NCM112j – Perioperative, Hematology, Cellular Aberration, Immunology

Module 2: INTRA-OPERATIVE PHASE

Intra-Operative Phase Principles of Sterile Technique
• Corresponds to the period in which 1. THE STERILE TEAM WEARS
anesthesia is administered, the STERILE ATTIRE
operation is done and the client is Rationale:
transferred to the post anesthesia care • Sterile attire prevents cross
unit. contamination between the wearer and
the field.
Welcoming a Patient to OR • It also provides a protective barrier to
• Welcome patient strike-through contamination
• Introduce yourself 2. WHEN IN DOUBT, DISCARD
• Get personal information from patient Rationale:
• Ask if he/she need any further help • Unsterile instruments can serve as
• Show her around (where to sit, agents for infection when used during
bathroom, changing room etc.) the surgery.
• Ask to remove jewelry • The use of sterile instruments prevent
nosocomial infection.
Aseptic Technique 3. TABLES ARE STERILE ONLY AT
• A group of procedures that prevent TOP LEVEL
contamination of microorganisms It is impractical to sterilized the whole
through the knowledge of contain and table. However, it can still be used during
control. the operation by making the tabletop
Sterile Technique sterile.
• Methods by which contamination 4. STERILE-TO-STERILE;
of an item is prevented by maintaining UNSTERILE-TO UNSTERILE
the sterility of an item/area involved Rationale:
with the procedure. • Sterile persons touch only sterile items
& occupy sterile spaces, while unsterile
Practices Involving Aseptic persons touch only unsterile items &
Technique occupy unsterile spaces.
• Items in use may be sterile and 5. ONCE OPENED, USE AT ONCE
unsterile. AND DO NOT REUSE
Items are used for an individual patient Rationale:
only. • Once the sterile solution is opened, it
• Items are not always used within a should be used only for the ongoing
sterile field. procedure.
• The brush used in surgical scrub is not • There is a great chance that the
considered sterile at anytime during its pouring edges will be contaminated
use. when recapped.
• Contamination is contained. 6. BELOW THE TOP OF A STERILE
• Reusable items must terminally TABLE IS UNSTERILE
sterilized or high level disinfectant Rationale:
before reuse. • There is no exact definition of the
• Items are not necessarily stored in a boundaries between sterile & unsterile
sterile condition. areas. (Ex. The edges of wrappers on
Intra- Operative Phase sterile packages & the caps on solution
bottles)

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NCM112j – Perioperative, Hematology, Cellular Aberration, Immunology
Module 2: INTRA-OPERATIVE PHASE
7. A STERILE FIELD IS CREATED 11. UNSTERILE PERSONS AVOID
AS CLOSE AS POSSIBLE TO THE STERILE AREAS
SCHEDULED TIME USE Rationale:
Rationale: • Unsterile persons should be aware at
• The risk of contamination is all times of what areas are sterile,
approximately equal to the length of unsterile, clean and contaminated and
time in which sterile items are exposed their proximity to each other.
to the environment. The longer the
sterile field is exposed, the greater is 12. ONCE THE STERILE PACK OR
the chance that it will be contaminated. DRAPE IS DAMAGED, IT
8. STERILE AREAS MUST BE BECOMES CONTAMINATED
CONSTANTLY KEPT IN SIGHT Rationale:
Rationale: • The integrity of the sterile package or
• Unintentional contamination of sterile sterile drapes is destroyed by
areas must be anticipated. Watching perforation, puncture or strike-
over the sterile field ensures sterility. through.
9. STERILE PERSONS SHOULD 13. MICROORGANISM MUST BE AT
MAINTAIN STERILITY MINIMUM LEVEL
Rationale: Rationale:
• Sterile and nonsterile people are • Though sterile technique is the ideal
equally responsible for the set up in the surgical environment, it is
maintenance of sterility of the not absolute. Not all microorganism
instruments. can be killed, but this is not the reason
• However, because sterile persons are for not complying with strict sterile
in direct contact with the sterile field, technique.
they possess a high level of surgical
conscience for the safety of the Preparation of Surgical Supplies
patient. • Decontamination – contaminates
are removed either by hand cleaning or
mechanical methods using specific
solutions.
• Disinfection- to use to
destroy/kill/inhibit growth of microbes
thru application of antiseptic solution.
- 2% activated aqueous glutaraldehyde
soln (Cidex)- is the agent often
10. STERILE PERSONS LIMIT employed for liquid disinfection
CONTACT WITH STERILE AREAS - Must be immersed for 10hrs –
Rationale: sterilization
• It Minimizes the risk of breaching - Must be thoroughly rinsed in sterile
sterility. Sterile persons must allow a distilled water
wide space during surgical procedure. • Sterilization- rendering an item
totally free of all living microorganisms
including spores.

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NCM112j – Perioperative, Hematology, Cellular Aberration, Immunology
Module 2: INTRA-OPERATIVE PHASE
STERILIZATION - is the process of • The efficiency of the operating room
killing microorganism in their vegetative depends much upon its physical
and spore state. organization and the organization of its
personnel.
Methods of Sterilization: • Clean and contaminated areas should
1. Thermal (Physical) be well differentiated
• Heat
• Sterilization Areas in the Operating Room
2. Chemical A. Unrestricted Area
• Ethylene Oxide Gas • Street cloths are permitted
• Hydrogen Peroxide • This area provides an entrance and exit
from the suite for personnel,
• Liquid Chemical Agent
equipment, and patients.
3. Radiation
• It serves as an outside-to-inside access
2 Major Types:
area to communication with personnel
• Non-ionizing and patients families outside the suite.
• Ionizing Radiation • Admission area, PACU, Dressing
rooms, Surgeon lounge.
THE CARDINAL RULE OF INFECTION
CONTROL: B. Transition Zone
• DO NOT DISINFECT, WHEN YOU • Can enter in street clothing and exit
CAN STERILIZED STERILIZATION into the semi- restricted area.
• Lockers serve as a transition zone
STERILIZATION FAILURE between the outside and inside of a
• TOO TIGHT PACKS surgical suite.
• IMPROPERLY LOADED AUTOCLAVE
• DEFECTIVE AUTOCLAVE B. Semi- restricted Area
• INSUFFICIENT TEMPERATURE AND • Traffic is limited to properly attired
PRESSURE (dressed) personnel
• TOO SHORT EXPOSURE TIME • Body and head coverings are required
( scrub suite, cap and
ORGANIZATION OF AREAS IN THE • masks)
OPERATING ROOM • The patient may be transferred to a
• The efficiency of the operating room clean inside stretcher on entry to this
depends much upon its physical area
organization and the organization of its • The patient’s hair must be covered
personnel. • This area includes peripheral support
• The universal problem of areas and access corridors to the
environmental control to prevent operating rooms.
wound infection exerts a great
influence on the design of the C. Restricted Area
operating room(OR) suite • surgical attire
• The design and size of the surgical • Sterile procedures are carried out in
suite is determined by the functions this area
and needs of the institution and
community it serves.

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NCM112j – Perioperative, Hematology, Cellular Aberration, Immunology
Module 2: INTRA-OPERATIVE PHASE
POSITIONING EQUIPMENT

OPERATING TABLE

• Anesthesia Screen

POSITIONING EQUIPMENT

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NCM112j – Perioperative, Hematology, Cellular Aberration, Immunology
Module 2: INTRA-OPERATIVE PHASE
• Adhesive Tape for anal procedure • Leg Prepper

• Stirrups

• Clamps and Sockets

Goals of Proper Positioning

• To maintain patient’s airway and avoid
constriction or pressure on the chest
cavity
• To maintain circulation
• To prevent nerve damage
• To provide adequate exposure of the
operative site
• To provide comfort and safety to the
• Headrests patient

Factors to consider when

positioning a client
1. Site of operation
2. Age and size of the patient
3. Type of anesthetic used regional –
position patient first general – position
patient last
4. Pain normally experienced by the
patient upon movement
5. Must not hinder respiration and
circulation
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NCM112j – Perioperative, Hematology, Cellular Aberration, Immunology
Module 2: INTRA-OPERATIVE PHASE
General Considerations in 7. Neurosurgical sitting- for intra
Positioning a Client cranial procedures
1. OR bed is securely locked
2. The anesthesia provider guards the Operating Room Attire
HEAD Surgical Attire:
3. Operative site must be adequately • Gowns
exposed. • Gloves
4. Avoid undue exposure. • Masks
5. Strap the person to prevent falls. • Hair Covering
6. Maintain adequate respiratory • Protective Eyewear
function.
7. The vascular supply should not be SEQUENCE IN APPLYING
obstructed by an awkward position PROTECTIVE GEAR
or undue pressure on a part. • uSe Camey hand and body soap in
8. There should be no interference with moisturizing your hand...
the patient’s respiration as a result • Ca- cap
of the pressure of the arms on the • M- mask
chest or constriction of the neck or • Ey- eye goggles
chest caused by the gown. • Hand- surgical scrubbing
9. Nerves must be protected from • Body- sterile gown
undue pressure. • Hand – sterile gloves
10. Precautions for patient safety must
be observed, particularly with thin, Sequence in Removing Protective
elderly, or obese patients. Gear
11. The patient needs gentle restraint • Gloves
before induction, in case of • Mask
excitement. • Gown
12. Maintain good body alignment. • Eye goggles
13. Do not allow the persons extremity • cap
dangle over the sides of the table
14. Avoid excessive muscle strain. SURGICAL SAFETY CHECKLIST
(FIRST EDITION)
Common Surgical Positions Before induction of anesthesia
1. Dorsal Recumbent- for abdominal SIGN IN
surgery such as bowel resection; chest • Patient has confirmed
surgery such as mastectomy • Identity
2. Trendelenburg- for abdominal/ • Site
pelvic surgery as the intestines are • Procedure
displaced into the upper abdomen • Consent
3. Dorsal lithotomy- for vaginal and • Site marked/not applicable
rectal surgery • Anesthesia safety check completed
4. Prone- for spinal or back surgery • Pulse oximeter on patient and
5. Kraske/ jack knife- for hemorrhoids functioning
or proctologic
6. Reverse Trendelenburg- for gall
bladder or biliary tract procedure

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NCM112j – Perioperative, Hematology, Cellular Aberration, Immunology
Module 2: INTRA-OPERATIVE PHASE
• Does patient have a: SURGICAL SAFETY CHECKLIST
• Known allergy? (FIRST EDITION)
• no Before patient leaves operating
• yes room
• Difficult airway/aspiration risk? SIGN OUT
• no • Nurse verbally confirms with the
• yes, and equipment/assistance team:
available • the name of the procedure recorded
• Risk of >500ml blood loss • that instrument, sponge and needle
• (7ml/kg in children)? • counts are correct (or not
• no applicable)
• yes, and adequate intravenous • How the specimen is labelled
access (including patient name)
• And fluids planned • Whether there are any equipment
• Problems to be addressed
SURGICAL SAFETY CHECKLIST • Surgeon, anesthesia professional
(FIRST EDITION) • And nurse review the key concerns
Before skin incision • For recovery and management of this
TIME OUT patient
• Confirm all team members have
• Introduced themselves by name and SURGICAL TEAM
role
• Surgeon, anesthesia professional
• And nurse verbally confirm
⁃ Patient
⁃ Site
⁃ Procedure
• Anticipated critical events
• Surgeon reviews: what are the Surgical Team
• Critical or unexpected steps, A. Sterile Team:
• Operative duration, anticipated Surgeons: “Captain of the ship”;
• Blood loss? perioperative diagnosis ; performs the
• Anaesthesia team reviews: are there surgical procedure ; specific site for
• Any patient-specific concerns? operation; surgical position
• Nursing team reviews: has sterility First Assistant: Maintains visibility of
• (including indicator results) been surgical site; skin preparation;
• Confirmed? Are there equipment positioning; Handles tissues and
• Issues or any concerns? instruments; the operating techniques
• Has antibiotic prophylaxis been given Second Assistant: if needed
within the last 60 minutes? Scrub Nurses: Roles before, during &
⁃ Yes after.
⁃ Not applicable Others: Student nurses, surgical intern,
• Is essential imaging displayed? nurse trainee .
⁃ Yes
⁃ Not applicable

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NCM112j – Perioperative, Hematology, Cellular Aberration, Immunology
Module 2: INTRA-OPERATIVE PHASE
B. Non-sterile Team 4. Informs the surgeon of the drug used
• Anesthesia provider during the surgery.
• Circulating nurse 5. If two scrub nurses are necessary, one
• Nurse anesthetist may prepare the supplies that will be
• Others: Nursing auxillary, biomedical used during the operation while the
technician, la. Or x-ray personnel other passes instruments and supplies
to the surgeon.
Scrub Nurse
• Before the Operation Circulating Nurse
With the help of the circulating nurse: • Before the Operation
1. identifies the client . However, the 1. With the help of the scrub nurse,
nurse can also ask for the following; identifies the client by checking the
• name of the surgeon, contemplated following data and requirements;
operation, signed consent, compliance name, age, name of attending
to nothing per orem (NPO), and the surgeon, contemplated operation,
removal of any prosthesis, jewelry, nail date and time of surgery, signed
polish, and lipstick. Any consent, compliance to NPO, and the
inconsistentency should be corrected presence of prosthesis, jewelry, nail
or validated. Check the following polish, and lipstick. Any inconsistency
documents that are necessary for the should be corrected, validated, or
operation; clearance for surgery, blood reported to the surgeon.
transfusion forms, and diagnostic 2. Accompanies the client when he/she is
results. transferred to the OR.
2. Validates with the surgeon his/her 3. Identifies and reports any potential
preference of sutures and surgical danger in the environment or stressful
instruments/supplies. situation involving the client.
3. Prepares protective attire such as eye 4. Keeps personal items of the client,
gear or apron. such as religious articles, hearing aid,
4. Accounts for all sponges, sharps, and eyeglasses, dentures, jewelry, and the
instruments before and after the like if the client is alone; otherwise,
procedure. endorses these items to the relatives.
5. Checks and labels the drugs and 5. With the scrub nurse, sets up the
syringes that will be used in the operating room and positions the
operation. equipment appropriately:
a. Ensures that the OR table is draped,
• During the Operation and lifting linen or board, armboard
1. Prepares and arranges sterile covers, safety straps, headcover and
instruments and supplies needed leggings for the client is brought to the
during the surgery. OR.
2. Establishes and maintains the b. Ensures that OR lights and
integrity, safety, and efficiency of the negatoscope are functioning.
sterile field throughout the procedure. 6. Records all the sponges, sharps, and
3. Anticipates plans for, and responds to instruments to be used during the
the needs of the surgeon and other operation.
team members. 7. Ensures the safety and comfort of the
client on the way to and from the OR.

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NCM112j – Perioperative, Hematology, Cellular Aberration, Immunology
Module 2: INTRA-OPERATIVE PHASE
a. Checks for the effectiveness and 7. Ensures patient safety throughout the
safety of the equipment, e.g., procedure.
monitoring equipment, electrocautery
machine. Circulating Nurse
b. Ensures that the OR table is locked. • After the Operation
c. Applies necessary straps/restraints on 1. Determines the outcome of the final
the client and places him/her in a counts as correct or incorrect,
comfortable position. including the need for a radiograph to
d. Provides rolls or pads necessary to look for a lost item.
avoid pressure on the client. 2. Writes an incident report on counts
e. Checks if the stretcher to be used is that remain unresolved.
functioning well. 3. Records any medications the surgeon
8. Assists the anesthesiologist in used in the surgical site, such as
inducting anesthesia. antibiotics on local anesthesia.
9. Helps the first assistant or nursing 4. Makes the pathology request and
assistant in placing the client in the conducts proper documentation and
desired position. labeling of specimens to be sent to the
10. Prepares equipment needed for skin laboratory for safekeeping.
preparation. 5. Gives health teachings to the client or
11. Performs skin preparation if the policy his/her relatives.
of the institution requires it. 6. Assists in transferring the patient from
12. Directs all activities of all learners, the OR table to the PACU.
e.g., orientees and students, in the OR. 7. In some institutions, monitors the
13. Applies electrosurgical pads as health situation of the client in the
needed. PACU.
8. Helps in the after care of the OR suite.
Circulating Nurse
• During the Operation ANESTHESIA
1. Provides promptly any supply, • Anesthesia - Is an induced state of
instruments and equipment as partial or total loss of sensation,
needed. occurring with or without loss of
2. Provides assistance to any member of consciousness. To permit the
the OR team. performance of surgery or other painful
3. Acts as a communication link between procedures.
events, and between team members Purposes of Anesthesia
in the sterile field and persons who are • To produce muscle relaxation
not in the OR but are concerned with • To produce analgesia
the outcome of the surgical • To produce artificial sleep or to cause
procedure. loss of consciousness
4. Directs or supervises the scrub nurse • To block transmission of nerve
when necessary. impulses
5. Requests for blood products when • To suppress reflexes
needed.
6. Ensures that everyone complies with
the principle of sterile Tecnique.

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NCM112j – Perioperative, Hematology, Cellular Aberration, Immunology
Module 2: INTRA-OPERATIVE PHASE
Common Anesthetic Technique • General anesthetics are agents that
Minimal Sedation block the pain stimulus at the cortex
• Patient remains conscious where interpretation of pain takes
• Protective reflexes remain intact place
• Can respond to verbal commands
Moderate Sedation Produces a state of the ff:
• state of depressed level of • Analgesia
consciousness that does not impair • Amnesia
patient’s ability to maintain a patent • Unconsciousness characterized by loss
airway and to respond to physical of reflexes and muscle tone
stimulation and verbal commands.
Deep Sedation
• Drug induced state during which the
patient can’t be easily aroused but can
respond purposefully after repeated
stimulation

A. GENERAL ANESTHESIA
1. Intravenous
2. Inhalation
3. Muscle relaxants
B. Regional Anesthesia
- (Blocks pain stimulus at its origin)
1. Local Anesthesia
a. Topical Application
b. Local Infiltration
TYPES OF ANESTHESIA
TYPES OF ANESTHESIA Techniques in Administering
Regional Anesthesia Anesthesia:
- (Blocks pain stimulus along its afferent 1. Inhalation – via mask or
neurons) endotracheal tube
1. Field Block 2. Intravenous Injection (GIV)
2. Peripheral Nerve Block
Regional Anesthesia Stages of General anesthesia
- (Blocks pain stimulus along the Spinal Stage 1: Onset or Induction or
Cord) Beginning anesthesia
1. Spinal Anesthesia 1. Begins with induction and ends with
2. Epidural Anesthesia loss of consciousness
3. Caudal Anesthesia 2. Client feels drowsy and dizzy, has a
reduced sensation to pain and is amnesic
GENERAL ANESTHESIA 3. Hearing is exaggerated
• Is a reversible loss of consciousness
Stage 2 (Excitement, delirium)-
induced by inhibiting neuronal
extends from the time of loss of
impulses in several areas of the central
consciousness to the time of loss of lid
nervous system
reflex.

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NCM112j – Perioperative, Hematology, Cellular Aberration, Immunology
Module 2: INTRA-OPERATIVE PHASE
• Characterized by struggling, shouting, subarachnoid space, generally through a
laughing, singing or crying--- maybe fine needle, usually 9 cm long (3.5
prevented if anesthetic is administered inches).
smoothly and quickly • Produces a nerve block in the
• Client may have irregular breathing, subarachnoid space by introducing a
increased muscle tone, and involuntary local anesthetic at the lumbar level,
movement of the extremities during usually between
this stage • L4 and L5.
• Laryngospasm or vomiting may occur • Autonomic nerve fibers are the first
• Pupils becomes dilated but contract if affected and the last to recover
exposed to light B. Epidural- achieved by inducing an
Stage 3 ( Operative anesthesia, anesthetic agent into the epidural space.
surgical anesthesia) C. Caudal Anesthesia- produced by
• This stage extends from the loss of lid injecting local anesthesia into the caudal
reflex to the loss of most reflexes and or sacral canal
depression of vital organs
1. Begins with generalized muscle
relaxation and ends with loss of
reflexes and depression of vital
function
2. Pupils are small but contract when
exposed to light. Respirations are
regular, the pulse rate and volume are
normal, and the skin is pink or slightly
flushed Complications of Spinal and
3. The jaw is relaxed, and there is quite, Epidural Anesthesia
regular breathing. 1. Spinal Headache
4. The client cannot hear 2. Ruptured nucleus pulposus
5. Sensations are lost 3. Respiratory paralysis
Stage 4 (Danger) 4. Hypotension
• This stage is reached when too much
anesthesia has been administered LOCAL ANESTHESIA
1. Begins with depression of vital function • Injection of a solution containing
and ends with respiratory failure, anesthetic into the tissues at the
cardiac arrest, and possible death planned incision site.
2. Respiratory muscles are paralyzed; • Briefly disrupts sensory nerve impulse
apnea occurs transmission form a specific body area
3. Pupils are fixed and dilated. or region.

Regional Anesthesia Types of Local Anesthesia

A. SPINAL - also called spinal 1. Topical anesthesia – topical
analgesia , spinal block or sub- agents are applied directly to the
arachnoid block (SAB), is a form of area of skin or mucous membrane
regional anesthesia involving injection surfaced to be anesthetized
of a local anesthetic into the

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NCM112j – Perioperative, Hematology, Cellular Aberration, Immunology
Module 2: INTRA-OPERATIVE PHASE
2. Local infiltration – is the injection Surgical incision
of an anesthetic agent directly into Abdominal Incisions
the surrounding nerve of the tissue
around an incision, wound, or lesion.

Local Conduction Blocks

• Brachial plexus block- produces
anesthesia of the arm
• Para vertebral anesthesia- produces
anesthesia of the nerves supplying the Incisions for Caesarean Section
chest, abdominal wall and extremities
• Trans sacral (caudal) block – produces
anesthesia of the perineum and
occasionally the lower abdomen
SKIN PREPARATION
• The removal of as many bacteria as
possible from the patient’s skin
through shaving, mechanical, Layers of the Abdomen
washing, and chemical disinfection

Nursing Consideration
1. Determine the area to be shaved and
its extent; know the operation to be
done; the organ involved and its
location and the proposed incision.
2. Practice modesty and provide privacy
3. Ask the patient’s permission in cutting
the eyelashes and hair.
4. Examine the area to be shaved for any
signs of irritation or any abnormal
condition. Sutures and Needles
5. Do not cut the patient’s skin. SURGICAL SUTURES
6. In abdominal operations, pay CLASSIFICATION:
particular attention to the umbilicus. 1. Absorbable
7. Shave the operative site before the 2. Non-absorbable
operation TYPES:
• Discard soiled sponges in your kidney 1. Atraumatic / Non-traumatic
basin. 2. Traumatic
8. In shaving, follow the direction of the
growth of the hair while free hand Absorbable sutures
exerts an opposite force by pulling the • Chromic Gut - Brown
skin to the opposite direction. • Plain Gut -Yellow
• If a wound is present on the area to • Vicryl - Purple
be shaved, start from the clean area
to the dirty area.

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NCM112j – Perioperative, Hematology, Cellular Aberration, Immunology
Module 2: INTRA-OPERATIVE PHASE
Non-Absorbable Sutures SURGICAL SCRUB
• Silk - Black Surgical scrub – is the process of
• Prolene - Royal Blue removing as many microorganisms as
• Nylon - Green possible from the hands and arms
• Cotton - white through mechanical & chemical
antisepsis.
Different Types Of Needles • Surgical scrubbing of hands and arms
are done just before gowning and
gloving for each surgical procedure.

Materials:

Preparations Prior to Scrub

1. Skin must be free from breaks or cuts.
2. No jewelry.
3. Hair covered by headgear.
4. Adjust mask to fit snugly over nose &
mouth.
5. Adjust eyeglasses.
6. Adjust water temperature.

Length of Scrub
Accdg. to Phillips (2004)
• a study revealed that microorganism
decreases by 50% with each six minute
scrub.
• A vigorous 5 minute w/ a reliable agent
is effective as a 10 minute scrub.

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NCM112j – Perioperative, Hematology, Cellular Aberration, Immunology
Module 2: INTRA-OPERATIVE PHASE
Methods of Surgical Scrub:
1. Five-Minute Scrub – by anatomical
area
2. Alcohol-based Surgical Hand Scrub
Product
Drying of Hands and Arms
• Done right after scrubbing. This
prevents strike-through contamination
of the gown by microorganism from
skin and scrub attire.
• The gown package of must contained
one sterile towel

Gowning and Gloving

• Sterile gown & gloves are worn to
prevent the skin from contaminating &
to create a barrier between sterile &
unsterile areas.
Gloving
A. Gloving by Closed-Glove Technique

Draping
TYPES OF DRAPES
1. Self-adhering plastic sheeting
2. Non-woven fabric drapes
3. Woven Textile fabrics

The Basic Surgical Instruments

• Cutting and Dissecting
• Grasping and Holding
• Retracting and Exposing
• Clamping and Occluding
• Miscellaneous

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