Which patients require hospital stays

after surgery?
Trauma Pts, Acutely Ill Pts, Major
Surgery Pts

What are the five categories of

surgery based on urgency?
Emergent, Urgent, Required, Elective,
Optional

Define, List Indications, and list

examples of emergent surgery.
-Patient requires immediate attention,
may be life threatening
-Schedule surgery without delay
-Burns, Severe blood loss, bladder or GI
obstruction, skull fracture, gun or stab
wound

Define, List Indications, and list

examples of urgent surgery.
-Patient requires prompt attention
-Schedule within 24-30 hrs
-Acute gallbladder infection,
Kidney/Utereral stones

Define, List Indications, and list

examples of required surgery.
-Patient needs to have surgery
-Schedule within a few weeks or
months
-Prostatic Hyperplasia w/o obstruction,
Thyroid, Cataracts

Define, List Indications, and list

examples of elective surgery.
-Patient should have surgery
-Failure to not have surgery not

catastrophic
-Scar repair, simple hernia, vaginal
repair

Define, List Indications, and list

examples of optional surgery.
-Decision rests with patient
-Based on personal preference
-Cosmetic

List important factors needed to

evaluate elderly patients regarding
surgery.
-Disease course -vs- Life Expectancy
-State of independence
-Personal Motivation
-Risk factors -vs- non-operative
management

What is one of the most important

considerations for elderly surgical
patients?
Positioning

Which patients are especially

susceptible to infection during
surgery?
Obese patients due to fatty tissue

When does the preoperative phase of

surgery begin?
Begins when the decision to proceed
with surgery intervention is made.

When does the preoperative phase of

surgery end?
Ends when the patient is transfered to
the OR table

Define informed consent.

Voluntary and written communication
from Pt gathered before surgery is
performed which ensures patient is
provided all information to enable them
to evaluate surgery before agreeing to
it.

Who obtains informed surgical

consent?
The surgeon performing the procedure.

What are the four basic elements of

informed surgical consent?
-Document that Pt or rep has capacity
to make medical decision
-Surgeon discusses details regarding
diagnoses and treatment so Pt can
make medical decisions
-Pt understands disclosed information
-Pt freely authorizes a specific Tx plan
w/o influence

List all preoperative health

assessments
I/O Status, Drug/Alcohol use, respiratory
status, cardio status, hepatic/renal
function, endocrine function, immune
function, medication use, psychosocial
factors, spiritual/cultural beliefs, genetic
disorders

List preoperative nursing management

practices.
-Appropriate time and place for
teaching
-Prepare bowels and skin (enema/bath)

-Administer pre-op meds

-Promote mobility (RoM)
-Manage I/O status

List examples of pre-operative

medications to be administered by
nurse.
Antibiotic, anti-anxiety, antacid, reglan
(anti-nausea)

List preoperative education

interventions used by nurses.
Address fears, explanation of pre/postop routine, TCBD (Turn/Cough/Deep
Breath), Lines/Caths/Tubes, Incentive
spirometer, pain management,
ambulation or excercises

Identify all surgical team members.

Circulating nurse, scrub nurse/tech,
specialty nurse (RNFA),
Anesthesiologist, surgeon

List duties of a circulating nurse.

Manage OR conditions, continually
assess Pt, verify consent, coordinate
team, monistor aseptic practices,
specimen managements, time outs

List duties of a scrub nurse/tech.

Responsible for equipment, count items
after

List duties of specialty nurse (RNFA).

Handle tissues, suturing, monitor
homeostasis

List duties of anesthesiologist.

Assess patient, select and measure
anesthesia, intubating, supervise
patient

List duties of surgeon.

Perform surgical procedure, lead team

What is the intention of the zone

system?
Designed to reduce surgical asepsis.

Describe unrestricted zone dress.

Street clothes are allowed.

Describe semi-restricted zone dress.

Scrubs and caps.

Describe restricted zone dress.

Scrub clothes, shoe covers, caps, masks
on at all times.

Define health hazards associated with

surgical environments.
Exposure to blood and body fluids, latex
allergy, laser risk

Define anesthesia.
State of narcosis, analgesia, relaxation
and reflex loss used in medical
procedures.

Describe general anesthesia.

Gas or IV administration. Pt not
arousable, require assistance to
maintain airway due to lost ventilation
function.

Describe local anesthesia.

Blocks nerve response in PNS/CNS.

Describe regional anesthesia.

Injected around nerves, normally in
spinal and epidural injection.

Describe moderate/analgesia
anesthesia.
Conscious sedation which is short term.

Describe intraoperative goals and

management techniques.
-Reduce anxiety: go through
expectations, who is in OR
-Prevent injury due to position
-Protect from injury
-Maintain patient dignity

List potential complications present in

intraoperative procedures.
Nausea & vomiting, anaphylaxis,
hypoxia, hypothermia and malignant
hypothermia, disseminated
intravascular coagulations

Describe patient placed in a dorsal

recumbent position.
Lying flat on back with one arm on
surgical table with hand facing down.
Second arm on board for
IV/Blood/medication administration.

Describe patient placed in a

trendelenburg position.

Table area containing head and upper

body are lowered, as well as feet and
legs. Padded shoulder braces in place.

Describe patient placed in a lithotomy

position.
Hips are extended over the edge of the
table with feet placed in stirrups raised
above table. Mostly used in
perineal/rectal/vaginal surgeries.

Describe patient placed in a

sims/lateral position.
Placed on non-operative side. Generally
used in renal surgery. Pillow placed
between the legs to relieve pressure.

Who moves patient from OR to PACU

in post-operative procedure?
Anesthesiologist.

List steps of post-op assessment.

ABC, pain, nausea/vomiting, vitals,
color/temp skin, conciousness, IV,
surgical site, tubing, comfort,
position/safety

List three types of surgical drains used

in post-operative care.
Penrose, Jackson-Pratt, Hemovac.

Describe a Penrose surgical drain.

Loose stitch keeps drain from slipping
into wound. Loose tube facilitates drain
on to gauze.

Describe a Jackson-Pratt surgical

drain.
Tube which drains out of wound into
bulb at the end.

Describe Hemovac surgical drain.

Spring loaded circular drain which rises
creating suction for tubing leading out
of wound.

Describe a dehiscence wound.

Wound or incision disrupted which
exposes adipose tissue and muscle.

Describe an evisceration wound.

Wound or incision disrupted which
exposes protrusion through the wound
i.e. bowel

Describe assessments measured when

considering discharging a patient from
the PACU.
Stable vitals, orientation of
person/place/time/events,
uncompromised pulmonary function,
pulse oximeter readings indicate
adequate blood oxygen, urine output at
least 30mL hour, nausea & vomiting
under control, minimal pain
Preoperative care - Obtaining consent
- Surgeon is responsible for obtaining
consent
- the nurse may witness the client
signing and the nurse must be sure that
the client has understood
- the nurse needs to document the
witnessing

Preoperative care - Nutriton

- Review the physician's prescription
regarding NPO status
- NPO status usually prescribed to
prevent aspiration (6-8 hours before
GA, 3 hours for LA

Preoperative care - Elimination

- If the client is having intestinal or
abdominal surgery, an enema or
laxative may be prescribed
- client should void immediately before
surgery

Preoperative care - Surgical Site

- Clean surgical site with mild
antiseptic, and shave the area as
prescribed

Preoperative care - Client teaching

- Inform the client what to expect
postoperatively, and to tell the nurse if
the client experiences pain
- Demonstrate the use of PCA if
prescribed
- Instruct the client in deep-breathing
techniques, and their importance
- Instruct the client in leg and foot
exercises to prevent venous stasis of
blood
- Inform the client of any invasive
advice that may be needed after
surgery (Foley, IV, epidural), and
instruct not to pull on any of the
devices

Preoperative care - Client teaching,

Deep Breathing
- In a sitting position, instruct the client
to breath deeply 3 times, inhaling with
the nose and exhaling with the mouth
through pursed lips, the third breath
should be held for 3 seconds, then the
client should be instructed to cough 3
times

Preoperative care - Client teaching,

Incentive Spirometry
- Instruct to take a sitting position,
instruct to place the mouth tightly
around the mouthpiece and inhale
slowly and maintain the indicator
between 600-900. Hold for 5 seconds
and then exhale through pursed lips

Preoperative care - Client teaching,

Leg and Foot
- instruct the client to move both ankles
by pointing the toes down and up
- instruct the client to press the back of
the knees and the relax
- instruct the client to circle with each
foot

Preoperative care - Splinting the

Incision
- Advise the client to place a pillow or
one hand and the other on top, over the
incision
- During deep breathing and coughing,
the client presses gently over area to
splint or support it

Postoperative care, Stages

Immediate postoperative stage: 1-4

hours after surgery
Intermediate postoperative stage: 4-24
hours
Extended postoperative stage : 1 to 4
days

Postoperative care, Assessment,

Respiratory
- Monitor airway patency and ensure
adequate ventilation
- Assess breath sounds, stridor,
wheezing, or crowing sounds can
indicate partial bronchospasm
- Observe chest movement for
symmetry and use of accessory muscle
- Monitor oxygen administration and
pulse oximetry
- Encourage deep breathing

Postoperative care, Assessment,

Cardiovascular
- Monitor circulatory status: skin color,
peripheral pulse, capillary refill,
absence of edema, tingling and
numbness
- Monitor for bleeding
- Assess pulse rate and rhythm
- Monitor for hypertension or
hypotension (could indicate bleeding)
- Monitor cardiac dysrhythmias

Postoperative care, Assessment,

Musculoskeletal
- Assess movement of the extremities
- Encourage ambulation if prescribed
- Avoid positioning client in supine
position, low Fowler's position after

surgery promotes lung expansion

- Turn every 2 hour if client is unable to
move

Postoperative care, Assessment,

Neurological
- Asess LOC
- Make several attempts to awaken the
client
- Orient the client to the environment
- Maintain the client's body temperature

Postoperative care, Assessment,

Temperature
- Monitor temperature
- Monitor signs of hypothermia and
apply warm blankets until temperature
is within normal range

Postoperative care, Assessment,

Integumentary
- Assess surgical site, drains, wound
dressing,
- Assess the skin for redness, abrasions,
breakdowns
- Maintain a dry, intact dressing
- Change dressing as prescribed and
note color and amount of drainage

Postoperative care, Assessment,

Electrolyte balance
- Monitor IV fluid as prescribed
- Record intake and output

Postoperative care, Assessment, GI

- Monitor for nausea and vomiting
- Monitor for abdominal distention
- Monitor for flatus and bowel sounds

- When oral fluids are permitted start

with ice chips and water

Postoperative care, Assessment, Renal

system
- Assess bladder for distention
- Monitor urine output, should me
30mL/hr

Postoperative care, Assessment, Pain

manegement
- Assess type of anesthetic used and
the postoperative medication the
patient received
- Assess the client's pain using 1-10
scale
- Administer pain medication as
prescribed
- Assess effectiveness of pain
medication

Postoperative care, Complication,

Atalectasis
- collapsed or airless state of the lung
that may the result of airway
obstruction caused by accumulated
secretion
- Asses for decreased RR, crackles,
productive cough, chest pain
- Intervention: assess lung and breath
sounds, encourage deep breathing and
ambulation, encourage fluid intake

Postoperative care, Complication,

Hypoxemia
- Inadequate concentration of oxygen in
arterial blood
- Asses for restlessness, dyspnea,

diaphoresis, tachycardia, hypertension,

cyanosis
- Intervention: Monitor, administer
oxygen as prescribed, encourage deep
breathing, encourage ambulation

Postoperative care, Complication,

Pulmonary embolism
- Embolus blocking the pulmonary
artery and disrupting blood flow at one
or more lobes of the lungs
- Assess for sudden dyspnea, sudden
sharp chest pain, cyanosis, tachycardia,
drop in BP
- Intervention, notify the physician
immediately, monitor VS, give oxygen
as prescribed

Postoperative care, Complication,

Hemorrhage
- loss of a large amount of blood
- Assess: restlessness, weak and rapid
pulse, drop in BP, cool clammy skin
- Intervention: Provide pressure to
bleeding site, notify the physician,
administer blood as prescribed, prepare
client for surgical procedure

Postoperative care, Complication,

Shock
- loss of circulatory fluid volume
- Assess for restlessness, weak and
rapid pulse, drop in BP, cool clammy
skin
Intervention: elevate the legs,
determine the source of shock, monitor
level of consciousness and VS, input
and output, assess color, temperature,

and moisture of skin and mucous

membranes

Postoperative care, Complication,

thrombophlebitis
- inflammation of the vein accompanied
by clot formation
- Assess: vein inflammation, aching or
cramping pain, veins feels hardened
Intervention: monitor for leg swelling,
inflammation, pain, tenderness, venous
distention. Elevate the extremity
without allowing any pressure, ROM
exercise and encourage early
ambulation

Postoperative care, Complication,

Urine retention
- involuntary accumulation of urine in
the bladder as a result of loss of muscle
tone, caused by the effects of opioids
- assess intake and output, inability to
void, restlessness, lower abdominal
pain, distended bladder, on percussion
bladder sounds like a drum
- Intervention, encourage early
ambulation, encourage fluid intake,
provide privacy, pour warm water on
the perineum, catheterize the client

Postoperative care, Complication,

Constipation
- abnormal infrequent passage of stool
- Assess bowel sounds, abdominal
distention, anorexia
- Intervention, encourage fluid intake up
to 3000 ml/day, encourage early

ambulation, provide privacy, administer

stool softener or laxatives as prescribed

Postoperative care, Complication,

Paralytic Ileus
- failure of appropriate forward
movement of bowel contents
(anesthetic, or manipulation of bowels
during surgery)
- Assess vomiting, abdominal
distention, absence of bowel sounds
- Intervention: monitor intake and
output, maintain patient NPO until
bowel sounds return, administer IV
solution or PN, administer medication to
increase GI motility

Postoperative care, Complication,

Wound infection
- Assess fever and chills, warm, tender,
painful, and inflamed incision site, and
elevated WBC
- Intervention: monitor temparture,
incision sites, maintain patency of
drains, maintain asepsis and change
the dressing as prescribed

Postoperative care, Complication,

Wound dehiscence
- seperation of the wound edge at the
suture line (usually occurs 6 to 8 days
after surgery)
- Assess: increased drainage, open
wound edges
- Intervention: place the client in low
fowlers with knees bent, cover the
wound with a sterile NS dressing

Postoperative care, Complication,

Wound evisceration
- protrusion of the internal organs
through the incision
- Assess: discharge of serosanguineous
fluid from a previously dry wound,
appearance of loops of bowel or other
abdominal content
- Intervention: place the client in low
fowlers with knees bent, cover the
wound with a sterile NS dressing, notify
physician

166. A nurse has just reassessed the

condition of a
postoperative client who was admitted
1 hour
ago to the surgical unit. The nurse
plans to monitor
which of the following parameters
most
carefully during the next hour?
1. Urinary output of 20 mL/hr
2. Temperature of 37.6 C (99.6 F)
3. Blood pressure of 100/70 mm Hg
4. Serous drainage on the surgical
dressing
1. Urinary output of 20 mL/hr
Urine output should be maintained at a
minimum
of 30 mL/hr for an adult. An output of
less than 30 mL for each of 2
consecutive hours should be reported
to the physician. A temperature higher
than 37.7 C (100 F) or lower than 36.1
C (97 F) and a falling systolic blood
pressure, lower than 90 mm Hg, are
usually considered reportable

immediately. The client's preoperative

or baseline blood pressure is used to
make informed postoperative
comparisons. Moderate or light serous
drainage from the surgical site is
considered normal.

167. A postoperative client asks a

nurse why it is so
important to deep breathe and cough
after surgery.
When formulating a response, the
nurse
incorporates the understanding that
retained pulmonary secretions in a
postoperative client can
lead to:
1. Pneumonia
2. Fluid imbalance
3. Pulmonary embolism
4. Carbon dioxide retention
1. Pneumonia
Postoperative respiratory problems are
atelectasis,
pneumonia, and pulmonary emboli.
Pneumonia is the
inflammation of lung tissue that causes
productive cough, dyspnea, and lung
crackles. Fluid imbalance can be a
deficit or excess related to fluid loss or
overload. Pulmonary embolus occurs as
a result of a blockage of the pulmonary
artery that disrupts blood flow to one or
more lobes of the lung; this is usually
due to clot formation. Carbon dioxide
retention results from an inability to
exhale carbon dioxide in conditions

such as chronic obstructive pulmonary

disease.

168. A nurse is developing a plan of

care for a client
scheduled for surgery. The nurse
should include
which activity in the nursing care plan
for the client
on the day of surgery?
1. Have the client void immediately
before going
into surgery.
2. Avoid oral hygiene and rinsing with
mouthwash.
3. Verify that the client has not eaten
for the last
24 hours.
4. Report immediately any slight
increase in
blood pressure or pulse.
1. Have the client void immediately
before going
into surgery.
The nurse would assist the client to
void immediately
before surgery so that the bladder will
be empty.
A slight increase in blood pressure and
pulse is common during the
preoperative period and is usually the
result of anxiety. The client usually has
a restriction of food and fluids for 6 to 8
hours before surgery instead of 24
hours. Oral hygiene is allowed, but the
client should not swallow any water.

169. A client with a perforated gastric

ulcer is scheduled
for surgery. The client cannot sign the
operative
consent form because of sedation
from
opioid analgesics that have been
administered.
The nurse should take which
appropriate action
in the care of this client?
1. Obtain a court order for the surgery.
2. Send the client to surgery without
the consent
form being signed.
3. Have the hospital chaplain sign the
informed
consent immediately.
4. Obtain a telephone consent from a
family
member, following agency policy.
4. Obtain a telephone consent from a
family
member, following agency policy.
Every effort should be made to obtain
permission
from a responsible family member to
perform surgery if the client is unable
to sign the consent form. A telephone
consent must be witnessed by two
persons who hear the family member's
oral consent. The two witnesses then
sign the consent with the name of the
family member, noting that an oral
consent was obtained. Consent is not
informed if it is obtained from a client
who is confused, unconscious, mentally
incompetent, or under the influence of

sedatives. In an emergency, a client

may be unable to sign and family
members may not be available. In this
situation, a physician is permitted
legally to perform surgery without
consent. Options 1 and 3 are not
appropriate in this situation. Also,
agency policies regarding informed
consent should always be followed.

170. A preoperative client expresses

anxiety to a nurse
about upcoming surgery. Which
response by the
nurse is most likely to stimulate
further discussion
between the client and the nurse?
1. "If it's any help, everyone is nervous
before
surgery."
2. "I will be happy to explain the entire
surgical
procedure to you."
3. "Can you share with me what
you've been
told about your surgery?"
4. "Let me tell you about the care
you'll receive
after surgery and the amount of pain
you
can anticipate."
3. "Can you share with me what you've
been
told about your surgery?"
Explanations should begin with the
information
that the client knows. By providing the
client with individualized explanations

of care and procedures, the nurse can

assist the client in handling anxiety and
fear for a smooth preoperative
experience. Clients who are calm and
emotionally prepared for surgery
withstand anesthesia better and
experience fewer postoperative
complications. Options 1, 2, and 4 will
produce anxiety in the client.

171. A nurse is conducting

preoperative teaching with
a client about the use of an incentive
spirometer.
The nurse should include which piece
of information
in discussions with the client?
1. Inhale as rapidly as possible.
2. Keep a loose seal between the lips
and the
mouthpiece.
3. After maximum inspiration, hold the
breath
for 15 seconds and exhale.
4. The best results are achieved when
sitting up
or with the head of the bed elevated
45 to
90 degrees.
4. The best results are achieved when
sitting up
or with the head of the bed elevated 45
to
90 degrees.
For optimal lung expansion with the
incentive spirometer, the client should
assume the semi-Fowler's or high
Fowler's position. The mouthpiece

should be covered completely and

tightly while the client inhales slowly,
with a constant flow through the unit.
The breath should be held for 5 seconds
before exhaling slowly.

172. A nurse has conducted

preoperative teaching for a
client scheduled for surgery in 1 week.
The client
has a history of arthritis and has been
taking acetylsalicylic acid (aspirin).
The nurse determines that the client
needs additional teaching if the client
states:
1. "Aspirin can cause bleeding after
surgery."
2. "Aspirin can cause my ability to clot
blood to
be abnormal."
3. "I need to continue to take the
aspirin until
the day of surgery."
4. "I need to check with my physician
about the
need to stop the aspirin before the
scheduled
surgery."
3. "I need to continue to take the
aspirin until
the day of surgery."
Anticoagulants alter normal clotting
factors and
increase the risk of bleeding after
surgery. Aspirin has properties that can
alter the clotting mechanism and
should be discontinued at least 48
hours before surgery. However, the

client should always check with his or

her physician regarding when to stop
taking the aspirin when a surgical
procedure is scheduled. Options 1, 2,
and 4 are accurate client statements.

173. A nurse assesses a client's

surgical incision for
signs of infection. Which finding by the
nurse
would be interpreted as a normal
finding at the
surgical site?
1. Red, hard skin
2. Serous drainage
3. Purulent drainage
4. Warm, tender skin
2. Serous drainage
Serous drainage is an expected finding
at a surgical
site. The other options indicate signs of
wound infection. Signs and symptoms
of infection include warm, red, and
tender skin around the incision.
Purulent material may exit from drains
or from separated wound edges.
Infection may be caused by poor
aseptic technique or a contaminated
wound
before surgical exploration; existing
client conditions such as diabetes
mellitus or immunocompromise may
place the client at risk. Wound infection
usually appears 3 to 6 days after
surgery. The client also may have a
fever and chills.

174. A nurse is monitoring the status

of a postoperative
client. The nurse would become
most concerned with which of the
following
signs that could indicate an evolving
complication?
1. Increasing restlessness
2. A pulse of 86 beats/min
3. Blood pressure of 110/70 mm Hg
4. Hypoactive bowel sounds in all four
quadrants
1. Increasing restlessness
Increasing restlessness is a sign that
requires continuous and close
monitoring because it could indicate a
potential complication, such as
hemorrhage, shock, or pulmonary
embolism. Hypoactive bowel sounds
heard in all four quadrants are a normal
occurrence. A blood pressure of 110/70
mm Hg with a pulse of 86 beats/min is
within normal limits.

175. A nurse is reviewing a physician's

prescription
sheet for a preoperative client that
states that
the client must be NPO after midnight.
The
nurse would telephone the physician
to clarify
that which of the following
medications should
be given to the client and not
withheld?
1. Prednisone
2. Ferrous sulfate

3. Cyclobenzaprine (Flexeril)
4. Conjugated estrogen (Premarin)
1. Prednisone
Prednisone is a corticosteroid. With
prolonged
use, corticosteroids cause adrenal
atrophy, which reduces the ability of
the body to withstand stress. When
stress is severe, corticosteroids are
essential to life. Before and during
surgery, dosages may be increased
temporarily. Ferrous sulfate is an oral
iron preparation used to treat iron
deficiency anemia.
Cyclobenzaprine (Flexeril) is a skeletal
muscle relaxant.
Conjugated estrogen (Premarin) is an
estrogen used for hormone
replacement therapy in
postmenopausal women. These last
three medications may be withheld
before surgery without undue effects on
the client.

176. A client who has undergone

preadmission
testing has had blood drawn for serum
laboratory
studies, including a complete blood
count, coagulation studies, and
electrolytes
and creatinine levels. Which of the
following
laboratory results should be reported
to the
surgeon's office by the nurse, knowing
that it
could cause surgery to be postponed?

1.
2.
3.
4.
2.

Sodium, 141 mEq/L

Hemoglobin, 8.0 g/dL
Platelets, 210,000/mm3
Serum creatinine, 0.8 mg/dL
Hemoglobin, 8.0 g/dL

Routine screening tests include a

complete blood
count, serum electrolyte analysis,
coagulation studies, and a serum
creatinine test. The complete blood
count includes the hemoglobin analysis.
All these values are within normal
range except the hemoglobin. If a client
has a low hemoglobin level, the surgery
likely could be postponed by the
surgeon.

177. A nurse receives a telephone call

from the postanesthesia care unit
stating that a client is being
transferred to the surgical unit. The
nurse plans
to do which of the following first on
arrival of
the client?
1. Assess the patency of the airway.
2. Check tubes or drains for patency.
3. Check the dressing to assess for
bleeding.
4. Assess the vital signs to compare
with preoperative
measurements.
1. Assess the patency of the airway.
The first action of the nurse is to assess
the patency
of the airway and respiratory function.
If the airway is not patent, the nurse

must take immediate measures for the

survival of the client. The nurse then
takes vital signs followed by checking
the dressing and the tubes or drains.
Options 2, 3, and 4 are all nursing
actions that should be performed after
a patent airway has been established.
H&P What are some pre-exisitng
medical condition that important to
know?
CHF, DM, ischemia heart disease.
Tobacco use, Et-OH use, drugs.

What are pre-operative medication

that patient should stop prior to
surgery?
DM meds, anticoagulants, and
anitplatelet agents.

What is the % of postoperative

stroke?
>80% caused by hypotension or
cardiogenic emboli during a. Fib.

A patient with stroke that require

should be delayed surgery for a time
period of?
Minimum of 2 weeks ideally for 6
weeks.

What are some routine preoperative

testing:
CBC, UA, Serum electrolytes,
creatinine, and BUN, coagulation
studies, biochemical and profile (CMP),
Pregnancy testing, Chest-Xray, EKG,
Blood types, cross type screen

What is the leading causes of death

after noncardiac surgery?
Cardiovascular disease
Risk factor: Age>70, Unstable angina,
CHF, DM, valvular heart disease,
arrhythmias, PVD, MI

What valvular heart disease is a risk

factor?
Aortic stenosis

What are the risk factor for

perioperative coronary events for
arrhythimas?
Supraventricular and ventricular
arrhythmias

How do you handle pacemaker and

internal defibrillators preoperative
management?
Pacemaker: should be turned to
uninhibited mode
Defibrillator: should be turned off

How long should a noncardiac

surgery take place after coronary
angioplasty or stenting?
6 weeks

Smoking should stop how many hours

before surgery?
48 hours.

What are the risk factor for

pulmonary disease?

-COPD (Very important)

-Smoking
-Advance age
-Obesity
-Acute Respiratory infection

What is the most important

abnormalities in the peri-operative
period includes:
Hyperkalemia, intravascular volume
overload, and infectious complication.

What patient with chronic renal

insufficiency require chronic
hemodialysis?
Diabetes or hypertension

What can indicate intravascular

volume overload?
Elevated jugular venous pulsation or
crackles on lung examination

When should dialysis be performed

for a planned operative procedure?
within 24 hours.

What are the risk factor for

developing acute renal failure after
operation without preexisting chronic
renal insufficiency?
BUN, creatinine, CHF, advance age,
intraopertive hypotension, sepsis,
aminogylcosides, radiocontrast agents,
aortic clamping, ntravascular volume
contraction.

How do you prevent acute renal

failure?

hydration

What is the leading causes of

perioperative death among diabetic
patients?
MI

What is the most common indication

for warfarin therapy?
atrial fibrillation, venous
thromboembolism, and mechanical
heart valve

What is the safe value for INR to

perform surgery?
1.5

How can you reverse anticoagulation

before surgery?
plasma products must be administered.
In addition, Factor VII (8) can have
have immediate effects, whereas
vitamin K will have observable effects
within 8 hours.

How long does a patient be

maintained on IV fluids
postoperative ?
until they are tolerating oral intake.

Ulcer prophylaxis. Patient with a

history of peptic ulcer disease should
have some form of ulcer prophylaxis
in the perioperative period with either
acid-reducing agents or
cytoprotective agents, such as
sucralfate

Lab test postopertive:

-CBC: check blood loss
-Electrolytes, BUN, and creatinine: on
pt who are NPO
-Coagulation studies
-ECG and series of troponin level
-Chest X-Rays

What medication is useful for

perioperative stroke?
Aspirin 325mg

What can cause seizures without a

history of seizure?
metabolic derangement, including
electrolyte abnormalities
(hyponatremia, hypocalcemia,
hypoglycemia, sepsis, fever, and drugs.
-If none of the above is identifiable
then eval with head CT followed by a
lumbar puncture.

How can you treat recurrent tonicclonic seizure?

Phenytoin

How do you treat status epilepticus?

Diazepam

Infectious complication with high

fever in the first 24 hours is
commonly the result of a
streptococcal or clostridial wound
infection, aspiration pneumonitis, or
preexisting infection.
Streptococcal wound infection present
with severe local erythema and

incisional pain. Pencillin G or ampicillin

is effective therapy.
3-5 days postop
when is infection anticipated post-op

allow questions, explain why, handle

equipment
what are good tips for school age child

allow to play with equipment

preschool and school age teaching
preop

antibiotics and force fluids , CS sample

implementation of UTI

antibiotics, aseptic techniques, good

nutrition
implementation of infection to wound
from surgery

anticoagulants
implementation of DVT

aseptic technique
what type of sterile technique is
followed during surgery

aseptic technique
what type fo technique is used to
changed post op dressing change

atelectasis
collapse of part or (much less
commonly) all of a lung.

atelectasis, pneumonia
s/s of dyspnea, cyanosis, cough,
tachycardia, elevated temp, pain on
affected side

bowel sounds, NPO, mouth care, stool,

flatus, TED hose, SCD,
assess postop

catheterize pt. or have client stand if

tolerated
implementation of urinary retention

deep breathing, leg exercises,

incentive spirometer
what types of teaching are reviewed
before surgery for post-op

dehiscence
separation of wound edges

distraction, simple explanations

what are some tips for toddlers before
procedures

dont cross legs or elevate knees gatch

tell client to avoid these two positions

embolism
s/s dyspnea, pain, hemoptysis, restless,
Low PaO2, high PCO2 (ABG)

evisceration
bowel externalized and separation of
wound edges

expect resistance
adolescent teaching common behavior

hemorrhage or shock complication of

surgery
hypotensive increased pulse cold
clammy skin s/s of

homans sign
pain in the calf on dorsiflexion of the
patient's foot signs of DVT

hyperthermia, hypotension,
respiratory depression, n/v
common side effects of anesthesia

ICP and abdominal surgery (eye,

brain)
clients are encouraged to deep breath
but not cough in these types of
surgeries ofr condition

incision, drainage, amount and

character, drains,
what is assessed at the surgical sight
post op

infection
elevated WBC and temperature,
positive cultures s/s of this surgery
complication

involve family and help reinforce

teaching
who can help in preop teaching for
children

lie on unaffected side

how should atelactisis client lie in bed

long term benefits, accept regression

and provide privacy
what are good tips for adolescent
before procedure

loss of control and allow choices

what is fear before surgery of a school
age child and what is good
implementation

loss of independence and body image

disturbance, involve in procedure,
understanding and strengths
what is expected behavior of
adolescence pre surgery

low fowlers, no coughing NPO, cover

viscera with steril saline dressing,
notify physician
implement evisceration

low fowlers position, no coughing,

NPO, notify physician
implementation of dehiscence post op
surgery complication

monitor vitals, replace blood

implementation of hemorrhage

mutilation, encourage expressed

feelings, models
for a preschooler what is taught to
parents about the childs psyche before
surgery

nasogastric suction, IV fluids,

decompression tubes
implementation of paralytic ileus

paralytic ileus complication

s/s of absent bowel sounds, no flatus or
stool,

puppets, dolls, demonstrate

equipment, eye level
what are tips for pre-schooler

purulent fluid
pus or infected discharge from wound
or incision

second day post op, O2,

anticoagulants (heparin), IV fluids
implementation of PE

second day post-op, suction, postrual

drainage, antibiotics, turn and cough,
deep breathing
implementation of atelactisis and
pneumonia

separation, regression, difficult

separation
what to teach parent pre-op about
toddler going in for surgery

serosanquineous fluid
containing or consisting of both blood
and serous fluid

serous fluid

pale yellow and transparent, and of a

benign nature

simple directions
toddler teaching preop

someone who has had the surgery

before and talk about it helps
for adolescents this implementation is
helpful before surgery to minimize fear

stop anesthesia, muscle relaxant

what is done if client experiences
malignant hyperthermia when receiving
anesthesia

treat cause, O2, IV fluids

implementation of shock

turn, cough, deep breath, pain meds,

incentive spirometer, PCA, teach
mobility asap
what is taught to client post op unless
dr. stated restrictions

urinary retention
unable to void 8-12 hours post op with
bladder distention

UTI
foul smelling urine, elevated WBC, 5-8
days post op

vitals x 15 min, LOC, I/O, CVP,

potassium levels, respiratory care
what is closely monitored post-op

Perioperative nursing includes the key

concepts of these three areas of care.
1. Preoperative Care
2. Intraoperative Care
3. Postoperative Care

AORN
The Association of periOperative
Registered Nurses is one of the most
highly organized and influential
specialty organizations within the
nursing profession.

AORN standards and recommended

Practices keep nurses...
up to date on current practice

An important aspect of the

perioperative nursing role
Perioperative safety and the prevention
of complications of surgery

What is a very important part of

perioperative safety?
hand hygiene

Preventable perioperative errors cause

____% of surgery-related deaths
10

Impacts of preventable perioperative

errors
1. 1-% of surgery-related deaths
2. unfavorable financial impact on
healthcare institutions
3. physical and emotional harm to
patients

Name various government and private

organizations that stress the
importance of patient safety:
1. AORN
2. The Joint Commission (2012)
3. The National Priorities Partnership
(NPP) (2011)
4. The Institute for Healthcare
Improvement (IHI) (2011)

AORN stresses what in terms of

perioperative safety?
1. Prevention of injury
2. Freedom from infection

The Joint Commission National Patient

Safety Goals for 2012
1. Preventing infection
2. improving the accuracy of patient
identification
3. using medication safely
4. Performing time-out immediately
before starting
5. procedures to prevent mistakes in
surgery

The National Priorities Partnership

(NPP) Quality Forum established a
national priority that includes the aims
of
1. Achieving better care
2. Providing improved health for people
and communities
3. Making quality care more affordable
4. Making care safer by reducing harm
caused in the delivery of care

The Institute for Healthcare

Improvements (IHI) goal
To reduce morbidity and death in
American healthcare, including
perioperative care

The Institute for Healthcare

Improvements (IHI) campaigns
100,000 Lives and 5 Million Lives to
reduce surgical complications and
specifically surgical infections.

What are "Never Events"

Serious and costly errors resulting in
severe consequences for the patient,
and that are mostly preventable.

Medicare won't reimburse for these

Never Events because they are
believed to be mostly preventable

never events are also called

serious reportable events

Never events important to

perioperative care
1. Surgery on the wrong body part
2. Surgery on the wrong patient
3. Wrong surgery on a patient
4. Deep vein thrombosis or pulmonary
embolism after a total knee or hip
replacement
5. foreign body left in a patient after
surgery
6. surgical site infections after certain
elective procedures

AORN, The Joint Commission, NPP, and

IHI say that all surgical site infections
after surgery are
never events

The centers for disease control and

prevention (CDC) target ______ as
never events
certain antimicrobial-resistant bacterial
infections

The beginning and ending of the

PREoperative phase of care
1. the client's decision to have surgery
2. the client enters the operating room

The focus of preoperative phase

-identifying existing health concerns
-planning for intraoperative needs
-planning for postoperative needs
-providing preoperative teaching

More than ____ of surgeries in the US

are performed in outpatient setttings
two-thirds

The length of the preoperative period

and the extent of the patient teaching
depend on these
1. type of surgery
2. patient's overall health status

Classifications of surgeries
1. by body system
2. by purpose
3. by degree of urgency
4. by degree of risk

Seven surgeries by purpose

1. Ablative
2. diagnostic (explorative)
3. Palliative
4. Reconstructive
5. Cosmetic
6. Transplant
7. Procurement

Ablative Surgery
Removal of a diseased body part.

Diagnostic (explorative) Surgery

To confirm or rule out a diagnosis
(biopsy, fine-needle aspiration, invasive
testing - cardiac catheter)

Palliative surgery
to relieve discomfort or other disease
symptoms without producing a cure.
nerve root destruction for chronic pain.

Reconstructive surgery
to restore function - rotator cuff repair

Cosmetic surgery
improve appearance (my face-lift)

Transplant Surgery
replaces a malfunctioning body part,
tissue, or organ. Joint replacements,
organ replacement.

Procurement Surgery
related to transplant surgery. Organ or
tissue is harvested from someone

pronounced brain dead for

transplantation into another person.

Surgery by Degrees of Urgency

1. Emergency
2. Urgent
3. Elective

Emergency Surgery
required transport to the operating
suite as soon as possible to preserve
the patient's life or function. The
surgical team is summoned and
preparations are made rapidly. Internal
hemorrhage, rupture of an organ, and
trauma are common causes of
emergency surgery.

Urgent surgery
scheduled within 24-48 hours to
alleviate symptoms, repair a body part,
or restore function. removal of a
cancerous breast, internal fixation or a
fracture.

Elective surgery
recommended course of action, but the
condition is not time sensitive. The
client may delay surgery to gather info,
consider options, or organize care for
the family. torn ligament, removal of
rectal polyps, rhinoplasty

Surgery by Degree of Risk

Major and Minor surgery

Major Surgery

associated with a high degree of risk.

High potential for significant blood loss,
involve vital organs, be a prolonged or
complicated procedure, have significant
potential for postoperative
complications.
coronary artery bypass graft (CABG)
organ transplantation
nephrectomy (removal of a kidney)
colon resection

Minor Surgery
outpatient basis
involves little risk
Usually has few complications
arthroscopy
breast biopsy
inguinal hernia repair

What factors affect surgical risk?

Age (young and old)
Type of wound
Preexisting conditions
mental status
medications
personal habits
Allergies

Clean Wound Characteristics

Uninfected; minimal inflammation; little
risk of infection
AND
surgery does not involve the GI, GU or
Respiratory tracts

Clean-Contaminated Wound
Characteristics
Not infected, but carry increased risk
for infection
(surgical incisions that enter the GI,
Resp, or GU tracts)

Contaminated Wound Characteristics

Not infected, but carry high risk for
infection
(surgery to repair trauma to open
wounds such as compound fractures;
surgery in which a major break in
surgical asepsis occurred)

Infected wound characteristics

Evidence of infection such as purulent
drainage, necrotic tissue, or bacterial
counts above 100,000 organisms per
gram of tissue
(Postoperative surgical incision of any
type that has evidence of infection)

Name 8 chronic Preexisting conditions

that increase surgical risk
1. cardiovasuclar diseases
(hypertention, congestive heart failure,
MI)
2. Coagulation disorders
3. Chronic respiratory disorders
4. Renal disease
5. Diabetes mellitus
6. Liver disease
7. Neurological disorders (paralysis,
spinal cord injuries)
8. Nutritional disorders
(malnourishment, obese)

Name 2 acute preexisting conditions

that increase surgical risk
1. Upper respiratory tract infections
(postop pneumonia esp with general)
2. Acute infections tax the patient's
energy and physiological reserved,
increasing the risk for various
postoperative complications.

Medications that increase surgical risk

Antibiotics
Anticoagulants
Antidysrhythmics
Antihypertensives
Aspirin
Corticosteroids
Diuretics
Opioids
NSAIDs
Tranquilizers

Which medications increase the risk

for bleeding?
Anticoagulants
Aspirin
NSAIDs

Which medications may impair cardiac

function during anesthesia?
Antidysrhythmics
antihypertensives

Which medications alter respiratory

function during anesthesia?
Opioids
tranquilizers

Which medication may potentiate the

action of anesthetic agents?
Antibiotics

Which medication may increase the

risk for hypotension during surgery?
Antihypertensives

Which medication may delay wound

healing and increase risk for infection?
Corticosteroids

Which medication may alter fluid and

electrolyte balance (especially
potassium balance)
Diuretics

Which medication may inhibit platelet

aggregation
NSAIDs

Name 12 topics of a preoperative

focused nursing history
1. health history
2. physical status
3. allergies
4. medications
5. mental status
6. knowledge/understanding of the
surgery/anesthesia
7. cultural/spiritual factors
8. social resources
9. coping strategies
10. use of alcohol and drugs
11. values
12. expressed needs

Focused Physical Assessment

1. Brief head to tow physical

assessment
2. focused assessments as needed
3. Assess risk for thrombophlebitis

Optimal preoperative assessment of

older adults include...
1. cognitive ability
2. capacity to understand the surgery
3. nutritional status
4. risk factors for postoperative delirium
and pulmonary complications
5. pt's treatment goals and
expectations
6. family and social support system
7. depression
8. cardiac status
9. functional status
10. history of falls
11. detailed medication history
(polypharmacy)
12. baseline frailty score
13. diagnostic tests specific to elderly
patients

Preoperative diagnostic testing

depends on...
age
health history
facility policies

Most institutions require the following

preop diagnostic tests
CBC
Urinalysis
EKG (50+ pts)

Is age alone a risk factor for

postoperative complications?
No

Age + ______ increase the risk for post

operative complications.
multiple comorbidities such as
cardiovascular or pulmonary disease

All preoperative patients need/have...

preop teaching
anxiety
so you don't need a separate nursing
diagnosis to address teaching or
anxiety (unless it is out of normal
ranges)

Individualized nursing diagnoses for

the preoperative patient evolve
from .....
the nursing assessment

Identify an actual nursing diagnosis

only if the patient has...
the defining characteristics for it

Identify risk diagnoses only if the

patient has an underlying condition
that places him at
higher risk than the agerage surgical
patient.

NANDA-I nursing diagnoses for certain

preop patients
Anxiety

Ambulatory Surgery
same-day or outpatient surgery;
requires fewer tha 24 hours of surgery

Perioperative
describes the entire span of the
surgery, including before and after the
actual operation

Preoperative
begins with the decision to perform
surgery and continues until they reach
the operating area

Intraoperative
includes the entire surgical procedure
until transfer of the client to recovery
area

Postoperative
begins with admission to the recovery
area and continues until the client
receives a follow up visit or discharged;
factors such as age, nutritional status,
preexsisting disease, type of surgery
and length, and length/type of
anesthesia

What benefits of ambulatory surgery?

fewer after effects of anesthetics, more
active role in recovery for patient, early
post-op ambulation, cheaper, leaser
nosocomial risks

Diagnostic
removal and study of tissue; ie. breast
bisopsy

Exploratory
exploration to diagnose a problem; ie.
explore unexplained abdominal pain

Palliative
relief of symptoms or enhancement of
function wo cure; ie. resection of a
tumor to relieve pressure

Curative or reparative
removal of tumor or diseased organ or
replacement of defective tissue; ie. hip
replacement

Cosmetic
approve appearance or change feature;
ie. breast implants

Preventive or Prophylactic
removal of tissue that does not yet
contain cancer; ie. removal of ovaries

Reconstructive
repair or reconstruct physical
deformities and abnormalities; ie.
breast reconstruction after removal

Emergency surgery
immediate, condition is life threatening

Urgent surgery
within 24-30 hours, patient requires
prompt attention

Required surgery

planned a few weeks or month after

decision

Elective surgery
patient will not be harmed if surgery
not performed but will benefit if its
performed

Optional surgery
personal preference

Surgical Risk Factors

age, nutritional status, substance
abuse, medical problems

Preoperative Assessment
labs and diagnostics, Hx, surgical
consent, physical/psychological needs,
culture needs, preoperative teaching,
preop medications, pre-op checklist

Physical needs during assessment

vitals, weight & height, ability to
move/ambulate, communication ability,
LOC, prostheses

Psychological needs during

assessment
emotional state, coping strategies,
support system, roles and
responsibilities, level of understanding

Preoperative Labs and diagnostics

CBC, serum electrolytes, PT, platelets,
type blood, Bun and creatin, glucose,
urinalysis, chest x-ray, ECG

Surgical consent
physician must explain procedure and
obtain consent from the patient

Preoperative instruction should

include:
Time of Surgery/Routine, NPO Status,
Preoperative Medications, IV's to be
used, Visiting Hours, Special Equipment
& Frequent Monitoring, Pain
Management post operatively,
Coughing/Deep Breathing/Incentive
Spirometer,
Leg Exercises/Early
Ambulation/Antiembolism
Stockings/Sequential Compression
Device

Preoperative Physical Preparation

Skin Preparation, Elimination: Bowel &
Urinary: catheterization, Food and
Fluids, Care of Valuables
Attire/Grooming, Prostheses

What is the purpose of preoperative

teaching?
client have uncomplicated and shorter
recovery period

Skin preparation before surgery

patient might be asked to use
germicide soap several days before
surgery; hair will not be shaved unless
it interferes with the incision; if it needs
to be removed it is done so with electric
clippers

Elimination preparation before surgery

indwelling catheter may be used, if not

patient will void prior to preoperative
medications; enemas or laxatives may
be used prior to procedure to clean
bowels depending on procedure

Food and Fluids before surgery

usually no food or drink 8 to 10 hours
before surgery or after midnight; client
may be told they can have clear fluids
up to two hours before surgery

Care of valuables before surgery

client encouraged to give valuables to a
family member; if not, the nurse
itemizes the valuables, places them in
an envelope and locks them away;
client signs receipt

Attire/grooming before surgery

hair ornaments, all makeup and nail
polish must be removed; physician may
order TED's to be worn before surgery
to prevent venous stasis

Anticholinergics
decrease respiratory tract secretions,
dry mucous membranes, and interrupt
vagal stimulation

Antiemetics
decrease nausea during surgery

Tranquilizers
reduce anxiety and enhance
preoperative sedation

Sedatives
promote sleep, decrease anxiety,
reduces amount anesthesia needed

Psychosocial preparation before

surgery
prepare client emotionally and
spiritually reduces anxiety and fear

Preoperative checklist
completed by nurse before patient
leaves room for surgery; includes vitals,
weight, preoperative medication
administered, procedures performed,
whether client voided, disposition of
vitals, IV's

Anesthesia
partial or complete loss of sensation of
pain with or without loss of
consciousness

General anesthesia
acts on the central nervous system to
produce loss of sensation, reflexes and
consciousness; can be administered IV,
IM, inhaled or rectally

Stage 1:Beginning Anesthesia

administration of anesthesia and
endotracheal intubation
administration of anesthesia and
endotracheal intubation; client
experiences dizziness, detachment,
temporary heighten sense of awareness

Stage 2: Excitement

patient may struggle, talk, laugh, cry,

uncontrolled movements; team
members must protect client from
falling or injury

Stage 3: Surgical Anesthesia

patient remains unconscious through
continuous administration of
anesthesia; main remain for hours with
a range of light to deep anesthesia

Stage 4: Medullary Depression

receives to much anesthesia; shallow
respiration, weak pulse, dilated pupils,
death can occur

What does the team members monitor

patient for during general anesthesia
and during recovery from it?
effective breathing and oxygenation,
effective circulation status including BP
and pulse, temperature and fluid
balance

Regional Anesthesia
local anesthetics to block nerve pulses
in a specific region of the body; client
usually awake; types: local anesthetics,
spinal anesthetics and conduction
blocks

What does the team members monitor

patient for during Regional anesthesia
and during recovery from it?
allergic reactions, changes in vitals, and
toxic reactions; client is at risk for
injuries and burns; if sedation is too
high will cause respiratory depression

Procedural Sedation
Patient is free of pain, fear, anxiety, can
tolerate unpleasant procedures; Patient
maintains independent
cardiorespiratory function, can respond
to verbal commands and tactile
stimulation; IV anesthesia usually used

Sedation
pharmacologically induced state of
relaxation and emotional comfort

What do you use in case of over

sedation?
antagonists, also called reversal drugs,
reverse the side effects of opioids and
benzodiazepines

Intraoperative-Surgical Team consist

of?
Anesthesiologist, Anesthetist, Surgeon,
Surgical Assistants
Circulating Nurse, Scrub Nurse

Circulating Nurse
-Must be RN
- Review preoperative assessment
- Establishes and implements
intraoperative plan of care
- Evaluating the care
- Monitors sterile technique
- Monitors for safe operating room
environment
- Takes care of non-sterile equipment
- Verifies sponge and instrument counts
- Maintains accurate and complete
documentation

Scrub Nurse
- May be an RN, LPN, or surgical
technician
- Maintains sterile field
- Assists with applying sterile drapes
- Hands the surgeons the instruments
and other sterile supplies
- Counts the sponges and instruments

Intraoperative Complications:
INFECTIONS
Strict aseptic technique is necessary
before and after surgery. If a nurse
notices a break in aseptic technique she
is to notify the surgeon or OR personnel
immediately. The scrub nurse and
circulating nurse count all surgical
instruments, gauze sponges, and
sharps to prevent retention of foreign
objects in the wound.

Intraoperative Complications: FLUID

VOLUME
the circulating nurse is responsible for
recording and keeping a running total of
IV fluids administered, the
anesthesiologist usually adds fluid to
the IV lines, but the circulating nurse
can as well; measure urine OP from
catheter

Intraoperative Complications: INJURY

RELATED TO POSITIONING
careful positioning of client on the table
during surgery help prevent
interruption of blood supply secondary
to prolonged pressure, nerve damage,

hypo-tension, edema, and joint injury

due to alinement

Intraoperative Complications:
HYPOTHERMIA
client may be at risk for hypothermia
related to low temp in OR (70 deg),
administration of cold IV fluids,
inhalation of cold gases, exposure of
body surfaces

Intraoperative Complications:
MALIGNANT HYPERTHERMIA
inherited disorder when body temp,
muscle metabolism, and heat
production increase rapidly; S&S: jaw
muscle rigidity, rapid rise in temp,
elevate PaCO2 and serum potassium,
tachycardia, tachypnea, diaphoresis,
mottles skin, hypotension, irregular HR,
decreased urine OP. If this occurs the
anesthesia is discontinued and OR team
implements measures to reverse

Postoperative Care: PACU Nurse

Management - Initial Post-Operative
Assessment
Report given, Complete AssessmentPriority: Airway patency, Adequate
Circulation, Assess for initial
postoperative complications,
Hemorrhage, Shock, Hypoxia
Aspiration. Family able to visit.

Postoperative Care: PACU Nurse

Management - Later Post-Operative
Assessment

Nurse also evaluates readiness for

discharge from PACU: Vital signs stable,
Body temperature control
Good ventilatory function, Orientation
to surroundings
Absence of complications, Minimal pain,
Controlled wound drainage, Adequate
urine output

What is the PACU?

Postanesthesia Care Unit

Aldrete Scale
used to determine how a patient is
recovery from anesthesia; score of 9 or
greater indicates recovery

Postoperative Comfort
Pain assessment (Pain Scale),
Administer ordered pain medication,
Evaluate effectiveness,
Provide safety,
Provide hygiene,
Non-pharmacological Interventions,
Promote uninterrupted rest,
Quiet environment

Prevention of Postoperative
Complications: HEMORRAGHE
Nurse inspects dressing frequently for
signs of bleeding and checks bedding
for pools of blood. Bright red blood
indicates fresh blood; dark, brownish
red indicates older blood. If internal
bleeding client may need to return to
OR; blood transfusion may be
necessary; check wound drains and
know expected drainage amounts

Prevention of Postoperative
Complications: SHOCK
Fluid and electrolyte loss, trauma,
anesthetics and post op meds may
contribute. S&S: pallor, fall in BP, weal
rapid pulse, restlessness, cool, moist
skin. Treat early to prevent damage to
brain, kidneys and heart.

Prevention of Postoperative
Complications: HYPOXIA
Oxygen and suction equipment must be
available; observe for S&S of cyanosis
and dyspnea; reposition client on side
to relieve any obstructing, check
tongue

Prevention of Postoperative
Complications: RESPIRATORY
Nurse focuses on promoting gas
exchange and preventing atelectasis.
teach client to deep breathe and cough,
use incentive spirometer; O2 may be
required; encourage early mobility,
frequent position changes, suction as
needed

Prevention of Postoperative
Complications: CARDIOVASCULAR
Assess BP and circulation frequently;
Leg exercises (mobility), Antiembolism
stockings/SCD's, Early ambulation
(mobility), Position so not to interrupt
blood flow, Anticoagulant therapy as
ordered, Adequate fluid intake

Prevention of Postoperative
Complications: GASTRO-INTESTIONAL
Complications: Paralytic ileus,
abdominal distention
nausea & vomiting, constipation
Interventions: Bowel assessment, early
ambulation
Antiemetics as ordered, progression of
diet (can usually take fluids within 4 24hr), adequate fluid intake, fiber
laxatives , stool softeners as ordered

Prevention of Postoperative
Complications: URINARY
Complications: acute urinary retention,
UTI
Interventions: Assist patient to assume
normal positions during elimination,
Assess patient frequently for need to
void, Assess for bladder distention, I&O;
if the client cannot void within 8 hrs a
catheter is inserted

Prevention of Postoperative
Complications:
INTEGUMENTARY/WOUND
Complications: Wound infection, Wound
dehiscence
Wound evisceration, Delayed wound
healing, Skin breakdown
Interventions: Assessment of wound,
Aseptic technique
Handwashing, Teach patient to splint
wound
Promote adequate nutritional intake

Process of Wound Healing: Primary

Intention

wound layers are sutured together.

Heals in 8-10 days with minimal
scarring.

Process of Wound Healing: Secondary

Intention
Granulating tissue fills in wound . Skin
layers are not approximated.

Process of Wound Healing: Tertiary

Intention
The approximation of the wound edge
is delayed secondary to infection. When
wound is clean of infection the wound
edges are approximated. The scar is
wider.

What must the nurse be aware of to

prompt wound healing?
alert to S&S of impaired circulation,
such as swelling, coldness, absence of
pulse, pallor, mottling and report the
immediately. Provide adequate nutrition
and fluids. Obesity may contribute to
poor wound healing; excess fat
prolongs length of surgery and
necessitates the use of forceful
retraction, add pressure to wound
edges, decreases blood flow

Wound Dehiscene
separation of wound edges without
protrusion of organs; occurs when
wound separates and organ protrudes;
usually occur 7 -10 after surgery; place
client in position that places the least
strain on the wound;
Risk factors: older than 65, chronic

diabetes, hypotension, obesity,

malnutrition, tobacco use, defective
suturing

Serous Drainage
clear, watery plasma

Serosanguineous Drainage
drainage is a mixture of serous and
some blood tinged, seen with surgical
incisions. Pale, pink, watery mixture of
clear and red fluid

Sanguineous Drainage
capillary damage- large # RBC, severe
inflammation. Bright red indicates
active bleeding

Purulent Drainage
"pus", severe inflammation w/infection,
contains leukocytes, liquefied dead
cells, dead and living bacteria. Thick,
yellow, green, tan, or brown

Drains
Drains - special equipment that pulls
drainage from the surgical area when
wound has been closed

Penrose Drain
rubber type tube with openings on both
ends, drainage accumulates on gauze.

J. P. Drain - (Jackson-Pratt)
Closed suction drainage system. Empty
when full.

Hemovac Drain- Closed suction

drainage system
Closed suction drainage system

Nutritional Considerations after

surgery
Complications: poor appetite, nausea,
vomiting
Interventions: antiemetics as ordered,
progression of diet
small frequent meals, offer foods the
patient wants to eat,
patient needs about 1500 calories/day
post op,
increase protein, Vitamin A&C, Zinc

Discharge Teaching
Wound care, Activity, Diet, Medications,
Personal hygiene
Follow-up with physician, address any
other concerns that may be relevant
Perioperative Care refers to the time:
-When the patient is scheduled for
surgery until the patient's condition
stabilizes and patient is d/c from
facility.
-Preoperative, intraoperative, and
perioperative

What 3 things will you, as a nurse,

function as to the patient in
parioperative process?
An educator, advocate, and a promoter
of health.

The peri operative emphasis on:

Safety, advocacy, patient education,

and a culture of safety.

Objective to Perioperative Care:

-Provide care for the perioperative
client
-Provide nursing care for clients
experiencing signs and symptoms of
commonly occurring complications,
shock, and hemorrhage.
-Manage the pain of the perioperative
client
-Develop age-related teaching/learning
strategies for the perioperative client.

The preoperative period begins when:

The patient is scheduled for surgery
and ends at the time of transfer to the
surgical suite.

Reason for Surgery, Diagnostic:

Description: Performed to determine
the origin and cause of a disorder or the
cell type for cancer.
Condition of Surgical
Procedure: breast biopsy, exploratory
laparotomy, arthroscopy.

Reason for Surgery, Curative:

Description: Performed to resolve a
health problem by repairing or
removing the cause.
Condition of Surgical
Procedure: Cholecystectomy,
appendectomy, hysterectomy.

Reason for Surgery, Restorative:

Description: Performed to improve a

patient's functional ability.
Condition of Surgical
Procedure: Total knee replacement,
finger re-implantation.

Reason for Surgery, Palliative:

Description: Performed to relieve
symptoms of a disease process, but
does not cure.
Condition of Surgical
Procedure: Colostomy, nerve root
resection, tumor de-bulking, ileostomy.

Reason for Surgery, Cosmetic:

Description: Performed primarily to
alter or enhance personal appearance.
Condition of Surgical
Procedure: Liposuction, revision of
scars, rhinoplasty, blepharoplasty.

Urgency of Surgery, Elective:

Description: Planned for correction of
a nonactive problem.
Condition of Surgical
Procedure: Cataract removal, hernia
repair, hemorrhoidectomy, total joint
replacement.

Urgency of Surgery, Urgent:

Description: Requires prompt
intervention; may be life threatening if
treatment is delayed more than 2448hrs.
Condition of Surgical
Procedure: Intestinal obstruction,
bladder obstruction, kidney or ureteral

stones, bone fracture, eye injury, acute

cholecystitis.

Urgency of Surgery, Emergent:

Description: Requires immediate
intervention because of life-threatening
consequences.
Condition of Surgical
Procedure: Gunshot or stab wound,
severe bleeding, abdominal aortic
aneurysm, compound fracture,
appendectomy.

Degree of Risk of Surgery, Minor:

Description: Procedure without
significant risk; often done with local
anesthesia.
Condition of Surgical
Procedure: Incision and drainage
(I&D), implantation of a venous access
device (VAD), muscle biopsy.

Degree of Risk of Surgery, Major:

Description: Procedure of greater risk;
usually longer and more extensive than
a minor procedure.
Condition of Surgical
Procedure: Mitral valve replacement,
pancreas transplant, lymph node
dissection.

Extent of Surgery, Simple:

Description: Only the most overtly
affected areas involved in the surgery.
Condition of Surgical
Procedure: Simple/partial mastectomy.

Extent of Surgery, Radical:

Description: Extensive surgery beyond

the area obviously involved; is directed
at finding a root cause.
Condition of Surgical
Procedure: Radical prostatectomy,
radical hysterectomy.

Extent of Surgery, Minimally Invasive

Surgery (MIS):
Description: Surgery performed in a
body cavity or body area through one
or more endoscopes; can correct
problems, remove organs, take tissue
for biopsy, re-route blood vessels and
drainage systems; is a fast-growing and
ever-changing type of surgery.
Condition of Surgical
Procedure: Arthroscopy, tubal ligation,
hysterectomy, lung lobectomy,
coronary artery bypass,
cholecystectomy.

Risk Factors the Acknowledge In The

Preoperative Phase:
Age (older than 65),nutritional,
health status, fluid and electrolyte
imbalances, radiation,
cardiopulmonary, chemotherapy,
meds(antihypertensives, tricyclic
antidepressants, anticoagulants,
NSAIDs),family history (malignant
hyperthermia, cancer, bleeding
disorder), prior surgical
experience (less than optimal
emotional reaction, anesthesia
reactions or complications,
postoperative complications), type of
surgery (neck, oral, or facial
procedures [airway complications],

chest or high abdominal procedures

[pulmonary complications], abdominal
surgery [paralytic ileus, DVT).

Risk Factors the Acknowledge In The

Preoperative Phase Con't:
Medical history (decreased immunity,
diabetes, pulmonary disease, cardiac
disease, hemodynamic instability,
multisystem disease, coagulation
defect or disorder, anemia,
dehydration, infection, HTN,
hypotension, any chronic
disease), health history(malnutrition
or obesity, drug, tobacco, alcohol, or
illicit substance use or abuse, altered
coping ability).

The Preoperative Nurse:

-Validates & clarifies information
-Assess to identify problems that
warrant further patient assessment or
intervention before the procedure
-Obtains baseline vital signs

What types of assessments are done

in collaboration?
-History & data collection
-Age; discharge planning
-Drugs and substance use
-Medical history, including cardiac
pulmonary histories
-Previous surgical procedures &
anesthesia; blood donations.

Preoperative Phase-What Assessment

the Nurse Finds:

past & present: meds, diet, allergies

(latex), personal habits, occupation,
finances, family support, knowledge of
surgery, attitude.

Preoperative Phase-Assessment:
-Nursing hx (^).
-Physical Exam
-Diagnostic Tests: CBC, electrolytes,
creatinine, urinalysis, x-ray exams,
EKG, blood type, PTT, PT, platelet
count; Blood donations; pregnancy test;
clotting studies.
-Radiographic; CXR; EKG
-Bloodless Surgery/Discharge

Preoperative Teaching r/t Informed

Consent:
Surgeon is responsible for obtaining the
signed consent before sedation and/or
surgery. The nurse's role is to clarify
facts presented by the physician and
dispel myths that the patient or family
may have about surgery.

To Obtain an Informed Consent:

-Patient must be mentally competent. If
patient just received medications
that affect comprehensive neuro
status, cannot sign consent.
-If the patient is a minor, a guardian,
parent or court order will sign the
permit; the state dictates that age.

The Patient Self-Detemination Act

allow the patient to:
-Have the right to have or to initiate
advance directives, such as living will or

durable power of attorney.

-Advance directives provide legal
instructions to the health care providers
about the patient's wishes and are to
be followed. Surgery does not
provide an exception to a patient's
advance directives or living will.

Name 5 Expected Outcomes for

Deficient Knowledge Nursing
Diagnosis:
Patient will...
-Explain the purpose and expected
results of the planned surgery.
-Ask questions when a term or
procedure is not known
-Adhere to the NPO requirements
-State an understanding of preoperative
preparations (e.g., skin preparation,
bowel preparation).
-Demonstrate correct use of exercises
and techniques to be used after surgery
for the prevention of complications
(e.g., splinting the incision,
coughing/deep breathing, performing
leg exercises, ambulating as early as
permitted).

NPO Guidelines:
-Patient is instructed to not have
anything to eat or drink by mouth 68hrs prior to procedure.
-NPO decreases aspiration risk.
-Patients should be given written and
oral instructions to stress adherence
-Surgery can be cancelled if NPO 6-8hrs
prior to surgery is not followed.

Things to Consider When

Administering Regularly Scheduled
Medications:
-Medical physicians & anesthesia
providers should be consulted for
instructions about regularly taken
prescription medications prior to
surgery.
-Drugs for cardiac disease, respiratory
disease, seizures, and HTN are
commonly allowed with a sip of water
before surgery.
-Diabetic patient who takes insulin may
be given a reduced or modified dose of
intermediate- or long-acting insulin
based on the blood glucose level or
may be given regular (fast-acting)
insulin in divided doses on the day of
surgery. As an alternative, an IV
infusion of 5% dextrose in water may
be given with the insulin to prevent low
blood sugar during surgery.

Bowel or Intestinal Preps:

-Are performed to prevent injury to the
colon and to reduce the number of
intestinal bacteria.
-Enema or laxative may be ordered by
the physician.
-Perform skin preparation to decrease
the risk of impairment of skin integrity.

Skin Preparation Considerations:

-Skin prep before surgery is the first
step in the prevention of surgical wound
infection.
-Provide a warm, comfortable, and
private environment during the
procedure since it can be

uncomfortable to the patient.

-If pt is at home, he/she may shower
with antiseptic solution 2 days before
surgery; if in hospital, showering and
cleaning are repeated the night before
or in the morning before transfer to
surgical suite.

Skin Preparation Considerations Con't:

-The CDC recommends that if shaving is
necessary, the hair should be removed
using disposable sterile supplies and
aseptic principles immediately before
the start of the surgical procedure.
-Shaving is now considered an
inappropriate hair removal method;
only clippers or depilatories are to be
used for hair removal.

Preparing the Patient for Tubes:

Tubes: Pt may need an indwelling
urinary catheter (Foley) before, during,
or after surgery. A NG tube may be
inserted before abdominal surgery to
decompress or empty the stomach and
the upper bowel.

Preparing the Patient for Drains:

Drains: are often placed during surgery
to help remove fluid from the surgical
site. Some drains are under the
dressing; others are visible and require
emptying.

Preparing the Patient for Vascular

Access:
Vascular Access: is placed for
patients receiving a general anesthetic

and most patients receiving other types

of anesthetics. Access is needed to give
drugs and fluids before, during, and
after surgery.
-Patients who are dehydrated or are at
risk for dehydration may receive fluids
before surgery.

Preoperative-Implementation:
-Informed consent
-Nutrition/fluids-IV; NPO after MN
-Elimination-enemas, foley.
-Hygiene- skin scrub; remove nail
polish, hair pins, hospital gown.
-VS; Height/weight
-Special orders (insert tubes,
medications)
-Promote comfort-anti-anxiety meds
-Skin preparation

Pre-operative Teaching:
-Leg and deep breathing exercises
-ROM exercises
-Moving patient
-Coughing and splinting

Preoperative Monitoring:
-Patient and diagnostic tests
-TED socks, elastic wraps, pneumatic
compression devices, and early
ambulation.

Deep (Diaphragmatic) Breathing:

1. Sit upright on the edge of the bed or
in a chair, being sure that your feet are
placed firmly on the floor or stool. (After
surgery, deep breathing is done with
the patient in Fowler's position or in

semi-Fowler's position).
2. Take a gentle breath through mouth
then breath out gently and completely.
3. Take a deep breath through nose and
mouth, and hold this breath to the
count of 5; exhale though nose and
mouth

Expansion Breathing:
1. Find a comfortable upright position,
with knees slightly bent
2. Place hands on each side of lower rib
cage, just above waist
3. Take a deep breath though nose,
using shoulder muscles to expand lower
rib cage outward during inhalation.
4. Exhale, concentrating first on moving
chest, then on moving lower ribs
inward, while gently squeezing the rib
cage and forcing air out of the base of
lungs.

Splinting of the Surgical Incision:

1. Unless coughing is contraindicated,
place a pillow, towel, or folded blanket
over surgical incision and hold the item
firmly in place.
2. Take 3 slow, deep breaths to
stimulate your cough reflex.
3. Inhale through nose, and then exhale
through mouth.
4. On 3rd deep breath, cough to clear
secretions from lungs while firmly
holding the pillow, towel, or folded
blanket against incision.

Purpose of External Pneumatic

Compression Devices:

-To promote venous return and prevent

DVT.
-Examples: Kendall SCD machine,
sleeves and TED stockings; Venodyne
pneumatic compression system;
Flowtron DVT calf garments.

How to relieve anxiety pre and intraoperatively:

Decrease anxiety by providing a climate
of privacy, comfort, and confidentiality.
Interventions Include:
-Preoperative teaching
-Encouraging communication
-Promoting rest
-Using distraction
-Teaching family members

What to do on the Day of Surgery:

-Complete pre-op checklist sheet in
medical record, VS, skin prep removal
of prosthetics, hair pins, dentures,
bowel and bladder prep, TEDS, IV, NG
Tube, ID band, and pre-op medications.
Make sure lab informed & radiology
reports on chart. Be sure abn. labs
reported to MD.
-ALLERGIES

Preparation of Patient's room for

return after OR:
IV pole, open bed, suction, Oxygen,
emergency kits, and clamps.

Preoperative Patient Prep:

-Patient wears an identification band.
-Dentures, prosthetic devices, hearing

aids, contact lenses, fingernail polish,

and artificial nails must be removed.

Medications Hazardous to Surgery:

Certain Antibiotics: combined with
curariform muscle relaxant cause
respiratory paralysis and apnea.
Anti-Depressants: MAO inhibitorssecond line choice for tx of depression.
Cause hypotension effects of
anesthesia, St. Johns Wart. Parnate,
Nardil.
Phenothiazines: (Thorazineantipsychotic. Also for severe NV,
seizures) increase hypotension action of
anesthesia.

Medications Hazardous to Surgery

Con't:
Diuretics: electrolytes imbalance and
resp depression.
Steroids: inhibits wound healing
Anticoagulants: warfarin and heparinaffect bleeding, unexpected bleeding;
herbals-ASA, ginko, NSAIDS, Ticlid,
Plavix.

Intra Operative Care:

Primary concerns of the nurse is the
safety & advocacy for the patient
during surgery as the patient is unable
to protect or advocate for himself. It is
the responsibility of all of the surgical
team members to protect the patient.

Intraoperative Care, Holding area:

-Enter prior to OR; nurse continues to
prepare patient (insert Foley or start

IV).
-Nurse assist in transfer to and from
OR, maintain proper body alignment.

In the OR, ID site of Procedure:

When the procedure involves a specific
site, validating the side on which a
procedure is to be performed (e.g., for
amputation, cataract removal, hernia
repair) is the responsibility of each
health care professional before and at
the time of surgery. Facilities usually
have the patient and/or nurse initial the
correct surgical site.

NTK Before the Surgery:

-Code status
-Any allergies
-The position pt is supposed to be in
-Medical hx
-What meds have been taken
-Last PO intake.

6 Positions for Surgery:

-Supine
-Trendelenburg: supine with feet slightly
lowered.
-Jacknife: like leaning over a table with
arms out to the side
-Lithotomy: supine with feet in stirrups.
-Lateral
-Prone

Insufflation:
A minimally invasive procedure where
gas or air is injected into a body cavity
before surgery to separate organs and
improve visualization.

What are the 4 types of Anesthesia?

General (inhalation, IV,
balanced): depresses the CNS,
resulting in analgesia amnesia, and
unconsciousness, with loss of muscle
tone and reflexes. Used for surgery of
head, neck, upper torso, and abdomen.
Regional or local:
Cryothermia:
Hypnosis/Hypoanesthesia:

General Anesthesia, Inhalation:

Advantages: Most controllable
method; induction and reversal
accomplished with pulmonary
ventilation; few SE.
Disadvantages: must be used in
combination with other agents for
painful or prolonged procedures; limited
muscle relaxant effects; postop
nausea and shiver common;
explosive.
Common Agents: Suprance,
Ethrane, Fluothane!, Nitrous oxide
(N2O)!

General Anesthesia, IV:

Advantages: Rapid and pleasant
induction; low incidence of postop N/V;
requires little equipment.
Disadvantages: Must be metabolized
and excreted from the body for
complete reversal; contraindicated in
presence of hepatic or renal disease;
increased cardiac and respiratory
depression; retained by fat cells.
Common Agents: Pentothal!,

Ketalar, Diprivan; Hypnotics like

versed, ativan, valium are adjuncts
to general.

General Anesthesia, Balanced:

Advantages: Minimal disturbance to
physiologic function; minimal SE; can
be used with older and high-risk
patients
Disadvantages: Drug interactions can
occur; pharmacologic effects on the
body may be unpredictable.
*Common Agents: COMBINATION OF:
Nitrous oxide, for amnesia; morphine
for analgesia; pavulon (Pancuronium),
for muscle relaxation.

Name the 4 Adjunctive Anesthetic

Agents:
-Opioid analgesic: alfenta, demerol,
morphine.
-Anticholinergic: atropine, scopolamine
-Benzodiazepine: valium, versed
-Sedative-hypnotics: atarax, vistaril,
seconal, nembutal.

Use of Opioid Analgesic for an Adjunct

Agent:
-Anesthesia induction
-Alfenta
-Demerol and Morphine: pain
prevention and pain relief.

Use of Anticholinergic for an Adjunct

Agent:
-To dry up excessive secretions
-Atropine, scopolamine

Use of Benzodiazepine for an Adjunct

Agent:
-Amnesia and anxiety
-Valium and Versed

Use of Sedative-Hypnotics for an

Adjunct Agent:
-Amnesia and sedation
-Atarax, Vistaril, Seconal, Nembutal

Advantages of Regional or Local

Anesthesia:
Advantages: gag and cough
reflexes stay intact (decreases risk
for aspiration); allows participation
and cooperation by the pt; less
disruption of physical & emotional body
functions; decreased chance of
sensitivity to agent; decreased
intraoperative stress.

Disadvantages of Regional or Local

Anesthesia:
Disadvantages: not practical for
extensive procedures b/c of the
amount that would be required to
maintain anesthesia; difficult to
administer to an uncooperative or upset
pt; no way to control agent after
administration; absorbs rapidly into the
blood and causes cardiac depression
(hypotension) or overdose; increased
nervous system stimulation (overdose).

3 Common Agents for Regional or

Local Anesthesia:
-Xylocaine
-Lidocaine

-Novocain
Topical: Dermoplast (benzocaine)

4 Types of Regional (which is a form of

Local):
Epidural: Injection into the epidural
space (dura mater). For anorectal,
vaginal, perineal, hip, & lower extremity
surgeries.
Field: A series of injections around the
operative field. For chest procedures,
hernia repair, dental surgery, & some
plastic surgeries.
Spinal: Injection into the cerebrospinal
fluid in the subarachnoid space. For
lower abdominal, pelvic, hip, and knee
surgery.
Nerve: Injection into or around one
nerve or group of nerves in the involved
area. For limp surgery or to relieve
chronic pain.

Cryothermia Anesthesia:
Advantages: Reflexes remain
intact, decreases chance of adverse
reactions, decreased intraoperative
stress.
Disadvantages: Not used in long or
extensive procedure,no way to
control depth of anesthesia, may not be
appropriate for anxious patient.

Hypnosis/Hypoanesthesia:
*Advantages: reflexes remain intact.
Disadvantages:* requires patient
cooperation, requires special training.

Induces a passive, trance-like

state.

Conscious Sedation:
Conscious sedation is the IV delivery of
sedative, hypnotic, and opioid drugs to
reduce the level of consciousness but
allow the patient to maintain a patent
airway and to respond to verbal
commands.

What are the 2 common agents used

in conscious sedation?
Versed, Ativan
Flumzazenil/Romazicon:reversal
agent for benzodiazepines (Versed,
Ativan)

Name 7 Intraoperative Nursing

Concerns:
-Patent airway (ABCs)
-Breathing/Oxygenation
-Circulation
-Therapeutic response to anesthesia
-Risk for Injury: proper positioning
-Maintain surgical asepsis
-Risk for infection.
-Surgical site: closure of surgical
wounds with stitches, staples, or tapes.
Risk for infection.

Name 7 Intraoperative Complications:

-Hypoventilation
-Oral Trauma- endotracheal intubation
-Hypotension
-Cardiac dysrhythmias
-Hypothermia

-Peripheral nerve damage

-Malignant hyperthermia

Malignant Hyperthermia:
Due to abnormal and excessive
intracellular collection of Ca+ resulting
in hypermetabolism and increased
muscle contraction.

Manifestations of Malignant
Hyperthermia:
-Tachycardia, dysrhythmias, muscle
rigidity (especially of the jaw and upper
chest), hypotension, tachypnea, skin
mottling, cyanosis,
andmyoglobinuria (presence of
muscle proteins in the urine).
-The most sensitive indication is an
unexpected rise in the end-tidal carbon
dioxide level with a decrease in oxygen
saturation.

Name 7 S/S of MH:

-High fever ^ to 111.2F (late sign),
tachycardia (early sign)
-Dysrhythmias
-Muscle rigidity (esp. jaw & upper
chest), heart failure
-Pseudotetany
-Myoglobinuria (muscle protein in urine)
-^ CA+ & K+
-Skin mottling/cyanosis

Name 4 ways to Treat MH:

-Discontinue inhalent anesthetic
-Give Dantrium (Dantrolene)(for risk
or previous HX: may give before,
during, and after surgery to prevent)

-Intubate & oxygen 100%

-Cooling: cooling blanket, iced IV saline
or iced saline lavage of stomach,
bladder, rectum.
-More pg 275 Chart 17-1

Name 3 Complications During

Intraoperative Care:
-Overdose of anesthesia
-Unrecognized hypoventilation
-Intubation complications

Who is responsible for accompanying

pt and providing report to PACU
nurses? And what must they provide?
-Anesthesiologist and circulating nurse
-Must provide a "Hand-Off Report"
which allows for 2-way verbal
communications, information must be
clear & standardized (SBAR), and
provides for clarification of information
about patient.

Purpose of the PACU:

-Provides ongoing evaluation &
stabilization of patients.
-To anticipate, prevent, treat any
complications of surgery.

How often should you look at the

surgical incision in PACU?
Q15min

What 6 things are monitored in the

PACU?
Airway: breathing appropriately?
Labored? Why?
Mental Status: what is it? Is it

appropriate?
Surgical incision: bleeding? Look at it
q15min.
VS: Temp/Pulse/BP
IV Fluids: solution type, amount in
bag, rate
Other Tubes/Drains: Foley, NG, trach,
chest

What do you immediately assess when

pt comes into PACU?
Immediately assess for patent airway
and adequate gas exchange. Although
some patients may be awake and able
to speak, talking is not a good indicator
of adequate gas exchange.

What is the order of return to

consciousness after general
anesthesia?
1. Muscular irritability
2. Restlessness and delirium
3. Recognition of pain
4. Ability to reason and control behavior

What is the order of return of motor

and sensory functioning after local or
regional anesthesia?
1. Sense of touch
2. Sense of pain
3. Sense of warmth
4. Sense of cold
5. Ability to move

What type of assessments are very

important after epidural or spinal
anesthesia?
Motor and sensory assessment

When do you test for the return of

sympathetic nervous system tone?
-Begin after the patient's sensation has
returned to at least the spinal
dermatome level of T10.
-You test by gradually elevating the
patient's head and monitoring for
hypotension.

What is the best indicator of intestinal

activity?
-The passage of flatus or stool.
-The presence of active bowel sounds
usually indicates return of peristalsis;
however, the absence of bowel sounds
does not confirm a lack of peristalsis.

Name 4 causes of ineffective wound

healing:
-Infection
-Distention from edema or paralytic
ileus
-Stress at the surgical site
-Health problems (e.g., diabetes)

What 4 patients are more at risk for

fluid and electrolyte imbalance?
-Older or debilitated
-Diabetic
-Crohn's disease
-Heart failure

Wound Dehiscence:
-A partial or complete separation of the
outer wound layers, sometimes
described as "splitting open of the
wound"

-Occurs most often between the 5th

and 10th days after surgery

Wound Evisceration:
-The total separation of all wound layers
and protrusion of internal organs
through the open wound.
-Occurs most often between the 5th
and 10th days after surgery

What 5 patients does wound

separation occur most in?
-Obese
-Diabetic
-Immune deficiency
-Malnutrition
-Ones using steroids

Patients are also at risk for developing

pressure ulcers from:
-Positioning during surgery, prolonged
contact with damp surgical linens, and
contact with unpadded surfaces.
-Examine the patient's skin for areas of
redness or open areas.

What are 4 types of Drains?

Gravity Drains: Penrose and T-tube;
drain directly through a tube from the
surgical area.
Closed-Suction Drainage
System: Jackson-Pratt and Hemovac;
drain into a collecting vessel.

What is monitored with the Penrose

Drain?
Monitor the dressing for drainage.

What is assessed for the Jackson Pratt

& Hemovac drain?
Assess suction: compress to re-charge.

8 Guidelines for Post-Surgical

Dressings:
-Surgeon changes 1st dressing
-Changed to MD order specifications or
protocol
-Use aseptic technique until
sutures/staples removed
-Usually changed Qshift w/ sterile
saline. May be left open to air
-Staples usually removed after 6-8days
& steri-strips used; removed by MD or
nurse
-Note site appearance, temp, drainage
-Montgomery Straps
-Wound Infections: TX & depridement

Montgomery Straps
Are recommended to secure dressings
on wounds that require frequent
dressing changes. These straps allow
the nurse to perform wound care
without the need to remove adhesive
strips thus decreasing risk of skin
irritation and injury.
They are prepares strips of
nonallergenic tape with ties inserted
through holes at one end. Onset of
straps is placed on either side of a
wound and the straps are tied like
shoelaces.
Replace the ties and straps whenever
they are soiled or every 2-3 days

Name 10 Complications in Postop:

-Hypotension
-Dysrhythmia
-Venous Thrombosis
-Pulmonary Embolism
-Hiccoughs
-Abdominal distention (paralytic ileus)
-Immobility with skin integrity
-Urinary retention, UTI
-Wound infection, dehiscence,
hemorrhage, evisceration

What are the 5 common opioid agents

used for post-op pain relief?
-Morphine, Dilaudid, Demerol,
Percodan, tylox/Percocet
-Assess within 5-10min for hypotension,
decreased respiratory.
-Give on schedule instead of on
demand.
-Narcan reversal agent for
opioids;Flumazenil/Romaziconrevers
al agent for benzodiazepines (versed,
Ativan)

General Anesthesia Post-op Nutrition:

Progress from liquids to regular; NPO till
bowel sounds!
Perioperative
A term used to describe the entire span
of surgery, including before and after
the actual operation.

Three phases of perioperative

1. Preoperative
2. Intraoperative
3. Postoperative

Preoperative
Begins with the decision to perform
surgery and continues until the client
reaches the operating area

Intraoperative
Includes the entire surgical procedure
until transfer of the client to the
recovery area

Postoperative
Begins with admission to the recovery
area and continues until the client
receives a follow-up evaluation at home
or is discharged to a rehab unit.

Diagnostic surgery
Removal and study of tissue to make a
diagnosis; biopsy.

Exploratory surgery
More extensive than diagnostic;
involves exploration of a body cavity or
use of scopes inserted through small
incisions.

Curative or reparative surgery

Removal of a tumor or disease organ,
replacement of defective tissue to
restore function, or repair of multiple
wounds. Examples: Cholecystectomy or
total hip replacement

Palliative surgery
Relief of symptoms or enhancement of
function without sure. Example:
resection of a tumor to relief pressure.

Cosmetic surgery
Reshape normal body structures or
improve appearance or change a
physical feature. Example: Rhinoplasty,
cleft lip repair, Mammoplasty.

Preventive or prophylactic surgery

Removal of tissue that does not yet
contain cancer cells, but has a high
probability of becoming cancerous in
the future. Example: Prophylactic
bilateral oophorectomy.

Reconstructive surgery
Repair or reconstruct physical
deformities and abnormalities caused
by traumatic injuries, birth defects,
developmental abnormalities or
disease.

Emergency surgery
Immediate; condition is life threatening,
requiring surgery at once

Urgent surgery
Within 24-30 hours; client requires
prompt attention

Required surgery
Planned for a few weeks or months
after decision; client requires surgery at
some point

Elective surgery

Client will not be harmed if surgery is

not performed but will benefit if it is
performed.

Optional surgery
Personal preference, cosmetic surgery

Surgical risk factors

Age, nutritional status, substance
abuse, medical problems (immune,
respiratory, cardiovascular, hepatic,
renal, endocrine)

Surgical consent form when sign it

indicates that client is consenting to?
The procedure and understanding of its
risks and benefits as explained by the
surgeon.

How long should a patient be NPO

before surgery?
At least 8-10 hours before

When should the patient void before

surgery and why?
Immediately before receiving
preoperative medications. Cause the
patient will be at risk of falls after
medication is given.

Adequate intake of what is important

in wound healing?
Protein and ascorbic acid (vitamin C)

What should patient be aware of to

have removed before surgery?

Clothing (wears gown & cap), hair

ornaments, make-up, nail polish,
jewelry, glasses, hearing aid, contacts
and tampons

Anticholinergics
Medication can be given before surgery;
which decrease respiratory tract
secretions, gastric secretions, dry
mucous membranes, and interrupt
vagal stimulation. Prevent
laryngospasm & reflex bradycardia.

Examples of anticholinergics
Atropine sulfate, scopolamine,
glycopyrrolate (Robinul)

Histamine2- receptor antagonists

Medication that can be given before
surgery; Decrease gastric acidity and
volume.

Opioids
Medication that can be given before
surgery to decrease the amount of
anesthesia needed, help reduce anxiety
and pain, and promote sleep.

Examples of opioids
Morphine sulfate, meperidine
hydrochloride (Demerol)

Sedatives
Medication can be given before surgerypromotes sleep, decrease anxiety, and
reduce the amount of anesthesia
needed.

Examples of sedatives
Midazolam, hydrochloride (Versed),
barbiturates; pentobarbital (Nembutal),
secobarbital (Seconal)

Tranquilizers (Hyponotics)
Medication that can be given before
surgery which reduces nausea, prevent
emesis, enhance preoperative sedation,
reduce preoperative anxiety, slow
motor activity, and promote induction
of anesthesia.

Examples of Tranquilizers
Diazepam (Valium), flurazepam
(Dalmane), lorazepam (Ativan)

Before preoperative medications are

given a nurse should?
Check client's ID bracelet, ask about
allergies, obtain BP, pulse, respiratory
rates, have patient void, and make sure
consent is signed.

Antiemetics
Preoperative medication that reduces
nausea, prevent emesis, and enhance
preoperative sedation.

Examples of antiemetics
Droperidol (Inapsine), promethazine
(Phenergan)

Purpose of "Time-Out"

To conduct a final verification of the

correct client, procedure, site, and, as
applicable, implants.

Preoperative checklist usually includes

Assessment, preoperative medications,
IV, preoperative preparations, medical
record, signature of nurse

Universal protocol for preventing

wrong site, wrong procedure, wrong
person surgery:
Established by the Joint Commissionverify preoperative process, mark the
operative site, perform "time-out"

Anesthesia
Is the partial or complete loss of the
sensation of pain with or without loss of
consciousness.

Types of anesthesia
General, regional, local

General anesthesia
Acts on the CNS to produce loss of
sensation, reflexes, and consciousness.
Vital functions such as breathing,
circulation, and temperature control are
not regulated physiologically.

General anesthesia can be

administered by
IV, IM, inhaled, or rectal mediations

Stages of general anesthesia

1.
2.
3.
4.

beginning anesthesia
excitement
surgical anesthesia
medullary depression

Stage 1: Beginning anesthesia

This short period is crucial for producing
unconsciousness. The client
experiences dizziness, detachment, a
temporary heightened sense of
awareness to noises & movements &
sensation of "heavy" extremities,
unable to move.

Stage 2: Excitement
During this stage, the client may
struggle, shout, talk, sing, laugh, cry.
May make uncontrolled movements,
team members should protect the client
from falling or other injury. Quick &
smooth administration of anesthesia
can prevent this stage.

Stage 3: Surgical anesthesia

In this stage, the client remains
unconscious through continuous
administration of the anesthetic agent.
This level may be maintained for hours
with a range of light to deep
anesthesia.

Stage 4: Medullary depression

This stage occurs when the client
receives too much anesthesia. The
client will have shallow respirations,
weak pulse, and widely dilated pupils
unresponsive to light. Without prompt
intervention, death can occur.

Regional Anesthesia
Uses local anesthetics to block the
conduction of nerve impulses in a
specific region. The client experiences
loss of sensation and decreased
mobility to the specific area. Do NOT
lose consciousness. They can be
sedative before to promote relaxation
and comfort during procedure.

Advantages of regional anesthesia

Less risk for respiratory, cardiac, or
gastrointestinal complications.

Sedation refers to:

A pharmacologically induced state of
relaxation and emotional comfort.

Procedural sedation
Or conscious sedation; describes a
state in which the client is free of pain,
fear, and anxiety and can tolerate
unpleasant procedures; the client
maintains independent
cardiorespiratory function and the
ability to respond verbal commands
and tactile stimulation.

Anesthesiologist
A physician who has completed 2 years
of residency in anesthesia. They are
responsible for administering
anesthesia to the client and for
monitoring during and after surgical
procedure.

Anesthetist

May be a medical doctor who

administers anesthesia but has not
completed a residency in anesthesia, a
dentist who administers limited types of
anesthesia, or an RN who has
completed an accredited nurse
anesthesia program and passed the
certification exam. Are supervised by
an anesthesiologist.

Unrestricted zone
Includes a central point to monitor the
arrival of the patients, personnel, and
supplies. Street clothes are allowed in
this area

Semirestricted zone
Includes the peripheral support areas of
the surgical suite, with storage area for
sterile and clean supplies, work areas
for processing & storage of instruments
& corridors leading to the restricted
area of the OR. Personnel are required
to wear surgical attire, including twopiece pantsuits, cover jackets, and
caps.

Restricted zone
Includes the OR and procedure room,
the clean core, and scrub sink areas.
Personnel are required to wear full
surgical attire and cover all head/ facial
hair. Full surgical attire includes twopiece pantsuits, cover jackets, head
coverings, shoe covers, masks,
protective eyewear, and other
protective barriers.

What is the temperature of the OR

kept at?
Below 70 degrees F. to provide cooler
environment that does not promote
bacterial growth & to offer more
comfort for personnel.

Malignant hyperthermia
An inherited disorder that occurs when
body temperature, muscle metabolism,
and heat production increase rapidly,
progressively, and uncontrollably in
response to stress and some anesthetic
agents.

Aldrete scale
A useful assessment tool in which rates
the client's mobility, respiratory status,
circulation, consciousness, and pulse
oximetry. A score of 9 or greater
indicates that the client has recovered
from anesthesia.

WBAT
Weight bearing as tolerated

NWB
Non weight bearing

BLT
Bend, lift, twist

THP
Total hip precaution

AAT
Advanced as tolerated

Later postoperative period

Begins when the client arrives in the
hospital room or postsurgical care unit.

Nursing assessment during later

postoperative period:
Respiratory function; vital signs;
cardiovascular function and fluid status;
pain level; bowel & urinary elimination;
& dressings, tubes, drains, & IV lines.

Nursing management to prevent

postoperative respiratory problems:
Includes early mobility, frequent
position changes, deep-breathing and
coughing exercises, and use of
incentive spirometer.

Singultus
Hiccups

Postoperative pain reaches its peak

when?
12-36 hours after surgery and
diminishes significantly after 48 hours.

Three types of wound suction

devices/drains:
Penrose, Jackson-Pratt, Hemovac

How soon can most patients begin to

take fluids after surgery?
4-24 hours

If patient is not allowed fluids what

can we give them?

Mouth rinse, cool/wet cloth or ice chips

against the lips to relieve dryness.

How should fluids be introduced after

surgery?
Only a few sips of water or ice chips at
a time. Give slowly and in small
amounts to prevent vomiting. Can use
straw, but should be discouraged
because patient tend to swallow air as
well, which can lead to abdominal
distention & gastric discomfort.

Inflammatory stage
First phase of wound healing; when a
blood clot forms, swelling occurs, and
phagocytes ingest the debris from
damaged tissue & the blood clot. Phase
lasts 1-4 days.

Proliferative phase
Second phase of wound healing; in
which collagen is produced &
granulation tissue forms. Occurs over 520 days.

Maturation or remodeling phase

Last phase of wound healing; lasts from
21 days to several months to even 1-2
years. During this phase, the tensile
strength of the wound increases
through synthesis of collagen by
fibroblasts and lysis by collagenase
enzymes.

Three modes of wound healing:

Primary intention, secondary intention,
tertiary intention

Primary intention
The wound layers are sutured together
so that wound edges are well
approximated. This type of incision
usually heals in 8-10 days with minimal
scarring.

Secondary intention
Granulating tissue fills in the wound for
the healing process. The skin edges are
not approximated. This method is used
for ulcers and infected wounds. This
type of wound healing is slow, although
new products, such as antimicrobial
under dressings or calcium alginate
dressing, promote healing.

Tertiary intention
The approximation of wound edges is
delayed secondary to infection. When
the wound is drained & cleaned of
infection, the wound edges are sutured
together. The resulting scar is wider
than that with primary intention.

Wound dehiscence
The separation of wound edges without
the protrusion of organs

Evisceration
Occurs when the wound completely
separates and organs protrude.
Anesthesiologist
physician that specializes in anesthesia

Anesthetic
agent used to alter sensation so a
prodecure can be done safely and
painlessly

Dehiscence
opening of a surgical wound

Evisceration
organ protrudes outward

Hypothermia
body temp below 96 degrees F

Nurse anesthetist
same as anesthesiologist just a nurse.
Has to have an anesthesiologist
supervision. (doesn't have to be in rom)

Palliative
relieves symptoms

Sanguineous
red, bloody drainage

Serosanguineous
blood and serum drainage, usually
yellowish with a little blood, mixture
between sanguineous and serous

Serous
clear, watery drainage

Atelectasis
collapse of the alveoli

Bariatric

surgery for obesity (usually over 100

lbs overweight)

Cholecystectomy
removal of gall bladder
- can be cone laproscopic or open

Laproscopic
minimally invasive technique (small
incision, short recovery)

Moribund
dying condition, patient will die if they
don't have the surgery
- at risk for dying even with/from it but
will definitely die without it

obstructive sleep apnea

condition in which the flow of air pauses
or decreases during breathing while you
are asleep because the airway has
become narrowed, blocked, or floppy.
- nasal polyps

Sequential pneumatic compression

devices
-SCD
use on legs, inflate and deflate to
encourage venous return
- usually wear in hospital and then TED
hose at home

Perioperative
occurring in the period immediately
before, during, or after surgery

Pre-op

prior to surgery
- from time they decide to have surgery
until the actual surgery takes place

intra-op
care of patient during surgery

post-op
care after surgery

ambulatory/same day surgery

admitted for 23 hrs or less

In-patient
admitted to the hospital for >24 hrs

restorative
restores function/appearance

palliative
relieves/reduces intensity of disease
symptoms

cosmetic
to correct serious defects or to improve
personal appearance

transplant
procurement of organ from deceased to
living

constructive
restores function lost as a result of
congenital anomalies

Purposes of the patient interview

1. obtain patient health interview

2. determine patient's expectations
(surgery, anesthesia)
3. provide & clarify info about the
surgical experience
4. assess patient's emotional state &
readiness for surgery

life-threatening
True drug allergies are?

day of surgery
DOS

Nutritional needs post-op

surgery increases the metabolic rate
and can deplete potassium, vitamin C,
and vitamin B (all of which are needed
for wound healing and blood clotting)

physical exam
Joint commission mandates that the
_______ ____ must be documented on
pt's chart before going to OR

urinalysis
UA

chest x-ray
CXR

arterial blood gases

ABGs

capillary blood glucose

CBG

kidney function
A creatinine measures what?

pre-op nursing goals

- inform the pt on what to expect
- reduce patient anxiety
- decrease the risk of complications
during and after surgery

Pre-op teaching
- increases pt satisfaction
- decreases post-op vomiting, pain,
fear, anxiety, & stress
- decreases complications
- decreases hospital length of stay
(LOS)
- decreases recovery time following D/C

deep-breathing exercises
demonstrating technique of deep
breathing & coughing will assist pt in
performing post-op. Lungs not fully
inflated during surgery and cough reflex
suppressed so mucous collects in
airway passages

diaphragmatic breathing
improves lung expansion & oxygen
delivery without using excess energy.
Helps clear out anesthetic agents
remaining in the airways. Take slow,
deep, relaxed breaths

splinting incision
minimizes pain during coughing and
helps avoid dehiscence

lower legs

Where do most DVT's develop?

exercises to reduce DVT's

- point and retract toes 10 times an
hour
- tighten butt muscles for 5 sec and
then let go (repeat 5-10 times)

registration items
1 form of ID and insurance card

driver
______ has to stay on premises for all
inpatient procedures.

informed consent
ensures pt understands need for
procedure, steps involved, risks,
expected results, & alternative
treatments.
- legal document

anything invasive
what procedures require an informed
consent?

physician
Whose responsibility is it to inform
patient about surgery?

nurse
Whose responsibility is it to make sure
consent form is signed, dated, and
witnessed?

medical emergency
What overrides need to obtain consent?

medication
Must sign prior to pre-op __________.

qualified member of the health care

team
Who can witness an informed consent?

family member
A ______ ______ can not witness an
informed consent.

competent adult
A ________ _____ can sign an informed
consent.

parent/legal guardian/responsible
family member
Who can sign for a minor, unconscious,
or mentally incompetent patient?

requirements for informed consent

- written in laymans terminology
(procedure, risks, benefits, probability
of expected outcomes, risk of
alternative treatments)
- demonstrates clear
understanding/comprehension of the
info
- consent made voluntarily: can't force
- correct date, correct time: this is a
legal document
- signature of pt & witness
- placed in pt's medical record
- goes to OR with pt.

surgical team

surgeon
first assistant
scrub nurse/tech
circulating nurse
anesthesiologist & anesthetist
ancillary personnel (x-ray, etc.)

surgeon
who is in charge of the patient in the
OR?

scrub nurse
who does the instrument handling?

circulating nurse
who is in charge of the OR?
- makes sure everything is right
(supplies, positioning, aseptic
technique, must be RN)

general anesthesia
Type of anesthesia that acts on the CNS
and causes:
- loss of consciousness
- sedation
- skeletal muscle relaxation (reason for
intubation)
- loss of reflexes
- loss of pain perception
- loss of memory

inhalation & IV
what are the main methods of general
anesthesia administration?
- IM and rectally are uncommon

narcan

what drug is administered at the end of

a procedure to reverse the effects of
the anesthetic?

IV induction agents
Virtually all routine adult general
anesthetics begin this way
- so they can intubate you after you're
"out of it"
- induces a pleasant sleep w/ rapid
onset of action
- single dose lasts only a few minutes
(only long enough for intubation and
general started)

Inhalation agents
Foundation of general anesthesia
- may be volatile liquid (liquid at room
temp) or gas (gas at room temp)
- admin thru specially designed
vaporizer after being mixed with
oxygen as a carrier gas
- enters body thru alveoli in the lungs
- administer thru mask, endotracheal
tube, and laryngeal mask airway

complications of general anesthesia

inhalation agents
- coughing
- laryngospasms
- broncospasms
- increased secretions
- respiratory depression
- ET can cause irritation of the larynx &
respiratory tract (common to have sore
throat)
- individual agents have potential for
serious adverse effects such as

seizures, liver damage, cardia

dysrhythmias, n/v, death, malignant
hyperthermia

laryngospasms
muscular constriction of the larynx

reasons for endotracheal tube

- permits administration of airway
maintenance
- inhalation anesthesia
- control mechanical ventilation
- cuff is inflated to prevent leakage
during mechanical ventilation and
prevent aspiration of gastric content
while pt is unconscious

malignant hyperthermia
When this occurs surgery is interrupted
& measures are taken to cool the pt
(iced IV solutions, ice packs), 100% O2
is given along with lasix, mannitol,
sodium bicarbonate, diuretics &
dantrolene sodium
- occurs in response to certain drugs,
susceptibility to this response is
inherited, may occur when
succinylcholine is used with some
general anesthetic agents
- s&s: increasing body temp, increasing
metabolic rate, tachycardia,
hypotension, cyanosis, muscle rigidity

regional anesthesia
Blocks feeling to a large area of the
body (such as a limb or lower half of the
body)
- spinal: affects motor, sensory,

functions are blocked below the area,

must position correctly with feet lower
than head!
- epidural: pretty much the same as a
spinal
- nerve blocks

complications of regional anesthesia

- technical difficulty & discomfort
- post spinal headache
- toxic effects caused by overdose
- local tissue damage
- allergic response

local anesthesia
Blocks the conduction of nerve
impulses to a certain smaller area
- infiltration: shots all around an area to
deaden (ex. before stitches)
- topical

post spinal headache

headache caused by cerebral spinal
fluid leaking out at the injection site.
- can do blood patch: injecting patient's
own blood at leakage site
- usually try increases fluids and lying
flat first

conscious sedation
use of IV drugs to decrease pain or
awareness without loss of reflexes
- used in diagnostic & therapeutic
procedures such as cardiac cath,
endoscopy, colonoscopy
- RN with specialized training may
administer these drugs, monitor patient
closely

- must have precise documentation:

same as any drug

complications of conscious sedation

apnea, hypotension, excessive
sedation, agitation, combative

proper positioning
1. provide correct skeletal alignment
2. prevent undue pressure on nerves,
skin over bony prominences
3. provide for adequate thoracic
excursion
4. prevent occlusion of arteries & veins
5. provide modesty in exposure
6. recognize & respect individual needs
(previously assessed aches, pains,
deformities)

improper positioning
- muscle strain
- joint damage
- pressure ulcers
- nerve damage
- general anesthesia causes peripheral
vessel dilation
- position changes affect where pooling
occurs

post anesthesia care unit

PACU

airway, breathing, circulation

ABC's of surgery

immediate post surgery assessment

- ABC's
- vital signs (every 5 minutes, will be on

oxygen to help get rid of anesthesia

and meet increased demand for
oxygen)
- head to toe assessment (main focus
on LOC), look @ pupils, assess motor &
sensory function
- IV infusions
- dressings & drainage tubes
- stat orders!
- hypoxia, hemorrhage, shock

hypoxia
deficiency in the amount of oxygen
reaching the tissues

causes of hemorrhage and

hypovolemic shock
- effect of anesthesia or loss of blood
- external: see blood, easier to assess
- internal: look @ VS to assess

S&S of hemorrhage and hypovolemic

shock
- increased HR, thready pulse,
eventually decreases BP, in and out of
consciousness
- cool, clammy, pale skin
- restlessness

treatment of hemorrhage and

hypovolemic shock
stop the bleeding if possible, blood/fluid
replacement, monitor I&O, check IV, put
in trendelenburg to increase BP

PACU D/C criteria

- pt awake: may doze back off but able
to be awakened

- VS stable
- no excessive bleeding or drainage
- no respiratory depression
- O2 SAT >90% (still very low) - have pt
breath deep
- report given to nurse on the floor

ambulatory surgery D/C criteria

- all PACU D/C criteria met
- no IV narcotics for last 30 mins
- minimal nausea and vomiting
- voided
- able to ambulate (age appropriate, not
contraindicated)
- responsible adult present (pt not to
drive)
- D/C instructions given & understood:
always give written copy as well as
verbal

post-op room prep

- BP, thermometer
- emesis basin
- IV poles
- pads (chux, absorbent)
- possibly extra pillows for positioning,
splinting, and comfort
- needs dependent on type of surgery

prevent post-op complications

most significant general nursing
measure is to _______ ____-__
_____________.
- get them ambulating asap!!!

atelectasis
S&S: increased respiratory rate,
dyspnea, fever, crackles, productive

cough
nursing strategies: deep breathing,
coughing (splint the area for comfort),
get them up and moving!

pneumonia
S&S: fever, chills, productive cough,
chest pain, dyspnea, purulent mucus
cough
- nursing strategies: antibiotics and
fluids, rest during treatment (not
moving around), cough, deep breathing

pulmonary embolism
sudden onset
- dyspnea, sudden chest pain, cyanosis,
tachycardia, decreased BP, increased
pulse rate

respiratory interventions
- assess
- change position q2h: need to position
for full lung expansion
- cough & deep breathing q2h
- VS
- incentive spirometer
- O2
- fluids
- meds: maybe pre-medicate so they
don't have as much pain with coughing
and deep breathing
- ambulation
- hydration

F/E imbalances
- can cause cardiac problems (monitor
BP closely)
- normal response to stress of surgery

- excessive fluid losses

- improper IV replacement

fluid retention
Failure to eliminate fluids from the body
because of cardiac, renal, or metabolic
disease, or a high level of salt in the
body
-usually occurs first 2-5 days post-op
(stress response)
- serves to maintain blood volume & BP

fluid overload
medical condition where there is too
much fluid in the blood
- older pts more susceptible
- IV admin too rapidly
- chronic cardiac/renal disease

fluid deficit
excessive loss of water and electrolytes
in equal proportion
- lose through drain, wound: need to
keep strict I&O
- leads to decreased cardiac output
- decreased tissue profusion
- caused by untreated pre-op
dehydration
- caused by intra-op or post-op losses:
vomiting, bleeding, wound drainage,
suctioning (measure suctioning)
- urinary tract & GI tract loss
- low serum K+ (potassium) levels

S&S of fluid deficit

- abnormal ECG
- weakness
- confusion

- mental depression
- adequate K+ replacement 40
meq/day: not given unless adequate
renal function

deep vein thrombosis

DVT
- usually in calf, legs and pelvic area
(can't see)
- inactivity, body position, pressure,
older adult, obese pt, immobilized pt at
higher risk

S&S of DVT
- tenderness/pain
- reddened
- edema
- warm
- increased temp
- positive homan's sign (only 10% of
DVT's have + homan's sign)
- if other S&S present don't check
homan's sign for risk of dislodging

superficial thrombophlebitis
inflammation and thrombosis of
superficial veins which presents as a
painful induration with erythema, often
in a linear or branching configuration
forming cords.
- happens when IV infiltrates

pulmonary embolus
Moving clot lodged in lung
- PE
- MAJOR EMERGENCY!!!!

S&S of pulmonary embolus

tachypnea
dyspnea
tachycardia
sudden chest pain
hypotension
arrhythmias

syncope
fainting

CV complications to notify MD
- systolic BP <90 mmHg or >160 mmHg
- pulse <60 or >120 BPM
- pulse pressure narrows: difference
between systolic and diastolic pressures
(norm is 30-50)
- BP gradually decreases
- irregular cardiac rhythm develops
- significant variation from pre-op
readings

nursing implementation for Cv

complications
- I&O very important, MD will get mad if
you don't!
- monitor labs (look at them, know
what's going on)
- IV management: our job
- regular mouth care
- leg exercises
- AMBULATE!!!!
- position
- TEDs/mechanical devices/SCDs
- prophylactic measures venous
thrombosis & PE

prophylactic
preventive

Low-molecular-weight heparin (LMWH)

fragmin, lobinox
- comes in pre-prepared syringe with air
bubble, don't pop air bubble it helps
push med in subcut

advantages of LMWH
1. less major bleeding
2. decreased incidence of
thrombodytopenia
3. better absorption
4. longer duration of action (heparin is
short acting)
5. as effective or more effective
6. no lab monitoring required (some,
but not as much as normal heparin)

emergence dilirium
patient awakens agitated, thrashing,
usually resolves before discharge

delayed awakening
prolonged drug action, resolves with
time, can use narcan to help

N/V etiology post-op

- anesthetic agents & techniques
- more women than men
- abdominal, gynecological, eye, and
ear surgery have higher n/v incidence
- hx of n/v after surgery, history of
motion sickness

urinary complications post-op

- expect decreased urinary output (8001500ml) first 24 hrs
- needs to be at least 30 ml/hr (average

it out over a period of time before

calling Dr)
- have men stand and women sit if
possible
- observe/document color, amount,
clear/cloudy
- try to ambulate to bathroom or
bedside commode
- use running water to initiate,
encourage fluids, pour warm water over
perineum
- most people void in first 6-8 hrs postop (should be able to void 200 ml postop)
- check patency of catheter, check
order before calling Dr about
catheterizing

urinary retention
Inability to void
- distention, small amounts, pain
- men usually have more trouble
(sometimes will go if you mention
catheterization ;)
- can be caused by meds, anesthesia,
trauma from surgery, anxiety

GI complications post-op
GI mobility is slowed, altered food
intake, bowel handling during surgery,
slow/no peristalsis
- don't give ANYTHING by mouth until
hear bowel sounds or passed flatus (or
else will throw it up)

abdominal distention
increased abdominal girth
- c/o fullness or "gas pains"

- primary reason: lack of physical

activity, must ambulate ASAP!!!

Paralytic Ileus
paralysis of smooth muscles of small
intestines
- n/v, abdominal pain, distention (can
be severe enough to impair lung
function and decrease blood return in
legs), unable to pass flatus
- contact physician

Primary intention wound closure

clean, straight incision, closely
approximated, sutured or staples,
smaller scar

secondary intention wound closure

left open, let it heal by granulation from
bottom up and outside in

tertiary intention wound closure

initially left open and then closed later
(maybe left open for cleaning out
infection and then closed after)

wound interventions
- keep clean and dry
- keep splinted when coughing, avoid
strain on wound
- aseptic technique
- dressing changes clean except
dialysis, AB shunt, PIC line, catheter)

classic signs of infection

- redness
- swelling
- drainage

- increased WBC
- pain
- fever
- if infection develops under sutures =
greater risk for wound dehiscence

Gerontologic considerations
- respiratory: decreased coughing
ability
- vascular: decreased elasticity,
asterosclerosis, hypertension is
common
- drug toxicity: because of decreased
liver/kidney function, start with lowest
prescribed dose
- altered mental status: slower reflexes
- pain: don't usually ask as often, old
way = less pain meds

Normal Urinalysis
- straw color
- negative/0 RBC, WBC, bacteria,
glucose, acetone, other albumin
(protein)
- pH 4.8-8.0
- specific gravity 1.010-1.030

Normal hemoglobin
Male: 14-18
Female: 12-16

Normal hematocrit
Male: 40-54%
Female: 37-47%

Normal platelet count

150,000-350,000

normal RBC
4 1/2 - 5 million

normal WBC
M/F 5-10,000