NCM 112 : PRE-OPERATIVE NURSING
Pre-Operative Nursing
Surgery: ( kheirurgos )
● working by hand
● Concerned with the treatment of disease,injury & deformity
● Any procedure that involves entry in the human body
History of Surgery
● Emerged as a medical specialty in mid 19th century .
● Concepts about antiseptics were vague
● Surgery resulted in high immortality
● Surgery was performed as a last resort
● Sepsis was the result of the patient’s inability to withstand the procedure
● OR nursing education began.
Late half of the 19th century
● Ignaz Semmelweis (1847) - importance of handwashing before and after surgery
procedure (REMEMBER: the 5 moments of handwashing)
1. Before touching the patient
2. Before clean/aseptic technique
3. After body fluid exposure
4. After touching the patient
5. After touching patient’s surrounding
● Joseph lister (1865) - antiseptic technique , proposed that germs should be prevented from
entering the surgical wound.
3 Phases of Pre- Operative :
1.Pre-operative phase - from decision making to transfer to operating table.
Happens during : Informed consent , free admission testing, health teaching, skin prep (basic
like: bathing, shaving )
2. Intra-operative phase - transferred to operating table - admitted to PACU(recovery area)
● General
● Regional
3. Post-operative phase - admitted to recovery area - patient recovery follow up.
4 Major types of pathologic process requiring surgery:
● Obstruction- impairment to the flow of vital fluids
● Erosion - wearing off of a surface or membrane
● Perforation - rupture of an organ
● Tumors - abnormal new growths
4 Types of Surgery :
According to
1. Purpose:
● Diagnostic
● Exploratory
● Curative
● Palliative
● Cosmetics
2. Degree of urgency :
● Elective
● Urgency
● Emergency
● Optional
● Day
3. Degree of risk:
● Major
● Minor
4. Extent of surgery :
● Radical
● Simple
● Minimally invasive
According to Purpose:
1. Diagnostic - confirms and establishes diagnosis (biopsy )
2. Palliative - relieves or reduces pain or symptoms of a disease but does not cure
3. Exploratory- determine the extent of the disease conditions such as exploratory
laparatomy
4. Curative - treat the disease condition
3 types:
1. Appendectomy / ablative - removes a diseased body part
2. Palatoplasty / constructive - restores function or appearance that has been lost or reduced
3. Skin upgrafting / reconstructive - involves repair of damaged organ
5. Cosmetic - performed primarily to alter or enchance personal appearance
According to Urgency :
1. Emergency: performed immediately to preserve function of life.
Indication: without delay
● To control hemorrhage
● Fracture repair
● Extensive burns
● Bladder or intestinal obstruction
● Gunshot or stab wounds
2. Urgent / imperative- requires prompt attention
● indication: within 24-30hours
● Acute gallbladder infection
● Kidney/ ureteral stones
3. Required : needs to have surgery
● indication : plan within few weeks or months
● Prostatic hyperplasia without bladder obstruction
● Thyroid disorder
● Cataracts
4. Elective - should have surgery
● indication : failure to have surgery not catastrophic
● Repair of scars
● Simple hernia
● Vaginal repair
5. Optional - decision rest with the client
● indication : personal preference ex. Cosmetic surgery
6. Day/ ambulatory- done as outpatient basis
Risk :
Major surgery:
● High risk
● Complicated
● Prolonged
● Large blood loss
● More possible complication
Minor surgery
● Few complications
● Day surgery
● Ambulatory surgery centers
Extent of surgery
1. Radical - extensive surgery beyond the area obviously involves ( finding out the root)
2. Simple - only the most overly affected areas involved in the surgery (organ)
3. Minimally invasive - performed in a body cavity or body area thru one or more
endoscopes
PREFIX:
● supra : above, beyond
● Infra : below
● Ortho : bones , joints
● Chole : bile, gallbladder
● Cysto : urinary bladder
● Encephalo: brain
● Entero: intestine
● Hysreo : uterus
● Mast : breast
● Myo: muscles
● Meningo : brain meningest
● Nephro : kidney
● Neuro : nerves
● Oophor - ovary
● Pneumo - lungs
● Salphingo - fallopian tube
● Thoraco - thorax
● Viscero - internal organs
SUFFIX:
● Oma - tumor, swelling
● Ectomy - removal
● Rhapy - repair
● Scopy - examine/ viewing
● Ostomy - making an opening
● Otomy - cutting
● Plasty - repair, restore
● Itis - inflammation
● Cele - swelling
PRE-OPERATIVE PERIOD
● The time interval that begins when the decision for surgical intervention is made until the
client is transported to the OR
Focus: Preparation of the client indication
Goal : The patient to be in the best possible physical and emotion condition for surgery
Informed consent: implies that the client has been informed and involved in decisions affecting his or her
health.
● the healthcare provider who will do the procedure should obtain the consent
Informed consent
● Legal document where the patient is aware.
● Written informed consent
● Voluntary & free will to decide
Before obtaining the informed consent the surgeon needs to obtain:
1. The nature of and the reason for the surgery
2. All available option
3. Risk of the surgical procedure and its potential outcome
4. Name and qualification of the surgeon performing the procedure
5. The right to refuse
Role of the nurse :
● Witness the clients signature on the consent
● Discusses and review advanced directive documents
● Ensures that the patient signed the document voluntarily
● Ensures that the patient is competent to sign the document
Necessary in the following circumstances:
● Invasive procedures such as surgical incision,biopsy,cystoscopy,or paracentesis
● Procedure requiring sedation or anesthesia
● A non-surgical procedure,such as arteriography
● Procedure involving radiation
Who can sign the informed consent:
● Adult client > 18 y/o
● Except when unconscious,mentally incompetent to decide for one’s own care
● Relative
● In emergency situations, it is wise to have a 2nd listener to obtain permission via
telephone
Do not need informed consent:
● Immediate threat of life
● Experts confirm that there is an emergent need for surgery
● Client is unable to provide consent
● If legally authorized person cannot be located or reached in any means
Assessment:
Physical Assessment:
● Height
● Weight
● VS
● Mental status examination
● Cardio-pulmonary clearance
Education assessment:
● Previous experience
● Education level
● Sensory impairment
● Expectations
Diagnostic:
● CBC
● Na,K,BUN,Crea,FBS
● CXR
● UA
● ECG
● Coagulation studies : INR,PTT,aPTT
Others:
● Use of medication
● Presence of trauma
● Allergies
● Contraption
Diagnosis:
● Deficient knowledge
● Anxiety
● Grieving
● Ineffective coping
Planning:
● Diagnostic
● Bowel prep
● Skin prep
● Medications
● Contraption
● Anesthesia
● Jewelries
● Exercise
● Spirometry
● Pain
● Post op
● Diet
PRE- OPERATIVE (AUG. 11)
PLANNING/ IMPLEMENTATION
1. Instruct the client to assume sitting or upright position
2. Instruct the client to place the mouth tightly around the mouthpiece
3. Instruct the client to inhale slowly to raise and maintain the flow rate indicator between 600-900
4. Instruct the client to hold the breath for 5 seconds and to exhale thru pursed lips
5. Instruct the client to repeat this process 10 times every hour
MOVING
● TO PROMOTE VENOUS RETURN
● TO ENHANCE LUNG EXPANSION AND MOBILIZE SECRETIONS
● TO STIMULATE GI MOTILITY
● TO FACILITATE EARLY AMBULATION
LEG EXERCISES
● TO PROMOTE VENOUS RETURN, THEREBY PREVENTING THROMBOPHLEBITIS AND
THROMBUS FORMATION
-FLEX AND EXTEND
DEEP BREATHING AND COUGHING
● TO ENHANCE LUNG EXPANSION AND MOBILIZE SECRETIONS THEREBY
PREVENTING ATELECTASIS
WHEN THE PATIENT DONE SURGERY AND WANT TO COUGH ENCOURAGE YOUR PATIENT
TO PUT THE ABDOMINAL BINDER
PHYSICAL PREPARATION
NPO AFTER MIDNIGHT
● CONSUMPTION OR CLEAR LIQUIDS UP TO 2HRS BEFORE ELECTIVE SURGERY
● CONSUMPTION OF BREAST MILK 4HRS BEFORE SURGERY
● A LIGHT BREAKFAST 6HRS BEFORE THE PROCEDURE
● A HEAVIER MEAL 8HRS BEFORE THE SURGERY
● ENEMAS BEFORE SURGERY ARE NO LONGER ROUTINE BUT CLEANSING ENEMA
MAY BE ORDERED IF BOWEL SURGERY IS PLANNED
● CLIENTS ARE ASKED TO BATHE SHOWER THE EVENING OR MORNING OF
SURGERY TO REDUCE RISK OF WOUND INFECTION
● PRE MEDICATION CAN BE GIVEN DEPENDING TO THE ANESTHESIOLOGIST SUCH
AS SEDATIVES, NARCOTICS, ANTICHOLINERGICS, ANTIEMETIC, ANTIHISTAMINES
AND ANALGESICS
EXAMPLES: RANITIDINE/ FAMOTIDINE/ CIMETIDINE/ KETOROLAC/ TRAMADOL
COMMON ANTIEMETIC: METOCLOPRAMIDE, ONDANSETRON
● REMOVAL OF VALUABLES, NAIL POLISH, PROSTHESIS, DENTURES AND ETC.
INTRA OPERATIVE PERIOD
GOAL
● ASEPSIS
● HOMEOSTASIS
● SAFE ADMINISTRATION OF ANESTHESIA
GENERAL ANESTHESIA
REGIONAL ANESTHESIA
● HEMOSTASIS
GENERAL ANESTHESIA
● LOSS OF SENSATION AND CONSCIOUSNESS
● PROTECTIVE REFLEXES SUCH AS COUGH AND GAG
● ANALGESIA- LOSS OF REFLEXES AND MUSCLE TONE
● CHIEF ADVANTAGE: RESPIRATION AND CARDIAC DEPRESSION
REGIONAL ANESTHESIA
● TEMPORARY INTERRUPTION OF THE TRANSMISSION OF NERVE IMPULSES TO
AND FROM A SPECIFIC AREA OR REGION OF THE BODY
(eg.., dental, cs)
TOPICAL ANESTHESIA
● SKIN AREA
● LIDOCAINE
LOCAL ANESTHESIA
● INFILTRATION
● LIDOCAINE
NERVE BLOCK
● INJECTED THE NERVE OR SMALL NERVE GROUP THAT SUPPLIES SMALL AREA OF
THE BODY
SPINAL ANESTHESIA
● L2-S1
● INJECTED TO SUBARACHNOID
(eg…, CSF )
EPIDURAL ANESTHESIA
● ANESTHETIC AGENT IN EPIDURAL SPACE
STAGES OF ANESTHESIA
1. ONSET / INDUCTION
● EXTENDS FROM ADMINISTRATION OF ANESTHESIA TO THE TIME OF LOSS OF
CONSCIOUSNESS
2. EXCITEMENT/ DELIRIUM
● EXTENDS FROM THE TIME OF LOSS OF CONSCIOUSNESS BY THE TIME OF LOSS OF
LID REFLEX. IT MAY BE CHARACTERIZED BY SHOUTING, STRUGGLING OF THE
CLIENT
3. SURGICAL
● EXTENDS FROM THE LOSS OF LID REFLEX TO THE LOSS OF MOST REFLEXES.
SURGICAL PROCEDURE IS STARTED
4. MEDULLARY/ STAGE OF DANGER
● RESPIRATORY OR CARDIAC DEPRESSION OR ARREST
DIAGNOSIS
● IMPAIRED SKIN INTEGRITY
● INEFFECTIVE PERIPHERAL TISSUE PERFUSION
● RISK FOR ASPIRATION
● RISK FOR INJURY
● RISK FOR DEFICIENT FLUID VOLUME
PLANNING/ IMPLEMENTATION
● POSITION THE CLIENT APPROPRIATELY FOR SURGERY
● PERFORM PREOPERATIVE SKIN PREPARATION
● ASSIST IN PREPARING AND MAINTAINING STERILE FIELD
● OPEN AND DISPENSE STERILE SUPPLIES DURING SURGERY
● PROVIDE MEDICATIONS AND SOLUTIONS FOR THE STERILE FIELD
● MONITOR AND MAINTAIN A SAFE, ASEPTIC ENVIRONMENT
● MANAGE CATHETERS, TUBES, DRAINS, AND SPECIMENS
● PERFORM SPONGE, SHARP AND INSTRUMENT COUNTS
POSITION
1. SUPINE
2. DORSAL RECUMBENT (HERMIA REPAIR, MASTECTOMY, BOWEL RESECTION)
3. LITHOTOMY (VAGINAL REPAIR, D&C, RECTAL SURGERY, ABDOMINAL PERINEAL
RESECTION)
4. PRONE (LAMINECTOMY, SPINAL SURGERY)
MEMBERS
1. OPERATING SURGEON
2. ANESTHESIOLOGIST
3. SURGICAL ASSISTANT
4. SCRUB NURSE (assist the surgeon, sterile tech.,
5. CIRCULATING NURSE (assist the anes, coord all the personel, handle the specimen, assist the patient
positioning,
SURGEON
● PERFORMS THE PROCEDURE
● HEADS THE SURGICAL TEAM AND IS SPECIALLY TRAINED AND QUALIFIED
● HAS THE ULTIMATE RESPONSIBILITY FOR PERFORMING THE SURGERY IN AN
EFFECTIVE AND SAFE MANNER
ANESTHESIOLOGIST
● ASSESSES THE PATIENT BEFORE SURGERY
● SUPERVISES THE PATIENTS CONDITION
● MONITORS THE VS, ECG, OXYGEN SATURATION AND BODY TEMP
CIRCULATING NURSE
● COORDINATES ALL PERSONNEL IN THE OR
● MONITORS RESPONSIBLE COST COMPLIANCE ASSOCIATED WITH OR ROOM
PROCEDURE
● ENSURE ALL EQUIPMENT IS WORKING PROPERLY
● GUARANTEEING STERILITY OF INSTRUMENTS AND SUPPLIES
● ASSIST WITH POSITIONING
● PERFORMING SURGICAL SKIN PREP
● HANDLING SPECIMENS
● ASSISTING ANESTHESIA PERSONNEL
● MONITORS THE ROOM AND TEAM MEMBERS FOR BREAKS IN STERILE TECHNIQUE
● COORDINATES ACTIVITIES TO OTHER DEPARTMENTS
● DOCUMENTING CARE PROVIDED
● MINIMIZING CONVERSATION AND TRAFFIC WITHIN THE OR SUITE
SCRUB NURSE
● GATHERING OF EQUIPMENT AND SUPPLIES
● PREPARES ALL SUPPLIES AND INSTRUMENT USING STERILE TECHNIQUE
● MAINTAINS STERILITY DURING SURGERY
● HANDLES SUPPLIES AND INSTRUMENTS DURING SURGERY
● PERFORMS AFTERCARE
● KEEP ACCURATE COUNT OF SPONGES, SHARPS, AMD INSTRUMENT DURING THE
SURGERY
3 ZONES
1. UNRESTRICTED
● CAN WEAR STREET CLOTHES
● PATIENT RECEPTION AREA AND HOLDING AREA
2. SEMI RESTRICTED
● SCRUB ATTIRE IS REQUIRED
● MAY INCLUDE AREAS WHERE SURGICAL INSTRUMENTS ARE PROCESSED
3. RESTRICTED
● SCRUB CLOTHES, SHOE COVER CAPS AND MASKS ARE WORN
● OPERATING THEATER AND STERILE CORE AREA
SURGICAL ASEPTIC TECHNIQUE
● ALL MATERIALS IN CONTACT WITH SURGICAL WOUND OR USED WITHIN THE
STERILE FIELD MUST BE STERILE
● STERILE SURFACES OR ARTICLES MAY TOUCH OTHER STERILE SURFACES OR
ARTICLES REMAIN STERILE
● CONTACT WITH UNSTERILE OBJECTS AT ANY POINT RENDERS A STERILE AREA
CONTAMINATED
● GOWNS OF THE SURGICAL TEAM ARE CONSIDERED STERILE IN FRONT FROM THE
CHEST TO THE LEVEL OF THE STERILE FIELD
● THE SLEEVES ALSO CONSIDERED STERILE FROM 2 inches ABOVE THE ELBOW THE
STOCKINETTE OF THE CUFF
● STERILE DRAPES ARE USED TO CREATE A STERILE FIELD
● ONLY THE TOP SURFACES OF A DRAPED TABLE IS CONSIDERED STERILE
● AFTER A STERILE TECHNIQUE IS OPENED, THE EDGES ARE CONSIDERED
UNSTERILE
● THE MOVEMENTS OF THE SURGICAL TEAM ARE FROM STERILE TO STERILE
AREAS ONLY
● STERILE AREAS MUST BE KEPT IN VIEW DURING MOVEMENT AROUND THE AREA
● WHENEVER A STERILE BARRIER IS BREACHED, THE AREA MUST BE CONSIDERED
CONTAMINATED
● A TEAR OR PUNCTURE OF THE DRAPE PERMITTING ACCESS TO AN UNSTERILE
SURFACE UNDERNEATH RENDERS THE AREA UNSTERILE
● ITEMS OF DOUBTFUL STERILITY ARE CONSIRED UNSTERILE
POST OPERATIVE PERIOD
GOALS
● MAINTAIN ADEQUATE BODY SYSTEM FUNCTION
● RESTORE HOMEOSTASIS
● ALLEVIATE PAIN AND DISCOMFORT
● PREVENT POST OP COMPLICATIONS
● ENSURE DISCHARGE PLANNING AND TEACHING
AIRWAY
● O2 SATS AND VENTILATION
● CARDIO STATUS
● LOC
(GLASGOW COMA SCALE)
HIGHEST (15) LOWEST (3)
● COUGH AND GAG REFLEX
● ABILITY TO MOVE EXTREMITIES
● SKIN COLOR
● FLUID STATUS
● POST OPERATIVE SITE
● DRAINS
● PAIN AND SAFETY
