SURGERY

As a science and art; is the branch of medicine that comprises peri-operative patient care
encompassing such activities as pre-operative preparation, intra-operative judgement, and post-operative
care of patient.
As a discipline, surgery combines physiologic management with an interventional aspects of
treatment.

SURGICAL SETTING

1. INPATIENT
Refers to client who is admitted to a hospital
Admitted on the day of surgery (same-day-admission- SDA)
2. OUTPATIENT AND AMBULATORY
Refers to the client who goes to the surgical area the day of the surgery and returns home
on the same day (same-day-surgery SDS)

PREOPERATIVE NURSING
Assist client and their significant others through the surgical episodes, to help promote positive
outcomes, and to help clients achieve their optimal level of function and wellness after surgery.
Emphasis on safety and client education.
Use knowledge judgement and skills.

PREOPERATIVE PERIOD
Begins when the client is scheduled for surgery and ends at the time of transfer to surgical suite.

Focuses on client readiness client education and any intervention:

1. Reduces anxiety
2. Reduces complication
3. Promote cooperation

Needed for surgery to:

Validate and clarify information client receive received from surgeon or member of health
team.
Identify problems that warrant further assessment and/or intervention before surgery.
PREOPERATIVE ASSESMENT

Includes the medical/ health history, the psychosocial history, physical examination, cognitive
assessment and diagnostic testing.

PREOPERATIVE CARE

Obtaining informed consent:

The surgeon is responsible for obtaining the client consent for surgery.
Ensure that informed consent ad been signed and that any additional necessary consents
(e.g., limb disposal) have been obtained and you serve as a witness to the signature, not
to the fact that the client is informed.
Sedation should not be administered to the client before he or she signs the consent. Not
responsible for providing detailed in formation about the surgical procedure

ROLE: to clarify facts that have been presented by the physician and dispel myths that
the client or family may have about that surgical procedure.

PREOPERATIVE TEACHINGS

Reduce apprehension and fear.

Increased cooperation and participation in care after surgery
Decrease complications.

Client teaching:
 Describe what client should expect after surgery.
 Instruct client to notify nurse of pain after surgery and reassure client that pain medication will
be prescribed, to be given as the client request.
 Inform client that requesting a narcotic after surgery will not make the client drug addict.
 Demonstrate the use of a client controlled analgesia pump if its use is prescribed.
 Instruct client to use non-invasive pain relief techniques ( e.g., relaxation, distraction
techniques and guided imagery) before pain occurs and as soon as pain is noted
 Instruct client not to smoke for atleast 24 hours before surgery.
 Instruct client in deep breathing and coughing techniques, the use of incentive spirometry and
the importance of performing the techniques after the surgery to prevent development of
pneumonia and atelectasis.
 Tell the client that a sitting position permits the best lung expansion for coughing and deep
breathing exercise.
 Instruct client to breath deeply three times inhaling through the nostrils and exhaling slwly
thrugh pursed lips
 Tell client that the third breath should be held three seconds after which client should cough
deeply three times.
 Tell client to perform this exercise every two hours.
 Incentive spirometry- promote complete lung expansion and prevent pulmonary problems.
PREOPERATIVE CHECKLIST
Review checklist to ensure that each item is addressed before client is transported to
surgery.
Ensure that client is wearing an identification bracelet.
Assesses client for allergies.
Ensure that prescribed laboratory test results and electrocardiography and chest
radiography reports are documented in the clients record.
Remove client jewelry, make up, dentures, hairpins, nail polish, glasses and prosthesis
as appropriate.
Document that valuables have been given to clients family members or locked in the
hospital safe
Monitor and document clients vital signs
Prosthesis or dentures should be removed to prevent obstruction in the airway.

INTRAOPERATIVE PERIOD
Begins when the client is transferred to the OR bed ends when the client of transferred to an area
for Recovery from OR

Key words of OR practiced are:

1. Caring
2. Discipline
3. Technique
4. Conscience

Optimal client care requires an inherent surgical conscience, self discipline & the application of
principles of aseptic & sterile technique.

SURGICAL CONSCIENCE – “Surgical golden Ruler”

“Do unto the patient as you would have others do unto you”

Ones inner voice for the conscientious practice of asepsis and sterile technique at all times.
Conscience dictates that appropriate action should be taken, whether the person is with others o
alone and unobserved.
Foundation for the practice of strict aseptic and sterile technique.

ASEPTIS TECHNIQUE
Alternated term: ASEPTIC PRACTICE- to maintain asepsis (absence of microorganism
that caused disease).

STERILE TECHNIQUE
 Method by which contamination which microorganism is prevented to maintain sterility
throughout the procedure.
Is the responsibility of everyone caring for client in the operating room.
PRINCIPLES OF STERILE TECHNIQUE
1. ONLY STERILE ITEMS ARE USED WITHIN
STERILE FIELD
If you are in doubt about the sterility of
anything, consider it not sterile.
a. If sterilized package is found in a
nonsterile workroom.
b. If uncertain about actual timing or
operation of sterilizer. Items processed
in a suspect load are considered
unsterile.
c. If unsterile person comes into close
contact with a sterile table & vice versa.
d. If sterile table or unwrapped sterile
items are not under constant
observation.
e. If sterile package wrapped in material
other than plastic or moisture-resistant
barrier becomes damp or wet. Humidity
in storage area or moisture on hand may
seep into package.
f. If the integrity of the packaging material
is not intact.
g. If sterile package wrapped in a pervious
muslin or other woven material drops to
the floor or other area of questionable
cleanliness. These material allow
implosion of air into package. A dropped
package is considered contaminated.
h. If the wrapper is impervious & the area
of contact is dry, the item may be
transferred to the sterile field. Packages
that have been dropped on the floor
should not be put back into sterile
storage.
2. GOWNS ARE CONSIDERED STERILE
ONLY INFRONT FROM CHEST TO LEVEL OF
STERILE FIELD & THE SLEEVES FROM
ABOVE ELBOWS TO CUFF
a. Self-gowning & gloving should be done
from a sterile surface for this purpose
only to avoid dripping water onto sterile
supplies or sterile field.
b. Stockinet cuffs of gown are enclosed
beneath sterile gloves. Stockinet is
absorbent & will retain moisture, thus
this part of gown does not provide a
microbial barrier.
c. Sterile persons keep hands in sight @
all times & at or above level of waist or
sterile field.
d. Hands are kept away from face. Elbows
are kept close to sides. Hands are never
folded under arms because of
perspiration in axillary region. Neckline,
shoulders, & back also may become
contaminated with perspiration.
e. Sterile persons are aware of height of
team members in relation to each & the
sterile field. Changing levels @ sterile
field is avoided. Gown is considered
sterile only down to highest level of
sterile tables. If a sterile person must
stand on a platform to reach operative
field, platform should be positioned
before this person steps up to draped
area. Sterile person should sit only when
entire procedure will be performed @
this level.
3. TABLES ARE STERILE ONLY AT TABLE
LEVEL
a. Only top of a sterile draped table
considered sterile. Edges & sides of
drapes extending below table level are
considered unsterile.
b. Anything falling or extending over table
edge, such as a piece of suture, is
unsterile. Scrub person does not touch
part hanging below table level.
If unfolding a sterile drape, the part that drops
below table surface is not brought back up to
table level. Once placed, draped is not moved or
shifted
c. Cords, tubings, etc., are secured on the
sterile field with a non-perforating device
to prevent them from sliding over the
table edge.

4. PERSON WHO ARE STERILE TOUCH ONLY
STERILE ITEMS OR AREAS; PERSONS WHO
ARE NOT STERILE TOUCH ONLY UNSTERILE
ITEMS
a. Sterile team members maintain contact
with sterile field by means of sterile
gowns & gloves.
b. Nonsterile circulating nurse does not
directly contact the sterile field.
c. Supplies are brought to sterile team
memvers by the circulating nurse who
opens the wrappers on sterile packages.
The circulating nurse ensures sterile
transfer to the sterile field. Only sterile
items touch sterile surface.
5. UNSTERILE PERSONS AVOID REACHING
OVER A STERILE FIELD; STERILE PERSONS
AVOID LEANING OVER AN UNSTERILE AREA
a. Unsterile circulating nurse NEVER
reaches over a sterile field to transfers
sterile items.
b. In pouring solution into sterile basin,
circulating nurse holds only lip of bottle
over basin to avoid reaching over a
sterile area.
c. Scrub person sets basins or glasses to
be filled @ edge of the sterile table;
circulating nurse stands near this edge
fo the table to fill them.
d. Circulating nurse stands @ a distance
from the sterile field to adjust light over it
to avoid microbial fallout over field.
e. Surgeons turns away from sterile field to
have perspiration removed from brow.
f. Scrub persons drapes a nonsterile table
towards self first to protect gown.
Gloved hands are protected by cuffing
draped over them
g. Scrub persons stands back from
nonsterile table when draping it to avoid
leaning over an unsterile area.
6. EDGES OF ANYTHING THAT ENCLOSES
STERILE CONTENTS ARE CONSIDERED
UNSTERILE
a. In opening sterile packages, a margin of
safety is always maintained. The inside
of wrappers is considered sterile within 1
inch of the edges. The circulating nurse
opens top flap away from self, then turns
the sides under. Ends of flaps are
secured in hand so they do not dangle
loosely. The last flap are secured in
pulled toward person opening package,
thereby exposing package contents
away from nonsterile hand.
b. Sterile person lifts contents away from
packages by reaching down & lifting
them straight up, holding elbows high
c. Steam reaches only area within the
gasket of a sterilizer. Instrument trays
should not touch edge of the sterilizer
outside the gasket.
e. If a sterile wrapper is used as a table
cover, it should amply cover the entire
table surface. Only the interior & surface
level of the cover are considered sterile.
f. After a sterile bottle is opened, contents
must be used or discarded. Cap can be
replaced without contaminating pouring
edges.
7. STERILE FIELD IS CREATED AS CLOSE AS
POSSIBLE TO TIME OF USE
a. Sterile tables are set up just before the
operation.
b. It is virtually impossible to uncover a
table of sterile contents without
contamination. Covering sterile tables
for later use is not recommended.
8. STERILE AREAS ARE CONTINUALLY KEPT
IN VIEW
a. Sterile person face sterile areas.
b. When sterile packs are open in a room,
or a sterile field set up, someone must
remain in the room to maintain vigilance.
Sterility cannot be ensured without direct
observation. An unguarded sterile field
should be considered contaminated.
9. STERILE PERSONS KEEP WELL WITHIN
THE STERILE AREA
a. Sterile persons stand back at a safe
distance from the operating table when
draping the client.
 b. Sterile persons pass each other back to
back at 360° turn.
c. Sterile person turns back to nonsterile
person or area when passing.
d. Sterile person face sterile area to pass
it.
e. Sterile person asks nonsterile individual
to step aside rather than risk
contamination.
f. Sterile persons stay within the sterile
field. They do not walk around or go
outside the room.
g. Movement within & around a sterile areas
is kept to a minimum to avoid
contamination of sterile items or
persons.
10. STERILE PERSONS KEEP CONTACT
WITH STERILE AREAS TO A MINIMUM
a. Sterile persons do not lean on sterile
tables & on the draped client.
b. Sitting or leaning against a nonsterile
surface is a break in technique. If the
sterile team sits to operate, they do so
withou proximity to nonsterile areas.
13. MICROORGANISM MUST BE KEPT TO AN
IRREDUCIBLE MINIMUM
11. UNSTERILE PERSON AVOID STERILE
AREAS
a. Unsterile persons maintain a distance of
at 1 foot (30 cm) from any area of the
sterile field.
b. Unsterile persons face & observe a
sterile area when passing it to be sure
they do not touch it.
c. Unsterile persons never walk between
two sterile areas, e.g., between sterile
instrument tables.
d. Circulating nurse restricts to a minimum
all activity near sterile field.
12. DESTRUCTION OF INTEGRITY OF
MICROBIAL BARRIERS RESULTS IN
CONTAMINATION
a. Sterile packages are laid on dry
surfaces.
b. If sterile package wrapped in absorbent
material becomes damp or wet, it is
resterilized or discarded. The package is
considered nonsterile if any part of it
comes in contact with moisture.
c. Drapes are placed on a dry field.
d. If solution soaks through sterile drape to
nonsterile area, the wet area is covered
with impervious sterile draped or towels.
e. Packages wrapped in muslin or paper
are permitted to cool after removal from
a sterilizer & before being placed on
cold surface to prevent steam
condensation & resultant
contamination.
f. Sterile items are stored in clean dry
areas.
g. Sterile package are handled with clean
dry hands.
h. Undue pressure on sterile packs is
avoided to prevent forcing sterile are
out & pulling unsterile air into the pack.
A. Skin cannot be sterilized. Skin is a
potential source of contamination in
every operation.
1. Transient & resident flora are
removed from skin around
operative site of client & hands &
arms of sterile team members by
mechanical washing & chemical
antisepsis.
2. Gowning & gloving of operating
team is accomplished without
contamination of exterior of gowns
& gloves.
3. Sterile gloved hands do not directly
touch skin & then deeper tissues.
Instruments uses in contact with
skin are discarded & not reused.
4. If glove is torn or punctured by
needle or instrument, gloved is
changes immediately. Needle or
instrument is discarded from sterile
field.
5. Sterile dressing should be applied
before draped are removed to
reduce risk of the incision being
 touched by contaminated hands or
objects. TYPES OF ANESTHESIA

1. GENERAL ANESTHESIA
MEMEBERS OF SURGICAL TEAM Depresses CNS resulting:
amnesia, analgesia,
A. Surgeon- a physician who assumes unconsciousness, loss of
responsibility for the surgical procedures muscle tone and reflexes.
and any surgical judgements about the
client. 2. LOCAL ANESTHESIA/REGIONAL
B. Surgical Assistant- might be another Disrupts sensory nerve impulse
surgeon (or physician, resident or intern) transmission from a specific
or nurse, surgical technologist. area or region.
C. Anaesthesiologist- is a physician who is
specialized in giving anesthetic agents.
STAGES OF GENERAL ANESTHESIA

STAGE 1- STAGE OF INDUCTION

From the beginning of
administration of drugs/gas to
ANESTHESIA loss of consciousness.
“Negative sensation” Client appear drowsy and dizzy.
Is an induced state of partial or
Nursing action:
total loss of sensation, occurring  Close OR doors and
with or without loss of keep room quiet
consciousness.  Standby the client and
assist if necessary.
Puposes:
1. Block nerve impulse transmission.
2. Promote muscle relaxation.
3. Achieve a controlled level of
unconsciousness. STAGE 2- STAGE OF EXCITEMENT
From loss of consciousness to
Selection of anesthesia influenced by the relaxation
following:
a. Client’s health problem- major factor. Client appear excited, breathing
b. Type and duration of the procedure. is irregular
c. Area of the body having surgery. Client moves extremeties or
d. Safety issues to reduce injury-airway body
management Client is vey sensitive to
e. Whether the procedure is an emergency external stimuli
f. Options for management pain after
Nursing action:
surgery  Restrain client if needed
g. How long it has been since the client  Remain at client side
ate, had any liquid, or any drugs.  Be quiet and alert
h. Clients position needed for the surgical  Assist anaesthesiologist
procedure. if needed

STAGE 3- STAGE OF SURGICAL

ANESTHESIA AND RELAXATION
Loss of reflexes
Depression of vital function
 Respiration – regular, pupils
contracted C. MODIFIED FOWLERS POSITION
Eyelids reflexes disappear For neurosurgery
Loss of auditory senses

Nursing action:
 Begin final prep – D. PRONE POSITION
client is under Surgery on the posterior part of
control the body, laminectomy

E. LITHOTOMY POSITION
Perineal approach, cystoscopy,
vaginal hysterectomy

STAGE 4- DANGER STAGE F. LATERAL POSITION

Vital functions are to depressed Kidney, lungs or hip
Respiratory failure and possible
cardiac arrest
Not breathing, little or no pulse
G. JACKNIFE POSITION
and heartbeat.
Rectal surgery
Nursing action:
 Be ready to
resuscitate.

POST OPERATIVE PERIOD

POSITIONING
Putting client in proper body alignment Begins at the administration of the client
to expose the operative site or area. to the post-anesthesia area and ends when
healing is complete.
Qualification of a good position:
1. Free respiration Stages of Recovery
2. Free circulation  Immediate
3. No pressure on nerve postoperative stage.
4. Hand or feet properly supported The period one to
5. No undue postoperative discomfort four hours after
6. Accessible operative site. surgery.
 Intermediate
postoperative stage.
The period four to
twenty-four hours
A. SUPINE POSITION/ DORSAL
after surgery.
Laparotomy, appendectomy
 Extended
postoperative stage.
The period atleast
B. REVERSE MODIFIED one to four days
TRENDELENBURG POSITION after surgery.
Face and neck surgery
 The perioperative nurse as a scrub nurse
performs another essential role in the operating
room. Her expertise includes knowledge of
anatomy and physiology and the procedure to
be performed, ability to recognize the
instrumentation used in a particular surgery, and
critical thinking skills to gather specialty items
that may be needed during a procedure and in
event of an emergency.
The scrub nurse is a member of the sterile
surgical team. His/her primary responsibility is
maintenance of the sterile field. Other activity of
the scrub nurse includes:
 Assisting and preparing the procedure
room
 Gathering sterile supplies needed for the
procedure and those that may be
needed
 Setting up the sterile back table
 Dressing the surgeon and other
members of the surgical team in their
sterile attire
 Assisting in the placement of the sterile
drapes
 Passing the instruments to the surgical
team and assisting as needed to
enhance the continuity of the procedure


OR
Constant surveillance of the surgical
field thus maintaining sterility
 Anticipating the needs of the surgeon
and asking for items before they are
needed
 Reporting to the circulating nurse the
names of the specimens obtained during

NOTEBOOK 
surgery
Helps with the application of the sterile
dressing at the end of the procedure
 Removal of bioburden from used
instrumentation before sending it to be
processed in Central processing.
Prepared by:  Assist in the cleaning of the procedure
PRADO, Edelweis C. room to make ready for the next surgical
procedure.
BSN 3-F

PERIOPERATIVE DUTIES
Scrub Nurse
  Performing the surgical skin prep
 Conducting and maintaining accurate
Circulating Nurse records of counts
 Maintaining accurate documentation of
The Circulating nurse, by virtue of her nursing activities during the procedure
professional educational preparation and  Dispensing supplies and medications to
specialized skill, is responsible for managing the surgical field
patient care activities in the operating suite, so  Maintaining an aseptic and safe
his/her duties begin long before the patient environment
arrives in the operating room and continues until  Estimating fluid and blood loss
the final dispensation of the patient, operating
 Handling special equipment, specimens,
room records, and specimens is completed.
etc
The following list depicts some of the activities
performed by the circulating nurse prior to  Communicating special postoperative
induction of anesthesia, during the procedure, needs to appropriate persons at the
and upon conclusion of the procedure: conclusion of the case
 Assisting and preparing the procedure
room
 Supervising the transporting, moving,
and lifting of the patient
 Assisting anesthesia as requested
during induction and reversal of
anesthesia
 Positioning the patient for surgery

PREOPERATIVE CHECKLIST
and chest radiography
 Review checklist to reports are
ensure that each item documented in the
is addressed before clients record.
client is transported
to surgery.
 Ensure that client is
wearing an
identification
bracelet.
 Assesses client for
allergies.  Remove client
 Ensure that jewelry, make up,
prescribed laboratory dentures, hairpins,
test results and nail polish, glasses
electrocardiography
 and prosthesis as  Prosthesis or
appropriate. dentures should be
 Document that removed to prevent
valuables have been obstruction in the
given to clients airway.
family members or
locked in the
hospital safe
 Monitor and document
clients vital signs

Perioperative Duties
Scrub Nurse

The perioperative nurse as a scrub nurse performs another essential role in the
operating room. Her expertise includes knowledge of anatomy and physiology and
the procedure to be performed, ability to recognize the instrumentation used in a
particular surgery, and critical thinking skills to gather specialty items that may be
needed during a procedure and in event of an emergency.

The scrub nurse is a member of the sterile surgical team. His/her primary
responsibility is maintenance of the sterile field.

Other activity of the scrub nurse includes:

 Assisting and preparing the  Setting up the sterile back table

procedure room  Dressing the surgeon and other
 Gathering sterile supplies members of the surgical team
needed for the procedure and in their sterile attire
those that may be needed
  Assisting in the placement of
the sterile drapes
 Passing the instruments to the
surgical team and assisting as
needed to enhance the
continuity of the procedure
 Constant surveillance of the
surgical field thus maintaining
sterility
 Anticipating the needs of the
surgeon and asking for items
before they are needed
 Reporting to the circulating
nurse the names of the
specimens obtained during
surgery
 Helps with the application of
the sterile dressing at the end of
the procedure
 Removal of bioburden from
used instrumentation before
sending it to be processed in
Central processing.
 Assist in the cleaning of the
procedure room to make ready
for the next surgical procedure.

Circulating nurse
The Circulating nurse, by virtue of her professional
educational preparation and specialized skill, is
responsible for managing patient care activities in the
operating suite, so his/her duties begin long before the
patient arrives in the operating room and continues until
the final dispensation of the patient, operating room
records, and specimens is completed.

The following list depicts some of the activities

performed by the circulating nurse prior to induction of
anesthesia, during the procedure, and upon conclusion
of the procedure:

 Assisting and preparing the

procedure room
 Supervising the transporting,
moving, and lifting of the patient
 Assisting anesthesia as requested
during induction and reversal of
anesthesia
 Positioning the patient for surgery
 Performing the surgical skin prep
 Conducting and maintaining accurate  Maintaining accurate documentation
records of coun of nursing activities during the
procedure
  Dispensing supplies and medications  Communicating special
to the surgical field postoperative needs to appropriate
 Maintaining an aseptic and safe persons at the conclusion of the case
environment
 Estimating fluid and blood loss
 Handling special equipment,
specimens, etc

INTRAOPERATIVE PERIOD
Begins when the client is transferred to the OR bed ends when the client of
transferred to an area for Recovery from OR

Key words of OR practiced are:

Caring
Discipline
Technique
Conscience
Optimal client care requires an inherent surgical conscience, self discipline &
the application of principles of aseptic & sterile technique.

Surgical conscience – “Surgical golden Ruler”

“Do unto the patient as you would have others do unto you”

MEMEBERS OF SURGICAL TEAM

D. Surgeon- a physician who assumes
responsibility for the surgical procedures and
any surgical judgements about
the client.
 E. Surgical Assistant- might be another surgeon (or physician, resident or
intern) or nurse, surgical technologist.
F. Anaesthesiologist- is a physician who is specialized
in giving anesthetic agents.

STAGES OF GENERAL ANESTHESIA

STAGE 1 - STAGE OF INDUCTION
From the beginning of administration of drugs/gas to loss of consciousness.
Client appear drowsy and dizzy.
Nursing action:
Close OR doors and keep room quiet
Standby the client and assist if necessary.

STAGE 2- STAGE OF EXCITEMENT

From loss of consciousness to relaxation
Client appear excited, breathing is irregular
Client moves extremities or body
Client is vey sensitive to external stimuli

Nursing action:
Restrain client if needed
Remain at client side
Be quiet and alert
Assist anaesthesiologist if needed

STAGE 3- STAGE OF SURGICAL ANESTHESIA AND RELAXATION

Loss of reflexes
Depression of vital function
Respiration – regular, pupils contracted
Eyelids reflexes disappear
Loss of auditory senses
Nursing action:
Begin final prep – client is under control

STAGE 4- DANGER STAGE

Vital functions are to depressed
Respiratory failure and possible cardiac arrest
Not breathing, little or no pulse and heartbeat.
Nursing action:
Be ready to resuscitate.
POSITIONING
Putting client in proper body alignment to expose the operative site or area.

Qualification of a good position:

7. Free respiration
8. Free circulation
9. No pressure on nerve
10. Hand or feet properly supported
11. No undue postoperative discomfort
12. Accessible operative site.
SUPINE POSITION/ DORSAL
Laparotomy, appendectomy

REVERSE MODIFIED TRENDELENBURG POSITION

Face and neck surgery

MODIFIED FOWLERS POSITION

For neurosurgery

PRONE POSITION
Surgery on the posterior part of the body, laminectomy

LITHOTOMY POSITION
Perineal approach, cystoscopy, vaginal hysterectomy

LATERAL POSITION
Kidney, lungs or hip
JACKNIFE POSITION
Rectal surgery

POST OPERATIVE PERIOD

Begins at the administration of the client to the postanesthesia area and ends
when healing is complete.

Stages of Recovery
-immediate postoperative stage. The period one to
four hours after surgery.
-intermediate postoperative stage. The period four to
twenty-four hours after surgery.

-extended postoperative stage. The period atleast one

to four days after surgery.
O OR NOTEBOOK

PRESETED to:

GALON, Airyl RN

PRESENTED by:

PALMERO, Ara Fatima