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Surgical Environment
2. Principles in Design –
a. Exclusion of contamination from outside the suite with sensible traffic patterns
within
b. Separation of clean areas from contaminated areas within the suite.
3. Exchange Areas -
Surgical Area:
a. Unrestricted zone – street clothes are allowed
b. Semi-restricted zone – Attire consist of scrub clothes and caps
c. Restricted zone – scrub clothes, shoe covers, caps and masks are worn
Infection
Infection – is the product of the entrance, growth, metabolic activities &
pathophysiologic effects of microorganism in living tissues.
Classification of Infection
Sources of Contamination
1. Skin
2. Hair
3. Nasopharynx
4. Fomites
5. Air
6. Human Error
7. Cross Infection
2. Chemical
a. Ethylene oxide gas
b. Formaldehyde gas & solution
c. Hydrogen peroxide plasma / vapor
d. Ozone gas
e. Acetic acid solution
f. Glutaraldehyde solution
g. Peracetic acid solution
Disinfectants:
1. Chemicals
a. Alcohol 70% to 90% (ethyl & isopropyl)
b. Chloride compounds
c. Formaldehyde
1. 37% aqueous
2. 8% in alcohol
d. Glutaraldehyde 2%
e. Iodophors
f. Mercurial compounds
2. Physical
a. Boiling water
b. Ultraviolet irradiation
Surgical Scrub
= is the process of removing as many microorganisms as possible from the hands and
arms by mechanical washing and chemical antisepsis before participating in a surgical
procedure.
Purpose:
1. To remove soil, debris, natural skin oils, hand lotions and transient microorganism
from the hands and forearms of sterile team members.
2. To decrease the number of resident microorganisms on skin to an irreducible
minimum.
3. To keep the population of microorganisms during the surgical procedure by
suppression of growth.
4. To reduce the hazard of microbial contamination of the surgical wound by skin flora.
Purpose: Sterile gown and gloves are worn to exclude skin as a possible contaminant and
to create a barrier between the sterile and unsterile areas.
General Consideration:
1. The scrub person gowns and gloves self, then may gown and glove the surgeon and
assistant.
2. Gown packages preferably are opened on a separate table from other packages to avoid
any chance of contamination from dripping water.
3. Avoid splashing water on scrub attire during surgical scrub because moisture may
contaminate the sterile gown
1. Closed Glove Technique – is preferred except when changing a glove during a surgical
or when donning gloves for procedures not requiring gowns.
2. Open Glove Technique – is used for changing a glove or gown and gloves during a
surgical procedure. It is also used when only sterile gloves
are worn in administration of spinal anesthesia, intravenous
cutdown or for suturing lacerations.
Surgical Conscience
= awareness, which develops from a knowledge base, of the importance of strict
adherence to principles of aseptic and sterile techniques.
Nursing Responsibilities:
Good health is essential for any in the OR and any preoperative team member
with an infectious disease (e.g. URTI, infected skin lesions, hepatitis, infectious flu, colds
and cough) should not have direct patient contact. Until the infectious process has
resolved, the perioperative team member should not work in the O.R.
1. Patient
2. Circulating Nurse – also known as the “circulator”
Responsibilities:
a. Manages the operating room
b. Protects patient’s safety and health by monitoring the activities of the surgical
team
c. Checks and verifies the consent form
d. Ensure fire safety precautions, cleanliness, proper temperature,
humidity and lighting of the O.R.
e. Monitors safe functioning of the equipments.
f. Coordinates with the surgical / perioperative team and monitors aseptic
practices
g. Documents O.R. surgical activities
3. Scrub Nurse – responsible for scrubbing for the surgery.
Responsibilities:
a. Setting up sterile tables
b. Preparing sterile sutures, ligatures & special equipments (e.g. Laparoscope)
c. Assisting the surgeon & assistant surgeon, taking care tissue specimens
d. Count all needles, sponges & instruments together with the circulating nurse
4. Surgeon – head of the surgical team
Responsibilities
a. Performs the surgical procedure
5. Registered Nurse First Assistant – practices under the supervision of the surgeon
Responsibilities:
a. Suturing and handling of tissues
b. Providing exposure at the operative field
c. Providing homeostasis
6. Anesthesiologist – is a physician specifically trained in the art and science of
anesthesiology. Anesthetist is a qualified health care professional who administer
anesthetics.
Responsibilities:
a. Interviews and assesses the patient
b. Select & administer appropriate anesthesia
c. Monitors V/S, ECG, ABG & anesthesia levels
7. Post Anesthesia Care Unit (PACU) Nurse – responsible for caring for the patient
until the patient has recovered from the effects of anesthesia.
Responsibilities:
a. Monitors V/S and post-operative complications (bleeding, respiratory distress
etc)
b. Carry out postoperative orders
c. Refer any unusualities to the physician
Anesthesia
2. Moderate Sedation – a depressed level of consciousness that does not impair the
patient’s ability to maintain patent airway & respond to physical stimulation and
verbal commands, often called “ monitored anesthesia care” (e.g. intravenous
drugs: midazolam & diazepam)
3. Deep sedation – is a drug induced state which a patient cannot be easily aroused but
can respond purposely after repeated stimulation.
- Difference of deep sedation and anesthesia is that the anesthetized
patient is not arousable.
Types of Anesthesia:
Stage II Excitement –
characterized by struggling, shouting, laughing, crying, increased pulse and
irregular respirations. Pupils dilate but contract to light.
2. Regional Anesthesia –
is a form of local anesthesia that suspends sensation and motion in a body region
or part, the patient is awake and continuous monitoring is required.
3. Spinal Anesthesia –
is a local anesthetic injected into the subarachnoid space at the lumbar level to
block nerves and suspend sensation and motion to the lower extremities, perineum
and lower abdomen.
4. Conduction Blocks – suspend sensation and motion on various groups of nerves.
Types of conduction blocks:
a. Epidural block – anesthetic into space the dura mater
b. Brachial plexus – produces anesthesia on the arm
c. Paravertebral block – produces anesthesia of the chest, abdominal wall &
extremities
d. Transacral (caudal) – anesthesia of the perineum
1. Dorsal recumbent – flat on the back, used for most abdominal surgeries.
ex: hernia repair, mastectomy, bowel resection
2. Trendelenberg position - the head & body are lowered, used for surgery on the
lower abdomen and pelvis.
3. Lithotomy position – patient positioned at the back with the legs and thighs flexed used
for perineal, rectal and vaginal surgical procedures.
ex: D&C, vaginal repair, APR
4. Sims or lateral position – patient positioned on the nonoperative side, used for renal
surgery.
SURGICAL INCISIONS:
Draping - is the procedure of covering the patient and surrounding areas with a
sterile barrier to create and maintain an adequate sterile field.
Intraoperative Complications
1. Nausea and Vomiting – if it occur turn patient to sides, the head of the table is lowered
and a basin is provided to collect vomitus.
- Suction saliva and vomited gastric contents.
- Administration of anti-emetics.
2. Anaphylaxis – is a life threatening acute allergic reaction that causes vasodilation,
hypotension and bronchial constriction.
- Carefully observe the patient for changes in V/S and symptoms of
anaphylaxis.
3. Hypoxia & other Respiratory Complications – inadequate ventilation, occlusion of the
airway, inadvertent intubation of the esophagus and hypoxia are
potential problems of general anesthesia.
- Peripheral perfusion & pulse oximetry are monitored continuously.
- Vigilant assessment of the patient’s oxygenation status is a primary
function of the anesthesiologist or anesthetist or the circulating
nurse.
4. Hypothermia – body temperature below 36.6
- caused by low temperature in OR, infusion of cold fluids, inhalation of
cold gases, open body wounds, decreased muscle activity and
advanced age.
5. Malignant Hyperthermia – is an inherited muscle disorder chemically induced by
anesthetic agent.
- Susceptible people include those with strong and bulky muscles, a
history of muscle cramps or muscle weakness and unexplained
temperature elevation.
Clinical Manifestation:
1. Tachycardia >150 beats/min. (earliest sign)
2. Hypotension
3. Decreased cardiac output
4. Oliguria
5. Body temperature >40 Celsius (late sign)
6. Cardiac arrest
Medical Management:
1. Discontinuing the anesthesia and surgery
2. Administration of Dantrolene sodium (muscle relaxant) and Sodium Bicarbonate
3. Decrease body temperature
4. Correct electrolyte imbalance
5. Disseminated Intravascular Coagulopathy - is a life-threatening condition
characterized by thrombus formation and depletion of select coagulation proteins.
Nursing Management:
- Identify patients at risk; recognize the signs & symptoms have appropriate
medications and equipment available.