University of San Jose-Recoletos

SCHOOL OF ALLIED MEDICAL SCIENCES

NURSING

Health Care Situations:

Global National Local
• Increasing mortality • Shortage of • Defiance to protocols
rate of COVID manpower (nurses, • Misleading and biased
• Racial doctors, etc.) information
Discrimination • PhilHealth scandal • Lack of facilities
• Economic • Overworked, (isolation centers)
degradation underpaid scheme • Unemployment
• Accessibility to • Shortage of facilities
drugs and vaccines & equipment
• Shortage of medical • Deployment ban of
frontliners nurses abroad

Chronic Conditions are often defined as
medical conditions or health problems with
associated symptoms or disabilities that require
long-term management (3 months or longer).
Chronic condition can also be defined as
illnesses or diseases that have a prolonged
course, that do not resolve spontaneously, and
for which complete cures are unlikely or rare
Which you prioritize patient, is it
Acute or Chronic?
Answer: Acute, because patient who had acute
diseases have complications
Disability is a restriction or lack of ability to
perform an activity in a normal manner; the
consequences of impairment in terms of an
individual's functional performance and activity.
Disabilities represent disturbances at the level of
the person (e.g. bathing, dressing,
communication, walking, grooming)
Adjustment to Chronic Illness (and disability) is
affected by various factors:
• Suddenness, extent, and duration of
lifestyle changes necessitated by the
illness
• Family and individual resources for
dealing with stress
• Stages of individual/family life cycle
• Previous experience with illness and
crises
• Underlying personality characteristics
• Unresolved anger or grief from the past
What is the manifestation if the
patient is depress?
Answer: Patient will isolate himself/herself and
experience anxiety
Depression:
• S- Sleep Pattern;
• I - Loss of Interest (Anhedonia)
• G - Guilt /Aggression
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NURSING

• E - Loss or Low of Energy • Keeping chronic conditions under control

• C - Loss of Concentration requires persistent adherence to
• A - Increase / Low Appetite therapeutic regimens
• P - Psychomotor Retardation • One chronic disease can lead to the
• S - Suicidal Ideation development of the other chronic
conditions
Common Misconception About Chronic • Chronic illness affects the entire family
Disease: • The day-to-day management of illness is
1. Everyone has to die of something largely the responsibility of people with
2. People can live to old age even if they lead chronic disorders and their families
unhealthy lives (smokers are obese). • The management of chronic conditions is
3. Solutions for chronic disease prevention a process of discovery
and control are too expensive to be • Managing chronic conditions must be a
feasible for low-income and middle- collaborative process that involves many
income countries, different health care professional working
4. There is nothing that can be done together with patients and their families
anyway; chronic diseases cannot be to provide the full range of services that
prevented. are often needed for management at
5. If individuals develop chronic disease as a home
result of unhealthy "lifestyles," they have • The managing of chronic conditions is
no one to blame but themselves. expensive
6. Certain chronic diseases, especially heart • Chronic conditions raise difficult ethical
disease, primarily affect men. issues for patients, families, health care
7. Chronic disease primarily affect the professionals, and society
elderly. • Living with chronic illness means living
8. Chronic disease mainly affect people who with uncertainty
are rich (affluent)
9. The priority of low-income and middle- Phases in the Trajectory Model of
income countries should be on control of Chronic Illness
infectious disease Phase Description Focus of
10. Chronic diseases affect mostly high- Nursing Care
income countries.
PRE- Generic factors Refer for
Characteristics of Chronic Conditions: TRAJECTORY or lifestyle genetic
• Managing chronic illness involves more behaviors that testing and
than treating medical problems place a person counseling if
• Chronic conditions usually involve many or community indicated;
different phases over the course of a at risk for a provided
person's lifetime
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SCHOOL OF ALLIED MEDICAL SCIENCES
NURSING

chronic education everyday life about health

condition about activities are promotion
prevention of being managed and
modifiable within participation
risk factors limitations of in health
and illness; illness promoting
behaviors. management activities and
centered in health
TRAJECTORY Appearance or Provide
home. screening.
ONSET onset of explanations
noticeable of diagnostic UNSTABLE Characterized Provide
symptoms tests and by an guidance and
associated with procedures exacerbation support;
a chronic and reinforce of illness reinforce
disorder; information symptoms, previous
includes period and development teaching.
of diagnostic explanations of
workup and given by complications,
announcement primary or reactivation
of diagnosis; health care of an illness
may be provider; remission.
accompanied provide
ACUTE Severe and Provide direct
by uncertainty emotional
unrelieved care and
as patient support to
symptoms or emotional
awaits a patient and
the support to the
diagnosis and family.
development patient and
begins to
of illness family
discover and
complications members.
cope with
necessitating
implications of
hospitalization,
diagnosis.
bed rest, or
STABLE Illness course Reinforce interruption of
and symptoms positive the person’s
are under behaviors and usual activities
control as offer ongoing to bring illness
symptoms, monitoring; course under
resulting provide control.
disability and education
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NURSING

CRISIS Critical or life- Provide direct DOWNWARD Illness course Provide home
threatening care, characterized care and
situation collaborate by rapid or other
requiring with other gradual community-
emergency health care worsening of a based care to
treatment or team condition; help patient
care and members to physical and family
suspension of stabilize decline adjust to
everyday life patient’s accompanied changes and
activities until condition. by increasing come to
crisis has disability or terms with
passed. difficulty in these
controlling changes.
COMEBACK Gradual Assist in
symptoms.
recovery after coordination
an acute of care; DYING Final days or Provide direct
period and rehabilitative weeks before and
learning to live focus may death; supportive
with or to require care characterized care to
overcome from other by gradual or patients and
disabilities and health care rapid shutting their families
return to an providers; down of body through
acceptable way provide processes, hospice
of life within positive biographical programs.
the limitations reinforcement disengagement
imposed by the for goals and closure,
chronic identified and and
condition or accomplished. relinquishment
disability; of everyday life
involves interests and
physical activities.
healing,
limitations Cultural and Health Ethnic Disparities
stretching and Culturally Competent Care
through • Culture is the knowledge, belief, art,
rehabilitative morals, laws, customs, and any other
procedure. capabilities and habits acquired by
humans as a member of society.
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NURSING
• Culturally Competent Nursing Care is an
effective, individualized care that
demonstrates respect for the dignity,
personal rights, preferences, beliefs, and
practices of the person receiving care,
while acknowledging the biases of the
caregiver and preventing these biases
from interfering with the care provided.
Ethnic Culture has Four Basic Characteristics:
• It is learned from birth through
language and socialization.
• It is shared by members of the same
cultural group, and it includes an internal
sense and external perception of
distinctiveness.
• It is influenced by specific conditions
related to environmental and technical
factors and to the availability of resources.
• It is dynamic and ever changing.
Transcultural Nursing (By Madeleine
Leininger):
• Acculturation
• The process by which members of
a cultural group adapt to or take
on behaviors of another group.
• The circumstances when a person
gives up the traits of his or her
culture of origin as a result of
context with another culture, to
variable degrees.
• Assimilation
• The process of accepting some of
the cultural practices or traits of
the prevailing culture into one's
own daily activities
• The gradual adoption and
incorporation of characteristics of
the prevailing culture
• Enculturation
• Socialize with our primary culture
(e.g. Sinulog Festival)
• A natural conscious and
unconscious conditioning process
of learning accepted cultural
norms, values, and roles in society
and achieving competence in one's
culture through socialization
• Ethnocentrism
• Superior culture than the other;
centralization of culture because
they believe they are superior
• The universal tendency of human
to think their ways of thinking,
acting, and believing are the only
right, proper, and natural ways.
• Cultural Blindness
• The inability of people to recognize
their own values, beliefs, and
practices and those of others
because of strong ethnocentric
tendencies (the tendency to view
one’s culture as superior to
others).
• Cultural Imposition
• The tendency to impose one’s
cultural beliefs, values, and
patterns of behavior on a person
or people from a different culture.
• The intrusive application of the
majority group's cultural view
upon individuals and families
• Cultural Taboos
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• Activities or behaviors that are
avoided, forbidden, or prohibited
by a particular cultural group.
Components of Culturally Competent
Care
• Cultural Awareness
• Involves self-examination of in- depth
exploration of one’s cultural and
professional background. This
component begins with insight into one’s
cultural health care beliefs and values. A
cultural awareness assessment tool can
be used to assess a person’s level of
cultural awareness.
• Cultural Knowledge
• Involves seeking and obtaining
information base on different cultural and
ethnic groups. This component is
expanded by accessing information
offered through sources such as journal
articles, seminars, textbooks, internet
resources, workshop presentations and
university courses.
• Cultural Skill
• Involves the nurse’s ability to collect
relevant cultural data regarding the
patient’s presenting problem and
accurately perform a culturally specific
assessment. The Giger and Davidhizar
model offers a framework for assessing
cultural, racial, and ethnic differences in
patients.
• Cultural Encounter
• Is defined as the process that encourages
nurses to directly engage in cross-cultural
interactions with patients from culturally
diverse backgrounds. Nurses increase
cultural competence by directly
interacting with patients from different
cultural backgrounds. This is an ongoing
process; developing cultural competence
cannot be mastered.
• Cultural Desire
• Refers to motivation to become culturally
aware and to seek cultural encounters.
This component involves the willingness
to be open to others, to accept and
respect cultural differences and to be
willing to learn from others.
LEARN Model Guide in the Clinical
Encounter:
L Listen with empathy and understanding
to the patient’s perception of the
problem.
E Explain your perceptions of the problem.
A Acknowledge and discuss the differences
and similarities.
R Recommend treatment/ solution.
N Negotiate agreement.
Culturally Mediated Characteristics:
• Space and distance
• Eye contact
• Time
• Touch
• Observance of holidays
• Diet
• Biologic Variations (Psychosocial
adaptations)
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NURSING
Major World Religions and Common
Health Beliefs:
• Buddhism - practices no alcohol, lacto-
ovo vegetarian, avoid oily beans
- They meditate for the patient’s
condition and they don’t want any
medication to give for the patient.
• Mormons - no coffee, no alcohol, no
meat, no coke, no tea,
• Russians/Ukraine - all animal products are
forbidden during lent, fasting occurs
during advent
• Hinduism - no pork & no beans, children
aren’t allowed to participate fasting
- tying with a thread of the dead body,
place a basel on the patient’s tongue,
they used holy water and after
death, the body will not wash and
threads will not cut
• Muslims - Halal Foods, drain ang blood
(no blood), fasting, no alcohol and no pork
- they don’t allow autopsy, second
degree male relatives should be the
one to carry the dead, the patient
will request the positioning of the
bed to face the Mecca.
- Nurses will not discuss about death,
grief expresses through slapping and
hitting, same sex with handle the
dead patient
• Jehovah’s Witness - won't allow blood
transfusion, no blood food, they can eat
animal flesh but drain
• Judaism Orthodox - no combination of
meat and milk, fish & milk, fish should
have scales and fins, (Goat, sheep, dear -
Cloven Hoofed Animals), Yom Kippur: 24
hrs fasting is observed
- Client underlives support should not
be left alone, no autopsy and no
cremation
• Roman Catholic - no meat during lent
season
• Pentecostal - no alcohol, no foods added
blood, avoid pork
• Seventh Day Adventist - no alcohol and
caffeinated beverages, lacto-ovo, no pork
and over eating is prohibited, 5 to 6 hours
no snacks
SURGERY
• Is the use of instruments during an
operation to treat injuries, diseases, and
deformities.
• Is a stressful, complex event.
• The branch of medicine concerned with
diseases and trauma requiring operative
procedures.
• Surgical procedures are named according
to (1) the involved body organ, part, or
location and (2) the suffix that describes
what is done during the procedure.
• Physicians who perform surgery include
surgeons or other physicians trained to do
certain surgical procedures.
SURGICAL PROCEDURE SUFFIXES
• -ectomy – removal by cutting
• -orrhaphy – suture of or repair
• -oscopy – looking into
• -ostomy – formation of a permanent
artificial opening
• -otomy – incision or cutting into
• -plasty – formation or repair
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NURSING
CLASSIFICATION OF SURGERY
ACCORDING TO URGENCY
• EMERGENT – Patient requires immediate
attention; disorder may be life
threatening; immediately without delay
to maintain life or organ, remove damage,
stop bleeding.
• URGENT/ IMPERATIVE – Patient requires prompt
attention; within 24-30/48 hours.
• REQUIRED/ PLANNED – Patient needs to have
surgery, plan within a few weeks or months.
• ELECTIVE – Patient should have surgery; failure to
have surgery not catastrophic; planned/scheduled
with no time requirements.
• OPTIONAL – Decision rests with patient; at
preference of patient.
ACCORDING TO PURPOSE
• AESTHETIC – requested by patient
for improvement.
• DIAGNOSTIC – To obtain tissue
samples, make an incision, or use a
scope to make a diagnosis.
• EXPLORATORY – Confirmation or
measurement of extent of
condition.
• PREVENTIVE – removal of tissue
before it causes a problem.
• CURATIVE/ABLATIVE – removal of
a diseased abnormal tissue.
• RECONSTRUCTIVE – Correction of
defects of body parts.
• PALLIATIVE – Alleviation of
symptoms without curing the
disease.
ACCORDING TO EXTENT
• MAJOR – Extensive surgery that
involves serious risk and
complications, as it involves major
organ.
- High risk, extensive, prolonged, large
amount of blood loss, vital organs
may be handled or removed, great
risk of complications.
• MINOR – Involves minimal
complications and blood loss.
- Generally, not prolonged, leads to
few serious complications, involves
less risk.
PRINCIPLES OF SURGICAL ASEPSIS
MOISTURE CAUSES CONTAMINATION
• Prevent splashing of liquids in the sterile
field.
• Place wet objects on sterile, water-
impermeable surfaces, such as sterile
basin.
RATIONALE: microorganisms
travel more easily through moist
environment. When sterile
surfaces become moist,
microorganisms for the unsterile
surface may be transmitted into
the sterile surface.
NEVER ASSUME THAT AN OBJECT IS
STERILE
• Ensure that it is labeled as sterile.
• Always check the integrity of the
packaging.
• Always verify the expiration date on the
package.
• Whenever in doubt of the sterility of an
object, consider it unsterile.
RATIONALE: commercially
prepared products are labeled as
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NURSING
sterile on their packaging; special
indicators are used to show that
objects have completed their
sterilization process; packages that
are torn, punctured, or moist are
considered unsterile.
ALWAYS FACE THE STERILE FIELD
RATIONALE: objects that are out of
the line of vision may be
inadvertently contaminated.
STERILE ARTICLES MAY TOUCH ONLY
STERILE ARTICLES OR SURFACES IF THEY
ARE TO MAINTAIN THEIR STERILITY
RATIONALE: anything considered
unsterile may transfer
microorganisms to the sterile
object it touches.
STERILE EQUIPMENT OR AREAS MUST BE
KEPT ABOVE THE WAIST AND ON TOP OF
THE STERILE FIELD
RATIONALE: waist level is the limit
of good visual field. Maximum
visibility of all sterile objects
prevents inadvertent
contamination.
PREVENT UNNECESSARY TRAFFIC AND AIR
CURRENTS AROUND THE STERILE AREA
• Close doors.
• Unfold drapes or wrappers properly.
• Do not sneeze, cough, or talk excessively
over the sterile field.
• Do not reach across sterile fields.
• Move around a sterile field to reach for an
object, if necessary.
RATIONALE: microorganisms
cannot be excluded from the air;
overreaching across sterile fields
will render sterile objects
unsterile.
OPEN, UNUSED STERILE ARTICLES ARE NO
LONGER STERILE AFTER THE PROCEDURE
RATIONALE: one protective wrapping
has been removed, the article is being
contaminated by air so, it must be
discarded or sterilized before it is
used; liquids opened during the
procedure that remain in the
container are also considered
contaminated.
A PERSON WHO IS CONSIDERED STERILE
WHO BECOMES CONTAMINATED MUST
REESTABLISH STERILITY
RATIONALE: If a “scrubbed”
person punctures the gloves or is
contaminated by touching an
unsterile object, he or she must
change the contaminated articles;
if a “scrubbed” person leaves the
area of the sterile field, he or she
must go through the procedure of
rescrubbing, gowning, and gloving.
SURGICAL TECHNIQUE IS A TEAM EFFORT
• A collective and individual “sterile
conscience” is the best method of
enhancing sterile technique.
RATIONALE: Staff members must
rely on one another to maintain
sterile technique; periodic review
of procedures and infection
control surveillance reports
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enhance everyone’s sterile • Nutritional deficiency should be

technique.
FOUR MAJOR TYPES OF PATHOLOGIC
PROCESSES REQUIRING SURGICAL
INTERVENTION (POET)
P – Perforation
• Rupture of an organ O – Obstruction
• Impairment to the flow of vital fluids (e.g.,
blood, urine, CSF, bile)
E – Erosion
• Wearing off a surface or membrane
corrected before surgery.
• Nutrients important for wound healing
are protein, arginine, carbohydrates and
fats, water, vitamin C, vitamin B complex,
vitamin A, vitamin K, magnesium, copper,
zinc.
DRUG OR ALCOHOL USE
• The person with a history of chronic
alcoholism often suffers from
malnutrition and other systemic
problems that increase surgical risk.
AGE

T – Tumors • Very young

• Very old
• Abnormal new growths
PRESENCE OF DISEASE/S
EFFECTS OF SURGERY TO THE CLIENT • Respiratory
• Renal/ urinary
• Stress response is elicited.
• Cardiovascular
• Defense against infection is lowered.
• Endocrine
• Vascular system is disrupted.
• Hepatic
• Organ functions are disturbed.
• Lifestyle may change. SURGICAL RISK
FACTORS NUTRITIONAL AND FLUID
CONCURRENT OR PRIOR
STATUS
•
PHARMACOTHERAPY
Optimal nutrition is an essential factor in
promoting healing a resisting infection • A medication history is obtained from
and other surgical complications. each patient because of the possible
• Obesity, undernutrition, weight loss, effects of medications on the patient’s
malnutrition, deficiencies in specific perioperative course, including the
nutrients, metabolic abnormalities, and possibility of drug interactions.
the effects of medication on nutrition. • Stop aspirin 7-10 days before surgery.
• Nutritional needs may be measured • Currently it is recommended that the use
through BMI and waist circumference. of herbal products be discontinued 2 to 3
weeks before surgery.
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OTHER SURGICAL RISK FACTORS
• Nature of condition
• Location of the condition
• Magnitude and urgency of the surgical
procedure
• Mental attitude of the person toward
surgery
• Caliber of the professional staff and
health care facilities
THE SURGICAL TEAM
THE CIRCULATING NURSE
• Also known as the circulator.
• Manages the OR and protects the patient’s
safety and health by monitoring the
activities of the surgical team, checking
the OR conditions, and continually
assessing the patient for signs of injury and
implementing appropriate interventions.
• Verifying consent, coordinating the team,
and ensuring the cleanliness, proper
temperature, humidity, lighting, safe
function of equipment, and the availability
of supplies and materials.
• Monitors aseptic practices to avoid break
in technique.
• “Surgical or pre-procedure pause” or
“time-out”.
THE SCRUB ROLE
• Performs a surgical hand scrub.
• Setting up the sterile table.
• Prepares sutures, ligatures, and special
equipment.
• Assists the surgeon and the surgical
assistants during the procedure by
anticipating the instruments and supplies
that will be required.
• As the surgical incision is closed, the scrub
person and the circulator count all
needles, sponges, and instruments.
• Standards call for all sponges to be visible
on x-ray and for sponge counts to take
place at the beginning of surgery and twice
at the end.
• Tissue specimens obtained during surgery
are labeled by the scrub person and sent
to the laboratory by the circulator.
THE SURGEON
• Performs the surgical procedure and
heads the surgical team.
THE ANESTHESIOLOGIST AND
ANESTHETIST
• An anesthesiologist is a physician
specifically trained in the art and science
of anesthesiology.
• An anesthetist is a qualified health care
professional who administers anesthetics.
• They assess the patient before surgery,
selects the anesthesia, administers it,
intubates the patient, if necessary,
manages any technical problems related
to the administration of the anesthetic
agent, and supervises the patient’s
condition throughout the surgical
procedure.
THE SURGICAL ENVIRONMENT
• Known for its stark appearance and cool
temperature.
• Access is limited to authorized personnel.
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• The OR must be situated in a location that
is central to all supporting services.
• The OR must have a specific air filtration
device to screen out particles, dust, and
pollutants.
• The unrestricted zone (street clothes are
allowed); the semi-restricted zone (attire
consists of scrub clothes and caps); and
the restricted zone (scrub clothes, shoe
covers, caps, and masks are worn).
• Wet or soiled garments should be
changed.
• Masks are always worn at the restricted
zone.
• Upper respiratory tract infections and
skin infections in staff and patients are
sources of pathogens and must be
reported.
PERIOPERATIVE PHASES
PHASES OF PERIOPERTATIVE NURSING
• Preoperative phase begins when the
decision to proceed with surgical
intervention is made and ends with the
transfer of the patient onto the operating
room (OR) table.
• Intraoperative phase begins when the
patient is transferred onto the OR table
and ends with admission to the PACU.
• Postoperative phase begins with the
admission of the patient to the PACU and
ends with a follow-up evaluation in the
clinical setting or home
Advances in Technology and Anesthesia
• Advances in technology have led to more
complex procedures, more complicated
microsurgical and laser technology, more
sophisticated bypass equipment,
increased use of laparoscopic and
minimally invasive surgery, and more
sensitive monitoring devices.
• Surgery today can involve the
transplantation of multiple human
organs, the implantation of mechanical
devices, the reattachment of body parts,
and the use of robots and minimally
invasive procedures in the OR.
PREOPERATIVE PHASE
• Extends from the time the client is
admitted in the surgical unit, to the time
he/she is prepared physically,
psychosocially, spiritually, and legally for
the surgical procedure, until he is
transported into the operating room
• Begins when the decision to proceed with
surgical intervention is made and ends
with the transfer of the patient onto the
OR table involves establishing a baseline
evaluation of the patient before surgery
by carrying out a preoperative interview
• ensuring that necessary tests have been
or will be performed
• arranging appropriate consultations; and
providing education about recovery from
anesthesia and postoperative care
• On the day of surgery, patient teaching is
reviewed, the patient’s identity and
surgical site are verified, informed
consent is confirmed, and an IV infusion is
started.
GOALS
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• Assessing and correcting physiologic and • Fear of death

psychologic problems that might increase • Fear of disturbance of body image
surgical risk • Worries – loss of finances, employment,
• Giving the person and significant others social and family roles
complete learning/teaching guidelines
• Manifestations of fears
regarding surgery
• Anxiousness
• Instructing and demonstrating exercises
that will benefit the person during post • Bewilderment
operative period • Anger
• Planning for discharge and any projected • Tendency to exaggerate
changes in lifestyle due to surgery • Sad, evasive, tearful, clinging
• Inability to concentrate
Physiologic Assessment of the Client • Short attention span
Undergoing Surgery
• Failure to carry out simple directions
• Age
• Dazed
• Presence of pain
• Nutritional status Nursing Interventions to Minimize
• Fluid and electrolyte balance
Anxiety
• Infection • Explore client’s feelings
• Cardiovascular function • Assist client to identify coping strategies
• Pulmonary function that he or she has previously used to
decrease fear
• Renal function
• Allow client to speak openly about
• Gastrointestinal function
fears/concerns
• Liver function • Give accurate information regarding
• Endocrine function surgery
• Hematologic function • Give empathetic support
• Use of medication • Consider the person’s religious
• Presence of trauma preferences and arrange visit by
priest/minister as desired
Psychosocial Assessment and Care • Music therapy
• Causes of fears of the preoperative clients Nursing Activities in the Perioperative
 Fear of the unknown Phases of Care
• Fear of anesthesia, vulnerability while
unconscious Preoperative Phase
• Fear of pain
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Preadmission Testing (PAT)
1. Initiates initial preoperative assessment
2. Initiates teaching appropriate to patient’s
needs
3. Involves family in interview
4. Verifies completion of preoperative diagnostic
testing.
5. Verifies understanding of surgeon-specific
preoperative orders (eg, bowel, preparation,
preoperative shower)
6. Discusses and reviews advanced directive
document
7. Begins discharge planning by assessing
Admission to Surgical Center
1. Completes preoperative assessment
2. Assesses for risks for postoperative
complications
3. Reports unexpected findings or any deviations
from normal
4. Verifies that operative consent has been
signed
5. Coordinates patient teaching and plan of care
with nursing staff and other health team
members
6. Reinforces previous teaching
7. Explains phases in perioperative period and
expectations
8. Answers patient’s and family’s questions
In the Holding Area
1. Assesses patient’s status, baseline pain, and
nutritional status
2. Reviews chart
3. Identifies patient
4. Verifies surgical site and marks site per
institutional policy
5. Establishes intravenous line
6. Administers medications if prescribed
7. Takes measures to ensure patient’s comfort
8. Provides psychological support
9. Communicates patient’s emotional status
Informed Consent (Operative
Permit/Surgical Consent)
• necessary before non emergent surgery
can be performed
• permission obtained from a patient to
perform a specific test or procedure
Informed Consent
• Informed consent is the patient’s
autonomous decision about whether to
undergo a surgical procedure.
• Voluntary and written informed consent
from the patient is necessary before
non-emergent surgery can be
performed in order to protect the
patient from unsanctioned surgery and
protect the surgeon from claims of an
unauthorized operation.
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NURSING
• Consent is a legal mandate, but it also
helps the patient to prepare
psychologically, because it helps to
ensure that the patient understands the
surgery to be performed (Rothrock,
2007).
Purposes:
• to ensure that the client understands the
nature of the treatment including the
potential complications and
disfigurement (explained by AMD)
• to indicate that the client’s decision was
made without pressure
• to protect the client against unauthorized
procedure
• to protect the surgeon and hospital
against legal actions by a client who
claims that an unauthorized procedure
was performed
The Roles of Doctors VS Nurses
• The surgeon is responsible for explaining
the surgical procedure to the client and
answering the client’s questions.
• They must also inform the patient of the
benefits, alternatives, possible risks,
complications, disfigurement, disability,
and removal of body parts as well as what
to expect in the early and late
postoperative periods.
• The nurse is responsible and accountable
for the verification of and witnessing that
the patient or the legal representative has
Valid Informed Consent
signed the consent document in their
presence and that the patient, or the legal
representative, is of legal age and
competent to provide consent, which
indicates the client’s agreement to the
procedure based on the surgeon’s
explanation.
• They clarifies the information provided
and if the patient requests additional
information, the nurse notifies the
physician.
• The nurse ascertains that the consent
form has been signed before
administering psychoactive
premedication, because consent is not
valid if it is obtained while the patient is
under the influence of medications that
can affect judgment and decisionmaking
capacity.
• The nurse may witness the client’s signing
of the consent form, but the nurse must be
sure that the client has understood the
surgeon’s explanation of the surgery.
• Informed consent is necessary in the
following circumstances:
• Invasive procedures, such as a surgical
incision, a biopsy, a cystoscopy, or
paracentesis
• Procedures requiring sedation and/or
anesthesia
• A nonsurgical procedure, such as an
arteriography, that carries more than a
slight risk to the patient
• Procedures involving radiation
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1. Voluntary Consent
- Valid consent must be freely given,
without coercion. Patient must be at
least 18 years of age (unless an
emancipated minor), consent must
be obtained by a physician, and
patient’s signature must be
witnessed by a professional staff
member.
2. Incompetent Patient
- Legal definition: individual who is not
autonomous and cannot give or
withhold consent (eg, individuals
who are cognitively impaired,
mentally ill, or neurologically
incapacited)
3. Informed Subject
- Informed consent should be in
writing. It should contain the
following:
• Explanation of procedure and
its risks
• Description of benefits and
alternatives
• An offer to answer questions
about procedure
• Instructions that the patient
may withdraw consent
• A statement informing the
patient if the protocol differs
from customary procedure
4. Patient Able to Comprehend
- If the patient is non-English speaking,
it is necessary to provide consent
(written and verbal) in a language
that is understandable to the client.
A trained medical interpreter may be
consulted. Alternative formats of
communication (eg, Braile, large
print, sign interpreter) may be
needing if the patient has a disability
that affects vision or hearing.
Questions must be answered to
facilitate comprehension if material
is confusing.
• Minors (clients younger than 18 years)
may need a parent or legal guardian to
sign the consent form.
• Older clients may need a legal guardian to
sign the consent form.
• Psychiatric clients have a right to refuse
treatment until a court has legally
determined that they are unable to make
decisions for themselves.
• No sedation should be administered to
the client before the client signs the
consent form.
• Obtaining telephone consent from a legal
guardian or power of attorney for health
care is an acceptable practice if clients are
unable to give consent themselves. The
nurse must engage another nurse as a
witness to the consent given over the
telephone.
Circumstances Requiring a Permit:
• any surgical procedure where scalpel,
scissors, or sutures may be used
• any invasive procedure such as surgical
incision, a biopsy, a cystoscopy, or
paracentesis
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• a nonsurgical procedure, such as an
arteriography, that carries more than
slight risk to the patient
• procedures involving radiation
• procedures requiring sedation and/or
anesthesia
Requisites for Validity of Informed
Consent
• written permission is best and is legally
acceptable
• signature is obtained with the client’s
complete understanding of what is to
• occur
• adults sign their own operative permit
• obtained before sedation
• secured without pressure or duress
• a witness is desirable – nurse physicians
or authorized persons
• in an emergency, permission via
telephone or telefax is acceptable
• for minor (below 18), unconscious,
psychologically incapacitated, permission
is required from responsible family
member (parent/legal guardian)
Informed Consent Should Contain the
Following:
• explanation of procedure and its risks
• description of benefits and its alternatives
• an offer to answer questions about
procedure
• instructions that the patient may
withdraw consent
• a statement informing the patient if the
protocol differs from customary
procedure
Physical Preparation
• Before Surgery
• Correct any dietary deficiencies
• Reduce an obese person’s weight
• Correct fluid and electrolyte imbalances
• Restore adequate blood volume with
blood transfusion
• Treat chronic diseases
• Halt or treat any infectious process
• Treat an alcoholic person with vitamin
supplementation, IVF’s or oral fluids if
dehydrated
Teaching Preoperative Exercises
• Deep breathing exercises
• Practice in the same position client would
assume in bed after surgery
• Allow hands in a loose fist position to rest
lightly on the front of the lower ribs with
your fingertips against lower chest to feel
the movement
• Breathe out gently and fully as the ribs
sink down and inward toward midline
Diaphragmatic Breathing
Diaphragmatic breathing refers to a flattening of
the dome of the diaphragm during inspiration,
with resultant enlargement of the upper
abdomen as air rushes in. During expiration, the
abdominal muscles contract.
1. Practice in the same position you would
assume in bed after surgery: a semi-
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Fowler’s position, propped in bed with
the back and shoulders well supported
with pillows.
2. With your hands resting lightly on the
front of the lower ribs, and fingertips
against lower chest to feel the movement
3. Breathe out gently and fully as the ribs
sink down and inward toward midline
4. Then take a deep breath through your
nose and mouth, letting the abdomen rise
as the lungs fill with air
5. Hold this breath for a count of five
6. Exhale and let out all the air through your
nose and mouth
7. Repeat this exercise 15 times with a short
rest after each group of five
8. Practice this twice a day preoperatively
Client Teaching:
Deep-Breathing and Coughing Exercise
1. Instruct the client that a sitting position
gives the best lung expansion for
coughing and deep-breathing exercises.
2. Instruct the client to breathe deeply 3
times, inhaling through nostrils and
exhaling slowly through pursed lips
3. Instruct the client that third breath should
be held for 3 seconds; then the client
should cough deeply 3 times
4. The client should perform this exercise
every 1 to 2 hours.
Teaching Preoperative Exercises
• Take a deep breath your nose and mouth,
letting the abdomen rise as the lungs fill
with air
• Hold this breath for a count of five
• Exhale and let out all the air through your
nose and mouth
• Repeat this exercise 15 times with a short
rest after each group of five
• Practice twice daily preoperatively
Incentive spirometry
• Let client sit upright, at 45 degree
minimum
• Take two normal breaths. Place
mouthpiece of spirometer in mouth
• Inhale until target, designated by
spirometer light or rising ball, is reached,
and hold breath for 3 to 5 seconds
• Exhale completely
• Perform 10 sets of breaths each hour
Coughing Exercises
• Have client sit up and lean forward
• Show client how to splint incision with
hands, pillow, or blanket
• Have client inhale and exhale deeply
three times through mouth
• Have client take in deep breath and cough
out the breath forcefully with three short
coughs using diaphragmatic muscles.
Take in quick deep breath through mouth,
cough deeply, and deep breathe
Turning Exercises
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• Turn on your side with uppermost leg
flexed most and supported on a pillow
• Grasp the side rail as an aid to maneuver
to the side
• Practice diaphragmatic breathing and
coughing while on your side
Foot and Leg Exercises
• Lie in a semi-Fowler’s position
• Bend your knee and raise your foot –
hold it a few seconds, then extend the
leg and lower it to the bed
• Do this five times with each leg
• Then trace circles with the feet by
bending them down, in toward each
other, up, and then out
Preparing the Person Before Surgery
▪ Preparing the skin
o Have full bath to reduce
microorganisms in the skin
▪ Preparing the GI tract
o NPO; cleansing enema as required
▪ Preparing for anesthesia
o Avoid alcohol and cigarette and
smoking for at least 24 hours
before surgery
▪ Promoting rest and sleep
o Administer sedatives as ordered
Splinting the Incision
• If the surgical incision is abdominal or
thoracic, instruct the client to place a
pillow, or I hand with the other hand on
top, over the incisional area
• During deep breathing and coughing, the
client presses gently against the incisional
area to splint or support it
Preparing the Person on the Day
Surgery
Early morning care
• Awaken one hour before preoperative
medications
• Morning bath, mouth wash
• Provide clean gown
• Provide clean gown
• Remove hairpins, braid long hairs, cover
hair with cap
• Remove dentures, foreign materials
(chewing gum) colored nail polish,
hearing aid, contact lens
• Take baseline vital signs before
preoperative medication
• Check ID band and skin preparation
• Check for special orders – enema, GI tube
insertion, IV line
• Check NPO
• Have client void before preoperative
medication
• Continue to support emotionally
• Accomplish “preoperative care checklist”
Preoperative Medications/ Pre-
anesthetic Drugs
Goals:
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• To facilitate the administration of any • To minimize respiratory tract secretions

anesthetic and changes in heart rate
• To relax the client and reduce anxiety
AGENTS EFFECT OF INTERACTION WITH ANESTHETICS
Corticosteroids Cardiovascular collapse can occur if discontinued
Prednisone (Deltasone) suddenly. Therefore, a bolus of corticosteroid
may be administered intravenously immediately
before and after surgery
Diuretics During anesthesia, may cause excessive
Hydrochlorothiazide (HydroDIURIL) respiratory depression resulting from an
associated electrolyte imbalance
Phenothiazine May increase the hypotensive action anesthetics
Chlorpromazine (Thorazine)
Tranquilizers May cause anxiety, tension, and even seizures if
Diazepam (Valium) withdrawn suddenly
Insulin Interaction between anesthetics and insulin must
be considered when a patient with diabetes is
undergoing surgery. Intravenous insulin may
need to be administered to keep the blood
glucose within the normal range
Antibiotics When combines with a curariform muscle
Erythromycin (Ery-Tab) relaxant, nerve transmission to interrupted and
apnea from respiratory paralysis may result
Anticoagulants Can increase the risk of bleeding during the
Warfarin (Coumadin) intraoperative and postoperative periods; should
be discontinued in anticipation of elective
surgery. The surgeon will determine how long
before the elective surgery the patient should
stop taking an anticoagulant, depending on the
type of planned procedure and the medical
condition of the patient
Antiseizure Medications Intravenous administration of medication may be
needed to keep the patient seizure-free in the
intraoperative and postoperative periods
Thyroid Hormone (Levothroid) Intravenous administration may be needed
during the postoperative period to maintain
thyroid levels
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Opioids
• Narcotics
o Morphine sulfate
o Fentanyl (Sublamaze)
o Meperidine (Demerol)
o Analgesia; enhancement
postoperative pain relief
• Antianxiety and sedative hypnotics
o Diazepam (Valium)
o Hydroxyzine hcl (Vistaril)
o Lorazepam (Ativan)
o Midazolam (Versed)
o Phenobarnital sodium
o Sedation; anxiety reduction
• Anticholinergic
o Atropine sulfate
o Scopolamine hydrobromide
o Secretion reduction
• Antiemetic
o Ondansetron (Zofran)
o Metoclopramide (Reglan)
o Promethazine hcl (Phenergan)
o Control nausea and vomiting; may be
effective into the postoperative
period
• H2 antagonist
o Cimetidine (Tagamet)
o Ranitidine (Zantac)
o Famotidine (Pepcid)
o Reduction of acidic gastric secretions
in case aspiration occurs
• Antibiotic
NURSING
Long-term use of opioids for chronic (6 mo or
greater) in the preoperative period may alter the
patient’s response to analgesic agents
o Cefazolin (Ancef)
o Ampicillin (Omnipen
o Prevention of postoperative infection
Wound Healing Meachanisms
of
1. First-Intentions Healing
- Wounds made aseptically with a
minimum of tissue destruction that
are properly closed heal with little
tissue reaction by first intention
(primary union). When wounds heal
by first-intention healing,
granulation tissue is not visible and
scar formation is minimal.
Postoperatively, many of these
wounds are covered with a dry
sterile dressing. If a cyanoacrylate
tissue adhesive (Liquiband) was used
to close the incision without sutures,
a dressing is contraindicated.
2. Second-Intention Healing
- Second-intention healing occurs in
infected wounds (abscess) or in
wounds in which the edges have not
have been approximated. When an
abscess is incised, it collapses partly,
but the dead and dying cells forming
its walls are still being released into
the cavity. For this, reason, a
drainage tube or gauze packing to
escape easily. Gradually, the necrotic
material disintegrates and escapes,
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and the abscess cavity fills with red,

soft, sensitive tissue that bleeds
easily. This tissue is composed of
minute, thin-walled capillaries and
buds that later form connective
tissue. These buds, called
granulations, enlarge until they fill
the area left by the destroyed tissue.
The cells surrounding the capillaries
change their round shape to become
long, thin, and intertwined to form a
scar (cicatrix). Healing is complete
when skin cells (epithelium) grow
over these granulations. This method
of repair os called healing by
granulations of tissue has occurred
for any reason. When the post-
operative wound is to be allowed to
heal by secondary intention. It is
Intraoperative Phase
usually packed with saline-
moistened sterile dressings and • Begins when the client is transferred onto
covered with a dry sterile dressing. the OR table and ends with admission to
3. Third-Intention Healing the PACU
- Third-intention healing (secondary • Extends from the time the client is
suture) is used for deep wounds that admitted to the operating room, to the
either have not been sutured early or time of administration of anesthesia,
break down are resutured later, thus surgical procedure is done, until he/she is
bringing together two apposing transported to the recovery room/PACU
granulation surfaces. This results in a • Nursing activities include: providing
deeper and wider scar. These safety, maintaining an aseptic
wounds are also packed environment, ensure proper functioning
postoperatively with moist gauze of equipment, providing the surgeon with
and covered with a dry sterile specific instruments and supplies for the
dressing. surgical field, and proper documentation
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Goals of Care (HASH)
• H – homeostasis
• A – aspesis
• S – safe administration of anesthesia
• H – hemostasis
Positions During Surgery
• Dorsal Recumbent – hernia repair,
mastectomy, bowel resection
• Trendelenburg – lower abdomen, pelvic
surgeries
• Lithotomy – vaginal repairs, D and C,
rectal surgery
• Prone – spinal surgeries, laminectomy
• Lateral – kidney, chest, hip surgeries
• Explain purpose of position
• Avoid undue exposure
• Strap the person to prevent falls
• Maintain adequate respiratory and
circulatory function
• Maintain good body alignment
Types of Anesthesia
General
• Anesthesia is a state of narcosis,
analgesia, relaxation, and reflex loss
• Clients under general anesthesia are not
arousable, not even to painful stimuli
• Produces amnesia
• Can be administered through IV or
inhalation
• Gas anesthetics are administered by
inhalation and are always combined with
• oxygen
• Nitrous oxide is the most commonly used
gas anesthetic agent
• When inhaled, the anesthetics enter the
blood through the pulmonary capillaries
and act on cerebral centers to produce
loss of consciousness and sensation
• General anesthesia consists of four stage
Stage 1 (beginning anesthesia)
• extends from the administration of
anesthesia to the time of loss of
consciousness
• The client may have a ringing, roaring or
buzzing in the ears, and although still
conscious, may sense an inability to move
the extremities easily
• During this stage, noises are exaggerated
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• During this stage, noises are exaggerated.
Unnecessary noises and motions are
avoided when anesthesia begins.
Stage II (excitement/delirium)
• extends from the time of loss of
consciousness to the time of loss of lid
reflex
• It may be characterized by shouting,
struggling, talking, singing, laughing, or
crying of the client but often avoided if
anesthetic is administered smoothly and
quickly
• Assist anesthesiologist/ anesthetist if
needed to restrain client. Client should
not be touched except for purposes of
restraint.
Stage III (surgical anesthesia)
• extends from the loss of lid reflex to the
loss of most reflexes. Surgical procedure
is started
Stage IV (medullary depression)
• it is characterized by respiratory/cardiac
depression or arrest. It is due to overdose
of anesthesia. Resuscitation must be
done
Regional
• Reduce all painful sensations in one
region of the body without inducing
unconsciousness
• Topical, local infiltration, epidural, spinal
• Client receiving regional anesthesia is
awake and aware of his/her surroundings
unless medications are given to produce
mild sedation or to relieve anxiety
• Nurse must avoid careless conversation,
unnecessary noise, and unpleasant odors
• Diagnosis must not be stated allowed if
the client is not to know it at this time
• A postdural puncture headache may
occur after spinal and epidural blocks
caused by leakage of CSF. Small-gauge
spinal needle (less than gauge 25) helps
prevent headaches. Position the client flat
and force fluids to relieve headache. A
blood patch treatment can be done if
headache continues
Transfer from Surgery
• After surgery client is stabilized for
transfer
• After local anesthesia, the client may
return directly to a nursing unit
• After general and spinal anesthesia, the
client goes to the PACU or in some cases,
the intensive care unit
SAFETY is always a priority at this time!
• Never leave client alone
• Ensure patent airways and prevent falls
an injury
• Continuous monitoring of client
Nursing Activities in the Perioperative
Phases of Care
Intraoperative Phase
• Maintenance of Safety
1. Maintains aseptic, controlled
environment
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2. Effectively manages human resources, • Human skin is colonized by a large number of

equipment, and supplies for microorganisms known as the ‘resident’ or
individualized patient care ‘normal’ flora which tend to live deep in the
3. Transfers patient to operating room skin folds, sebaceous glands and hair follicles.
bed or table
4. Positions patient based on functional
alignment and exposure of surgical
site
5. Applies grounding device to patient
6. Ensures that the sponge, needle, and
instrument counts are correct
7. Completes intraoperative
documentation
Physiologic Monitoring
• The surfaces of the skin can also be
1. Calculates effects on patient of
contaminated with microorganisms from
excessive fluid loss or gain
body excretions/secretions, dirt or from
2. Distinguishes normal from abnormal
contact with contaminated surfaces or items
cardiopulmonary data
(‘transient’ flora).
3. Reports changes in patient’s vital signs
• Whilst all these microorganisms are harmless
4. Institutes measures to promote
on the surface of the skin, if they get into a
normothermia
surgical incision they can cause a surgical site
Psychological Support (Before Induction and infection.
When Patient Is Conscious)
Surgical Skin Preparation
1. Provides emotional support to patient
• Cleansing of the skin prior to surgery is
2. Stands near or touches patient during
therefore required to remove as many
procedures and induction
microorganisms as possible from the skin
3. Continues to assess patient’s
surface.
emotional status
• Soap and water physically removes dirt
Skin Preparation and Draping and secretions, and with it the transiently
Why skin preparation is important to prevent located microorganisms.
Surgical Skin Infection? • Antiseptic agents such as alcohol,
chlorhexidine, triclosan and iodine
Rationale: contain agents that can rapidly kill both
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resident and transient microorganisms.
Some agents are also able to suppress
their regrowth for the duration of the
surgical procedures.
Goal:
➢ Decrease the number of microorganisms
at the operative site. Dirt and skin oils are
removed with scrubbing action and
antimicrobial agents are used to reduce
the number of bacteria present on the
skin and prevent further microbial
growth.
➢ Cleansing and antisepsis of the skin are
accomplished by the circulating nurse
who wears sterile gloves and mask and
Summary of evidence for efficacy of
uses a sterile for the solution and
preoperative washing:
supplies.
There are several steps recommended for
preoperative skin preparation:
1. Pre-op washing
2. Appropriate hair removal from incision
site
3. Disinfection of site of incision
4. Reducing skin recolonization
Why is a shower/bath prior to surgery
recommended?
Rationale:
• The aim of pre-operative washing is to
ensure the skin is clean before surgery.
• Patients should be encouraged (or if
necessary assisted) to have a shower or
bath with soap.
What should be used for pre-
operative washing?
Rationale:
• Soap solutions are recommended to
physically remove dirt and remove
transient microorganisms from the
surface of the skin.
• Using antiseptic in the soap solution is
a strategy for reducing skin flora
however, there is limited evidence for
their efficacy in preventing SSI.
• Some patients may also have an
allergic reaction to some antiseptic
solutions
• High quality evidence from one
systematic review of seven Randomised
Controlled Trials (RCT) evaluating
chlorhexidine gluconate (CHG) solution
and one RCT evaluating povidone iodine
(PI) detergent solution found no evidence
to favor the use of one antiseptic over
another or in preference to soap alone.
• A systematic review including nine studies
(7 RCTs and two observational studies)
and a total of 17,087 adult patients
investigated preoperative bathing or
showering with an antimicrobial soap
compared to plain soap.
• This found moderate quality of evidence
that bathing with CHG soap does not
significantly reduce SSI rates compared to
bathing with plain soap.
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• A Cochrane review showed no clear • Hair clippers cut the hair close to the skin
evidence of benefit for preoperative without the blade actually touching it and
showering or bathing with CHG over is the preferred method of removing hair
other wash products, to reduce surgical as they are associated with the lowest risk
site infection. of causing abrasions. Electric clippers with
a disposable, single-patient use head are
Why remove hair from the site of
the most cost-effective method.
incision?
Summary of evidence for the efficacy of
Rationale:
different hair removal techniques:
• The removal of hair from the site of
• No significant difference in the rate of SSI
incision may be necessary to access the
was found in six RCTs comparing hair
surgical site.
removal (shaving, clipping or depilatory
• The perception that the presence of hair
cream) with no hair removal although the
at the site increases microbial
studies consisted of a small sample.
contamination and therefore risk of SSI is
• Shaving was found to double the risk of
not supported by evidence.
SSI compared with clipping in three
• Systematic reviews have found no
studies.
difference in SSI rates between
• No significant difference in SSI rates was
procedures involving hair removal and no
found in seven studies between hair
hair removal.
removal by shaving compared with
How should hair be removed from the depilatory cream, although studies
operative site? consisted of a small sample.
Rationale: When should hair be removed from the
operative site?
• If hair must be removed then the method
used should avoid damage to the skin. Rationale:
Micro-abrasions, such as those caused by
• There is limited evidence to inform the
razors, may encourage the proliferation
timing of hair removal. However,
of microorganisms on the skin
guidance recommends hair should be
surrounding the operative site and
removed as close to the time of surgery as
increase the risk of the incision becoming
possible, preferably on the day of surgery.
contaminated. The longer the period
• Patients should be advised not to shave
between hair removal and the incision
themselves prior to surgery as shaving
being made the greater the risk of
contamination.
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may increase their risk of developing an
SSI
Why use antiseptics to disinfect the skin
prior to surgery?
• Cleaning the skin with soap and water
removes dirt, skin secretions such as
sweat and sebum, together with
superficial microorganisms. However,
microorganisms that live in the folds of
the skin, sebaceous glands and hair
follicles are not removed by washing.
• The aim of skin disinfection is to apply
antiseptic solutions to rapidly kill or
remove skin microorganisms at the site of
the incision and reduce the risk of
contamination of the surgical site.
When should skin antiseptics be
applied?
Rationale:
• Preparation of the surgical site should
occur as close to the point of surgery as
possible and immediately prior to
draping.
• There is no evidence to suggest that
multiple applications of different skin
antiseptics increases efficacy.
Skin Disinfection
• The two main antiseptic agents used for
pre-operative skin preparation are:
✓ Chlorhexidine gluconate (CHG)
✓ Iodophors (povidone iodine; PI)
• They are available in either an aqueous or
alcohol-based form. There is limited
evidence to suggest that one agent is
better than another.
• Alcohol-based solutions should be used
where they are suitable for the particular
site of incision as they include an
additional, rapid acting antiseptic agent
that dries quickly.
• However, alcohol can damage mucous
membranes and aqueous solutions
should be used for this type of surgery.
The skin of pre-term infants is immature
and exposure to antiseptics should be
avoided as it may cause skin irritation,
erythema or burns.
• Both PI and CHG are effective against a
broad range of skin microorganisms and
exert persistent activity that prevents
regrowth for several hours after
application.
• CHG is a potential allergenic antiseptic in
susceptible individuals although allergy is
rare. It will initially cause a minor
hypersensitivity reaction, which should
be documented in the patient records, as
subsequent exposures to CHG may lead
to anaphylaxis.
• Allergic reactions to PI may also occur but
since this agent is less frequently used
these are uncommon. However, repeat
exposure to PI can cause iodine toxicity in
pregnant or breastfeeding women.
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Properties of Active Agents in Pre-operative Skin Preparations

Chlorhexidine Iodophors (PI) Alcohol
Gluconate (CHG)
Mechanism of action Disrupts cell membrane Releases iodine which Denatures cell wall
oxidises and substitutes protein
cell material
Preparation strength 0.5%; 2% 7-10% 70% isopropyl or ethyl
alcohol preferred but
can be 30-85%
Quick kill Moderate Rapid
Persistent activity High (up to 48 hrs) Moderate None
Use on eyes No (damage to cornea) Dilute 1:1 10% solution No
with balanced salts to
make 5%
Use on ears No (damages middle Yes Yes
ear)
Use on mouth Use 0.12% oral rinse Yes No
Use on genital area No Yes No
Use on tissues No No No
Contraindications • Sensitivity or • Sensitivity or • Sensitivity or
allergy allergy allergy
• Neonates • Neonates • Neonates
• Inactivated in • Inactivated in
presence of presence of
blood blood
Note: risk of iodine
toxicity in repeat use in
patients with thyroid
disorders,
pregnant/breastfeeding
women but unlikely to
be a problem for single
pre-operative skin
preparation
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When should skin antiseptics be
applied?
Rationale:
• The incision site should be rubbed with
sufficient solution to adequately cover
the site and ensure that microorganisms
in skin folds and sebaceous glands are
treated. Either gauze swabs or
commercially available applicators are
effective in achieving this.
• Good practice suggests that the direction
of cleansing should be away from the
incision site but there is no evidence that
support the efficacy of a particular
technique
Skin Preparation
Principles:
1. Maintain the dignity and privacy by
exposing only the necessary area of the
body.
2. Assess skin prior to beginning the
preparation. Breaks in the skin or
symptoms of infection may preclude the
surgery
3. Check patient allergies prior to using any
solution.
4. Use warm solution and keep patient well-
covered for comfort and to reduce the
risk of hypothermia.
5. Scrub in a circular motion form the
incisional site outward in an expanding
circle. Discard each sponge when the
periphery has been reached and start
again in the center of the circle with anew
sponge.
6. Never reapply a sponge to an area that
has been cleansed because bacteria
forma adjacent skin can in introduced on
the prepped area.
7. Do not allow prep solutions to pool under
the patients or under tourniquets,
grounding pads, or electrodes because
skin irritation and chemical burns may
occur. This is particularly true for the
patients with fair or sensitive skin and for
those who are place on warming blankets
during the procedure.
8. Alway move form cleanest to the dirties.
For instance, the vagina and rectum are
cleansed after the surrounding skin for a
perineal preparation. The axilla is
prepared last during a shoulder
preparation.
9. Limb preparation requires the limb to be
held up by another person or device to
allow the entire circumference to
prepared.
10. Cleansing is done gently when a
superficial malignancy is suspected so as
not to spread potentially cancerous cells.
11. Flammable liquids like acetone and
alcohol are not recommended because
remaining liquids or lingering fumes can
create a spark when used in conjunction
with electrocautery or lasers. If they are
used drapes should be applied.
12. Allow antiseptic paints to dry prior to
applying drapes.
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NURSING
Drapes
• The procedure of covering a patient and
surrounding areas with a sterile barrier to
create and maintain a sterile field during
a surgical procedure is called draping.
✓ The purpose of draping is to eliminate
the passage of microorganisms
between nonsterile and sterile areas.
Draping materials may be disposable
or non-disposable.
✓ Disposable drapes are generally paper
or plastic or a combination and may or
may not be absorbent. Non-
disposable drapes are usually double-
thickness muslin. Drapes must be
sterile.
• Part of the role of the perioperative nurse
is to “pull” the correct drapes as well as
instruments prior to each procedure.
• In order to provide the best protection for
each procedure, the perioperative nurse
needs to think through the basic
principles of draping.
Principles of Draping
1. Isolate
✓ Dirty from clean (e.g., groin,
colostomy and equipment from the
area to be prepped). Isolation is
accomplished by using an
impervious drape, usually
fabricated from a plastic material.
Any impervious material can be
used.
2. Barrier
✓ Provides an impervious layer; must
have a plastic film to prevent strike-
through
3. Sterile Field
✓ Creation of a sterile field is through
sterile presentation of the drape
and aseptic application technique.
If the drape used is not impervious,
an additional impervious layer
needs to be added.
4. Sterile Surface
✓ Because skin cannot be sterilized,
it is necessary to apply an incise
drape to create a sterile surface.
Only an incise drape can create a
sterile surface.
5. Equipment Cover
✓ Sterile drapes cover nonsterile
equipment or organize equipment
used on the sterile field. This helps
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NURSING
to protect the patient from the
equipment as well as to protect
and prolong the life of the
equipment.
6. Fluid Control
✓ Collection of fluid keeps the
patient dry, decreases healthcare
worker exposure and decreases
clean up. A fluid control system
should be used any time the
procedure is known to include
large amounts of body fluids or
irrigating solution.
Surgical Drape Characteristics
Regardless of which materials are used, all
surgical drape materials should possess the
following traits:
• Abrasion resistance—The material
surface should not abrade during normal
use, under wet and dry conditions.
• Barrier properties—The ability of a
material to resist the penetration of
liquids and/or micro organisms.
• Biocompatibility—A material free of toxic
ingredients.
• D r a p e a b i l i t y —The ability of a
material to conform to the shape of the
object over which it is placed
• Electrostatic properties—In the context
of a surgical drape, the ability of the
material to accept or dissipate an
electrical charge is desirable.
• Non-flammability—The materials should
not support open combustion.
• Non-linting—Drape materials should not
contain, or generate with normal use,
free fiber particles.
• Tensile strength—Drape materials
should be strong enough to withstand
the stresses encountered during typical
use when wet or dry.
• Breathable—Capable of allowing gas and
moisture vapor to pass through the
material while maintaining a barrier to
fluids and microorganisms.
• Absorbent—The ability to absorb and
hold fluid while maintaining a barrier to
penetration of fluid and microorganism
through the drape.
Postoperative Phase
• Extends from the time the client is
admitted to the recovery room, to the
time he is transported back into the
surgical unit, discharged from the
hospital, until the follow-up care
• Begins when the client is admitted to the
PACU or a nursing unit and ends with the
client’s postoperative evaluation in the
physician’s office
Goals:
• Maintain adequate body system
functions
• Restore homeostasis
• Alleviate pain and discomfort
• Prevent postoperative complications
• Ensure adequate discharge planning and
teaching
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Admission to PACU
• Goal is to promote safe recovery from
anesthesia
• Administer oxygen by nasal cannula or
mask as ordered
• Continuous monitoring is done for
ECG, pulse oximetry, and BP
measurements
• Assess surgical site and dressing
• Check for patency of catheter, drains
and tubes
• Measure body temperature
• Provide warming blanket
• Control shivering by administering
Meperidine (Demerol) when
anesthesia is the cause
• Provide supplemental oxygen during
shivering
• Perform hand washing between
clients
• VS taking every 5 to 15 minutes
General Interventions
• Avoid exposure
• Avoid rough handling
• Avoid hurried movement and rapid
changes
Assessment
• Appraise air exchange status and note
skin color
• Verify identity, operative procedure,
surgeon
• Assess neurologic status
• Determine VS
• Perform safety checks
Ensure maintenance of patent airway and
adequate respiratory function
• Lateral position with neck extended
• Keep airway in place until fully awake
• Suction secretions
• Encourage deep breathing
• Administer humidified oxygen as
ordered
Transfer from recovery room to surgical
unit:
Parameters for Discharge from Recovery
Room
• Activity: able to obey commands
• Respiration: easy, noiseless breathing
• Circulation: BP is within +/-20 mmHg
of the preop level
• Consciousness: responsive
• Color: pinkish skin and mucus
membrane
2-3 days after surgery (discharge
planning/teaching)
• Self-care activities
• Activity limitation
• Diet and medications
• Complications
• Referrals, follow-up check up
Postoperative discomforts
• Nausea and vomiting
• Restlessness & sleeplessness
• Thirst
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NURSING

• Constipation ✓ Assesses patient’s pain level and

• Pain
Nursing Activities in the Perioperative
Phases of Care
Postoperative Phase
Transfer of Patient to Post-anesthesia Care Unit
1. Communicates intraoperative information
Transfer of Patient to Post-anesthesia Care Unit
✓ Identifies patient by name
✓ States type of surgery performed
Surgical Nursing Unit
✓ Identifies type and amounts of anesthetic
and analgesic agents used
✓ Reports patient’s vital signs and response
to surgical procedure and anesthesia
✓ Describes intraoperative factors (eg,
insertion of drains or catheters,
administration of blood, medications
during surgery, or occurrence of
unexpected events)
✓ Describes physical limitations
✓ Reports patient’s preoperative level of
consciousness
✓ Communicates necessary equipment
needs
Home or Clinic
✓ Communicates presence of family or
significant others
Postoperative Assessment Recovery Area
✓ Determines patient’s immediate
response to surgical intervention
✓ Monitors patient’s vital signs and
physiologic status
administers appropriate pain relief
measures
✓ Maintains patient’s safety (airway,
circulation, prevention of injury)
✓ Administers medications, fluid, and blood
component therapy, if prescribed
✓ Provides oral fluids if prescribed for
ambulatory surgery patient
✓ Assesses patient’s readiness for transfer
to in-hospital unit or for discharge home
based on institutional policy
✓ Continues close monitoring of patient’s
physical and psychological response to
surgical intervention
✓ Assesses patient’s pain level and
administers appropriate pain relief
measures
✓ Provides teaching to patient during
immediate recovery period
✓ Assists patient in recovery and
preparation for discharge home
✓ Determines patient’s psychological status
✓ Assists with discharge planning
✓ Provides follow-up care during office or
clinic visit or by telephone contact
✓ Reinforces previous teaching and answers
patient’s and family’s questions about
surgery and follow-up care
✓ Assesses patient’s response to surgery
and anesthesia and their effects on body
image and function
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SCHOOL OF ALLIED MEDICAL SCIENCES
NURSING

✓ Determines family’s perception of Manifestations

surgery and its outcome
• Apprehension, restlessness, thirst, cold,
Shock moist, pale skin
• Deep rapid respiration, low body
• Response of the body to a decrease in the
temperature
circulating blood volume, which results to
• Low blood pressure, low hemoglobin
poor tissue perfusion and inadequate
tissue oxygenation • Circumoral pallor
• Progressive weakness
Hemorrhage
Management
Copious escape of blood from the blood vessel
• Administer Vitamin K as ordered
• Capillary – slow, generalized oozing • Pressure dressings
• Venous – dark in color and bubble out • Blood transfusion
• Arterial – spurts and is bright red in color • IV fluids
Types of Wound Drainage Femoral Phlebitis/ Deep
Type APPEARANCE Thrombophlebitis
A. Serous Clear, Watery Plasma Often occurs after operations on the lower
B. Purulent Thick, Yellow, Green, abdomen or during the course of septic
Tan or Brown
conditions as rupture ulcer or peritonitis
C. Haemoserous Pale, Red, Watery,
Mixture of Serous and Causes
Sanguineous
• Injury – damage to vein
D. Sanguineous Bright, Red: indicated
active bleeding • Hemorrhage
• Prolonged immobility
• Obesity/ debilitatio
Femoral Phlebitis/ Deep
Thrombophlebitis
Manifestations
• Pain
• Redness
• Swelling
• Heat/warmth
 University of San Jose-Recoletos
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NURSING

• Positive Homan’s sign Manifestations

Nursing Interventions (prevention) • Intermittent, sharp, colicky abdominal
pains
• Hydrate adequately to prevent
• Nausea and vomiting
hemoconcentration
• Abdominal distention
• Encourage leg exercises and ambulate
• Diarrhea (incomplete obstruction), no
early
bowel movement (complete)
• Avoid any restricting devices that can
• Return flow of enema is clear
constrict and impair circulation
• Prevent use of bed rolls or dangling over Nursing Interventions
the side of the bed with pressure on
• NGT insertion
popliteal area
• Administer electrolyte/ IV as ordered
• Bed rest, elevate the affected leg with
• Prepare for possible surgical intervention
pillow support
• Wear anti-embolic support hose from Wound Infections
the toes to the groin
Causes
• Avoid massage on the calf of the leg
• Initiate anticoagulant therapy as ordered • Staphylococcus aureus
• Escherichia coli
Pulmonary Complications
• Proteus vulgaris
• Atelectasis • Pseudomonas aeruginosa
• Bronchitis • Anaerobic bacteria
• Bronchopneumonia
Clinical manifestations
• Lobar pneumonia
• Pleurisy • Redness, swelling, pain, warmth
• Pus or other discharge on the wound
Nursing Interventions
• Foul smell from the wound
• Reinforce deep breathing, coughing, and • Elevated temperature; chills
turning exercises • Tender lymph nodes
• Encourage early ambulation
Rule of thumb:
• Incentive spirometry
• Fever within first 24 hours – pulmonary
Intestinal Obstruction
infection
Loop of intestine may kink due to • Within 48 hours – urinary tract infection
• Within 72 hours – wound infection
inflammatory adhesions
 University of San Jose-Recoletos
SCHOOL OF ALLIED MEDICAL SCIENCES
NURSING

Preventive interventions • Cover exposed intestine with sterile,

moist saline dressing
• Strict aseptic technique
• Reassure, keep him/her quiet and
• Wound care
relaxed
• Keep unit clean
• Prepare for surgery and repair of wound
• Antibiotic therapy as ordered
Wound Complications

• Hemorrhage
• Wound dehiscence – disruption in the
coaptation of wound edges (wound
breakdown)
• Wound evisceration – dehiscence +
outpouching of abdominal organs
Nursing interventions
• Apply abdominal binders
• Encourage proper nutrition (high
protein, vitamin C)
• Stay with client, have someone call for
the doctor
• Keep in bed rest
• Supine or Semi-Fowler’s position, bend
knees to relieve