PERIOPERATIVE NURSING

❖ Very old or very young requires general

PERIOPERATIVE NURSING anesthesia
→ It is the identification of the physiological, psychological, ▪ Organ Involved:
social and spiritual needs of the client and the ❖ Major surgery - Heart, Stomach, Lungs
formulation of an individualized plan of care before, ▪ Duration of surgery (gaano katagal)
during and after surgery. ▪ Extent of injury (gaano kalala)
• 3 Stages of Operative Nursing: ❖ Multiple or compound fracture of rib cage
o Periop (Ward) ▪ Expected amount of blood loss
o Intraop (OR Suite) ❖ The more blood loss, the lesser oxygen
o Post operative (PACU) goes to the brain → decreased LOC
• Physical and psychological needs ▪ Type of anesthesia
o Anxiety (balisa) - cause: unknown A. Minor
o Fear - cause: known o E.g , Skin grafting (18% of the body)
o Safety B. Major
▪ NPO o E.g., cesarean section, exploratory laparotomy
❖ To prevent aspiration; done before r/t multiple stabbed wounds
and after surgery 5. Urgency
▪ Enema A. Emergency
❖ To prevent defecation during surgery o Done within 24 hours
❖ Prone to infection o E.g., ruptured ectopic pregnancy, Cesarean
❖ OR will become contaminated Section r/t fetal distress
▪ Shaving and skin preparations B. Urgent
▪ Proper history taking o Done within 48 hours
o Post op instructions o E.g. Relief of intestinal obstruction
o Dentition C. Elective
o Scheduled surgery
Classification of Surgery, According to: o E.g., Repeat cesarean section
1. Purpose a. Required - the patient MUST undergo the
A. Curative surgery, but can be delayed
o Ablative - removing the diseased organs ❖ As the patient is delaying the performance
▪ “Ectomy” (e.g., appendectomy, of surgery the patient may experience the
mastectomy) degree of discomfort, pain and disability
▪ “Raphy” or “plasty” - repair ❖ E.g., removal of cataract → visual
o Palliative - manage of the complication and disability, abdominal hernia → affects the
signs and symptoms but do not treat the ability to lift heavy objects
disease process itself b. Cosmetic - to improve the aesthetic or image
▪ Amputation d/t diabetic foot s/t DM of the patient
B. Diagnostic - aids the doctor in diagnosing the ❖ E.g., tummy tuck, liposuction, rhinoplasty,
patient facial contouring
o “Scopy” (e.g., broncho, cystoscopy,
colonoscopy, biopsy-examination of tissue of a Objectives and Purposes of surgery:
living person) - visualization → To cure (e.g., appendectomy)
C. Exploratory - diagnostic and curative in nature; can → To relieve pain (e.g., appendectomy)
be combined → To prolong life
o E.g., Exploratory laparotomy with resection or → To maintain dynamic body equilibrium
anastomosis of the large intestine followed by → To treat and prevent infection (e.g., wound
temporary colostomy debridement)
2. Location → To correct deformities or defects (e.g., cheiloplasty,
A. External ORIF)
o E.g., Removal of cataract, circumcision, → To ensure the ability to earn a living
rhinoplasty
B. Internal SURGICAL TEAM
o E.g., Appendectomy, TAHBSO, Cesarean
Section Sterile Team Members
3. Mode → Performs donning gowning scrubbing
o 2 conditions that is amenable to surgery: → Operating Surgeon
▪ Congenital - in-born • Captain of the ship
▪ Acquired - through injury, trauma, accident or • Consultant doctor
disease process • Graduate of medicine, undergone
❖ E.g., hysterectomy r/t atony, Open residency in surgery or any field of
reduction r/t fracture, Explore lap r/t medicine (specialization)
fracture o CS - those doctors undergone
A. Constructive residency in obstetrics
o Manages congenital defect o Residency training - 2 years; allowance only;
o E.g., Cheiloplasty, rhinoplasty general surgery
B. Reconstructive • Responsible for:
o Manages acquired defect from a disease o Preoperative judgment of the patient
o E.g., vehicular accident - reconstructive (diagnosing the patient)
rhinoplasty o Intraoperative and postoperative management
▪ Open reduction r/t fracture, hysterectomy of the patient
r/t atony, explor lap r/t gunshot wound, o Can also witness of the counting
skin grafting r/t burns → Assistants of the Surgeon
4. Degree of Risk • Resident doctor
o Factors to consider to identify whether the surgery • Physician assistant (co resident) or non-physician
is minor or major assistant (medical student: intern or clerk)
▪ Age:
 • In PH, assigned in the OR/by means of experience o Characteristics of the protective covering: heat
(assigning body - PRC → examination → license) and chemical resistant
o E.g., ORNAP with PRC → certification → o Boiling does not destroy the spore; at least 130
standards → examination C or 270 F is needed
▪ DOH: maternal (fabella), critical (heart o Autoclave is used - heat and pressure could
center), psychiatric (national center of instantly kill the microorganism
mental health) → certification
• In other countries, by means of certification DISINFECTION
(training → exam → card) → Kills microorganism except spore
o E.g., CNOR - certified nurse in the operating → Physical
room → testing → online exam → passed • Boiling
(e.g., Richard Cruz, MSN, RN, CNOR/RNFA) o Average of 10-15 mins
▪ This certification is renewable o Start time when it started to boil
▪ RNFA (registered nurse first assistant of o Object is directly submerged in the water
the surgeon) - non-physician assistant; • Steaming
needs CNOR; undergo training, practical o Moist heat only; indirect
exam, and online exam o Average of 10-15 mins
❖ Holds retractor, do suctioning • Sunlight
• Responsible for: o Ultraviolet light came from the sunlight
o Retracting the operative site o Good for weak microorganism
o Assist during suturing → Chemical
o Suctioning in the operative site • Alcohol
o Labeling the specimen of the patient o To disinfect instrument; skin of the patient
(dimensions) • Chlorine
o Witness of the counting o To disinfect water, linens
o Clamps the bleeding vessel • Iodine
→ Scrub Nurse o 7.5% - yellowish brown colored solution
• Surgical nurse ▪ Use as cleanser, for surgical scrubbing,
• Board passer/licensed nurse first used at skin prep
• Responsible for: o 10% - dark brown; antiseptic
o Counting ▪ Used for lumbar prep, second used at skin
o Focusing on the patient prep
• Phenol
Unsterile Team Members o Used to disinfect
→ Wears basic OR attire; does not perform OR donning, ▪ Appendectomy → ligate and ligate → cut
gowning, scrubbing → cotton applicator (includes alcohol and
→ Anesthesiologist phenol on opposite ends) is used on the
• Maintain hemodynamics of the patient exposed lumen → burning effect →
• Result of vital signs, I&O, fluid and electrolyte destroy microorganism and promote
balance coagulation → to stop burning effect apply
o Rigid muscles during retraction indicates alcohol
hypoxia
→ Circulating Nurse STERILIZATION
• Responsible for: → Physical
o Documenting the count • Autoclave
o Measuring the UO o Steamed under pressure
o Communication link in and outside the OR o 30 mins-1 hr; fully loaded: 45 mins-1.5 hrs
o Witness of the count (1 CN + any doctor) o Uses steri tape - indicator of
o Counts the instrument on the floor sterility
o Monitors the sterile technique during the ▪ Flesh colored / Light brown
procedure ▪ Not autoclave and
o Main CI of the students exposed to heat - white
→ Adjunct personnel: Pediatrician (pasilip silip lang sa OR ▪ Heated - black
lol) o Instruments that cannot be
→ Biomedical Technician: autoclaved:
• Not employee of the hospital but guides the ▪ Sharps, scissors, needles, instruments
surgeon to the equipment with lens
o Use of new prosthetic equipment • Radiation
o UV light
Concept of Asepsis • Gas ETO ethylene oxide
→ Absence of disease producing microorganisms o Sterilizes instruments with lens
→ Medical Asepsis (endoscope)
• Practices or processes that decrease the number → Chemical
and limit the spread of microorganisms • Soaking/Immersion - used for instrument that
• AKA Clean technique cannot be autoclaved
• Use of disinfection - cleaning of all microorganisms o Uses cidex
except spores o Trays: 3
→ Surgical Asepsis ▪ Newly soaked
• Practices or processes that render an object or ▪ Partially soaked
area totally free from microorganism ▪ Fully soaked
• AKA Sterile technique ▪ The instruments should be placed into the
• Use of sterilization - cleaning of all microorganisms next tray to prevent recontamination
including spores
• Spore - microorganism with protective covering
(encapsulated); is in vegetative stage
SAMPLE STERILIZATION & LEVEL OF DISINFECTION FOR GLUTARALDEHYDE
Intermediate
Sterilizer High Level Low Level
Level
Solution (must be soaked Disinfection Disinfection Notes
Disinfection
for/sporicidal)

Usage: 14-30 days

Cidex Activated
Regular use (14):
alkaline 2.4% 45 mins - <10
10 hrs 15 mins-45 mins 5-15 mins once a day, every
dialdehyde (commonly hours
other day
used)
Full use (30): more
frequent

Cidex OPA, 0.55%

orthophthaldehyde **Not sporicidal 12 mins Usage: 14 days
(for rapid disinfection)

Cidex OPA (5.75%)

Used in automated
orthophthaldehyde
endoscopic high-
concentrate 32 hrs 5 mins
level disinfector
(super rapid rapid
as gas sterilizer
disinfection)

→ Not all surgical instruments are 100% sterile • Most expensive

→ Goal: at least a high level of disinfection must be
achieved if sterilization can’t take place 2 WAYS OF PACKING MATERIALS
→ Low level disinfection: kills some fungi and viruses → Method of packing depends on what to pack
→ Intermediate level disinfection: kills fungi, virus, some → Flap method
bacteria • Used for individually packed materials
→ High level disinfection: kills all except spores • Closing: Kidney basin placing downward → square
→ Sterilizer: kills all including spores (for diamond) → place basin at the center → fold
→ Orthophthaldehyde is more potent than alkaline the flap nearest to you and make a flap → fold sides
and make a flap each side → tightly closed
EARLE SPAULDING’S CLASSIFICATION OF PATIENT • Opening: unroll → use the flaps when opening →
CARE ITEMS once opened → offer the object to the scrub nurse
or drop into the sterile field
Sterilization or
Classification Use → Fan-fold method
Disinfection?
• Used for trays with contents
Penetrate intact skin, • Closing: Tray with contents placing upward → One
STERILIZED
tissue, and mucous fold horizontally facing on the packer → one fold
(needles,
CRITICAL membrane. facing to the other side → fold other side to the
scissors,
Enters vascular areas middle
catheters)
of the body. • Opening: use of transfer forceps → pull all sides
→ *Know the head of the instrument
STERILIZED (if
sterile
Used on non-intact instruments are PRINCIPLES OF STERILE TECHNIQUE
SEMI- skin & mucous not available, 1. Only sterile items are used within the sterile field
CRITICAL membranes (may high level • Sterile → Sterile
hiwa/sugat na) disinfected • Unsterile → Unsterile
instruments are 2. Sterile personnel are gowned and gloved.
used) • Gowns are considered sterile from shoulder to
waist in front only
LOW LEVEL,
Used on intact skin
INTERMEDIATE
o Anything that is below the waist is unsterile
and mucous • Sleeves are considered sterile from cuff to 2 inches
LEVEL
NON- membranes; for above elbow
(hospital linens,
CRITICAL external use only,
bedpan/urinal, • Axillary and back are considered unsterile
doesn’t penetrate
intact skin
stainless kidney • Folding the gown: hide right side (touches the
basin, forcep) sterile field); wrong side touch the scrub suit
o Hold two arm holes → fold lengthwise → fold
3 PACKAGING MATERIALS from neckline → roll → small fold bottoms
→ Muslin ▪ Top hides; bottom shows
• Most common; also known as linen • Wearing: hold the bottom → dry hands → face
• Economical/reusable; practical neckline place into the dresser (arm hole other
• Absorbent side) → kunin arm hole → slide hands and arms →
• Dust and microorganism can penetrate because of right side faces sterile field → open gloving / close
pores gloving → straps will be tied by the circulating
o 3 layers of linens should be used nurse
▪ To delay entrance of dust and • After surgery → remove the gown and then the
microorganism gloves
→ Paper (Wax) to prevent moisture • Removing of gloves: glove to glove, skin to skin
• Can be used as a sterile field • When reporting to the OR: wear cap then mask
→ Plastic o After the surgery, the cap is removed when
already outside the OR suite
• Not use in the sterile field
3. Tables are sterile only at table level.
• Pouched type
• Anything that falls under the table is unsterile.
• Best barrier against microorganisms
• Non-absorbent transparent material
 • Transfer forcep should not be used to adjust the BLADES USED DURING SURGERY:
linen placed at the sterile field; put another drape → Surgical blade
instead → Reusable blade holder
• Table can only be adjusted upward; sterility also • #3 - line of 1 (10, 11, 12, 15)
moves upward (the height of the table becomes the • #4 - line of 2 (20, 21, 22, 25)
basis for sterility)
• When you are the scrub nurse, drape the table near SURGICAL INSTRUMENTS:
you first (pwede na dumikit → drape the other 1. Sharps
side/away from you; use 2 forceps as much as → Knife
possible • Is both used for tough and delicate tissues
o If done vice/versa, the unsterile part can touch • 1st Knife - used for skin
your gown (sterile) hmp! o Placed on a kidney basin but is isolated once
• Sterile person: pass each other back-to-back (you used on the skin (contaminated)
can only face one sterile field) o Physician will be the one to get the knife
• Sterile field is made at the time of operation o Will be used again if there is a need for
o To avoid contamination extended incision
o If operation is delayed for 1 hour, cover the • 2nd knife - used for subcutaneous onwards;
sterile field with sterile linen pambutas
o If the surgery is moved: → Scissors (dissecting; tissues and layers)
▪ Why is the surgery moved? - possible • Mayo - used for tough - fascia
emergency CS d/t fetal distress, just cover o Shorter; because fascia is more superficial
the sterile table with go signal by the • Metz - used for delicate - peritoneum
surgeon o Longer and slender because peritoneum is
▪ For more than 1 hour, change the sterile more deeper
set; it is not patient assigned to the case → Needles
who’ll pay the charges, but the patient who • Straight
had an emergency surgery • Curve
• When the linen gets soaked with sterile water or any o Cutting
fluids, it is considered unsterile! ▪ half of the body is
o Ask the circulating nurse to get the basin, as round and half is
the scrub nurse, get the instrument tray (big in triangular and paper
size) to cover the damp linen and avoid moving point
the tray everywhere around the sterile field to ▪ Has sharp side
avoid unterility of the other instruments ▪ Used for skin, fascia,
o OR gown (if there is extra) can also be used to tendon, ligaments
cover the unsterile part of the linen since it is o Round
thick ▪ Body is round and tip
4. Sterile personnel touch only sterile items or areas; is paper point
Unsterile personnel touch only underlie items or areas. ▪ Used for muscle, peritoneum,
• Unsterile personnel can indirectly pass items to subcutaneous, intestines
unsterile person using forceps → Types of Suture Preparation:
5. Unsterile personnel avoid reaching over the sterile field • Free tie - just a strand of suture material
and sterile personnel avoid leaning over an unsterile o If the physician will ligate a superficial blood
area. vessel
6. The edges of anything that encloses sterile contents are • Stick Tie
considered unsterile. o Needle holder is needed
7. The sterile field is created as close as possible to the • Suture Ligature
time of use. o EYED Needle, needle holder, suture
8. Sterile areas are continuously kept in view. o Needle is reusable
• The scrub nurse and the circulating nurse inspects o Place the eye of the needle to the right side of
the environment the needle holder for a right-handed physician
9. Sterile personnel keep well within the sterile area. and vice versa
• (X) leaning on the wall; side of the arms may be • Atraumatic Suture
contaminated o EYELESS Needle, needle holder, suture
10. Sterile personnel keep contact with sterile areas to a o Needle is disposable
minimum. o Single arm - one needle per suture
11. Destruction of the integrity of microbial barriers results o Double arm attachment - two needle per suture
in contamination.

FIVE ABDOMINAL LAYERS

→ Skin - tough
→ Subcutaneous - delicate
→ Fascia -tough
• dissected and
Additional Notes
sutured together Counting of needles:
with the fascia → 10 eyed
• major abdominal → 2 eyed
support layer → 2 single
• If dehiscence → 3 double (= 3x2 needles)
happen, possibility → Total needles: 20 needles
of evisceration - protrusion of the internal organ
• Other organs would be affected if the fascia would 4 counts in Surgery:
1. Before the start of surgery
deteriorate
2. Before closing peritoneum
→ Muscle - delicate 3. Before closing fascia
→ Peritoneum -delicate 4. Before closing skin
 Note: 4 counts become 5 counts during cesarean operation
(double cavity operation/surgery): After 1st count, 2nd count
will be before closing the uterus then continue to peritoneum
onwards
Pairing of the Instruments in the Operating Room
Nursing responsibility:
If there is a discrepancy in the count Sharp Graspers Needle
1. Notify the surgeon
2. Doctor will order for recount Allis
Knife
3. If missing - the physician will order for search for the Tough Tissue Cutting
Mayo
missing needle forcep
4. If needle still missing after the search, physician will order
portable X- ray Babcock
• If the needle is found inside the patient’s body → the Knife Thumb
Delicate Round
physician will search for possible lacerations in Metz forcep
internal organs kelly
5. Close the incision
→ SHARPS + GRASPERS: OPENING / DISSECTING
6. Incident Report by scrub nurse after surgery
• If the needle is found → IR is not needed → GRASPERS + NEEDLE: CLOSING

2. Retractors
→ Graspers → Exposing instruments
• Holding instruments → Self-retaining retractor - has screws and lock; screws
• Thumb forcep - tiyani na walang ngipin; are counted
o for delicate tissues • Balfour
o Used for peritoneum

• Babcock
o Used for tubular organs: ureter, vas deferens,
fallopian tube, appendix • Weitlaner
o For delicate

• Allis
o Used for fascia and skin, tendons and
ligaments → Non-self-retaining - no screws; manual retraction is
o For tough needed
• Army-Navy

• Tissue forces
o For tough

• Richardson - single bladed / double bladed

→ Clamps
• In the absence of a grasper, clamp is used
• Occluding instruments; stops bleeding
• AKA hemostat
• Mosquito - small; fully serrated
• Deaver

• Crile - medium; 50% serrated; from the tip to the

middle • Bladder Retractor

• Kelly - large; fully serrated

• Malleable – ribbon

• Ochsner - kelly na may ngipin

SURGICAL POSITIONS AND INCISIONS

• Mixter - angled kelly; used for deep part and hard → Surgeon - determine the type of incision to be used
to reach organs → Anesthesiologist - determines the position of the patient
4 Quadrants of the Body o Prone to uterine rupture d/t near uterine
→ RUQ - appendix contraction
→ LUQ - spleen o For LGA babies
→ RLQ - cecum, appendix • Low vertical CS
o Poor healing
o Cuts against muscle fibers
• Transverse CS
o Muscle fibers particularly the myometrium are
horizontal (along) → the incision goes along
with the direction hence they can undergo
VBAC
o It has better wound healing
• Up to three surgeries only → adhesions
9 Regions of the Body (nagkakadikit dikit na yung layers)

→ Hysterectomy

Longitudinal Midline Incision

→ Circumvent into the umbilicus (nakaiwas)
→ Longest incision in the abdomen
→ Exploratory laparotomy

→ Right Lumbar - Body of the right kidney

Paramedian Incisions
→ Right Hypochondriac - Tip of the right kidney
→ Right Lower Paramedian - for ruptured appendix
→ Right hypogastric - Head of the pancreas
→ Allows peritoneal lavage
→ Epigastric - Body of the pancreas
→ Umbilical - Majority of the omentum and mesentery
→ Hypogastric - Urinary bladder, uterus

SURGICAL INCISIONS
Upper Midline Incision
→ Gastrectomy and Exploratory laparotomy

Mid abdominal Transverse Incision

→ For better exposure of the organ
→ To follow the contour of the organ (either vertical or
horizontal)

Lower Midline Incision

Thoracolumbar Incision
→ Slanted is more often used because it can expose the
kidneys more
→ Poor wound healing

→ CS; VBAC (Vaginal Birth After CS)

• Classic CS
o Poor healing
o Cuts against muscle fibers
Oblique Incisions Lateral Position
→ For inguinal hernia → Indication: Endoscopy
→ Paddings are placed
between the joints

Lithotomy Position
→ Is not used for NSD anymore
→ For men, towel and retractors are used
(to hold the scrotum)
→ Indications:
• Hemorrhoidectomy
• Perineal/vaginal surgeries
Mc Burney’s Incision • Cerclage
→ Appendectomy: Intact
Kraske or Jackknife Position
→ Indications:
• Hemorrhoidectomy

Pfannenstiel Incision
→ “Bikini” incision Other Positions
→ Scar is less noticeable → Trendelenburg position (T position)
• Not used often d/t diaphragm compression

→ Reverse Trendelenburg Position

• Head is higher
• Indicated for face, nose, and
neck surgery
SURGICAL POSITIONS • To minimize bleeding and
→ Nurses are allowed to break the table/positioning the prevent aspiration
OR table → Kidney position
• Table can be tilted
• Height can be adjusted

Supine Position
→ Foot board is used to prevent foot drop
• Ligament will hurt if foot drop happens
→ Hip and arm strap
→ Donut - where the occipital is placed to prevent DUTIES AND RESPONSIBILITIES OF OR NURSES AND
movement CIRCULATING NURSE
→ Indication:
• CS CIRCULATING NURSE
• Mastectomy 1. Receive patient from Surgical ward nurse (transports
• Cataract removal and endorse patient to the OR nurse)
• Open reduction • Endorsement: check Pre-operative Checklist,
which includes:
o Right patient, schedule
Prone Position o Informed Consent
→ The patient lies on their abdomen
→ One of the hardest position for the patient to assume d/t Consent - signifies patient’s willingness to undergo a
limited chest expansion procedure
• Shoulder roll - rolled lengthwise placed below for → General Consent
chest expansion • Secured upon admission
→ Indication: • Covers ALL routine procedures, ALL hospital staff
• Surgeries of the • E.g., blood extraction by medtech
back → Informed Consent
• Laminectomy • Purpose: “Protects the patient from any unwanted
procedure to be done on him and protects the
Semi fowler’s Position hospital from any claim of the pt that an unwanted
→ Indication: procedure was done on him”.
• Abdominal paracentesis • It protects both parties (hospital, staff and patient)
• Bronchoscopy o E.g., a patient reported to the OB clinic
• Thoracostomy regarding irregular menstruation, 6 months
• Closed tube thoracostomy and lasts for 8 days. The doctor ordered
diagnostic and laboratory exams, after which,
the doctor discussed the results of having
ovarian cancer. The doctor explains to
 undergo surgery and chemotherapy (best for o Light evening meal
the surgeon), but still can have a second o NPO post-midnight
opinion. The patient was pretty confident about o Psychological & spiritual support
the doctor, allowing the doctor to do the o Administer Laxative drug if ordered
treatment upon her. ▪ If no laxative during the night, there’ll be
▪ Gives/explains the consent - surgeon enema during the morning
▪ Signs the consent - qualified patient o Removal of nail polish
▪ Witnesses the consent - nurse ▪ To check nail beds for circulation and
• If the patient was admitted a day before the oxygen saturation
surgery, obtain and secure the consent the day • The morning of the surgery
before surgery o Ensure NPO
• The validity of the informed consent varies per ▪ If the patient had meals/anything by
hospital (24 or 48 hours) mouth, the surgery may be delayed within
• Considerations: the day
o Legal Age o Oral care
o Timing o Enema if ordered
▪ Before pre op medications are given as it ▪ 2-3 enema, until return flow is clear
can affect the LOC o Shaving
o Who is qualified to sign? ▪ Use clippers
▪ Minor: parents o Review post op exercises
▪ Legal age, illiterate: patient ▪ Review DBE, coughing technique,
▪ Legal age, insane: parents, guardian splinting, etc.
▪ Insane, confined for mental institution: o Pre-op medication
qualified representative of the institution o Monitoring
▪ Emergency, no family member present: ▪ Vital signs and I&O
surgeon o Removal of dentures - check pre-op checklist
▪ Both parents are minor, married, 9 months o Endorsement to OR
old baby 2. Establish rapport with client
❖ Can be classified as emancipated • Such as talking to the patient calmly, sharing
minors d/t marriage = parents can give information
consent 3. Place patient on the OR table & never leave patient
❖ In PH, the parent, minor of the parent alone
signs • Place the arm board and hip strap
❖ Practice: mother signs of the minor • The nurse should use peripheral vision and assess
patient the patient while doing their own thing
• Coverage: • To prevent accidental falling
o Preoperative Medications: 4. Position for anesthesia ( supine or quasi fetal position )
▪ Given AFTER consent is secured • Spinal anesthesia - quasi fetal position, shrimp
▪ Prepares client for anesthesia position or c position
▪ Potentiates effect of anesthesia 5. Perform Lumbar prep for Spinal/Epidural
▪ Allays patient’s fear and anxiety • Lumbar prep use 10% betadine
1. Narcotic Analgesic - Morphine (most
potent), Nubain, Demerol (ideal: does Induction of Anesthesia
not cause post op constipation, unlike 6. Supine position
the 2 drugs) • Assess the patient by asking them to move their
2. Sedative - Phenergan legs up and down and pricking the arms until they
3. Anticholinergic - Atropine SO4 cannot feel their extremities anymore
(reduces secretion; avoids aspiration)
➢ Given: 30-60 mins BEFORE
surgery
➢ Common SE: Dry mouth
→ Client preparation BEFORE the surgery
• The day & night before the surgery
o Pre-operative visit: To decreases pt’s fear &
7. Perineal Prep with proper positioning
anxiety
• Skin prep → abdominal incision
▪ Who should visit the patient? - Surgeon,
• For CS - Incision site: Umbilical area
Anesthesiologist and OR Nurse (at least 1)
o Preparation: Below the nipple line up to the
o Client education on Post-op activities
knee area
▪ Done 2-3 days before surgery (DBE,
splinting, coughing technique, turning,
Catheterization
dangling the legs)
8. Surgical position
o Ensure all lab & dx exam results are in and
9. Abdominal Skin prep
reported to MD
10. Surgical positioning
▪ CBC: To know for possible blood
11. Draping, contains
transfusion
• Mayo cover
o Check CP clearance
• Mayo towel
▪ Especially on the elder people
▪ Clearances: • 4 OR towels - outlines the surgical site; secured
with towel clips
❖ ECG - cardiac
❖ Pulmonary Function Test - pulmo • Foot drape
❖ ABG - pulmo; cardiac • Laparotomy sheet - has fenestration for the uterus
❖ Chest X-ray - pulmo • After draping and before cutting, time out is being
o Check Blood Products done
o Monitor VS, I&O o Check for spontaneous resuscitation
o Secure Consent o Check color of nail beds, lips (possible of
o Bathing PRN (to reduce number of anesthesia overdose → medullary stage →
microorganisms) respiratory arrest)
 o If cardiopulmonary arrest happens during the
Elbow 6 None None
medullary phase = let’s volt out!
▪ The scrub and circulating nurse will move
the mayo and back table away from the 6. Serve gowns and gloves to surgeons
patient 7. Instrument count
❖ The scrub nurse will hold and pull the 8. Draping
top/sterile part of the tables while the 9. Cutting time
circulating will hold and pull the bottom
part of the tables ANESTHESIA
▪ Scrub - remain sterile → Loss of sensibility to pain
▪ Assistant - compression → Stages:
▪ Surgeon - team leader 1. Induction - preparation of the client to
▪ CN 1- ambu bag administration of anesthetic agent (patient is in the
▪ CN 2 - medication (if extra CN is available) OR)
▪ If patient revived → change gowns of the 2. Excitement (there is struggle; magalaw)
team, change drape → skin prep 3. Surgical Anesthesia
❖ Most important: Scrub nurse is sterile, o The best time for the patient to undergo
table is sterile surgery
12. Cutting time o Do timeout before medullary stage
• Circulating nurse is responsible for: 4. Medullary (overdose)
o Charting (documenting the surgical o Time out is done here (to assess complication
procedure) and charging (list items used for arising from anesthesia - respiratory arrest)
the patient) o Nail beds, lips are checked
o Assisting any member of the team o Spontaneous breathing is also observed by the
o Strictly monitors sterile technique anesthesiologist
→ Types:
• General Anesthesia
Additional Notes
→ Pre op: Admission to admission OR
o Produces sensory, motor, reflex and mental
→ Intraop: OR to PACU block (cannot remember anything)
→ Post op: PACU until the wound healing is complete o Inhalation gas/liquid nitrous oxide; halothane
• Obsolete: from PACU until discharge ▪ Inhalation Agents:
o The patient remains a post-surgical patient until A. Non-Halogenated gas
the wound is completely healed 1. Nitrous oxide - BLUE - Initial
restlessness; mixed with oxygen
SCRUB NURSE 2. Cyclopropane - Orange- for short
procedure
1. Receive patient from Surgical ward nurse
B. Halogenated Fluid
• They can receive the patient if the circulating nurse
1. Halothane - RED - Hypotension;
is preoccupied
vaporized first then mixed with
2. Prepare & organize the OR unit based on the case
oxygen
3. Open sterile packs & add sterile supplies & instruments
2. Enflurane - Yellow - muscle
4. Perform surgical scrubbing, gowning and gloving
relaxation
5. Organize sterile fields
3. Sevoflurane - sweet taste - pedia
o IV - ketamine/ketalar (causes hallucination and
SURGICAL SCRUBBING (SURGICAL CONSCIENCE)
euphoria); thiopental Na; Na pentothal
▪ Intravenous Barbiturates:
TIME METHOD
❖ Thiopental
TIME 2ND ▪ Neuroleptic Agents
1ST ROUND 3RD ROUND
METHOD ROUND ❖ Fentanyl - decreases motor function
▪ Dissociative agents
Hand 1 min 1 min ½ min
❖ Ketamine - hallucinations
Arm 1 min 1 min None

Elbow ½ min None None STAGES OF GENERAL ANESTHESIA

2.5 x 2 = 5 2x2=4 ½x2=1 ● Beginning anesthesia

mins mins min ● Drowsy, dizzy
STAGE I (INDUCTION)
● Depressed pain
→ Total = 10 minutes sensation
→ 1st-3rd round is done ideally during the first hand scrub
of the day ● Excitement
• After 1st surgery, you can utilize only the 1st round STAGE II ● Irregular breathing
(5 mins) of scrubbing for 2nd surgery (EXCITEMENT/DELIRIUM) ● Involuntary motor
→ If there is a second scrub, there is no need to brush. movements
This is to prevent abrasions. Hand washing with
betadine or sterillium will suffice ● Appropriate for
surgery
STAGE III (SURGICAL) ● Muscle relaxation,
BRUSH-STROKE METHOD constricted pupils,
BRUSH- ● Absent pupil reflex
2ND
STROKE 1ST ROUND 3RD ROUND
ROUND ● Medullary depression
METHOD STAGE IV
● Near death
Finger tips 10/3 5/3 3

Hand 10 5 3
• Regional Anesthesia
o Spinal - sub arachnoid space (where CSF is)
Arm 6 3 None → alters pressure
▪ Medullary stage - overdose
 ▪ L3-L4 - recommended ▪ Absorbed at the rate of 25% per year
▪ L1-L2 - too high; might causes paralysis, ❖ Minimum: 4 years
respiratory depression
▪ Post-op position: flat on bed without pillow POSTOPERATIVE PHASE
for 6-8 hours
❖ To prevent spinal headache IMMEDIATE POST-OP CARE/ RR
o Epidural - epidural space 1. Assure ABC
▪ Faster effect; continuous anesthesia • Provide O2 therapy with client on side/lateral
o Nerve Blocks - plexus position if applicable
o Local - infiltration, application, spray o To promote drainage of secretions
▪ Infiltration: injected surrounding the • Maintain artificial airway until gag reflex returns
incision o Oral airway is placed
▪ Application: EMLA (eutectic mixture of • Suction secretions PRN & encourage coughing and
local anesthetic) - used for removal of deep breathing
warts then cautery will be done • Check VS q 15 min (for 1 hour) until stable, then 30
▪ Spray: to prevent stimulation of gag reflex min (for 1 hour) → 1 hour → 2 hours
(Xylocaine spray) • Check skin color, temp, drains, dressings
▪ Produces analgesia without LOC o Sutures: Should move on the non-operative
(LIDOCAINE & PROCAINE) side; to prevent pressure on the operative side
▪ Types of Local Anesthesia: 2. Note level of consciousness: reorient client
1. TOPICAL: applied over surgical site 3. Discharge from RR when awake & responsive with easy
(EMLA) breathing & acceptable BP & circulation.
2. FIELD/NERVE BLOCK: injected into • Fully awake and conscious, responsive
SQ or perineural space near or around
desired anesthesia site. CONTINUING POST-OP CARE
3. SPINAL: into subarachnoid space 1. Promote optimal respiration: coughing, deep breathing,
(inside arachnoid) splinting incision, early ambulation, turning in bed.
4. EPIDURAL: into epidural space • Splinting: use pillow
(outside arachnoid), used in OB o If no pillow, interlock the fingers to support
operative side
SUTURES: • Coughing: soft and 3 coughs only
→ It closes the wound 2. Promote optimal circulation: early ambulation, leg
→ Absorbable: exercises
• Non-synthetic - from natural source • Ambulation: after 24 hours
o Cut gut • Binder used in CE
▪ From intestine of the sheep 3. Promote optimum nutrition, F&E balance, monitor IV,
▪ Made up of protein which attracts water I&O, UO, drains, dressings, return of peristalsis
▪ Do not soak in sterile water as it will lose (flatus, bowel movement)
tensile strength (aalsa) • Promote nutrition by diet of the patient
▪ Lubrication can be done just before • Presence of bowel sounds (borborygmi) - indicates
serving them to the doctor peristalsis
o Chromic o Clear liquid diet → General liquid → Soft diet
▪ Brown → DAT (diet as tolerated)/Therapeutic Diet
▪ Widely used: all layers, internal organs, 4. Pain control: analgesics & comfort measure
except subcutaneous • Biogesic
▪ 90 days to be absorbed • PCA - Patient-Controlled Analgesia
o Plain 5. Wound care
▪ Light yellow
▪ Used for subcutaneous Hemostasis
▪ 70 days to be absorbed → Used during surgery to minimize blood loss
• Synthetic - from synthetic source → Nurses participate in hemostasis by offering different
o Dexon methods of hemostasis
▪ Green • Remind the surgeons or assistants properly to use
▪ Support 90 days hemostasis
▪ Not soaked → 3 Types of Hemostasis
o Vicryl • Mechanical
▪ Violet o Pressure - manual, digital; dressing, clamps,
▪ Support: 110-120 days gel foam (absorbs fluid → aalsa → pressure;
▪ Not soaked absorbable, made of protein), drain penrose
o PDS • Chemical
→ Non-Absorbable o Coagulant drugs: vit k, tranexamic acid
• Non-synthetic - derived from natural source (hemostan), oxytocin
o Silk • Thermal
▪ Most common o Electrocautery (uses electric current, heat)
▪ Came from saliva of silk worm ▪ For cutting and coagulation
▪ Black in color ▪ Nursing Responsibility: Make sure the
▪ True color is Navy Blue ground is under the patient’s body (to
▪ Loses tensile strength when wet prevent electrocution)
▪ Used over the skin; can stay on the skin for ▪ Remove eschar to prevent infection
seven days o Cryosurgery - liquid nitrogen
o Cotton ▪ Freezes specific organ, new growth, skin
▪ White in color tag then removed
▪ True color is light pink
▪ Gains tensile strength when wet
▪ Can be used internally
• Synthetic
o Nylon