SURGERY As a science and art; is the branch of medicine that comprises peri-operative patient care encompassing such activities

as pre-operative preparation, intra-operative judgement, and post-operative care of patient. As a discipline, surgery combines physiologic management with an interventional aspects of treatment. SURGICAL SETTING 1. INPATIENT Refers to client who is admitted to a hospital Admitted on the day of surgery (same-day-admission- SDA) OUTPATIENT AND AMBULATORY Refers to the client who goes to the surgical area the day of the surgery and returns home on the same day (same-day-surgery SDS)

2.

PREOPERATIVE NURSING Assist client and their significant others through the surgical episodes, to help promote positive outcomes, and to help clients achieve their optimal level of function and wellness after surgery. Emphasis on safety and client education. Use knowledge judgement and skills. PREOPERATIVE PERIOD Begins when the client is scheduled for surgery and ends at the time of transfer to surgical suite. Focuses on client readiness client education and any intervention: 1. Reduces anxiety 2. Reduces complication 3. Promote cooperation Needed for surgery to: Validate and clarify information client receive received from surgeon or member of health team. Identify problems that warrant further assessment and/or intervention before surgery.

PREOPERATIVE ASSESMENT testing. Includes the medical/ health history, the psychosocial history, physical examination, cognitive assessment and diagnostic

PREOPERATIVE CARE Obtaining informed consent: The surgeon is responsible for obtaining the client consent for surgery. Ensure that informed consent ad been signed and that any additional necessary consents (e.g., limb disposal) have been obtained and you serve as a witness to the signature, not to the fact that the client is informed. Sedation should not be administered to the client before he or she signs the consent. Not responsible for providing detailed in formation about the surgical procedure ROLE: to clarify facts that have been presented by the physician and dispel myths that the client or family may have about that surgical procedure.

PREOPERATIVE TEACHINGS Reduce apprehension and fear. Increased cooperation and participation in care after surgery Decrease complications.

Client teaching: Describe what client should expect after surgery. Instruct client to notify nurse of pain after surgery and reassure client that pain medication will be prescribed, to be given as the client request. Inform client that requesting a narcotic after surgery will not make the client drug addict. Demonstrate the use of a client controlled analgesia pump if its use is prescribed. Instruct client to use non-invasive pain relief techniques ( e.g., relaxation, distraction techniques and guided imagery) before pain occurs and as soon as pain is noted Instruct client not to smoke for atleast 24 hours before surgery. Instruct client in deep breathing and coughing techniques, the use of incentive spirometry and the importance of performing the techniques after the surgery to prevent development of pneumonia and atelectasis. Tell the client that a sitting position permits the best lung expansion for coughing and deep breathing exercise. Instruct client to breath deeply three times inhaling through the nostrils and exhaling slwly thrugh pursed lips Tell client that the third breath should be held three seconds after which client should cough deeply three times. Tell client to perform this exercise every two hours. Incentive spirometry- promote complete lung expansion and prevent pulmonary problems.

PREOPERATIVE CHECKLIST Review checklist to ensure that each item is addressed before client is transported to surgery. Ensure that client is wearing an identification bracelet. Assesses client for allergies. Ensure that prescribed laboratory test results and electrocardiography and chest radiography reports are documented in the clients record. Remove client jewelry, make up, dentures, hairpins, nail polish, glasses and prosthesis as appropriate. Document that valuables have been given to clients family members or locked in the hospital safe Monitor and document clients vital signs Prosthesis or dentures should be removed to prevent obstruction in the airway.

INTRAOPERATIVE PERIOD Begins when the client is transferred to the OR bed ends when the client of transferred to an area for Recovery from OR Key words of OR practiced are: 1. Caring 2. Discipline 3. Technique 4. Conscience Optimal client care requires an inherent surgical conscience, self discipline & the application of principles of aseptic & sterile technique. SURGICAL CONSCIENCE Surgical golden Ruler Do unto the patient as you would have others do unto you Ones inner voice for the conscientious practice of asepsis and sterile technique at all times. Conscience dictates that appropriate action should be taken, whether the person is with others o alone and unobserved. Foundation for the practice of strict aseptic and sterile technique. ASEPTIS TECHNIQUE Alternated term: ASEPTIC PRACTICE- to maintain asepsis (absence of microorganism that caused disease).

STERILE TECHNIQUE Method by which contamination which microorganism is prevented to maintain sterility throughout the procedure. Is the responsibility of everyone caring for client in the operating room.

PRINCIPLES OF STERILE TECHNIQUE 1. ONLY STERILE ITEMS ARE USED WITHIN STERILE FIELD Neckline, shoulders, & back also may become contaminated with perspiration. Sterile persons are aware of height of team members in relation to each & the sterile field. Changing levels @ sterile field is avoided. Gown is considered sterile only down to highest level of sterile tables. If a sterile person must stand on a platform to reach operative field, platform should be positioned before this person steps up to draped area. Sterile person should sit only when entire procedure will be performed @ this level.

If you are in doubt about the sterility of anything, consider it not sterile.
a. b.

e.

c. d. e.

f. g.

h.

If sterilized package is found in a nonsterile workroom. If uncertain about actual timing or operation of sterilizer. Items processed in a suspect load are considered unsterile. If unsterile person comes into close contact with a sterile table & vice versa. If sterile table or unwrapped sterile items are not under constant observation. If sterile package wrapped in material other than plastic or moisture-resistant barrier becomes damp or wet. Humidity in storage area or moisture on hand may seep into package. If the integrity of the packaging material is not intact. If sterile package wrapped in a pervious muslin or other woven material drops to the floor or other area of questionable cleanliness. These material allow implosion of air into package. A dropped package is considered contaminated. If the wrapper is impervious & the area of contact is dry, the item may be transferred to the sterile field. Packages that have been dropped on the floor should not be put back into sterile storage.

3. TABLES ARE STERILE ONLY AT TABLE LEVEL a. Only top of a sterile draped table considered sterile. Edges & sides of drapes extending below table level are considered unsterile. b. Anything falling or extending over table edge, such as a piece of suture, is unsterile. Scrub person does not touch part hanging below table level. If unfolding a sterile drape, the part that drops below table surface is not brought back up to table level. Once placed, draped is not moved or shifted c. Cords, tubings, etc., are secured on the sterile field with a non-perforating device to prevent them from sliding over the table edge. 4. PERSON WHO ARE STERILE TOUCH ONLY STERILE ITEMS OR AREAS; PERSONS WHO ARE NOT STERILE TOUCH ONLY UNSTERILE ITEMS a. Sterile team members maintain contact with sterile field by means of sterile gowns & gloves. b. Nonsterile circulating nurse does not directly contact the sterile field. c. Supplies are brought to sterile team memvers by the circulating nurse who opens the wrappers on sterile packages. The circulating nurse ensures sterile transfer to the sterile field. Only sterile items touch sterile surface. 5. UNSTERILE PERSONS AVOID REACHING OVER A STERILE FIELD; STERILE PERSONS AVOID LEANING OVER AN UNSTERILE AREA a. Unsterile circulating nurse NEVER reaches over a sterile field to transfers sterile items. b. In pouring solution into sterile basin, circulating nurse holds only lip of bottle over basin to avoid reaching over a sterile area.

2. GOWNS ARE CONSIDERED STERILE ONLY INFRONT FROM CHEST TO LEVEL OF STERILE FIELD & THE SLEEVES FROM ABOVE ELBOWS TO CUFF a. Self-gowning & gloving should be done from a sterile surface for this purpose only to avoid dripping water onto sterile supplies or sterile field. b. Stockinet cuffs of gown are enclosed beneath sterile gloves. Stockinet is absorbent & will retain moisture, thus this part of gown does not provide a microbial barrier. c. Sterile persons keep hands in sight @ all times & at or above level of waist or sterile field. d. Hands are kept away from face. Elbows are kept close to sides. Hands are never folded under arms because of perspiration in axillary region.

c.

Scrub person sets basins or glasses to be filled @ edge of the sterile table; circulating nurse stands near this edge fo the table to fill them. d. Circulating nurse stands @ a distance from the sterile field to adjust light over it to avoid microbial fallout over field. e. Surgeons turns away from sterile field to have perspiration removed from brow. f. Scrub persons drapes a nonsterile table towards self first to protect gown. Gloved hands are protected by cuffing draped over them g. Scrub persons stands back from nonsterile table when draping it to avoid leaning over an unsterile area.

a.

Sterile persons stand back at a safe distance from the operating table when draping the client. b. Sterile persons pass each other back to back at 360 turn. c. Sterile person turns back to nonsterile person or area when passing. d. Sterile person face sterile area to pass it. e. Sterile person asks nonsterile individual to step aside rather than risk contamination. f. Sterile persons stay within the sterile field. They do not walk around or go outside the room. g. Movement within & around a sterile areas is kept to a minimum to avoid contamination of sterile items or persons. 10. STERILE PERSONS KEEP CONTACT WITH STERILE AREAS TO A MINIMUM a. Sterile persons do not lean on sterile tables & on the draped client. b. Sitting or leaning against a nonsterile surface is a break in technique. If the sterile team sits to operate, they do so withou proximity to nonsterile areas.

6. EDGES OF ANYTHING THAT ENCLOSES STERILE CONTENTS ARE CONSIDERED UNSTERILE a. In opening sterile packages, a margin of safety is always maintained. The inside of wrappers is considered sterile within 1 inch of the edges. The circulating nurse opens top flap away from self, then turns the sides under. Ends of flaps are secured in hand so they do not dangle loosely. The last flap are secured in pulled toward person opening package, thereby exposing package contents away from nonsterile hand. b. Sterile person lifts contents away from packages by reaching down & lifting them straight up, holding elbows high c. Steam reaches only area within the gasket of a sterilizer. Instrument trays should not touch edge of the sterilizer outside the gasket. e. If a sterile wrapper is used as a table cover, it should amply cover the entire table surface. Only the interior & surface level of the cover are considered sterile. f. After a sterile bottle is opened, contents must be used or discarded. Cap can be replaced without contaminating pouring edges. 7. STERILE FIELD IS CREATED AS CLOSE AS POSSIBLE TO TIME OF USE a. Sterile tables are set up just before the operation. b. It is virtually impossible to uncover a table of sterile contents without contamination. Covering sterile

11. UNSTERILE PERSON AVOID STERILE AREAS a. Unsterile persons maintain a distance of at 1 foot (30 cm) from any area of the sterile field. b. Unsterile persons face & observe a sterile area when passing it to be sure they do not touch it. c. Unsterile persons never walk between two sterile areas, e.g., between sterile instrument tables. d. Circulating nurse restricts to a minimum all activity near sterile field. 12. DESTRUCTION OF INTEGRITY OF MICROBIAL BARRIERS RESULTS IN CONTAMINATION a. Sterile packages are laid on dry surfaces. b. If sterile package wrapped in absorbent material becomes damp or wet, it is resterilized or discarded. The package is considered nonsterile if any part of it comes in contact with moisture. c. Drapes are placed on a dry field. d. If solution soaks through sterile drape to nonsterile area, the wet area is covered with impervious sterile draped or towels. e. Packages wrapped in muslin or paper are permitted to cool after removal from a sterilizer & before being placed on cold surface to prevent steam condensation & resultant contamination. f. Sterile items are stored in clean dry areas. g. Sterile package are handled with clean dry hands. h. Undue pressure on sterile packs is avoided to prevent forcing sterile are out & pulling unsterile air into the pack.

tables for later use is not recommended.

8. STERILE AREAS ARE CONTINUALLY KEPT IN VIEW a. Sterile person face sterile areas. b. When sterile packs are open in a room, or a sterile field set up, someone must remain in the room to maintain vigilance. Sterility cannot be ensured without direct observation. An unguarded sterile field should be considered contaminated. 9. STERILE PERSONS KEEP WELL WITHIN THE STERILE AREA

13. MICROORGANISM MUST BE KEPT TO AN IRREDUCIBLE MINIMUM A. Skin cannot be sterilized. Skin is a potential source of contamination in every operation. 1. Transient & resident flora are removed from skin around operative site of client & hands & arms of sterile team members by mechanical washing & chemical antisepsis. 2. Gowning & gloving of operating team is accomplished without contamination of exterior of gowns & gloves. 3. Sterile gloved hands do not directly touch skin & then deeper tissues. Instruments uses in contact with skin are discarded & not reused. 4. If glove is torn or punctured by needle or instrument, gloved is changes immediately. Needle or instrument is discarded from sterile field. 5. Sterile dressing should be applied before draped are removed to reduce risk of the incision being touched by contaminated hands or objects. MEMEBERS OF SURGICAL TEAM A. Surgeon- a physician who assumes responsibility for the surgical procedures and any surgical judgements about the client. Surgical Assistant- might be another surgeon (or physician, resident or intern) or nurse, surgical technologist. Anaesthesiologist- is a physician who is specialized in giving anesthetic agents.

TYPES OF ANESTHESIA

1.

GENERAL ANESTHESIA
Depresses CNS resulting: amnesia, analgesia, unconsciousness, loss of muscle tone and reflexes.

2.

LOCAL ANESTHESIA/REGIONAL
Disrupts sensory nerve impulse transmission from a specific area or region.

STAGES OF GENERAL ANESTHESIA

STAGE 1- STAGE OF INDUCTION

From the beginning of administration of drugs/gas to loss of consciousness. Client appear drowsy and dizzy. Nursing action: Close OR doors and keep room quiet Standby the client and assist if necessary.

B.

C.

STAGE 2- STAGE OF EXCITEMENT

ANESTHESIA Negative sensation Is an induced state of partial or total loss of sensation, occurring with or without loss of consciousness. Puposes: 1. Block nerve impulse transmission. 2. Promote muscle relaxation. 3. Achieve a controlled level unconsciousness.

From loss of consciousness to relaxation Client appear excited, breathing is irregular Client moves extremeties or body Client is vey sensitive to external stimuli Nursing action: Restrain client if needed Remain at client side Be quiet and alert Assist anaesthesiologist needed

if

of

STAGE 3- STAGE OF SURGICAL ANESTHESIA AND RELAXATION

Loss of reflexes Depression of vital function Respiration regular, pupils contracted Eyelids reflexes disappear Loss of auditory senses

Selection of anesthesia influenced by the following: a. Clients health problem- major factor. b. Type and duration of the procedure. c. Area of the body having surgery. d. Safety issues to reduce injury-airway management e. Whether the procedure is an emergency f. Options for management pain after surgery g. How long it has been since the client ate, had any liquid, or any drugs. h. Clients position needed for the surgical procedure.

Nursing action: Begin final prep client is under control

G.

JACKNIFE POSITION Rectal surgery

STAGE 4- DANGER STAGE

Vital functions are to depressed Respiratory failure and possible cardiac arrest Not breathing, little or no pulse and heartbeat. Nursing action: Be ready to resuscitate.

POST OPERATIVE PERIOD Begins at the administration of the client to the post-anesthesia area and ends when healing is complete.

Stages of Recovery

POSITIONING Putting client in proper body alignment to expose the operative site or area.

Qualification of a good position:

1. 2. 3. 4. 5. 6.

Free respiration Free circulation No pressure on nerve Hand or feet properly supported No undue postoperative discomfort Accessible operative site.

Immediate postoperative stage. The period one to four hours after surgery. Intermediate postoperative stage. The period four to twenty-four hours after surgery. Extended postoperative stage. The period atleast one to four days after surgery.

A.

SUPINE POSITION/ DORSAL Laparotomy, appendectomy

B.

REVERSE MODIFIED TRENDELENBURG POSITION Face and neck surgery

C.

MODIFIED FOWLERS POSITION For neurosurgery

D.

PRONE POSITION Surgery on the posterior part of the body, laminectomy

E.

LITHOTOMY POSITION Perineal approach, cystoscopy, vaginal hysterectomy

OR NOTEBOOK Prepared by: PRADO, Edelweis C. BSN 3-F PERIOPERATIVE DUTIES Scrub Nurse The perioperative nurse as a scrub nurse performs another essential role in the operating room. Her expertise includes

F.

LATERAL POSITION Kidney, lungs or hip

knowledge of anatomy and physiology and the procedure to be performed, ability to recognize the instrumentation used in a particular surgery, and critical thinking skills to gather specialty items that may be needed during a procedure and in event of an emergency. The scrub nurse is a member of the sterile surgical team. His/her primary responsibility is maintenance of the sterile field. Other activity of the scrub nurse includes:

Circulating Nurse The Circulating nurse, by virtue of her professional educational preparation and specialized skill, is responsible for managing patient care activities in the operating suite, so his/her duties begin long before the patient arrives in the operating room and continues until the final dispensation of the patient, operating room records, and specimens is completed. The following list depicts some of the activities performed by the circulating nurse prior to induction of anesthesia, during the procedure, and upon conclusion of the procedure:

Assisting and preparing the procedure room Gathering sterile supplies needed for procedure and those that may be needed Setting up the sterile back table Dressing the surgeon and other members of the surgical team in their sterile attire Assisting in the placement of the sterile drapes Passing the instruments to the surgical team and assisting as needed to enhance the continuity of the procedure Constant surveillance of the surgical field thus maintaining sterility Anticipating the needs of the surgeon and asking for items before they are needed Reporting to the circulating nurse the names of the specimens obtained during surgery Helps with the application of the sterile dressing at the end of the procedure Removal of bioburden from used instrumentation before sending it to be processed in Central processing. Assist in the cleaning of the procedure room to make ready for the next surgical procedure. the

Assisting and preparing the procedure room Supervising the transporting, moving, and lifting of the patient Assisting anesthesia as requested induction and reversal of anesthesia Positioning the patient for surgery Performing the surgical skin prep Conducting and maintaining accurate records of counts Maintaining accurate documentation of nursing activities during the procedure Dispensing supplies and medications to the surgical field Maintaining an aseptic and safe environment Estimating fluid and blood loss Handling special equipment, specimens, etc Communicating special postoperative needs to appropriate persons at the conclusion of the case during

PREOPERATIVE CHECKLIST Review checklist to ensure that each item is addressed before client is transported to surgery. Ensure that client is wearing an identification bracelet. Assesses client for allergies. Ensure that prescribed laboratory test results and electrocardiography and chest radiography reports are documented in the clients record. Remove client jewelry, make up, dentures, hairpins, nail polish, glasses and prosthesis as appropriate. Document that valuables have been given to clients family members or locked in the hospital safe Monitor and document clients vital signs Prosthesis or dentures should be removed to prevent obstruction in the airway.

Perioperative Duties Scrub Nurse The perioperative nurse as a scrub nurse performs another essential role in the operating room. Her expertise includes knowledge of anatomy and physiology and the procedure to be performed, ability to recognize the instrumentation used in a particular surgery, and critical thinking skills to gather specialty items that may be needed during a procedure and in event of an emergency. The scrub nurse is a member of the sterile surgical team. His/her primary responsibility is maintenance of the sterile field. Other activity of the scrub nurse includes:

Assisting and preparing the procedure room Gathering sterile supplies needed for the procedure and those that may be needed Setting up the sterile back table Dressing the surgeon and other members of the surgical team in their sterile attire Assisting in the placement of the sterile drapes Passing the instruments to the surgical team and assisting as needed to enhance the continuity of the procedure Constant surveillance of the surgical field thus maintaining sterility

Anticipating the needs of the surgeon and asking for items before they are needed Reporting to the circulating nurse the names of the specimens obtained during surgery Helps with the application of the sterile dressing at the end of the procedure Removal of bioburden from used instrumentation before sending it to be processed in Central processing. Assist in the cleaning of the procedure room to make ready for the next surgical procedure.

Circulating nurse The Circulating nurse, by virtue of her professional educational preparation and specialized skill, is responsible for managing patient care activities in the operating suite, so his/her duties begin long before the patient arrives in the operating room and continues until the final dispensation of the patient, operating room records, and specimens is completed. The following list depicts some of the activities performed by the circulating nurse prior to induction of anesthesia, during the procedure, and upon conclusion of the procedure:

Assisting and preparing the procedure room Supervising the transporting, moving, and lifting of the patient Assisting anesthesia as requested during induction and reversal of anesthesia Positioning the patient for surgery Performing the surgical skin prep Conducting and maintaining accurate records of coun

Maintaining accurate documentation of nursing activities during the procedure Dispensing supplies and medications to the surgical field Maintaining an aseptic and safe environment Estimating fluid and blood loss Handling special equipment, specimens, etc Communicating special postoperative needs to appropriate persons at theconclusionofthecasE

INTRAOPERATIVE PERIOD Begins when the client is transferred to the OR bed ends when the client of transferred to an area for Recovery from OR Key words of OR practiced are: Caring Discipline Technique Conscience

Optimal client care requires an inherent surgical conscience, self discipline & the application of principles of aseptic & sterile technique. Surgical conscience Surgical golden Ruler Do unto the patient as you would have others do unto you

MEMEBERS OF SURGICAL TEAM D. Surgeon- a physician who assumes responsibility for the surgical procedures and any surgical judgements about the client.

E. F.

Surgical Assistant- might be another surgeon (or Anaesthesiologist- is a physician who is specialized

physician, resident or intern) or nurse, surgical technologist. in giving anesthetic agents.

STAGES OF GENERAL ANESTHESIA STAGE 1 - STAGE OF INDUCTION From the beginning of administration of drugs/gas to loss of consciousness. Client appear drowsy and dizzy. Nursing action: Close OR doors and keep room quiet Standby the client and assist if necessary. STAGE 2- STAGE OF EXCITEMENT From loss of consciousness to relaxation Client appear excited, breathing is irregular Client moves extremities or body Client is vey sensitive to external stimuli Nursing action: Restrain client if needed Remain at client side Be quiet and alert Assist anaesthesiologist if needed STAGE 3- STAGE OF SURGICAL ANESTHESIA AND RELAXATION Loss of reflexes

Depression of vital function Respiration regular, pupils contracted Eyelids reflexes disappear Loss of auditory senses Nursing action: Begin final prep client is under control STAGE 4- DANGER STAGE Vital functions are to depressed Respiratory failure and possible cardiac arrest Not breathing, little or no pulse and heartbeat. Nursing action: Be ready to resuscitate. POSITIONING Putting client in proper body alignment to expose the operative site or area.

Qualification of a good position: 7. Free respiration 8. 9. 11. Free circulation No pressure on nerve No undue postoperative discomfort

10. Hand or feet properly supported 12. Accessible operative site. SUPINE POSITION/ DORSAL Laparotomy, appendectomy REVERSE MODIFIED TRENDELENBURG POSITION Face and neck surgery

MODIFIED FOWLERS POSITION For neurosurgery PRONE POSITION Surgery on the posterior part of the body, laminectomy LITHOTOMY POSITION Perineal approach, cystoscopy, vaginal hysterectomy

LATERAL POSITION Kidney, lungs or hip JACKNIFE POSITION Rectal surgery

POST OPERATIVE PERIOD Begins at the administration of the client to the postanesthesia area and ends when healing is complete

Stages of Recovery

-immediate postoperative stage. The period one to four hours after surgery. -intermediate postoperative stage. The period four to twenty-four hours after surgery. -extended postoperative stage. The period atleast one to four days after surgery.