Operating Room Nursing

VERGEL G. LEONARDO RN. MAN

SUBJECT: PERIOPERATIVE NURSING –
NCM112
 COURSE OUTCOMES:
– Focuses on understanding the basic concepts, and
principles related to different phases of surgery.
- the student will be able to meet the needs of the
patients during the learning process.
1. Discuss the nursing responsibilities during the
Preoperative checklist in the preparation of
surgery (PREOPERATIVE PHASE )
2. Identify the responsibilities of the other members of
the surgical team. (INTRAOPERATIVE PHASE)
3. Explain the Surgical Safety Checklist during the
operation and State the Stages of Anesthesia and
common anesthetics used in the surgery.
( INTRAOPERATIVE PHASE)
4. State the position to be assumed by the patient on
the operating table for the various types of surgery.
( INTRAOPERATIVE PHASE)
5. Describe the Comprehensive Postoperative Nursing
Care on the day of the surgery and its complications.
( POSTOPERATIVE PHASE)
 HISTORICAL BACKGROUND
Begins:
Historical development of surgery comes from:
 Babylonian law- The code of Hammurabi in
1913 B.C.
 According to this law:
If the patient died after a surgical
procedure, retribution would reflected on the
surgeon in the form of amputation of his right
hand.
 History of International Surgery

 5,000 to 10,000 BC.

 Early medical providers were known as Healers,
shamans, priest, barbers and medicine men
 Originally all medical providers were essentially surgeons
as they treated wounds, drained infections, broken
bones, and stopped bleeding by applying hot metal or
hot oil to wounds.
 In Surgical Instrumentation

 Historical Overview:
 Archeologist revealing evidence of a surgical
procedure known as trephining ( an opening of
the skull) was performed to release the demons
believed to be trapped inside the patient.
 TREPANATION
Surgical procedure:
is the act of drilling openings into skull to release
so called evil spirit from the dates back to the
Mesolithic periods.
While in the period of Hieroglyphic in ancient
Egypt and textbooks that were the foundation of
Ayurvedic medicine ( Sushruta Samshita)
describe many operations, including CS,
rhinoplasty, craniotomy, and laparoscopy
performed while using wine and Cannibis indica
as anesthesia.
Trepanation- the act of drillings into the skull to release
so- called evil spirits from the body..
 Definition of Terms
Peri-operative nursing
- total surgical experience that encompasses with pre-
operative, intra-operative, and post-operative phases of
patient care

Operating room / Operating theatre

- room in a health care facility in which patients are
prepared for surgery, undergo surgical procedures, and
recover from the anesthetic procedures required for
surgery
 Definition of Terms
Surgery
- branch of medicine concerned with disease or
conditions requiring or amenable to operative or
manual procedures
Surgical procedure
- invasive incision into body tissues or minimally
invasive entrance into a body cavity for either
therapeutic or diagnostic purposes during which
protective reflexes or self-care abilities are
potentially compromised
 Definition of Terms
Surgical conscience
- awareness which develops from a
knowledge base of the importance of strict
adherence to principles of aseptic and sterile
techniques
OR nurse
- duly licensed registered nurse legally
responsible for the nature and quality of the
nursing care patients
 Definition of Terms
Asepsis
- freedom from infection or absence
of microorganism
Sepsis
- general reaction from the action of
bacteria or their products.
 Definition of Terms

Disinfection
- process of destroying all pathogenic
microorganisms except spore bearing ones.
Aseptic technique
- methods by which contamination of
microorganism is prevented.
 Definition of Terms
Antiseptic
- substance which combat sepsis and
cause bacteriostasis
Anesthesia
- insensibility to pain and trauma with or
without loss of consciousness
 3 Types of Surgery
1. Elective surgery- performed when surgery is
preferred treatment and improve the client’s
life, but not essential for the health.

2. URGENT surgery- essential for the client’s

health and may prevent complications.

3. EMERGENCY surgery- must be done

immediately to save the client’s life or
preserve function of a body part.
 PURPOSE OF THE SURGERY
1. Diagnostic Surgery- done to confirm/
establish a diagnosis
2. Ablative surgery-
done to excise of tissue/ remove a diseased
body part.
3. Palliative surg- done to reduce pain or intensity of
symptoms
4. Reconstruction surg-restores appearance of
function to traumatized or malfunctioned tissue.
5. Transplant surg- malfunctioning structure replaces
or organs.
 SERIOUSNESS of the Case:

1. Major surgery-
involves extensive reconstruction or
alteration of body parts

2. Minor surgery-
minimal risk and minimal alteration of
body parts.
 FOUR MAJOR TYPES OF PATHOLOGIC PROCESSES
REQUIRING SURGICAL INTERVENTION.

 O – BSTRUCTION. Impairment to the flow of vital fluids.

e. g blood, urine, CSF, bile.
 P – ERFORATION. Rupture of an organ
 E – ROSION. Wearing off of a surface or membrane.
 T – UMOR. Abnormal new growth
 THE EFFECTS OF SURGERY TO THE CLIENT

 Stress response is elicited.

 Defense against infection is lowered.
 Vascular system is disrupted.
 Organ function are disrupted.
 Body image may be disturbed.
 Lifestyles may change.
 EXPECTED BEHAVIOR / ATTITUDE
PERIOPERATIVE NURSE/S
 Honest / sincere
 Communicative / Impartial, Objective
 Efficiency and well organized
 Flexible and adaptable
 Ethical
 Versatile, intellectual & curious
 Sense of humor
 Sensible and perceptive
 Empathy
 Open-minded and creative
 Supportive, understanding and considerate
 PREOPRATIVE PHASE
 Preoperative nursing care begins with the
nurse’s initial contact with the surgical patient.

 Objective:
is to identify individual needs in order that
accepted protocols of care can be modified.
 Pre-op Situation:
Mrs Sy, 55yrs old is admitted in the Surgical
Ward with the chief complaint of acute
right upper quadrant pain which radiates to
the back. She is extremely nauseated and
has vomitted several times. She has been
diagnosed or tentative diagnosis of
Cholelithiasis with Cholecystitis.
Questions:
1. What is Cholelithiasis?
2. What is Cholecystitis?
3. What is open cholecystectomy / laparoscopic
cholecystectomy?
4. What are the modifiable
and non-modifiable
factors?
5. What is/are your Nursing Dx in pre-operative phase /
intraoperative / postoperative phase?
6. Labs/Diagnostics/ Operation Performed?
 Labs tests/ work up:
1. Leukocytosis may be observed in cholecystitis.
2. Alanine aminotransferase (ALT) and aspartate
aminotransferase (AST) levels are used to evaluate for the
presence of hepatitis and may be elevated in cholecystitis
or with common bile duct obstruction.
3. Bilirubin and alkaline phosphatase assays are used to
evaluate for common bile duct obstruction.
4. Amylase/lipase assays are used to evaluate for the
presence of pancreatitis. Amylase may also be elevated
mildly in cholecystitis.
5. An elevated alkaline phosphatase level is observed in
25% of patients with cholecystitis.
 Labs tests/ work up:
 6. Urinalysis is used to rule out pyelonephritis and renal
calculi.
 7. All females of childbearing age should undergo
pregnancy testing.
 8. Sonography is the preferred initial imaging test for the
diagnosis of acute cholecystitis.
 9. CT is a secondary imaging test that can identify
extrabiliary disorders and complications of acute
cholecystitis, such as gangrene, gas formation, and
perforation.
 10. MRI
 Assessment : For NCP
would include observing for alteration in :
– normal physiologic functioning,
– determining specific nutritional needs, evaluating
current pharmacotherapy, and
– identifying psychosocial patterns of behavior.
 This assessment process should result in a detailed
nursing care plan.
 PREOPERATIVE PHASE

 Any kind of surgery whether

major or minor is always
preceded by emotional as well as
physiological changes hence, the
need for 3 extensive preparations.
 A. Psychological Preparation
Fears related to surgery ( 2 Types)
1. General fear
- fear of the unknown-worst fear of all.
- what to expect and what are the
consequences of surgery
- nursing action: allay anxieties by giving
the patient opportunities to express
his/her fears.
 A. Psychological Preparation
Fears related to surgery
2. Specific fears
- fear of destruction of body image
- threat to sexuality
- fear of permanent disability
- fear of pain
- fear of dying
 Application Of Nursing Process / NCP
Assessment
 Subjective
- know the level of understanding of the patient
- type of surgery
- site
- information from surgeon regarding extent of
hospitalization
- limitations
- tests
- cost of hospitalization
- support from family, religion, & friends
 Application Of Nursing Process /Nursing Care
Plan
Assessment
 Objective
*signs of anxiety differ from person to person
- increased PR, RR, BP (physical signs)
- restlessness, constant hand movement,
sweating
- frequent voiding, changes in sleep patterns
- angry, resentful & aggressive behaviors
 Application Of Nursing Process /
Intervention:

Goal: (Nursing Diagnosis )

Ex: To decrease the level of
anxiety / fear
- conclusions based on analysis &
interpretation of human response
patterns revealed by the assessment
data
 Application Of Nursing Process
Outcome Identification
 Realistic, attainable, & consistent with
medical regimen
 Results of care should be documented in
standardized language
 Examples
- absence of physical injury
- maintenance of skin integrity
- maintenance of fluids & electrolytes
balance
 Application Of Nursing Process
Planning
 Should reflect current standards, facilitates
the prescribed medical care, & work toward
attainment of desired outcomes
 The scope of plan is determined by
assessment data
 Example
- patient will demonstrate understanding of
the procedure
- patient will be injury-free
- patient will be infection-free
 Application Of Nursing Process
Implementation
 Plan of care is implemented throughout the perioperative
period
 Scientific principles provide the basis for patient care
interventions that are consistent with the plan for
continuity of patient care in the perioperative
environment
 Suggested interventions
- identify concerns if he/she is given opportunities to talk
about
 Application Of Nursing Process
Evaluation
 Continual process of reassuring the patient and
his/her responses to implementation of the plan of
care
 Examples
- Risk for deficient knowledge – patient verbalizes
understanding
 Preoperative Teaching Exercises
Post-op exercises
 Equipment used during post-op period
- oxygen, pulse oximeter, CVP
- MV care
- NEBU/NGT care
- IV medications
- FC care
 Pain medication and when to request it
- Patient-Controlled Anesthesia (PCA)
 NPO
 B. PHYSIOLOGICAL PREPARATION

 Before surgery is performed, the patient undergoes

several tests. There are several factors which may affect
the patient’s response to surgery, therefore, it is
necessary to obtain the essential data to identify
potential problems. Factors that affects are as follows:
 Physiologic Preparation

Factors that affect surgery

1. Age
2. Nutrition
3. Presence of disease
condition
4. Prior drug therapy
 1. Age
-Factors that affect surgery under Physiological
preparation

 The very young

- tolerates trauma of surgery well.
- sensitive to temperature changes & rough
handling.
 The elderly
- tolerates trauma of surgery poorly.
 2. Nutrition
-Factors that affect surgery under Physiological
preparation

 Dehydration and malnutrition cause potential

complications post-operatively.

Parenteral fluids are prescribed to correct fluid &

electrolyte deficiencies prior to surgery.
 2. Nutrition
 -Factors that affect surgery under
Physiological preparation

 Malnutrition may be corrected by high caloric diet,

protein & vitamin supplements.

 Obese people breathe poorly & are prone to pulmonary

complications.
 3. Presence Of Disease
-Factors that affect surgery under Physiological
preparation

a. Cardiovascular disease
- ECG, 2-D-Echo, Stress tests, Blood tests
- CVP measurement for elderly, major
surgeries
- blood typing and cross-matching
- HPN, Bleeding disorders

b. Respiratory disease
- CXR, ABGs
- PTB, Pneumonia, COPD
 3. Presence Of Disease
Factors that affect surgery under Physiological
preparation
c. Renal Disease
- Urinalysis, BUN/ Creatinine,
- Acute nephritis, Acute renal
insufficiency, UTI

d. Endocrine disease
- FBS, Thyroid function tests
- Uncontrolled DM,
Hypo/hyperthyroidism
 4. Prior Drug Therapy-
-Factors that affect surgery under Physiological
preparation

 *certain medications can interfere with

anesthesia or contribute to postoperative
complications. Like…
– Anticoagulants –
– Antihypertensive-
Antibiotics
*prior to surgery, most of the drugs are
discontinued and new orders are given post-op
 4. Prior Drug therapy
-Factors that affect surgery under Physiological
preparation
certain medications can interfere with anesthesia or
contribute to postoperative complications.

 Diuretics-
 Steroids-
 Tranquilizers
 Antidepressants-
 C. PHYSICAL PREPARATION
Common preparations
1. Gastrointestinal Prep: The Eve before OR must have:
- light meal the night before surgery
- NPO (food & water -post midnight – safe is 6hrs-2 hours b4
is still possible to give a sips of water.
- this order should be carefully
explained to patients
.
 C. PHYSICAL PREPARATION con’t.

2. Completed early morning of surgery

- Final skin prep: shaving, topical antiseptics
(esp. in ortho cases)
- GIT preparation, enema as ordered
- Foley catheter, NGT, IV as ordered
 C. Physical preparation con’t.
3. Urinary
- empty bladder before patient is sent to the OR*
b4 giving pre-meds. Pt. must empty his bladder.
4. Circulatory
- antiembolic stockings for elderly & for long surgeries
- skin prep, shaving, oral & body hygiene -* can reduce the no.
of microorganism.
 Nurse’s Responsibility
 Perform/supervise skin prep & cleansing
 Notify MD of drug allergies, severe anxiety, unusual ECG or
abnormal lab findings-
 Ensure all consent forms are signed ( Gen. & Informed)
 Administer pre-op meds on time-1 hr b4 anesthesia. ATSO4 to
decrease bronchial sectertion.
 Complete pre-op checklist
 Check if history & PE database are on chart
 Remove dentures, nail polish, hair pins, jewelries
C. Legal Preparation
 TWO TYPES OF CONSENT-under legality
1. General Consent-
forms given during admission. The physicians and nurses
should be knowledgeable about the statements on the form
used in their facility or hospital policy.

2. INFORMED CONSENT
SURGICAL / INFORNMED CONSENT- is a process-not
necessary a mere document. Explanations of the procedure,
risks, benefits, and alternative therapy are made verbally to the
patient’s level of understanding.
 Preparing The Patient On The Day Of
Surgery
 The nurses awakens the patient before he/she receives pre-op
meds, VS is taken & recorded
 Check & make certain that skin preparation has been
completed in a thorough manner
 Ask the patient to void, measure & record the output of urine
 Oral hygiene, remove nail polish, false dentures, glasses
(contact lens, jewelries, & give to responsible person).
Narcotics Box ( HN is responsible)
 Right to Refuse a Surgical
Procedure
 The patient has the right to withdraw consent at any
time before the surgical procedure. Notify the doctor
and obtain a form for refusal to operation.
 *When a patient signs an agreement, consent is given for the specific
procedure indicated on the form.
 *Included in the lists of forms:
– A. Who will be performing the procedure or the Surgeon,
– B. Anesthesiologist
– C. Ass. Surgeon/Resident
– D. circulating nurse
– E. Scrub nurse
Responsibility for Informed Consent before a surgical
procedure:

 Surgeon / Doctor – should include the risks, benefits,

and possible complications of all proposed surgical
procedures. Documented the procedures and becomes
the permanent part of the patient’s record.
 VALIDATION OF CONSENT: for
 1. Minor -parent or legal
guardian should sign.
 2. Illiterate- may sign with X “ after
which the witness
writes” Patient THUMB Mark”
 3. Unconscious- big no
 4. Mentally incompetent-big no
 5. Mentally incapacitated by alcohol or other chemical substances.-
big no
 CONSENT IN EMERGENCY SITUATIONS:

In life threatening emergency

 the consent to treat and stabilize is not
essential.
 Legal Preparation / Considerations:

 Written consent: Prior to this ,the surgeon must

explain everything to the patient.
 Must have at least two consent ( Gen.& Informed)
 In case of minor ( < 18), the parents or the
guardian sign the consent.
 If or during emergency, the surgeon may operate
if is in life threatening-saving measure( house
rule / presumed consent)
 Liability
- legally responsible for personal actions
 Things to remember in the day of
surgery (Pre op Phase) Checked!
 NPO
 Consent form signed
 Pre-op meds given
 Skin prep done
 In gown /cap on
 Allergy NOTED in red mark /ID band on
 Side-rails up after pre-op meds
 No jewelry
 Nail polished removed
 Things to remember in the day of surgery

 Client teaching completed

 Voiding prior to transfer
 Contact lenses out
 Dentures out
 VS within 4 hrs of surgery or 30 mins pre-
op
 Pre-op lab work ups and plates
  NURSE’S PRE-OPERATIVE CHECKLIST-DAY OF SURGERY in the WARD
 Date:
 Last Name First Name MiddleName AMD Hosp PIN
 Operation Proposed:_________________________________
 Date of Operation: _______________ Time__________
 Surgeon:_______________ Anesthesiologist Anesthesia________
 YES NO YES NO
 Pre-Op Med given   False Teeth  
 IV Fluids Ordered   Hair Pins  
 IV Fluids Started   Jewelry  
 Schedule Slip Sent   Nail Polish  
 Weight Taken   Underwear  
 NPO signage on bedside   Enema (if ordered  
 Pre-op bath or shower   Vaginal irrigation  
 Cath, retain & clamp   Pt. visited by the chaplain  
 Patient urinated   History & P.E.  
 Pre-anesthesia Eval.  
 Valid consent signed  

 External Prep. Done by:_____________ Checked by:_________________________

 Allergies:________________________
 Blood Pressure Taken AM  PM 
 Laboratory Exams ( if Ordered):
 DONE NOT YET DONE DONE NOT YET DONE
 Blood Test   ECG  
 Urine Test   X-ray  
 If not yet done, w/PLATES
 Specimen sent to lab  
Patient prepared for O.R
by_____________________________________
Printed Name & Signature
(Staff Nurse)

Final Checking done by:__________________________

Printed Name & Signature
( Nurse Manager / Head Nurse)
Legal aspect and Liability from
Clients & Health Workers
 Legal Preparation w/ liability
 Negligence
- failure to use the proper care or skills.

 Malpractice
- professional misconduct
- illegal or immoral conduct
- unreasonable lack of skill or judgment
 Legal Preparation / Liability
 Borrowed servant rule
- “captain of the ship”
- surgeons have supervisory control &
right to give orders & is directly liable
 Legal Preparation
Doctrine of res ipsa loquitur

“the thing speaks for itself.”

 Legal Preparation
Invasion of privacy
- patient has the right to expect that all communications &
records pertaining to individualized care will be treated as
confidential & will not be misused
- right to privacy during interview, examination & treatment
 Legal Preparation
 Doctrine of respondeat superior
- an employer may be liable for an employees
negligent & conduct.
 Assault
- unlawful threat to harm another physically
 Battery
- carrying of bodily harm as by touching without
authorization or consent
 Legal Preparation
 Abandonment
- leaving the patient for any reason when
the patient’s condition is contingent on the
presence of the caregiver
-
 Legal Preparation
 Surgical conscience for the surgical
team
- key elements of perioperative practice
caring, conscience, discipline &
techniques
END of Preoperative Nursing…
Thanks!