Sei sulla pagina 1di 109

Operating Room Nursing

 At the end of the course, the student is expected to: 1. Identify the different phases of surgery.

Vergel G. Leonardo RN, MAN




The course focuses on understanding the basic concepts, and principles related to surgery in providing various supportive measures from the members on the health team.

Providing a client with specific needs during the different phases of surgery, the student will be able to meet the needs of the patients and share the various learned during the learning process
1. Discuss the nursing responsibilities during the different phases of surgery.

A. Psychological Preparation


a.1. General Fear

a.1.1. Fear of unknown a.2. 1. Fear of destruction of body image a.2. 2. Treat to sexuality a.2. 3. Fear of permanent disability a.2. 4. Fear of dying a.2. 5. Fear of pain

 a. 2. Specific Fear

Nursing Process Application  a.3. ASSESSMENT  a.3.1. Subjective Data  a.3.2. Objective Data  a.4. Intervention

B. Physiological Preparation
b. 1. Age b. 2. Nutrition b. 3. Presence of Disease Conditions  b.3.1. Cardiovascular disease  b.3.2. Respiratory disease  b.3.3. Elimination disturbances  b.3.4. Endocrine disturbances  b.3.5. Prior Drug Therapy

C. PHYSICAL PREPARATION  C.1. Gastrointestinal  C.2. Urinary  C.3. Circulatory  C.4. Integumentary  C.5. Nervous

d. 1.Consent d. 2.Religion d. 3.House Rules


a.1. Surgeon a.2. Ass. surgeon a.3. Anesthesiologist a.4. Scrub Nurse a.5. Circulating Nurse



B.1. Types of Anesthesia B.2. Stages of Anesthesia

Principles of Aseptic technique  D. Positioning: During surgery  . Physical Set-up : SetInstrumentation


 Major Lap Set:  Minor Lap Set


Immediate Postoperative or Postanesthetic Phase.  B. Early postoperative Phase ( Return of the patient to the unit)  C. Discharge Planning  Others:  Nursing care Plan:



30% ..40% .15% ..15% ..15%




Nancymarie Philipps, Berry & Kohn s Operating Room Technique, tenth edition, 2004 by Mosby, Inc. Susan C. Dewit, Keanne s Essentials of MedicalMedicalSurgical Nursing, Third Edition, W. B. Sauders Co., ( ANY EDITION) Heidi C. Dyangko, RN, Ed.D. Operating room Technique Instructional Manual, Fifth edition, Busybook 2003. ANY M-S BOOKS (applicable). MPrepared by: Vergel G. Leonardo RN, MAN

OR Historical Background begins:

Historical development of surgery comes from:  Babylonian law- The code of lawHammurabi (1955-1913 B.C.) (1955 According to this law: If the patient died after a surgical procedure, retribution would reflected on the surgeon in the form of amputation of his right hand.

Another history says : According to the ancient Persians there be a 3x successful procedures before being pronounced as a competent to practice surgery.

In the history of surgery Claudius Galen (130(130200)

considered the father of experimental physiology.  Remained a primitive practice and lacked a scientific base research for the next 1200 years.  Until 19th century the early teams (surgeon / surgical nurses) recognized that the complexity of the surgical procedures were dynamic.

Definition of Terms
PeriPeri-operative nursing - total surgical experience that encompasses with pre-operative, preintraintra-operative, and post-operative postphases of patient care Operating room / Operating theatre - room in a health care facility in which patients are prepared for surgery, undergo surgical procedures, and recover from the anesthetic procedures required for surgery

Definition of Terms
Surgery - branch of medicine concerned with disease or conditions requiring or amenable to operative or manual procedures Surgical procedure - invasive incision into body tissues or minimally invasive entrance into a body cavity for either therapeutic or diagnostic purposes during which protective reflexes or self-care selfabilities are potentially compromised

Definition of Terms
Surgical conscience - awareness which develops from a knowledge base of the importance of strict adherence to principles of aseptic and sterile techniques OR nurse - duly licensed registered nurse legally responsible for the nature and quality of the nursing care patients

Definition of Terms
Asepsis - freedom from infection or absence of microorganism Sepsis - general reaction from the action of bacteria or their products.

Definition of Terms
Disinfection - process of destroying all pathogenic microorganisms except spore bearing ones Aseptic technique - methods by which contamination of microorganism is prevented

Definition of Terms
Antiseptic - substance which combat sepsis and cause bacteriostasis Anesthesia - insensibility to pain and trauma with or without loss of consciousness

Common Indications For Surgical Procedures

 DiagnosticDiagnostic RepairRepair RemovalRemoval Reconstruction  Palliation

Biopsy tissue closing of a hernia Foreign body CreationCreation-new breast relief of obstruction

Common Indications For Surgical Procedures Aesthetics facelift Harvest skin grafting Procurement Donor organ Transplant placement of DO

Common Indications For Surgical Procedures  Bypass / Shunt vas. Rerouting


/ Evacuation I&D repair of a frac C/S

 Stabilization  Parturition

Common Indications For Surgical Procedures

 Termination  Staging  Extraction  Exploration  Diversion

abor.of pregnancy checking of CA removal of invasive exam. creation of stoma for urine

Expected or Attributes Behavior of OR nurse / Perioperative Nursing


/ sincere  Empathy  Efficiency and well organized  Conscientious  Flexible and adaptable  Sensible and perceptive  Open-minded Open Supportive and understanding

Expected or Attributes Behavior Of Perioperative Nurse


/ impartial,  Versatile, intellectual & curious  Sense of humor  Ethical  Enduring  Objective  Creative  considerate

Operating Room Nurse

Is intellectually and physically

demanding yet rewarding always challenging, never tedious.

FOUR MAJOR TYPES OF PATHOLOGIC PROCESSES REQUIRING SURGICAL INTERVENTION. O BSTRUCTION. Impairment to the flow of vital fluids. E.g blood, urine, CSF, bile.  P ERFORATION. Rupture of an organ  E ROSION. Wearing off of a surface or membrane.  T UMOR. Abnormal new growth


1. According to PURPOSE a. Diagnostic. To establish the presence of Diagnostic. a disease condition. E.g biopsy. b. Exploratory. To determine the extent of Exploratory. the disease condition. E.g. exploratory laparotomy. laparotomy. c. Curative. To treat the disease Curative. condition. c.1 Ablative. Involves removal of an organ ( suffix used is ectomy )

c.2 Constructive. Involves repair of Constructive. congenitally defective organ.( suffix used are plasty , orrhaphy , pexy ) e.g. cheiloplasty, cheiloplasty, c.3 Reconstructive. Involves repair of Reconstructive. damaged organ. E.g. plastic surgery after severe burns. d. Palliative. To relieve distressing Palliative. signs and symptoms, not necessarily to cure the disease.

2. According to Degree of RISK (Magnitude / Extent) Major Surgery Minor Surgery

Criteria for Major Surgery

high risk Extensive & prolonged Large amount of blood loss Vital organs may be handled or removed Great risk of complications

Criteria for Minor Surgery

generally not prolonged leads to few serious complications involves less risk

3. According to URGENCY
Emergency. Emergency. To be done immediately to save life.( Limb if affected) Planned Required. Necessary for well Required. being. May be scheduled weeks or months. Elective. Elective. Not absolutely necessary for survival. Delay or omission will not cause adverse effect. Optional. Optional. Requested by the client. Usually for aesthetic purposes. Day ( Ambulatory Surgery). Done on out patient basis.



response is elicited.  Defense against infection is lowered.  Vascular system is disrupted.  Organ function are disrupted.  Body image may be disturbed.  Lifestyles may change.

Phases Of Perioperative Nursing


phase  Intraoperative phase  Postoperative phase

Preoperative Phase

nursing care begins with the nurse s initial contact with the surgical patient.  The goal of the preoperative patient is to identify individual needs in order that accepted protocols of care can be modified or accepted.


would include observing for alteration in : normal physiologic functioning, determining specific nutritional needs, evaluating current pharmacotherapy, and identifying psychosocial patterns of behavior.

assessment process should result in a detailed nursing care plan.



kind of surgery whether major or minor is always preceded by emotional as well as physiological changes hence, the need for extensive preparations. These are presented into:

Preoperative Care

Care  Preoperative Teaching  Physical Care  Nurses Responsibility

A. Psychological Preparation
Fears related to surgery  General fear - fear of the unknown-worst fear of all. unknown- what to expect and what are the consequences of surgery - nursing action: allay anxieties by giving the patient opportunities to express his/her fears

A. Psychological Preparation
Fears related to surgery  Specific fears - fear of destruction of body image - threat to sexuality - fear of permanent disability - fear of pain - fear of dying

Application Of Nursing Process / NCP

Assessment  Subjective - know the level of understanding of the patient - type of surgery - site - information from surgeon regarding extent of hospitalization - limitations - tests - cost of hospitalization - support from family, religion, & friends

Application Of Nursing Process /Nursing Care Plan

Assessment  Objective *signs of anxiety differ from person to person - highly anxious person may talk rapidly, ask too many questions, repeat same questions, deny worries, or withdraw & refuse to talk to people, & avoid topics related to feelings - increased PR, RR, BP (physical signs) - restlessness, constant hand movement, sweating - frequent voiding, changes in sleep patterns - angry, resentful & aggressive behaviors

Application Of Nursing Process / Intervention:

Goal: (Nursing Diagnosis ) Ex: To decrease the level of anxiety / fear - conclusions based on analysis & interpretation of human response patterns revealed by the assessment data *Medical Diagnosis - defines problems on the basis of a patient s pathologic conditions

Application Of Nursing Process

Outcome Identification  Expected perioperative outcomes are the desired patient objectives after a surgical intervention  Patient s rights and preferences are the cornerstone for expected outcomes  Realistic, attainable, & consistent with medical regimen  Results of care should be documented in standardized language  Examples - absence of physical injury - maintenance of skin integrity - maintenance of fluids & electrolytes balance balance

Application Of Nursing Process

Planning  Should reflect current standards, facilitates the prescribed medical care, & work toward attainment of desired outcomes  The scope of plan is determined by assessment data  Example - patient will demonstrate understanding of the procedure - patient will be injury-free injury- patient will be infection-free infection- patient will remain physiologically stable - patient will demonstrate psychologic comfort - patient will return to normal activities of daily living

Application Of Nursing Process

Implementation  Plan of care is implemented throughout the perioperative period  Scientific principles provide the basis for patient care interventions that are consistent with the plan for continuity of patient care in the perioperative environment  Suggested interventions - identify concerns if he/she is given opportunities to talk about - allowing the patient & the family to participate in decisiondecision-making concerning his/her care helps the patient meet his/her need for control - fear of the unknown can be partly relieved by providing information

Application Of Nursing Process

Evaluation  Continual process of reassuring the patient and his/her responses to implementation of the plan of care  Examples - Risk for deficient knowledge patient verbalizes understanding - Risk for impaired skin integrity patient s skin remains intact - Risk for hypothermia patient is normothermic - Risk for injury patient is free from injury



PostPost-op exercises Equipment used during post-op period post- oxygen, pulse oximeter, CVP - ventilator - NGT - IV medications - foley catheter Pain medication and when to request it - Patient-Controlled Anesthesia (PCA) PatientNPO

Preoperative Teaching


surgery is performed, the patient undergoes several tests. There are several factors which may affect the patient s response to surgery, therefore, it is necessary to obtain the essential data to identify potential problems. Factors that affects are as follows:

Physiologic Preparation
Factors that affect surgery 1. Age 2. Nutrition 3. Presence of disease condition 4. Prior drug therapy

1. Age
very young - tolerates trauma of surgery well. - sensitive to temperature changes & rough handling.  The elderly - tolerates trauma of surgery poorly.

2. Nutrition

and malnutrition cause potential complications postpostoperatively.  It is essential for the nurse to identify these baseline data - nausea, vomiting, anorexia.  Parenteral fluids are prescribed to correct fluid & electrolyte deficiencies prior to surgery.

2. Nutrition

may be corrected by high caloric diet, protein & vitamin supplements.  Obesity increases the seriousness of complications to a great extent.  Fatty tissues are prone to infection therefore, dehiscence & wound infections are common.  Obese people breathe poorly & are prone to pulmonary complications.

3. Presence Of Disease
a. Cardiovascular disease - ECG, 2-D-Echo, Stress tests, Blood tests 2- CVP measurement for elderly, major surgeries - blood typing and cross-matching cross- HPN, Bleeding disorders b. Respiratory disease - CXR, ABGs - PTB, Pneumonia, COPD

3. Presence Of Disease
c. Renal Disease - Urinalysis, BUN/ Creatinine, Creatinine, - Acute nephritis, Acute renal insufficiency, UTI d. Endocrine disease - FBS, Thyroid function tests - Uncontrolled DM, Hypo/hyperthyroidism

4. Prior Drug TherapyTherapycertain medications can interfere with anesthesia or contribute to postoperative complications.


increase bleeding - aspirin, heparin, warfarin  Antihypertensive- affects anesthesia Antihypertensive Antibiotics e.g neomycin, STSO4, with there will be muscle relaxant interrupt nerve transmission and apnea due to resp. paralysis. *prior to surgery, most of the drugs are
discontinued and new orders are given postpost-op

4. Prior Drug therapy

certain medications can interfere with anesthesia or contribute to postoperative complications.

 Diuretics- K loss/ resp. depression Diuretics Steroids- anti-inflam. Effect and delay Steroids- anti-inflam.

wound healing  Tranquilizers potentiates effect of narcotics and barbiturates. They cause hypotension.  Antidepressants- (monoamine oxide) Antidepressantshypotensive effects *prior to surgery, most of the drugs are discontinued and new orders are given post-op post-

Patient is prepared the night before the scheduled surgery Common preparations 1. Gastrointestinal Prep: The Eve before OR must have: - light meal the night before surgery - NPO (food & water -post midnight safe is 6hrs - this order should be carefully explained to patients - during anesthesia, reflexes (gag, sphincter) are absent & food in the stomach can easily gain to the tracheobronchial tree, cause aspiration pneumonia & respiratory failure - enemas for GI surgeries / Skin prep/shaving


2. Completed early morning of surgery - Final skin prep: shaving, topical antiseptics (esp.ortho cases) (esp.ortho - GIT preparation, enema as ordered - Foley catheter, NGT, IV as ordered - *Administer preop medications( 1 hr before going to OR) - Always with side rails up - Blood glucose if ordered esp DM case

C. Physical preparation con t.

3. Urinary - empty bladder before patient is sent to the OR-note* ORb4 giving pre-meds. Pt. must empty his bladder. pre4. Circulatory - antiembolic stockings for elderly & long surgeries - stockings or bandages compress superficial veins & increase blood flow through deep vein pressure preventing venous stasis & thromboembolism 5. Integumentary - skin prep, shaving, oral & body hygiene -* can reduce the no. of microorganism.

Nurse s Responsibility


Perform/supervise skin prep & cleansing Notify AMD of drug allergies, severe anxiety, unusual ECG or abnormal lab findings-* note findingsdrug allergy /allergy cannot lessen through nursing intervention while fear, obesity & smoking can be. Ensure all consent forms are signed ( Gen. & Informed) Administer pre-op meds on time-1 hr b4 pretimeanesthesiaanesthesia-to reduce resp.secretions-AtSo4 resp.secretionsComplete pre-op checklist preCheck if history & PE database are on chart Remove dentures, nail polish, hair pins, jewelries


all consent forms are signed ( Gen. & Informed)  Administer inj. pre-op meds on time-1 hr pretimeb4 OR -to reduce resp.secretions-AtSo4* resp.secretions Premeds tabs given before midnight(optional)  Complete pre-op checklist pre Check if history & PE database are on chart  Remove dentures, nail polish, hair pins, jewelries

Nurse s Responsibility

Remember: Preparing GIT On The Eve Of Surgery Most common preparation for GIT

restriction for 6 hours or ( NPO after 12mn.  Fluid restriction (NPO after 12mn) or for 6  Administration of enema (fleet enema) till clear flow  Insertion of nasogastric tube (NGT) if needed  FC if needed.

Preparing The Patient On The Day Of Surgery  The nurses awakens the patient before he/she receives pre-op meds, VS is taken & recorded pre Check & make certain that skin preparation has been completed in a thorough manner  Ask the patient to void, measure & record the output of urine  Oral hygiene, remove nail polish, false dentures, glasses (contact lens, jewelries, & give to responsible person). Narcotics Box ( HN is responsible)



General Consent- forms given during Consentadmission. The physicians and nurses should be knowledgeable about the statements on the form used in their facility. (House Rules). Most facilities require the patient or his or her legal guardian to sign a general consent form on admission. Ex: Rendered day to day treatment, Hosp. charges etc.


2. SURGICAL/ INFORMED CONSENT INFORNMED CONSENT- is a process-not CONSENTprocessnecessary a mere document. Explanations of the procedure, risks, benefits, and alternative therapy are made verbally to the patient s level of understanding. A surgeon or anesthesia provider may be held liable for negligence if the patient can prove failure to disclose significant information that would have influenced a reasonable person s decision to consent.

The risks of anesthesia should be explained without causing the patient undue stress. Reasonable approach to Informed Consent. Consent. 1. What is your plan or What kind of operation ? This is ask by the client.  2. Why do you want to do this procedure?  3. Are there any alternatives to this plan?  4. What things should I worry about?  5. What are the greatest risks or the worst thing that could happen?  * Note* the patient has the right to waive an explanation of the nature and consequences of the procedure and the right to refuse the treatment/ surgery.

Right to Refuse a Surgical Procedure

patient has the right to decide what will or will not be done to him or her. Only after making this decision is the patient asked to sign a written consent for a surgical procedure.  The patient has the right to withdraw consent at any time before the surgical procedure. Notify the doctor and obtain a form for refusal to operation.


a patient signs an agreement, consent is given for the specific procedure indicated on the form.  *Additional procedures should be listed and signed separately-not added after the patient separatelyhas already signed the form.  *Included in the lists of forms:
A. Who will be performing the procedure or the Surgeon, B. Anesthesiologist C. Residents D. interns or first assistants E. OR nurses during OR procedure


Responsibility for Informed Consent before a surgical procedure: Surgeon / Doctor should include the risks, benefits, and possible complications of all proposed surgical procedures. Documented the procedures and becomes the permanent part of the patient s record.

VALIDATION OF INFORMED CONSENT:  Content:  Patient s in full name w/ legal age and mentally competent  Surgeon s full name  Specific procedure to be performed  The sig. of the patient and the date of the signature  Authorized witness (es) (es)



-parent or legal guardian should sign.  2. Illiterate - may sign with X after which the witness writes Patient THUMB Mark  3. Unconscious  4. Mentally incompetent  5. Mentally incapacitated by alcohol or other chemical substances.




life threatening emergency  the consent to treat and stabilize is not essential.  Although, permission for life saving procedures, especially for a minor, may be accepted from a legal guardian or relatives by phone , fax , txt or other written com. then, two nurses must sign the form. And , later or upon arrival at the facility the concern person must sign.

To sum up in Legal Preparation / Considerations:


Written consent: Prior to this ,the surgeon must explain everything to the patient. Must have at least two consent ( Gen.& Informed) In case of minor ( < 18), the parents or the guardian sign the consent. If or during emergency, the surgeon may operate if is in life threatening-saving threateningmeasure( house rule / presumed consent) Liability - legally responsible for personal actions

Final Day Of Surgery Pre-op PreChecklist

prior to transfer  Pre-op meds ready Pre Side-rails up after pre-op meds Sidepre Contact lenses out  Dentures out  VS within 4 hrs of surgery or 30 mins prepre-op  Pre-op lab work ups and plates Pre Voiding

Before the patient is transport to the OR theater: Checked!!!


All pertinent data should be recorded: Patient s chart Consent / V/S PrePre-medications Labs / X-rays/IV s, /Bladder/ side rails-up XrailsCheck by the charge nurse Nurse accompanies the pt to the OR. Endorsed.



Date: Last Name First Name MiddleName AMD Hosp PIN Operation Proposed:_________________________________ Date of Operation: _______________ Time__________ Surgeon:_______________ Anesthesiologist Anesthesia________

PrePre-Op Med given IV Fluids Ordered IV Fluids Started Schedule Slip Sent Weight Taken NPO signage on bedside PrePre-op bath or shower Cath, retain & clamp Patient urinated PrePre-anesthesia Eval. Valid consent signed

False Teeth Hair Pins Jewelry Nail Polish Underwear Enema (if ordered Vaginal irrigation Pt. visited by the chaplain History & P.E.

External Prep. Done by:_____________ Checked by:_________________________ Allergies:________________________ Blood Pressure Taken AM PM Laboratory Exams ( if Ordered):  DONE NOT YET DONE DONE NOT YET DONE Blood Test ECG Urine Test X-ray If not yet done, w/PLATES Specimen sent to lab

Patient prepared for O.R by_____________________________________

Printed Name & Signature (Staff)

 Final Checking done by:___________________________  Printed Name & Signature  ( Head Nurse)

Legal aspect and Liability from Clients & Health Workers

Legal Preparation w/ liability


- failure to use the proper care or skills. - careless performance of duty - cause damage to a patient who may file lawsuits  Malpractice - professional misconduct - illegal or immoral conduct - unreasonable lack of skill or judgment

Legal Preparation / Liability

Borrowed servant rule - captain of the ship - surgeons have supervisory control & right to give orders & is directly liable Doctrine of a reasonable man - patient has the right to expect all personnel & technical nursing personnel will use knowledge, skills, & judgment in performing duties that meet standards exercised by other reasonably prudent persons involve in similar circumstances.

Legal Preparation

Doctrine of res ipsa loquitur - the thing speaks for itself. - court allow the patient s injury to stand as inference of negligence *Before this doctrine can be applied, 3 conditions must exist 1. The type of injury. 2. The injury was caused by the conduct or instrumentality within the exclusive control of the person or persons being sued 3. The injured person could not have contributed to negligence or voluntarily assumed risk

Invasion of privacy

Legal Preparation

- patient has the right to expect that all communications

& records pertaining to individualized care will be treated as confidential & will not be misused - right to privacy during interview, examination & treatment - NOTE: Surgery schedule bearing the names of the patients should not be posted in a location where the public or other patients can read it. - written consent for videotaping or photographing his/her surgical procedure for medical education or research, w/o a permit is a BIG NO. (just remember the cannester case / u tube.)

Legal Preparation

of respondeat superior - an employer may be liable for an employees negligent conduct  Assault - unlawful threat to harm another physically  Battery - carrying of bodily harm as by touching without authorization or consent

Legal Preparation

- leaving the patient for any reason when the patient s condition is contingent on the presence of the caregiver - if the caregiver leaves the room knowing there is potential need for care during his/her absence, even under the order of a physician, the caregiver is liable for his/her own action

Legal Preparation

conscience for the surgical

team - key elements of perioperative practice caring, conscience, discipline & techniques - optimal patient care requires an inherent surgical conscience, selflessness, selfself-discipline & the application of principles of asepsis & sterile technique



a pt has an old incision, is it best to make a subsequent incision next to or through the old incisions. Bec. it has scar Bec. tissue that limits the amount collaterals that would be needed to heal an incision placed next to it.  Used to incise the epidermis is the Scalpel blade or the first knife.  Used to incise the dermis is the scalpel or electrocautery. electrocautery.

Knife Handles

7 handle with 15 blade (deep knife) - Used to cut deep, delicate tissue. 3 handle with 10 blade (inside knife) - Used to cut superfic tissue. 4 handle with 20 blade (skin knife) - Used to cut skin. Firs

#7, #3, #4 (left to right)


Dissecting tissue layer of the body

Dissecting tissue layer of the body


Abdominal Incisions
Incision Site R-Subcostal incision Paramedian Types of Surgery Gallbladder and billiary tract surgery. Right side billiary tract, gallbladder

Left side splenectomy, gastrectomy, hiatal hernia repair Transverse Rectus gastrectomy Right side small bowel resection Left side Mc Burney incisions Midline Lower Pfannensteil sigmoid colon resection

AP-right side APFemale reproductive tract Gynecologic surgery

Abdominal incision

Abdominal incision

Sternotomy = Midline sternotomy incision for heart procedures, less painful than a lateral thoracotomy. Thoracotomy= Usually through the 4th or 5th ICS, very painful, but many are performed with muscle sparing ( muscle retraction and not muscle transection). Liver transplant = chevron or MercedesMercedesBenz incision in the upper abdomen.


WOUND CLOSURE Methods of wound closure include sutures, clips, staples, tapes, and glue. Suture denotes the acts of sewing by bringing tissues together and holding them until healing has taken place.

the material is tied around a blood vessel to occlude the lumen, it is called a LIGATURES or TIE. A suture attached to TIE. a needle for a single stitch for hemostasis is referred to as a STICK TIE or SUTURE LIGATURE. LIGATURE.  FREE TIE is a single strand of material handed to the surgeon in the tip of a forceps is referred to as a tie on a passer.

Examples of Suturing techniques:


continuous  Continuous locking  Simple interrupted  Horizontal mattress  Vertical mattress