ORT(1).pptx

The Theatre
 Definition:
An operating room (OR)
The surgery center
The Unit of a hospital where surgical procedures are
performed.
1

OR-----
 A room specifically for use by the anesthesia and
surgical teams& must not be used for other purposes
Both rooms require:
Good lighting and ventilation
Dedicated equipment for procedures
 Equipment to monitor pts, as required for procedure
 Drugs, other consumables for routine & emergency use
2

Ensure that procedures are established for the correct
use of the O.R. and all staff is trained to follow them.
Store some sutures and extra equipment in the O.R. to
decrease the need for people to enter and leave the
O.R. during a case.
Keep to a minimum the number of people allowed to
enter the O.R. , especially after an operation has
started.
3

OR---
Keep O.R. uncluttered/organized and easy to clean
B/n cases, clean & disinfect table & instrument
surfaces
 At the end of each day, clean the O.R.
Start cleaning at the top and continue to the floor,
including all furniture, overhead equipment and lights.
 Use a liquid disinfectant at a dilution recommended by
the manufacturer
4

OR------
Sterilize all surgical instruments & supplies after use
Store instruments in place protected & ready for the
next use.
Leave the OR-ready for use in case of emergency.
5

Terminology
OPERATING DEPARTMENT:
 A unit consisting of one or more operating Suites together with
ancillary accommodations .
 Such as:-
 Changing room. - Reception room
 Transfer room. - Rest room
 Recovery room - Circulatory room
6

Terminology-----
OPRATING SUITE:
 That comprises of the operating theatre
 Room together with in immediate ancillary areas.
Such as:–
 Anesthetic rooms.
 Sterile lay up or preparation room
 Disposal room
 Scrub up and gowning areas
 Exit room.
7

Terminology----
OPERATING THEATER:
 This is in which surgical operations
and certain diagnostic procedures are
carried up.
Such as:-
 Hysterectomy.
 Thyroidectomy
 Herniorrhaphy.
 Hemoroidectomy.
 Cholecystectomy
8

Designing and planning consideration of physical facility of a
theatre:-
Determination of the no of operation rooms.
The future surgical needs of the community.
The future development in surgical technology.
9

The major consideration during designation
Traffic and commerce.
Surgical support system -
e.g. Temperature, Humidify, ventilation.
 Communication and information.
Administration units.
10

The basic design principles
 The design must be simple and easy to keep it clean
 There should be separate rooms for:-
Clean
Sterile and
Soiled instruments to prevent cross contamination
11

Design principles----
Sufficient space to ensure the safe transportation of
patients and staff.
The layout of department be convenient enough for
the supervisors to control incoming and out going
traffics.
12

Zonal Division of Operating Department
Protective zone/limited access area/unrestricted area
Street cloths are permitted to wear in this zone .
A corridor on the periphery accommodates traffic from
out side including pt.
13

Protective zone----
The area is isolated by doors from the main
corridor and from other areas.
It serves as an outside to inside access area.
Traffic is not limited.
14

Protective zone----
Is monitored at a central location.
Exit from clean zone and sterile zone
Transfer or change over section.
 providing 1st stage of entry to an operation department
15

Protective zone----
The zone includes:-
Recovery room.
Plaster room
Change room for staff & other personnel
Various offices are located here( reception offices)
Seminar and teaching facilities.
16

Clean /Semi Restricted /Semi sterile zone:-
Rooms of the department arranged in a continuous
Progression from the entrance through zones
Traffic is limited to properly attired/dressed personnel
Body and head coverings are required
Peripheral support areas & access corridors to the OR.
17

Clean zone-----
The pt transferred to a clean side & stretcher is on
entry to this area.
The pt’s hair must be covered.
Approach sterility to operating theatre
Approach to sterile preparation room.
18

Clean zone-----
The zone includes:-
Scrubbing room.
Gowning area
Anesthetic room
Exit lobby.
Clean movements
Rest area.
Sterile store.
19

Sterile/restricted Zone
Completely restricted
Lay up / surgical preparations for items
Masks, caps, shoes & trousers are required
Sterile procedures are carried out
Surgical scrubbing is done
20

Sterile Zone -----
 The zone includes:
Sterile preparation rooms.
scrubbing rooms
Consist of operating rooms, scrub sink
Recovery rooms near by(post anesthesia care unit)
21

The Disposal Zone
The least clean area of the whole department
 The zone includes:
The disposal room
Interim storage area.
The disposal corridor
22

List of materials included in each operating theatre:-
Pipe line suction apparatus
Sterile hand lotion bowl ,unopened packet
Diathermy machine (electrosurgical unit)
Cautery cable with knife and needle packed
 Mobile supplementary operating light fitting
Swabs count board.
23

List of materials-----
X-ray viewing screen
 Swab or sponge checking rack.
 Trolley
 Operating table
 Anesthetic machines
 O2 cylinder.
24

Lighting in Theatre
Natural light
Artificial light.
Service light.
25

Ventilation in theatre
The purpose:
Supply heated or cooled ,humidified, contamination
free air to room.
 Introduce air in to theatre & to remove contaminants
liberated there.
 Prevent entry of air from adjacent contaminated area.
Should be 25 times air exchange/hr.
26

Humidity:-
To prevent ventilating air not to be dry.
The humidity must be b/n 50-60% .
Controlled by an instrument called Hygrometer to
measure the level.
27

Heating:-
The room temperature of operating room must
be b/n 18.5 and 22 C0 may exceed to 24Co
28

Peri-operative Nursing protocol:-
 Definition of Surgery
Is any procedure performed on the human body that uses
instruments to alter tissue or organ integrity.
Perioperative Nursing-
The nurse assesses of the client & collecting
,organizing,& prioritizing patient data.
Establishing nursing diagnosis; identifies desired patient
outcomes.
 Develop & implements a plan of care & evaluates that
care in terms of outcomes achieved by the patient.
29

Perioperative Nursing----
 The period extending from the time of
hospitalization for surgery to the time of discharge
 The term used to describe the wide variety of
nursing functions associated with the patient’s
surgical experience.
 It encompassing term that incorporates the three
phases of surgical experience.
30

Phases
Pre-operative
Intra-operative
 Post- operative phases.
31

Nursing protocol------
Through out the entire peri-operative phase the pt is:
Continually assessed
Nursing care plan modified
Implementation is effected
The cycle is evaluated for outcome attainments
32

Pre Operative Phase.
 It begins when the decision for surgery is made and ends w/n
the pt is transferred to the operating room.
 Major roles of nurse:- Relief anxiety, assesses nutritional
status, correct life style of pt and intervene any health change,
psychological and emotional support
33

 Intra Operative Phase:-
It begins from the time the pt is transferred to the
operating room ,until the time the pt is transferred to
the recovery facility.
Major roles of nurse:- prevention of hemorrhage,
shock, cardiac arrest; keep pt’s dignity
34

Post Operative Phase:
 Involves those actives occur from the time the patient is
transferred from the operating room to PACU until the client
has progressed beyond the acute phase of client recovery
Major roles of nurse:
 Prevention of Complications such as:-
 Infection
 Internal bleeding
35

Major roles------
V/s abnormality
Input-out put imbalances.
Tubing and drainage blockages
36

post-surgical patient
 Think of the “4 W’s”
Wind: prevent respiratory complications
Wound: prevent infection
Water: monitor I & O,( I = O )
Walk: prevent thrombophlebitis
37

Immediate patient care----
Keep the patient lying down for the prescribed
length of time.
Document all observations in the patient’s chart
38

Immediate patient care-----
Dressing the wound:
Sterile material used to cover the incision
Serves to keep wound clean
Reduces bleeding
Absorbs fluid drainage
39

Postoperative Procedures ---
Dressing the wound:
Reduces discomfort to the patient
Speeds healing
Reduces the possibility of scarring
40

Postoperative Procedures ---
Bandaging the wound:
A clean strip of gauze or elastic material
Holds the dressing in place.
41

Bandaging the wound-----
May also improve circulation.
Provides support or reduces tension on the wound.
Prevents the wound from reopening.
Prevents movement of the area of the body.
42

Postoperative Instructions
Guidelines for pain management
Instruction for wound care
Dietary restriction
Activity restriction
43

Postoperative Instructions
Follow-up appointment
Timing for follow-up appointments
Provided in writing and included in the
postoperative information packet.
44

Apply Your Knowledge
A dressing is a sterile material used to cover the
incision.
whereas a bandage is a clean strip of gauze or elastic
material used to hold the dressing in place.
45

Surgical Indications & Classifications
Surgical Indications :
Diagnostic- biopsy, exploratory laparotomy.
Exploratory- Seeing and feeling.
Curative- Tumor excision, acute/chronic, infectious disease
of(tissue, organ) treatment.
Organ transplantation- Replacement/substitution of
organs
46

Surgical Indications----
Corrective surgery-Reposition, enhancement of (bone,
ligaments, tendons/organ conduits)
Reparative- multiple wounds are repaired
Implantation-Artificial and electronic devices
replacement
47

Indications----
Reconstructive or cosmetics sugary.
mammoplasty
cheloplasty
palatoplasty
Rhinoplasty
48

Indications----
 PALLIATIVE SURGERY:
Relief of pain,discharge,spotting.
Transient Problems are corrected
e.g.
 Gastrostomy tube insertion for swallowing problem.
Hysterectomy for chronic cervical bleeding (ca)
49

Surgery Classification based on severity
Required
 Elective
Optional.
50
Emergency
Urgency

Classification-----
classification indications Examples
Emergency :
pt requires immediate
attention disorders may be
life threatening
With out delay -severe bleeding
- bladder or
intestinal
obstruction
-fractured skull.
- Gunshot/ stab
wounds
- Extensive burns.
-Urgent-
pt require prompt quick
attention
with in 24-30
hrs
Acute gall bladder
in faction 51

Classification-
Classification indications Examples
Elective :
pt should or cold case operated
up on
Failure to have
surgery ,not
catastrophic
-repair of scars
-simple hernia
-Eu- thyroid
-Vaginal repair….etc
Optional:
decision resets with patient
Personal
preference
Cosmotics surgery
52

Selected factors that increase surgical risk.
Age- Very young and older clients.
Nutrition- a malnourished client is prone to poor
tolerance of anesthesia, infection, poor wound healing
and the potential for multiple organ failure after
surgery.
Obesity- often have difficulty in resuming normal
activity after surgery.
53

Physical assessment/clinical manifestations
General survey- gestures and body movements may
reflect decreased energy or weakness caused by illness.
Cardiovascular system- alterations in cardiac status
are responssible for as many as 30% of perioperative
death.
Respiratory system- a decline in ventilatory function,
assessed through breathing pattern and chest excursion,
may indicate a client’s risk for respiratory
complications.
54

Physical assessment---
Renal system-Abnormal renal function can altered
fluid and electrolyte balance and decrease the
excretion of preoperative medications and anesthetic
agents.
Neurologic system- a client’s LOC will change as a
result of general anesthesia but should return to the
preoperative state of consciousness after surgery.
55

Physical assessment---
Musculoskeletal system- Deformities may
interfere with intraoperative and postoperative
positioning. Avoid positioning over an area where the
the skin shows signs of pressure over bony
prominences.
Gastrointestinal system- alteration in function
after surgery may result in decreased or absent bowel
sound and distention.
Head and Neck- the condition of oral mucous
membranes reveals the level of hydration.
56

Gerontological Considerations
Cardiovascular
Coronary flow decreases
Heart rate decreases
Response to stress decreases
Peripheral vascular decreases
Cardiac output decreases
Cardiac reserve decreases
57

Gerontological Considerations----
Respiratory System
Static lung volumes decreases
Pulmonary static recoil decreases
Sensitivity of the airway receptors decreases
Nervous system
Increased incidence of post.op confusion
Increased incidence of delirium
Increased sensitivity to anesthetic agents
58

 Renal System
Renal blood flow declines 1.5% per year
Renal clearance reduced
 Gastrointestinal
Decreased intestinal motility
Decreased liver blood flow
Delayed gastric emptying
59

Musculoskeletal
Decreased mass, tone, strength
Decreased bone density
Integumentary
Decreased elasticity
Decreased lean body mass
Decreased subcutaneous fat
60

Laboratory and diagnostic studies
 Screening tests depend on the condition of the client
and the nature of the surgery. If test reveals severe
problems the surgery may be canceld until the
condition is stabilized.
Blood type and Rh screen,Hgb
urinalysis,
EKG
Chest X-ray are ordered to screen for pre-existing
abnormalities.
61

Surgical settings
Surgical suites /set
Ambulatory care setting
Clinics
Physician offices
Community setting
Homes
62

Surgical settings----
Disadvantages
Less time for rapport/empathy
Less time to assess, evaluation, teach
 Risk of potential complication post operatively.
Advantages of outpatient:
Low cost
Low risk of infection
Less interruption of routine
Less resource for work
Less stress
63

Method of teaching surgical pt
Timing-most useful when started a week before
admission and reinforced before surgery & the client is
less anxious.
Content:
Surgical Procedure
Preoperative routines
Intra operative routines
Postoperative routines
Sensory preparation
Pain relief
64

Iv fluids
Body fluids are vital to maintain normal body
function
Total body water (TBW), accounts for
approximately 60% of total body weight.
• This will be :
 70% in new born
 50-55% in matured women
 60% in male
 Body fluid can be intracellular or extracellular
65

Fluids types
• Fluids used in clinical practice are usefully classified as
Colloids, crystalloids , blood products
1. colloids
 Contains large molecules
 Expands the intravascular and draw fluids from extracellular
compartment
e.g. Dextran & artificial plasma volume,blood transfusion
2. Crystalloids: small molecules that easily flows across cell
membrane
 Allowing transfer of fluid from blood stream to cells body tissues
 Increase intravascular volume and interstitial space (extracellular)
66

Fluids ----
• Crystalloids are subdivided in to :
 A. Isotonic B. Hypotonic C. Hypertonic
A. Isotonic fluids : Similar concentration, increase,
intravascular volume
e.g.
 0.9 % sodium chloride ( Nacl)
 Lactated ringer’s solution
 5% dextrose in water (D5W)
 Ringer’s solution
67

fluid -------
B. Hypotonic fluids
 lower concentration
Flows from intravascular space to intracellular and
interstitial space
e.g.
0.45% Nacl, dextrose 2.5%
68

Fluids used ---
• Hypertonic fluids :
Higher tonicity /solute concentration
Draws water out of cellular space
Used as volume expander
Increases intravascular volume
e.g. 3% Nacl, 5% dextrose in normal saline (D5NS)
69

Surgical Team
Definition:
 A group of professionals providing the continuum
of care during :-
pre-operative.
intra-operative and
postoperative and recovery area
70

Surgical Team---
The specialized team members:
surgeon
assistant surgeon
circulating nurse/runner
71

specialized team----
scrubbing nurse
Anesthetist.
Anesthesiologist
janitor/ cleaner
72

Responsibility of the surgeon team
 The surgeon is the leader of the surgical team
He has ultimate responsibility for performing the
surgery in an effective and safe manner.
He is dependent upon other members of the team.
Coordinate the team for the patient's emotional well-
being and physiologic monitoring.
73

Responsibility----
The anesthesiologist/anesthetist must be
constantly aware of the surgeon's actions.
 He must do every thing possible to ensure the
safety of the patient
 Reduce the stress of the operation.
74

Definitions of
 Anesthesiologist:
is a physician who is trained in the
administration of anesthetics.
Anesthetist. is a registered professional nurse
who is trained to administer anesthetics.
75

The responsibilities of the anesthesiologist/anesthetist
Providing a smooth induction of the patient's
anesthesia in order to prevent pain.
Maintaining satisfactory degrees of relaxation of the
patient for the duration of the surgical procedure
76

The responsibilities of the anesthesiologist
Continuous monitoring to the physiologic status of
the patient(oxygen exchange, circulatory functions,
systemic circulation, vital signs.)
Advising the surgeon of impending complications
and independently intervening as necessary.
77

Responsibility of Scrub Nurse:
The scrub nurse prepares the setup
Work with the surgeon
Select surgical instruments
Identify appropriate suture materials
78

Circulating Nurse Responsibility
Obtain supplies
 Answer the team requests
deliver supplies to the sterile field,
carry out the nursing care plan
liaison between scrubbed personnel and those
outside of the operating room.
Teaches students
Strictly observes the team activities
79

Circulating Nurse-----
Providing for psychological comfort of the patient prior
to and during induction of anesthesia.
Making initial assessment of the patient and continued
monitoring.
Saving all discarded sponges; during surgery.
participates in the sponge count .
80

Circulating Nurse-----
Observing the surgical procedure
anticipating the needs for equipment, instruments,
medications, blood units.
Preparing labels for the patient specimens
Submits to the laboratory for analysis.
81

Sterile team
Definition:- persons working together in the sterile
field during operation
Sterile team members:
Surgeon
asst. surgeon
Scrub nurse
The patient
82

Surgical Team---
Clean team- those persons working
together out of sterile field in the operating
theatre during the operation.
clean team members:
circulating nurse .
anesthetist/ anesthesiologist.
Cleaner/ janitor.
83

Sterile field
Definition:
the only restricted area where sterile team
members are supposed to work together
during operation.
It is not allowed to clean team to work in
and cross the sterile field.
84

Intra- Operative Nursing
Described in terms of circulating and scrubbing
nurse.
The Circulating Nurse Activities:-
Manage the operating room
Protects the safely and health needs of the pt.
Monitor the activities of the members of the
surgical team.
Checking the conditions in the operating room
85

Circulating Nurse----
Assuring cleanliness
Assuring proper temperature, humidity, lighting.
Assuring safe fun of the equipment.
Looks for availability of supplies and materials.
Monitors the aseptic technique/ practices
Monitor the pt condition through out the procedure
86

The Scrub Nurse activities
scrubbing for surgery
setting up the sterile tables .
Preparing the suturing materials and ligatures.
Collect special equipment.
Assisting the surgeon and surgical assistant
Anticipating the required instruments ,
sponges, drains and procedures
87

Scrub Nurse-----
Keeping the track of time, the pt is under
anesthesia and the wound opened.
Make the surgical count.
Collect the specimen for pathology.
Keep the principles of asepsis
The capacity to handle any emergency situation in
the operating room.
88

Safety surgery
DEFINITION
Is one that does not harm or expose the
patient or the provider to any avoidable risk.
89

Safety--------
Safe Surgery will focus on two main points:
The implementation of the safe surgery checklist.
The monitoring and evaluation of surgical outcomes.
90

WHO safe surgery check list
1.The team will operate on the correct patient at the
correct site.
2.The team will use methods known to prevent harm
from administration of anesthetics, while protecting
the patient from pain.
3.The team will recognize and effectively prepare for life
threatening, loss of airway or respiratory function.
91

check list------
4.The team will recognize and effectively prepare
for risk of high blood loss.
5.The team will avoid inducing an allergic or
adverse drug reaction for which the patient is
known to be at significant risk.
6.The team will consistently use methods known
to minimize the risk for surgical site infection.
92

check list------
7.The team will prevent inadvertent retention of
instruments and sponges in surgical wounds.
8.The team will secure and accurately identify all
surgical specimens.
93

check list------
9.The team will effectively communicate and
exchange critical information for the safe
conduct of the operation.
10.Hospitals and public health systems will
establish routine surveillance of surgical
capacity, volume and results
94

Operating Room Attire/PPE
Purpose:-To provide effective barriers that
prevent the dissemination of m/os to the pt or
from the pt.
 General Principles:-
Each operating room department should have a
specific complete written policy.
Only approved clean OR attire worn with in
restricted area of OR suites.
95

PPE-----
The OR attire is not worn outside of operating room
suite.
Eye glasses should be wiped with tissue wet with
antiseptic solution.
Comfort table supportive shoes should be worn to
relieve fatigue.
Personal hygiene must be re-emphasized.
No, person with acute infection allowed to visit OR.
96

Components Of OR Attire
 body cover
 mask muslin 40%
Muffin- 99%
 Head cover/ caps
97

Components----
Foot cover/ shoes
Goggles
Gloves
mackintosh/ plastic apron
98

Types of Gloves
sterile/ HLD surgical glove
clean examination glove
utility/ heavy duty gloves
Elbow length gloves
99

Gloves Requirements for Procedures
Are gloves
needed ?
Preferable
gloves
Acceptable
gloves
blood pressure check No - -
Temperature check No - -
injection No - -
blood drawing Yes exam HLD
Iv insertion/ removal Yes exam HLD
IUD insertion Yes exam HLD
IUD removal Yes exam HLD
manual vacuum aspiration Yes exam HLD
Norplant’s implants insertion Yes s. glove HLD
Vaginal delivery Yes s. glove HLD
C/S/ Laparotory Yes s. glove HLD
Vasectomy/ laparotory Yes s. glove HLD
Handling and cleaning instrument Yes Utility Exam/ HLD
Handling contaminated waste Yes Utility Exam/ HLD
100

When to Double Gloves
The procedure that involves coming in contact
with large amounts of blood/ body fluids.
Orthopedic procedure in sharp bone fragments,
wire sutures and other sharps.
Surgical gloves when re-used.
Surgical procedures lasting more than 45 minutes.
101

Elbow Length Gloves Are Used During:-
vaginal deliveries
Cesarean section .
Manual removal of placenta.
Large volume of blood/ body fluids contact .
102

Elbow Length----
Cut the four fingers of gloves completely off
sterilize or disinfect 2-3 pairs of cut off (finger
less) gloves
103

How to Use It
Perform surgical scrub
Put finger less sterile/ HLD gloves & pull up to
the fore-arms.
Put intact sterile/ HLD glove
104

Some Do’s and Don’ts about gloves.
Do- wear the correct size gloves
Do- change s- gloves every 45 minutes ’
Do- keep finger nails trimmed moderately short.
Do- pull the gloves up over cuffs of gown
Do -use water soluble hand lotions
105

Don’t------
Don’t – oil based hand lotions or creams.
Don’t – use latex gloves if you have allergy.
Don’t – store gloves that are cracked
Don’t -reprocess gloves that are cracked.
Don’t –reprocess exam gloves for reuse.
106

Surgical Scrubbing/hand hygiene
Definition: -
 It is the process of removing as many M/os as
possible from the hands and arms by mechanical
washing and chemical antisepsis before
participating in an operative procedure.
107

WHO 5 Stages of Hand Washing
Before touching a patient.
Before cleaning aseptic procedure.
After body fluid exposure risk.
 After touching a patient.
 After touching a patient’s surrounding
area.
108

Nursing responsibility of Hand Washing
Practice safe hand washing techniques.
Be pro-active and lead by example.
Encourage other health staff to do the same.
Educate patients and colleagues.
Help build hand wash stations in your hospital
109

Three types of hand hygiene
Normal, between daily activities at home.
 When at work and caring for patients.
When getting ready for surgery: surgical scrub.
110

Normal hand hygiene
carried out :-
Before touching food.
After using the toilet.
 After gardening or outside activity.
 After touching animals.
Before touching your eyes.
111

Normal hand hygiene----
It takes 15-30 second hand wash with home soap
and clean water.
Clean the back and front of the hand, between
fingers, the nails and wrist.
112

Normal hand------
Wipe with clean cloth or paper-towel
Tip: Try and buy liquid soap because a bar of soap
can sit there holding bacteria from the last person
who used it.
113

At work and caring for patients
Before and after patient care, after toilet, before and
after food, after touching contaminated materials.
Can be a 15-30 second hand wash to the entire hand
and wrist (just like the home wash)
114

At work and caring----
You can do this with hospital grade and approved
liquid hand soap and clean water or waterless jelly
foam
Dry with a clean paper-towel
Wait till your hands are dry before you touch the
next patient or other objects.
115

Surgical scrub
Before a surgical operation
116
1. Alcohol hand rub
2. Routine hand wash 10-15 seconds
3. Aseptic procedures 1 minute
4. Surgical wash 3-5 minutes

M-o:- the skin is inhibited by-
1.Transient organism:
acquired by direct contact
usually loosely attached to the skin surface
Completely removed by thorough washing
with soap or detergent and water.
117

Resident organism:-
Are below the skin surface in hair follicles and
in sebaceous and sweat glands.
Are more adherent and resistant to removal.
Their growth is inhibited by the chemical phase
of the surgical scrub .
118

The purpose: -
To remove soil, debris natural skin oil, M/Os from the
hands and fore arms of the surgical team/sterile team .
To decrease the no of M/os on skin to an irreducible
minimum.
To reduce the hazards of microbial contamination of the
operative wound by skin flora.
To keep the population of the M/os minimal during the
operative procedure by suppression of growth.
119

General preparations:-
The skin and nails should be kept clean.
Finger nails should not reach beyond the finger
tip.
Finger nail polishing avoided.
Artificial devices should not cover natural finger
nails.
120

Surgical scrub procedures:-
 The pre-operative surgical antisepsis consists of
three processes.
Hand hygiene
Gloving of the surgical team
Applying antiseptic agent to the surgical site
121

The methods of scrubbing:-
Two methods:-
The counted brush-stroke method
The time scrub method
Note :-The Surgical Scrub Is Prior to Gowning.
122

The length of surgical scrubbing depends on:-
The frequency of scrubbing.
The agent used.
The method.
123

What hand solution being used
 Bar of soap.
 Liquid soap for home.
 Liquid soap for hospital daily use.
 Liquid soap for surgical scrub.
 Waterless gel/spray for use at home.
 Waterless gel/spray for hospital daily use.
 Waterless gel/spray for surgical scrub
124

Steps in surgical scrubbing:-
Remove rings, watches, and bracelets.
Wash hands thoroughly b/n fingers and forearms
to the elbow with soap, water, brush/ sponges
Clean nails with nail cleaner.
Rinse hands and fore arms with water.
125

Steps----
Apply antiseptic agent to all surface of hands and
forearm.
Holding the hands higher than the elbows, rinse
hands and fore arms with clean water.
Keep hands up and away from the body don’t
touch any surface.
 Put sterile surgical gown, then gloves on both
hands after drying hands .
126

Gowning & gloving
The sterile gown is put on immediately after
the surgical scrub.
The sterile gloves are donned immediately
after gowning .
127

Jewelry and Watch
It is hard to clean under
your jewelry or watch
Bacteria and dirt can sit
under your jewelry or watch
Remove jewelry to
ensure a complete clean
129

Nail Polish and False Nails
Bad
Good
If it is less than 4 days old
you can keep it on
130

Skin Integrity (condition)
Bad
Cuts, breaks and weeping
can spread infection
Good
No open wounds,
bleeding or weeping
132

Result
No jewelry
No watch
No nail polish
No false nails
No long nails
No cracked skin
You are now ready to wash
133

General consideration
The scrub person gowns and gloves himself.
Gown packages opened on separate table.
Avoid splashing water on scrub attire.
The circulator nurse assists gowning.
134

General consideration---
Two types of gloving technique.
 closed system
 open system
135

Universal precaution:
Wear appropriate protective equipments.
Always wash your hands.
Wear gloves for direct contact with:
Blood/body fluids
Broken skin or mucus membranes
136

Universal precaution----
Discard sharps safely:
Never re-sheath needles
Place all sharps directly in to sharps bin
Discard bin when three-fourth full.
137

Universal precaution-----
 Keep cuts and abrasions covered.
 Disinfect blood/body fluid spillages.
138

Maintaining a safe, Environment
The role of cleaners:-
cleaners to wash wall and windows weekly .
cleaners to clean floors, showers and latrines
twice daily.
Cleaners to empty and wash basins, bowls as
they are used.
139

Maintaining a safe---
Cleaners to discarded dirty water outside
Cleaners to discard contaminated drapes
post- operatively.
Cleaners clean the floor of theatre after
each operation/TOT
140

Health Care Provider.
Avoiding malpractice
Leave the pt alone
 Negligence malpractice Talking, laughing
Not monitoring V/S
failure to make Pre-op ass’ment
In correct intubations
 Criminal malpractice partiality out looks
Incorrect dosage
Incorrect installation
.
141

Surgical Instruments
Historical prospective:-
 The history of surgical instruments dates
back to 2500 BC: - ancient Greece, Egyptians
and Hindu instruments resemble today’s
instrument.
142

Instruments---
• The 1st surgical instruments were made of
Animal teeth
Wood
Ivory
143

Instruments---
In mid 1800’s (civil war in USA) instruments made
of:
Kitchen Knife
Carpenter saw
Table pork
144

Instruments---
In the beginning of 20th century-delicate
instrument seen more useful than heavy one
and
Replaces the handles of wood, ivory, so that
instrument could resist repeat sterilization.
145

Composition of surgical instrument
Surgical instruments are manufactured
from stainless steel of:
Iron
Carbon
Chromium of varying qualities
146

Instruments---
Types of Instrument Finishes are several
Bright –called mirror finish.
satin (dull)- tend to eliminate reselections .
Embodied finish- finish-black and the golden
handle.
147

Instruments---
Categories of Surgical Instruments.
1.Cutting, dissecting, sharp.
2.Hemoeostasis/ occluding/ clamping
148

Instruments---
3.grasping, holding,(a traumatic to tissue )
4.Retractors (Exposing )
5.Dilating
6.Probing
7.suturing
149

Categories and examples
Cutting / dissecting /sharps:
eg.scissors, scalpels, curettes,kelly artery forceps
Grasping /holding:
eg.allies, babkocks,pinsets, sponge holders,
 Hemostasis/ occluding/ clamping:
eg.forceps, hemostats, clamps.
150

Categories and examples---
Retracting, dilating, and probing :
e.g. retractors, dilators, probes
Suturing :-e.g. needle holders, needles,
packaged suture materials.
151

Order of handling instruments :-
Cutting instruments
Grasping instruments
Retractors
Probes
Suture materials
Needle holders, sponge holders
152

Instruments---
 The purpose of surgical instruments :-
Simply selection for arranging the basic sets of
instrument for surgical procedures.
Specific Instrument selection for specific operation
To specialize in operating room nursing and types
of instruments
153

Instruments---
OR trays /sets named according to their functions
e.g. Operating sets prepared as :-
 Major/general set
 Minor set
 Plastic/ suturing sets.
According to each pts need instruments are more
individualized e.g. intestinal set, vascular sets….etc.
154

Instruments---
In the same way basic instruments are selected for
operating other body cavities: eg chest, skull,
pelvic.
Instruments are selected according to the size of
the body, structure and nature of organ involved.
Instruments designed for surgery on infants, eyes,
ear, blood vessel, nerve and brain are differing from
the above. They are fine, more delicate according
to the purpose, but the same basic principles are
used.
155

Principles of Passing instruments
Gown and glove.
Selected according to standard basic sets.
Arrange instruments on instrument table
and make count.
Drape the mayo tray.
156

Principles------
Don’t go beyond the confine of the room
Grown and glove the surgeon and assistant
Don’t interrupt the surgical counts.
Bring mayo- stand to the position over, after
draping completed.
Be sure it should not rest over the pt.
157

Principles------
Hand the knife to the surgeon, and hemostasis
to the assistant.
W/n passing always hold the handle blade down
and point to ward your wrist never to surgeon.
Anticipate surgeons need one- step ahead of
him w/n passing surgical instruments.
158

Principles------
Pass instruments in decisive & positive manner.
W/n passed properly surgeon known that he has it.
His eyes do not have to leave operative site
W/n the surgeon extends his hand instruments
should be slapped firmly in his palm in proper
position for him to use it.
159

Instruments---
 Proper Positions for Scrub Nurse to the Surgeon :-
If the surgeon is opposite side of the table pass
with your Rt hand.
If the surgeon is on the same side of the table
and to the Lt of you use your Rt hand.
160

Proper Positions----
If the surgeon is opposite side of the table pass
with your right hand.
If the surgeon is on the same side of the table
and to the left of you, use your right hand.
161

Instruments---
• Your Consideration in the sterile field:-
Keep instruments clean.
Keep the table and sterile field as dry as possible.
Discard a piece of suture material, tubings, gauze.
Keep hands at waist level.
Don’t reach behind a member of sterile team/field.
162

Your Consideration----
Go another side of members of sterile team back to
back not back to front.
Don’t return your back to sterile team/ field.
Keep talking to a minimum.
Don’t allow cross b/n sterile team .
163

General Instruments
Are arranged according to the types of
operation.
It must include sufficient basic instrument for
any of the operations performed in theatre.
The basic general set of instruments could
consist of the following
164

The General Set:-
Scalpel handles No. 3,4,5,7 (2)
Dissecting forceps toothed small (2)
 Dissecting forceps toothed large (2)
 Dissecting forceps non-toothed small & large (2)
Mayo scissors curved small and Large (2)
165

The General Set---
Mayo scissors straight (2) for cutting tissue
 Mayo scissors straight (2) for cutting stitch
 Artery forceps curved (10 )for clamping
Artery forceps Straight (10 Monyhan)
Artery forceps Straight 10 (spencer wellis)
166

The General Set---
Dissector for tissue-------- 2
 Aneurysm needle ----------2
Curetting spoon------------2
Sponge holding forceps---------6
167

The General Set---
Needle holder small and large -----4
(short and long ones)
Retractors different type and size---------6
Tissue forceps------------------------------6
168

Diathermy
 Definition:-Production of heat in the body tissue by a
high frequency of electric current.
Types of diathermy
Medical diathermy:- sufficient heat is used to warm the
tissues but not harm them.
Short – wave diathermy:- used in physiotherapy to
relieve pain or heat infection.
Surgical diathermy:- of very high frequency, used to
coagulate blood in vessels, cut & desiccation of tissues.
169

Functions of Diathermy
Electrotomy/ cutting (generation of heat destroys tissue cell)
Blend (cutting & coagulation )
Fulguration (cell walls destroyed through dehydration)
Coagulation / Desiccation( dryness of tissues)
170

Physiology ofcoagulation of diathermy.
Retraction of blood vessels
Contraction of the muscle
The dryness of tissue cell
Minimum out put of power.
171

Advantages of diathermy
Relief pain
Prevention of infection
Shortens the duration of surgery
Controls minute bleedings
172

Disadvantages of diathermy
Delayed wound healing
Channeling (thrombosis formation)
Explosions/sparking
Burn/ignition
Organ perforation
Gas embolism
173

two ways of delivering
1.Monopolar delivery 2. Bipolar delivery
Monopolar
 The current is passed through a large volume of
tissue.
Large surface area of the body contact.
A very low current density passed through most
of the body.
174

bipolar delivery
Involves the current being passed b/n two point
electrodes .A very high current density.
High heating effect, is produced over a very small
volume of tissue.
Virtually no heat generated else where in the body. be
used with relatively low currents
For coagulation of small blood vessels. Its greatest
application is in microsurgery(the hand &
in neurosurgery.
175

Diathermy burn occurs b/c of:-
Faulty applications of different
electrodes
Failure to insulate/protect the pt
Failure to insulate the cable
Inadvertent actions/activity
176

proper applications
place the diathermy plate near to
operation site
 If the site is below the heart-
 Put on the gluteus muscle portion
 If the site is above the heart-
Put on the shoulder muscle portion
177

Wound Closure (suture) Materials
Are used to approximate the edge of incision
(=tissue apposition)
Facilitates wound healing.
Minimizes the size of scar.
Firmly holds the organs in position.
178

Wound Closure---
Classifications
A suture – a stitch used in surgery to approximate
living tissue or Structures until the normal process
of healing are completed.
A ligature- is a suture used to encircle blood vessels
to arrest or control bleeding
179

Characteristics of Suture Material
Absorbable Vs. Nonabsorbable
Monofilament Vs. Multifilament
Natural Vs Synthetic
180

 Absorbable – sutures or ligatures are two types
 Absorbable natural
Catgut
Collagen
 Living tissue
181

Absorbable
Absorbable synthetic :-
 polygicolic acid
 PDS/ Polyd-ioxinon suture
 Vicryl
 Dexon
182

The absorbable- Natural sutures
Are digested and absorbed during process of
healing
The most commonly used in this group is
surgical catgut .
It is made of from sub mucosa layer of 1st, 3rd
layer of the intestine of the sheep
183

Natural absorbable sutures----
It has two parts.(plain and chromic catgut)
Plain catgut: absorbable rate 5-7 day.
Chromic catgut: absorbable rate 15-21 days.
184

Natural sutures----
In order to prolong the time of absorption and to
reduce irritation, the row, catgut can be hardened
or chromicised by immersing strands in chromic
salt solution
The degree of hardness depends up on how long
the cat gut is immersed in chromic salt solution
• e.g.- in peritoneum and serous membrane less
day(2-3) day’s immersion.
185

Natural sutures----
The size of catgut:- has two systems
metric system 0.75, 1, 1.5, 2, 2.5 , 3 4, 5, 6
Old system 6/0, 5/0,4/0,3/0, 2/0, 0, 1, 2,
3.
186

sutures----
Sterilization of surgical catgut effected by
Gamma- radiation, before it has been packed and
sealed.
The choice of the surgical catgut for ligature of
small blood vessels are 2/0, 3/0 plain cat gut is
sufficient.
For ligation of large blood vessels 2/0, 3/0 and
pedicles in gynecological requires chromic catgut
3 or 2.
187

sutures----
The size of the catgut depends on the requirements
of particular surgeon.
The suturing of stomach and bowels in adult are 2/0,
3/0 but in children 3/0 chromic catgut is sufficient .
Adult peritoneum and muscle are sutured with the
size of 2/0 or o chromic catgut.
Fascia can be sutured with the size of 1and 2 chromic
catgut but, in children 2/0, 3/0 is sufficient
188

sutures----
Subcutaneous tissue can be sutured with plain
catgut 2/0, 3/0 are preferable.
Some surgeons use chromic catgut through out
the operation.
Plain catgut is not used in peritoneum or fascia
suturing due to its rapid absorption.
It is widely used in urinary tract operation to
prevent formation of renal calculi.
189

Absorbable Synthetic- Polymers
They are either dyed or undyed, are intruded and
braided to form multifilament absorbable suture.
Are absorbed by a slow hydrolysis process in the
presence of tissue fluid.
Are – non antigenic, no pyrogenic and produce
only mild tissue reaction during absorption.
190

Synthetic-----
Are very tensile strength longer than catgut
e.g. PDS- 60-90 day’s duration for absorption.
Dexon- maximum absorption, 30 days but
complete absorption 60-90days.
Coated vicrygl- absorption takes place with in 30
days to complete absorption. The sizes are like cat
gut.
191

Non- Absorbable, Ligature/ Suture.
natural (silk worm linen cotton)
 Silk warm gut- from animal larval is obtained
from the glands of silk worm and it is draw out
in to monofilament.
It lacks flexibility and difficult to tie
192

Non- Absorbable-----
It is braided or twisted ,stronger used to
close GI tract, fascia and skin.
Used also in ophthalmic surgery
The sizes are the same with others
193

synthetic non absorbable
– Polyamides monofilament – single nylon
• Multi filament
– Polyesters ------ Polyethylene
– Polyethylene (prolene) is: –
monofilament
Colored deep blue
Stronger than line
It will be easily crushed at the note- holding
It is suitable for any instance where a non
absorbable suture is required.
194

The Metallic Wires
• Prepared from:-
Stainless steel used for orthopedic & thoracic
surgery.
Alloys of tantalum
Silver obtained as a single strained suture & /
twisted/braided.
.
195

Prepared-----
used in closing abdominal incisions in obese or (ca)
client.
For esophageal anastomosis for closure of chest
incision or as mesh in the repair of hernial defect
196

Metal Clips (Sutures)
Applied with special instrument:-
The insertion forceps known as:
 Michel-----applier
 Kifa------ Removal
Adhesive skin closure.
197

Surgical Needles:-
Are needed to safely carrying the suture material
via tissue with the least amount of trauma.
Are strong enough doesn’t break easily
Are rigid enough to prevent excess bending
198

Surgical Needles---
Sharp enough to penetrate tissue with minimal
resistance.
 Approximately the size with suture
Free of corrosion to prevent infection and trauma.
199

Metal Clips-----
All surgical needles have 3 basic
components:-
The point the body/ shaft of the eyes.
The point of needles mostly used for cutting
tapered or blunt.
200

Metal Clips-----
Body of needle- naries in wire length shape
and finish (depend on nature and location of
tissue.)
French eye needle (spring eye/ spring eye.)
Eyeless needle- continuous suture.
201

Common Suturing Technique
• The primary suture: - that holds wound edges in
approximation during healing by
1st intention continuous
Intermittent
• Continuous technique: - A series of stitches
taken with one strands of material tied only at the
end of suture line. e.g. peritoneum and
subcutaneous tissue .
202

Common Suturing-----
Interrupted suture: –Each stitch is taken and tied
separately.
If an interrupted suture brakes or looses the
remaining suture may still hold the wound
together.
203

In the presence of infection M/os are less
likely to follow the primary suture line.
Buried suture: - placed under skin.
purse- string suture: - A continuous suture placed
around the lumen and tightened
204

subcuticular suture:- Type of continuous suture is
placed beneath the epithelial layer of the skin
cosmetic stitch minimal scar left on the skin.
Retention:-suture line with interrupted non
absorbable suture on each side of 1st degree suture
line to relieve tension.
The suture line passed includes the skin,
subcutaneous tissue, fascia rectus muscle,
peritoneum of the abdominal tissue.
205

Positioning Surgical Patient.
Basically surgical positioning are three :-
Supine, dorsal or laparotomy.
Lateral.
prone
206

Guide lines for surgical pt positioning
Knowledge: both the theoretical and practical
principles of arranging the posture of an unconscious
or an awake patient for operation.
Planning: encompasses an understanding of the
intended operation, as well as the specific problems
that face the surgeon and the anesthesia provider
207

Guide lines------
Teamwork: involves the careful coordination of the
activities of all personnel.
Housekeeping: includes having the appropriate
positioning devices on hand and ensuring that each
part fits and functions as intended.
208

Steps of safe pt positioning
Assessing the patient’s needs.
Developing a plan of care .
Assembling the necessary positioning devices
209

Steps of-----
The actual positioning of the patient.
Re-evaluating body alignment and tissue
integrity intra-operatively.
Evaluating patient outcomes with respect to
positioning-related complications.
210

Modified positions
Trendlenberg –Places head down along with
the whole body
Reverse trendlenberg- places head end up & feet
down
Lithotomic
fowler’s
211

Modified positions----
Sitting upright.
knee-chest
Simi’s position.
212

Types Of Positions depends On
Age
 sex
types of operative site
 size of pt.
213

Criteria For Qualifications Of Positioning.
optimum exposure of the operative site
free access of breathing
free access of circulation.
214

Criteria-------
no, pressure on any nerve
e.g.
 Bracheal plexus.
Ulnar
 Radial
 Facial.
215

Criteria-------
Accessibility for anesthetic administration
 No, undue post operative discomforts
e.g.
-Strain on muscle.
- Prolonged neck extension stiffness
216

Positioning-------
• Individual requirements while positioning
Obesity
Size of pt
Arthritis pt
 Cardiac pt
217

Positioning-------
The obese pt’s hands should be put on arm
boards.
preservation of pt’s dignity
218

Positioning-------
operating table different type and attachment,
joints/ breaks for diversification
Special equipments for stabilizing the pt on
desired position to prevent trauma or abrasions
Anesthesia screen. To prevent breathing from the
nose of pt contaminating the sterile field
219

Positioning-------
Anesthesia screen Placed after positioning and
induction
Metal clips to hold the towel.
Wrist or arm strips to fix the pts hands
220

Positioning-------
Arm board- to rest the pt’s hand
Elbow pads or protectors.
Shoulder bridge/ thyroid elevator
Ring pads for head rest.
221

Surgical Procedures & their Specific Positions
supine/laparatomy/ dorsal/ recumbent for
operations on:
orthopedic, urologic, ophthalmologic,
otorhinolaryngologic, plastic and thoracic
operations.
eye, ear, nose, face, chest, abdomen, legs,
breast, arms or hands.
222

Specific Positions---
Trendelenburg position for:- head tilt down
Bladder operation
Hydorocelectomy.
Sulphingectoy
Sulphingo- ooprorectomy
Sulphengostomy.
Rectal operation.
223

Specific Positions----
Gall bladder and liver position.
 Reverse trendelenberg position : leg tilt down
 for throidectomy eye, ear, nose , throat , dental;
thyroidectomies & laparoscopic cholecystectomy
operations
Lateral position for- Nephrectomy operation.
224

Lithotomy position- for external genitalia :-
hemorroidectomy
circumcision /vaginal hystrectomy
scopic examination
225

• prone position- used for cerebral operation
-High cervical
- On back e.g. lipoma,lamenectomy
• fowler’s position- for craniotomy
cranial procedure s cranioectory
Cranioplasty.
• Sitting position- upright: - oto- rhinology.
• Knee chest position- sigmodoscopy,Cord prolapse
226

Hazards during positioning patient
Both for pt and personnel are.
potential electrical shock.
 burns fire
Explosions/ flammable substances e.g. oxygen.
227

Positioning------
mechanical injury.
e.g. fall from the table
. Sliding fall and injury
.Sharp injures
228

Common Terms in Anesthesia
Amnesia – loss of memory
Analgesia – lessening of insensibility to pain
Anesthesia – loss of feeling or sensation of
pain
Anesthesiologist – a doctor of medicine who
specialization in the field of anesthesia.
229

Common Terms-----
Anesthetic agent – a drug that produces
local or general loss of sensitivity.
 Anesthetist- a person who has been
trained to administer an anesthetics .
Hypoxia – low blood oxygen, subnormal
oxygen content absence of oxygen.
Anoxia -Absence of oxygen
230

Common Terms-----
Apnea -suspension or cessation of breathing.
Arrhythmia- lack of rhythm designating alteration
or abnormality of normal cardiac rhythm.
Assisted respiration- the maintenance of
adequate alveolar ventilation by supplementing
the pts respiration by manual or mechanical
means .respiratory rate is controlled by pt, tidal
volume by an anesthesiologist.
231

Common Terms-----
Biotransformation- metabolism of anesthetic
drugs. It occurs by one of the four mechanisms.
oxidation, conjugation, hydrolysis, reduction
Brady cardiac- slowness of heart beat less than 60
beat per minute .
Depolarization- neutralization of polarity as in
nerve or muscle cells in the conduction of
impulses
232

Common Terms-----
Fasciculation – it is uncoordinated skeletal muscle
contraction in which groups of muscle fibers
innervated by the same neuron contract together.
Hemodynamic- the study of how the physical
properties of the blood and its circulation
Hypomania- less amount of CO2 in the blood
Hypercapina – excessive amount of carbon dioxide in
the blood
233

Common Terms-----
hyperkalemia – above normal elevation of
potassium in the blood
Hypnosis – a state of altered consciousness or
sleep.
Hypnotic – a drug or verbal suggestion that
induces sleep.
Hypovolemia – Low or decreased blood volume.
234

Common Terms-----
Induction- the period from the beginning of
administration of anesthetics until the pt loses
consciousness.
Pa o2- partial pressure of arterial O2 tension.
Perfusion – introduction of fluids in to tissues by
their injection in to blood vessels/passage of a
fluid through spaces.
235

Common Terms-----
Ph. Expression for H2 ion concentration
(acidity of blood)
Alkalemia :blood alkaline value above 7.42
Acidemia – blood acid value below 7.34
Normal –Ph value 7.3
236

Common Terms-----
Polarity. The state of having poles or regions
intensity with mutually opposite qualities.
Regional anesthesia- In sensitivity of part of the
body to pain .
• Ventilation. The constant supply of O2 through
the lungs.
237

Common Terms-----
Respiratory acidosis. The reduction of CO2
excretion through lungs caused by respiratory
depression or obstruction or pulmonary
disease
Pain- is a perceptual phenomenon, a disturbed
sensation causing suffering to pt .
238

Pre-Operative Premeditation
 Types of medication given to the client prior to
operation in order to alleviate anxiety for
operation.
Purposes.
To allay preoperative anxiety
To produce some amnesia
To have dull awareness of the OR environment
239

Purposes--------.
Have secretion in the respiratory tract.
It counteract undesirable side effects of
anesthetic
It raises pain threshold.
Prolog the effect of anesthetics and are
respiratory depressant effect
240

Choice of Drugs for pre-medicaion
Made by anesthetic sinologist/ anesthetist.
Based on pt’s physical and emotional status
including age and weight.
The surgeons’ requirements for minimal or
maximal relaxation.
The anesthetist anesthetic sinologist own skills
and personal experience.
241

Right time Given
Time is calculated then maximum effect is
reached before induction.
It is usually given 45-60 minutes prior to
induction.
Adequate action is desired for induction and
maintenance.
242

Drugs Used Classified
As sedatives.
As tranquilizers
As narcotics
As anticholinegics
243

Drugs Used-----
for hypnotic and sedative effect.
.Barbiturates:.
e.g.
Seco - barbital
 Pentobarbital
 Phenobarbital
244

Tranquilizer actions
 allays anxiety
 relieves tension
 calming effect
1.Diazepam e.g.
 Valium
 Benzodiazepine
 Droperidol
 Haloperidol (haldol)
245

Drugs Used-----
Narcotics e.g. morphine sulphate – commonly used
Meperidin deemed (Deemed - synthetic narcotic)
Anti cholinergic drugs- e.g.
 Atropine
 Scopolamine
246

Special Consideration in Premeditation
Hypnosis- is valuable as a premedicant in children.
Clients metabolic rate varies with age, body fluid
and general condition
Heavy smokers, alcoholics, hyperthyroid, toxic,
emotional, high fever pts, require more
medication.
Person with drug addiction (abuse of barbiturates,
narcotics, cocaine or amphetamine.)
247

Choice of Anesthesia:-
made by anesthetist/ anesthesiologist or
surgeon .
The primary consideration with any anesthetic
is that it should be associated with low
morbidity and mortality.
Anesthetic drugs are not specific but depress
activities of all cells
248

Special requirements to client
provide maximum safety for the patient
provide optimum operating condition
Provide pt comfort.
Have a low index of toxicity.
249

Special requirements----
Provide potent predicable analgesia extending to
postoperative period.
Produce adequate muscle relaxation.
Provide ammenesia.
Have rapid and easy reversibility.
Provide minimum side effect.
250

Important Factors during Anesthesia.
Age of patient
Physical and mental status of pt.
Presence of complicating systemic disease.
Previous anesthesia experience.
• Position required for operation.
251

Important Factors---
Type and expected length of procedure.
Local and systemic toxicity of the agent.
Expertise of the anesthesiologist / anesthetist.
presence of infection at the site of operation
Preference of the pt.
252

Types of Anesthesia
General anesthesia
regional anesthesia
Local
253

General Anesthesia
Anesthesia is produced as central nervous system
is affected .
Association path way are blocked in cerebral
cortex to produce more or less complete lack of
sensory perception and motor discharge.
Most anesthetic agents are potentially lethal
substance.
The anesthetist/ anesthesiologist must constantly
observe the body reflex responses to stimuli.
254

General Anesthesia----
Respiratory and circulatory depression
observed during operation.
Continuous watching and appraisal of all
clinical signs must be monitored.
The levels of anesthesia judged the light
moderate and deep and provide the pt with
optimum care.
255

Three traditional administration method
Inhalation.
intravenous injection
rectal installation
256

Characteristics of the ideal general anesthetic.
Produces analgesia.
 Produces complete loss of consciousness.
 Provides a degree of muscle relaxation.
 Obtunds reflexes.
 Is safe and has minimal side effects.
257

Require of general anesthesia.
Major head and neck surgery.
Intracranial surgery. require
 Thoracic surgery.
 Upper abdominal surgery.
 Upper and lower extremity surgery.
258

Induction of General anesthesia
 Induction and emergency from general
anesthesia are two crucial periods requiring
maximum attention from operating team.
259

Key Points during induction
The circulating nurse should remain at the pt’s
side.
Should be quite, excitement, cough, vomiting,
laryngospasm should be avoided.
Absolute avoidance of stimulation of the pt is
mandatory.
260

Precautions during induction
Continuous electrocardiography.
Use of chest stethoscope.
Ready availability of resuscitative
equipment including defibrillator.
Induction is individualized
261

Inhalational anesthesia
The most controllable method in the up take.
The most controllable method of eliminating
anesthetic agents
Are mainly accomplished by pulmonary
ventilation
The blood and lungs functioning as the transport
system.
262

Inhalational take Up has two phases:-
Transfer of anesthetics from alveoli to
blood
Transfer of anesthetics from blood to
tissue.
263

Technique of Inhalational Anesthesia
 Musk inhalation- in closed system of anesthesia
machine.
 Endotracheal administration: - inhaled in to
trachea through nasal or oral tube insertion.
Intubations- insertion of tub directly in to trachea.
 Extubation- removal of tube from trachea.
264

Complications of Intubations
Trauma to teeth.
Trauma to pharynx
Trauma to vocal cord.
Trauma to trachea.
Esophageal or endobroncheal intubations
265

Inhalational Anesthetize Agent
I.Nitrous oxide (N2o)
Commonly used.
Inorganic gas of slight potency.
Has pleasant sweet fruit like odder.
Supports combustion w/n combined with
oxygen.
266

II.Nitrous oxide (N2o)---
Administration – inhalation.
Advantage – comfortable, rapid induction and
recovery non toxic, none irritating.
Few hrs effect except headache
No vertigo and drowsiness
267

Nitrous oxide (N2o)---
Excellent analgesia for minor operation
Disadvantage:- poor relaxation
Excitement
 Laryhgospasm.
Hypoxia
268

III.Cyclopropane-----
Very potent gas very seldom used.
Highly explosive
Administration- inhalation
269

Cyclopropane-----
• Advantage: –
pleasant
Rapid induction
270

Cyclopropane-----
Moderate relaxation
Supports circulation.
• Disadvantage: - flammable, explosive
271

IV.Halothane (fluthane)
Administration--- inhalational.
Volatile liquids.
Very widely used .
Has a pleasant odor.
272

Halothane----
Advantage: –
non flammable
Potent
Chemically stable
273

Halothane Advantage: –---
Rapid induction.
None irritating for respiratory tract.
Does not stimulate respiratory secretion.
Useful for pts with bronchial asthma
274

Disadvantage: –---
Potentially toxic to liver
Respiratory depressant.
CVS depressant:-
Hypotension
Brady cardiac
Cardiac arrest
275

V. Thiopental sodium (pentothal sodium)
 Intravenous Administration
Most commonly used barbiturate
Short acting in small does
Used for induction.
276

Thiopental sodium---
• Advantage-
Pleasant rapid induction (30- 60 seconds)
Nonflammable, nausea, vomiting are rare
Non irritant.
277

Thiopental sodium---
Disadvantage:
Large doses cause:
Rapid, prolonged respiratory depression
 Circulatory depression
Coughing, laryngeal-spasm.
278

Note: - morphine sulfate and nitrous oxide
have a synergistic action with thiopental
sodium. (Each potentates the action of
other).
279

Ketamine hydrochloride
IV administration or IM to yield profound
anesthesia.
Produces rapid induction 30 sec. IV, 2-4 minutes
280

Ketamine hydrochloride----
Advantage –
For short procedure in childres (2-10yrs)
For plastic and eye procedures.
281

Ketamine----
Disadvantage: –
Emergence reaction with psychological
manifestations in recovery.
Delirium
Hallucination
Increases B/P
282

Stages of General Anesthesia
Consists of four stages.
Each stages presents definite group of s/s
283

Stages of---
Stage 1: Beginning Anesthesia.
As pt breathes in the anesthetic mixture, warmth,
dizziness and feeling of detachment experienced .
Pt may have ringing, roaring , buzzing in ears .
Pt conscious but unable to move extremities.
Unnecessary noises should be avoided.
284

Stages of---
Stage 2:- Excitement
Characterized variously by struggling shouting talking
singing laughing, crying.
W/n anesthesia smoothly and quickly administered it will
be avoided.
Pupils are dilated, but contract w/n exposed to light.
Pulse rate rapid respiration irregular.
Anesthetist is attended by some one to help restrain the
pt with strap and secure arm board.
285

Stage 3:- Surgical Anesthesia
This stages is reached w/n continuous
anesthesia is given as vapor or gas.
The pt is unconscious, lying quietly, on table.
The pupils are small and contract.
286

Stage 3-----
Respiration is regular.
Pulse rate and volume are normal .
Skin pink, slightly flushed.
With proper administration the stage
maintained .
287

Stage 4:- over Dosage
This stage is reached w/n too much
anesthesia is administered.
Respiration is shallow.
Pulse weak and three-day pupil widely
dilated no contraction.
Cyanosis developed.
288

Stage 4-----
Unless prompt action death follows rapidly.
Anesthetics showed be discontinuoued.
Circulatory and respiratory support
289

Nurses Role in Anesthetized Patient
positioning the patient’s
Evaluating patient’s ability to detoxify
anesthetic agents and tolerate stress.
Patient’s respiratory and circulatory care.
Measuring the pt’s urinary out put.
Constantly aware of potential trauma to the
patient.
290

Local Anesthesia
The local anesthesia depresses superficial
nerves.
Blocks the conduction of pain.
291

Advantages:-
Infiltrated of anesthetic agents are non explosive.
 It needs minimal simple equipment.
 Loss of consciousness does not occur.
 It does not need fasting .
Surgeon can do operation with out
anesthesiologist.
292
Local Anesthesia

Local Anesthesia----
Contra Indication.
Allergic sensitivity.
local infection.
septicemia .
Highly nervous, apprehensiveness.
293

Regional anesthesia
Nerve block – anesthetizing of a selected
nerve at a given point.
Field block – blocking off of operative site
with wall of anesthetic solution by series of
injection
e.g. Abdominal wall block for herinorrhaphy
Brachial nerve block for hand surgery
294

Spinal Anesthesia
Intrathecal block. Is usually refereed to as spinal
anesthesia.
The agent is injected in to the subarachnoid
space using the lumber inters pace.
Desensitizing of the spinal ganglia and motor
roots.
The absorption in the nerve fiber is rapid.
295

Spinal------
Depends On Various Factors:-
Positioning during and immediately after injection.
CSF pressure.
Site and rate of injection.
Volume, dosage and specific gravity (baricity) of
solution
296

Spinal------
Procedure.
Lateral position- the most common.
Sitting position.
Prone position.
297

Spinal------
Necessary Equipment:-
drape /fenestrated towel.
ampoule file.
Ampoule of local anesthesia.
298

Necessary Equipment:---
tray (medication glass)
sponges
Needles 25 gauge hypodermic for infiltration.
22-26 gauge needle for interthecal with
stylet
299

Indication-----
Lower abdominal or pelvic procedure.
Intestinal obstruction.
Inguinal/ lower extremities.
C/S
300

Epidural Anesthesia
Lumbar approach – epidural block.
Caudal approach – epidural sacral block
301

Epidural-----
Indication :-
Anorectic
- obstetrics
Vaginal
intractable pain
Perineal
302

Local and anesthetic Agents
cocaine – the 1st local anesthetics introduced
Toxic most .
procaine hydrochloride (Novocain)less toxic)
Lido-caine hydrochloride /xylo-caine)
Toxic more.
Potent.
Rapid onset.
303

Tetracaine hydrochloride(pontocaine)
very potent agent
slow onset of anesthesia
duration of effect is long
toxic
304

bupivacine hydrochloride (marcaine)
more potent
long acting
High toxicity.
305

Neuromuscular Blocking Agent
• Non depolarizing agents
1.Tubo curanine chloride (curare)
Derived from a poison from certain south
American plants.
1st used centuries ago by the Indians.
Their poison arrows caused death by suffocation
from respiratory paralysis.
306

Tubo-----
The action is predominately a paralysis at
voluntary muscle by blocking of the trans
mission of nerve impulses to muscle fibers.
The muscle relaxation is potentate by
curtained anesthetizes (halothane, effleurage,
diethyl ether, matchbox flurane and by some
antibiotics.)
307

Neuromuscular----
2. Pancuronium bromide- a long acting systemic muscle
relaxant similar in action to curare but & more potent.
3. Gallamine triethiodide (flaxedil)
Similar to curare in mechanism and duration of action.
It advantages over curare is an absence of
hypotension and bronchus spasm.
It may cause tachycardia and of in arterial pressure
308

Complication Of Spinal Anesthesia
Transient or permanent neurological
sequale from trauma irritation by the
agent.
Lack of asepsis, loss of spinal fluid.
Decreased intracranial pressure syndrome.
e.g. spinal head ache
309

Complication-------
Auditory and ocular disturbances such as
tinnitus diplopic, arachnoiditis, meningitis.
Caudal equine syndrome (failure to regain use
of legs or control of urinary or bowel function.
Temporary parenthesis such as number and
tingling .
310

Spinal Anesthesia
Advantage:-
 Pt is conscious.
 throat reflexes are maintained
 None irritating to respiratory tract.
 No difficulty with airway problems.
 Quiet breathing.
 Contracted bowel.
 Decreased bleeding
311

Spinal Anesthesia---
• Disadvantage:-
Circulatory depressant
Hypotension.
Nausea and emesis .
Danger of trauma, infection
Pt can hear.
Distress.
312

Post Anesthesia Care Unit (PACU)
Nurse’s major considerations:
Transfer of pt from the operation room to Pacu.
Referred to as the post anesthesia recovery
room/ PACU
Special consideration of the pt’s incision site
vascular changes and exposure.
Wounds are closed under considerable tension
313

major considerations----
While positioning or transferring the pt not lying on
and obstructing drains or drainage tubes.
Serious arterial hypotension way occur when the pt
is moved from one position to another such as :
 From lithotomy position to horizontal.
 From lateral to supine.
 From prone to supine.
314

• Transferring the postoperative pt is the
responsibility of anesthesiologist with
members of other surgical team.
315

Sites of PACU
usually located adjacent to the operating room.
Because of nurses and surgeons to care for the
post operative pt in theatre
Because of availability of monitoring and special
equipments, emergency medications, and
replacement of fluids in theatre
316

PACU----
PACU painted quiet in soft, pleasing colors
and have :-
Indirect lighting
 sound proof ceiling
equipments that controls or eliminates
noise
317

PACU have ----
Isolated quarters/ gas encased /for disruptive pts to
decrease anxiety
Room temperatures should be 20’c to 22. 2 0C
Room should be well ventilated
Pt should stay in PACU until adequate respiratory
function, a minimum of 95% of 02 saturation.
Pt should gain reasonable degree of consciousness
318

Immediate Post- Operative Assessment
The PACU nurse should review.
Medical diagnoses and types of surgery performed
Pts age and general condition, airway potency,
vital-signs.
 Anesthetic and other medications used muscle
relaxants, antibiotic, IV fluids
319

Immediate P.O Assessment-----
Vital signs- presence of artificial airway, o2
sat,BP,pulse, temperature.
LOC- ability to follow command, pupillary
response.
Urinary output
320

Immediate P.O Assessment----
Skin integrity.
Pain.
Condition of surgical wound.
Presence of IV lines.
Position of patient.
321

Immediate Post- Op----
Any problem that occurred in operating room
that might influence post care. e.g. extensive
hemorrhage, shock, cardiac arrest.
Pathology encountered (if Malignant
suspected )
Types of fluid administered; blood loss and
replacement, ph of the blood.
322

Immediate Post- Op----
Any tubing, draining catheters, or
supportive aids.
Specific information’s for which surgeon or
anesthetist wishes to be notified
323

Areas of Assessment
Respiration point
score
Ability to breathe deeply and cough---------2
Limited respiratory effort (dyspnea )---------1
No, spontaneous effort -----------------------0
324

Areas of Assessment
 Circulation: SAP point
score
> 80% of pre anesthetic level-------------2
50% of pre anesthetic level --------------1
< 50% of pre anesthetic level ----------0
325

Assessment---
Color:- point
score
 Normal skin color and appearance--------- 2
 Altered skin color: place---------------------- 1
 Cyanosis--------------------------------------- 0
326

Assessment-----
Muscle activity point score
Ability to move all extremities ----------2
Ability to move two extremities ---------1
Unable to control any extremity---------0
Total: required for discharge form recovery room:
7-8:- points
327

Post Operative Complication
Airway obstruction
 cardiac arrest
Hypoventilation.
Atelectasis / pulmonary collapse.
Pulmonary embolism.
328

Post Operative-----
Pulmonary edema.
Venous stasis .
Hypertension/ hypotension.
Shock.
329

Post Operative-----
Hemorrhage.
Post- op wound infection.
Urinary retention/ fullbladdder.
330

Gerontologic considerations
Mental status- attributed to medications, pain,
anxiety, depression.
Delirium- infection, malignancy, trauma, MI,
CHF, opioid use.
Dementia-sundowning=sleep disturbances,
lack of structure in the afternoon or early
morning, sleep apnea.
331

Nursing Intervention
V/s are monitored every 15 minutes
Potency of airway and respiratory function.
Cardiovascular function.
Clearing secretion from airway
332

Intervention ----
Proper positioning of pt.
IV solution drip rate setting.
Level of responsiveness
Pain mgt.
333

Intervention ----
Quite environment
Drainage management
Body temperature
-Above 37.7c0
- Below 36.1c0
- Bp Sbp < 90 mmHg
Dbp < 60 mm hg
334

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