Prepared by:Rachelle M. Ganuelas RN, MAN

PERIOPERATIVE NURSING

DEFINITION OF TERMSSURGERY -It is the branch of medicine

concerned with diseases and conditions which require or are amenable to operative procedures. Surgery is the work done by a surgeon.

-"Surgery can involve cutting, abrading, suturing, laser or otherwise physically changing body tissues and organs."

SURGEON - A physician who treats disease, injury, or deformity by operative or manual methods. A medical doctor specialized in the removal of organs, masses and tumors and in doing other procedures using a knife (scalpel)

STERILE - free from living germs or microorganisms; aseptic: sterile surgical instruments.

ASEPSIS - The state of being free of pathogenic microorganisms.

- The process of removing pathogenic microorganisms or protecting against infection by such organisms.

SEPSIS - a toxic condition resulting from the spread of bacteria or their toxic products from a focus of infection; especially : septicemia

SEPSIS - is a severe illness caused by overwhelming infection of the bloodstream by toxin-producing bacteria.

- is caused by bacterial infection that can originate anywhere in the body.

DISINFECTANT - any chemical agent used chiefly on inanimate objects to destroy or inhibit the growth of harmful organisms.

ANTISEPTICS - is a substance that prevents or arrests the growth or action of microorganisms either by inhibiting their activity or by destroying them. The term is used especially for preparations applied topically to living tissue

STERILIZATION -the destruction of all living microorganisms, as pathogenic bacteria, vegetative forms, and spores.

BACTERIOSTATIC -Capable of inhibiting the growth or reproduction of bacteria.

- An agent, such as a chemical or biological material, that inhibits bacterial growth.

BACTERICIDAL - Capable of killing bacteria.

BACTERIOCIDES - is a substance that kills bacteria .Bactericides are either disinfectants, antiseptics or antibiotics.

PREFIXES & SUFFIXESPrefixes & Suffixes can explain the type of

procedure the client will undergo:PREFIXES Supra – above ; beyond Ortho – joint Chole – bile or gall Cysto – bladder Encephalo- brain

Entero – intestine Hystero – uterus Mast – breast Meningo – membrane; meninges Myo – muscle Nephro – kidney Neuro – nerve Oophor - ovary

Pneumo – lungs Pyelo – kidney pelvis Salphingo – fallopian tube Thoraco – chest Viscero – organ esp. abdomen

SUFFIXES Oma – tumor ; swelling Ectomy – removal of an organ or gland Rhapy – suturing or stitching of a part

or an organ Scopy – looking into Ostomy – making an opening or a

stoma Otomy – cutting into

Plasty – to repair or restore Cele – tumor ; hernia ; swelling Itis – inflammation of

PHASES OF O.R. NURSING :I. PREOPERATIVE PHASEThe rendering of nursing care to the

surgical client as soon as he is admitted & the decision to undergo surgery is made.

It ends on the time the client is transferred to the O.R.

NURSING ACTIVITIES :Assessment of the client (baseline

evaluation of the pt. before the day of surgery-interview)

Identification of potential/actual health problems.

PREADMISSION TESTING- ensure necessary tests have been performed

Pre-op teaching involving client & support persons.

Day of surgery : pt. teaching reviewed informed consent confirmedpt.’s identity & surgical site verified IVF started.

PREPARATION FOR SURGERYPsychological Support :a)Assess client’s fears, anxieties,

support systems & patterns of coping.b)Establish trusting relationship with

client & significant others.c)Explain routine procedures, encourage

verbalization of fears & allow client to ask questions.

d) Demonstrate confidence in surgeon & staff.

e) Provide for spiritual care if appropriate.

PREOPERATIVE TEACHINGFrequently done on an outpatient

basis.Assess client’s level of understanding

of surgical procedure & its implications.

Answer questions, clarify & reinforce explanations given by the surgeon.

Explain routine pre- & post-op procedures & any special equipment to be used.

PREOPERATIVE TEACHINGPreoperative experiencePreoperative medication Breathing exercises, coughing, incentive

spirometerLeg exercises Position changes and movementPain managementReducing anxiety and fear, support of copingSpecial considerations related to outpatient

surgery

Preoperative Nursing InterventionsPHYSICAL PREPARATIONS:Patient safety is a primary concern.Obtain history of past medical

conditions, surgical procedures, dietary restrictions & medications.

Perform baseline head-to-toe assessment, including VS, height & weight.

Ensure that diagnostic procedures pertinent to surgery are performed as ordered:

1. CBC2. Electrolytes3. PT/PTT (Prothrombin Time;Partial

thromboplastin time)4. Urinalysis5. ECG6. Blood typing & crossmatch

NPO- to prevent aspirationBowel prep and skin prep - cleansing enema or laxative before

surgery to allow satisfactory visualization of the surgical site.

- goal of pre-op skin prep is to decrease bacteria without injuring the skin.

Immediate preoperative preparation Complete checklist and chartHospital gown, voiding, removal of

dentures, jewelry, contacts, etc. Preoperative medication

Transporting the pt. to the Presurgical area about 30 to 60 minutes before anesthetics is to be given.

Attend to family needs

LEGAL PREPARATION:Surgeon obtains operative permit

(informed consent)1.Surgical procedures, alternatives ,

possible complications & disfigurements or removal of body parts are explained.

2.It is part of the nurse’s role as client advocate to confirm that the client understands information given.

INFORMED CONSENT is necessary in the ff. Circumstances:

Invasive procedures, such as surgical incisions, biopsy, cystoscopy or paracentesis.

Procedures requiring sedation or anesthesia

A non-surgical procedure, such as arteriography

Procedures involving radiation

Adult client (over 18 y/o) signs own permit unless unconcious or mentally incompetent.

1.If unable to sign, relative (spouse or next of kin) or guardian will sign.

2.In an emergency, permission via telephone or telegram is acceptable; have a 2nd listener on phone when telephone permission is given

3. Consents are not needed for emergency care if all 4 of the ff. criteria are met:

a. There is an immediate threat to life.b. Experts agree that it is an

emergency.c. Client is unable to consent.d. A legally authorized person cannot

be reached.

Minors (under 18 y/o) must have consent signed by an adult (i.e. Parent or legal guardian)

Emancipated minor (married or independently earning his or her own living)may sign his/ her own consent.

Witness to informed consent may be a nurse, another M.D., clerk or any other authorized person.

The nurse witnessing informed consent, specifies whether witnessing explanation of surgery or just signature of the client.

PREOPERATIVE MEDICATIONSPURPOSES:1.To relieve fear & anxiety.2.To reduce dose needed for induction &

maintenance of anesthesia.3.To prevent reflex bradycardia that

happens during induction of anesthesia.

4.To minimize oral secretions.

II. INTRAOPERATIVE PHASE Giving nursing care to client

undergoing surgery. It starts from the time the pt. was

admitted to the O.R. , during operation until it ends & transferred to the PACU.

NURSING ACTIVITIES:Activities providing for pt’s safety.Maintenance of aseptic environment.Ensuring proper function of equipments.Providing surgeons with specific instruments

& supplies for surgical field.Completing documentation.Positioning pts.Acting as scrub/circulating nurse.

Members of the Surgical TeamPatientAnesthesiologist or anesthetist

SurgeonNurses (Scrub & Circulating)

Surgical technologists

SCRUB TEAM @ WORK

PATIENT – the most important member of the surgical team. May feel relaxed & prepared, or fearful & highly stressed.

- is also subject to several risks.OPERATING SURGEON – pre-op dx & care. - performance of operation. - post-op mgt & care - assumes all responsibility for all medical

acts of judgement & mgt.

SURGEON & ASSISTANTS – scrub & perform the surgery.

REGISTERED NURSE 1ST ASST. – practices under the direct supervision of the surgeon. (handling tissue, suturing, maintaining hemostasis)

ANESTHESIOLOGIST / NURSE ANESTHETIST – administers the

anesthetic agent & monitors the pt’s physical status throughout the surgery.

SCRUB NURSE – provides sterile instruments & supplies to the surgeon during the procedure.

- performs surgical hand scrub.

CIRCULATING NURSE – coordinates the care of the pt. in the O.R.

- care provided includes assisting with pt. positioning , skin prep, managing surgical specimens & documenting intraoperative events.

SCRUB NURSE

CIRCULATING NURSE

:O) anesthesiologist.Assistant surgeon

surgeon

                                                                                                                                                                      

Prevention of InfectionThe surgical environment – stark

appearance & cool temperature. Located central to all supporting services. Unrestricted zone – where street clothes

are allowed.Semirestricted zone- where attire

consists of scrub clothes & caps.Restricted zone- where scrub clothes,

shoe covers, caps & masks are worn.

THE OPERATING ROOM

SURGICAL ASEPTIC TECHNIQUE

BEFORE AN OPERATION, it is necessary to sterilize and keep sterile all instruments, materials, and supplies that come in contact with the surgical site. Every item handled by the surgeon and the surgeon's assistants must be sterile. The patient's skin and the hands of the members of the surgical team must be thoroughly scrubbed, prepared, and kept as aseptic as possible.

DURING THE OPERATION, the surgeon, surgeon's assistants, and the scrub nurses must wear sterile gowns and gloves and must not touch anything that is not sterile.

Maintaining sterile technique is a cooperative responsibility of the entire surgical team.

Each member must develop a surgical conscience, a willingness to supervise and be supervised by others regarding the adherence to standards.

BASIC PRINCIPLES OF SURGICAL ASEPSIS All personnel assigned to the

operating room must practice good personal hygiene. This includes daily bathing and clothing change.

Those personnel having colds, sore throats, open sores, and/or other infections should not be permitted in the operating room.

Operating room attire (which includes scrub suits, gowns, head coverings, and face masks) should not be worn outside the operating room suite. If such occurs, change all attire before re-entering the clean area. (The operating room and adjacent supporting areas are classified as "clean areas.")

All members of the surgical team having direct contact with the surgical site must perform the surgical hand scrub before the operation.

All materials and instruments used in contact with the site must be sterile.

· The gowns worn by surgeons and scrub corpsmen are considered sterile from shoulder to waist (in the front only), including the gown sleeves.

· If sterile surgical gloves are torn, punctured, or have touched an unsterile surface or item, they are considered contaminated.

The safest, most practical method of sterilization for most articles is steam under pressure.

· Label all prepared, packaged, and sterilized items with an expiration date.

· Use articles packaged and sterilized in cotton muslin wrappers within 28 calendar days.

Use articles sterilized in cotton muslin wrappers and sealed in plastic within 180 calendar days

Unsterile articles must not come in contact with sterile articles.

Make sure the patient's skin is as clean as possible before a surgical procedure.

Take every precaution to prevent contamination of sterile areas or supplies by airborne organisms.

HANDLING STERILE ARTICLES When you are changing a dressing,

removing sutures, or preparing the patient for a surgical procedure, it will be necessary to establish a sterile field from which to work. The field should be established on a stable, clean, flat, dry surface.

An article is either sterile or unsterile; there is no in-between. If there is doubt about the sterility of an item, consider it unsterile

Any time the sterility of a field has been compromised, replace the contaminated field and setup.

Do not open sterile articles until they are ready for use.

Do not leave sterile articles unattended once they are opened and placed on a sterile field.

Do not return sterile articles to a container once they have been removed from the container.

Never reach over a sterile field. When pouring sterile solutions into

sterile containers or basins, do not touch the sterile container with the solution bottle. Once opened and first poured, use bottles of liquid entirely. If any liquid is left in the bottle, discard it.

Never use an outdated article. Unwrap it, inspect it, and, if reusable, rewrap it in a new wrapper for sterilization.

Intraoperative Complications Nausea and vomitingAnaphylaxisHypoxia and respiratory complicationsHypothermiaMalignant hyperthermiaDisseminated intravascular coagulation

(DIC)

Potential Adverse Effects of Surgery and AnesthesiaAllergic reactions and drug toxicity or

reactionsCardiac dysrhythmiasCNS changes and oversedation or

undersedationTrauma: laryngeal, oral, nerve, and skin,

including burnsHypotensionThrombosis

Nursing Goals for the Patient in the Intraoperative PeriodReducing anxietyPreventing positioning injuriesMaintaining patient safetyMaintaining the patient's dignityAvoiding complications

Protecting the Patient from InjuryPatient identification Correct informed consent Verification of records of health history and

examResults of diagnostic testsAllergies (include latex allergy)Monitoring and modifying the physical

environment

Safety measures such as grounding of equipment, restraints, and not leaving a sedated patient

Verification and accessibility of blood

III. POSTOPERATIVE PHASE Begins with the admission of the

client to PACU & ends with discharge of client from hospital or facility providing continuity of care.

Post-Anesthesia Care UnitThe PACU environmentBeds and other equipment

Nursing Management in the PACUProvide care for the patient until he/she has

recovered from the effects of anesthesia. Patient has resumption of motor and

sensory function, is oriented, has stable VS, and shows no evidence of hemorrhage or other complications of surgery.

Frequent skilled assessment of the patient is vital

Responsibilities of the PACU NurseReview pertinent information and baseline

assessment upon admission to the unit.Assessments include airway and

respirations, cardiovascular function, surgical site, function of the central nervous system; also assess IVs and all tubes and equipment.

Reassess VS and patient status every 15 minutes or more frequently as needed.

Provide report and transfer the patient to another unit or discharge the patient to home.

Outpatient Surgery/Direct DischargeDischarge planning and discharge

assessment

Provide written and verbal instructions regarding follow-up care, complications, wound care, activity, medications, and diet.

Give prescriptions and phone numbers. Discuss actions to take if complications occur.

Outpatient Surgery/Direct DischargeGive instructions to the patient and a

responsible adult who will accompany the patient.

Patients are not to drive home or be discharged to home alone. Sedation and anesthesia may cloud memory and judgment and affect ability.