PERI – OPERATIVE NURSING

- identification of the physiological, psychological, social, and spiritual needs of the client and the formulation of an individualized plan of
care before, during and after surgery.
o Pre – Op: admission to OR
o Intra – Op: OR to PACU
o Post – OP: from PACU to unit, discharged, wound healing is completed.

Classification of Surgery:
1. Purpose
a. Curative:
- Ablative: removal of a diseased organ Ex: ectomy
- Palliative: management of signs and symptoms or complication (not treat the disease itself) Ex: dM foot
b. Diagnostic
- Biopsy (examination of tissue) -oscopy
c. Exploratory
- Exploring

2. Location
a. External
b. Internal

3. Mode (congenital – Inborn; acquired – Injury)

a. Constructive: Inborn {cheiloplasty)
b. Reconstructive: Acquired (reconstructive rhinoplasty)

4. Degree of Risk factors to consider: Organ involved, expected amount of blood loss, duration of surgery, extent of injury, age of the patient, type
of anesthesia)
a. Minor:
b. Major: heart surgery, ORIF, appendectomy ruptured

5. Urgency
a. Emergency: done within 24 hrs / ASAP
b. Urgent: done within 48 hrs. (intestinal obstruction)
c. Elective: done based on the surgeon/client’s preference
i. Required: client must undergo the surgery, can be delayed but it may cause disability or pain (hernia, cataract)
ii. Cosmetic: aesthetic purposes to improve body image and self-esteem. (tummy tuck, liposuction, breast enlargement)

Objectives and Purposes of surgery:

- To cure
- To relieve pain
- To prolong life
- To maintain dynamic body equilibrium
- To treat and prevent infection
- To correct deformities or defects (rhinoplasty)
- To ensure the ability to earn a living (prosthesis)

Surgical Team
Sterile Team Members: scrub, glove, gown
- Operating Surgeon: captain of the ship (pre-op judgement of the pt.; intra op-performance of the surgery; post-op management of client)
- Assistants of the Surgeon: Physician / Non-Physician (nurse)
- Scrub Nurse: RN assigned in the operating room

Unsterile Team Members: basic OR attire

- Anesthesiologist
- Circulating Nurse: RN

Example:
- he suctions the blood from the operative site retracts the operative site; assist the surgeon during suturing: assistant of the surgeon
- pressure dressing on the operative site: surgeon
- counts sponges on the floor; measures urine output; documents the count: circulating nurse
- interprets the I/O: anesthesiologist
- they witness the count start of surgery: scrub nurse, surgeon / assistant; circulating nurse
- major abdominal surgery: 4 (start, before closing peritoneum, fascia, skin)
- 5 counts: CS: start, closing uterus, peritoneum, fascia, skin
- *Report the discrepancy to surgeon: recount, search, if not found: Xray; if not inside: close; IR*
Concept of Asepsis
- Medical Asepsis- practices or processes that decrease the number and limit the spread of microorganisms. (CLEAN) (DISINFECTION)
- Surgical Asepsis- practices or processes that render an object or area totally free from microorganisms. (STERILE) (STERILIZATION)

*Spore: vegetative stage/encapsulated (protective covering) – heat and chemical resistant

DISINFECTION: NOT ENOUGH TO KILL THE SPORE

Physical Chemical
- Boiling: average of 10 (10 to 15 mins) timing: when the water - Alcohol: 70 %
begins to boil 100C (submerge) - Chlorine: linens
- Steaming: not submerge - Iodine: 7.5% - soak (scrubbing); 10% - antiseptic
- Sunlight: UV light - Lumbar prep: 10% only
- Abdominal skin prep: 7.5% - remove - 10%
- Phenol: Appendectomy (alcohol – burning effect for pus)

AGILITY (mabilis kumilos pero tama); ALERTNESS (keen observer) ; ANTICIPATION (you anticipate what will goes next)

STERILIZATION: KILL INCLUDING SPORES

Physical Chemical
- Autoclave: the most widely used. Steam under pressure. 130˚C or 270˚F to destroy the spores. - Smoking/immersion
 Muslin (linen) most widely used since reusable; Paper; Plastic – most ideal transparent, but
cannot be used as a sterile field
 How many days to consider sterile in an open cabinet: 21 days / Closed cabinet 28 days
 FIFO (first in – first out): management of resources
- Radiation: UV light
 dark linen (12 -24 hrs) labas ang plug
 Glass or lens
- Gas

Sample Sterilization & Level of Disinfection for Glutaradehyde – ideal soaking container (3)

Solution Sterilizer High level Disinfection Intermediate Level Low level Disinfection Notes
Disinfection
Cidex Activated alkaline 2.4% 10 hrs 45 mins 15 mins-45 mins 5-15 mins Usage: 14-30 days
dialdehyde All are destroyed except Fungi, virus, and some fungi, virus,no bacteria
spores bacteria
Cidex OPA, 0.55% 12 mins Usage: 14 days
orthophthalaldehyde
Cidex OPA (5.75%) Used in automated endoscopic
orthophthaladehyde concentrate 32 hrs 5 mins high level disinfector

Earle Spaulding’s Classification of Patient Care Items

Classification Use Sterilization or Disinfection?
CRITICAL Cuts intact skin and mucous membrane. Enters vascular areas of the body. STERLIZE
SEMI-CRITICAL Used on non-intact skin & mucous membranes STERILIZE
NON-CRITICAL Used on intact skin and mucous membrane DISINFECT

Principles of Sterile Techniques:

1. Only sterile items are used within the sterile field.
2. Sterile personnel are gowned and gloved.
o Sterile gown: 2 inches above elbow * axillary area is consider unsterile
o Packing: right side should hide – arm hole – lengthwise – roll neckline then end fold so its easy to unroll
o Wearing – neckline facing you * lumabas kamay (open) * hindi lumabas (close)
o Donning – Gown then gloves remove separately (glove to glove then skin to skin)
3. Tables are sterile only at table level. Scrub nurse draping – near her
4. Sterile personnel touch only sterile items or areas; Unsterile personnel touch only underlie items or areas.
5. Unsterile personnel avoid reaching over the sterile field and sterile personnel avoid leaning over an unsterile area.
6. The edges of anything that encloses sterile contents are considered unsterile.
7. The sterile field is created as close as possible to the time of use.
8. Sterile areas are continuously kept in view.
9. Sterile personnel keep well within the sterile area.
10. Sterile personnel keep contact with sterile areas to a minimum.
11. Destruction of the integrity of microbial barriers results in contamination.
Surgical Instruments
Sharps
Knife : Scalpel (versatile) Scissors: dissecting scissors Needles: closing
1st Once used back to table considered Mayo (tough): Maliit pero malapad Straight
unsterile Curve
2nd Cutting - Tough
BH 3 10, 11, 12, 13, 15 Metz (delicate): Mahaba pero payat Round - Delicate
BH 4 20, 21, 22, 23, 25 (peritoneum)

Suture Prep:
o Free Tie – suture only (mababaw lang)
o Stick tie – suture + needle holder / Kelly
o Suture ligature – suture + Needle Holder + needle (eyed) reusable
o Atromatic suture – suture + needle holder + needle (eyeless) disposable
o Single arm attachment (may isang needle) ; double arm (may dalawang needle each end)
o Right handed = eye of the needle is on the Right side

DISSECT CLOSING
Parts
Sharp Grasper Grasper Needle
Though
Knife Allis Allis
Skin, Fascia, Ligaments, Tendon, Cutting – tapper point
Mayo Tissue Forcep Tissue Forcep
Bones
Delicate Round – eye to
Knife Thumb Forcep Thumb Forcep middle (round)
Subcutaneous, Muscle,
Metz Bobcock (tubular)/ Kelly Bobcock (tubular)/ Kelly middle to end
Peritoneum
(triangular)

Graspers: Holding instruments

- Thumb forcep: (delicate) toothless
- Babcock: (delicate) – used to hold tubular organs (fallopian tube, appendix, urether) peritoneum (clamp can be used)
- Allis:(Though) -
- Tissue forces: (toothed)

Clamps: hemostat – occlude instrument; controls bleeding (have serration)

- Mosquito: 100% serrated
o Mosquito curve: 1st to offer: Curve (skin)
- Crile: 50%
- Kelly: 100%
- Ochsner: 100% - toothed Kelly

Retractors: exposing instruments

- Self-retaining retractor – with screw
o Balfour: retract sideward – retract downward
o Weitlaner: exposing thyroid gland

- Non-self-retaining – no screw
o Army-Navy: small
o Richardson: single / double
o Deaver:
o Bladder Retractor
o Ribbon / Malleable

Surgical Position
4 Quadrants of the body
1. Right upper quadrant
2. Left upper quadrant
3. Right lower quadrant
4. Left lower quadrant

9 REGIONS OF THE BODY

Right hypochondriac region Epigastric region Left hypochondriac region
Right lumbar region Umbilical region Left lumbar region
Right iliac region Hypogastric region Left iliac region
 Abdominal Organs Renal System Female Reproductive Organ
- Kidney - Fallopian Tube
- Ureter - Ovary
- Bladder - Uterus
- Urethra - Cervix
- Vagina

Incisions:
1. Upper midline incision
2. Lower midline incision = Hysterctomy, TAHBSO
3. Longitudinal midline incision = exlap with gun shot wound
4. Paramedian incision = end section of ascending colon
5. Mid – abdominal transverse incisions = abdominal transverse incision
6. Thoracolumbar incision = kidney
7. Oblique incisions
8. Mc burney’s incision – appendectomy
9. Pfannenstiel incision – for skin

VAGINAL BIRTH AFTER CS – VBAC

 Classical cs = cuts across (not allowed for vbac)
 Low vertical cs = cuts across (not allowed)
 Low transverse cs = allowed for vbac : muscle fiber of uterus is nakahiga (it cuts along the muscle fiber)

Benefit of position surgeon

- Ease of entry and exit of operative site

Benefit of position for anesthesiologist

- No pressure on major blood vessels and nerves
- The position will not impede respiration

Breaking the table: changing position only

Position
 Supine position / Dorsal Recumbent: CS – removal of cataract
 Prone position: one of the positions that is difficult: surgery of the back
 Semi – fowler: closed tube thoracostomy
 Lateral:
 Lithotomy: vaginal delivery; Hemmorroidectomy
 Kraske or jacknife position: hemmorroidectomy
 Trendelenburg– position
 Reverse trendelenburg position: neck, face and nose
 Kidney position / Lateral Jacknife: ( right kidney removal – right kidney position) (lateral jacknife = left lateral)

DUTIES & RESPONSIBILITIES OF OR NURSES

- Informed Consent
o Consent- signifies pt ’s willingness to undergo a procedure
o General consent – secured upon admission / covers routine procedure
o Purpose: “Protects the pt from any unwanted procedure to be done on him and protects the hospital from any claim of the pt that
an unwanted procedure was done on him. “
 Doctor = get informed consent
 Patient = qualified patient to sign the consent
 Nurse = witness
o Considerations:
 Legal Age
 Timing
 Who is qualified to sign?
 Coverage:
 Each surgical operation
 Any entrance into the body cavity
 Hazardous treatment or therapy
 Anesthesia
- Pre-operative Medications: 30 to 60 minutes prior to procedure
o Prepares client for anesthesia
o Potentiates effect of anesthesia
o Allays pt’s anxiety
1. Narcotic Analgesic: Morphine (post-op constipation), Demerol, Nubain (post-op constipation)
2. Sedative: Phenergan
3. Anticholinergic: Atrophine (reduces secretion)

A. CIRCULATING NURSE
1) Receive pt from Surgical ward nurse
o Endorsement- Pre-operative Checklist
o Right Pt, schedule
o Informed Consent
o Client preparation before the surgery.
 The day & night before the surgery
 The morning of the surgery
o The day & night before the surgery
 Conduct a Pre-operative visit (surgeon, anesthesiologist, scrub nurse)
 Client education on Post-op activities (1 – 2 days prior to surgery)
 Ensure all lab(CBC) & dx exam results are in and reported to MD
 Check CP clearance
 Check Blood Products
 Monitor VS, I&O
 Secure Consent
 Bathing prn
 Light evening meal
 NPO post midnight
 Psychological & spiritual support
 Administer Laxative drug if ordered
 Removal of nail polish
o The morning of the surgery
 Ensure NPO
 Oral care
 Enema if ordered
 Shaving
 Review post op exercises
 Pre-op medication
 Monitoring
 Removal of dentures
 Endorsement to OR
o Receive pt from Surgical ward nurse (endorsement)
o Establish rapport with client.
o Place pt on OR table & never leave pt alone.
o Position for anaesthesia ( supine or quasi fetal position )
o Perform Lumbar prep for Spinal/Epidural

Induction of Anesthesia
o Supine position
o Perineal Prep with proper positioning

Catheterization
o Supine
o Surgical positioning
o Abdominal Skin prep
o Draping
 Mayo cover (parang pillowcase)
 Mayo towel (over the mayo cover)
 4 OR towels = outlines the incision site
 Foot drape = to cover leg area
 Laparotomy sheet (lap sheet) = cover entire patient
o Cutting time

B. SCRUB NURSE
1. Receive pt from Surgical ward nurse.
 2. Prepare & organize the OR unit based on the case.
3. Open sterile packs & add sterile supplies & instruments.
4. Perform surgical scrubbing, gowning and gloving.
5. Organize sterile fields

Surgical Scrubbing: Surgical conscience

Time method 1st round 2nd round 3rd round
Hand 1 min 1 min ½ min
Arm 1 min 1 min None
Elbow ½ min None None
2.5 x 2 = 5 mins 2 x 2 = 4 mins ½ x 2 = 1 min

Brush – stroke method 1st round 2nd round 3rd round

Fingertips 10/3 5/3 3
Hand 10 5 3
Arm 6 3 None
Elbow 6 None none

6. Serve gowns and gloves to surgeons

7. Instrument count
8. Draping
9. Cutting time

Anesthesia Types:

General – Produces sensory, motor, reflex and mental block Regional

- Inhalation gas/liquid – sellick’s manuever - Local- infiltration, application, spray. It
- IV produces analgesia without LOC (Lidocaine
Inhalation Agents: & Procaine)
A. Non-Halogenated gas - TOPICAL: applied over surgical site EMLA
- Nitrous oxide- BLUE- Initial restlessness - FIELD/NERVE BLOCK: injected into SQ or
- Cyclopropane- Orange- for short procedure perineural space near or around desired
anesthesia site.
B. Halogenated Fluid - SPINAL: into subarachnoid space (inside
- Halothane- RED- Hypotension arachnoid) 6 to 8hrs (gradual)
- Enflurane - Yellow- muscle relaxation - EPIDURAL: into epidural space (outside
- Sevoflurane- sweet taste- pedia arachnoid), used in OB

C. Intravenous Barbiturates:
- Thiopental Na

D. Neuropleptic Agents
- Fentayl – decreases motor

E. Dissociative Agents:
- Ketamine (ketallar) – hallucinations

Stages of General Anesthesia : Anesthesia: loss of sensibility of pain

STAGE I (INDUCTION) Beginning anesthesia Drowsy, dizzy, Depressed pain sensation
STAGE II (EXCITEMENT/ DELIRIUM) Excitement Irregular breathing, Involuntary motor movements
STAGE III (SURGICAL) Appropriate for surgery, Muscle relaxation, constricted pupils, absent pupil reflex
STAGE IV Medullary depression Near death

SUTURES
Absorbable:
NON SYNTHETHIC
CUT GUT Intestine of the sheep – made of protein = protein attracts water
CHROMIC Brown 90 days before absorption Fascia, muscle, peritoneum
PLAIN Light yellow 70 days before absorption subcutaneous
SYNTHETIC
DEXON Green 90 days
VICRYL / PDS Violet Max of 90 Do not soak
*** do not soak but can be wet just to lubricate
Non – Absorbable
NON SYNTHETHIC
SILK Black / NAVY BLUE Saliva of caterpillar Do not soak
COTTON White Cotton tree Wet
SYNTHETIC
NYLON 25% a year absorption

POSTOPERATIVE PHASE
IMMEDIATE POST-OP CARE/ RR
1. Assure ABC
- O2 therapy with client on side/lateral position if applicable
- Maintain artificial airway until gag reflex returns
- Suction secretions & encourage deep breathing
- Check VS q 15 min until stable, then 30 min
- Check skin color, temp, drains, dressings
2. Note level of consciousness: reorient client
3. Discharge from RR when awake and responsive with easy breathing and acceptable BP and circulation
4. Promote optimal respiration: coughing, deep breathing, splinting incision, early ambulation, turning in bed.
5. Promote optimal circulation: early ambulation (sitting, turning) surgical wound splinted, leg exercises
6. Promote optimum nutrition, F&E balance, monitor IV, I&O, UO, drains, dressings, return of peristalsis (flatus, bowel movement) {paralytic ileus
– motor activity of the bowel is impaired} “auscultation of bowel sound”
7. Pain control: analgesics & comfort measure
8. Wound care
Hemostasis – to control/ minimize blood loss = prevent hypovolemic shock
- Mechanical
o Pressure: manual, digital, dressing, clamps, gel foam, drain, penrose
- Chemical – coag – Hemostan ,vit k, oxytocin
- Thermal – electrocautery; cryosurgery
o Eschar – burn tissue (possible peritonitis if drop inside the body)

Common discomforts:
- Pain
- Urinary retention – indwelling catheter
- Hiccups