NuCM 116 MEDSURG PERIOPERATIVE PERIOPERATIVE THEORY AND

PRACTICE

A. Preoperative period
1. History of ORT.

2. Common terms- Perioperative, Surgery, Surgical conscience, Surgical procedure

 Perioperative- total surgical experiences that encompasses pre,intra,
postoperative surgical care
 Surgery- procedure of branch of medicine that encompasses all the
procedures that the patient will have
o go through under the knife/ scalpel
o Not all surgical interventions need the use of knife or scalpel
o encompasses all the that the patients will have in perioperative.
o Solely the work of surgeon or attending surgeon
 Surgical conscience -The essential elements of perioperative practice are
caring, conscience, discipline, and technique. Optimal patient care requires an
inherent surgical conscience, selflessness, self-discipline, and the application
of principles of asepsis and sterile technique. All are inseparably related.
o Awareness that develops based on importance of aseptic technique
o When you try to prepare sterile instruments you need to have surgical
conscience
o Need to have surgical conscience
o Any form of contamination can cause sever postop infection
o Infection which can be localized, in post op clients can be systemic
o Patients undergo several components, immune status, age of clients,
nutrition
o Sepsis can cause multiple organ failure which can lead to death
 Nursing in the Perioperative Period
o Perioperative Nursing -nursing functions in the total surgical
experience of the patient preoperative, intraoperative, postoperative
A. Preoperative -begins from the time a decision is made for
the surgical intervention to the transfer of the patient to the OR
B. Intraoperative-begins from the time the patient is admitted to
OR until admitted in the PACU/RR.
C. Postoperative- begins from the time the patient is admitted
to the PACU/RR unit to the extended postoperative period.

NOTE: The normal function is disrupted by tumor or trauma: these conditions needs
to have surgical procedure to be fix and return to normal functions
ELEMENTS OF SURGICAL CONSCIENCE
 A sense of moral obligation and responsibility
 Self-regulation and control
 Honesty and integrity in professional practice
 Personal commitment
 Ethical value system
 Admit and remedy errors
 Sincere desire to do the right thin

3. Indications of surgical procedures

> SURGICAL PROCEDURE- invasive incision in the body tissues. Invasion of the
body cavity or part.
INDICATIONS:
 Diagnostics
 Repair
 Removal
 Palliation
 Aesthetic
 Incision and drainage – for abscess in the interstitial spaces
 Harvest – removal of tissue somewhere in the body for grafting
 Procurement- organ donation
 Transplant – placement of donor organ
 Bypass/Shunt- CABG
 Parturation – CS
 Termination – abortion
 Staging
 Destruction
 Exploration
 Diversion – normal function are directed through stomas (e.g. colostomy
chucuhcu)
 Stabilization- for orthopedics; internal fixation for comminuted fracture- the
bone is fragmented and it will be place back and put in original position
 Comminuted fracture – a bone place back by its original position
 Evacuation
 Termination
 Staging
 Extraction
 Exploration- diagnostic’ laparoscopic
 Diversion- creation of colostomy; jejutomy; Previous location are diverted to
stomas

4. Attributes of an OR Nurse-empathy, efficiency, sensitivity, etc.

  Attributes- specific quality of an OR Nurse
o Empathy
o Efficiency
o Sensitivity
o Consenciousness
o Flexible and Adaptable
o Communicative
o Open-Minded
o Even-tempered
o Versatility
o Creative, Analytic, High-Stamina
o Manual Dexterity
o Sense of Humor
o Hygiene
o Strong sense of Truth, and Goodness
o Curiosity

5. Moral, Ethical and Legal aspects of OR Nursing

 Patient's rights- Patient's Bill of Rights, Patient Advocacy
 Accountability- patients, employer, institution, profession or vocation, self
and other team members
 Professionalism

PATIENTS RIGHT
- As a consumer the patient purchases services to fulfill health care needs and
is entitled to certain rights. Access to health care is recognized as a right, not
a privilege, of every human being.
-
PATIENT ADVOCACY
- A patient advocate recognizes the patient’s and the family’s need for
information and assistance in coping with the surgical experience, regardless
of the setting. As an advocate the perioperative nurse can provide information
discovered during patient assessment that identifies specific needs or health
concerns requiring action
-
ACCOUNTABILITY
- means answering to someone for an obligatory action. As both learners and
caregivers, perioperative nurses and surgical technologists are accountable to
the following people/ entities:
• Patients receiving services
• Employer
• Educational institution providing learning experiences
 • Profession or vocation to uphold established standards of
practice
• Self and other team members

A lack of accountability for behavior in the perioperative environment may

result in patient injury or dissatisfaction with care. Health care providers have a legal
and moral obligation to identify and correct situations that threaten a patient’s safety
and well-being.

LIABILITIES
To be liable is to be legally bound and responsible for personal actions that
adversely affect another person. Every patient care provider should always perform
duties in accordance with standards and practice guidelines established by federal
statutes, state practice acts, professional organizations, and regulatory agencies and
those that are common practice throughout the community.

 Negligence is the failure to use the care or skills that any caregiver in the
same or a similar situation would be expected to use. These acts of omission
or commission that cause damage to a patient may give rise to tort action,
which is a civil lawsuit.
 Malpractice is any professional misconduct, unreasonable lack of skill or
judgment, or illegal or immoral conduct.
o Factors contributing to a successful lawsuit on behalf of the plaintiff
have been called the “four D’s of malpractice”:
1. Duty to deliver a standard of care directly proportional to the
degree of specialty training received
2. Deviation from that duty by omission or commission
3. Direct causation of a personal injury or damage because of
deviation of duty
4. Damages to a patient or personal property caused by the
deviation from the standard of care

a. Malpractice -failure to deliver a standard of care

-ommission or commission of duty
- direct causation of injury or damage because of deviation of duty
-injury/damages to a patient of family due to deviation of standard of care

b. Independent contractor - prudence in having a loyalty to an employer

c. Doctrine of the Reasonable man- prudence that you have to be in terms of

being a rational person, advocate person for patient and family

d. Res ipsa loquitor- basis for negligence

  DOCTRINE OF RES IPSA LOQUITUR
- Under this doctrine, the courts allow the patient’s injury to stand as
inference of negligence. The defendant has to prove that he or she did not act
negligently. This doctrine applies to injuries sustained by the patient while in the
perioperative environment, such as a retained foreign object.
1. The type of injury would not ordinarily occur without a negligent act.
2. The injury was caused by the conduct or instrumentality within the
exclusive control of the person or persons being sued.
3. The injured person could not have contributed to negligence or
voluntarily assumed risk.
e. Respondeat superior
 This implies that the master will answer for the acts of a servant. If a patient is
injured as a result of an employee’s negligent act within the scope of that
employment, the employer is responsible to the injured patient. The patient
may name both the facility and the employee in a civil suit, but the employee
may be dropped from the suit if he or she was following facility policy and
procedure and acting within the appropriate scope of practice
f. Doctrine of corporate negligence
 Under the corporate negligence doctrine, the facility may be liable not for the
negligence of employees but for its own negligence in failing to ensure that an
acceptable level of care is provided
g. Extension doctrine
 This doctrine implies that the patient’s explicit consent for a surgical
procedure serves as an implicit consent for any or all procedures deemed
necessary to cope with unpredictable situations that jeopardize the patient’s
health. By medical necessity and sound judgment, the surgeon may perform a
different or an additional surgical procedure when unexpected conditions are
encountered during the course of an authorized surgical procedure (e.g.,
finding an abscess near the target organ or finding a tumor extended into
adjacent structures)

h. Assault and battery

 Assault is an unlawful threat to harm another physically. Battery is the
carrying out of bodily harm, as by touching without authorization or consent
i. Invasion of privacy
 The patient’s right to privacy exists by statutory or common law. The patient’s
chart, medical record, videotapes, x-rays, and photographs are considered
confidential information for use by physicians and other health care personnel
directly concerned with that patient’s care.

j. Abandonment- never leave patient even in a single moment

6. Nursing Process
 》 Assessment- identify actual, potential problems, needs, health status
considerations through appraisal of the physiologic, psychosocial, objective,
subjective, cultural, ethnic data- bearing on the patients desire towards recovery,
beliefs of patients and comorbidities;
》Nursing diagnosis- prioritize actual and potential problems, prioritize in
highest priority actual and potential problems
》Expected outcomes- Measurable and attainable outcomes and goals
collaborated with the patient.

NOTE: Surgical fever- 38.5 or 39 but it doesn't mean they have fever, reaction of
patient to extreme environment, centralized aircon , the body will adapt to certain
temperatures

》Planning-prioritizing set of interventions, establish contingency plans

Implementation-activating interventions
》Evaluation- to determine effectiveness of the plan

STANDARDS OF PERIOPERATIVE NURSING PRACTICE (FROM BOOK)

 Standard I: Assessment
o The perioperative nurse collects patient health data from which the nursing
diagnoses are derived. Data collection is continual and ongoing. It may be
gathered in the preoperative holding area, on the patient care unit, in the
clinic, or by a telephone call to the patient at home. It includes but is not
limited to the following parameters:
 Current medical diagnosis and therapy
 Diagnostic studies and laboratory test results
 Physical status and physiologic responses, including allergies and
sensory or physical deficits
 Psychosocial status, including education level
 Spiritual needs, ethnic and cultural background, and lifestyle
 Previous responses to illness, hospitalization, and surgery
 Patient’s understanding, perceptions, and expectations of the
procedure
o Physiologic Assessment
 The perioperative nurse performs a physical assessment of the
patient. Techniques include inspection/observation, auscultation,
percussion, palpation, and olfaction. The assessment of major body
systems establishes the baseline health status of the patient. It
provides a basis for planning appropriate patient care and provides a
database for postoperative evaluation.
o Psychosocial Assessment
 
The perioperative nurse performs a psychosocial assessment. Illness
makes a person vulnerable, and individuals vary in their ability to cope
with stressful situations. Culture, religion, and socioeconomic factors
have an effect on a patient’s interpretation of illness and response to
the interaction with the perioperative environment.
o Documentation
 Pertinent information should be recorded in the patient’s chart or
EHR for use by the perioperative team. Data collection sets the
baseline for ongoing care in the perioperative environment and into
the remote postoperative care period.

 Standard II: Diagnosis

o Nursing diagnoses are conclusions based on analysis and interpretation of the
human response patterns revealed by the assessment data. These are concise
written statements about a patient’s actual or potential problems, needs, or
health status considerations amenable to nursing intervention

1. Defining characteristics. Human responses to altered body processes and other

contributing factors describe the acuity of an actual or potential health status
deviation.
 Problem. Any health care condition that requires diagnostic, therapeutic, or
educational action. Problems can be active (requiring immediate action) or
inactive (having been solved).
 Need. A lack of something essential for the maintenance of health that may
be met through the plan of care
 Health status considerations. A personal habit, lifestyle, or influencing agent
that if uncontrolled can lead to a decline in physiologic or psychologic well-
being (e.g., occupational hazards, exposure to chemical agent or smoke,
substance abuse).

2. Signs (objective) and symptoms (subjective). Data obtained during the

assessment identify the defining characteristics of the patient’s actual or potential health
problems.
3. Etiology/related factors. The causes of problems may be related to physiologic,
psychosocial, spiritual, environmental, or other factors contributing to the patient’s health
status.

 Standard III: Outcome Identification

o The perioperative nurse identifies expected outcomes unique to the patient.
Each outcome can be affected by nursing care (also referred to as “nurse
sensitive”1) and is specific to the individual, the family, and the community.
The nurse measures the patient’s responses and uses a fivepoint Likert scale
 to tally the score. A numeric baseline range is documented and the numeric
target outcome is identified. Expected perioperative outcomes are the
desired and obtainable patient objectives after a surgical intervention.

 Standard IV: Planning

o The plan should include a provision for all phases of patient care in the
perioperative environment. Strategic concepts to consider in planning
perioperative patient care include but are not limited to the following:
 Participation of the patient and/or significant others in formulation of the plan
 Medical diagnosis and effect of surgical intervention on the patient’s physiology
 Psychosocial and spiritual needs of the patient and his or her significant others
 Environmental safety, comfort, and well-being
 Provision of supplies, equipment, and technical expertise
 Current best nursing practice
 Standard V: Implementation
o The plan of care is implemented throughout the perioperative care period by
the entire team. Scientific principles provide the basis for patient care
interventions that are consistent with the plan for continuity of patient care
in the perioperative environment. They are performed with safety, skill,
efficiency, and effectiveness. The patient’s welfare and individual needs are
paramount in every facet of activity and must not be compromised.
Seemingly routine details are significant.
o Focus primarily on direct and indirect interventions that perioperative and
perianesthesia nurses and surgical technologists perform to ensure
achievement of expected patient outcomes. Implementation of safe and
efficient patient care requires the application of technical and professional
knowledge, sound clinical judgment, and a surgical conscience on the part of
all team members. Nurses have a responsibility to monitor constantly the
physical and psychologic responses of patients to care. They control
environmental factors that affect outcomes of surgical intervention.
o Documentation
 This written documentation becomes part of the patient’s permanent
record. The circulating nurse accountable for the patient’s care is
responsible for the documentation either in writing or through the
EHR. The person completing the documentation should sign with a
complete name and title. Interventions contributing to patient
comfort and safety are identified.

 Standard VI: Evaluation

o The perioperative nurse evaluates the patient’s progress toward the
attainment of outcomes with an actual outcome statement as described in
the PNDS. Evaluation is a continual process of reassessing the patient and his
 or her responses to implementation of the plan of care. Perioperative
caregivers accommodate a variety of intense situations within a short time.
The perioperative team is always on the alert for, and prepared to respond
to, the unexpected. The flexibility of the team is manifest in the quick
modifications to the plan of care during emergency situations.

7. Gordons Functional Health Patterns - identify alteration and inabilites or failures of

patient to function, identify and formulate nursing diagnosis; coupled with nursing
process

8. Informed consent/Operative permit - a legal document/form signed by the patient

and witnessed, granting permission to have a surgical procedure performed by the
patient's health care provider.

 Informed Consent (FROM BOOK)

 State statutes differ in their interpretation
of the doctrine of informed consent, but all
recognize the physician’s duty to inform
the patient of the risks, benefits, and
alternatives of a procedure and to obtain
consent before treatment. Failure to do so
may be considered a breach of duty.
Informed consent is a process—not a
paper document that is signed.
Explanations of the procedure, risks,
benefits, and alternative therapy are made verbally to the patient’s level of
understanding. Informed consent is a protective act for the patient and the treating
physician and should be documented appropriately. The circulating nurse, as patient
advocate, should ensure that this process has taken place before permitting the
patient to be transferred to the OR.
 VALIDATION OF CONSENT
o The patient should personally sign the consent unless he or she is a minor, is
unconscious or mentally incompetent, or is in a life-threatening situation. The
next of kin, legal guardian, or other authorized person should sign for these
patients. The physician gives explanations to the parent of a minor or to the
legal guardian of an incompetent adult.
o A consent document should contain the patient’s name in full, the surgeon’s
name, the specific procedure to be performed, the signatures of the patient
and authorized witness(es), and the date of signatures. A signed consent is
regarded as legally valid for as long as the patient still consents to the same
procedure. Institutional policy may vary.
  A minor, a parent or legal guardian should sign.
 An emancipated minor, married, or independently earning a living, he
or she may sign.
 A minor who is the parent of an infant or child who is having a
procedure, he or she may sign for his or her own child.
 Illiterate, he or she may sign with an X, after which the witness writes,
“Patient’s mark.” Because illiteracy implies the inability to read and
write, the patient should indicate an understanding of a verbal
explanation.
 Unconscious, a responsible relative or guardian should sign.
 Mentally incompetent, the legal guardian—who may be either an
individual or an agency—should sign. A court order may be necessary
to legalize the procedure in the absence of the legal guardian.
 An adult or an emancipated minor who is mentally incapacitated by
alcohol or other chemical substance, the spouse or responsible
relative of legal age may sign when the urgency of the procedure does
not allow time for the patient to regain mental competence

 Purposes:
1. Ensure that the client understands the nature of treatment including
potential complications.
2. Indicate that the patient's decision was made without pressure.
3. Protect the client against unauthorized procedure.
4. Protect the surgeon and the hospital against legal suits from clients who
claim that unauthorized procedure was performed.

NOTE: Day before visit as well as the anesthesiologist for further

assessment, history taking, pre op instructions and orders on what meds to
be administered, identify other problems especially with comorbidities; talk
with staff with ongoing meds by patient, prepare preop meds the
anesthesiologist prescribed by anesthesiologist complications will rise
anytime during pre op or post op

 A Consent is NULL and VOID if:

o Signed/"thumbmarked" by clients with mental incompetence
subconscious/coma/illiterate/minor (except in some instances)
1. Written consent is best and is legally acceptable.
2. Obtained with client's complete understanding of what is to
occur. And without coercion.
3. A witness is desirable- either a nurse or a responsible
member of family
 4. Responsible member of the family would act as witness
(actual and or by phone in emergency cases.
5. If client is illiterate, may put an X mark but needs to have 2
witness to make it acceptable
6. Have a separate consent for each procedure.
o Contents of an Informed Consent:
1. Name of the attending physician
2. The procedure to be performed
3. Benefits, Advantages, Risks, Disadvantages, alternative
management, complications, anesthesia used and mode of
administration, possible complications.

CONSENT in cases of emergency (life threatening conditions): - telephone,

telefax, email

 Procedures requiring a permit:

1. Surgical procedures - use scalpels, scissors, hemostats,
electrocoagulation equipment
2. Procedures requiring invasion to a body cavity- endoscopies,
thoracentesis, paracentesis
3. Use of contrast medium in certain diagnostic/imaging procedures -
CTS, MRI, IVP, UGI or LGI series
4. Introduction of anesthesia- general, local, regional block, epidural

NOTE: 1 informed consent for every surgical procedure

Recommended Practices:
1. Strict adherence to policies and procedures- scope of practice by whom,
protection of employees and patients.
2. Client's ID- ask to spell name, wristband
3. Identification of surgical site-place mark that is none confusing (x mark)
4. Protection of personal property
5. Observation of the patient
6. Positioning the patient
7. Aseptic and Sterile technique
8. Accountability of accurate
9. Use of equipment
10. Prevention of Skin injury
11. Administration of Drugs
NOTE: Tramadol Hydrochloride, pre anesthetic antibitiocs given by
infusion drip, anti anxiety meds diazepam to relax patient and have good
night sleep
12. Monitoring the patient following adm. of anesthetic agents
 NOTE: Not all patients react immediately, some patients develop reaction
about 1 week after meds administered
13. Preparation of specimen

NOTE: patient have excision, your responsibility is that sample of specimen

will be sent to labs for laboratory processes, make sure not contaminated,
place in a uncontaminated container, label properly

14. Patient teaching

NOTE: Day of admission continues until post op period

 ETHICAL DILEMMA - When choice between 2 or more alternatives creates

a conflict between the individual's value system and moral obligation to the
patient, family or significant others, to the physician, employer or co worker.

- Conflicts can be between rights, duties, responsibilities

》Reproductive sterilization
》Abortion
》Human experimentation
》Fetal Tissue and Stem Cell
》HIV and other infection
》Quality of Life
》Euthanasia
》Right to die
》Organ Donation and Transplant
》Death and Dying

Lesson No. 2 THE SURGICAL TEAM .

 Surgeon
 Certified RN Anes.
 Scrub nurse
 Circulating Nurse
 Surgical Technician
 Residents/students
 M.D Assist
 Medical device company representative CDC Guideline for the Prevention of
Surgical Site Infection (SSI)

1. Surgical MASK-fully covers the mouth and nose when entering the OR, if an
operation is about to begin or on-going, or if sterile instruments are exposed. Wear
throughout the operation
2. CAP or hood SHOULD fully cover hair on the head and face when entering the
OR.
3. Wear Shoe covers inside OR suite.
4. Wear sterile gloves after donning a sterile gown.
5. Use surgical gowns and drapes that are effective barriers when wet (1.e.,
materials that resist liquid penetration).
6. Change scrub suits that are visibly soiled, contaminated, and/or penetrated by
blood or other potentially infectious materials. (Demo/Ret. Dem of HW, Gowning,
Gloving, Sequence in removing used gown and gloves).

EXTRA NOTES FOR QUIZ!!

Surgical Classifications

The decision to perform surgery may be based on facilitating a diagnosis (a diagnostic

procedure such as biopsy, exploratory laparotomy, or laparoscopy), a cure (e.g., excision of

a tumor or an inflamed appendix), or repair (e.g., multiple wound repair). It may be

reconstructive or cosmetic (such as mammoplasty or a facelift) or palliative (to relieve pain or

correct a problem—such as debulking a tumor to achieve comfort, or removal of a

dysfunctional gallbladder). In addition, surgery might be rehabilitative (e.g., total joint

replacement surgery to correct crippling pain or progression of degenerative osteoarthritis.)

Surgery can also be classified based upon the degree of urgency involved: emergent,

urgent, required, elective, and optional.

 Prophylactic Surgery

o Prophylactic or risk reduction surgery involves removing non-vital tissues or

organs that are at increased risk of developing cancer. The following factors

are considered when discussing possible prophylactic surgery:

o Family history and genetic predispositionPresence or absence of signs and

symptomsPotential risks and benefitsAbility to detect cancer at an early stage

Alternative options for managing increased riskThe patient’s acceptance of

the postoperative outcome

o Colectomy, mastectomy, and oophorectomy are examples of prophylactic

surgeries. Identification of genetic markers indicative of inherited cancer

syndromes or a predisposition to develop some types of cancer plays a role in

decisions concerning prophylactic surgeries. However, what is adequate

justification for prophylactic surgery remains controversial. For example,

several factors are considered when deciding to proceed with a prophylactic

mastectomy, including a strong family history of breast cancer; positive

 BRCA1 or BRCA2 findings; an abnormal physical finding on breast

examination, such as progressive nodularity and cystic disease; a proven

history of breast cancer in the opposite breast; abnormal mammography

findings; abnormal biopsy results; and individual factors that may influence

the patient’s decision-making process (Mahon, 2014). Prophylactic surgery is

discussed with patients and families along with other approaches for

managing increased risk of cancer development. Preoperative education and

counseling, as well as long-term follow-up, are provided.

 Palliative Surgery

o When surgical cure is not possible, the goals of surgical interventions are to

relieve symptoms, make the patient as comfortable as possible, and promote

quality of life as defined by the patient and family. Palliative surgery is

performed in an attempt to relieve symptoms, such as ulceration, obstruction,

hemorrhage, pain, and malignant effusions (see Table 15-6). Honest and

informative communication with the patient and family about the goal of

surgery is essential to avoid false hope and disappointment.

 Reconstructive Surgery

o Reconstructive surgery may follow curative or extensive surgery in an attempt

to improve function or obtain a more desirable cosmetic effect. It may be

performed in one operation or in stages. The surgeon who will perform the

surgery discusses possible reconstructive surgical options with the patient

before the primary surgery is performed. Reconstructive surgery may be

indicated for breast, head and neck, and skin cancers.

o The nurse assesses the patient’s needs and the impact that altered

functioning and body image may have on quality of life. Nurses provide

patients and families with opportunities to discuss these issues. The individual

needs of the patient undergoing reconstructive surgery and their families must

be accurately recognized and addressed.

TABLE 15-6 Types of Palliative Surgery and Interventions

1026