Administer IV fluids
& Cover with sterile gauze soaked with NSS & Administer medications that increase GI motility and
& If standing, low fowler’s with knees bent secretions.
& WOF: shock # Metoclopramide (Plasil/Reglan)
& Prepare for surgery
DEEP VEIN THROMBOPHLEBITIS
- Inflammation of the vein, often accompanied by clot
URINARY RETENTION formation.
- An involuntary accumulation of urine in the bladder as a - Common in ortho surgeries
result of loss of muscle tone - Caused by:
- Appears 6-8 hours after surgery o Prolonged immobility
- Common in epidural and spinal anesthesia
o Obesity or debilitation
Clinical Manifestations
Clinical Manifestations
' Distended bladder
' (+) Homan’s sign
' Lower abdominal pain ' Redness
' Diaphoresis ' Swelling (affected leg)
' Hypertension ' Heat/warmth
' Veins feel hard and cordlike and is tender to touch.
Nursing Intervention
& Ambulation Nursing Intervention
& Increased OFI & Hydration
& Apply alternating warm and cold compress & Encourage leg exercises and ambulation
& Elevate the affected leg with pillow support (on the feet)
& Catheterize the patient if she cannot void after 6-8 hours. & Avoid massage
& Anticoagulant, anti-embolic stocking
CONSTIPATION

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YOU ARE GOING TO MAKE IT: TRUST ME.
PSALM 23