NCM 212 - SURGERY a.

Maintain aseptic technique to provide

safety (sterile environment)
b. note - surgical site infection (SSI)
OUTLINE c. Surgical positioning
d. Equipments are properly functioning, also
I. SURGERY
provide necessary Equipments
II. PERIOPERATIVE NURSING
3. Post Operative Phase - from time of admission to
III. CLASSIFICATION OF SURGICAL
the RR, to the time he is transported back to the
PROCEDURES
surgical unit, discharges from the hospital, until the
IV. PREOPERATIVE PHASE
follow up care.
V. NURSING RESPONSIBILITY
BEGINNING: admission to RR
VI. INTRAOPERATIVE PHASE END: discharge
VII. APPLICATION OF STERILE
TECHNIQUE CONDITIONS REQUIRING SURGERY: (OPET)
VIII. PRINCIPLES OF STERILE 1. Obstruction - blockage to any organ
TECHNIQUE 2. Perforation - fracture or hole in organ, PPUD
IX. ANESTHESIA (perforated peptic ulcer disease)
3. Erosion - wearing OFF
4. Tumor - any abnormal new growth that has no
SURGERY physiologic function (benign or malignant)
SURGERY - designates the branch of medicine that Under diagnostic
encompasses pre-operative care, intra-operative judgement, - Melena - Blood in stool
and post-operative care of patients
OPERATION - for correction of deformities and defects, repair
CLASSIFICATION OF SURGICAL PROCEDURES:
of injuries, diagnosis and cure of disease processes, relief of
suffering and prolongation of life.
ACCORDING TO PURPOSE
1. Diagnostic - Process of determining the nature of
PERIOPERATIVE NURSING the disease
- describes the nursing functions in the total surgical scopy - a. Bronchoscopy - viewing of pulmonary
viewing System
experience of the patients
- Specialize area of practice providing care to surgical b. Colonoscopy - viewing of the colon
clients 2. Exploratory - an investigative operation on a wound,
tissue or cavity
3 PHASES OF PERIOPERATIVE NURSING: tomy - a. otomy- incision
incision b. example to know what organ is affected
1. Pre-operative Phase - from the time the decision is
made for surgical intervention to the transference of (ruptured appendix - so need siyag
the patient to the operating. laparotomy)
START: When decision was made 3. Curative - to treat the disease condition
ENDS: Transference of the patient to OR a. Ablative - removal of a diseased organ
a. Informed consent i. ectomy - removal
b. Demographic data ii. Eg. appendectomy, amputation
- Check personal information- b. Constructive - repair of congenitally
name, age, history of illness or defective organ
allergies, previous surgery i. plasty- surgical repair
c. Health teaching ii. Eg. cheiloplasty, herniorrhaphy,
d. Physical assessment and emotional orchiopexy
assessment is performed c. Reconstructive - to treat disease
e. Laboratory Phase conditions, restore the partially or
2. Intra Operative Phase - from the time the patient is completely damaged organ and tissue.
received in the operating room, to the time of I. eg. skin graft after a burn, total
administration of anaesthesia, surgical procedure is joint replacement, rhinoplasty,
done, until admitted to the RR/PACU perineorrhaphy, ORIF (Open
BEGINNING: starts once transferred to OR and Reduction Internal Fixation)
given with anaesthesia
NOTE:
END: admitted to PACU (POST-ANAESTHETIC
• Perineorrhaphy and Episiorrhaphy is the same
CARE UNIT)
but performed in different conditions

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 1

 accidental

• Perineorrhaphy - cause of tear is accidental on - This events are LIFE-THREATENING

the perineum area during childbirth scenarios
• Episiorrhaphy - cause is intentional for example i. Fetal distress, excessive
during giving birth after episiotomy ii. Ruptured appendix it is
intentional emergency
iii. Obstetric emergencies
4. Palliative - alleviates symptoms without curing the
iv. Ruptured aneurysm
disease condition
v. Life threatening trauma
a. remove the affective area and suture back
vi. Intestinal obstruction
the health are of the patient, will not cure it
b. Multiple injury
just relieve symptoms
2. Urgent/Imperative - to be done within 24 to 30 hours
b. Eg. bowel resection in patient with terminal
(or 24 - 48)
cancer
- It is urgent and requires immediate
5. Transplant - to replace/ organs tissue
attention within the given time frame
a. Heart, lungs, liver, kidney, cornea
a. essential to perform surgery but not an
emergency
NOTE:
o Eyeball removal is impossible due to nerve that is b. Eg. amputation resulting from gangrene,
connected such as the optic nerve, removal of the fractured hp, heart bypass surgery,
said organ causes total blindness appendectomy
3. Elective - performed for the patient’s well being
ACCORDING TO DEGREE OF RISK a. depending on the assessment and findings
(MAGNITUDE/EXTENT) of the surgeon
1. MAJOR b. the doctor will schedule the surgery
- major cavities are opened (chest, c. but the time of surgery depending on the
abdomen, skull) assessment of the doctor
- so much blood loss and usually would last 4. Planned/Required - necessary surgery, needed by
for 8 to 12 hours. (Cataract surgery is the patient but the time of the surgery is scheduled
considered a major surgery) by the physician or surgeon
- Extensive critical assault to the area a. Cataract surgery
- High risk for mortality and morbidity 5. Optional - performed for patients aesthetic
- Prolonged hours of procedure purposes, personal preferences
- Vital organs are affected a. plastic surgery like rhinoplasty
i. Transplant NOTES:
ii. Caesarean - Emergency/ Stat performed immediately
iii. Total hip replacement - Scheduled / Elective
iv. cholecystectomy
v. joint replacement SURGICAL RISK FACTORS (MAMDOCRARD)
2. MINOR 1. AGE - extreme ages :< 2 years or > 65 years have
- only superficial tissues are opened and higher risks
does not open major cavities of the body - - Infant (young age group) blood depletion
can be done in a ambulatory surgery due to their low fluid reserves which can
- Ambulatory surgery means, after the cause (such as) hypovolemic shock
surgery the patient can go home or be - Old - cognitive problems that involves age
discharge on the same day without being related changes, Less physiologic reserves
admitted to the hospital due to old age, diminish blood flow thus
a. A minor surgery can become a major there will be inadequate tissue perfusion
surgery if prolonged 4-5 hrs (due to Nsg. Implications:
complication) ● Consider using lesser doses of anesthesia for
b. Examples desired effect.
i. Debridement - general anesthesia (GA) for children
ii. RASPA OR D & C (dilatation and - Epidural anesthesia for adults bc lesser ang
curettage) side effects
iii. SKIN LESION REMOVAL ● Adjust nutritional intake to conform to higher protein
iv. BREAST BIOPSY and vitamin needs.
v. Removal of warts - Protein for tissue or antibody repair esp in
patients who undergone surgical procedure
ACCORDING TO URGENCY - Vitamin C for immune booster referring to
1. Emergency - to be done immediately surgical patient for antibody formation
- Done without delay to save the life of the - Vitamin A for wound healing; food sources
patient are dairy products

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 2

 - Vitamin K for blood clotting hemostan, 3.5mg/dl, pt is prone to have a cardiac arrest. For
soybean, broccoli calcium it is important for nerve conduction as well
● Anticipate problems from long standing chronic as conduction for heart muscles.
disorders such as DM, anaemia, obesity, CV
disorders, respiratory disorders. For ex, if pt has 5. CARDIOVASCULAR DISORDER
severe anemia need muna mag BT before - Increases risk of DVT or hypovolemic shock
undergoing surgery bc there will be blood loss. For and pulmonary embolism and fluid overload
DM, it should be corrected bc there will be a wound;
di magheal if may DM
2. OBESITY Nsg. Implications:
- Poor vascularity causes tearing in the ● Diligently monitor VS, especially PR, regularity and
suture site and can thus delay wound rhythm, and general condition of the client
healing ● Closely monitor fluid intake bc if too much fluid it will
- full of adipose tissue there is a possibility affect functioning of your heart
that the wound will open ● Assess skin color esp if dehydrated, cyanotic
- dehiscence is greater due to secretion (assess lips, nail beds) if pt has dark skin, check
- Difficulty in breathing causing respiratory upper palate
disorder and they move less that can cause ● Assess for chest pain, lung congestion, and
circulatory problems that will cause peripheral edema
thrombophlebitis ● Observe signs of hypoxia and administer oxygen as
- Unable to breathe or breathe poorly and ordered 2 LPM
difficulty moving esp in supine position ● Early postoperative ambulation and leg exercises
turn side to
Nsg. Implications: ● 2 Encourage change of position but avoid sudden
side every
● Promote weight reduction if time permits (anticipate hours exertion. 24 hrs after surgery or if already awake, pt
several problems like poor wound healing when has to ambulate or to move in bed so as not to have
performing surgery on a obese patient) respiratory problems. Kasi if magkaresp problem,
● Monitor closely for wound and cardiopulmonary magkaroon ng fluid in the lungs of pt esp in the alveoli
complications postoperatively. Prone to atelectasis then pt will have difficulty of breathing
or respiratory problems ● Sudden change of position might cause hypotension
● Encourage coughing, turning, and diaphragmatic
breathing exercise and early ambulation 6. RESPIRATORY DISORDER
- High risk to contribute to another respiratory
3. MALNUTRITION disorder
- Body reserve is not sufficient to respond Nsg. Implications:
satisfactory organ failure and shock may ● Closely monitor RR, PR, and breath sounds
result ● Assess for hypoxia, dyspnea, lung congestion and
- vulnerable to pressure ulcers due to chest pain
surgical positioning (there is pressure on ● Encourage coughing, turning, and diaphragmatic
bony prominences tissues breathing exercises and early postoperative
- Poor inadequate nutrition result in delay ambulation
wound healing ● Encourage client to quit smoking or at least to reduce
the number of cigarettes smoked
Nsg. Implications: ● Patients with chronic pulmonary problems such as
● Promote weight gain by providing a well-balanced emphysema, bronchiectasis, etc. should be treated
diet high in calories, protein and vitamin C. for several days preoperatively with bronchodilators,
● Administer total parenteral nutrition, nutritional aerosol medications, and conscientious mouth care.
supplements and tube feedings as prescribed.
● Daily weights and calorie counts may be ordered. 7. DIABETES MELLITUS
- increased risk for surgery due to fluctuating
4. DEHYDRATION/ ELECTROLYTE IMBALANCE blood glucose levels
- Depending on the degree of dehydration or - can develop cardiovascular disorder
depending on type of imbalance cardiac - susceptible to delay in wound healing
failure may occur Nsg. Implications:
Nsg. Implications: ● Monitor the client closely for signs and symptoms of
● Assess patient esp fluid status hypo/hyperglycemia. If pts have diabetes then may
● Administer IV fluid as ordered. If severely dehydrated medications, meds should be continued even during
ang pt, hydrate pt first before surgery. Probably 2L or surgery esp when they have insulin bc pt is under
3L fast drip stress so the more that endocrine system will cope
● Keep a detailed I&O record up with the stress so magincrease use ng sugar
● Monitor for evidence of electrolyte imbalance (Na+, ● Monitor blood glucose levels every 4 hours as
K+, Ca++, etc.). if taas ang potassium, more than ordered

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 3

 ● Administer insulin as prescribed given even - And causes respiratory
intraoperatively; as circulating nurse, check if may depression
insulin para di madelay Nsg Implications:
● Encourage intake of food at the designated meal and ● Monitor I&O and electrolytes.
snack times ● Assess cardiovascular and respiratory status.
c. Antihypertensive (phenothiazine)
8. RENAL AND LIVER DYSFUNCTION - Can increase the hypotensive
- decrease metabolism and decrease effect of anaesthesia that result in
excretion of drugs causing anaesthesia to hypovolemic shock
not work Nsg. Implications:
- Kidney for elimination of anaesthetic drug - Closely monitor blood pressure.
- Anaesthetic drug has Side Effects d. Antidepressant (MOA inhibitors)
Nsg. Implications: - monoamine oxidase inhibitors;
● Evaluate closely for drug side effects and evidence increase hypotensive effect of
of acidosis or alkalosis. anaesthesia
● Monitor for fluid volume overload, I&O, and response Nsg. Implications:
to medication. ● Closely monitor blood pressure.
● decrease wound healing check e. Antibiotics
- Incompatible with anaesthetic
9. ALCOHOLISM agent and potentiate the
- Accompanied with problems in malnutrition hypotensive effect of anaesthesia
such as delay wound healing and increased Nsg. Implication
risk for infection - Monitor Respirations
- Require high dose in anaesthetic drugs
11. OTHER FACTORS
since they are immune to normal levels due
1. Nature of the condition – what is the surgery
to alcohol intake
all about, or para saan ang gagawin for pt,
Nsg. Implications: would it be beneficial for the pt to do the surgery
- Monitor closely for signs of delirium tremens (form of or not
psychosis caused by alcohol withdrawal in the body) 2. Location of the condition – location: heart,
so pts will have seizures, hypotension brain; and what type of brain surgery are they
- Encourage a well-balanced diet. Esp rich in vitamin going to have, is it only evacuation or clipping
B complex bc liver produces this vitamin so if of aneurysm.
diseased na ang liver, iheal muna bago sched ng 3. Magnitude and urgency of the surgical
procedure – for ex. clipping of aneurysm – it is
surgery
very urgent bc there is pooling of blood sa brain
- Monitor for wound complications. which may cause to have bleeding, seizure,
- Administer supplemental nutrients parenterally as hypotension, also cause death.
ordered. 4. Mental attitude of the person toward the
- monitor the patient intake surgery – if patient is psychologically prepared,
does the pt experiences anxiety.
10. MEDICATIONS 5. Calibre of the professional staff health care
Note: - Obtained even info such as medications facilities – how good the surgeon, number of
ASPIRIN times that the surgeon have done this
should be that the pt is currently taking to determine
procedure, facilities if kaya ba ng hosp to have
given appropriate drugs to be given that procedure.
operatively a. Anticoagulants/ Salicylates
because it
- Known as to prevent blood clot COMMON SUFFIXES IN SURGERY
may increase
the bleeding formation
- Cause intra and post op bleeding o ectomy – removal of an organ or a gland
Nsg implications: o orrphaphy – repair
● Monitor for bleeding. Post-op check if may good o ostomy – providing an opening (stoma)
o otomy – cutting into
wound closure, dry dressing and no blood
o plasty – formation or plastic repair
● Assess PTT/PT values. o oscopy – looking into viewing
● PTT - partial thromboplastin time, PT -
prothrombin time COMMON ABBREVIATIONS
● values will tell the clotting time of patient; determine
if long or normal ABBREVIATIONS
b. Diuretics (Thiazides) TTAHBSO Total Abdominal Hysterectomy and Bilateral
Salpingo-Oophorectomy
- Cause fluid and electrolyte TURP transurethral resection of
imbalance the bladder tumor
- Produce altered cardiovascular
TURBT transurethral resection of
problems
the bladder tumor

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 4

 STSG split thickness skin
PSYCHOLOGICAL PREPARATION
grafting
- surgery can be distressing to the family and the
BKA below knee amputation patient
AKA above knee amputation B
ECCE w/ IOL extra capsular cataract FEAR - an emotion marked by dread, apprehension and alarm
construction with caused by anticipation or awareness of danger and
intraocular lens manifested by anxiety. Distress emotion that is aroused
implantation TYPES OF FEAR (CAUSE OF FEAR OF THE
CHOLE w/ IOL cholecystectomy with PREOPERATIVE CLIENT)
intraoperative 1. Fear of the UNKNOWN - most common
cholangiogram a. the expected is less traumatic than the
D&C dilatation of the cervix and unexpected
curettage of the uterus 2. Fear of ANAESTHESIA - fear of loss consciousness
SMR submucous resection of is closely aligned with fear of death
the nasal septum 3. Fear of PAIN and DISCOMFORT - pain is powerful
MRM emotion than sensation brought by anxiety
modified radical
4. Fear of DEATH - a very valid fear
mastectomy
5. Fear of DISFIGUREMENT, MUTILATION LOSS OF
LCCS lower cervical cesarean A VALUED BODY PART - Hard to accept the
section possible outcomes after surgery. Real suffering
LSTCS low segment transverse psychologically
cesarean section 6. Fear of loss of LIVELIHOOD - due to financial
ORIF open reduction internal instability, or loss of finances due to surgery
fixation
BTL bilateral tubal ligation MANIFESTATION OF FEAR:
● Bewilderment
EXLAP exploratory laparotomy
● Anxiousness
SAB subarachnoid block ● Anger
CEB continuous epidural block ● Tendency to exaggerate
CSEA combined spinal epidural ● Sad, evasive, tearful, clinging
anesthesia ● Inability to concentrate
RASAB regional anesthesia ● Short attention span
subarachnoid block ● Failure to carry out simple directions
TIVA total intravenous
anesthesia NURSING INTERVENTIONS TO MINIMIZE
GA general anesthesia via ANXIETY:
1. Explore the client's feelings.
mask/LMA
2. Allow clients to speak openly about fears/concerns.
GETA general electrical 3. Give empathetic support.
anesthesia 4. Consider the person’s religious preferences and
arrange for visit by priest/minister as desired.
ROOT WORD
• arthro – joint (arthroplasty)
LEGAL CONSIDERATIONS (OPERATIVE PERMIT/
• blepharo – eyelids (blepharoplasty)
SURGICAL CONSENT)
• cholecyst – gallbladder (cholecystectomy)
Informed consent
• colpo – vagina (colporrhaphy) - is a LEGAL document required for certain diagnostic
• cranio – skull (craniotomy)
procedures or therapeutic measures, including
• cysto – urinary bladder (cystectomy)
surgery
• gastro – stomach (gastroscopy)
• hepato – liver (hepatotomy) - Written in simple words and sentences
• entero – intestines (enterostomy) - Medico required and will serve as evidence
• hystero – uterus (hysterectomy)
• mast – breast (mastectomy) PURPOSES: (MADE TO PROTECT PATIENT
• myo – muscle (myomectomy – muscle tumor) DOCTOR AND THE SURGICAL TEAM)
• nephro – kidney (nephrectomy) 1. To ensure that the client understands the nature
• pneumo – lung (pneumonectomy) of the treatment including the potential
• procto – anus (proctoscopy) complications and disfigurement.
• rhino – nose (rhinoplasty) - The patient has to be informed what would
• thoraco – chest (thoracotomy) be the benefits and risks.
• tracheo – trachea; windpipe (tracheostomy) 2. To indicate that the client’s decision was made
without pressure.
PREOPERATIVE PHASE

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 5

 - Not under any medication and under the 4. Emancipated minors - earning married minors
influence of drugs when making the 5. Emergency Situation - next of kin/create a surgical board to
decision, pt needs to be aware when decide for the px
- the attending physician will sign the consent when
making the decision, to avoid legal
the situation is emergency
problems.
6. Illiterate - making an x then the witness writes “patient’s
3. To protect the client against unauthorized
mark” - pt who cannot read/write pwede thumb mark
procedure.
- To know that the person doing the surgery NURSING RESPONSIBILITY:
is a certified surgeon - knows what that - Witnessing the exchange of information b/w the
surgeon is doing. If the procedure is not client and the surgeon
stated in the consent, then the doctor - Witnessing the client’s signature
cannot do such additional procedures. E.g., - Establishing that the client really did understand.
BTL during caesarean section. Nurses should not explain, only the surgeon. As a
4. To protect the surgeon and the hospital against nurse, we should just make sure that the patient
legal action by a client who claims that an really did understand what's going to happen during
unauthorized procedure was performed. the surgery.
- Two-way protection to the doctor and the
hospital PHYSIOLOGICAL PREPARATIONS

NURSING RESPONSIBILITY LABORATORY AND DIAGNOSTIC TESTS

3 MAJOR ELEMENTS OF THE INFORMED 1. Cardiovascular - Ecg
CONSENT - For patients aged 40 years and above
1. VOLUNTARY 2. Hematologic - CBC, Hgb, and Hct, WBC, PTT, and
2. INFORMED (ultimate decision maker) PT, Platelet count
3. Patient must be competent to understand the 3. Respiratory - Chest X-ray, Pulmonary function
information and alternatives Test/PFT
NOTE: 4. Metabolic - FBS, Electrolytes (K+, Na++, etc.)
- the patient will sign a waiver if he or she does not 5. Genitourinary - routine urine analysis
want to get the surgery so when something happens
to the patient it was his and her decision to not accept PHYSICAL PREPARATIONS:
the surgery
TEACHING POST OP EXERCISES
“OBTAINING THE INFORMED CONSENT IS THE 1. Deep breathing exercise (diaphragmatic)
RESPONSIBILITY OF THE SURGEON “ - To promote lung expansion and ventilation
- the surgeon will ask the patient to sign and enhance blood oxygenation
- the nurse will witness the signing of the waiver from - Patient should be fully awake and
the surgeon and patient conscious
- Position the patient in fowlers or semi
fowler. Inhale thru the nose and hold for at
least 5 seconds. Exhale thru the mouth and
repeat every 2 hours.
2. Coughing exercises
- Incentive spirometer
- Contraindicated to pt with head or eye
surgery; can increase intraocular pressure
and intracranial pressure
- To loosen, mobilize and remove pulmonary
secretions
3. Turning Exercises
- Performed 5 times every hours
- Tas wa ko kabalo diri ahhahaha
4. Leg, Ankle, and Foot exercises
- Purpose of leg exercises is to promote
venous blood return from the extremities
- Wala nako naminaw diri:<
HHHAHAHAHAHAHA
Fig 1. Example of Waiver
NIGHT PRIOR TO SURGERY:
WHO SIGNS THE CONSENT?
● Preparing the skin
1. Adults
2. Next of Kin (if married: spouse) - Includes shaving the hair of the affected
3. Parent or Legal Guardian area to ensure the close clean shave

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 6

 - Upon shaving we can injure the site thru ● Have client void before pre op medication
shaving with small cuts thus increasing risk - Allow the pt to void; anes is a sedative thus
for infection or unsa ba pt is at risk of accidents
- Changes in skin prep is done during itnra op - To avoid any bladder injury
hindi na in pre op
● Preparing GIT (GASTROINTESTINAL TRACT) SURGICAL CHECKLIST
- Bowel preparation (cleansing enema) ● Certain things that need to be done before surgery to
- Place the patient in NPO post-midnight make sure everything is accomplish and to reduce
- according to ASA there is no need for NPO risk of accidents
post-midnight ● Pink sheet (checklist)
- To prevent help, reduce incidence post op
N/V and may develop post op bleeding
- placing a patient on NPO can give
satisfactory viewing of the operating site
- We place patient on NPO to decrease risk
of aspiration pneumonia under while
anesthesia
- If we are the pre op nurse, we must ensure
that the patient is being reminded to stay
under npo till surgery to reduce risk of
aspiration
Fig 2. Surgical Checklist
● Preparing for anesthesia
- Remind the patient to avoid alcohol at least PREOPERATIVE MEDICATIONS/ PREANESTHETIC
24 hours DRUGS
- anesthesia consent check if the - It must be administered 60-90 minutes before
anesthesiologist has obtained consent prior surgery
to surgery GOALS:
● Promoting rest and sleep 1. To allay anxiety
- By administering sedatives as ordered - Either give barbiturates or tranquilizers to
alleviate anxiety
ON THE DAY OF SURGERY: 2. To minimize respiratory tract secretions to
EARLY AM CARE: prevent incidence of aspiration and changes in
● Awaken on hour before pre op medications
HR
-
- Anticholinergics
● Morning bath, mouth wash
3. Create amnesia for the events that precede
-
surgery
● Provide clean gown
-
- so there will be no cross contamination.
4. To decrease body metabolism so less anesthetic
● Remove hairpins, braid long hair, cover hair wash
will be used
cap
- We need to give analgesics preoperatively
- To prevent contamination
to decrease metabolism that created by
● Remove dentures, foreign materials, colored nail
your anesthetic agent
polish, hearing aid, contact lens, wedding ring ,
underwear PRE-OP MEDS:
- Remove Dentures to avoid aspiration that 1. Sedatives and Hypnotics (Versed (Midazolam)
may cause airway obstruction Phenergan (Promethazine,
- Remove colored nail polish to check - Reduce pt anxiety
capillary refill - Decrease BP and HR
● Take baseline VS before pre op medication 2. Barbiturates/ Tranquilizers
- Sometimes before transporting the patient - Same effect of sedatives
● Check ID band, skin prep - Calming effect administered a night prior to
- Check id band to confirm identification of surgery
the patient this is to avoid the “wrong - Valium (Diazepam) most
patient, wrong procedure” common; Inapsine (Droperidol)
- if you don’t check it mag incident report ka 3. Narcotic Analgesics(Valium (DiazepamP,)
● Check special orders- enema, tube insertion, IV line - It can be given pre op if pre op pain is
(in the morning) anticipated
- - Morphine sulfate (most common)
● Check NPO- ensure that patient has not taken food - Fentanyl (sublimaze)
for the last 10 hours - Demerol (meperidine hcl)
-

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 7

 4. Anticholinergics - Autoclave machine - free vacuum, high
- Drugs that block the action of acetylcholine temp steam sterilizer
- To reduce oral resp unsa daw to?? - sterile/autoclave tape -
- Interrupts vagal unsa daw - Pressure greater than the atmosphere;
- Atropine sulfate(most common) temp set 132 c
- Glycopyrrolate (Robinul) 2. Gas Chemical Sterilization
- Scopolamine - Is used to sterilize items that are heat or
- moisture-sensitive
5. Histamine- H2 Receptor Antagonist - Instruments that are made of rubber or
- Inhibits gastric acid production to reduce plastic such as asepto syringe
gastric ulcer so even w/o food our GIT - Uses a chemical agent (ethylene oxide gas)
keeps producing 3. Liquid Chemical Sterilization
6. Anxiolytics - eg. diazepam (valium) - When items cannot tolerate sterilization by
- Drug used to reduce anxiety saturated steam under pressure and when
- Most common is Diazepam time for gas sterilization is impractical
(Valium) - Instruments used are to be soaked for 30
7. Antiemetics mins to 1 hour
- Drug used to treat N/V
- Reduce incidence of N&V intra or post STERILE FIELD
operatively - The area the surgical site or introduction of any
8. Prophylactic Antibiotics are instrumentation into a body orifice that has been
- Cephalosporins (Cefazolin) prepared for the sterile field
- Surgical prophylaxis - Includes furnitures covered with sterile drapes
- Personnel who are properly attire is included in
PRE-OP NURSING DIAGNOSIS sterile field
● Anxiety related to the surgical experience
(anaesthesia, pain) and the outcome of surgery STERILE TECHNIQUE/SURGICAL ASEPSIS
● Fear related to perceived threat of the surgical - method/practices used to prevent contamination
procedure and separation from support system
SURGICALLY CLEAN
● Knowledge deficit of preoperative procedures and
- It uses chemical, physical or mechanical means that
protocols and postoperative expectation
markedly reduced the no. of microorganisms
- After surgical scrubbing is not considered sterile
INTRAOPERATIVE PHASE
(surgically clean ra siya)
TERMINOLOGIES
DISINFECTION
SURGICAL CONSCIENCE
- Process of destroying pathogens except spores
- May simply state as a surgical golden rule “Do unto
- Can be used in inanimate objects; cannot be used in
the patient as you would have others do unto you.”
skin tissues.
ASEPSIS
- Absence of microorganisms that causes the disease
ANTISEPTIC
- Freedom from infection
- Used on tissue and skin
- Absence of pathogenic microorganisms; aseptic-
- Can be used in endogenous that can be found inside
without infection
the body
STERILE
- Alcohol, povidone iodine (betadine)
- Free of microorganisms, including spores-
microorganisms present in the environment; inactive
MEDICAL ASEPSIS
- May it be pathogenic or non pathogenic - Include all practices to confine a specific
- Absence of all types of microbial form microorganism to a specific area limiting the no.,
SPORES growth and spread of microorganisms
- An inactive but viable state of microorganisms in the
Objects referred as:
environment a. Clean - non pathogenic microorganisms are
STERILIZATION present; absence of pathogenic organisms
- Process of killing all microorganisms, including
b. Dirty (soiled) - presence of pathogenic
spores
microorganisms
- Absolute term used to properly kill all the
NOTE:
microorganisms Trash Bins
● Black - dry
3 METHODS OF STERILIZATION ● Yellow - soiled or contaminated
1. Saturated Steam under Pressure
- Is a dependable physical agent for
destruction of all forms of microbial life, APPLICATION OF STERILE TECHNIQUE
including spores

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 8

 - Strict adherence to sterile technique to ensure pt - Tables would be 1 inch from the edge would
safety be considered unsterile
● Preparation for operation 4. Gowns are considered sterile in front from the
○ dusting, wiping, cleaning everything on the shoulder level to table level, from the sleeves to 2
inside of OR with a disinfectant: bed, pillow, inches above the elbows.
table, all instruments are already sterilized - Gowns are stock on the table on top each
● Preparation of the operating team other, so take the gown on top, we cant
○ Do surgical hand scrub choose the sizes of the gown, kung ano
○ Don sterile gloves yung nasuot, yun na yun
○ Don Sterile gown - Shoulder level to table level/waist level
● Creation and maintenance of the sterile field o (sterile area)
before and after the operation - Below waist level are unsterile
○ Cover the patient with sterile linen - After donning sterile gloves and gown hand
○ Must not break sterile technique should be on chest
● Maintenance of sterility and asepsis thru-out the - The sterile area depends on the table level
operative procedure - Putot stool: for mga putot; foot stool
● Terminal sterilization and disinfection at the - Front and back of gown sleeves, shoulders
conclusion of the operation are also considered sterile
○ What is done in the preparation should also - Under the sleeves is placed on the table or
be done in terminal sterilization and touching the table kaya sterile
disinfection after the operation - If sitting: place hand on chest/diaphragm
- In SPMC: may pocket ang gown however
PRINCIPLES OF STERILE TECHNIQUE mag contradict siya sa sterile technique
(since gina instruct doon na ilagay sa
1. All items used within a sterile field must be sterile. pocket ang hands, mg contradicts since
- Make sure that the items are always sterile dapat everything is in sight, hindi matago;
○ Check the indicator tape/sterile and baka may butas yung pocket)
tape if na lagay ba siya sa - Transfer of position, one area to another:
autoclave back to back (practice sterile to sterile,
○ Check the integrity of the package unsterile to unsterile) not allowed to touch
○ Check presence of puncture, our head and mag kalot
perforation, tears - Hands should be place on top and not tuck
○ Check the presence of moisture in under the forearms
○ Check the expiration date by 5. Tables are sterile only at table level.
looking or checking the date of - Sterile table if it has sterile drape or cover
sterilization only the top portion is considered to be
2. All sterile barriers that have been permeated must be sterile
considered contaminated. - Turn to sides then drop to the kick
- Surgical Equipment are double pack basin/bucket: trash can sa OR
- When you are opening the outer pack, used 6. Sterile persons and items touch only sterile areas,
your hands but hold at the edges (1 inch at unsterile persons and items touch only unsterile
the edge of the sterile field) areas.
- For opening the second pack, sterile - At least 12 inches to not touch the table
forceps must be used - If the surgeon is perspiring, they face away
- Hands are away from sterile fields and the nurse use the back portion of their
- Use sterile pick-up forceps to pick up item gown to wipe the sweat. Do not use the
from wrapper front part; sterile.
- Take note: hands be away from opening 7. Movement within or around the sterile field must not
- Use sterile glove not working glove contaminate that field.
- The edges of a sterile container are - In pouring sterile water, the scrub nurse
considered unsterile once the package is must turn to the sides, bringing the basin
opened. and the circulating nurse will pour
3. The edges of a sterile container are considered - Margin of safety for at least 12 inches
UNSTERILE once the package is opened - If youre unsterie maintain a distance to
- Boundaries between unsterile and sterile avoid contaminating the sterile field
are not defined - Sterile person pass each other back to back
- Margin safety 1INCH to the edge manner to avoid contaminating sterile field
- Use banana peel technique to release -
gloves 8. All items and areas of doubtful sterility are
considered contaminated.

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 9

 - If unsure or doubtful, consider unsterile. OPERATING ROOM ATTIRE
- Eg. sterile package in an unsterile - Scrub suit
environment consider unsterile. - Sterile gown
- Head cover
DRAPE - Shoes
UNSTERILE - no or gown yet PERSONAL PROTECTIVE DEVICES
- Drape away from me/you starting at the opposite - Surgical eye protective devices
ends - Surgical face mask
- Cover the table then cover the area towards you - Sterile gloves
- UNSA DAWWWWWWWW LUTAW NA ME :’>
OR ROOM
SOURCES OF CONTAMINATION
1. Members of the operating room
- Scrub nurse, surgeon
2. The patient
- Infectious disease
3. Articles used in the wound and on the sterile set-
up
- Instruments used
4. Dust in the air
- Salt air and rust in your door, i never
needed anything more
- Whispers of are you sure, never have i ever
before <3
5. Other personnel or visitors in the OR
- Medtech, Xray Tech, etc.

HOW TO ELIMINATE OR REDUCE TO A MINIMUM:

1. Covering the mouth and nose
2. Clean or clothes (scrub suit) and shoes NOT worn
outside the OR.
3. Meticulous housekeeping practices.
4. Proper methods of sterilization of all items used.
5. Strict aseptic techniques in all details.
6. Minimum of activity in the room and of movement
NOTE: Figure 3 & 2. Operating Room
- Ideally 6-8 person are only allowed inside the OR
that includes the patient GOALS:
1. Strict compliance to aseptic technique.
3 ZONES OF THE OPERATING ROOM 2. Safe administration of anesthesia
1. Non-restricted zone - street clothes are allowed 3. Homeostasis
● When you are going to enter the OR, and 4. Hemostasis- No large amount of blood loss
just wearing your type A uniform you are
just going to be allowed before the red mark MEMBERS OF THE SURGICAL TEAM
● You can now enter the OR when you have 1. SURGEON
changed into your scrub suit, mask, cap ● Head of the surgical team or captain of the ship
● Visitors only on the red line ● Possesses the ability to perform the intended
2. Semi-restricted zone - attire consist of scrub suits and surgical procedure to the patient
surgical caps from type c to type b ● Physician who specializes in performing surgical
● Post anes room, area wherein instruments procedures.
are sterilized
● Hallway and in the work room 2. ASSISTANT TO THE SURGEON
● Documentation room or record room ● It could be an intern, resident, nurse, highly trained
3. Restricted zone - scrub suits, caps, and surgical masks personnel, nursing aid or another doctor
are required ● Provide exposure to operative site; suction the
● Sterile supply stock room
secretions and ligate BV
● Also known as ante room
● In US, may certification to be the first assistant
● Inside the OR
● Works closely with the surgeon in performing the
● During surgery, u can wear goggles to avoid
procedure
splashes
● Sponge and suctions wounds
● Assist suturing
SURGICAL ATTIRE

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 10

 - The patient should not develop respi
3. ANESTHESIOLOGIST paralysis
● Administers anesthetics and monitors the patient’s - Use additional pillows, rubberize eme
physiologic status during the procedure - Muscle weakness brought about by
● (CRNA) - A physician that specializes in anesthesia and also due to kalimot nako
administration of anesthetic ??
● Monitor patients’ physiologic status during the 4. Musculoskeletal Considerations
procedure - Make sure the position of the pt does not
• Evaluate the client preoperatively, if the cause discomfort
patient is surgically capable ba yung pt. 5. Soft tissue Considerations
• Transfuse blood products and IV products
- Mostly elderly
• In cases there are discrepancy in the vital
signs of the patient, the anesthesiologist will - Increase risk of pressure ulcer
alert the surgeon development
• Supervise the client status in the PACU 6. Accessibility of surgical site
- To be able to expose properly through
4. NURSE ANESTHETIST (CRNA) body alignment so that surgeon can
● A registered nurse who has an advance training on prevent trauma while ongoing surgery
anesthetics - To minimize trauma and save operating
● Same as an anesthesiologists time
● Advance nurse who has been trained and certified to 7. Accessibility of anesthesia admin
administer anesthesia - Place the pt in side lying or fetal position in
admi epidural anesthesia
5. CIRCULATING NURSE
● Ensures proper ventilation
COMMONLY USED SURGICAL POSITIONS
● Assists in surgical positioning; assist 1. Dorsal Recumbent/ Supine
anesthesiologist
● Prepares the skin of the patient - Used for many abdominal surgeries, a well
● Monitors aseptic technique as for some thoracic surgeries, and some
● record essential data surgeries
● along with scrub nurse will be accountable with the
instruments, Equipments and sponges
6. SCRUB NURSE
● Responsible for the preparation of the sterile
supplies and instrumentation Fig 4. Dorsal Recumbent / Supine
● Assists the surgeon; can’t be unsterile
2. Trendelenburg
SURGICAL POSITIONS
POSITIONING -Head is lowered and foot part is raised
- placing the patient in proper body alignment to have -procedure s includes lower abdomen
a better exposure of the operative area or site. surgery for GI, Colon, bladder or pelvic
- After administering anesthesia we are going to surgery or any procedure that need to
position the patient access the lower viscera unsa daw
NOTE: LATER NANI IKUAN, b
ANATOMIC AND PHYSIOLOGIC - BRAKE/OR table facilitates surgical positioning
CONSIDERATIONS
1. Respiratory Considerations
- Maintain adequate respiratory action within
the area
- In surgical position is potential for
discomfort and injury due to prolonged
position overtime
- Prevent hypoxia
2. Circulatory Consideration
- The surgical position still be able to
maintain circulatory system Fig 5. Trendelenburg
- And facilitate venous blood return into
systemic circulation 3. Reverse Trendelenburg
- To maintain the bp and promote the good - Surgeries on the thyroid and neck areas
oxygenation - To Facilitate Breathing
3. Peripheral Nerve Considerations - Prevent pooling of blood on the site to
reduce blood loss

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 11

Fig 6. Reverse Trendelenburg
4. Lithotomy Fig 9. Lateral

- Internal or external : External hemorrhoids 7. kraske/jackknife

will sustain this position
- Used for gynecologic, urologic, perineal - For proctologic surgeries
(hemorrhoidectomy) or rectal surgeries - If the pt has internal hemorrhoids to retract
- The thighs and the legs always at the right the buttocks para ma expose ang area
angle

Fig 10. Kraske/Jackknife

Fig 7. Lithotomy NURSING RESPONSIBILITY

1. explain purpose of position
5. Prone - The patient has always right to know or be
aware of the surgical position
- This pos is used in spinal surgery wherein 2. avoid undue exposure
the back part should be expose - Even if our pt is under anesthesia we
- Example is laminectomy should still maintain our pt privacy
- 4 the pt will be place in the table pt is still - And provide comfort by exposing only the
on the stretcher and will be given needed site
anesthesia then we are going to transfer 3. strap the pt. to prevent falls
the pt into the OR table assuming the - Especially if the pt is under general
prone position anesthesia
- Anesthesia will be given general spinal - Using gentle restraints with consent esp if
anesthesia our pt is under general anes
- Position the pt gradually to allow 4. maintain adequate respiratory and circulatory
adjustment of the cardiovascular such as function
sudden changes in VS therefore - To prevent complications, discomfort and
injury
5. maintain good body alignment
- Precautionary measure should be
implemented especially to pt who is obese

Note: after positioning the circulating nurse will prepare the

skin / surgical site of the patient

TIME OUT (Surgical Pause)

Fig 8. Prone - A pause performed immediately before incision is
made to re-confirm that the CORRECT:
6. Lateral ● Patient is on the table
● Surgery is to be performed
- Surgeries including the chest kidney, hip
● side/site will be operated on
surgeries
- This form is to be signed by the surgeon,
anesthesiologist and the circulating nurse

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 12

 been
SURGICAL SAFETY CHECKLIST confirmed?
- SERVE AS GUIDE BY OUR CIRCULATING NURSE o Are there
- ANY OPERATING ROOM FACILITY OPERATED equipment
THIS ONE issues or
- This a tool to provide safety and conformity of the any
concerns?
procedure
- A list to be filled up by the scrub nurse Is essential
imaging
SURGICAL SAFETY CHECKLIST displayed?
before induction of before skin before patient o Yes
anesthetist (with at incision (with leaves operating o Not
least nurse and nurse room with nurse applicable
anesthesia) anesthetist and anesthetist and
surgeon) surgery
Has the patient Confirm all Nurse Verbally ANESTHESIA
confirmed his/her team members Confirms: - It is an artificially induced state of partial or total loss
identity. have o The name of of sensation with or without loss of consciousness
o Yes introduced the
themselves by procedure EFFECTS OF ANESTHESIA
Is the site marked? name and role. Completion ● Analgesia
o Yes of
● Amnesia
o Not Confirm the instrument,
applicable patient's name, o sponge and ● Hypnosis
procedure, and needle ● Muscle relaxation
Is the anesthesia where the counts
machine and incision will be Specimen FACTORS CONSIDERED IN CHOICE OF
medication check made. labelling ANESTHESIA
complete? (read 1. Physical condition
o Yes Has antibiotic o specimen 2. Age
prophylaxis labels
3. Presence of coexisting disease
is the pulse been given aloud,
oximeter on the within the last o including 4. Type, site, duration of surgery
patient and 60 minutes? patient 5. Anesthesiologist’s preference - depends on the
functioning o Yes name) condition of the pt.
o Yes o Not Whether 6. Patient’s preference
applicable there are
Does the patient any TYPES OF ANESTHESIA
have a known Anticipated o equipment ● GENERAL Anesthesia
allergy Critical Events problems to
- Artificially induced state of total loss of sensation or
o No be
o Yes To Surgeon: addressed loss of consciousness
o What are - Produces analgesia, amnesia, unconsciousness and
Difficult airway or the critical To Surgeon, loss of reflexes and muscle tone
aspiration risk or non- Anesthetist and - Advantage in terms of smooth and easy
o No routine Nurse: administration and can be eliminated through
o Yes, and steps? o What are the respiratory system
equipment/ o How long key concerns
- Can be adjusted through the length of the procedure
assistance will the for recovery
available case take? and - DANGERS: can induce CNS depression; respiratory
o What is the management arrest, cardiac arrest
Risk of >500ml anticipated of this Types of general anesthesia
blood loss blood loss? patient? a. inhalation anesthesia - mixture of volatile liquids or
(7ml/kg in gas and o2
children)? To Anesthetist: ○ mask inhalation
o No o Are there ○ endotracheal administration - GETA;
o Yes, and two any
IVs/central patient- general endotracheal tube resulting in quick
o access and specific response
fluids planned concerns? ○ laryngeal mask airway (LMA) - same with
GETA but it uses endotracheal tube
To Nursing ○ Difficult or unsuccessful insertion of
Team: endotracheal tube
o Has sterility
(including
GAS Anesthetics:
indicator
- Highly flammable and explosive
results)
● nitrous oxide - common

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 13

 ● cyclopropane 1. Begin preparation (if indicated) only when the
anesthetist indicates stage 3 has been reached and
VOLATILE Liquids client is breathing well, with stable VS.
● Halothane (Fluothane ) common
● Isoflurane (Furane ) common IV. DANGER/ MEDULLARY
● Methoxyflurane ( Pentrane )Ketamine Hcl ( - Vital functions too depressed with respiratory
Ketalar ) Droperidol ( Inapsine ) and circulatory failure
Nursing intervention:
Intravenous Anesthesia 1. If arrest occurs, respond immediately to assist in
- Directly administered into vein or rapid pleasant establishing airway.
induction
- Absence of explosive hazards Note:
- Low incidence of N&V o VS to be monitored
- Disadvantages is it can cause respiratory depression o PR, RR, pupillary response,
resulting to respiratory arrest
● Ketamine Hcl ( Ketalar ) common STAGE 1 – the patient can become euphoric drowsy, dizzy
● Droperidol ( Inapsine ) common STAGE 2 - everything is increase since there is increase in
● Fentayl ( Innovar ) common autonomic response
STAGE 3 - stage of anesthesia, regular breathing, normal bp,
● Thiopental Na ( Penthotal Na ) common
muscles relaxed, pupils small but still contract upon light
stimulation
STAGE 4 - VS: weak and thready pulse shallow pulse and
pupils are dilated
- Resuscitate patient if that's the case

Fig. Epidural anesthesia

STAGES OF GENERAL ANESTHESIA

I. ONSET/ ANALGESIA / INDUCTION

Form administration of anesthetics to the time of loss ● REGIONAL ANESTHESIA
consciousness - Reduce all painful sensation in one region of the
VISUAL HALLUCINATION, body only and does not result in unconsciousness
DROWSINESS, groggy
- Types
Nursing Interventions:
1. close OR doors ● Topical anesthesia
2. keep room quiet ○ The anesthetic agents are directly
3. stand by assist client applied on the area to be desensitized
● Local infiltration anesthesia
II. EXCITEMENT OR DELIRIUM ○ The anesthesia is
- Extends from the loss of consciousness to injected into the tissues
the loss of eyelid reflexes at the incisional site to
- Pt at risk for accidents block unsa to
Nursing Interventions: ● Nerve block
1. stand by assist client ○ Anesthetic agent is administered
2. Assist anes into/around a specific nerve or small
nerve group
III. SURGICAL EXCITEMENT/ ANESTHESIA ○ No sensation; brachial plexus nerve
- Extends from the loss of eyelid reflexes to the block.
cessation of respiratory effort ○ Used to detect brain activity
Nsg interventions: ● Spinal anesthesia/intrathecal anesthesia
o sub arachnoid block

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 14

 o injected into sub arachnoid space using 5. Neurologic complications ( eg. paraplegia-
interspaces paralysis; sensory motor loss in the trunk, severe
o Non irritating to respiratory system muscle weakness in legs )
o Can be used for almost any type of - Causes:
major procedure performed below the 1. unsterile needle, syringes, and
level of the diaphragm anesthetic medications;
o Toes - feet- abdomen; raise leg, induce 2. pre existing disease of CNS
pain. 3. Transient response to anesthetics
o Side lying position, fetal position; 4. Position during surgery
maximum (positioned for 8 hrs)
o Indicator that syringe has reached the - Intervention:
subarachnoid spaces is when there is - Supportive care for transient forms
csf flowing out related to medication
● Epidural Anesthesia - Antibiotics (d/t infection) and
● Injected in the epidural space; lumbar, steroids for infectious causes
sacral, thoracic, caudal - Permanent paralysis will require
● Same with spinal anesthesia but differ in rehabilitation
location - Prevention:
● Painless delivery - Strict sterile technique
● Used as control measure when patient undergo - Heat-sterilized medications and
cesarean section instruments
● Advantage - Lesser degree of headache - Careful pre op neurologic exam to
ascertain presence of neurologic
COMPLICATIONS AND DISCOMFORTS OF disease
ANESTHESIA: 6. Malignant hyperpyrexia (hyperthermia) - a rare
1. Hypotension reaction to anesthetic inhalants and muscle
- Effect Of Spinal Anesthesia relaxants
- Cause: paralysis of vasomotor nerves - Due to an abnormal, excessive intracellular
- Intervention: accumulation of calcium resulting to
- admin. O2 by inhalation hypermetabolism and increase in
- Pt. Trendelenburg’s pos. if level of - Tachycardia, arrhythmias, tachypnea,
anesthesia is fixed, 10-20 min muscle rigidity, fever (>40 deg Celsius),
after increase cardiac output cyanosis, acidosis, hyperkalemia, cardiac
2. Nausea and vomiting induction failure.
- Cause: Undergone abdominal surgery - Halothane + pancuronium bromide,
because of traction… succinylcholine,
- Effect of hypotension brought by spinal Treatment:
anesthesia - dantrolene Na
- Intervention: - dextrose 50% (with extra insulin to enhance
- Ephedrine, Antiemetics, O2, its utilization)
Fluids - Diuretics - to prevent renal damage; can
3. Headache (can be extremely painful, may last a accumulate to the kidneys obstructing
week urinary flow
- Effects by spinal anesthesia - antidysrhythmic
- Cause: leakage of CSF with loss of - Na (sodium) Bicarb (for severe acidosis)
cushioning effect increased by: - hypothermic measures - cooling blankets,
- Use of large spinal needle and cold IV saline solutions
poor dehydration
- Intervention:
- Apply tight abdominal SURGICAL INCISION-
binder - the result of cutting into a body tissue sharp
- Fluids, Analgesics instrument
- Keep client flat and quiet - Surgical proceed usually starts with an incision
6-8 hr post-op
4. Respiratory paralysis - Subcostal
- Cause: occurs if drug reaches upper - also called upper oblique, kocher’s incision
- Intervention: - Gallbladder and biliary tract surgery
- Artificial respiration - HOW TO DOCU: subcostal incision made
by surgeon (DR. JUJA EME) then time
assisted by if another physician note it if
nurse no need

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 15

 - Paramedian
- Upper r side (biliary tract, gallbladder) SURGICAL INSTRUMENTS
- Upper l side (splenectomy, gastrectomy) Classification of Instruments
- Lower r side (small bowel resection) 1. cutting/dissecting
- Lower l side (sigmoid colon resection) - design to cut tissues
- Midline
- upper and lower abdominal incision
(hysterectomy)
- Transverse- Also Called Lumbotomy Incision
- Transthoracic surgeries, kidney surgeries
- Lateral position
- Mcburneys
- For appendectomy
- If acute appendicitis then use mcburneys
since our appendix is located over
mcburney's point
- Butterfly
- Craniotomy
- Pfannenstiel
- Gynecologic procedures
- Bikini chcuhu??
- limbal
- Eye surgeries
- Surgery made in the limbus
- In point of sclera and ???
- Halstead/ Elliptical
- Breast surgery
- Removal of the breast

2. grasping / clamping
- Specifically designed for holding tissue or
other materials
- Are divided in the following categories:
a. Hemostats
Note: Any instruments has several teeth’s - for hard tissue
If without teeth - soft tissue

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 16

 3. Exposing/Retracting absorbable such a silk (kase if
- Are used to hold back the wounds edges, absorbable to close the sach the
structures, or tissue to provide exposure of sac have the tendency to open)
the operative site - Used for wounds
- 2 types manually retracting and self- - ex. silk, ethilon, dermalon,
retracting? mersilene, prolene, surgilene,
surgical stainless steel
SUTURE - is an all-exclusive term for any strand of material
used for ligating (tying or closing) or approximating tissue
- Used for ligating/ closing approximating tissue
- Made by synthetic fibers/ natural fibers

Classifications of Surgical sutures:

Absorbable
- Strand of sterile material that can
be digested
- It xan mixed with water for ambot
- Prepared from collagen, derived
from healthy mammals or
synthetic polymers; can be
absorbed by a living
mammal/tissue; can be absorbed
after 6 weeks, no need to reopen TYPES OF SUTURES:
the 1. Atraumatic (ATR)
patient ma absorbed lang - Strand of suture that is continuously that
- ex. plain, chromic, vicryl, dexon, attached to a needle
polysorb, maxon, monocryl 2. Non-atraumatic (non ATR)
- A strand a suture; a basic thread

LAYERS OF THE ABDOMEN:

1. skin - monocryl 3/0 or 2/0 ,vicryl 4/0,safi

l4/0,dexon 4/0,silk 3/0,skin stapler
2. subcutaneous - plain 2/0
3. fascia-vicryl 1 or 0, safil 1 or 0, dexon 1 or 0
4. muscle
5. peritoneum-chromic2/0,monocryl2/0or3/0

Note: the number refers to the sizes of your suture

The higher the number the finer the diameter

Surgical Needles: Types:

- Cutting - for hard tissues
- Round - for soft tissues

CLASSIFICATION OF SURGICAL NEEDLES;

1. eyed needle/ free needle/ non-atr
2. eyeless/ swaged needle/ atr
- Mag lagay ng strand of suture to the
needle
Non-absorbable
- Strands of natural or synthetic
materials that resist enzymatic
digestion/ absorption; not any
have reaction.
- Cannot be hydrolyzed
- They can stay for a long time w/o
being mixed or naaklimto kos term
w/o affecting the pt or producing
harm
- Example: In appendectomy, we
need to close the sac, used a non-

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 17

DOUBLE ARM: TWO NEEDLE

7. accessory and ancillary instruments

- Are designed to enhance the use of basic
instrumentation or facilitate the procedure

- Cautery or bouie
Circle- round
Triangle-cutting - ESU (electro surgical ??)
- HA wa nako kasabot

4. cutting/dissecting NOTE:
5. grasping/clamping - Instruments have diff sized
- are divided in the following categories: - Deeper cavity we will be using bigger and longer
- hemostats instruments then vice versa
- occluding clamps graspers and holders - The size depends on the function and purpose
- forceps or pick-ups
6. exposing/retracting
- Are used to hold back the wounds edges, Counting and Reporting of SIN (sponges, needles,
structures, or tissue to provide exposure of instruments)
- are performed to prevent patient injury from a
the operative site
retained foreign object usually 4
- 2 types manually retracting and self
- counts (usually abdominal): initial,
retracting?
- Accurate counting and recording is essential for the
protection of the patient, personnel, and the
institution.
- Usually 4 counts (especially abdominal)
- Initial Counting (before the procedure starts,
Instruments sponges, Needles or INS)
- 1st (before closure of the peritoneum)
- First inner layer (peritoneum)
- Para before mag close, complete na and di
ma reopen ang peritoneum
- 2nd (before closure of the fascia)
- 3rd (before closure of the skin)

Every after each counting, the circulating nurse will report to

the surgeons and anesthesiologists

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 18

Counting of closure: SIN - From the first day up to the 4th day or
several days and up until the pt is
Start counting from the operating site discharged

If kulang instrument or sponges: report: "excuse me, doc. NOTE:

Kulang ang sponges dapat meron akong 12 sponges." Be MIS - MINIMALLY INVASIVE SURGERY
firm and dapat pangitaon jud. Pag nakita na dapat count ulit.
SPECIAL CONSIDERATIONS IN TRANSPORTING
THE PATIENT
1st to 2nd Counting Script:
- Avoid exposure
- Avoid rough handling
“Excuse me Dr Grey and Dr. Shepherd and the rest of the
- Avoid hurried movement and rapid changes in
surgical team, the first/second counting of sponges,
position
instruments and needles is complete”
- to prevent from sudden up of blood pressure
- Protect incision site (everytime the pt being move
3rd Counting Script:
and rmr to prevent further strain in incision site)

“Excuse me Dr Grey and Dr. Shepherd and the rest of the ASSESSMENT
surgical team, the third and final counting of sponges, - If you’re the rr nurse upon receiving the pt the vital
instruments and needles is complete” assessment is to check respiratory condition of the
patient
Must be acknowledge by the Surgeon then pag welcome 1. Appraise air exchange note skin color (to check
circulation)
2. Verify & identify, operative procedure, surgeon
INTRA-OPERATIVE NURSING DIAGNOSES: - Admission report; the procedure and important data
- Risk of aspiration
3. Assess neurologist status (LOC)
- Ineffective protection
- You need to awaken the pt every now and
- Impaired skin integrity
then until the pt is fully awake and orient
- Risk of intraoperative positioning injury
the pt
- Risk of imbalance body temperature
4. Determine VS and Skin temp
- Ineffective tissue perfusion
- Sequence to monitor the pt. Start with RR
- Risk of deficient fluid volume
to incision site
5. Examine operative site and check dressing
Documentation: for incision
- Ex. need to take note the surgical incision site and - Assess the wound status
type 6. Perform safety checks
- Make sure that the side rails are up
POST OPERATIVE PHASE - even before you transport dapat the side
- Starts when transferred/admitted to the rails is raised
RECOVERY ROOM or PACU - if gentle restrains is needed you can put
some on
GOALS 7. Require briefing on problems or encountered in OR
1. Maintain adequate body system functions
2. Restore homeostasis INTERVENTIONS
3. Alleviate pain and discomfort 1. Ensure patent airway and adequate respiratory
4. Prevent post-op complications function
5. Ensure adequate discharge planning and teaching. a. Lateral position with neck extended to
prevent aspiration
3 PHASES OF POST OPERATIVE PERIOD b. Keep airway in place until fully awake,
1. Immediate post op recovery phase suction secretions
- First 4 hours post op c. Administer humidified O2 as ordered
- In this time pt is in RR or PACU d. Encourage deep breathing
- Maximum hours that the patient can stay 2. Assess status of circulatory system
ideally is 4 hours but it will depend on case a. Monitor VS and report abnormalities
to case basis b. Observe signs & symptoms of shock &
2. Intermediate hemorrhage
- From the 4th hours to the 24th hours c. Promote comfort and maintain safety
- Binalik na ang pt sa surgical ward or their d. Continuous, anesthesia
own room e. Recognize stress factors that may affect
3. Extended post op recovery phase the client in RR and minimize these factors

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 19

 - Urine output at least 30 ml/hr.
- Nausea and vomiting absent or under control
- Minimal pain

POST OPERATIVE DISCOMFORTS

1. NAUSEA AND VOMITING
- Cause by abdominal distention due to
abdominal procedure
Preventive measures:
a. Insert NGT intraoperatively
- to prevent abdominal
distention
b. Determine if client is sensitive to
morphine, meperidine (demerol)
COMMON CARDIOVASCULAR COMPLICATION or other opioids
IMMEDIATE POST OP c. Be alert for client's verbalization
1. HYPOTENSION INTERVENTIONS:
- constant surveillance of the client until he - Encourage client to deep breathe
is completely out of - Support wounds during retching and vomiting
- Caused by anesthesia, improper - Discard vomitus & refresh pt.
positioning - Report excessive or prolonged vomiting that can
- assessments: lead to fluid imbalance
a. Weak, thready pulse - Maintain accurate I & O record & replace fluids as
b. A drop in BP ordered
c. Skin: cold clammy, pale and
cyanotic 2. THIRST TRAP
d. Restlessness of apprehension - Causes: NPO, anticholinergics, fluid loss
(dehydration, blood loss)
Nursing Responsibilities
a. INTERVENTIONS: INTERVENTIONS:
- Administer fluids
i. O2 INHALATION
- Offer sips of hot tea w/ lemon juice if diet orders
ii. Administer drugs as ordered
allow
1. ex. lidocaine (xylocaine)
- Apply moistened CB or gauze over lips
2. procainamide (pronestyl)
occasionally
iii. Attach cardiac monitor to patient
- Allow pt. To rinse mouth w/ mouthwash
for continuous surveillance
- Obtain hard candies or chewing gum, if allowed

ALDERETTE SCORING 3. CONSTIPATION & GAS CRAMPS

- Causes: Food intolerances. Gas or bloating
may occur if your digestive system can't break
down and absorb certain foods, such as the
sugar in dairy products (lactose) or proteins
such as gluten in wheat and other grains.
Constipation. Constipation may make it difficult
to pass gas

PREVENTIVE MEASURE:
- Encourage early ambulation
- Provide adequate fluid intake - soft stools and
hydration
- Advocate proper diet - DAT
- do not use of non-opioid analgesia - this may
Interpretation cause constipation
7 points up - required for discharge from PACU
- assess bowel sound frequently - flatus sign that
Determining Readiness for Discharge from PACU: bowel are back to normal condition
- Stable VS
- Orientation to person, place, events, and time NURSING INTERVENTIONS:
- Ask pt. about any usual remedy for
- Uncompromised pulmonary function
constipation and try it, if appropriate
- Pulse oximetry readings indicating adequate blood
O2 sat

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 20

 - Insert a gloved, lubricated finger and break - Cause by hemorrhage or bleeding
up the fecal impaction manually, if - If has cold clumsy skin, circumoral
necessary cyanosis, hypotension, rapid RR,
- Administer enema, if prescribed. hypothermia, restless A SIGN FOR
- Administer GI stimulants, laxatives, HYPOVOLEMIC SHOCK JUST ELEVATE
suppositories and stool softeners, as THE FEET to assess systemic circulation
prescribed. or venous blood return back to the heart

4. POST OPERATIVE PAIN Nursing Interventions:

- Causes: surgical procedure 1. if shock develops, elevate legs
- Earliest symptoms that the pt experience - allow the blood flow back to the
upon the pt was transferred heart to become more
oxygenated
CLINICAL MANIFESTATIONS 2. determine and treat the cause of shock
1. Elevated Blood Pressure 3. administer O2 as prescribed
2. Increased in HR & PR 4. monitor loc
3. Rapid and Irregular aspiration 5. monitor vs
4. Increase in perspiration 6. monitor I&O
5. Increase in muscle tension or activity 7. Administer IV fluids and blood as
6. Irritability prescribed
7. Increase in anxiety
8. Attention focused on Pain B. HEMORRHAGE/HEMATOMA
9. Complaints of Pain - Major contributory factor
GENERAL: primary
INTERVENTIONS - Bleeding during procedure
- Use basic comfort measures
- Recognize the power of Suggestion INTERMEDIATE
- Assist in relaxation techniques (deep - Blood loss after the procedure
breathing exercise)
SECONDARY
- Apply cutaneous counter stimulation
- Sometime after discharge or pt is in already at
- Give analgesics as prescribes in a timely
home
manner
Pharmacological Mgt. Nursing Intervention and Management:
- Oral and parenteral analgesia 1. inspect the site of the wound as a possible site for
1. Parenteral analgesic commonly prescribed bleeding.
2-4 days post-op or until incisional Pain 2. Apply Pressure Dressing Over external bleeding
abates site
2. Nurse’s Responsibility 3. keep pt calm and quiet
a. Make sure drug is given safely & 4. increase IVF infusion rate and administer blood, if
assessed for Efficacy necessary, as soon as possible
5. admin vit. K (aquamephyton), Hemostat as ordered
PATIENT CONTROLLED ANALGESIA (PCA)
6. ligation of bleeders (closing of vessels by means…
- Pain controller that enables patient to self-
suture)
administer when pain is felt
- A means by which the patient can self-administer
C. THROMBOPHLEBITIS/DVT
pain medication
- Causes: Bleeding, prolonged immobility
- Uses a computerized pump which introduces
- Encouraged: Early ambulation
specific drugs
- Clinical manifestations: pain, redness, swelling,
- COMMON DRUG: morphine sulfate
heat/ warmth, (+) Homan’s sign
BENEFITS
- Bypasses the delays inherent in traditional
Nsg Interventions:
analgesic
- Medication is administered IV A. Hydrate adequately to prevent hemoconcentration
- Patient retains control over pain relief. B. Encourage leg exercises and ambulate early.
- Decreased nursing time in frequent C. Avoid any restricting devices that can constrict and
delivery of analgesics impair circulation
D. Prevent use of bed rolls, knee patches (pads),
POST OPERATIVE COMPLICATIONS dangling over the side of the bed w/ pressure on
CIRCULATORY COMPLICATIONS: popliteal area.
A. SHOCK
E. Elevate the affected leg w/ pillow support
- Patient can experience calcium tetani

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 21

 F. Wear anti-embolic support hose from the toes to the
groin. WOUND COMPLICATIONS
G. Avoid Massage on the calf of the leg; cover the A. Wound infection
affected leg with warm moist compress B. hemorrhage /hematoma
H. Initiate anticoagulant as ordered C. Wound dehiscence and evisceration
a. Heparin - Due to infection, tight/loose suture, excessive
b. Coumadin/warfarin na caffeine
- At risk for wound dehiscence obese and DM,
PULMONARY COMPLICATIONS malnourished pt.
A. Atelectasis (lung collapse specifically the Notes:
alveoli) 2-3 days post op - Dehiscence – sudden discharge of serosanguineous
- If left untreated it will lead to fluid form the wound
- Evisceration – edges of the wound may part & the
pneumonia
intestines may gradually push out.
B. Pneumonia
- Can cause because of anesthesia POSTOPERATIVE PSYCHOLOGICAL
- Turn patient every 2 hrs or for DISTURBANCES
elderly every 1 hr A. DELIRIUM
- State of excitement
Nursing Interventions - Due to prolonged anesthetics, alcoholic (delirium
1. Measures to prevent pooling of secretions tremens= withdrawal) electrolyte imbalance, sepsis
2. Measure liquefy or remove secretions B. ACS (Acute Confusional Stage)
3. Reinforce deep breathing, coughing, turning Nursing Management
exercises (DBCT) 1. Administer Sedative as ordered
4. Other measures incentive spirometer 2. Explain the reasons for
interventions
URINARY DIFFICULTIES 3. Listen and talk to the client &
A. URINARY RETENTION Significant Others
- Involuntary collection of urine in the bladder 4. Provide Physical comfort
- Cause by anesthesia

Nursing measures: REFERENCES

1. Psychological aid-running water I. Mrs. Dela Cerna’s PPT
2. Forcer fluids II. Notes from Discussion
3. Alternate hot and cold water pouring over
the perineum
4. Crede’s maneuver
5. Assuming proper position if unsuccessful:
catheterization; bethanechol (urecholine)

GASTROINTESTINAL COMPLICATIONS
A. PARALYTIC ILEUS

Nsg mgt:
- NPO until peristalsis has returned
- Medication as ordered: prostigmin
bromide/noestigmine

B. GAS PAIN

Prevention:
a. Early ambulation
b. Turn to side every 2 hours
c. Minimize talking/laughing

Nursing Management
- Aspiration of gas
- Rectal suppository as ordered
- Rectal tube insertion
- Meds: simethicone (mylicone)
C. INTESTINAL OBSTRUCTION
D. HICCUPS

ALDEA, EMBERADOR, ERBINA, MILLAMA, MASUKOL, VILLAMON BSN 3H & 3G 22