MEDICAL SURGICAL NURSING PAIN AND SURGERY -- MODULE 1.

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

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

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

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

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

Peripheral Support Areas

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

e. Furniture and other Equipment Inside the Operating Room

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

REVIEW OF INFECTION CONTROL CROSS INFECTION

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

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

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

E. INFECTION 5 MAIN ROUTES

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

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

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

practices and procedures that keep an area or object totally free from all a cleaning process that destroys most microorganisms through the use of
microorganisms. certain chemicals or boiling water. uses a DISINFECTANT, an agent that
kills growing microorganisms.
MEDICAL SURGICAL NURSING
2. METHODS OF DISINFECTION
A. PHYSICAL DISINFECTANTS
Boiling of water (212’F or 100’C). Minimum boiling period is 30
minutes.
Horizontal and vertical scrubbing with soap and water.
UV Radiation and fumigation with chemicals are NO LONGER
recommended because of the limitation of their practical usefulness.
B. CHEMICAL DISINFECTANTS
Alcohol (70%-90%) ethyl or isoprophyl – used as a housekeeping
disinfectant and can be used in semicritical instruments. Hazard :
volatile and it will harden and swell plastic tubing.
Chlorine compounds – has limited use in hospital. Ex. Sodium
hypochlorite 0.5-1%
Phenolic compounds – kills microorganisms by coagulation of
protein. Major choice when dealing with fecal contamination.
Formaldehyde (either in solution or gas form) – is sporicidal in
minimum of 12 hours.
Glutaraldehyde – agent of choice for sterilization. Good also for
instruments that can not be steam sterilized. Recommended soaking
time is 15-30 minutes.
3. DEFINITION OF STERILIZATION
a cleaning process that kills all microorganisms, including spores.
uses a chamber or equipment known as STERILIZER, to attain either
physical or chemical sterilization.
4. METHODS OF STERILIZATION
a. Physical Means
• Steam under pressure (moist heat/ autoclave) – easy, safe, surest
method, fastest, least expensive and leaves no harmful residues.
Disadvantage: dangerous and subject to human errors.
*Radiation – has a very low temperature effect on materials but penetrates
materials very well.
b. Chemical Means
• Immersion / Soaking in Glutaraldehyde – penetrates into crevices of
instruments; noncorrosive, non-staining, safe, does not damage the
lenses. Disadvantages includes it mild but irritating odor, it has low
toxicity so rinse the objects with sterile water prior to use.
• soaking solution should be changed every 28th day of use.
ex. Cidex, Zephiran erile water prior to use.
5. Guidelines on Sterilization & Disinfection
✓ IN HOUSE PACKAGING MATERIALS - materials used for IHP
and wrapping of sterile supplies should :
• Be compatible with the sterilization process.
• Provide a cost-effective barrier to microorganisms.
PAIN AND SURGERY -- MODULE 1.2
• Allow for ease in aseptic presentation.
• be free of toxic ingredients and non-fast dyes and be relatively
nonabrasive.
✓ All items to be sterilized should be prepared to reduce the bio burden.
✓ All articles to be sterilized should be arranged so all surfaces will be
directly exposed to the sterilizing agent for the prescribed time and
temperature.
✓ All wrapped articles to be sterilized should be packed in materials
that meet the standards/
criteria in the recommended practice for in-hospital packaging
materials.
✓ Chemical indicators, also known as sterilization process indicators,
should be used to indicate that items have been exposed to a
sterilization process.
✓ The efficacy of the sterilization process should be monitored at a
regular interval with reliable biological indicators.
✓ Every package should be labeled with the date of sterilization,
autoclave number & the sterilizer used.
✓ Sterilized items should be carefully handled and only when
necessary. They should be stored in well-ventilated, limited access
area with controlled temperature and humidity.
✓ Flash sterilization should be used for emergency sterilization of clean,
unwrapped instruments and porous items only.
✓ Performance record for all sterilizers should be maintained as well as
the preventive maintenance should be performed according to
individual policies on a scheduled basis by qualified personnel.
✓ Policies and procedures for sterilization and disinfection should be
written and reviewed periodically. This should be readily available
within the practice setting for easy reference.
6. Considerations in Selecting the Method of Sterilization OR
Disinfection
✓ availability / efficiency of sterilizing agent / disinfectant;
✓ physical properties of the item;
✓ urgency of need;
✓ standards of practice;
✓ hazard of toxic residue;
✓ infection control;
✓ manufacturer’s recommendation
✓ decontamination requirements;
✓ packaging requirement;
✓ ease of transport and storage;
✓ environmental / disposal requirements;
✓ cost containment