Or Review Notes

PERIOPERATIVE
CARE
Lesson 1.1:
THE PRINCIPLES OF
ASEPSIS
Michell Jane Cagurol,RN

PERIOPERATIVE CARE
Lesson 1.1 : THE PRINCIPLES OF ASEPSIS
INTENDED LEARNING OUTCOMES
At the end of this lesson, the students can:
• Comprehensively discuss the principles of asepsis relating to

the operating room environment
• Cite the measures done the perioperative nurse to ensure the

maintenance of sterility
• Cite evidences to support or to reject current nursing practice

PERIOPERATIVE CARE
What is Asepsis?
Asepsis is a condition in which no living

disease-causing microorganisms are present. Its
goal is to prevent contamination, which can
be ensured by the use of sterile devices,
materials and instruments and by creating an
environment that is low in microbe volume.
(G.D Dockery,2012)
PERIOPERATIVE CARE
ASEPSIS IN THE OPERATING ROOM
Surgical asepsis prevents the contamination of surgical

wounds. The patient’s natural skin flora or a previously existing
infection may cause postoperative wound infection.
Rigorous adherence to the principles of surgical asepsis

by OR personnel is basic to preventing surgical site infections.
All surgical supplies, instruments, needles, sutures,

dressings, gloves, covers, and solutions that may come in
contact with the surgical wound or exposed tissues must be
sterilized before use(Rothrock, 2014).
PERIOPERATIVE CARE
ASEPSIS IN THE OPERATING ROOM
This includes preparations starting with proper

disinfection of the surgical theatre, surgical scrub by the
scrub personnel and the surgeon, the skin preparation of
the client, sterile draping and after care of the area.
For further information, please read pages 1268-1271 of

your book.
PERIOPERATIVE CARE
THE PRINCIPLES OF STERILITY
1. All articles used in an operation have been

sterilized previously.
2. Persons who are sterile touch only sterile
articles; persons who are not sterile touch only
unsterile articles.
3. Sterile persons avoid leaning over an unsterile
area; non-sterile persons avoid reaching a
sterile field. Unsterile persons do not get
closer than 12 inches from a sterile field.
PERIOPERATIVE CARE
4. If in doubt about the sterility of anything consider it

not sterile. If a non-sterile person close consider
yourself contaminated.
5. Gowns are considered sterile only from the waist to
shoulder level in front and the 2 inches above the
elbow
✔Keep hands in sight or above waist level away from
the face.
✔Arms should never be folded.
✔Articles dropped below waist level are discarded.
PERIOPERATIVE CARE
6. Sterile persons keep well within the sterile area

and follow those rules from passing:
✔Face to face or back to back.
✔Turn back to a non-sterile person or when
passing.
✔Face a sterile area when passing the area.
✔Ask a non-sterile person to step aside rather
than trying to crowd past him.
PERIOPERATIVE CARE
✔Step back away from the sterile field to sneeze or

cough.
✔Turn head away from sterile field to have perspiration
mopped from brow.
✔Stand back at a safe distance from the operating table
when draping the patient.
✔Members of the sterile team remain in the operating
room if waiting for the case.
✔Do not wander around the room or go out in the
corridors.
PERIOPERATIVE CARE
End of Lesson 1.1

SURGICAL ASEPSIS
Surgical Hand Scrub,

Donning and Closed
Gloving Method
Michell Jane B. Cagurol,RN
SURGICAL ASEPSIS
At the end of this lesson, the students can:
• Comprehensively discuss the principles of asepsis

relating to the operating room environment;
• Perform the skill with 100% accuracy through a
return demonstration; and
• Apply critical thinking through a post lecture drill.
Definition:
► Surgical hand scrub is the
systematic way of cleaning the
hands, fingernails, and forearms
before undertaking a surgical
procedure. Closed gloving method
in donning of sterile gloves, is
used by the scrub personnel to
ensure that the sterility of the
surgical attire/gown and sterile
field is maintained.
Definition:
The process of scrubbing, gowning,
and gloving is requisite that all
members of the surgical team
must complete before each
operation. In the surgical scrub,
the hands and forearms are
decontaminated. A sterile surgical
gown and pair of gloves are
subsequently donned, creating an
aseptic environment.
Purpose:
► The purpose of surgical hand scrub is

to sterilize the hands prior
to gowning and gloving.
► Sterile gowns and gloves are worn to

prevent the migration of microbes
from the skin and scrub attire of the
sterile team member to the sterile
field.
Principles to abide in OR:
► Start from cleanest to dirtiest
► Aseptic principle is applied
during this procedure.
► Anything below your waist and
above your shoulder is
considered unsterile.
► If in doubt throw out.
Principles to abide in OR:
► Only the front of your sterile
Gown is sterile.
► If you accidentally
contaminate an area or
yourself, you may be asked
to don sterile attire again.
► Practice your surgical
conscience.
Materials
► Surgical cap (if available)
► Face mask
► Shoe cover ( if available )
► Surgical scrub brush
► Providone Iodine 7.5% or
alcohol-based solution for asepsis
► Sterile gloves
► Sterile Surgical Gown
Procedure: HAND SCRUBBING
Procedure: DRYING HANDS/ GOWNING
Procedure: DRYING HANDS/ GOWNING
Procedure: CLOSED GLOVING
Procedure: CLOSED GLOVING
Procedure: DOFFING GOWN
AND GLOVES
END
References
► https://www.ncbi.nlm.nih.gov/books/NBK143227/#:~:te
xt=A%20full%20count%20of%20sponges%2C%20needles%2C
%20sharps%2C%20instruments%20and,or%20thoracic%20ca
vity%20is%20entered
► https://www.infectioncontroltoday.com/view/aorns-rec
ommended-practices-sponge-sharp-and-instrument-count
s-review
►
Sponge counts should be performed:
-- before the procedure to establish a baseline,
-- before closure of a cavity within a cavity,
-- before wound closure begins,
-- at skin closure or end of procedure, and
-- at the time of permanent relief of either the scrub
person or the circulating nurse.
Nursing Department
College of Arts and Sciences
Notre Dame of Marbel University
THE PREOPERATIVE PHASE

Senior Clinical Instructor
NCM-N 112 A
Intended Learning Outcome:
By the end of the lecture-discussion, students can:
1. Determine the characteristics of a valid informed consent;

2. Specify the medications used in different phases of the
perioperative period;
3. Correctly fill up forms relevant in the preoperative phase;and
4. Cite different special procedures, their indications and their
nursing responsibilities.
NCM-N 112 A
Preoperative phase
period of time from when the decision for

surgical intervention is made to when the
patient is transferred to the operating room
NCM-N 112 A
THE PREOPERATIVE CARE
Legal Aspect of surgery: INFORMED CONSENT
Informed consent is the patient’s

autonomous decision about whether
to undergo a surgical procedure
(Brunner and Suddarth, 2017)
Surgical procedure and anaesthesia

consent is explained by the doctor,
is signed by the client, and is
witnessed by the nurse
Must be voluntary signed by

the patient
Patient signing the consent should be

of legal age (unless emancipated
minor) and sound mental capability
(cognitively impaired, neurologically
incapacitated, mentally ill)
If patient is below legal age,

consent is usually signed by the
patient’s parents
Validity for consent for surgical

procedure depends on the
institutional policy, but is
usually 24 hours
Is signed by the patient before

giving psychoactive
premedication.
Consent is a legal mandate, but it

also helps the patient to prepare
psychologically, because it helps to
ensure that the patient understands
the surgery to be performed
(Rothrock, 2014).
An informed consent should be in

writing and should contain the
following:
1. Explanation of procedure and its

risks
2. Description of benefits and

alternatives;
3. An offer to answer questions about
procedure;
4. Instructions that the patient may
withdraw consent;
If the patient is non-English

speaking, it is necessary to
provide consent (written and
verbal) in a language that is
understandable to the client
5. A statement informing the

patient if the protocol differs
from customary procedure.
SAMPLE SURGICAL CONSENT

POSSIBLE NURSING DIAGNOSES
1. Anxiety related to upcoming

surgical procedure
2. Risk of latex allergy response due

to possible exposure to latex in OR
environment
POSSIBLE NURSING DIAGNOSES
3. Risk for perioperative positioning

injury related to positioning in the OR;
4. Risk for infection; and
5. Risk for compromised human dignity
related to general anesthesia or
sedation.
PREOPERATIVE MEDICATIONS
❏ Pain Medications:
Nubain, Tramadol, Ketorolac,
Paracetamol
NURSING RESPONSIBILITIES:
1. Ensure Patient is Vitally Stable;
2. Patient Safety;
3. Secure airway and IV access patency.
❏ Anxiolytics:
Diazepam,Tramadol*,Nalbuphine*
1. Ensure Patient is Vitally Stable;
2. Patient Safety;
3. Secure airway and IV access patency.
❏ GI Prophylaxis:
Omeprazole, Ranitidine,
Metoclopramide
1. Ensure proper administration;
2. Ensure safety (dizziness).
❏ DVT Prophylaxis:***
Low Molecular Weight Heparin
(Enoxaparin)
Antiembolic (TED) Stocking
❏ DVT Prophylaxis:***
1. Monitor coagulation profile (aPTT,CT/BT);
2. ** Check: on hold or continued administration
3. Place compression/antiembolic stockings as
ordered
Medications that may cause bleeding are

usually discontinued 1 week before
scheduled OR or as prescribed by the
doctor
Common Diagnostic Procedures
· Urinalysis
· Blood type and screen ( for
infectious diseases)
· Complete blood count or
hemoglobin level and hematocrit
· Clotting studies (prothrombin

time [PT], international
normalized ratio [INR], activated
partial thromboplastin time
[aPTT], platelet count)
· Electrolyte levels
· Serum creatinine and blood urea
nitrogen levels
· Depending on a female patient's
age and the nature of the surgery,
a pregnancy test may be required
•Radiologic studies ( esp for orthopaedic

surgery)
•ECG ( anesthesia protocol for young

population and older adults, patients
with cardiac disease)
Other Preparations
✔NPO
**8-10 hours
1. Ensure NPO;
2. Monitor for signs of hypoglycemia**
3. Ensure IVF is running.
Other Preparations
✔ENEMA
Indications:
1. Evacuate Bowel for Surgery
2. Endoscopy
Other Preparations
✔ENEMA
1. Secure Doctors order;
2. Privacy
3. Empty bladder
4. Clear Return.
Other Preparations
✔IV FLUIDS
NURSING
RESPONSIBILITIES:
1. Ensure Patency;
2. Use large-bore IV
Catheter
3. Place on the
unaffected side.
Nursing Department
College of Arts and Sciences
Notre Dame of Marbel University

Senior Clinical Instructor
NCM-N 112 A
CLASSIFICATION
OF
INSTRUMENTS
Presented By:
Jayson L. Montaño, RN
OBJECTIVES
■ After this interactive short lecture-discussion, the

students can:
1. Identify the use and function of each type of surgical
instrument;
2. Distinguish different types of suture and their indicated use;
3. Identify the different type of sponges during operation; and
4. Demonstrate the appropriate methods for handling each
type of instrument and setting up of mayo table.
CLASSIFICATION OF
INSTRUMENTS
■ Surgical instruments are designed to provide
the tools the surgeon needs for each
maneuver.
■ All instruments should be used only for their
intended purpose, and they should not be
abused.
DISSECTING AND
CUTTING
INSTRUMENTS
Dissection instruments have sharp edges. They are used to cut,
incise, separate, or excise tissues.
DISSECTING AND CUTTING
INSTRUMENTS
1. Scalpels
■ most commonly used has
a reusable handle; made
of brass and handles vary
by width and length
INSTRUMENTS
2. Disposable blades
■ blade is attached to a
reusable handle by slipping
the blade into the grooves
on the narrow edge of the
handle
■ Needle Holder is used to
attach and detach the
blade, never the finger
INSTRUMENTS
2. Disposable blades
rounded toward the tip and are often

Number 10 blades
used to open the skin
linear edge with a sharp tip; used to make
Number 11 blades
the initial skin puncture for tiny deep
incisions.
Number 12 blades curved cutting surface like a hook;
commonly used for tonsillectomy
Number 15 blades short rounded edge for shallow short

controlled incisions
Number 20 shaped similar to number 10 blades but

blades larger
INSTRUMENTS
3. Knives
■ usually have a blade at one end that may have one or two cutting edges
Cataract Knife
INSTRUMENTS
4. Scissors
■ The blades of scissors may be straight,
angled, or curved, as well as serrated,
wedge-shaped, sharp, blunt, or combined
sharp-blunt tips.
■ used only to cut or dissect tissues; others
are used to cut other materials.
■ Tissue/dissecting scissors have sharp or
blunt tips
■ Curved or angled blades are needed to
reach under or around structures.
Iris Metzembum Mayo Curved
INSTRUMENTS
4. Scissors
■ Suture scissors have sharp-blunt
points to prevent structures
close to the suture from being
cut.
■ Wire scissors are used instead of
suture scissors to cut stainless
steel sutures
■ Short jaw sharp-tipped scissors
are used for deep, confined
areas such as the nasal cavity
(Joseph nasal scissors) Suture Wire Joseph
scissors scissors nasal
scissors
INSTRUMENTS
4. Scissors
■ Sharp-tipped angled scissors
with short jaws are used for
vascular surgery (Potts angled
scissors)
■ Dressing/bandage scissors are
used to cut drains and dressings
and to open items such as
plastic packets (Lister bandage
scissors)
■ Small scissors with specially
wedge-shaped tips such as
tenotomy scissors used for blunt
and sharp dissection (Tenotomy Potts angled Bandage
scissors ) Tenotomy
scissors scissors scissors
INSTRUMENTS
5. Bone Cutters and Saws
■ types of instruments
that have cutting edges
suitable for cutting into
or through bone and
cartilage
INSTRUMENTS
6. Blunt Dissectors
■ Friable tissues or tissue
planes can be separated by
blunt dissection.
■ Elevators, strippers, and
dissectors can be used to
remove adherent tissue
such as periosteum from
bone or dura from the inner
aspect of the skull.
DEBULKING
INSTRUMENTS
include curettes, chisels, osteotomes, gouges, rasps,
and files.
these instruments decrease the bulk of firm tissue and
not necessarily cut along defined tissue planes.
DEBULKING INSTRUMENTS
1. Biopsy forceps and
punches.
■ A small piece of tissue for
pathologic examination
may be removed with a
biopsy forceps or punch.
These instruments may be
used through an
endoscope
2. Curettes
■ Soft tissue or bone is
removed by scraping
with the sharp edge of
the loop, ring, or scoop
on the end of a curette
3. Snares
■ A loop of wire may be put around a
pedicle to dissect tissue such as a
tonsil or a polyp. The wire cuts the
pedicle as it retracts into the
instrument. The wire is discarded
and replaced with a new one after
use
GRASPING AND HOLDING
INSTRUMENTS
1. Delicate Forceps
■ fine tissues such as eye tissue are held with delicate

forceps; can be toothed or smooth, straight or
angled.
INSTRUMENTS
2. Adson Forceps
■ Forceps are used to
pick up or hold soft
tissues in
approximation
during closure; can
be toothed or
smooth.
INSTRUMENTS
4. Smooth Tissue Forceps
■ Also referred to as thumb forceps or pick-ups, smooth forceps resemble
tweezers; atraumatic and will not injure delicate structures
■ tapered and have serrations (grooves) at the tip; straight or bayonet (angled),
short or long, and delicate or heavy
INSTRUMENTS
5. Toothed Tissue Forceps
■ they have a single tooth on one side that fits between two teeth on the opposing side
or they have a row of multiple teeth at the tip
■ provide a firm hold on tough tissues, including skin. Finer versions have delicate
teeth for holding more delicate tissue
INSTRUMENTS
6. Allis Forceps
■ have ringed handles and lock with
ratchets. Each jaw curves slightly
inward, and there is a row of teeth at
the end
INSTRUMENTS
7. Babcock Forceps
ratchets. The end of each jaw of a
Babcock forceps is rounded to fit
around a tubular structure (i.e.,
fallopian tube) or to grasp tissue
without injury; not occlusive or
crushing.
INSTRUMENTS
8. Lahey Forceps
ratchets. The jaws of the Lahey
forceps have sharp apposing points
for grasping tough organs or tumors
during excision; not occlusive or
crushing.
INSTRUMENTS
9. Stone Forceps
■ Either curved or straight forceps are
used to grasp polyps or calculi such
as kidney stones or gallstones. Stone
forceps have blunt loops or cups at
the end of the jaws and do not have
ratchets.
INSTRUMENTS
10. Tenaculums
ratchets and may have a single tooth
or multiple teeth, such as a Jacob
tenaculum
■ penetrate tissue to grasp firmly
INSTRUMENTS
11. Bone Holders
■ types of heavy holding forceps to
stabilize bone
■ some styles have ring handles and
locking ratchets. Others have
compression grips and do not lock.
CLAMPING AND
OCCLUDING
INSTRUMENTS
Instruments that clamp and occlude are used to apply pressure
CLAMPING AND OCCLUDING
INSTRUMENTS
1. Hemostatic Clamps/Hemostats
■ most commonly used surgical
instruments and are used primarily to
clamp blood vessels
INSTRUMENTS
2. Crushing Clamps
■ Many variations of hemostatic forceps
are used to crush tissues or clamp
blood vessels. The jaws may be straight,
curved, or angled, and the serrations
may be horizontal, diagonal, or
longitudinal.
■ The features of the instrument will
determine its use. Fine tips are needed
for small vessels and structures. Longer
and sturdier jaws are needed for larger
vessels, dense structures, and thick
tissue. Longer shanks are needed to
reach structures deep in body cavities.
INSTRUMENTS
2. Crushing Clamps
■ The features of the
instrument will determine its
use. Fine tips are needed for
small vessels and structures.
Longer and sturdier jaws are
needed for larger vessels,
dense structures, and thick
tissue. Longer shanks are
needed to reach structures
deep in body cavities.
INSTRUMENTS
3. Noncrushing Clamps
■ used to occlude bowel or major
blood vessels temporarily,
which minimizes tissue trauma.
The jaws of these types of
clamps have opposing rows of
fine serrations, but have a
softer hold on tissues.
RETRACTING AND
EXPOSING
INSTRUMENTS
Soft tissues, muscles, and other structures should be pulled aside
for exposure of the intended surgical site.
RETRACTING AND EXPOSING
INSTRUMENTS
1. Manual Retractors
■ Most handheld
retractors have an
ergonomic handle and
blade; The blades vary
in width and length to
correspond to the size
and depth of the
incision.
INSTRUMENTS
1. Manual Retractors
■ Some retractors have
different sized blades at both
ends with a handle in the
middle
■ Other retractors have
traction grooves or serrations
for slippery surfaces
INSTRUMENTS
2. Malleable Retractors
■ a flat length of
low-carbon stainless
steel, silver, or
silver-plated copper
that may be bent to
the desired angle and
depth for retraction
INSTRUMENTS
3. Hooks
■ used to retract delicate

structures.
■ commonly used to
retract skin edges
during a wide-flap
dissection such as a
facelift or mastectomy
Skin hook
INSTRUMENTS
4. Self-Retaining
Retractors
■ Holding devices with two
or more flat or hooked
blades can be inserted to
spread the edges of an
incision and hold them
apart
Gelpi Retractor
Weitlaners
INSTRUMENTS
4. Self-Retaining
Retractors
■ Some retractors have
ratchets or spring locks
to keep the device
open; others have wing
nuts to secure the
blades.
Balfou
r
O’Sullivan-O’Conn
or.
Retracting and Exposing
Instruments
5. Bed-Mounted Retractors
■ Some self-retaining
retractors can be attached
to the operating bed for
stability when a long
surgical incision is planned
Bookwalter
CLOSURE AND
APPROXIMATION
INSTRUMENTS
CLOSURE AND APPROXIMATION
INSTRUMENTS
1. Needle Holders
■ used to grasp and hold
curved surgical needles.
Most needle holders
resemble hemostatic
forceps; the basic difference
is the shortness of the jaws
INSTRUMENTS
2. Staplers
■ all surgical staplers are
bulky, heavy
instruments
■ The staples are usually
made from titanium,
stainless steel, or
absorbable material
INSTRUMENTS
5. Internal Anastomosis Staplers
■ designed to connect hollow
organ segments to fashion a
larger pouch or reservoir.
■ The instrument is fired, and
the tubes are stapled along
the adjoining lengths.
INSTRUMENTS
6. End-to-End Circular Staplers
■ designed to staple two hollow,
tubular organs end to end to
create a continuous circuit.
■ These staplers are commonly
used for bowel anastomosis
after resection
VIEWING
INSTRUMENTS
Examine the interior of body cavities, hollow organs, or structures
with viewing instruments and can perform many procedures
through them
VIEWING INSTRUMENTS
1. Speculums
■ hinged, blunt blades of a
speculum enlarge and hold open
a canal or a cavity.
VIEWING INSTRUMENTS
2. Endoscopes
■ round or oval sheath of an
endoscope is inserted into a
body orifice (rigid or flexible) or
through a small percutaneous
skin incision guided by a trocar
assembly
ASPIRATION, INSTILLATION, AND
IRRIGATION INSTRUMENTS
■ Blood, body fluids, tissue, and irrigating solution may
be removed by mechanical suction or manual
aspiration.
■ Aspiration, or suction, involves the application of
negative pressure (less than atmospheric pressure)
for evacuating blood or fluids, usually for visibility at
the surgical site.
■ The style of the suction tip depends on where it is to
be used and the surgeon’s preference .
1. Poole Abdominal Tip
■ a straight hollow tube with a
perforated outer filter shield.
■ It is used during abdominal
laparotomy or within any cavity in
which copious amounts of fluid or pus
are encountered.
■ The outer filter shield prevents the
adjacent tissues from being pulled
into the suction apparatus.
2. Frazier Tip
■ a right-angle tube with a small
diameter.
■ It is used when encountering little or
no fluid except capillary bleeding and
irrigating fluid, such as in brain, spinal,
plastic, or orthopedic procedures.
3. Yankauer Tip
■ a hollow tube that has an angled shaft
and a perforated round-ball tip.
■ Large quantities of blood and fluid can
be suctioned quickly, which is useful
for visualization
4. Trocar
■ A trocar assembly may be needed to
cut through tissues for access to fluid
or a body cavity.
DILATING AND PROBING
INSTRUMENTS
■ Probes are used to explore the
depth of a wound or to trace the
path of a fistula.
■ Probes and dilation instruments
used as tunneling devices can
make a passage under the skin for
a vascular graft or shunt.
HEGAR
dilator (cervix
PRATT dilator
dilation)
(uterus
dilation)
MEASURING INSTRUMENTS
■ Rulers, depth gauges, templates, and
trial sizers are used to measure parts of
the patient’s body.
■ Some of these devices are used to
determine the precise size needed for
an implant, such as a joint or breast
prosthesis.
Caliper
ACCESSORY INSTRUMENTS
■ Many accessories are used in addition to the basic instruments previously

discussed.
CHOICE OF SUTURE
MATERIAL
TYPE DEFINITION EXAMPLE
• Monocryl
capable of being absorbed by living
• Vicryl
Absorbable sutures mammalian tissue but may be treated or
• Velosorb
coated to modify resistance to absorption
• Polysorb
• Silk
Strands of natural or synthetic material
Nonabsorbable Cotton
that effectively resist enzymatic digestion
sutures • Prolene
or absorption in living issue.
• Surgipro II
CHOICE OF SUTURE
MATERIAL
POINT OF THE NEEDLE
1. Conventional Cutting Needles
– Two opposing cutting edges form a
triangular configuration with a third
edge on the body of the needle.
2. Reverse-Cutting Needles
– A triangular configuration extends along
the body of the needle. The edges near
the point are sharpened or honed to
precision points.
3. Side-Cutting Needles
– Relatively flat on the top and bottom,
angulated cutting edges are on the
sides. Used primarily in ophthalmic
surgery
POINT OF THE NEEDLE
SPONGES
used for absorbing blood and fluids, protecting tissues, applying
pressure or traction, and blunt dissection
TYPES OF SPONGES
1. Gauze sponges
■ called swabs in some countries
■ When opened out to a single ply during
blunt dissection, fibers along the raw
edges could become foreign bodies in
the wound
TYPES OF SPONGES
2. Laparotomy tapes (lap pads, tapes, or
packs)
■ are used for retaining the viscera and

keeping them moist and warm.
■ Tapes are either square or oblong and
have a loop of blue twill tape sewn on
one corner
TYPES OF SPONGES
3. Dissecting sponges Cherry balls
■ have a self-contained, x-ray–detectable

element incorporated into the weave
■ Peanut sponges are very small, ovoid soft

gauze sponges used for blunt dissection or
absorption of fluid in delicate procedures.
Peanuts
■ Cherry sponges are firm ball-shaped
dissectors.
TYPES OF SPONGES
4. Compressed absorbent cottonoids
■ small squares or rectangles made of

compressed rayon or cotton; they are
very absorbent and resemble a strip of
felt.
TYPES OF SPONGES
5. Towels
■ occasionally but not universally used for

protecting the viscera
PASSING
SURGICAL
INSTRUMENTS
https://youtu.be/PXOJfvye7O0
PREPARATION OF
INSTRUMENTS
https://youtu.be/ZUrNlWmjb54
RESOURCES
Cnor, P. N. R. P. R. (2016). Berry & Kohn’s Operating Room

Technique (13th ed.). Mosby.
JMJ Marist Brothers NCN-N 112A
Notre Dame of Marbel University Care of Clients with Problems in
College of Arts and Sciences Oxygenation,Infectious, Inflammatory,&
Nursing Department Immune Response, Fluid & Electrolytes,CA
INTRAOPERATIVE
PHASE
Perioperative Nursing Care
Intraoperative Phase
At the end of Lesson 3, the students can:

1. Discover the types of anaesthesia as to classification,
advantages, disadvantages,
potential adverse effects and possible nursing
interventions;
2. Identify drugs used intra operatively, their action,
possible adverse reaction and possible nursing
intervention; and
3. Correctly identify the function of each member of the
surgical team and their roles.
The Intraoperative Phase
period of time that begins with transfer of
the patient to the operating room area and
continues until the patient is admitted to the
post anaesthesia care unit.
Please read chapter 18, starting from page
1255 onwards to better understand this
concept.
Preparing the Skin
The goal of preoperative skin

preparation is to decrease bacteria
without injuring the skin.
Preparing the Skin
There are still arguments as to
whether hair on the operative site
should be shaved or clipped.
When hair is an obstruction to the
operative site they may be clipped.
Preparing the Skin
Skin prep is also done in the OR using

providone Iodine Solution,
Chlorhexidine, or 70% Alcohol.
Preparing the Skin
7.5 % povidone iodine is used on the
outer surfaces of the skin ( 1st layer );
10% povidone iodine is used for inner

structures such as in peritoneal cavity
washing. (2nd layer )
Preparing the Skin
Access your schoology account.
NCM 112A
Perioperative Care concepts
Week 3 to check the full Video
Skin Preparation
Anesthesia
Anesthesia is a state of narcosis

(severe central nervous system
depression produced by pharmacologic
agents), analgesia, relaxation, and
reflex loss.
Anesthesia
Anesthetic agents are substances, such

as a chemical or gas, used to induce
anesthesia
Anesthesia
The main types of anesthesia are
general anesthesia (inhalation, IV),
regional anesthesia (epidural, spinal,
and local conduction blocks),
moderate sedation (monitored
anesthesia care [MAC]), and local
anesthesia.
General Anesthesia
Patients under general anesthesia are

not arousable, not even to painful
stimuli.
General Anesthesia
They lose the ability to maintain

ventilatory function and require
assistance in maintaining a patent airway.
Cardiovascular function may be impaired as
well.
Induction of General
Anesthesia
General Anesthesia
General Anesthesia
General Anesthesia
Advantage:
This method provides safe and controlled

anesthetic delivery, especially for older
and high-risk patients.
General Anesthesia
Disadvantage:
This method is risky as it suppresses
respiratory
Function. Serious complications may
occur such as:
· Anesthetic overdose
· Intubation complication
· Unrecognised hypoventilation
General Anesthesia
Because of risks involved in GA, a

surgeon must be present in case there
is failure in intubation in case
tracheotomy is needed
General Anesthesia
General Anesthesia
Common Drugs used during induction of GA:
IV Medications
● Propofol (Lipuro/ IV Pro) *milk of amnesia
● Muscle relaxant (Rocuronium/ succinylcholine)
● Opioid analgesics (nalbuphine/morphine)
● Fentanyl
● Ketamine
PERIOPERATIVE CARE:
GENENERAL ANESTHESIA
General Anesthesia
INHALANTS
● Sevoflurane
Less potent compared to Isoflurane, Costly, less side effects
● Isoflurane
Potent, incidence of complication is high
● Nitrous Oxide
Less potent than Sevoflurane and Isoflurane
PERIOPERATIVE CARE:
GENENERAL ANESTHESIA
General Anesthesia
DESCRIPTION NURSING RATIONALES
INTERVENTION
Stage 1 ( analgesia, sedation, relaxation )
Begins with induction and Close operating room Avoiding external
ends with loss of doors, control traffic in stimuli promotes
consciousness the OR relaxation
Patient feels drowsy and Position patients with Using safety measures
dizzy, has reduced safety belts/ body in stage 1 prepares for
sensation to pain and is straps to prevent fall stage 2
amnesic
Hearing is exaggerated Void unnecessary noise To avoid patient
agitation
Stage 2 ( Excitement/ Delirium)
Begins with loss of Avoid physical and Sensory stimuli can
consciousness and ends in auditory stimuli contribute to the patient’s
relaxation, regular response
breathing, and loss of eyelid
reflex
Patient may have irregular Protect extremities Safety measures help
breathing, increased muscle prevent injury
tone and involuntary
movement of the extremities
Laryngospasm or vomiting Assist anaesthesiologist Adequate suctioning of

may occur or CRNA with suctioning vomitus can prevent
as needed aspiration
Patient is susceptible to Stay with patient Staying with the patient

external stimuli is
emotionally supportive
Stage 3 ( Operative anesthesia, Surgical Anesthesia )
Begins with generalized Assist anaesthesiologist Providing assistance

muscle relaxation and ends with intubation. promotes smooth intubation
with loss of reflexes and ∙ Place patient in the and prevent injury
depression of vital functions operative position. ∙ Performing procedures
∙ The jaw is relaxed and ∙ Skin prep is done ASAP promotes time
breathing is quiet and regular management to minimize
∙ The patient can’t hear total anesthesia time for
∙ Sensations are lost patient
Stage 4 ( Danger)
Begins with depression of vital Prepare for assists in Teamwork and

functions and ends with treatment of cardiac and/or preparedness help decrease
respiratory failure, cardiac pulmonary arrest injuries and complications
arrest, and possible death ∙ Document occurrence in and promote the possibility
∙ Respiratory muscles are the patient’s chart of a desired outcome for the
paralyzed, apnea occurs patient
∙ Pupils are fixed and dilated
General Anesthesia
● NURSING RESPONSIBILITY:
READY EMERGENCY MEDICATIONS

READY MACHINES (SUCTION,ANESTHESIA MACHINE,etc)
REVERSAL MEDS/ANTIDOTE
KEEP PATIENT MONITORED AT ALL TIMES
General Anesthesia
The Sellick maneuver is an

effective means of preventing
passive aspiration of gastric
content
Sellick Maneuver
General Anesthesia
Activity!
To Sellick or to not Sellick?
Should the Sellick maneuver still be practiced

during intubation?
*Instructions and materials available at schoology
Good luck and enjoy!

Regional Anesthesia
In this method, an anesthetic agent is

injected around nerves so that the
region supplied by these nerves is
anesthetized. The effect depends on
the type of nerve involved .
Regional Anesthesia
Spinal Anesthesia
vs
Epidural anesthesia
Regional Anesthesia
Spinal anesthesia
Injection through the dura mater into the

subarachnoid space surrounding the
spinal cord usually between L4 and L5
REGIONAL Anesthesia
Regional ANESTHESIA
• Produces anesthesia of the lower

extremities, perineum, and lower
abdomen
· Produces after-effect: spinal headache
(CSF leakage, Hydration status)
Regional Anesthesia
Epidural anestesia
Achieved by injecting a local anesthetic

agent into the epidural space that
surrounds the dura mater of the spinal
cord.
REGIONAL Anesthesia
Regional ANESTHESIA
Doses are much higher because the

epidural anesthetic agent does not make
direct contact with the spinal cord or
nerve roots
Regional Anesthesia
Advantage :
Absence of headache, longer anesthesia

effect
Regional Anesthesia
Disadvantage:
Greater technical challenge of

introducing the anesthetic agent into the
epidural space rather than the
subarachnoid space.
Regional Anesthesia
Cross-section of injection sites

Regional Anesthesia
Spinal Needle (A), Epidural Set (B)
A B
Epidural Catheter Insertion

Regional Anesthesia
Local Conduction Blocks
The anesthetic is injected near a specific nerve

or bundle of nerves to block sensations of pain
from a specific area of the body. Nerve blocks
usually last longer than local anesthesia.
Regional Anesthesia
Brachial plexus block, which produces anesthesia
of the arm
Paravertebral anesthesia, which produces

anesthesia of the nerves supplying the chest,
abdominal wall, and extremities
Transsacral (caudal) block, which produces

anesthesia of the perineum and, occasionally, the
lower abdomen
Regional Anesthesia
Meds Commonly Used:
1. Bupivacaine (Sencorcaine) Heavy 5%

2. Bupivacaine (Sencorcaine) Isobaric
3. Morphine
4. Atropine***
** Morphine Precaution
Regional Anesthesia
Post Op clients on spinal and

epidural anesthesia is usually
positioned flat on bed for 2
hours to prevent spinal leak
Local Anesthesia
Injection of a solution containing the

anesthetic agent into the tissues at the
planned incision site
Local Anesthesia
Advantages:
· It is simple,and economical;
· Equipment needed is minimal;
· Postoperative recovery is brief; and
· Undesirable effects of general anesthesia are
avoided.
Disadvantage:
· Short Acting
Local Anesthesia
Local anesthesia is sometimes

incorporated with Epinephrine.
Local Anesthesia
Epinephrine constricts blood vessels,

which prevents rapid absorption of the
anesthetic agent and thus prolongs its
local action and prevents seizures
Monitored Anesthesia Care (MAC)
(conscious sedation) involves the use of sedation

to depress the level of consciousness without
altering the patient’s ability to maintain a
patent airway and to respond to physical stimuli
and verbal commands.
● Light Sedation
● Moderate Sedation
Monitored Anesthesia Care (MAC)
Moderate sedation is given by an anesthesiologist

or certified registered nurse anesthetist (CRNA)
· Deeper sedation, provider must be ready to

convert to GA in case of respiratory and
anesthesia fail
Potential Adverse Effects of Surgery and Anesthesia
1. Allergic Reaction;
2. Anesthesia Awareness;
3. Cardiac Dysrhythmia from electrolyte imbalance or
adverse effects of anesthetic Agents;
4. Myocardial depression, bradycardia, and circulatory
collapse;
5. CNS agitation or disorientation, especially in older
Potential Adverse Effects of Surgery and Anesthesia
6. Oversedation or undersedation;
7. Hypoxemia and hypercarbia due to hypoventilation and
inadequate respiratory support;
8. Laryngeal trauma, oral trauma, and broken teeth;
9. Hypothermia due to cool temperatures, exposure of body
cavities, and secondary to use of anesthetic agents;
10. Hypotension due to blood loss or adverse effects of
anesthesia
A skilled nurse must always anticipate and prepare
needed equipment in case anesthesia fails and must be
ready to assist incase anesthesia is converted to GA
The Operating Room
The surgical suite is located out of the mainstream

of the hospital and near the PACU and support
services (e.g., blood bank, pathology, CSSD and
laboratory departments).
Traffic flow is patterned to reduce contamination

from outside the suite. Within the suite, clean and
contaminated areas are separate.
The Operating Room
· Unrestricted Zone / Clean Area– interfaces other

areas:
Holding area, reception area and locker
room/changing room
The Operating Room
· Semi restricted Area/ Sub-sterile area– area in the

operating room where scrub attire is required :
Nurses Station, hallway, ante room
The Operating Room
· Restricted Area/ Sterile Area-area in the OR where

scrub attire, OR cap, mask are required :
OR Theatre, scrub area
The Surgical Team
1. Surgeon- a physician who is responsible for the surgical

procedure and any surgical judgments about the patient.
2. Surgical Assistant- might be another surgeon or a nurse,

who, under the direction of the surgeon may hold
retractors, suction the wound (to improve viewing of the
operative site), cut tissue, suture, and dress wounds
The Surgical Team
3. Anaesthetist-specializes in giving anesthetic agents to

induce and maintain anesthesia and delivers other
drugs to support the patient during surgery.
4. Anaesthesia practitioner/ Nurse Anaesthetist– an

advanced practice registered nurse with additional
education and credentials who delivers anesthetic
agents under the supervision of an anesthesiologist,
surgeon, dentist, or podiatrist
The Surgical Team
5. Scrub Nurse- registered nurse, licensed practical nurse, or

surgical technologist who scrubs and dons sterile surgical
attire, prepares instruments and supplies, and hands
instruments to the surgeon during the procedure.
6. Circulating Nurse/ Circulator–manages the OR and protects

the patient’s safety and health by monitoring the activities of
the surgical team, checking the OR conditions, and
continually assessing the patient for signs of injury and
implementing appropriate interventions.
The Surgical Team
7. Post Anesthesia Care Unit (PACU Nurse) - a registered

nurse that provides care until the patient has recovered
from the effects of anesthesia (e.g., until resumption of
motor and sensory functions), is oriented, has stable
vital signs, and shows no evidence of hemorrhage or
other complications (Helvig, Minick, & Patrick, 2014;
Noble & Pasero, 2014; Penprase & Johnson, 2015).
The Health Hazards in OR
1. Retained instrument, sponges

or needles in patient’s body.
wound infection
abscess formation,
and fistulas may develop between
organs (Rothrock, 2014).
2. Inhalation of toxins
electric cautery units

general anesthesia exhaust
fumes.
Exposure to blood and other body fluids.
Double-gloving is routine in trauma and other types

of surgery where sharp bone fragments are present.
rubber boots,
a waterproof apron, and sleeve protectors.
Goggles, or a wraparound face shield
HIGHLIGHT ON MALIGNANT HYPERTHERMIA
Malignant hyperthermia is a rare inherited

muscle disorder that is chemically induced by
anesthetic agents (Rothrock, 2014).
It usually manifests about 10 to 20 minutes
after induction of anesthesia, it can also occur
during the first 24 hours after surgery.
Manifestations:
The initial symptoms of malignant hyperthermia are often cardiovascular,

respiratory, and abnormal musculoskeletal activity.
*Tachycardia (heart rate greater than 150 bpm) may be an early sign.
* Hypercapnia, an increase in carbon dioxide (CO2), may be an early
respiratory sign.
* Generalized muscle rigidity is one of the earliest signs.
**Late sign: Elavated Body temperature (increases 1°C to 2°C every 5

minutes) that can exceed 42°C
Sympathetic nervous stimulation also leads to

ventricular dysrhythmia, hypotension,
decreased cardiac output, oliguria, and, later,
cardiac arrest. With the abnormal transport of
calcium, rigidity or tetanus-like movements
occur, often in the jaw.
Medical Management:
1. Postpone surgery if possible
2. Change anesthetic agents
3. Ensure proper support intraoperatively
Nursing Role
1. Identify patients at risk,
2. Recognize the signs and symptoms,
3. Have the appropriate medication and
equipment available,
INTRAOPERATIVE
PHASE
Postoperative Phase

Intended Learning Outcome
At the end of this session, the students can:
Describe the responsibilities of the nurse in the

01 prevention of immediate postoperative
complications;
02 Identify common post operative

complications and their management; and
Comprehensively relate the totality of

03 Perioperative care by making a
conceptual paradigm; and
POST
OPERATIVE
PHASE
period of time that begins
with the admission of the
patient to the PACU and
ends after follow-up
evaluation in the clinical
setting or home
POST OPERATIVE CARE
The postanesthesia care unit (PACU)
Recovery Room
Monitoring
Access to skilled personnel, equipment and medications
POST OPERATIVE CARE
Phases in PACU
In phase I PACU, used during the immediate recovery phase,

intensive nursing care is provided.
In the phase II PACU, the patient is prepared for self-care or an

extended care setting.
POST OPERATIVE CARE
In phase III PACU, the patient is prepared for discharge.
Step down
Prepared for discharge
Transition from clinical area to home care setting
POST OPERATIVE CARE
** care provided until the patient has recovered

from the effects of anesthesia
GOALS:
Stabilization
Pain Management
CORNERSTONE IN PACU
1. Airway;
2. Respiratory Function;
3. Cardiovascular function;
4. Skin color;
5. LOC; and
6. Ability to obey commands
Maintaining a Patent Airway
**maintain ventilation and prevent hypoxemia and

hypercapnia.
depth,rate , rhythm, ease of respiration, oxygen

saturation, and breath sounds
** Hypopharyngeal Obstruction / Aspiration:
Assessment:
1. Choking
2. Noisy irregular respiration
3. Decreased 02 saturation
4. Cyanosis
***Properly check if patient is ventilating
** Hypopharyngeal Obstruction/ Aspiration:
Diagnosis:
- Ineffective Airway Clearance
Plan:
- Establish and maintain Patent Airway
- Prevent complications related to airway
obstruction
Intervention (Hypopharyngeal Obstruction):
1. Head Tilt/ Jaw Thrust Maneuver

2. Administer O2 as ordered
3. Place Oral Airway
4. Inform Anesthesiologist
Maintaining Cardiovascular Status
Hypotension and Shock:
Hypotension can result from blood loss,

hypoventilation, position changes,
pooling of blood in the extremities, or side effects
of medications and anesthetics.
> 500 ml Blood loss (Rapid)

Assessment:
pallor; cool, moist skin; rapid breathing;
cyanosis of the lips, gums, and
tongue; rapid, weak, thready pulse; narrowing
pulse pressure; low blood
pressure; and concentrated urine.
Diagnosis:
1. Decreased Cardiac Output.
2. Deficient Fluid Volume.
3. Ineffective Tissue Perfusion
Plan:
1. Prevention and Correction of Symptoms

Intervention:
1. Replace Fluid Volume (LR,NSS, Colloids,Blood
components)
2. Oxygen support (facemask, nasal cannula, ventilation)
3. Close Monitoring of Vital Signs, Urine Output, LOC
4. Position properly if not contraindicated.
Hemorrhage
can present insidiously or

emergently at any time in the immediate
postoperative period or up to
several days after surgery
Hemorrhage
Assessment:
Initial findings:
Change in mood and LOC
Labored Breathing
Hyperthermia
Possible Tinnitus
Hemorrhage
Assessment:
hypotension; rapid, thready pulse;
disorientation; restlessness; oliguria;
and cold, pale skin.
Hemorrhage
Intervention:
1. Determine the Cause
2. Control the bleeding (apply pressure dressing/
elevate to heart level.
3. Correct Vital Signs
Hypertension
sympathetic nervous system stimulation from

pain, hypoxia, or bladder distension
Dysrhythmia
associated with electrolyte imbalance, altered

respiratory function, pain, hypothermia, stress,
and anesthetic agents. Both
hypertension and dysrhythmias are
managed by treating the underlying
causes.
**Relieving Pain and Anxiety
**Control Nausea and Vomiting
POST OPERATIVE CARE
EVALUATION TOOL:
1.Modified Aldrette Score

2.Post op Handover Checklist
POST OPERATIVE CARE
COMMON POST OPERATIVE MEDICATIONS
✔ Pain Management: Nalbuphine, Ketorolac, tramadol,

Paracetamol, diclofenac,Morphine
✔ Hyperthermia: Paracetamol IV
✔ Nausea/ Vomiting: Metoclopramide
✔ Allergic Reaction: Promethazine, Diphenhydramine
✔ Antibiotic of choice
✔ Continuous IVF
Postoperative Phase

I hopeyou were paying enough attention!
An online assessment will commence at this point in time.

Read and follow the instructions carefully. Once you’re done
with the quiz, meet me in our conference in BBB for another
surprise!
You may access the quiz by logging on to your SCHOOLOGY account

and clicking NCM 112A: Perioperative Care concepts. Find the folder with
the title Week 3-4: Post operative Phase, and take the unit test.
Good luck!
Congratulations on making it to end of this module!
This last leg will test what you have learned so far. Make a concept map of
the perioperative nursing care. Compose your answer in a legal size paper,
using Arial 12 font with single spacing. Submit your final output in PDF using
your SCHOOLOGY account. Outputs are expected to be handed in at 11:30
PM today.
Good luck!

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PERIOPERATIVE

Michell Jane Cagurol,RN

INTENDED LEARNING OUTCOMES

At the end of this lesson, the students can:

• Comprehensively discuss the principles of asepsis relating to

• Cite the measures done the perioperative nurse to ensure the

• Cite evidences to support or to reject current nursing practice

Asepsis is a condition in which no living

Surgical asepsis prevents the contamination of surgical

Rigorous adherence to the principles of surgical asepsis

All surgical supplies, instruments, needles, sutures,

This includes preparations starting with proper

For further information, please read pages 1268-1271 of

1. All articles used in an operation have been

4. If in doubt about the sterility of anything consider it

6. Sterile persons keep well within the sterile area

✔Step back away from the sterile field to sneeze or

THE PRINCIPLES OF STERILITY

End of Lesson 1.1

Surgical Hand Scrub,

At the end of this lesson, the students can:

• Comprehensively discuss the principles of asepsis

► The purpose of surgical hand scrub is

► Sterile gowns and gloves are worn to

THE PREOPERATIVE PHASE

Michell Jane B. Cagurol,RN

Intended Learning Outcome:

By the end of the lecture-discussion, students can:

1. Determine the characteristics of a valid informed consent;

period of time from when the decision for

Informed consent is the patient’s

Surgical procedure and anaesthesia

Must be voluntary signed by

Patient signing the consent should be

If patient is below legal age,

Validity for consent for surgical

Is signed by the patient before

Consent is a legal mandate, but it

An informed consent should be in

1. Explanation of procedure and its

Legal Aspect of surgery: INFORMED CONSENT

2. Description of benefits and

If the patient is non-English

Legal Aspect of surgery: INFORMED CONSENT

5. A statement informing the

SAMPLE SURGICAL CONSENT

POSSIBLE NURSING DIAGNOSES

1. Anxiety related to upcoming

2. Risk of latex allergy response due

POSSIBLE NURSING DIAGNOSES

3. Risk for perioperative positioning

Medications that may cause bleeding are

Common Diagnostic Procedures

Common Diagnostic Procedures

· Clotting studies (prothrombin

Common Diagnostic Procedures

Common Diagnostic Procedures

•Radiologic studies ( esp for orthopaedic

•ECG ( anesthesia protocol for young

THE PREOPERATIVE PHASE