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Roles:
1. Surgeon
- responsible for determining the preoperative dis, the diagnosis, choice and execution of the surgical
procedure, the explanation of the risk and benefits, obtaining inform consent and the postoperative
management and the patient’s
2. Scrub nurse
- RN or scrub tech
- Preparation of supplies and equipment on the sterile field; maintenance of patient safety and integrity:
observation of the scrubbed team for breaks in the sterile fields; provision of appropriate sterile
instrumentation, sutures, and supplies; sharps count
3. Circulating nurse
- Responsible for creating a safe environment, managing the activities outside the sterile field, providing
nursing care to the patient
- Document intraoperative nursing care and ensures surgical specimens are identified and placed in the
right media
- In charge of the instrument and sharps count and communicating relevant information to individual
outside of the OR, such as family members
4. Anesthesiologist and anesthetist
- Anesthetizing the patient appropriate levels of pain relief, monitoring the patient’s physiologic status
and providing the best operative conditions for surgeons
5. Other personnel
- Pathologist, radiologist, perfusionist, EVS personnel
Prevention of infection
The surgical environment – stark appearance and cool temperature. Located central to all supporting services
o Unrestricted zone – where street clothes are allowed
o Semi restricted zone – where attire consists of scrub clothes and caps
o Restricted zone – where scrubs clothes, shoe covers, caps, as masks are worn
Surgical asepsis
o Ensure sterility
o Alert of breaks – surgical conscience
o Surgical conscience
The awareness, which develops from a knowledge base, of the importance of strict adherence
to principles of aseptic and sterile techniques
Guidelines:
All materials in contact with the wound and within the sterile field must be sterile
Gowns are sterile in the front from chest to the level of the sterile field and sleeves form
2 inches above the elbow to the cuff
Only the top of a draped table is considered sterile. During draping, the drape is held
well above the area and is placed from front to back
Whenever a sterile barrier is breached, the area is considered contaminated
Every sterile field is constantly maintained and monitored. Items of doubtful sterility are
considered unsterile
Sterile field are prepared as close as possible to time of use
Before an operation:
It is necessary to sterilize and keep all instruments, materials, ad supplies that come in
contact with the surgical site
Every item handed by the surgeon and the surgeon’s assistants must be sterile
The patient’s skin and the hands of the members of the surgical team must be
thoroughly scrubbed, prepared, and kept as aseptic as possible
Dayak – is an indicator of sterility; will change color; clear but will change into a darker
color when already sterile
Surgeons will do the final painting
During the operation
The surgeon, surgeon’s assistants, a d the scrub burse must wear sterile gowns and
gloves and must not touch anything that is not sterile
Maintaining a sterile technique is a cooperative responsibility of the entire team
Each member must develop a surgical conscience, a willingness to supervise and be
supervised by others regarding the adherence to standards
All personnel assigned to the operating room must practice god personal hygiene. This
includes daily bathing and clothing change
Those personnel having colds, sore throats, open sores, and/or other infections should
not be permitted in the operating room
Operating room attire (which includes scrub suits, gowns, head coverings, and face masks)
should not be worn outside the operating room suite. If such occurs, change all attire before re-
entering the clean area. (the operating room and adjacent supporting areas are classified as
“clean areas”)
All members of the surgical team having direct contact with the surgical site must perform the
surgical hand scrub before the operation
All materials and instruments used in contact with the site must be sterile
The gowns worn by surgeon and scrub and other scrub members are considered sterile
from shoulder to waist (in the front only), including the gown sleeves
If sterile surgical are torn, punctured, or have touched an unsterile surface or item, they
are considered contaminated
The safest, most practical method of sterilization for most articles is steam under pressure
Label; all prepared, packaged, and sterilized items with an expiration date
Use articles packaged and sterilization in cotton muslin wrappers within 28 calendar days
Use articles sterilized in cotton muslin wrappers and sealed in plastics within 180 calendar days
Unsterile articles must not come in contact with sterile articles
Make sure the patient’s skin is as clean as possible before a surgical procedure
Take every precaution to prevent contamination of sterile areas or supplies by airborne
organisms
When you are changing a dressing, removing sutures, or preparing the patient for a surgical procedure, it will be
necessary to work . the field should be established on a stable, can, flat, dry surface
An article is either sterile or unsterile; there is no in-between. If there is doubt about the sterility of an item,
consider it unsterile
Any time the sterility of a filed has been compromised, replace the contaminated field and setup
Do not open sterile articles until they are ready to use
Do not leave sterile articles unattended once they are opened and placed on a sterile field
Do not return sterile articles to a container once they have been removed form the container
Never reach over a sterile field
When pouring a sterile solution into sterile containers with the solution bottle. Once opened and first poured,
use bottles of liquid entirely. If any liquid is left in the bottle , discard it
Never use an outdated article. Unwrap it, inspect t it, and if reusable, rewrap it in a new wrapper for sterilization
**ASA Classfication
Anesthetic Triad
1. Analgesia-NOL Monitoring
2. Amnesia-BIS
3. Muscle relaxation
Phases of Anes
1. Induction
2. Maintenance
3. Emergence
Anesthesia agents
1. Gas
a. Nitrous oxide
Advanteage : light analgesia
Disadvantage: accumulation in airway spaces
2. Volatile liquieds
a. Isoflurane
Adva
b.
General Anesthesia
Reversible loss of consciousness is induced by inhibiting neuronal impulses in several areas of the central
nervous system
State can be achieved
Intravenous agents
- Agents than produce anesthesia in large doses through sedative- hypnotic-analgesic actions
- 3 categories:
Barbiturates and others
- Act directly in the CNS producing and effect ranging form mild sedation to sleep
- Thiopental Sodium, Ketalar, Propofol (diprivan) – MJ used; milky white
Opioid analgesics
- Pain free
- Demerol, morphine sulfate, valium
Muscle relaxants
- Anesthesia adjuncts
- Provide muscle relaxation during surgery and/or facilitate the passage of an
endotracheal tube
- Pavulon, norcuron, tracrium, etc.
Complications
Epidural (pedidural)
- Involves the injection of an anesthetic agent into the epidural space, the area outside
the dura mater, but inside spinal column
- Administered via bolus injection or through a small, thin catheter
- Can be used for anorectal, vaginal, and perineal as well as higher intraabdominal
procedures
- Injected into epidural space rather than subarachnoid fluid (usually safer)
- Used in OR and OB
- Epidural catheter can be left in place for postop pain management (PCA)
General anesthesia
- Reversible loss of consciousness is induced by inhibiting neural impulses in several areas of the central
nervous system
- State can be achieved by a single agent or a combination of agents
- Central nervous system is depressed, resulting in analgesia, amnesia, and unconsciousness, with loss of
muscle tone and reflexes
- Effects:
The body systems affected by general anesthetics are neurologic, respiratory, and
cardiovascular systems
General anesthesia is best suited surgery of the head, neck, upper torso, and back: for
prolonged surgical procedures: or for clients are unable to lie quietly who are unable to
prolonged period of time
General anesthetics agents affect all tissues in the body to some degree
- Stages:
Stage 1 – onset (amnesia/analgesia)
- From administration to loss of consciousness
- Assessment
o client maybe drowsy or dizzy
o may experience auditory or visual hallucinations
- Nursing interventions
o close O.R. doors
o keep room quiet
o standby to assist anesthesiologist
Stage 2 – excitement/delirium
- Loss of consciousness to loss of eyelid reflexes
- Most dangerous stage
- Assessment
o increase autonomic activity
o irregular breathing
o client may struggle
- Nursing interventions
o Remain quietly at client’s side
o Assist anesthesiologist, if needed
o Remain alert for any emergency situations
o Considered an extremely dangerous stage that could result in laryngospasms
o Vomiting
o Aspiration
o Arrythmias
o Myoclonic movement - twitches or jerks usually are caused by sudden muscle
contractions, called positive myoclonus, or by muscle relaxation, called
negative myoclonus
Balanced anesthesia
- Combination of intravenous drugs and inhalation agents used to obtain specific effects
- Combination used to provide hypnosis, amnesia, analgesia, muscles relaxation, and reduced reflexes
with minimal disturbances of physiologic function
Conscious sedation
- IV delivery of sedative, hypnotic and opioid drugs reduces the level of consciousness but allows the
client to maintain a patent airway and to respond to verbal commands
- Most common drugs
Diazepam Fentanyl
Midazolam Alfentanil
Meperidine
- Nursing Assessment
Airway
Level of consciousness
Oxygen saturation
Electrocardiographic status
Vital signs – monitored q 15 min
Intraoperative Complication
- Signs and symptoms
Tachycardia – most consistent early symptoms; usually sudden and unexplained
Tachypnea
Unstable BP
Arrythmias
Dark blood at the surgical field
Cyanosis and mottling of skin
Profuse sweating
Fasciculations and/or rigidity
Metabolic/respiratory acidosis
Sudden rise in temperature (43°C)
TYPES OF SUTURES
- Absorbable or non-absorbable
- Monofilament or multifilament (braided)
- Dyed or undyed
- Sized 3 to 12-0 (numbers alone indicate progressively larger sutures, whereas numbers followed by 0 indicate
progressively smaller)
- New antibacterial sutures
- Non-absorbable - Absorbable
Not biodegradable and permanent Degraded via inflammatory response
Nylon Licryl monocryl
Prolene PDS
Stainless steel Chromic
Silk (natural, can break down over Cat gut (natural)
years)
SURGICAL NEEDLES
- wide variety with different company’s naming systems
- 2 basic configurations for cured needles
Cutting – cutting edge can cut through tough tissues, such as skin
tapered – no cutting edge. for softer tissues inside the body
WOUND EVALUATION
- Time of incident
- Size of wound
- depth of wound
- tendon/nerve involvement
- bleeding at site
NURSING PROCESS
Intervention
o Safety
o Advocacy
o Verification
o Counting – SIN (sponges, instruments, needles)
Evaluation
o Expected
o Unexpected
o Documented
o Informing client and family
o Surgical wating room
o Ongoing updates by OR team
INTRAOPERATIVE SAFETY
Is a method of aachieving rapid control of the airway while minimizing the risk of regurgitation and aspiration of gastric
contents.
Commonly used where GA must be induced before the patient has had the time to fast long enough to empty the
stomach
Steps:
Application of backward pressure on the cricoid cartilage with a force of 20-40 newtons to occlude the
esophagus, preventing aspiration of gastric contents during induction of anesthesia.
Adjuncts to Anesthesia
TIVA/TCI
A technqieu of GA which uses a combination of agents given exclusively by the IV route without the use fo
inhilation agents
Marsh and Schnider models
Sensory nerve impulse transmission from a specific body area or region is briefly disrupted
Motor fuction my be affected
Client remains conscious and able to follow instructions
Gag and cough reflexes remain intact
Sedatives, opioid analgesics, or hypnotics are often used as supplements to reduce anxiety