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Operating Room

Course Outline

NURSING SKILLS ENHANCEMENT

LEVEL III

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5/4/12 copyright (your organization) 2003 22

TOPIC OUTLINE

Definition of terms Principles of sterile technique Types of surgery Phases of surgery

Peri-operative phase Intra-operative phase Post-operative phase

Instrumentation

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5/4/12 copyright (your organization) 2003

DEFINITION OF TERMS

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Definition of terms

1. ANTISEPTICS Inorganic chemicalcompounds that combat sepsis by inhibitinggrowth of microorganisms without

necessarily killing them. Used in skin andtissue to arrests growth of endogenousmicroorganism like resident flora, they must

not destroy tissue.

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Definition of terms

ASEPTIC TECHNIQUE Methods by whichcontamination with microorganism isprevented.

CIRCULATOR The unsterile member of thesurgical team who attends to the immediateneeds of the sterile surgical team.

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Definition of terms

CONTAMINATED Soiled or infected bymicroorganisms.

CUFF The white or green elastic end

portion of the sleeves of the gown. DISINFECTION Chemical or physical process

of destroying most forms of pathogenic

microorganisms except bacterial spores,used for inanimate objects , but not ontissue.

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Definition of terms

ELECTIVE CASE The prepared or scheduledsurgical procedure to be done;postponement of which may not be life

threatening to the patient. EMERGENCY CASE A surgical procedure

that must be done at once; postponement

of which may be life threatening to thepatient.

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Definition of terms

OPERATING ROOM The place where thesurgical procedure is performed.

OR SUITE - A specific room inside the

operating room where the actual surgicalprocedure is conducted.

RECOVERY ROOM - A place where the

patient is transferred after a surgicalprocedure until he has recovered fromanesthesia

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Definition of terms

SCRUB SUITE The prescribed OR attirewhich is composed of an upper suite andpants.

SPECIMEN With very few exceptions, alltissue, including exudates removed from apatient is sent to pathology for

examination. STERILE Free of microorganisms including

all spores.

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Definition of terms

STERILIZATION Process by which allpathogenic and non- pathogenicmicroorganisms including spores are killed.

STERILIZER Chamber or equipment used toattain either physical or chemicalsterilization agent used may be capable of

killing all forms of microorganisms.

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Definition of terms

STERILE FIELD An area created inside theOR suite where the sterile drapes, gowns,instruments and sets are being used.

SURGICAL TEAM A group of persons who aredirectly responsible for the patient insidethe operating room.

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Definition of terms

SURGERY Is the term traditionally used fortreatments that involve cutting or stitchingtissue.

It is sometimes used to aid in the diagnosis of aproblem.

It is a medical specialty that uses operativemanual and instrumental technique on a patientthat investigate or treat a pathologicalcondition such as disease or injury, to helpimprove bodily function or appearance orsometimes for some other reason.

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Definition of terms

SUTURE Is an inclusive term for any strandof material used for ligating orapproximating tissue.

TERMINAL DISINFECTION Cleaning andsanitation of the OR suite to includeequipment and furniture using antiseptics

after each surgical procedure.

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Definition of terms

THE SCRUB One who performs the handscrubbing technique, dons sterile gown andgloves, set the sterile field.

UNSTERILE Inanimate object that has notbeen subjected to a sterilization process;outside wrapping of package containing

sterile item. WRAPPER TAIL The edge of the linen

wrapper.

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PRINCIPLES OF STERILETECHNIQUE

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Only sterile items are used within sterilefield.

If in doubt about the sterility of anything

consider it not sterile. Sterile person are gowned and gloved.

Gowns are considered sterile only in front from

the chest level of the sterile field, and thesleeves from above elbows to cuffs. Sterile onlyin the area you can see in front down to thelevel of the sterile field.

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Sterile person are gowned and gloved. Gowns are considered sterile only in front from

the chest level of the sterile field, and the

sleeves from above elbows to cuffs. Sterile onlyin the area you can see in front down to thelevel of the sterile field.

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Tables are sterile only at table level. Only the top of the sterile draped table is

considered sterile. Edges and sides extending

below table level are considered unsterile. The scrub person does not touch the part

hanging below table level.

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Unsterile persons avoid reaching over thesterile field; Sterile person avoid leaningover unsterile area.

Unsterile circulator never reaches over a sterilefield to transfer sterile item.

Scrub person stands back from the unsteriletable when draping it to avoid leaning over anunsterile area.

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The scrub person sets basin or glasses to befilled at the edge of the sterile field; thecirculator stands near this edge of the table tofill them.

Surgeon turns away from the sterile field tohave perspiration removed from the brow.

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Edges of anything that encloses sterilecontent are considered unsterile.

In opening a sterile packages, a margin of safety

is always maintained. Sterile field is created as close as possible

to time of use.

Sterile tables are set upjust before the surgicalprocedure. Covering sterile tables for later used is not

recommended.

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Sterile areas are continuously kept in view. Sterile person face only sterile area. Sterility cannot be ensured without direct

observation. An unguarded sterile field should be considered

contaminated.

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Sterile person keep well within sterile area. Sterile persons pass each other back to back at

a 30 degree turn.

A sterile person faces a sterile field or area topass .

A sterile person stay within the sterile field.They do not walk around or go outside the

room.

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Sterile person keep contact with sterileareas to minimum.

Sterile person do not lean on sterile table or on

the draped patient. Sitting or leaning against an unsterile surface is

a break in the technique.

C S O S

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Unsterile persons avoid sterile areas. Unsterile person maintain a distance of at least

1 foot( 30 cm ) from any area of the sterile

field. Unsterile persons face and observe a sterile

area when passing it to be sure they do nottouch it.

Unsterile persons never walk between twosterile fields.

Circulator restricts to a minimum all activitynear the sterile field.

PRINCIPLES OF STERILE

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Destruction of integrity of microbial barriersresults in contamination.

Strike through is the soaking through of barrier

from sterile to non-sterile to vice versa. Microorganism must be kept to irreducible

minimum.

A perfect asepsis is an idea. All microorganismscannot be eliminated. Skin cannot be sterilized.Air is contaminated by droplets.

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TYPES OF SURGERY

Major surgery These are surgeries of thehead, neck, chest and abdomen. Therecovery time can be lengthy and may

involve a stay in intensive care or severaldays in the hospital. There is a higher riskof complications after such surgeries.

Removal of brain tumors Correction of bone malformation and

amputations. Exploratory laparotomy

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TYPES OF SURGERY

Minor surgery These surgeries are mostoften done as an outpatient, and patientcan return home the same day.

Hernia repair Excision Biopsy

Removal od skin lesion Cauterization

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TYPES OF SURGERY

Elective surgery These are procedures yourpatients decide to undergo, which may behelpful, but are not necessary essential.

Removal of warts Any plastic surgery/repair.

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TYPES OF SURGERY

Required surgery These are proceduresthat need to be done to ensure the qualityof your patients life in the future.

Cheiloplasty Spinal fusion to correct severe curvature

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TYPES OF SURGERY

Urgent or Emergency This type of surgeryis done in response to an urgent medicalneed.

Vehicular accident Gun shoot Ruptured appendicitis

Ectopic pregnancy Etc.

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PHASES OF SURGERY

PRE OPERATIVE PHASE

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PRE OPERATIVE PHASE

This is the time period between the decisionto have surgery and the beginning of thesurgical procedure.

This is a period during which the nurse admitsthe patient to the surgical unit and help in theindividual prepare physically and emotionallyfor the operation.

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PREADMISSION PROCEDURES

Tests and records must be completed andavailable when the patient is scheduled forelective surgical procedure. Pre operative

preparations include: Medical history and physical examination. These

must be done and documented by a physician.

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Laboratory tests. Testing should be based onspecific clinical indicators or risks factors thatcould affect surgical management oranesthesia. These include age, sex, pre-existingdisease, magnitude of surgical procedure, andtype of anesthesia.

Hemoglobin, haematocrit, BUN, and blood glucose( for 60 yrs and older ).

Hematocrit( usually ordered for women of all agesbefore administration of general anesthesia. )

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CBC, platelet count, activated partialthromboplastin time, and prothrombin time may bealso ordered.

Urinalysis may be indicated by medical history

and/or physical examination. Blood type and cross-matched. If transfusion is

anticipated. Chest x-ray film. (This maybe medically

indicated as an adjunct to clinical evaluation ofpatients with cardiac or pulmonary disease andfor smokers, person age 60 and older, andcancer patients.)

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ECG ( for the patient 40 years and older) Written instructions.

NPO after midnight

Skin preparation to prepare the surgical site.Surgical procedureon the face, ear, or neck areadvised to shampoo hair .

Nail polish and acrylic nail should be removed topermit observation on the nail bed during surgical

procedure. Jewelry and valuables should be left at home to

ensure housekeeping.

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Informed consent. The patient and legal desingnee must give consent

for the surgical procedure. After explaining thesurgical procedure and its risk, the surgeon may

have the patient sign the consent form. The nurseshould witness in signing of the consent.

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Bowel preparation. Enemas till clear may beordered when it is advantageous to have thebowel and rectum empty.

Douche. A douche to cleanse the vagina may beordered before a vaginal or pelvic procedure. Bedtime sedation for sleep.

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PRE OPERATIVE CHECKLIST

Patient puts on a hospital gown. Jewelry is removed for safe housekeeping. Dentures and removable bridges are

removed before administration of generalanesthesia to prevent obstruction torespiration.

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All removable prostheses, such as eyes,extremity, contact lenses, hearing aids, eyeglasses are removed for safe housekeeping.

Long hair maybe braided. Hairpin isremoved to prevent scalp injury.

Antiembolicstockings or elastic bandages

may be ordered for lower extremities toprevent embolic phenomena.

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The patient voids to prevent over distentionof the bladder or incontinence duringunconsciousness. Time of voiding is

recorded. If ordered antibiotic is given to increase the

blood level preoperatively.

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Preanesthesia medications are given asordered.

The patient, bed, and chart are accurately

identified, and identifications are fastenedsecurely in place. Allergies should beprominently noted on the chart.

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NOTE: Preoperative checklist helps ensurethat the patient has been properlyprepared. If preparation is inadequate, the

surgical procedure may be cancelled. Allessential records, including the plan of care,must accompany the patient.

PREOPERATIVE ASSESSMENT AND

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PREOPERATIVE ASSESSMENT ANDTEACHING

Assessment of clients physical andpsychological condition.

General appearance: skin, coloring, weight.

Level of anxiety.

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Preoperative instructions like: Importance to preoperative lab tests and

diagnostic exam.

Discuss bowel and bladder preparation. Discuss skin preparation.

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Explain the need to restrict food and fluid atleast 8 hours prior to surgery.

Explain individual contraptions ordered byphysicians. Ex. IV therapy, nasogastric tube,etc.

Inquire about allergies to drugs and food if any.

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Teach and explain the importance ofmoving, turning, leg exercises, deepbreathing and coughing exercises.

Check the following documents. Clinical cover sheet Consent for surgery.

Doctors order sheet CP/OB Gyne/ pedia clearance.

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PHASES OF SURGERY

INTRA OPERATIVE PHASE

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Recheck identification of the patient andreview of chart contents by the circulatingnurse.

Assists in the transferring of the patient tothe OR table, proper positioning duringinduction of anesthesia and in surgery.

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Know the 4 stages of anesthesia. Stage 1 : INDUCTION. This is the period between

the initial administration of the medication and

loss of consciousness. Nursing management arethe following: close OR room, keep the roomquite, stand by to assists the client.

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Stage II: EXCITEMENT. It is the period followingthe loss of consciousness and marked bydelirious activity. The heart rate and respirationis irregular, there may be uncontrolled

movements. The combination of spasticmovement and irregular respiration this maylead to airway compromise , rapidly actingdrugs are used to minimize time in this stageand reach stage 3 as fast as possible. Nursingmanagement are the following: Remain quite atthe clients side, Assists the anesthesiologist ifnecessary.

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Stage III: SURGICAL. During this stage, theskeletal muscle relax, and the patientsbreathing becomes regular, eye movement

slow, then stop, and surgery can begin.Nursing management is to get ready for theoperation and take note of the cutting time.

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Stage IV: OVERDOSE/DANGER. This is the stagewhere too much medication has been given andthe patient has severe brain stem or medullarydepression. This result in a cessation of

respiration and potential; cardiovascularcollapse. This stage is lethal withoutcardiovascular and respiratory support. Nursingmanagement is if arrest occur, assistsimmediately in establishing airway, providecardiac arrest tray, drug, syringes, assistssurgeon with cardiac massage.

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Responsibilities of the scrub nurse: Prepare instrument s and supplies Establishing and maintaining the sterile field

Anticipating procedural steps and surgeonsneeds

Caring for the instruments Cleaning routines after the procedure.

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Responsibilities of the circulating nurse: Helps in the positioning of the patient during

induction of anesthesia

Preparing the operative area by the surgeon Anticipating needs and requirements of the

surgery Caring for specimens, instruments. Cleaning routine after the procedure.

sponges, sharps and instruments counts bythe scrub and circulator.

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COUNTING PROCEDURE

A counting procedure is a method of accountingfor items put on the sterile table for use duringthe surgical procedure, Sponges, sharps, andinstruments should be counted on all

procedures.

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COUNTING PROCEDURE

INITIAL COUNTING The scrub person should touch each item, he or she

and the circulator number each one aloud until allitems are counted.

The circulator immediately records the count foreach type of item on the sponge sponge countsheet/form.

Counting should not be interrupted. If uncertain

about the count because of interruption, fumbling,or any other reason, repeat it.

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COUNTING PROCEDURE

FIRST COUNTING Counts are taken in three areas before the surgeon

starts the closure of a body activity or a deep orlarge incision.

Field count Either the surgeon or the assistantassists the scrub person with the surgical fieldcount. This area may be counted first. Counting thisarea last could delay closure of the patients woundarea prolong anesthesia.

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COUNTING PROCEDURE

Table count The scrub person and the circulatortogether they count all items on the mayo table andback up table. The surgeon and the assists may beclosing the wound while this count is in process.

Floor count - The circulator count sponges and anyother items that have been recovered from the flooror passed off the sterile field. These count shouldbe verified by the scrub person.

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Strict implementation to principles andprocedures of asepsis, disinfection,sanitation and safety precautions and

practices. Proper documentation in-patient chart.

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PHASES OF SURGERY

POST OPERATIVE PHASE

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POS OP RA P AS

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After the operation the patient istransferred to the recovery room on thestretcher following GA, SA, etc. a complete

endorsement on the status of the patient,procedure, medication given, wound anddressing and allergies if any is given to therecovery room nurse by the perioperativenurse.

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Monitoring of vital signs (T,RP,RR,BP,Temp)every 15 mins per doctors order.

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Positioned clients comfortably on bed andprovide side rails.

Unconscious patient is positioned on side; no

pillows with race slightly down, thus preventingocclusion of the larynx and allowing drainage ofmucous and vomitous.

Clients who have had spinal anesthesiais to

remain flat on bed for a specified period oftime.

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Assess level of consciousness, orientation totime, place and person.

Not responding

Arousable on calling Fully awake

Provide adequate airway.

Suction airway as indicated.

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Check for the presence of protectivereflexes, Ex. Gag, cough. Ability to moveextremities and color of the skin, lips, nail

beds. Ex. Pale, blotchy, cyanotic, jaundiced. Check condition of operative site, status of

dressing, patency character and amount of

drainage from catheters, tubes and drains.

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Assess the type, location and severity ofpain and any side effects such as nausea andvomiting. Medicate the client as indicated.

Provide safety using side rails.

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Assess the type and amount of intravenousfluids, flow rate and infusion site.

Monitor fluid intake and output

Watch for signs of circulatory overload. Ensure that the replacement of fluids lost

during surgery is sufficient to maintain bloodpressure.

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Encourage deep breathing and coughingexercises, leg exercises, moving, turning toprevent post-op complications.

Pain management . Patient should be taught on how to rate their

discomfort on a pain scale of 1-10. Use alternative methods of pain control may

also be presented like: Destruction, imagery,positioning, music therapy.

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Refer to surgeons as necessary. Proper documentation.

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INSTRUMENTATION

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INSTRUMENTATION

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P t f th i t t

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Parts of the instrument

Finger ring/ring handle Provides a placefor the user to place his her fingers and gripthe instrument securely.

Ratchet Allows the instruments to belocked in place.

Shank Connects the boxlock to the finger

ring. Box lock Controls the jaws of the

instrument. Also known as the hinge joint.

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P t f th i t t

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Jaws Along with the tip is the workingparts of the instruments. The jaw maybesmooth, serrated,or cross-hatched for

grasping tissue or suture. Jaws can bestraight or curved to various degrees,depending on the intended use of theinstrument.

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Parts of the instr ment

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Tip The tip can be pointed or round andhave teeth or no teeth (atraumatic). Theintended use of the instruments determines

the number of teeth the tip has and how thetip is designed.

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4 Main categories of the

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ginstruments

Dissectors - Which may be blunt or sharp,are instruments designed to cut andseparate tissue and bone.

Scissor metzenbaum or iris Scalpel/blade

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ginstruments

Clamps/forceps Are instrument specificallydesigned for holding tissue or othermaterials, most have an easily recognizable

design. Occluding clamp/forcep usually have vertical

serrations or finely meshed multiple rows oflongitudinal teeth to prevent leakage and to

minimize trauma when clamping vessels. Ex.Mosquito curve and Kelly curve.

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ginstruments

Grasping or holding instruments are used tograsp and hold tissue or bone for dissection orretraction or to assists suturing. Ex; Ochsner(grasp slippery tissue such as fascia), Allis (has

multiple fine teeth on the tip so as not to crushor damage tissue.) Bobcock (has curved tip withno teeth, and it grasp delicate structures suchas ureters, fallopian tubes.)

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ginstruments

Non clamp graspers Also known as tissueforceps or pick ups and are designed to griptissue with a minimum amount of trauma. Pickup with teeth are used in thick or slippery

tissue. Pick up without teeth can be used ondelicate thin tissue.

Grasping clamp Can hold objects as well.Sponge forcep can be used to hold tissue,however, they are most frequently used to holdgauze sponges.

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ginstruments

Retractors Are used to assists invisualization of the operative field. They aredesigned to provide a best exposure with a

minimum of trauma to the surroundingtissue. Retractors comes in various sizeswith the blade usually at a right angle tothe handle.

Manual Are retractors manipulated by hand.Ex. Army-navy, Richardson, bladder, etc.

Permanent Instruments with screw. Ex: self-

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ginstruments

Accessory instruments Are designed toenhanced the use of basic instrumentationor facilitate the procedure.

suction tip, cautery pencil, dilators, probe

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Stages of anesthesia

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Stage 1 - INDUCTION It is the period between the initialadministration of the medication andloss of consciousness. During this stagethe patient progresses from analgesiawithout amnesia . Patient can carry outa conversation at the same time.

Nursin Mana ement: 8383 activity. The patients heart rate and

i ti t b i l Th

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respiration rate may be irregular. Theremay be uncontrolled movement, breath

holding, vomiting. The combination ofspastic movement, vomiting and irregularrespiration may lead to airway compromise.

Rapid acting drugs are used to minimizetime in this stage and reach stage 3 asap.

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Stage 111 SURGICAL

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Stage 111 - SURGICAL

During this stage, the skeletal muscle relax,and the patients breathing becomes regular eye movements becomes slow then stop,

and surgery can begin. Nursing Management:

a. Begin the skin preparation only when the

anaesthesiologists permits to start, and thepatients breathing is stable and the rest ofthe V/S.

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Stage 1V OVER DOSE/DANGER

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Stage 1V OVER DOSE/DANGER

This is the stage where too much medicationhas been given and the patient has severemedullary depression (brain stem). This

result in cessation or respiration andpotential cardiovascular collapse. This stageis lethal without cardiovascular andrespiratory support.

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Nursing Management: a. Assists immediately in establishing

airway, provide cardiac arrests tray , drugs,

syringes, long needles. b. Assists surgeon with open cardiac

massage.

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COMMON TYPES OF ANESTHESIA

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COMMON TYPES OF ANESTHESIA

1. General A state of unconsciousnessproduced by anaesthetic agent, with thedesired results of amnesia, analgesia, and

muscle relaxation. Sensation of pain all overthe body is controlled. Drugs used: Inhalation-halothane, isoflurane

Intravenous-propofol, ketaminehydrochloride

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Local or Regional block This type ofanaesthesia is produced in a limited areaand does not affect the consciousness of the

client. The sensory nerves in one area orregion of the body are anaesthetized. A. Topical anaesthetic drug is applied

directly to the skin or into an open wound. B. Local infiltration drug is injected

intracutaneously and subcutaneously intothe tissue.

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Spinal or Epidural Anaesthesia This type ofanaesthesia is produced by injecting anagent beneath the membrane of the spinal

cord. Sensation of pain is blocked at a levelbelow the diaphragm. There is no loss ofconsciousness in clients which had beengiven spinal or epidural anaesthesia.

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