PERIOPERATIVE

Clinical Instructor: Keith C. Lambojon, RN

PERIOPERATIVE NURSING - Example:

o Colostomy
- Used to describe the nursing care provided in the total o Debridement of necrotic tissue
surgical experience of the patient o Rhizotomy
- Has 3 phases: TRANSPLANT
- To replace organs or structure that are diseased or
PHASES START END malfunctioning.
- WOF: Risk of rejection
PREOPERATIVE Decision of Transport to OR o Signs:
patient to have ▪ High HR, BP
surgery is
made (signed ▪ Febrile
informed
consent) ▪ Anuria (common) or oliguria
▪ Elevated WBC
INTRAOPERATIVE OR table Transport to
o To prevent rejection, administer:
PACU
▪ Immunosuppressant or steroids
POSTOPERATIVE Admission to Wound is • AT RISK for infection.
PACU completely
healed • Restrict visitors
- Examples:
o Kidney transplant
o Corneal transplant
TYPES OF SURGERY o Liver transplant
ACCORDING TO PURPOSE
DIAGNOSTIC AESTHETIC
- To confirm and establish diagnosis. - To improve physical features that are NORMAL. -
- Examples: Examples:
o Biopsy o Rhinoplasty
o Exploratory laparotomy
ACCORDING TO DEGREE OF URGENCY
EXPLORATORY EMERGENT
- To know the EXTENT of the disease. - Requires IMMEDIATE action.
- Examples: - Without any delay
o Exploratory laparotomy - May be life-threatening.
- Performed immediately to preserve life
o Pelvic laparotomy
- Examples:
o Skull fractures
RECONSTRUCTIVE
o Intestinal obstruction
- To restore function of TRAUMA or malfunctioning tissue
and to improve self-concept. ▪ Inguinal hernia
- Examples:
▪ Adenocarcinoma
o Skin graft (commonly in inner thigh)
o Plastic revision ▪ Adhesions
o Scar revision o Internal hemorrhage
o Extensive burns
CONSTRUCTIVE o Fracture
- To repair CONGENITAL ANOMALIES
- Example: ▪ Chest fracture = impaired bleeding
o Cheiloplasty (cleft lip) pattern
o Palatoplasty (cleft palata) o Perforated ulcer
o Closure of atrial septal defect
URGENT
CURATIVE / ABLATIVE - Requires a PROMPT attention.
- To remove DISEASED body part. - Indication: should be done within 24-48 hours. -
- Usually ends with “-ectomy” Examples:
- Examples: o Cholecystectomy
o Thyroidectomy o Appendectomy
o Gastrectomy o Colon resection
o Appendectomy o Amputation
▪ DM foot
PALLIATIVE
- To relieve or reduce pain or symptom of a disease. -
It does not cure.
 REQUIRED - Examples:
- NEEDS to have surgery. o Prostatic hyperplasia
- Indication: plans within a few weeks or months. o Patient o Thyroid disorders
has an illness where it can be managed through
medication. However, it still ELECTIVE
needs surgery as it affects quality of life. - SHOULD have the surgery.
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PSALM 23

- Indications: failure to have surgery is not catastrophic.

- Risk factors are reduced.
▪ Spine surgeries ▪ Digit (hands and feet)
- Delay or omission will not cause adverse effect. - - Expected blood loss
Examples:
o Tonsillectomy 🡺 repeated tonsilitis 🡺 RHD o TIME OUT
Hernia repair - Before the procedure or skin incision
o Cataract extraction - OR team introduce themselves
- Check identifier of patient including the procedure and
site marking
OPTIONAL
- Rests with the patient or PATIENT PREFERENCE - - Antibiotic within 60 minutes
Examples: - Critical events (discussed by surgeon and
anesthesiologist)
o Cosmetic surgery
- Imaging (common in brain, internal, and fracture
o Circumcision surgeries)
ACCORDING TO DEGREE OF RISK SIGN OUT
MAJOR - Before patient leaves OR
- Blood loss: > 500 ml - Confirm the name of procedure.
- Prolonged time: > 2 hours - Count (instruments and sponge)
o WOF: potassium count 🡺 hyperkalemia - Specimen.
- Prone for complications
- Involves major body organs
- Examples:
o Cataract surgery
o Kidney transplant
o Cesarean
o Lap chole

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

PREFIXES OR SUFFIXES
o Contraindication:
▪ Neonates = permanent
- Checks anesthesia machine and medication -
Pulse oximeter
- Assess for airway and allergy
• Supra-: above or beyond • Ortho-: joint • Oophor-: ovaries • -ostomy: making an opening or stoma
• Chole-: bile or gall • Cysto-: bladder • Pneumo-: lungs • -otomy: cutting into
• Encephalo-: brain • Entero-: intestine • Salphingo-: fallopian tube • -plasty: to repair or restore
• Hystero-: uterus • Thoraco-: chest • -itis: inflammation • -cele: tumor; swelling;
• Mast-: breast • Viscero-: organ especially in the hernia

• Meningo-: meninges or membranes abdomen

• -oma: tumor or swelling
• Myo-: muscles
• -ectomy: removal of an organ or gland
• Nephro-: kidney
• -rhapy: suturing or stitching
• Neuro-: nerve
• -scopy: looking into
PREOPERATIVE PHASE the decision for surgical intervention is • Focus: preparation of the patient
made until the client is transported to the
- Refers to the time interval that begins when OR. • Goal: best possible physical and emotional
condition for surgery
▪ Laterality
SURGICAL SAFETY CHECKLIST INFORMED CONSENT
SIGN IN - It is required.
- Before induction of anesthesia - Proof that client has been informed and decided on his or
- Validate identity and consent her health.
- Site marking –– done by the surgeon (usually initials of - The healthcare provider (HCP) should obtain the
the surgeon and the procedure is written on the site) o consent.
When it involves the: - Valid only for 24 hours.

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PSALM 23

Before obtaining the informed consent, the surgeon or HCP

should provide the following information to the client: Consents are not needed for emergency care if all 4 are
1. Nature of and the reason for the surgery met: 1. Immediate threat to life
2. Available options and its risks. 2. Emergency
3. Risk and benefits 3. Client is unable to consent.
4. Name and qualifications of performing the procedure. 4. A legally authorized person cannot be reached.
5. Right to refuse or withdraw.
PHYSICAL ASSESSMENT
Role of Nurse - Baseline assessment
• Witness the client’s signature.
1. Height and weight
• Ensure that client is competent and signing voluntarily. • a. For anesthesia medications
Discuss and review the document.
o The document should not have any erasures, 2. Vital signs
abbreviations. a. BP: +/- 20 in PACU
o Should contain the:
3. Mental status examination
▪ Complete name of the patient, HCP, a. Ask the name and date of birth of the patient
and the procedure. b. To determine if the patient is competent
▪ Date of birth of the patient enough to sign informed consent

4. Cardiovascular and Pulmonary

Procedures that need informed consent:
a. Respiratory depression
1. Radiation
2. Invasive procedures
5. Endocrine and Renal
3. Anesthesia with sedation
a. If diabetic = poor wound healing
b. If patient has CKD = cannot excrete
Who can give informed consent:
anesthesia = STAT HD
1. At least 18 years old
2. Conscious, coherent and mentally competent
6. Gastrointestinal
3. Voluntarily
a. Common complication: constipation
4. Emancipated minors
a. <18 years old with spouse, children, pregnant
or special power of attorney 7. Neurologic
a. Determine if the patient has any paralysis or
weakness.
Who cannot give consent:
8. Integumentary
1. Minors
a. No nail polish, dentures, and make up
2. Unconscious
3. Mentally ill person
DIAGNOSTICS
!! If the patient is illiterate, they are not allowed to give consent 1. Complete Blood Count (CBC)
immediately !! a. Postpone surgery if:
i. Low Hgb
What if I cannot give an informed consent: ii. Elevated
1. Spouse iii. Low WBC (immunosuppressed or
2. Son or daughter of legal age viral infection
3. Either of the parents (priority: mother) iv. Low platelet 🡺 bleeding
4. Brother or sister of legal age
v. High platelet 🡺 clotting
5. Guardian or next of kin
2. Serum and Electrolytes
3. Creatinine and Bun
a. To determine kidney function
 4. AST, ALT, LDH, Bilirubin 11. ABG
a. To determine coagulation and drug 12. Pregnancy test
metabolism a. If patient is pregnant, check FHR before and
5. FBS after the surgery.
a. Normal blood sugar prior surgery should be 13. Other radiologic studies
within 80-110 mg/dL to prevent complications
6. Chest Xray PSYCHOLOGICAL ASSESSMENT
7. Urinalysis 1. Fear of unknown
a. To determine renal function 2. Fear of death
8. Coagulation studies (PT, PTT, bleeding and clotting 3. Fear of anesthesia
time) 4. Concern on threat of permanent incapacity
a. High = bleeding 5. Loss of work, time, job and support
b. Low = clotting 6. Spiritual beliefs
9. ECG 7. Cultural values and beliefs
10. CT Scan, MRI, PET Scan 8. Fear of pain

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PSALM 23

- Goal: to provide a medication that the client requires

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

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PSALM 23

" Grieving related to perceived loss of body part • Antiemetic

associated with planned surgery. # Metoclopramide (Plasil/Reglan)
○ Crying
○ Aloof # Ondansetron (Onsia/Zofran)
○ DABDA • Histamine-receptor antihistamines = decrease gastric
" Ineffective coping related to lack of clear outcomes of content
surgery. # Ranitidine
○ No idea on postop preparations
# Famotidine
• Proton pump inhibitors
PLANNING OR IMPLEMENTATION
⇒ Include the following:
# Omeprazole
• Diagnostics (same as diagnostics see page 3) •
Medications # Pantoprazole

• Exercises # Esomeprazole

• Incentive spirometry # Lansoprazole

• Skin preparation • Analgesics

• Pain management # Paracetamol

• Elimination Prior to giving the medication

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

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PSALM 23

• Trimming or clipping of the hair may be done in the

operative area
# Lactulose (Duphalac, Lilac)
ELIMINATION # Bisacodyl (Dulcolax, Correctal)
• Enema, laxatives or both can be given depending to # Senna (Senakot)
physician’s orders
# Mineral and castor oil
• Enemas before surgery are no longer routine. o
However, it is done during: Types of enemas
▪ Bowel surgeries 1. Cleansing –– to remove feces.
2. Carminative –– to expel flatus.
▪ Colonoscopy
3. Oil retention –– to soften the feces and to lubricate the
▪ Colostomy insertion rectum and anal canal 🡺 facilitate passage of feces. 4.
• Upon the administration of enema, the client should Return-flow –– to expel flatus.
position in left lateral position 5. Fleet –– uses a salt called sodium phosphate to keep
water in the intestines.
o To facilitates the flow of solution (due to
anatomical position) by gravity into the
ANTI-EMBOLIC STOCKINGS
sigmoid and descending colon, which are on
- Purpose:
the left side.
o Having the right leg acutely flexed provides for ✅ To facilitate venous return from the lower
adequate exposure of the anus. extremities
✅ To prevent venous stasis and DVT
Laxatives ✅ To reduce peripheral edema
DIET o Homeostasis: stable VS
• Always review the surgeon’s prescriptions regarding the ▪ Responsible: anesthesiologist
NPO status during the surgery o Safe administration of anesthesia
o Clear liquids: at least 2 hours prior surgery
▪ Responsible: anesthesiologist
o Breast milk: at least 4 hours prior surgery
o Light meals (anything that has no meat): at o Hemostasis: no bleeding and intact suture
least 6 hours prior surgery ▪ Responsible: surgeon
▪ Bread
TYPES OF ANESTHESIA
▪ Fruits
GENERAL ANESTHESIA
▪ Vegetables - Effect:
o Heavy meals: at least 8 hours prior surgery o Analgesia
o Amnesia
CONTRAPTIONS o Unconsciousness
• Nasogastric tube o Loss of reflexes and muscle tone

• Indwelling catheter (FC) - Chief disadvantage: respiratory and cardiac depression

• Epidural catheters
" Ineffective protection
• Wound drains ○ Prone to aspiration, fall, and injury
• Arterial line
Conscious sedation
• Intravenous lines - Depress consciousness but maintains airway and
• Oxygen support ventilation.
- Usually used during MRI, CT, spinal and regional
• Subclavian or intrajugular line anesthesia
- Examples:
• Jackson-Pratt drains
# Midazolam
• Blake-drain
# Ketamine
• Penrose drain
# Fentanyl

PSYCHOSOCIAL PREPARATION REGIONAL ANESTHESIA

• Inform the client about what to expect postoperatively. • - Temporary interruption of the transmission of nerve
Level of anxiety impulses to and from a SPECIFIC AREA or REGION of
the body.
• Answer any questions of concerns that the client may
have regarding surgery. ①Topical Anesthesia
• Psychosocial support. - Usually applied to skin and mucous membranes. -
Effect will be felt after 15 minutes.
INTRAOPERATIVE PHASE - Open skin surfaces, wounds, and burns
- Usually used during neonatal circumcision.
- Examples:
- Goal:
o Asepsis # Lidocaine
▪ Responsible: scrub nurse and # Benzocaine
surgeon

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PSALM 23

②Local Anesthesia ③Nerve Block

- Infiltration - Injected to the nerve or small nerve group that supplies
- Injected to a specific area small area of the body.
- It may be characterized by shouting, struggling of the - Examples:
client. # Brachial plexus – arms
' Increased autonomic activity
# Facial nerve
- Used for the minor surgical procedure such as suturing a
small wound or performing biopsy. # Pudendal block
- Examples:
# Lidocaine ④ Spinal Anesthesia
- AKA Subarachnoid block
# Tetracaine - Requires lumbar puncture through on of the interspaces
 between lumbar disk and the sacrum. - Injected to - Extends from the loss of lid reflex of most reflexes. -
subarachnoid space surrounding the spinal cord. Surgical procedure is started.
- Complications: ' Unconscious and lies quietly
% Nausea and vomiting
' VS are within normal limits
% Hypotension
' Constricted pupils
& IV fluids
% Spinal Headache STAGE 4: MEDULLARY DEPRESSION / DANGER - Too
much anesthesia had been administered. & If this stage
& Flat on bed for 6-8 hours
develops, discontinue anesthesia and initiate respiratory and
% Respiratory paralysis circulatory support.
% Neurologic complications ' Widely dilated pupils
' Shallow respiration, weak and thready pulse
⑤Epidural Anesthesia ' Death
- Anesthetic agent in the epidural space that surrounds
the dura mater of the spinal cord. ' Respiratory or cardiac depression or arrest
- Advantage: Absence of headache.
- Disadvantage: Greater technical challenge of introducing NURSING DIAGNOSIS
the anesthetic agents into the epidural rather than the
subarachnoid space. " Risk for aspiration
- Medications given in epidural catheter: opioids and " Risk for injury
anesthetic medications
" Ineffective protection
# Morphine
" Risk for imbalanced body temperature
# Fentanyl
" Impaired skin integrity
# Oxycodone
" Ineffective peripheral tissue perfusion
& Ensure that the catheter is completely
removed. " Risk for deficient fluid volume
▪ Blue tip signifies the complete
SURGICAL TEAM
removal of epidural catheter.
OPERATING SURGEON
- Head of the surgical team; Captain of the ship -
STAGES OF ANESTHESIA
Ultimate responsible in performing the procedure
STAGE 1: BEGINNING / ONSET / INDUCTION
- Extends from administration of anesthesia to the time of ANESTHESIOLOGIST
loss of consciousness.
- Assess the patient before the procedure.
- Close OR doors - Supervises the patient throughout the procedure -
# Propofol Monitor VS, ECG, blood oxygen saturation, urinary output,
' Dizziness, drowsy, hallucination
and blood loss.

' Feeling of detachment CIRCULATING NURSE

' Ringing, roaring or buzzing in the ears - Coordinates all personnel in the OR
- Monitors responsible cost compliance associated with
OR procedures
STAGE 2: EXCITEMENT / DELIRIUM - Ensure all equipment are working properly.
- Extends from the time of loss of consciousness by the - Guaranteeing sterility of instruments and supplies. -
time of loss of lid reflex. Assisting with positioning.
' Dilated pupils - Performing surgical skin preparation.
' Rapid pulse rate - Handling specimens.
- Assisting anesthesia personnel.
' Irregular and increased RR - Monitors the room and team members for breanks in
' Uncontrolled movement sterile technique.
- Coordinating activities with other departments. -
& Use safety straps on both arms and thigh Documenting care provided
area. - Minimizing conversation and traffic within the OR suite

STAGE 3: SURGICAL SCRUB NURSE

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PSALM 23

- Gathering of equipment and supplies. instruments during surgery,

- Prepares all supplies and instruments using sterile
technique. ZONES
- Maintains sterility during surgery. UNRESTRICTED ZONE
- Handles supplies and instruments during surgery. - - Can wear street clothes
Performs after care - Patient reception area and holding attire
- Keep accurate count of sponges, sharps, and
 - Area in the OR that interfaces with other department. AIRWAY
• Assess for breath sounds
SEMI-RESTRICTED ZONE
- Scrub clothes and caps are required • Wheezing, stridor (infant), crowing, crackles (fluid
- May include areas where surgical instruments are overload) or rhonchi
processed.
• Monitor for the secretions
RESTRICTED ZONE • Avoid positioning the client in supine position and
- Scrub clothes, shoe cover, caps, and masks are worn. - moderate high back rest
Operating theater and sterile core area 🡺 sterile gown and • Always ensure lateral position (side-lying)
gloves
OXYGEN SATURATION AND VENTILATION
SURGICAL ASEPTIC TECHNIQUE
1. All materials in contact with surgical wound or used • Observe for the chest movement for symmetry • Hook to
within the STERILE FIELD MUST BE STERILE. continuous pulse oximeter and oxygen support • DBE
2. Sterile surfaces or articles may touch other sterile
( WOF: respiratory distress, atelectasis, or respiratory
surfaces or articles remain sterile 🡺 STERILE to
complications.
STERILE.
3. CONTACT WITH UNSTERILE OBJECTS at any point o first sign: 'ALOC
renders a sterile area CONTAMINATED. • Low fowler’s
4. Gowns of the surgical team are considered sterile in front
form the CHEST TO THE LEVEL OF THE STERILE
FIELD. CARDIAC STATUS
5. The sleeves are also considered from 2 inches above • Skin color, pulses, and capillary refill
the elbow to the stockinette of the cuff.
6. Sterile drapes are used to create a sterile field. a. Only • Absence of edema, numbness or tingling
the top surface of a draped table is considered sterile. • Hypertension and hypotension
7. After a sterile package is opened, the edges are
considered unsterile. • Cardiac dysrhythmias
8. The movements of the surgical team are from sterile to o Most common: sinus bradycardia
sterile areas only.
9. Sterile areas must be kept in view during movement • Encourage the use of anti-embolic stockings, sequential
around the area. compression device.
10. Whenever a sterile barrier is breached, the area must o To promote venous return.
be considered contaminated. o Strengthen muscle tone.
11. A tear or puncture of the drape permitting access to an o Prevent pooling of blood in the extremities.
unsterile surface underneath renders the area
unsterile. LEVEL OF CONSCIOUSNESS
12. Items of doubtful sterility are considered unsterile.
• Make a frequent periodic attempts to awaken the client
POSTOPERATIVE PHASE until the client awakens.

ABILITY TO MOVE EXTREMITIES

- Goal:
o Return homeostasis. • One of the discharge criteria
o Maintain adequate body system function.
o Alleviate pain and discomfort. FLUID STATUS
o Prevent postop complications. • IV fluid administration
o Ensure discharge planning and teaching.
ASSESSMENT • Record intake and output
Assess the following in order: • Monitor for signs of fluid and electrolyte imbalances
1. Airway
2. Oxygen saturation and ventilation POSTOPERATIVE SITE AND DRAINS
3. Cardio status
• Assess for the surgical site, drains and wound dressing
4. Level of consciousness
5. Cough and gag reflex • Record I&O
6. Ability to move extremities o Always ensure that JP drain is in negative
7. Fluid status pressure
8. Postoperative site o Drain the drains qshift or as needed.
9. Drains o
10. Pain and safety
• Monitor for signs of fluid and electrolyte imbalance
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PSALM 23
 associated with, or resembling that associated with,
Serous • Clear or straw colored. actual or potential tissue damage.
• Occurs as a normal part of the
TYPES OF PAIN: LOCATION
healing ① REFERRED PAIN
- Pain that appears or arise in different areas of the body.
Serosanguineous • Pink colored due to the presence of
a small amount of blood cells ② VISCERAL PAIN
mixed with serous drainage. - Pain arising from organs or hollow visceral or perceived
• Occurs as a normal part of the area in a remote area.
healing process.
TYPES OF PAIN: DURATION
Purulent • Yellow, gray, or green drainage Acute Chronic
due to infection in the wound
Duration < 6 mos > 6 mos
Sanguineous • Red drainage from trauma to blood
vessel. SNS/PNS SNS PNS
• May occur with wound cleansing or Vital signs Increased Within normal
other trauma to wound bed. limits
• Abnormal in wounds.
Physiologic Physiologic Psychologic
or
Hemorrhage • Frank blood from a leaking blood Psychologic
vessel.
• May require emergency treatment Visible Yes No
to control bleeding. symptoms?
• Abnormal wound exudate.

TERMS
CRITERIA IN DISCHARING TO PACU
• Pain threshold –– is the least amount of stimuli that is
• Activity 🡺 able to obey commands such as DBE •
needed for a person to label a sensation as pain. • Pain
Respiration 🡺 easy and noiseless breathing • Circulation tolerance –– is the maximum of painful stimuli that a
🡺 BP is within +/- 20 mmHg preoperative level person is willing to withstand or to endure.

• Consciousness 🡺 responsive PAIN ASSESMENT

• Color 🡺 pinkish skin and mucous membrane P What are the factors that precipitated
(Precipitatin the pain? What are you doing?;
!! Score of ≥ 9 = safe discharge from PACU !! g/ WHAT
Provoking)
PAIN MANAGEMENT
Pain Q Crashing? Throbbing? Burning?
- 5th vital sign; always subjective (Quality) Tingling?
- An unpleasant sensory and emotional experience
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PSALM 23

0 NO PAIN
1
R Where is the pain? Does it 2 MILD PAIN
(Radiation) radiate?; WHERE 3
4
S Pain scale; HOW 5 MODERATE PAIN
(Severity) 6
7
T How long? Intermittent?; WHEN 8
(Timing) SEVERE PAIN 9
10

PATIENT CONTROLLED ANALGESIA (PCA)

- Allows the patient to control the administration of their
 own medication within predetermined safety limits - A PCA
pump is electronically controlled by a timing device
- The pump delivers a preset amount of medication. - It
permits the patient to administer continuous infusion of HYPOXEMIA
medication (basal rates) safely and to administer extra - Inadequate concentration of oxygen in the blood - Can
medication (bolus doses / rescue rate) with episodes of be due to shallow breathing caused by anesthesia
increased pain or painful activities
- The time can be programmed to prevent additional doses Clinical Manifestations
from being administered until a specified time period
' Restlessness –– first sign
has elapsed (lock-out time).
- Even if the patient pushes the button multiple times in a ' Dyspnea
rapid succession, no additional doses are released. ( ' Diaphoresis
Always watch out for respiratory depression and pruritus.
' Tachycardia, tachypnea
Mild Moderate Severe
Late signs
# Paracetamol # Fentanyl ' Cyanosis
#Hydrocodone
# Aspirin # ' Low pulse oximetry reading
#Codeine
# Ibuprofen Hydromorphon
#Tramadol e# Nursing Intervention: Atelectasis, Pneumonia, and
# Hypoxemia
Oxycodone
Indomethacin & Administer oxygen as ordered.
# # Morphine
Ketorolac & DBE and coughing
# #
Celecoxib & Use of incentive spirometry
Oxymorphon
& Turning and early ambulation
e#
Methadone & Notify MD

S2 requiring –– WOUND INFECTION

yellow RX; - Onset: 3-6 days
regulated
Cause or Risk Factors
1. Poor aseptic technique
2. Contaminated wound prior surgery
3. Diabetes mellitus
COMPLICATIONS
4. Immunoccompromised
!! BEST WAY TO PREVENT COMPLICATIONS:
EARLY AMBULATION !!
Clinical Manifestations
ATELETASIS ' Fever and chills
- Collapsed or airless state ' Warm, tender, painful and inflamed site
- Caused by:
o Accumulated secretions ' Edematous site
o Failure to DBE ' Elevated WBC
o Failure to ambulate
Management
PNEUMONIA & Administer antibiotics
- Inflammation of the alveoli caused by infectious process.
- Caused by: & Monitor VS
o Infection & Assess wound drainage
o Aspiration
& Maintain asepsis, change dressing, and perform from
o Immobility
wound irrigation
ATELECTASIS PNEUMONIA & Monitor for signs of infection
' Redness
' Ecchymosis
Onset 1-2 days after 3-5 days after ' Drainage
surgery surgery
' Approximation
Dyspnea and increased respiratory rate,
crackles, elevated body temperature,
productive cough and chest pain

10
YOU ARE GOING TO MAKE IT: TRUST ME.
 PSALM 23

HEMORRHAGE
- Loss of large amount of blood externally and internally in
a short period of time. CONSTIPATION
- Abnormal infrequent passage of stool
Clinical Manifestations - Failure to pass stool within 48 hours
' Restlessness ' Absence of BM
' Weak and rapid pulse ' Abdominal distention
' Hypotension, tachypnea ' Anorexia, headache, and nausea
' Cool, clammy skin
Nursing Intervention
' Reduced urine output.
& Ambulation
Nursing Intervention & Increased OFI
& Pressure to the site of the bleeding & High fiber diet
& Administer Vitamin K and Tranexamic acid & Stool softeners and laxative
(Hemostan) & Administer oxygen as needed ○ Stool softeners: Castor and mineral oil
& Blood transfusion and IV fluids ○ Laxative: Dulcolax, lactulose

& Notify MD PARALYTIC ILEUS

- No forward movement of bowel contents
WOUND DEHISCENCE - Due to anesthesia or bowel surgery
- Is the separation of the wound edges at the suture line -
Usually occurs 6-8 days after surgery. Clinical Manifestations
' Vomiting
WOUND EVISCERATION
- Is the protrusion of the internal organs through an ' Abdominal distention
incision. ' No bowel sound, BM, or flatus
- Usually occurs 6-8 days after surgery
Nursing Intervention
!! Evisceration is most common among obese clients who have
had abdominal surgery !! & NPO status
& Maintain NGT
Nursing Intervention: Dehiscence and
& Ambulation
Evisceration & Splint
& Administer IV fluids
Evisceration & Administer medications that increase GI motility and
& Cover with sterile gauze soaked with NSS secretions.
& If standing, low fowler’s with knees bent # Metoclopramide (Plasil/Reglan)
& WOF: shock
DEEP VEIN THROMBOPHLEBITIS
& Prepare for surgery - Inflammation of the vein, often accompanied by clot
formation.
URINARY RETENTION - Common in ortho surgeries
- An involuntary accumulation of urine in the bladder as a - Caused by:
result of loss of muscle tone o Prolonged immobility
- Appears 6-8 hours after surgery o Obesity or debilitation
- Common in epidural and spinal anesthesia
Clinical Manifestations
Clinical Manifestations ' (+) Homan’s sign
' Distended bladder
' Redness
' Lower abdominal pain
' Swelling (affected leg)
' Diaphoresis
' Heat/warmth
' Hypertension
' Veins feel hard and cordlike and is tender to touch.
Nursing Intervention
Nursing Intervention
& Ambulation
& Hydration
& Increased OFI
& Encourage leg exercises and ambulation
& Apply alternating warm and cold compress
& Elevate the affected leg with pillow support (on the
& Catheterize the patient if she cannot void after 6-8
feet) & Avoid massage
hours.
& Anticoagulant, anti-embolic stocking