Perioperative Nursing
Content
PERIOPERATIVE NURSING care of your patient around the operative period preoperative o physical prep laboratories: CBC y Hgb o2 carrying capacity of the blood (risk for decreased tissue perfusion); NV - 12 y Hct percentage of the hemo concentration (solute:solvent); increased dehydration; decreased - bleeding y WBC presence/absence of infection; increased - bacterial y RBC o2 carrier y Plt clotting Laboratories: UA y Reflects basic level of function of kidneys (for excretion of medications) CP clearance pt. older than 40 y 12-lead ECG y CXR IV access (memorize colors!) y Large bore needle usually - 16, 18 (green), 20 (pink), 22 (blue), 24 (yellow) NPO y General surgery min. 6-8 hrs y Regional min 4 hrs Bowel prep y Gradual, progressive diet y (Full diet soft diet general liquids clear liquids NPO) y Neomycin & metronidazole Prophylactic y 30 mins prior to cutting time Remove nail polish pulse oximeter; assess tissue perfusion Remove underwear catheterization; in case of need to defibrillate Remove dentures and contact lenses o Mental prep Informed consent y Who should sign the consent? PATIENT (except less than 18 pero kung emancipated, go lang; unconscious; not of sound mind) y Role of the nurse witness and for clarifications Health teachings (2 types: process what pt should expect; procedural what pt should perform after surgery) y DB inhale (2 secs), hold (3 secs), exhale (4 secs) y CE y Spirometry NV post-op = 5001000 o Emotional prep Who will be with pt in the OR? Expectations post-op o Spiritual prep Chaplain or Pastoral care o PREOPERATIVE MEDICATIONS Anticholinergics (decrease secretions) y Atropine SO4 y Diphenhydramine (sedative also) Analgesics y Nalbuphine (increase pain threshold post-op) Sedative y Diazepam and dormicum (easier induction & lesser anxiety) o AREAS IN OR Non-restricted Area y Lobby y Attire street clothes are allowed Semi restricted Areas
Supply room, staff room, sterilization room, instrumentation room, hallways y Attire clean scrub suit, OR shoes, bonnet Restricted areas y OR suite y Attire scrub suit, OR shoes, bonnet, mask
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Intraoperative o Categories of Surgery Emergency immediately to save life or limb Elective patient s and surgeon s convenience; short delay is fine PURPOSES: y Diagnostic visualize, determine underlying prob y Curative y Ablative removal of a deceased organ o Prefixes/suffixes Pan All Retro behind, posterior Centesis puncture Lith stone/calculus Ostomy opening into Plasty surgical formation Pexy fixation o Operating Room Team Members Surgeon head of the team th Asst Surgeon medical clerk (4 year med students) intern (med school grad w/o license) resident (licensed) fellow (w/ specialization consultant Anesthesiologist hemodynamic monitoring Scrub nurse initial and closing count Circulating nurse 2 steps ahead of the surgeon; coordinates with family members during procedure; specimen-handling; endorse to PACU; surgical safety checklist (Sign In identification, anticipated problems, preop antibiotics, medications, O2; Time Out each member will introduce themselves, surgeon will state operation, instrument count and sterility, standby equipment; Sign Out endorse specimen, untoward post-op expectations) Pathologist y Histopathology (malignancy) y Clinical Pathology (labs) y Blood bank y Autopsy Others y Supervisor y Head nurse coordination w/ other departments; scheduling of procedures (dirty procedures last) y Nurse aide operates sterilization equipments; receptionists y Orderly assist circulating nurse in pt transfer to PACU; positioning patient; cleaning suite y Billing clerk y Internist CP clearance y Intern y Med tech - Phlebotomy y Radiologist y Radiologic technician y Biomed o Biomedical technician check-up, maintenance, repair o OR technician setup of machines o Perfusionist heart-lung machine y Chaplain
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Medical-social services (DSWD) NBI DOH DILG - disposal of medical records (q 5-10 years); along with MMDA and RMAO y RMAO maintenance of cultural heritage sites y Security samga gusto magabscond ASEPSIS AND PRINCIPLES OF STERILE TECHNIQUE Terms: y Asepsis absence of microorganisms y Disinfection reduction of pathologic microorganisms w/o destroying spores y Contaminated soiled w/ microorganisms y Infection invasion of the body by pathogenic microorganisms y Spores inactive but viable state of microorganism y Sterile free from microorganism including spores y Surgical conscience selfinspection and moral obligation involving scientific and intellectual honesty Sources of contamination Skin never sterile Respiratory tract minimize talking Articles used in procedure first knife (never used again for deeper tissues; given again if surgeon wants to extend incision) Circulating air OR traffic Scrub team/patient s hair MEDICAL AND SURGICAL INSTRUMENTS AND SUPPLIES CATEGORY Category I: Critical Items y Sterilized! y Will come in contact with blood vessels or non-intact mucosa y Clamps, scissors Category II: Semi critical Items y Preferred to be sterile y Disinfection is acceptable y Will come in contact with intact mucosa or non-intact skin y Scopes Category III: Non critical items y Will come in contact with intact skin y Clean METHODS OF STERILIZATION Physical y Moist heat (Autoclaving) steam under pressure = appropriate time (min. 15 mins), temp (121-123 degrees C), pressure (15-17 psi) y Dry heat (dry heat autoclaving) y FLASH time (3-10min), temp (132 C), pressure (27 psi) Chemical y Ethylene oxide 6 hrs sterilize + 12 hrs aeration y Sterrad plasma hydrogen peroxide gas sterilization ; choice method for scissors; 30 mins; bawalang moist items and lumix DISINFECTION PROCEDURES High Level Disinfectant prolonged exposure can sterilize item y Activated gluteraldehyde (Cydex) Intermediate Level Disinfectant cannot sterilize; skin prep y 70% alcohol, Iodine compounds Low level disinfectant
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Phenolic compounds, chlorine compounds (bleach) STERILIZATION AND DISINFECTION Labels: y Process date y Expiration date y Item y Packer y Process Wrappers Shelf life y Time-related concept method of sterilization (autoclave = 2 wks, EO = 3 months) y Event-related concept packaging opened, exposure to moisture, etc Indicators y Chemical indicators color change (autoclave tape: white black [exposure to pressure], EO: yellow blue, Sterrad: red yellow/gold) y Biological indicators live bacterial spores (sent to laboratory to check if culture will grow) ANESTHESIA Factors that determine the choice of anesthesia y Physical/mental condition y Age and weight y Operation to be performed (above nipple line/T4 upward general anes; below nipple line/T4 below regional anes) y Patient s preference y Type and probable duration of operation (epidural long, spinal short) y Laboratory findings y Any known idiosyncrasies Stages of Anesthesia y Stage 1 Induction/Stage of Analgesia o Induction loss of consciousness o Drowsy/dizzy o KEEP ROOM QUIET y Stage 2 excitement/delirium o Loss of consciousness loss of reflexes o Excited, irreg breathing, sensitive to external stimuli o MAINTAIN SILENCE y Stage 3 surgical anesthesia o Loss of reflexes respiratory paralysis o Regular respiration, constricted pupils, jaws relax, auditory sensation is lost o ASSIST THE TEAM
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Stage 4 Stage of Danger o STAND BY FOR POSSIBLE CPR Types of Anesthesia y General Anesthesia o Association pathways are broken in the cerebral cortex to produce more or less lack of sensory and motor perception o Pain is controlled by general insensibility, unconsciousness, lack of
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hearing/feeling/moveme nt o Above thoracic level o INHALATION o volatile gases/vapors; mask (short operation, not so secure) or endotracheal tube (orotracheal/nasot racheal) o Sevoflurane (sevorane) o Desflurane (Suprane) o Halothane o INTRAVENOUS o May produce hypnosis, sedation, amnesia and or analgesia o Thiopental Na o Propofol (diprivan) o Ketamine (Ketalar) y Regional Anesthesia o Suppresses superficial nerves and interferes with the conduction of pain impulses from certain area or region o Pain is controlled without loss of consciousness; one region or an area of the body is anesthetized o EPIDURAL o Long procedures below thoracic level o Post-op management of pain o Epidural catheter (perifix) o Bupivacaine (Sensorcaine isobaric, Marcaine) o Lidocaine (for testing) o SUBARACHNOID o spinal anesthesia o short cases below thoracic level o spinal needle gauge = 22, 25, 27 o Bupivacaine hyperbaric (sensorcaine heavy) o PDE (Tetracaine [pontocaine], Dextrose, Ephedrine) o FIELD/NERVE BLOCKS o Surrounding tissues or group of nerves at a given point o LOCAL INFILTRATION o Tissues around incision site o Lidocaine o TOPICAL o Directly to mucosa or surface o Lidocaine spray Complications of Anesthesia y Malignant hyperthermia
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Antidote: Dentroline Na
INCISIONS, POSITION, DRAPING Layers of Abdomen: skin, subcutaneous, peritoneum, fascia Regions of the abdomen (know the locations of organs) Incisions: y RUQ Kocher s Incision y Midline suprapubic/infraumbilical y Paramedial y McBurney s y Inguinal y Pfannensteil transverse suprapubic y Collarline (curvilinear) thyroidectomy y Coronal, butterfly craniotomy y Thoracotomy anterolateral or lateral posterothoracic y Lumbotomy kidney surgery y Sternal for open heart surgery y Limbal cataract extraction y Elliptical halsted incision radical mastectomy y Caldwell Luc Positioning y Factors to consider: o Length of procedure o Site of the operation o Pain upon moving o Kind of anesthetic y Good positioning: o Not interfere with respirations o Not interfere with circulation o Not cause pressure on any nerve o Provide total accessibility for administration of anesthesia and surgery o Reflect proper body alignment, no undue post-op discomfort y Common positions: o Dorsal/supine o Fowler s, sitting o Lithotomy (bastaperineal area) o Etcetcetc y Common injuries o Brachial plexus (pagnahuhulog from body strap) o Ulnar/radial nerve o Saphenous and peroneal nerve damage (stirrups should be padded) o Integumentary damage y SKIN PREPARATION o Determine the area and the extent to be prepared including proposed incision
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Practice modesty and privacy Examine area to be prepared
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INSTRUMENTS Clamping Grasping/holding (Pick ups) Retracting Cutting/dissecting y Handle 4 20 (first knife for skin) y Handle 3 10, 11, 12 (sickle knife), 15 (small-bellied knife) y Handle 7 - 11 (stab), 12, 15 o Gas tanks/cylinders Green O2 Gray CO2 (ETCO2 monitor connected to GETA) Yellow Compressed air Blue Nitrous oxide Black Nitrogen Brown helium o Cautery machine GROUNDING PAD: area with good muscle mass, good tissue perfusion, no keloids/scars, no hair, no moisture, far from metal implants Monopolar Bipolar o Sutures and needles Suture any material used to sew, stitch or hold Ligature tie or ligate blood vessels Primary suture line main layers of tissues w/c must be sutured Stay or tension suture additional support TYPES: y Natural (can cause more tissue reaction)/Synthetic y Absorbable/Non-absorbable (tensions areas i.e. fascia and skin) y Monofilament/Multifilament (more tissue reaction; not ideal for infected area) NEEDLES y 3 basic sections: point, shaft, eye y POINTS: o Taper (round) delicate tissues o Blunt o Cutting tapercut conventional cutting reverse cutting y EYE: o Atraumatic or Swaged o Eyed o French eyed or Spring o Controlled release ALTERNATIVES y Surgical strips y Skin clips y Skin staples y Ligation clips y Surgical staples y Tissue adhesions o Hemostatic Agents Bone Wax Absorbable gelatin sponge Collagen sponge Oxidized cellulose Postoperative
Responsibilities Adequate respiratory function Adequate circulatory function Normal reflex return Safety and comfort Pain management Promotion of wound healing Fluid and electrolyte balance
Supply room, staff room, sterilization room, instrumentation room, hallways y Attire clean scrub suit, OR shoes, bonnet Restricted areas y OR suite y Attire scrub suit, OR shoes, bonnet, mask
y
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Intraoperative o Categories of Surgery Emergency immediately to save life or limb Elective patient s and surgeon s convenience; short delay is fine PURPOSES: y Diagnostic visualize, determine underlying prob y Curative y Ablative removal of a deceased organ o Prefixes/suffixes Pan All Retro behind, posterior Centesis puncture Lith stone/calculus Ostomy opening into Plasty surgical formation Pexy fixation o Operating Room Team Members Surgeon head of the team th Asst Surgeon medical clerk (4 year med students) intern (med school grad w/o license) resident (licensed) fellow (w/ specialization consultant Anesthesiologist hemodynamic monitoring Scrub nurse initial and closing count Circulating nurse 2 steps ahead of the surgeon; coordinates with family members during procedure; specimen-handling; endorse to PACU; surgical safety checklist (Sign In identification, anticipated problems, preop antibiotics, medications, O2; Time Out each member will introduce themselves, surgeon will state operation, instrument count and sterility, standby equipment; Sign Out endorse specimen, untoward post-op expectations) Pathologist y Histopathology (malignancy) y Clinical Pathology (labs) y Blood bank y Autopsy Others y Supervisor y Head nurse coordination w/ other departments; scheduling of procedures (dirty procedures last) y Nurse aide operates sterilization equipments; receptionists y Orderly assist circulating nurse in pt transfer to PACU; positioning patient; cleaning suite y Billing clerk y Internist CP clearance y Intern y Med tech - Phlebotomy y Radiologist y Radiologic technician y Biomed o Biomedical technician check-up, maintenance, repair o OR technician setup of machines o Perfusionist heart-lung machine y Chaplain
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Medical-social services (DSWD) NBI DOH DILG - disposal of medical records (q 5-10 years); along with MMDA and RMAO y RMAO maintenance of cultural heritage sites y Security samga gusto magabscond ASEPSIS AND PRINCIPLES OF STERILE TECHNIQUE Terms: y Asepsis absence of microorganisms y Disinfection reduction of pathologic microorganisms w/o destroying spores y Contaminated soiled w/ microorganisms y Infection invasion of the body by pathogenic microorganisms y Spores inactive but viable state of microorganism y Sterile free from microorganism including spores y Surgical conscience selfinspection and moral obligation involving scientific and intellectual honesty Sources of contamination Skin never sterile Respiratory tract minimize talking Articles used in procedure first knife (never used again for deeper tissues; given again if surgeon wants to extend incision) Circulating air OR traffic Scrub team/patient s hair MEDICAL AND SURGICAL INSTRUMENTS AND SUPPLIES CATEGORY Category I: Critical Items y Sterilized! y Will come in contact with blood vessels or non-intact mucosa y Clamps, scissors Category II: Semi critical Items y Preferred to be sterile y Disinfection is acceptable y Will come in contact with intact mucosa or non-intact skin y Scopes Category III: Non critical items y Will come in contact with intact skin y Clean METHODS OF STERILIZATION Physical y Moist heat (Autoclaving) steam under pressure = appropriate time (min. 15 mins), temp (121-123 degrees C), pressure (15-17 psi) y Dry heat (dry heat autoclaving) y FLASH time (3-10min), temp (132 C), pressure (27 psi) Chemical y Ethylene oxide 6 hrs sterilize + 12 hrs aeration y Sterrad plasma hydrogen peroxide gas sterilization ; choice method for scissors; 30 mins; bawalang moist items and lumix DISINFECTION PROCEDURES High Level Disinfectant prolonged exposure can sterilize item y Activated gluteraldehyde (Cydex) Intermediate Level Disinfectant cannot sterilize; skin prep y 70% alcohol, Iodine compounds Low level disinfectant
y y y y
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Phenolic compounds, chlorine compounds (bleach) STERILIZATION AND DISINFECTION Labels: y Process date y Expiration date y Item y Packer y Process Wrappers Shelf life y Time-related concept method of sterilization (autoclave = 2 wks, EO = 3 months) y Event-related concept packaging opened, exposure to moisture, etc Indicators y Chemical indicators color change (autoclave tape: white black [exposure to pressure], EO: yellow blue, Sterrad: red yellow/gold) y Biological indicators live bacterial spores (sent to laboratory to check if culture will grow) ANESTHESIA Factors that determine the choice of anesthesia y Physical/mental condition y Age and weight y Operation to be performed (above nipple line/T4 upward general anes; below nipple line/T4 below regional anes) y Patient s preference y Type and probable duration of operation (epidural long, spinal short) y Laboratory findings y Any known idiosyncrasies Stages of Anesthesia y Stage 1 Induction/Stage of Analgesia o Induction loss of consciousness o Drowsy/dizzy o KEEP ROOM QUIET y Stage 2 excitement/delirium o Loss of consciousness loss of reflexes o Excited, irreg breathing, sensitive to external stimuli o MAINTAIN SILENCE y Stage 3 surgical anesthesia o Loss of reflexes respiratory paralysis o Regular respiration, constricted pupils, jaws relax, auditory sensation is lost o ASSIST THE TEAM
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Stage 4 Stage of Danger o STAND BY FOR POSSIBLE CPR Types of Anesthesia y General Anesthesia o Association pathways are broken in the cerebral cortex to produce more or less lack of sensory and motor perception o Pain is controlled by general insensibility, unconsciousness, lack of
y
hearing/feeling/moveme nt o Above thoracic level o INHALATION o volatile gases/vapors; mask (short operation, not so secure) or endotracheal tube (orotracheal/nasot racheal) o Sevoflurane (sevorane) o Desflurane (Suprane) o Halothane o INTRAVENOUS o May produce hypnosis, sedation, amnesia and or analgesia o Thiopental Na o Propofol (diprivan) o Ketamine (Ketalar) y Regional Anesthesia o Suppresses superficial nerves and interferes with the conduction of pain impulses from certain area or region o Pain is controlled without loss of consciousness; one region or an area of the body is anesthetized o EPIDURAL o Long procedures below thoracic level o Post-op management of pain o Epidural catheter (perifix) o Bupivacaine (Sensorcaine isobaric, Marcaine) o Lidocaine (for testing) o SUBARACHNOID o spinal anesthesia o short cases below thoracic level o spinal needle gauge = 22, 25, 27 o Bupivacaine hyperbaric (sensorcaine heavy) o PDE (Tetracaine [pontocaine], Dextrose, Ephedrine) o FIELD/NERVE BLOCKS o Surrounding tissues or group of nerves at a given point o LOCAL INFILTRATION o Tissues around incision site o Lidocaine o TOPICAL o Directly to mucosa or surface o Lidocaine spray Complications of Anesthesia y Malignant hyperthermia
o o
Antidote: Dentroline Na
INCISIONS, POSITION, DRAPING Layers of Abdomen: skin, subcutaneous, peritoneum, fascia Regions of the abdomen (know the locations of organs) Incisions: y RUQ Kocher s Incision y Midline suprapubic/infraumbilical y Paramedial y McBurney s y Inguinal y Pfannensteil transverse suprapubic y Collarline (curvilinear) thyroidectomy y Coronal, butterfly craniotomy y Thoracotomy anterolateral or lateral posterothoracic y Lumbotomy kidney surgery y Sternal for open heart surgery y Limbal cataract extraction y Elliptical halsted incision radical mastectomy y Caldwell Luc Positioning y Factors to consider: o Length of procedure o Site of the operation o Pain upon moving o Kind of anesthetic y Good positioning: o Not interfere with respirations o Not interfere with circulation o Not cause pressure on any nerve o Provide total accessibility for administration of anesthesia and surgery o Reflect proper body alignment, no undue post-op discomfort y Common positions: o Dorsal/supine o Fowler s, sitting o Lithotomy (bastaperineal area) o Etcetcetc y Common injuries o Brachial plexus (pagnahuhulog from body strap) o Ulnar/radial nerve o Saphenous and peroneal nerve damage (stirrups should be padded) o Integumentary damage y SKIN PREPARATION o Determine the area and the extent to be prepared including proposed incision
o o o
Practice modesty and privacy Examine area to be prepared
o
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INSTRUMENTS Clamping Grasping/holding (Pick ups) Retracting Cutting/dissecting y Handle 4 20 (first knife for skin) y Handle 3 10, 11, 12 (sickle knife), 15 (small-bellied knife) y Handle 7 - 11 (stab), 12, 15 o Gas tanks/cylinders Green O2 Gray CO2 (ETCO2 monitor connected to GETA) Yellow Compressed air Blue Nitrous oxide Black Nitrogen Brown helium o Cautery machine GROUNDING PAD: area with good muscle mass, good tissue perfusion, no keloids/scars, no hair, no moisture, far from metal implants Monopolar Bipolar o Sutures and needles Suture any material used to sew, stitch or hold Ligature tie or ligate blood vessels Primary suture line main layers of tissues w/c must be sutured Stay or tension suture additional support TYPES: y Natural (can cause more tissue reaction)/Synthetic y Absorbable/Non-absorbable (tensions areas i.e. fascia and skin) y Monofilament/Multifilament (more tissue reaction; not ideal for infected area) NEEDLES y 3 basic sections: point, shaft, eye y POINTS: o Taper (round) delicate tissues o Blunt o Cutting tapercut conventional cutting reverse cutting y EYE: o Atraumatic or Swaged o Eyed o French eyed or Spring o Controlled release ALTERNATIVES y Surgical strips y Skin clips y Skin staples y Ligation clips y Surgical staples y Tissue adhesions o Hemostatic Agents Bone Wax Absorbable gelatin sponge Collagen sponge Oxidized cellulose Postoperative
Responsibilities Adequate respiratory function Adequate circulatory function Normal reflex return Safety and comfort Pain management Promotion of wound healing Fluid and electrolyte balance
