Operation room techniques

Introduction to operating
room techniques
Up on completion of this session , students will be able to :
 Define common terminologies
 Understand physical organization of operating room
 Identify deign of operating room
 Distinguish traffic flow and activity patterns
 Identify operating suite equipment's.
 Identify the relationship between operating team
 Identify and prevent hazards in operating room
2

Brain storming
 What is ORT?
 Have you ever worked as OR team ? If yes share
Your experience.
3

Introduction
 Usually the treatment of a wide variety of
illnesses and injury includes some type of
surgical intervention.
 Surgery is an invasive method of treatment that
may be planned or unplanned, major or minor,
and that may involve any body part or system.
 Surgical procedures require physical and
psychosocial adaptations and are stressors for
both the patient and the family, no matter what
the extent might be.
4

cont....
 The patient’s recovery from a surgical procedure requires
skillful and knowledgeable nursing care whether the
surgery is done on an outpatient basis or in the ideal
operation room.
 All phases of the nursing process are used peri-operatively
to make assessments, arrive at a diagnosis, make
appropriate plans and provide interventions necessary to:
 Promote the recovery of health,
 Prevent further injury or illness, and
 Facilitate coping with alterations in physical structure and
function.
5

Common TermINOLOGIES
 Absorbable suture - any suture that is absorbed by
body tissue
 Analgesia – the absence of pain
 Anastomosis – an opening between two normally
distinct spaces or organs; used in surgery to refer to
the joining of two hollow structures with suture.
 Anesthetic – an agent that produces analgesia
 French eye - a delicate needle whose double eye
contains a spring.
6

8
cont….
___________________________
 Aseptic – free of disease- causing microorganisms.
 Atraumatic - the suture - needle combination when the
suture is swaged into the needle; can also refer to any
suture that causes little tissue trauma.
 Attire – Cloths to be worn in the operating room
 Autoclave – steam sterilizer
 Chromic salts - chemicals used in the treatment of catgut
that cause it to resist absorption.
 Contaminated – soiled or infected by microorganisms.
 Cross-contamination – a process whereby infection or
disease is spread from one source to another.

Cont…
 Decontamination – process that makes inanimate
objects safer to be handled by staff before cleaning.
 Defamation – a derogatory statement made by someone
about another.
 Disinfectant – an agent that kills or inactivates
microorganisms on inanimate surfaces.
 Ethylene oxide – a gas used in the sterilization of items.
 Flaking – the tendency of some suture materials to
release tiny particles of the suture in the wound.
 Flash autoclave – an autoclave used in surgery to
sterilize equipment quickly by steam under pressure.
9

Organizations of areas in the
Operation room
 The efficiency of the operating room depends
much upon its physical organization and the
organization of its personnel.
 An intelligent design in the layout of the
operating room facilitates the efficient
movement of patients and staff and the
economical use of space.
10

Design of the operating room
Principles in design
 The universal problem of environmental
control to prevent wound infection exerts a
great influence on the design of the operating
room (OR) suite.
 Clean and contaminated areas should be well
differentiated.
 Architects follow two principles in planning the
physical layout of the OR suite:
11

Cont..
 Exclusion of contamination from outside the suite
with sensible traffic patterns within the suite
 Separation of clean areas from contaminated areas
within the suite.
 Physical planning of an OR suite, which separates
clean from contaminated areas, makes it easier to
carry out good aseptic techniques.
 The clean area is often referred to as the restricted
area.
 For operating rooms, there are many different
designs.
12

Cont...
 The basic design principles
1. Simple and easy
2. Safe Wall and floor surface.
3. Separate rooms for clean or sterile
instruments and soiled ones
4. Safe transportation of patients and staff.
5. Convenient to control the incoming and
outgoing traffics
6. Near recovery room to the operating room.
13

Space Allocation within the Operation
Room and Traffic Patterns
 Increases efficiency .
 Large enough to allow for correct technique.
 Provision must be made for traffic control.
 The type of design will predetermine traffic
patterns.
 All persons – staff, patients, and visitors – should
follow the delineated patterns in appropriate
attire.
 Signs should be posted that clearly indicate the
attire and environmental controls required.
14

Surgical unit
Is often divided into four designated areas, which are defined by
the activities performed in each:
A. Unrestricted area
B. Transition zone
C. Semi-restricted area
D. Restricted area
 Environmental controls and use of surgical attire increase as one
moves from unrestricted to restricted areas
 Staff with respiratory or skin infections should not be allowed in the
surgical unit
Note: Post signs in each surgical unit area to clearly indicate the
appropriate environmental control and surgical attire required
15

A. Unrestricted Area
 Is the point through which staff, patients, and materials
enter the surgical unit
 Street cloths are permitted.
 A corridor on the periphery accommodates traffic from
outside, including patients.
 This area is isolated by doors from the main corridor
and from other areas of OR suite.
 It serves as an outside-to-inside access area.
 Traffic, although not limited, is monitored at a central
location
16

B. Transition zone:
 Consists primarily of dressing rooms and
lockers
 Is where staff put on surgical attire that
allows them to move from unrestricted to
semi-restricted or restricted areas in the
surgical unit
 Only authorized staff should enter this area
17

C. Semi-restricted area:
. The peripheral support area of the surgical unit
Includes
– Preoperative and recovery rooms
– Storage space for sterile and high-level disinfected
items
– Corridors leading to the restricted area
 Support activities (e.g., instrument processing and
storage) for the operating room occur here
 Limit traffic to authorized staff and patients at all times
18

Cont..
 Have a work area for processing of clean
instruments
 Have doors limiting access to the restricted
area
 Staff should wear surgical attire and a cap at
all times
 Staff should always wear clean, closed shoes
that will protect their feet from fluids and
dropped items
19

D. Restricted area:
 Sterile procedures are carried out in this area
 Consists of the OR and scrub sink areas
 Limit traffic to authorized staff and patients at all times
 Keep the door closed at all times, except during
movement of staff, patients, supplies, and equipment.
 Scrubbed staff must wear full surgical attire and cover
head and facial hair with a cap.
 Masks are required to supplement surgical attire
20

Identify operating suite equipments
1. Wall Clock: -
 put in each room
 used to time tourniquet applications,
administration of medications, the duration of
cardiac and respiratory arrests and to note the
time of events such as childbirth.
2. X-ray Viewing Boxes: -The surgeon may need
to view an x-ray before or during the procedure.
3. Lights: -The overhead lights should specially
designed to provide a range of intensity. They should be
freely movable, shadow less and less heat emitting
21

The Operating Table
 The table should be fully adjustable in all directions to
create postures needed for various surgical positions.
1.Mayo Stands: -This stand is used to hold
instruments that will be used frequently during
a particular case.
2.Back Table: -The back table is used to place
extra supplies and instruments used during
surgery.
3.Ring Stand: -The ring stand is used to hold a
basin which contains normal saline or sterile
water during surgery.
22

Cont…
4. Kick Bucket: -The kick bucket (a bucket on
wheels) is used to place soiled sponges during
surgery.
5. Supply Cabinets: -These cabinets are used to
store frequently used items such as drapes,
dressings, solutions, sutures, etc. Cabinets with
doors are preferred to those without so as to
reduce exposure of the content to dust.
6. Anesthesia Equipment: -Equipment, including
the gas machine, physiological monitor, and
anesthesia supply cart, and sitting stools, is
located in each room.
23

Operating team & relationship
 . Just as there is a logical order to the physical design,
there is a logical division of duties among the operating
room staff.
Operating Room Team
 When the patient arrives to the operating room, he/she is
received and surrounded by a surgeon, one or two
assistants, an anesthesia provider, a scrubbed nurse, a
circulating nurse etc.
 These individuals, each with specific functions to perform,
form the operating team
24

Cont...
 This team literally has the patient’s life in its hands.
 The operating room team works in harmony with
his/her colleagues for the successful accomplishment
of the expected outcomes of the patient.
 The operating room team is subdivided according to
the functions of its members:
1. Sterile team
2. Unsterile team
25

cont...
1.The sterile team consists of:
 Surgeon
 Assistants to the surgeon
 Scrub nurse
2. The unsterile team includes:
 Anesthesia provider
 Circulator/ Runner nurse
 Others, such as students, cleaners and those who
may be needed to set up and operate specialized
equipment or monitoring devices.
26

Sterile team members
 Wash (scrub) their hands and arms,
 Put on (don) a sterile gown and gloves
 Enter the sterile field.
 Establish a sterile field
 The scrubbed and sterile team members
function within this limited area and handle only
sterile items.
27

Unsterile team members
 Do not enter the sterile field
 They function outside and around it.
 They assume responsibility for maintaining
sterile technique during the surgical
procedure.
 Following the principles of aseptic technique,
they keep the sterile team supplied, provide
direct patient care, and handle other
requirements that may arise during the
surgical procedure.
28

Preventing hazards in the
operating theatre
 Is a danger or risk that can occur and cause damage in
the operating room
Environmental Hazards
 The perioperative environment poses many hazards for
both patients and personnel.
 The potential for physical injury from electric shock,
burns, fire, explosion, exposure to blood-borne
pathogens, and inhalation of toxic substances is ever
present.
 Therefore, it is important that staff have knowledge of the
hazards involved in equipment use, the causes of
accidental injury and the source of health risks.
29

Cont…
 All individuals have a personal responsibility
to ensure a safe environment for
themselves and others.
 Faulty equipment or improper usage
increases the hazards of potential risk
factors.
30

Cont...
– Purpose
 Helps to prevent the occurrence of hazards
 Helps to control the damage due to hazards
 Helps to minimize the incidence of hazards
Hazards Injuries can be caused by:
 Using faulty equipment
 Using equipment improperly
 Exposing oneself or others to toxic or irritating agents, or
 Coming into contact with harmful agents
31

Hazards classification
 Physical: including back injury, fall, noise
pollution, irradiation, electricity and fire
 Chemical: including anesthetic gases, toxic
fumes from gases and liquids, cytotoxic
drugs and cleaning agents
 Biologic: including the patient (as a host for
or source of pathogenic microorganisms),
infectious waste, cuts or needle-stick injuries,
surgical plume and latex sensitivity
32

Methods of prevention
 Following recommended Standards
guidelines.
 Implementing policies and procedures of the
health care facility
 Using electronic devices appropriately
33

Preventing infection in the operating
theatre
34

Preventing infection in the
operating theatre
q
35

Some of Infection prevention
techniques
36

Preventing infection in the
operating theatre
37
Hand
Hygiene

General preparation
 The infection prevention practices are
intended for use in all types of health care
facilities.
 The principles are based on CDC guidelines
issued in 1996.
 Standard precautions
 Transmission based precautions
38

Infection prevention principles
 Consider every person potentially infectious and
susceptible to infection.
 Washing hands before and after any procedure
is the most practical procedure for preventing
cross-contamination.
 Donning (wearing) gloves before touching
anything potentially infectious and wet such as
broken skin, mucous membrane, body fluids,
body secretions and excretions, or soiled
instruments and other items.
39

Cont...
 Using personal protective equipment (PPE)
to provide barriers, if splashes or spills of any
blood, body fluids, secretions or excretions
are anticipated.
 Using antiseptic agents for cleansing the skin
or mucous membrane prior to surgery,
cleaning wounds, or doing handrubs or
surgical handscrub.
.
40

Cont...
 Using safe work practices, such as not recapping
or bending needles, safely passing sharp
instruments, and disposing sharps in puncture
resistant containers
 Processing instruments and other items
 Routinely cleaning and disinfecting equipment
and furniture in patient care areas.
 Disposing contaminated materials and
contaminated waste properly
41

Operative room cleaning
 Cleaning is the process that physically
removes all visible dust, soil, blood or other
body fluids from inanimate objects including
the OR floor and walls to reduce risks of
disease transmission in the OR.
 Cleaning can be made in daily (at the
beginning of the day’s activity, in between
the cases, and at the end of the day) as well
as on weekly basis.
42

Cont..
 Areas to be considered are walls, floors,
ceilings, storage shelves, all furniture and
equipment in the OR including the operating
bed/table
 Following a surgical case, after the patient
has left the OR, the nurse gathers all of the
instruments (including soiled and not used)
and terminally decontaminate in the washer
(terminal decontamination).
43

Cont...
 All linen is placed in the linen hamper.
 Disposable items in the trash
 Large equipment is wiped with a disinfectant
and placed in its usual storage
 The floors are cleaned with disinfectant
 The stationary equipment (operating table,
electrosurgical power unit, etc) are all wiped
clean with disinfectant.
 Any visible soil is washed with disinfectant
44

Operating Room Attire
 The techniques employed by operating room
personnel when preparing themselves to take
part in sterile procedures can be varied.
 However, the fundamental principles of aseptic
technique must be adhered to when scrubbing,
gowning and gloving prior to surgical
intervention.
45

Cont..
 It consists of body covers, such as trousers,
shirts, head covers, masks, gowns, gloves and
shoe covers, as appropriate
 Each has an appropriate purpose to combat
sources of contamination external (exogenous) to
the patient.
 It helps to provide effective barriers that prevent
the dissemination of microorganisms to the patient
and protect personnel from blood and body
substances of patients
46

Dress code
 The operating room should have specific
written policies and procedures for proper attire
to be worn within the operating room suite. The
policies include:
 Dressing rooms are located in the unrestricted
area of the OR suite.
 Only freshly laundered, clean attire is worn in
the OR
 OR attire should not be worn outside the
operating room suite.
47

Cont..
 Impeccable personal hygiene is emphasized
(frequent and thorough hand washing, removal
of jewelry, keeping fingernails short and clean,
denial of access to team members with acute
infections …).
 Comfortable, supportive shoes should be worn
to minimize fatigue and for personal safety.
 Masks and head covers should be changed
between patients.
48

Components of Attire
 Body cover
 Head cover
 Shoe cover
 Mask
 Apron
 Gloves
 Gown, eyewear /goggles and face shield.
49

Criteria for Operating Room Attire
 An effective barrier to microorganisms.
 Designed and composed to minimize
microbial shedding.
 Made of closely woven material void of
dangerous electrostatic properties.
 Resistant to blood, aqueous fluids and
abrasion to prevent penetration by
microorganisms.
50

Cont...
 Designed for maximal skin coverage.
 Hypoallergenic, cool, and comfortable
 Made of a pliable material to permit freedom
of movement.
 Able to transmit heat and water vapor to
protect the wearer.
 Colored to reduce glare under lights.
 Easy to don and remove.
51

Hand Hygiene Practices
 Hand washing
Hand antisepsis
Antiseptic hand rub
Surgical hand scrub
52

Hand washing
 Is washing hands with plain soap and water
to mechanically remove soil and debris from
skin and reduce the number of transient
microorganisms.
 If tap water is contaminated, use water that
has been boiled for 10 minutes and filtered to
remove particulate matter or use chlorinated
water
53

Hand antisepsis
 Remove soil and debris and reduce both
transient and resident flora on the hands.
 Use of soap containing an antimicrobial
agent (often chlorhexidine, iodophors, or
triclosan) instead of plain soap or detergent.
 Medicum, Life Boy, and Dettol are some of
the commonly found soaps with antimicrobial
agents
54

Antiseptic Hand Rub
 Hand rub product is more effective in
killing transient and resident flora than
plain or medicated soap and water.
 Antiseptic hand rub is quicker and easier to
use and gives a greater initial reduction in
hand flora
 Hand rubs also contain a small amount of an
emollient such as glycerin, propylene glycol,
or sorbitol that protects and softens skin
55

Cont..
 Alcohol-based hand rubs provide several
advantages compared with hand washing
with soap and water because they:
– Require less time
– Act faster
– Are more accessible than sinks
– Are more effective for standard hand
washing than soap
– Can provide improved skin condition
56

Cont..
 A non irritating, antiseptic hand rub can be
made by adding glycerin, propylene glycol, or
sorbitol to alcohol
 2mL in 100mL of 60 to 90 percent ethyl or
isopropyl alcohol solution
57

The technique for performing
antiseptic hand rub
1. Apply enough (5mL) alcohol-based hand rub to
cover the entire surface of hands and fingers.
2. Rub the solution vigorously in to hands, especially
between the fingers and under the nails until dry
(15 to 30 seconds)
3. Do not rinse hands after applying hand rub
58

Surgical Hand Scrub
 The Surgical scrub is the process of removing as many
microorganisms as possible from the hands and arms by
mechanical washing and chemical antisepsis before participating in
a surgical procedure.
 It is done just before gowning and gloving for each surgical
procedure.
 Prevent wound contamination by microorganisms from the hands
and arms of the surgeon and assistants if there is a break in the
integrity of the gloves or gown
59

Cont...
The steps in surgical hand scrub include the following:
 Remove all rings, watches, and bracelets.
 Thoroughly wash hands, especially between fingers,
and fore arms up to the elbows with soap and water.(If
a brush is used, it should be cleaned and either
sterilized or high-level disinfected before reuse or
shared with others. Sponges ,if used, should be
discarded.)
– Clean nails with a nail cleaner
– Rinse hands and forearms thoroughly with clean,
running water.
60

Cont...
– Apply an antiseptic agent (e.g., 2 to 4 percent
chlorhexidine gluconate [CHG]) to all surfaces of
hands and forearms to the elbows and rub hands and
forearms vigorously for at least two minutes.
– Rinse hands and arms thoroughly, holding hands
higher than the elbows (if tap water is contaminated,
use boiled and cooled water or chlorinated water and
filter if necessary).
– Keep hand suspend away from the body, do not touch
any surface or articles, and dry the hands and
forearms with a sterile towel.
61

Scrub Sink
 Adequate scrubbing and hand washing facilities should be
provided for all operating team members.
 The scrub room is adjacent to the OR for safety and convenience.
 The sink should be deep and wide enough to prevent splash.
 Scrub sinks should be used only for scrubbing or hand washing.
 They should not be used to clean or rinse contaminated
instruments or equipment.
Equipment
 Soft brush or disposable sponges
 Soap or detergent
 Running water
62

Methods of Scrubbing
 There are two methods of scrub procedures.
– The counted brush-stroke method or
– The timed scrub method
 If properly executed, they are both effective, and each exposes
all surfaces of the hands and forearms to mechanical cleansing
and chemical antisepsis.
 One should think of the fingers, hands, and arms as having four
sides or surfaces. In cases of a numbered stroke method, a
certain number of brush strokes are designated for each finger,
palm, back of hand, and arm.
63

Cont..
 The alternative method is the timed scrub, and
each scrub should in average last 5-minute
consisting of the following:
1.Locate scrub equipment (brushes, soaps, nail
cleaners) which are available at each scrub
station.
2.Remove Jewelry (watch and rings)
3.Wash hands and arms with soap and water
4.Clean subungual areas with a nail file
64

Cont..
6.Start timing – scrub each side of each finger,
between the fingers, and the back and front
of the hand for 2 minutes
7.Proceed to scrub the arms, keeping the hand
higher than the arm at all times. This prevents
bacteria – laden soap and water from
contaminating the hand
8.Wash each side of the arm to 2 inches (5cm)
above the elbow for 1 minute.
65

Cont..
9. Repeat the process on the other hand and
arm, keeping hands above elbows at all
times. If at any time the hands touch anything
except the brush and or soap, the scrub must
be lengthened by one minute for the area
that has been contaminated
66

Cont..
10. Rinse hands and arms by passing them
through the water in one direction only, from
fingertips to elbow. Do not move the arm
back and forth through the water. Proceed to
the operating room suite holding hands
above
67

wearing sterile gloves and gowns
 The sterile gown is put on immediately after
the surgical scrub.
 The sterile gloves are donned immediately
after gowning
 A sterile gown and gloves are worn to exclude
skin as a possible contaminant and to create a
barrier between the sterile and non sterile
areas
68

General Considerations
 The scrub person gowns and gloves himself/herself and
then may gown and glove the surgeon and his
assistants.
 Gown packages preferably are opened on a separate
table from other packages to avoid any chance of
contamination from dripping water.
 Avoid splashing water on scrub attire during the surgical
scrub because moisture may contaminate the sterile
gown.
 The circulator will assist by pulling the gown up over the
shoulders and tying it.
69

Gloves and Gloving
Types of gloves available in Ethiopia
1.Sterile or high-level disinfected surgical
gloves
2.Clean/ examination gloves, and
3.Utility gloves
70

UNIT TWO
Contribute to the assessment
of patient undergoing
surgical intervention
71

Session objectives
At the end of this learning outcome students
will be able to: -
 Perform preoperative nursing assessment of
cardiovascular, respiratory, hepatic, renal,
immunity,endocrine system
 Perform preoperative nursing assessment of
Psychological & spiritual components of pt.
 Identify risk factors for surgical complication
72

.......
Perioperative nursing
 Nursing functions associated with the patient
surgical experience
Perioperative
 Preoperative phase
 Intra operative phase
 Post operative phase
The Perioperative nurse
 Provides nursing care during all three phases
73

Phases of surgery
Pre-operative phase
 Begins when the patient or someone acting
on the patient’s behalf .
 Ends with the transfer of the pt to the
operation table.
 used to physically and psychologically
prepare the patient for surgery.
 The length of the preoperative period is
varies
74

Cont.....
 Diagnostic studies and medical regimens are
initiated
 Used to prepare a plan of care for the
patient.
 Directed toward patient support, teaching
and preparation for the procedure.
75

Surgical indications and
classifications
1.Surgery may be performed for a variety of
reasons
 Diagnostic
 Curative
 Reparative
 Reconstructive or cosmetics
 Palliative
76

Cont....
2. It may be classified also based on the
degree of urgency.
 Emergency
 Urgency
 Required
 Elective
77

Intra operative phase
 Begins when the patient is transferred to the operating
room bed and
 Ends with transfer to the post anesthesia care unit or
another area where immediate postsurgical recovery
care is given.
 The patient is monitored, anesthetized, prepared, and
draped, and the procedure is performed
 Patient safety, facilitations of the procedure, prevention
of infection, and satisfactory physiologic response to
anesthesia and surgical intervention.
78

Postoperative phase
 Begins with the patients transfer to the
recovery unit
 Ends with the resolution of surgical sequelae.
 Either brief or extensive, and most commonly
ends outside the facility where the surgery
was performed
79

Preoperative nursing assessment
 Cardiovascular assessment
 Respiratory assessment
 Nutritional & fluid assessment
 Nutritional requirements
 Obesity
 Narcotic, drug or Alcohol use
80

Risk factors for surgical
complication
 Common Surgical Risks:
1. Anesthesia Complications during
Surgery
2. Malignant hyperthermia-
3. Bleeding Problems during Surgery
4. Blood Clots Caused by Surgery
81

Cont…
5. Death Due to Surgery
6. Delayed Healing After Surgery
7.Difficulty Breathing After Surgery
8. Infections after Surgery
9. Injury during Surgery
10.Paralysis Caused by Surgery
82

Cont…
11.Poor Results after Surgery
12.Numbness & Tingling After Surgery
13.Scarring after Surgery
14. Swelling and Bruising After Surgery
83

Assignments
 Create groups
 Each group comprises at least 10 students .
 Each student should participate actively.
 Make yourself ready for presentation .
 Maximum time for presentation =20 mins.
 Total page for submission should not
exceeds 4-5 pages
 Follow assignment writing protocol .
84

Questions
1.Discus on Cleaning and Decontamination
 Write commonly used solution and common methods used for
processing equipment in your organization.
2.Discuss on Disinfection and sterilization
 Write commonly used solution and common methods used for
processing equipment in your organization.
3. Describe the goal , function and composition of IP committee in your
organization .
 Do you think that all of IP committee functions are practiced in your
organization ? If your answer is no what are the possible reasons.
4. Write at least 3 OHS symbols posted in your organization and categorize
them under appropriate OHS sign categories
85

Cont....
5.Develop pre-operative nursing care plan based
on Gordano’s approach.
6. Develop and post operative nursing care plan
based on Gordano’s approach .
86

UNIT -THREE
CONTRIBUTE TO THE PLANNING CARE
FOR PRE/ POST AND INTRA OPERATIVE
CLIENT

Preoperative Nursing Interventions

Objective
At the end of the lesson students will be
able to
 Provide preoperative informed consent, pt.
education , pain management and
psychological interventions
 Perform bowel, urinary and skin preparations

Informed consent
 To attain the right to operate it is necessary
for the surgeon to obtain a voluntary and
informed consent from the patient.
 Such written permission protects the patients
against unauthorized surgery and protects
the surgeon against unauthorized operation.

Cont..
 The nurses responsibility is to ensure that
with informed consent has been taken/
voluntarily
 Before the patient signs the consent the
surgeon should inform the patients
 Risk complication ,disfigurement, disability
and removal of body parts as well as what to
expect in the early and late postoperative
periods

Cont..
Informed consent is necessary when
 The process is invasive
 Anesthesia is used
 A non surgical procedure is performed when
it is going to have a risk to patient
 Procedure is performed that involves
radiation.

Preoperative Patient Education

A. Diaphragmatic Breathing (Deep
Breathing)
1. Refers to a flattening of the dome of the
diaphragm during inspiration with resulting
enlargement of the upper abdomen as air rushes
in during expiration, the abdominal muscles
contract position your patient in fowler’s position
2. With the hands in loose fist position, allow the
hands to rest lightly on the front of the lower ribs
fingernails against lower chest to feel the
movements

Cont..
3. Breath out gently and fully as the ribs sinks
down and inward to ward midline.
4. Then take a deep breath through your nose
and mouth letting the abdomen rise as the
longs fill with air

Cont..
4. Hold his breath for a count of five
5. Exhale and let out all the air through the
nose & mouth
6. Repeat 15 minutes with a short rest after
each group of five
7. Practice this twice a day preoperatively

B. Coughing
1. Lean forward slightly from a sitting position
in bed interlace the fingers together, and
place hands across the incision size to act
as a splint when coughing
2. Breathe with the diaphragm as described in
“A”
3. With the mouth slightly open, breathe it fully
4. Reply for three short breaths

Cont..
 Then, keeping the mouth open, take in quick
deep breath and immediately give a strong
cough once or twice.
 This helps clear secretion from the chest, it
may cause some discomfort but will not harm
incision.

C. Leg exercise
 Lie in semi fowlers position
 Bend the knee and raise the foot hold it a few
second then extend the leg and lower it to
the bed
 Do this five times for both legs
 Then trace circles with feet by bending them
down, in toward, each other, up and them out
 Repeat this movements five minutes

D. Turns to the side
 Turn-on your side with the uppermost leg
flexed most and supported on a pillow
 Grasp the side rail as an aid to maneuver the
side
 Practice diaphragmatic breathing and
coughing while on tour side.

Deep Breathing & Coughing Exercise
Breathing Deeply:
 Moves air down to the bottom areas of the lungs
 Opens air passages and moves mucous out
(coughing is also easier)
 Helps the blood and oxygen supply to your
lungs, boosting circulation

Cont..
 Lowers the risk of lung complications such as
pneumonia and infections
 Coughing helps bring up mucous from deep
within your lungs.
 As you do your breathing exercises, you may
feel this in the back of your throat or hear a
rattling sound when you breath.
 Be sure to cough when this occurs.

How To Perform Deep Breathing &
Coughing Exercises
 Get yourself into a comfortable position such
as: lying on your back with your knees bent,
lying on your side or sitting up in a seated
position.
 Place your hands on your stomach. Take a
deep breath in through your nose. Continue
until your lungs feel full of air and you notice
your stomach pushing against your hand.

Cont..
 Through pursed lips, slowly blow air out in one long,
slow breath.
 When you breathe out, concentrate on making your
stomach sink in. Repeat steps one, two and three to
complete five breathing cycles.
 Take another deep breath – hold for three seconds
then huff out three times.
 (Huffing is a short sharp pant – imagine that you are
trying to create mist on a pane of glass.)

Cont..
 On the third huff, cough deeply from the
lungs, not the throat.
 Repeat steps two and four to complete five
coughing exercises.
 Until you are walking, these exercises should
be done every hour while awake. Ask for
pain medication if you are sore and not able
to do your coughing exercises.

Preoperative Pain Management
Pre-anesthetic medication
1. Barbiturates (Tranquilizers)
– for sedation
2. Opiates
 To reduce the general anesthesia required to
produce analgesia

Cont..
Anticholinergics
 To decrease respiratory secretion atropine is
given.
Timing of administration of medications
 it should be given 45-75 minutes before
anesthesia is began

Cont..
Preoperative record
 All patients records such as history ,consent
and laboratory reports attached to it has to
be placed in good condition
Transportation to pre surgical suite
 On a bed or stretcher

Preoperative psychological
intervention
 Level of anxiety
 Coping ability
 Support systems

Cont..
Anxiety
 The nurse must consider the patient’s family and
friends when planning psychological support.
 Empowering their sense of control.
 Activities that decreasing anxiety are deep
breathing, relaxation exercises, music therapy,
massage and animal-assisted therapy.
 Use of medication to relieve anxiety

General preoperative nursing
intervention
Provide teaching regarding turning in the
bed.
 Instruct the patient to use a pillow or bath
blanket to splint where the incision will be.
 Ask the patient to raise his or her left knee
and reach across to grasp the right side rail
of the bed when turning toward his or her
right side.

Cont..
 If patient is turning to his or her left side, he
or she will bend the right knee and grasp the
left side rail.
 When turning the patient onto his or her right
side, ask the patient
 When turning the patient onto his or her right
side, ask the patient

Cont..
a. To push with bent left leg and
b. Pull on the right side rail.
 Explain to patient that you will place a pillow
behind his/her back to provide support, and
that the call bell will be placed within easy
reach.
 Explain to the patient that position change is
recommended every 2 hours.

Provide Teaching About Pain
Management.
 Discuss past experiences with pain and
interventions that the patient has used to reduce
pain.
 Discuss the availability of analgesic medication
postoperatively.
 Discuss the use of patient controlled analgesia
(PCA), as appropriate.
 Explore the use of other alternative and non
pharmacologic methods to reduce pain, such as
position change, massage, relaxation/diversion,
guided imagery, and meditation.

Provide Skin Preparation.
 Ask the patient to bath or shower with the
antiseptic solution. Remind the patient to
clean the surgical site.
 Preparing the Patients Skin- Shave against
the grain of hair shaft to insure close shave.
Most of the time in actual practice this is
done before the patient is transferred to OR
1. Provide teaching about and follow
dietary/fluid restrictions.

Cont..
2. Explain to the patient that both food and
fluid will be restricted before surgery to
ensure that the stomach contains a minimal
amount of gastric secretions.
 This restriction is important to reduce the risk
of aspiration.

Cont..
 Emphasize to the patient the importance of
avoiding food and fluids during the prescribed
time period, because failure to adhere may
necessitate cancellation of the surgery.
3. Provide intestinal preparation, as appropriate. In
certain situations, the bowel will need to be
prepared by administering enemas or laxatives to
evacuate the bowel and to reduce the intestinal
bacteria.

Cont..
4. As needed, provide explanation of the
purpose of enemas or laxatives before surgery.
 If pay Check administration of regularly
scheduled medications.
 Review with the patient routine medications,
over-the-counter medications, and herbal
supplements that are taken regularly.

Cont..
 Check the physician’s orders and review with
the patient which medications he or she will
be permitted to take the day of surgery.
 Patient will be administering an enema,
clarify the steps as needed.
5.Remove PPE, if used. Perform hand hygiene.

UNIT-FOUR
PERFORM CLINICAL NURSING ACTIONS
THAT ARE APPROPRIATE TO THE CARE
OF PRE/POST AND INTRA OPERATIVE
CLIENTS
120

Cont....
 The activities of the "scrub" nurse include,
but are not limited to, the following:
 Reviews anatomy, physiology, and the
surgical procedure.
 Assists with preparation of the room.
 Scrubs, gowns, and gloves self and other
members of the sterile surgical team.
 Passes instrument to the surgeon in a
prescribed manner.
124

Cont...
 Maintains sterile and an orderly surgical field.
 Assists with the draping procedure.
 Keeps track of irrigation solutions used for
calculation of blood loss.
 Keeps the instrument table neat so that
supplies can be handed quickly and
efficiently.
125

Cont...
 Anticipates and meets the needs of the
surgeon by watching the progress of the
surgery and knowing the various steps of the
procedure.
 Takes part in sponge, needle, and instrument
counts
 Identifies and preserves specimens properly.
126

Cont.....
 The activities of the circulating nurse
include, but are not limited to, the
following:
 Reviews anatomy, physiology, and the
surgical procedure.
 Assists with preparing the room, observes
aseptic technique at all times to see that it is
maintained properly.
 Identifies and assesses the patient. Then
plans and coordinates the intraoperative
128

Cont.....
 Admits the patient to the operating room and
assumes responsibility with the other
members of the team for the comfort and the
safety of the patient.
 Keeps the "scrub" nurse with supplies e.g.
suture materials, dressings etc.
 Opens sterile supplies before and during the
case, replace saline or water in basins as
necessary.
129

Cont...
 Positions the patient on the surgery table
 Assists the anesthetist when required
 Takes part in sponge and instrument counts
and their documentation,
 Ties the gowns of scrubbed personnel
130

131
Skin preparation and draping of surgical site
Basic preparation procedure for skin:
1. Expose only the skin area to be prepared.
2. Wear sterile gloves.
3. Place towels above and below to protect gloved hand
from touching the blanket.
4. Wet the sponge with antiseptic agent but squeezed out
5. Scrub the skin .
6. Discard the sponge after reaching the periphery

Draping
132
Draping is" The procedure of covering pt. and
surrounding areas with a sterile barriers to create
and maintain sterile field during operation."
1. Towels
2. Laparotomy sheet
3. Stockinet
4. Ortho pack sheet
types of Drapes:

Positions
133
Position and Explanation Illustration
1. Supine/Dorsal Recumbent
In the supine position, the patient lies face up on the
padded table with arms tucked in at the sides (using the
lift sheet), or extended on (padded) arm boards
Uses: Employed for procedures on the face ,the neck,
the abdomen, the upper extremities and the lower
extremities.
2. Trendelenburg's position
The patient is on the back on a table or bed whose upper
section is inclined 45 degrees so that the head is lower than the
rest of the body; the adjustable lower section of the table or bed
is bent so that the patient's legs and knees are flexed. There is
support to keep the patient from slipping.
Uses: Employed for abdominal hysterectomy and other
procedures in the pelvic area

Positioning/Surgical
Positions
134
3. Reverse Trendelenburg's
Supine position with the patient on a plane inclined
with the head higher than the rest of the body and
appropriate safety devices such as a footboard.
Uses: Employed for neck procedures as
thyroidectomy, Para thyroidectomy, It is also used to
perform laparoscopic procedures as cholecystectomy.
4. Fowler's position a position
In which the head of the patient's bed is raised 30 to
90 degrees above the level, with the knees sometimes
also elevated.
Uses: Employed for posterior craniotomy, selected
shoulder, and ear, nose, and throat ,(ENT)
procedures.

Positioning/Surgical Positions
135
5. Lithotomy position
The patient lies on the back with the legs well
separated, thighs
acutely flexed on the abdomen, and legs on thighs;
stirrups may be used to support the feet and legs.
Uses :Employed for low rectal resections, for some
vaginal surgeries..
6. Sims’ (Semi-Prone) position
The patient lies on the left side with the left thigh
slightly flexed and the right thigh acutely flexed on the
abdomen; the left arm is behind the body with the body
inclined forward, and the right arm is positioned
according to the patient's comfort. See illustration.
Called also lateral position
Uses : Employed for procedures requiring access to
the vagina, anorectal, and perineum.

136
7. Prone Position
The patient lying face down with arms bent comfortably at the
elbow and padded with the arm boards positioned forward.
Uses : Employed for anorectal procedures.
8. Lateral Kidney position
The patient is placed in the lateral position
and the iliac crest positioned over the “kidney”
elevator .The head is placed on a padded
donut, protecting the face and ear on the unaffected
side from undue pressure.
Uses : Employed for procedures on the upper urinary
tract (e.g., kidney),and structures in the
retroperitoneal space.

137
9. knee-chest position
The patient rests on the knees and chest with
head is turned to one side, arms extended on
the bed, and elbows flexed and resting so that
they partially bear the patient's weight; the
abdomen remains unsupported, though a small
pillow may be placed under the chest.
Uses: Employed for rectal examination

Some considerations for OR staffs:
A . General Important considerations
138
1. Persons in sterile attire touch only sterile articles.
2. Persons in sterile attire preparing a sterile field or draping an un-
sterile surface always face the area being prepared.
3. Persons in sterile attire do not turn their backs to a sterile field
4. Gloved hands are protected while draping by making a cuff with the drape.
5. Persons in sterile attire do not lean or reach over un-sterile surfaces
6. Persons in non-sterile attire only touch non-sterile articles.
7. Persons in non-sterile attire avoid reaching over or touching the sterile
field when delivering sterile supplies to the sterile field.

139
8. Tables draped with sterile drapes are sterile only at table level.
9. Scrub persons perform all work on the sterile surface of the table
10. Materials that hang over the edge of the sterile field are not
considered sterile and are discarded.
11. Items that fall below the level of the sterile field are not brought back
onto the sterile field.
12. The gown is considered sterile from the level of the umbilicus to the
axillary level in front.
13. Sleeves are considered sterile to two inches above the elbow.
14. The back of the gown is not considered sterile.

140
15. Areas of the gown outside the specified boundaries do not touch the
sterile field or sterile articles.
16. Articles that drop below the umbilical level of the gown are discarded.
17. Hands are not placed under the arms in the axillary region.
18. The edges of containers enclosing sterile items are not considered
sterile once the container is opened.
19. Non sterile persons maintain a safe distance from sterile areas.
20. Corrective measures are to be instituted immediately if
contamination occurs. If there is any doubt as to the sterility of an
item or surface, it is considered contaminated.

141
B. Respiratory consideration
C. Circulatory considerations
D. peripheral nerves consideration:

Counting Procedure
 A counting procedure is a method of
accounting for items put on the sterile table
for use during the surgical procedure.
 Sponges, sharps, and instruments should be
counted and/or accounted for on all surgical
procedures.
 This includes any material introduced into the
patient during the procedure.
 A counting procedure is made three times in
a surgical procedure.
142

First Count
 The person who assembles and wraps items
for sterilization will count them.
 In commercially prepackaged sterile items,
the count is performed by the manufacturer
143

Second Count
 The scrub nurse and the circulator.
 These initial counts provide the baseline for
subsequent counts.
 Any item initially placed in the wound is
recorded.
 As the scrub nurse touches each item,
she/he and the circulator number each item
aloud until all items are counted.
 The circulator immediately records the count
144

Third Count
 Counts are taken in three areas before the
surgeon starts the closure of a body cavity or
a deep/large incision:
 Field Count. Either the surgeon or the
assistant assists the scrub nurse with the
surgical field count.
 Additional items are accounted for at this
time.
145

Cont....
 Table Count. The scrub nurse and the
circulating nurse together count all items on
the Mayo stand and instrument table.
 The surgeon and assistant may be closing
the wound, while this count is in process.
 Floor Count. The circulating nurse counts
sponges and any other items that have been
recovered from the floor or passed off the
sterile field to the kick buckets.
 These counts should be verified by the
146

operating room nurses
 The occupation of operating room nurses is
both demanding and rewarding.
 Certain qualifications are a prerequisite to
join this field should be .
A. Stamina
B. Emotional stability
C. Respect
D. Stable health
E. Good humor
F. Team sprit
147

Anesthesia concepts and considerations
148
Anesthesiology
Anesthesia
Branch of medicine that is concerned with the
administration of medication or anesthetic
agent to relieve pain and support physiological
function during a surgical procedure.
Greek words means negative sensation.
So it means “Loss of feeling or sensation” of pain with
loss of protective reflexes.(Absence of sensation)

Analgesia
149
Losing of pain sensation without producing
loss of consciousness.
loss of memory.
Amnesia
Induction of anesthesia
Period from beginning of administration of anesthesia
agent until pt. loses consciousness.

Biotransformation
150
Metabolism of anesthetic drugs by broken
down in hepatic cells.
Individual tolerance for pain.
Pain threshold
Endotracheal intubation
Insertion of endotracheal tube.
Laryngospasm
Involuntary spasmodic reflexes action that partially or
completely closes the vocal cord.

Purposes of Pre anesthetic
medication
151
1) Decrease preoperative anxiety.
2) To produce some analgesia an amnesia .
3) Decrease secretions in the respiratory tract.
I . Anesthetic drugs made by anesthesiologist and
based on :
1) Assessment of physical and emotional status.
2) Age, medical history , weight.
3) Lab test , X rays , ECG, smoking.

II. Classification of Pre anesthetic medication used:
152
1. Sedative and Tranquilizer :
To reduce anxiety, and produce amnesia to provide comfort.(Valium, Nembutal
2. Antiemetic :
To relieve nausea and vomiting Example : ( Pramine )
3. Narcotics:
To produce analgesia but depress respiration, and may lead to
nausea, vomiting and urinary retention.(Pethedine and Fentanyl
4. Anticholinergic :
To decrease mucus secretion and to relieve Bradycardia. (Atropine , Scopolamine)

III. Choice of anesthesia :
153
• Factors to be considered by anesthesiologist
• Some characteristics of an ideal anesthetic agent
1. Provides maximum safety for the patient
2. Provides optimal operating conditions for the surgeon
3. Provides patient comfort
4. Has a low index of toxicity
5. Provides potent, predictable analgesia extending into the postoperative period
6. Produces adequate muscle relaxation
7. Provides amnesia
8. Has a rapid onset and easy reversibility
9. Produces minimum side effects

Types Of Anesthesia
154
1. General anesthesia :
. Pain is controlled by general insensibility with loss of consciousness.
 The depth and duration of anesthesia depends on the type and
the amount of anesthetic employed of the agent(s) administer
2. Local or Regional block:
 Pain is controlled without loss of consciousness
3. Spinal or Epidural anesthesia :
 Sensation of pain is blocked at the level below the
diaphragm without loss of consciousness

Anesthesia
155
 Anesthesia is produced as CNS is affected.
 Unconsciousness is produced
 Methods of administration general anesthesia:
1. IV injection:
a) Pre oxygenation : Ventilating the pt. by mask of 100 % oxygen for few
minutes
b) Loss of consciousness induced by IV administration of drug agent.
DRUGES USED :
1. Pentothal Sodium ( concentration 2.5% ) 5mg / kg short acting drug given for
rapid induction within 30 second.
2. Fentanyl :short acting drug to produce good analgesia.

Muscle Relaxant : drugs which given before intubation to relax
jaw , larynx and body muscles.
156
1. pavlon --- long acting ( 30 -45 minutes ).
2. Scoline --- short acting ( 5 minutes. )
 Performed after administration of general anesthesia.
 It can however be performed in the awake patient with local or topical
anesthesia, or in an emergency without any anesthesia at all
 Facilitated by using a conventional laryngoscope, or bronchoscope
 Inhalation gases can be delivered from anesthetic machine through:
1) Face mask inhalation
2) Laryngeal mask inhalation
3) Endotracheal tub
2. Inhalation of anesthesia :

Advantages of ET tube:
157
1. Ensure patent airway and control of respiration.
2. Protects lungs from aspiration of blood, vomiting of gastric content.
3. Helps in minimizing scape of gas into room.
1. Trauma to teeth , larynx, vocal cord.
2. pulmonary aspiration of stomach contents
3. Hypoxia and hypoxemia intubation or extubation.
Complications of endotracheal tube :

Inhaled anesthetic agents:
158
1)Halothane : ( Fluothane)
1. Nonflammable
2. Produce rapid and smooth induction
3. Useful for pt. with bronchial asthma.
Advantages :
Disadvantages:
1. Cause hypotension and Bradycardia.
2. Potentially toxic to liver.
3. May cause hypothermia and limited abdominal muscle relaxation.

159
2) Enflorane : It is similar to halothane.
1. Rapid induction and recovery.
2. Muscle relaxant is produced.
Advantages :
Disadvantages:
1. Depression of BP and respiration.
2. Contraindication in renal failure.

160
3) Isoflurane:
1. Rapid induction and recovery.
2. More patent muscle relaxant.
3. Used for asthmatic pt.
Advantages :
Disadvantages:
1. Expensive
2. Respiratory depressant.

161
4) Nitrous oxide :
 Rapid inhalation and elimination.
Advantages :
Disadvantages:
1. No muscle relaxant.
2. Hypoxia develop and should not use alone.
At the end of surgery:
Muscle relaxant should be reversed by using Myostagmine combined with atropine to
manage Bradycardia which is caused by Myostagmine drug , and the ET tube should
be removed when the pt. is breathing spontaneously and semi or full awake.

Local , Regional Anesthesia
162
1.Local ( topical ) anesthesia :
o The anesthesiologist inject the drug to depress sensory nerves and
blocks conduction of pain impulses from their site and the pt. will
stay full awake.
o The duration of local anesthesia is 20 -30 minutes.
o Agents of local anesthesia could be : ointment , spray , or solution.
e.g. Lidocaine 0.5%–2%
o Local anesthesia is frequently used for lesser procedures,
e.g. Dentistry , Ophthalmic, and Anorectal procedures

163
2. Regional Anesthesia
o The drug is injected into or around a specific never or a group of
nerves to depress the entire pain sensation.
o There are many types of regional anesthesia that are performed
on the lower abdomen and lower extremities
A) Spinal Anesthesia
a) It is performed by anesthesiologist.
b) The drug is injected into or around a specific nerve or a group of nerves to
depress the entire pain sensation.
Note : The headache which caused by spinal anesthesia is caused by leaking through
the needle hole in Dura.

164
2. Regional Anesthesia
B. Epidural anesthesia
a) The epidural space lie between Dura and vertebral column contain network of
blood vessels and spinal never roots.
b) The anesthetic is injected outside the spinal canal (no direct contact between
spinal fluid and anesthetic).
c) Agents of spinal , epidural and local anesthesia:
• Lidocaine 1.0%–2.0%/
• Tetracaine 0.5%–1.0%/
Note: In case of sever hypotension which caused by spinal anesthesia, Ephedrine is
the drug of choice.

Spinal and Epidural Anesthesia
165

Wound healing and methods of hemostasis
166
Types of wound:
 Open wounds
1. Surgical Incision
2. Lacerations wounds
3. Abrasions wound
4. Avulsions wound
5. Ulceration wound
6. Puncture wound
 Closed wound
 Contusion wound

Factors influencing wound healing:
167
1. Age
2. Weight
3. Nutritional status
4. Fluid and electrolyte imbalance
5. General health
6. Drug therapy
7. Post-operative complication.
8. Physical Activity

Operation room techniques

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