PERIOPERATIVE NURSING


* Perioperative nursing includes those activities performed by the nurse in the preoperative, intraoperative and postoperative phases of surgery.

* Surgery refers to surgical operation or procedure, especially one involving the removal or replacement of a diseased organ or tissue. It is a planned alteration that encompasses three phases collectively called the perioperative period.

* Perioperative nurses are registered nurses who work in hospital surgical departments and ambulatory surgery units; they work closely with the surgical patients, significant others, and other health care professionals throughout the perioperative period.

Perioperative and perianesthesia nursing addresses the nursing roles relevant to the three phases of the surgical experience: preoperative, intraoperative, and postoperative.

     1. Preoperative phase - begins when the decision to proceed with surgical intervention is made
         and ends with the transfer of the patient onto the operating room table.
     2. Intraoperative phase - begins when the patient is transferred onto the operating room table and
         ends when he or she is admitted to the postanesthesia care unit (PACU).
     3. Postoperative phase - begins with the admission of the patient to the PACU and ends with a
         follow-up evaluation in the clinical setting or at home.

SURGICAL CLASSIFICATION

I. reason for the surgery

a. diagnostic - performed to determine the origin and cause of a disorder or the cell type of a cancer
e.g., breast biopsy, exploratory laparotomy
b. curative - performed to resolve a health problem by repairing or removing the cause
e.g., cholelithiasis, mastectomy, hysterectomy
c. restorative - performed to improve a patient's functional ability
e.g., total knee replacement, finger reimplantation
d. palliative - performed to relieve symptoms of a disease process, but does not cure
e.g., colostomy, nerve root resection, tumor debulking, ileostomy
e. cosmetic - performed primarily to alter or enhance a person's appearance
e.g., revision of scars, liposuction, rhinoplasty, blepharoplasty

II. urgency of surgery

a. elective - planned for correction of a nonacute problem
e.g., cataract removal, hernia repair, total joint replacement
b. urgent - requires prompt intervention; or may be life-threatening if treatment delayed
e.g., intestinal obstruction, bladder obstruction, kidney or urethral stones
c. emergency - requires immediate intervention because of life-threatening consequences
e.g., gunshot wound, stab wound, severe bleeding

III. degree of risk of surgery

a. minor surgery (low degree of risk) - procedure without significant risk, often done with local anesthesia
e.g., incision and drainage, muscle biopsy
b. major surgery (high degree of risk) - procedure of greater risk, usually longer and more extensive than a minor procedure
e.g., mitral valve replacement (MVR), pancreas implant, lymph node dissection

IV. extent of surgery

a. simple - only the most overtly affected areas involved in the surgery
e.g., simple or partial mastectomy
b. radical - extensive surgery beyond the area obviously involved; is directed at finding a root cause
e.g., radical mastectomy or prostatectomy

EFFECTS OF SURGERY ON THE CLIENT

Physical Effects
Stress response (neuroendocrine response) is activated.
Resistance to infection is lowered due to surgical incision.
Vascular system is disturbed due to severing of blood vessels and blood loss.
Organ function may be altered due to manipulation.

Psychologic Effects
      Common fears: pain, anesthesia, loss of control, disfigurement, separation from loved ones,
      alterations in roles or life-style

Diagnosis
      NURSING DIAGNOSES
           Based on the assessment data, major preoperative nursing diagnoses of the surgical patient
      may include the following:
  • Anxiety related to the surgical experience (anesthesia, pain) and the outcome of surgery
  • Fear related to perceived threat of the surgical procedure and separation from support system
  • Knowledge deficit of preoperative procedures and protocols and postoperative expectations

FACTORS INFLUENCING SURGICAL RISK

Age: very young and elderly are at increased risk.
Nutrition: malnutrition and obesity increase risk of complications.
Fluid and electrolyte balance: dehydration, hypovolemia, and electrolyte imbalances can pose problems during surgery.
General health status: infection, cardiovascular disease, pulmonary problems, liver dysfunction, renal insufficiency, or metabolic disorders create increased risk.

Medications
Anticoagulants (including aspirin and NSAIDS) predispose to hemorrhage; discontinue 2 weeks before surgery.
Tranquilizers (e.g., phenothiazines) may cause hypotension and potentiate shock.
Antibiotics: aminoglycosides may intensify neuromuscular blockade of anesthesia with resultant respiratory paralysis.
Diuretics: may cause electrolyte imbalances.
Antihypertensives: can cause hypotension and contribute to shock.
Long-term steroid therapy: causes adrenocortical suppression; may need increased dosage during perioperative period.

Type of surgery planned: major surgery (e.g., thoractomy) poses greater risk than minor surgery (e.g., dental extraction).
Psychologic status of client: excessive fear or anxiety may have adverse effect on surgery.

PREOPERATIVE PERIOD

Psychologic Support
  • Assess client's fears, anxieties, support systems, and patterns of coping.
  • Establish trusting relationship with client and significant other
  • Explain routine procedures, encourage verbalization of fears, and allow client to ask questions.
  • Demonstrate confidence in surgeon and staff.
  • Provide for spiritual care if appropriate.
Preoperative Teaching
  • Frequently done on an outpatient basis.
  • Assess client's level of understanding of surgical procedure and its implications.
  • Answer questions, clarify and reinforce explanations given by surgeon.
  • Explain routine pre- and post-op procedures and any special equipment to be used.
  • Teach coughing and deep-breathing exercises, splinting of incision, turning side to side in bed, and leg exercises; explain their importance in preventing complications; provide opportunity for return demonstration.
  • Assure client that pain medication will be available post-op.
Physical Preparation

     1. Obtain history of past medical conditions, surgical procedures, allergies, dietary restrictions,

         and medications.
     2. Perform baseline head-to-toe assessment, including vital signs, height, and weight.
     3. Ensure that diagnostic procedures are performed as ordered: common tests are
          a. CBC (complete blood count)
          b. Electrolytes
          c. PT/PTT (prothrombin time; partial thromboplastin time)
          d. Urinalysis
          e. ECG (electrocardiogram)
          f. Type and crossmatch


     4. Prepare client's skin.
          a. Shower with antibacterial soap to cleanse skin if ordered; client may do this at home the
              night before surgery if outpatient admission.
          b. Skin prep if ordered: shave or clip hairs and cleanse appropriate areas to reduce bacteria on
              skin and minimize chance of infection.

     5. Administer enema if ordered (usually for surgery on GI tract, gynecologic surgery).
     6. Promote adequate rest and sleep.
          a. Provide back rub, clean linens.
          b. Administer bedtime sedation.

     7. Instruct client to remain NPO after midnight to prevent vomiting and aspiration during surgery.
    Legal Responsibilities

         1. Surgeon obtains operative permit (informed consent).
              a. Surgical procedure, alternatives, possible complications, disfigurements, or removal of body
                  parts are explained.
              b. It is part of the nurse's role as client advocate to confirm that the client understands
                  information given.


         2. Informed consent is necessary for each operation performed, however minor. It is also
             necessary for major diagnostic procedures, e.g., bronchoscopy, thoracentesis, etc., where a
             major body cavity is entered.
         3. Adult client (over 18 years of age) signs own permit unless unconscious or mentally
             incompetent.
              a. If unable to sign, relative (spouse or next of kin) or guardian will sign.
              b. In an emergency, permission via telephone or telegram is acceptable; have a second listener
                  on phone when telephone permission being given.
              c. Consents are not needed for emergency care if all four of the following criteria are met.
                   1. There is an immediate threat to life.
                   2. Experts agree that it is an emergency.
                   3. Client is unable to consent.
                   4. A legally authorized person cannot be reached.
           4. Minors (under 18) must have consent signed by an adult (i.e., parent or legal guardian). An
               emancipated minor (married, college student living away from home, in military service) may
               sign own consent.
           5. Witness to informed consent may be nurse, another physician, clerk, or other authorized person.
           6. If nurse witnesses informed consent, specify whether witnessing explanation of surgery or just
               signature of client.

      Preparation Immediately Before Surgery

           1. Obtain baseline vital signs; report any elevated temperature.
           2. Provide oral hygiene and remove dentures.
           3. Remove client's clothing and dress in clean gown.
           4. Remove nail polish, cosmetics, hair pins, prostheses.
           5. Instruct client to empty bladder.
           6. Check identification band.
           7. Administer pre-op medications as ordered.
                a. Narcotic analgesics (meperidine [Demerol], morphine sulfate) relax client, reduce anxiety,
                    and enhance effectiveness of general anesthesia.
                b. Sedatives (secobarbital sodium [Seconal]), sodium pentobarbital [Nembutal] decrease
                    anxiety and promote relaxation and sleep.
                c. Anticholinergics (atropine sulfate, scopolamine [Hyoscine]) and glycopyrrolate (Robinul)
                    decrease tracheobronchial secretions to minimize danger of aspirating secretions in lungs,
                    decrease vagal response to inhibit undesirable effects of general anesthesia (bradycardia).
                d. Droperidol, fentanyl or a combination may be ordered; should not be given with sedatives
                    because of danger of respiratory depression; also helpful in control of postoperative nausea
                    and vomiting.
             8. Elevate side rails and provide quiet environment.
             9. Prepare client's chart for OR including operative permit and complete pre-op check list.

        PATIENT’S EDUCATION

        A. Preoperative Instructions to Prevent Postoperative Complication

             1. Diaphragmatic Breathing - refers to a flattening of the dome of the diaphragm during
                inspiration, with resultant enlargement of the upper abdomen as air rushes in. During expiration,
                 the abdominal muscles contract.



             2. Splinting when coughing                                        



             3. Leg Exercises



             4. Turning to side
             5. Getting out of bed

          B. Pain Management

          Cognitive Coping Strategies
               Cognitive strategies may be useful for relieving tension, overcoming anxiety, decreasing fear, and
               achieving relaxation. Examples of such strategies include the following:
          • Imagery—The patient concentrates on a pleasant experience or restful scene.
          • Distraction—The patient thinks of an enjoyable story or recites a favorite poem or song.
          • Optimistic self-recitation—The patient recites optimistic thoughts (“I know all will go well”).


          C. Preoperative Psychosocial Interventions

               1. Reducing preoperative anxiety
               2. Decreasing fear
               3. Respecting Cultural, Spiritual, and Religious Beliefs


          D. General Preoperative Nursing Intervention

               1. Managing Nutrition and Fluids
               2. Preparing the Bowel for Surgery
               3. Preparing the skin

          E. Immediate Preoperative Nursing Interventions

          INTRAOPERATIVE PERIOD

          12 PRINCIPLES OF OR TECHNIQUE
          1. All articles in the operating room are previously sterilized.
          2. Persons who are sterile touch only sterile articles, persons who are unsterile touch only unsterile articles.
          3. If in doubt of sterility of something, consider it unsterile.
          4. Non-sterile persons avoid reaching over sterile field, sterile persons avoid leaning over unsterile field.
          5. Tables are sterile only at table level.
          6. Gowns are considered sterile only from waist to shoulder level, in front and on the sleeves.
          7. Edge of anything that encloses sterile articles is considered unsterile
          8. Sterile persons keep well within the sterile area.
          9. Non-sterile persons keep away from sterile area.
          10. Sterile persons keep in contact with sterile areas in a minimum.
          11. Moisture may cause contamination
          12. When bacteria cannot be eliminated from a field, they must be kept at an irreversible minimum.


          SURGICAL CONSCIENCE – inner voice that tells us what is right or wrong.
          Ø   Should be present to every member of the surgical team.

          Inner voice for the conscientious practice of asepsis and sterile technique at all times.
          A surgical conscience is the foundation for the practice of strict asepsis and sterile technique.

          SURGICAL SCRUB – it is the process of removing as many microorganisms as possible from the hands
                      and arms by mechanical washing and chemical asepsis before participating in an operation

          Skin and nails should be kept clean
          Fingernails should not reach beyond the fingertip to avoid glove puncture
          Fingernail polish should not be worn.
          No artificial nails allowed.

          ASEPSIS – absence of any infectious agents and therefore it is aimed at eliminating microorganisms
                      present in the surgical environment including harmless microorganisms living in the body
                      surface or within.

          MEDICAL ASEPSIS – prevention of pathogenic microorganism to spread

          SURGICAL ASEPSIS – prevention of microorganisms to enter the patient


          PREP. IMMEDIATELY BEFORE SCRUB:

          1. Inspect hands for cuts and abrasions. Skin integrity of hands and forearms should be intact.
          2. Remove all finger jewelry
          3. Be sure all hair is covered by headgear
          4. Adjust disposable mask snugly and comfortably over nose and mouth

          OR TEAM

          1. STERILE TEAM – team members scrub their hands and arms, don sterile gown and gloves, and enter the sterile field.

          STERILE FIELD – area in the OR that immediately surrounds and is especially prepared for the
               patient. All the items in the sterile field needed for surgical procedure are sterilized, which are
               the processes by which all living microorganisms are killed.
                         a. Operating surgeon
                         b. Assistant to the surgeon
                         c. Scrub nurse

            1. UNSTERILE TEAM
                           a. Anesthesiologist

            ANESTHESIA

            General Anesthesia

                 A. General information
                      1. Drug-induced depression of CNS; produces decreased muscle reflex activity and loss of
                          consciousness.
                      2. Balanced anesthesia: combination of several anesthetic drugs to provide smooth induction,
                          appropriate depth and duration of anesthesia, sufficient muscle relaxation, and minimal
                          complications.

                 B. Stages of general anesthesia: induction, excitement, surgical anesthesia, and danger stage.
                 C. Agents for general anesthesia
                      1. Inhalation agents
                           a. Gas anesthetics
                                1. nitrous oxide: induction agent; component of balanced anesthesia; used alone for
                                    short procedures; always given in combination with oxygen
                                2. cyclopropane: obstetric anesthesia; clients with cardiovascular complications; highly
                                    flammable and explosive
             


                           b. Liquid anesthetics 
                                1. halothane (Fluothane): widely used; rapid induction, low incidence of post-op nausea
                                    and vomiting; may cause bradycardia and hypotension; contraindicated in clients with
                                    liver disease. 
                                2. enflurane (Ethrane): effects similar to halothane, but muscle relaxation is stronger and
                                    hepatotoxicity not a problem; use cautiously in clients with cardiac disease. 
                                3. methoxyflurane (Penthrane): very potent agent with slow onset and recovery;
                                    circulatory depression at high concentrations; associated with liver and kidney
                                    damage; rarely used. 
                                4. isoflurane (Forane): rapid induction and recovery; potentiates muscle relaxants;
                                    causes profound respiratory depression; monitor respirations carefully. 

                      2. IV anesthetics: used primarily as induction agents; produce rapid, smooth induction; may be
                          used alone in short procedures such as dental extractions. 
                           a. Common IV anesthetics: methohexital (Brevital), sodium thiopental (Pentathol) 
                           b. Disadvantages: poor relaxation; respiratory and myocardial depression in high doses;
                               bronchospasm, laryngospasm; hypotension, respiratory depression
                            3. Dissociative agents: produce state of profound analgesia, amnesia, and lack of awareness
                                without loss of consciousness; used alone in short surgical and diagnostic procedures or for
                                induction prior to administration of more potent general anesthetics. 
                                 a. Agent: ketamine (Ketalar) 
                                 b. Side effects: tachycardia, hypertension, respiratory depression, hallucinations, delirium 
                                 c. Precautions: decrease verbal, tactile, and visual stimulation during recovery period
                              4. Neuroleptics: produce state of neuroleptic analgesia characterized by reduced motor activity,
                                  decreased anxiety, and analgesia without loss of consciousness; used alone for short
                                  surgical and diagnostic procedures, as premedication or in combination with other
                                  anesthetics for longer anesthesia. 
                                   a. Agent: fentanyl citrate with droperidol (Innovar) 
                                   b. Side effects: hypotension, bradycardia, respiratory depression, skeletal muscle rigidity,
                                       twitching 
                                   c. Precautions: reduce narcotic doses by 1/2 to 1/3 for at least 8 hours postanesthesia as
                                       ordered to prevent respiratory depression.
                           D. Adjuncts to general anesthesia: neuromuscular blocking agents: used with general anesthetics
                                to enhance skeletal muscle relaxation.

                      Agents: gallamine (Flaxedil), pancuronium (Pavulon), succinylcholine (Anectine), tubocurarine, atracurium besylate (Tubarine), vecuronium bromide (Norcuron)

                      Precaution: monitor client's respirations for at least 1 hour after drug's effect has worn off.

                      TABLE 4.12 Stages of Anesthesia



                      Stage
                      From
                      To
                      Client Status
                      Stage I (induction)
                      Beginning administration of anesthetic agent
                      Loss of consciousness
                      May appear euphoric, drowsy, dizzy.
                      Stage II (delirium or excitement)
                      Loss of consciousness
                      Relaxation
                      Breathing irregular; may appear excited; very susceptible to external stimuli.
                      Stage III (surgical anesthesia)
                      Relaxation
                      Loss of reflexes and depression of vital functions
                      Regular breathing pattern; corneal reflexes absent; pupillary constriction.
                      Stage IV (danger stage)
                      Vital functions depressed
                      Respiratory arrest; possible cardiac arrest
                      No respirations; absent or minimal heartbeat; dilated pupils

                      Regional Anesthesia

                      General information (see also Table 4.13).
                      Produces loss of painful sensation in one area of the body; does not produce loss of consciousness.
                      Uses: biopsies, excision of moles and cysts, endoscopies, surgery on extremities; childbirth
                      Agents: lidocaine (Xylocaine), procaine (Novocain), tetracaine (Pontocaine)




                      TABLE 4.13 Regional Anesthesia


                      Types
                      Method
                      Topical
                      Cream, spray, drops, or ointment applied externally, directly to area to be anesthetized.
                      Local infiltration
                      Injected into subcutaneous tissue of block surgical area
                      Field block
                      Area surrounding the surgical site injected with anesthetic.
                      Nerve block
                      Injection into a nerve plexus to anesthetize part of body.
                      Spinal
                      Anesthetic introduced into subarachnoid space of spinal cord producing anesthesia below level of diaphragm.
                      Epidural
                      Anesthetic injected extradurally to produce anesthesia below level of diaphragm; used in obstetrics.
                      Caudal
                      Variation of epidural block; produces anesthesia of perineum and occasionally lower abdomen; commonly used in obstetrics.
                      Saddle block
                      Similar to spinal, but anesthetized area is more limited; commonly used in obstetrics.
                       
                            a. Circulating nurse
                            b. Others – med tech, rad tech, transport aides

                      DUTIES OF A SCRUB NURSE

                      A. Before the surgeon arrives 

                           1. Do a complete scrub according to accepted practice 
                           2. Gown and glove 
                           3. Drape tables as necessary 
                           4. Drape mayo stand 
                           5. Count and arrange the instruments on instrument table. Count sponges and count instruments,
                         needles and sharps. 
                           6. Arrange the instruments on the mayo stand making and opening initial incisions

                           Instruments are classified as: 
                                     a. Cutting or dissecting – knives and scissors 
                                     b. Grasping and holding – tissue and thumb forceps 
                                     c. Clamping and occluding – hemostatic forceps and clamps 
                                     d. Exposing – retractors 
                                     e. Suturing – needle holders

                           7. Put blades on knife handles (Scalpel) 
                                     Blade holder # 3 – blade # 10,11,12,15 
                                     Blade holder # 4 – blade # 20 and above

                           8. Prepare sutures in the sequence in which the surgeon will use them
                                     Free Ties – use to ligate blood vessels if not they can also use the cautery machine.

                           LAYERS OF ABDOMEN 
                                     1. Peritoneum 
                                     2. Muscle 
                                     3. Anterior fascia 
                                     4. Subcutaneous 
                                     5. Skin



                           9. Count surgical needles with circulating nurse 
                           10. Count all sponges with circulating nurse. Circulating nurse immediately records it
                        • counts before the start of the operation 
                        • counts before the surgeon starts closure of a body cavity or deep or large incision
                                a. Table count – scrub nurse and CN count all items in the instrument table and mayo  stand 
                                b. Floor count – CN counts sponges and other items that are recovered from the floor 
                                c. Field count – CN totals floor and table count. Then inform surgeon if sponge count is correct
                        • counts all over again before subcuticular closure. If sponges are intentionally retained for packing or instrument remains with the patient, this should be documented in the patient chart
                            INCORRECT COUNT 
                                1. Entire count is repeated immediately 
                                2. CN looks at trash receptacles, under furniture, linen hamper or throughout the room 
                                3. SN looks over drapes and under items on table and mayo stand
                                4. Surgeon rechecks field and wound
                                5. CN should call HN to check the count
                                6. X-ray must be taken before the patient leaves OR whenever a sponge or instrument
                                    count is incorrect
                                7. CN makes an incident report.

                      B. After Surgeon and Assistants Scrub

                           1. Gown and glove the surgeons and assistants as soon as they enter the room 
                           2. Assist in draping the patient accdg. to the routine procedure 
                           3. Bring mayo table into position after draping is completed. Position the table at right angle to
                               operating table

                      C. During the Operation 

                            1. Hand skin knife to surgeon and hemostat to assistant. When handling knife, hold the handle
                                blade down and pointed toward your wrist NEVER toward the surgeon 
                            2. Watch field and anticipated the needs of the surgeon. Keep one step ahead of him in offering
                                instruments, sutures, or sponges. Notify CN quietly for supplies not in the table 
                            3. Pass instruments in a positive manner. When surgeon extends the hand, instruments should be
                          slapped firmly into the palm in proper position for use.

                                Hemostat – bleeding
                                Scissors – need to cut tissues
                                Mayo scissors – cut sutures
                        • keep instruments clean as  possible wipe blood with moist sponge 
                        • return instruments to mayo stand promptly after use
                           4. Save all tissue specimen 
                        • Never use a large clamp for all small specimens. It may crash. 
                        • Put in a specimen bottle, basin wrapper or towel NEVER in a sponge. Tell CN what specimen it is if not sure asks MD.
                           5. Maintain sterile technique. Watch for any breaks

                      D. During Closure

                           1. Count sponges, needles, instruments with CN  when surgeon begins closure of the wound 
                           2. Clear off mayo stand as time permits leaving a knife handle with blade, tissue forcep, scissors,
                               4 hemostat and 2 allis forceps 
                           3. Have a damp sponge ready to wash blood from the area surrounding the incision as soon as
                               skin closure is completed. 
                           4. Have betadine, dressings and plaster ready

                      DUTIES OF THE CIRCULATING NURSE

                      CN must assist the sterile SN by providing the sterile supplies needed

                      A. After Scrub person/Nurse Scrubs 

                           1. Fasten back of scrub persons gown.
                           2. Open packages of sterile supplies like syringes, sutures, sponges gloves if a sterile package
                               wrapped in porous material drops to the floor, DISCARD it. It can no longer be considered
                               sterile. 
                           3. Flip suture packets onto the instrument table or open overwraps for scrub person to take
                               packets 
                           4. Pour NSS into the round basin for sponges on instrument table 
                           5. Count sponges, needles and instruments with the scrub nurse and record immediately 

                      B. After the patient arrives 

                      CN attends to the patient 
                           1. Greets and identify patient. Check wristband 
                           2. Heck NCP and patients chart for pertinent information including CONSENT 
                           3. Be sure patients hair is covered with cap 
                           4. Assist the patient in moving from the stretcher to the OR table. 
                           5. Apply restraint straps over legs and arms. Keep patient covered with blanket for privacy and
                               provide warmth. 
                                a. Patients legs should not be crossed 
                                b. Put arm board on L or R arm if IV is to be infused 
                                 6. Help anesthesiologist, surgeon or assistant as needed

                      C. During induction of General Anesthesia

                           1. Stay in the room and near patient to provide comfort and assist anesthesiologist in the
                              event that the patient gets excited. Patient must be guarded during induction to prevent
                              possible injury or fall from OR table 
                           2. Be quiet as much as possible 
                        • excitement may occur during induction from tactile or auditory stimulation
                           D. After the patient is Anesthetized 

                                1. Reposition patient only after the anesthesiologist say so 
                                2. Attach anesthesia screen and other table attachments 
                                3. Note patient’s position. All safety measures must be observed 
                                4. If cautery is to be used, place inactive dispersive electrode plate in contact with patient’s
                                    skin to ground the patient properly. Avoid scar tissues, hairy or bony areas. 
                                5. Expose appropriate area for skin prep 
                                6. Turn overhead spotlight over site of incision 
                                7. Arrange sterile prep 
                                8. Cover the prep tray immediately after use
                        
                      E. After Surgeon and Assistant scrub

                           1. Be alert to anticipate needs of sterile team
                        • CN watches closely the operation and anticipate the needs without having the team ask for them
                        • Should know where all supplies are to facilitate time and get them quickly 
                                 2. Stay in the room. Inform SN if you must leave 
                           3. Keep discarded sponges carefully collected, separated by sizes and counted. Sponges
                               forceps or gloves never bare hands are used to handle and count sponges 
                           4. Assist in monitoring blood loss. Weigh sponges if requested by surgeon. Measure blood
                               volume from suction container 
                           5. Obtain blood products for transfusion. 
                           6. Know the condition of the patient at all times 
                           7. Prepare and label specimens for transportation to lab 
                           8. Complete the patient chart, permanent operating room records, and requisition for lab test,
                               etc. 
                           9. Be alert to any break in sterile technique 

                      F. During Closure 

                           1. Count sponges, sharps and instruments with scrub nurse
                        • report counts as correct or incorrect to surgeon
                        • complete count records
                                2. If another patient is scheduled to follow: 
                                     a. CN should call the ward for the next patient at least 45 min before the scheduled time of
                                         operation to request that pre-op medication be given 
                                     b. Ask transport aide to get patient from the ward 30 min before OR

                      G. After the operation is completed 

                           1. Open neck and back closures of gowns of surgeons and assistants so they can remove
                               them without contaminating themselves  
                           2. Assist with dressing. SN should roll drapes off patient before outer layer of dressing is
                               applied 
                           3. Connect all drainage system as indicated 
                           4. See to it that the client is clean – wash off blood, feces. Put on a clean gown and blanket 
                           5. Have transport aide bring a clean RR stretcher 
                           6. Help move patient to stretcher or bed. Place pt to stretcher with a 4 man carry 
                           7. Be sure chart and proper records including NCP accompany patient 
                           8. Final completion of the client chart should include documentation of: 
                                a. assessment of patients skin condition prior to and at completion of operation
                                    i.e. skin discoloration, rashes, pressure sores, burns
                                b. urine output and blood loss – I and O
                                c. type of dressing used
                                d. time patient was discharged from OR 
                           9. Have nursing assistant help transport pt to RR
                        
                      SCRUBBING, GOWNING and GLOVING

                           1. Washes hands, forearms and upper arms 
                           2. Picks up brush and forceps 
                           3. Rinses brush 
                           4. Gets soap solution 
                           5. Scrubs hand for 1 ½ minutes starting from fingertips 
                           6. Scrubs forearms for 1 minute 
                           7. Scrub upper arms for ½ minutes 
                           8. Scrub other hands, forearms and arm for the prescribed time 
                           9. Rinses brush hands, forearms and upper arms 
                           10. Repeats scrubbing
                                 Hands – 1 minute each
                                 Forearms – ½ minute each 
                           11. Rinses brush, hands and forearms 
                           12. Repeat scrubbing
                                 Hands – ½ minute each 
                           13. Discards brush 
                           14. Rinses hands 
                           15. Keeps hands higher than the arms through steps 5-15 
                           16. Dries hands and arms on hem and gown 
                           17. Lets hem face below table level 
                           18. Grasps gown at armhole 
                           19. Puts arms through sleeves of gown 
                           20. Allows assistant to tie laces at the back; bends sideward allow assistant to grasp belt of
                                 gown
                           21. Opens packages of glove, transfers powder to the hand, and discard paper package of
                                 powder 
                           22. Powders hands seeing to it that the powder does not fall on gloves 
                           23. Grasps one glove by the cuff and puts glove on 
                           24. Inserts gloved fingers into the cuff of the other glove; puts on the other glove 
                           25. Folds sleeve of gown to fit wrist and unfolds cuff of glove over sleeve 
                           26. Repeats step 25 with the other sleeve 
                           27. Inserts gloved hands into pouch of gown 
                           28. Maintain asepsis throughout gloving and gowning 
                                a. keeps hands above table level 
                                b. does not turn back towards sterile field