PERIOPERATIVE

NURSING
PROFESSOR: JOSEPH CHRISTIAN G. BACLEON, RN
 PERIOPERATIVE NURSING

01 PREOPERATIVE NURSING MANAGEMENT

02 INTRAOPERATIVE NURSING MANAGEMENT

03 POSTOPERATIVE NURSING MANAGEMENT

02
INTRAOPERATIVE
NURSING
MANAGEMENT
THE SURGICAL TEAM
§ Patient
§ Surgeon
§ Anesthesiologist and CRNA
§ Scrub Nurse
§ Circulating Nurse
§ Registered Nurse First Assistant (RNFA)
The Patient
§ relaxed & prepared or fearful & highly stressed.
§ OR nurse is the patient’s advocate

Nursing Responsibilities:
§ providing for the safety and well-being of the patient
§ provides the patient with information and reassurance
§ continuing the care initiated by preoperative nurses
§ reinforces the patient’s healthy coping strategies
§ protecting dignity & interests with patients under anesthesia
Surgeon
§ head of the surgical team
§ performs the surgical procedure

Qualifications:
§ Licensed physician (MD or DO)
§ Oral surgeon (DDS or DMD)
§ Podiatrist (DPM)
Anesthesiologist & CRNA
ANESTHESIOLOGIST
§ a physician specifically trained in the art and science of
anesthesiology.

CERTIFIED REGISTERED NURSE ANESTHETIST (CRNA)

§ a qualified and specifically trained health care professional
who administers anesthetic agents
§ graduated from an accredited nurse anesthesia program
§ passed examinations sponsored by the American Association
of Nurse Anesthetists.
Anesthesiologist & CRNA
Responsibilities:
§ assesses the patient before surgery
§ selection & administration of anesthesia
§ intubates the patient (if necessary)
§ supervises the patient’s condition throughout the surgery
Scrub Nurse
qualifications: registered nurse, licensed practical nurse, or
surgical technologist (or assistant)

Scrub Roles (Before Procedure)

§ performing hand hygiene
§ setting up the sterile equipment, tables, and sterile field
§ preparing sutures, ligatures, special equipment (laparoscope)
§ assisting the surgeon and the surgical assistants
Scrub Nurse
Scrub Roles (After Procedure)
§ STANDARD CALL: done during incision closing – counts all
needles, sponges, and instruments to prevent foreign body
retention – may also use X-ray for further checking
§ LABEL tissue specimens obtained during surgery
Circulating Nurse
§ circulating nurse (or circulator); a qualified registered nurse
§ works in collaboration with the surgical team.

Responsibilities:
§ verifying consent (no consent, no surgery)
§ manipulates OR environment (ensures cleanliness, proper
temperature, humidity, appropriate lighting, safe function of
equipment, and the availability of supplies and materials)
§ monitors aseptic practices
Circulating Nurse
Responsibilities:
§ Time-out (surgical pause, or universal protocol)
Ø second verification of the surgical procedure and site takes

place and is documented – use the checklist by WHO

Ø implement prior to induction of anesthesia
Ø Every member of the surgical team verifies the patient’s

name, procedure, and surgical site using objective

documentation and data before beginning the surgery.
Circulating Nurse
Responsibilities:
§ Team debriefing session
Ø led by the circulating nurse

Ø often follows the completion of surgery to identify potential

problems with the postsurgical care of the patient and

potential areas for improvement
Registered Nurse First Assistant
§ another member of the OR team
§ practices under the direct supervision of the surgeon

RNFA responsibilities:
§ handling tissue
§ providing exposure at the operative field
§ suturing, and maintaining hemostasis
 SAFETY AND
INFECTION PREVENTION
The Surgical Environment
OR (surgical suite)
§ restricted area; behind double doors
§ with special air filtration devices, laminar flow ventilation
§ temperature: cool
Prevention of OR Fires
Fire Risk Assessment Tool
§ assess the dangers of fires for
each surgical case

§ fire risk is discussed during the

surgical time-out
Surgical Attire
Surgical area is divided into 3 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.
Surgical Attire
Guidelines (AORN, 2019a)
§ Wear close-fitting cotton scrub shirts and pants, gowns
§ Shirts & waist drawstrings should be tucked inside the pants
§ Masks are worn at all times; should fit tightly
§ Headgear should completely cover the hair
§ Shoes – exclusive use for OR; use shoe covers
Infection Prevention Principles
SURGICAL ASEPSIS
§ prevents the contamination of surgical wounds.

STERILE TECHNIQUE
§ implies that the area is free of living microorganisms.
Infection Prevention Principles
STRICT ASEPTIC PRACTICES
§ hand scrubbing
§ machine and room cleaning
§ sterile supply and instrumentation use
§ limited movement
Health Hazards
Health Hazards Associated with the Surgical Environment
a. Faulty & improper use of equipment
b. Exposure to toxic substances
c. Surgical plume (smoke generated by electrosurgical cautery)
d. Infectious waste, cuts, needlestick injuries, and lasers
e. Unintentional retention of an object (sponge, instrument) –
can cause wound infection or disruption à abscess
formation à fistulas may develop between organs
Health Hazards
Safety Measures
Surgical Plume/Smoke:
§ use of smoke evacuators
§ don an N95 respirator mask

Exposure to Blood and Body Fluids:

§ don double sterile gloves, eye protection, surgical mask, a
sterile gown, and shoe covers.
§ use of puncture-resistant containers (sharps bin)
Health Hazards
Unintentional Retention of an Object:
§ minimized distractions during the counting process
§ clear communication of the surgical team
§ radiofrequency (RF) technology
Ø acts as a “back-up method” for sponge counting using low-
frequency RF chips inside sponges that can be detected via a
wand or other scanning detection device.
ROBOTICS
Robotics
§ first introduced in the 1980s
§ more precise and less invasive for patients
§ has articulated arms (offer a 360-degree wristlike movement
for precision grasping, manipulation, dissection, and suturing
of tissue)

Technologic advancements of the robot include:

§ 3D high-definition imaging
§ better motion control of instrumentation
THE SURGICAL EXPERIENCE
ANESTHESIA
§ is a state of narcosis (severe central nervous system
depression produced by pharmacologic agents), analgesia,
relaxation, and reflex loss.

GOAL OF ANESTHESIA
§ to provide analgesia, sedation, and muscle relaxation
appropriate for the type of operative procedure
Types of Anesthesia and Sedation
§ GENERAL ANESTHESIA
§ MULTIMODAL ANESTHESIA
§ REGIONAL ANESTHESIA
§ MODERATE SEDATION
§ LOCAL ANESTHESIA
General Anesthesia
§ a reversible state consisting of complete loss of
consciousness. Protective reflexes are lost.
§ not arousable, lose the ability to maintain ventilatory function

CONSISTS OF FOUR STAGES:

§ Stage I: beginning anesthesia
§ Stage II: excitement
§ Stage III: surgical anesthesia
§ Stage IV: medullary depression
General Anesthesia (stages)
STAGE I: BEGINNING ANESTHESIA
§ upon induction: dizziness and a feeling of detachment
§ ringing, roaring, or buzzing in the ears
§ although still conscious à inability to move the extremities
§ noises are exaggerated (including low voices/minor sounds)
Ø unnecessary noises and motions are avoided when

anesthesia begins.
General Anesthesia (stages)
STAGE II: EXCITEMENT
§ struggling, shouting, talking, singing, laughing, or crying
§ pupils dilate, but constricts if exposed to light
§ rapid PR; irregular respirations

responsibilities:
§ high risk for uncontrolled movements (ready for possible
restraint – secure an advance doctor’s order/consent)
General Anesthesia (stages)
STAGE III: SURGICAL ANESTHESIA
§ patient is unconscious and lies quietly on the table.
§ pupils: small but constricts when exposed to light
§ regular respirations; PR and volume are normal
§ skin (pink or slightly flushed)

this stage may be maintained for hours in one of several planes:

§ ranging from light (1) to deep (4)
General Anesthesia (stages)
STAGE IV: MEDULLARY DEPRESSION
§ this stage is reached if too much anesthesia has been given
§ shallow respirations; weak & thready pulse
§ pupils: widely dilated and (-) reaction to light
§ cyanosis à death (if left unmanaged)

responsibilities:
§ anesthetic agent is discontinued immediately
§ respiratory and circulatory support is initiated
§ narcotic antagonist (if due to opioid overdose) – rarely used
General Anesthesia
METHODS OF ANESTHETIC AGENT DELIVERY:
1. INHALATION
2. INTRAVENOUS (IV)
General Anesthesia
INHALATION
§ volatile liquid and gases anesthetic agents
§ given in combination with oxygen + nitrous oxide
§ when D/C à eliminated thru lungs
General Anesthesia
INHALATION

ANESTHETIC DELIVERY METHODS:

§ Laryngeal Mask Airway (LMA) – a flexible tube with an
inflatable silicone ring & cuff that can be inserted into the
larynx
§ Endotracheal technique (inserted thru nasal or mouth) –
introducing a soft rubber or plastic ET into the trachea,
usually by means of a laryngoscope.
General Anesthesia
INHALATION
VOLATILE LIQUID ANESTHETIC AGENTS
§ produce anesthesia when their vapors are inhaled

GAS ANESTHETIC AGENTS

§ given by inhalation and are always combined with oxygen.
§ when inhaled à anesthetic agents enter the blood through
the pulmonary capillaries à act on cerebral centers à
produces loss of consciousness and sensation.
General Anesthesia
INTRAVENOUS ADMINISTRATION
§ given to induce (given alone) or maintain anesthesia (often
used in combination with inhalation anesthetic agents)
§ also used to produce moderate sedation
General Anesthesia
INTRAVENOUS ADMINISTRATION

ADVANTAGES:
§ onset of anesthesia is pleasant (lesser stage I symptoms)
§ duration of action is brief
§ low incidence of postoperative nausea and vomiting (PONV)
§ nonexplosive
§ require little equipment; easy to administer
General Anesthesia
INTRAVENOUS ADMINISTRATION

IV neuromuscular blockers (muscle relaxants)

§ blocks the transmission of nerve impulses at the
neuromuscular junction of skeletal muscles.
§ used to relax muscles in abdominal and thoracic surgery,
relax eye muscles in certain types of eye surgery
§ facilitates endotracheal intubation
§ treat laryngospasm
§ assists in mechanical ventilation.
Multimodal Anesthesia
Multimodal Analgesia Regimens
§ the use a combination of scheduled, nonopioid analgesic
agents and regional anesthesia techniques

§ aims to reduce opioid requirements and associated risks such

as sedation, respiratory depression, nausea, vomiting, and
potential of overuse of opioids.

§ a growing trend in the enhanced recovery after surgery

(ERAS) pathways
Multimodal Anesthesia
Multimodal Analgesia Regimens
§ Instead of general anesthesia, regional/local anesthesia (LA)
is administered à Nonopioid medications such as
acetaminophen and nonsteroidal anti-inflammatory drugs
(NSAIDs), ketamine, and gabapentinoids are preferred pain
control methods in ERAS pathways.
Regional Anesthesia
§ anesthetic agent is injected around nerves so that the region
supplied by these nerves is anesthetized.

§ the effect depends on the type of nerve involved.

§ patient receiving RA is awake & aware of their surroundings.

§ a quiet environment is therapeutic.

Regional Anesthesia
TYPES
§ EPIDURAL ANESTHESIA
§ SPINAL ANESTHESIA
§ PERIPHERAL NERVE BLOCKS
Regional Anesthesia
EPIDURAL ANESTHESIA
§ injecting a local anesthetic agent into the epidural space
(surrounds the dura mater of the spinal cord)

§ medication diffuses across the layers of the spinal cord to

provide anesthesia and pain relief

§ blocks sensory, motor, and autonomic functions

Regional Anesthesia
EPIDURAL ANESTHESIA
§ injecting a local anesthetic agent into the epidural space
(surrounds the dura mater of the spinal cord)

§ medication diffuses across the layers of the spinal cord to

provide anesthesia and pain relief

§ blocks sensory, motor, and autonomic functions

Regional Anesthesia
EPIDURAL ANESTHESIA
Advantage:
§ absence of headache
Disadvantage:
§ if inadvertent puncture of the dura à anesthetic agent travels
toward the head à high spinal anesthesia can result à
severe hypotension and respiratory depression and arrest.
Ø management: airway support, IV fluids, vasopressors.
Regional Anesthesia
SPINAL ANESTHESIA
§ injection into the subarachnoid space at the lumbar level
(between L4 and L5)
§ produces anesthesia of the lower extremities, perineum, and
lower abdomen.

Continuous Spinal Anesthesia

§ the tip of a plastic catheter remains in the subarachnoid space during the
surgical procedure so more anesthetic medication may be injected PRN
§ allows greater control of the dosage.
Regional Anesthesia
SPINAL ANESTHESIA (PROCEDURE)
§ patient usually lies on the side in a knee–chest position
§ after injection à patient is positioned in supine

Aftereffect: Headache (spinal headache)

§ Several factors are related to the incidence of headache:
Ø the size of the spinal needle used

Ø the leakage of fluid from the subarachnoid space

through the puncture site

Ø the patient’s hydration status.
Regional Anesthesia
SPINAL ANESTHESIA

Aftereffect: Headache (spinal headache)

§ Measures that increase cerebrospinal pressure are
helpful in relieving headache:
Ø maintain a quiet environment

Ø keeping the patient lying flat

Ø keeping the patient well hydrated

Regional Anesthesia
PERIPHERAL NERVE BLOCKS (PNBs)
§ used in conjunction with general or MAC anesthesia, or as a
stand-alone method.

§ Instead of a single nerve being targeted, a bundle of nerves is

located via ultrasound and injected with an anesthetic, opioid,
or steroid.
Regional Anesthesia
PERIPHERAL NERVE BLOCKS (PNBs)

Examples of common local conduction blocks include:

§ Brachial plexus block – produces anesthesia of the arm
§ Paravertebral anesthesia – produces anesthesia of the nerves
supplying the chest, abdominal wall, and extremities
§ Transsacral (caudal) block – produces anesthesia of the
perineum and, occasionally, the lower abdomen
Moderate Sedation
§ previously referred to as conscious sedation

§ a form of anesthesia that involves the IV administration of

sedatives or analgesic medications to reduce patient anxiety
and control pain during diagnostic or therapeutic procedures.

§ goal: ensures the patient’s comfort during and cooperation

with the procedures.
Moderate Sedation
MONITORED ANESTHESIA CARE (MAC)
§ also referred to as monitored sedation

§ a moderate sedation given by an anesthesiologist or CRNA

who must be prepared and qualified to convert to general
anesthesia if necessary.

§ may be used for healthy patients undergoing relatively minor

surgical procedures and for patients who can’t tolerate
anesthesia without extensive support
Local Anesthesia
§ injection of a solution containing the anesthetic agent into
the tissues at the planned incision site.

§ often it is combined with a local regional block by injecting

around the nerves immediately supplying the area.

§ often given in combination with epinephrine (constricts blood

vessels, which prevents rapid absorption of the anesthetic
agent and thus prolongs its local action)
Local Anesthesia
Advantages of LA are as follows:
§ It is simple, economical, and nonexplosive.
§ Equipment needed is minimal.
§ Postoperative recovery is brief.
§ Undesirable effects of general anesthesia are avoided.
§ It is ideal for short and minor surgical procedures.
POSTERIOR SUPERIOR ALVEOLAR NERVE (PSAN) BLOCK
Ø a dental nerve block
Ø used for profound local anesthesia of the maxillary molars.
DORSAL PENILE NERVE BLOCK
Ø an effective technique for gaining regional anesthesia of the penis
Ø uses small volumes of a local anesthetic
EPISIOTOMY REPAIR
Ø first step is the placement of a swab and infiltration of local anaesthetic
for the repair before actually suturing
Ø commonly used agent is LIDOCAINE.
Local Anesthesia
Local Anesthetic Systemic Toxicity (LAST)
§ a potentially life-threatening event
§ occurs when a bolus of LA is inadvertently injected into
peripheral tissue or venous or arterial circulation during a PNB
or spinal nerve block procedure à rapidly absorbed into
systemic circulation à cardiovascular or neurologic collapse
§ a rare event
Local Anesthesia
Local Anesthetic Systemic Toxicity (LAST)

Signs and symptoms of LAST are:

§ Metallic taste
§ Oral numbness
§ Auditory changes
§ Slurred speech
§ Arrhythmias
§ Seizure
§ Respiratory arrest
Local Anesthesia
Local Anesthetic Systemic Toxicity (LAST)

Management:
§ Airway management
§ Administering 100% oxygen and obtaining IV access
§ IV infusion of lipid emulsions (an emulsion of soybean oil, egg
phospholipids, and glycerin) – can reverse the effects of LAST
on the heart and CNS.
POTENTIAL INTRAOPERATIVE
COMPLICATIONS
POTENTIAL INTRAOPERATIVE
COMPLICATIONS
§ Anesthesia Awareness
§ Nausea and Vomiting
§ Anaphylaxis
§ Hypoxia and Other Respiratory Complications
§ Hypothermia
§ Malignant Hyperthermia
Anesthesia Awareness
§ also known as unintended intraoperative awareness
§ refers to a patient becoming cognizant of surgical
interventions while under general anesthesia and then
recalling the incident.

Indications of the occurrence of anesthesia awareness:

§ increase in the blood pressure
§ rapid heart rate
§ patient movement
Nausea and Vomiting
Risk factors:
§ female gender; age less than 50 years
§ history of PONV
§ opioid administration

If gagging occurs:
1. patient is turned to the side
2. head of the table is lowered
3. basin is provided to collect the vomitus.
4. suction is used to remove saliva & vomited gastric contents.
Nausea and Vomiting
MANAGEMENT:
§ Antiemetics (preoperatively or intraoperatively)
Ø to counteract possible aspiration

Ø given by anesthesiologist or CRNA

§ Cimetidine/Famotidine (decrease gastric acid production)

VOMITUS ASPIRATION COMPLICATIONS:

§ an attack with severe bronchial spasms and wheezing is
triggered à Pneumonitis and pulmonary edema develops
Anaphylaxis
§ may occur in response to many medications, latex, etc.

Latex allergy
§ the sensitivity to natural rubber latex products
§ mgt: use latex-free products in the OR

Fibrin sealants, cyanoacrylate tissue adhesives

§ can cause an allergic reaction
Respiratory Complications
§ Inadequate ventilation (compromised gas exchange)
Ø respiratory depression (due to anesthetic agents)

Ø aspiration of respiratory tract secretions or vomitus

Ø patient’s position on the operating table

§ Occlusion of the airway

§ Inadvertent intubation of the esophagus
§ Hypoxia (can cause brain damage)
Ø monitor (by anesthesiologist or CRNA) – peripheral

perfusion, capnography readings, respiratory patterns

Hypothermia
§ core body temperature that is lower than normal (< 36.6°C)
CAUSES:
§ low temperature in the OR
§ infusion of cold fluids; inhalation of cold gases
§ open body wounds or cavities
§ decreased muscle activity; advanced age
§ pharmaceutical agents used (vasodilators, phenothiazines,
general anesthetic medications)
Hypothermia
Risks of intraoperative hypothermia:
§ cardiovascular events
§ SSIs, bleeding
§ delayed arousal from anesthesia

Management:
§ Manual manipulation of OR temp; V/S monitoring
§ Pre-operative & intraoperative warming
§ Wet gowns/drapes are removed promptly, replaced with dry
§ Warm air blankets and thermal blankets
Malignant Hyperthermia
§ a rare inherited muscle disorder that is chemically induced by
anesthetic agents.

CAUSE:
§ genetic autosomal dominant disorder involving a mutation on
the ryanodine receptor that causes an atypical increase in
release of calcium in muscle cells
Malignant Hyperthermia
PATHOPHYSIOLOGY:
§ potent agents (inhalation anesthetic agents) à may trigger
the symptoms of malignant hyperthermia à hypermetabolic
condition of calcium in skeletal muscles à increases muscle
contraction (rigidity) à causes hyperthermia à subsequent
CNS damage
Malignant Hyperthermia
CLINICAL MANIFESTATIONS
§ Tachycardia (HR >150 bpm) – early sign
§ Hypercapnia – early respiratory sign
§ Generalized muscle rigidity
§ Late sign: rise in temperature
Ø develops rapidly

Ø body temperature can increase 1° to 2°C (2° to 4°F) q 5 mins

Ø core body temperature can exceed 42°C (107°F)

Malignant Hyperthermia
MEDICAL MANAGEMENT
§ postponed anesthesia and surgery (if possible)
§ end-tidal CO2 monitoring
§ Dantrolene Sodium (Dantrium) – postsynaptic muscle
relaxant that lessens excitation-contraction coupling in
muscle cells.
PATIENT POSITIONS ON THE
OPERATING TABLE
A. DORSAL RECUMBENT
§ usual position for surgery; flat on back
§ used for most abdominal surgeries

B. TRENDELENBURG POSITION
§ usually is used for surgery on the lower abdomen and pelvis
C. LITHOTOMY POSITION is used for
nearly all perineal, rectal, and vaginal
surgical procedures

D. SIMS OR LATERAL POSITION is

used for renal surgery. The patient is
placed on the nonoperative side with
an air pillow 12.5 to 15 cm (5 to 6
inches) thick under the loin, or on a
table with a kidney or back lift.
 END!
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