Requisites for Validity of Informed Consent

 Written permission is best and legally

accepted.
 Signature is obtained with the client’s
complete understanding of what to occur.

- adult sign their own operative permit

-obtained before sedation

 For minors, parents or someone standing in

 Then take a deep breath through the nose
their behalf, gives the consent.
and mouth, letting the abdomen rise as the
Note: for a married emancipated minor parental lungs fill with air.
consent is not needed anymore, spouse is accepted  Hold breath for a count of 5.
 Exhale and let out all the air through your
 For mentally ill and unconscious patient, nose and mouth.
consent must be taken from the parents or  Repeat this exercise 15 times with a short
legal guardian rest after each group of 5.
 If the patient is unable to write, an “X” is
accepted if there is a witness to his mark
 Secured without pressure and threat
 A witness is desirable – nurse, physician or
authorized persons.
 When an emergency situation exists, no
consent is necessary because inaction at
such time may cause greater injury.
(permission via telephone/cellphone is
accepted but must be signed within 24hrs.)

Preoperative Care

Physical Preparation

Before Surgery: Turning
 Correct any dietary deficiencies  Promotes removal of chest secretions.
 Reduce an obese person’s weight  Interlace his fingers and place hands over
 Correct fluid and electrolyte imbalances the proposed incision site, this will act as a
 Restore adequate blood volume with blood splint and will not harm he incision.
transfusion (BT)  Lean forward slightly while sitting in bed.
 Treat chronic diseases  Breath, using diaphragm
 Halt or treat any infectious process  Inhale fully with the mouth slightly open.
 Treat an alcoholic person with vitamins  Let out 3-4 sharp hacks.
 supplementation, IVF or fluids if dehydrated  With mouth open, take in a deep breath and
quickly give 1-2 strong coughs.

Foot and Leg Exercise

 Moving the legs improves circulation and

muscle tone.
 Have the patient lie supine, instruct patient
to bend a knee and raise the foot
 – hold it a few seconds and lower it to the
bed.
 Repeat above about 5 times with one leg
and then  with the other. Repeat the set 5
times every 3-5 hours.
  Then have the patient lie on one side and
exercise the legs by pretending to pedal a
bicycle.
 For foot exercise, trace a complete circle
with the great toe.

Preparing the Patient the Evening Before Surgery

Preparing the Skin

- have a full bath to reduce microorganisms in the

skin.

- hair should be removed within 1-2 mm of the skin

to  avoid skin breakdown,  use of electric clipper is
preferable.

Preparing the G.I tract

- NPO, cleansing enema as required

Preparing for Anesthesia

- Avoid alcohol and cigarette smoking for at least 24

hours before surgery.

Promoting rest and sleep

Transporting the Patient to the OR
- Administer sedatives as ordered
 Adhere to the principle of maintaining the
comfort and safety of the patient.
 Accompany OR attendants to the patient’s
bedside for introduction and proper
identification.
 Assist in transferring the patient from bed to
stretcher.
 Complete the chart and preoperative
checklist.
 Make sure that the patient arrive in the OR
at the proper time.

Patient’s Family
Preparing the Person on the Day Of Surgery
 Direct to the proper waiting room.
Early A.M Care  Tell the family that the surgeon will probably
contact them immediately after the surgery.
 Awaken 1 hour before preop medications  Explain reason for long interval of waiting:
 Morning bath, mouth wash anesthesia prep, skin prep, surgical
 Provide clean gown procedure, RR.
 Remove hairpins, braid long hair, cover hair  Tell the family what to expect postop when
with cap if available. they see the patient
 Remove dentures, colored nail polish,
hearing aid, contact lenses, jewelries. PHASE 2 : INTRAOPERATIVE
 Take baseline vital sign before preop
medication. Goals
 Check ID band, skin prep
 Check for special orders – enema, IV line  Asepsis
 Check NPO  Homeostasis
 Have client void before pre-op medication  Safe Administration of Anesthesia
 Continue to support emotionally  Hemostasis
 Accomplished “pre-op care checklist"
Surgical Setting

Semi-restricted Area

 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  The temperature in the procedure room
persons should maintained    between 68 F - 75 F
 peripheral support areas consists of: storage ( 20 - 24 degrees C)
areas for clean and sterile supplies,  Humidity level between 50 - 55 % at all
sterilization equipment and corridors leading times
to procedure room.
Ventilation and Air Exchange System
Restricted Area
 Air exchange in each procedure room should
 includes the procedure room where surgery be at least    25 air exchanges every hour,
is performed and adjacent sub-sterile areas and five of that should be    fresh air.
where the scrub sinks and autoclaves are  A high filtration particulate filter, working at
located 95%    efficiency is recommended.
 personnel working in this area must be in  Each procedure room should maintained
proper operating room attire 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

Electrical Safety

 Faulty wiring, excessive use of extension

cords, poorly    maintained equipment and
lack of current safety    measures are just
some of the hazardous factors that    must
be constantly checked
 All electrical equipment new or used, should
be  routinely checked by qualified personnel.
 Equipment that fails to function at 100%
efficiency should be taken out of service
immediately

Environmental Safety

 The size of the procedure room

 Temperature and humidity control
 Ventilation and air exchange system
 Electrical Safety
 Communication System

Size of the Procedure Room

 Usually rectangular or square in shape

 20 x 20 x 10 with a minimum floor space of
360 square feet
 Each procedure room must have the
following equipment:
 Communication System
 Oxygen and vacuum outlets
 Mechanical ventilation assistance equipment
 Respiratory and Cardiac monitoring
equipment
 X ray film illumination boxes
 Cardiac defibrillator
 High-efficiency particulate air filters
 Adequate room lighting
 Emergency lighting system

Temperature and Humidity Control

Position During Surgery

Supine ( Dorsal Recumbent )

- Abdominal, extremity, vascular, chest, neck, facial,

ear  breast surgery

Positioning Techniques

 Patient lies flat on back with arms either

extended on arm boards  or placed along
side of body.
 Small padding placed under patient’s head,
neck and under knees
 Vulnerable pressure points should be
padded.
 Safety strap applied 2 in. above knees.
 Eyes should be protected by using eye patch
and ointment.

Prone Position

- Surgeries involving posterior surface of the body

( spine, neck, buttocks and lower extremities )
Positioning Techniques - Perineal, vaginal, rectal surgeries; combined
abdominal vaginal procedure
 Chest rolls or bolster are placed on
operating table prior to positioning Positioning Techniques
 Foam head rest, head turned to side or
facing downward  Patient is placed in supine position with
 Patient’s arms are rotated to the padded arm buttocks near lower break in the table
boards that face head,  bringing them ( sacrum are should be well padded )
through their normal range of motion.  Feet are placed in stirrups, stirrups height
 Padding for knees and pillow for lower should not be    excessively high or low, but
extremities to prevent toes from  touching even on both sides.
mattress.  Knee brace must not compress vascular
 Safety strap applied 2 in. above the knees structures or nerves in the popliteal space.
 Pressure from metal stirrups against upper
inner aspect of thigh  and calf should be
avoided.
 Legs should be raised and lowered slowly
and simultaneously    ( may require two
people )

Trendelenburg Position

- Surgeries involving lower abdomen, pelvic organ

when there is a need to tilt abdominal viscera away
from the pelvic area.

Positioning Techniques

 Patient is supine with head lower than feet. Modified Fowler ( Sitting Position )
 Shoulder braces should not be used as
they  may cause damage brachial plexus. - Otorhinology (ear and nose ), neurosurgery
 When patient is returned to supine position, Positioning Techniques
care must be taken move leg section slowly,
then the entire table to level position.  Patient is supine, positioned over the upper
 Modification of this position can be used break in  the table
for  hypovolemic shock.  Backrest is elevated, knees flexed
 Extremity position and safety strap are the  Arms rest on pillow, placed in lap; safety
same as for supine. strap 2 in.  above the knees.
 Slow movement in and out of position must
be used to prevent drastic changes in blood
volume  movement.
 Anti embolic hose should be used to assist
venous   return.
 When using special neurologic headrest,
eyes must be  protected.

Reverse Trendelenberg Position

-Upper abdominal, head, neck and facial surgery

Positioning Technique
Jack Knife Position
 Patient is supine with head higher than feet.
- Rectal procedures, sigmoidoscopy and
 Small pillow under neck and knees.
colonoscopy
 Well - padded footboard should be used to
prevent slippage to foot of the  table. Positioning Techniques
 Anti embolic hose should be used if position
is to be maintained for an extended period  Table is flexed at center break
of time.  All precautions taken with prone position
 Patient should be returned slowly to supine are taken with Jack knife position.
position.  Table strap applied over thighs

Lithotomy

ANETHESIA
  State of “Narcosis”
 Anesthetics can produce muscle relaxation,
block transmission of pain nerve impulses
and suppress reflexes.
 It can also temporary 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
1. General Anesthesia

 Reversible state consisting of complete loss

of consciousness and sensation.
 Protective reflexes such as cough and gag
are lost
 Provides analgesia, muscle relaxation and
sedation.
 Produces amnesia and hypnosis

Techniques used in General Anesthesia

A. Intravenous Anesthesia

 This is being administered intravenously and

extremely rapid. B. Spinal Anesthesia 
 Its effect will immediately take place after
thirty minutes of introduction. ( Subarachnoid block )
 It prepares the client for smooth transition
to the surgical anesthesia  local anesthetic is injected through
lumbar puncture, between L4 and L5
B. Inhalation Anesthesia  anesthetic agent is injected into
subarachoid spaceb surrounding the
 This comprises of volatile liquids or gas spinal cord.
and oxygen.
 Administered through a mask or - Low spinal, for perineal/rectal areas
endotracheal tube.
- Mid spinal T10 ( below level of umbilicus)

for hernia repair and appendectomy.

-High spinal T4 ( nipple line ), for CS

 agents used are procaine, tetracaine,

lidocaine and bupivacaine. 

Stages of General Anesthesia

Stage 1: Onset / Induction.

Stage 2: Excitement / Delirium.

Stage 3: Surgical

Stage 4: Medullary / Stage of Danger

C. Epidural Anesthesia

 Achieved by injecting local anesthetic

into epidural space by way of a lumbar
puncture.
 Result similar to spinal analgesia
 agents use are chloroprocaine, lidocaine
and bupivacaine.

G. Field Block/Local Anesthesia

 The area proximal to a planned incision can

be injected and
infiltrated with local anesthetic agents.
 Nursing Management
 Assessment
 Diagnosis
 Planning
 Intervention
D. Peripheral Nerve Block  Evaluation

 Achieved by injecting a local anesthetic

to anesthetize the surgical site. Complications and Discomforts of Anesthesia
 Agents use are chloroprocaine, lidocaine
and bupivacaine.  Hypoventilation - inadequate ventilatory
support after paralysis of respiratory
muscles.
 Oral Trauma
 Malignant Hyperthermia - uncontrolled
skeletal muscle contraction
 Hypotension - due to preoperative
hypovolemia or untoward reactions to
anesthetic agents.
 Cardiac Dysrhythmia - due to preexisting
cardiovascular compromise, electrolyte
imbalance or untoward reaction to
anesthesia.
E. Intravenous Block ( Beir block )  Hypothermia - due to exposure to a cool
ambient OR environment and loss of
 Often used for arm,wrist and hand thermoregulation capacity from anesthesia.
procedure  Peripheral Nerve Damage - due to improper
  An occlusion tourniquet is applied to positioning of patient or use of restraints.
the extremity to prevent infiltration and  Nausea and Vomiting
absorption of the injected IV agents  Headache
beyond the involved extremity.
PHASE 3 : POSTOPERATIVE

Goals:

 Restore homeostasis and prevent

complication
 Maintain adequate cardiovascular and tissue
perfusion.
 Maintain adequate respiratory function.
 Maintain adequate nutrition and elimination.
 Maintain adequate fluid and electrolyte
balance.
 Maintain adequate renal function.
 Promote adequate rest, comfort and safety.
 Promote adequate wound healing.
F. Caudal Anesthesia
 Promote and maintain activity and mobility.
 Provide adequate psychological support.
 Is produced by injection of the local
anesthetic into the caudal
or sacral canal

POST ANESTHESIA CARE UNIT (PACU ) CARE

Transport of client from Operating Room (OR ) to  Initiate O2 therapy, to increase
Recovery Room (RR) O2 availability from the blood.
 Place the patient in shock position with
 avoid exposure  his feet elevated ( unless contraindicated
 avoid rough handling )
 avoid hurried movement and rapid changes
in position. Maintaining Adequate Respiratory Function

Initial Nursing Assessment 1. Place the patient in lateral position with

 Verify patient’s identity, operative neck extended ( if not contraindicated ) and
procedure and the surgeon who performed upper arm supported on a pillow.
the procedure. 2. Turn the patient every 1 to 2 hours to
 Evaluate the following sign and verify their facilitate breathing and ventilation.
level of stability with the anesthesiologist: 3. Encourage the patient to take deep breaths,
use an incentive spirometer.
- Respiratory status 4. Assess lung fields frequently by auscultation.
5. Periodically evaluate the patient’s
- Circulatory status orientation – response to name and
command.
- Pulses Note: Alterations in cerebral function may
suggest impaired  O2 delivery
- Temperature

- Oxygen Saturation level Assessing Thermoregulatory Status

- Hemodynamic values  Monitor temperature per protocol to be

alert for malignant hyperthermia or to detect
 Determine swallowing and gag reflex , Level hypothermia.
of Consciousness (LOC ) and patients  Report a temperature over 37.8 C or under
response to stimuli. 36.1 C
 Evaluate lines, tubes, or drains, estimate  Monitor for postanesthesia shivering, 30-45
blood loss, condition of wound, medication minutes after admission to the PACU.
used, transfusions and output.  Provide a therapeutic environment with
 Evaluate the patient’s level of comfort and proper temperature and humidity.
safety.
 Perform safety check; side rails up and Maintaining Adequate Fluid Volume
restraints are properly in placed.
 Evaluate activity status, movement of  Administer I.V solutions as ordered.
extremities.  Monitor evidence of F&E imbalance such as
 Review the health care provider’s orders. N&V
 Evaluate mental status, skin color and turgor
Initial Nursing Interventions  Recognized signs of:

Maintaining a Patent Airway A. Hypovolemia

- decrease BP
- decrease urine output
- decreased CVP
- increased pulse

B. Hypervolemia

- increase BP
- changes in lung sounds (S3 gallop )
- increased CVP
-Monitor I&O

Minimizing Complications of Skin Impairment

Assessing Status of Circulatory System  Perform hand washing before and after
contact with the patient
 Take VS per protocol, until patient is  Inspect dressings routinely and reinforce
well stabilized. them if necessary.
 Monitor intake and output closely.  Record the amount and type of wound
 Recognized early symptoms of shock or drainage.
hemorrhage:  Turn patient frequently and maintain good
 cool extremities body alignment.

- decreased urine output ( less than 30ml/hr )

- slow capillary refill ( greater than 3 sec. ) Maintaining Safety
- lowered BP
- narrowing pulse pressure  Keep the side rails up until the patient is
- increased heart rate fully awake.
  Protect the extremity into which I.V fluids
are running so needle will not become
accidentally dislodged.
 Avoid nerve damage and muscle strain by
properly supporting and padding pressure
areas.
 Recognized that the patient may not be able
to complain of injury such as the pricking of
an open safety pin or clamp that is exerting
pressure.
 Check dressing for constriction

Parameter for Discharge from PACU/RR

 Activity.  Able to obey commands

 Respiratory. Easy, noiseless breathing
 Circulation. BP within 20mmHg of pre- Common Post-Operative Orders
op level  NPO until fully alert, then ice chips as
 Consciousness. Responsive tolerated.
 Color. Pinkish skin and mucus membrane Advance diet as tolerated.
 Suction prn
Nursing Care of the Client During the Intermediate  Complete current IV then discontinue if pt.
Postop Period (RR – Unit ) tolerating fluids.
Baseline Assessment  Compazine 5 mg prn for nausea and
vomiting
 Respiratory Status  Morphine Sulfate 10 mg IM every 3-4 hours
 Cardiovascular Status prn
 Vital Signs  Accurate intake and output
 Color and Temperature of Skin  T,C, and DB every 2 hours
 Level of Consciousness  Hemoglobin and hematocrit in a.m.
 Catheter if patient can’t void in 8 – 10 hours
-Tubes  Reinforce dressing prn
- Drain
WOUND CARE
- NGT
Commonly Used Wound Dressing
- T-tube                  

 Position

Immediate Post-Op Assessment and Interventions

The strips of tape should be placed at the ends of the

dressing and must
be sufficiently long and wide to secure the dressing.
The tape should
adhere to intact skin.
 Incision Support

Cleaning Surgical Site

Wound Irrigation

Use kidney basin and syringe to safely irrigate surgical

wound