c

c



à At the end of the discussion, the student will be able to:

à 1. Describe the interdisciplinary approach to the care of care of the

patient during surgery.
à 2. Describe the principles of surgical asepsis.
à 3. Describe the various nursing roles as well as the role of the
surgical team during the intraoperative phase perioperative nursing.
à 4. Identify the types, effects of surgery and anesthesia.
à 5. Identify the surgical risk factors and nursing interventions to
reduce those risks.
à 6. Identify the use of the nursing process for optimizing patient
outcomes during the intraoperative phase.

à Reference: Medical-Surgical Nursing by Brunner and Suddarth

à 10th Edition Volume 1 (Chapter 19)
ÿ Nursing care focuses on the client's emotional well-being, safety,
positioning, maintaining surgical asepsis and controlling the
environment.
ÿ Surgical team is a group of highly trained and educated professionals
who coordinate their efforts to assure the welfare and safety of the
patient.

à c

c  c

ÿ Second phase of the Perioperative Nursing
ÿ Known as " Operating Room Nursing "
ÿ Basic Nursing Responsibilities during Intraoperative :

à 1. Maintain safety and prevent injury.

à 2. Promote wound healing and prevent infection.
à 3. Monitoring of Physiologic Responses
à 4. Documentation of Intraoperative Care
à 5. Moving and Transportation of Patients from Operating Room to
PACU
à c    begins when the client enters a surgical suite and
ends with admission in the recovery area.
à  During´ surgery; begins when the patient is
transferred onto the OR table and ends with admission to the PACU.
à Members of the surgical team group of highly trained and educate
individuals who must worked together as a coordinated team for the
welfare and safety of the client undergoing operative and other
invasive procedure.

1. Surgeon
2. Anesthesiologist
3. Circulating Nurse
4. Scrub person or surgical technologist
5. Assisstant

à †   heads and makes the major decision concerning the

course of the surgery such as whether to remove an organ or amputate
limb. He should be alert at all times to reports from the
anesthesiologist provided concerning the changing physiologic needs
of the client undergoing the stress of surgery.
à †   : Alleviate pain, promote relaxation and
medication specialist.
1. Maintain the clients¶ airway.
2. Ensure that client has an adequate gas exchange.
3. Infuse blood, fluids and medication to maintain hemodynamic
stability.
4. Monitor circulation and respiration, estimation of blood loss and fluid
loss.
5. Alert surgeon for complication.
à †   
1. Checks that all equipment is working properly before surgery.
2. Ensures sterility of instrument for surgery.
3. Assist with the positioning of the client.
4. Perform skin prep on the client.
5. Alert team members to any break in sterile techniques.
6. Assist the anesthesiologist with monitoring vital function such as urine
output and blood loss.
7. Label specimens.
8. Coordinates activities with other department such as x-ray and
pathology.
9. Document the care provided.
6. Ensure that staff conversation traffic kept to a minimum.
7. Promote smooth and safer function in the OR by bringing needed supplies
and medication to the operating table.
8. Sponge, sharp and instrument count.
9. Removing unneeded items or specimens.

à †  
à Before surgeon arrives:
a. Do a complete scrub according to the institutional procedure.
b. Gown and glove from a surface separate from the intended sterile field.
c. Drape tables as necessary according to institutional policy.
d. Count sponges, surgical needles and other sharps and instrument with the
circulator according to established institutional policy and procedure.
e. Arrange instrument and accessory items on the mayo stand for making and
opening the initial incision.

à    c  
1. Cutting or Dissecting  knives and scissors.
2. Grasping and Folding  Tissue forcep.
3. Clamping and Occuluding  Hemostatic forceps and clamps.
4. Exposing  retractors.
5. Suturing  needle holder.
à       
à a. Gown and glove the surgeon and assistant as soon after they
enter the room.
à b. Assist in draping the patient according to routine procedure.
à c. Bring the mayo stand into position over the patient after draping
is completed.

  

a. Pass the knife to the surgeon and a hemostat to the assistant.
b. Hand up sterile towels or lap sponges if requested for covering skin
at the incision edges.
c. Watch the field and try to anticipate the surgeon and the assistant
needs.
d. Pass instrument in a decisive and position manner.
e. Keep two lap sponges or tapes in the field.
f. Save and care for all tissue specimens according to policy and
procedure.
g. Maintain sterile technique. Watch for any breaks.
 
a. Count sponges, sharps and instrument with the circulation when the
surgeon begins the closure of the wound in accordance with
established count procedure.
b. Clear the mayo stand as time permits leaving a knife handle with
blade, tissue forceps, suture, scissors, four hemostats and two Alli¶s
forceps.
c. Have a clean, saline-moistened sponge ready to wash blood from
the area surrounding the incision as skin closure is completed.
d. Have dressings ready.

à c c  !"!
c !
# c$

à † Infection is a serious postoperative complication that may
become life threatening for the patient OR team members must know
and apply the principle of aseptic and sterile technique at all times.
à Postoperative wound infection can originate in the OR from a break in
technique by a team member from airborne contaminants of
improperly cleaned floors, furniture, and ventilating system or from
inadequate sterilized instrument and supplies.
1. Only sterile items are used within sterile field.
2. Sterile persons are gowned and gloved.
3. Tables are sterile only at table level.
4. Sterile person touch only sterile items or areas; unsterile person touch only
unsterile items or areas.
5. Unsterile person avoid reaching over sterile field; sterile person avoid leaning
over unsterile area.
6. Edges of anything that encloses sterile contents are considered unsterile.
7. Sterile field is created as close as possible to time of use.
8. Sterile areas are continuously kept in view.
9. Sterile persons keep contact with sterile area.
10. Sterile persons keep contact with sterile areas to minimum.
11. Unsterile persons avoid sterile areas.
12. Destruction of integrity to microbial barriers results in contamination.
13. Microorganism must be kept to irreducible minimum.
à - Perfect asepsis in the surgical wound is an ideal to be approached; it is
not absolute. All microorganisms cannot be eliminated but this does not
obviate the necessity for strict sterile technique. It is generally agreed that:
à a. Skin cannot be sterilized.
à b. Some areas cannot be scrubbed.
à c. Infected areas grossly contaminated.
à d. Air is contaminated by dust, droplets and shedding.
à    means the absence of pain.

à
%  &'     

1. General anesthesia
2. Regional

à
  
à Best suited for surgery of the head, neck, upper torso, back, prolonged
surgical procedure. Client who are unable to lie quietly fro prolonged
period of time.

à Blocked pain stimulus at the cerebral cortex, drug induced depression

of the CNS that is reversed either by metabolites elimination in the
body or by pharmacologic means.
 !!
! 
Stage From To Assessment Nursing
Intervention

I Onset Anesthetic Loss of Drowsy or dizzy, Close operating

Administration Consciousness may experience room doors; keep
auditory and visual room quiet and
hallucination. stand by to assist
client.

II Excitement Loss of Loss of eyelid Increase in Remain quietly at

consciousness reflexes autonomic activity patient¶s side; assist
irregular breathing; anesthetist, if
client may struggle. needed.

III Surgical Loss of eyelid Loss of most Client is Begin preparation

Anesthesia reflexes reflexes, depression unconscious, (if indicated) only
of vital function muscles are when anesthetic
relaxed, no blink or indicates stage III
gag reflex has been reached
and client is under
good control.
 IV Danger(death) Vital functions too Respiratory and Client is not If arrest occurs,
depressed circulatory failure breathing, may or respond
may not move have immediately to
heart beat. assist in
establishing
airway; provide
cardiac arrest tray,
drugs, syringes,
long needles; assist
surgeon with.

à
% 
  
à 1. Intravenous
à rapid introduction
à unconsciousness, generally occurs about 30mins.
à Commonly used as an induction agent before inhalation anesthesia is
given.
à Used for dental extraction, pelvic examination.
à x c 
à Mixture of volatile liquid or gas and oxygen.
à Given through mask or endotracheal tube.
à Advantageous because of the case of administration and elimination through
respiration system.
à Nitrous oxide  commonly used gas anesthesia.
à IV anesthesia is often administered before the use of inhalation
anesthetics-promotes rapid transition from the conscious stage to the
surgical anesthesia stage.
à
à 1.      via rectal tube.
à 2.   c and are given mainly to facilitate intubations,
relax the muscle within the surgical field ease laryngospasm, and relax
muscle for controlled ventilation.
à Regional Anesthesia  is useful in many clinical situations.
à
à
%    
(
  
a. Directly applied to the area.
b. Is most often applied to the respiratory passages to eliminate laryngeal
reflexes of cough for insertion of airways before induction or during
light general anesthesia or for therapeutic and diagnostic procedure
such as bronchoscope or laryngoscope.
c. Ointment, solution, gel, cream or powder.
d. Used for minor surgery such as rectal exam when painful hemorrhoids
are present, bronchoscope.
  c    
a. Involved injection of anesthesia agent such as lidocaine into the skin
and subcutaneous tissue.
b. Blocks only the peripheral nerves around the area of incision.
c. Physician should not allow the needle to slip into one of the veins-it
may cardiovascular collapse or convulsions.
d. Physician always aspirate before injection to ensure the needle is not in
a vein.

x " )*  

a. area proximal to the incision is injected and filtrated with local
anesthetics and thereby forming a barrier between the incision and the
nervous system.

+   )*  

a. Finger-digital nerve block
b. Entire upper arm-brachial plexus nerve block
c. Chest or abdominal wall-intercostals nerve block.
   
a. Injecting certain local anesthesia into the subarachnoid space.
b. Autonomic nerve fibers are the first to be affected by spinal anesthesia
and the last to recover.
c. Blocks the following fiber in order: touch, pain, motor, pressure,
proprioceptive fibers.
d. Performed for almost any type of major procedure below the level of
diaphragm.
e. Positioning:
(      the most common; the patient¶s back is at the edge
of the operative table, parallel to it. Knees are flexed into the abdomen
and the head is flexed to the knees. Hips and shoulder are vertical to
the table to prevent rotation of the spine.
x      the patient sits on the side of the operating table
with feet resting on a stool. The spine is flexed, with chin lowered to
sternum, arms crossed and supported on a pillow on an adjustable table
or mayo stand.
(     the patient lies face downward on operating table.
f. Advantage:
1. Safe
2. Provide excellent muscle relaxation.
3. Does not clouds the client with full stomach, because they will be
awake to maintain their airway if they vomit.
 ! ! 
Complication Cause Intervention Prevention

Hypotension Paralysis of the Oxygen inhalation, 500 to 800 ml fluid

vasomotor nerve usually vasoactive drugs, administered rapidly
occurs shortly after tredelenburg position if prior to block.
induction of anesthesia. level of anesthesia is
fixed 10 to 20 minutes
after induction. Oxygen,
fluids and anti-emetics.

Nausea and Vomiting During abdominal Oxygen, fluids and anti-

surgery, because of emetics
fraction placed on
various structures within
the abdomen or
hypotension.

Headache CSF Apply tight abdominal Use very small spinal

binder. Fluids, analysis,
inject 10 ml of client¶s
blood to plug hole.
needle, administers IV
and oral fluids before and
after induction. Keep
client flat on bed for 8
hours post op.
 Respiratory Paralysis If drug reaches upper Artificial Respiration Avoid extreme
thoracic and cervical trendelenburg position
cord in large amount or 10-20 minutes following
in heavy concentration. induction.

1. Epidural, Peridural Block  the term epidural, peridural and

extradural are used synonymously.
à Lumbar Approach  is a peridural block. Equipment is similar to
that for a spinal with the addition of 19 gauze x 3 ½ inches long,
thin walled needle with sty let with a rigid shaft and short bevel tip
to minimize danger of inadvertent dural puncture. Insertion of a
catheter allows repeated injection for continuous epidural
anesthesia, requiring additional needles, stopcocks and plastic
catheter in the set-up.
1. Caudal Anesthesia
à † Is an epidural sacral block. Epidural injection is through the
caudal canal, desensitizing nerves emerging from the dural sac.
à † Position for injection is prone with hips flexed, sacrum
horizontal, and heels turned outward to expose the injection site.
à † Skin and ligaments are infiltrated with local anesthetic agent
before the spinal needles is inserted.
à
%  ,
à †  c  -  the surgeon cuts through intact
tissue for the purpose of exposing or excising tissue. An incision is a
cut or an opening into a tissue. An excision is the removal of a tissue.
à †
  c'  traumatic wounds are considered closed or
open, simple or complicated, clean or contaminated. Wound closure is
predicated on type, location, severity and extent of injury.
(  .  skin is intact in a close wound, but underlying tissue
are injured. A blister filled with serum or a hematoma of blood and
serum may form under epidermis. Torn ligaments and simple fractures
are close wounds.
x  .  the continuity of skin is broken by abrasion, laceration
or penetration.
à !.  continuity of skin is interrupted in simple wounds,
but without loss or destruction of tissue and without implantation of a
foreign body. These laceration are usually caused by a sharp-edged
object cutting or penetrating at a low velocity.
1.   .  tissue is lost or destroyed by crush or burn,
or a foreign body is implanted by high velocity penetration. The
depth of a penetrating wound is irrigated and may be excised. Skin
grafting may be required following destruction of dermis.
x  .  will heal by first intention after closure of all tissue
layers and wound edges. The cosmetic care of lacerated areas is
important, as is treatment to provide normal function of a part.
+    .  when dirty objects penetrate skin,
microorganisms multiple rapidly. Debridement is done to
thoroughly wash and irrigate a wound. Devitalized tissue is removed
because it acts as a culture medium. After initial debridement to
remove foreign body including dirt and dead or deviated tissue, the
wound may be left open to heal by second or third.
à †  .  pressure sores and decubitus ulcers may
result from a comprised circulation over bony prominences for
extend period of time.venous stasis or inadequate circulation in the
legs may cause skin ulcer.

&  . 

Wound healing is nature¶s way of restoring continuity and strength to
injured or incised tissue. When a tissue is cut, the body¶s inherent
defense mechanism responds immediately to begin repair.
à &c
  !"! "
/! !
c !"!
c 0/

ÿ   " 

à a. Site of Operation
à b. Age and Size of Patient
à c. Type of Anesthetic Use
à d. Pain normally experience on movement
ÿ     
à a. Maximum safety and comfort (Body Alignment).
à b. No interference of respiration.
à c. No interference with circulation.
à d. No pressures on nerves
à e. Accessibility of Operative Site
à f. Accessibility of Anesthetic Administration
à g. No undue postoperative discomfort
à h. Individual requirements met
ÿ    
à a. Dorsal Recumbent: Coronary Bypass/ Hernia Repair
Mastectomy/Bowel Resection
à b. Trendelenberg : Permits displacement of intestines into upper abdomen
( Lower Abdomen Surgery or Pelvis )
à c. Lithotomy: Exposes perineal and rectal areas (Vaginal repairs/D and C
and Rectal Surgery)
à d. Lateral (Kidney Position): Kidney/ Chest or Hip Surgery
à e. Prone: Posterior Chest, Trunk, Legs and at times rectal areas
à f. Kraske ( Jacknife ) : Hemorroidectomy
ÿ  % &
à 1. Proper identification of patient when transferring from OR table and
affirmation of operative site.
à 2. Table securely locked in position with application of brake.
à 3. Anesthesiologist guards the head at all times and head support is done.
à 4. Physician assumes responsibility for protecting unsplinted fracture if any
on movement.
à 5. If arm board is used, it must be guarded. Don't hyperextend arm or
dislodged IVF.
à 6. Move slowly and gently to allow circulatory adjustment.
à 7. If patient is on his back, ankles and les must not cross.
à 8. If patient is on his side, a pillow must be placed lengthwise between the
legs.
à
à 9. If patient is on prone, thorax must be relieved of pressure to facilitate
respiration.
à 10. Adequate assistance in lifting patients and constant vigilance to prevent
falls.
à 11. Position should not obstruct tubing¶s.
à 12. Patient is not moved without permission from the anesthesiologist.

Method of accounting for items put on sterile table performed by scrub nurse and
circulating nurse.

a. FIRST COUNT (Person who wraps items for sterilization counts them
in standardized multiple units)
b. SECOND COUNT (Circulating and Scrub Nurse count together when
packages are open before OR begins)
c. THIRD COUNT (Counts are taken in 3 areas when surgeon starts
wound closure)
d. FOURTH COUNT (Before incision is closed)
ÿ   #1
1. All plugs and wires are inspected for correct attachments.
2. All working equipment is checked to ensure good working order.
3. Grounding of all electrical equipment is essential for safety and prevention of
stray leakage current.
à 
c !  c
ÿ Ensures sterility of all instruments and supplies.
ÿ Key words in Operating Room Practice (Caring, Conscience,
Discipline, and Technique)

à !
à One's inner voice for conscientious practice of asepsis and
steriletechnique at all times.

à  !!!! !
2

à 1. Preparation by sterilization of all instruments and materials use.
à 2. Preparation of surgical team in handling supplies and contact with
surgical wound.
à 3. In creation and maintenance of sterile field and preparation of
client in order to prevent wound contamination.
à 4. Maintenance of sterility and asepsis in the operative procedure.
à 5. Terminal sterilization and disinfections at conclusion of the
operation.
à &
c " ,  # c
  
c "
c "
c
à † Product of entrance, growth and metabolic activities and
pathophysiological effects of microorganisms in living tissue.
à † Classification of Infection
à 1. Source ( Home or Nosocomial )
à 2. Etiology ( Bacterial or Nonbacterial )

à c  c
"

 c "
c
à † Malnutrition
à † Age
à † Obesity
à † Chronic Diseases
à † Remote Infections
à † Impaired Defense Mechanisms
à † Cardiovascular and Respiratory Determinants
à † Lengthy Preoperative Stay
à † Types of Operation
à † Duration of Operation
à † Operative Technique
à † Indiscriminate Use of Antibiotics
à  c c !& c"

c !"!, !c "
c

à § Redness, excessive swelling, and tenderness

à § Red streaks in the skin near the wound
à § Pus or other discharges from the wound
à § Tender lymph nodes in axillary region
à § Foul smell from wound
à § Generalized body chills
à § Elevated body temperature and pulse


c !"!, !c "
c

à § Control of infection
à § Use of strict sterile techniques
à § Careful Operative Technique
à § Reduction of Environmental sources of Contamination
à § Thorough, Prompt Cleansing and Debridement of Traumatic Wounds
à § Prevention of Intraoperative Contamination of Wound
à § Judicious use of Prophylactic Antibiotics
à § Meticulous Hand washing
à Sterile Technique for Dressing Change
à & c
c
!"!#/ c 
c!  

à )%
 

à 1. Prevention of hypothermia and hyperthermia.
à 2. Provide blanket to minimize heat loss without causing
vasodilation which may cause bleeding.
à 3. Special Considerations to infants.

à 
à Õ Malignant HyperthermiaÕ
à 1. Genetic disorder characterized by uncontrolled skeletal muscle
contraction leading to fatal hyperthermia
à 2. Occurs in combination with succinnylcholine and halothane
anesthetics and within 30 minutes of anesthesia induction.
à 3. Signs and symtoms : Increase end tidal oxygen; masseter muscle
rigidity cardiac dysrhythmias; hypermetabolic rate
à 4. Treatment: Datrolene (Muscle relaxant)
à &

c !"!c

c!

Time patient arrived in and departed from OR

Level of consciousness or anxiety manifested by observable physical
responses

Site, time started, type of needle or cannula, solutions administered
intravenously including blood products.

Position and type of restraints and supports

Skin condition and antiseptics

Location of electrosurgical grounding and monitoring electrodes

Operation performed

Specimen and cultures sent to laboratory.

Medications given and anesthetics used

Sites and types of drains applied

Type of dressing applied

Unusual incident or complications
à &c
! !
 
c
!
c
!"&!  !
!
à ÿ Wiping of any excess blood, skin preparation and debris from the
patient's skin
à ÿ Provide clean gown and blanket on patient.
à ÿ Enough personnel for moving and transporting.
à ÿ Avoid rapid movements in changing the patient's position.
à ÿ Watch out for effects of anesthesia.
à ÿ Careful with devices attached to patients
à ÿ Provide privacy in transfer, avoid rough handling may damage fragile
skin.
à ÿ Provide privacy in transfer; avoid rough handling my damage fragile
skin.
à ÿ Provide warm blanket and secure safety belts and siderails.

à Patients who may be transferred to ICU

à 1. Clients at risk of severe complications.
à 2. Undergone major surgery
à 3 Suffered cardiac or respiratory arrest during or immediately following
surgery.
à 4. Clients who came to surgery from Intensive Care Units
à 
: Family should be notified of patient's progress.