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PERIOPERATIVE NURSING

Earl Francis R. Sumile, RN, MAN


Coordinator and Clinical Faculty, College of Nursing , University of Santo Tomas

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Dearest Lord, true source of light and wisdom, give us a keen sense of understanding, a
retentive memory, and the capacity to grasp things correctly. Grant us the grace to be
accurate in our expositions, and the skills to express ourselves with thoroughness and
clarity. Be with us at the start of our study, guide its progress and bring it to completion,
grant this through Jesus Christ, our Lord. Amen
Mother Mary Immaculate Seat of Wisdom, Pray for us.

Perioperative Nursing

Pre-operative Phase
Intra-operative Phase
Post-operative Phase

Preoperative Phase

Assessment and History


Physical Needs
Laboratory works
CP Clearance
Diagnostics Procedures
Psychosocial Needs
Health Teachings
Informed Consent
Procedural and Process Information
Spiritual Preparation

Preoperative Teachings

Process Information
Procedural Information
Dietary Restrictions
Preoperative Shave
Family Orientation
Postoperative expectations
Rehabilitation
Follow up

Preoperative Medications

Anticholinergics - Atropine SO4


Analgesics - Nalbuphine
Sedatives - Diazepam, Dormicum
Antibiotics
Antihistamines - Promethazine, Diphenhydramine

Operating Room Setting


Areas In the Operating Room

Non-restricted Area
Semi-restricted Area
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Restricted Area

Intra-operative Phase
Categories of surgery

Emergency - Done immediately to save life or limb, Takes precedence over any other surgery
scheduled
Elective - Done at the patients and surgeons convenience , May be performed within days and
even months after diagnosis

Musts for an OR Nurse

Must work rapidly but efficiently even under tension


Must think and react quickly
Must anticipate always one step ahead of the surgeon
Must be Organized and must work smoothly
Must follow rules rigidly
Must be patient
Must have presence of mind all the time!

Operating Room Team Members

Surgeon
Assistant Surgeon
Anesthesiologist
Scrub Nurse
Circulating Nurse
Pathologist
Others

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Prefixes

A
Ecto
Infra
Inter
Intra

-Without, absence
- External, outside
- Below
- Between
- Within

Pan
- All
Peri - Around
Poly - Many
Pseudo - False
Retro - Behind, Posterior
Supra - Above

Logy - study
Lysis - destruction, dissolution,
loose
Oma - tumor
Ostomy
opening into
Plasty - surgical formation
Pexy fixation
Rrhapy
suturing of, repair

Glosso
Hepar
Hyster
Lapar
Lipo
Mast/Mammo
Nephro
Oculo
Oophor
Orchi
Osteo
Oto
Phlebo
Pneumo
Procto
Pyelo
Rhino
Salphingo
Thoraco
Urano
Uretero

Suffixes

Algia - pain
Centesis puncture
Copy - to view
Ectomy
surgical removal
Itis
- inflammation
Lith - stone or calculus
Lithotomy removal of stones

Rootwords

Adeno - gland
Ano - Anus
Arthro - joint
Angio -Blood or lympathic vessel
Blephar
- eyelid
Broncho
- Bronchus
Cardio - Heart
Cephalo
- Head
Cerebro
- Brain
Cheilo - lip
Chole - gall, bile
Cholecyst- gall bladder
Choledocho- Common Bile Duct
Chondro
- Cartilage
Colo - Large intestine, Colon
Colpo - Vagina
Costo - Rib
Cranio - Skull
Cysto - Bladder
Esophago- Esophagus
Gastro - Stomach

- Tongue
- Liver
- uterus
- abdomen
- fat
Breast
- Kidney
- Eye
- Ovary
- Testis
- bone
- Ear
- Vein
- Lungs
- Rectum
- renal pelvis
-Nose
- Fallopian tube
- Chest
- Palate
- Ureter
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Asepsis and Principles of Sterile Technique


Definition of terms

Asepsis Absence of microorganisms


Disinfection Reduction of pathologic microorganisms without destroying the spores
Contaminated Soiled with microorganisms
Infection Invasion of the body by pathogenic microorganisms
Spores Are inactive but viable state of a microorganism
Sterile Free from microorganisms including spores
Surgical Conscience Involves the concept of self-inspection and moral obligation
involving scientific and intellectual honesty.

Sources of Contamination

Skin
Respiratory tract
Articles used in the procedure
Circulating Air
Scrub team/patients hair

Principles on Asepsis

Sterile Items
Sterile Field
Traffic

Drapes
Gowns
Gloves

Medical and Surgical Instruments and Supplies Category

Category I : Critical Items - Must be sterilized


Category II: Semi critical Items - Sterilization if preferred but disinfection is acceptable
Category III: Non critical Items - clean

Sterilization Procedures
Physical Sterilization

Moist heat ( boiling, Autoclaving)


Dry Heat (dry heat autoclaving)

Chemical Sterilization

Ethylene Oxide
Sterrad

Disinfection Procedures

High Level Disinfectant - Activated glutaraldehyde


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Intermediate Level Disinfectant - 70% alcohol, Iodine compounds


Low Level Disinfectant - Phenolic compounds, Chlorine compounds

Sterilization and Disinfection

Labels
Wrappers
Shelf life

Indicators
o Chemical Indicators
o Biologic indicators

Type and probable duration of


operation
Laboratory findings
Any known idiosyncracies

Anesthesia
Factors That Determine the Choice of Anesthesia

Physical and mental condition of


patient
Age and weight of patient
Operation to be performed
Patients preference

Stages of Anesthesia
Stage 1 (Induction/stage of analgesia)

Starts from induction period until paient loses consciousness


Patient may appear drowsy or dizzy
Keep the room quiet

Stage 2 (Excitement/delirium)

Lasts from the time the patient loses consciousness until he loses certain reflexes such as
swallowing,gag and eyelid.
May appear excited , may breathe irregularly
Sensitive to external stimuli
Maintain silence

Stage 3 (Surgical anesthesia)

From the period the patient lost certain reflexes and respiratory paralysis occurs
Patient with regular respiration, constricted pupils, jaws relax and auditory sensation is
lost

Stage 4 (Stage of Danger)

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Reached when too much anesthesia has been given and the patient has not been observed
carefully.
Death may result from respiratory and or cardiac arrest unless resuscitated properly
Patient is not breathing with little to no heart beat.

Types of Anesthesia
General Anesthesia

Association pathways are broken in the cerebral cortex to produce more or less lack of
sensory and motor perception
Pain is controlled by general insensibility , the patient is unconscious, he cannot hear,
feel, or move his whole body.
Used in operations above the Thoracic level

Regional Anesthesia

Depresses superficial nerves and interferes with the conduction of pain impulses from
certain area or region
Pain is controlled without loss of consciousness; one region or an area of the body is
anesthetized

General Anesthesia
Inhalation - with the use of volatile gases and vapors, Either per mask or Endotracheal tube
Common Anesthetics

Sevoflurane (sevorane)
Desflurane (Suprane)

Isoflurane (forane)
Halothane(fluothane)

Intravenous - Drugs that may produce hypnosis, sedation, amnesia and or analgesia is
administered via IV
Common Anesthetics

Thiopental Na
(pentothal)

Propofol (diprivan)

Ketamine (Ketalar)

Regional Anesthesia
Epidural Anesthesia

Used for Long Procedures below the Thoracic Level


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Used for post op management of pain.


Uses an epidural Catheter (perifix)

Common Anesthetics:

Bupivacaine (Sensorcaine Isobaric, Marcaine)


Lidocaine (for testing)

Subarachnoid Block

Commonly termed as spinal anesthesia


For short cases below the thoracic level
Uses spinal needle gauge 22,25 or 27

Common Anesthetics

Bupivacaine hyperbaric (sensorcaine Heavy)


PDE (Tetracaine(pontocaine), Dextrose, Ephedrine)

Field/Nerve blocks - Anesthetizing surrounding tissues (field) or group of nerves (nerves) at a


given point
Common Anesthetics

Bupvacaine Isobaric (sensorcaine, Marcaine)


Lidocaine

Local Infiltration - Agent is injected into the tissues around incision site
Anesthetics: Lidocaine, sensorcaine isobaric
Topical - Agent applied directly into a mucosa or surface Ex: Lidocaine spray
Other Medications Used for Anesthesia
Premedications Used: Midazolam(Dormicum) , Diazepam (valium)
Opiod Narcotic: Fentanyl (sublimaze)
Muscle Relaxants

Succinyl Choline (anectine)


Rocoronium Bromide (Esmeron)
Atracurium (tracrium)

Pancoronium Bromide (pavulon)


Vecuronium Bromide (norcur

Anticholinergics - acetylcholinesterase Inhibitor


Dantrolene
Incisions, Position and Prepping
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Right Subcostal (kochers Incision)


Median Upper Abdominal
B. Median Lower Abdominal
Mc Burneys Incision
Inguinal Incision
Transverse Suprapubic
(Pfannensteil)
Miscellaneous Incisions
Collarline (curvilinear incision)
Used for Thyroidectomy
Coronal, Butterfly Incisions
Craniotomy

Thoracotomy Incision
Anterolateral or Lateral
Posterothoracic
Lumbotomy Incision
Kidney surgery
Sternal Split - sternotomy
Limbal Incision
Cataract Extraction
Elliptical Halsted Incision
Radical Mastectomy
Post/Pre Aural Incision
Caldwell Luc

Positioning - Choice of Position is made by the surgeon and positioning is done by the members
of the surgical team
Factors to Consider:

Length of the procedure


Site of the operation

Pain upon moving


Kind of anesthetic

Qualifications of a Good Position

Not interfere with respirations


Not interfere with circulation
Not cause pressure on any nerve
Provide total accesibility for administration of anesthesia and surgery
Reflect proper body alignment, resulting in no undue post operative discomfort
Patient safety

Equipments for Positioning

OR Table
Body Strap
Pillows
Shoulder Roll
Doughnut

Trochanter rolls
Stirrups
Foot boards
Sand bags

Common Positions

Dorsal/supine
Fowlers, Sitting Position
Lithotomy
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Trendelenburg/reverse Trendelenburg
Prone
Sims, Knee-chest
Kidney Position
Chest Position

Common Injuries related to positioning

Brachial plexus injury


Ulnar/radial nerve injury
Saphenous and peroneal nerve damage
Integumentary damage
Eye and facial injury

Skin Preparation
(Special Considerations)

Determine the area and the extent to be prepared including proposed incision.
Practice modesty and privacy
Examine area to be prepared
In abdominal operations focus on the umbilicus
In shaving follow the direction of the hair growth while the other hand exerts an opposite
force
If a wound is present start from the clean area first before the dirty area

Basic Surgical Instruments Equipments and Supplies


Instrument Classification

Clamping/Hemostats
Grasping/Holding
Retracting Instruments
Cutting/Dissecting
Suturing Instruments

Parts of an Instrument
Gas Tanks/ Gas Cylinders

Green Oxygen
Gray Carbon Dioxide
Yellow Compressed Air

Blue Nitrous oxide


Black Nitrogen
Brown - Helium
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Other Instruments

Cautery machine
Suction machine
Heart Lung Machine
Radiologic Devices
Endoscopic devices
Laparoscopic Instruments

Sutures and Needles


Definiton of terms

Suture any material used to sew, stitch or hold tissues or body parts together
Ligature a tie, to ligate blood vessels
Primary suture line main layers of tissues which must be sutured
Stay or tension suture sutures placed at the incision to act as reinforcement
Tensile strength amount of tension of pull that a strand will withstand

Uses of suture

Ligating
Suturing
Closing

Types of Sutures

Absorbable or Non absorbable


Monofilament or Multifilament

Criteria for a good suture

Versatility
Ease of handling
Minimal tissue reaction and inability to create a favorable environment for infection and
tissue rejection
High tensile strength
Easy to thread, easy to sterilize and will not shrink
Made of non electrolyte, non capillary, non allergenic and non carcinogenic materials
Absorbed with minimal tissue reaction

Surgical Needles
Three Basic Sections

Point
Body or Shaft
Eye

Points
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Taper Point
Blunt Point
Cutting Point
o Tapercut
o Conventional cutting
o Reverse cutting

The Eye of the Needle

Atraumatic or Swaged
Eyed
French Eyed or Spring
Controlled release

Suturing Responsibilities

Handling Sutures
Suturing techniques
Needle Counts

Alternative Methods to Suturing


Surgical Strips
Skin Clips
Skin Staples
Ligation Clips
Surgical Staples
Tissue adhesives
SurgicalScrubbing,
Gowning and Gloving

Agents
PreparationsHemostatic
immediately
before scrub
Bone wax
1. Makesure
you have checked
room and table including gowns and gloves to be used.
Absorbable
gelatine your
sponge
sponge
2. Attend toCollagen
your personal
needs i.e. Hunger, voiding, defecating etc.
Oxidized cellulose
3. Inspect hands for cuts and abrasions. Skin integrity of hands and arms
4. Remove all finger jewelry. Jewelry harbors microorganisms.
5. Be sure all hair is covered by cap or bonnet.
6. Adjust mask snugly and comfortably over nose and mouth.
7. Fold sleeves of the scrub suit if too long.
8. Clean eyeglasses if worn. Adjust eyewear or face shield comfortably in relation to mask. Secure if
necessary.
Principles of Asepsis Related to Surgical Gowning and Gloving

Sterile persons keep well within sterile area.


o Sterile persons pass each other back to back or front to front.
o Sterile person faces a sterile area to pass it
o Sterile persons stay within the sterile field
Gowns are considered sterile only from the waist to shoulder level, in front and in the
sleeves.
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Sterile persons keep hands in sight and at or above waist level only
Arms are never folded because there may be perspirations in the axillary region.
Items dropped below the waist level are considered unsterile and must be discarded
Hands are kept away from the face with elbows close to side

Legal and Ethical Dimensions in the Practice of OR Nursing


Common Issues

Consent
Wrong Patient/Site surgery
Counting
Specimen Handling
o Labeling
o RFS
o Medico-legal
Medication errors
Negligence

Postoperative Care
General Postoperative responsibilities

Promotion of Adequate Respiratory Function


Promotion of Adequate Circulatory Function
Promotion of Normal Reflex return
Promotion of Safety and Comfort
Pain Management
Promotion of Wound Healing
Promotion of Fluid and electrolyte balance

THE STORY OF THE LOST HANDS


One morning as I knelt and prayed I gazed at the statue of Christ in clay. And lo! To
my dismay Hes got no arms and hands that sway. I searched around from roof to
ground and even beyond. His wounded hands could not be found.
So I turned to Him and asked the Lord if its a dream why in His glorious seat He
seemed incomplete? He replied YOU ARE MY HANDS
heal the wounds of the afflicted
care for the poor
give hope to the helpless
reach out to the weary
clothe the naked
By doing this, my child you will RESTORE MY HANDS