NCM 212 - SURGERY a.

Maintain aseptic technique to provide

safety (sterile environment)
b. note - surgical site infection (SSI)
OUTLINE c. Surgical positioning
d. Equipments are properly functioning, also
I. SURGERY
provide necessary Equipments
II. PERIOPERATIVE NURSING
3. Post Operative Phase - from time of admission to
III. CLASSIFICATION OF SURGICAL
the RR, to the time he is transported back to the
PROCEDURES
surgical unit, discharges from the hospital, until the
IV. PREOPERATIVE PHASE
follow up care.
V. NURSING RESPONSIBILITY
BEGINNING: admission to RR
VI. INTRAOPERATIVE PHASE END: discharge
VII. APPLICATION OF STERILE
TECHNIQUE CONDITIONS REQUIRING SURGERY: (OPET)
VIII. PRINCIPLES OF STERILE 1. Obstruction - blockage to any organ
TECHNIQUE 2. Perforation - fracture or hole in organ, PPUD
IX. ANESTHESIA (perforated peptic ulcer disease)
X. 3. Erosion - wearing OFF
4. Tumor - any abnormal new growth that has no
physiologic function (benign or malignant)
SURGERY Under diagnostic
SURGERY - designates the branch of medicine that - Melena - Blood in stool
encompasses pre-operative care, intra-operative judgement,
and post-operative care of patients CLASSIFICATION OF SURGICAL PROCEDURES:
OPERATION - for correction of deformities and defects, repair ACCORDING TO PURPOSE
of injuries, diagnosis and cure of disease processes, relief of 1. Diagnostic - Process of determining the nature of
suffering and prolongation of life.
the disease
PERIOPERATIVE NURSING a. Bronchoscopy - viewing of pulmonary
- describes the nursing functions in the total surgical System
experience of the patients b. Colonoscopy - viewing of the colon
- Specialize area of practice providing care to surgical 2. Exploratory - an investigative operation on a wound,
clients tissue or cavity
a. otomy- incision
3 PHASES OF PERIOPERATIVE NURSING: b. example to know what organ is affected
1. Pre-operative Phase - from the time the decision is (ruptured appendix - so need siyag
made for surgical intervention to the transference of laparotomy)
the patient to the operating. 3. Curative - to treat the disease condition
START: When decision was made a. Ablative - removal of a diseased organ
ENDS: Transference of the patient to OR i. ectomy - removal
a. Informed consent ii. Eg. appendectomy, amputation
b. Demographic data b. Constructive - repair of congenitally
- Check personal information- defective organ
name, age, history of illness or i. plasty- surgical repair
allergies, previous surgery ii. Eg. cheiloplasty, herniorrhaphy,
c. Health teaching orchiopexy
d. Physical assessment and emotional c. Reconstructive - to treat disease
assessment is performed conditions, restore the partially or
e. Laboratory Phase completely damaged organ and tissue.
2. Intra Operative Phase - from the time the patient is I. eg. skin graft after a burn, total
received in the operating room, to the time of joint replacement, rhinoplasty,
administration of anaesthesia, surgical procedure is perineorrhaphy, ORIF (Open
done, until admitted to the RR/PACU Reduction Internal Fixation)
BEGINNING: starts once transferred to OR and NOTE:
given with anaesthesia • Perineorrhaphy and Episiorrhaphy is the same
END: admitted to PACU (POST-ANAESTHETIC but performed in different conditions
CARE UNIT)

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 1

 • Perineorrhaphy - cause of tear is accidental on - This events are LIFE-THREATENING
the perineum area during childbirth scenarios
• Episiorrhaphy - cause is intentional for example i. Fetal distress, excessive
during giving birth after episiotomy ii. Ruptured appendix it is
emergency
iii. Obstetric emergencies
4. Palliative - alleviates symptoms without curing the
iv. Ruptured aneurysm
disease condition
v. Life threatening trauma
a. remove the affective area and suture back
vi. Intestinal obstruction
the health are of the patient, will not cure it
b. Multiple injury
just relieve symptoms
2. Urgent/Imperative - to be done within 24 to 30
b. Eg. bowel resection in patient with terminal
hours (or 24 - 48)
cancer
- It is urgent and requires immediate
5. Transplant - to replace/ organs tissue
attention within the given time frame
a. Heart, lungs, liver, kidney, cornea
a. essential to perform surgery but not an
emergency
NOTE:
b. Eg. amputation resulting from gangrene,
• Eyeball removal is impossible due to nerve that is
connected such as the optic nerve, removal of the fractured hp, heart bypass surgery,
said organ causes total blindness appendectomy
3. Elective - performed for the patient’s well being
ACCORDING TO DEGREE OF RISK a. depending on the assessment and findings
(MAGNITUDE/EXTENT) of the surgeon
1. MAJOR b. the doctor will schedule the surgery
- major cavities are opened (chest, c. but the time of surgery depending on the
abdomen, skull) assessment of the doctor
- so much blood loss and usually would last 4. Planned/Required - necessary surgery, needed by
for 8 to 12 hours. (Cataract surgery is the patient but the time of the surgery is scheduled
considered a major surgery) by the physician or surgeon
- Extensive critical assault to the area a. Cataract surgery
- High risk for mortality and morbidity 5. Optional - performed for patients aesthetic
- Prolonged hours of procedure purposes, personal preferences
- Vital organs are affected a. plastic surgery like rhinoplasty
i. Transplant NOTES:
ii. Caesarean - Emergency/ Stat performed immediately
iii. Total hip replacement - Scheduled / Elective
iv. cholecystectomy
v. joint replacement SURGICAL RISK FACTORS (MAMDOCRARD)
2. MINOR 1. AGE - extreme ages :< 2 years or ? 65 years have
- only superficial tissues are opened and higher risks
does not open major cavities of the body - - Infant (young age group) blood depletion
can be done in a ambulatory surgery due to their low fluid reserves which can
- Ambulatory surgery means, after the cause (such as) hypovolemic shock
surgery the patient can go home or be - Old - cognitive problems that involves age
discharge on the same day without being related changes, Less physiologic reserves
admitted to the hospital due to old age, diminish blood flow thus
a. A minor surgery can become a major there will be inadequate tissue perfusion
surgery if prolonged 4-5 hrs (due to Nsg. Implications:
● Consider using lesser doses of anaesthesia for
complication)
desired effect.
b. Examples
- general anaesthesia (GA) for children
i. Debridement
- Epidural anaesthesia for adults bc lesser
ii. RASPA OR D & C (dilatation and
ang side effects
curettage)
● Adjust nutritional intake to conform to higher protein
iii. SKIN LESION REMOVAL
and vitamin needs.
iv. BREAST BIOPSY
v. Removal of warts - Protein for tissue or antibody repair esp in
patients who undergone surgical procedure
ACCORDING TO URGENCY - Vitamin C for immune booster referring to
1. Emergency - to be done immediately surgical patient for antibody formation
- Done without delay to save the life of the - Vitamin A for wound healing; food sources
patient are dairy products

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 2

 - Vitamin K for blood clotting hemostan,
soybean, broccoli
● Anticipate problems from long standing chronic
disorders such as DM, anaemia, obesity, CV
disorders, respiratory disorders. For ex, if pt has
severe anemia need muna mag BT before
undergoing surgery bc there will be blood loss. For
DM, it should be corrected bc there will be a wound;
di magheal if may DM
2. OBESITY
- Poor vascularity causes tearing in the
suture site and can thus delay wound
healing
- full of adipose tissue there is a possibility
that the wound will open
- dehiscence is greater due to secretion
- Difficulty in breathing causing respiratory
disorder and they move less that can cause
circulatory problems that will cause
thrombophlebitis
- Unable to breathe or breathe poorly and
difficulty moving esp in supine position
Nsg. Implications:
● Promote weight reduction if time permits (anticipate
several problems like poor wound healing when
performing surgery on a obese patient)
● Monitor closely for wound and cardiopulmonary
complications postoperatively. Prone to atelectasis
or respiratory problems
● Encourage coughing, turning, and diaphragmatic
breathing exercise and early ambulation
3. MALNUTRITION
- Body reserve is not sufficient to respond
satisfactory organ failure and shock may
result
- vulnerable to pressure ulcers due to
surgical positioning (there is pressure on
bony prominences tissues
- Poor inadequate nutrition result in delay
wound healing
Nsg. Implications:
● Promote weight gain by providing a well-balanced
diet high in calories, protein and vitamin C.
● Administer total parenteral nutrition, nutritional
supplements and tube feedings as prescribed.
● Daily weights and calorie counts may be ordered.
4. DEHYDRATION/ ELECTROLYTE IMBALANCE
- Depending on the degree of dehydration or
depending on type of imbalance cardiac
failure may occur
Nsg. Implications:
● Assess patient esp fluid status
● Administer IV fluid as ordered. If severely dehydrated
ang pt, hydrate pt first before surgery. Probably 2L or
3L fast drip
● Keep a detailed I&O record
● Monitor for evidence of electrolyte imbalance (Na+,
K+, Ca++, etc.). if taas ang potassium, more than
ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G
3.5mg/dl, pt is prone to have a cardiac arrest. For
calcium it is important for nerve conduction as well
as conduction for heart muscles.
5. CARDIOVASCULAR DISORDER
- Increases risk of DVT or hypovolemic shock
and pulmonary embolism and fluid overload
Nsg. Implications:
● Diligently monitor VS, especially PR, regularity and
rhythm, and general condition of the client
● Closely monitor fluid intake bc if too much fluid it will
affect functioning of your heart
● Assess skin color esp if dehydrated, cyanotic
(assess lips, nail beds) if pt has dark skin, check
upper palate
● Assess for chest pain, lung congestion, and
peripheral edema
● Observe signs of hypoxia and administer oxygen as
ordered
● Early postoperative ambulation and leg exercises
● Encourage change of position but avoid sudden
exertion. 24 hrs after surgery or if already awake, pt
has to ambulate or to move in bed so as not to have
respiratory problems. Kasi if magkaresp problem,
magkaroon ng fluid in the lungs of pt esp in the alveoli
then pt will have difficulty of breathing
● Sudden change of position might cause hypotension
6. RESPIRATORY DISORDER
- High risk to contribute to another respiratory
disorder
Nsg. Implications:
● Closely monitor RR, PR, and breath sounds
● Assess for hypoxia, dyspnea, lung congestion and
chest pain
● Encourage coughing, turning, and diaphragmatic
breathing exercises and early postoperative
ambulation
● Encourage client to quit smoking or at least to reduce
the number of cigarettes smoked
● Patients with chronic pulmonary problems such as
emphysema, bronchiectasis, etc. should be treated
for several days preoperatively with bronchodilators,
aerosol medications, and conscientious mouth care.
7. DIABETES MELLITUS
- increased risk for surgery due to fluctuating
blood glucose levels
- can develop cardiovascular disorder
- susceptible to delay in wound healing
Nsg. Implications:
● Monitor the client closely for signs and symptoms of
hypo/hyperglycemia. If pts have diabetes then may
medications, meds should be continued even during
surgery esp when they have insulin bc pt is under
stress so the more that endocrine system will cope
up with the stress so magincrease use ng sugar
● Monitor blood glucose levels every 4 hours as
ordered
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 ● Administer insulin as prescribed given even
intraoperatively; as circulating nurse, check if may
insulin para di madelay
● Encourage intake of food at the designated meal and
snack times
8. RENAL AND LIVER DYSFUNCTION
- decrease metabolism and decrease
excretion of drugs causing anaesthesia to
not work
- Kidney for elimination of anaesthetic drug
- Anaesthetic drug has Side Effects
Nsg. Implications:
● Evaluate closely for drug side effects and evidence
of acidosis or alkalosis.
● Monitor for fluid volume overload, I&O, and response
to medication.
● decrease wound healing check
9. ALCOHOLISM
- Accompanied with problems in malnutrition
such as delay wound healing and increased
risk for infection
- Require high dose in anaesthetic drugs
since they are immune to normal levels due
to alcohol intake
Nsg. Implications:
- Monitor closely for signs of delirium tremens (form of
psychosis caused by alcohol withdrawal in the body)
so pts will have seizures, hypotension
- Encourage a well-balanced diet. Esp rich in vitamin
B complex bc liver produces this vitamin so if
diseased na ang liver, iheal muna bago sched ng
surgery
- Monitor for wound complications.
- Administer supplemental nutrients parenterally as
ordered.
- monitor the patient intake
10. MEDICATIONS
- Obtained even info such as medications
that the pt is currently taking to determine
appropriate drugs to be given
a. Anticoagulants/ Salicylates
- Known as to prevent blood clot
formation
- Cause intra and post op bleeding
Nsg implications:
● Monitor for bleeding. Post-op check if may good
wound closure, dry dressing and no blood
● Assess PTT/PT values.
● PTT - partial thromboplastin time, PT -
prothrombin time
● values will tell the clotting time of patient; determine
if long or normal
b. Diuretics (Thiazides)
- Cause fluid and electrolyte
imbalance
ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G
- Produce altered cardiovascular
problems
- And causes respiratory
depression
Nsg Implications:
● Monitor I&O and electrolytes.
● Assess cardiovascular and respiratory status.
c. Antihypertensive (phenothiazine)
- Can increase the hypotensive
effect of anaesthesia that result in
hypovolemic shock
Nsg. Implications:
- Closely monitor blood pressure.
d. Antidepressant (MOA inhibitors)
- monoamine oxidase inhibitors;
increase hypotensive effect of
anaesthesia
Nsg. Implications:
● Closely monitor blood pressure.
e. Antibiotics
- Incompatible with anaesthetic
agent and potentiate the
hypotensive effect of anaesthesia
Nsg. Implication
- Monitor Respirations
11. OTHER FACTORS
1. Nature of the condition – what is the surgery
all about, or para saan ang gagawin for pt,
would it be beneficial for the pt to do the surgery
or not
2. Location of the condition – location: heart,
brain; and what type of brain surgery are they
going to have, is it only evacuation or clipping
of aneurysm.
3. Magnitude and urgency of the surgical
procedure – for ex. clipping of aneurysm – it is
very urgent bc there is pooling of blood sa brain
which may cause to have bleeding, seizure,
hypotension, also cause death.
4. Mental attitude of the person toward the
surgery – if patient is psychologically prepared,
does the pt experiences anxiety.
5. Calibre of the professional staff health care
facilities – how good the surgeon, number of
times that the surgeon have done this
procedure, facilities if kaya ba ng hosp to have
that procedure.
PREOPERATIVE PHASE
PSYCHOLOGICAL PREPARATION
- surgery can be distressing to the family and the
patient
FEAR - an emotion marked by dread, apprehension and alarm
caused by anticipation or awareness of danger and
manifested by anxiety. Distress emotion that is aroused
TYPES OF FEAR (CAUSE OF FEAR OF THE
PREOPERATIVE CLIENT)
1. Fear of the UNKNOWN - most common
a. the expected is less traumatic than the
unexpected
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 2. Fear of ANAESTHESIA - fear of loss consciousness
is closely aligned with fear of death
3. Fear of PAIN and DISCOMFORT - pain is powerful
emotion than sensation brought by anxiety
4. Fear of DEATH - a very valid fear
5. Fear of DISFIGUREMENT, MUTILATION LOSS OF
A VALUED BODY PART - Hard to accept the
possible outcomes after surgery. Real suffering
psychologically
6. Fear of loss of LIVELIHOOD - due to financial
instability, or loss of finances due to surgery
MANIFESTATION OF FEAR:
● Bewilderment
● Anxiousness
● Anger
● Tendency to exaggerate
● Sad, evasive, tearful, clinging
● Inability to concentrate
● Short attention span
● Failure to carry out simple directions
NURSING INTERVENTIONS TO MINIMIZE
ANXIETY:
1. Explore the client's feelings.
2. Allow clients to speak openly about fears/concerns.
3. Give empathetic support.
4. Consider the person’s religious preferences and
arrange for visit by priest/minister as desired.
LEGAL CONSIDERATIONS (OPERATIVE PERMIT/
SURGICAL CONSENT)
Informed consent
- is a LEGAL document required for certain diagnostic
procedures or therapeutic measures, including
surgery
- Written in simple words and sentences
- Medico required and will serve as evidence
PURPOSES: (MADE TO PROTECT PATIENT
DOCTOR AND THE SURGICAL TEAM)
1. To ensure that the client understands the nature
of the treatment including the potential
complications and disfigurement.
- The patient has to be informed what would
be the benefits and risks.
2. To indicate that the client’s decision was made
without pressure.
- Not under any medication and under the
influence of drugs when making the
decision, pt needs to be aware when
making the decision, to avoid legal
problems.
3. To protect the client against unauthorized
procedure.
- To know that the person doing the surgery
is a certified surgeon - knows what that
surgeon is doing. If the procedure is not
stated in the consent, then the doctor
cannot do such additional procedures. E.g.,
BTL during caesarean section.
ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G
4. To protect the surgeon and the hospital against
legal action by a client who claims that an
unauthorized procedure was performed.
- Two-way protection to the doctor and the
hospital
NURSING RESPONSIBILITY
3 MAJOR ELEMENTS OF THE INFORMED
CONSENT
1. VOLUNTARY
2. INFORMED (ultimate decision maker)
3. Patient must be competent to understand the
information and alternatives
NOTE:
- the patient will sign a waiver if he or she does not
want to get the surgery so when something happens
to the patient it was his and her decision to not accept
the surgery
“OBTAINING THE INFORMED CONSENT IS THE
RESPONSIBILITY OF THE SURGEON “
- the surgeon will ask the patient to sign
- the nurse will witness the signing of the waiver from
the surgeon and patient
Fig 1. Example of Waiver
WHO SIGNS THE CONSENT?
1. Adults
2. Next of Kin (if married: spouse)
3. Parent or Legal Guardian
4. Emancipated minors - earning married minors
5. Emergency Situation - next of kin/create a surgical board to
decide for the px
- the attending physician will sign the consent when
the situation is emergency
6. Illiterate - making an x then the witness writes “patient’s
mark” - pt who cannot read/write pwede thumb mark
NURSING RESPONSIBILITY:
- Witnessing the exchange of information b/w the
client and the surgeon
- Witnessing the client’s signature
- Establishing that the client really did understand.
Nurses should not explain, only the surgeon. As a
5
 nurse, we should just make sure that the patient
really did understand what's going to happen during
the surgery.
PHYSIOLOGICAL PREPARATIONS
LABORATORY AND DIAGNOSTIC TESTS
1. Cardiovascular - Ecg
- For patients aged 40 years and above
2. Hematologic - CBC, Hgb, and Hct, WBC, PTT, and
PT, Platelet count
3. Respiratory - Chest X-ray, Pulmonary function
Test/PFT
4. Metabolic - FBS, Electrolytes (K+, Na++, etc.)
5. Genitourinary - routine urine analysis
PHYSICAL PREPARATIONS:
TEACHING POST OP EXERCISES
1. Deep breathing exercise (diaphragmatic)
- To promote lung expansion and ventilation
and enhance blood oxygenation
- Patient should be fully awake and
conscious
- Position the patient in fowlers or semi
fowler. Inhale thru the nose and hold for at
least 5 seconds. Exhale thru the mouth and
repeat every 2 hours.
2. Coughing exercises
- Incentive spirometer
- Contraindicated to pt with head or eye
surgery; can increase intraocular pressure
and intracranial pressure
- To loosen, mobilize and remove pulmonary
secretions
3. Turning Exercises
- Performed 5 times every hours
- Tas wa ko kabalo diri ahhahaha
4. Leg, Ankle, and Foot exercises
- Purpose of leg exercises is to promote
venous blood return from the extremities
- Wala nako naminaw diri:<
HHHAHAHAHAHAHA
NIGHT PRIOR TO SURGERY:
● Preparing the skin
- Includes shaving the hair of the affected
area to ensure the close clean shave
- Upon shaving we can injure the site thru
shaving with small cuts thus increasing risk
for infection or unsa ba
- Changes in skin prep is done during itnra op
hindi na in pre op
● Preparing GIT (GASTROINTESTINAL TRACT)
- Bowel preparation (cleansing enema)
- Place the patient in NPO post-midnight
- according to ASA there is no need for NPO
post-midnight
- To prevent help, reduce incidence post op
N/V and may develop post op bleeding
ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G
- placing a patient on NPO can give
satisfactory viewing of the operating site
- We place patient on NPO to decrease risk
of aspiration pneumonia under while
anesthesia
- If we are the pre op nurse, we must ensure
that the patient is being reminded to stay
under npo till surgery to reduce risk of
aspiration
● Preparing for anesthesia
- Remind the patient to avoid alcohol at least
24 hours
- anesthesia consent check if the
anesthesiologist has obtained consent prior
to surgery
● Promoting rest and sleep
- By administering sedatives as ordered
ON THE DAY OF SURGERY:
EARLY AM CARE:
● Awaken on hour before pre op medications
-
● Morning bath, mouth wash
-
● Provide clean gown
- so there will be no cross contamination.
● Remove hairpins, braid long hair, cover hair wash
cap
- To prevent contamination
● Remove dentures, foreign materials, colored nail
polish, hearing aid, contact lens, wedding ring ,
underwear
- Remove Dentures to avoid aspiration that
may cause airway obstruction
- Remove colored nail polish to check
capillary refill
● Take baseline VS before pre op medication
- Sometimes before transporting the patient
● Check ID band, skin prep
- Check id band to confirm identification of
the patient this is to avoid the “wrong
patient, wrong procedure”
- if you don’t check it mag incident report ka
● Check special orders- enema, tube insertion, IV line
(in the morning)
-
● Check NPO- ensure that patient has not taken food
for the last 10 hours
-
● Have client void before pre op medication
- Allow the pt to void; anes is a sedative thus
pt is at risk of accidents
- To avoid any bladder injury
SURGICAL CHECKLIST
● Certain things that need to be done before surgery to
make sure everything is accomplish and to reduce
risk of accidents
● Pink sheet (checklist)
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 - Inhibits gastric acid production to reduce
gastric ulcer so even w/o food our GIT
keeps producing
6. Anxiolytics - eg. diazepam (valium)
- Drug used to reduce anxiety
- Most common is Diazepam
(Valium)
7. Antiemetics
- Drug used to treat N/V
- Reduce incidence of N&V intra or post
Fig 2. Surgical Checklist operatively
8. Prophylactic Antibiotics are
PREOPERATIVE MEDICATIONS/ PREANESTHETIC
- Cephalosporins (Cefazolin)
DRUGS
- It must be administered 60-90 minutes before - Surgical prophylaxis
surgery
PRE-OP NURSING DIAGNOSIS
GOALS:
● Anxiety related to the surgical experience
1. To allay anxiety
(anaesthesia, pain) and the outcome of surgery
- Either give barbiturates or tranquilizers to
● Fear related to perceived threat of the surgical
alleviate anxiety
procedure and separation from support system
2. To minimize respiratory tract secretions to
● Knowledge deficit of preoperative procedures and
prevent incidence of aspiration and changes in
protocols and postoperative expectation
HR
- Anticholinergics
INTRAOPERATIVE PHASE
3. Create amnesia for the events that precede
TERMINOLOGIES
surgery
- SURGICAL CONSCIENCE
4. To decrease body metabolism so less anesthetic - May simply state as a surgical golden rule “Do unto
will be used the patient as you would have others do unto you.”
- We need to give analgesics preoperatively ASEPSIS
to decrease metabolism that created by - Absence of microorganisms that causes the disease
your anesthetic agent - Freedom from infection
- Absence of pathogenic microorganisms; aseptic-
PRE-OP MEDS: without infection
1. Sedatives and Hypnotics (Versed (Midazolam) STERILE
Phenergan (Promethazine, - Free of microorganisms, including spores-
- Reduce pt anxiety microorganisms present in the environment; inactive
- Decrease BP and HR - May it be pathogenic or non pathogenic
2. Barbiturates/ Tranquilizers - Absence of all types of microbial form
- Same effect of sedatives SPORES
- Calming effect administered a night prior to - An inactive but viable state of microorganisms in the
surgery environment
- Valium (Diazepam) most STERILIZATION
common; Inapsine (Droperidol) - Process of killing all microorganisms, including
3. Narcotic Analgesics(Valium (DiazepamP,) spores
- It can be given pre op if pre op pain is - Absolute term used to properly kill all the
anticipated microorganisms
- Morphine sulfate (most common)
- Fentanyl (sublimaze) 3 METHODS OF STERILIZATION
1. Saturated Steam under Pressure
- Demerol (meperidine hcl)
- Is a dependable physical agent for
4. Anticholinergics
destruction of all forms of microbial life,
- Drugs that block the action of acetylcholine
including spores
- To reduce oral resp unsa daw to??
- Autoclave machine - free vacuum, high
- Interrupts vagal unsa daw
temp steam sterilizer
- Atropine sulfate(most common)
- sterile/autoclave tape -
- Glycopyrrolate (Robinul)
- Pressure greater than the atmosphere;
- Scopolamine
temp set 132 c
-
2. Gas Chemical Sterilization
5. Histamine- H2 Receptor Antagonist
- Is used to sterilize items that are heat or
moisture-sensitive

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 7

 - Instruments that are made of rubber or
plastic such as asepto syringe
- Uses a chemical agent (ethylene oxide gas)
3. Liquid Chemical Sterilization
- When items cannot tolerate sterilization by
saturated steam under pressure and when
time for gas sterilization is impractical
- Instruments used are to be soaked for 30
mins to 1 hour
STERILE FIELD
- The area the surgical site or introduction of any
instrumentation into a body orifice that has been
prepared for the sterile field
- Includes furnitures covered with sterile drapes
- Personnel who are properly attire is included in
sterile field
STERILE TECHNIQUE/SURGICAL ASEPSIS
- method/practices used to prevent contamination
SURGICALLY CLEAN
- It uses chemical, physical or mechanical means that
markedly reduced the no. of microorganisms
- After surgical scrubbing is not considered sterile
(surgically clean ra siya)
DISINFECTION
- Process of destroying pathogens except spores
- Can be used in inanimate objects; cannot be used in
skin tissues.
ANTISEPTIC
- Used on tissue and skin
- Can be used in endogenous that can be found inside
the body
- Alcohol, povidone iodine (betadine)
MEDICAL ASEPSIS
- Include all practices to confine a specific
microorganism to a specific area limiting the no.,
growth and spread of microorganisms
Objects referred as:
a. Clean - non pathogenic microorganisms are
present; absence of pathogenic organisms
b. Dirty (soiled) - presence of pathogenic
microorganisms
NOTE:
Trash Bins
● Black - dry
● Yellow - soiled or contaminated
APPLICATION OF STERILE TECHNIQUE
- Strict adherence to sterile technique to ensure pt
safety
● Preparation for operation
○ dusting, wiping, cleaning everything on the
inside of OR with a disinfectant: bed, pillow,
table, all instruments are already sterilized
● Preparation of the operating team
○ Do surgical hand scrub
ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G
○ Don sterile gloves
○ Don Sterile gown
● Creation and maintenance of the sterile field o
before and after the operation
○ Cover the patient with sterile linen
○ Must not break sterile technique
● Maintenance of sterility and asepsis thru-out the
operative procedure
● Terminal sterilization and disinfection at the
conclusion of the operation
○ What is done in the preparation should also
be done in terminal sterilization and
disinfection after the operation
PRINCIPLES OF STERILE TECHNIQUE
1. All items used within a sterile field must be sterile.
- Make sure that the items are always sterile
○ Check the indicator tape/sterile
tape if na lagay ba siya sa
autoclave
○ Check the integrity of the package
○ Check presence of puncture,
perforation, tears
○ Check the presence of moisture
○ Check the expiration date by
looking or checking the date of
sterilization
2. All sterile barriers that have been permeated must be
considered contaminated.
- Surgical Equipment are double pack
- When you are opening the outer pack, used
your hands but hold at the edges (1 inch at
the edge of the sterile field)
- For opening the second pack, sterile
forceps must be used
- Hands are away from sterile fields
- Use sterile pick-up forceps to pick up item
from wrapper
- Take note: hands be away from opening
- Use sterile glove not working glove
- The edges of a sterile container are
considered unsterile once the package is
opened.
3. The edges of a sterile container are considered
UNSTERILE once the package is opened
- Boundaries between unsterile and sterile
are not defined
- Margin safety 1INCH to the edge
- Use banana peel technique to release
gloves
- Tables would be 1 inch from the edge would
be considered unsterile
4. Gowns are considered sterile in front from the
shoulder level to table level, from the sleeves to 2
inches above the elbows.
- Gowns are stock on the table on top each
other, so take the gown on top, we cant
choose the sizes of the gown, kung ano
yung nasuot, yun na yun
8
 - Shoulder level to table level/waist level
(sterile area) SOURCES OF CONTAMINATION
- Below waist level are unsterile 1. Members of the operating room
- After donning sterile gloves and gown hand - Scrub nurse, surgeon
should be on chest 2. The patient
- The sterile area depends on the table level - Infectious disease
- Putot stool: for mga putot; foot stool 3. Articles used in the wound and on the sterile set-
- Front and back of gown sleeves, shoulders up
are also considered sterile - Instruments used
- Under the sleeves is placed on the table or 4. Dust in the air
touching the table kaya sterile - Salt air and rust in your door, i never
- If sitting: place hand on chest/diaphragm needed anything more
- In SPMC: may pocket ang gown however - Whispers of are you sure, never have i ever
mag contradict siya sa sterile technique before <3
(since gina instruct doon na ilagay sa 5. Other personnel or visitors in the OR
pocket ang hands, mg contradicts since - Medtech, Xray Tech, etc.
dapat everything is in sight, hindi matago;
and baka may butas yung pocket) HOW TO ELIMINATE OR REDUCE TO A MINIMUM:
- Transfer of position, one area to another: 1. Covering the mouth and nose
back to back (practice sterile to sterile, 2. Clean or clothes (scrub suit) and shoes NOT worn
unsterile to unsterile) not allowed to touch outside the OR.
our head and mag kalot 3. Meticulous housekeeping practices.
- Hands should be place on top and not tuck 4. Proper methods of sterilization of all items used.
in under the forearms 5. Strict aseptic techniques in all details.
5. Tables are sterile only at table level. 6. Minimum of activity in the room and of movement
- Sterile table if it has sterile drape or cover NOTE:
- Ideally 6-8 person are only allowed inside the OR
only the top portion is considered to be
that includes the patient
sterile
- Turn to sides then drop to the kick
3 ZONES OF THE OPERATING ROOM
basin/bucket: trash can sa OR 1. Non-restricted zone - street clothes are allowed
6. Sterile persons and items touch only sterile areas, ● When you are going to enter the OR, and
unsterile persons and items touch only unsterile just wearing your type A uniform you are
areas. just going to be allowed before the red mark
- At least 12 inches to not touch the table ● You can now enter the OR when you have
- If the surgeon is perspiring, they face away changed into your scrub suit, mask, cap
and the nurse use the back portion of their ● Visitors only on the red line
gown to wipe the sweat. Do not use the 2. Semi-restricted zone - attire consist of scrub suits and
front part; sterile. surgical caps from type c to type b
7. Movement within or around the sterile field must not ● Post anes room, area wherein instruments
contaminate that field. are sterilized
- In pouring sterile water, the scrub nurse ● Hallway and in the work room
must turn to the sides, bringing the basin ● Documentation room or record room
and the circulating nurse will pour 3. Restricted zone - scrub suits, caps, and surgical masks
- Margin of safety for at least 12 inches are required
- If youre unsterie maintain a distance to ● Sterile supply stock room
avoid contaminating the sterile field ● Also known as ante room
- Sterile person pass each other back to back ● Inside the OR
manner to avoid contaminating sterile field ● During surgery, u can wear goggles to avoid
- splashes
8. All items and areas of doubtful sterility are
considered contaminated. SURGICAL ATTIRE
OPERATING ROOM ATTIRE
- If unsure or doubtful, consider unsterile.
- Scrub suit
- Eg. sterile package in an unsterile
- Sterile gown
environment consider unsterile.
- Head cover
- Shoes
DRAPE
UNSTERILE - no or gown yet PERSONAL PROTECTIVE DEVICES
- Drape away from me/you starting at the opposite - Surgical eye protective devices
ends - Surgical face mask
- Cover the table then cover the area towards you - Sterile gloves
- UNSA DAWWWWWWWW LUTAW NA ME :’>

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 9

 OR ROOM • Transfuse blood products and IV products
• In cases there are discrepancy in the vital
signs of the patient, the anesthesiologist will
alert the surgeon
• Supervise the client status in the PACU

4. NURSE ANESTHETIST (CRNA)

● A registered nurse who has an advance training on
anesthetics
● Same as an anesthesiologists
● Advance nurse who has been trained and certified to
administer anesthesia

5. CIRCULATING NURSE
● Ensures proper ventilation
● Assists in surgical positioning; assist
anesthesiologist
● Prepares the skin of the patient
● Monitors aseptic technique
● record essential data
● along with scrub nurse will be accountable with the
instruments, Equipments and sponges
6. SCRUB NURSE
● Responsible for the preparation of the sterile
supplies and instrumentation
● Assists the surgeon; can’t be unsterile
Figure 3 & 2. Operating Room
SURGICAL POSITIONS
GOALS: POSITIONING
1. Strict compliance to aseptic technique. - placing the patient in proper body alignment to have
2. Safe administration of anesthesia a better exposure of the operative area or site.
3. Homeostasis
4. Hemostasis- No large amount of blood loss ANATOMIC AND PHYSIOLOGIC
CONSIDERATIONS
MEMBERS OF THE SURGICAL TEAM 1. Respiratory
1. SURGEON 2. Circulatory
● Head of the surgical team or captain of the ship 3. Peripheral Nurse
● Possesses the ability to perform the intended 4. Musculoskeletal
surgical procedure to the patient 5. Soft tissue
● Physician who specializes in performing surgical 6. Accessibility of surgical site
procedures. 7. Accessibility of anesthesia admin

2. ASSISTANT TO THE SURGEON COMMONLY USED SURGICAL POSITIONS

● It could be an intern, resident, nurse, highly trained 1. Dorsal Recumbent/ Supine
personnel, nursing aid or another doctor 2. Trendelenburg
● Provide exposure to operative site; suction the 3. Reverse Trendelenburg
secretions and ligate BV 4. Lithotomy
● In US, may certification to be the first assistant 5. Prone
● Works closely with the surgeon in performing the 6. Lateral
procedure 7. Kraske/Jackknife
● Sponge and suctions wounds
● Assist suturing NURSING RESPONSIBILITY
1. explain purpose of position
3. ANESTHESIOLOGIST 2. avoid undue exposure
● Administers anesthetics and monitors the patient’s 3. strap the pt. to prevent falls
physiologic status during the procedure 4. maintain adequate respiratory and circulatory
● (CRNA) - A physician that specializes in function
administration of anesthetic 5. maintain good body alignment
● Monitor patients’ physiologic status during the
procedure ANESTHESIA
• Evaluate the client preoperatively, if the - It is an artificially induced state of partial or total loss
patient is surgically capable ba yung pt. of sensation with or without loss of consciousness

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 10

 EFFECTS OF ANESTHESIA STAGES OF GENERAL ANESTHESIA
● Analgesia
● Amnesia I. ONSET/ ANALGESIA / INDUCTION
● Hypnosis Form administration of anesthetics to the time of loss
● Muscle relaxation consciousness
VISUAL HALLUCINATION,
DROWSINESS, groggy
FACTORS CONSIDERED IN CHOICE OF Nursing Interventions:
ANESTHESIA 1. close OR doors
1. Physical condition
2. keep room quiet
2. Age
3. stand by assist client
3. Presence of coexisting disease
4. Type, site, duration of surgery II. EXCITEMENT OR DELIRIUM
5. Anesthesiologist’s preference - depends on the - Extends from the loss of consciousness to
condition of the pt. the loss of eyelid reflexes
6. Patient’s preference - Pt at risk for accidents
Nursing Interventions:
TYPES OF ANESTHESIA 1. stand by assist client
● GENERAL Anesthesia 2. Assist anes
- Artificially induced state of total loss of sensation or
loss of consciousness III. SURGICAL EXCITEMENT/ ANESTHESIA
- Produces analgesia, amnesia, unconsciousness and - Extends from the loss of eyelid reflexes to the
loss of reflexes and muscle tone cessation of respiratory effort
- Advantage in terms of smooth and easy Nsg interventions:
administration and can be eliminated through 1. Begin preparation (if indicated) only when the
respiratory system anesthetist indicates stage 3 has been reached and
- Can be adjusted through the length of the procedure client is breathing well, with stable VS.
- DANGERS: can induce CNS depression; respiratory
arrest, cardiac arrest IV. DANGER/ MEDULLARY
Types of general anesthesia - Vital functions too depressed with respiratory
a. inhalation anesthesia - mixture of volatile liquids or and circulatory failure
gas and o2 Nursing intervention:
○ mask inhalation 1. If arrest occurs, respond immediately to assist in
○ endotracheal administration - GETA; establishing airway.
general endotracheal tube resulting in quick
response Note:
○ laryngeal mask airway (LMA) - same with • VS to be monitored
GETA but it uses endotracheal tube nay • PR, RR, pupillary response,
sumpay pa ni…

GAS Anesthetics:
- Highly flammable and explosive
● nitrous oxide - common
● cyclopropane

VOLATILE Liquids
● Halothane ( Fluothane ) common
● Isoflurane ( Furane ) common
● Methoxyflurane ( Pentrane )Ketamine Hcl (
Ketalar ) Droperidol ( Inapsine )

intravenous anesthesia
- Directly administered into vein or rapid pleasant
induction
- Absence of explosive hazards
- Low incidence of N&V
- Disadvantages is it can cause respiratory depression
resulting to respiratory arrest
● Ketamine Hcl ( Ketalar ) common
● Droperidol ( Inapsine ) common
● Fentayl ( Innovar ) common
● Thiopental Na ( Penthotal Na ) common
STAGE 1 -
STAGE 2 - everything is increase since there is increase in
autonomic response
STAGE 3 - stage of anesthesia, regular breathing, normal bp,
muscles relaxed, pupils small but still contract upon light
stimulation
STAGE 4 - VS: weak and thready pulse shallow pulse and
pupils are dilated

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 11

 - Resuscitate patient if that's the case
● REGIONAL ANESTHESIA
- Reduce all painful sensation in one region of the
body only and does not result in unconsciousness
- Types
● Topical anesthesia
○ The anesthetic agents are directly
applied on the area to be desensitized
● Local infiltration anesthesia
○ The anesthesia is
injected into the tissues
at the incisional site to
block unsa to
● Nerve block
○ Anesthetic agent is administered
into/around a specific nerve or small
nerve group
○ No sensation; brachial plexus nerve
block.
○ Used to detect brain activity
● Spinal anesthesia/intrathecal anesthesia
o sub arachnoid block
o injected into sub arachnoid space using
interspaces
o Non irritating to respiratory system
o Can be used for almost any type of
major procedure performed below the
level of the diaphragm
o Toes - feet- abdomen; raise leg, induce
pain.
o Side lying position, fetal position;
maximum
o Indicator that syringe has reached the
subarachnoid spaces is when there is
csf flowing out
● Epidural Anesthesia
● Injected in the epidural space; lumbar,
sacral, thoracic, caudal
● Same with spinal anesthesia but differ in
location
● Painless delivery
ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G
● Used as control measure when patient undergo
cesarean section
● Advantage - Lesser degree of headache
COMPLICATIONS AND DISCOMFORTS OF
ANESTHESIA:
1. Hypotension
- Effect Of Spinal Anesthesia
- Cause: paralysis of vasomotor nerves
- Intervention:
- admin. O2 by inhalation
- Pt. Trendelenburg’s pos. if level of
anesthesia is fixed, 10-20 min
after increase cardiac output
2. Nausea and vomiting induction
- Cause: Undergone abdominal surgery
because of traction…
- Effect of hypotension brought by spinal
anesthesia
- Intervention:
- Ephedrine, Antiemetics, O2,
Fluids
3. Headache (can be extremely painful, may last a
week
- Effects by spinal anesthesia
- Cause: leakage of CSF with loss of
cushioning effect increased by:
- Use of large spinal needle and
poor dehydration
- Intervention:
- Apply tight abdominal
binder
- Fluids, Analgesics
- Keep client flat and quiet
6-8 hr post-op
4. Respiratory paralysis
- Cause: occurs if drug reaches upper
- Intervention:
- Artificial respiration
5. Neurologic complications ( eg. paraplegia-
paralysis; sensory motor loss in the trunk, severe
muscle weakness in legs )
- Causes:
1. unsterile needle, syringes, and
anesthetic medications;
2. pre existing disease of CNS
3. Transient response to anesthetics
4. Position during surgery
(positioned for 8 hrs)
- Intervention:
- Supportive care for transient forms
related to medication
- Antibiotics (d/t infection) and
steroids for infectious causes
- Permanent paralysis will require
rehabilitation
- Prevention:
- Strict sterile technique
- Heat-sterilized medications and
instruments
12
 - Careful pre op neurologic exam to
ascertain presence of neurologic
disease
6. Malignant hyperpyrexia (hyperthermia ) - a rare
reaction to anesthetic inhalants and muscle
relaxants
- Due to an abnormal, excessive intracellular
accumulation of calcium resulting to
hypermetabolism and increase in
- Tachycardia, arrhythmias, tachypnea,
muscle rigidity, fever (>40 deg Celsius),
cyanosis, acidosis, hyperkalemia, cardiac
failure.
- Halothane + pancuronium bromide,
succinylcholine,
Treatment:
- dantrolene Na
- dextrose 50% (with extra insulin to enhance
its utilization)
- Diuretics - to prevent renal damage; can
accumulate to the kidneys obstructing
urinary flow
- antidysrhythmic
- Na (sodium) Bicarb (for severe acidosis)
- hypothermic measures - cooling blankets,
cold IV saline solutions

REFERENCES
I. Mrs. Dela Cerna’s PPT
II. Notes from Discussion

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 13