Perioperative nursing describes the wide variety of nursing functions associated with the patient’s surgical management. Perioperative nursing has three phases of the surgical experience namely:
- Preoperative phase. This phase begins when the decision for surgical intervention is made and ends when the patient is transferred from the operating room.
- Intraoperative phase. This phase begins when the patient is admitted or transferred to the surgery department and ends when he or she is admitted to the recovery area.
- Postoperative phase. This phase begins with the admission of the patient to the recovery area and ends with a follow-up evaluation in the clinical setting or at home.
- 1 Preoperative Phase
- 188.8.131.52 Goals during the Preoperative Phase
- 184.108.40.206 Physiologic Assessment during the Preoperative Phase
- 220.127.116.11 Diagnostic tests may be carried out during the preoperative phase such as:
- 18.104.22.168 The following are the physiologic assessments necessary during the preoperative phase:
- 22.214.171.124 Psychological Nursing Assessment during the Preoperative Period
- 126.96.36.199 Psychological Nursing Interventions:
- 188.8.131.52 Informed consent
- 2 Intraoperative Phase
- 184.108.40.206 Goals during the Intraoperative Phase
- 220.127.116.11 The Surgical Team
- 18.104.22.168 Intraoperative Nursing Functions
- 22.214.171.124 Classification of Physical status for Anesthesia before Surgery
- 126.96.36.199 Anesthesia
- 188.8.131.52 Nursing Assessment after Spinal Anesthesia
- 184.108.40.206 Side Effects of Anesthesia
- 220.127.116.11 How do anesthesiologists determine the type of anesthesia to be used?
- 18.104.22.168 Position a Patient on the Operating Table
- 22.214.171.124 Reason of Performing a Surgical Procedure
- 126.96.36.199 Nursing Responsibility during the Intraoperative Phase
- 3 Postoperative Phase
- 188.8.131.52 Goals during the Postoperative Period
- 184.108.40.206 Patient Care during Immediate Postoperative Phase: Transferring the Patient to RR or PACU
- 220.127.116.11 Nursing Care for Patient in the PACU or RR
- 18.104.22.168.1 AIRWAY: Maintain a patent airway.
- 22.214.171.124.2 BREATHING: Maintaining adequate respiratory function.
- 126.96.36.199.3 CIRCULATION: Assess status of circulatory system.
- 188.8.131.52.4 THERMOREGULATION: Assessing the patient’s thermoregulatory status.
- 184.108.40.206.5 FLUID VOLUME: Maintaining adequate fluid volume.
- 220.127.116.11.6 SAFETY: Promoting patient safety.
- 18.104.22.168.7 COMFORT: Promoting patient comfort.
- 22.214.171.124.8 SKIN INTEGRITY: Minimizing skin impairment.
- 126.96.36.199.9 EVALUATION in PACU
- 188.8.131.52 Patient Care during Immediate Postoperative Phase: Transferring the Patient from RR to the Surgical Unit
- 184.108.40.206 Nursing care during the intermediate postoperative period:
The patient who consents to have surgery, particularly surgery that requires a general anesthetic, renders himself dependent on the knowledge, skill, and integrity of the health care team. In accepting this trust, the health care team members have an obligation to make the patient’s welfare their first consideration during the surgical experience.
The scope of activities during the preoperative phase includes the establishment of the patient’s baseline assessment in the clinical setting or at home, carrying out preoperative interview and preparing the patient for the anesthetic to be given and the surgery.
Goals during the Preoperative Phase
Although the physician is responsible for explaining the surgical procedure to the patient, the patient may ask the nurse questions about the surgery. There may be specific learning needs about the surgery that the patient and support persons should know. A nursing care plan and a teaching plan should be carried out. During this phase, emphasis is placed on:
- Assessing and correcting physiological and psychological problems that may increase surgical risk.
- Giving the patient and significant others complete learning and teaching guidelines regarding the surgery.
- Instructing and demonstrating exercises that will benefit the patient postoperatively.
- Planning for discharge and any projected changes in lifestyle due to the surgery.
Physiologic Assessment during the Preoperative Phase
Before any treatment is initiated, a health history is obtained and a physical examination is performed during which vital signs are noted and a data base is establish for future comparisons.
Diagnostic tests may be carried out during the preoperative phase such as:
- Blood analyses such as complete blood count, sedimentation rate, c-reactive protein, serum protein electrophoresis with immunofixation, calcium, alkaline phosphatase, and chemistry profile
- X-ray studies
- MRI and CT scans (with or without myelography)
- Electrodiagnostic studies
- Bone scan
- Tissue biopsies
- Stool studies
- Urine studies
Significant physical findings are also noted to further describe the patient’s overall health condition. When the patient has been determined to be an appropriate candidate for surgery, and has elected to proceed with surgical intervention, the pre-operative assessment phase begins. The purpose of pre-operative evaluation is to reduce the morbidity of surgery, increase quality of intra-operative care, reduce costs associated with surgery, and return the patient to optimal functioning as soon as possible.
The following are the physiologic assessments necessary during the preoperative phase:
- Nutritional status and needs – determined by measuring the patient’s height and weight, triceps skin fold, upper arm circumference, serum protein levels and nitrogen balance. Obesity greatly increases the risk and severity of complications associated with surgery.
- Fluid and Electrolyte Imbalance – Dehydration, hypovolemia and electrolyte imbalances should be carefully assessed and documented.
- Drug and alcohol use – the acutely intoxicated person is susceptible to injury.
- Respiratory status – patients with pre-existing pulmonary problems are evaluated by means pulmonary function studies and blood gas analysis to note the extent of respiratory insufficiency. The goal for potential surgical patient us to have an optimum respiratory function. Surgery is usually contraindicated for a patient who has a respiratory infection.
- Cardiovascular status – cardiovascular diseases increases the risk of complications. Depending on the severity of symptoms, surgery may be deferred until medical treatment can be instituted to improve the patient’s condition.
- Hepatic and renal function – surgery is contraindicated in patients with acute nephritis, acute renal insufficiency with oliguria or anuria, or other acute renal problems. Any disorder of the liver on the other hand, can have an effect on how an anesthetic is metabolized.
- Endocrine function – diabetes, corticosteroid intake, amount of insulin administered
- Immunologic function – existence of allergies, previous allergic reactions, sensitivities to certain medications, past adverse reactions to certain drugs, immunosuppression
- Previous medication therapy – It is essential that the patient’s medication history be assessed by the nurse and anesthesiologist. The following are the medications that cause particular concern during the upcoming surgery:
- Adrenal corticosteroids – not to be discontinued abruptly before the surgery. Once discontinued suddenly, cardiovascular collapse may result for patients who are taking steroids for a long time. A bolus of steroid is then administered IV immediately before and after surgery.
- Diuretics – thiazide diuretics may cause excessive respiratory depression during the anesthesia administration.
- Phenothiazines – these medications may increase the hypotensive action of anesthetics.
- Antidepressants – MAOIs increase the hypotensive effects of anesthetics.
- Tranquilizers – medications such as barbiturates, diazepam and chlordiaxepoxide may cause an increase anxiety, tension and even seizures if withdrawn suddenly.
- Insulin – when a diabetic person is undergoing surgery, interaction between anesthetics and insulin must be considered.
- Antibiotics – “Mycin” drugs such as neomycin, kanamycin, and less frequently streptomycin may present problems when combined with curariform muscle relaxant. As a result nerve transmission is interrupted and apnea due to respiratory paralysis develops.
- Presence of trauma
Psychological Nursing Assessment during the Preoperative Period
- Fear of the unknown
- Fear of death
- Fear of anesthesia
- Concerns about loss of work, time, job and support from the family
- Concerns on threat of permanent incapacity
- Spiritual beliefs
- Cultural values and beliefs
- Fear of pain
Psychological Nursing Interventions:
- Explore the client’s fears, worries and concerns.
- Encourage patient verbalization of feelings.
- Provide information that helps to allay fears and concerns of the patient.
- Give empathetic support.
An informed consent is necessary to be signed by the patient before the surgery. The following are the purposes of an informed consent:
- Protects the patient against unsanctioned surgery.
- Protects the surgeon and hospital against legal action by a client who claims that an unauthorized procedure was performed.
- To ensure that the client understands the nature of his or her treatment including the possible complications and disfigurement.
- To indicate that the client’s decision was made without force or pressure.
Criteria for a Valid Informed Consent
- Consent voluntarily given. Valid consent must be freely given without coercion.
- For incompetent subjects, those who are NOT autonomous and cannot give or withhold consent, permission is required from a responsible family member who could either be apparent or a legal guardian. Minors (below 18 years of age), unconscious, mentally retarded, psychologically incapacitated fall under the incompetent subjects.
- The consent should be in writing and should contain the following:
- Procedure explanation and the risks involved
- Description of benefits and alternatives
- An offer to answer questions about the procedure
- Statement that emphasizes that the client may withdraw the consent
- The information in the consent must be written and be delivered in language that a client can comprehend.
- Should be obtained before sedation.
The intraoperative phase extends from the time the client is admitted to the operating room, to the time of anesthesia administration, performance of the surgical procedure and until the client is transported to the recovery room or postanethesia care unit (PACU). Throughout the surgical experience the nurse functions as the patient’s chief advocate. The nurse’s care and concern extend from the time the patient is prepared for and instructed about the forthcoming surgical procedure to the immediate preoperative period and into the operative phase and recovery from anesthesia. The patient needs the security of knowing that someone is providing protection during the procedure and while he is anesthetized because surgery is usually a stressful experience.
Goals during the Intraoperative Phase
- Promote the principle of asepsis asepsis.
- Safe administration of anesthesia
The Surgical Team
The intraoperative phase begins when the patient is received in the surgical area and lasts until the patient is transferred to the recovery area. Although the surgeon has the most important role in this phase, there are key members of the surgical team.
- Surgeon – leader of the surgical team. He or she is ultimately responsible for performing the surgery effectively and safely; however, he is dependent upon other members of the team for the patient’s emotional well being and physiologic monitoring.
- Anesthesiologist or anesthetist – provides smooth induction of the patient’s anesthesia in order to prevent pain. This member is also responsible for maintaining satisfactory degrees of relaxation of the patient for the duration of the surgical procedure. Aside from that, the anesthesiologist continually monitors the physiologic status of the patient for the duration of the surgical procedure and the physiologic status of the patient to include oxygen exchange, systemic circulation, neurologic status, and vital signs. He or she then informs and advises the surgeon of impending complications.
- Scrub Nurse or Assistant – a nurse or surgical technician who prepares the surgical set-up, maintains surgical asepsis while draping and handling instruments, and assists the surgeon by passing instruments, sutures, and supplies.
- Circulating Nurse – respond to request from the surgeon, anesthesiologist or anesthetist, obtain supplies, deliver supplies to the sterile field, and carry out the nursing care plan.
Intraoperative Nursing Functions
The circulating nurse manages the operating room and protects the safety and health needs of the patient by monitoring activities of members of the surgical team and checking the conditions in the operating room. Responsibilities of a circulation nurse are the following:
- Assures cleanliness in the OR.
- Guarantees the proper room temperature, humidity and lighting in OR.
- Make certain that equipments are safely functioning.
- Ensure that supplies and materials are available for use during surgical procedures.
- Monitors aseptic technique while coordinating the movement of related personnel.
- Monitors the patient throughout the operative procedure to ensure the person’s safety and well being.
- Scrubbing for surgery.
- Setting up sterile tables.
- Preparing sutures and special equipments.
- Assists the surgeon and assistant during the surgical procedure by anticipating the required instruments, sponges, drains and other equipment.
- Keeps track of the time the patient is under anesthesia and the time the wound is open.
- Checks equipments and materials such as needles, sponges and instruments as the surgical incision is closed.
Classification of Physical status for Anesthesia before Surgery
The anesthesiologist should visit the patient before the surgery to provide information, answer questions and allay fears that may exist in the patient’s mind. The choice of anesthetic agent will be discussed and the patient has an opportunity to disclose and the patient has opportunity to disclose previous reactions and information about any medication currently being taken that may affect the choice of an agent. Aside from that, the patient’s general condition must also be assessed because it may affect the management of anesthesia. Thus, the anesthesiologist assesses the patient’s cardiovascular system and lungs. Inquiry about preexisting pulmonary infection sand the extent to which the patient smokes must also be determined. The classification of a client’s physical status for anesthesia before surgery is summarized below.
|Classification of Physical Status for Anesthesia Before Surgery|
|Good||No organic disease; no systemic disturbance||Uncomplicated hernias, fracture|
|Fair||Mild to moderate systemic disturbance||Mild cardiac (I and II) disease, mild diabetes|
|Poor||Severe systemic disturbance||Poorly controlled diabetes, pulmonary complications, moderate cardiac (III) disease|
|Serious||Systemic disease threatening life||Severe renal disease, severe cardiac disease (IV), decompensation|
|Moribund||Little chance of survival but submitting to operation in desperation||Massive pulmonary embolus, ruptured abdominal aneurysm with profound shock|
|Emergency||Any of the abive when surgery is performed in an emergency situation||An uncomplicated hernia that is now strangulated and associated with nausea and vomiting.|
Source: Brunner and Suddarth’s Medical-Surgical Nursing by Smeltzer and Bare
Anesthesia controls pain during surgery or other medical procedures. It includes using medicines, and sometimes close monitoring, to keep you comfortable. It can also help control breathing, blood pressure, blood flow, and heart rate and rhythm, when needed. Anesthetics are divided into two classes:
- Those that suspend sensation in the whole body – General anesthesia
- Those that suspend sensation in certain parts of the body – local, regional, epidural or spinal anesthesia
This type of anesthesia promotes total loss of consciousness and sensation. General anesthesia is commonly achieved when the anesthetic is inhaled or administered intravenously. It affects the brain as well as the entire body. Types of general anesthesia administration:
- Volatile liquid anesthetics – this type of anesthetic produces anesthesia when their vapors are inhaled. Included in this group are the following:
- Halothane (Fluothane)
- Methoxyflurane (Penthrane)
- Enflurane (Ethrane)
- Isoflurane (Forane)
- Gas Anesthetics – anesthetics administered by inhalation and are ALWAYS combined with oxygen. Included in this group are the following:
- Nitrous Oxide
Stages of General Administration
Anesthesia consists of four stages, each of which presents a definite group of signs and symptoms.
Stage I: Onset or Induction or Beginning anesthesia. This stage extends from the administration of anesthesia to the time of loss of consciousness. The patient may have a ringing, roaring or buzzing in the ears and though still conscious, is aware of being unable to move the extremities easily. Low voices or minor sounds appear distressingly loud and unreal during this stage.
Stage II: Excitement or Delirium. Stage II extends from the time of loss of consciousness to the time of loss of lid reflex. This stage is characterized by struggling, shouting, talking, singing, laughing or even crying. However, these things may be avoided if the anesthetic is administered smoothly and quickly. The pupils become dilated but contract if exposed to light. Pulse rate is rapid and respirations are irregular.
Stage III: Surgical Anesthesia. This stage extends from the loss of lid reflex to the loss of most reflexes. It is reached by continued administration of the vapor or gas. The patient now is unconscious and is lying quietly on the table. Respirations are regular and the pulse rate is normal.
Stage IV: Overdosage or Medullary or Stage of Danger. This stage is reached when too much anesthesia has been administered. It is characterized by respiratory or cardiac depression or arrest. Respirations become shallow, the pulse is weak and thread and the pupils are widely dilated and no longer contract when exposed to light. Cyanosis develops afterwards and death follows rapidly unless prompt action is taken. To prevent death, immediate discontinuation of anesthetic should be done and respiratory and circulatory support is necessary.
Local anesthetics can be topical, or isolated just to the surface. These are usually in the form of gels, creams or sprays. They may be applied to the skin before the injection of a local anesthetic that works to numb the area more deeply, in order to avoid the pain of the needle or the drug itself (penicillin, for example, causes pain upon injection).
Regional anesthesia blocks pain to a larger part of the body. Anesthetic is injected around major nerves or the spinal cord. Medications may be administered to help the patient relax or sleep. Major types of regional anesthesia include:
- Peripheral nerve blocks. A nerve block is a shot of anesthetic near a specific nerve or group of nerves. It blocks pain in the part of the body supplied by the nerve. Nerve blocks are most often used for procedures on the hands, arms, feet, legs, or face.
- Epidural and spinal anesthesia. This is a shot of anesthetic near the spinal cord and the nerves that connect to it. It blocks pain from an entire region of the body, such as the belly, hips, or legs.
With regional anesthesia, an anesthetic agent is injected around the nerved so that the area supplied by these nerves is anesthetized. The effect depends on the type of nerve involved. The patient under a spinal or local anesthesia is awake and aware of his or her surroundings.
Regional anesthesia carries more risks than local anesthesia, such as seizures and heart attacks, because of the increased involvement of the central nervous system. Sometimes regional anesthesia fails to provide enough pain relief or paralysis, and switching to general anesthesia is necessary.
This is a type of conduction nerve block that occurs by introducing a local anesthetic into the subarachnoid space at the lumbar level which is usually between L4 and L5. Sterile technique is used as the spinal puncture is made and medication is injected through the needle. The spread of the anesthetic agent and the level of anesthesia depend on:
- the amount of fluid injected
- the speed with which it is injected
- positioning of the patient after injection
- specific gravity of the agent
Nursing Assessment after Spinal Anesthesia
- Monitoring vital signs.
- Observe patient and record the time when motion and sensation of the legs and the toes return.
Side Effects of Anesthesia
- Some numbness or reduced feeling in part of your body (local anesthesia)
- Nausea and vomiting.
- A mild drop in body temperature.
How do anesthesiologists determine the type of anesthesia to be used?
The type of anesthesia the anesthesiologist chooses depends on many factors. These include the procedure the client is having and his or her current health.
Position a Patient on the Operating Table
The nurse should have an idea which patient position is required for a certain surgical procedure to be performed. There are lots of factors to consider in positioning the patient which includes the following:
- Patient should be in a comfortable position as possible whether he or she is awake or asleep.
- The operative area must be adequately exposed.
- The vascular supply should not be obstructed by an awkward position or undue pressure on a part.
- There should be no interference with the patient’s respiration as a result of pressure of the arms on the chest or constriction of the neck or chest caused by a gown.
- The nerves of the client must be protected from undue pressure. Serious injury or paralysis may result from improper positioning of the arms, hands, legs or feet.
- Shoulder braces must be well padded to prevent irreparable nerve injury.
- Patient safety must be observed at all times.
- In case of excitement, the patient needs gentle restraint before induction.
Reason of Performing a Surgical Procedure
- To cure an illness or disease by removing the diseased tissue or organs.
- To visualize internal structures during diagnosis.
- To obtain tissue for examination.
- To prevent disease or injury.
- To improve appearance.
- To repair or remove traumatized tissue and structures.
- To relieve symptoms or pain.
Nursing Responsibility during the Intraoperative Phase
- Safety. Is the Highest Priority of nurses.
- Simultaneous placement of feet. This is to prevent dislocation of hip.
- Always apply knee strap.
- Arms should not be more than 90°
- Prepare and apply cautery pad. Cautery is used to stop bleeding.
The postoperative period of the surgical experience extends from the time the client is transferred to the recovery room or past-anesthesia care unit (PACU) to the moment he or she is transported back to the surgical unit, discharged from the hospital until the follow-up care.
Goals during the Postoperative Period
During the postoperative period, reestablishing the patient’s physiologic balance, pain management and prevention of complications should be the focus of the nursing care. To do these it is crucial that the nurse perform careful assessment and immediate intervention in assisting the patient to optimal function quickly, safely and comfortably as possible.
- Maintaining adequate body system functions.
- Restoring body homeostasis.
- Pain and discomfort alleviation.
- Preventing postoperative complications.
- Promoting adequate discharge planning and health teaching.
Patient Care during Immediate Postoperative Phase: Transferring the Patient to RR or PACU
Special consideration to the patient’s incision site, vascular status and exposure should be implemented by the nurse when transferring the patient from the operating room to the postanethesia care unit (PACU) or postanesthesia recovery room (PARR). Every time the patient is moved, the nurse should first consider the location of the surgical incision to prevent further strain on the sutures. If the patient comes out of the operating room with drainage tubes, position should be adjusted in order to prevent obstruction on the drains.
- Assess air exchange status and note patient’s skin color
- Verify patient identity. The nurse must also know the type of operative procedure performed and the name of the surgeon responsible for the operation.
- Neurologic status assessment. Level of consciousness (LOC) assessment and Glasgow Coma Scale (GCS) are helpful in determining the neurologic status of the patient.
- Cardiovascular status assessment. This is done by determining the patient’s vital signs in the immediate postoperative period and skin temperature.
- Operative site examination. Dressings should be checked.
Moving a patient from one position to another may result to serious arterial hypotension. This occurs when a patient is moved from a lithotomy to a horizontal position, from a lateral to a supine position, prone to supine position and even when a patient is transferred to the stretcher. Hence, it is very important that patients are moved slowly and carefully during the immediate postoperative phase.
Promoting Patient Safety
When transferred to the stretcher, the patient should be covered with blankets and secured with straps above the knees and elbows. These straps anchor the blankets at the same time restrain the patient should he or she pass through a stage of excitement while recovering from anesthesia. To protect the patient from falls, side rails should be raised.
Safety checks when transferring the patient from OR to RR:
S – Securing restraints for I.V. fluids and blood transfusion.
A – Assist the patient to a position appropriate for him on her based on the location of incision site and presence of drainage tubes.
F – Fall precaution implementation by making sure the side rails are raised and restraints are secured well.
E – Eliminating possible sources of injuries and accidents when moving the patient from the OR to RR or PACU.
Nursing Care for Patient in the PACU or RR
AIRWAY: Maintain a patent airway.
- Keep airway in place until the patient is fully awake and tries to eject it. The airway is allowed to remain in place while the client is unconscious to keep the passage open and prevents the tongue from falling back. When the tongue falls back, airway passage obstruction will result. Return of pharyngeal reflex, noted when the patient regains consciousness, may cause the patient to gag and vomit when the airway is not removed when the patient is awake.
- 2. Suction secretions as needed.
BREATHING: Maintaining adequate respiratory function.
- B – Bilateral lung auscultation frequently.
- R – Rest and place the patient in a lateral position with the neck extended, if not contraindicated, and the arm supported with a pillow. This position promotes chest expansion and facilitates breathing and ventilation.
- E – Encourage the patient to take deep breaths. This aerates the lung fully and prevents hypostatic pneumonia.
- A – Assess and periodically evaluate the patient’s orientation to name or command. Cerebral function alteration is highly suggestive of impaired oxygen delivery.
- T – Turn the patient every 1 to 2 hours to facilitate breathing and ventilation.
- H – Humidified oxygen administration. During exhalation, heat and moisture are normally lost, thus oxygen humidification is necessary. Aside from that, secretion removal is facilitated when kept moist through the moisture of the inhaled air. Also, dehydrated patients have irritated respiratory passages thus, it is very important make sure that the inhaled oxygen is humidified.
CIRCULATION: Assess status of circulatory system.
- Obtain patient’s vital signs as ordered and report any abnormalities.
- Monitor intake and output closely.
- Recognize early symptoms of shock or hemorrhage such as cold extremities, decreased urine output – less than 30 ml/hr, slow capillary refill – greater than 3 seconds, dropping blood pressure, narrowing pulse pressure, tachycardia – increased heart rate.
THERMOREGULATION: Assessing the patient’s thermoregulatory status.
- Hourly temperature assessment to detect hypothermia or hyperthermia.
- Report temperature abnormalities to the physician.
- Monitor the patient for postanethesia shivering or PAS. This is noted in hypothermic patients, about 30 to 45 minutes after admission to the PACU. PAS represents a heat-gain mechanism and relates to regaining the thermal balance.
- Provide a therapeutic environment with proper temperature and humidity. Warm blankets should be provided when the patient is cold.
FLUID VOLUME: Maintaining adequate fluid volume.
- Assess and evaluate patient’s skin color and turgor, mental status and body temperature.
- Monitor and recognize evidence of fluid and electrolyte imbalances such as nausea and vomiting and body weakness.
- Monitor intake and output closely.
- Recognize signs of fluid imbalances. HYPOVOLEMIA: decreased blood pressure, decreased urine output, increased pulse rate, increased respiration rate, and decreased central venous pressure (CVP). HYPERVOLEMIA: increased blood pressure and CVP, changes in lung sounds such as presence of crackles in the base of both lungs and changes in heart sounds such as the presence of S3 gallop.
SAFETY: Promoting patient safety.
- Avoid nerve damage and muscle strain by properly supporting and padding pressure areas.
- Frequent dressing examination for possible constriction.
- Raise the side rails to prevent the patient from falling.
- Protect the extremity where IV fluids are inserted to prevent possible needle dislodge.
- Make sure that bed wheels are locked.
COMFORT: Promoting patient comfort.
- Observe and assess behavioral and physiologic manifestations of pain.
- Administer medications for pain and document its efficacy.
- Assist the patient to a comfortable position.
SKIN INTEGRITY: Minimizing skin impairment.
- Record the amount and type of wound drainage.
- Regularly inspect dressings and reinforce them if necessary.
- Proper wound care as needed.
- Perform hand washing before and after contact with the patient.
- Turn the patient to sides every 1 to 2 hours.
- Maintain the patient’s good body alignment.
EVALUATION in PACU
Patients in PACU are evaluated to determine the client’s discharge from the unit. The following are the expected outcomes in PACU:
- Patient breathing easily.
- Clear lung sounds on auscultation.
- Stable vital signs.
- Stable body temperature with minimal chills or shivering.
- No signs of fluid volume imbalance as evidenced by an equal intake and output.
- Tolerable or minimized pain, as reported by the patient.
- Intact wound edges without drainage.
- Raised side rails.
- Appropriate patient position.
- Maintained quiet and therapeutic environment.
Patient Care during Immediate Postoperative Phase: Transferring the Patient from RR to the Surgical Unit
To determine the patient’s readiness for discharge from the PACU or RR certain criteria must be met. The parameters used for discharge from RR are the following:
- Uncompromised cardiopulmonary status
- Stable vital signs
- Adequate urine output – at least 30 ml/ hour
- Orientation to time, date and place
- Satisfactory response to commands
- Minimal pain
- Absence or controlled nausea and vomiting
- Pulse oximetry readings of adequate oxygen saturation
- Satisfactory response to commands
- Movement of extremities after regional anesthesia
Most hospitals use a scoring system to assess the general condition of patient in RR or PACU. Observation and evaluation of the patient’s physical signs is based on a set of objective criteria. The evaluation guide used is a modification of the APGAR scoring system used for newborns. Through this, a more objective assessment of the patient’s physical condition is guaranteed while recovering the RR or PACU. The perfect possible score in this modified APGAR scoring system is 10. To be discharge from RR or PACU the patient is required to have at least 7 to 8 points. Patients with score less than 7 must remain in RR or PACU until their condition improves. Areas of assessment in PACU or RR evaluation guide are:
- Respiration – ability to breathe deeply and cough.
- Circulation – systolic arterial pressure >80% of preanesthetic level
- Consciousness Level – verbally responds to questions or oriented to location
- Color – normal skin color and appearance: pinkish skin and mucus
- Muscle activity – moves spontaneously or on command
Nursing care during the intermediate postoperative period:
- Respiratory status: airway patency, depth, rate and character of respirations, nature of breath sounds
- Circulatory Status: vital signs including blood pressure and skin condition
- Neurologic: level of responsiveness
- Drainage: presence of drainage, need to connect tubes to a specific drainage system, presence and condition of dressings
- Comfort: type of pain and location, nausea and vomiting, position change required
- Psychologic: nature of patient’s questions, need for rest and sleep, disturbance by noise, visitors, availability of call bell or call light
- Safety: need for side rails, drainage tubes unobstructed, IV fluid properly infusing and IV sites properly splinted
- Equipment: checked for proper functioning
- Goals and Interventions
- P – Preventing and/or relieving complications
- O – Optimal respiratory function
- S – Support: psychosocial well-being
- T – Tissue perfusion and cardiovascular status maintenance
- O – Observing and maintaining adequate fluid intake
- P – Promoting adequate nutrition and elimination
- A – Adequate fluid and electrolyte balance
- R – Renal function maintenance
- E – Encouraging activity and mobility within limits
- T – Thorough wound care for adequate wound healing
- I – Infection Control
- V – Vigilant to manifestations of anxiety and promoting ways of relieving it
- E – Eliminating environmental hazards and promoting client safety