NCM 112

CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION,

FLUIDS and ELECTROLYTES, INFECTIOUS, INFLAMMATORY,
and IMMUNOLOGIC RESPONSE,
CELLULAR ABERRATIONS, ACUTE and CHRONIC

______________________________________________________

PERIOPERATIVE NURSING CARE

______________________________________________________

MARIA SOCORRO C. DOMINGO, DNS, RN

College of Nursing
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Effective Date: 7-DEC-2016

WESTERN MINDANAO STATE UNIVERSITY

Copyright © by Western Mindanao State University
All rights reserved. Published (Year)
Printed in the Philippines
ISBN _________________
No part of this publication may be reproduced or distributed
in any form or by any means, or stored in a database or
retrieval system, without prior written permission of
WESTERN MINDANAO STATE UNIVERSITY

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The Perioperative Domain

Welcome to the realm of the Perioperative Nursing. It is an area that is fast-paced and
dynamic as well as enlightening, since you will get to appreciate the actual picture and
structure of the human anatomy. It is also rewarding because most often than not you get to
see the improvement of your patient’s quality of life, which is the outcome of the erudite,
compassionate care of the health team.
The patient’s physical and psychological needs are in the hands of the perioperative
nurse and the rest of the team who are expected to ensure the safety and well-being of the
patient. A patient’s pathway through the perioperative environment starts when the patient
learns of the need for the surgery and agrees to the mode of treatment (preoperative), to the
surgical intervention (intraoperative), and finally to recuperation phase, wherein the
patient’s state of health is comparable to the pre-illness state or an improvement of the
patient’s health status achieved (postoperative).
Hence, the perioperative nurse provides care for patients in the period before, during,
and after surgical intervention. Each phase requires nurses to render comprehensive attention,
that will ensure the safety of the patient under one’s care.
However, while each nurse plays a different role, they work as a team focusing on one
patient at a time with one goal in mind, the betterment of their patient. The competence,
meticulous attention to detail, and altruism, ensure that these goals will come to fruition.
This module addresses Perioperative Care in three lessons. Lesson 1 introduces
preoperative phase, Lesson 2, the intraoperative phase, and Lesson 3 discusses about the
postoperative period. Throughout all these lessons, the nursing process framework will be in
the forefront of the discussion.

Lesson I. Pre-Operative Phase

_________________________________________________

INTRODUCTION

The preoperative period starts when the patient, the patient’s family, or significant
other, is advised on the need for surgery and decides to undergo the surgical procedure. This
is the phase where the professional bond is established between the patient and the health
team. It is also during this phase that the patient is prepared physically and psychologically
for the impending surgery. This period ends when the patient is received by the intraop nurse
and transferred to the operating room bed.

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LEARNING OUTCOMES

At the end of this lesson, you should be able to:

1. Discuss essential facts about surgery

2. Determine the process in preparing a patient physically and psychologically for
surgery
3. Formulate a plan of care utilizing the nursing process on a patient who will undergo
surgery
___________________________________________________________________________

Topic Outline:

I. Basic Surgical Concepts

a. Medical prefixes and suffixes
b. Surgery defined
c. Categories of surgery based on:
1) Urgency
2) Risk
3) Purpose
II. The Surgical Procedure and patient’s preparation
III. Preparing the patient before transport to the Operating Room
a. Patients physical preparation and attire
b. Patient’s record
c. Medications

TRY THIS!

“You go in through the front door of the hospital and depending on how successful your
treatment is, determines whether you leave through the front door
or in a box out of the back door.”
― Steven Magee

Do you know of anyone who underwent a surgical procedure? Perhaps a member of

your family, a neighbor, or a close friend? Did they have the same mindset as the writer
Steven Magee? What were their experiences before, during and after the procedure?
You are now tasked to search for that one person (whom we may call as your
“partner” ) who is willing to talk about their experiences and share their views and feelings as
they go through one of the most unnerving events in their life.
Remember though to apply the therapeutic techniques in communication you have
learned in the lower years to effectively connect with your partner.

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THINK AHEAD!

For lesson 1, you need to select only one identified individual from your short list.
Record the experiences of your participant from the time of admission, and before
being transported to the operating room. The table below will serve as your guide in
this activity as you vicariously journey along with your learning partner.

Use the following symbol for the health worker involved.

P = health care provider (surgeon) ORN = OR nurse
A = anesthesiologist WN = Ward nurse

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Activities Yes No Concept Discussed Health Worker

Interviews:
 Was he/she
interviewed?
 Can he/she still recall
the conversation?
 Did the activity in any
way alleviate their
anxieties?

Laboratory Exam and

Diagnostic Procedures
 Can they recall what
exams or procedures
they underwent?
 x-ray
 blood exams
 urinalysis
 others

Exercises
 Were they coached in
postop exercises?
List them down

Other Instructions
 NPO post-midnight or
hours before surgery
 Medications taken

The information you have gathered will direct you as to the process of interacting and
caring for a preop patient. As you go through this module, you will realize that there might be
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some procedures/activities that were not carried out or additional ones were done. There is
nothing to be alarmed about since each individual situation is unique and is treated according
to the hospital’s policy where they were confined.

Congratulations! You may not have been exposed to the surgical areas; nonetheless,
you were able to vicariously experience the care that is given to a patient in this area. One
tiny step at a time toward achieving the goal of familiarizing yourself with the role of a
perioperative nurse.

READ AND PONDER

As previously mentioned, the preop period begins when the patient is informed and agrees of
the need for surgery. It starts in the ward and ends in the operating room. This is the phase
where patients are physically and psychologically prepared for the surgical procedure through
the following routine.

1. Initial diagnostic studies and medical regimens

2. In-depth interview and assessment are used to formulate the plan of care
3. The preop nurse equips the patient for the procedure through:
 establishment of rapport,
 ascertaining that the patient understands the instructions given,
 ensuring that patient is safe and comfortable during examinations and preparation

BASIC SURGICAL CONCEPTS

We start with the familiarization of some surgical terms. The best method of doing this is by
exploring the medical prefixes and suffixes. Medical terms will be easier to understand once
you grasp the meaning of the combined words. For additional examples you can click on the
hyperlinks included. https://www.caregiverology.com/medical-prefixes-suffixes.html
https://www.thoughtco.com/biology-prefixes-and-suffixes-otomy-tomy-373769

A. Glossary of Terms

1. Prefixes can be seen at the beginning of a medical word. They refer to the site or the
body part being discussed.
a. (angio-) signifies a type of receptacles such as vessel (e.g. angioplasty)
b. (arthro-) refers to a joint or a junction that separates different parts (e.g.
arthroplasty, arthroscopy)
c. (endo-) means inner or internal (e.g. endoscopy)
d. (epi-) indicates a position that is above, on, or near a surface (e.g. episiorrhaphy)
e. (hystero-) denoting the uterus (e.g. hysterectomy, hysterotomy)
f. (nephro-) referring to the kidney (e.g. nephrectomy)
g. (thoraco-) indicating the chest (e.g. thoracotomy, thoracentesis)

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2. Suffixes, when applied to medical terms would connote a procedure, condition, or disease
of the body part. These letters are situated at the end of words which changes the original
meaning.
a. (-centesis) to puncture a cavity to remove fluid (e.g. amniocentesis, arthrocentesis)
b. (-ectomy) to remove or excise (e.g. appendectomy, cholecystectomy)
c. (-ostomy) the surgical creation of an opening in an organ for the removal of waste
(e.g. colostomy, tracheostomy)
d. (-otomy) the cut or make an incision but without removal (e.g. craniotomy,
e. (-oorhaphy) to repair or suture (e.g. cystorrhaphy, herniorrhaphy)
f. (-opexy) surgical suspension or fixation (e.g. hysteropexy)
g. (-oplasty) surgical repair or remodel (e.g. angioplasty, rhinoplasty)
h. (-otripsy) crushing or destroying (e.g. lithotripsy)
i. (-scopy) examination often related to visual observation with an endoscope (e.g.
endoscopy)

B. What is surgery?
Also termed as operation, it is the branch of medicine performed for the purpose of
mechanically altering the human body by the incision or destruction of tissues. (American
College of Surgeons, lifted July 4, 2020)

C. Categories of Surgery

The classification of surgical procedures are grouped into according to their urgency, risk,
and purpose.

According to Urgency
Type of Surgery Description Examples
 Removal of inflamed
appendix
 Control of hemorrhage from
 Performed immediately or as gunshot or stabbed wound
1. Emergent soon as possible  Repair of severe accidental
 Without delay trauma
 Extensive burns
 Bladder or intestinal
obstruction
 Requires prompt attention  Acute gallbladder infection
2. Urgent
 Within 24-30 hours  Kidney or ureteral stones
 Prostatic hyperplasia without
 Patient needs to undergo surgery bladder obstruction
3. Required
 Within a few weeks or months  Thyroid disorders
 Cataracts
 Performed for the patient’s well-
being but is not urgent  Repair of keloid formation
4. Elective  May be planned weeks or months  Herniorrhaphy
ahead of the procedure  Colporrhaphy

 Surgery that is requested or

5. Optional  Cosmetic surgery
decided by the patient

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According to Risk
 Risk deals with the probability of morbidity or death from surgery.
 The risk period covers the entire perioperative phase
Risk Factors Components Nursing Responsibility
Age  Extremely young or old  Detailed assessment
 Obese or emaciated  Initiate teaching
Nutrition
 Nutritional deficits appropriate to patient’s
Fluid and Electrolyte  Dehydration needs
Balance  Electrolyte imbalance  Involve family during
 Problems with the: interview and health
 Pulmonary teaching
 Cardiovascular  Verify completion of
General Health Status  Liver preoperative diagnostic
 Renal testing
 Metabolic disorders  Ensure patient and family
 Infection understanding of surgeon’s
 Anticoagulant preoperative orders
 Tranquilizers  Examine and review
 Antibiotics advanced directive
Medications document
 Diuretics
 Anti-hypertensives  Initiates discharge
 Long term steroid therapy planning

According to Purpose
Approach Rationale Example
 This method is done by the
excision or incision of a
specimen for laboratory
1. Diagnostic  Breast biopsy
analysis in order for
confirmation of the surgeon’s
diagnosis.
 Opening into the
 Performed to confirm the abdominal cavity to
2. Exploratory extent or to make or confirm a assess abnormal tissue
diagnosis growth or trauma

 This method is done to

improve the patient’s
 Performed to relieve the quality of life, whose
symptoms of a disease process condition is terminal or
3. Palliative
correcting the disease causing incurable (e.g.
the symptoms colostomy for bowel
tumor)

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 A surgical intervention to
repair or remove an organ or a
portion of it for the described
as the following:
 Reconstructive - repair of  Plastic surgery for
tissues or organs whose considerable area of
4. Corrective or appearance or function was scarring due to burn
curative damaged
 Constructive - refers to the  Cleft lip or palate
repair of congenitally
malformed organs
 Ablative – (to take away or  Gallbladder or appendix
cut off) refers to the
removal of diseased organs

D. Pre-Admission Practices
 Total analysis of the blood, organ functions, and medical routines are started in the
preop period
 Nursing care plan is based on the data and evidences gathered
Procedures Rationale Nursing Responsibility

1. Medical history and physical  Allergies and sensitivities  Establishes the baseline vital
examination should be noted signs

2. Laboratory tests  Hemoglobin  Prepares patient for the

 Hematocrit procedure both physically
 Complete blood count and psychologically
 Urinalysis  Ensures that all laboratory
examinations are completed
 Differentiates between
normal values from the
abnormal values and refer
accordingly

3. Blood type and cross  In events of blood  Ascertains that the required
matching transfusion (BT) laboratory and diagnostic
 Appropriate examinations are carried out
documentation should be with the patient’s safety in
completed for patients mind through:
who refuse BT  Confirming that the
patient understands the
procedure to be done
 Clarifying
uncertainties
 Ensure the patient’s’
comfort during the
procedures

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4. Chest x-ray  Required of patients  Ascertains that the

with: required laboratory and
 cardiac or diagnostic examinations
pulmonary disease, are carried out with the
 smokers patient’s safety in mind
 60 years old and up through:
 Cancer patients  Confirming the
 Now Mandatory due to patient’s knowledge
the COVID-19 and understanding of
pandemic the procedure
 Clarifying
uncertainties
 Ensure the patient’s’
comfort during the
procedures

5. Electrocardiogram  Routinary for patients  Reviews with patient

40 years or older keeping in mind the
 Mandatory for patients level of literacy or
with cardiac disease comprehension
6. Diagnostic procedures  Special procedures  Assesses patient’s
when ordered (Doppler understanding of the
studies for vascular procedure and answer
surgery) questions to clarify
worries
 Coordinates with
surgeon for any
additional questions
7. Written instructions  Written pre-op
instructions  Prepares the patient’s
8. Informed consent  Includes the surgical plan of care
procedure and risks,  Supplements Pre-op
benefits, and instructions of the health
alternatives team
 Surgeon should  Provides information
document the process unique to the patient’s
9. Nurse interview  Physiological and surgical procedure.
psychological
assessments
10. Anesthesia assessment  For patients with high
risk, and a high degree
of anxiety

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E. Pre-Operative Preparations
Before transporting patient to the Operating Room

Nursing Responsibility Rationale

1. Assess patient’s physical and emotional status  Untoward apprehension should be reported to
the surgeon since they could affect the patient’s
intraoperative course
2. Assess vital signs
 Abnormal vital signs should also be reported
and recorded for proper intervention
 To prevent cross-contamination from blood and
3. Clean hospital gown body fluids thus protecting both the patient and
health care professionals
 Jeweleries are removed for asepsis and
safekeeping and
4. Jewelry (wedding ring)
 Tape wedding ring to prevent loss if it cannot be
removed
5. Dentures, Bridges
 Removed during general anesthesia to prevent
 Remove before general anesthesia unless
obstruction of respiration
ordered
 Permitted with local anesthesia to facilitate
airway maintenance
 Allowed with local anesthesia
 Dentures are necessary to retain facial contours
for some plastic surgery procedures
6. Removable prostheses
 Eye
 Removed for safekeeping
 Extremity
 Circulating nurse will safeguard them and sends
 Contact lenses
them to the PACU with the patient
 Hearing aid
 Eyeglasses
7. Hairs  Braiding and removing of pins will prevent
 Braided scalp injury
 Remove hair pins  Covering hair with surgical cap for reasons of
 Cover with surgical cap asepsis
 Applied before abdominal or pelvic procedures
 Used on patients with:
 varicosities
8. Anti-embolic stockings or elastic bandages
 prone to thrombus formation
 with history of emboli
 geriatric patients
 To prevent overdistention of the bladder or
incontinence during unconsciousness required in
9. Voiding urologic procedures
 Record time of voiding
 Check whether a urine specimen is needed
 Given 1-hour preop is ordered, to establish and
10. Antibiotics reach a therapeutic blood level of antibiotic
prophylaxis intraoperatively
11. Pre-anesthesia medications
 Give as ordered. Drugs may cause
drowsiness, vertigo, or postural hypotension  To reduce apprehension by making the patient
clam, drowsy and comfortable.
 Caution patient to remain in bed
 Raise bed side rails
 Call bell within patient’s reach
 To ensure the correct patient and accurate
12. Proper identification and essential records
procedure

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SEE IF YOU CAN DO THIS!

Consider this scenario.

JDC is a 46-year-old woman who was admitted a day before to the surgical ward for laparoscopic
cholecystectomy under general anesthesia. On physical examination, her vital signs are the following:
 Temperature is 36.6°C (97.88°F),
 Blood Pressure is 120/ 76mmHg.
 Pulse is 82 beats per minute
 Respiration is 21 breaths per minute
 Weight is 72 kgs
 Height is 5’0
Upon admission, her medical record presented with a 24-hour history of abdominal pain that began
approximately 1 hour after a large dinner. The pain initially began as a dull ache in the epigastrium but then
localized in the right upper quadrant (RUQ). She described some nausea but no vomiting.
Since her consultation in the emergency department, the pain has improved significantly to the point of
her being nearly pain free. She describes having had similar pain in the past that would resolve after a few
hours.
Physical examination showed that the abdomen is nondistended with minimal tenderness in the Right
Upper Quadrant (RUQ). Findings from the liver examination appear normal. The rectal and pelvic
examinations reveal no abnormalities.
Her complete blood count reveals a white blood cell (WBC) count of 13,000/mm3. Serum chemistry
studies demonstrate total bilirubin 0.8 mg/dL, direct bilirubin 0.6 mg/dL, alkaline phosphatase 100 U/L,
aspartate transaminase (AST) 45 U/L, and alanine transaminase (ALT) 30 U/L. Ultrasonography of the RUQ
demonstrates stones in the gallbladder, a thickened gallbladder wall, and a common bile duct (CBD) diameter
of 4.0 mm.

Today is your patient’s day for surgery. As JDC’s preop nurse, you need to complete the
following task to ensure a safe and successful operation.

1. Categorize JDC’s surgery according to:

a. Urgency _____________________________________________________________
b. Risk ________________________________________________________________
c. Purpose______________________________________________________________

2. Evaluate your patient’s risk for surgery.

Is it safe for her to undergo the procedure? _____Yes _____ No
Support your answer. _____________________________________________________
_______________________________________________________________________
_______________________________________________________________________

3. Create your preoperative plans in preparing the patient for surgery and give the rationale
Preoperative Preparations
Nursing Care Rationale

Good job! You are now ready to move into the next phase.

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Lesson 2. Intraoperative Phase

___________________________________________________________________________

INTRODUCTION

The Intraop phase begins with positioning of the patient on the operating room bed
and continues until the patient is admitted to the post anesthesia care unit (PACU).
Implementation of the plan and evaluation of care continue during this phase. The
perioperative nurse either functions as a scrub or circulating nurse who applies the patient’s
plan of care efficiently and effectively, with the patient’s safety being taken into
consideration. In some instances, modifications of the care plan can occur when essential.
The patient is the most important person inside the operating room. This is
because the patient is at their most vulnerable, WHY the helplessness? This is because of
their reduced or absence of sensations of pain and depressed reflexes. You will observe a
patient who is:
 unable to act or make personal care decisions
 incapable of communicating
 defenseless against injury.
These weaknesses increase patients’ surgical risks, thus health care workers should ensure
that patent is safe all throughout the intraoperative phase.

LEARNING OUTCOMES

At the end of this session, you should be able to:

1. Identify members of the surgical team

2. Determine the roles and responsibilities of the surgical team members
3. Differentiate between the three (3) types of anesthesia
4. Relate the nursing responsibilities to the stages of general anesthesia
5. Compare the responsibilities of the circulating nurse with that of the scrub nurse
6. Correlate the principles of asepsis and sterility to patient care in the intraop phase
7. Formulate a plan of care utilizing the nursing process on a patient during the
intraoperative phase

Topic Outline:

I. Members of the Surgical Team and Responsibilities

a. Sterile team
b. Nonsterile team
II. Types of anesthesia
a. Nursing Care of patients under anesthesia
III. The circulating nurse and the scrub nurse
a. The role and responsibilities of a circulating nurse
b. The role and responsibilities of a scrub nurse
IV. Principles of asepsis and sterility

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TRY THIS!

You are the circulating nurse of patient JDC whom you met a day prior for a preop
visit. As the intraop nurse, determine the initial measures that you should observe as you
receive the patient from the preop nurse to ensure a safe and successful surgery.
For lesson 2, the Circulating Nurse’s responsibilities are enumerated, you are now
tasked to do the following:
1. Analyze their expected role and give the rationale for each intervention.
2. Compare your assumptions to the answers in page 16.

THINK AHEAD!

Circulating Nurse Responsibility Rationale

1. Greets and introduces self
2. Covers patient with a warm blanket
3. Compares patient’s identification by name
and date of birth
4. Inspects the side rails, restraining straps,
IV infusions, indwelling catheter if secured
5. Observes for reaction to medications
6. Observes patient’s level of anxiety

7. Checks for:
 Consent
 Laboratory and diagnostic results
 Medical record

8. Reviews the plan of care and the surgical

checklist regarding:
 Allergies
 Previous reactions to anesthesia, blood
transfusion
 Patient’s unique and individual needs
9. Cover the patient’s head with a cap

3. Were you able to correctly guess the reasons for the interventions? fall Check the
box corresponding to your result. Remember, this is a self-evaluation, your score
will not be graded.
a) I must read! (0 correct)
b) Not bad! (1-3 correct answers)
c) Better! (4 – 6 correct answers)
d) The best! (7 to 9 correct answers)

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Read and Ponder

Intraoperative – (admission to the OR for the surgical procedure to the Post

Anesthesia Care Unit [PACU])
 The patient is the most important person
 This is where the patient’s vital signs and status are monitored,
 Induction of anesthesia is done
 Skin is prepped (painted with antiseptic) then covered with surgical drapes
 The surgical procedure commences
 Nursing activities are centered in:
 The patient’s safety
 Ensuring an expeditious, uncomplicated procedure
 Observing infection control
 The appropriate patient’s physiologic response to anesthesia and surgery

A. The Intraoperative Nurse Responsibility

Receiving Patient in the Presurgical Area

Nursing Responsibility Rationale
 Introducing self is the first, integral part of
the treatment process. It is a form of treating
1. Greet patient. Introduces self
the patient as an individual, not a faceless
part of the job.
 To keep patient warm and prevent
2. Cover patient with a warm blanket
hypothermia
3. Verify patient identification
 By name and date of birth  To decrease the instances of performing the
 Ask the patient to state and or spell their wrong procedure on the wrong patient
name  The use of two patient identifiers improves
 Check identification against patient’s the reliability of the patient identification
chart, surgical procedure, site, and process
surgeon verbally with the patient and/or
family as appropriate
4. Check: rails, straps, IVF, catheters  To ensure patient’s safety
 An anxious patient can cause the delay or
5. Observe level of anxiety
postponement of the procedure
6. Check the patient’s medical records for:  Consent forms authorizes the attending
 Consent physician and the health care staff to render
 Laboratory results treatment
 Medical history and physical exam  Patient’s records will serve as the baseline
 Verify allergies and medication history for treatment and interventions
 Assessment of patient is a continuous
process in all perioperative phases. The
7. Check skin tone and integrity
surgeon should be notified of any
remarkable changes
 To enable the intraop team to assist patient
8. Verify physical limitation
during positioning and transfer
 To protect hair in case patient vomits
9. Cover the head with a cap  Prevent cross contamination
 Prevent hypothermia

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Intraop Nurse’s Role Inside the Operating Room

Nursing Responsibility Rationale

 It is during this stressful time that the patient
1. Spend time, stay close needs a trusted, competent, and compassionate
person
2. Protect:  The patient will feel embarrassed from body
 Modesty exposure in front of strangers
 Dignity  Patient’s perception of quality care is based on
 Privacy how they are being treated by the health workers
 Noise contributes to the atmosphere of fear
3. Avoid loud noises
perceived by the patient
 The sense of hearing is the last sense lost when
4. Refrain from speaking near the becoming unconscious. The patient may relate
patient everything heard personally and may react
unfavorably
5. Think before speaking
 To ensure patient’s safety from falls or injury
6. Never leave a sedated patient
from equipment
unattended
 The feeling of abandonment is also evaded
7. Identify patient, surgical site and  To avoid errors in medication and surgical
medications procedure
8. Create, maintain, and control a  The OR should be kept quiet to maximize the
therapeutic environment effects of sedation. A tranquil, relaxed, and
 temperature comfortable atmosphere is conducive to team
 humidity concentration
 personnel  Minimal traffic flow should be observed to
 traffic flow decrease the microbial count in the room

I. The Surgical Team

 Scrubs
 Dons st
 Enters
 Handle
patient

Permission to post allowed by concerned personnel

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The NON-STERILE Team

 Anesthesia Provider
(Anesthesiologist)
 Circulating Nurse
 Others (students, technicians)

 Provide direct care outside of the

sterile field and environment
 Handle supplies and equipment that are
not considered sterile

Permission to post allowed by concerned personnel

The Sterile and Nonsterile Team in their PPE (personal protective equipment)
in the COVID-19 Pandemic

Circulating Nurse – holding patient’s chart, with blue-colored, clean surgical gloves

Scrub Nurse – positioned right beside the instruments

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II. Anesthesia

I. Definition:
 A loss of feeling, sensation of pain and protective reflexes
 Analgesia – absence of sensibility to pain without loss of consciousness
 Anesthesiology – branch of medicine, it is the administration of medication or
anesthetic agents for the purpose relieving pain while supporting physiologic
functions
 Anesthetics – drugs that produces local or general loss of sensibility
II. Choice of anesthesia is done by the:
 Anesthesia provider (anesthesiologist)
 Surgeon
 Patient
III. Primary consideration in providing anesthesia
 Low morbidity
 Low mortality
 Lowest concentration
IV. Types of Anesthesia
1. General
2. Spinal and epidural
3. Local
1. General Anesthesia

 General anesthesia (GA) – patient is rendered unconscious, immobile,

will not feel any pain, who does not recall the surgical procedure
 Click on this hyperlink for you to fully appreciate the process of
general anesthesia
https://www.uclahealth.org/body.cfm?id=3453&fr=true#vm_A_54a1c
bb7

 Stages of general anesthesia

Stages of GA Signs Nursing Responsibility

1. Stage I (beginning  Begins to lose 1. Close OR door

anesthesia) consciousness 2. Keep room quiet
(drowsiness, dizziness) 3. Stand by to assist

2. Stage I  Irregular breathing 1. Restrain patient

(excitement  Movements of 2. Remain at patient’s side
phase) extremities quietly but ready to
 Patient is susceptible to assist anesthesia
external stimuli (noise, provider as needed
touch)

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3. Stage III (surgical  Loss of reflexes – 1. Position patient

anesthesia) depression of vital 2. Prepare skin for surgery
functions
 Regular respiration
Relaxed muscles

4. Stage IV (danger  Vital functions are Prepare for

stage) overly depressed cardiopulmonary
 Respiratory failure resuscitation
 Possible cardiac arrest

2. Spinal and Epidural Anesthesia

 Reduces all pain sensation in one region of the body

 Patient is conscious
 Click on this hyperlink for you to fully understand the mechanics of
this type of anesthesia
https://www.youtube.com/watch?v=fjMm0Kh6XjE

3. Local Anesthesia

 The loss of sensation along specific nerve pathways through

depression of the sensory nerves and by blocking the conduction of
pain impulses
 Patient remains conscious
 Click this hyperlink to fully grasp the approach using this type of
anesthesia https://www.youtube.com/watch?v=v29EyjxHMc8

III. The Role of the

Circulating and
Scrub Nurse

CIRCULATING NUR
(supervisor, adviser, teache
 Applies the nursing process in directin
coordinating all activities related to pa
 Creates and maintains a safe, and com
environment for the patient by implem
principles of asepsis
 Provides assistance to any of the OR t
that the sterile team is supplied with ev
necessary to perform the surgical proc
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efficiently
 Identifies environmental danger or stre
involving the patient and the team
 Maintains communication link betwee
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Permission to post allowed by concerned personnel

SCRUB NURSE

 Establishes & maintains integrity, safety, and

efficiency of the sterile field throughout the
surgical procedure
 Plans for, anticipates, and responds to the needs of
the surgeon and other sterile team members by
constantly watching the sterile field
 Possesses the following essential attributes:
 manual dexterity, stamina,
 ability to work under pressure and a stable
temperament
 a keen sense of responsibility
 concern for accuracy in performing all duties

Permission to post allowed by concerned personnel

IV. Principles of Asepsis and Sterility

ASEPTIC & STERILE Techniques: Facts to Consider

1. These practices are based on sound scientific principles and are carried out
primarily to prevent the transmission of microorganisms that can cause infection
2. An object can be aseptic without being sterile
3. It is impossible to remove all microorganisms from the environment, nevertheless,
every effort is made to maximize and control the organisms.

ASEPSIS – the absence of pathogenic (viruses, bacteria, fungi, protozoa, and worms)
microorganisms that cause infection
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Practices Involving Aseptic Technique

(commonly referred to as the “Clean Technique”

Guidelines Practice
 Unsterile gloves are used handle
1. Items in use may be sterile or contaminated or dirty items
unsterile  Sterile gloves are used within the sterile
field
2. Items are used for individual patient  A disposable item should not be washed
only and reused for another patient
 The brush used in surgical scrub is not
considered sterile at any time during its
3. Items are not always used within a
use, yet aseptic practice in surgery requires
sterile field
the hands to be cleaned before donning
sterile gown and gloves.
 An oral suction tip that fell on the floor is
discarded and a new one is obtained even
4. Contamination is contained
though the mouth is not considered part of
the sterile field
5. Reusable items must be terminally  Instruments and accessories are either gas
sterilized or high-level disinfected or steam sterilized before usage
 A reusable item may be stored in opened
6. Items are not necessarily stored in
state if it is not to be used within a sterile
sterile condition
field

STERILE TECHNIQUE
 the process of creating and working within a sterile field
 the foundation of modern surgery

Practices Involving Sterile Technique

1. Items used are sterile without exception
2. Items used have been stored in sterile conditions
3. Contamination is avoided or remedied immediately
4. Reusable items are rendered sterile before reuse
What you should remember about Sterile Technique:

 The patient is the center of the sterile field to include the surgical team, the OR
bed, and the furniture to be used
Guidelines Practice

1. The patient is at risk for infection once

tissues are disrupted, or equipment is
introduced into the vascular system  Sterilize needed instruments and
supplies prior to use
2. Sterile technique should be applied  Sterile team should scrub, gown, and

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during: glove
a) Setting up for an invasive procedure  Patient’s skin is prepped (painted with
b) Preparation of the sterile team to skin antiseptic) and draped (covered
handle the sterile supplies and come with sterile drapes
in contact with the surgical site  Breaks in sterility are immediately
c) Creation of the sterile field corrected
d) Maintenance of the sterile field

3. Microorganisms in the sterile field are

kept to an irreducible minimum to
protect the patient during invasive
procedures

Principles of Aseptic and Sterile Technique

Principles Practices
1. Only sterile items are used within the  If in doubt, consider it unsterile
sterile field  Contaminated items must not be placed
in the sterile field
 Sterile areas of the surgical gown
 Front: 4 inches from the neck
(axillary line) to the waist
 Gloved hand to two inches above the
elbows

Ster

2. Sterile persons are gowned and gloved Non

Fiel

 Scrubbed persons should remember that:

 Anything outside of the yellow
frame is considered unsterile

3. Tables are sterile only at table level

 The top of the table covered with sterile

drape is considered sterile

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 Maintain contact with the sterile field by

4. Sterile persons touch only sterile items means of gowns and gloves
or areas  Avoid leaning over or against a
nonsterile field
 Circulating nurse does not come into
contact with the sterile field and should
remember to:
 Stand at a distance when pouring
solution into sterile receptacles

5. Unsterile persons avoid reaching over

the sterile field

 Edges of flaps (sterile gloves) are

securely held and pulled back so they do
not touch the sterile area

6. The edges of anything that encloses

sterile contents are considered unsterile

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 Contamination is imminent when sterile

7. The sterile field is created as close as
items that are unnecessarily exposed to
possible to the time of use
the environment.
 Sterile persons face the sterile areas
8. Sterile areas are continuously kept in  A staff must remain in the room once
view sterile packs are opened, to ensure that
sterility is not compromised
 Sterile persons allow a wide margin of
safety when passing unsterile areas (at
least 1 foot)
 Sterile persons pass each other back to
back

9. Sterile persons keep well within the

sterile areas

 Avoid leaning on sterile tables or on the

10. Sterile persons keep contact with sterile draped patient – leaning on the patient
areas to a minimum can cause injury to tissues and structures

 The nonsterile team should make sure

they face the sterile field when passing
11. Unsterile persons avoid sterile areas and that a margin of at least 1 foot is
observed when passing a sterile area

 Integrity of sterile packages are

destroyed through:
 Perforations and punctures
 Strikethrough – soaking of the sterile
12. Destruction of the integrity of microbial field by moisture or fluid from an
barriers results in contamination unsterile layer
 The integrity of a sterile package, its
expiration date, and appearance should
be noted prior to opening

 That is why the:

13. When microorganisms cannot be  Sterile team scrubs, dons gown and
eliminated from a field, they must be gloves
kept to an irreducible minimum  Patient’s skin is prepped then drape

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SEE IF YOU CAN DO THIS!

1. As the circulating nurse, create a care plan to ensure your patient JDC is safe and
comfortable inside the operating while she is being prepared for anesthesia induction.
Remember to include the rationale.

Inside the Operating Room

Circulating Nurse Responsibilities Rationale
1.

2.

3.

4.

5.

6.

7.

8.

2. As the CN for this surgery, organize your plan of care based on the Principles of Aseptic
and Sterile Techniques, your responsibilities to ensure that sterility is observed all
throughout the procedure. Select only the principles that are applicable to your role. As
always, include the rationale. (I have identified 9, are we in the same page?)

Principle Rationale

Congratulations! Well done. Let us go to Lesson 3

Lesson 3 Postoperative Phase

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___________________________________________________________________________

INTRODUCTION

The postoperative phase of a patient’s perioperative experience begins after the

surgical intervention is completed and then admitted to a post anesthesia care unit (PACU).
Postop care is the management of the patient right after surgery, to include care given
during the immediate postoperative period, both in the operating room (OR), the post
anesthesia care unit (PACU), and the days following surgery in the surgical unit.

LEARNING OUTCOMES

At the end of this session, you should be able to:

1. Categorize patient’s condition according to the immediate postop and post anesthesia
assessment
2. Arrange in order of priority care of the patient upon admission to the PACU
3. Validate patient’s data and needs postoperatively before endorsement to the surgical
ward
4. Develop the immediate postop nursing care and rationale

Topic Outline
I. Post anesthesia care
II. Admission to the PACU
III. Postoperative observation in the PACU
IV. Discharge from the PACU

Try this!

Consider the image below. This picture depicts the care of an immediate
postoperative patient. You are the PACU nurse of JDC. The intraop nurse just called
in to inform you that the patient’s surgery is done and will be transferred within 15
minutes. Given the image below, prioritize your nursing care by numbering the image
from 1 to 5; with #1 being the highest priority and #5 the least priority.

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THINK AHEAD!

Priority Nursing Care Rationale

1.
2.
3.
4.
5.

READ AND PONDER!

 Successful surgery depends on the following factors:

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1) The physiologic and psychosocial wellbeing of the patient are vital to

the health workers,
2) Their observance of the principles of asepsis, and
3) Their procedural knowledge and skills
 These attributes are necessary to promote, restore, and maintain the patient’s
physiologic stability in a safe, comfortable, and effective environment.
 The competent care provided by trained nurses in the PACU aims to prevent
problems of airway obstruction, laryngospasm, hemorrhage, and cardiac arrest.
 The goal of postop care is to prevent complications like bleeding, pneumonia,
and infection at the same time promote healing of the surgical incision and
patient recovery.

I. Immediate Postop and Post Anesthesia Assessment

 The following data are recorded by the PACU nurse even before patient is
transported to the unit

Postoperative Observation Category

1. Patient’s’ condition  Alert and oriented vs. unresponsive
 Ventilator dependent vs. awake and
2. Need for physiologic support
extubated
3. Complexity of the surgical procedure  Open laparotomy vs. laparoscopy
4. Type of anesthetic administered  General inhalation vs. local infiltration
 Intermittent analgesic vs. continuous
5. Need for pain therapy
epidural effusion
6. Prescribed period for monitoring
 Stable vs. unstable vital signs
parameters to evaluate physiologic status

II. Guidelines for PACU Nurses Post Anesthetic Care

Category Assessment Guide

 Assessment of:
 Airway patency
 Respiratory rate
 Oxygen saturation
1. Respiratory
 Pay particular attention to monitoring oxygenation and
ventilation
 If patient is ventilator dependent or awake and
extubated
 Monitor heart rate and blood pressure
2. Cardiovascular
 ECG monitors is a must
 Periodically assessed mental status
3. Mental Status
 Alert and oriented vs. unresponsive

 Need for pain therapy

 Pain is considered the fifth vital sign
 It is described as both physiologic and psychologic
4. Pain
 The adult patient is offered an opportunity to
describe pain according to a numbered scale of 1 to
10 (see figures 1 & 2)
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 The patient’s ethnicity and sex can influence the

expression of pain (some group consider showing
pain to be a form of weakness)
 Certain operations may involve significant blood loss
5. Hydration
and require additional intravenous fluids management
6. Urine  Urine output and voiding is assessed
 Should be periodically assessed to prevent postop
7. Drainage and Bleeding
complications
 Informing members of the family and significant others
regarding patient’s status and admission to the PACU
8. Advocacy
will help alleviate anxieties and concern.

PAIN MEASUREMENT SCALE

Figure 1. Pediatric (adopted from https://www.disabled-world.com/health/pain/scale.php)

Figure 2. Adult (adapted from https://elleandtheautognome.wordpress.com/2017/09/07/1-10-pain-

scale-descriptors-for-patients-and-doctors/)

10
Excruciating Pain Cannot function. Unable to move
9
8
Very Severe Pain Intense cramping pain. Interferes with basic need
7
6
Severe Pain Distressing. Interferes with concentration
5
4
Moderate Pain Interferes with tasks. Uncomfortable
3
2
Mild Pain Bearable pain. Can be ignored
1
0 No Pain

III. Discharging patient from the PACU

 Most patients are discharged from the PACU at least one hour or until recovery from
anesthesia is ascertained by the nurse and concurred by the anesthesiologist.
 Patient’s stability is ensured upon endorsement (hand-off report) of the patient to the
postop nurse at the receiving (surgical) unit.

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Patient Endorsement Data (Hand-Off Report Information)

Postop Nurse Responsibilities Rationale

The following data should be in the initial patient care
 Proper identification and accuracy of
the surgical procedure and post
1. Patient name, age, and sex
anesthetic care are critical for patient’s
safety and appropriate care
2. Physiologic condition and assessment
 Assessment  Baseline vital signs, along with
patient’s history are crucial during
 Allergies
endorsements since they serve as the
 Vital signs
criteria for care and basis of patient’s
 Preoperative medical and surgical postop status
history
3. Surgeon and the procedure performed
4. Anesthetic used and patient’s response
5. Any unusual circumstances during the
procedure
 May include known infectious  These data will serve as a guide in the
findings accuracy of patient care in terms of:
6. Blood loss and fluid replacement  Type of surgery
 Includes intake and output  Medications
 Fluid and electrolyte imbalances
7. All medications given in PACU
 Cross contamination
 Pain
 Coordinated care with other allied
 Postop nausea and vomiting health care workers
 IV Fluids
8. Dressings and drains
 Foley catheter
9. Tests and treatments performed in
PACU and any postop orders
10. Valuables and their quality
 Prosthetics  Removable prostheses are safeguarded
by the PACU nurse then properly
 Eyeglasses
endorsed to the postop nurse for any
 Hearing aids
changes in the usage
 Others

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11. Location and contact information for  The presence of family or significant
significant other or caregiver others is important in providing
 Social information effective psychological and emotional
 Communication barriers support.
 Language  Knowledge of cognitive and
 Cognition communication challenges will enable
the nurse to counter them accordingly

SEE IF YOU CAN DO THIS!

1. After going through the three phases of perioperative nursing care, you are now familiar
with the interventions that are needed to render effective care. You are therefore tasked to
synthesize the nursing care from pre to intra to postop care with their rationale.

Nursing Responsibility Rationale

Preoperative Preparations
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Receiving Patient in The Pre-Surgical Area
1.
2.
3.
4.
5.
6.
7.
8.
9.

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Nursing Responsibility Rationale

Intraop Nurse’s Role Inside the Operating Room
1.
2.
3.
4.
5.
6.
7.
8.
Postop Endorsement to the Surgical Nurse
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

2. Recall your preop activity. Remember your perioperative learning partner and his/her
journey through the surgical experience. Your task is to:
a) Determine the perioperative nurses’ responsibilities that were missed. Use the
given table below. Enter only those that were not carried out regardless of the
quantity.
b) Write a reflective journal based on the enumerated missed nursing care.
c) You will be evaluated according to the Rubric on Reflective Journal (See
Appendix A. You will find the write-up about this method (reflective journaling)
in the Appendices.

Nursing Responsibility Rationale

Pre-Admission Preparations
1.
2.
3.
Preoperative Preparations
1.
2.
3.
Postoperative Care
1.
2.
3.

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REFERENCES

American College of Surgeons. (July 4, 2020). Definition of surgery. Retrieved from

https://www.facs.org/~/media/files/advocacy/state/definition

AORN (2017). AORN position statement on patient safety. Retrieved from

https://doi.org/10.1016/j.aorn.2017.03.002

AORN (2015). Association of perioperative Registered Nurses guidelines for perioperative

practice. Retrieved from https://www.aorn.org/guidelines/about-aorn-guidelines

John Hopkins University School of Nursing. The B.U.R.P.S. list. Retrieved from

https://nursing.jhu.edu/academics/documents/burps.pdf

Phillips, N. (2017). Berry & Kohn’s operating room technique. 13th edition. Elsevier. eBook.

Rothrock, J.C. (2019). Alexander’s care od the patient in surgery. 16th edition. Elsevier.

eBook.

Smeltzer, S.C., Bare, B.G., Hinkle, J.L., Cheever, K.H. (2010). Brunner & Suddarth’s

textbook of medical-surgical nursing. 12th edition. Wolters Kluwer, Lippincott Williams

& Wilkins. eBook.

Wicker, P. (2015). Perioperative practice at a glance. John Wiley & Sons, Ltd. eBook

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APPENDICES
Appendix A. Rubric on Reflective Journal

CATEGORY 4 3 2 1
SCORE
Intellectual skills
 Rich in  Substantial  Information  Rudimentary
content, information is thin and and
 Clear  General commonplace superficial
1. Critical connections connections  Connections  No
thinking made to the are made to are limited connections,
given the given to the given to the given
situation situation situation situation

 High quality  Some  Little  No evidence

relationship evidence of evidence of of
between the relationship relationship relationship
2. Depth of patient between the between the between the
interview, patient patient patient
reflection learning, and interview, interview, interview,
reading learning, and learning, and learning, and
reading reading reading

 Highly  Evidence of  Some  No analysis,

insightful insightful analysis, synthesis, or
3. Synthesis analysis, analysis, synthesis, evaluation
and synthesis, synthesis, and
Integration and and evaluation
evaluation evaluation

Practical Skills: Communication

 Output is  Output  Output  Output
without or contains 3 to contains 3 to contains
contains 1 to 5 errors 5 errors more than 5
4. Academic 2 errors  Does not  Errors errors
 Does not impede occasionally  Errors
writing impede readability impede impede
conventions readability readability readability
of the entire
output

 Task is  Task is  Task is  Task is

submitted submitted 1 submitted 2 submitted 3
before day after the days after days after
5. Timeliness midnight on due date due date due date
due date

TOTAL SCORE
19 – 20 = 1.0 10 = 3.25
18 = 1.25 9 = 3.5
17 = 1.5 8 = 3.75
16 = 1.75 7 = 4.0
__________________________________
15 = 2.0 6 = 4.25 Final Rating
14 = 2.25 5 = 4.5
13 = 2.5 4 = 4.75
12 = 2.75 3↓ = 5.0 __________________________________
11 = 3.0
Date
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