PRE- OPERATIVE PHASE

Objectives:
After 8 hours of interactive discussion, the
students will be able to:
1. recall perioperative nursing;
2. discuss the different responsibilities of the
circulating & the scrub nurse;
3. name & differentiate the different
instruments used in the OR.
 PRE-OPERATIVE PHASE
• Begins when the client decides to have
surgery and ends when the client is
transferred to the operating bed.

Nursing activity:
• Assessment of client
• Identification of potential or actual health problems.
• Planning specific care based on the individual’s need
• Pre-op teaching including client and support persons
INTRA-OPERATIVE PHASE
 INTRAOPERATIVE PHASE
• Begins when the client is transferred to the
operating room and ends when the client is
admitted to the post anesthesia area or
recovery room.
 Activities during Intraoperative phase

• To provide the client with comprehensive,

safe, & effective care during the surgical
procedure.
> Assessing the client’s physiologic & psychologic status
> Reviewing the results of the diagnostic tests & laboratory
studies
> Positioning the client for surgery
> Performing the surgical skin prep
> Assisting in preparing the sterile field
> Opening & dispensing sterile supplies during surgery
Activities during Intraoperative phase

> Monitoring and maintaining a safe, aseptic environment.

> Managing catheters, tubes, drains, & specimens.
> Performing sponge, sharps, and instrument counts
> Administering medications & solutions to the sterile field.
> Documenting the nursing care provided & the client’s
response to the nursing interventions
 Abdominal Surgical Incisions
TYPES OF INCISION:
> Two main factors governing incisions are
direction & location

Assignment or seatwork:
 SURGICAL SKIN PREPARATION
• This involves cleaning the surgical site,
removing hair or shaving operative site if
necessary, & applying an anti- bacterial agent.
 PURPOSE of skin prep.
• To reduce the risk of post-operative wound
infection. This is done by:
> Removing soil & transient microbes from the skin.
> reducing the resident microbial count to sub-pathogenic amounts
in a short time & with the least amount of tissue irritation.
> Inhibiting rapid rebound growth of microbes.
• Nurse inspects the prospective surgical area for
growths, mole, rashes, pustules, irritations,
abrasions, bruises or any broken or ischemic areas:
this should be recorded & reported to the surgeon.
• Nurse determines if client is allergic to any
solutions used in skin preparation.
 ANTISEPTICS
1. Iodine & Iodophors
> 1.5 or 2% in water or in 70% alcohol is an excellent
antiseptic.
> Iodophors (Betadine Surgical scrub) are iodine complexes
combined with detergents.
> Povidone-iodine has a surfactant, wetting & dispersive agent.
> Iodophor in 70% alcohol- an excellent cleansing agent that
removes debris from the skin surfaces while slowly releasing
iodine.
> Broad- spectrum anti- microbial agent & have some
sporicidal activity. Non-toxic & virtually non-irritating to skin or
mucous membrane.
 Antiseptics
2. Alcohols
> Isopropyl or Ethyl alcohols are broad spectrum agents that
denature proteins in cells. Alcohol coagulates protein, it is not
to be applied to mucous membranes or used in an open
wound.
> Scrub the skin starting at the site of incision with a circular
motion in ever-widening circles to the periphery. Use enough
pressure & friction to remove dirt & microorganisms from the
skin and pores.
 SKIN PREPARATIONS
• ABDOMINAL PREPARATION
> Area includes breast line to upper third of
thighs, from table line with patient in supine
position. Shaded area shows anatomic area to
be prepared. Arrows w/in area show direction
of motion on operating table.
 Skin Prep
2. RECTOPERINEAL & VAGINAL PREPARATION
> Area includes pubis, vulva, labia, anus, and
adjacent area, including inner aspects of
upper third of thighs.
 Skin prep
3. LATERAL THORACOABDOMINAL PREPARATION
> Area includes axilla, chest, & abdomen from the neck to
crest of ilium. Area extends from the midline, anteriorly &
posteriorly. Patient is in lateral position on operating table.
 Skin Prep
4. CHEST & BREAST PREPARATION
> Area includes shoulder, upper arm down to elbow, axilla, &
chest wall to table line & beyond sternum to opposite
shoulder. If patient is in lateral position, back is also prepped.
 Skin Prep
5. Hip Preparation
> Area includes abdomen on affected side, thigh to knee,
buttock to table line, groin, & pubis
 Skin Prep.
6. Knee & Lower Leg preparation
> Area includes entire circumference of affected leg & extends
from foot to upper part of thigh.
 Commonly Used Positions
1. Dorsal position
- patient lies on back in a horizontal recumbent position
with arms extended at the sides & held in place by draw
sheet
 Commonly used positions
2. Dorsal Lithotomy position
> legs are flexed on the abdomen and held in place by
stirrups.
 Commonly used positions
3. Trendelenburg position
- table is tilted so the pelvis is higher than the head.
 Commonly used positions
4. Jack knife or modified knee chest position
- Patient lies on his abdomen with the hip joint over the break
of the table
 Commonly used positions
5. Lateral/side-lying/ sim’s
- body is turned to the side
 ANESTHESIA
TYPES OF ANESTHESIA:
1. General anesthesia
- a reversible state of consciousness produced by anesthetic
agents in w/c motor, mental, sensory, & reflex functions are
lost.
- Basic elements include: loss of consciouness, analgesia
(insensibility to pain), hypnosis (artificial sleep) & relaxation
(rendering a part of the body less tense)
- Unconsciousness is produced when blood circulating to the
brain contains an adequate amount of anesthetic agent.
- Results in an immobile, quiet client who does not racall the
surgical procedure.
 ANESTHESIA
ADVANTAGES of General anesthesia:
1. Client is unconscious, so respiration & cardiac
function is readily regulated.
2. Anesthesia can be adjusted to the length of
the operation & the client’s age & physical
status.
3. Depresses the respiratory & circulatory
systems.
 Anesthesia
METHODS OF ADMINISTERING General
anesthesia:
1. Inhalation
- The most common controllable method of administration
because uptake & elimination of anesthetic agents are
accomplished mainly by pulmonary ventilation
- The anesthetic vapor of a volatile liquid or anesthetic gas is
inhaled & carried to the bloodstream by passing across the
alveolar membrane into the general circulation & onto the
tissue.
- Ventilation & pulmonary circulation are the 2 critical
factors involved in the process
 Anesthesia
1.1 Halothane (Fluothane)
- Halogenated volatile compound
- Potent, non-irritating, pleasant odor, cardiovascular &
respiratory depressant.
- incomplete muscle relaxation
- Useful for patients with bronchial asthma, because it induces
bronchodilation.
- Used in all types of surgical procedures except routine
obstetrics where uterine relaxation is not desired
Disadvantages:
- Potentially toxic to the liver
- Progressively depressant to respiration
- Cardiovascular depressant that can cause hypotension &
bradycardia or cardiac arrest
 Anesthesia
1.2 Enflurane (Ethane)

1.3 Methoxyflurane (Penthrane)

1.4 Nitrous oxide (N2O)

 Anesthesia
2. INTRAVENOUS
- injected directly into circulation usually via a peripheral vein.
- given always with oxygen
2.1 Barbiturates
2.2 Ketamine Hydrochloride
2.3 Narcotics
2.3.1 Morphine sulfate
2.3.2 Fentanyl (Sublimaze)
2.3.3 Meperidine Hydrochloride (Demerol)
 Anesthesia
2.4 Narcotic Agonists- Antagonist
> Agonist
- Combines with receptors such as opiate receptors to
initiate drug actions.
> Antagonist
- Neutralizes or impedes action of another drug
(reverses its effects)
- Narcotic produces respiratory depression can be
reversed by opiate antgonists.
2.4.1 Naloxone Hydrochloride (Narcan)
2.4.2 Nalbuphine Hydrochloride (Nubain)
2.4.3 Butophanol Tartrate (Stadol)
 Anesthesia
2.5 Tranquilizers
2.5.1 Diazepam (valium)
2.5.2 Midazolam (Versed)
3. Local or regional anesthesia
- loss of sensation in a specific body part or region.
- produced by blocking conductivity of sensory nerves
supplying that area.
- The anesthetic drug is injected around a specific nerve or
group of nerves to interrupt pain impulses
 Anesthesia
TECHNIQUES:
A. Topical anesthesia
- applied directly to the skin mucous membrane, open skin
surfaces, wounds or burns. Mucous membrane readily
absorbs topical agents because of their vascularity.
- acts rapidly
COMMONLY USED TOPICAL AGENTS ARE:
- Cocaine (4-10%)
- Lidocaine (Xylocaine)
- Benzocaine
 Anesthesia
B. Local Anesthesia (Infiltration)
- injection of the anesthetic agent drug intracutaneously &
subcutaneously into tissues to block peripheral nerve
stimuli at their origin
- Used for minor surgical procedures such as suturing a
small wound or performing a biopsy.
- Lidocaine or Tetracaine 0.1% may be used.
C. Regional Application
C.1 Nerve Block
- Loss of sensation is produced by injecting the
anesthetic drug around a specific nerve or nerve plexus to
interrupt sensory, motor or sympathetic transmission of
impulses.
 Anesthesia
- Major block involves multiple nerves or a plexus (e.g.
the brachial plexus anesthetizes the arm)
- Minor blocks involve single nerve (e.g. facial nerve)
C.2 Intravenous Block (Bier Block)
- Used most often for procedures involving the arm wrist
and hand.
- an occlusion tourniquet is applied to the extremity to
prevent infiltration & absorption of the injected
intravenous agent beyond the involved extremity.
 Anesthesia
4. SPINAL anesthesia/ intrathecal Block
- Loss of sensation below the level of the diaphragm,
produced by intrathecal injection of the anesthetic drug into
the subarachnoid space w/o loss of consciousness.
- Requires a lumbar puncture through one of the interspace
between L4 and L5.
Complication:
- Postural dependent spinal headache-
Treatment:
- Flat on bed for 6-8 hours
- Hydrate patient to replace loss CSF
- Give analgesic
 Anesthesia
Use of Spinal Anesthesia:
1. Abdominal surgery, pelvis surgery & urologic procedures.
2. It is advised for alcoholics, barbiturate addicts, & very
muscular patients.
3. May be used in patients with hepatic, renal and metabolic
diseases.

POSITION:
> Client is usually in a lateral position. Patients back is at the
edge of the OR table, parallel to it. Knees are flexed onto
abdomen & head is flex to knees. Hips & shoulder are vertical
to table to prevent rotation of the spine.
 OPERATING ROOM TECHNIQUE
12 Principle of OR Technique:
1. All articles in the OR are previously sterilized.
2. Persons who are sterile touch only sterile
articles; persons who are unsterile touch only
unsterile articles.
3. If in doubt of the sterility of something
consider it unsterile.
4. Non-sterile persons avoid reaching over
sterile field; sterile persons avoid leaning over
unsterile field.
 OR technique
5. Tables are sterile only at table level.
6. Gowns are considered sterile only from the
waist to shoulder infront level, and on the
sleeves.
7. Edges of anything that encloses sterile articles
is considered unsterile.
8. Sterile persons keep well w/in the sterile area.
9 Non-sterile persons keep away from the sterile
area.
 OR technique
10. Sterile persons keep in contact with aterile
areas in a minimum.
11. Moisture may cause contamination.
12. When bacteria cannot be eliminated from a
field, they must be kept to an irreversible
minimum
 Surgical conscience
• Inner voice that tells us what is right or wrong
should be present to every member of the
surgical team.
• Inner voice for the conscientious practice of
asepsis & sterile technique at all times.
• A surgical conscience is the foundation for the
practice of strict asepsis & sterile technique
 SURGICAL SCRUB
• It is the process of removing as many microorganisms
as possible from the hands & arms by mechanical
washing & chemical asepsis before participating in an
operation.
• Skin and nails should be kept clean.
• Fingernails should not reach beyond the fingertips to
avoid glove puncture.
• Nail polish should not be worn. The lacquer may chip
& peel providing harbor for microorganisms to get into
operative site.
 SURGICAL ASEPSIS
• Prevention of microorganisms to enter the client.

Preparation immediately before scrub:

1. Inspect hands for cuts & abrasions
- Skin integrity of hands & forearms should be intact.
2. Remove all finger jewelry.
- Harbors microorganisms
3. Be sure all hair is covered by headgear.
4. Adjust disposable mask snugly & comfortably over
nose & mouth.
 GOWNING
• Gowns should be long enough to completely
cover the uniform & once contaminated, it
must never be worn outside the area.

PROCEDURE:
 GLOVING TECHNIQUE
• OPEN METHOD is used for minor operations.
• CLOSED METHOD is used for major
procedures.

PROCEDURE:
 OR TEAM
1. Sterile team
- team members scrub their hands and arms,
put on sterile gown & gloves, & enter the
sterile field.
- consist of: Operating Surgeon
assistant to the surgeon
scrub nurse
 OR team
2. Unsterile Team
a. Anesthesiologist
b. circulating nurse
c. Others: Medical technician; Transport Aides
 Duties of a scrub nurse
A. Before the Surgeon Arrives:
1. Do a complete scrub according to accepted
practice.
2. Put on sterile gown and glove.
3. Drape tables as necessary.
4. Drape the mayo stand.
5. Count sponges, instruments, needles &
sharps.
 Duties of a scrub nurse
6. Arrange the instruments on mayo stand for
making & opening initial incision.
7. Count surgical needles with circulating nurse.
8. Count all sponges w/ circulating nurse.
Circulating nurse should immediately record it.
- Counts before the start of the operation.
- Counts before the surgeon starts closure of
the body cavity or deep or large incision.