Medical Surgical Nursing - PERIOPERATIVE NURSING

DEFINITION OF TERMS
SURGERY - 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.

SURGEON - A physician who treats disease, injury, or deformity by operative or manual

methods.

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

ASEPSIS- The state of being free of pathogenic microorganisms.

SEPSIS - a toxic condition resulting from the spread of bacteria or their toxic products from a
focus of infection.
- Septicemia

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.

STERILIZATION- the destruction of all living microorganisms, as pathogenic bacteria,

vegetative forms, and spores.

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

BACTERICIDAL- Capable of killing bacteria.

BACTERIOCIDES- is a substance that kills bacteria.

PREFIXES & SUFFIXES

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; heria; swelling
Itis - inflammation of

PERIOPERATIVE NURSING
OPERATING ROOM NURSING
- The identification of physiological & sociological needs of the client, & the
implementation of an individualized program of nursing care in order to restore or
maintain the health & welfare of the patient before, during & after surgical
intervention.

PHILOSOPHY:
- To give service that aims to provide comprehensive support physically, morally,
psychologically, spiritually, & socially to a patient undergoing surgery.

GOALS:
- To provide safe, supportive & comprehensive care.
- To assist the surgeon by functioning effectively as a member of the surgical team
- To create & maintain an aseptic / sterile environment.

Fundamental purposes of the O.R.:

It is a place...
- To correlate theory & practice.
- To develop skills in assisting the surgeon in the operation.
- To create a suitable sterile field for surgical procedures to prevent complications.

Perioperative Nursing
- refers to the nursing care provided in the total surgical experience of the patient

PHASES OF PERIOPERATIVE NURSING CARE:

1. Preoperative Phase - the period of time from the decision for surgery until the patient
is transferred into the operating room.
 2. Intraoperative Phase - the period of time from when the patient is transferred to the
operating room, to the admission to post-anesthesia care unit (PACU).
3. Postoperative Phase - the period of time that begins with admission to the PACU and
ends with follow-up evaluation in the clinical setting or at home.

PREOPERATIVE PHASE
1. OBTAINING INFORMED CONSENT
- Surgeon
- Minors
- Older clients
- Nurses

● No sedation should be administered to the client before the client signs the consent.

● INFORMED CONSENT is necessary in the following 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

● Consents are not needed for emergency care if all 4 of the following criteria are met:
- There is an immediate threat to life.
- Experts agree that it is an emergency.
- Client is unable to consent.
- A legally authorized person cannot be reached.
NUTRITION
● Review the physician's orders regarding the NPO status before surgery.
- 6 to 8 hours before general anaesthesia
- 3 hours before surgery with local anaesthesia

● IV line and administer IV fluids as prescribed

● administer total parenteral nutrition (TPN) to clients who are

- Malnourished
- protein or metabolic deficiencies
- cannot ingest foods

ELIMINATION
● intestinal or abdominal surgery,
- an enema or laxative
● void before surgery
● insert a Foley catheter
- it should be emptied immediately before surgery
- document the amount and characteristics of the urine

SURGICAL SITE
 - Prepare to clean the surgical site with a mild antiseptic soap the night before surgery
as prescribed
- Prepare to shave the operative site as prescribed.
- Hair should be shaved only if it will interfere with the surgical procedure and only if
prescribed.

PREOPERATIVE CLIENT TEACHING

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
- patient teaching reviewed
- informed consent confirmed
- patient's identity & surgical site verified
- IVF started

PREOPERATIVE TEACHING
- Assess the 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.
- Assess the 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 MEDICATIONS
PURPOSES:
- To relieve fear & anxiety.
- To reduce dose needed for induction & maintenance of anaesthesia.
- To prevent reflex bradycardia that happens during induction of anaesthesia.
- To minimize oral secretions.

PREOPERATIVE MEDICATIONS
1. Sedatives/Hypnotics/Tranquilizers
- Decrease anxiety
- Provide sedation
● Nembutal (pentobarbital sodium)
● Vistaril (hydroxyzine)
● Valium (diazepam)
● Phenergan (promethazine)
● Versed (midazolam)

2. Narcotics
- Relieve pain/discomfort
● Demerol
● OMS
● Dilandia
● Fentanyl
- Check respiratory depression

3. Anticholinergics
- Decreases secretion of saliva and gastric juices; Prevents bradycardia
● Atropine Sulfate
● Robinul
● Scopolamine
- Check BP & HR
- Dry mouth, drowsiness, urinary hesitancy

4. Antiulcer (Histamine H2 Antagonists)

- Prevent aspiration pneumonitis
● Ranitidine ( Zantac)
● Cimetidine (Tagamet)
● Famotidine (Pepcid)

5. Antiemetics
- Increase gastric emptying; decrease n/v
● Metoclopramide (Reglan)
● Droperidol (Inapsine)
PREPARATION FOR SURGERY
Psychological Support:
- Assess client's fears, anxieties, support systems & patterns of coping
- Establish trusting relationships with clients & significant others.
- Explain routine procedures, encourage verbalization of fears & allow clients to ask
questions.
- Demonstrate confidence in surgeon & staff
- Provide for spiritual care if appropriate

Preoperative Nursing Interventions

PHYSICAL 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
● СВС
● Electrolytes
● PT/PTT (Prothrombin Time; Partial thromboplastin tire)
● Urinalysis
● ECG
● Blood typing & crossmatch
- Nothing Per Orem
- Bowel prep and skin prep
- Immediate preoperative preparation
- Transporting the patient to the Presurgical area about 30 to 60 minutes before
anaesthetics is to be given.
- Attend to family needs

CLASSIFICATIONS OF SURGERY
According to Urgency
● EMERGENT - requires immediate attention; disorder may be life-threatening.
● URGENT - requires prompt attention
● REQUIRED - needs to have surgery
● ELECTIVE - should have surgery
● OPTIONAL - decision rests with the patient

According to Purpose
● DIAGNOSTIC - verifies suspected diagnosis
● EXPLORATORY - estimates the extent of the disease or injury.
● CURATIVE - removes or repairs damaged tissues.
● ABLATIVE - removing diseased organs that can't wait anymore.
● PALLIATIVE - relieves symptoms but does not cure the underlying disease process.
● RECONSTRUCTIVE - partial or complete restoration of a damaged organ tissue to
bring back the original appearance & function.
● CONSTRUCTIVE - repairing the damaged tissue or congenitally defective organ.

According to Location
● INTERNAL - inside the body
● EXTERNAL - outside the body

FOUR BASIC PATHOLOGIC CONDITIONS THAT REQUIRE

SURGERY
1) OBSTRUCTION
2) PERFORATION
3) EROSION
4) TUMORS

THE SURGICAL RISK PATIENTS

- Extremes of age (very young & very old)
 - Extremes of weight (emaciation, obesity)
- Dehydrated pts.
- Nutritional deficits
- Severe trauma or injury, infection/sepsis
- Cardiovascular disease
- Endocrine dysfunction (diabetes mellitus)
- Hypertensive & hypotensive pts.
- Hypovolemia
- Hepatic disease
- Preexisting mental or physical disability

PROBLEMS THAT MAY ARISE IN SURGERY:

- Surgical risk pts.
- Pain
- Haemorrhage
- Injection
- UTI

INTRAOPERATIVE PHASE
NURSING ACTIVITIES:
- Activities providing for patient' safety.
- Maintenance of an aseptic environment.
- Ensuring proper function of equipment.
- Providing surgeons with specific instruments & supplies for surgical field
- Completing documentation.
- Positioning patients.
- Acting as scrub/circulating nurse.

Members of the Surgical Team

- Patient
- Anesthesiologist or anaesthetist
- Surgeon
- Nurses (Scrub & Circulating)
- Surgical technologists

SCRUB NURSE
- Prepare sterile supplies
- Sponge count
- Maintain sterility
- Gown / glove assistant

CIRCULATING NURSE
- Sets up room
- Maintains supplies
- Check safety/function of equipment
- Positions client
- Cleans surgical filed before draping
Basic Guidelines for Surgical Asepsis
- All materials in contact with the wound and within the sterile field must be sterile
- Gowns are sterile in the front from chest to the level of the sterile field, and sleeves
from 2 inches above the elbow to the cuff
- Only the top of a draped table is considered sterile During draping, the drape is held
well above the area and is placed from front to back
- Items are dispensed by methods to preserve sterility.
- Movements of the surgical team are from sterile to sterile and from unsterile to sterile
only.
- Movement around the sterile field must not cause contamination of the field. At least
a 1-foot distance from the sterile field must be maintained.
- Whenever a sterile barrier is breached, the area is considered contaminated.
- Every sterile field is constantly maintained and monitored. Items of doubtful sterility
are considered unsterile.
- Sterile fields are prepared as close as possible to time of use.

SURGICAL ASEPTIC TECHNIQUE

BEFORE AN OPERATION
- It is necessary to sterilise 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 aseptic as possible.

DURING THE OPERATION

- Maintaining sterile technique is a cooperative responsibility of the entire surgical
team.
- Each member must develop a surgical conscience and 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.
- Those personnel having colds, sore throats, open sores, and/or other infections
should not be permitted in the operating room.
- Operating room attire should not be worn outside the operating room suite.
- 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 the 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 18o
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.

8. The wrapper of a sterile pack must be opened, away from the body, the distal flap first, the
lateral flaps next, and the proximal flap toward the body last, thus it is unnecessary to reach
over the sterile field.

9. The sterile zone is confined to the tabletop or to above waist level. Anything that hangs,
falls, or touches below these levels is considered contaminated.

10. Any area of 1 inch or so surrounding the outer edge of the sterile field must be
considered unsterile.

11. The sterile field must be kept in sight at all times. Do not turn your back on it or leave. If
you do, you cannot be sure that it is still sterile.

12. The floor must be recognized as the most grossly contaminated area. Clean or sterile
items that fall on the floor should be discarded or decontaminated.

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
- An article is either sterile or unsterile; there is no in-between.
- 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 stenle 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.

SURGICAL HAND SCRUB

PURPOSE: To reduce resident and transient skin flora (bacteria) to a minimum.
- Proper hand scrubbing and the wearing of sterile gloves and a sterile gown provide
the patient with the best possible barrier against pathogenic bacteria in the
environment and against bacteria from the surgical team.

TYPES OF ANESTHESIA
ANESTHESIA - is a state of narcosis, analgesia, relaxation & reflex loss. Involves the use of
medications that block pain sensations (analgesia) during surgery and other medical
procedures.

Types of Anesthesia
- General Anesthesia
- Local Anaesthesia
- Regional Anaesthesia
- Moderate Sedation
- Monitored Anesthesia Care

GENERAL ANESTHESIA

GENERAL ANESTHESIA
- effècts your entire body and renders you unconscious.
- Suppresses many of your body's normal automatic functions, such as these that
control breathing, heartbeat, circulation of the blood (such as blood pressure),
movements of the digestive system, and throat reflexes such as swallowing,
coughing, or gagging.
- General anaesthesia is commonly begun (induced) with intravenous (IV)
anesthesias, but inhalation agents also may be used. Once you are unconscious,
anaesthesia may be maintained with an inhalant anaesthetic alone, with a
combination of intravenous anaesthetics, or a combination of the two.

STAGES OF GENERAL ANAESTHESIA

STAGE 1 - BEGINNING ANAESTHESIA
- Warmth, dizziness, & feeling of detachment.
- Ringing, roaring or buzzing in the ears.
- Still conscious but may sense inability to move the extremities easily
- Noises are exaggerated
- Unnecessary noises & motions should be avoided

STAGE 2 - EXCITEMENT
- Struggling, shouting talking, singing, laughing or crying
- Pupils dilate
- PR rapid & RR irregular
- Restraining the patient may be possible.

STAGE 3 - SURGICAL ANESTHESIA

- Reached by continuous administration of anaesthetic vapour or gas.
- Patient is unconscious & lies quietly.
- Pupils are small but contract when exposed to light
- RR regular, PR & volume WNL, skin pink/flushed

STAGE 4 - MEDULLARY DEPRESSION

- Reached when too much anaesthesia has been administered.
- Respirations shallow, pulse weak & thready.
- Pupils widely dilated & no longer contract when exposed to light.
 - CYANOSIS develops & w/o prompt intervention → DEATH (Anaesthetics are
discontinued immediately. Circulatory support initiated.)

REGIONAL ANAESTHESIA

REGIONAL ANAESTHESIA - involves injection of a local anaesthetic (numbing agent)

around major nerves or the spinal cord to block pain from a larger but still limited part of the
body.

TYPES :
1. EPIDURAL
2. SPINAL
3. LOCAL CONDUCTION BLOCKS