PERI-OPERATIVE

NURSING
Course description.
Peri-operative Nursing: historical development;
principles and concepts; operating theatre-
layout, theatre equipment and instruments;
drapes; different roles of the nurse in theatre
nursing-Anaesthetic drugs; infection prevention
and management; medico-legal issues;
application of nursing process in the
management of  peri-operative patients. 
PERIOPERATIVE NURSING:
OBJECTIVES:
 Describe the historical background and
concepts of peri-operative nursing.
 Define peri-operative nursing and describe it’s

three phases.
 Describe the operating theatre layout, it’s

equipments and instruments.

 Describe the roles of different nurses in theatre.
Objectives ct….
 Medical legal issues associated with peri-
operative nursing.
 Application of the nursing process in the

management of peri-operative patients.

 Describe preoperative measures that decrease

the risk of post-operative infections and

complication.
LESSON 1: HISTORICAL
BACKGROUND.
 Perioperative nursing care in Australia is one
of the oldest specialties dating back to 1910.
 OR, underwent considerable change during

the 20th century with the advent of

sophisticated anesthesia,complex surgeries n
technology.
 The use of the term perioperative nursing-

1970s-moved away from the traditional OR

operations to include –pre, intra n
postoperative phases.
Concept.
 Perioperative nurse is a professional who
provides care to ptns. in high dependency
situations.
AIMS;
 Safe & effective care-in colabo.with other

health care personel

 Acts as the ptns. Advocate during the

periop.period.
 Peri-op. Nurse is a unique and “privileged”

person coz he is there during surgery.

 Concepts ct…
 He is conscious for the unconscious ptn.
 Provide psychological care-Thus making

‘ordinary the extraordinary’ event of

surgery.
Philosophy of peri-op. nursing.

It encompasses an holistic, multidisciplinary

approach that is concerned with;
 Provision of safe environment.
 Protect from adverse effect.
 Achieve optimum outcome.
 Provide cost effective, result based health care.
 Acknowledge- persons diverse physical,
cultural n emotional background.
PERIOPERATIVE NURSING.
 Perioperative nursing– used to describe the
nursing care provided in the total surgical
experience of the patient: It includes; pre-
operative, intra-operative &post-operative
periods and extends to the follow-up care.
Perioperative phases.
  Pre-operative Phase :extends from the time
the client is admitted in the surgical unit, to the
time he/she is prepared for the surgical
procedure, until he is handed over into the
operating room.
 Intra-operative Phase: extends from the time

the client is admitted to the OR, to the time of

administration of anesthesia, surgical
procedure is done, until he/she is transported
to the RR/PACU.
 Phases Ct…
 Postoperative Phase : extends from the time
the client is admitted to the recovery room, to
the time he is transported back into the
surgical unit, discharged from the hospital,
until follow-up care.
 NB: -Read on the role of the nurse in every

phase.
 -Read on potential complications during intra

and postoperative phases.

Perioperative standards.
 All Policy & Procedures of the medical and surgical
nursing division will be adhered to.
 Patients shall ALWAYS wear a legible identification
band
 Operative permit(s) must be signed and witnessed
according to hospital policy, The procedure
documented on the operative permit MUST MATCH
what is scheduled on the OR schedule
 The history and physical exam shall be completed
according to policy and be part of the medical record
prior to surgery.
Peri-operative standards ct…
 All ordered lab work shall be collected and
results placed in the medical record in
accordance with the physician’s orders.
 Dentures, hairpins, jewelry, wigs, contact
lenses, nail polish, make-up and prosthesis
shall be removed as requested by the physician
 Any jewelry not removed shall be secured
with tape and documented as such.
Peri-operative standards of care ct..
• Pre-operative skin prep shall be done without
abrading, cutting or irritating the patient’s skin
• Patient privacy shall be provided at all times
• Any pre-operative drainage tubes shall be
placed without tissue trauma and be completed
utilizing sterile techniques when indicated
• All IV infusions shall be monitored to
maintain the appropriate flow rate and type of
solution and remain patent without signs of
inflammation or swelling
Peri-Op Standards ct..
 The patient shall be provided with emotional
and educational support to reduce pre-operative
anxiety.
 The patients shall be provided a safe and
normothermic environment in the pre-op
waiting area.
 The patient shall be transferred safely to the OR
table and safety straps appropriately applied.
PRE-OPERATIVE PHASE
 Goals -Assessing and correcting physiologic
and psychological problems that may increase
surgical risk.
 Giving the person and significant others
complete learning / teaching guidelines
regarding surgery. Instructing and
demonstrating exercises that will benefits the
person during postop period.
 Planning for discharge and any projected
 Goals of pre-op period…
 Physiological Assessment of the Client Undergoing
Surgery.
 Address any Presence of Pain .

 Nutritional & Fluid and Electrolyte Balance.

Cardiovascular / Pulmonary Function .

 Renal Function , Gastrointestinal / Liver Function

Endocrine Function
 Neurologic Function

 Hematologic Function

 Use of Medication .

 Presence of Trauma & Infection. 

Goals of pre-op..
 Routine Pre-operative Screening -CBC
RBC,Hgb,Hct are important to the oxygen
carrying capacity of blood.
 WBC are indicator of immune function.
 Blood grouping/ X Determined in case blood
transfusion is required during or after surgery.
 Fasting Blood High level may indicate
undiagnosed DM Glucose
Physical pre-op Preparation
 Diaphragmatic Breathing- The goal is to promote
optimal lung expansion and resulting blood
oxygenation following anesthesia-
 Refers to a flattening of the dome of the diaphragm
during inspiration, with resultant enlargement of
upper abdomen as air rushes in during expiration,
abdominal muscles contract.
 In a semi-Fowlers position, with your hands loose-
fist, allow to rest lightly on the front of lower ribs
Diaphragmatic breathing
 …breathe out gently and fully as the ribs sink
down and inward toward mid-line, then take a
deep breath through the nose and mouth,
letting the abdomen rise as the lungs fill with
air.
 Hold breath for a count of 5,exhale and let out
all the air through your nose and mouth.
Repeat this exercise 15 times with a short rest
after each group of 5.
Physical pre operative pre…
 Coughing Splinting-Promotes removal of chest
secretions.
 Interlace his fingers and place hands over the
proposed incision site, this will act as a splint and
will not harm the incision.
 Lean forward slightly while sitting in bed. Breath,
using diaphragm, Inhale fully with the mouth
slightly open, Let out 3-4 sharp hacks. With mouth
open, take in a deep breath and quickly give 1-2
strong coughs
Physical pre-operative preparation
ct…
 Incentive Spirometer-Encourage to use incentive
spirometer bout 10 to 12 times per hour.
 Deep inhalations expand alveoli, which prevents
atelectasis and other pulmonary complication .
 There is less pain with inspiratory concentration
than with expiratory concentration.
Physical pre-operative preparation.
 Foot and Leg Exercise -Moving the legs improves
circulation and muscle tone.
 Have the patient lie supine, instruct patient to bend a
knee and raise the foot – hold it a few seconds and
lower it to the bed.
 Repeat above about 5 times with one leg and then
with the other. Repeat the set 5 times every 3-5
hours.
 Then have the patient lie on one side and exercise
the legs by pretending to pedal a bicycle.
PRE-OPERATIVE MEDICATIONS.
Goals: To aid in the administration of an
anesthetics, to minimize respiratory tract
secretion and changes in heart rate and
to relax the patient and reduce anxiety.
Commonly used Pre-op Meds.- Tranquilizers
& Sedatives – Midazolam, Diazepam ( Valium )
,Lorazepam ( Ativan ) ,Diphenhydramine-
Analgesics -Nalbuphine ( Nubain )-
Anticholinergics -Atropine Sulfate.
Proton Pump Inhibitors -Omeprazole
POSTOPERATIVE CARE

Goals:
 Restore homeostasis and prevent

complications.
 Maintain adequate cardiovascular and tissue

perfusion.
 Maintain adequate respiratory function.

 Maintain adequate nutrition and elimination.

Post op care..

Goals…
 Maintain adequate fluid and electrolyte

balance.
 Maintain adequate renal function.

 Promote adequate rest, comfort and safety.

 Promote adequate wound healing.

 Promote and maintain activity and mobility.

 Provide adequate psychological support.

PACU CARE.

 Transporting of client from OR to RR -avoid

exposure, avoid rough handling , avoid
hurried movement and rapid changes in
position.
 Initial Nursing Assessment :Verify patient’s
identity, operative procedure and the surgeon
who performed the procedure.
PACU Care ct..
 Evaluate the following sign and verify their
level of stability with the anesthesiologist: -
Respiratory status - Circulatory status - Pulses
- Temperature - Oxygen Saturation level -
Hemodynamic values .
 Determine swallowing and gag reflex , LOC
and patients response to stimuli.
 Evaluate lines, tubes, or drains, estimate
blood loss,condition of wound, medication
PACU Care ct..
 Perform safety check; side rails up and restraints are
properly in placed.
 Evaluate activity status, movement of extremities.
 initial Nursing Interventions
  Maintaining a Patent Airway -Allow the airway ( ET
tube ) to remain in place until the patient begins to
waken and is trying to eject the airway.
 The airway keeps the passage open and prevents the
tongue from falling backward and obstructing the air
passages.
LAYOUT OF AN OPERATING
THEATRE.
Design.
Although the physical features of an operating
theatre differ, they all have acceptable principles
which must be adhered to;
 Floor-smooth, non-porous made of fireproof.
 Walls-Hard, non-porous, fire resistant, stain

proof and easy to clean.

 Doors- surface sliding recommended .
Physical layout.
Divided into three;
i). Unrestricted area-
Outside-inside access,NO traffic restriction,
street clothes permited-e.g-dressing rooms,
ptn.recieving rooms, offices..
ii).Semi restricted area-
Authorized psns.only-staff&ptns,acess from
unrestricted to restricted.
iii).Restricted areas-
Where surgical procedures are carried
out. Authorized personnel only, Dress- Proper
OR attire including a mask must be worn in
these areas e.g
 Scrub sink areas
 Operating suites
 Sterile supply rooms
Ct….Layout.

 Electric system-Multiple electrical outlets

available from separate circuits –prevents loss
of power if a fuse blows.`
 Lighting-Two types-General room lights
&Operating spot light-illuminate oper.site.
 Good lighting
 Mobile lamps.
 Operating lights.
 Ring lights.
Equipments found in operating room.

 Operating table.
 Instruments table.
 Mayo stand with tray.
 Prep.table.
 Anaethetic machine.
 An I.V stand.
SURGICAL CLASSIFICATION.
 Surgery can be classified according to;
i). Purpose
ii).Degree of urgency-Emergent, Urgent,
Required, Elective and Optional.
iii).According to degree of risk;
- Major or minor.
According to purpose of surgery.
 Diagnostic - Determines cause of symptoms
(Exploratory laparotomy and biopsy)
 Curative - Removal of diseased part
(Appendectomy, Ovarian Cyst, Cancerous
Tumors)
 Restorative or Reconstructive - Strengthens

a weakened part (Herniorrhaphy or cervical

rings) rejoins disconnected areas (orthopedic
surgeries), corrects deformities, (Mitral Valve
Regugitation joint replacement, etc)
According to purpose ct..
 Palliative - Relieves symptoms without
curing (some lower back surgeries,
tumorectomies)
 Cosmetic - Repairing a burn scar or

changing breast shape, altering physical

appearance
According to the urgency of surgery
 Emergent-Immediate attention-life
threathening. E.g…Severe bleeding e.t.c.
 Urgent-Prompt attention-e.g-Renal stones,

Acute gall bladder.

 Required-Patient needs to have surgery-e.g

cataracts.
 Elective –Ptn. Should have surgery-e.g

vaginal repair.
 Optional-Decision rests on the ptn.e,g

cosmetic
According to degree of risk.
Major- Present a real threat to life-More extensive
procedure-a body cavity is entered or normal
anatomy is altered.
Minor - Present little threat to life-skin,mucous
membrane or connective tissue –e.gbiobsy, tooth
extraction,

NOTE: **** All patients consider their surgery a

major thing ****
Classification…
1).Ambulatory Surgery/ Same-day Surgery /
Outpatient Surgery-e.g Teeth extraction ,
Circumcision Vasectomy , Cyst removal, Tubal
ligation.
 Advantages: - Reduces length of hospital stay and

cuts costs - Reduces stress for the patient - Less

incidence of hospital acquired infection - Less time
lost from work by the patient; minimal disruptions on
the patient’s activities and family life.
 Disadvantages:- Less time to assess the patient and

perform preoperative teaching.- Less time to establish

rapport, less opportunity to assess post-op
complications.
Surgical procedures.
Surgical procedures r named according to;
i).The involed body organ,part or location.
Eg-Vasectomy etc..
ii).The suffix that describes what is done
during the procedure.
 Ostomy-Forming of an artificial opening e.g…
 Oscopy-Looking into-visualizing e.g…
 Orrhaphy-Suture or repair e.g…
 Ectomy-Removal by cutting e.g…
 Otomy-Incision or cutting into e.g…
Surgical posns.
 Facilitated through the nursing process.
Dependent Upon:
 The surgical procedure
 Exposure at the surgical field
 Surgeon’s preference and idiosyncrasies
 Patient’s condition

Special Considerations:
 Geriatric patients
 Obese patients
 Malnourished patients
Types of surgical positions.
Supine ( Dorsal Recumbent ) -
Abdominal,extremity,vascular,chest,neck,facial
ear &breast .Patient lies flat on back with arms
either extended on arm boards or placed along
side of body. Small padding placed under
patient’s head,neck and under knees. Vulnerable
pressure points should be padded above knees.
Eyes should be protected by using eye patch and
ointment.
Positions ct…
 Trendelenburg Position - Surgeries involving
lower abdomen, pelvic organ when there is a
need to tilt abdominal viscera away from the
pelvic area.
 Positioning Techniques- Patient is supine with

head lower than feet. Shoulder braces should

not be used as they may cause damage
brachial plexus.
Prone Position - Surgeries involving posterior
surface of the body ( spine, neck, buttocks and
lower extremities ).
Positioning Techniques-Chest rolls or bolster are
placed on operating table prior to positioning.
Foam head rest, head turned to side or facing
downward . Patient’s arms are rotated to the
padded arm boards that face head, bringing them
through their normal range of motion.
Positions ct..
 Lithotomy - Perineal, vaginal, rectal surgeries;
combined abdominal vaginal proced.
 Positioning Techniques -Patient is placed in

supine position with buttocks near lower break in

the table ( sacrum are should be well padded ).
 Feet are placed in stirrups, stirrups height should

not be excessively high or low, but even on both

sides.Knee brace must not compress vascular
structures or nerves in the popliteal space.
Posn….
Reverse Trendelenburg Position - Upper
abdominal, head, neck and facial surgery.
Positioning Technique-Patient is supine with
head higher than feet. Small pillow under neck
and knees. Well - padded footboard should be
used to prevent slippage to foot of the table.
Posn….
 Modified Fowler ( Sitting Position ) -
Otorhinology (ear and nose )-Used for
neurosurgery.
 Positioning Tech.-Patient is supine, positioned

over the upper break in the table. Backrest is

elevated, knees flexed .
 Arms rest on pillow, placed in lap above the

knees. Slow movement in and out of position

must be used to prevent drastic changes in
blood volume movement.
Jack Knife Position - Rectal procedures,
sigmoidoscopy and colonoscopy.
Positioning Techniques- Table is flexed at center
break. All precautions taken with prone position
are taken with Jack knife position.Table strap
applied over thighs.
THANK YOU..
Lesson 2:SURGICAL TEAM.

The surgical team constitute;

 The Patient .
 The surgeon.
 Anaesthesiologist/Anaesthetist.
 Scrub Nurse.
 Circulating nurse.
 Surgical technicians.
The surgeon.(Sterile)

 Responsibilities.
 Primary responsible for the preop.med.hx and
physical assessment.
 Perform operative procedure according to the

needs of the patients.

 The primary decision maker regarding surgical

technique to use during the procedure.

 May assist with positioning.
 First Assistant to the
Surgeon/technicians.(Sterile).
 May be a resident, intern , physician’s
assistant or a perioperative nurse.
Responsibilities
 Assists with retracting, hemostasis, suturing

and any other tasks requested by the surgeon

to facilitate speed while maintaining quality.
Roles;Unsterile team
member(Circulating nurse)
 Responsible for nursing care in the operating
room(aseptic technique)
 Responsible for the organization of the workload

 Responsible for the maintenance of policy and

procedures
 Responsible for signing and documentation

 The Circulating Nurse is the professional staff

member in the operating room, representing the

patient (Patient Advocate) and the hospital
administration
The Scrub nurse.(sterile)
The nurse who is the immediate assistant to the
surgeon is often called the “scrub” or “sterile”
nurse.
Roles.
Performs surgical hand scrub.
Setting up sterile tables, Prepares-sutures,
ligatures. Assisting during the surgical
procedure. /May be either a nurse or a surgical
tecnician.Assists with the preparation of the
room. Scrubs, gowns and gloves self and other
Scrub nurse Ct…
 Prepares the instrument table and organizes
sterile equipment for functional use.
 Assists with the drapping procedure. Passes

instruments to the surgeon and assistants by

anticipating their need. Counts sponges,
needles and instruments. Monitor practices of
aseptic technique in self and others.
Anesthetist/Anesthesiologist.
Responsibilities.
 Anesthetist-Selects the mode anesthesia,
administers it, manages technical problems
related to the administration of anesthetic
agents, and supervises the ptns .condition
throughout the surgical procedure.
 Anaesthesiologist-A physician who
specializes in the administration and
monitoring of anesthesia while maintaining
the overall well-being of the patient.
Anesthesia.

Anesthesia is defined as-State of “Narcosis”

(Severe central nervous system depression
produced by pharmacological agents.)
Anesthetics can produce muscle relaxation,
block transmission of pain nerve impulses and
suppress reflexes. It can also temporary decrease
memory retrieval and recall.
.
Types of anesthesia.

i. General anesthesia.
ii. Regional anesthesia.
iii. Moderate sedation .
iv. Local anesthesia.
Types of anesthesia.
1).General Anesthesia -A reversible state
consisting of complete loss of consciousness and
sensation.
 Protective reflexes such as cough and gag are

lost provides analgesia, muscle relaxation and

sedation. produces amnesia and hypnosis.
 Not arousable not even to painfull stimuli.-

Otherwise it will give rise to ‘anesthetic

awareness’…….???
Techniques in G. anesthesia Ct..
ii) Inhalation Anesthesia.
 This comprises of volatile liquids or gas and

oxygen, Administered through a mask or

endotracheal tube-e.g halothane,nitrousoxide.
 Inhaled anesthesia-enter bld thro’pulmonar

capi-enter cerebral centre-produce-loss of

consc.n senastion.
 Long acting hence combination- both-

inhalation& I.V.give gd.outcome.

Regional anesthesia.
2). Regional Anesthesia –
 Temporary interruption of the transmission of nerve
impulses to and from specific area or region of the
body.
 Its achieved by injecting local anesthetics in close
proximity to appropriate nerves.
 It reduces all painful sensation in one region of the
body without inducing unconsciousness-Patient is
awake n aware of the enviroment.
 Agents used are lidocaine and bupivacaine
Techniques used in Regional Anesthesia
i). Epidural Anesthesia
Achieved by injecting local anesthetic into
epidural space by way of a lumbar puncture.
result similar to spinal analgesia agents use are
chloroprocaine, lidocaine and bupivacaine.
ii)Spinal Anesthesia ( Subarachnoid block )
local anesthetic is injected through lumbar
puncture-into the subarachnoid space between
L2 and S1 .
Low spinal, for perineal/rectal areas - Mid
spinal T10 ( hernia repair and appendectomy.
-High spinal T4 ( nipple line ), for CS . agents
used are procaine, tetracaine, lidocaine and
bupivacaine.
Tech..regional anesthesia ct…
Others.
 Topical Anesthesia - applied directly to the skin and

mucous membrane, open skin surfaces, wounds and

burns. Its readily absorbed and act rapidly used
topical agents are lidocaine and benzocaine.
 Local conduction blocks.

 Brachial plexus block…

 Paravertebral anesthesia….
 Transcaudal block….
Moderate sedation.
3). Moderate sedation-Reffers to IV
administration of sedatives n analgesics to
reduce anxiety n relief pain during diagnostic or
therapeutic procedure-short term surgical
procedures.
-Depresses the LOC to a moderate level.
-Ptn. Is awake, able to maintain patent airway,
retain protective reflexes, can respond to verbal
n physical stimuli.
4). Local Anesthesia.
 An anesthetic agent is injected into the tissues
at planned incision site.
Advantages.
Simple, economical n non-explosive.
Minimal equipment.
Brief post recovery.
Avoids undesirable effects of G/A.
Ideal for-short or minor surgeries.
Complications and Discomforts of
Anesthesia.
Hypoventilation - inadequate ventilatory
support after paralysis of respiratory muscles.
Oral Trauma , Malignant Hyperthermia -
uncontrolled skeletal muscle contraction
Hypotension - due to preoperative hypovolemic
or untoward reactions to anesthetic agents.
Cardiac Dysrhythmia - due to preexisting
cardiovascular compromise, electrolyte
imbalance n reaction to anesthesia.
Comp….ct..
 Hypothermia - due to exposure to a cool
ambient OR environment and loss of
thermoregulation capacity from anesthesia.
Peripheral Nerve Damage - due to improper
positioning of patient or use of restraints.
 Nausea and Vomiting Headache.
THANK YOU.
LESSON 3:SURGICAL ASEPSIS.
Infection prevention.
The primary purpose of infection prevention in
health care facilities is two folds.
 To minimize infection due to microorganisms

causing serious wound infections, Abdominal

abcesses,gagrene and tetanus among others.
 Prevent transmission of serious life threatening

diseases such as hepatitis B and HIV.

Infection prevention Ct…..
 Preventing surgical site infection in the OR is one of
the primary goals of the perioperative team, and the
team performs many infection prevention best
practices to support this goal.
 In the perioperative setting, good infection prevention

and control is essential to ensure that patients who

undergo any surgical procedure receive safe and
effective care.
 Safe working practices are also necessary to ensure

the safety of the OR team members.

Ct….
 IP is the responsibility of every theatre staff
but to a greater extent influenced by the
competency of the theatre –manager-(nurse).
 The manager –strict to ensure that all IP

policies are adhered to and prevent any source

of contamination. Discuss.
 IP can be achieved through ,Double gloving,

adherence to PPE, disinfection and

sterilization.
Standard for infection prevention.
Personal Protective Equipment,(PPE)
 PPE is specialized clothing and/or equipment

for eyes, face, head, body, and extremities;

 protective clothing; respiratory devices; and

protective shields and barriers that is designed

to protect the worker from injury or exposure
to a patient’s blood ,body fluids or any other
potentially infectious materials.
Ct….
 All theatre staff must be in full theatre attire –
Gown,cap,mask & shoes before entering
theatre &unnecessary movement. In and out of
theatre should be avoided-minimized.
 Gowns should cover both front and back ,not
in contact with the floor and sleeves long
enough to be tacked in after scrubbing.
 All hair must be well covered - masks should
cover the mouth and the nose.
 Discard all used caps and masks –do not re-
Surgical gloving.
 The intact surgical glove is the most important
barrier to protect the patient from the hand of
the surgical team and vice versa.The
preoperative surgical hand preparation(hand
scrub) can significantly reduce but not
eradicate the resident flora on the surgeon’s
hands;
Surgical gloving ct…
it reduces but does not eliminate any risk of
transmission of these organisms into the
Operative site.Conversely, blood-borne
pathogens can be transmitted from the patient to
the surgeon and pose a safety risk to the
perioperative team members.
Double gloving.
 Perioperative team members should wear two
pairs of surgical gloves, one over the other,
during surgical and other invasive procedures
with the potential for exposure to blood, body
fluids, or other potentially infectious materials.
 This use of double gloving will add extra

protection.
Double gloving ct….
 Double gloving reduces the risk of exposure to
patient blood by as much as 87% when the
outer glove is punctured.
 Volume of blood on a solid suture needle is

reduced by as much as 95% when passing

through two glove layers.
Benefits of double gloving.
 Wearing double gloves helps prevent
SSI(surgical Site Infection) and protect health
care providers hands.
 Effective way to reduce the risk of

percutaneous injuries.
 May increase the wearer’s awareness of a

perforation which may protect against

exposure during surgery.
Benefits of double gloving.
 Minimizes the amount of blood that is transferred to
the healthcare provider’s hands during a needle stick
injury.
 Reduces risk of glove perforation with a lengthy

procedure.
 Reduces the risk of perforation of the inner-most

glove.
 Perioperative personnel’s risk decreased by 70%

when double-gloving in comparison to wearing a

single-glove.
Benefits of gloving ct…
 May protect the wearer’s skin from needle
sticks because breaches will most likely occur
to the outer gloves, not the inner gloves.
 Several studies showed that the rate of

contamination with blood was 13 times higher

with single gloving as opposed to double
gloving.
Glove failure
Factors that increase the incidence of glove failures
during use include:
 Length of procedure.
 Mechanical stress.
 Type of surgery.
 Number of instruments used in the surgical

procedure and
 The role of the glove wearer in the surgical

procedure.
Standards of infection prevention.
 Minimize talking in operating theatre
 Staff working in theatre should be free from
infection- esp RTI and skin condition.
 Minimize traffic to the unit and the adjacent
corridors.
 Use every room for its intended purpose.
 Ensure adequate scrubbing.
 Wet clean and carbolize all theatre trolleys,
theatre tables and stands.
Ct…
 Weekly thorough cleaning of the operating room
should be observed.
 Scrub the operating room floor after every procedure.
 Linen soaked in blood should be washed separately

before general washing. Wash theatre linen separately

from the general ward linen.
 Mops and drapes, theatre linen should be used for the

correctly intended purposes.

 Do not pack instruments using torn material and

ensure proper folding.

Ct..
 Autoclave general ward and theatre linen
separately.
 Avoid lending and borrowing items between

theatre and the general ward.

 General ward trolleys and stretchers should

not be allowed into the operating theatre.

 Keep all specimens in air tight containers,

immersed in formalin.
 Prevent decomposition of tissues in theatre.
 Prepare a sterile field as close as possible to
the time of use.
 Operation site or any exposed region must be

disinfected.
 Ensure prevention of exposure to blood and

body fluids by wearing protective gear-boots,

eye shields, water proof aprons , double
gloving/well fitting sterile gloves.
 Assign nurses to separate rooms on rotational
basis to encourage responsibility.
 Circulating nurse –should be very vigilant to

ensure proper IP measures are adhered to and

intervene where there is breach of infection
control protocols.
Patients at risk of complication-post
operatively.
 Diabetic ptns.
 Poor nutri.standards.
 Obese
 Cardiac cdns.
 Chronic Lung Diseases
 Elderly
 HTN
 Thoracic or Abdominal Surgeries
 Immobilizing Surgery
Preventing potential complication
 Identifythose @ risk
 Provide adequate hydration/nutrition
 NPO after Mid night…
 Leg exercises
 Breathing exercises.
 Input & output…
Ct….Prev.compl.
 Splint Incision to cough
 Anticoagulant Therapy - Heparin
 Ambulate - ASAP
 Discourage smoking
 Fluid and fiber ASAP, laxatives. Enemas
 Clean Hands-IP.
 Instruct in proper wound care.
 Sleep/Rest
How to reduce anxiety.
 Early teaching and counseling
 Diversion activities
 Encourage family support
 Encourage verbalization of fears/loss of

control
 Deep breathing
Ct.. Decrease anxiety.
 Spiritual support (communion, bible reading,
prayers, rituals, chants)
 Inform family where to wait, buy food,
bathroom, phone, overnight and visiting policy
 Possible use of sedative or tranquilizer or PRN
medications
 Dolls/favorite toy for children.
 ASSINGMENT.
Discuss the post operative complications associated
with the following patients.
 Diabetic patients.
 Patients with poor nutritional standards.
 Obese patients.
 Elderly patients.
 Hypertensive patients.
 Patients following immobilizing Surgeries.

(10 marks @).

THANK YOU.
LESSON 4: INFORMED CONSENT

 Def-Informed consent: Refers to the ptns.

Autonomous decision about whether to
undergo surgical procedure.
 A voluntary n written consent is required b4
all non-emergent surgeries.
 Helps 1).Prevent the ptn from unsanctioned
surgery and2). Protect the surgeon from claims
of unauthorized operation.
Informed consent……
Informed consent is also important in that it
helps the patient to be psychologically prepared
because it helps to ensure that the patient
understands the surgery and the anticipated
outcome.
Informed consent…
 It’s the responsibility of the surgeon to
explain clearly to the ptn. What the surgery
entails, benefits, alternatives, possible comp.
disfigurement etc as well as what to expect in
the early and late post op periods….. prio to
signing the consent.
 The responsibility of the nurse is to -clarify,
n witness the signing.
Purpose;
 To ensure that the client understand the nature
of the treatment including the potential
complications and disfigurement.
 To indicate that the client’s decision was made

without pressure.
 To protect the client against unauthorized

procedure.
 To protect the surgeon and hospital against

legal action by a client who claims that an

authorized procedure was performed.
Circumstances Requiring Consent
 Any surgical procedure where scalpel,
scissors, suture, hemostats of
electrocoagulation may be used.
 Entrance into body cavity.
 Radiologic procedures, particularly if a

contrast material is required.

 General anesthesia, local infiltration and

regional block.
Essential Elements of Informed Consent
 The diagnosis and explanation of the
condition.
 A fair explanation of the procedure to be done

and the consequences.

 A description of alternative treatment or

procedure.
 A description of the benefits to be expected.

The prognosis, if the recommended care,

procedure is refused.
Requisites for Validity of Informed
Consent.
 Written permission is best and legally accepted.
 Signature is obtained with the client’s complete
understanding of what to occur. - adult sign their
own operative permit -obtained before sedation
 For minors, parents or someone standing in their
behalf, gives the consent.
 For mentally ill and unconscious patient, consent
must be taken from the parents or legal guardian .
Requisites for validity…
 If the patient is unable to write, an “X” is
accepted if there is a witness to his mark
Secured without pressure and threat a witness
is desirable – nurse, physician or authorized
 When an emergency situation exists, no
consent is necessary because inaction at such
time may cause greater injury. (permission via
telephone/cellphone is accepted but must be
signed within 24hrs).
VALID INFORMED CONSENT-
COMPONENTS…
i).Voluntary consent-A valid consent must be
given voluntarily without coercion. The ptn. Must
be >18 years.except for emancipated minors.
ii).The ptn.should be competent –Consent should
not be taken from any ptn who is not autonomous
and cannot give or withhold consent eg-Mentally
ill, cognitively impaired or neurologically
incapacitated, unconscious-consent from parents
or legal guardian-assent???
VALID INFORMED CONSENT.
iii).The consent must be informed.
 Informed consent should be in writing. It

should contain-
 Explanation of the procedure n its risk.
 Description of benefits n alternatives.
 An offer to answer questions about the

procedure.
 Instructions that ptn. may withdraw the

consent.
Ct… valid consent.
iv).The ptn should be able to comprehend-
 Provide the consent (both written and verbal)

in a language the ptn can understand.

 Engage a trained medical interpreter /sign

language interpreter incase of a ptn. With

hearing disability.
 MEDICO-LEGAL ISSUES.
Often arise when physical or Psychological
injury is caused.
Ethical principles-violation
i). Respect for autonomy.
This principle is the basis of informed consent.
The patient has the capacity to act intentionally
with understanding and without controlling
influences that could mitigate against a free and
voluntary act. The right to self-determination and
full disclosure are the major components on
which informed consent is based.
ii).Beneficence &Non-maleficence
The principle of beneficence :states that above
everything do good. While the principle of
non-maleficence : requires that we do NOT
intentionally create harm or injury to the patient
either through acts of commission or omission
iii).The principle of justice: Emphasizes the
need for fairness entitlement and equity for all.
No favourism in service delivery.
iv).Confidentiality :refers to surety given to a
patient or ptn. that the shared information will be
kept private.
Negligence Vs Malpractice.
Negligence-Refers to failure to exercise the care
that a reasonably prudent person would exercise
under similar circumstances.-Harm caused by
carelessness not intentional.
Malpractice-Professional negligence occurs
when a licensed person fails to provide services
as per standards set by the governing body-sub-
siquently causing harm.-filed in civil court-
compensation for mental or physical injuries
caused.
LESSON 5: THE NURSING PROCESS.
The nursing process is a proven form of
problem solving based on the scientific method
it consists of five components.
 Assessment
 Nursing diagnosis
 Outcome identification and planning
 Implementation
 Evaluation
Ct….
 Based on the data collected during the
assessment, the nurse determines nursing
diagnoses, plans and implements nursing care,
and then evaluates the results.
 The process does not end here but continues

through reassessment, establishment of new

diagnoses, additional plans, implementation, and
evaluation until all the patient’s nursing problems
are identified and dealt with.
The nursing process.
Assessment.
 Nursing assessment is a skill that nurses must
practice and perfect through study and
experience.
 The nurse - skilled in understanding the

concepts of verbal and nonverbal

communication.
 Assessment data is obtained thro’ hx. Taking

n physical exam.
Assessment ct…
 …During this phase, relationship of trust
begins to build btn. the nurse n the ptn.
 Careful listening and recording of subjective
data ( spoken by the Ptn.or family) and
careful observation n recording of objective
data (observable by the nurse) are essential to
obtaining a complete picture.
Nursing Diagnosis

 The process of determining a nursing

diagnosis begins with the analysis of
information (data) gathered during the
assessment.
 The nurse develops the nursing dx based on;
 Actual or potential health problems that fall

within the range of nursing practice.

Nursing diagnosis ct…
 These diagnoses are not medical diagnoses but
are based on the individual response to a
disease process, condition, or situation.
 Nursing diagnoses change as the patient’s
responses change; therefore, diagnoses are in a
continual state of re-evaluation and
modification.
Nursing dx ct….
 Nursing diagnoses are subdivided into three
types: actual, risk, and wellness diagnoses.
 Actual nursing diagnoses identify existing

health problems, actual nursing diagnosis

reflect the presence of signs and symptoms
.e.g……
Nursing Dx.

 Risk nursing diagnoses identify health

problems to which the patient is especially
vulnerable. These identify patients at high risk
for a particular problem.eg…..
 Wellness nursing diagnoses identify the

potential of a person, family, or community to

move from one level of wellness to a higher
level.e.g…
Expected outcomes or planning.
 These outcomes (goals) should be specific,
stated in measurable terms, and include a time
frame.
 The goal must be realistic, individualized or

focused on t@ ptn , and attainable. After goals

have been set, nursing actions are proposed.
 Although a number of possible diagnoses

may be identified, the nurse must review

them, rank them by urgency.
Implementation

This is the process of putting the nursing care plan

into action. These actions may be independent,
dependent, or interdependent.
Independent nursing actions are actions that

may be performed based on the nurse’s own

clinical judgment, for example, initiating
protective skin care for an area that might break
down.
Implementation ct…
 Dependent nursing actions, such as
administering analgesics for pain, are actions
that the nurse performs as a result of a
physician’s order.
 Interdependent nursing actions are actions

that the nurse must accomplish in conjunction

with other health team members, such as meal
planning with the dietary therapist and
teaching breathing exercises with the
respiratory therapist.
Evaluation

 Evaluation is a vital part of the nursing process

since it measures the success or failure of the
nursing plan of care.
 Like assessment, evaluation is an ongoing

Process, it is achieved by determining if the

identified outcomes have been met.
Evaluation ct..
 The criteria of the nursing outcomes determine
if the interventions were effective.
 If the goals have not been met in the specified

time or if implementation is unsuccessful, a

particular intervention may need to be
reassessed n revised.
Application of nursing process-Post-
operative ptn.
Assessment.
 Monitoring of vital signs-respiratory status-

risk of pulmonary complications following

surgery.
 Check airway patency,
 Assess L.O.C., Pain tolerance, speech,

orientation, input -output,

Nursing Dx.
• Decrease cardiac output related to shock or
heamorrhage.
• Risk of ineffective airway clearance related to
depressed resp.fxn.
• pain and immobility-Acute pain related to surgical
incision.
• Impaired skin intergrity related to surgical incision.
• Ineffective thermoregulation related to surgical
enviroment n anesthetic agents.
• Nutrition,Anxiety…..
Planning n Goals
 Pain relief.
 Optimum resp.fxn.
 Optimum cardiovascular fxn.
 Nutritional balance.
 Sufficient knowledge.
 No complications.
Intervention/Implementation.
 Prevent resp comp.-Frequent turning, deep
breathing, splintting the incision area, early
ambulation.
 Pain relief-Appropriate analgesics.
 Promote cardiac output-Early ambulation.
 Provide emotional support.
 Aseptic technique in wound caring…..
Evaluation.
 Resp-Ptn. Performs deep breathing.
 Has clear breath sounds.
 Pain-verberlizes pain reduction.
 Activity-increase ambulation-progressivly.

-Resumes normal activity within expected

time frame.
 Wound-heal with no complication.
 Body temp. within normal limits.
 Normal bowel sounds…….
PERIOPERATIVE NURSING

Loise H,et al. ( 2000 )Perioperative nursing: An

introductory Text,Prince of wales Hospital.
Suzanne J et al. (2009),Oxford handbook for of
perioperative practice.
Brunner & Suddarth; (1995) Textbook of Medical-
Surgical Nursing. J.B. Lippincott Company;
Philadelphia.
 FIN…..
THANK YOU.