The anesthesiologist or CRNA uses the American Society of

Anesthesiologists (ASA) Physical Status Classification System

Surgeon
Responsibilities

• Primary responsible for the preoperative medical history

and physical assessment.

• Performance of the operative procedure according to the

needs of the patients.
• The primary decision maker regarding surgical technique
to use during the procedure.
• May assist with positioning and prepping the patient or
may delegate this task to other members of the team
Nurses
Scrub Nurse
Responsibilities
• May be either a nurse or a surgical technician.
• Reviews anatomy, physiology and the surgical procedures.
• Assists with the preparation of the room.
• Scrubs, gowns and gloves self and other members of the
surgical team.
• Prepares the instrument table and organizes sterile equipment
for functional use.
• Assists with the drapping procedure.
• Passes instruments to the surgeon and assistants by
anticipating their need.
• Counts sponges, needles and instruments.
• Monitor practices of aseptic technique in self and others.
• Keeps track of irrigations used for calculations of blood loss
Circulating Nurse
The circulating nurse coordinates the care of the patient
in the OR.

Care provided by the circulating nurse includes planning

for and assisting with patient positioning, preparing the
site for surgery, managing surgical specimens, anticipating
the needs of the surgical team, and documenting
intraoperative events.

Collaboration of the core surgical team using evidence-

based practices tailored to the specific case results in
optimum patient care and improved outcomes.
Responsibilities

• Must be a registered nurse who, after additional

education and training, specialized in perioperative
nursing practice.
• Responsible and accountable for all activities occurring
during a surgical procedure including the management of
personnel equipment, supplies and the environment
during a surgical procedure.
• Patient advocate, teacher, research consumer, leader
and a role model.
• May be responsible for monitoring the patient during
local procedures if a second perioperative nurse is not
available.
Registered Nurse First Assistant
Responsibilities
• May be a resident, intern , physician’s
assistant or a perioperative nurse.
• Assists with retracting, hemostasis,
suturing and any other tasks requested by
the surgeon to facilitate speed while
maintaining quality during the procedure.
Very defined activities during surgery:

• Ensure all equipment is working properly.

• Guarantees sterility of instruments and supplies.
• Assists with positioning.
• Monitor the room and team members for breaks in
the sterile technique.
• Handles specimens.
• Coordinates activities with other departments,
such as radiology and pathology.
• Documents care provided.
• Minimizes conversation and traffic within the
operating room suite.
The Surgical Environment
Surgical area is divided into three zones:

Unrestricted zone, where street clothes are

allowed;

Semi-restricted zone, where attire consists of scrub

clothes and caps;

Restricted zone, where scrub clothes, shoe covers,

caps, and masks are worn.
Surgical Setting

• Unrestricted Zone
- provides an entrance and exit from the
surgical suite for personnel, equipment and
patient
- street clothes are permitted in this area,
and the area provides access to
communication with personnel within the
suite and with personnel and patient’s
families outside the suite
Unrestricted Area
Surgical Setting

• Semi-restricted Zone
- provides access to the procedure rooms and
peripheral support areas within the surgical suite.
- personnel entering this area must be in proper
operating room attire and traffic control must be
designed to prevent violation of this area by
unauthorized persons
- peripheral support areas consists of: storage
areas for clean and sterile supplies, sterilization
equipment and corridors leading to procedure room
Surgical Setting

• Restricted Zone
- includes the procedure room where
surgery is performed and adjacent
substerile areas where the scrub sinks and
autoclaves are located
- personnel working in this area must be in
proper operating room attire
Restricted Zone
Principles of Surgical Asepsis
Surgical asepsis prevents the contamination
of surgical wounds.

All surgical supplies, instruments, needles,

sutures, dressings, gloves, covers, and
solutions that may come in contact with the
surgical wound or exposed tissues must be
sterilized before use.
Surgical team members wear long-sleeved, sterile gowns
and gloves. Head and hair are covered with a cap, and a
mask is worn over the nose and mouth to minimize the
possibility that bacteria from the upper respiratory tract
will enter the wound.
Medical vs. Surgical Asepsis
Principles of Surgical Asepsis
(Sterile Technique)

• Sterile object remains sterile only when touched by

another sterile object
• Only sterile objects may be placed on a sterile field
• A sterile object or field out of range of vision or an
object held below a person’s waist is contaminated
Principles of Surgical Asepsis
(Sterile Technique)
• When a sterile surface comes in contact with a wet,
contaminated surface, the sterile object or field becomes
contaminated by capillary action
• Fluid flows in the direction of gravity
• The edges of a sterile field or container are
considered to be contaminated (1 inch)
Environmental Controls
Floors and horizontal surfaces are cleaned between cases
with detergent, soap, and water or a detergent-germicide.

Sterilized equipment is inspected regularly to ensure

optimal operation and performance.

Airborne bacteria are a concern. To decrease the amount

of bacteria in the air, standard OR ventilation provides 15
air exchanges per hour, at least 3 of which are fresh air.

Systems with high-efficiency particulate air (HEPA) filters

are needed to remove particles larger than 0.3 μm

A room temperature of 20°C to 24°C (68°F to 73°F), humidity

between 30% and 60%, and positive pressure relative to
adjacent areas are maintained.
Ventilation and Air Exchange System

• A high filtration particulate filter, working at 95%

efficiency is recommended.
• Each procedure room should maintained with positive
pressure, which forces the old air out of the room and
prevents the air from surrounding areas from entering
into the procedure room
The Surgical Experience
During the surgical procedure, the patient will need
sedation, anesthesia, or some combination of these.
ANESTHESIA - State of “Narcosis” (severe central nervous system
depression produced by pharmacologic agents), analgesia, relaxation, and reflex
loss.
• Anesthetics can produce muscle relaxation, block transmission
of pain nerve impulses and suppress reflexes.
• It can also temporarily decrease memory retrieval and recall.
The effects of anesthesia are monitored by considering the
following parameters:
- Respiration
- O2 saturation
- CO2 levels
- HR and BP
- Urine output
 Types of Anesthesia and
Sedation
✓General anesthesia (inhalation, IV),

✓Regional anesthesia (epidural, spinal, and local

conduction blocks),

✓Moderate sedation (monitored anesthesia care [MAC]),

✓Local anesthesia.
Types of Anesthesia
1. General Anesthesia

Patients under general anesthesia are not arousable,

not even to painful stimuli.

Lose the ability to maintain ventilatory function and

require assistance in maintaining a patent airway.

Cardiovascular function may be impaired as well.

ANESTHESIA AWARENESS
-phenomenon of patients being partially awake while under
general anesthesia

Patients at greatest risk of anesthesia awareness are;

➢Cardiac patients,
➢Obstetric patients
➢Major trauma patients.
Stages of General Anesthesia

STAGE 1: BEGINNING ANESTHESIA.

STAGE 2: EXCITEMENT.

STAGE 3: SURGICAL ANESTHESIA.

STAGE 4: MEDULLARY DEPRESSION.

STAGE 1: BEGINNING ANESTHESIA.
✓Dizziness and a feeling of detachment may be
experienced during induction.

✓The patient may have a ringing, roaring, or buzzing in

the ears and, although still conscious, may sense an
inability to move the extremities easily.

✓These sensations can result in.

✓agitation
✓During this stage, noises are exaggerated; even low
voices or minor sounds seem loud and unreal.

✓For these reasons, unnecessary noises and motions

are avoided when anesthesia begins.
STAGE 2: EXCITEMENT.
The excitement stage, characterized variously by
struggling, shouting, talking, singing, laughing, or crying,
is often avoided if IV anesthetic agents are given
smoothly and quickly.

The pupils dilate, but they constrict if exposed to light; the

pulse rate is rapid, and respirations may be irregular.

Because of the possibility of uncontrolled movements of

the patient during this stage, the anesthesiologist or CRNA
must always be assisted by someone ready to help
restrain the patient or to apply cricoid pressure in the
case of vomiting to prevent aspiration.
STAGE 3: SURGICAL ANESTHESIA.
Surgical anesthesia is reached by administration of
anesthetic vapor or gas and supported by IV agents
as necessary.

The patient is unconscious and lies quietly on the table.

The pupils are small but constrict when exposed to light.

Respirations are regular, the pulse rate and volume are
normal, and the skin is pink or slightly flushed.

With proper administration of the anesthetic agent, this

stage may be maintained for hours in one of several
planes, ranging from light (1) to deep (4), depending on
the depth of anesthesia needed.
STAGE 4: MEDULLARY DEPRESSION.
This stage is reached if too much anesthesia has been
given.

Respirations become shallow, the pulse is weak and

thready, and the pupils become widely dilated and no
longer constrict when exposed to light.

Cyanosis develops and, without prompt intervention,

death rapidly follows.

If this stage develops, the anesthetic agent is

discontinued immediately, and respiratory and
circulatory support is initiated to prevent death.
A. Intravenous Anesthesia

This is being administered intravenously

and extremely rapid.
Its effect will immediately take place after
thirty minutes of introduction.
It prepares the client for smooth transition to the
surgical anesthesia.
B. Inhalation Anesthesia

This comprises of volatile liquids or gas and

oxygen.
Administered through a mask or endotracheal
tube.
Nitrous oxide is the most commonly used gas
anesthetic agent.
Regional Anesthesia
•An anesthetic agent is injected around nerves so that
the region supplied by these nerves is anesthetized.

•Patient receiving regional anesthesia is awake and

aware of their surroundings unless medications are
given to produce mild sedation or to relieve anxiety.
Nurse Responsibilities

The health care team must avoid careless

conversation, unnecessary noise, and unpleasant
odors; these may be noticed by the patient in the OR
and may contribute to a negative response to the
surgical experience.

A quiet environment is therapeutic.

The diagnosis must not be stated aloud if the patient

is not to know it at this time.
Epidural Anesthesia
Epidural anesthesia is achieved by injecting a local
anesthetic agent into the epidural space that surrounds the
dura mater of the spinal cord
Epidural anesthesia
blocks sensory, motor, and autonomic functions; it differs
from spinal anesthesia by the site of the injection and
the amount of anesthetic agent used.

Epidural doses are much higher because the epidural

anesthetic agent does not make direct contact with the
spinal cord or nerve roots

An advantage of epidural anesthesia is the absence of

headache that can result from spinal anesthesia.

A disadvantage is the greater technical challenge of

introducing the anesthetic agent into the epidural space
rather than the subarachnoid space.
Spinal Anesthesia
local anesthetic agent is introduced into the subarachnoid
space at the lumbar level, usually between L4 and L5
Anesthesia of the lower extremities, perineum, and lower
abdomen.

For the lumbar puncture procedure, the patient usually lies

on the side in a knee–chest position.

Sterile technique is used as a spinal puncture is made and

the medication is injected through the needle.

As soon as the injection has been made, the patient is

positioned on their back.

If a relatively high level of block is sought, the head and

shoulders are lowered.
Spinal Anesthesia
A few minutes after induction of a spinal anesthetic agent,
anesthesia and paralysis affect the toes and perineum and
then gradually the legs and abdomen.

Nausea, vomiting, and pain may occur during surgery

when spinal anesthesia is used.

Headache may be an aftereffect of spinal anesthesia.

Measures that increase cerebrospinal pressure are helpful

in relieving headache.

These include maintaining a quiet environment, keeping

the patient lying flat, and keeping the patient well
hydrated.
Local Conduction Blocks
Examples of common local conduction blocks include:

Brachial plexus block, which produces anesthesia of the

arm

Paravertebral anesthesia, which produces anesthesia of

the nerves supplying the chest, abdominal wall, and
extremities

Transsacral (caudal) block, which produces anesthesia

of the perineum and, occasionally, the lower abdomen
Moderate Sedation
Moderate sedation, previously referred to as conscious
sedation, is a form of anesthesia that involves the IV
administration of sedatives or analgesic medications
to reduce patient anxiety and control pain during
diagnostic or therapeutic procedures.

For specific short-term surgical procedures in hospitals

and ambulatory care centers

The goal is to depress a patient’s level of

consciousness to a moderate level to enable surgical,
diagnostic, or therapeutic procedures to be performed
while ensuring the patient’s comfort during and
cooperation with the procedures.
Nurse Responsibilities
The patient receiving moderate sedation is never left alone
and is closely monitored by a physician or nurse who is
knowledgeable and skilled in detecting dysrhythmias,
administering oxygen, and performing resuscitation

The continual assessment of the patient’s vital signs, level

of consciousness, and cardiac and respiratory function is
an essential component of moderate sedation.

Pulse oximetry, a continuous ECG monitor, and frequent

measurement of vital signs are used to monitor the
patient.
Monitored Anesthesia Care
Monitored anesthesia care (MAC), also referred to as
monitored sedation, is moderate sedation given by an
anesthesiologist or CRNA who must be prepared and
qualified to convert to general anesthesia if necessary.

MAC may be used for healthy patients undergoing

relatively minor surgical procedures and for some critically
ill patients who may be unable to tolerate anesthesia
without extensive invasive monitoring and pharmacologic
support
Local Anesthesia
Local anesthesia is the injection of a solution containing
the anesthetic agent into the tissues at the planned
incision site.

Often it is combined with a local regional block by injecting

around the nerves immediately supplying the area.

It is given directly to the surgical field, and the circulating

nurse observes and monitors the patient for possible side
effects

Local anesthesia is often given in combination with

epinephrine.
Advantages of local anesthesia are as
follows:
1. It is simple, economical, and non-explosive.
2. Equipment needed is minimal.
3. Postoperative recovery is brief.
4. Undesirable effects of general anesthesia
are avoided.
5. It is ideal for short and minor surgical
procedures.
Potential Intraoperative Complications
The surgical patient is subject to several risks.

Potential intraoperative complications include

1. Anesthesia awareness,
2. Nausea and vomiting,
3. Anaphylaxis,
4. Hypoxia,
5. Hypothermia, and
6. Malignant hyperthermia.
Anesthesia Awareness
refers to a patient becoming cognizant of surgical
interventions while under general anesthesia and then
recalling the incident.

Indications of the occurrence of anesthesia awareness

include;

✓an increase in the blood pressure,

✓rapid heart rate, and
✓patient movement.

However, hemodynamic changes can be masked by

paralytic medication, beta-blockers, and calcium channel
blockers, thus the awareness may remain undetected.
Nausea and Vomiting
Nausea and vomiting, or regurgitation, may affect patients
during the intraoperative period.

If gagging occurs, the patient is turned to the side,

the head of the table is lowered, and a basin is provided to
collect the vomitus.

Suction is used to remove saliva and vomited gastric

contents.
Anaphylaxis
An anaphylactic reaction can occur in
response to many medications, latex,
or other substances.

The reaction may be immediate or

delayed.

Anaphylaxis can be a life-threatening

reaction
Hypoxia and Other Respiratory
Complications
Associated potential complication with General
Anesthesia;

✓Inadequate ventilation,
✓Occlusion of the airway,
✓Inadvertent intubation of the esophagus, and
✓Hypoxia
Nurse Responsibilities
Brain damage from hypoxia occurs within minutes;
therefore, vigilant monitoring of the patient’s oxygenation
status is a primary function of the anesthesiologist or
CRNA and the circulating nurse.

Peripheral perfusion is checked frequently, and pulse

oximetry values are monitored continuously.
Hypothermia
Patient’s temperature may fall.

Glucose metabolism is reduced, and as a result, metabolic

acidosis may develop.

A core body temperature that is lower than normal (36.6°C

[98°F] or less).

Unintentional hypothermia needs to be avoided. If it

occurs, it must be minimized or reversed.

If hypothermia is intentional, the goal is safe return

to normal body temperature.
Nurse Responsibilities
Environmental temperature in the OR can temporarily be
set at 25°C to 26.6°C (78°F to 80°F).

IV and irrigating fluids are warmed to 37°C (98.6°F).

Wet gowns and drapes are removed promptly and replaced

with dry materials, because wet materials promote heat
loss.

Warm air blankets and thermal blankets can also be used

on the areas not exposed for surgery, and minimizing the
area of the patient that is exposed will help maintain core
temperature.
Whatever methods are used to rewarm the
patient, warming must be accomplished
gradually, not
rapidly.

Conscientious monitoring of core temperature,

urinary output, ECG, blood pressure, arterial
blood gas levels, and serum electrolyte levels
is required.
Malignant Hyperthermia
is a rare inherited muscle disorder that is chemically
induced by anesthetic agents

This disorder can be triggered by myopathies, emotional

stress, heatstroke, neuroleptic malignant syndrome,
strenuous exercise exertion, and trauma.

It occurs in 1 in 50,000 to 100,000 adults.

Susceptible people include those with strong and bulky

muscles, a history of muscle cramps or muscle weakness
and unexplained temperature elevation, and an
unexplained death of a family member during surgery
that was accompanied by a febrile response.
Clinical Manifestations of Malignant
Hyperthermia
Tachycardia (heart rate greater than 150 bpm) – early sign
Hypercapnia –early respiratory sign

Ventricular dysrhythmia
Hypotension
Decreased cardiac output
Oliguria

Late sign
Cardiac arrest
Rise in temperature
1°C to 2°C (2°F to 4°F) every 5 minutes
Core body temperature can exceed 42°C (107°F)
Medical Management for Malignant
Hyperthermia
Goals of treatment are;

✓To decrease metabolism,

✓Reverse metabolic and respiratory acidosis,
✓Correct dysrhythmias,
✓Decrease body temperature,
✓Provide oxygen and nutrition to tissues, and
✓Correct electrolyte imbalance.
Nursing Management
✓Identify patients at risk,
✓Recognize the signs and symptoms,
✓Have the appropriate medication and
equipment available,
✓Be knowledgeable about the protocol to
follow.
✓Preparation may be lifesaving for the
patient.
Patient Position
A. The dorsal recumbent position, usual position for
surgery. This position is used for most abdominal
surgeries, except for surgery of the
gallbladder or pelvis

B. The Trendelenburg position usually is used for

surgery on the lower abdomen and pelvis to obtain good
exposure by displacing the intestines into the upper
abdomen.

C. The lithotomy position is used for nearly all perineal,

rectal, and vaginal
surgical procedures

D. The Sims or lateral position is used for renal

surgery.
Nursing Management
Assessment
Diagnosis
Planning
Intervention
Evaluation

Discussed further on RLE

Postoperative Nursing
Management
Immediate Postoperative Nursing
Interventions
The postoperative period extends from the time the patient
leaves the operating room (OR) until the last follow-up
visit with the surgeon.

This may be as short as a day or two or as long as several

months.

Careful assessment and immediate intervention assist the

patient in returning to optimal function quickly, safely, and
as comfortable as possible.

Ongoing care in the community through home care, clinic

visits, office visits, or telephone follow-up facilitates an
uncomplicated recovery.
Care of the Patient in the Postanesthesia
Care Unit
Postanesthesia care unit (PACU), formerly referred to
as the recovery room or postanesthesia recovery room,

located adjacent to the OR suite.

Patients still under anesthesia or recovering from

anesthesia are placed in this unit for easy access to
experienced, highly skilled nurses, anesthesia providers,
surgeons, advanced hemodynamic and pulmonary
monitoring and support, special equipment, and
medications.
Phases of Postanesthesia Care
Phase I PACU - intensive nursing care is provided during
the immediate recovery phase

Phase II PACU - the patient is prepared for self-care or

an extended care setting

Phase III PACU - the patient is prepared for discharge

Patients may remain in a PACU for as long as 4 to 6
hours, depending on the type of surgery and any
preexisting conditions or comorbidities.
Admitting the Patient to the Postanesthesia
Care Unit
During Transport from the OR to the PACU, the anesthesia
provider remains at the head of the stretcher (to maintain
the airway), and a surgical team member remains at the
opposite end.
Nursing Management in the Postanesthesia
Care Unit
The nursing management objectives for the patient in the
PACU are;

To provide care until the patient

✓has recovered from the effects of anesthesia (e.g., until

resumption of motor and sensory functions),
✓is oriented,
✓has stable vital signs, and
✓shows no evidence of hemorrhage or other
complications
Assessing the Patient
Assessments of the patient’s

✓Airway,
✓Respiratory function,
✓Cardiovascular function,
✓Skin color,
✓Level of consciousness, and
✓Ability to respond to commands

are the cornerstones of nursing care in the PACU

Initial Nursing Assessment
ｷ Verify patient’s identity, operative procedure and the surgeon who
performed the procedure.

ｷ Evaluate the following sign and verify their level of stability with the
anesthesiologist:

- Respiratory status
- Circulatory status
- Pulses
- Temperature
- Oxygen Saturation level
- Hemodynamic values

ｷ Determine swallowing and gag reflex , LOC and patients response

to stimuli. Copyright © 2008 Lippincott Williams & Wilkins.
ｷ Evaluate lines, tubes, or drains, estimate blood loss, condition of
wound, medication used, transfusions and output.

ｷ Checks any intravenous (IV) fluids with the goal of

maintaining a euvolemic state

ｷ Evaluate the patient’s level of comfort and safety.

ｷ Perform safety check; side rails up and restraints are properly in

placed.

ｷ Evaluate activity status, movement of extremities.

ｷ Review the health care provider’s orders.

Maintaining a Patent Airway
The primary objective in the immediate postoperative
period is to maintain ventilation and thus prevent

➢hypoxemia (reduced oxygen in the blood) and

➢hypercapnia (excess carbon dioxide in the blood).

The nurse assesses;

✓Respiratory rate and depth,
✓Ease of respirations,
✓Oxygen saturation, and
✓Breath sounds.
Patients who have experienced prolonged anesthesia
usually are unconscious, with all muscles relaxed.

When the patient lies on their back, the lower jaw

and the tongue fall backward and the air passages become
obstructed called hypopharyngeal obstruction

Signs of occlusion include

➢Choking;
➢Noisy and irregular respirations;
➢Decreased oxygen saturation scores; and, within
minutes, a blue, dusky color (cyanosis) of the skin.
Nurse needs to place the palm of the hand at the
patient’s nose and mouth to feel the exhaled Breath

Because movement of the thorax and the diaphragm does

not necessarily indicate that the patient is breathing,
The anesthesiologist or CRNA may leave a hard rubber or
plastic airway in the patient’s mouth to maintain a
patent airway

Such a device should not be removed until signs such as

gagging indicate that reflex action is returning.
Maintaining a Patent Airway

ﾘ Allow the airway ( ET tube ) to remain in place until

the patient begins to waken and is trying to eject the
airway.

ﾘ The airway keeps the passage open and prevents the

tongue from falling backward and obstructing the air
passages.

ﾘ Aspirate excessive secretions when they are heard in

the nasopharynx and oropharynx.
Maintaining Cardiovascular Stability
the nurse assesses;

✓Level of consciousness;
✓Vital signs;
✓Cardiac rhythm;
✓Skin temperature, color, and moisture;
✓Urine output.
✓Patency of all IV lines.
The primary cardiovascular complications seen in the
PACU include;

✓Hypotension and shock,

✓Hemorrhage,
✓Hypertension, and
✓Dysrhythmias.
Hypotension and Shock
Hypotension can result from;

➢Blood loss,
➢Hypoventilation,
➢Position changes,
➢Pooling of blood in the extremities, or
➢Side effects of medications and anesthetics.

If the amount of blood loss exceeds 500 mL

(especially if the loss is rapid), replacement is usually
indicated.
Shock
➢one of the most serious postoperative complications, can
result from hypovolemia and decreased intravascular
volume

Types of shock are classified as;

➢HYPOVOLEMIC, (the most common type of shock)

➢CARDIOGENIC,
➢NEUROGENIC,
➢ANAPHYLACTIC,
➢SEPTIC.
Classic signs of hypovolemic shock (the most common
type of shock) are;

✓pallor;
✓cool, moist skin;
✓rapid breathing;
✓cyanosis of the lips, gums, and tongue;
✓rapid, weak, thready pulse;
✓narrowing pulse pressure;
✓low blood
✓pressure; and
✓concentrated urine.
Hypovolemic shock can be avoided largely by the
timely administration of;

➢IV fluids,
➢blood,
➢blood products, and
➢medications that elevate blood pressure.

The primary intervention for hypovolemic shock is

volume replacement, with an infusion of lactated
Ringer solution, 0.9% sodium chloride solution,
colloids, or blood component therapy
Hemorrhage
Hemorrhage is an uncommon yet serious complication of
surgery that can result in hypovolemic shock and
death.

The patient presents with;

✓Hypotension;
✓Rapid, thready pulse;
✓Disorientation;
✓Restlessness;
✓Oliguria;
✓Cold, pale skin.
TYPES OF HEMORRHAGE
The early phase of shock will manifest in;

✓ Feelings of apprehension,
✓ Decreased cardiac output, and
✓ Vascular resistance.
✓ Breathing becomes labored, and “air hunger” will
be exhibited;
✓ The patient will feel cold (hypothermia) and may
experience tinnitus.

Transfusing blood or blood products and determining

the cause of hemorrhage are the initial therapeutic
measures.
The patient is placed in the shock position (flat on back;
legs elevated at a 20-degree angle; knees kept
straight).

If hemorrhage is suspected but cannot be visualized, the

patient may be taken back to the OR for emergency
exploration of the surgical site.
Hypertension and Dysrhythmias
Hypertension is common in the immediate postoperative
period secondary to sympathetic nervous system
stimulation from pain, hypoxia, or bladder distention.

Dysrhythmias are associated with electrolyte imbalance,

altered respiratory function, pain, hypothermia, stress, and
anesthetic agents.

Both hypertension and dysrhythmias are managed by

treating the underlying causes.
Immediate Post-Op
Assessment and Interventions
Areas of Concern Intervention
Neurological Status Assess LOC– response to name
Return of swallow and gag reflex
Fluid and Electrolyte Intake and Output
Balance IV Fluids

Dressing, Tubes, Drains Color, consistency and amount of

drainage

Pain May need 1/2 to 1/3 less analgesia in

recover room

Safety and Comfort Side rails

Warmth
Aseptic Technique
 Areas of Concern Intervention

Respiratory ASSESS !!!

Position on Side
Keep Airway in
Oxygen
Cardiovascular ASSESS !!!
Watch for:
Post-op hypotension; cardiac arrest;
hemorrhage
Signs of Hemorrhage:
↑ pulse and respiratory rate; restlessness;
↓ blood pressure; cold, clammy skin; thirst; pallor
Copyright © 2008 Lippincott Williams & Wilkins.
Common Post-Operative Orders

• NPO until fully alert, then ice chips as tolerated.

Advance diet as tolerated.
• Suction prn
• Complete current IV then discontinue if pt. tolerating
fluids.
• Compazine 5 mg prn for nausea and vomiting
• Morphine Sulfate 10 mg IM every 3-4 hours prn
Common Post-Operative Orders

• Accurate intake and output

• T,C, and DB every 2 hours
• Hemoglobin and hematocrit in a.m.
• Catheter if patient can’t void in 8 – 10 hours
• Reinforce dressing prn
Copyright © 2008 Lippincott Williams & Wilkins.
Determining Readiness for Post anesthesia
Care Unit Discharge
A patient remains in the PACU until fully recovered from
the anesthetic agent.

Indicators of recovery include;

✓ Stable blood pressure,

✓ Adequate respiratory function, and
✓ Adequate oxygen saturation level compared with
✓ Baseline.

The Aldrete score is used to determine the patient’s

general condition and readiness for transfer from the PACU
The Aldrete score is usually between 7 and 10 before
discharge from the PACU.

Patients with a score of less than 7 must remain

in the PACU until their condition improves or until
they are transferred to an ICU, depending on their
preoperative baseline score
Preparing the Postoperative Patient for
Direct Discharge
Ambulatory surgical centers frequently have a step-
down PACU similar to a phase II PACU.

Patients seen in this type of unit are usually healthy,

and
the plan is to discharge them directly to home.

Prior to discharge, the patient will require verbal and

written instructions and information about follow-up
care.
Promoting Home, Community-Based,
and Transitional Care
To ensure patient safety and recovery, expert patient
education and discharge planning are necessary when a
patient undergoes same-day or ambulatory surgery

Alternative formats (e.g., large print, Braille) of

instructions or the use of a sign language interpreter may
be required to ensure patient and family understanding.

A translator may be required if the patient and family

members do not understand English.
Discharge Preparation
The patient and caregiver (e.g., family member,
friend) are informed about expected outcomes and
immediate postoperative changes anticipated

•The nurse provides Written instructions covering

each of those points.
•Prescriptions are given to the patient.
•The nursing unit or surgeon’s telephone number is
provided, and the patient and caregiver are
encouraged to call with questions and to schedule
follow-up appointments.
Patient advice;
Limited activity for 24 to 48 hours.

During this time, the patient should not;

➢drive a vehicle,
➢drink alcoholic beverages, or
➢perform tasks that require high levels of energy or skill.

Fluids may be consumed as desired and smaller than

normal amounts may be eaten at mealtime.

Patients are cautioned not to make important decisions at

this time because the medications, anesthesia, and
surgery may affect their decision-making ability.
Receiving the Patient in the Clinical Unit
The patient’s room is readied by assembling the necessary
equipment and supplies:

✓IV pumps,
✓Drainage receptacle holder,
✓Suction equipment,
✓Oxygen,
✓Emesis basin,
✓Tissues,
✓Disposable pads,
✓Blankets, and
✓Postoperative documentation forms.