intraoperative lecture
TRANSCRIPT
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Intraoperative CareMS. LOURADEL MATOL ULBATA, RN, MAN
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Preparing the Patient the Evening Before
Surgery
Preparing the Skin
- have a full bath to reduce microorganisms in the
skin.
- hair should be removed within 1-2 mm of the skinto avoid skin breakdown, use of electric clipper is
preferable.
Preparing the G.I tract
- NPO, cleansing enema as required
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ASA (American Society of Anesthesiologists)
Guidelines for Preoperative Fasting
Liquid and Food Intake Minimum
Fasting Period
CLEAR LIQUIDS 2
BREASTMILK 4
NONHUMAN MILK 6
LIGHT MEAL 6
TEGULAR/ HEAVY MEALS 8
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Preparing for Anesthesia
- Avoid alcohol and cigarette smoking for at
least 24 hours before surgery.
Promoting rest and sleep
- Administer sedatives as ordered
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PREOPERATIVE MEDICATIONS
Goals:
To aid in the administration of an anesthetics.
To minimize respiratory tract secretion andchanges in heart rate.
To relax the patient and reduce anxiety.
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Commonly used Preop Meds.
Tranquilizers & Sedatives
* Midazolam
* Diazepam ( Valium )* Lorazepam ( Ativan )
* Diphenhydramine
Analgesics
* Nalbuphine ( Nubain )
Anticholinergics
* Atropine Sulfate
Proton Pump Inhibitors
* Omeprazole ( Losec )
* Famotidine
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Transporting the Patient to the OR
Adhere to the principle of maintaining the comfortand safety of the patient.
Accompany OR attendants to the patients bedside
for introduction and proper identification.
Assist in transferring the patient from bed to
stretcher.
Complete the chart and preoperative checklist.
Make sure that the patient arrive in the OR at theproper time.
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Patients Family
Direct to the proper waiting room.
Tell the family that the surgeon will probably contact
them immediately after the surgery.
Explain reason for long interval of waiting:
anesthesia prep, skin prep, surgical procedure, RR.
Tell the family what to expect postop when they see
the patient
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Intraoperative Phase
Transfer onto the operating table
Phases of anesthesia
Operative procedure Transfer from operating table to stretcher
Safe transport to post-operative area (PACU)
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LOCATION
The OR suite is usually located in an area
accessible to the critical care surgical
patient areas and the supportive service
departments, the pathology department,and the radiology department. A terminal
location is necessary to prevent unrelated
traffic from passing through suites. Blood
bank is an important factor.
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SPACE ALLOCATIONS AND TRAFFIC
PATTERNS
Space is allocated within the OR suite to provide forthe work to be done, with considerations given tothe efficiency within which it can be accomplished.
The OR suite should be large enough to allow forcorrect technique yet small enough to minimize themovements of the patient, personnel and supplies.
Provision must be made for traffic control. The typeof design will predetermine traffic patterns. Allpersonsstaff, patients, and visitorsshould followthe delineated patterns in appropriate time.
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Surgical Environment
Unrestricted Area
- provides an entrance and exit from the surgical
suite for personnel, equipment and patient
- street clothes are permitted in this area, and the
area provides access to communicationwith personnel
within the suite and with personnel and patientsfamiliesoutside the suit.
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Surgical Environment
Semi-restricted Area
- provides access to the procedure rooms and
peripheral support areas within the surgical suite.
- personnel entering this area must be in properoperating room attire and traffic control must be
designed to prevent violation of this area by
unauthorized persons
- peripheral support areas consists of: storage areas
for clean and sterile supplies, sterilization equipment
and corridors leading to procedure room
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Surgical Environment
Restricted Area
- includes the procedure room where surgery is
performed and adjacent substerile areas where the
scrub sinks and autoclaves are located
- personnel working in this area must be in proper
operating room attire
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VESTIBULAR OR EXCHANGE AREAS
POST-ANESTHESIA CARE UNIT (PACU)
The PACU may be outside the OR suite, or it may be adjacent to thesuite so that it may be incorporated into the unrestricted areas withaccess from both the semi-restricted area and an outside corridor.In the latter design, the PACU becomes a vestibular area for thedeparture of patients.
DRESSING ROOM AND LOUNGES
Dressing room must be provided for both men and women tochange from street clothes into OR attire before entering the semi-restricted area, and vice versa. Lockers are usually provided. Doorsseparate this area from lavatory facilities and adjacent lounges.
PERIPHERAL SUPPORT AREASAdequate space must be allocated to accommodate the needs ofthe OR personnel and support services.
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VESTIBULAR OR EXCHANGE AREAS
CONFERENCE ROOMS/CLASSROOM- A conference or a classroom is located within the semi-restricted area. This is used for patient care staff in cervicalstaff for teaching.
SUPPORT SERVICE- The size of the health care facility and the types of servicesprovided, determine whether laboratory and radiologyequipment is needed within the OR suite.
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VESTIBULAR OR EXCHANGE AREASLABORATORY
A small laboratory where the pathologist can examine tissue and performfrozen sections expedites the decisions that the surgeon must make during asurgical procedure when diagnosis is questionable. A refrigerator for storing bloodfor transfusions may also be located in this room.
RADIOLOGY SERVICESSpecial procedure rooms may be outfitted with X-ray and imaging
equipment for diagnostic and invasive radiological procedures or insertion ofcatheters, pacemakers, and other devices.
WORK AND STORAGE AREASClean and sterile supplies and equipment must be separated from soiled
items and trash. If the OR suite has a clean core area, soiled materials should notbe taken into this area.
ANESTHESIA WORK AND STORAGE AREASpace must be provided for the storage of the anesthesia equipment and
supplies. A separate workroom usually is provided for care of anesthesiaequipment. Dirty and clean supplies must be kept separated
V S I ULA O XCHANG A AS
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VESTIBULAR OR EXCHANGE AREAS
HOUSEKEEPING STORAGE AREASCleaning supplies and equipment need to be stored; the equipment
used within the restricted area is kept separated from that used to cleanother areas. Sinks are provided, as well as shelves for supplies. Trash andsoiled laundry receptacles should not be allowed to accumulate in thesame room where clean supplies are kept.
UTILITY ROOMSome hospitals use a closed-cart system and take contaminated
instruments to a central area outside the OR suite for clean-up proceduresin the substerile room. Many, by virtue of the limitations of the physicalfacilities, bring the instruments to a utility room. This room contains awashersterilizer, sinks, cabinets and all the necessary aids for cleaning.
VESTIBULAR OR EXCHANGE AREAS
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VESTIBULAR OR EXCHANGE AREAS
STERILE SUPPLY ROOMhospitals keep a supply of sterile drapes, sponges, gloves, gowns, and other
sterile items ready for use in the sterile supply room within the OR suite. Asmany shelves as possible should be freestanding from the walls, which permitssupplies to be put into one side and removed from the other, thus older packagesare always used first.
INSTRUMENT ROOMThe instrument room contains cupboards in which all clean and
decontaminated instruments are stored when not in use. Instruments usuallyare segregated on shelves according to surgical specialty services.
VESTIBULAR OR EXCHANGE AREAS
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VESTIBULAR OR EXCHANGE AREAS
SCRUB ROOM
- An enclosed area for surgical scrubbing ofhands and arms must be provided adjacent to
each OR suite. It is a restricted area within the
OR suite.
PHYSICAL LAYOUT OF THE OR
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PHYSICAL LAYOUT OF THE OR
OPERATING-ROOM SETUP SHOWING TABLES FOR
INSTRUMENTS AND SUPPLIES DESIGNED TO FACILITATE THEWORK OF THE SURGEON, HIS ASSISTANTS, AND THE NURSES
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PACU (post anesthesia care unit)
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OR suite (operating room-central
Processing area)
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scrub area
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Draped patient andoperating bed
Mayo stand
1st
assistant
Scrub
nurse
Surgeon
Kick
bucket
Instrument table
Electrosurgical
unit
Suction
container
Kick
bucket
Anesthesia
machineAnesthesia
provider
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A. SCIENTIFIC PRINCIPLES INVOLVED IN OR
TECHNIQUE
ANATOMY AND PHYSIOLOGY
adequate knowledge of the human body parts is a prerequisite in being apart of the OR team. [Ex.: epidermis is the term used to designate theouter or surface layer of the skin and the dermis is considered to be thesecond layer. There are sebaceous and sweat glands of the skin. the skinprotects the body tissues against pathogenic microorganisms and injuryfrom mechanical devices.]
CHEMISTRYuse of antiseptics can reduce bacterial count. Excessive use of soap mayharden the skin, as soap is alkaline and removes protecting oils from theskin.
MICROBIOLOGY
Skin protects the body from certain diseases. Handwashing is the most
effective means of conserving ordinary cleanliness for protection of thepatient as well as the nurses.
PHARMACOLOGY
drugs that are used for soothing and reducing irritation of surfaces thathave been abraded or irritated is classified as demulcents. Ethyl alcohol(70%) is an effective solution for disinfection of equipment.
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PSYCHOLOGYthe proper explanation to the patient regarding the
upcoming operation should be established.
SOCIOLOGYhome methods of disinfection and sterilization may be
taught by the visiting nurse. The attitude of theisolated patient whether at home or in the hospitalmay depend on the knowledge of his disease and themanner of its transmission from one person to another.
PHYSICS
the autoclave used for sterilization sterilizes by means ofpressurized steam.
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PRINCIPLESof SURGICAL
ASEPSIS
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Remember the
word
ASEPSIS
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AAlways face thesterile field
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SShould be above
waist level andon top of sterile
field
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EEliminate
moisture thatcauses
contamination
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PPrevent unnecessarytraffic & air current
( close door, minimizetalking dont reach across
sterile field)
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SSafer to assume
contaminated
when in doubt
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IInvolves team effort( collective and
individual sterile
conscience)
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SSterile articles unusedand opened are no
longer sterile afterthe procedure
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Anesthesia
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Anesthesia loss of feeling or sensation, especially loss of the sensation
of pain with loss of protective reflexes.
State of Narcosis
Anesthetics can produce muscle relaxation, block
transmission of pain nerve impulses and suppress reflexes.
It can also temporary decrease memory retrieval and recall.
The effects of anesthesia are monitored by considering the
following parameters:
- Respiration
- O2 saturation / CO2 level
- HR and BP
- Urine output
Types of Anesthesia:
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Types of Anesthesia:
1. General Anesthesia
reversible state consisting of complete loss of
consciousness and sensation.
protective reflexes such as cough and gag are
lost
provides analgesia, muscle relaxation and
sedation.
produces amnesia and hypnosis.
T h i d i G l
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Techniques used in General
Anesthesia A. Intravenous Anesthesia
This is being administered intravenously and extremely rapid.
Its effect will immediately take place after thirty minutes of
introduction.
It prepares the client for smooth transition to the surgical
anesthesia.
B. Inhalation Anesthesia This comprises of volatile liquids or gas and oxygen.
Administered through a mask or endotracheal tube
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Induction of General Anesthesia:
Preoxygenation
the anesthesia provider may have the patient breath pure (100%)oxygen by facemask for a few minutes. This provides a marginof safety in the event of airway obstruction or apnea duringinduction, with resultant hypoxia.
Loss of Consciousnessunconsciousness is induced by IV administration of a drug or by
inhalation of an agent mixed with oxygen. Because thetechnique is rapid and simple, an IV drug usually is preferredby anesthesia providers and often is requested by patients.
Intubation
a patent airway must be established to provide adequateoxygenation and to control breathing of the unconsciouspatient. The patients tongue and secretions can obstructrespiration in the absence of protective reflex.
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ANESTHESIA MACHINE
General Anesthesia is maintained by
inhalation of gases and IV injection of drugs.
An anesthesia machine is always used to
deliver oxygen-anesthetic mixtures to thepatient through a breathing system.
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S S C i l d
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ANESTHESIA MACHINE includes:
Sources of oxygen and gases with flowmeters for measuring and controlling theirdelivery
Devices to volatilize and deliver liquidanesthetics
Gas-driven mechanical ventilator
Devices for monitoring the ECG, BP, inspiredoxygen, and end-tidal carbon dioxide
Alarm systems
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ANESTHESIA MACHINES have the following
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g
features:
Sources of oxygen and compressed gases.
Means for measuring and controlling delivery
of gases.
Means to volatilize liquid and deliver
anesthetic vapor or gas.
Device for disposal of Carbon Dioxide
f i
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Safety Devices:
Oxygen analyzers
Oxygen pressure interlock system End-tidal carbon dioxide monitors
Pressure and disconnect alarms to notify the
anesthesia provider if the flow of oxygen and
gases becomes disproportional
Pin-index safety system to release excess gases
Gas scavenger system to collect exhaled gases
Physiologic indicators of a difficult airway include the following:
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Physiologic indicators of a difficult airway include the following:
~ Inability to open mouth. Patients with previous jaw surgery may havejaw wires in place. Wire cutters should be immediately available in
the event of a return to surgery.~ Immobility of the cervical spine. Patients with vertebral disease or
injury may not have full range of motion necessary for intubation.
~ Chin or jaw deformities. Patients with small jaws or chin may have adifficult airway. Edentulous patients commonly have some bone loss
that alters facial contours.~ Detention can be an issue if the patient has loose teeth or periodontal
disease. A tooth can be aspirated during the airway maintenanceprocess.
~ Short neck or morbid obesity.
~ Pathology of the head and neck such as tumors or deformity. Anenlarged tongue can be an obstruction to a full view of the glottis.
~ Previous tracheostomy scar, which can cause a stricture.
~ Trauma.
D th f G l A th i
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Depth of General Anesthesia
From To Patients
Responses
Patient Care
Considerations
Induction of generalanesthesia andbeginning of inhalantand/ or IV drug
Begins to loseconsciousness; willhave recallBispectral state 100
Drowsy, dizzy,amnesic
Close OR doors. Keeproom quiet. Stand byto assist. Initiatecricoid pressure if
requested.
Loss of consciousness;excitement phase
Relaxation, lighthypnosis; low
probability of recallBispectral state 70 to50
May be excited withirregular breathing
and movements ofextremities;susceptible to externalstimuli (e.g., noise,touch)
Restrain patient.Remain at patients
side, quietly, butready to assistanesthesia provider asneeded.
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Surgicalanesthesia stageof relaxation
Loss ofreflexes:depression ofvital functionsBispectral state40:maintenancerange
Regularrespiration;contractedpupils; reflexesdisappear;muscle relax;auditorysensation lost
Position patientand prepareskin only whenanesthesiaproviderindicates thisstage isreached andunder control.
Danger stage:vital functionstoo depressed
Respiratoryfailure; possiblecardiac arrest
Bispectral state0
Not breathing;little or nopulse or
heartbeat
Prepare forcardiopulmonaryresuscitation.
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Most Commonly Used General Anesthetic AgentsGeneric Name Trade Name Administration Characteristics Uses
INHALATION
AGENTSNitrous oxide None Inhalation Inorganic gas;slight potency;
pleasant, fruitlike
odor;
nonirritating; non-
flammable but
supports
combustion; poormuscle relaxation
Rapid inductionand recovery;
short procedures
when muscle
relaxation
unimportant;
adjunct to potent
agents
Halothane Fluothane Inhalation Halogenated
volatile liquid;
potent; pleasant
odor;
nonirritating;
cardiovascular
and respiratory
depressant;
incomplete
muscle relaxation;
potentially toxic
to liver
Rapid induction;
wide spectrum for
maintenance;
depth of
anesthesia easily
altered; rapid
reversal
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Enflurane Ethrane Inhalation Halogenated
ether; potent;
some muscle
relaxation;
respiratorydepressant
Rapid induction
and recovery;
wide spectrum
for maintenance
Isoflurane Forane Inhalation Halogenated
methyl ether;
potent; muscle
relaxant;
profound
respiratory
depressant;metabolized in
liver
Rapid induction
and recovery
with minimal
aftereffects;
wide spectrum
for maintenance
INTRAVENOUS
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AGENTS
Thiopental sodium
Pentothal sodium Intravenous Barbiturate;
potent; short acting
with cumulative
effect; rapid uptake
by circulatory
system; no muscle
relaxation;
respiratory
depressant
Rapid induction
and recovery; short
procedures when
muscle relaxation
not needed; basal
anesthetic
Methohexital
sodiuim
Brevital Intravenous Barbiturate;
potent; circulatory
and respiratory
depressant
Rapid induction;
brief anesthesia
Propofol Diprivan Intravenous Alkylphenol;potent short-acting
sedative-hypnotic;
cardiovascular
depressant
Rapid inductionand recovery; short
procedures alone;
prolonged
anesthesia in
combination with
inhalation agents
or opioids
K t i K t j t K t l I t Di i ti d R id i d ti
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Ketamine
hydrochloride
Ketaject. Ketalar Intravenous,
Intramuscular
Dissociative drug;
profound amnesia
and analgesia; may
cause psychologic
problems during
emergence
Rapid induction;
short procedures
when muscle
relaxation not
needed; children
and young adults
Fentanyl Sublimaze Intravenous Opioid; potent
narcotic; metabolizes
slowly; respiratory
depressant
High-dose narcotic
anesthesia in
combination with
oxygen
Sufentanil citrate Sufenta Intravenous Opioid; potent
narcotic, respiratory
depressant
Premedication; high-
dose narcotic
anesthesia in
combination with
oxygen
Fentanyl and
droperidol
Innovar Intravenous Combination
narcotic and
tranquilizer; potent;
long acting
Neuroleptanalgesia
Diazepam Valium Intravenous, Benzodiazepin Premedication;
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p ,
intramuscular
p
e; tranquilizer;
produces
amnesia,
sedation, and
muscle
relaxation
;
awake
intubation;
induction
Midazolam Versed Intravenous,
intramuscular
Benzodiazepine
; sedative;
short-acting
amnesic; central
nervous system
and respiratory
depressant
Premedication;
conscious
sedation;
induction in
children
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2. Local or regional block anesthesia
temporary interruption of the transmission of nerve impulses to and from specific area or region of the
body.
achieved by injecting local anesthetics in closeproximity to appropriate nerves.
reduce all painful sensation in one region of the body
without inducing unconsciousness.
agents used are lidocaine and bupivacaine.
Techniques used in Regional Anesthesia
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Techniques used in Regional Anesthesia
A. Topical Anesthesia
applied directly to the skin and mucous membrane, open skin surfaces, wounds
and burns.
readily absorbed and act rapidly
used topical agents are lidocaine and benzocaine
B. Spinal Anesthesia ( Subarachnoid block )
local anesthetic is injected through lumbar puncture, between L2 and S1
anesthetic agent is injected into subarachoid space surrounding the spinal cord.
- Low spinal, for perineal/rectal areas
- Mid spinal T10 ( below level of umbilicus) for hernia repair and appendectomy.
- High spinal T4 ( nipple line ), for CS
anesthetic block conduction in spinal nerve roots and dorsal ganglia; paralysis and
analgesia occur below
level of injection
agents used are procaine, tetracaine, lidocaine and bupivacaine.
Indicating a site for insertion of the lumber puncture
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g p
needle into the subarachnoid space of the spinal
canal.
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E. Intravenous Block ( Beir block )
often used for arm,wrist and hand procedure
an occlusion tourniquet is applied to the extremity to prevent infiltration
and absorption of the injected IV agents beyond the involved extremity.
F. Caudal Anesthesia
Is produced by injection of the local anesthetic into the caudal or sacral
canal
G. Field Block Anesthesia The area proximal to a planned incision can be injected and infiltrated
with local anesthetic agents.
Techniques used in Regional Anesthesia
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OTHER TECHNIQUES OF ADMINISTRATION OF LOCAL
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OR REGIONAL ANESTHESIA:
Topical Application the anesthetic is directly applied to a mucous membrane, to a
serous surface, or into an open wound.
Cryoanesthesia
involves blocking local nerve conduction of painful impulses bymeans of marked surface cooling of a localized area. It is usedin such brief procedures as the removal of warts ornoninvasive popular surface lesions.
Simple Local Infiltration is injected intracutaneously and subcutaneously into tissues atand around the incisional site to block peripheral sensorynerve stimuli at their origin. It is used for suturing superficiallacerations or excising minor lesions.
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Administration of Local Anesthesia
in the absence of an anesthesia provider, a qualifiedregistered nurse is responsible for monitoring the
patients physiologic status and safety during local
anesthesia. This should be the only activity assigned
to this nurse for the duration of the procedure. He or
she should not perform circulating duties
simultaneously.
Comparison of Toxicity and Allergy Caused by Local
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Anesthetic Drugs
Toxic Reaction Allergic Reaction
Symptoms vary depending on thedrug
Immediate localized reactionfollowed by generalized bodyreaction
SUBJECTIVEDizziness, somnolence,paresthesia, nausea,visual/speech problems
Sense of uneasiness, pruritus,agitation, paresthesia
OBJECTIVE
Decreased breathing rate anddepth, muscle twitches, tremors,slurred speech, seizures,vomiting unconsciousness, coma
Erythema, urticaria, wheals
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VASOVAGAL
Dysrhythmia, bradycardia,
vasodilation, hypotension,myocardial depression,
cardiac arrest
Coughing, sneezing, wheezing,
bronchospasm, hypotension,hypovolemia, vasodilation,
cardiovascular collapse,
cardiac arresr
TREATMENT
Supportive, airway
management; need intravenous
(IV) line; Trendelenburg
position; muscular contractionsare treated with diazepam
(Valium)
Especially with amino ester
type: airway management, IV
fluids, epinephrine,
diphenhydramine, and steroidsas needed
Guidelines in Monitoring a Patient Receiving a Local
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Guidelines in Monitoring a Patient Receiving a LocalAnesthetic:
The patient is monitored for reaction to drugs and forbehavioral and physiologic changes.
The nurse attending the patient should have basicknowledge of the function and use of monitoringequipment, ability to interpret information, and working
knowledge of resuscitation equipment. The nurse shouldhave appropriate training and knowledge in pharmacologyand the application of the drugs used in the patients care.
Accurate reflection of perioperative care should bedocumented on the patients record.
Institutional policies and procedures in regard to patientcare, including monitoring, should be written, reviewedannually, and readily available. This information should beincluded in orientation and inservice programs.
Local and Regional Anesthetic Agents
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Local and Regional Anesthetic Agents
Generic
Name
Trade
Name(s)
Uses Concentratio
n
Duration of
Effect(Hours)
Maximum
Dosage
AMINO
AMIDES
Bupivacaine
hydrochloride
Marcaine
Sensorcaine
Local
infiltration
Regionalblock
Surgical
epidural
0.25% to
0.50%
2 to 3 400mg
Dibucainehydrochlorid
e
NupercainePercaine
Cinchocaine
Localinfiltration
Peripheral
nerves
0.05% to0.1%
3 to 3 30mg
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Etidocaine
hydrochlori
de
Duranest Peripheral
nrves
Epidural
0.5% to 1% 2 to 3 500mg
Lidocaine
hydrochlori
de
Xylocaine
Lignocaine
Topical
Infiltration
Peripheral
nerves
Nerve block
Spinal
Epidural
2-4%
0.5%
1-2%
to 2 200mg
500mg or
7mg/kg
body weight
Mepivacaine
hydrochlori
de
Carbocaine InfiltrationPeripheral
nerves
Epidural
0.5-1%1-2%
to 2 500mg
Prilocaine
hydrochlori
Citanest Infiltration
Peripheral
1-2%
2 3%
to 2 600mg
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hydrochlori
de
Peripheral
nerves
Regional
Block
Epidural
2-3%
Ropivacaine Naropin Infiltration
Field block
Nerve block
Epidural
Postoperativ
e painmanagemen
t
Not used for
Bier block
0.2%
0.5%
0.75%
1%
2 for
surgical
analgesia; 6
to 10 for
surgical
nerve block
200mg for
analgesia;
300mg for
nerve block
AMINO
ESTERS
Chloroproc
aine
hydrochlori
de
Nesacaine Infiltration
Peripheral
nerves
Nerve block
Epidural
0.5%
2%
2%
2-3%
to 1000mg
Cocaine Topical 4-10% 200mg or
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hydrochlori
de
4mg/kg
body
weight
Procaine
hydrochlori
de
Novocain Infiltration
Peripheral
nervesSpinal
0.5%
1-2%
to 1000mg or
14mg/kg
bodyweight
Tetracainehydrochlori
de
CetacainePontocaine
TopicalSpinal
2%1%
2 to 4 20mg
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POSITIONING
Lateral position: the patient lies on the side withthe back at the edge of the operating bed. Theknees are flexed onto the abdomen, and thehead is flexed to the chest. The hips andshoulders are vertical to the operating bed to
prevent rotation of the spine.
Sitting position: the patient sits on the side ofthe operating bed with the feet resting on a
stool. The spine is flexed, with the chin loweredto the sternum; the arms are crossed andsupported on a pillow on an adjustable table.
Positioning Surgical Patient (Spinal
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Positioning Surgical Patient (SpinalAnesthesia)
Sitting PositionLateral Position
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Stages of
Anesthesia
St I St f
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Stage I . Stage of
Analgesia / induction
phase
This stage extends from the
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This stage extends from the
beginning of Administrationof an anesthetic to the
beginning of the loss ofconsciousness. The
sensation of pain is not lost.
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Stage I . Stage of Analgesia / induction phase
The client maybe
drowsy or dizzy
May experiencehallucinations
Circulating nurse
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Circulating nurse
should close the OR
doorsKeep quiet
Stand by to assist
client
St II St f
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Stage II. Stage of
Delirium / Excitement
Extends from the loss of
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Extends from the loss of
consciousness to the lossof eyelid reflex. Any
stimulation has thepotential to cause the
client to become difficult
to control
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Stage II. Stage of Delirium / Excitement
Increased muscletone
Irregular respiration
REM ( rapid eye
movement)
Retching & Vomiting
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Retching & Vomiting
may occur
Circulating nurseshould remain quietly
by patients side
Assist if needed
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Stage III Stage of
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Stage III. Stage of
Surgical Anesthesia
Extends from loss of lid
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Extends from loss of lid
reflex to cessation ofrespiratory effort or
depressed vital
functions.
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Stage III. Stage of Surgical Anesthesia
completely dilated &unresponsive pupils
absence of reflex
( muscles completelyrelaxed)
Client is unconscious
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Client is unconscious
Begin preparation
Client is in good
control
Stage IV Stage of
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Stage IV. Stage of
Danger / Medullary
stage
From vital functions too
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From vital functions too
depressed to Respiratoryfailure/ Death & Disability
due to too highconcentration of
anesthetic in the CNS.
Client is not
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Client is not
breathing
May not have heartbeat
Assist in
resuscitation
Speed of EMERGENCE
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Speed of EMERGENCE
(recovery from anesthesia) depends on typeof anesthesia, length of time & many other
factors- try to time with end of surgery
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Care of the anesthetized
patient:
Considerations:
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A deficit in pulmonary and/or cardiac functions isdetrimental to the patients physiologic status.Abnormalities of pulmonary ventilation and diffusioninfluence the course of the anesthesia and diminishtolerance to stress or the insults from the anesthetic and theprocedure.
Circulation is affected both centrally and peripherally.Individual agents are associated with characteristichemodynamic patterns.
The liver is affected by general agents. Alterations in liverfunction tests may follow anesthesia.
Kidney function is affected by disturbances in systemiccirculation, since kidneys normally receive 20% to 25% of
cardiac output. Biotransformation of agents varies with metabolitesexcreted by the kidneys. Urinary excretion of IV agents maybe slow and unpredictable.
Agents may cause nausea, emesis, or systematiccomplications.
Safety Factors:
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The patients position is changed slowly and gently to allowcirculation to readjust.
Proper positioning and padding are important to avoid pressurepoints, stretching of nerves, or interference with circulation to anextremity.
The patients chest must be free of adequate respiratory excursionduring the surgical procedure. The airway must be patent.
The lungs must be adequately ventilated intraoperatively andpostoperatively by either voluntary or mechanical means.
The anesthesia provider assists in transferring the patient to astretcher or bed, safeguarding the head and neck, when it is safe
to move the patient. The anesthesia provider gives the nurse a verbal report, including
specific problems in regard to this patient, and completes recordsbefore the transfer of responsibility.
Complication and Discomforts of
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Anesthesia
Hypoventilation - inadequate ventilatory support after paralysis of respiratory
muscles.
Oral Trauma
Malignant Hyperthermia
Hypotension - due to preoperative hypovolemia or untoward reactions to
anesthetic agents.
Cardiac Dysrhythmia - due to preexisting cardiovascular compromise, electrolyte
imbalance or untoward reaction to anesthesia.
Hypothermia - due to exposure to a cool ambient OR environment and loss of
thermoregulation capacity from anesthesia.
Peripheral Nerve Damage - due to improper positioning of patient or use ofrestraints.
Nausea and Vomiting
Headache
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SURGICAL TEAM
Members of Sterile
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Surgical Team
the sterile team members scrub their hands and arms
wears sterile gown and gloves
enter the sterile field. [To establish sterile field, all
items needed for the procedure are sterilized.]After the process, the scrubbed and sterile teammember functions within the limited area and the onlysterile items.
1. Surgeon
2. Assistants to the surgeon
3. Scrub person
*SURGEON
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must have the knowledge, skills and judgmentrequired to successfully perform the intendedsurgical procedure and any deviationsnecessitated by unforeseen difficulties.
must be prepared for the unexpected.
responsibilities include pre-operative diagnosis &cure, selection & performance of surgery & post-operative management of care.
licensed physician (MD), oral surgeons, etc.
appropriate clinical skills & personal character areimportant attributes of a surgeon.
*ASSISTANTS TO THE SURGEON
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under the direction of the operatingsurgeon, one or two assistants help tomaintain visibility of the surgical site,control bleeding, close wounds, and applydressing.
Handles tissues & uses instruments
Anticipates blood loss, anesthesia time for
patient, fatigue affecting OR team &potential complications
*1STASSISTANT IN SURGERY
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qualified surgeon or a resident doctor
capable of performing procedures for
primary surgeon
post-graduate intern & medical intern
surgeon may request assistance of an
associate physician w/ whom the
surgical procedure is shared & towhom part of patients care is
delegated
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Non-Sterile Members of the
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Surgical Team
1. Anesthesia Provider2. Circulator3. Others (the OR team may include biomedical
technicians, radiology technicians, and others who may
be needed to set up and operate specializedequipment or monitoring devices during the surgicalprocedure)
the unsterile team members DO NOT enter the sterilefield.
They handle supplies and equipments that are not
considered sterile.Following the principles of aseptic technique, they keep
the sterile team supplied.
*ANESTHESIA PROVIDER
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this refers to the person responsible for the
inducing anesthesia, maintaining anesthesiaat the required levels, and managing
untoward reactions to anesthesia throughout
the surgical procedure.
*CIRCULATOR
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the circulator plays a role that is vital tothe smooth flow of events before, during,
and after the surgical procedure.
The circulators role as a patient advocate
and protector is critical to the safety and
welfare of the patient and extends
throughout the entire pre-operative
environment.
Sterile Field
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Sterile Field
The area surrounding the client and thesurgical site that is free from all
microorganisms.
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DUTIES AND RESPONSIBILITIES OFTHE SCRUB AND CIRCULATING
NURSE
SCRUB NURSE
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SCRUB NURSE
Both the circulator and the scrub person set up the room and positionthe equipment. The case cart and room furniture are checked byboth persons as a team. The duties and activities change when thepatient arrives at the OR suite. The circulator begins working withthe patient while the scrub nurse continues readying the room.
THE SCRUB NURSE DUTIES:When all supplies have been obtained and opened and the
room is ready for the patients arrival, the scrub nurse prepares forthe surgeons arrival. At all times, the integrity of the sterile field isclosely monitored. The principles of asepsis and sterile technique
are followed.
Preparation of the sterile field:
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The scrub nurse should be sure that his or her gownand gloves are open and ready on a surface separatefrom the sterile field.
perform a complete surgical hand cleansing accordingto the facility procedure.
gown and glove using closed gloving method. drape unsterile tables according to standarddepartmental setup procedure with drapes from thedrape pack.
a second instrument table may be needed for extensive
surgical procedures or special types of instrumentation(e.g., tables for preparation of an implant or organ fortransplant)
drape both the frame and the tray of the Mayo stand
arrange on the Mayo stand the instruments and accessory
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arrange on the Mayo stand the instruments and accessoryitems to create primary precision. Arrange other
instruments and items on the instrument table. (the Mayostand should be kept neat throughout the surgicalprocedure. Do not overload it with sponges and sharps)
count sponges, surgical needles, other sharps, and
instruments with the circulating nurse according toestablished facility policy and procedure.
secure surgical needles and all other sharps, including theknife blades. They should never be loose on the Mayostand.
prepares sutures in the sequence in which the surgeon willuse them.
After the surgeon and assistant(s) scrub:
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gown and glove the surgeon and assistant(s) assoon after they enter the OR as possible.
assist in draping according to the type of procedure
and the surgeons preference.
after draping is completed, bring the Mayo standinto position over the patient, making sure it does
not rest on the patient.
position the instrument table at a right angle to the
operating bed. assist the surgeon in securing sterile light handles
for adjustment of the operating light.
During the surgical procedure:
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pass the skin knife to the surgeon, and pass a hemostat andsuction to the assistant. When passing the knife, take care todirect the blade away from yourself and other personnel.
hand up sterile towels or lap sponges if requested for coveringskin at the edges of the incision.
watch the field and try to anticipate the needs of the surgeonand assistant. Keep one step ahead of them in passinginstruments, sutures, and sponges and in handing up thespecimen basin.
return instruments to the Mayo stand or instrument table afteruse.
keep instruments as clean as possible. repeat the size of a suture or ligature when handing it to the
surgeon as appropriate.
be logical in selecting the instruments used for suturing.
have scissors ready when the knot is tied.
remove waste ends of suture material from the field Mayo
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remove waste ends of suture material from the field, Mayo
stand, and instrument table, and place them in the trash
disposal container. follow established institutional policy and procedure for
securing sharps during the surgical procedure.
keep the specimen basin on the field until all tissue has been
removed or all contaminated items have been placed in it. Before closure, the surgeon may request several liters of
fresh, warm irrigation solution to rinse the abdomen or
smaller amounts to irrigate other surgical wounds. Keep
track of the amount of irrigation used, and report it to thecirculating nurse for the permanent record.
alert the circulating nurse that closure is about to begin, andhand up the wound closure materials.
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in accordance with established procedures, count sponges,sharps, and instruments with the circulator as the surgeon
begins closure of the wound. Verify that intraabdominal orother cavity packing materials and towels have beenremoved.
place unneeded instruments and supplies on the instrumenttable in the original set position
have a clean, warm, saline-moistened sponge ready towash blood from the area surrounding the incision assoon as skin closure is completed.
have the sterile dressings ready.
after the dressing is in place, the team will undrape the
patient. Place the soiled drapes in the appropriatereceptacleNOT on the instrument table or Mayo stand
The Eight Ps to consider
when preparing for aSterile Field Considerations Environment Considerations
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when preparing for a
Surgical Procedurefor the Scrub Nurse for the Circulating Nurse
PROPER PLACEMENT-items should be placed so
they will not need to be
moved during the procedure.
The Mayo stand should not
be moved during the
procedure. Drapes may not
be moved on the patients
skin.
Suction canisters, tourniquet,
and the electro-surgical unit
(ESU) need to be stationary.
The operating lights should
be directed toward the field.
PROPER FUNCTION
-items should be tested forsafety and usefulness before
they are needed, to prevent
delay in the case.
Test the efficiency of
instruments (e.g., scissors,needle holders, clamps) as
they are needed.
Test the ESU, tourniquet,
laser, and other equipmentbefore the patient enters the
room.
PLACE IT ONCE
-items should not be
i l d d i h
When setting up the field,
each item (e.g., a basin)The operating bed should be
h i h l f h
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manipulated during the
procedure. Energy and
attention should not be
diverted to resetting the
field.
each item (e.g., a basin)
should be placed where it
will be used during the
procedure with minimalhandling.
at the right place for the
procedure. The dispersive
electrode should not be
moved or displaced.
POINT OF CONTACT
-items used within the
field could cause harm or
be rendered useless ifthey do not reach the
intended point of
contact.
The scrub nurse should be
aware of the passing of
the instruments and how
they are securely placed
in the waiting hand of the
surgeon or first assistant.
The circulating nurse should
evaluate the delivery of
items to the sterile field.
Some items (e.g., staplers)should be handed; others
can be transferred in other
ways.
POSITION OF FUNCTION-items should be
positioned so they will be
useable during the
procedure.
When passing
instruments, they should
be placed in the surgeons
hand in a useable way.
For example, the curve of
the instrument should
match the curve of the
hand.
The use of a laser with
articulating arm, ormicroscope should be
preplanned so they may be
positioned while the
procedure is in progress.
Basins should be placed
close to the edge of the
table so the circulating nursePour solutions directly into the
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POINT OF USE
-items should be as close to
the area of use as possible.
g
can pour without requiring
the basin to be repositioned.
The ESU pencil holder
should be close to the field
for safe containment of the
tip.
Pour solutions directly into the
basins, open and hand sponges
or sutures directly to the scrub
nurse as they are needed.
PROTECTED PARTS
-items and surfaces shouldbe rendered safe for the
patient and the team.
Apply jaw liners to
instruments during setup.
Hand instruments with care
to avoid causing injury with
the tip or sharp surface. Do
not lay items on or against
the patients body.
Cords, cables, and tubing
should be secured and
appropriately directed awayfrom the field. Pad the
operating bed and patient as
appropriate. Use safety belts.
PERFECT PICTURE
-items within and aroundthe field should not be at
risk for causing harm or
becoming damaged. The
environment should not be
cluttered.
The sterile field should
remain neat and orderly,with instruments and
supplies within easy sight
and reach. Consistent setup
fosters a sense of comfort
and confidence in the scrub
role.
The entire room should appear
neat and tidy. The door should
be closed, and thetemperature and humidity
should be appropriate.
Forethought to having a clear
path for the crash cart or
emergency equipment is
essential.
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-before entering the OR suite, the circulating nurse mustwash his/her hands and arms as required by institutional
policy and procedure, but he/she does not don sterile
gowns and gloves.
--should assist the sterile scrub nurse by providing andopening sterile supplies needed to prepare for arrival of the
patient and the surgeon.
--test all equipments before bringing to the OR suite.
After scrub nurse scrubs:
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fasten the back of scrub nurses gown check with the scrub nurse to see if additional
supplies or instruments are needed.
check the list of suture materials and sizes on thesurgeons preference card and verify with the surgeon
before opening pockets establish a baseline of table of contents for the record,
count sponges, sharps and instruments together withthe scrub nurse in the manner as described in facilitypolicy and procedure.
the instrument counts will be recorded on theinstrument tray sheet packed with the set.
After the patient arrives:
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attend to patient while scrub nurse continues toprepare the instrument table for the arrival of the
surgeon.
greet and identify the patient, introduce yourself, and
identify your title and role. ask patient to verbally identify himself/herself.
verify any allergies and other environmental/chemical
sensitivities the patient may have.
be sure the patients hair is covered with a cap
loosen the neck and back ties on the patients gown
f h h f d h b d l
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after the patient has transferred to the operating bed, apply
safety belt over the thighs 2-3 inches above the patients
knees, and place his/her arms on armboards.
help anesthesia provider as needed
apply and connect monitoring devices, and assist with IV
infusion, induction, and intubations as necessary.
before handing the IV bag, check first the expiration date,
and gently squeeze it to detect leaks.
check the solution for clarity or discoloration; a cloudy
solution is contaminated. Check the label on the container
before the solution is administered.
During induction of anesthesia:
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g
remain at patients side during the induction ofanesthesia.
assist the anesthesia provider during induction
and intubation.
maintain a quiet environment. Tactile or auditorystimulation may produce excitement in the patient
during induction.
After the patient is anesthetized:
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attach anesthesia screen and other table attachments asneeded.
reposition the patient only after the anesthesia provider
says the patient is anesthetized to the extent that he/she
will not be disturbed by being moved or touched.
before the draping begins, note the patients position to be
certain all measures for his/her safety have been observed.
-prepare the patients skin with antiseptic solution.
turn on the overhead spotlight over the site of the incision.
bag and discard the sponges from a reusable prep tray
immediately after use.
After the surgeon and assistants scrub:
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-assist with gowning the team. Fasten the waist tie,
followed by the neck closure to allow the upper body more
freedom of motion for gloving.
should stand by to help with the back flap tie-in of the
gown.
observe for any breaks in sterile technique during draping.Stand near the head end of the operating bed to assist the
anesthesia provider in fastening the drape over the
anesthesia screen or around an IV pole next to the
armboard. assist the scrub nurse in moving the Mayo stand and
instrument table into position, being careful not to touch
the drapes.
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place steps or platforms for team members who need
them, or place stools in position foe the team that need to
operate while seated.
position kick buckets on each side of the operating bed.
connect suction, the ESU cord, the dispersive electrode
cable, or any other powered equipment to be used.
place foot pedals within easy reach of the surgeons right
foot.
confirm and document the desired settings on the
machines.
During the Surgical Procedure:
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be alert to anticipate the needs of the sterile team, such asadjusting the operating lights, removing perspiration from brows,and keeping the scrub nurse supplied with sponges, sutures, warmsaline, and other necessary items.
watch the surgical procedure closely enough to see when routinesupplies are needed and gives them to the scrub nurse without
being asked for them. should know how to use and care for all supplies, instruments,
and equipment and be able to get them quickly.
stay in the room. Inform scrub person if you must leave to getsomething.
be available to answer questions, obtain supplies and assist teammembers.
keep discarded sponges carefully collected; separated bysizes, and counted according to the number they arepackaged in.
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p g
assist the surgeon and the anesthesia provider monitor bloodloss. Weigh sponges if requested to do so.
know the condition of the patient at all times. Inform the ORmanager of any marked changes, unanticipated additionalprocedure, or delays.
communicate periodically with the patients family or
significant others to inform them of the progress of theprocedure as appropriate.
prepare and label specimens for transfer to the laboratory.Always wash hands thoroughly after removing gloves thathave been worn to handle specimens.
as required, complete the documentation in the patientschart, permanent OR records, and requisition for laboratorytests or chargeable items.
During Closure:
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count sponges, sharps, and instruments with the scrubnurse. Report counts as correct or incorrect to thesurgeon. Complete the count records. Collect usedsponges for disposal in the appropriately markedreceptacles.
obtain the washer-sterilizer tray, instrument tray, andother items necessary or the cleanup procedure.
send for a postanesthesia care unit (PACU) stretcher oran intensive care unit (ICU) bed, or prepare thepatients stretcher or bed with a clean sheet; followwhatever is the institutional procedure.
obtain a transfer monitor and oxygen tank with tubingif needed.
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COMMON ABDOMINALINCISIONS
1. Paramedian Incision
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is a vertical incision made approximately 4cm (2 in)
lateral to the midline on either side in the upper andlower abdomen
it limits trauma, avoids nerve injury, is easilyextended, and gives a firm closure
it allows quick entry into and excellent exposure ofthe abdominal cavity
ex: access to the biliary tract/pancreas (right upperquadrant) and resection of the sigmoid colon (left
lower quadrant)
2. Longitudinal Midline Incision
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can be upper abdominal, lower abdominal, or acombination of both going around the umbilicus
depending on the length of the incision, it begins
in the epigastrum at the level of the xiphoidprocess and may extend vertically to the
suprapubic region
upper midline incision offers excellent exposure
of a rapid entry into the upper abdominal
contents
3. Subcostal, Upper Quadrant ObliqueIncision
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a right or left oblique incision begins in the
epigastrum and extends laterally and obliquelyjust below the lower costal margin
affords limited exposure except for upperabdominal viscera, it provides good cosmetic
results because it follows skin lines and produceslimited nerve damage
biliary modified subcostal incision (ChevronIncision) is made for increased visibility during a
liver transplantation or resection ex: biliary procedures and splenectomy
4. McBurney's Incision
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located in the right lower quadrant just below
the umbilicus 4cm (2 in) medial from the
anterior superior iliac spine
involves a muscle-splitting incision that
extends through the fibers of the external
oblique muscle
a fast and easy incision, but exposure is
limited
its primary use is for appendectomy
5. Thoracoabdominal Incision
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patient is placed in a lateral position either a right or left incision that begins at a point
midway between the xiphoid process andumbilicus and extends across the abdomen to the
7th
and 8th
interspace and along the interspaceinto the thorax
allows excellent exposure for the upper end ofthe stomach and the lower end of the esophagus
ex: esophageal varices and the repair of a hiatalhernia
6. Midabdominal Transverse Incision
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starts on either the right or left side andslightly above or below the umbilicus
the advantages are rapid incision, easy
extension, a provision for retroperinealapproach, and a secure postoperative wound
ex: choledochojejunostomy and transverse
colostomy
7. Pfannstiel's Incision
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a curved transverse incision across the lowerabdomen and within the hairline of the pubis
this lower transverse incision provides good
exposure and strong closure for pelvicprocedures
its primary use is for an abdominal
hysterectomy
8. Inguinal Incision, Lower Oblique
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right or left incision that extends from the pubic
tubercule to the anterior crest of the ilium,
slightly above and parallel to the inguinal crease
incision of the external oblique fascia providesaccess to the cremaster muscle, inguinal canal
and cord structure
its primary use is for inguinal herniorrhaphy
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LAYERS OF THE ABDOMEN
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BASIC SURGICAL INTSTRUMENTS
OPERATION ROOM SET-UP (EQUIPMENTS
AND APPARATUS)
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)
- standardized basic sets of sterile instrumentsare selected for each specific surgical
procedure
- a set is a group of instruments that mayinclude all appropriate classifications of
instruments or the instruments needed for a
specific part of the procedure (e.g. gallbladderset)
Classifications:
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Cutting and Dissecting Grasping and Holding
Retracting and Exposing
Clamping and Occluding Miscellaneous
Cutting and Dissecting Instruments
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are sharp and are used to cut body tissue or surgical supplies.
Knife Handle, Scissors(left to right)
Cutting and Dissecting Instruments
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7 handle with 15 blade (deep knife)- Used to cut deep,delicate tissue.
3 handle with 10 blade (inside knife)Used to cut superficial
tissue.
4 handle with 20 blade (skin knife) - Used to cut skin.
#7, #3, #4(left to right)
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Surgical Blades
10 1112 15
20
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Cutting and Dissecting Instruments
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Straight Mayo scissors- Used to cut suture and supplies. Alsoknown as: Suture scissors.
EX: Straight Mayo scissors being used to cut suture.
Cutting and Dissecting Instruments
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Curved Mayo scissors- Used to cut heavy tissue (fascia,muscle, uterus, breast). Available in regular and long sizes.
Curve and Straight Scissors
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Cutting and Dissecting Instruments
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Metzenbaum scissors- Used to cut delicate tissue. Availablein regular and long sizes.
Metzenbaum
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ELECTROCAUTERY MACHINE
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Cutting and Dissecting
Instruments
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Scalpel holderCurved and Straight Mayo
Scissors Metzenbaum
Lister/Bandage Scissors Suture ScissorsStitch Scissors
Clamping and Occluding Instruments
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are used to compress blood vessels or hollow organs forhemostasis or to prevent spillage of contents.
Clamping and Occluding Instruments
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Ahemostatis used to clamp blood vessels or tag sutures. Itsjaws may be straight or curved. Other names: crile, snap or
stat.
Clamping and Occluding Instruments
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A mosquitois used to clamp small blood vessels. Its jaws maybe straight or curved.
hemostat, mosquito (left to right)
Clamping and Occluding Instruments
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A Kellyis used to clamp larger vessels and tissue. Available inshort , MEDIUMand long sizes. Other names: Rochester Pean.
Kelly, hemostat, mosquito (left to right)
Clamping and Occluding Instruments
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A burlisheris used to clamp deep blood vessels. Burlishershave two closed finger rings. Burlishers with an open finger
ring are called tonsil hemostats. Other names: Schnidt tonsilforcep, Adson forcep.
Clamping and Occluding Instruments
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A right angleis used to clamp hard-to-reach vessels and toplace sutures behind or around a vessel. A right angle with a
suture attached is called a "tie on a passer." Other names:
Mixter.
Clamping and Occluding Instruments
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A hemoclip applier with hemoclipsapplies metal clips ontoblood vessels and ducts which will remain occluded.
hemoclip applier with hemoclips
Clamping and Occluding Instruments
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Straight Mosquito
Kelly Clamp
Pean (Rochester-Pean) Clamp
Crile Clamp
Right-Angled (Mixter/Dissector) Forceps
Grasping and Holding Instruments
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are used to hold tissue, drapes or sponges.
Grasping and Holding Instruments
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An Allisis used to grasp tissue. Available in short and longsizes. A "Judd-Allis" holds intestinal tissue; a "heavy allis"
holds breast tissue.
Grasping and Holding Instruments
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A Babcockis used to grasp delicate tissue (intestine, fallopiantube, ovary). Available in short and long sizes.
Grasping and Holding Instruments
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A Kocheris used to grasp heavy tissue. May also be used as aclamp. The jaws may be straight or curved. Other names:
Ochsner.
Grasping and Holding Instruments
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A Foerster sponge stickis used to grasp sponges. Othernames: sponge forcep.
Foerster sponge stick EX: Sponge sticks holding a 4 X 4
and probang.
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Grasping and Holding Instruments
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A Backhaus towel clip is used to hold towels and drapes inplace. Other name: towel clip.
Backhaus towel clip Large & small towel clips
Grasping and Holding Instruments
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Pick ups and thumb forceps are available in various lengths,with or without teeth, and smooth or serrated jaws.
Grasping and Holding Instruments
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Russian tissue forcepsare used to grasp tissue.
Grasping and Holding Instruments
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Adson pick upsare either smooth: used to grasp delicatetissue; or with teeth: used to grasp the skin. Other names:
Dura forceps.
Grasping and Holding Instruments
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Long smooth pick-ups are called dressing forceps. Shortsmooth pick-ups are used to grasp delicate tissue.
Grasping and Holding Instruments
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DeBakey forcepsare used to grasp delicate tissue, particularlyin cardiovascular surgery.
Grasping and Holding Instruments
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Thumb forcepsare used to grasp tough tissue (fascia,breast). Forceps may either have many teeth or a single
tooth. Single tooth forceps are also called "rat tooth
forceps."
single tooth forceps, many teeth forceps(top to bottom)
Grasping and Holding Instruments
(Tissue Forceps)
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DeBakey TissueForceps
Adson TissueForceps
Russian TissueForceps
These are available in various lengths, with or without teeth,
and smooth or serrated jaws.
Grasping and Holding Instruments
Russian Tissue Forceps
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They have serration up to the tips, allowing bettergrasp of tissue with minimum trauma.
Grasping and Holding Instruments
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Mayo-Hegar needle holdersare used to hold needles whensuturing. They may also be placed in the sewing category.
short, medium & long(top to bottom)
EX: Needle holder with suture.
Suturing Instruments
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Hook and Dissector
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Grasping and Holding Instruments
Randall Stone Forceps
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To hold/remove kidney stones
Retracting and Exposing Instruments
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used to hold back or retract organs or tissue to gain exposureto the operative site. They are either "self-retaining" (stay
open on their own) or "manual" (held by hand). When
identifying retractors, look at the blade, not the handle.
Retracting and Exposing Instruments
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A Deaverretractor (manual) is used to retract deep
abdominal or chest incisions. Available in various widths.
Retracting and Exposing Instruments
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A Richardsonretractor (manual) is used to retract deep
abdominal or chest incisions
Retracting and Exposing Instruments
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An Army-Navyretractor(manual) is used to retract shallow or
superficial incisions. Other names: USA, US Army.
Retracting and Exposing Instruments
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A goulet(manual) is used to retract shallow or superficial
incisions.
Retracting and Exposing Instruments
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A malleable or ribbonretractor (manual) is used to retract
deep wounds. May be bent to various shapes.
Retracting and Exposing Instruments
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A Weitlaner retractor (self-retaining) is used to retract shallow
incisions.
( )
Retracting and Exposing Instruments
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A Gelpiretractor (self-retaining) is used to retract shallow
incisions.
lf i h bl dd bl d ( lf ) d
Retracting and Exposing Instruments
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A Balfour with bladder blade(self-retaining) is used to retract
wound edges during deep abdominal procedures.
Richardson Retractor
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Vein retractor
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Senn Retractor
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Retracting and Exposing Instruments
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Senn
Volkmann Rake
US Army Navy Deaver
Malleable Vein Retractor Green Goiter
WeitlanerLangenbeck Skin Hooks Vaginal Speculum
Richardson
SUTURES
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SUTURES
Is a medical device used to hold tissue
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Is a medical device used to hold tissuetogether after an injury or surgery till healingtakes place.
Sutures (also known as stitches) are dividedinto two kindsthose which are:
1. Absorbable
2. Non-absorbable.
ABSORBABLE
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- will break down harmlessly in the body over timewithout intervention
- digested by body cells and fluids during thehealing period.
- used therefore in many of the internal tissues ofthe body. In most cases, three weeks sufficient forthe wound to close firmly
- originally made of the intestinesof sheep, the socalled catgut.
ABSORBABLE
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untreated (plain gut) tanned with chromium salts to increase their
persistence in the body (chromic gut)
heat-treated to give more rapid absorption (fast
gut).
Examples: Chromic, Plain,Polydiaxone (PDS), Polyglactin
910 (Vicryl),Polyglycolic Acid(Biovek)- Used for those who cant return for suture removal/in
internal body tissues
ABSORBABLE
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Plaindissolves within 5-10 days, YellowChromic- dissolves within 1 month, Brown
Vicryl/Safil-dissolves within 60-90 days,
LavenderPDS (Polydioxone)- dissolves 2 times longer
than the other absorbable sutures, White
Non-absorbable sutures
The non absorbable ones have to be removed after
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The non absorbable ones have to be removed afterspecified time. The type of suture is decided againby the location of the wound.
Nonabsorbable suturesare made of materials which
are not metabolized by the body, and are usedtherefore either on skin wound closure, where thesutures can be removed after a few weeks, or insome inner tissues in which absorbable sutures arenot adequate.
Examples: Silk,Nylon,Prolene (Polypropylene)
Types:
Non-absorbable sutures
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Types:
Silk- is an animal product from silk worm cocoons.(Black)
Cotton-made from long staple cotton, treated to make itsmooth, (White)
Prolene- biosynthetic, non-absorbable suture material, assubstitute to silk
Wire- gives the greatest strength to any suture material.
ABSORBABLE SUTURE
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NONABSORBALE SUTURE
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SUTURE NEEDLES
1. Traumatic needles
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1. Traumatic needles
- are needles with holes or eyes which are supplied tothe hospital separate from their suture thread.
- The suture must be threaded on site, as is done whensewing at home.
2. Atraumatic needles
- with sutures comprise an eyeless needle attached to aspecific length of suture thread.
Needles may also be classified by theirpoint geometry; examples include:
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taper (needle body is round and tapers smoothly to apoint)
cutting (needle body is triangular and has a sharpenedcutting edge on the inside)
reverse cutting (cutting edge on the outside) trocar point or tapercut (needle body is round and
tapered, but ends in a small triangular cutting point)
blunt points for sewing friable tissues
side cutting or spatula points (flat on top and bottomwith a cutting edge along the front to one side) for eyesurgery
Different Types Of Needles
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Viewing- surgeons can examine the interior of body cavities, hollow organs, orstructures with viewing
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1. Speculums
- the hinged, blunt blades of a speculum enlarge and hold open a canal
2. Endoscopes
- round or oval sheath of an endoscope is inserted into a body orifice or
through a small skin incision
a. Hollow Endoscopes
- the rigid hollow sheath permits viewing in a forward direction throughthe endoscope
b. Lensed Endoscopes
- have either rigid or flexible sheathes, and they have eyepiece with atelescopic lens system fr viewing in several direction
Suctioning and Aspirating-
- blood, body fluids, tissue, and irrigating solution may be
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, y , , g g y
removed by mechanical suction or manual aspiration
Suction
- involves the application of pressure to withdraw blood
or fluids, usually for visibility at the surgical site
a. Poole Abdominal Tip
- straight hollow tube with perforated outer filter shield
- used during abdominal laparotomy or within any cavityin which copious amounts of fluid or pus are encountered
b. Frazier Tip
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p
- a right-angle tube with a small diameter- used when encountering little or no fluidexcept capillary bleeding and irrigating fluid
c. Yankauer Tip
- hollow tube that has an angle for use in themouth or throat
d. Aspirating Tube- long, straight tube that is used through an
endoscope
Yankauer Tip
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FRAZIER SUCTION TIP
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GENERAL CONSIDERATIONS
1. Handle loose instruments separately toprevent interlocking or crushing.
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a. Instruments are never piled one on top ofanother on an instrument table
b. Microsurgical, ophthalmic, and other delicate
instruments are vulnerable to damage
through rough handling
c. Metal-to-metal contact should be avoided or
minimized
2. Inspect instruments such as scissors andforceps for alignment, imperfections, cleanliness,
and working conditions
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a. Scalpel blades should be properly set in handlesusing a heavy instrument, not fingers.
b. Teeth and serrations should align exactly
c. Tips should be straight and in alignmentd. Scissors should be snug and sharp in action
e. Cannulae should be clear and without
obstruction
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3. Sort instruments neatly by
classifications
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5. Leave retractors and other heavy instruments in atray or container or lay them out on a flat surface of
the table
6. Protect sharp blades, edges, and tips
a. Sets of instruments may be in sterilization racks so
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ythat the blades and tips are suspended
b. Tip-protecting covers or instrument-protectingplastic should be removed and discarded before theinstruments are used on the patient
c. If they are not in the rack, handles should besupported on a rolled towel or gauze sponge
Counting Procedure Each institution has its own written policy and procedure regarding the
counting of sponges (varying types), sharps, and instruments.
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The following guidelines should be observed when counting all objects
potentially subject to inadvertent inclusion within a wound:
1. The scrub person and the circulator count together (aloud) all items on
the sterile field as the scrub person touches to each item.
2. The circulator immediately records the number (count) of each type of
item. Keeping a record of the count is the legal responsibility of the
circulator.
3. If there is any uncertainty regarding any count, it is repeated.
4. As additional items (e.g., sponges or needles) are introduced to the
sterile field during the procedure, the scrub person counts the item(s)with the circulator, who adds the item to the count in the record and
initials it.
5. Nothing (including laundry, trash, instruments, or sponges) may be removed from an OR
Counting Procedure
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while a procedure is in progress until the final count is acknowledged to be correct. The onlyexception to this is when a specimen is sent to the laboratory for immediate inspection (e.g.,
frozen section) and the specimen remains attached to a counted item (as by sutures to
maintain its orientation); this must be noted and initialed on the intraoperative record.
6. Whenever there is a change of team members, a count is taken.
The name of the replacement person(s) is documented on the intraoperative record.
7. When a package containing an incorrect number of items is opened, the items should bepassed off the table, bagged, and labeled accordingly. The bag with the incorrect number of
sponges is labeled, set aside, and not included in the count. The bag may not be removed
from the room.
8. Counts are taken before the procedure begins, before wound closure begins, and when
skin closure is initiated.
9. An additional count is taken prior to the closure of an organ with a cavity (e.g., uterus,bladder, or bowel).
Incorrect closure counts must be repeated immediately. If the
Counting Procedure
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count remains incorrect, the circulator alerts the surgeon,
who will inspect the patients wound for the missing item.
If the item is not located, hospital policy must be followed,
i.e., usually to include immediate x-ray examination.
Notification of the OR supervisor and an incident report must
be filed as part of the chart, the permanent record.
Any item inadvertently left in a wound may become a source
of infection and result in subsequent litigation.
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POSTOPERATIVE PHASE
POSTOPERATIVE PHASE
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Goals: Maintain adequate body system functions
Restore homeostasis
Alleviate pain and discomfort Prevent postop complication
Ensure adequate discharge planning and
teaching.
PACU CARE
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Transport of client from OR to RR avoid exposure
avoid rough handling
avoid hurried movement and rapid changes in position.
Initial Nursing Assessment
Verify patients identity, operative procedure and the surgeon
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who performed the procedure. Evaluate the following sign and verify their level of stability
with the anesthesiologist:
- Respiratory status
- Circulatory status
- Pulses
- Temperature
- Oxygen Saturation level
- Hemodynamic values
Initial Nursing Assessment
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Determine swallowing and gag reflex , LOC and patientsresponse to stimuli.
Evaluate lines, tubes, or drains, estimate blood loss, condition
of wound, medication used, transfusions and output.
Evaluate the patients level of comfort and safety.
Perform safety check; side rails up and restraints areproperly
in placed.
Evaluate activity status, movement of extremities.
Review the health care providers orders.
Initial Nursing Interventions
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Mai