Perioperative Nursing PDF

NURSING By Rhizza Gene Mae P. Ragasa, RN  01 INTRODUCTION TO PERI- OPERATIVE NURSING 02 PRE-OPERATIVE PHASE LIST OF 2.1 PRE-OPERATIVE ASSESSMENT CONTENTS AND PREPARATION 2.2 ETHICO-LEGAL ASPECT 3.1 SUR...

NURSING By Rhizza Gene Mae P. Ragasa, RN  01 INTRODUCTION TO PERI- OPERATIVE NURSING 02 PRE-OPERATIVE PHASE LIST OF 2.1 PRE-OPERATIVE ASSESSMENT CONTENTS AND PREPARATION 2.2 ETHICO-LEGAL ASPECT 3.1 SURGICAL ENVIRONMENT AND TEAM 3.2 POSITIONING, INCISION, ASEPTIC TECHNIQUES 3.3 ANESTHESIA 4.1 POST ANESTHESIA CARE UNIT (PACU) NURSING MANAGEMENT IN 4.2 SURGICAL UNIT SURGERY KHEIRURGOS - working by hand SURGERY Concerned with the treatment of disease, injury and deformity Any procedure that involves entry into the human body  SURGERY Emerged as medical specialty in mid 19th century Concepts about antisepsis were vague Surgery resulted in high mortality Surgery was performed as a last resort Sepsis was the result of the patient’s inability to withstand the procedure  SURGERY Later half of the 19th century Ignaz Semmelweis Joseph Lister  SURGERY Semmelweis - 1847 Importance of handwashing before and after surgical procedures  SURGERY Joseph Lister - 1865 Proposed that germs should be prevented from entering the surgical wound His theory opened the door to the development of antiseptic techniques in surgery  SURGERY The presence of nurses in the surgical arena was not recognized as important during the early years of surgery In the late part of the 19th century, OR Nursing education began PHASE begins when the patient is transferred onto the OR table and ends with admission to the PACU. Nursing duties involve acting as scrub nurse, circulating nurse, or registered nurse first assistant (RNFA) PERIOPERATIVE 3 PHASES PHASE 1.Preoperative Phase begin and end at a 2.Intraoperative particular point in the READ MORE Phase sequence of events in the 3.Postoperative surgical experience Phase PHASE begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient onto the operating room (OR) table. PHASE begins when the patient is transferred onto the OR table and ends with admission to the PACU. Nursing duties involve acting as scrub nurse, circulating nurse, or registered nurse first assistant (RNFA) PHASE begins with the admission of the patient to the PACU and ends with a follow-up evaluation in the clinical setting or home 4 BASIC PATHOLOGIC CONDITIONS THAT REQUIRE SURGERY 1. OBSTRUCTION a blockage, an impairment of flow; are dangerous because they block the flow of blood, air, CSF, urine & bile through the body. 2. PERFORATION Rupture of the organ, artery or bleb 25K+  3. EROSION Break in the continuity of tissue surface Caused by irritation, infection, ulceration or inflammation 25K+ Can damage the walls of blood vessels resulting in serious bleeding  4. TUMORS Abnormal growth of tissue that serves no physiologic function in the body 25K+ 1.Diagnostic - to establish the presence of a disease condition (Breast biopsy, Arthroscopy) 2.Exploratory - to determine the extent of disease condition (Exploratory laparotomy) 3.Curative - to treat the disease condition a. Ablative b. Constructive c. Reconstructive / Restorative 4. Palliative – to relieve distressing sign and symptoms, not necessarily to cure the disease (Colostomy, nerve root resection, tumor debulking) 5. Cosmetic – performed primarily to alter or enhance personal appearance (Rhinoplasty, Liposuction) 1. Minor Surgery - has no significant risk - often done with local anesthesia - Incision and Drainage (I & D), implantation of venous access device, muscle biopsy, suturing 2. Major Surgery - carry greater risks - longer and more extensive than minor surgery - could be complicated or may lead to large losses of blood, vital organs may be involved - post-op complications maybe likely - CS, Craniotomy, Lymph node dissection, mitral valve replacement 1. Simple - only the most overly affected areas involved in the surgery - mastectomy 2. Radical - extensive surgery beyond the area obviously involved - directed at finding a root cause - Radical prostatectomy, radical mastectomy, radical hysterectomy 3. Minimally Invasive Surgery (MIS) - performed in a body cavity or body area through one or more endoscopes - can correct problems, remove organs, take tissue biopsy - fast growing and ever changing type of surgery - Arthroscopy, laparoscopic surgery Inpatient - patient admitted to a hospital –The patient may be admitted the day before or, more often, the day of surgery (often termed same-day admission [SDA]), or the patient may already be an inpatient when surgery is needed. Outpatient and Ambulatory - patient who goes to the surgical area the day of the surgery and returns home on the same day (i.e., same- day surgery [SDS]). - Hospital-based ambulatory surgical centers, freestanding surgical centers, physicians' offices, and ambulatory care centers are common. The overall goal of the preoperative assessment is to identify risk factors and plan care to ensure patient safety throughout the surgical experience. Goals of the assessment are to: ✓ Determine the patient’s psychologic status in order to reinforce the use of coping strategies during the surgical experience. ✓ Determine physiologic factors directly or indirectly related to the surgical procedure that may contribute to operative risk factors. ✓ Establish baseline data for comparison in the intraoperative and postoperative period. ✓ Participate in the identification and documentation of the surgical site and/or side (of body) on which the surgical procedure will be performed. ✓ Identify prescription drugs, over-the-counter medications, and herbal supplements taken by the patient that may result in drug interactions affecting the surgical outcome. ✓ Document the results of all preoperative laboratory and diagnostic tests in the patient’s record, and communicate this information to appropriate health care providers. ✓ Identify cultural and ethnic factors that may affect the surgical experience. ✓ Determine if the patient has received adequate information from the surgeon to make an informed decision to have surgery and that the consent form is signed and witnessed. 1. Nutritional and Fluid Status Identify factors that can affect the patient’s surgical course –Obesity, weight loss, malnutrition, deficiencies in specific nutrients, metabolic abnormalities and effects of medications on nutrition BMI and waist 2. Dentition Assess for dental carries, dentures: decayed teeth or dental prostheses may become dislodged during intubation and occlude the airway This is especially important for older patients as well as those who may not have regular dental care Infection in the mouth can be a source of post-op infection 3. Drug or Alcohol Use Moderate amount of alcohol prior -> weaken immune system and increase post-op complications Illicit drugs -> impede the effectiveness of some meds person with a history of alcohol abuse often suffers from malnutrition and other systemic problems or metabolic imbalances that increase surgical risk 4. Respiratory Status Respiratory infections: postpone surgery Underlying respiratory disease Other comorbid conditions, like HIV and Parkinson’s disease Smoking should be stopped 4 to 8 weeks before surgery 5. Cardiovascular Status Cardiovascular system should be able to support the following for the perioperative period: –Oxygen, fluid, nutritional needs 6. Hepatic and Renal Function Medications and anesthetic agents are properly metabolized 7. Endocrine Function Diabetics: increased risk of hypoglycemia and hyperglycemia Taking of corticosteroids: increased of adrenal insufficiency Thyroid disorders: increased thyrotoxicosis (hyperthyroid disorders) -> Respiratory failure (hypothyroid conditions) 8. Immune Function Presence of allergies including: – medications –Blood transfusions –Contrast agents –Latex food products Immunosuppression 9. Previous Medication Use Important for possible medication interactions –Aspirin – d/c 7-10 days before surgery –Herbal medications – d/c 2 weeks before surgery  Preoperative Interview – occur in advance or on the day of surgery oPurposes: 1) Obtain the patient’s health information 2) Provide and clarify information about the planned surgery, including anesthesia 3) Assess the patient’s emotional state and readiness for surgery, including his or her expectations about the surgical outcomes  Provide baseline data Predict potential complications Preadmission testing (PAT) – for patient scheduled for sx in an ambulatory surgical center or admitted to the hospital on the morning of or day before sx –24 hours to 28 days before the scheduled sx ✓CBC ✓Serum K ✓Serum Na ✓Glucose (FBS) ✓BUN and Creatinine ✓Prothrombin Time ✓CxR ✓ECG  Determine patient’s level of anxiety, coping ability and support systems  Common fears that may arise: 1. Pain 2. Death 3. Anesthesia 4. Disfigurement and Altered Sexuality 5. Separation and Change in Roles  Nursing Interventions to decrease anxiety: 1. Assess client’s fears, anxieties, support systems and patterns of coping 2. Establish rapport with the patient to decrease feelings of depersonalization. 3. Explain the preoperative and postoperative nursing care to decrease fear if the unknown. 4. Explain that anxiety is a normal reaction.  Nursing Interventions to decrease anxiety: 5. Use of humor (sometimes) 6. Enlist patient’s active participation in learning and practicing postoperative activities to give control over the environment. 7. When teaching include family and significant other to promote support.  Tips to Remember: 1. Showing respect for a patient’s cultural values and beliefs facilitates rapport and trust. 2. Identifying the ethnic group to which the patient relates and the customs and beliefs the patient holds about illness and healthcare providers. 3. Listening carefully to the patient is perhaps the most valuable skill at the nurse’s disposal, especially when obtaining the history. 4. An unhurried, understanding and caring nurse promotes confidence on the part of the patient.  Manage preoperative anxiety Decrease secretions in the respiratory tract Reduce reflex irritability Relieve pain and lower the body’s metabolism = less anesthetic is required Administered 45 to 60 mins prior to induction or as ordered  Anticholinergics: decrease secretion of saliva and gastric juices Antiulcer (Histamine H2 Antagonists): Prevent aspiration pneumonitis –Ranitidine, Cimetidine, Famotidine Antiemetics: To increase gastric emptying and decrease nausea and vomiting – Metoclopramide 1. Perform a through assessment of the client and necessary laboratory request are done. 2. Dietary Restrictions 1. NPO (no eating, no drinking including water or smoking) - stomach contains limited volume of gastric secretions = risk for aspiration Nursing Consideration: Remove food and water from the bedside at midnight. Inform caretakers, SO, and all other family members of the client‘s NPO status 3. Skin Preparation: bacteria to a minimum Nursing Consideration: The use of mild antiseptic such as iodine cleanser on the night or on the day before the scheduled surgery. Mechanical shaving can increase skin bacteria. The best practice is to refrain from hair removal unless it interferes with the surgical procedure or wound closure. If hair is removed, it should be done so near to the surgical time. 4. Bowel and Bladder Preparations: prevent injury to the colon and to reduce the number of intestinal bacteria Bowel evacuation – major abdominal, pelvic, perineal or perianal surgery Nursing Consideration: If the client is to have abdominal surgery, an enema or laxative or both may be prescribed the night before surgery. Prepare to insert a Foley Catheter in place, it should be emptied immediately before surgery and the amount and quality of urine output documented 1. Reinforce what the patient has been told about the surgery. Know enough basic information about common procedures to anticipate and answer the common questions. 2. Balance telling too little versus too much. 3. Avoid anxiety-producing words – “pain” (discomfort) 4. Include family members, if possible. 5. Let the patient explain; do return demonstrations. 6. Prepare patient for OR situations (cold, bright, light, never left alone, etc.) INCENTIVE SPIROMETRY INCENTIVE SPIROMETRY INCENTIVE SPIROMETRY The nurse instructs the patient to: 1. Assume a semi-Fowler position or an upright position before initiating therapy. 2. Use diaphragmatic breathing. 3. Place the mouthpiece of the spirometer firmly in the mouth, breathe air in (inspire) slowly through the mouth, and hold the breath at the end of inspiration for about 3 seconds to maintain the ball/indicator between the lines. Exhale slowly through the mouthpiece. INCENTIVE SPIROMETRY The nurse instructs the patient to: 4. Cough during and after each session. Splint the incision when coughing postoperatively. 5. Perform the procedure approximately 10 times in succession, repeating the 10 breaths with the spirometer each hour during waking hours.  COUGHING - May be performed along with deep breathing every 1 to 2 hours after surgery - Purposes: > expel secretions > keep the lungs clear > allow full aeration > prevent pneumonia and atelectasis COUGHING The nurse instructs the patient to: Lean forward slightly from the sitting position in bed, interlace your fingers together, and place your hands across the incision site to act as a splint for support when coughing. Breathe with the diaphragm. With your mouth slightly open, breathe in fully. COUGHING The nurse instructs the patient to: “Hack” out sharply for 3 short breaths. Then keeping your mouth open, take in a quick deep breath and immediately give a strong cough once or twice. This helps clear secretions from your chest. It my cause some discomfort but will not harm your incision. DIAPHRAGMATIC BREATHING The nurse instructs the patient to: POC: semi-Fowler, propped in bed with the back and shoulders well supported with pillows. Feel the movement with your hands resting lightly on the front of the lower ribs and fingertips against the lower chest. Breathe out gently and fully as the ribs sink down and inward toward midline. DIAPHRAGMATIC BREATHING The nurse instructs the patient to: Then take a deep breath through your nose and mouth, letting the abdomen rise as the lungs fill with air. Hold this breath for a count of five. Exhale and let out the air through your nose and mouth. Repeat for 15 times with a short rest after each group of five Practice this 2x a day post-op. SPLINTING - Holding the incision area - Purpose: support feeling of security reduce pain during coughing LEG EXERCISE The nurse instructs the patient to: Lie in a semi-Fowler position Bend your knee and raise your foot – hold it a few seconds, then extend the leg and lower it to the bed. Do this 5 times with one leg and then repeat with the other leg. LEG EXERCISE Then trace circles with the feet by bending them down, in toward each other, up and then out. Repeat these movements five times. TURNING TO THE SIDE Turn on your side with the uppermost leg flexed most and supported on a pillow. Grasp the side rail as an aid to maneuver to the side. Practice diaphragmatic breathing and coughing while on your side. GETTING OUT OF BED Turn on your side. Push yourself with one hand as you swing your legs out of bed. ✓Patient changes into hospital gown, left untied and open at the back ✓Long hair maybe braided, hairpins removed, head is covered with disposable hair cap ✓Dentures or plates are removed ✓NO jewelries ✓Void immediately before going to the OR ✓Administering preanesthetic medication ❑Kept in bed with side rails raised ❑Observe untoward reaction to the medication ❑Immediate surroundings are kept quiet ✓ Maintaining preoperative record ❑Completed medical record ❑Surgical consent  ❑Lab reports ❑Nurses’ records ❑Last minute observations ✓ Transporting the patient to the OR ❑Transported 30 – 60 mins before the anesthetic is to be givem ❑Positioned comfortably on a stretcher, provided with a small head pillow ❑Surrounding area should be quiet  ❑Patient education, surgical procedure and surgical site are verified ✓ Attending to family needs ❑Kept informed of the patient’s progress ❑Inform ahead of time if the patient has attachments post-op, like IV lines, catheters, oxygen lines, etc.  Invasive procedures, such as a surgical incision, a biopsy, a cystoscopy, or paracentesis Procedures requiring sedation or anesthesia A nonsurgical procedure, such as an arteriography, that carries more than a slight risk to the patient Procedures involving radiation Blood product administration  Autonomous decision about whether to undergo a surgical procedure Voluntary and written informed consent from the patient is necessary -> protect the patient from unsanctioned surgery and protect the surgeon from claims of an unauthorized operation  Consent documentation encompasses at least the following: ✓ The patient's name (and legal guardian, if applicable) ✓ Name of the facility in which the procedure is being performed ✓ Specific name of the surgical procedure (or when multiple procedures are being done, the names of those procedures) in terms the patient understands ✓ Site/side of the planned procedure ✓ Name of the practitioner(s) performing the procedure or important aspects of it ✓ Risks of the procedure ✓ Alternative procedures, treatments, or therapies ✓ Signature of the patient (or legal guardian, if applicable) ✓ Date and time consent is obtained ✓ Statement that the procedure was explained to the patient (or legal guardian or both if applicable) ✓ Name and signature of the person who explained the procedure, usually the primary surgeon or physician performing the procedure ✓ Signature of person witnessing the consent Nurse: legal responsibilities to a surgical client is to make sure that the “Operating Permit” / “Informed Consent” is signed active client advocate = to confirm that the client understands the information provided by the surgeon Nurse: witness the signature clarifies the information provided notifies the physician if patient ask for additional information Surgeon: obtain the Operative Permit provide the patient through explanation of the surgical procedure, alternatives, possible complications, benefits, disfigurements or removal of body parts.  Adult client >18 y/o Except when unconscious, mentally incompetent to decide for one’s own care Relative (spouse, next kin or guardian) if cannot sign his own consent In emergency situations, it is wise to have a 2nd listener to obtain permission via a telephone. A telegram is also acceptableIn emergency situations, it is wise to have a 2nd listener to obtain permission via a telephone. A telegram is also acceptable Consent is not needed in an emergency situation if all four of the following criteria are present: 1. There is an immediate threat of life 2. Experts confirm that there is an emergent need for surgery. 3. Client is unable to provide consent and, 4. In some situations that a legally authorized person cannot be located or reached in any means.  Pre-Operative Checklist 1. Ensure that the client is wearing an ID bracelet. 2. Assess for allergies. 3. Review the preoperative checklist to be sure that each item is addressed before the client is transported to surgery. 4. Ensure that informed consent forms were signed for the operative procedures, for any blood transfusion, for disposal of limb, or for surgical sterilization procedures.  Pre-Operative Checklist 5. Ensure that the history and physical exam were completed and documented in the client’s record. 6. Ensure that consultations prescribed were completed and documented in the client’s record. 7. Ensure the prescribed laboratory results are documented in the client’s record.  Pre-Operative Checklist 8. Ensure that ECG and CXR reports are documented in the client’s record. 9. Ensure that a blood type and screening test and cross match is performed and documented in the client’s record. 10. Remove jewelry, makeup, dentures, hairpins, nail polish, glasses and prosthesis.  Pre-Operative Checklist 11. Document that valuables were given to the client’s family members or locked in the hospital safe. 12. Document the last time the client ate or drank. 13. Document that the client has voided prior to surgery.  Pre-Operative Checklist 14. Document that the prescribed pre-op meds were given. 15. Monitor and document client’s vitals signs. 16. Preoperative medications are given to allay anxiety, to decrease pharyngeal secretions, to reduce side effects of anesthetic gents and to induce amnesia.  Pre-Operative Checklist 17. Prepare to administer pre-op meds as prescribed, or on call to the OR immediately before surgery. 18. Inform the client that he/she will get drowsy shortly after the medications are administered. 19. Turn off bright lights to avoid glare. 20. After administering pre-op meds, keep the client in bed with side rails up. Pre-Op sample checklist.pptx  -ectomy -oscopy -orrhapy / rrhapy -plasty -ostomy -otomy -lysis 1. Stress Response Peripheral vasoconstriction with increased coagulability Tachycardia with increased CO, BP & coronary artery dilation Na and water retention Increased gastric acidity and decreased peristalsis 1. Stress Response Bronchial dilatation CHON metabolism Proliferation of granulation and connective tissue Increased blood sugar and mobilization of fat stores Increased cortisol and increased inflammatory response Increased metabolic rate 2. Disruption of vascular system Approaches to stop bleeding: – Use of hemostats/clamps – Sutures – Free ties – Cautery – Gel foams – Pressure dressings 2. Lowered defense against infection 3. Disruption of organ function which could be associated with: The effect of anesthesia Manipulation of the organs 4. Body image disturbance Some surgical procedures involve removal of some body parts or incision in areas of the body that are exposed 5. Lifestyle Change  Begins when the patient enters the surgical suite and ends at the time of transfer to the post anesthesia recovery area, same- day surgery unit or ICU Main concerns of peri-op nurses: – Safety – Patient advocacy (prevent, reduce, control and manage hazards) ZONES OF THE SURGICAL AREAA 1. UNRESTRICTED AREAA ▪provides an entrance and exit from the surgical suite for personnel, equipment and patient ▪Street clothes are allowed 2. SEMIRESTRICTED AREA ▪ provides access to the procedure rooms and peripheral support areas within the surgical suite ▪ Scrub clothes and caps ZONES OF THE SURGICAL AREAA 3. RESTRICTED AREA ▪ includes the procedure room where surgery is performed and adjacent substerile areas where the scrub sinks and autoclaves are located. THE SURGICAL TEAM ▪ Consists of: ✓Patient ✓Anesthesiologist (Physician) / Certified Registered Nurse Anesthetist (CRNA) ✓Surgeon ✓Nurses (Circulating / Scrub) ✓Surgical technicians ✓Registered Nurse First Assistants (RFNAs) / Certified Surgical Technologists Assistants SURGEON ❑ Responsible for the surgical procedure and any surgical judgments about the patient ❑ Performs surgical procedure ❑ Heads the surgical team ❑ Assumes responsibility for all medical acts of judgment and management SURGICAL ASSISTANT ❑Can be another surgeon (resident, intern) or an advanced practice nurse, physician assistant, certified nurse first assistant (CRNFA) or surgical technologist ANESTHESIA PROVIDER ❑Anesthesiologist – give anesthetic agent ❑Certified Registered Nurse Anesthetist (CRNA) - advanced practice registered nurse with additional education and credentials who delivers anesthetic agents under the supervision of an anesthesiologist, surgeon, dentist, or podiatrist ANESTHESIA PROVIDER ❑ Responsibilities: a. Assess patient before surgery b. Selects anesthesia and administers it c. Intubates patient if necessary d. Manages any technical problems r/t administration of anesthetic agent e. Supervises the patient’s condition throughout the surgical procedure SCRUB ROLE ❑The registered nurse, licensed practical nurse, or surgical technologist (or assistant) performs the activities of the scrub role SCRUB NURSE ❑ Responsibilities: a. Setting up the sterile equipment, tables and sterile fields b. Preparing sutures, ligatures and special equipment c. Assisting the surgeon and the surgical assistants d. Together with the circulating nurse, counts all needles, sponges and instruments -> Beginning of the surgery and twice at the end (when wound closure begins and skin is being closed) CIRCULATING NURSE ❑Responsibilities: a. Manages the OR b. Protects the patient’s safety and health by monitoring the activities of the surgical team c. Checks the OR conditions d. Verifies consent CIRCULATING NURSE ❑Responsibilities: e. Continually assess the patient for signs of injury and implementing appropriate interventions f. Monitors aseptic practices to avoid breaks in technique while coordinating the movement of related personnel CIRCULATING NURSE ❑ Responsibilities: g. Monitors the patient and documents specific activities throughout the operation to ensure the patient’s safety and well- being h. Responsible for ensuring that the second verification of the surgical procedure and site takes place and is documented -> Referred to as a time out, surgical pause or universal protocol Factors you need to think about when repositioning the patient for surgery. (Lopez, et., al, 2011). ✓ The client should be as comfortable as possible. ✓ The operative field must be exposed. ✓ The position should not obstruct vascular supply. ✓ Respiration should not be impeded by pressure of arms on the chest or by a gown that constricts the neck and chest. ✓ Nerves must be protected by undue pressure. ✓ Precautions for safety must be observed. ✓ The client needs gentle restraints in case of excitement. 1.General 2.Regional  refers to the depression of the central nervous system A medically-induced coma and loss of protective reflexes resulting from the administration of one or more anesthetic agents  Methods: Inhalation Intravenous  General anesthesia is accomplished in 4 phases: Pre-induction Induction Maintenance Reversal/extubation  Stage I, also known as the "induction“ or stage of analgesia begins with the administration of the anesthetic agents and ends with the loss of consciousness.  During this stage, the patient becomes drowsy, dizzy and progresses from analgesia without amnesia to analgesia with amnesia. Patients can carry on a conversation at this time.  Stage II, stage of delirium/excitement the period following the loss of consciousness and ends with the onset of regular breathing and loss of eyelid reflexes  During this stage, respirations and heart rate may become irregular. There may be uncontrolled movements, vomiting and pupillary dilation  Stage III, stage of surgical anesthesia begins with onset of regular breathing/loss of eyelid reflexes and ends with the loss of most reflexes and depression of vital functions  Stage IV, stage of danger/medullary stage begins with the cessation of respiration and leads to death  refers to the suspension of sensation on affected side of the body or in one region of the body  Temporarily interrupts transmission of nerve impulses to and from a specific area or region Client does not lose cosnciousness  Methods Topical/surface Local Peripheral nerve block Spinal anesthesia Epidural block Acupuncture Cryothermia  Methods Topical/surface -Applied directly to the surface or area to be anesthetized (ointment / spray) - for respiratory intubation, dx tests (laryngoscopy, bronchoscopy, etc.)  Methods Local - injection intracutaneously into the tissue surrounding an incision, a wound, or a lesion - Blocks peripheral nerve stimulation at its origin - Suturing of superficial lacerations  Methods Peripheral nerve block - injecting local anesthetic agent into or around a nerve supplying the involved area; interrupts sensory, motor or sympathetic transmission - lidocaine  Methods Spinal anesthesia Injection of the anesthetic agent into the subarachnoid space at the level of L2-3 or L3-4 Produces analgesia with relaxation, effective for abdominal and pelvic sx procedures  Methods Epidural block anesthetic medications are injected into the epidural space to block sensory and motor spinal nerve roots in the thoracic, abdominal, pelvic, and lower extremity areas  Methods Acupuncture Insertion of long needles into acupuncture points Cryothermia Use of cold to induce anesthesia Factors to consider in determining the type of anesthesia: Age and physical condition of the patient Type, location and duration of surgery Degree of technical intricacy of surgery Previous anesthetic history Personal preference, expertise and judgment of anesthesiologist Patient’s preference  Supine Flat on OR table with arms at sides or supported by arm boards  Modified supine The patient is placed in supine position with the : Neck extended Shoulders elevated  Prone The patient lies flat on OR table with the patient facing the OR table  Disruption of vascular system  Sitting/Fowler’s The patient lies on back with 0 the body section raised 45 to 900  Trendelenburg Head part is lower than the foot part  Reverse trendelenburg Head part is elevated and is higher than the foot part  Lithotomy The legs are flexed at right angles and placed on stirrups to expose perineal and rectal areas  Kraske/Jack Knife The patient is in prone position with head and feet at a lower level; hips over center break of the table  Lateral position Patient lies on side with upper leg straight and under leg flexed  Phases of the post-operative period Immediate post-operative period Later post-operative period  Immediate post-operative care: Transferring patient to the PACU Patient care at the PACU  Immediate post-op care at the PACU involves monitoring the following: 1. Patent airway and respiration 2. Vital signs 3. Bleeding 4. Level of consciousness 5. Gadgets attached 6. Proper position  Care of post-operative patients: Promotion of cardiovascular function Promotion of respiratory function  Promotion of fluid balance and nutrition Promotion of elimination Promotion of wound healing Prevention of complications Protection from injury and promotion of comfort  Prevention and management of complications: a. Cardiovascular complications Hemorrhage Shock Cardiac arrest Thrombophlebitis b. Pulmonary complications Atelectasis Pneumonia Pulmonary embolism c. Urinary complications Urinary retention UTI Renal failure d. Wound complications Wound infection Dehiscence Evisceration e. GI complications Constipation Paralytic ileus Stress ulcer  Widespread dense adhesions around the small bowel causing obstruction Obstructed bowel Cut-away view of the abdomen