PERIOPERATIVE
Terms: Suffixes
o -ectomy → Removal
Craniectomy → removal of the cup of the head, curative
Mastectomy → removal of the breast
Appendectomy → removal of appendix
No confirmatory for Appendicitis
Curative or prophylactic surgery
Laparoscopic Procedure → using hole instead of incision (1-1.5 cm)
o -otomy
Creation of the opening
Craniotomy → palliative surgery, reduces pressure via surgery
Fasciotomy →
Tracheotomy →
Thoracotomy → procedure wherein you make an incision for thoracostomy
o -ostomy
Maintenance of the opening
Via tube, stoma (NORMAL: red/pinkish and moist appearance | If dry, dehydration of the stoma | if black, necrosis
| if pale, cyanosis | if there’s pus, indication of infection)
o -centesis
Aspiration
Arthrocentesis
Thoracentesis → emergency procedure, small amount of fluid, air, and blood removal
o -clasis
To break something
Thrombolytics → lyse/destroy the plaque, Ex; Streptokinase, Ritavase, Eminase
Thromboclasis
o -plasty
Molding
Angioplasty → Balloon and/or Stent
o -pexy
Fixation of an organ
Example Problem: Tracheal Compression
Aortopexy → fixation of the aorta
Example problem: Nephroptosis → descending of the kidney due to heavy lifting, pregnancy, or increase
abdominal pressure
Nephropexy → fixation of the kidney
o -rrphaphy
Suturing
Example problem: Crowning (delivery)
Episiorrhaphy → suturing of the episiotomy
Set-up of the Operating Room:
o Unrestricted Area / Unrestricted Zone
Attire: Outside or Street Clothes
o Transition Area
Changing Area
Smack Gown
Attire: Outside or Street clothes
o Semi-Restricted Area / Zone
Waiting Room
Recovery Room
NICU
Attire: OR shoes, OR Cap, Scrub suit
o Restricted Area / Zone
Attire: Scrub suit, OR shoes, OR Cap, OR Mask
Phases of Surgery:
o Pre-operative
Starts at surgical unit (AKA Surgical Ward)
Until Semi-restricted Zone (waiting area)
o Intra-operative
Starts at Restricted Zone/Area
Until Restricted Zone/Area
o Post-operative
Starts at Semi-Restricted (Recovery Room AKA PACU)
Surgical Unit
Until you go home
o PRE-OPERATIVE ELEMENTS:
Consent → Should be obtained by Surgeon because they are the one who will explain the procedure
The patient should be understood the procedure
18 years old and above signed by the patient.
17 years old and below should be signed by parents or guardian or emancipated minor.
o Emancipated it not in the Board Exam because Philippines has family code.
Needs Witnessed: (to make the consent viable)
o Should be witnessed by Nurse.
o Telephone Consent: Needs 2 witness (2 Nurses)
Clients Nutrition
NPO
o General Anesthesia → NPO for 6 – 8 hours
Spinal Anesthesia → NPO for 6 – 8 hours
o Local Anesthesia → NPO for 3 hours
IVF
o Fluid replacement and Access
Malnutrition:
o Prepare TPN (Total Parenteral Nutrition)
Clients Elimination
Void (urination and defecation), instruct client to void immediately before surgery.
Insertion of Foley Catheter
Administration of Laxative as order to loosen the stool
Administration of Enema as order
Skin preparation
To cleanse the surgical site using soap (mild antiseptic) and water
Clipping → as much as possible
Shave → last option
Pre-operative teachings
Purpose: To raise awareness to post-operative
S – Splint → using hand or pillow (best)
o Increase intraabdominal Pressure → coughing, sneezing, repositioning
P – Pain → Analgesics (to lessen/minimize the pain after procedure)
A – Atelectasis → Coughing technique (BEST POSITION: Sitting), Deep Breathing Exercise, and
Incentive Spirometry
D – Devices (Invasive) → NGT, FC, IVF, Drains
E – Exercises
o Dorsiflexion and Extension of the foot → AKA “Calf-Pumping” or “Gastrocnemius Exercise”
To prepare the client for ambulation
o Foot Circles → rotation of the foot
For lower extremities exercise
o Quadricep Exercise
Quadriceps are located at above knee
o Hip and Knee Exercise
Flex the hip 90 degrees and Knee at 90 degrees
DEEP BREATHING EXERCISES INCENTIVE SPIROMETER
DRAINS
Inhale: Nose Inhale: Mouth → Ball at 600 to 900 mL (proper inhalation)
OPEN CLOSED
Exhale: Mouth (Pursed-lip) Exhale: Mouth (pursed-lip)
Increase IVF Decrease IVF
Hold → for 3 seconds Hold → 5 seconds in duration
Collected via OS Collected via Bulb
Repeated 3 times per hour Repeated at 10 times per hour
Penrose Jackson-Pratt
Checklist → Guidelines for the Nurse to do
D – Dentures, hairpins, glasses → should be removed
I – Informed consent → should be signed, if no signed and not emergency the surgery is not pushed
through
A – Allergies: Latex.
o If patient has allergy to surgery, postpone surgery because of histamine therapy (2 -3 hours)
o If patient has emergency surgery and has allergy, prepare for intubation
M – Monitor Vital Signs → Anesthesiologist (responsible for overall status of the patient)
O – Observe accuracy → blood typing and cross matching
N – Note for Physical Exam (CP (Cardiopulmonary) Clearance) and History of the patient
o Stop Aspirin take 2 days prior to surgery → Aspirin prolonged the bleeding time.
o Corticosteroid continues, it will help to avoid complications.
D – Document last voiding , pre-operative medications
S – Secure clients belongings
o INTRA-OPERATIVE
Sterile Field → Absences of microorganisms
Observe Principle of Aseptic Technique:
o Sterile to Sterile and Unsterile to Unsterile
o Confirm the sterility
Check the expiry date
Check for dryness
Check for OR-Tape or Autoclave Tape → chemical indicator for sterility of items
o Opening of Packs
Closes to the time of use → 15 – 20 minutes prior the surgery
1st to open → top flaps (away)
2nd to open → side flaps
3rd to open → bottom flaps (towards)
o When in DOUBT, THROW OUT (not totally throw out, just consider it as unsterile)
o Sterile → table – sleeves – shoulders
o Unsterile (table) → 1 inch from edge of table
o No laughing, sneezing, coughing, excessive talking
o Always face the sterile field
o Dropping of instruments → 1 arm length , 6 – 8 inches high
o Sterile Water
Lid → unsterile
Lip → unsterile
Bottle → unsterile
Bottom of the bottle → unsterile
Inside the bottler → sterile
Water → sterile
o Pouring of Fluids → 1 arm length, 4 – 6 inches high
o Honesty
Observe proper barriers:
o Gloves → Sterile outside the gloves
o Gown → Sterile outside the gown
o Packs → Sterile inside the packs
Surgical Team
Sterile Team
o Surgeon
o Scrub Nurse
o 1st Assists (Resident on Duty)
Non-Sterile Team
o Anesthesiologist
o Circulating Nurse
o Radiologist (If bone surgery)
Universal Precaution
UNIVERSAL PRECAUTION STANDARD PRECAUTION
Avoid mistakes Avoid contamination
Use of X-Marking using indelible ink PPE
Bilateral Organs Proper disposal of sharps
0 phase
Phases of Operation:
Sign-In Phase → before induction (Anesthesia administration) (Universal Precaution before induction)
Time-Out Phase → before incision (Introduction of the Team Members)
Sign-Out Phase → before closure of the wound (Post-Operative Order and Final counting of instrument)
NOTE:
o Head of Surgical Team: Surgeon
o Head of the Unsterile Team: Anesthesiologist
o OR Manager: Circulating Nurse
o POST-OPERATIVE
Consideration:
IMMEDIATE INTERMEDIATE EXTENSION
1 – 4 hours 4 – 24 hours 1 – 4 days
INCISION R → active bleeding COD WOF: infection
NUTRITION NPO (+) Peristalsis Movement – Increase Vitamins and Protein
Feeding Resumes
UO (-) OU 30 cc/hr Normal OU
DVT Report (+) Homan’s Sign Anti-embolic Stockings ROME
EXERCISE Dorsiflexion and Extension of Supported Ambulation Independent Ambulation
foot
Complication:
Hypoxia
o Decrease Oxygen
o Due to Allergy
o Failure → Oropharyngeal Airway (OPA)
o Paleness
o Numbness
o Tingling Sensation
o Restlessness → Initial sign of hypoxia
o Refer to the physician
o Oxygen Administration → 2 – 3 L/min
o Intubation
o OPA
Pulmonary Embolism
o Hypoxia
o Dyspnea
o Petechial Rashes → Chest and Neck
o Heparin
o Oxygen Administration → 2 – 3 L/min
Atelectasis → Lung Collapse (elasticity of alveoli)
o Common complication of Anesthesia → Atelectasis
o Diminished Breath Sounds
o Impaired Gas Exchange → Decrease in Oxygenation
o Secretion formation
o Productive Cough
o Pneumonia
o Coughing Technique
o Deep Breathing Exercise and Incentive Spirometry
o Antibiotics as ordered
Hemorrhage → Loss of significant blood (500 cc and above)
o Causes: Lengthy Surgery Time and Complication
o Signs and Symptoms:
Hypotension
Tachycardia Initial sign
Tachypnea
Paleness
Coolness
Tingling Sensation
o Management:
Pressure
Refer to Attending Physician
Administer IVF as ordered → to prepare patient for Blood Transfusion
Shock → Loss in Vital Process
o Causes:
Hemorrhage
Infection
Allergies
o Signs and Symptoms:
Hypotension
Tachycardia Initial sign
Tachypnea
Paleness
Coolness
Tingling Sensation
Hypo-Brady-Brady → Late sign
o Management:
Elevate the legs
Refer to Attending Physician
Administer IVF as ordered → to prepare patient for Blood Transfusion
Constipation
o Absences of Feces
o Causes: Anesthesia
o Feeding Client
o Abdominal Distention
o Diet: Increase Fiber
o Laxative as order
Paralytic Ileus
o Absences of Peristaltic Movement
o Causes: Anesthesia
o Client in NPO Status
o Abdominal Distention
o Diet: NGT Insertion → For decompression of stomach
o Prokinetics as order → Motilium
Thrombophlebitis → inflammation of the phleb or blood vessel due to thrombus
o Pain
o Positive Homan’s Sign
o Fever
o Distal:
Paleness
Coolness
Numbness
Tingling Sensation
o Management:
Elevate lower extremities
Without pressure in Popliteal Area → pressure must be in heel or dorsalis pedis
Instruct the client to avoid dangling of the feet
Administer Anti-Pyretic as order
Anti-Embolic Stockings as order
Heparin as order
Thrombolytic as order
DEHISCENCE EVISCERATION
Separation of wound edges Protrusion of loops of bowel
Adipose Tissue Loops of Bowel
Initial Sign: Popping Sound (Loosening of the Suture Line) Initial Sign: Popping Sound (Loosening of the Suture Line)
Occurs 6 – 8 days after Surgery DT Increase Intrabdominal Pressure Occurs 6 – 8 days after Surgery DT Increase Intrabdominal Pressure
Management:
C – Cover with Sterile, Saline-Soaked Gauze or Dressing
L – Low fowlers with knees flexed → to relax the abdominal organ
O – Observe complication of the Shock
V – Vomiting → Anti-Emetic as order
E – Educate → Less than 10 lbs. (Lifting)
S – Splint