The document outlines objectives and definitions for a level II student peri-operative nursing course. It discusses scrubbing, gowning, gloving and arranging surgical equipment. Key points include defining peri-operative nursing phases and terms like asepsis and sterilization. It also describes the operating room setup, personnel roles like surgeons and circulators, and traffic patterns to maximize efficiency while maintaining sterility.

1. Scrubbing, Gowning, Gloving and Arranging of Surgical Equipment

2. OBJECTIVES: After 12 hours of discussion and demonstration, the Level II students will be able to: define the following terms: 1.1 Peri-operative nursing 1.1.1 Pre-operative phase 1.1.2 Intra-operative phase 1.1.3 Post-operative phase 1.2 analgesia 1.3 anesthesia 1.4 antiseptics 1.5 asepsis 1.6 consent 1.7 disinfection 1.8 homeostasis 1.9 medical asepsis 1.10 resident bacteria 1.11 Sterile 1.12 sterilization 1.13 surgery 1.14 surgical asepsis 1.15 surgical conscience 1.16 surgical team 1.17 Surgically clean 1.18 transient bacteria

3. 2. discuss the operating room as to its: 2.1 personnel 2.2 physical lay-out 2.3 attire 2.4 set-up (equipment and apparatus) 3. identify the following: 3.1 scientific principles involved in OR technique 3.2 basic rules of surgical asepsis 3.3 duties and responsibilities of the scrub and circulating nurse 4. familiarize the following: 4.1 basic instruments found in the basic set 4.2 major and minor pack 4.3 operative preparation and positions 5. discuss the following: 5.1 classification of surgery 5.1.1 different layers of the abdomen 5.1.2 common abdominal incisions 5.1.3 different types of: a. suture b. suture needles c. blades

4. 5.2 sterilization process 5.3 anesthesia 5.3.1 types of anesthesia 5.3.2 stages of anesthesia 6. demonstrate beginning skills in: 6.1 filling-up the consent form and peri-operative checklist 6.2 opening the sterile pack 6.3 packing and sterilization 6.4 performing the following OR techniques a. surgical scrubbing b. gowning and closed gloving c. draping d. serving of instruments e. assisting in the operation f. circulating

5. 1. Definition of terms: a. Peri-operative Nursing ~ Nursing care provided to surgery patients during the entire in-patient period from admission to discharge. b. Pre-operative phase ~ occurring or related to the period or preparations before a surgical operation. ~ begins with 1 st preparations of patient such as scheduling of surgery, patient has work-up done or physical examination is done and ends with the induction of anesthesia. c. Intra-operative phase ~ occurring during a surgical operation. ~ from OR to recovery room. d. Post-operative phase ~ happening or done after an operation. ~ transfer from recovery room to ward or admission room.

6. e. Analgesia ~ a decreased or absent sensation of pain without the loss of consciousness. f. Anesthesia ~ The absence of all sensation, especially to pain, as induced by an anesthetic substance or by hypnosis or as occurs with traumatic or pathophysiologic damage to nerve tissue. ~ the total or partial loss of sensation, especially tactile sensibility, induced by disease, injury, acupuncture, or an anesthetic such as chloroform or nitrous oxide. ~ local or general insensibility to pain with or without the complete loss of consciousness. ~ anesthesia induced for medical or surgical purposes may be topical, local, regional, or general and is named for the anesthetic agent used, the method or procedure followed, or the area or organ anesthetized.

7. g. Antiseptics ~ Substances that tend to inhibit the growth and reproduction of microorganisms when applied to living tissue. h. Asepsis ~ the absence of germs. ~ the state of being free of pathogenic microorganisms. i. Consent ~ acceptance or approval of what is planned or done by another. ~ to give approval, assent, or permission. j. Disinfection ~ the process of killing pathogenic organisms or rendering them inert. ~ treatment to destroy harmful microorganisms.

8. k. Homeostasis ~ a relative constancy in the internal environment of the body, naturally maintained by adaptive responses that promote healthy survival. Various sensing, feedback, and control mechanisms function to effect this steady state. L. Medical Asepsis ~ procedures used to reduce the number of microorganisms and prevent their spread. M. Resident Bacteria ~ bacteria living in a specific area of the body. N. Sterile ~ free of living microorganisms. O. Sterilization ~ a technique for destroying microorganisms of inanimate objects, using heat, water, chemicals, or gases. P. Surgery ~ the branch of medicine concerned with diseases and trauma requiring operative procedures.

9. Q. Surgical Asepsis ~ procedures used to eliminate any microorganisms; sterile technique. R. Surgical Conscience ~ the foundation upon which the growth and development of a surgical technologist is built. The principle of sterile technique must be scrupulously maintained. ~ addresses an importance of strict adherence to aseptic technique principles. S. Surgical Team ~ a unit providing the continuum of care beginning with pre-operative care and extending through intra-operative procedures, and post-operative patients. ~ each specialist in the team, whether surgeon, anesthesiologist, or nurse, has advanced training for his/her role before, during, and after surgery. ~ Group of highly trained individuals who must work together, with coordination, for patient’s welfare. ~ Composed of surgeon, assistants, anesthesiologist or nurse anesthetist, scrub nurse and circulating nurse.

10. t. Surgically Clean ~ State of being sterile done by autoclaving. u. Transient bacteria ~ a type of bacteria remaining in place for only a brief time.

11. 2. Discuss the operating room as to its: A. PERSONNEL Operating Room Team The Sterile 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 team member functions within the limited area and the only sterile items. 1. Surgeon 2. Assistants to the surgeon 3. Scrub person

12. *SURGEON ♣ must have the knowledge, skills and judgment required to successfully perform the intended surgical procedure and any deviations necessitated 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 are important attributes of a surgeon.

13. *ASSISTANTS TO THE SURGEON † under the direction of the operating surgeon, one or two assistants help to maintain visibility of the surgical site, control bleeding, close wounds, and apply dressing. † Handles tissues & uses instruments † Anticipates blood loss, anesthesia time for patient, fatigue affecting OR team & potential complications

14. *1 ST ASSISTANT IN SURGERY  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 & to whom part of patient’s care is delegated

15. *NON-PHYSICIAN 1 ST ASSISTANT required to complete a formal education program for 1 st assistant according to their practice discipline *PHYSICIAN’S ASSISTANT (PA) - must have additional surgical training *SCRUB PERSON is a patient care staff member of the sterile team. Responsible for maintaining the integrity, safety and efficiency of the sterile field throughout the surgical procedure.

16. THE UNSTERILE TEAM 1. Anesthesia Provider 2. Circulator 3. Others (the OR team may include biomedical technicians, radiology technicians, and others who may be needed to set up and operate specialized equipment or monitoring devices during the surgical procedure)  the unsterile team members DO NOT enter the sterile field.  They handle supplies and equipments that are not considered sterile.  Following the principles of aseptic technique, they keep the sterile team supplied.

17. *ANESTHESIA PROVIDER this refers to the person responsible for the inducing anesthesia, maintaining anesthesia at the required levels, and managing untoward reactions to anesthesia throughout the surgical procedure.

18. *CIRCULATOR the circulator plays a role that is vital to the smooth flow of events before, during, and after the surgical procedure. The circulator’s 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.

19. B. PHYSICAL LAYOUT OF THE OPERATING ROOM SUITES *No. of rooms regulated depends on: - length of surgical procedures to be performed - type of distribution by specialties of surgical shift & equipment for each - proportion of elective in-patient & emergency surgical procedures to ambulatory patient and minimally invasive procedure. - scheduling policies related to no. of hours/day & days/week the suite will be in use & staffing needs - systems and procedures established for the efficient flow of patients, personnel, and supplies - consideration of volume changes & needs for future expansion capabilities

20. 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.

21. SPACE ALLOCATIONS AND TRAFFIC PATTERNS Space is allocated within the OR suite to provide for the work to be done, with considerations given to the efficiency within which it can be accomplished. The OR suite should be large enough to allow for correct technique yet small enough to minimize the movements of the patient, personnel and supplies. 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 time.

22. UNRESTRICTED AREA Street clothes are permitted. A corridor on the periphery accommodates traffic from the outside; including patients. This area is isolated by doors from the main hospital corridor, elevators and form the areas of the OR suite. SEMI-RESTRICTED AREA Traffic is limited to properly attired personnel. Body and head coverings are required. This area includes peripheral support areas and access to corridors to the Ors. RESTRICTED AREA Masks are required to supplement the OR attire. Sterile procedures are carried out in the OR. The area also includes scrub sink areas and substerile rooms or clean core area where unwrapped supplies are sterilized.

23.  VESTIBULAR OR EXCHANGE AREAS This transition zone, inside the entrance to the OR suite, separates the OR corridors from the rest of the facility.  PRE-OPERATIVE CHECK-IN UNIT If remote same-day procedure is not available for admission of patients who arrive shortly before a surgical procedure, facilities must be provided within the unrestricted area of the OR suite for patients from street clothes to gown. Lockers should be provided for safeguarding patient’s clothes.  PRE-OPERATIVE HOLDING AREA A designated room or area should be available for patients to wait in the OR suite that shields them from potentially distressing sights or sounds. Hair removal and insertion of intravenous (IV) lines, indwelling catheters, and/or gastric tubes may be done.  INDUCTION ROOM It is where the patient waits and is prepared pre-operatively before administration of anesthesia. Invasive IV lines and/or regional anesthesia may be administered in this area.

24.  POST-ANESTHESIA CARE UNIT (PACU) The PACU may be outside the OR suite, or it may be adjacent to the suite so that it may be incorporated into the unrestricted areas with access from both the semi-restricted area and an outside corridor. In the latter design, the PACU becomes a vestibular area for the departure of patients.  DRESSING ROOM AND LOUNGES Dressing room must be provided for both men and women to change from street clothes into OR attire before entering the semi-restricted area, and vice versa. Lockers are usually provided. Doors separate this area from lavatory facilities and adjacent lounges.  PERIPHERAL SUPPORT AREAS Adequate space must be allocated to accommodate the needs of the OR personnel and support services.

25.  CENTRAL CONTROL DESK - From a central control point, traffic in and out of the OR suite may be observed. This area usually is within the unrestricted area.  CONFERENCE ROOMS/CLASSROOM - A conference or a classroom is located within the semi-restricted area. This is used for patient care staff in cervical staff for teaching.  SUPPORT SERVICE - The size of the health care facility and the types of services provided, determine whether laboratory and radiology equipment is needed within the OR suite.

26.  LABORATORY A small laboratory where the pathologist can examine tissue and perform frozen sections expedites the decisions that the surgeon must make during a surgical procedure when diagnosis is questionable. A refrigerator for storing blood for transfusions may also be located in this room.  RADIOLOGY SERVICES Special procedure rooms may be outfitted with X-ray and imaging equipment for diagnostic and invasive radiological procedures or insertion of catheters, pacemakers, and other devices.  WORK AND STORAGE AREAS Clean 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 not be taken into this area.  ANESTHESIA WORK AND STORAGE AREA Space must be provided for the storage of the anesthesia equipment and supplies. A separate workroom usually is provided for care of anesthesia equipment. Dirty and clean supplies must be kept separated.

27.  HOUSEKEEPING STORAGE AREAS Cleaning supplies and equipment need to be stored; the equipment used within the restricted area is kept separated from that used to clean other areas. Sinks are provided, as well as shelves for supplies. Trash and soiled laundry receptacles should not be allowed to accumulate in the same room where clean supplies are kept.  CENTRAL PROCESSING AREA Conveyor, dumbwaires, and elevators connect the OR suite with a central processing area on another floor of the hospital. If efficient material flow can be accomplished, support functions can be removed from the OR suite.  UTILITY ROOM Some hospitals use a closed-cart system and take contaminated instruments to a central area outside the OR suite for clean-up procedures in the substerile room. Many, by virtue of the limitations of the physical facilities, bring the instruments to a utility room. This room contains a washer – sterilizer, sinks, cabinets and all the necessary aids for cleaning.

28.  STORAGE Storage spaces should fit logically into the design of the suite.  STERILE SUPPLY ROOM Most hospitals 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. As many shelves as possible should be freestanding from the walls, which permits supplies to be put into one side and removed from the other, thus older packages are always used first.  INSTRUMENT ROOM The instrument room contains cupboards in which all clean and decontaminated instruments are stored when not in use. Instruments usually are segregated on shelves according to surgical specialty services.  STORAGE ROOM Some large portable equipment must also be stored in the OR suite, readily accessible for use. A storage room for this equipment may not be used daily, keeps equipment out of corridors when not in use.

29. SCRUB ROOM - An enclosed area for surgical scrubbing of hands and arms must be provided adjacent to each OR suite. It is a restricted area within the OR suite.

30. C. OPERATING ROOM ATTIRE

31. PURPOSE:  to provide effective barriers that prevent the dissemination of microorganisms to patient and protect personnel from blood & body substances of patients. DEFINITION:  consists of body covers, such as 2-piece pantsuit, headcover, mask & shoe covers as appropriate.  Sterile gown & gloves are added for scrubbed sterile team members

32. CONSIDERATIONS FOR APPROPRIATE ATTIRE: 1. dressing rooms located in unrestricted area adjacent to semi-restricted area of OR suite are reached through outer corridor 2. only approved, clean and/or freshly laundered attire for use in OR is worn within semi-restricted areas. This applies to  everyone entering the OR suite, both professional and non-professional.  clean, fresh attire is donned each time on arrival in the OR & as necessary at other times, if attire becomes wet or grossly soiled  adequate supply of clean attire should always be available  masks should be changed between patients 3. OR attire should not be worn outside the OR suite. Before leaving the OR, everyone should change to street clothes.  on occasions such as lunch breaks, a single use cover gown covers all may be worn over OR attire outside the suite  a clean, fresh scrub suit should be put on in re-entering the suite  attire should not be hung or put in a locker after wearing. It should be discarded in a trash bin or put in a laundry hamper after hygiene is emphasized

33. 4. impeccable personal hygiene is emphasized  person with acute infection such as colds should not be permitted to get inside in the OR suite; persons with cuts, burns or skin lesions should not scrub or handle sterile supplies because serum may seep from eroded area  sterile team members who are known carriers of pathogen microbes should routinely scrub and bathe with appropriate skin antiseptic agent and shampoo daily  fingernails should be kept short  jewelry should be removed before entering semi-restricted & restricted areas  facial make-up should be minimal  eyeglasses should be wiped with a cleaning solution before each surgery  external apparel that doesn’t serve a functional purpose should not be worn 5. comfortable, supportive shoes should be worn to minimize fatigue and for personal safety

34. COMPONENTS OF ATTIRE A. BODY COVER - variety of scrub suits, either 2-pc. Pantsuit or 1-pc. overalls, are available in either a solid color or attractive print all should fit body snuggly - scrubsuit should be changed ASAP whenever it becomes visibly soiled B. HEAD COVER - since hair is a gross contaminant, cap/hood is put on before scrub suit to protect it from hair contamination - all facial & head hairs are completely covered in semi-restricted & restricted areas - hair should not be combed while wearing a scrub suit - persons with scalp infection should be excluded from the OR suite - most of them are made of disposable, lint-free, nonporous, nonwoven fabrics. - headgear should fit well so that it confines and prevents escape of any hair

35. C. SHOE COVERS may be worn in the semi-restricted and restricted areas as needed to protect from body fluids. Knee-high imper vious styles will protect wearer from spills into shoes during procedures wherein extens ive fluid irri gation and/or blood loss can be an ticipated . can inadvertently become soiled and harbor microorganisms they should be removed before entering the dressing room area and must be removed before leaving the OR suite. legs of scrub pants are tucked into boots

36. D. MASKS - worn in the restricted area to contain and filter droplets containing microorganisms expelled from the mouth and nasopharynx during breathing, talking, sneezing and coughing - provide some protection to the sterile team members from bloodborne pathogens that may splash or spray toward the nose or mouth. Wearing double masks forms a barrier instead of a filter and may actually cause expulsion of airborne particles to escape from the cheek folds. - some tight-fitting masks also effectively reduce exposure to submicron particles by filtration of inhaled air. - many masks filter about 99% of particular matter larger than 5mm in diameter but only 45% to 60% of particles measuring 0.3mm in diameter

37. E. PERSONAL PROTECTIVE ATTIRE a. APRONS - decontamination apron= worn over scrubsuit to protect against liquids and cleaning agents during cleaning; full-front barrier - fluid-proof apron= worn by sterile team members under permeable reasonable sterile gown when extensive blood loss or irrigation is anticipated; lightweight and full-front cover - lead aprons= worn over sterile gowns to protect against radiation exposure b. EYEWEAR (goggles, eyeglasses, etc.) - face shield is worn whenever there is risk of blood or any body substances of patient splashing in the eyes of sterile team member - laser eyewear protects from laser

38. c. GLOVES  sterile gloves worn by sterile team member and for all invasive procedures  lead gloves protect from radiation  thick gloves to protect skin from ethylene oxide exposure  utility gloves fro cleaning and house keeping duties  non sterile latex/vinyl gloves for handling materials contaminated by blood  worn to permit the wearer ton handle sterile supplies and tissues of the surgical site  made of natural rubber latex, synthetic rubber, thermoplastic elastomers, neoprene, vinyl, or polyethylene

39. F. SURGICAL GOWN  worn over scrubsuit to permit wearer to come within sterile field  prevent intercontamination between wearer and field and differentiate sterile from non sterile member  should provide a protective barrier from strike-through (i.e. migration of microorganisms from the skin and scrub suit of the wearer to the sterile field and the patient, penetration of the blood and body substances from the patient to the scrub suit and skin of the wearer)  should be resistant to penetration by fluids and should be comfortable without producing excessive heat build up

40. G. SURGICAL GLOVES  Worn to permit the wearer to handle sterile supplies and tissues of the surgical site  Made of natural rubber latex, synthetic rubber, thermoplastic elastomers, neoprene, vinyl, or polyethylene  Packaged in pairs with an everted cuff on each to protect the outside of the sterile glove during donning  It is important to remove the powder from the outside of the gloves after donning them.

41. CRITERIA FOR OR ATTIRE:  effective barrier to microbes  Made of closely woven material void of dangerous electrostatic properties  designed for maximal skin coverage  hypoallergenic, cool and comfortable  Nongenerative of lint  Made of pliable material to permit freedom of movement  Able to transmit heat and water vapor to protect the wearer  easy to don and remove  resistant to blood, aqueous fluids and abrasion to prevent penetration by microbes

42. OR ATTIRE

43. A. COMPONENTS OF ATTIRE HEAD COVER

44. Shoe cover

45. Mask

46. B. PERSONAL PROTECTIVE EQUIPMENT - Aprons

47. Eyewear: Face shield

48. Laser eyewear

49. Gloves: Latex

50. Lead

51. Utility Gloves

52. Surgical gown

53. Surgical gloves

54. PHYSICAL LAY-OUT OF THE OR OPERATING-ROOM SETUP SHOWING TABLES FOR INSTRUMENTS AND SUPPLIES DESIGNED TO FACILITATE THE WORK OF THE SURGEON, HIS ASSISTANTS, AND THE NURSES

55. PACU (post anesthesia care unit)

56. OR suite (operating room-central Processing area)

57. Preoperative Holding area – sterile supply room

58. Preoperative Check-in Unit – utility room

59. Induction room (for anesthesia) – instrument room

60. Dressing room and lounger – scrub room

61. Central Control desk

62. Anesthesia work and storage area

63. Housekeep ing storage A rea

64. D. SET-UP (EQUIPMENT & APPARATUS) The accepted operating room practice causes much useless motion and delay on the part of the assistants and the nurses in handling the instruments and supplies. The redesigned arrangement shown eliminates many motions in that the instruments and supplies are on either side of the surgeon, enabling the nurses to face the operating table instead of turning around to procure necessary articles from tables ordinarily located behind them.

65. Draped patient and operating bed Mayo stand 1 st assistant Scrub nurse Surgeon Kick bucket Instrument table Electrosurgical unit Suction container Kick bucket Anesthesia machine Anesthesia provider

66. A. SCIENTIFIC PRINCIPLES INVOLVED IN OR TECHNIQUE  ANATOMY AND PHYSIOLOGY adequate knowledge of the human body parts is a prerequisite in being a part of the OR team. [Ex.: epidermis is the term used to designate the outer or surface layer of the skin and the dermis is considered to be the second layer. There are sebaceous and sweat glands of the skin. the skin protects the body tissues against pathogenic microorganisms and injury from mechanical devices.]  CHEMISTRY use of antiseptics can reduce bacterial count. Excessive use of soap may harden the skin, as soap is alkaline and removes protecting oils from the skin.  MICROBIOLOGY skin protects the body from certain diseases. Handwashing is the most effective means of conserving ordinary cleanliness for protection of the patient as well as the nurses.  PHARMACOLOGY drugs that are used for soothing and reducing irritation of surfaces that have been abraded or irritated is classified as demulcents. Ethyl alcohol (70%) is an effective solution for disinfection of equipment.

67.  PSYCHOLOGY the proper explanation to the patient regarding the upcoming operation should be established.  SOCIOLOGY home methods of disinfection and sterilization may be taught by the visiting nurse. The attitude of the isolated patient whether at home or in the hospital may depend on the knowledge of his disease and the manner of its transmission from one person to another.  PHYSICS the autoclave used for sterilization sterilizes by means of pressurized steam.

68. B. BASIC RULES OF SURGICAL ASEPSIS  Only sterile items are used in the sterile field.  Sterile articles may touch other articles and remain sterile.  Sterile persons are gowned and gloved.  If you are unsure of the article’s sterility, then consider it unsterile.  Sterile instrument is only used for one patient.  The back of the scrubbed person is considered unsterile.  Sterile nurse is a scrub nurse.  Unsterile burse is a circulating nurse.  Unsterile arm of the circulator must not extend over the sterile field.  If a scrubbed person leaves the OR suite, then he is unsterile.

69.  Front waist to shoulder area including gowned forearms & gloved hands of the scrubbed person is sterile.  Gloved hands of the scrubbed person are sterile.  Sterile drape is held well above the surface of the operating table & is placed from front to back.  Only top of patient or OR table is considered sterile.  Drapes hanging over the edge are unsterile.  Drapes are kept in position with towel clips.  Tear or puncture of drapes or gloves renders area unsterile.  Lips or mouth of solution bottles are unsterile.  Edges of the drapes covering sterile articles are unsterile.  Unsterile articles are to be dropped at a considerable distance from the edge of the sterile area.  Avoid splashing when pouring sterile fluids to sterile bowls.

70. PRINCIPLES OF STERILE TECHNIQUE † Only sterile items are used w/in the sterile field. † Sterile persons are gowned and gloved. † Tables are sterile only at table level. † Only sterile persons touch sterile items or areas, while unsterile persons touch only unsterile items. † Unsterile persons avoid reaching over sterile field. Sterile persons avoid leaning over unsterile area. † The edges of anything that encloses sterile contents are considered unsterile. † The sterile field is created as close as possible to the time of use. † Sterile areas are continuously kept in view.

71. † Sterile persons keep well within sterile area. † Sterile persons keep contact with sterile items to a minimum. † Unsterile persons avoid sterile areas. † Destruction of integrity of microbial barriers results in contamination. † If a sterilized package wrapped in absorbent material becomes damp or used, it is resterilized or discarded. † Drapes are placed on dry field. † Microorganisms must be kept to an irreducible minimum. † No compromise of sterility; it is either sterile or unsterile.

72. C. DUTIES AND RESPONSIBILITIES OF THE SCRUB AND CIRCULATING NURSE Both the circulator and the scrub person set up the room and position the equipment. The case cart and room furniture are checked by both persons as a team. The duties and activities change when the patient arrives at the OR suite. The circulator begins working with the 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 patient’s arrival, the scrub nurse prepares for the surgeon’s arrival. At all times, the integrity of the sterile field is closely monitored. The principles of asepsis and sterile technique are followed.

73. Preparation of the sterile field: The scrub nurse should be sure that his or her gown and gloves are open and ready on a surface separate from the sterile field. perform a complete surgical hand cleansing according to the facility procedure. gown and glove using closed gloving method. drape unsterile tables according to standard departmental setup procedure with drapes from the drape 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 for transplant)

74. drape both the frame and the tray of the Mayo stand arrange on the Mayo stand the instruments and accessory items to create primary precision. Arrange other instruments and items on the instrument table. (the Mayo stand should be kept neat throughout the surgical procedure. Do not overload it with sponges and sharps) count sponges, surgical needles, other sharps, and instruments with the circulating nurse according to established facility policy and procedure. secure surgical needles and all other sharps, including the knife blades. They should never be loose on the Mayo stand. prepares sutures in the sequence in which the surgeon will use them.

75. After the surgeon and assistant(s) scrub: gown and glove the surgeon and assistant(s) as soon after they enter the OR as possible. assist in draping according to the type of procedure and the surgeon’s preference. after draping is completed, bring the Mayo stand into 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.

76. During the surgical procedure: pass the skin knife to the surgeon, and pass a hemostat and suction to the assistant. When passing the knife, take care to direct the blade away from yourself and other personnel. hand up sterile towels or lap sponges if requested for covering skin at the edges of the incision. watch the field and try to anticipate the needs of the surgeon and assistant. Keep one step ahead of them in passing instruments, sutures, and sponges and in handing up the specimen basin. return instruments to the Mayo stand or instrument table after use. 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.

77. have scissors ready when the knot is tied. 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 the circulating nurse for the permanent record .

78. During closure: alert the circulating nurse that closure is about to begin, and hand up the wound closure materials. in accordance with established procedures, count sponges, sharps, and instruments with the circulator as the surgeon begins closure of the wound. Verify that intraabdominal or other cavity packing materials and towels have been removed. place unneeded instruments and supplies on the instrument table in the original set position have a clean, warm, saline-moistened sponge ready to wash blood from the area surrounding the incision as soon 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 appropriate receptacle – NOT on the instrument table or Mayo stand

79. The Eight “Ps” to consider when preparing for a Surgical Procedure Sterile Field Considerations for the Scrub Nurse Environment Considerations 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 patient’s 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 for safety 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 equipment before the patient enters the room.

80. PLACE IT ONCE -items should not be manipulated during the procedure. Energy and attention should not be diverted to resetting the field. When setting up the field, each item (e.g., a basin) should be placed where it will be used during the procedure with minimal handling. The operating bed should be 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 if they 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 surgeon’s 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, or microscope should be preplanned so they may be positioned while the procedure is in progress.

81. POINT OF USE -items should be as close to the area of use as possible. Basins should be placed close to the edge of the table so the circulating nurse 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 should be 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 patient’s body. Cords, cables, and tubing should be secured and appropriately directed away from the field. Pad the operating bed and patient as appropriate. Use safety belts. PERFECT PICTURE -items within and around the 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 the temperature and humidity should be appropriate. Forethought to having a clear path for the crash cart or emergency equipment is essential.

82. RESPONSIBILITIES OF A CIRCULATING NURSE: before entering the OR suite, the circulating nurse must wash 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 and opening sterile supplies needed to prepare for arrival of the patient and the surgeon. - test all equipments before bringing to the OR suite.

83. After scrub nurse scrubs: fasten the back of scrub nurse’s gown check with the scrub nurse to see if additional supplies or instruments are needed. check the list of suture materials and sizes on the surgeon’s 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 with the scrub nurse in the manner as described in facility policy and procedure. the instrument counts will be recorded on the instrument tray sheet packed with the set.

84. After the patient arrives: attend to patient while scrub nurse continues to prepare 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 patient’s hair is covered with a cap

85. loosen the neck and back ties on the patient’s gown after the patient has transferred to the operating bed, apply safety belt over the thighs 2-3 inches above the patient’s 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.

86. During induction of anesthesia: remain at patient’s side during the induction of anesthesia. assist the anesthesia provider during induction and intubation. maintain a quiet environment. Tactile or auditory stimulation may produce excitement in the patient during induction.

87. After the patient is anesthetized: attach anesthesia screen and other table attachments as needed. 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 patient’s position to be certain all measures for his/her safety have been observed. -prepare the patient’s 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.

88. After the surgeon and assistants scrub:

90. During the Surgical Procedure: be alert to anticipate the needs of the sterile team, such as adjusting the operating lights, removing perspiration from brows, and keeping the scrub nurse supplied with sponges, sutures, warm saline, and other necessary items. watch the surgical procedure closely enough to see when routine supplies 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 get something. be available to answer questions, obtain supplies and assist team members.

91. keep discarded sponges carefully collected; separated by sizes, and counted according to the number they are packaged in. assist the surgeon and the anesthesia provider monitor blood loss. Weigh sponges if requested to do so. know the condition of the patient at all times. Inform the OR manager of any marked changes, unanticipated additional procedure, or delays. communicate periodically with the patient’s family or significant others to inform them of the progress of the procedure as appropriate. prepare and label specimens for transfer to the laboratory. Always wash hands thoroughly after removing gloves that have been worn to handle specimens. as required, complete the documentation in the patient’s chart, permanent OR records, and requisition for laboratory tests or chargeable items.

92. During Closure: count sponges, sharps, and instruments with the scrub nurse. Report counts as correct or incorrect to the surgeon. Complete the count records. Collect used sponges for disposal in the appropriately marked receptacles. obtain the washer-sterilizer tray, instrument tray, and other items necessary or the cleanup procedure. send for a postanesthesia care unit (PACU) stretcher or an intensive care unit (ICU) bed, or prepare the patient’s stretcher or bed with a clean sheet; follow whatever is the institutional procedure. obtain a transfer monitor and oxygen tank with tubing if needed.

93. After Surgical Procedure is Complete: assist with dressing the surgical wound and managing the surgical drainage systems. secure the outer layer of the dressing with appropriate type of tape. open the neck and back closures of the surgeon’s and assistants’ gowns so they can remove them without contaminating themselves. see that the patient is clean. raise side rails before the patient is transported out of the OR suite.

94. Different Sutures: Sutures (also known as stitches) are divided into two kinds – those which are absorbable and will break down harmlessly in the body over time without intervention, and those which are non-absorbable and must be manually removed if they are not left indefinitely. The type of suture used varies on the operation, with the major criteria being the demands of the location and environment.

95. Sutures to be placed internally would require re-opening if they were to be removed. Sutures which lie on the exterior of the body can be removed within minutes, and without re-opening the wound. As a result, absorbable sutures are often used internally; non-absorbable externally. Sutures to be placed in a stressful environment, for example the heart (constant pressure and movement) or the bladder (adverse chemical presence) may require specialized or stronger materials to perform their role; usually such sutures are either specially treated, or made of special materials, and are often non-absorbable to reduce the risk of premature degradation.

96. Absorbable sutures – the absorbable ones get dissolved in the body on their own and do not require removal. are made of materials which are broken down in tissue after a given period of time, which depending on the material can be from ten days to eight weeks. They are used therefore in many of the internal tissues of the body. In most cases, three weeks is sufficient for the wound to close firmly. The suture is not needed any more, and the fact that it disappears is an advantage, as there is no foreign material left inside the body and no need for the patient to have the sutures removed.

97. Absorbable sutures were originally made of the intestines of sheep, the so called catgut . The manufacturing process was similar to that of natural musical strings for violins and guitar , and also of natural strings for tennis racquets. The inventor, a 10th century surgeon named al- Zahrawi reportedly discovered the dissolving nature of catgut when his lute 's strings were eaten by a monkey. Today, gut sutures are made of specially prepared beef and sheep intestine, and may be untreated (plain gut), tanned with chromium salts to increase their persistence in the body (chromic gut), or heat-treated to give more rapid absorption (fast gut). Each major suture manufacturer has its own proprietary formulations for its brands of synthetic absorbable sutures; various blends of polyglycolic acid (Biovek for example), polylactic acid or caprolactone are common. Occasionally, absorbable sutures can cause inflammation and be rejected by the body rather than absorbed.

98. However, the majority of absorbable sutures are now made of synthetic polymer fibers, which may be braided or monofilament; these offer numerous advantages over gut sutures, notably ease of handling, low cost, low tissue reaction, consistent performance and guaranteed non-toxicity. In Europe and Japan, gut sutures have been banned due to concerns over bovine spongiform encephalopathy (mad-cow disease), although the herds from which gut is harvested are certified BSE-free.

99. Non-absorbable sutures - The non absorbable ones have to be removed after specified time. The type of suture is decided again by the location of the wound. Nonabsorbable sutures are made of materials which are not metabolized by the body, and are used therefore either on skin wound closure, where the sutures can be removed after a few weeks, or in some inner tissues in which absorbable sutures are not adequate. This is the case, for example, in the heart and in blood vessels, whose rhythmic movement requires a suture which stays longer than three weeks, to give the wound enough time to close. Other organs, like the bladder, contain fluids which make absorbable sutures disappear in only a few days, too early for the wound to heal. Inflammation caused by the foreign protein in some absorbable sutures can amplify scarring, so if other types of suture are less antigenic (ie, do not provoke as much of an immune response ) it would represent a way to reduce scarring.

100. There are several materials used for nonabsorbable sutures. The most common is a natural fiber, silk , which undergoes a special manufacturing process to make it adequate for its use in surgery. Other nonabsorbable sutures are made of artificial fibers, like polypropylene , polyester or nylon ; these may or may not have coatings to enhance their performance characteristics. Finally, stainless steel wires are commonly used in orthopedic surgery and for sternal closure in cardiac surgery .

101. Different Suture Needles: Traumatic needles are needles with holes or eyes which are supplied to the hospital separate from their suture thread. The suture must be threaded on site, as is done when sewing at home. Atraumatic needles with sutures comprise an eyeless needle attached to a specific length of suture thread. The suture manufacturer swages the suture thread to the eyeless atraumatic needle at the factory. There are several advantages to having the needle pre-mounted on the suture. The doctor or the nurse or odp does not have to spend time threading the suture on the needle. More importantly, the suture end of a swaged needle is smaller than the needle body. In traumatic needles with eyes, the thread comes out of the needle's hole on both sides. When passing through the tissues, this type of suture rips the tissue to a certain extent, thus the name traumatic . Nearly all modern sutures feature swaged atraumatic needles.

102. There are several shapes of surgical needles, including: straight half curved or ski 1/4 circle 3/8 circle 1/2 circle 5/8 circle compound curve

103. Needles may also be classified by their point geometry; examples include: taper (needle body is round and tapers smoothly to a point) cutting (needle body is triangular and has a sharpened cutting 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 bottom with a cutting edge along the front to one side) for eye surgery

104. Finally, atraumatic needles may be permanently swaged to the suture or may be designed to come off the suture with a sharp straight tug. These "pop-offs" are commonly used for interrupted sutures, where each suture is only passed once and then tied.

105. Ideal suture characteristics The ideal suture has the following characteristics: Sterile All-purpose (composed of material that can be used in any surgical procedure) Causes minimal tissue injury or tissue reaction (ie, nonelectrolytic, noncapillary, nonallergenic, noncarcinogenic) Easy to handle Holds securely when knotted (ie, no fraying or cutting) High tensile strength Favorable absorption profile Resistant to infection

106. ABSORBABLE SUTURE

107. NONABSORBALE SUTURE

108. SUTURE NEEDLES

109. BLADES 1. A no. 10 blade is used most often. This blade has a rounded cutting edge along one side and fits on no.3, 7 and 9 handles. No. 20, 21 and 22 blades are the same shape but are larger. They fit on no.4 handles. 2. A no.11 blade has a straight edge that comes to a sharp point. It fits on no. 3,7 and 9 handles. 3. A no. 12 blade is shaped like a hook with the cutting edge on the inside curvature. It fits on no. 3, 7 and 9 handles. 4. No. 15 blade has a smaller and shorter curved cutting edge than a no. 10 blade. This blade also fits on no. 3, 7 and 9 handles. A no. 15C blade has the same shape but is smaller for tiny incisions, such as those for some pediatric procedures. 5. A no.23 blade has a curved cutting edge that comes to move of a point than no. 20, 21 and 22 blades. The no. 23 blade fits on a no. 4 handle.

110. Anesthesia – loss of feeling or sensation, especially loss of the sensation of pain with loss of protective reflexes.

111. Types of Anesthesia: 1. General Anesthesia pain is controlled by general insensibility. Basic elements include loss of consciousness, analgesia, interference with undesirable reflexes, and muscle relaxation. Three methods of administering general anesthetic are inhalation, IV injection, and rectal instillation.

112. 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 margin of safety in the event of airway obstruction or apnea during induction, with resultant hypoxia. Loss of Consciousness unconsciousness is induced by IV administration of a drug or by inhalation of an agent mixed with oxygen. Because the technique is rapid and simple, an IV drug usually is preferred by anesthesia providers and often is requested by patients. Intubation a patent airway must be established to provide adequate oxygenation and to control breathing of the unconscious patient. The patient’s tongue and secretions can obstruct respiration in the absence of protective reflex .

113. Physiologic indicators of a difficult airway include the following: ~ Inability to open mouth. Patients with previous jaw surgery may have jaw 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 a difficult 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 maintenance process. ~ Short neck or morbid obesity. ~ Pathology of the head and neck such as tumors or deformity. An enlarged tongue can be an obstruction to a full view of the glottis. ~ Previous tracheostomy scar, which can cause a stricture. ~ Trauma.

114. Depth of General Anesthesia From To Patient’s Responses Patient Care Considerations Induction of general anesthesia and beginning of inhalant and/ or IV drug Begins to lose consciousness; will have recall Bispectral state 100 Drowsy, dizzy, amnesic Close OR doors. Keep room quiet. Stand by to assist. Initiate cricoid pressure if requested. Loss of consciousness; excitement phase Relaxation, light hypnosis; low probability of recall Bispectral state 70 to 50 May be excited with irregular breathing and movements of extremities; susceptible to external stimuli (e.g., noise, touch) Restrain patient. Remain at patient’s side, quietly, but ready to assist anesthesia provider as needed.

115. Surgical anesthesia stage of relaxation Loss of reflexes: depression of vital functions Bispectral state 40: maintenance range Regular respiration; contracted pupils; reflexes disappear; muscle relax; auditory sensation lost Position patient and prepare skin only when anesthesia provider indicates this stage is reached and under control. Danger stage: vital functions too depressed Respiratory failure; possible cardiac arrest Bispectral state 0 Not breathing; little or no pulse or heartbeat Prepare for cardiopulmonary resuscitation.

116. Most Commonly Used General Anesthetic Agents Generic Name Trade Name Administration Characteristics Uses INHALATION AGENTS Nitrous oxide None Inhalation Inorganic gas; slight potency; pleasant, fruitlike odor; nonirritating; non-flammable but supports combustion; poor muscle relaxation Rapid induction and 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

117. Enflurane Ethrane Inhalation Halogenated ether; potent; some muscle relaxation; respiratory depressant 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 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

118. 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 induction and recovery; short procedures alone; prolonged anesthesia in combination with inhalation agents or opioids 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

119. 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

120. Diazepam Valium Intravenous, intramuscular Benzodiazepine; tranquilizer; produces amnesia, sedation, and muscle relaxation Premedication; awake intubation; induction Midazolam Versed Intravenous, intramuscular Benzodiazepine; sedative; short-acting amnesic; central nervous system and respiratory depressant Premedication; conscious sedation; induction in children

121. 2. Balanced Anesthesia the properties of general anesthesia (i.e., hypnosis, analgesia, and muscle relaxation) are produced, in varying degrees, by a combination of agents. Each agent has a specific purpose. This often is referred to as neuroleptanesthesia. The technique is especially useful for preventing CNS depression in older and poor-risk patients. Induction can be accomplished with a thiobarbiturate derivative (thiopental sodium [ Pentothal], methohexital [Brevital]), diazepam (Valium), midazolam (Versed), or other induction agent. Oxygen is administered in physiologic quantities. Neuromuscular blockers permit control of ventilation while providing muscle relaxation during intubation.

122. Maintenance Neuroleptanalgesia refers to an intense analgesic and amnesic state resulting from the combination of a narcotic (potent analgesic) and a neuroleptic (psychotropic tranquilizer). The analgesia, amnesia, and sedation produced are not true anesthesia. Neuroptansthesia when the narcotic-neuroleptic drug combination is reinforced by an anesthetic,. Supplementation is necessary for extensive surgical procedures. Nitrous oxide or a halogenated inhalations agent and IV narcotics provide analgesia.

123. Emergence residual effects of narcotics or muscle relaxants may require reversal by antagonists during and/or at the conclusion of the surgical procedure. Other precautions are taken as for any patient emerging from general anesthesia.

124. Induced Hypothermia Hypothermia- is an artificial, deliberate lowering of body temperature below the normal limits. it reduces the metabolic rate and oxygen needs of the tissues in conditions causing hypoxia or during a decrease or interruption of circulation. Normal core temperature: 98.2 to 99.9°F (36.8° to 37.7°C) Systemic hypothermia may be: ~Light: 98.6-89.6°F (37-32°C) ~Moderate: 89.6-78.8°F (32-26°C) ~Deep: 78.8-68°F (26-20°C) ~Profound: 68°F (20°C) or below - Sensorium fades at: 91 to 93°F (33 to 34°C)

125. Hypothermia may be used as follows: for direct-vision intracardiac repair of complex congenital defects in infants and in other cardiac procedures after cardiac resuscitation, to decrease oxygen requirements of vital tissues and limit further damage to the brain after anoxia in treatment of hyperpyrexia and some other nonsurgical conditions, such as hypertensive crisis to increase tolerance in septic shock in neurosurgery, to decrease cerebral blood flow, cerebrospinal fluid volume, and venous and intracranial pressures to aid in transplantation of organs

126. Attaining Hypothermia * Surface-induced hypothermia - external cooling of infants and small children weighing less than 20 pounds may be attained by immersion in iced water, packing the body in ice, or alcohol sponging. * Internal cooling a decreased or interruption of blood flow can be achieved by placing sterile iced saline slush packs around a specific internal organ or by irrigation of cold fluids within a body cavity, such as intraperitoneal lavage. The cold cardioplegia technique combines cold from saline slush with drugs injected into coronary arteries for myocardial protection during heart surgery.

127. * Systemic Hypothermia the bloodstream is cooled by diverting blood through heat-exchanging devices of extracorporeal circulation and returning it to the body by a continuous flowing circuit (e.g., core cooling by cardiopulmonary bypass or IV administration of cold fluids). Systemic hypothermia is used in adults and larger children to 78.8°F (26°C).

128. Complications in the use of hypothermia: it affects the myocardium, decreasing its resistance to ventricular fibrillation and predisposing the patient to cardiac arrest heart block effects on vascular system atrial fibrillation embolism microcirculation stasis undesired downward drift of temperature tissue damage metabolic acidosis numerous effects on othe organ systems

129. Induced Hypotension induced, deliberate hypotension is the controlled lowering of arterial blood pressure during anesthesia as an adjunct to the surgical procedure. Hypotensive anesthesia is used to shorten the operating time, reduce blood loss and the need for transfusion, and facilitate dissection and visibility, especially of tumor margins in radical procedures.

130. Hypotension may be specifically induced for the following: Surgical procedures in which excessive blood loss is anticipated, such as spinal surgery, to decrease gross hemorrhage or venous oozing. Surgical procedures on the head, face, neck, and upper thorax, especially radical dissection, in which the position of the patient allows blood to pool in dependent areas and reduces venous return to the heart and cardiac output. Neurosurgical procedures when control of intracranial vessel hemorrhage may be difficult. It reduces leakage, makes an aneurysm less turgid and prone to rupture, decreases blood loss in the case of rupture, and facilitates placement of ligating clips. Surgical procedures in which blood transfusions should be avoided, such as when compatible blood is unavailable or transfusion is against the patient’s religious belief. Surgical procedures on the spine or posterior torso. Blood loss is decreased in the prone position. Total hip replacement.

131. Attaining Hypotension: Deep general anesthesia with halothane or isoflurane, followed by a vasodilator, produces the desired minute-to-minute effect. With increased concentration, halogenated agents produce hypotension as a result of myocardial and peripheral vascular depression. Sodium nitroprusside is a potent, fast-acting vasodilator that reduces virtually all resistance in vascular smooth muscle. It also reduces preload and afterload of the heart and pulmonary vascular resistance. Nitroglycerin, primarily a vasodilator, directly dilates capacitance vessels. It reduces preload and improves myocardial perfusion during diastole- a protection against potential ischemia.

132. Trimethapan camsylate (Arfonad) blocks sympathetic ganglia, which results in relaxation of resistance and capacitance vessels and reduces arterial pressure. Fentanyl may be used as a basal anesthetic for hypotension. The blood pressure can be maintained at the desired level by the addition of a small amount of a volatile agent. Fentanyl lowers arterial pressure; volatile agents reduce cardiac output.\ Other drugs such as verapamil, nifedipine, phentolamine, tetrodotoxin, or adenosine triphosphate may be used.

133. Precautions in the use of Hypotension: Careful selection of the patient Preoperative cardiac, renal, and hepatic evaluation of the patient to avoid circulatory insufficiency in vital organs Selection of an appropriate but not arbitrary level of blood pressure. Administration and evaluation by expert anesthesia providers Use for only a short time and lowering of blood pressure only enough to obtain the desired result Maintenance of blood volume at an optimal level by continuous infusion Controlled ventilation with adequate oxygenation via and an endotracheal tube, because hypotension increases susceptibility to hypoxia Extensive monitoring: ECG, core temperature, esophageal stethoscopy, urinary output, central venous pressure and arterial catheters, and electrophysiologic brain monitoring or EEG via Bispectral Index monitoring

134. 3. Local or regional block anesthesia Pain is controlled without loss of consciousness. The sensory nerves in one area or region of the body are anesthetized. This is sometimes called conduction anesthesia. Acupuncture is sometimes used. Are used to decrease intraoperative stimuli, thereby diminishing stress response to surgical trauma. Injected at or near the nerves of the surgical site, the anesthetic drug temporarily interrupts sensory nerve impulses during manipulation of sensitive tissues.

135. Administration of Local Anesthesia in the absence of an anesthesia provider, a qualified registered nurse is responsible for monitoring the patient’s 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.

136. Comparison of Toxicity and Allergy Caused by Local Anesthetic Drugs Toxic Reaction Allergic Reaction Symptoms vary depending on the drug Immediate localized reaction followed by generalized body reaction SUBJECTIVE Dizziness, somnolence, paresthesia, nausea, visual/speech problems Sense of uneasiness, pruritus, agitation, paresthesia OBJECTIVE Decreased breathing rate and depth, muscle twitches, tremors, slurred speech, seizures, vomiting unconsciousness, coma Erythema, urticaria, wheals

137. 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 contractions are treated with diazepam (Valium) Especially with amino ester type: airway management, IV fluids, epinephrine, diphenhydramine, and steroids as needed

138. Guidelines in Monitoring a Patient Receiving a Local Anesthetic: The patient is monitored for reaction to drugs and for behavioral and physiologic changes. The nurse attending the patient should have basic knowledge of the function and use of monitoring equipment, ability to interpret information, and working knowledge of resuscitation equipment. The nurse should have appropriate training and knowledge in pharmacology and the application of the drugs used in the patient’s care. Accurate reflection of perioperative care should be documented on the patient’s record. Institutional policies and procedures in regard to patient care, including monitoring, should be written, reviewed annually, and readily available. This information should be included in orientation and inservice programs.

139. Advantages, Disadvantages, and Contraindications of Local Anesthetics:

140. ADVANTAGES: Use of local anesthetic agents can minimize the recovery period. The patient can ambulate, eat, void, and resume normal activity. Use of local anesthetic requires minimal equipment and is economical. Loss of consciousness does not occur unless anesthesia is supplemented with additional drugs. Local anesthesia avoids the undesirable effects of general anesthesia. Local anesthesia is suitable for patients who recently ingested food or fluids (e.g., before an emergency procedure) Local anesthesia is useful for ambulatory patients having minor procedures. Local anesthesia is ideal for procedures in which it is desirable to have the patient awake and cooperative.

141. DISADVANTAGES: Local anesthesia is not practical for all types of procedures. There are individual variations in response to local anesthetic drugs. Rapid absorption of the drug into the bloodstream cam cause severe, potentially fatal reactions. Apprehension may be increased by the patient’s ability to see and hear. Some patients prefer to be unconscious and unaware.

142. CONTRAINDICATIONS: Allergic sensitivity to the local anesthetic drug. Local infection or malignancy at the site of injection, which may be carried to and spread in adjacent tissues by injection. Septicemia. In a proximal nerve block, a needle may open new lymph channels that drain through a region, thereby causing new foci and local abscess formation from the perforation of small vessels and escape of bacteria. Extreme nervousness, apprehension, excitability or inability to cooperate because of mental stage or age.

143. COMPLICATIONS OF LOCAL AND REGIONAL ANESTHESIA:

144. Local Effects: tissue trauma hematoma ischemia drug sensitivity infection * can be minimized by the use of proper drugs and equipment, sterile technique, avoidance of local anesthetics with vasoconstrictors in sites with smaller vascular structures, and avoidance of repetitive injection that promotes trauma, edema, tissues necrosis, infection.

145. Systemic Effects: cardiovascular neurologic respiratory drug interactions

146. TECHNIQUES OF ADMINISTRATION OF LOCAL 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 by means of marked surface cooling of a localized area. It is used in such brief procedures as the removal of warts or noninvasive popular surface lesions. Simple Local Infiltration is injected intracutaneously and subcutaneously into tissues at and around the incisional site to block peripheral sensory nerve stimuli at their origin. It is used for suturing superficial lacerations or excising minor lesions.

147. Regional Injection is injected into or around a specific nerve or group of nerves to depress the entire sensory nervous system of a limited, localized area of the body. The injection is at a distance from the surgical site. A wider, deeper area is anesthetized than with simple infiltration. There are types of regional blocks: Nerve Block – are performed to interrupt sensory, motor, and/or sympathetic transmission. Bier Block – is a regional IV injection of a local anesthetic to an extremity below the level of a double-cuffed tourniquet. Field Block – the surgical site is blocked off with a wall of anesthetic drug. A series of injections into proximal and surrounding tissues will provide a wide area of anesthesia, as in an abdominal wall block for herniorrhaphy.

148. COMPLICATIONS OF BLOCKS: *Intercostal blocks: Pneumothorax, atelectasis, total spinal anesthesia, air embolism, tranverse myelitis *Brachial plexus blocks: Pneumothorax, hemothorax, recurrent laryngeal nerve paralysis, phrenic paralysis, subarachnoid injection, Horner syndrome * Stellate ganglion blocks: pneumothorax *Celiac blocks: large vessel perforation, pancreatic injury, total spinal anesthesia

149. Local and Regional Anesthetic Agents Generic Name Trade Name(s) Uses Concentration Duration of Effect (Hours) Maximum Dosage AMINO AMIDES Bupivacaine hydrochloride Marcaine Sensorcaine Local infiltration Regional block Surgical epidural 0.25% to 0.50% 2 to 3 400mg Dibucaine hydrochloride Nupercaine Percaine Cinchocaine Local infiltration Peripheral nerves 0.05% to 0.1% 3 to 3 ½ 30mg

150. Etidocaine hydrochloride Duranest Peripheral nrves Epidural 0.5% to 1% 2 to 3 500mg Lidocaine hydrochloride Xylocaine Lignocaine Topical Infiltration Peripheral nerves Nerve block Spinal Epidural 2-4% 0.5% 1-2% ½ to 2 200mg 500mg or 7mg/kg body weight Mepivacaine hydrochloride Carbocaine Infiltration Peripheral nerves Epidural 0.5-1% 1-2% ½ to 2 500mg

151. Prilocaine hydrochloride Citanest Infiltration Peripheral nerves Regional Block Epidural 1-2% 2-3% ½ to 2 ½ 600mg Ropivacaine Naropin Infiltration Field block Nerve block Epidural Postoperative pain management Not used for Bier block 0.2% 0.5% 0.75% 1% 2½ for surgical analgesia; 6 to 10 for surgical nerve block 200mg for analgesia; 300mg for nerve block AMINO ESTERS Chloroprocaine hydrochloride Nesacaine Infiltration Peripheral nerves Nerve block Epidural 0.5% 2% 2% 2-3% ¼ to ½ 1000mg

152. Cocaine hydrochloride Topical 4-10% ½ 200mg or 4mg/kg body weight Procaine hydrochloride Novocain Infiltration Peripheral nerves Spinal 0.5% 1-2% ¼ to ½ 1000mg or 14mg/kg body weight Tetracaine hydrochloride Cetacaine Pontocaine Topical Spinal 2% 1% 2 to 4 20mg

153. 4. Spinal or epidural anesthesia -sensation of pain is blocked at a level below the diaphragm without loss of consciousness. The agent is injected in the spinal canal. * Spinal anesthesia also referred to as an intrathecal block, causes desensitization of spinal ganglia and motor roots. The agent is injected into the CSF in the subarachnoid space of the meninges using a lumbar interspace in the vertebral column. - is often used for abdominal or pelvic procedures requiring relaxation, inguinal or lower extremity procedures, surgical obstetrics and urologic procedures.

154. Choice of agent: The drug used depends on various factors such as the duration, intensity, and level of anesthesia desired, the anticipated surgical position of the patient, and the surgical procedure. Duration of Agent: The variable duration of anesthesia depends on physiologic and metabolic factors. It is prolonged by the addition of a vasoconstrictor. Anesthesia diminishes as the agent is absorbed into the systematic circulation

155. Level of Anesthesia to be produced: Lateral position: the patient lies on the side with the back at the edge of the operating bed. The knees are flexed onto the abdomen, and the head is flexed to the chest. The hips and shoulders are vertical to the operating bed to prevent rotation of the spine. Sitting position: the patient sits on the side of the operating bed with the feet resting on a stool. The spine is flexed, with the chin lowered to the sternum; the arms are crossed and supported on a pillow on an adjustable table.

156. ADVANTAGES, DISADVANTAGES AND CONTRAINDICATIONS OF SPINAL ANESTHESIA

157. Advantages: The patient is conscious if desired The procedure can be performed with IVCS Throat reflexes are maintained Breathing is quiet The bowel is contracted

158. Disadvantage: produces a circulatory depressant effect Hypotension Stasis of blood nausea and emesis may accompany cerebral ischemia

159. Complications: Transient or permanent neurologic sequelae from cord trauma Irritation by the agent Lack of asepsis Loss of spinal fluid with decreased intracranial pressure syndrome Spinal headache Auditory and ocular disturbances Transverse myelitis Temporary paresthesias

160. Stages of anesthesia: 1 st Induction 2 nd Excitement 3 rd Operative 4th Danger

161. Choice of anesthesia: Selection of anesthesia is made by the anesthesia provider in consultation with the surgeon and the patient. It should be associated with low morbidity and mortality. Characteristics: Provide maximum safety for the patient Provide optimal operating conditions for the surgeon Provide patient comfort Have a low index of toxicity Provide potent, predictable analgesia extending into the postoperative period Provide adequate muscle relaxation Provide amnesia Have a rapid onset and easy reversibility Produce minimum side effects.

162. Anesthesia State control of motor sensory mental reflex functions

163. Care of the anesthetized patient:

164. Considerations: A deficit in pulmonary and/or cardiac functions is detrimental to the patient’s physiologic status. Abnormalities of pulmonary ventilation and diffusion influence the course of the anesthesia and diminish tolerance to stress or the insults from the anesthetic and the procedure. Circulation is affected both centrally and peripherally. Individual agents are associated with characteristic hemodynamic patterns. The liver is affected by general agents. Alterations in liver function tests may follow anesthesia. Kidney function is affected by disturbances in systemic circulation, since kidneys normally receive 20% to 25% of cardiac output. Biotransformation of agents varies with metabolites excreted by the kidneys. Urinary excretion of IV agents may be slow and unpredictable. Agents may cause nausea, emesis, or systematic complications.

165. Safety Factors: The patient’s position is changed slowly and gently to allow circulation to readjust. Proper positioning and padding are important to avoid pressure points, stretching of nerves, or interference with circulation to an extremity. The patient’s chest must be free of adequate respiratory excursion during the surgical procedure. The airway must be patent. The lungs must be adequately ventilated intraoperatively and postoperatively by either voluntary or mechanical means. The anesthesia provider assists in transferring the patient to a stretcher 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 records before the transfer of responsibility.

166. BASIC INSTRUMENTS

167. Classifications: A. Cutting and Dissecting - used to dissect, incise, separate, or excise tissues 1. Scalpels - the type of scalpel most commonly used has a reusable handle with a disposable blade

168. 2. Knives - usually have a blade at one end, and the blade may have one or two cutting edges. 3. Scissors - the blades of scissors may be straight, angled, or curved, as well as either pointed or blunt at the tips

169. 4. Bone Cutters and Debulking Tools - the purpose of these instruments is to decrease the bulk of firm tissue. - include chisels, osteotomes, gouges, rasps, and files 5. Other Sharp Dissectors Biopsy forceps and punches a small piece of tissue may be removed for pathologic examination with biopsy forceps or punch These instruments may be used through an endoscope Curettes tissue or bone is removed by scraping with the sharp edge of the loop, ring, or scoop on the end of a curette Snares a loop or wire may be put around a pedicle to dissect tissue such as a tonsil

170. 6. Blunt Dissectors - friable tissues or tissue planes can be separated by blunt dissection. - the scalpel handle, the blunt sides of tissue scissors blades, and dissecting sponges may be used for this purpose B. Grasping and Holding - tissues should be grasped and held in position so surgeon can perform the desired maneuver, such as dissecting or suturing, without injuring the surrounding tissue 1. Tissue Forceps - used to pick up or hold soft tissues and vessels a. Smooth Forceps - also referred to as thumb forceps pr pick ups - smooth forceps resemble tweezers They are tampered and have serrations (grooves) at the tip

171. b. Toothed Forceps - they have a single tooth on one side that fits between two teeth on the opposing side or a row of multiple teeth at the tip c. Allis Forceps - has a scissors action - each jaw curves slightly inward, and there is a row of teeth at the end - the teeth hold tissue gently but securely d. Babcock Forceps - the end of each jaw is rounded to fit around a structure or to grasp tissue without injury

172. 2. Stone Forceps - either curved or straight forceps are used to grasp calculi such as kidney stones or gallstones - have blunt loops or cups at the end of the jaws 3. Tenaculums - the curves or angled points on the end of the jaws of tenaculums penetrate tissue to grasp firmly - may have a single tooth or multiple teeth 4. Bone Holders -grasping forceps, vice-grip pliers, and other types of heavy holding forceps stabilize bone

173. C. Clamping and Occluding - used to apply pressure Hemostatic Forceps - used for occluding blood vessels have two opposing serrated jaws that are stabilized by a box lock and controlled by ringed handles a. Hemostats - most commonly used surgical instruments and are used primarily to clamp blood vessels - have either straight or curved slender jaws; the serration go across the jaws

174. b. Crushing Clamps - many variations of hemostatic forceps are used to crush tissues or clamp blood vessels - the jaws may be straight, curved, or angled, and the serrations may be horizontal, diagonal, or longitudinal - the tip may be pointed or rounded or have tooth - the length of the jaws and handles vary - some are designed to be used on specific organs - the features of the instrument will determine its use

175. Noncrushing Vascular Clamps - used to occlude peripheral or major blood vessels temporarily, which minimizes tissue trauma - the jaws of these types of clamps have opposing rows of finely serated teeth - the jaws may be straight, curved, angled, or S-shaped D. Exposing and Retracting - soft tissues, muscles, and other structures should be pulled aside for exposure of the surgical site 1. Handheld Retractors - most retractors have a blade on a handle - the blade vary in width and length to correspond to the size and depth of the incision

176. a. Malleable Retractors - with a malleable retractor, a flat length of low-carbon stainless steel, silver, or silver-plated copper may be bent to the desired angle and depth for retraction b. Hooks - single, double, or multiple very fine hooks with sharp points are used to retract delicate structures - used to retract skin edges during a wide-flap dissection 2. Self-Retaining Retractors - holding devices with two or more blades can be inserted to spread the edges of an incision

177. E. Suturing or Stapling 1. Needleholders - used to grasp and hold curved surgical needles a. Tungsten Carbide Jaws - jaws with an insert of solid tungsten carbide with diamond-cut precision teeth are designed specifically to eliminate the twisting and turning of the needleholder b. Crosshatched Serrations - the serrations on the inside surface of the jaws are crosshatched - crosshatching provides a smoother surface and prevents damage to the needle

178. c. Smooth Jaws - used with small needles, such as those for plastic surgery 2. Staplers - reusable or disposable - reusable staplers have many moving parts and are disassembled for cleaning and assembled at the sterile field before use - sterile, single-use, disposable staplers that are completely assembled eliminate the many problems associated with reusable instruments a. Clip Appliers - used to mark tissue and to occlude vessels or small lumens of tubes

179. b. Terminal End Staplers - designed for closing the end of a hollow organ with a double staggered line of staples c. Internal Anastomosis Staplers - designed to connect hollow organ segments to fashion a larger pouch or reservoir d. End-to-End Circular Staplers - designed to staple two hollow, tubelike organs end to end to create a continuous circuit

180. F. Viewing - surgeons can examine the interior of body cavities, hollow organs, or structures with viewing 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 through the endoscope b. Lensed Endoscopes - have either rigid or flexible sheathes, and they have eyepiece with a telescopic lens system fr viewing in several direction

181. G. Suctioning and Aspirating - blood, body fluids, tissue, and irrigating solution may be 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 cavity in which copious amounts of fluid or pus are encountered

182. b. Frazer Tip - a right-angle tube with a small diameter - used when encountering little or no fluid except capillary bleeding and irrigating fluid c. Yankauer Tip - hollow tube that has an angle for use in the mouth or throat d. Aspirating Tube - long, straight tube that is used through an endoscope e. Autotransfusion - a double-lumen suction tip is used to remove blood for autotransfusion

183. Aspiration - blood, body fluid, or tissue may be aspirated manually to obtain a specimen for laboratory examination or to obtain bone marrow for transplantation a. Trocar - may be needed to cut through tissues for a ccess to fluid or a body cavity b. Cannula - used to open blocked vessels or ducts for drainage or to shunt blood flow from the surgical site H. Dilating and Probing - a dilator is used to enlarge orifices and ducts - probes are used to explore the depth of a wound or to trace the path of a fistula I. Measuring - used to measure parts of the patient’s body - some of these devices are used to determine the precise size needed for an implant

184. MAINTENANCE OF GENERAL ANESTHESIA - the anesthesia provider attempts to maintain the lightest level of anesthesia in the brain compatible with operating conditions.

185. Five Objectives of General Anesthesia 1. Oxygenation Tissues, especially the brain, must be continuously perfuse with oxygenated blood. 2. Unconsciousness The patient remains asleep and unaware of the environment during the surgical procedure. 3. Analgesia The patient must be free of pain during the surgical procedure. 4. Muscle Relaxation Must be constantly assessed to provide necessary amounts of drugs that cause skeletal muscle to relax. 5. Control of Autonomic reflexes Anesthetic agents affect cardiovascular and respiratory systems.

186. 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 the patient through a breathing system.

187. ANESTHESIA MACHINE includes: Sources of oxygen and gases with flow meters for measuring and controlling their delivery Devices to volatilize and deliver liquid anesthetics Gas-driven mechanical ventilator Devices for monitoring the ECG, BP, inspired oxygen, and end-tidal carbon dioxide Alarm systems

188. ANESTHESIA MACHINES have the following 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

189. 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

190. PREOPERATIVE PREPARATION OF ALL PATIENTS Specific activities such as the preoperative history and physical are completed and documented before the patient arrives in the OR. The preoperative physical preparations are designed to help all patients overcome the stresses of anesthesia, pain, fluid and blood loss, immobilization and trauma.

191. Preoperative Preparations include the ff.: 1. Medical history and physical examination These are performed and documented by a physician. 2. Laboratory Tests a. Testing should be based on specific clinical indicators or risk factors that could affect surgical management ar anesthesia. b. Hemoglobin, hematocrit, blood urea nitrogen, and blood glucose for persons 60 years of age and older. c. Hematocrit is usually ordered for women of all ages before the administration of General Anesthetic. d. CBC, differential, platelet count, activated partial thromboplastin time, and prothrombin time may also be ordered. e. Urinalysis may be indicated by the type of surgical procedure, medical history, and physical examination. 3. Blood type and Cross match If a transfusion is anticipated, the patients, blood is typed and crossmatched.

192. 4. Chest x-ray study routinely required for all patients It may be required by facility policy or medically indicated as an adjunct to the to the clinical evaluation of the patients with cardiac or pulmonary disease and for smokers, persons age 60 and older, and for cancer patients. 5. Electrocardiogram If the patient has known or suspected cardiac disease, an ECG is mandatory. 6. Diagnostic Procedures Special diagnostic procedures are performed when specifically indicated. 7. Written instructions The patient should follow written Preoperative instructions before admission for the surgical procedure.

193. PREOPERATIVE INSTRUCTIONS DIETARY RESTRICTIONS Avoid alcoholic beverages and cigarette smoking for at least 24 hours before surgery. Finish dinner the evening before surgery no later than . Nothing to eat or drink after the night before surgery. Eating or drinking may result in the delay or cancellation of surgery. FOR SAFETY AND COMFORT No makeup Remove nail polish and artificial nails from at least one finger on each hand Do not bring valuables or jewelry Dress simply in loose-fitting clothes UPON ARRIVAL Report to Main Lobby Admission Desk AFTER SURGERY No driving, operating of heavy machinery, heavy physical activity, or decision making for 24hrs after receiving an anesthetic. If you are returning home on the same day as your surgery, please make arrangements for a responsible adult to accompany you. Call your surgeon for postoperative appointments

194. 8. Informed Consent The physician should obtain informed consent from the patient or legal designee. 9. Nurse Interview A perioperative/perianesthesia nurse should meet with the patient to make a preoperative assessment. 10. Anesthesia assessment An anesthesia history and physical assessment are performed before a regional anesthetic is administered.

195. BEFORE LEAVING FOR THE OPERATING ROOM before the patient goes to the OR suite, his or her physical and emotional status and vital signs should be assessed and recorded by the nurse on the surgical unit or in the same-day admission unit.

196. Physical Preparation: 1. The patient puts on a clean hospital gown. 2. Jewelry is removed for safekeeping. 3. Unless ordered, dentures and removable bridges are removed before the administration of general anesthesia to safeguard them and to prevent them from obstructing respiration. 4. All removable prostheses are removed for safekeeping. 5. Long hair may be braided. Wigs should be removed. 6. Antiembolic stockings or elastic bandages may be ordered for the lower extremities to prevent embolic phenomena. 7. The patient voids to prevent over distention of the bladder or incontinence during unconsciousness. 8. If ordered, an antibiotic is given preoperatively to establish and reach a therapeutic blood level of antibiotic prophylaxis intraoperatively.

197. 9. Preanesthesia medications are given as ordered. 10. The patient, bed, and chart are accurately identified, and identifications are fastened securely in place.

198. Emotional Preparation The caregiver helps to provide the patient with as much peace of mind as possible. If the patient has not seen his cleric or the hospital chaplain and makes such a request, the nurse should make every effort to contact that person for the patient. Family members should be permitted to stay with the patient until he goes to the OR.

199. MAYO STAND - is a frame with a removable rectangular stainless steel tray. The frame slides under the operating bed and over the sterile field. The tray serves to bring near the surgical field a supply of instruments that are used frequently during the surgical procedure

200. PREPARATION FOR POSITIONING Before the patient is brought into the operating room, the circulator should do the following: 1. Review the proposed position by referring to the procedure book and the surgeon’s preference card. 2. Ask for assistance if unsure how to position the patient. 3. Consult the surgeon as soon as he or she arrives if not sure which position is to be used. 4. Check the working parts of the operating bed before bringing the patient into the room. 5. Assemble all attachments and protective pads anticipated for the surgical procedure. 6. Test positioning devices for patient safety. Check for cleanliness. 7. Review the plan of care for unique needs of the patient.

201. SURGICAL POSITIONS A. Supine (Dorsal) Position - the patient lies flat on the back with the arms secured at the sides with the lift sheet or wrist strap, and the palms extend along the side of the body - the legs are straight and parallel and are in line with the head and spine B. Trendelenburg Position - the patient lies on his or her back with supine position with the knees over the lower break of the operating bed - used for procedures in the lower abdomen or pelvis

202. C. Reverse Trendelenberg Position - patient lies on his or her back in the supine position - the mattress is adjusted so the surgical area is over the elevator bridge on the operating bed - used for thyroidectomy, laparascopic gallbladder or biliary tract procedures D. Fowler’s Position - the patient lies on his or her back with the buttocks at the flex in the operating bed and the knees over the lower break E. Sitting Position - the patient is placed in Fowler’s position except that the torso is in a upright position - used on occasion for some otorhinologic and neurosurgical procedures

203. F. Lithotomy Position - used for perineal, vaginal, endourologic, or rectal procedures -stirrups are secured in holders on each side of the operating bed at the level of the patient’s upper thighs G. Prone Position - the is anesthesized and intubated in the supine position, usually on a transport stretcher H. Modified Prone Positions a. Kraske (Jackknife) Position - the patient remains supine until anesthesized and is then turned onto his or her abdomen (prone position) by rotation - the hips are positioned over the center break of the operating bed between the body and leg sections

204. b. Knee-Chest Position - used for sigmoidoscopy or culdoscopy - an extension is attached to the foot section - the operating bed is is flexed at the center break. And the lower section is broken until it is at right angle to the operating bed - the patient kneels on the lower section - the arms are placed around the head with the elbows flexed I. Lateral Positions - the operating bed remains flat - the patient is anesthesized and intubated in the supine position, then turned to the unaffected side

205. a. Kidney Position - the flank region is positioned over the kidney elevtor on the operating bed when the patient is turned onto the unaffected side - used for procedures on the kidney and ureter b. Lateral Jackknife Position - the patient is first placed in the lateral position, and then the operating bed is flexed at the level of the patient’s flank or lower ribs - the operating bed is tilted so the torso is level c. Lateral Chest (Thoractomy) Position - modifications are used for unilateral transthoracic procedures with a lateral approach d. Anterior Chest Position - a small, firm pillow is placed under the shoulder; another pillow is placed under the buttocks on the affected side - the knee on the affected side I flexed slightly, and a large, soft pillow is placed beneath it

206. e. Sims Recumbent Position - the patient lies on his or her left side with the upper leg flexed at the hip and knees; the lower leg is straight - the lower arm is extended along the patient’s back - the upper arm rests in a flexed position on the operating bed

207. COMMON ABDOMINAL INCISIONS

208. 1. Paramedian Incision  is a vertical incision made approximately 4cm (2 in) lateral to the midline on either side in the upper and lower abdomen  it limits trauma, avoids nerve injury, is easily extended, and gives a firm closure  it allows quick entry into and excellent exposure of the abdominal cavity  ex: access to the biliary tract/pancreas (right upper quadrant) and resection of the sigmoid colon (left lower quadrant)

209. 2. Longitudinal Midline Incision can be upper abdominal, lower abdominal, or a combination of both going around the umbilicus depending on the length of the incision, it begins in the epigastrum at the level of the xiphoid process and may extend vertically to the suprapubic region upper midline incision offers excellent exposure of a rapid entry into the upper abdominal contents

210. 3. Subcostal, Upper Quadrant Oblique Incision a right or left oblique incision begins in the epigastrum and extends laterally and obliquely just below the lower costal margin affords limited exposure except for upper abdominal viscera, it provides good cosmetic results because it follows skin lines and produces limited nerve damage biliary modified subcostal incision (Chevron Incision) is made for increased visibility during a liver transplantation or resection ex: biliary procedures and splenectomy

211. 4. McBurney's Incision 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

212. 5. Thoracoabdominal Incision patient is placed in a lateral position either a right or left incision that begins at a point midway between the xiphoid process and umbilicus and extends across the abdomen to the 7 th and 8 th interspace and along the interspace into the thorax allows excellent exposure for the upper end of the stomach and the lower end of the esophagus ex: esophageal varices and the repair of a hiatal hernia

213. 6. Midabdominal Transverse Incision starts on either the right or left side and slightly above or below the umbilicus the advantages are rapid incision, easy extension, a provision for retroperineal approach, and a secure postoperative wound ex: choledochojejunostomy and transverse colostomy

214. 7. Pfannstiel's Incision a curved transverse incision across the lower abdomen and within the hairline of the pubis this lower transverse incision provides good exposure and strong closure for pelvic procedures its primary use is for an abdominal hysterectomy

215. 8. Inguinal Incision, Lower Oblique 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 provides access to the cremaster muscle, inguinal canal and cord structure its primary use is for inguinal herniorrhaphy

216. OPERATION ROOM SET-UP (EQUIPMENTS AND APPARATUS) - standardized basic sets of sterile instruments are selected for each specific surgical procedure - a set is a group of instruments that may include all appropriate classifications of instruments or the instruments needed for a specific part of the procedure (e.g. gallbladder set)

217. 1. Handle loose instruments separately to prevent interlocking or crushing. a. Instruments are never piled one on top of another 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

218. 2. Inspect instruments such as scissors and forceps for alignment, imperfections, cleanliness, and working conditions a. Scalpel blades should be properly set in handles using a heavy instrument, not fingers. b. Teeth and serrations should align exactly c. Tips should be straight and in alignment d. Scissors should be snug and sharp in action e. Cannulae should be clear and without obstruction

219. 3. Sort instruments neatly by classifications

220. 4. Keep ring-handled instruments together with the curvatures and angles pointed in the same direction a. Hang ring handles over a rolled towel or over the edge of the instrument tray or container b. remove instrument stringers or holders if used to keep box locks open during processing c. close box locks on the first ratchet

221. 5. Leave retractors and other heavy instruments in a tray or container or lay them out on a flat surface of the table

222. 6. Protect sharp blades, edges, and tips a. Sets of instruments may be in sterilization racks so that the blades and tips are suspended b. Tip-protecting covers or instrument-protecting plastic should be removed and discarded before the instruments are used on the patient c. If they are not in the rack, handles should be supported on a rolled towel or gauze sponge