Perioperative Nursing Manual

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Concept on Surgery
By Romeo Q. Rivera Jr MSN
UEP- College of Nursing
INTRODUCTION
“The only predictable things in the operating room are the

unpredictable one”
a. Perioperative refers to the total span of surgical
intervention. Surgical intervention is a common treatment for
injury, disease, or disorder. The surgeon intervenes in the
disease process by repairing, removing, or replacing body
tissues or organs. Surgery is invasive because an incision is
made into the body or a part of the body is removed.
b. Perioperative patient care is a variety of nursing activities
carried out before, during, and after surgery.
Accountability and Professional Obligations
https://www.youtube.com/watch?v=9tVekSBMZGI
https://www.youtube.com/watch?v=SsucIlBjs0w
https://www.youtube.com/watch?v=3BOg1xv-PIc
I. Legal and Ethical Issues- Primum non nocere+ to do

patient no harm
a. liability- to be liable is to be legally bound, as to make
good any loss or damage that occurs in the transaction;
to be an answerable; to responsible
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Romeo Rivera Jr. MSN
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Negligence- is the lack of care or skills that any RN

in the same situation would be expected to use.
Omission to something that a reasonable person
would do.
Malpractice- any professional misconduct,
unreasonable lack of skill or judgment, or illegal or
immoral conduct.
Tort- legal wrong committed by one person involving
injury to another person, or loss or damage to
property. All person committed tort will be legally
liable.
II. Borrowed servant rule- the surgeon is liable for acts of
team members only when he or she has the right to
control and supervise the way which an RN performs the
work.
III. Independent contractor- hold an individual responsible for
his acts. Unlike the master-servant rule where in the
employer is held responsible.
IV. Doctrine of The reasonable Man- patient has the right to
expect that all professionals and technical nursing will use
knowledge, skills, and judgment in performing duties that
meet standards exercised by other reasonably prudent
individual involved in similar circumstances.
V. Doctrine of Res Ipsa Loquitor- the things speak itself
VI. Doctrine of Respondeat superior- master-servant rule
where in the employer is held responsible.
VII. Doctrine of Corporate Negligence- the facility may be
liable, not for the negligence of the employees, but for its
own negligence in failing to ensure that an acceptable
level of care is provided.
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VIII. Doctrine of Informed refusal- right to withdraw

written consent before the surgical procedure if his or her
determination to do so is reached while in the rational
state (right to self determination).
IX. Doctrine of informed consent- recognizes the physician’s
duty to inform the patient and to obtain consent before the
treatment. Failure to do so may be considered a breach of
duty.
X. Extension Doctrine- if the surgeons go beyond the limit to
which the patient consented, liability for assault and
battery may be charged. In this doctrine the surgeon may
extend the surgical procedure to correct or removed any
abnormal or pathologic condition.
XI. Assault and Battery
Assault- is an unlawful threat to harm another physically
Battery – is the carrying out of bodily harms, as by
touching without authorization or consent.
XII. Invasion of privacy- all data concerning clients are
considered confidential
XIII. Abandonment- consists of leaving the client for any
reason when the patient’s condition is contingent on the
presence of the caregiver.
Universal Moral Principles Guide in Ethical decision making

I. Autonomy- self-determination implies freedom of choice
and ability to make decisions to determine one’s course of
action.
II. Beneficence- weighing the pro’s and con’s. benefits must
outweigh the risk of the procedure
III. Nonmalifecence- duty to do no harm
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IV. Justice- equality in all care given to different client.

V. Veracity- truthfulness
VI. Fidelity- quality of faithfulness, based on honesty and
trust
VII. Confidentiality- respect for privileged information
received from another person and disclosure only to
appropriate others.
Bioethical situation that may cause dilemma in the operating

room
I. reproductive sterilizations
II. abortion
III. HIV and other Infections
IV. Human experimentations
V. Quality of life
VI. Euthanasia
VII. Right to die
VIII. Organ donation and transplantation
IX. Death and dying
Patient bill of rights

1. The patient has the right to considerate and respectful care.
2. The patient has the right to and is encouraged to obtain from
physicians and other direct caregivers relevant, current, and
understandable information concerning diagnosis, treatment,
and prognosis.
3. The patient has the right to make decisions about the plan of
care prior to and during the course of treatment and to refuse a
recommended treatment or plan of care to the extent permitted
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by law and hospital policy and to be informed of the medical

consequences of this action. In case of such refusal, the patient
is entitled to other appropriate care and services that the
hospital provides or transfer to another hospital. The hospital
should notify patients of any policy that might affect patient
choice within the institution.
4. The patient has the right to have an advance directive (such as
a living will, health care proxy, or durable power of attorney
for health care) concerning treatment or designating a
surrogate decision maker with the expectation that the hospital
will honor the intent of that directive to the extent permitted
by law and hospital policy.
5. The patient has the right to every consideration of privacy.
Case discussion, consultation, examination, and treatment
should be conducted so as to protect each patient's privacy.
6. The patient has the right to expect that all communications and
records pertaining to his/her care will be treated as
confidential by the hospital, except in cases such as suspected
abuse and public health hazards when reporting is permitted or
required by law.
7. The patient has the right to review the records pertaining to
his/her medical care and to have the information explained or
interpreted as necessary, except when restricted by law.
8. The patient has the right to expect that, within its capacity and
policies, a hospital will make reasonable response to the
request of a patient for appropriate and medically indicated
care and services
9. The patient has the right to ask and be informed of the
existence of business relationships among the hospital,
educational institutions, other health care providers, or payers
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that may influence the patient's treatment and care.

10. The patient has the right to consent to or decline to
participate in proposed research studies or human
experimentation affecting care and treatment or requiring
direct patient involvement, and to have those studies fully
explained prior to consent.
11. The patient has the right to expect reasonable continuity
of care when appropriate and to be informed by physicians
and other caregivers of available and realistic patient care
options when hospital care is no longer appropriate.
12. The patient has the right to be informed of hospital
policies and practices that relate to patient care, treatment, and
responsibilities.
Code of Ethics
Ethical behavior
 E arnestness
 T ruthfulness
 H onesty
 I ntegrity
 C onscientiousness
 S incerity
Professional obligations to perioperative team

I. work assignment
II. right to refuse assignment
III. physicians order
IV. keep nurse manager informed
V. impaired team members
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VI. working conditions

VII.sexual harassment
Settings for surgery

I. inpatient settings
a. hospitals
II. outpatient settings
a. hospital-based ambulatory surgical centers
b. free-standing surgical centers
c. physicians' offices
d. ambulatory care centers
Classifications of surgical procedures
I. according to purpose
a. diagnostic i. performed to determine the origin and
cause of a disorder or the cell type of a cancer
a. e.g., breast biopsy, exploratory laparotomy
b. curative i. performed to resolve a health problem by
repairing or removing the cause
a. e.g., cholelithiasis, mastectomy, hysterectomy
c. restorative i. performed to improve a patient's
functional ability
a. e.g., total knee replacement, finger reimplantation
d. palliative i. performed to relieve symptoms of a disease
process, but does not cure
a. e.g., colostomy, nerve root resection, tumor
debulking, ileostomy
e. cosmetic i. performed primarily to alter or enhance a
person's appearance
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a. e.g., revision of scars, liposuction, rhinoplasty,

blepharoplasty
II. according to urgency of surgery

a. elective i. planned for correction of a nonacute problem
a. e.g., cataract removal, hernia repair, total joint

replacement
b. urgent i. requires prompt intervention; or may be life-
threatening if treatment delayed
a. e.g., intestinal obstruction, bladder obstruction,
kidney or urethral stones
c. emergency i. requires immediate intervention because
of life-threatening consequences
a. e.g., gunshot wound, stab wound, severe bleeding
d. optional- performed in personal references, usually the
purpose is either to enhance or correct physical
imperfections or to achieve desired physical attributes.
III. according to degree of risk of surgery

a. minor surgery (low degree of risk) i. procedure without
significant risk, often done with local anesthesia
a. e.g., incision and drainage, muscle biopsy
b. major surgery (high degree of risk) i. procedure of
greater risk, usually longer and more extensive than a
minor procedure
a. e.g., mitral valve replacement (MVR), pancreas
implant, lymph node dissection
IV. according to extent of surgery

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a. simple i. only the most overtly affected areas involved

in the surgery
a. e.g., simple or partial mastectomy
b. radical i. extensive surgery beyond the area obviously
involved; is directed at finding a root cause
a. e.g., radical mastectomy or prostatectomy
INFORMED CONSENT
 Is an active, shared decision-making process between the
provider and the recipient of care.
 A true medical emergency may override the need to obtain
consent.
Indication of informed consent

 Invasive procedure
 Use of anesthesia
 Non surgical procedure which might be slightly risky
 Radiation
Criteria for valid consent

1. voluntary consent- freely given without coercion
2. competent patient- individuals who are autonomous and can
give or withhold consent ( incompetent patients include
individual who are mentally retarded, mentally ill,
unconscious, comatose )
3. subjects able to comprehend
 minor/mentally ill- next of kin or legal guardian should
give the consent
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 emancipated minor- married/ lives on his or her own: may

give consent
- informed patient- consent should be in writing, and should
include the following
 explanation of the procedures and risk
 descriptions of benefits and alternative
 an offer to answer questions about the procedure
 instructions that patient may withdraw consent
 a statement informing the patient if the protocols differ
from customary procedure
THE OPERATING ROOM TEAM
I. STERILE TEAM
A. Operating room surgeon

Responsibility
- Preoperative diagnosis
- Selection and diagnosis of surgical procedure
- Postoperative management of care
Requirements of operating room surgeon

- Licensed physician, osteopath, oral surgeon, podiatrist ( 4
years medical school + two years surgical residency before
post grad education in surgical specialty
- Certification by American board of medical specialist
- MD degree before 1968+ 5 years surgical privileges in an
institution accredited by JCAHO
- Members of the medical staff of the hospital
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B. Assistant to surgeon
- Help maintain visibility of the surgical site
- Control bleeding
- Close wounds
- Apply dressing
- Handles tissues and uses instrument
C. Physician first assistant

- Qualified surgeon
- Resident in an accredited surgical education program
- Referring staff physician granted by the medical staff
D. Non physician first assistant

- RN
- Surgical technologist
Criteria for eligibility for appointment

- Exercising judgement within areas of competence
- Participate directly in the management of patients under
supervision of medical staff
- Record reports, progress notes and written orders
- Perform services in conformity with applicable provisions
of medical staff
Qualifications
A. Demonstrated competency in both scrub and circulator
roles
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B. Knowledge and skills in applying principles of aseptic

and sterile technique to ensure infection control
C. Knowledge of surgical anatomy, physiology and
pathology and wound healing process
D. Comprehension of risk factor and potential intraoperative
complications and knowledge of actions to minimize them
E.Technical and manual dexterity in handling tissue,
providing exposure, use of instrument and device, providing
hemostasis, suturing and knot tying and applying dressings
F.Ability to recognize safety hazards and initiate preventive
and corrective actions
G. Ability to perform cooperatively and effectively with
other team members
H. Ability to perform effectively in stressful and emergency
situations
I. Certification in perioperative nursing
J. Certification in BLS and ACLS
E. Second assistant to surgeon
F. Scrub person- RN, LPN, VN, ST

- Maintaining the safety efficiency and integrity of the sterile
field throughout the procedure
- Handles equipment and materials to the surgeon
- Setting up of the stretcher table
- Prepares sutures, ligatures, and special equipment
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- Assisting the surgeon and surgeon’s assistant during the

procedure by anticipating the required instrument, sponges,
drains, etc.
- Keep track of time the patient is under anesthesia and time
the wound is open
- Counts needles, sponges, and instruments
- Specimen care
II. UNSTERILE TEAM
1. Anaesthesiologist /anesthesist
a. Nurse anesthesist (CRNA)
b. Dentist
c. Physician
“No anesthetic agent is safer than its worst administrator”
Responsibility
i. Induce anesthesia
ii. Maintain anesthesia at required level
iii. Managing of untoward reactions of anesthesia
throughout the surgical procedures
2. Circulator (RN)
- Prepping of the surgical site
- Verifies consent
- Ensure adequacy of supplies
- Handles document
- Handle sterile items by forceps
- Advocate and protector of clients
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- Application of nursing process throughout the procedure

- Monitor and coordinate all activities within the room and
manage the care required for each patient
- Assist member of OR team in a manner in which the
circulator is qualified
- Identify potential danger and stressful situation
- Maintenance of communication link between events and
team members
- Direct activities of all learner
3. X- ray technician and other team members
Intraoperative Care
The typical operating room suite is constructed in such a way

that there is a continous progression from the entrance, through
zones that increasingly approach sterility, to the operating rooms.
There are basically three zones in a standard operating suite in

the hospital. The outer zones (unrestricted area) is represented by
the areas within the operating suite but still outside the room in
which operations are actually performed. Street shoes and clothes
are removed upon entering the outer zone and replaced by clean
scrub suit and operating room shoes or slippers.
The middle zone (semirestricted area) is represented by the

main hallway of the operating suite which interconnects the
operating room proper. It also contains the scrubbing areas for
surgical instruments. All persons entering this middle zone should
already be wearing the proper operating room attire, namely clean
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scrub suit, shoes, slippers, cap and mask.
In the holding area, the perioperative nurse makes the final

identification and assessment before the patient is transferred into
the OR for surgery. Procedures such as inserting intravenous (IV)
catheters and arterial lines, removing casts, and drug
administration may occur here.
The inner zone (restricted area) is represented by the room

where the operation is actually performed. If an operation is going
on, it involves a sterile operative field, sterile personnel wearing a
sterile scrub attire, and sterile instruments exposed to the room
environment. Thus, all persons inside the operating room proper
should be in proper attire. Talking should be minimal. All
movement should be smooth and minimal to reduce air current that
may contaminate the operative field with bacteria-containing air
particles.
The OR is a unique acute care setting removed from other

hospital clinical units. It is controlled geographically,
environmentally, and bacteriologically, and it is restricted in terms
of the inflow and outflow of personnel.
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Fig. 1. An Operating Room Suite
Operating Room Scrubbing Area

Proper III Operating Room
Proper III
Supply Room III

Operating Room
Proper III
Hallway II
Operating Room
Proper III Female Dressing
Room I
Male Dressing Anteroom I Supervisor’s
Room I Entrance Office I
Aseptic Technique
The terms aseptic and antiseptic are often used interchangeably.

Historically, sterile technique was first carried out with chemicals
such as carbolic acid and phenol, which were used in instrument as
well as in the skin. This was known as antiseptic technique. With
the introduction of steam autoclave and other techniques more
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effective than chemicals in sterilizing instruments and linens, the

term aseptic technique is used to distinguish the newer methods
from the older ones. The distinction however, has been lost.
Current sterilization method relies on both chemical and physical
method.
Aseptic technique then is a body of technique for ensuring that

all bacteria are excluded from the sterile field in which the
procedure is done. Although the goal is complete sterility, this is
impossible to attain. Every surgical wound is contaminated by at
least a few bacteria. These bacteria can come from 5 sources that
includes:
1. The operating room physical environment

2. The patient himself
3. The nonscrubbed personnel
4. The scrubbed personnel
5. The operative tools and instrument
Even the most advanced aseptic technique have not yet

produced a complete absence of bacteria from the operative
environment. Nevertheless the attention to aseptic technique is still
of utmost importance in minimizing the risk of infection in all
surgical procedures.
The greatest source of contamination in a basically clean

operation is the operative environment, a term that covers all other
element in the operating room, from the nonscrubbed personnel to
the air over the surgical wound.
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Studies of operating room during the periods of inactivity

indicate that although the walls, the floors, and the furniture may
contain considerable numbers of bacteria, these organisms do not
enter the air of the room. Bacteria do not become airborne unless
they are pushed into the air by blast or brushing.
PRINCIPLE STERILE TECHNIQUE

‘The center of the sterile field is the site of incision’
1. Only sterile team is used within the sterile field.
2. Sterile persons are gowned and gloved.
3. Tables are sterile only at table level.
4. Sterile persons touch only sterile items or areas; unsterile
touch only unsterile items or areas.
5. Unsterile persons avoid reaching over sterile fields; sterile
persons avoid leaning over unsterile areas.
6. Edges of anything that encloses the sterile contents are
considered unsterile
7. Sterile field is created as close as possible to time of use
8. Sterile areas are continuously kept in view
9. Sterile person’s keep well within sterile areas
10. Sterile persons keep contact with sterile areas to
minimum
11. Unsterile persons avoid sterile areas
12. Destruction of integrity of the microbial barriers result in
contamination
13. Microorganism must be kept to irreducible minimum
The goal of asepsis and aseptic technique is to prevent the

transfer of microorganisms into the surgical wound. Preventing
surgical site contamination requires the efforts of all trained
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surgical team members to use their knowledge and experience in

aseptic practices to provide their patients with optimal care
resulting in positive surgical outcomes.
Aseptic technique for the instruments, sutures, linens, fluids,

and other surgical materials
A. Steam autoclaving
- Machine that sterilizes with steam under pressure
- Normal sterilization cycle, 120C at 20-25 lb pressure for
30 minutes
- Sterilization of drapes, gown, sheets, towels, lap pads and
surgical instruments not damaged by intense heat
- “flashing” used when critical instrument is dropped; cycle
is 270F at 30 lb pressure for 4-7 min only
- Preparations include double wrapping of linen or special
paper placed in a special metal box placed with a filter
before sterilization
B. Ethylene oxide sterilization (gas)
- Chemical sterilization under carefully controlled time,
temperature and humidity condition
- Sterilization of heat labile items such as plastic, finely
sharpened instruments, suture materials and lenses
- Needs aeration
- A colorless gas, very toxic and flammable
C. Soaking in germicidal solutions
- Instrument must be dry before immersion
- Three hours exposure time is needed to destroy spores
- Formalin’s
- Iodophors
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- Benzalkonium chloride
- 70 % ethyl alcohol
- Glutaraldehyde (cidex) the most common disinfectants
D. Gama irradiations of sutures
- Used to sterilize prepacked materials
- Common sources of irradiation are electron beam and
cobalt-60
E.Millipore filtration of fluids
Aseptic technique for the non scrubbed personnel

1. Proper operating room attire
2. Proper operating room decorum, like minimizing talking and
unnecessary movement
3. Maintenance of sterility of sterile operative field, sterile
personnel and sterile instruments and objects
Aseptic technique for the scrubbed personnel

1. Proper operating room attire
2. Proper operating room decorum
3. Preoperative aseptic technique
- Scrubbing
- Gowning
- Gloving
- draping of operative field
4. Operative aseptic technique
- Use of sterile surgical instrument and materials
- Maintenance of sterility of operative field
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Preoperative surgical phase

I. begins when the patient decides to have surgery and ends
when the patient is transferred to the operating room bed
The preoperative nursing assessment is performed to:

1. Determine the patient’s psychologic and physiologic factors
that may contribute to operative risk factors
2. Establish baseline data
3. Identify and document the surgical site
4. Identify prescription and over-the-counter (OTC) drugs and
herbal products
5. Confirm laboratory results
6. Note cultural and ethnic factors that may affect the surgical
experience
7. Validate that the consent form has been signed and witnessed
Common fears associated with surgery

1. Fear of unknown
2. Fear of pain and discomfort
3. Fear of death
4. Fear of anesthesia
5. Fear of impending procedure and resultant prognosis
6. Fear of disfigurement, mutilation and loss of body parts
7. Fear of isolation, rejection, neglect and abandonment
8. Fear of depersonalization and loss of self- control
9. Fear of restriction of movement or activity
10. Fear of invasion of privacy
11. Fear of loss of livelihood
12. Fear of burdening others
13. Fear of reliance on mechanical object or transplanted
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organ
Focus of the Preoperative assessment

1. In the nursing assessment, information should also be
obtained about the patient’s family concerning any history of
adverse reactions to or problems with anesthesia.
2. All findings on the medication history should be documented
and communicated to the intraoperative and postoperative
personnel.
3. Patients should also be screened for possible latex allergies.
4. The preoperative assessment of the older person’s baseline
cognitive function is especially crucial for intraoperative and
postoperative evaluation.
5. The patient with diabetes mellitus is especially at risk for
adverse effects of anesthesia and surgery.
6. Obesity stresses both the cardiac and pulmonary system and
makes access to the surgical site and anesthesia
administration more difficult.
Preoperative teaching involves the following:
A. Three types of information:

 sensory,
 process,
 and procedural.
B. Different patients,
 with varying cultures,
 backgrounds,
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 and experiences,
 may want different types of information.
C. All teaching should be documented in the patient’s medical

record.
D. All patients should receive instruction about deep breathing,

coughing, and moving postoperatively.
PREOPERATIVE FASTING
Prolonged preoperative fasting is a timed honored tradition.
The typical order of NPO after midnight (or no food or liquid after
12:00 am on the day of surgery) has been challenged in recent
years.
Based on the extensive evidence, the American Society of
Anesthesiologist (ASA) revised in practice guidelines for
preoperative fasting in healthy patients undergoing elective
procedures.
Preoperative Fasting Recommendation

Liquid and food intake Minimum fasting period
(HR)
Clear liquids 2
Breast milk 4
Non human milk, 6
including infant formula
Light meal 6
Regular or heavy meals 8
On the day of surgery, the nurse is responsible for the

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following:
1. Final preoperative teaching
2. Assessment and communication of pertinent findings
3. Ensuring that all preoperative preparation orders have been
completed
4. Ensuring that records and reports are present and complete
to accompany the patient to the OR
5. Verifying the presence of a signed operative consent
6. Laboratory data
7. A history and physical examination report
8. A record of any consultations
9. Baseline vital signs
10. Nurses’ notes complete to that point.
Frequently performed procedures in the older adult are

1. cataract extraction,
2. coronary and vascular procedures,
3. prostate surgery,
4. herniorrhaphy,
5. cholecystectomy,
6. and hip repair.
Older adults may have sensory, motor, and cognitive deficits
necessitating that more time may be needed to complete
preoperative testing and understand preoperative instructions.
These changes also require attention to promote patient safety and
prevent injury.
Preoperative nursing assessment of the patient:

i. nursing history i. past medical history, in particular:
a. bleeding disorders i. e.g., thrombocytopenia, leukemia,
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bone marrow depression from chemotherapy

b. cardiac disease i. e.g., recent myocardial infarction,
dysrhythmias, congestive heart failure
c. renal disease
d. chronic respiratory disease i. e.g., emphysema,
bronchitis, asthma
e. diabetes mellitus
f. liver disease
g. uncontrolled hypertension
h. upper respiratory infection
ii. past surgical history
iii. patients' and significant others' perception and
understanding of the surgery
iv. medication and substance abuse history, in particular:
a. antibiotics i. potentates the action of anesthetic agents
b. antidysrhythmics i. can reduce cardiac contractility and
impair conduction during anesthesia
c. anticoagulants i. increases risk of hemorrhage
d. anticonvulsants i. can alter metabolism of anesthetic
agents after long-term use
e. antihypertensives i. interact with anesthetic agents to
cause bradycardia, hypotension, and impaired circulation
f. corticosteriods i. impair the body's ability to withstand
stress by causing adrenal atrophy g. insulin
h. diuretics i. potentiates electrolyte imbalances
v. allergies
vi. smoking habits
vii. alcohol habits
viii. significant other support
ix. occupation
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x. emotional health i. e.g., feelings about surgery, self-concept,

coping mechanisms, body image
Physical examination i. should include all body systems
Surgical risk factors, in particular:

i. age
ii. nutritional status
iii. obesity
iv. radiotherapy
v. fluid and electrolyte imbalance
vii. mental status
Surgical diagnostic screening

i. laboratory screening:
a. e.g., CBC, serum electrolytes, coagulation study, serum
creatinine, BUN, urinalysis, type and cross match,
hemoglobin and hematocrit
Radiological screening: a. e.g., chest x-ray, MRI, CAT scan

iii. other diagnostic screenings:
a. e.g., ECG e. presence of autologous or directed blood
donations
Pertinent discharge planning needs i. e.g., home environment,

self-care capabilities, significant other support systems
Preoperative nursing planning/implementations for the

patient
On the day of surgery, the nurse is responsible for the
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following:
11. Final preoperative teaching
12. Assessment and communication of pertinent findings
13. Ensuring that all preoperative preparation orders have
been completed
14. Ensuring that records and reports are present and
complete to accompany the patient to the OR
15. Verifying the presence of a signed operative consent
16. Laboratory data
17. A history and physical examination report
18. A record of any consultations
19. Baseline vital signs
20. Nurses’ notes complete to that point.
Preoperative teaching
i. people included in preoperative teaching
a. patient
b. significant others
ii. appropriate timing for preoperative teaching
a. more than one day before surgery
b. when the patient is ready to learn i. e.g., less anxious,
fearful
iii. content of preoperative teaching
a. surgical procedure
b. preoperative routines
c. intraoperative routines
d. postoperative routines
e. pain relief
f. postoperative exercises
i. breathing exercises
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a. e.g., deep (diaphragmatic) breathing,

expansion breathing
ii. incentive spirometry
iii. coughing and splinting the incision
iv. leg exercises
v. early ambulation
vi. ROM exercises
g. postoperative leg procedures
i. antiembolism stockings a. e.g., T.E.D. stockings or
Jobst hose
ii. elastic wraps
iii. pneumatic compression devices
h. access devices
i. tubes a. e.g., Foley catheter, nasogastric tube
ii. drains a. e.g., penrose, t-tube, Jackson-Pratt,
Hemovac
iii. intravenous a. e.g., peripheral, CVP, Swan-Ganz
Prepare the patient physically for surgery i. preparation of the

patient's gastrointestinal tract for surgery
a. reasons for gastrointestinal preparation
i. empty the gastrointestinal tract
ii. sterilize the normal flora of bacteria present in the
gastrointestinal tract
b. examples of gastrointestinal preparation i. stomach,
duodenum, and proximal jejunum
a. oral laxative i. e.g., castor oil, bisacodyl (Dulcolax)
b. clear liquid diet the evening before surgery
c. NPO after midnight
ii. small intestine
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a. oral laxative i. e.g., magnesium citrate

b. clear liquid diet the evening before surgery
c. multiple-position tap-water enemas the evening before
surgery or GoLYTELY
d. NPO after midnight
iii. large intestine to rectum
a. multiple or combination of oral laxatives 12-24 hours
before surgery
b. multiple-position tap-water or antibiotic enemas (three
times or until the return flow is clear) the evening and
morning before surgery or GoLYTELY
c. oral antibiotics 24 hours before surgery
i. e.g., neomycin, erythromycin
d. clear liquid diet the evening before surgery
e. NPO after midnight
iv. preparation of the patient's skin for surgery
a. reasons for skin preparation
i. remove soil and transient microbes from the skin
ii. reduce the residual microbial count to
subpathogenic amounts in a short period of time and
with the least amount of tissue irritation
iii. inhibit rapid rebound growth of microbes
b. examples of skin preparation
i. cleaning the skin over the surgical site with
antimicrobial solution
a. e.g., povodine-iodine (Betadine)
ii. removing hair over the surgical site only if
necessary
a. e.g., shaving hair, clipping hair (becoming more
popular)
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iii. apply antimicrobial solution to the skin over the

surgical site
a. e.g., povodine-iodine (Betadine)
Diminish the patient's anxiety about the surgery

i. e.g., preoperative teaching, encouraging communication,
using distraction, including family and significant others
Prepare the patient for rest and sleep i. e.g., backrub, administer
sleeping medication f. day of surgery
i. complete preoperative assessment sheet
ii. assess vital signs
iii. provide necessary hygiene
iv. prepare hair and remove cosmetics
v. remove prostheses
vi. finish preparation of patient's gastrointestinal tract
vii. have patient void (if no catheter inserted)
viii. apply leg procedures
ix. perform special procedures a. e.g., insert foley, NG tube
x. safeguard valuables
xi. administer preoperative medications
a. reasons for preoperative medication
i. reduce anxiety
ii. promote relaxation
iii. reduce pharyngeal secretions
iv. prevent laryngospasm
v. inhibit gastric secretions
vi. decrease the amount of anesthetic required for
induction and maintenance of anesthesia
b. categories of preoperative medications
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i. sedatives and hypnotics

a. e.g., pentobarbitol sodium (Nembutal),
secobarbitol sodium (Secobarbitol), chloral
hydrate
ii. tranquilizers
a. e.g., chlorpromazine hydrochloride
(Thorazine), hydroxine hydrochloride (Vistaril),
diazepam (Valium)
iii. opioid analgesics
a. e.g., meperidine hydrochloride (Demerol),
morphine sulphate, hydromorphone
hydrochloride (Dilaudid)
iv. anticholinergics
a. e.g., atropine sulphate, scopolomine
(Hycosine)
v. H2-receptor antagonists
a. e.g., cimetidine (Tagamet), ranitidine
hydrochloride (Zantac), famotidine (Pepcid)
vi. antiemetics
a. e.g., metrochlopromide (Reglan), droperidol
(Inapsine), promethazine hyrdrochloride
(Phenergan)
D. Intraoperative surgical phase

I. begins when the patient is transferred to the operating room bed
and ends when
the patient is admitted to the postanesthesia area
Assessment data important to intraoperative nursing care

include
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1. the patient’s vital signs, height, weight, and age;

2. allergic reactions to food, drugs, and latex;
3. condition and cleanliness of skin;
4. skeletal and muscle impairments; perceptual difficulties;
5. level of consciousness;
6. nothing-by-mouth (NPO) status;
7. and any sources of pain or discomfort.
The operation
Basically the standard major operation consists of the following

chronological steps or phase:
1. Anesthesia
2. Positioning of the patient
3. Prepping and draping of the operative field
4. Incision
5. Exploration or intraoperative assessment
6. Operative procedure
7. Hemostasis
8. Instrument and sponge count
9. Closure of incision
10. Dressing
ANESTHESIA
1. An absolute contraindication of any anesthetic technique is
patient refusal.
2. Moderate sedation/analgesia (conscious sedation):
 Is a drug-induced depression of consciousness that retains the
patient’s ability to maintain her or his own airway and respond
appropriately to verbal commands
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 In this type of anesthesia, the patient achieves a level of

emotional and physical acceptance of a painful procedure
(e.g., colonoscopy).
ASA physical status classification system

- P1 a normal healthy client
- P2 a patient with mild systemic diseases without functional
limitations
- P3 a patient with severe systemic disease associated with
functional limitations
- P4 a patient with incapacitating systemic disease that is a
constant threat to life
- P5 a moribund patient who is not expected to survive for 24
hours with or without operation
- P6 patient is brain dead and is being prepared for organ
donation
Types of anesthesia
a. General anesthesia
i. produces total loss of consciousness by blocking
awareness centers in the brain, amnesia (loss of memory),
analgesia (insensibility to pain),
hypnosis (artificial sleep), and relaxation (rendering a part
of the body less tense)
Stages of anesthesia
Stage 1. Beginning anesthesia
- Patient feels warmth, dizziness and feeling of
detachment
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- There is ringing, roaring or buzzing in the ears

- Patient is aware of being unable to move the
extremities; noises are exaggerated
Stage 2. Excitement
- Patient is struggling, shouting, talking, singing,
laughing, crying
- Pupil dilates but constrict in light
- PR is rapid; RR is irregular
- Restraints may be applied
Stage 3. Surgical anesthesia
- Patient is unconscious
- Pupils are small but reactive
- RR is irregular, PR is normal
- Skin is pink and flushed
Stage 4. Medullary depression
- Occurs if too much anesthesia was given
- RR is shallow, pulse is weak and thready
- Pupils are widely dilated and nonreactive
- Cyanosis can occur and eventually death
iii. administration of general anesthesia

a. inhalation of gases and/or volatile agents through
an endotracheal tube or face mask
i. gases a. e.g., nitrous oxide (N20)
ii. volatile agents (liquids that are vaporized for
inhalation)
a. e.g., halothane (Fluothane), enflurane
(Ethrane), isoflurane (Forane)
b. intravenous infusion of barbiturates or
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nonbarbiturates
i. barbiturates a. e.g., thiopental sodium
(Pentothal)
ii. non-barbiturates a. e.g., ketamine (Ketalar),
propolol (Diprivan), fentanyl citrate with
droperidol (Innovar)
iv. adjuncts to general anesthetic agents
a. hypnotics i. e.g., midazolam (Versed), lorazepam
(Ativan), diazepam (Valium)
b. Opioids analgesics i. e.g., morphine sulphate,
meperidine hydrochloride (Demerol), fentanyl citrate
(Sublimaze)
c. neuromuscular blocking agents
i. non-depolarizing agents
a. block acetylcholine at the neuromuscular
junction
b. e.g., pancuronium (Pavulon), atacurium
(Tracium), vecuronium (Norcuron)
ii. depolarizing agents
a. depolarize the motor end plate at the
neuromuscular junction
b. e.g., succinycholine (Anectine)
v. complications of general anesthesia
a. malignant hyperthermia
i. genetic predisposition (diagnosed by a muscle
biopsy) for a life-threatening reaction to general
anesthetic agents
ii. signs/symptoms: tachycardia, dysrthymias,
muscle rigidity (especially jaw and upper chest),
hypotension, tachypnea, cola –colored urine,
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extreme hyperthermia (late sign)

iii. treatment: dantrolene (Dantrium)
b. overdose
c. complications related to specific anesthetic agents
i. e.g., shivering, hypotension, bradycardia,
dysrthymias, respiratory depression, decreased
seizure threshold
d. complications of endotracheal intubation
i. e.g., broken caps, teeth, swollen lip, trauma to the
vocal cords, improper neck extension
b. local or regional anesthesia

i. reduces all painful sensation in one region of the body
without inducing unconsciousness
ii. administration of local anesthesia
a. topical local anesthesia
i. description
a. application of an anesthetic agent directly to the
surface of the tissue to be anesthetized, e.g.:
i. the skin or the mucosal surfaces of the mouth,
throat, nose, cornea
ii. mechanism of action a. the anesthetic agents
used produce anesthesia by inhibiting sensory
system conduction of pain from the local nerves
supplying the tissue to be anesthetized
iii. uses of topical local anesthesia
a. prior to injection of regional anesthesia
b. prior to endotracheal intubation
c. prior to various diagnostic procedures, e.g.:
i. laryngoscopy
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ii. bonchoscopy
iii. cystoscopy
iv. endoscopy
iv. types of topical local anesthetic agents
a. cocaine
b. benzocaine
c. ethyl aminobenzoate
d. lidocaine
e. tetracaine
f. bupivacaine
b. infiltration local anesthesia
i. description
a. injection of an anesthetic agent intracutaneously
and subcutaneously directly into the tissue to be
anesthetized
ii. mechanism of action of infiltration local
37pioids37ia a. the anesthetic agents used produce
anesthesia by inhibiting sensory system conduction
of pain from the local nerves supplying the tissue to
be anesthetized
iii. uses of local infiltration anesthesia
a. prior to injection of regional anesthesia
b. prior to suturing of superficial lacerations
c. at the end of surgery into the incision for
postoperative pain relief
d. prior to dental procedures e. prior to minor
surgical procedures, e.g.:
i. excision of skin lesions or wound
debridement
ii. repair of an episiotomy
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iv. types of local infiltration anesthesia agents

a. etidocaine
b. procaine
c. prilocaine
d. lidocaine
e. chloroprocaine
f. mepivicaine
iii. Administration of regional anesthesia

a. nerve block
i. description
a. injection of an anesthetic agent into or around a specific
nerve, nerve trunk, or several nerve trunks supplying the
tissue to be Anesthetized
ii. mechanism of action of nerve block regional anesthesia
a. the anesthetic agents used produce anesthesia by
Inhibiting sensory system conduction of pain from the
local nerves in the tissue to be anesthetized
iii. uses of nerve block regional anesthesia
a. prior to dental procedures
b. control of pain during plastic surgery
c. control of pain during surgery in an area supplied
by that specific nerve, nerve trunk, or nerve trunk(s)
d. to diagnose and treat chronic pain conditions
e. to increase circulation in some vascular disorders
b.. spinal anesthesia
i. description
a. injection of an anesthetic agent into the cerebrospinal
fluid in the subarachnoid space around the nerve roots
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ii. mechanism of action of spinal regional anesthesia

a.the anesthetic agents used produce anesthesia by
inhibiting sensory system conduction of pain from
nerve roots supplying the tissue to be anesthetized by
acting on them as they exit the spinal cord before
they leave the spinal canal through the intervertebral
foramina uses of spinal regional anesthesia
a. control of pain during surgery of the lower abdomen below
the umbilicus, the groin, or the lower extremities
b. complications of spinal anesthesia
a. hypotension
i. cause
a. paralysis of vasomotor nerves
` ii. Intervention
a. administer O 2 as ordered
b. administer vasoactive drugs as ordered
c. Trendelenburg position if level of anesthesia is
fixed
b. nausea and vomiting i. cause a. traction placed on
various structures within abdomen or hypotension
c. respiratory paralysis
i. cause
a. reaching of drug to the upper thoracic and cervical
amounts or in heavy concentrations
ii. Intervention
a. artificial respiration
d. neurologic complications (e.g., paraplegia, severe
muscle weakness in legs)
c. epidural anesthesia
i. description
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a. injection of an anesthetic agent into the epidural space

surrounding the dura mater around the nerve roots
ii. mechanism of action of epidural regional anesthesia a.
the anesthetic agents used produce anesthesia by
inhibiting sensory system conduction of pain from nerve
roots supplying the tissue to be anesthetized by acting on
them as they leave the spinal canal through the
intervertebral foramina
iii. uses of epidural regional anesthesia
a. control of pain during surgery of the lower
abdomen below the umbilicus, the groin, or the lower
extremities
b. control of pain during labor and delivery
d. types of regional anesthetic agents
i. short
a.duration
i. (1/2- 1 hour)
b. agents
i. Procaine (Novocaine)
ii. Chloroprocaine (Nesacaine)
c. action
i. ester type regional anesthetic agents
ii. produce short-acting regional anesthesia by
blocking depolarization preventing generation
and conduction of nerve impulses
ii. intermediate
a. duration
i. (1-3 hours)
b. agents
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i. Lidocaine (Xylocaine)
ii. Mepivacaine (Carbocaine)
iii. Mepivacaine (Carbocaine)
c. action
i. amide type regional anesthetic agents
ii. produce intermediate acting regional
anesthesia by block depolarization preventing
generation and conduction of nerve impulses
iii. long
a. duration
i.(3-10 hours)
b. agents
i. Bupivacaine (Marcaine)
ii. Dibucaine (Nupercaine)
iii. Etiodocaine (Duranest)
c. action
i. amide type regional anesthetic agents
ii. produce long-acting regional anesthesia by
blocking depolarization preventing generation
and conduction of nerve impulses
iv. adjuncts to local or regional anesthetic agents
a. 41pioids analgesics
i. e.g., morphine sulfate, meperidine hydrochloride
(Demerol), fentanyl citrate (Sublimaze)
b. hypnotics
i. e.g., midazolam (Versed), lorazepam (Ativan),
diazepam (Valium)
v. complications of local or regional anesthesia
a. overdosage
b. incorrect administration technique
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i. e.g., gangrene, infection

c. systemic absorption
d. patient sensitization to the anesthetic agent
Positioning of the patient

- Performed after anesthesia is given
- Provide correct position for the specific procedure
- Protect bony prominences
- Avoid injury or strains to muscles, bones and joints
- Protect the skin- lift rather than pull or roll the client into
position
Integumentary System
Autograft Site is immobilized for 3-7 days
burns of face and head Elevate head of the bed
Circumferential burns Elevate extremities above the level of the
of face and extremities heart
Skin graft Elevate and immobilized graft site
Reproductive system
Mastectomy Semifowlers and affected arm elevated
Pereineal and vaginal Lithotomy position
procedure
Endocrine system
Hypophysectomy Elevate head of the bed
Throidectomy semifowlers
Gastro intestinal system
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hemorrhoidectomy Lateral side lying

Gastroesophageal Reverse trendelenburg
reflux
Liver biopsy During FNAB; Supine with pillow on
the back, after; left side lying
NGT Insertion: head elevated and jaw touching
the chest
Feeding and irrigation: high fowlers
Rectal enemas Left sims position
Senstaken Blakemore Head elevated
tube (3 Lumen) and
Minnesota tube ( 4
lumen)
Respiratory system
COPD orthopneic
Laryngectomy (radical Semi-fowlers or fowlers
neck Dissection)
Bronchoscopy Semifowlers
postoperatively
Postural drainage Lung segment that will be drained should
be in uppermost position
Thoracentesis During insertion the client is placed in
sitting position (orthopneic) or maybe
done lying on the bed with the head
elevated and affected part is exposed
Thoracotomy Check physicians order in positioning
Cardiovascular system
Abdominal aneurysm 45 degrees and maybe turn side to side
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resection
Amputationof lower First 24 hour elevate foot of the bed
extremities supported by pillows; after 24 hours
consult physician and maybe placed on
prone position for 30 min
Arterial vascular Affected extremities is kept straight and
grafting of an bed rest is imposed for first 24 hours;
extremities Limit movement and avoid flexion of hip
and knee
Cardiac catheterization If femoral artery is used, bed rest for 3-4
hours and may turn from side to side
Affected extremities is kept straight and
head is elevated no >30 degrees until
hemostasis is achieved
CHF and pulmonary Position upright with legs dangling at the
edema side of the bed
Peripheral arterial Elevate feet at rest but not above the heart
disease
deep vein thrombosis If extremities are red and edematous and
receiving traditional heparin therapy the
feet maybe elevated with bed rest
Varicose veins Feet elevation above heart level and
minimize prolonged sitting or standing
Venous leg ulcers Leg elevation
Sensory system
Cataract surgery Semi fowlers
Retinal detachment Bedrest and bilateral eyepatching; if gas
bubbles are used, face down or angled
toward the unoperative side
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Neurologic system
Autonomic dyreflexia High fowlers
Cerebral aneurysms Bed rest or semifowlers or fowler’s
Cerebral angiography Bed rest for 12- 24 hours and extremity
with contrast medium is straightened and
immobility is maintained
CVA Hemorrhagic stroke; 30 degrees bed
elevation
Ischemic stroke; flat
Craniotomy Avoid extreme hip and neck flexion;
fowlers and position in unoperative site
Laminectomy Back is kept straight, log roll the client
when moving
Increased ICP Semi and fowlers
Lumbar puncture During; fetal position , after; supine 4-12
hours
Myelogram postop Water soluble solution ; 12 hours semi or
fowlers
Oil based; flat on bed
Spinal cord injury Immobilization and log rolling
Musculoskeletal system
Total Hip Replacement Avoid extreme internal and external
rotation, avoid adduction and placed
pillow in between the legs to maintain
abduction
Prepping and Draping of the operative field
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Prepping of the operative field

The operative field is prepared through the following aseptic
technique;
1. Mechanical cleansing and scrubbing using detergent
2. Sterilization using antiseptic solution like iodophors or
benzalkonium chloride
3. Shaving and depilation of hair in the operative field if
necessary
4. Better to over prep than to under prep
5. Duration is five minutes
6. Extent of prepping depends on the proposed operative field
as well as the possible extension
7. Starts in the operative field then peripherally
8. from cleanest to dirtiest
Draping the operative field

The proposed field that has been prepped is enclosed using
sterile towels each folded one third back on itself. The towels are
then stabilized with clips or sutures.
Incision
Basic surgical instrument in the OR (5 major categories)
1. cutting instrument
- scalpel- use for making incision, for puncturing, and for
sharp dissection
 No.11 used in stabbing or puncturing tissue. Known as
stab knife
 no. 15 has a small belly, used for small and curvilinear
incision
 no 10 has bigger belly, used for longer incision like
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number 20
 no. 20 has a much bigger belly
- Scissors- used primarily for sharp cutting, used for blunt
dissection by spreading the blades of the scissors between
tissue planes. Classified in terms of;
 shape; maybe curved (directional mobility and greater
visibility for deep wounds and cut with smooth curved) or
straight(used for cutting tough tissues and for more
precise straight cutting)
 tip; blunt or sharp used for blunt dissection
 purpose; mayo scissors are used for cutting bandages and
other hard structures
 size; long metzenbaums needed for dissection, iris
scissors are used for small and fine tissue dissection
- bone cutters and debulking tools
2. grasping instruments
- tissue forceps- are grasping instrument with so many
functions that includes;
 hold tissues during cutting
 retract for exposure
 stabilize during suturing
 to extract needles
 to grasp vessels for cautery
 pass ligatures around hemostats deep in the wound
 to pack sponges
 clear blood with sponge
- tissue forceps may be toothed (may caused laceration and
puncture to hollow structure but have less crushing effect
compared to toothless forceps) or toothless; or named as
thumb or Adson forceps
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- needle holder- primarily used for holding surgical needles

and the tie knot
- surgical clamps- grasping instrument used for hemostatic
purposes; known also as hemostat
 may be short or long; curved or straight; toothed or flat
 kellies are longer and bigger
 mosquitos are smaller
 mixter clamp have a curved right angled tip
 tripod grip is most secure way of clamping tissues
- towel clips
- Allis forceps
- Babcock- has ends that are round to fit the structure and
avoid injury
- Vice grips- holding bone structure
3. retracting instrument
- hand retractors are those held by assistants, namely;
 skin hooks, rake retractors, army navy used for skin and
subcutaneous tissue retractions
 Richardson- abdominal wall
 deaver – abdominal viscera
- self retaining retractors do not need efforts of the assistant
 balfour for abdominal surgery
 finochietto for thoracic surgery
4. Suction devices- remove blood and other body fluids in the
operative field. This results in a dry field that allows clear
visualization for the surgeons dissection.
- Frazier tip suction
- Jackson Pratt suction
5. Electrosurgical machines- uses electric current to heat a wire.
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The modulation of the current allows for cutting and

coagulation. Also known as ligator or cautery.
- Advantages include decrease blood loss, clean and drier
field. Disadvantage may include poor depth control with
damage to the underlying structures and unintentional burns.
Surgical needles
- Shape; can be straight- convex superficial tissues or curved-
superficial or deep tissues
- Size varies according to length and thickness or diameter of
the needle
- Type of point; round/taper or cutting needle. Cutting needle
maybe conventional or reverse cutting needle. Reverse
cutting needle is preferred by most of the surgeon
- Suture attachments; swaged or threaded/eyed needle
Viewing instruments
- Speculums- vaginal and nasal speculums; enlarge and holds
open a canal
- Endoscopes- inserted in an orifice or canal to view specific
site
Suctioning
- Suction involves application of pressure to withdraw blood
or fluids for visibility of the surgical site
a) Poole abdominal tip- used in abdominal laparatomy or
within any cavity with copious amount of fluid or pus
b)Frazier tip- in a very little fluid or bleeding capillary
such as in brain, spinal and orthopedic case
c) Yankauer tip- in mouth and throat such as ruptured
aneurysms
d)Autotransfusion
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Surgical drains
- Penrose- thin walled cylinder of radiopaque latex secured
with asuture
- Jackson-Pratt and hemovac are used to suction uninfected
closed wound such as chest wall upper abdomen and areas
of joint replacement
Exploration or intraoperative assessment
Hand signals
 Hemostat- extend the hand supinated
 Scissors- extend the index and the middle fingers, adduct and
abduct the fingers in shearing motion
 Scalpel- hold hand pronated with thumb opposed against the
distal phalange of the index finger and flex the wrist. ( incising
motion)
 Forceps- hold hand pronated and oppose the thumb and the
index finger (open and close).
 Suture- extend the hand in a position of bringing the hand
from pronation to supination
 Tie- hold the hand elevated with the palm toward the suture
nurse
COMMON SURGICAL PROCEDURES

1. Appendectomy
2. Breast biopsy- maybe done by FNAB or cyst excision
3. Carotid endarterectomy- removal of blockage of carotid
arteries
4. Cataract surgery
5. CS
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6. Cholecystectomy
7. Coronary artery bypass graft
8. Debridement of wounds, burns and infection
9. D and C
10. Free skin Graft
11. Hemorrhoidectomy
12. Hysterectomy
13. Hysteroscopy
14. Inguinal hernia repair
15. Mastectomy
- Partial (segmental) mastectomy
- Total (simple) mastectomy
- Modified radical mastectomy
- Radical mastectomy
14. partial colectomy
15. prostatectomy
16. tonsillectomy
Closure of incision
Sutures
- Absorbable- collagen derived from healthy animals or
synthetic polymer.
 Plain gut 1-2 weeks
 Chromic gut 2-3 weeks
 Dexon 2-3 weeks
 vicryl
- Non absorbable
 Silk
 Cotton
 Braided synthetic Dacron or mesilene
Page 52 of 101
- Monofilament synthetics
 Nylon
 Prolene
Guidelines and suggestion in the use of sutures

- Skin- non absorbable (nylon, to be removed), absorbable
(dexon or vicryl)
- Subcutaneous- absorbable
- Fascia- nonabsorbable or absorbable synthetics
- Peritoneum- absorbable
- Vascular repair- nonabsorbable
- Intestinal anastomosis- absorbable and nonabsorbable (2
layers)
Nonbabsorbable (1 layer)
Methods of suturing
1. everting suture- use for skin edges
 Simple continuous (running); can be used to close multiple
layers with one suture
 Simple interrupted; individual stitch is placed, tied and cut in
succession from one suture
 Continous running/locking (blanket stitch); single stitch is
passed in and out of the tissue layers and looped through the
free end before the needle is passed through the free end
before the needle is passed through the tissue for another stitch
 Horizontal mattress; stitches are placed parallel to wound
edsges
 Vertical mattress; uses deep superficial bites, with each stitch
crossing the wound at right angles; for deep wound
2. inverting sutures; used for two layers anastomosis of hollow
internal organs (bowel and stomach)
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 Halstead suture- modification of horizontal mattress suture

used for friable suture
 Connell suture; continuous single-layer suture of gut used for
hemostasis in the inner layer of the bowel with a separate
outer inverting layer of alternating horizontal and vertical
mattress sutures
 Cushing suture; continuous vertical mattress suture that unites
one half of the lumen followed by a second continuous
vertical mattress suture that completes the second half of the
circumference
 Grey-turner suture; series of inverted interrupted horizontal or
vertical mattress stitches
 Purse string suture; continuous stitches that encircle and closes
a lumen while inverting the edges
Suture sizes
- Sizes range from heavy 10 (largest) to very fine 12-0
(smallest)
- Sizes increase with each number above 1 and decreases with
each 0 added. The more 0’s added in the number the smaller
the brand
Type of sutures for abdominal uterine and abdominal layer

Brand/type Layer/tissue Size/ USP
1. safil a. skin i. 4/0
2. plain b. ii. 2/0
yellow subcutaneous iii. 0
3. monoplus c. fascia iv. 2/0
4. chromic d. v. 2/0
5. chromic peritoneum vi. 1/0
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6. chromic e. vii. 1/0

7. chromic perimetrium
f.
myometrium
g.
endometrium
Removal of sutures
- Facial wounds- 3-5 days
- Scalp wounds- 7-10 days
- Limbs- 10 to 14 days
- Joints- 14 days
- Trunk of the body- 7-14 days
Classification of surgical wounds

 Clean wound (infection rate: 1% to 5%)
- Elective procedure with wound under ideal operating room
conditions
- Primary closure, wound not drained
- No break in sterile technique during surgical procedure
- No inflammation present
- Alimentary, respiratory, and genitourinary tract or
oropharyngeal activity not entered
 Clean contaminated wound (infection rate: 8% to 11%)
- Primary closure, wound drained
- Minor break in technique occurred
- No infection or inflammation present
- Alimentary. Respiratory, and genitourinary tracts or
oropharyngeal cavity entered under controlled conditions
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without significant spillage or unusual contamination

 Contaminated wound (infection rate 15% to 20%)
- Open fresh traumatic wound of less than 4 hours duration
- Major break in technique occured
- Acute nonpurulent inflammation present
- Gross spillage/contamination from gastrointestinal tract
- Entrance into genitorurinary or biliary tracts with infected
urine or bile present
 Dirty and infected wound (infection rate 27% to 40%)
- Old traumatic wound of more than four hours duration from
dirty source or with retained necrotic tissue, foreign body or
fecal contamination
- Organisms present in surgical field before procedure
- Existing clinical infection: acute bacterial infection
encountered, with or without purulence; incision to drain
abscess
- Perforated viscus
Dressing
Purpose of dressing
- Protection from injury, bacterial contamination
- Provide humidity
- Insulation
- Absorb drainage
- Debride the wound
- Prevent hemorrhage
- Splint/immobile
- Comfort
Types of dressings
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- Dry to dry- trap necrotic debris and exudates

- Wet to dry (saline and anti microbial solutions)- softens
debris as it dries; dilutes exudates
- Wet to damp- wound is debrided if gauze is removed
- Wet to wet- moisture dilutes exudates
Pressure ulcer dressing
- Dry gauze stage- stages II to IV
- Tegaderm film/ hydrocolloid- stages I to II
- Absorptive dressing- stage III
- Hydrogel stage II to III
Postoperative surgical phase

I. begins with the admission of the patient to the postanesthesia
care unit (PACU) and ends with the discharge of the patient from
the hospital or facility providing the continuing care
Postoperative care starts right after dressing. The surgeon
should assess the patient immediately after the operation.He should
accompany the patient to the recovery room and do postoperative
orders. He may leave the patient only if everything is stabilized
and under control.
POSTANESTHESIA CARE UNIT

Priority care in the post anesthesia care unit (PACU)
1. monitoring and management of respiratory and
circulatory function, pain, temperature, and the surgical
site.
2. Assessment begins with an evaluation of the airway,
breathing, and circulation (ABC). Any evidence of
respiratory compromise requires prompt intervention.
3. Pulse oximetry monitoring is initiated because it
Page 57 of 101
provides a noninvasive means of assessing the adequacy

of oxygenation.
4. Electrocardiographic (ECG) monitoring is initiated to
determine cardiac rate and rhythm.
5. The initial neurologic assessment focuses on level of
consciousness, orientation, sensory and motor status, and
size, equality, and reactivity of the pupils.
6. Because hearing is the first sense to return, the nurse
explains all activities to the patient from the moment of
admission to the PACU.
Aldrete Score also known as the Postanesthetic recovery score,

is used in PACUs to objectively assess the physical status of clients
recovering from the anesthesia and serve as a basis for discharge in
the PACU.
The first five items are used to discharge from the PACU.
Clients are assessed at the time of admission to the PACU and
every 15 minutes until discharge. The first five items include
assessing activity, respiration, consciousness, circulation and color
(oxygen saturation). Typically a minimum score of 8 is needed for
discharged from the PACU.
Criteria Admit 15 30 45 60
min min min min
Activit Able to move 2 2 2 2 2
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y voluntarily 4ext 1 1 1 1 1
On command 0 0 0 0 0
2
0
Respira Able to breathe 2 2 2 2 2
tion deeply, cough freely
Dyspnea or limited 1 1 1 1 1
breathing 0 0 0 0 0
Apnea
Circula BP + 20 of 2 2 2 2 2
tion preanesthesia level 1 1 1 1 1
BP +20-50 of 0 0 0 0 0
preanesthesia level
BP +50 of
preanesthesia level
Consci Fully awake 2 2 2 2 2
ousnes Arousable on calling 1 1 1 1 1
s Not responding 0 0 0 0 0
O2 Able to maintain O2 2 2 2 2 2
saturati saturation >92% on
on room air 1 1 1 1 1
Needs O2 inhalation
to maintain O2 sat 0 0 0 0 0
>90%
O2 sat <90% even
with O2
supplementation
POTENTIAL COMPLICATIONS IN THE PACU

Page 59 of 101
Respiratory
 In the immediate post anesthesia period, the most common
causes of airway compromise include airway obstruction,
hypoxemia, and hypoventilation.
Patients at risk include
1. those who have had general anesthesia,
2. are older,
3. smoke heavily,
4. have lung disease,
5. are obese,
6. or have undergone airway, thoracic, or abdominal
surgery.
Priority care in the post anesthesia care unit (PACU)
o monitoring and management of respiratory and
circulatory function, pain, temperature, and the surgical
site.
o Assessment begins with an evaluation of the airway,
breathing, and circulation (ABC). Any evidence of
respiratory compromise requires prompt intervention.
o Pulse oximetry monitoring is initiated because it provides
a noninvasive means of assessing the adequacy of
oxygenation.
o Electrocardiographic (ECG) monitoring is initiated to
determine cardiac rate and rhythm.
o The initial neurologic assessment focuses on level of
consciousness, orientation, sensory and motor status, and
size, equality, and reactivity of the pupils.
o Because hearing is the first sense to return, the nurse
explains all activities to the patient from the moment of
admission to the PACU.
Page 60 of 101
II. immediate postoperative nursing assessments of/interventions

for the patient in the PACU:
a. respiratory status
i. assessments
a. respiratory rate, rhythm, depth
b. patency of airway
c. presence of oral airway
d. breath sounds
e. use of accessory muscles
f. skin color g. ability to cough
h. ABG'S
i. O2 saturation (pulse oximetry)
ii. interventions
a. ask patient to expel airway
b. position patient on side to prevent aspiration
c. suction artificial airways and oral cavity as
necessary
d. ask patient to perform respiratory exercises
e. administer O 2 as needed
b. circulatory status
i. assessments
a. heart rate
b. blood pressure
c. skin color
d. heart sounds
e. peripheral pulses
f. capillary refill
g. edema
Page 61 of 101
h. skin temperature
i. urine output
j. Homan's sign
k. changes in vital signs symbolizing shock
l. type, amount, color, odor, and character of drainage
from tubes, drains, catheters or incision
ii. interventions
a. check under patient for pooling of blood
b. check dressings, tubes, drains, and catheters for
blood
c. monitor changes in heart rate and blood pressure
c. thermoregulatory status
i. assessments
a. temperature
b. shivering
ii. interventions
a. apply warming blankets
d. central nervous system status
i. assessments
a. LOC
Specific criteria for categorizing the recovery
room patient. sss
(a) Comatose -- unconscious; unresponsive
to stimuli.
(b) Stupor -- lethargic and unresponsive;
unaware of surroundings.
(c) Drowsy -- half asleep, sluggish; responds
to touch and sounds.
(d) Alert -- able to give appropriate response
to stimuli
Page 62 of 101
b. mental status
c. movement and sensation in extremities
d. presence of gag and corneal reflexes
ii. interventions
a. orient patient to PACU environment
b. protect eyes if corneal reflex absent
c. protect airway if gag reflex absent
e. wound status
i. assessments
a. warmth, swelling, tenderness or pain around
incision
b. type, amount, color, odor, and character of
drainage on dressings
c. amount, consistency, color of drainage
d. dependent areas (e.g., underneath the patient)
e. drains and tubes and be sure they are intact, patent,
and properly connected to drainage systems
ii. interventions
a. reinforce dressings as necessary
f. urinary status
i. assessments
a. bladder distention
b. amount, color, odor, and character of urine from
foley catheter if present
ii. interventions
a. catheterize if necessary
b. notify MD if urinary output is less than 30 cc/hr
g. gastrointestinal status
i. assessments
a. abdominal distention
Page 63 of 101
b. N & V
c. bowel sounds
d. passage of flatus
e. type, amount, color, odor, and character of
drainage from nasogastric tube if present
ii. interventions
a. take notes of flatus and keep on NPO status until
further DO
h. fluid and electrolyte balance
i. assessments
a. I & O
b. color and appearance of mucus membranes
c. skin turgor, tenting, and texture
d. status of IV's
e. type, amount, color, odor, and character of
drainage from tubes, drains, catheters, and incision
f. type, amount of solultion, flow rate, tubing,
infusion site
ii. interventions
a.
i. comfort
i. assessments
a. pain
ii. interventions
a. administer analgesic medication as ordered when
necessary (usually IV opioid analgesics)
DISCHARGE
 The choice of discharge site is based on patient acuity, access
to follow-up care, and the potential for postoperative
complications.
Page 64 of 101
 The decision to discharge the patient from the PACU is based

on written discharge criteria.
 Discharge to the clinical unit:
o Vital signs should be obtained, and patient status should
be compared with the report provided by the PACU.
Documentation of the transfer is then completed, followed
by a more in-depth assessment. Postoperative orders and
appropriate nursing care are then initiated.
 Ambulatory surgery discharge:
o The patient leaving an ambulatory surgery setting must
be mobile and alert to provide a degree of self-care
when discharged to home.
o The nurse specifically documents the discharge
instructions provided to the patient and family.
III. postoperative nursing assessments of/interventions for the
patient post-PACU:
a. respiratory status
i. assessments
a. same as in the PACU
ii. interventions
a. encourage patient to perform respiratory exercises
b. encourage early ambulation
c. assist patients who are restricted to bed to turn
every 1 to 2 hours
d. suction as necessary
b. circulatory status
i. assessments
ii. interventions
a. encourage patient to perform leg exercises
Page 65 of 101
b. apply leg procedures

c. encourage early ambulation
d. position patient in bed so that blood supply is not
interrupted to extremities
e. administer anticoagulants as ordered
f. promote adequate fluid intake
c. gastrointestinal status
i. assessments
ii. interventions
a. assist patient to assume a normal position during
defecation
b. progress diet as ordered and tolerated
c. encourage early ambulation
d. promote adequate fluid intake
e. administer fiber supplements, stool softeners,
enemas, rectal suppositories, and rectal tubes as
ordered
d. urinary status
i. assessments
ii. interventions
a. assist patient to assume normal position during
voiding
b. check the patient frequently to determine need to
void
c. monitor I & O
e. wound status
i. assessments
Page 66 of 101
ii. interventions
a. change dressings as ordered utilizing aseptic
technique
f. comfort
i. assessments
ii. interventions
a. administer pain medications as ordered (especially
for the first 24-48 hours)
IV. preventing posoperative complications:

a. wound infection
i. causes
a. break in aseptic technique or a dirty wound
b. predisposing factors: diabetes, uremia, obesity,
malnutrition, corticosteroid therapy
ii. major clinical manifestations
a. fever
b. foul-smelling, greenish-white drainage from
wound
c. persistent edema
d. redness
iii. treatment
a. antibiotics on basis of wound culture and
sensitivity
iv. preventive nursing interventions
a. strict aseptic technique in the operating room and
during postoperative dressing changes
b. wound dehiscence and eviseration
i. causes a. inadequate surgical closure
Page 67 of 101
b. increased intra-abdominal pressure from

coughing, vomiting, or straining at stool
c. poor wound healing caused by malnutrition, poor
circulation, old age, or preoperative radiation
a. discharge of serosanguineous drainage from the
wound
b. sensation that ?something gave or let go?
iii. treatment
a. lay patient down
b. cover wound with sterile saline-soaked gauze or
towels
c. prepare to return patient to operating room for
repair
d. monitor for shock
a. splint wound when patient coughs
b. medicate for nausea and vomiting
c. highest risk during 5th to 8th postoperative days,
so teach patient s/s as they may already be discharged
c. singultus
i. causes
a. idiopathic irritation of the phrenic nerve
a. periodic release of air through the glottis,
emanating noise, abdominal distention
iii. treatment
a. breathe in and out of paper bag for 5-minute
intervals
b. administration of 5% carbon dioxide in oxygen
Page 68 of 101
mix for a few minutes

a. none
d. elevated temperature
i. causes
a. infection
b. dehydration
c. response to stress and trauma
d. prolonged hypotension
e. transfusion reaction
f. respiratory congestion
g. thrombophlebitis
a. temperature elevated above 99.5° (37.5° C)
b. elevated pulse and respiratory rates
c. diaphoresis
d. lethargy
iii. treatment
a. antipyretics
b. cooling sponge baths
c. increasing fluids
a. dependent of cause
e. urinary retention
i. causes
a. lack of urge to void because of anesthetic, narcotic,
or anticholinergic drugs
b. surgery of pelvic or perineal area resulting in
edema in area of bladder
Page 69 of 101
a. little or no output or frequent small amounts

b. palpably distended bladder
c. restlessness
d. discomfort
iii. treatment
a. measures to promote voiding (privacy, running
water, sitting patient up
b. catheterization if above methods fail
a. adequate hydration
b. early ambulation
f. urinary tract infection
i. causes
a. urinary retention
b. catheterization
c. contamination of urinary tract
a. mild fever
b. dysuria
c. hematuria
d. malaise
iii. treatment
a. adequate hydration
b. maintenance of good bladder drainage
c. antibiotics on basis of urine culture and sensitivity
a. encourage fluid intake
b. early ambulation
c. avoid catheterization or remove within 2 days
g. adhesions
Page 70 of 101
i. causes
a. unknown; represents overhealing of tissue and is
more extensive if inflammatory process is present
a. bowel obstruction
b. pain
iii. treatment
a. surgery for lysis of adhesions
a. aseptic technique in operating room and during
dressing changes
h. pneumonia
i. causes
a. aspiration
b. infection
c. decreased cough reflex
d.increased secretions from anesthesia
e.dehydration
f.immobilization
g.atelectasis
ii.major clinical manifestations
a. increased temperature
b. chills
c. cough productive of purulent or rusty sputum
d. crackles e. wheezes
f. dyspnea
g. chest pain
h. tachypnea
i. increased secretions
iii.treatment
Page 71 of 101
a. promote full aeration of lungs by positioning in

semi-Fowlers or Fowlers
b. administer O 2 as ordered
c. maintain fluid status
d. administer antibiotics on basis of sputum culture
and sensitivity
e. administer expectorants and analgesics as ordered
f. chest physiotherapy
a. turn, coughing and deep breathing
b. frequent position changes
c. early ambulation
i. atelectasis
i. causes
a. obstruction of airway by secretions
b. closure of bronchioles because of shallow
breathing or failure to periodically hyperventilate
lungs
a. decreased lung sound over affected area
b. dyspnea
c. cyanosis
d. crackles
e. restlessness
f. apprehension
g. fever
h. tachypnea
iii. treatment
a. position in semi-Fowler?s or Fowler?s
b. administer O 2 as ordered
Page 72 of 101
maintain hydration
administer analgesics as ordered
chest physiotherapy suctioning
administer brochodilators and mucolytics via
nebulizer
a. early ambulation
b. turn, cough, and deep breathing
c. incentive spirometry
j. paralytic ileus
i. causes
a. anesthetic agents
b. manipulation of the bowel
c. wound infection
d. electrolyte imbalance
a. absent bowel sounds
b. no passage of flatus or feces
c. abdominal distention
iii. treatment
a. nasogastric suction
b. IV fluids
c. rectal tube
d. ambulate
a. early ambulation
b. abdominal tightening exercises
c. keep NPO if inactive bowel sounds
k. bowel obstruction
i.. causes
Page 73 of 101
a. intestinal adhesions
a. similar to paralytic ileus although bowel movement
may occur before obstruction
iii. treatment
a. bowel decompression with a Miller-Abbot tube
b. surgical correction
l. pulmonary embolism
i. causes
a. formed from venous thrombus; usually originating
in legs, pelvis, or right side of heart, then traveling to
and being trapped in pulmonary circulation
a. dyspnea
b. sudden severe chest pain or tightness
c. cough
d. pallor or cyanosis
e. increased respirations
f. tachycardia
g. anxiety
h. bradycardia
i. hypotension
j. restlessness
iii. treatment
a. contact physician stat
b. maintain bedrest with HOB in semi-Fowler?s
c. maintain fluid balance
d. administer O 2 as ordered
e. administer anticoagulants as ordered
f. administer analgesics as ordered
Page 74 of 101

a. passive and active range of motion exercises to
legs
b. antiembolic stockings
c. low-dose heparin administration if predisposing
factors present
d. early ambulation
m. hematoma
i. causes
a. imperfect hemostasis
b. use of anticoagulants
c. coagulation disorders
a. active bleeding
iii. treatment
a. elevation and discoloration of wound edges if
small, may reabsorb; otherwise surgical evacuation
n. hypovolemic shock
i. causes
a. hemorrhage
a. decreased blood pressure
b. cold, clammy skin
c. weak, rapid, thready pulse
d. deep, rapid respirations
e. decreased urinary output
f. thirst g. apprehension
h. restlessness
iii. treatment
a. position flat with legs elevated 45 degrees
Page 75 of 101
b. administer fluid resuscitation as well as whole

blood or its components as ordered
c. administer O 2 as ordered
d. place extra covering to maintain warmth
e. prepare for OR
o. thrombophlebitis
i. causes
a. venous stasis caused by prolonged immobilization
or pressure on vein walls from leg straps in operating
room or leg holders for lithotomy position
a. pain and cramping in the calf of the involved
extremity
b. redness, swelling in the affected area of the
involved extremity
c. increased temperature of the involved extremity
d. increased diameter of the involved extremity
iii. treatment
a. administer analgesics as ordered
b. measure bilateral calf or thigh circumferences
c. administer anticoagulants as ordered
d. elevate affected extremity to heart level
e. maintain bedrest
f. apply moist heat on affected extremity as ordered
a. antiembolic stockings or sequential penumatic
compressions stockings
b. postoperative leg exercises c. early ambulation
OPERATING ROOM TOUR

Page 76 of 101
https://www.youtube.com/watch?v=-YKfXXNSPeY
The Operating Room

https://www.youtube.com/watch?v=PCgxuknwets
Different ROLES in the OR

https://www.youtube.com/watch?v=uavgh2lhOfs
Introduction to the Operating Room: Masking, Scrubbing,

Gowning, Gloving and O.R. Etiquette
https://www.youtube.com/watch?v=dpYOml02OBQ
Setting up for SURGERY

https://www.youtube.com/watch?v=JaSnvS-XNas
General Minor Instrument Tray

https://www.youtube.com/watch?v=RGa4YsCUg_E
Major Abdominal Instrument Set

https://www.youtube.com/watch?v=RDR7T_0vB8E
How an Anesthesiologist Sets Up an Operating Room for

Surgery
https://www.youtube.com/watch?v=pEb-dtC5WCk
Anaesthesia - General anaesthetic

https://www.youtube.com/watch?v=65h8N4j9MIc
Surgical Anticipation and Instrument Passing

Page 77 of 101
https://www.youtube.com/watch?v=PRenVFrea7Q
Basic Surgical Instrument Passing

https://www.youtube.com/watch?v=1KXv3St9Bgg
https://www.youtube.com/watch?v=KpOcvz9NSgo
Learn How To Suture - Best Suture Techniques and Training

https://www.youtube.com/watch?v=TFwFMav_cpE
https://www.youtube.com/watch?v=Akyr4zlBS9E
Electrosurgery & The Bovie

https://www.youtube.com/watch?v=5o1ape2Pz9M
Zone Medical electrosurgical demonstration video

https://www.youtube.com/watch?v=Q6rqhSUxGCQ
The Anatomy of a C-Section

https://www.youtube.com/watch?v=ckQzMtptw4w
https://www.youtube.com/watch?v=VkxwN8xQz80
Every Major Tool A Heart Surgeon Uses | Expert Toolbox

https://www.youtube.com/watch?v=cJ81GuY1K-U
Every Major Tool A Plastic Surgeon Uses | Expert Toolbox

https://www.youtube.com/watch?v=c_iQyAIzAgI
Cataract Surgery Animation Extracapsular Cataract Lens

Extraction
https://www.youtube.com/watch?v=n_3cG9oeuNo
Page 78 of 101
Flatfoot Repair with Arthrex® Calcaneus Step Plate

https://www.youtube.com/watch?v=sf_Q9NSiPvk
Outpatient Knee Surgery: Day in the Life

https://www.youtube.com/watch?v=6FqwLNJyuK8
Epidural Live Technique

https://www.youtube.com/watch?v=ndYzw_lSfJA
Spinal Anesthesia Explained Part 1- Crash course with Dr.

Hadzic
https://www.youtube.com/watch?v=-dDrNNdFhNg
Epidural, spinal, and combined spinal-epidural overview

https://www.youtube.com/watch?v=DtzI5bX7NyA
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DELORINO JUNALE7:20 AM
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Perioperative Nursing Manual

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Perioperative Nursing Manual

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Page 1 of 101

“The only predictable things in the operating room are the

Accountability and Professional Obligations

I. Legal and Ethical Issues- Primum non nocere+ to do

Negligence- is the lack of care or skills that any RN

VIII. Doctrine of Informed refusal- right to withdraw

Universal Moral Principles Guide in Ethical decision making

IV. Justice- equality in all care given to different client.

Bioethical situation that may cause dilemma in the operating

Patient bill of rights

by law and hospital policy and to be informed of the medical

that may influence the patient's treatment and care.

Professional obligations to perioperative team

VI. working conditions

Settings for surgery

Classifications of surgical procedures

a. e.g., revision of scars, liposuction, rhinoplasty,

II. according to urgency of surgery

a. e.g., cataract removal, hernia repair, total joint

III. according to degree of risk of surgery

IV. according to extent of surgery

a. simple i. only the most overtly affected areas involved

Indication of informed consent

Criteria for valid consent

 emancipated minor- married/ lives on his or her own: may

THE OPERATING ROOM TEAM

A. Operating room surgeon

Requirements of operating room surgeon

C. Physician first assistant

D. Non physician first assistant

Criteria for eligibility for appointment

B. Knowledge and skills in applying principles of aseptic

E. Second assistant to surgeon

F. Scrub person- RN, LPN, VN, ST

- Assisting the surgeon and surgeon’s assistant during the

II. UNSTERILE TEAM

- Application of nursing process throughout the procedure

3. X- ray technician and other team members

The typical operating room suite is constructed in such a way

There are basically three zones in a standard operating suite in

The middle zone (semirestricted area) is represented by the

scrub suit, shoes, slippers, cap and mask.

In the holding area, the perioperative nurse makes the final

The inner zone (restricted area) is represented by the room

The OR is a unique acute care setting removed from other

Fig. 1. An Operating Room Suite

Operating Room Scrubbing Area

Supply Room III

The terms aseptic and antiseptic are often used interchangeably.

effective than chemicals in sterilizing instruments and linens, the

Aseptic technique then is a body of technique for ensuring that

1. The operating room physical environment

Even the most advanced aseptic technique have not yet

The greatest source of contamination in a basically clean

Studies of operating room during the periods of inactivity

PRINCIPLE STERILE TECHNIQUE

The goal of asepsis and aseptic technique is to prevent the

surgical team members to use their knowledge and experience in

Aseptic technique for the instruments, sutures, linens, fluids,

Aseptic technique for the non scrubbed personnel

Aseptic technique for the scrubbed personnel

Preoperative surgical phase

The preoperative nursing assessment is performed to: