OR NURSE

- knowledgeable
- skillful
- attitude (bravery)

PNA (Philippine Nurses Organization)

- only organization accredited by DOH

ORNAP

OR nurse
- chill if walang px

Surgeon
Asst Surgeon
Scrub Nurse
Anesthesiologist
Circulating Nurse

PERIOPERATIVE NURSING
used to describe the nursing care provided in the total surgical experience of the patient:
a. preoperative
b. intraoperative
C. postoperative

Preoperative Phase
extends from the time the client is admitted in the surgical unit, to the time he/she is prepared
for the surgical procedure, until he is transported into the operating room.
*CONSENT!! obtained by DOCTOR, secured by the NURSE
*battery (???) touching without consent
*informed consent is for self-determination

Intraoperative Phase
extends from the time the client is admitted to the OR, to the time of administration of
anesthesia, surgical procedure is done, until he/she is transported to the RR/PACU.
*post anesthesia care unit/ recovery room
*anesthesia is administered in this phase

Postoperatve Phase
extends from the time the client is admitted to the recovery room, to the time he is transported
back into the surgical unit, discharged from the hospital, until the follow-up care.

4 Major Types of Pathologic Process

Requiring Surgical Intervention (OPET)
• Obstruction - impairment to the flow of vital fluids (blood, urine, CSF,bile)
• Perforation - rupture of an organ.
• Erosion - wearing off of a surface or membrane.
• Tumors - abnormal new growths.

Identify the type of pathologic process

requiring surgery
Hydrocephalus - Obstruction
Burn - Erosion
Benign Prostatic Hyperplasia - Tumor
Cholelithiasis - Obstruction
Intussusception - Obstruction
Ruptured Aneurysm - Perforation

According to PURPOSE:
Diagnostic to establish the presence of a
disease condition. (e.g biopsy )

Exploratory - to determine the extent of

disease condition (e.g Ex-Lap/ exploratory laparotomy )
• spleen - bleeder - blood transfusion, IV therapy

Curative - to treat the disease condition.

* Ablative - removal of an organ “ectomy”
* Constructive - repair of congenitally
defective organ "plasty,oorhaphy,pexy"
* Reconstructive - repair of damage organ

> Palliative - to relieve distressing sign and symptoms, not necessarily to cure the disease.

Identify the type of surgery according to purpose:

•Pap Smear: Diagnostic
•Tonsilectomy: Curative - Ablative
•Nephrocapsulectomy: Curative - Ablative
•Osteoplasty: Curative - Constructive
•Perineorrhaphy: Curative -Reconstructive
•Skin Grafting: Curative -Reconstructive

According to URGENCY
> Emergent
> Urgent/Imperative
> Required
> Elective
> Optional (cosmetic surgery)
According to DEGREE OF RISK

> Major Surgery

- High risk / Greater Risk for Infection
- Extensive
- Prolonged
- Large amount of blood loss
- Vital organ may be handled or removed

> Minor Surgery

- Generally not prolonged
- Leads to few serious complication
- Involves less risk

Ambulatory Surgery/ Same-day Surgery / Outpatient Surgery

Advantages:
- Reduces length of hospital stay and cuts costs
- Reduces stress for the patient
- Less incidence of hospital acquired infection
- Less time lost from work by the patient; minimal
disruptions on the patient's activities and family life.

Disadvantages:
- Less time to assess the patient and perform preoperative teaching
- Less time to establish rapport
- Less opportunity to assess for late postoperative complication.

Note:
• Health Teaching - Night before the Surgery
• "Hindi ko po alam anong gagawin sakin" - cancel surgery, call doctor (be a patient advocate)
• Explain the procedure of surgery - DOCTOR ONLY

Example of Ambulatory Surgery

Teeth extraction
Circumcision
Vasectomy
Cyst removal
Tubal ligation

Surgical Risk
> Obesity
> Poor Nutrition
> Fluid and Electrolyte Imbalances
> Age
> Presence of Disease (Cardiovascular dse.,
DM, Respiratory dse. )
> Concurrent or Prior Pharmacotherapy
other factors:
- nature of condition
- loc. of the condition
- magnitude / urgency of the surgery
- mental attitude of the patient
- caliber of the health care team

NOTE:
> If px is drunk - sign DAMA, discharge if that's what px wants - avoid false imprisonment

fidelity - panagutan ang sinabi sa px

veracity - only state facts to px
non-malificence - do not harm
beneficence - only do good to px

PREOPERATIVE
Goals
- Assessing and correcting physiologic and
psychologic problems that may increase surgical risk.
- Giving the person and significant others complete learning / teaching guidelines regarding
surgery.
- Instructing and demonstrating exercises that will
benefits the person during postop period.
- Planning for discharge and any projected changes in lifestyle due to surgery.

Physiologic Assessment of the Client Undergoing Surgery

+ Presence of Pain
+ Nutritional & Fluid and Electrolyte Balance
+ Cardiovascular / Pulmonary Function (CP CLEARANCE)
+ Renal Function (input and output)
+ Gastrointestinal /Liver Function
+ Endocrine Function
+ Neurologic Function
+ Hematologic Function
+ Use of Medication
+ Presence of Trauma & Infection

Note:
- post op
- NPO - to avoid aspiration
- clear liquids (tubig)
- general liquid (milk)
- soft diet (lugaw)
- DAT (regular diet)

assess: GAG reflex before introducing anything orally

> T3 & T4 assessment before surgery for hyperthyroidism - bc thyroid gland is bleeder

> HIV & AIDS MEDICATION - Antiretroviral drugs - ACYCLOVIR

> CBC (hemoglobin - 12-14 F, 14-16 M normal, 10-11 surgery go but with transfusion, 8
cancelled first), hematocrit, wbc)

AB+ - universal recipient (prone for depression); A - proned for gastritis; O - universal donor

2 NURSES are needed to verify and do blood transfusion to check:

- date of extraction
- px name ( blood & result)
- serial no
- exp. date
- blood type
- cc (dose/volume of blood)

Psychosocial Assessment and Care

Causes of Fears of the Preoperative Clients
- Fear of Unknown (Anxiety)
- Fear of Anesthesia
- Fear of Pain
- Fear of Death
- Fear of disturbance on Body image
- Worries - loss of finances, employment, social and family roles.
- anxiousness
- anger
- tendency to exaggerate
- sad, evasive, tearful, clinging
- inability to concentrate
- short attention span
- failure to carry out simple directions
- dazed

Nursing Intervention to Minimize Anxiety

+ Explore client's feeling
+ Allow client's to speak openly about fears/concern.
+ Give accurate information regarding surgery (brief, direct to the point and in simple terms)
+ Give empathetic support
+ Consider the person's religious preference and arrange for visit by a priest / minister as
desired.

INFORMED CONSENT
Purposes:
- To ensure that the client understand the natureof the treatment including the potential
complications and disfigurement
(explained by AMD)
- To indicate that the client's decision was made without pressure.
- To protect the client against unauthorized
procedure.
- To protect the surgeon and hospital against
legal action by a client who claims that an
authorized procedure was performed.

> Circumstances Requiring Consent

> Any surgical procedure where scalpel, scissors, suture, hemostats of electrocoagulation may
be used.
- Entrance into body cavity.
- Radiologic procedures, particularly if a
contrast material is required.
- General anesthesia, local infiltration and
regional block.

Essential Elements of Informed Consent

- The diagnosis and explanation of the condition.
- A fair explanation of the procedure to be done and used and the consequences.
- A description of alternative treatment or
procedure.
- A description of the benefits to be expected.
- The prognosis, if the recommended care,
procedure is refused.

Requisites for Validity of Informed Consent

- Written permission is best and legally accepted.
- Signature is obtained with the client's complete understanding of what to occur.
- adult sign their own operative permit
- obtained before sedation
- For minors, parents or someone standing in their behalf, gives the consent.
Note: for a married emancipated minor parental consent is not needed anymore, spouse is
accepted
- For mentally ill and unconscious patient, consent must be taken from the parents or legal
guardian

If the patient is unable to write, an “X” is accepted if there is a witness to his mark
- Secured without pressure and threat
- A witness is desirable - nurse, physician or
authorized persons.

PATTERNALISM: When an emergency situation exists, NO CONSENT is necessary because

inaction at such time may cause greater injury. (permission via telephone/cellphone is accepted
but must be signed within 24hrs.)

*Jehovah's witness - does not accept blood transfusion

PRE OPERATIVE CARE

Before Surgery
- Correct any dietary deficiencies
- Reduce an obese person's weight
- Correct fluid and electrolyte imbalances
- Restore adequate blood volume with BT
- Treat chronic diseases
- Halt or treat any infectious process
- Treat an alcoholic person with vit. supplementation, IVF or fluids if dehydrated

Note: Epidural - Shrimp like position

Pre Operative Teaching

- Incentive Spirometer
- Diaphragmatic Breathing
- Coughing
- Splinting
- Turning (done every 2hrs)
- Foot and Leg Exercise
- Early Ambulation

Note:
Evisceration -
Deshiscence -

Preparing the Patient the Evening Before Surgery

Preparing the Skin
- have a full bath to reduce microorganisms in the skin.
- hair should be removed within 1-2 mm of the skin to avoid skin
breakdown, use of electric clipper is preferable.
Preparing the GI tract
- NPO, cleansing enema as required
- Preparing for Anesthesia
- Avoid alcohol and cigarette smoking for at least 24 hours before surgery.
- Promoting rest and sleep
- Administer sedatives as ordered

Preparing the Person on the Day Of Surgery

- Awaken 1 hour before preop medications

Morning bath, mouth wash
- Provide clean gown
- Remove hairpins, braid long hair, cover hair with cap if available.
- Remove dentures, colored nail polish, hearing aid, contact lenses, jewelries (put on SAFE
BOX)
- Take baseline vital sign before preop medication.
- Check ID band, skin prep
- Check for special orders - enema, IV line
- Check NPO
- Have client void before preop medication
Continue to support emotionally
- Accomplished “preop care checklist"

Note: braces - go surgery, stent - take clearance fr previous physician who conducted operation

Preop Medications
Goals:
o To aid in the administration of an
anesthetics.
o To minimize respiratory tract secretion
and changes in heart rate.
o To relax the patient and reduce anxiety.

Commonly used Preop Meds

> Tranquilizers & Sedatives
* Midazolam
* Diazepam ( Valium)
* Lorazepam ( Ativan )
* Diphenhydramine
> Analgesics
 * Nalbuphine (Nubain )
* Anticholinergics
* Atropine Sulfate
> Proton Pump Inhibitors
* Omeprazole ( Losec )
* Famotidine

Transporting the Patient to the OR

- Adhere to the principle of maintaining the
comfort and safety of the patient.
- Accompany OR attendants to the patient's
bedside for introduction and proper identification.
- Assist in transferring the patient from bed to stretcher.
- Complete the chart and preoperative checklist.
- Make sure that the patient arrive in the OR at the proper time.

Patient's Family
- Direct to the proper waiting room.
- Tell the family that the surgeon will probably contact them immediately after the surgery.
- Explain reason for long interval of waiting:
anesthesia prep, skin prep, surgical procedure, RR.
- Tell the family what to expect postop when they see the patient

best way to determine identity of px

1. name tag
2. ask px name and dob

INTRAOPERATIVE

Goals
Asepsis
Homeostasis
Safe Administration of Anesthesia
Hemostasis

Surgical Setting
> Unrestricted Area
- provides an entrance and exit from the
- surgical suite for personnel, equipment and patient
- street clothes are permitted in this area, and the area provides access to communication with
personnel within the suite and with personnel and patient's families outside the suite
> Semi-restricted Area
• provides access to the procedure rooms and peripheral support areas within the surgical suite.
• personnel entering this area must be in proper operating room attire and traffic control must be
designed to prevent violation of this area by unauthorized persons peripheral support areas
consists of:
• storage areas for clean and sterile supplies, sterilization
• equipment and corridors leading to procedure room

> Restricted Area

• includes the procedure room where surgery is performed and adjacent substerile areas where
the scrub sinks and autoclaves are located
• personnel working in this area must be in proper operating room attire

Environmental Safety
• The size of the procedure room
• Temperature and humidity control
• Ventilation and air exchange system
• Electrical SafetyCommunication System

Size of the Procedure Room

• Usually rectangular or square in shape
• 20 x 20 x 10 with a minimum floor space of 360 square feet
• Each procedure room must have the following equipment:
- Communication System
- Oxygen and vacuum outlets
- Mechanical ventilation assistance equipment
- Respiratory and Cardiac monitoring equipment
- X ray film illumination boxes
- Cardiac defibrillator
- High-efficiency particulate air filters
- Adequate room lighting
- Emergency lighting system

Temperature and Humidity Control

• The temperature in the procedure room should maintained between 68 F - 75 F ( 20 - 24
degrees C)
• Humidity level between 50 - 55 % at all times

Ventilation and Air Exchange System

Air exchange in each procedure room should be at least 25 air exchanges every hour, and five
of that should be fresh air.
• A high filtration particulate filter, working at 95% efficiency is recommended.
• Each procedure room should maintained with positive
pressure, which forces the old air out of the room and
prevents the air from surrounding areas from entering
into the procedure room

Electrical Safety
Faulty wiring, excessive use of extension cords, poorly
maintained equipment and lack of current safety
measures are just some of the hazardous factors that
must be constantly checked
• All electrical equipment new or used, should be routinely
• checked by qualified personnel.
• Equipment that fails to function at 100% efficiency
• should be taken out of service immediately.

NOTE: For surgery use Gauge 18 - preparation for blood transfusion

Proper Donning and

Doffing of Personal
Protective Equipment (PPE)

Personal Protective Equipment (PPE)

• Refers to protective clothing,
• helmets, gloves, face shields,
• goggles, facemasks and/or
• respirators or other equipment
• designed to protect the wearer from
• injury or the spread of infection or
• illness.

Personal Protective Equipment (PPE)

- Effective use of PPE includes properly removing and disposing of contaminated PPE to
prevent exposing both the wearer and other people to infection.

Infected Waste
Used PPE (Personal Dispose in yellow bag
protective equipments)

Types of PPE Used in Healthcare

Settings
• GLOVES - protect hands
• GOWNS/ APRONS - protect skin and/or clothing
• MASKS and RESPIRATORS - protect mouth/nose
• RESPIRATORS - protect respiratory tract from airborne
• infectious agents.
• GOGGLES - protect eyes
• FACE SHIELDS - protect face, mouth, nose, and eyes

Factors influencing PPE Selection

• Type of exposure anticipated
• Splash/spray versus touch
- Category of isolation precautions
• Durability and appropriateness for the
task
• Fit

Types of Precaution
Standard - gloves and handwashing
Contact - gloves (syphilis, HIV)
Droplet - mask & shield
Airborn - respirator

Element of handwashing
- water
- friction
- hand
*antiseptic solution

Key Definitions

Hand Hygiene
• A general term that applies to any one of the following:
1. Handwashing with plain (nonantimicrobial) soap and water).
2.Antiseptic handwash (soap containing antiseptic agents and water).
3.Antiseptic handrub (waterless antiseptic product, most often alcohol-based, rubbed on all
surfaces of hands).
4.Surgical hand antisepsis (antiseptic handwash or antiseptic handrub performed preoperatively
by surgical personnel to eliminate transient hand flora and reduce resident hand flora).

>Mask
• A term that applies collectively to items used to cover the nose and mouth and includes both
procedure masks and surgical masks.

1. Procedure Mask
• A covering for the nose and mouth that is
intended for use in general patient care situations.
• These masks generally attach to the face with ear loops rather than ties or elastic.

2. Surgical Mask
• A device worn over the mouth and nose by operating room personnel during surgical
procedures to protect both surgical patients and operating room personnel from transfer of
microorganisms and body fluids.

Proper way to wear mask

If with flu, the white side should attach to the face (colored side faces out) to filter organisms not
to spread to others.
If not ill, the white side should face out to prevent from contracting microorganisms.

How do I know that the mask is on correctly?

•The metal nose piece is at the top.
•The white, or smoothest side, is on the
inside against the wearer's skin; the color
always faces out.
• The pleats fall downwards and away from the nose (called a "waterfall” pleat).

3. Respirator
- A personal protective device worn by healthcare personnel to
- protect them from inhalation exposure to airborne infectious agents that are < 5 um in size.
- N95 disposable particulate, air purifying, respirator is the type used most commonly by
healthcare personnel.
- N-99
- N-100 particulate respirators
- Powered air-purifying respirators (PAPRS) with high efficiency filters
- Non-powered full-facepiece elastomeric negative pressure respirators.

Goggles
These are tight-fitting eye protection
that completely cover the eyes, eye
sockets and the facial area
immediately surrounding the eyes
and provide protection from impact,
dust and splashes.

• Face Shields
These transparent sheets of plastic extend from the eyebrows to below the chin and across the
entire width of the employee's head. Face shields protect against nuisance dusts and potential
splashes or sprays of hazardous liquids but will not provide adequate protection against impact
hazards.

• Natural (Latex) Rubber Gloves

They feature outstanding tensile strength, elasticity and temperature resistance. Latex gloves
have caused allergic reactions in some individuals and may not be appropriate for all
employees. Hypoallergenic gloves, glove liners and powderless gloves are possible alternatives
for workers who are allergic to latex gloves.
**allergic to tropical fruits

• Nitrile Gloves
Are made of a copolymer and provide protection from chlorinated solvents such as
trichloroethylene and perchloroethylene. They offer protection when working with oils, greases,
acids, caustics and alcohols but are generally not recommended for use with strong oxidizing
agents, aromatic solvents, ketones and acetates.

Facts about Eye Protection

• Eye protection can be in the form of goggles, safety glasses, or face shields. Personal
eyeglasses and contact lenses provide some but not complete protection and are not
considered adequate eye protection.
• Reusable eve protection should be cleaned
according to the manufacturer's instructions.

Facts about Gloves

• Although gloves do not prevent needlestick orsharps injuries, studies have demonstrated that
the transmission of blood-borne pathogens may be significantly reduced due to the 'cleaning'
effect the material of the glove has on the instrument as it passes through the glove. Gloves
may also reduce the injured person's contact time with the source's blood.
• Prolonged and indiscriminate use of gloves should be avoided as they may cause adverse
reactions and skin sensitivity.
• In countries with limited resources and an
inadequate supply of gloves, used sterile
gloves may be washed, sterilized and reused
for hygiene purposes only - not for invasive
procedures.