Intraoperative Lecture

8/12/2019 Intraoperative Lecture

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Intraoperative CareMS. LOURADEL MATOL ULBATA, RN, MAN


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Preparing the Patient the Evening Before

Surgery

Preparing the Skin

- have a full bath to reduce microorganisms in the

skin.

- hair should be removed within 1-2 mm of the skinto avoid skin breakdown, use of electric clipper is

preferable.

Preparing the G.I tract

- NPO, cleansing enema as required


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ASA (American Society of Anesthesiologists)

Guidelines for Preoperative Fasting

Liquid and Food Intake Minimum

Fasting Period

CLEAR LIQUIDS 2

BREASTMILK 4

NONHUMAN MILK 6

LIGHT MEAL 6

TEGULAR/ HEAVY MEALS 8


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Preparing for Anesthesia

- Avoid alcohol and cigarette smoking for at

least 24 hours before surgery.

Promoting rest and sleep

- Administer sedatives as ordered


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PREOPERATIVE MEDICATIONS

Goals:

To aid in the administration of an anesthetics.

To minimize respiratory tract secretion andchanges in heart rate.

To relax the patient and reduce anxiety.


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Commonly used Preop Meds.

Tranquilizers & Sedatives

* Midazolam

* Diazepam ( Valium )* Lorazepam ( Ativan )

* Diphenhydramine

Analgesics

* Nalbuphine ( Nubain )

Anticholinergics

* Atropine Sulfate

Proton Pump Inhibitors

* Omeprazole ( Losec )

* Famotidine


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Transporting the Patient to the OR

Adhere to the principle of maintaining the comfortand safety of the patient.

Accompany OR attendants to the patients bedside

for introduction and proper identification.

Assist in transferring the patient from bed to

stretcher.

Complete the chart and preoperative checklist.

Make sure that the patient arrive in the OR at theproper time.


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Patients Family

Direct to the proper waiting room.

Tell the family that the surgeon will probably contact

them immediately after the surgery.

Explain reason for long interval of waiting:

anesthesia prep, skin prep, surgical procedure, RR.

Tell the family what to expect postop when they see

the patient


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Intraoperative Phase

Transfer onto the operating table

Phases of anesthesia

Operative procedure Transfer from operating table to stretcher

Safe transport to post-operative area (PACU)


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LOCATION

The OR suite is usually located in an area

accessible to the critical care surgical

patient areas and the supportive service

departments, the pathology department,and the radiology department. A terminal

location is necessary to prevent unrelated

traffic from passing through suites. Blood

bank is an important factor.


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SPACE ALLOCATIONS AND TRAFFIC

PATTERNS

Space is allocated within the OR suite to provide forthe work to be done, with considerations given tothe efficiency within which it can be accomplished.

The OR suite should be large enough to allow forcorrect technique yet small enough to minimize themovements of the patient, personnel and supplies.

Provision must be made for traffic control. The typeof design will predetermine traffic patterns. Allpersonsstaff, patients, and visitorsshould followthe delineated patterns in appropriate time.


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Surgical Environment

Unrestricted Area

- provides an entrance and exit from the surgical

suite for personnel, equipment and patient

- street clothes are permitted in this area, and the

area provides access to communicationwith personnel

within the suite and with personnel and patientsfamiliesoutside the suit.


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Semi-restricted Area

- provides access to the procedure rooms and

peripheral support areas within the surgical suite.

- personnel entering this area must be in properoperating room attire and traffic control must be

designed to prevent violation of this area by

unauthorized persons

- peripheral support areas consists of: storage areas

for clean and sterile supplies, sterilization equipment

and corridors leading to procedure room


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Restricted Area

- includes the procedure room where surgery is

performed and adjacent substerile areas where the

scrub sinks and autoclaves are located

- personnel working in this area must be in proper

operating room attire


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VESTIBULAR OR EXCHANGE AREAS

POST-ANESTHESIA CARE UNIT (PACU)

The PACU may be outside the OR suite, or it may be adjacent to thesuite so that it may be incorporated into the unrestricted areas withaccess from both the semi-restricted area and an outside corridor.In the latter design, the PACU becomes a vestibular area for thedeparture of patients.

DRESSING ROOM AND LOUNGES

Dressing room must be provided for both men and women tochange from street clothes into OR attire before entering the semi-restricted area, and vice versa. Lockers are usually provided. Doorsseparate this area from lavatory facilities and adjacent lounges.

PERIPHERAL SUPPORT AREASAdequate space must be allocated to accommodate the needs ofthe OR personnel and support services.


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CONFERENCE ROOMS/CLASSROOM- A conference or a classroom is located within the semi-restricted area. This is used for patient care staff in cervicalstaff for teaching.

SUPPORT SERVICE- The size of the health care facility and the types of servicesprovided, determine whether laboratory and radiologyequipment is needed within the OR suite.


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VESTIBULAR OR EXCHANGE AREASLABORATORY

A small laboratory where the pathologist can examine tissue and performfrozen sections expedites the decisions that the surgeon must make during asurgical procedure when diagnosis is questionable. A refrigerator for storing bloodfor transfusions may also be located in this room.

RADIOLOGY SERVICESSpecial procedure rooms may be outfitted with X-ray and imaging

equipment for diagnostic and invasive radiological procedures or insertion ofcatheters, pacemakers, and other devices.

WORK AND STORAGE AREASClean and sterile supplies and equipment must be separated from soiled

items and trash. If the OR suite has a clean core area, soiled materials should notbe taken into this area.

ANESTHESIA WORK AND STORAGE AREASpace must be provided for the storage of the anesthesia equipment and

supplies. A separate workroom usually is provided for care of anesthesiaequipment. Dirty and clean supplies must be kept separated

V S I ULA O XCHANG A AS


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HOUSEKEEPING STORAGE AREASCleaning supplies and equipment need to be stored; the equipment

used within the restricted area is kept separated from that used to cleanother areas. Sinks are provided, as well as shelves for supplies. Trash andsoiled laundry receptacles should not be allowed to accumulate in thesame room where clean supplies are kept.

UTILITY ROOMSome hospitals use a closed-cart system and take contaminated

instruments to a central area outside the OR suite for clean-up proceduresin the substerile room. Many, by virtue of the limitations of the physicalfacilities, bring the instruments to a utility room. This room contains awashersterilizer, sinks, cabinets and all the necessary aids for cleaning.



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STERILE SUPPLY ROOMhospitals keep a supply of sterile drapes, sponges, gloves, gowns, and other

sterile items ready for use in the sterile supply room within the OR suite. Asmany shelves as possible should be freestanding from the walls, which permitssupplies to be put into one side and removed from the other, thus older packagesare always used first.

INSTRUMENT ROOMThe instrument room contains cupboards in which all clean and

decontaminated instruments are stored when not in use. Instruments usuallyare segregated on shelves according to surgical specialty services.



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SCRUB ROOM

- An enclosed area for surgical scrubbing ofhands and arms must be provided adjacent to

each OR suite. It is a restricted area within the

OR suite.

PHYSICAL LAYOUT OF THE OR


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PHYSICAL LAYOUT OF THE OR

OPERATING-ROOM SETUP SHOWING TABLES FOR

INSTRUMENTS AND SUPPLIES DESIGNED TO FACILITATE THEWORK OF THE SURGEON, HIS ASSISTANTS, AND THE NURSES


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PACU (post anesthesia care unit)


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OR suite (operating room-central

Processing area)


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scrub area


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Draped patient andoperating bed

Mayo stand

1st

assistant

Scrub

nurse

Surgeon

Kick

bucket

Instrument table

Electrosurgical

unit

Suction

container

Kick

bucket

Anesthesia

machineAnesthesia

provider


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A. SCIENTIFIC PRINCIPLES INVOLVED IN OR

TECHNIQUE

ANATOMY AND PHYSIOLOGY

adequate knowledge of the human body parts is a prerequisite in being apart of the OR team. [Ex.: epidermis is the term used to designate theouter or surface layer of the skin and the dermis is considered to be thesecond layer. There are sebaceous and sweat glands of the skin. the skinprotects the body tissues against pathogenic microorganisms and injuryfrom mechanical devices.]

CHEMISTRYuse of antiseptics can reduce bacterial count. Excessive use of soap mayharden the skin, as soap is alkaline and removes protecting oils from theskin.

MICROBIOLOGY

Skin protects the body from certain diseases. Handwashing is the most

effective means of conserving ordinary cleanliness for protection of thepatient as well as the nurses.

PHARMACOLOGY

drugs that are used for soothing and reducing irritation of surfaces thathave been abraded or irritated is classified as demulcents. Ethyl alcohol(70%) is an effective solution for disinfection of equipment.


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PSYCHOLOGYthe proper explanation to the patient regarding the

upcoming operation should be established.

SOCIOLOGYhome methods of disinfection and sterilization may be

taught by the visiting nurse. The attitude of theisolated patient whether at home or in the hospitalmay depend on the knowledge of his disease and themanner of its transmission from one person to another.

PHYSICS

the autoclave used for sterilization sterilizes by means ofpressurized steam.


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PRINCIPLESof SURGICAL

ASEPSIS


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Remember the

word

ASEPSIS


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AAlways face thesterile field


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SShould be above

waist level andon top of sterile

field


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EEliminate

moisture thatcauses

contamination


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PPrevent unnecessarytraffic & air current

( close door, minimizetalking dont reach across

sterile field)


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SSafer to assume

contaminated

when in doubt


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IInvolves team effort( collective and

individual sterile

conscience)


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SSterile articles unusedand opened are no

longer sterile afterthe procedure


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Anesthesia


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Anesthesia loss of feeling or sensation, especially loss of the sensation

of pain with loss of protective reflexes.

State of Narcosis

Anesthetics can produce muscle relaxation, block

transmission of pain nerve impulses and suppress reflexes.

It can also temporary decrease memory retrieval and recall.

The effects of anesthesia are monitored by considering the

following parameters:

- Respiration

- O2 saturation / CO2 level

- HR and BP

- Urine output

Types of Anesthesia:


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Types of Anesthesia:

1. General Anesthesia

reversible state consisting of complete loss of

consciousness and sensation.

protective reflexes such as cough and gag are

lost

provides analgesia, muscle relaxation and

sedation.

produces amnesia and hypnosis.

T h i d i G l


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Techniques used in General

Anesthesia A. Intravenous Anesthesia

This is being administered intravenously and extremely rapid.

Its effect will immediately take place after thirty minutes of

introduction.

It prepares the client for smooth transition to the surgical

anesthesia.

B. Inhalation Anesthesia This comprises of volatile liquids or gas and oxygen.

Administered through a mask or endotracheal tube


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Induction of General Anesthesia:

Preoxygenation

the anesthesia provider may have the patient breath pure (100%)oxygen by facemask for a few minutes. This provides a marginof safety in the event of airway obstruction or apnea duringinduction, with resultant hypoxia.

Loss of Consciousnessunconsciousness is induced by IV administration of a drug or by

inhalation of an agent mixed with oxygen. Because thetechnique is rapid and simple, an IV drug usually is preferredby anesthesia providers and often is requested by patients.

Intubation

a patent airway must be established to provide adequateoxygenation and to control breathing of the unconsciouspatient. The patients tongue and secretions can obstructrespiration in the absence of protective reflex.


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ANESTHESIA MACHINE

General Anesthesia is maintained by

inhalation of gases and IV injection of drugs.

An anesthesia machine is always used to

deliver oxygen-anesthetic mixtures to thepatient through a breathing system.


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S S C i l d


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ANESTHESIA MACHINE includes:

Sources of oxygen and gases with flowmeters for measuring and controlling theirdelivery

Devices to volatilize and deliver liquidanesthetics

Gas-driven mechanical ventilator

Devices for monitoring the ECG, BP, inspiredoxygen, and end-tidal carbon dioxide

Alarm systems


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ANESTHESIA MACHINES have the following


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g

features:

Sources of oxygen and compressed gases.

Means for measuring and controlling delivery

of gases.

Means to volatilize liquid and deliver

anesthetic vapor or gas.

Device for disposal of Carbon Dioxide

f i


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Safety Devices:

Oxygen analyzers

Oxygen pressure interlock system End-tidal carbon dioxide monitors

Pressure and disconnect alarms to notify the

anesthesia provider if the flow of oxygen and

gases becomes disproportional

Pin-index safety system to release excess gases

Gas scavenger system to collect exhaled gases

Physiologic indicators of a difficult airway include the following:


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Physiologic indicators of a difficult airway include the following:

~ Inability to open mouth. Patients with previous jaw surgery may havejaw wires in place. Wire cutters should be immediately available in

the event of a return to surgery.~ Immobility of the cervical spine. Patients with vertebral disease or

injury may not have full range of motion necessary for intubation.

~ Chin or jaw deformities. Patients with small jaws or chin may have adifficult airway. Edentulous patients commonly have some bone loss

that alters facial contours.~ Detention can be an issue if the patient has loose teeth or periodontal

disease. A tooth can be aspirated during the airway maintenanceprocess.

~ Short neck or morbid obesity.

~ Pathology of the head and neck such as tumors or deformity. Anenlarged tongue can be an obstruction to a full view of the glottis.

~ Previous tracheostomy scar, which can cause a stricture.

~ Trauma.

D th f G l A th i


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Depth of General Anesthesia

From To Patients

Responses

Patient Care

Considerations

Induction of generalanesthesia andbeginning of inhalantand/ or IV drug

Begins to loseconsciousness; willhave recallBispectral state 100

Drowsy, dizzy,amnesic

Close OR doors. Keeproom quiet. Stand byto assist. Initiatecricoid pressure if

requested.

Loss of consciousness;excitement phase

Relaxation, lighthypnosis; low

probability of recallBispectral state 70 to50

May be excited withirregular breathing

and movements ofextremities;susceptible to externalstimuli (e.g., noise,touch)

Restrain patient.Remain at patients

side, quietly, butready to assistanesthesia provider asneeded.


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Surgicalanesthesia stageof relaxation

Loss ofreflexes:depression ofvital functionsBispectral state40:maintenancerange

Regularrespiration;contractedpupils; reflexesdisappear;muscle relax;auditorysensation lost

Position patientand prepareskin only whenanesthesiaproviderindicates thisstage isreached andunder control.

Danger stage:vital functionstoo depressed

Respiratoryfailure; possiblecardiac arrest

Bispectral state0

Not breathing;little or nopulse or

heartbeat

Prepare forcardiopulmonaryresuscitation.


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Most Commonly Used General Anesthetic AgentsGeneric Name Trade Name Administration Characteristics Uses

INHALATION

AGENTSNitrous oxide None Inhalation Inorganic gas;slight potency;

pleasant, fruitlike

odor;

nonirritating; non-

flammable but

supports

combustion; poormuscle relaxation

Rapid inductionand recovery;

short procedures

when muscle

relaxation

unimportant;

adjunct to potent

agents

Halothane Fluothane Inhalation Halogenated

volatile liquid;

potent; pleasant

odor;

nonirritating;

cardiovascular

and respiratory

depressant;

incomplete

muscle relaxation;

potentially toxic

to liver

Rapid induction;

wide spectrum for

maintenance;

depth of

anesthesia easily

altered; rapid

reversal


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Enflurane Ethrane Inhalation Halogenated

ether; potent;

some muscle

relaxation;

respiratorydepressant

Rapid induction

and recovery;

wide spectrum

for maintenance

Isoflurane Forane Inhalation Halogenated

methyl ether;

potent; muscle

relaxant;

profound

respiratory

depressant;metabolized in

liver

Rapid induction

and recovery

with minimal

aftereffects;

wide spectrum

for maintenance

INTRAVENOUS


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AGENTS

Thiopental sodium

Pentothal sodium Intravenous Barbiturate;

potent; short acting

with cumulative

effect; rapid uptake

by circulatory

system; no muscle

relaxation;

respiratory

depressant

Rapid induction

and recovery; short

procedures when

muscle relaxation

not needed; basal

anesthetic

Methohexital

sodiuim

Brevital Intravenous Barbiturate;

potent; circulatory

and respiratory

depressant

Rapid induction;

brief anesthesia

Propofol Diprivan Intravenous Alkylphenol;potent short-acting

sedative-hypnotic;

cardiovascular

depressant

Rapid inductionand recovery; short

procedures alone;

prolonged

anesthesia in

combination with

inhalation agents

or opioids

K t i K t j t K t l I t Di i ti d R id i d ti


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Ketamine

hydrochloride

Ketaject. Ketalar Intravenous,

Intramuscular

Dissociative drug;

profound amnesia

and analgesia; may

cause psychologic

problems during

emergence

Rapid induction;

short procedures

when muscle

relaxation not

needed; children

and young adults

Fentanyl Sublimaze Intravenous Opioid; potent

narcotic; metabolizes

slowly; respiratory

depressant

High-dose narcotic

anesthesia in

combination with

oxygen

Sufentanil citrate Sufenta Intravenous Opioid; potent

narcotic, respiratory

depressant

Premedication; high-

dose narcotic

anesthesia in

combination with

oxygen

Fentanyl and

droperidol

Innovar Intravenous Combination

narcotic and

tranquilizer; potent;

long acting

Neuroleptanalgesia

Diazepam Valium Intravenous, Benzodiazepin Premedication;


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p ,

intramuscular

p

e; tranquilizer;

produces

amnesia,

sedation, and

muscle

relaxation

;

awake

intubation;

induction

Midazolam Versed Intravenous,

intramuscular

Benzodiazepine

; sedative;

short-acting

amnesic; central

nervous system

and respiratory

depressant

Premedication;

conscious

sedation;

induction in

children


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2. Local or regional block anesthesia

temporary interruption of the transmission of nerve impulses to and from specific area or region of the

body.

achieved by injecting local anesthetics in closeproximity to appropriate nerves.

reduce all painful sensation in one region of the body

without inducing unconsciousness.

agents used are lidocaine and bupivacaine.

Techniques used in Regional Anesthesia


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A. Topical Anesthesia

applied directly to the skin and mucous membrane, open skin surfaces, wounds

and burns.

readily absorbed and act rapidly

used topical agents are lidocaine and benzocaine

B. Spinal Anesthesia ( Subarachnoid block )

local anesthetic is injected through lumbar puncture, between L2 and S1

anesthetic agent is injected into subarachoid space surrounding the spinal cord.

- Low spinal, for perineal/rectal areas

- Mid spinal T10 ( below level of umbilicus) for hernia repair and appendectomy.

- High spinal T4 ( nipple line ), for CS

anesthetic block conduction in spinal nerve roots and dorsal ganglia; paralysis and

analgesia occur below

level of injection

agents used are procaine, tetracaine, lidocaine and bupivacaine.

Indicating a site for insertion of the lumber puncture


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g p

needle into the subarachnoid space of the spinal

canal.


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E. Intravenous Block ( Beir block )

often used for arm,wrist and hand procedure

an occlusion tourniquet is applied to the extremity to prevent infiltration

and absorption of the injected IV agents beyond the involved extremity.

F. Caudal Anesthesia

Is produced by injection of the local anesthetic into the caudal or sacral

canal

G. Field Block Anesthesia The area proximal to a planned incision can be injected and infiltrated

with local anesthetic agents.



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OTHER TECHNIQUES OF ADMINISTRATION OF LOCAL


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OR REGIONAL ANESTHESIA:

Topical Application the anesthetic is directly applied to a mucous membrane, to a

serous surface, or into an open wound.

Cryoanesthesia

involves blocking local nerve conduction of painful impulses bymeans of marked surface cooling of a localized area. It is usedin such brief procedures as the removal of warts ornoninvasive popular surface lesions.

Simple Local Infiltration is injected intracutaneously and subcutaneously into tissues atand around the incisional site to block peripheral sensorynerve stimuli at their origin. It is used for suturing superficiallacerations or excising minor lesions.


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Administration of Local Anesthesia

in the absence of an anesthesia provider, a qualifiedregistered nurse is responsible for monitoring the

patients physiologic status and safety during local

anesthesia. This should be the only activity assigned

to this nurse for the duration of the procedure. He or

she should not perform circulating duties

simultaneously.

Comparison of Toxicity and Allergy Caused by Local


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Anesthetic Drugs

Toxic Reaction Allergic Reaction

Symptoms vary depending on thedrug

Immediate localized reactionfollowed by generalized bodyreaction

SUBJECTIVEDizziness, somnolence,paresthesia, nausea,visual/speech problems

Sense of uneasiness, pruritus,agitation, paresthesia

OBJECTIVE

Decreased breathing rate anddepth, muscle twitches, tremors,slurred speech, seizures,vomiting unconsciousness, coma

Erythema, urticaria, wheals


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VASOVAGAL

Dysrhythmia, bradycardia,

vasodilation, hypotension,myocardial depression,

cardiac arrest

Coughing, sneezing, wheezing,

bronchospasm, hypotension,hypovolemia, vasodilation,

cardiovascular collapse,

cardiac arresr

TREATMENT

Supportive, airway

management; need intravenous

(IV) line; Trendelenburg

position; muscular contractionsare treated with diazepam

(Valium)

Especially with amino ester

type: airway management, IV

fluids, epinephrine,

diphenhydramine, and steroidsas needed

Guidelines in Monitoring a Patient Receiving a Local


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Guidelines in Monitoring a Patient Receiving a LocalAnesthetic:

The patient is monitored for reaction to drugs and forbehavioral and physiologic changes.

The nurse attending the patient should have basicknowledge of the function and use of monitoringequipment, ability to interpret information, and working

knowledge of resuscitation equipment. The nurse shouldhave appropriate training and knowledge in pharmacologyand the application of the drugs used in the patients care.

Accurate reflection of perioperative care should bedocumented on the patients record.

Institutional policies and procedures in regard to patientcare, including monitoring, should be written, reviewedannually, and readily available. This information should beincluded in orientation and inservice programs.

Local and Regional Anesthetic Agents


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Local and Regional Anesthetic Agents

Generic

Name

Trade

Name(s)

Uses Concentratio

n

Duration of

Effect(Hours)

Maximum

Dosage

AMINO

AMIDES

Bupivacaine

hydrochloride

Marcaine

Sensorcaine

Local

infiltration

Regionalblock

Surgical

epidural

0.25% to

0.50%

2 to 3 400mg

Dibucainehydrochlorid

e

NupercainePercaine

Cinchocaine

Localinfiltration

Peripheral

nerves

0.05% to0.1%

3 to 3 30mg


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Etidocaine

hydrochlori

de

Duranest Peripheral

nrves

Epidural

0.5% to 1% 2 to 3 500mg

Lidocaine

hydrochlori

de

Xylocaine

Lignocaine

Topical

Infiltration

Peripheral

nerves

Nerve block

Spinal

Epidural

2-4%

0.5%

1-2%

to 2 200mg

500mg or

7mg/kg

body weight

Mepivacaine

hydrochlori

de

Carbocaine InfiltrationPeripheral

nerves

Epidural

0.5-1%1-2%

to 2 500mg

Prilocaine

hydrochlori

Citanest Infiltration

Peripheral

1-2%

2 3%

to 2 600mg


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hydrochlori

de

Peripheral

nerves

Regional

Block

Epidural

2-3%

Ropivacaine Naropin Infiltration

Field block

Nerve block

Epidural

Postoperativ

e painmanagemen

t

Not used for

Bier block

0.2%

0.5%

0.75%

1%

2 for

surgical

analgesia; 6

to 10 for

surgical

nerve block

200mg for

analgesia;

300mg for

nerve block

AMINO

ESTERS

Chloroproc

aine

hydrochlori

de

Nesacaine Infiltration

Peripheral

nerves

Nerve block

Epidural

0.5%

2%

2%

2-3%

to 1000mg

Cocaine Topical 4-10% 200mg or


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hydrochlori

de

4mg/kg

body

weight

Procaine

hydrochlori

de

Novocain Infiltration

Peripheral

nervesSpinal

0.5%

1-2%

to 1000mg or

14mg/kg

bodyweight

Tetracainehydrochlori

de

CetacainePontocaine

TopicalSpinal

2%1%

2 to 4 20mg


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POSITIONING

Lateral position: the patient lies on the side withthe back at the edge of the operating bed. Theknees are flexed onto the abdomen, and thehead is flexed to the chest. The hips andshoulders are vertical to the operating bed to

prevent rotation of the spine.

Sitting position: the patient sits on the side ofthe operating bed with the feet resting on a

stool. The spine is flexed, with the chin loweredto the sternum; the arms are crossed andsupported on a pillow on an adjustable table.

Positioning Surgical Patient (Spinal


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Positioning Surgical Patient (SpinalAnesthesia)

Sitting PositionLateral Position


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Stages of

Anesthesia

St I St f


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Stage I . Stage of

Analgesia / induction

phase

This stage extends from the


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This stage extends from the

beginning of Administrationof an anesthetic to the

beginning of the loss ofconsciousness. The

sensation of pain is not lost.


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Stage I . Stage of Analgesia / induction phase

The client maybe

drowsy or dizzy

May experiencehallucinations

Circulating nurse


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Circulating nurse

should close the OR

doorsKeep quiet

Stand by to assist

client

St II St f


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Stage II. Stage of

Delirium / Excitement

Extends from the loss of


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Extends from the loss of

consciousness to the lossof eyelid reflex. Any

stimulation has thepotential to cause the

client to become difficult

to control


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Stage II. Stage of Delirium / Excitement

Increased muscletone

Irregular respiration

REM ( rapid eye

movement)

Retching & Vomiting


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Retching & Vomiting

may occur

Circulating nurseshould remain quietly

by patients side

Assist if needed


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Stage III Stage of


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Stage III. Stage of

Surgical Anesthesia

Extends from loss of lid


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Extends from loss of lid

reflex to cessation ofrespiratory effort or

depressed vital

functions.


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Stage III. Stage of Surgical Anesthesia

completely dilated &unresponsive pupils

absence of reflex

( muscles completelyrelaxed)

Client is unconscious


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Client is unconscious

Begin preparation

Client is in good

control

Stage IV Stage of


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Stage IV. Stage of

Danger / Medullary

stage

From vital functions too


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From vital functions too

depressed to Respiratoryfailure/ Death & Disability

due to too highconcentration of

anesthetic in the CNS.

Client is not


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Client is not

breathing

May not have heartbeat

Assist in

resuscitation

Speed of EMERGENCE


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Speed of EMERGENCE

(recovery from anesthesia) depends on typeof anesthesia, length of time & many other

factors- try to time with end of surgery


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Care of the anesthetized

patient:

Considerations:


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A deficit in pulmonary and/or cardiac functions isdetrimental to the patients physiologic status.Abnormalities of pulmonary ventilation and diffusioninfluence the course of the anesthesia and diminishtolerance to stress or the insults from the anesthetic and theprocedure.

Circulation is affected both centrally and peripherally.Individual agents are associated with characteristichemodynamic patterns.

The liver is affected by general agents. Alterations in liverfunction tests may follow anesthesia.

Kidney function is affected by disturbances in systemiccirculation, since kidneys normally receive 20% to 25% of

cardiac output. Biotransformation of agents varies with metabolitesexcreted by the kidneys. Urinary excretion of IV agents maybe slow and unpredictable.

Agents may cause nausea, emesis, or systematiccomplications.

Safety Factors:


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The patients position is changed slowly and gently to allowcirculation to readjust.

Proper positioning and padding are important to avoid pressurepoints, stretching of nerves, or interference with circulation to anextremity.

The patients chest must be free of adequate respiratory excursionduring the surgical procedure. The airway must be patent.

The lungs must be adequately ventilated intraoperatively andpostoperatively by either voluntary or mechanical means.

The anesthesia provider assists in transferring the patient to astretcher or bed, safeguarding the head and neck, when it is safe

to move the patient. The anesthesia provider gives the nurse a verbal report, including

specific problems in regard to this patient, and completes recordsbefore the transfer of responsibility.

Complication and Discomforts of


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Anesthesia

Hypoventilation - inadequate ventilatory support after paralysis of respiratory

muscles.

Oral Trauma

Malignant Hyperthermia

Hypotension - due to preoperative hypovolemia or untoward reactions to

anesthetic agents.

Cardiac Dysrhythmia - due to preexisting cardiovascular compromise, electrolyte

imbalance or untoward reaction to anesthesia.

Hypothermia - due to exposure to a cool ambient OR environment and loss of

thermoregulation capacity from anesthesia.

Peripheral Nerve Damage - due to improper positioning of patient or use ofrestraints.

Nausea and Vomiting

Headache


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SURGICAL TEAM

Members of Sterile


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Surgical Team

the sterile team members scrub their hands and arms

wears sterile gown and gloves

enter the sterile field. [To establish sterile field, all

items needed for the procedure are sterilized.]After the process, the scrubbed and sterile teammember functions within the limited area and the onlysterile items.

1. Surgeon

2. Assistants to the surgeon

3. Scrub person

*SURGEON


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must have the knowledge, skills and judgmentrequired to successfully perform the intendedsurgical procedure and any deviationsnecessitated by unforeseen difficulties.

must be prepared for the unexpected.

responsibilities include pre-operative diagnosis &cure, selection & performance of surgery & post-operative management of care.

licensed physician (MD), oral surgeons, etc.

appropriate clinical skills & personal character areimportant attributes of a surgeon.

*ASSISTANTS TO THE SURGEON


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under the direction of the operatingsurgeon, one or two assistants help tomaintain visibility of the surgical site,control bleeding, close wounds, and applydressing.

Handles tissues & uses instruments

Anticipates blood loss, anesthesia time for

patient, fatigue affecting OR team &potential complications

*1STASSISTANT IN SURGERY


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qualified surgeon or a resident doctor

capable of performing procedures for

primary surgeon

post-graduate intern & medical intern

surgeon may request assistance of an

associate physician w/ whom the

surgical procedure is shared & towhom part of patients care is

delegated


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Non-Sterile Members of the


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Surgical Team

1. Anesthesia Provider2. Circulator3. Others (the OR team may include biomedical

technicians, radiology technicians, and others who may

be needed to set up and operate specializedequipment or monitoring devices during the surgicalprocedure)

the unsterile team members DO NOT enter the sterilefield.

They handle supplies and equipments that are not

considered sterile.Following the principles of aseptic technique, they keep

the sterile team supplied.

*ANESTHESIA PROVIDER


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this refers to the person responsible for the

inducing anesthesia, maintaining anesthesiaat the required levels, and managing

untoward reactions to anesthesia throughout

the surgical procedure.

*CIRCULATOR


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the circulator plays a role that is vital tothe smooth flow of events before, during,

and after the surgical procedure.

The circulators role as a patient advocate

and protector is critical to the safety and

welfare of the patient and extends

throughout the entire pre-operative

environment.

Sterile Field


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Sterile Field

The area surrounding the client and thesurgical site that is free from all

microorganisms.


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DUTIES AND RESPONSIBILITIES OFTHE SCRUB AND CIRCULATING

NURSE

SCRUB NURSE


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SCRUB NURSE

Both the circulator and the scrub person set up the room and positionthe equipment. The case cart and room furniture are checked byboth persons as a team. The duties and activities change when thepatient arrives at the OR suite. The circulator begins working withthe patient while the scrub nurse continues readying the room.

THE SCRUB NURSE DUTIES:When all supplies have been obtained and opened and the

room is ready for the patients arrival, the scrub nurse prepares forthe surgeons arrival. At all times, the integrity of the sterile field isclosely monitored. The principles of asepsis and sterile technique

are followed.

Preparation of the sterile field:


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The scrub nurse should be sure that his or her gownand gloves are open and ready on a surface separatefrom the sterile field.

perform a complete surgical hand cleansing accordingto the facility procedure.

gown and glove using closed gloving method. drape unsterile tables according to standarddepartmental setup procedure with drapes from thedrape pack.

a second instrument table may be needed for extensive

surgical procedures or special types of instrumentation(e.g., tables for preparation of an implant or organ fortransplant)

drape both the frame and the tray of the Mayo stand

arrange on the Mayo stand the instruments and accessory


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arrange on the Mayo stand the instruments and accessoryitems to create primary precision. Arrange other

instruments and items on the instrument table. (the Mayostand should be kept neat throughout the surgicalprocedure. Do not overload it with sponges and sharps)

count sponges, surgical needles, other sharps, and

instruments with the circulating nurse according toestablished facility policy and procedure.

secure surgical needles and all other sharps, including theknife blades. They should never be loose on the Mayostand.

prepares sutures in the sequence in which the surgeon willuse them.

After the surgeon and assistant(s) scrub:


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gown and glove the surgeon and assistant(s) assoon after they enter the OR as possible.

assist in draping according to the type of procedure

and the surgeons preference.

after draping is completed, bring the Mayo standinto position over the patient, making sure it does

not rest on the patient.

position the instrument table at a right angle to the

operating bed. assist the surgeon in securing sterile light handles

for adjustment of the operating light.

During the surgical procedure:


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pass the skin knife to the surgeon, and pass a hemostat andsuction to the assistant. When passing the knife, take care todirect the blade away from yourself and other personnel.

hand up sterile towels or lap sponges if requested for coveringskin at the edges of the incision.

watch the field and try to anticipate the needs of the surgeonand assistant. Keep one step ahead of them in passinginstruments, sutures, and sponges and in handing up thespecimen basin.

return instruments to the Mayo stand or instrument table afteruse.

keep instruments as clean as possible. repeat the size of a suture or ligature when handing it to the

surgeon as appropriate.

be logical in selecting the instruments used for suturing.

have scissors ready when the knot is tied.

remove waste ends of suture material from the field Mayo


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remove waste ends of suture material from the field, Mayo

stand, and instrument table, and place them in the trash

disposal container. follow established institutional policy and procedure for

securing sharps during the surgical procedure.

keep the specimen basin on the field until all tissue has been

removed or all contaminated items have been placed in it. Before closure, the surgeon may request several liters of

fresh, warm irrigation solution to rinse the abdomen or

smaller amounts to irrigate other surgical wounds. Keep

track of the amount of irrigation used, and report it to thecirculating nurse for the permanent record.

alert the circulating nurse that closure is about to begin, andhand up the wound closure materials.


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in accordance with established procedures, count sponges,sharps, and instruments with the circulator as the surgeon

begins closure of the wound. Verify that intraabdominal orother cavity packing materials and towels have beenremoved.

place unneeded instruments and supplies on the instrumenttable in the original set position

have a clean, warm, saline-moistened sponge ready towash blood from the area surrounding the incision assoon as skin closure is completed.

have the sterile dressings ready.

after the dressing is in place, the team will undrape the

patient. Place the soiled drapes in the appropriatereceptacleNOT on the instrument table or Mayo stand

The Eight Ps to consider

when preparing for aSterile Field Considerations Environment Considerations


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when preparing for a

Surgical Procedurefor the Scrub Nurse for the Circulating Nurse

PROPER PLACEMENT-items should be placed so

they will not need to be

moved during the procedure.

The Mayo stand should not

be moved during the

procedure. Drapes may not

be moved on the patients

skin.

Suction canisters, tourniquet,

and the electro-surgical unit

(ESU) need to be stationary.

The operating lights should

be directed toward the field.

PROPER FUNCTION

-items should be tested forsafety and usefulness before

they are needed, to prevent

delay in the case.

Test the efficiency of

instruments (e.g., scissors,needle holders, clamps) as

they are needed.

Test the ESU, tourniquet,

laser, and other equipmentbefore the patient enters the

room.

PLACE IT ONCE

-items should not be

i l d d i h

When setting up the field,

each item (e.g., a basin)The operating bed should be

h i h l f h


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manipulated during the

procedure. Energy and

attention should not be

diverted to resetting the

field.

each item (e.g., a basin)

should be placed where it

will be used during the

procedure with minimalhandling.

at the right place for the

procedure. The dispersive

electrode should not be

moved or displaced.

POINT OF CONTACT

-items used within the

field could cause harm or

be rendered useless ifthey do not reach the

intended point of

contact.

The scrub nurse should be

aware of the passing of

the instruments and how

they are securely placed

in the waiting hand of the

surgeon or first assistant.

The circulating nurse should

evaluate the delivery of

items to the sterile field.

Some items (e.g., staplers)should be handed; others

can be transferred in other

ways.

POSITION OF FUNCTION-items should be

positioned so they will be

useable during the

procedure.

When passing

instruments, they should

be placed in the surgeons

hand in a useable way.

For example, the curve of

the instrument should

match the curve of the

hand.

The use of a laser with

articulating arm, ormicroscope should be

preplanned so they may be

positioned while the

procedure is in progress.

Basins should be placed

close to the edge of the

table so the circulating nursePour solutions directly into the


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POINT OF USE

-items should be as close to

the area of use as possible.

g

can pour without requiring

the basin to be repositioned.

The ESU pencil holder

should be close to the field

for safe containment of the

tip.

Pour solutions directly into the

basins, open and hand sponges

or sutures directly to the scrub

nurse as they are needed.

PROTECTED PARTS

-items and surfaces shouldbe rendered safe for the

patient and the team.

Apply jaw liners to

instruments during setup.

Hand instruments with care

to avoid causing injury with

the tip or sharp surface. Do

not lay items on or against

the patients body.

Cords, cables, and tubing

should be secured and

appropriately directed awayfrom the field. Pad the

operating bed and patient as

appropriate. Use safety belts.

PERFECT PICTURE

-items within and aroundthe field should not be at

risk for causing harm or

becoming damaged. The

environment should not be

cluttered.

The sterile field should

remain neat and orderly,with instruments and

supplies within easy sight

and reach. Consistent setup

fosters a sense of comfort

and confidence in the scrub

role.

The entire room should appear

neat and tidy. The door should

be closed, and thetemperature and humidity

should be appropriate.

Forethought to having a clear

path for the crash cart or

emergency equipment is

essential.


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-before entering the OR suite, the circulating nurse mustwash his/her hands and arms as required by institutional

policy and procedure, but he/she does not don sterile

gowns and gloves.

--should assist the sterile scrub nurse by providing andopening sterile supplies needed to prepare for arrival of the

patient and the surgeon.

--test all equipments before bringing to the OR suite.

After scrub nurse scrubs:


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fasten the back of scrub nurses gown check with the scrub nurse to see if additional

supplies or instruments are needed.

check the list of suture materials and sizes on thesurgeons preference card and verify with the surgeon

before opening pockets establish a baseline of table of contents for the record,

count sponges, sharps and instruments together withthe scrub nurse in the manner as described in facilitypolicy and procedure.

the instrument counts will be recorded on theinstrument tray sheet packed with the set.

After the patient arrives:


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attend to patient while scrub nurse continues toprepare the instrument table for the arrival of the

surgeon.

greet and identify the patient, introduce yourself, and

identify your title and role. ask patient to verbally identify himself/herself.

verify any allergies and other environmental/chemical

sensitivities the patient may have.

be sure the patients hair is covered with a cap

loosen the neck and back ties on the patients gown

f h h f d h b d l


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after the patient has transferred to the operating bed, apply

safety belt over the thighs 2-3 inches above the patients

knees, and place his/her arms on armboards.

help anesthesia provider as needed

apply and connect monitoring devices, and assist with IV

infusion, induction, and intubations as necessary.

before handing the IV bag, check first the expiration date,

and gently squeeze it to detect leaks.

check the solution for clarity or discoloration; a cloudy

solution is contaminated. Check the label on the container

before the solution is administered.

During induction of anesthesia:


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g

remain at patients side during the induction ofanesthesia.

assist the anesthesia provider during induction

and intubation.

maintain a quiet environment. Tactile or auditorystimulation may produce excitement in the patient

during induction.

After the patient is anesthetized:


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attach anesthesia screen and other table attachments asneeded.

reposition the patient only after the anesthesia provider

says the patient is anesthetized to the extent that he/she

will not be disturbed by being moved or touched.

before the draping begins, note the patients position to be

certain all measures for his/her safety have been observed.

-prepare the patients skin with antiseptic solution.

turn on the overhead spotlight over the site of the incision.

bag and discard the sponges from a reusable prep tray

immediately after use.

After the surgeon and assistants scrub:


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-assist with gowning the team. Fasten the waist tie,

followed by the neck closure to allow the upper body more

freedom of motion for gloving.

should stand by to help with the back flap tie-in of the

gown.

observe for any breaks in sterile technique during draping.Stand near the head end of the operating bed to assist the

anesthesia provider in fastening the drape over the

anesthesia screen or around an IV pole next to the

armboard. assist the scrub nurse in moving the Mayo stand and

instrument table into position, being careful not to touch

the drapes.


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place steps or platforms for team members who need

them, or place stools in position foe the team that need to

operate while seated.

position kick buckets on each side of the operating bed.

connect suction, the ESU cord, the dispersive electrode

cable, or any other powered equipment to be used.

place foot pedals within easy reach of the surgeons right

foot.

confirm and document the desired settings on the

machines.

During the Surgical Procedure:


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be alert to anticipate the needs of the sterile team, such asadjusting the operating lights, removing perspiration from brows,and keeping the scrub nurse supplied with sponges, sutures, warmsaline, and other necessary items.

watch the surgical procedure closely enough to see when routinesupplies are needed and gives them to the scrub nurse without

being asked for them. should know how to use and care for all supplies, instruments,

and equipment and be able to get them quickly.

stay in the room. Inform scrub person if you must leave to getsomething.

be available to answer questions, obtain supplies and assist teammembers.

keep discarded sponges carefully collected; separated bysizes, and counted according to the number they arepackaged in.


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p g

assist the surgeon and the anesthesia provider monitor bloodloss. Weigh sponges if requested to do so.

know the condition of the patient at all times. Inform the ORmanager of any marked changes, unanticipated additionalprocedure, or delays.

communicate periodically with the patients family or

significant others to inform them of the progress of theprocedure as appropriate.

prepare and label specimens for transfer to the laboratory.Always wash hands thoroughly after removing gloves thathave been worn to handle specimens.

as required, complete the documentation in the patientschart, permanent OR records, and requisition for laboratorytests or chargeable items.

During Closure:


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count sponges, sharps, and instruments with the scrubnurse. Report counts as correct or incorrect to thesurgeon. Complete the count records. Collect usedsponges for disposal in the appropriately markedreceptacles.

obtain the washer-sterilizer tray, instrument tray, andother items necessary or the cleanup procedure.

send for a postanesthesia care unit (PACU) stretcher oran intensive care unit (ICU) bed, or prepare thepatients stretcher or bed with a clean sheet; followwhatever is the institutional procedure.

obtain a transfer monitor and oxygen tank with tubingif needed.


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COMMON ABDOMINALINCISIONS

1. Paramedian Incision


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is a vertical incision made approximately 4cm (2 in)

lateral to the midline on either side in the upper andlower abdomen

it limits trauma, avoids nerve injury, is easilyextended, and gives a firm closure

it allows quick entry into and excellent exposure ofthe abdominal cavity

ex: access to the biliary tract/pancreas (right upperquadrant) and resection of the sigmoid colon (left

lower quadrant)

2. Longitudinal Midline Incision


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can be upper abdominal, lower abdominal, or acombination of both going around the umbilicus

depending on the length of the incision, it begins

in the epigastrum at the level of the xiphoidprocess and may extend vertically to the

suprapubic region

upper midline incision offers excellent exposure

of a rapid entry into the upper abdominal

contents

3. Subcostal, Upper Quadrant ObliqueIncision


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a right or left oblique incision begins in the

epigastrum and extends laterally and obliquelyjust below the lower costal margin

affords limited exposure except for upperabdominal viscera, it provides good cosmetic

results because it follows skin lines and produceslimited nerve damage

biliary modified subcostal incision (ChevronIncision) is made for increased visibility during a

liver transplantation or resection ex: biliary procedures and splenectomy

4. McBurney's Incision


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located in the right lower quadrant just below

the umbilicus 4cm (2 in) medial from the

anterior superior iliac spine

involves a muscle-splitting incision that

extends through the fibers of the external

oblique muscle

a fast and easy incision, but exposure is

limited

its primary use is for appendectomy

5. Thoracoabdominal Incision


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patient is placed in a lateral position either a right or left incision that begins at a point

midway between the xiphoid process andumbilicus and extends across the abdomen to the

7th

and 8th

interspace and along the interspaceinto the thorax

allows excellent exposure for the upper end ofthe stomach and the lower end of the esophagus

ex: esophageal varices and the repair of a hiatalhernia

6. Midabdominal Transverse Incision


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starts on either the right or left side andslightly above or below the umbilicus

the advantages are rapid incision, easy

extension, a provision for retroperinealapproach, and a secure postoperative wound

ex: choledochojejunostomy and transverse

colostomy

7. Pfannstiel's Incision


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a curved transverse incision across the lowerabdomen and within the hairline of the pubis

this lower transverse incision provides good

exposure and strong closure for pelvicprocedures

its primary use is for an abdominal

hysterectomy

8. Inguinal Incision, Lower Oblique


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right or left incision that extends from the pubic

tubercule to the anterior crest of the ilium,

slightly above and parallel to the inguinal crease

incision of the external oblique fascia providesaccess to the cremaster muscle, inguinal canal

and cord structure

its primary use is for inguinal herniorrhaphy


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LAYERS OF THE ABDOMEN


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BASIC SURGICAL INTSTRUMENTS

OPERATION ROOM SET-UP (EQUIPMENTS

AND APPARATUS)


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)

- standardized basic sets of sterile instrumentsare selected for each specific surgical

procedure

- a set is a group of instruments that mayinclude all appropriate classifications of

instruments or the instruments needed for a

specific part of the procedure (e.g. gallbladderset)

Classifications:


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Cutting and Dissecting Grasping and Holding

Retracting and Exposing

Clamping and Occluding Miscellaneous

Cutting and Dissecting Instruments


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are sharp and are used to cut body tissue or surgical supplies.

Knife Handle, Scissors(left to right)



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7 handle with 15 blade (deep knife)- Used to cut deep,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.

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


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Surgical Blades

10 1112 15

20


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Straight Mayo scissors- Used to cut suture and supplies. Alsoknown as: Suture scissors.

EX: Straight Mayo scissors being used to cut suture.



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Curved Mayo scissors- Used to cut heavy tissue (fascia,muscle, uterus, breast). Available in regular and long sizes.

Curve and Straight Scissors


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Metzenbaum scissors- Used to cut delicate tissue. Availablein regular and long sizes.

Metzenbaum


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ELECTROCAUTERY MACHINE


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Cutting and Dissecting

Instruments


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Scalpel holderCurved and Straight Mayo

Scissors Metzenbaum

Lister/Bandage Scissors Suture ScissorsStitch Scissors

Clamping and Occluding Instruments


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are used to compress blood vessels or hollow organs forhemostasis or to prevent spillage of contents.



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Ahemostatis used to clamp blood vessels or tag sutures. Itsjaws may be straight or curved. Other names: crile, snap or

stat.



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A mosquitois used to clamp small blood vessels. Its jaws maybe straight or curved.

hemostat, mosquito (left to right)



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A Kellyis used to clamp larger vessels and tissue. Available inshort , MEDIUMand long sizes. Other names: Rochester Pean.

Kelly, hemostat, mosquito (left to right)



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A burlisheris used to clamp deep blood vessels. Burlishershave two closed finger rings. Burlishers with an open finger

ring are called tonsil hemostats. Other names: Schnidt tonsilforcep, Adson forcep.



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A right angleis used to clamp hard-to-reach vessels and toplace sutures behind or around a vessel. A right angle with a

suture attached is called a "tie on a passer." Other names:

Mixter.



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A hemoclip applier with hemoclipsapplies metal clips ontoblood vessels and ducts which will remain occluded.

hemoclip applier with hemoclips



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Straight Mosquito

Kelly Clamp

Pean (Rochester-Pean) Clamp

Crile Clamp

Right-Angled (Mixter/Dissector) Forceps

Grasping and Holding Instruments


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are used to hold tissue, drapes or sponges.



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An Allisis used to grasp tissue. Available in short and longsizes. A "Judd-Allis" holds intestinal tissue; a "heavy allis"

holds breast tissue.



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A Babcockis used to grasp delicate tissue (intestine, fallopiantube, ovary). Available in short and long sizes.



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A Kocheris used to grasp heavy tissue. May also be used as aclamp. The jaws may be straight or curved. Other names:

Ochsner.



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A Foerster sponge stickis used to grasp sponges. Othernames: sponge forcep.

Foerster sponge stick EX: Sponge sticks holding a 4 X 4

and probang.


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A Backhaus towel clip is used to hold towels and drapes inplace. Other name: towel clip.

Backhaus towel clip Large & small towel clips



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Pick ups and thumb forceps are available in various lengths,with or without teeth, and smooth or serrated jaws.



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Russian tissue forcepsare used to grasp tissue.



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Adson pick upsare either smooth: used to grasp delicatetissue; or with teeth: used to grasp the skin. Other names:

Dura forceps.



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Long smooth pick-ups are called dressing forceps. Shortsmooth pick-ups are used to grasp delicate tissue.



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DeBakey forcepsare used to grasp delicate tissue, particularlyin cardiovascular surgery.



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Thumb forcepsare used to grasp tough tissue (fascia,breast). Forceps may either have many teeth or a single

tooth. Single tooth forceps are also called "rat tooth

forceps."

single tooth forceps, many teeth forceps(top to bottom)


(Tissue Forceps)


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DeBakey TissueForceps

Adson TissueForceps

Russian TissueForceps

These are available in various lengths, with or without teeth,

and smooth or serrated jaws.


Russian Tissue Forceps


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They have serration up to the tips, allowing bettergrasp of tissue with minimum trauma.



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Mayo-Hegar needle holdersare used to hold needles whensuturing. They may also be placed in the sewing category.

short, medium & long(top to bottom)

EX: Needle holder with suture.

Suturing Instruments


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Hook and Dissector


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Randall Stone Forceps


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To hold/remove kidney stones

Retracting and Exposing Instruments


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used to hold back or retract organs or tissue to gain exposureto the operative site. They are either "self-retaining" (stay

open on their own) or "manual" (held by hand). When

identifying retractors, look at the blade, not the handle.



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A Deaverretractor (manual) is used to retract deep

abdominal or chest incisions. Available in various widths.



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A Richardsonretractor (manual) is used to retract deep

abdominal or chest incisions



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An Army-Navyretractor(manual) is used to retract shallow or

superficial incisions. Other names: USA, US Army.



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

incisions.



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A malleable or ribbonretractor (manual) is used to retract

deep wounds. May be bent to various shapes.



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A Weitlaner retractor (self-retaining) is used to retract shallow

incisions.

( )



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A Gelpiretractor (self-retaining) is used to retract shallow

incisions.

lf i h bl dd bl d ( lf ) d



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A Balfour with bladder blade(self-retaining) is used to retract

wound edges during deep abdominal procedures.

Richardson Retractor


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Vein retractor


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Senn Retractor


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Senn

Volkmann Rake

US Army Navy Deaver

Malleable Vein Retractor Green Goiter

WeitlanerLangenbeck Skin Hooks Vaginal Speculum

Richardson

SUTURES


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SUTURES

Is a medical device used to hold tissue


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Is a medical device used to hold tissuetogether after an injury or surgery till healingtakes place.

Sutures (also known as stitches) are dividedinto two kindsthose which are:

1. Absorbable

2. Non-absorbable.

ABSORBABLE


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- will break down harmlessly in the body over timewithout intervention

- digested by body cells and fluids during thehealing period.

- used therefore in many of the internal tissues ofthe body. In most cases, three weeks sufficient forthe wound to close firmly

- originally made of the intestinesof sheep, the socalled catgut.

ABSORBABLE
http://en.wikipedia.org/wiki/Intestinehttp://en.wikipedia.org/wiki/Catguthttp://en.wikipedia.org/wiki/Catguthttp://en.wikipedia.org/wiki/Intestine


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untreated (plain gut) tanned with chromium salts to increase their

persistence in the body (chromic gut)

heat-treated to give more rapid absorption (fast

gut).

Examples: Chromic, Plain,Polydiaxone (PDS), Polyglactin

910 (Vicryl),Polyglycolic Acid(Biovek)- Used for those who cant return for suture removal/in

internal body tissues

ABSORBABLE


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Plaindissolves within 5-10 days, YellowChromic- dissolves within 1 month, Brown

Vicryl/Safil-dissolves within 60-90 days,

LavenderPDS (Polydioxone)- dissolves 2 times longer

than the other absorbable sutures, White

Non-absorbable sutures

The non absorbable ones have to be removed after


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The non absorbable ones have to be removed afterspecified time. The type of suture is decided againby the location of the wound.

Nonabsorbable suturesare made of materials which

are not metabolized by the body, and are usedtherefore either on skin wound closure, where thesutures can be removed after a few weeks, or insome inner tissues in which absorbable sutures arenot adequate.

Examples: Silk,Nylon,Prolene (Polypropylene)

Types:

Non-absorbable sutures


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Types:

Silk- is an animal product from silk worm cocoons.(Black)

Cotton-made from long staple cotton, treated to make itsmooth, (White)

Prolene- biosynthetic, non-absorbable suture material, assubstitute to silk

Wire- gives the greatest strength to any suture material.

ABSORBABLE SUTURE


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NONABSORBALE SUTURE


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SUTURE NEEDLES

1. Traumatic needles


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1. Traumatic needles

- are needles with holes or eyes which are supplied tothe hospital separate from their suture thread.

- The suture must be threaded on site, as is done whensewing at home.

2. Atraumatic needles

- with sutures comprise an eyeless needle attached to aspecific length of suture thread.

Needles may also be classified by theirpoint geometry; examples include:


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taper (needle body is round and tapers smoothly to apoint)

cutting (needle body is triangular and has a sharpenedcutting edge on the inside)

reverse cutting (cutting edge on the outside) trocar point or tapercut (needle body is round and

tapered, but ends in a small triangular cutting point)

blunt points for sewing friable tissues

side cutting or spatula points (flat on top and bottomwith a cutting edge along the front to one side) for eyesurgery

Different Types Of Needles
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Viewing- surgeons can examine the interior of body cavities, hollow organs, orstructures with viewing
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1. Speculums

- the hinged, blunt blades of a speculum enlarge and hold open a canal

2. Endoscopes

- round or oval sheath of an endoscope is inserted into a body orifice or

through a small skin incision

a. Hollow Endoscopes

- the rigid hollow sheath permits viewing in a forward direction throughthe endoscope

b. Lensed Endoscopes

- have either rigid or flexible sheathes, and they have eyepiece with atelescopic lens system fr viewing in several direction

Suctioning and Aspirating-

- blood, body fluids, tissue, and irrigating solution may be


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, y , , g g y

removed by mechanical suction or manual aspiration

Suction

- involves the application of pressure to withdraw blood

or fluids, usually for visibility at the surgical site

a. Poole Abdominal Tip

- straight hollow tube with perforated outer filter shield

- used during abdominal laparotomy or within any cavityin which copious amounts of fluid or pus are encountered

b. Frazier Tip


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p

- a right-angle tube with a small diameter- used when encountering little or no fluidexcept capillary bleeding and irrigating fluid

c. Yankauer Tip

- hollow tube that has an angle for use in themouth or throat

d. Aspirating Tube- long, straight tube that is used through an

endoscope

Yankauer Tip


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FRAZIER SUCTION TIP


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GENERAL CONSIDERATIONS

1. Handle loose instruments separately toprevent interlocking or crushing.


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a. Instruments are never piled one on top ofanother on an instrument table

b. Microsurgical, ophthalmic, and other delicate

instruments are vulnerable to damage

through rough handling

c. Metal-to-metal contact should be avoided or

minimized

2. Inspect instruments such as scissors andforceps for alignment, imperfections, cleanliness,

and working conditions


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a. Scalpel blades should be properly set in handlesusing a heavy instrument, not fingers.

b. Teeth and serrations should align exactly

c. Tips should be straight and in alignmentd. Scissors should be snug and sharp in action

e. Cannulae should be clear and without

obstruction


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3. Sort instruments neatly by

classifications


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5. Leave retractors and other heavy instruments in atray or container or lay them out on a flat surface of

the table

6. Protect sharp blades, edges, and tips

a. Sets of instruments may be in sterilization racks so


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ythat the blades and tips are suspended

b. Tip-protecting covers or instrument-protectingplastic should be removed and discarded before theinstruments are used on the patient

c. If they are not in the rack, handles should besupported on a rolled towel or gauze sponge

Counting Procedure Each institution has its own written policy and procedure regarding the

counting of sponges (varying types), sharps, and instruments.


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The following guidelines should be observed when counting all objects

potentially subject to inadvertent inclusion within a wound:

1. The scrub person and the circulator count together (aloud) all items on

the sterile field as the scrub person touches to each item.

2. The circulator immediately records the number (count) of each type of

item. Keeping a record of the count is the legal responsibility of the

circulator.

3. If there is any uncertainty regarding any count, it is repeated.

4. As additional items (e.g., sponges or needles) are introduced to the

sterile field during the procedure, the scrub person counts the item(s)with the circulator, who adds the item to the count in the record and

initials it.

5. Nothing (including laundry, trash, instruments, or sponges) may be removed from an OR

Counting Procedure


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while a procedure is in progress until the final count is acknowledged to be correct. The onlyexception to this is when a specimen is sent to the laboratory for immediate inspection (e.g.,

frozen section) and the specimen remains attached to a counted item (as by sutures to

maintain its orientation); this must be noted and initialed on the intraoperative record.

6. Whenever there is a change of team members, a count is taken.

The name of the replacement person(s) is documented on the intraoperative record.

7. When a package containing an incorrect number of items is opened, the items should bepassed off the table, bagged, and labeled accordingly. The bag with the incorrect number of

sponges is labeled, set aside, and not included in the count. The bag may not be removed

from the room.

8. Counts are taken before the procedure begins, before wound closure begins, and when

skin closure is initiated.

9. An additional count is taken prior to the closure of an organ with a cavity (e.g., uterus,bladder, or bowel).

Incorrect closure counts must be repeated immediately. If the

Counting Procedure


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count remains incorrect, the circulator alerts the surgeon,

who will inspect the patients wound for the missing item.

If the item is not located, hospital policy must be followed,

i.e., usually to include immediate x-ray examination.

Notification of the OR supervisor and an incident report must

be filed as part of the chart, the permanent record.

Any item inadvertently left in a wound may become a source

of infection and result in subsequent litigation.


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POSTOPERATIVE PHASE

POSTOPERATIVE PHASE


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Goals: Maintain adequate body system functions

Restore homeostasis

Alleviate pain and discomfort Prevent postop complication

Ensure adequate discharge planning and

teaching.

PACU CARE


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Transport of client from OR to RR avoid exposure

avoid rough handling

avoid hurried movement and rapid changes in position.

Initial Nursing Assessment

Verify patients identity, operative procedure and the surgeon


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who performed the procedure. Evaluate the following sign and verify their level of stability

with the anesthesiologist:

- Respiratory status

- Circulatory status

- Pulses

- Temperature

- Oxygen Saturation level

- Hemodynamic values

Initial Nursing Assessment


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Determine swallowing and gag reflex , LOC and patientsresponse to stimuli.

Evaluate lines, tubes, or drains, estimate blood loss, condition

of wound, medication used, transfusions and output.

Evaluate the patients level of comfort and safety.

Perform safety check; side rails up and restraints areproperly

in placed.

Evaluate activity status, movement of extremities.

Review the health care providers orders.

Initial Nursing Interventions


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Mai

Intraoperative Lecture

Documents