PAIN AND SURGERY

PAIN AND SURGERY
JOCELYN G. GAVIETA, RN

GRADING SYSTEM
QUIZ 80 %
RECITATION 10 %
REQUIREMENTS 5%
ATTENDANCE 5%
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100 %

PAIN
• a feeling of distress, suffering or agony
caused by the stimulation of specialized
nerve endings

• a blend of physiological and
psychological experience of events
occurring within the patient's body
which is always unpleasant and
associated with the impression of
damage to the tissues

PAIN
• First symptom of injury;
• Indicator of a disease process
• The fifth vital sign

SOURCES OF PAIN STIMULI
NOCICEPTORS
receptors that transmit pain sensation.

NOCICEPTION
physiologic processes related to pain
perception.

PHYSIOLOGY OF PAIN
FOUR PHASES OF NOCICEPTION
2. TRANSDUCTION
 Noxious stimuli (tissue injury) trigger
the release of biochemical
mediators (e.g., prostaglandins,
bradykinin, serotonin, histamine,
stubstance P) that sensitize
nociceptors.

Noxious or painful stimulation also
causes movement of ions across cell
membranes, which excite nociceptors.
Pain medication can work at this phase:
by blocking production of prostaglandins
(e.g., ibuprofen) or by decreasing the
movement of ions across the cell
membrane (e.g., local anesthetic)

2. TRANSMISSION
 Neuronal action potential must be transmitted to &
through the CNS before pain is perceived.

 Involves 3 segments before pain impulse is
transmitted:
 1st Segment – pain impulse travels from the
peripheral nerve fiber to the spinal cord

 2nd Segment – pain transmission from the spinal
cord ascending to the brain via spinothalamic tracts
to the brainstem and thalamus.

 3rd Segment – transmission of signals between the
thalamus to the somatic sensory cortex.

2 Types of nociceptor fibers cause this
transmission to the dorsal horn of the spinal
cord:
a. C fibers – large & myelinated; carry pain
impulse at a rapid rate; throbbing, dull,
aching pain.
b. A-Delta fibers – small & unmyelinated;
carry pain sensation at a slower rate;
sharp, localized pain

Pain control can take place during this
process:
Opioid (narcotics) block the release of
neurotransmitters, particularly
substance P, which stops the pain at
the spinal level.

Pain Threshold – the point at which a
stimulus is perceived as pain.

Pain Tolerance – amount of pain a
person is willing to endure; only the
person determines tolerance level.

3. PERCEPTION
 When the client becomes conscious of
pain.
Pain perception occurs in the cortical
structures, which allows for different
cognitive-behavioral strategies to be
applied to reduce the sensory & afferent
components of pain.
e.g., nonpharmacologic interventions such
as distraction, guided imagery, & music
can help direct the client’s attention away
from the pain.

4. MODULATION
Described as “descending system”

Occurs when neurons in the brain stem
send signals back down to the dorsal horn
of the spinal cord.

These descending fibers release
substances such as endogenous opioids,
serotonin, norepinephrine, which can
inhibit the ascending noxious impulses in
the dorsal horn.

PAIN MODULATION
ENDOGENOUS OPIOIDS – pain inhibiting
neurochemicals
2. Enkephalins
 Inhibits the release of substance P - a
neurotransmitter that enhances transmission
of pain impulses
3. Endorphins
 More potent than enkephalins
4. Dynorphins
 Have analgesic effect, which is 50% more
potent than endorphins
5. Neuromodulators
 Modify pain (chemical regulators)

PHYSIOLOGICAL
THEORIES OF PAIN
TRANSMISSION

1. SPECIFICITY THEORY
 There are specific nerve receptors for
particular stimuli. e.g.,

 Nociceptors – noxious stimuli (always
interpreted as PAIN)

 Thermoreceptors – heat/cold
 Mechanoreceptors – pressure, pulling or
tearing sensation
 Chemoreceptors – chemicals

PATTERN THEORY
States that pain is produced by
intense stimulation on nonspecific
fiber receptors, so any stimulus could
be perceived as painful if the
stimulation is intense enough.

GATE CONTROL THEORY
States that there is a “gate” in the spinal cord
(substantia gelatinosa)

When the gate is open, pain stimulus is
transmitted thus pain is perceived.

When the gate is closed, pain is blocked
thus no pain is perceived.

 The gate is controlled by the balance impulse
input from the small and large peripheral nerve
fibers

ACCORDING TO DURATION
1. ACUTE PAIN
• Temporary, immediate onset
• Last for less than 6 months
• Eventually subside after treatment or
sometimes without treatment
e.g., headache, postop pain, labor pain,
toothache

2. CHRONIC PAIN
• Continuous, may begin gradually,
persist or recur for an indefinite
period of time, more difficult to
manage effectively
• (last 6 months or longer)

3 TYPES of Chronic Pain:
b.Chronic Nonmalignant Pain
e.g., low back pain, Rheumatoid A.
b. Chronic Intermittent Pain
e.g., migraine headache
c. Chronic Malignant Pain
e.g., cancer

ACCORDING TO SOURCE/ORIGIN

1. CUTANEOUS PAIN
• Includes superficial somatic structures
located in the skin & the subcutaneous
tissues
• “direct pain” since the pain accurately
localizes the point of disturbance
• e.g., finger cut, knot hair pulled out while
combing, 1st degree burn

2. DEEP SOMATIC PAIN
• Includes bones, nerves, muscles & other
tissues supporting these structures
• Poorly localized; frequently radiates from
primary site.
• e.g., ankle sprain, jamming a knee

3. VISCERAL PAIN
• Includes all body organs located in a body
cavity
• Diffuse, poorly localized, vague, dull pain
• e.g., obstructed bowel, cardiovascular
disease

ACCORDING TO INTENSTIY

1. MILD
• One that is bearable usually tolerated by
the client

2. SEVERE
• One which is intense & usually could not
be tolerated by the client

ACCORDING TO LOCATION
1. RADIATING PAIN
• Perceived at the source of the pain &
extends to nearby tissue
Cardiac pain – chest, left shoulder, down the
arm
2. REFERRED PAIN
• Felt in an area distant from the site of the
stimulus
MI – left arm, shoulder, or jaw pain
Cholecystitis – back pain & angle of scapula

3. INTRACTABLE PAIN
• Pain that is highly resistant to relief
• Advanced Malignancy

4. NEUROPATHIC PAIN
• Result of current or past damage to the
peripheral or CNS & may not have a
stimulus, such as tissue or nerve damage.
• Nerve injury that serves the hand would
be perceived a pain-hand even though the
injury may be at the spinal cord level.

5. PHANTOM PAIN
• Painful sensation perceived in a body part
that is missing

FACTORS AFFECTING PAIN
PERCEPTION AND RESPONSE
1. ETHNIC & CULTURAL VALUES
• Filipinos are known to be sufferers who
consider pain as sacrifice for sins
committed.
• Voicing pain – appropriate Italians
inappropriate Germans (stoicism)
• Mexicans/arabs – moaning/crying use to
alleviate pain rather than need for
intervention

2.DEVELOPMENTAL STAGES

• Infants - sensitivity
• Toddlers – cry & anger - threat to
security & punishment
• School-age – not cry or express much
pain so that parents will not get angry
• Adolescent – not report pain weakness
• Adults – not report pain indicates poor
diagnosis, weakness, failure

3. ENVIRONMENT & SUPPORT PEOPLE
• Hospital environment can be associated
with pain; Places that are noisy & have
glaring lights can compound pain
sensation

4. POST PAIN EXPERIENCES
• A person who has witnessed a family
member who experienced severe pain
may have difficulty enduring the same
experience once it arises

5. MEANING OF PAIN
• A woman giving birth may tolerate pain
infavor of a desired baby
• An athlete who undergone knee surgery to
prolong his career may tolerate pain better
than one who was shot by an enemy

6. ANXIETY & STRESS
• A person who suffers fatigue may not
have a good coping with pain

PAIN ASSESSMENT TOOLS
Onset
Location
Duration
Characteristics
Aggravating factors
Radiation
Treatment

2. FACES RATING SCALE

3. 10 POINT PAIN INTENSITY SCALE

MISCONCEPTION & MYTHS OF
PAIN
• Myth: Addiction occurs with
prolonged use of Morphine and
Morphine derivatives

• FACT: THE INCIDENCE OF
ADDICTION IS LESS THAN 0.1%

• Myth: The nurse or the physician is
the best judge of a client's pain.
• FACT: ONLY THE CLIENT CAN
JUDGE THE LEVEL & DISTRESS OF
THE PAIN, THAT'S WHY CLIENTS
SHOULD BE INCLUDED IN PAIN
MANAGEMENT.

• Myth: Pain is a result not a cause.
• FACT: UNRELIEVED PAIN CAN
CAUSE OTHER PROBLEMS SUCH
AS ANGER, ANXIETY, IMMOBILITY,
RESPIRATORY PROBLEMS, &
DELAY IN HEALING.

• Myth: It is better to wait until a
client has pain before giving
medication.
• FACT: IT IS BETTER TO ROUTINELY
ADMINISTER ANALGESIA TO
MAINTAIN LOW LEVEL OF PAIN
THAN TO “CATCH-UP” ONCE PAIN
ARISES.

• Myth: Real pain has an identifiable
cause.

• FACT: THERE ARE ALWAYS
CAUSES OF PAIN BUT SOME MAY
BE VERY OBSCURE.

• Myth: The same physical stimulus
produces the same pain intensity,
duration and distress in the same
people.
• FACT: INTENSITY, DURATION, AND
DISTRESS VARY WITH EACH
INDIVIDUAL

• Myth: Some clients lie about the
existence or severity of their pain.

• FACT: VERY FEW PEOPLE LIE
ABOUT THEIR PAIN

• Myth: Very young or very old
people do no have as much pain.

• FACT: ALL CLIENTS WITH INTACT
NEUROLOGIC SYSTEM
EXPERIENCE PAIN. AGE IS NO A
DETERMINANT OF PAIN
EXPERIENCE.

• Myth: Pain is a part of aging.

• FACT: PAIN DOES NOT
ACCOMPANY AGING UNLESS A
DISEASE, OR AN AILMENT IS
PRESENT

• Myth: If a person is asleep they are
not in pain.
• FACT: PAIN CAN CAUSE
EXHAUSTION WHICH CAN LEAD TO
CLIENTS IN PAIN TO SLEEP, BUT
THEY ARE IN PAIN. SOME CLIENTS
USE SLEEP AS AN ESCAPE FROM
PAIN.

• Myth: If the pain is relieved by non-
pharmaceutical pain relief
techniques, the pain was not real
anyway.
• FACT: NON-PHARMACEUTICAL
METHODS CAN BE EFFECTIVE IN
RELIEVING PAIN.

ASSESSMENT
• Ask the client about the pain and to describe it
in terms of degree, quality, area, and
frequency

• Observable indicators of pain include:
moaning; crying; irritability; restlessness;
grimacing or frowning; inability to sleep, rigid
posture; increased blood pressure, heart rates,
or respirations; nausea; and diaphoresis

• Ask the client to use a number-based pain
scale (a picture-based scale may be used in
children) to rate the degree of pain

PAIN MANAGEMENT
Refers to the techniques used
to prevent, reduce, relieve pain.

A. NON-PHARMACOLOGIC PAIN
MANAGEMENT
1. PHYSICAL INTERVENTION
 Includes providing comfort, altering
physiologic responses & reducing fears
associated with pain-related immobility or
activity restriction.

c. CUTANEOUS STIMULATION
 Redirects the client’s attention to the tactile
stimuli away from the pain stimuli; It releases
endorphins; it stimulates large diameter A-
beta sensory nerve fibers.

• MASSAGE
 back rub to reduce pain; stimulate
client’s skin by lightly kneading,
pulling or pressing with fingers, palms
or knuckles.
o ACCUPRESSURE
 Application of pressure to areas or points
used in acupuncture known as Meridians
o CONTRALATERAL STIMULATION
 Stimulating the skin opposite to the painful
area.

o HEAT & COLD APPLICATION
 The application of heat and cold or the
alternate application can soothe pain
resulting from muscle strain

 Heat applications may include warm-
water compresses, warm blankets,
Aquathermia pads, and tub and whirlpool
baths; may require a physician’s order

b. IMMOBILIZATION

Restricting movement of body
part may help manage episodes
of acute pain
e.g., Splint holds joints or
fractured bones that maybe painful
once moved

C. TRANSCUTANEOUS ELECTRICAL
NERVE STIMULATION (TENS)
 (portable, battery operated device) is a
method of applying low voltage
electrical stimulation directly over
identified pain areas.

C/I in clients with pacemakers,
arrhythmias or in areas of skin breakdown.

D. ACCUPUNCTURE

 very thin metal needles are skillfully
inserted into the body @ designated
locations & @ various depths & angles
Meridians – accupuncture points
distributed patterns
disease interrupts energy flow in the
body and insertion of needles at
specific points will re establish healthy
energy flow.

Acupuncture
Acupuncture is a traditional Chinese medicine that stimulates specific
points in the body in order to restore a proper balance of various
chemicals. Some people who suffer from chronic pain find that
acupuncture provides a measure of pain relief where all other methods
fail. The way acupuncture suppresses pain remains a mystery. Some
scientists now believe that it triggers the release of pain-relieving body
chemicals called endorphins and enkephalins. Others argue that
acupuncture’s pain-relieving effects are brought about by a patient’s

2. MIND-BODY INTERVENTION
(Cognitive-Behavioral)
A. DISTRACTION
 Directs away the attention of the client
from the painful sensation or the
negative emotional arousal associated
with pain

TYPES OF DISTRACTION:
1. Visual Distraction – read or watch tv
2. Auditory Distraction – humor, listen to
music

MUSIC
 Physiologic mechanism has not been
established in the use of music to relieve pain
but possible theories include distraction, release
of endogenous opioids, & dissociation

HUMOR
 Believed to help increased the production of
endogenous opioids endorphines, which are
natural pain killers.

3.Tactile Distraction – massage, slow
rhythmic breathing

4. Intellectual Distraction – card games,
crossword puzzle

B. RELAXATION TECHNIQUES
Gradually tighten then deeply relax various
muscle groups proceeding systematically
from one area to the next
Reduce muscle tension & anxiety

C. IMAGERY
 Help client visualize a pleasant experience
 Help distract themselves from their pain
which may increase pain tolerance;
produce relaxation response; diminished
the source of pain (e.g.tension headache)

D. MEDITATION
 Client sits comfortably & quietly with
focused attention away from pain
E.g., flow of the breath; picture image of
great spiritual being or peaceful place

E. BIOFEEDBACK

Biofeedback in Progress
A patient at a biofeedback clinic sits connected to electrodes on his
head and finger. Biofeedback is a technique in which patients attempt to
become aware of and then alter bodily functions such as muscle tension
and blood pressure. It is used in treating pain and stress-related
conditions, and may help some paralyzed patient use of their limbs.

Biofeedback in Progress
A patient at a biofeedback clinic sits connected to electrodes on his
head and finger. Biofeedback is a technique in which patients attempt to
become aware of and then alter bodily functions such as muscle tension
and blood pressure. It is used in treating pain and stress-related
conditions, and may help some paralyzed patient use of their limbs.

F. HYPNOSIS
 Hypnotic state; suggest to alter
character of pain or one’s attitude toward
it

G. THERAPEUTIC TOUCH
 use hands to rearrange energy field to normal

H. MAGNETS
 Believed that the pull of magnet increased
blood flow to the region of pain, opening the
NaCl channels in the cell.

PHARMACOLOGIC PAIN
MANAGEMENT

1. OPIOID ANALGESICS
(NARCOTIC)
 Derived from natural opium alkaloids
& their synthetic derivatives
 Suppress pain impulses but can
suppress respiration and coughing by
acting on the respiratory and cough
center in the medulla of the brain stem
 Can produce euphoria and sedation
 Can cause physical dependence

PHYSICAL DEPENDENCE
 means that a person experiences physical
discomfort, known as withdrawal syndrome,
when a drug that client has taken routinely
for some time is abruptly discontinued.

 to avoid withdrawal symptoms, drugs that
are known to cause physical dependence
are discontinued gradually. Dosage or
frequency of adm. is lowered over 1 week
or longer.

NARCOTIC ANALGESICS
 MEPERIDINE HYDROCHLORIDE
(Demerol)
 Can cause respiratory depression, tachycardia,
constipation, urine retention, hypotention, and
dizziness

• Used for acute pain and as a preoperative
medication

• Contraindicated in head injuries and in the
presence of increased intracranial pressure,
respiratory disorders, hypotentions, shock and
severe hepatic or renal didsease,

• Should not be taken with alcohol or sedative
hypnotics; may increase CNS depression
• To administer intravenously, dilute in at least
5 ml of sterile water or NSS for injection, then
administer dose over 4 to 5 minutes

 CODEIN SULFATE
• Also used in low doses as a cough
suppressant
• Can cause constipation

 MORPHINE SULFATE
• Can cause respiratory depression, postural
(orthostatic) hypotention, urine retention,
constipation, and papillary constriction

• May cause nausea and vomiting because of
increased vestibular sensitivity

• Used to ease acute pain resulting from
myocardial infarction or cancer, for dyspnea
resulting from pulmonary edema, and as a
preoperative medication

• Monitor intake and output and assess
client for urine retention

• Instruct client to avoid activities that
require alertness

• Have a narcotic antagonist available (e.g.,
Naloxone (Narcan), oxygen, and
resuscitation equipment available

NARCOTIC ANTAGONISTS
Description
• Use to treat respiratory depression from
narcotic overdose - Naloxone (Narcan)
Interventions
• Monitor BP, pulse, & RR q 5 mins. initially,
tapering to q 15 minutes, & then q 30
mins. until the client’s condition is stable
• Attach a cardiac monitor to the client &
observe cardiac rhythm

• Auscultate breath sounds
• Have resuscitation equipment available
• Do not leave client unattended
• Monitor client closely for several hours;
when the effects of the antagonist
wears off,
• the client may again display signs of
narcotic overdose

3 Primary Types of Opioids:
1. FULL AGONISTS
 pure opiod drugs producing maximum pain
inhibition, an agonists effect.
 No ceiling on the level of analgesia
 Dose can be steadily increased to relieve
pain
 No maximum daily dose limit
 Demerol, Morphine, Codeine

2. MIXED AGONISTS-ANTAGONIST

 can act like opioids & relieve pain (agonist
effect) when given to client who has not taken
any pure opioids.
 block or inactivate other opioid analgesics
when given to client who has been taking pure
opioids (antagonist effect)
 have ceiling dose & not recommended for
use w/ terminally ill clients.
 Nubain, Stadol

3. PARTIAL AGONISTS

 have ceiling effect in contrast to a full
agonist.
 Buprenorphine (Buprenex)
Pentazocine (Talwin)

2. NON-OPIOID ANALGESICS
 They relieve pain by acting on
peripheral nerve endings at the injury
site
& decreasing the level of
inflammatory mediators
 & interfering with the production of
prostaglandins at the site of injury.

ACETAMINOPHEN (TYLENOL)
Description
• Inhibits prostaglandin synthesis
• Used to decreased pain and fever
Contraindications
• Hepatic or renal disease, alcoholism, and
hypersensitivity
Side Effects
• Major concern is hepatotoxicity

NSAIDs and ACETYLSALICILIC
ACID (Aspirin)
• NSAIDs are aspirin and aspirin-like medications that
inhibit the synthesis of prostaglandins

• Act as analgesics to relieve pain, as antipyretics to
reduce body temperature, and as anticoagulants to
inhibit platelet aggregation

• Used to relieve inflammation and pain and to treat
rheumatoid arthritis, bursitis, tendonitis,
osteoarthritis, and acute gout

3. ADJUVANT ANALGESICS
Is a medication that was developed for
other than analgesia but has been
found to reduce chronic pain &
sometimes acute pain, in addition to its
primary action.
 Muscle Relaxant – muscle spasm
Anticonvulsants – nerve injury
Corticosteroids – reduce inflammation &
edema

Concept on surgery

CORRECT POSITION OF HANDS AFTER SURGICAL SCRUBBING

SURGERY
as a science and an art
 surgery is the branch of medicine that
comprises perioperative patient care
encompassing such activities as pre-
operative preparation, intra-operative
judgement, and post-operative care of
patients.

CATEGORIES & PURPOSES
OF SURGERY
ACCORDING TO PURPOSE
1. Diagnostic
 Performed to determine the origin &
cause of a disorder or the cell type for
cancer
 breast biopsy

2. Exploratory
 Estimation of the extent of disease or
confirmation of a diagnosis
 exploratory laparotomy, pelvic laparotomy

3. Curative
 Performed to resolve a health problem by
repairing or removing the cause

 Classification:
– Ablative
Includes removal of an organ;
e.g., appendECTOMY (suffix)

b.Constructive
Involves the repair of congenitally damaged
organ
e.g., cheiloPLASTY, orchidoPEXY

c.Reconstructive
Involves repair of damaged organ
e.g., Total joint replacement

4. Palliative
 Performed to relieve symptoms of a
disease process, but does not cure
 Nerve root resection, Colostomy

5. Cosmetic
 Performed primarily to alter or enhance
personal appearance
 Rhinoplasty, Blepharoplasty

ACCORDING TO URGENCY
1. Emergent
 condition is life-threatening that requires
surgery at once
 e.g., gunshot or stab wound, severe bleeding

2. Urgent
 performed as soon as client is stable &
infection is under control; life threatening if
treatment is delayed more than 24-48H
 e.g., appendectomy, intestinal obstruction

3. Required
 Client should have surgery; planned for a
few weeks or months
 e.g., Prostatic hyperplasia w/o obstruction,
Cataracts, Simple Hernia

4. Elective
 Client will not be harmed if surgery is not
performed but will benefit if it is performed
 e.g., Revision of Scars, Vaginal Repair

5. Optional
 Personal preference usually for aesthetic
purposes
 e.g., Cosmetic surgery

ACCORDING TO DEGREE OF RISK
3.Minor
 Procedure of less risk; generally not
prolonged; leads to few complications

2. Major
 Procedure of greater risk; usually longer &
more extensive; great risk of complications

ACCORDING TO EXTENT OF SURGERY
2. Simple
 Only the most overtly affected areas involved
in the surgery
 e.g., Simple or Partial Mastectomy

3. Radical
 Extensive surgery beyond the area obviously
involved
 e.g., Radical Mastectomy, Radical
Hysterectomy

SURGICAL SETTING
1. INPATIENT
 Refers to client who is admitted to a hospital
 Admitted on the day of surgery (Same-day
Admission – SDA)
2. OUTPATIENT & AMBULATORY
 Refers to a client who goes to the surgical
area the day of the surgery & returns home
on the same day (Same-day Surgery –
SDS)

PERIOPERATIVE NURSING
Assist clients and their significant others
through the surgical episode,
o help promote positive outcomes, and
 to help clients achieve their optimal level
of function and wellness after surgery.

Emphasis on safety & client education

Use Knowledge, judgement & skills

PREOPERATIVE
PERIOD
Begins when the client is scheduled for
surgery & ends at the time of transfer to
surgical suite

PREOPERATIVE PERIOD
 Focuses on client’s readiness – client education
& any intervention:
1. Reduce anxiety
2. Reduce complication
3. Promote cooperation
 Needed before surgery to:
1. Validate & clarify information client received
from surgeon or members of health team
2. Identify problems that warrant further
assessment &/or intervention before surgery

PREOPERATIVE ASSESSMENT

A. MEDICAL/HEALTH HISTORY
 Purpose of reviewing medical history is to
determine operative risk.

COLLECT THE FOLLOWING DATA:
1. AGE
Older – risk of complication; immune
system functioning; delays wound healing;
frequency of chronic illness; alter
operative response/risk

2. DRUGS & SUBSTANCE USE
o Tobacco - risk of pulmonary
complications (changes in lungs & cavity)
o Alcohol & illicit subs. – alter response to
anesthesia & pain meds.
withdrawal before surgery may
lead to delirium tremens

o PRESCRIPTION & OVER THE COUNTER –
affect how client reacts to operative
experience
o Potential effects for reaction or serious
adverse effect with some herbs & specific
drugs.

3. MEDICAL HISTORY
o Chronic illness increased surgical risk

4. CARDIAC HISTORY
o Complications from anesthesia occur
often
o Impair ability to withstand hemodynamic
changes & alter response to anesthesia
o Risk for MI during surgery higher with
pre-existing cardiac problem

5. PULMONARY HISTORY
o Smoker/Chronic Respiratory Problem -
chest rigidity & loss of lung elasticity
reduce anesthesia excretion.
o Smoking - blood level of
Carboxyhemoglobin which decreases O2
delivery to organs
acts on cilia of pulmonary mucous
membrane which lead to retain secretion &
predisposes clients to pneumonia &
atelectasis (reduce gas exchange &
causes intolerance of anesthesia)

Chronic lung problems (asthma, emhysema,
chronic bronchitis)
reduce lung elasticity
reduce gas exchange
reduce tissue oxygenation
7. ANESTHESIA
o Affect readiness for surgery
o those w/ complication - fear & concerns of
scheduled surgery

8. DISCHARGE PLANNING

o Assess client’s home, environment, self-
care capabilities, support system, &
anticipate post-op needs before surgery
Older clients & dependent adult need
transport referrals
Home care nurse/health center nurse
need to monitor recovery & provide
instruction

B. PHYSICAL ASSESSMENT
To obtain baseline data
Complete set V/S – abnormal V/S
may postpone surgery until problem
is treated & condition is stable

1. CARDIOVASCULAR SYSTEM
Cardiac problems – 30% of surgery-related
deaths
HPN – common & often undiagnosed affect
response to surgery
 Assess cardiac sounds for rate, regularity &
abnormalities
 Hands & feet – for temp, color, peripheral
pulses, capillary refill, & edema

REPORT: absent peripheral pulses, pitting
edema, cardiac symptoms ( chest pain,
dyspnea) for further assessment &
evaluation

2. RESPIRATORY SYSTEM
Age, smoking history (second
handsmoke), chronic illness
Overall posture, RR, rhythm & depth,
overall respiratory effort & lung expansion
Document clubbing of fingertips ( swelling
base nailbeds caused by chronic lack of
O2) or cyanosis

3. RENAL/URINARY SYSTEM
Kidney function – affects excretion of drugs &
waste products including ANESTHETIC &
ANALGESIC AGENTS
Renal function reduced (Older client) – fluid
& electrolyte balance can be altered

KIDNEY IMPAIRED:
 excretion of drugs & anesthetic agent
 Drug effectiveness may be altered
 Buscopan, Morphine, Demerol, Barbiturates
causes confusion, disorientation,
apprehension, restlessness with kidney
function

4. NEUROLOGIC SYSTEM
Assess overall mental status – LOC,
orientation, ability to follow commands)
before planning preoperative teaching &
care
Assess motor & sensory deficits –
problems may affect type of care
needed during surgical experience

Risk for falling (esp older) – evaluate
mental status, muscle strength,
steadiness of gait, sense of
independence, ability to ambulate

5. MUSKULOSKELETAL SYSTEM
 Problems may interfere with positions during &
after surgery. e.g., w/ Arthritis
 – may be able to assume surgical position but
have discomfort after surgery from prolonged
joint immobilization

 History joint replacement & document exact
location of prosthesis – ensure that
electrocautery pads are not place ON or NEAR
area of prosthesis – cause electrical burn

6. NUTRITIONAL STATUS
Malnutrition & Obesity - surgical risk
metabolic rate & depletes K, Vit C & B –
needed for wound healing & blood clotting

Malnourished - S. CHON slows recovery &
negative nitrogen balance may result from
depleted CHON store - risk delayed wound
healing, possible dehiscence & evisceration,
dehydration & sepsis

OBESE CLIENT – often malnourished
because of imbalance diet
 risk poor wound healing – excessive
adipose (fatty) tissue few blood vessels,
little collagen, nutrients needed for
wound healing
Stresses heart & reduces lung volume –
affects surgery & recovery
Need large doses of drugs & may retain
them longer after surgery

7. PSYCHOSOCIAL ASSESSMENT
To determine level of anxiety, coping ability,
& support system
– provide information & offer support as needed
Degree of Anxiety & Fears varies according:
Type of surgery
Perceived effects of surgery & potential
outcome
Client’s personality
SURGICAL THREAT – life, body image, self-
esteem, self-concept, or lifestyle

FEAR of death, pain, helplessness, socio-
economic status, dx of life-threatening
conditions, possible disabling/crippling
effects or unknown
ANXIETY & FEAR affect client’s ability to
learn
Cope & cooperate w/ teaching & operative
procedures
May influence amount & type anesthesia
needed & may slow recovery

8. LABORATORY ASSESSMENT
 Provide baseline data about health & help predict
potential complications
 OUTPATIENT – PAT (preadmission testing) 24-28
days before surgery
valid unless there’s change in condition or taking
drugs that can alter lab values ( Warfarin, Aspirin,
Diuretics)

 COMMON: Urinalysis, Blood type,
crossmatching, CBC, Hgb, Hct, Clotting
studies (PT, platelet count), electrolyte
levels, s. creatinine

 Urinalysis – assess abnormal subs.-
 CHON, glucose, blood, bacteria

 Report Electrolyte imbalance to surgeon &
anesthesiologist before surgery
♠ K - risk toxicity if taking digoxin
- slow recovery from anesthesia
- cardiac irritability
♠ K - risk dysrhythmias esp. w/ use of
anesthesia
K must be corrected before surgery
 Baseline ABG – w/ chronic pulmonary problem

9. RADIOGRAPHIC ASSESSMENT
CHEST XRAY – often young healthy adults
not required

Determine size & shape of heart, lungs, &
major vessels

Determine presence of pneumonia or TB

Provides baseline data in care of
complication

Results assist anesthesiologist in selecting
anesthesia for emergency surgery

 Abnormal findings alert for potential cardiac
or pulmonary complication

 Cardiac failure, cardiomyopathy,
pneumonia or infiltrates may cause
cancellation or delay of elective surgery

CT SCAN OR MRI

Electrocardiogram (ECG)
• Common non-invasive diagnostic test that
aids evaluation of heart function by recording
electrical activity

• Abnormal findings alert for potential cardiac
or pulmonary complication

Obtaining Informed Consent
• The surgeon is responsible for obtaining the
client’s consent for surgery
• Ensure that informed consent has been
signed and that any additional necessary
consents (e.g., limb disposal) have been
obtained & you serve as a WITNESS to the
signature, not to the fact that the client is
informed
• Sedation should not be administered to the
client before he or she signs the consent

Nurse:
Not responsible for providing detailed
information about the surgical procedure
ROLE: to clarify facts that have been
presented by the physician & dispel myths
that the client or family may have about the
surgical procedure

• The patient should personally sign the consent
unless she/he:

• MINOR – A PARENT OR LEGAL GUARDIAN

• EMANCIPATED MINOR (married or independently
earning a living – he/she may sign

A MINOR WHO HIS THE PARENT OF AN INFANT
OR CHILD WHO IS HAVING A PROCEDURE -
he or she may sign for his/her child

ILLITERATE- HE/SHE MAY SIGN WITH AN “X”,
AFTER WHICH THE WITNESS WRITE “PATIENT
MARK”

CANNOT WRITE:
Sign w/ an X with 2 witnessess
Emergency:
Phone or telegram authorization but follow-up
with written consent ASAP
Lifethreatening:
With effort to contact person w/ medical power of
atty., consent is desired but not essential
Written consultation by 2 physician not assoc. w/
the case ( formal consultation legally supports
decision for surgery until appropriate person
signs the consent)

No family:
Courts appoints legal guardian
Blind:
May sign his own consent with 2 witnessess
Other language:
Translator and a 2nd witness

A WITNESS VERIFIES THAT THE CONSENT
WAS SIGNED WITHOUT COERCION AFTER
THE SURGEON EXPLAINED THE DETAILS
OF THE PROCEDURE ( physician, nurse,
facility employee, family members (as
established by policy)

Advance Directive
Provides legal instruction to healthcare
providers about the client’s wishes & are to
be followed.
Encompasses durable power of attorney
and living will

Living will or durable power of attorney as
mandated by The Patient self-
determination act. (USA)

Nutrition
• Assess the surgeon's orders regarding the intake of
food and fluids before surgery and for the
administration of intravenous fluids

• NPO - NO eating, drinking & smoking (nicotine
stimulates gastric secretion) for 8 hours before the
surgical procedure – to decrease risk of aspiration
• Fasting > 8H – possible fluid & electrolyte
imbalance & blood glucose levels

• Emphasize the IMPORTANCE OF ADHERENCE -
failure result in cancellation or increase risk of
aspiration during surgery

Elimination
• If the client is to undergo intestinal or abdominal
surgery, an enema, a laxative, or both may be
prescribed for the night before surgery – to prevent
injury to colon & reduce number of intestinal
bacteria

• The client should void immediately before surgery
• FC is in place, it should be emptied immediately
before surgery & the amount & quality of UO
documented

Surgical Site
• Prepare to clean the surgical site with a mild
antiseptic soap the night before surgery, as
prescribed
• – reduces contamination & no. of organism
@ site

• Hair should be shaved only if it will interfere
with the surgical procedure and only if
prescribed

• Skin prep is the first step in prevention of
surgical wound infection.

Medications
• Note medications client is taking, including herbal
products; some medications (e.g.,
antihypertensives and antidysrhythmics) can
interact with anesthetic agents

• Check with the surgeon regarding administration of
prescribed medications; some medications (e.g.,
cardiac medications) may be administered with a
sip of water

• If the client has diabetes mellitus, check with the
surgeon regarding administration of an oral
hypoglycemic or insulin

Preoperative Teaching
• Reduce apprehension and fear
• Increased cooperation & participation in care
after surgery
• Decrease complications

Client Teaching
• Describe what client should expect after surgery

• Instruct client to notify nurse of pain after surgery
and reassure client that pain medication will be
prescribed, to be given as the client requests

• Instruct client not to smoke for at least 24 hours
before surgery

• Instruct client in deep-breathing and coughing
techniques, the use of incentive spirometry and its
importance

Incentive Spirometer – promote complete lung
expansion & prevent pulmonary problems

Chest Physiotherapy
 Percussion and vibration over the thorax to loosen
secretions in the affected area of the lungs
Contraindications
• When bronchospasm occurs by its use stop the
procedure • Rib fracture
• History of pathological fractures • Chest incisions

LEG AND FOOT EXERCISES
• Instruct client in leg and foot exercises to
prevent venous stasis of blood and
facilitate venous blood return [Figure]

• Splinting
Provide support, promotes a feeling of
security, & reduces pain during coughing

• Coughing
May be performed along with deep
breathing q 1-2H after surgery
To expel secretions, keep lungs clear,
allow full aeration, prevent pneumonia &
atelectasis
“Do Not Cough” – hernia repair

• Inform client of any invasive devices that
may be needed after surgery (e.g.,
nasogastric tube, drain, Foley catheter,
epidural catheter, intravenous or
subclavian line)

• Instruct client not to pull on invasive
devices and reassure client that they will
be removed as soon as possible

• Early Ambulation
Stimulates intestinal motility, enhance lung
expansion, mobilizes secretion, promotes venous
return, prevents joint rigidity, relieves pressure

• ROME – prevent joint rigidity & muscle contracture

Psychosocial Preparation
• Assess client's anxiety level

• Address client's questions and
concerns regarding surgery

• Give client privacy to prepare
psychologically for surgery

Preoperative Checklist
• Review checklist to ensure that each item is
addressed before client is transported to
surgery
• Ensure that client is wearing an identification
bracelet
• Assess client for allergies
• Ensure that prescribed laboratory-test results
and electrocardiography and chest-
radiography reports are documented in the
client's record

• Remove client's jewelry, makeup,
dentures, hairpins, nail polish, glasses,
and prostheses as appropriate

• Document that valuables have been
given to client's family members or
locked in the hospital safe

• Monitor and document client's vital signs

3. Prosthesis or Dentures- should be removed to
prevent obstruction in the airway

2. GIT /Elimination- insertion of indwelling catheter (foley
catheter), administration of cleansing enema- this is to ensure that
neither of the bladder, nor the bowel is distended during surgery
- nutrition/ hydration
-- NPO 8 hours before surgery, but some institution may allow clear
liquids 3-4 hours before
-- IVF infusion may be started to ensure adequate hydration

Pre operative medications
Anticholinergics - Atropine SO4,
Scopolamine Glycopyrrolate
- control secretions
• Antiemetics - Dropiridol, Thorazine
- prevents vomiting
• Tranquilizers- Diazepam, Lorazepam
- decrease anxiety
• - Sedatives- Medazolam, Phenobarbital
- induce sleep and decrease anxiety
• Opioids- Morphine SO4, Meperidine Hcl
- relieve pain, decrease anxiety

• Tell the client that he or she will feel
drowsy shortly after the medications are
administered

• After administering the preoperative
medications, keep the client in bed with
the side rails up and place the call bell
next to the client

• Instruct the client not to get out of bed
and to call for assistance if needed

Transporting the client to the operating
room
• Per stretcher – enough help for safety
• Cover with blanket – protect from drafts
• Place side rails and restraint above knee
• Record accompanies client
• Smooth as possible – sedated- to prevent
nausea vomiting
• Avoid rapid walking or swinging around
corners
• Prepare room for post operative care

Arrival in the Operating Room
• When the client arrives in the operating
room, the operating-room nurse will check
the identification bracelet against the client's
verbal response

• The client's chart will be checked for
completeness and reviewed for informed
consent

• The surgeon's orders will be reviewed to
ensure that they were carried out

INTRAOPERATIVE
PERIOD
begins when the client is transferred to
the operating room bed and ends when
the client is transferred to an area for
recovery from anaesthesia

Key words of OR practiced are:
1. Caring 3. Discipline
2. Conscience 4. Technique
 Optimal client care requires an inherent
surgical conscience, self-discipline & the
application of principles of aseptic & sterile
technique

SURGICAL CONSCIENCE – “Surgical Golden
Rule”
“Do unto the patient as you would have others
do unto you.”

Surgical Conscience
 One’s inner voice for the conscientious
practice of asepsis & sterile technique @
all times.

 Conscience dictates that appropriate
action to be taken, whether the person is
with others or alone & unobserved

 Foundation for the practice of strict aseptic
& sterile technique

ASEPTIC TECHNIQUE

– to maintain asepsis (absence of
microorganism that caused diseased)

STERILE TECHNIQUE
 Method by which contamination which
microorganism is prevented to maintain
sterility throughout the operative procedure.
 Is the responsibility of everyone caring for
the client in the OR.

PRINCIPLES OF STERILE TECHNIQUE ARE
APPLIED:

1. In preparation for operation by sterilization of
necessary materials & supplies
2. In preparation of operating team to handle
sterile supplies & intimately contact wound
3. In maintenance of sterility & asepsis
throughout operative procedure
4. In terminal sterilization & disinfection at
conclusion of operation

PRINCIPLES OF STERILE TECHNIQUE
1. ONLY STERILE ITEMS ARE USED WITHIN
STERILE FIELD
If you are in doubt about the sterility of anything,
consider it not sterile.
c. If sterilized package is found in a nonsterile
workroom.
d. If uncertain about actual timing or operation of
sterilizer. Items processed in a suspect load are
considered unsterile.
e. If unsterile person comes into close contact with a
sterile table & vice versa.

d. If sterile table or unwrapped sterile items are not
under constant observation.

a. If sterile package wrapped in material other than
plastic or moisture-resistant barrier becomes
damp or wet. Humidity in storage area or
moisture on hand may seep into package.
b. If the integrity of the packaging material is not
intact.
c. If sterile package wrapped in a pervious muslin
or other woven material drops to the floor or
other area of questionable cleanliness. These
material allow implosion of air into package. A
dropped package is considered contaminated.

If the wrapper is impervious & the area of contact
is dry, the item may be transferred to the sterile
field. Packages that have been dropped on the
floor should not be put back into sterile storage.

2. GOWNS ARE CONSIDERED STERILE ONLY
INFRONT FROM CHEST TO LEVEL OF
STERILE FIELD & THE SLEEVES FROM
ABOVE ELBOWS TO CUFF

a. Self-gowning & gloving should be done from a sterile
surface for this purpose only to avoid dripping water
onto sterile supplies or sterile field.

b. Stockinet cuffs of gown are enclosed beneath
sterile gloves. Stockinet is absorbent & will retain
moisture, thus this part of gown does not provide
a microbial barrier.
c. Sterile persons keep hands in sight @ all times
& at or above level of waist or sterile field.
d. Hands are kept away from face. Elbows are
kept close to sides. Hands are never folded
under arms because of perspiration in axillary
region. Neckline, shoulders, & back also may
become contaminated with perspiration.

e. Sterile persons are aware of height of team
members in relation to each & the sterile field.
Changing levels @ sterile field is avoided. Gown
is considered sterile only down to highest level
of sterile tables. If a sterile person must stand on
a platform to reach operative field, platform
should be positioned before this person steps up
to draped area. Sterile person should sit only
when entire procedure will be performed @ this
level.

3. TABLES ARE STERILE ONLY AT TABLE
LEVEL
a. Only top of a sterile draped table considered
sterile. Edges & sides of drapes extending below
table level are considered unsterile.
b. Anything falling or extending over table edge, such
as a piece of suture, is unsterile. Scrub person
does not touch part hanging below table level.
c. If unfolding a sterile drape, the part that drops
below table surface is not brought back up to table
level. Once placed, draped is not moved or
shifted.
d. Cords, tubings, etc., are secured on the sterile
field with a non-perforating device to prevent them
from sliding over the table edge.

4. PERSON WHO ARE STERILE TOUCH ONLY
STERILE ITEMS OR AREAS; PERSONS WHO ARE
NOT STERILE TOUCH ONLY UNSTERILE ITEMS

a. Sterile team members maintain contact with sterile
field by means of sterile gowns & gloves.
b. Non-sterile circulating nurse does not directly
contact the sterile field.
c. Supplies are brought to sterile team members by the
circulating nurse who opens the wrappers on sterile
packages. The circulating nurse ensures sterile
transfer to the sterile field. Only sterile items touch
sterile surface.

5. UNSTERILE PERSONS AVOID REACHING OVER A
STERILE FIELD; STERILE PERSONS AVOID LEANING
OVER AN UNSTERILE AREA

a. Unsterile circulating nurse NEVER reaches over a
sterile field to transfers sterile items.
b. In pouring solution into sterile basin, circulating
nurse holds only lip of bottle over basin to avoid
reaching over a sterile area.
c. Scrub person sets basins or glasses to be filled @
edge of the sterile table; circulating nurse stands
near this edge fo the table to fill them.
d. Circulating nurse stands @ a distance from the
sterile field to adjust light over it to avoid microbial
fallout over field.

e. Surgeons turns away from sterile
field to have perspiration removed from
brow.

f. Scrub persons drapes a nonsterile table
towards self first to protect gown. Gloved
hands are protected by cuffing draped
over them
g. Scrub persons stands back from
nonsterile table when draping it to avoid
leaning over an unsterile area.

6. EDGES OF ANYTHING THAT ENCLOSES STERILE
CONTENTS ARE CONSIDERED UNSTERILE

a. In opening sterile packages, a margin of safety
is always maintained. The inside of wrappers is
considered sterile within 1 inch of the edges.
The circulating nurse opens top flap away from
self, then turns the sides under. Ends of flaps
are secured in hand so they do not dangle
loosely. The last flap are secured in pulled
toward person opening package, thereby
exposing package contents away from nonsterile
hand.

b. Sterile person lifts contents away from packages
by reaching down & lifting them straight up, holding
elbows high
c. Steam reaches only area within the gasket of a
sterilizer. Instrument trays should not touch edge of
the sterilizer outside the gasket.
d. Flaps on peel-open packages should be pulled back
not torn, to expose sterile contents. Contents should
be flipped or lifted upward & not permitted to slide
over edges. Inner edge of the heat seal is
considered the line of demarcation between sterile &
unsterile.
e. If a sterile wrapper is used as a table cover, it
should amply cover the entire table surface. Only
the interior & surface level of the cover are
considered sterile.

f. After a sterile bottle is opened, contents must be
used or discarded. Cap can be replaced without
contaminating pouring edges.

7. STERILE FIELD IS CREATED AS
CLOSE AS POSSIBLE TO TIME OF
USE
• Sterile tables are set up just before the operation.
• It is virtually impossible to uncover a table of sterile
contents without contamination. Covering sterile
tables for later use is not recommended.

8. STERILE AREAS ARE CONTINUALLY KEPT
IN VIEW
a. Sterile person face sterile areas.
b. When sterile packs are open in a room, or a
sterile field set up, someone must remain in
the room to maintain vigilance. Sterility cannot
be ensured without direct observation. An
unguarded sterile field should be considered
contaminated.

9. STERILE PERSONS KEEP WELL WITHIN
THE STERILE AREA

a. Sterile persons stand back at a safe distance
from the operating table when draping the client.
b. Sterile persons pass each other back to back at
360° turn.
c. Sterile person turns back to nonsterile person or
area when passing.
d. Sterile person face sterile area to pass it.
e. Sterile person asks nonsterile individual to step
aside rather than risk contamination.
f. Sterile persons stay within the sterile field. They
do not walk around or go outside the room.

g. Movement within & around a sterile areas is
kept to a minimum to avoid contamination of sterile
items or persons.

10. STERILE PERSONS KEEP CONTACT
WITH STERILE AREAS TO A MINIMUM
b. Sterile persons do not lean on sterile tables & on
the draped client.
c. Sitting or leaning against a nonsterile surface is a
break in technique. If the sterile team sits to
operate, they do so without proximity to nonsterile
areas.

11. UNSTERILE PERSON AVOID STERILE
AREAS
a. Unsterile persons maintain a distance of at 1
foot (30 cm) from any area of the sterile field.
b. Unsterile persons face & observe a sterile area
when passing it to be sure they do not touch it.
c. Unsterile persons never walk between two
sterile areas, e.g., between sterile instrument
tables.
d. Circulating nurse restricts to a minimum all
activity near sterile field.

12. DESTRUCTION OF INTEGRITY OF
MICROBIAL BARRIERS RESULTS IN
CONTAMINATION
a. Sterile packages are laid on dry surfaces.
b. If sterile package wrapped in absorbent
material becomes damp or wet, it is resterilized
or discarded. The package is considered
nonsterile if any part of it comes in contact with
moisture.
c. Drapes are placed on a dry field.
d. If solution soaks through sterile drape to
nonsterile area, the wet area is covered with
impervious sterile draped or towels.

e. Packages wrapped in muslin or paper are
permitted to cool after removal from a sterilizer &
before being placed on cold surface to prevent
steam condensation & resultant contamination.
f. Sterile items are stored in clean dry areas.
g. Sterile package are handled with clean dry
hands.
h. Undue pressure on sterile packs is avoided to
prevent forcing sterile are out & pulling unsterile
air into the pack.

13. MICROORGANISM MUST BE KEPT TO
AN IRREDUCIBLE MINIMUM
A. Skin cannot be sterilized. Skin is a potential
source of contamination in every operation.
2. Transient & resident flora are removed from
skin around operative site of client & hands &
arms of sterile team members by mechanical
washing & chemical antisepsis.
3. Gowning & gloving of operating team is
accomplished without contamination of exterior
of gowns & gloves.
4. Sterile gloved hands do not directly touch skin
& then deeper tissues. Instruments uses in
contact with skin are discarded & not reused.

4. If glove is torn or punctured by needle or
instrument, gloved is changes immediately. Needle
or instrument is discarded from sterile field.
5. Sterile dressing should be applied before draped
are removed to reduce risk of the incision being
touched by contaminated hands or objects.
B. Some areas cannot be scrubbed. (Operative
includes mouth, nose throat, or anus in various
parts of the body such as GIT & vagina) to
reduce number of microorganism & prevent them
from scattering:
3. Surgeons makes an effort to use a sponge only
once, then discards it.
• GIT, especially colon, is contaminated. Measure
are used to prevent spreading this contamination.

C. Infected areas are grossly contaminated. The
teams avoids disseminating the contamination.

D. Air is contaminated by dust & droplets
2. Drapes over anesthesia screen or attached to IV
poles separate anesthesia area from sterile field.
3. Talking is kept to minimum in OR. Moisture
droplets expelled with force into mask during
process of articulating words.
4. Movement around sterile field is kept to
minimum to avoid air turbulence.
5. Drapes are not flipped, fanned or shaken to
avoid dispersion of lint & dust.

MEMBERS OF THS SURGICAL TEAM
• SURGEON – is a physician who assumes
responsibility for the surgical procedure &
any surgical judgments about the client
• SURGICAL ASSISTANT – might be
another surgeon (or physician, resident or
intern) or nurse, surgical technologist
• ANESTHESIOLOGIST – is a physician who
specializes in giving anesthetic agents

Anesthesia provider monitors the client
during surgery by assessing & monitoring the
following:

2. The level of anesthesia
3. Cardiopulmonary function & hemodynamic
monitoring
4. Vital signs
5. Intake & Output
*Gives Intravenous fluids, including blood &
blood products

OPERATING ROOM STAFF

A. Circulating Nurse – sets up OR & ensure that
supplies, including blood products & diagnostic
support, are available as needed;
• assists the anesthesia provider with the induction
• 2.“prep” (scrub) the surgical site
• notifies PACU of client’s estimated time of arrival &
any special needs

Throughout the surgery, the circulating
nurse:
1. Monitors traffic around the room
2. Assesses the amount of urine & blood loss
3. Reports findings to the surgeon & anesthesia
provider
4. Ensures that the surgical team maintains sterile
technique & a sterile team
5. Anticipates the client’s & surgical team’s needs,
providing supplies & equipment as needed.
6. Communication information regarding the client’s
status w/ family members during long or unique
procedures
7. Document care, events, interventions & findings

B. Scrub Nurse – sets up sterile field, drapes the
client, & hands sterile instruments to the surgeon
& the assistant place; maintains accurate count of
sponges, sharps, instruments & amount of
irrigation fluid & drugs used
 Knowledge duration of anesthesia
anticipation surgeon’s anxiety & tension

PREPARATION OF THE SURGICAL SUITE &
TEAM SAFETY

A. LAYOUT
 Surgical areas are divided in 3 zones to
ensure proper movement of clients &
personnel:
a. Unrestricted
b. Semirestricted
c. Restricted

STERILIZATION
• PROCESS BY WHICH ALL PATHOGENIC
AND NON PATHOGENIC
MICROORGANISMS INCLUDING SPORES
ARE DESTROYED OR KILLED.

METHODS OF STERILIZATION
THERMAL (PHYSICAL)
• STEAM UNDER PRESSURE
• Hot/Dry air

CHEMICAL
• ETHYLENE OXIDE GAS
• FORMALDEHYE SOLUTION OR GAS
• HYDROGEN PEROXIDE/PLASMA VAPOR
• OZONE GAS
• GLUTARALDEHYDE SOLUTION

RADIATION
• MICROWAVE (NON IONIZING)
• X-RAY (IONIZING)

B. HEALTH & HYGIENE OF THE
SURGICAL TEAM

 Anyone who has open wound, cold or any
infection should not participate in surgery
 Shedding of organisms & skin debris is
greatest immediately after showering – bathe
few hours before changing into OR attire
 Jewelries carries organisms – minimal
 Handwashing
 Routine Culture q 3-6 months
 Surgical attire & surgical scrub help
contamination

C. SURGICAL ATTIRE
 Clean, not sterile
 Worn to reduce contamination from home & areas
outside of the surgical setting.
a. Body cover (shirt & pants)
b. Head cover (cap or hood)
c. Shoe coverings/inside shoes
d. Protective attire: mask, eyewear, glove, gown &
shoe covers
 Change in the locker rooms, not at home

D. SURGICAL SCRUB

 Process of removing as many microorganisms as
possible from the hands & arms by mechanical
washing & chemical antisepsis before participating
in a surgical procedure.

E. GOWNING
 Puts on a sterile gown

F. GLOVING
 Puts on sterile gloves
1. Open gloving technique
2. Closed gloving technique

G. ANESTHESIA

 “Negative Sensation”
 Is an induced state of partial or total loss of
sensation, occurring with or without loss of
consciousness.
PURPOSES:
4. Block nerve impulse transmission
5. Promote muscle relaxation
6. Achieve a controlled level of
unconsciousness

SELECTION OF ANESTHESIA
INFLUENCED BY THE FOLLOWING:
a. Client’s health problem – major factor
b. Type & duration of the procedure
c. Area of the body having surgery
d. Safety issues to reduce injury – airway mgt.
e. Whether the procedure is an emergency
f. Options for management of pain after surgery
g. How long it has been since the client ate, had
any liquid, or any drugs
h. Client’s position needed for the surgical
procedure

TYPES OF ANESTHESIA
1. GENERAL ANESTHESIA
 Depresses CNS resulting:
♠ amnesia ♠ unconsciousness
♠ analgesia ♠ loss of muscle tone & reflexes

6. LOCAL ANESTHESIA OR REGIONAL
 Disrupts sensory nerve impulse transmission from
a specific area or region

STAGES OF GENERAL ANESTHESIA

STAGE I – STAGE OF INDUCTION
 From the beginning of administration of
drugs/gas to loss of consciousness
 Client appear drowsy & dizzy
Nursing Action:
 Close OR doors & keep room quiet
 Standby the client & assist if necessary

STAGE II – STAGE OF EXCITEMENT

 From loss of consciousness to relaxation
 Client appear excited, breathing is irregular
 Client moves extremities or body
 Client very sensitive to external stimuli
NURSING ACTION:
 Restrain client if needed
 Remain at client’s side
 Be quiet & alert
 Assist anesthesiologist if needed

STAGE III – SURGICAL ANESTHESIA &
RELAXATION

 Loss of reflexes
 Depression of vital functions
 Respiration – regular, pupils contracted
 Eyelids reflexes disappear
 Loss of auditory senses
NURSING ACTION:
 Begin final prep – client is under control

STAGE IV – DANGER STAGE

 Vital functions are to depressed
 Respiratory failure & possible cardiac arrest
 Not breathing, little or no pulse & heartbeat
NURSING ACTION:
 Be ready to resuscitate

ADMINISTRATION OF GENERAL
ANESTHESIA
1. INHALATION
 Inhales anesthetic gas or vapor through
a mask, endotracheal or nasotracheal
c. GASEOUS AGENTS – Nitrous oxide
d. VOLATILE AGENTS – Liquid agent
vaporized for inhalation
 cause shivering after surgery – effect on
hypothalamus

2. INTRAVENOUS INJECTION
a. BARBITURATES – mild sedation to deep loss of
consciousness.

c. KETAMINE (KETALAR) – dissociative anesthetic
agent (one that promote a feeling of separation or
dissociation from the env’t.)
 Emergence reaction during recovery –
combative or restless

d. PROPOFOL (DIPRIVAN) – short actin; hypnosis
occur less than 1 minute & responsive within 8
minutes after infusion ends

3. ADJUNCTS TO GENERAL ANESTHESIA

a. HYPNOTICS – Midazolam or Diazepam
(Benzodiazepines)
 Hypnotic, sedative, muscle relaxant & amnesic
effect
 May be used as part of IV conscious sedation

b. OPIOID ANALGESICS – used during surgery
helps provide pain relief after surgery
 MSO4, Demerol, Sublimaze
 All opioids depressed respiration

c. NEUROMUSCULAR BLOCKING AGENTS
 Used to relax the jaw & vocal cords
immediately after induction so that the ET
can be placed.
 May be used during surgery to provide
continued muscle relaxation
 Tracium, Anectine

4. COMPLICATIONS OF INTUBATIONS

– broken or injured teeth, swollen lip, vocal
cord trauma
 Difficult intubation – small oral cavity, tight
jaw joint, present of tumor
 Improper neck extension during intubation –
may cause injury
ET PLACEMENT – tracheal irritation & edema,
sore throat

REGIONAL ANESTHESIA
 Produces a loss of painful sensation in only
one region of the body & does not result in
unconsciousness

1. TOPICAL ANESTHESIA – directly applied onto
the area to be disensitized

2. LOCAL INFILTRATION ANESTHESIA –
injection of an anesthetic agent into the skin &
SQ tissue of the area to be anesthetized.

3. NERVE BLOCK
– injection of the local anesthetic agent into or
around a nerve or group of nerves in the
involved area.
 Disrupts motor & sensory impulse transmission
 If injected bloodstream seizure, cardiac &
respiratory depression, dysrhythmias

NERVE BLOCK
 Radial, Medial & Ulnar nerve (elbow, wrist,
hands, & fingers)
 Intercostal nerves (chest & abdominal wall)
 Brachial plexus (upper arm)
 Cervical plexus (betweem jaw & clavicle)

4. SPINAL ANESTHESIA – injecting an anesthetic
agent into the CSF on the subarachnoid space
 Lower abdominal & pelvic surgery

6. EPIDURAL ANESTHESIA -Anesthetic agent
injected into the epidural space & spinal cord
areas are never entered

COMPLICATIONS OF REGIONAL
ANESTHESIA:

3. Sensitivity to anesthetic agent
4. Overdosage
5. Systemic absorption
6. Cardiac arrest (rare – spinal)
7. Edema & inflammation (local)
8. Abscess formation – contamination during injection
9. Necrosis & gangrene (rare - prolonged blood vessel
constriction injected area)

NURSE’S ROLE IN THE DELIVERY OF
ANESTHESIA:
1. Assisting the anesthesia provider
2. Observing for breaks in the sterile technique
3. Providing emotional support for the client
4. Staying with the client
5. Offering information & reassurance
6. Positioning the client comfortable & safely

POSITIONING
PUTTING CIENT IN PROPER BODY
ALIGNMENT TO EXPOSE THE OPERATIVE SITE
OR AREA.

• QUALIFICATION OF A GOOD POSITION:
1. free respiration
2. Free circulation
3. No pressure on nerve
4. hand or feet properly supported
5. No undue postoperative discomfort
6. accessible operative site

Supine position/dorsal
- laparotomy, appendectomy

Reverse modified trendelenburg position
- face and neck surgery

Modified fowler’s position
for neurosurgery

Prone position
- surgery on the posterior part of the body
- laminectomy

Lithotomy position
- perineal approach
- cystoscopy, vaginal hysterectomy

Lateral position
- kidney, lungs or hip

Jacknife position
- rectal surgery

SUTURES
 Any strand of materials used for ligating or
approximating tissue, bringing tissues together &
holding them until healing takes place.

1. ABSORBABLE
• Surgical gut – is collagen derived from
submucosa of sheep intestine or serosa of beef
intestine.
• Collagen sutures – extended from a homogenous
dispersion of pure collagen from the flexor
tendons of beefs (opthalmic surgery)
• Synthetic Absorbable Polymers – Polydiaxanone
suture (PDS), monocryl. Maxon, vicryl, dexon

2. NONABSORBABLE

♥Silk ♥Cotton ♥Steel ♥Synthetic nonabsorbable
polymers – nylon, prolene, novafil
TENSILE STRENGTH
 Amount of weight or pull necessary to break
suture material.
LIGATURE OR TIE
 Material is tied around a blood vessel to occlude
the lumen
SUTURE LIGATURE/STICK TIE
 A suture attached to a needle for a single stitch
for hemostasis.
TIE ON A PASSER
 A tie handled to the surgeon in the tip of a forcep

5 LAYERS OF THE ABDOMEN
1. skin
2. subcutaneous
3. fascia
4. muscle
5. peritoneum

DRAPING
Procedure of covering the client & surrounding
areas with a sterile barrier to create & maintain
an adequate sterile field.

Sternal split, oblique subcostal, upper vertical
midline , thoracoabdominal, McBurney, lower
vertical midline, pfannensteil

Scrubbing, Gowning and Gloving

SURGICAL
HAND SCRUBBING
• IS THE PROCESS OF REMOVING AS
MANY MICROORGANISMS AS
POSSIBLE FROM THE HANDS AND
ARMS BY MECHANICAL WASHING
AND CHEMICAL DISINFECTION
BEFORE PARTICIPATING IN A
SURGICAL PROCEDURE.

MECHANICAL – PROCESS OF
REMOVING DIRT, SOIL AND
TRANSIENT ORGANISM BY
FRICTION
• CHEMICAL – PROCESS REDUCES
RESIDENT FLORAE AND
INACTIVATES MICROORGANISMS
WITH AN ANTIMICROBIAL OR
ANTISEPTIC AGENT

TYPES OF ANTIMICROBIAL
SKIN-CLEANSING AGENTS
• CHLORHEXIDINE GLUTANATE
• IODOHORS
• TRICLOSAN
• ALCOHOL
• HEXACHLOROPHENE
• PARACHLOROMETAXYLENOL

GOWNING – DONNING OF
STERILE GOWN
• GLOVING – WEARING OF STERILE
GLOVES TO COMPLETE THE ATTIRE.

CLOSED/ OPEN TECHNIQUE

GOWNS ANS GLOVES ARE WORN TO
EXCLUDE SKIN FROM POSSIBLE
CONTAMINATION AND TO CREATE A
BARRIER BETWEEN THE STERILE AND
UNSTERILE AREA

Surgical instruments are designed to provide
the
tools the surgeon needs for each maneuver

• Whether they are small or large, short or long,
straight or curved or sharp or blunt, all
instruments
can be classified by their function.

• All instruments should be used only for their

SURGICAL INSTRUMENTATION

CUTTING & DISSECTING

Basic instruments are essential to accomplish most types of
general surgery.
Each instrument can be placed into one of the four following
basic categories:
Cutting and Dissecting
Clamping and Occluding
Grasping and Holding
Retracting and Exposing

 MEASURING
 Ruler, depth gauges, caliper
 ACCESSORY INSTRUMENTS
 Mallet, screw drivers, hudson brace
 MICROINSTRUMENTATION
 Powered surgical instruments – saw, drill,
dermatone

SPONGES
Are used for absorbing blood & fluids,
protecting tissues, applying pressure or
traction, & dissecting tissues.
Gauze sponges, lap packs, peanuts, tonsil
balls, cottonoids, cherries

SPONGE, SHARPS, & INSTRUMENT
COUNTS
ACCOUNTABILITY
 Is a professional responsibility that rests primarily
on the scrub nurse & the circulator.
COUNTING PROCEDURES
 Is a method of accounting for items put on the
sterile table for use during the surgical procedure.
 Counts are performed for client & personnel safety,
infection control, & inventory purposes.

1. BASELINE COUNT DURING SET- UP FOR
THE SURGICAL PROCEDURE

 Count all item before the surgical procedure
begins & during the surgical procedure as each
additional package is opened & added to the
sterile field.
2. CLOSING COUNT (FIRST CLOSING COUNT)
 Counts are taken before the surgeon starts the
closure of a body cavity or a deep or large
incision. Field count table floor
3. FINAL COUNT (SECOND CLOSING COUNT)
 Performed before any part of a cavity or a cavity
within a cavity is closed.

WOUND CLOSURE
• Continuous suture (running stitch) – peritoneum
& vessels because it provides leak proofs
suture line.
• Interrupted suture – each stitch is taken & tied
separately.
• Buried suture – suture is placed under the skin,
buried either continuous or interrupted.
• Purse-string method – a continuous suture is
placed around a lumen & tightened, drawing
fashion, to close the lumen.
• Subcuticular suture – a continuous suture is
placed beneath epithelial layers of skin I short
lateral stitches

B. DRAINS – is placed in a separate small incision
parallel to the operative incisions to drain blood &
serum from the operative site.

MONITORING
BODY TEMPERATURE
 OR standard cool level – inhibit bacterial growth
& allow optimal performance of surgical team

 keep client warm w/o causing vasodilation
(more bleeding) – warm blankets,
booties/socks, warmed IV solution

CARDIAC & RESPIRATORY ARREST
 No need for code blue
 Surgeon talk to family in case of death

ALLERGIC REACTION
 Ideally not occur if adequate history taken
 Some do not recall an allergy - Identify allergy only
if occurrence of 2nd allergic reaction to triggering
agent during surgery (e.g., latex)
DOCUMENT INTRAOPERATIVE CARE

MOVING & TRANSPORTING THE
CLIENT
 Clean the client
 Avoid rapid movement when changing position –
develop hypotension
 During emergency (revival) from anesthesia,
client prone to: nausea, confusion, hypotension
 Check tubes
 Modesty maintained
 SAFETY: warm blankets, body straps, side rails
up
 Notify family of client status

POSTOPERATIVE
PERIOD

BEGINS WITH THE ADMISSION OF THE
CLIENT TO THE POSTANESTHESIA AREA
AND ENDS WHEN HEALING IS COMPLETE

Stages of Recovery
• Immediate postoperative stage The
period 1 to 4 hours after surgery.
• Intermediate postoperative stage The
period 4 to 24 hours after surgery.
• Extended postoperative stage The
period at least 1 to 4 days after surgery.

POST-ANESTHESIA NURSING

GOAL: to assist uncomplicated return
to safe physiologic function after an
anesthetic procedure by providing
safe, knowledgeable, individualized
nursing care for clients & their family
members in the immediate post-
anesthesia phase.

UPON RECEIVING:
1. AIRWAY PATENCY/POSITION
SAFELY/STABLE
Unconscious adult – extend neck & thrust jaw
forward
Preferred position – (lateral sim’s position)
sidelying allows the client’s tongue to fall
forward & mucous or vomitus to drain from the
mouth.
2. ENDORSEMENT – verbal detailed report of
events from OR.

IMMEDIATE ASSESSMENT IN
PACU

AIRWAY – tubes/ respiratory assistive device
BREATHING – RR & depth, breath sounds, stay
beside til gag reflex returns
CIRCULATION – PR, BP, skin color, ECG,
O2Sat, dressing, wound status
OTHERS – LOC, muscle strength, ability to
follow command, IV, drains, tubes, inspect skin
(burns, bruises, temperature)

POSTOPERATIVE NURSING CARE

ASSESSMENT
1. ASSESS RESPIRATORY STATUS
Patent airway ♠ HYPOXIA
2. ASSESS CIRCULATION
• V/S, skin, color, temperature
• Weakness, numbness, pressure ulcers
• Early ambulation – leg exercise if not tolerated
3. ASSESS NEUROLOGIC STATUS
LOC, orientation, lingering effects of anesthesia

4. MONITOR WOUND

a. Assess dressing amount & charac. Drainage,
wound appearance
b. Measure drainage – drains, ostomy bag
c. Wound dressing
 DEHISCENCE & EVISCERATION
5. MONITOR IV LINES
Check IV lines – patency, I & O,
Infiltration – mild heat to decreased local pain

6. MONITOR DRAINAGE TUBES
• Drainage tube to suction/gravity drain
• Note amt, color, consistency of drainage
NGT – decompression, removal of intestinal
secretion, promote GI rest, allow GIT to heal,
monitor GI bleeding, prevent intestinal
obstruction
Until peristalsis begin – may remove w/ order
Bowel sounds NGT clamp & removed

Passage of flattus if tolerated w/o N/V
hunger

7. PROMOTE COMFORT
• Pain meds
Oral – reassess after 30 minutes
IV – reassess after 5-10 minutes
8. REDUCE NAUSEA & VOMITING
Vomiting – is a reflex stimulated
♥CTZ (chemoreceptor trigger zone) ♥ ICP
♥GIT distention or irritation
♥Pain
♥vagal stimulation ♥centers in cerebrum
♥disequilibrium -vestibular labyrinth ear

Atelectasis and Pneumonia
• Collapse of the alveoli with retained mucous
secretions
• The most common postoperative complication;
usually occurs 1 to 2 days after surgery

Assessment
• Dyspnea, increased respiratory rate, productive
cough, chest pain
• Crackles over involved lung area
• Increased temperature

Interventions
• Reposition client every 1 to 2 hours;
encourage deep breathing, coughing, and
use of the incentive spirometer
• Encourage fluid intake
• Encourage early ambulation
• Perform suctioning to clear secretions if
client is unable to cough

Hypoxia
• An inadequate concentration of oxygen in
arterial blood

Assessment
• Restlessness
• Dyspnea
• Diaphoresis
• Cyanosis

Interventions
• Monitor client for signs of hypoxia
• Eliminate cause of hypoxia
• Monitor lung sounds and pulse oximetry
• Administer oxygen as prescribed

Pulmonary Embolism
• An embolus blocking the pulmonary artery
and disrupting blood flow to one or more
lobes of the lung

Assessment
• Dyspnea
• Sudden, sharp chest or upper-abdominal
pain
• Cyanosis
• Tachycardia and tachypnea
• Anxiety

Interventions
• Notify surgeon immediately
• Monitor vital signs
• Administer oxygen and medications as
prescribed

Hemorrhagic and Shock
• Loss of circulatory fluid volume as a result of
losing a large amount of blood externally or
internally in a short period

Assessment
• Restlessness
• Weak, rapid pulse
• Hypotension
• Tachypnea
• Cool, clammy skin
• Reduced urine output

Interventions
• Put pressure on site of bleeding & elevate legs
• If client has had spinal anesthesia, do not elevate
legs any higher than placing them on the pillow;
otherwise the diaphragm muscles could be
impaired

• Adm. intravenous fluids , oxygen & blood as
prescribed
• Monitor LOC, vital signs, and intake & output
• Prepare client for surgery, if necessary

Thrombophlebitis
• Inflammation of a vein (most commonly in the
leg), often accompanied by clot formation

Assessment
• Vein inflammation
• Aching or cramping pain
• Vein feels hard and cordlike and is tender to
touch
• Increased temperature
• Homans' sign

Interventions
• Prevention measures include ROME every 2H if
the client is restricted to bed rest & early
ambulation as prescribed; instruct client not to sit
in one position for an extended period
• Monitor legs for swelling, inflammation, pain,
tenderness, venous distention, & cyanosis
• Elevate leg 30° w/o placing any pressure on
popliteal area
• Maintain an intermittent pulsatile compression
device or use antiembolism stockings, as
prescribed
• Administer heparin sodium or warfarin sodium
(Coumadin), as prescribed

Urine Retention
• Caused by anesthetics & narcotic analgesics
• Usually appears 6 to 8 hours after surgery
Assessment
• Inability to void
• Restlessness and diaphoresis
• Lower-abdominal pain & a distended bladder
• On percussion, bladder sounds like a drum

Interventions
• Monitor client for voiding and assess for
distended bladder
• Encourage fluid intake, unless contraindicated
• Assist client in voiding by helping him or her
stand; provide privacy
• Pour warm water over the perineum or allow the
client to hear running water to promote voiding
• Catheterize client as prescribed after all
noninvasive techniques have been attempted

Paralytic Ileus
Description
• Failure of bowel contents to move along
appropriately
• May occur as a result of anesthetic
medications or manipulation of the bowel
during surgery
Assessment
• Nausea & vomiting immediately after surgery
• Abdominal distention
• Absence of bowel sounds, bowel movement,
or flatus

Interventions
• First treated nonsurgically by means of bowel
decompression through the insertion of a
nasogastric tube attached to intermittent-to-
constant suction

• Keep client from eating or drinking until bowel
sounds return; administer intravenous fluids as
prescribed

• Encourage walking

• Administer medications, as prescribed, to
increase gastrointestinal motility and secretions

Constipation
Description
• When client resumes a solid diet after
surgery, failure to pass stool within 48
hours is a cause for concern

Assessment
• Abdominal distention
• Absence of bowel movements
• Anorexia, headache, and nausea

Interventions
• Encourage fluid intake up to 3000 mL/ day, unless
contraindicated

• Encourage early ambulation

• Encourage consumption of fiber-rich foods, unless
contraindicated

• Administer stool softeners and laxatives as
prescribed

• Provide privacy and adequate time for elimination

Wound Infection
Description
• Wound becomes contaminated with a
microorganism

Assessment
• Fever and chills
• Warm, tender, painful, inflamed incision site
• Edematous skin at incision and tight skin sutures
• Increased white blood cell count

Interventions
• Monitor client’s temperature
• Monitor incision site for approximation of suture
line, edema, or bleeding, signs of infection
• Maintain patency of drains and assess drainage
amount, color, and consistency
• Change dressing as prescribed; maintain
asepsis
• Administer antibiotics as prescribed

Wound Dehiscence
Description
• Separation of the wound
edges at the suture line
Assessment
• Increased drainage
• Opened wound edges
• Appearance of
underlying tissues
through the wound

Interventions
• Place the client in low Fowler's position with the
knees bent to prevent abdominal tension on an
abdominal suture line


• Cover wound with a sterile normal saline
dressing

EVISCERATION
• Abdominal wound becomes infected &
abdominal incision opens, the fascia or internal
organs may be visible.
• Preceded gush of serosanguinous drainage

Interventions
• cover wound sterile NS dressing
• Monitor V/S
• Keep client as calm as possible
• Notify surgeon

Criteria for Client Discharge
• Client is alert and oriented
• Client has voided
• Client has no respiratory distress
• Client can walk, swallow, and cough
• Client tolerates a small amount of fluid and food
• Pain is minimal
• Client is not vomiting
• Bleeding from incision site, if any, is minimal
• A responsible adult is available to drive the client
home
• The surgeon has signed a release form

Discharge Teaching
• Should be performed before date of scheduled
procedure
• Provide written instructions to client and family
regarding specifics of care
• Instruct client & family about possible
postoperative complications
• Provide appropriate resources for home-care
support
• Instruct client to call surgeon, ambulatory center,
or emergency department if postoperative
problems occur
• Instruct client to keep follow-up appointments
with surgeon

• Demonstrate care of incision & how to change
dressing , provide extra dressings for home use

• Instruct client on importance of returning to
surgeon's office for follow-up

• Instruct client that sutures are usually removed
in surgeon's office 7 to 10 days after surgery

• Inform client that staples are removed 7-14 days
after surgery & that skin may become slightly
reddened when they are ready to be removed

• Instruct client on use of medications: purpose,
doses, administration, side effects

• Instruct client on diet and remind him or her to
drink six to eight glasses of liquid a day
•
• Instruct client on activity levels; tell him or her to
resume normal activities gradually

• Instruct client to avoid lifting for 6 weeks (or as
prescribed by the surgeon) if a major surgical
procedure has been performed

• Instruct client with an abdominal incision not
to lift anything weighing 10 pounds or more
(or as prescribed by surgeon)

• Instruct client on signs and symptoms of
complications and when to call surgeon

Generally client can return to work in 6 to 8
weeks, as prescribed by surgeon

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