Intraoperative Lecture

Intraoperative Care
MS. LOURADEL MATOL ULBATA, RN, MAN

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 skin
to avoid skin breakdown, use of electric clipper is
preferable.

Preparing the G.I tract
- NPO, cleansing enema as required
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
Preparing for Anesthesia
- Avoid alcohol and cigarette smoking for at
least 24 hours before surgery.

Promoting rest and sleep
- Administer sedatives as ordered
Preparing the Person on the Day Of Surgery

Early A.M Care
Awaken 1 hour before preop medications
Morning bath, mouth wash
Provide clean gown
Remove hairpins, braid long hair, cover hair with cap if available.
Remove dentures, colored nail polish, hearing aid,
contact lenses, jewelries.
Take baseline vital sign before preop medication.
Check ID band, skin prep
Check for special orders enema, IV line
Check NPO
Have client void before preop medication
Continue to support emotionally
Accomplished preop care checklist
PREOPERATIVE MEDICATIONS
Goals:
To aid in the administration of an anesthetics.
To minimize respiratory tract secretion and
changes in heart rate.
To relax the patient and reduce anxiety.
Commonly used Preop Meds.

Tranquilizers & Sedatives
* Midazolam
* Diazepam ( Valium )
* Lorazepam ( Ativan )
* Diphenhydramine

Analgesics
* Nalbuphine ( Nubain )
Anticholinergics
* Atropine Sulfate
Proton Pump Inhibitors
* Omeprazole ( Losec )
* Famotidine

Transporting the Patient to the OR

Adhere to the principle of maintaining the comfort
and 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 the
proper time.
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
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)
PHYSICAL LAYOUT OF THE
OPERATING ROOM SUITES

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.
SPACE ALLOCATIONS AND TRAFFIC
PATTERNS
Space is allocated within the OR suite to provide for
the work to be done, with considerations given to
the efficiency within which it can be accomplished.
The OR suite should be large enough to allow for
correct technique yet small enough to minimize the
movements of the patient, personnel and supplies.
Provision must be made for traffic control. The type
of design will predetermine traffic patterns. All
persons staff, patients, and visitors should follow
the delineated patterns in appropriate time.

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 communication with personnel
within the suite and with personnel and patients
familiesoutside the suit.
Semi-restricted Area
- provides access to the procedure rooms and
peripheral support areas within the surgical suite.
- personnel entering this area must be in proper
operating 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

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

VESTIBULAR OR EXCHANGE AREAS

POST-ANESTHESIA CARE UNIT (PACU)
The PACU may be outside the OR suite, or it may be adjacent to the
suite so that it may be incorporated into the unrestricted areas with
access from both the semi-restricted area and an outside corridor.
In the latter design, the PACU becomes a vestibular area for the
departure of patients.

DRESSING ROOM AND LOUNGES
Dressing room must be provided for both men and women to
change from street clothes into OR attire before entering the semi-
restricted area, and vice versa. Lockers are usually provided. Doors
separate this area from lavatory facilities and adjacent lounges.

PERIPHERAL SUPPORT AREAS
Adequate space must be allocated to accommodate the needs of
the OR personnel and support services.


CONFERENCE ROOMS/CLASSROOM
- A conference or a classroom is located within the semi-
restricted area. This is used for patient care staff in cervical
staff for teaching.

SUPPORT SERVICE
- The size of the health care facility and the types of services
provided, determine whether laboratory and radiology
equipment is needed within the OR suite.


LABORATORY
A small laboratory where the pathologist can examine tissue and perform
frozen sections expedites the decisions that the surgeon must make during a
surgical procedure when diagnosis is questionable. A refrigerator for storing blood
for transfusions may also be located in this room.

RADIOLOGY SERVICES
Special procedure rooms may be outfitted with X-ray and imaging
equipment for diagnostic and invasive radiological procedures or insertion of
catheters, pacemakers, and other devices.

WORK AND STORAGE AREAS

Clean 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 not
be taken into this area.

ANESTHESIA WORK AND STORAGE AREA
Space must be provided for the storage of the anesthesia equipment and
supplies. A separate workroom usually is provided for care of anesthesia
equipment. Dirty and clean supplies must be kept separated

HOUSEKEEPING STORAGE AREAS
Cleaning supplies and equipment need to be stored; the equipment
used within the restricted area is kept separated from that used to clean
other areas. Sinks are provided, as well as shelves for supplies. Trash and
soiled laundry receptacles should not be allowed to accumulate in the
same room where clean supplies are kept.

UTILITY ROOM
Some hospitals use a closed-cart system and take contaminated
instruments to a central area outside the OR suite for clean-up procedures
in the substerile room. Many, by virtue of the limitations of the physical
facilities, bring the instruments to a utility room. This room contains a
washer sterilizer, sinks, cabinets and all the necessary aids for cleaning.


STERILE SUPPLY ROOM
hospitals 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. As
many shelves as possible should be freestanding from the walls, which permits
supplies to be put into one side and removed from the other, thus older packages
are always used first.

INSTRUMENT ROOM
The instrument room contains cupboards in which all clean and
decontaminated instruments are stored when not in use. Instruments usually
are segregated on shelves according to surgical specialty services.


SCRUB ROOM

- An enclosed area for surgical scrubbing of
hands and arms must be provided adjacent to
each OR suite. It is a restricted area within the
OR suite.

PHYSICAL LAYOUT OF THE OR

OPERATING-ROOM SETUP SHOWING TABLES FOR
INSTRUMENTS AND SUPPLIES DESIGNED TO FACILITATE THE
WORK OF THE SURGEON, HIS ASSISTANTS, AND THE NURSES
PACU (post anesthesia care unit)

OR suite (operating room-central
Processing area)
scrub area

Draped patient and
operating bed
Mayo stand
1
st

assistant
Scrub
nurse
Surgeon
Kick
bucket
Instrument table
Electrosurgical
unit
Suction
container
Kick
bucket
Anesthesia
machine
Anesthesia
provider
A. SCIENTIFIC PRINCIPLES INVOLVED IN OR
TECHNIQUE

ANATOMY AND PHYSIOLOGY
adequate knowledge of the human body parts is a prerequisite in being a
part of the OR team. [Ex.: epidermis is the term used to designate the
outer or surface layer of the skin and the dermis is considered to be the
second layer. There are sebaceous and sweat glands of the skin. the skin
protects the body tissues against pathogenic microorganisms and injury
from mechanical devices.]
CHEMISTRY
use of antiseptics can reduce bacterial count. Excessive use of soap may
harden the skin, as soap is alkaline and removes protecting oils from the
skin.
MICROBIOLOGY
Skin protects the body from certain diseases. Handwashing is the most
effective means of conserving ordinary cleanliness for protection of the
patient as well as the nurses.
PHARMACOLOGY
drugs that are used for soothing and reducing irritation of surfaces that
have been abraded or irritated is classified as demulcents. Ethyl alcohol
(70%) is an effective solution for disinfection of equipment.

PSYCHOLOGY
the proper explanation to the patient regarding the
upcoming operation should be established.

SOCIOLOGY
home methods of disinfection and sterilization may be
taught by the visiting nurse. The attitude of the
isolated patient whether at home or in the hospital
may depend on the knowledge of his disease and the
manner of its transmission from one person to another.

PHYSICS
the autoclave used for sterilization sterilizes by means of
pressurized steam.

PRINCIPLES
of SURGICAL
ASEPSIS
Remember the
word
ASEPSIS
A
Always face the
sterile field
S
Should be above
waist level and
on top of sterile
field
E
Eliminate
moisture that
causes
contamination
P
Prevent unnecessary
traffic & air current
( close door, minimize
talking dont reach across
sterile field)
S
Safer to assume
contaminated
when in doubt
I
Involves team effort
( collective and
individual sterile
conscience)
S
Sterile articles unused
and opened are no
longer sterile after
the procedure
Anesthesia
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:
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.
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
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 margin
of safety in the event of airway obstruction or apnea during
induction, with resultant hypoxia.

Loss of Consciousness
unconsciousness is induced by IV administration of a drug or by
inhalation of an agent mixed with oxygen. Because the
technique is rapid and simple, an IV drug usually is preferred
by anesthesia providers and often is requested by patients.

Intubation
a patent airway must be established to provide adequate
oxygenation and to control breathing of the unconscious
patient. The patients tongue and secretions can obstruct
respiration in the absence of protective reflex.

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 the
patient through a breathing system.

ANESTHESIA MACHINE includes:

Sources of oxygen and gases with flow
meters for measuring and controlling their
delivery
Devices to volatilize and deliver liquid
anesthetics
Gas-driven mechanical ventilator
Devices for monitoring the ECG, BP, inspired
oxygen, and end-tidal carbon dioxide
Alarm systems
ANESTHESIA MACHINES have the following
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
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:

~ Inability to open mouth. Patients with previous jaw surgery may have
jaw 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 a
difficult 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 maintenance
process.
~ Short neck or morbid obesity.
~ Pathology of the head and neck such as tumors or deformity. An
enlarged tongue can be an obstruction to a full view of the glottis.
~ Previous tracheostomy scar, which can cause a stricture.
~ Trauma.

Depth of General Anesthesia

From To Patients
Responses
Patient Care
Considerations
Induction of general
anesthesia and
beginning of inhalant
and/ or IV drug
Begins to lose
consciousness; will
have recall
Bispectral state 100
Drowsy, dizzy,
amnesic
Close OR doors. Keep
room quiet. Stand by
to assist. Initiate
cricoid pressure if
requested.
Loss of consciousness;
excitement phase
Relaxation, light
hypnosis; low
probability of recall
Bispectral state 70 to
50
May be excited with
irregular breathing
and movements of
extremities;
susceptible to external
stimuli (e.g., noise,
touch)
Restrain patient.
Remain at patients
side, quietly, but
ready to assist
anesthesia provider as
needed.
Surgical
anesthesia stage
of relaxation
Loss of
reflexes:
depression of
vital functions
Bispectral state
40:
maintenance
range
Regular
respiration;
contracted
pupils; reflexes
disappear;
muscle relax;
auditory
sensation lost
Position patient
and prepare
skin only when
anesthesia
provider
indicates this
stage is
reached and
under control.
Danger stage:
vital functions
too depressed
Respiratory
failure; possible
cardiac arrest
Bispectral state
0
Not breathing;
little or no
pulse or
heartbeat
Prepare for
cardiopulmonary
resuscitation.

Most Commonly Used General Anesthetic Agents

Generic Name Trade Name Administration Characteristics Uses
INHALATION
AGENTS
Nitrous oxide

None

Inhalation

Inorganic gas;
slight potency;
pleasant, fruitlike
odor;
nonirritating; non-
flammable but
supports
combustion; poor
muscle relaxation

Rapid induction
and 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
Enflurane Ethrane Inhalation Halogenated
ether; potent;
some muscle
relaxation;
respiratory
depressant
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
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 induction
and recovery; short
procedures alone;
prolonged
anesthesia in
combination with
inhalation agents
or opioids
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,
intramuscular
Benzodiazepin
e; tranquilizer;
produces
amnesia,
sedation, and
muscle
relaxation
Premedication;
awake
intubation;
induction
Midazolam Versed Intravenous,
intramuscular
Benzodiazepine
; sedative;
short-acting
amnesic; central
nervous system
and respiratory
depressant
Premedication;
conscious
sedation;
induction in
children
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 close
proximity 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
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
needle into the subarachnoid space of the spinal
canal.
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.
C. Epidural Anesthesia
achieved by injecting local anesthetic into epidural space by
way of a lumbar puncture.
result similar to spinal analgesia
agents use are chloroprocaine, lidocaine and bupivacaine.

D. Peripheral Nerve Block
achieved by injecting a local anesthetic to anesthetize the
surgical site.
agents use are chloroprocaine, lidocaine and bupivacaine.
OTHER TECHNIQUES OF ADMINISTRATION OF LOCAL
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 by
means of marked surface cooling of a localized area. It is used
in such brief procedures as the removal of warts or
noninvasive popular surface lesions.

Simple Local Infiltration
is injected intracutaneously and subcutaneously into tissues at
and around the incisional site to block peripheral sensory
nerve stimuli at their origin. It is used for suturing superficial
lacerations or excising minor lesions.

Administration of Local Anesthesia

in the absence of an anesthesia provider, a qualified
registered 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
Anesthetic Drugs

Toxic Reaction Allergic Reaction
Symptoms vary depending on the
drug
Immediate localized reaction
followed by generalized body
reaction
SUBJECTIVE
Dizziness, somnolence,
paresthesia, nausea,
visual/speech problems

Sense of uneasiness, pruritus,
agitation, paresthesia
OBJECTIVE
Decreased breathing rate and
depth, muscle twitches, tremors,
slurred speech, seizures,
vomiting unconsciousness, coma

Erythema, urticaria, wheals
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 contractions
are treated with diazepam
(Valium)

Especially with amino ester
type: airway management, IV
fluids, epinephrine,
diphenhydramine, and steroids
as needed
Guidelines in Monitoring a Patient Receiving a Local
Anesthetic:
The patient is monitored for reaction to drugs and for
behavioral and physiologic changes.
The nurse attending the patient should have basic
knowledge of the function and use of monitoring
equipment, ability to interpret information, and working
knowledge of resuscitation equipment. The nurse should
have appropriate training and knowledge in pharmacology
and the application of the drugs used in the patients care.
Accurate reflection of perioperative care should be
documented on the patients record.
Institutional policies and procedures in regard to patient
care, including monitoring, should be written, reviewed
annually, and readily available. This information should be
included in orientation and inservice programs.

Local and Regional Anesthetic Agents

Generic
Name
Trade
Name(s)
Uses Concentratio
n
Duration of
Effect
(Hours)
Maximum
Dosage
AMINO
AMIDES
Bupivacaine
hydrochlorid
e

Marcaine
Sensorcaine

Local
infiltration
Regional
block
Surgical
epidural

0.25% to
0.50%

2 to 3

400mg
Dibucaine
hydrochlorid
e
Nupercaine
Percaine
Cinchocaine
Local
infiltration
Peripheral
nerves
0.05% to
0.1%
3 to 3 30mg
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
Mepivacain
e
hydrochlori
de
Carbocaine Infiltration
Peripheral
nerves
Epidural
0.5-1%
1-2%
to 2 500mg
Prilocaine
hydrochlori
de
Citanest Infiltration
Peripheral
nerves
Regional
Block
Epidural
1-2%
2-3%
to 2 600mg
Ropivacaine Naropin Infiltration
Field block
Nerve block
Epidural
Postoperativ
e pain
managemen
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
hydrochlori
de
Topical 4-10% 200mg or
4mg/kg
body
weight
Procaine
hydrochlori
de
Novocain Infiltration
Peripheral
nerves
Spinal
0.5%
1-2%
to 1000mg or
14mg/kg
body
weight
Tetracaine
hydrochlori
de
Cetacaine
Pontocaine
Topical
Spinal
2%
1%
2 to 4 20mg
POSITIONING
Lateral position: the patient lies on the side with
the back at the edge of the operating bed. The
knees are flexed onto the abdomen, and the
head is flexed to the chest. The hips and
shoulders are vertical to the operating bed to
prevent rotation of the spine.

Sitting position: the patient sits on the side of
the operating bed with the feet resting on a
stool. The spine is flexed, with the chin lowered
to the sternum; the arms are crossed and
supported on a pillow on an adjustable table.

Positioning Surgical Patient (Spinal
Anesthesia)
Sitting Position
Lateral Position
Stages of
Anesthesia
Stage I . Stage of
Analgesia / induction
phase
This stage extends from the
beginning of Administration
of an anesthetic to the
beginning of the loss of
consciousness. The
sensation of pain is not lost.
Stage I . Stage of Analgesia / induction phase
The client maybe
drowsy or dizzy
May experience
hallucinations
Circulating nurse
should close the OR
doors
Keep quiet
Stand by to assist
client
Stage II. Stage of
Delirium / Excitement
Extends from the loss of
consciousness to the loss
of eyelid reflex. Any
stimulation has the
potential to cause the
client to become difficult
to control.
Stage II. Stage of Delirium / Excitement
Increased muscle
tone
Irregular respiration
REM ( rapid eye
movement)

Retching & Vomiting
may occur
Circulating nurse
should remain quietly
by patients side
Assist if needed
Stage III. Stage of
Surgical Anesthesia
Extends from loss of lid
reflex to cessation of
respiratory effort or
depressed vital
functions.
Stage III. Stage of Surgical Anesthesia
completely dilated &
unresponsive pupils
absence of reflex
( muscles completely
relaxed)
Client is unconscious
Begin preparation
Client is in good
control

Stage IV. Stage of
Danger / Medullary
stage
From vital functions too
depressed to Respiratory
failure/ Death & Disability
due to too high
concentration of
anesthetic in the CNS.
Client is not
breathing
May not have heart
beat
Assist in
resuscitation
Speed of EMERGENCE
(recovery from anesthesia) depends on type
of anesthesia, length of time & many other
factors- try to time with end of surgery

Care of the anesthetized
patient:

Considerations:

A deficit in pulmonary and/or cardiac functions is
detrimental to the patients physiologic status.
Abnormalities of pulmonary ventilation and diffusion
influence the course of the anesthesia and diminish
tolerance to stress or the insults from the anesthetic and the
procedure.
Circulation is affected both centrally and peripherally.
Individual agents are associated with characteristic
hemodynamic patterns.
The liver is affected by general agents. Alterations in liver
function tests may follow anesthesia.
Kidney function is affected by disturbances in systemic
circulation, since kidneys normally receive 20% to 25% of
cardiac output.
Biotransformation of agents varies with metabolites
excreted by the kidneys. Urinary excretion of IV agents may
be slow and unpredictable.
Agents may cause nausea, emesis, or systematic
complications.
Safety Factors:

The patients position is changed slowly and gently to allow
circulation to readjust.
Proper positioning and padding are important to avoid pressure
points, stretching of nerves, or interference with circulation to an
extremity.
The patients chest must be free of adequate respiratory excursion
during the surgical procedure. The airway must be patent.
The lungs must be adequately ventilated intraoperatively and
postoperatively by either voluntary or mechanical means.
The anesthesia provider assists in transferring the patient to a
stretcher 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 records
before the transfer of responsibility.

Complication and Discomforts of
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 of
restraints.
Nausea and Vomiting
Headache
SURGICAL TEAM
Members of Sterile
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 team
member functions within the limited area and the only
sterile items.

1. Surgeon
2. Assistants to the surgeon
3. Scrub person
*SURGEON

must have the knowledge, skills and judgment
required to successfully perform the intended
surgical procedure and any deviations
necessitated 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 are
important attributes of a surgeon.

*ASSISTANTS TO THE SURGEON

under the direction of the operating
surgeon, one or two assistants help to
maintain visibility of the surgical site,
control bleeding, close wounds, and apply
dressing.
Handles tissues & uses instruments
Anticipates blood loss, anesthesia time for
patient, fatigue affecting OR team &
potential complications

*1
ST
ASSISTANT IN SURGERY

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 & to
whom part of patients care is
delegated

*NON-PHYSICIAN 1
ST
ASSISTANT
required to complete a formal education
program for 1
st
assistant according to their
practice discipline

*PHYSICIANS ASSISTANT (PA)
- must have additional surgical training

*SCRUB PERSON
is a patient care staff member of the sterile team.
Responsible for maintaining the integrity, safety
and efficiency of the sterile field throughout the
surgical procedure.

Non-Sterile Members of the
Surgical Team
1. Anesthesia Provider
2. Circulator
3. Others (the OR team may include biomedical
technicians, radiology technicians, and others who may
be needed to set up and operate specialized
equipment or monitoring devices during the surgical
procedure)

the unsterile team members DO NOT enter the sterile
field.
They handle supplies and equipments that are not
considered sterile.
Following the principles of aseptic technique, they keep
the sterile team supplied.

*ANESTHESIA PROVIDER

this refers to the person responsible for the
inducing anesthesia, maintaining anesthesia
at the required levels, and managing
untoward reactions to anesthesia throughout
the surgical procedure.
*CIRCULATOR

the circulator plays a role that is vital to
the 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
The area surrounding the client and the
surgical site that is free from all
microorganisms.
DUTIES AND RESPONSIBILITIES OF
THE SCRUB AND CIRCULATING
NURSE

SCRUB NURSE
Both the circulator and the scrub person set up the room and position
the equipment. The case cart and room furniture are checked by
both persons as a team. The duties and activities change when the
patient arrives at the OR suite. The circulator begins working with
the 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 for
the surgeons arrival. At all times, the integrity of the sterile field is
closely monitored. The principles of asepsis and sterile technique
are followed.

Preparation of the sterile field:

The scrub nurse should be sure that his or her gown
and gloves are open and ready on a surface separate
from the sterile field.
perform a complete surgical hand cleansing according
to the facility procedure.
gown and glove using closed gloving method.
drape unsterile tables according to standard
departmental setup procedure with drapes from the
drape 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 for
transplant)

drape both the frame and the tray of the Mayo stand
arrange on the Mayo stand the instruments and accessory
items to create primary precision. Arrange other
instruments and items on the instrument table. (the Mayo
stand should be kept neat throughout the surgical
procedure. Do not overload it with sponges and sharps)
count sponges, surgical needles, other sharps, and
instruments with the circulating nurse according to
established facility policy and procedure.
secure surgical needles and all other sharps, including the
knife blades. They should never be loose on the Mayo
stand.
prepares sutures in the sequence in which the surgeon will
use them.

After the surgeon and assistant(s) scrub:

gown and glove the surgeon and assistant(s) as
soon 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 stand
into 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:

pass the skin knife to the surgeon, and pass a hemostat and
suction to the assistant. When passing the knife, take care to
direct the blade away from yourself and other personnel.
hand up sterile towels or lap sponges if requested for covering
skin at the edges of the incision.
watch the field and try to anticipate the needs of the surgeon
and assistant. Keep one step ahead of them in passing
instruments, sutures, and sponges and in handing up the
specimen basin.
return instruments to the Mayo stand or instrument table after
use.
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
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 the
circulating nurse for the permanent record.

alert the circulating nurse that closure is about to begin, and
hand up the wound closure materials.
in accordance with established procedures, count sponges,
sharps, and instruments with the circulator as the surgeon
begins closure of the wound. Verify that intraabdominal or
other cavity packing materials and towels have been
removed.
place unneeded instruments and supplies on the instrument
table in the original set position
have a clean, warm, saline-moistened sponge ready to
wash blood from the area surrounding the incision as
soon 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 appropriate
receptacle NOT on the instrument table or Mayo stand
The Eight Ps to consider
when preparing for a
Surgical Procedure
Sterile Field Considerations
for the Scrub Nurse
Environment Considerations
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 for
safety 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 equipment
before the patient enters the
room.
PLACE IT ONCE
-items should not be
manipulated during the
procedure. Energy and
attention should not be
diverted to resetting the
field.
When setting up the field,
each item (e.g., a basin)
should be placed where it
will be used during the
procedure with minimal
handling.
The operating bed should be
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 if
they 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, or
microscope should be
preplanned so they may be
positioned while the
procedure is in progress.
POINT OF USE
-items should be as close to
the area of use as possible.
Basins should be placed
close to the edge of the
table so the circulating nurse
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 should
be 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 away
from the field. Pad the
operating bed and patient as
appropriate. Use safety belts.
PERFECT PICTURE
-items within and around
the 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 the
temperature and humidity
should be appropriate.
Forethought to having a clear
path for the crash cart or
emergency equipment is
essential.
-before entering the OR suite, the circulating nurse must
wash 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 and
opening 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:

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 the
surgeons 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 with
the scrub nurse in the manner as described in facility
policy and procedure.
the instrument counts will be recorded on the
instrument tray sheet packed with the set.

After the patient arrives:

attend to patient while scrub nurse continues to
prepare 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
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:
remain at patients side during the induction of
anesthesia.
assist the anesthesia provider during induction
and intubation.
maintain a quiet environment. Tactile or auditory
stimulation may produce excitement in the patient
during induction.

After the patient is anesthetized:

attach anesthesia screen and other table attachments as
needed.
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:

-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.

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:

be alert to anticipate the needs of the sterile team, such as
adjusting the operating lights, removing perspiration from brows,
and keeping the scrub nurse supplied with sponges, sutures, warm
saline, and other necessary items.
watch the surgical procedure closely enough to see when routine
supplies 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 get
something.
be available to answer questions, obtain supplies and assist team
members.

keep discarded sponges carefully collected; separated by
sizes, and counted according to the number they are
packaged in.
assist the surgeon and the anesthesia provider monitor blood
loss. Weigh sponges if requested to do so.
know the condition of the patient at all times. Inform the OR
manager of any marked changes, unanticipated additional
procedure, or delays.
communicate periodically with the patients family or
significant others to inform them of the progress of the
procedure as appropriate.
prepare and label specimens for transfer to the laboratory.
Always wash hands thoroughly after removing gloves that
have been worn to handle specimens.
as required, complete the documentation in the patients
chart, permanent OR records, and requisition for laboratory
tests or chargeable items.

During Closure:

count sponges, sharps, and instruments with the scrub
nurse. Report counts as correct or incorrect to the
surgeon. Complete the count records. Collect used
sponges for disposal in the appropriately marked
receptacles.
obtain the washer-sterilizer tray, instrument tray, and
other items necessary or the cleanup procedure.
send for a postanesthesia care unit (PACU) stretcher or
an intensive care unit (ICU) bed, or prepare the
patients stretcher or bed with a clean sheet; follow
whatever is the institutional procedure.
obtain a transfer monitor and oxygen tank with tubing
if needed.

After Surgical Procedure is Complete:

assist with dressing the surgical wound and
managing the surgical drainage systems.
secure the outer layer of the dressing with
appropriate type of tape.
open the neck and back closures of the
surgeons and assistants gowns so they can
remove them without contaminating
themselves.
see that the patient is clean.
raise side rails before the patient is transported
out of the OR suite.

COMMON ABDOMINAL
INCISIONS

1. Paramedian Incision

is a vertical incision made approximately 4cm (2 in)
lateral to the midline on either side in the upper and
lower abdomen
it limits trauma, avoids nerve injury, is easily
extended, and gives a firm closure
it allows quick entry into and excellent exposure of
the abdominal cavity
ex: access to the biliary tract/pancreas (right upper
quadrant) and resection of the sigmoid colon (left
lower quadrant)

2. Longitudinal Midline Incision

can be upper abdominal, lower abdominal, or a
combination of both going around the umbilicus
depending on the length of the incision, it begins
in the epigastrum at the level of the xiphoid
process 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 Oblique
Incision

a right or left oblique incision begins in the
epigastrum and extends laterally and obliquely
just below the lower costal margin
affords limited exposure except for upper
abdominal viscera, it provides good cosmetic
results because it follows skin lines and produces
limited nerve damage
biliary modified subcostal incision (Chevron
Incision) is made for increased visibility during a
liver transplantation or resection
ex: biliary procedures and splenectomy
4. McBurney's Incision

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
patient is placed in a lateral position
either a right or left incision that begins at a point
midway between the xiphoid process and
umbilicus and extends across the abdomen to the
7
th
and 8
th
interspace and along the interspace
into the thorax
allows excellent exposure for the upper end of
the stomach and the lower end of the esophagus
ex: esophageal varices and the repair of a hiatal
hernia

6. Midabdominal Transverse Incision
starts on either the right or left side and
slightly above or below the umbilicus
the advantages are rapid incision, easy
extension, a provision for retroperineal
approach, and a secure postoperative wound
ex: choledochojejunostomy and transverse
colostomy
7. Pfannstiel's Incision
a curved transverse incision across the lower
abdomen and within the hairline of the pubis
this lower transverse incision provides good
exposure and strong closure for pelvic
procedures
its primary use is for an abdominal
hysterectomy
8. Inguinal Incision, Lower Oblique

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 provides
access to the cremaster muscle, inguinal canal
and cord structure
its primary use is for inguinal herniorrhaphy
LAYERS OF THE ABDOMEN
BASIC SURGICAL INTSTRUMENTS
OPERATION ROOM SET-UP (EQUIPMENTS
AND APPARATUS)
- standardized basic sets of sterile instruments
are selected for each specific surgical
procedure
- a set is a group of instruments that may
include all appropriate classifications of
instruments or the instruments needed for a
specific part of the procedure (e.g. gallbladder
set)

Cutting and Dissecting
Grasping and Holding
Retracting and Exposing
Clamping and Occluding
Miscellaneous

Classifications:
Cutting and Dissecting Instruments
are sharp and are used to cut body tissue or surgical supplies.
Knife Handle, Scissors
(left to right)
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)
Surgical Blades
10
11
12
15
20
Blade Handle

Straight Mayo scissors - Used to cut suture and supplies. Also
known as: Suture scissors.

EX: Straight Mayo scissors being used to cut suture.
Curved Mayo scissors - Used to cut heavy tissue (fascia,
muscle, uterus, breast). Available in regular and long sizes.

Curve and Straight Scissors
Metzenbaum scissors - Used to cut delicate tissue. Available
in regular and long sizes.

Metzenbaum
ELECTROCAUTERY MACHINE
Cutting and Dissecting
Instruments

Scalpel holder
Curved and Straight Mayo
Scissors Metzenbaum
Lister/Bandage Scissors Suture Scissors
Stitch Scissors
are used to compress blood vessels or hollow organs for
hemostasis or to prevent spillage of contents.
Clamping and Occluding Instruments
A hemostat is used to clamp blood vessels or tag sutures. Its
jaws may be straight or curved. Other names: crile, snap or
stat.
A mosquito is used to clamp small blood vessels. Its jaws may
be straight or curved.

hemostat, mosquito (left to right)
A Kelly is used to clamp larger vessels and tissue. Available in
short , MEDIUMand long sizes. Other names: Rochester Pean.

Kelly, hemostat, mosquito (left to right)
A burlisher is used to clamp deep blood vessels. Burlishers
have two closed finger rings. Burlishers with an open finger
ring are called tonsil hemostats. Other names: Schnidt tonsil
forcep, Adson forcep.

A right angle is used to clamp hard-to-reach vessels and to
place sutures behind or around a vessel. A right angle with a
suture attached is called a "tie on a passer." Other names:
Mixter.

A hemoclip applier with hemoclips applies metal clips onto
blood vessels and ducts which will remain occluded.

hemoclip applier with hemoclips

Straight Mosquito
Kelly Clamp
Pean (Rochester-Pean) Clamp
Crile Clamp
Right-Angled (Mixter
/Dissector) Forceps
Grasping and Holding Instruments
are used to hold tissue, drapes or sponges.
An Allis is used to grasp tissue. Available in short and long
sizes. A "Judd-Allis" holds intestinal tissue; a "heavy allis"
holds breast tissue.

A Babcock is used to grasp delicate tissue (intestine, fallopian
tube, ovary). Available in short and long sizes.
A Kocher is used to grasp heavy tissue. May also be used as a
clamp. The jaws may be straight or curved. Other names:
Ochsner.
A Foerster sponge stick is used to grasp sponges. Other
names: sponge forcep.

Foerster sponge stick EX: Sponge sticks holding a 4 X 4
and probang.
A dissector is used to hold a peanut.
dissector
EX: Dissector holding a peanut.
A Backhaus towel clip is used to hold towels and drapes in
place. Other name: towel clip.

Backhaus towel clip Large & small towel clips
Pick ups and thumb forceps are available in various lengths,
with or without teeth, and smooth or serrated jaws.
Russian tissue forceps are used to grasp tissue.
Adson pick ups are either smooth: used to grasp delicate
tissue; or with teeth: used to grasp the skin. Other names:
Dura forceps.
Long smooth pick-ups are called dressing forceps. Short
smooth pick-ups are used to grasp delicate tissue.
DeBakey forceps are used to grasp delicate tissue, particularly
in cardiovascular surgery.
Thumb forceps are 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)

(Tissue Forceps)
DeBakey Tissue
Forceps
Adson Tissue
Forceps
Russian Tissue
Forceps
These are available in various lengths, with or without teeth,
and smooth or serrated jaws.

Russian Tissue Forceps
They have serration up to the tips, allowing better
grasp of tissue with minimum trauma.

Mayo-Hegar needle holders are used to hold needles when
suturing. They may also be placed in the sewing category.
short, medium & long
(top to bottom)
EX: Needle holder with suture.
Suturing Instruments

Randall Stone Forceps
Tenaculum
Babcock Clamp Foester / Ovum
Sponge Forceps
Backhaus Towel
Clamp
Allis Clamp
Kocher/ Oschsner
Clamp
They Are used to hold tissue, drapes or sponges.
Hook and Dissector

Randall Stone Forceps
To hold/remove kidney stones
Retracting and Exposing Instruments
used to hold back or retract organs or tissue to gain exposure
to 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.
A Deaver retractor (manual) is used to retract deep
abdominal or chest incisions. Available in various widths.

A Richardson retractor (manual) is used to retract deep
abdominal or chest incisions

An Army-Navy retractor (manual) is used to retract shallow or
superficial incisions. Other names: USA, US Army.

A goulet (manual) is used to retract shallow or superficial
incisions.
A malleable or ribbon retractor (manual) is used to retract
deep wounds. May be bent to various shapes.
A Weitlaner retractor (self-retaining) is used to retract shallow
incisions.
A Gelpi retractor (self-retaining) is used to retract shallow
incisions.
A Balfour with bladder blade (self-retaining) is used to retract
wound edges during deep abdominal procedures.
Richardson Retractor

Vein retractor
Senn Retractor
Senn
Volkmann Rake
US Army Navy Deaver
Malleable Vein Retractor Green Goiter
Weitlaner
Langenbeck Skin Hooks Vaginal Speculum
Richardson
SUTURES
SUTURES
Is a medical device used to hold tissue
together after an injury or surgery till healing
takes place.

Sutures (also known as stitches) are divided
into two kinds those which are:

1. Absorbable
2. Non-absorbable.

ABSORBABLE

- will break down harmlessly in the body over time
without intervention
- digested by body cells and fluids during the
healing period.
- used therefore in many of the internal tissues of
the body. In most cases, three weeks sufficient for
the wound to close firmly
- originally made of the intestines of sheep, the so
called catgut.
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
Plain dissolves within 5-10 days, Yellow
Chromic- dissolves within 1 month, Brown
Vicryl/Safil- dissolves within 60-90 days,
Lavender
PDS (Polydioxone)- dissolves 2 times longer
than the other absorbable sutures, White

ABSORBABLE
Non-absorbable sutures
The non absorbable ones have to be removed after
specified time. The type of suture is decided again
by the location of the wound.

Nonabsorbable sutures are made of materials which
are not metabolized by the body, and are used
therefore either on skin wound closure, where the
sutures can be removed after a few weeks, or in
some inner tissues in which absorbable sutures are
not adequate.
Examples: Silk,Nylon,Prolene (Polypropylene)

Types:

Silk- is an animal product from silk worm cocoons.
(Black)
Cotton- made from long staple cotton, treated to make it
smooth, (White)
Prolene- biosynthetic, non-absorbable suture material, as
substitute to silk
Wire- gives the greatest strength to any suture material
.
Non-absorbable sutures

ABSORBABLE SUTURE

NONABSORBALE SUTURE

SUTURE NEEDLES
1. Traumatic needles
- are needles with holes or eyes which are supplied to
the hospital separate from their suture thread.
- The suture must be threaded on site, as is done when
sewing at home.

2. Atraumatic needles
- with sutures comprise an eyeless needle attached to a
specific length of suture thread.
Needles may also be classified by their
point geometry; examples include:
taper (needle body is round and tapers smoothly to a
point)
cutting (needle body is triangular and has a sharpened
cutting 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 bottom
with a cutting edge along the front to one side) for eye
surgery

Different Types Of Needles
Viewing

- surgeons can examine the interior of body cavities, hollow organs, or
structures with viewing

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 through
the endoscope

b. Lensed Endoscopes
- have either rigid or flexible sheathes, and they have eyepiece with a
telescopic lens system fr viewing in several direction

Suctioning and Aspirating
-
- blood, body fluids, tissue, and irrigating solution may be
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 cavity
in which copious amounts of fluid or pus are encountered

b. Frazier Tip
- a right-angle tube with a small diameter
- used when encountering little or no fluid
except capillary bleeding and irrigating fluid
c. Yankauer Tip
- hollow tube that has an angle for use in the
mouth or throat
d. Aspirating Tube
- long, straight tube that is used through an
endoscope

Yankauer Tip
FRAZIER SUCTION TIP
GENERAL CONSIDERATIONS
1. Handle loose instruments separately to
prevent interlocking or crushing.

a. Instruments are never piled one on top of
another 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 and
forceps for alignment, imperfections, cleanliness,
and working conditions
a. Scalpel blades should be properly set in handles
using a heavy instrument, not fingers.
b. Teeth and serrations should align exactly
c. Tips should be straight and in alignment
d. Scissors should be snug and sharp in action
e. Cannulae should be clear and without
obstruction
3. Sort instruments neatly by
classifications

4. Keep ring-handled instruments together with the
curvatures and angles pointed in the same direction

a. Hang ring handles over a rolled towel or over the
edge of the instrument tray or container
5. Leave retractors and other heavy instruments in a
tray 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
that the blades and tips are suspended
b. Tip-protecting covers or instrument-protecting
plastic should be removed and discarded before the
instruments are used on the patient
c. If they are not in the rack, handles should be
supported 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.
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
while a procedure is in progress until the final count is acknowledged to be correct. The only
exception 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 be
passed 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).

Counting Procedure
Incorrect closure counts must be repeated immediately. If the
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.
Counting Procedure
POSTOPERATIVE PHASE
POSTOPERATIVE PHASE
Goals:
Maintain adequate body system functions
Restore homeostasis
Alleviate pain and discomfort
Prevent postop complication
Ensure adequate discharge planning and
teaching.
PACU CARE
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
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

Determine swallowing and gag reflex , LOC and patients
response 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 Assessment
Maintaining a Patent Airway

Allow the airway ( ET tube ) to remain in place until the
patient begins to waken and is trying to eject the airway.
The airway keeps the passage open and prevents the tongue
from falling backward and obstructing the air passages.
Aspirate excessive secretions when they are heard in the
nasopharynx and oropharynx.
Initial Nursing Interventions
Assessing Status of Circulatory System
Take VS per protocol, until patient is well stabilized.
Monitor intake and output closely.
Recognized early symptoms of shock or hemorrhage:
- cool extremities
- decreased urine output ( less than 30ml/hr )
- slow capillary refill ( greater than 3 sec. )
- lowered BP
- narrowing pulse pressure
- increased heart rate
* initiate O2 therapy, to increase O2 availability from the blood.
* place the patient in shock position with his feet elevated ( unless
contraindicated )
Maintaining Adequate Respiratory Function

Place the patient in lateral position with neck extended ( if not
contraindicated ) and upper arm supported on a pillow.
Turn the patient every 1 to 2 hours to facilitate breathing and
ventilation.
Encourage the patient to take deep breaths, use an incentive spirometer.
Assess lung fields frequently by auscultation.
Periodically evaluate the patients orientation response to name and
command.
Note: Alterations in cerebral function may suggestimpaired O2 delivery.
Administer humidified oxygen if required.
Use mechanical ventilation to maintain adequate pulmonary ventilation if
required.
Assessing Thermoregulatory Status

Monitor temperature per protocol to be alert for
malignant hyperthermia or to detect hypothermia.
Report a temperature over 37.8 C or under 36.1 C
Monitor for postanesthesia shivering, 30-45
minutes after admission to the PACU.
Provide a therapeutic environment with proper
temperature and humidity.
Minimizing Complications of Skin Impairment

Perform handwashing before and after contact with the
patient
Inspect dressings routinely and reinforce them if necessary.
Record the amount and type of wound drainage.
Turn patient frequently and maintain good body alignment.
Maintaining Adequate Fluid Volume
Administer I.V solutions as ordered.
Monitor evidence of F&E imbalance such as N&V and weakness.
Evaluate mental status, skin color and turgor
Recognized signs of:
a. Hypovolemia
- decrease BP
- decrease urine output
- decreased CVP
- increased pulse
b. Hypervolemia
- increase BP
- changes in lung sounds (S3 gallop )
- increased CVP
Monitor I&O
Maintaining Safety
Keep the side rails up until the patient is fully awake.
Protect the extremity into which I.V fluids are running so
needle will not become accidentally dislodged.
Avoid nerve damage and muscle strain by properly
supporting and padding pressure areas.
Recognized that the patient may not be able to complain of
injury such as the pricking of an open safety pin or clamp that
is exerting pressure.
Check dressing for constriction
Promoting Comfort
Assess pain by observing behavioral and
physiologic manifestations.
Administer analgesic and document efficacy.
Position the patient to maximize comfort.
Parameter for Discharge from
PACU/RR

Activity. Able to obey commands
Respiratory. Easy, noiseless breathing
Circulation. BP within 20mmHg of preop level
Consciousness. Responsive
Color. Pinkish skin and mucus membrane
END

Intraoperative Lecture

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Intraoperative Care

MS. LOURADEL MATOL ULBATA, RN, MAN

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