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PERIOPERATIVE NURSING

 PRE-OP is admission to OR Objectives and Purposes of Surgery

 INTRA OP is OR to PACU (recovery room)
 POST OP is PACU to unit Discharge-healing cmplt  To cure
 To relieve pain
1. Purpose:  To prolong life
a. Diagnostic- biopsy, exploratory  To maintain dynamic body equilibrium
b. Curative- removal/replacement (Ablative)  To treat and prevent infection
c. Palliative –relief pain  To correct deformities or defects
2. Location:  To ensure the ability of the client to earn a living
a. External
b. Internal
Surgical team
3. Mode: Sterile members
a. Constructive – congenital, acquired
b. Reconstructive  Operating surgeon – preop judgement of
patient, intraop and post op management of
4. Degree of risk the px
a. Minor  Assistant of the surgeon – physician, non-
b. Major physician
5. Urgency
 Scrub nurse – RN
a. Emergency- asap- 24 hours
b. Urgent-within 48 hours Unsterile Team Members
c. Elective – as scheduled  Anesthesiologist
 Required  Circulating nurse
 Cosmetic (Optional)

Objectives and Purposes of Surgery

 To cure
 To relieve pain
 To prolong life
 To maintain dynamic body equilibrium
 To treat and prevent infection
 To correct deformities or defects
 To ensure the ability of the client to earn a
living

Medical asepsis
– practices or processes that decrease the number
and limit the spread of microorganisms

Surgical asepsis
– practices or processes that render an object or area
totally from free from microorganisms
a. elective – as scheduled based on surgeon’s or Disinfection
patient’s time preference
 required – px must undergo the
surgery but it can be delay but
delaying may result to discomfort or
disability
 cosmetic – aesthetic
purposes/improves client’s self-
image and self-worth
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2. Sterile personnel are gowned and gloved

3. Tables are sterile only at table level
Physical
4. Sterile personnel touch only sterile items or
- Boiling
areas; unsterile personnel touch only underlie
- Steaming
items or areas
- Sunlight
5. unsterile personnel avoid reaching the sterile
Chemical
field and sterile personnel avoid leaning over an
- Alcohol
unsterile area
- Chlorine 6. the edges of anything that encloses sterile
- Iodine contents are considered unsterile
- Phenol 7. The sterile field is created as close as possible to
the time of use
Sterilizatio 8. Sterile areas are continuously kept in view
9. Sterile personnel keep well within the sterile
n Physical area
- Autoclave 10. Sterile personnel keep contact with sterile areas
- Radiation to a minimum
- Gas 11. Destruction of the integrity of microbial barriers
Chemical results in contamination
- Soaking/Immersion !! Remove the gown and then the gloves, remove glove
to glove and then skin to skin

Earle Spaulding’s Classification of Patient Care

Items Example of board exam question:
Sample Sterilization & level of Disinfection for In performing close-gloving technique
Glutaradehyde
a. The nurse will put the first glove on her hand in
prone position fingers pointing away from her
Sterilization or b. The nurse will place the gloves on her hand in
Classification Use prone position fingers pointing towards from
Disinfection?
her
c. The nurse will place the gloves on her hand in
Cuts intact skin
supine position fingers pointing towards from
and mucus
her
membrane
Critical S d. The nurse will place the gloves on her hand in
Enters vascular
supine position fingers pointing away from her
areas of the
body Answer: B - Prone position,

Used on non- towards Surgical instruments:

intact skin & 1. Sharps
Semi-critical S or/if NA D
mucus a. Knife – use for Sharp – dissecting, cutting
membranes
both tough & Graspers – holding
Used on intact Clamps – occluding
delicate
Non-critical skin and mucus D Retractors – exposing
- 1st knife – skin
membrane
Principles of Sterile Techniques:
- 2nd knife – next
other

1. Only sterile items are used within the sterile layers Surgical blade (disposable)
field Blade holder (reusable)

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!! Use needle holder to hold BH  all numbers start with

1 BH #3 & with 2 is BH #4  when giving the  1st count – before the start of surgery
instrument to the surgeon, place it in the kidney basin  2nd count – before closing peritoneum
and the surgeon will be the one to get it  to prevent  3rd count – before closing the fascia
injury  4th count – before closing the skin
b. Scissors
- Mayo – short & narrow, for tough ex. fascia
- Metzenbaum (Metz) – long & slender, use to Board Exam Question:
delicate layers ex. peritoneum 1. When will the 4th count become 5th?
c. Needles
- Straight – use for tough - skin Answer: During a double cavity operation
- Curve
 Cutting – use for tough – skin, fascia
2. What is your nursing responsibility if there is
 Round – delicate – subcutaneous, muscle,
a discrepancy in the count?
peritoneum
Answer:
Five (5) Abdominal Layers: a. report to the surgeon
1. Skin – b. recount
tough Tough – bones,
c. surgeon orders for a search
tendons, ligaments
d. if needle is not found, doctor order for xray
2. Subcutaneous - delicate e. if needle is not inside the body, close the
3. Fascia – tough  anterior, posterior patient
4. Muscle – delicate f. make an IR  incident report
5. Peritoneum – delicate

Graspers
Four (4) Types of Suture Preparation - Thumb forcep
- Babcock – use for tubular organs ex.
1. Free tie – a strand of suture material
fallopian tube, ureter, vas deferens
2. Stick tie/suture with a carrier – NH
- Allis
+ suture
- Tissue forcep
3. Sut lig (suture ligature) – suture + NH
+ eyed needle Clamps Hemostat – occluding instrument; controls
4. Atraumatic suture (Atrau) – suture + NH bleeding serration
+ eyeless needle - Mosquito 100%
- Crile 50%
- Kelly 100%
Single arm attachment Start of the surgery - Ochsner 100%
Double arm 10 eyed needles
3 single arm Wound closure
2 double arm
Question: 3 eyed materials Absorbable
2 single
How many times are you sutures
4 double arms
going to perform surgical 1. Non-synthetic – derived from natural resources
count in a major abdominal What is the total of  ex. Cut gut – intestine of the sheep (made up of
surgery? needles after the
protein)
surgery?? 30 needles
Answer: 4 a. Chromic – brown  treated with chromium salt
soln – absorption takes 90 days  to delay the

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enzymatic digestion of the plain suture  a. Silk – navy blue/black – from silk worm 
almost use in all EXCEPT use over the skin
SUBCUTANEOUS!  Do NOT wet – losses tensile strength
b. Plain – yellowish  absorption takes 70 days b. Cotton – light pink/white – can be wet
 Use in subcutaneous tissue 2. Synthetic
Handling characteristic: Nylon – maximum of 25%/year
Hemostasis – control or arrest of bleeding
- If not yet in use, not soak in sterile water, 1. Mechanical
the protein will absorb the water thus it Hemostat/clamps, suture, pressure –
loses tensile strength manual/digital, dressing, gelfoam
- Before serving it to the surgeon, are we
2. Chemical
allowed to wet them in sterile water –
YES!
 Wet using sterile water just before 3. Thermal Coagulant
serving It to the surgeon Vit k
Purpose: To lubricate the suture Hemostan/Tranexamic acid
Absorption starts 1 week after Oxytocin
placement
Bone wax – will apply to
fracture bone  stops the
bleeding
Sterile field then inner package with suture materials inside
Cryosurgery – liquid nitrogen  can be
soaked in solution (alcohol)  peel the outer package so that
sprayed & applied
you can drop the inner package in the sterile field – it will Electrocautery – heat
now then open by the scrub nurse next will drop into kidney
basin. What will happen in the alcohol solution, will it
evaporate, YES or NO?? YES – what will happen to the
suture? Dry – due to exposure in air.
Surgical Positions and Incisions
If the chromic/plain suture are not yet in use, are we allowed
to soak them in sterile water? NO – they are made up in
protein. What will be the reaction? Protein absorbs water 
swells. Will it lose tensile strength or increase tensile
strength? It loses tensile strength

2. Synthetic – derived from artificial sources

a. Dexon – green – 90 days
b. Vicryl – violet – 110 to 120 days

Suture line: Below the xiphoid above the umbilicus

Procedures: Gastrectomy (Billroth 1 & 2),
1 - Exploratory Laparotomy
malaki 1-0
2 - mataba If the suture opens up it called wound dehiscence
2-0 Protrusion of the suture called evisceration

Primary suture – closes the wound

Secondary suture – support the primary suture

Non-absorbable
1. Non-synthetic
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To follow the contour of the organ

Question:
The doctor will do a resection and anastomosis of the
ending portion of ascending colon. What will the doctor
use? Right upper paramedian incision or Right Mid-
Abdominal Transverse Incision?

Answer: Right Upper Paramedian Incision – because

the organ (ascending colon) is in vertical to maximum
exposure
Procedures: Hysterectomy, Tubal Ligation,
Exploratory Laparotomy

Procedure: Nephrectomy
Procedures: Exploratory Laparotomy

Other name: Right Upper and Lower Subcostal,

Left Upper and Lower Inguinal
Vertical incision

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Board Exam Question: Benefit of position to surgeon:

 Maximum exposure the operative site
What type of incision is use in appendectomy?  Ease of entry and exit from the operative site
 Minimum of physiotrauma
Answer: Mc Burney’s Incision – If the appendix is still  The position should not abstain the operative
intact BUT if it is already ruptured Right Lower site
Paramedian

Benefit of position to anesthesiologist:

What procedure will the surgeon perform during
appendectomy once the appendix is already been taken  Position should not impede the respiration
out to minimize the possibility of peritonitis post-op? and circulation
Question:
Answer: Peritoneal Lavage  betadine 10% 50-50 200
mL soln order by the doctor Are we allowed to
Nurse will get 50% of 200 mL – 100 mL betadine 10% breaking the table?
then combine with a 100 mL NSS (to make up with
50- 50% 200 mL followed by 500 mL pure NSS for - Position the table
washing based on the
surgical position of
the patient  by
section/segment of
the OR

Ex. CS, Cataract removal

The ONLY curve incision

Ex. Lumbar Laminectomy

Ex. Abdominal Paracentesis, Closed-tube thoracostomy,

Bronchoscopy

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 Monitor VS, I&O

 Secure consent
 Bathing prn
 Light evening meal
 NPO post midnight
 Psychological & spiritual support
 Administer laxative drug if ordered
 Removal of nail polish

Ex. Endoscopy  The morning of the surgery

 Ensure NPO
 Oral care
 Enema if ordered
 Shaving
 Review post-op exercises
 Pre-op medication
 Monitoring
 Removal of dentures
 Endorsement to OR
 Consent – signifies patient’s willingness to
Ex. Perineal Surgery, Vaginography, undergo a procedure
Episiotomy, Episiorrhapphy  General consent – secured upon
admission/covers routine procedure
 Informed consent
 Purpose: “Protects the patient from any
unwanted procedure to be done on him and
protects the hospital from any claim of the
patient that an unwanted procedure was done
on him.”

Considerations:
 Legal age
Other positions:  Timing
 T-position  Who is qualified to sign?
 Reverse T-position  Coverage
 Kidney position Each surgical operation
Any entrance into the body cavity
Duties & Responsibilities of OR Nurses Hazardous treatment or therapy
Anesthesia
a. Circulating Nurse
1. Receive pt from surgical ward nurse Pre-operative Medications:
 Endorsement – Pre-operative checklist - Prepares client for anesthesia
- Right patient, schedule - Potentiates effect of anesthesia
- Informed consent - Allays patient’s anxiety
- Client preparation before the surgery
 The day & night before the surgery 1. Narcotic analgesic – Morphine (most)
 Pre-operative visit Nalbuphine (least), Demerol (ideal)
 Client education on post-op 2. Sedative – Phenergan
activities 3. Anticholinergic – to decrease saliva secretion
 Ensure all lab & diagnostic exam 4. Establish rapport with client
results are in and reported to MD 5. Place patient on OR table & never leave patient
 Check cp clearance
 Check blood products
alone

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6. Position for anesthesia (supine or quasi fetal Types:

position) 1. General – produces sensory, motor, reflex, and
7. perform lumbar prep for spinal/Epidural mental block
induction of anesthesia - Inhalation gas liquid
8. supine position - IV
9. perineal prep with proper positioning, 2. Regional
catheterization - Spinal
10. supine - Epidural
11. sure positioning - Nerve blocks – plexus
12. Abdnal Skin prep - Local infiltration, application, spray
13. Draping – 4 OR towels, foot drape, Lap
sheet (fenestration) (time out) General anesthesia
14. Cutting time
Inhalation Agents:

A. Non-Halogenated gas
b. Scrub Nurse
1. Nitrous oxide – blue – initial restlessness
1. Receive patient from surgical ward nurse
2. Cyclopropane – orange for short procedure
2. Prepare & organize the OR unit based on the
B. Halogenated fluid
case
1. Halothane – red – hypotension
3. Open sterile packs & add sterile supplies
2. Enflurane – yellow – muscle relaxation
& instruments
4. Perform surgical scrubbing, gowning 3. Sevoflurane – sweet taste – pedia
and gloving
Intravenous Barbiturates:
5. Organize sterile fields
- Thiopental Na

Neuroleptic Agents
- Fentanyl – decreases motor

Dissociative agents
- Ketamine – hallucinations

6. Serve gowns and gloves to surgeons

7. Instrument count
8. Draping
9. Cutting time

Anesthesia – loss of sensibility to pain

Stages:
 Induction
 Excitement
 Surgical anesthesia
 Medullary

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