Module 14
PERIOPERATIVE CARE:
IMPLICATIONS FOR THE NURSING PROCESS
INTRODUCTION
This module addresses perioperative care in three units. Unit 1 reviews preoperative care,
Unit 2 is a brief overview of intraoperative dynamics, and Unit 3 summarizes current
post-operative care. Throughout all the units we will use the framework of the nursing
process for discussion.
There are self-tests at the end of each unit. Use these to check your understanding of the
content.
Unit l
Preoperative Care
INTRODUCTION
OBJECTIVES
• Discuss essential facts about anesthesia, surgery, and preoperative planning and
care.
• Discuss essential facts related to preoperative techniques and care.
• Describe how to prepare a patient physically and psychologically for surgery.
Important Terms
Following are some terms and definitions which may be helpful to learning:
aeration: the process by which the blood exchanges carbon dioxide for oxygen in the
lungs
anemia: a condition in which the blood is deficient in red blood cells or hemoglobin
456
cilia: hair like projections of the mucous membrane of the respiratory tract
coagulate: to clot
cyanosis: a bluish tinge of the skin and mucous membrane due to excessive
concentration of reduced hemoglobin (hemoglobin without oxygen) in the blood.
embolus: a blood clot that has moved from its place of origin and is obstructing the
circulation in a blood vessel (plural: emboli)
exudate: material that has escaped from blood vessels and been deposited in tissues or
on tissue surfaces
hematocrit: the percentage of red blood cell mass in proportion to whole blood
hemoglobin: the red pigment in red blood cells, which carries oxygen
perioperative: phases involving the initial preoperative care through postoperative care
and discharge planning
umbilicus: the navel; the site where the umbilical cord was attached to the fetus
457
Types of Surgery
Surgical procedures are commonly classified into three general categories according to
urgency, risk and purpose.
Emergency
Elective
Elective surgery is performed for the patient’s well-being, but is not urgent. It may be
planned weeks or months ahead of the procedure, and can include most surgical
procedures. Examples are:
• tonsil removal
• gallbladder removal
Optimal
Optimal surgery is surgery that is requested by the patient. It is not necessary for physical
health but is important for cosmetic or psychological reasons. Examples are:
• face lift
• reconstruction surgery on the nose
Surgical classifications
Major. Major surgery is extensive, and may be prolonged or involve significant blood
loss. The surgeon may need to remove vital organs or handle them at length. There is a
greater risk of complication in this type of surgery. Examples of major surgery include:
• organ transplants
• open-heart surgery
• kidney removal
Minor. Minor surgery is not prolonged. It involves little risk and produces few
complications. Examples include:
• breast biopsy
• nasal polyp removal
• removal of most skin cancers
458
Risk deals with the probability of morbidity or death from surgery. The risk period
extends from preoperative preparation through postoperative recovery.
• age
• obesity
• immobility
• malnutrition
• emergencies requiring surgery
• pneumonia
• cardiac arrest
• renal failure
• stroke
• pulmonary emboli
• sepsis
• peritonitis
• hypovolemic shock
Because surgery involves injury or trauma to body tissues, many aspects of the patient’s
health need to be considered beforehand to make the period of surgery and recovery as
safe as possible for the patient. While the magnitude of operation influences the degree of
surgical risk, the patient’s health status also greatly affects risk. The degree of risk the
patient experiences is dependent on:
a. whether the tumor is benign or malignant, or how important the organ is to the
body’s functioning.
b. the location of the organ or organs requiring surgery (heart surgery is more
serious than gall bladder surgery).
c. the general condition of the patient (patients experiencing chronic disorders
are at a greater risk).
3. the mental attitude of the patient toward surgery (whether the patient is fearful or
depressed, or accepts and understands what is going to happen).
4. the degree of professional skill exhibited by the medical and nursing personnel
caring for the patient; the degree to which the health care facility is equipped,
especially in dealing with specialty areas.
Physical examination
For elective or optional surgery, the physical examination is usually done in the
physician’s office prior to admission to the health care facility. For emergency surgery
the physical examination is done upon admission. Knowledge of the patient’s overall
health status is essential in preventing complications and reducing the surgical risk.
Nursing assessment of the person undergoing surgery should involve the following areas
of concern.
Age. Infants, young children, and the elderly all experience physiological changes which
place them at greater surgical risk
460
Presence of pain. Careful assessment of the nature of pain and the person’s reaction to it
will contribute to better care.
Nutritional status. The person who is well nourished preoperatively will respond better
postoperatively. Two major nutritional problems noted preoperatively are: (1)
malnutrition resulting from protein, iron and vitamin deficiencies, and (2) obesity. A
nursing intervention for patients who are malnourished pre-op is to encourage a diet high
in protein, vitamins, and iron. Sometimes parenteral nutrition will be administered for a
week to several days pre-op. Enteral (tube feeding) therapy may also be instituted.
Obesity should be corrected before any surgery that is not emergency in nature because
obesity predisposes a person to postoperative complications such as hypertension, wound
infection, and respiratory insufficiency.
Infection. Any infection (even a minor one) can adversely affect the course of surgery.
Note any symptoms the patient displays which might indicate the presence of infection,
such as elevated temperature, lethargy. Monitor white blood cell count also and report
any abnormal findings.
• anticoagulants
• antibiotics
• tranquilizers
• thiazide diuretics
• steroids
Be careful to document any known drug allergies and make an exact list of all the
medications the person is currently taking or has recently stopped taking.
Presence of trauma. When surgery becomes necessary due to the existence of a stab
wound or trauma from a severe accident or fall, try to determine the details of the
occurrence as accurately as possible. Such information may help to determine whether
there might be an underlying cause to the incident that has been undetected; trauma in
children may be an indication of child abuse which will require careful documentation in
nurse’s notes.
461
Cardiac conditions. Take note of conditions such as angina pectoris, recent myocardial
infarction, severe hypertension, or severe congestive heart failure. Well-controlled
cardiac problems are generally considered little operative risk, but should be noted,
nonetheless.
Blood coagulation problems. These problems can cause severe bleeding, hemorrhage,
and subsequent shock.
Renal disease. Renal diseases usually means that the adequate excretion of body wastes
is impaired. Examples are acute nephritis and renal insufficiency.
Diabetes mellitus. This disease predisposes the patient to wound infection and delayed
healing.
Liver disease. Diseases such as cirrhosis can impair the liver’s ability to detoxify
medications used during surgery, to produce the prothombin necessary for blood clotting,
and to metabolize nutrients essential for healing.
Psychological adjustment. Last, but not by any means the least, of the areas needing
assessment by nursing personnel is psychological adjustment. Fears about surgery are not
always directly exhibited in proportion to the seriousness of the surgery. People facing
surgery may exhibit several defense mechanisms to deal with their anxiety. Common
ones include denial (manifested by a casual attitude toward the impending operation or
minimizing of symptoms), and regression (exhibited when the person behaves in a more
dependent and child-like manner). Still a third mechanism employed is detachment, in
which the person discusses the impending surgery rationally, calmly, and without
emotion. Several studies have been conducted documenting the importance of
preoperative psychological preparation. The following is a list of the benefits of this type
of preparation:
A final impact on patients’ psychological adjustment to surgery is the will to live or get
better. Patients who have lost the will to live need extra help and encouragement from the
surgical team, you as the nurse, significant others, and possibly counselors.
Surgery can also impose heavy financial burdens on patients and their significant others.
Explore this area with sensitivity and provide assistance personally and professionally
where needed. The patient may be required to experience a radical change in lifestyle
postoperatively which could greatly affect his or her future economic, social and
emotional status.
Screening tests
It is the physician’s responsibility to order all the radiologic and laboratory tests and
examinations that are to be conducted for each patient. The nurse’s responsibility is to
check the orders carefully, to see that they are carried out, and to ensure that the results
are obtained prior to surgery.
Chest x-ray film. This is taken to determine the condition of the patient’s lungs and, in
some situations, heart size and location. The results may influence both the type of
preoperative sedation ordered and the type of anesthetic administered.
Blood analysis. Routine blood tests, usually done the day before surgery, may include
complete blood count (CBC), hemoglobin (Hgb), and hematocrit (Hct). If substantial
blood loss is anticipated during surgery, the physician may also order a blood typing and
cross-match for a specific number of pints (units) of blood for a replacement transfusion.
When bleeding problems are suspected, and analysis of bleeding or clotting time or
prothrombin time may also be ordered. The results of blood tests are important in ruling
out many problems that could increase the surgical risk. For example, a high white blood
cell count (WBC) can indicate that presence of an infection; a low red blood cell count
(RBC) and/or low hemoglobin indicates anemia. Both conditions delay the healing
process.
Urine analysis. A routine urinalysis is done for all patients before surgery. The results
may indicate the presence of urinary infection, diabetes, or other abnormalities that
warrant treatment prior to surgery.
Nursing history
The nursing history acquired on admission provides data about the patient that can assist
the nurse with preoperative and postoperative care planning. Although forms vary
considerably among institutions and agencies, essential preoperative information includes
the following:
463
Physical condition. The patient’s general appearance is noted in terms of color, weight,
hydration status, and energy level. Problems such as obesity, dehydration, malnutrition,
or marked fatigue may indicate the need for intervention before surgery.
Mental attitude. Determine whether the patient is unduly anxious over impending
surgery.
Experience with previous surgeries or any prior serious illness. The patient may
respond negatively to the impact of surgery if previous encounters with illness or surgery
have been traumatic.
Smoking habits. Smoking can definitely affect adequate oxygenation of the patient,
especially during anesthesia. Encourage the patient to refrain from smoking for as long as
possible prior to surgery.
Occupation. Surgery may affect the person’s ability to perform his or her job.
Significant others. Is the patient married or single? How many dependents does the
patient have? Knowing this can help determine the amount of help the patient will have
upon returning home.
Religious affiliation. Certain religious beliefs affect the plan of treatment. Also, it may
be necessary to contact a minister or hospital chaplain for the patient and/or family.
Does the patient have any questions about the surgery? Have you answered them?
Preliminary information
Before preparing the patient for surgery, the nurse needs certain information:
The type of surgery. The surgeon usually indicates the type of surgery in the
preoperative order on the patient’s chart. From this information, the nurse can determine
the kind and extend of skin preparation required, if it has not been specified on the order.
Agencies usually have procedures describing the skin preparations for various surgical
procedures.
The time of the surgery. The surgeon usually arranges the date for the surgery and may
specify this in the order. The exact time often is not known until the surgical schedule for
the hospital is distributed.
The name of the surgeon. The surgeon is specified in the preoperative order.
The agency’s practice for preoperative care. Many agencies outline the nursing
responsibilities for preoperative care.
Verification that the consent form has been signed by the patient of the family. The
consent form states that the patient or family consents to the surgery. It is important to
know the agency policies in regard to consent form. Usually surgery does not take place
without a signed consent form, except in life-threatening situations. Signing a consent
form implies that the patient is informed about the forthcoming surgery. If a consent form
has not been signed, most agencies designate that a particular department of the hospital
needs to be notified and is responsible for arranging the form to be signed.
Verification that the physician has completed the medical history and physical
examination. Most hospitals require that these be completed before surgery, except in
emergency situations. Nurses need to check the agency’s policies.
Preoperative teaching
Keep in mind several principles of teaching and learning when reviewing with your
patients the essential things you want them to remember.
465
1. To be sure the information you are presenting is accurate, consult with the
physician first to determine what information the patient has already received.
2. Determine how much information your patient actually wants or needs. Too much
information can sometimes increase anxiety.
3. Speak clearly and use language the person understands.
4. Plan short, frequent teaching sessions so as not to overwhelm the patient with too
much information at one time.
5. Always allow time for the person to ask questions.
6. Ask whether the person understands the material.
7. Ask the person to give return demonstrations of skills or procedures taught.
8. Repeat information as necessary, keeping in mind that anxiety may be interfering
with retention of information.
9. Remember that each person is unique, so alter your teaching methods to fit
individual needs. Children require special innovations for teaching.
10. Involve the person’s significant others in preoperative teaching. Keep them
informed of the person’s progress.
Nurses usually need to teach preoperative patients about moving, leg exercises, coughing,
and deep breathing. The skills taught in these areas help to prevent a variety of
complications and improve the patient’s postoperative convalescence. When time
permits, this teaching should begin several days prior to the surgery.
Moving. Turning in bed and early ambulation help patients to maintain their blood
circulation, stimulate respiratory functions, and decrease the stasis of gas in the intestines
and resulting discomfort. Patients who practice turning before surgery usually find it
easier to do so postoperatively. Some patients require special aids, such as a pillow
between the legs, to maintain skeletal alignment. The nursing car plan and/or the
agency’s procedures need to be c checked for this.
Leg exercises. Leg exercises help prevent thrombophlebitis due to slowed venous
circulation (venous stasis) The major concern of thrombophlebitis is the formation of
thrombi, which can become emboli and lodge in the arteries of the heart, brain, or lungs
causing serious injury or death.
466
Leg exercises act to contract and relax the quadriceps and gastrocnemius muscles. The
three exercises that patients need to learn are:
1. Alternately dorsiflex and plantarflex the feet. This is sometimes referred to as calf
pumping, since it alternately contracts and relaxes the calf muscles, including the
gastrocnemius muscles.
2. Flex and extend the knees, pressing the backs of the knees into the bed. (see Figure
1.) If the patient cannot raise his or her legs, the muscles can be consciously
contracted and relaxed (isometric exercises).
3. Raise and lower the legs alternately from the surface of the bed with the knee of the
moving leg extended. (see Figure 2.) This contracts and relaxes the quadriceps
muscles.
The exercises are normally started as soon as the patient is able after surgery. The
frequency of exercising depends on the patient’s condition and the agency’s practices. It
is not unusual to suggest that the exercises be performed once per hour during the
patient’s waking hours.
Figure l
A-Flexing the knees
B-Extending the knees
C-Pressing the backs of the knees against the bed surface.
467
Figure 2
Contracting and relaxing the right quadriceps muscles
Coughing and deep breathing help to remove mucous, which can form and remain in the
lungs as a result of a general anesthetic and medications. These drugs depress the action
of both the cilia and the mucous membranes lining the respiratory tract and the
respiratory center in the brain. Deep breathing also assists with aeration of the lung tissue
and, thereby, helps to prevent pneumonia. Pneumonia may result from stagnation of fluid
in the lungs.
In deep breathing, the maximum amount of air needs to be inhaled and exhaled. On
inhalation, the diaphragm contracts or flattens, thus pulling down or lengthening the chest
cavity, while the ribcage is pulled upward. On exhalation, the diaphragm relaxes or
moves upward and the ribcage is pulled downward.
Deep breathing can be demonstrated to the patient by the nurse. The nurse places hands
palm down on the border of his or her ribcage and inhales slowly and evenly until the
greatest chest expansion is achieved. The breath is held for a few seconds, then slowly
exhaled by blowing the air out through the mouth. Exhalation proceeds until maximal
chest contraction is achieved. To assist the patient to breathe deeply, the nurse then
instructs the patient to do the same or places his/her own hands on the patient’s chest
border.
The number of breaths and the frequency of deep breathing periods throughout the day
vary in accordance with the patient’s condition. Patients on bedrest or who have had
abdominal or chest surgery need to be encouraged by the nurse to perform deep breathing
at least three or four times daily. Each session should include a minimum of five deep
breaths. For patients who are prone to pulmonary problems, deep breathing exercises may
be implemented every hour. Special breathing exercises (e.g., pursed-lip breathing and
abdominal breathing exercises) are required for patients with chronic respiratory disease
468
The day before an operation, nursing functions include the following areas of care:
elimination nutrition and fluids, psychological factors, hygiene, rest, and medications.
Elimination. Depending upon the patients’ condition, the type of surgery, and the
physician’s order or agency practice, an enema may be given the evening before surgery.
In some instances a rectal suppository may be given instead of an enema or the enema
may be administered the day of surgery. In other instances, no special elimination care is
given.
Nutrition and fluids. Adequate hydration and nutrition are necessary for normal
physiologic functioning and specifically for the healing process. It is important for nurses
to record any signs of malnutrition. Weighing the patient and recording the weight
provide one measure of nutrition. If the patient is on intravenous fluids or measured fluid
intake, the nurse ensures that the fluids are carefully measured and documented.
The nurse needs to find out what the surgery means to the patient and support persons.
The patient’s self-image may be threatened by disfigurement; a long hospital stay may
mean financial hardship, etc. Once the nurse knows what the surgery means, he or she
can offer accurate information and a supportive manner to help the patient deal with these
problems. Nurses need to listen carefully to patients and not dismiss their fears by saying,
“Everything will be all right.” Often a nurse can clarify misconceptions and relieve
anxiety. Also, by listening carefully, nurses can often assist patients to identify and talk
through their fears.
Children require explanations that are meaningful to them. The nurse has to introduce
information at a speed that keeps their attention but does not overwhelm them. A child
may be allowed to see the anesthetic machine and try on the mask beforehand. The
postanesthesia room is also explained; it can be referred to as the “wakeup room.” The
469
nurse can explain about discomfort using words that the children understands, such as
“sore tummy.” All postoperative care should be explained. The most important fact to
children is when their parents will come.
Hygiene. The hygiene care of preoperative patients is often described in agency policies.
In many settings the patient is asked to bathe using an antimicrobial agent the evening or
the morning before surgery. The bath includes a shampoo whenever possible. The nails
should be free of polish so that the color of the nail beds can be readily assessed. Bluish
discoloration (cyanosis) and pallor indicate inadequate oxygen of the blood.
Surgical skin preparation. Surgical skin preparations are carried out prior to most
surgeries. Procedures for surgical skin preparations vary from agency to agency. Areas of
controversy about skin preparation center around the following:
• whether scrubbing or bathing the skin is necessary
• the type of solution used to scrub the skin
• how to remove hair from the operative site (razors, clippers, creams)
• whether hair removal is even necessary before surgery
On the basis of this, nurses should be aware of their agency’s protocol for each surgical
procedure and follow accordingly. If hair removal is performed, be sure to document the
condition of the skin after the procedure is performed. Be sure your patient knows why
hair removal is necessary.
Vital signs. Take the vital signs to obtain comparative baseline data against which to
assess the patient’s responses during and following surgery. Report promptly to the
responsible nurse and to the physician abnormalities in any of these signs (for example,
and elevated temperature) since surgery may need to be postponed.
Fasting and oral care. The patient’s fasting period must be maintained. Because the
patient may feel thirsty or have a dry mouth, assist her or him with oral care and provide
mouthwash. Caution the patient not to swallow water during oral care but just to rinse out
the mouth.
Hygiene and wearing apparel. Assist the patient with a complete or partial bath as
required. Have the patient put on a clean hospital gown and fasten it only at the neck or
not at all, in accordance with agency policy. A gown that is untied can be readily
removed during the operative and immediate postoperative period. Check the agency’s
policies about use of surgical caps or stockings. These are often put on patients to provide
470
added warmth and protection. In some agencies, antiemboli stockings are ordered for
patients. These compress the peripheral veins and increase the venous return during the
inactive period, thus preventing the formation of thrombi or emboli.
Hair and cosmetics. Remove or have the patient remove hairpins or clips that may
cause pressure or accidental damage to the scalp when the patient is unconscious. Long
hair can be braided and fastened with elastic bands to keep it in place. All cosmetics
(lipstick, rouge, nail polish, etc.) must be removed since they interfere with observations
of the skin, lips, and nail beds for assessing circulation (for example, signs of cyanosis
may indicate impaired circulation) during and after the surgical procedure. Check the
agency’s practices for solutions used to remove nail polish (such as acetone) if the patient
does not have nail polish remover.
Valuables. Label valuables such as watches, rings and other jewelry, or money and
place them in safekeeping to avoid loss or damage to them and subsequent legal
problems. Most agencies provide special envelops for these items and a locked storage
area on the unit. If a patient does not want to have a wedding band removed, it can be
taped in place. Wedding bands must be removed, however, if there is danger of the
fingers swelling following surgery. Some situations surrounding removal of a wedding
band are surgery and/or a cast application to that arm, and a breast operation that involves
removal of the lymph nodes since this may result in edema of the arm and hand or that
side.
Prostheses. Remove all prostheses (artificial body parts) such as partial or complete
dentures, eyeglasses, contact lenses, artificial eyes, artificial limbs, wigs, false eyelashes,
and hearing aids to prevent their damage or loss. Partial dentures can become dislodged
and cause choking during the period of unconsciousness. Also check for a loose tooth
that could become dislodged and aspirated during anesthesia. This is a common problem
with the 5- or 6-year old child who is having tonsils removed. Check the agency policies
on the handling of prostheses. Some agencies place them in a locked storage area; others
store them in the patients bedside unit.
Bowel and bladder. Check that the patient’s bowel and bladder are emptied prior to
surgery. This is done for several reasons:
If an enema is ordered, administer it soon enough on the day of the surgery so that the
patient has adequate time to expel it. Also make sure that the patient voids, or insert a
retention (Foley) catheter if ordered. If the patient is unable to void, note this fact on the
patient’s record.
471
Special orders. Check the patient’s order for special requirements, such as the insertion
of a Nasogastric tube prior to surgery.
Medications. Patients may receive a sedative that night before surgery and some type of
parenteral preoperative medication prior to surgery. Under apparent current investigation
is the practice of giving preoperative medication to all patients prior to surgery. Children
seldom receive preoperative injections unless they are extremely anxious or, for certain
reasons, the physician wishes to order one in a particular instance.
After the preoperative medications are given, the patient needs to remain quietly in bed.
Raise the side rails and leave the bed in low position. Place the call light within easy
reach. Be sure the patient understands your instructions. The timing of the preoperative
medication is crucial to ensure that the patient receives the maximum benefit from the
medications given. Some preoperative medications will be scheduled and some will be
“on call” to the operating room. One action that will facilitate administration of
preoperative sedation is to be sure the drugs ordered are on the unit in plenty of time
before they are needed. This will prevent a “last minute rush” when the transport care is
on the unit to get the patient and the medication that has not yet been given.
Recording. Most agencies use a preoperative checklist to record all or most of the items
mentioned here. Check the agency’s form, and follow the appropriate procedures for
recording. It is essential that all pertinent records be assembled and completed (laboratory
records, X-rays, consents, etc.) so that the health care team in the operating room and
recovery room can refer to them.
Transfer the patient to surgery. When the operating room transport person arrives for
the patient, carefully check the patient’s identification bracelet against the patient’s chart.
Generally, one staff member reads the identifying data from the bracelet while the other
checks it against the patient’s record. Do not rely on the patient, who is sedated and
drowsy, to identify himself or herself. Assist the patient onto the stretcher.
Preparation for postoperative care. Prepare the patient’s bed and room for the
postoperative period. Unit 3 of this module addresses nursing care during the
postoperative period.
472
Unit 1
Self-Test
1. Surgery that may be planned for weeks or months ahead is considered ___________.
3. Two surgical risk factors that are known to influence the patient’s recovery are:
a. _______________________________
b. _______________________________
4. The degree of risk the patient experiences is dependent in part on the ____________,
__________________, and _______________________ of the condition.
5. Nutritionally, the two predisposing factors that can impact a patient’s surgical
outcome are:
a. ________________________________
b. ________________________________
7. Usually surgery does not take place without a __________________ unless a life-
threatening situation exists.
11. Wedding bands may be left in place and taped when the patient is going into surgery
unless _______________________________________________________________
13. When the transport cart arrives on the unit to pick up patient,____________________
must be checked with the patient’s chart before leaving the unit.
473
Unit 2
Intraoperative Care: Nursing Implications
INTRODUCTION
This unit is included to acquaint the nurse who is caring for the patient pre and
postoperatively with some of the occurrences within the surgical suite itself.
Intraoperative care has become highly specialized, utilizing nurses specifically trained
to function in an operative setting. They are an integral part of the surgical team as it
carries out its duties from day to day. It is hoped that after reviewing this unit, the
“general duty” or “medical-surgical” nurse practicing in a hospital or surgical center
will gain a fresh understanding of what his or her patients have endured during their
time in the surgical suite.
When patients leave the surgical unit, they are generally taken to a “holding room” or
presurgical “waiting area.” Exceptions to this would occur if a particular hospital did
not have such a room or the surgery was being done on an emergency or urgent basis.
The patient’s personal dignity is maintained here as much as possible. Nurses are in
attendance to reassure patients if they are anxious and to observe them for safety
reasons. When a patient is transferred to the surgical area, he or she becomes the
responsibility of the surgical team. The surgical team is composed of the surgeon, the
anesthetist (specially-trained registered nurse) or anesthesiologist (an MD),
circulating nurse, scrub nurse, and surgeon assistants (other surgeons or residents in
training). Certain programs throughout the country are now being offered to train
“technicians” to assist with scrub nurse responsibilities. These people are trained and
licensed, but are usually not all nurses and would be referred to as paraprofessionals.
TYPES OF ANESTHESIA
It has been said that anesthesia represents almost “clinical death” in certain respects.
The correct administration of anesthesia is a tremendous responsibility requiring
highly-skilled and competent personnel. Anesthesia is a loss of sensation or feeling. A
substance (liquid, gas, etc.) that provides anesthesia is called an anesthetic. There are
three types of anesthesia: general, regional, and local.
General
With a general anesthetic, the patient loses all sensation and consciousness. This type
of anesthetic is administered by inhalation, intravenous infusion, or rectal infusion.
Some patients become more anxious about a general anesthetic than about the surgery
itself. Often this is because they fear the loss of ability to control their own bodies
while under the anesthetic. Some hospitals have a policy in which the anesthetist or
anesthesiologist who will be doing the patient’s surgery visits him or her the night
before the operation to explain what will happen and see if the patient has any
questions. Frequently, these same people will visit the patient soon after surgery and
474
during the postoperative stay to check on the patient’s progress and answer any
further questions. Classifications of general anesthetic agents are:
Regional
A regional anesthetic blocks painful sensations in one area of the body. The patient is
fully conscious, but unable to feel the surgery. There are a number of kinds of regional
anesthetics. Two of the most common are the spinal anesthetic and the nerve block. In a
nerve block, an anesthetic agent is injected into a nerve plexus, such as the brachial
plexus. Commonly used regional anesthetic agents are Novacaine, Cargocaine, and
Marcaine. Regional anesthetic agents are used for procedures such as biopsies; excision
of moles or cysts; hernia repairs; some eye, ear, nose, and throat procedures; endoscopies
of the GI, respiratory, and urinary tracts; and operations on extremities.
Local
A local anesthetic desensitizes a small tissue area. It may be sprayed or painted on the
skin or mucous membrane, or it may be injected into tissue. Commonly used local
anesthetic agents are Pontocaine and Xylocxaine.
Complications of anesthesia
The following are complications which can occur from administering general anesthesia.
1. circulatory problems
2. respiratory problems
3. decreased gastrointestinal motility (nausea and vomiting)
4. decreased urinary output
5. slowed or disturbed metabolic activities
6. neurological changes (elderly—CVA)
7. corneal abrasions from interference with blinking and tearing
8. damage to mouth, lips, vocal cords, etc., from endotracheal intubation
9. peripheral nerve injury from improper positioning on an OR table
10. problems arising from overdoes of anesthetic agent
11. malignant hyperthermia (rare complication causing high temperature and muscle
rigidity; it affects patients with known muscle disorders).
Spinal anesthesia can produce the following complications, for which the patient must be
monitored.
• hypotension
• nausea and vomiting
• respiratory paralysis
• neurologic complications
Before leaving this subject, two unusual types of anesthesia now occasionally accepted
for modern surgery can be mentioned. They are acupuncture and hypnosis. Space and
time do not permit further review of these interesting avenues. You are encouraged to
investigate these methods further if they interest you.
The surgical team is responsible for positioning the patient properly for surgery, ensuring
adequate circulation and respiratory exchange. They also need to preserve the patient’s
dignity and secure him or her to the table with well-padded straps (padding nerves,
muscles, and bony prominences if necessary). Figure 2 depicts the five common surgical
positions. Listed below is a description of the five positions and the types of surgery
indicated by these positions.
476
Figure 3
Five Surgical Positions
The last step in the surgical procedure is closure of the surgical incision. The preferable
method of closure is determined by the physician.
Sutures are used sparingly and gently to facilitate wound healing. Nonabsorbable and
absorbable sutures are available in various strengths. Staples and retention sutures are
used for wound approximation that is difficult to accomplish. Future developments in
surgery, such as using the laser, may make some types of suture closure obsolete.
Following surgery, the patient is transferred to some type of recovery area and with
nurse-to-nurse reports given about the patient’s condition
477
Unit 2
Self-Test
_____________________________
_____________________________
_____________________________
5. Nausea and vomiting are complications that can occur after the
administration of _____________________________.
Unit 3
Postoperative Care
INTRODUCTION
Nursing care during the postoperative period is critical to the patient’s recovery. The
anesthetic impairs the ability of patients to help themselves. The degree of consciousness
of patients will vary, which will affect their ability to respond to environmental stimuli.
Moreover, the surgery itself traumatizes the body, which decreases the body’s resistance
and energy. The goals of postoperative nursing care are to assess the patients
postoperative condition, prevent or relieve discomfort, prevent complications, and
facilitate optimum recovery.
OBJECTIVES
When you have completed this unit, you should be able to:
IMPORTANT TERMS
Following are some terms and definitions which may be helpful to you in this unit:
malignancy: abnormal tissue having a tendency to progress and invade other tissues
singultus: hiccups
Immediately following surgery, most patients are taken to a special area of the hospital
referred to as the recovery room (RR), postanesthetic care unit (PACU), or anesthetic
room (AR). Patients who have had minor surgery involving only a local anesthetic will
most likely return directly to the nursing unit rather that going to the RR. The time
patients spend in the RR will vary depending on their condition and the time it takes to
awaken from the general anesthetic. For patients who have had extensive surgery or
whose condition is serious, nursing care may be provided in the intensive care unit (ICU)
for anywhere from one to several days.
Immediate postoperative care includes preparation of a surgical bed unit for the patient,
initial postoperative assessment of the patient on return from the RR, initiating immediate
nursing measures, and planning and establishing a postoperative nursing care plan for the
patient.
Before the patient returns to the nursing unit, the nurse prepares the bed unit. Usually the
bed is made up as a surgical bed, and the furniture and equipment are arranged for
convenience.
In some agencies the patient is brought back to the unit on a stretcher and transferred to
the bed in his or her room. At other agencies, the surgical bed is taken to the RR and the
patient is transferred there. If the latter occurs, the surgical bed needs to be made as soon
as the patient goes to the operating room so that it can be taken to the RR at any time.
The nurse sets up all special equipment, such as suction, intravenous stands, and oxygen.
If these are not requested on the patient’s record, the nurse consults with the responsible
nurse about the equipment that will be needed. Some surgeons have postoperative
routines requiring certain equipment. In some instances, nursing personnel in the RR will
notify the nursing unit before the patient arrives if special equipment is required.
480
The following list is a guide to the supplies and equipment that are required. However,
check agency practices with regard to setting up a surgical unit.
• Make a surgical bed. If the bed is to remain in the room, move it so that the
stretcher can be placed alongside it or at right angles to it.
• Obtain an emesis basis and tissues.
• Have available a sphygmomanometer and cuff and a stethoscope. Some agencies
have sphygmomanometers attached to the wall at the head of the bed.
• Obtain needed special equipment, such as an intravenous stand, suction, oxygen
equipment and orthopedic appliances (traction, etc.).
• Place an intake and output record nearby.
When the patient is returned to the unit, carefully assist her or him into the bed, if the
patient is not already in it.
The sequence of these activities and the order in which the nurse completed them will
vary according to the situation. For example, stat orders of the physician may need to be
checked before the initial assessment so that nursing interventions to implement the
orders can be carried out at the same time as the assessment.
spinal anesthetics are usually kept flat for 8 to 12 hours. Check the agency
practice in this regard. If the patient is in an unconscious or semiconscious
state, place on his/her side, if this is possible, or in a position in which
secretions will drain readily from the mount. Otherwise, follow the patient’s
preference. Most patients prefer a back-lying position.
9. For the patient’s safety, raise the side rails on the bed. This will keep the
patient from inadvertently rolling out of bed.
10. Check the patient for pain or discomfort, and note when the patient last had an
analgesic.
11. Record the patient’s condition, including your assessment, on the chart. Some
agencies provide checklists for this purpose. Hospitals also often have
postoperative routines for regular assessment of patients. At some agencies,
assessments are made every 15 minutes until the vital signs are stable, every
hour thereafter for the day of surgery, and every 4 hours for the next two days.
It is very important that the assessments be made as required by the patient’s
condition.
Respiratory needs
• Encourage the patient to do deep breathing and coughing hourly or at least every
two hours during the waking hours for the first few days.
482
Circulatory needs
Nursing measures to meet the patient’s circulatory needs are provided to prevent the
formation of thrombi, emboli, and thrombophlebitis. Nursing interventions include the
following:
• Encourage leg exercises every hour or at least every two hours during the waking
hours. Muscle contractions compress the veins, preventing the stasis of blood in
the veins. Contractions also promote arterial blood flow.
• Encourage early ambulation.
• When ordered, apply tensor bandages up to the knees or antiembolism stockings
to support the superficial veins of patients who have cardiovascular problems.
• Encourage adequate fluid intake, and/or maintain IV infusions. Sufficient fluids
prevent dehydration and the resulting concentration of the blood that along with
venous stasis is conducive to thrombi formations.
• Avoid the use of pillows or rolls under the patient’s knees. Pressure on the
popliteal blood vessels can slow the blood circulation to and from the lower
extremities.
• Assess the patient’s circulation to the lower extremities and be alert to signs of
circulatory complications. Note the color and temperature of the skin.
Hydration
Postoperative patients often complain of thirst and a dry, sticky mouth. These discomforts
are a result of the preoperative fasting period, preoperative medications (such as
atropine), and loss of body fluid for a variety of reasons (such as blood loss, perspiration,
and vomiting). Intravenous infusions are usually given to balance such losses. Nursing
measures to meet hydration needs and to relieve the discomfort of thirst or a dry mouth
include the following:
• For the patient who cannot take fluids by mouth, sucking ice chips may be
permitted. Check the physician’s orders.
• Provide mouth care and place a mouthwash at the patient’s bedside so that the
patient can rinse her or his mouth frequently.
• Measure the patient’s fluid intake and output.
• Assess the patient for signs of dehydration.
Nutrition
The physician is responsible for ordering the patient’s postoperative diet. Depending on
the extent of surgery and the organs involved, some patients may be given intravenous
fluids and nothing by mouth for a few days. Others may progress from a clear liquid diet
to full fluid to a light diet within a few days.
Pain is usually greatest 12 to 36 hours after surgery and decreases on the second or third
day. Patient controlled anesthesia (PCA) has recently become widely used in the
treatment of postoperative pain. Use of this pump allows patients to deliver their own
medication IV by simply pressing the button on the PCA pump. Pumps are programmed
not to deliver usually more than two mg at the maximum every ten minutes. PCA pumps
are quite popular with patients because they feel they have some control over their
situation, and some studies have shown that the patients themselves actually used the
machine for pain relief less often than their nurses gave them injections. The most
frequently administered drug via this pump is morphine sulfate. The primary nursing
observation connected with PCA usage are monitoring the respiratory rate frequently and
determining whether the dosage is effective in relieving the patient’s pain.
One step further has been taken even beyond the PCA pump in the attempt to eliminate or
reduce postoperative pain to a minimum. Certain patients are now able to receive
administration of intrathecal morphine, which is usually placed up alongside the spinal
column. Intrathecal morphine is usually administered by anesthesiologists trained for the
purpose. These clients are generally transferred to a type of unit where they can receive
one-to-one nursing care because they require such close respiratory observation. These
484
patients experience very little pain for 24 to 36 hours after surgery. They are able to
ambulate, cough, and deep breath much more effectively. Longitudinal studies will need
to be undertaken to determine if the benefits of intrathecal morphine will outweigh the
disadvantages.
Analgesics are usually administered every three or four hours the first day, and by the
third day most patients require only oral analgesics, believing their pain is not severe
enough. In this situation, inform the patient that in analgesic given prior to the occurrence
of severe pain is more effective in decreasing pain than one given after the pain has
become severe. Analgesics also help the patient to do deep breathing, coughing, and
ambulation more readily. Nursing measures to relieve pain and promote rest include the
following:
• Listen attentively to the patient’s complaints of pain; note location, note the type
of pain, severity of pain, and attempt to determine the cause.
• Observe the patient for signs of acute pain, such as pallor, perspiration, tension
and restlessness.
• Move and position the patient to minimize discomfort.
• Administer analgesics as ordered and as required.
• Plan to give analgesics before activities (such as ambulation or meals) or rest
periods (example, before bedtime).
• Assess and document the effectiveness of the analgesics.
• Provide comfort measures that relax the patient, such as back rubs, position
changes, rest periods, and diversional activities. (Tension increases pain
perception and responses.)
• Promote quite, restful environment.
Urinary elimination
• For all patients who have intravenous infusions and urinary catheters or other
drainage devices, measure and record the patient’s intake and output for at least
two days until maintenance of the patient’s fluids balance is established.
• Note any difficulties the patient has with voiding, and assess the patient for
bladder distention
• Promptly report to the responsible nurse if the patient does not void within 8
hours following surgery.
• Provide measures that promote urinary elimination. For example, help the male
patient stand at the bedside, ensure that the patient is free from pain, ensure that
the fluid intake is adequate, and ambulate the patient as permitted.
485
• Catheterize the patient when all measures to promote voiding have failed. In some
agencies, a doctor’s order is required prior to catheterizing the patient.
Bowel elimination
Abdominal distention is very common after surgery because of reduced peristalsis. Many
patients who have had abdominal surgery experience this discomfort about the third day
after surgery. Nursing measures to relieve distention include the following:
Activity
Wound protection
• Inspect the dressing regularly to ensure that it is clean and dry. Report excessive
bleeding immediately.
• Ensure that the dressing is fastened securely.
• Apply abdominal binders as ordered to provide support.
• Change dressings, using sterile technique, when drainage is present or in
accordance with the physician’s or nursing orders.
486
POSTOPERATIVE COMPLICATIONS
For most people who have surgery, recovery is without incident. Complications from
surgery occur relatively rarely, yet nursing personnel must be aware of the possibility of
complications and their clinical signs. Most pre and postoperative nursing care measures
are designed to prevent complications.
Respiratory
Measures such as coughing, deep breathing, turning, and early ambulation are employed
to assist in removal of mucous and prevention of atelectasis. Sufficient fluid intake helps
the sputum remain liquid. If the patient cannot cough out the secretions, use suction to
remove them.
Pulmonary embolism. The clinical signs of pulmonary embolism are sudden chest pain,
shortness of breath, and shock. The physician will usually begin anticoagulant therapy to
prevent further emboli. Stasis of blood in the veins, venous injury, increase in blood
coagulability, and disease predispose to the formation of emboli. Stasis of blood can
occur with prolonged bed rest, obesity, advanced age, burns, and postpartum (after
childbirth). Venous injury can occur during surgery on the legs, pelvis, abdomen, and
thorax, and from fractures of the pelvis and legs. Increased coagulability can occur with
malignancies and in conjunction with oral contraceptives that are high in estrogen.
Supportive nursing measures for pulmonary embolism include drug therapy, oxygen if
needed to relieve dyspnea, and analgesics for discomfort. Preventive measures include
487
coughing, deep breathing, turning, exercise, and the application of elastic stockings to
enhance the venous blood return from the legs. Avoid rubbing the legs in order not to
dislodge any clots in the leg veins.
Circulatory
Hemorrhage. Hemorrhage can be a very serious problem if not detected and treated
early. The escaped blood may appear on the surgical dressing, or it may remain inside
the patient. The clinical signs of hemorrhage include a drop in blood pressure; thready,
rapid pulse; pallor; cold, clammy skin; and restlessness. The signs of hemorrhage must
be reported immediately to the responsible nurse or surgeon. Treatment for hemorrhage
usually includes the administration of blood or intravenous solutions, medications, and
oxygen therapy. Extra covers will help warm the patient.
Shock. Hypovolemic shock can result when the volume of circulating fluid is markedly
reduced, for example, as a result of hemorrhage. The clinical signs of shock include cold,
clammy skin; pallor; cyanosis; a drop in blood pressure; rapid pulse; shallow, rapid
breathing; and restlessness. Notify the responsible nurse or the physician immediately,
and be prepared to administer oxygen, medications, intravenous solutions, or blood.
Urinary
Urinary retention with overflow can also occur. The patient voids small amounts of urine
frequently while retaining most of the urine in the bladder. Measuring the patient’s fluid
intake and output will provide data about fluid imbalance and urinary retention.
Retention may be indicated when intake is considerably larger than output. Report
urinary retention to the responsible nurse or surgeon if measures to help the patient to
void are unsuccessful.
488
Infection. Urinary infection tends to occur when there is immobilization and limited
fluid intake by the patient. Clinical signs of urinary infection include burning sensation
upon voiding, urgency, cloudy urine, and lower abdominal pain. Encourage the patient to
take fluids, and report the clinical signs to the surgeon. Measures to prevent urinary
infections include good perineal hygiene, ample fluid intake, and early ambulation.
Gastrointestinal
Constipation. Constipation can be caused by lack of roughage in the patient’s food and
decreased motility of the gastrointestinal tract due to the administration of analgesics.
Ample fluid intake and early ambulation help prevent constipation.
Nausea and vomiting. The patient may report feeling nauseated or “sick to my
stomach.” Vomiting produces emesis, which needs to be assessed as to appearance and
amount. Nursing measures to prevent nausea and vomiting include encouraging the
patient to lie still and breathe deeply, keeping the environment free from unpleasant
odors, and providing analgesics to prevent severe pain. The physician may order an
antiemetic (an agent that prevents nausea and vomiting).
Psychological
Depression. Depression may occur after some surgery. The patient may learn that the
surgeon’s findings have serious implications; for example, a malignancy may have been
found. Some of the clinical signs of depression are sleep disturbances (excessive
sleeping and insomnia), anorexia, tearfulness, loss of ambition, withdrawal, rejection of
others, and dejected affect. The loss of health, like other losses, may be grieved.\
Nursing interventions include ensuring adequate rest, since sleeping disturbances can
aggravate depression, encouraging the patient to take part in some kind of physical
activity, which increases self-esteem and promotes rest, and assisting the patient to
express negative feelings, such as anger.
489
Wound
Infection. Some of the clinical signs of wound infections are purulent exudates, redness,
tenderness, elevated body temperature, and odor. Identification of the presence of
microorganisms through laboratory examination of a specimen of drainage will confirm
this. Nursing intervention includes encouraging fluid intake, maintaining the cleanliness
of the wound, and preventing the transmission of the microorganisms to others.
BIBLIOGRAPHY
Lewis, S., Heitkemper, M., & Dirkson, S. (2004). Medical-surgical nursing: Assessment
and management of clinical problems. (6th ed.). St. Louis: Mosby.
Perry, A., & Potter, P. (2002). Clinical nursing skills & techniques. (5th ed.) St. Louis:
Mosby.
Potter, P. & Perry, A. (2001). Fundamentals of nursing. (5th ed.) St. Louis: Mosby.
Unit 3
Self-Test
a. _______________________________________________
b. _______________________________________________
c. _______________________________________________
3. A patient who is fully conscious upon return from the recovery room is aware of
time, _____________________________, ______________________________,
and ___________________________________________.
5. Avoid using pillows or rolls under a patient’s knees during the postoperative
phase because
__________________________________________________________________
__________________________________________________________________
7. Before a patient is able to return to solid food, the nurse must determine by
auscultating the abdomen that
________________________________________________________________.
a. ____________________________________________________________
b. ____________________________________________________________
10. The earliest time that newly-postoperative patients should probably be ambulated
is ______________________________________________________.
13. A drop in blood pressure; thready, rapid pulse; and cold, clammy skin are clinical
signs of ___________________________________.
14. Use of elastic stockings on patients will help to prevent one postoperative
complication of ________________________________________________.
15. If the patient becomes nauseated, which results in emesis, the two characteristics
of emesis that need to be assessed are
a. ______________________________________________________
b. ______________________________________________________
16. Allowing the postoperative patient to express negative feelings, such as anger,
will help to relieve the ________________________________________ he or
she may feel if the outcome of the surgery was not favorable.
493
Module 14
Answers to Self-Tests
Unit 1
1. elective
2. minor, same-day surgery
3. any of the following: age, obesity, immobility, malnutrition, emergency surgery
4. a. nature
b. location
c. duration
5. a. obesity
b. malnutrition
6. denial
7. signed consent form
8. a. moving
b. leg exercises
c. coughing
d. deep breathing
9. depress
10. cyanosis in nailbeds
11. leaving them in place will cause fingers to swell
12. dries
13. the patient’s identification bracelet
Unit 2
1. general, regional, local
2. loss of control
3. inhalation, IV infusion, rectal infusion
4. spinal, nerve block
5. general, regional
6. Trendelenburg
Unit 3
1. intensive care
2. a. suction
b. oxygen
c. IV stands
3. place, person
4. two
5. pressure on popliteal vessels can slow circulation to and from lower extremities
6. ice chips or water sips
7. peristalsis has returned
8. any of the following: offer back rubs, diversional activities, reposition, rest
periods
9. 6 – 8
494