Surgery a branch of medicine that deals with disease and trauma through surgical / operative procedures.

In the Middle Ages surgery was developed within the Arabic world with renowned practitioners such as Abdulcasis. Modern surgery developed rapidly with the scientific era and the first modern surgeons were battlefield doctors in the Napoleonic Wars. Naval surgeons were often barber surgeons, who combined surgery with their main jobs as barbers. Three main developments permitted the transition to modern surgical approaches - control of bleeding, control of infection and control of pain (anesthesia).

History of Surgery: History of surgery can be divided into three eras: ancient, middle & modern Two prehistoric cultures had developed forms of surgery: Neolithic times & Ancient Egypt The oldest known surgical texts date back to Indian physician Sushruta the Father of Surgery around 600 BC, author of Susrutha Samhita the oldest known surgical book. Ancient Greek culture: Hippocrates who innovated the Hippocratic Oath. Ancient Chinese culture: Hua Tuo famous Chinese physician who was the first person to perform surgery with the aid of anesthesia.

Perioperative Nursing refers to the activities performed by the professional nurse during the clients total surgical experience. Perioperative period encompasses a clients total surgical experience, including the preoperative, intraoperative and postoperative phases.

Phases of Perioperative Nursing

1. Preoperative Phase begins with the decision to perform surgery and ends with the clients transfer to the operating room (O.R.) table.

2. Intraoperative Phase begins when the client is received in the O.R. and ends with his admission to the postanesthesia care unit (PACU) / Recovery Room. 3. Postoperative Phase begins when the client is admitted to postanethesia care unit and extends through follow-up home or clinic evaluation. Categories of Surgery based on Urgency: 1. Emergent / Emergency - patient requires immediate attention, disorder may be life threatening. Indication: without delay Examples: severe bleeding (gunshot or stab wounds), bladder or intestinal obstruction, fractured skull and extensive burns 2. Urgent patient requires prompt attention. Indication: within 24-30 hours Examples: acute gallbladder infection, kidney or ureteral stones, appendicitis 3. Required patient needs to have surgery. Indication: plan within a few weeks or months Examples: prostatic hyperplasia (without obstruction), thyroid disorders and cataracts 4. Elective patient should have surgery. Indication: failure to have surgery not catastrophic

Examples: repair of scars, hernia and vaginal repair 5. Optional decision rest with the patient. Indication: personal preference Example: cosmetic surgery

Classification of Surgery:
1. Diagnostic e.g. biopsy or exploratory laparotomy (Ex-Lap) 2. Curative e.g. tumor excision & inflamed vermiform appendix 3. Reparative e.g. multiple wound repairs 4. Reconstructive or cosmetic e.g. facelift 5. Palliative e.g. to relieve pain or a problem

Informed Consent
permission obtained from a patient to perform a specific test or procedure. Criteria for a Valid Informed Consent: 1. Voluntary consent valid consent must be freely given without coercion.

2. Competent patient individual who is autonomous and can give or withhold consent. 3. Informed subject - consent must be in writing & must contain the following: a. Explanation of the procedure and its risk. b. Description of benefits and alternatives. c. Instructions that the patient may withdraw consent. d. A statement informing the patient if the protocol differs from customary procedure. 4. Patient able to comprehend information must be written and delivered in language understandable to the patient. Informed Consent is necessary in the following procedures: 1. Invasive procedures e.g. surgical incision, a biopsy, cystoscopy or paracentesis. 2. Procedures requiring sedation or anesthesia 3. Non-surgical procedure e.g. arteriography, lumbar puncture 4. Procedures involving radiation

Nursing Responsibilities: 1. The surgeon must provide a clear and simple explanation of the surgical procedure. 2. The nurse may ask the patient to sign the consent form. 3. The nurse may witness the patients signature. 4. If the patient needs additional information about the procedure, nurse notifies the surgeon. 5. The nurse ascertains that the consent form has been signed before administering psychoactive drugs. 6. If the patient is a minor, unconscious or incompetent, permission must be obtained from a responsible family member or legal guardian. 7. An emancipated minor (married or independently living or earning on his own) may sign his own consent form. 8. No patient should be urged or coerced to sign an operative permit. 9. In an emergency, a surgeon can operate without the patients informed consent. 10. Refusing to undergo a surgical procedure is a persons legal right and privilege.

Preoperative Phase:
Assessment of health factors that affects patients preoperatively: 1. Nutritional status optimal nutrition is an essential factor in promoting healing and resisting infection and other surgical complications.

f. Vitamin A for wound healing, tissue synthesis & increased immune function. g. Iron to replace iron loss. h. Vitamin K important for normal blood clotting. i. Zinc needed for protein synthesis and wound healing, needed for normal phagocyte and lymphocyte response. 2. Drug or Alcohol use person with a history of chronic alcoholism often suffers from malnutrition and other systemic problems that increase the surgical risk. 3. Respiratory status the goal for potential surgical patients is optimal respiratory function. - surgery is usually postponed if patient has a respiratory infection. - patient with COPD (emphysema, bronchiectasis etc.) are assessed carefully. - patients who smoke are urge to stop 2 months before surgery. 4. Cardiovascular status the goal in preparing any patient for surgery is to ensure a well functioning cardiovascular system to meet the oxygen, fluid and nutritional needs of the perioperative period.

Nutrients important for wound healing: a. Protein to restore blood volume and plasma CHON lost. - For tissue repair and resistance to infection. - For replacement of lean body mass. b. Calories to restore normal weight and spare protein. - To replace losses related to lack of oral intake and hypermetabolism. c. Water to replace fluid lost through vomiting, hemorrhage, fever, exudates, drainage & diuresis. d. Vitamin C needed for antibody and capillary formation, tissue synthesis and wound healing through collagen formation. e. Thiamine, Niacin, Riboflavin, Folic Acid & B12 for cell proliferation thus tissue synthesis, important for RBC maturation.

5. Hepatic and Renal function pre-surgical goal is optimal function of the liver and urinary system to enhance removal of medications, anesthetics agents, body wastes and toxins from the body 6. Endocrine function patient with diabetes who is undergoing surgery is at risk for hypoglycemia and hyperglycemia. 7. Immune function an important function of the preoperative assessment is to determine the existence of allergies. 8. Previous Medication use a medication history is obtained from each patient because of the possibility of drug interactions. Medications with the potential to affect the surgical experience: a. Corticosteroids can cause cardiovascular collapse if discontinued suddenly. b. Diuretics during anesthesia may cause respiratory depression resulting from an associated electrolyte imbalance. c. Phenothiazines increases the hypotensive action of anesthetics. d. Tranquilizers may cause anxiety, tension & seizures if withdrawn suddenly.

e. Insulin its interaction with anesthetics must be considered in a patient with diabetes. f. Antibiotics (erythromycin) when combine with curariform muscle relaxant, nerve transmission is interrupted and apnea from respiratory paralysis g. Anticoagulants increase the risk of bleeding during intraoperative and postoperative. h. Antiseizure medications should be administered intravenously to keep patient seizure-free. i. Monoamine Oxidase (MAO) inhibitors may increase hypotensive action of anesthesia. 9. Psychosocial factors 10. Spiritual and Cultural Beliefs Preoperative Nursing Problems: 1. Anxiety related to the surgical experience (anesthesia & pain) & outcome of surgery 2. Fear related to perceived threat of the surgical procedure and separation from support system 3. Knowledge deficit of preoperative procedures and protocols and postoperative expectations

Preoperative Nursing Management: 1. Teach deep-Breathing, Coughing and Incentive Spirometer 2. Encourage mobility and active body movement 1. Reducing Preoperative Anxiety music therapy 3. Pain management patient-controlled analgesia (PCA), epidural catheter bolus or infusion & patient controlled epidural analgesia (PCEA) 4. Teach cognitive coping strategies a. Imagery patient concentrates on a pleasant experience or restful scene. b. Distraction patient thinks of an enjoyable story or recites a favorite poem or song. c. Optimistic self-recitation patient recites optimistic thoughts (I know all will go well) 5. Instruction for Ambulatory Surgical patients: a. Inform the patient the scheduled date and time of the surgery and where to report. b. Instruct what to bring (insurance card, list of meds & allergies) c. Instruct what to leave at home (jewelry, watch, medications & contact lenses) d. Instruct what to wear (loose-fitting, comfortable clothes & flat shoes) 2. Decreasing Fear 3. Respecting Cultural, Spiritual and Religious Beliefs General Preoperative Nursing Management: 1. Managing Nutrition and Fluids 2. Preparing the Bowel for Surgery 3. Preparing the Skin Immediate Preoperative Nursing Management: 1. Administering Pre-anesthetic Medication 2. Maintaining the Preoperative Record 3. Transporting the Patient to the Pre-surgical Area 4. Attending to Family Needs Nursing Evaluation: 1. Reports relief of anxiety e. Remind the patient not to eat or drink as directed (fasting period of 8 hours or more is recommended) Preoperative Psychosocial Management:

2. Reports that fear is decreased 3. Voices understanding of surgical intervention

c. Restricted zone scrub clothes, shoe covers, caps and masks are worn 4. Peripheral Support Areas

4. Shows no evidence of preoperative complications a. Central Administrative Control b. Offices c. Conference Room/Classroom d. Laboratory / Radiology Services e. Anesthesia Work & Storage Areas f. Housekeeping Storage Areas g. Utility Room h. General Workroom i. Storage Room j. Sterile Supply Room k. Instrument Room l. Scrub Room 5. Operating Room surgical suite is behind double doors (sliding doors). - Access is limited to authorized personnel. - External precautions include adhering to principles of surgical asepsis. - Strict control of the operating room environment is required. - OR has special air filtration devices to screen out contaminating particles, dust, and pollutants. - Temperature, humidity and airflow patterns are controlled.

Intraoperative Phase:
Surgical Environment Physical Layout of the O.R. Suite: 1. Location operating room is situated that is central to all supporting services (laboratory, radiology, pathology & central supply room) 2. Principles in Design a. Exclusion of contamination from outside the suite with sensible traffic patterns within the suite. b. Separation of clean areas from contaminated areas within the suite. 3. Exchange Areas Surgical Area: a. Unrestricted zone street clothes are allowed b. Semi-restricted zone Attire consist of scrub clothes and caps

Infection Types of Nosocomial Infections: Infection is the product of the entrance, growth, metabolic activities & pathophysiologic effects of microorganism in living tissues. Three Stages of infection: 1. Invasion 2. Localization 3. Resolution leading to recovery 1. Exogenous infection is acquired from sources outside the body (personnel & environment) 2. Endogenous infection develops from sources within the body. (e.g. abdominal sepsis caused from enteric flora due to perforation) Classification of Surgical Wounds: 1. Clean Wound - No inflammation present - Procedure under ideal O.R. conditions - No break in sterile technique - GIT, respiratory, genitourinary & oropharyngeal cavity not entered Infection rate: 1% to 5% 2. Clean-Contaminated Wound - No inflammation or infection present - Minor break in technique occurred - Primary closure, wound drained - GIT, respiratory, genitourinary tracts & oropharyngeal cavity entered under controlled conditions & no spillage & contamination Infection rate: 8% to 11% 3. Contaminated Wound - Major break in technique occurred

Classification of Infection: 1. Community-Acquired Infections are natural disease processes that developed or were incubating before a patients admission to the hospital or ambulatory care facility. 2. Communicable Disease Systemic bacterial, viral or fungal infections may be transmitted from one person to another (HIV, hepatitis & Tuberculosis) 3. Spontaneous Infections Localized infections requiring surgical diagnosis and or treatment for management or that occur as adjuvants to medical therapy (acute appendicitis, cholecystitis & bowel perforation with peritonitis) 4. Nosocomial Infections are hospital-associated or acquired during the course of health care of the patient.

- Open fresh traumatic of less than 4 hours - Acute nonpurulent inflammation present - Gross spillage/contamination from GIT - Entrance to genitourinary or biliary tracts with infected urine or bile present Infection rate: 15% to 20%

7. Cross Infection Environmental / Infection Control: 1. Rigorous adherence to the principles of surgical asepsis by OR personnel is the foundation of preventing surgical site infections. 2. All surgical supplies, any instruments, needles, sutures, dressings, gloves, covers and solutions that may come in contact with the surgical and exposed tissues must be sterilized before use. 3. Surgical asepsis requires meticulous cleaning and maintenance of the OR environment. 4. Floors and horizontal surfaces are cleaned frequently with detergent, soap and water or a detergent germicide. 5. Sterilized equipment is inspected regularly to ensure optimal operation and performance. Methods of Sterilization:

4. Dirty and Infected Wound - Organism present in surgical field before procedure - Perforated viscus - Old traumatic wound of more than 4 hours - Existing clinical infection: acute bacterial inflammation encountered, with or without purulence Infection rate: 27% to 40% Sources of Contamination: 1. Skin 2. Hair 3. Nasopharynx 4. Fomites 5. Air 6. Human Error

1. Thermal (physical) a. Steam under pressure moist heat b. Hot air dry heat c. Microwaves nonionizing radiation 2. Chemical a. Ethylene oxide gas b. Formaldehyde gas & solution c. Hydrogen peroxide plasma / vapor

d. Ozone gas e. Acetic acid solution f. Glutaraldehyde solution g. Peracetic acid solution 3. Ionizing radiation (physical)

Purpose: 1. To remove soil, debris, natural skin oils, hand lotions and transient microorganism from the hands and forearms of sterile team members. 2. To decrease the number of resident microorganisms on skin to an irreducible minimum.

Disinfectants: 1. Chemicals a. Alcohol 70% to 90% (ethyl & isopropyl) b. Chloride compounds c. Formaldehyde 1. 37% aqueous 2. 8% in alcohol d. Glutaraldehyde 2% e. Iodophors f. Mercurial compounds 2. Physical a. Boiling water b. Ultraviolet irradiation Surgical Scrub is the process of removing as many microorganisms as possible from the hands and arms by mechanical washing and chemical antisepsis before participating in a surgical procedure. 3. To keep the population of microorganisms during the surgical procedure by suppression of growth. 4. To reduce the hazard of microbial contamination of the surgical wound by skin flora.

Gowning and Gloving Techniques Purpose: Sterile gown and gloves are worn to exclude skin as a possible contaminant and to create a barrier between the sterile and unsterile areas. General Consideration: 1. The scrub person gowns and gloves self, then may gown and glove the surgeon and assistant. 2. Gown packages preferably are opened on a separate table from other packages to avoid any chance of contamination from dripping water.

3. Avoid splashing water on scrub attire during surgical scrub because moisture may contaminate the sterile gown Types of gloving technique: 1. Closed Glove Technique is preferred except when changing a glove during a surgical or when donning gloves for procedures not requiring gowns. 2. Open Glove Technique is used for changing a glove or gown and gloves during a surgical procedure. It is also used when only sterile gloves are worn in administration of spinal anesthesia, intravenous cutdown or for suturing lacerations. Principles of Surgical Asepsis: 1. All materials in contact with the surgical wound and used within the sterile field must be sterile. 2. Gowns of the surgical / perioperative team are considered sterile in front from chest to the level of the sterile field / waist level. 3. Sterile drapes are used to create a sterile field.

6. Sterile areas / field must be kept in view during movement around the area; at least 1 foot distance from sterile field must be maintained. 7. A tear or puncture of the drape permitting access to an unsterile surface underneath renders the area unsterile. 8. Items of doubtful sterility are considered unsterile. 9. Sterile fields should be prepared as close as possible to the time of use. 10. The sleeves are considered sterile from 2 inches above the elbow to the stockinet cuff. 11. Outmost caution and vigilance must be used when handling sterile fluids to prevent splashing or spillage. 12. Contact with unsterile objects at any point renders a sterile area contaminated. Surgical Conscience awareness, which develops from a knowledge base, of the importance of strict adherence to principles of aseptic and sterile techniques.

Surgical Asepsis
4. After a sterile package is open, the edges are considered unsterile. 5. Scrubbed persons and sterile item contact only sterile areas, circulating nurses and unsterile items contact only unsterile areas. Nursing Responsibilities: Good health is essential for any in the OR and any preoperative team member with an infectious disease (e.g. URTI, infected skin lesions, hepatitis, infectious flu, colds and cough) should not have direct patient contact. Until

the infectious process has resolved, the perioperative team member should not work in the O.R. Surgical / Perioperative team The Surgical Team / Perioperative Team: 1. Patient 2. Circulating Nurse also known as the circulator Responsibilities: a. Manages the operating room b. Protects patients safety and health by monitoring the activities of the surgical team. c. Checks and verifies the consent form d. Ensure fire safety precautions, cleanliness, proper temperature, humidity and lighting of the O.R. e. Monitors safe functioning of the equipments. f. Coordinates with the surgical / perioperative team and monitors aseptic practices g. Documents O.R. surgical activities 3. Scrub Nurse responsible for scrubbing for the surgery. Responsibilities: a. Setting up sterile tables b. Preparing sterile sutures, ligatures & special equipments (e.g. Laparoscope) c. Assisting the surgeon & assistant surgeon, taking care tissue specimens d. Count all needles, sponges & instruments together with the circulating nurse 4. Surgeon head of the surgical team Responsibilities

a. Performs the surgical procedure 5. Registered Nurse First Assistant practices under the supervision of the surgeon Responsibilities: a. Suturing and handling of tissues b. Providing exposure at the operative field c. Providing homeostasis 6. Anesthesiologist is a physician specifically trained in the art and science of anesthesiology. Anesthetist is a qualified health care professional who administer anesthetics. Responsibilities: a. Interviews and assesses the patient b. Select & administer appropriate anesthesia c. Monitors V/S, ECG, ABG & anesthesia levels 7. Post Anesthesia Care Unit (PACU) Nurse responsible for caring for the patient until the patient has recovered from the effects of anesthesia. Responsibilities: a. Monitors V/S and post-operative complications (bleeding, respiratory distress etc) b. Carry out postoperative orders c. Refer any unusualities to the physician Anesthesia Anesthesia a state of narcosis, analgesia, relaxation and loss of reflexes.

Levels of Sedation and Anesthesia: 1. Minimal sedation is a drug-induced state wherein patient can respond normally to verbal command. Cognitive & coordination is impaired but respiratory & cardiovascular is not affected. 2. Moderate Sedation a depressed level of consciousness that does not impair the patients ability to maintain patent airway & respond to physical stimulation and verbal commands, often called monitored anesthesia care (e.g. intravenous drugs: midazolam & diazepam) 3. Deep sedation is a drug induced state which a patient cannot be easily aroused but can respond purposely after repeated stimulation. - Difference of deep sedation and anesthesia is that the anesthetized patient is not arousable . Types of Anesthesia: 1. General anesthesia (inhaled or intravenously) refers to drug-induced depression of the central nervous system that produces analgesia, amnesia and unconsciousness. a. Volatile liquids Halothane, Isofluorane, methoxyflurane, enflurane etc. b. Gases Nitrous oxide c. Tranquilizers and Sedative-Hypnotics Midazolam (versed), Diazepam (valium), Lorazepam (ativan) d. Opioids - Morphine, Meperidine Hcl (demerol)

e. Neuroleptanalgesics - Fentanyl (sublimaze), Sufentanil (sufenta) f. Dissociative Agent Ketamine (ketalar) g. Barbiturates Thiopental sodium (pentothal), Methohexital Na (brevital) h. Nonbarbiturates Hypnotics Etomidate (amidate), Propofol (Diprivan) Stages of General Anesthesia: Stage I Beginning anesthesia feeling of warmth, dizziness & detachment may be experienced, unable to move extremities easily, experiences roaring, ringing & buzzing in the ears. Stage II Excitement characterized by struggling, shouting, laughing, crying, increased pulse and irregular respirations. Pupils dilate but contract to light. Stage III Surgical Anesthesia patient is unconscious and lies quietly on the table, surgical procedure begins. Pupils are small but contract when exposed to light. Respirations are regular, pulse rate normal; skin is pink and slightly flushed. Stage IV Medullary Depression/Danger this stage is reached when too much anesthesia has been administered. Respiration is shallow, pulse is weak & thready, pupils dilated & non-reactive, cyanosis develops & without prompt intervention death rapidly follows. 2. Regional Anesthesia is a form of local anesthesia that suspends sensation and motion in a body region or part,

the patient is awake and continuous monitoring is required. 3. Spinal Anesthesia is a local anesthetic injected into the subarachnoid space at the lumbar level to block nerves and suspend sensation and motion to the lower extremities, perineum and lower abdomen. 4. Conduction Blocks suspend sensation and motion on various groups of nerves. Types of conduction blocks: a. Epidural block anesthetic into space the dura mater b. Brachial plexus produces anesthesia on the arm c. Paravertebral block produces anesthesia of the chest, abdominal wall & extremities d. Transacral (caudal) anesthesia of the perineum Local Anesthetics Agents: 1. Lidocaine (xylocaine) topical or injection Advantages: Rapid, longer duration of action compared with procaine & free from local irritative effect 2. Bupivacaine (sensoracaine) infiltration, peripheral nerve block & epidural Advantages: Duration is 2-3 times longer than lidocaine or mepivacaine 3. Procaine (novocaine) subcutaneously, intramuscular, intravenously & spinal

Advantages: low toxicity & inexpensive 4. Tetracaine (pontocaine) topical, infiltration & nerve block Advantages: low toxicity & inexpensive 5. Etidocaine (duranest) infiltration & nerve block Advantages: Longer action than lidocaine

Intraoperative Complications Potential Intraoperative Complications: 1. Nausea and Vomiting if it occurs turn patient to sides, the head of the table is lowered and a basin is provided to collect vomitus. - Suction saliva and vomited gastric contents. - Administration of anti-emetics. 2. Anaphylaxis is a life threatening acute allergic reaction that causes vasodilation, hypotension and bronchial constriction. - carefully observe the patient for changes in V/S and symptoms of anaphylaxis. 3. Hypoxia & other Respiratory Complications inadequate ventilation, occlusion of the airway, inadvertent intubation of the esophagus and hypoxia are potential problems of general anesthesia.

- Peripheral perfusion & pulse oximetry are monitored continuously. - Vigilant assessment of the patients oxygenation status is a primary function of the anesthesiologist or anesthetist or the circulating nurse. 4. Hypothermia body temperature below 36.6 - caused by low temperature in OR, infusion of cold fluids, inhalation of cold gases, open body wounds, decreased muscle activity and advanced age. 5. Malignant Hyperthermia is an inherited muscle disorder chemically induced by anesthetic agent. - Susceptible people include those with strong and bulky muscles, a history of muscle cramps or muscle weakness and unexplained temperature elevation. Clinical Manifestations: 1. Tachycardia >150 beats/min. (earliest sign) 2. Hypotension 3. Decreased cardiac output . Oliguria 5. Body temperature >40 Celsius (late sign) 6. Cardiac arrest Medical Management: 1. Discontinuing the anesthesia and surgery

2. Administration of Dantrolene sodium (muscle relaxant) and Sodium Bicarbonate 3. Decrease body temperature 4. Correct electrolyte imbalance Nursing Management: - Identify patients at risk, recognize the signs & symptoms, have appropriate medications and equipment available. Intraoperative Complications 5. Disseminated Intravascular Coagulopathy - is a lifethreatening condition characterized by thrombus formation and depletion of select coagulation proteins. Patient Position on the Operating Table: 1. Dorsal recumbent flat on the back, used for most abdominal surgeries. 2. Trendelenberg position - the head & body are lowered, used for surgery on the lower abdomen and pelvis. 3. Lithotomy position patient positioned at the back with the legs and thighs flexed used for perineal, rectal and vaginal surgical procedures. 4. Sims or lateral position patient positioned on the nonoperative side, used for renal surgery.

Preparation of the Operative Site - Skin preparation (skin prep) begins before the patient arrives in the OR. Purpose:

skilled nurse, anesthesiologists, nurse anesthetist, surgeons and special equipments & medications. - PACU is kept quiet, clean & free of unnecessary equipments & well ventilated Phases of PACU:

- is to render the surgical site as free as possible from transient and resident microorganisms, dirt, and skin oil so the incision can be made through the skin with minimal danger of infection from this source. Draping - is the procedure of covering the patient and surrounding areas with a sterile barrier to create and maintain an adequate sterile field.

1. Phase I PACU used during the immediate recovery phase and intensive nursing care is provided 2. Phase II PACU is reserved for patients who requires less frequent observation and less nursing care - The patient is prepared for discharge. Admitting Patient to PACU: 1. Anesthesiologist or anesthetist is responsible in transferring the patient from the O.R. to the PACU

Postoperative Phase:
Objective of Postoperative Period: 1. Maintain adequate body system functions. 2. Restore homeostasis 3. Alleviate pain and discomfort 4. Prevent postoperative complications 5. Ensure adequate discharge planning and teaching Postanesthesia Care Unit (PACU) is located adjacent to the operating rooms, patients under anesthesia are placed in this unit for easy access to experienced, highly

2. Avoid unnecessary body exposure. 3. Avoid rough handling 4. Avoid hurried movement & rapid changes in position 5. Nurse who admits patient to the PACU reviews the following information: a. Medical diagnosis and type of surgery performed b. Pertinent past medical history & allergies c. Patients age and general condition, airway patency & vital signs

d. Anesthetics & other medication used in the procedure Nursing Management in the PACU: 1. Assessing the Patient a. Appraise air exchanges status & note skin color. b. Verify & identify operative status & surgeon. c. Assess neurologic status (LOC) d. Examine operative site & check dressings e. Perform safety checks good body alignment, side rails & restraints for IVF & blood transfusion f. Require briefing on problems encountered in OR 2. Maintaining a Patent Airway a. Lateral position with neck extended b. Keep airway in place until fully awake c. Suction secretions d. encourage deep breathing e. administer humidified oxygen as ordered 3. Maintaining Cardiovascular Stability a. Monitor VS and report abnormalities b. Observe signs & symptoms of shock and hemorrhage Classic signs/symptoms of shock: 1. Pallor 2. Cool & moist skin 3. Rapid Breathing 4. Cyanosis of the lips gums & tongue 5. Rapid, weak, thready pulse

6. Decreasing pulse pressure 7. Hypotension & concentrated urine c. Promote comfort & maintain safety d. Continuous monitoring until patient is completely out of anesthesia e. Recognize & minimize factors that may affect the patient in PACU. 4. Relieving Pain & Anxiety a. Opioid analgesics administration b. Allow family member to visit PACU 5. Controlling Nausea & Vomiting a. Administration of anti-emetics (e.g. metoclopramide (plasil), promethazine) Determining Readiness for Discharge from the PACU: 1. Stable vital signs 2. Orientation to person, place, events and time 3. Uncompromised pulmonary function 4. Pulse oximetry readings indicating adequate blood oxygen saturation 5. Urine output at least 30 cc/hr 6. Nausea & vomiting absent or under control 7. Minimal pain

Modified Aldrete Scoring System determine the patients general condition and readiness for transfer from PACU, it allows more objective assessment at regular interval. Postoperative Complications Shock response of the body to a decrease in the circulating blood volume which results to poor tissue perfusion & inadequate tissue oxygenation (tissue hypoxia) 1. Hemorrhage copious escape of blood from the blood vessel Capillary: slow, generalized oozing Venous: dark in color and bubble out Arterial: spurts & is bright red in color Clinical Manifestations: 1. Apprehension, restlessness, thirst, cold, moist, pale skin 2. Deep & rapid RR, low body temperature 3. Low cardiac output Medical Management: 1. Vitamin K (aquamephyton), Hemostan 2. Ligation bleeders, pressure dressing, BT & IV fluids

2. Femoral Phlebitis / Deep Thrombophlebitis often occurs after operation on the lower abdomen or during the course of septic conditions as ruptured ulcer or peritonitis. Etiologic factors: 1. Injury: damage to vein 2. Hemorrhage 3. Prolonged immobility 4. Obesity / Debilitation Clinical Manifestations: 1. Pain 2. Redness 3. Swelling 4. Heat / warmth 5. Homans sign (cardinal sign) Nursing Management: (Active Intervention) 1. Bed rest; elevate affected leg with pillow support 2. Wear antiembolic support hose from the toes to the groin 3. Avoid massage on the calf of the leg 4. Initiate anticoagulant therapy as ordered Preventions: 1. Hydrate adequately (to prevent hemoconcentration) 2. Leg exercises and ambulate early 3. Avoid any restricting devices 4 Preventing use of bed rolls, knee gatches, dangling over the side of the bed with pressure on popliteal area

3. Wound Infections Etiologic Factors: a. Staphylococcus aureus b. Escherichia coli c. Proteus vulgaris d. Pseudomonas aerogenosa e. Anaerobic bacteria Clinical Manifestations: 1. Redness, swelling, pain, warmth 2. Pus or other discharges on the wound 3. Foul smell from the wound 4. Elevated temperature chills 5. Tender lymph nodes on the axilla or groin Rule of thumb 1. Fever 1st 24 hours Pulmonary infection 2. within 48 hours Urinary Tract Infection 3. within 72 hours Wound Infection Preventive Interventions: 1. Housekeeping cleanliness in the OR 2. Strict Aseptic Technique . Antibiotic therapy 4. Wound Complications Kinds 1. Hemorrhage / Hematoma

2. Wound dehiscence disruption in the coaptation of wound edges 3. Wound Evisceration dehiscence with outpouching of abdominal organs

Nursing Management: 1. Apply abdominal binder 2. Encourage proper nutrition 3. Keep in Bed 4. Stay with client, have someone call M.D. 5. Cover exposed intestine with sterile, moist saline dressing 6. Supine or semi-fowlers, bend knees to relieve tension on abdominal muscle 5. Pulmonary Complications atelectasis, Brochitis, Bronchopneumonia, Lobar pneumonia, Hypostatic pulmonary congestion & pleurisy Nursing Management: 1. Reinforce deep breathing, coughing, turning exercises 2. Encourage early ambulation 3. Incentive spirometer 6. Intestinal Obstruction (3rd 5th Postop day) Loop of intestine may kink due to inflammatory adhesion Clinical Manifestation: 1. Intermittent sharp, colicky abdominal pains 2. Nausea and vomiting (fecaloid) 3. Abdominal distention, hiccups

4. Diarrhea, shock & death Nursing Management: 1. NGT insertion 2. Administer electrolyte / IV as ordered 3. Prepare for possible surgical intervention 7. Hiccups intermittent spasms of the diaphragm causing a sound hic that result from the vibration of closed vocal cords as air suddenly into the lungs Etiologic Factor: 1. Irritation of phrenic nerve between the spinal cord and terminal ramifications on undersurface of the diaphragm. Nursing Management: 1. Remove the cause 2. NGT for abdominal distention 3. Hold breath while taking a large swallow of water / Metoclopramide administration 4. Breath in and out paper bag (CO2) Promoting Home and Community-Based Care: 1. Teaching Patients self care a. Give written instructions on medications, medical check-ups, wound care, activity & diet. b. Provide the nurse and surgeons number 2. Continuing Care a. Assess patients physical status (surgical incision, respiratory, cardiovascular & pain management)

3. Previous teachings is reinforced as needed 4. Change the wound dressings, monitor the drainage system & administer medications 5. Patient reminded of the importance of follow-up appointments.