Perioperative Nursing

Total surgical experience that encompasses preoperative, intraoperative and postoperative phases of patient care. Total care before, during and after surgery

 consists

of the time from when it is decided that surgery is needed until the patient arrives in the operating room.

 begins

when the client is transferred in the operating room and ends when the client is admitted to the post anesthesia care unit (PACU).

 begins

when client is admitted in the post anesthesia area and ends when healing is complete.

 can

be defined as the art and science of treating diseases, injuries and deformities by operation and instrument

Types of Surgery

Based on Purpose

Diagnostic- determination of the presence and/or extent of pathology (e.g., lymph node biopsy) Curative-elimination or repair of pathology (e.g., removal of a ruptured appendix or ovarian cysts) Palliative-alleviation of symptoms without cure (e.g., cutting a nerve root (rhizotomy) to remove symptoms of pain, or creating colostomy to bypass an inoperable bowel obstruction.

Exploration-surgical examination to determine the nature or extent of a disease (e.g.,laparotomy) Cosmetic Improvement-examples include repairing a burn scar or changing breast type. Constructive-to restore function of congenital anomalies (e.g., cleft palate repair and closure of atrial septal defect)

Preventive-examples include removal of the mole before it become malignant or removal of the colon in patient with tumor. Transplant-replaces malfunctioning structures; for example hip replacement.

Elective-is performed when surgical intervention is the preferred treatment for a condition that is not imminently life threatening (but may ultimately threaten life or well being) Examples: Tonsillectomy, cholecystectomy for chronic gallbladder disease, hernia repair, hemorriodectomy, scar revision, hip replacemen

 

Optional-Decision rest with patient (personal preference) Example: Cosmetic Surgery Required- patient needs to have surgery. Plans within few weeks or months Examples: Thyroid disorders, cataracts

Urgent-Usually done within 24-48 hours. to prevent further tissue damage To restore function preserve health remove and repair body parts  Examples: coronary artery bypass, surgical removal of malignant tumor, amputation


 

Emergency-performed immediately to preserve life. Examples: Control of hemorrhage, repair of trauma, intestinal obstruction, repair of fractures, tracheotomy.

Major-involves a high degree of risk, for a variety of reasons: It may be complicated or prolonged, large losses of blood may occur, vital organs may be involved or postoperative complications may be likely. Examples: organ transplant, open heart surgery, nepherctomy, ORIF, mastectomy, amputation, colostomy

Minor-normally involves little risk, produces few complications and is often performed in a day surgery Examples: breast biopsy, removal of tonsils, teeth extraction, cataract extraction, D&C, removal of warts.

All articles used in an operation have been sterilized previously

 

Articles used may be obtained from the stock supply of sterile packages. Other instruments maybe sterilized immediately preceding the operation and removed directly from the sterilizer to the sterile table ( sharp instruments)

Person who are sterile touches only the sterile articles; persons who are not sterile touch only non sterile articles


All supplies for the sterile members reach them by means of the CN (Circulating Nurse) through the medium of sterile forceps or sterile wrappers.

If in doubt about the sterility of anything consider it non-sterile.

   

If a packaging is found in the non sterile place If uncertain about the actual timing of a sterilizer If non sterile person brushes close to a sterile table and vice versa If a sterile table or articles are left unguarded and uncovered

Sterile person touch only sterile items or areas; sterile person avoid leaning over an Unsterile Area.


The SN (sponge nurse) sets basin bowls to be filled at the edge of the sterile table/mayostand;the CN (circulating nurse) stands near at the edge of the table/myostand to fill them The CN stands at the distance from the sterile field to adjust the light over it The surgeon turns away from the sterile field to have perspiration mopped on his brow The sterile nurse drapes non-sterile table away from her If the CN,using sterile forceps drapes the table, she drapes away from her

Tables are sterile only at table level



Linens or suture falling over table edge are discarded. The SN does not touch the part hanging below table level When the CN uncovers a sterile table, she is careful that the part of the sheet, which drapes down below the table level is not brought up to the table top

Gowns are considered sterile only from the waist to shoulder level, in front and the sleeves
   

Sterile person keep in sight and at or above waist level Hands are kept away from the face, elbows close to side Arms are never folded Article dropped below waist level are discarded

The edge of any wrapper that encloses a sterile content is not considered sterile


The edges of the wrapper of sterile packages, the caps of solution flasks or bottles. The SN lifts content from the sterile packages by reaching down and lifting them straight up; holding elbows The CN pull the cover of a solution so that the edge of the cover never touches the lip

Sterile person keep well within the sterile area. They allow a wide margin of safety when passing non-sterile areas and follow rules of passing


  

Sterile person stand back at a safe distance at the operating table when draping the patient Scrub nurses pass each other back to back A sterile person passes a sterile area facing it A sterile person asks non-sterile person one to step aside rather than to crowd past him A sterile person stays near the sterile tables while waiting for the case to start. They don`t wander around the room

Non-sterile person keeps away from sterile areas. They allow a wide margin of safety when passing sterile areas


Non-sterile person face a sterile area when passing it. So they have to be sure they have not touched it.

Sterile person keep contact with sterile areas to a minimum

 

Sterile person do not lean on a sterile tables and on the draped patient. Sitting or leaning against a non sterile surface is a break in technique.

Moisture may cause contamination. When moisture soaks through a sterile area to a non sterile area or vice versa, it provides a means of transporting bacteria to the specific area.
  

Sterile package becomes damp or wet it is re-sterilized or discarded Drapes are place on a dry field Linen packages from the sterilizer are allowed to cool before putting them on the shelves

When bacteria cannot be eliminated from a field. They must be kept to an irreducible minimum.

   

Skin cannot be sterilized Some areas cannot be scrubbed Infected areas are grossly contaminated Air is contaminated by dust and droplet

Surgical Conscience


inner voice for conscientious of practice of aseptic and sterile technique at all times. This applies to every activity and intervention as well as personal hygiene and health.

ASEPSIS  A-absence of microorganism  S-should be above elbow  E-eliminate moist  P-prevent traffic Air Current  S-should maintain teamwork  I-immediately consider Unsterile when in doubt  S-should consider all open items unsterile

Appropriate Operating Room Attire

  

Scrub suit- attire intended for wear in the operating room. Head covers (cap/bonnet) - should fit well and prevent the escape of any hair. Shoe covers- worn in semi-restricted and restricted areas in operating room to protect from blood and fluid

Mask- covers the nose and mouth and conforms to facial contours. Uppers strings are tied at the back of the head; lower strings are tied behind the neck. Filters droplets from mount and nasopharynx during breathing, talking, sneezing and coughing. Eye wear- protection from blood and body substances splashing from patient. Surgical Gloves- worn to permit the wearer to handle sterile supplies and tissues of surgical site. Surgical Gown- permits the wearer to enter the sterile field

Surgical Scrub

Surgical Scrub


Is the removal of as many bacteria as possible from the hands and arms by mechanical washing and chemical disinfection before participating in an operation. Done prior to gowning and gloving for each operation.

Purpose:


To help prevent the possibility of contamination of the operative wound by bacteria on the hands and arms.

Preparation prior to Scrub

   

Skin and nails should be kept clean and in good condition and cuticles uncut. Fingernails should not reach beyond the fingertip to avoid glove puncture Fingernail polish should not be worn. Inspect hands for cuts and abrasions. Skin of hands and forearms should be intact,w/o open lesions and crack skin.

 

  

Remove all jewelry Be sure all hair is covered by headgear. Pierced-ear studs must be contained by the head cover. Adjust disposable mask snugly and comfortably over nose and mouth. Adjust eye glasses comfortably in relation to mask. Adjust water to a comfortable temperature.

Length of Scrubbing


The length of surgical scrub varies from one institution to another. Variations in length may depend on frequency of scrubbing and the agent used.

Types of Surgical Scrubbing

 

Time method Counted brush-stroke method

Time Method


Finger, hands and arms are scrubbed by allotting a prescribed amount of time to each anatomical area or each step of the procedure.

Complete scrub takes 5-7 mins. that is done:

    

In morning before the first gowning & gloving Following a clean case if gloves have been removed inadvertently before the gown. Following a clean case, if gloves have had a hole between them. Following a clean case if hands have been contaminated Before and emergency case.

Short scrub takes 3 minutes, that is done following a clean case, if the hands and arms have not been contaminated. Done to remove bacteria that have emerged from the pores and multiplied while the gloves where on.

Brush Stroke Method



A prescribed number of brush strokes, applied lengthwise of the brush or sponge, is used for each surface of the fingers,hands,and arms. Scrub the nails of one hand 30 strokes, all sides of each fingers 20 strokes, back of the hand 20 strokes, palm of the hand 20 strokes, the arms with 20 strokes each third of the arm,to 3 inches above elbow

      

Turn on the water and get antiseptic solution. Wash hands prior to scrub. Clean finger nails under running water. Scrub left hand Scrub left arm Scrub left elbow area Rinse brush and transfer to other hands

         

Scrub right hand Scrub right arm Scrub right elbow area Rinse left hand and brush Rinse left hand and elbow area Rinse right hand Rinse right hand and elbow area Complete scrub as indicated in anatomical timed or stroke count scrub method. Turn water faucet if hand w/ brsuh if hand controlled. Walk in the operating room

Drying Hands After Surgical Scrub

  

When drying hands stay away from the objects and people. When picking up the towel, do it with swift, efficient motion. Take the towel in the midline, being careful not to contaminate the sterile gown under it.

  

Bend the waist to help prevent the sterile towel from touching the unsterile gown while drying your hands and arms Dry the hand mid-lower arm; transfer dry end of towel to the other hand. Do not dry hand and then arm & return to same hand. After the second hand & mid-lower have been dried fold towel in thirds and dry elbows. Be sure hands is well covered. When transfer of towel is made from one hand to other.

Discard the towel in the linen hamper

 

To exclude skin as a possible contaminant and to create a barrier between sterile and unsterile areas. To permit the wearer to come within the sterile field To carry out sterile techniques during an operative procedure.

General Considerations:


The scrub nurse gowns and gloves self; then gowns and gloves surgeon and assistants. Gown packages preferably are opened on a separate table from other packages to avoid any chance of contamination from dripping water.

After scrubbing, hands and arms must be thoroughly dried before the sterile gown is donned to prevent contamination of the gown by strike-through of organisms from skin to scrub attire To put the sterile gown, the scrub nurse needs the assistance of the circulating nurse. The scrub nurse receives the sterile gown from the circulating nurse if the gown is not individually packed.

Gowning Technique:
    

Gowning for open glove technique Gowning for closed glove technique Gowning another person Changing gown during operation Removing gown

Gowning for open glove technique



Reach down to the sterile package and lift the folded gown directly upward or scrub nurse receives sterile gown from the circulating nurse Step back away from the table, into a clear area, to provide a wide margin of safety while gowning Holding the folded gown carefully locate the neckband and centerfold

While holding the neckband with both hands or holding the centerfold with one hand, gently shake the folds from the gown. Slip both hands into the sleeves, holding the hands upward on the ;level with the shoulder without touching the outside part of the gown with bare hands Circulating nurse reaches inside the gown to the sleeves seams and pulls the sleeves over the hand and wrists.

Circulating nurse fastens back part, ties waist band, touching outside of the gown at the line of ties of fasteners at the back only. (after the procedure, the scrub nurse gets ready to wear sterile gloves)

Gowning for closed glove technique



Reach down to the sterile package and lift the folded gown directly upward or scrub nurse receives sterile gown from the circulating nurse Step back away from the table, into a clear area, to provide a wide margin of safety while gowning

 

Holding the folded gown carefully locate the neckband and centerfold While holding the neckband with both hands or holding the centerfold with one hand, gently shake the folds from the gown Slip both hands into the sleeves, holding the hands upward on the ;level with the shoulder without touching the outside part of the gown with bare hands

Circulating nurse reaches inside the gown to the sleeves seams and pull the gown on, leaving the cuffs of the sleeves extended over the hands Circulating nurse fastens back part, ties waist band, touching outside of the gown at the line of ties of fasteners at the back only

Gowning another person

  

Give the towel to the surgeon, being careful not to touch the hand Unfold the gown, holding it at the neckband Keep the hands on the outside part of the gown under the protective cuff and shoulder area, offer the inside of the gown to the surgeon. The surgeon slips into the sleeves.

Release the gown. The surgeon holds arms outstretched while the circulating nurse pulls the gown onto the shoulders and adjust the sleeves and cuffs.

Removing Gown
   

With gloves on loosen the cuffs of the gown, shake them over wrists. Then grasp the right shoulder of the gown with left hand. Pull the gown off arms, turn away from the body with flexed elbow. Grasp the other shoulder with the other hand and remove gown entirely,pulling it off inside out.Thus arms keep clean.

Gloves
 

Sterile gloves complete the attire for scrubbed team members. The sterile gloves are put on immediately after gowning.

Purposes:
  

To exclude skin as a possible contaminant To create a barrier between sterile and unsterile areas. To permit the wearer to handle sterile supplies or tissues of the operative wound.

Close Gloving Technique



Using the left hand and keeping it within the cuff of the left sleeve,pick up the glove, from the inner wrap of the glove package, by grasping the folded cuff. Extend the right forearm with palm upward. Place the palm of the glove against the palm of the right hand the top edge of the cuff, above the palm.

In correct position. glove fingers are pointing towards you and the thumb of the glove is to the right. The thumb side of the glove is down Grasp the back of the cuff in the left hand and turn it over the end of the right sleeve and hand. Pull glove on over extended right fingers until it complexly covers the stockinet cuff Glove the left hand in the same manner, reversing hands. Use gloved right hand and pull on the left glove.

Gloving another person



Pick up the right glove, grasp it firmly, with fingers under the everted cuff. Hold the pal of glove towards the surgeon Stretch the cuff sufficiently for the surgeon to insert the hand. Avoid touching the hand by holding your thumbs out Exert upward pressure as the surgeon plunges the hand into the glove

 

Unfold the everted glove cuff over the cuff of the sleeve Repeat for the left hand.