Scissors • All types of scissors can have blunt or sharp blades • (A: Sharp:Sharp, B: Blunt:Blunt).
• Mayo and Metzenbaum• Mayo scissors (B) are used for cutting heavy fascia and sutures.• Metzenbaum scissors (A) are more delicate than Mayo scissors.• Metzenbaum scissors are used to cut delicate tissues.• Metzenbaum scissors have a longer handle to blade ratio.
• All types can have either straight or curved blades.
• Forceps: consist of two tines held together at one end with a spring device that holds the tines open. Forceps can be either tissue or dressing forceps.• Dressing forceps have smooth or smoothly serrated tips.• Tissue forceps have teeth to grip tissue. Many forceps bear the name of the originator of the design, such as Adson tissue forceps.
• Rat Tooth: A Tissue Forceps• Interdigitating teeth hold tissue without slipping.• Used to hold skin/dense tissue.
• Adson Tissue Forceps• Small serrated teeth on edge of tips.• The Adsons tissue forceps has delicate serrated tips designed for light, careful handling of tissue.
• Intestinal Tissue Forceps: Hinged (locking) forceps used for grasping and holding tissue.• Allis: An Intestinal Tissue Forceps• Interdigitating short teeth to grasp and hold bowel or tissue.• Slightly traumatic, use to hold intestine, fascia and skin.
• Babcock: An Intestinal Tissue Forceps• More delicate that Allis, less directly traumatic.• Broad, flared ends with smooth tips.• Used to atraumatically hold viscera (bowel and bladder).
• Sponge Forceps• Sponge forceps can be straight or curved.• Sponge forceps can have smooth or serrated jaws.• Used to atraumatically hold viscera (bowel and bladder).
• Hemostatic forceps: Hinged (locking) Forceps. Many hemostatic forceps bear the name of the designer (Kelly, Holstead, Crile). They are used to clamp and hold blood vessels.
• Classification by size and shape and size of tips• Hemostatic forceps and hemostats may be curved or straight.
• Kelly Hemostatic Forceps and Mosquito Hemostats• Both are transversely serrated.• Mosquito hemostats (A) are more delicate than Kelly hemostatic forceps (B).
• Comparison of Kelly and Mosquito tips• Mosquito hemostats (A) have a smaller, finer tip.
• Carmalt• Heavier than Kelly.• Preferred for clamping of ovarian pedicals during an ovariohysterectomy surgery because the serrations run longitudinally.
• Doyen Intestinal Forceps• Doyen intestinal forceps are non-crushing intestinal occluding forceps with longitudinal serrations.• Used to temporarily occlude lumen of bowel.•
• Payr Pylorus Clamps• Payr pylorus clamp is a crushing intestinal instrument.• Used to occlude the end of bowel to be resected.
• Needle holder: Hinged (locking) instrument used to hold the needle while suturing tissue.• Good quality is ensured with tungsten carbide inserts at the tip of the needle holder.• Mayo-Hegar• Heavy, with mildly tapered jaws.• No cutting blades.
• Olsen-Hegar• Includes both needle holding jaw and scissors blades.• The disadvantage to having blades within the needle holder is the suture material may be accidentally cut
• Senn• Blades at each end.• Blades can be blunt (delicate) or sharp (more traumatic, used for fascia).
• Hohman• Levers tissue away from bone during orthopedic procedures.
• Weitlaner• Ends can be blunt or sharp.• Has rake tips.• Ratchet to hold tissue apart.
• Gelpi• Has single point tips.• Ratchet to hold tissue apart.
• Scissors and Hemostats:• The thumb and ring finger are inserted into the rings of the scissors while the index and middle finger are used to guide the instrument.• The instrument should remain at the tips of the fingers for maximum control.
• This is the wrong way to hold the scissors. The ring finger should be inserted into the ring.
• This is also the wrong way to hold the scissors. The tips of the scissors should be pointing upwards.
• Thumb Forceps:• Thumb forceps are held like a pencil.
• Thumb Forceps are not called tweezers.• Thumb Forceps are not held like a knife.
• Scalpels:• The scalpel is held with thumb, middle and ring finger while the index finger is placed on the upper edge to help guide the scalpel.• Long gentle cutting strokes are less traumatic to tissue than short chopping motions.
Autoclave • An autoclave is a self locking machine that sterilizes with steam under pressure. • Sterilization is achieved by the high temperature that steam under pressure can reach. • The high pressure also ensures saturation of wrapped surgical packs.
Preparation for sterilization• All instruments must be double wrapped in linen or special paper or placed in a special metal box equipped with a filter before sterilization.• Flashing is when an instrument is autoclaved unwrapped for a shorter period of time. Flashing is often used when a critical instrument is dropped.
• Color Change Sterilization Indicators• The white stripes on the tape change to black when the appropriate conditions (temperature) have been met.• Indicators should be on the inside and outside of equipment pack.• Expiration dates should be printed on all equipment packs.
• Biological sterilization indicators contain spores that are supplied in closed containers and are included with the instrument being autoclaved. Inability to culture the spores after autoclaving confirms adequate sterilization. Biological indicators are the most accurate sterilization indicators.
Ethylene Oxide Sterilization: ETO Gas • Large Two-Chamber EtO Sterilizer • Colorless gas, very toxic and flammable. • Requires special equipment • Odor similar to ether. • Used for heat sensitive instruments: plastics, suture material, lenses and finely sharpened instruments. • Materials must be well aerated after sterilization. • Materials/instruments must be dry.
Cold (Chemical) Sterilization • Instruments must be dry before immersion. • Glutaraldehyde (Cidex) is the most common disinfectant. • 3 hours exposure time is needed to destroy spores. • Glutaraldehyde is bactericidal, fungicidal, viricidal, and sporicidal.
Radiation Sterilization• High energy ionizing radiation destroys microorganisms and is used to sterilize prepacked surgical equipment.• Used for instruments that cant be sterilized by heat or chemicals.• Common sources of radiation include electron beam and Cobalt-60
Autograft After surgery, site is immobilized: 3-7 daysBurns of face & head Elevate head of bedCircumferential burns of Elevate extremities above the extremities level of the heartSkin graft Elevate & immobilize graft site Avoid weight bearing
Hypophysectomy Elevate the headThyroidectomy Place in Semi-Fowlers Sandbags or pillows may be used to support the head or neck.
Mastectomy Head of bed elevated at least 30 0 (Semi-Fowlers) w/ affected arm elevated on a pillow Turn only to the back & unaffected side.Perineal & Place on lithotomy post vaginal procedures
Hemorrhoidectomy Assist to a lateral (side- lying) postGastroesophageal reflux Reverse Trendelenburg’s post may be prescribed
Liver biopsy DURING: Supine, w/ right side of upper abd exposed Right arm is raised & extended over the left shoulder behind the head AFTER: Assist to a lateral (side-lying) post Place a small pillow or folded towel under he puncture site for at least 3 0 to provide pressure to the site & prevent bleeding
Bronchoscopy Place in Semi-Fowlers post (to postop prevent choking or aspiration resulting from impaired ability to swallow)Laryngectomy Place in Semi-Fowlers or (radical neck Fowler’s post (to maintain a dissection) patent airway & minimize edema)1.Sengstaken- Maintain elevation of the head Blakemore (3 of bed lumen) & Minnesota tubes ( 4 lumen)
Thoracentesis sitting on the edge of the bed & leaning fwd over the bedside table, w/ feet supported on a stool, or lying in bed on the unaffected side w/ head of the bed elevated about 45 0 Fowler’s postThoracotomy Lateral, unaffected side
Abd aneurysm After surgery, limit elevation of the resection head to 45 0 Fowler’s post (to avoid flexion of the graft) May be turn from side to sideAmputation of 1st 24 0 after amputation, elevate foot of lower extremity the bed Consult physician & put in prone post 2x/day for a 20-3o min periodArterial vascular Bed rest is maintained for 24 0,& grafting of an affected extremity is kept straight. extremity Limit movt & avoid flexion of the hip & knee
Cardiac If femoral artery was used, maintain catherization on bed rest for 3-4 0; client may turn from side to side Affected extremity is kept straight & head is elevated no > 30 0 until hemostasis is adequately achieved.1. CHF & pulmonary Post upright, preferably w/ legs dangling edema over the side of the bed
Peripheral arterial disease Obtain physicians order for positioning Because swelling can prevent arterial blood flow, advise to elevate feet at rest, but not raise legs above the level of the heart (extreme elevation slows blood flow), some are advised to maintain a slightly dependent post (to promote perfusion)DVT If extremity is red, edematous & painful & traditional heparin therapy is initiated, bed rest w/ leg elevation may be prescribed If receiving low-molecular-weight heparin, usually can be out-of-bed after 24 0 if pain level permits.Varicose veins Leg elevation above heart level; minimized prolonged sitting or standing during daily activities
1. Cataract surgery Post-op: elevate head of bed (Semi-Fowlers or Fowler’s) post on the back or the non-operative side (to prevent the devt of edema at the operative site)
1. Retinal If detachment is large, bedrest & detachment/ bilateral eye patching may be prescribed (to minimize eye movt & prevent extension of the detachment) Restrictions in activity & post ff a repair of detachments depends on the physician’s preference & surgical procedure performed If gas bubble has been injected to flatten the retina & reinforce repair, post so that the gas rises in the eye & presses against the repair (usually face down or angled toward the unoperative site)
1. Autonomic dysreflexia Elevate head of bed to High Fowler’s post (to adequate ventilation & assist in the prevention of HPN stroke)1. Cerebral aneurysm Bed rest is maintained w/ the head of the bed elevated 30-45 0 Semi-Fowlers or Fowler’s post (to prevent pressure on the aneurysm site)1. Cerebral angiography Maintain bed rest for 12-24 0 as prescribed The extremity into w/c the contrast medium is injected is kept straight & immobilized for 8 0
1. CVA W/ hemorrhagic stroke, head of bed is elevated to 30 0 (to reduce ICP & facilitate venous drainage) W/ ischemic stroke, head of bed is kept flat Maintain head in midline, neutral post (to facilitate venous drainage from the head) Avoid extreme hip & neck flexion (extreme hip flexion may increase intrathoracic pressure; extreme neck flexion prohibits venous drainage from the brain)1. Craniotomy Don’t post on the operated site, esp if the bone flap has been removed (because the brain has no bony covering on the affected site) Elevate head of bed to 30-45 0 Semi-Fowlers or Fowler’s post & maintain head in midline, neutral post (to facilitate venous drainage from the head) Avoid extreme hip & neck flexion
1. Laminectomy Logroll the client- surgical cutting When out of bed, back is kept straight into the (placed in straight-backed chair) w/ backbone to feet resting comfortably on the floor obtain access into the spinal cord.1. ICP Elevate head of bed to 30-45 0 Semi- Fowlers or Fowler’s post & maintain head in midline, neutral post (to facilitate venous drainage from the head) Avoid extreme hip & neck flexion
1. Lumbar puncture DURING: Assist to a lateral (side-lying) post, w/ back bowed at the edge of the examining table, knees flexed upto abd, & head bent so that chin is resting on the chest. AFTER: Place in supine post for 4-12 0 as prescribed1. Myelogram postop If water soluble dye is used, head of bed is elevated to 30-60 0 for 12 0 (to keep the dye from irritating the cerebral meninges) If oil-based dye is used, a supine post for several hours after the dye has been removed (to prevent leakage of CSF)
Spinal cord injury/ Immobilize on spinal backboard, w/ head in neutral post (to prevent complete injury from becoming complete) Prevent head flexion, rotation or extension; head is immobilized w/ a firm, padded cervical collar. Logroll the client; no part of the body should be twisted or
Total hip Post depends on surgical technique replacement used, method of implantation & prosthesis Avoid extreme internal & external rotation Avoid adduction Maintain abduction when in supine post on the unoperative side Check physician’s order re elevation of head of bed; flexion is usually limited: 60 0 : 1st post-op week 90 0 : 2-3 mos thereafter