PRE-OP CHECKLIST DAY OF SURGERY

 Preoperative education completed

 NPO bowel prep
 Skin prep shower or bath in antimicrobial soap
 Documentation or checklist of valuables voided prior to transfer
 Pre op meds given and charted
 Side rails up after pre op bed in low position
 Hospital gown
 Allergy band
 Id band
 Dentures, eyeglasses, hearing aids, contacts left in place or removed
 Make up and nail polish removed
 Vital signs before transfer
 Preop lab work on chart surgeon notified of abnormal values
 Medications
 History
 MAR on chart
 EHR/EMR up to date
 High alert meds noted

PATIENT INFORMATION
1. Patient name and age
2. Medical history
3. Allergy status
4. Name of procedure
5. Current status of patient
ANESTHETIC INFORMATION
6. Type of anesthesia
7. Intra operative anesthetic course and any complications
8. Anticipated post operative problems especially bleeding pain and airway problems
9. Monitoring and range for physiological parameters e.g. BP, urine output
10. Analgesia plan
11. Plan for Iv fluids
12. Post op investigations
13. Contact number of person in case of anesthetic problems
SURGICAL INFORMATION
14. Intra operative surgical course and any complications
15. Blood loss
16. Antibiotic plan
17. Medication plans drugs to be restarted
18. DVT prophylaxis
19. Plan for tubes and drains
20. NG and feeding plan
21. Post op investigations
22. Contact number for any surgical problems
ALDERETE SCORING
A score of eight required for transfer from PACU

Activity
2 points - moves all extremities
1 point - moves two extremities
0 points - unable to move extremities

Respirations
2 points - coughs and breeds deeply
1 point – shallow breathing, dyspneic or limited breathing
0 points – apneic

Circulation
2 points - bp +/- 20 mmhg of pre-op level
1 point - bp +/- 20-50 mmhg of pre-op level
0 points - bp +/- 50 mmhg of pre-op level

Consciousness
2 points - fully awake
1 point - arousable to voice
0 points - not responsive

O2 saturation
2 points - spo2 > 92% on room air
1 point - supplemental oxygen required to maintain > 90%
0 points - spo2 < 90% with supplementation
 Patient Identification
PREOPERATIVE MANAGEMENT UR No.
Name
Date / / Admission Ward Post Op Ward
Dosa Observation
Weight Height Temp Bp Pulse Resp O2 Sat

Allergies ________________________________________ special orders: _________________________________________

_______________________________________________ _____________________________________________________
Additional precautions required: No ☐ Yes ☐ _____________________________________________________
If yes specify: ____________________________________ _____________________________________________________
Legend: /: yes X: no N/A: not applicable
Ward Theatre PACU Ward Theatre PACU
Fasting from: food N/A Consent Form N/A
Fluids N/A History/progress notes
Identification band ID labels (20 minimum)
Correct theatre attire medication chart N/A
Pre-op shower/shave N/A Premedication: ordered N/A
Attended to : given
Dentures: with patient Group & hold/X-match
Jewellery removed/taped BSL
Make-up/nail polish removed N/A X rays
Spectacles/ contact lenses/ Pathology results
prosthesis removed. attached
Hearing aid: with patient Extras taken to theater
List extras taken to theatre:

Signatures: Ward Theatre: PACU:

Have you had a blood transfusion or become pregnant since your PAC visit? Yes ☐ No ☐
if yes please contact anesthetist
Pre Operative Management
Please note:
 Drug and intravenous therapy orders must be written on the inpatient medication record IP12
 Other pre operative orders:
____________________________________________________________________________________________________
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PERFORM SAFETY CHECK
Before lifting the patient, perform safety check:
 Examine all hooks and fasteners to ensure they will not unhook during use
 Double check position and stability of straps and other equipment before lifting patient
 Ensure clips, latches, and bars are securely fastened and structurally sound.
 For electric lifts, make sure batteries are always charged.

PREPARE EQUIPMENT
Do not use lift to transport patient unless lift is specifically designed for transport.
 Ensure battery is charged for transfer.
 Task lift controls before bringing lift to patient.
Make sure the emergency release feature works.
 In short receiving surface is stable and locked.
 In short slings, hooks, chains, straps and supports are available, appropriate and correct
sized.
 Check lift and sling weight limits. In short patient’s weight does not exceed the limits.
 Examine sling and attachment areas for tears, holes and frayed seams.
DO NOT use sling with any signs of wear.
Review of emotional health _______________________________________
a. Surgery is psychologically stressful _______________________________________
b. Nurse should assess the client's feelings _______________________________________
about the surgery, self-concept, body _______________________________________
image and coping resources -> To _______________________________________
understand the impact of surgery on a _______________________________________
client’s and family's emotional health. _______________________________________
c. Explain that it is normal to have fears _______________________________________
and concerns. _______________________________________
d. Clients ability to share feelings partially _______________________________________
depends on the nurses willingness to _______________________________________
listen. The nurse should be supportive _______________________________________
and clarify misconceptions. _______________________________________
e. Client feels powerless or loss of control _______________________________________
-> attempt to determine the reason; _______________________________________
Azure client of his/her right to ask _______________________________________
questions and seek information. _______________________________________
f. Assess manifestations of anger and _______________________________________
anxiety. _______________________________________
Self-concept _______________________________________
a. assess and identify personal strengths _______________________________________
and weaknesses. _______________________________________
b. Poor self-concept hinders ability to _______________________________________
adapt to the stress of surgery and _______________________________________
aggravates feelings of guilt or _______________________________________
inadequacy. _______________________________________
body image _______________________________________
a. response is determined by culture, self- _______________________________________
concept, degree of self-steam. _______________________________________
b. Nurses should encourage expression of _______________________________________
concerns about sexuality. _______________________________________
Coping resources _______________________________________
a. yeah nurses must be aware of the _______________________________________
responses; Assist in stress _______________________________________
management; determined behaviors _______________________________________
that help resolve any tension and/or _______________________________________
nervousness; and identify every sources _______________________________________
of support. _______________________________________
Culture _______________________________________
a. culture refers stem of beliefs that have _______________________________________
been developed overtime and _______________________________________
subsequently been passed on through _______________________________________
many generations. The nurse should _______________________________________
acquire knowledge regarding a client's _______________________________________
cultural and ethnic heritage. _______________________________________
client expectations _______________________________________
a. assess expectations. _______________________________________
b. Nurse should provide accurate _______________________________________
 information and clarify misconceptions. _______________________________________
_______________________________________
_______________________________________
Physical assessment key points _______________________________________
- Pre-operative vital signs -> to establish _______________________________________
big slide with which to compare _______________________________________
alteration that occurs during and after _______________________________________
surgery. _______________________________________
- Elevated temperature: A cause of _______________________________________
concern -> if the client has underlying _______________________________________
infection, the surgeon may choose to _______________________________________
postpone the surgery until infection has _______________________________________
been treated. _______________________________________
- Elevated temperature also increases _______________________________________
the risk of fluid and electrolyte _______________________________________
imbalance.

MEDICATION HISTORY
No Effects during surgery
Antibiotics Antibiotics potentiate action of anesthetic
agents. If taken within two weeks prior to
surgery, aminoglycosides (gentamicin,
tobramycin, neomycin) may cause mild
respiratory depression from depressed
neuromuscular transmission.
Anti dysrhythmias Anti dis rhythmics can reduce cardiac
contractility and impair cardiac conduction
during anesthesia.
Anticoagulants Anticoagulants alter normal clotting factors and
thus increased risk of hemorrhaging. They
should be discontinued at least 48 hours prior
to surgery. Aspirin is a commonly used
medication that can alter clotting mechanisms.
Anticonvulsants Long term use of certain anticonvulsants such
as dilantin and phenobarbital can alter
metabolism of anesthetic agents.
Anti hypertensives Anti hypertensive agents interact with
anesthetic agents to cause bradycardia,
hypertension and impaired circulation. They
inhibit synthesis and storage of norepinephrine
in sympathetic nerve endings.
Corticosteroids With bra long use, corticosteroids cause
adrenal hypertrophy, which reduces the body's
ability to withstand stress. Before and during
surgery, dosages may be temporarily increased.
Insulin Diabetic clients need for insulin after surgery is
altered. Stress response and Ivy administration
of glucose solutions can increase dosage
requirements after surgery. Decrease
nutritional intake and decrease dosage
 requirements.
Diuretics Diuretics potentiate electrolyte imbalances
particularly potassium after surgery.
NSAIDS Nsaids Inhibit platelet aggregation and may
prolong bleeding time, increasing susceptibility
to post operative bleeding.
Herbal therapies: ginger, gingko, ginseng The herbal therapies have the ability to affect
platelet activity and increase susceptibility to
postoperative bleeding. Ginseng may increase
hypoglycemia with insulin therapy.

Allergies
a. allergies need to be delineated from unpleasant side effects.
b. Latex allergy -> provide a latex-free environment.
Smoking habits
a. smokers have increased amount and thickness of mucus secretions.
b. GA increases airway irritation and stimulates pulmonary secretions which are then retained
as a result of reduction in ciliary activity during anesthesia -> ineffective airway clearance.
c. nurse should emphasize on the importance of post-operative deep breathing and coughing.
Family support
a. It is best to have the client identify his or her source of support.
b. Family presence should be encouraged.
c. Family members can become the clients coach, offering valuable support during the post
operative. When the client's participation is vital.

ASSESSMENT
Medical Conditions That Increase The Risk Of Surgery
Type of condition Reason for risk
Bleeding disorders Increases risks 4 hemorrhaging during and after
(thrombocytopenia, hemophilia) surgery
Diabetes mellitus Increase ascept ability to infection and may
impair wound healing from altered glucose
metabolism and associated circulatory
impairment. Stress off surgery may cause
increases in blood glucose levels.
Heart disease (recent MI, dysrhythmias, CHF) Stress of surgery increases demands on
and peripheral vascular disease myocardial to maintain cardiac output. General
anesthetic agents depressed cardiac functions.
Obstructive sleep apnea Administration of opioids increases the risks of
airway obstruction post operatively. Clients
with desaturated revealed by drop in O2
saturation by pulse oximetry.
Upper respiratory infection Increases risk of respiratory complications
during anesthesia for example pneumonia and
spasms of laryngeal muscles.
Liver disease Alters metabolism and elimination of drugs
administered during surgery and impairs
wound healing and glopping time because of
alterations in protein metabolism.
Fever Predisposes client to fluid and electrolyte
 imbalances and may indicate underlying
infection.

Chronic respiratory disease Reduces clients means the compensate for acid
(emphysema, bronchitis, asthma) base alterations.
These reduce respiratory function, increasing
risk for severe hypoventilation.
Immunological disorders (leukemia, AIDS, bone Increased risk of infection and delayed wound
marrow depression, and use of healing after surgery.
chemotherapeutic drugs or
immunosuppressive agents)
Drug abuse Person abusing drugs may have underlying
disease (HIV/hepatitis) which all affect healing.
Chronic pain Regular use of pain medication may result in
higher tolerance.
Increase doses of analgesics may be acquired
to achieve postoperative pain control.

Assessment considerations for clients undergoing surgery

Age
a. Very young and old clients are at risk during surgery -> in mature or declining physiological
status.
b. Infant: normal body temperature must be maintained.
c. Shivering reflex is underdeveloped.
d. Anesthesia adds to the risk of hypothermia -> anesthetics can cause vasodilation and heat
loss.
Nutritional status
a. Post-operative clients require at least 1500 kcal/day two maintain energy reserves.

B. Increase in CHON, Vitamin A and C and zinc to facilitate healing.

C. Malnourished clients are more prone to poor tolerance to Anesthesia, negative nitrogen balance,
delayed blood clotting mechanism, infection, poor wound healing, and a potential for multiple organ
failure.

Obesity bariatrics

A. Increase surgical risk>Reduces ventilatory and cardiac function> HTN, DM, CHF Or common
bariatrics.

B. Postoperative complications Embolus, atelectasis, pneumonia.

C. Susceptible to poor wound healing >Because of the structure of fatty tissues which contain a poor
blood supply slow delivery of essential nutrients, antibodies and enzymes needed for wound healing.

D. Often difficult to close surgical wound>Because of the thick adipose layer.

E. At risk for dehiscence(Opening of the suture line).

Immunocompetence
 A. Cancer patient surgeon waits for four to six weeks(ideally) after completion of the radiation
treatment before performing surgery>Chemotherapy agent Immunosuppressive
medications, etc, increase the risk for infection.

Fluid and electrolyte imbalances

A. The body responds to surgery as a form of trauma.

B. Adrenal cortical stress response sodium and water retention and potassium is lost within the first
three to five days post operatively.

Pregnancy

A. Surgery is performed on pregnant clients only on emergency or urgent basis.

B. General anesthesia is administered with caution> General anesthesia increases the risk for fatal
death and preterm labor.

Previous surgery

A. Client’s past experience with surgery can influence physical and physiological responses to
procedure.

Perception and understanding of surgery

A. Ethical dilemma. The client is misinformed about unaware of the reason for surgery

B. Nurse should confer with the physician if the client has an inaccurate perception or knowledge of
the surgical procedure before the client is sent to delivery room.

C. Determine whether the physician explained routine preoperative and post operative procedure.

1.Assessment

Medical condition that increase the risk for surgery

Types of condition Reason for risk

breast feeding disorders (thrombocytopenia, increase risk of hemorrhaging during the and
hemophilia) after surgery.

diabetes mellitus Increases susceptibility to infection and may

impair wound healing from altered glucose
metabolism and associated circulatory
impairment. Stress of surgery may cause
 increases in blood glucose level.
heart disease (recent myocardial infarction this Stress of surgery increases demands on the
Christmas, congestive heart failure) and myocardium to maintain cardiac output.
peripheral vascular disease General anesthetic agent depressed cardiac
functions
obstructive sleep apnea Administration of opioid increases the risk of
airway obstruction postoperatively. Clients will
this saturate as revealed by drop in oxygen
saturation by pulse oximetry.
upper respiratory infection Increases risk of respiratory complications
during anesthetics (example pneumonia and
spasms of the rolling JL muscles).
liver disease Alters metabolism and elimination of drugs
administered during surgery and impairs
wound healing and clotting time because of
alterations in protein metabolism.
fever Predisposes clients to fluid and electrolyte
imbalances and may indicate underlying
infection.
chronic exploratory disease (infima, bronchitis, Reduces clients means to compensate for acid
asthma) base alteration. Anesthetic agents reduce
respiratory function. Increasing risk for severe
hyperventilation.
immunological disorder (leukemia, acquired
immunodeficiency syndrome, bone marrow Increases risk of infection and delayed wound
depression, and use of chemotherapeutic drugs healing after surgery
or immunosuppressive agent).
Drug abuse Person abusing drugs may have underlying
disease (HIV, hepatitis, which oil affect healing).
Chronic pain. Regular use of pain medications may result in
higher tolerance. Increase those sets of
analgesics maybe of analogists may be acquired
to achieve post-operative pain control.

Assessment consideration for clients undergoing surgery

Age

a. Very young and old clients are at risk during surgery. Immature or declaiming physiological status.

b. Infant normal body temperature must be maintained

c. She wearing reflects is underdeveloped

d. Anesthesia adds to the risk of hypothermia. Anesthetics can cause vasodilation and heat loss.

Nutritional status

a. Postoperative clients required at least 1500 calories per day to maintain energy reserves.
 A. Surgery

Surgery refers to the treatment of injury, disease, or deformity through invasive operative methods.
It is a unique experience with no two clients responding alike to similar operations. Surgery is the art
and science of treating disease, injuries, and deformities by operating and instrument.

1. CLASSIFICATION OF SURGICAL PROCEDURE

Types Description Examples

Seriousness
Major Involves intensive restruction Coronary artery bypass,:
or alteration in body parts, resection, removal of larynx,
possess great risk to resection of lung Lobe.
wellbeing.
Minor Involves minimal alterations Cataract extraction facial
in body parts, often designed plastic surgery, tooth
to correct deformities extraction.
involves minimal risk
compared with major
procedures.
Urgency

Elective Is performed on basis of the Facial plastic surgery, hernia

clients choice, is not essential repair, breast reconstruction.
and may not be necessary for
health.
Urgent Is necessary for clients health Execution of cancerous
may prevent additional tumour, removal of gallbladder
problems from developing for stones, vascular repair of
(example tissue destruction obstructed artery.
or impaired organ function,
not necessarily emergency).
Emergency Must be done immediately to Repair of prepare for rated
save life or preserve function appendix, repair of traumatic
of body part. amputation, control of internal
hemorrhaging.
Purpose

Diagnostic Surgical exploration that Exploratory laparotomy

allows physician to confirm (incision into the Barrett
diagnosis, may involve O’Neill cavity to inspect
removal of tissue for further abdominal organs), breast
diagnostic testing. must biopsy.

Ablative Execution or removal of Amputation, removal of

disease body part. appendix, cholecystectomy
 - Empty bowel – reduces risk of injury to the intestines and minimizes contamination of the
operative wound if a portion of the bowel is incised or opened accidentally.
- Give enemas until clear - administer enemas until enema return contains no solid fecal
material.
- Recheck potassium level after bowel preparation – too many enemas given in a short period
of time can cause serious fluid and electrolyte imbalance.
- Instruct the patient to void just before leaving the OR and before preoperative medications
are given.
- Empty bladder – prevents client from being incontinent during the surgery, makes the
abdominal organ more accessible.
- Insertion of a foley catheter – to maintain empty bladder

Promotion of Rest and Comfort

- Rest is essential for normal healing.

- Nurse should attempt to make the client’s environment quiet and comfortable.
- Sedative-Hypnotics – affect and promote sleep
- Anxiolytic agents – act on the cerebral cortex and limbic system to relieve anxiety.

Preparation on the Day of Surgery

- Hygiene
a) Basic measures to provide additional comfort before surgery.
b) If patient is unwilling to take a bath - partial bath is refreshing and it removes
irritating secretions or drainage from the skin.
c) Provide clean hospital gowns.
d) Offer the client mouthwash and toothpaste – caution the client not to swallow
water.
- Hair and cosmetics
a) Ask the client to remove hairpins and clips before leaving surgery.
b) Hairpieces or wigs should be removed.
c) All make-up lipstick, powder, blush, nail polish should be removed - to expose
normal skin color and aid in the assessment of skin and mucus membrane to
determine the client’s level of oxygenation and circulation.
d) Contact lenses and eyeglasses, false lashes, must be removed as well.
e) Client’s eyeglasses can be given to the family immediately before client enters the
OR.

- Removal of Prostheses
 a) Remove all prostheses including partial or complete dentures, artificial limbs,
artificial eyes, and hearing aids.
b) Brace or splints – check with the physician to determine whether it should remain
with the client.
c) Privacy should be observed as the personal items are removed.
d) Client may keep personal items until he/she reaches the preoperative area.
e) Dentures are placed in a special container labeled with the client’s name and other
identification required by the agency for safekeeping and to prevent loss or
breakage.
f) Nurses must document inventory of all prosthetic devices or personal items and
have them locked away for safekeeping.
g) Give prosthesis to family members or keep the devices at client’s bedside.
h) Document in the nurse notes and surgical checklist or per agency policy should
reflect above actions.
- Safeguarding valuables
a) The nurse should give them to the family members or secure them for safekeeping.
b) Clients are required to sign a release to free institution of responsibility for lost
valuables.
- Preparing the bowel and bladder
a) Enemas or cathartics may be required in the morning of the surgery.
b) Allow time for the client to defecate without rushing.
c) Client should void before surgery.
d) If client is unable to void - note on the preoperative checklist.
e) Indwelling urinary catheter may be placed if the surgery is long or the incision is in
the lower abdomen.
- Vital Signs
a) If preoperative vital signs are abnormal, surgery may be postponed.

- Documentation
b) Check the contents of the medical record – to be sure that pertinent laboratory
results are present.
c) Check consent forms for accuracy of information.
d) Preoperative checklist – provides the nurse with guidelines for ensuring completion
of nursing interventions.
e) Check nurse’s notes – to be sure that documentation of care is current. This is
especially important if the client experienced unprecedented problems the night
before the surgery.
- Administering preoperative medications
a) Preoperative meds – to reduce the client’s anxiety, the amount of GA required, the
risk of nausea and vomiting and resultant aspiration and respiratory secretions.
b) Consent forms needs to be signed before the administration of preoperative
medications.
c) The client should not be allowed to leave the bed or stretcher until surgical
personnel arrives to transport the client to the OR.
d) Warn the client to expect drowsiness and dry mouth.
 - Preoperative medication – are used for a variety of reasons.

Purpose of Preoperative Medication

Provide analgesia Facilitate induction of anesthesia
Prevent nausea and vomiting Relieve apprehension and anxiety
Promote sedation and amnesia Prevent autonomic reflex response
Decrease anesthesia requirements Decrease respiratory and gastrointestinal
secretions
Frequency Used Preoperative Medications
Benzodiazepines Antacids
Narcotics Antiemetics
Histamine H2-receptor antagonists Anticholinergics

a) Premedications nay be administered orally, IV, SQ or IM.

- Oral medications should be given 60 to 90mins before the patient goes to the OR. Because
patients are fluid restricted before surgery, the patient should swallow these medications
with a minimal amount of water.
- IM and SQ injections should be given 30 to 60mins before arrival at the OR.
- IV Medications are usually administered to the patient after arrival in the preoperative
holding area or OR.

- Latex sensitivity allergy

a) Most at risk include person with genetic predisposition to latex allergy, children with
spinal bifida, clients with urogenital abnormalities or spinal cord injury.
b) Signs and symptoms of latex allergy: Mild – urticaria (rashed, irregularity shaped skin
eruptions with varying sizes.
- Dehydrated client > At risk for developing serious fluid and electrolyte imbalance
intraoperatively.
- Inspect full possibility of local and systemic infection.
- Jugular vein distention > at risk for cardiovascular complications during surgery.
- Loose or capped teeth: must be identified > they can become dislodged during end
tracheal intubation.
- Dentures: must be removed
- Inspect Bony prominences of the skin: prolonged surgery > increased risk of pressure
ulcers
- Older adult > at high risk for alteration in skin integrity from positioning and sliding on the
OR table, causing shear and pressure
- Wheezing in the Airways: laryngeal spasm (caused by certain anesthetics) > at risk for
further airway narrowing during surgery and after excavation > inform the physician
- Peripheral pulses are not palpable > use a Doppler instrument for assessment of their
presence. Normal capillary refill time: < 2 seconds
- Note and be aware of a client entering surgery with weakness and or immobility of the
lower extremities and do not be alarmed when full motor function does not return as a
spinal anesthesia wears off.
 - spinal anesthesia: causes temporary paralysis of the lower extremities.

2. Nursing Diagnosis

3. Planning

 Involve the client and family in preoperative instruction

 Provide therapies aimed at minimizing the clients fear or anxiety regarding surgery
 Plan therapies to reduce surgical risks
 Consult with other health care providers

4. Implementation

 Informed consent
- Surgery cannot be legally or ethically performed until the client understands the need for a
procedure, the steps involved, risks, expected results and alternative therapy.
- The client is protected against unauthorized procedures while the members of the surgical
team and the health care facility and its employees are protected against claims that an
unauthorized procedure was performed.
- Surgeon is responsible for explaining the procedure and obtaining the informed consent.
- Nurse should ensure that the consent form has been completed and placed in the client’s
medical record.
- Consent forms must be signed FIRST before preoperative medications are given.

Three conditions must be met for consent to be valid:

- There must be adequate disclosure of the diagnosis; the nature and purpose of the
proposed treatment; the risks and consequences of the proposed treatment; the
 probability of a successful outcome; the availability, benefits, and risks of alternative
treatments; and the prognosis if treatment is not instituted.
- The patient must demonstrate clear understanding and comprehension of the information
being provided.
- The recipient of care must give consent voluntarily and must not be persuaded or coerced
in any way to undergo the procedure. Although the physician is ultimately responsible for
obtaining the consent, the nurse may be responsible for obtaining and witnessing the
patient’s signature on the consent form. If the patient is a minor, is unconscious, or is
mentally incompetent to sign the permit, the written permission may be given by a legally
appointed representative or responsible family member.

 Pre-operative teaching
- But it operatively teaching is an important aspect of the surgical experience
- A systematic and structured format has a positive influence on the client’s recovery.
- Information about sensations typically experienced post operatively should be provided.
- Preparatory information helps the client anticipate steps of procedure and thus helps
them form realistic image of the surgical experience. Clients are better able to cope and
attend to the experience.
- Every preoperative teaching program must include explanation and demonstration.
- Diaphragmatic breathing, incentive spirometry, coughing, turning and leg exercises should
be taught to prevent postoperative complications.

 Physical Preparation
- NPO: to keep the stomach empty > reduce the risk of vomiting and aspiration
- Preoperative diet: high CHON, sufficient CHO, fats and vitamins
- Fasting from intake of light meal or non-human milk for 6 hours or more; breast
milo: 4 or more hours; clear liquids: 2-3 hours; before elective procedures requiring
GA, RA, or sedation (American Society of Anesthesiologist)
- Nurse:
- Can allow the client to rinse mouth with water or mouthwash and brush the teeth
immediately prior to surgery as long as the client does not swallow the water.
- Notify the surgeon and anesthesiologist if the client eats or drinks during the fasting
period.
  Maintenance of Normal Fluid and Electrolytes
- IV route for fluid replacement is started
 Reduction of Risks for Surgical Wound Infection
- Determinant of developing a surgical wound infection
- Amount and type of microorganism contaminating a wound
- susceptibility of the host
- the surgical wound itself
- antibiotics may be ordered preoperatively
- improper skin preparation > I’ll be damned increased risk of postoperative wound
infection
- if required, hair removal preferably with a Clipper or shaver, is performed as close to
the time of surgery as possible.
 Prevention of Bowel and Bladder Incontinence
- Manipulation of the gastrointestinal tract: results in absence of peristalsis for 24
hours (sometimes longer)
- Enemas and cathartics: cleanse the gastrointestinal tract > to prevent interpretive
incontinence and postoperative constipation

h.  Bacteria travel on airborne particles and will enter the sterile field with excessive air
movements and currents. 

i. Bacteria travel by capillary action through moist fabrics and

j. Contamination occurs. Bacteria that may be harbored on the patient's and  the team
members’ hair, skin and respiratory tracts must be confined by appropriate attire. 

 Anesthesia 

Anesthesia refers to the absence of normal sensation. 

- Analgesia refers to pain relief without producing anesthesia. 

- The Anesthesiologist is a licensed physician educated and skilled in the delivery of

anesthesia who also adds ‘to the knowledge of anesthesia through research or other
scholarly ‘pursuits. 

A nurse anesthetist is a qualified RN who administers anesthesia. 

- Experienced registered nurses (RNs) with a baccalaureate degree can become
certified nurse anesthetists (CRNAs) after completing two or more years of
graduate education in nurse anesthesia.
- Nurses must demonstrate competency in the care of clients requiring anesthesia.
 - Knowledge of anatomy, physiology, cardiac dysrhythmias, procedural complications and
pharmacological principles related to the administration of anesthesia is
essential. 
- Nurses must be able to assess, diagnose and intervene in the event of untoward reactions
and demonstrate skill in airway management and O2 delivery. Resuscitation equipment
must be readily available. 

Classification of Anesthesia
- General Anesthesia 
a. Loss of sensation with loss of consciousness, skeletal muscle relaxation, analgesia, and
elimination of the somatic, autonomic and endocrine responses, including coughing, gagging.
vomiting and sympathetic nervous system responsiveness.
b. Results in an immobile, quiet client who does not recall the surgical procedure.
c. The client’s amnesia acts as a protective measure from the unpleasant events of the procedure. 

- Regional Anesthesia 
a. Results in loss of sensation in an area of the body. 
b. No loss of consciousness occurs but the client may be sedated. 
c. if the level of anesthesia rises > can cause respiratory paralysis and requires immediate
resuscitation.

NURSING
DRUGS ADVANTAGES DISADVANTAGES INTERVENTIONS

Gaseous Agents -Rapid acting

Nitrous Oxide -Non-irritating to
respiratory system
 -Devoid of toxicity to
body organs

-Most widely used in

the Induction and
emergence phase

-Potetiates volatile -Weak anesthetic -Produces little or no

agents, allowing a -Rarely used alone toxicity
reduction in their -Must be -Monitor for effects
dosage and their administered with of volatile liquids
negative effects and Oxygen to prevent when nitrous oxide
increases the rate of hypoxemia is used as an
induction

- May cause
- Can be hallucinations and
- Rarely used
administered IV or nightmares.
Dissociative -Anticipate
IM - Increased ICP and
Anesthetics administration of a
-Potent analgesis IOP
Ketamine (Ketalar) benzodiazepine if
amnestic - Increased HR and
agitation and
HTN
hallucinations occur

DJUNCTS TO GENERAL ANESTHESIA

Agents
Uses During Nursing
Anesthesia Adverse Effects Interventions

Opioids - Induce and - Respiratory - Assess respiratory

Fentanyl (Sublimaze) maintain anesthesia Depression status
Sufentanil (Sufenta) Reduce stimuli from - Stimulation of - Monitor pulse
Morphine Sulfate Stimulation of Vomiting center Oxymetry protect
Mepedrine sensory nerve Possible bradycardia airway in
(Demerol) endings and peripheral anticipation of
 vasodilation (when
Alfentanil (Alfenta) -Provide analgesia
Combined with
Remifentanil (Ultiva) during anesthetic
anesthetics) vomiting
Methadone recovery
(Dolophine)

-Induce and
Benzodiazepines maintain anesthesia - Potentiation of the
- Monitor
Midazolam (Versed) -Provides conscious effects of opiods,
cardiopulmonary
Diazepma (valium) sedation during increasing potential
status, LOC
Lorazepma (Ativan) regional anesthesia for respiratory

- Apnea related to
paralysis of
- Monitor respiratory
- Faciltate respiratory muscles,
rate and pattern
endotracheal prolonged muscle
Neuromuscular until patient is able
intubation relaxation due to
Blocking Agents to cough and return
Promote skeletal longer action of
Depolarizing Agents: to previous levels of
muscle relaxation nondepolarizing
Succinylcholine muscle strength
(paralysis) to agents than reversal
(anectine) -Maintain patent
enhance access to agents cardiac
airway tor the
surgical sites. alterations
patient

mechanical exsanguination using a compression bandage and a tourniquet. This type of block
provides not only analgesia, but also the ability to work in a bloodless field.
- Spinal and epidural anesthesia - are also types of regional anesthesia. Spinal anesthesia involves
the injection of a local anesthetic into the cerebrospinal fluid found in the subarachnoid space,
usually below the level of L2.
- Epidural block - involves injection of a local anesthetic into the epidural (extradural) space via either
a thoracic or lumbar approach, The anesthetic agent does not enter the cerebrospinal fluid, but
works by binding to nerve roots as they enter and exit the spinal cord.

GENERALANESTHESIA
DRUGS ADVANTAGES DISADVANTAGES NURSING
 INTERVENTION
Intravenous Agents
Barbiturates -Rapid induction -Higher doses: -Minimal post-
Thiopental -Small dosage -Cardiac alterations operative effects
(Penthotal) -Duration of action -Hypotension due to extremely
Methohexital less than 5 minutes -Tachycardia short effects
(Brevital)|- -Respiratory
Duration  depression

Non- -Produces little -Associated with. =Observe for

Barbiturate changes in adverse effects of transient skeletal
Hypnotics cardiovascular myoclonia muscle movements
Etomidate dynamics -Nausea and vomiting (myoclonia), nausea
(Amidate) -Useful for Hiccoughs and and vomiting.
hemodynamically adrenocortical hiccoughs,
unstable patients Inhibition hypotension and
Hypoglycemia.
-ideal for short -May cause
Propofol outpatient bradycardia and -Short action leads
(Diprivan) procedures because other arrhythmias to minimal
of rapid onset of -Hypotension postoperative
action and -Apnea effects
elimination -Phlebitis -Monitor injection
-May be sued for -Nausea and Site for phlebitis
maintenance of -Cardiac monitoring
anesthesia as well as vomiting if unstable
induction -Hiccougns

Inhalation Agents
Volatile All volatile liquids: All volatile liquids: -Assess and treat
Liquids -Muscle relaxation -Myocardial apin during early
Halothane - Low incidence of depression anesthesia recovery
(Fluothane) nausea and -Early onset of pain -Assess tor adersSe
Entlurane vomiting because of rapid reactions such as
(ethrane) Halothane: elimination cardiopulmonary
Isoflurane -Bronchodilation Halothane: depression with
(Forane) Isoflurane: -Hypotension and hypotension and
Desflurane -Less cardiac Possible hepatoxicity prolonged
(Suprane) depression Eflurane: respiratory
Sevotiurane Desflurane: -Increased ICP depression,
(Ultane) - Rapid onset of -Unpredictable Contusion, nausea
action duration of action and vomiting
Sevoflurane:
-Predictable effects
on cardiovascular
and respiratory
 d. Elevation of the upper body parts prevents resplratory
paralysis.
e. Endotracheal tube is unnecessary since the client is
responsive and capable of breathing voluntarily.

- Local Anesthesia

a. Commonly used for minor procedures

b. Involves loss of sensation at the-desired site
c. Lidocaine - inhibits nerve conduction until the drug
diffuses into the circulation; maybe injected locally
or applied topically.

- Conscious Sedation

a. Routinely used for procedures that does not require

complete anesthesia but rather a depressed level of
consciousness ("twilight sleep").
b. Client must independently retain a patent airway and
airway reflexes and be able to respond appropriately
to physical and verbal stimuli.
c. Short-acting IV sedatives such as midazolam are
given.
d. Advantages of conscious sedation: adequate sedation,
and reduction of fear and anxiety with minimal risk,
amnesia, relief of pain, and noxious stimuli; mood
alteration, elevation of pain threshold, enhanced client
Cooperation, stable vital signs, and rapid recovery.

- Anesthesia for Pediatric Clients

a. Have a parent present when the anesthesiologist

Examines the child and performs the preoperative
assessment.

b. Explain the procedure at the child's level of

understanding such as "This mask will help you go to
sleep for a while."
c. Allow the child to play with a mask.

Fasting: Infants and Small Children

 a. infants and small children have a high metabolic need
and can tolerate only short periods ot fasting. (4 hours
or less).

Methods for Administering Local Anesthesia

- Topical application - is application of the agent directly

to the skin, mucous membranes, or open surface.
- Local infiltration - is the injection of the agent into the
tissues through which the surgical incision will pass.
-Regional (peripheral) nerve block,- is achieved by the
injection of a local anesthetic into or around a specific
nerve or group of nerves. Nerve blocks may be used to
provide intraoperative anesthesia and postoperative
analgesia and for the diagnosis and treatment of chronic
pain
- Intravenous nerve block (Bier block) - is the intravenous
injection of a local anesthetic into the extremity following.

1. Assessment

Safety Alert: Verification of the client response compared

to the chart and arm band is completed. This is done
before sedation. The chart is reviewed for consent forms,
allergies, medical history, physical assessment findings
and test results. The nurse verifies with the client the
planned surgical procedure and the surgical site before
anesthesia is administered. some agencies have the client
mark the surgical site. The nurse ensures that prosthetic
devices and valuables have been removed.

2. Nursing Diagnoses

 The nurse reviews preoperative nursing diagnosis and

modifies them to individualize the care plan in the operating
room.

3. Planning

 Maintain client's safety to maintain homeostasis.

4. Implementation
 Asepsis
 The absence of pathogenic microorganisms.

- Aseptic Technique
A collection of principles used to control and/ or prevent
the tranşlfer of pathogenic microorganisms from sources
within (endogenous) and outside (exogenous) the client.

-Principles of Basic Aseptic Technique in the Operating Room

a. All materials that enter the sterile field must be sterile

b. If a sterile item comes in contact with an unsterile

item, it is contaminated.

c. Contaminated items should be removed immediately

from the sterile field.

d. Sterile team members must wear only sterile gowns

and gloves; once dressed for the procedure, they
should recognize that the only parts of the gown
considered sterile are the front from chest to table
level and the sleeves to 2 inches above the elbow.

e. A wide margin of safety must be maintained between

the sterile and unsterile field.

f. Tables are considered sterile only at tabletop level;

items extending beneath this level are considered
contaminated.

g. The edges of a sterile package are considered

contaminated once the package has been opened.

 Post-anesthetic Nursing Responsibilities

 Maintenance of Pulmonary Ventilation
a. Position patient to side-lying or semi-prone position to prevent aspiration.
Oropharyngeal or nasopharyngeal airway is left on place following administration of
general anesthetic until pharyngeal reflexes have returned. They should be removed as
soon as the patient begins to awaken and has regained the cough and swallowing
reflexes.
b. All patients should receive O2 at least until they are conscious and are able to take deep
breaths on command.
c. Shivering of the patient must be avoided to prevent an increased O2 demand.
 Maintenance of Circulation- Most common encountered cardiovascular complications in the
immediate post-anesthetic period are:
a. Hypotension
Causes:
o Moving patient from OR to his bed: jarring during transport
o Reaction to drug and anesthesia
o Loss of blood and other body fluids
o Cardiac arrythmias and cardiac failure
o Inadequate ventilation
o Pain

Assessment:

o Weak, thread pulse with a significant drop in BP may indicate hemorrhage or

circulatory failure
o Skin- cold, moist, pale, or cyanotic
o Restlessness or apprehension

Nursing Responsibilities:

o Vital signs taken 15 minutes for the first 4 hours or until stable

b. Cardiac Arrythmias
Causes:
o Hypoxemia
o Hypercapnia- which are common causes of premature beats and sinus tachycardia

Intervention:

o Oxygen therapy
o Drug administration
o Lidocaine (Xylocaine)
o Procainamide (Pronestyl)

 Protection from injury and Promotion of Comfort

a. Provide side rails- placed up until patient is full awake
 1. Immediate Post-operative Recovery
 It is the surgeon’s responsibility to describe the client’s status, the results of surgery and
any complications that may have been encountered.
 PACU nurse anticipates how quickly the client should regain consciousness and to
anticipate analgesic needs.
 Nursing care in the PACU focuses on monitoring and maintaining respiratory, circulatory
and neurological status and on managing pain.
2. Post-operative care
 Aldrete Score- also known as the Postanesthetic Recovery Score that is used in PACUs to
objectively assess the physical status of the client recovering from the anesthesia and
serves as the basis for discharge from the PACU.
o Clients are assessed at the time of admission to the PACU and every 15 minutes
until discharge.
o Recently adopted to also assess the readiness of clients for discharge from
ambulatory surgery.

Aldrete Score Post-anesthetic Recovery Score

Activity Able to move extremities or on command 2

Able to move 2 extremities voluntarily or on command 1
Able to move 0 extremities voluntarily or on command 0
Respiration Able to breathe deeply and cough freely 2
Dyspnea or limited breathing 1
Apneic 0
Consciousness Full awake 2
Arousable on calling 1
Not responding 0
Circulation B/P = 20% of preanesthetic level 2
B/P = 20% to 50% of preanesthetic level 1
B/P = 50% preanesthetic level 0
Color Normal 2
 Pale, dusky, blotchy, jaundiced, other 1
0
Additional Assessments: Aldrete Score/Postanesthetic Recovery Score
of the Clients Having Anesthesia on an Ambulatory Basis
Dressing Dry and clean 2
Wet but stationary or marked 1
Growing area of wetness 0
Pain Pain free 2
Mild pain handled oral medication 1
Severe pain requiring parenteral medication 0
Ambulation Able to stand up and walk straight 2
Vertigo when erect 1
Dizziness when supine 0
Fasting/feeding Able to drink fluids 2
Nauseated 1
Nausea and vomiting 0
Urine output Has voided 2
Unable to void but comfortable 1
Unable to void and uncomfortable 0

5. Qualifications and Responsibilities of Members of the Surgical Team

 Sterile Team Members

o Surgeon
a. A doctor of medicine
b. Identifies the need for surgery
c. Determines and plans appropriate treatment
d. Discusses surgical risks, benefits, possible complications and treatment
alternative with the client
e. Obtains informed consent
f. Performs the surgery
o First Assistant
a. May be an associate physician
b. Assists the surgeon
c. Retracts tissues and aids in the removal of blood and fluids at the operative site
d. Assists with the homeostasis and wound closure
o Second and Third Assistant
a. May be a registered nurse
b. Usually holds retractors
 o Scrub Nurse
a. A registered nurse
b. Provides services under the direction of the circulating nurse
c. Opens the sterile supplies
d. Assists in gowning and gloving of other sterile team members
e. Prepares instrument and the sterile field
f. Maintains the integrity, safety, and efficiency of the sterile field
g. Assists with the sterile draping of client’s operative site
h. Passes or hands instruments, sutures, and the like to the surgeon
i. Anticipates and meets the needs of the surgeon for instruments and supplies
during the operation
j. Performs instrument, sponge, and sharp counts
k. Aids in cleaning room after procedure

 Non-sterile Team Members

o Anesthesiologist
a. May be a doctor of medicine
b. Assesses client during a preoperative visit
c. Chooses, induces, and maintains anesthesia
d. Monitors oxygenation and gas exchange
e. Manages untoward effects of anesthesia during surgery and postoperatively
f. Monitors and maintains fluid and electrolyte balance
 Circulating Nurse
a. Always a registered nurse
b. Controls the number and behavior of visitors in the OR
c. Responsible and accountable for all activities during a surgical procedure
d. Manages personnel, equipment, supplies, the environment, and the
communication throughout the operation
e. Arranges furniture and equipment in the OR
f. Opens sterile supplies of sterile team members
g. Ties gowns of sterile team members
h. Attends to the needs and supplies of sterile team members
i. Identifies and assesses the patient
j. Brings the patient to the OR and transfer to OR table
 k. Applies and assists in insertion of monitoring devices
l. Assists the anesthesiologist in the induction of anesthesia
m. Positions the patient for surgery
n. Performs the designated skin prep
o. Assist with sterile draping and setup of sterile field around the operative site
p. Monitors sterile technique of surgical team members
q. Collects, labels and distributes specimen to designated areas
r. Completes intraoperative record
s. Monitors blood and fluid loss
t. Counts sponges, instruments and sharps with scrub nurse and reports results to
the surgeon
u. Communicates with the surgical team members and others such as the client’s
family, pathologist
v. Applies dressings
w. Assists in transferring client to the PACU
x. Aids in cleaning the OR after the procedure

D. POST-OPERATIVE PERIOD

The post-operative period- is the time during the surgical experience that begins with the end of the
surgical procedure and lasts until the client is discharged and not just from the hospital or
institution, but from medical care by the surgeon.

Positioning

 Do not position the client until the stage of complete relaxation is achieved

- Assessment
a. complaint of a "giving" sensation in the incision
b. sudden, profuse leakage of fluid from the incision
c. dressing saturated with clear. pink drainage
d. verbalization of "popped out" feeling on the wound
—Management:
a. Position patient to low Fowler's position; instruct not to cough, sneeze. eat or
drink, and remain quiet until surgeon arrives.
b. Protruding viscera should be covered with warm. sterile, saline dressing.
 C. Community Setting: May be covered with Banana leaf.

(2-4 inches - adult; 1-3 inches - children): prolonged stimulation of the anal sphincter may result in a
loss of neuromuscular response. It may cause pressure necrosis of the mucous surface

d. Fleet enema
Constipation — due to decreased food intake and decreased activity
Mast patients who are eating solid foods. drinking adequate amounts of fluid
and ambulating will have a bowel movement within 3 to 4 days after surgery.
Urinary Complication
— Return of Urinary Function
a. Usually after 6-8 hours

First voiding may not be more than 200 mL and total output may be more than 1500 ml-.
This is due to the loss of fluids during surgery and to perspiration. hyperventilation, vomiting
and increased secretion of ADH Complications:

a. Urinary retention Causes:

a. prolonged recumbent position

b. Nervous tension
c. Effect of anesthetic that interferes with bladder sensation and the ability to
void
d. Use of narcotics that reduce the sensation of bladder distention e.
Pain at theside or by movement Management
a. Force fluid.
b. place patient on bed pan at regular intervals.
c. Pour warm water over the perineum.
d. Ensure patient privacv.
e. Assume proper position.
f. Catheterization i f bladder is palpable over the suprapuhic bone because
pressure causes discomfort. Done to prevent stretching of the vesical wall.
- Urinary Tract Infection Management,
a. Instruct the patient to empty the bladder completely during each voiding,
b. Use sterile non-traumatic technique in catheterization if necessary.
5. post-operative Discomforts
• post-operative pain - narcotics can be given every 3-4 hours during the first 48 hours post-op
for severe pain without danger of addiction.

• Hiccup — brought about by dilation of the stomach. Irritation of the diaphragm, Peritonitis and
uremia cause either reflex or CNS stimulation of the phrenic nerve
• Paper bag blowing
— C02 inhalation - C02 and 95% 02 5 minutes everv hour
6, Wound Complications: Sutures are usually removed about the 5th„7th day post-op with the
exception of wire retention sutures placed deep in muscles removed usually 14-21 days after
• Hemorrhagefiom the wound — most likely to occur within the first 48 hours post-op or as late as
6th or 7th post-op day.

• Hemorrhage occurring soon after operation — slipping of a ligature or mechanical dislodging of a

blood clot:
caused by the reestablished blood flow through vessel — Hemorrhage after a few days:

a_ sloughing of a clot or of a tissue

b. infection
c. erosion Ofa blood vessel by a drainage tube
Assessment

— bright red blood

— pallor
— decreased BP

• increased PR and RR
• weakness
• cold, moist skin
— restlessness

— streptococcus

— staphylococcus

Assessment, From 3-6 days after surgery the patient begins to have a low grade fever and the wound
becomes painful and swollen. There maybe purulent drainage on dressing.
• Dehiscence and Evisceration — Definitiom
a. Dehiscence (wound disruption) — refers to a partial• to-complete separation of the wound
edges.
b. Evisceration - refers to the protrusion of the abdominal viscera through the incision and onto the
abdominal wall.
— streptococcus

— staphylococcus

Assessment, From 3-6 days after surgery the patient begins to have a low grade fever and the wound
becomes painful and swollen. There maybe purulent drainage on dressing.
• Dehiscence and Evisceration — Definitiom
c. Dehiscence (wound disruption) — refers to a partial• to-complete separation of the wound
edges.
d. Evisceration - refers to the protrusion of the abdominal viscera through the incision and onto the
abdominal wall.
surgery which results in fluid retention by the potential for overhydration therefore exists since fluids
being given IV may exceed fluid output by the kidney.

 Electrolyte Imbalance: particularly Na and K imbalance as a result of blood loss. Stress of

surgery increases adrenal hormonal activity resulting to increased aldosterone and
glucocorticoids resulting in increased sodium reabsorption by the kidney and as sodium is
reabsorbed, potassium is excreted. Increased potassium loss from tissue breakdown.
 Management: IV of D5W alternated with D5NSS or one-half strength NSS to prevent Na
excess.
Gastrointestinal Complications
▪ Paralytic ileus — cessation of peristalsis due to extensive handling of Gl organs
Nursing Management:

a) No fluids or food are given until peristalsis has returned as evidenced by auscultation of bov,
zl sounds or by the passing of flatus.
▪ Vomiting — usually is a result of certain anesthetics on the stomach or due to eating food
or drinking water before peristalsis returns. Psychologic factors also contribute to
vomiting.
Nursing Management.
a) Position patient on his side to aspiration.
b) When vomiting has subsided4 ice chips, sips of ginger ale or hot tea or eating small amounts
of dry solid foods may relieve nausea. c.
c) Anti-emetic drugs:
d) trimethobenzamide HCI (Tigan)
e) prochlorperazine dimaleate (compazine)
▪ Abdominal Distention — results from the accumulation of non-absorbable gas in the
intestine.
Causes:

a) Reaction to the handling of the bowel during surgery

b) Swallowing of air during recovery from anesthesia
c) Passage of gases from the blood stream to the atonic portion of the bowel
- Gas Pain — results from contraction of unaffected portion of the bowel in order to
move accumulated gas in the intestinal tract
Management:

a) Aspiration of fluid or gas with an NGT

b) Ambulation - stimulates the return of peristalsis and the expulsion of flatus
c) Rectal tube insertion - inserted just past the rectal sphincter and removed after
approximately 20 minutes

b. Patient is turned frequently and placed in good body alignment to prevent nerve damage
from pressure.

c. Administration of narcotic analgesic to relieve incisional pains. Post-operative dose is usually

reduced to half the dose the patient will be taking after fully recovering from anesthesia.
 3. Discharge from PACU

• The nurse evaluates the readiness for discharge from the PACU based on vital signs stability
in comparison with the preoperative data.

• Other criteria considered are good ventilatory function, level of consciousness, absence of
complications etc.

• Client must receive a composite score of 8 to 10 (using the Aldrete Score) before discharge
from PACU.

• Review physician orders that require attention.

• Before the PACU nurse leaves the acute care area, the staff nurse assuming care for the
patient takes a complete set of vital signs to compare with PACU findings minor vital signs
variations normally occur after transposing the patient.

4. Post-operative Nursing Care after Discharge from PACU: directed toward prevention of
complication and postoperative discomfort

 Respiratory Complication - e.g., atelectasis and pneumonia

- Atelectasis — is suspected whenever there is sudden rise in temperature 24-48 hours

after surgery. Collapse alveoli are highly susceptible to infection (pneumonia).
a. occurs usually in high abdominal surgery when prolonged inhalation anesthesia has been
necessary and vomiting has occurred during the operation or while the patient is recovering
from anesthesia.

- Nursing Management
a. Measures to prevent pooling of secretions, include changing of position, altering
height of bed from low to high fowlers, moving out of bed or walking — activity stimulates
deeper breathing and prevents pooling of secretions.

b. Measures to liquify and remove secretions

 encourage increased fluid intake breathing in moist air provided by moist

tents or ultrasonic mist
 deep breathing followed by coughing may be contraindicated in cases of
brain surgery, spinal or eye surgery. Administer analgesic before coughing is
attempted after thoracic or abdominal surgery.

splint operative area with a draw sheet or towel to promote comfort while coughing

c. Other measures to increase pulmonary ventilation

  blow bottle exercise
 incentive spirometer — designed to encourage sustained maximal inspiration (SMI)
rebreathing tubes — increase C02 stimulates the respiratory center to increase the depth
of breathing thus increasing the amount of inspired air
 intermittent positive pressure breathing (IPPB)
Circulatory Complication
- Causes of venous stasis

a. muscular inactivity

b. • respiratory and circulatory depression

c. increased pressure on blood vessels due to tight dressing

d. intestinal distention

e. prolonged maintenance of a sitting position

- Contributing factors

a. obesity

b. cardiovascular disease

c. debility

d. malnutrition

e. old age

- Most Common circulatory complications

a. Phlebothrombosis

b. Thrombophlebitis — positive Homan's sign — pain on dorsiflexion of the foot; usually

described or referred to as "pain of the calf”

Nursing measures

a. Limbs must never be massaged for a post-operative patient.

b. Do not allow patient to stand unless pulse has returned close to baseline to prevent
orthostatic hypotension.

c. Wear elastic bandages or stockings when in bed and when walking for the first time.

d. Remove stockings or bandages at least once daily to permit washing of the legs.

Fluid and Electrolyte Imbalances

- Causes

a. blood loss

b. increased insensible fluid loss through skin after surgery through vomiting, copious wound,
drainage from tubes as in NGT
c. since surgery is a stressor, there is increased production of ADH for the first 12-24 hours
following