Pain And Surgery Module 1.3-1.5 PDF

Medical-Surgical Nursing 1 Lecture Pain and Surgery Module 1.3 Operating Room Attire, Surgical Hand the surgeon often relied on the nurse to have the Scrubbing, Gowning, Closed Gloving and necessary instrumen...

Medical-Surgical Nursing 1 Lecture Pain and Surgery Module 1.3 Operating Room Attire, Surgical Hand the surgeon often relied on the nurse to have the Scrubbing, Gowning, Closed Gloving and necessary instruments in her apron pocket. Instrumentation - the apron was replaced by a scrub suit while OPERATING ROOM ATTIRE long sleeves are recommended for Description: anesthesiology and circulators to reduce spread - consists of body covers, such as a two piece of contamination pantsuit, head cover or cap/turban, mask. shoe cover, or booties, googles, and apron Joseph Lister- Fist use of caps and sterile gowns - protects us from blood and body substance of occurred in Germany while the value of joseph lister’s patient principle of antiseptic surgery to exclude putrefactive bacteria from wounds was still Purpose: - From 1908 to 1930, various styles of turbans and - to provide effective barriers that prevent the shower cap-style head covering were worn. dissemination of microorganisms to the px - protects personnel from infected patients and Charles Mayo (1913) against exposure to communicable disease and... - the team and mayo were photographed - Has been shown to reduce particle count of … operating in surgical gowns, caps and from the body from over 10,000 particles per masks min to 3000 per min, or from 50, 000 1930- 1940- scrub dresses began to replace microorganisms per cubic foot to 500 nurses’ regular uniforms heretofore worn under microorganisms per cubic foot. the sterile gown, observers in the OR were gowned, capped and masked. Historical Background: 1958- disposable latex gloves was introduced - OR nurse take a bathe before a surgical - most efficient masks are disposable ones procedure, to take a carbolic bath (anti microbial containing a high efficiency filter soap) before laparotomy and to wear long 1960- full skirts were replaced by close fitting sleeves and clean apron for the surgical scrub dresses and pantsuits that reduces the procedure hazard of brushing against a sterile table when near or passing by it Gustav Neuber (1883)- he insisted in wearing of caps 1950- OR personnel were required to change by OR personnel shoes when entering the OR suite and to wear only those shoes when within the suite. Hunter Robb- a gynecologist at Johns Hopkins hosp Currently, disposable shoe covers are commonly Baltimore, insisted on OR cleanliness and on the worn. wearing of caps and sterile gowns CRITERIA FOR OPERATING ROOM ATTIRE Dr. William Halsted (1897)- He designed a semicircular OR attire should be: instrument table to separate himself, in sterile gown and Should be an effective barrier to gloves, from observers in street clothes who watched microorganisms. Both reusable woven and him operate. disposable nonwoven materials are used. Design and composition should minimize microbial Johann von Mikuliez (1896)- a pioneering german shedding. surgeon, advocated the wearing of cotton gloves in 1896 Closely woven material void of dangerous but these were soon found to lack the qualities of electrostatic properties. The garment must meet impermeable rubber gloves for infection control. He also the fire protection standards, including advocated the use of gauze masks in 1897. Until 1900 resistance to flame. Nylon and other static spark-producing materials are forbidden as outer garments.  Should be resistant to blood, aqueous fluids, and 7. Personal hygiene must be re-emphasized abrasions to prevent penetration by a. A person with an acute infection such as microorganisms cold or sore throat should not be Designed for maximal skin coverage. permitted within the or suite. Should be hypoallergenic, cool and comfortable b. Persons with cuts, burns or skin lesions Should be non-generative of lint. Lint can should not scrub or handle sterile increase the particle count of contaminants in the supplies because serum may seep from OR the eroded area Should be made of pliable material to permit c. Sterile team members who are known freedom of movement for the practice of sterile carriers of pathogens should routinely technique. bathe and scrub with appropriate Should be able to transmit heat and water vapor antiseptic agent & shampoo their hair to protect the wearer daily Should be colored to reduce glare under lights. d. Fingernails should be kept short. Nail Various types of clothes are colorful and the polish is not allowed. Studies have necessary criteria are both attractive and shown that artificial nails and other functional. enhancers harbor microorganisms esp. Should be easy to don and remove fungi & gram-negative bacilli. Should be an effective barrier to microorganisms e. Jewelries including rings & watches should be removed before entering the DRESS CODE semi restricted & restricted areas. - these are written policies and procedures for Necklaces & chains can grate on the proper attire to be worn within the skin, increasing desquamation which semi-restricted and restricted areas of the OR might fall into a wound or contaminate suite the sterile field. Pierced-ear studs must - should include personal hygiene be confined within the head cover. - protocols must be abided Dangling earrings are inappropriate in the OR. 1. Location of the dressing room f. Facial makeup should be minimal 2. Street clothes are never worn beyond the g. Eyeglasses should wiped with a cleaning unrestricted area solution before each surgical procedure 3. Only approved, clean, and/or freshly and properly secured laundered or attire worn within the h. Hands must be washed frequently and semi-restricted area. thoroughly. hand cream may be used This applies to all, both professional, after to prevent chapping and drying of non-professional and visitors alike. hands. 4. OR attire should not be worn outside the or 8. Comfortable, supportive shoes should be worn suite. This protects the or environment from to minimize fatigue and for personal safety, microorganisms inherent in the outside shoes should have enclosed toes and heels; environment and protects the outside from clogs, slippers contamination normally associated with the or. 9. External apparel that doesn't serve any Before leaving the or suite, everyone functional purpose should not be worn in the should change to street clothes OR. *lab gowns and smock gowns (this practice is not encouraged) COMPONENTS OF OPERATING ROOM ATTIRE 5. A clean, fresh scrub suit should be put on after Body cover or Scrub suit return for reentry to the suite. - One piece overall with attached hoods and boots 6. OR attire should be hung or put in a locker are convenient garb for visitors whose presence for wearing a second time. If disposable, in the OR will be brief like the pathologist. discard in the strash one use.  - Scrub suit must be donned before entering a - Protective gloves should be worn to change semi-restricted area. shoe covers whenever they become wet, soiled, - Available also in pantsuits which is more or torn. preferred than the overall type. Mask - The shirt and waistline drawstrings are tucked - Worn in the restricted areas to contain and filter inside the scrub pants to avoid touching sterile droplets containing microorganisms expelled areas and to reduce fallout of skin debri from from the mouth and nasopharynx during thoracic and abdominal areas. breathing, talking, sneezing and coughing. - Scrub suit should be changed as soon as possible - Should be worn at all times in the restricted whenever it becomes wet or visibly soiled. areas where sterile supplies are exposed. - Persons who will not be part of the sterile team - Reusable cotton masks are obsolete because they member should wear long sleeved jackets over a filter ineffectively as soon as they become moist scrub suit. - Reusable cotton masks are obsolete because they filter ineffectively as soon they become moist Headcover/ Cap/ Turban - at least 95% efficient in filtering miscorebed - All facial and head hair must be completely from droplet particles covered. - disposable mask made of soft, cloth-like - Cap or hood is put on before a scrub suit to material in very fine synthetic fiber mats is more protect the garment from contamination by hair. appropriate to use because: - types include disposable, lint-free, nonporous, at least 95% efficient in filtering nonwoven fabrics. A reusable cap should be microbes from droplet particles made of a dense woven material and laundered a fluid resistant mask is advantageous daily (after use put it in the hamper and send it cool, comfortable and non obstructive to to the department) respiration - net caps are not acceptable non irritating to the skin because of its - hair should not be combed while wearing a polypropylene, polyester or rayon fibers scrub suit - should be worn over both nose and mouth and - persons with scalp infection should be excluded should conform to facial contours to prevent from the OR and treated first leakage of expired air. - If the hair is long, a helmet or hood must be - double masking is not recommended because the worn to cover the neck area. it should be well extra thickness can cause venting from the effort fitted to confine and prevent escape of any hair. to breathe through it - caps of different colors are helpful to differentiate personnel To prevent cross infection, mask should: Be handled only by the strings. Do not handle Shoe cover the mask excessively - should be clean, washable and soft-soled Never be lowered to hang loosely around the - protect the wearer from spilled into or onto neck, on top of the cap, or put in a pocket. Avoid shoes during procedures disseminating microorganisms - maybe worn in semi-restricted and restricted Be promptly discarded into the proper receptacle areas on removal. Remask with a fresh mask between - shoes restricted to wear in the OR or shoe cover patients. overshoes are preferable in reducing microbial Be changed frequently. Do not permit the mask transfer from the outside into the OR suite. to become wet. Talking should be kept to a - can inadvertently become soiled and harbor minimum. microorganisms, so should be removed from entering the dressing room and after leaving the Eyewear/Goggles OR - Worn to reduce risk of blood or body fluids from the px splashing into the eyes of sterile team members, or bone chips or splatter alike.  - with side shields, anti-fog goggles, combination - sterile and non-sterile single-use disposable latex surgical mask with a visor eye shield. and vinyl gloves are discarded after use. they - eyewear or face shield that becomes should not be washed or reused contaminated should be decontaminated or discarded promptly. Sterile Gown - laser eye must be worn for eye protection from - is worn over the scrub suit to permit the wearer laser beams to come within the sterile field. - eyewear with a face shield should be worn when - differentiates sterile from unsterile members. handling or washing the instruments when the - although the entire gown is sterilized, the back activity could result in a splash, spray or splatter is not sterile, nor any area below table level, to the eye or face. once the gown is donned - wrap around sterile gowns that provide coverage Sterile Gloves is more recommended - Non-sterile latex or vinyl gloves should be worn - if the gown is close by ties along the back, a when handling contaminated materials sterile vest should be put on to cover the back - Surgical gloves are made of natural latex rubber, - The cuffs of the gowns are stockinette (rib-knit) synthetic rubber, vinyl, or polyethylene to tightly fit the wrists. sterile gloves cover the cuffs of the gown Latex - polymeric membrane of natural rubber with an - should be resistant to penetration by fluids and infinite number of holes between lattices blood - better barrier than vinyl type - should be comfortable without producing - contains protein antigen & is cured with agents excessive heat build-up. that may cause an allergic dermatitis or - reusable gowns must be made of densely woven systemic anaphylaxis material. - vary in thickness (minimum 0.1mm) - Pima cotton with a 270-280 thread count per - petroleum-based lotions or lubricants should sq inch treated with a moisture-repellant finish not be used on the hands before dining latex - Some reusable are cotton-polyester blend. gloves. Hydrocarbons will penetrate latex, - seams of the gown should be constructed to causing a change in its physical characteristics, prevent penetration of fluids. including tear resistance. - woven textile gowns withstand about 75 - sterile and non sterile single use disposable latex launderings and sterilizing cycles before and vinyl gloves are discarded after use. They discarding them. should not be washed and reused. - if punctured or torn, the gown should be - hands must be washed thoroughly after changed during the procedure. removing the gloves - all woven and some non-woven gowns are not flame retardants. Fire-resistant gowns should Surgical Gloves- clean objects and sterile packages be worn for laser surgery and when should not be handled with contaminated; worn in electrosurgery is used surgical procedures Gowning Lead gloves a. The circulator brings the gown over the shoulder by reaching inside to the shoulder and arms Thick gloves- should be worn for skin protection from seams. The gown is pulled on, leaving the cuffs ethylene oxide exposure if sterilized packages must be of the the sleeves extended over the hands. The handled before operation back of the gown is securely tied or fastened at the neck and waist; touching the outside of the Working Gloves- utility gloves are worn for cleaning gown at the line of ties or fasteners, in the back and housekeeping. only.  b. The scrub nurse, putting down, gently shakes out To help prevent the possibility of contamination folds, then slips both arms into the armholes of of the operative wound by bacteria on the hands the sleeves simultaneously without touching the and arms. sterile outside of the gown with bare hands. To remove soil, debris, natural skin oils, hand c. After drying your hands, Pick up the sterile lotions and transient microorganisms from the gown, lift it directly upward and step away to hands & forearms of sterile members. avoid touching the edge of the wrapper. To decrease the number of resident microorganisms on skin to an irreducible Drying Hands and Arms minimum. To keep the microorganisms to minimum during After scrubbing, hands and arms must be thoroughly the surgical procedure by suppression of growth. dried before the sterile gown is donned to prevent To reduce the hazard of microbial contamination contamination of the gown by strike -through of of the surgical wound by skin flora. microorganisms from wet skin. Materials needed for Surgical Hand Scrub Apron Scrub Sink - Fluid proof aprons is adjacent to the OR for safety and convenience - Lead aprons automatic control or foot or knee operated - a decontamination apron should be worn over faucets; - sink is deep & wide enough the scrub suit to protect against liquids and Should be used only for scrubbing or hand cleaning agents during cleaning procedures. this washing only. should be a full front barrier Should not be used to clean or rinse contaminated/ soiled instruments and equipment. Lead Apron - protects against radiations exposure or when Scrub Brush handling radioactive implants (x-rays,C-arms, reusable scrub brushes coronary angiogram) disposable sponges - protects against radiation exposure or when single use disposable brush-sponge combination handling radioactive implants. with impregnated antiseptic detergent agents. - protects against radiation exposure or when Brush should not cause skin abrasion handling radioactive implants. reusable brush may be wrapped to provide sterile individual packages. Reusable nail cleaners should be used to clean REVIEW OF SURGICAL HAND SCRUBBING under the nail. Definition: Orangewood sticks are not used because the Surgical hand scrubbing is the process of removing as wood may splinter & harbor Pseudomonas many microorganisms as possible from the hands and arms by mechanical washing & chemical antisepsis Antiseptic Agents before participating in surgery. antiseptic agents are approved by FDA - Mechanical washing with friction removes different agent has different specific microbial transient organisms. agent. - Chemical antisepsis reduces resident flora & agents alter the physical or chemical properties inactivates microorganisms with antiseptic of the cell membrane of microorganisms, thus agents. destroying or inhibiting cellular functions. - Done before gowning & gloving for each should be a broad spectrum antimicrobial agent; surgical procedure. should be fast acting and effective; should be nonirritating and non sensitizing; should be prolonged-acting; Purpose of Surgical Hand Scrub should be independent of cumulative action 4% Chlorhexidine Gluconate- produces effective, Adjust comfortably in relation to the mask. immediate, and cumulative reductions of resident & Adjust water to a comfortable temperature and transient flora. The effect is maintained for more than 6 amount. hours. Non irritating to the skin but highly irritating if splashed in the eye. Types of Surgical Scrub Procedure Time Method Iodophors- is a povidone-iodine complex against gram Complete scrub (5-7 minutes) positive & gram negative microorganisms; irritating to Short scrub (3 minutes) the skin; not sustained for a prolonged period (6hrs). Brush-stroke Method or counted Method 1% Triclosan- nontoxic, non irritating, & develops a 30 strokes method prolonged cumulative suppressive action when used 15 strokes method routinely. Less effective than Chlorhexidine Gluconate and Iodophors Steps in 5-minute time scrub method 1. Wet hands and forearms. Apply 2 to 3 ml (6 gtts) 60% / 90% Alcohol- nontoxic, does not have residual of antiseptic agents to the hands activity, has drying effect on skin. 2. Lather & Wash hands several times up to 2 5. 3% Hexachlorophene - most effective after buildup inches above the elbow. Then rinse thoroughly of cumulative suppressive action. Available by under running water with hands upward. prescription only 3. Take the sterile brush, apply antiseptic agent & scrub following the time allotted per part: * 30 Preparation for Surgical Scrub seconds each nail, *30 seconds each finger, *30 Skin & nails should be kept clean and in good seconds each hand condition and cuticles should be uncut. 4. With brush in hand, clean under fingernails with Fingernails should not reach beyond the nail cleaner on running water then discard after fingertip to avoid glove puncture. use the cleaner Fingernail polish should not be worn. Artificial 5. Again scrub each individual finger, nail and devices must not cover natural fingernails. hands with the brush a half minute for each Remove all jewelries from fingers, wrists and hand, maintaining lather neck. 6. Rinse hands and arms and discard brush; Ensure to fold the sleeves of the scrub suit at Reapply the antiseptic agent and wash the hands least 2 to 3 inches above the elbow. & arms with friction up to the elbow for 3 minutes. Interlace the fingers to cleanse between Before proceeding to the scrub sink them Open out the sterile gown pack onto a clean 7. Rinse the hands and arms thoroughly. back table, only grabbing the outermost edges to 8. Stay for a few seconds at the scrub sink for the maximize the sterile field. dripping of water, then proceed to the assigned Open the sterile glove packet and let it drop onto OR suite. DO NOT INTERLACE THE the open sterile gown pack FINGERS. Preparations Immediately Before scrubbing Steps in Brushstroke method (15 Strokes Method) Inspect the hands for cuts and abrasions. Skin 1. Wet hands and arms up to 2 inches above the integrity should be intact. elbow All hair is covered properly by headgear 2. Lather with antiseptic agent. including the pierced ear studs. 3. With the hands held under running water, clean Adjust disposable mask snugly & comfortably under the fingernails of both hands with nail over nose & mouth. cleaner & discard after use Clean eyeglasses if worn. 4. Rinse both hands and arms under running water, keeping hands up  5. Take a sterile brush and apply an antiseptic agent The back of the gown is securely tied or fastened and start doing the brush stroke method on ONE at the neck and waist; touching the outside of the HAND first following: gown at the line of ties or fasteners, in the back a. 15 strokes each nail only. b. 15 strokes all sides of each finger c. 15 strokes each dorsum Serving of sterile gown d. 15 strokes each palm 1. Open the hand towel and lay it on the surgeon’s e. 15 strokes for each third of the arm up to hand, being careful not to touch the hand. 2 inches above the elbow. If no towel is available, the lower part of 6. Repeat the above steps for the other hand and the gown may be used to dry the hands of the arm surgeon. 7. Rinse the hands and arms thoroughly 2. Keeping your hands on the outside of the gown 8. Stay at the scrub sink for a few seconds for the under a protective cuff of the neck and shoulder dripping of water while maintaining the hands area, offer the inside of the gown to the surgeon. up. The surgeon slips the arms into the sleeves. 3. Release the gown. The surgeon holds arms GOWNING AND DONNING OF SURGICAL outstretched while the circulator pulls the gown GLOVES onto the shoulders and adjusts the sleeves so the Purpose: cuffs are properly placed. In doing so, only the - Sterile gown is worn to exclude skin as a inside of the gown is touched at the seams. possible contaminant and to create a barrier between the sterile and unsterile areas. Donning of sterile surgical gloves by Closed glove technique General Considerations 1. Using the left hand and keeping it within the a. The scrub person gowns & gloves self, then may cuff of sleeve, a gowned scrub person picks up gown and glove the surgeon & assistants. the right glove. Palm of glove is placed against b. Gown packages preferably are opened on a palm of right hand, grasping top edge of glove separate table from other packages to avoid cuff above palm. contamination from dripping water. c. Avoid splashing water on scrub attire during CORRECT POSITION: Fingers of glove are surgical scrub because moisture may pointing towards you and the thumb of the glove contaminate the sterile gown. is aligned with the thumb of the hand. The thumb side of the glove is down. Wearing of Sterile gown by self After scrubbing, hands and arms must be 2. Back of the cuff is grasped in the left hand and thoroughly dried before the sterile gown is turned over the right sleeve and hand. Cuff of donned to prevent contamination of the gown by the glove is now over the stockinette cuff of the strike-through of microorganisms from wet skin. sleeve, with the hand still inside the sleeve. After drying of hands, pick up the sterile gown, 3. Top of the right glove & underlying sleeve of the lifts it directly upward and steps away to avoid gown are grasped with the left hand. By pulling touching the edge of wrapper. the sleeve up, the glove is pulled onto the hand. The scrub nurse, putting on a gown, gently 4. Using the gloved right hand, the left glove is shakes out folds, then slips both arms into the picked up and placed with the palm of the glove armholes of the sleeves simultaneously without against the palm of the left hand. Back of the touching the sterile outside of the gown with cuff is grasped, above the palm in the right hand bare hands. & turned over the left sleeve and hand. The Circulator brings the gown over the 5. Cuff of the left glove is now over the stockinette shoulder by reaching inside to the shoulder and cuff of the sleeve, with the hand still inside the arms seams. The gown is pulled on, leaving the sleeve. Top of the left glove and underlying cuffs of the sleeves extended over the hands. gown sleeve are grasped with the right hand, and  the sleeve is pulled up, pulling the glove onto 6. Repeat step 5 for the right cuff, using the left the hand. hand and thereby completely gloving the right hand. Serving of Sterile gloves 1. Pick up the right glove, grasp it firmly, with the Reminders in Glove technique fingers under the everted cuff. Hold the palm of Avoid contact of sterile gloves with ungloved the glove toward the surgeon. hands during closed-gloving procedure. 2. Stretch the cuff sufficiently for the surgeon to For close gloving method, never let the fingers introduce the hand. Avoid the touching the hand extend beyond the stockinette cuff during the by holding your thumbs out. procedure. Contact with ungloved fingers 3. Exert upward pressure as the surgeon plunges constitutes contamination of the gloves. the hand into the glove For open glove method, touch only the cuff of 4. Unfold the everted glove cuff over the cuff of the glove with the ungloved hand, and then only the sleeve; Repeat for the left hand. glove to glove for the other hand. 5. If a sterile vest is needed, hold it for the surgeon If contamination occurs during either procedure, to slip the hands into the armholes. Be careful both gown and gloves must be discarded and not to contaminate gloves at the neck level. If new gown and gloves must be added. the gown is a wraparound, assist the surgeon. When removing gloves after a procedure is finished, the gloves are removed using glove-to Donning of sterile surgical gloves by Open glove glove, skin to skin technique, after the gown is technique removed inside out technique. This method of gloving uses a skin-to-skin, glove-to-glove technique. The hand, although scrubbed, Removing of gown is not sterile and must not come in contact with the 1. Grasp the right shoulder of the loosened gown exterior of the sterile gloves. The everted cuff on the with the left hand and pull the gown downward gloves exposes the inner surface. from the shoulder an off the right arm, turning the sleeve inside out; The first glove is put on with skin-to-skin 2. Turn the outside of the gown away from the technique, bare hand to inside cuff. The sterile fingers of body with flexed elbows; that gloved hand then may touch the sterile exterior of 3. Grasp the left shoulder with the right hand and the second glove, that is glove-to-glove technique remove the gown entirely, pulling it off (inside out); Open Glove Method 4. Discard in a laundry hamper or in a trash 1. With the left hand, grasp the cuff of the right receptacle (if disposable) glove on the fold. Pick up the glove and step back from the table. Glove removal 2. Insert the right hand into the glove and pull it on, The key to removing both sterile and non-sterile leaving the cuff turned well down over the hand. gloves is "Dirty to Dirty - Clean to Clean" that 3. Slip the fingers of the gloved right hand under is, contaminated surfaces only touch other the everted cuff of the left glove. Pick up the contaminated surfaces: your bare hand, which is glove and step back. clean, touches only clean areas inside the other 4. Insert the hand into the left glove and pull it on, glove. leaving the cuff turned down over the hand. 1. Take hold of the first glove at the wrist. 5. With the fingers of the right hand, pull the cuff 2. Fold it over and peel it back, turning it inside out of the left glove over the cuff of the left sleeve. as it goes. Once the glove is off, hold it with If the stockinette is not tight, fold a pleat, your gloved hand. holding it with the right thumb while pulling the 3. To remove the other glove, place your bare glove over the cuff. Avoid touching the bare fingers inside the cuff without touching the wrist. glove exterior. Peel the glove off from the inside,  turning it inside out as it goes. Use it to envelope silicon, molybdenum, sulfur and other elements the other glove. to prevent corrosion or add tensile strength. - Alloys make the instruments resistant to SURGICAL INSTRUMENTATION corrosion when exposed to blood and Historical Background body fluids, cleaning solutions, Code of Hammurabi (Circa 1900 BC)- describes a sterilization, and atmosphere. bronze lancet Parts of the Surgical Instrument Incas of Peru- use razor-sharp flint and animal teeth Tip Serrated Jaws Egyptians (1900 - 1200 BC)- blades made of flint, reed, Boxlock and bronze Shank Ratchet Hippocrates (460 -377 BC)- advocated the heating of Finger ring or Ring Handle tips of rounded and pointed blades before using Rome (1st century AD)- use of scalpel handles with blunt dissecting ends, knives, saws, forceps, and clamps with locking handles, probes, and hooks for retraction. Ambroise Pare (1509-1590)- 1st person to grasp blood vessels with a pinching instrument that was the predecessor of the hemostat used today American Civil War (1861-1865) - trademark of this period were amputations - In some instances, amputations were performed on kitchen tables with heavy knives and Classification of instruments instruments. Even tables forks were used as Cutting and Dissecting retractors. Grasping and Holding Clamping and Occluding 18th-19th centuries Exposing and Retracting - surgical tools were made by skilled silversmiths, Suturing and Stapling coppersmiths, and woodworkers. some Viewing instruments handles were made of ivory, bone, Suctioning and Aspirating or wood with velvet cases Dilating and Probing Accessory Instruments 20th Century: - instruments are made entirely of metals such as CUTTING & DISSECTING carbon steel, silver, and brass, and the velvet - Have sharp edge case was replaced by sterilizer trays. - use to dissect, incise, separate, and excise tissues - should be protected during cleaning, 1900s sterilization, and storing; - development of stainless steel from Germany, - should be kept separate from other instruments Sweden, France, England, Pakistan, and United and demand careful handling at all times States - made of titanium, cobalt-based alloy (Vitallium), Scalpels stainless steel or other metals - made of brass and the blade is made of carbon - Stainless steel: alloy of iron, chromium and steel; carbon. It may also contain nickel, manganese, - most frequently used has a reusable handle  - may also be available in disposable type Metzenbaum scissors (Metz)- used to cut Handle # 3, 7, 9 – Blade # 10, 11, 12, 15 delicate tissue; also known as tissue or operating scissor Straight MAYO scissors (Suture scissors)- used to cut sutures and supplies; also known as suture scissor Handle # 4 – Blade # 20, 21, 22, 23 ○ Blade # 10- most frequently use; has a rounded cutting edge along one side Curved MAYO scissors- available in regular ○ Blades # 20, 21, 22- have the same and long sizes. used to cut heavy and tough shape but larger tissues (fascia, muscles, uterus, breast) ○ Blade # 11- straight edge that comes to a sharp point; known as the stab knife ○ Blade # 12- shaped like a hook with the cutting edge on the inside curvature Blade # 15- has a smaller and shorter Wire scissors (stitch)- have short, heavy blades; curved cutting edge than no. 10 blade used instead of suture scissors to cut stainless Blade # 23- has a curved cutting edge steel scissors; heavy wire cutters are used to cut that comes to more of a point than nos. bone fixation wires. 20, 21, and 22 Dressing / Bandage scissors- used to cut drains and dressings and to open items such as plastic packets - bandage is used to cut the uterus and umbilicus during CS operation Knives - comes in various sizes and configuration - usually have a blade at one end and the blade have one or two cutting edges - some have detachable Sharp Dissectors- includes biopsy forceps and punches, Scissors curettes (has a sharp edge with loop, ring or scoop on the - blades of the scissors maybe straight, angled or end), snares ( loop of wire may be put around a pedicle curved, pointed or blunt at the tips, and the to dessert tissue such as a tonsil handles maybe long or short; - used only to cut or dissect tissues  Babcock Forceps- maybe used in fallopian tube - The end of each jaw is rounded to fit around a structure or to grasp tissue without injury. GRASPING AND HOLDING Tissue Forceps - used often in pairs, to pick up or hold soft tissues and vessels Stone Forceps - Used to grasp calculi such as kidney stones or gallstones - either curved or straight forceps - have blunt loops or cups at the end of the jaw Thumb Forceps/smooth, non toothed forceps- used to hold delicate tissues; are tapered with serrations at the tip; maybe straight or angled, short or long and delicate or heavy. Tenaculum- curved or angled points on the ends of the jaw penetrate tissue - May have single tooth or multiple teeth (dilatation & curettage) Toothed/ pick up/ Rat tooth Forceps- have a single tooth on one side that fits between two teeth on the opposing side; use to hold tough tissues - Allis Forceps- has a scissor action. Each jaw curves slightly inward with a row of teeth at the end; - holds tough tissue gently but securely Bone Holders- - includes vice-grip, pliers and other types of heavy holding forceps use to stabilize the bone  Crushing Clamps- used to crush tissues or clamp blood vessels; - fine tips are used for small vessels and structures while longer and sturdier jaws are needed for larger vessels, dense structures and thick tissues CLAMPING AND OCCLUDING Hemostatic forceps - Usually have two opposing serrated jaws that are Kocher or Ochsner Forcep- usually used in stabilized by a box lock and controlled by ringed colon surgery; for placing cardiac wires when handles performing sternotomy - When closed, the handles remain locked on ractchets - most commonly used surgical instruments - used primarily to clamp blood vessels - either straight or curved slender Non-crushing Vascular Clamps - used to occlude peripheral or major blood vessels temporarily - minimizes tissue trauma - jaws, either straight curved or S shaped, have opposing rows of finely Crile / Stet / Tag Forceps- for shallow layers of tissues EXPOSING AND RETRACTING Handheld or Non self-retaining Retractors - usually used in pairs and held by the first or second assist; Kelly Forceps: for deep layers of tissues or - Some have blades on one end, either curved or cavity angled, dull or sharp while some have blade on both ends - used by the assistant surgeon - used to pull soft tissue and muscle aside to expose surgical site Army-navy retractor - abdominal operation  - some holding devices have 2 or more blades that can be inserted to spread the edges of incision and hold them apart - Balfour abdominal retractor - Bladder retractor Deaver retractor -for deeper retraction Harrington Retractor - to protect the organ; minimizes the trauma SUTURING OR STAPLING Needle Holder- - used to grasp and hold curved surgical needles - resembles hemostatic forceps but the basic difference is the jaws Single end richardson retractor - used in - has a short, sturdy jaws for grasping a needle cesarean section without damaging it or the suture material. - the size of the needle holder should match the size of the needle - either long or short, with serrations on jaws, some are non - the higher the number, the smaller the needle Goulet retractor - intended for the abdominal procedure Tungsten Carbide Jaws - jaws with an insert of solid tungsten carbide with diamond cut precision teeth designed to eliminate twisting and turning if the needle in the needle holder; Malleable ribbon retractor (straight, thin, - can be identified by the gold plating on bendable) the handles - intended for handling needles Self – retaining Retractors - May have shallow or deep blades, some have ratchets or spring locks to keep the device open, while others have wings to secure the blades;  Smooth jaws needle holder- needle holders that Ear speculum- is like used to visualize the have jaws without serrations which are used for inner parts of the nose small needles like in plastic and microsurgery Castroviejo Needle Holder - intended for Endoscopes- made of a round or oval sheath that is sutures; for smaller needles; blood vessel repair inserted into a body orifice or through a small skin incision - used for viewing in specific anatomic locations Staplers- available in reusable and disposable type SUCTIONING AND ASPIRATING Suction- is the application of pressure to withdraw blood or fluids, usually for visibility at the surgical site; - made of style tip and sterile tubing; - style of the suction tip depends where it is to be used and the surgeon’s preference VIEWING INSTRUMENTS Speculum- has a hinged, blunt blessed that enlarges and holds a canal open such as the vagina Poole Abdominal Tip- straight hollow tube with a perforated outer filter shield that prevents the adjacent tissues from being pulled into the Nasal speculum- funnel like and used to suction apparatus visualized the inner parts of the nose - used during abdominal laparotomy or within any cavity in which copious amount of fluid or pus are encountered  Frazier Tip Suction- right angle tube with a small diameter - used when little or no fluid except Cannula - has a blunt end and perforations capillary bleeding an irrigating fluid is around the tip to aspirate fluid without cutting encountered such as brain, spinal, into tissues; plastic, and ortho procedures - also used to open blocked vessels or - keeps the field dry without the need for ducts for drainage or to shunt blood flow sponging from the surgical site DILATING AND PROBING Yankauer Tip - hollow tube that has an angle of Dilators- used to enlarge orifices and ducts mouth; connected is connected to rubber tubing; Hegar Dilators used in tonsillectomy Aspiration - done manually to obtain a specimen (blood, Probes- used to explore a structure or to locate an body fluid, or tissue for lab examination); also used for obstruction bone marrow aspiration (BMA) - Aspirating tube is a long straight tube used through an endoscope Trocar- has a sharp cutting edge at the end of a ACCESSORY INSTRUMENTS hollow tube intended to cut through tissues for Mallet- used to strike bones access to fluid or a body cavity. Used for bone marrow and laparoscopy - has a fitted blunt and end cannula inside to keep fluid or gas from escaping until the cannula is removed. Screwdrivers - for plating b. Microsurgical, ophthalmic and other delicate instruments are vulnerable to damage through rough handling. c. Metal to metal contact should be avoided or minimized 2. Inspect instruments such as scissors and forceps for alignment, imperfections, cleanliness and working condition a. Blades must be properly set b. Exact alignment of teeth and serrations is necessary Categories of Instruments c. Set aside or remove any defective A. Sharps instruments B. Grasping and Holding 3. Sort instruments neatly by classifications C. Clamping andOccluding 4. Keep ring - handled instruments together, with D. Retractors curvatures and angles pointed in the same direction. HANDLING OF INSTRUMENTS BEFORE a. Hang ring handles over a rolled towel or SURGICAL PROCEDURE over the edge of the instrument tray or 1. Scrub nurse should be the one to prepare the container instrument on the mayo and back table. Avoid b. remove instrument pins or holders if preparing the instruments by wearing only used box locks open sterile gloves. Prepare with complete PPE c. close box locks on the 1st ratchet 2. Uncovered, exposed instruments are never 5. Leave retractors and other heavy instruments in transported through corridors. a back table 3. The scrub nurse should not go beyond the 6. Protect sharp blades, edges and tips. They confines of the room. should not touch anything 4. Scrub and circulating nurses should count the a. some orthopaedic instruments can instruments, sharps and spongers; they must be remain in the racks during the initial accounted for throughout every procedure. table set up and until they are needed during the surgical procedure Counting Procedure- is a method of accounting for b. Tip: Protective covers or instrument items put on the sterile table for use during the surgical plastic sleeves should be left on until the procedure instrument is actually used. - sponges, sharps and instruments should be c. If they are not in a rack or tip guard, counted on all procedures. support handles on a rolled towel or - counting ensures the expensive instruments like gauze sponge to keep blades and tips of towel clips and scissors are not accidentally micro instruments suspended in mid air. thrown away with the drapes - counts are also performed for infection control HANDLING OF INSTRUMENTS DURING and inventory control purposes SURGICAL PROCEDURES In passing an instrument to the surgeon: KEY POINTS IN HANDLING INSTRUMENTS 1. Know the name and use of each instrument 1. Handle loose instruments separately to prevent interlocking or crushing 2. Handle instruments individually a. Never pile one instrument on top of another on an instrument table; lay them 3. Hand the surgeon or assistant the correct side by side instrument for each particular task. Principle “use for intended purpose only”  a. avoid placing fingers in the ring handle 6. Wipe the blood and organic debris off the as the instrument is passed instrument promptly after each use with a moist b. Many surgeons use hand signals to sponge. indicate the type of instrument needed. a. dried blood and debris on instrument An understanding of what is taking surface like in box lock and in crevices, place at the surgical site makes the increased bioburden signals meaningful. b. use demineralized sterile distilled water c. Select appropriate instruments for in wiping the instruments saline/other location of surgical site; shorty solution can damage surfaces instruments for superficial work and c. a non fibrous sponge should be used to long ones for deep in a body cavity. wipe microsurgical, ophthalmic and Experience will facilitate instrument delicate tip instruments. This can selection according to the surgeon’s prevent snagging and breaking of preference and need. delicate tips. d. Many instruments are used in pairs or in sequence. 7. Flush the suction tip and tubing with sterile distilled water periodically to keep the lumens 4. Pass the instrument decisively and firmly. when patient. Keep a tally of the amount of fluid used passing a curved instrument, the curve of the to clear the suction line and deduct this amount instrument aligns with the direction of the curve from the total used to irrigate the surgical site. of the surgeon's hand (palm) This is to have an accurate accounting of blood In passing an instrument to the surgeon: loss from the operation. If the surgeon is on the opposite side of the table, pass across the right hand to 8. Remove debris from electrosurgical tips to the right hand or with the left hand to a ensure electrical contact. Disposable abrasive tip left-handed surgeon. cleaners are helpful for maintaining the If the surgeon or assistant is on the same conductivity and effectiveness of the surface of side of the table and to the right, pass the tip. Avoid using the scalpel blade because with your left hand; if the surgeon is to the debris may become airborne and your left, pass with your right hand. contaminate the surgical field. Hemostatic forceps are held near the box lock by the scrub persona and 9. Place used instrument not needed again into a passed by rotating wrist clockwise to tray or basin during or at the end of the surgical place the handle directly into the procedure surgeon.. a. Blood and gross debris must be removed if the surgeon or assist is on the same first side of the abele and to the right (pass b. Careless dropping, tossing or throwing with your left hand) of instrument into a basin is highly sharp and delicate instrument placed on prohibited a flat surface for the surgeon to pick up. c. Keep instruments accessible for final to avoid the potential contact with items counts such as blades, sharp points. d. Bloody instruments should not be soaked in a basin of solution for a 5. Watch the sterile field for loose instruments. prolonged period. Instruments that have remove them promptly after use to the mayo been wiped can be immersed in a basin table. The weight of the instrument can injure of sterile demineralized distilled water, the px or cause post-op. NOT SALINE SOLUTION, NaCl in saline solution and blood is corrosive. e. Never place heavy instruments like retractions on top of tissue and  hemostatic and other clamps. Place crevices. This is effective in a wide range of them in a separate tray. water qualities. - Water with a low-sudsing, near-neutral detergent HANDLING OF INSTRUMENTS AFTER - Plain, clean, demineralized distilled water SURGICAL PROCEDURE - Liquid detergents are preferred. All instruments on the mayo and back tables, whether used or unused are considered contaminated and DON'Ts: should be promptly and properly be cleaned, inspected, BLEACH - corrosive solution should not be terminally sterilized and prepared for subsequent use. used 1. Check all the drapes, towels and table covers to CHLORINE COMPOUNDS be sure that no instruments will go to the laundry IODOPHOR - soaking should not exceed 1 hour or into the trash. A final quick count is a safeguard. Washing- done to remove residual blood and debris 2. Collect all the instruments from the mayo, back before terminal sterilization or high level disinfection. table and other small tables including those have 1. Clean, warm water with noncorrosive, low been dropped or passed off the sterile field. sudsing, free rinsing detergent. 3. Separate delicate, small instruments and those with sharp and semi sharp edges for special Regardless of the water content, the detergent handling. should be anionic or nonionic with a pH close 4. Disassemble all instruments with parts to expose to neutral. all surfaces for cleaning. Alkaline detergent (pH over 8.5) will 5. Open all hinged instruments to expose box locks stain instruments and serrations. Acidic detergent (pH below 6) will 6. Separate instruments of dissimilar metals. Clean corrode or pit the instruments. the instruments per type to prevent electrolyte 2. Wash instruments carefully to guard against deposition of other metals. splashing and creating aerosols. 7. Flush with cold distilled water through hollow Use a soft-bristled brush to clean instruments or channels like suction tips or serrations and box locks. endoscopes to prevent drying of organic debris. Keep instruments submerged while 8. Rinse off blood and debris with demineralized brushing to minimize aerosolizing distilled water or any enzymatic detergent microorganisms solution. Use a soft cloth to wipe surfaces or a 9. Follow procedures for preparing the instruments non-fibrous cellulose sponge to prevent for decontamination or terminal sterilization. damage to delicate tips. Procedure varies depending on the type of Remove bone, tissue and other debris instrument and its components and the from cutting instruments. equipment available and its location. Never scrub surfaces with steel wool, wire brushes, scouring pads or powders DECONTAMINATION PROCESS OF to protect the protective finish on metal INSTRUMENTS (this protects the base metal from 1. Pre rinsing or presoaking oxidation) 2. Washing Rinsing 3. Rinsing Use hot distilled or deionized water in rinsing; - 4. Sterilizing Should be done thoroughly to avoid staining the instruments. Pre rinsing / Pre soaking- done to prevent blood and After rinsing, put instruments back into debris from drying on instruments or to soften and sterilization racks or trays remove dried blood and debris. Arrange instruments that can be steam sterilized - Proteolytic Enzymatic Detergent dissolves blood in a decontaminator. and protein and removes dissolved debris from Sterilizing 13. Distribute weight as evenly as possible in the The sterilizing agent must come in direct contact tray. Some trays have dividers, clips and pins with all surfaces of every instrument. attached to the bottom of the tray so as to Instruments should be packed, individually or in prevent the instruments from shifting and keep sets to allow adequate exposure to sterilant, to them in alignment. prevent air from being trapped and moisture 14. Place a chemical indicator on the outside from being retained during the sterilization wrapper or container as well as inside the tray. process, and to ensure sterile transfer to the 15. Label appropriately for intended use including sterile field. the name of the instruments or set, date Instruments are put in a container or tray, or sterilized, name of the person who packed the wrapped in a small set or individually, for instruments and the control number sterilizing and transporting. Instruments may be sterilized unwrapped immediately before use in Handling Powered Instruments a high speed pressure sterilizer, they may be Electrically powered instruments like saws, prepared in advance as for a case cart, or drills, dermatomes, nerve stimulators retained in storage until needed. Air powered instruments are small, lightweight, free of vibration and easy to handle Steps in Assembling Instruments Sets in Sterilizer for pinpoint accuracy at high speeds 1. Make sure instruments are thoroughly dry. Battery powered instruments are cordless with 2. Place an absorbent towel or foam in the bottom rechargeable batteries of the tray to absorb condensate, unless Wipe off any organic debris between uses during contraindicated. the surgical procedures 3. Count the instruments as they are placed in the Accessories are disassembled prior to cleaning tray and record the number on a preprinted form. Do not immerse the motor in liquid. 4. Arrange instruments in a definite pattern to Lubricate as recommended using a silicone oil. protect from damage and to facilitate removal for counting and use. SURGEON’ ARMAMENTUM 5. Place heavy instruments like retractors in the The surgeon relies on surgical instruments to bottom of the tray. enhance his or her skill in the art and science of surgery. 6. Open hinges and box locks on all hinged The nursing staff must ensure that these instruments instruments. function properly and sterilize adequately. Instruments 7. Place sharp and delicate instruments on top of are selected on the basis of safety for their intended use. other instruments. Blades of scissors & delicate They must be inspected, maintained and used tips should not touch other instruments. appropriately. 8. Place concave or cupped instruments with these surfaces down so that water condensate does not collect in them during the sterilization process. 9. Place ring-handled instruments on pins or holders designed for this purpose. Curved instruments should be pointing in the same direction, grouped together by style & classification. Do not use rubber bands because steam cannot penetrate through or under bands. 10. Disassemble all detachable parts. Secure properly the small parts. 11. Separate dissimilar metals like brass instruments from stainless steel instruments. 12. Place instruments with a lumen like suction tip in as near a horizontal position as possible.  Module 1.4 Pre, Intra, Post Operative Care c. Patient skin should be cleansed prior to PREOPERATIVE PREPARATION OF THE operation using an antimicrobial soap for several PATIENT days pre op. Laboratory & Physiological Preparation Wash face, ear, neck, and shampoo the Medical history and physical examination- done by hair physician Male patients have to cut their hair short and shave on the day of the operation. Laboratory tests- ordered by the surgeon and should be completed 24 hours before admission so results will be d. Nail polish and acrylic nails should be removed available for review. to permit observation of oxygenation and H & H, BUN (liver & kidney function test), circulation (capillary refill test) Blood Glucose- routine for 60 y.o. up Oxisensor of pulse oximeter Hematocrit Nail bed is a vascular part CBC, Platelet count, Prothrombin time Blood typing and crossmatch e. Leave jewelries and all valuables at home. Metal Urinalysis and/or Fecalysis jewelries like wedding bands must be removed to prevent burns if electrosurgery will be used. Radiologic tests Chest X-ray- not all but required to patient with f. Other instructions of what to expect before, cardiac or pulmonary disease, smokers, cancer during and after operation– explained by the patients, and persons with 60 y/o and older. surgeon When to arrive in the hospital for ECG- routine to patients with cardiac disease and admission persons of 40 y/o and up. Where the immediate family will stay and wait before and after the operation Diagnostic procedures- performed when specifically indicated, like in vascular surgery. INFORMED CONSENT Informed Consent- should be facilitated by the surgeon Written instructions- will come from the surgeon and and follow-up by the nurse; the surgeon explains the should be reviewed and followed by the patients before surgical procedure and the risks to the patient. admission. Prognosis a. Should not ingest solid foods preceding the Management operation to prevent aspiration and regurgitation Quality of life or emesis. “NPO after midnight” Informed Consent Solid foods- will take 12 hours before it - Is a legal document that provides evidence of empties the stomach patient’s agreement to allow a procedure to be Clear liquids- maybe unrestricted until 2 performed on him/her; to 3 hours before the operation but still - A signed consent is legally regarded as VALID depends on the discretion of the surgeon for a period of about 6 months or for as long as and anesthesiologist. the patient consents to the same procedure. Less time of NPO- infants, small Institutional policy may vary. children, diabetic and elderly patients prone to dehydration. Purposes of Informed Consent 1. It provides a mechanism to protect a patient’s b. Oral medications- can be taken with minimal right to self-determination regarding surgical fluid intake up to 1hour pre op as prescribed intervention; with 150ml or less of water. 2. It provides a means by which the patient can make an educated choice about having a procedure performed. General Consent making certain that the patient or legal guardian - This form authorizes the physician and the adequately understands everything. hospital staff to render treatment or perform 3. Consent should contain the following: procedures as the physician deems advisable. Patients full name (maiden name) - This is relied on ONLY for routine duties Surgeon’s full name performed in the hospital. Complete and specific procedure to be - Nurses should be knowledgeable about the performed statements on the form used in their hospital. Signature of the patient Complete name of authorized witness Surgical Consent Date and time of signature - Specifically outlines each procedure to be 4. Every patient is entitled to receive the sufficient performed and explains the risks and benefits; information to be performed on him/her. They - Should answer the following patient question: have the right to waive an explanation of the a. What do you plan to do to me? nature and consequences of the procedure. They b. Why do you want to do this procedure? have the right to decide what will and not be c. Are there any alternatives to this plan? done. Only after making this decision is the d. What things should I worry about? patient asked for a signed written consent for e. What are the greatest risks or the worst operation. thing that could happen? 5. The patient has the right to refuse the treatment. - Is required for: 6. Consent should be signed by the patient before a. Each surgical procedure to be performed premedication and before going to the OR including secondary procedures like I & except in life threatening emergency situations. D; 7. There should be a WITNESS verifying the b. Any procedure for which a general consent was signed without consent. anesthetic agent is administered such as an examination of a child under Who should Sign the Consent? anesthesia; 1. Should be of legal age c. Procedures involving entrance into a 2. Should be mentally competent body cavity such as endoscopy; 3. An emancipated minor, married or d. Any hazardous therapy such as radiation independently earning a living 4. Illiterate may sign with an “X” after Purposes of Surgical Consent which the witness writes “patient’s 1. To ensure that the client understand the nature of mark” the treatment including the potential complication and disfigurement; Who should not Sign the Consent? 2. To indicate that the client’s decision was made 1. A minor without pressure; 2. Unconscious 3. To protect the client against unauthorized 3. Mentally incompetent procedures; 4. To protect the surgeon and hospital against legal *PARENT/LEGAL GUARDIAN/NEXT of KIN action by the client. *SURGEON- should not sign the consent in behalf of the patient Guidelines of Consent 1. ONLY the surgeon assigned is responsible to Consent in Emergency Situation inform the patient about the proposed procedure, Consent in an emergency situation is its interest. Risks, complications and what the desired but not essential. Although every effort patient may expect during and after the should be made to obtain the consent, the operation; patient’s physical condition takes precedence 2. Complete explanations should be given to the over a permit. patient and the surgeon is responsible for  Permission for a life saving procedure in ○ fear of permanent disability a minor may be accepted from a legal guardian ○ fear of pain - fear of dying by TELEPHONE, TELEGRAM, or WRITTEN COMMUNICATION. Skin Preparation of Patient Purpose of Skin Preparation: If obtained by telephone, two nurses To render the surgical site as free as possible from should monitor the call and sign the form, which transient and resident microorganisms, dirt and skin oil is signed later by the parent on arrival at the so the incision can be made through the skin with hospital. In lieu of these methods, a written minimal danger of infection from this source. consultation by two physicians other than the surgeon will suffice until a relative can sign a Hair removal is necessary especially if the hair consent. surrounding the surgical site is so thick ; it interferes with exposure, closure and dressing ; it prevents 8. Pre-operative visit of the Perioperative Nurse. adequate skin contact with electrodes. 9. Pre-operative visit by the Anesthesiologist or Clipper - available in electric type or cordless Nurse handle with rechargeable batteries. Anesthetist – an interview will be - Electric clippers with fine teeth cut hair conducted before admission with close to the skin. patients who have complex medical - Clipping can be done immediately histories are high risk or have high before the surgical procedure or up to 24 degrees of anxiety. hours preoperatively using short strokes against the direction of hair growth. PREOPERATIVE PREPARATIONS EVENING BEFORE THE ELECTIVE SURGERY Depilatory Cream - Skin testing should be done PROCEDURE first for possible allergies. - Should not be used 1. GIT Preparation (Bowel Preparation) around the eyes and genitalia. - Should be “Enemas till clear” may be ordered. applied on the skin, wait for 20 minutes before Golytely or Colyte normally clear the washed off. bowel in 4 to 6 hours 2. Douche- used to cleanse the vagina during Razor - shaving should be done as near the time vaginal and pelvic procedures. of incision as possible if this method must be - Patients who will be admitted the day of used. the surgical procedure may be instructed - Wear gloves when shaving with razor to to self administer enema or douche at prevent cross contamination even home. though this is a surgically clean 3. Hair removal/preparation of shaving procedure 4. Bedtime sedation for sleep Skin Preparation for Different Surgeries Psychological Preparation Chest Surgery Fears related to surgery - For chest surgery, the skin is shaved and General fear cleansed on the affected side from mid hip over ○ fear of the unknown the shoulder, including the axilla, to the shoulder ○ what to expect and what are the on the unaffected side. consequences of surgery ○ Nursing action: allay anxieties by Retroperitoneal Surgery giving the patient opportunities to - For rectal surgery, support the legs and thighs in express his/her fears the lithotomy position. Shave the pubic, Specific fears perineal, thigh, and anal areas (in a radius of ○ fear of destruction of body image about 10 inches from the anus). ○ threat to sexuality Vaginal Surgery INTRAOPERATIVE PREPARATION OF THE - For gynecological surgery (perineal prep) PATIENT support legs and thighs in the lithotomy position Nursing Care Plan and shave the anterior surface from the Assessment umbilicus down: the pubic area, the external Assess respiratory status, including history of genitalia, the perineum, including the area pulmonary problems to identify risk factors for around the anus, and the buttocks. Shave inner postoperative complications. thighs halfway to the knees from the middle of Assess for and report evidence of F/E imbalance anterior to middle of posterior thighs. Assess emotional status of client. Examine the client’s record for endocrine or Surgery of the Limbs metabolic problems that could affect his - For surgery of the limbs, the area includes the response to surgery (DM). entire circumference. The extent of the prep Assess immunologic and hematologic functions varies depending upon the type of operation. As history of allergies previous reactions to blood an example, for surgery of the hand, the prep transfusions history of substance abuse Assess would normally extend distally from the elbow. neurologic functions. A manicure or pedicure is also necessary. Assess integumentary system Evaluate Fingernails or toenails must be clipped short, medication history for drugs that could increase cleaned, and scrubbed. operative risk for affecting coagulation time or interacting anesthetics. Skin Marking Assess the client for any type of prosthetic Surgeons use a staining solution to mark the incision device or metal implants. lines on the skin. This may be done before the patient is Assess the client and his family’s knowledge prepped. base to guide the preoperative teaching program. Assess the laboratory and diagnostic results of If the skin is marked after prep, a sterile dye solution and the patient (x-ray, cbc, wbc, etc.) applicator or a sterile marking pen must be used. - Methylene Blue or Alcoholic Gentian Violet Nursing Diagnosis Pre-operative Health Teachings Anxiety Post-op exercises Knowledge deficit Equipment used during post-op period ○ oxygen, pulse oximeter, CVP Planning and Outcome Identification ○ ventilator Major Goals: ○ NGT Decreased anxiety and increased knowledge of ○ IV medications the surgical experience. ○ Foley catheter Promote measures that help decrease anxiety for Provide client and family teaching, instruct the the client and his family. client in: ○ relaxation technique ANESTHESIA ○ deep breathing and coughing exercises Definition of Anesthesia ○ Post op Exercises of extremities turning - branch of medicine that is concerned with the and moving techniques administration of medication or anesthetic ○ pain-control techniques agents to relieve pain and support physiologic ○ Incentive spirometry use function during a surgical procedure - is a specialty that requires knowledge of biochemistry, clinical pharmacology, cardiology and respiratory physiology. - the practice of medicine dealing with management of procedures for rendering a  patient insensible to pain during surgical movements of extremities, susceptible to stimuli procedures and with support of life functions like noise and touch. under the stress of anesthetic and surgical - patient is not to be stimulated during this stage manipulations. (accdg. to ABA). and restrain the patient - Nurse’s responsibility: Make sure that the straps Terminologies are on for safety purposes Amnesia – loss of memory; an indifference to pain Stage III – Stage of Surgical Anesthesia (Stage of Analgesia – lessening of or insensibility to pain Relaxation) Anesthesia – loss of feeling or sensation, esp. - extends from the loss of lid reflex to the loss of loss of the sensation of pain with loss of most reflexes. protective reflexes - surgical procedure is started Analgesic – drug that relieves pin by altering - there is regular respiration, contracted pupils, perception of painful stimuli without producing reflexes disappear, muscles relax, lost auditory loss of consciousness sensation. Anesthetist – person who administers anesthesia Anesthesiologist – doctor of medicine who Stage IV – Danger Stage specializes in the field of anesthesia - characterized by respiratory & cardiac Anoxia – absence of oxygen depression or arrest. It is due to an overdose of Apnea – suspension or cessation of breathing anesthesia. Fasciculation – uncoordinated skeletal muscle - resuscitation must be done contraction in which groups of muscle fibers - not breathing, little or no pulse or heartbeat innervated by the same neuron contract together. - resuscitation equipments and materials must be Induction – period from beginning of ready at within reach administration of anesthetic until patient loses consciousness and is stabilized in the desired Pre-anesthetic Premedication plane of anesthesia. Maybe given to allay preoperative anxiety, produce Emergence – return of sensation and reflexes; to some analgesia and amnesia and dull awareness of the regain consciousness following general OR environment. anesthesia. Intubation – insertion of endotracheal tube Reasons: Extubation – removal of endotracheal tube 1. Reducing the risk of nausea and vomiting- Hypnosis – artificially