( UTERINE FIBROID )

KURSUS PENGKHUSUSAN PERAWATAN PERIOPERATIF

SESI 2/200615TH JULY 2006 – 14TH JAN 2007

Compiled by

PBS ZUBAIDAH @ SALMA BT MOKHTAR

COLLEGE OF NURSING PENANG.

TABLE OF CONTENTNUM CONTENT PAGE

1. Acknowlegdements 12. Objective 23. Introduction 34. Anatomy and physiology of female

reproductive system10

5. Introduction of case 196. Preparation of patient 217. Preparation of operation room attire 248. Preparation and Maintenance of the Operating

Room Environment29

9. Preparation of Operating Room 3210. Preparation of Operating Room Equipment 3711. Receiving patient - responsibilities 4912. Preparation of sterile team members 5113. Induction of patient 6614. Positioning of patient for surgery 7215. Preparation of instrument trolley and Mayo’s

stand 73

16. Painting Procedure 8017. Draping Procedure 8118. Operation Procedure 8519. Principle of Collecting and Fixing specimen 9920. Concept of confine and contain 10121. Reversal of patient 10322. Cleaning and checking of instrument 10423. Removal of gown and gloves 10524. Post operative care in Recovery Room 10825. Post Operative Visit 10926. Nursing Diagnosis and Intervention 11127. Bibliography 115

ACKNOWLEDGEMENTS

I wish to express my gratitude to a few person for their contributions during the preparations of this case study.

To my college principal Pn Dermawan Mohd Ismail, my tutor Miss Yee Siew Fong, all Sister in Operating Department Penang as sister incharge and Local

Preseptors who always gave me a lots of precious motivation, advice and unending support, confidence and patience to me in making me to successfully complete this

case study.

Also a lots of thanks to all the doctors including the anesthetist and surgeon and also Operating Department

Staff who generously spend their time and share their knowledge in this case study.

And last but not least to my loving husband and daughter who have been there for me through the transitions of life.

Again, thank you very much to all of you.

PBS ZUBAIDAH @ SALMA BINTI MOKHTARPERIOPERATIVE NURSING

GROUP 2/2006

OBJECTIVES

GENERAL OBJECTIVE~ To gain knowledge and understanding and practice skill to provides high quality perioperative care to the patient undergoing surgery.~ To fulfill requirement of the post basic perioperative course.~ To understand the principles of studies technique.

SPECIFIC OBJECTIVE~To understand the processes involved in preparing a patient undergoing the operation of Total Abdominal Hysterectomy Bilateral Salphingo-Oopherectomy.~ To provide insight regarding patient care, instrument preparation, instrument care and potential complication that may arise.~To documents all the relevant steps involved in the process and reason why certain things are done in certain way.~To shared my knowledge with colleague those are not expose in Gynae Surgery.~To provide better nursing care for patient undergoing for Total Abdominal Hysterectomy Bilateral Salphingo-Oopherectomy.~To identified the phase of surgery, including the usage of specialized instrument and supplies during the intraoperative phase.~To practice safety precaution for patient during pre, intra and post operatively.

INTRODUCTIONHISTORICAL DEVELOPMENT OF PELVIC

SURGERY.

The ovariotomy and myomectomy was performed before the hysterectomy was attempted.

In 1843, Charles Clay of Manchester removed a fibroid. The patient was doing well until the day 12th of the surgery, but on the 13th day of the surgery, the patient was fell on the floor while the nurse turning her to arrange the bed and died on the morning of the 15th day of the surgery.

In 1853 - Massachussets, by Dr. Walter Burnham of Lowell, the first successful removal of fibroid uterus was performed. It was forced to removed the uterus without intending to do so. The abdomen had been opened to removed what was thought to be ovarian cyst, suddently the patient vomited and extruded the fibroid uterus through the incision. The operator could not replace it and was force to removed it. The patient survived and Burnham was encouraged to attempt further hysterectomy.

In 1856 - On November, 13th William J. Baker and associates performed the first successful abdominal hysterectomy with bilateral salpingo-oophorectomy in Knoxville, Tennessee. The patient recovered uneventfully and lived for 34 years after her procedure.

( From the 1Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas; and 2Gynecologic Oncology Service, Baptist Hospital of East Tennessee, Knoxville, Tennessee. )

UTERINE FIBROID

A uterine fibroid (known medically as a leiomyoma, or simply myoma) is a benign (noncancerous) growth composed of smooth muscle and connective tissue. The size of a fibroid varies from that of a pinhead to larger than a melon. Fibroid weights of more than 20 pounds have been reported.

Fibroids originate from the thick wall of the uterus and are categorized by the direction in which they grow:

Intramural fibroids grow within the middle and thickest layer of the uterus (called the myometrium). They are the most common fibroids.

Subserosal fibroids grow out from the thin outer fibrous layer of the uterus (called the serosa). Subserosal can be either stalk-like ( pedunculated) or broad-based ( sessile). These are the second most common fibroids.

Submucous fibroids grow from the uterine wall toward and into the inner lining of the uterus (the endometrium). Submucous fibroids can also be stalk-like or broad-based. Only about 5% of fibroids are submucous.

Figure 1

Uterine fibroids (lelomyomas) are common noncancerous (benign) tumors of the uterus. They grow from the muscular wall of the uterus and are made up of muscle and fibrous tissue, they may be single or multiple. (refer figure 1)

These tumors may grow into the uterine cavity (submucous fibroids), they may be located in the uterine wall (subserous).

In some women, uterine fibroids may cause heavy bleeding and pelvic discomfort. The other symptom of uterine fibroids as following;

Painfull periods

Bleeding between periods

Pain during sex

Lower back pain

Feeling ‘full’ in the lower abdomen-pelvic pressure

Reproductive problem, such as infertility and multiple miscarriages.

Submucous fibroids are the type that commonly cause significant problems, even small tumors located in or bulging into the uterine cavity may cause heavy bleeding, anemia, pain, infertility or miscarriage. Because of their location on the endometrium, submucosal fibroids place pressure on the uterine lining that builds with each menstrual cycle. This, in turn, can cause abnormal bleeding.

Pelvic pressure from the size of a growing fibroids present, can also bring on abnormal bleeding. Excessive bleeding can cause anemia.

Anemia occurs when there is a decrease in your blood red cells due to blood loss. If anemia is confirmed through a blood test, taking iron supplementation may help.

Constipation and hemorrhoids are additional symptoms caused by the pressure of growing fibroids.

Depending upon the individual, any one of these solutions may bring some relief from the symptoms experienced as a result of uterine fibroids. When symptoms are resolved most women feel cured and find no need to take additional action with their uterine fibroids.

There is no known cause for uterine fibroids. There is also no known reasons as to why some women acquire severely symptomatic fibroids while othera do not.

There has been so little research on the risk factors for developing symptomatic uterine fibroids, that almost begs the issue to try and list what little we do know here

. Even so, age, race lifestyle and genetics may well play part in the overall scheme of health and body tendency to develop symptomatic uterine fibroids.

Here the few known associative risk factors:

African-americans are 2-3 times more likely to present with symptomatic uterine fibroids and typically will do so at a younger age than the rest of the population of women with uterine fibroids.

Average age range for fibroids to become symptomatic 35-50.

Asian women have a lower incidence of symptomatic uterine fibroids.

Obesity is associated with the presence of uterine fibroids. ( of cause, which came first – the weight or the fibroids- is still an unanswered question.)

Consumption of beef, red meat (other than beef), and ham has been associated with the presence of uterine fibroids.

In addition, we also know the following: Changes in a woman’s hormone levels may

impact fibroids growth

Fibroids grow rapidly during pregnancy when hormone levels elevated.

Fibroids shrink after menopause when hormone levels are decreased.

Estrogen and progesterone play in fibroids growth.

Mdm Aini was diagnosed as having the Multiple Intramural Fibroid

Treatment for uterine fibroids.

If treating the symptom of the uterine fibroids is ineffective in bringing about relief and patient’s quality of life is dwindling away, it may be time to move more aggressive methods of dealing with the uterine fibroids. It may be time to switch from treating the symptom to treating the fibroids.

There are a variety of treatment options for benign uterine fibroids which allow patient to retain the uterus. These include;

Watch & Wait Medical Therapy Myomectomy Uterine Fibroids Embolization (UFE) Myolysis Hysterectomy

Watch & Wait Many women choose to do nothing and simply treat the

symptom since fibroids often shrink in size and become asymptomatic as a women goes through menopause. The average age of menopause is 51. can we just watch and wait?

Medical Therapy One way to reduce symptom of uterine fibroids is using

one of a group of hormones called gonadotropin releasing hormone agonists (GnRHa). These hormones block the body from making the hormones thatcause women to menstruate or have their periods.

If women have symptoms, have health conditions that make surgery less advisable, and are near menopause or do not want children, they may receive GnRHa therapy to treat the fibroids.

Myomectomy Myomectomy is a type of surgery that removes the

fibroid without removing the uterus. For women over the age of 35, this procedure may provide adequate

relief until the age of menopause when fibroids shrink naturally due to a decline hormones.

There are numerous ways that doctors perform a myomectomy. The type, size and location of the fibroids determine which of the following myomectomies might be recommended;

Laparoscopic Myomectoy Hysteroscopic Myomectomy Laparotomy ( Abdominal Myomectomy) Laparocopic Myomectomy with Mini-Laparotomy Laparoscopic Assisted Vaginal Myomectomy

(LAVM)

Uterine Fibroids Embolization (UFE) Uterine fibroids embolization also known as uterine

artery embolization (UAE) is a minimally-invasive, non-surgical procedure performed by an interventional radiologist (IR). This procedure involves placing a catheter into the artery and guiding it to the uterus. Small particles are then injected into the fibroids. The whole procedure only takes about an hour.

Within a minutes after the procedure the fibroids begin dying. Generally, but not always, there is an overnight stay in the hospital because many women feel intense abdominal cramping and pain. Pain from this procedure is usually controlled through the use of narcotics.

Myolysis Involves surgical instrument that are inserted through a

laparoscopic incision in the abdomen and high frequency electrical current that is sent to the fibroid. The electrical current causes the blood vessels to vaso-constrict and this basically cut off the blood flow to the fibroids. The fibroids remain in place and are not surgically removed. Without a blood supply, the fibroids eventually die and shrink.

Myolysis is only performed on subserousal fibroids that fit a certain size range.

HYSTERECTOMYHysterectomy is a removal of the women’s uterus which is it

was a major procedure, and it was done to a healthy and non diseased organ. It was performed for a various gyneacological problem. There was a few indications for this surgery, such as;

Fibroids Endometriosis Cancer of uterus, cervix or ovaries Pelvic inflammatory disease Irregular menstrual bleeding such as heavy menstrual

bleeding. Emergency hysterectomy such as may be necessary for

severe bleeding after delivery or during surgery.

In this case study, the indication is UTERINE FIBROID. After a hysterectomy was performed, the patient can no longer be able to bear children and no longer menstruate.

There are a few type of hysterectomy; Subtotal hysterectomy

Involves only the removal of the uterus. The pelvic structural ligaments are not cut and the cervix is left in the place. Fallopian tubes and ovaries may or may not be removed. This procedure is always done through the abdomen.

Total hysterectomy Involves removing both the body of the uterus

and the cervix, which is the lower part of the uterus. It can sometimes be done through the vagina ( vagina hysterectomy) ; at the other times, a surgical incision in the abdomen is preferable. For example, if there is large fibroids tumors, it is difficult to safely remove the uterus through the vagina, then abdominal hysterectomy will be performed. In a total hysterectomy and bilateral ( both sides) salphingo-oophorectomy, the ovaries and fallopian tubes are removed, along with the uterus and cervix.

Radical hysterectomy It is reserved for serious disease such as cancer.

The entire uterus and usually both tubes and ovaries as well as the pelvic lymph nodes are removed through the abdomen.

Usually, one or both ovaries and fallopian tubes are removed during hysterectomy. When both ovaries and fallopian tubes are removed it is called bilateral salphingo-oopherectomy.

A hysterectomy may be life-saving in the case of cancer. It can also relieve the symptoms of bleeding, discomfort or uterine prolapse related to fibroids.

For Mdm Aini, Total Abdominal Hysterectomy Bilateral Salphingo-oopherectomy is going to be performed which is the uterus, cervix, both fallopian tubes and ovaries are removed through abdominal incision and opening of the peritoneal cavity.

INTRODUCTION OF CASE

INTRODUCTION OF PATIENT

PATIENT PARTICULAR

Name : Mrs Aini

Age : 50 years old

RN : 546058

I/C : 560617-02-5650

Mrs Aini was stay at Alor Setar, Kedah. She is a very pleasant lady and cooperative. She is a fulltime housewife and stay with 3 son and 1 daughter also her husband. Her husband is a retired ARMY and now was working as a security guard in one of the factory in Bayan Lepas. Mrs Aini was married to her husband 30 years ago.

According to Mrs Aini, all of her children was born through the Spontaneous Vaginal Delivery. Now her 1st son already 28 years old and married, and her youngest daughter is 15 years old.

Mrs Aini was look apparently well and healthy. There is no symptom that she was in pain. Her 1st menses (Menarche) when she was 14 years old with normal menstrual cycle 28-30 days, duration was 4-5 days and heavy flow for 4 days.

Her normal flow is 2nd day every month, and her last period is 2nd July 2006, but when she has a Sexual Intercourse with her husband on 17th July, the next menses goes to 18th July and the next month the date is still on 18th August with heavy flow and not shows to be stop.

Mrs Aini went to medical check-up at private clinic in Alor Setar. Ultra sound was done by the doctor, and she was diagnosed as Intramural Uterine Fibroids. Then she was referred to Gynecology Clinic Hospital Pulau Pinang on 25th August 2006. Ultra sound was done again by Gyneacologist in Gynea Clinic and the finding is confirm Intramural Uterine Fibroids. Then, she was

decided for Total Abdominal Hysterectomy Bilateral Salphingo-Oopherectomy by Gynecologist on 7th September 2006.

1) Physical Examination and AssessmentResult of vital sign;

Blood pressure : 125/85mmHgPulse : 76bpmTemperature : 37.2oc

On Cardovascular system, there is no any abnormality found. No heart murmur detected and lungs also clear.

2) Medical HistoryNo post medical history, accept the heavy flow menses. No history of drug allergy. No history of recurrent ill and no cough and fever.

3) Surgical historyNo past surgical history.

4) Investigation Full Blood Count Blood Urea Serum Electrolite Random Blood Sugar Electrocardiogram 4 pint Whole Blood PT/APTT Group and Cross Matched

PREPARATION OF PATIENTPREOPERATIVE VISIT

The preoperative visit was usually done a day before operation day. The purpose is;

To gain rapport between patient and perioperative nurse.

To orientates patient about environment in operating department.

To orientates patient before and after operation. To allay fear and anxiety in patient and family

members. To develop a care plan for the patient who is brought

into the perioperative environment.

Before seeing the patient, the perioperative nurse usually review the patient case notes to get a correct assessment for the patient on the biological data, physical findings and the special therapy ordered by Doctors give to the patient.

Mrs Aini was admitted on 6th September 2006, perioperative visit was done on 7th September 2006 and she was scheduled for Total Abdominal Hysterectomy Bilateral Salphingo-Oopherectomy on 8th September 2006

The perioperstive nurse started the conversation by greeting Mdm Aini with a pleasant smile and introduced herself to Mdm Aini. She also explained the purpose of the visit. Mdm Aini was understood and she looked happy. The perioperative nurse asked the names. Age and where she lives. Mdm Aini answered the question nicely.

When the perioperative nurse asked why Mdm Aini admitted in the ward, she said that the doctor wanted to do the operation and to remove the uterus because she had uterine fibroid. She was not clear about the condition, but she hope, after the operation, her life getting well. Mdm Aini asked a lot of question about the operation and perioperative nurse refer to the doctor incharge and he answer as the best as possible.

Mdm Aini was orientated about the operation theatre environment, the member of the operation team includes the

perioperative nurse, interpret policies and routine such as scheduled time of the surgical procedure, view on set up of OR, reception and recovery. She also explained where the family can wait during operation.

The perioperative nurse explained to Mdm Aini that she will be received by the reception nurse at the reception counter and will be transferred to operating room stretcher which is clean ,to prevent contamination from outside to inside OR environment and will be send to holding bay. Mdm Aini was told about the air conditioning system which is cold and she is free to ask for the extra blanket from any other nurses there. She also was told about the OR staff attires were different from the ward staff which is their are wearing the OR attires with mask and caps.

Perioperative nurse explained to Mdm Aini the perioperative preparation such as;

Diagnostic test Full Blood Count Blood Urea Serum Electrolite Random Blood Sugar Group and Cross Match Electrocardiogram Chest X-ray

Remove any prosthesis such as contact lenses and denture, to

prevent airway obstruction. jewellery or hair pin for safety from diathermy burn.

Fasting starting 12 midnight on wards must be strictly followed to prevent possibilities of regurgitation which is could lead to aspiration into the lung during surgery.

Skin preparation was done preoperatively such having a good bath especially hair shampoo and cleaning of the operating site properly in the morning of the operation day.

Try to have a good night sleep.

Change the cloth to operation gown and cap when called by operation room nurse and will be send to OR with stretcher by ward staff.

The anesthesiologist visited Mdm Aini at the evening before operation day. The nurse in the ward prepared the Bed Head Ticket (BHT) together with all the investigation result. The anesthesiologist reviewed the past and the present medical record of Mdm Aini and tooks history by questioning allergies, adverse reaction to drugs, past anesthetic experience, smoking habit,genetic, metabolic problems and reaction to previous blood transfusion.

BLOOD INVESTIGATION

Full Blood Count Reference Range WBC 6.4 x 10 (3) / UL 5.2 - 12.4 x 10

(3) / UL RBC 5.1 x 10 (6) / UL 4.2 - 5.4 x 10

(6) / UL HGB 14.5g / dL 12.0 - 16.0g / dL PLT 327 x 10 (3) / UL 130 - 400 x 10 (3) / UL

Blood Urea Serum Electrolyte Reference Range

Sodium 139 mmol/L 135 - 145 mmol/L Potassium 3.7 mmol/L 3.5 - 5.0 mmol/L Urea 2.7 mmol/L 1.7 - 8.3 mmol/L Creatinine 70 mmol/L 57 - 130 mmol/L

Random Blood Sugar - 4.6 mmol/L

PT / APTT Prothrombin time Reference Range Prothrombin time 11.7 sec 11.5 - 13.5 sec INR 1.0 sec 0.8 - 1.2 sec APTT 29.9 sec 24.0 - 35.0 sec

Mdm Aini’s blood investigation, ECG and chest X-ray results were within normal range.

PREPARATION AND MAINTENANCE OF THE OR ENVIROMENT

Certain routine and maintenance procedure must be carried out to maintain a clean, safe OR for all our surgical patients.

Although most post-operative wound infections are related to endogenous bacteria, microorganisms from exogenous sources are also capable of producing post-operative wound infections.

It is quite impossible to completely eliminate all exogenous microorganisms from the operating room but directing environmental control measures to two specific sources can reduce their numbers :-

Contaminated air Operating Room surface

CLEANING

Operating room has many surfaces, which require dust removal as dust harbors microorganisms. Hard surface do not require treat with disinfectant, warm water with detergent is usually sufficient to remove all organism contamination.

The floor of the OR is a large, much used surface, it accumulates setting or floor traffic bacteria. Thus, it is important to ensure the floor be free from cracks and pits where soil might accumulate.

Good sanitation practices must be established in the OR to decrease or eliminate bacteria, there by preventing the transmission of pathogenic microorganisms to the patient.

Principles of cleaning the OR is from inner to outer of the room (clean to dirty) start from the OT light, sterile room, induction room and finally the sucker machine, diathermy machine and OT table. This was perform 1 hour before elective list begin.

ENVIRONMENT

Air and Dust Control Microorganisms are transported though the air and dust.

Preventive measure must be taken to control the dust in the OR by eliminating its sources.

Operating Room personnel must use event possible means to reduce lint dissemination and air violation by reducing / minimizing unnecessary and filters changed frequently.

Temperature of Operating Room Temperature of the OR should be maintained between 18 –

22 degrees Celsius. The ideally temperature is 21 degress Celsius. The air flow rate is 15-25per min always come from the ceiling and exit through the wall below either positive pressure of lamina flows.

Humidity The ideally humidity of the OR between 50% - 60%, if less

than 60% dry air leading to build up the static current and agent causing sparks to occur, if more than 60% moisture in the air may cause fungal infection.

VENTILATION

The operation room ventilation system must ensure a controlled supply of filtered air. Air changes and circulation provide fresh air and prevent accumulation of anesthetic gasses in the room.

Concentration of gasses is dependent solely on the proportion of pure air entering the air system to the air re-circulated though the system.

Air exchanges was between 20 to 30 per hour are recommended for room with re-circulated, a gas scavenger system is mandatory to prevent the built-up of waste anesthetic gasses. Various types of scavengers and evacuation are used to minimize air pollution’s that are health risk for team members.

Ultra clean laminar airflow is installed in some operation room. This high-flow unidirectional air-blowing system is housed in a

wall or ceiling enclosure. The value of this system in reducing airborne contamination is inconclusive.

Filtration though high-efficiency particular air (HEPA) filters can be 90% efficient in removing particles that are larger than 0.5 um. These microbial filters in ducts filter the air, practically eliminating all dust particles. The ventilating system in the operation rooms suite is separate from the hospital general system.

Positive air pressure (0.005 inch of water pressure) in each operation room greater than that in corridors, scrub areas and sub sterile rooms. Positive pressure forces air from the room, the inlet is at the ceiling. Air leaves though the outlets at floor level. Air is drawn into the room around the doors and through open doors. Microorganism in the air can enter the room unless positive pressure is maintained.

An air-conditioning system is Adele and valuable. It controls humidity, which helps to reduce the possibility of explosion. High relative humidity (weigh of water vapor present) should be maintained between 50% to 60%. Moisture provides a relatively conductive medium, allowing static charge to leak to earth as fast as it is generated, sparks from more readily in atmospheres of low humidity.

Room temperature is maintained within a range of 18 degress Celsius to 22 degress Celsius.

Even with controls of humidity and temperature, air conditioning units may be sources of microorganism that comes through the filters. These must be change at regular intervals. Ducts must be cleaned regularly.

PREPARATION OF OPERATING ROOM1. RECEPTION ROOM

Damp dusting Reception nurse must clean and damp dust all the

surface area and the horizontal area.

They should do cleaning to created a good environment also give therapeutic environment to the patient before they enter the operation department.

Check the equipment Check the functioning of the trolley to make sure that

trolley is safe to use as wheel can lock and both side rail is patent. Check the oxygen cylinder to make sure the amount of oxygen present is sufficient for use. Prepare the oxygen tubing and face mask at the trolley.

The perioperative nurse also prepares clean blankets and pillows to receive the patient and make sure there are enough for the day.

Check and make sure the documentation form, message book, blood book, and specimen are at the counter and also the call list.

The reception nurse calls the patients according to the operating list ½ hour before operation starts.

Reception nurse get enough personnel to transfer patient from ward trolley to operation room stretcher.

2. INDUCTION ROOM Damp dusting

The perioperative nurse damp dust the Induction room using warm water at all surface area and horizontal area.

The purpose performed damp dusting is to reduce microorganisms are stay that area. The cleaning suppose to do at early in the morning. Damp dusting should be performed before starting the case.

The anesthetist and the perioperative nurse should prepare all equipments needed and check the anesthetic machine and gas cylinder. The machine was assembling for use the correct circuit was fixed up and gases supply of nitrous oxide and oxygen was checked. Both cylinder must always be checked before use the machine.

~ suction apparatus was connected and tested ready for use.

~ intubation trolley prepared with :-

Figure 2

Endotracheal Tube (ETT) various size (depends to patients needed) and syringe 20cc for inflated the ETT cuff. Check the functioning example the cuff is not leaking. For female patients, size 7.0mm to 7.5mm are required.

2 Laryngoscopes in working order with secure light bulb.

2 differential size oropharyngeal airway various size of face mask McGill forceps and Endotracheal stylet

Lignocaine jelly to lubricate Endotracheal Tube, plasters to secure the ETT and gauze

Sterile water for irrigation for suction A selection tube connector Patient breathing circuit The head ring (donut) to stabilize the head

~ the intravenous infusion fluid and other line required like a :-

Warm intravenous drip solution and top up the solution in the warmer provided for later use

Artery line for monitoring any bleeding intra operation

CVP (Central Venous Pressure) for monitor dehydration

Monitoring devices such as ECG machine, pulse oxymeter and dynamicmachine.

Anesthetic nurse must check the anesthetic machine:-

Figure 3 The pipeline and cylinder, sources of oxygen and

compressed gases. The alarm system for the functioning. The breathing circuit system must be clean, dry and not

leaking and must be assemble correctly and use push and twist method to secure properly.

Ventilator alarm operates correctly for low airway pressure.

The vapouriser is full and refill when necessary, such as volatile agent – Sevoflurane and Isoflurane.

The anesthetic drug must be ready, such as injection:- Fentanyl

Norcuron

Propofol

Tracium

Morphine

Atropine

Labutolol

Thiopentom

In Mdm Aini case, she will be given Epidural anesthesia combine with General Anesthesia. A trolley for epidural anesthesia been prepared with epidural set:- Spinal set

Epidural set content :--Touchy needle

-Epidural catheter-Epidural bacterial filter-Loss of resistance syringe or 10cc syringe with normal saline

Local anesthetic agent – lignocaine 2% Epidural infusion solution – plain marcaine Povidone soulution / spirit Opsite spray Opsite dressing and hyperfix plaster.

OPERATION ROOM

Beside a clean operating room and suitable environment, there are also other things that are equally important in order to procedure a smooth operation. During the surgery, preparation and maintenance of the operating room environment safely very important to perioperative nurse and patients. This can prevent the exposure of perioperative nurse and patient to unknown organism transmitted through blood and body fluids.

All the horizontal surface must be wipe from dust starting from the overhead operating light, operation bed, mayo stand, trolley and all surfaces equipment using moist cloth of disinfectant solution. Disinfectant solution that been used is Germicep 0.5gm diluted with 8 liter. Mirror of the operating light or any mirror inside become gray. The floor also been mopped with Germicep by house keeping staff.

While waiting the operating room surface to dry, ventilation system of the operating room been checked to ensure a controlled supply of filtered air. A good air changes and circulating provides fresh air and prevent accumulation of anesthetic gases in the room and it has been recommended to have 20-30 air exchanges per hour for room with recirculated air.

Air condition controls the humidity which helps to reduce the possibility of the explosion. The ideal humidity level to archive minimal static and reduce microbial growth is between 50% - 60% and not less than 45%. It also to consequent ignition of any flammable solution or to objects used in the operating room. The operating room temperature is maintained at 18-22degrees Celcius.

All the equipment must be checked the functionql order before the surgery performed. This is to prevent any delay during the operation and for saving life purpose. The equipment to be used is operating table, light, sucker machine, diathermy machine and the GA machine should be checked.

PREPARATION OF OPERATING ROOM EQUIPMENT

LIGHTING.

A) Ceiling Light Most of room light are white fluorescent but may be incandescent. Lighting should be evenly distributed throughout the room. The anesthesia provider must have sufficient light, at least 200 foot candles, to adequately evaluate the patient’s color.

To minimize eye fatique, the ratio of intensity of general room lighting to that at the surgical site should not exceed 1:5, preferably 1:3. This contrast should be maintained in corridors and scrub areas, as well as in the room itself.

Color and hue of the light also should be consistent. All the ceiling light in the operating room must be checked by the perioperative team nurse for proper working prior to the operation

B) Operation Light

Figure 4 : Operating Light

The scrub nurse and circulating nurse should damp dust the operating before operating check the light for proper working including focusing, brightness

and any fused bulb. Bulb must be changed if found fused.

Illumination of the surgical site is dependent on the quality of light from an overhead sources and the reflection from the drapes and tissues, white glistering tissues need less light than dull, dark tissues. Light must be of such quality that the pathologic conditions are recognizable.

The overhead operating light must be:- Make an intense light, within a range of

2500 to 12,500 foot candles into the incision without glare on the surface. It must give controls to the dept and relationship of all anatomic structure. The light may be equipped with an intensity control.

Be shadow less.

Produce the blue white color of daylight.

Be freely adjustable to any position or angle by either a vertical or horizontal of motion.

Produce a minimum of heat to prevent injury and drying exposed tissues.

Be easy cleaned and maintained. Suspension mounted hacks or centrically mounted fixture must have smooth surfaces that are easily accessible cleaning.

OPERATING TABLE

Figure 5 : Operation Table

Modern operating table are designed to support and accommodate the various anatomic configurations required in surgical position.

They are electrically or battery operated with a manual back up.

Their height can be raised or lowered, tilt laterally and trandelenburg position.

They have roller wheels, which allow them to be easily moved , and brakes that can lock them in place.

The operating table are composed of a flat platform divided into 3 sections. The section is the head, body and foot section.

Each section has a corresponding removable mattress, which usually attaches to the main platform by Velcro or straps.

The joints of the operating table are referred to as breaks.

The side rails of table can accommodate multitude of attachments including stirrups, screens, arm boards and various retractors.

The operating table’s width is narrow to allow ease of access to the operative side.

Underneath the operating table platform is tunnel that runs under the entire body and legs sections to support x-ray cassettes.

The head section of the operating table can be flexed, lowered or removed. It is connected to the bed by two horizontal posts that fit into corresponding grooves in front of the body section.

The body section is attached to the base of the operating table. Since this section supports the heaviest part of the body, the chest, the abdomen and pelvis. This section also has a break in the centre at the hip level that can be flexed or lowered to allow the head and chest areas to be elevated or lowered.

The leg section of the operating table can be flexed or lowered to the extend that it folds deeply beneath the lumber section to allow leg room for sitting surgeon to gain access to the perineal area when the patient is in lithotomy position.

Check the functioning order of the operation table, as for this case, patient need to be put on trendelenburg position, the necessary equipment needed such as arm boards, padding, body stripes must be available.

Check that the operating table ‘gear system’ is functioning or the table winder is available. If the automatic control table used, check that the remote control was charged and ready for use. This is to provide smooth surgery.

ELECTRO SURGERY UNIT (DIATHERMY MACHINE)

Figure 6 : Electro Surgical Unit

To complete the electric circuit to coagulate or cut tissue current must flow from generator via an active dispersive electrode. Electro surgical is utilized to a greater or lesser extent in all surgical specialities.

The scrub nurse and circulating must be familiar with manufacturer’s detail manual of operating instruction for each type use.

Electro surgical unit or know as diathermy is common practice in the operating room is poses a conciderable degree of danger to patient, surgeons and the nurses, especially if there is lack of knowledge of the function of electro surgical unit and the principle behind it.

Electro surgery unit is a high frequency electric current producing machine consists of electro surgical generator. The generator consists of following:-

a. A cable to power source.

b. An ON / OFF switch to permit the power to flow through the electrode.

c. A switch or dial for selecting coagulation, cutting or blend dials to select the cutting or coagulation mood.

d. A receptacle for the dispersive electrode cable, the active electrode cable and foot control.

The active electrodes which commonly used now are the pregelled type dispersive pad, which can be moulded to thigh or calf.

Type of Electro Surgical Unit :-

A) Monopolar Diathermy.

- Only one pole is active and it carries current to operation site. It is dispersed over the dispersive electrode ( ground pad) and returned to Electro Surgical Unit via the dispersive electrode cable.

B) Bipolar Diathermy.

- Bipolar active electrode has a forceps configuration. The active electrode is in the inner side and the inactive is in outer side of the forcep. The current flows from the unit through the active side, arcs through the tissue to the inactive side and returns to the unit via the same cord.

SUCTION APPARATUS

Figure 7 : Suction Apparatus

Suction equipment is equipment used to aspirate fluids from body orifices or cavities with the application of negative pressure.

There are 2 types of suction apparatus portable system – run by electricity and can be

taken from place to place central pump unit – connected by a pipe line

system to operating suites

Parts of suction system a suction tip referred to as the sucker head or

catheter. The basic configuration includes the single hole, the ‘whistle tip’ and the multiple ends.

the sterile tubing connected to the sucker tip to use on the surgical procedure, suction tube connected to the bottle. Disposable tubing and disposable bottle recommended by universal precaution to reduce possibility of cross infection.

suction regulator to control the degree of vacuum calibrated in mmHg or CmH20.

bacterial filter to prevent cross infection from aspirated material is avoided and should be changed daily or when contaminated.

usage of suction in the operating room is during operative surgery, endoscope, anesthesia, resuscitation, suction curettage, smoke evacuation and suction lipectomy.

Two units suction apparatus should be available in operating room. One for anesthesiologist, to evaluate gastric content or secretion in the respiratory so that can maintains patient airways. Another one is to be used by surgeon in order to minimize the accumulation of blood, body fluids and indignation fluids in surgical wound

Routine maintains and inspection of suction apparatus are important duties of nurse to check good performance of suction.

Connect suction tubing to patient suction tube connection or inlet and the outlet is for the vacuum.The suction tubing is approximately 2 ½ to 3 yards long.

Clear tubing is recommended as it allows easy viewing of materials passing through it during suctioning.

Tubing must be good condition, without punctures and with a clean lumen.

The degree of suction required initially by compressing the tubing after switching on machine whilst setting the adjustable valve at the necessary position.

After used, suck water to rinse through to aid in cleaning the nozzle and tubing.

The collection bottle and tubing always be thoroughly cleaned and sterilized after used. The applies only to reuseable bottle and tubing.

Checked the functional order of the machine. Check the washer if there is leakage there will be no vacuum created. Check wall outlet for proper connected.

Avoid kinking or being compress the sucker tubing from wall to machine because they will increase pressure and this will weaken the power and later spoil.

Show the anesthetist the nature and amount of content.

SCRUB ROOM

Figure 8 : Scrub Room

Adequate scrubbing and hand washing facilities should be provided for all operating members.

The scrub room is adjacent to the OR for safety and convenience. Individually enclosed scrub sinks with automatic sensor control, foot, knee or elbow operated faucets were used to eliminate the hazards of contaminating the hands after use. The sink was deep and wide enough to prevent splashing. Scrub sinks should be used only for scrubbing or hand washing. They should not be used to clean or rinse contaminated instrument or equipment.

Sterile dispenser with reuseable sterile brushes was hung up. Each must be removed without contaminating the others. The brush must be soft enough not cause abrasion.

Various antimicrobial ( antiseptic ) detergents are used for surgical scrub. Scrub lotion such as hibiscrub or povidone iodine was used as the antimicrobial/ antiseptic agent due to its;

Effectiveness and broad spectrum property Fast and prolonged action Non – irritating and non – sensitizing Independent of cumulative action

A sterile gown cannot be donned over damp scrub attire without resultant contamination. Reuseable woven gowns may be particularly vulnerable to strike-through of moisture after repeated washing. The scrub room was prepared by the scrub and circulating nurse by starting with damp dusting the scrub room.

RECOVERY ROOM

Figure 9 : Recovery Room

Recovery nurse do the cleanliness the counter, the patient trolley, cabinets and equipment such as ECG machine, suction apparatus and pulse oxymeter.

The perioperative nurse washes the circuit tubings which are already used, change the water in oxygen humidifier bottle, oxygen tubing, suction tubing and suction bottle.

Recovery nurse also prepare the suction catheter and mask are various sizes each every section, checked the emergency trolley and make sure all the drugs and item are available for emergency.

Also indenting the lotion, anesthesia drug and DDA ( Dangerous Drug Acts).

PREPARATION OF OPERATION ROOM ATTIRE

Introduction of Operation Room Attire All operating room personnel were requires to changed the street clothes to proper operating room attire when entering the operative suite.

The purpose of wearing the operating room attire is to provide the effectives barrier that prevent dissemination of these microorganism to patients and protects personnel from blood and body substances of patients. before perfomed the procedure are ready with clean and neat OR attire.

OR attire consist of body covers such as two piece pantsuits, cap, mask and shoes including the shoes cover. Personal Protective Equipment such as eyewear, gloves and aprons and also a part of OR attire. this is to prevent sources of external contamination to the patient. Proper attire is a part of aseptic environmental control that also protect personnel against exposure to communicable disease and hazardous materials.

OR attire should not be worn outside the OR department or outdoors. Before leaving the OR department, everyone should change the street clothes.

OR personnel should remove all jewellery including rings, watches and chain before entering the Operation Theatre. Microorganism may harbored under the rings thus preventing effective hand washing. The necklace or chain can grate on the skin increasing tesquanation it can fall into wound or contaminate a sterile field.

COMPONENTS OF APPROPRIATE OPERATING ROOM ATTIRE

Figure 10

~ each of attire is means for contaiment of on protection against

and potential sources of environment contamination including skin, hair and nasopharyngeal flora and microorganism in air, blood and body fluids.

HEAD COVER / CAP

Figure 11

Hair is a gross contaminant, so that a cap is put on before changing the cloth to the OR attire in the semirestricted area (changing room). The caps meets same safety requirement as the scrub suit and should donned before scrub to prevent the shedding the bacteria from the hair to the OR attire.

All hair surfaces must be covered including sideburns. The cap should be clean, lint free and completely covers all head. Head cover should be freshly laundered daily. Persons with scalp infection should not entering the operating room.

BODY COVER

Figure 12

Everyone dons attire intended for use within a semirestricted or restricted area such as two piece pantsuits. All should fit the body snugly for comfort and appearance. Pantsuits confine organisms shed from the perineal region and legs effectively.

Shirt and waistline drawstrings are tuck inside pants to avoid their touching sterile areas. The scrub suit should be changed as soon as possible whenever becomes wet or visibly soiled.

OR personnel must worn a clean freshly laundered pantsuit everyday. The sleeves should be short enough to perform a proper hand scrub and also prevent the sleeves from becoming wet during the scrub. When pants are donned, they should not allowed to touch the floor, since dust and bacteria can contaminate team.

SHOES

Shoes should be cover the toes and soles. A good pair of shoes should provide support and protection for feet, easy to clean, well padded and not slippery. Shoes should be comfortable, supportive and closed in all sides to minimize fatigue and for personnel safety. Sandal or clog type shoes are hazardous in the operating room because they may slip off or cause a fall if a person most move quickly, shoes must be wash and dry regularly when dirties and also it must be put on before enter semirestricted area.

PERSONAL PROTECTIVE EQUIPMENT

Personnel should be protected from hazardous condition in the semirestricted and restricted areas.protective attire does not allow blood or other potentially injurious materials to reach the inner clothing, skin or eyes.

1. Aprons A decontamination apron worn over the scrub

suit to protect against liquids and cleaning agent during cleaning procedure. It should be full front barrier. Fluid proof aprons worn by sterile gown when extensive blood cores or irrigation is anticipated.

Leads aprons worn under sterile gowns protect against radiation exposure during procedures performed under fluoroscopy or image intensification or when personnel are exposed to radioactive implants.

2. Eyewear Eyewear or face shield is worn whenever a risk

exists of bleeding or body substances from the patient splashing into the eyes of sterile team members. A combination surgical mask with a visor eye shield or a chin-length face shield is another option. Care is taken that the lower edge of the face shield does not touch the front of the gown.

3. Gloves Nonsterile latex or vinyl gloves are worn to

handle any material or items contaminated by blood and body substances. Gloves are never washed between patients contact, they are discarded. Clean or sterile item should not be handled with contaminated gloves.

Sterile gloves are worn by sterile team members for all invasive procedures. Sterile gloves are packaged impairs with an averted cuff on each to

protect the outside of the sterile glove during donning.

4. Mask Mask is worn in the restricted area to contain and

filter droplets containing microorganisms expelled from the mouth and nasopharynx during breathing, talking, sneezing and coughing.

Mask filter about 99% of particulate matter larger than 5mm in diameter but only about 45% to 60% of particles 0.3mm in diameter.

The mask should be cover the nose and mouth completely and it must be tie securely at the back of the head for upper string and behind the neck for lower string and pinched to confirm the nose to provide a secure proper fix.

Mask never left hanging around the neck, place it top of the cap or put it in the pocket for future use. It must be removed and discard when wet and for every patient and handle it to the ties only. After discard the mask, the personnel must wash and dry the hands thoroughly.

RECEIVEING PATIENT ~ RESPONSIBILITIES

BEFORE Called ward staff for send patient to the Operation Room by

charting the name of the ward staff and time of calling. In this case, Mdm Aini was numbered as number 3 in the operating list. So that, reception nurse was called patient at 10am.

While waiting patient arrive to OR, the perioperative nurse check the stretcher whether it is functioning good such as it can be locked or unlocked. To prevent patient from fall from the trolley which is can be a hazardous to the patient.

The perioperative nurse prepared the pillow and the blanket for covering patient from cold.

DURING When the patient arrives, the perioperative nurse greeted

and welcomed patient with the pleasant smile. The perioperative nurse introduced herself and also give the

gently touch to Mdm Aini to creat a good rapport and allay her fear and anxiety.

She asked the full name Mdm Aini, age and identity card number and compared the information with the consent form and operating list to make sure that the correct patient.

The perioperative nurse checked the consent for the signature, the date for validity, the type of the operation and site clearly written on the consent. The patient giving consent must be legal age and mentally competent and signed consent is legally regarded as valid not more than 14 days. It is to protect the patient from ungratified and unwanted procedure and to protect the surgeon and hospital or facility from claims of an unauthorized operation or other invasive procedure.

The perioperative nurse asked Mdm Aini when she takes the last meal and drink. The patient should ingest nothing by mouth 6 to 8 hours before the operation to prevent regurgitation or emesis and aspiration of gastric contents during or after intubation.

The perioperative nurse asked the patient about the jewelleries and prosthesis or implant to prevent possible burn because of electro surgical unit will be used and the denture to prevent obstructed airway.

The perioperative nurse also confirming the investigation result, ECG chart, X-ray film and availability of blood, with the ward staff.

The perioperative nurse makes sure the patient was completely wearing OT attire, which is clean OT gown and cap.

The patient was transferred to a clean trolley and change to a clean pillow and blanket to avoid contamination from outside to inside OR. During transfer the patient, perioperative nurse make sure the intravenous infusion not dislodge. Place patient’s arms, legs and head in canvas.

One personnel must be at the other side of the trolley to receive patient and transfer patient slowly, gently, smoothly and simultaneously to provide safety.

AFTER Perioperative nurse securely the side rails in place to prevent

patient from fall and injured. Check the intravenous infusion and it was functioning well

and no redness or swollen at the puncture site and put the intravenous infusion on drip stand.

The vital sign was checked by perioperative nurse such as blood pressure, pulse rate and temperature before sending Mdm Aini to OR for database during anesthetized.

The perioperative nurse sent the patient to the waiting bay. Patient was observed the anxiety level by perioperative

nurse and make sure patient is in comfortable and provide a safe and quiet environment at the waiting bay.

Figure 13 : Reception Area

INDUCTION OF PATIENTAfter Mdm Aini wheeled to the induction room, the anesthetist nurse applied the blood pressure cuff at the right arm to monitor the blood pressure for database before, during and post anesthesia for the patient undergoing anesthetized. Intravenous line with Hartman’s solutionwas set up at the left arm.

The anesthetist performs scrubbing, gowning and gloving. Then anesthetist nurse and the circulating nurse put the patient in the sitting position. The spine is flexed with chin lowered to sternum, arms crossed and hold the pillow.

After positioning the patient, the anesthetist nurse help the anesthetist give the Epidural with:-

Opened the outer layer of the spinal set. Pour the 10% povidone iodine to the patient skin for

antiseptics purpose. Opened the:-

- Epidural set. - syringe 5cc & 10cc - Lignocaine 2% for local anesthesia

Figure 14

EPIDURAL ANESTHESIAThe Epidural space is a part of the human spine inside the spinal canal separated from the spinal cord and its surrounding cerebrospinal fluids by the dura mater.

Figure 15

Epidural is often short for Epidural anesthesia, a form of regional anesthesia involving injection of drugs through a catheter placed into the epidural spaced. The injection can cause loss of feeling and loss of pain (analgesia).

Common local anesthetics include lidocaine, bupivicaine, ropivicaine and chloroprocaine. Common apoids are fentanyl and pethidine. These are then injected in relatively small doses.

Using a strict aseptic technique a small volume of local anesthetic, such as 1% lignocaine, is injected into the skin and interspinous ligament. A 16, 17 or 18 gauge touhy needle is then inserted into the interspinous ligament and a “loss of resistance” technique is used to identify the epidural space.

Traditionally anesthetists have used either air or saline for identifying the epidural space. After placement of the tip of the touhy needle into the epidural space the catheter is threaded through the needle.

The needle is then removed. Generally the catheter is then withdrawn slightly so that 4-6 cm remains in the epidural space.

The anesthetist performed scrubbing, gowning and gloving then arrange the spinal. The anesthetist nurse assist the Doctor with open the epidural set.

Figure 16

The Anesthetist painted the Mdm Aini’s back at the area where the Epidural will be given with povidone iodine 10% to reduce the number of microorganisms and remove the dirt, residue at the skin.

Then the Anesthetic drape the area with a fenestrated drape which only expose the lumbar puncture site.

The Anesthetist palpate the iliac crest to felt the level of the L4 vetebra and mark it. He give the intradermal local anesthesia lignicaine 1% about 3mls exactly the chosen interspace to reduce the pain while touhy needles inserted.

Figure 16

The anesthetist inserts the 18 gauge touhy needles about 1-1.5cm into the epidural space between L3-L4. the anesthetist push in the air via the needle using the loss of resistance syringe and no resistance seen.

Figure 17

The Anesthetist confirm that the correct space, he push the percutaneous indwelling catheter until 5cm mark and connect the catheter to the bacterial filter.

Figure 18

The anesthetist nurse spray with opsite spray at the puncture site and secure with a small opsite dressing. Then the catheter was secure with a plaster.

Figure 19

The anesthetist clears the things and removed all the drapes. Then the anesthetist nurse ask Mdm Aini to lay down and wheeled Mdm Aini into the operating room.

GENERAL ANESTHESIA

Mdm Aini was transferred to the operating table. The anesthetist nurse and the circulating nurse put Mdm Aini in the supine position and was make sure that Mdm Aini are comfortable.

The anesthetist nurse applied the ECG lead and the pulse oxymeter to monitor the heart rate and oxygen level in blood circulation. She was also put the doughnut for support the patient head.

The Anesthetist was request ETT tube size 7 for intubation. The anesthetist nurse lubricates the tip till the cuff part of the Ett with K-Y jelly for easy to intubate.

Mdm Aini was preoxgenated with 100% of 10 liters oxygen via face mask. The patient was instructed to breath deeply. This is to provide a margin safety in event of airway obstruction of apnea during intubations.

The anesthetist was induced analgesic injection Fentanyl 50mg via intravenous administration, followed by an induction agent as Sodium Thiopentone 200mg to put patient to sleep.

Then, the muscle relaxant agent short acting, Suxamethonium 50mg was given which act about 5-10 minutes. The Anesthetist hold the face mask and bagging the reservoir bag to give patient 100% oxygen because patient cannot breath herself.

When fasculation had occurred, the anesthetist was intubated Mdm Aini with ETT size 7. The Anesthetist nurse was inflated the cuff with a 10cc of air.

The anesthetist auscultated the patient to make sure the ETT was properly placed by listening the air entry both lung. The anesthetist nurse was anchored the ETT at the 19cm marked by a plaster and the anesthetist connect to the GA machine.

The anesthesia was maintained with used the Nitrous Oxide 2 liter per minutes, oxygen 1.5 liter per minutes. Long acting

muscle relaxant injection Atracurium 10mg every 30-45 minutes was given via intravenous administration.

The anesthetist and the nurse had a close observation of the monitor screen and record the observation every 5 minutes. They also checked the intravenous infusion was flowing well and top up as required.

PREPARATION OF STERILE TEAM MEMBERS

SCRUBBING, GOWNING AND GLOVING1) Scrubbing

The purpose of scrubbing is to reduce the bacterial to an absolute minimum to prevent from multiplying during the operation.

Before scrubbing, the scrub nurse must be completely attired – wearing the operating room attire with hair covered by cap and mask covering the nose and mouth.

Figure 20

The recommended method is the counted brush stroke method following the anatomical pattern of hand and arms

The hands and arms are divided anatomically into sections and equal number of strokes. This method is to ensure that each area are covered during the procedure.

Hand washing step;- 1) Initial scrub

Remove any jewelry or watch on hands and wrists.

Wet hands and forearms. Dispense surgical

Wet both hands and forearms up to 2 inches above the elbow.

Rinse the hands and arms thoroughly under running water with hand upwards allowing water to drip from the flexed elbow.

2) Surgical Scrub

Pick a sterile brush from the dispenser.

Dispense the small amount of chemical agent on the brush.

Brush a nail of both hands applying 10 brush strokes. Rinse nails of both hands and brush.

Dispense a small amount of chemical

agent on brush and brush all sides of each finger, the web of the fingers 10 strokes.

The palm of the hand – 10 strokes

The back of the hands – 10strokes

The four planes of the applying 10 brush strokes to each plane up to 2 inches above elbow.

Scrub the elbow 2 inches about 10 strokes

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Rinse the brush, the hands and the arms up to 2 inches above the elbow thoroughly from under running water to drip from the flexed elbow. Discard brush. Repeat for other hands

and arms.

3) Hygienic hand washing

Dispense an antiseptic agent on the palm

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Apply the antiseptic agent using friction palm to palm.

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Right palm over the left dorsum and left palm over the right dorsum

Backs of fingers to opposing palms with fingers interlocked.

Rotational rubbing of right thumb clasped in left palm and vice versa.

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64

Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa.

Rotational rubbing of right wrist and vice versa. Rinse and dry thoroughly.

Rinse the hands and arms thoroughly under running water with hand upwards allowing water to drip from the flexed elbow.

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After scrubbing, the hands must be kept higher then the elbow to allow water to flow from clean area.

It is important that splashing be avoided because wet scrub attire will contaminate the sterile gown when it is donned and can be a strike through.

2) GowningPURPOSE

The sterile gown are worn to Exclude the skin as a possible contaminant. Create the barrier between the sterile and non-sterile area. Prevent microorganisms from the hands and clothing of the

surgical team being transferred to the wound.

The package of the sterile gown was opened by circulator nurse without touching any sterile area of the sterile package.

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Then, the scrub nurse will open the second layer of the package which is sterile.

The scrub nurse reach down to pick up the towel without contaminate the gown.

After scrubbing, the scrub nurse’s hands and arms must be thoroughly dried before wearing the sterile gown. This is to prevent contamination of sterile by organism from the skin and the scrub attire.

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Open towel full length, holding one end away non-sterile scrub attire. Bend slightly forward to avoid towel touching attire.

To dry the arm – hold the towel in the opposite hand and using an oscillating motion or the arm, draw the towel up to elbow. Then, repeat the same motion to the other hand using the unused end of the towel.

All gown are folded and packaged for sterilization with the inside exposed so that the scrub nurse and the surgeon may handle the gown without contaminating the outside of the gown.

Grasp the inside of the gown and lift the gown away from the table.

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Unfold the gown by placing the hands at the neck edge.

Locate the arms holes. Slips the arm carefully with the eyes follow when the hands slip into the sleeve to avoid touching the unsterile area. Do not thrust hands through the cuffs.

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Circulator pulls the back of the gown and ties the gown strings from the back.

The circulator passed the sterile glove to the scrub nurse without touching inner layer of the sterile glove.

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Place the right glove on the right palm. Thumb of the glove over the thumb and the finger of the glove facing towards wearer.

Grasp a bit the glove cuff with the thumb, stretch over the end of sleeves with hand within the sleeve. Work fingers into the glove.

Cover the cuff of the sleeve with the cuff of the glove.

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Repeat the same technique to the left hand.

Sterile person always keeps hands in sight, above waist level to prevent contamination to sterile gown and gloves.

The perioperative nurse ready for laying out the instrument and assisting the operation.

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Gown are considered sterile 2” from neck line to waist line and 2” above the elbow and below

PREPARERATION OF INSTRUMENT TROLLEY AND MAYO’S STAND.

The circulating nurse open the outer layer of the sterile pack instrument pack. She lifts the wrapper back while keeping hands on the outside. Hands is in folded cuff to avoid contaminating the inner layer of the pack.

Then, the scrub nurse open the inner layer of the pack. Touch the inner layer and drapes the trolley as necessary according to standard procedure.

In this procedure, the nurse use 3 trolleys including the Mayo stand for layout the General set and Total Abdominal Hysterectomy Extra.

The scrub nurse drape the Mayo stand. Both the frame and the tray are draped.

Figure 21

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The Mayo stand cover is like a pillowcase. It is transfolded with a wide cuff to protect gloved hands. With hands in cuff, fold the drape are supported on the arms, in bend of the elbows to prevent its falling below wrist level.

Figure 22

While sliding cover on, place foot on base of stand to stabilize it.

The scrub nurse count sponges, sharps items and instruments with circulating nurse according to the list.

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GENERAL SET

Figure 23 : General Set

BIL ITEM QUANTITY1. Instrument Tray 12. Kidney Dish 33. Gallipot 44. Backhaus towel clip 85. Sponge holder 46. Scssor’s:-

Mayo’s straight 14cm and 17cm Mayo’s curved 15cm Metzenbaum curved

211

7. B/P Handle - size 4- size 5

21

8. 1st Mayo’ pin:- Halstead Delicate Artery Forceps Crile Artery Forceps

88

9. 2nd Mayo’ pin:- Babcock tissue forceps Allis tissue forceps Littlewood tissue forceps Duvals tissue forceps Spencer well artery forceps,straight Needle holder Yaunker sucker Pool sucker Sucker tubing – long

222223111

10. Dissecting forceps:-

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Mc Indoe Gillies Medium toothed Medium non toothed Waugh toothed Waugh non toothed

111111

11. Retractor:- Small Langenback Medium Langenback Morris

1 Pair1 Pair1Pair

12. Mc Donald Dissector 113. Dennis Brown 114. Raytex gauze – 10 pieces per bundle 2 bundles

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TOTAL ABDOMINAL HYSTERECTOMY EXTRAS SET

Figure 24 : TAH extra

BIL ITEMS QUANTITY1. Instruments tray 12. Deavers retractor 23. Scissors :-

Mayo uterine Straight 9”

11

4. Dissecting forceps:- Toothed Non toothed

11

5. Mayo’ pin :- Kocher curved tissue forceps Kocher straight tissue Littlewood tissue forceps Teale vulsellum forceps

6662

6. Balfour Abdominal Retractor with centre blade

1

7. Gynae pad 1

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LAYOUT OF THE INTRUMENT The scrub nurse arrange the instruments and accessory

items on mayo stand and instrument trolley. The circulating nurse open the packages of sterile supplies such as diathermy flex with pin, light handle, sutures and blade.

She flip the blade packet from over wrap into the kidney dish, then she opened the light handle packages and diathermy pin. Scrub nurse take contents from wrapped open and avoid touch the unsterile outer wrapper.

Figure 25 : Layout instrument on the instrument trolley

The scrub nurse put the blades on the bard parker handle using spencer well never use finger alone. Holding the cutting edge down and away from eyes or anybody. Grasp the blade at its widest, strongest part, and slip the blade into groove on the knife handle.

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Figure 26 : Layout the instrument on the Mayo stand

A click indicates the blade is in the place. To prevent damage the blade, the instrument must not touch the cutting edge. The scrub nurse fix the diathermy pin.

The circulating nurse pour the povidone iodine 10% into the gallipot for skin preparation. The scrub nurse put 3 pieces of the gauze into the gallipot without touching the solution because the solution is not sterile and the glove can be contaminate.the scrub nurse ready for arrival of the surgeon.

The surgeon request for a catheter to insert the CBD to Mdm Aini. The circulating nurse prepare the set for the catheterization.

The circulating nurse open the outer layer of the catheterization set, then the scrub nurse open the inner layer of the set.

Circulating nurse pour the Hibitine in Aques, water and K-Y jelley. She also gives the catheter size 18FR and syringe 10cc for syringe out the water. Then, she assist in any way possible.

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After catheterization is over, Mdm Aini was put back on supine position.

The scrub nurse put the inactive plate at the Right thigh muscle. It should be as closed as possible to site of incision to minimize current through the body.

The plate should cover as large of patient’s skin as possible in an area free of hair, scar tissue, which tend to act as insulation.

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Figure 27

RESPONSIBILITIES AND THE SAFE OPERATION OF ELECTRO SURGICAL UNIT ( ESU )

Responsibilities Before.

a. The perioparative nurse must have knowledge to use and maintain the Electro Surgical Unit.

b. Must know which Electro Surgical Unit is to be used and how to use it. Read and follow instruction manual.

c. Only used equipment that is designed and approved for unit.

d. Check the functioning order of the ESU for any damage or with missing parts e.g. broken plugs, missing part, dials, frayed cracked cable and the power point is working.

e. Check the generator , on generator and check to ensure the alarm systems are working. This is to prevent diathermy burns

f. The dial, turn to ‘ 0 ‘ before switch on the unit.

g. Used the correct dispersive pad according to patient’s weight and size, make sure there is enough gel to ensure good contact. Do not cut, dispersive pad to ensure safety.

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h. Check the area applying the dispersive pad is dry, avoid bony protuberance, skin folds, scar tissues, excessively fatty or hairy areas, to be x-ray or skin lesion. All this to ensure good skin contact.

i. Avoid place dispersive pad at the sites where fluids might pool.

j. Apply the dispersive pad after positioning patient to prevent dislodges and get the dispersive pad is dry.

k. Check and ensure no skin surface is touching any metal parts of the table and its accessories to prevent diathermy burn.

l. Fixed up the active electrode and turn the unit on and set the dials, start at very low setting and slowly increase.

m. Inform surgeon of the dial setting.

n. Do not learn the generator and place heavy objects or solution on top to ensure safety.

Responsibilities During.

a. Position all cable or wires so that they do not present a tripping hazard. Do not wheel equipment over the cords.

b. Check and ensure the active electrode tip is firmly secured.

c. Keep the active electrode clean at all times during surgery. Escher build-up increases resistance, reduce performance and require higher settings.

d. Keep the electrode separate from all conductors on the sterile field.

e. An unused active electrode should be place in a protective sheath or pocket because the electrode can be activated accidentally and so burns the patient or medical personnel.

Responsibilities After.

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a. Disconnect the unit, turn the dial to ‘0’ and turn the power switch OFF.

b. Disconnect the cable from the active electrode by grasping the plug not the cable to prevent damage to the cable.

c. Remove the dispersive pad gently, support the skin and peel the dispersive pad slowly to remove it.

d. Check the site of dispersive pad for any redness or burn. Clean the skin to remove all gel.

e. Document in the swab count form the site dispersive pad applied and condition of the skin.

f. Coil the cable or wire loosely to prevent kink.

Wipe all the equipment with damp cloth to maintain cleanliness.

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POSITIONING OF THE PATIENT FOR SURGERY

After obtaining permission from the anesthetist, Mdm Aini was positioned to supine. In this position Mdm Aini lay flat on the back with the head and spine in a horizontal line, do not cross touching each other legs.

The head supported by a medium donut to prevent stretching of neck muscles that supported the head. Arm were placed on the padded arm board and positioned less than 90 degree angle to prevent injury to brachial nerve. The arms were placed supine (palm up) to prevent ulnar nerve compression.

Proper body alignment was carefully giving attention to prevent muscles strengthening. The patient was not disturbed by being moved or touched until the permission was granted by the anesthetist.

The anesthetic (L) screen was attached at the head end of the table so that during draping the head ring of the patient was not covered and this allowed the anesthetist to check and observe the patient throughout the surgery.

Anesthetist nurse applied warming blanket at the upper chest area to keep patient warm and to prevent hypothermia and temperature also generally cool in operation room to reduce mortifications of microorganisms. To reduce the potential of compression or electric burn, no part of patient’s naked body allowed contacting with metal surfaces.

The door of the operating room were kept in close at all time except as needed for passage of personnel. Traffic in and out of the operating room was kept to a minimum.

Activity increase air turbulence which carries bacteria to wound. Therefore, movement in operating room was reduced to minimum.

Personnel with acute infection such as upper respiratory infection or skin lesion were excluded from the operating room.

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PAINTING PROCEDURE Povidone iodine 10% was used for painting because its act

as an antiseptic agent, which leave a residue on the skin to inhibit the growth of microorganisms.

After the scrub nurse passes the sponges and povidone iodine 10% to the surgeon, the circulating nurse fold back the blanket and patient’s gown 2inches beyond limits of prep area.

The surgeon wet the sponge with antiseptic agent and squeeze out excess solution and start the painting.

The painting starting at side of incision, with a circular motion to periphery, with uses enough pressure and friction to remove dirt and microorganisms from skin pores. The surgeon discard sponge after reaching the periphery and repeat painting with a separate sponge for each round.

Painting was commenced at the incision site and is extended away from the centre. One swab used for each cleansing round. Painting is done from breast line to upper third pf thigh including pubic area. The objective is to remove microorganisms, dirty and oil from the skin and create an antiseptic field for the incision to prevent infection intra operatively and post operatively. After painting sponge holder and gallipot would be discarded.

Figure 28

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DRAPING PROCEDURE

After the surgeon painting the patient, the scrub nurse ready to assist in draping and the circulating nurse ready to wacth for breaks in technique.

If the drape contaminated or expose of a non sterile area might be source of an infection for the patient. For this operation, square drape are used.

Draping technique was performed by two sterile persons. The drape was place around the operative site to expose only the operation site.

The scrub nurse hand, one end of fan folded sterile towel across table to surgeon, and one hand to the assistant and they holding it tent until it is opened, then lay it down on the below site incision.

The scrub nurse never touch the surgeon hand glove because it may be contaminated to povidone during painting.

Drapes were held high enough to avoid touching non sterile area below and the operating light above.

Gloved hands were protected from any contamination by cuffing end of sterile folded towel over them and the hand was stretched out to hand the drape to the surgeon on the opposite side.

Below incision site must covered with 2 layer and follow to drape the upper incision site.

After that, the scrub nurse give the towel, one for the surgeon, one for the assistant to drape the side of the incision by fold ¾ and secure it with towel clips.

Repeat the same to cover the below and upper site of incision. After draping, the scrub nurse put the extra towel below incision site to practice SEPTIC TOWEL TECHNIQUE to maintain the sterile field by avoid the spillage from vagina

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vault and attach the suction tubing and diathermy cord along with the flex pin to drape and secure with towel clip.

Ample length was allowed to reach both incision area and the machine. One sterile towel cover the coil of tables and diathermy pin pointed away from the incision site to ensure safety to the scrub nurse.

The scrub nurse bring the Mayo stand into position over patient and makes sure that it does not rest on the patient and position the instrument trolley at a right angle to operating table.

The circulating nurse in moving Mayo stand and instrument trolley into position, being carefully not to touch drapes.

The circulating nurse connect the suction and diathermy cable and the scrub nurse checked the functioning order of the equipments.

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POSITIONING OF OPERATING TEAM1

2 3

4

5

7 6

8

910

1114

13

12

16 15 15

Figure 29

1. GA MACHINE2. WARMING MACHINE3. GA DOCTOR4. OPERATING TABLE5. DRAPE PATEINT 6. 1ST ASSISTANT7. SURGEON8. 2ND ASSISTANT9. MAYO’S TABLE10. 1ST SCRUB NURSE11. INSTRUMENT TROLLEY12. 2ND SCRUB NURSE13. DIATHERMY MACHINE14. SUCTION APPARATUS15. KICK BUCKET-CLINICAL

WASTE16. KICK BUCKET-GENERAL

WASTE

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ANATOMY AND PHYSIOLOGY OF THE FEMALE REPRODUCTIVE SYSTEM.

Figure 30 ; Location of the uterus

THE UTERUSThe uterus is a hollow, flattened, muscular, pear-

shaped organ which lies in the true pelvis above the vagina, receiving the insertions of the two fallopian tubes into its upper and outer angles. It lies in the pelvic cavity between the urinary bladder and the rectum in an anteverted anteflexed position.

Anteverted – means that the uterus leans forward

Anteflexion – means that it is bent forward almost at right angles to the vagina with its anterior surface resting on the urinary bladder. As the bladder fills the degree of anteflexion is reduced slightly. When the body is in the upright position the uterus lies in an almost horizontal position.

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It measures 3 inches (7.6cm) in length, 2 inches (5.1cm) in width at its widest part and 1 inch (2.5cm) in depth, whilst its walls are ½ inch (1.3cm) in thickness. The uterine cavity is therefore 2 ½ inches (6.4cm) long. The uterus weight about two ounces (56g). It consist of the following parts:

The body ~ is the main part which comprises the upper two-thirds of the uterus. It is narrowest inferiorly at the internal os where it is continuous with the cervix.

The fundus ~ is the dome-shaped part of the uterus above the opening of the uterine tubes, which is the portion of the body of the uterus lying between the insertions of two fallopian tubes.

The cervix ~ protrudes through the anterior wall of the vagina, opening into it at the external os.

The walls of the uterus are composed of three layers of tissue; Endometrium Myometrium Perimetrium

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Figure 29

THE ENDOMETRIUM This is the mucous membrane which lines the interior of the

uterus. The mucosa of the uterine body differs markedly from that of the cervical canal. It is composed of columnar epithelium and contains many straight tubular glands. The thickness of this layer varies during the monthly menstrual cycle. The upper two-third of the cervical canal is lined with mucous membrane. The lower third is lined with squamous epithelium, continuous with that of the vagina.

THE PERIMETRIUMThe perimetrium consists of peritoneum. It covers the fundus

and the anterior sutface to the internal os, and is then reflected on to the bladder forming a small pouch between the uterus and the bladder, termed as uterovesical pouch. The posterior surface is covered to where the cervix protrudes into the vagina and is then reflected on to the rectum forming the rectouterine pouch. Laterally the perimetrium extends over the uterine tubes forming a double fold, the broad ligament leaving the lateral border of the body uncovered.

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THE MYOMETRIUM The myometrium is a thick muscle layer composed of

bundles of smooth muscle fibres arrange in 3 interlacing layers. The inner layer of fibres runs in a circular fashion. The middle layer of fibres runs obliquely. The outer layer of fibres runs in a longitudinal fashion.

Figure 31

THE FALLOPIAN TUBESThese are two small tubes, each about 4 inches (10.1cm)

long and one –quarter of an inch (6mm) in diameter, which are attached to the cornua of the uterus. They pass laterally from the uterus across the pelvis almost to reach its side walls, where they turn backwards and downwards towards the ovaries.

The tubes posses a lumen which communicates with the cavity of the uterus medially and which opens into the peritoneal cavity laterally.

The female genital tract is thus an open pathway which leads from the exterior to the peritoneal cavity via the vulva, vagina, uterus and fallopian tubes.

The tubes are attached medially to the uterus, and as they pass transversely across the pelvis they carry with them the peritoneum. This is draped across them forming a fold which

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passes down to the pelvic floor below, so constituting the broad ligaments.

Where the lateral extremities of the tubes bend backwards, the peritoneum is continued as folds to the side walls of the pelvis, producing what are known as the infundibulo-pelvic ligaments.

It can thus be appreciated that these are peritoneal structures and not true ligaments, although they do accord some means of support both to the Fallopian tubes and ovaries. They also transmit the ovarian vessels, lymphatics and nerves.

THE OVARIESThe ovary is an organ whose structure and function vary at

different ages of the individual. The ovaries are two small almond-shaped bodies, dull white in colour and corrugated on the surface, measuring 3cm in length, 2cm in breadth and 1cm in thickness and weighing about 6 grammes. They are attached to the posterior layer of the broad ligament, and lies inside the peritoneal cavity. They sometimes rest in a small depression in the parietal peritoneum on the lateral wall of the pelvis below the bifurcation of the common iliac artery, which is known as the ovarian fossa of Waldeyer. The lateral portion of the Fallopian tube arches over the ovary and end in close proximity to it, being connected to it by the fimbria ovarica. When the uterus is retroverted the ovaries may lie in Pouch of Douglas.

The place of attachment of the ovary to the posterior layer of the broad ligament is known as the mesovarium, and the part of the broad ligament extending above this point to the Fallopian tube is called the mesosalpinx.

This attachment however is too weak to support the ovary, which is suspended from the uterine cornu by the ovarian ligament. As described above this is a strong structure, containing smooth muscle, through the medial margin of the mesovarium.

Similarly the lateral pole of the ovary is suppoted by the infundibulo-pelvic ligament, which has already been described as a fold of peritoneum running to the side wall of the pelvis and transmitting the ovarian vessels, lymphatics and nerves.

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THE CERVIXThe cervix of the uterus tapers below the body and its lower

end is clasped tapers of the vagina into which it protrudes. Its thus has vaginal (lower) and supravaginal (upper) parts.

The latter like the body of the uterus having intestinal and vesical surfaces. The intestinal surface is covered by peritoneum that contenoues from the body on the upper part of the fornix, forming the anterior wall of the recto uterine Pouch of Douglas.

The body of the uterus is rarely exactly in the midline, when deviated to one side the cervix becomes deflected to the opposite side, so one ureter may be closer to the cervix than the other.

The canal of the cervix is continuous with the cavity of the body at what is commonly called the internal os. The lower opening into vagina is the external os.

THE VAGINAThe vagina is thin-walled, 8cm fibromuscular tube extending

from the vestibule obliquely backward and upward to the uterus, where the cervix project into the top of the anterior wall.

The vagina is elastic and capable of distention during intercourse and parturition. The bladder lies anteriorly to it. The rectum lies posteriorly to it. It is lined with mucous membrane and contains glands that procedure a cleansing acid secretion.

The anterior vaginal wall is shorter than the posterior wall. The upper third of the posterior wall is covered by peritoneum reflected onto the rectum. Normally the anterior and posterior walls relax and are in contact.

The vault (dome, or upper part of the vagina) is divided into four fornices. The anterior fornix, in front of the cervix, is adjacent to the base of the bladder and distal ends of the ureters.

The pouch of Douglas directly behind the larger posterior fornix lies behind the cervix.

This pouch separates the back of the uterus from the rectum, anteriorly by the uterine peritoneal covering, which continues down

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to cap the posterior vaginal fornix and posteriorly by the anterior wall of the rectum. Lateral uterosacral ligaments embrace the lower third of the rectum.

The lateral fornices lie on either side of the cervix, in contact with anterior and posterior sheets of the broad ligaments surrounding the uterus.

Proximal structures are the uterine artery, ureters, fallopian tubes, ovaries and sigmoid colon.

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SUPPORT OF THE UTERUS

Figure 32

The uterus is supported in the pelvic cavity by the surrounding organs muscles of the pelvic floor and ligaments that suspend it from the walls of the pelvis. The supporting structures is;

THE TWO BROAD LIGAMENTSAlthough these are mentioned here for the sake of completeness, it must be clearly understood that they are not consederations of pelvis fascia, but are, intead, folds of peritoneum passing laterally from the uterus to the side walls of the pelvis. They are not true ligaments in any way, and are more fully described later.

The uterus and pelvic cellular tissue lie in the pelvis above the levator ani muscles, which form a platform to support them in their normal positions. When these muscles relax, as during defaecation, the ligaments act

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as direct supports of the uterus, the most important in this way being the cardinal ligaments.

THE TWO ROUND LIGAMENTSBegin at the cornua of the uterus, pass downwards, forwards and outwards within the broad ligaments, and then cross the lateral parts of the pelvic floor to reach the internal inguinal ligaments in the anterior abdominal wall. They then turn medially around the deep epigastric vessels and enter the inguinal canals in the groins. They traverse the canals, emerge through the external rings in the oblique muscles, and end in the fatty tissue of the labia majora.

These ligaments are of embryological interest, for they mark the route along which the testes descend in the male, in whom the scrotum corresponds to the fused labia majora.

THE TWO CARDINAL LIGAMENTS Also known as the transverse cervical ligaments and Mackenrodt’s ligament, run in a radiating of the manner from the lateral aspect of the cervix below the level of the internal os and the lateral fornices of the vagina to the side walls of the pelvis, where they are attached to the fascia overlying the obturator internus muscles. The ureters on their way to the bladder pass through these ligaments, lying in what are known as the ureteric canals.

THE TWO UTERO-SACRAL LIGAMENTSPass from the cervix in an upward and backward direction, and encircle the rectum to become attached to the periosteum of the sacrum.

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BLOOD SUPPLY

Figure 33

The main blood supply to the uterus is from the uterine arteries which are branches of the internal iliac arteries. They run up the lateral borders of the uterus and anastomose with the ovarian arteries just below the level of the uterine tube.

The blood vessls run a tortuous course twisting in and out through the muscle fibres. There is a plexus of veins which lies between the layers of the broad ligament and which drains blood from the uterus into the uterine and ovarian veins.

LYMPHATICS DRAINAGEThe main lymphatic drainage is through the deep and superficial iliac glands.

NERVE SUPPLYThe nerve supply is through the sympathetic and parasympathetic nerves. The sympathetic nerves are derived from the hypogastric plexus and the parasympathetic from the first, second and third sacral nerves.

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OPERATION PROCEDURE

Figure 34

When the scrub nurse ready for assisting the surgery, the scrub nurse give the surgeon one gauze to wipe off the povidone iodine from incision site and surgeon will discard the gauze into the clinical waste receptacle.

The scrub nurse passed the blade size 23 in the kidney dish to surgeon to make skin incision to avoid accidentally cut. The blade were put at the edge of the trolley because the skin is not sterile and the blade consider contaminated. Then the scrub nurse give two gauze one for the surgeon, one for the assistant.

The surgeon made a Pfeannenstiel skin incision. The first cut should extent well into the subcutaneous layer, these

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were then separated with the knife down to the rectus sheath.

Figure 35

At the same time, the circulator documented the operating time start into the Swab Count Form.

Figure 36

Small vessel in the subcutaneous layer bleed and surgeon diathermized using dissecting forcep.

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Figure 37

The full depth of the fat was incised down to rectus sheath but only in about the central 3 or 4 cm of the skin wound this is done with one stroke of the scaple with the left hand steadying in the wound area so that there is no sideways slip.

Figure 38

The rectus sheath is cut transversely, exposing the rectus and the paramidalis muscle.

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Figure 39

Freeing anterior rectus sheath from underlying muscles. The sheath is release in an upwards direction with mayo scissor cuts as shown and the recti muscles fall back from the raise sheath.

Figure 40

The rectus muscles are cut transversely. The deep epigastric vessels are ligated and cut. Transversalis fascia is exposed. The assistant use the 1/2 “ langenback to exposed it.

The transversalis and peritoneum are cut transversely. Care was taken at the lower end of the wound to be sure that the gut or bladder was not injuired.

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The taut fold was palpated between forefinger and thumb before incision to exclude the presence of underlying structures.

Figure 41

When the peritoneal cavity was opened, scrub nurse take all the loose gauze away and removed from the operation site. Swab on stick and abdominal pack was used instead.

Once the uterus was identified, the Balfour Retractor was used to ensure adequate exposure and scrub nurse gave 2 warm saline abdominal pack to surgeon to pack of the guts thus gave better exposure to work on the uterus. The abdominal pack were marked with crile artery forceps that clamped at the tape attached. This is to ensure the correct count.

Then the surgeon ask the anesthetist and inform the circulator to put the patient in trendelenburg position to provide better visualization of the pelvic cavity. At the same time circulating nurse and scrub nurse make sure that Mayo tray not touch patient’s leg and patient in good body alignment.

The scrub nurse watch operation field and try to anticipate the surgeon’s needs. She must be one step a head of the surgeon in passing the instrument, sutures and sponges. The scrub nurse passes the instrument in a decisive and

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positive manner. The tip is visible, hands is free. Handle was placed directly into surgeon palm.

Figure 42

Figure 43 Kocher Curved and Straight

The surgeon elevate the uterus, then the scrub nurse gave 2 curved kocker artery forceps one by one with handle placed firmly and directly into surgeon hand. The kocker forcep is to clamp the round ligament near uterine cornu and followed by the mayo curved scissor to cut . The scrub nurse passed the safil 1 Taper Cut Needle to ligate a short distal lateral to the clamp. Assistant ready to cut suture with suture cutting scissors. One end of the suture was held with the crile artery forceps while the other strand was cut. This was done one

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side at a time. Curved kocker artery forceps was then handed to assistant, thus opening up the anterior leaf of the broad ligament. While passing the instrument scrub nurse hold the instrument by hinge.

Figure 44

The forcep on the uterine remnant of the ligament were left there which allow a means of traction to exposure. The posterior leaf of the broad ligament was pushed forward through the opening of the anterior leaf with the surgeon. It was then incised with metzenbaum scissors to create opening.

To removed the tube and ovary the infundibulo pelvic ligament was clamp with curved kocker artery forcep on the ovarian side and lateral side with one more curve kocker artery forcep. Then the scrub nurse give curved mayo scissor to cut the ligament. The same was done to the other side. The ligament were transfixed with Safil 1 suture.

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Figure 45

While assisting, the scrub nurse still do the same thing such as give the instrument to the surgeon with the handle was placed into surgeon palm firmly, maintain the aseptic technique and keep talking to a minimum to avoid contamination.

Figure 46

The anterior utero vesical fold was incised using the metzenbaum scissor aided by waught non toothed dissecting forceps. Holding the peritoneum covering the bladder with the dissecting forceps the curved scissor are used to separate the bladder off the front of the lower uterus and cervix in direction of the arrow. Surgeon do not favour the

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method of using a gauze on finger or swab on the stick to push the bladder down, because it is liable to result in tearing of weak bladder wall.

The uterine arteries running close to the uterus along its lateral wall was clamp with curved kocker forceps, then cut with Mayo scissor and transfixed with Safil 1 suture.

The circulating nurse give the suture and the scrub nurse take the suture pocket opened and held by circulating nurse. The scrub nurse clips the neelde – needle holder and gives to surgeon. The surgeon suturing the stump using suture and tie technique.

Figure 47

The cardinal ligaments or the transverse cervical ligament was now clamped, cut and sutured with Safil suture. This was done by placing the straight kocker artery forceps parallel to the cervix, squeezing the paracervical tissue off the cervix to give the most lateral room and protection to the uterus. Since the blood supply had been controlled a single clamp suffices and the incision was made. The same was done for the other side.

Once the opening of the vaginal vault was made, Septic Towel Technique was practiced. This was to prevent contamination of spillage to other surrounding tissue and

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organs in the peritoneal cavity and also soiling of sterile drapes and other instruments.

After the surgeon had identify the vagina and make sure the bladder was mobilized from the cervix and vagina, a knife was plunged into the anterior fornix. The vaginal vault was incised and

Figure 48 Uterine scissors

cut with uterine scissor. Littlewood tissue forceps were applied on the edges of the vaginal vault one at a time while the surgeon continued to cut the vaginal vault until the uterus was removed.

Figure 49

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Figure 50 : Littlewood

Scrub nurse get ready to receive the specimen together with the forceps attached and put on top of sterile towel placed earlier. This is to avoid contamination to the sterile area.

The circulating nurse put on the glove and get ready to receive the specimen. The scrub nurse confirmed with the surgeon type of specimen gives it to the circulating nurse, avoiding from touching the circulating nurse’s glove hand.

Figure 51

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Prior to the closure of the vaginal vault, blades, sutures and swab were counted by the scrub nurse with the circulating nurse to confirm the correct number.

Figure 52

The vaginal vault was sutured with Vicryl 1 suture. The corner of the vaginal vault were tied off with the cardinals and round ligaments to give support.

Figure 53

The instrument used on the vaginal vault were considered contaminated. They were littlewoods forcep, toothed dissecting

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forcep, uterine scissors, knife, needle holder, suture scissor, yaunker sucker and sutures.

They were all receive in the kidney dish and when the vaginal vault was closed, scrub nurse wrap the kidney dish with the towel that put earlier and gave to the circulating nurse who were ready to receive the things. The circulating nurse lay out the instrument on the floor for counting purpose.

The surgeon checked for bleeding points and diathermized using dissecting forcep. Before close the peritoneum, patient was put back in supine position.

Two abdominal pack put earlier in the peritoneum cavity was taken out. Balfour self retaining retractor also removed.

Then, the scrub nurse start to counting the sponges, atraumatics needles and instrument with the circulating nurse. All the sponges, needles and instrument count were found correct and the surgeon was noted and he acknowledged the scrub nurse.

The circulating nurse bring the swab count form during the counting and documented immediately.

The surgeon request for the drainage tube. The scrub nurse put the blade size 23 in the kidney dish and pass it to the surgeon to make the incision at the right abdomen to insert size D portex drain with 3 holes and put back the blade into the kidney dish to prevent injury during passing the blade either to the surgeon or scrub nurse. The surgeon used Fraser Kelly Artery Forcep to pull the drainage tube outside the abdomen. The drainage tube was anchored with Silk 2/0 Cutting Needle by assistant.

4 crile artery forcep were used to hold the rectus sheath during closing the peritoneum. The surgeon used Safil 1 Taper Cutting Needle to close the peritoneum and assistant wait with suture cutting scissor in the hand for cutting. Then, surgeon used the Safil 1 for closing the rectus sheath.

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Figure 54

The scrub nurse start to count gauze, abdominal pack, needles, sharp instrument and all instruments that uses during operation side to mayo tray, instrument trolley and finally on the floor with the circulating nurse. The count must be tally with the Swab Count Form. It to avoid any of them left inside patient and injured her.

Before closed the skin, the scrub nurse perform the final count with the circulating nurse and documented in the Swab Count Form assure that swabs , needles and instrument used were correct.

The surgeon used the Monosyn 3/0 to closed the skin. During skin closure, key hole opsite dressing was prepared to put on the drain site. At the same time, scrub nurse dissemble blade from B/P handle. Discard the blade into adhesive pack, then put sharp instrument in the kidney dish.

After skin closure had finished, the scrub nurse get ready 2 pieces of gauze, 1 gauze soaked with normal saline and 1 gauze dry. The scrub nurse put the soaked gauze into the incision, roll it up from one side to a side. Then scrub nurse protect the wound with the dry gauze. The soaked gauze was used to clean the surrouding area around the incision and followed by dry gauze.

The scrub nurse applied the dressing at the wound and key hole at the drain site and plastered with hyperfix dressing. The portex drain was connected to a urine bag. After applying the dressing, the scrub nurse took the towel clips

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from the drapes. The nurse removed the drapes with roll it to prevent sparking and air borne contamination and put into the linen bag.

The circulating nurse switch off the operating light, suction apparatus and diathermy machine. She disconnected the sucker tubing and removed the inactive dispersive plate. The nurse checked the sign and symptom of burn at the skin where the inactive dispersive plate was placed and the skin looked normal.

The scrub nurse push away the Mayo stand and the instrument trolley from the operating table. The scrub nurse wet the extra gauze for removing the excess povidone iodine 10% from skin patient. The circulating nurse cover the patient with warmed blanket to provide hypothermia and avoid unnecessary expose the patient.

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PRINCIPLE OF COLLECTING AND FIXING SPECIMEN

Collecting and fixing specimen is responsibilities by the circulating nurse.

Before the case was start, the circulating nurse get ready the correct size of specimen container to fix the specimen. The correct size is must be able to contain the specimen with the fixative agent 10-20 times volume of specimen.

Figure 55

Get ready the fixative agent to used – 10% formaline in saline, to make sure the specimen was fresh and light can penetrate through.

Get ready the correct specimen form and label. Label the patient’s full name, R/N, I/C No, ward follow the admission form.

During the procedure, while the specimen was out, the circulating nurse get ready to receive the specimen with wearing the Personnel Protective Equipment such as mask,

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gloves and goggles to prevent spillage to the eyes and contamination.

Figure 56

Then the circulating nurse confirmed the nature of the specimen with the scrub nurse and as the surgeon whether the surgeon want to cut or not or get the permission from the surgeon to fix the specimen immediately to prevent autolysis, decomposition and putrefaction. This is to obtain correct pathology result.

After that the circulating nurse put the specimen into the container and pour the formaldehyde until the specimen immerse or the volume is 10 – 20 times of the specimen.

After fix the specimen, disinfect the surrounding container along with the cover with swab spirit 70% for safety handling and to prevent contamination.

The label must applied at the side of the container not on the cover, this is to prevent mistake.

Put the container in biohazard plastic bag to prevent cross infection.

After operation finished, circulating nurse along with the scrub nurse checked the HPE form filled correctly and tally with the label at the container and make sure Doctor has sign.

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Lastly circulating nurse documented the specimen in swab count form and recorded in the specimen dispatch book before sent to Pathology Department.

CONCEPT OF CONFINE AND CONTAIN Confine and contain princip was originally introduced to

perioperative nurse in earlier 1970. this principles recommended that personnel restricted all patient micros to an area of 3 feet around the patient and that when the patient leave that limited area they should be either confined to all impervious container to be destroyed. Establishment of procedure to implement this principle prevent the transfer of micros and protects patients and personnel.

After operation was over, the circulating nurse put all soiled sponges bloodied waste and disposable items in the appropriate impervious bag and tie it. Then she put it into an impervious receptacle to prevent contamination.

Figure 57

Kick bucket is normally design to practice confine and contain with for easy movement in the theatre. It is consist of a wheel frame and a basin in it. The basins is line with a biohazard impervious plastic bag with a cuff turned over the edge and create a drain to receive the soiled sponges during surgery and it should be thoroughly tie up before discarded after every case to prevent contamination.

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Effective sanitation technique is should be established to control and reduce the possibility of cross infection of patient in the OR. Blood and tissue fluids from any patient may contain microorganism. That is pathogenic to other persons. OR structure should be developed to provide complete isolation from each patient. This isolation is accomplished by considering surgical wound to be potentially contaminated.

The scrub nurse put the blades, atraumatic needles that were used into an appropriate rigid, puncture proof container to prevent injury and contamination.

Figure 58

All the clinical waste was put in the sluice room and hospital support service worker will removed it for destroyed.

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REVERSAL OF PATIENT The anesthetist was turned off the Isoflorane and

Nitrous Oxide at the last skin stiches. He was off the ventilator and disconnected the circuit and do manual bagging until gag reflux seen. Then the reversal was given injection Neostigmine 2-5mgm and proceeds by injection Atropine 1mgm. The Neostigmine can cause bradycardia and increase the secretion. The atropine was given to minimize side effect of the Neostigmine.

The anesthetist nurse carried out the suction and the anesthetist called the patient’s name. When the patient opened her eyes and breathe spontaneously, the anesthetist nurse deflated the cuff and the anesthetist removed the tube. The patient was given 100% oxygen via face mask and oral airway was put in her mouth to prevent airway obstruction.

Before transfer the patient GA nurse check and make sure the oxygen cylinder under the OR stretcher is full with oxygen. When her vital were stable, oxygen saturation was good, the monitoring attachments were removed. The patient was transferred to the OT stretcher. Before transferring, the stretcher was locked. Head, both hands and both legs of patient were within the canvas to prevent injury. GA nurse, scrub nurse and circulating nurse will help to assist in transfer the Mdm Aini to OT stretcher. They transfer Mdm Aini gently, smoothly and simultaneously.

Check again patient’s both hands and legs is tug under the blanket before wheeled the patient to the recovery to prevent crush injury to pateint’s hands or legs. GA nurse passed over the patient to the recovery nurse and inform patient’s name, type of surgery done and type of anesthesia. Inform any problem that had been occurred in the OR eg difficulties during intubation.

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CLEANING AND CHECKING OF INSTRUMENT

After sent Mdm Aini to the recovery room, the scrub nurse come back in the operating room. She must clean all the instrument was used and circulating nurse was helping her.

The scrub nurse collect the instruments from mayo stand and instrument trolley. She separates the sharp instrument to avoid injury during cleaning. She also opens the all hinged instruments to expose box locks and secretion.

The instrument was brought into the sluice room for cleaning. The scrub nurse rinse the instruments with warm water to removed the dried blood and debris.

After rinsing, the scrub nurse count and arrange the instruments as they placed in the tray, together with circulating nurse. The instruments count must tally with the instrument list.

The scrub nurse wrap the tray and put it outside the sluice room and attendant from TSSU will take the sets for cleaning before sterilization.

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REMOVAL OF GOWN AND GLOVES At the end of the procedure, used gown are untied and

removed. The gown is always removed inside out to protect the arms and scrub suit from the contaminated outside of the gown. The gown is removed as followed:-

Figure 59

Grasp the left shoulder with the right hand and pull the gown downward from the shoulder and off the left arm, turning the sleeve inside out.

Figure 60 Turn the outside of the gown away from the body with

flexed elbows.

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Figure 61

Grasp the right shoulder with the left hands and remove gown entirely. Fold the gown inside out.

Figure 62 Pulling it off inside out. And put it directly in the linen

receptacle. The gloves are also removed inside out, using technique

of dirty to dirty and clean to clean. The cuff of the gloves usually turn sown as the gown is pulled

off the arms. A glove to glove, then technique is used to protect

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the clean hands from the contaminated outside of the glove. The glove is removed as followed:-

Grasp the cuff of the left glove with the glove fingers of the right hand and pull it inside out.

Figure 63

Slip the ungloved fingers of the left hand under the cuff of the right glove and slip it off inside out.

Figure64

Discard the gloves in the trash receptacle and wash hands.

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PREPARATION OF OPERATION ROOM FOR THE NEXT PATIENT

The cleaning procedures described provided adequatede decontamination and terminal sterilization after any surgical procedure. With a well coordinated team, minimal turnover time between surgical procedures can be accomplished; in an average time of 15 to 20 minutes, the room will be ready for next patient. The turnover time includes cleaning up after one procedure and setting up for the next procedure.

Additional equipment brought into the room and should be damp-dusted before sterile supplies are opened for the next case. After the patient leaves, the circulating nurse is free to assist with clean up of the room. Environmental service personnel may also be available to assist with cleaning.

Clean but not sterile gloves are worn to complete the room clean up. The scrub nurse changed gloves after the sterile field is dismantled. Decontamination of the environment includes the following:-

FURNITUREWash horizontal surfaces of all tables and equipment, including the anesthesia machine, with a disinfectant solution or warm water according to hospital policy.

OVERHEAD OPERATING LIGHTWipe overhead light reflectors with a clean cloth that has been damp with warm water or disinfectant solution. Commercial reflector cleaner prevent clouding of the surface than can cause dullness and glare.

ANESTHESIA EQUIPMENTAll reusable anesthesia masks and tubing are cleaned and sterilized before reusing. Some of this equipment can be steam sterilized; if not, it may be sterilized by EO gas and aerated before reuse. If the method is not available, items should be chemically sterilized according to the sterilant manufacturer’s recommendations.

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LAUNDRYAfter all cleaning procedures have been completed, discard cleaning clots or put in a laundry bag if they are not disposable. To help protect laundry personnel, an alginate bag that dissolves in hot water may be used as the primary laundry bag or as a liner within a cloth bag. Transport reusable woven fabrics soiled with blood or body fluids in leak-proof bags.

TRASH OR WASTECollect all trash in a plastic or impervious bag, including disposable drapes and kick bucket and wastebasket liners. Trash can be separated into infections waste, noninfectious trash and recyclable items. Separate receptacles should be available.

WALLSIf wall are splashed with blood or organic debris during the surgical procedure, wash those areas. Otherwise, walls are not be washed between surgical procedures.

FLOORClean a perimeter of several feet in circumference of the

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POST OPERATIVE CARE IN RECOVERY Recovery room is the place provide maximal care of patients

immediately following their operations. It is evolved to meet a need for constant observation of patients within facilities equipped for specialized care until recover from anesthesia.

When Mdm Aini arrived in the recovery room, the anesthetist nurse passed over the case to the recovery nurse. The anesthetist nurse informed that Mdm Aini was given General Anesthesia combined Epidural Anesthesia and was undergo the Total Abdominal Hysterectomy Bilateral Salphingo-Oophorectomy.

The recovery nurse give oxygen 6 liter/perminute via facemask and apply the monitor devices such as ECG lead, blood pressure cuff and pulse oxymeter. After that cover Mdm Aini with warming blanket to prevent from hypothermia.

The recovery nurse observes the monitoring and charts the vital sign at the GA form every 10 minutes. Assure that intravenous infusion in functioning well, the infusion pump was connected by the anesthetist to the Epidural line, observe dressing site for bleeding, make sure that drainage tube not kinking and flowing well and monitor urine output. She also observe for level of consciousness by calling MdmAini’s name, listen for any bubling or gagling sound, if got recovery nurse will do the suction to clear the airwayand observe the color of the patient for pale, cyanosed or dusky.

After Mdm Aini’s vital sign and general condition are stable and orientated, the anesthesiologist score the patient according to the GA form. Mdm Aini was discharge from recovery room after 45 minutes.

The recovery nurse call the ward staff C20 to take Mdm Aini back to the ward. After 15 minutes, the ward staff came and the recovery nurse passesover the patient. The nurse make sure Mdm Aini is safe during transferring to ward stretcher. At the same time ward staff check the dressing, drainage tube, CBD, intravenous infusion and the vital sign chart. After satisfied with patient condition, ward staff wheeled the patient to the ward.

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POST OPERATIVE VISIT In the ward, Mdm aini was put in the acute cubicle for closed

observation. She was on Epidural infusion ( Bupivacaine 0.1% + Fentanyl 2mg/min) 5mls perhour. When the perioperative nurse visits her after 5 hour post operation, she was alert but slightly dizziness and weak. She was able to move both lower limb and no any other complaint except slightly pain at the operative site.

Mdm Aini ‘s post operative care was carried out by the ward staff as it was ordered by the surgeon in the operation notes as followed:-

Keep nil by mouth until review. Intravenous drip 5 pint for 24 hours (2 pint Dextrose 5%

and 3 pint Normal Saline) Epidural as planned by anesthetist SC heparin 5000ǜ BD till ambulating well Strict I/O , pad and drain chart. Vital sign monitoring every 5 minutes for 2 hours, then ½

hours for 2 hours then hourly monitoring the blood pressure and pulse rate.

Wound inspection Day 3 Hb Day 2

Post Op Day 1 Mdm Aini was looked well. Her vital sign was stable. Blood pressure 100/60mmHg,

Pulse 60/min Patient complaint of nausea/ vomiting – I/V Maxolone 10mg

TDS was given ordered by Doctor. She complaint of slightly pain at the operative site. APS still

continue at 5mls / hour. Drain bag - 100cc( Haemoserous fluids)

She was allowed to take nourishing fluids. IVDrip was off but the branula was kept insitu.

CBD still insituPerioperative nurse advise MdmAini to encourage early ambulation for better and fast recovery.

Post Op Day 2

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Mdm Aini was looked comfortable and starting to walk to the toilet. Her vital sign was stable and she was allowed to take high protein diet.

Her APS was still kept as she still complaint pain over the operative site. Doctor was ordered C. Tramadol 50mg TDS for the pain.

Drain tube and CBD was off. FBC was taken according the order from the Doctor.Perioperative nurse advised Mdm Aini to do deep breathing exercise .

Post Op Day 3 Wound inspection was done and no sign of inflammation

seen. Patient was tell to inspect her wound herself and observe for sign and symptom of infection such as redness and purity and avoid to lift heavy thing or ruff cough to prevent wound gaping.

APS was off as she can tolerate with the pain.

Post Op Day 4 Mdm aini was discharge and was given the follow up gynae

appointment on 9/10/2006 in Gynae Clinic Hospital Pulau Pinang at 8am.

Medication was supllied by the Doctor as required. Perioperative nurse give health education to Mdm aini such

as:- ~ avoid stair climbing for at least 1 month

~ avoid lifting heavy thing more than 4.5kg to 9kg ~ encourage walking ~ consume food that aid healing tissue such as high in protein, iron and vitamin C~ try to calm down when the sign and symptom of menopause such as mood swinging, night sweat and hot flashes.

Follow Up Day Mdm Aini was looked confident and the wound was found

healthy. The HPE result shown that no sign of malignancy. She was given Hormone Replacement Therapy by Doctor

and also the next appointment on the next 6/52.

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NURSING PROCESS1

NURSINGDIAGNOSIS

OBJECTIVES INTERVENTION EVALUATION

Fear and Anxiety related to the surgery and prognosis

To make patient discus fears and anxiety

To make patient talk realistically of future

1.Encourage patient to talk and ask question and give time to listen during preoperative visit2.Involved family in discussion where appropriate but allows patients privacy when needed.3. Give explanations of all procedure doing for patient such as Branula insertion, CBD insertion, transfer and transporting and General Anesthesia and Epidural Anesthesia.4. Provide information related to post surgical treatment regimen.5. Allow patient and family to ask question6. Encourage family to give emotional support to patient7. Explian to patient the operation team will be around to help her8. Carry out the preoperative visit.

The patient looks more confident

Family and patient able to recognize their fears

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2NURSINGDIAGNOSIS

OBJECTIVES INTERVENTION EVALUATION

Potential for infection due to surgical interuption of skin intergrity

Infection will not occurBody temperature maintain at 37 degress celcius.

1.Assess for allergies before skin prep2.Notice the presence of any skin rashes, bruises, laceration, acchymoses and record them3.Knowledgeable and conscientious observence of aseptic technique should be shown by all theatre personnel.4. Entry of personnel into the operating theatre is restricted5. Regulation regarding the clothing to be worn in the operating room to avoid possible transmission of organism by steert cloth.6. Bedding from the ward is not brought into the theatre

No sign of infection

Wound heal without complication

Body temperature maintain 36.5 – 37.4 degress celcius

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3NURSINGDIAGNOSIS

OBJECTIVES INTERVENTION EVALUATION

Pain related to surgical procedure.

Patient will experience less pain and more comfortable.

1.Monitor the patient for the presence of pain assessment aids in proper management

2.Encourage relaxion and slow breathing technique to minimize pain.

3.Use non pharmacological method of relieving discomfort such as back rubs, or push up the head bed or change the position it is because this technique can reduce the pain

Patient states that the pain is reduce and she was comfortable

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4NURSINGDIAGNOSIS

OBJECTIVES INTERVENTION EVALUATION

Mobility is impaired as a result of surgery, decreased energy and presence of drainage tube

The patient will demonstrate intact skin with no areas of redness or oedema.

Ability to move about freely

Ambulation progressively increases over the first few days post operatively

1. Assist patient to perform deep breathing exercise and encourage compliance with programmed initiated by the physiotherapist

2.Change the patient position every 2-4 hours while she cannot move. Assess condition of skin regularly to prevent wound break down.

3.Encourage early mobilization gently increase activities from sitting on side of the bed to walking and sitting in a chair.

4. Observe incision and drainage tube sites for signs of redness, tenderness, swelling and drainage during each dressing changed.

Early ambulation promotes respiratory and circulatory function and helps prevent complications

Movement reduces stasis and vascular pooling in leg.

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5NURSINGDIAGNOSIS

OBJECTIVES INTERVENTION EVALUATION

Hypothermia related to room temperature, skin exposure and an open wound.

The patient’s temperature will maintain between 36.8-37 degrees Celcius

1. Provide the patient with a blanket prior to induction of anesthesia to avoid the patient from cool

2. Put the warming mattress under the patient during operation.

3. Ensure that normal saline for irrigation iswarm to provide the vasodilatations

4. Cover patient with warm blanket after operation finish till to the recovery to avoid from cool and shivering

5. Put the patient under radiant heater in the recovery room to warm the patient

Patient will be free from hypothermia and injury related to heat loss.

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BIBLIOGRAPHY1. Atkinson L.J.(2000), Berry And Kohn’s Operating Room Technique (9th ed.)St.Louis:Mosby Year Book Incorpotion.

2. David H.L & Albert S (1978) Abdominal Operations For Benign Conditions (2nd ed.) London: Wolfe Medical Publications Ltd

3. Huth, M., & Meecker. (1999). Care of Patient in Surgery. (7th ed) U.S:Mosby Year Book.

4. John A.R&Howard W.J (2003) Te’ Linde’s Operative Gynaecology (9th ed.) Philadelphia: Lippincott William & Wilkins.

5. Jordan K (1994)Atlas of Regional Anesthesia (2nd ed.) USA: Appleton&Lange

6. Phillips Fortunato N.(2004) Berry & Kohn’s Operating Room Technique (10th ed.) Mosby INC.

7. Ross J.S & Wilson K.L.W. (1973) Faundations of Anatomy & Phisiology (4th ed.) Edinburg: Churchill Livingstone.

8. Smeltzer, S.C., &Bare, G.B. (2000). Textbook Of Medical Surgical Nursing. (9th ed).New York:Lippincott Williams and Wilkins Com.

9. Susan S. Fairchild (1999), Peri Operative Nursing Principles And Practice (2nd ed). London:Little,Brown And Company.

10. Wilson K.J.W. (1992), Anatomy And Physiology In Health And Illness (7th ed). Edinburg:Churchill Livingstone.

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