MODULE

in
PERIOPERATIVE
NURSING
(RELATED LEARNING EXPERIENCE)
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AUTHOR/S:
ENRICO S. DEL ROSARIO
MARK REYNIE RENZ V. SILVA

CONTRIBUTOR/S:
FRANCES ANNE R. CORPUZ
SHERYLYN R. DUCUSIN
JOEL C. ESTACIO
SALVADOR P. LLAVORE
JIMA J. MAMUNGAY
CHARI V. RIVO
ROSE ANN R. TAN

First Semester, SY 2020-2021

TABLE OF CONTENTS
Introduction 3
Learning Outcomes 3
Module Organizer 3
Area of Assignment 4
RLE Guidelines Amidst COVID 19 Pandemic 7
Directions 10
Lesson 1 Overview 11
Preoperative Nursing Care 11
Intraoperative Nursing Care 18
Postoperative Nursing Care 32
Lesson 2 Skills Laboratory Activities 40
I. Surgical Hand Asepsis 40
II. Applying Sterile Gloves via the Open Method 42

III. Applying Sterile Gloves and Gown via

the Closed method 44

Module Summary 51
References 52
Appendices
A 53
B 55
C 56
D 57
E 58
F 60
G 61
H 62
I 63
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RELATED LEARNING EXPERIENCE: PERIOPERATIVE NURSING CARE

INTRODUCTION
This module introduces Perioperative Nursing Care as part of your
course Care of Client with Problems in Oxygenation, Fluid and Electrolytes,
Infectious, Inflammatory and Immunologic Response, Cellular Aberrations,
Acute and Chronic. Perioperative Nursing Care means the delivery of care to
patients during the preoperative, intraoperative and postoperative period of
surgery. This module will help you deliver appropriate and safe care and
interventions to patients who will undergo surgical procedures that will hone
you to become good and responsible nurses in the future.

LEARNING OUTCOMES
On completion of this perioperative RLE module, you will be able to

1. differentiate the common purposes and settings of surgery.

2. utilize the nursing process in the care of individuals and families who
will undergo surgical procedures during the perioperative period.
3. ensure a well-organized and accurate documentation system of patient
perioperatively.
4. observe bioethical concepts and principles, core values and nursing
standards in the care of clients during the perioperative period.
5. collaborate appropriately with patient/s, their families, and the health
care team to promote SAFETY of patients before (preoperative), during
(intraoperative), and after (postoperative) surgery to ensure patient-
centered care.
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6. apply basic principles of aseptic technique used in the operating room to

promote safety relative to patients, equipment, and

MODULE ORGANIZER
Hi! My name is Jima J. Mamungay and I am your Clinical
Coordinator for this semester. I will be assigning you your clinical instructor
each group. In case you encounter difficulty, discuss this with me or with your
assigned clinical instructor during the scheduled virtual meeting via google
meet or zoom. If not, contact me or your clinical instructor with the following
contact details:

NAME OF
FACULTY
MEMBER
JIMA J. jmamungay@dmmmsu.edu.ph Jima Querrer 09178417848
MAMUNGAY Jose Mamungay

FRANCES facorpuz@dmmmsu.edu.ph Frances Anne 09776958104

ANNE R. Corpuz
CORPUZ
ENRICO S. DEL edelrosario@dmmmsu.edu.ph Enrico Del 09052124265
ROSARIO Rosario
SHERYLYN R. skducusin@dmmmsu.edu.ph Sherylyn Karessa 09282425005
DUCUSIN R. Ducusin
JOEL C. jestacio@dmmmsu.edu.ph 09177740279
ESTACIO
SALVADOR P. sllavore@dmmmsu.edu.ph Salvador P. 09171534850
LLAVORE Llavore
CHARI V. RIVO crivo@dmmmsu.edu.ph Chari V. Rivo 09167437731
MARK REYNIE mrrsilva@dmmmsu.edu.ph Renz Silva 09950800893
RENZ V. SILVA
ROSE ANN R. ratan@dmmmsu.edu.ph Rose Ann Ringor- 09457557674
TAN Tan

AREA OF ASSIGNMENT

You are assigned to Operating Room Complex. You are

given 3 days to complete this Module (Thursday-Saturday). You are also
assigned to a Clinical Instructor whom you can consult and submit your
requirements on this module. Below is the list of groupings with your
respective Clinical Instructor in this Clinical Rotation.

NAME OF NAME OF STUDENTS/GROUP NO.

FACULTY
ENRICO S. Group 1:
DEL ROSARIO 1. ACOSTA, Ma. Jessica C.
2. AMMOGAWEN, Ar-en C.
3. ANASTACIO, Maria Rubina Maraggun
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4. ANCHETA, Gabrielle Audrey Gateb

5. ANCHETA, Joely Princess Alzate
6. APILLANES, Maica Shane Santos
7. BAGUIOEN, Kathlene Kaye L.
8. BALBOA, Cristine Joy Quiñones
9. BILOG, Christine Joy Valdez
10.BOADILLA, Jill Calera
11.BOADO, Tiffany Kate Fontanilla
12.CALONGE, Romeo III Madarang
13.CARPIO, Rosemae Lyn
14.CLARO, Joan Binabise
SHERYLYN R. Group 2:
DUCUSIN 1. COLOMA, Geraldine Eugrapia
2. COSTALES, Jackielyn Fajardo
3. DACANAY, Nicole Paula Adube
4. ENCARNACION, Jella Rexie Mariano
5. ESLAO, Duke Manuel Antonio V Colos
6. GARCIA, Elidia Pacle
7. GAYO, Reyna Rose Mangaoang
8. JACABAN, Freddie Boy Gacujas
9. JAPPAR, Sittie Norjanipa Mangoda
10.JUGUILON, Kathlyn Galicia
11.LAPIDANTE, Jay Franklin Resonable
12.LAROCO, Thalia Nicole Bautista
13.LAROYA, Ma. Eliza Padilla
14.LOPEZ, Jason Flores
15.MANONGDO, Mary Rose Mallare
SALVADOR P. Group 3:
LLAVORE 1. MILO, Meredith Boado
2. OCHEA, Anna Marie Oligo
3. PUAPO, Trishafhate Irichelle Gayo
4. REFUGIA, Erica Antonio
5. ROMERO, Shaira Mae Yante
6. SAGUN, Rolando Jr. Colcol
7. SORIA, Renzel Kaye Labagnoy
8. SORIANO, Ricobel John Santiago
9. UGAY, Rachel Abanes
10.USON, Gemma Rose Sapasap
11.VALENCIA, RachelViduya
12.VIAZON, Ana Grace Ruiz
13.ADUBE, Maria Francesca Estalilla
14.ALBA, Angel Mae Gayo
ROSE ANN R. Group 4:
TAN 1. Ambulo Eda Rissa Paydon
2. Baguioen Kathlene Kyla Lupdag
3. Barcelon Christal AnneCacas
4. Bautista Mary Joy Gurtiza
5. Cabanlig Jelena Rose Hernando
6. CasemDenzel Marc Ramos
7. CasillaRyan Jay Ogoc
8. David Jan Joshua Maglaya
9. Dayag Juna-Mae Paculan
10.De Guzman Angel Jasmin Halog
11.Enriquez Mariecor Sulat
12.Eslao DanicaMiranda
13.Fernandez Jennica may Maglambayan
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14.Gamboa Stephanie Padilla

15.Genove Mary GerleneMadriaga
MARK REYNIE Group 5:
RENZ V. SILVA 1. Gracias Frances May Pocsidio
2. Jacla Marielice Boado
3. Jucutan Rosemarie Joy Sotelo
4. Jugo Jacqueline Joy Valdez
5. Juguilon Rissa Mangonon
6. Labayog Xyra Jasmine Garcia
7. Llobrera Ferlyn Loulo Colubong
8. Lupdag Juniece Giron
9. Marata Karl Joshua Carrera
10.Morla Marie Magdalene Alib
11.Oloresisimo Meya Sison
12.Paculan Mary Rose Arceo
13.Pascua Ranee Mediatrix Dulay
14.Ramos, Kathleen Jayne Milana

CHARI V. Group 6:
RIVO 1. RAMOS, Vianne Ross Rivera
2. RIMANDO, Lora Mae Frias
3. SORIANO, Carmela Joy Marantal
4. SULTAN, Norhaina Laron
5. VERCELES, Aila Marie Abalos
6. VERCELES, Marivic Estolas
7. VILLANUEVA, Kimberly Perez
8. ACOSTA , Anna Clarissa Dolores
9. AQUINO, Abraham Joseph Serraon
10.BALIBOL, Jirah Nelvida
11.BOADILLA, Cecil Joyce Costales
12.BOADILLA, Nelly Regacho
13.BUCCAT, Christianne Joyce Tumamao
14.CABURIAn, Jessa Boado
15.CARTAS, May-Anne Pascual
ROSE ANN R. Group 7:
TAN 1. DUCUSIN, Florevic Medriano
2. DULAY, Florence MaeGeneta
3. DUNGAN, Danilo Jr. Milan
4. ESTACIO, Christian Garcia
5. FARIÑAS, Faith Althea Pimentel
6. FERNANDEZ, LJ Gloria Carpio
7. GALOY, Christine Marie Romero
8. GAMBOA, Promil Ramjes Garcia
9. GARCIA, Astra Fe Lorraine Monserate
10.GUTIERREZ, Ryan Ferdinand Maramba
11.HUFALAR, Angelica Marquez
12.LACHICA, Marvie Joyce Eisma
13.LACHICA, Novem Kaye Sunio
14.MAALA, Cherrie Lou Castro
15.MACAYAN, Niña Sophia Coloma
FRANCES Group 8:
ANNE R. 1. MAGNO, Elisa Lagmay
CORPUZ 2. MAGRAMO, Erika Diva
3. MOVIDA, Leomir Paragas
4. NOTARTE, Jedidah Keith Alipio
5. PAGUIRIGAN, Jedidiah Orallo
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6. RAMIREZ, Bernadine Faith Concha

7. RINGOR, Jinky Pedral
8. ROCACORBA, Sheena Del Rosario
9. SANTIAGO, Ma. Ericka Lictaoa
10.SINEN,Kyle Hezzekiah Munar
11.TARANGCO, Guia Bautista
12.VELORIA, Jemarry Tion
13.VILLEGAS, Laura Cendaña

RELATED LEARNING EXPERIENCE

GUIDELINES

General Information
This “RLE Guidelines” is created to direct you amidst the uncertainties
brought by COVID 19 pandemic. It will make the most out of your learning
experience without compromising your safety and health. It will give you a
brief overview of how we will course through the conduct of your related
learning experience without conceding proper decorum and discipline

Attendance:
You are expected to attend scheduled virtual meetings. If you failed to
attend for 3 consecutive virtual meetings, you will be referred to your Program
Chair.

Observance of Proper Netiquette

You should always practice appropriate decorum when communicating
with your Clinical Instructor and with your classmates within our educational
platform. If you fail to do so, you will be referred to your Program Chair. There
are guidelines that you are expected to know during our virtual meetings.
These guidelines are the following:

1. Avoid typing in ALL CAPS

You can express your emotions, opinions, ideas or feelings in any
way you want HOWEVER IN MOST CONDITIONS, TYPING IN ALL
CAPITAL LETTERS IS UNSUITABLE. All caps may be viewed as shouting,
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yelling or intensified emotions, opinions, ideas or feelings which

could be misinterpreted by your reader.

2. Be Polite
There are many sources of mistaken arguments in virtual world.
Sarcasm is one of the sources where the commenter’s intent is hard
to understand. To avoid misunderstanding, you should be nice,
humble and respectful in giving your remarks or observations online
even if you don’t agree with someone. In addition, don’t use bad
words in disagreeing to the idea of someone. Moreover, besides
appropriate punctuation and spelling, you should give polite greetings
and signatures. Don’t forget to use the words “please” and “thank
you” as you always practice in actual conversation.

3. Don’t abuse the chat box

In every online class, chat box serves as a venue for you to share
and give thoughts and ask inquiries related to the lesson. But this
chat box depends on how you will use it to deliver your ideas and
questions. It can be a useful resource or be a main disturbance during
discussions. So, do not post unnecessary or unrelated topics such as
online selling, photo liking contest and the like.

4. Read and Think before you ask

Read and understand previous messages, announcements, and
discussions. Spend time to search or figure out questions on your
own. But in case you are still unsure, confused or trapped in one
discussion or topic, that is the time you are going to ask your clinical
instructor for clarifications or confirmations.

5. Cyber bullying is NO NO!

Remember that you are communicating to a human person. They
also have feelings like you, so respect them. Don’t be offensive
online because it could backfire to you. Moreover, anything could be
saved then sent to anyone who could be use this information against
you.

6. Submit files the right way

Because we are in a new normal where face to face meeting is
not allowed, your activities will be submitted online. You should be
aware on how you will submit your work to your clinical instructor. In
order to have organized file from submitted assignment, you will be
instructed about the ground rules by your clinical instructor. Failure
to do these instructions suggests that you have a bad netiquette.

7. Be on Time, Presentable and Prepared.

Being punctual is very important for online meetings. This will
ensure that everyone can be gathered to start classes on time and
utilize limited time wisely. While this set up is conducted at the
comfort of your own home, this is nonetheless similar to a lesson
conducted inside the classroom. Be sure to look presentable and
make sure that all the materials needed for your class are already
prepared near you.
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8. Be attentive and Participative

Giving your focused attention is one of the best things you can do
to learn efficiently whether learning online or inside the classroom.
Stay focus and be attentive always. Be participative when your
teacher is leading the class in a discussion or dialogue where you
should speak up and share your thoughts.

9. RESPECT
You should always give respect to others especially during virtual meetings. If
someone is talking or discussing, listen and do not do anything that could distract
the speaker. Always remember that do unto others what you want others do unto
you. So if you want respect, respect others too.

RELATED LEARNING EXPERIENCE

Bachelor of Science in Nursing- Third Year
FIRST SEMESTER
Clinical  NUPC113 – 255 hours
 NUPC 114 – 51 hours
 NUPC 115- 51 hours
Skills Laboratory  NUPC 113 – 51 hours
 NUPC 112 – 51 hours

Dress Code
During VIRTUAL RLE meetings, consultation and return demonstrations,
you are expected to wear the prescribed related learning experience. Failure
to wear the prescribed uniform shall be considered as unexcused absence from
duty. In case that you left your uniform in your respective boarding house last
semester, you are required to wear white polo/ collared shirt. The following
are the description of your prescribed uniform during RLE and CP:

In the clinical setting

 For Females: White dress that is knee level or one inch below the
knee.
 For Males: White pants and white polo shirt with plain white
undershirt with pin on left collar
 

In the community setting (for both men and women)

 Type A (RHU Uniform): White blouse and polo shirt with RHU (dark
blue) pants
 Type B: Dark maong pants with CCHAMS T-shirt
 Type C: Any attire appropriate with the activity as prescribed by
your Clinical Instructor

Grooming Standard
 For female students who will attend the VIRTUAL RLE meetings,
consultation and return demonstrations, you are required to observe
the following:
Hair should not touch the collar. Bangs should not extend
below the eyebrow. Long hair should be braided or secured
neatly into a bun.
Black or dark brown hair clips may be used but no fancy clips,
ribbons, and headbands shall be allowed
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Headbands should be flat and black with no more than 1 inch

width
Only light make-up is allowed
No colored contact lens is allowed
No polished or colored fingernails is allowed
Hair color should be dark brown and black ONLY.
  
 For male students who will attend the VIRTUAL RLE meetings,
consultation and return demonstrations, you are required to observe
the following:
Haircut should either be high cut, semi-high cut, flat top, crew
cut, or semi low cut. Hair at the back should be barber’s cut.
No spikes, fancy or other very fashionable hairstyle. No dyeing
of hair is allowed.
No moustache, beard or sideburns is allowed
No make up
No colored contact lens is allowed
Hair color should be dark brown and black ONLY.

 Accessories
Only the prescribed watch shall be allowed. No accessories or
jewelry shall be worn during VIRTUAL RLE meetings,
consultation and return demonstrations.
Married individuals are allowed to wear their wedding rings

Requirements/ Evaluation
At the end of every clinical module, you are being evaluated by your
clinical instructor assigned to you which will be submitted to your respective
clinical level coordinator. Requirements are assigned in each module and
deadline of submission is 1 week after the end of each module. Format and
templates for Requirements are still the same. Rubrics will be attached in each
module. Late submission of requirements will be entertained depending on the
reason behind it. You are required to submit a letter of explanation to your
clinical instructor assigned to you and he/she will classify it if excused or
unexcused. The equivalent grade of requirements that are submitted late will
be 75%. Meanwhile, those who will not pass their requirements will
automatically have a grade of ZERO. You are still required to have your clinical
duty in the area but in case that the current situation will still the same, your
final grade will be marked as IN PROGRESS. Catch up plan will be created to
meet your clinical duty needs.

DIRECTION
DIRECTIONS
There are two lessons in the module. Read each lesson
carefully. Lesson 1 and 2 starts with the brief overview of
the topic and followed by skills laboratory activities. After
reading each lesson, you are required to answer the exercises/activities to find
out how much you have benefited from it. Sample format and templates are
provided and seen at the appendices. Work on these exercises carefully
because they are graded and submit your output to my email given to you.
Rubrics will be used to evaluate your outputs that are seen in the appendices
section of this module.
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Good luck and happy reading!!!

Lesson 1

OVERVIEW
This module aims to provide comprehensive foundation and principles of
perioperative nursing. This will also facilitate in exploring, advancing, and
developing your skills and knowledge in perioperative nursing. Similarly, you
will develop professional attitude and competence in perioperative nursing.

This PERIOPEATIVE NURSING Related Learning Experience Module relates to

the various concepts, principles, and procedures in the Surgical Unit, Operating
Room, Post-Anesthesia Care Unit, and care provided to the patient in three
stages of surgeries:

 Preoperative;
 Intraoperative; and
 Postoperative

I. PREOPERATIVE NURSING CARE

The preoperative phase commence with decision for surgery and ends
with transfer to the operating room. Preoperative care is the physical and
psychological care provided to the patient to help them prepare to undergo
surgery.

A. ROLES OF PREOPERATIVE NURSE

 Performs a baseline preoperative assessment

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 Provide explanations and instructions.

 Offer patients and families emotional and psychological support to ease
anxiety.
 Develops a plan of care
 Verifies the patient’s name, surgical site (along with the patient),
allergies, and related information when the patient arrives in the
surgical area.

To ensure patient safety at all times and minimize intra/postoperative

complications by:

 delivering the required nursing care for the preoperative patient

 minimizing potential problems by ensuring patients have carried out
certain procedures and are prepared safely for theatre. These include:

a. Consent.
b. Preoperative fasting/ Nutritional Status
c. Skin preparation
d. Marking skin for surgery
e. preoperative pregnancy testing
f. preventing toxic shock syndrome from tampons (female only)
g. patient education
h. application of antiembolic stockings (graduated elastic compression
stockings)
i. assessment for latex allergy

B. CONSENT
For consent to be valid the patient must
1. Be competent to take the particular decision
 the ability to understand and retain the information provided,
especially around the consequences of having or not having the
procedure.
2. Have received sufficient information to make a decision
 This is so the patient has a understanding of the procedure and the
purpose behind it.
3. Not be acting under duress.
 this is without pressure or undue influence to either undertake or
not undertake treatment.

TABLE 1.1. Obtaining Informed Consent

OBTAINING INFORMED CONSENT
The surgeon is responsible for Older client may need a legal guardian to sign
obtaining the consent the consent form
No sedation should be The nurse may witness the client’s signing of
administered to the clients the consent form, but the nurse must be sure
before the client signs the that the client understood the surgeon’s
surgery. explanation of the surgery
Minors may need a parent or The nurse needs to document the witnessing
legal guardian to sign the of the signing of the consent form after the
consent form client acknowledges understanding of the
procedure.
Psychiatric clients have a right Obtaining telephone consent from a legal
to refuse treatment until a guardian or power of attorney for health care
court has legally determined is an acceptable practice if clients are unable
that they are unable to make to give consent themselves. The nurse must
decisions for themselves. engage another nurse as a witness to the
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consent given over the telephone.

****Gaining/Obtaining of consent, unless it is an emergency, should be treated as a process,
rather than a one-off event.

C. PREOPERATIVE FASTING/ NUTRITIONAL STATUS

Table 1.2. Preoperative Fasting/ Nutritional Status

Preoperative Fasting/ Nutritional Status
Review physician’s orders regarding Prepare to initiate IV line and
the NPO status administer IV fluids as prescribed.
Solid food and liquids usually are Prepare to administer Total Prenteral
withheld for 6 to 8 hjours before Nutrition to clients whop arte
general anesthesia anf for 3 hours malnourished, have protein or
before surgery for local anesthesia to metabolic, deficiencies, or cannot
avoid aspiration. ingest foods
Insert an intravenous (IV) line and administer IV fluids, if prescribed; per
agency policy, the IV catheter size should be large enough to administer blood
products if they are required.
Elimination
If the client is to have intestinal or The client should void immediately
abdominal surgery, enema or laxative before surgery
or both may be ordered.
Prepare to insert IFC if ordered Empty IFC bag before transporting
client to OR suite.
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Box. 1.1 Sample Informed Consent

To whom it may concern,

I, _______________________________________, ___________ years old, single/ married/

widowed, hereby consent to the performance upon ______________________________________
(name of the patient)
who is my _____________________________, the procedure/ operation/anesthesia hereunder
stated after these have been fully explained to me by the doctor/s concerned including the risks
involved and their alternative procedures:

PROCEDURE/ OPERATION/ ANESTHESIA EXPLAINED BY:

__________________________________ ________________________________
__________________________________ ________________________________

I consent to the proper disposal by authorities of the DMMMSU-Hospital of whatever tissue may be
removed.

I consent to the taking of photographs in the course of this medical/surgical management for the
purpose of advancing medical knowledge

In witness whereof, I hereunto set my hands this ___ day of ______, 20__ .

__________________________
SIGNATURE OVER PRINTED NAME OR THUMB MARK OF THE PATIENT

If Minor

Name of the patient: Printed Name and Signature of the Parents/s/ Legal Guardian:
________________________________ _____________________________________________________
Address: ________________________ Address: ______________________________________________
Contact Number: _______________________________________

Ensuring that the patient understands the rationale for fasting is

important in order to reduce anxiety. For elective surgery patients are kept
NPO long enough to allow the stomach to empty. This means that patients can
have water or clear fluids up to 2 hours before surgery and solid foods up to 6
hours before, provided this is light food.
Patients being fed via a nasogastric or gastrostomy tube should have
their feed stopped 6 hours prior to surgery but they are able to have water up
to 2 hours before surgery.
The key principles of the ERAS protocol include pre-operative
counselling, preoperative nutrition, avoidance of perioperative fasting and
carbohydrate loading up to 2 hours preoperatively, standardized anesthetic and
analgesic regimens (epidural and non-opiod analgesia) and early mobilization.
This involves the use of clear carbohydrate drinks the day prior to surgery and
up to 2 hours before. In addition to the metabolic effects, it facilitates
accelerated recovery through early return of bowel function and shorter
hospital stay, ultimately leading to an improved perioperative well-being
(Melnyk, Casey, Black, & Koupparis, 2011).
 15

D. LEGAL AND PROFESSIONAL ISSUES

1. Namebands/ Identification Bands

 are fundamental in the identification of patients.
 Includes date of birth, in the format dd/mm/yyyy, name (surname
first in capitals followed by the first name with the first letter in
capitals) and the patient’s ID number

2. Preoperative Pregnancy Testing

 Surgery and anaesthesia can cause congenital abnormalities or
spontaneous abortion during the early gestation period has shown
that there is no increase in the rate of congenital defects.
 Recent guidelines suggest that all women who are able to bear
children should undergo pregnancy testing preoperatively to rule
out this possibility.

3. Prevention of toxic shock syndrome from tampon use

 Toxic shock syndrome (TSS) is a rare, life-threatening bacterial
infection. It happens when the bacteria Staphylococcus aureus and
Streptococcus pyogenes, which normally live harmlessly on the
skin, enter the body’s bloodstream and produce poisonous toxins.
 Female patients of menstruating age therefore need to be made
aware of the dangers of using tampons which can cause infection
leading to toxic shock syndrome.
 At the time of admission it is important to ask patients if they are
menstruating and to highlight the dangers of using tampons during
surgery.
 If these are left in situ for longer than 6 hours, infection may
develop.
 Nurses can offer a sanitary pad as an alternative.

4. Assessment of latex allergy

 Latex is a natural rubber composed of proteins and added
chemicals.
 Its durable, flexible properties give it a high degree of protection
from many micro-organisms, which make it an ideal fibre to use
for many healthcare products.
 It is found in the following products
1. Gloves.
2. Airways.
3. Intravenous tubing.
4. Stethoscopes.
5. Catheters.
6. Dressings and bandages.
 If a suspected or confirmed latex sensitivity or allergy is
found, this information must be communicated to all
members of the healthcare team and departments that the
patient may visit, including theatre, recovery, pathology
and radiology
 The anaesthetist will need to be informed so that decisions
can be made regarding potential allergy prophylaxis
preoperatively

E. SURGICAL SITE
Table 1.3. Surgical Site
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SURGICAL SITE
Prepare to clean the surgical site with Hair should be shaved only if it will
mild antibacterial soap as prescribed interfere with the procedure and as
prescribed.
Prepare to shave the operative site

Traditionally perioperative preparation has included the removal of body

hair from the planned surgical wound site. Hair can interfere with the exposure
of the incision, suturing and application of tape or dressings as well as
increasing the risk of acquiring a surgical site infection (SSI) due to its
associated bacteria.
Three methods of hair removal are currently used.
1. Shaving
 using a sharp blade held within a razor which is drawn over the
patient’s skin to cut hair close to the skin’s surface.
2. Clipping
 using clippers with fine teeth to cut hair to about 1 mm from
patient’s skin. Heads of clippers are either disposable or
disinfected.
3. Chemical depilation
 using chemicals to dissolve hair. Cream needs to remain in contact
with skin for 5–20 minutes. There is a risk of causing irritation or
allergic reaction so a patch test needs to be carried out 24 hours
before cream applied.

Research suggests that SSI can be associated when clients’ hair is

removed before surgeries. Then, some research concluded shaving is not
advisable and found to cause cuts and abrasions whereby micro-organisms can
enter and colonize these cuts, contaminating the surgical sites, and any
exudate produced provides a culture medium which can cause postoperative
wound infections.
If hair will interfere with the surgical procedure and removal is essential
then the following best practice is advised.
 Hair removal should be done on the day of surgery, in a location outside
the operating room such as the anaesthetic room or ward.
 Only hair interfering with the surgical procedure should be removed.
 Depilation creams or clipping should be used to remove hair instead of
shaving.
 If clipping is used then the clipper should be single-use electric or
battery operated, or a clipper with a reusable head that can be
disinfected between patients.
 If using clippers it is recommended to do this on the day of surgery.

F. SITE MARKING
 It may be that the surgeon needs to mark an area of the body for
surgery.
 This is normally a limb to be operated on or the position of an organ
such as a specific kidney in a patient undergoing a nephrectomy.
 The marking should be undertaken by the surgeon performing the
operation or a deputy who will be present at the surgery, using an
indelible pen, to ensure the correct site is marked and this should be
checked against the patient’s consent form.

G. PSYCHOSOCIAL PREPARATION
 Be alert to the client’s level of anxiety.
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 Answer any questions or concerns that the client may have regarding
surgery.
 Allow time for privacy for the client to preparepsychologically for
surgery.
 Provide support and assistance as needed.
 Take cultural aspects into consideration when providing care.

H. PATIENT EDUCATION
 Patient education not only meets patients’ information needs but
also assists in reducing anxiety levels and promotes the patients’
well-being
 Patient information booklets can also help patients to gain a greater
understanding of surgery and what is expected of them.
 Preoperative education can address some of the patients’ concerns
and fears. As pain and anaesthesia are patients’ greatest worries,
they need to be discussed in the preoperative period so that anxiety
can be reduced which may result in patients requiring less analgesia.
 Preoperative visiting by recovery staff allows patients to ask
questions, which could help them to manage their anxiety and
provide baseline information about patients, which is important for
effective management postoperatively, for example, of pain.

Information about the equipment and intravenous access extension sets

that the patient will be attached to postoperatively should also be provided to
ensure they know what to expect and are fully informed as this can be
disconcerting to both the patient when they return from theatre and the
patient’s relatives when they see them immediately post surgery. Additional
information on when the patient will be expected to mobilize, when they can
eat and drink and the length of time they can expect to be in hospital is also
important at this time.

Table 1.4. Preoperative Teaching

Preoperative Teaching
1. Inform the client about what to expect postoperatively.
2. Inform the client to notify the nurse if the client experiences any pain
postoperatively and that pain medication will be prescribed and given as the
client requests. The client should be informed that some degree of pain
should be expected and is normal.
3. Inform the client that requesting an opioid after surgery will not make the
client a drug addict.
4. Demonstrate the use of a patient-controlled analgesia (PCA) pump if
prescribed.
5. Instruct the client how to use noninvasive pain relief techniques such as
relaxation, distraction techniques, and guided imagery before the pain
occurs and as soon as the pain is noticed.
6. The nurse should instruct the client not to smoke (for at least 24 hours
before surgery);
7. Smoking cessation treatments and programs.
8. Instruct the client in deep-breathing and coughing techniques, use of
incentive spirometry, and the importance of performing the techniques
postoperatively to prevent the development of pneumonia and atelectasis.
See procedure for incentive spirometry. REVIEW TECHNIQUES OF DBE.
REVIEW THE PROCEDURE FOR INCENTIVE SPIROMETRY FOUND IN
OXYGENATION MODULE.
9. Instruct the client in leg and foot exercises to prevent. Review Leg and foot
 18

exercises venous stasis of blood and to facilitate venous blood return.

Review leg and foot exercises. REVIEW LEG AND FOOT EXERCISES.
10.Instruct the client in how to splint an incision, turn, and reposition.
REVIEW PROCEDURES ON SPLINTING INCISION.
11.Inform the client of any invasive devices that may be needed after surgery,
such as a nasogastric tube, drain, urinary catheter, epidural catheter, or IV
or subclavian lines.
12.Instruct the client not to pull on any of the invasive devices; they will be
removed as soon as possible.

I. PREOPERATIVE CHECKLIST

Table 1.5. Preoperative Checklist

PREOPERATIVE CHECKLIST
1. Ensure that the client is wearing an identification bracelet.
2. Assess for allergies, including an allergy to latex
3. Review the preoperative checklist to be sure that each item is addressed
before the client is transported to surgery.
4. Follow agency policies regarding preoperative procedures, including
informed consents, preoperative checklists, prescribed laboratory or
radiological tests, and any other preoperative procedure.
5. Ensure that informed consent forms have been signed for the operative
procedure, any blood transfusions, disposal of a limb, or surgical
sterilization procedures.
6. Ensure that a history and physical examination have been completed and
documented in the client’s record.
7. Ensure that consultation requests have been completed and documented
in the client’s record.
8. Ensure that prescribed laboratory results are documented in the client’s
record.
9. Ensure that electrocardiogram and chest radiography reports are
documented in the client’s record.
10.Ensure that a blood type, screen, and crossmatch are performed and
documented in the client’s record within the established time frame per
agency policy.
11.Remove jewellery, makeup, dentures, hairpins, nail polish (depending on
agency procedures), glasses, and prostheses.
12.Document that valuables have been given to the client’s family members
or locked in the hospital safe.
13.Document the last time that the client ate or drank.
14.Document that the client voided before surgery.
15.Document that the prescribed preoperative medications were given
16.Monitor and document the client’s vital signs.

J. Preoperative Checklist
 Please refer to Sample Preoperative Checklist in

Sample Preoperative Orders

 19

NOTE:
All things must be carried out that would include, scheduling the
patient for the procedure and OR notifications follow. Laboratories must
be carried out and laboratory in-charge must be notified. Treatments must
be administered during admission and medications should be given as
ordered in accordance with preferred time of the surgeon. Patient
education must be considered preoperatively.

K. ARRIVAL IN THE OPERATING ROOM

1. Guidelines to prevent wrong site and wrong procedure surgery
a. The surgeon meets with the client in the preoperative area and
uses indelible ink to mark the operative site.
b. In the operating room, the nurse and surgeon ensure and
reconfirm that the operative site has been appropriately marked.
c. Just before starting the surgical procedure, a time-out is
conducted with all members of the operative team present to
identify the correct client and appropriate surgical site again.
2. When the client arrives in the operating room, the operating room nurse
will verify the identification bracelet with the client’s verbal response
and will review the client’s chart.
3. The client’s record will be checked for completeness and reviewed for
informed consent forms, history and physical examination, and allergic
reaction information.
4. The surgeon’s prescriptions will be verified and implemented.
5. The IV line may be initiated at this time (or in the preoperative area), if
prescribed.
6. The anesthesia team will administer the prescribed anesthesia.
 20

II. INTRAOPERATIVE NURSING NURSING CARE

 Intraoperative care is the physical and psychological care given to the

patient in the anaesthetic room and operating theatre until transfer to
the recovery room.
 The intraoperative period begins when the patient enters the surgical
suite (operating room [OR]) and ends at the time of transfer to the
postanesthesia recovery area, SDS unit, or ICU.

A. The Operating Room Environment

The unit is sterile and organized environment. As a member of

perioperative team, you are required to enter the operating room either
preparing a surgical procedure or during the procedure. It is mainly significant
to know when to enter the Operating Room or not.

Each members of surgical team have to work hard to ensure safety and care
of the surgical patients. This is to:
 To ensure that the patient understands what will happen in the operating
theatres at all times in order to minimize anxiety.
 To ensure that the patient has the correct surgery for which the consent
form was signed.
 To ensure patient safety at all times and minimize postoperative
complications by:
1. giving the required care for the unconscious patient
2. ensuring injury is not sustained from hazards associated with the use
of swabs, needles, instruments, diathermy and power tools
3. minimizing postoperative problems associated with patient
positioning, such as nerve or tissue damage
4. maintaining asepsis during surgical procedures to reduce the risk of
postoperative wound infection in accordance with hospital policies on
infection control.

B. ROLES OF INTRAOPERATIVE NURSE

1. Coordinates use of supplies, instrumentation and equipment for
operative care
2. Ensures equipment is functioning correctly
3. Maintains patient safety standards
4. Monitors, records and communicates patient's condition and needs with
the interdisciplinary team
5. Manages overall care of the patient before, during and after the surgical
procedure
6. Advocates on behalf of the patient
Documents preoperative and intraoperative care to be delivered in
accordance with the surgeon, hospital, and regulatory agencies
7. Evaluates, remediates and documents the surgical environment for
aseptic merit
8. Provides patient care with an understanding of age, culture-specific
needs
9. Addresses the biological, emotional, developmental, psychosocial and
educational status of the patient and his or her family and seeks to
address concerns
10.Coordinates professional development within their practice
11.Performs core job functions with minimal supervision
 21

C. PERSONNELS IN THE OPERATING ROOM

a. Sterile OR Personnel
1. Surgeon
2. Surgical assistant
3. Scrub nurse
b. Non-sterile OR Personnel
1. Anesthesiologist
2. Circulating nurse
3. Technologist, student, or observer
c. Functions Of Intraoperative Nurses
NOTE: REVIEW FUNCTIONS/ROLES OF:
1. Circulating Nurse
2. Scrub Nurse

D. TRAFFIC PATTERNS IN THE SURGICAL SUITE

Traffic control patterns suggest movement into, and out of, the
surgical suite, as well as movement within the suite.

 Unrestricted Area
 This includes corridors and rooms connected to public areas on
one side and often restricted areas on the other, including but not
limited to, employee locker room or lounge, PACU, and OR desk
area outside the red line. Street clothes are permitted in this
area.
 Semi-Restricted Area
 This area describes most of the peripheral support areas of the
surgical suites. Corridors, clean core, sub-sterile rooms,
anesthesia work room, and equipment storage are included in this
category. Traffic is limited to authorized personnel and patients
only. Surgical attire with head covering, jackets, and facial hair
covering is required.
 Restricted Area
 This includes the OR suites when sterile supplies are open. Scrub
attire, jackets if not scrubbed in, head and facial hair covering,
and masks will be worn in these areas. Compliance with Dress
Code Policy is required in these areas

GUIDELINES:
1. Patients entering the Operating Room will have clean linens and
wear gowns and their head should be covered with a disposable
bouffant. Patients are transported on stretchers or beds typically.
2. Doors to all operating room suites should remain closed once sterile
supplies are open through the completion of any surgical procedure.
This maintains proper air exchanges in each suite, optimizing the
infection control principles important to each procedure.
3. Factors within the suite that increase air turbulence, such as
movement, number of people in the room, talking, should be
minimized while sterile supplies are open or the patient is in the
suite.
 22

4. Life threatening patient emergencies or fire and safety hazards may

necessitate modification of traffic control practices. Appropriate
accommodations are at the discretion of the staff in the room to
best care for the patient.
5. Movement of clean and sterile supplies/equipment should be
separated as much as possible from soiled equipment/waste by
space, time or traffic patterns. Clean and sterile supplies will be
transported to the OR using the clean elevator from the Sterile
Processing Department. They may be transported in a covered, open
cart, or hand carried.
6. Materials are removed from external shipping
containers/boxes/cartons or uncovered in an unrestricted area
before transfer to an OR area. Shipping containers, etc. are subject
to dust, insects, and the like, which can transfer to this restricted
area. Outside cardboard boxes are not permitted in semi-restricted
or restricted areas.
7. If equipment is brought in from outside, it will be wiped down with
an approved disinfectant prior to moving into the semi-restricted
area. It is the responsibility of the person using that equipment to
do so. Soiled supplies, instruments, equipment needing
reprocessing, trash, and soiled linen are contained in the OR suite
or immediately adjacent to the suite, prior to transport. All items
are transported through the semi-restricted corridor to the
appropriate receiving location. Covering of these items is as
important during transport as clean or sterile items. All used/soiled
items are taken to the soiled utility area. Linen and waste is placed
in corresponding receptacles, while instruments and equipment
needing reprocessing are transported up the soiled utility elevator
in a closed cart to the decontamination area in SPD (Sterile
Processing Department).
8. Clean or unused items needing to be returned to the clean areas are
placed in the Core for return or "put away."
9. Hallways must be kept clear for safe passage of patients and proper
allowances for fire/emergency egress.
10.The exit door leading to the stairwell in the back of the department
is activated with an audible alarm if opened, either from the inside
or outside. It stops alarming when closed, but access is restricted to
authorized personnel only. This door should not be used for entry.
11.Clean supplies and deliveries are received at the door near the
nurse's station on the second floor.
12.Clean instrument carts and internally delivered supplies are
transported via the clean elevator from SPD.
13.Other equipment or supplies may be delivered/picked up directly to
the Soiled utility using the side door entrance from PACU. This may
include trash receptacles, recycle containers, and pathology
specimens.

E. INTRAOPERATIVE CARE: ANESTHESIA

 23

When the patient is transferred and received to the operating room, the
Anesthetist/anesthesiologist and preop nurse/circulating nurse are then
responsible at this point. In the guidelines of the Royal Marsden Hospital
Manual of Clinical procedures, the patient is then anesthetized at anesthesia
room bvefore transferring to the operating theatre. The WHO UNIVERSAL
SURGICAL SAFETY CHECKLIST is then utilized.
When the patient arrives in the anaesthetic room, it is important to
check the patients and their details to ensure that the correct patient is being
received. At this point, consent is verified with the patient and the final phase
of the preoperative checklist is completed to ensure that it is the correct
patient. This is the final patient check prior to commencing surgery and is
crucial to ensuring the patient’s safety.
The Sign In part is done before the ansthesia induction. There are
various techniques of administering anesthesia depending on the plan of care
with the scheduled procedure. (Review types of anesthesia administration)

F. UNIVERSAL SURGICAL SAFETY CHECKLIST

The purpose of this safety checklist is to ensure that the correct
procedure is performed on the correct patient, encourage team work and
improve communication amongst the surgical teams from all disciplines. The
safety checklist comprises three parts: sign in, time out and sign out Sign in is
completed in the anaesthetic room before the patient.

Sign-In (Before Anesthesia)

Your surgical team will review the Sign-In checklist before you go into
the operating room. As your team goes through each step on the list, do not
hesitate to speak up if you think there has been an error or if you would like
clarification.

1. Confirming Your Identity

 During Sign-In, the nurse or anesthesiologist will ask your name to ensure
that it matches your medical record and the consent form you signed for
surgery.
2. Planned Surgical Site, Procedure and Surgical Consent
 Your surgical team will ask you to confirm everything about your planned
surgery, including the incision site and the type of surgery planned. You
will be asked to verify that everything you said is the same information
that is on the surgical consent form.
3. Proper Surgical Site Marking
 You will be asked to verify that the incision site previously marked by
your surgeon is correct.
4. Medication Allergies
 You will be asked to confirm all of your allergies to medications.

5. Anesthesia Checklist
 Your anesthesiologist will ask you several important questions to help
them prepare you for anesthesia. Tell your anesthesiologist if you or a
member of your family has had an adverse reaction to anesthesia during
previous surgeries.
6. Preparing for a Blood Transfusion
 Your surgical team will confirm with you that you have completed
specific blood tests, or in some cases, pre-donated blood, in the event a
blood transfusion is needed.

Time-Out (Before Skin Incision)

 24

When you are in the operating room, your surgical team will use the
Time-Out checklist to share important information about you and your
upcoming surgery. During this time, the team will be very quiet and attentive
to make sure that everything is correct.

1. Team Member Introductions

 To improve communication during your surgery, all the members of your
surgical team will introduce themselves to each other by name and role.
2. Reconfirm Surgical Consent
 Your surgeon, anesthesiologist, and nurse will review your surgical
consent together one final time to make sure that everything is correct.
3. Review of Surgical, Nursing and Anesthesia Plans
 During Time-Out, each member of your surgical team will review with the
others his or her respective plan for your procedure. For example, the
surgeon will review the surgical plan with the nurse, and make sure all is
ready, including any devices or implants, or special considerations.
4. The nursing team will review the nursing plan—double-checking the planned
procedure and needed instruments, equipment, implants, and anything
special you might need during your surgery.
 Also during this time, the anesthesiologist will review the anesthesia plan
to make sure everything is ready for you, and ensure that special
equipment is available, if needed.
5. Giving Antibiotics
 In many cases, antibiotics are given before surgery to reduce the chance
of infection. If it has been determined that antibiotics are needed in your
case, the team will confirm that the drugs have been given prior to
starting surgery.

Sign-Out (Before Leaving the Operating Room)

After your surgery is finished, but before you leave the operating room,
your surgical team will use the Sign-Out checklist to complete medical record
documentation and to address anything that could be made better for future
surgical cases.

1. Recording Your Procedure

 The nurse will check with the surgeon to make sure that the specific
details of your procedure are clearly documented in your medical
record. This documentation could include the operation performed,
the anesthetic used, types of implants, blood loss, and any
complications that occurred.
2. Counting the Instruments, Needles and Sponges
 To minimize the chance of leaving any surgical items in your wound,
the team will check to make sure that all instruments are accounted
for and that needle and sponge counts are correct.

3. Labeling of Specimens
 If tissue or fluid samples were collected during your procedure for
later testing, your team will check to make sure each specimen is
labeled correctly with your name and the test to be run before it is
sent to the lab.
4. Equipment Check
 After your surgery is completed, your operating team will inspect all
the equipment used to make sure that it is processed properly so that
it is available for future cases.
5. Discussing a Postoperative Recovery Plan
 25

 The team will discuss all of your needs to make your recovery a
smooth one. With your surgery fresh in their minds, they will discuss
and record routine or special orders to identify and minimize any
potential problems that may occur. All of this is done with the goal of
giving you the best chance possible to fully recover.
G. INTRAOPERATIVE CARE: THEATRE

The team in theatre includes the anaesthetist, surgeon, registrar,

anaesthetic assistant, scrub and circulating assistant. Once the patient has
been transferred and positioned on the operating table, before surgical
intervention, the theatre team will complete the second section of the safety
checklist which is ‘time out’. This ensures that the team is fully aware and
readily equipped for any eventuality that may arise during the procedure. WHO
checklist (part 2) ‘Time out’ has to be read out loud for all team members to
hear and respond to and has to be completed before the start of the surgical
intervention, that is skin incision

1. Preoperative Consideration in the Operating Room

 Equipments
In the operating room the staff should ensure that all equipment
is ready and checked before the first patient is sent for.
a. Anaesthetic machine and vital signs monitor
 This allows the anaesthetists to administer the correct dosage of
oxygen and air whilst the monitor displays what is happening to
the cardiovascular system such as heartbeat, blood pressure and
also the level of oxygen in the blood.
b. Suction unit
 This is attached to the anaesthetic machine and will help in the
event of obstruction or aspiration due to vomit.
c. Vaporizer
 This is also attached to the anaesthetic machine and helps to
administer inhaling anaesthetic agents. This allows the patient to
remain asleep during the procedure.
d. Scavenging system
 This absorbs and draws away all the anaesthetic gases that the
patient exhales so it is important to ensure that this is
operational. If it isn’t the exhaled gases would be released into
the air and can be harmful to the staff.
e. Operating table
 As part of the equipment check, the operating table is assessed to
ensure it is fully operational and performs all the required
functions to enable correct positioning of the patient. It is also
possible to adjust the height of the operating table in relation to
the height of the surgeon and team to prevent any unnecessary
strain on the back and neck. The power to the table is provided
by a battery. This is charged overnight via the mains.
f. Diathermy machine/ Cautery Machine
 Diathermy is used routinely during surgery to control haemorrhage
by sealing bleeding vessels or cutting body tissues. It uses heat
from electricity and this is achieved by passing normal electrical
current through the diathermy machine and converting it into a
 26

NAME: BIRTHDATE AGE: SEX NAME OF PROCEDURE: DATE:

_______________________________________ __/__/__ ________ MALE/FEMALE HOSPITAL #:

WHO UNIVERSAL SURGICAL SAFETY CHECKLIST PROTOCOL

SIGN IN TIME OUT SIGN OUT
PRIOR TO INDUCTION OF ANESTHESIA BEFORE SKIN INCISION BEFORE THE PATIENT LEAVES THE OPERATING ROOM
(WITH AT LEAST NURSE AND ANESTHETIST) (WITH NURSE, ANESTHETIST, AND SURGEON) (WITH NURSE, ANESTHETIST, AND SURGEON)
 Patient Confirmed  Confirmed All Team Members Have Introduced Nurse verbally confirms with the team
 Identity Themselves By Name And Role  The name of the procedure recorded
 Site  Surgeon, Anesthesia Professional, And Nurse Verbally  That instrument, sponge, and needle counts are
 Procedure Confirmed correct(or not applicable)
 Consent  Patient  How specimen is labelled (including patient’s name)
 Site  Whether there are equipment problems needed to be
 Site marked/ not applicable  Procedure address
 SURGEON, ANESTHESIA PROFESSIONAL, AND NURSE
 Anesthesia Safety Check Completed ANTICIPATED CRITICAL EVENTS REVIEW THE KEY CONCERNS FOR RECOVERY AND
 Surgeon Reviews: What Are The Critical Or Unexpected MANAGEMENT OF THIS PATIENT
 Pulse Oximeter on Patient and Functioning Steps, Operative Duration, Anticipates Blood Loss CONFORME
 Anesthesia Team Reviews: Are There Any Patient-
Does patient have a Specific Concerns?
Known allergy?  Nursing Team Reviews: Has Sterility (Including Signature over printed name
 No Indicator Results) Been Confirmed? Are There Equipment Surgeon
 Yes Issues Or Any Concerns?
Signature over printed name
Difficult Airway/ Aspiration Risk Has Antibiotic Prophylaxis Has Been Given Within The Anesthetist
 No Last 60 Minutes?
 Yes, and Equipment and Assistance Available  Yes
 Not Applicable Signature over printed name
Risk of >500mL Blood loss Scrub Nurse
(7mL/Kg in Children)? Is Essential Imaging Been Displayed?
 No  Yes
 Yes, Adequate Intravenous Access And Fluid  Not Applicable Signature over printed name
Planned Circulating Nurse
 27

 high frequency alternating current. There are two types of diathermy.

 Monopolar: this works by producing current from an active
electrode such as diathermy forceps, which are insulated so
that the skin does not come into contact with metal, and then
returned back to the machine through another electrode such
as a patient diathermy plate/pad. This creates a complete
circuit.
 Bipolar: this does not require a patient diathermy plate/pad.
It works by current coming from the machine down one side of
the forceps prong, through the tissue and back to the machine
through the other side of the forceps prong.

H. PRINCIPLES OF STERILE TECHNIQUE

1. Only sterile items are used within the sterile field.
 Items such as sterile instrument sets, drapes, sponges and basins are
obtained from the sterile core.
2. Sterile persons are Gowned and Gloved.
 Gowns are considered sterile only from the chest to the level of the
sterile field in the front, and from 2 inches above the elbows to the
cuffs and sleeves. When wearing a gown, only the area that can be
seen in front down to the level of the sterile field should be
considered sterile.
3. Tables are sterile only at Table level
 Only the top of a sterile and draped table is considered sterile. The
edges and sides of the drape extending below the table are considered
contaminated.
4. Sterile persons touch only sterile items or areas, while unsterile persons
touch only unsterile items and areas.
 Supplies are brought to sterile team mebers by the circulator, who
opens the wrappers using aseptic technique. The curculator ensures a
sterile transfer to the sterile field.
5. The edges of anything that encloses sterile contents are considered
unsterile.
6. The sterile field is created as close as possible to the time of use.
7. Sterile areas are continuously kept in view.
8. Sterile persons keep well within the sterile area.
9. Sterile persons keep contact with sterile areas to a minimum.
10.Unsterile persons avoid sterile areas.
11.Destruction of the integrity of Microbial barriers results in contamination.
 The integrity of a sterile package or sterile drape is destrpyed by
perforation, puncture, or strike-through.
12.Microorganisms must be kept to an irreducible minimum.
 All possible means are used to prevent the entrance of
microorganisms into the wound. Preventive measures include the
following:
a. Mechanical washing and chemical antisepsis.
b. Gowning and gloving of the OR team is accomplished
without contamination of the sterile exterior of gowns and
sloves.
c. Sterile gloved hands do not directly touch the skin and then
touch deeper tissues. Instruments used in contact with skin
are discarded and not reused.
 28

Procedure 1.1 Surgical Hand Asepsis

PROCEDURES
1. Remove rings, watches, and bracelets before beginning surgical scrub.
2. Use a deep sink with side or foot pedal to dispense antimicrobial soap and control
water temperature and flow.
3. Have two surgical scrub brushes and nail file.
4. Apply surgical shoe covers and a cap to cover hair and ears completely.
5. Apply mask.
6. Before beginning surgical scrub:
a. Open sterile package containing gown; using aseptic technique, make a sterile
field with inside of gown’s wrapper.
b. Open sterile towel and drop it onto center of field.
c. Open outer wrapper from sterile gloves and drop inner package of gloves onto
sterile field beside folded gown and towel.
7. At a deep sink under warm, flowing water, wet hands, beginning at tips of
fingers, to forearms – keeping hands at level above elbows. Prewash hands and
forearms to 2 inches above elbow.
8. Apply liberal amount of soap onto hands and rub hands and arms to 2 inches
above elbows.
9. Use nail file under running water; clean under each nail both hands, and drop file
into sink when finished.
10. Wet and apply soap to scrub brush, if needed. Open prepackaged scrub brush, if
available. Hold brush in dominant hand, use a circular motion to scrub nails and all
skin areas of nondominant hand and arm(10 strokes to each of following areas):
a. Nail
b. Palm of hand and anterior side of fingers.
11. Rinse brush thoroughly and reapply soap.
12. Continue to scrub nondominant arm with a circular motion for 10 strokes each
to lower, middle, and upper arm; drop brush into sink.
13. Maintaining hands and arms above elbow level, place fingertips under running
water and thoroughly rinse fingers, hands, and arms (allow water to run off elbow
into sink); take care not to get uniform wet.
14. Take second scrub brush and repeat Actions 10 – 13 on dominant hand and arm.
15. Keep arms flexed and proceed to area (operating or procedure room) with
sterile items.
16. Secure sterile towel by grasping it on one edge, opening towel, full length,
making sure it does not touch uniform.
17. dry each hand and arm separately; extend one side of towel around fingers and
hand and dry in a rotating motion up to elbow:
18. Reverse towel and repeat same action on other hand and arm, thoroughly drying
skin.
19. Discard towel into a linen hamper.

Procedure 1.2. Applying Sterile Gloves and Gown via the Closed Method
PROCEDURES
Gowning
 29

1. Wash hands/hand hygiene.

2. Sterile gown is folded inside out.
3. Grasp gown inside neckline, step back, and allow gown to open in front of you;
keep inside of gown toward you; do not allow it to touch anything.
4. With hands shoulder level, slip both arms into gown; keep inside sleeves of gown.
5. Circulating nurse will step up behind you and grasp inside of gown, bring it over
your shoulders, and secure ties at neck and waist.
Close Gloving
6. With hands still inside gown sleeves, open inner wrapper of gloves on sterile
gown field.
7. With nondominant sleeved hand, grasp glove cuff for dominant hand and lay it on
extended dominant forearm; with palm up; place palm of glove against sleeved
palm, with fingers of glove pointing toward elbow.
8. Manipulate glove so that sleeved thumb of dominant hand is grasping cuff; with
nondominant hand, turn cuff over end of dominant hand and gown’s cuff.
9. With sleeved nondominant hand, grasp glove cuff and gown’s sleeve of dominant
hand; slowly extend fingers into glove, making sure glove cuff remains above gown
sleeve cuff.
10. With gloved dominant hand, repeat Actions 7 and 8.
11. Interlock gloved finger; secure fit.
12. Wash hands/hand hygiene.
Image 1.1 Sample Gowning Procedure

Image 1.2 Sample Close Gloving Technique Procedure

 30

Procedure 1.3. Applying Sterile Gloves via the Open Method

PROCEDURES
1. Wash hands/hand hygiene.
2. Place inner wrapper onto a clean, dry surface. Open inner wrapper to expose
gloves.
3. Identify right and left hand; glove dominant hand first.
4. Grasp cuff with thumb and first two fingers of nondominant hand, touching only
inside of cuff.
5. Pull glove over dominant hand, making sure thumb and fingers fit into proper
spaces.
6. With the gloves dominant hand, slip fingers under cuff of other glove, gloved
thumb abducted, making sure it does not touch any part on nondominant hand.
7. Slip the glove onto nondominant hand, making sure fingers slip into proper
spaces.
8. With gloved hands, interlock fingers to fit gloves onto each finger.
 If gloves are soiled, remove by turning inside out as described in the
following Actions:
9. Slip gloved fingers of dominant hand under cuff of opposite hand or grasp outer
part of glove at wrist if there is no cuff.
10. Pull glove down to fingers, exposing thumb
11. Slip uncovered thumb into opposite glove at wrist, allowing only glove – covered
fingers of hand to touch soiled glove.
12. Pull glove down over dominant hand almost to fingertips and slip glove on to
other hand.
13. With dominant hand touching only inside of other glove, pull glove over
dominant hand so that only the inside (clean surface) is exposed.
14. Dispose of soiled gloves.
15. Wash hands/hand hygiene.

I. SETTING UP A STERILE FIELD

 31

Aseptic procedures require a sterile area in which to work with sterile objects.
A sterile field is a sterile surface on which to place sterile equipment that is
considered free from microorganisms.
A sterile field is required for all invasive procedures to prevent the transfer of
microorganisms and reduce the potential for surgical site infections. Sterile fields can
be created in the OR using drapes, or at the bedside using a prepackaged set of
supplies for a sterile procedure or wound care. Many sterile kits contain a waterproof
inner drape that can be set up as part of the sterile field. Sterile items can be linen
wrapped or paper wrapped, depending on whether they are single- or multi-use.
Always check hospital policy and doctor orders if a sterile field is required for a
procedure.

J. COUNTING PROCEDURES
a. General Guidelines in Counting Instruments, Sharps, and Sponges
Counts are performed to account for all items and to lessen the
potential for injury to the patient as a result of a retained foreign body.
Complete and accurate counting procedures help promote optimal
perioperative patient outcomes and demonstrate the perioperative
practitioners’ commitment to patient safety.

Instrument, Sharp, and Sponge counts should be performed:

1. before the procedure to establish a baseline,
2. before closure of a cavity within a cavity,
3. before wound closure begins,
4. at skin closure or end of procedure, and
5. at the time of permanent relief of either the scrub person or the circulating
nurse.

 Sponge Count
 Sponges should be separated, counted audibly, and concurrently viewed
during the count procedure by two individuals, one of whom should be a
registered nurse circulator.
 When additional sponges are added to the field, they should be counted at
that time and recorded as part of the count documentation to keep the
count current and accurate.
 Perioperative personnel should count all prepackaged sterilized sponges for
accuracy. Any package containing an incorrect number of sponges should be
removed from the field, bagged, labeled, and isolated from the rest of the
sponges in the OR. Containing and isolating the entire package helps reduce
the potential for error in subsequent counts.
 Sponge counts should be conducted in the same sequence each time as
defined by the facility. The counting sequence should be in a logical
progression, (eg, from large to small or from proximal to distal).
 All sponges used during a surgical procedure should be x-ray detectable.
Radiopaque indicators facilitate locating an item presumed lost or left in
the surgical field when a count discrepancy occurs. X-ray detectable
sponges should not be used as dressings. 
 Towels without radiopaque markers should not be used in the wound. If
towels are used in the open wound, they should be included in the count as
a miscellaneous item, and should be easily distinguishable from other towels
on the sterile field.
 Sponges should be left in their original configuration and should not be cut.
 Nonradiopaque gauze dressing materials should be withheld from the field
until the wound is closed or the case is completed. Counted sponges should
not be used as postoperative packing
 32

 All counted sponges should remain within the OR or sterile field during the
procedure. 
 Sponges should be removed from the OR at the end of the procedure.

 Sharps and other miscellaneous items

 Initial sharps counts should be performed and recorded on all procedures.
 Sharps and miscellaneous items should be counted audibly and viewed
concurrently by two individuals, one of whom should be a registered nurse
circulator. 
 Accurately accounting for sharps during a surgical procedure is a primary
responsibility of the perioperative nurse and the surgical team members.
Additional sharps and miscellaneous items added to the field, should be
counted when added and recorded as part of the count documentation.
 Suture needles should be counted and recorded according to the number
marked on the outer package and verified by the scrub person when the
package is opened. Opening all packages during the initial needle count is
not recommended and would result in needles being exposed during the
entire surgical procedure. This creates an additional opportunity for lost or
retained needles during the procedure. 
 The scrub person should be able to account for all sharps on the sterile
field.
 Whenever possible, sharps must be handed to and from the surgeon on an
exchange basis using a neutral zone or hands free technique.
 Sharps counts should be conducted in the same sequence each time as
defined by the facility.
 Members of the surgical team should account for sharps or other
miscellaneous items that may have been broken or become separated within
the confines of the surgical site in their entirety. 
 All counted sharps should remain within the OR and/or sterile field during
the procedure. If a sharp is passed or dropped off the sterile field, the
circulating nurse should retrieve it in a safe manner, show it to the scrub
person, and isolate it from the field to be included in the final count. Linen
or waste containers should not be removed from the OR until all counts are
completed and resolved and the patient has been taken from the room.
Confinement of all sharps to the OR helps minimize the possibility of an
incorrect count.
 Sharps must be handled according to OSHA Bloodborne Pathogen Standards.
Proper use, handling, and disposal of contaminated sharps helps minimize
the risk of exposure to bloodborne pathogens from patient to health care
worker and from health care worker to patient.

 Instruments Count
 Instrument counts protect the patient by reducing the likelihood that an
instrument will be retained in the patient.
 Instruments should be counted when sets are assembled for sterilization.
This assembly count provides a basic reference for the instrument set and is
not to be considered the initial count before the surgical procedure. A count
performed outside the OR that is considered an initial count increases the
number of variables that can contribute to an inaccurate count and
unnecessarily extends responsibility to personnel not involved in direct
patient care.
 Initial counts in the OR establish a baseline for subsequent counts,
particularly with the increase in minimally invasive surgery and the
potential for additional procedures.
 33

 Individual pieces of assembled instruments (eg, suction tips, wing nuts,

blades, sheathes) should be accounted for separately on the count sheet.
 When additional instruments are added to the field, they should be counted
when added and recorded as part of the count documentation.
 Instruments should be counted audibly and viewed concurrently by two
individuals, one of whom should be a registered nurse circulator.
Concurrent verification of counts by two individuals assists in ensuring
accurate counts
 Members of the surgical team should account for instruments that may have
been broken or become separated within the confines of the surgical site in
their entirety. 
 Instrument counts should be conducted in the same sequence each time as
defined by the facility.
 All counted instruments should remain within the OR during the procedure
until all counts are completed and resolved. If a counted instrument is
passed or inadvertently dropped off the sterile field, the circulating nurse
should retrieve it, show it to the scrub person, and isolate it from the field
to be included in the final count. 
 All instruments should be accounted for and removed from the room during
end-of-procedure clean-up.
 Instrument sets should be standardized with the minimum types and
numbers of instruments needed for the procedure. Instruments that are not
routinely used on procedures should be deleted from sets.
 Preprinted count sheets that are identical to the standardized sets should
be used to record the counted items. 
 Contaminated instruments must be handled according to OSHA Bloodborne
Pathogen Standards.

 Documentation of counts
 Counts should be recorded on a count sheet or nursing record.
 The names and positions of the personnel performing the counts should be
recorded on the count sheet and in the patient's record.
 The results of surgical counts should be recorded as correct or incorrect.
 Instruments and sponges intentionally left with the patient should be
documented on the count sheet and in the patient's record.
 Any action taken in the event of a count discrepancy or incorrect count
should be documented in the patient's record. Reasons for not conducting a
count in cases that normally demand a count should be documented in the
patient's record.

 Count Discrepancies
 When a discrepancy in the count(s) is identified, the surgical team is
responsible for carrying out steps to locate the missing item. Count
discrepancy reported to surgeon; Procedure suspended, if patients condition
permits;
 The perioperative registered nurse circulator and scrubbed person should
ask the surgeon to conduct a manual search of the wound to locate the
missing item(s). The scrubbed person and circulator should do a manual and
visual search, respectively, of the sterile area surrounding the wound and
the remainder of the sterile field. The circulator should conduct a search of
the nonsterile areas of the room in an attempt to locate the item(s).
 Visual inspection of the area surrounding the surgical field, including floor,
kick buckets, and linen and trash receptacles;
 34

 If unable to reconcile the counts, they should immediately notify the

surgeon and the operating room supervisor and conduct a search for the
missing item, including the patient, floor, garbage and linen
 intraoperative x-ray taken and read before patient leaves the OR, if the
patients condition permits;  If the item is not recovered, an intraoperative
x-ray should be taken and read prior to the final closure of the wound. The
purpose of the x-ray should be specified to rule out retained foreign body
(eg, needle, sponge, instrument). Studies show greater accuracy when x-
rays are read by a radiologist. In the case of missing needles, there is no
definitive evidence as to how effective x-rays are in detecting small suture
needles. Studies done in recent years have demonstrated that needles 17
mm and smaller may not be consistently visible on x-ray.
 Following institutional policy, documentation of an incorrect count should
include all the measures taken to recover the missing item and
communications made regarding the outcome. This is considered a sound
professional practice and demonstrates that all reasonable efforts were
made to protect the patients safety The circulating registered nurse should
inform and receive an acknowledgment from the surgeon as soon as it is
known that any part of the surgical count (ie, sponge, sharp, instrument) is
incorrect.
 A critical investigation should be conducted of any patient safety incident
process. Error and near miss reporting are the first steps to addressing error
reduction.

K. PRINCIPLES OF DRAPING
1. Place Drapes on a dry area. The area around or under the patient may become
damp from solutions used for skin preparation. The circulator moves damp
items or covers the area to provide a dry field on which to lay sterile drapes.
2. Allow sufficient time to permit careful application.
3. Allow sufficient space to observe sterile technique. Do not reach across a
nonsterile surface.
4. Handle drapes as little as possible.
5. Never reach across the operating bed to drape the opposite side, go around it.
6. Take towels and towel clips, if used, to the side of the operating bed from
which the surgeon is going to apply them before handling them to her or him.
7. Carry folded drapes to the operating bed. Watch the front of the sterile gown;
it may bulge and touch the nonsterile operating bed or blanket on the patient.
Stand well back from the nonsterile operating bed.
a Hold drapes high enough to avoid touching nonsterile areas, but avoid
touching the overhead operator light.
b Hold a drape high until it is directly over the proper area, and then lay it
down where it is to remain. Once a sheet is placed, do not adjust it. Be
careful not to slide the sheet out of place when opening the folds.
c Protect gloved hands by cuffing the end of the sheet over them. Do not let
gloved hands touch the skin of the patient.
8. In unfolding a sheet from the prepped area toward the foot or head of the
operating bed, protect the gloved hand by enclosing it in a turned back cuff of
sheet provided for this purpose. Leep hands at table level.
9. If a drape becomes contaminated, do not handle it further. Discard it without
contaminating gloves or other items.
a. If the end of a sheet falls below waist level, do not handle it further.
Drop it, and use another.
b. If in doubt as to its sterility, consider a drape contaminated.
c. If a drape is incorrectly placed, discard it. The circulator peels it from
the operating bed without contaminating other drapes or the prepped
area.
 35

10.A towel clip has been fastened through a drape has its point contaminated.
Remove it only if absolutely necessary, and then discard it from the sterile
setup without touching the points. Cover the area from which it was removed
with another piece of sterile draping material.
11.If a hole found in a drape after it is laid down, the hole must be covered with
another piece of draping material or the entire drape is cancelled.
12.A hair found on a drape must be removed, and the area must be covered
immediately. Although hair can be sterilized, the source of a hair is usually
unknown when it is found on a sterile drape. It would cause a foreign body
tissue reaction in a patient if it got into the wound. Remove the hair with a
hemostat, and hand the instrument off the sterile field; cover the area with a
towel or another piece of draping material.

After setting up the sterile field, and all surgical team members don scrubbing
and gowning, the part 2-Sign Out of the checklist can be done before commencing the
surgical procedure.

Prior to transfer to POSTANAESTHETIC Recovery Unit

Once the procedure in the operating room has been completed and the patient
is ready to be transferred to the postanaesthetic unit, the final part of the WHO
checklist (part 3) has to be completed. This is done before any member of the team
can leave the operating theatre.

Transfer of patient from operating theatre to POST-ANAESTHESIA CARE

UNIT

The patient is accompanied from the operating theatre to the post-anaesthesia

care unit (PACU) with the anaesthetist and the scrub assistant. They will refer to the
theatre care plan which would have identified care given during the procedure. The
anaesthetic assistant will ensure that the patient is monitored for heart rate and
oxygen saturations during the transfer and also that portable suction is available.

III. POST-OPERATIVE CARE

Postoperative care is the management of a client after surgery and includes

care given during the immediate postoperative period as well as during the days
following surgery.

The goal of postoperative care is to prevent complications, to promote healing

of the surgical incision, and to return the client to a healthy state.

A. ROLES OF PACU NURSE

1. Monitor patient vital signs as they wake from anesthesia 
2. Treat pain, nausea, and other patient post-op symptoms and any side
effects of anesthesia
3. Comfort patients who awaken scared or confused after surgery
4. Work with an interdisciplinary medical team
5. Document and keep the team informed of the patient’s progress
6. Educate the patient and family on post-surgery care

a. Equipment required in the PACU

 36

Speed, efficiency and economy of movement are essential when time becomes
a critical factor in the ultimate safety of the patient in the recovery room.

 Basic equipment for monitoring airway maintenance

 wall-mounted piped oxygen with tubing and facemask (with both
fixed and variable settings), a T-piece and full range of oral and
nasopharyngeal airways. Spare oxygen cylinders with flow meters
should also be available in case of piped oxygen failure.

 Suction
 regulator with tubing and a range of oral and endotracheal suction
catheters. An electric-powered portable suction machine should also
be available in case of pipeline vacuum failure.

 Sphygmomanometer and stethoscope

 automatic blood pressure recorders are a valuable means of saving
time and minimizing disturbance to patients, especially those in pain
or disorientated,leaving the nurse’s hands free to attend to other
needs.
 However, such equipment can be non-functioning in certain cases, for
example shivering or profoundly bradycardic patients, or if electrical
and mechanical failure occurs. Therefore, manual equipment must
always be available.

 Pulse oximeter

 Miscellaneous items
 receivers, tissues, disposable gloves, sharps container and waste
receptacle.

Upon receiving the patient at the PACU, PACU Nurse should know what is
needed to be prioritized

Table 1.6. Nursing Consideration And Assessment Of System

Review Nursing consideration and assessment of system
1. Respiratory System
2. Cardiovascular System
3. Musculoskeletal system
4. Neurological System
5. Temperature Control
6. Integumentary System
7. Fluid and Electrolyte balance
8. Gastrointestinal system
9. Renal System
10.Pain Management

Gerontologic Considerations
 Elderly patients continue to be at increased risk for postoperative
complications. Age-related physiologic changes in respiratory, 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.
 37

 Careful monitoring of electrolyte, hemoglobin, and hematocrit levels and urine

output is essential because the older adult is less able to correct and
compensate for fluid and electrolyte imbalances. Elderly patients may need
frequent reminders and demonstrations to participate in care effectively.

Table 1.7. Postoperative Complication

Postoperative Complication
1. Pneumonia and atelectasis
2. Hypoxemia
3. Pulmonary embolism
4. Hemorrhage
5. Shock
6. Thrombophlebitis
7. Urinary retention
8. Constipation
9. Paralytic ileus
10.Wound infection

Patient Care during Immediate Postoperative Phase: Transferring the Patient from
RR to the Surgical Unit

B. Discharge from PACU

Discharge from the recovery room is the responsibility of the anaesthetist but
the recovery staffs are responsible for keeping the anaesthetist informed about any
changes in the patient’s condition that may arise during the recovery phase. This
could be cardiovascular, respiratory or the level of consciousness. The recovery staff
uses the discharge criteria as an assessment tool to determine whether the patient
has achieved optimum recovery to enable them to return to the ward safely.
However, if there are any changes in the patient’s condition, this needs to be
discussed with the anaesthetist who should assess the patient before their return to
the ward.
The length of patient stay in the recovery room is dependent on the patient’s
cardiovascular and respiratory condition and the rate at which that patient recovers
physically and emotionally from the anaesthetic. A prior knowledge of the patient’s
cardiovascular and respiratory parameters as well as past medical history obtained
through preoperative contact is of great value when assessing their return to normal
state. It also has the advantage of helping the patient to orientate to time and place,
as familiarity generates a degree of security and confidence. The patients must meet
the criteria below before they can be discharged from the recovery room to the ward.

Table 1.8. Discharge criteria from PACU to ward

Discharge criteria from PACU to ward
1. The patient is fully conscious, able to maintain own airway, exhibits
protective airway reflexes and is orientated.
2. Respiratory function and good oxygenation are being maintained.
3. The cardiovascular system is stable with no unexplained cardiac irregularity.
The specific values of pulse and blood pressure are within normal
preoperative limits on consecutive observations.
4. There is no persistent or excessive bleeding from wound or drainage sites.
5. Patients with urinary catheters have passed adequate amounts of urine
(more than 0.5 mL/kg/h)
6. Pain and emesis should be controlled and suitable analgesia and antiemetic
regimes should be prescribed by the anaesthetist
7. Body temperature is at least 36oC
 38

C. ALDRETE’S SCORING SYSTEM 

 a commonly used scale for determining when people can be safely discharged
from the POST-ANESTHESIA CARE UNIT (PACU) to either the postsurgical ward
or to the second stage (Phase II) recovery area.
 was devised in 1970 by Jorge Antonio Aldrete, a Mexican anesthesiologist, while
working at the Denver's Veterans Affairs Hospital.
 The evaluation, also known Post Anesthesia Recovery (PAR), focuses on the
following directions:
 Muscle activity is assessed by observing the patient’s ability to move his
extremities, spontaneously or on command. This is helpful in the
evaluation of patients with subarachnoid or epidural blocks.
 Respiratory efficiency reflected the respiratory effort.
 Circulation is evaluated through systemic blood pressure and compared
to the preanesthetic level.
 Consciousness is reflected by full alertness and ability to answer
questions.
 Tegument color evaluates whether the skin aspect is normal or cyanotic
or jaundiced.

Table 1.8. Aldrete’s Point Scale

Criteria Point value
Consciousness Fully awake (2)
Arousable (1)
Not responding (0)
Activity Able to move four extremities (2)
Able to move two extremities (1)
Able to move 0 extremities (0)
Respiration Able to breathe deeply and Coughs freely (2)
Dyspnea, shallor or limited breathing (1)
Apnea (0)
Circulation Systemic BP ≠ 20% of the preanesthetic level (2)
Systemic BP between 20% and 49% of the preanesthetic level
(1)
Systemic BP ≠ 50% of the preanesthetic level (0)
Oxygenation SpO2 92% on Room Air
SpO2 > 90% on Oxygen
SpO2 < 90% on Oxygen

Score interpretation
 Each of the five items in the Aldrete score calculator is awarded from 0 to 2
points, depending on the answer chosen in the evaluation. The higher the
score, the more likelihood of recovery without need of observation.
 Results vary between 0 and 10. Patients with scores of 9 and 10 can be safely
discharged from PACU.
 Scores of 10 indicate, according to the original study, a patient in the best
condition. Scores of 7 and below come with indication of continuous close
observation.

D. Discharge planning
 39

All patients, whether short- or long-stay, those with few needs or those with
complex needs, should receive comprehensive discharge planning. Postoperatively,
discharge planning needs to be tailored to the individual needs of the patients,
particularly in relation to advice and information on recovery and self-management.

E. Discharge teaching
1. Discharge teaching should be performed before the date of the scheduled
procedure.
2. Provide written instructions to the client and family regarding the specifics
of care.
3. Instruct the client and family about postoperative complications that can
occur.
4. Provide appropriate resources for home care support.
5. Instruct the client not to drive, make important decisions, or sign any legal
documents for 24 hours after receiving general anesthesia.
6. Instruct the client to call the surgeon, ambulatory center, or emergency
department if postoperative problems occur.
7. Instruct the client to keep follow-up appointments with the surgeon.

Table 1.9. Postoperative Discharge Teaching

Postoperative Discharge Teaching
1. Assess the client’s readiness to learn, educational level, and desire to
change or modify lifestyle.
2. Assess the need for resources needed for home care.
3. Demonstrate care of the incision and how to change the dressing.
4. Instruct the client to cover the incision with plastic if showering is allowed.
5. Ensure that the client is provided with a 48-hour supply of dressings for
home use.
6. Instruct the client on the importance of returning to the surgeon’s office for
follow-up.
7. Instruct the client that sutures usually are removed in the surgeon’s office 7
to 10 days after surgery.
8. Inform the client that staples are removed 7 to 14 days after surgery and
that the skin may become slightly reddened when staples are ready to be
removed.
9. Sterile adhesive strips (e.g., Steri-Strips) may be applied to provide extra
support after the sutures are removed.
10.Instruct the client on the use of medications, their purpose, dosages,
administration, and side effects or adverse effects.
11.Instruct the client on diet and to drink 6 to 8 glasses of liquid a day.
12.Instruct the client about activity levels and to resume normal activities
gradually.
13.Instruct the client to avoid lifting for 6 weeks if a major surgical procedure
was performed.
14.Instruct the client with an abdominal incision not to lift anything weighing
10 pounds or more and not to engage in any activities that involve pushing
or pulling.
15.The client usually can return to work in 6 to 8 weeks depending on the
procedure and as prescribed by the surgeon.
16.Instruct the client about the signs and symptoms of complications and when
to call the surgeon.

F. Ambulatory Care or 1-Day Stay Surgical Units

1. General criteria for client discharge
2. Is alert and oriented.
 40

3. Has voided.
4. Has no respiratory distress.
5. Is able to ambulate, swallow, and cough.
6. Has minimal pain.
7. Is not vomiting.
8. Has minimal, if any, bleeding from the incision site.
9. Has a responsible adult available to drive the client home
10.The surgeon has signed a release form.

SURGICAL UNITS NURSE’S NOTES: PREOPERATIVE

Date/ Focus D-A-R Signature
Shift/
Time
July 13, Acute pain related D: S> "Masakit yung tyan ko sa may
2020 to obstructed bandang kanan" as verbalized by the
7-3am appendix. patient" and reports pain rating as 7/10.
7:05 am O> received patient on bed with ongoing
IVF of D5LRS 1L to run for 8 hrs at full
level hooked at left metacarpal vein using
IV Catheter g. 18; scheduled for Elective
Appendectomy at 8 AM. VS of BP 110/70
mmHg; RR 19 cpm; PR 82 bpm; andT 37.2
o
C;
A: Established rapport; regulated IVF
accordingly; monitored VS and recorded;
preoperative care rendered; verified
surgery schedule, patient identification
band, chart, and signed operative
consent for surgical procedure; Noted
pain rating including duration, location
and intensity; Provided preoperative
education, including visit with OR
personnel before surgery; Inform patient
or SO of nurse’s intraoperative advocate
role; asked the patient to void prior to
transfer to OR; Provided comfort
measures to decrease pain level such as
back rub and deep breathing.
Administered preoperative medications as
ordered; Prevent unnecessary body
exposure during transfer and in OR suite;
Introduced staff at time of transfer to
operating suite.
8:10 am D: >Reported pain rating as 7/10;
>endorsed to Operating Room Nurse with
same IVF mentioned above; for
emergency Appendectomy;

OR NURSES NOTES
Date/ Focus D-A-R Signature
Shift/
Time
July 14, Intraoperative Care D: Into OR a 29y/o male accompanied by
2020 Surgical Unit nurse, SO, and transporter
7-3 per stretcher; with ongoing IVF of D5LRS
 41

8:15AM at 900mL level infusing well at left arm;

for Appendectomy with signed informed
consent attached to chart under the
service of DR. Tuazon with initial VS of BP
110/70 mmHg; RR 19 cpm; PR 82 bpm;
and 37.2 oC
8:30 am A: Sign In Done; transferred to OR table
and ensured safety by placing straps;
administered O2 inhalation at 3Lpm by
nasal cannula; placed electrodes and
attached to cardiac monitor; attached
pulse oximeter at left index finger; BP
cuff attached to arm; positioned to right
side lying with knee flexed; lumbar prep
8:44 am done aseptically; Subarachnoid block
inducted by Dr. De Leon; patient
positioned to supine; Initial count of
instruments, sponges, and sutures done;
inserted IFC aseptically and connected to
urine bag; abdominal skin prep done
aseptically; draping done aseptically;
WHO Surgical Safety Checklist (Time-
9:10 am out)done; an incision made at Mc Burney's
point by Dr Tuazon assisted by Dr. Silva
whereas operation started; Deepening of
incision done; handover instruments to
surgeon accordingly; anticipated the
needs of surgical team; bleeders clamped
and sponged blood; suctioned blood;
retractors applied for better visualization
of operative site done; dissection done;
appendix identified; grasped appendix;
9:15 am ligation and dissection; extracted
appendix; Specimen Out (appendix);
bleeders check; homeostasis; Counting of
instruments, sponges, and sutures done
before closing of cavity, correct and
complete; suturing started layer by layer;
needs of the patient attended; Final
count of instruments, sponges, and
sutures done correct and complete; ;
9:37 am suturing done whereby operation ended;
Povidone Iodine applied to wound and
sterile dressings applied and secured;
estimated blood loss recorded;
postoperative care rendered initially;
Sign Out done; Transferred patient to
stretcher and ensured safety; estimated
blood loss recorded;
R: Forwarded to PACU per stretcher
status post Appendectomy with ongoing
IVF of D5LRS 1L at 500 ml level infusing
well at left arm; with intact IFC
connected to Urine bag draining clear
colored urine; with intact clean dressing;
endorsed to PACU for postoperative care
 42

and management.

PACU Notes
Date/ Focus D-A-R Signature
Shift/
Time
July 14, Immediate Into OR a 29 year old male per
2020 Postoperative Care stretcher status post
7-3 appendectomy under SAB/
10:00 spinal anesthesia
am accompanied by Circulating
Nurse and Anesthesia Resident
in charge; with ongoing IVF
D5LRS 1L at 500 ml level
infusing well at Left arm;
with intact IFC connected to
Urine bag; with intact surgical
dressing;
A: Transferred to PACU bed
and ensured safety; hooked to
O2 inhalation via nasal
cannula at 2-3; kept warm
with blanket; Assessed airway
patency and level of
consciousness; monitored vital
sign, muscle activity status;
circulatory status, pain status,
and level of sensation after
regional anesthesia; assessed
surgical site;
thermoregulated; due
medications given as
indicated; ALDRETE's Criteria
for PACU Discharge done with
8 score; referred to
anesthesiologist for discharge
and carried out thereafter.
R: Stable vital signs; patent
airway; no active bleeding;
transferred to Surgical Unit
via stretcher and endorsed
accordingly for further
postoperative care and
management;

SURGICAL UNITS NURSE’S NOTES: POSTOPERATIVE CARE (WARD)

Date/ Focus D-A-R Signature
Shift/
Time
July 14, Acute Pain related S; "Masakit sa may kanang
2020 to presence of bahagi ng tyan ko" as
7-3 surgical incision verbalized by the patient"
2:30 PM Secondary to > Pain rating as 4/10
Appendectomy as
 43

evidenced by O: Received patient as

reports of pain. endorsed by PACU Nurse with
ongoing IVF of D5LRS 1L
infusing well at left arm;
conscious and coherent at
700mL level; On oxygen
inhalation at 3Lpm; Status
post Appendectomy; VS of BP
130/80 mmHg; RR 20 cpm;
PR 96 bpm; and T 36.4 oc; 02
Sat 97%
Transferred to unit bed and
ensured safety; regulated IVF
accordingly; administered
oxygen inhalation via nasal
cannula at 2-3 Lpm;
Assessed patency of airway
and LOC; Assess pain, noting
location, characteristics,
severity (0–10 scale)and
report changes in pain as
appropriate. Inspected
surgical dressing; Keep NPO
as ordered; administered
analgesics and due
medications as indicated;
Encourage early ambulation
as possible. Provided
diversional activities; Placed
ice bag on abdomen
periodically during initial 24–
48 hr, as appropriate. Watch
closely for possible surgical
complications.
R: Report pain is controlled.
No signs and symptoms of
surgical complications; with
clean surgical dressing;
endorsed to next shift for
further postoperative nursing
care and management.

Common Instruments in Obstetrics and Gynecological procedure

Blades Scissors
 #10 blade, #3 handle  Mayo Straight
 #20 blade, #4 handle  Mayo Curve
 Metzembaum
Forceps Clamps
 1 Long Thumb  Kelly curves
 1 Long Tissue  Allis
 Heaney Forceps  Bobcock
 Singley  kocher
 Adson  Pean
 Russian  Heaney
 44

Retractors Sutures
 Army Navy  Vicryl 3.0
 Richardson  Vicryl 1.0
 Balfour  Chromic 2.0
 Bladder Retractor  Plain 2.0
 Free Ties

Lesson 2

SKILLS LABORATORY ACTIVITIES

In this section, you will find the skills laboratory activities that you will
accomplish. You are expected to send a video or have a virtual return demonstration
with your assigned Clinical Instructor. Checklists are included as your guide to
perform the said activities and it will serve as your evaluation. Videos about the skills
that you will perform are to be uploaded in the google classroom. Your performance
in each skill will be graded and recorded. Good luck and God Bless.

I. SURGICAL HAND ASEPSIS

Name:_______________________________Date:_________Section/Group: _________

Surgical Hand Asepsis

CHECKLIST
Legend:
3-Done
2-Done with Supervision
1-Not Done
PROCEDURES 3 2 1 0
1. Remove rings, watches, and bracelets before beginning surgical scrub.
2. Use a deep sink with side or foot pedal to dispense antimicrobial soap and
control water temperature and flow.
3. Have two surgical scrub brushes and nail file.
4. Apply surgical shoe covers and a cap to cover hair and ears completely.
5. Apply mask.
6. Before beginning surgical scrub:
a. Open sterile package containing gown; using aseptic technique, make a
sterile field with inside of gown’s wrapper.
b. Open sterile towel and drop it onto center of field.
c. Open outer wrapper from sterile gloves and drop inner package of gloves
onto sterile field beside folded gown and towel.
7. At a deep sink under warm, flowing water, wet hands, beginning at tips of
fingers, to forearms – keeping hands at level above elbows. Prewash hands and
forearms to 2 inches above elbow.
8. Apply liberal amount of soap onto hands and rub hands and arms to 2 inches
above elbows.
9. Use nail file under running water; clean under each nail both hands, and drop
file into sink when finished.
10. Wet and apply soap to scrub brush, if needed. Open prepackaged scrub
brush, if available. Hold brush in dominant hand, use a circular motion to scrub
nails and all skin areas of nondominant hand and arm(10 strokes to each of
following areas):
 45

a. Nail
b. Palm of hand and anterior side of fingers.
11. Rinse brush thoroughly and reapply soap.
12. Continue to scrub nondominant arm with a circular motion for 10 strokes
each to lower, middle, and upper arm; drop brush into sink.
13. Maintaining hands and arms above elbow level, place fingertips under
running water and thoroughly rinse fingers, hands, and arms (allow water to run
off elbow into sink); take care not to get uniform wet.
14. Take second scrub brush and repeat Actions 10 – 13 on dominant hand and
arm.
15. Keep arms flexed and proceed to area (operating or procedure room) with
sterile items.
16. Secure sterile towel by grasping it on one edge, opening towel, full length,
making sure it does not touch uniform.
17. dry each hand and arm separately; extend one side of towel around fingers
and hand and dry in a rotating motion up to elbow:
18. Reverse towel and repeat same action on other hand and arm, thoroughly
drying skin.
19. Discard towel into a linen hamper.

For the next items, evaluate the students in general according to the criteria. (5
as the highest score)
5- Excellent
4- Very Satisfactory
3- Satisfactory
2- Unsatisfactory
1- Needs Improvement

5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.

Student’s Name and Signature: ______________________________________

Evaluator’s Name and Signature: ____________________________________

Comments:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________
 46

II. APPLYING STERILE GLOVED VIA THE OPEN METHOD

Name:____________________________________Date:________Section/Group:____

Applying Sterile Gloves via the Open Method

CHECKLIST
Legend:
3-Done
2-Done with Supervision
1-Not Done
PROCEDURES 3 2 1 0
1. Wash hands/hand hygiene.
2. Place inner wrapper onto a clean, dry surface. Open inner wrapper to
expose gloves.
3. Identify right and left hand; glove dominant hand first.
4. Grasp cuff with thumb and first two fingers of nondominant hand,
touching only inside of cuff.
5. Pull glove over dominant hand, making sure thumb and fingers fit into
proper spaces.
6. With the gloves dominant hand, slip fingers under cuff of other glove,
gloved thumb abducted, making sure it does not touch any part on
nondominant hand.
7. Slip the glove onto nondominant hand, making sure fingers slip into
proper spaces.
8. With gloved hands, interlock fingers to fit gloves onto each finger.
 If gloves are soiled, remove by turning inside out as described in the
following Actions:
9. Slip gloved fingers of dominant hand under cuff of opposite hand or grasp
outer part of glove at wrist if there is no cuff.
10. Pull glove down to fingers, exposing thumb
11. Slip uncovered thumb into opposite glove at wrist, allowing only glove –
covered fingers of hand to touch soiled glove.
12. Pull glove down over dominant hand almost to fingertips and slip glove
on to other hand.
13. With dominant hand touching only inside of other glove, pull glove over
dominant hand so that only the inside (clean surface) is exposed.
14. Dispose of soiled gloves.
15. Wash hands/hand hygiene.

For the next items, evaluate the students in general according to the criteria. (5
as the highest score)
5- Excellent
4- Very Satisfactory
3- Satisfactory
2- Unsatisfactory
1- Needs Improvement

5 4 3 2 1
Mastery
Orderliness
 47

Proper attitude in assessing the client followed.

Ability to answer questions
Proper reporting observed.

Student’s Name and Signature: ______________________________________

Evaluator’s Name and Signature: ____________________________________

Comments:________________________________________________________________
__________________________________________________________________________
_________________________________________________________
 48

III. APPLYING STERILE GLOVED AND GOWN VIA THE CLOSED

METHOD

Name: _______________________________ Date: ________Section/Group: _______

Applying Sterile Gloves and Gown via the Closed Method

CHECKLIST
Legend:
3-Done
2-Done with Supervision
1-Not Done
PROCEDURES 3 2 1 0
Gowning
1. Wash hands/hand hygiene.
2. Sterile gown is folded inside out.
3. Grasp gown inside neckline, step back, and allow gown to
open in front of you; keep inside of gown toward you; do not
allow it to touch anything.
4. With hands shoulder level, slip both arms into gown; keep
inside sleeves of gown.
5. Circulating nurse will step up behind you and grasp inside of
gown, bring it over your shoulders, and secure ties at neck and
waist.
Close Gloving
6. With hands still inside gown sleeves, open inner wrapper of
gloves on sterile gown field.
7. With nondominant sleeved hand, grasp glove cuff for dominant
hand and lay it on extended dominant forearm; with palm up;
place palm of glove against sleeved palm, with fingers of glove
pointing toward elbow.
8. Manipulate glove so that sleeved thumb of dominant hand is
grasping cuff; with nondominant hand, turn cuff over end of
dominant hand and gown’s cuff.
9. With sleeved nondominant hand, grasp glove cuff and gown’s
sleeve of dominant hand; slowly extend fingers into glove,
making sure glove cuff remains above gown sleeve cuff.
10. With gloved dominant hand, repeat Actions 7 and 8.
11. Interlock gloved finger; secure fit.
12. Wash hands/hand hygiene.

For the next items, evaluate the students in general according to the criteria. (5
as the highest score)
5- Excellent
4- Very Satisfactory
3- Satisfactory
2- Unsatisfactory
1- Needs Improvement
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
 49

Ability to answer questions

Proper reporting observed.

Student’s Name and Signature: ______________________________________

Evaluator’s Name and Signature: ____________________________________

Comments:________________________________________________________________
__________________________________________________________________________
_________________________________________________________
 50

Surgical Unit
Case Analysis

Patient’s Profile:
Name: Juan Dela Cruz
Age: 44
Sex: Male
Address: Consolacion Agoo, La Union
Civil Status: Married
Occupation: Street Vendor
Race: Asian
Nationality: Filipino
Ethnicity: Ilocano
Religious Affiliation: Roman Catholic
Educational Attainment: High School Undergraduate
Birthday: March 24, 1975
Birth Place: Rosario, La Union
Chief Complaint: Abdominal Pain
Admitting Physician: Dr. J. Mamungay
Date and Time of Admission: September 29, 2020 @ 7:40 am
Hospital: La Union Medical Center

SITUATION

A 44-year-old man presents in the Emergency

Department with a 24-hour history of abdominal
pain that began approximately 1 hour after a
large dinner following a drinking session with
comrades. The pain initially began as a dull ache
in the epigastrium but then localized in the right upper quadrant (RUQ). He
describes some nausea but no vomiting. Since his presentation to this
department, the pain has improved significantly to the point being nearly pain
free. He describes having had similar pain in the past with all previous episodes
being self-limited. His past medical history is significant for type 2 diabetes
mellitus. On physical examination his vital signs are as follows. BP: 90/60 mm
Hg, RR: 25 cpm, PR: 60 bpm, temperature of 39.9 °C, Weight: 72 kg, and
Height 5’7”. The abdomen is distended with minimal tenderness in the RUQ.
Consent for admission to Surgical Unit and Care was obtained. The following
orders made and carried out accordingly by ED Nurse:

 To Surgical Unit
 Obtain Consent for admission
 NPO temporarily
 V/S every 4 hours
 Diagnostic
 CBC typing
 Blood typing
 Bilirubin, AST/ALT
 HBT Ultrasound
 Therapeutic
 PNSS1L x 8 hrs
 Ketorolac 30mg q6 RTC
 Paracetamol 600mg now then 300mg q4 for fever >38.5oC
 Omeprazole 40mg IV OD
 51

 HNBB in between doses of ketorolac for breakthrough pain

Hence, the patient was then forwarded to Surgical Unit.

SURGICAL UNIT

At 10:00 AM:

The Emergency Department called the Surgical Unit for admission of a

patient with presenting case mentioned above. You are assigned to Surgical
Unit and in-charge for this admission. Your patient diagnosis is Acute
Cholecystitis. Below are the results of tests done to your patient:

PARAMETER RESULT UNIT REF.RANGE PARAMETE RESULT UNIT REF.RANGE

R
Hemoglobin 108 g/L 120-160 MCV 76.5 Fl 80.0-100.0
Haematocrit 0.30 0.37-0.47 MCH 27.3 Pg 27.0-34.0

Erythrocytes 4.0 x10^9/L 4.0-5.4 MCHC 358 g/L 310-370

WBC 25.8 x10^9/L 4.0-10.0 RDW-CV 0.019 % 0.110-0.160

RDW-SD 50.7 FL 35.0-56.0

Differential IG# 0.3 %

count
Neutrophils 86.9 % 55.0-65.0 NRBC# 0.0 %

Lymphocytes 5.2 % 25.0-35.0

Monocytes 5.2 % 3.0-6.0

Eosinophils 01.9 % 2.0-4.0

Basophils 0.8 % 0.0-1.0

Platelet count 540 x10^9/L 150-450

HBT Ultrasound Findings

Findings from the liver

examination appear normal. The
rectal and pelvic examinations reveal
no abnormalities. Serum chemistry
studies demonstrate total bilirubin
0.8 mg/dL, direct bilirubin 0.6
mg/dL, (AST) 45 U/L, and alanine
transaminase (ALT) 30 U/L.
Ultrasonography of the RUQ
demonstrates stones in the
gallbladder, ( A)shows a markedly
dilated common bile duct measuring
1.65 cm ; (B) a large stone with
posterior acoustic shadowing in the
gallbladder; and (C) and a stone
within the common bile duct.
 52

10:20 AM

Your patient was seen and further assessed by Dr. Mamungay and reveals that
present signs and symptoms of Cholecystitis is still noted. You need to carry out the
new orders made by the aforementioned doctor. Below are the orders made:

 For Open Cholecystectomy, CBDE and IOC at 1430H;

 Secure informed consent for procedure
 Inform Operating Room for Scheduling
 Inform Anesthesiologist for Pre Anesthesia
 Notify Radiology for IOC
 Laboratory tests:
 Secure 2 ‘u’ Packed RBC, properly typed and cross matched
 Treatments/Assessments
 NPO
 Preoparative Vital Sign
 Preopartive Checklist
 No Shaving
 Incentive Spirometry Teaching
 Medication:
 Cafazolin 1gm IV 30minutes prior to OR ( )ANST.
 Ondansetron 4mg IV en route to OR.

ACTIVITY: APPLYING CRITICAL THINKING

Basing from the situation above carefully read and

then answer what is asked. Write your answer in a
separate sheet and send your answer to your respective
Clinical Instructor. Follow the templates provided and
see rubrics located in the appendix on how your activity
will be evaluated.

PART I. Accomplish the following activities.

1. List down at least 5 nursing diagnosis that you identify from the given situation.
Prioritize them accordingly.
2. Make 1 NCP with your most prioritized problem.
3. Based from the given ORDERS PREOPERATIVELY, list down the drugs indicated
for the client’s health status (include the medications ordered at the ED). Make a
complete drug study for each medication.
4. Create your FDAR documentation.
 Operating Room
Case Analysis

Operating Room

You are assigned as a Circulating/ Scrub Nurse in the operating Room for the
case of Mr. Juan Dela Cruz, 44, male, scheduled for Open Cholecystectomy, CBDE and
IOC at 1430H wiith IVF of . The Unit called the operating room that the patient is on
his way to the Operating Room. Your patient arrives at 1355H.

Accomplish the following activities:

Part I. Nurse’s Role

As a Scrub Nurse,

1. What are the things you need to prepare with this case? FOLLOW THE FORMAT
FOR OPERATING ROOM WRITE UP FOR THIS CASE. You list down the
miscellaneous such as sutures and sponges needed.

List of Instruments needed for this Operation.

List of Materials needed for this Operation(Sutures, Sponges, etc.,)

As Circulating Nurse

1. Based from the given situation, create FDAR documentation in accordance

with the operation of Mr. Dela Cruz. Utilize the time/sequence below for
your documentation.
Surgeon: J. Mamungay
Asst. Surgeon: R. Silva
Anesthesiologist: F. Reyes
Scrub Nurse: YOU
Circulating Nurse: YOU
 Arrival at the OR: 1355H
Sign In: 1400H
Anesthesia Plan: CSEA
Anesthesia Induction: 1405H
Time Out: 1425H
Operation Started: 1430H
Dye Introduction: 1500H
Removal of gallstones: 1520H
Extraction of Gallbladder: 1540H
Operation ended: 1610H

Part II. Critical Thinking.

1. When receiving the patient, you reviewed the informed consent was not yet
signed, your patient is not well informed about the procedure and the risks of
the operation is not discussed. You also checked that there is no patient
Identification band, there are no lab results attached in the chart, dentures
and nail polish are present. With this situation, what are your nursing actions?
Are you going to receive the patient, why or why not?

2. You accompanied your patient to Operating Room 1 for Open Cholecystectomy,

CBDE and IOC, and yet your surgeon and radiologist are not yet present, what
will you do? The schedule of the operation is at 1430H. What actions should be
made?

3. As a Circulating Nurse, you ensure that the WHO Surgical Safety Checklist is
properly and safely delivered, Sign In is done, and you are ready to start the
Time-Out. Your patient is already draped, but OR Team is not aware of this
procedure, and your Scrub Nurse handed the knife to your surgeon and about to
start without performing the Time-out. What action/s should be made? Is this
checklist important? Why or Why not?

4. During the operation, you notice that your Surgeon’s hand touches the light
source which is unsterile, what actions should be made?

5. As a scrub nurse, your surgeon is about to close the peritoneal cavity and you
have not counted your instruments, sponges, and needles. What actions should
be made?

6. When doing the counting of instruments, sponges, and needles, count

discrepancy is noted during the procedure, what actions should you made if
there is a missing instrument? List all the possible solutions
 MODULE SUMMARY

In this module, you have learned about Perioperative Nursing. You have
learned their meanings and importance. You have also learned how to assess,
plan and implement nursing care to a patient who will undergo operations.
Always remember to provide safe and quality nursing care to your patient.
Utilize your nursing process in dealing with patient who has problems in
oxygenation. Always observe bioethical concepts and principles and nursing
standards to protect and ensure safety not only to your patients but also to
yourself. Practice good and comprehensive documentation. Most importantly,
have a good relationship and rapport between the health care team that caters
the needs of your patient.

To sum it up, this module has two lessons. Lesson 1 discusses the
perioperative nursing care rendered to patient. Lesson 2 discusses about the
skills laboratory activities that you should learn and do.

Congratulations! You have just studied this Module.

CONGRATULATIONS!
You are now ready to move on to the next
module! God Bless!

REFERENCES
AORN. (2020). AORNs Recommended Practices for Sponge, Sharp, and
Instrument Counts is Up for Review.

Dougherty, L., & Lister, S. (2020). The Royal Marsden Hospital Mannual of
Clinical Nursing Procedures Student Edition 10th Edition. The Atrium,
Southern Gate, Chichester, West Sussex, PO19 8SQ, UK: John Wiley &
Sons Ltd.

Melnyk, M., Casey, R. G., Black, P., & Koupparis, A. (2011). Enhanced recovery
after surgery (ERAS) protocols: Time to change practice? Canadian
Urological Association Journal, 342-348.

WHO. (2020). Safe Surgery. Retrieved from

https://www.who.int/teams/integrated-health-services/patient-
safety/research/safe-surgery&publication=9789241598552

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M.

(2018). Medical-Surgical Nursing: Concepts for Interprofessional
Collaborative Care 9th Edition. Missouri: Elsevier.

Lemone, P., Burke, K., Bauldoff, G., Gubrud , P. (2017). Medical-Surgical

Nursing: Critical Thinking for Person-Centered Care 3 rd Edition.
Melbourne: Pearson Australia
 APPENDIX A
SAMPLE OF OPERATING ROOM WRITE UP

OPERATING ROOM WRITE UP

Name: JUAN DELA CRUZ Year/Section/Group: BSN 3-A

Patient’s Name: MAKISIG MORALES Age: 16 Gender: MALE
Address: BRGY. SAPANG BATO, BAUANG LA UNION
Pre-op diagnosis: ACUTE APPENDICITIS
Post-op Diagnosis: ACUTE SUPPRATIVE APPENDICITIS STATUS
POST EMERGENCY APPENDECTOMY
Operation done: EMERGENCY APPENDECTOMY
Date of operation: SEPTEMBER 30, 2020 Type of Anesthesia: SAB
Time started: 8:30 AM Time Ended: 9:10AM
Surgeon:J. MAMUNGAY Anesthesiologist: F. CORPUZ
Scrub Nurse: MR. R. SILVA

History of the patient:

Five hours prior to admission, the patient experienced right lower quadrant
pain characterized as non- radiating, 8 in severity, aggravated by coughing and
when changing position. The patient seek medical consultation at LUMC
Emergency Department. He was seen by Dr. Mamungay, and physical
examination done. Presenting signs and symptoms of acute appendicitis was
noted. Hence, admitted and for ‘E’ Appendectomy.

Discussion of the disease/condition/pathophysiology:

Note:

You discuss the disease entity of disease/ operation/

You can focus your discussion on the pathophysiology of the disease through
algorithm.

For example, your case tackles Appendicitis; you can search the disease entity
or focus on pathophysiology of this case.

Discussion of the operation done:

Discuss the operation done.

For instance the case above tackles acute appendicitis and the operation is
appendectomy.
You may generally discuss the operation which is appendectomy, however in
the actual setting; you discuss the operation performed to your respective
patient.

Instruments: (separate sheet)

In this section, draw the instruments involved in this operation.

In this time, you may search on the required instruments for this case which is
appendectomy.

On the other hand, in the actual setting, you ONLY include instrument that is
used DURING your case.

For instance, the needed instruments for this case are surgical scissors (Mayo
Curve, Mayo Straight, Metzembaum), Richardson, Army Navy, Bobcock, Thumb
and Tissue Forceps, AND, Adson Forceps.

YOU MUST DRAW THE TIP OF THE INSTRUMENTS FOR BETTER IDENTIFICATION
AND CLASSIFICATION.

EXAMPLE:

Name and Signature of the Clinical Instructor: ____________________________

 APPENDIX B
OPERATING ROOM WRITE UP
OPERATING ROOM WRITE UP

Name: ___________________________________Year/Section/Group: _____________________

Patient’s Name: __________________________Age: ______ Gender: ______________________
Address: _________________________________________________________________________
Pre-op diagnosis: __________________________________________________________________
Post-op Diagnosis: _________________________________________________________________
Operation done: ___________________________________________________________________
Date of operation: ____________________________Type of Anesthesia ____________________
Time started: _________ Time Ended: ___________
Surgeon:_______________________________________ Anesthesiologist: ___________________
Scrub Nurse: __________________________________
History of the patient:

Discussion of the disease/condition/pathophysiology:

Discussion of the operation done:

 Instruments: (separate sheet)
Name and Signature of the Clinical Instructor: _______________________________________
 APPENDIX C
TEMPLATE FOR NURSING CARE PLAN

Don Mariano Marcos Memorial State University

South La Union Campus
COLLEGE OF COMMUNITY HEALTH AND ALLIED MEDICAL SCIENCES
Agoo, La Union
Tel. 072.682.0663/ichams.dmmmsu-sluc.com Care to learn, Learn to care
NURSING DEPARTMENT
Embracing World Class Standards

NURSING CARE PLAN

EXPLANATION OF THE
ASSESSMENT OBJECTIVE INTERVENTIONS RATIONALE EVALUATION
PROBLEM
 APPENDIX D
TEMPLATE FOR DRUG STUDY

Don Mariano Marcos Memorial State University

South La Union Campus
COLLEGE OF COMMUNITY HEALTH AND ALLIED MEDICAL SCIENCES
Agoo, La Union
Embracing World Class Standards
Tel. 072.682.0663/ichams.dmmmsu-sluc.com Care to learn, Learn to care
NURSING DEPARTMENT

DRUG STUDY
DRUG NAME (Generic DRUG MODE OF ACTION SIDE EFFECTS AND CONTRAINDICATION NURSING
Name, Brand Name, CLASSIFICATION ADVERSE REACTIONS MANAGEMENT/
Dose, Route, Dosage) CONSIDERATION
 APPENDIX E
RUBRICS FOR NCP

CRITERIA EXCEEDS MEETS NEARLY MEETS DOES NOT MEET SCORE

ECXPECTATIONS EXPECTATION EXPECTATIONS EXPECTATIONS
(8) (6) (4) (2)
Interview Correctly identifies Correctly identifies Correctly Correctly identifies
assessment five clear, specific four clear, identifies three two clear, specific,
includes subjective and relevant specific, and clear, specific, and relevant
and historical data interview relevant interview and relevant interview
that support (subjective) data (subjective) data interview (subjective) data
nursing diagnosis points. All data are points. All data are (subjective) data points. Data are
organized and are organized and/or points. Data are unorganized, and
related to a are mostly related marginally relevance to
nursing diagnosis. to a nursing organized, and nursing diagnosis is
diagnosis. relevance to unclear.
nursing diagnosis is
unclear.
Physical Correctly identifies Correctly identifies Correctly Correctly identifies
assessment five clear, specific, four clear, identifies three two clear, specific,
includes objective and relevant specific, and clear, specific, and relevant
data that support physical relevant physical and relevant physical (objective)
nursing diagnosis (objective) data (objective) data physical data points. Data
points. All data are points. All data are (objective) data are unorganized,
organized and are organized and/or points. Data are and relevance to
related to a are mostly related marginally nursing diagnosis is
nursing diagnosis. to a nursing organized, and unclear.
diagnosis. relevance to
nursing diagnosis is
unclear.
Nursing diagnosis Properly identifies Properly identifies Properly identifies Diagnoses are not
Includes relevant four or more three or fewer two or fewer NANDA approved,
NANDA approved nursing diagnoses nursing diagnoses nursing diagnoses appropriate for
diagnoses written that are clearly that are clearly that are clearly patient, or not
in proper form supported by the supported by the supported by the prioritized.
(includes stem, data and reflect data, and reflect data, and reflect Diagnosis may not
related to (RT), accurate clinical accurate clinical accurate clinical be clearly
and as evidenced judgment. They judgment. They judgment. They supported by
by (AEB) are appropriate for are appropriate for may not be assessment data.
the patient, well the patient, well appropriate for
prioritized, NANDA prioritized, NANDA the patient, well
approved, and approved, and prioritized, NANDA
written in correct written in correct approved, or
format. format. written in correct
format.
Outcomes / At least four short Three short- and Two or fewer short Goal portion is
planning including and long-term long-term goals are and long-term incomplete or
patient and family goals are identified identified that goals are completely
short- and long- that clearly relate clearly relate to identified. Goals unrelated to the
term goals based to the nursing the nursing may not relate to nursing diagnosis.
upon the diagnosis. diagnosis, are diagnosis, are the nursing
Goals must be written in a written in a diagnosis, may not
patient focused, patient-focused patient-focused be written in a
realistic, and have manner, and are manner, and are patient focused
clear measurable realistic. Each goal realistic. Each goal manner, or are
criteria with a contains clear contains clear unrealistic. Each
target date/time. criteria for criteria for goal is missing
measurement and measurement and a clear criteria for
a time frame for time frame for measurement and
evaluation evaluation. a time frame for
evaluation.
Implementation Identifies at least Identifies fewer Identifies fewer Interventions are
nursing three specific than three specific than three specific unclear or do not
interventions or interventions for interventions for interventions for clearly focus on
 actions that each outcome each outcome each outcome the etiology of the
directly relate to criterion in order criterion in order criterion related nursing diagnosis or
the etiology of the to help the to help the to the etiology of relate to the
nursing diagnosis patient/family patient/family the nursing patient goals
and the patient reach the desired reach the desired diagnosis. Not all outcomes.
goal and desired goal. goal. interventions may Rationales provided
outcome. Each be specific. do not demonstrate
intervention must Rationalizations an understanding
include referenced are included but of the purpose of
rationale (including they may be weak, the interventions
source and page or references are or no references
number if incomplete or are provided.
applicable) from sources that
may not be
reliable.
Evaluation outlines Evaluation portion Clearly states how Evaluation portion Evaluations portion
the methods to be contains data that each outcome does not is incomplete or
used in evaluating are listed as would be consistently does not relate to
outcome criteria, criteria in goal evaluated. Able to contain data that diagnosis, goal
expectations for statement and lists correctly identify are listed as statement, or
goals being met, expectations for criteria for goal criteria in goal interventions.
and what would meeting the goal. being met, statement. May
determine that Clear explanation partially met, or also not describe
goal is met, of criteria for goals unmet. Identifies goal as met,
partially met, or being met, revisions for care partially met, or
unmet. Explain partially met, or plan but may not not met. May also
how the plan of not met. Includes include accurate not include
care would be plan for rationale for revision or new
revised or continuation or revision, or evaluation
continued in each revision, clearly references may be date/time.
case, including a referenced from sources that
new realistic rationale for may not be
evaluation revisions from reliable, or a new
date/time. reliable sources, date is not
and a new provided for
evaluation reevaluation.
date/time.
Identification of Identifies, labels, Identifies, labels, Identifies, labels, Unable to identify,
the main and understands all and understands all and understands label, and
issues/problems relevant main but one or two all but three or understand
issues and/or relevant main four relevant main relevant main
problems. issues and/or issues and/or issues and/or
problems. problems. problems.
Linkage of course Excellent inquiry Good inquiry into Limited inquiry Incomplete or no
readings and other into the problems/ the into the problems/ inquiry into
resources to questions with problems/questions questions with problems/questions
problem/question clearly with clearly clearly with clearly
documented documented documented documented
linkages to the linkages to the linkages to the linkages to the
material read in material read in material read in material read in
class, other class, and/or other class, or other class, other
assigned resources, assigned resources, assigned assigned resources,
previously gained previously gained resources, previously gained
knowledge, and knowledge, and/or previously gained knowledge, and/or
outside resources. outside resources. knowledge, or outside resources.
outside resources.
Formatting, No errors in APA Minimum errors in May have some Multiple errors in
spelling, grammar citations or APA citation and errors in APA APA citations and
references. There references. There citations and references. There
are no mechanical are minimal references. There are multiple
errors such as mechanical errors are some mechanical errors
spelling, such as spelling, mechanical errors such as spelling,
formatting, and formatting, and such as spelling, formatting, and
grammar. grammar. formatting, and grammar.
grammar.
TOTAL: 72 points
 APPENDIX F
RUBRICS FOR DRUG STUDY

CRITERIA EXCEEDS MEETS NEARLY MEETS DOES NOT MEET SCORE

ECXPECTATIONS EXPECTATION EXPECTATIONS EXPECTATIONS
(20) (15) (10) (5)
Content discussion Contents are 50% of the contents 25% of the All data are
of the drugs accurate and are accurate and contents are incorrect and
correct. No data correct. Some data accurate and incomplete. No
are missing are missing. correct. Most of output given.
the data are
missing.
Formatting, No errors in APA Minimum errors in May have some Multiple errors in
spelling, grammar citations or APA citation and errors in APA APA citations and
references. There references. There citations and references. There
are no mechanical are minimal references. There are multiple
errors such as mechanical errors are some mechanical errors
spelling, such as spelling, mechanical errors such as spelling,
formatting, and formatting, and such as spelling, formatting, and
grammar. grammar. formatting, and grammar.
grammar.
TOTAL: 40 points
 APPENDIX G
RUBRICS FOR PRIORITIZATION

CRITERIA EXCEEDS MEETS NEARLY MEETS DOES NOT MEET SCORE

ECXPECTATIONS EXPECTATION EXPECTATIONS EXPECTATIONS
(8) (6) (4) (2)
Identification of Identifies, labels, Identifies, labels, Identifies, labels, Unable to identify,
the main and understands all and understands all and understands label, and
issues/problems relevant main but one or two all but three or understand
issues and/or relevant main four relevant main relevant main
problems. issues and/or issues and/or issues and/or
problems. problems. problems.
Nursing diagnosis Properly identifies Properly identifies Properly identifies Diagnoses are not
Includes relevant four or more three or fewer two or fewer NANDA approved,
NANDA approved nursing diagnoses nursing diagnoses nursing diagnoses appropriate for
diagnoses written that are clearly that are clearly that are clearly patient, or not
in proper form supported by the supported by the supported by the prioritized.
(includes stem, data and reflect data, and reflect data, and reflect Diagnosis may not
related to (RT), accurate clinical accurate clinical accurate clinical be clearly
and as evidenced judgment. They judgment. They judgment. They supported by
by (AEB) are appropriate for are appropriate for may not be assessment data.
the patient, well the patient, well appropriate for
prioritized, NANDA prioritized, NANDA the patient, well
approved, and approved, and prioritized, NANDA
written in correct written in correct approved, or
format. format. written in correct
format.
Prioritization of Prioritizes all the Prioritizes 5 actual Prioritizes 2 actual No prioritized
the Identified actual and and potential and potential problems. Unable
Problems based potential problems problems identified problems to identify actual
from NANDA identified based based from the identified based and potential
from the criteria: criteria: ABCs, from the criteria: problems.
ABCs, Maslow’s Maslow’s Hierarchy ABCs, Maslow’s
Hierarchy of of Needs, Patient’s Hierarchy of
Needs, Patient’s Complain, and Needs, Patient’s
Complain, and Urgency of the Complain, and
Urgency of the problem. Urgency of the
problem. problem.
Formatting, No errors in APA Minimum errors in May have some Multiple errors in
spelling, grammar citations or APA citation and errors in APA APA citations and
references. There references. There citations and references. There
are no mechanical are minimal references. There are multiple
errors such as mechanical errors are some mechanical errors
spelling, such as spelling, mechanical errors such as spelling,
formatting, and formatting, and such as spelling, formatting, and
grammar. grammar. formatting, and grammar.
grammar.
TOTAL: 32 points
 APPENDIX H
RUBRICS FOR OR WRITE-UP

Score

Preliminary profile complete 2 points

History of the patient thorough 5 points
Discussion of the disease
Comprehensive 5 points
Discussion of the operation
Accurate 5 points
Instruments drawn complete
And properly labelled 8 points
Total:
30 points
 APPENDIX I
RUBRICS FOR CASE ANALYSIS