Final Output of o.r. Technique

8/3/2019 Final Output of o.r. Technique

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Scrubbing, Gowning and arranging instruments

1. Define the following terms:

1.1 Pre-operative Nursing

1.1.1 Pre-operative Phase

1.1.2 Intra-operative Phase

1.1.3 Post-operative Phase

1.2 Analgesia

1.3 Anesthesia

1.4 Antiseptic

1.5 Asepsis

1.6 Consent

1.7 Disinfection

1.8 Homeostasis

1.9 Medical Asepsis

1.10 Resident Bacteria

1.11 Sterile

1.12 Sterilization

1.14 Surgery

1.15 Surgical Asepsis

1.16 Surgical Conscience

1.17 Surgically clean

1.18 Transient bacteria

2. Discuss the operating room as to its:


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2.1 Personnel

2.1.1 Sterile

2.1.2 Unsterile

2.2 Physical lay-out

2.3 Attire

2.3.1 Components

2.3.2 Steps in donning operating room attire

2.3.3 Importance of wearing attire

2.4 Set-up (Equipment and apparatus)

3. Recognize the importance of the following:

3.1 Scientific Principles involved

3.2 Basic rules of surgical asepsis

3.3 Duties and responsibilities of scrub and circulating nurse

4. Familiarize the following:

4.1 Basic instruments fundamental in basic set

4.1.1 Clamping and occluding

4.1.2 Cutting and dissecting

4.1.3 Grasping and holding

4.1.4 Exposing and retracting

4.1.5 Suturing and stapling

4.1.6 Viewing

4.1.7 Suctioning and aspirating

4.1.8 Dilating and probing

4.1.9 Measuring

4.2 Major pack and minor pack


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4.3 Sites for skin preparation

4.4 Operative position

5. Discuss the following:

5.1 Classification of survey according to

5.1.1 Major/ Minor

5.1.2 Purpose

5.1.3 Category of surgery based on urgency

5.2 Common surgical complications

5.3 Different layers of the abdomen

5.4 Common abdominal incisions

5.5 Different types of:

5.5.1 Suture

5.5.2 Suture needle

5.5.3 Blades

5.6 Sterilization Procedure

5.6.1 Types

5.6.2 Advantages and disadvantages

5.7 Operative checklist needed during surgery

5.7.1 Pre-operative checklist

5.7.2 Consent forms

5.7.3 WHO operative checklist

5.7.4 Other checklist for specific operations

6. Show beginning skills in:

6.1 Filling up the consent form: pre-operative checklist

6.2 Opening the sterile pack


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6.3 Packing and sterilization

6.4 Perform the following operating room technique

6.4.1 Medical handwashing

6.4.2 Surgical handwashing

6.4.3 Draping

6.4.4 Serving instruments

6.4.5 Assisting in the operation

6.4.6 Circulating

Definition of terms:

Pre-operative Phase


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- begins with the patients decision to have surgery and ends with thetransfer of the patient to the operating table.

Intra-operative Phase

- begins with the transference of the patient to the procedure room,and ends with the admission of the patient to the designated postanesthesia area.

Post-operative Phase

- begins with the clients admittance to the postanesthesia care unitand ends with the clients complete recovery from the surgicalintervention.

Analgesia

- the sensation of pain and the associated psychic reactions areabolished or reduce without impairment of consciousness; theperception of pain is altered.

- reduction or absence of response to pain stimuli.

Anesthesia

- a state of narcosis, analgesia, relaxation and reflex loss.

- loss of feeling or sensation.

Antiseptic

- chemical agents that fights sepsis by inhibiting growth ofmicroorganisms without necessarily killing them; used only on livingtissue.

Asepsis

- absence of pathogenic microorganism.

Consent

- a form signed by the client and witnessed by another person, grantingpermission to have the procedure described by the clients physician.

Disinfection

- the chemical or physical process of destroying all pathogenic

microorganisms except spore-bearing ones.


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Homeostasis

- come from Greek word nomoios meaning like and stasis meansstanding.

- state of balance between the supply and demand of essentialsubstances within the body.

Medical Asepsis

- clean technique

- concerned with limiting the spread of microorganisms

Resident bacteria

- Normally picked out by hands in the usual ADL- Bacteria living in a specific area of the body.

Sterile

- free from microorganisms

Sterilization

- process by which all pathogenic and non-pathogenic microorganisms

including spores are killed.

Surgery

- is the term traditionally used for treatment that involve cutting orstitching tissues.

Surgical Asepsis

- sterile technique

- refers to keeping microorganisms from specific area.

Surgical conscience

- foundation upon which the skills and techniques employed by the ORnurse are built.

Surgical team

- a group of highly trained individuals who must work together as a

coordinated team for the welfare and safety of patient.


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Surgically clean

- mechanically or physically cleaned, but unsterile.

- items are considered surgically clean by the use of chemical, physicalor mechanical means that reduce the number of microorganisms.

Transient bacteria

- Bacteria temporarily living in a specific area of the body- Normally picked out by the hands in the usual activities of the daily

living

OPERATING ROOM AS TO ITS:

Personnel

Divided to the function to its Members

o Sterile team

- keep within the sterile team

- the part of a surgical gown considered sterile are the

sleeves ( expect for the axillary area) and the front the

table to a few inches below the neck opening

-A sterile team field to have perspiration mopped from his

elbow

a) Operating surgeon

- the surgeon must have the knowledge, skills, and the judgement

required to successfully perform the intended operation and any to have

devotions in procedure necessitated by unforeseen difficulties.


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b) Surgical assistant- under the operating surgeon direction, one or two assistant hold

retractors in the wound to expose the operative site, place clamps on

blood vessels in suturing during the operation.

* First assistant to the surgeon

The first assistant should be capable of assuming the responsibility

of the operating surgeon in case of emergency.

*second assistant surgeon

Qualified nurses and technicians may be utilized as the second or

third assistants during operation requiring a physician foe assistant during

operation requiring a physician first assistant during operation in which the

surgeon deems this assistance is adequate and for which they have been trained

c) Scrub nurse

- is used to designated the nursing remember of the sterile team whoactually may or may not be a nurse, the role of the scrub nurse may be filled by

a registered nurse, a particular nurse or an Operating room technique.


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o Unsterile Team-keep the way from al the sterile ares- should allow a wide margin of safety when passing the sterile

glass areas . should not go with the sterile circle,

a)Anesthesiologist or ansesthetist

-An Anesthesiologist is a person , not necessarily a physician , whoadministered ansthetics .


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b)Circulating nurse

- plays a role that is vital to the smooth flow of events before,during and after operation .

c)Head nurse

- functions in a middle management position as liaison between

staff members and administrative personnel

Physical layout

- should be designed and equipped with the patient safety at the forefront

1.) Floors

-Should be a piece of linoleum without seems although all the little fibbers

made mode of non- porous little are more expensive.

2) Ceiling

` -should be painted with washable that is amenable to cleansing

3) Plumbing

- do not need any fancy scrub sink

4) Emergency power

- is an important consideration. Enough back up power is necessary for our

normally planed replenish

5) Storage space


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` -cabinetry is a novel way to store most, if not all if not all the clean items

and variety of other clean items and variety of other equipments and supplies.

General

2

2

Neurology

1

1

General

4

4

OB

6

6

Ophthalmi

c

8

8

Ophthalmic

7

7

Urology

3

3

General

5

5

Laparoscopi

c

9

9

Supply

Room

Restricted

Area

Semi-

Restricted

Doctors

Lounge

Central

Supply

Dining

Room

Outpatient

Dressing

Room

Work

Room

Autoclave

Female

Doctors &

Nurses

Room

Male Staff

Dressing

Room

Male

Doctors

Dressing

Room

Station

Outpatient

Waiting

Area

N

O

N

R

E

S

T

R

IC

T

E

D

A

R

E

A

PACU


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Attire

- consists of body such as scrub dress, jump suit, pant, or shirt,

trouser, head covers, mask, shoe cover and sterile gowns

o Components

1)Body cover

-variety of suites, fits smugly

2)Head cap

-a cap or hood is put on the scrub suit for protection, all facial and

head hair must be covered in a restricted area .

3)Mask

-covering of the face to prevent any substance to get the faceespecially the mouth

4)Shoe cover

-disposable or canvas cover also must be worn at all time in the restricted

area.

5)Shoe

- must be comfortable and supportive

o Personal protective Equipment

1) Apron

-Protects against and agents, radiation when personnel are exposed to

radioactive implaints

2) Eyewear


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-Worn where a risk of exist blood or blood substance from the patient

splashing into the Eyes of sterile team members

3) Gloves-Non sterile latex or gloves are worn to handle any team

contaminated by blood substance

o Steps in donning operating room attire

Clean fresh attire is donned each time on arrival at the OR suite and as

necessary at the other times, if it is wet or grossly soiled.

NOTE. Showers should be available to personnel in case of gross contamination

during a procedure.

Masks and head covers should be changed between patients. As extraprecautions , known carrier who participate as sterile team members should.

1. Routinely bathe and scrub with an appropriate skin antiseptic agent;

shampoo hair daily

2. Change clothing frequently

3. Wear two masks; use anti microbial nasal ointment.

4. Use two scrub agents successively, double gown and double glove

5. Use no touch technique ; avoid touching any part of an instrument in direct

contact with tissue

6. Wash hands frequently

Special attire is worn with laminar airflow system in high risk operation.

Attire varies from hospital to hospital but may consist of a presterilized

jumpsuit as basic attire, covered by sterile gown and gloves. A vacuumhelmet is worn.


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o Importance of wearing attire

1) To provide effective barriers that prevent the dissemination of

microorganism to the patient

2) Protect personnel from blood and body substance of patients.

SET-UP( equipment & apparatus)

* Operating room table

-operating room tables are available that can be flexed, turned from side

to side, lowered or raised and placed in the trendelenburg and reverse

trendelenburg positions.

* Mayo stand

- the scrub nurse usually places sterile instruments supplies on the

mayo stand once it has been draped in a sterile fashion.

* Ring stand

-the ring stand is used by the scrub team for rinsing their gloves

after it is draped an a sterile fashion.

* spotlight s

-Spotlights are designed to provide an intense light a relatively

small area. They must be easy to clean and should be movable

most directions

* Back table

-there are various sizes and designs of these tables which are used

by the scrub nurse for sterile supplies needed during surgery, such as

drapes, extra instrument ,and suture.

* Kickbuckets

-there are usually two kickbuckets in the operating room one is

located in each side of the operating table ,and they used by the scrub

team for discarding soiled sponges.

* Lifts or stand


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-Lifts or stand vary in length and height depending upon their use.

They are used by nay member of the scrub team who requires more

height in order to be functioning member of the team.

* Suction

-Each operating room must have at least two suctions one for the

anesthesiologist at the patients head and other for the scrub team, which

is used at the operative site.

*X-ray viewer

-each operating room should have at least one viewer and

preferably two.

Scientific Principles

1. Anatomy and Physiology

- To know where the incision should be done and their function of the

anesthesia to the nervous system and where to drape the patient.

2. Microbiology

- Sterility must always be maintained in the operating room. Sterile to

sterile; unsterile to unsterile

3. Chemistry

- Using of betadine solution in surgical handwashing.

4. Physics

- Applying friction during medical and surgical handwashing.

5. Time and Energy

- Prepare all the necessary materials and avoid contaminating sterile

materials.


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6. Sociology

- Interacting between the members of the OR team.

7. Body Mechanics

- Maintain proper posture in carrying the materials, doing the surgical

and medical handwashing and assisting the scrub nurse or the

surgeon.

Basic rules of Surgical Asepsis

General

- Sterile surfaces/ articles may touch other sterile surfaces/ articles andremain sterile; unsterile contact at any point renders a sterile areacontaminated.

- If there is any doubt about the sterility of an article/ area, it is consideredunsterile.

- Whatever is sterile for one patient (an opened sterile tray/ tables with

sterile supplies) can be used for this patient only. Unused sterile suppliesmust be discarded/ resterilized if they are to be used again.

Personnel

- Scrubbed personnel remain in the area of the operation; if a scrubbedperson leaves the room, that persons sterile status is lost. To return tothe operation, this person is required to go through the procedure ofscrubbing, gowning and gloving.

- Only a small part of a scrubbed persons body is considered sterile:from front waist to the shoulder area; forearms and gloves.

- Therefore the gloved hands must be kept in front and above thewaistline.

- In some clinics, a special wraparound gown is worn which extends thesterile area.

- The circulator and any unscrubbed personnel remain on the peripheryof the surgical operating area at a safe distance in order not to

contaminate any sterile area.


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Draping

- During draping of a table or patient, the sterile drape is held well above

the surface to be covered and is placed from front to back.

- Only the top of the patient or table which is draped is considered sterile;drapes hanging over the edge are not regarded as sterile.

- Sterile drapes are not to be kept in position by the use of clips oradherent material; drapes are not to be moved during the operation. Atear or puncture of the drape permitting access to an unsterile surfaceunderneath renders the area unsterile.

Delivery of Sterile Supplies

- Packages are wrapped or sealed in such a way that they can be openedeasily without risk of contaminating contents.

- Sterile supplies, including solutions, are delivered to a sterile field orhanded to a scrubbed person in such a way that sterility of the object orfluid remains intact.

- Edges of wrappers covering sterile supplies or outer lips of bottles orflasks containing sterile solutions are not considered sterile.

- The unsterile arm of the circulator must not extend over a sterile area.Sterile articles are to be dropped at a reasonable distance from the edgeof the sterile area.

Fluids

- Sterile fluids are poured from a point high enough to prevent accidentaltouching of the sterile receiving cup or basin, but not so high as toproduce splashing (this may cause fluid to touch an unsterile surface andthen flow back into the receptacle, causing contamination).

Duties of Circulating Nurse

1. Reviews anatomy, physiology and surgical procedures.2. Assists with preparing room.3. Practices aseptic technique.4. Monitors activities of others.5. Ensures that needed items are available and sterile (if required).6. Checks mechanical and electrical equipment and environment

factors.7. Arranges furniture in workable order.8. Identifies and assesses client.


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9. Checks chart and relates pertinent data.10. Admits client to operating room suite.11. Assists with transferring client to operating room bed.12. Protects client during induction with anesthesia.13. Positions client.

14. Helps with insertion or application of monitoring devices.15. Prepares clients skin for surgical incision.16. Monitors draping procedure and all activities requiring asepsis17. Provides well-functioning suction.18. Completes intra-operative record.19. Records, labels and sends to proper locations tissue

specimens and cultures.20. Evaluates blood and fluid loss.21. Coordinates all activities in operating room between team

members and other hospital departments.22. Counts sponges, needles and instruments.23. Accompanies the client to postanesthesia recovery area.24. Reports pertinent information to recovery area nurses.

Duties of Scrub Nurse

1. Reviews anatomy, physiology and surgical procedures.

2. Assist with preparation of room.3. Scrubs, gowns and gloves self and other members of surgical team.4. Prepares instrument table and organizes sterile equipment.5. Assists with draping procedure.6. Passes instruments to surgeon and assistants.7. Counts sponges, needles and instruments.8. Monitors practices of aseptic technique.9. Keeps track of irrigation solution used for more accurate calculation

of blood loss.10. Reports amount of local anesthetics and epinephrine solutions

to anesthetist.

Responsibilities of Circulating Nurse

1. Always a registered nurse.2. Responsible and accountable for all activities during a surgical

procedure.3. Manages personnel, equipment, supplies, the environment and

communication throughout the operation.4. Arranges furniture and equipment in room.


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5. Opens sterile supplies.6. Tie gowns of sterile team members.7. Attends to needs and supplies of sterile team members.8. Identifies and assesses client.9. Brings client to operating room and transfer to operating room

table.10. Applies and assists in insertion of monitoring devices.11. Assists anesthesiologist with induction of anesthesia.12. Positions client for surgery.13. Performs designated surgical skin preparation.14. Assists with sterile draping and set up of sterile field around

operative site.15. Monitors sterile technique of surgical team.16. Collects labels and distributes specimens.17. Completes intraoperative record.18. Monitors blood and fluid loss.19. Counts sponges, instruments and sharps with scrub nurse

report results to surgeon.20. Communicates with surgical team members and others such

as client family, pathologist.21. Applies dressing22. Assists in transferring client to cart may assist in

transporting to postanesthesia care unit.23. Aids in cleaning room after procedure.

Responsibilities of Scrub Nurse

1. May be a Registered Nurse, Licensed Vocational Nurse or SurgicalTechnologist who is qualified by training or experience.

2. More than 1 scrub nurse may be needed for complicated operations.3. Provides services under the direction of the circulation nurse4. Opens sterile supplies.5. Scrubs, dons sterile gown and gloves.6. Assist in gowning and gloving other sterile team members.

7. Prepares instrument tables.8. Maintains integrity, safety and efficiency of sterile field.9. Assists with sterile draping of clients operative site.10. Passes instruments, sutures etc. to the surgeon.11. Assists with instruments sponge, and sharp counts.12. Aids in cleaning room after procedure.

Basic Instruments in Basic Set

CLAMPING AND OCCLUDING


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A hemostat is used to clamp blood vessels or tag sutures. Its jaws may be straightor curved. Other names: crile, snap or stat.

Hemostat

A mosquito is used to clamp small blood vessels. Its jaws may be straight orcurved.

hemostat, mosquito(left to right)

A Kelly is used to clamp larger vessels and tissue. Available in short and long sizes.Other names: Rochester Pean.


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Kelly, hemostat, mosquito(left to right)

A burlisher is used to clamp deep blood vessels. Burlishers have two closed fingerrings. Burlishers with an open finger ring are called tonsil hemostats. Other names:

Schnidt tonsil forcep, Adson forcep.

Burlisher

A right angle is used to clamp hard-to-reach vessels and to place sutures behind oraround a vessel. A right angle with a suture attached is called a "tie on a passer."Other names: Mixter.
http://library.sccsc.edu/surgtech/images/tonsil.jpghttp://library.sccsc.edu/surgtech/images/tonsil.jpg


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Crile hemostatic clamp- also called as snap,hemostat,used for clamping tissue or

vessels.

Miscellaneous:most commonly used,maybe straight or curved.

Towel clip= used for grasping, securing towels or drapes or reducing small bone

fractured.


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Cutting and Dissecting

Thomas currette- also known as dull currette, this is used for scraping and

endocervical and endometrial linings.

Miscellaneous:blunt blades

Sims curette- also known as sharp curette, this is used for

endocervical and endometrial linings.

Miscellaneous: sharp blades


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Straight mayo also known as suture scissors, this is used for cutting

sutures,dressing,drains.

Miscellaneous :heavy blades

Curved Mayo Scissors- also known as dissecting scissors, this is used for

cutting heavy tissue or muscles

Miscellaneous :heavy blades


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Metzenbaum scissors- also known as Metz, this is used for cutting

delicate tissue.

Miscellaneous :delicate blades, do not use for suture

Operating scissors- used for cutting delicate tissue or even dressing


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Miscellaneous :delicate a heavy blades can have 1 sharp or 2 sharp


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Lister scissors-known as bandage scissors, this is used for cutting

dressings and bandages

Miscellaneous: guarded blades

Iris scissors- used for cutting delicate tissue


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Miscellaneous: blade can be curved or straight

Wire cutting scissors (angled blades)- known as wire cutter, used for

cutting wire sutures,wire or wire mesh.

Miscellaneous: has 1 serrated blade to avoid slipping

Utility scissors- also known as trauma scissors, trauma shears, used for cutting

heavy things like clothing.

Miscellaneous: serrated blades


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Scalpel handles- also known as knife handle, used holding scalpel

blade

Miscellaneous: used with no. 11,12 and 15 blade

GRASPING OR HOLDING INSTRUMENTS

Graspers or holding instruments are used most commonly tograsp and hold tissues as in retraction or for suturing.


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Thumb forceps

Plain (small serrations; little trauma to tissue)- commonly use forAbdominal or general surgery (delicate tissues, G.I tissue).(it depends tothe surgeon)

Single-tooth (two sharp teeth on one side Abdominal orgeneral surgery (tougher tissues, muscle)

And one on the other

Multiple (many small teeth on both sides) Abdominal orgeneral surgery (delicate tissues, peritoneum)


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Russian (multiple serrations around edges on point)

`

Allis tissue forceps

An Allis is used to grasp tissue.Available in short and long sizes.A "Judd-Allis" holds intestinal tissue; a "heavy allis" holds breast tissue.


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Babcock tissue forceps

A Babcock is used to grasp delicate tissue (intestine, fallopian tube,ovary). Available in short and long sizes.

babcock

Pennington tissue forceps- commonly use for Perineal surgery


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#7, #3, #4(left to right)

#7 handle with 15 blade (deep knife)- Used to cutdeep, delicate tissue.

#3 handle with 10 blade (inside knife) - Used to cut superficial tissue.

#4 handle with 20 blade (skin knife) - Used to cut skin.

Blades

#10 blades usually for skin incisieon

#11 blades for small punctures

#12 blades curved with cutting surface on the inside

#15 used for cutting small vessels and tissue


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Blade knife handle- beaver blade handle, used for holding knife

handle

Miscellaneous: use with series 50,60,70

Gigli saw- also known as wire saw, or bone saw, used for sawing bones

Miscellaneous: use with both types o handles


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RETRACTING AND EXPOSING

Retracting and exposing instruments are used to hold back or retract organs ortissue to gain exposure to the operative site. They are either "self-retaining" (stayopen on their own) or "manual" (held by hand). When identifying retractors, look atthe blade, not the handle.

Volkman retractor-also known as rake, use for exposing superficial wounds

Miscellaneous: hand held can be sharp or blunt.

Weitlaner retractor-use in exposing superficial wound

Miscellaneous: self retaining, prongs can be sharp or dull

A Richardson retractor (manual) is used to retract deep abdominal or chestincisions

A Deaver retractor (manual) is used to retract deep abdominal or chestincisions.Available in various widths.

An Army-Navy Rectractor(manual) is used to retract shallow or superficialincisiond. Other names USA or US Army

A goulet(manual) is used to retract shallow or superficial incisions

Cerebellar retractor-also known as adson retractor,used for exposing wound

Beckman retractor- used in retracting soft tissue.

Gelpi retractor-use in exposing superficial wound


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Weitlaner retractor

Retracting Instruments

U.S. Army-Navy

Volkmann

(Rake)Weitlaner Deaver Richardson Ribbon


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Cerebellar retractor

Beckman retractor


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Gelpi retractor

Deaver retractor

army navy retractor

goulet


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Suturing and stapling

Surgical staples are specialized staples used in surgery in place ofsutures

to close skin wounds, connect or remove parts of the bowels or lungs. A more

recent development, from the 1990s, uses clips instead of staples for some

applications; this does not require the staple to penetrate.

Suture needle

End to end circular stapler
http://en.wikipedia.org/wiki/Staple_(fastener)http://en.wikipedia.org/wiki/Surgeryhttp://en.wikipedia.org/wiki/Surgical_suturehttp://en.wikipedia.org/wiki/Skinhttp://en.wikipedia.org/wiki/Anastomosishttp://en.wikipedia.org/wiki/Bowelhttp://en.wikipedia.org/wiki/Lunghttp://en.wikipedia.org/wiki/Staple_(fastener)http://en.wikipedia.org/wiki/Surgeryhttp://en.wikipedia.org/wiki/Surgical_suturehttp://en.wikipedia.org/wiki/Skinhttp://en.wikipedia.org/wiki/Anastomosishttp://en.wikipedia.org/wiki/Bowelhttp://en.wikipedia.org/wiki/Lung


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Viewing

Anoscope with obturator- viewing the inside of the anus , retracting

Sigmoidoscope;proctoscope-viewing the inside of the canal and sigmoid colon


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Suctioning ad Aspirating

Blood, body fluids, tissue, and irrigating solution may be removed bymechanical suction. Many of these items are available in disposable models. Thestyle of the suction tip will depend on where it is to be used and the surgeons

preference.

Poole Abdominal TipThe Poole abdominal tip is a straight hollow tube with a perforated outer

filter shield. It is used during abdominal laparotomy or within any cavity in whichcopious amounts of fluid or pus are encountered. The outer filter shield preventsthe adjacent tissues from being pulled into the suction apparatus.

Frazier Suction TipThe Frazier tip is a rightangle tube with a small diameter. It is used when

little or no fluid except capillary bleeding and irrigating fluid is countered, such

as in brain, spinal, plastic, or Orthopaedics procedures. The Frazier tip keeps thefield dry without the need for sponging.

Yankauer TipThe Yankauer tip is a hollow tube that has an angle for use in the mouth or

throat, and surface suction.


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Dilating and Probing

Bakes common bile duct dilators- use for common bile duct

Miscellaneous: comes in diff size

Probe and groove director also known as larry probe and grooved director- it

is used probing fistulas ,ducts


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Major pack and minor pack

Major pack

1 lap sheet

6 gowns

6 hand towels

6 draping towels

2 mayo cover

Minor pack

6 gowns

6 hand towels

6 draping towels

2 plain sheet

Operative Positions

Supine Position

-the supine or dorsal, position is the usual position for inductive for

general anesthesia and for entering the major body cavity.

-patient lies on his back with his arms in anatomical position and

the legs slightly apart. The palm of hands should be facing the body

to prevent undue muscle strains on the arms.

Modified Trendelenburg position-is generally used for lower abdominal surgery and some lower

extremity surgery.

-patient is positioned as in the supine position, and the entire

operating table is slightly titled so that the patients head is lower

than his feet by 1-5 degrees.

Modified reversed Trendelenburg position


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-is generally used for upper abdominal surgery and for neck and

face surgery.

-this position permit improved operative exposure because gravity

keeps the intestine mostly in the lower parts of the abdomen.

Lithotomy

- Is used in sugeries requiring a perineal approach.

- The patient is in a supine position during induction with the

buttocks near the lower break in the operating table.

- After the anesthesiologist gives permission, two people lift the

patients legs at the same time. The nurse must have good

control of the patients leg.

` CLASSIFICATION OF SURGERY ACCORDING TO:

MAJOR/MINOR:

1. MAJOR SURGERY

- These are surgeries of the head, neck, chest, and abdomen.

- The recovery time can be lengthy and may involve a stay in intensive care

or several days in the hospital.

- There is a higher risk of complication after such surgeries.

Types:

1. Removal of brain tumor

2. Correction of bone malformations of the skull and face.

3. Repair of congenital heart disease, transplantation of organs, andrepair of intestinal malformations.

4. Correction of spinal abnormalities and treatment of injuries

sustained from major blunt trauma.

5. Correction of problems in fetal development of the lungs,

intestines, diaphragm or anus.

2. MINOR SURGERY

- The recovery time is short and children return to their usual activities

rapidly.


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- These surgeries are most of often done as an out of patient, and patients

can return home the same day.

- Complications from these types of surgeries are rare.

Types:

1. Placement of ear tubes

2. Hernia repairs

3. Correction of bone fractures

4. Removal of skin lesions

PURPOSE:

1. DIAGNOSTIC

- Performed to obtain a biopsy for definitive diagnosis of a mass.

2. CURATIVE

- Performed to remove a diseased area.

Example:

Lumpectomy for breast cancer

Appendectomy

3. RESTORATIVE

- Performed to restore function.

Example:

Joint Replacement

4. PALLIATIVE

- Performed primarily for comfort measures.

Example:

Joint debulking

URGENCY

1. EMERGENT PROCEDURES


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- Need to be performed immediately after identifying the need for surgery.

Example:

Surgery to stop bleeding from trauma

Shooting

Stabbing

Dissecting aortic aneurism

2. URGENT PROCEDURES

- Are scheduled after the determination of surgical need is made.

Example:

Tumor removal

Removal of kidney stones

3. ELECTIVE PROCEDURES

- Are scheduled in advance at a time that is convenient for both patient and

surgeon.

- Postponement of the surgery for several weeks or even a month will not

cause harm to the patient.

Example:

Cosmetic procedure

COMMON SURGICAL COMPLICATIONS

1. CARDIOVASCULAR COMPLICATIONS

- Due to physiological stress of surgery, side effects of the anesthesia or

other medications.

- Myocardial infarction (MI), cardiac arrhythmias, or hypertension are likely

during or in the immediate postoperative period.

SIGNS AND SYMPTOMS:

1. Chest pain which may radiate to back, neck, jaw, or arm due to

ischemia in MI.


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2. Shortness of breath due to altered cardiac output and tissue

perfusion

3. Dizziness or lightheadedness due to diminished cardiac output and

cerebral tissue perfusion or cardiac arrhythmia.

4. Cardiac arrhythmias due to myocardial irritability possibly due

to ischemia, medication side effect, electrolyte imbalance.

5. Low blood pressure due to diminished cardiac output.

2. RESPIRATORY COMPLICATIONS

- Patients with preexisting respiratory disorders obesity or thoracic or upper

abdominal surgical procedures are at greater risk of developing respiratory

complications postoperatively.

- After surgery, patients are not mobile which leads to diminished chest wall

and diaphragmatic movement, resulting in a decreased amount of air exchange

- Pain medications can adversely affect respiratory status by decreasing

respiratory drive.

SIGNS AND SYMPTOMS:

1. Shortness of breath due to diminished air flow and resultant

decreased oxygenation.

2. Chest pain in the area of atelectasis due to collapse of the alveolar

sacs within that area o the lung.

3. Productive cough due to pneumonia.

4. Fever due to infection in pneumonia.

5. Sudden onset of chest pain and shortness of breath in pulmonary

embolism as clot blocks arterial flow within the lung.

6. Diminished oxygen levels as gas exchange is impaired inatectasis, pneumonia, or pulmonary embolism.

3. GASTROINTESTINAL COMPLICATIONS

- Following administration of anesthesia or pain medication, patients may

experience nausea, vomiting, constipation, or paralytic ileus.

- Nausea is a common side effect of both anesthesia and pain medication.

- Abdominal surgery may cause direct visceral afferent stimulation,

resulting in nausea and vomiting.

SIGNS AND SYMPTOMS:


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1. Nausea as a side effect of medication.

2. Vomiting due to visceral afferent stimulation or activation of

chemoreceptor trigger zone.

3. Mild, generalized abdominal discomfort and distention with

paralytic ileus due to decreased intestinal motility.

4. Slow bowel sounds with constipation; absent bowel sounds with

paralytic ileus due to change in intestinal motility.

4. INFECTION

- Skin is the first line of defense against infection. During surgery, this line

of defense is penetrated possibly become infected.

- Wound infection can develop in the postoperative period.

- Nosocomial infections can also occur at the surgical site.

SIGNS AND SYMPTOMS:

1. Increase in pain at surgical wound due to inflammatory process

early in infection.

2. Redness at wound edges that spreads if untreated.

3. Drainage from wound site due to bodys response to bacterial

presence ( change in color and odor of drainage)

4. Fever due to infection.

5. Elevated white blood cell count.

LAYERS OF THE ABDOMEN

Skin

-the outer protective covering of the body consisting of the dermis and theepidermis.

Subcutaneous

- A continuous layer of connective tissue over the entire body between the skin and

the deep fascial investment of the muscles. It comprises an outer normally fatty

layer and an inner thin elastic layer.

Fascia

- the fibrous connective tissue membrane of the body that may be separated from

other specially organized structures, such as the tendons, the aponeuroses, and the

ligaments, and that covers, supports and separates muscles.
http://medical-dictionary.thefreedictionary.com/dermishttp://medical-dictionary.thefreedictionary.com/epidermishttp://medical-dictionary.thefreedictionary.com/epidermishttp://medical-dictionary.thefreedictionary.com/dermishttp://medical-dictionary.thefreedictionary.com/epidermis


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Muscle

- A kind of tissue composed of fibers or cells that are able to contract, causing

movement of body parts and organs.

Peritoneum

-the serous membrane lining the walls of the abdominal and pelvic cavities (parietal )

and investing the contained viscera (visceral), the two layers enclosing a potential space, the

peritoneal cavity.

COMMON ABDOMINAL INCISIONS

Midabdominal Transverse Incision

starts on either the right or left side and slightly above or below the

umbilicus. It may be carried laterally to the lumbar region between the ribs and crest

of the ilium. The intercostal nerves are protected by cutting the posterior rectus

sheath and peritoneum in the direction of the divided muscle fibers. The advantages

are rapid incision, easy extension, a provision for retroperitoneal approach, and a

secure postoperative wound.

Examples of use: choledochojejunostomy and transverse colostomy.

Pfannenstiel Incision

a curved transverse incision across the lower abdomen and within the

hairline of the pubis. The rectus fascia is severed transversely and the muscles are

separated. The peritoneum is incised vertically in the midline. This lower transverse

incision provides good exposure and strong closure for pelvic procedures.

Examples of use:

abdominal hysterectomy (TAH & TAHBSO).
http://medical-dictionary.thefreedictionary.com/cavityhttp://medical-dictionary.thefreedictionary.com/cavity


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Subcostal Upper Quadrant Oblique Incision

a right oblique incision begins in the epigastrium and extends laterally and

obliquely just below the lower costal margin. It continues through the rectus muscle,

which is either retracted r transversely divided. Although this type of incision

affords limited exposure except for upper abdominal viscera, it provides goodcosmetic results because it follows skin lines and produces limited nerve damage.

Although painful, it is a strong incision postoperatively.

Examples of use:

splenectomy

Inguinal Incision (Lower Oblique)

extends form the pubic tubercle to the anterior crest of the ilium, slightly

above and parallel to the inguinal crease. Incision of the external oblique fascia

provides access to the cremaster muscle, inguinal canal, and cord structures.

Examples of use:

inguinal herniorrhaphy

Longitudinal Midline Incision

can be upper abdominal, lower abdominal, or a combination of both going

around the umbilicus. Depending on the length of the incision, it begins in the

epigastrium at the level of the xiphoid process and may extend vertically to the

suprapubic region. After incision of the peritoneum, the falciform ligament of theliver is divided. An upper midline incision offers excellent exposure of and rapid

entry into the upper abdominal contents.

McBurneys Incision

McBurneys point is located in the right lower quadrant, just below the

umbilicus and 4cm (2in) medial from the anterior superior iliac spine. A McBurney

incision involves a muscle-splitting incision that extends through the fibers of the

external oblique muscle. The incision is deepened, the internal oblique and

transversalis muscles are split and retracted, and the peritoneum is entered. This is a

fast, easy incision, but exposure is limited.

Examples of use:

appendectomy

Paramedian Incision

a vertical incision made approximately 4cm (2in) lateral to the midline on

either side in the upper or lower abdomen. After the skin and subcutaneous tissue

are incised, the rectus sheath is split vertically and the muscle is retracted laterally.

This incision allows quick entry into and excellent exposure of the abdominal

cavity. It limits trauma, avoids nerve injury, is easily extended, and gives a firm

closure.


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Examples of use:

sigmoid colon resection

Thoracoabdominal Incision

the patient is placed in a lateral position. Either a right or a left incision

begins at a point midway between the xiphoid process and umbilicus and extends

across the abdomen to the seventh or eighth costal interspace and along the interspace

into the thorax. The rectus, oblique, serratus, and intercostal muscles are divided.

A - Upper Longitudinal Midline Incision

B - Right Upper Paramedian Incision

C - Right Subcostal Upper Quadrant Oblique Incision

D - Right Midabdominal Transverse Incision

E - McBurneys Incision

F - Right Inguinal, Lower Oblique Incision

G - Lower Longitudinal Midline Incision

H - Left Lower Paramedian Incision

I - Pfannenstiel Incision

J - Thoracoabdominal Incision

A

D

B

E

F

G H

C

I

J


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TYPES OF SUTURES:

I. Absorbable Suture

- Sutures that are broken down and dissolve by enzymes produced by the

body.

Example:

Catgut

II. Nonabsorbable Suture

- Not dissolved by enzymes. This suture remains encapsulated in tissue or

is removed when used as a skin closure. Nonabsorbable sutures are made ofmetal, organic material or synthetics.

OTHER TYPES OF SUTURES:

1. Continuous Suture

Single suture used to join two wound edges and tied at each end.

2. Interrupted Suture

single sutures placed and tied separately.

3. Ligature or tie suture

suture material used to close off ends of severed blood vessels;

may be single strands or continuous from a reel.

4. Stick tie or Suture Ligature

- suture material on a needle used to ligate a blood vessel.

5. Retention Suture

heavy nonabsorbable suture used to reinforce a wound where

unusual stress on the suture line is anticipated.

6. Swaged-on or Autraumatic Suture

suture attached to an eyeless needle during the manufacturing.


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SUTURE NEEDLES

Classification of needles:

1.Body

a. Straight used generally on the skin

b. circle mostly internal to skin

c. 3/8 circle skin, plastic surgery

2.By the eye

a. Eye present will require threading

b. Lack of eye the needle and suture are one unit

Atralox double arm (two needles)

Atraumatic or swaged on

3.By the point

a. Cutting- spear or trocar

b. Round tapered point

COMMON SUTURE NEEDLES AND USES

Name Body Eye Point Common usage

Keith Straight Both Spear Skin

King 3/8 circle Both Spear Retention

Fistula circle(heavy) Eye Spear Back and thigh

muscle

Trocar circle Both Trocar Cervix

Scalp circle Eye Trocar Scalp

Reverse cutting circle Both Spear Skin, plastic

surgery

Ferguson circle

(medium siz

circle e)

Both Round Subcutaneous,

fascia,

peritoneum,


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abdominal muscle

Mayo circle

(heavy)

Both Round Uterine muscle

Gastrointestinal circle (thin) Both Round Gastrointestinal

surgery

Cardiovascular circle

(double arm 2

needles)

Autromatic Round Cardiovascular

TYPES OF BLADES

Straight Blades (#11)

(pkg/10)

(pkg/100)

Contour Blades (#10)

ABDOMINAL LAYER


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Sterilization Practice

Types:

A. Thermal (Physical)

Heat is dependable physical agent for the destruction of

all forms of microbial life, including spores.

Most reliable and commonly used method of

sterilization is steam under pressure

a. Steam under pressure/Moist heat/Autoclaves

Heat destroys microorganisms, and this process ishastened by the addition of moisture.

Moist heat in the form of steam under pressure

causes the denaturation and coagulation of protein or

the enzyme-protein system within cells.

Direct saturated steam contact is the basis of the

steam sterilization process.

Exposure time depends on the size and contents ofthe load and the temperature within the sterilizer.


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Microorganisms die at 130 to 150F (54 to 65C)

Some bacterial spores can withstand at 240F

(115C) for more than 3 hours.

No living organism can survive direct exposure tosaturated steam of 250F (121C).

Types of Steam Sterilizers

1. Gravity Displacement Sterilizer

- air is more than twice as heavy as steam

- standard cycle: 250 to 254F (121 to 123C)

- exposure time: 15 minutes

2. Prevacuum Sterilizer

- air is almost completely evacuated from the

chamber before the

sterilizing steam is admitted

- a period of 8 to 10 minutes effectively removes the

air to minimize

the steam penetration time

- the Bowie-Dick test is performed daily to ensure

that the air vacuum

pump is functioning properly

- temperature controlled at 270 to 276F (132 to

141C for 4 minutes)

- complete cycle: 15 to 30 minutes

3. Flash/High-Speed Pressure Sterilizer

- may be a gravity displacement or a prevacuum

cycle

- use only in unplanned, urgent, or emergency

situations

b. Hot air/Dry heat


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Dry heat in the form of hot air is used primarily to

sterilize anhydrous oils, petroleum products, and talc

which steam and ethylene oxide gas cannot penetrate.

Slow burning process

Types of Dry Heat Sterilizers

1. Mechanical Convection Oven

- blower forces hot air in motion around items in the

load to hasten the heating of substances and to

ensure a uniform temperature in all areas of the oven

- Early models: 320 to 340 F (160 to 171C) for 1

to 2 hours

Faster portable table-top models: 375 to 400F

(190.5 to 204C)

- total cycle: 6 minutes for unwrapped items

: 12 minutes for wrapped ones2. Gravity Convection Oven

-used for dry heat sterilization

- heat is provided by steam in the jacket only

-temperature: 250F (121C) or 270F (132C) for at

least 6 hours and preferably overnight

B. Chemical

a. Ethylene oxide gas

Used to sterilize items that are sensitive to heat or

moisture

Chemical alkylating agent that kills microorganisms by

interfering with the normal metabolism of protein and

reproductive processes, resulting in cell death

b. Formaldehyde gas and solution


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a 37% aqueous solution (formalin) or 8% formaldehyde

in 70% isopropyl alcohol kills microorganisms by

coagulating protein in cells

effective at room temperature

c. Hydrogen peroxide plasma/vapor

Creates a reactive plasma

Free radicals of the hydrogen peroxide interact with cell

membranes, enzymes, or nucleic acids to disrupt the life

functions of microorganisms

d. Ozone gas

Oxidation, a process that destroys organic and inorganic

matter. It penetrates the membrane of cells, causing

them to explode.

Low temperature method of sterilization

e. Acetic acid solution

If mixed with salts (Bionox) kills microorganisms by a

process of oxidation to denature proteins

Takes 20 minutes at a room temperature of 77F (25C)

f. Glutaraldehyde solution

a 2.4%, 2.5% or 3.4% aqueous solution of activated,

buffered alkaline Glutaraldehyde kills microorganisms

by the denaturation of protein in cells

reusable until it expires

effective on room temperature of 77F (25C)

g. Peracetic acid 0.2% solution

Is an acetic acid plus an extra oxygen atom that reacts

with most cellular components to cause cell death

h. Hypochlorous acid (electrochemical conversion process)

Kills many spores on well-cleaned endoscopes and other

heat-sensitive items


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Steriolox liquid chemical HLD system is non-toxic and

environmentally safe

C. Radiation (Physical)

a. Microwave (nonionizing)

Produces hyperthermic conditions that disrupt life

processes.

Heating action affects water molecules and interferes

with cell membranes

Cycle is 30 seconds

b. Gamma Ray and Beta Particle Sterilization (ionizing)

Produces ions by knocking electrons out of atoms

Ionic energy that results becomes converted to thermal

and chemical energy

This energy kills microorganisms by disrupting the

deoxyribonucleic acid molecule, thus preventing cellular

division and the propagation of biological life.

Advantages and Disadvantages

A. Steam Sterilization

Advantages:

1. Steam sterilization is the easiest, safest, and surest method

of on-site sterilization. Heat-stable and moisture-stable

items that can be steam-sterilized without damage should

be processed with this method.

2. Steam is the fastest method; its total time cycle is theshortest.

3. Steam is the least expensive and most easily supplied

agent. It is piped in from the facilitys boiler room. An

automatic, electrically powered steam generator can be

mounted beneath the sterilizer for emergency standby

when steam pressure is low.

4. Most sterilizers have automatic controls and recording

devices that eliminate the human factor from the


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sterilization process as much as possible when operated

and cared for according to the recommendations of the

manufacturer.

5. Steam leaves no harmful residue. Many items such as

stainless steel instruments withstand repeated processing

without damage.

Disadvantages:

1. Precautions must be used in preparing and packaging

items, loading and operating the sterilizer, and drying the

load.

2. Items need to be clean, free of grease and oil, and not

sensitive to heat.

3. Steam must have direct contact with all areas of an item. It

must be able to penetrate packaging material, but the

material must be able to maintain sterility.

4. The timing of the cycle is adjusted for differences in

materials and sizes of loads; these variables are subject to

human error.

5. Steam may not be pure. Steam purity refers to the amount

of solid, liquid or vapor contamination in steam. Impurities

can cause wet or stained packs and stained instruments.

B. Dry Heat Sterilization

Advantages:

1. Hot air penetrates certain substances that cannot be

sterilized by steam sterilization or another methods.

2. Dry heat is a protective method of sterilizing some delicate,sharp, or cutting-edge instruments. Steam may erode

Disadvantages:

1. A long exposure period is required, because hot air

penetrates slowly and possibly unevenly.

2. The time and temperature required will vary for different

substances.

3. Overexposure may ruin some substances.


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C. EO Gas Sterilization

Advantages:

1. EO gas is an effective substitute agent to use with most

items that cannot be sterilized by heat, such as plasticswith low melting points.

2. EO gas provides an effective method of sterilization for

items that steam and moisture may erode; it is

noncorrosive and does not damage items.

3. EO gas completely permeates all porous material; it does

not penetrate metal, glass, and petroleum-based

lubricants. Whether or not it penetrates oils, liquids, or

powder depends on the amount in the containers. Notrecommended for oils, liquids and powder.

4. Automatic controls preclude human error by establishing

proper levels of pressure, temperature, humidity, and gas

concentration.

5. EO gas leaves no film on items.

6. EO gas sterilization is used extensively in the preparation

of commercially available, packaged, presterilized items,

because packaging materials that prolong storage of life.

Disadvantages:

1. EO gas sterilization is a complicated process that is

carefully monitored.

2. EO sterilization takes longer than steam sterilization; it is a

long, slow process.

3. EO gas requires special, expensive equipment.

4. Items that absorbed gas during sterilization, as rubber,

polyethyl or silicone, require.

5. Toxic by-products can be formed in the presence of

moisture droplets during the exposure of some plastics,

particularly polyvinyl chloride.

6. Repeated sterilization can increase the concentration of the

total EO residues in porous items. These increased levels

can be hazardous unless the gas can be dissipated.


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7. EO is vesicant when in contact with skin and mucous

membranes.

8. Inhaled EO gas can be irritating to mucous membranes.

9. Long-term exposure to EO is known to be a potentialoccupational carcinogen, causing leukemia.

D. Hydrogen Peroxide Plasma Sterilization

Advantages:

1. The process is dry and nontoxic.

2. The by-products of oxygen and water vapor are safely

evacuated into the room atmosphere.

3. Aeration is not necessary.

4. A low temperature allows the safe sterilization of some

heat-sensitive items.

5. Plasma has significantly less effect on metal than does

steam sterilization; corrosion does not occur on moisture-

sensitive microsurgical and powered instruments.

6. The sterilizer is simple in design and connects to standard

electrical oulets.

Disadvantages:

1. Metal trays block radiofrequency waves.

2. Hydrogen peroxide is not compatible with cellulose.

3. Nylon becomes brittle after repated exposure to hydrogen

peroxide sterilization.

4. This method is not approved in the USA for use with flexible

endoscopes with lumens.

E. Ozone Gas Sterilization

Advantages:

1. The sterilizer generates its own agent using hospital

oxygen, water and the electrical supply. It is simple and

inexpensive to operate.


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2. Ozone gas sterilization provides an alternative to EO gas

sterilization of many heat- and moisture-sensitive items.

3. Ozone gas sterilization does not affect titanium, chromium,

silicone, neoprene and Teflon.

4. Aeration is not necessary; ozone leaves no residue and

converts to oxygen in a short time.

5. Low temperature is safer for heat sensitive

instrumentation.

Disadvantages:

1. Ozone can be corrosive. It will oxidize steel, iron, brass,

copper, and aluminium.

2. It destroys natural rubber, such as latex, natural fibers, and

some plastics

F. Radiation Sterilization

Advantage:

1. Ionizing radiation is the most effective sterilization method.

Disadvantage:

1. Limited to industrial use

Sterilization Process

A. Product Associated Parameters

a. Boiburden

b. Bioresistance

c. Bioshielding

d. Density

e. Biostate

B. Process Associated Parameters

a. Temperature

b. Tine


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c. Purity of Agent

Anesthesia1. General Anesthesia pain is controlled by general insensibility

it acts by blocking awareness centers in the brain causingamnesia (loss of memory), analgesia (insensibility to pain), hypnosis (artificialsleep) and relaxation (rendering a part of the body less tense) administered through intravenous infusion2. Regional Anesthesia is the temporary interruption of the transmission of nerveimpulses to and from a specific area or region of the body pain is controlled without loss of consciousness

These can be used for operations on the lower body such as

Caesarean sections, bladder operations or replacing a hip jointForms of Regional Anesthesia:

Spinal Anesthetic often used for lower abdominal, pelvic,rectal, or lower extremity surgery. This type of anesthetic involvesinjecting a single dose of the anesthetic agent directly into thefluid surrounding the spinal cord in the lower back, causingnumbness in the lower body

Epidural Anesthetic commonly used for surgery of thelower limbs and during labor and childbirth. This type ofanesthesia involves continually infusing medication via a thincatheter that has been placed into the epidural space of the spinal

column in the lower back, causing numbness in the lower body3. Local Anesthesia is injected into a specific area and is used for minor surgical used in procedures such as suturing a small wound or performingbiopsy

Stages of Anesthesia

STAGE ONSET PHYSICAL REACTIONS NURSING INTERVENTIONS

ONSET

Anesthetic

administration to

loss ofconsciousness

Drowsiness/Dizziness

Auditory and visualhallucinations

Close OR doors

Keep room quiet Standby to assist client

EXCITEMEN

T

Loss of

consciousness to

loss of eyelid

reflexes

Increase in autonomic

activity

Irregular breathing,

client may struggle

Remain quiet at clients side Assist anesthesiologist asnecessary

SURGICAL

ANESTHESI

A

loss of eyelid

reflexes to loss of

most reflexes and

depression of vital

function

Unconsciousness

Relaxation of muscles

Diminished gag and

blink reflex

Begin preparation only whenanesthesiologist indicates Stage 3has been reached and client isbreathing well with stable vital signs

DANGER Depression of vital Client is not breathing If arrest occurs, assist


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function to

respiratory and

circulatory failure

Heartbeat may or may

not be present

immediately in establishing airway,provide cardiac arrest tray, drugs,syringes, long needles, assistsurgeon with closed or open cardiacmassage

Stages of AnesthesiaSTAGE I: RELAXATION (AMNESIA/ANALGESIA)

SCOPEo From the beginning of anesthesia to the loss of consciousness, painsensation is not completely lost, but reaction to pain has been altered.

PATIENT REACTION/ BIOLOGIC RESPONSEo Feeling of drowsiness and dizzinesso Hearing becomes exaggeratedo May appear inebriatedo Pain sensation is decreased

NURSING IMPLICATIONS

o Close the operating room doors to reduce extraneous noises.o Confirm proper positioning, including all safety factors.o Verify if anesthesia suction is available and working correctly.o Reduce talking, unnecessary movement, and noise to only what is

absolutely necessary.o Remain at the head of the operating room table; assist the

anesthesia clinician, and provide the patient with emotionalsupport.

STAGE II: DELIRIUM/EXCITEMENT

SCOPEo From the loss of consciousness to the onset of respiratory depression and

loss of lid reflexes. PATIENT REACTION/ BIOLOGIC RESPONSE

o Irregular respirationo Loss of lid reflexeso Increased muscle tone and involuntary motor responseo Sensitive to external stimuli (can be startled)

NURSING IMPLICATIONSo Avoid any type of extraneous stimulation.o Lightly restrain extremities to avoid injury.o Remain at the head of the table to assist anesthesia personnel as

needed.

o Remain alert for many emergency situations that could arise.

STAGE III: SURGICAL ANESTHESIA SCOPE

o From the regular pattern or respirations to the total paralysis of theintercostals muscle and cessation of voluntary ventilation. This stage canbe further divided into four plane ranging from light anesthesia throughexcessively deep anesthesia.

PLANE I: LIGHT ANESTHESIAo Loss of lid reflexes, pupils are smallero Patterns of normal breathing visibleo Vomiting/ gag reflex gradually is disappearing

o Respiratory rate and depth may increaseo Eye movement may still be present


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PLANE II: MEDIUM ANESTHESIA (SURGERY MAY BEGIN)o Ventilations are more regular, but tidal volume has decreasedo Loss of eye movement: Pupil in midline, concentrically fixedo Vocal cord reflex (which could result in laryngospasm) begins to

disappearo

Decreased muscle tone as anesthesia deepens PLANE III: DEEP SURGICAL ANESTHESIA

o Begin with decreased intercostals muscle movemento Only diaphragmatic activity remainso Increased muscle relaxation

PLANE IV: DEEPER ANESTHESIAo Begin with intercostals paralysis and progress to complete cessation

of spontaneous ventilationo If allowed to go deeper, circulatory system failure is imminento Pupils no longer react to light

NURSING IMPLICATIONS:o Be available to assist anesthesia personnel as necessary.o Validate with the anesthesia appropriate time to position and

prepare.o Recheck patient positioning and reaffirm safety precautions.

STAGE IV: DANGER SCOPE

o From the time of cessation of ventilation to failure of circulation caused byhigh levels of anesthesia in the CNS accidentally reached; not desirable.

PATIENT REACTION/ BIOLOGIC RESPONSEo Medullary peristalsis, cardiac /respiratory collapseo Pupils fixed and dilatedo Pulse rapid and threadyo Ventilation ceases, coma developso Circulatory and respiratory arrest

NURSING IMPLICATIONSo Be prepared to assist in emergency resuscitation measureo Obtain emergency cart and defibrillatoro Remain in the room at all timeso Document all events and therapies as they occur

OPERATIVE CHECKLIST:

A. Pre operative checklist

Please be aware of the following information:

1. Insurance information and I.D.(for ex, a driver's licence must be

available at the time of registration.

2. Consume no solid food, no milk, and/or no orange juice after

midnight before surgery.

3. Do not smoke,chew gum or suck on hard candy sfter mightnight

before surgery.


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4. Stay away from asprin/aspirin products. No Advil or anti-

inflammatory drugs at least 7-10 days prior to surgery.

On the Day of Surgery, please:

1. Wear NO makeup or nail polish.

2. Wear NO jewelry.

3. Leave valuable at home. We are not responsible for personal

items, money,credit cards, wallets, jewelry, etc.

4. Bring a case for contact lenses and/or glasses.

5. Feel free to wear your dentures to the operating room.

6. Wear no metal hair accessories.

7. Wear loose fitting clothing appropriate for the type of surgery

being performed.

For 24 Hours After surgery, it is suggested that you:

1. Do not make critical decisions.

2. Do not drink alcoholic beverages.

3. Do not drive a motor vehicle.

4. Do not operate machinery or potentially dangerous machinery.

5. Have an adult stay with you. This is strongly advised.

B. Consent Forms

1. Implied consent

Much of a physician's work is done on the basis of consent which

is implied either by the words or the behaviour of the patient or by

the circumstances under which treatment is given. For example, it is

common for a patient to arrange an appointment with a physician,


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to keep the appointment, to volunteer a history, to answer

questions relating to the history and to submit without objection to

physical examination. In these circumstances consent for the

examination is clearly implied. To avoid misunderstanding, however,

it may be prudent to state to the patient an intention to examinethe breasts, genitals or rectum.

The foregoing notwithstanding, in many situations the extent

to which consent was implied may later become a matter of

disagreement. Physicians should be reasonably confident the

actions of the patient imply permission for the examinations,

investigations and treatments proposed. When there is doubt, it is

preferable the consent be expressed, either orally or in writing.

2. Expressed consent

Expressed consent may be in oral or written form. It should be

obtained when the treatment is likely to be more than mildly

painful, when it carries appreciable risk, or when it will result in

ablation of a bodily function.

Although orally expressed consent may be acceptable in many

circumstances, frequently there is need for written confirmation. As

physicians have often observed, patients can change their minds or

may not recall what they authorized; after the procedure or

treatment has been carried out, they may attempt to take the

position it had not been agreed to or was not acceptable or justified.

Consent may be confirmed and validated adequately by means of asuitable contemporaneous notation by the treating physician in the

patient's record.

Expressed consent in written form should be obtained for surgical

operations and invasive investigative procedures. It is prudent to

obtain written consent also whenever analgesic, narcotic or

anaesthetic agents will significantly affect the patient's level of

consciousness during the treatment.


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3. Informed Consent

An agreement by a client to accept a course of treatment or a

procedure after complete information, including the risks of

treatment and facts relating to it, has been provided by the

physician.

It is an exchange between a client and a physician. Usually

the client signs a form provided by the agency. The form is a

record of the informed consent, not the informed consent itself.

C. WHO Operative Checklist

In order to implement the Checklist during surgery, a single personmust be made responsible for performing the safety checks on the list.This designated Checklist coordinator will often be a circulating nurse, butit can be any clinician participating in the operation.

The Checklist divides the operation into three phases, eachcorresponding to a specific time period in the normal flow of a procedurethe period before induction of anaesthesia, the period after inductionand before surgical incision, and the period during or immediately afterwound closure but before removing the patient from the operating room.In each phase, the Checklist coordinator must be permitted to confirmthat the team has completed its tasks before it proceeds onward. Asoperating teams become familiar with the steps of the Checklist, they canintegrate the checks into their familiar work patterns and verbalize theircompletion of each step without the explicit intervention of the Checklistcoordinator. Each team should seek to incorporate use of the Checklistinto its work with maximum efficiency and minimum disruption while

aiming to accomplish the steps effectively.

All steps should be checked verbally with the appropriate teammember to ensure that the key actions have been performed. Therefore,before induction of anaesthesia, the person coordinating the Checklist willverbally review with the anaesthetist and patient (when possible) thatpatient identity has been confirmed, that the procedure and site arecorrect and that consent for surgery has been given. The coordinator willvisualize and verbally confirm that the operative site has been marked (ifappropriate) and will review with the anaesthetist the patients risk ofblood loss, airway difficulty and allergic reaction and whether an

anaesthesia machine and medication safety check has been completed.Ideally the surgeon will be present during this phase as the surgeon may


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have a clearer idea of anticipated blood loss, allergies, or othercomplicating patient factors. However, the surgeons presence is notessential for completing this part of the Checklist.

Before skin incision, each team member will introduce him or herself

by name and role. If already partway through the operative day together,the team can simply confirm that everyone in the room is known to eachother. The team will confirm out loud that they are performing the correctoperation on the correct patient and site and then verbally review withone another, in turn, the critical elements of their plans for the operation,using the Checklist for guidance. They will also confirm that prophylacticantibiotics have been administered within the previous 60 minutes andthat essential imaging is displayed, as appropriate.

Before leaving the operating room, the team will review theoperation that was performed, completion of sponge and instrumentcounts and the labelling of any surgical specimens obtained. It will alsoreview any equipment malfunctions or issues that need to be addressed.Finally, the team will discuss key plans and concerns regardingpostoperative management and recovery before moving the patient fromthe operating room.

Having a single person lead the Checklist process is essential for itssuccess. In the complex setting of an operating room, any of the stepsmay be overlooked during the fast-paced preoperative, intraoperative, orpostoperative preparations. Designating a single person to confirm

completion of each step of the Checklist can ensure that safety steps arenot omitted in the rush to move forward with the next phase of theoperation. Until team members are familiar with the steps involved, theChecklist coordinator will likely have to guide the team through thisChecklist process.

A possible disadvantage of having a single person lead the Checklistis that an antagonistic relationship might be established with otheroperating team members. The Checklist coordinator can and shouldprevent the team from progressing to the next phase of the operationuntil each step is satisfactorily addressed, but in doing so may alienate orirritate other team members. Therefore, hospitals must carefully consider

which staff member is most suitable for this role. As mentioned, for manyinstitutions this will be a circulating nurse, but any clinician can coordinatethe Checklist process.

Focused - The Checklist should strive to be concise, addressing thoseissues that are most critical and not adequately checked by other safetymechanisms. Five to nine items in each Checklist section are ideal.

Brief - The Checklist should take no more than a minute for each sectionto be completed. While it may be tempting to try to create a more


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exhaustive Checklist, the needs of fitting the Checklist into the flow ofcare must be balanced with this impulse.

Actionable - Every item on the Checklist must be linked to a specific,

unambiguous action. Items without a directly associated action will resultin confusion among team members regarding what they are expected todo.

Verbal - The function of the Checklist is to promote and guide a verbalinteraction among team members. Performing this team Checklist iscritical to its success it will likely be far less effective if used solely as awritten instrument.

Collaborative - Any effort to modify the Checklist should be incollaboration with representatives from groups who might be involved in

using it. Actively seeking input from nurses, anaesthetists, surgeons andothers is important not only in helping to make appropriate modificationsbut also in creating the feeling of ownership that is central to adoptionand permanent practice change.

Tested - Prior to any rollout of a modified Checklist, it should be tested ina limited setting. The real-time feedback of clinicians is essential tosuccessful development of a Checklist and its integration into theprocesses of care. Testing through a simulation as simple as running

through the Checklist with team members sitting around a table isimportant. We also suggest using the Checklist for a single day by a singleoperating team and collecting feedback. Modify the Checklist or the waythat it is incorporated into care accordingly and then try the Checklistagain in a single operating room. Continue this process until you arecomfortable that the Checklist you have created works in yourenvironment. Then consider a wider implementation program.

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