PERIOPERATIVE NURSING

JOEFREY D. GAERLAN RN RM MAN

 PRE-OPERATIVE

From decision for surgical

intervention to transfer to
operating room
 Intra-operative

From received in
operating room to
admission in the recovery
room
 Post-operative

From admission in the

recovery room to follow up
evaluation
 Types of surgery
Optional- at the
preference of patient.
Surgery not needed
Example: cosmetic
surgery, liposuction
Elective- at the
convinience of patient as
failure to have surgery is
not catastrophic
Example: excision of
superficial cyst
Planned/required-within
a
few weeks as surgery is
important
Example: cataract
extraction
 Urgent/imperative

Within24 to 48 hours
Exmaple: cancer surgery
 Emergency
Immediately without delay
to maintain life or
organ,remove damage,
stop bleeding
Exmaple: intestinal
obstruction
 Diagnostic

To confirm a diagnosis

Example: excision or
biopsy
 Exploratory
To estimate the extent of
the disease and confirm
diagnosis as well
Example: exploratory
laparotomy
 Curative

Ablative-removal of
diseased organ
Example: hysterectomy
Contructive-repair of
congenital defects
Exmaple: repair of cleft
lip or palate
 Reconstructive

Restoration of damaged
organ
Example: episioraphy
 Pallative
Relieves symptom but
does not cure the disease
Example: rhizotomy and
chordotomy (for pain
relief); myringotomy (for
otitis media).
 Types of surgery
according to extent:
Major; extensive surgery
that involves serious risk
and complications (and loss
of blood) as it involves
major organ
Minor: surgery that involves
minimal (few) complications and
minimal blood loss.
Principles of surgical asepsis
Always face the sterile field
Should be above waist level
and on top of sterile field.
Eliminate moisture that causes
contamination
Prevent unnecessary traffic and
air current (close door, minimize
talking, don’t reach across the
sterile field).
Safer to assume
“contaminated” when in
doubt.
Involves team effort
(collective and individual
“sterile conscience”
Sterile articles unused and
opened and no longer sterile
after procedure.
 Surgical hand scrub
Put on sterile attire
Perform initial handwashing (to
remove gross contamination)
Use warm water
Band elbows so that hand is
higher than elbows (no
contamination of hand during the
scrub).
Use “counted brush stroke
method’ starting fingertips
with scrubbing every part of
fingers, web space, palmar
surface, dorsal surface, and
forearm. Scrub vigorously with
vertical and circular strokes.
Do not touch anything( faucet,
clothings, or other objects)
Rinse under running water
with hand higher than
elbows and keep held up
Dry with sterile towel
Operating Room Nurse
(Perioperative Nurse)

Definition: It is a field of
nursing where in nurses provide
care and support to
patients before, during and
after surgery.
These nurses are responsible
for maintaining a sterile
environment in the operating
room, monitoring the patient
during surgery and coordinating
care throughout the process.
These are registered nurses
who work in hospital surgical
departments, day-surgery units,
clinics and physician’s
offices.They are relied upon for
their professional judgement and
critical thinking skills.They help
plan, implement and evaluate
treatment of the patient.
Special Qualifications:

a)Knowledge-it is mandatory
of operating room techniques
and management.
b)Education-graduated from
an accredited school of
nursing.
c)Training-completion of an
operating room nursing course.
d)Experience-a minimum of 12
months.Experience should
include all phases of operating
room techniques and
management such as preparing
operating room units, preparing
patients for surgery and
assisting medical officer during
surgery and equipment
sterilization procedure.
Roles a perioperative nurse may
play:
1)Scrub nurse-selecting and
handling instruments and
supplies used for the operation.
2)Circulating nurse-managing the
overall nursing care in the
operating room and helping to
maintain a safe and comfortable
environment.
3)RN first assistant-delivering
direct surgical care by assisting
the surgeon in controlling
bleeding, providing wound
exposure and suturing during the
actual procedure
Duties and responsibilities:

1)Pre operative procedure

a.The OR nurse reviews
patient’s medical history.
b.Coordinates with ward
personnel to obtain patient
information.
c.Assists in transporting, moving
and positioning the patient.
d.Assists in the care and
handling of supplies and
equipments and confers with the
surgeons concerning instruments,
sutures, prosthesis and special
equipments to be used.
e.Ensures aseptic
techniques are used in
preparation of the
materials, equipments and
instruments before surgical
procedure.
2)Intra operative procedure
a.The OR nurse ensures aseptic
techniques are maintained during
surgical procedure.
b.Initiates ACLS measures and
implements emergency measures
as needed.
c.Conducts proper needle and
sponge count before and after
each procedure.
3)Post operative procedure
a.The OR nurse packages
instruments for sterilization and
assists in the care and handling
of supplies and equipments.
b.Ensures equipments are
disassembled, sterilized,
cleaned and stored correctly..
c.Ensures collection of
medical waste.
d.Sends specimen to the
laboratory
4)Administrative duties
a.Assists with clinical research
by means of data collection..
b.Provides nursing
oversight to all
paraprofessional health
care providers
c.Maintains current licensure
and/or certificate as required.
d.Maintain stock level for OR
sets and supplies.
e.Provides orientation and on
the job training to newly
assigned nurses and other
paraprofessionals.
Qualities of an OR nurse:

1)Leadership skill
2)Problem-solving skill
3)communication skill
4)Resource management skill
5)Teamwork/cooperation
6)Frequent public
contact/customer relations
Commonly used pre-
operative medications
 Tranquilizer

Diazepam( Valium)-
decrease anxiety and
apprehension
Undesried effect: confusion,
clumsiness, dizziness
 SEDATIVES
Promethazine ( Phenargan)-
decrease anxiety and
antiemetic
Undesired effect;
hypotension during and after
surgery
Secobarbital- decrease
anxiety, promote sedation
Undesired effect;
disorientation
 Analgesic
Morphine sulfate- relieve pain,
decrease anxiety, sedation
Undesired effect: respiratory
depression
Hypotension, circulatory
depression, decrease gastric
motility (vomiting)
 Anticholinergics

Atropine sulfate- control

secretion
Undesired effect: excessive
dryness of the mouth,
tachycardia
 Histmamine (H2)
Receptor Antagonist
Cimtedine (Tagamet)
Ranitidine (Zantac)
Inhibits gastric acid production
Undesired effect; mild
dizziness, diarrhea,
somnolence
Amnesia—The loss of memory.

Analgesia—A state of insensitivity to

pain even though the person remains
fully conscious.

Anesthesiologist—A medical specialist

who administers an anesthetic to a
patient before he is treated.
Anesthetic—A drug that causes
unconsciousness or a loss of
general sensation.

Arrhythmia—Abnormal heart beat.

Barbiturate—A drug with hypnotic

and sedative effects.
Catatonia—Psychomotor disturbance
characterized by muscular rigidity,
excitement or stupor.

Hypnotic agent—A drug capable of

inducing a hypnotic state.
Hypnotic state—A state of heightened
awareness that can be used to modulate
the perception of pain.
Hypoxia—Reduction of oxygen supply
to the tissues.

Malignant hyperthermia—A type of

reaction (probably with a genetic
origin) that can occur during general
anesthesia and in which the patient
experiences a high fever, muscle
rigidity, and irregular heart rate and
blood pressure.
Medulla oblongata—The lowest
section of the brainstem, located next to
the spinal cord. The medulla is the site
of important cardiac and respiratory
regulatory centers.
Opioid—Any morphine-like
synthetic narcotic that produces the
same effects as drugs derived from
the opium poppy (opiates), such as
pain relief, sedation, constipation
and respiratory depression.
Pneumothorax—A collapse of the
lung.

Stenosis—A narrowing or
constriction of the diameter of a
passage or orifice, such as a blood
vessel.
Currently used inhaled general
anesthetics include halothane,
enflurane, isoflurane, desfluorane,
sevofluorane, and nitrous oxide.
* Halothane (Fluothane) is a
powerful anesthetic and can easily
be overadministered. This drug
causes unconsciousness but little
pain relief so it is often used with
other agents to control pain. Very
rarely, it can be toxic to the liver in
adults, causing death
It also has the potential for causing
serious cardiac dysrhythmias.
Halothane has a pleasant odor, and was
frequently the anesthetic of choice for
use with children, but since the
introduction of sevofluorane in the
1990s, halothane use has declined.
* Enflurane (Ethrane) is less potent and
results in a more rapid onset of
anesthesia and faster awakening than
halothane. In addition, it acts as an
enhancer of paralyzing agents.
Enflurane has been found to increase
intracranial pressure and the risk of
seizures.
* Isoflurane (Forane) is not toxic to the
liver but can cause some cardiac
irregularities. Isofluorane is often used
in combination with intravenous
anesthetics for anesthesia induction.
Awakening from anesthesia is faster
than it is with halothane and
enfluorane.
* Desfluorane (Suprane) may increase
the heart rate and should not be used in
patients with aortic valve stenosis;
however, it does not usually cause heart
arrhythmias.
Desflurane may cause coughing and
excitation during induction and is
therefore used with intravenous
anesthetics for induction. Desflurane is
rapidly eliminated and awakening is
therefore faster than with other inhaled
agents.
* Sevofluorane (Ultane) may also cause
increased heart rate and should not be
used in patients with narrowed aortic
valve (stenosis); however, it does not
usually cause heart arrhythmias.
Unlike desfluorane, sevofluorane does
not cause any coughing or other related
side effects, and can therefore be used
without intravenous agents for rapid
induction. For this reason, sevofluorane
is replacing halothane for induction in
pediatric patients.
* Nitrous oxide (laughing gas) is a
weak anesthetic and is used with other
agents, such as thiopental, to produce
surgical anesthesia. It has the fastest
induction and recovery and is the safest
because it does not slow breathing or
blood flow to the brain.
However, it diffuses rapidly into
air-containing cavities and can
result in a collapsed lung
(pneumothorax) or lower the
oxygen contents of tissues
(hypoxia).
Commonly administered intravenous
anesthetic agents include ketamine,
thiopental, opioids, and propofol.
* Ketamine (Ketalar) affects the
senses, and produces a
dissociative anesthesia
(catatonia, amnesia, analgesia)
in which the patient may appear
awake and reactive, but cannot
respond to sensory stimuli.
These properties make it especially
useful for use in developing countries
and during warfare medical treatment.
Ketamine is frequently used in
pediatric patients because anesthesia
and analgesia can be achieved with an
intramuscular injection.
It is also used in high-risk geriatric
patients and in shock cases, because it
also provides cardiac stimulation.
* Thiopental (Pentothal) is a barbiturate
that induces a rapid hypnotic state of
short duration. Because thiopental is
slowly metabolized by the liver, toxic
accumulation can occur; therefore, it
should not be continuously infused.
Side effects include nausea and
vomiting upon awakening.
* Opioids include fentanyl, sufentanil,
and alfentanil, and are frequently used
prior to anesthesia and surgery as a
sedative and analgesic, as well as a
continuous infusion for primary
anesthesia. Because opioids rarely
affect the cardiovascular system, they
are particularly useful for cardiac
surgery and other high-risk cases.
Opioids act directly on spinal cord
receptors, and are frequently used
in epidurals for spinal anesthesia.
Side effects may include nausea
and vomiting, itching, and
respiratory depression.
* Propofol (Diprivan) is a
nonbarbiturate hypnotic agent and the
most recently developed intravenous
anesthetic. Its rapid induction and short
duration of action are identical to
thiopental, but recovery occurs more
quickly and with much less nausea and
vomiting
. Also, propofol is rapidly metabolized
in the liver and excreted in the urine, so
it can be used for long durations of
anesthesia, unlike thiopental. Hence,
propofol is rapidly replacing thiopental
as an intravenous induction agent. It is
used for general surgery, cardiac
surgery, neuro-surgery, and pediatric
surgery.
General anesthetics are given only by
anesthesiologists, the medical
professionals trained to use them.
These specialists consider many
factors, including a patient's age,
weight, medication allergies, medical
history, and general health, when
deciding which anesthetic or
combination of anesthetics to use.
General anesthetics are usually
inhaled through a mask or a
breathing tube or injected into a
vein, but are also sometimes given
rectally.
General anesthesia is much safer today
than it was in the past. This progress is
due to faster-acting anesthetics,
improved safety standards in the
equipment used to deliver the drugs,
and better devices to monitor
breathing, heart rate, blood
pressure, and brain activity during
surgery. Unpleasant side effects are
also less common.
Recommended dosage

The dosage depends on the type of

anesthetic, the patient's age and
physical condition, the type of surgery
or medical procedure being done, and
other medication the patient takes
before, during, or after surgery.
Precautions

Although the risks of serious

complications from general anesthesia
are very low, they can include heart
attack, stroke, brain damage, and death.
Anyone scheduled to undergo general
anesthesia should thoroughly discuss
the benefits and risks with a physician.
The risks of complications depend, in
part, on a patient's age, sex, weight,
allergies, general health, and history of
smoking, drinking alcohol, or drug use.
Some of these risks can be minimized
by ensuring that the physician and
anesthesiologist are fully informed of
the detailed health condition of the
patient, including any drugs that he or
she may be using.
Older people are especially
sensitive to the effects of certain
anesthetics and may be more likely
to experience side effects from
these drugs.
Patients who have had general
anesthesia should not drink alcoholic
beverages or take medication that slow
down the central nervous system (such
as antihistamines, sedatives,
tranquilizers, sleep aids, certain pain
relievers, muscle relaxants, and anti-
seizure medication) for at least 24
hours, except under a doctor's care.
Special conditions

People with certain medical conditions

are at greater risk of developing
problems with anesthetics. Before
undergoing general anesthesia, anyone
with the following conditions should
absolutely inform their doctor.
ALLERGIES. Anyone who has had
allergic or other unusual reactions to
barbiturates or general anesthetics in
the past should notify the doctor before
having general anesthesia.
In particular, people who have had
malignant hyperthermia or whose
family members have had
malignant hyperthermia during or
after being given an anesthetic
 OR ATTIRE
Scrub dress- worn only in the
operating suite
Head cover- used to cover hair
completely.
Shoes- should be clean and
conductive, washable and soft-
soled covered by shoe covers.
Mask-is put on by all personnel
before coming into the OR and
must be worn over nose and
mouth.
Sterile gown- are worn over
scrub attire
Sterile gloves-are worn to
complete the attire for scrubbed
team members.
 Position for surgery
Supine position- usual position for
induction of general anesthesia
and for entering the major cavities.
Modified trendelenburg position-
used for lower abdominal surgery
and lower extremity surgery
Modified reverse trendelenburg
position- used for upper abdominal
surgery and for neck and
Lithotomy position- use din operation
requiring perinneal approach.
Prone position- those having surgery
on the posterior part of the body
Lateral position- used for operation on
the kidneys, lungs or hips.
Modified fowler’s position- most
usedly in neurosurgery.
 Types of tie

Free tie- ties are free at hand

Stick tie- parallel to the tip of
the clamp
- strand attach with the
forcep
 Surgical scrub procedure

Time method
a. complete scrub- 5-7 mins.
b. short scrub- 3 mins
Brush Stroke Method- scrub the
nails of one hand 30 strokes, all
sides finger 20 strokes, the
back of the hand 20 strokes,
the palm of the hand 20
strokes, the arms 20 strokes for
each third of the arm to 3
inches above the elbow.
 Layers of tissue
 The five main layers of the
abdominal tissue from the outer
most are:
1. Skin
2. Subcutaneous
3. Fascia
4. Muscle
5. Peritoneum
 Parts of a needle holder

Ring holder
Ratchets

Box lock

Jaw-serrated, cross, plain

Shank
STAGES OF ANESTHESIA
* Stage One: Analgesia. The patient
experiences analgesia or a loss of
pain sensation but remains
conscious and can carry on a
conversation.
* Stage Two: Excitement. The patient
may experience delirium or become
violent. Blood pressure rises and
becomes irregular, and breathing rate
increases. This stage is typically
bypassed by administering a
barbiturate, such as sodium pentothal,
before the anesthesia.
* Stage Three: Surgical Anesthesia.
During this stage, the skeletal
muscles relax, and the patient's
breathing becomes regular. Eye
movements slow, then stop, and
surgery can begin.
* Stage Four: Medullary Paralysis. This
stage occurs if the respiratory centers in
the medulla oblongata of the brain that
control breathing and other vital
functions cease to function. Death can
result if the patient cannot be revived
quickly.
POINTS TO PONDER
Circulating nurse assist
the anesthesiologist with
positioning the patient
for SAB.
The most important duty of the
CN is to be available and to
reassure the patient by placing
a reassuring hand on the
patient’s arm or shoulder.
The safest position for
most unconscious patients
is the lateral position
Be an operating room
nurse…..
Challenge yourself…
Thank you so much..