PERIOPERATIVE NURSING Earl Francis R. Sumile, MAN, RN

Coordinator and Clinical Faculty, College of Nursing, University of Santo Tomas

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Dearest Lord, true source of light and wisdom, give us a keen sense of understanding, a retentive memory, and the capacity to grasp things correctly. Grant us the grace to be accurate in our expositions, and the skills to express ourselves with thoroughness and

clarity. Be with us at the start of our study, guide its progress and bring it to completion, grant this through Jesus Christ, our Lord. Amen

Mother Mary Immaculate – Seat of Wisdom, Pray for us.

Perioperative Nursing

Pre-operative Phase Intra-operative Phase Post-operative Phase

Preoperative Phase

Assessment and History Physical Needs Laboratory works CP Clearance Diagnostics Procedures Psychosocial Needs Health Teachings Informed Consent Procedural and Process Information Spiritual Preparation

Preoperative Teachings

Process Information Procedural Information Dietary Restrictions Preoperative Shave Family Orientation Postoperative expectations Rehabilitation Follow up

Preoperative Medications

Anticholinergics - Atropine SO4 Analgesics - Nalbuphine Sedatives - Diazepam, Dormicum Antibiotics Antihistamines - Promethazine, Diphenhydramine

Operating Room Setting

Areas In the Operating Room

Non-restricted Area Semi-restricted Area Restricted Area

Intra-operative Phase

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Categories of surgery

Emergency - Done immediately to save life or limb, Takes precedence over any other surgery scheduled

Elective - Done at the patient’s and surgeon’s convenience , May be performed within days and even months after diagnosis

Musts for an OR Nurse

Must work rapidly but efficiently even under tension Must think and react quickly Must anticipate always one step ahead of the surgeon Must be Organized and must work smoothly Must follow rules rigidly Must be patient Must have presence of mind all the time!

Operating Room Team Members

Surgeon Assistant Surgeon Anesthesiologist Scrub Nurse Circulating Nurse Pathologist Others

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Prefixes

A -Without, absence Ecto - External, outside Infra - Below Inter - Between Intra - Within

Pan - All Peri - Around Poly - Many Pseudo- False Retro - Behind, Posterior Supra - Above

Suffixes

Algia - pain Centesis – puncture Copy - to view Ectomy – surgical removal Itis - inflammation Lith - stone or calculus Lithotomy – removal of stones Logy - study

Lysis - destruction, dissolution, loose

Oma - tumor Ostomy – opening into Plasty - surgical formation Pexy – fixation Rrhapy – suturing of, repair

Rootwords

Adeno - gland Ano - Anus Arthro - joint Angio -Blood or lympathic vessel Blephar - eyelid Broncho - Bronchus Cardio - Heart Cephalo - Head Cerebro - Brain Cheilo - lip Chole - gall, bile Cholecyst- gall bladder Choledocho- Common Bile Duct Chondro - Cartilage Colo - Large intestine, Colon Colpo - Vagina Costo - Rib Cranio - Skull Cysto - Bladder Esophago- Esophagus Gastro - Stomach

Glosso - Tongue Hepar - Liver Hyster - uterus Lapar - abdomen Lipo - fat Mast/Mammo – Breast Nephro - Kidney Oculo - Eye Oophor - Ovary Orchi - Testis Osteo - bone Oto - Ear Phlebo - Vein Pneumo - Lungs Procto - Rectum Pyelo - renal pelvis Rhino -Nose Salphingo - Fallopian tube Thoraco - Chest Urano - Palate Uretero - Ureter

Asepsis and Principles of Sterile TechniquePage | 3

Definition of terms

Asepsis – Absence of microorganisms Disinfection – Reduction of pathologic microorganisms without destroying the spores Contaminated – Soiled with microorganisms Infection – Invasion of the body by pathogenic microorganisms Spores – Are inactive but viable state of a microorganism Sterile – Free from microorganisms including spores Surgical Conscience – Involves the concept of self-inspection and moral obligation

involving scientific and intellectual honesty.

Sources of Contamination

Skin Respiratory tract Articles used in the procedure Circulating Air Scrub team/patient’s hair

Principles on Asepsis

Sterile Items Sterile Field Traffic

Drapes Gowns Gloves

Medical and Surgical Instruments and Supplies Category

Category I : Critical Items - Must be sterilized Category II: Semi critical Items - Sterilization if preferred but disinfection is acceptable Category III: Non critical Items - clean

Sterilization Procedures

Physical Sterilization

Moist heat ( boiling, Autoclaving) Dry Heat (dry heat autoclaving)

Chemical Sterilization

Ethylene Oxide Sterrad

Disinfection Procedures

High Level Disinfectant - Activated glutaraldehyde Intermediate Level Disinfectant - 70% alcohol, Iodine compounds Low Level Disinfectant - Phenolic compounds, Chlorine compounds

Sterilization and Disinfection

Labels WrappersPage | 4

Shelf life Indicators

o Chemical Indicatorso Biologic indicators

Anesthesia

Factors That Determine the Choice of Anesthesia

Physical and mental condition of patient

Age and weight of patient Operation to be performed Patients preference

Type and probable duration of operation

Laboratory findings Any known idiosyncracies

Stages of Anesthesia

Stage 1 (Induction/stage of analgesia)

Starts from induction period until paient loses consciousness Patient may appear drowsy or dizzy Keep the room quiet

Stage 2 (Excitement/delirium)

Lasts from the time the patient loses consciousness until he loses certain reflexes such as swallowing,gag and eyelid.

May appear excited , may breathe irregularly Sensitive to external stimuli Maintain silence

Stage 3 (Surgical anesthesia)

From the period the patient lost certain reflexes and respiratory paralysis occurs Patient with regular respiration, constricted pupils, jaws relax and auditory sensation is

lost

Stage 4 (Stage of Danger)

Reached when too much anesthesia has been given and the patient has not been observed carefully.

Death may result from respiratory and or cardiac arrest unless resuscitated properly Patient is not breathing with little to no heart beat.

Types of Anesthesia

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General Anesthesia

Association pathways are broken in the cerebral cortex to produce more or less lack of sensory and motor perception

Pain is controlled by general insensibility , the patient is unconscious, he cannot hear, feel, or move his whole body.

Used in operations above the Thoracic level

Regional Anesthesia

Depresses superficial nerves and interferes with the conduction of pain impulses from certain area or region

Pain is controlled without loss of consciousness; one region or an area of the body is anesthetized

General Anesthesia

Inhalation - with the use of volatile gases and vapors, Either per mask or Endotracheal tube

Common Anesthetics

Sevoflurane (sevorane) Desflurane (Suprane)

Isoflurane (forane) Halothane(fluothane)

Intravenous - Drugs that may produce hypnosis, sedation, amnesia and or analgesia is administered via IV

Common Anesthetics

Thiopental Na (pentothal)

Propofol (diprivan) Ketamine (Ketalar)

Regional Anesthesia

Epidural Anesthesia

Used for Long Procedures below the Thoracic Level Used for post op management of pain. Uses an epidural Catheter (perifix)

Common Anesthetics:

Bupivacaine (Sensorcaine Isobaric, Marcaine) Lidocaine (for testing)

Subarachnoid Block

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Commonly termed as spinal anesthesia For short cases below the thoracic level Uses spinal needle gauge 22,25 or 27

Common Anesthetics

Bupivacaine hyperbaric (sensorcaine Heavy) PDE (Tetracaine(pontocaine), Dextrose, Ephedrine)

Field/Nerve blocks - Anesthetizing surrounding tissues (field) or group of nerves (nerves) at a given point

Common Anesthetics

Bupvacaine Isobaric (sensorcaine, Marcaine) Lidocaine

Local Infiltration - Agent is injected into the tissues around incision site

Anesthetics: Lidocaine, sensorcaine isobaric

Topical - Agent applied directly into a mucosa or surface Ex: Lidocaine spray

Other Medications Used for Anesthesia

Premedications Used: Midazolam(Dormicum) , Diazepam (valium)

Opiod Narcotic: Fentanyl (sublimaze)

Muscle Relaxants

Succinyl Choline (anectine) Rocoronium Bromide (Esmeron) Atracurium (tracrium)

Pancoronium Bromide (pavulon) Vecuronium Bromide (norcur

Anticholinergics - acetylcholinesterase Inhibitor

Dantrolene

Incisions, Position and Prepping

Right Subcostal (kochers Incision) Median Upper Abdominal

B. Median Lower Abdominal Mc Burney’s Incision Inguinal Incision Transverse Suprapubic

(Pfannensteil) Miscellaneous Incisions Collarline (curvilinear incision)

Used for Thyroidectomy Coronal, Butterfly Incisions Craniotomy Thoracotomy Incision Anterolateral or Lateral

Posterothoracic Lumbotomy Incision Kidney surgery Sternal Split - sternotomy

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Limbal Incision Cataract Extraction Elliptical Halsted Incision

Radical Mastectomy Post/Pre Aural Incision Caldwell Luc

Positioning - Choice of Position is made by the surgeon and positioning is done by the members of the surgical team

Factors to Consider:

Length of the procedure Site of the operation

Pain upon moving Kind of anesthetic

Qualifications of a Good Position

Not interfere with respirations Not interfere with circulation Not cause pressure on any nerve Provide total accesibility for administration of anesthesia and surgery Reflect proper body alignment, resulting in no undue post operative discomfort Patient safety

Equipments for Positioning

OR Table Body Strap Pillows Shoulder Roll Doughnut

Trochanter rolls Stirrups Foot boards Sand bags

Common Positions

Dorsal/supine Fowlers, Sitting Position Lithotomy Trendelenburg/reverse Trendelenburg Prone Sims, Knee-chest Kidney Position Chest Position

Common Injuries related to positioning

Brachial plexus injury

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Ulnar/radial nerve injury Saphenous and peroneal nerve damage Integumentary damage Eye and facial injury

Skin Preparation (Special Considerations)

Determine the area and the extent to be prepared including proposed incision. Practice modesty and privacy Examine area to be prepared In abdominal operations focus on the umbilicus In shaving follow the direction of the hair growth while the other hand exerts an opposite

force If a wound is present start from the clean area first before the dirty area

Basic Surgical Instruments Equipments and Supplies

Instrument Classification

Clamping/Hemostats Grasping/Holding Retracting Instruments Cutting/Dissecting Suturing Instruments

Parts of an Instrument

Gas Tanks/ Gas Cylinders

Green – Oxygen Gray – Carbon Dioxide Yellow – Compressed Air

Blue – Nitrous oxide Black – Nitrogen Brown - Helium

Other Instruments

Cautery machine Suction machine Heart Lung Machine Radiologic Devices Endoscopic devices Laparoscopic Instruments

Sutures and Needles

Definiton of terms

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Suture – any material used to sew, stitch or hold tissues or body parts together Ligature – a tie, to ligate blood vessels Primary suture line – main layers of tissues which must be sutured Stay or tension suture – sutures placed at the incision to act as reinforcement Tensile strength – amount of tension of pull that a strand will withstand

Uses of suture

Ligating Suturing Closing

Types of Sutures

Absorbable or Non absorbable Monofilament or Multifilament

Criteria for a good suture

Versatility Ease of handling Minimal tissue reaction and inability to create a favorable environment for infection and

tissue rejection High tensile strength Easy to thread, easy to sterilize and will not shrink Made of non electrolyte, non capillary, non allergenic and non carcinogenic materials Absorbed with minimal tissue reaction

Surgical Needles

Three Basic Sections

Point Body or Shaft Eye

Points

Taper Point Blunt Point Cutting Point

o Tapercut o Conventional cuttingo Reverse cutting

The Eye of the Needle

Atraumatic or Swaged Eyed French Eyed or Spring Controlled release

Suturing Responsibilities

Handling Sutures Suturing techniques Needle Counts

Alternative Methods to Suturing

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Surgical Strips Skin Clips Skin Staples Ligation Clips Surgical Staples Tissue adhesives Hemostatic Agents Bone wax Absorbable gelatine sponge Collagen sponge Oxidized cellulose

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Surgical Scrubbing, Gowning and Gloving Preparations immediately before scrub

1. Make sure you have checked your room and table including gowns and gloves to be used.

2. Attend to your personal needs i.e. Hunger, voiding, defecating etc.

3. Inspect hands for cuts and abrasions. Skin integrity of hands and arms

4. Remove all finger jewelry. Jewelry harbors microorganisms.

5. Be sure all hair is covered by cap or bonnet.

6. Adjust mask snugly and comfortably over nose and mouth.

7. Fold sleeves of the scrub suit if too long.

8. Clean eyeglasses if worn. Adjust eyewear or face shield comfortably in relation to mask. Secure if necessary.

Principles of Asepsis Related to Surgical Gowning and Gloving

Sterile persons keep well within sterile area. o Sterile persons pass each other back to back or front to front.o Sterile person faces a sterile area to pass ito Sterile persons stay within the sterile field

Gowns are considered sterile only from the waist to shoulder level, in front and in the sleeves. Sterile persons keep hands in sight and at or above waist level only Arms are never folded because there may be perspirations in the axillary region. Items dropped below the waist level are considered unsterile and must be discarded Hands are kept away from the face with elbows close to side

Legal and Ethical Dimensions in the Practice of OR Nursing

Common Issues

Consent Wrong Patient/Site surgery Counting Specimen Handling

o Labeling o RFSo Medico-legal

Medication errors Negligence

Postoperative Care

General Postoperative responsibilities

Promotion of Adequate Respiratory Function Promotion of Adequate Circulatory Function Promotion of Normal Reflex return Promotion of Safety and Comfort Pain Management Promotion of Wound Healing Promotion of Fluid and electrolyte balance