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PERIOPERATIVE NURSING
 Perioperative 
      Period of time that constitutes the surgical experience which 
include the pre operative, intraopera...
Intraoperative Phase
Period of time when the patient is transferred to
the operating room table to when he or she is
admit...
B. Surgical Team
1. Patient
2. Circulating Nurse/ Circulator
o Protects the patient’s safety and health by
monitoring the ...
• Assisting the surgeon, and the surgical
assistants during the procedure
• Tissue specimen obtained must be labeled
and s...
5. Registered nurse 1st
assistant
• Responsibilities may include handling
tissue, providing exposure at the operative
fiel...
• Physician specifically trained in the art
and science of anesthesiology.
• An anesthetist is a qualified health care
pro...
• Manages the technical problems related
to the administration of anesthetic agents
• Supervises the patient’s condition
t...
3. Reconstructive or Cosmetic
4. Palliative
CATEGORIES OF SURGERY BASED ON
URGENCY
1. Emergent
 Patient requires immediat...
2. Urgent
 Patient required prompt attention
 Within 24 – 30 hours
3. Required
 Patient needs to have surgery
 Plan wi...
4. Elective
 Patient should have
surgery
 Failure to have surgery is not
catastrophic
5. Optional
 Decision rests with ...
NURSING INTERVENTIONS
A. PRE – OPERATIVE
PHASE
Pre admission testing
1. Initiates preoperative assessment
• Nutritional an...
• Hepatic function
• Immune Function
• Endocrine function
• Previous medication use
• Psychosocial factors
• Spiritual and...
• Instruction for ambulatory surgical
patient
• Cognitive coping strategies
• Pain Management
• Mobility and active body m...
3. Involves family in interview
4. Verifies completion of pre – operative testing
5. Verifies understanding of surgeon – s...
6. Assess patient’s need for post operative
transportation and care
Admission to Surgical Center or unit
1. Completes pre ...
4.Verifies the operative consent has been signed
5. Coordinated patient teaching with other
nursing staff
6. Reinforces pr...
In the holding area
1. Assess patient’s status
(baseline pain and nutritional status)
2. Reviews chart
3. Identifies patie...
6. Administers medication if prescribe
a. Sedatives
 Given to decrease the patient’s anxiety
 Lowers BP, and Pulse
 Red...
c. Tranquilizers
b. Anticholinergic
 Given to reduce the amount of
tracheobronchial secretions
 Interrupts vagal nerve i...
d. Prophylactic antibiotics
• Causes dangerous hypotension both
during and after surgery.
• Eg. Phenergan, Thorazine
• Dec...
8. Provides psychological support
7. Takes measures to ensure patient’s comfort
 They have a tendency to cause vomiting,
...
• Reduce anxiety
• Decreasing Fear
9. Communicates patient emotional status to
other appropriate members of the health tea...
 cover the head with disposable
cap
 Mouth is inspected for dentures or
plates are remove
 Remove jewelry, body piercin...
Anesthesia
Factors that influence the Choice of Anesthesia
1. Patient’s wishes and understanding of the
types of anesthesi...
6. Options for management of postoperative
pain
7. Type and duration of the surgical
procedure
8. Patient’s position durin...
Types of Anesthesia Care
1. General Anesthesia – is a reversible,
unconscious state characterized by
amnesia, analgesia, d...
• Both inhalation of volatile liquid and
gaseous anesthetics causes respiratory
and circulatory depression.
• Highly flamm...
Stage 2 is from the loss consciousness
to the onset of regular breathing and loss
of the eyelid reflex
Stage 3 begins with...
Phases of General Anesthesia
a. Induction
b. Maintenance
c. Emergence
Types of General Anesthesia
a. IV technique
b. Inhal...
 Muscle Relaxants are used by
anesthesia providers primarily to
facilitate intubation and to provide
good operating condi...
Spinal anesthesia – a local anesthetic is
injected into the cerebrospinal fluid in the
subarachnoid space.
Complications:
...
Epiduaral and Caudal Anesthesia
a. Epidural anesthesia – the local
anesthetic is usually injected through
the intervertebr...
Complications:
 Inadvertent Dural puncture
 Subarchnoid Injection
 Vascular Injection
Peripheral Nerve Blocks – wide va...
Intravenous Regional Anesthesia (Bier
Block) it is often used on the upper
extremities. It is highly reliable and easy
to ...
Conscious Sedation/Analgesia – is being
administered increasingly for specific short-
term surgical, diagnostic and therap...
Local Anesthesia – refers to the
administration of an anesthetic agent to
one part of the body by local infiltration or
to...
• Cardiovascular
o Hypotension
o Hypovolemia
o Hypertension
o Dsyrhythmias
• Thermoregulation and Temperature
Abnormalitie...
• Disturbed Thought Processes
• Nausea and Vomiting
• Aspiration
• Acute pain
Stages of Anesthesia
1. Induction of Anesthe...
2. Excitement of Delirium – from the loss
of consciousness to the loss of lid reflex
characterized by shouting, struggling...
 BP is normal
4. Medullary or Stage of Danger – from loss
of respiration to circulation.
 Reached when too much anesthes...
SURGICAL ASEPSIS
SURGICAL ASEPSIS
A.   Principles of Aseptic Technique
1. Only sterile items are use within the sterile
field
2.  Items of ...
4. Sterile gowns are considered sterile in
front from shoulder to level of the sterile
field and at the sleeves 2 inches a...
8. Movement within or around sterile field
must not contaminate the field.
B. Traffic Control
1. Unrestricted area
•      ...
2. Semi restricted area
•   Comprises the peripheral support areas
within the surgical suite
•  Surgical attire should be ...
•      Surgical attire should be worn which
includes hair coverings, and mask
C.   Surgical Attire
1. Surgical gown
2. Ste...
D. Scrub Procedure
1. Turn on the faucet. Most scrubs sinks
have automatic or knee controls for the
faucet.
2. Moisten arm...
4. Wash hands and forearms using the
antimicrobial soap or detergent. Rinse
before beginning the surgical hand scrub.
The ...
6. Rinse the hands and arms thoroughly ,
exercising care to hold the hand higher
than the elbows. Avoid splashing water
on...
7. If the brush or sponge is impregnated with
antimicrobial soap, moisten the brush or
sponge and begin scrubbing. If the ...
8. Scrub each side of the forearm with a
circular motion upto the elbows
9. Hold the arms and hands away from the
body wit...
10. Rinse the hands and arms thoroughly.
11. If the sink is not automatically timed, turn
off the faucet by using the knee...
E. Gowning
1. Self – Gowning Procedure
a.      Grasp the sterile gown at the neckline
with both hands and lift from the wr...
c. Keep the hands on the inside of the
gown while it completely unfolds
d. Slip both hands into the open armholes,
keeping...
f. If the open gloving technique will be use.
Advance the hands completely through
the cuffs of the gown.
The circulating ...
h. Tie or clasp the neckline and tie the inner
waist ties of the gown touching only the
inner aspect of the gown. The gown...
i. After gloving the scrub person hands the
tab attached to the back tie of the gown
to the circulating nurse. The scrub
p...
j. The scrubbed person retrieves the back
tie by carefully pulling it out of the tab
held by the circulating nurse and tie...
b. The gown is opened in the manner
previously describe.
c. The inner side with the open armholes
is turned towards the in...
e. The circulating nurse assist in pulling the
gown onto the shoulders, adjusting the
back and tying the tapes. The wrap
a...
b. The hands are not extended from the
sleeves and cuff when the gown is put
on.
c.  The hands are pushed through the cuff...
b. Keep the hands in direct view, not lower
than the waist level.
c. The gowned person flexes the elbow.
d. Exerting a lig...
Be sure the palm of the glove is
turned toward the ungloved
individual’s hand with the thumb of
the glove directly opposed...
G.   REMOVING SOILED GOWN, GLOVES AND
MASK
1. Wipe gloves clean with a wet sterile towel.
2. Untie surgical gown. Circulat...
5. Repeat steps 3 – 4 for the other side.
6. Keep arms and gown away from body
while turning the gown inside out and
disca...
8. Using the ungloved hand, grasp the fold
of the everted cuff of the hand of the
other glove and remove the glove
inverti...
H.   Universal Precaution
1. Hand hygiene – hands are to be washed
whenever they are visibly soiled, after
contact with bo...
3. Masks, eye protection, and face shields
– mask and eye protection or a face
shields are to be worn at any time
patient ...
5. Sharps – needles, scalpels, and other
sharps are to be handled in a manner to
avoid injury. Needles should never be
rec...
6. Patient Care equipment – single use
items are to be discarded after use.
Reusable equipment must be cleaned
and reproce...
8. Environmental control – adequate
procedures or routine care and cleaning
of environmental surfaces, beds, and
associate...
Physiologic Monitoring
1. Calculates effects on patient of excessive fluid
loss or gain
2. Distinguishes normal from abnor...
Psychological Support (Before Induction and when
the patient is conscious)
1. Provides emotional support to patient
2. Dis...
Psychological Support (Before Induction and when
the patient is conscious)
1. Provides emotional support to patient
2. Sta...
2. Maintaining patent airway
3. Maintaining cardiovascular Stability
∀ Hypotension and shock (dec BP,
pallor, widening pul...
6. Communicates intra-operative information
• Identifies patient by name
• States type of surgery performed
• Identify typ...
 Insertion of drainage
 Catheters
 Administration of blood
 Analgesic
 Occurrence of unexpected events
• Describes ph...
• Communicates presence of family and or
significant others
Determining Readiness to PACU
• Stable vital signs
• Orientati...
Post operative assessment (Recovery Area)
1. Determines patient’s immediate response to
surgical intervention
2. Monitors ...
7. Assess patient’s readiness for transfer to in –
hospital unit or for discharge home based on
institutional policy.
Surg...
4. Assist patient in recovery and preparation for
discharge home.
5. Determines patient’s psychological status
6. Assists ...
2. Reinforces previous teaching and answers
patient’s and family’s questions about surgery
and follow – up care
3. Assess ...
POST OPERATIVE DISCOMFORTS
1. Nausea and vomiting
Causes:
• Most often related to inhalation
anesthetics, which may irrita...
• Small sip of carbonated beverages
• Support the wound
• Turn patient’s head to one side to
prevent aspiration
2. Constip...
Nsg. Mngt:
• Early ambulation
• Laxatives, enema and stool softeners as
ordered
3. Thirst
Causes:
• Side Effect of atrophi...
Nsg Mngt:
• Administer fluid by vein or mouth if
permitted
• Allow patient to rinse mouth with
mouthwash
• Hot tea with le...
POST OPERATIVE COMPLICATIONS
1. Respiratory Complications
Signs: Sudden rise in temp 24 – 48 hours
after surgery
 Likely ...
Interventions
a. Deep breathing and coughing except when
contraindicated. (eye, brain and spinal
surgery)
b. Comfort durin...
2. Fluid and Electrolyte Imbalance
Causes: blood loss, vomiting, copius
round drainage or drainage from tubes
such as NGT’...
4. Gastrointestinal Complications
 No patient should be urged to eat solid
food 1 to 2 days following anesthesia or
surge...
b. Abdominal Distention
 Accumulation of gas due to
excessive handling of bowel during
surgery
 Swallowing of air during...
5. Urinary Complications
 Urinary functions usually return 8 hours
post op
 If bladder is palpable over the pubic bone
a...
a. Hemorrhage from the wound
• Most likely to occur within first 48 hours
• Assessment – bright red blood, decrease
BP, in...
c. Dehiscence and Evisceration
Dehiscence – is a partial to complete
separation of the wound edges
Evisceration – protrusi...
Intervention
a. Low fowler’s position, remain quiet, not to
cough, not to drink or eat anything until
the surgeon arrives
...
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Transcript of "Perioperative nursing"

  1. 1. PERIOPERATIVE NURSING
  2. 2.  Perioperative        Period of time that constitutes the surgical experience which  include the pre operative, intraoperative and post operative  phases of nursing care.  Preoperative Phase Period of time when the decision for surgical intervention is made to when the patient is transferred to the operating room table CARE OF SURGICAL PATIENT A.   Definition of Terms 3 Phases
  3. 3. Intraoperative Phase Period of time when the patient is transferred to the operating room table to when he or she is admitted to the PACU (Post anesthesia care unit) Post operative Phase Period of time that begins with the admission of patient to the PACU and ends after a follow – up evaluation in the clinical setting or home.
  4. 4. B. Surgical Team 1. Patient 2. Circulating Nurse/ Circulator o Protects the patient’s safety and health by monitoring the activities of the surgical team o Coordinates with the other members of the health team 3.The scrub role • Performs the surgical hand scrub.
  5. 5. • Assisting the surgeon, and the surgical assistants during the procedure • Tissue specimen obtained must be labeled and sent to the laboratory by the circulator. 4. Surgeon • Performs the surgical procedure • Heads the surgical team • Setting up the sterile tables, preparing sutures, ligatures and equipments
  6. 6. 5. Registered nurse 1st assistant • Responsibilities may include handling tissue, providing exposure at the operative field, suturing, and providing hemostasis • Another member of the operating room staff 6. Anesthesiologist • Physician specifically trained in the art and science of anesthesiology.
  7. 7. • Physician specifically trained in the art and science of anesthesiology. • An anesthetist is a qualified health care professional who administers anesthetics. • Most anesthetist are nurses who have graduated from an accredited nurse anesthesia program (American Association of Nurse Anesthetists) • Interviews and assess the patient prior to surgery
  8. 8. • Manages the technical problems related to the administration of anesthetic agents • Supervises the patient’s condition throughout the surgical procedure. • Selects the anesthesia, administers it, intubates the patient if necessary. SURGICAL CLASSIFICATION 1. Diagnostic 2. Curative
  9. 9. 3. Reconstructive or Cosmetic 4. Palliative CATEGORIES OF SURGERY BASED ON URGENCY 1. Emergent  Patient requires immediate attention disorder may be life – threatening  Without a delay
  10. 10. 2. Urgent  Patient required prompt attention  Within 24 – 30 hours 3. Required  Patient needs to have surgery  Plan within few weeks or months
  11. 11. 4. Elective  Patient should have surgery  Failure to have surgery is not catastrophic 5. Optional  Decision rests with patient  Personal preference
  12. 12. NURSING INTERVENTIONS A. PRE – OPERATIVE PHASE Pre admission testing 1. Initiates preoperative assessment • Nutritional and Fluid Status • Drug or alcohol use • Respiratory Status • Cardiovascular status
  13. 13. • Hepatic function • Immune Function • Endocrine function • Previous medication use • Psychosocial factors • Spiritual and Cultural Beliefs
  14. 14. • Instruction for ambulatory surgical patient • Cognitive coping strategies • Pain Management • Mobility and active body movements • Deep breathing, coughing and incentive spirometers 2. Initiates teaching appropriate to patient’s needs
  15. 15. 3. Involves family in interview 4. Verifies completion of pre – operative testing 5. Verifies understanding of surgeon – specific preoperative orders  Managing nutrition and fluids  Preparing the bowel for surgery  Instruction for ambulatory surgical patient
  16. 16. 6. Assess patient’s need for post operative transportation and care Admission to Surgical Center or unit 1. Completes pre – operative assessment 2. Assess for risks for post – operative complications 3. Reports unexpected findings or any deviations from normal
  17. 17. 4.Verifies the operative consent has been signed 5. Coordinated patient teaching with other nursing staff 6. Reinforces previous teachings 7. Explain phases in peri – operative period and expectations 8. Answers patient’s and family’s question 9. Develops a plan of care
  18. 18. In the holding area 1. Assess patient’s status (baseline pain and nutritional status) 2. Reviews chart 3. Identifies patient 4. Verifies surgical site and marks site per institutional policy 5. Establishes intravenous line
  19. 19. 6. Administers medication if prescribe a. Sedatives  Given to decrease the patient’s anxiety  Lowers BP, and Pulse  Reduce the amount of general anesthetic to be given in surgery  Overdose can lead to respiratory depression  Eg. Pentobarbital Na (Nembutal), Secobarbital (Seconal)
  20. 20. c. Tranquilizers b. Anticholinergic  Given to reduce the amount of tracheobronchial secretions  Interrupts vagal nerve impulses which acts to slow the heart  Overdose can cause severe tachycardia  Eg. Atrophine Sulfate • Lowers a patient’s level of anxiety
  21. 21. d. Prophylactic antibiotics • Causes dangerous hypotension both during and after surgery. • Eg. Phenergan, Thorazine • Decrease the number of microorganisms in the system e. Narcotic Analgesics  Given to relax the patient, to lower anxiety and to reduce the amount of narcotics given during surgery.
  22. 22. 8. Provides psychological support 7. Takes measures to ensure patient’s comfort  They have a tendency to cause vomiting, respiratory depression, and postural hypotension.  Eg. Morphine, Meperidine HCl
  23. 23. • Reduce anxiety • Decreasing Fear 9. Communicates patient emotional status to other appropriate members of the health team Immediate Preoperative Nursing Intervention • Patient changes into a hospital gown • Long hair maybe braided • Remove the hairpins
  24. 24.  cover the head with disposable cap  Mouth is inspected for dentures or plates are remove  Remove jewelry, body piercings, contactlens, glasses, prosthetic devices and are given to the family members properly labelled with patient’s name. • Allow the patient to void
  25. 25. Anesthesia Factors that influence the Choice of Anesthesia 1. Patient’s wishes and understanding of the types of anesthesia. 2. Patient’s physiologic status 3. Presence and severity of coexisting diseases 4. Patient’s mental and psychologic status 5. Postoperative recovery from various kinds of anesthesia
  26. 26. 6. Options for management of postoperative pain 7. Type and duration of the surgical procedure 8. Patient’s position during surgery 9. Any particular requirements of the surgeon Premedication Purpose: to sedate the patient and reduce anxiety • administered 60 – 90 mins before induction of anesthesia
  27. 27. Types of Anesthesia Care 1. General Anesthesia – is a reversible, unconscious state characterized by amnesia, analgesia, depression of reflexes, muscle relaxation and homeostasis of specific manipulation of physiologic systems and functions. • Inhalation of volatile liquid – ethyl ether, halothane • Inhalation of gaseous anasthetics – nitrous oxide, ethylene, cycloproprane
  28. 28. • Both inhalation of volatile liquid and gaseous anesthetics causes respiratory and circulatory depression. • Highly flammable and explosive when mixed with air or oxygen. Dangers: a. Laryngospasm b. Hypotension c. Respiratory Arrest
  29. 29. Stage 2 is from the loss consciousness to the onset of regular breathing and loss of the eyelid reflex Stage 3 begins with the onset of a regular breathing pattern and lasts until cessation of respiration Stage 4 is from cessation of respiration to circulatory failure that leads to death Stage 1 is from the initial administration of anesthetic agents to loss of consciousness Levels of General Anesthesia
  30. 30. Phases of General Anesthesia a. Induction b. Maintenance c. Emergence Types of General Anesthesia a. IV technique b. Inhalation technique c. Combination of IV an inhalation techniques
  31. 31.  Muscle Relaxants are used by anesthesia providers primarily to facilitate intubation and to provide good operating conditions at lighter planes of general anesthesia. 2. Regional Anesthesia – (conduction anesthesia) is broadly defined as a reversible loss of sensation in a specific area or region of the body when a local anesthetic is injected to purposefully block or anesthesize nerve fibers in and around the operative site.
  32. 32. Spinal anesthesia – a local anesthetic is injected into the cerebrospinal fluid in the subarachnoid space. Complications:  Hypotension  Total Spinal Anesthesia  Positioning Problems  Postdural Puncture Headache • Procaine (Novocaine), Tetracaine (Pontocaine), Lidocaine (Xylocaine)
  33. 33. Epiduaral and Caudal Anesthesia a. Epidural anesthesia – the local anesthetic is usually injected through the intervertebral spaces in the lumbar region although it can also be injected into the cervical or thoracic regions. b. Caudal anesthesia – the local anesthetic is also injected into the epidural but the approach is through the caudal canal in the sacrum.
  34. 34. Complications:  Inadvertent Dural puncture  Subarchnoid Injection  Vascular Injection Peripheral Nerve Blocks – wide variety of peripheral nerves can be effectively blocked by injecting local anesthetic around them to provide adequate surgical anesthesia.
  35. 35. Intravenous Regional Anesthesia (Bier Block) it is often used on the upper extremities. It is highly reliable and easy to accomplish. Monitored Anesthesia Care – (MAC) is provided when infiltration of the surgical site with a local anesthetic is performed by the surgeon and the anesthesia provider supplements the local anesthesia with IV drugs that provide sedation and systemic analgesia.
  36. 36. Conscious Sedation/Analgesia – is being administered increasingly for specific short- term surgical, diagnostic and therapeutic procedures within a hospital or ambulatory center. • It refers to the intravenous administration of certain sedatives and analgesics that produce a condition in which the patient exhibits a depressed level of consciousness but retains the ability to independently maintain a patent airway and respond appropriately to verbal commands or physical stimulation.
  37. 37. Local Anesthesia – refers to the administration of an anesthetic agent to one part of the body by local infiltration or topical application. Postoperative Complications • Respiratory o Airway Obstruction o Laryngospasm o Bronchospasm
  38. 38. • Cardiovascular o Hypotension o Hypovolemia o Hypertension o Dsyrhythmias • Thermoregulation and Temperature Abnormalities o Hypothermia o Hyperthermia
  39. 39. • Disturbed Thought Processes • Nausea and Vomiting • Aspiration • Acute pain Stages of Anesthesia 1. Induction of Anesthesia – from the administration of anesthetic agents to loss of consciousness.  Pupil Size is normal and reacts to light  BP is normal  Irregular pulses
  40. 40. 2. Excitement of Delirium – from the loss of consciousness to the loss of lid reflex characterized by shouting, struggling and talking.  Pupils are dilated by reactive to light Pulse is rapid  Irregular respiration 3. Surgical – From loss of lid reflex to loss of respiration.  Pupils are small and reactive to light  Respiration is is regular
  41. 41.  BP is normal 4. Medullary or Stage of Danger – from loss of respiration to circulation.  Reached when too much anesthesia has been given
  42. 42. SURGICAL ASEPSIS
  43. 43. SURGICAL ASEPSIS A.   Principles of Aseptic Technique 1. Only sterile items are use within the sterile field 2.  Items of doubtful sterility must be considered unsterile 3. Whenever a sterile barrier is permeated it must be considered contaminated
  44. 44. 4. Sterile gowns are considered sterile in front from shoulder to level of the sterile field and at the sleeves 2 inches above the elbow cuff 5. Tables are sterile only at table level 6. The edges of sterile enclosure are considered unsterile 7. Sterile persons touch only sterile items or areas; unsterile person touch only unsterile items or areas.
  45. 45. 8. Movement within or around sterile field must not contaminate the field. B. Traffic Control 1. Unrestricted area •         Area includes areas outside of the surgical suite as well as a control point to monitor the entrance of patients, personnel and materials
  46. 46. 2. Semi restricted area •   Comprises the peripheral support areas within the surgical suite •  Surgical attire should be worn which includes hair coverings •  Ex. Storage area, work areas, corridors 3. Restricted area •      Includes the operating rooms, procedure rooms, central core, the scrub sink areas
  47. 47. •      Surgical attire should be worn which includes hair coverings, and mask C.   Surgical Attire 1. Surgical gown 2. Sterile Gloves 3. Masks, and googles
  48. 48. D. Scrub Procedure 1. Turn on the faucet. Most scrubs sinks have automatic or knee controls for the faucet. 2. Moisten arms and forearms 3. Using foot control, dispense a few drops of antimicrobial soap or detergent into the palms. Add small amounts of water to make a lather
  49. 49. 4. Wash hands and forearms using the antimicrobial soap or detergent. Rinse before beginning the surgical hand scrub. The amount of time needed varies with the amount of soil and effectiveness of the cleansing agent. 5. If a packed scrub brush or sponge is used, open the package. Remove the brush and nail cleaner and discard the package. Hold the brush in one hand while cleaning the nails on the other hand.
  50. 50. 6. Rinse the hands and arms thoroughly , exercising care to hold the hand higher than the elbows. Avoid splashing water onto the scrub suit because this moisture can cause subsequent contamination of the sterile gown
  51. 51. 7. If the brush or sponge is impregnated with antimicrobial soap, moisten the brush or sponge and begin scrubbing. If the brush or sponge is not impregnated with soap, apply anti – microbial soap or detergent solution to hands. Starting at the fingertips, scrub the nails vigorously holding the brush perpendicular to the nails. Scrub all sides of each digit including the connecting webbed spaces. Scrub the palm of the hand
  52. 52. 8. Scrub each side of the forearm with a circular motion upto the elbows 9. Hold the arms and hands away from the body with the hands above the level of the elbows while scrubbing, allowing the water and detritus to flow way from the first scrubbed and cleanest area. Add small amounts of water during the scrub to develop suds and remove detritus.
  53. 53. 10. Rinse the hands and arms thoroughly. 11. If the sink is not automatically timed, turn off the faucet by using the knee control or by using the edge of the brush on a hand control. Discard the brush or sponge. 12.  Hold the hands and arms up in front of the body with elbows slightly flexed and enter the operating room
  54. 54. E. Gowning 1. Self – Gowning Procedure a.      Grasp the sterile gown at the neckline with both hands and lift from the wrapper. Step into the area where the gown maybe opened without risk for contamination. b. Hold the gown away from the body and allow it to unfold with the inside toward the wearer
  55. 55. c. Keep the hands on the inside of the gown while it completely unfolds d. Slip both hands into the open armholes, keeping the hands at shoulder level and away from the body. e. Push the hands and forearms into the sleeves of the gown, advancing the hands only to the proximal edge of the cuff if the close gloving technique will be used.
  56. 56. f. If the open gloving technique will be use. Advance the hands completely through the cuffs of the gown. The circulating Nurse should do the following: g. Pull the gown over the scrubbed person’s shoulders touching only the inner shoulder and side seams
  57. 57. h. Tie or clasp the neckline and tie the inner waist ties of the gown touching only the inner aspect of the gown. The gown should be completely fastened by the circulator before the scrub person dons gloves, to prevent contamination from the gown flapping. To secure the gown the scrubbed person and the circulating nurse should do the following:
  58. 58. i. After gloving the scrub person hands the tab attached to the back tie of the gown to the circulating nurse. The scrub person then makes ¾’s turn to the left while the circulating nurse extends the back tie to its fullest. This action effectively wraps the back panel of the gown around the scrubbed person and covers the previously tied inner waist ties.
  59. 59. j. The scrubbed person retrieves the back tie by carefully pulling it out of the tab held by the circulating nurse and ties it with the other tie, which had been secured to the front tap of the gown. 2.  Assisted Gowning Procedure a. A gowned and gloved person may assist another person in donning a sterile gown
  60. 60. b. The gown is opened in the manner previously describe. c. The inner side with the open armholes is turned towards the individual who is to be gowned. d. A cuff is made of the neck and shoulder area of the gown to protect the gloved hands. The gown is held until the person’s hand and forearms are in the sleeves of the gown.
  61. 61. e. The circulating nurse assist in pulling the gown onto the shoulders, adjusting the back and tying the tapes. The wrap around back on the gown is fixed into position by the scrubbed person after the gloving is completed. F.   Gloving Donning Gloves 1. Closed Gloving Technique a. The gloves are handled through the fabric of gown sleeves.
  62. 62. b. The hands are not extended from the sleeves and cuff when the gown is put on. c.  The hands are pushed through the cuff openings as the gloves are pulled into place. 2.   Open Gloving technique a. The everted cuff of each glove permits a gowned person to touch the glove’s inner side with ungloved fingers and to touch the gloves outer side with gloved fingers.
  63. 63. b. Keep the hands in direct view, not lower than the waist level. c. The gowned person flexes the elbow. d. Exerting a light even pull on the glove brings it over the hand and using a rotating movement brings the cuff over the wristlet. 3.   Assisted gloving technique a. Grasp the glove under the everted cuff.
  64. 64. Be sure the palm of the glove is turned toward the ungloved individual’s hand with the thumb of the glove directly opposed to the thumb of the person’s hand b. Using the fingers stretch the cuff to open the glove. c. The ungloved individual can then insert his/her hand into the glove. d. The procedure is repeated for the other hand.
  65. 65. G.   REMOVING SOILED GOWN, GLOVES AND MASK 1. Wipe gloves clean with a wet sterile towel. 2. Untie surgical gown. Circulator must unfasten back closures. 3. Grasp gown at one shoulder seam without touching scrub clothing. 4. Bring neck and sleeves of the gown forward, over, and off the gloved hand, turning the gown inside out and everting the cuff of the gown
  66. 66. 5. Repeat steps 3 – 4 for the other side. 6. Keep arms and gown away from body while turning the gown inside out and discarding carefully in the designated receptacle. 7. Using the gloved fingers of one hand to secure the everted cuff, remove the glove turning it inside out. Discard appropriately.
  67. 67. 8. Using the ungloved hand, grasp the fold of the everted cuff of the hand of the other glove and remove the glove inverting the glove as it is removed. Discard appropriately. 9. After leaving the restricted area remove the mask by touching the ties or elastic only 10. Discard in the designated receptacle. 11. Wash hands and forearms.
  68. 68. H.   Universal Precaution 1. Hand hygiene – hands are to be washed whenever they are visibly soiled, after contact with body fluids and upon glove removal. 2. Gloves – gloves are to be worn when touching blood, body fluids, secretions, excretions and contaminated items.
  69. 69. 3. Masks, eye protection, and face shields – mask and eye protection or a face shields are to be worn at any time patient care activities are likely to generate sprays or splashes of blood or body fluids, secretions and excretions 4. Gowns- gowns are to be worn at any time patient care activities are likely to generate sprays or splashes of blood and body fluids, secretions and secretions.
  70. 70. 5. Sharps – needles, scalpels, and other sharps are to be handled in a manner to avoid injury. Needles should never be recapped using any technique that directs the point of the needle toward any body part. If recapping is necessary, it should be done using a mechanical device or a one handled scoop technique.
  71. 71. 6. Patient Care equipment – single use items are to be discarded after use. Reusable equipment must be cleaned and reprocessed to ensure safe use for another patient. 7. Linens – linens soiled with blood, body fluids, secretions or excretions should be handled in a manner to avoid skin and mucous membrane exposure. Clothing contamination and transfer of microorganism to another patients, personnel, and the environment.
  72. 72. 8. Environmental control – adequate procedures or routine care and cleaning of environmental surfaces, beds, and associated equipment are to be developed and the use of this procedure is monitored on a regular basis. 9. Patient Placement – patients who contaminate the environment or who are unable to maintain appropriate hygiene or environmental control are to be housed in a private room with appropriate handling and ventilation.
  73. 73. Physiologic Monitoring 1. Calculates effects on patient of excessive fluid loss or gain 2. Distinguishes normal from abnormal cardio – pulmonary data 3. Reports changes in patient’s vital signs. 4. Institutes measures to promote normothermia
  74. 74. Psychological Support (Before Induction and when the patient is conscious) 1. Provides emotional support to patient 2. Distinguishes normal from abnormal cardio – pulmonary data 3. Reports changes in patient’s vital signs. 4. Institutes measures to promote normothermia
  75. 75. Psychological Support (Before Induction and when the patient is conscious) 1. Provides emotional support to patient 2. Stands near or touches patient during procedures and induction C. POST – OPERATIVE PHASE Transfer of patient to post anesthesia care unit 1. Assessment of the patient
  76. 76. 2. Maintaining patent airway 3. Maintaining cardiovascular Stability ∀ Hypotension and shock (dec BP, pallor, widening pulse pressure, cold clammy skin) • Hemorrhage • HPN and dysrhythmias 4. Relieving pain and anxiety 5. Controlling nausea and vomiting
  77. 77. 6. Communicates intra-operative information • Identifies patient by name • States type of surgery performed • Identify type of anesthetic used • Reports patient’s response to surgical procedure and anesthesia • Describes intra-operative factors
  78. 78.  Insertion of drainage  Catheters  Administration of blood  Analgesic  Occurrence of unexpected events • Describes physical limitation • Reports patient’s pre – operative levels of consciousness • Communicates necessary equipment needed
  79. 79. • Communicates presence of family and or significant others Determining Readiness to PACU • Stable vital signs • Orientation to person, place, event and time • Uncompromised pulmonary function • Pulse oximetry reading indicating adequate O2 saturation • Nausea and vomiting absent or undercontrol • Minimal pain
  80. 80. Post operative assessment (Recovery Area) 1. Determines patient’s immediate response to surgical intervention 2. Monitors patient’s physiologic status 3. Assess patient’s pain level and administer appropriate pain relief. 4. Maintains patient’s safety 5. Administers medication, fluid and blood component therapy if prescribe.
  81. 81. 7. Assess patient’s readiness for transfer to in – hospital unit or for discharge home based on institutional policy. Surgical Unit 1. Continuous close monitoring of patients physical and psychological response to surgical intervention. 6. Provides oral fluids if prescribe for ambulatory surgery patient
  82. 82. 4. Assist patient in recovery and preparation for discharge home. 5. Determines patient’s psychological status 6. Assists with discharge planning 3. Provides teaching to patient during immediate recovery period 2. Assess patient’s pain level and administers appropriate pain relief measures.
  83. 83. 2. Reinforces previous teaching and answers patient’s and family’s questions about surgery and follow – up care 3. Assess patient’s response to surgery and anesthesia and their effects on body image and function 4. Determines family’s perception of surgery and its outcome. 1. Provides follow – up care during office or clinic visit or by telephone contact Home or Clinic
  84. 84. POST OPERATIVE DISCOMFORTS 1. Nausea and vomiting Causes: • Most often related to inhalation anesthetics, which may irritate the stomach lining and stimulate the vomiting center of the brain • Accumulation of fluid or food in the stomach Nsg Mngt: • Deep breathing – facilitiates elimination of anesthetics • Side effect of narcotics
  85. 85. • Small sip of carbonated beverages • Support the wound • Turn patient’s head to one side to prevent aspiration 2. Constipation and Gas Cramps Cause: • Trauma and manipulation of the bowel during surgery as well as narcotic use will retard peristalsis
  86. 86. Nsg. Mngt: • Early ambulation • Laxatives, enema and stool softeners as ordered 3. Thirst Causes: • Side Effect of atrophine sulfate • Fluid restriction
  87. 87. Nsg Mngt: • Administer fluid by vein or mouth if permitted • Allow patient to rinse mouth with mouthwash • Hot tea with lemon, gum or hard candies 4. Pain Cause: Stimulation to or trauma to nerve endings Nsg Mngt: Comfort measures
  88. 88. POST OPERATIVE COMPLICATIONS 1. Respiratory Complications Signs: Sudden rise in temp 24 – 48 hours after surgery  Likely to occur after high abdominal operations when prolonged inhalation anesthesia has been necessary and vomiting has occurred during the operation.  Eg. Atelectasis and Pneumonia
  89. 89. Interventions a. Deep breathing and coughing except when contraindicated. (eye, brain and spinal surgery) b. Comfort during coughing by splinting operative side with a draw sheet or supporting both sides of the incision by hand. c. Increase pulmonary ventilation by using blow bottles, incentive spirometer
  90. 90. 2. Fluid and Electrolyte Imbalance Causes: blood loss, vomiting, copius round drainage or drainage from tubes such as NGT’s 3. Circulatory Complications (Thrombophlebitis, phlebothrombosis) Causes: muscular inactivity, post – op circulatory and respiratory depression, increase pressure of blood vessels from tight dressings.
  91. 91. 4. Gastrointestinal Complications  No patient should be urged to eat solid food 1 to 2 days following anesthesia or surgery a. Paralytic Ileus  Cessation of peristalsis due to excessive handling of bowel during surgery Interventions  No fluid or food until (+) peristalsis
  92. 92. b. Abdominal Distention  Accumulation of gas due to excessive handling of bowel during surgery  Swallowing of air during recovery from anesthesia Interventions a. Rectal tube is inserted just pass the rectum (2-4 inches) for approximately 20 minutes.
  93. 93. 5. Urinary Complications  Urinary functions usually return 8 hours post op  If bladder is palpable over the pubic bone and suprapubic pressure cause discomfort then catheterization is ordered to prevent stretching of vesical wall. 5. Wound Complications o Sutures are removed on about 5 – 7th day post op
  94. 94. a. Hemorrhage from the wound • Most likely to occur within first 48 hours • Assessment – bright red blood, decrease BP, increase RR and PR, cold and moist skin, pallor, weakness and restlessness b. Infection • Assessment – low grade fever 3 – 6 days post op, wound is painful and swollen, purulent discharge on the dressings
  95. 95. c. Dehiscence and Evisceration Dehiscence – is a partial to complete separation of the wound edges Evisceration – protrusion of the abdominal viscera through the incision onto the abdominal wall. Assessment – sudden profuse leakage of fluid from the incision, dressings saturated with clear, pink drainage.
  96. 96. Intervention a. Low fowler’s position, remain quiet, not to cough, not to drink or eat anything until the surgeon arrives b. Protruding viscera should be covered with warm sterile saline dressing.

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