Pain and Surgery Trans

NCM112: MEDICAL SURGICAL NURSING
Concept 1: Pain and Surgery
PERI OPERATIVE NURSING: HISTORY

§ Understanding of the principles of sterile and
aseptic technique basic knowledge and skills CODE OF HAMMURABI
about OR Nursing in order to provide surgical - If a patient died after a surgical procedure,
care. retibution would be reflected on the surgeon in
§ To develop confidence, alertness and competence the form of amputation of his right hand.
in meeting the patients’ needs.
§ To apply nursing processes in the care PERSIAN RULE OF SURGERY
management of patient undergoing preoperative, - Successful procedure on 3 Infidels before being
intra operative and post operative. pronounced as competent to practice surgery.
§ the care of a client or patient before, during, and
after and operation. GALEN OF PERGAMUM
§ It is a specialized nursing area wherein - Performing extensive dissection in animals
a registered nurse works as a team member of - Performed and stressed important of human
other surgical health care professionals. dissection
§ Activities performed by RN. During pre, intra and - Recommend students to practice dissection as
post operation phases of nursing care. often as possible
§ Total surgical experience that encompasses pre, - Study muscle, spinal cord, heart, urinary system
intra and post operation phases. and proved that arteries are full of blood
- Believes that blood originated in the liver, and
sloshed back and forth through the body, passing
SURGERY AS AN ARTS AND SCINCE through the heart, where it was mixed with air, by
- Branch of medicine that comprises perioperative pores in the septum.
nursing care encompassing such activities as - Introduced the spirit system consisting of natural
preoperative preparation, intraoperative spirits
preparation, and postoperative preparation.
LORD BERKELEY GEORGE ANDREW
SURGERY AS A SCIENCE MOYNINAN
o branch of medicine concerned with - Born in Malta, where his father was ensign in
disease or conditions requiring or the army
amenable to operative or manual - Enrolled at the Leeds School of Medicine in
procedures. 1883,
o It is a total care of illness with an extra - Graduate in 1887 with a degree form London
modality of treatment, the surgical and the conjoint diploma.
procedure. - Go medicine instead of joining the ARMY
- Become house surgeon to McGill and obtained 5
SURGERY AS AN ART years practical experience before being elected as
- comprises perioperative patient care an Assistant surgeon.
encompassing such activities as preoperative - Lecturer in 1896
preparation, intra operative judgment & - Nationally known as a professor of clinical
management, and post-operative care of patients. surgery by 1910 within the University Leeds.
- “Abdominal operation” earned him an
SURGERY AS A DESCIPLINE international reputation
- Combines physiologic management with - By 1925 be became Professor of Surgery
intervention aspect of treatment. - 1926-1931 President of the Royal College of
- Is a total care of illness with an extra modality of Surgeons of England
treatment and procedure
“SURGERY HAS BEEN MADE SAFE FOR THE
PATIENT; WE MUST NOW MAKE THE PATIENT
SAFE FOR SURGERY”
CHRISTINE JOYCE MARANAN 1

IMPROVEMENT IN PERIOPERATIVE PATIENT DISINFECTION

CARE TECHNOLOGY - process of destroying all pathogens
microorganism except spore bearing ones.
§ Surgical specialization of surgeons and team;
§ Sophisticated diagnostic and intraoperative STERILIZATION
imaging techniques; - Process of killing all microorganism including
§ Minimally invasive equipment and technology; spores
§ Ongoing research and technological
advancement. SURGICAL INTERVENTION
- Therapeutic process rendered to sterile health or
SURGERY RELATED TO TERMINOLOGIES maintain health
OPERATION ROOM/ OPERATING THEATER
- A room which patients are prepared for surgery, SURGICAL PROCEDURE
undergo surgical procedures, and recover from - Invasive incision into the body tissues or
the anesthetic procedures required for surgery. minimally invasive entrance into a body cavity or
for either therapeutic or diagnostic purpose
PERIOPERATIVE during which protective reflexes or self-care
- Used to describe the entire span of surgery which abilities are potentially compromised.
includes before, during and after of an actual
procedure. ANTISEPTIC
- Substance which combat sepsis and cause
PERIOPERATIVE NURSING bacteriostasis
- includes activities performed by the registered
nurse during the pre-operative, intra operative, ANESTHESIA
and post-operative phases of patient’s care. - Insensibility to pain and trauma with or without
o Total surgical experience that loss of consciousness.
encompasses pre-operative, intra-
operative and post operative phases of NECROSIS
patient care. - Death of a tissue
OR NURSE INFORMED CONSENT

- duty licensed registered nurse legally responsible - is a legal document that provides evidence of
for the nature and quality of the nursing care patient’s agreement to allow a procedure to be
patients. performed on him/her ; a signed consent is legally
regarded as VALID for a period of about 6
SURGICAL CONSENCE months or for as long as the patient consents to
- awareness that develops from a knowledge based the same procedure. Institutional policy may
on the importance of strict adherence to principles vary.
of aseptic and sterile technique.
ROOT MEANING
ASEPSIS Abdomen (o) Abdomen
- freedom form absence of microorganism
Adem (o) Gland
ASEPTIC TECHNIQUE Angi (o) Vessel
- method to prevent the contamination of
microorganism Arthr (o) Joint
- sterile to sterile Broncho (o) Bronchus
Card, Cardi (o) heart
Cephal (o) Head

Chole, Chol (o) Bile DIAGNOSTIC- Biopsy tissue sample
Chondr (o) Cartilage
REPAIR- Closing of hernia
Colo Colon
Cost (o) Rib PALLIATION- Relief of an obstruction
Crani (o) skull AESTHETHICS- Facelift
PROCUREMENT- Donor organ

SUFFIX MEANING
Cele Tumor, hernia TRANSPLANT- Placement of a donor organ
Centhesis Puncture
Ectomy Surgical incision BYPASS/ SHUNT- Vascular rerouting
Itis Inflammation
DRAINAGE/ EVACUATION- Incision of abscess
Litho Stone/ calculus
Ostomy/stomy Creation of new opening
STABILIZATION- Repair of a structure
Rhapy Repair
Oscopy Examination with a
STAGING- Checking of cancer progression
lighted instrument
Plasty Surgical repair or re-
snaping PARTURITION- Caesarian section
Pexy To fix or suture in place.
EXTRACTION- Removal of a tooth
SURGERY EXPLORATION- Invasive examination
- - branch of medicine concerned with disease or DIVERSION- Operation of stoma

conditions requiring or amenable to operative or
manual procedures. The discipline of surgery is
both an art and a science. 4 MAJOR TYPE OF PATHOLOGIC PROCESSES
REQUIRING SURGICAL INTERVENTION
OBJECTIVES OF SURGERY
Þ Prolongation of life O – OBSTRUCTION
Þ Relief of suffering - Impairment to the flow of vital fluids.
Þ Diagnosis and cure of disease process Ex. Blood urine, CSF, bile
Þ Alter form or structure P- PERFORATION
Þ Repair of injuries - Rupture of an organ
Þ Correction of deformities and defects E- EROSION
- Wearing of a surface or membrane
COMMON INDICATION OR SURGERY
T- TUMOR
- Abnormal new growth.
INCISION- Opening tissue or structure by sharp
dissection
EXCISION- Remove tissue or structure by sharp

dissection

§ PALLIATIVE SURGERY
REASONS FOR SURGICAL INTERVENTION - to relieve distressing signs and
q To preserve life symptoms, not necessarily to cure the
q To maintain dynamic body equilibrium disease.
q To undergo diagnostic procedures Ex. Resection of a tumor to relieve pressure and
q To prevent infection and to promote healing pain
q To obtain comfort.
q To ensure the ability to earn a living § COSMETIC SURGERY
q To alter cosmetic appearance - correction of defects, improvement of
q To restore or reconstruct a part of the body appearance or change to a new physical
that is congenitally malformed or damaged by feature.
trauma or disease. Ex. Rhinoplasty ; Cleft lip repair
CONDITIONS TREATED BY SURGERY

q Congenital – inborn deformity ACCORDING TO URGENCY
q Acquired – conditions resulting from trauma
or injury. § EMERGENCY
- immediate ; condition is life threatening
3 CATEGORIES OF SURGICAL PROCEDURE requiring surgery at once.
q Invasive surgery Ex. GSW
q Minimally Invasive surgery
q Non-Invasive surgery § URGENT OR IMPARATIVE
- client requires prompt attention within 24
CLASSIFICATION OF SURGICAL PROCEDURES to 30 hours.
Ex. Acute GB infection
ACCORDING TO PURPOSE
§ PLANNED OR REQUIRED
§ DIAGNOSTIC SURGERY - planned for a few weeks or months after
- to establish the presence of a disease decision and the client requires it at some
condition. It enables the surgeon to point.
verify a suspected diagnosis. Ex. Cataract removal
§ EXPLORATORY SURGERY § ELECTIVE

- to determine the extent of the disease - client will not be harmed if surgery is not
condition and at times to make or confirm performed but will benefit if it is
a diagnosis performed.
Ex. Revisions of scar
§ CURATIVE/REPARATIVE/RESTORATIV
E SURGERY § OPTIONAL
o Ablative – involves removal of - personal preference and usually aesthetic
deceased organ purposes.
Ex. AP ; Cholecystectomy Ex. Liposuction
o Constructive – involves repair of
congenitally defective organ ACCORDING TO EXTENT OR RISK INVOLED.
Ex. Orchidopexy ; THRA
o Reconstructive – involves repair of a § MAJOR- life threatening
damaged organ § MINOR- non life treatening.
Ex. Plastic surgery after burn.

SURGICAL RISKS PATIENTS PERIOPERATIVE NURSING

q OBESITY – increase incidence of morbidity - Perioperative nursing practice includes activities
and mortality due to low recovery after surgery. performed by the professional registered nurse during the
q FLUID – electrolyte Imbalance & Nutritional preoperative (before), intraoperative (during) and
problems – can cause delay and poor wound postoperative (after) phases of the patient’s surgical
healing experience.
q AGE – too young or too old
q Person with disability KEY ELEMENTS OF PERIOPERATIVE NURSING
q Patients with current disease or illness PRACTICE
q Patients with concurrent or prior Þ Caring
pharmacotherapy Þ Conscience
q Nature and location of condition Þ Discipline
q Magnitude and urgency of the surgical Þ Technique
procedure
q Mental attitude of the patient towards surgery CONCEPT OF SURGICAL CONSCIENCE
q Caliber of the professional staff and health care (Surgical Golden Rule)
facilities “ Do Unto The Patient As You Would Have Others Do
Unto You.”
POTENTIAL EFFECTS OF SURGERY TO THE
PATIENT OPERATING ROOM NURSING
q Stress response is elicited; PHILOSOPHY
q Defense against infection is lowered; To give service that aims to provide comprehensive
q Vascular system is disrupted; support physically, morally, psychologically,
q Organ functions are disturbed; spiritually and socially to a patient undergoing
q Body image maybe altered; surgery.
q Lifestyle is changed
GOALS
LEGAL LIABILITY, ACCOUNTABILITY, AND q To provide a safe, supportive and comprehensive
ETHICAL ISSUES care to patient;
q To assist the surgeon by functioning effectively
Safeguard the patient in the OR against hazards. as a member of the surgical team;
Protect the nurse, technologist, surgeons, q To create and maintain an aseptic / sterile
anesthesiologist and the hospital. Prevention focuses environment all the times.
on Quality Assurance.
OBJECTIVES
Q – quality improvement as an ongoing process. q To help the patient return as rapidly as possible
U - understanding regulations, standards, policies to the best physical and mental health attainable.
and procedure. q In case the patient did not return to his health, pain
A - accountability for one’s own actions. and discomfort should be eased and she/he should
L - legal rights of the patients be allowed to die in peace and with dignity
I - individualized patient care
T - technical competency
Y - your surgical & ethical conscience
“To be liable is to be legally bounded, responsible and

answerable.”

PERIOPERATIVE NURSE q Skilled listener, keen observer and abled

is a nurse who provides patient care, manages, communicator
teaches and studies the care of patients undergoing
invasive or non-invasive procedures. He/she possesses a
depth and breadth of knowledge that allows for the
coordination of care of the surgical patient. PERIOPERATIVE CARE
is the practice of patient-centered, multidisciplinary,
RESPONSIBILITIES and integrated medical care of patients from the moment
q Prioritizes interventions based on a of contemplation of surgery until full recovery.
comprehensive body of scientific knowledge and
variations in patient’s responses; 3 PHASES OF PERIOPERATIVE CARE
q Uses critical thinking skills in applying the PREOPERATIVE PHASE
nursing process, acting as a patient advocate, • begins with the decision to perform
and exercising judgment in a professionally surgery and continues until the client
accountable manner; reaches the operating area.
q Provides specialized nursing care to patients • in this phase, the perioperative nurse
before, during and after their surgical & invasive performs the assessment and planning
procedure; components of the nursing process.
q Works closely with all members of the surgical
team; INTRAOPERATIVE PHASE
q Helps plan, implement and evaluate treatment of • begins with the placement of patient on
the patient; the operating table, including the entire
q Designs, coordinates, and delivers care to meet surgical procedure and extends until
the identified physiological, psychological, transfer of the client to the recovery
sociocultural and room. The implementation component
q spiritual needs of the patients. of the nursing process is performed here.
EXPECTED ATTRIBUTES POSTOPERATIVE PHASE

q Considerate • each member of the operating room
q Informative & sincere team is an integral entity in unison and
§ Versatile harmony with his/her colleagues for the
q Analytical successful accomplishment of the
q Creative & resourceful expected outcomes.
q Humanistic
q Ethical PERIOPERATIVE PATIENT CARE TEAM
q With sense of humor (OPERATING ROOM)
q Objective each member of the operating room team is an integral
q Enduring entity in unison and harmony with his/her colleagues for
q Impartial, non-judgmental, open-minded the successful accomplishment of the expected outcomes.
q Manual and intellectual dexterity
q Intellectually eager and curious to learn STERILE TEAM
SURGEON
PERSONAL ATTRIBUTES each member of the operating room team is an
q Empathic integral entity in unison and harmony with his/her
q Conscientious colleagues for the successful accomplishment of the
q Efficient and well organized expected outcomes.
q Flexible and adaptable
q Sensitive & Perceptive Who can be the head surgeon?
q Understanding, reassuring, supportive q Licensed MD
q q DO (osteopath)

- RN, LPN (licensed practical nurse) or
q DDS or Oral surgeon (Doctor of Dental Surgery) LVN (licensed vocational nurse), ST
q DMD (Doctor of Dental Medicine) (surgical technologist)
q DPM (Doctor of Podiatric Medicine)
Major Responsibilities
Attributes q Responsible for maintaining the integrity, safety,
q compassionate interpersonal behavior; and efficiency of the sterile field throughout the
q accountability; procedure.
q humanistic concern; q Responsible for preparing and arranging the
q appropriate clinical skills in data gathering; sterile instruments and supplies for the surgical
q good decision making & problem solving skills; procedure;
q critical thinking ability q Anticipates, plan for and respond to the needs of
the surgeon by constantly watching the sterile
Major Responsibilities field;
q Preoperative diagnosis and care; q Should have knowledge, skills and experience
q procedure; with aseptic and sterile techniques;
q Post operative management. q Should have manual dexterity, physical stamina,
q Selection & performance of the surgical stable temperament, able to work under pressure,
with keen sense of responsibility and concern for
ASSISTANT TO SURGEON (first assistant/ second accuracy in performing all duties.
assistant)
qualified surgeon or a resident in an accredited NON-STERILE TEAM
surgical education program. ANESTHESIOLOGIST
- The resident is maybe an associate with is an MD or DO, certified by the Phil. Board of
whom surgical practice is shared and to Anesthesiology, who specializes in administering
whom part of the patient’s care maybe anesthetics to produce various states of anesthesia.
delegated.
- In hospital with accredited postgrad Major Responsibilities
surgical residency training programs, the q Choice and application of appropriate anesthetic
surgical resident in the third or later year agents & suitable techniques of administration &
usually acts as 1st asst. The resident is monitoring of physiologic functions;
given more responsibilities under q Maintenance of fluid & electrolyte balance &
supervision at the operating table to blood replacement during the surgical procedure;
acquire skill and judgment. q Minimize the hazards of shock, electrocution and
NURSE is free to refuse to perform as first assist out of fire;
concern for the well-being of the patient and for his/her q Responsible for overseeing the positioning &
professional accountability. movement of patients;
q Able to use and interpret correctly a wide variety
Major Responsibilities of Assistant to Surgeons of monitoring devices;
q Must perform duties under the direct supervision q Oversee the PACU to provide resuscitative care
of a certified surgeon; until each patient has regained control of vital
q Help maintain visibility of the surgical site, functions;
control bleeding, close wounds, apply dressings, q Participate in the hospital’s program of CPR as
handle tissues and uses instruments. teachers & team members. As well as consultants
and managers for problems of acute and chronic
respiratory insufficiency requiring inhalation
therapy & other fluid, electrolyte and metabolic
disturbances requiring IV therapy;
SCRUB NURSE – instrument and suture nurse q They are integral staff member of Pain Therapy
- nursing staff member of the sterile team; clinics.

CIRCULATING NURSE VENTILLATION

a RN or ST (surgical technologist) who functions must ensure a controlled supply of filtered air.
under the supervision of an RN. Air changes and circulation provide fresh air & prevent
accumulation of anesthetic gases in the room.
Major Responsibilities q AIR CONDITIONING is ideal and valuable; it
q Nursing judgment & decision-making skill are controls humidity;
requisites to assessing, planning, implementing q positive pressure system
and evaluating the plan of care before, during & after q filter air at 20 changes / hour
surgical operation. This is the professional q temperature from -18oC - 24oC
perioperative role; q humidity 50-55%
q Creation & maintenance of a safe & comfortable
environment for the patient through DOOR
implementing the principles of asepsis, ideally, sliding doors should be used. They
demonstrate a strong sense of surgical eliminate the air currents caused by swinging doors.
conscience;
q Constant flexibility in identifying potential FLOOR
environmental danger, stressful situation & meet must be suitably hard, durable for heavy
the unexpected, act in an efficient, rational equipment especially during transport from one room to
manner at all times; another & easy to clean.
q Maintenance of the communication link between
events & team members at the sterile field & LIGHTHING
persons not in the OR but concerned with the General illumination is furnished by ceiling lights in
outcome of the operation; white fluorescence bulbs which are evenly distributed
q Provision of assistance to any member of the OR throughout the room.
team in any manner in which the circulator is q Should be shadowless;
qualified; q be freely adjustable to any position or angle by
q Direction of the activities of all learners. The CN vertical or horizontal range of motion.
must have the supervisory capability & teaching q produce minimum heat to prevent injuring
skills needed to ensure maintenance of a safe & exposed tissues;
therapeutic environment for the patient. q be easily cleaned
NURSE ANESTHETIST PRINCIPLES IN DESIGNING AN OPERATING

refers to a qualified RN, anesthesiologist assistant ROOM
(AA), dentist, or physician who administers anesthetics. q Exclusion of contamination from outside the
suite with sensible traffic pattern within the
suite.
PERIOPERATIE ENVIRONMENT q Separation of clean areas from contaminated
is a specially designed and regulated area that areas within the suite
plays a significant role in patient safety during the surgical
procedure. TYPES OF DESIGNS
q Central Corridor or Hotel plan;
PHYSICAL FACILITIES q Central Core or Clean core plan;
LOCATION q Peripheral corridor;
located accessible to the critical care surgical patient q Combination central core & peripheral corridor
areas & the supporting service department, CSR, or Racetrack plan;
Radiology, pathology, etc. q Three corridor layout;
- many of OR suites are UNDER - q Grouping or cluster plan
GROUND or have solid walls without
windows

The OR suite should be large enough to allow for - The adequate size of an operating room is at least
correct technique yet small enough to minimize the 20x20x10 feet (400 sq ft or 37 m2) of floor space
movement of patients, personnel and supplies. Provision or maximum of 20x30x10 feet (600 sq ft or 60
must be made for traffic control. The type of design will m2).
predetermine traffic patterns. Signage should be posted - other rooms are designated for special procedures
properly. like endoscopy, TURP, etc.
3 AREAS OR DIVISIONS OF OPERATING ROOM

SUITE SUBSTERILE ROOM
q Unrestricted or Unsterile Area q work area or packing area
• Vestibular or Exchange Area (Transition q steam sterilizing room
Zone) q washer – sterilizer area
q Semi restricted or Semi sterile Area q storage room for supplies
q Restricted or Sterile Area q record room
• Sub sterile Room
VESTIBULAR/ EXCHANGE AREAS
1. UNRESTRICTED AREA/ UNSTERILE (TRANSITION ZONE)
AREA inside the entrance to the OR suite, separates the
this area is isolated by doors from the OR corridors from the rest of the facility.
main hospital corridor or elevators and from other q Pre-operative check-in unit - this is an
areas of the OR suite. unrestricted area of the OR for patient to change
• serves as an OUTSIDE-to-INSIDE from street clothes to gown;
access area, i.e. vestibular/exchange - must ensure privacy, create a feeling of
area. warmth & security, with lockers for
• Street clothes are permitted. safeguarding patient’s clothes & with lavatory
facilities.
2. SEMI RESTRICTED/ SEMI STERILE q Dressing rooms and Lounges - Access is from
AREA an unrestricted area to change from street clothes
personnel should be wearing OR scrub to OR attire before entering the semi-restricted
suit with cap. areas or vice versa. Clothes hanging areas must
• this area includes peripheral support be provided for both males and females. Shoe
areas and access corridors to the OR rack is advisable for the OR scrub suit.
like PACU, SICU, offices for anesthesia q PACU (formerly RR) - maybe outside the OR or
department & administrative OR nursing adjacent to the OR suite.
personnel, etc. - part of unrestricted area with access from both
semi restricted areas.
3. RESTRICTED/ STERILE AREA q Post-op holding area - a designated room for
personnel should be wearing complete patients to wait in the OR suite that shields them
OR scrub suit including mask. from distressing sights and sounds;
• this area performs sterile procedures. - provides privacy like individual cubicles with
• includes OR suite room, scrub sink curtain.
areas, sub sterile rooms where - simple procedures can be perform here like
catheterization, gastric tube, iv insertion, etc.
unwrapped supplies are sterilized.
• operating rooms is more desirable if all
PERIPHERAL SUPPORT AREAS
have the same size, so they can be used
q Central Administrative control – this area is
interchangeably to accommodate elective
maybe within the unrestricted or semi restricted
& emergency cases. It must accommodate
areas. Offices for administrative personnel are
equipment like laser, microscope, video
best located where they have access to both areas.
equipment, c-arm, portable light, etc.
q

q Sterile supply room – for storing sterile linens, REVIEW OF INFECRTION CONTROL
sponges, gowns and instrument packs. is the most basic and important procedure in
q Work and storage areas – clean and sterile nursing care, and it will deter-mine the quality of care
supplies must be separated from soiled items and given in a facility.
trash.
q General work room – must be centrally located MICROORGANISM
to the OR suite for wrapping / packaging of Are living things so tiny that cannot be seen by
supplies for sterilization. naked eye.
q Utility room – contains a washer-sterilizer, sinks, q Also called microbes or germs.
cabinet, & all necessary aids for cleaning. q always present in the environment and on the
q Housekeeping Storage area – stores all cleaning body.
supplies & equipment. Equipment used within the q not all micro organisms are harmful. Some are
restricted area is kept separated from that used to helpful. MO can also serve both good and
clean the other areas. harmful purposes.
q Anesthesia work & storage areas – serves as q microorganisms that cause disease is called
storage of anesthesia equipment & supplies, also pathogens.
provides space for drugs and anesthetic agents.
TYPES OF MICROBES
FURNITURE AND OTHER EQUIPMENT INSIDE • BACTERIA (Bacterium)
THE OPERATING ROOM - single-celled microscopic organisms that
q OR Table – divided into head, body and leg multiplies rapidly. Some are beneficial
sections. Attachment includes knee strap, arm to humans while others can cause
strap, arm board, anesthesia screen, metal infection.
footboard, etc.
q Instrument table or Back table • FUNGI (fungus)
q Mayo table – placed above and across the patient - microscopic, single celled or multi-celled
and contains instruments that are in constant use plants that live either on plants or
during operation. animals.
q Small table for patient’s preparation equipment - can infect the mouth, vagina, skin, feet &
(skin prep table) other body parts.
q Ring stand for basin (s).
q Anesthesia table and machine • PROTOZOA (protozoan)
q Sitting stools and foot stools/standing platforms - single-celled, microscopic animals,
q IV stands and hangers for IV solutions usually living in water and can cause
q Suction machine, bottles and tubing disease.
q Cautery machine
q Kick buckets in wheeled bases • RICKETTSIE
q Basin in wheeled bases for soiled sponges and - found in fleas, lice, ticks and other insects;
gloves spread to humans by insect bites. Person
q Communication system / Intercom infected may experience fever, chills,
q Defibrillator headaches, rashes, etc.
q Negatoscope
q Wall Clock with second hand • VIRUS
q White board for recording of sponge, instrument - smallest known living infectious agents that
and sharps counting grows in living cells.
q Blood warmer machine attached to IV pole
q Other monitoring machines
q Cabinets / carts – for storing supplies and drugs

CONDITIONS THAT FAVOR THE BACTERIAL q nausea and vomiting

GROWTH q increased PR & RR
1. Food q diarrhea and rashes
- bacteria grow well in leftover foods. q redness & swelling of a body part
2. Moisture q discharge or drainage from the affected part.
- bacteria grow well in moist places. q sores in mucous membrane
3. Temperature
- high temp (170’F) kills most bacteria. At CHAIN OF INFECTION
normal human body temp (98.2’F), bacteria
thrive easily on & in the human body. Low
1. Causative Agent or Source
temp (32’F) do not kill bacteria but retard - is the pathogen that causes the infection or
their growth & activity. disease (bacteria, virus, fungi, protozoa).
4. Oxygen –
a. aerobic – w/ O2 2. Reservoir
b. anaerobic – w/o O2 q is the place where the causative agent is able
4. Matter to live and reproduce.
a. saprophytes – live on dead matter or
tissue. q Humans with active disease
b. parasites – live on living matter or q Humans who are carriers
tissue. q Animals
5. Light q Fomites or objects
- darkness favors the development of bacteria q Environment
where they become active and multiply
rapidly. Light is the worst enemy where
3. Portal of Exit
bacteria become sluggish and die rapidly.
- is the means by which the pathogens leave
INFECTION the reservoir like human secretions.
The invasion and growth of disease-causing q urine, feces
microorganisms in the body. q saliva, tears
• Local – involves a certain body part. q drainage, excretions
• Systemic – involves the whole body. q blood
NOSOCOMIAL INFECTION 4. Mode/Route/ Method of Transmission

- infection that is required as a result of being in the - the way the pathogen is transmitted from one
health care facility environment. reservoir to the new host’s body
CROSS INFECTION MAIN ROUTES
- occurs when one patient or staff passes the
CONTACT TRANSMISSION
pathogens to another patient, staff or visitors.
- most important and most frequent route.
• Direct contact
COMMUNITY ACQUIRED INFECTION
- direct body-surface-to-body-
- these are natural disease process that developed
surface c ontact &
or were incubating before the patient is admitted
transfer of pathogens.
to the hospital.
• Indirect contact
SIGNS AND SYMPTOMS OF INFECTION - involves contact with a
q fever contaminated objects like
q pain and tenderness needles, instruments, un-
q fatigue and loss of energy washed hands and gloves
q loss of appetite (anorexia)

DROPLET TRANSMISSION 3. Cilia

- occurs when droplets containing 4. Coughing and sneezing
microorganisms are sent flying a SHORT 5. Tears
DISTANCE through the air & are deposited 6. Stomach acid
on the eyes, nose or mouth (sneezing, 7. Fever
coughing, and droplets). 8. Phagocytes
9. Inflammation
AIRBORNE TRANSMISSION 10. Immune response
- occurs when evaporated droplets
containing pathogens remain in the air for ASEPSIS
LONG PERIODS OF TIME and are Is a freedom of infection or infectious
carried along by air currents. materials.
COMMON VEHICLE TRANSMISSION
MEDICAL ASEPSIS
- occurs when pathogens are transmitted by
- practices and procedures to maintain a clean
contaminated items like food, water,
environment by removing or destroying the
medications, hospital equipment and
pathogens.
machines.
SURGICAL ASEPSIS
VECTOR – BORNE TRANSMISSION
- practices and procedures that keep an area or
occurs when intermediate hosts such as infected rats, flies
object totally free from all microorganisms.
or mosquitoes, transmit
COMMON ASEPTIC PRACTICES
5. Portal of Entry
q Perform daily personal hygiene.
- is the means by which the pathogens enter the
q Habitual hand washing
body such as:
q cuts or breaks in the skin or mucous
q Covering nose and mouth when coughing and
membrane; sneezing
q respiratory tract; q Proper waste segregation and disposal
q gastrointestinal tact q Practice the three (3) R – reuse, recycle, reduce
q Genito-urinary tract; q Proper wearing of the Personal Protective
q circulatory system; Barriers or Equipment (PPE).
q passage from mother to fetus
SURGICAL ASEPTIC TECHNIQUE PRINCIPLES.
6. Susceptible Host q All objects used in a sterile field must be sterile.
- is the individual who harbors the pathogens q Surgical gowns are considered sterile in front
where they reproduce and cause infection. from shoulder to table level. The sleeves are
sterile to 2 inches above the elbow.
FACTORS THAT AFFECT THE INFECTION q Sterile items that are out of vision or below the
RATE waist level of the nurse are considered unsterile.
q Malnutrition q The edges of a sterile field are considered
q Obesity unsterile.
q Age – too young and too old q The skin cannot be sterilized and is unsterile.
q Presence of chronic disease and impaired defense q Sterile objects can become unsterile thru
mechanism prolonged exposure to airborne microorganisms.
q Certain type of operation q Movement within or around a sterile field must
not cause contamination of the sterile field.
BODY’S DEFENSE AGAINST INFECTION q A sterile barrier that has been permeated must be
1. Skin – body’s most important defense. considered contaminated.
2. Mucous membrane – mucus secretions

q Items of doubtful sterility should be considered METHODS OF DISINFECTION
unsterile. PHYSICAL DISINFECTANTS
q Sterile objects should be touch by sterile - Boiling of water (212’F or 100’C). Minimum
personnel only. If touches by anything unsterile, boiling period is 30 minutes.
both are considered contaminated. - Horizontal and vertical scrubbing with soap and
q If unsterile, use a pickup forcep to get or pick water.
sterile objects. Observe proper handling of the - UV Radiation and fumigation with chemicals
forceps. Fluid flows in the direction of gravity. are NO LONGER recommended because of
q The outside package is NOT STERILE and can the limitation of their practical usefulness.
be handle and touch by bare hands. The edges of
the sterile fields are considered unsterile once the CHEMICAL DISINFECTANTS
package is opened. • Alcohol (70%-90%) ethyl or isoprophyl – used
q Dispose all sharps in designated puncture- as a housekeeping disinfectant and can be used
resistant containers. in semicritical instruments. Hazard : volatile
and it will harden and swell plastic tubing.
STANDARD PRECAUTION • Chlorine compounds – has limited use in
formerly known as UNIVERSAL hospital. Ex. Sodium hypochlorite 0.5-1%
PRECAUTION, protect health care workers from • Phenolic compounds – kills microorganisms
contact with blood and body fluids of all patients. by coagulation of protein. Major choice when
dealing with fecal contamination.
Purpose of Standard Precaution • Formaldehyde (either in solution or gas form)
- To prevent transmission of infection from – is sporicidal in minimum of 12 hours.
blood-borne pathogens. •
Glutaraldehyde – agent of choice for sterilization. Good
Rationale of Standard Precaution also for instruments that can not be steam sterilized.
- Is that health care worker may not know who Recommended soaking time is 15-30 minutes
is and is not infected.
METHODS OF STERILIZATION
PRACTICES PHYSICAL MEANS
q Hand washing - Steam under pressure (moist heat/ autoclave) –
q Wearing of appropriate PPE easy, safe, surest method, fastest, least expensive
q Environment cleaning and spills management and leaves no harmful residues.
q Proper handling of waste and waste disposal
q Do not recap, bend or break used needles. Disadvantage: dangerous and subject to human
errors.
STERILIZATION AND DISINFECTION o Radiation – has a very low
DISINFECTION temperature effect on materials but
Þ a cleaning process that destroys most penetrates materials very well.
microorganisms through the use of certain
chemicals or boiling water. CHEMICAL MEANS
Þ uses a DISINFECTANT, an agent that kills - Immersion / Soaking in Glutaraldehyde –
growing microorganisms. penetrates into crevices of instruments;
STERILIZATION noncorrosive, non-staining, safe, does not
Þ a cleaning process that kills all microorganisms, damage the lenses. Disadvantages includes it
including spores. mild but irritating odor, it has low toxicity so rinse
Þ uses a chamber or equipment known as the objects with sterile water prior to use.
STERILIZER, to attain either physical or • soaking solution should be changed
chemical sterilization. every 28th day of use.
Ex. Cidex, Zephiran erile water prior to use.

GUIDELINES ON STERILIZATION & Þ Performance record for all sterilizers should be

DISINFECTION maintained as well as the preventive maintenance
Þ IN HOUSE PACKAGING MATERIALS - should be performed according to individual
materials used for IHP and wrapping of sterile policies on a scheduled basis by qualified
supplies should : personnel.
• Be compatible with the sterilization
process. Þ Policies and procedures for sterilization and
• Provide a cost-effective barrier to disinfection should be written and reviewed
microorganisms. periodically. This should be readily available
• Allow for ease in aseptic presentation. within the practice setting for
• be free of toxic ingredients and non-fast
dyes and be relatively nonabrasive. CONSIDERATIONS IN SELECTING THE
METHOD OF STERILIZATION OR
Þ All items to be sterilized should be prepared to DISINFECTION
reduce the bio burden. q availability / efficiency of sterilizing agent /
disinfectant;
Þ All articles to be sterilized should be arranged so q physical properties of the item;
all surfaces will be directly exposed to the q urgency of need;
sterilizing agent for the prescribed time and q standards of practice;
temperature. q hazard of toxic residue;
q infection control;
Þ All wrapped articles to be sterilized should be q manufacturer’s recommendation
packed in materials that meet the standards/ q decontamination requirements;
criteria in the recommended practice for in- q packaging requirement;
hospital packaging materials. q ease of transport and storage;
q environmental / disposal requirements;
Þ Chemical indicators, also known as sterilization q cost containment
process indicators, should be used to indicate
that items have been exposed to a sterilization
process.
Þ The efficacy of the sterilization process should be

monitored at a regular interval with reliable
biological indicators.
Þ Every package should be labeled with the date of

sterilization, autoclave number & the sterilizer
used.
Þ Sterilized items should be carefully handled and

only when necessary. They should be stored in
well-ventilated, limited access area with
controlled temperature and humidity.
Þ Flash sterilization should be used for emergency

sterilization of clean, unwrapped instruments and
porous items only.

OPERATING ROOM ATTIRE

consists of body covers, such as a two-piece Þ First use of caps and sterile gowns occurred in
pantsuit, head cover or cap/turban, mask, shoe cover Germany while the value of Joseph Lister’s
or booties, goggles, and apron. principle of antiseptic surgery to exclude
putrefactive bacteria from wounds was still being
PURPOSE debated.
q Provide effective barriers that prevent the
dissemination of microorganisms to the patient. Þ From 1908 to 1930, various styles of turbans and
q Protect personnel from infected patients and shower cap-style head coverings were worn.
against exposure to communicable diseases and Þ In 1913, Charles Mayo & team were
hazardous materials. photographed
q Has been shown to reduce particle count of
shedding from the body from over 10,000 Þ operating in surgical gowns, caps and masks.
particles per minute to 3000 per minute, or from Þ In 1930 & 1940s, scrub dresses began to replace
50,000 microorganisms per cubic foot to 500 nurses’ regular uniforms, heretofore worn under
microorganisms per cubic foot. the sterile gown, Observers in the OR were
gowned, capped and masked.
HISTORICAL BACKGROUND
Þ OR nurse take a bathe before a surgical Þ In 1958, disposable latex gloves were introduced.
procedure, to take a carbolic bath before Þ The most efficient masks are disposable ones
laparotomy & to wear long sleeves & clean apron containing a high efficiency filter.
for the surgical procedure. Þ In the 1960s full skirts were replaced by close
fitting scrub dresses and pantsuits that reduced
Þ In 1883, Gustav Neuber insisted the wearing of the hazard of brushing against a sterile table when
caps by OR personnel. near or passing by it.
Þ Hunter Robb, a gynecologist at Johns Hopkins Þ In 1950, OR personnel were required to change
Hosp, Baltimore, insisted on OR cleanliness & on shoes when entering the OR suite and to wear
the wearing of caps & sterile gowns in the OR. only those shoes when within the suite. Currently
disposable shoe covers are
Þ In 1897, Dr. William Halsted designed a Þ commonly worn.
semicircular instrument table to separate himself,
in sterile gown & gloves, from observers in street CRITERIA FOR OPERATING ROOM ATTIRE
clothes who watched him operate. q Should be an effective barrier to microorganisms.
Both reusable woven and disposable nonwoven
Þ Johann von Mikuliez, a pioneering German materials are used. Design and composition
surgeon, advocated the wearing of cotton gloves should minimize microbial shedding.
in 1896 but these were soon found to lack the
qualities of impermeable rubber gloves for q Should be closely woven material void of
infection control. He also advocated the use of dangerous electrostatic properties. The garment
gauze masks in 1897. must meet the fire protection standards, including
resistance to flame.
Þ Till 1900, the surgeon often relied on the nurse to
have the necessary instruments in her apron
pocket. q Nylon and other static spark-producing materials
are forbidden as outer garments.
Þ Apron was replaced by scrub suit while long q Should be resistant to blood, aqueous fluids, and
sleeves are recommended for anesthesiologist & abrasions to prevent penetration by
circulators to reduce the shedding of organisms. microorganisms.

q Designed should be for maximal skin coverage. o Persons with cuts, burns or skin lesions
q Should be hypoallergenic, cool and comfortable should not scrub or handle sterile
q Should be non-generative of lint. Lint can supplies because serum may seep from
increase the particle count of contaminants in the the eroded area.
OR.
o Sterile team members who are known
q Should be made of pliable material to permit carriers of pathogens should routinely
freedom of movement for the practice of sterile bathe and scrub with appropriate
technique. antiseptic agent & shampoo their hair
q Should be able to transmit heat and water vapor daily.
to protect the wearer
o Fingernails should be kept short. Nail
q Should be colored to reduce glare under lights. polish is not allowed. Studies have
Various types of clothes in colorful prints that shown that artificial nails and other
fulfill the necessary criteria are both attractive enhancers harbor microorganisms esp.
and functional. fungi & gram-negative bacilli.
q Should be easy to don and remove o Jewelries including rings & watches
q Should be an effective barrier to microorganisms. should be removed before entering the
semi restricted & restricted areas.
DRESS CODE Necklaces & chains can grate on the skin,
ü Location of dressing room; increasing desquamation which might
ü Street clothes are NEVER worn beyond the fall into a wound or contaminate the
unrestricted area; sterile field. Pierced-ear studs must be
ü Only approved, clean, and/or freshly laundered confined within head cover. Dangling
or attire is worn within the semi restricted areas. earrings are inappropriate in the OR.
This applies to all, both professional,
nonprofessional and visitors alike; o Facial makeup should be minimal.
ü OR ATTIRE should not be worn outside the o Eyeglasses should be wiped with a
OR suite. This protects the OR environment from cleaning solution before each surgical
micro-organisms inherent in the outside procedure & properly secured.
environment and protects the outside from
contamination normally associated with the OR. o Hands must be washed frequently and
thoroughly. Hand cream maybe use after
ü Before leaving the OR suite, everyone should to prevent chapping and drying of hands.
change to street clothes.
ü lab gown, smock gown (THIS PRACTICE IS ü Comfortable, supportive shoes should be worn to
NOT ENCOURAGED) minimize fatigue and for personal safety. Shoes
ü A clean, fresh scrub suit should be put on after should have enclosed toes and heels; clogs,
return for reentry to the suite. slippers and sandals should not be worn. Shoes
must be cleaned frequently.
ü OR ATTIRE should be hung or put in a locker ü External apparel that does not serve any
for wearing a second time. If disposable, discard functional purpose should not be worn inside the
in the trash after one use. OR.
ü Personal hygiene must be reemphasized.

o Person with an acute infection such as
cold or sore throat should not be
permitted within the or suite.

COMPONENTS OF OPERATING ROOM ATTIRE 3. SHOE COVER

1. BODY COVER q should be clean, washable and soft-soled;
q one piece overall with attached hoods and boots q maybe worn in semi restricted and restricted
are convenient garb for visitors whose presence areas;
in the OR will be brief like the pathologist.
q protect the wearer from spills into or onto shoes
q must be don a scrub suit before entering a semi- during procedures;
restricted area.
q shoes restricted to wear in the OR or shoe covers
q available also in pantsuits which is more over shoes are preferable in reducing microbial
preferred than the overall type. transfer from the outside into the OR suite.
q the shirt and waistline drawstrings are tucked q can inadvertently become soiled and harbor
inside the scrub pants to avoid touching sterile microorganisms, so it should be removed before
areas and to reduce fallout of skin debri from entering the dressing room and be removed
thoracic and abdominal areas. before leaving the OR suite.
q scrub suit should be changed as soon as possible q protective gloves should be worn to change shoe
whenever it becomes wet or visibly soiled. covers whenever they become wet, soiled or torn.
q persons who will not be part of the sterile team 4. MASK

member should wear long sleeved jackets over a q worn in the restricted areas to contain and filter
scrub suit. droplets containing microorganisms expelled
from the mouth and nasopharynx during
2. HEAD COVER/ CAP/ TURBAN breathing, talking, sneezing and coughing.
q cap or hood is put on before a scrub suit to protect
the garment from contamination by hair; q should be worn at all times in the restricted areas
where sterile supplies are exposed.
q all facial and head hair must be completely
covered; q reusable cotton masks are obsolete because they
filter ineffectively as soon as they become moist.
q types include disposable, lint free, nonporous,
nonwoven fabrics. Reusable cap should be made q disposable mask made of soft, cloth like material
of a dense woven material and laundered daily; in very fine synthetic fiber mats is more
appropriate to use because:
q net caps are not acceptable; o at least 95% efficient in filtering
q hair should not be combed while wearing a scrub microbes from droplet particles;
suit; o a fluid resistant mask is advantageous;
o cool, comfortable and non-obstructive to
q persons with scalp infection should be excluded respiration;
from the OR and treated first; o non irritating to the skin because of its
polypropylene, polyester or rayon fibers.
q if hair is long, a helmet or hood must be worn to q should be worn over both nose and mouth and
cover the neck area. It should be well fitted to should conform to facial contours to prevent
confine and prevent escape of any hair. leakage of expired air.
q caps of different colors are helpful to differentiate q double masking is not recommended because the
personnel. extra thickness can cause venting from the effort
to breathe through it.

To prevent cross infection, mask should: before donning latex gloves. Hydrocarbons will
1. be handled only by the strings. Do not handle the penetrate latex, causing a change in its physical
mask excessively; characteristics, including tear resistance.
2. never be lowered to hang loosely around the • clean objects and sterile packages should not
neck, on top of the cap, or put in a pocket. Avoid be handled with contaminated gloves.
disseminating microorganisms; • sterile gloves are worn by sterile team
• be promptly discarded into the proper members and for all invasive procedures.
receptacle on removal. Remask with a • utility or working nons-terile gloves are
fresh mask between patients. worn for cleaning and housekeeping.
• be changed frequently. Do not permit
the mask to become wet. Talking should - sterile and non-sterile single use disposable latex
be kept to a minimum. and vinyl gloves are discarded after use. They
should not be washed and reused.
5. EYE WEAR / GOGGLES - hands must be washed thoroughly after removing
q worn to reduce risk of blood or body fluids from the gloves.
the patient splashing into the eyes of sterile team
members, or bone chips or splatter alike. 7. STERILE GOWN
q is worn over the scrub suit to permit the wearer to
q with side shields, anti fog goggles, combination come within the sterile field.
surgical mask with a visor eye shield. q differentiate sterile from unsterile members.
q eye wear or face shield that becomes q although the entire gown is sterilized, the BACK
contaminated should be decontaminated or IS NOT STERILE, NOR ANY AREA BELOW
discarded promptly. TABLE LEVEL, once the gown is donned.
q laser eye wear must be worn for eye protection q wrap around sterile gowns that provide coverage
from laser beams. to the back by an overlap is more
RECOMMENDED.
q eye wear with face shield should be worn when
handling or washing the instruments, when the q If the gown is closed by ties along the back, a
activity could result in a splash, spray or splatter STERILE VEST should be put on to cover the
to the eyes or face. back.
6. STERILE GLOVES q cuffs of the gown are stockinette (rib-knit) to

q non sterile latex or vinyl gloves should be worn tightly fit wrists. Sterile gloves cover the cuffs of
when handling contaminated materials. the gown.
q surgical gloves are made of natural latex rubber, q should be resistant to penetration by fluids &
synthetic rubber, vinyl, or polyethylene. blood.
q should be comfortable without producing

LATEX excessive heat build up.
- is a polymeric membrane of natural rubber with
an infinite number of holes between lattices. It is q reusable gowns must be made of a densely woven
better barrier than vinyl type. Latex contains material.
protein antigen & is cured with agents that may
cause an allergic dermatitis or systemic q Pima cotton with a 270-280 thread count per
anaphylaxis. Petroleum-based lotions or square inch treated with a moisture-repellent
lubricants SHOULD NOT be used on the hands finish

ü To decrease the number of resident
q some reusable are cotton-polyester blend. microorganisms on skin to an irreducible
q seams of the gowns should be constructed to minimum.
prevent penetration of fluids. ü To keep the microorganisms to minimum during
the surgical procedure by suppression of growth.
q woven textile gowns withstand about 75 ü To reduce the hazard of microbial contamination
launderings & sterilizing cycles before discarding of the surgical wound by skin flora.
them.
MATERIALS NEEDED FOR SURGICAL
q If punctured or torn, gown should be changed HAND SCRUB
during the procedure. SCRUB SINK
• is adjacent to the OR for safety and convenience;
q all woven & some nonwoven gowns are not • automatic control or foot or knee operated
flame-retardant. Fire-resistant gowns should be faucets;
worn for laser surgery and when electro surgery • sink is deep & wide enough
is used. • Should be used only for scrubbing or hand
washing only.
8. LEAD APRON • Should not be used to clean or rinse
q decontamination apron should be worn over the contaminated/ soiled instruments and equipment.
scrub suit to protect against liquids and cleaning
agents during cleaning procedures. This should SCRUB BRUSH
be a full front barrier. • reusable scrub brushes
• disposable sponges
q should be light weight and full front. Aprons
• single use disposable brush-sponge combination
protect the surgeon & nurse against liquid and
with impregnated antiseptic detergent agents.
cleaning agents during operation.
• Brush should not cause skin abrasion
q protects against radiation exposure or when • reusable brush maybe wrapped to provide sterile
handling radioactive implants. individual packages.
• Reusable nail cleaners should be use to clean
REVIEW OF SURGICAL HAND SCRUBBING under the nail.
Þ is the process of removing as many • Orangewood sticks are not used because the
microorganisms as possible from the hands and wood may splinter & harbor Pseudomonas
arms by mechanical washing & chemical organisms.
antisepsis before participating in surgery.
Þ Mechanical washing with friction removes ANTISEPTIC AGENTS
transient organisms. Chemical antisepsis reduces • antiseptic agents are approved by FDA.
resident flora & inactivates microorganisms with • different agent has different specific microbial
antiseptic agents. agent.
Þ Done before gowning & gloving for each surgical • agents alter the physical or chemical properties of
procedure the cell membrane of microorganisms, thus
destroying or inhibiting cellular functions.
Purposes of Surgical Hand Scrub • should be a broad spectrum antimicrobial agent;
ü To help prevent possibility of contamination of • should be fast acting and effective;
the operative wound by bacteria on the hands and • should be nonirritating and non sensitizing;
arms. • should be prolonged-acting;
ü To remove soil, debris, natural skin oils, hand • should be independent of cumulative action.
lotions and transient microorganisms from the
hands & forearms of sterile members.

PREPARATIONS IMMEDIATELY BEFORE
1. 4% Chlorhexidine Gluconate SCRUBBING
o produces effective, immediate, and q Inspect the hands for cuts and abrasions. Skin
cumulative reductions of resident & transient integrity should be intact.
flora. q All hair is covered properly by headgear
o effect is maintained for more than 6 hours. including the pierced ear studs.
Non irritating to the skin but highly irritating q Adjust disposable mask snugly & comfortably
if splashed in the eye. over nose & mouth.
q Clean eyeglasses if worn. Adjust comfortably in
2. Iodophors relation to mask.
o is a povidone-iodine complex against gram q Adjust water to a comfortable temperature and
positive & gram negative microorganisms. amount.
o irritating to the skin
o not sustained for a prolonged period (6hrs). TYPES OF SURGICAL SCRUB PROCEDURE
1. Time Method
3. 1% Triclosan - a. Complete scrub (5-7 minutes)
o nontoxic, nonirritating, & develops a b. Short scrub (3 minutes)
prolonged cumulative suppressive action 2. Brush-stroke Method or Counted Method
when used routinely. Less effective than a. 30 Strokes Method
Chlorhexidine Gluconate and Iodophors. b. 15 Strokes Method
4. 60% / 90% Alcohol STEPS IN BRUSH STROKE METHOD (15 STROKES

o nontoxic, does not have residual activity, has METHOD)
drying effect on skin. q Wet hands and arms up to 2 inches above the
elbow;
5. 3% Hexachlorophene q Lather with antiseptic agent;
o most effective after buildup of cumulative q With the hands held under running water,
suppressive action. Available by prescription clean under the fingernails of both hands with
only. nail cleaner & discard after use;
q Rinse both hands and arms under running
PREPARATION FOR SURGICAL SCRUB water, keeping hands up;
q Skin & nails should be kept clean and in good
q Take a sterile brush and apply an antiseptic
condition and cuticles should be uncut.
q Fingernails should not reach beyond the fingertip
agent and start ding the brush stroke method
to avoid glove puncture. on ONE HAND first following:
q Fingernail polish should not be worn. q 15 strokes each nail
q Artificial devices must not cover natural q 15 strokes all sides of each finger
fingernails q 15 strokes each dorsum
q Remove all jewelries from fingers, wrists and q 15 strokes each palm
neck. q 15 strokes for each third of arm up to
q Ensure to fold the sleeves of the scrub suit at least 2 inches above the elbow.
2 to 3 inches above the elbow. q Repeat the above steps for the other hand and
arm;
BEFORE PROCEEDING TO THE SCRUB SINK: q Rinse the hands and arms thoroughly;
q Open out the sterile gown pack onto a clean back
q Stay at the scrub sink for a few seconds for
table, only grabbing the outermost edges to
maximize the sterile field. the dripping of water while maintaining the
q Open the sterile glove packet and let it drop onto hands up.
the open sterile gown pack.

q Keeping your hands on the outside of the gown
GOWNING AND DONNING OF SURGICAL under a protective cuff of the neck and shoulder
GLOVES area, offer the inside of the gown to the surgeon.
Purpose The surgeon slips the arms into the sleeves.
• Sterile Gown is worn to exclude the skin as a
possible contaminant and to create a barrier q Release the gown. The surgeon holds arms
between the sterile and unsterile areas. outstretched while the circulator pulls the gown
onto the shoulders and adjusts the sleeves so the
General Considerations cuffs are properly placed. In doing so, only the
• The scrub person gowns & gloves self, then may inside of the gown is touched at the seams.
gown and glove the surgeon & assistants.
• Gown packages preferably are opened on a DONNING OF STERILE SURGICAL GLOVES BY
separate table from other packages to avoid CLOSED GLOVE TECHNIQUE
contamination from dripping water. q Using the left hand and keeping it within cuff of
• Avoid splashing water on scrub attire during sleeve, gowned scrub person picks up the right
surgical scrub because moisture may contaminate glove. Palm of glove is placed against palm of
the sterile gown. right hand, grasping top edge of glove cuff above
palm.
WEARING OF STERILE GOWN BY SELF
q After scrubbing, hands and arms must be CORRECT POSITION
thoroughly dried before the sterile gown is Fingers of glove are pointing towards you and thumb of
donned to prevent contamination of the gown by the glove is align with the thumb of the hand. The thumb
strike-through of microorganisms from wet skin. side of the glove is down.
q After drying of hands, pick up the sterile gown, ü Back of cuff is grasp in left hand and turned over
lifts it directly upward and steps away to avoid right sleeve and hand. Cuff of glove is now over
touching the edge of wrapper. stockinette cuff of sleeve, with hand still inside
sleeve.
q The scrub nurse, putting on gown, gently shakes ü Top of right glove & underlying sleeve of gown
out folds, then slips both arms into the armholes are grasped with left hand. By pulling sleeve up,
of the sleeves simultaneously without touching glove is pulled onto hand.
sterile outside of gown with bare hands. ü Using gloved right hand, left glove is picked up
and placed with palm of glove against palm of left
q The Circulator brings the gown over the shoulder hand. Back of cuff is grasped, above palm in right
by reaching inside to the shoulder and arms hand & turned over left sleeve and hand.
seams. The gown is pulled on, leaving the cuffs ü Cuff of left glove is now over stockinette cuff of
of the sleeves extended over the hands. sleeve, with hand still inside sleeve. Top of left
glove and underlying gown sleeve are grasped
q The back of the gown is securely tied or fastened with right hand, and sleeve is pulled up, pulling
at the neck and waist; touching the outside of the glove onto hand.
gown at the line of ties or fasteners, in the back
only. OPEN GLOVE METHOD
q With the left hand, grasp the cuff of the right
SERVING OF STERILE GOWN glove on the fold. Pick up the glove and step back
q Open the hand towel and lay it on the surgeon’s from the table.
hand, being careful not to touch the hand. If no
towel is available, the lower part of the gown q Insert the right hand into the glove and pull it on,
maybe used to dry the hands of the surgeon. leaving the cuff turned well down over the hand
q Unfold the gown carefully, holding it at the neck-

band.

q Discard in a laundry hamper or in a trash
q Slip the fingers of the gloved right hand under the receptacle (if disposable).
everted cuff of the left glove. Pick up the glove
and step back. GLOVE REMOVAL
q The key to removing both sterile and non-sterile
q Insert the hand into the left glove and pull it on, gloves is “Dirty to Dirty - Clean to Clean" that
leaving the cuff turned down over the hand. is, contaminated surfaces only touch other
contaminated surfaces: your bare hand, which is
clean, touches only clean areas inside the other
q With the fingers of the right hand, pull the cuff of glove;
the left glove over the cuff of the left sleeve. If the
stockinette is not tight, fold a pleat, holding it q Take hold of the first glove at the wrist;
with the right thumb while pulling the glove over q Fold it over and peel it back, turning it inside out
the cuff. Avoid touching the bare wrist. as it goes. Once the glove is off, hold it with your
gloved hand;
q Repeat step 5 for the right cuff, using the left hand
and thereby completely gloving the right hand. q To remove the other glove, place your bare
fingers inside the cuff without touching the glove
REMINDERS IN GLOVING TECHNIQUE exterior. Peel the glove off from the inside,
ü Avoid contact of sterile gloves with ungloved turning it inside out as it goes. Use it to envelope
hands during closed-gloving procedure. the other glove.
ü For close gloving method, never let the fingers SURGICAL INSTRUMENTATION
extend beyond the stockinette cuff during the
procedure. Contact with ungloved fingers HISTORICAL BACKGROUND
constitutes contamination of the gloves. CODE OF HAMMURABI (CIRCA 1900 BC) –
- describes a bronze lancet
ü For open glove method, touch only the cuff of the
glove with ungloved hand, and then only glove to INCAS of PERU –
glove for other hand. - use razor sharp flint and animal teeth
ü If contamination occurs during either procedure, EGYPTIANS (1900 – 1200 BC ) –

both gown and gloves must be discarded and new - blades made of flint, reed & bronze
gown and gloves must be added.
HIPPOCRATES (460 – 377 BC) –
ü When removing gloves after a procedure is - advocated the heating of tips of rounded
finished, the gloves are removed using glove-to and pointed blades before using.
glove, skin to skin technique, after the gown is
removed inside out technique. ROME (1st Century AD) –
- use of scalpel handles with blunt
REMOVING OF GOWN dissecting ends, knives, saws, forceps
q Grasp the right shoulder of the loosened gown and clamps with locking handles, probes,
with the left hand and pull the gown downward and hooks for retraction.
from the shoulder and off the right arm, turning
the sleeve inside out; AMBROISE PARE (1509 – 1590) –
q Turn the outside of the gown away from the body - first person to grasp blood vessels with a
with flexed elbows; pinching instrument that was the
q Grasp the left shoulder with the right hand and predecessor of the hemostat used today.
remove the gown entirely, pulling it off (inside
out);

AMERICAN CIVIL WAR (1861 – 1865 ) – CLASSIFICATIONS OF INSTRUMENTS

- trademark of this period were ¨ Cutting and Dissecting
AMPUTATIONS. In some instances, ¨ Grasping and Holding
amputations were performed on kitchen ¨ Clamping and Occluding
tables with heavy knives and ¨ Exposing and Retracting
instruments. Even table forks were used
¨ Suturing and Stapling
as retractors.
¨ Viewing
18th – 19th CENTURIES ¨ Suctioning and Aspirating
- surgical tools were made by skilled ¨ Dilating and Probing
silversmiths, coppersmiths and ¨ Accessory Instruments
woodworkers. Some instruments
handles were made of ivory, bone or CUTTING & DISSECTING
wood with velvet cases. Þ have sharp edges;
Þ use to dissect, incise, separate, and excise tissues
20th CENTURY – Þ should be protected during cleaning, sterilizing
- instruments are made entirely of metals and storing;
such as carbon steel, silver and brass Þ should be kept separate from other instruments
and the velvet case was replaced by and always demand careful handling.
sterilizer trays.
SCALPELS
1900s • made of brass & the blade is made of carbon
- development of stainless steel from steel;
Germany, Sweden, France, England, Pakistan, • most frequently used has a reusable handle with a
and United States. disposable blade;
- made of titanium, cobalt-based alloy • may also be available in disposable type.
(Vitallium), stainless steel or other
metals. o Handle # 3, 7, 9 – Blade # 10 , 11, 12, 15
o Handle # 4 – Blade # 20, 21, 22, 23
STAINLESS STEEL o Blade # 10 – most frequently use; has a
Þ is an alloy of iron, chromium, and carbon. It may rounded cutting edge along one side. Blades
also contain nickel, manganese, silicon, # 20, 21, 22 have the same shape but larger.
molybdenum, sulfur, and other elements to o Blade # 11 – has a straight edge that comes
prevent corrosion or add tensile strength. to a sharp point; known as the STAB
KNIFE.
Þ Alloys make the instruments resistant to o Blade # 12 – is shaped like a hook with the
corrosion when exposed to blood and body fluids, cutting edge on the inside curvature.
cleaning solutions, sterilization, and atmosphere. o Blade # 15 – has a smaller and shorter curved
cutting edge than no. 10 blade.
PARTS OF THE SURGICAL INSTRUMENT o Blade # 23 – has a curved cutting edge that
¨ Tip comes to more of a point than no. 20, 21, and
¨ Serrated Jaws 22 blades.
¨ Box lock
¨ Shank KNIVES
¨ Ratchet • comes in various sizes and configurations
¨ Finger ring or Ring Handle • usually have a blade at one end & the blade have
one or two cutting edges.
• some have detachable and replaceable blades like
adenotome & dermatome

SCISSORS GRASPING AND HOLDING

• blades of the scissors maybe straight, angled or ¨ Tissue Forceps
curved, pointed or blunt a the tips and the handles ¨ Stone Forceps
maybe long or short; ¨ Tenaculum
• used only to cut or dissect tissues. ¨ Bone Holders
• to maintain the sharpness of the scissors, it should
be used ONLY for their intended purpose. TISSUE FORCEPS
Þ used often in pairs, to pick up or hold soft tissues
o Metzenbaum scissors - Used to cut delicate and vessels
tissue; also known as TISSUE OR
OPERATING SCISSOR q Thumb Forceps / Smooth / Non
toothed Forceps – used to hold delicate
o Straight MAYO scissors - Used to cut tissues ; are tapered with serrations at the
sutures and supplies ; also known as tip ; maybe straight or angled, short or
SUTURE SCISSOR. long and delicate or heavy.
o Curved MAYO scissors - Used to cut q Toothed / Pick up / Rat Tooth Forceps
heavy and tough tissues (fascia, muscles, – have a single tooth on one side that fits
uterus & breast) ; available in regular and between two teeth on the opposing side;
long sizes. use to hold tough tissues.
o Wire scissors – have short, heavy blades ; q Allis Forceps – has a scissor action.
they are used instead of suture scissors to cut Each jaw curves slightly inward with a
stainless steel sutures ; Heavy wire cutters are row of teeth at the end ; Holds tough
used to cut bone fixation wires. tissue gently but securely
o Dressing / Bandage scissors – used to cut q Babcock Forceps – the end of each jaw
drains and dressings and to open items such is rounded to fit around a structure or to
as plastic packets. grasp tissue without injury.
• Bandage is used to cut the uterus and

umbilicus during CS operation. STONE FORCEPS
• used to grasp calculi such as kidney stones or gall
SHARP DISSECTORS stones.
• includes biopsy forceps and punches, curettes • either curved or straight forceps;
(has a sharp edge with loop, ring or scoop on the • have blunt loops or cups at the end of the jaws.
end), snares (a loop of wire may be put around a
pedicle to dissect tissue such as a tonsil, then the TENACULUM
wire cuts the pedicle as it retracts into the • curved or angled points on the ends of the jaws
instrument and the wire is replaced after use) . penetrate tissue to grasp firmly
• may have a single tooth or multiple teeth
BONE HOLDERS
• includes vice-grip, pliers and other types of
heavy holding forceps use to stabilize the bone.

CLAMPING AND OCCLUDING • some holding devices have two or more blades
¨ Hemostats that can be inserted to spread the edges of incision
¨ Crushing Clamps and hold them.
¨ Non crushing Vascular Clamps
SUTURING OR STAPLING
HEMOSTATIC FORCEPS ¨ Needle Holder
• usually have two opposing serrated jaws that ¨ Staplers
are stabilized by a box lock and controlled by
ringed handles. When closed, the handles NEEDLE HOLDER
remain locked on ratchets; • used to grasp and hold curved surgical needles;
• most commonly used surgical instruments; • resembles hemostatic forceps but the basic
• used primarily to clamp blood vessels; difference is the jaws;
• either straight or curved slender jaws that taper • has a short, sturdy jaws for grasping a needle
to a fine point; without damaging it or the suture material.
• the size of the needle holder should match the size
Crile / Stet / Tag Forceps – for shallow layers of tissues of the needle;
Kelly Forceps – for deep layers of tissues or cavity • either long or short, with serrations on jaws, some
are non;
CRUSHING CLAMPS
• used to crush tissues or clamp blood vessels; TUNGSTEN CARBIDE JAWS
• fine tips are used for small vessels and structures • jaws with an insert of solid tungsten carbide with
while longer and sturdier jaws are needed for diamond cut precision teeth designed to eliminate
larger vessels, dense structures and thick tissues. twisting and turning of the needle in the needle
holder;
NON CRUSHING VASCULAR CLAMPS • can be identified by the gold plating on the
• used to occlude peripheral or major blood vessels handles.
TEMPORARILY.
• minimizes tissue trauma; STAPLERS
• jaws, either straight, curved or S shaped, have • available in reusable and disposable type
opposing rows of finely serrated teeth
VIEWING INSTRUMENTS
EXPOSING AND RETRACTING o Speculum
¨ Hand held or Non self-retaining Retractors o Endoscopes
¨ Self – retaining Retractors
SPECULUM
HANDHELD OR NON SELF-RETAINING • has a hinged, blunt blades that enlarges and holds
RETRACTORS a canal open such as the vagina, or a cavity, such
• usually used in pairs and held by the first or as the nose
second assist
• some have blades on one end, either curved or ENDOSCOPES
angled, dull or sharp while some have blades on • made of a round or oval sheath that is inserted into
both ends. a body orifice or through a small skin incision;
• used for viewing in a specific anatomical
SELF - RETAINING RETRACTORS locations.
• may have shallow or deep blades, some have
ratchets or spring locks to keep the device open,
while others have wing to secure the blades;

SUCTIONING AND ASPIRATING Þ has a fitted blunt end cannula inside to keep
¨ Suction fluid or gas from escaping until the cannula is
¨ Aspiration removed.
SUCTION CANNULA
• is the application of pressure (less than Þ has a blunt end and perforations around the
atmospheric pressure) to withdraw blood or tip to aspirate fluid without cutting into
fluids, usually for visibility at the surgical tissues;
site; Þ also used to open blocked vessels or ducts for
• made of style tip and sterile tubing; drainage or to shunt blood flow from the
• style of the suction tip depends surgical site.
• where it is to be used and the surgeon’s
preference. DILATING AND PROBING
¨ Dilators
POOLE ABDOMINAL TIP ¨ Probes
Þ is a straight hollow tube with a perforated
A. Dilators - used to enlarge orifices and ducts
outer filter shield that prevents the adjacent B. Probes - used to explore a structure or to locate an
tissues from being pulled into the suction obstruction.
apparatus.
Þ used during abdominal laparotomy or within ACCESSORY INSTRUMENTS
any cavity in which copious amount of fluid ¨ Mallet
or pus are encountered. ¨ Screw drivers
FRAZIER TIP CATEGORIES OF INSTRUMENTS

Þ is a right-angle tube with a small diameter; q SHARPS
q GRASPING AND HOLDING
Þ used when little or no fluid except capillary
q CLAMPING AND OCCLUDING
bleeding and irrigating fluid is encountered, q RETRACTORS
such as brain, spinal, plastic and ortho
procedures HANDLING OF INSTRUMENTS BEFORE
SURGICAL PROCEDURE
YANKAUER TIP 1. Scrub nurse should be the one to prepare the
Þ is a hollow tube that has an angle for use in instruments on the mayo and back table.
the mouth or throat. 2. Avoid as much as possible preparing the
instruments wearing only sterile gloves.
ASPIRATION 3. Uncovered, exposed instruments are never
transported through corridors.
• done manually to obtain a specimen like 4. The scrub nurse should not go beyond the
blood, body fluid, or tissue for laboratory confines of the room.
examination or to obtain bone marrow for 5. The scrub nurse together with the circulating
transplantation which is frequently done with nurse should person counting of instruments,
a syringe and needle. sharps, and sponges. They must be accounted for
throughout every procedure.
TROCAR
Þ has a sharp cutting edge at the end of a hollow
tube intended to cut through tissues for access
to fluid or a body cavity.

COUNTING PROCEDURE
Þ is a method of accounting for items put on the a. Some orthopedic instruments can remain
sterile table for use during the surgical procedure. the racks during the initial table set up
Þ sponges, sharps and instruments should be and until they are needed during the
counted on all procedures surgical procedure
Þ counting ensures that expensive instruments like b. Tip – protecting covers or instrument-
towel clips and scissors are not accidentally protecting plastic sleeves should be left
thrown away with the drapes. on until the instruments are actually used.
c. If they are not in a rack or tip guard,
¨ Counts are also performed for infection control support handles on a rolled towel or
and inventory control purposes. gauze sponge to keep blades and tips of
micro instruments suspended in mi air.
KEY POINTS IN HANDLING INSTRUMENTS
1. Handle loose instruments separately to prevent HANDLING OF INSTRUMENTS DURING
interlocking or crushing. SURGICAL PROCEDURE
a. Never pile one instrument on top of 1. Know the name and use of each instrument.
another on an instrument table; lay them 2. Handle instruments individually.
side by side. 3. Hand the surgeon or assistant the correct
b. Microsurgical, ophthalmic, and other instrument for each particular task.
delicate instruments are vulnerable to
damage through rough handling. Remember the principle:“ use for intended purpose
c. Metal to metal contact should be avoided only”
or minimized. • Avoid placing fingers in the ring handle as the
instrument is passed because it may inadvertently
2. Inspect instruments such as scissors and forceps drop or snag on drapes;
for alignment, imperfections, cleanliness, and • Many surgeons use hand signals to indicate the
working conditions. type of instrument needed. An understanding of
a. Blades must be properly set. what is taking place at the surgical site makes
b. Exact alignment of teeth and serrations is these signals meaningful;
necessary. • Select appropriate instruments for location of
c. Set aside or remove any defective surgical site; short instruments for superficial
instruments work and long ones for deep in a body cavity.
Experience will facilitate instrument selection
3. Sort instruments neatly by classifications. according to the surgeon’s preference and need.
• Many instruments are used in pairs or in
4. Keep ring - handled instruments together, with sequence.
curvatures and angles pointed in the same
direction. 4. Pass instruments decisively and firmly. The
a. Hang ring handles over a rolled towel or instrument should be slapped or placed firmly into the
over the edge of the instrument tray or surgeon’s palm in the proper position for use. Generally,
container. when passing a curved instrument, the curve of the
b. Remove instrument pins or holders if instrument aligns with the direction of the curve of the
used to keep box locks open. surgeon’s hand.
c. Close box locks on the 1st ratchet
IN PASSING AN INSTRUMENT TO THE SURGEON:
5. Leave retractors and other heavy instruments in a • if the surgeon is on the opposite side of the table,
back table. pass across right hand to right hand or with the
left hand to a left-handed surgeon.
6. Protect sharp blades, edges and tips. They should •
not touch anything.

• if the surgeon or assistant is on the same side of a. Blood and gross debris must be removed
the table and to the right, pass with your left hand; first.
if the surgeon is to your left, pass with your right b. Careless dropping, tossing, or throwing
hand. of instruments into a basin is highly
• Sharp and delicate instruments maybe placed on prohibited.
a flat surface for the surgeon to pick up. This c. Keep instruments accessible for final
avoid the potential contact with items such as counts
blades, sharp points and needles. Always protect d. Bloody instruments should not be soak
hands when handling sharps. in a basin of solution for a prolonged
period. Instruments that have been
4. (5) Watch the sterile field for loose instruments. wiped can be immersed in a basin of
Remove them promptly after use to the mayo sterile demineralized distilled water,
table. The weight of the instruments can injure the NOT SALINE SOL’N NaCl in saline
patient or cause post op discomfort. Keeping solution and blood is corrosive.
instruments off the field also decreases the e. Never place heavy instruments like
possibility of falling to the floor. retractors on top of tissue and
hemostatic forceps and other clamps.
7. (6) Wipe blood and organic debris off instruments Place them in a separate tray.
promptly after each use with a moist sponge.
HANDLING OF INSTRUMENTS AFTER
a. Dried Blood and debris on instrument SURGICAL PROCEDURE.
surface like in box lock and in crevices, All instruments on the mayo and back tables, whether
increase bioburden that could be carried used or unused are considered contaminated and should
into the surgical site. be promptly and properly be cleaned, inspected,
b. Use demineralized sterile distilled water terminally sterilized, and prepared for subsequent use.
in wiping the instruments. Saline or other
solution can damage surfaces, causing ¨ Check all the drapes, towels and table covers to
corrosion and ultimately pitting. be sure that no instruments will go to the laundry
c. A non-fibrous sponge should be used to or into the trash. A final quick count is a
wipe microsurgical, ophthalmic, and safeguard.
delicate tips instruments. This can ¨ Collect all the instruments from the mayo, back
prevent snagging and breaking of table and other small tables including those have
delicate tips. been dropped or passed off the sterile field.
7. Flush the suction tip and tubing with sterile ¨ Separate delicate, small instruments and those
distilled water periodically to keep the lumens patent. with sharp and semi sharp edges for special
Keep a tally of the amount of fluid used to clear the handling.
suction line and deduct this amount from the total used to ¨ Disassemble all instruments with parts to expose
irrigate the surgical site. This is to have an accurate all surfaces for cleaning.
accounting of blood loss from the operation; ¨ Open all hinged instruments to expose box locks
and serrations.
8. Remove debris from electrosurgical tips to ¨ Separate instruments of dissimilar metals. Clean
ensure electrical contact. Disposable abrasive tip cleaners the instruments per type to prevent electrolyte
are helpful for maintaining the conductivity & effective-
deposition of other metals.
ness of the surface of the tip. Avoid using the scalpel
¨ Flush with cold distilled water through hollow
blade because the debris may become airborne and
instruments or channels like suction tips or
contaminate the surgical field.
endoscopes to prevent drying of organic debris.
9. Place used instruments not needed again into a tray or ¨ Rinse off blood and debris with demineralized
basin during or at the end of the surgical procedure. distilled water or any enzymatic detergent
solution.

o Alkaline detergent (pH over 8.5) will

¨ Follow procedures for preparing the instruments stain instruments;
for decontamination or terminal sterilization. o Acidic detergent (pH below 6) will
Procedure varies depending on the type of corrode or pit the instruments.
instrument and its components and the equipment
available and its location. b. Wash instruments carefully to guard against
splashing and creating aerosols.
DECONTAMINATION PROCESS OF • Use a soft-bristled brush to clean serrations and
INSTRUMENTS. box locks;
Includes the following procedures: • Keep instruments submerged while brushing to
q Pre rinsing or presoaking, minimize aerosolizing microorganisms;
q Washing, • use a soft cloth to wipe surfaces or a non-fibrous
q Rinsing, cellulose sponge to prevent damage to delicate
tips;
q Sterilizing
• remove bone, tissue and other debris from cutting
instruments;
PRE RINSING / PRE SOAKING • never scrub surfaces with steel wool, wire
Þ done to prevent blood and debris from drying on brushes, scouring pads or powders to protect the
instruments or to soften and remove dried blood protective finish on metal (this protects the base
and debris. metal from oxidation)
Þ Proteolytic Enzymatic Detergent dissolve blood
and protein and remove dissolved debris from RINSING
crevices. This is effective in a wide range of water
Þ Use hot distilled or deionized water in
qualities.
rinsing;
Þ Water with a low-sudsing, near-neutral detergent
Þ Should be done thoroughly to avoid
Þ Plain, clean, demineralized distilled water staining the instruments.
Þ Liquid detergents are preferred. Þ after rinsing, put instruments back into
sterilization racks or tray;
DONTS’: Þ arrange instruments that can be steam
q BLEACH – corrosive solution should not be sterilized in decontaminator.
used.
q CHLORINE COMPOUNDS STERILIZING
q IODOPHOR – Soaking should not exceed 1 hour.
Þ The sterilizing agent must come in direct
q Should not be cleaned in scrub sinks or utility
contact with all surfaces of every instrument.
sinks in the sub sterile room;
q Do not pour directly the liquid or solid detergents Þ Instruments should be packed, individually or
on instruments in sets to allow adequate exposure to sterilant,
to prevent air from being trapped and
moisture from being retained during the
WASHING sterilization process, and to ensure sterile
Þ done to remove residual blood and debris transfer to the sterile field.
before terminal sterilization or high level Þ Instruments are put in a container or tray, or
disinfection. wrapped in a small set or individually, for
sterilizing and transporting. Instruments
a. Clean, warm water with noncorrosive, low maybe sterilized unwrapped immediately
sudsing, free rinsing detergent before use in a high-speed pressure sterilizer,
• Regardless of the water content, the detergent they may be prepared in advance as for a case
should be anionic or nonionic with a pH close cart, or retained in storage until needed.
to neutral.
o

STEPS IN ASSEMBLING INSTRUMENTS SETS name of the person who packed the instruments
IN STERILIZER: and the control number.
a. Make sure instruments are thoroughly dry;
b. Place an absorbent towel or foam in the bottom HANDLING POWERED INSTRUMENTS
of the tray to absorb condensate, unless q Electrically powered instruments like saws,
contraindicated; drills, dermatomes, nerve stimulators;
c. Count the instruments as they are placed in the
tray and record the number on a preprinted form; q Air powered instruments are small,
lightweight, free of vibration and easy to
d. Arrange instruments in a definite pattern to handle for pinpoint accuracy at high speeds;
protect from damage and to facilitate removal for
counting and use; q Battery powered instruments are cordless
e. Place heavy instruments like retractors in the
bottom of the tray; with rechargeable batteries;
f. Open hinges and box locks on all hinged q Wipe off any organic debris between uses during
instruments; the surgical procedure;
q Accessories are disassembled prior to cleaning;
g. Place sharp and delicate instruments on top of q Do not immerse the motor in liquid.
other instruments. Blades of scissors & delicate q Lubricate as recommended using a silicone oil.
tips should not touch other instruments;
h. Place concave or cupped instruments with these SURGEON’ ARMAMENTUM
surfaces down so that water condensate does not The surgeon relies on surgical instruments to
collect in them during sterilization process; enhance his or her skill in the art and science of surgery.
The nursing staff must ensure that these instruments
i. Place ring-handled instruments on pins or holders function properly and sterilized adequately. Instruments
designed for this purpose. Curved instruments are selected on the basis of safety for their intended use.
should be pointing in the same direction, grouped They must be inspected, maintained and used
together by style & classification. Do not use appropriately.
rubber bands because steam cannot penetrate
through or under bands;
j. Disassemble all detachable parts. Secure

properly the small parts;
k. Separate dissimilar metals like brass instruments
from stainless steel instruments;
l. Place instruments with a lumen like suction tip in
as near a horizontal position as possible;
m. Distribute weight as evenly as possible in the

tray. Some trays have dividers, clips and pins
attach to the bottom of the tray so as to prevent
the instruments from shifting and keep them in
alignment;
n. Place a chemical indicator on the outside wrapper

or container as well as inside the tray;
o. Label appropriately for intended use including
the name of the instruments or set, date sterilized,

PRE-OPERATIVE PATIENT CARE • infants, small children, diabetic and elderly
patients prone to dehydration.
LABORATORY & PHYSIOLOGICAL b. Oral medications – can be
PREPARATION taken with minimal fluid intake up to 1
hour pre op as prescribed with 150ml or
1. MEDICAL HISTORY AND PHYSICAL less of water.
EXAMINATION – physician.
PHYSICAL PREPARATION OF PATIENT
2. LABORATORY TESTS – ordered by the • Patient skin should be cleansed prior to operation
surgeon and should be completed 24 hours before using an antimicrobial soap for several days pre
admission so results will be available for review. op.
a. H & H, BUN, Blood Glucose – routine
for 60 years old and above
• Wash face, ear, neck and shampoo the hair
b. Hematocrit
§ Male patients have to cut their
c. CBC, Platelet count, Prothrombin time
hair short and shave on the day
d. Blood typing and cross match
of the operation
e. Urinalysis or/and Fecalysis
• Nail polish and acrylic nails should be remove to
3. RADIOLOGIC TESTS
a. Chest X-ray – not all but required to permit observation of oxygenation and
patients with cardiac or pulmonary circulation.
§ Oxisensor of Pulse oximeter
disease, smokers, cancer patients &
§ Nail bed is a vascular part
persons with 60 y/o and older
4. ECG – routine to patients with cardiac disease • Leave jewelries and all valuables at home. Metal
and persons of 40 y/o and up. jewelries like wedding band must be removed to
prevent burns if electro surgery will be used.
5. DIAGNOSTIC PROCEDURES – performed • Other instructions of what to expect before,
when specifically indicated, like in vascular during and after operation – surgeon
surgery.
Þ when to arrive in the hospital for admission
6. WRITTEN INSTRUCTIONS – will come from Þ where the immediate family will stay and wait
surgeon and should be reviewed and followed by before and after the operation.
the patients before admission.
a. Should not ingest solid foods preceding INFORMED CONSENT
the operation to prevent aspiration and Þ should be facilitated by the surgeon and follow up
regurgitation or emesis. by the nurse; the surgeon explains the surgical
procedure and the risks to the patient.
“ NPO AFTER MIDNIGHT ” – Þ is a legal document that provides evidence of
patient’s agreement to allow a procedure to be
Solid foods performed on him/her;
• will take 12 hours before it empties the Þ a signed consent is legally regarded as VALID for
stomach a period of about 6 months or for as long as the
Clear liquids patient consents to the same procedure.
• maybe unrestricted until 2 to 3 hours before Institutional policy may vary.
the operation but still depends on the
discretion of the surgeon & anesthesiologist. PURPOSES of INFORMED CONSENT
q It provides a mechanism to protect a patient’s
right to self-determination regarding surgical
intervention;
Less time of NPO q

q It provides a means by which the patient can make GUIDELINES ON CONSENT

an educated choice about having a procedure q ONLY the surgeon assigned is responsible to
performed; inform the patient about the proposed procedure,
its interest. Risks, complications and what the
GENERAL CONSENT patient may expect during and after the operation;
Þ this form authorizes the physician and the
hospital staff to render treatment or perform q Complete explanations should be given to the
procedures as the physician deems advisable. patient and the surgeon is responsible for making
Þ this is relied on ONLY for routine duties certain that the patient of legal guardian is
performed in the hospital. adequately understands everything;
Þ Nurses should be knowledgeable about the
statements on the form used in their hospital
q Consent should contain the following:
ü Patient’s full name (maiden name)
SURGICAL CONSENT
ü Surgeon’s full name
Þ specifically outlines each procedure to be
ü Complete and specific procedure to be
performed and explains the risks and benefits; performed
ü Signature of the patient
should answer the following patient questions:
ü Complete name of authorized witness
a. What do you plan to do to me? ü Date and Time of signature
b. Why do you want to do this procedure? ü
c. Are there any alternatives to this plan? q Every patient is entitled to receive the sufficient
d. What things should I worry about? information to be performed on him/her. They
e. What are the greatest risks or the worst have the right to waive an explanation of the
thing that could happen? nature and consequences of the procedure. They
have the right to decide what will and not to be
Is required for: done. Only after making this decision is the
q Each surgical procedure to be performed patient asked to sign a written consent for
including secondary procedures like I & D; operation;
q Any procedure for which a general anesthetic
agent is administered such as an examination of a q The patient has the right to refuse the treatment.
child under anesthesia; q Consent should be signed by the patient before
q Procedures involving entrance into a body cavity premedication and before going to the Operating
such as endoscopy; Room except in life threatening, emergency
q Any hazardous therapy such as radiation. situation.
PURPOSES of SURGICAL CONSENT q There should be a WITNESS verifying the

q To ensure that the client understand the nature of consent was signed without coercion;
the treatment including the potential
complications and disfigurement;
q Pre operative visit of the Peri operative Nurse;
q To indicate that the client’s decision was made
without pressure;
q Preoperative visit by the Anesthesiologist or
q To protect the client against unauthorized Nurse Anesthetist – An interview will be
procedures; conducted before admission with patients who
q To protect the surgeon and hospital against legal have complex medical histories, are high risk or
action by the client. have high degrees of anxiety.

WHO SHOULD SIGN THE CONSENT ? • what to expect and what are the consequences
q Should be of legal age of surgery
q Should be mentally competent • nursing action: allay anxieties by giving the
q An emancipated minor, married or independently patient opportunities to express his/her fears
earning a living
q Illiterate may sign with an “X”, after which the Þ Specific fears
witness writes “patient’s mark”. • fear of destruction of body image
• threat to sexuality
WHO SHOULD NOT SIGN THE CONSENT ? • fear of permanent disability
q A minor
• fear of pain
q Unconscious
• fear of dying
q Mentally incompetent
SKIN PREPARATION OF PATIENT
* PARENT / LEGAL GUARDIAN / NEXT of
Purpose of Skin Preparation:
KIN
Þ To render the surgical site as free as possible from
* SURGEON – should not sign the consent in
behalf of the patient transient and resident microorganisms, dirt and
skin oil so the incision can be made through the
CONSENT in EMERGENCY SITUATION skin with minimal danger of infection from this
source.
Þ If obtained by telephone, 2 nurses should monitor
the call and sign the form, which is signed later Þ Hair removal is necessary especially if the hair
by the parent on arrival at the hospital. In lieu of surrounding the surgical site is so thick ; it
interfere with exposure, closure an dressing ; it
these method, a written consultation by two
physicians other than the surgeon will suffice prevent adequate skin contact with electrodes.
until a relative can sign a consent. Þ Clippers
q Depilatory cream application
PREOPERATIVE PREPARATIONS AN q Razor
EVENING BEFORE ELECTIVE SURGICAL CLIPPER
PROCEDURE. • available in electric type or cordless handle with
1. GIT Preparation (Bowel Preparation) rechargeable batteries.
a. “Enemas till clear” maybe ordered.
• Electric clippers with fine teeth cut hair close to
b. Golytely or Colyte normally clear the
the skin.
Bowel in 4 to 6 hours.
• Clipping can be done immediately before the
surgical procedure or up to 24 hours
2. Douche
preoperatively using short strokes against the
• use to cleanse the vagina during vaginal and
direction of hair growth.
pelvic procedures.
• Patients who will be admitted the day of the DEPILATORY CREAM
surgical procedure may be instructed to self-
• Skin testing should be done first for possible
administer enema or douche at home.
allergies.
• Should not be used around the eyes and genitalia.
3. Hair removal / preparation or Shaving
4. Bedtime sedation for sleep • Should be applied on the skin, wait for 20 minutes
before washed off.
PSYCHOLOGICAL PREPARATION
Fears related to surgery RAZOR
Þ General fear • shaving should be done as near the time of
incision as possible if this method must be used.
• fear of the unknown

q Wear gloves when shaving with razor to VAGINAL SURGERY

prevent cross contamination even though • For gynecological surgery (perineal prep)
this is a surgically clean procedure support legs and thighs in the lithotomy
position and shave the anterior surface from
• Avoid making nicks and cuts in the skin. (Nicks the umbilicus down: the pubic area, the
done 30 minutes before the surgical procedures external genitalia, the perineum, including the
are considered CLEAN WOUNDS.) area around the anus, and the buttocks. Shave
• Use a sharp, clean razor blade. Hold the skin taut inner thighs halfway to the knees from the
and shave by stroking in the direction of hair middle of anterior to middle of posterior
growth. thighs.
HEAD SURGERY SURGERY of the LIMBS

• For surgery of the cranium, follow the outline • For surgery of the limbs, the area includes the
indicated by the surgeon. Clip the hair before entire circumference. The extent of the prep
attempting to shave the scalp. Find out if long varies depending upon the type of operation.
hair is to be saved for the patient. If so, follow As an example, for surgery of the hand, the
local procedures. The actual shaving is often prep would normally extend distally from the
done in the surgical suite just before surgery, elbow. A manicure or pedicure is also
and the preparation done on the ward may be necessary. Fingernails or toenails must be
limited to cutting or clipping the hair close to clipped short, cleaned, and scrubbed.
the scalp.
SKIN MARKING
ABDOMINAL SURGERY • Surgeon uses a staining solution to mark the
• Male patient's skin is shaved and cleaned from incision lines on the skin. This maybe done
the nipple line to the upper third of the thigh, before the patient is prepped.
including the pubes (hair over the pubic
regions) from side to side anteriorly. For a • If the skin is marked after prep, a sterile dye
female, the upper boundary is the breast fold solution and applicator or a sterile marking
on the chest wall. Particular care must be pen must be used.
taken to assure adequate cleaning of crevices o METHYLENE BLUE or ALCO-
and indentations in the skin. An example on HOLIC GENTIAN VIOLET
the abdomen is the umbilicus. For kidney
operations and surgery of the proximal third PRE-OPERATIVE HEALTH TEACHINGS
of the ureters, the skin is shaved from the Ø Post-op exercises
axilla (which is prepped) to the groin. Ø Equipment used during post-op period
o oxygen, pulse oximeter, CVP
CHEST SURGERY o ventilator
• For chest surgery, the skin is shaved and o NGT
cleansed on the affected side from mid hip o IV medications
over the shoulder, including the axilla, to the o Foley catheter
shoulder on the unaffected side. Ø Provide client and family teaching, instruct the
client in:
RETROPERITONEAL SURGERY o relaxation technique
• For rectal surgery, support the legs and thighs o deep breathing and coughing exercises
in the lithotomy position. Shave the pubic, o Post op Exercises of extremities
perineal, thigh, and anal areas (in a radius of o turning and moving techniques
about 10 inches from the anus). o pain – control techniques
o Incentive spirometry use

ASSESSMENT ANESTHESIA
Assess respiratory status, including history of Þ branch of medicine that is concerned with the
pulmonary problems to identify risk factors for administration of medication or anesthetic agents
postoperative complications to relieve pain and support physiologic function
Assess for and report evidence of F/E imbalance during a surgical procedure;
Assess emotional status of client. Þ is a specialty that requires knowledge of
Examine the client’s record for endocrine or biochemistry, clinical pharmacology, cardiology,
metabolic problems that could affect his and respiratory physiology.
response to surgery (DM). Þ the practice of medicine dealing with
Assess immunologic and hematologic functions management of procedures for rendering a patient
history of allergies insensible to pain during surgical procedures and
previous reactions to blood transfusions with support of life functions under the stress of
history of substance abuse anesthetic and surgical manipulations. (accdg. to
Assess neurologic functions ABA).
Assess integumentary system
Evaluate medication history for drugs that could TERMINOLOGIES
increase operative risk for affecting coagulation ¨ Amnesia – loss of memory; an indifference to
time or interacting anesthetics;
pain
Assess the client for any type of prosthetic
device or metal implants.
¨ Analgesia – lessening of or insensibility to pain
Assess the client and his family’s knowledge
base to guide the preoperative teaching program. ¨ Anesthesia – loss of feeling or sensation, esp. loss
Assess the laboratory and diagnostic results of of the sensation of pain with loss of protective
reflexes
the patient (x-ray, cbc, wbc, etc.)
NURSING DIAGNOSIS ¨ Analgesic – drug that relieves pin by altering

Anxiety perception of painful stimuli without producing
Knowledge deficit los of consciousness
PLANNING AND OUTCOME IDENTIFICATION ¨ Anesthetist – person who administers anesthesia

Major goals: ¨ Anesthesiologist – doctor of medicine who
Ø Decreased anxiety and increased knowledge of specializes in the field of anesthesia
the surgical experience.
Ø Promote measures that help decrease anxiety for ¨ Anoxia – absence of oxygen
the client and his family. ¨ Apnea – suspension or cessation of breathing
¨ Fasciculation – uncoordinated skeletal muscle

contraction in which groups of muscle fibers
innervated by the same neuron contract together.
¨ Induction – period from beginning of

administration of anesthetic until patient loses
consciousness and is stabilized in the desired
plane of anesthesia.
¨ Emergence – return of sensation and reflexes; to

regain consciousness following general
anesthesia.

¨ Intubation – insertion of endotracheal tube 3. Diminishing vagal nerve effects on the heart;
¨ Extubation – removal of endotracheal tube 4. Counteracting the undesirable side effects of
¨ Hypnosis – artificially induced sleep the anesthetic medicines;
¨ Hypnotic – a drug which induces sleep 5. Raising the pain threshold.
¨ Margin of Safety – the difference between
therapeutic and lethal dosage CONSIDERATIONS IN THE CHOICE OF PRE
ANESTHETIC DRUGS:
q Patient’s physical and emotional status;
STAGES OF ANESTHESIA
q Age;
Stage I – Onset / Induction q Weight;
• extends from the administration of anesthesia to q Medical and Medication history;
the time of loss of consciousness; q Laboratory test result;
• drowsy, dizzy, amnesic, exaggerated hearing, q Radiographic and ECG findings;
decreased pain q Demands of the surgical procedures;
q Patient’s concerns
Stage II – Excitement / Delirium Stage (Loss of
Consciousness Stage) Þ In choosing pre anesthetic premedication, the
• extend from time of loss of consciousness to the anesthesiologist aims to disturb respiration and
time of loss of lid reflex. circulation as little as possible;
• may be characterized by shouting, struggling of
the patient, excited with irregular breathing & Þ The primary consideration with any anesthetic is
movements of extremities, susceptible to stimuli that it should be associated with LOW
like noise and touch. MORBIDITY & MORTALITY.
• patient is NOT TO BE STIMULATED during this
stage and restrain the Patient Þ An ideal preoperative medication has quick
onset, short duration of action and minimal side
Stage III – Stage of Surgical Anesthesia (Stage of effects;
Relaxation)
• extends from the loss if lid reflex to the loss of Time Given:
most reflexes. Premedication is usually given at least 45 minutes
• surgical procedure is started before induction. Some drugs require 60 to 90 minutes
• there is regular respiration, contracted pupils, to reach peak effect.
reflexes disappear, muscle relax, lost auditory
sensation. Premedicines:
Ø Sedatives and tranquilizers
Stage IV – Danger Stage Ø Narcotics
• characterized by respiratory & cardiac depression Ø Antimuscarinics / Anticholinergics
or arrest. It is due to overdose of anesthesia. Ø Antiemetics / Antinauseants
• resuscitation must be done
• not breathing, little or no pulse or heartbeat TYPES OF ANESTHESIA
Choice of Type of Anesthesia:
d. Pre-anesthetic Premedication Provide maximum safety for the patient;
• maybe given to allay preoperative anxiety, Provide optimum operating conditions for the
produce some analgesia and amnesia and dull surgeon;
awareness of the OR environment; Provide patient comfort;
Have a low index of toxicity;
Reasons: Provide potent, predictable analgesia extending
1. Reducing the risk of N & V into post op period;
2. Decreasing secretions in the respiratory tract; Produce adequate muscle relaxation;
Provide amnesia;

Have rapid onset and easy reversibility; DISADVANTAGES:

Produce minimum side effects q Too rapid absorption of the drug into the blood
q Anxiety and fear are not allayed, patient
FACTORS TO CONSIDER IN THE CHOICE OF continues to see and hear throughout the
ANESTHESIA : procedure;
1. Age and size /weight of the patient; q Difficult to use with small children, senile
2. Physical, mental, and emotional status of patient; patients and uncooperative persons.
3. Presence of systemic diseases or concurrent drug
therapy; CONTRAINDICATIONS:
4. Presence of infection at the site of the surgical q Local infection or malignancy which may be
procedure; carried to and spread in adjacent tissues by
5. Previous anesthesia experience; infection of needles;
6. Anticipated procedure; q Septicemia
7. Position required for procedure; q Allergies
8. Type and expected length of procedure; q Highly nervous, apprehension and excitable
9. Local or systemic toxicity of the agent; patients or those unable to cooperate because of
10. Expertise of the anesthesiologist; mental stage like children.
11. Preference of the patient
TECHNIQUES OF ADMINISTRATION OF
TYPES OF ANESTHESIA REGIONAL ANESTHESIA
¨ General Anesthesia 1. TOPICAL ANESTHESIA
¨ Regional Anesthesia • drug is sprayed or dropped onto an area to be
o Topical desensitized, block peripheral nerve endings, in
o Local Block the skin, mucus membrane of the vagina,
o Field Block rectum, nasopharynx and mouth.
o Nerve Block o Cocaine 4 to 10% solution
o Spinal Anesthesia o Butacaine
¨ Epidural Anesthesia o Pontocaine
o Lidocaine (Xylocaine)
GENERAL ANESTHESIA
Þ pain is controlled by general insensibility; there 2. REGIONAL ANESTHESIA
is total loss of consciousness and sensation; LOCAL BLOCK
produces amnesia, analgesia, interference with o only the peripheral nerves around the
undesirable reflexes and muscle relaxation. area of the incision are blocked
Þ administered through INTRAVENOUS,
INHALATION or RECTAL INSTILLATION FIELD BLOCK
o the area surrounding the incision is
REGIONAL ANESTHESIA injected and infiltrated with local
• sometimes called CONDUCTION anesthesia.
ANESTHESIA; produces loss of painful
sensation in one area or region of the body and NERVE BLOCK
does not result in unconsciousness. o blocks nerve (brachial, inter costal,
radial, femoral
ADVANTAGES:
q Use of minimal and simple equipment; economy SPINAL ANESTHESIA (SUB ARACHNOID)
q No loss of consciousness o sensation of pain is blocked at a level
q Suitable for ambulatory patients below the diaphragm, the agent is
q Better airway control injected in the spinal canal.
q Fewer respiratory complications

3. EPIDURAL ANESTHESIA
o the anesthetic agent is injected into the • frequently involve injection of drugs through a
subarachnoid space if the spinal fluid is catheter placed into the epidural space. The
clear and flowing freely. injection can result in a loss of sensation—
o HIGH, MID, LOW SPINAL including the sensation of pain—by blocking the
ANESTHESIA transmission of signals through nerves in or near
the spinal cord.
SPINAL ANESTHESIA MEDICATIONS
ü Procaine HCL (Novocaine) SPINAL VS EPIDURAL ANESTHESIA :
ü Dibucaine HCL (Nupercaine) Ø To achieve epidural analgesia or anaesthesia, a
ü Tetracaine HCL (Pontocaine) larger dose of drug is typically necessary than
ü Lidocaine (Xylocaine) with spinal analgesia or anaesthesia;
ü Mepivacaine (Carbocaine)
ü Bupivacaine (Marcaine) Ø The onset of analgesia is slower with epidural
analgesia or anaesthesia than with spinal
ADVANTAGES OF REGIONAL ANESTHESIA: analgesia or anaesthesia;
q Ease of administration
q Expensive equipment & drugs not necessary Ø An epidural injection may be performed
q Relative safety of method anywhere along the vertebral column (cervical,
q Excellent muscle relaxation provided thoracic, lumbar, or sacral), while spinal
q Does not cause fetal depression injections are typically performed below the
q Does not cloud patient consciousness or alertness second lumbar vertebral body to avoid piercing
q can be used for patients with full stomach since and consequently damaging the spinal cord;
the patient will be awake to maintain his own
airway in event of vomiting Ø It is easier to achieve segmental analgesia or
anaesthesia using the epidural route than using
COMPLICATIONS OF REGIONAL ANESTHESIA: the spinal route;
Ø Hypotension – due to paralysis of vasomotor
nerves Ø An indwelling catheter is more commonly placed
Mgt: O2 administration in the setting of epidural analgesia or anaesthesia
Trendelenburg position than with spinal analgesia or anaesthesia.
Ephedrine IV as stimulant
Blood or plasma by IV DANGERS AND GENERAL COMPLICATIONS OF
Ø Nausea and Vomiting ANESTHESIA:
Ø Pain during surgery 1. Cardiac Arrest – certain agent result in the
Ø Headache retention of CO2 which leads to anorexia,
Mgt : respiratory acidosis and cardiac arrest.
o Administer fluids 2. Respiratory depression – excess mucus; use of
o Administer analgesics muscle relaxants; use of depressants.
o Apply tight abdominal binder 3. Bronchospasm and laryngospasm – may lead
Ø Respiratory paralysis to airway obstruction due to allergic reaction to
Mgt : the anesthesia and irritating effects of agents on
o Artificial respiration by bronchial and laryngeal mucosa.
anesthesia machine 4. Diminished circulation – due to poorly
o Resuscitation or mouth to mouth distributed blood supply in the body.
breathing 5. Hypotension and Shock – due to preoperative
medications and blood loss.
Ø Neurologic complications like paraplegia, 6. Vomiting and Aspiration – due to full stomach
severe muscle weakness in the legs (due to use of and reflex stimulation of the patient’s vomiting
unsterile needles, syringes and anesthetic agents) center.

SURGICAL POSITIONS large soft pillow on the lap. Feet should rest on
FACTORS THAT INFLUENCE POSITIONING OF the padded footboard to prevent foot drop.
THE PATIENT Þ Safety belt is secured 2 inches above the knees.
1. Procedure to be performed Þ used for shoulder, nasopharyngeal, facial and
2. Surgeon’s choice of surgical approach breast reconstruction procedures.
3. Age, height, weight of patient
4. Cardiopulmonary status 5. LITHOTOMY POSITION
5. Pre-existing diseases Þ Patient is on back with foot section of table
lowered to right angle with body on table. Knees
DIFFERENT SURGICAL POSITIONS are flexed and legs are on inside of metal posts or
1. SUPINE POSITION stir ups. Note the buttocks are even with the table
Þ Patient lies straight on back, face upward, with edge.
arms at sides, legs extended parallel and Þ Patient is on back with foot section of table
uncrossed, feet slightly separated. Strap is placed lowered to right angle with body on table. Knees
above knees. Head is in line with spine. Note that are flexed and legs are on inside of metal posts or
small pillow under ankles to protect heels from stir ups. Note the buttocks are even with the table
pressure. edge.
o Face, neck, shoulder, antero-lateral 6. DORSAL RECUMBENT POSITION

procedures; Þ The patient is in supine position except that the
o Breast, axillary, upper extremity or Hand knees are flexed and thighs externally rotated.
surgery; Soles of the feet rest on the table. Pillows maybe
placed under the knees if needed for support.
2. TRENDENBURG’S POSITION Þ This position is used for some vaginal and
Þ The patient lies on the back in supine position perineal procedures.
with knees over the lower break of the table. The
knees must bend with the table break to prevent 7. MODIFIED RECUMBENT POSITION (FROG-
pressure on peroneal nerves and veins in the legs. LEGGED)
Þ This position is used for procedures in the lower Þ The patient is in supine position except that the
abdomen or pelvis when it is desirable to tilt the knees are slightly flexed with a pillow beneath
abdominal viscera away from the pelvic area for each. The thighs are externally rotated.
better exposure. Þ for surgical procedures in region of the groin or
lower extremities.
3. REVERSE TRENDELENBURG’S POSITION
Þ The patient lies on back. Footboard is padded and 8. KRASKE (JACK KNIFE) POSITION
raised. The entire OR table is tilted so head is Þ Patient’s hips are over central break in the OR
higher than feet. Strap of the OR table is placed table and knees strap is below knees. Note chest
below the knees. rolls in place and pillow under feet.
Þ used for gallbladder or biliary tract procedures to Þ This position is used for rectal surgeries like
allow abdominal viscera to fall away from the hemorrhoidectomy and pilonidal sinus procedure.
epigastrium, giving access to upper abdomen.
9. KNEE – CHEST POSITION
4. FOWLER’S POSITION Þ An extension is attached to the foot section. The
Þ The patient lies on the back with the buttocks at OR table is flexed at the center break, the lower
the flex of the table and knees over the lower section is broken until it is at a right angle to the
break. The foot of the table is lowered slightly, table. The patient kneels on the lower section and
flexing the knees. The body section is raised 45 the entire table is tilted to elevate the pelvis.
degrees, thereby becoming the back rest. Arms Þ The knees are thus flexed at a right angle to the
may rest on arm boards parallel to table or on a body. The upper portion of the table maybe raised

slightly to support the head, which is turned to the 14. PRONE POSITION
side. The arms are placed around the head with Þ Patient lies on abdomen. Chest rolls under axillae
elbows flexed, with soft pillow beneath. The and sides of chest to iliac crests raise body weight
chest rests on the table. Safety belt is above the from chest to facilitate respiration; pillow under
knees. feet to protects toes.
Þ This position is used for sigmoidoscopy and Þ this position is mostly used for spinal surgeries.
culdoscopy.
NURSING RESPONSIBILITIES IN POSITIONING
10. SIM’S RECUMBENT POSITION THE PATIENT
Þ A modified left lateral recumbent position, the Explain why the position and restraints are
patient lies on the left side with the upper leg necessary;
flexed at the hip and knees. The lower leg is Preserve client’s dignity by providing privacy
straight. The lower arm is extended along the and avoid undue exposure;
patient’s back with weight of the chest on the Secure patient with well-padded straps to prevent
table. The upper arm rests in a flexed position on nerve and tissue damage;
the table. Maintain adequate respiratory and vascular
Þ this position is preferred for endoscopic circulation by avoiding pressure on body parts
examination performed via the anus in obese or because it can impair circulation;
geriatric patients. Do not allow client’s extremities to dangle over
the side of the OR table;
11. LATERAL POSITION Place hand support on the sides of the table;
Þ Referred to synonymously as lateral, lateral Avoid excessive strain on the patient’s muscles;
decubitus or lateral recumbent. Always move both lower extremities at the same
Þ Note strap across hip of the patient to stabilize the time when putting them up in the stir ups and
body. Pillow between legs can be placed to when lowering down the hips to prevent hip
relieve pressure on lower leg. dislocation and muscle straining.
Þ This position is used for access to the hemo
thorax, kidneys, or retroperitoneal space. SURGICAL DRAPING
Draping - is the procedure of covering the patient and
12. LATERAL JACK KNIFE POSITION surrounding areas with a sterile barrier to create and
Þ Patient is in lateral position with kidney region maintain an adequate sterile field.
over the table break. Note kidney strap across the
hip to stabilize the body; raised kidney elevator CRITERIA IN DRAPING
for hyper-extending surgical site and pillow q Blood and fluid resistant to keep drapes dry and
between legs. Patient’s side is horizontal from prevent migration of microorganisms. Material
shoulder to hip. should be impermeable to moist microbial
penetration.
13. SITTING POSITION
Þ Patient is placed in fowler’s position except that q Resistant to tear, puncture or abrasions that
the torso is in upright position. Shoulders and causes fiber breakdown and thus permits
torso should be supported with body straps but microbial penetration.
not so tightly as to impede circulation and q Lint free to reduce airborne contamination and
respiration. shedding into the surgical site.
Þ this position is used for some otorhinologic and
neuro-surgical procedures. q Antistatic to eliminate risk of a spark from static
electricity. Material must meet standards of
Bureau of Fire Protection.

q Sufficiently porous to eliminate heat buildup so 4. Regular fabric drapes are applied over the plastic
as to maintain an iso-thermic environment sheeting unless plastic is incorporated into the
appropriate for patient’s body temperature fenestrated area of the drape.
q Drapable to fit around contours of patient, 2. NONWOVEN FABRIC DISPOSABLE DRAPE

furniture and equipment. • are compressed layers of synthetic fibers (i.e.
q Dull, non-glaring to minimize color distortion rayon, nylon or polyester) combined with
from reflected light. cellulose (wood pulp) and bonded together
chemically or mechanically without knitting,
q Free of toxic ingredients such as laundry residues tufting or weaving.
and non-fast dyes. • may be either absorbent or nonabsorbent.
q Flame resistant to self-extinguish rapidly on
removal of an ignition source. ADVANTAGES OF USING NONWOVEN FABRIC
DISPOSABLE DRAPES:
DRAPING MATERIALS They are moisture repellant. They retard blood
1. SELF-ADHERING SHEETING – sterile, waterproof, and aqueous fluid moisture strike-through to
antistatic and transparent or translucent plastic sheeting prevent contamination.
that can be applied to dry skin. They are lightweight, yet strong enough to resist
tears.
ADVANTAGES : They are lint free unless cellulose fibers are torn
ü Resident microbial flora from skin pores, or cut.
sebaceous glands and hair follicles cannot Contaminants are disposed of along with drapes.
migrate laterally to the incision. They are antistatic and flame retarded for OR use.
ü Microorganisms do not penetrate the They are prepackaged and sterilized by the
impermeable material. manufacturer, which eliminates washing,
ü Landmarks and skin tones are visible through the mending, folding, and sterilizing processes.
transparent plastic.
ü Inert adhesive holds drapes securely, eliminating 3. WOVEN TEXTILE FABRICS
the need for towel clips and possible puncture of • are tightly woven fabrics that inhibit migration of
the patient’s skin. microorganisms. Reusable drapes may be made
ü Plastic sheeting conforms to body contours and of 270- or 280- thread-count pima cotton or 100%
has elasticity to stretch without breaking its Polyester.
adhesion to skin.
ü Have some sufficient moisture-vapor THINGS TO CONSIDER ABOUT REUSABLE
permeability to reduce excessive moisture build- WOVEN TEXTILE DRAPES:
up that could macerate the skin/ and / or loosen Material must be steam-penetrable and must
adhesive. withstand multiple sterilization cycles.
ü The heat retaining property of plastic causes the
patient to perspire excessively, but the nonporous When packaged for sterilization, drapes must be
nature of the sheeting prevents evaporation. properly folded and arranged in sequence of use.
Drapes may be fan-folded or rolled.
SELF-ADHERING SHEETING IS USED IN THE
FOLLOWING MANNER:
1. The usual skin preparation is done; Material must be free from holes and tears.
2. The scrubbed area must be dry; Drapes must be sufficiently impermeable to
3. Transparent plastic material is applied firmly to prevent moisture from soaking through them.
the skin, with the initial contact along the
proposed line of incision. The drape is smoothed Reusable fabrics must maintain barrier qualities
away from the incision site. through multiple launderings. The number of
uses, washings, and sterilizing cycles should be

recorded and drapes that are no longer effective NURSING DIAGNOSIS

as barriers should be taken out of use. ü Risk for fluid volume deficit or excess
ü Risk for hypothermia and hyperthermia
o 75 washings – densely woven treated ü Risk for infection and injury
cotton
o 30 washings – untreated cotton PLANNING
ü Maintenance of fluid balance
TYPES/ STYLES OF DRAPES ü Maintenance of normothermia
ü Towels ü Prevention of infection
ü Draw Sheet ü Absence of Injury
ü Stockinette
ü Fenestrated Sheets IMPLEMENTATION
• Laparotomy Sheet Promote measures that will maintain adequate
• Thyroid Sheet fluid and electrolyte balance by :
• Chest Sheet ü Monitoring I / O accurately
• Hip Sheet ü Assessing for signs of dehydration
• Perineal Sheet ü Assessing for circulatory overload
(breath sounds, peripheral edema and
• Laparoscopy Sheet
jugular vein distention)
ü Separate Sheets
Promote measures that will maintain patient’s
• Split sheet
normal body temperature.
• Minor sheet Promote measures that will decrease risk of
• Medium sheet infection
• Single sheet Ensure patient’s safety in the operating room.
• Leggings
• St. Mary’s sheet
SURGICAL INCISIONS
Þ is a cut made through the skin and soft tissue to
INTRA OPERATIVE NURSING CARE PLAN: facilitate operation or procedure.
Þ The aim is to employ the most suitable type of
ASSESSMENT incision for the particular surgical procedure by
1. Classifying the patient’s physical status for achieving these 3 things: accessibility,
anesthesia; extensibility and security.
2. Assess the patient’s record for appropriate
documentation; LAYER OF ANTERIOR ABDOMINAL WALL
3. Maintaining safety and preventing injuries during ü Skin
positioning at the OR table; ü Subcutaneous Tissue
Ø Explain the purpose of positioning ü Superficial Fascia
Ø Safely and securely strap the patient to ü Deep Fascia
prevent falls ü Muscle
Ø Maintain adequate respiratory and circulatory ü Peritoneum
function
Ø Maintain good body alignment TYPES OF SURGICAL INCISIONS
4. Assess for surgical consideration and precautions; 1. VERTICAL INCISION
5. Assess patient’s risk for accidental hypothermia or Ø Midline or Laparotomy Incision or
malignant hyperthermia; Celiotomy - most traditional and common
surgical incision;
WHO Surgical Checklist Form - • Varies in size / length depending on the
type of surgery;

• Incision is made mostly in avascular Ø Thoraco-abdominal Incision

plane and does not impose a great risk • Unique incision that connects the
to the blood supply; pleural cavity and the peritoneal cavity;
• Almost bloodless, no muscle fibers are • Right sided incision provides good
divided & no nerves are injured; exposure of the hepatic region and right
• Provides the best visualization and kidney;
intra-abdominal access; • Left sided incision provides good
• Commonly used for exploratory exposure of the stomach and distal
procedures and traumas. esophagus
Ø Paramedian incision Ø Pfannenstiel Incision

• Offsets vertical incision to right or • Is a transverse lower abdominal
left, providing access to lateral organs incision that is made superior to the
like spleen or kidneys. pubic ridge.
• Closure is more secure because rectus • Commonly used for cesarean sections,
muscle can act as a buttress between urologic, orthopedic and pelvic
posterior and anterior fascial plane. surgeries;
• provides limited exposure beyond the
2. TRANSVERSE & OBLIQUE INCISIONS pelvis.
Ø Kocher or Subcostal Incision
• Incision on the right side of the Ø Maylard Incision (Mackenrodt)
abdomen to expose the gall bladder and • Is a transverse incision 6 cm above the
biliary tree; pubic tubercle that is made through the
• Incision made inferior and parallel to rectus abdominis to gain access to
the subcostal margin extending through pelvic structures.
the anterior rectus fascia, rectus
muscle, internal oblique, transverse Ø Chevron Incision
abdominis, transversalis fascia & • Incision made that crosses the midline
peritoneum. of the abdomen;
• Post operative pain is greater due to the • Is a subcostal incision that extends from
severing of the rectus muscle. the mid to lateral costal ridge, across
• Incision made is not on an avascular the midline to the contralateral side;
plane; • Provides good exposure of hepatic,
pancreatic, upper gastrointestinal
Ø Abdominal Incision region, adrenal or renal surgeries;
• for abdominal surgeries
Ø Sub-clavicular (Infra-clavicular) Incision
Ø Lumbotomy or Transverse Incision • Transversely made through the skin
• for Kidney surgeries and subcutaneous tissue inferior to the
clavicle, giving access to the subclavian
Ø McBurney’s Incision or Gridiron vessels.
• for Appendectomy
Ø Supraclavicular Incision
Ø Lanz or Rockey-Davis Incision • Is a transverse incision superior to the
• Similar to a gridiron incision and is clavicle;
useful for open appendectomies. • Advantage of this incision is that it can
• Incision is horizontal incision while the meet a sternotomy incision or a cervical
gridiron incision is on an oblique angle. incision to provide greater exposure to
cervical anatomy or thoracic anatomy

• most often utilized in trauma to gain POST OPERATIVE PHASE

access to the subclavian vessels.
A. THREE PHASES OF THE POST OPERATIVE
Ø McEvedy Incision PERIOD.
• Is a vertical incision from the femoral
canal and brought superior to above the B. CRITERIA TO LOOK INTO THE PATIENT
inguinal ligament; PRIOR TO DISCHARGE FROM THE PACU
• Caution should be made not to injure ACCORDING TO FAIRCHILD (1993).
the femoral vein, artery or nerve;
• Incision made to repair femoral hernias C. POTENTIAL POST OPERATIVE PROBLEMS
c.1. Respiratory problems
Ø Inguinal or Groin Incision c.2. Circulatory problems
• Is a transverse or oblique incision over c.3. Urinary problems
the inguinal canal which is made c.4. GI problems
through the skin to the subcutaneous c.5. Wound healing problems
fat, through camper and scarpa fascia;
• used for open inguinal hernia repairs; d. THE EMPHASIS OF NURSING CARE AFTER
SURGERY is maintenance of proper respiration,
Ø Gibson Incision circulatory and gastro intestinal functions, alleviation of
• Is made 3 centimeters above and pain, promoting faster wound healing, maintaining a safe
parallel to the inguinal ligament; environment and preventing / managing potential post-
operative complications.
• Used in gynecological procedures and
urological procedures
Ø Supra-umbilical/ Infra-umbilical Incision

• Used for access into the peritoneum
through the tissues surrounding the
umbilicus;
• Commonly used for repair of umbilical
hernias.
Ø Para-rectus Incision
• Incision made through the semilunar
line laterally to the rectus abdominis
muscle;
• Used for spigelian hernia repair or if
modified, can be used for an ostomy.
Ø Butterfly Incision – for craniotomy

Ø Limbal Incision – for eye surgeries
Ø Halstead / Elliptical – for breast surgeries

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NCM112: MEDICAL SURGICAL NURSING

Concept 1: Pain and Surgery

PERI OPERATIVE NURSING: HISTORY

CHRISTINE JOYCE MARANAN 1

IMPROVEMENT IN PERIOPERATIVE PATIENT DISINFECTION

OR NURSE INFORMED CONSENT

CHRISTINE JOYCE MARANAN 2

PROCUREMENT- Donor organ

SURGERY EXPLORATION- Invasive examination

- - branch of medicine concerned with disease or DIVERSION- Operation of stoma

EXCISION- Remove tissue or structure by sharp

CHRISTINE JOYCE MARANAN 3

CONDITIONS TREATED BY SURGERY

§ EXPLORATORY SURGERY § ELECTIVE

CHRISTINE JOYCE MARANAN 4

SURGICAL RISKS PATIENTS PERIOPERATIVE NURSING

“To be liable is to be legally bounded, responsible and

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PERIOPERATIVE NURSE q Skilled listener, keen observer and abled

EXPECTED ATTRIBUTES POSTOPERATIVE PHASE

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CIRCULATING NURSE VENTILLATION

NURSE ANESTHETIST PRINCIPLES IN DESIGNING AN OPERATING

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3 AREAS OR DIVISIONS OF OPERATING ROOM

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CONDITIONS THAT FAVOR THE BACTERIAL q nausea and vomiting

NOSOCOMIAL INFECTION 4. Mode/Route/ Method of Transmission

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DROPLET TRANSMISSION 3. Cilia

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GUIDELINES ON STERILIZATION & Þ Performance record for all sterilizers should be

Þ The efficacy of the sterilization process should be

Þ Every package should be labeled with the date of

Þ Sterilized items should be carefully handled and

Þ Flash sterilization should be used for emergency

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OPERATING ROOM ATTIRE

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ü Personal hygiene must be reemphasized.

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COMPONENTS OF OPERATING ROOM ATTIRE 3. SHOE COVER

q persons who will not be part of the sterile team 4. MASK

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6. STERILE GLOVES q cuffs of the gown are stockinette (rib-knit) to

q should be comfortable without producing

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4. 60% / 90% Alcohol STEPS IN BRUSH STROKE METHOD (15 STROKES

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q Unfold the gown carefully, holding it at the neck-

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ü If contamination occurs during either procedure, EGYPTIANS (1900 – 1200 BC ) –

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AMERICAN CIVIL WAR (1861 – 1865 ) – CLASSIFICATIONS OF INSTRUMENTS

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SCISSORS GRASPING AND HOLDING

• Bandage is used to cut the uterus and

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FRAZIER TIP CATEGORIES OF INSTRUMENTS