MEDICAL SURGICAL NURSING PAIN AND SURGERY MODULE 1.

MODULE 1.1 SURGERY B. IMPROVEMENT IN PERIOPERATIVE PATIENT CARE

TECHNOLOGY IS ATTRIBUTED TO THE FOLLOWING:
SURGERY AS A SCIENCE → Surgical specialization of surgeons and team;
→ branch of medicine concerned with disease or conditions requiring or → Sophisticated diagnostic and intra-operative imaging techniques;
amenable to operative or manual procedures.
→ Minimally invasive equipment and technology;
→ It is a total care of illness with an extra modality of treatment, the
→ Ongoing research and technologic advancements
surgical procedure.

SURGERY AS AN ART SURGERY RELATED TERMINOLOGIES

comprises perioperative patient care encompassing such activities as
preoperative preparation, intra operative judgment & management, and A. Operating Room / Operating Theatre – room in a health care
facility in which patients are prepared for surgery, undergo surgical
post-operative care of patients.
procedures, and recover from anesthetic procedures required for
SURGERY AS A DISCIPLINE surgery.
combines physiologic management with an interventional aspect of
treatment. B. Perioperative - is a term used to describe the entire span of surgery,
including before and after the actual operation.
EVOLUTION OF SURGERY
C. Perioperative nursing – includes activities performed by the
A. HISTORICAL BACKGROUND registered nurse during the pre-operative, intra operative, and post-
operative phases of patient’s care.
→ Code of Hammurabi (1955-1913BC) – if a patient died after a
surgical procedure, retribution would be reflected on the surgeon in
the form of amputation of his right hand. → Total surgical experience that encompasses pre-operative, intra-
operative and post operative phases of patient care.
→ Persians rule on surgery – successful procedures on 3 infidels D. OR nurse - duly licensed registered nurse legally responsible for the
before being pronounced as competent to practice surgery. nature and quality of the nursing care patients.

→ Galen of Pergamum (130-200AD) - Claudius Galen is a Greek E. Surgical Conscience - awareness which develops from a knowledge
physician performing extensive dissections in animals. Although based on the importance of strict adherence to principles of aseptic
human dissections had fallen into disrepute, he also performed and and sterile techniques.
stressed to his students the importance of human dissections. He
recommended that students practice dissection as often as possible. F. Asepsis – freedom from infection or absence of microorganism.
He studied the muscles, spinal cord, heart, urinary system, and proved
that the arteries are full of blood. He believed that blood originated in G. Aseptic Technique – methods by which contamination of
the liver, and sloshed back and forth through the body, passing microorganisms is prevented.
through the heart, where it was mixed with air, by pores in the
septum. H. Disinfection - process of destroying all pathogenic microorganisms
except spore bearing ones.
→ Lord Berkeley George Moynihan (1865 – 1936) - was born in
Malta, where his father was an ensign in the army. He enrolled at the I. Sterilization - process of killing all micro-organisms including
Leeds School of Medicine in 1883, graduating in 1887 with a degree spores.
from London and the conjoint diploma. He became House Surgeon to
McGill and obtained 5 years practical experience before being elected J. Surgical Intervention - therapeutic process rendered to restore or
an Assistant Surgeon and Lecturer in Surgery in 1896. maintain health (i.e. the ability o function).

K. Surgical Procedure - invasive incision into the body tissues or a

→ By 1910 he was nationally known and became the first Professor of
minimally invasive entrance into a body cavity for either therapeutic
Clinical Surgery within the University of Leeds. His
or diagnostic purpose during which protective reflexes or self-care
book ‘Abdominal Operations’ earned him an international
abilities are potentially compromised.
reputation. In 1925 he became Professor of Surgery. Between 1926
and 1931 he was President of the
L. Antiseptic - substance which combat sepsis and cause bacteriostasis.

→ Royal College of Surgeons of England. M. Anesthesia - insensibility to pain and trauma with or without loss of
consciousness.
→ He believed that “Surgery has been made safe for the patient; we
must now make the patient safe for surgery.” N. Informed consent - is a legal document that provides evidence of
patient’s agreement to allow a procedure to be performed on him/her;
a signed consent is legally regarded as VALID for a period of about
6 months or for as long as the patient consents to the same procedure.
Institutional policy may vary.
MEDICAL SURGICAL NURSING PAIN AND SURGERY MODULE 1.1
→ Staging – checking of cancer progression
Abdomin (o) Abdomen
→ Parturition - caesarean section
Aden (o) Gland
Angi (o) Vessel → Extraction – removal of a tooth
Arthr (o) Joint → Exploration – invasive examination
Broncho Bronchus → Diversion – creation of a stoma
Card, Cardi (o) Heart
Cephal (o) Head D. PATHOLOGIC CONDITIONS REQUIRING SURGICAL
Chole, Chol (o) Bile INTERVENTION
Chondr (o) Cartilage a. Obstruction – impairment on the flow of vital fluids
Colo Colon b. Perforation – rupture of an organ
Cost (o) Rib c. Erosion – wearing off of a surface or membrane
Crani (o) Skull d. Tumor – abnormal growth
Cele Tumor, Hernia
Centhesis Puncture E. REASONS FOR SURGICAL INTERVENTION
Ectomy Surgical Excision
→ To preserve life
Itis Inflammation
Litho Stone, Calculus → To maintain dynamic body equilibrium
Ostomy Creation of a new opening → To undergo diagnostic procedures
Rhapy Repair → To prevent infection and to promote healing
Oscopy Examination using a lighted → To obtain comfort
instrument → To ensure the ability to earn a living
Plasty Plastic repair
→ To alter cosmetic appearance
Pexy To fix or suture in place
→ To restore or reconstruct a part of the body that is congenitally
malformed or damaged by trauma or disease.

F. CONDITIONS TREATED BY SURGERY

SURGERY
→ Congenital – inborn deformity
A. DEFINITION OF SURGERY → Acquired – conditions resulting from trauma or injury.
branch of medicine concerned with disease or conditions requiring or
amenable to operative or manual procedures. The discipline of surgery is G. THREE (3) CATEGORIES OF SURGICAL PROCEDURE
both an art and a science. → Invasive surgery
→ Minimally Invasive surgery
B. OBJECTIVES OF SURGERY
a. Correction of deformity and defects; → Non-Invasive surgery
b. Repair of injuries;
c. Alter form or structure; H. CLASSIFICATIONS OF SURGICAL PROCEDURE
d. Diagnosis & Cure of disease process;
e. Relief of suffering; A. ACCORDING TO PURPOSE
f. Prolongation of life. a.1. Diagnostic surgery – to establish the presence of a disease condition.
It enables the surgeon to verify a suspected diagnosis.
C. COMMON INDICATIONS OF SURGERY Ex. Breast biopsy
→ Incision – open tissue or structure by sharp dissection
a.2. Exploratory surgery – to determine the extent of the disease
→ Excision – remove tissue or structure by sharp dissection
condition and at times to make or confirm a diagnosis.
→ Diagnostics – biopsy tissue sample Ex. Exploratory Laparotomy
→ Repair – closing of a hernia
→ Removal – FBE a.3. Curative / Reparative / Restorative surgery
→ Reconstruction – creation of new breast → Ablative – involves removal of deceased organ
→ Termination – abortion of a pregnancy Ex. AP ; Cholecystectomy

→ Palliation – relief of an obstruction → Constructive – involves repair of congenitally defective organ

→ Aesthetics – facelift Ex. Orchidopexy ; THRA
→ Harvest – skin grafting
→ Reconstructive – involves repair of a damaged organ
→ Procurement – donor organ Ex. Plastic surgery after burns
→ Transplant – placement of a donor organ
a.4. Palliative surgery – to relieve distressing signs and symptoms, not
→ Bypass / shunt – vascular rerouting
necessarily to cure the disease.
→ Drainage / evacuation – incision of abscess
→ Stabilization – repair of a fracture Ex. Resection of a tumor to relieve pressure and pain
MEDICAL SURGICAL NURSING PAIN AND SURGERY MODULE 1.1

a.5. Cosmetic surgery – correction of defects, improvement of appearance Safeguard the patient in the OR against hazards. Protect the nurse,
or change to a new physical feature. technologist, surgeons, anesthesiologist and the hospital. Prevention
Ex. Rhinoplasty ; Cleft lip repair focuses on Quality Assurance.

B. ACCORDING TO URGENCY Q quality improvement as an ongoing process.

b.1. Emergency – immediate ; condition is life threatening requiring U understanding regulations, standards, policies and procedures
A accountability for one’s own actions.
surgery at once.
L legal rights of the patients
Ex. GSW
I individualized patient care
T technical competency
b.2. Urgent or Imperative – client requires prompt attention within 24 to
Y your surgical & ethical conscience
30 hours.
Ex. Acute GB infection
NOTE: To be liable is to be legally bounded, responsible and answerable.
b.3. Planned or Required – planned for a few weeks or months after PERIOPERATIVE NURSING
decision and the client requires it at some point.
Ex. Cataract removal A. DEFINITION OF PERIOPERATIVE NURSING
Perioperative nursing practice includes activities performed by the
b.4. Elective – client will not be harmed if surgery is not performed but professional registered nurse during the preoperative (before),
will benefit if it is performed. intraoperative (during) and postoperative (after) phases of the patient’s
Ex. Revisions of scar surgical experience.

b.5. Optional – personal preference and usually aesthetic purposes. B. KEY ELEMENTS OF PERIOPERATIVE NURSING PRACTICE
Ex. Liposuction → Caring
→ Conscience
C. ACCORDING TO LOCATION → Discipline
c.1. External – outside the body → Technique
Ex. Skin grafting
C. CONCEPT OF SURGICAL CONSCIENCE
c.2. Internal – inside the body (Surgical Golden Rule)
Ex. Hysterectomy “ Do Unto The Patient As You Would Have Others Do Unto You.”

D. ACCORDING TO EXTENT OR RISK INVOLVED D. PHILOSOPHY OF OPERATING ROOM NURSING

(MAGNITUDE) To give service that aims to provide comprehensive support physically,
Major – life threatening morally, psychologically, spiritually and socially to a patient undergoing
Minor – non life threatening surgery.

I. SURGICAL RISKS PATIENTS E. GOALS OF OPERATING ROOM NURSING

a. Obesity – increase incidence of morbidity and mortality due to low → To provide a safe, supportive and comprehensive care to patient;
recovery after surgery.
b. Fluid – electrolyte Imbalance & Nutritional problems – can cause → To assist the surgeon by functioning effectively as a member of the
delay and poor wound healing surgical team;
c. Age – too young or too old → To create and maintain an aseptic / sterile environment all the times.
d. Person with disability
e. Patients with current disease or illness F. OBJECTIVES OF OPERATING ROOM NURSING
f. Patients with concurrent or prior pharmacotherapy → To help the patient return as rapidly as possible to the best physical
g. Nature and location of condition
and mental health attainable.
h. Magnitude and urgency of the surgical procedure
i. Mental attitude of the patient towards surgery → In case the patient did not return to his health, pain and discomfort
j. Caliber of the professional staff and health care facilities should be eased and she/he should be allowed to die in peace and with
dignity.
J. POTENTIAL EFFECTS OF SURGERY TO THE PATIENT
a. Stress response is elicited; PERIOPERATIVE NURSE
b. Defense against infection is lowered;
c. Vascular system is disrupted;
A. DEFINITION OF PERIOPERATIVE NURSE
d. Organ functions are disturbed;
a nurse who provides patient care, manages, teaches, and studies the care
e. Body image maybe altered;
of patients undergoing invasive or non-invasive procedures. He/she
f. Lifestyle is changed
possesses a depth and breadth of knowledge that allows for the
g. Legal Liability, Accountability & Ethical Issues
coordination of care of the surgical patient.
MEDICAL SURGICAL NURSING PAIN AND SURGERY MODULE 1.1

B. RESPONSIBILITIES OF A PERIOPERATIVE NURSE

→ Prioritizes interventions based on a comprehensive body of scientific
knowledge and variations in patient’s responses;
→ Uses critical thinking skills in applying the nursing process, acting as
a patient advocate, and exercising judgment in a professionally
accountable manner;
→ Provides specialized nursing care to patients before, during and after
their surgical & invasive procedure;
→ Works closely with all members of the surgical team;
→ Helps plan, implement and evaluate treatment of the patient;
→ Designs, coordinates, and delivers care to meet the identified
physiological, psychological, sociocultural and
→ spiritual needs of the patients.

C. EXPECTED ATTRIBUTES OF A PERIOPERATIVE NURSE

→ Considerate
→ Informative & sincere
→ Versatile
→ Analytical
→ Creative & resourceful
→ Humanistic
→ Ethical
→ With sense of humor
→ Objective
→ Enduring
→ Impartial, non-judgmental, open-minded
→ Manual and intellectual dexterity
→ Intellectually eager and curious to learn

D. PERSONAL ATTRIBUTES OF A PERIOPERATIVE NURSE

→ Empathic
→ Conscientious
→ Efficient and well organized
→ Flexible and adaptable
→ Sensitive & Perceptive
→ Understanding, reassuring, supportive
→ Skilled listener, keen observer, and abled communicator
MEDICAL SURGICAL NURSING PAIN AND SURGERY -- MODULE 1.2

PERIOPERATIVE CARE
2. Assistants to Surgeon (First assistant / Second assistant ) - qualified
THREE (3) PHASES OF PERIOPERATIVE CARE surgeon or a resident in an accredited surgical education program.
- The resident is maybe an associate with whom surgical practice is
A. Preoperative phase shared and to whom part of the patient’s care maybe delegated.
• Begins with the decision to perform surgery and continues until the - In hospital with accredited postgrad surgical residency training
client reaches the operating area. programs, the surgical resident in the third or later year usually acts
as 1st asst. The resident is given more responsibilities under
• In this phase, the perioperative nurse performs the assessment and supervision at the operating table to acquire skill and judgment.
planning components of the nursing process.

B. Intraoperative phase NOTE: NURSE is free to refuse to perform as first assist out of concern
• Begins with the placement of patient on the operating table, including for the well-being of the patient and for his/her professional
the entire surgical procedure and extends until transfer of the client to accountability.
the recovery room. The implementation component of the nursing
process is performed here.
2.a Major Responsibilities of Assistants to Surgeon
C. Postoperative phase ✓ Must perform duties under the direct supervision of a certified
• Begins with admission to the RR (recovery room) / PACU (Post surgeon;
Anesthesia Care Unit) and continues until the client receives a follow ✓ Help maintain visibility of the surgical site, control bleeding, close
– up evaluation at home or is discharged to a rehabilitation unit. wounds, apply dressings, handle tissues and uses instruments.
Evaluation component of the nursing process is completed in this
phase.
3. Scrub Nurse – Instrument & Suture Nurse
PERIOPERATIVE PATIENT CARE TEAM (OPERATING - nursing staff member of the sterile team;
ROOM TEAM) - RN, LPN (licensed practical nurse) or LVN (licensed vocational
nurse), ST (surgical technologist)
Each member of the operating room team is an integral entity in unison and
harmony with his/her colleagues for the successful accomplishment of the 3.a Major Responsibilities of a Scrub Nurse
expected outcomes. ✓ Responsible for maintaining the integrity, safety, and efficiency of the
sterile field throughout the procedure.
A. STERILE TEAM ✓ Responsible for preparing and arranging the sterile instruments and
1. Surgeon – a physician who realistically appreciate his or her own supplies for the surgical procedure;
cognitive skills & personal characteristics & can intervene ✓ Anticipates, plan for and respond to the needs of the surgeon by
constantly watching the sterile field;
Must have the knowledge, skill and judgment required to successfully ✓ Should have knowledge, skills and experience with aseptic and sterile
performed the intended surgical procedure. techniques;
✓ Should have manual dexterity, physical stamina, stable temperament,
1.A. Who can be the head surgeon?
able to work under pressure, with keen sense of responsibility and
✓ Licensed MD concern for accuracy in performing all duties.
✓ DO (osteopath)
✓ DDS or Oral surgeon (Doctor of Dental Surgery) B. NON-STERILE TEAM
✓ DMD (Doctor of Dental Medicine) 1. Anesthesiologist – is an MD or DO, certified by the Phil. Board of
✓ DPM (Doctor of Podiatric Medicine) Anesthesiology, who specializes in administering anesthetics to produce
various states of anesthesia.
1.B. Attributes of a Surgeon
✓ compassionate interpersonal behavior; 1.a Major Responsibilities of Anesthesiologist
✓ accountability; ✓ Choice and application of appropriate anesthetic agents & suitable
✓ humanistic concern; techniques of administration & monitoring of physiologic functions;
✓ appropriate clinical skills in data gathering; ✓ Maintenance of fluid & electrolyte balance & blood replacement
during the surgical procedure;
✓ good decision making & problem solving skills;
✓ Minimize the hazards of shock, electrocution and fire;
✓ critical thinking ability
✓ Responsible for overseeing the positioning & movement of patients;
1.C. Major Responsibilities of a Surgeon ✓ Able to use and interpret correctly a wide variety of monitoring
devices;
✓ Preoperative diagnosis and care;
✓ Oversee the PACU to provide resuscitative care until each patient has
✓ Selection & performance of the surgical procedure;
regained control of vital functions;
✓ Post operative management.
✓ Participate in the hospital’s program of CPR as teachers & team
members. As well as consultants and managers for problems of acute
and chronic respiratory insufficiency requiring inhalation therapy &
MEDICAL SURGICAL NURSING PAIN AND SURGERY -- MODULE 1.2
other fluid, electrolyte and metabolic disturbances requiring IV - be easily cleaned
therapy;
✓ They are integral staff member of Pain Therapy clinics. B. 2 PRINCIPLES IN DESIGNING AN OPERATING ROOM
✓ Exclusion of contamination from outside the suite with sensible
2. Circulating Nurse - a RN or ST (surgical technologist) who functions traffic pattern within the suite.
under the supervision of an RN. ✓ Separation of clean areas from contaminated areas within the suite

2.A MAJOR RESPONSIBILITIES OF A CIRCULATING NURSE C. TYPES OF OR DESIGNS

✓ Nursing judgment & decision-making skill are requisites to assessing, ✓ Central Corridor or Hotel plan;
planning, implementing ✓ Central Core or Clean core plan;
and evaluating the plan of care before, during & after surgical
operation. This is the professional perioperative role; ✓ Peripheral corridor;
✓ Creation & maintenance of a safe & comfortable environment for the ✓ Combination central core & peripheral corridor or Racetrack plan;
patient through implementing the principles of asepsis, demonstrate a ✓ Three corridor layout;
strong sense of surgical conscience; ✓ Grouping or cluster plan
✓ Constant flexibility in identifying potential environmental danger,
stressful situation & meet the unexpected, act in an efficient, rational - The OR suite should be large enough to allow for correct technique
manner at all times; yet small enough to minimize the movement of patients, personnel
✓ Maintenance of the communication link between events & team and supplies. Provision must be made for traffic control. The type of
members at the sterile field & persons not in the OR but concerned design will predetermine traffic patterns. Signage should be posted
with the outcome of the operation; properly.
✓ Provision of assistance to any member of the OR team in any manner
in which the circulator is qualified; D. THREE (3) AREAS / DIVISION OF OPERATING ROOM SUITE
✓ Direction of the activities of all learners. The CN must have the ✓ Unrestricted or Unsterile Area
supervisory capability & teaching skills needed to ensure ✓ * Vestibular or Exchange Area (Transition Zone)
maintenance of a safe & therapeutic environment for the patient.
✓ Semi restricted or Semi sterile Area
3. Nurse Anesthetist - refers to a qualified RN, anesthesiologist assistant ✓ Restricted or Sterile Area
(AA), dentist, or physician who administers anesthetics. ✓ * Sub sterile Room

PERIOPERATIVE ENVIRONMENT 1. Unrestricted / Unsterile Area - this area is isolated by doors from the
main hospital corridor or elevators and from other areas of the OR suite.
PHYSICAL FACILITIES - serves as an OUTSIDE-to-INSIDE access area, i.e.
vestibular/exchange area.
1. Location - located accessible to the critical care surgical patient areas & - Street clothes are permitted.
the supporting service department, CSR, Radiology, pathology, etc.
2. Semi-restricted / Semi sterile Area - personnel should be wearing OR
- many of OR suites are UNDER -GROUND or have solid walls
without windows scrub suit with cap. This area includes peripheral support areas and
access corridors to the OR like PACU, SICU, offices for anesthesia
2. Ventilation - must ensure a controlled supply of filtered air. Air changes department & administrative OR nursing personnel, etc.
and circulation provide fresh air & prevent accumulation of anesthetic.
- AIR CONDITIONING is ideal and valuable; it controls humidity. 3. Restricted / Sterile Area - personnel should be wearing complete OR
- positive pressure system scrub suit including mask.
- filter air at 20 changes / hour - this area performs sterile procedures.
- temperature from -18oC - 24oC - includes OR suite room, scrub sink areas, sub sterile rooms where
- humidity 50-55% unwrapped supplies are sterilized.
- operating rooms is more desirable if all have the same size, so they
3. Door - ideally, sliding doors should be used. They eliminate the air can be used interchangeably to accommodate elective & emergency
currents caused by swinging doors. cases. It must accommodate equipment like laser, microscope, video
equipment, c-arm, portable light, etc.
4. Floor - must be suitably hard, durable for heavy equipment especially - The adequate size of an operating room is at least 20x20x10 feet (400
during transport from one room to another & easy to clean. sq ft or 37 m2) of floor space or maximum of 20x30x10 feet (600 sq
ft or 60 m2).
5. Lighting - General illumination is furnished by ceiling lights in white - other rooms are designated for special procedures like endoscopy,
fluorescence bulbs which are evenly distributed throughout the room. TURP, etc.
- Should be shadowless. 4. Sub sterile Room –
- be freely adjustable to any position or angle by vertical or horizontal ✓ work area or packing area
range of motion.
✓ steam sterilizing room
- produce minimum heat to prevent injuring exposed tissues.
✓ washer – sterilizer area
MEDICAL SURGICAL NURSING PAIN AND SURGERY -- MODULE 1.2
✓ storage room for supplies ✓ Communication system / Intercom
✓ record room ✓ Defibrillator
✓ Negatoscope
5. Vestibular / Exchange Areas (Transition Zone) – inside the entrance ✓ Wall Clock with second hand
to the OR suite, separates the OR corridors from the rest of the facility. ✓ White board for recording of sponge, instrument and sharps
✓ Pre-operative check-in unit - this is an unrestricted area of the OR counting
for patient to change from street clothes to gown; ✓ Blood warmer machine attached to IV pole
- must ensure privacy, create a feeling of warmth & security, with ✓ Other monitoring machines
lockers for safeguarding patient’s clothes & with lavatory ✓ Cabinets / carts – for storing supplies and drugs
facilities.
✓ Dressing rooms and Lounges - Access is from an unrestricted area
to change from street clothes to OR attire before entering the semi-
restricted areas or vice versa. Clothes hanging areas must be provided
for both males and females. Shoe rack is advisable for the OR scrub
suit.
✓ PACU (formerly RR) - maybe outside the OR or adjacent to the OR
suite.
- part of unrestricted area with access from both semi restricted
areas.
✓ Post-op holding area - a designated room for patients to wait in the
OR suite that shields them from distressing sights and sounds;
- provides privacy like individual cubicles with curtain.
- simple procedures can be perform here like catheterization, gastric
tube, iv insertion, etc.

Peripheral Support Areas

❑ Central Administrative control – this area is maybe within the
unrestricted or semi restricted areas. Offices for administrative
personnel are best located where they have access to both areas.
❑ Sterile supply room – for storing sterile linens, sponges, gowns and
instrument packs.
❑ Work and storage areas – clean and sterile supplies must be
separated from soiled items and trash.
❑ General work room – must be centrally located to the OR suite for
wrapping / packaging of supplies for sterilization.
❑ Utility room – contains a washer-sterilizer, sinks, cabinet, & all
necessary aids for cleaning.
❑ Housekeeping Storage area – stores all cleaning supplies &
equipment. Equipment used within the restricted area is kept
separated from that used to clean the other areas.
❑ Anesthesia work & storage areas – serves as storage of anesthesia
equipment & supplies, also provides space for drugs and anesthetic
agents.

e. Furniture and other Equipment Inside the Operating Room

✓ OR Table – divided into head, body and leg sections. Attachment
includes knee strap, arm strap, arm board, anesthesia screen, metal
footboard, etc.
✓ Instrument table or Back table
✓ Mayo table – placed above and across the patient and contains
instruments that are in constant use during operation.
✓ Small table for patient’s preparation equipment (skin prep table)
✓ Ring stand for basin (s).
✓ Anesthesia table and machine
✓ Sitting stools and foot stools/standing platforms
✓ IV stands and hangers for IV solutions
✓ Suction machine, bottles and tubing
✓ Cautery machine
✓ Kick buckets in wheeled bases
✓ Basin in wheeled bases for soiled sponges and gloves
MEDICAL SURGICAL NURSING PAIN AND SURGERY -- MODULE 1.2

REVIEW OF INFECTION CONTROL CROSS INFECTION

occurs when one patient or staff passes the pathogens to another patient,
staff or visitors.
A. DEFINITION OF INFECTION CONTROL – is the most basic and
important procedure in nursing care, and it will deter-mine the quality COMMUNITY ACQUIRED INFECTION
of care given in a facility. these are natural disease process that developed or were incubating before
the patient is admitted to the hospital.
B. MICROORGANISMS - are living things so tiny that can not be seen
by the naked eye.
2. SIGNS AND SYMPTOMS OF INFECTION
✓ also called microbes or germs.
✓ always present in the environment and on the body. ✓ fever
✓ not all microorganisms are harmful. Some are helpful. MO can also ✓ pain and tenderness
serve both good and harmful purposes. ✓ fatigue and loss of energy
✓ microorganisms that cause disease is called pathogens. ✓ loss of appetite (anorexia)
✓ nausea and vomiting
C. TYPES OF MICROBES ✓ increased PR & RR
✓ diarrhea and rashes
Bacteria (bacterium) ✓ redness & swelling of a body part
single-celled microscopic organisms that multiplies rapidly. Some are ✓ discharge or drainage from the affected part.
beneficial to humans while others can cause infection.
✓ sores in mucous membrane
Fungi (fungus)
microscopic, single celled or multi-celled plants that live either on plants or 3. CHAIN OF INFECTION
animals. It can infect the mouth, vagina, skin, feet & other body parts.
A. Causative Agent or Source - is the pathogen that causes the infection
Protozoa (protozoan) or disease (bacteria, virus, fungi, protozoa).
single-celled, microscopic animals, usually living in water and can cause
B. Reservoir
disease.
The place where the causative agent is able to live and reproduce.
Rickettsiae
Humans with active disease
found in fleas, lice, ticks and other insects; spread to humans by insect
Humans who are carriers
bites. Person infected may experience fever, chills, headaches, rashes, etc.
Animals
Virus Fomites or objects
smallest known living infectious agents that grows in living cells. Environment

D. CONDITIONS THAT FAVORS THE BACTERIAL GROWTH C. Portal of Exit

is the means by which the pathogens leave the reservoir like human
1. Food – bacteria grow well in leftover foods.
secretions.
2. Moisture – bacteria grow well in moist places.
3. Temperature - high temp (170’F) kills most bacteria. At normal * urine, feces
human body temp (98.2’F), bacteria thrive easily on & in the human body. * saliva, tears
Low temp (32’F) do not kill bacteria but retard their growth & activity. * drainage, excretions
4. Oxygen – aerobic (with O2) and anaerobic (without O2) * blood
5. Matter – saprophytes (live on dead matter or tissue.) and
parasites (live on living matter or tissue.)
6. Light - darkness favors the development of bacteria where they become D. Mode/Route/ Method of Transmission
active and multiply rapidly. Light is the worst enemy where bacteria the way the pathogen is transmitted from one reservoir to the new host’s
become sluggish and die rapidly. body.

E. INFECTION 5 MAIN ROUTES

1. Definition of Infection - The invasion and growth of disease-causing 1. Contact Transmission - most important and most frequent route.
A. Direct contact - direct body-surface-to-body-surface contact &
Local – involves a certain body part. transfer of pathogens.
Systemic – involves the whole body. B. Indirect contact - involves contact with a contaminated objects
like needles, instruments, un-washed hands, and gloves
NOSOCOMIAL INFECTION
infection that is required as a result of being in the health care facility 2. Droplet Transmission - occurs when droplets containing
environment. microorganisms are sent flying a SHORT DISTANCE through the air &
MEDICAL SURGICAL NURSING PAIN AND SURGERY -- MODULE 1.2
are deposited on the eyes, nose or mouth (sneezing, coughing, and
droplets).
D. COMMON ASEPTIC PRACTICES
3. Airborne transmission - occurs when evaporated droplets containing
pathogens remain in the air for LONG PERIODS OF TIME and are ✓ Perform daily personal hygiene.
carried ✓ Habitual hand washing
✓ Covering nose and mouth when coughing and sneezing
4. Common vehicle transmission - occurs when pathogens are transmitted ✓ Proper waste segregation and disposal
by contaminated items like food, water, medications, hospital equipment ✓ Practice the three (3) R – reuse, recycle, reduce
and machines. ✓ Proper wearing of the Personal Protective Barriers or Equipment
(PPE).
5. Vector – borne transmission - occurs when intermediate hosts such as
infected rats, flies or mosquitoes, transmit the microorganisms.
E. SURGICAL ASEPTIC TECHNIQUE PRINCIPLES.
E. PORTAL OF ENTRY
is the means by which the pathogens enter the body such as: ✓ All objects used in a sterile field must be sterile.
✓ Surgical gowns are considered sterile in front from shoulder to table
cuts or breaks in the skin or mucous membrane;
level. The sleeves are sterile to 2 inches above the elbow.
respiratory tract;
✓ Sterile items that are out of vision or below the waist level of the
gastrointestinal tact
nurse are considered unsterile.
Genito-urinary tract;
✓ The edges of a sterile field are considered unsterile.
circulatory system;
✓ The skin cannot be sterilized and is unsterile.
passage from mother to fetus
✓ Sterile objects can become unsterile thru prolonged exposure to
airborne microorganisms.
F. Susceptible Host ✓ Movement within or around a sterile field must not cause
The individual who harbors the pathogens where they reproduce and cause contamination of the sterile field.
infection. ✓ A sterile barrier that has been permeated must be considered
contaminated.
Factors that Affect the Infection Rate ✓ Items of doubtful sterility should be considered unsterile.
✓ Sterile objects should be touch by sterile personnel only. If touches
✓ Malnutrition
by anything unsterile, both are considered contaminated.
✓ Obesity
✓ If unsterile, use a pickup forcep to get or pick sterile objects. Observe
✓ Age – too young and too old proper handling of the forceps. Fluid flows in the direction of gravity.
✓ Presence of chronic disease and impaired defense mechanism ✓ The outside package is NOT STERILE and can be handle and touch
✓ Certain type of operation by bare hands. The edges of the
sterile fields are considered unsterile once the package is opened.
5. Body’s Defense against Infection ✓ Dispose all sharps in designated puncture-resistant containers.
1. Skin – body’s most important defense.
2. Mucous membrane – mucus secretions
3. Cilia F. STANDARD PRECAUTION
4. Coughing and sneezing formerly known as UNIVERSAL PRECAUTION, protect health care
5. Tears workers from contact with blood and body fluids of all patients.
6. Stomach acid
1. Purpose of Standard Precaution
7. Fever
To prevent transmission of infection from blood-borne pathogens.
8. Phagocytes
9. Inflammation 2. Rationale of Standard Precaution
10. Immune response Is that health care worker may not know who is and is not infected.

3. Practices
ASEPSIS ✓ Hand washing
✓ Wearing of appropriate PPE
A. DEFINITION OF ASEPSIS ✓ Environment cleaning and spills management
freedom from infection or infectious materials. ✓ Proper handling of waste and waste disposal
✓ Do not recap, bend or break used needles.
B. MEDICAL ASEPSIS OR CLEAN TECHNIQUE
practices and procedures to maintain a clean environment by removing or
destroying the pathogens. G. STERILIZATION AND DISINFECTION

C. SURGICAL ASEPSIS OR STERILE TECHNIQUE 1. DEFINITION OF DISINFECTION

practices and procedures that keep an area or object totally free from all a cleaning process that destroys most microorganisms through the use of
microorganisms. certain chemicals or boiling water. uses a DISINFECTANT, an agent that
kills growing microorganisms.
MEDICAL SURGICAL NURSING PAIN AND SURGERY -- MODULE 1.2
• Allow for ease in aseptic presentation.
2. METHODS OF DISINFECTION • be free of toxic ingredients and non-fast dyes and be relatively
nonabrasive.
A. PHYSICAL DISINFECTANTS
✓ All items to be sterilized should be prepared to reduce the bio burden.
Boiling of water (212’F or 100’C). Minimum boiling period is 30 ✓ All articles to be sterilized should be arranged so all surfaces will be
minutes. directly exposed to the sterilizing agent for the prescribed time and
Horizontal and vertical scrubbing with soap and water. temperature.
UV Radiation and fumigation with chemicals are NO LONGER ✓ All wrapped articles to be sterilized should be packed in materials
recommended because of the limitation of their practical usefulness. that meet the standards/
criteria in the recommended practice for in-hospital packaging
materials.
B. CHEMICAL DISINFECTANTS
✓ Chemical indicators, also known as sterilization process indicators,
Alcohol (70%-90%) ethyl or isoprophyl – used as a housekeeping should be used to indicate that items have been exposed to a
disinfectant and can be used in semicritical instruments. Hazard : sterilization process.
volatile and it will harden and swell plastic tubing. ✓ The efficacy of the sterilization process should be monitored at a
Chlorine compounds – has limited use in hospital. Ex. Sodium regular interval with reliable biological indicators.
hypochlorite 0.5-1% ✓ Every package should be labeled with the date of sterilization,
Phenolic compounds – kills microorganisms by coagulation of autoclave number & the sterilizer used.
protein. Major choice when dealing with fecal contamination. ✓ Sterilized items should be carefully handled and only when
Formaldehyde (either in solution or gas form) – is sporicidal in necessary. They should be stored in well-ventilated, limited access
minimum of 12 hours. area with controlled temperature and humidity.
Glutaraldehyde – agent of choice for sterilization. Good also for ✓ Flash sterilization should be used for emergency sterilization of clean,
instruments that can not be steam sterilized. Recommended soaking unwrapped instruments and porous items only.
time is 15-30 minutes. ✓ Performance record for all sterilizers should be maintained as well as
the preventive maintenance should be performed according to
individual policies on a scheduled basis by qualified personnel.
3. DEFINITION OF STERILIZATION ✓ Policies and procedures for sterilization and disinfection should be
written and reviewed periodically. This should be readily available
a cleaning process that kills all microorganisms, including spores.
within the practice setting for easy reference.
uses a chamber or equipment known as STERILIZER, to attain either
physical or chemical sterilization.
6. Considerations in Selecting the Method of Sterilization OR
Disinfection
4. METHODS OF STERILIZATION

a. Physical Means ✓ availability / efficiency of sterilizing agent / disinfectant;

✓ physical properties of the item;
• Steam under pressure (moist heat/ autoclave) – easy, safe, surest ✓ urgency of need;
method, fastest, least expensive and leaves no harmful residues. ✓ standards of practice;
✓ hazard of toxic residue;
Disadvantage: dangerous and subject to human errors. ✓ infection control;
✓ manufacturer’s recommendation
*Radiation – has a very low temperature effect on materials but penetrates
materials very well. ✓ decontamination requirements;
✓ packaging requirement;
b. Chemical Means ✓ ease of transport and storage;
✓ environmental / disposal requirements;
• Immersion / Soaking in Glutaraldehyde – penetrates into crevices of ✓ cost containment
instruments; noncorrosive, non-staining, safe, does not damage the
lenses. Disadvantages includes it mild but irritating odor, it has low
toxicity so rinse the objects with sterile water prior to use.
• soaking solution should be changed every 28th day of use.

ex. Cidex, Zephiran erile water prior to use.

5. Guidelines on Sterilization & Disinfection

✓ IN HOUSE PACKAGING MATERIALS - materials used for IHP

and wrapping of sterile supplies should :
• Be compatible with the sterilization process.
• Provide a cost-effective barrier to microorganisms.
MEDICAL SURGICAL NURSING PAIN AND SURGERY MODULE 1.3

OPERATING ROOM ATTIRE, SURGICAL HAND d. CRITERIA FOR OPERATING ROOM ATTIRE
SCRUBBING, GOWNING, CLOSED GLOVING, AND Should be an effective barrier to microorganisms. Both reusable
INSTRUMENTATION woven and disposable nonwoven materials are used. Design and
composition should minimize microbial shedding.
OPERATING ROOM ATTIRE Should be closely woven material void of dangerous electrostatic
properties. The garment must meet the fire protection standards,
a. DESCRIPTION including resistance to flame.
consists of body covers, such as a two-piece pantsuit, head cover or Nylon and other static spark-producing materials are forbidden as
cap/turban, mask, shoe cover or booties, goggles, and apron. outer garments.
b. PURPOSE Should be resistant to blood, aqueous fluids, and abrasions to prevent
Provide effective barriers that prevent the dissemination of penetration by microorganisms.
microorganisms to the patient. Designed should be for maximal skin coverage.
Protect personnel from infected patients and against exposure to Should be hypoallergenic, cool and comfortable
communicable diseases and hazardous materials. Should be non-generative of lint. Lint can increase the particle count
Has been shown to reduce particle count of shedding from the body of contaminants in the OR.
from over 10,000 particles per minute to 3000 per minute, or from Should be made of pliable material to permit freedom of movement
50,000 microorganisms per cubic foot to 500 microorganisms per for the practice of sterile technique.
cubic foot. Should be able to transmit heat and water vapor to protect the wearer
Should be colored to reduce glare under lights. Various types of
c. HISTORICAL BACKGROUND clothes in colorful prints that fulfill the necessary criteria are both
OR nurse take a bathe before a surgical procedure, to take a carbolic attractive and functional.
bath before laparotomy & to wear long sleeves & clean apron for the Should be easy to don and remove
surgical procedure. Should be an effective barrier to microorganisms.
In 1883, Gustav Neuber insisted the wearing of caps by OR
personnel. e. DRESS CODE
Hunter Robb, a gynecologist at Johns Hopkins Hosp, Baltimore, 1. Location of dressing room;
insisted on OR cleanliness & on the wearing of caps & sterile gowns 2. Street clothes are NEVER worn beyond the unrestricted area;
in the OR. 3. Only approved, clean, and/or freshly laundered or attire is worn
In 1897, Dr. William Halsted designed a semicircular instrument within the semi restricted areas. This applies to all, both
table to separate himself, in sterile gown & gloves, from observers in professional, nonprofessional and visitors alike;
street clothes who watched him operate. 4. OR ATTIRE should not be worn outside the OR suite. This
Johann von Mikuliez, a pioneering German surgeon, advocated the protects the OR environment from micro-organisms inherent in the
wearing of cotton gloves in 1896 but these were soon found to lack outside environment and protects the outside from contamination
the qualities of impermeable rubber gloves for infection control. He normally associated with the OR.
also advocated the use of gauze masks in 1897. 5. Before leaving the OR suite, everyone should change to street
Till 1900, the surgeon often relied on the nurse to have the necessary clothes.
instruments in her apron pocket. - lab gown, smock gown (THIS PRACTICE IS NOT
Apron was replaced by scrub suit while long sleeves are ENCOURAGED)
recommended for anesthesiologist & circulators to reduce the 6. A clean, fresh scrub suit should be put on after return for reentry to
shedding of organisms. the suite.
First use of caps and sterile gowns occurred in Germany while the 7. OR ATTIRE should be hung or put in a locker for wearing a
value of Joseph Lister’s principle of antiseptic surgery to exclude second time. If disposable, discard in the trash after one use.
putrefactive bacteria from wounds was still being debated. 8. Personal hygiene must be reemphasized.
From 1908 to 1930, various styles of turbans and shower cap-style a. Person with an acute infection such as cold or sore throat should
head coverings were worn. not be permitted within the or suite.
b. Persons with cuts, burns or skin lesions should not scrub or
In 1913, Charles Mayo & team were photographed
handle sterile supplies because serum may seep from the eroded
operating in surgical gowns, caps and masks.
area.
In 1930 & 1940s, scrub dresses began to replace nurses’ regular c. Sterile team members who are known carriers of pathogens
uniforms, heretofore worn under the sterile gown, Observers in the should routinely bathe and scrub with appropriate antiseptic
OR were gowned, capped and masked. agent & shampoo their hair daily.
In 1958, disposable latex gloves were introduced. d. Fingernails should be kept short. Nail polish is not allowed.
The most efficient masks are disposable ones containing a high Studies have shown that artificial nails and other enhancers
efficiency filter. harbor microorganisms esp. fungi & gram-negative bacilli.
In the 1960s full skirts were replaced by close fitting scrub dresses e. Jewelries including rings & watches should be removed before
and pantsuits that reduced the hazard of brushing against a sterile entering the semi restricted & restricted areas. Necklaces &
table when near or passing by it. chains can grate on the skin, increasing desquamation which
In 1950, OR personnel were required to change shoes when entering might fall into a wound or contaminate the sterile field. Pierced-
the OR suite and to wear only those shoes when within the suite. ear studs must be confined within head cover. Dangling earrings
Currently disposable shoe covers are are inappropriate in the OR.
commonly worn. f. Facial makeup should be minimal.
MEDICAL SURGICAL NURSING PAIN AND SURGERY MODULE 1.3
g. Eyeglasses should be wiped with a cleaning solution before each reusable cotton masks are obsolete because they filter ineffectively as
surgical procedure & properly secured. soon as they become moist.
h. Hands must be washed frequently and thoroughly. Hand cream disposable mask made of soft, cloth like material in very fine
maybe use after to prevent chapping and drying of hands. synthetic fiber mats is more appropriate to use because:
9. Comfortable, supportive shoes should be worn to minimize a. at least 95% efficient in filtering microbes from droplet particles.
fatigue and for personal safety. Shoes should have enclosed toes b. a fluid resistant mask is advantageous.
and heels; clogs, slippers and sandals should not be worn. Shoes c. cool, comfortable and non-obstructive to respiration.
must be cleaned frequently. d. nonirritating to the skin because of its polypropylene, polyester or
10. External apparel that does not serve any functional purpose rayon fibers.
should not be worn inside the OR. should be worn over both nose and mouth and should conform to
facial contours to prevent leakage of expired air.
f. COMPONENTS OF OPERATING ROOM ATTIRE double masking is not recommended because the extra thickness can
1. Body Cover cause venting from the effort to breathe through it.
one piece overall with attached hoods and boots are convenient garb
for visitors whose presence in the OR will be brief like the
pathologist. TO PREVENT CROSS INFECTION, MASK SHOULD:
must be don a scrub suit before entering a semi-restricted area.
available also in pantsuits which is more preferred than the overall 1. be handled only by the strings. Do not handle the mask excessively;
type. 2. never be lowered to hang loosely around the neck, on top of the cap,
the shirt and waistline drawstrings are tucked inside the scrub pants to or put in a pocket. Avoid disseminating microorganisms;
avoid touching sterile areas and to reduce fallout of skin debri from be promptly discarded into the proper receptacle on removal. Remask
thoracic and abdominal areas. with a fresh mask between patients.
scrub suit should be changed as soon as possible whenever it be changed frequently. Do not permit the mask to become wet.
becomes wet or visibly soiled. Talking should be kept to a minimum.
persons who will not be part of the sterile team member should wear
long sleeved jackets over a scrub suit. 5. Eye Wear / Goggles
worn to reduce risk of blood or body fluids from the patient splashing
2. Head Cover/ Cap/ Turban into the eyes of sterile team members, or bone chips or splatter alike.
cap or hood is put on before a scrub suit to protect the garment from with side shields, anti fog goggles, combination surgical mask with a
contamination by hair; visor eye shield.
all facial and head hair must be completely covered; eye wear or face shield that becomes contaminated should be
types include disposable, lint free, nonporous, nonwoven fabrics. decontaminated or discarded promptly.
Reusable cap should be made of a dense woven material and laser eye wear must be worn for eye protection from laser beams.
laundered daily; eye wear with face shield should be worn when handling or washing
net caps are not acceptable; the instruments, when the activity could result in a splash, spray or
hair should not be combed while wearing a scrub suit; splatter to the eyes or face.
persons with scalp infection should be excluded from the OR and
treated first; 6. Sterile Gloves
if hair is long, a helmet or hood must be worn to cover the neck area. nonsterile latex or vinyl gloves should be worn when handling
It should be well fitted to confine and prevent escape of any hair. contaminated materials.
caps of different colors are helpful to differentiate personnel. surgical gloves are made of natural latex rubber, synthetic rubber,
vinyl, or polyethylene.
3. Shoe Cover
LATEX – a polymeric membrane of natural rubber with an infinite number
should be clean, washable and soft-soled;
of holes between lattices. It is better barrier than vinyl type. Latex contains
maybe worn in semi restricted and restricted areas;
protein antigen & is cured with agents that may cause an allergic dermatitis
protect the wearer from spills into or onto shoes during procedures;
or systemic anaphylaxis. Petroleum-based lotions or lubricants SHOULD
shoes restricted to wear in the OR or shoe covers over shoes are
preferable in reducing microbial transfer from the outside into the OR NOT be used on the hands before donning latex gloves. Hydrocarbons
suite. will penetrate latex, causing a change in its physical characteristics,
can inadvertently become soiled and harbor microorganisms, so it including tear resistance.
should be removed before entering the dressing room and be removed clean objects and sterile packages should not be handled with
before leaving the OR suite. contaminated gloves.
protective gloves should be worn to change shoe covers whenever sterile gloves are worn by sterile team members and for all invasive
they become wet, soiled or torn. procedures.
4. Mask utility or working nonsterile gloves are worn for cleaning and
worn in the restricted areas to contain and filter droplets containing housekeeping.
microorganisms expelled from the mouth and nasopharynx during - sterile and non-sterile single use disposable latex and vinyl gloves are
breathing, talking, sneezing and coughing. discarded after use. They should not be washed and reused.
should be worn at all times in the restricted areas where sterile - hands must be washed thoroughly after removing the gloves.
supplies are exposed.
MEDICAL SURGICAL NURSING PAIN AND SURGERY MODULE 1.3
7. Sterile Gown C. MATERIALS NEEDED FOR SURGICAL HAND SCRUB
is worn over the scrub suit to permit the wearer to come within the C.1. SCRUB SINK
sterile field. → is adjacent to the OR for safety and convenience.
differentiate sterile from unsterile members. → automatic control or foot or knee operated faucets.
although the entire gown is sterilized, the BACK IS NOT STERILE,
→ sink is deep & wide enough
NOR ANY AREA BELOW TABLE LEVEL, once the gown is
donned. → Should be used only for scrubbing or hand washing only.
wrap around sterile gowns that provide coverage to the back by an → Should not be used to clean or rinse contaminated/ soiled instruments
overlap is more RECOMMENDED. and equipment.
If the gown is closed by ties along the back, a STERILE VEST
should be put on to cover the back. C.2. SCRUB BRUSH
cuffs of the gown are stockinette (rib-knit) to tightly fit wrists. Sterile → reusable scrub brushes
gloves cover the cuffs of the gown. → disposable sponges
should be resistant to penetration by fluids & blood. → single use disposable brush-sponge combination with impregnated
should be comfortable without producing excessive heat build up. antiseptic detergent agents.
reusable gowns must be made of a densely woven material. → Brush should not cause skin abrasion
Pima cotton with a 270-280 thread count per square inch treated with
→ reusable brush maybe wrapped to provide sterile individual packages.
a moisture-repellent finish
→ Reusable nail cleaners should be use to clean under the nail.
some reusables are cotton-polyester blend.
seams of the gowns should be constructed to prevent penetration of → Orangewood sticks are not used because the wood may splinter &
fluids. harbor Pseudomonas organisms.
woven textile gowns withstand about 75 launderings & sterilizing
cycles before discarding them. C.3. ANTISEPTIC AGENTS
If punctured or torn, gown should be changed during the procedure. → antiseptic agents are approved by FDA.
all woven & some nonwoven gowns are not flame-retardant. Fire- → different agent has different specific microbial agent.
resistant gowns should be worn for laser surgery and when electro → agents alter the physical or chemical properties of the cell membrane
surgery is used. of microorganisms, thus destroying or inhibiting cellular functions.
→ should be a broad spectrum antimicrobial agent;
8. Lead Apron
→ should be fast acting and effective;
decontamination apron should be worn over the scrub suit to protect
→ should be nonirritating and non sensitizing;
against liquids and cleaning agents during cleaning procedures. This
should be a full front barrier. → should be prolonged-acting;
should be light weight and full front. Aprons protect the surgeon & → should be independent of cumulative action.
nurse against liquid and cleaning agents during operation.
protects against radiation exposure or when handling radioactive 1.) 4% CHLORHEXIDINE GLUCONATE
implants. produces effective, immediate, and cumulative reductions of resident
& transient flora.
effect is maintained for more than 6 hours. Non irritating to the skin
REVIEW OF SURGICAL HAND SCRUBBING but highly irritating if splashed in the eye.
2.) IODOPHORS
a. DEFINITION • is a povidone-iodine complex against gram positive & gram
is the process of removing as many microorganisms as possible from negative microorganisms.
the hands and arms by mechanical washing & chemical antisepsis • irritating to the skin
before participating in surgery.
• not sustained for a prolonged period (6hrs).
Mechanical washing with friction removes transient organisms.
3.) 1% TRICLOSAN
Chemical antisepsis reduces resident flora & inactivates
microorganisms with antiseptic agents. • nontoxic, nonirritating, & develops a prolonged cumulative
Done before gowning & gloving for each surgical procedure suppressive action when used routinely. Less effective than
Chlorhexidine Gluconate and Iodophors.
4.) 60% / 90% ALCOHOL
B. PURPOSES OF SURGICAL HAND SCRUB
To help prevent possibility of contamination of the operative wound • nontoxic, does not have residual activity, has drying effect on
by bacteria on the hands and arms. skin.
5.) 3% HEXACHLOROPHENE
To remove soil, debris, natural skin oils, hand lotions and transient
microorganisms from the hands & forearms of sterile members. • most effective after buildup of cumulative suppressive action.
To decrease the number of resident microorganisms on skin to an Available by prescription only.
irreducible minimum.
To keep the microorganisms to minimum during the surgical D. PREPARATION FOR SURGICAL SCRUB
procedure by suppression of growth. Skin & nails should be kept clean and in good condition and cuticles
To reduce the hazard of microbial contamination of the surgical should be uncut.
wound by skin flora. Fingernails should not reach beyond the fingertip to avoid glove
puncture.
MEDICAL SURGICAL NURSING PAIN AND SURGERY MODULE 1.3
Fingernail polish should not be worn. With the hands held under running water, clean under the fingernails
Artificial devices must not cover natural fingernails of both hands with nail cleaner & discard after use;
Remove all jewelries from fingers, wrists and neck. Rinse both hands and arms under running water, keeping hands up;
Ensure to fold the sleeves of the scrub suit at least 2 to 3 inches above Take a sterile brush and apply an antiseptic agent and start ding the
the elbow. brush stroke method on ONE HAND first following:
15 strokes each nail
E. BEFORE PROCEEDING TO THE SCRUB SINK: 15 strokes all sides of each finger
Open out the sterile gown pack onto a clean back table, only grabbing 15 strokes each dorsum
the outermost edges to maximize the sterile field. 15 strokes each palm
Open the sterile glove packet and let it drop onto the open sterile 15 strokes for each third of arm up to 2 inches above the elbow.
gown pack. 6. Repeat the above steps for the other hand and arm.
7. Rinse the hands and arms thoroughly.
F. PREPARATIONS IMMEDIATELY BEFORE SCRUBBING 8. Stay at the scrub sink for a few seconds for the dripping of water while
Inspect the hands for cuts and abrasions. Skin integrity should be maintaining the hands up.
intact.
All hair is covered properly by headgear including the pierced ear GOWNING AND DONNING OF SURGICAL GLOVES
studs.
Adjust disposable mask snugly & comfortably over nose & mouth. A. PURPOSE
Clean eyeglasses if worn. Adjust comfortably in relation to mask. Sterile Gown is worn to exclude the skin as a possible contaminant and to
Adjust water to a comfortable temperature and amount. create a barrier between the sterile and unsterile areas.

B. GENERAL CONSIDERATIONS
G. TYPES OF SURGICAL SCRUB PROCEDURE
The scrub person gowns & gloves self, then may gown and glove the
1. Time Method surgeon & assistants.
1.a. Complete scrub (5-7 minutes)
Gown packages preferably are opened on a separate table from other
1.b. Short scrub (3 minutes) packages to avoid contamination from dripping water.
2. Brush-stroke Method or Counted Method Avoid splashing water on scrub attire during surgical scrub because
2.a. 30 Strokes Method moisture may contaminate the sterile gown.
2.b. 15 Strokes Method
C. WEARING OF STERILE GOWN BY SELF
STEPS IN FIVE MINUTE TIME SCRUB METHOD After scrubbing, hands and arms must be thoroughly dried before the
sterile gown is donned to prevent contamination of the gown by
strike-through of microorganisms from wet skin.
Wet hands and forearms. Apply 2 to 3 ml (6 gtts) of antiseptic agents
After drying of hands, pick up the sterile gown, lifts it directly
to the hands;
upward and steps away to avoid touching the edge of wrapper.
Lather & Wash hands several times up to 2 inches above the elbow.
The scrub nurse, putting on gown, gently shakes out folds, then slips
Then rinse thoroughly under running water with hands upward;
both arms into the armholes of the sleeves simultaneously without
Take the sterile brush, apply antiseptic agent & scrub following the touching sterile outside of gown with bare hands.
time allotted per part:
The Circulator brings the gown over the shoulder by reaching inside
→ 30 seconds each nail to the shoulder and arms seams. The gown is pulled on, leaving the
→ 30 seconds each finger cuffs of the sleeves extended over the hands.
→ 30 seconds each hand; The back of the gown is securely tied or fastened at the neck and
With brush in hand, clean under fingernails with nail cleaner on waist; touching the outside of the gown at the line of ties or fasteners,
running water then discard after use the cleaner; in the back only.
Again, scrub each individual finger, nail and hands with the brush a
half minute for each hand, maintaining lather;
Rinse hands and arms and discard brush; D. SERVING OF STERILE GOWN
Reapply the antiseptic agent and wash the hands & arms with friction
Open the hand towel and lay it on the surgeon’s hand, being careful
up to the elbow for 3 minutes. Interlace the fingers to cleanse
not to touch the hand. If no towel is available, the lower part of the
between them;
gown maybe used to dry the hands of the surgeon.
Rinse the hands and arms thoroughly;
Unfold the gown carefully, holding it at the neck-band.
Stay for a few seconds at the scrub sink for the dripping of water,
Keeping your hands on the outside of the gown under a protective
then proceed to the assigned OR suite. DO NOT INTERLACE
cuff of the neck and shoulder area, offer the inside of the gown to the
THE FINGERS.
surgeon. The surgeon slips the arms into the sleeves.
Release the gown. The surgeon holds arms outstretched while the
STEPS IN BRUSH STROKE METHOD (15 STROKES METHOD) circulator pulls the gown onto the shoulders and adjusts the sleeves so
the cuffs are properly placed. In doing so, only the inside of the gown
Wet hands and arms up to 2 inches above the elbow; is touched at the seams.
Lather with antiseptic agent;
MEDICAL SURGICAL NURSING PAIN AND SURGERY MODULE 1.3
E. DONNING OF STERILE SURGICAL GLOVES BY CLOSED Repeat step 5 for the right cuff, using the left hand and thereby
GLOVE TECHNIQUE completely gloving the right hand.

Using the left hand and keeping it within cuff of sleeve, gowned H. REMINDERS IN GLOVING TECHNIQUE
scrub person picks up the right glove. Palm of glove is placed against ✓ Avoid contact of sterile gloves with ungloved hands during closed-
palm of right hand, grasping top edge of glove cuff above palm. gloving procedure.
✓ For close gloving method, never let the fingers extend beyond the
CORRECT POSITION
stockinette cuff during the procedure. Contact with ungloved fingers
→ Fingers of glove are pointing towards you and thumb of the glove is constitutes contamination of the gloves.
align with the thumb of the hand. The thumb side of the glove is ✓ For open glove method, touch only the cuff of the glove with
down. ungloved hand, and then only glove to glove for other hand.
Back of cuff is grasp in left hand and turned over right sleeve and ✓ If contamination occurs during either procedure, both gown and
hand. Cuff of glove is now over stockinette cuff of sleeve, with hand gloves must be discarded and new gown and gloves must be added.
still inside sleeve.
✓ When removing gloves after a procedure is finished, the gloves are
Top of right glove & underlying sleeve of gown are grasped with left removed using glove-to glove, skin to skin technique, after the gown
hand. By pulling sleeve up, glove is pulled onto hand. is removed inside out technique.
Using gloved right hand, left glove is picked up and placed with palm
of glove against palm of left hand. Back of cuff is grasped, above
palm in right hand & turned over left sleeve and hand. I. REMOVING OF GOWN
Cuff of left glove is now over stockinette cuff of sleeve, with hand Grasp the right shoulder of the loosened gown with the left hand and
still inside sleeve. Top of left glove and underlying gown sleeve are pull the gown downward from the shoulder and off the right arm,
grasped with right hand, and sleeve is pulled up, pulling glove onto turning the sleeve inside out;
hand. 2. Turn the outside of the gown away from the body with flexed
elbows;
F. SERVING OF STERILE GLOVES Grasp th left shoulder with the right hand and remove the gown
entirely, pulling it off (inside out);
Pick up the right glove, grasp it firmly, with the fingers under the
Discard in a laundry hamper or in a trash receptacle (if disposable).
everted cuff. Hold the palm of the glove toward the surgeon;
Stretch the cuff sufficiently for the surgeon to introduce the hand.
Avoid the touching the hand by holding your thumbs out; I. GLOVE REMOVAL
Exert upward pressure as the surgeon plunges the hand into the glove; The key to removing both sterile and non-sterile gloves is “Dirty to
Unfold the everted glove cuff over the cuff of the sleeve; Dirty - Clean to Clean" that is, contaminated surfaces only touch
Repeat for the left hand; other contaminated surfaces: your bare hand, which is clean, touches
If a sterile vest is needed, hold it for the surgeon to slip the hands into only clean areas inside the other glove;
the armholes. Be careful not to contaminate gloves at the neck level. Take hold of the first glove at the wrist;
If the gown is a wraparound, assist the surgeon. Fold it over and peel it back, turning it inside out as it goes. Once the
glove is off, hold it with your gloved hand;
G. DONNING OF STERILE SURGICAL GLOVES BY OPEN To remove the other glove, place your bare fingers inside the cuff
GLOVE TECHNIQUE without touching the glove exterior. Peel the glove off from the
This method of gloving uses a skin-to-skin, glove-to-glove inside, turning it inside out as it goes. Use it to envelope the other
technique. The hand although scrubbed is not sterile and must not glove.
come in contact with the exterior of the sterile gloves. The everted
cuff on the gloves exposes the inner surface.
The first glove is put on with skin-to-skin technique, bare hand to SURGICAL INSTRUMENTATION
inside cuff. The sterile fingers of that gloved hand then may touch the
sterile exterior of the second glove, that is glove-to-glove technique. a. Historical Background –
• CODE OF HAMMURABI (CIRCA 1900 BC) –- describes a
bronze lancet
OPEN GLOVE METHOD
• INCAS of PERU – use razor sharp flint and animal teeth
• EGYPTIANS (1900 – 1200 BC ) – blades made of flint, reed &
With the left hand, grasp the cuff of the right glove on the fold. Pick
bronze
up the glove and step back from the table.
Insert the right hand into the glove and pull it on, leaving the cuff • HIPPOCRATES (460 – 377 BC) – advocated the heating of tips of
turned well down over the hand rounded and pointed blades before using.
Slip the fingers of the gloved right hand under the everted cuff of the • ROME (1st Century AD) – use of scalpel handles with blunt
left glove. Pick up the glove and step back. dissecting ends, knives, saws, forceps and clamps with locking
Insert the hand into the left glove and pull it on, leaving the cuff handles, probes, and hooks for retraction.
turned down over the hand. • AMBROISE PARE (1509 – 1590) – first person to grasp blood
With the fingers of the right hand, pull the cuff of the left glove over vessels with a pinching instrument that was the predecessor of the
the cuff of the left sleeve. If the stockinette is not tight, fold a pleat, hemostat used today.
holding it with the right thumb while pulling the glove over the cuff. • AMERICAN CIVIL WAR (1861 – 1865 ) – trademark of this
Avoid touching the bare wrist. period were AMPUTATIONS. In some instances, amputations were
MEDICAL SURGICAL NURSING PAIN AND SURGERY MODULE 1.3
performed on kitchen tables with heavy knives and instruments. → Blade # 12 – is shaped like a hook with the cutting edge on the inside
Even table forks were used as retractors. curvature.
• 18th – 19th CENTURIES -- surgical tools were made by skilled → Blade # 15 – has a smaller and shorter curved cutting edge than no.
silversmiths, coppersmiths, and woodworkers. Some instruments 10 blade.
handles were made of ivory, bone or wood with velvet cases.
→ Blade # 23 – has a curved cutting edge that comes to more of a point
• 20th CENTURY – instruments are made entirely of metals such as than no. 20, 21, and 22 blades.
carbon steel, silver and brass and the velvet case was replaced by
sterilizer trays. B. KNIVES
• 1900s -- development of stainless steel from Germany, Sweden, comes in various sizes and configurations
France, England, Pakistan, and United States. usually have a blade at one end & the blade have one or two cutting
- made of titanium, cobalt-based alloy (Vitallium), stainless steel or edges.
other metals. some have detachable and replaceable blades like adenotome &
dermatome
STAINLESS STEEL
• is an alloy of iron, chromium, and carbon. It may also contain nickel, C. SCISSORS
manganese, silicon, molybdenum, sulfur, and other elements to blades of the scissors maybe straight, angled or curved, pointed or
prevent corrosion or add tensile strength. blunt a the tips and the handles maybe long or short;
• Alloys make the instruments resistant to corrosion when exposed to used only to cut or dissect tissues.
blood and body fluids, cleaning solutions, sterilization, and to maintain the sharpness of the scissors, it should be used ONLY for
atmosphere. their intended purpose.
Metzenbaum scissors - Used to cut delicate tissue; also known as
B. PARTS OF THE SURGICAL INSTRUMENT TISSUE OR OPERATING SCISSOR
Tip Straight MAYO scissors - Used to cut sutures and supplies ; also
Serrated Jaws known as SUTURE SCISSOR.
Box lock Curved MAYO scissors - Used to cut heavy and tough tissues
Shank (fascia, muscles, uterus & breast) ; available in regular and long sizes.
Ratchet Wire scissors – have short, heavy blades ; they are used instead of
Finger ring or Ring Handle suture scissors to cut stainless steel sutures ; Heavy wire cutters are
used to cut bone fixation wires.
C. CLASSIFICATIONS OF INSTRUMENTS Dressing / Bandage scissors – used to cut drains and dressings and
Cutting and Dissecting to open items such as plastic packets.
Grasping and Holding Bandage is used to cut the uterus and umbilicus during CS operation.
Clamping and Occluding
Exposing and Retracting D. SHARP DISSECTORS
Suturing and Stapling includes biopsy forceps and punches, curettes (has a sharp edge with
Viewing loop, ring or scoop on the end), snares (a loop of wire may be put
around a pedicle to dissect tissue such as a tonsil, then the wire cuts
Suctioning and Aspirating
the pedicle as it retracts into the instrument and the wire is replaced
Dilating and Probing after use) .
Accessory Instruments
GRASPING AND HOLDING
CUTTING & DISSECTING
have sharp edges; a. Tissue Forceps
use to dissect, incise, separate, and excise tissues b. Stone Forceps
should be protected during cleaning, sterilizing and storing; c. Tenaculum
should be kept separate from other instruments and always demand d. Bone Holders
careful handling.
A. TISSUE FORCEPS
A. SCALPELS
used often in pairs, to pick up or hold soft tissues and vessels
made of brass & the blade is made of carbon steel;
most frequently used has a reusable handle with a disposable blade; Thumb Forceps / Smooth / Non toothed Forceps – used to hold
may also be available in disposable type. delicate tissues ; are tapered with serrations at the tip ; maybe straight
or angled, short or long and delicate or heavy.
→ Handle # 3, 7, 9 – Blade # 10 , 11, 12, 15 Toothed / Pick up / Rat Tooth Forceps – have a single tooth on
one side that fits between two teeth on the opposing side; use to hold
→ Handle # 4 – Blade # 20, 21, 22, 23
tough tissues.
→ Blade # 10 – most frequently use; has a rounded cutting edge along Allis Forceps – has a scissor action. Each jaw curves slightly inward
one side. Blades # 20, 21, 22 have the same shape but larger.
with a row of teeth at the end ; Holds tough tissue gently but securely
→ Blade # 11 – has a straight edge that comes to a sharp point; known
Babcock Forceps – the end of each jaw is rounded to fit around a
as the STAB KNIFE.
structure or to grasp tissue without injury.
MEDICAL SURGICAL NURSING PAIN AND SURGERY MODULE 1.3

B. STONE FORCEPS SUTURING OR STAPLING

used to grasp calculi such as kidney stones or gall stones. a. Needle Holder
either curved or straight forceps; b. Staplers
have blunt loops or cups at the end of the jaws.
A. NEEDLE HOLDER
C. TENACULUM used to grasp and hold curved surgical needles;
curved or angled points on the ends of the jaws penetrate tissue to resembles hemostatic forceps but the basic difference is the jaws;
grasp firmly has a short, sturdy jaws for grasping a needle without damaging it or
may have a single tooth or multiple teeth the suture material.
the size of the needle holder should match the size of the needle;
D. BONE HOLDERS either long or short, with serrations on jaws, some are non;
includes vice-grip, pliers and other types of heavy holding forceps use to
stabilize the bone. TUNGSTEN CARBIDE JAWS
jaws with an insert of solid tungsten carbide with diamond cut
CLAMPING AND OCCLUDING precision teeth designed to eliminate twisting and turning of the
needle in the needle holder;
a. Hemostats can be identified by the gold plating on the handles.
b. Crushing Clamps
c. Non crushing Vascular Clamps B. STAPLERS
available in reusable and disposable type
A. HEMOSTATIC FORCEPS
usually have two opposing serrated jaws that are stabilized by a box VIEWING INSTRUMENTS
lock and controlled by ringed handles. When closed, the handles
remain locked on ratchets; a. Speculum
most commonly used surgical instruments; b. Endoscopes
used primarily to clamp blood vessels;
either straight or curved slender jaws that taper to a fine point; A. SPECULUM
has a hinged, blunt blades that enlarges and holds a canal open such
Crile / Stet / Tag Forceps – for shallow layers of tissues as the vagina, or a cavity, such as the nose
Kelly Forceps – for deep layers of tissues or cavity
B. ENDOSCOPES
B. CRUSHING CLAMPS made of a round or oval sheath that is inserted into a body orifice or
used to crush tissues or clamp blood vessels; through a small skin incision.
fine tips are used for small vessels and structures while longer and used for viewing in a specific anatomical location.
sturdier jaws are needed for larger vessels, dense structures and thick
tissues. SUCTIONING AND ASPIRATING

C. NON-CRUSHING VASCULAR CLAMPS a. Suction

used to occlude peripheral or major blood vessels TEMPORARILY. b. Aspiration
minimizes tissue trauma;
jaws, either straight, curved or S shaped, have opposing rows of A. SUCTION
finely serrated teeth is the application of pressure (less than atmospheric pressure) to
withdraw blood or fluids, usually for visibility at the surgical site;
EXPOSING AND RETRACTING made of style tip and sterile tubing;
style of the suction tip depends
a. Hand held or Non self-retaining Retractors
where it is to be used and the surgeon’s preference.
b. Self – retaining Retractors
POOLE ABDOMINAL TIP
A. HANDHELD OR NON-SELF-RETAINING RETRACTORS
is a straight hollow tube with a perforated outer filter shield that
• usually used in pairs and held by the first or second assist prevents the adjacent tissues from being pulled into the suction
• some have blades on one end, either curved or angled, dull or sharp apparatus.
while some have blades on both ends. used during abdominal laparotomy or within any cavity in which
copious amount of fluid or pus are encountered.
B. SELF - RETAINING RETRACTORS
• may have shallow or deep blades, some have ratchets or spring locks FRAZIER TIP
to keep the device open, while others have wing to secure the blades; is a right-angle tube with a small diameter.
• some holding devices have two or more blades that can be inserted to used when little or no fluid except capillary bleeding and irrigating
spread the edges of incision and hold them. fluid is encountered, such as brain, spinal, plastic and ortho
procedures
MEDICAL SURGICAL NURSING PAIN AND SURGERY MODULE 1.3
KEY POINTS IN HANDLING INSTRUMENTS
YANKAUER TIP 1. Handle loose instruments separately to prevent interlocking or
is a hollow tube that has an angle for use in the mouth or throat. crushing.
a. Never pile one instrument on top of another on an
ASPIRATION instrument table; lay them side by side.
done manually to obtain a specimen like blood, body fluid, or tissue for b. Microsurgical, ophthalmic, and other delicate instruments
laboratory examination or to obtain bone marrow for transplantation which are vulnerable to damage through rough handling.
is frequently done with a syringe and needle. c. Metal to metal contact should be avoided or minimized.
2. Inspect instruments such as scissors and forceps for alignment,
TROCAR imperfections, cleanliness, and working conditions.
has a sharp cutting edge at the end of a hollow tube intended to cut a. Blades must be properly set.
through tissues for access to fluid or a body cavity. b. Exact alignment of teeth and serrations is necessary.
has a fitted blunt end cannula inside to keep fluid or gas from c. Set aside or remove any defective instruments
escaping until the cannula is removed. 3. Sort instruments neatly by classifications.
4. Keep ring - handled instruments together, with curvatures and
CANNULA angles pointed in the same direction.
has a blunt end and perforations around the tip to aspirate fluid a. Hang ring handles over a rolled towel or over the edge of
without cutting into tissues. the instrument tray or container.
b. Remove instrument pins or holders if used to keep box
also used to open blocked vessels or ducts for drainage or to shunt
locks open.
blood flow from the surgical site.
c. Close box locks on the 1st ratchet
5. Leave retractors and other heavy instruments in a back table.
DILATING AND PROBING
6. Protect sharp blades, edges, and tips. They should not touch
anything.
A. Dilators - used to enlarge orifices and ducts a. Some orthopedic instruments can remain the racks during
B. Probes - used to explore a structure or to locate an obstruction. the initial table set up and until they are needed during the
surgical procedure
ACCESSORY INSTRUMENTS b. Tip – protecting covers or instrument-protecting plastic
sleeves should be left on until the instruments are actually
A. Mallet used.
B. Screw drivers c. If they are not in a rack or tip guard, support handles on a
rolled towel or gauze sponge to keep blades and tips of
D. CATEGORIES OF INSTRUMENTS micro instruments suspended in mi air.
SHARPS
F. HANDLING OF INSTRUMENTS DURING SURGICAL
GRASPING AND HOLDING
PROCEDURE
CLAMPING AND OCCLUDING 1. Know the name and use of each instrument.
RETRACTORS 2. Handle instruments individually.
3. Hand the surgeon or assistant the correct instrument for each particular
E. HANDLING OF INSTRUMENTS BEFORE SURGICAL task.
PROCEDURE
1. Scrub nurse should be the one to prepare the instruments on the mayo *NOTE: Remember the principle:“ use for intended purpose only”
and back table.
Avoid placing fingers in the ring handle as the instrument is passed
2. Avoid as much as possible preparing the instruments wearing
because it may inadvertently drop or snag on drapes;
only sterile gloves.
3. Uncovered, exposed instruments are never transported through Many surgeons use hand signals to indicate the type of instrument
corridors. needed. An understanding of what is taking place at the surgical site
4. The scrub nurse should not go beyond the confines of the room. makes these signals meaningful;
5. The scrub nurse together with the circulating nurse should person Select appropriate instruments for location of surgical site; short
counting of instruments, sharps, and sponges. They must be instruments for superficial work and long ones for deep in a body
accounted for throughout every procedure. cavity. Experience will facilitate instrument selection according to the
surgeon’s preference and need.
COUNTING PROCEDURE Many instruments are used in pairs or in sequence.
is a method of accounting for items put on the sterile table for use
during the surgical procedure. 4. Pass instruments decisively and firmly. The instrument should be
sponges, sharps and instruments should be counted on all procedures slapped or placed firmly into the surgeon’s palm in the proper position for
use. Generally, when passing a curved instrument, the curve of the
counting ensures that expensive instruments like towel clips and
scissors are not accidentally thrown away with the drapes. instrument aligns with the direction of the curve of the surgeon’s hand.
* Counts are also performed for infection control and inventory control
purposes.
MEDICAL SURGICAL NURSING PAIN AND SURGERY MODULE 1.3
IN PASSING AN INSTRUMENT TO THE SURGEON: 3. Separate delicate, small instruments and those with sharp and semi
if the surgeon is on the opposite side of the table, pass across right sharp edges for special handling.
hand to right hand or with the left hand to a left-handed surgeon. 4. Disassemble all instruments with parts to expose all surfaces for
if the surgeon or assistant is on the same side of the table and to the cleaning.
right, pass with your left hand; if the surgeon is to your left, pass with 5. Open all hinged instruments to expose box locks and serrations.
your right hand. 6. Separate instruments of dissimilar metals. Clean the instruments per
Sharp and delicate instruments maybe placed on a flat surface for the type to prevent electrolyte deposition of other metals.
surgeon to pick up. This avoid the potential contact with items such 7. Flush with cold distilled water through hollow instruments or
as blades, sharp points and needles. Always protect hands when channels like suction tips or endoscopes to prevent drying of organic
handling sharps. debris.
8. Rinse off blood and debris with demineralized distilled water or any
enzymatic detergent solution.
5. Watch the sterile field for loose instruments. Remove them promptly
9. Follow procedures for preparing the instruments for decontamination
after use to the mayo table. The weight of the instruments can injure the
or terminal sterilization. Procedure varies depending on the type of
patient or cause post op discomfort. Keeping instruments off the field also instrument and its components and the equipment available and its
decreases the possibility of falling to the floor. location.
6. Wipe blood and organic debris off instruments promptly after each use
with a moist sponge. H. DECONTAMINATION PROCESS OF INSTRUMENTS.
a. Dried Blood and debris on instrument surface like in box lock and in
• includes the following procedures:
crevices, increase bioburden that could be carried into the surgical
Pre rinsing or presoaking,
site.
b. Use demineralized sterile distilled water in wiping the instruments. Washing,
Saline or other solution can damage surfaces, causing corrosion and Rinsing,
ultimately pitting. Sterilizing
c. A non-fibrous sponge should be used to wipe microsurgical,
ophthalmic, and delicate tips instruments. This can prevent snagging PRE-RINSING / PRE-SOAKING
and breaking of delicate tips. done to prevent blood and debris from drying on instruments or to
7. Flush the suction tip and tubing with sterile distilled water periodically soften and remove dried blood and debris.
to keep the lumens patent. Keep a tally of the amount of fluid used to clear Proteolytic Enzymatic Detergent dissolve blood and protein and
the suction line and deduct this amount from the total used to irrigate the remove dissolved debris from crevices. This is effective in a wide
surgical site. This is to have an accurate accounting of blood loss from the range of water qualities.
operation; Water with a low-sudsing, near-neutral detergent
8. Remove debris from electrosurgical tips to ensure electrical contact. Plain, clean, demineralized distilled water
Disposable abrasive tip cleaners are helpful for maintaining the Liquid detergents are preferred.
conductivity & effective-ness of the surface of the tip. Avoid using the
scalpel blade because the debris may become airborne and contaminate DONTS’:
the surgical field. BLEACH – corrosive solution should not be used.
9. Place used instruments not needed again into a tray or basin during or at CHLORINE COMPOUNDS
the end of the surgical procedure. IODOPHOR – Soaking should not exceed 1 hour.
a. Blood and gross debris must be removed first. Should not be cleaned in scrub sinks or utility sinks in the sub sterile
b. Careless dropping, tossing, or throwing of instruments into a basin is room;
highly prohibited. Do not pour directly the liquid or solid detergents on instruments
c. Keep instruments accessible for final counts
d. Bloody instruments should not be soak in a basin of solution for a
WASHING
prolonged period. Instruments that have been wiped can be immersed
in a basin of sterile demineralized distilled water, NOT SALINE Done to remove residual blood and debris before terminal
SOL’N NaCl in saline solution and blood is corrosive. sterilization or high-level disinfection.
e. Never place heavy instruments like retractors on top of tissue and
hemostatic forceps and other clamps. Place them in a separate tray. a. Clean, warm water with noncorrosive, low sudsing, free rinsing
detergent
G. HANDLING OF INSTRUMENTS AFTER SURGICAL
PROCEDURE. Regardless of the water content, the detergent should be anionic or
• All instruments on the mayo and back tables, whether used or unused nonionic with a pH close to neutral.
are considered contaminated and should be promptly and properly be - Alkaline detergent (pH over 8.5) will stain instruments;
cleaned, inspected, terminally sterilized, and prepared for subsequent - Acidic detergent (pH below 6) will corrode or pit the instruments.
use. b. Wash instruments carefully to guard against splashing and creating
1. Check all the drapes, towels and table covers to be sure that no aerosols.
instruments will go to the laundry or into the trash. A final quick Use a soft-bristled brush to clean serrations and box locks;
count is a safeguard. Keep instruments submerged while brushing to minimize
2. Collect all the instruments from the mayo, back table and other small aerosolizing microorganisms;
tables including those have been dropped or passed off the sterile use a soft cloth to wipe surfaces or a non-fibrous cellulose sponge to
field. prevent damage to delicate tips;
MEDICAL SURGICAL NURSING PAIN AND SURGERY MODULE 1.3
remove bone, tissue and other debris from cutting instruments; I. HANDLING POWERED INSTRUMENTS
never scrub surfaces with steel wool, wire brushes, scouring pads or
powders to protect the protective finish on metal (this protects the Electrically powered instruments like saws, drills, dermatomes, nerve
base metal from oxidation) stimulators;
Air powered instruments are small, lightweight, free of vibration and
RINSING easy to handle for pinpoint accuracy at high speeds;
Use hot distilled or deionized water in rinsing; Battery powered instruments are cordless
Should be done thoroughly to avoid staining the instruments. with rechargeable batteries;
after rinsing, put instruments back into sterilization racks or tray; Wipe off any organic debris between uses during the surgical
arrange instruments that can be steam sterilized in decontaminator. procedure;
Accessories are disassembled prior to cleaning;
STERILIZING Do not immerse the motor in liquid.
The sterilizing agent must come in direct contact with all surfaces of Lubricate as recommended using a silicone oil.
every instrument.
Instruments should be packed, individually or in sets to allow
adequate exposure to sterilant, to prevent air from being trapped and SURGEON’ ARMAMENTUM
moisture from being retained during the sterilization process, and to The surgeon relies on surgical instruments to enhance his or her skill in the
ensure sterile transfer to the sterile field. art and science of surgery. The nursing staff must ensure that these
Instruments are put in a container or tray, or wrapped in a small set or instruments function properly and sterilized adequately. Instruments are
individually, for sterilizing and transporting. Instruments maybe
selected on the basis of safety for their intended use. They must be
sterilized unwrapped immediately before use in a high-speed pressure
inspected, maintained, and used appropriately.
sterilizer, they may be prepared in advance as for a case cart, or
retained in storage until needed.

Steps in Assembling Instruments Sets in Sterilizer:

a. Make sure instruments are thoroughly dry;
b. Place an absorbent towel or foam in the bottom of the tray to
absorb condensate, unless contraindicated;
c. Count the instruments as they are placed in the tray and record
the number on a preprinted form;
d. Arrange instruments in a definite pattern to protect from
damage and to facilitate removal for counting and use;
e. Place heavy instruments like retractors in the bottom of the
tray;
f. Open hinges and box locks on all hinged instruments;
g. Place sharp and delicate instruments on top of other
instruments. Blades of scissors & delicate tips should not touch
other instruments;
h. Place concave or cupped instruments with these surfaces down
so that water condensate does not collect in them during
sterilization process;
i. Place ring-handled instruments on pins or holders designed for
this purpose. Curved instruments should be pointing in the
same direction, grouped together by style & classification. Do
not use rubber bands because steam cannot penetrate through or
under bands;
j. Disassemble all detachable parts. Secure properly the small
parts;
k. Separate dissimilar metals like brass instruments from stainless
steel instruments;
l. Place instruments with a lumen like suction tip in as near a
horizontal position as possible;
m. Distribute weight as evenly as possible in the tray. Some trays
have dividers, clips and pins attach to the bottom of the tray so
as to prevent the instruments from shifting and keep them in
alignment;
n. Place a chemical indicator on the outside wrapper or container
as well as inside the tray;
o. Label appropriately for intended use including the name of the
instruments or set, date sterilized, name of the person who
packed the instruments and the control number
MEDICAL SURGICAL NURSING PAIN AND SURGERY MODULE 1.4

MODULE 1.4: PRE, INTRA AND POST OPERATIVE PATIENT E. Nail polish and acrylic nails should be removed to permit observation of
CARE oxygenation and circulation.

PRE-OPERATIVE PATIENT CARE A. Oxisensor of Pulse Oximeter

B. Nail bed is a vascular part
A. LABORATORY & PHYSIOLOGICAL PREPARATION
F. Leave jewelries and all valuables at home. Metal jewelries like wedding
band must be removed to prevent burns if electro surgery will be used.
1. MEDICAL HISTORY AND PHYSICAL EXAMINATION –
PHYSICIAN
G. Other instructions of what to expect before, during and after operation –
2. LABORATORY TESTS – ordered by the surgeon and should be surgeon: when to arrive in the hospital for admission ; where the immediate
completed 24 hours before admission so results will be available for family will stay and wait before and after the operation.
review. INFORMED CONSENT
a. H & H, BUN, Blood Glucose – routine for 60 years old and
above should be facilitated by the surgeon and follow up by the nurse; the
b. Hematocrit surgeon explains the surgical procedure and the risks to the patient.
c. CBC, Platelet count, Prothrombin time is a legal document that provides evidence of patient’s agreement to
d. Blood typing and cross match allow a procedure to be performed on him/her;
e. Urinalysis or/and Fecalysis a signed consent is legally regarded as VALID for a period of about
6 months or for as long as the patient consents to the same
3. RADIOLOGIC TESTS procedure. Institutional policy may vary.
a. Chest X-ray – not all but required to patients with cardiac or
pulmonary disease, smokers, cancer patients & persons with 60 PURPOSES of INFORMED CONSENT
y/o and older
It provides a mechanism to protect a patient’s right to self-
4. ECG – routine to patients with cardiac disease and persons of 40 y/o determination regarding surgical intervention.
and up. It provides a means by which the patient can make an educated
choice about having a procedure performed.
5. DIAGNOSTIC PROCEDURES – performed when specifically GENERAL CONSENT
indicated, like in vascular surgery.
this form authorizes the physician and the hospital staff to render
6. WRITTEN INSTRUCTIONS – will come from surgeon and should treatment or perform procedures as the physician deems advisable.
be reviewed and followed by the patients before admission. this is relied on ONLY for routine duties performed in the hospital.
A. Should not ingest solid foods preceding the operation to prevent
Nurses should be knowledgeable about the statements on the form
aspiration and regurgitation or emesis.
used in their hospital
“ NPO AFTER MIDNIGHT ” –
SURGICAL CONSENT
Solid foods
will take 12 hours before it empties the stomach
specifically outlines each procedure to be performed and explains the
risks and benefits.
Clear liquids
should answer the following patient questions:
maybe unrestricted until 2 to 3 hours before the operation but still - What do you plan to do to me?
depends on the discretion of the surgeon & anesthesiologist. - Why do you want to do this procedure?
- Are there any alternatives to this plan?
Less time of NPO - What things should I worry about?
infants, small children, diabetic and elderly patients prone to - What are the greatest risks or the worst thing that could happen?
dehydration.
Is required for:
B. Oral medications – can be taken with minimal fluid intake up to 1-hour Each surgical procedure to be performed including secondary
pre op as prescribed with 150ml or less of water. procedures like I & D;
Any procedure for which a general anesthetic agent is administered
such as an examination of a child under anesthesia;
B. PHYSICAL PREPARATION OF PATIENT
Procedures involving entrance into a body cavity such as endoscopy;
C. Patient skin should be cleansed prior to operation using an antimicrobial Any hazardous therapy such as radiation.
soap for several days pre op.
PURPOSES OF SURGICAL CONSENT
D. Wash face, ear, neck and shampoo the hair To ensure that the client understand the nature of the treatment
(Male patients have to cut their hair short and shave on the day of the including the potential complications and disfigurement;
operation) To indicate that the client’s decision was made without pressure;
To protect the client against unauthorized procedures;
MEDICAL SURGICAL NURSING PAIN AND SURGERY MODULE 1.4
To protect the surgeon and hospital against legal action by the client. b. Golytely or Colyte normally clear the Bowel in 4 to 6 hours.

GUIDELINES ON CONSENT 2. Douche

ONLY the surgeon assigned is responsible to inform the patient use to cleanse the vagina during vaginal and pelvic procedures.
about the proposed procedure, its interest. Risks, complications and Patients who will be admitted the day of the surgical procedure may
what the patient may expect during and after the operation; be instructed to self-administer enema or douche at home.
Complete explanations should be given to the patient and the surgeon
3. Hair removal / preparation or Shaving
is responsible for making certain that the patient of legal guardian is
4. Bedtime sedation for sleep
adequately understands everything;
Consent should contain the following: E. PSYCHOLOGICAL PREPARATION
✓ Patient’s full name (maiden name)
✓ Surgeon’s full name FEARS RELATED TO SURGERY
✓ Complete and specific procedure to be performed General fear
✓ Signature of the patient - fear of the unknown
✓ Complete name of authorized witness - what to expect and what are the consequences of surgery
✓ Date and Time of signature - nursing action: allay anxieties by giving the patient opportunities to
Every patient is entitled to receive the sufficient information to be express his/her fears
performed on him/her. They have the right to waive an explanation of Specific fears
the nature and consequences of the procedure. They have the right to
decide what will and not to be done. Only after making this decision - fear of destruction of body image
is the patient asked to sign a written consent for operation. - threat to sexuality
The patient has the right to refuse the treatment. - fear of permanent disability
Consent should be signed by the patient before premedication and - fear of pain
before going to the Operating Room except in life threatening, - fear of dying
emergency situation.
There should be a WITNESS verifying the consent was signed F. SKIN PREPARATION OF PATIENT
without coercion.
Preoperative visit of the Peri operative Nurse; 1. Purpose of Skin Preparation:
Preoperative visit by the Anesthesiologist or Nurse Anesthetist – An To render the surgical site as free as possible from transient and resident
interview will be conducted before admission with patients who have microorganisms, dirt, and skin oil so the incision can be made through the
complex medical histories, are high risk or have high degrees of skin with minimal danger of infection from this source.
anxiety.
Hair removal is necessary especially if the hair surrounding the surgical
WHO SHOULD SIGN THE CONSENT? site is so thick ; it interfere with exposure, closure an dressing ; it prevent
Should be of legal age adequate skin contact with electrodes.
Should be mentally competent Clippers
An emancipated minor, married or independently earning a living Depilatory cream application
Illiterate may sign with an “X”, after which the witness writes Razor
“patient’s mark”.
CLIPPER
WHO SHOULD NOT SIGN THE CONSENT ?
- available in electric type or cordless handle with rechargeable
A minor batteries.
Unconscious - Electric clippers with fine teeth cut hair close to the skin.
Mentally incompetent - Clipping can be done immediately before the surgical procedure or up
to 24 hours preoperatively using short strokes against the direction of
* PARENT / LEGAL GUARDIAN / NEXT of KIN hair growth.
* SURGEON – should not sign the consent in behalf of the patient
DEPILATORY CREAM
CONSENT IN EMERGENCY SITUATION - Skin testing should be done first for possible allergies.
If obtained by telephone, 2 nurses should monitor the call and sign the - Should not be used around the eyes and genitalia.
form, which is signed later by the parent on arrival at the hospital. In lieu of - Should be applied on the skin, wait for 20 minutes before washed off.
these method, a written consultation by two physicians other than the
surgeon will suffice until a relative can sign a consent. RAZOR
D. PREOPERATIVE PREPARATIONS AN EVENING BEFORE - shaving should be done as near the time of incision as possible if this
ELECTIVE SURGICAL PROCEDURE. method must be used.
 Wear gloves when shaving with razor to prevent cross contamination
1. GIT Preparation (Bowel Preparation) even though this is a surgically clean procedure
a. “Enemas till clear” maybe ordered.
MEDICAL SURGICAL NURSING PAIN AND SURGERY MODULE 1.4
- Avoid making nicks and cuts in the skin. (Nicks done 30 minutes • NGT
before the surgical procedures are considered CLEAN WOUNDS.) • IV medications
- Use a sharp, clean razor blade. Hold the skin taut and shave by • Foley catheter
stroking in the direction of hair growth. Provide client and family teaching, instruct the client in:
- relaxation technique
HEAD SURGERY
- deep breathing and coughing exercises
For surgery of the cranium, follow the outline indicated by the surgeon. - Post op Exercises of extremities
Clip the hair before attempting to shave the scalp. Find out if long hair is to - turning and moving techniques
be saved for the patient. If so, follow local procedures. The actual shaving
- pain – control techniques
is often done in the surgical suite just before surgery, and the preparation
- Incentive spirometry use
done on the ward may be limited to cutting or clipping the hair close to the
scalp. 1. ASSESSMENT
Assess respiratory status, including history of pulmonary problems to
ABDOMINAL SURGERY identify risk factors for postoperative complications
Male patient's skin is shaved and cleaned from the nipple line to the upper Assess for and report evidence of F/E imbalance
third of the thigh, including the pubes (hair over the pubic regions) from Assess emotional status of client.
side to side anteriorly. For a female, the upper boundary is the breast fold Examine the client’s record for endocrine or metabolic problems that
on the chest wall. Particular care must be taken to assure adequate cleaning could affect his response to surgery (DM).
of crevices and indentations in the skin. An example on the abdomen is the Assess immunologic and hematologic functions
umbilicus. For kidney operations and surgery of the proximal third of the history of allergies
ureters, the skin is shaved from the axilla (which is prepped) to the groin. previous reactions to blood transfusions
history of substance abuse
CHEST SURGERY Assess neurologic functions
For chest surgery, the skin is shaved and cleansed on the affected side from Assess integumentary system
mid hip over the shoulder, including the axilla, to the shoulder on the
Evaluate medication history for drugs that could increase operative
unaffected side. risk for affecting coagulation time or interacting anesthetics;
RETROPERITONEAL SURGERY Assess the client for any type of prosthetic device or metal implants.
For rectal surgery, support the legs and thighs in the lithotomy position. Assess the client and his family’s knowledge base to guide the
Shave the pubic, perineal, thigh, and anal areas (in a radius of about 10 preoperative teaching program.
inches from the anus). Assess the laboratory and diagnostic results of the patient (x-ray, cbc,
wbc, etc.)
VAGINAL SURGERY
For gynecological surgery (perineal prep) support legs and thighs in the 2. NURSING DIAGNOSIS
lithotomy position and shave the anterior surface from the umbilicus down: Anxiety
the pubic area, the external genitalia, the perineum, including the area Knowledge deficit
around the anus, and the buttocks. Shave inner thighs halfway to the knees
from the middle of anterior to middle of posterior thighs. 3. PLANNING AND OUTCOME IDENTIFICATION
Major goals:
SURGERY of the LIMBS Decreased anxiety and increased knowledge of the surgical
For surgery of the limbs, the area includes the entire circumference. The experience.
extent of the prep varies depending upon the type of operation. As an Promote measures that help decrease anxiety for the client and his
example, for surgery of the hand, the prep would normally extend distally family.
from the elbow. A manicure or pedicure is also necessary. Fingernails or
toenails must be clipped short, cleaned, and scrubbed. ANESTHESIA

A. DEFINITION OF ANESTHESIOLOGY
SKIN MARKING
Surgeon uses a staining solution to mark the incision lines on the
skin. This maybe done before the patient is prepped. • branch of medicine that is concerned with the administration of
If the skin is marked after prep, a sterile dye solution and applicator medication or anesthetic agents to relieve pain and support
or a sterile marking pen must be used. physiologic function during a surgical procedure.
 METHYLENE BLUE or ALCO-HOLIC GENTIAN VIOLET • is a specialty that requires knowledge of biochemistry, clinical
pharmacology, cardiology, and respiratory physiology.
G. PRE-OPERATIVE HEALTH TEACHINGS • the practice of medicine dealing with management of procedures for
rendering a patient insensible to pain during surgical procedures and
with support of life functions under the stress of anesthetic and
Post-op exercises
surgical manipulations. (accdg. to ABA).
Equipment used during post-op period
• oxygen, pulse oximeter, CVP
• ventilator
MEDICAL SURGICAL NURSING PAIN AND SURGERY MODULE 1.4
B. TERMINOLOGIES REASONS:
1. Reducing the risk of N & V
Amnesia – loss of memory; an indifference to pain 2. Decreasing secretions in the respiratory tract;
Analgesia – lessening of or insensibility to pain 3. Diminishing vagal nerve effects on the heart;
Anesthesia – loss of feeling or sensation, esp. loss of the sensation of pain 4. Counteracting the undesirable side effects of the anaesthetic medicines;
with loss of protective reflexes 5. Raising the pain threshold.
Analgesic – drug that relieves pin by altering perception of painful stimuli
without producing los of consciousness CONSIDERATIONS IN THE CHOICE OF PRE ANESTHETIC
Anesthetist – person who administers anesthesia DRUGS:
Anesthesiologist – doctor of medicine who specializes in the field of Patient’s physical and emotional status;
anesthesia Age;
Anoxia – absence of oxygen Weight;
Apnea – suspension or cessation of breathing Medical and Medication history;
Fasciculation – uncoordinated skeletal muscle contraction in which groups Laboratory test result;
of muscle fibers innervated by the same neuron contract together. Radiographic and ECG findings;
Induction – period from beginning of administration of anesthetic until Demands of the surgical procedures;
patient loses consciousness and is stabilized in the desired plane of Patient’s concerns
anesthesia.
Emergence – return of sensation and reflexes; to regain consciousness In choosing pre anesthetic premedication, the anesthesiologist aims to
following general anesthesia. disturb respiration and circulation as little as possible.
Intubation – insertion of endotracheal tube
Extubation – removal of endotracheal tube The primary consideration with any anesthetic is that it should be
Hypnosis – artificially induced sleep associated with LOW MORBIDITY & MORTALITY.
Hypnotic – a drug which induces sleep
Margin of Safety – the difference between therapeutic and lethal dosage An ideal preoperative medication has quick onset, short duration of
action and minimal side effects.
C. STAGES OF ANESTHESIA
TIME GIVEN:
Stage I – Onset / Induction Premedication is usually given at least 45 minutes before induction.
Some drugs require 60 to 90 minutes to reach peak effect.
• extends from the administration of anesthesia to the time of loss
of consciousness.
PREMEDICINES:
• drowsy, dizzy, amnesic, exaggerated hearing, decreased pain
Sedatives and tranquilizers
Stage II – Excitement / Delirium Stage (Loss of Consciousness Stage) Narcotics
Antimuscarinics / Anticholinergics
• extend from time of loss of consciousness to the time of loss of
Antiemetics / Antinauseants
lid reflex.
• may be characterized by shouting, struggling of the patient, E. TYPES OF ANESTHESIA
excited with irregular breathing & movements of extremities,
susceptible to stimuli like noise and touch.
Choice of Type of Anesthesia:
• patient is NOT TO BE STIMULATED during this stage and
Provide maximum safety for the patient;
restrain the Patient
Provide optimum operating conditions for the surgeon;
Stage III – Stage of Surgical Anesthesia (Stage of Relaxation) Provide patient comfort;
• extends from the loss if lid reflex to the loss of most reflexes. Have a low index of toxicity;
Provide potent, predictable analgesia extending into post op period;
• surgical procedure is started
Produce adequate muscle relaxation;
• there is regular respiration, contracted pupils, reflexes
disappear, muscle relax, lost auditory sensation. Provide amnesia;
Have rapid onset and easy reversibility;
Stage IV – Danger Stage Produce minimum side effects
• characterized by respiratory & cardiac depression or arrest. It is
due to overdose of anesthesia. Factors to Consider in the Choice of Anesthesia :
• resuscitation must be done 1. Age and size /weight of the patient;
2. Physical, mental, and emotional status of patient;
• not breathing, little or no pulse or heartbeat
3. Presence of systemic diseases or concurrent drug therapy;
4. Presence of infection at the site of the surgical procedure;
D. PRE-ANESTHETIC PREMEDICATION 5. Previous anesthesia experience;
• maybe given to allay preoperative anxiety, produce some 6. Anticipated procedure;
analgesia and amnesia and dull awareness of the OR 7. Position required for procedure;
environment. 8. Type and expected length of procedure;
MEDICAL SURGICAL NURSING PAIN AND SURGERY MODULE 1.4
9. Local or systemic toxicity of the agent; Pontocaine
10. Expertise of the anesthesiologist; Lidocaine (Xylocaine)
11. Preference of the patient
2. REGIONAL ANESTHESIA
Types of Anesthesia
General Anesthesia LOCAL BLOCK
Regional Anesthesia
• only the peripheral nerves around the area of the incision are blocked
a. Topical
b. Local Block FIELD BLOCK
c. Field Block
• the area surrounding the incision is injected and infiltrated with local
d. Nerve Block
anesthesia.
e. Spinal Anesthesia
Epidural Anesthesia NERVE BLOCK
• blocks nerve (brachial, inter costal, radial, femoral
GENERAL ANESTHESIA
pain is controlled by general insensibility; there is total loss of
SPINAL ANESTHESIA (SUB ARACHNOID)
consciousness and sensation; produces amnesia, analgesia,
interference with undesirable reflexes and muscle relaxation. • sensation of pain is blocked at a level below the diaphragm, the agent
administered through INTRAVENOUS, INHALATION or is injected in the spinal canal.
RECTAL INSTILLATION • the anesthetic agent is injected into the subarachnoid space if the
spinal fluid is clear and flowing freely.
REGIONAL ANESTHESIA
sometimes called CONDUCTION ANESTHESIA; produces loss of • HIGH, MID, LOW SPINAL ANESTHESIA
painful sensation in one area or region of the body and does not result
in unconsciousness. SPINAL ANESTHESIA MEDICATIONS
Procaine HCL (Novocaine)
ADVANTAGES: Dibucaine HCL (Nupercaine)
Use of minimal and simple equipment; economy Tetracaine HCL (Pontocaine)
No loss of consciousness Lidocaine (Xylocaine)
Suitable for ambulatory patients Mepivacaine (Carbocaine)
Better airway control Bupivacaine (Marcaine)
Fewer respiratory complications
ADVANTAGES OF REGIONAL ANESTHESIA:
DISADVANTAGES: Ease of administration
Too rapid absorption of the drug into the blood Expensive equipment & drugs not necessary
Anxiety and fear are not allayed, patient continues to see and hear Relative safety of method
throughout the procedure. Excellent muscle relaxation provided
Difficult to use with small children, senile patients, and Does not cause fetal depression
uncooperative persons. Does not cloud patient consciousness or alertness
can be used for patients with full stomach since the patient will be
CONTRAINDICATIONS:
awake to maintain his own airway in event of vomiting
Local infection or malignancy which may be carried to and spread in
adjacent tissues by infection of needles. COMPLICATIONS OF REGIONAL ANESTHESIA:
Septicaemia Hypotension – due to paralysis of vasomotor nerves
Allergies MGT:
Highly nervous, apprehension and excitable patients or those unable O2 administration
to cooperate because of mental stage like children. Trendelenburg position
Ephedrine IV as stimulant
TECHNIQUES OF ADMINISTRATION OF REGIONAL Blood or plasma by IV
ANESTHESIA Nausea and Vomiting
Pain during surgery
1. TOPICAL ANESTHESIA
Headache
MGT:
• drug is sprayed or dropped onto an area to be desensitized, block Administer fluids
peripheral nerve endings, in the skin, mucus membrane of the vagina, Administer analgesics
rectum, nasopharynx and mouth.
Apply tight abdominal binder
Cocaine 4 to 10% solution
Butacaine Respiratory paralysis
MEDICAL SURGICAL NURSING PAIN AND SURGERY MODULE 1.4
MGT: knees. Head is in line with spine. Note that small pillow under ankles to
Artificial respiration by anaesthesia machine protect heels from pressure.
- Face, neck, shoulder, antero-lateral procedures;
Resuscitation or mouth to mouth breathing
- Breast, axillary, upper extremity or Hand surgery;
➢ Neurologic complications like paraplegia, severe muscle weakness
in the legs (due to use of unsterile needles, syringes and anesthetic
agents)

3. EPIDURAL ANESTHESIA

frequently involve injection of drugs through a catheter placed into the

epidural space. The injection can result in a loss of sensation—including
the sensation of pain—by blocking the transmission of signals through
2. Trendenburg’s Position
nerves in or near the spinal cord.
- The patient lies on the back in supine position with knees over the
lower break of the table. The knees must bend with the table break to
SPINAL VS EPIDURAL ANESTHESIA : prevent pressure on peroneal nerves and veins in the legs.
1. To achieve epidural analgesia or anaesthesia, a larger dose of drug is - This position is used for procedures in the lower abdomen or pelvis
typically necessary than with spinal analgesia or anaesthesia; when it is desirable to tilt the abdominal viscera away from the pelvic
2. The onset of analgesia is slower with epidural analgesia or area for better exposure.
anaesthesia than with spinal analgesia or anaesthesia;
3. An epidural injection may be performed anywhere along the vertebral
column (cervical, thoracic, lumbar, or sacral), while spinal injections
are typically performed below the second lumbar vertebral body to
avoid piercing and consequently damaging the spinal cord;
4. It is easier to achieve segmental analgesia or anaesthesia using the
epidural route than using the spinal route;
5. An indwelling catheter is more commonly placed in the setting of
epidural analgesia or anaesthesia than with spinal analgesia or 3. Reverse Trendelenburg’s Position
anaesthesia. - The patient lies on back. Footboard is padded and raised. The entire
OR table is tilted so head is higher than feet. Strap of the OR table is
DANGERS AND GENERAL COMPLICATIONS OF ANESTHESIA: placed below the knees.
1. Cardiac Arrest – certain agent result in the retention of CO2 which - used for gallbladder or biliary tract procedures to allow abdominal
leads to anorexia, respiratory acidosis and cardiac arrest. viscera to fall away from the epigastrium, giving access to upper
2. Respiratory depression – excess mucus; use of muscle relaxants; abdomen.
use of depressants.
3. Bronchospasm and laryngospasm – may lead to airway obstruction
due to allergic reaction to the anesthesia and irritating effects of
agents on bronchial and laryngeal mucosa.
4. Diminished circulation – due to poorly distributed blood supply in
the body.
5. Hypotension and Shock – due to preoperative medications and
blood loss.
6. Vomiting and Aspiration – due to full stomach and reflex
4. Fowler’s Position
stimulation of the patient’s vomiting center.
- The patient lies on the back with the buttocks at the flex of the table
SURGICAL POSITIONS and knees over the lower break. The foot of the table is lowered
slightly, flexing the knees. The body section is raised 45 degrees,
thereby becoming the back rest. Arms may rest on arm boards
A. FACTORS THAT INFLUENCE POSITIONING OF THE
parallel to table or on a large soft pillow on the lap. Feet should rest
PATIENT
on the padded footboard to prevent foot drop.
1. Procedure to be performed
- Safety belt is secured 2 inches above the knees.
2. Surgeon’s choice of surgical approach
3. Age, height, weight of patient - used for shoulder, nasopharyngeal, facial and breast reconstruction
4. Cardiopulmonary status procedures.
5. Pre-existing diseases

B. DIFFERENT SURGICAL POSITIONS

1. Supine Position
Patient lies straight on back, face upward, with arms at sides, legs extended
parallel and uncrossed, feet slightly separated. Strap is placed above
MEDICAL SURGICAL NURSING PAIN AND SURGERY MODULE 1.4
- This position is used for sigmoidoscopy and culdoscopy.
5. Lithotomy Position
- Patient is on back with foot section of table lowered to right angle
with body on table. Knees are flexed and legs are on inside of metal
posts or stir ups. Note the buttocks are even with the table edge.
- Patient is on back with foot section of table lowered to right angle
with body on table. Knees are flexed and legs are on inside of metal
posts or stir ups. Note the buttocks are even with the table edge.

10. Sim’s Recumbent Position

- A modified left lateral recumbent position, the patient lies on the left
side with the upper leg flexed at the hip and knees. The lower leg is
straight. The lower arm is extended along the patient’s back with
weight of the chest on the table. The upper arm rests in a flexed
position on the table.
- this position is preferred for endoscopic examination performed via
6. Dorsal Recumbent Position the anus in obese or geriatric patients.
- The patient is in supine position except that the knees are flexed and
thighs externally rotated. Soles of the feet rest on the table. Pillows
maybe placed under the knees if needed for support.
- This position is used for some vaginal and perineal procedures.

11. Lateral Position

- Referred to synonymously as lateral, lateral decubitus or lateral
recumbent.
- Note strap across hip of the patient to stabilize the body. Pillow
7. Modified Recumbent Position (Frog-legged) between legs can be placed to relieve pressure on lower leg.
- The patient is in supine position except that the knees are slightly - This position is used for access to the hemo thorax, kidneys, or
flexed with a pillow beneath each. The thighs are externally rotated. retroperitoneal space.
- for surgical procedures in region of the groin or lower extremities.

8. Kraske (Jack knife) Position

- Patient’s hips are over central break in the OR table and knees strap is
below knees. Note chest rolls in place and pillow under feet.
- This position is used for rectal surgeries like hemorrhoidectomy and
pilonidal sinus procedure.

12. Lateral Jack Knife Position

Patient is in lateral position with kidney region over the table break. Note
kidney strap across the hip to stabilize the body; raised kidney elevator for
hyper-extending surgical site and pillow between legs. Patient’s side is
horizontal from shoulder to hip.

9. Knee – Chest Position

- An extension is attached to the foot section. The OR table is flexed at
the center break, the lower section is broken until it is at a right angle
to the table. The patient kneels on the lower section and the entire
table is tilted to elevate the pelvis.
- The knees are thus flexed at a right angle to the body. The upper
portion of the table maybe raised slightly to support the head, which 13. Sitting Position
is turned to the side. The arms are placed around the head with
- Patient is placed in fowler’s position except that the torso is in upright
elbows flexed, with soft pillow beneath. The chest rests on the table.
position. Shoulders and torso should be supported with body straps
Safety belt is above the knees.
but not so tightly as to impede circulation and respiration.
MEDICAL SURGICAL NURSING PAIN AND SURGERY MODULE 1.4
- this position is used for some otorhinologic and neuro-surgical 6. Drapable to fit around contours of patient, furniture and equipment.
procedures. 7. Dull, non-glaring to minimize color distortion from reflected light.
8. Free of toxic ingredients such as laundry residues and non-fast dyes.
9. Flame resistant to self-extinguish rapidly on removal of an ignition
source.

C. DRAPING MATERIALS
1. Self-adhering Sheeting – sterile, waterproof, antistatic and transparent
or translucent plastic sheeting that can be applied to dry skin.

Advantages :
✓ Resident microbial flora from skin pores, sebaceous glands and hair
14. Prone Position follicles cannot migrate laterally to the incision.
- Patient lies on abdomen. Chest rolls under axillae and sides of chest ✓ Microorganisms do not penetrate the impermeable material.
to iliac crests raise body weight from chest to facilitate respiration; ✓ Landmarks and skin tones are visible through the transparent plastic.
pillow under feet to protects toes. ✓ Inert adhesive holds drapes securely, eliminating the need for towel
- this position is mostly used for spinal surgeries. clips and possible puncture of the patient’s skin.
✓ Plastic sheeting conforms to body contours and has elasticity to
stretch without breaking its adhesion to skin.
✓ Have some sufficient moisture-vapor permeability to reduce
excessive moisture build-up that could macerate the skin/ and / or
loosen adhesive.
✓ The heat retaining property of plastic causes the patient to perspire
excessively, but the nonporous nature of the sheeting prevents
evaporation.
C. NURSING RESPONSIBILITIES IN POSITIONING THE SELF-ADHERING SHEETING IS USED IN THE FOLLOWING
PATIENT MANNER:
1. Explain why the position and restraints are necessary; 1. The usual skin preparation is done;
2. Preserve client’s dignity by providing privacy and avoid undue 2. The scrubbed area must be dry;
exposure; 3. Transparent plastic material is applied firmly to the skin, with the
3. Secure patient with well-padded straps to prevent nerve and tissue initial contact along the proposed line of incision. The drape is
damage; smoothed away from the incision site.
4. Maintain adequate respiratory and vascular circulation by avoiding 4. Regular fabric drapes are applied over the plastic sheeting unless
pressure on body parts because it can impair circulation; plastic is incorporated into the fenestrated area of the drape.
5. Do not allow client’s extremities to dangle over the side of the OR
table; 2. Nonwoven Fabric Disposable Drape
6. Place hand support on the sides of the table; - are compressed layers of synthetic fibers (i.e. rayon, nylon or
7. Avoid excessive strain on the patient’s muscles; polyester) combined with cellulose (wood pulp) and bonded together
8. Always move both lower extremities at the same time when putting chemically or mechanically without knitting, tufting or weaving.
them up in the stir ups and when lowering down the hips to prevent - may be either absorbent or nonabsorbent.
hip dislocation and muscle straining.
ADVANTAGES OF USING NONWOVEN FABRIC DISPOSABLE
SURGICAL DRAPING DRAPES:
They are moisture repellant. They retard blood and aqueous fluid
A. DEFINITION moisture strike-through to prevent contamination.
Draping - is the procedure of covering the patient and surrounding areas They are lightweight, yet strong enough to resist tears.
with a sterile barrier to create and maintain an adequate sterile field. They are lint free unless cellulose fibers are torn or cut.
Contaminants are disposed of along with drapes.
B. CRITERIA IN DRAPING They are antistatic and flame retarded for OR use.
1. Blood and fluid resistant to keep drapes dry and prevent migration of They are prepackaged and sterilized by the manufacturer, which
microorganisms. Material should be impermeable to moist microbial eliminates washing, mending, folding, and sterilizing processes.
penetration.
2. Resistant to tear, puncture or abrasions that causes fiber breakdown 3. Woven Textile Fabrics
and thus permits microbial penetration.
are tightly woven fabrics that inhibit migration of microorganisms.
3. Lint free to reduce airborne contamination and shedding into the
Reusable drapes may be made of 270- or 280- thread-count pima cotton or
surgical site.
4. Antistatic to eliminate risk of a spark from static electricity. Material 100% Polyester.
must meet standards of Bureau of Fire Protection.
5. Sufficiently porous to eliminate heat buildup so as to maintain an iso-
thermic environment appropriate for patient’s body temperature
MEDICAL SURGICAL NURSING PAIN AND SURGERY MODULE 1.4

THINGS TO CONSIDER ABOUT REUSABLE WOVEN TEXTILE WHO SURGICAL CHECKLIST FORM:
DRAPES: B. NURSING DIAGNOSIS
Material must be steam-penetrable and must withstand multiple ✓ Risk for fluid volume deficit or excess
sterilization cycles. ✓ Risk for hypothermia and hyperthermia
When packaged for sterilization, drapes must be properly folded and ✓ Risk for infection and injury
arranged in sequence of use. Drapes may be fan-folded or rolled.
Material must be free from holes and tears. C. PLANNING
Drapes must be sufficiently impermeable to prevent moisture from Maintenance of fluid balance
soaking through them. Maintenance of normothermia
Reusable fabrics must maintain barrier qualities through multiple Prevention of infection
launderings. The number of uses, washings, and sterilizing cycles
Absence of Injury
should be recorded and drapes that are no longer effective as barriers
should be taken out of use.
D. IMPLEMENTATION
75 washings – densely woven treated cotton Promote measures that will maintain adequate fluid and electrolyte
30 washings – untreated cotton balance by:
✓ Monitoring I / O accurately
D. TYPES/ STYLES OF DRAPES ✓ Assessing for signs of dehydration
✓ Towels ✓ Assessing for circulatory overload (breath sounds, peripheral edema
✓ Draw Sheet and jugular vein distention)
✓ Stockinette Promote measures that will maintain patient’s normal body
✓ Fenestrated Sheets temperature.
• Laparotomy Sheet Promote measures that will decrease risk of infection
Ensure patient’s safety in the operating room.
• Thyroid Sheet
• Chest Sheet SURGICAL INCISIONS
• Hip Sheet
• Perineal Sheet A. DEFINITION
• Laparoscopy Sheet is a cut made through the skin and soft tissue to facilitate operation or
✓ Separate Sheets procedure.
• Split sheet The aim is to employ the most suitable type of incision for the
• Minor sheet particular surgical procedure by achieving these 3 things:
accessibility, extensibility, and security.
• Medium sheet
• Single sheet B. LAYER OF ANTERIOR ABDOMINAL WALL
• Leggings ✓ Skin
• St. Mary’s sheet ✓ Subcutaneous Tissue
✓ Superficial Fascia
INTRA OPERATIVE NURSING CARE PLAN: ✓ Deep Fascia
✓ Muscle
A. ASSESSMENT ✓ Peritoneum
1. Classifying the patient’s physical status for anesthesia;
2. Assess the patient’s record for appropriate documentation. C. TYPES OF SURGICAL INCISIONS
3. Maintaining safety and preventing injuries during positioning at the OR 1. Vertical Incision
table; Midline or Laparotomy Incision or Celiotomy - most traditional
and common surgical incision;
➢ Explain the purpose of positioning • Varies in size / length depending on the type of surgery;
➢ Safely and securely strap the patient to prevent falls • Incision is made mostly in avascular plane and does not impose
➢ Maintain adequate respiratory and circulatory function a great risk to the blood supply;
➢ Maintain good body alignment • Almost bloodless, no muscle fibers are divided & no nerves are
injured;
4. Assess for surgical consideration and precautions; • Provides the best visualization and intra-abdominal access;
5. Assess patient’s risk for accidental hypothermia or malignant • Commonly used for exploratory procedures and traumas.
hyperthermia;

Paramedian Incision
MEDICAL SURGICAL NURSING PAIN AND SURGERY MODULE 1.4
• Offsets vertical incision to right or left, providing access to K. Supraclavicular Incision
lateral organs like spleen or kidneys. - Is a transverse incision superior to the clavicle;
• Closure is more secure because rectus muscle can act as a - Advantage of this incision is that it can meet a sternotomy incision or
buttress between posterior and anterior fascial plane. a cervical incision to provide greater exposure to cervical anatomy or
thoracic anatomy
2. Transverse & Oblique Incisions - most often utilized in trauma to gain access to the subclavian vessels.
A. Kocher or Subcostal Incision
- Incision on the right side of the abdomen to expose the gall bladder L. McEvedy Incision
and biliary tree; - Is a vertical incision from the femoral canal and brought superior to
- Incision made inferior and parallel to the subcostal margin extending above the inguinal ligament;
through the anterior rectus fascia, rectus muscle, internal oblique, - Caution should be made not to injure the femoral vein, artery or
transverse abdominis, transversalis fascia & peritoneum. nerve;
- Post operative pain is greater due to the severing of the rectus muscle. - Incision made to repair femoral hernias
- Incision made is not on an avascular plane; M. Inguinal or Groin Incision
- Is a transverse or oblique incision over the inguinal canal which is
B. Abdominal Incision - for abdominal surgeries made through the skin to the subcutaneous fat, through camper and
scarpa fascia;
C. Lumbotomy or Transverse Incision - for Kidney surgeries - used for open inguinal hernia repairs;
N. Gibson Incision
D. McBurney’s Incision or Gridiron - for Appendectomy - Is made 3 centimeters above and parallel to the inguinal ligament;
- Used in gynecological procedures and urological procedures
E. Lanz or Rockey-Davis Incision O. Supra-umbilical/ Infra-umbilical Incision
- Similar to a gridiron incision and is useful for open appendectomies. - Used for access into the peritoneum through the tissues surrounding
- Incision is horizontal incision while the gridiron incision is on an the umbilicus;
oblique angle. - Commonly used for repair of umbilical hernias.
P. Para-rectus Incision
F. Thoraco-abdominal Incision
- Incision made through the semilunar line laterally to the rectus
- Unique incision that connects the pleural cavity and the peritoneal abdominis muscle;
cavity;
- Used for spigelian hernia repair or if modified, can be used for an
- Right sided incision provides good exposure of the hepatic region and ostomy.
right kidney; Q. Butterfly Incision – for craniotomy
- Left sided incision provides good exposure of the stomach and distal R. Limbal Incision – for eye surgeries
esophagus S. Halstead / Elliptical – for breast surgeries

G. Pfannenstiel Incision POST OPERATIVE PHASE

- Is a transverse lower abdominal incision that is made superior to the
pubic ridge. A. THREE PHASES OF THE POST OPERATIVE PERIOD.
- Commonly used for cesarean sections, urologic, orthopedic and
pelvic surgeries; B. CRITERIA TO LOOK INTO THE PATIENT PRIOR TO
- provides limited exposure beyond the pelvis. DISCHARGE FROM THE PACU ACCORDING TO FAIRCHILD
(1993).
H. Maylard Incision (Mackenrodt)
Is a transverse incision 6 cm above the pubic tubercle that is made through C. POTENTIAL POST OPERATIVE PROBLEMS
the rectus abdominis to gain access to pelvic structures. c.1. Respiratory problems
c.2. Circulatory problems
I. Chevron Incision c.3. Urinary problems
- Incision made that crosses the midline of the abdomen; c.4. GI problems
- Is a subcostal incision that extends from the mid to lateral costal c.5. Wound healing problems
ridge, across the midline to the contralateral side;
- Provides good exposure of hepatic, pancreatic, upper gastrointestinal D. THE EMPHASIS OF NURSING CARE AFTER SURGERY
region, adrenal or renal surgeries; The maintenance of proper respiration, circulatory and gastro intestinal
functions, alleviation of pain, promoting faster wound healing, maintaining
J. Sub-clavicular (Infra-clavicular) Incision a safe environment and preventing / managing potential post-operative
Transversely made through the skin and subcutaneous tissue inferior to the complications.
clavicle, giving access to the subclavian vessels.