L1. Perioperative Nursing PDF

Lec-1 Management of Surgical Client Nisha Sivapalan MSN NURS 310  OBJECTIVES 1. Define the three phases of perioperative patient care. 2. Describe a comprehensive preoperative assessment 3. Identify legal and ethical considerations related to obtaining informed consent for surgery. 4. Desc...

Lec-1 Management of Surgical Client Nisha Sivapalan MSN NURS 310  OBJECTIVES 1. Define the three phases of perioperative patient care. 2. Describe a comprehensive preoperative assessment 3. Identify legal and ethical considerations related to obtaining informed consent for surgery. 4. Describe preoperative nursing measures 5. Develop a preoperative teaching plan 6. Describe the interdisciplinary approach to the care of the patient during surgery. 7. Describe the principles of surgical asepsis. 8. Describe the roles of the surgical team members 9. Identify the types of anesthesia. 10.Use the nursing process to optimize patient outcomes during the intraoperative period. 11. Describe the role of the nurse in ensuring patient safety during the intraoperative period. 12.Describe the responsibilities of the post anesthesia care unit nurse in the prevention of immediate postoperative complications. 13.Identify common postoperative problems and their management. TABLE OF CONTENTS 01. Pre operative Nursing 02. Intra operative Nursing 03. Post operative Nursing INTRODUCTION Surgery is any procedure performed on the human body that uses instruments to alter tissue or organ integrity.  Perioperative phase Period of time that constitutes the surgical experience; includes the preoperative, intraoperative, and postoperative phases of nursing care Perioperative nursing describes the wide variety of nursing functions associated with the patient’s surgical management. Perioperative Nursing is the care of a client or patient before, during, and after and operation. It is a specialized nursing area wherein a registered nurse works as a team member of other surgical health care professionals  Perioperative phase Period of time that begins with transfer of the patient to the operating room area and continues until the patient is admitted to the post anesthesia care unit Preoperative Phase Intra operative Phase Post operative Phase Period of time from Period of time that begins with when the decision for the admission of the patient to surgical intervention is the post anesthesia care unit and made to when the ends after follow-up evaluation in patient is transferred to the clinical setting or home the operating room table  Advances in surgical and anesthesia approaches 1. Minimally invasive surgeries 2. Robotic surgeries –more precise accuracy for dissecting &suturing, better ROM of instruments, access to deep structures, 3D visual feedback ❖ Short hospital stay ❖ Promote patients’ comfort Surgical Classifications The decision to perform surgery may be based on facilitating the following ❖ Diagnostic procedure – e.g., biopsy, exploratory laparotomy, or laparoscopy ❖ Curative - e.g., excision of a tumor or an inflamed appendix ❖ Reparative - e.g., multiple wound repair ❖ Reconstructive or cosmetic- e.g., mammoplasty or a facelift ❖ Palliative (to relieve pain or correct a problem)- e.g., debulking a tumor to achieve comfort, or removal of a dysfunctional gallbladder ❖ Rehabilitative- e.g., total joint replacement surgery to correct crippling pain or progression of degenerative osteoarthritis. Preoperative Phase Informed Consent ✔ Informed consent is the patient’s autonomous decision about whether to undergo a surgical procedure. ✔ Voluntary and written informed consent from the patient is necessary before nonemergent surgery.Consent is a legal mandate, prepare psychologically, patient understands the surgery to be performed ✔ Surgeon’s responsibility is to provide a clear and simple explanation about the surgery, benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts ✔ Nurse verifies the presence of signature and witness the signature. ✔ Consent form must be signed before administering psychoactive premedication, because consent is not valid if it is obtained while the patient is under the influence of medications that can affect judgment and decision-making capacity. ✔ The signed consent form is placed in a prominent place on the patient’s medical record and accompanies the patient to the OR  Informed Consent Informed consent is necessary in : ⮚ Invasive procedures, such as a surgical incision, a biopsy, a cystoscopy, or paracentesis ⮚ Procedures requiring sedation and/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 Patient signs the consent if of legal age and mentally capable. To operate as a lifesaving measure without the patient’s informed consent, contact the patient’s family by telephone, fax, or other electronic means and consent obtained No patient should be urged or coerced to give informed consent. Refusing is a person’s legal right and privilege Provide consent (written and verbal) in an understandable language. A trained medical interpreter may be consulted. If disability-Alternative formats of communication (e.g., Braille, large print, sign interpreter)  Preoperative Assessment Address risk factors –Eg: genetic disorders, allergies and comorbid conditions Health history Physical examination -vital signs, joint mobility Ask about any that may affect anesthesia Prescription and over-the-counter (OTC) medications, including herbal and other supplements Activity and functional levels Known allergies to drugs, foods, and latex could avert an anaphylactic response If a patient states that he or she is allergic to kiwi, avocado, or banana, or cannot blow up balloons, there may be an association with an allergy to latex A latex allergy can manifest as a rash, asthma, or anaphylactic shock.  Preoperative Assessment Nutritional and fluid status -obesity, weight loss, malnutrition, deficiencies in specific nutrients, metabolic abnormalities Measurement of body mass index and waist circumference Hydration status –NPO, bowel preparation might cause dehydration Dentition-dental caries, dentures, and partial plates, oral infection Drug or alcohol use -ask frank questions with patience, care, and a nonjudgmental attitude Respiratory status-educate about breathing exercises and the use of an incentive spirometer, surgery is usually postponed for elective cases if the patient has a respiratory infection Stop smoking 30 days before surgery Cardiovascular status-obtain ECG, uncontrolled hypertension: surgery may be postponed until the blood pressure is under control. Hepatic and renal function- liver and renal function tests Acute liver disease is associated with high surgical mortality Surgery is contraindicated if a patient has acute nephritis, acute renal insufficiency with oliguria or anuria  Preoperative Assessment Endocrine function ▪ Diabetes-frequent monitoring of blood glucose levels before, during, and after surgery ▪ Patients who have received corticosteroids are monitored for signs of adrenal insufficiency ▪ Patients with uncontrolled thyroid disorders are at risk for thyrotoxicosis or respiratory failure Immune function ▪ Laboratory tests -White Blood Count (WBC) and the urinalysis. Previous medication use –Aspirin should be discontinued 7 to 10 days before surgery; otherwise, the patient may be at increased risk for bleeding Psychosocial factors -extent and role of the patient’s support network, readiness to learn Spiritual and cultural beliefs -showing respect for a patient’s cultural values and beliefs facilitates rapport and trust. Preoperative Nursing Interventions Providing Patient Education 1. Deep Breathing, Coughing, and Incentive Spirometry ⮚ Goal-Promote optimal lung expansion and blood oxygenation post-anesthesia. ⮚ Sitting position to enhance lung expansion. ⮚ Patient is instructed to breathe deeply, exhale through the mouth, take a short breath, and cough deeply in the lungs. ⮚ Use of an incentive spirometer. ⮚ Splinting the incision to minimize pressure and control pain. ⮚ Effective coughing stimulates the cough reflex. ⮚ Failure to cough effectively may lead to atelectasis, pneumonia, or other lung complications.  Preoperative Nursing Interventions Mobility and Active Body Movement ⮚ Promotes circulation improvement, prevents venous stasis, and enhances respiratory function. ⮚ Encourage early and frequent ambulation to prevent complications. ⮚ Encourages exercise of extremities, including extension and flexion of knee and hip joints. ⮚ Emphasizes proper body mechanics and proper body alignment. Pain Management ⮚ Postoperative medication is given to relieve pain and maintain comfort without suppressing respiratory function. ⮚ Analgesic agents for inpatients include PCA, epidural catheter bolus or infusion or patient-controlled epidural analgesia (PCEA). ⮚ Oral analgesic agents are likely to be administered for patients expected to go home. Preoperative Nursing Interventions ❖ Patient-controlled analgesia (PCA) is an interactive method of pain management that allows patients to treat their pain by self- administering doses of analgesic agents. ❖ It is used to manage all types of pain by multiple routes of administration, including oral, IV, subcutaneous, epidural, and perineural. ❖ A PCA infusion device is programmed so that the patient can press a button (pendant) to self- administer a dose of an analgesic agent (PCA dose) at a set time interval (demand or lockout) as needed. Preoperative Nursing Interventions Cognitive Coping Strategies ⮚ Guided Imagery: Focusing on a pleasant experience or restful scene. ⮚ Distraction: Thinking of enjoyable stories or favorite songs. ⮚ Optimistic self-recitation: Reciting optimistic thoughts. (“I know all will go well”). ⮚ Music therapy: Listening to soothing music. ⮚ Aroma therapy : Inhales aromatic oils ⮚ Reiki : Place hands over the patient to transfer energy Preoperative psychosocial interventions 1. Reducing Preoperative Anxiety 2. Decreasing Fear 3. Respecting Cultural, Spiritual, and Religious Beliefs Preoperative Nursing Interventions Ambulatory Surgical Patient - Preoperative Education ✔ Provide information on patient reporting, what to bring, what to leave at home, and what to wear. ✔ The last preoperative phone call reminds patients to avoid eating or drinking as directed. ✔ Food and fluid restrictions may be extended depending on the patient's fluid status, age, pulmonary status, and surgical procedure. ✔ The purpose of withholding food before surgery is to prevent aspiration, a serious problem with high mortality rates. ✔ Fluids may be administered intravenously in some patients to ensure adequate fluid volume. Preoperative Nursing Interventions Maintaining Patient Safety-Summary of the 2019 National Patient Safety Goals (Adapted from Joint Commission (2019). 2019 National Patient Safety Goals.) ✔ Identify patients correctly ✔ Improve staff communication ✔ Use medicines safely ✔ Use alarms safely ✔ Prevent infection ✔ Identify patient safety risks ✔ Prevent mistakes in surgery Managing Nutrition and Fluids Adults are advised to fast for 8 hours after consuming fatty food and 4 hours after ingesting milk products. Clear liquids are allowed up to 2 hours before an elective procedure in healthy patients.  Preoperative Nursing Interventions Preparing the Bowel for Surgery ⮚ If abdominal or pelvic surgery ,a cleansing enema or laxative may be prescribed the evening before surgery and repeated the morning of surgery. ⮚ Goals are to allow satisfactory visualization of the surgical site and prevent intestine trauma or peritoneum contamination. ⮚ If hospitalized, the toilet or bedside commode is used for enema evacuation. ⮚ Antibiotics may be prescribed to reduce intestinal flora. Preoperative Skin Preparation ⮚ Aims to decrease bacteria without injuring the skin. ⮚ Use soap with detergent-germicide to cleanse the skin area/full body wash before surgery. ⮚ Preoperative hair removal is usually done if it interferes with the operation. ⮚ If necessary, electric clippers are used for safe hair removal before the operation. ⮚ Surgical site is marked by the patient and surgeon prior to the procedure Immediate Preoperative Nursing Interventions 1. Confirm patient’s identity 2. Patient changes into untied hospital gown. 3. Long hair may be braided and hairpins removed. 4. Mouth is inspected and dentures or plates removed. 5. Jewelry is not worn to the OR; wedding rings and body piercings removed. 6. All articles of value, including assistive devices, dentures, glasses, and prosthetic devices, given to family members or labeled with patient's name. 7. Urinary catheterization performed only as necessary. 8. Patients should void immediately before going to the OR. 9. Administering Preanesthetic Medication and antibiotics. ✔ If prescribed, it is given in the preoperative holding area. ✔ Patient is kept in bed with side rails raised to prevent lightheadedness or drowsiness. 1. Attend family needs Preoperative patient warming for a period of at least 30 minutes can be beneficial to prevent hypothermia after inducing anesthesia. (warm blankets, forced air warming , warmed IV fluids etc) Maintaining the Preoperative Record Contains critical elements that need to be checked preoperatively  NURSING PROCESS Assessment · Physical condition, including respiratory, cardiac, and other major body systems · Results of blood tests, x-ray studies, and other diagnostic tests · Nutritional and fluid status and medication use · Psychological preparedness for surgery (anxiety, fear, spiritual and cultural beliefs) · Special considerations, including the ambulatory surgery patient, gerontologic considerations, obesity, the patient with a disability etc Nursing diagnoses · Anxiety related to the surgical experience (anesthesia, pain) and the outcome of surgery · Fear related to perceived threat of the surgical procedure and separation from support system · Knowledge deficit of preoperative procedures and protocols and postoperative expectations Nursing Interventions · Reducing preoperative anxiety · Decreasing fear · Providing patient education · Monitoring and managing potential complications  Intra operative Phase  Intraoperative Nursing Management The Surgical Team ▪ Patient, anesthesiologist or Certified Registered nurse anesthetist (CRNA), surgeon, intraoperative nurses, and surgical technologists. ▪ Anesthesiologist administers anesthetic agent and monitors the patient’s physical status. ▪ Surgeon and assistants scrub and perform surgery. ▪ Scrub role provides sterile instruments and supplies. ▪ Circulating nurse coordinates patient care in operating room. ▪ Care includes patient positioning, skin preparation, surgical specimen management, and intraoperative event documentation.  Intraoperative Nursing Management Nursing Care in Surgery Providing patient safety and well-being. Coordinating OR personnel and performing scrub and circulating activities. Supporting patient's emotional state. Encouraging active participation in care plan, considering cultural, ethnic, and religious considerations. Establishing trust and relaxation environment Monitoring potential injury factors like patient position, equipment malfunction, and environmental hazards. Protecting patient's dignity and interests during anesthesia. Maintaining surgical standards, identifying risks, and minimizing complications. Nurses should be aware of Cultural, Ethnic, and Religious Diversities ✔ Muslims and Jewish faith may not wish to use porcine-based products [heparin (porcine or bovine)]. Buddhists may choose not to use bovine products ✔ patients should be allowed to apply their own surgical cap.  Intraoperative Nursing Management Circulating Nurse Role in Operating Room 1. Manages the operating room and ensures patient safety. 2. Monitors surgical team activities, checks operating room conditions, and assesses patients for signs of injury. 3. Verifies consent, coordinates team, ensures cleanliness, temperature, humidity, lighting, equipment functioning, and supplies availability. 4. Monitors aseptic practices, coordinates personnel movement, and implements fire safety precautions. 5. Documents patient activities to ensure safety and well-being. 6. Second verification of surgical site and procedure The Scrub Role ✔ Performs surgical hand scrub. ✔ Sets up sterile tables. ✔ Prepares sutures, ligatures, and special equipment Eg; laparoscope. ✔ Assists surgeon and assistants during procedure. ✔ Preparation of necessary instruments like sponges, drains. ✔ As the surgical incision is closed, the scrub person and the circulating nurse count all needles, sponges, and instruments to be sure they are accounted for and not retained as a foreign body in the patient. ✔ Tissue specimens obtained during surgery must also be labeled by the scrub person and sent to the laboratory by the circulating nurse.  Intraoperative Nursing Management The Surgeon Performs the surgical procedure, heads the surgical team. The Anesthesiologist and CRNA Anesthesiologists and CRNA are healthcare professionals trained in anesthesiology. Assess patients before surgery, select anesthesia, administer it, intubate if necessary, manage technical issues, and supervise the patient's condition. Visit patients before surgery to perform assessments, provide information, and answer questions  Intraoperative Nursing Management Safety and Infection Prevention -The Surgical Environment ▪ The surgical environment is characterized by its stark appearance and cool temperature, with access limited to authorized personnel. ▪ The operating room (OR) is central to all supporting services and has special airfiltration devices to screen out contaminants. ▪ The OR 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 ▪ Headgear should cover the hair to prevent single strands of hair from falling on the sterile field. ▪ Shoes covered with disposable shoe covers for protection from soiling. ▪ Artificial fingernails are banned by OR personnel due to their potential to harbor microorganisms and cause nosocomial infections.  Intraoperative Nursing Management Surgical Asepsis Principles Surgical asepsis prevents contamination of surgical wounds. All surgical supplies, instruments, needles, sutures, dressings, gloves, covers, and solutions must be sterilized before use. Traditional practice involves scrubbing hands and arms with antiseptic soap and water. Surgical team members wear long-sleeved, sterile gowns and gloves. Head and hair are covered with a cap and mask. Only scrubbed, gloved, and gowned personnel touch sterilized objects during surgery. An area of the patient's skin larger than that requiring exposure is cleansed and an antiseptic solution is applied. Hair removal is performed immediately before the procedure with electric clippers. The rest of the patient's body is covered with sterile drapes. Intraoperative Nursing Management Surgical Aseptic Practice Guidelines 1. All materials in contact with the surgical wound must be sterile. 2. Gowns and sleeves of the surgical team are considered sterile from chest to sterile field level. 3. Sterile drapes are used to create a sterile field, with the top surface of a draped table considered sterile. 4. Items should be dispensed to a sterile field using methods that preserve the sterility of the items and the field's integrity. 5. Movements of the surgical team should be from sterile to sterile areas and from unsterile to unsterile areas. 6. Movement around a sterile field must not cause contamination, and at least a 1-foot distance from the field must be maintained. 7. Any breach of a sterile barrier or tear of the drape allowing access to an unsterile surface renders the area unsterile. 8. Every sterile field should be constantly monitored and maintained, with items of doubtful sterility considered un-sterile. 9. Sterile fields are prepared as close as possible to the time of use. Intraoperative Nursing Management Intraoperative Nursing Management Types of Anesthesia and Sedation -During the surgical procedure, the patient will need sedation, anesthesia, or some combination of these. General Anesthesia Anesthesia is a state of narcosis (severe central nervous system depression produced by pharmacologic agents), analgesia, relaxation, and reflex loss. Patients under general anesthesia are not arousable, not even to painful stimuli. They lose the ability to maintain cardiovascular and ventilatory function and require assistance in maintaining a patent airway. Stages Stage I: Beginning Anesthesia: Experiences warmth, dizziness, and detachment. Stage II: Excitement: Characterized by struggles, shouting, talking, singing, laughing, or crying. Stage III: Surgical Anesthesia: Patient is unconscious and lies quietly on the table. Stage IV: Medullary depression: occurs when excessive anesthesia is administered, causing shallow respirations, weak pulse, and wide dilated pupils. Anesthetic is discontinued immediately and respiratory and circulatory support is initiated METHODS – Inhalation, Intravenous  Types of anesthesia and sedation Regional Anesthesia Anesthetic agent is injected around nerves so that the area supplied by these nerves is anesthetized. Patient remains awake and aware of surroundings unless medications are given for mild sedation or anxiety relief. Avoid careless conversation, noise, and unpleasant odors to maintain a therapeutic environment. Diagnosis should not be stated aloud if the patient is not aware of it at the time. Epidural Anesthesia: Injecting a local anesthetic agent into the epidural space surrounding the spinal cord. Provides anesthesia and pain relief by diffusing medication across the spinal cord's layers. Advantage: Absence of headache. Disadvantage: Greater technical challenge of introducing the anesthetic agent into the epidural space. Types of Anesthesia and Sedation Spinal Anesthesia Produces anesthesia of the lower extremities, perineum, and lower abdomen. Headache may be an aftereffect of spinal anesthesia Local Conduction Blocks 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  Types of Anesthesia and Sedation Moderate Sedation 1. IV administration of sedatives or analgesics to reduce patient anxiety and control pain during diagnostic or therapeutic procedures. 2. Used for short-term surgical procedures in hospitals and ambulatory care centers. 3. Patient maintains a patent airway, retains protective airway reflexes, and responds to stimuli. 4. Continuous assessment of vital signs, consciousness level, and cardiac and respiratory function is essential. Local anesthesia Local anesthesia is the injection of a solution containing the anesthetic agent into the tissues at the planned incision site. Advantages: Simple, economical, nonexplosive, minimal equipment needed. Short postoperative recovery. Avoids undesirable effects of general anesthesia. Ideal for short, minor surgical procedures.  Potential Intraoperative Complications ⮚ Anesthesia Awareness ⮚ Nausea and Vomiting -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 ⮚ Anaphylaxis –medications, latex ⮚ Hypoxia and Other Respiratory Complications -Inadequate ventilation, airway occlusion, esophagus intubation. ⮚ Hypothermia - low room temperature, cold fluid infusion, inhalation of cold gases, open wounds Rewarm the patient include setting the OR environment at 25°C to 26.6°C, warming IV and irrigating fluids to 37°C, replacing wet gowns and drapes with dry ones, and using warm air blankets and thermal blankets. ⮚ Malignant hyperthermia -rare inherited muscle disorder that is chemically induced by anesthetic agents Early signs include tachycardia, ventricular dysrhythmia, hypotension, decreased cardiac output, oliguria, hypercapnia and cardiac arrest. Body temperature can increase 1°C to 2°C (2°F to 4°F) every 5 minutes, and core body temperature can exceed 42°C (107°F) NURSING PROCESS Assessment Physiologic status: health-illness level, consciousness. Psychosocial status: anxiety, communication problems, coping mechanisms. Physical status: surgical site, skin condition, preparation effectiveness, joint mobility. Ethical concerns Nursing diagnoses Anxiety related to surgical or environmental concerns Risk of latex allergy response due to possible exposure to latex in OR environment Risk for perioperative positioning injury related to positioning in the OR Risk for injury related to anesthesia and surgical procedure Risk for compromised human dignity related to general anesthesia or sedation  Nursing Interventions Reducing Anxiety Introduce yourself warmly and frequently to the patient, verify details, and provide explanations. Use basic communication skills like touch and eye contact to reduce anxiety. Pay attention to physical comfort such as warm blankets, padding, and position changes. Inform the patient about other patients, procedure duration, and other details. Use guided imagery techniques to decrease anxiety during anesthesia induction. Reducing Latex Exposure Early identification of latex allergies. Maintenance of latex allergy precautions throughout the perioperative period. Manufacturers and hospital materials managers should identify latex content in items used by patients and healthcare personnel. Preventing Perioperative Positioning Injury Affects sensory, motor, or both nerve functions.. Nerves should be protected from undue pressure and improper positioning can cause serious injury or paralysis. Shoulder braces must be well padded to prevent irreparable nerve injury Positioning Dorsal recumbent position: for most abdominal surgeries, except gallbladder or pelvis surgery. Trendelenburg position: for lower abdomen and pelvis surgery, displacing intestines into upper abdomen. Reverse Trendelenburg position: Provides space for upper abdomen operation, shifting intestines into pelvis. Lithotomy position: for perineal, rectal, and vaginal surgical procedures Sims or lateral position: Used for renal surgery, placed on nonoperative side with an air pillow or on a table with a kidney or back lift. Protecting the patient from injury Verify that all required documentation is completed. The patient is identified, and the planned surgical procedure and type of anesthesia are verified. review the patient’s record for : ✔ Correct informed surgical consent, with patient’s signature ✔ Completed records for health history and physical examination ✔ Results of diagnostic studies ✔ Allergies (including latex) Preventing Physical Injury ✔ Using safety straps and bed rails. ✔ Avoiding leaving the patient unattended. ✔ Safely transferring the patient from the stretcher to the OR table. ✔ Properly positioning the grounding pad under the patient to prevent shock. ✔ Removing excess surgical germicide from the patient’s skin. ✔ Prompt and completely draping exposed areas after sterile field creation. ✔ Preventing Injury from Excessive Blood Loss ✔ Preparing for blood transfusions for higher-risk procedures. Prevent retaining surgical items-count sponges ,needles instruments at beginning of surgery, prior wound and skin closure Post operative Phase Care of the Patient in the Post anesthesia Care Unit 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. The post anesthesia care unit (PACU), or the recovery room, is located adjacent to the OR suite Phase I PACU: Provides intensive nursing care during immediate recovery. Phase II PACU: Prepares patient for self-care or extended care setting. Phase III PACU: Prepares patient for discharge, Recliners are standard in many phase III units. Phase II and III units often combined in hospitals. Patients may remain in PACU for 4 to 6 hours, depending on surgery type and preexisting conditions. In facilities without separate units, patient remains in PACU and may be discharged home. Admitting the Patient to the Post anesthesia Care Unit 1. The anesthesiologist and other OR team members are responsible for transferring the postoperative patient from the OR to the PACU. 2. Special consideration is given to the incision site, potential vascular changes, and exposure during transport. 3. The patient is positioned to avoid obstructing drains or drainage tubes. 4. The patient is moved slowly and carefully to prevent orthostatic hypotension. 5. As soon as the patient is placed on the stretcher or bed, the soiled gown is removed and replaced with a dry gown 6. The patient is covered with lightweight blankets and warmed. 7. The nurse who admits the patient to the PACU reviews essential information with the anesthesiologist or CRNA. 8. Oxygen is applied and monitoring equipment is attached.  Nursing Management in the Post anesthesia Care Unit 1. Frequent assessments of patient's airway, respiratory, cardiovascular, skin color, consciousness, and command response. 2. Recording of vital signs and level of consciousness. 3. Baseline assessment and check of surgical site for drainage or hemorrhage. 4. Checking of intravenous fluids to maintain euvolumic state. 5. Verification of correct dosage and rate of infusing medications. 6. Monitoring of vital signs and general physical status every 15 minutes. 7. Awareness of significant patient history, including deafness, seizures, diabetes, or medication allergies. 8. Prioritization of administration of postoperative analgesic medications for pain relief and early ambulation.  Maintaining a Patent Airway Maintain ventilation to prevent hypoxemia and hypercapnia. Assess respiratory rate, depth, ease of respirations, oxygen saturation, and breath sounds. Prolonged anesthesia can lead to hypopharyngeal obstruction, where the lower jaw and tongue fall backward, obstructing air passages. The treatment of hypopharyngeal obstruction involves tilting the head back and pushing forward on the angle of the lower jaw. This maneuver pulls the tongue forward and opens the air passages Maintaining Cardiovascular Stability Hypotension and shock -due to blood loss, hypoventilation, position changes, pooling of blood in extremities, or medication side effects. The classic signs of shock are: Pallor Cool, moist skin Rapid breathing Cyanosis of the lips, gums, and tongue Rapid, weak, thready pulse Decreasing pulse pressure Low blood pressure and concentrated urine. Treatment-Volume replacement Untreated hemorrhage can lead to decreased cardiac output, rapid drop in blood pressure and hemoglobin levels, pallid lips and conjunctivae, spots before eyes, ringing in the ears, and weaker but conscious patient until near death. Treatment-blood or blood products transfusion and determining the cause of bleeding. If bleeding is evident, a sterile gauze pad and pressure dressing are applied, and the bleeding site is elevated to heart level. If bleeding source is concealed, the patient may be taken back to the operating room for emergency exploration. Hypertension and dysrhythmias Hypertension is common postoperatively due to sympathetic nervous system stimulation. Dysrhythmias are linked to electrolyte imbalance, altered respiratory function, pain, hypothermia, stress, and anesthetic medications. Both conditions are managed by treating the underlying causes. Relieving Pain and Anxiety Opioid analgesics. psychological support. Family visits can decrease anxiety and make the patient feel more secure. Controlling Nausea and Vomiting Common medications include Inapsine, Reglan, Compazine, and Promethazine. Ondansetron is a frequently used, effective antiemetic with few side effects. At the slightest indication of nausea, the patient is turned completely to one side to promote mouth drainage and prevent aspiration of vomitus, which can cause asphyxiation and death Determining Readiness for Discharge From the PACU · Stable vital signs · Orientation to person, place, events, and time · Uncompromised pulmonary function · Pulse oximetry readings indicating adequate blood oxygen saturation · Urine output at least 30 mL/h · Nausea and vomiting absent or under control · Minimal pain Care of the Hospitalized Postoperative Patient  Immediate Postoperative Nursing Interventions 1. Assess breathing and administer supplemental oxygen, if prescribed. 2. Monitor vital signs and note skin warmth, moisture, and color. 3. Assess the surgical site and wound drainage systems. Connect all drainage tubes to gravity or suction as indicated and monitor closed drainage systems. 4. Assess level of consciousness, orientation, and ability to move extremities. 5. Assess pain level; pain characteristics (location, quality); and timing, type, and route of administration of the last dose of analgesic. 6. Administer analgesic medications as prescribed and assess their effectiveness in relieving pain. 7. Place the call light, emesis basin, ice chips (if allowed), and bedpan or urinal within reach. 8. Position the patient to enhance comfort, safety, and lung expansion. 9. Assess IV sites for patency and infusions for correct rate and solution. 10. Assess urine output in closed drainage system or use blaadder scanner to detect distention. 11. Reinforce the need to begin deep breathing and leg exercises. 12. Provide information to the patient and family.  NURSING PROCESS Assessment vital signs, respiratory status, potential complications ,pain level, cardiovascular function,surgical site for bleeding, dressing type and integrity, and drains, anxiety, bladder distention. Nursing diagnoses Risk for ineffective airway clearance related to depressed respiratory function, pain, and bed rest Acute pain related to surgical incision Decreased cardiac output related to shock or hemorrhage Risk for activity intolerance related to generalized weakness secondary to surgery Impaired skin integrity related to surgical incision and drains Ineffective thermoregulation related to surgical environment and anesthetic agents Risk for imbalanced nutrition, less than body requirements related to decreased intake and increased need for nutrients secondary to surgery Risk for constipation related to effects of medications, surgery, dietary change, and immobility Risk for urinary retention related to anesthetic agents Risk for injury related to surgical procedure/positioning or anesthetic agents Anxiety related to surgical procedure Deficient knowledge related to wound care, dietary restrictions, activity recommendations, medications,  Nursing Interventions Preventing respiratory complications 1. Promote deep-breathing and coughing exercises or using an incentive spirometer at least every 2 hours to prevent atelectasis and pneumonia. 2. Chest physical therapy 3. Detect hypoxemia by pulse oximetry, which measures blood oxygen saturation. Factors affecting the accuracy of pulse oximetry readings include cold extremities, tremors, atrial fibrillation, acrylic nails, and black or blue nail polish. 4. Oxygen is given as prescribed to prevent or relieve hypoxia. 5. Careful splinting of incision sites helps overcome the fear that coughing might open the incision. 6. Administer analgesic agents to permit more effective coughing 7. Coughing is contraindicated in patients with head injuries, intracranial surgery, eye surgery, or plastic surgery. 8. Early ambulation increases metabolism and pulmonary aeration and improves all body functions. Nursing Interventions Relieving pain 1. Postoperative pain intensity gradually subsides over time 2. Postoperative pain severity and patient tolerance depend on incision site, surgical procedure, surgical trauma, anesthesia type, and administration route. 3. Preoperative preparation includes information about expectations, reassurance, psychological support, and communication techniques. 4. Opioid analgesic medications 5. Patient-Controlled Analgesia (PCA) -PCA promotes patient participation in care, eliminates delayed administration of analgesic medications, maintains a therapeutic drug level, and reduces postoperative pulmonary complications. Nursing Interventions Promoting cardiac output IV fluid replacement may be prescribed for up to 24 hours post-surgery. Close monitoring is necessary to detect fluid volume deficit, altered tissue perfusion, and decreased cardiac output. Maintain intake and output records, including emesis and output from wound drainage Assess IV line patency and ensuring correct fluids are given at the prescribed rate Early leg exercises and frequent position changes are initiated to stimulate circulation. Venous return is promoted by antiembolism stockings and early ambulation. Encouraging activity Early ambulation Orthostatic hypotension, an abnormal drop in blood pressure, is a concern when a patient gets out of bed for the first time. The nurse assists the patient in getting out of bed by helping them move gradually from the lying to the sitting position, position the patient completely upright, and help them stand beside the bed.  Wound-Healing Mechanisms First-Intention Healing: 1. Wounds made aseptically with minimal tissue destruction heal with little tissue reaction. 2. Granulation tissue is not visible and scar formation is minimal. 3. Postoperatively, many wounds are covered with a dry sterile dressing. Second-Intention Healing: 1. Infected wounds or wounds with unapproximate edges are treated with granulation. 2. The abscess cavity fills with red, soft, sensitive tissue that bleeds easily. 3. Granulations enlarge and skin cells grow over the granulations, completing healing. 4. Postoperative wounds are usually packed with saline-moistened sterile dressings and covered with a dry sterile dressing.  Wound-Healing Mechanisms Third-Intention Healing: 1. Used for deep wounds that have not been sutured early or break down and are resutured later. 2. This results in a deeper and wider scar. Caring for wounds Surgical Site Assessment - Inspecting for wound edges, sutures or staples, redness, discoloration, warmth, swelling, unusual tenderness, or drainage. Factors such as adequate nutrition, glycemic control, cleanliness, rest, and position influence the speed of healing. Surgical Drains  Care of Surgical Drains 1. Nursing interventions to promote wound healing include managing surgical drains. 2. Drains are tubes that exit the peri-incisional area, either into a portable wound suction device or into the dressings. 3. The principle is to allow the escape of fluids that could serve as a culture medium for bacteria. 4. Types of wound drains include the Penrose, Hemovac, and Jackson-Pratt drains. 5. Output (drainage) from wound systems is recorded. 6. The amount of bloody drainage on the surgical dressing is assessed frequently. 7. Increasing amounts of fresh blood on the dressing should be reported immediately. 8. Some wounds are irrigated heavily before closure in the OR, and open drains exiting the wound may be embedded in the dressings.  Changing the Dressing Dressings are applied to wounds for wound healing, drainage absorption, immobilization, protection from mechanical injury, bacterial contamination, hemostasis promotion, and patient comfort. The dressing change is performed by the nurse, with patient informed of the procedure The dressing change is performed at a suitable time, with privacy maintained and the patient not exposed. Hand hygiene is performed before and after the dressing change, with disposable gloves used. The dressing is removed by pulling it parallel to the skin surface and in the direction of hair growth. The soiled dressing is deposited in a designated biomedical waste container. If the patient is sensitive to adhesive tape, the dressing may be held in place with hypoallergenic tape. The dressing is changed and a new dressing is applied. Educate the patient on how to care for the incision and change the dressings at home. Maintaining normal body temperature Low body temperature is reported to the primary provider, and the room is maintained at a comfortable temperature. Treatment includes oxygen administration, adequate hydration, and proper nutrition including glycemic control. The risk of hypothermia is greater in older adults and patients who were in the cool OR environment for a prolonged period. Managing gastrointestinal function and resuming Nutrition Nasogastric tubes if required. Postoperative hiccups can occur due to irritation of the phrenic nerve The nature of the surgery and type of anesthesia directly affect the gastric activity. Clear liquids are typically the first substances desired and tolerated by the patient after surgery. Postoperative distention of the abdomen results from the accumulation of gas in the intestinal tract. Promoting bowel function Decreased mobility, oral intake, and opioid analgesic medications can cause constipation. Irritation and trauma during surgery can inhibit intestinal movement. Early ambulation, improved diet, and stool softeners promote bowel elimination. Chewing gum can restore bowel function and prevent paralytic ileus. Nurses should assess abdomen for distention and frequency of bowel sounds. If no movement by second or third postoperative day, primary provider should be notified. Managing Voiding Bladder distention and urge to void should be assessed at the time of patient's arrival and frequently thereafter. The patient is expected to void within 8 hours after surgery. Methods to encourage voiding include letting water run, applying heat to the perineum, and using a warm bedpan If the patient cannot void, catheterization is not delayed solely based on the 8-hour time frame and do ultrasound bladder scan. Intermittent catheterization may be prescribed every 4 to 6 hours until spontaneous voiding is possible. Maintaining a safe environment -three-side rail position and bed in a low position, call bell within reach  PATIENT EDUCATION -Wound Care Instructions Until Sutures Are Removed 1. Keep the wound dry and clean. 2. If there is no dressing, ask the nurse or physician if he can bathe or shower. 3. If a dressing or splint is in place, do not remove it unless it is wet or soiled. 4. If wet or soiled, change dressing himself if he has been taught to do so; otherwise, call nurse or physician for guidance. 5. Immediately report any of these signs of infection: redness, marked swelling; tenderness; or increased warmth around wound, red streaks in skin near wound, pus or discharge, foul odor, chills or temperature higher than 37.7°C (100°F) 6. If soreness or pain causes discomfort, apply a dry cool pack (containing ice or cold water) or take prescribed acetaminophen tablets every 4–6 h. 7. Avoid using aspirin without direction or instruction because bleeding can occur with its use. 8. Swelling after surgery is common. To help reduce swelling, elevate the affected part to the level of the heart  PATIENT EDUCATION -Wound Care Instructions After Sutures Are Removed 1. Although the wound appears to be healed when sutures are removed, it is still tender and will continue to heal and strengthen for several weeks. 2. Follow recommendations of physician or nurse regarding extent of activity. 3. Keep suture line clean; do not rub vigorously; pat dry. 4. Wound edges may look red and may be slightly raised. This is normal. 5. If the site continues to be red, thick, and painful to pressure after 8 weeks, consult the health care provider. (This may be due to excessive collagen formation and should be checked.)  MANAGING POTENTIAL COMPLICATIONS 1.Venous Thromboembolism Anticoagulants like low-molecular-weight heparin and low-dose warfarin is used. External pneumatic compression and anti-embolism stockings can be used. DVT symptoms include calf pain, leg swelling, fever, chills, and diaphoresis Prevention by- Early ambulation and leg exercises Avoid the use of blanket rolls, pillow rolls, or any form of elevation that can constrict vessels under the knees. Avoid prolonged “dangling” (having the patient sit on the edge of the bed with legs hanging over the side) because pressure under the knees can impede circulation Adequate hydration with juices and water offered throughout the day. 2.Hematoma Occurs when concealed bleeding occurs beneath the skin at the surgical site. Small clots - don't require treatment. Large clots –surgical removal 3. Infection (Wound Sepsis) may not be evident until at least postoperative day 5. Signs and symptoms of wound infection include increased pulse rate and temperature, elevated white blood cell count, wound swelling, warmth, tenderness, or discharge, and increased incisional pain. Treatment- remove sutures or staples, separate the wound edges, insert a drain, and initiate antimicrobial therapy and a wound care regimen.  MANAGING POTENTIAL COMPLICATIONS Wound Dehiscence and Evisceration. ❑ Wound dehiscence -disruption of surgical incision or wound ❑ Evisceration -protrusion of wound contents When the wound edges separate slowly, the intestines may protrude gradually or not at all, and the earliest sign may be a gush of bloody (serosanguineous) peritoneal fluid from the wound. When a wound ruptures suddenly, coils of intestine may push out of the abdomen. The patient may report that “something gave way.” The evisceration causes pain and may be associated with vomiting. If disruption of a wound occurs, the patient is placed in the low Fowler’s position and instructed to lie quietly. These actions minimize protrusion of body tissues. The protruding coils of intestine are covered with sterile dressings moistened with sterile saline solution, and the surgeon is notified at once  REFERENCES · Smeltzer, S.C., & Bare B.G. (2018). Brunner & Suddarth’s textbook of medical surgical nursing. 15th ed. Philadelphia: Lippincott. · Clinical Handbook for Brunner & Suddarth's Textbook of Medical-Surgical Nursing,14th Ed. 2018 Author(s): Lippincott Williams & Wilkins ISBN/ISSN978149635514 · Medical-Surgical Nursing Assessment and Management of Clinical Problems, 12th Edition, 2020. Author(s): Sharon Lewis, Linda Bucher, Margaret Heitkemper, Mariann Harding, Jeffrey Kwong, and Dottie Roberts. eBook ISBN: 9780323371438 Imprint: Mosby Published Date: September 2016 Page Count: 1776 · Doenges, M., Moorhouse, M., Murr, A. (2019). Nursing Care Plans: Guidelines for individualizing client care across the life span 10th edition. Philadelphia: F.A. Davis company. · Vallerand, A. and Sanoski, C. (2019) Davis’s Drug Guide for nurses, 17th ed. D.A. Davis · Adams, M, Holland, L, & Urban, C. (2017). Pharmacology for Nurses: A Pathophysiological Approach, Second Canadian Edition, 5th edition, Pearson · Berman A. , Snyder, S. , & Frandsen, G. (2021). Kozier & Erb's Fundamentals of Nursing: concepts, process and practice. 11th ed. 71