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PERIOPERATIVE NURSING

Earl Francis R. Sumile, MAN, RN


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
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• Sedatives - Diazepam, Dormicum

• Antibiotics

• Antihistamines - Promethazine, Diphenhydramine

Operating Room Setting


Areas In the Operating Room

• Non-restricted Area

• Semi-restricted Area

• 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 patient’s and surgeon’s 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 • Pan - All
• A -Without, absence • Peri - Around
• Ecto - External, outside • Poly - Many
• Infra - Below • Pseudo - False
• Inter - Between • Retro - Behind, Posterior
• Intra - Within • Supra - Above
Suffixes

• Algia - pain • Logy - study

• Centesis – puncture • Lysis - destruction, dissolution,


loose
• Copy - to view
• Oma - tumor
• Ectomy – surgical removal
• Ostomy – opening into
• Itis - inflammation
• Plasty - surgical formation
• Lith - stone or calculus
• Pexy – fixation
• Lithotomy – removal of stones
• Rrhapy – suturing of, repair
Rootwords

• Adeno - gland • Chole - gall, bile

• Ano - Anus • Cholecyst- gall bladder

• Arthro - joint • Choledocho- Common Bile Duct

• Angio -Blood or lympathic vessel • Chondro - Cartilage

• Blephar - eyelid • Colo - Large intestine, Colon

• Broncho - Bronchus • Colpo - Vagina

• Cardio - Heart • Costo - Rib

• Cephalo - Head • Cranio - Skull

• Cerebro - Brain • Cysto - Bladder

• Cheilo - lip • Esophago- Esophagus

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• Gastro - Stomach • Osteo - bone

• Glosso - Tongue • Oto - Ear

• Hepar - Liver • Phlebo - Vein

• Hyster - uterus • Pneumo - Lungs

• Lapar - abdomen • Procto - Rectum

• Lipo - fat • Pyelo - renal pelvis

• Mast/Mammo – Breast • Rhino -Nose

• Nephro - Kidney • Salphingo - Fallopian tube

• Oculo - Eye • Thoraco - Chest

• Oophor - Ovary • Urano - Palate

• Orchi - Testis • Uretero - Ureter

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

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• Articles used in the procedure

• Circulating Air

• Scrub team/patient’s hair

Principles on Asepsis

• Sterile Items • Drapes

• Sterile Field • Gowns

• Traffic • 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 Chemical Sterilization

• Moist heat ( boiling, Autoclaving) • Ethylene Oxide

• Dry Heat (dry heat autoclaving) • Sterrad


Disinfection Procedures
• High Level Disinfectant - Activated glutaraldehyde

• Intermediate Level Disinfectant - 70% alcohol, Iodine compounds


• Low Level Disinfectant - Phenolic compounds, Chlorine compounds
Sterilization and Disinfection

• Labels • Indicators

• Wrappers o Chemical Indicators

• Shelf life o Biologic indicators

Anesthesia
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Factors That Determine the Choice of Anesthesia

• Physical and mental condition of • Type and probable duration of


patient operation

• Age and weight of patient • Laboratory findings

• Operation to be performed • Any known idiosyncracies

• 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)

• 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.

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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) • Isoflurane (forane)

• Desflurane (Suprane) • Halothane(fluothane)


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

• Thiopental Na • Propofol (diprivan) • Ketamine (Ketalar)


(pentothal)

Regional Anesthesia
Epidural Anesthesia

• Used for Long Procedures below the Thoracic Level

• Used for post op management of pain.

• Uses an epidural Catheter (perifix)

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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) • Pancoronium Bromide (pavulon)

• Rocoronium Bromide (Esmeron) • Vecuronium Bromide (norcur

• Atracurium (tracrium)
Anticholinergics - acetylcholinesterase Inhibitor
Dantrolene
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Incisions, Position and Prepping

• Right Subcostal (kochers Incision) • Thoracotomy Incision

• Median Upper Abdominal • Anterolateral or Lateral


B. Median Lower Abdominal Posterothoracic

• Mc Burney’s Incision • Lumbotomy Incision

• Inguinal Incision • Kidney surgery

• Transverse Suprapubic • Sternal Split - sternotomy


(Pfannensteil)
• Limbal Incision
• Miscellaneous Incisions
• Cataract Extraction
• Collarline (curvilinear incision)
• Elliptical Halsted Incision
• Used for Thyroidectomy
• Radical Mastectomy
• Coronal, Butterfly Incisions
• Post/Pre Aural Incision
• Craniotomy
• 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 • Pain upon moving

• Site of the operation • 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

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• OR Table • Trochanter rolls

• Body Strap • Stirrups

• Pillows • Foot boards

• Shoulder Roll • Sand bags

• Doughnut
Common Positions

• Dorsal/supine

• Fowlers, Sitting Position

• Lithotomy

• 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

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• 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 • Blue – Nitrous oxide

• Gray – Carbon Dioxide • Black – Nitrogen

• Yellow – Compressed Air • Brown - Helium


Other Instruments

• Cautery machine

• Suction machine

• Heart Lung Machine

• Radiologic Devices

• Endoscopic devices

• Laparoscopic Instruments

Sutures and Needles


Definiton of terms
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• 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 Types of Sutures

• Ligating • Absorbable or Non absorbable

• Suturing • Monofilament or Multifilament

• Closing
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

• Taper Point

• Blunt Point

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• Cutting Point
o Tapercut

o Conventional cutting

o Reverse cutting

The Eye of the Needle

• Atraumatic or Swaged Suturing Responsibilities

• Eyed • Handling Sutures

• French Eyed or Spring • Suturing techniques

• Controlled release • Needle Counts

Alternative Methods to Suturing

• Surgical Strips

• Skin Clips

• Skin Staples
Surgical Scrubbing, Gowning and Gloving
• Ligation
Preparations Clips before scrub
immediately
1. Make•sure
Surgical Staples
you have checked your room and table including gowns and gloves to be used.
• toTissue
2. Attend adhesives
your personal needs i.e. Hunger, voiding, defecating etc.
• hands
3. Inspect Hemostatic
for cutsAgents
and abrasions. Skin integrity of hands and arms
• all
4. Remove Bone waxjewelry. Jewelry harbors microorganisms.
finger

• all
5. Be sure hair is covered
Absorbable by cap
gelatine or bonnet.
sponge
6. Adjust• mask snuglysponge
Collagen and comfortably over nose and mouth.
7. Fold sleeves of the cellulose
• Oxidized 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


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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.

• Sterile persons keep hands in sight and at or above waist level only
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