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Definition
The postoperative phase of the surgical experience extends from the time the client is transferred to the recovery room or
postanesthesia 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.
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Goals
During the postoperative period, reestablishing the patients 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.
The mnemonic POSTOPERATIVE may also be helpful:
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
To PACU
Patient Care during Immediate Postoperative Phase: Transferring the Patient to RR or PACU
Patient Assessment
Special consideration to the patients 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 patients 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 patients vital signs in the immediate postoperative
period and skin temperature.
Operative site examination. Dressings should be checked.
Positioning
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.
Postoperative Nursing Care
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.
Suction secretions as needed.
Breathing
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 patients 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
Obtain patients 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
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
Assess and evaluate patients 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
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.
GI Function and Nutrition
If in place, maintain nasogastric tube and monitor patency and drainage.
Provide symptomatic therapy, including antiemetic medications for nausea and vomiting.
Administer phenothiazine medications as prescribed for severe, persistent hiccups.
Assist patient to return to normal dietary intake gradually at a pace set by patient (liquids rst, then soft foods, such as
gelatin, junket, custard, milk, and creamed soups, are added gradually, then solid food).
Remember that paralytic ileus and intestinal obstruction are potential postoperative complications that occur more frequently in patients undergoing intestinal or abdominal surgery.
Arrange for patient to consult with the dietitian to plan appealing, high-protein meals that provide sufcient
ber, calories, and vitamins. Nutritional supplements, such as Ensure or Sustacal, may be recommended.
Instruct patient to take multivitamins, iron, and vitamin C supplements postoperatively if prescribed
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.
Drainage
Presence of drainage, need to connect tubes to a specific drainage system, presence and condition of dressings
Skin Integrity
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 patients good body alignment.
Assessing and Managing Voluntary Voiding
Assess for bladder distention and urge to void on patients arrival in the unit and frequently thereafter (patient
should void within 8 hours of surgery).
Obtain order for catheterization before the end of the 8-hour time limit if patient has an urge to void and cannot, or if
the bladder is distended and no urge is felt or patient cannot void.
Initiate methods to encourage the patient to void (eg, letting water run, applying heat to perineum).
Warm the bedpan to reduce discomfort and automatic tightening of muscles and urethral sphincter.
Assist patient who complains of not being able to use the bedpan to use a commode or stand or sit to void
(males), unless contraindicated.
Take safeguards to prevent the patient from falling or fainting due to loss of coordination from medications or
orthostatic hypotension.

Note the amount of urine voided (report less than 30 mL/h) and palpate the suprapubic area for distention or
tenderness, or use a portable ultrasound device to assess residual volume.

Continue intermittent catheterization every 4 to 6 hours until patient can void spontaneously and postvoid residual is
less than 100 mL.
Encouraging Activity

Encourage most surgical patients to ambulate as soon as possible.

Remind patient of the importance of early mobility in preventing complications (helps overcome fears).

Anticipate and avoid orthostatic hypotension (postural hypotension: 20-mm Hg fall in systolic blood pressure or 10mm Hg fall in diastolic blood pressure, weakness, dizziness, and fainting)

Assess patients feelings of dizziness and his or her blood pressure rst in the supine position, after patient sits up, again
after patient stands, and 2 to 3 minutes later.

Assist patient to change position gradually. If patient becomes dizzy, return to supine position and delay getting out of
bed for several hours.

When patient gets out of bed, remain at patients side to give physical support and encouragement.

Take care not to tire patient.

Initiate and encourage patient to perform bed exercises to improve circulation (range of motion to arms, hands and ngers, feet, and legs; leg exion and leg lifting; abdominal and gluteal contraction).

Encourage frequent position changes early in the postoperative period to stimulate circulation. Avoid positions
that compromise venous return (raising the knee gatch or placing a pillow under the knees, sitting for long periods, and dangling the legs
with pressure at the back of the knees).

Apply antiembolism stockings, and assist patient in early ambulation. Check postoperative activity orders before getting patient out of bed. Then have patient sit on the edge of bed for a few minutes initially; advance to ambulation as tolerated
Gerontologic Considerations
Elderly patients continue to be at increased risk for postoperative complications. Age-related physiologic changes in respi-ratory,
cardiovascular, and renal function and the increased incidence of comorbid conditions demand skilled assessment to detect early signs of
deterioration. Anesthetics and opioids can cause confusion in the older adult, and altered pharmacokinetics results in delayed excretion and
prolonged respiratory depressive effects. Careful monitoring of electrolyte, hemoglo-bin, and hematocrit levels and urine output is essential
because the older adult is less able to correct and compensate for uid and electrolyte imbalances. Elderly patients may need
frequent reminders and demonstrations to participate in care effectively.

Maintain physical activity while patient is confused. Physi-cal deterioration can worsen delirium and place patient
at increased risk for other complications.

Avoid restraints, because they can also worsen confusion. If possible, family or staff member is asked to sit with
patient instead.

Administer haloperidol (Haldol) or lorazepam (Ativan) as ordered during episodes of acute confusion; discontinue these
medications as soon as possible to avoid side effects.

Assist the older postoperative patient in early and progressive ambulation to prevent the development of problems such
as pneumonia, altered bowel function, DVT, weakness, and functional decline; avoid sitting positions that promote venous stasis in the lower
extremities.

Provide assistance to keep patient from bumping into objects and falling. A physical therapy referral may be indicated
to promote safe, regular exercise for the older adult.

Provide easy access to call bell and commode; prompt void-ing to prevent urinary incontinence.

Provide extensive discharge planning to coordinate both professional and family care providers; the nurse, social
worker, or nurse case manager may institute the plan for continuing care.
Evaluation
Patients in PACU are evaluated to determine the clients discharge from the unit. The following are the expected outcomes in
PACU:
1.
Patient breathing easily.
2.
Clear lung sounds on auscultation.
3.
Stable vital signs.
4.
Stable body temperature with minimal chills or shivering.
5.
No signs of fluid volume imbalance as evidenced by an equal intake and output.
6.
Tolerable or minimized pain, as reported by the patient.
7.
Intact wound edges without drainage.
8.
Raised side rails.
9.
Appropriate patient position.
10.
Maintained quiet and therapeutic environment.
To Surgical Unit
Patient Care during Immediate Postoperative Phase: Transferring the Patient from RR to the Surgical Unit
To determine the patients readiness for discharge from the PACU or RR certain criteria must be met. The parameters used for
discharge from RR are the following:
1.
Uncompromised cardiopulmonary status
2.
Stable vital signs
3.
Adequate urine output at least 30 ml/ hour
4.
Orientation to time, date and place
5.
Satisfactory response to commands
6.
Minimal pain
7.
Absence or controlled nausea and vomiting
8.
Pulse oximetry readings of adequate oxygen saturation
9.
Satisfactory response to commands

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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
patients 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 patients 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
Definition
Perioperative nursing describes the wide variety of nursing functions associated with the patients 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.
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Reasons
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.
Classifications of Surgical Procedures
There are different classifications of surgical procedures which can be classified as to: urgency, purpose and risk. These
classifications can help identify the risk of degree of the surgery.
Based on Purpose
Diagnostic. These kind of surgeries are done to determine cause of illness and/or make confirm a diagnosis. Examples
includes: biopsy, exploratory laparotomy (explorelap)
Ablative/Curative. These kind of surgeries are performed to remove a diseased part or organ. Examples include:
gastrectomy (partial or full removal of stomach), thyroidectomy, and appendectomy.
Palliative. To relieve symptoms without curing the disease. These include: colostomy, debridement of necrotic tissue.
Re-constructive. These includes skin graft, plastic surgery, scar revisions. These are done to restore function to
traumatized or malfunctioninig tissue and to improve self concept.
Transplant. To replace organs or structures that are diseased or malfunctioning.
Constructive. To restore function in congeinital anomalies. Cleft palate repaire (palatoplasty), closure of atrial-septal
defect.
Exploratory. To estimate of the extend of the disease or confirmation of diagnosis. Examples: Exploratory laparotomy,
pelvic laparotomy.
Aesthetic. To improve of physical features that are within normal range. Example: breast augmentation.
Based on Urgency
Elective. These are kind of surgeries wherein they are pre-planned. Delay of surgery has no ill-effects. These can be
scheduled in advanced based on the clients choice. Examples: tonsillectomy, hernia repaire, cataract extraction, mammoplasty, face lift, and
cesarean section.
Urgent. Surgeries that are necessary for the clients health, usually done within 24 to 48 hours. Examples: Removal of
gall bladder, amputation, colon resection, coronary artery bypass, surgical removal of tumor
Emergent. Surgeries that must be done immediately to preserve clients life, body part of body function.
Examples: Control of hemorrhage, perforated ulcer, intestinal obstruction, repair of trauma, tracheostomy
Related Concerns
Alcohol: acute withdrawal
Cancer
Diabetes mellitus/Diabetic ketoacidosis
Fluid and electrolyte imbalances
Hemothorax/Pneumothorax
Metabolic acidosis
Metabolic alkalosis
Peritonitis
Pneumonia, microbial
Psychosocial aspects of care
Respiratory acidosis
Respiratory alkalosis
Sepsis/Septicemia
Thrombophlebitis: DVT
Total nutritional support

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Assessment
Data depends on the duration/severity of underlying problem and involvement of other body systems. Refer to specific plans of
care for data and diagnostic studies relevant to the procedure and additional nursing diagnoses.
CIRCULATION
May report: History of cardiac problems, heart failure (HF), pulmonary edema, peripheral vascular disease, or vascular
stasis (increases risk of thrombus formation)
May exhibit: Changes in heart rate (sympathetic stimulation)
EGO INTEGRITY
May report: Feelings of anxiety, fear, anger, apathy
Multiple stress factors, e.g., financial, relationship, lifestyle
May exhibit: Restlessness, increased tension/irritability
Sympathetic stimulation, e.g., changes in heart rate (HR), respiratory rate
ELIMINATION
May report: History of kidney/bladder conditions; use of diuretics/laxatives
FOOD/FLUID
May report: Pancreatic insufficiency/DM (predisposing to hypoglycemia/ketoacidosis)
Use of diuretics
May exhibit: Malnutrition (including obesity)
Dry mucous membranes (limited intake/nothing-by-mouth [NPO] period preoperatively)
RESPIRATION
May report: Infections, chronic conditions/cough, smoking
May exhibit: Changes in respiratory rate (sympathetic stimulation)
SAFETY
May report: Allergies or sensitivities to medications, food, tape, latex, and solution(s)
Immune deficiencies (increases risk of systemic infections and delayed healing)
Presence of cancer/recent cancer therapy
Family history of malignant hyperthermia/reaction to anesthesia, autoimmune diseases
History of hepatic disease (affects drug detoxification and may alter coagulation)
History of blood transfusion(s)/transfusion reaction
May exhibit: Presence of existing infectious process; fever
TEACHING/LEARNING
May report: Use of medications such as anticoagulants, steroids, antibiotics, antihypertensives, cardiotonic glycosides,
antidysrhythmics, bronchodilators, diuretics, decongestants, analgesics, anti-inflammatories, anticonvulsants, or antipsychotics/antianxiety
agents, as well as over-the-counter (OTC) medications, herbal supplements, or alcohol or other drugs of abuse (risk of liver damage affecting
coagulation and choice of anesthesia, as well as potential for postoperative withdrawal)
Diagnostic Studies
General preoperative requirements may include: Complete blood count (CBC), prothrombin time (PT)/activated
partial thromboplastin time (aPTT), chest x-ray. Other studies depend on type of operative procedure, underlying medical conditions, current
medications, age, and weight. These tests may include blood urea nitrogen (BUN), creatinine (Cr), glucose, arterial blood gases (ABGs),
electrolytes; liver function, thyroid, nutritional studies, electrocardiogram (ECG). Deviations from normal should be corrected if possible
before safe administration of anesthetic agents.
CBC: An elevated white blood cell (WBC) count is indicative of inflammatory process (may be diagnostic, e.g.,
appendicitis); decreased WBC count suggests viral processes (requiring evaluation because immune system may be dysfunctional). Low
hemoglobin (Hb) suggests anemia/blood loss (impairs tissue oxygenation and reduces the Hb available to bind with inhalation anesthetics);
may suggest need for crossmatch/blood transfusion. An elevated hematocrit (Hct) may indicate dehydration; decreased Hct suggests fluid
overload.
Electrolytes: Imbalances impair organ function, e.g., decreased potassium affects cardiac muscle contractility, leading
to decreased cardiac output.
ABGs: Evaluates current respiratory status, which may be especially important in smokers, patients with chronic lung
diseases.
Coagulation times: May be prolonged, interfering with intraoperative/postoperative hemostasis; hypercoagulation
increases risk of thrombosis formation, especially in conjunction with dehydration and decreased mobility associated with surgery.
Urinalysis: Presence of WBCs or bacteria indicates infection. Elevated specific gravity may reflect dehydration.
Pregnancy test: Positive results affect timing of procedure and choice of pharmacological agents.
Chest x-ray: Should be free of infiltrates, pneumonia; used for identification of masses and COPD.
ECG: Abnormal findings require attention before administering anesthetics.
Nursing Priorities
Reduce anxiety and emotional trauma.
Provide for physical safety.
Prevent complications.
Alleviate pain.
Facilitate recovery process.
Provide information about disease process/surgical procedure, prognosis, and treatment needs.
Discharge Goals
Patient dealing realistically with current situation.
Injury prevented.
Complications prevented/minimized.
Pain relieved/controlled.

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Wound healing/organ function progressing toward normal.

Disease process/surgical procedure, prognosis, and therapeutic regimen understood.
Plan in place to meet needs after discharge.
Preoperative Phase
Main Article: Preoperative Phase
The preoperative phase begins when the decision for surgical intervention is made and ends when the patient is transferred from
the operating room.
Responsibilities included during the preoperative phase are:
Pre-admission Testing
Initiates initial preoperative assessment.
Initiates teaching appropriate to patients to patients needs.
Verifies completion of preoperative testing.
Verifies understanding of surgeon-specific preoperative orders (e.g. bowel preparation, preoperative shower)
Assess patients need for postoperative transportation and care.
Admission to Surgical Center or Unit
Completes preoperative assessment.
Assess for risk for postoperative complications.
Reports unexpected findings or any deviation from normal.
Verifies that operative consent has been signed.
Reinforce previous teaching.
Explain phase in perioperative period and expectation.
Develop a plan of care.
In Holding Area
Assess patients status, baseline pain and nutritional status.
Review chart.
Identifies patient.
Verifies surgical site and marks site per institutional policy.
Establishes intravenous line.
Administers medication if prescribed.
Takes measures to ensure patients comfort.
Provides psychological support.
Communicates patients emotional status to other appropriate members of the health care team.
Intraoperative Phase
Main Article: Intraoperative Phase
The intraoperative 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.
Maintenance of Safety
Maintains aseptic, controlled environment.
Effectively manages human resources, equipment, and supplies for individualized patient care.
Transfer patient to operating room bed or table.
Position the patient: function alignment, exposure of surgical site.
Applies grounding device to patient.
Ensure that the sponge, needle, and instrument counts are correct.
Completes intraoperative documentation.
Physiologic Monitoring
Calculates effect on patient of excessive fluid loss or gain.
Distinguishes normal from abnormal cardiopulmonary data.
Reports changes in patients vital signs.
Postoperative Phase
Main Article: Postoperative Phase
The postoperative 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.
Some of the responsibilities entailed during postoperative phase are:
Communicates intraoperative information
Identifies patient by name.
States type of surgery performed.
Identifies type of anesthetic used.
Reports patients response to surgical procedure and anesthesia.
Describes intraoperative factors (e.g., insertion of drains or catheters, administration of blood, analgesic agents, or other
medications during surgery, occurrence of unexpected events.
Describes physical limitations.
Reports patients preoperative level of consciousness.
Postoperative Assessment Recovery Area
Determines patients immediate response to surgical intervention.
Monitor patients physiologic status.
Assess patients pain level and administers appropriate pain relief measures.

Maintains patients safety(airway, circulation, prevention of injury)

Administer medication, fluid and blood component therapy, if prescribed.
Assess patients readiness for transfer to in-hospital unit or for discharge home based on institutional policy.
Transfer to Surgical Unit/Ward
Continues monitoring of patients physical and psychological response to surgical intervention.
Provides teaching to patient during immediate recovery period.
Assist patient in recovery and preparation for discharge home.
Determines patients psychological status.
Assist with discharge planning.
Home or Clinic
Provides follow-up care during office or clinic visit or by telephone contact.
Reinforce previous teaching and answer patients and family questions about surgery and follow-up care.
Assess patients response to surgery and anesthesia and their effects on body image and function.
Definition
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 healthcare team members have an obligation to make
the patients welfare their first consideration during the surgical experience.
The scope of activities during the preoperative phase includes the establishment of the patients 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.
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Goals
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
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.
The following are the physiologic assessments necessary during the preoperative phase:
Age
Obtain a health history and perform a physical examination to establish vital signs and a database for future
comparisons.
Assess patients usual level of functioning and typical daily activities to assist in patients care and recovery or
rehabilitation plans.
Assess mouth for dental caries, dentures, and partial plates. Decayed teeth or dental prostheses may become dislodged
during intubation for anesthetic delivery and occlude the airway.
Nutritional status and needs determined by measuring the patients height and weight, triceps skinfold, 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.
Infection
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 patients 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.
Presence of trauma
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 patients 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.

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Tranquilizers medications such as barbiturates, diazepam and chlordiazepoxide 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.
Gerontologic Considerations
Monitor older patients undergoing surgery for subtle clues that indicate underlying problems since elder patients have
less physiologic reserve than younger patients.
Monitor also elderly patients for dehydration, hypovolemia, and electrolyte imbalances.
Nursing Diagnosis
The following are possible nursing diagnosis during the preoperative phase:
Anxiety related to the surgical experience (anesthesia, pain) and the outcome of surgery
Risk for Ineffective Therapeutic Management Regiment related to deficient knowledge of preoperative procedures and
protocols and postoperative expectations
Fear related to perceived threat of the surgical procedure and separation from support system
Deficient Knowledge related to the surgical process
Diagnostic Tests
These diagnostic tests may be carried out during the perioperative phase:
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
Endoscopies
Tissue biopsies
Stool studies
Urine studies
Significant physical findings are also noted to further describe the patients 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 intraoperative care, reduce
costs associated with surgery, and return the patient to optimal functioning as soon as possible.
Psychological Assessment
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 clients fears, worries and concerns.
Encourage patient verbalization of feelings.
Provide information that helps to allay fears and concerns of the patient.
Give empathetic support.
Informed consent
Reinforce information provided by surgeon.
Notify physician if patient needs additional information to make his or her decision.
Ascertain that the consent form has been signed before administering psychoactive premedication. Informed consent is
required for invasive procedures, such as incisional, biopsy, cystoscopy, or paracentesis; procedures requiring sedation and/or anesthesia;
nonsurgical procedures that pose more than slight risk to the patient (arteriography); and procedures involving radiation.
Arrange for a responsible family member or legal guardian to be available to give consent when the patient is a
minor or is unconscious or incompetent (an emancipated minor [married or independently earning own living] may sign his or her own
surgical consent form).
Place the signed consent form in a prominent place on the patients chart.
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 clients 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.
Nursing Interventions
Reducing Anxiety and Fear
Provide psychosocial support.
Be a good listener, be empathetic, and provide information that helps alleviate concerns.
During preliminary contacts, give the patient opportunities to ask questions and to become acquainted with those
who might be providing care during and after surgery.
Acknowledge patient concerns or worries about impending surgery by listening and communicating therapeutically.
Explore any fears with patient, and arrange for the assistance of other health professionals if required.
Teach patient cognitive strategies that may be useful for relieving tension, overcoming anxiety, and achieving
relaxation, including imagery, distraction, or optimistic affirmations.
Managing Nutrition and Fluids
Provide nutritional support as ordered to correct any nutrient deficiency before surgery to provide enough protein
for tissue repair.
Instruct patient that oral intake of food or water should be withheld 8 to 10 hours before the operation (most common),
unless physician allows clear fluids up to 3 to 4 hours before surgery.
Inform patient that a light meal may be permitted on the preceding evening when surgery is scheduled in the morning,
or provide a soft breakfast, if prescribed, when surgery is scheduled to take place after noon and does not involve any part of the GI tract.
In dehydrated patients, and especially in older patients, encourage fluids by mouth, as ordered, before surgery,
and administer fluids intravenously as ordered.
Monitor the patient with a history of chronic alcoholism for malnutrition and other systemic problems that increase
the surgical risk as well as for alcohol withdrawal (delirium tremens up to 72 hours after alcohol withdrawal).
Promoting Optimal Respiratory and Cardiovascular Status
Urge patient to stop smoking 2 months before surgery (or at least 24 hours before).
Teach patient breathing exercises and how to use an incentive spirometer if indicated.
Assess patient with underlying respiratory disease (eg, asthma, chronic obstructive pulmonary disease
[COPD]) carefully for current threats to pulmonary status; assess patients use of medications that may affect postoperative recovery.
In the patient with cardiovascular disease, avoid sudden changes of position, prolonged immobilization, hypotension or
hypoxia, and overloading of the circulatory system with fluids or blood.
Supporting Hepatic and Renal Function
If patient has a disorder of the liver, carefully assess various liver function tests and acidbase status.
Frequently monitor blood glucose levels of the patient with diabetes before, during, and after surgery.
Report the use of steroid medications for any purpose by the patient during the preceding year to the anesthesiologist
and surgeon.
Monitor patient for signs of adrenal insufficiency.
Assess patients with uncontrolled thyroid disorders for a history of thyrotoxicosis (with hyperthyroid disorders) or
respiratory failure (with hypothyroid disorders).
Promoting Mobility and Active Body Movement
Explain the rationale for frequent position changes after surgery (to improve circulation, prevent venous stasis, and
promote optimal respiratory function) and show patient how to turn from side to side and assume the lateral position without causing pain or
disrupting IV lines, drainage tubes, or other apparatus.
Discuss any special position patient will need to maintain after surgery (eg, adduction or elevation of an extremity) and
the importance of maintaining as much mobility as possible despite restrictions.
Instruct patient in exercises of the extremities, including extension and flexion of the knee and hip joints (similar
to bicycle riding while lying on the side); foot rotation (tracing the largest possible circle with the great toe); and range of motion of the
elbow and shoulder.
Use proper body mechanics, and instruct patient to do the same. Maintain patients body in proper alignment
when patient is placed in any position.
Respecting Spiritual and Cultural Beliefs
Help patient obtain spiritual help if he or she requests it; respect and support the beliefs of each patient.
Ask if the patients spiritual adviser knows about the impending surgery.
When assessing pain, remember that some cultural groups are unaccustomed to expressing feelings openly. Individuals
from some cultural groups may not make direct eye contact with others; this lack of eye contact is not avoidance or a lack of interest but a
sign of respect.

Listen carefully to patient, especially when obtaining the history. Correct use of communication and interviewing skills
can help the nurse acquire invaluable information and insight. Remain unhurried, understanding, and caring.
Providing Preoperative Patient Education
Teach each patient as an individual, with consideration for any unique concerns or learning needs.
Begin teaching as soon as possible, starting in the physicians office and continuing during the pre admission visit,
when diagnostic tests are being performed, through arrival in the operating room.
Space instruction over a period of time to allow patient to assimilate information and ask questions.
Combine teaching sessions with various preparation proce-dures to allow for an easy flow of information.
Include descriptions of the procedures and explanations of the sensations the patient will experience.
During the preadmission visit, arrange for the patient to meet and ask questions of the perianesthesia nurse,
view audiovisuals, and review written materials. Provide a telephone number for patient to call if questions arise closer to the date of surgery.
Reinforce information about the possible need for a ventilator and the presence of drainage tubes or other types of
equipment to help the patient adjust during the postoperative period.
Inform the patient when family and friends will be able to visit after surgery and that a spiritual advisor will be
available if desired.
Teaching the Ambulatory Surgical Patient
For the same day or ambulatory surgical patient, teach about discharge and follow-up home care. Education can be
provided by a videotape, over the telephone, or during a group meeting, night classes, preadmission testing, or the preoperative interview.
Answer questions and describe what to expect.
Tell the patient when and where to report, what to bring (insurance card, list of medications and allergies), what to
leave at home (jewelry, watch, medications, contact lenses), and what to wear (loose-fitting, comfortable clothes; flat shoes).
During the last preoperative phone call, remind the patient not to eat or drink as directed; brushing teeth is
permitted, but no fluids should be swallowed.
Teaching Deep Breathing and Coughing Exercises
Teach the patient how to promote optimal lung expansion and consequent blood oxygenation after anesthesia
by assuming a sitting position, taking deep and slow breaths (maximal sustained inspiration), and exhaling slowly.
Demonstrate how patient can splint the incision line to minimize pressure and control pain (if there will be a thoracic or
abdominal incision).
Inform patient that medications are available to relieve pain and that they should be taken regularly for pain relief to
enable effective deepbreathing and coughing exercises.
Explaining Pain Management
Instruct patient to take medications as frequently as prescribed during the initial postoperative period for pain relief.
Discuss the use of oral analgesic agents with patient before surgery, and assess patients interest and willingness to
participate in pain relief methods.
Instruct patient in the use of a pain rating scale to promote postoperative pain management.
Preparing the Bowel for Surgery
If ordered preoperatively, administer or instruct the patient to take the antibiotic and a cleansing enema or laxative the
evening before surgery and repeat it the morning of surgery.
Have the patient use the toilet or bedside commode rather than the bedpan for evacuation of the enema, unless
the patients condition presents some contraindication.
Preparing Patient for Surgery
Instruct patient to use detergentgermicide for several days at home (if the surgery is not an emergency).
If hair is to be removed, remove it immediately before the operation using electric clippers.
Dress patient in a hospital gown that is left untied and open in the back.
Cover patients hair completely with a disposable paper cap; if patient has long hair, it may be braided; hairpins are
removed.
Inspect patients mouth and remove dentures or plates.
Remove jewelry, including wedding rings
If patient objects, securely fasten the ring with tape.
Give all articles of value, including dentures and prosthetic devices, to family members, or if needed label articles
clearly with patients name and store in a safe place according to agency policy.
Assist patients (except those with urologic disorders) to void immediately before going to the operating room.
Administer preanesthetic medication as ordered, and keep the patient in bed with the side rails raised. Observe
patient for any untoward reaction to the medications. Keep the immediate surroundings quiet to promote relaxation.
Transporting Patient to Operating Room
Send the completed chart with patient to operating room; attach surgical consent form and all laboratory reports
and nurses records, noting any unusual last minute observations that may have a bearing on the anesthesia or surgery at the front of the chart
in a prominent place.
Take the patient to the preoperative holding area, and keep the area quiet, avoiding unpleasant sounds or conversation.
Attending to Special Needs of Older Patients
Assess the older patient for dehydration, constipation, and malnutrition; report if present.
Maintain a safe environment for the older patient with sensory limitations such as impaired vision or hearing
and reduced tactile sensitivity.
Initiate protective measures for the older patient with arthritis, which may affect mobility and comfort. Use
adequate padding for tender areas. Move patient slowly and protect bony prominences from prolonged pressure. Provide gentle massage to
promote circulation.

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Take added precautions when moving an elderly patient because decreased perspiration leads to dry, itchy, fragile
skin that is easily abraded.
Apply a lightweight cotton blanket as a cover when the elderly patient is moved to and from the operating
room, because decreased subcutaneous fat makes older people more susceptible to temperature changes.
Provide the elderly patient with an opportunity to express fears; this enables patient to gain some peace of mind and a
sense of being understood
Attending to the Familys Needs
Assist the family to the surgical waiting room, where the surgeon may meet the family after surgery.
Reassure the family they should not judge the seriousness of an operation by the length of time the patient is in the
operating room.
Inform those waiting to see the patient after surgery that the patient may have certain equipment or devices in place (ie,
IV lines, indwelling urinary catheter, nasogastric tube, suction bottles, oxygen lines, monitoring equipment, and blood transfusion lines).
When the patient returns to the room, provide explanations regarding the frequent postoperative observations.
Spiritual Considerations
Help patient obtain spiritual help if he or she requests it; respect and support the beliefs of each patient.
Ask if the patients spiritual adviser knows about the impending surgery.
When assessing pain, remember that some cultural groups are unaccustomed to expressing feelings openly. Individuals
from some cultural groups may not make direct eye contact with others; this lack of eye contact is not avoidance or a lack of interest but a
sign of respect.
Listen carefully to patient, especially when obtaining the history. Correct use of communication and interviewing skills
can help the nurse acquire invaluable information and insight. Remain unhurried, understanding, and caring.
Definition
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 postanesthesia care unit
(PACU).
Throughout the surgical experience the nurse functions as the patients chief advocate. The nurses 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.
Contents [show]
Goals
Promote the principle of asepsis asepsis.
Homeostasis
Safe administration of anesthesia
Hemostasis
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 patients emotional well being and physiologic monitoring.
Anesthesiologist or anesthetist provides smooth induction of the patients 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.
Nursing Functions
Circulating Nurse
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 persons safety and well being.
Scrub Nurse
The scrub nurse assists the surgeon during the whole procedure by anticipating the required instruments and setting up the sterile
table. The responsibilities of the scrub nurse are:
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 patients 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 patients general condition must also be assessed because it may affect the management of anesthesia. Thus, the anesthesiologist
assesses the patients 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 clients physical status for anesthesia before surgery is summarized below.
Classification of Physical Status for Anesthesia Before Surgery

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Classification

Description

Example

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 above when surgery is performed in an

emergency situation

An uncomplicated hernia that is now strangulated and associated with nausea and vom

Source: Brunner and Suddarths Medical-Surgical Nursing by Smeltzer and Bare

Anesthesia
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
General 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
Cyclopropane
Stages
General 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 Anesthesia

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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
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.
Spinal Anesthesia
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
The following are nursing assessment after anesthesia:
Monitoring vital signs.
Observe patient and record the time when motion and sensation of the legs and the toes return.
Side Effects
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.
Positioning
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 patients 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.
Nursing Responsibilities
Here are the nursing responsibilities during intraoperative phase:
Safety is the highest priority.
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.

Chn
OPAR or Community Organizing Participatory Action Research is a vital part of public health nursing. COPAR aims to
transform the apathetic, individualistic and voiceless poor into dynamic, participatory and politically responsive community.
Definition
COPAR stands for Community Organizing Participatory Action Research
A social development approach that aims to transform the apathetic, individualistic and voiceless poor into dynamic,
participatory and politically responsive community.
A collective, participatory, transformative, liberative, sustained and systematic process of building peoples
organizations by mobilizing and enhancing the capabilities and resources of the people for the resolution of their issues
and concerns towards effecting change in their existing oppressive and exploitative conditions (1994 National Rural
Conference).

A process by which a community identifies its needs and objectives, develops confidence to take action in respect to
them and in doing so, extends and develops cooperative and collaborative attitudes and practices in the community
(Ross 1967).
A continuous and sustained process of educating the people to understand and develop their critical awareness of their
existing condition, working with the people collectively and efficiently on their immediate and long-term problems, and
mobilizing the people to develop their capability and readiness to respond and take action on their immediate needs
towards solving their long-term problems (CO: A manual of experience, PCPD).

Process
The sequence of steps whereby members of a community come together to critically assess to evaluate community conditions
and work together to improve those conditions.
Structure
Refers to a particular group of community members that work together for a common health and health related goals.
Contents [show]
Emphasis
1. Community working to solve its own problem.
2. Direction is established internally and externally.
3. Development and implementation of a specific project less important than the development of the capacity of the
community to establish the project.
4. Consciousness raising involves perceiving health and medical care within the total structure of society.
Importance
1. COPAR is an important tool for community development and people empowerment as this helps the community
workers to generate community participation in development activities.
2. COPAR prepares people/clients to eventually take over the management of a dvelopment.programs in the future.
3. COPAR maximizes community participation and involvement; community resources are mobilized for community
services.
Principles
1. People especially the most oppressed, exploited and deprived sectors are open to change, have the capacity to change
and are able to bring about change.
2. COPAR should be based on the interest of the poorest sector of the community.
3. COPAR should lead to a self-reliant community and society.
Critical Steps
1. Integration
2. Social Investigation
3. Tentative program planning
4. Groundwork
5. Meeting
6. Role Play
7. Mobilization or action
8. Evaluation
9. Reflection
10. Organization
Phases of COPAR
COPAR has four phases namely: Pre-Entry Phase, Entry Phase, Organization-building phase, and sustenance and strengthening
phase.
1. Pre-Entry Phase
Is the initial phase of the organizing process where the community organizer looks for communities to serve and help. Activities
include:
Preparation of the Institution
Train faculty and students in COPAR.
Formulate plans for institutionalizing COPAR.
Revise/enrich curriculum and immersion program.
Coordinate participants of other departments.
Site Selection
Initial networking with local government.
Conduct preliminary special investigation.
Make long/short list of potential communities.
Do ocular survey of listed communities.
Criteria for Initial Site Selection
Must have a population of 100-200 families.
Economically depressed.No strong resistance from the community.
No serious peace and order problem.
No similar group or organization holding the same program.
Identifying Potential Municipalities
Make long/short list of potential municipalities
Identifying Potential Community
Do the same process as in selecting municipality.
Consult key informants and residents.
Coordinate with local government and NGOs for future activities.
Choosing Final Community

 Conduct informal interviews with community residents and key informants.

Determine the need of the program in the community.
Take note of political development.
Develop community profiles for secondary data.
Develop survey tools.
Pay courtesy call to community leaders.
Choose foster families based on guidelines
Identifying Host Family
House is strategically located in the community.
Should not belong to the rich segment.
Respected by both formal and informal leaders.
Neighbors are not hesitant to enter the house.
No member of the host family should be moving out in the community.
2. Entry Phase
sometimes called the social preparation phase. Is crucial in determining which strategies for organizing would suit the chosen
community. Success of the activities depend on how much the community organizers has integrated with the community.
Guidelines for Entry
Recognize the role of local authorities by paying them visits to inform their presence and activities.
Her appearance, speech, behavior and lifestyle should be in keeping with those of the community residents without
disregard of their being role model.
Avoid raising the consciousness of the community residents; adopt a low-key profile.
Activities in the Entry Phase
Integration. Establishing rapport with the people in continuing effort to imbibe community life.
living with the community
seek out to converse with people where they usually congregate
lend a hand in household chores
avoid gambling and drinking
Deepening social investigation/community study
verification and enrichment of data collected from initial survey
conduct baseline survey by students, results relayed through community assembly
Core Group Formation
Leader spotting through sociogram.
Key Persons. Approached by most people
Opinion Leader. Approached by key persons
Isolates. Never or hardly consulted
3. Organization-building Phase
Entails the formation of more formal structure and the inclusion of more formal procedure of planning, implementing, and
evaluating community-wise activities. It is at this phase where the organized leaders or groups are being given training (formal, informal,
OJT) to develop their style in managing their own concerns/programs.
Key Activities
Community Health Organization (CHO)
preparation of legal requirements
guidelines in the organization of the CHO by the core group
election of officers
Research Team Committee
Planning Committee
Health Committee Organization
Others
Formation of by-laws by the CHO
4. Sustenance and Strengthening Phase
Occurs when the community organization has already been established and the community members are already actively
participating in community-wide undertakings. At this point, the different committees setup in the organization-building phase are already
expected to be functioning by way of planning, implementing and evaluating their own programs, with the overall guidance from the
community-wide organization.
The family nursing process is the same nursing process as applied to the family, the unit of care in the community. These are the
common assessment cues and diagnoses for families in creating Family Nursing Care Plans.
First level Assessment
The process of determining existing and potential health conditions or problems of the family. These health conditions are
categorized as:
I. Presence of Wellness Condition
Stated as Potential or Readiness; a clinical or nursing judgment about a client in transition from a specific level of wellness
or capability to a higher level. Wellness potential is a nursing judgment on wellness state or condition based on clients performance, current
competencies, or performance, clinical data or explicit expression of desire to achieve a higher level of state or function in a specific area on
health promotion and maintenance. Examples of this are the following
A. Potential for Enhanced Capability for:
Healthy lifestyle-e.g. nutrition/diet, exercise/activity

Healthy maintenance/health management

Parenting
Breastfeeding
Spiritual well-being-process of clients developing/unfolding of mystery through harmonious interconnectedness that
comes from inner strength/sacred source/God (NANDA 2001)
Others. Specify.
B. Readiness for Enhanced Capability for:
Healthy lifestyle
Health maintenance/health management
Parenting
Breastfeeding
Spiritual well-being
Others. Specify.
II. Presence of Health Threats
Are conditions that are conducive to disease and accident, or may result to failure to maintain wellness or realize health
potential. Examples are the following:
A. Presence of risk factors of specific diseases (e.g. lifestyle diseases, metabolic syndrome, smoking)
B. Threat of cross infection from communicable disease case
C. Family size beyond what family resources can adequately provide
D. Accident hazards specify.
Broken chairs
Pointed /sharp objects, poisons and medicines improperly kept
Fire hazards
Fall hazards
Others specify.
E. Faulty/unhealthful nutritional/eating habits or feeding techniques/practices. Specify.
Inadequate food intake both in quality and quantity
Excessive intake of certain nutrients
Faulty eating habits
Ineffective breastfeeding
Faulty feeding techniques
F. Stress Provoking Factors. Specify.
Strained marital relationship
Strained parent-sibling relationship
Interpersonal conflicts between family members
Care-giving burden
G. Poor Home/Environmental Condition/Sanitation. Specify.
Inadequate living space
Lack of food storage facilities
Polluted water supply
Presence of breeding or resting sights of vectors of diseases
Improper garbage/refuse disposal
Unsanitary waste disposal
Improper drainage system
Poor lightning and ventilation
Noise pollution
Air pollution
H. Unsanitary Food Handling and Preparation
I. Unhealthy Lifestyle and Personal Habits/Practices. Specify.
Alcohol drinking
Cigarette/tobacco smoking
Walking barefooted or inadequate footwear
Eating raw meat or fish
Poor personal hygiene
Self medication/substance abuse
Sexual promiscuity
Engaging in dangerous sports
Inadequate rest or sleep
Lack of /inadequate exercise/physical activity
Lack of/relaxation activities
Non use of self-protection measures (e.g. non use of bed nets in malaria and filariasis endemic areas).
J. Inherent Personal Characteristics
e.g. poor impulse control
K. Health History, which may Participate/Induce the Occurrence of Health Deficit
e.g. previous history of difficult labor.

L. Inappropriate Role Assumption

e.g. child assuming mothers role, father not assuming his role.
M. Lack of Immunization/Inadequate Immunization Status Especially of Children
N. Family Disunity
Self-oriented behavior of member(s)
Unresolved conflicts of member(s)
Intolerable disagreement
O. Others. Specify._________
III. Presence of health deficits
These are instances of failure in health maintenance.
Examples include:
A. Illness states, regardless of whether it is diagnosed or undiagnosed by medical practitioner.
B. Failure to thrive/develop according to normal rate
C. Disability
Whether congenital or arising from illness; transient/temporary (e.g. aphasia or temporary paralysis after a CVA) or permanent
(e.g. leg amputation, blindness from measles, lameness from polio)
IV. Presence of stress points/foreseeable crisis situations
Are anticipated periods of unusual demand on the individual or family in terms of adjustment/family resources. Examples of this
include:
A. Marriage
B. Pregnancy, labor, puerperium
C. Parenthood
D. Additional member-e.g. newborn, lodger
E. Abortion
F. Entrance at school
G. Adolescence
H. Divorce or separation
I. Menopause
J. Loss of job
K. Hospitalization of a family member
L. Death of a member
M. Resettlement in a new community
N. Illegitimacy
O. Others, specify.___________
Second-Level Assessment
Second level assessment identifies the nature or type of nursing problems the family experiences in the performance of their
health tasks with respect to a certain health condition or health problem.
I. Inability to recognize the presence of the condition or problem due to:
A. Lack of or inadequate knowledge
B. Denial about its existence or severity as a result of fear of consequences of diagnosis of problem, specifically:
Social-stigma, loss of respect of peer/significant others
Economic/cost implications
Physical consequences
Emotional/psychological issues/concerns
C. Attitude/Philosophy in life, which hinders recognition/acceptance of a problem
D. Others. Specify _________
II. Inability to make decisions with respect to taking appropriate health action due to:
A. Failure to comprehend the nature/magnitude of the problem/condition
B. Low salience of the problem/condition
C. Feeling of confusion, helplessness and/or resignation brought about by perceive magnitude/severity of the situation or
problem, i.e. failure to break down problems into manageable units of attack.
D. Lack of/inadequate knowledge/insight as to alternative courses of action open to them
E. Inability to decide which action to take from among a list of alternatives
F. Conflicting opinions among family members/significant others regarding action to take.
G. Lack of/inadequate knowledge of community resources for care
H. Fear of consequences of action, specifically:
Social consequences
Economic consequences
Physical consequences
Emotional/psychological consequences
I. Negative attitude towards the health condition or problem-by negative attitude is meant one that interferes with
rational decision-making.
J. In accessibility of appropriate resources for care, specifically:
Physical Inaccessibility
Costs constraints or economic/financial inaccessibility
K. Lack of trust/confidence in the health personnel/agency
L. Misconceptions or erroneous information about proposed course(s) of action
M. Others specify._________
III. Inability to provide adequate nursing care to the sick, disabled, dependent or vulnerable/at risk member of the family due to:

A. Lack of/inadequate knowledge about the disease/health condition (nature, severity, complications, prognosis and
management)
B. Lack of/inadequate knowledge about child development and care
C. Lack of/inadequate knowledge of the nature or extent of nursing care needed
D. Lack of the necessary facilities, equipment and supplies of care
E. Lack of/inadequate knowledge or skill in carrying out the necessary intervention or treatment/procedure of care (i.e.
complex therapeutic regimen or healthy lifestyle program).
F. Inadequate family resources of care specifically:
Absence of responsible member
Financial constraints
Limitation of luck/lack of physical resources
G. Significant persons unexpressed feelings (e.g. hostility/anger, guilt, fear/anxiety, despair, rejection) which his/her
capacities to provide care.
H. Philosophy in life which negates/hinder caring for the sick, disabled, dependent, vulnerable/at risk member
I. Members preoccupation with on concerns/interests
J. Prolonged disease or disabilities, which exhaust supportive capacity of family members.
K. Altered role performance, specify.
Role denials or ambivalence
Role strain
Role dissatisfaction
Role conflict
Role confusion
Role overload
L. Others. Specify._________
IV. Inability to provide a home environment conducive to health maintenance and personal development due to:
A. Inadequate family resources specifically:
Financial constraints/limited financial resources
Limited physical resources-e.i. lack of space to construct facility
B. Failure to see benefits (specifically long term ones) of investments in home environment improvement
C. Lack of/inadequate knowledge of importance of hygiene and sanitation
D. Lack of/inadequate knowledge of preventive measures
E. Lack of skill in carrying out measures to improve home environment
F. Ineffective communication pattern within the family
G. Lack of supportive relationship among family members
H. Negative attitudes/philosophy in life which is not conducive to health maintenance and personal development
I. Lack of adequate competencies in relating to each other for mutual growth and maturation
Example: reduced ability to meet the physical and psychological needs of other members as a result of familys preoccupation
with current problem or condition.
J. Others specify._________
V. Failure to utilize community resources for health care due to:
A. Lack of/inadequate knowledge of community resources for health care
B. Failure to perceive the benefits of health care/services
C. Lack of trust/confidence in the agency/personnel
D. Previous unpleasant experience with health worker
E. Fear of consequences of action (preventive, diagnostic, therapeutic, rehabilitative) specifically :
Physical/psychological consequences
Financial consequences
Social consequences
F. Unavailability of required care/services
G. Inaccessibility of required services due to:
Cost constraints
Physical inaccessibility
H. Lack of or inadequate family resources, specifically
Manpower resources, e.g. baby sitter
Financial resources, cost of medicines prescribe
I. Feeling of alienation to/lack of support from the community
e.g. stigma due to mental illness, AIDS, etc.
J. Negative attitude/ philosophy in life which hinders effective/maximum utilization of community resources for health
care

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