Operating Room

ARE YOU READY FOR

YOUR OPERATION

?

Goals of Patient Safety

Provide safe patient care Knowledge of procedure Ensure the correct patient, correct site, correct

level, and correct procedure Knowledge of positioning Adhere to safe medication administration

guidelines Perform surgical counts

Provide a safe environment Adhere to asepsis Promote coordinated and effective

communication

Nursing Roles in the OR

Circulating NurseScrub personRN first assistant (RNFA)

Perioperative educatorSpecialty team leaderPerioperative manager

Scope of Nursing Practice

AdvocateProtectorTeacherChange agentManager of patient care

Activities in the Pre-op

Assessing the clientsIdentifying potential or actual health problems

Planning specific careProviding pre-operative teaching

Ensure consent is signed

Activities during the Intra-op

Assisting the surgeon as scrub nurse and circulating nurse

Activities in the POST-op Assessing responses to surgery

Performing interventions to promote healing

Prevent complicationsPlanning for home-careAssist the client to achieve optimal recovery

SURGICAL RISK

Probability of morbidity

or death from surgery

A. Nature of condition

Maybe benign or malignant1. Location – depends on the

location of the disease and the organ requiring surgery

2. Duration – length of the time the patient has been exposed to the illness dictates the degree of risk involved.

B. Magnitude/urgency of the surgical procedure

Operative risk is proportional

with the magnitude of the operation

C. Physical and Mental conditions

Based on health status and person’s

mental attitude toward surgery

C. 1. Physical Condition

a. Age – infants and elderly have the lowest tolerance to the stressful effects of surgery.

b. Nutritional status – a well-nourished pre-op client is better prepared for surgical stress and return to optimal health after surgery.

A. ObesityB. Malnutrition

C. 1. Physical Condition

c. Fluid and electrolyte problems – fluid volume deficit leads to possible intra and post-op complications.

d.Presence of diseases – increases the operative risk

Presence of diseases

a. Pulmonary – impairs ability to exchange oxygen and carbon dioxide.

b. Cardiovascular – a heart that pumps effectively and blood vessels that constrict well is necessary for prevention of shock and fluid and electrolyte imbalance.

Presence of diseases

c. Hematologic – blood coagulation problem causes severe hemorrhage

d. Genito-urinary – difficulty in eliminating wastes from the body and preserve fluid and electrolyte balance

e. Endocrine – affect clients response to surgery

Presence of diseases

f. Liver – unable to detoxify medications or metabolize carbohydrates, fats and amino acids.

g. Neurologic – for possible effect of anesthetic meds which is to depress CNS

Presence of diseases

h. Gastrointestinal – changes in GI status.

i. Integumentary – bleeding tendencies.

j. Disabilities – influences response to surgery including those that affect and limit activity.

C. 1. Physical Condition

e. Use of medications1.Tranquilizers – causes anxiety,

tension and even seizures if withdrawn suddenly

2.Insulin3.Adrenal corticosteroids –

cardiovascular collapse might occur if discontinued suddenly

C. 1. Physical Condition

e. Use of medications4. Diuretics – thiazide may cause

excessive respiratory depression during anesthesia

5. Phenothiazines and antidepressants (MAO) – may increase hypotensive action of anesthetics

6. Antibiotics – when combined with muscle relaxant, nerve transmission is interrupted.

C. 2. Mental Condition

FEAR1. Fear of the unknown2. Fear of anesthesia3. Fear of pain4. Fear of death5. Fear of disturbance of

body image6. Worries

Manifestations of Fear

1.Anxiousness2.Bewilderment3.Anger4.Tendency to

exaggerate5.Sad, evasive, tearful,

clingy

Manifestations of Fear

6.Inability to concentrate

7.Short attention span8.Failure to carry out

simple instructions9.Dazed

Three types of defense mechanism:

1.Regression – behaves in a childlike manner.

2.Denial – appears unalarmed

3. Intellectualization – would discuss operation and illness rationally but without emotion

D. Professional Resources

Caliber of the professional staff and health care facilities

E. Financial resourses

The health care team: Division of OR Team and their function

MEMBERS OF THE SURGICAL TEAM

1.Surgeon2.Assistant to the surgeon3.Anesthesiologist4.Nurse anesthetist

(CRNA)5.Circulating nurse6.Scrub nurse

Patient

– all major system are disrupted by anesthesia and surgery. Most client can effectively compensate for surgical trauma and effects of anesthesia but all clients are at risk during the operative phase

2. Scrub Nurse or Surgical Technician – sets up the sterile table; prepares sutures, ligatures and other supplies,

assists the surgeon and the surgical assistants during the procedure by anticipating / handling instruments and other equipments,

maintains sterility of field during procedure

together with circulating nurse, counts all needles, sponges and instruments after procedure to ensure patient well being

labels tissue specimen obtained during procedure

keep track of time the patient is under anesthesia

time wound is opened, incisions closed

3. Circulating Nurse – also known as circulator

main responsibilities include verifying consent, coordinating the team, ensuring cleanliness, proper temperature, humidity and lighting, safe functioning of equipments and availability of supplies

manages OR & protects the safety and health needs of client

assists in positioning clients performs surgical skin preparation monitors aseptic practices to avoid breaks in

technique coordinates movement of related personnel

(medical, radiography, laboratory) implement fire safety precautions monitors patient and documents specific

activities throughout operation to ensure patient’s safety and well-being

sends tissue specimen to the laboratory

4. Operating Surgeon – heads the surgical team; performs and makes decisions concerning surgical procedures

5. Assistant to Surgeon – hold retractors to expose operative site, clamp bleeding blood vessels, suction blood to provide clear view of the operative site and assist in suturing or closing the wound

6. Anesthesiologist – reassess patient’s physical condition immediate prior to initiating anesthesia, administer anesthesia and monitor patient’s vital signs during entire procedure

7. Anesthetist – works under the direct supervision of an anesthesiologist; most are nurses with required training

8. Intraoperative Nurses Responsible for safety and well-

beingCoordination of OR personnelPerformance of scrub or circulatory

nurse activities Responsible for emotional state

which has been started by the ward nurse (provide information and realistic reassurance)

Supporting coping strategiesReinforcing patient’s ability to

influence outcomes

The Surgical Patient

Effects of Surgery upon

the Person

1.Stress response is elicited.

2.Defense against infection is lowered.

3.Vascular system is disrupted.

4.Organ functions are disturbed.

5.Body image may be disturbed.

6.Lifestyles may change.

Nursing Responsibili

ty: Preoperativ

e Phase

1. assessment: physiological and psychological response

Preoperative health teaching

2. Pre-operative teaching

Leg exercises To stimulate blood circulation in the extremities to prevent thrombophlebitis

Deep breathing and Coughing Exercises

To facilitate lung aeration and secretion mobilization to prevent atelectasis and hypostatic pneumoniaDone every two to four hours

Positioning and Ambulation

For circulation, stimulate respiration, decrease stasis of gas

Diaphragmatic Breathing and Splinting When Coughing

Leg Exercises and Foot Exercises

3. Physical preparations

Correct any dietary deficiencies.

Reduce an obese person’s weight.

Correct fluid and electrolyte imbalances.

Restore adequate blood volume with blood transfusion.

Treat chronic diseases.Halt or treat infectious process.

Treat an alcoholic person with vitamin supplementation, IVF or oral fluids if dehydrated.

On the Night of Surgery

Preparing the skinPreparing the GI tractPreparing for anesthesia

Promoting rest and sleep

On the Day of Surgery

Early AM care1.Awaken an hour before

pre-op medications.2.Morning bath, mouth

wash3.Provide clean gown4.Remove hairpins, braid

long hairs, cover hair with cap.

On the Day of Surgery

Early AM care5. Remove dentures, foreign

materials, colored nail polish, hearing aid, contact lens (wedding ring secured to waist).

6. Take baseline VS before pre-op meds.

7. Check ID band8. Skin prep

On the Day of Surgery

Early AM care9. Check for special orders –

enema, IV line10.Check NPO11.Have client void before pre-op

meds.12.Continue to support

emotionally.13.Accomplish “pre-op checklist.”

4. PRE-OP CHECKLIST

Client has ID band and allergy bracelet

Informed consent is signed and witnessed

Diagnostic and laboratory test results

Client voidedDocument height and weightVital signs before exiting the

wardPre-op meds givenDocument allergy

5. Pre Anesthesia or Pre Medication

Purpose: allay anxiety, produce amnesia, reduce n&v, dec resp secretions, dec vagal nerve stimulations, inc pain threshold, inc effects of anesthetic agents

Peak effect is desired at the time of induction

Usually given 45 min before induction

Pre-operative medications Pre-op Drugs Example Purpose

Anti-anxiety Diazepam To decrease nervousnessPromote relaxation

Anti-cholinergic Atropine Decreases secretionsPrevent bradycardia

Muscle relaxant Succinylcholine To promote muscle relaxation

Anti-emetic Promethazine To prevent nausea and vomiting

Antibiotic Cephalosporin To prevent infection

Pre-operative medications Pre-op Drugs Example Purpose

Analgesics Meperidine To decrease pain and decrease anesthetic dose

Anti-histamine Diphenhydramine To decrease occurrence of allergy

H-2 antagonist Cimetidine To decrease gastric fluid and acidity

Make sure pre-op meds are givenensure all documentation and pre-operative procedures and orders are complete

Send entire medical record or chart to the Operating room with patient

6. Transporting the client to the OR30-60’ in the holding area

7. Patient’s familyDirect proper waiting room.

Doctor informs family immediately after surgery.

Explain reason for long interval of waiting.

Explain what to expect.

8. LEGAL Considerations

Informed Consent - (Operative Permit / Surgical Consent)

- LEGAL document required for certain diagnostic procedures or therapeutic measures, including surgery.

Legal aspect of the informed consent

PURPOSES: To ensure that the client understands

the nature of the treatment including the potential complications and disfigurement.

To indicate that the client’s decision was made without pressure.

To protect the client against unauthorized procedure.

To protect the surgeon and hospital against legal action by a client who claims that an unauthorized procedure was performed.

3 Major Elements of Informed Consent

1. The consent must be given voluntarily.

2. The consent must be given to individual who have the capacity to understand.

3. The client must be given information to be the ultimate decision maker.

Circumstances requiring a permit:

Any surgical procedure where scalpel, scissors, suture, hemostats or electrocoagulation may be used.

Entrance into a body cavityGeneral anesthesia, local infiltration, regional block

Consent The surgeon is responsible for obtaining the consent for surgery

No sedation should be administered before SIGNING the consent

The nurse may serve as witness

Requisites for Validity of Informed Consent:

Written permission is best and is legally acceptable.

Signature is obtained with the client’s complete understanding of what is to occur. (Adults sign their own operative permit and obtained before sedation)

Secured without pressure. Signed at least 24 hours before elective surgery Patient signs own consent if he or she is of age (18

yrs or older), mentally capable, or is an emancipated minor (<18 yrs but independent from parents)

In emergency where client is unable to sign or there is immediate threat to life, effort should be made to contact family and 2 surgeons sign the consent

Requisites for Validity of Informed Consent:

A witness is desirable.In an emergency, permission via telephone or telefax is acceptable.

For minor, unconscious, psychologically incapacitated, permission is required from a responsible family member.

Sterile Field – area around the site of incision into tissue or introduction of any instrumentation into the body orifice that has been prepared for use of sterile supplies and equipments including all furniture covered w/ sterile drapes and personnel who are properly attired.

Sterile Technique – method by which contamination w/ microorganism is prevented to maintain sterility throughout the operative procedure.

Surgically Clean – mechanically cleansed but unsterile.

Disinfection – process of destroying all pathogenic microorganism except spore – bearing one.

Antiseptic – used on tissue and skin and the growth of endogenous bacteria.

Incision – the result of cutting into a body tissue using sharp instrument.

Medical Asepsis – include all practices intended to confine a specific microorganism to a specific area limiting the new growth and spread of microorganism.

Surgical Asepsis (or sterile technique) – refers to those practices that keep an area or object free of all microorganisms including practices destroying all microorganisms and spores.

SCRUB OUT !!!

PRINCIPLES OF STERILE TECHNIQUE

1. Only sterile items are used within the sterile field.

2. Gowns are considered sterile only from the waist to shoulder level in front and sleeves.

3. Tables are sterile only at table level.

4. Persons who are sterile touch only sterile items or areas; persons who are not sterile.

5. Unsterile persons avoid reaching over a sterile field; sterile persons avoid leaning over an unsterile area.

6. Edges of anything that encloses sterile contents are considered unsterile.

7. Sterile field is created as close as possible to time of use.

8. Sterile areas are continuously kept in view.

9. Sterile persons keep well within the sterile area.

10.Sterile persons keep contact with sterile areas to a minimum.

11.Unsterile persons avoid sterile areas.

12.Destruction of integrity of microbial barriers results in contamination.

13.Microorganisms must be kept to an irreducible minimum.

Surgical Environment

“PERIOPERATIVE NURSING IS NOT

JUST A TECHNICAL WORK ANYONE

CAN DO!”

“IF YOU CAME THROUGH YOUR

SURGERY IN GOOD SHAPE, THANK A PERIOPERATIVE

NURSE”

Surgical Environment:- a surgical suite is

designed to promote safe therapeutic environment for the patient.

1. Traffic control- The in and out of the

operating room is kept to minimum

-3 zones:

3 ZONESUnrestricte

dstreet clothes

Semi-restrictedscrub suit and cap

Restricted scrub suit, cap, shoe covers, gloves

a. unrestricted area-provide entrance to and

exit from the operating room-people may wear street

clothes.-it includes the holding

area, lounges, dressing room and offices.

b. semirestricted area-provide access to the

restricted zone and peripheral support

areas within the surgical suite

- scrub attire is required with capsc. restricted area

-includes the individual OR’s, scrub areas, sub sterile room, and clean core areas.

-in this area, scrub attire, hair covering and masks must be worn

2. Operating Room Attirea. masksb. headgear

- should cover completely the hair, neckline and beard

c. gownd. gloves

Tradition for excellence....

Operating room attireOR gown/scrub suits

Masks

Gloves

Foot socks

Headgear/headcover