Surgical Scrubbing, Gowning & Gloving Return Demonstration
J.A.K.E
SURGICAL SCRUBBING, GOWNING & GLOVING
Preparing to scrub
- Surgical scrubs (bare below the elbows, including
removing watches and rings)
- Footwear such as clogs
- Theatre hat (with hair tied up if necessary)
- ID badge
1) First, open the gown. Carefully use the edges of the
paper to open the packet and expose the surgical
gown.
2) Next, choose your gloves. Peel the plastic glove
packet open over the gown and drop the gloves onto
the sterile gown without touching them. This will
ensure your gloves and gown are untouched, and
therefore sterile.
3) Finally, put on a surgical mask and eyewear
protection. Make sure you are comfortable, as you
cannot adjust these once you are scrubbed.
Pre-scrub wash
1) Run the tap to an adequate temperature and flow (to avoid
water splashing). Then test the water before starting to
scrub to ensure the temperature is comfortable.
2) Open the package containing the nail brush/scrub sponge
and nail pick, then lie it on the back of the scrub sink still
in the opened package.
3) Wet the hands and arms for an initial pre-scrub wash. Use
several drops of scrub solution and work up a heavy lather,
then wash the hands and arms to the elbows. Cleansing
solutions are non-irritating to most people and include:
• Povidone Iodine
• Chlorhexidine
• Some hospitals use dispensable alcohol gel, which
can be used between short, ‘clean’ procedures.
Check with the operating surgeon if they are happy for
you to use this.
4) Rinse the hands and arms thoroughly, allowing the water
to run from the hands to the elbows.
5) Remove the sterile nail brush and nail pick from the
opened package. Clean under the nails with the nail pick
and then discard in the bin (making sure not to touch the
bin by using a foot-pedal).
6) Moisten the nail brush and dispense antimicrobial
solution onto the sponge-side.
7) Lather the fingertips with sponge-side of brush, washing
all four sides of the fingers.
8) Then using the bristle side of the nail brush, scrub the
spaces under the fingernails of the right or left hand.
Repeat the process on the other hand
Scrubbing procedure
Step 1
• Wet the hands and forearms.
• Apply the specified amount of appropriate antimicrobial
solution, according to the manufacturer’s
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recommendations, from the dispenser (one downward
stroke action).
• Work the cleaning solution into the hands palm to palm,
creating a lather.
Step 2
• Rub the right palm over the back of the left and vice versa
with the fingers interlaced.
Step 3
• Rub hands palm to palm, with fingers interlaced.
Step 4
• Perform rotational rubbing backwards and forwards with
clasped fingers of the right hand into the left palm hand
and vice versa.
Step 5
• Perform rotational rubbing of the right thumb clasped in
the left hand and vice versa.
Step 6
• Rub the fingertips of the left hand on the palm of the right
hand and vice versa.
Step 7
• Continue with the rotating action down opposing arms,
working to just below the elbows.
Step 8
• Rinse and repeat steps 1-7 keeping hands raised above
elbows at all times.
• The second wash should only cover two-thirds of the
forearms to avoid compromising the cleanliness of the
hands.
• Local policy may include repeating these steps a third
time but to wrists only.
• The scrub procedure should last for 5 minutes, with
further scrubs during the day lasting 3 minutes.
Step 9
• Rinse the hands under running water, allowing the water
to run from fingertips to elbows.
• Turn the tap off (if necessary) with your elbow and keep
your hands up, allowing water to drip from your elbows.
Step 10
• Pick up one hand towel from the top of the gown pack and
step back from the
• surface.
• Grasp the towel and open it fully. Do not allow the towel to
touch any unsterile
• object or unsterile parts of your body.
• Hold your hands and arms above your elbow, and keep
your arms away from
• your body.
Step 11
• Holding one end of the towel with one hand dry the fingers
of the opposite hand using a blotting rotational motion.
• Move to the dry area of the towel and continue in this
manner down the forearm to the elbow.
• Ensure you do not retrace from the forearm back up to the
hands and do not wipe the skin dry. This may contaminate
J.A.K.E Surgical Scrubbing, Gowning & Gloving
your hands with microorganisms from your proximal
forearm – you will be asked to re-scrub.
• Repeat with the other towel from the pack for the other
hand and arm.
Gowning
Picking up the gown
1) With one hand, pick up the entire folded gown from the
wrapper by grasping the gown through all layers, being
careful to touch only the inside top layer which is exposed.
2) Once your hands are securely pinching the gown in these
slots, step back from the shelf and allow the gown to drop.
3) Make sure the gown does not touch any surrounding
unsterile objects.
Inserting your arms into the sleeves of the gown
4) Grasp the inside shoulder seams and open the gown with
the armholes facing you.
5) Carefully insert your arms partway into the gown one at a
time, keeping hands at shoulder level away from the body.
6) Slide the arms further into the gown sleeves and when the
fingertips are level with the proximal edge of the cuff,
grasp the inside seam at the cuff hem using thumb and
index finger. Be careful that no part of the hand protrudes
from the sleeve cuff.
Fastening the gown
7) A theatre assistant will fasten the gown behind you,
positioning it over the shoulders by grasping the inside
surface of the gown at the shoulder seam. The theatre
assistant’s hands should only ever be in contact with the
inside surface of the gown.
8) The theatre assistant then prepares to secure the gown at
the neck and upper back. Gowns differ in how they are
secured, but most with have either ties, buttons or velcro
tabs.
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NCMB 312 RLE
Final tie
1) There is a cardboard slip holding two ties together across
the front of the gown.
2) Detach the cardboard slip from the short tie, ensuring you
keep hold of the short tie in your left hand.
3) Now pass the cardboard slip to the theatre assistant,
ensuring not to make direct contact with their hand
4) They will pass the tie around your back – now take the tie,
and let them pull the cardboard off the tie so that you can
tie a bow at your waist
Proper Gloving Technique
1) Open the inner glove packet that you previously dropped
onto your sterile field.
2) Pick up one glove by the folded cuff edge with your sleeve-
covered hand.
3) Place the glove on the opposite gown sleeve facing palm
down, with the glove fingers pointing towards you. The
palm of the hand inside the gown sleeve must be facing
upward toward the palm of the glove.
- Place the glove’s rolled cuff edge at the seam that
connects the sleeve to the gown cuff. Grasp the
bottom rolled cuff edge of the glove with the thumb
and index finger of the hand the glove is on top of.
4) While holding the glove’s cuff edge with one hand, grasp
the uppermost edge of the glove’s cuff with the opposite
hand.
5) Continuing to grasp the glove, stretch the cuff of the glove
over the hand
- Using the opposite sleeve covered hand, grasp both
the glove cuff and sleeve cuff seam and pull the glove
onto the hand. Pull any excessive amount of glove
sleeve from underneath the cuff of the glove.
6) Using the hand that is now gloved put on the second glove
in the same manner. Check to make sure that each gown
cuff is secured and covered completely by the cuff of the
glove.
7) Adjust the fingers of each glove as necessary so that they
fit appropriately.
Do not forget:
• Keep your hands in your sleeves so that you do not touch
the glove on the outside of the gown with your bare hands.
• Keep your hands above your waist and in front of you
• Ensure you do not touch anything around you that is not
sterile – this includes your face, mask, and hat!
OR Instruments, Sutures, Principles of Aseptic Techniques
J.A.K.E NCMB 312 RLE

OPERATING ROOM INSTRUMENTS

Classifications of Surgical Instruments
• Cutting and Dissecting (Sharps)
• Clamping and Occluding (Clamps)
• Grasping and Holding (Graspers)
• Exposing and Retracting (Retractors)
• Suturing and Stapling
• Viewing • Iris Scissors
• Suction and Aspirating - Used for fine dissection and cutting fine suture.
• Dilating and Probing - Originally for ophthalmic procedures, but now serves
• Measuring multipurpose role
• Accessory Instruments

Cutting and Dissecting (Sharps)

Knife / Scalpel
- Handle #4 is the first knife used to cut tough tissues.
- Handle #3 is the second knife used to cut delicate tissues, • Bandage Scissors
and is used for minor surgeries. - used to cut the uterus and umbilical cord.

Clamping and Occluding (Clamps)

Hemostatic Forceps
- used temporarily clamp and occlude bleeding vessels.
- can be straight or curved

Scissors • Kelly Forceps – longest; used for deep abdominal layers

• Mayo Scissors (Straight / Curved)
- used to cut tough tissues.
- Heavy scissors available in multiple varieties. Straight
scissors are used for cutting suture (“suture
scissors”), while curved scissors are used for cutting
heavy tissue (e.g., fascia).
and cavities
• Crile Forceps – medium; used for shallow layers
• Mosquito Forceps – shortest; used for minor surgery,
pediatrics, and superficial layers
Mixter Forceps
- used to reach around and ligate blood vessels.

• Metzenbaum Scissors (Straight / Curved)

- used to cut delicate tissues.
- Lighter scissors used for cutting delicate tissue (e.g.,
heart) and for blunt dissection.
- Also called “Metz” in practice
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Ochsner Forceps Babcock Forceps

- used to grasp medium to heavy tissue or occlude heavy, - used to grasp delicate tissue and hold tubular organs
dense vessels - used with intestinal and laparotomy procedures

Ovum Forceps
- used to remove placental fragments inside the uterus

Grasping and Holding (Graspers)

Adson Forceps (Toothed)
- used for handling dense tissue, such as in skin closures

Towel Clips
- used to hold drapes in place, to keep only the operating
field exposed

Adson Forceps (Toothless)

- used for fine surgical procedures to hold delicate or
superficial tissues
- Forceps toothed at the tip used for handling dense tissue,
such as in skin closures.
Bonney Forceps
- Heavy forceps used for holding thick tissue (e.g., fascial
closure)

Thumb Forceps
- used for grasping, holding or manipulating body tissue

Tissue Forceps
- used in surgical procedures for grasping tissue
- designed to minimize damage to biological tissue
- Nontoothed forceps used for fine handling of tissue and
traction during dissection.
Allis Forceps
- used to hold or grasp heavy tissue like bones, tendons,
uterus, and fascia
Exposing and Retracting (Retractors)
Self Retaining Retractors
• Balfour Abdominal Retractor – used in laparotomy
procedures, and for specific abdominal procedures
where the abdomen needs to be held open for
examination or evaluation, such as cesarean sections
and bowel resection

Pennington Forceps
- used for grasping tissue, particularly during rectal
operations
• Mastoid Retractor – used to retract the external canal
skin anteriorly for better visualization of external canal and
middle ear.

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J.A.K.E OR Instruments, Sutures, Principles of Aseptic Techniques NCMB 312 RLE

• Malleable Retractor
- used to retract deep wounds and may be bent to
various shapes.

• Gelpi Retractor – used for holding back organs and

tissues while accessing areas below an incision during
lumbar spine procedures
Suturing and Stapling
Needle Holder
- used to hold a suturing needle for closing wounds during
suturing and surgical procedures

Non-Self Retaining Retractors

• Army Navy Retractor
- used for shallow or superficial wounds, and to retract
Skin Stapler
skin or bones
- used to close incisions after surgery

• Richardson Retractor
- used to retract, expose or push tissue, muscles, Viewing
organs or bones during surgery Speculum
- used to see inside a hollow part of the body

• Deaver Retractor
- used to hold back the abdominal wall during
abdominal or thoracic procedures, and to move or Endoscope
hold organs away from the surgical site - used to look deep into the body and used in procedures
called an endoscopy

• Murphy Rake Retractor

- used to gently retract tissue and give better visibility to
the surgical field

• Senn Retractor
- used to retract fat tissue in minor sugery

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J.A.K.E OR Instruments, Sutures, Principles of Aseptic Techniques NCMB 312 RLE

Suction and Aspirating Accessory Instruments

Suction Mallet
- used to remove substances such as blood, saliva, mucus, - used with a chisel to split teeth and reshape or remove
and vomit bones

SUTURES
- a stitch or row of stitches holding together the edges of a
wound or surgical incision
- can classified into Absorbable and Non-Absorbable
- Absorbable sutures are broken down by the body via
enzymatic reactions or hydrolysis. The time in which this
absorption takes place varies between material, location
Dilating and Probing
of suture, and patient factors. Examples:
Urethral Sounds
- used in urological surgery for dilatation of strictures or for • Vicryl
obtaining access to the bladder • PolyDioxanone Suture (PDS)
• Monocryl
- Non-Absorbable sutures are used to provide long-term
tissue support, remaining walled-off by the body’s
inflammatory processes (until removed manually if
required). Examples:
• Nylon
• Prolene
• Silk
Surgical Probes
- a blunt-ended surgical instrument used for exploring a Suture Size
wound or part of the body - The diameter of the suture will affect its handling
properties and tensile strength.
- The larger the size ascribed to the suture, the smaller the
diameter is, for example a 7-0 suture is smaller than a 4-0
suture.

Measuring
Caliper
- used in plastic surgery procedures to ascertain precise
measurements

Surgical Needles
- The surgical needle allows the placement of the suture
within the tissue, carrying the material through with
minimal residual trauma.
- Characteristics:
Ruler
• rigid enough to resist distortion, yet flexible enough
- used to obtain precise measurements during orthopedic
to bend before breaking
surgical procedures
• as slim as possible to minimize trauma
• sharp enough to penetrate tissue with minimal
resistance
• stable within a needle holder to permit accurate
placement.
Surgical Needles – 3 Parts
• Swaged end - connects the needle to the suture
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J.A.K.E OR Instruments, Sutures, Principles of Aseptic Techniques NCMB 312 RLE

8) Sterile areas are continuously kept in view.

9) Sterile persons keep well within the sterile area.
10) Sterile persons wear gown and gloved.
11) Unsterile persons avoid sterile area.
12) Destruction of integrity of microbial barriers results in
contamination.
13) Microorganisms must be kept to an irreducible minimum.

Surgical Needles – 3 Parts

• Needle Body or Shaft - the region grasped by the needle
holder, and can be round, cutting, or reverse cutting.
- Round bodied needles are used in friable tissue such
as liver and kidney.
- Cutting needles are triangular in shape, and have 3
cutting edges to penetrate tough tissue such as the
skin and sternum, and have a cutting surface on the
concave edge.
- Reverse cutting needles have a cutting surface on
the convex edge, and are ideal for tough tissue such
as tendon or subcuticular sutures, and have reduced
risk of cutting through tissue.
Surgical Needles – 3 Parts
• Needle point - acts to pierce the tissue, beginning at the
maximal point of the body and running to the end of the
needle, and can be either sharp or blunt.
- Blunt needles are used for abdominal wall closure,
and in friable tissue, and can potentially reduce the
risk of blood borne virus infection from needlestick
injuries.
- Sharp needles pierce and spread tissues with
minimal cutting, and are used in areas where leakage
must be prevented.
Surgical Needles – Shapes
- The needle shape vary in their curvature and are
described as the proportion of a circle completed – the ¼,
⅜, ½, and ⅝ are the most common curvatures used.
- Different curvatures are required depending on the access
to the area to suture.

PRINCIPLES OF ASEPTIC TECHNIQUE

1) Only sterile items are used within the sterile field.
2) Gowns are considered sterile only from the waist to
shoulder level infront and the sleeves.

3) Tables are sterile at table level.

4) Sterile persons touch only sterile items or areas . Unsterile
persons touch only unsterile items or areas.
5) Unsterile avoid reaching over sterile field. Sterile persons
avoid leaning unsterile areas.
6) Edges of anything that encloses sterile content are
considered unsterile.
7) Sterile fields is created as close as possible to time of use.

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Operating Room Nursing
J.A.K.E
OPERATING ROOM NURSING
- The identification of the physiological, psychological and
sociological needs of the patient, and the implementation
of an individualized program of nursing care in order to
restore or maintain the health and welfare of the patient
before, and after surgical intervention.
- Goals
• to provide a safe, supportive, and comprehensive
care.
• to assist the surgeon by functioning effectively as a
member of the surgical team.
• to create and maintain as aseptic/sterile environment.
- Suffixes
• -ectomy – removal of apart from the body.
• -otomy – making of an opening
• -rrhaphy – repair of a part of the body
- Conditions Treated by Surgery
• Congenital
• inborn deformities
• Acquired
• conditions resulting from trauma or injury.
Four Basic Pathologic Conditions that require surgery
• Obstruction – blockage in obstructions that are
dangerous because they block the flow of blood, air, CSF,
urine and bile through the body.
- Choledocholithiasis
• Perforation – is the rupture of an organ, artery or bleb.
- Organ – are made up of tissues and are grouped into
system, such as digestive system. It is PART of a living
thing, distinct from the other parts, that is adapted for
a specific function.
- Artery – any of the blood vessel that carries
oxygenated blood away from the heart to the body’s
cells, tissues, & organs. Arteries are flexible, elastic
tubes with muscular walls that expand and contract
to pump blood through the body.
- Bleb – like blisters, bubble, rounded outgrowth on the
surface of the cell
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NCMB 312 RLE
• Erosion – break in the continuity of tissue surface it can
be caused by irritation, infection, ulceration or
inflammation. It may damage the walls of the blood
vessels resulting in serious bleeding.
• Tumors – abnormal growth of tissue that serves no
physiologic function in the body.
Classifications of surgery
Location
• Internal: inside the body
• External: outside the body
Degree of Risk to The Person
• Major - life threatening when major or vital organs are
involved and those surgeries that may involve serious
bleeding.
• Minor – non-life threatening, less serious.
Purpose
• Diagnostic – verifies a suspected diagnosis.
• Exploratory – estimates the extent of the diseases or
injury.
• Curative – removes or repairs damaged tissues, diseased
or congenitally malformed organs or tissues.
• Ablative – removing diseased organs. Ex: Appendectomy
• Palliative – relieves symptoms but does not cure the
underlying disease process. Ex: Tracheostomy
Mode of Operation
• Reconstructive
- a partial or complete restoration of a damaged organ
or tissue to its original appearance and function.
- Skin grafting after severe burns
• Constructive
- repair of a congenitally defective organ, improving its
function or appearance.
- Cheiloplasty
Categories of Surgeries According to Urgency
• Emergency Surgery – done immediately to save life, limb
or a part of the body. Ex. Explore Lap, CS
• Urgent Surgery – must be done within 24-48 hours. Ex.
relief of intestinal obstruction.
• Elective surgery – done at the patient's or surgeon's
convenience. It can be completed within days or months.
• Required Surgery – done to improve patients health or
well being and is not catastrophic if omitted. Ex. Cataract
removal
• Cosmetic surgery – done for aesthetic purposes
- On call any time, any date, operation can be done.
At Risk Patients
• Hypertensive and hypotensive
• Alcoholic
• Young and elderly
• Dehydrated
• Underweight
• Overweight
• Diabetic patient
J.A.K.E Operating Room Nursing
Scope of Nursing Practice
• Application and execution of physician legal orders.
• Observation patient’s s/s and reaction.
• Supervision of patient as to his care.
• Supervision of others who contribute to the care of the
patient except the doctor.
• Accurate reporting and recording.
Qualities of an Ideal OR Nurse
• Works rapidly even under tension and under close
supervision of both MD and RN.
• Must have a quick reaction time and make change for
unexpected changes without notice.
• Must anticipate the surgeon’s needs and keeps one step
ahead of him.
• Must organize work effectively so that not a single minute
is lost, not a motion overflows.
• Must work fit and smoothly as a member of a closely
functioning team.
• Must be patient with those who sometimes become
impatient in a tense situation because some degree of
tension maybe present at times.
• Must possess kindness, poise, sureness and within that
short contact can allay the patient’s fears.
• Must have a quiet, responsive and pleasing personality.
• Must possess a genuine interest and eagerness to learn
and increase her proficiency.
• Be able and willing to take on call operations without
complain.
Operating Room team
Sterile Team
- scrubbed, gowned and gloved personnel.
- Operating Surgeon
- Assistant to the surgeon
- Scrub person
Unsterile team
- In scrub suit, mask and cap attire only.
- Anesthesiologist or Anesthetist
- Circulating nurse
- Functions of Sterile personnel
Assistant to the surgeon
- Holds retractors in the wound to expose operative site.
- Clamp bleeding blood vessels.
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- Assist in suturing during operation or closing the
wound/operative site.
- Suction body fluid/blood to provide clear view of the
operative site.
Scrub Person
- Maintain integrity of, safety, and efficiency of the sterile
field.
- Prepare and arrange instruments and supplies.
- Assist the surgeon and assistant’s surgeon and assistants
throughout the operation by providing sterile instruments
and supplies.
Functions of Unsterile Personnel
Anesthesiologist or Anesthetist
- Administers and maintain anesthesia and manages
untoward reaction to anesthesia.
Circulating Nurse
- Application of the nursing process in directing and
coordinating all nursing activities related to the care and
support of the patient.
- Creation and maintenance of a safe and comfortable
environment for the patient through implementing the
principles of asepsis.
- Provision of assistance to any member of the OR team in
any manner in which the CN is qualified. Identification of
any potential environment dangers or stressful situations.
- Maintenance of communication link between events and
team members as the sterile field and persons not in the
OR but concerned with the outcome of the operation.
- Direction of the activities of the learners.
- Communication links inside and outside the OR.
- Charting/Organizing.
Division of Duties of Scrub and Circulating Nurse
Duties Circulating Nurse
Preliminary Preparations of the OR
1) Done before First Operation of the day.
2) Housekeeping duties that must be done at least
3) 1 hour before scheduled incision time.
4) Remove unnecessary equipments and tables from the OR.
5) Perform dusting using a damp cloth wet with disinfectant.
6) OR light furniture, etc.
7) Disinfect the floor.
8) Turn on aircon.
Before each operation and After the room is cleaned
Secondary Preparations of the OR
1) Place a clean sheet, arm straps and a pillow on the OR
table.
2) Position OR light, tables and check for proper functioning.
3) Assemble and check suction machine.
4) Provide a clean kick bucket.
Before each operation after the room is cleaned
1) Arrange furniture according to use.
2) Obtain sterile instruments, sets, drapes and sterile
supplies that will be needed during operation.
3) Refer to surgeon's preference card for additional supplies.
When Patient Arrives
1) Greet and identify the patient.
J.A.K.E Operating Room Nursing 312 RLE

2) Check the patient's chart for consent and if Preoperative After Operation
preparations are carried out. • Assist the surgeon and assistants in removing their gowns.
3) Be sure to cover the patient's hair with the cap. • Assist with dressing.
4) Transfer the patient to OR table. • Clean the patient.
5) Make the patient comfortable. • Transport the patient to Recovery Room (RR), Intensive
During Induction of Anesthesia: Care Unit (ICU) or ward.
1) Help/ assist the anesthesiologist in positioning the patient. • Endorse the patient properly.
2) Assist the patient in assuming the position for anesthesia.
3) Anticipate the anesthesiologist's needs Duties of the Scrub Nurse
4) If spinal anesthesia 1) Check instruments and supplies.
• Place the patient in quasi fetal position, provide 2) Do a complete scrub
pillows. 3) Gown and Glove
• Perform lumbar prep aseptically. 4) Drape and Mayo Stand – mayo cover first then mayo towel.
• Anticipate anesthesiologist's needs. 5) Count sponges, surgical needles and instruments as the
5) After the Patient is Anesthetized C.N stands to countercheck the counting.
• Reposition the patient per anesthesiologist's 6) Arrange the instruments on the mayo table and on the
instruction back table.
• attach anesthesia screen and arm boards. 7) ex. Mayo Table – scissors, knife/ scalpel
• apply restraints on the patient. 8) clamps, graspers, and army – navy.
• Expose the area for skin preparation. 9) Place blade on the knife handle. Assemble suction tip and
• Catheterize the patient. suction tube. Assemble the drapes according to use and
• Turn on OR light. ready the towel clips.
• Perform skin prep. 10) Prepare sutures and needles according to use.
During Operation When Surgeon Arrives After Scrubbing
• Be alert to anticipate the needs of both sterile and 1) Gown and glove the surgeon and his assistants as soon as
unsterile team members. they arrive.
• Collect soiled sponges for counting. 2) Assist in draping the patient according to routine
procedure.
• Monitor blood loss
3) Bring mayo stand and back table in position after draping
• Charting Watch out for any break in aseptic technique.
is completed.
• Provide 2 sponges on the operative site prior to skin
4) Drop the end of the suction tube and cautery cord for the
incision.
circulating nurse to connect to their proper attachment.
• Pass the first knife for the skin to the surgeon's needs.
5) Check the suction machine.
• Pass instruments in a decisive and positive manner. After Scrub Person Scrubs
• watch out for signals and keep instruments as clean as • Fasten the back of the scrub person's gown.
possible.
• Open package of the sterile supplies.
• Notify C.N. if you need additional instruments as clean as
• Assist the scrub nurse in counting the sponges, needles
possible.
and instruments. write the figure on the white board.
• Keep two clean sponges on the field. After Surgeon and Assistants' Scrub
• Save and care for tissue specimen according to hospital • Assist with gowning.
policy.
• Observe for sterile technique during draping.
• Maintain sterile technique and watch for any breaks.
• Assist the scrub nurse in moving the mayo stand and
• Step away from sterile field of contaminated. back table
• Change gloves when pricked by needles. • Focus OR light
• Do not turn your back from sterile field. • Position kick buckets on the operating side.
• Keep sterile field as dry as possible • Connect suction tube to suction machine.
• Discard soiled sponges from a sterile field.
• Keep talking to a minimum. Three Division of OR Suite
During Closure • Unrestricted/ Unsterile Area – This area is isolated by
• Assist in counting sponges, needles and instruments. doors from the main hospital corridor.
Report counts as to complete or incomplete. • Semi-restricted/ Semi-sterile Area – OR attire is
• Count sponges, needles and instruments with C.N. required. This area includes peripheral support areas and
• Always ready your sutures, clamp, forceps, and straight access corridors to the OR.
scissors. • Restricted/ Sterile Area – Marks are required to
• Have a clean damp sponge ready to clean the incision site. supplement OR attire. Sterile procedures are carried out
• Have a dressing and antiseptic ready. in this room.
• Assist in application of pressure dressing.

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J.A.K.E Operating Room Nursing
Dressing Rooms and Lounges
- Clothes changing areas must be provided for both men
and women. Access is from an unrestricted area to
change from street clothes to OR attire before entering the
semi restricted areas or vice versa.
Scrub Room
- for surgical scrubbing and must be provided adjacent to
each OR.
Furniture and other equipment’s
- OR Table/ Operating Table – divided into bed, body and leg
sections.
Instrument Tables
• Mayo Stand/Table
• placed just above and across the patient serves to bring
near the operative field.
• Small tables
• for patient’s preparation equipments.
• Ex. Skin Prep
Other Equipment’s
• Anesthesia machine and tables for anesthesiologist’s
equipments.
• Sitting stools and standing flat forms or foot stools.
• IV stands
• Suction Machine, bottles and tubing.
• Linen bumper
• Kick buckets in wheeled bases
Operating Room Attire
- Consists of body covers such as scrub suit, head cover,
mask and scrub shoes.
- Purpose: To provide effective barriers that prevents the
dissemination of microorganism to the patient.\
Points to Remember:
• Only approved, clean OR attire must be worn within the
restricted area of the OR.
• OR attire is not worn outside the OR suite.
• Eyeglasses should be wiped with the tissue wet with
antiseptic solution to prevent cross contamination.
• Personal hygiene must be emphasized.
• No unauthorized person should be permitted in the OR.
• Personnel with skin diseases or wounds must never be
allowed to scrub.
• Jewelry and nail polished should not be worn inside the
OR.
Components of attire:
• Body Cover – must be done before entering a restricted or
semi restricted areas.
• Head Covers – cap protects the garment/ body cover
from contamination by hair.
• Shoe Covers/ Scrub Shoes – must be worn to prevent
spread of microorganisms.
• Mask – must be worn in restricted area to contain or filter
microorganisms expelled from the moth and nasopharynx
by coughing.
• Gloves – a pair of sterile gloves completes the attire for
sterile team members.
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312 RLE
• Gown – a sterile gown is worn over the scrub suit to permit
the wearer to come within the sterile field.
Criteria for Attire:
• Effective barrier for microorganisms
• Resistant to blood and aqueous fluid abrasion to prevent
penetration by microorganism.
• Designed for maximal skin coverage.
• Hypoallergenic, cool and comfortable.
• Pliable material to permit freedom to movement.
• Easy to don and remove.
Surgical Scrubbing
- The process of removing as many as microorganisms as
possible from the hand and arms by mechanical washing
and chemical antisepsis before participating in an
operation.
- Purpose:
• To decrease the number of microorganism on the skin.
• To keep the population of microorganism minimal
during the operative procedure by suppression of
growth.
• To reduce the hazard of microbial contamination of
the operative wound by skin flora.
Preparation for Surgical Scrubbing:
1) Skin integrity of hands and arms must be intact.
2) Remove all finger jewelry because it harbors
microorganism
3) Be sure that all hairs are covered by headgear because
they are potential foreign body inside the operative wound
4) Adjust mask snugly and comfortably on the nose and
mouth
5) Adjust eyeglasses comfortably in relation to mask.
6) Adjust water to comfortable temperature.
Method of Surgical Scrubbing
1) Time Method
- allotting a prescribed length of time.
2) Brush Stroke Method
- allotting prescribed number of strokes to each sides
of the hands.
Principle involved
- Surgical scrubbing starts from the cleanest area to the
dirtiest area. (fingers, hands, arms and elbows 3 inches
above)
Prerequisites to Surgical Scrubbing
• Wear scrub suit, put on mask cover all hair with a cap.
• Remove jewelries
• Fingernails must be short and no nail polish.
• Hands must be free from wounds.
• Eyeglasses must be washed and secured.
Scrub Room
- Area wherein surgical scrubbing is done.
- Equipments for Surgical Scrubbing:
• Antimicrobial Solution – contained in a liquid soap
dispenser near the sink often operated by foot pedal.
• Deep sink with foot or knee controls for water
• Nail cleaning tool-file or orange stick.
J.A.K.E Operating Room Nursing 312 RLE

• Surgical scrub brushes - Repeat above for right hand then rinse hands, arms and
Procedure: Time scrub method then discard brush, rinse hands, arms. Turn off the faucet
1) Wet hands and forearms under running water, holding the then proceed to OR.
hands above the level of the elbows so that the water runs
from the fingertips to the elbows. Gowning and Gloving
2) Clean the nails with a file or an orange stick. Rinse hands - The sterile gown is put on after the surgical scrubbing.
and arms under running water while keeping the hands - The sterile gloves are put on immediately after gowning.
higher than the elbows. - Purpose: Sterile gowns and gloves are worn exclude skin
3) Get a sterile brush and rinse it under running water. Apply as possible contaminant and to create a barrier between
antiseptic on the brush. Start brushing the fingernails, sterile and unsterile areas.
back and the palm of the hand, forearm and the elbow Gowning
while allotting a prescribed time of brushing for each part. - Reach down to the sterile package and lift the folded gown
4) At the end of the scrub dry your hands with a sterile towel upward.
beginning at the tip of the fingers to the elbow. Rotate the - Move one step backward for safety margin while gowning.
towel and repeat the procedure on the other - Holding the folded gown, carefully locate the neck band.
hand. Proceed to put on a sterile gown. - Unfold the gown and be careful not to touch the outside
Time allotted: portion of the gown.
• Left hand – 1 minute - Slip both hands into the arm holds simultaneously.
• Left arm – 1 minute - The circulating nurse brings gown shoulders by reaching
inside the shoulder and arm seams. The gown is pulled
• Left elbow – ½ minute
out the lowering the sleeves extended to both hands. The
• RINSE BRUSH
back of the gown is securely tied or fastened at the neck
• Right hand - 1 minute
and waist.
• Right arm - 1 minute Closed Gloving Technique
• Right elbow – ½ minute - Using the left hand, while keeping it within the cuff of the
• Rinse hands, arms and brush left sleeve, pick up the right glove.
• Left hand – 1 minute - Place the palm of the right glove against the palm of the
• Right arm - 1 minute right hand. Glove fingers must be pointing toward the
• RINSE BRUSH wearer.
• Right hand - 1 minute - Secure hold the lower portion of the cuff of the right glove
• Right arm - 1 minute with right hand that is still hidden inside the sleeves.
• RINSE HANDS, ARMS AND BRUSH Secure upper portion of cuff of the glove with your left
• Left hand – ½ minute hand
• Right hand – ½ minute - Slip/slide your right hand into the right glove. Arrange
• RINSE HANDS, ARMS AND BRUSH AND PROCEED TO OR sleeve and glove with your left hand.
Brush Stroke Method - Do the same procedure in donning the left glove.
- Follow the procedure of time method from nos. – 1-5 - Removing gowns and gloves: the gown is removed first
except that instead of allotting time, you’re going to allot before the gloves.
prescribed no. of strokes for each part. - Sterile Field – any area covered with a sterile drape.
- Prescribed no. of Strokes Principle of Sterile Technique
• Left hand: Nails – 20 stroke across nails. • Only sterile items are used within the sterile field.
• Fingers – 10 strokes to each side • If you are in doubt about the sterility of anything, consider
• Hand – 10 strokes to each side it unsterile.
• Left arm – 6 strokes to each side • Gowns are considered sterile ONLY from the waist to
• Left elbow – 6 strokes shoulder level in front and themselves.
• RINSE BRUSH • Sterile persons keep hands in sight and at or above waist
• Repeat the above procedure to your right hand. level.
• RINSE HANDS, ARMS AND BRUSH • Hands are kept from the face and never held under the
• Left hand – nails – 10 strokes, fingers – 5 and hand - 5 axillaries region.
• Left arm – 3 strokes to each side. • Changing table levels are avoided.
Rinse Brush • Items dropped below waist level are considered unsterile.
- Repeat above for right hand then rinse hands, arms and • Tables are considered sterile only at table level.
brush. • Anything that extends below the table level is considered
- Left hand – nails – 5 strokes, fingers – 3 and hand – 3 then unsterile.
brush then rinse • In unfolding sterile drape, the part that drops below the
table level is considered unsterile.
• Sterile persons touch only sterile items or areas, unsterile
persons touch only unsterile items or areas.
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J.A.K.E Operating Room Nursing 312 RLE

• Unsterile persons should not directly get in contact with

the sterile field. Use sterile transfer forceps.
• Unsterile persons a void reaching over a sterile field and
sterile persons avoid leaning over an unsterile field.
• In pouring into a sterile field and sterile persons avoid
leaning over the basin to avoid over reaching.
• The scrub nurse should set the basin or glasses to be
filled at the edge of the sterile table.
• Surgeons turn away from the sterile field and to have
perspiration removed from the brow.
• Sterile persons keep well within the sterile area.
• Sterile persons pass each other back to back.
• Sterile persons turn back to non-sterile person or area
when passing.
• Unsterile persons avoid sterile areas.
• Unsterile person should maintain at least 1 foot distance
from any sterile area.
• Unsterile persons never walk between 2 sterile areas.
• Sterile field is created as close as possible to the time of
use.
• Sterile areas are continuously kept in view.
• Destruction of integrity of the microbial barriers results in
contamination.
• Microorganisms must be kept to a minimum.

Theories Involve
Maslow’s Hierarchy of Human Needs

Stages of Illness

OR NUSING 6 of 6
Perioperative nursing – Preoperative and Intraoperative Phase
J.A.K.E
PERIOPERATIVE NURSING
The Perioperative Period
Perioperative period is divided into three phases namely:
• preoperative phase
• intraoperative phase and
• postoperative phase
Preoperative Phase
- This extends from the time the client is admitted to the
surgical unit, to the time he/she is prepared physically,
psychosocially, spiritually and legally for the surgical
procedure, until he/she is transported into the operating
room.
Intraoperative Phase
- Extends from the time the client is admitted to the
operating room, to the time of administration of
anesthesia, surgical procedure is done, until he/she is
transported to the recovery room (RR) / post-anesthesia
care unit (PACU)
Postoperative Phase
- extends from the time the client is admitted to the
recovery room, to the time he is transported back into the
surgical unit, discharged from the hospital, until the follow
- up care.
Preoperative Phase
- the time the patient is prepared physically, psychosocially,
spiritually and legally for the surgical procedure
The Four Types of Conditions Requiring Surgery:
1) Obstruction – Imairment to the flow of vital fluids, like
blood, urine, bile, CSF
2) Perforation – Rupture of an organ, ruptured appendix,
ruptured uterus
3) Erosion – Wearing off of a surface or membrane, e.g.
peptic ulcer
4) Tumors – Abnormal new growth, breast tumor, bone
tumor, lung tumor, brain tumor.
Classification of Surgical Procedures
According to PURPOSE
1) Diagnostic – To confirm the presence of a disease
condition, e.g. biopsy.
2) Exploratory – To determine the extent of the disease
condition, e.g., exploratory laparotomy (exploration of
the abdominal cavity and abdominal organs)
3) Curative – To treat the disease condition. The different
types of curative surgeries are as follows:
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a) Ablative. Involves removal of an organ. Suffix used is
“ectomy.” E.g. Appendectomy – removal of the
appendix; Hysterectomy – removal of the uterus;
Oophorectomy – removal of the ovary; Mastectomy –
removal of the breast; Pneumonectomy – removal of a
lung; Tonsillectomy – removal of tonsils;
Cholecystectomy – removal of the gall bladder.
b) Constructive. Involves repair of congenitally defective
organ. Suffixes used are “plasty,” “orrhaphy,” “pexy.”
E.g. Cheiloplasty – repair of cleft lip; Uranoplasty
– repair of cleft palate; Herniorrhaphy – repair of
hernia; Orchidopexy – repair of undescended testes.
c) Reconstructive. Involves repair of damaged organ. E.g.
plastic surgery after severe burns, scar revision.
4) Palliative – To relieve distressing signs and symptoms,
not necessarily to cure the disease. E.g., colostomy,
debridement of necrotic tissues, resection of nerve roots
According to DEGREE OF RISK/ MAGNITUDE/ EXTENT
1) Major Surgery – The criteria for major surgery are as
follows:
• Involves high risk of morbidity or mortality
• It is extensive and prolonged. Involves a considerable
period of time
• It may involve large amount of blood loss
• Vital organs are manipulated or removed
• Involves great risk of occurrence of complications
• E.g., craniotomy; open heart surgery;
pneumonectomy; total abdominal hysterectomy with
bilateral salpingo oophorectomy (TAHBSO).
2) Minor surgery
• The procedure is not prolonged.
• Involves lesser risk.
• Does not usually involve serious complications.
• E.g., appendectomy, tonsillectomy, blepharoplasty
(repair of eyelids).
According to URGENCY
1) Emergency. The surgery should be done immediately to
save the client’s life or limb. E.g., emergency
hysterectomy due to ruptured uterus; emergency
amputation of a limb due to crushing injury; emergency
appendectomy due to acute appendicitis.
2) Imperative. The procedure should be done within 24 to 48
hours. E.g., profusely bleeding peptic ulcer, evacuation of
blood clots from the brain.
3) Planned Required. The procedure is necessary for the
well – being of the client. However, it may be scheduled
weeks or months. E.g., tonsillectomy, thyroidectomy,
cataract extraction.
4) Elective. The procedure is not absolutely necessary for
survival. Delay or omission will not cause adverse effect.
E.g., removal of simple, non – toxic goiter.
5) Optional. The procedure is requested by the client. It is
usually for aesthetic purposes. E.g., rhinoplasty (repair of
the nose); blepharoplasty (repair of the eyelids).
J.A.K.E Perioperative nursing – Preoperative and Intraoperative Phase
Surgical risk patient:
• Extremes of age (very young & very old)
• Extremes of weight (emaciation & obesity)
• Dehydrated patients with severe trauma or injury
• Nutritional deficits
• Patients with severe trauma or injury, infection/ sepsis
• Patients with cardiovascular disease
• Patients with endocrine dysfunction (DM)
• Hypertensive and hypotensive patients
• Hypovolemia
• Hepatic disease
• Preexisting mental of physical disability
GOALS of Nsg Care During Preop:
• Assessing and correcting physiologic and psychologic
problems that might increase surgical risk.
• Instructing and demonstrating exercises that will benefit
the person during postoperative period.
• Planning for discharge and any projected changes in
lifestyle due to surgery.
Preoperative Nursing Assessment
Physiologic Assessment of the Client Undergoing Surgery
The physical preparations of the patient before surgery include
the following:
1) Correcting any dietary deficiencies.
2) Reducing an obese person’s weight, as time permits.
3) Correcting fluid and electrolyte imbalances.
4) Restoring adequate blood volume with blood
transfusion.
5) Treating chronic diseases – DM, heart disease, renal
insufficiency, bleeding disorders.
6) Treating any infectious process
7) Treating an alcoholic person with vitamin
supplementation, IV fluids or oral fluids, if dehydrated.
Psychosocial Assessment of the Client Undergoing
Surgery
The common causes of fears of the preoperative client are as
follows:
1) Fear of the unknown. This is the greatest fear of most
patients undergoing surgery.
2) Fear of anesthesia. Many patients fear their
vulnerability while unconscious. They also fear the
potential complications of anesthesia including death.
3) Fear of pain. Patients fear the agony, suffering, or
distress that may result from the surgical procedure
especially postop wound and from contraptions.
4) Fear of death. This is due to the risk of complications
of anesthesia and the surgical procedure, itself.
5) Fear of disturbance of body image. For example, loss
of limb, loss of reproductive organs, alteration in
bowel and bladder elimination, cause disturbance of
a person’s body image.
6) Fear and worries from loss of finances, employment,
social and family roles.
The nurse should assess the client for manifestations of fear
that include the following:
• Anxiousness
• Anger
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• Tendency to exaggerate
• Sad, evasiveness, tearfulness, and clinging behavior
• Inability to concentrate
• Short attention span
• Failure to carry out simple directions
• Dazed appearance
The nurse may implement the following nursing interventions
to minimize anxiety:
• Explore the client’s feelings
• Allow client’s to speak openly about fears and
concerns.
• Give accurate information regarding surgery.
• Provide empathetic support. Accept individual’s
reactions to the surgical experience.
• Consider the person’s cultural and religious
preferences. Arrange for visit by chaplain/priest/
minister/religious adviser as desired by the patient
and his family.
Informed Consent
- The Legal Aspects of Surgical Interventions: Written
Informed Consent/ Operative Permit/ Surgical Permit
- The PURPOSES of the written informed consent are as
follows:
1) To ensure that the client understands the nature of
the treatment including the potential complications
and disfigurement. These are explained by the
surgeon.
2) To indicate that the client’s decision was made
without pressure.
3) To protect the client against unauthorized procedure.
4) To protect the surgeon and the hospital against legal
action by a client who claims that an unauthorized
procedure was performed.
- The circumstances requiring written informed consent are
as follows:
1) Any surgical procedure where scalpel, scissors,
suture, hemostats of electrocoagulation may be used
2) Any invasive procedure, or procedure that involves
entry into a body cavity. E.g. paracentesis,
bronchoscopy, cystoscopy, colonoscopy,
proctosigmoidoscopy.
3) Any procedure that involves general anesthesia, local
infiltration anesthesia or regional block anesthesia
- The requisites for validity of written informed consent are
as follows:
• Written permit/ consent is best and is legally
acceptable.
• Patient’s signature is obtained with the client’s
complete understanding of what is to occur.
• Adults sign their own consent unless he/she is
physically and mentally incapacitated.
• If the patient is a child or minor (below 18 years old),
the parent or legal guardian will sign the consent.
• Consent is obtained before sedation.
• The patient is not under the influence of drugs or
alcohol & is secured without pressure or duress or
threat.
J.A.K.E Perioperative nursing – Preoperative and Intraoperative Phase
• Signature of witness is required. The nurse, physician
or other authorized persons may sign as witness
• NURSING PRIORITY: The consent/permit should be
signed before the client receives preoperative
medications
• In an emergency, permission via telephone is
acceptable. The physician should document the
nature of the emergency situation.
• Emancipated minors are allowed to sign without
written consent. (Emancipated minors are those who
are married, those who live on their own or financially
independent from their parents. This is applicable in
the U.S. only.)
Preparation of the patient before surgery includes
EXERCISES that will prevent postoperative complications.
• Deep breathing and coughing exercises. To promote
adequate lung expansion and ventilation, and expel
mucous secretions.
• Incentive spirometry. To enhance deep inspiration and
promote maximum lung expansion
• Turning exercises. To promote adequate lung expansion,
promote circulation, and prevent pressure sores.
• Foot and leg exercises. Flexion and extension exercises of
the lower extremities promote circulation; prevent venous
stasis, thereby preventing thrombophlebitis.
Preparation of the patient the evening before the surgery
include the following:
1) Preparing the skin
- It is ideal for the patient to bathe or shower, using a
bacteriostatic soap to reduce microorganisms in the
skin
- Shaving should be performed as close to the
operative time as possible. Hair grows again,
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overnight. Shaving should be done in the direction of
hair growth.
2) Preparing the Gastrointestinal Tract
- Preparation of the bowel for intestinal surgery to
prevent escape of bacteria and sepsis includes the
following:
• Cathartics and enemas.
• Oral antimicrobials to reduce bacterial flora.
• Enemas “until clear” the evening before surgery.
No more than three enemas should be given to
prevent fluid – electrolyte imbalances.
• NPO for 6 hours before surgery. Patients having
morning surgery are kept NPO from midnight.
Clear fluids, like water may be given up to 4 hours
before surgery if ordered to help client swallow
medications
3) Preparing for Anesthesia
- The patient should avoid alcohol and cigarette
smoking for at least 24 hours before surgery. This can
help reduce potential complications of anesthesia.
4) Promoting Rest and Sleep
- Provide comfort measures, e.g. clean gown and linens,
correct room temperature, subdued lighting, back rub.
Administer sedative as ordered.
When preparing the patient on the day of surgery, the
nurse should include the following:
1) Awaken the patient, one hour before preoperative
medications.
2) Provide morning bath and mouth wash.
3) Provide clean gown.
4) Remove hairpins, braid long hairs, cover hair with cap.
5) Remove dentures, foreign materials (chewing gum) from
patient’s mouth.
6) Remove colored nail polish, hearing aid, contact lens,
jewelries. If the patient refuses to remove the wedding ring,
tie it with gauze and fasten around the wrist.
7) Take baseline vital signs before administration of preop
medications.
8) Check patient identification (ID) band and area of “skin
prep” as applicable.
9) Check for special orders, e.g. enema, gastrointestinal
tube insertion, IV line. Ensure that these orders are carried
out.
10) Check if NPO is maintained.
11) Have client void before administration of preop
medications. Some preop medications may cause
hypotension and increase risk for falls. For patient safety,
put up side rails, put call light within patient’s reach, and
instruct patient to ask for help if he/she needs to void.
12) Continue to support the patient emotionally. Anxiety level
may be high at this time.
13) Accomplish the “Preop Care Checklist”.
14) BEST PRACTICE: If surgery will be done to a body part
which is present on both sides of the body, e.g., eyes, ears,
arms, breasts, legs, practice “TIME OUT” to check if the
right patient is sent for surgery. Avoid SENTINEL EVENT
related to surgery of the wrong body part.
J.A.K.E Perioperative nursing – Preoperative and Intraoperative Phase 312 RLE

Preoperative Medications/ Preanesthetic Drugs Purposes:

• To facilitate the administration of any anesthetic.
• To minimize respiratory tract secretions and changes in
heart rate.
• To relax the client and reduce anxiety
• Types of Preop Medications:
1) Opiates – morphine (Roxanol) and meperidine
(Demerol) are given to relax the patient and potentiate
anesthesia.
2) Anticholinergics – atropine sulfate, scopolamine, and
glycopyrrolate (Robinul) are given to reduce
respiratory tract secretions and to prevent severe
reflex slowing of the heart during anesthesia.
3) Barbiturates/ Tranquilizers – Phenobarbital
(Nembutal) and other hypnotic agents are given the
night before surgery to help ensure a restful night’s
sleep.
4) Prophylactic antibiotic - administered just before or
during surgery when bacterial contamination is
expected; ideally before skin incision is made
• BEST PRACTICE: Preanesthetic medications should be
given exactly the time they are prescribed. If given too
early, the maximum potency will have passed before it is
needed; if given too late, the action will not have began
before anesthesia is started.
• When transporting the patient to the operating room,
promote safety.
Care of the patient’s family includes the following:
1) Directing the family to the proper visiting room or waiting
lounge.
2) Informing them that they will be contacted by the surgeon
immediately.
3) Explaining reason for long interval of waiting. This is due to
anesthesia preparation, skin prep, surgical procedure and
recovery room/post anesthesia care unit stay. This action
helps prevent unnecessary anxiety by the family.
4) Explaining what to expect during the postoperative period,
e.g., IV fluids, blood transfusions, oxygen therapy, tubes
and other contraptions
Preop checklist day of surgery
• Preoperative education completed
• Informed consent signed
• NPO – Bowel prepo
• Skin prep – shower or bath in antimicrobial soap
• Documentation/ checklist of valuables
• Voided prior to transfer
• Preop meds – given and charted
• Side rails up after preop bed in low position
• Hospital gown
• Allergy band ID band
• Dentures, eyeglasses, hearing aids, contacts – left in
place or removed
• Makeup and nail polish removed
• Vital signs before transfer
• Preoplab work on chart, surgeon notified abnormal values
• Medication: history, MAR on char, HER/ EMR up to date,
high alert meds noted.

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J.A.K.E Perioperative nursing – Preoperative and Intraoperative Phase 312 RLE

Intraoperative Phase
Goals of Care During Intraoperative Period
• Asepsis and Infection Control
• Homeostasis
• Safe administration of anesthesia
• Hemostasis

Surgical Conscience
- Means attention to aseptic principles during the
perioperative period.
- It involves constant inspection, monitoring and regulation
of the surgical patient, environment, personnel and
equipment.
- The nurse anticipates the patient’s and the surgical
team’s needs and gives unselfish, vigilant care to the
patient.
- Attire:
• Purpose: To provide effective barriers that prevent the
dissemination of microorganisms to the patient and to
protect personnel from infected patients
• Consists of body covers such as:
o Scrub suit/ dress
o Head cover / Bonnet/ Cap
o Mask
o Sterile gloves
o Scrub Shoes (worn only inside the OR)
o (Surgical glasses/ Visor)

Operating Room Divisions

Design & Traffic Pattern – 3 Zone Concept
1) Unrestricted Area which includes the patient
reception area, locker rooms, lounges and offices
2) Semi-restricted Areas which include the storage areas
for clean and sterile supplies, work areas for storage
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J.A.K.E Perioperative nursing – Preoperative and Intraoperative Phase 312 RLE

and processing of instruments and corridors to Preparation for Surgery

restricted areas of the suite. Traffic is limited to
authorized personnel and patients. Personnel are
required to wear gown and hair covering.
3) Restricted Area includes all areas where personnel
are required to wear surgical masks and scrub attire
at all times. It includes operating suites, clean core
and scrub areas.
“Implementation of strategies, such as storage of instruments
and components in the operating room and education of OR
personnel, is required to reduce door openings in the OR.”
American Journal of Medical Quality
- Measurement of Foot Traffic in the Operating Room:
Implications for Infection Control
- Surgical site infections cause significant morbidity and
mortality in the postoperative period. Opening of the
operating room door disrupts its filtered atmosphere,
increasing contamination above the wound.
- We conducted a study of traffic in the operating room as a
risk for infections. This is an observational study of
recorded behaviors in the operating room.
- Data collected included number of people entering/exiting,
the role of these individuals, and the cause for the event.
A total of 3071 door openings were recorded in 28 cases.
- Traffic varied from 19 to 50 events per hour across
specialties.
- The preincision period represented 30% to 50% of all
events. Information requests accounted for the majority of
events. Door openings increase in direct proportion to
case length, but have an exponential relationship with the
number of persons in the operating room. There is a high
rate of traffic across all specialties, compromising the
sterile environment of the operating room. (Am J Med Qual.
2009;24:45-52)
- Perioperative nurses at our institution voiced concerns
about the amount of traffic in the ORs. We formed a
workgroup consisting of perioperative nurses, educators,
and leaders and initiated a quality improvement (QI)
project to identify the amount of OR traffic that occurs
during a procedure.
- The workgroup developed a check sheet to record door
swings, staff classifications, reasons for opening the door,
and the number of people in the OR at 15‐minute intervals.
- Baseline results showed that average door swings ranged
from 33 per hour in general surgery to 54 per hour in
cardiac surgery.
- Nurses accounted for the most traffic, citing retrieving
supplies as the main reason. Interventions focused on
decreasing nurse traffic for retrieval of supplies in general
surgery.
- Follow‐up observations showed that average door swings
increased to 41 per hour in general surgery, but nurse
traffic decreased. Monitoring and limiting traffic could
positively affect patient safety and outcomes.
- “Principles remain the same; it is the degree of adherence
that varies”
- The skin of the patient and the members of the surgical
team require disinfection before the surgical procedure
begins.
- The commonly used antimicrobial agents include
povidone-iodine, chlorhexidine, alcohol, and
hexachlorophene.
- Before the application of the chosen antimicrobial agent,
the patient’s skin may be prepared by shaving, clipping
(trimming), or using a depilatory.
The skin of the surgical team is scrubbed, using a brush
and nail cleaner or a foam preparation for a length of time
determined by the facility.
Prepare the field using the principles of asepsis.
Patient Positioning
• Provides optimal visualization
• Provides optimal access for assessing and maintaining
anesthesia and function
• Protects patient from harm
Positioning the Client for Surgery
1) Supine
- Back-lying position.
- Careful placement of the extremities is important to
avoid injury. The most common injury occurs to the
brachial plexus when the arm is abducted greater
than 90 degrees. Fingers, elbows and bony
prominences must be supported with padding to
prevent pressure.
- Most commonly used surgical position. It is the basic
position for most abdominal surgery and is also
frequently used in orthopedic, urologic,
ophthalmologic, otorhinolaryngologic, plastic and
thoracic operations.
2) Trendelenburg’s
- Variation of supine position with the patient’s head
positioned down.
- Shift of the abdominal viscera impedes free
movement of the diaphragm and intrathoracic
pressure is increased.
- When requested it is usually intended to facilitate
surgical exposure during colorectal or genitourinary
procedures..
3) Lithotomy
- Lying on the back with the legs flexed and supported
on stirrups.
- Decreases respiratory effectiveness because the
diaphragm is restricted.

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J.A.K.E Perioperative nursing – Preoperative and Intraoperative Phase
- Two members of the surgical team should move the
legs simultaneously to prevent sacroiliac dislocation.
- Used to manipulate a surgical instrument either in the
vagina or in a perineal incision.
4) Modified Fowler’s
- Or sitting position is physiologically best for
respiratory function.
- Venous pooling may lead to hypotension.
- It’s overall use has decreased. It may be used for neck
dissections or dental problems.
5) Lateral / (lateral decubitus position)
- Side – lying or lateral position decreases respiratory
efficiency because the body’s weight is on the lower
chest.
- May interfere with respiratory efficiency.
- Peripheral nerve injuries can occur in faulty position
of the arm.
- Has been associated most commonly with
thoracotomies for cardiothoracic procedures, but
may also be used to advantage for renal, obstetric,
gynecologic, neurosurgical and orthopedic operations.
6) Prone / (ventral decubitus position)
- Face – down position requires the patient to be
anesthetized on the stretcher being turned over on the
abdomen.
- Respiration is restricted because of the weight of the
body on the abdomen; the BP may fall.
- Used for posterior craniotomies and for spine-related
procedures, such as spinal fusions, resections of
masses (e.g., lipomas) and repair of dermal defects.
PP & IP 7 of 9
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7) Jackknife (Kraske position)
- Respiratory system is severely compromised
- Blood pooling in the extremities occur
- Similar to Knee-Chest or Kneeling positions and is
often used for colorectal surgeries.
BEST PRACTICE: When positioning the client for surgery,
the nurse should do the following:
• Explain the purpose of the position to the client.
• Avoid undue pressure on any body part.
• Strap the client securely but snugly to prevent falls.
• Maintain adequate respiratory and circulatory
function.
• Ensure good body alignment
Position patient during surgery
Abdominal surgeries supine
Bladder surgery Trendelenburg (slightly)
Perineal surgery Lithotomy
Brain surgery Modified fowler’s/ sitting
Spinal cord surgery Prone
Colorectal surgery Kraske
Anesthesia
- The goals of anesthesia are to provide analgesia, sedation
and muscle relaxation, as well as to control the
autonomic nervous system
- Anesthetics are classified as general and local.
• General anesthetics depress the CNS, alleviate pain,
and cause a loss of consciousness.
• Local anesthetics block pain at the site of
administration, allowing consciousness to be
maintained.
- Balanced anesthesia, a combination of drugs, is
frequently used in general anesthesia, balanced
anesthesia generally includes the following:
1) A hypnotic given the night before;
2) Premedication, such as narcotic analgesic or
benzodiazepine (e.g., Midazolam [Versed]) and an
anticholinergic (e.g., atropine, robinul), given about 1
hour before surgery to decrease secretions.
3) A short-acting barbiturate, such as thiopental sodium
(Pentothal);
4) An inhaled gas, such as nitrous oxide and oxygen;
5) A muscle relaxant, e.g. Anectine (Succinyl Choline),
Pavulon (Pancuronium Hydrobromide).
Common Anesthetic Techniques
1) Conscious Sedation
- Patient remains conscious with some alteration of
mood, drowsiness and sometimes analgesia.
- Protective reflexes remain intact.
J.A.K.E Perioperative nursing – Preoperative and Intraoperative Phase 312 RLE

- Commonly used drugs include morphine, meperidine, • Stage IV: Medullary Depression
fentanyl, diazepam (valium), midazolam (versed). - stage is reached when too much anesthesia is given
2) Deep Sedation - RR become shallow, pulse is weak and thready, pupils
- Patient is asleep but easily arousable. widely dilated
- Protective reflexes are minimally depressed. - Without proper treatment death will follow
3) General Anesthesia - Discontinue anesthetic abruptly
- Complete loss of consciousness. Complications and Discomforts of Spinal Anesthesia
- A reversible state that provides analgesia, muscle • Hypotension
relaxation and sedation • Nausea/ vomiting
- Protective reflexes are lost.
• Headache
- Produced by IV or inhaled anesthetics
• Respiratory Paralysis
4) Regional anesthesia
• Neurologic complications (e.g. paraplegia, severe muscle
- Production of anesthesia in a specific body part.
weakness of the legs)
- Achieved by injecting local anesthetics in close
BEST PRACTICE: Blood pressure should be monitored during
proximity (usually by injection) to appropriate nerves.
administration of nerve block local anesthetic, because
(Nerve Block)
hypotension may occur
5) Spinal Anesthesia
Activities during the Intraoperative
- Local anesthetic is injected into lumbar intrathecal
Assisting the surgeon as scrub nurse or circulating nurse
space.
- Anesthetic blocks conduction in spinal nerve roots
and dorsal ganglia; paralysis and analgesia occur
below the level of injection.
6) Epidural Anesthesia
- Achieved by injecting local anesthetic into epidural
space by way of a lumbar puncture.
- Results are similar to spinal analgesia
7) Peripheral Nerve Blocks
- Achieved by injecting local anesthetic to anesthetize
the surgical site.

Scrub Nurse
• Assists the surgical team
• Maintains sterility
• Handles instruments, prepares sutures, receives
specimen, counts
• Drapes patient
• Wears sterile gown, gloves
Circulating Nurse
• Assists the Scrub nurse, opens& obtains instrument,
keeps record, adjust lights, receives specimen,
coordinates
• Positions the patient for surgery
Stages of anesthesia
• Stage I: Analgesia (Beginning Anesthesia)
- patient may have ringing, still conscious, sense
inability to move extremities
- noises are exaggerated
- avoid unnecessary noises or motions
• Stage II: Excitement
- characterized by struggling, shouting, talking, crying.
(agitation)
- pupils dilate, rapid pulse and irregular RR
- restrain the patient
• Stage III: Surgical Anaesthesia
- surgical anaesthesia is reached
- patient unconscious and lies quietly
- respirations are regular and CR
- may be maintained in hours if properly given
PP & IP 8 of 9
J.A.K.E Perioperative nursing – Preoperative and Intraoperative Phase 312 RLE

Surgical Incisions
• Butterfly Incision. For craniotomy.
• Limbal Incision. For eye surgeries.
• Halstead / Elliptical Incision. For breast surgeries
(mastectomy).
• Abdominal Incision. For abdominal surgeries (e.g. midline
abdominal incisions; paramedian incisions).
• Mc Burney’s Incision. For appendectomy.
• Pfannenstiel Incision. For Cesarian section. Also called
“bikini line” incision.
• Lumbotomy or Transverse Incision. For kidney surgeries.

PP & IP 9 of 9
Perioperative nursing – Postoperative Nursing Phase
J.A.K.E
POSTOPERATIVE NURSING CARE
Goals of Care During Postoperative Period
• Maintain adequate body system functions.
• Restore homeostasis.
• Alleviate pain and discomfort.
• Prevent postop complications.
• Ensure adequate discharge planning and teaching.
Nursing Care of Clients During the Immediate
Postoperative Recovery (Post anesthesia Care Unit or
Recovery Room)
Admission of client to recovery area
1) Position client to promote patent airway and prevent
aspiration.
2) Avoid exposure of the client. To protect privacy and
prevent chills.
3) Avoid rough handling of the patient. This affects his/her
comfort.
4) Avoid hurried movement and rapid changes in position.
This may cause hypotension.
5) Perform baseline assessment.
• Vital signs
• Status of respirations, pulse oximetry
• General color
• Neurologic status (level of consciousness)
• Type of amount of fluid infusing (IV fluids, blood
transfusion).
• Special equipment
• Dressings
6) Determine specifics regarding the operation from the
operating room nurse
• Client’s overall tolerance of surgery.
• Type of surgery performed.
• Type of anesthetic agents used.
• Results of procedure: was the condition corrected?
• Any specific complications to watch for.
• Status of fluid intake and urinary output.
• Common postoperative complications.
BEST PRACTICE: The client’s respiratory status is a priority
concern on admission to the operating room and
throughout the postoperative recovery period.
Nursing Management During Recovery
• Ensure maintenance of patent airway and adequate
respiratory function.
- Lateral position with neck extended or back with the
head turned to the side to prevent aspiration.
- Leave airway in place until gag reflex has returned.
The airway keeps the passage open and prevents the
tongue from falling backward and obstructing the air
passages.
- Suction excess secretions and prevent aspiration.
- Encourage coughing and deep breathing to promote
chest expansion.
- Administer humidified oxygen.
PP 1 of 10
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- Auscultate breath sounds.
• Maintain cardiovascular activity
- Monitor vital signs every 15 minutes until condition is
stable
- Observe signs and symptoms of shock and
hemorrhage. Report blood pressure that is continually
dropping 5 to 10 mmHG with each reading.
- Evaluate quality of pulse and presence of
dysrhythmias.
- Evaluate adequacy of cardiac output and tissue
perfusion.
- Cool extremities, decreased urine output, slow
capillary refill, tachycardia, narrowing pulse pressure
are often indication of decreased cardiac output
(C.O.).
• Maintain adequate fluid status.
- Evaluate blood loss in surgery and response to fluid
replacement
- Measure urine output.
- Evaluate for bladder distention.
- Evaluate electrolyte status.
- Evaluate hydration status.
- Observe amount and character of drainage if
nasogastric tube is in place.
- Evaluate amount and characteristics of any emesis.
BEST PRACTICE: Antidiuretic hormone secretion is increased
in the immediate postoperative period. Administer fluid with
caution; it is easy to cause fluid overload in a client
BEST PRACTICE: When client is vomiting, prevent aspiration
by positioning client on the left side and suctioning, if
appropriate.
• Maintain incisional areas.
- Evaluate amount and character of drainage from
incision and drains.
- Check and record status of Hemovac, Jackson-Pratt,
Penrose or any other wound drains. Serosanguinous
drainage is normal during the first 24 hours postop.
• Maintain psychological equilibrium.
- Speak to client frequently in calm, unhurried manner.
- Continually orient client; it is important to tell client
that surgery is over and where he or she is.
- Maintain quiet, restful atmosphere.
- Promote comfort by maintaining proper body
alignment.
- Explain all procedures, even if the client is not awake.
- In the anesthetized client, sense of hearing is the last
to be lost and the first to return.
• Client meets criteria to return to room
- Parameters for discharge from postanesthesia care
unit (PACU) or recovery room (RR).
1) Activity. The client is able to obey commands, e.g.,
deep breathing and coughing.
J.A.K.E Perioperative nursing – Postoperative Nursing Phase
2) Respiration. The client has easy, noiseless
breathing. He/she can maintain a patent airway
without assistance.
3) Circulation. Blood pressure is within ± 20 mmHg
of the preoperative level
4) Consciousness. The client is awake, responsive
and reflexes have returned.
5) Color. The client has pinkish skin and mucous
membrane.
Nursing Care of Clients During Intermediate Postoperative
Period (Transfer from PACU to the Surgical Unit to Day 1
Postop)
• Maintain cardiovascular function and tissue perfusion.
- Monitor vital signs and report abnormalities.
- Evaluate skin color and nail beds for pallor and
cyanosis.
- Monitor level of hematocrit.
- Encourage early activity and ambulation.
• Maintain respiratory function
- have client turn, cough and breathe deeply every 2
hours.
- Use incentive spirometry to promote deep breathing.
- Administer nebulizer treatment and bronchodilator as
ordered.
- Maintain adequate hydration to keep mucus
secretions thin and easily mobilized.
• Maintain adequate nutrition and elimination
- Assess for return of bowel sounds and normal
peristalsis.
- Do not allow oral intake of fluids until gastrointestinal
function returns.
- Assess client with a nasogastric tube for return of
peristalsis.
- Assess client’s tolerance of oral fluid; usually begin
with clear fluids.
- Encourage intake of fluids, unless contraindicated.
- Progress diet as client’s condition and appetite
indicate or as ordered.
- Record bowel movements; normal bowel function
should return on the second or third postoperative
day (provided that the client is eating).
- Assess urinary output.
- Baseline assessment
1) Client should void 8 to 10 hours after surgery.
2) Assess urine output; should be at least 30 ml/hr.
3) Promote voiding by allowing client to stand or use
bedside commode (if permissible).
4) Avoid catheterization if possible.
• Maintain fluid and electrolyte balance.
- Assess for adequate hydration.
1) Most mucous membranes.
2) Adequate urine output.
3) Good skin turgor.
- Assess laboratory results of serum electrolytes.
- Assess character and amount of gastric drainage
through the nasogastric tube.
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- Assess urine output as it correlates with fluid intake;
maintain good intake and output records.
- Evaluate laboratory data for indications of decreased
renal function.
• Promote comfort
- Determine nonpharmacological pain relief measures
- Administer analgesics.
Postoperative Discomforts
Nausea and Vomiting
• Causes
- Most often related to inhalation anesthetics, which
may irritate the stomach lining and stimulate the
vomiting center in the brain.
- Results from accumulation of fluid or food in the
stomach before peristalsis returns.
- May occur as a result of abdominal distention, which
follows manipulation of abdominal organs.
- Likely to occur if the patient believes preoperatively
that vomiting will occur (psychological induction).
- May be a side effect of narcotics.
• Preventive Measures
- Insert nasogastric tube intraoperatively for operations
on gastrointestinal tract to prevent abdominal
distention, which triggers vomiting.
- Determine whether client is sensitive to morphine or
meperidine (Demerol), or other narcotic because they
may induce vomiting in some patients.
- Be alert for any significant comment such as, “I just
know I will vomit under anesthesia.” Report such
comment to the anesthesiologist, who may prescribe
an antiemetic drug and also talk to the client before
the operation.
• Nursing Interventions
- Encourage client to breathe deeply to facilitate
elimination of anesthetic.
- Support the wound during wretching and vomiting;
turn client’s head to side to prevent aspiration.
- Discard vomitus and refresh patient – mouthwash for
mouth care, clean linens for bed.
- Small sips of a carbonated beverage such as ginger
ale if tolerated or allowed.
- Report excessive or prolonged vomiting so the cause
may be investigated.
- Maintain accurate intake and output record and
replace fluids as ordered.
- Detect presence of abdominal distention or hiccups,
suggesting gastric retention.
- Administer medications as ordered.
- Antiemetics used after anesthesia:
• Prochlorperazine (Compazine)
• Ondansetron (Zofran)
• Dolasetron (Anzemet)
• Promethazine (Phenergan)
• Metochlopramide (Reglan)
• Droperidol (Inapsine)
*be aware that these drugs may potentiate the
hypotensive effects of narcotics.
J.A.K.E Perioperative nursing – Postoperative Nursing Phase
Thirst
• Causes
- Inhibition of secretions by preoperative medication
with atropine.
- Fluid lost by way of perspiration, blood loss and
dehydration due to preoperative fluid restriction.
• Preventive Measures
- Thirst is a common and troublesome symptom that is
often unavoidable due to anesthesia
• Nursing Interventions
- Administer intravenous fluids or oral fluids if tolerated
and permitted.
- Offer sips of hot tea with lemon juice to as orders
allow.
- Apply a moistened gauze square over lips
occasionally.
- Allow the client to rinse mouth with mouthwash.
- Obtain hard candies or chewing gum, if allowed, to
help in stimulating saliva flow and in keeping the
mouth moist.
Constipation and Gas Cramps
• Causes
- Trauma and manipulation of the bowel during surgery,
as well as narcotic use, will retard peristalsis.
- Local inflammation, peritonitis, abscesses.
- Long-standing bowel problem; this may lead to fecal
impaction.
• Preventive Measures
- Encourage early ambulation to aid in promoting
peristalsis.
- Provide adequate fluid intake to promote soft stools
and hydration.
- Advocate proper diet to promote peristalsis.
- Encourage early use of non-narcotic analgesia
because many opiates increase chance of
constipation.
- Assess bowel sounds frequently.
• Nursing Interventions
- Ask client about usual remedy for constipation and try
it, if appropriate.
- Perform manual extraction for fecal impaction, if
necessary.
- Administer an oil retention enema (180 – 200 ml) if
prescribed, to help soften the fecal mass and
facilitate evacuation.
- Administer a return-flow enema or insert a rectal tube
(if prescribed) to decrease painful flatulence.
- Administer gastrointestinal stimulants, laxatives,
suppositories and stool softeners as prescribed.
Postoperative Pain
- Pain is a subjective symptom in which the patient exhibits
a feeling of distress. Stimulation of, or trauma to, certain
nerve endings as a result a surgery causes pain.
- General Principles:
• Pain is one of the earliest symptoms that the patient
expresses on return to consciousness.
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• Maximal postoperative pain occurs between 12 and
36 hours after surgery and usually diminishes
significantly by 48 hours.
• Soluble anesthetics are slow to leave the body and
therefore control pain for a longer time than insoluble
agents; but the patient is more restless and
complains more of pain.
• Older people seem to have a higher tolerance for pain
than younger or middle-aged people.
• There is no documented proof that one sex tolerates
pain better than the other.
- Clinical Manifestations
1) Automatic
• Elevation of blood pressure.
• Increase in heart rate and pulse rate
• Rapid and irregular respiration
• Increase in perspiration
2) Skeletal Muscle
• Increase in muscle tension or activity
3) Psychological
• Increase in irritability
• Increase in apprehension
• Increase in anxiety
• Attention focused on pain
• Complaints of pain
4) Patient’s reaction depends on
• Previous experience
• Anxiety or tension
• State of health
• Ability to concentrate away from the problem or
be distracted
• Meaning that pain has for the patient
- Preventive Measures
• Reduce anxiety due to anticipation of pain
• Teach patient about pain management
• Review analgesics with patient and reassure that the
pain relief will be available quickly
• Establish a trusting relationship and spend time with
patient
- Nursing Interventions
2) Use basic comfort measures.
- Provide therapeutic environment – proper
temperature and humidity, ventilation, visitors.
- Massage the patient’s back and pressure points
with soothing strokes – move patient easily and
gently and with prewarning.
- Other diversional activities, soft radio music, or
favorite quiet television program.
- Provide for fluid needs by giving a cool drink; offer
a bedpan.
- Investigate possible causes of pain such as
bandage or adhesive that is too tight, full bladder,
cast that is too snug, or elevated temperature,
suggestive of inflammation or infection
- Instruct client to splint wound when moving
- Keep bedding clean, dry and free of wrinkles and
debris
J.A.K.E Perioperative nursing – Postoperative Nursing Phase
3) Recognize the power of suggestion.
- Provide reassurance that the discomfort is
temporary and that the medication will aid in pain
reduction.
- Clarify patient’s fears regarding the perceived
significance of pain.
- Assist patient in maintaining a positive, hopeful
attitude.
4) Assist in relaxation techniques.
- Imagery, meditation, controlled breathing, self-
hypnosis/suggestion (autogenic training), and
progressive relaxation
5) Apply cutaneous counter stimulation (unless
contraindicated).
- Vibration – a vigorous form of massage that is
applied to a nonoperative site. It lessens patient’s
perception of pain. (Avoid applying this to the calf,
because doing so may dislodge an unhealed
thrombus).
- Heat or cold – apply to operative or non-operative
site as prescribed. Cold is safer because it does
not usually pose danger of burns. Heat works well
with muscle spasm.
6) Give analgesics as prescribed in a timely manner.
- Instruct client to request analgesic before the
pain becomes severe.
- If pain occurs consistently and predictably
throughout a 24-hour period, analgesics should
be given around the clock – avoiding the usual
“demand cycle” of dosing that sets up eventual
dependency and provides less adequate pain
relief.
- Administer prescribed medication to patient
before anticipated activities and painful
procedures (e.g., dressing changes).
- Monitor for possible side effects of analgesic
therapy (e.g., respiratory depression, hypotension,
nausea, skin rash). Administer naloxone
hydrochloride (Narcan) to relieve significant
narcotic-induced respiratory depression.
7) Pharmacologic management: Oral and Parenteral
Analgesia
- Parenteral analgesic for 2 to 4 days until
incisional pain abates. Then, oral analgesic,
narcotic or non-narcotic, will be prescribed.
- The nurse ensures that the drug is given safely
and assessed for efficacy.
BEST PRACTICE: The client who remains sedated due to
analgesia is at risk for complications such as aspiration,
respiratory depression, atelectasis, hypotension, falls and
poor postoperative course. Promotion of client’s safety
should be given priority.
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Patient-Controlled Analgesia (PCA)
- Benefits
• Bypasses the delays inherent in traditional analgesic
administration (the “demand cycle”).
• Medication is administered by IV, producing more
rapid pain relief and greater consistency in patient
response.
• The patient retains control over pain relief.
• Decreased nursing time in frequent delivery of
analgesics.
- The PCA device delivers a preset dosage of narcotic
(Morphine, Dilaudid). An adjustable “lockout interval”
controls the frequency of dose administration, preventing
another dose from being delivered prematurely. An
example of PCA settings might be a dose of 1 mg.
morphine with a lockout interval of 6 minutes (total
possible dose is 10mg/hour).
- The patient pushes a button to self-administer a small
dose of narcotic when pain occurs.
- Reassure patient that he/she will not be overdosed by the
machine.
Epidural Analgesia
- Requires injection of narcotics into the epidural space by
way of a catheter inserted by an anesthesiologist until
aseptic conditions.
- Produces effective analgesia without sensory, motor, or
sympathetic changes.
- Provides for longer periods of analgesia
- Side effects include generalized pruritus, nausea, urinary
retention, respiratory depression, hypotension, motor
block, and sensory/ sympathetic block. These side
effects are due to the narcotic used – morphine
(Duramortph), or Fentanyl (Sublimaze), and catheter
position.
- Strict asepsis is necessary when injecting the epidural
catheter.
- Narcotic – related side effects are reversed with naloxone
hydrochloride (Narcan).
- Occasionally, concurrent use of low-dose anesthetics
such as bupivacaine (Marcaine) may be added to
potentiate efficacy of epidural analgesia.
Postoperative Complications
• Shock
• Hemorrhage
• Deep Vein Thrombosis
• Pulmonary Complications – Atelectasis, Aspiration,
Pneumonia
• Pulmonary Embolism
• Urinary Retention
• Intestinal Obstruction
• Hiccups (Singultus)
• Wound Infection
• Wound Dehiscence/Evisceration
J.A.K.E Perioperative nursing – Postoperative Nursing Phase
Shock
- A response of the body to a decrease in the circulating
blood volume; tissue perfusion is impaired culminating
eventually in cellular hypoxia and death.
Impaired Tissue Metabolism
↓ • Ligation of bleeders by the surgeon as necessary.
Cell / Organ Death
- Preventive Measures
• Have blood available if there is any indication that it
may needed.
• Measure accurately any blood loss and monitor all
fluid intake and output.
• Anticipate progression of symptoms on earliest
manifestation
• Monitor vital signs per protocol unit they are stable
• Assess vital signs deviation: evaluate blood pressure
in relation to other physiologic parameters of shock
and patient’s premorbid values. Orthostatic pulse and
blood pressure are important indicators of
hypovolemic shock.
• Prevent infection (e.g., indwelling catheter care,
wound care, pulmonary care) because this will
minimize the risk of septic shock.
Hemorrhage
- Copious escape of blood from the blood vessel.
- Classification of hemorrhage are as follows:
1) General
• Primary – occurs at the time of operation
• Intermediary – occurs within the first few hours
after surgery. Blood pressure returns to normal
and causes loosening of some ligated sutures and
flushing out of weak clots from unligated vessels.
• Secondary – occurs sometime after surgery due
to ligature slip from blood vessel and erosion of
blood vessel.
2) According to blood vessels
• Capillary – slow, general oozing from capillaries.
• Venous – bleeding that is dark in color and bubble
out.
• Arterial – bleeding that spurts and is bright red in
color
3) According to location
• Evident or external – visible bleeding on the
surface.
• Internal (concealed) – bleeding that cannot be
seen.
- Clinical Manifestations:
• Apprehension; restlessness; thirst; cold, moist, pale
skin; and circumoral pallor.
• Pulse increases, respirations become rapid and deep
(“air hunger”), temperature drops.
• With progression of hemorrhage
- Decrease in cardiac output and narrowed pulse
pressure.
- Rapidly decreasing blood pressure, as well as
hematocrit and hemoglobin.
- Patient grows weaker until death occurs.
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- Nursing Interventions:
• Inspect the wound as a possible site of bleeding.
Apply pressure dressing over external bleeding site.
• Increase IV fluid infusion rate and administer blood if
necessary and as soon as possible.
NURSING PRIORITY: The client should be monitored
closely for signs of increased bleeding tendencies after
transfusions. Numerous, rapid blood transfusions may
induce coagulopathy and prolonged bleeding time.
Deep Vein Thrombosis (DVT)
- occurs in pelvic veins or in deep veins of the lower
extremities in postoperative patients. The incidence of
DVT varies between 10% and 40% depending on the
complexity of the surgery or the severity of the underlying
illness.
- DVT is most common after hip surgery, followed by
retropubic prostatectomy, and general thoracic or
abdominal surgery.
- Venous thrombi located above the knee are considered
the major source of pulmonary emboli
- Causes:
• Injury to intimal layer of the vein wall
• Venous stasis
• Hypercoagulopathy, polycythemia.
• High risks include obesity, prolonged immobility,
cancer, smoking, estrogen use, advancing age,
varicose veins, dehydration, splenectomy and
orthopedic procedures.
- Clinical Manifestations:
• Pain or cramps in the calf (positive Homan’s sign) or
thigh, progressing to painful swelling of the entire leg.
• Slight fever, chills, perspiration.
• Marked tenderness over anteromedial surface of thigh.
• Intravascular clotting without marked inflammation
may develop, leading to phlebothrombosis.
• Circulation distal to DVT may be compromised if
sufficient swelling is present.
- Nursing Interventions:
• Hydrate the client adequately postoperatively to
prevent hemoconcentration.
• Encourage leg exercises and ambulate the patient as
soon as permitted by the surgeon.
• Avoid any restricting devices such as tight straps that
can constrict and impair circulation.
• Avoid rubbing or massaging calves and thighs.
• Instruct patient to avoid standing or sitting in one
place for prolonged periods or crossing legs when
seated.
• Refrain from inserting IV catheters into legs or feet of
adults.
• Assess distal peripheral pulses, capillary refill, and
sensation of lower extremities.
• Check for positive Homan’s sign – calf pain on
dorsiflexion of the foot.
J.A.K.E Perioperative nursing – Postoperative Nursing Phase
• Prevent the use of bed rolls or knee gatches in
patients at risk because there is danger of constricting
the vessels under the knee
• Initiate anticoagulant thearaphy either intravenously,
subcutaneously, or orally as prescribed.
• Prevent swelling and stagnation of venous blood by
applying appropriately fitting elastic stockings or
wrapping the legs from the toes to the groin with
elastic bandage.
• Apply pneumatic stockings, intraoperatively to
patients at highest risk of DVT.
Pulmonary Complications
• Causes and Clinical Manifestations
1) Atelectasis
- Incomplete expansion of lung or portion of it
occurring within 48 hours of surgery.
- Attributed to absence of periodic deep breaths.
- A mucus plug closes a bronchiole, causing alveoli
distal to the plug to collapse.
- Symptoms are often absent – many comprise
mild to severe tachypnea, tachycardia, cough,
fever, hypotension and decreased breath sounds
and chest expansion of affected side.
2) Aspiration
- Caused by inhalation of food, gastric contents,
water, or blood into the tracheobronchial system.
- Anesthetic agents and narcotics depress the
central nervous system, causing inhibition of gag
or cough reflexes.
- Nasogastric tube insertion renders both upper
and lower esophageal sphincters partially
incompetent.
- Usually, evidence of atelectasis occurs within 2
minutes of aspiration. Other symptoms include
tachypnea, dyspnea, cough, bronchospasm,
wheezing, rhonchi, crackles, hypoxia and frothy
sputum.
3) Pneumonia
- This is an inflammatory response in which cellular
material replaces alveolar gas.
- In postoperative patient, most often caused by gram –
negative bacilli due to impaired oropharyngeal
defense mechanisms.
- Predisposing factors include atelectasis, upper
respiratory infection, copious secretions, aspiration,
dehydration, prolonged intubation or tracheostomy,
history of smoking, impaired normal host defenses
(cough reflex, mucociliary system, alveolar
macrophage activity).
- Symptoms include dyspnea, tachypnea, pleuritic
chest pain, fever, chills, hemoptysis, cough (rusty or
purulent sputum), and decreased breath sounds over
involved area.
- Preventive Measures
• Report any evidence of upper respiratory infection to
the surgeon.
• Suction nasopharyngeal or bronchial secretions if
patient is unable to clear own airway.
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312 RLE
• Prevent regurgitation and aspiration through proper
patient positioning.
• Recognize the predisposing causes of pulmonary
complications:
- Infections – mouth, nose, sinuses, throat.
- Aspiration of vomitus.
- History of heavy smoking, chronic pulmonary
disease.
- Obesity.
- Avoid oversedation.
- Nursing Interventions:
• Slight temperature, pulse and respiration elevation.
o Apprehension and restlessness or a decreased
level of consciousness.
o Complaints of chest pain, signs of dyspnea or
cough.
• Promote full aeration of the lungs.
o Turn the patient frequently
o Encourage the patient to take 10 deep breaths
hourly, holding each breath to a count of 5 and
exhaling.
o Use a spirometer or any device that encourages
the patient to ventilate more effectively.
o Assist the patient in coughing in an effort to bring
up mucous secretions. Have patient splint chest
or abdominal wound to minimize discomfort
associated with deep breathing and coughing.
o Encourage and assist the patient to ambulate as
early as the health care provider will allow.
• Initiate specific measures for particular pulmonary
problems
o Provide cool mist or heated nebulizer for the
patient exhibiting signs of bronchitis or thick
secretions.
o Encourage patient to take fluids to help “liquefy”
secretions and facilitate expectoration (in
pneumonia).
o Elevate the head of bed and ensure proper
administration of prescribed oxygen.
o Prevent abdominal distention – nasogastric tube
insertion may be necessary.
o Administer prescribed antibiotics for pulmonary
infections.
Pulmonary Embolism
- Causes:
• Pulmonary embolism (PE) is caused by the
obstruction of one or more pulmonary arterioles by an
embolus originating somewhere in the venous system
or in the right side of the heart.
• Postoperatively, the majority of emboli develop in the
pelvic or iliofemoral veins before becoming dislodged
and traveling to the lungs.
- Clinical Manifestations:
• Sharp, stabbing pains in the chest
• Anxiousness and cyanosis
• Papillary dilation, profuse perspiration.
• Rapid and irregular pulse become imperceptible –
leads rapidly to death
J.A.K.E Perioperative nursing – Postoperative Nursing Phase
• Dyspnea, tachypnea, hypoxemia.
• Pleural friction rub (occasionally).
- Nursing Manifestations:
• Administer oxygen with the patient in an
upright/sitting position (if possible).
• Reassure and keep the patient calm.
• Monitor vital signs, ECG, and arterial blood gases.
• Treat for shock or heart failure as needed
• Give analgesics or sedatives to control pain or
apprehension.
• Prepare for anticoagulation or thrombolytic therapy or
surgical intervention.
Urinary Retention
- This is accumulation of 500 mls of urine or more, in the
urinary bladder due to relaxation of its detrusor muscles.
- Causes:
• Occurs postoperatively, especially after operations of
the rectum, anus, vagina, or lower abdomen
• Caused by spasm of the bladder sphincter.
• More common in male clients due to inherent
increases in urethral resistance to urine flow
• Can lead to urinary tract infection and possibly renal
failure.
- Clinical Manifestations:
• Inability to void.
• Voiding small amounts at frequent interval. E.g.,
voiding 30 to 60 mls every 15 to 30 minutes. This
indicates overdistended bladder with “overflow” of
urine.
• Palpable bladder.
• Lower abdominal discomfort.
- Nursing Interventions:
• Assist client to sit or stand (if permissible) because
many patients are unable to void while lying in bed.
• Provide the client with privacy.
• Run the tap water – frequently; the sound or sight of
running water relaxes spasm of the bladder sphincter.
• Use warmth to relax sphincters (e.g., Sitz bath, warm
compresses).
• Notify physician if patient does not urinate regularly
after surgery.
• Administer bethanecol chloride (Urecholine)
intramuscularly if prescribed.
• Catheterize only when other measures are
unsuccessful.
- Urinary Retention results in a partial or complete
impairment to the forward flow of bowl contents. Loop of
intestine may kink due to inflammatory adhesions. Most
obstructions occur in the small bowel, especially at its
narrowest point – the ileum.
Intestinal Obstruction
- This is due to decreased or absent peristalsis, causing
accumulation of gas and feces in the intestines.
- Clinical Manifestations:
• Intermittent sharp, colicky abdominal pains.
• Nausea and vomiting. Vomitus is fecaloid due to
reverse peristalsis.
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• Abdominal distention, hiccups.
• Diarrhea for partial obstruction; absence of bowel
movement for complete obstruction.
• High pitched bowel sounds for partial obstruction;
absent bowel sounds for complete obstruction.
• Shock, then death occurs.
NURSING PRIORITY: Auscultate the four quadrants of the
abdomen for 5 minutes before concluding that there is
absence of bowel sounds.
- Nursing Interventions:
• Monitor for adequate bowel sound return after surgery.
Assess bowel sounds and degree of abdominal
distention (may need to measure abdominal girth).
• Monitor and document characteristics of emesis and
nasogastric drainage.
• Relive abdominal distention by passing a nasoenteric
suction tube, as ordered.
• Replace fluid and electrolytes.
• Monitor fluid, electrolyte (especially potassium and
sodium), and acid-based status.
• Administer narcotics judiciously because the
medications may further suppress peristalsis.
• Prepare the client for surgical intervention if
obstruction continues unresolved.
• Closely monitor patient for signs of shock.
• Provide frequent reassurance to patient; use
nontraditional methods to promote comfort (touch,
relaxation, imagery).
Hiccups (Singultus)
- Intermittent spasms of the diaphragm causing a sound
(“hic”) that result from the vibration of closed vocal cords
as air rushes suddenly into the lungs.
- Causes:
• Irritation of phrenic nerve between the spinal cord and
terminal ramifications on undersurface of the
diaphragm.
• Direct – distended stomach, peritonitis, abdominal
distention, pleurisy, tumors pressing on nerves.
• Indirect – toxemia, uremia.
• Reflex – exposure to cold, drinking very hot or very
cold liquids, intestinal obstruction.
- Clinical Manifestations:
• Audible “hic”
• Distress and fatigue
• Vomiting
• Wound dehiscence in severe cases
- Nursing Interventions:
• Identify and resolve the cause, if possible.
• When removal of the cause is not possible, remedies
may include if appropriate:
1) Have client swallow a large gulp of water.
2) Place tablespoon of coarse, granulated sugar on
back of client’s tongue and have client swallow it.
3) Administer a phenothiazine drug such as
prochlorperazine (Compazine) or Chlorpromazine
(Thorazine) as directed.
J.A.K.E Perioperative nursing – Postoperative Nursing Phase
4) Introduce a small catheter into the patient’s
pharynx (about 8 to 10 cm or 3 to 4 inches); rotate
gently and jiggle back and forth.
5) For rare, intractable hiccups, an extreme
procedure is surgical alteration of the phrenic
nerve.
Wound infections
- The second most common nosocomial infections. The
infection may be limited to the surgical site (60 – 80%) or
may affect the patient systemically.
- Causes:
• Drying tissues by long exposure, operations on
contaminated structures, gross obesity, old age,
chronic hypoxemia and malnutrition are directly
related to an increased infection rate.
• The patient’s own flora is most often implicated in
wound infections (Staphylococcus aureus).
• Other causative agents in wound infection include
Escherichia coli, Klebsiella, Enterobacter, and
Proteus.
• Wound infections typically present 5 to 7 days
postoperatively.
- Factors affecting the extent of infection include:
• Kind, virulence and quantity of contaminating
microorganisms.
• Presence of foreign bodies or devitalized tissue.
• Location and nature of the wound.
• Amount of dead space or presence of hematoma.
• Immune response of the patient.
• Presence of adequate blood supply to wound.
• Presurgical condition of the patient (e.g. elderly,
alcoholism, diabetes, malnutrition).
- Clinical Manifestations:
• Redness, excessive swelling, tenderness, warmth.
• Red streaks in the skin near the wound.
• Pus or other discharge from the wound.
• Tender, enlarged lymph nodes in axillary region or
groin close to wound.
• Foul smell from wound.
• Generalized body chills or fever.
• Elevated temperature and pulse.
• Increasing pain from incision care.
BEST PRACTICE: The elderly do not mount an inflammatory
response to infection as readily, so may not present with
fever, redness and swelling. Increasing pain, fatigue,
anorexia and changes in mental status are signs of
infection in the elderly
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312 RLE
NURSING PRIORITY: Mild transient fever appears
postoperatively due to tissue necrosis, hematoma or
cauterization. Higher sustained fever arises with the
following four most common postoperative
complications:
a. Atelectasis within the first 48 hours
b. Wound infections in 5 – 7 days
c. Urinary infections in 5 – 8 days
d. Thrombophlebitis in 7 to 14 days
- Nursing Interventions:
• Preoperative
- Encourage the patient to achieve an optimal
nutritional level. Enteral or parenteral
alimentation may be ordered preoperatively to
reduce hypoproteinemia with weight loss.
- Reduce preoperative hospitalization to a
minimum to avoid acquiring nosocomial
infections.
• Operative
- Follow strict asepsis throughout the operative
procedure.
- When a wound has exudates, fibrin dessicated fat,
or nonviable skin, it is not approximated by
primary closure but approximation is delayed
(secondary closure).
• Postoperative
- Keep dressing intact, reinforcing if necessary,
until prescribed otherwise.
- Use strict asepsis when dressings are changed.
- Monitor and document amount, type and location
of drainage. Ensure that all drains are working
properly.
• Postoperative care of an infected wound
- The surgeon removes one or more stitches,
separates wound edges, and examines for
infection using a hemostat or a probe.
- A culture is taken and sent to the laboratory for
bacterial analysis.
- Wound irrigation may be done; have asepto
syringe and saline available.
- A drain may be inserted, or the wound may be
packed with sterile gauze.
- Antibiotics are prescribed.
- Wet-to-dry dressings may be applied.
- If deep infection is suspected, the patient may be
taken back to the operating room for debridement.
NURSING PRIORITY: Mental status changes are signs of
infection in the elderly. The elderly do not exhibit
inflammatory response readily and may not experience
fever, redness and swelling.
Wound Dehiscence and Evisceration
- Wound dehiscence is disruption in the
coaptation/approximation of wound edges. It is wound
breakdown.
- Evisceration is dehiscence with protrusion of intestines.
J.A.K.E Perioperative nursing – Postoperative Nursing Phase
- Causes:
• Commonly occurs between 5th and 8th day
postoperatively when incision has weakest tensile
strength; greatest strength is found between the 1st
and 3rd postoperative day.
• Chiefly associated with abdominal surgery.
• This catastrophe is often related to the following:
o Inadequate sutures or excessively tight closures
(the latter compromises blood supply).
o Hematomas, seromas.
o Infections
o Excessive coughing, hiccups, retching.
o Poor nutrition, immunosuppression
o Uremia, diabetes mellitus
o Steroid use.
- Preventive Measures:
• Apply abdominal binder for heavy or elderly patients
or those with weak or pendulous abdominal walls.
• Encourage patient to splint incision while coughing.
• Monitor for and relieve abdominal distention.
• Encourage proper nutrition with emphasis on
adequate amounts of protein and vitamin C.
- Clinical Manifestations:
• Dehiscence is heralded by sudden discharge of
serosanguinous fluid from wound.
• Patient complains that suddenly “gave way” in the
wound.
• In an intestinal wound, the edges of the wound may
part and the intestines may gradually push out.
Observe for drainage of peritoneal fluid on dressing
(clear or serosanguinous fluid).
- Nursing Interventions:
• Stay with the patient and have someone notify the
surgeon immediately.
• If intestines are exposed, cover with sterile moist
saline dressings.
• Monitor vital signs and watch for shock.
• Keep the patient on absolute bed rest.
• Instruct patient to bend knees, with head of bed
elevated in semi-Fowler’s position to relive tension on
abdomen.
• Assure the patient that the wound will be properly
card for; attempt to keep patient quiet and relaxed.
• Prepare the patient for surgery and repair of the
wound.
Postoperative Psychological Disturbances
Depression
- Causes: perceived loss of health or stamina, pain, altered
body image, various drugs, and anxiety about an uncertain
future.
- Clinical Manifestations: withdrawal, restlessness,
insomnia, nonadherence to therapeutic regimen,
tearfulness and expressions of hopelessness.
- Nursing Interventions:
• Clarify misconceptions about surgery and its future
complications.
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312 RLE
• Listen to, reassure and support patient.
• If appropriate, introduce patient to representatives of
ostomy, mastectomy, or amputee support groups.
• Involve patient’s partner and support people in care;
psychiatric consultation is obtained for severe
depression.
Delirium
- Causes: prolonged anesthesia, cardiopulmonary bypass,
drug reaction, sepsis, alcoholism (delirium tremens),
electrolyte imbalances and other metabolic disorders.
- Clinical Manifestations: disorientation, hallucinations,
perceptual distortions, paranoid delusions, reversed day-
night pattern, agitation, insomnia, delirium tremens often
appears within 72 hours of last alcoholic drink and may
include autonomic overactivity – tachycardia, dilated
pupils, diaphoresis, and fever
- Nursing Interventions:
• Assist with assessment and treatment of the
underlying cause (restore fluid and electrolyte
balance, discontinue offending drug).
• Reorient to the environment and time.
• Keep surroundings calm.
• Explain in detail every procedure done to the patient.
• Sedate patient as ordered to reduce agitation, prevent
exhaustion, and promote sleep. Assess for
oversedation.
• Allow extended periods of uninterrupted sleep.
• Reassure family members with clear explanations of
patient’s aberrant behavior.
• Have contact with patient s much as possible; apply
restraints to patient only as last resort if safety is in
question and if ordered by health care provider.
Nursing Care of Clients During Extended Postoperative
Period
- Provision of specific and individualized postoperative
discharge instructions is of primary important that the
nurse ensures at this time. These instructions should be
written by a provider (physician) and reinforced verbally by
the nurse. A provider telephone contact should be
included, as well as information regarding follow-up care
and appointments. These instructions should be signed by
the patient, provider and nurse, and a copy becomes part
of the patient’s chart. Forms and procedures for discharge
instructions may vary per facility.
Patient education involves the following:
Rest and activity
- It is common to feel tired and frustrated about not being
able to do all things you want; this is normal.
- Plan regular naps and quiet activities, gradually increasing
your exercise over the following weeks.
- When you begin to exercise more, start by taking a short
walk to or three times a day. Consult your health care
provider if more specific exercises are required.
- Climbing stairs in your home may be surprisingly tiring at
first. Do this gradually until your strength has returned.
J.A.K.E Perioperative nursing – Postoperative Nursing Phase 312 RLE

- Consult your health care provider to determine the Bending and Lifting
appropriate time to return to work. - How much bending, stretching and lifting you are allowed
Eating depends on the location and nature of your surgery.
- Follow dietary instructions provided at the hospital before - Typically, for most major surgeries, you should avoid
you discharge. lifting anything heavier than 5 lbs for 4 to 8 weeks.
- It is not surprising to find that your appetite is limited at - It is ideal to secure home assistance for the first 2 to 3
first or that you may feel bloated after meals; this should weeks after discharge.
become less a problem as you become more active. If
symptoms persists, consult your health care provider. Postoperative Period: Nursing Diagnoses
- Eat small, regular meals and make them as nourishing as - Ineffective airway clearance related to prolonged sedation.
possible to promote wound healing. - Risk for aspiration related to reduce level of
Sleeping consciousness.
- If sleeping is difficult because of wound discomfort, try - Ineffective breathing pattern related to incisional pain.
taking your pain medication at bedtime. - Constipation related to decreased peristalsis.
- Attempt to get sufficient sleep to aid your recovery. - Fear related to surgical procedures and prognosis.
Wound Healing - Risk for deficient fluid volume related to inadequate intake,
- Your wound will go through several stages of healing. After wound drainage, and gastric decompression.
initial pain at the site, the wound may feel tingling, itchy, - Hyperthermia related to inflammatory process.
numb or tight (a slight pulling sensation) as healing occurs. - Risk for infection related to surgical wound.
- Do not pull off any scabs because they protect the - Risk for injury related to anesthesia and sedation.
delicate new tissues underneath. They will fall off without - Pain related to surgical incision.
any help when ready. Change the dressings according to - Disturbed sleep pattern related to anxiety and pain.
surgeon’s instructions. - Urinary retention related to effects of anesthesia.
- Consult your health care provider if the amount of pain in
your wound increases or if you notice increased redness,
swelling, or discharge from wound.
Bowel
- Irregular bowel habits can result from changes in activity
and diet or the use of some drugs.
- Avoid straining because it can intensify discomfort in
some wounds; instead, use a rocking motion while trying
to pass stool.
- Drink plenty of fluids and increase the fiber in your diet
through fruits, vegetables and grains as tolerated.
- It may be helpful to take a mild laxative. Consult your
health care provider if you have any questions.
Bathing, Showering
- You may get your wound wet within three days of your
operation if the initial dressing has already been changed
(unless otherwise advised).
- Showering is preferable because it allows for thorough
rinsing of the wound.
- If you are feeling too weak, place a plastic or metal chair
in the shower so you may be seated during showering.
- Be sure to dry your wound thoroughly with a clean towel
and dress it as instructed before discharge.
Clothing
- Avoid tight belts and underwear and other clothes with
seams that may rub against the wound.
- Wear loose clothing for comfort and to reduce mechanical
trauma to wound.
Driving
- It is important to ask your health care provider when you
may resume driving. Safe driving may be affected by your
pain medication. In addition, any violent jarring from an
accident may disrupt your wound.

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Respiratory Care Modalities Return Demonstration
J.A.K.E NCMB 312 RLE

PULSE OXIMETRY Fingertip

- is one of the most commonly employed monitoring
modalities in the critical care setting.
- A good indicator of the oxygenation status of a person,
especially hypoxemia.
Parts
- most accessible segment of the body
- nail polish/ varnish can affect the measurement of oxygen
saturation, particularly black, green, and blue

Toes
- as good as the fingers as a pulse oximeter measuring site
- helpful in detecting problems in arterial blood flow such
as in lower extremity arterial disease
- Earlobe
- can be clipped either on the tip or lower part of the pinna
(earlobe)
- medical anomalies with the hands or fingers that hinder
precise measurement of oxygen saturation
Soles and Palm
- pulse oximeter probes that are used on the palm and
soles utilize a wrap sensor instead of the ones that are
clipped

- A pulse oximeter reads the concentration of oxygen bound

to hemoglobin in the blood by shining infrared and red
light through a translucent part of the body and measuring
the ratio of light reflected and light absorbed by
oxygenated and deoxygenated hemoglobin
- Oxygen that is inhaled from the atmosphere diffuses
through the lungs and into the bloodstream to be used up
by body tissues for energy
- the oxygen is bound to the hemoglobin component of a
red blood
- few are dissolved in plasma
- 95% - 100% - Normal SpO2. or Normal oxygen saturation
of the peripheral blood Forehead
- below 95% - Hypoxemia - In more rare cases, wherein the digits and ear are
- 85% and below - Critical level inaccessible, a pulse oximetry reflectance probe may be
- Cerebral hypoxia (low oxygen level in the brain) may follow attached low across the forehead and just right above the
in a few minutes and cause irreversible brain damage. eyebrows, making sure that it is placed away from a major
Several vital organs might also be affected. The person vessel.
warrants immediate treatment and oxygenation. • Handheld Oximeter
- Where Can You Use A Pulse Oximeter?
• To be able to get an accurate reading, a pulse
oximeter probe must be placed on a translucent part
of the body so that light emitted from the light
transmitter will be received by the photodetector on
the opposite side
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J.A.K.E Respiratory Care Modalities Return Demonstration
• Tabletop Oximeter
• Wrist-Worn Oximeter
PULSE OXIMETERS ERRORS & TROUBLESHOOTING
Failure to obtain a signal
- Measuring site must be kept clean and dry. You may
reposition the user’s finger.
- Change the monitoring site.
- Vital signs should be assessed including the measuring
site, whether there is adequate blood flow.
- The sensor and a blood pressure cuff must not be placed
on the same hand.
- check for loose wirings or whether the probe is properly
attached to the base unit that should be connected to a
power source.
Limitations
- High levels of artificial light and dirt under your nails or nail
varnish may affect the reading.
- The oximeter needs to read at least 5 fingertip pulse beats
and therefore should not be read in an instant.
- Movement, such as shaking or shivering can affect the
reading and preexisting medical conditions such as
anemia, heart or circulation problems.
- Make sure to READ it in a room with adequate lighting.
direct AVOID bright light shining at the probe, such as
sunlight or operating light.
INCENTIVE SPIROMETRY
- also referred to as sustained maximal inspiration (SMI), is
a component of bronchial hygiene therapy.
- As it measures how well your lungs fill up with each breath.
- an incentive spirometer helps exercise your lungs to help
keep your alveoli (air sacs where oxygen and carbon
dioxide are exchanged) INFLATED.
Parts
RCM 2 of 6
NCMB 312 RLE
Indications
1. Presence of conditions predisposing to the development
of pulmonary atelectasis
o Upper-abdominal surgery
o Thoracic surgery
o Surgery in patients with chronic obstructive
pulmonary disease (COPD)
2. Presence of pulmonary atelectasis
3. Presence of a restrictive lung defect associated with
quadriplegia and/or dysfunctional diaphragm
Contraindications
1) IF Patient cannot be instructed or supervised to assure
appropriate use of the device.
2) IF Patient cooperation is absent or patient is unable to
understand or demonstrate proper use of the device.
3) is contraindicated in patients unable to deep breathe
effectively (eg, with vital capacity [VC] less than about 10
mL/kg or inspiratory capacity [IC] less than about one
third of predicted).
4) The presence of an open tracheal stoma is not a
contraindication but requires adaptation of the spirometer.
Materials
• Incentive spirometer (may require a prescription from
your doctor)
• Pillow (if you have an incision)
• Comfortable place to sit
Procedure
1) Sit or lie upright in a comfortable position.
2) Hold the incentive spirometer upright, with both hands.
3) Slide the indicator (located in the left-hand column when
you are facing the spirometer) to the desired level. For
example, start at 1250 milliliters and slowly increase as
your treatment progresses.
4) Place the mouthpiece into your mouth and tightly seal
your lips around it.
5) With your lips tightly sealed around the mouthpiece,
breathe in slowly and as deeply as possible. The piston
that is resting below the indicator should now rise toward
the top of the column.
6) Hold your breath for at least 3 seconds and allow the
piston to fall back to the bottom of the column.
7) After each set of deep breathing, cough to help clear your
airways of mucus.
8) Rest for a few seconds and repeat steps two through eight,
10 times each hour while you are awake
TIPS:
- If you are coughing and you have an incision, press firmly
against the area with a pillow. It will offer additional
support and comfort.
- Normally, an incentive spirometer is recommended for
people who can't walk or get out of bed. If you are
recovering from surgery or a COPD exacerbation, you can
use your incentive spirometer to keep your lungs inflated.
J.A.K.E Respiratory Care Modalities Return Demonstration NCMB 312 RLE

NEBULIZATION CHEST PHYSIOTHERAPY

- is the process by which a liquid medication is converted
into a fine mist that can be inhaled.
- The device that is used to convert the liquid drug into
aerosol droplets suitable for patients to inhale is known as
a “Nebulizer”.
- can be used to deliver bronchodilator (airway-opening)
medicines such as albuterol (Ventolin®, Proventil® or
Airet®) or ipratropium bromide (Atrovent®).
Parts
- Includes postural drainage, chest percussion, vibration,
coughing and deep breathing exercise
- PVPD
Purposes
• To mobilize and eliminate secretions, re-expand lung
tissue, and promote efficient use of respiratory muscles
• To prevent or treat atelectasis or to prevent pneumonia
Indications
• It is indicated for patients in whom cough is insufficient to
clear thick, tenacious, or localized secretions
• Cystic fibrosis
• Bronchiectasis
• Atelectasis
• Neuromuscular diseases
• Pneumonias in dependent lung regions.

Contraindications
• Active pulmonary bleeding with hemoptysis and the
immediate post-hemorrhage state
• Fractured ribs or unstable chest wall
Indicators • Lung contusions
• Tightness in chest • PTB
• Increased or thick secretions • Untreated pneumothorax
• Pneumonia (congestion) and/or • Acute asthma or bronchospasm
• Atelectasis • Lung abscess or tumor
• Bony metastasis
Contraindications • Head injury
• Increased blood pressure • Recent MI
• Increased pulse
• History of adverse reaction to the medication. Auscultations

Procedure
1) Carefully measure the medicine exactly as you have been
instructed. Use a separate, clean measuring device
(dropper or syringe) for each medicine.
2) Once you turn on the compressor, you should see a light
mist coming from the back of the tube opposite the
mouthpiece.
3) Sit up straight on a comfortable chair.
4) If you are using a mask, position it comfortably and
securely on your face.
5) If you are using a mouth piece, place it between your teeth
and seal your lips around it.
6) Take slow, deep breaths through your mouth. If possible,
hold each breath for two to three seconds before
breathing out. This allows the medication to settle into the
airways.
7) Continue the treatment until the medication is gone
(about 7 to 10 minutes).
8) If you become dizzy or feel "jittery," stop the treatment and
rest for about five minutes. Then continue the treatment
but try to breathe more slowly. If these symptoms
continue with future treatments, inform your health care
provider.
9) Take several deep breaths and cough.

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J.A.K.E Respiratory Care Modalities Return Demonstration NCMB 312 RLE

Postural Drainage
- Lower and middle lobe bronchi: head-down position
- Upper lobe bronchi: head-up position
- If one lung is more affected than the other opposite side
- When tipping the child over pillows place under the pelvis,
NOT under the chest.
- In babies, it may be more usual for the upper lobes to be
affected sitting position
- Before the procedure:
• May receive bronchodilator/nebulization
- Frequency:
• 2-3 times daily depending on the degree of congestion
- Best time to perform: Upper Lobe
• Before meals Apical bronchus
• Late afternoon - Sitting upright (a)
• Before bedtime Anterior bronchus
• AVOID: hours shortly after meals - Lying supine with the knees slightly flexed. (c)
- Assume each position:
• 10-15 minutes
- After the procedure:
• Auscultate to evaluate effectiveness
- Principle to follow:
• Secretions opposite the gravitational pull

Posterior Bronchus
Right
- Lying on the left side and turn his face 45º resting
against a pillow, with another pillow supporting the head.
(f)
Left
- Lying on the right side turning his/her face 45º with 3
pillows arranged to lift the shoulders by 12 inches. (b)

Middle Lobe (Right)

- -Lateral and medial bronchus
- Lying supine with the body a quarter turned to the left
maintained by a pillow under the right side from
shoulder to hip and foot end raised by 14 inches (35
cms). (d)

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J.A.K.E Respiratory Care Modalities Return Demonstration NCMB 312 RLE

Lingula (Left) • Cover the area with towel or gown

- Superior and inferior bronchus Lying supine with the body Cup your hands when performing chest percussions.
a quarter turned the right maintained by a pillow under the
left side from shoulder to hip and foot end raised by 14
inches (35 cm). (e)

Vibration
- In vibration, the nurse uses rhythmic contractions and
relaxations on her arm and shoulder muscles while
Lower Lobe holding thee patient flat on the patient’s chest as the
Apical basal bronchus patient exhales.
- Lying prone with a pillow under the hips. (g) - The purpose is to help loosen respiratory secretions so
Anterior basal bronchus that they can be expectorated with ease.
- Lying supine with the buttocks resting on a pillow and the - QUIVERING of the back by hands
knees flexed. Foot of the bed raised by 18 inches (45 cm). - Apply vibration using:
(h) • Heel of the hands
- When to apply vibration:
• Upon patient’s EXHALATION
- When to stop:
• When patient INHALES
- Duration:
• Vibrate during five exhalations over one affected lung
segment
- After vibration:
• Instruct the patient to expectorate
Position hands as shown below to perform chest vibration

Percussion
- Chest percussion involves striking the chest wall over the
area being drained.
- Percussing lung areas involves the use of cupped palm to
loosen pulmonary secretions so that they can be
expectorated with ease.
- Usually the patient will be positioned in supine or prone
and should not experience any pain.
- A.k.a clapping Nursing Care
• Forceful striking of the skin with CUPPED hands • Know the normal range of patient’s vital signs
- Duration: • Know the patient’s medications.
• 1-2 minutes per lung segment • Know the patient’s medical history
- Correctly done when: • Know the patient’s cognitive level of functioning.
• Produces a hollow popping sound • Beware of patient’s exercise tolerance.
- Avoid percussion on:
• Breast, sternum, spinal column, and kidneys
- Provide comfort:

RCM 5 of 6
J.A.K.E Respiratory Care Modalities Return Demonstration NCMB 312 RLE

Bronchiectasis
- a chronic, irreversible dilation of the bronchi and
bronchioles. Under the new definition of COPD, it is
considered a disease process separate from COPD (GOLD,
2008).
- Bronchiectasis may be caused by a variety of conditions,
including:
• Airway obstruction
• Diffuse airway injury
• Pulmonary infections and obstruction of the bronchus
or complications of long-term pulmonary infections
• Genetic disorders such as cystic fibrosis
• Abnormal host defense (eg, ciliary dyskinesia or
humoral immunodeficiency)
• Idiopathic causes
- People may be predisposed to bronchiectasis as a result
of recurrent respiratory infections in early childhood,
measles, influenza, tuberculosis, or immunodeficiency
disorders.
- Irreversible DILATION of the bronchial tree
- Predisposing factors:
• Recurrent RTI
• Cystic fibrosis
- S/Sx:
• Consistent productive cough
• Dyspnea
• Rales/crackles
- Dx:
• ABG: hypoxemia
• Bronchoscopy
- Mngt:
• Force fluids
• Low flow oxygen
• CBR
• COPD meds

RCM 6 of 6
Tracheostomy Care Suctioning Return Demonstration
J.A.K.E NCMB 312 RLE

TRACHEOSTOMY
•Tracheostomy is a surgical opening in the trachea
(windpipe) to make breathing easier
• Opening is called a Stoma
Indications
• Mechanical ventilation
• Failed endotracheal intubation
• Large tumor of the head and neck

Tracheostomy Ties
 Types: twill, Velcro, metal bead

Types of Tracheostomy Tube

• Uncuffed
- may be plastic or metal, which allows for air to flow
around the tube (permanent tracheostomy)
• Cuffed
- are surrounded by an inflatable cuff that produces an
airtight seal between the tube and the trachea.
- Often used immediately after a tracheostomy and are
essential when ventilating a tracheostomy client with a
Advantages
mechanical ventilator.
• Maintains airway patency
• Fenestrated
• Maintains cleanliness and prevents infection at the
- has holes in the outer cannula. Is used when the client
tracheostomy site
is being weaned (gradual discontinuation
of mechanical support – kase matagal na, naol • Facilitates healing and prevents skin excoriation
nagtatagal djkkk) around the tracheostomy incision
• Promotes comfort
Parts of a Tracheostomy Tube (tube w/ inner cannula)
Disadvantage
• Outer Cannula – that is inserted to the trachea • Air is no longer filtered and humidified; special
• Inner Cannula – may be removed for periodic cleaning precautions are necessary
• Neck Plate (Flange) – rests against the neck and allows Solution:
the tube to be secured in place with tape or ties • Wear a light scarf or 4x4 inch gauze held in place with
• Obturator – used to insert the outer cannula and then a cotton twill ties over the stoma to filter the air
removed; it is kept at the client’s bedside in case the tube Nursing Responsibilities
becomes dislodged and needs to be reinserted • Provide tracheostomy care at least every 8 hrs after the
• Cuff – produces an airtight seal between the tube and the initial inflammatory response
trachea. This seal prevents aspiration of oropharyngeal • Hyper oxygenate the client and perform suctioning to
secretions and air leakage between the tube and the remove secretions from the lumen of the tube (10-15
trachea secs.) (total time – 5 mins.)
• Fenestration- hole in the outer cannula • If an inner cannula is present, remove and clean and
replace with a new one
• Sterile technique must be observed all throughout the
procedure
• Assessment of the peristomal skin and incision site must
be done and notify the Physician for any abnormalities.

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J.A.K.E Tracheostomy Care Suctioning Return Demonstration NCMB 312 RLE

SUCTIONING Suction catheter

- When: Suction as necessary • Tip
- Aspirating secretions through a catheter connected to a o Open-tipped – nag suction din sa tip of catheter yung
suction machine or wall outlet mga phlegm na
- Upper airway suctioning: o Whistle tipped – top is not open, nasa gilid lang ung
• Nasopharyngeal suctioning mga butas sa suctioning.
• Oropharyngeal suctioning • Sizes
- Maintain a patent airway and prevent airway obstruction o Adult: Fr 12 to Fr 18
- Promote respiratory function (optimal exchange of O2 and o Children: Fr 8 to Fr 10
CO2 into and out of the lungs) o Infants: Fr 5 to Fr 8
- Prevent pneumonia that may result from accumulated - the bigger the number, the bigger the diameter
secretions Suction machine
Complications • Portable suction unit (nadadala kung saan saan)
- Suctioning stimulates cough reflex and stimulates o Adult: 10-15mmHg
mucus production o Children: 5-10mmHg
- It should only be done when breath sounds indicate that o Infants: 2-5mmHg
the need is present! - Always refer to hospital level policy of suctioning levels
- The diameter of the suction catheter should be about • Wall suction unit
half the inside diameter of the tracheostomy tube to o Adult: 100-120mmHg
prevent hypoxia o Children: 95-110mmHg
Respiratory o Infants: 50-95mmHg
- hypoxemia, trauma to airway, cardiac dysrhythmia NOTE: always remember remove the mask of the patient
related to hypoxemia
- Bronchospasm
- Tracheobronchial mucosal trauma resulting in potential
pulmonary hemorrhage
- Contamination of airway leading to nosocomial infection
(kapag hindi na practice ng maayos ang aseptic
technique!)
- Unplanned extubation
- Atelectasis (loss of ciliary function/glottis closure) Things to remember:
- Right upper lobe collapse (Excessive suction pressure) - Do not force through nares during insertion (wag ipilit
- Pneumothorax kung ayaw tehhh, hindi yung nag s stock na sya
Cardiovascular pinapasok mo pa din ng pinapasok)
- Vagal response bradycardia - Never suction on the way in
- Hemodynamic instability - Length of insertion
- Pulmonary vasoconstriction • Oropharyngeal
Neurological - measure from tip of the nose to angle of mandible (2 to 4
- Changes in cerebral blood flow velocity/ raised ICP inches)
- Decreased O2 availability in cerebral blood flow • Nasopharyngeal
- Hypoxic – ischemic encephalopathy o Adult: 16m (6 inches)
Infection o Older children: 8 to 12 cm (3 to 5 inches)
- nosocomial infections o Infants and young children: (4 to 8 cm (2 to 3
Pain inches)
- behavioral response in infants - Suction time
Purposes o Each suction: 10 – 15 seconds
• To remove secretions that obstruct the airway o Interval or in-between suction: 1 minute (basta
• To facilitate ventilation hanggang sa kaya na ulit ni patient)
• To obtain secretion for diagnostic purposes (such us o Whole procedure: maximum of 5 minutes
sputum collection for determine TB) NOTE: PreO2 before suctioning
• To prevent infection that may result from accumulated Indications
secretions • Audible secretions during respiration
• Adventitious breath sounds
• Pressure of suction equipment to prevent trauma to
mucous membrane of airways
• Appropriate size of sterile suction water
• Visible secretions – rattling or bubbling sounds, audible
with or without a stethoscope
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J.A.K.E Tracheostomy Care Suctioning Return Demonstration NCMB 312 RLE

• Decreased oxygen saturation levels – mga nasa 85% 8) Place sterile towel across the patient’s chest.
ganun 9) Hyperoxygenation the patient before, during and after the
• Brady/tachycardia procedure.
• Increased Pco2 – EBG mababa 10) Flush and lubricate the Suction catheter.
• Deteriorating blood gas values 11) Press the Ambu Bag 3-5 times as the client inhales.
• Change in respiratory rate and pattern with increase 12) Quickly but gently insert the catheter (6 in., without
respiratory distress applying suction) until the client coughs or if you feel
• Change of color (cyanosis, pallor, mottled) resistance.
• Suspected endotracheal tube obstruction (increased ICP, 13) If resistance is felt, withdraw the tube for about 1-2 cm
pulmonary retention, pulmonary edema na e exacerbate before applying suction.
during suctioning) 14) Perform suctioning.
15) Apply intermittent suction about 5-10 sec.
• Ventilator alarms i.e. increased proximal airway
16) Rotate the catheter while withdrawing to prevent tissue
pressure/decreased tidal volume
trauma.
• Decreased breath sound/absent of chest movements
17) Hyperventilate the patient.
• Increased airway pressure when ventilated (decreased
18) If the secretion is thick, flush the catheter.
tidal voul)
19) Reassess the patient’s oxygenation status and repeat
• Decreased chest excursion/asymmetry
suctioning as needed.
• Patient agitation 20) Allow 2-3 minutes between suction as possible to provide
Position the opportunity for reoxygenation of the lungs.
Unconscious 21) Repeat until the air passage is clear and the breathing is
- Lateral position and the patient facing you – nakatagilid effortless and quiet.
ang ulo ni patient 22) After each suction, ventilate the patient with 5 breaths.
Conscious 23) Dispose equipment’s
- Semi- fowler’s position – head turned to one side for oral 24) Provide client’s comfort and safety
suctioning and neck hyperextended for nasal suctioning 25) Document.
Materials:
o Resuscitation bag (Ambu bag) connected to 100% Cleaning a Double-Cannula Tube/ Changing a
Oxygen) Tracheostomy dressing and ties
o Sterile towel - When: dressing is soiled- harbors microorganisms and
o Suction machine source of skin breakdown, and infection.
o Suction catheter - Check order of doctor if there is an order for antibiotic
o Sterile Gloves ointment to the stoma. (e.g., Bactroban ointment)
o Sterile Water for flushing - When: excessive secretions, soiled tracheostomy
o Goggles/ Gown if necessary dressing or ties, labored breathing indicating diminished
o Moisture-resistant bag air flow through trach tube
- Open appropriate suction kit or catheter using sterile - To maintain cleanliness and prevent infection at the
technique tracheostomy site.
- Place a sterile drape over the chest of the patient - To maintain airway patency.
- Open sterile basin and fill with approx. 100ml of sterile - To prevent skin breakdown around the stoma. (may mga
normal saline solution or water materials na pang linis na ginagamit to change the
- Open lubricant and squeeze small amount onto sterile dressing)
catheter package
Steps II
• Naso – water soluble lubricant
• Oro – sterile water or NSS 1) Assess the need for cleaning the stoma.
- Apply gloves 2) Greet the patient, explain the procedure.
3) Prepare the equipments.
• Naso – sterile
4) Don gloves and suction if indicated.
• Oro – clean
5) Remove the soiled dressing using pick up forceps.
Steps 6) Remove the inner cannula (counterclockwise) by gently
1) Asses the need for suctioning. pulling it towards you and in line with its curvature.
2) Greet the patient, explain the procedure. 7) Soak the inner cannula in diluted Hydrogen peroxide to
3) Place the patient in Semi-fowler’s position to promote moisten and loosen secretions.
breathing, maximum lung expansion, and productive 8) Put oxygen source.
coughing. 9) Clean the flange and the stoma using sterile water/saline.
4) Prepare the equipment’s. Pat dry.
5) Attach the resuscitation apparatus to the oxygen source. 10) Change gloves and replace it with sterile gloves.
6) Open the sterile supplies in readiness for use 11) Remove the cannula from the soaking solution.
7) Put on sterile glove 12) Clean the lumen and entire inner cannula thoroughly.
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J.A.K.E Tracheostomy Care Suctioning Return Demonstration NCMB 312 RLE

13) Agitate in sterile saline.

14) Inspect the cannula for cleanliness by holding it at the eye
level and looking through it into the light.
15) After rinsing the cannula, gently tap it against the inside
edge of the sterile solution bowl.
16) Dry inside of cannula.
17) Insert the inner cannula and secure it.
18) Place a sterile dressing.
19) To make a tracheostomy dressing from a 4 x 4 gauze, open
gauze to an 8” x 4” size, then fold lengthwise.
20) Fold gauze corners up.
21) Slide folded gauze under tracheostomy strings.
22) Change ties.
23) Document relevant data.

TCS 4 of 4
Breast & Testicular Self- Examination
J.A.K.E NCMB 312 RLE

BREAST SELF- EXAMINATION
- A valuable tool by which women learn the appearance and
feel of their own breasts
- Performed 5-7 days after the menstrual period
(Premenopausal)
- Menopausal- select the same day each month for BSE
2 parts of BSE
1) Inspection
- Stand in front of the mirror
- Inspect for: skin changes, redness, visible bumps,
nipple crusting, symmetry
- Raise arms up and inspect: breast should rise evenly,
watch for dimpling and retraction
2) Palpation
- Raise the arm and feel with opposite hand, pay
special attention on the upper outer quadrant.
- Performed with the pads of the fingers: tips too
sensitive, palm to insensitive
- Move fingers in small, circles, about the size of a dime
- Feel for thickenings the size of a marble
- Work your way around the breast in a clockwise
fashion using small circles of the hand as you go.
- Feel the entire breast
- Feel the armpit
- Use the same circular motions.
- Feel for breast lumps and lymph nodes.
- Enlarged lymph nodes are about the size of a pencil
eraser, but longer and thinner.
- Assess for nipple discharge
- Strip the ducts towards the nipple.
- Normally, one or two drops of clear, milky or green-
tinged secretions.
- Should not be bloody or in large quantity, squirting out
or staining the inside of a bra.
7) Inspect the scrotum for appearance, general size and
symmetry
8) Ask the client to hold the penis out of the way
9) Cup testicles (It’s normal that one is lower than the
other) – Firm but not hard
10) Check one testicle at a time
• Hold the testicle between the thumb and fingers
• Gently roll the testicle between your index and
thumb
• Feel for any lumps, bump or painful areas
• Don’t squeeze too hard
11) At the back you’ll feel the epididymis
12) Feel up the spermatic cord
13) Document findings
Other signs to look out for
• Any enlargement of a testicle
• A significant loss of size in one of the testicles
• A feeling of heaviness in the scrotum
• A dull ache in the lower abdomen or in the groin
• A sudden collection of fluid in the scrotum
• Pain or discomfort in a testicle or in the
Chemo drug computation
1) Calculate the patient’s BSA in 𝑚𝑚2
2) Calculate the desired dose: Dosage ordered per 𝑚𝑚2 x BSA
= desired dose

TESTICULAR SELF-EXAMINATION
- Performed to detect testicular cancer early
- Performed once a month
- Ideally for men over the age of 14
- Best performed during or after a bath or shower (Skin of
the scrotum is relaxed)
- Stand in front of the mirror and look for swelling
- Hold the penis out of the way and check one testicle at a
time
- Feel for any hard lumps or smooth rounded bumps
- Assess for changes in size, shape or consistency of the
testicles.
1) Gather equipment (clean gloves)
2) Introduce yourself and verify client’s identity
3) Explain the procedure, why it is necessary and how he
can cooperate
4) Performhand hygiene and wear gloves
5) Provide privacy. Request the presence of another
person if needed.
6) Cover the pelvic are with a sheet

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J.A.K.E Breast & Testicular Self- Examination NCMB 312 RLE

BSE & TSE 2 of 2

ABG Analysis & IV Therapy and Medication
J.A.K.E NCMB 312 RLE

ABG ANALYSIS Level Of Compensation

- To assess ventilation and acid base balance Partially Compensation
- Radial artery is the common site for withdrawal of blood - abnormal pH, pCO2, and HCO3
specimen. Avoid suctioning prior the procedure Uncompensated
- Use 10 ml pre-heparenized syringe to draw blood - abnormal pH, abnormal pCO2 or HCO3
specimen to prevent clotting of the specimen Fully Compensated
- Place the specimen in a container with ice to prevent - normal pH, abnormal pCO2 or HCO3
hemolysis. If hemolysis occurs, oxygen and carbon ABG Analysis
dioxide are released and cannot be measured accurately. CO2 O2 HC03 pH
36 91 35 7.52
Allens test 58 80 22 7.26
- to assess for adequacy of collateral circulation of the
43 85 14 7.13
hand
39 95 23 7.38
Normal Values
32 99 45 7.63
pH 7.35-7.45
CO2 35-45
pO2 80-100
HCO3 22-26
O2 Sat. 95-100%

ABG ANALYSIS
CO2 O2 HCO3 pH Level Of Oxygenation
56 81 15 7.12 • Mild Hypoxemia - O2 = 60-79
• Moderate Hypoxemia - O2 = 40-69
28 90 32 7.76
• Severe Hypoxemia - O2 = 20-39
35 100 24 7.37
• Very Severe Hypoxemia - O2 = 0-19
45 95 18 7.28
ABG Analysis with Level Of
30 87 45 7.53
Compensation And Oxygenation
CO2 O2 HCO3 pH
21 173 24 7.58
35 68 12 7.23
63 88 34 7.13
57 195 29 7.35
42 209 45 7.76

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J.A.K.E ABG Analysis & IV Therapy and Medication NCMB 312 RLE

Respiratory Acidosis
• Increase CO2 , Decrease Ph
• Carbonic acid excess Above 45 , below 7.35
• Hypercapnia Hypoventilation
• CO2 Retained K excess
• COPD O2 therapy
• Overdose of narcotics and sedatives
• Depressed respiratory center

Respiratory Alkalosis
• Decrease CO2 , Increase Ph
• Carbonic acid deficit Below 35 , above 7.45
• Hypocapnia Hyperventilation
• CO2 Eliminated K deficit
• Pneumonia Brown bag
• Aspirin poisoning Anxiety

Metabolic Acidosis
• Decrease bicarbonate, Decrease Ph
• Bicarbonate deficit Below 22, below 7.35
• Diarrhea Loss of alkaline in GIT
• NPO K excess
• Kussmaul breathing Renal failure
• DM/Diabetic ketoacidosis
• Circulatory shock Celiac Disease
• Excessive infusion of chloride Anaerobic metabolism of
glucose
• Sodium Bicarbonate

Metabolic Alkalosis
• Increase bicarbonate, Increase Ph
• Bicarbonate excess Above 26, above 7.45
• Vomiting Loss of acid in GIT
• Gastric lavage Intestinal fistula
• K deficit Cushing syndrome
• Depressed breathing Hyperaldosteronism
• Excessive adrenal corticoid hormone
• Increase secretion of HCO3 in kidneys (Diuretics)
• Excessive ingestion of baking soda

ABG & IV 2 of 5
J.A.K.E ABG Analysis & IV Therapy and Medication NCMB 312 RLE

DRUG COMPUTATION Parenteral / Oral Medication (Liquid)

10 Rights in Giving Medications 𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷 𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑 𝑥𝑥 𝑄𝑄𝑄𝑄𝑄𝑄𝑄𝑄𝑄𝑄𝑄𝑄𝑄𝑄𝑄𝑄 𝑜𝑜𝑜𝑜 𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷
= 𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠 𝐴𝐴𝐴𝐴
• Right Drug 𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠 𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑
- The first right of drug administration is to check and Example 1:
verify if it’s the right name and form. Beware of look- - The expectorant guiafenesin (Robitussin) 300 mg p.o.
alike and sound-alike medication names. Misreading has been ordered. The bottle is lab 100 mg/ 5ml. How
medication names that look similar is a common many milliliters should be given?
mistake. These look-alike medication names may also - Answer is: 15 ml / 1 tablespoon / 3 teaspoons
sound alike and can lead to errors associated with Example 2:
verbal prescriptions. - A patient is to receive NPH 50 u/ml subcutaneously
• Right Patient daily. Stock is 100 u/ml in 10 vial. How many milliliter
- Ask the name of the client and check his/her ID band should be administered?
before giving the medication. Even if you know that - Answer is: 0.5 ml
patient’s name, you still need to ask just to verify. Example 3:
• Right Dose - The antibiotic amoxicillin 250 mg IM has been ordered.
- Check the medication sheet and the doctor’s order The bottle is labeled 500 mg/ 2ml. How many
before medicating. Be aware of the difference milliliters should be given?
between an adult and a pediatric dose. - Answer is: 1 ml
• Right Route
- Check the order if it’s oral, IV, SQ, IM, etc.. Pediatric Dose:
• Right Time and Frequency Clark’s Rule
𝑤𝑤𝑤𝑤𝑤𝑤𝑤𝑤ℎ𝑡𝑡 𝑖𝑖𝑖𝑖 𝑙𝑙𝑙𝑙𝑙𝑙 𝑋𝑋 𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢 𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎 𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑
- Check the order for when it would be given and when = 𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆 𝐶𝐶𝐶𝐶
was the last time it was given. 150𝑙𝑙𝑙𝑙𝑙𝑙
Example:
• Right Documentation
- Baby Tina weighs 30 lbs and the adult dose 25 mg/ml.
- Make sure to right the time and any remarks on the
What is the safest dose for Baby Tina?
chart correctly.
- Answer is: 5 mg/ml
• Right History and Assessment
Freid’s Rule
- Secure a copy of the client’s history to drug 𝐴𝐴𝐴𝐴𝐴𝐴 𝑖𝑖𝑖𝑖 𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚ℎ𝑠𝑠 𝑋𝑋 𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢 𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎 𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑
interactions and allergies. = 𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆 𝐶𝐶𝐶𝐶
150 𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚ℎ𝑠𝑠
• Drug approach and Right to Refuse Example:
- Give the client enough autonomy to refuse the - Baby Joey is now 12 months old, the adult dose is 50
medication after thoroughly explaining the effects. mg/ml. What is the safest child’s dose according to
• Right Drug-Drug Interaction and Evaluation Freid’s rule?
- Review any medications previously given or the diet of - Answer is: 4 mg/ml
the patient that can yield a bad interaction to the drug Young’s Rule
to be given. Check also the expiry date of the 𝐴𝐴𝐴𝐴𝐴𝐴 𝑖𝑖𝑛𝑛 𝑦𝑦𝑦𝑦𝑦𝑦𝑦𝑦𝑦𝑦 𝑋𝑋 𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢 𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎 𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑
medication being given. = 𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆 𝑐𝑐ℎ𝑖𝑖𝑖𝑖𝑖𝑖’𝑠𝑠 𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑
𝑎𝑎𝑎𝑎𝑎𝑎 𝑖𝑖𝑖𝑖 𝑦𝑦𝑦𝑦𝑦𝑦𝑦𝑦𝑦𝑦 + 12
• Right Education and Information Example:
- Provide enough knowledge to the patient of what drug - Baby Jay is 13 years old last December 25, 2011, the
he/she would be taking and what are the expected adult dose is 75 mg/tablet. What is the safe child’s
therapeutic and side effects. dose?
- Answer is: 39 mg/tablet
Adult Dose
Oral Medication (Solid) Intravenous
𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷 𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑 - Direct IV, IV Push, IV infusion
= 𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠 𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎 𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑
𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆 𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑 - Most rapid route of absorption of medication
Example 1: - Route can be use for clients with compromised
- An hypertensive agent, minoxidil (Loniten) 5 mg p.o. is gastrointestinal function or peripheral circulation
ordered. Stock is 2.5 mg/tab. How many tablets - Large doses of medication can be administered
should be administered? - Purpose:
- Answer is: 2 tablets • Fluid and electrolytes imbalance
Example 2:
• Provide food
- An hypertensive agent, Captopril (Capoten) ½ grain
• Vehicle for medication
p.o. is ordered. Stock is 60 mg/tab. How tablet will
• For blood transfusion
you give to your patient?
- Equipment’s:
- Answer is: ½ tablet
• IV Fluid, IV set, Micropore, tourniquet, cotton balls,
alcohol, splint

ABG & IV 3 of 5
J.A.K.E ABG Analysis & IV Therapy and Medication
IV Fluid Formula
𝑣𝑣𝑣𝑣𝑣𝑣𝑣𝑣𝑣𝑣𝑣𝑣 𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑 𝑓𝑓𝑓𝑓𝑓𝑓𝑓𝑓𝑓𝑓𝑓𝑓
𝑥𝑥
𝑡𝑡𝑡𝑡𝑡𝑡𝑡𝑡 60
Example:
- The doctor ordered for 1L of PNSS to run for 10 hrs
with drop factor of 15. How many drops per minute?
- Answer is:25 gtts/minute
• The doctor ordered for 500ml of 0.45 NaCl to run for 6hrs
with drop factor of 10. How many drops per minute?
Answer is: 13 – 14 gtts/minute
• The doctor ordered for 100ml of D5 water to run for 1hr
with drop factor of 60mcgtts. How many drops per
minute? Answer is: 100 mcgtts/minute
Common Practices in Medication Preparation for Fluids
and Electrolytes
Hypokalemia
- The -oral route of administration is the safest and
preferred mode of potassium replacement. Oral
potassium should be given preferably in liquid with or
without meals, or tablet, which must be swallowed and
not dissolve with the mouth. Dose depends on the clinical
situations and the estimated deficit. Kalium durule 0.75
gm (10meq) TID PO X 2-3 days or Oral KCL solution 15-30
cc on TID (1gm = 14 meq K) or intravenous of 20-60 meq
KCl in PNSS X 12 hours
Hyperkalemia
- Creatinine normal and not oliguric
- Recheck serum potassium
- Stop drugs which increase potassium level (Betablockers,
ACE inhibitors, NSAID)
- Check other etiology of hyperK (renal failure with olguria)
ABG & IV 4 of 5
NCMB 312 RLE
Creatinine increase and or oliguric
Mild hyperK
- potassium level less than 5.5 mmol/L
- Restrict potassium intake, stop culprit drugs
Moderate hyperK
- potassium level less than 5.5 – 6.5 mmol/L
- Kayexelate or Sorbisterit 20 grams in 150cc juice TID
for 3 doses only or up to 4-5 doses only
- Diuretics: Furosemide 40-80 mg IV stat dose
- Optional: Beta 2 – agonist (Salbutamol) nebulization
Severe hyperK
- potassium level more than 6.5 mmol/L and/or with
ECG changes
- Mix D50-50 ml + 5 units Humulin R slow IV stat then
every 6 hours X 3 doses
- 500 ml of 10% dextrose + 10 units insulin over 30-60
minutes (if volume overload is not a problem)
Calcium gluconate
- 10 ml 1 amp in 10% solution slow IV push in 5
minutes at 2ml/min, repeat after 10 minutes if no ECG
changes
Sodium Bicarbonate
- 1 amp slow IV push in 10 minutes - Metabolic acidosis
occurs after the heart stops, due to a buildup of the
acid waste materials in the body. corrects metabolic
acidosis during a cardiac arrest.
- 50 ml NaHCO3 to 1 L of PNSS
HypoCalcemia
Calcium gluconate
- 10ml/ampule; 1-2 ampule slow IV push in 10-15
minutes with cardiac moitoring then incorporate 1
amp calcium gluconate to present IV fluids.
J.A.K.E ABG Analysis & IV Therapy and Medication NCMB 312 RLE

Calcium carbonate
- 500 mg 1 tab BID/TID
- Vitamin B3 supplementations calicitriol 0.25 mcg cap
OD/BID (Dose; 0.5-1.0 mcg/day)
- Patients with severe or recurrent symptoms should
have a continuous infusion of dextrose solution with
an elemental calcium concentration

• Hydrate the patient – Give 0.9% NSS at 150-600 cc/hr until

no loner hypotensive up to 1-4 liters in 24 hours
• Saline dieresis with 0.9 saline infused at 300-600 cc/hour
to replace urine loss
• Consider furosemide 20-40 mg IV every 8-12 hours if with
danger of CHF
• Calcitonin salmon (Miacalcic) 50-100 in SQ or IM OD/BID
Hypomagnesemia
For symptomatic patient with magnesium of less than
1mg% or mg/dl
• Day 1 - Give 48.6 meq (6 grams) in 1 L IV fluid over 4 hours
followed by 2 liters (48.6 meq each) over the remaining 24
hours
• Day 2-5 – Give 48.6 meq (6 grams) over 24 hours daily
• Preparation MgSo4 250mg/ml in 10 ml or 2.5 gm per 10 ml
amp
• Give 1-2 grams MgSO4 IV over 15 minutes
For asymptomatic or serum of Magnesium between 1.1 –
1.4 mg/dl
• Give oral magnesium
• Milk of Magnesia (13-15meq/5ml) 5ml PO OD-QID
Hypermagnesemia
In patients without CRF
• Saline dieresis with NSS at 100-200 cc/hr to promote
magnesium excretion
Symptomatic patient with increased Mg levels
• Calcium gluconate 10% solution – 1 to 2 amps IV in 10-15
minutes
• Furosemide 20-40mg IV every 8 hours
• Stat hemodialysis for Mg more than 9 mg/dl

ABG & IV 5 of 5
Burn injury
J.A.K.E
BURNS
- Causes:
• Thermal – hot objects or substances
• Chemical – strong acids, alkali
• Electrical – electrical appliances and sources
• Radiation – excessive exposure to sunlight
- Classifications:
• 1st Degree – Superficial thickness burn - epidermis,
reddish, painful
• 2nd Degree – Partial thickness burn - dermis, moist
surface, with vesicles, painful
• 3rd Degree – Full thickness burn - epidermis, dermis
and other underlying structure, subcutaneous layer,
pearly white, no pain
• 4th Degree – Deep full thickness burn - muscles &
bones, blackish or charred, no pain
Stages of Burns
First Stage
- Shock/ Fluid Accumulation Phase
- first 48 hours (1-2 days)
- avoid oral fluids – decreased peristalsis
- NGT for decompression
- generalized dehydration
- hypovolemia – plasma loss, decrease BP
- oliguria – no urine output
- hyponatremia, hyperkalemia (fluid shifting)
- CBC results = hemoconcentration - increase hematocrit
(because liquid blood component is lost)
Second Stage
- Diuretic/ Fluid Remobilization Phase
- after 48 hours (3-4 days)
- hypervolemia
- diuresis – increased urine output
- Hyponatremia, hypokalemia
- CBC results – hemodilution, decrease hematocrit
Third Stage
- Recovery (5th day onwards)
- Hypocalcemia
- utilized in granulation tissue formation
- Negative Nitrogen balance
- increase CHON intake
Management of Burns
• Stop the burning process
a) immersed affected part in cold water/running water
b) advised client to roll on the ground if clothing is
flaming
c) throw a blanket over to the client to smother the flame
d) neutralized the chemical
• Promoting respiratory function
a) establish airway
b) oxygen therapy
• Promoting fluid, electrolytes, acid base balance
a) Colloids – blood, plasma expanders
b) Electrolytes – Lactated ringers
Burn Injury 1 of 1
NCMB 312 RLE
c) Non-electrolytes – D5Water
• Promoting comfort
a) Morphine SO4 – to relief pain
b) Bed cradle – to relieve pressure from topsheet
• Preventing infection
a) Asepsis
b) Reverse-protective isolation
c) Tetanus-toxoid immunization
d) Sterile NSS to irrigate the area
• Maintaining adequate nutrition
a) Avoid oral fluids – decreased peristalsis
b) Diet – increase CHON, increase CHO, low Fat,
increase vitamins and minerals
• Wound care
- Antimicrobials - Mafenide acetate 10% (Sulfamylon)-
good choice as penetrate in the eschar
• Skin grafting
- Isograft / Syngeneic graft – identical twin
- Homograft / Allograft – another human being
- Autograft – self
- Heterograft / Xenograft – animal (temporary)
- Skin grafting is a surgical procedure that involves
removing skin from one area of the body and moving it,
or transplanting it, to a different area of the body. This
surgery may be done if a part of your body has lost its
protective covering of skin due to burns, injury, or
illness. STSG – Split Thickness Skin Grafting
% of Burns (Rule of Nine)
Head, face, neck = 9%
Anterior trunk = 18%
Posterior trunk = 18%
Upper extremities (each) = 9%
Lower extremities (each) = 18%
Genital = 1%
100%
Parkland Formula
- A calculation used to calculate the total volume of fluids
that a patient is going to need about 24 hours after
receiving a severe burn
- widest and easy to use to immediately initiate replace
fluids and electrolytes losses
- Volume LR = 4mL x BSA % x kg
- Common solution used: Lactated ringers- is an isotonic
solution that will help expand the intravascular
compartment
- 4ml x 63% x 83 kg = 20,916 ml
• 1st 8hrs (half) VLR x .50 = 10,458 to run for first 8
hours with drop factor of 20 = 436 - 437gtts/min
• 2nd 8hrs VLR (one fourth) x 0.25 = 5,229 ml
flow rate: 5229 to run for second 8 hours x drop factor
of 20 = 218 - 219 gtts/min
• 3rd 8hrs VLR (one fourth) x 0.25 = 5,229ml, flow rate:
5229 to run for third 8 hours x drop factor of 20 = 218 –
219 gtts/min
• 20,916 ml for the first 24 hours