Perioperative Nursing

PERIOPERATIVE NURSING
Prioritization:  Urinalysis
 Airway o Specific gravity -  in DHN
o Obstruction
 CPC – Cardiopulmonary Clearance
 Breathing Pattern
o Required in patient older than 35
o Lung expansion
o Chest x-ray – indicates lung capacity
o Pain, pleural effusion
o 12L ECG
 Circulation
o Tissue perfusion  NPO
o Required for general anesthesia
Nursing Process:  Risk for regurgitation
 Assessment o At least 6 to 8 hours
o Subjective (must be followed by assessment)
and objective data (intervention, priority  Bowel Preparation
diagnosis) o 3 days preparation
o Maslow’s Hierarchy of Needs o Progressive diet
o Think of something that will kill the patient if o Laxatives, Enema
withdrawn from him
o O2 – fluids – nutrition – thermoregulation -  Antibiotics
comfort o Neomycin
 Planning  Aminoglycosides - gram (-)
o Must have proper objective  Local effect – intestines
 Specific o Poorly absorbed in the GI
 Measureable o Metronidazole
 Antiprotozoal, antibacterial
 Attainable
o Give 1 hour prior to OR
 Realistic
 Time-bound  IV Line
o Best manifestation of effective care o D5 containing IV
 Intervention  Source of glucose or else will result to
o Nursing action – independent catabolic activities
o Priority action – dependent or interdependent o Large bore needle
 Evaluation
o If reached the objective o Colors:
 G 16 Gray
Perioperative Nursing – care of pts around the phases of  G 18 Green
operation  G 20 Pink
 Preoperative  G 22 Blue
o Decided to undergo procedure  brought to  G 24 Yellow
OR
 Intraoperative o  number  size
o Patient is brought to OR  PACU o  number  size – Fr
 Postoperative
o PACU  full recovery  Pulse oximeter
o O2 sat
PREOPERATIVE PHASE o Remove nail polish including colorless
 Endorsement must include physical, psychological, o NO direct sunlight – Infrared
emotional, spiritual preparation o If exposed to sunlight - cover

Physiologic  Remove prosthesis, false teeth, loose teeth

 CBC
o Hgb - oxygen carrying capacity of blood that
helps transport oxygen throughout the body
 At least 120
  Hgb – tissue perfusion problem
 Blood loss > 500 mL: needs extra
pRBC
o Hct – hemoconcentration or hemodilution
 DHN – hemoconcentration
 Can indicate possible bleeding
  internal bleeding
  active bleeding
o RBC – O2 carrier
o WBC – if with infx, start antibx tx
o Plt – thrombocytes; blood clotting
o Crucial for general anesthesia
o Risk for aspiration
o Remove before giving anesthesia
 Remove underwear
Mental
 Health Teachings (2 types)
o Process Information
 About surgical experience, time,
meds, set-up
 Prepare on what to anticipate
 Do not give too much information
o Procedural Information
 Things that they have to do post-op
 Deep breathing

University of Santo Tomas – College of Nursing / JSV

 Perioperative Nursing
o Increase the amount of air
o Inhale – nose
o Exhale – pursed-lip
o Every hour x 10 during INTRAOPERATIVE PHASE
waking hours Reasons for Surgery
 Coughing exercises  Diagnostic
o Effort comes from the lungs o Removal and study of instruments to make a
o Deep breathing first diagnosis
o At least every 2 hours o Breast biopsy
o  Tympanoplasty, Neuro -  Exploratory
 ICP o More extensive means to diagnose,
 Incentive spirometry exploration of body cavity or use of scopes
o Semi-fowler’s inserted through small incision
o Breath through the mouth – o Exploratory laparotomy - exploration of
tight seal abdomen for unexplained pain
o Sustain  Curative
o 3 to 4 secs o Removal or replacement of defective tissue to
o 500 – 600 immediate post- restore fxn
op o Cholecystectomy, hip replacement
 Palliative
 Consent o Relief of symptoms or enhancement of
o 18 year old and above function w/o cure
o Free will, sound mind  Cosmetic
o Vertical first o Improve the appearance
o Nurse – sign as witness and verify o Correction of defects
understanding
o MD – secure consent
Categories of Surgery
Emotional  Emergency
o Who will be with the patient during surgery o Done immediately to save life or limb
o Circulating RN – informs the family about the status of o Takes precedence over any other sx
the sx scheduled
 Elective
Spiritual o Done at the pt and surgeon’s convenience
o Pastoral care service/ chaplain o May be performed w/in days and even
Preoperative Medications months after diagnosis
 Anticholinergic
o  secretions and acidity Prefixes
o May cause tachyPR  A without, absence
o Atropine S04  Ecto external, outside
 Analgesics  Infra below
o  pain threshold  Inter between
o Nalbuphine, Fentanyl  Pan all
o Antidote: Naloxone (Narcan)  Peri around
o Check RR, BP (hypotension), GU (urinary  Poly many
retention), GI (constipation)  Pseudo false
 Sedatives  Retro behind, posterior
o Diazepam, Midazolam  Supra above
 Anti-histamines
o Anticholinergic and sedative property Suffixes
o Promethazine, Diphenhydramine  Algia pain
 Antibiotics  Centesis puncture
 Copy to view
AREAS IN THE OPERATING ROOM  Ectomy surgical removal
 Non-restricted Area  Itis inflammation
o OR lobby  Lith stone or calculus
o Street clothes  Lithotomy removal of stones
 Semi-restricted Area  Logy study
o Hallways, work area, instruments room,  Lysis destruction, dissolution, loose
sterilization room  Oma tumor
o Scrub suit – clean  Ostomy opening into
o OR shoes, bonnet  Plasty surgical formation
 Restricted Area  Pexy fixation
o Suite, operating instruments open  Rrhapy repair; suturing of repair
o Scrubs, OR shoes, bonnet, mask
o Scrub sink (IDEAL)

University of Santo Tomas – College of Nursing / JSV

 Perioperative Nursing
 Scrub Nurse
o Overall maintenance of sterility
o One step ahead, anticipate needs
o Sterile team
o Indispensible nursing tandem
Rootwords  Circulating Nurse
 Adeno gland o Coordinate
 Ano anus o Two step ahead
 Arthro joint o Indispensible nursing tandem
 Angio blood or lymphatic vessel o Overseer; more senior
 Blephar eyelid o Counting instruments, before closing the 1st
 Broncho bronchus layer
 Cardio heart o Initiates Surgical Safety Checklist
 Cephalo head
 Cerebro brain Sign IN
 Cheilo lip  Before the actual start of surgery
 Chole gall, bile  Identifying the patient, site
 Cholecyst gall bladder  Allergies, Antibiotics, Anticipated blood loss (if
 Choledocho common bile duct greater than 500 or 7ml/kg in children, need
 Chondro cartilage BT), Pulse Oximeter
 Colo large intestine, colon
 Colpo vagina Time OUT
 Costo rib  Introduction of patient and procedure by
 Cranio skull doctor
 Cysto bladder  Identity of team
 Esophago esophagus  Special concerns by anesth
 Gastro stomach  Completeness and sterility of equipment by
 Glosso tongue scrub nurse
 Hepar liver  Done before skin incision
 Hyster uterus
 Lapar abdomen Sign OUT
 Lipo fat  Completeness of instruments
 Mast/Mammo breast  Proper endorsement of specimen
 Nephron kidney  Must be labeled with name, age, gender,
 Oculo eye specimen/location, surgeon, pathologist
 Oophor ovary  For normal histopathology
 Orchi testis - On buffered formalin sol’n
 Osteo bone - After 7-10 working days
 Oto ear - Labeled properly
 Phlebo vein  Frozen section
 Pneumo lungs - Clean plastic bag
 Procto rectum - Labeled properly
 Pyelo renal pelvis - Labeled immediately and sent
 Rhino nose right away
 Salphingo fallopian tube  Follow up histopath results to physician
 Thoraco chest
 Urano palate  Pathologist
 Uretero ureter o Clinical – specimens (stool, urine, CBC)
Lith – stone o Histopath – benign or malignant
Lithiasis – condition o Autopsy – cause of death
Lithotomy – removal  Forensic pathologist – more specific
Ostomy – opening into; input or output  Medico-legal – doctor lawyers
Otomy – opening for sx o Blood bank – lab screening, BT
Pexy – fixation; suturing into place
Paxy – endoscopic crushing Additional Members
 Supervisor
* No incision in TURP, ESWL or –scopy o In charge of admin functions
* Layman’s term if communicating w/ patient  Head Nurse
o Day-to-day tasks, coordinate to other depts.
Operating Room Team Members  Nurse Aide
 Surgeon o Receptionist, assists
o Leader o  scrub
o Decision maker  Orderly
 Asst. Surgeon o Transport patient, position, draping
 Anesthesiologist  Clerk
o In tandem with surgeon  Ward Clerk
o Monitors hemodynamic stability o Documentation
o Checks amount of blood loss  Billing Clerk

University of Santo Tomas – College of Nursing / JSV

 Perioperative Nursing
o Charges  Scrub team/ patient’s hair
 OR Tech Patient’s hair
o Set-up of instruments o No shaving - Microabrasion
o Hair clippers – electric razor
o Depilatory creams (Veet) but patch allergy testing
must be done
 Biomed Tech
o Engineer repairing the instruments/ equipment Principles on Asepsis
o Check up and technical assistance of
machines  Sterile items
 Med Tech o Sterile to sterile only
o Assists pathologist  Sterile field
 Internist o Should always be in the line of vision
o Doctor of Internal Medicine o Back table, mayo table
o CPC o Under table and back are unsterile
 Resident o Back table is the basis for “under the table”
o Licensed  Traffic
 Intern o Kept to a minimum
o Graduate of medicine  Drapes
o No license o Should not be removed once placed
 Radiologist o Do not transfer
o Read and check chest x-ray  Gowns
o Ortho and endoscopic procedures o Below waist, back, elbow and above are
 Rad tech unsterile
o Operate equipment  Gloves
Secondary o Glove Tear
 Security  If w/o time – double
 Janitorial  If w/ time – change
o Outside the OR o Dressing and tape before removing gloves
o Disposal of biowaste
 Medical/ Social Services  Room disinfection
o Assist family, support system  Spilled blood
o Financial assistance o Contain
 Medico-legal o Drainage and floor suction
o Give to head nurse and she will refer to  Lights
medico-legal department o Moist and dry
 Pastoral (Chaplain) o Smudge – glaring
 Medical Records  1 to 2 ft away from sterile field
 NBI
 MMDA MEDICAL AND SURGICAL INSTRUMENTS
o Disposal
 RMAO (Records Management Archives Office)  Category I: Critical Items
o Disposed every 5 years; Cultural Heritage o Must be sterilized
o Come in contact with blood vessels and non-
PRINCIPLES OF ASEPSIS AND STERILITY intact mucosa
 Category II: Semi-critical Items
Definition of Terms o Sterilization is preferred but disinfection is
 Asepsis – absence of microorganisms acceptable
 Disinfection – reduction of pathologic microorganisms o Intact mucosa or non-intact skin
without destroying the spores  Category III: Non-critical Items
 Contaminated – soiled with microorganisms o Clean
 Infection – invasion of the body by pathogenic o Intact skin
microorganisms o Ball pen, stethoscope, BP app
 Spores – inactive but viable state of a microorganism
 Sterile – free from microorganisms including spores STERILIZATION PROCEDURES
 Surgical Conscience – involves the concept of self-
inspection and moral obligation involving scientific and  Physical Sterilization
intellectual honesty o Moist heat
 Autoclaving
Sources of Contamination o Steam under pressure
 Skin – never sterile o Temperature: 121 – 123 °C
 Respiratory tract o Pressure: 15 – 17 psi
 Articles used in the procedure o Time: 15 – 30 mins
o First knife used for skin incision should not be o Not sterile if not all are
used again achieved
 Circulating air  Flash Sterilization
o Should ideally be closed o Temperature: 132 °C
o Sterile field not open unnecessarily o Pressure: 15 – 17 psi

University of Santo Tomas – College of Nursing / JSV

 Perioperative Nursing
o Time: 3 - 10 mins o Below nipple line – regional anesthesia
 Cost effective  Epidural
 Sensitive items cannot be  Spinal
autoclaved  Type and probable duration of operation
 Sharps become dull o Epidural – has a port where you can infuse
o Dry heat (Dry heat autoclaving) add’l meds
 Patient’s preference
 Laboratory finding
 Chemical Sterilization  Any known idiosyncrasies
o Ethylene oxide – Best sterilization Stages of Anesthesia
 Temperature: 16 – 18 °C  Stage 1 (Induction/ Stage of Analgesia)
 Time consuming o Starts from induction period until patient loses
 Scopes consciousness
 Yellow to blue o Patient may appear drowsy or dizzy
o Plasma hydrogen peroxide gas (Sterrad) o Safety – bed rails and body straps
 30 mins o Keep the room quiet
  liquid, items with lumix (scopes,
camera) – hazy  Stage 2 (Excitement/ Delirium)
 Best for sharps o Lasts from the time the patient loses
consciousness until he loses certain reflexes
Disinfection Procedures such as swallowing, gag and eyelid
 High level disinfectant o May appear excited, may breathe irregularly
o Activated glutaraldehyde o Sensitive to external stimuli
o Powder (activator) o Maintain silence
o Disinfects but prolonged exposure may
become unsterile  Stage 3 (Surgical Anesthesia)
o After soaking, rinse with sterile water o From the period the patient lost certain
 Intermediate level disinfectant reflexes and respiratory paralysis occurs
o 70% alcohol, iodine compounds o Patient with regular respiration, constricted
o Chlorhexidine pupils, jaws relax and auditory sensation is lost
o Skin o Assist the team!
 Low level disinfectant  Stage 4 (Stage of Danger)
o Phenolic compounds, chlorine compounds o Reached when too much anesthesia has
o IV, floor been given and the patient has not been
STERILIZATION AND DISINFECTION observed carefully
 Labels – process, date, expiration dates, item, packer, o Death may result from respiratory and or
processer cardiac arrest unless resuscitated properly
 Wrappers o Patient is not breathing with little to no heart
 Shelf life beat
o Time-related – depends on method o Medullary paralysis – cardiopulmo arrest
 Autoclave – 2 weeks o Too much anesthesia
 Sterrad – 1 month
 Ethylene oxide – 2 months Types of Anesthesia
o Event-related  General Anesthesia
 Sterile as long as package is intact o Association pathways are broken in the
 More recommended cerebral cortex to produce more or less lack
 Indicators of sensory and motor perception
o Chemical indicators o Pain is controlled by general insensibility, the
 Change in color when exposed to a patient is unconscious, he cannot hear, feel,
situation or substance or move his whole body
 Underwent sterilization process – o Used in operations above the thoracic level
white to brown or black o Cannot be aroused
 Ethylene oxide – yellow to blue  Regional Anesthesia
 Plasma gas – red/ maroon to yellow/ o Depresses superficial nerves and interferes
gold with the conduction of pain impulses from
o Biologic indicators certain area or region
 Best indicator of sterility o Pain is controlled without loss of
 Small test tube then sterilize consciousness, one region or an area of the
body is anesthetized
ANESTHESIA
Factors that determine the choice of anesthesia General Anesthesia
 Physical and mental condition of patient  Inhalation
o  MENTAL – ability to comprehend o With the use of volatile gases and vapors
 Age and weight of patient o Either per mask or endotracheal tube
o Child – general o Common anesthetics:
o Adult - regional  Nitrous oxide
 Operation to be performed  Sevoflurane (Sevorane)
o Above nipple line – general anesthesia  Desflurane (Suprane)

University of Santo Tomas – College of Nursing / JSV

 Perioperative Nursing
 Isoflurane (Forane)
 Halothane (Fluothane)
o GAOT (General anesthesia orotracheal)
o GANT (General anesthesia nasotracheal)
o GETA (General endotracheal anesthesia) –
fastest
o Laparoscopic sx
 Intravenous
o Drugs that may produce hypnosis, sedation,
amnesia and/ or analgesia is administered via
IV
o Common anesthetics:
 Thiopental Na (Pentothal)
 Propofol (Diprivan)
 Ketamine (Ketalar)
o No premature awakening
 Complication:
o Malignant Hyperthermia (GA)
 Gases and succinylcholine
 Spasm
  Carbon dioxide and heat
 Blood is brown to black
 Acidosis
 Antidote: Dantrolene Na
 Ice bag
Regional Anesthesia
 Epidural Anesthesia
o Used for long procedures below the thoracic
level
o Used for post-op management of pain
o Uses an epidural catheter (Perifix)
o Common anesthetics:
 Bupivacaine (Sensorcaine Isobaric
Marcaine)
 Lidocaine (for testing)
o Complication:
 Urinary retention – foley catheter
 Subarachnoid Block
o Commonly termed as Spinal Anesthesia
o For short cases below the thoracic level
 2 to 3 hrs procedure
 3 to 4 hrs maximum
o Uses spinal needle gauge 22, 25 or 27
o Relaxes all muscles
o Common anesthetics:
 Bupivacaine Hyperbaric
(Sensorcaine Heavy)
 PDE (Tetracaine (Pantocaine))
 Dextrose, Ephedrine –
vasoconstriction, slow absorption
o Wear off 1 hour/ level
o Complications:
 Spinal Headache – CSF leak –
pressure
o Hydrate, flat on bed
 Vasodilation – pre-load 1L IVF to
prevent drop in BP
 Field/ Nerve Block
University of Santo Tomas – College of Nursing / JSV
o Anesthetizing surrounding tissues (field) or
group of nerves at a given point
o Common anesthetics:
 Bupivacaine Isobaric (Sensorcaine,
Marcaine)
 Lidocaine
 Local Infiltration
o Agent is injected into the tissues around
incision site
o Anesthetic: Lidocaine
 Topical
o Agent applied directly into a mucosa or
surface
o Anesthetic: Lidocaine spray
INCISION, POSITION AND DRAPING
Layers
 Skin – tough, non-absorbable suture, cutting needle
 Subcutaneous - thin
 Muscle – do not suture
 Fascia – tough connective tissue, non-absorbable
suture
 Peritoneum – thin
Incisions
 Right subcostal (Kocher’s incision) – biliary, gall bladder
 Median Upper Abdominal
 Median Lower Abdominal – pelvic, gyne
 Paramedian – side of median
 McBurney’s Incision – appendectomy
 Rocky Davies – straight for appendectomy
 Inguinal
 Transverse suprapubic (Pfanessteil) – cuts across the
muscle, long wound healing
Miscellaneous Incision
 Collarline (Curvilinear incision) – used for thyroidectomy
 Coronal, butterfly incisions – craniotomy
 Thoracotomy incision – anterolateral or lateral
posterothoracic
 Lumbotomy incision – kidney surgery
 Sternal split – sternotomy
 Limbal – cataract
 Elliptical Halsed – radical mastectomy
 Post/pre Aural incision
 Caldwell Luc – sinuses
Positioning
 Choice of position is made by the surgeon and
positioning is done by the members of the surgical
team
 Factors to consider:
o Length of the procedure
o Site of the operation
o Pain upon moving
o Kind of anesthesia
 Reflect proper body alignment
 Cystoscopy – lithotomy
 Thoracentesis – unaffected side, orthopneic
 Chest tube – supine, HOB elevated
Qualifications of a Good Position
 Not interfere with respiratory
 Not interfere with circulation
 Not cause pressure on any nerve
 Provide total accessibility
Common Injuries related to Positioning
 Brachial plexus injury
 Ulnar/ radial nerve injury
 Perioperative Nursing
 Saphenous and peroneal nerve damage  Bipolar – w/ grounding pad
o Lithotomy – lift together
 Integumentary damage  Do’s
 Eye and facial injury o Place it in area with good muscle mass – tissue
Skin Preparation (Special Considerations) perfusion
 Determine the area and the extent to be prepared  Don’t
including proposed incision o Areas that might get wet
 Practice modesty and privacy o Near metal implants
 Examine area to be prepared o Hairy
 In abdominal operations focus on the umbilicus o Keloids or scars
 In shaving follow the direction of the hair growth while
the other hand exerts an opposite force
 Inside to outside when infected
BASIC SURGICAL INSTRUMENTS
Instrument Classification SUTURES
 Clamping/Hemostats Definition of Terms
o Kelly, Mosquito, Tonsils/Adson, Mixter  Suture – any material used to sew, stitch or hold tissues
or body parts together
 Grasping/Holding  Ligature – a tie, to ligate blood vessels
o Delicate – thumb forceps  Primary suture line – main layers of tissues which must
o Tough – tissue forceps – w/ teeth be sutured
o Russian, Adson  Stay or tension suture – sutures placed at the incision to
o De Bakey – more sensitive tissues act as reinforcement or support
o Bobcock – delicate tissue (fallopian tube,  Tensile strength – amount of tension of pull that a strand
ovary) will withstand
 Retracting Instruments
o Army navy, Richardson Criteria for a Good Suture
o Maleable  Versatility
o Deaver  Ease of handling
o Weilaner  Minimal tissue reaction and inability to create a
favorable environment for infection and tissue rejection
 Cutting/Dissecting  High tensile strength
o Metz – delicate tissue blood vessel  Easy to thread, easy to sterilize and will not shrink
o Mayo curve – tough  Made of non-electrolyte, non-capillary, non-allergenic
o Straight – supplies and non-carcinogenic materials
o Blade  Absorbed with minimal tissue reaction
20
11 Stab knife I&D Uses of Suture
12 Hook knife Oropharyngeal  Ligating
Hallow/ tubular  Suturing
structure  Closing
15 Small-
bellied knife Types of Sutures
 Natural or synthetic
 Suturing instruments o Natural – comes from environment; silk,
o 4-0 – regular needle holder catgut, metals, cotton – may react easily
o Larger than 4-0 – catalejo o Synthetic – more refined, less reaction
 Absorbable or non-absorbable
* Curve of instrument follows the curve of surgeon’s hand o Absorbable –naturally dissolved
o Non absorbable – tough tissues/ high support
Knife Handle  Monofilament or multifilament
 #4 20 and  o Multifilament – faster reactivity
 #3 10, 11, 12, 15
 #7 7, 11, 12, 15 Progression Chart
 Lower than 0 – smaller
Gas Tanks/ Gas Cylinders  Higher than 0 - larger
 Green Oxygen
 Gray Carbon dioxide – lap procedures Surgical Needles
 Yellow Compressed air  Three basic sections
 Blue Nitrous oxide o Point
 Black Nitrogen  Taper (round) – for delicate tissues
 Brown Helium  Blunt – for more delicate tissues
Cautery  Cutting – tough tissues/ skin
 Monopolar – needs grounding pad at leg o Tapercut
(gastrocnemius) - good muscle mass and perfusion o Conventional cutting
o May have electrical burns o Reverse cutting
o Pads must not be placed in scars, kelloids,
might get wet, near metal implants and hairy o Body or Shart

University of Santo Tomas – College of Nursing / JSV

 Perioperative Nursing
o Eye (trauma)
 Atraumatic or Swaged – attached to
suture since with suture already
o Keloid formers
 French Eyed or Spring
 Controlled release

Alternative Methods to Suturing

 Surgical Strips
 Skin clips
 Skin staples
 Ligation clips
 Surgical staples
 Tissue adhesives

Hemostatic Agents
 Bone wax
 Absorbable gelatin sponge
 Collagen sponge
 Oxidized cellulose - Surgicel
 Gel foam

Surgical Scrubbing and Gloving

 Fingertips to elbow
 10 mins
 Grasp the gown at the center, lift and step back, dry
hands at hemline, wrong side facing you
 Open gloving
 Serving the glove – four fingers outside
 Remove the gown, then gloves

University of Santo Tomas – College of Nursing / JSV