Medical Surgical Nursing Module 12

NUR 1213: MSN- PAIN AND SURGERY
NOVEMBER 2021 | FEU LECTURES, HANDOUTS 7 PPTs | GUMAPAC, SOLIS

• First professor of clinical surgery within the
University of Leeds
OUTLINE
• Book: Abdominal Operations earned him an
1 Surgery
international operation
2 Perioperative Care *Surgery has been made safe for the patient;
3 Operating Room Attire, Surgical Hand we must now make the patient safe
Scrubbing, Gowning, Closed Gloving, and for surgery. *
Instrumentation Improvement in Perioperative Patient Care
4 Pre, Intra, Post Operative Care Technology is attributed to the following:
5 Pain and Pain Management • Surgical specialization of surgeon and team
• Sophisticated diagnostic and intraoperative
imaging techniques
MODULE 1 - SURGERY • Minimally invasive equipment and
Definition technology
• Surgery, as a discipline, combines • On-going research and technological
physiologic management with an advancements
interventional aspect of treatment SURGERY RELATED
• Total care of illness with an extra modality of TERMINOLOGIES
treatment, the surgical procedure • Operating Room/ Operating Theatre- room
• Branch of medicine that comprises pre- in health care facility in which patients are
operative, intraoperative, and post operative prepared for surgery, undergo surgical
• Surgery as a Science procedures, and recover from the anesthetic
• Surgery as an Art procedures required for surgery
EVOLUTION OF SURGERY • Perioperative- term used to describe entire
Historical Background span of surgery including before and after the
• Code of Hammurabi (1955-1913BC) - if actual operation
patient died after surgical procedure, • Perioperative nursing- includes activities
surgeons will be retribution in the form of performed by the RN that encompasses pre-
amputation of his right hand operative, intraoperative, and post-operative
• Persians rule on surgery- successful phases of patient’s care
procedure on 3 infidels before being • OR nurse- duly licensed nurse legally
pronounced as competent to practice surgery responsible for the nature and quality of the
• Galen of Pergamum (130-200AD) nursing care patients
• Caludius Galen - a Greek physician who • Surgical Conscience- awareness which
performed animal dissections and fallen into develops a knowledge based on the
disrepute; stressed the importance of human importance of strict adherence to principles of
dissections; aseptic and sterile techniques
• Studied the muscles, spinal cord, heart, • Breach in sterility: stop and tell what
urinary system, and proved that the arteries happened (surgical team)
are full of blood. • What will happen: Infection, poor wound
• Believed that blood originated in the liver, and healing, financial burden
sloshed back and forth through the body, • Be a patient-advocate
passing through the heart, where it was mixed • Asepsis- free from infection or absence
with air, by pores in the septum microorganism
• Also introduced the spirit system consisting of • Aseptic Technique- methods by which
natural spirit or “pneuma” (air he thought was contamination of microorganism is prevented
found in the veins), vital spirit (blood mixed • Disinfection- process of destroying all
with air he believed to found in the animals) pathogenic microorganisms except spore
bearing ones
• Sterilization- killing all microorganisms
including spores; by heat using autoclave; by
chemical using EO gas, plasma sterilization
Lord Berkeley George Moynihan (1865 – 1936)-
formal education
GUMAPAC, E., SOLIS, L. 1

• Surgical Intervention- therapeutic process • Incision- open tissue of structure by sharp
rendered to restore or maintain health (i.e. the dissection; using scalpel
ability to function) • Excision- removal of tissue or structure by
• Surgical Procedure- invasive incision into sharp dissection
the body tissues or a minimally • Diagnostics- biopsy tissue sample; common
invasive entrance into a body cavity for either example: lumps (benign or malignant)
therapeutic or diagnostic purpose during • Repair- e.g. closing of hernia
which protective reflexes or self-care abilities
• Removal- FBE
are potentially compromised
• Reconstruction- creation of new breast
• Antiseptic- substances which combat sepsis
and cause bacteriostasis • Termination- abortion of pregnancy
• Anesthesia- insensibility to pain and trauma • Palliation- relief on an obstruction
with or without loss of consciousness • Aesthetics- facelift
• Informed consent- the patient’s autonomous • Harvest- skin grafting
decision about whether to undergo a surgical • Procurement- donor organ
procedure, based on the nature of the • Transplant- placement of a donor organ
condition, the treatment options, and the risks • Bypass/ shunt- vascular rerouting
and benefits involved • Drainage/ evacuation- incision of abscess
Abdomin (o)- abdomen
Aden (o)- gland
• Stabilization- repair of fracture
Angi (o)- vessel • Staging- checking of cancer progression
Arthr (o)- joint • Parturition- C-section
Broncho- bronchus • Extraction- removal of tooth
Card, Cardi (o)- heart • Exploration- invasive examination
Cephal (o)- head • Diversion- creation of stoma
Chole, Chol (o)- bile Four Major Pathologic Conditions Requiring
Chondr (o)- cartilage Surgical Intervention
Colo- colon
• Obstruction- impairment to the flow of vital
Cost (o)- rib
fluids e.g. blood, urine, CSF, bile
Crani (o)- skull
Cele- tumor, hernia • Perforation- rupture of an organ
Centhesis - puncture • Erosion- wearing off a surface or
Ectomy- surgical excision/ removal membrane
Itis- inflammation • Tumor- abnormal new growth
Litho - stone/ calculus Reasons for Surgical Intervention
Ostomy- creation of new opening • To preserve life
Rhapy- repair • To Maintain dynamic body equilibrium
Oscopy- examination w/a lighted instrument • To undergo diagnostic procedures
Plasty- surgical repair or reshaping
Pexy- suture in place • To prevent infection and promote healing
• To obtain comfort
SURGERY • Ensure the ability to earn a living
Surgery is performed for the purpose of structurally • To restore or reconstruct a part of the body
altering the human body by incision or destruction of that is congenitally malformed or damaged
tissues and is part of the practice of medicine. by trauma or disease
Objectives of Surgery • To alter cosmetic appearance
• Repair of injuries Conditions treated by Surgery
• Alter form or structure • Congenital- inborn deformity
• Correction of deformities and defects • Acquired- resulting from trauma or injury
• Relief of suffering Three (3) Categories of Surgical Procedure
• Diagnosis and cure of disease process • Invasive surgery- major surgeries; open
• Prolongation of life • Minimally Invasive surgery- surgical
Common Indications of Surgery procedures that use specialized instruments

inserted into the body either through natural • Elective- client will not be harmed if surgery
orifices or through small incision is not performed but will benefit if it is
• less risky; laparoscopic surgeries performed; revision of scars, vaginal repairs
• Non-Invasive surgery- unrisky • Optional- personal preference usually
Classifications of Surgical Procedure aesthetic purposes; cosmetic surgery
According to Purpose: • Risks:
• Diagnostic surgery- to establish the • Preoperative: body disturbance
presence of a disease condition; enables the • Intraoperative: infection, safety
surgeon to verify a suspected diagnosis; e.g.
• Post-operative: pain
breast biopsy, biopsy of skin lesion
According to Location
• Exploratory surgery- to determine the • External- outside the body; e.g.
extent of the disease condition and at times
hysterectomy
to make or confirm a diagnosis; e.g.
exploration of abdomen for unexplained pain, • Internal- inside the body; e.g. hysterectomy
exploratory laparotomy According to Extent or Risk Involved (Magnitude)
• Curative • Major- life-threatening
- High risk, extensive prolong, large amount of
• Ablative- removal of
blood loss, major or vital vital organs are
deceased organ (suffix used is
involved, great risk of complications
“ectomy”); e.g cholecystectomy/
- Heart surgery, colorectal
appendectomy
• Minor- non-life threatening, less
• Constructive- repair of
serious generally not prolong, few
congenitally defective organs
serious complications; e.g. biopsy,
(suffixes used are “plasty,”
excision
“orrhaphy,” “pexy,”); e.g. total
Surgical Risks Patients
hip replacement, orchiopexy
(surgery for undescended • Obesity- increased incidence of morbidity
testes) and mortality; degree of morbidity varies with
the severity of the obese condition
• Reconstructive- involves
repair of damaged organ; e.g. • Fluid, electrolyte, and nutritional problems:
plastic surgery after burns will cause delay and poor wound healing
• Palliative surgery- to relieve distressing • Difficult to close up; larger structures, more
signs and symptoms, not necessarily to cure difficult
the disease; e.g. resection of tumor to relieve • Comorbidities, complications due to existing
pressure and pain problems (HPN, DM)
• Cosmetic surgery- correction of defects, • Undernourished- slow poor healing and
improvement of appearance or change to a recovery due
physical feature; e.g. rhinoplasty, cleft lip • Extremely young- underdeveloped
repair, mammoplasty structures and immunity
• Extremely old- physical changes;
According to Urgency: comorbidities
• Emergency- Immediate; life-threatening • Person with disability
conditions requiring surgery; e.g gunshot • Presence of Disease/ Illness- has
wound, severe bleeding, small bowel comorbidity; DM patients have poor wound
obstruction; patient may deteriorate healing
immediately • Concurrent or prior pharmacotherapy- ask
• Urgent or Imperative- within 24-30 hours- what meds are taken by the patient; some
client requires prompt attention; kidney meds may alter physiologic functions that
stones, acute gallbladder infection, fractured may affect the surgery (anticoagulants-
hip bleeding)
• Planned or required: planned for a few • Other factors
weeks or months after decision; client • Nature and location of
requires surgery at some point condition

• Magnitude and urgency of • To assist the surgeon by functioning
the surgical procedure effectively as a member of the surgical team
• Mental attitude of the • To create and maintain an aseptic/ sterile
person toward surgery- e.g. environment at all times
anxiety Objectives of Operating Room Nursing
• Caliber of the professional • To help the patient return as rapidly as
staff and health care facilities possible to the best physical and mental
Potential Effects of surgery to the Patient health attainable
• Stress response is elicited • In case the patient did not return to his heath,
• Vascular system is disrupted pain and discomfort should b eased and s/he
• Defense against infection is lowered should be allowed to die with dignity
PERIOPERATIVE NURSE
• Organ functions are disturbed
Definition
• Body image may be disturbed Perioperative Nurse is a nurse who provides patient
• Lifestyle may be changed care, manages, teaches, and studies the care of
Legal Liability, Accountability & Ethical Issues patients undergoing invasive or non-invasive
Safeguard the patient in the OR against hazards. procedures. S/he possesses a depth and breadth of
Protect the nurse, technologist, surgeons, knowledge that allows for the coordination of care of
anesthesiologist, and the hospital. Prevention focuses the surgical patient.
on the quality assurance Responsibilities of a Perioperative Nurse
• Prioritizes interventions based on a
Quality improvement as an ongoing process comprehensive body of scientific knowledge
Understanding regulations, standards, policies, and and variation in patient’s responses
procedures
Accountability for one’s own actions
• Uses critical thinking skills in applying the
nursing process, acting as a patient advocate,
Legal rights of the patients
and exercising judgment in a professionally
Individualized patient care
accountable manner
Technical competency
Your surgical and ethical conscience. • Provides specialized nursing care to patients
before, during, and after their surgical and
To be liable is to be legally bounded, responsible, and invasive procedure
answerable. • Works closely with all members of the surgical
PERIOPERATIVE NURSING team
Definition • Helps plan, implement, and evaluate
Perioperative Nursing Practice- includes activities treatment of the patient
performed by the professional registered nurse during • Designs, coordinates, and delivers care to
the preoperative (before), intraoperative (during), and meet the identified
postoperative (after) phases of the patient’s surgical physiological, psychological, and spiritual;
experience. needs of the patients
Key Elements of Perioperative Nursing Practice Expected Attributes of a Perioperative Nurse
• Caring • Considerate
• Conscience • Informative and sincere
• Discipline • Versatile
• Technique • Analytical
Concept of Surgical Conscience • Creative resourceful
“Do unto the patient as you would have others do unto
• Humanistic and Ethical
you.”
Personal Attributes of a Perioperative Nurse
Philosophy of Operating Room Nursing
To give service that aims to provide comprehensive • With sense of humor
support physically, morally, psychologically, spiritually, • Objective
and socially to a patient undergoing surgery. • Enduring
Goals of Operating Room Nursing • Impartial, nonjudgmental, open-minded
• To provide a safe, supportive, and • Manual and intellectual
comprehensive care to patient • Curious to lean

• Empathic, conscientious, efficient • DDS (Doctor of Dental Surgery) or Oral
• Well-organized surgeon
MODULE 2 – PERIOPERATIVE CARE • DMD (Doctor of Dental Medicine)
Three Phases of Perioperative Care • DPM (Doctor of Podiatric Medicine)
Preoperative Phase Attributes of a surgeon
• Begins with the decision to perform surgery • Compassionate interpersonal behavior
and continues until the client reaches the • Accountability
operating area • Humanistic concern
• During this phase, the perioperative nurse • Appropriate clinical skills in data gathering
performs the assessment and planning • Good decision making & problem-solving
components of the nursing process. skills
Questions to ask:
• Critical thinking ability
• Allergies Major responsibilities of a surgeon
• Medications/ Diet (NPO) • Preoperative diagnosis and care
• Practices (smoking, alcohol/ drug intake) • Selection and performance of the surgical
• Location (left, right, bilateral) procedure
Intraoperative Phase • Post-operative management
• Begins with placement of patient on the Assistants to Surgeon (First Assistant/ Second
operating table, including the entire surgical Assistant)- qualified surgeon or a resident in an
procedure and extends until transfer of the accredited surgical education program.
client to the recovery room. The - The resident is maybe an associate with
implementation component of the nursing whom surgical practice is shared and to whom
process is performed here part of the patient’s care maybe delegated.
Postoperative Phase - In hospital with accredited postgrad surgical
• Begins with admission to the RR recovery residency training programs, the surgical
room/ PACU (Post Anesthesia Care Unit) and resident in the third or later year usually acts
continues until the client receives a follow up as 1st assistant. The resident is given
evaluation at home or is discharged to a increasing responsibilities under supervision
rehabilitation unit evaluation component of at the operating table to acquire skill and
the nursing process is completed in this judgement.
phase. • NURSE is free to refuse to perform as first
• Discharge plan, complications, wound care assist out of concern for the well-being of the
PERIOPERATIVE PATIENT CARE TEAM (OR patient and for his/her professional
TEAM) accountability.
Major Responsibilities of Assistants to
Surgeon
Operating Room Team • Help maintain visibility of the surgical site,
• Each member of the operating room team is control bleeding, close wounds, apply
an integral entity in unison and harmony with dressings, handle tissues, and uses
his/her colleagues for the successful instruments
accomplishment of the expected outcomes.
• OR Team is subdivided according to the
functions of its members: sterile and unsterile
team Scrub nurse - Instrument and Suture
Sterile team (Surgeon, Assistant Surgeon, and Nurse - Nursing staff member of the sterile team
Scrub Nurse) - RN, LPN (licensed practical nurse) or LVN
Surgeon- Must have the knowledge, skill, and (licensed vocational nurse), ST (surgical
judgement required to successfully perform the technologist)
intended surgical procedure. Major Responsibilities of a Scrub Nurse
Who can be the head surgeon: • Responsible for maintaining the integrity,
safety, and efficiency of the sterile field
• Licensed MD
throughout the procedure.
• DO (osteopath)

• Responsible for preparing and arranging the through implementing the principles of
sterile instruments and supplies for the asepsis, demonstrate a strong sense of
surgical procedure. surgical conscience.
• Anticipates, plan for, and respond to the • Constant flexibility in identifying
needs of the surgeon by constantly watching environmental danger stressful, situations,
the sterile field. and meet the unexpected act in an efficient,
• Should have knowledge, skills, and rational manner at all times.
experience with aseptic and sterile • Maintenance of the communication link
techniques. between events and team members at the
• Should have manual dexterity, physical sterile field and
stamina, stable temperament, able to work • Provision of assistance to any member of the
under pressure, with keen sense of OR team and any manner in which the
responsibility and concern for accuracy in circulator is qualified.
performing all duties. • Direction of the activities of all learners. The
Nonsterile Team CN must have the supervisory capability and
Anesthesiologist - is an MD or DO, certified by the teaching skills needed to ensure maintenance
Philippine Board of Anesthesiology, specializes in of a safe and therapeutic environment for the
administering anesthetics to produce various states of patient.
anesthesia. Nurse anesthetist- refers to a qualified RN,
Major Responsibilities of an Anesthesiologist anesthesiologist assistant (AA), dentist, our physician
• Choice and application of appropriate who administers anesthetics.
anesthetic agents and suitable techniques of PERIOPERATIVE ENVIRONMENT
administration and monitoring of physiologic Physical Facilities
functions. Location- located accessible to the critical care
• Maintenance of fluid and electrolyte balance surgical patient areas and the supporting service
and blood replacement during the surgical department-CSR, radiology, pathology, etc.
procedure. • Many OR suites are UNDERGROUND or
• Minimize the hazards of shock, electrocution, have solid walls without windows.
and fire. Ventilation - Must ensure a controlled supply of filtered
• Responsible for overseeing the positioning air. Air conditioning is ideal and valuable; it controls
and movement of patients. humidity
• Able to use and correctly interpret a wide Door - Ideally, sliding doors should be used.
variety of monitoring devices. Floor - Must be suitably hard, suitable for heavy
• Oversee the PACU to provide resuscitative equipment specially during transport from one room to
provide care until each patient has regained another and easy to clean.
control vital functions. Lighting- General illumination is furnished by ceiling
• Participate in the hospital’s program of CPR lights in white fluorescence bulbs which are evenly
as teachers and team members. As well as distributed throughout the room.
consultants and managers for problems of • Should be shadowless o Be freely adjustable
acute and chronic respiratory insufficiency to any position or angle by vertical or
requiring inhalation therapy and other fluid, horizontal range of motion
electrolyte and metabolic disturbances • Produce minimum heat to prevent injuring
requiring IV therapy. exposed tissues o Be easily cleaned
• They are integral staff member of Pain Two Principles in designing an Operating Room
Therapy clinics. a. Exclusion of contamination from outside the
Circulating nurse - A RN or ST (surgical suite
technologist) who functions under the supervision of b. Separation of clean areas from contaminated
an RN. areas
Major Responsibilities of a Circulating nurse Types of OR Designs
• Nursing judgement and decision-making skill • Central Corridor
are requisites to assessing, planning, • Central Core
implementing, and evaluating the plan of care • Peripheral corridor
before, during, and after surgical operation. • Combination central core & peripheral
• Creation and maintenance of a safe and corridor
comfortable environment for the patient • Three corridor layouts

• Grouping or cluster plan • Desirable if all have the same size, so they
can be used interchangeably to
The OR suite should be large enough to allow accommodate elective and emergency
for correct technique yet small enough to cases.
minimize the movement of patients, personnel • Must accommodate equipment like laser,
and supplies. Provision must be made for traffic microscope, video equipment, c-arm, portable
control. The type of design will predetermine light, etc.
traffic patterns. Signage should be posted • Adequate size is at least 20x20x10 feet (400
properly. sq ft or 37 m2) of floor space or maximum of
20x30x10 feet (600 sq ft or 60 m2).
Three Areas/Division of Operating Room Suite Sub sterile Room
Unrestricted / Unsterile Area
• Work Area
• This area is isolated by doors from the main
hospital corridor or elevators and from other • Steam Sterilizing Room
areas of the OR suite. • Washer
• Serves as an OUTSIDE-to-INSIDE access • Storage Room for Supplies
area • Record Room
• Street clothes are permitted Peripheral Support Areas
Vestibular / Exchange Areas (Transition Zone) - • Central Administrative control
inside the entrance to the OR suite, separates the OR • Sterile supply room
corridors from the rest of the facility
• Work and storage areas
• Preoperative check-in unit - this is an
unrestricted area of the OR for patient to
• General work room
change from street clothes to gown. • Utility room
• Dressing rooms and lounges - clothes • Housekeeping Storage area
hanging areas must be provided for both • Anesthesia work & storage areas
males and females. Shoe rack is advisable for Furnitures and other Equipment Inside the
the OR scrub suit. Operating Room
• Post-operative holding area - A designated 1. OR Table - divided into head, body, and leg
room for patients to wait in the OR suite that sections. Attachment includes knee strap,
shields them from distressing sights and arm strap, arm board, anesthesia screen,
sounds. metal foot board, etc
• PACU - may be outside the OR or adjacent to 2. Instrument table or Back table
the OR suite. o Part of unrestricted area with 3. Mayo table - placed above and across the
access from both semi restricted areas. patient and contains instruments which are in
Semi-restricted / Semi sterile Area constant use during operation.
• Personnel should be wearing OR scrub suit 4. Small table for patient’s preparation
with cap. equipment (skin prep table)
• This area includes peripheral support areas 5. Ring stand for basin (s).
and access corridors to the OR like PACU, 6. Anesthesia table and machine
SICU, offices for anesthesia department and 7. Sitting stools and footstools/standing
administrative OR nursing personnel, etc. platforms
• Work area or packing area 8. IV stands and hangers for IV solutions
• Steam sterilizing room 9. Suction machine, bottles, and tubing
• Washer-sterilizer area 10. Cautery machine
11. Kick buckets in wheeled bases
• Storage room for supplies o Record room
12. Basin in wheeled bases for soiled sponges
Restricted / Sterile Area
and gloves
• Personnel should be wearing complete OR 13. Communication system / Intercom
scrub suit including mask. 14. Defibrillator
• This area performs sterile procedures o 15. Negatoscope- obsolete device for displaying
Includes OR suite room, scrub sink areas, sub Xray films
sterile rooms where unwrapped supplies are 16. Wall Clock with second hand
sterilized. 17. White board for recording
18. Blood warmer machine attached to IV pole

19. monitoring machines the team and mayo were photographed operating in
• Cabinets / carts surgical gowns, caps, and masks
MODULE 3 - OR Attire, Surgical Hand • 1930- 1940 - Scrub dresses began to replace
nurses’ regular uniforms heretofore worn
Scrubbing, Gowning, Closed Gloving, under the sterile gown, observers in the OR
and Instrumentation were gowned, capped, and masked.
Operating Room Attire • 1958 - Disposable latex
Description: gloves were introduced
• Consists of body covers, such as a two- • Most efficient masks are disposable ones
piece pantsuit, head cover or cap/turban, containing a high efficiency filter
mask. shoe cover, or booties, googles, and • 1960 - Full skirts were replaced by close
apron fitting scrub dresses and pantsuits that
• Protects us from blood and body substance of reduces the hazard of brushing against a
patient sterile table when near or passing by it
• 1950 - OR personnel were required to change
Purpose: shoes when entering the OR suite and to wear
• To provide effective barriers that prevent the only those shoes when within the suite.
dissemination of microorganisms to the px Currently, disposable shoe covers are
• Protects personnel from infected patients and commonly worn.
against exposure to communicable disease CRITERIA FOR OR ROOM ATTIRE
• Has been shown to reduce particle count OR attire should be:
from the body from over 10,000 particles per • An effective barrier to microorganisms. Both
min to 3000 per min, or from 50, 000 reusable woven and disposable nonwoven
microorganisms per cubic foot to 500 materials are used. Design and composition
microorganisms per cubic foot. should minimize microbial shedding.
Historical Background: • Closely woven material void of dangerous
• OR nurse take a bathe before a surgical electrostatic properties. The garment must
procedure, to take a carbolic bath (anti- meet the fire protection standards, including
microbial soap) before laparotomy and to resistance to flame.
wear long sleeves and clean apron for the • Nylon and other static spark-producing
surgical procedure materials are forbidden as outer garments.
• Resistant to blood, aqueous fluids, and
Gustav Neuber (1883)- He insisted on wearing of abrasions.
caps by OR personnel • Designed for maximal skin coverage.
Hunter Robb - A gynecologist at Johns Hopkins hosp • Hypoallergenic, cool, and comfortable
Baltimore, insisted on OR cleanliness and on the • Non generative
wearing of caps and sterile gowns • Easily to don and remove
Dr. William Halsted (1897) - He designed a • Effective barrier to microorganisms
semicircular instrument table to separate himself, in • Made of pliable material to permit freedom of
sterile gown and gloves, from observers in street movement for the practice of sterile
clothes who watched him operate. technique
Johann von Mikuliez (1896) - A pioneering german • Colored to reduce glare under lights
surgeon, advocated the wearing of cotton gloves in
1896 but these were soon found to lack the qualities of DRESS CODE
impermeable rubber gloves for infection control. He
also advocated the use of gauze masks in 1897. • These are written policies and procedures for
Joseph Lister- Fist use of caps and sterile gowns proper attire to be worn within the semi-
occurred in Germany while the value of joseph lister’s
restricted and restricted areas of the OR suite
principle of antiseptic surgery to exclude putrefactive
• Should include personal hygiene
bacteria from wounds was still
• Protocols must be abided
• From 1908 to 1930, various styles of turbans
• Location of the dressing room
and shower cap-style head covering were
worn. • Street clothes are never worn beyond the
Charles Mayo (1913) unrestricted area

• Only approved, clean, and/or freshly • Must be don a scrub suit before entering a
laundered or attire worn within the semi- semi restricted area
restricted area. • Shirt and waistline drawstrings are tucked
• This applies to all, both professional, non- inside pants to avoid their touching sterile
professional and visitors alike. areas and to reduce fallout of skin debris from
• OR attire should not be worn outside the or thoracic and abdominal areas
suite. • Scrub suit should be changed as soon as
• Before leaving the or suite, everyone should possible whenever it becomes wet or visibly
change to street clothes soiled
§ *lab gowns and smock • Person who will not be sterile team members
gowns should wear long-sleeved jackets
• A clean, fresh scrub suit should be put on after Headcover/ Cap/ Turban
return for reentry to the suite. • All facial and head hair must be completely
• OR attire should be hung or put in a locker covered.
for wearing a second time. If disposable, • Cap or hood is put on before a scrub suit to
discard in the trash one use. protect the garment from contamination by
• Personal hygiene must be re-emphasized hair.
- A person with an acute infection • Types include disposable, lint-free,
- Persons with cuts, burns or skin lesions nonporous, nonwoven fabrics. A reusable cap
should not scrub or handle sterile supplies should be made of a dense woven material
because serum may seep from the eroded and laundered daily. (after use put it in the
area hamper and send it to the department)
- Sterile team members who are known to carry • Net caps are not acceptable
are pathogens. • Hair should not be combed while wearing a
- Fingernails should be kept short. Nail polish is scrub suit
not allowed. • Persons with scalp infection should be
- Pierced-ear studs must be confined within excluded from the OR and treated first
headcover • If the hair is long, a helmet or hood must be
- Jewelry (rings and watches) should be worn to cover the neck area. It should be well
removed before entering the semi-restricted fitted to confine and prevent escape of any
and restricted areas. hair.
- Necklaces and chains can grate on the skin, • Caps of different colors are helpful to
increasing desquamating differentiate personnel
- Facial makeup should be minimal Shoe cover
- Eyeglasses should wiped with a cleaning • Should be clean, washable and soft-soled
solution before each surgical procedure and • Protect the wearer from spilled into or onto
properly secured shoes during procedures
- Hands must be washed frequently and
• Maybe worn in semi-restricted and restricted
thoroughly. Hand cream may be used after to
areas
prevent chapping and drying of hands.
• Shoes restricted to wear in the OR or shoe
• Comfortable, supportive shoes should be
cover overshoes are preferable in reducing
worn to minimize fatigue and for personal
microbial transfer from the outside into the OR
safety, shoes should have enclosed toes and
suite.
heels; clogs, slippers
• Can inadvertently become solid and harbor
• External apparel that doesn't serve any
microorganisms should be removed from
functional purpose should not be worn in the
entering the dressing room and after leaving
OR.
the OR
COMPONENTS OF OPERATING ROOM
• Protective gloves should be worn to change
Body cover or Scrub suit
shoe covers whenever they become wet,
• One piece overall with attached hoods and
soiled, or torn.
boots are convenient garb for visitor whose
Mask
presence in the OR will be brief like the
• Worn in the operating room
pathologist
• Should be worn at all times in the restricted
• Pantsuits are preferred than the one-piece
areas where sterile supplies are exposed
overall. 90% of bacteria

• Reusable cotton masks are obsolete because Latex - polymeric membrane of natural rubber with an
they filter ineffectively as soon they biome infinite number of holes between lattices
moist • Better barrier than vinyl tape
• At least 95% efficient in filtering miscorebed • Contains protein antigen & is cured with
from droplet particles agents that may cause an allergic dermatitis
• Disposable mask made of soft, cloth-like or systemic anaphylaxis
material in very fine synthetic. • Vary in thickness (minimum 0.1mm)
• A fluid-resistant mask is advantageous • Petroleum-based lotions or lubricants should
• Cool, comfortable, and nonobstructive to not be used on the hands before dining latex
respiration gloves. Hydrocarbons will penetrate latex,
• Non-irritating to the skin because of its causing a change in its physical
polypropylene, polyester, or rayon fibers. characteristics, including tear resistance.
• Should be worn over both nose and mouth Surgical Gloves- clean objects and sterile packages
and should conform to facial contours to should not be handled with contaminated; worn in
prevent leakage of expired air surgical procedures
• Double masking is NOT recommended • Hands must be washed thoroughly after
because the extra thickness can cause removing the gloves
venting from the effort to breathe through it. Lead gloves
• To prevent cross-infection, masks should be Thick gloves- should be worn for skin protection from
handled by the strings. DO NOT handle the ethylene oxide exposure if sterilized packages must be
mask excessively; handled before operation
• Never be lowered to hang loosely around the Working Gloves- utility gloves are worn for cleaning
neck, on top of the cap, or put in a pocket. and housekeeping.
Avoid disseminating microorganisms • Sterile and non-sterile single-use disposable
• Be promptly discarded into proper receptor latex and vinyl gloves are discarded after use.
• Changed frequently. Do not permit the mask They should not be washed or reused
to become wet. Talking should be kept at a Sterile Gown
minimum. • Is worn over the scrub suit to permit the
Eyewear/Goggles wearer to come within the sterile field.
• Worn to reduce risk of blood or body fluids • Differentiates sterile from unsterile members.
from the px splashing into the eyes of sterile • Although the entire gown is sterilized, the
team members, or bone chips or splatter back is not sterile, nor any area below table
alike. level, once the gown is donned
• With side shields, anti-fog goggles, • Wrap around sterile gowns that provide
combination surgical mask with a visor eye coverage
shield. • If the gown is close by ties along the back, a
• Eyewear or face shield that becomes sterile vest should be put on to cover the
contaminated should be decontaminated or back
discarded promptly. • The cuffs of the gowns are stockinette (rib-
• Laser eye must be worn for eye protection knit) to tightly fit the wrists. Sterile gloves
from laser beams cover the cuffs of the gown (close method
• Eyewear with a face shield should be worn gowning)
when handling or washing the instruments • Should be resistant to penetration by fluids
when the activity could result in a splash, and blood
spray or splatter to the eye or face. • Should be comfortable without producing
excessive heat build-up.
Sterile Gloves • Reusable gowns must be made of densely
• Non-sterile latex or vinyl gloves should be woven material.
worn when handling contaminated materials • Pima cotton with a 270-280 thread count per
• Surgical gloves are made of natural latex sq inch treated with a moisture-repellant
rubber, synthetic rubber, vinyl, or finish
polyethylene • Some reusable are cotton-polyester blend.
• Seams of the gown should be constructed to
prevent penetration of fluids.

• Woven textile gowns withstand about 75
launderings and sterilizing cycles before
discarding them.
• If punctured or torn, gown should be changed Purpose of Surgical Hand Scrub
during the procedure. • To help prevent the possibility of
• All woven and some non-woven gowns are contamination of the operative wound by
not flame retardants. Fire-resistant gowns bacteria on the hands and arms.
should be worn for laser surgery and when • To remove soil, debris, natural skin oils, hand
electrosurgery is used lotions and transient microorganisms from the
Gowning hands & forearms of sterile members.
• The circulator brings the gown over the • To decrease the number of resident
shoulder by reaching inside to the shoulder microorganisms on skin to an irreducible
and arms seams. The gown is pulled on, minimum.
leaving the cuffs of the the sleeves extended • To keep the microorganisms to minimum
over the hands. The back of the gown is during the surgical procedure by suppression
securely tied or fastened at the neck and of growth.
waist; touching the outside of the gown at the • To reduce the hazard of microbial
line of ties or fasteners, in the back only. contamination of the surgical wound by skin
• The scrub nurse, putting down, gently shakes flora.
out folds, then slips both arms into the Materials needed for Surgical Hand Scrub
armholes of the sleeves simultaneously Scrub Sink
without touching the sterile outside of the • is adjacent to the OR for safety and
gown with bare hands. convenience
• After drying your hands, pick up the sterile • automatic control or foot or knee operated
gown, lift it directly upward and step away to faucets; - sink is deep & wide enough
avoid touching the edge of the wrapper. • Should be used only for scrubbing or hand
Drying Hands and Arms washing only.
After scrubbing, hands and arms must be thoroughly • Should not be used to clean or rinse
dried before the sterile gown is donned to prevent contaminated/ soiled instruments and
contamination of the gown by strike-through of equipment.
microorganisms from wet skin. Scrub Brush
Apron • reusable scrub brushes
• Fluid proof aprons • disposable sponges
• Lead aprons • single use disposable brush-sponge
• A decontamination apron should be worn over combination with impregnated antiseptic
the scrub suit to protect against liquids and detergent agents.
cleaning agents during cleaning procedures. • Brush should not cause skin abrasion
This should be a full front barrier • reusable brush may be wrapped to provide
Lead Apron sterile individual packages.
• Protects against radiations exposure or when • Reusable nail cleaners should be used to
handling radioactive implants (x-rays,C-arms, clean under the nail.
coronary angiogram) • Orangewood sticks are not used because the
REVIEW OF SURGICAL HAND SCRUBBING wood may splinter & harbor Pseudomonas
Description: Antiseptic Agents
Surgical hand scrubbing is the process of removing • Antiseptic agents are approved by FDA
as many microorganisms as possible from the hands
• Different agent has different specific microbial
and arms by mechanical washing & chemical
agent.
antisepsis before participating in surgery.
• Agents alter the physical or chemical
- Mechanical washing with friction
properties of the cell membrane of
removes transient organisms.
microorganisms, thus destroying or inhibiting
- Chemical antisepsis reduces resident
cellular functions.
flora & inactivates microorganisms with
antiseptic agents. • Should be a broad spectrum antimicrobial
- Done before gowning & gloving for each agent;
surgical procedure. • Should be fast acting and effective;

• Should be nonirritating and non sensitizing; • 30 strokes method
• Should be prolonged-acting; • 15 strokes method
• Should be independent of cumulative action Steps in 5-minute time scrub method
4% Chlorhexidine Gluconate- produces effective, 1. Wet hands and forearms. Apply 2 to 3 ml (6
immediate, and cumulative reductions of resident & gtts) of antiseptic agents to the hands
transient flora. The effect is maintained for more 2. Lather & Wash hands several times up to 2
than 6 hours. Nonirritating to the skin but highly inches above the elbow. Then rinse
irritating if splashed in the eye. thoroughly under running water with hands
Iodophors- is a povidone-iodine complex against upward.
gram positive & gram-negative microorganisms; 3. Take the sterile brush, apply antiseptic agent
irritating to the skin; not sustained for a prolonged & scrub following the time allotted per part: *
period (6hrs). 30 seconds each nail, *30 seconds each
1% Triclosan- nontoxic, non-irritating, & develops finger, *30 seconds each hand
a prolonged cumulative suppressive action when 4. With brush in hand, clean under fingernails
used routinely. Less effective than Chlorhexidine with nail cleaner on running water then
Gluconate and Iodophors discard after use the cleaner
60% / 90% Alcohol- nontoxic, does not have 5. Again scrub each individual finger, nail and
residual activity, has drying effect on skin. hands with the brush a half minute for each
5. 3% Hexachlorophene - most effective after 1. hand, maintaining lather
buildup of cumulative suppressive action. Available 6. Rinse hands and arms and
by prescription only discard brush; Reapply the
Preparation for Surgical Scrub antiseptic agent and wash the hands & arms
• Skin & nails should be kept clean and in good with friction up to the elbow for 3 minutes.
condition and cuticles should be uncut. Interlace the fingers to cleanse between
• Fingernails should not reach beyond the them
fingertip to avoid glove puncture. 7. Rinse the hands and arms thoroughly.
• Fingernail polish should not be worn. Artificial 8. Stay for a few seconds at the scrub sink for
devices must not cover natural fingernails. the dripping of water, then proceed to the
• Remove all jewelries from fingers, wrists and assigned OR suite. DO NOT
neck. INTERLACE THE FINGERS.
• Ensure to fold the sleeves of the scrub suit at Steps in Brushstroke method (15 Strokes Method)
least 2 to 3 inches above the elbow. 1. Wet hands and arms up to 2 inches above
Before proceeding to the scrub sink the elbow
• Open out the sterile gown pack onto a clean 2. Lather with antiseptic agent.
back table, only grabbing the outermost 3. With the hands held under running water,
edges to maximize the sterile field. clean under the fingernails of both hands
• Open the sterile glove packet and let it drop with nail cleaner & discard after use
onto the open sterile gown pack 4. Rinse both hands and arms under running
Preparations Immediately Before scrubbing water, keeping hands up
• Inspect the hands for cuts and abrasions. Skin 5. Take a sterile brush and apply an antiseptic
integrity should be intact. agent and start doing the brush stroke
• All hair is covered properly by headgear method on ONE HAND first following:
including the pierced ear studs. a. 15 strokes each nail
b. 15 strokes all sides of each
• Adjust disposable mask snugly & comfortably
over nose & mouth. finger
c. 15 strokes each dorsum
• Clean eyeglasses if worn.
d. 15 strokes each palm
• Adjust comfortably in relation to the mask.
e. 15 strokes for each third of
Adjust water to a comfortable temperature the arm up to 2 inches above
and amount. the elbow.
Types of Surgical Scrub Procedure
6. Repeat the above steps for the other
Time Method
hand and arm
• Complete scrub (5-7 minutes) 7. Rinse the hands and arms
• Short scrub (3 minutes) thoroughly
Brush-stroke Method or counted Method

8. Stay at the scrub sink for a few 3. Release the gown. The surgeon holds arms
seconds for the dripping of water while outstretched while the circulator pulls the gown onto
maintaining the hands up. the shoulders and adjusts the sleeves, so the cuffs are
GOWNING AND DONNING OF SURGICAL properly placed. In doing so, only the inside of the gown
GLOVES is touched at the seams.
Purpose: Donning of sterile surgical gloves by Closed glove
- Sterile gown is worn to exclude skin as a technique
possible contaminant and to create a 1.Using the left hand and keeping it within the cuff of
barrier between the sterile and unsterile sleeve, a gowned scrub person picks up the right glove.
areas. Palm of glove is placed against palm of right hand,
General Considerations grasping top edge of glove cuff above palm.
A. The scrub person gowns & gloves CORRECT POSITION: Fingers of glove are
self, then may gown and glove the pointing towards you and the thumb of the glove
surgeon & assistants. is aligned with the thumb of the hand. The thumb
B. Gown packages preferably are side of the glove is down.
opened on a separate table from 2, Back of the cuff is grasped in the left hand and turned
other packages to avoid over the right sleeve and hand. Cuff of the glove is now
contamination from dripping water. over the stockinette cuff of the sleeve, with the hand
C. Avoid splashing water on scrub attire still inside the sleeve.
during surgical scrub because 3.Top of the right glove & underlying sleeve of the gown
moisture may contaminate the are grasped with the left hand. By pulling the sleeve up,
sterile gown. the glove is pulled onto the hand.
Wearing of Sterile gown by self 4.Using the gloved right hand, the left glove is picked
• After scrubbing, hands and arms must be up and placed with the palm of the glove against the
thoroughly dried before the sterile gown is palm of the left hand. Back of the cuff is grasped, above
donned to prevent contamination of the gown the palm in the right hand & turned over the left sleeve
by strike-through of microorganisms from wet and hand.
skin. 5.Cuff of the left glove is now over the stockinette cuff
• After drying of hands, pick up the sterile gown, of the sleeve, with the hand still inside the sleeve. Top
lifts it directly upward and steps away to avoid of the left glove and underlying gown sleeve are
touching the edge of wrapper. grasped with the right hand, and the sleeve is pulled
• The scrub nurse, putting on a gown, gently up, pulling the glove onto the hand.
shakes out folds, then slips both arms into the Serving of Sterile gloves
armholes of the sleeves simultaneously 1. Pick up the right glove, grasp it firmly, with
without touching the sterile outside of the the fingers under the everted cuff. Hold the
gown with bare hands. palm of the glove toward the surgeon.
• The Circulator brings the gown over the 2. Stretch the cuff sufficiently for the surgeon to
shoulder by reaching inside to the shoulder introduce the hand. Avoid the touching the
and arms seams. The gown is pulled on, hand by holding your thumbs out.
leaving the cuffs of the sleeves extended 3. Exert upward pressure as the surgeon
over the hands. plunges the hand into the glove
• The back of the gown is securely tied or 4. Unfold the everted glove cuff over the cuff of
fastened at the neck and waist; touching the the sleeve; Repeat for the left hand.
outside of the gown at the line of ties or 5. If a sterile vest is needed, hold it for the
fasteners, in the back only. surgeon to slip the hands into the armholes.
Serving of sterile gown Be careful not to contaminate gloves at the
1. Open the hand towel and lay it on the surgeon’s neck level. If the gown is a wraparound,
hand, being careful not to touch the hand. assist the surgeon.
*If no towel is available, the lower part of the Donning of sterile surgical gloves by Open glove
gown may be used to dry the hands of the technique
surgeon.* This method of gloving uses a skin-to-skin, glove-
2. Keeping your hands on the outside of the gown to-glove technique. The hand, although scrubbed,
under a protective cuff of the neck and shoulder area, is not sterile and must not come in contact with the
offer the inside of the gown to the surgeon. The exterior of the sterile gloves. The everted cuff on the
surgeon slips the arms into the sleeves. gloves exposes the inner surface.

The first glove is put on with skin-to-skin technique, Glove removal
bare hand to inside cuff. The sterile fingers of that The key to removing both sterile and non-sterile gloves
gloved hand then may touch the sterile exterior of is "Dirty to Dirty - Clean to Clean" that is, contaminated
the second glove, that is glove-to-glove technique surfaces only touch other contaminated surfaces: your
Open Glove Method bare hand, which is clean, touches only clean areas
1. With the left hand, grasp the cuff of the right inside the other glove.
glove on the fold. Pick up the glove and step 1. Take hold of the first glove at the
back from the table. wrist.
2. Insert the right hand into the glove and pull it 2. Fold it over and peel it back, turning
on, leaving the cuff turned well down over the it inside out as it goes. Once the glove is
hand. off, hold it with your gloved hand.
3. Slip the fingers of the gloved right hand under • To remove the other glove, place
the everted cuff of the left glove. Pick up the your bare fingers inside the cuff without
glove and step back. touching the glove exterior. Peel the
4. Insert the hand into the left glove and pull it glove off from the inside, turning it inside
on, leaving the cuff turned down over the hand. out as it goes. Use it to envelope the
5. With the fingers of the right hand, pull the cuff other glove.
of the left glove over the cuff of the left sleeve. If SURGICAL INSTRUMENTS
the stockinette is not tight, fold a pleat, holding it Historical Background
with the right thumb while pulling the glove over Code of Hammurabi (Circa 1900 BC)- describes a
the cuff. Avoid touching the bare wrist. bronze lancet
6. Repeat step 5 for the right cuff, using the left Incas of Peru- use razor-sharp flint and animal teeth
hand and thereby completely gloving the right Egyptians (1900 - 1200 BC) - blades made of flint,
hand. reed, and bronze
Reminders in Glove technique Hippocrates (460 -377 BC)- advocated the
• Avoid contact of sterile gloves with ungloved heating of tips of rounded and pointed blades
hands during closed-gloving procedure. before using
• For close gloving method, never let the fingers Rome (1st century AD)- use of scalpel handles with
extend beyond the stockinette cuff during the blunt dissecting ends, knives, saws, forceps, and
procedure. Contact with ungloved fingers clamps with locking handles, probes, and hooks for
constitutes contamination of the gloves. retraction.
• For open glove method, touch only the cuff of Ambroise Pare (1509-1590)- 1st person to grasp
the glove with the ungloved hand, and then blood vessels with a pinching instrument that was the
only glove to glove for the other hand. predecessor of the hemostat used today.
• If contamination occurs during either American Civil War (1861-1865) - trademark of this
procedure, both gown and gloves must be period were amputations
discarded and new gown and gloves must be - In some instances, amputations were
added. performed on kitchen tables with heavy
• When removing gloves after a procedure is knives and instruments. Even tables forks
finished, the gloves are removed using glove- were used as retractors.
to glove, skin to skin technique, after the gown 18th-19th centuries
is removed inside out technique. • Surgical tools were made by skilled
Removing of gown silversmiths, coppersmiths, and
Grasp the right shoulder of the loosened gown with the woodworkers. Some instruments handles
left hand and pull the gown downward from the were made of ivory, bone, or wood with velvet
shoulder an off the right arm, turning the sleeve inside cases
out; 20th Century:
1. Turn the outside of the gown away • Instruments are made entirely of metals such
from the body with flexed elbows; as carbon steel, silver, and brass, and the
2. Grasp the left shoulder with the right velvet case was replaced by sterilizer trays.
hand and remove the gown entirely, 1900s
pulling it off (inside • Development of stainless steel from
out); Germany, Sweden, France, England,
3. Discard in a laundry hamper or in a Pakistan, and United States
trash receptacle (if disposable)

• Made of titanium, cobalt-based alloy
(Vitallium), stainless steel or other metals
• Stainless steel: alloy of iron, chromium and
carbon. It may also contain nickel,
manganese, silicon, molybdenum, sulfur and Classification of instruments
other elements to prevent corrosion or add • Cutting and Dissecting
tensile strength. • Grasping and Holding
• Alloys make the instruments resistant to • Clamping and Occluding
corrosion when exposed to blood and body
• Exposing and Retracting
fluids, cleaning solutions, sterilization, and
atmosphere. • Suturing and Retracing
Parts of the Surgical Instrument • Suturing and Stapling
• Tip • Viewing
• Serrated Jaws • Suctioning and Aspirating
• Boxlock • Dilating and Probing
• Shank • Accessory Instruments
• Ratchet CUTTING AND DISSECTING
• Finger ring or Ring Handle • Have sharp edge
• Use to dissect, incise, separate, and
excise tissues
• Should be protected during
cleaning, sterilization, and storing;
• Should be kept separate from other
instruments and demand careful
handling at all times
Scalpels
• Made of brass and the blade is
made of carbon steel;
• Most frequently used has a reusable
handle
• May also be available in disposable
type
Handle # 3, 7, 9 – Blade # 10, 11, 12, 15

Knives
• Comes in various sizes and
configuration
• Usually have a blade at one end and
the blade have one or two cutting
edges
• Some have detachable
Scissors
• Blades of the scissors maybe
straight, angled or curved, pointed or
blunt at the tips, and the
Handles maybe long or short;
Handle # 4 – Blade # 20, 21, 22, 23 • Used only to cut or dissect tissues
• Blade # 10- most frequently use; Metzenbaum scissors (Metz)- used to cut
has a rounded cutting edge along one delicate tissue; also known as tissue
side or operating scissor
• Blades # 20, 21, 22- have the same
shape but larger
• Blade # 11- straight edge that
comes to a sharp point; known as
the stab knife
• Blade # 12- shaped like a hook with
the cutting edge on the inside curvature
• Blade # 15- has a smaller and
shorter curved cutting edge than no. 10
blade Straight MAYO scissors (Suture
• Blade # 23- has a curved cutting scissors) used to cut sutures and supplies;
edge that comes to more of a point than also known as suture scissor
nos. 20, 21, and 22

Curved MAYO scissors - available in regular

and long sizes. used to cut heavy and Sharp Dissectors - includes biopsy forceps and
tough tissues (fascia, muscles, uterus, punches, curettes (has a sharp edge with loop, ring or
breast) scoop on the end), snares (loop of wire may be put
around a pedicle to dessert tissue such as a tonsil
Wire scissors (stitch)- have short, heavy

blades; used instead of suture scissors to
GRASPING AND HOLDING
cut stainless steel scissors; heavy wire
Tissue Forceps
cutters are used to cut bone fixation wires.
- used often in pairs, to pick up or hold soft
tissues and vessels
Dressing / Bandage scissors - used to cut

drains and dressings and to open items such as
plastic packets
- bandage is used to cut the uterus and
umbilicus during CS operation
Thumb Forceps/smooth, non-
toothed forceps - used to hold delicate tissues; are
tapered with serrations at the tip; maybe straight or
angled, short or long and delicate or heavy.

Toothed/ pick up/ Rat tooth Forceps- have a single

tooth on one side that fits between two teeth on the
opposing side; use to hold tough tissues Stone Forceps
- • Used to grasp calculi such as kidney
stones or gallstones
• either curved or straight forceps
• have blunt loops or cups at the end
of the jaw
Allis Forceps- has a scissor action. Each jaw curves

slightly inward with a row of teeth at the end;
o holds tough tissue gently
but securely
Tenaculum - curved or angled points on the ends of

the jaw penetrate tissue
• May have single tooth
or multiple teeth (dilatation &
curettage)
Babcock Forceps- maybe used in fallopian tube

The end of each jaw is rounded to fit around a
structure or to grasp tissue without injury.

CLAMPING AND OCCLUDING

Hemostatic forceps
• Usually have two opposing serrated
jaws that are stabilized by a box lock
and controlled by ringed handles
• When closed, the handles remain
locked on ractchets
• most commonly used surgical
instruments
• used primarily to clamp blood
vessels
• either straight or curved slender
Bone Holders - includes vice-grip, pliers and other

types of heavy holding forceps use to stabilize the
bone
Crile / Stet / Tag Forceps- for shallow layers of

tissues

Kelly Forceps: for deep layers of tissues or cavity Kocher or Ochsner Forcep- usually used in
colon surgery; for placing cardiac wires when
performing sternotomy
Crushing Clamps- used to crush tissues or clamp

blood vessels;
- fine tips are used for small vessels and structures
while longer and sturdier jaws are needed for larger Non-crushing Vascular Clamps
vessels, dense structures and thick tissues • used to occlude peripheral or major
blood vessels temporarily
• minimizes tissue trauma
• jaws, either straight curved or S
shaped, have opposing rows of finely

Deaver retractor -for deeper retraction
EXPOSING AND RETRACTING

Handheld or Non self-retaining Retractors
• usually used in pairs and held by the
first or second assist;
• Some have blades on one end,
either curved or angled, dull or sharp
while some have blade on
both ends
• used by the assistant surgeon
• used to pull soft tissue and muscle
aside to expose surgical site
Army-navy retractor - abdominal operation
Harrington Retractor - to protect the organ; minimizes

the trauma

Single end richardson retractor - used in cesarean keep the device open, while others
section have wings to secure the blades;
• some holding devices have 2 or
more blades that can be inserted to
spread the edges of incision
and hold them apart
• Balfour abdominal retractor -
Bladder retractor
Goulet retractor - intended for the abdominal

procedure
SUTURING AND STAPLING

Needle Holder
• used to grasp and hold curved
surgical needles
Malleable ribbon retractor (straight, • resembles hemostatic forceps but
thin, bendable) the basic difference is the jaws
• has a short, sturdy jaws for grasping
a needle without damaging it or the
suture material.
• the size of the needle holder should
match the size of the needle
• either long or short, with serrations
on jaws, some are non
Self – retaining Retractors

• May have shallow or deep blades,
some have ratchets or spring locks to

•
the higher the number, the smaller the
needle
•
Castroviejo Needle Holder - intended
for sutures; for smaller needles; blood
Tungsten Carbide Jaws - jaws with an insert of solid vessel repair
tungsten carbide with diamond cut precision teeth
designed to eliminate twisting and turning if the needle Staplers- available in reusable and disposable
in the needle holder; type
o can be identified by
the gold plating on the VIEWING INSTRUMENTS
handles Speculum- has a hinged, blunt blessed that enlarges
o intended for handling and holds a canal open such as the vagina
needles
Smooth jaws needle holder- needle holders that Nasal speculum- funnel like and used to visualized
have jaws without serrations which are used for small the inner parts of the nose
needles like in plastic and microsurgery

SUCTIONING AND ASPIRATING

Suction- is the application of pressure to withdraw
blood
or fluids, usually for visibility at the surgical site;
• made of style tip and sterile tubing;
• style of the suction tip depends
where it is to be used and the surgeon’s
preference
Ear speculum- is like used to visualize the inner parts
of the nose
Poole Abdominal Tip- straight hollow tube with a

perforated outer filter shield that prevents the adjacent
tissues from being pulled into the suction apparatus
Endoscopes- made of a round or oval sheath that

is inserted into a body orifice or through a small
skin incision
• used for viewing in specific anatomic •
used during abdominal laparotomy or
locations within any cavity in which
copious amount of fluid or pus are
encountered
Frazier Tip Suction- right angle tube with a small
diameter
• used when little or no fluid except
capillary bleeding an irrigating fluid is

encountered such as brain, Trocar- has a sharp cutting edge at the end of a hollow
spinal, plastic, and ortho procedures tube intended to cut through tissues for access to fluid
o keeps the field dry without or a body cavity. Used for bone marrow and
the need for sponging laparoscopy
• has a fitted blunt and end cannula
inside to keep fluid or gas from escaping
until the cannula is removed.
Cannula - has a blunt end and perforations around the

tip to aspirate fluid without cutting into tissues;
• also used to open blocked vessels or
ducts for drainage or to shunt blood flow
from the surgical site
Yankauer Tip - hollow tube that has an angle of mouth;

connected is connected to rubber tubing; used in
tonsillectomy
Aspiration - done manually to obtain a specimen

(blood, body fluid, or tissue for lab examination); also
used for bone marrow aspiration (BMA)
- Aspirating tube is a long straight tube used
through an endoscope

DILATING AND PROBING
CATEGORIES OF INSTRUMENTS
A. Sharps
B. Grasping and Holding
C. Clamping and
Occluding Retractors
Dilators- used to enlarge orifices and ducts HANDLING OF INSTRUMENTS BEFORE
• Hegar Dilators SURGICAL PROCEDURE
1. Scrub nurse should be the
Probes- used to explore a structure or to locate an one to prepare the instrument on the mayo
obstruction and back table. Avoid preparing the
instruments by wearing only sterile
gloves. Prepare with complete PPE
2. Uncovered, exposed instruments
are never transported through corridors.
ACCESSORY INSTRUMENTS 3. The scrub nurse should not go
Mallet- used to strike bones beyond the confines of the room.
4. Scrub and circulating nurses should
count the instruments, sharps and spongers;
they must be accounted for throughout every
procedure.
Counting Procedure- is a method of accounting for
items put on the sterile table for use during the surgical
procedure
Screwdrivers - for plating • Sponges, sharps, and instruments
should be counted on all procedures.
• Counting ensures the expensive
instruments like towel clips and
scissors are not accidentally thrown
away with the drapes
• Counts are also
performed for infection control and
inventory control purposes
KEYPOINTS IN HANDLING INSTRUMENTS
1.Handle loose instruments separately to
prevent interlocking or crushing

A. Never pile one instrument on top of instrument needed. An understanding
another on an instrument table; lay of what is taking place at the surgical
them side by side site makes the signals meaningful.
B. Microsurgical, ophthalmic and other c. Select appropriate
delicate instruments are vulnerable instruments for location of surgical
to damage through rough handling. site; shorty instruments for superficial
C. Metal to metal contact should be work and long ones for deep in a body
avoided or minimized cavity. Experience will facilitate
2.Inspect instruments such as scissors and instrument selection according to the
forceps for alignment, imperfections, surgeon’s preference and need.
cleanliness and working condition d. Many instruments are used
a. Blades must be properly in pairs or in sequence.
set 4. Pass the instrument decisively and firmly.
b. Exact alignment of teeth when passing a curved instrument, the curve of
and serrations is necessary the instrument aligns with the direction of the
c. Set aside or remove any d curve of the surgeon's hand (palm) In passing
efective instruments an instrument to the surgeon:
3.Sort instruments neatly by classifications § If the surgeon is on the opposite side
4,Keep ring - handled instruments together, of the table, pass across the right hand to
with curvatures and angles pointed in the same the right hand or with the left hand to a
direction. left-handed surgeon.
a. Hang ring handles over a § If the surgeon or assistant is on the
rolled towel or over the edge of same side of the table and to the right,
the instrument tray or container pass with your left hand; if the surgeon is
b. remove instrument pins or to your left, pass with your right hand.
holders if used box locks open § Hemostatic forceps are held near
c. close box locks on the the box lock by the scrub persona and
1st ratchet passed by rotating wrist clockwise to
5. Leave retractors and other heavy place the handle directly into the
instruments in a back table surgeon.
6. Protect sharp blades, edges and § if the surgeon or assist is on the
tips. They should not touch anything same side of the abele and to the right
A, Some orthopedic instruments can remain in the (pass
racks during the initial table set up and until they are with your left hand)
needed during the surgical procedure § sharp and delicate instrument
B.Tip: Protective covers or instrument plastic placed on a flat surface for the surgeon to
sleeves should be left on until the instrument is actually pick up. to avoid the potential contact with
used. items such as blades, sharp points.
C.If they are not in a rack or tip guard, support handles 5. Watch the sterile field for loose instruments.
on a rolled towel or gauze sponge to keep blades and remove them promptly after use to the mayo
tips of micro instruments suspended in mid air. table. The weight of the instrument can injure the
HANDLING OF INSTRUMENTS px or cause post-op.
DURING SURGICAL PROCEDURES 6. Wipe the blood and organic debris off the
In passing an instrument to the surgeon: instrument promptly after each use with a moist
1. Know the name and use of each instrument sponge.
2. Handle instruments individually a. Dried blood and debris on
3. Hand the surgeon or instrument surface like in box lock and
assistant the correct instrument for each in crevices, increased bioburden
particular task. Principle “use for b. Use demineralized sterile distilled
intended purpose only” water in wiping the instruments saline/other
a. Avoid placing fingers in the solution can damage surfaces
ring handle as the instrument c. A non-fibrous sponge should be
is passed used to wipe microsurgical, ophthalmic and
b. Many surgeons use hand delicate tip instruments. This can prevent
signals to indicate the type of snagging and breaking of delicate tips.

7. Flush the suction tip and tubing with sterile 3. Separate delicate, small instruments
distilled water periodically to keep the lumens and those with sharp and semi sharp edges for
patient. Keep a tally of the amount of fluid used special handling.
to clear the suction line and deduct this amount 4. Disassemble all instruments with
from the total used to irrigate the surgical site. parts to expose all surfaces for cleaning.
This is to have an accurate accounting of blood 5. Open all hinged instruments to
loss from the operation. expose box locks and serrations.
8. Remove debris from electrosurgical tips to 6. Separate instruments of dissimilar
ensure electrical contact. Disposable abrasive metals. Clean the instruments per type to
tip cleaners are helpful for maintaining the prevent electrolyte deposition of other metals.
conductivity and effectiveness of the surface of 7. Flush with cold distilled water
the tip. Avoid using the scalpel blade because through hollow instruments or channels like
the debris may become airborne and suction tips or endoscopes to prevent drying of
contaminate the surgical field. organic debris.
9. Place used instrument not needed again into 8. Rinse off blood and debris with
a tray or basin during or at the end of the surgical demineralized distilled water or any enzymatic
procedure detergent solution.
a. Blood and gross debris 9. Follow procedures for preparing the
must be removed first instruments for decontamination or terminal
b. Careless dropping, tossing sterilization. Procedure varies depending on
or throwing of instrument into a basin the type of instrument and its components and
is highly the equipment available and its location.
prohibited DECONTAMINATION PROCESS OF
c. Keep instruments INSTRUMENTS
accessible for final counts 1. Pre rinsing or presoaking
d. Bloody instruments should 2. Washing
not be soaked in a basin of solution 3. Rinsing
for a prolonged period. Instruments 4. Sterilizing
that have been wiped can be Pre-rinsing / Pre-soaking- done to prevent blood
immersed in a basin of sterile and debris from drying on instruments or to soften
demineralized distilled water, NOT and remove dried blood and debris.
SALINE SOLUTION, NaCl in o Proteolytic Enzymatic Detergent
saline solution and blood is dissolves blood and protein and
corrosive. removes dissolved debris from
e. Never place heavy crevices. This is effective in a wide
instruments like retractions on top of range of water qualities.
tissue and hemostatic and other o Water with a low-sudsing, near-
clamps. Place them in a separate neutral detergent
tray. o Plain, clean, demineralized distilled
HANDLING OF INSTRUMENTS water
AFTER SURGICAL PROCEDURES o Liquid detergents are preferred.
All instruments on the mayo and back tables, whether DON'Ts:
used or unused are considered contaminated and o BLEACH - corrosive solution should
should be promptly and properly be cleaned, not be used
inspected, terminally sterilized, and prepared for o CHLORINE COMPOUNDS
subsequent use. o IODOPHOR - soaking should not
1. Check all the drapes, towels and exceed 1 hour
table covers to be sure that no instruments will Washing - done to remove residual blood and debris
go to the laundry or into the trash. A final quick before terminal sterilization or high-level disinfection.
count is a safeguard. 1. Clean, warm water with
2. Collect all the instruments from the noncorrosive, low sudsing, free rinsing
mayo, back table and other small tables detergent.
including those have been dropped or passed Regardless of the water content, the
off the sterile field. detergent should

be anionic or nonionic with a pH sterilized unwrapped immediately
close to neutral. before use in a high-speed pressure
• Alkaline detergent (pH over sterilizer, they may be prepared in
8.5) will stain instruments advance as for a case cart, or retained
• Acidic detergent (pH below in storage until needed.
6) will corrode or pit the Steps in Assembling Instruments Sets in
instruments. Sterilizer
2. Wash instruments carefully to guard 1. Make sure instruments are
against splashing and creating aerosols. thoroughly dry.
2. Place an absorbent towel or foam in
• Use a soft-bristled brush to
the bottom of the tray to absorb
clean serrations and box locks.
condensate, unless contraindicated.
• Keep instruments 3. Count the instruments as they are
submerged while brushing to placed in the tray and record the
minimize aerosolizing number on a preprinted form.
microorganisms 4. Arrange instruments in a definite
• Use a soft cloth to wipe pattern to protect from damage and to
surfaces or a non-fibrous facilitate removal for counting and
cellulose sponge to prevent use.
damage to delicate tips. 5. Place heavy instruments like
• Remove bone, tissue and retractors in the bottom of the tray.
other debris from cutting 6. Open hinges and box locks on all
instruments. hinged instruments.
• Never scrub surfaces with 7. Place sharp and delicate
steel wool, wire brushes, instruments on top of other
scouring pads or powders to instruments. Blades of scissors &
protect the protective finish on delicate tips should not touch other
metal instruments.
(this protects the 8. Place concave or cupped
base metal from instruments with these surfaces down
oxidation) so that water condensate does not
Rinsing collect in them during the sterilization
• Use hot distilled or deionized water process.
in rinsing; Should be done thoroughly to 9. Place ring-handled instruments on
avoid staining the instruments. pins or holders designed for this
• After rinsing, put instruments back purpose. Curved instruments should
into sterilization racks or trays be pointing in the same direction,
grouped together by style &
• Arrange instruments that can be classification. Do not use rubber bands
steam sterilized in a decontaminator. because steam cannot penetrate
Sterilizing through or under bands.
• The sterilizing agent must come in 10. Disassemble all
direct contact with all surfaces of every detachable parts. Secure properly the
instrument. small parts.
• Instruments should be packed, 11. Separate dissimilar metals
individually or in sets to allow adequate like brass instruments from stainless
exposure to sterilant, to prevent air steel instruments.
from being trapped and moisture from 12. Place instruments with a
being retained during the sterilization lumen like suction tip in as near a
process, and to ensure sterile transfer horizontal position as possible.
to the sterile field. 13. Distribute weight as evenly
• Instruments are put in a container or as possible in the tray. Some trays
tray, or wrapped in a small set or have dividers, clips and pins attached
individually, for sterilizing and to the bottom of the tray so as to
transporting. Instruments may be

prevent the instruments from shifting • Blood typing and crossmatch
and keep them in alignment. • Urinalysis and/or Fecalysis
14. Place a chemical Radiologic tests
indicator on the outside ● Chest X-ray- not all but required to patient with
wrapper or container as well as inside cardiac or pulmonary disease, smokers,
the tray. cancer patients, and persons with 60 y/o
15. Label appropriately for and older.
intended use including the name of the ECG- routine to patients with cardiac disease and
instruments or set, date sterilized, persons of 40 y/o and up.
name of the person who packed the Diagnostic procedures- performed when
instruments and the control number specifically indicated, like in vascular surgery.
Handling Powered Instruments Written instructions- will come from the surgeon
• Electrically powered and should be reviewed and followed by the patients
instruments like saws, drills, before admission.
dermatomes, nerve stimulators a. Should not ingest solid foods
• Air powered instruments are preceding the operation to prevent
small, lightweight, free of vibration and aspiration and regurgitation or emesis.
easy to handle for pinpoint accuracy at § “NPO after midnight”
high speeds § Solid foods- will take 12
• Battery powered instruments are hours before it empties the
cordless with rechargeable batteries stomach
• Wipe off any organic debris between § Clear liquids- maybe
uses during the surgical procedures unrestricted until 2 to 3 hours
• Accessories are disassembled prior before the operation but still
to cleaning depends on the discretion of
the surgeon and
• Do not immerse the motor in liquid.
anesthesiologist.
• Lubricate as § Less time of NPO- infants,
recommended using a silicone oil. small children, diabetic and
SURGEON’S ARMAMENTUM elderly patients prone to
The surgeon relies on surgical instruments to dehydration.
enhance his or her skill in the art and science of b. Oral medications- can be taken
surgery. The nursing staff must ensure that with minimal fluid intake up to 1hour pre
these instruments function properly and sterilize op as prescribed with 150ml or less of
adequately. Instruments are selected on the water.
basis of safety for their intended use. They c. Patient skin should be cleansed prior
must be inspected, maintained, and used to operation using an antimicrobial soap
appropriately. for several days pre op.
MODULE 4 – PRE, INTRA, & § Wash face, ear, neck, and
POST OPERATIVE CARE shampoo the hair
PRE-OPERATIVE PREPARATION OF § Male patients have to cut
their hair short and shave on the
THE PATIENT day of the operation.
Laboratory & Physiological Preparation Medical d. Nail polish and acrylic nails should
history and physical examination- done by be removed to permit observation of
physician oxygenation and circulation (capillary
Laboratory tests- ordered by the surgeon and should refill test)
be completed 24 hours before admission so results will ● Oxisensor of pulse
be available for review. oximeter
• H & H, BUN (liver & kidney function ● Nail bed is a
test), vascular part
Blood Glucose- routine for 60 y.o. up e. Leave jewelries and all valuables at
• Hematocrit home. Metal jewelries like wedding bands
• CBC, Platelet count, Prothrombin must be removed to prevent burns if
time electrosurgery will be used.

f. Other instructions of what to expect d. What things should I worry
before, during and after operation– about?
explained by the surgeon e. What are the greatest risks
o When to arrive in the hospital for or the worst thing that could
admission happen?
o Where the immediate • Is required for:
family will stay and wait before and a. Each surgical procedure to
after the operation be performed including
INFORMED CONSENT secondary procedures like I
Informed Consent - should be facilitated by the &
surgeon and follow-up by the nurse; the D;
surgeon explains the surgical procedure and the b. Any procedure for which a
risks to the patient. general anesthetic agent is
o Prognosis administered such as an
o Management examination of a child under
o Quality of life anesthesia;
Informed Consent c. Procedures involving
• Is a legal document that provides entrance into a body cavity
evidence of patient’s agreement to allow such as endoscopy;
a procedure to be performed on him/her; d. Any hazardous therapy
• A signed consent is legally regarded such as radiation
as VALID for a period of about 6 months Purposes of Surgical Consent
or for as long as the patient consents to 1. To ensure that the client understand
the same procedure. the nature of the treatment including the
Institutional policy may vary. potential
Purposes of Informed Consent complication and disfigurement;
1. It provides a mechanism to protect a 2. To indicate that the client’s decision
patient’s right to self-determination was made without pressure;
regarding surgical intervention; 3. To protect the client
2. It provides a means by which the against unauthorized procedures;
patient can make an educated choice 4. To protect the surgeon and hospital
about having a procedure performed. against legal action by the client.
General Consent Guidelines of Consent
• This form authorizes the physician 1. ONLY the surgeon assigned is
and the hospital staff to render responsible to inform the patient about the
treatment or perform procedures as proposed procedure, its interest. Risks,
the physician deems advisable. complications and what the patient may
expect during and after the
• This is relied on ONLY for routine
operation;
duties performed in the hospital.
2. Complete explanations should be
• Nurses should be knowledgeable given to the patient and the surgeon is
about the statements on the form used responsible for making certain that the patient
in their hospital. or legal guardian adequately understands
Surgical Consent everything.
• Specifically outlines each procedure 3. Consent should contain the
to be performed and explains the risks following:
and benefits; - Should answer the o Patients full name (maiden
following patient question: name)
a. What do you plan to do to o Surgeon’s full name
me? o Complete and specific
b. Why do you want to do this procedure to be performed
procedure? o Signature of the patient
c. Are there any alternatives o Complete name of
to this plan? authorized witness
o Date and time of signature

4. Every patient is entitled to receive • Anesthetist – an interview
the sufficient information to be performed on will be conducted before
him/her. They have the right to waive an admission with patients who
explanation of the nature and consequences have complex medical histories
of the procedure. They have the right to are high risk or have high
decide what will and not be done. Only after degrees of anxiety.
making this decision is the patient asked for a PREOPERATIVE PREPARATIONS EVENING
signed written consent for operation. BEFORE THE ELECTIVE SURGERY PROCEDURE
5. The patient has the right to refuse 1. GIT Preparation (Bowel
the treatment. Preparation)
6. Consent should be signed by the ● “Enemas till clear” may be ordered.
patient before premedication and before ● Golytely or Colyte normally clear the bowel in 4 to
going to the OR except in life threatening 6 hours
emergency situations. 2. Douche- used to cleanse the vagina
7. There should be during vaginal and pelvic procedures.
a WITNESS verifying the consent was signed - Patients who will be admitted the day of the
without consent. surgical procedure may be instructed to self-
Who should Sign the Consent? administer enema or douche at home.
1. Should be of legal age 3. Hair removal/preparation of shaving
2. Should be mentally 4. Bedtime sedation for sleep
competent Psychological Preparation
3. An emancipated minor, Fears related to surgery
married or independently earning a • General fear
living o Fear of the unknown
4. Illiterate may sign with an o What to expect and what
“X” after which the witness writes are the consequences of surgery
“patient’s mark” o Nursing action: allay
Who should not Sign the Consent? anxieties by giving the patient
1. A minor opportunities to express his/her fears
2. Unconscious
• Specific fears
3. Mentally incompetent
o Fear of destruction of body
*PARENT/LEGAL GUARDIAN/NEXT of KIN
image
*SURGEON - should not sign the
o Threat to sexuality
consent on behalf of the patient
o Fear of permanent
Consent in Emergency Situation
disability
Consent in an emergency situation is desired
o Fear of pain - fear of dying
but not essential. Although every effort should
Skin Preparation of Patient Purpose of Skin
be made to obtain the consent, the patient’s
Preparation:
physical condition takes precedence over a
To render the surgical site as free as possible
permit.
from transient and resident
microorganisms, dirt, and skin oil so the incision
Permission for a lifesaving procedure in a minor may
can be made through the skin with minimal
be accepted from a legal guardian by TELEPHONE,
danger of infection from this source.
TELEGRAM, or WRITTEN COMMUNICATION.
If obtained by telephone, two nurses should monitor the
Hair removal is necessary especially if the hair
call and sign the form, which is signed later by the
surrounding the surgical site is so thick; it
parent on arrival at the hospital. In lieu of these
interferes with exposure, closure and dressing ;
methods, a written consultation by two physicians other
it prevents adequate skin contact with
than the surgeon will suffice until a relative can sign a
electrodes.
consent.
8. Pre-operative visit of the • Clipper - available in electric type or
Perioperative Nurse. cordless handle with rechargeable
9. Pre-operative visit by the batteries.
Anesthesiologist or Nurse o Electric clippers with fine
teeth cut hair close to the skin.

o Clipping can be • Post-op exercises
done immediately • Equipment used during post-op
before the surgical procedure or period
up to 24 hours preoperatively 1. Oxygen, pulse oximeter,
using short strokes against the CVP
direction of hair growth. ○ ventilator
• Depilatory Cream - Skin testing ○ NGT
should be done first for possible allergies. ○ IV medications
- Should not be used around the eyes and ○ Foley catheter
genitalia. - Should be applied on the skin, • Provide client and family teaching,
wait for 20 minutes before washed off. instruct the client in:
• Razor - shaving should be done as o Relaxation technique
near the time of incision as possible if this o Deep breathing and
method must be used. coughing exercises
- Wear gloves when shaving with o Post op exercises of
razor to prevent cross extremities turning and moving
contamination even though this is techniques
a surgically clean procedure o Pain-control techniques
Skin Preparation for Different Surgeries o Incentive spirometry use
Chest Surgery
- For chest surgery, the skin is shaved and INTRAOPERATIVE PREPARATION OF THE
cleansed on the affected side from mid hip PATIENT
over the shoulder, including the axilla, to the Nursing Care Plan
shoulder on the unaffected side. Assessment
Retroperitoneal Surgery • Assess respiratory status, including
- For rectal surgery, support the legs and history of pulmonary problems to identify
thighs in the lithotomy position. Shave the risk factors for postoperative
pubic, perineal, thigh, and anal areas (in a complications.
radius of about 10 inches from the anus).
• Assess for and report evidence of
Vaginal Surgery
F/E imbalance
- For gynecological surgery (perineal prep) support
Assess emotional status of client.
legs and thighs in the lithotomy position and shave
the anterior surface from the umbilicus down: • Examine the client’s record for
the pubic area, the external genitalia, the perineum, endocrine or metabolic problems that
including the area around the anus, and the could affect his response to surgery
buttocks. Shave inner thighs halfway to the knees (DM).
from the middle of anterior to middle of posterior • Assess immunologic and
thighs. hematologic functions history of allergies
Surgery of the Limbs previous reactions to blood transfusions
- For surgery of the limbs, the area includes the history of substance abuse Assess
entire circumference. The extent of the prep varies neurologic functions.
depending upon the type of operation. As an • Assess integumentary system
example, for surgery of the hand, the prep would Evaluate medication history for drugs that
normally extend distally from the elbow. A manicure could increase operative risk for affecting
or pedicure is also necessary. Fingernails or toenails coagulation time or interacting
must be clipped short, cleaned, and scrubbed. anesthetics.
Skin Marking • Assess the client for any type of
Surgeons use a staining solution to mark the incision prosthetic device or metal implants.
lines on the skin. This may be done before the • Assess the client and his family’s
patient is prepped. knowledge base to guide the
If the skin is marked after prep, a sterile dye solution preoperative teaching program.
and applicator or a sterile marking pen must be • Assess the laboratory and
used. diagnostic results of the patient (x-ray,
- Methylene Blue or Alcoholic Gentian Violet cbc, wbc, etc.)
Pre-operative Health Teachings Nursing Diagnosis

• Anxiety loses consciousness and is stabilized in the
• Knowledge deficit desired plane of anesthesia.
Planning and Outcome • Emergence – return of sensation
Identification Major Goals: and reflexes; to regain consciousness
• Decreased anxiety and increased following general anesthesia.
knowledge of the surgical experience. • Intubation – insertion of
• Promote measures that endotracheal tube ● Extubation – removal
help decrease anxiety for the client of endotracheal tube
and his family. • Hypnosis – artificially induced
ANESTHESIA sleep
Definition of Anesthesia • Hypnotic – a drug which induces
• branch of medicine that is concerned sleep
with the administration of medication or • Margin of Safety – the difference
anesthetic agents to relieve pain and support between therapeutic and lethal dosage
physiologic function during a surgical Stages of Anesthesia
procedure Stage I – Onset / Induction
• is a specialty that requires • Extends from the administration of
knowledge of biochemistry, clinical anesthesia to the time of loss of
pharmacology, cardiology and respiratory consciousness;
physiology. • Drowsy, dizzy, amnesic,
• the practice of medicine dealing with exaggerated hearing, decreased pain
management of procedures for rendering a Stage ii – Excitement / Delirium Stage (Loss
patient insensible to pain during surgical of Consciousness Stage)
procedures and with support of life functions • Extend from time of loss of
under the stress of anesthetic and surgical consciousness to the time of loss of lid reflex.
manipulations. (accdg. to ABA). • May be characterized by shouting,
Terminologies struggling of the patient, excited with irregular
• Amnesia – loss of memory; an breathing & movements of extremities,
indifference to pain susceptible to stimuli like noise and touch.
• Analgesia – lessening of or • Patient is not to be
insensibility to pain stimulated during this stage and restrain the
• Anesthesia – loss of feeling or patient
sensation, esp. loss of the sensation of pain • Nurse’s responsibility: make sure
with loss of that the straps are on for safety purposes
protective reflexes Stage III – Stage of Surgical Anesthesia (Stage of
• Analgesic – drug that relieves pin Relaxation)
by altering perception of painful stimuli • Extends from the loss of lid reflex to the loss
without producing loss of consciousness of most reflexes.
• Anesthetist – person who • Surgical procedure is started
administers anesthesia • There is regular respiration, contracted pupils,
• Anesthesiologist – Doctor of reflexes disappear, muscles relax, lost auditory
Medicine who specializes in the field of sensation.
anesthesia Stage IV – Danger Stage
• Anoxia – absence of oxygen • Characterized by respiratory & cardiac
• Apnea – suspension or cessation of depression or arrest. It is due to an overdose of
breathing anesthesia.
• Fasciculation – uncoordinated • Resuscitation must be done
skeletal muscle contraction in which groups • Not breathing, little or no pulse or heartbeat
of muscle fibers innervated by the same • resuscitation equipments and materials must
neuron contract together. be ready at within reach
• Induction – period from beginning Pre-anesthetic Premedication
of administration of anesthetic until patient

Maybe given to allay preoperative anxiety, • Narcotics
produce some analgesia and amnesia and dull • Antimuscarinics / Anticholinergics
awareness of the OR environment.
• Antiemetics / Antinauseants
Reasons:
Choice of Type of Anesthesia
1. Reducing the risk of nausea and
The primary consideration with any anesthetic is
vomitingantiemetic meds
that it should be associated with low morbidity and
2. Decreasing secretions in the
mortality.
respiratory tract- in prep for anesthesia
3. Diminishing vagal nerve effects on • Provide maximum safety for the
the heart patient
4. Counteracting the undesirable side • Provide optimum operating
effects of the anesthetic medicines conditions for the surgeon
5. Raising the pain threshold. • Provide patient comfort
Considerations in the Choice of Pre anesthetic • Have a low index of toxicity
Drugs: • Provide potent, predictable
• Patient’s physical and emotional analgesia extending into post op
status period
• Age • Produce adequate muscle
• Weight relaxation
• Medical and Medication history • Provide amnesia
• Laboratory test result: liver and • Have rapid onset and easy
kidney functions as these affects the reversibility
metabolism of anesthetics/ drugs • Produce minimum side effects
• Radiographic and ECG findings Factors to Consider in the Choice of Anesthesia
• Demands of the surgical 1. Age and size /weight of the patient;
procedures 2. Physical, mental and emotional
• Patient’s concerns status of patient;
3. Presence of systemic diseases or
• In choosing pre anesthetic
concurrent drug therapy;
premedication, the anesthesiologist aims
4. Presence of infection at the site of
to disturb respiration and
the surgical procedure;
circulation as little as possible,
5. Previous anesthesia experience;
The primary consideration with any anesthetic is
6. Anticipated procedure;
that it should be associated with low morbidity &
7. Position required for procedure;
mortality.
8. Type and expected length of
procedure;
An ideal preoperative medication has quick onset,
9. Local or systemic toxicity of the
short duration of action and minimal side
agent;
effects.
10. Expertise of the anesthesiologist;
Prior to anesthetic administration, the nurse
11. Preference of the patient
should:
Types of Anesthesia
1. Take the baseline vital signs
General Anesthesia
2. Do not give the meds if the patient is
hypotensive. • Pain is controlled by general
3. Monitor the patient’s airways after insensibility
pre anesthesia medication • There is total loss of consciousness
administration and sensation
4. Elevate the head of the bed to • Produces amnesia, analgesia,
prevent airway obstruction interference with undesirable reflexes
Time Given: and muscle relaxation.
Premedication is usually given at least 45 minutes • Administered through
before induction. Some drugs require 60 to 90 intravenous, inhalation
minutes to reach peak effect. (via gas), or rectal instillation
Premedicines: • Patients are intubated
• Sedatives and tranquilizers • More expensive

Regional Anesthesia • Nerve Block- blocks nerve
• sometimes called conduction (brachial, intercostal, radial, femoral
anesthesia • Spinal
• produces loss of painful sensation in Anesthesia (subarachnoid space)
one area or region of the body and does sensation of pain is blocked at a level
not result in unconsciousness. below the diaphragm, the agent is injected
Advantages: in the spinal canal.
• Use of minimal and simple o The anesthetic agent is injected into
economical equipment the subarachnoid space if the spinal fluid
• No loss of consciousness is clear and flowing freely.
• Suitable for ambulatory patients
o High, mid, low spinal anesthesia
o Should lay down after to prevent
• Better airway control spinal headache
• Fewer respiratory complications Spinal Anesthesia Medications:
Disadvantages: • Procaine HCL (Novocaine)
• Too rapid absorption of the drug into • Dibucaine HCL (Nupercaine)
the blood
• Tetracaine HCL (Pontocaine)
• Anxiety and fear are not allayed,
patient continues to see and hear
• Lidocaine (Xylocaine)
throughout the • Mepivacaine (Carbocaine)
procedure • Bupivacaine (Marcaine)
• Difficult to use with small children, Advantages of Regional Anesthesia:
senile patients, and uncooperative • Ease of administration
persons. • Expensive equipment & drugs are
Contraindications: not necessary
• Local infection or • Relative safety of method
malignancy which may be carried to • Excellent muscle relaxation
and spread in adjacent provided
tissues by infection of needles; • Does not cause fetal depression
• Septicemia • Does not cloud patient
• Allergies consciousness or alertness
• Highly nervous, apprehension and • Can be used for patients with full
excitable patients or those unable to stomach since the patient will be awake to
cooperate because of mental stages like maintain his own airway in event of
children. vomiting
Techniques of Administration of Regional Complications of Regional Anesthesia:
Anesthesia Topical Anesthesia- drug is sprayed • Hypotension– due to paralysis of
or dropped onto an area to be desensitized, block vasomotor nerves Management:
peripheral nerve endings, in the skin, mucus
• O2 administration
membrane of the vagina, rectum, nasopharynx and
mouth. • Trendelenburg position
• Cocaine 4 to 10% solution • Ephedrine IV as stimulant
• Butacaine • Blood or plasma by IV
• Pontocaine • Nausea and Vomiting
• Lidocaine (Xylocaine) • Pain during surgery
Regional Anesthesia • Headache Management:
• Local Block- only the peripheral • Administer fluids
nerves around the area of the incision are • Administer analgesics
blocked; for breast mass excision, mole • Apply tight abdominal
removal binder
• Field Block- the area surrounding • Supine, flat in bed
the incision is injected and infiltrated with • Respiratory paralysis Management:
local anesthesia

• Artificial respiration by anesthesia 5. Hypotension and Shock – due to
machine preoperative medications and blood loss.
• Resuscitation or mouth to mouth 6. Vomiting and Aspiration – due to
breathing full stomach and reflex stimulation of the
patient’s vomiting center.
• Neurologic complications like
Surgical Positions
paraplegia, severe muscle weakness in the
Factors That Influence Positioning of the Patient
legs (due to use of unsterile needles,
1. Procedure to be performed
syringes and anesthetic agents)
2. Surgeon’s choice of surgical
• Epidural Anesthesia- frequently approach
involves injection of drugs through a 3. Age, height, weight of patient
catheter placed into the epidural space. 4. Cardiopulmonary status
The injection can result in a loss of 5. Pre-existing diseases
sensation— including the sensation of DIFFERENT SURGICAL POSITIONS
pain— by blocking the transmission of Supine Position- patient lies straight on back, face
signals through nerves in or near the spinal upward, with arms at sides, legs extended parallel and
cord. uncrossed, feet slightly separated.
Spinal vs. Epidural Anesthesia:
1. To achieve epidural analgesia or
anaesthesia, a larger dose of drug is typically
necessary than with spinal analgesia or
anaesthesia;
2. The onset of analgesia is slower with
epidural analgesia or anaesthesia than with
spinal
Trendelenburg's Position - the patient lies on
analgesia or anaesthesia;
the back in supine position with knees over the
3. An epidural injection may be
lower break of the table.
performed anywhere along the vertebral
column (cervical, thoracic, lumbar, or sacral),
while spinal injections are typically
performed below the second lumbar
vertebral body to avoid piercing and
consequently damaging the spinal cord;
4. It is easier to achieve segmental
analgesia or anaesthesia using the epidural
route than using
the spinal route;
5. An indwelling catheter is more
commonly placed in the setting of epidural Reverse Trendelenburg’s Position- The
analgesia or anaesthesia than with spinal patient lies on back. Footboard is padded and
analgesia or anaesthesia. raised. The entire OR table is tilted so the head
Dangers and Complications of Anesthesia
is higher than feet.
1. Cardiac Arrest – certain agents
result in the retention of CO2 which leads to
anorexia, respiratory acidosis and cardiac
arrest.
2. Respiratory depression – excess
mucus; use of muscle relaxants; use of
depressants.
3. Bronchospasm and
laryngospasm – may lead to airway
obstruction due to allergic reaction to the
anesthesia and irritating effects of agents on
bronchial and laryngeal mucosa.
4. Diminished circulation – due to
poorly distributed blood supply in the body.

Fowler’s Position- The patient lies on the back
with the buttocks at the flex of the table and
knees over the lower break
Kraske (Jack knife) Position - Patient’s hips are over

the central break in the OR table and knees strap is
below knees. Note chest rolls in place and pillow under
feet. This position is used for rectal surgeries like
Lithotomy Position - Patient is on back with foot hemorrhoidectomy and pilonidal sinus procedure.
section of table lowered to right angle with body on
table. Knees are flexed and legs are on inside of metal
posts or stirrups.
Knee – Chest Position - An extension is attached to

the foot section. The OR table is flexed at the center
break, the lower section is broken until it is at a right
angle to the table. The patient kneels on the lower
Dorsal Recumbent Position - The patient is in supine section and the entire table is tilted to elevate the
position except that the knees are flexed, and thighs pelvis. The knees are thus flexed at a right angle to the
externally rotated. Soles of the feet rest on the table. body. The upper portion of the table may be raised
slightly to support the head, which is turned to the side.
The arms are placed around the head with elbows
flexed, with a soft pillow beneath. The chest rests on
the table. Safety belt is above the knees. This position
is used for sigmoidoscopy and culdoscopy.
Modified Recumbent Position (Frog-legged) - The

patient is in supine position except that the knees are
slightly flexed with a pillow beneath each. The thighs
are externally rotated. For surgical procedures in the
region of the groin or lower extremities.

Sim’s Recumbent Position - A modified left respiration. This position is used for some
lateral recumbent position, the patient lies on otorhinologic and neuro-surgical procedures.
the left side with the upper leg flexed at the hip
and knees. The lower leg is straight. The lower
arm is extended along the patient’s back with
the weight of the chest on the table. The upper
arm rests in a flexed position on the table. This
position is preferred for endoscopic examination
performed via the anus in obese or geriatric
patients.
Prone Position - Patient lies on abdomen. Chest

rolls under axillae and sides of chest to iliac crests
Lateral Position - Referred to synonymously raise body weight from chest to facilitate respiration;
as lateral, lateral decubitus or lateral pillow under feet to protect toes. This position is
recumbent. Note strap across the hip of mostly used for spinal surgeries.
the patient to stabilize the body. Pillow between
legs can be placed to relieve pressure on the
lower leg. This position is used for access to the
hemothorax, kidneys, or retroperitoneal space.
Nursing Responsibilities in Positioning the Patient

1. Explain why the position and
restraints are necessary;
2. Preserve client’s dignity by providing
Lateral Jack Knife Position - Patient is in lateral
privacy and avoid undue exposure;
position with kidney region over the table break.
3. Secure patient with well-padded
Note kidney strap across the hip to stabilize the
straps to prevent nerve and tissue
body; raised kidney elevator for hyper-extending
damage;
surgical site and pillow between legs. Patient’s side
4. Maintain adequate respiratory and
is horizontal from shoulder to hip.
vascular circulation by avoiding pressure
on body parts because it can impair
circulation;
5. Do not allow client’s extremities to
dangle over the side of the OR table;
6. Place hand support on the sides of
the table;
7. Avoid excessive strain on the
patient’s muscles;
8. Always move both lower
Sitting Position - Patient is placed in fowler’s extremities at the same time when
position except that the torso is in upright position. putting them up in the stirrups and
Shoulders and torso should be supported with body when lowering down the hips to
straps but not so tightly as to impede circulation and prevent hip dislocation and muscle
straining.

SURGICAL DRAPING • Have some sufficient moisture-vapor
Definition permeability to reduce excessive
Draping - is the procedure of covering the moisture build-up that could macerate
patient and surrounding areas with a sterile the skin and/or loosen adhesive
barrier to create and maintain an adequate • The heat retaining property of plastic
sterile field. causes the patient to perspire
Criteria in Draping excessively, but the nonporous nature
1. Blood and fluid resistant to keep of the sheeting prevents evaporation.
drapes dry and prevent migration of Self-Adhering Sheeting is used in the following
microorganisms. Material should be manner:
impermeable to moist microbial 1. The usual skin preparation is done;
penetration. 2. The scrubbed area must be dry;
2. Resistant to tear, puncture or 3. Transparent plastic material is
abrasions that causes fiber breakdown applied firmly to the skin, with the initial
and thus permits microbial penetration. contact along the proposed line of incision.
3. Lint free to reduce airborne The drape is smoothed away from the
contamination and shedding into the incision site.
surgical site. 4. Regular fabric drapes are applied
4. Antistatic to eliminate risk of a spark over the plastic sheeting unless plastic is
from static electricity. Material must meet incorporated into the fenestrated area of the
standards of the Bureau of Fire drape.
Protection. Nonwoven Fabric Disposable Drape – are
5. Sufficiently porous to compressed layers of synthetic fibers
eliminate heat buildup so as to (i.e. rayon, nylon or polyester) combined with
maintain an iso- cellulose (wood pulp) and bonded together
thermic environment appropriate for chemically or mechanically without knitting,
patient’s body temperature tufting or weaving.
6. Drapable to fit around the contours - may be either absorbent or nonabsorbent.
of patients, furniture and equipment. Advantages of using Nonwoven Fabric Disposable
7. Dull, non-glaring to minimize color Drapes:
distortion from reflected light.
• They are moisture repellant. They
8. Free of toxic ingredients such as
retard blood and aqueous fluid moisture
laundry residues and non-fast dyes.
strike-through to prevent contamination.
9. Flame resistant to self-extinguish
rapidly on removal of an ignition source • They are lightweight, yet strong
Draping Materials enough to resist tears.
Self-adhering Sheeting– sterile, waterproof, • They are lint free unless cellulose
antistatic and transparent or translucent plastic fibers are torn or cut.
sheeting that can be applied to dry skin. • Contaminants are disposed of along
Advantages : with drapes.
• Resident microbial flora from skin • They are antistatic and flame
pores, sebaceous glands and hair retarded for OR use.
follicles cannot migrate laterally to the • They are prepackaged and sterilized
incision. by the manufacturer, which eliminates
• Microorganisms do not penetrate the washing, mending, folding, and sterilizing
impermeable material. processes.
• Landmarks and skin tones are Woven Textile Fabrics– are tightly woven
visible through the transparent plastic. fabrics that inhibit migration of microorganisms.
• Inert adhesive holds drapes Reusable drapes may be made of 270- or 280-
securely, eliminating the need for towel thread-count pima cotton or 100% Polyester.
clips and possible puncture of the Things to Consider About Reusable Woven Textile
patient’s skin. Drapes:
• Plastic sheeting conforms to body • Material must be steam-penetrable
contours and has elasticity to stretch and must withstand multiple sterilization
without breaking its adhesion to skin. cycles.

• When packaged for sterilization, o Maintain good body
drapes must be properly folded and alignment
arranged in sequence of use. 4. Assess for surgical consideration
Drapes may be fan-folded or rolled. and precautions;
• Material must be free from holes and 5. Assess patient’s risk for accidental
tears. hypothermia or malignant
hyperthermia;
• Drapes must be sufficiently
WHO Surgical Checklist Form -
impermeable to prevent moisture from
Nursing Diagnosis
soaking through them.
• Reusable fabrics must maintain • Risk for fluid volume deficit or
excess
barrier qualities through multiple
launderings. The number of uses, • Risk for hypothermia and
washings, and sterilizing cycles should hyperthermia
be recorded and drapes that are no • Risk for infection and injury
longer effective as barriers should be Planning
taken out of use. • Maintenance of fluid balance
○ 75 washings – densely woven treated • Maintenance of normothermia
cotton • Prevention of infection
○ 30 washings – untreated cotton
• Absence of Injury
Types/ Styles of Draping
Implementation
• Towels • Promote measures that will maintain
• Draw Sheet adequate fluid and electrolyte balance by
• Stockinette :
• Fenestrated Sheets ○ Monitoring I / O accurately
1. Laparotomy Sheet ○ Assessing for signs of dehydration
○ Thyroid Sheet ○ Assessing for circulatory overload
○ Chest Sheet (breath sounds, peripheral edema
○ Hip Sheet and jugular vein distention)
○ Perineal Sheet • Promote measures that will maintain
○ Laparoscopy Sheet the patient's normal body temperature.
• Separate Sheets • Promote measures that will
1. Split sheet decrease risk of infection
○ Minor sheet • Ensure patient’s safety in
○ Medium sheet the operating room.
○ Single sheet SURGICAL INCISION
○ Leggings Surgical Incision – Is a cut made through the skin and
○ St. Mary’s sheet soft tissue to facilitate an operation or procedure.
INTRAOPERATIVE NURSING CARE PLAN
Assessment TYPES OF SURGICAL INCISIONS:
1. Classifying the patient’s 1.Vertical Incision
physical status for anesthesia; • Midline incision or Laparotomy incision
2. Assess the patient’s record for appr – Most traditional and common surgical
opriate documentation; incision. Almost bloodless, no muscle fibers
3. Maintaining safety and preventing are divided & no nerves injured.
injuries during positioning at the OR • Paramedian Incision- Offset vertical incision
table;
to right or left providing access to lateral
o Explain the purpose of organs like spleen or kidneys.
positioning
• Transverse & Oblique Incisions
o Safely and securely strap
• Kocher (subcostal) Incision – Incision on
the patient to prevent falls
the right side of the abdomen to exposed gall
o Maintain adequate
bladder and biliary tree. Post operative pain is
respiratory and circulatory
greater due to the severing of the rectus
function
muscle.

• Abdominal incision – for abdominal Three phases of the postoperative period
surgeries Criteria to look into the patient prior to discharge
• Lumbotomy/ transverse – for kidney from the PACU according to Fairchild (1993).
surgeries Potential postoperative problems
• Mcburney incision or Gridiron incision – • Respiratory problems
for appendectomy • Circulatory problems
• Lanz (Rockey – Davis) incision – useful for • Urinary problems
open appendectomy; Incision is horizontal • GI problems
while Gridiron incision is on oblique angle
• Wound healing problems
• Thoracoabdominal (Ivor Lewis) Incision-
Unique incision that connects the pleural • The emphasis of nursing care
cavity and the peritoneal cavity after surgery Maintenance of proper
• Pfannenstiel (Kerr/Pubic) Incision- respiration, circulatory and
Commonly used for cesarean sections, gastrointestinal functions
urologic, orthopedic and pelvic surgeries. • Alleviation of pain
• Maylard Incision (Mackenrodt) - incision • Promoting faster wound healing
6cm above the pubic tubercle that is made • Maintaining a safe environment
through the rectus abdominis to gain access • Preventing/ managing
to pelvic structures. potential postoperative
• Chevron Incision – incision that crosses the complications.
midline of the abdomen. Provides MODULE 5 – PAIN & PAIN
good exposure of hepatic, pancreatic, upper
gastrointestinal region, adrenal or renal MANAGEMENT
surgeries.
• Subclavicular Incision- made through the Pain - The sensory experience evoked by stimuli that
skin and subcutaneous tissue inferior to the injure or threaten to destroy tissue, defined
clavicle, giving access to the subclavian introspectively by every man as that which hurts.
vessels.
• Supraclavicular Incision- transverse Pain Perceptions – The conscious experience of
incision superior to the clavicle. Often utilized discomfort.
in trauma to gain access to the subclavian - Infants (1-2 days old) are less sensitive to
vessels. pain. A full behavioral response to pain is
• Mcevedy Incision – vertical incision from the apparent 3- 12 months of
femoral canal and brought superior to above age.
the inguinal ligament.
• Inguinal Incision – incision over the inguinal Pain Threshold – The lowest intensity of a painful
canal which is made through the skin to the stimulus that is perceived by a person as a pain.
subcutaneous fat through camper and scarpa - Older children between 15 – 18
fascia. years, tend to have a lower pain threshold than adults.
• Gibson Incision- used in gynecological
procedures and urological procedures. Pain Tolerance – The maximum intensity or duration
• Supra-umbilical/ infra-umbilical incision – of pain is willing to endure once threshold has been
used for access into the peritoneum through reached.
tissues surrounding the umbilicus; commonly
used for repair of umbilical hernias. Pain tolerance is DECREASED:
• Pararectus Incision- used for spigelian • With repeated exposure to pain
hernia repair or if modified, can be used for an • By fatigue, anger, boredom,
ostomy. apprehension
• Sleep deprivation
OTHER TYPES OF SURGICAL INCISIONS Pain tolerance is INCREASED:
• Butterfly incision – For craniotomy • By alcohol consumption
• Limbal incision – For eye surgery • Medication hypnosis
• Halstead/elliptical - For breast surgery • Warmth, distracting activities
POSTOPERATIVE PHASE
• Strong beliefs or faith.

Referred Pain – used to describe discomfort that is
Pain Expression – actual feeling that a particular perceived in a general area of the body, but not in the
client shows in pain and the view of the health care exact site where an organ is anatomically located.
professional, also governed by cultural values.
Types of referred pain
TYPES OF PAIN 1.Myofascial Pain – trigger points, small hyperirritable
A.According to Source areas within a m, in which n. impulses bombard CNS
1.Nociceptive Pain – is believed to be caused by and are expressed at referred pain.
ongoing activation of pain receptors in either the • Active – hyperirritable; causes
surface or deep tissues in the body obvious complaint
• Latent – dormant; produces no pain
2 types of Nociceptive Pain except loss of ROM
A.Somatic pain – Caused by injury to skin, muscles, 2.Sclerotomic & Dermatomic Pain – deep pain;
bone, joint and connective tissue; often involves may originate from sclerotomic, myotomic or
inflammation of injured tissue. dermatomic nerve root
• Sclerotome: area of bone that is
B. Viscera pain - Refers to pain that originates from
supplied by a single nerve area
ongoing injury to the internal organs or the tissues that
support them; usually accompanied by NAS symptoms • Myotome: m. supplied by a single n.
such as nausea & vomiting, pallor, hypotension & root
sweating. • Dermatome: area of skin supplied
by a single nerve foot.
2. Neuropathic Pain – Pain that is processed
abnormally by the nervous system and usually results Transmission of Pain
from damage to either that pain pathways in peripheral 1.Transduction - is the conversion of chemical
nerves or pain processing centers in the brain. information in the cellular environment to electrical
impulses that move toward the spinal cord.
3.Psychogenic pain – is a simple label for all kinds of 2.Transmission- the phase during which the
pain that can be best explained by psychological peripheral nerve fibers form synapses w/ neurons
problems. in the spinal cord, the pain impulses move from the
spinal cord sequentially levels in the brain.
B. According to Characteristics 3.Perception- refers to the phase
1.Acute Pain of impulse transmission during w/c the brain
• Increased or decreased BP, experiences pain at conscious level.
tachycardia, diaphoresis, tachypnea, 4.Modulation - last phase of pain impulse
focusing on the pain transmission during which the brain interacts with the
spinal nerves in a downward fashion to alter the pain
• Accompanied by observable
experience.
physical response
2.Chronic pain (divided into 3 types)
Pain Control Theories
a. Chronic nonmalignant pain – from 1.Intensity theory – state that pain is the result
low back pain to rheumatoid arthritis of excessive stimulation of sensory receptors.
b. Chronic intermittent – such as 2.Pattern theory – describes that painful and non-
migraine, headache painful sensations are transmitted
c. Chronic malignant pain – cancer by nonspecific receptors
3.Specificity theory – describes four types of
Characteristics of Acute and Chronic Pain cutaneous sensation: touch, warmth, cold and pain
Acute pain Chronic Pain 4.Gate Control theory – Nerve fibers carry touch and
Responds favorably to drug Responds poorly to pain impulses from the receptors on the skin to the
therapy drug therapy spinal cord.
Requires gradually Requires increasing
decreased frug therapy drug therapy P-Q-R-S-T Format
Diminishes with healing Persists beyond healing • Provocation- How the injury
stage occurred and what activities provoke the
Suffering decreases Suffering intensifies pain

• Quality – Characteristics of pain; • Opioid analgesics- this includes all drugs that
aching (impingement), burning (nerve interact with opioid receptors in the nervous
irritation, sharp (acute injury), radiating system.
within dermatome (pressure on the 2. Nondrug intervention
nerve). • Heat & Cold - heat helps soothe stiff joints and
• Referral/radiation - site distant to relax muscles. Cold helps numb sharp pain
damaged tissue that does not follow the and reduce inflammation.
course of a peripheral n. • Transcutaneous electrical stimulation
• Severity – pain scale (TENS) - a device is an electrical unit that
delivers different frequencies and intensities
• Timing – When does it occur?
of stimulation to the skin through electrodes.
Pain Assessment Tool • Acupuncture &acupressure - Acupuncture is
a system of integrative medicine that involves
pricking the skin or tissues with needles, used
to alleviate pain and to treat various physical,
mental, and emotional conditions.
• Percutaneous electrical nerve stimulation
(PENS) - combines electro-acupuncture and
TENS which uses acupuncture like needles
probes as electrodes placed dermatomal
levels corresponding local pathology.
• Non-invasive technique
PAIN MANAGEMENT Psychological Pain Control Methods

Refer to techniques used to prevent, reduce
or relieve pain • Psychological / Mind-
Goals in Managing Pain body Therapy – There may be a vicious
1.Reduce pain cycle in which pain causes stress, and
2.Controle acute pain stress, in turn, causes more pain.
3.Protect the patient from further injury. Mind/body therapy addresses these
issues and provides a variety of benefits
Five general techniques for achieving pain including a greater sense of control, improved
management coping skills, decreased pain intensity
1.Blocking brain preceptors and distress, and increased sense of
2.Interrupting pain by transmitting chemicals at the site wellbeing and relaxation.
of injury. • Cognitive–Behavioral
3.Combing analgesics with adjuvant drugs Therapy (CBT) - Effective in reducing pain
4.Using gate-closing mechanisms and disability when used as a part of
5.Alternating pain transmission at the level of the spinal therapeutic treatment for chronic pain.
cord. Provides educational information
and diffuses feelings of fear and
Pain Management helplessness. Include teaching of
1. Pharmacological or drug intervention life skills and coping skills that can assist the
• Adjuvant drug therapy - defined as drugs that patient in productive problem solving and the
are on the market for indications other than prevention or minimization of future pain
pain but may be analgesics in selected episodes.
circumstance.
• Non opioid analgesics - includes Psychological Pain Control Methods (Non-Invasive
acetaminophen or paracetamol dipyrone and Therapy)
NSAIDs. The NSAIDs are nonspecific • Imagery – is the use of imagined pictures,
analgesics and can potentially be used for any sounds, or sensation for generalized
type of acute or chronic pain. relaxation or for specific therapeutic goals
such as reduction of pain.
• Relaxation – Relaxation systematic
relaxation of the large muscle groups. -

Relaxation therapies include a range of
techniques. such as autogenic training,
various forms of meditation, progressive
muscle relaxation, deep breathing, and paced
respiration. The goal of these therapeutic
approaches is overall relaxation and stress
reduction.
• Biofeedback- to provide patients with
immediate feedback on heart rate, blood
pressure, muscle tension, or brain wave
activity. This allows the patient to learn how to
influence these bodily responses through
conscious control and regulation.
• Hypnosis - relaxation + suggestion +
distraction + altering the meaning of pain.
During hypnosis, changes like those found in
meditation can occur, such as a slowing of the
pulse and respiration, and an increase in
alpha brain waves.
• Prayer - Changes in the concept of health
and illness, a broadening view of healing and
curing, and interest in other cultural systems
of medicine have created a growing openness
to the spiritual dimensions of health
• Physical Therapy- is useful in teaching
patients to control pain, to move in safe and
structurally correct ways, to improve range of
motion, and to increase flexibility, strength,
and endurance.
• Exercise – it may reduce the risk of
secondary pain problems like muscle strains
and may also lead to improved confidence
and sense of wellbeing.

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NUR 1213: MSN- PAIN AND SURGERY

NOVEMBER 2021 | FEU LECTURES, HANDOUTS 7 PPTs | GUMAPAC, SOLIS

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Handle # 3, 7, 9 – Blade # 10, 11, 12, 15

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Curved MAYO scissors - available in regular

Wire scissors (stitch)- have short, heavy

Dressing / Bandage scissors - used to cut

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Toothed/ pick up/ Rat tooth Forceps- have a single

Allis Forceps- has a scissor action. Each jaw curves

Tenaculum - curved or angled points on the ends of

Babcock Forceps- maybe used in fallopian tube

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CLAMPING AND OCCLUDING

Bone Holders - includes vice-grip, pliers and other

Crile / Stet / Tag Forceps- for shallow layers of

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Crushing Clamps- used to crush tissues or clamp

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Deaver retractor -for deeper retraction

EXPOSING AND RETRACTING

Harrington Retractor - to protect the organ; minimizes

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Goulet retractor - intended for the abdominal

SUTURING AND STAPLING

Self – retaining Retractors

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SUCTIONING AND ASPIRATING

Poole Abdominal Tip- straight hollow tube with a

Endoscopes- made of a round or oval sheath that

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Cannula - has a blunt end and perforations around the

Yankauer Tip - hollow tube that has an angle of mouth;

Aspiration - done manually to obtain a specimen

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