Capitol University

Corrales Extension, Cagayan de oro city

College of Nursing
In partial fulfillment of the requirements in Related Learning Experience
Roles and function of Scrub nurse, Circulating nurse and recovery room nurse Skin preparation Draping Instrumentation Packaging of Instruments Abdominal Layers Incision types and sites Types of Suture Submitted to: Mr. Enrico G. Galang Jr.

Submitted by: Huemer O. Uy

OR light and OR table • Make sure theater is clean • Arrange furniture according to use • Place a clean sheet. suction machine. arm board (arm strap) and a pillow on the OR table • Provide a clean kick bucket and pail • Collect necessary stock and equipment • Turn on aircon unit • Help scrub nurse with setting up the theater • Assist with counts and records During the Induction of Anesthesia • Turn on OR light • Assist the anesthesiologist in positioning the patient • Assist the patient in assuming the position for anesthesia • Anticipate the anesthesiologist’s needs • If spinal anesthesia is contemplated: Place the patient in quasi fetal position and provide pillow Perform lumbar preparation aseptically Anticipate anesthesiologist’s needs After the patient is anesthetized • Reposition the patient per anesthesiologist’s instruction • Attached anesthesia screen and place the patient’s arm on the arm boards • Apply restraints on the patient • Expose the area for skin preparation • Catheterize the patient as indicated by the anesthesiologist • Perform skin preparation During Operation • Remain in theater throughout operation • Focus the OR light every now and then • Connect diatherapy. • Position kick buckets on the operating side • Replenishes and records sponge/ sutures • Ensure the theater door remain closed and patient’ s dignity is upheld • Watch out for any break in aseptic technique End of Operation • Assist with final sponge and instruments count • Signs the theater register • Ensures specimen are properly labeled and signed After an Operation • Hands dressing to the scrub nurse • Helps remove and dispose of drapes • Helps to prepare the patient for the recovery room • Assist the scrub nurse.DUTIES OF CIRCULATING NURSE Before an operation • Checks all equipment for proper functioning such as cautery machine. suction. etc. taking the instrumentations to the service (washroom) • Ensures that the theater is ready for the next case .

assist in draping the patient aseptically according to routine procedure • Place blade on the knife handle using needle holder. instruments and needle count. assemble suction tip and suction tube • Bring mayo stand and back table near the draped patient after draping is completed • Secure suction tube and cautery cord with towel clips or allis • Prepares sutures and needles according to use During an operation • Maintain sterility throughout the procedure • Awareness of the patient’s safety • Adhere to the policy regarding sponge/ instruments count/ surgical needles • Arrange the instrument on the mayo table and on the back table Before the Incision Begins • Provide 2 sponges on the operative site prior to incision • Passes the 1st knife for the skin to the surgeon with blade facing downward and a hemostat to the assistant surgeon • Watch the field/ procedure and anticipate the surgeon’s needs • Pass the instrument in a decisive and positive manner • Watch out for hand signals to ask for instruments and keep instrument as clean as possible by wiping instrument with moist sponge • Always remove charred tissue from the cautery tip • Notify circulating nurse if you need additional instruments as clear as possible • Keep 2 sponges on the field • Save and care for tissue specimen according to the hospital policy • Remove excess instrument from the sterile field • Adhere and maintain sterile technique and watch for any breaks End of Operation • Undertake count of sponges and instruments with circulating nurse • Informs the surgeon of count result • Clears away instrument and equipment • After operation: helps to apply dressing • De-gown • Prepares the patient for recovery room • Completes documentation • Hand patient over to recover room . Then. Start with towel. draw sheet and then lap sheet. towel clips. checks with circulating nurse When surgeon arrives after scrubbing • Perform assisted gowning and gloving to the surgeon and assistant surgeon as soon as they enter the operation suite • Assemble the drapes according to use.DUTIES OF SCRUB NURSE Before an operation • Ensures that the circulating nurse has checked the equipment • Ensures that the theater has been cleaned before the trolley is set • Prepares the instruments and equipment needed in the operation • Uses sterile technique for scrubbing. gowning and gloving • Receives sterile equipment via circulating nurse using sterile technique • Performs initial sponges.

Recovery room nurses must be registered nurses who have been extensively trained in critical care.THE JOB DESCRIPTION OF A RECOVERY ROOM NURSE The recovery room nurse is the primary patient advocate following surgery. Considerations o Recovery room nurses can work any type of shift. and to intravenous therapy for fluids and pain medication. Patient Monitoring o Patient observation is an essential role of the recovery room nurse. The nurse ensures that the patient is breathing properly and administers oxygen when needed. and intravenous and epidural infusions. Additional Duties o Recovery room nurses make complete notes on the charts. calling for assistance and beginning cardiopulmonary resuscitation if necessary. asks patients about their level of pain. and communicate information in verbal or written form to other PACU nurses and to physicians. The recovery room nurse connects the patient to devices such as cardiac monitoring equipment. Pain Intervention o Pain intervention is another important part of the job description of a recovery room nurse. They complete any forms required by the facility. Recovery room nurses must have excellent observation skills. pulse and temperature. This nurse monitors patients when they are still under the effects of anesthesia. Recovery room nurses must react rapidly to signs of negative physical changes. be able to think critically. This may be a time frame anywhere from 30 minutes to a few hours until the patient is stable enough either to be transported to his hospital room or discharged from the facility. days or nights. On a regular basis. He notifies the physician if more pain medication appears to be needed. and be able to make quick and effective decisions. Traveling nurse organizations recruit for recovery room nurses as well. and also can work on a per diem. Initial Care o A recovery room nurse provides constant care to patients immediately following surgery. and administers pain medications that have been prescribed. . such as blood pressure. or as needed. she takes the patient's vital signs. basis. The nurse must be able to use patient-controlled pumps. They must be able to communicate effectively with patients of different ages and backgrounds. Some recovery room nurses supervise supplemental staff members. and the area they work in is called the post-anesthesia care unit (PACU). The nurse observes patients to assess their comfort level.

of course. then open it downward over the patient's feet and upward over the anesthetist screen. leave it in place and place another drape over it. protect the gloved hand by enclosing it in the turned back cuff of the sheet. The third towel is passed the same way. leaving only enough exposed skin for the incision. Draping materials may be disposable or nondisposable. The procedure of covering a patient and surrounding areas with a sterile barrier to create and maintain a sterile field during a surgical procedure is called draping. Disposable drapes are generally paper or plastic or a combination and may or may not be absorbent. The third step in draping is placing the four sterile towels around the line of incision. Since draping is very important in preparing a patient for surgery. It also closes some of the opening in the laparotomy sheet. The first three towels are cuffed toward the scrub. Drop it and use another drape. b. (3) Hold the drapes high enough to avoid touching nonsterile area but avoid touching the overhead light. except the towel is placed on the upper side (toward head) the line of incision. muslin drapes (for example. passes the towel drape to the surgeon with the strip side facing the scrub. then drop (open fingers and release sheet) it down where it is to remain.DRAPING THE PATIENT a. The towels are cuffed by the scrub about 3 inches and the folded edge goes next to the line of incision. Nondisposable drapes are usually double-thickness muslin. (5) Protect the gloved hands by cuffing the end of the sheet over them. (2) Never reach across the operating table to drape the opposite side. The scrub will select the sheet and hand one end to the surgeon across the operating table. NOTE: The only procedure changes that are made with nondisposable. The scrub unfolds first towel. the towels usually have a removable strip with an adhesive on the folded edge. go around the table. (8) If the end of a drape falls below waist level. During the draping procedure. must be sterile. The second towel is placed in the same way. Drapes. The scrub must know the procedure perfectly and be ready to assist with it. the scrub will select the surgical drape (lap sheet). Aseptic technique must be observed at all times in the draping process. (3) Finally. c. The lap sheet will have an arrow or some other indication to identify the head or foot portion of the drape. except the towel is placed on the lower side (toward feet) of the line of incision. If the drape is incorrectly placed. the circulator should stand by to direct the scrub as necessary and to watch carefully for breaks in sterile technique. the fourth towel is cuffed toward the surgeon. it must be done correctly. discard it immediately. (4) Hold the drape high until it is directly over the proper area. and then removes the adhesive strip. hand towels) are as follow. Drop the folds over the sides of the table. The second drape sheet is handled in the same manner. then drop it (open fingers and release sheet). . The entire surgical team should be familiar with the draping procedure. NEVER ADJUST ANY DRAPE. You should: (1) Handle the drapes as little as possible. if necessary. The purpose of draping is to eliminate the passage of microorganisms between nonsterile and sterile areas. (9) If in doubt about sterility. The scrub places the opening directly over the skin area outlined by the drape towels and in the direction indicated for the foot or head of the table. (7) If a drape becomes contaminated. supporting the folds. The towels are held in place by towel clips rather than by adhesive. (6) In unfolding a sheet from the operative site toward the foot or head of the table. The surgeon places the towel within the scrubbed area on the near side of the line of incision. Do not let the gloved hand touch the skin of the patient. The last towel is passed to the surgeon with the adhesive strip facing the surgeon and is placed on the far side of the line of incision. discard the drape. This draping sheet provides extra thickness of material under the area from the Mayo tray to the incision where instruments and sponges are placed. keeping it high. and holding it taut until it is opened. This sheet is placed below the incision site with the edge of the sheet just below the incision site. do not handle it further. (2) When disposable drapes are used. The adhesive area holds the towel drapes in place. This lap sheet has a fenestration (opening) in the drape for the incision. (1) The first step in draping is the placing of a drape sheet from the foot to the knees.

a factor that should motivate hospitals to minimize the incidence of postoperative infections (6). accounting for approximately a quarter of all nosocomial infections. In these cases. During the mid1970s. Adherence to recommendations in the 1999 Centers for Disease Control and Prevention guidelines should reduce the incidence of infection in surgical patients. such as laparoscopic (minimally invasive) operations or those that require only a short postoperative stay. among an estimated 27 million surgical procedures (2). and the cost of hospitalization was correspondingly increased when postoperative infection developed after six common operations (4). Infections result in longer hospitalization and higher costs. Advances in risk assessment comparison may involve use of the standardized infection ratio. incisional infections are further divided into superficial (skin and subcutaneous tissue) and deep (deep soft tissue-muscle and fascia). The incidence of infection varies from surgeon to surgeon.Surgical Skin Preparation Wound site infections are a major source of postoperative illness. These costs and the length of hospital stay are undoubtedly lower today for most surgical procedures that are done on an outpatient basis. However. prevention. most infections are diagnosed and treated in the outpatient clinic or the patient's home. from one surgical procedure to another. . major complications such as deep sternal infections continue to have a grave impact. and logistic regression models. increasing the duration of hospitalization as much as 20-fold and the cost of hospitalization fivefold (5). These definitions should be followed universally for surveillance. and--most importantly--from one patient to another. National studies have defined the patients at highest risk for infection in general and in many specific operative procedures. organ. Any surgical site infection after open heart surgery results in a substantial net loss of reimbursement to the hospital compared with uninfected cases. These infections are classified into incisional.000 per year. or other organs and spaces manipulated during an operation. Description of Surgical Site Infections The Centers for Disease Control and Prevention (CDC) term for infections associated with surgical procedures was changed from surgical wound infection to surgical site infection in 1992 (7). These infections number approximately 500. and control of surgical site infections. and account for approximately one quarter of the estimated 2 million nosocomial infections in the United States each year (3). Detailed criteria for these definitions have been described (7). the average hospital stay doubled. procedure-specific risk factor collection. Postoperative surgical site infections remain a major source of illness and a less frequent cause of death in the surgical patient (1). from hospital to hospital.

surgical instruments must be repackaged in either a sterilization bag or woven wrapping intended for use in an autoclave. Cover the ends of sharp instruments with plastic. Ensure all instruments have been pre-cleaned and are free of body fluids and debris. 3Place two square sterilization sheets on a large. Close the flap over the open end of the bag. Insert a sterilization indicator strip into the package. 1 Choose the packaging for your surgical instruments. sterilization tape and sterilization indicator tabs. Always follow your facility's instrument packaging protocol. Gather sterilization bags or double-layer woven wrapping. autoclave-approved tip protectors to prevent puncture of the bag. Arrange instruments over the gauze in a single layer. Packaging surgical instruments is a precise procedure which requires knowledge of proper technique. Secure the outside sheet with sterilization tape.How to Package Surgical Instruments Surgical instruments are placed in specialized packaging to keep them sterile. Open any closed instruments. Place a single layer of gauze in the middle of the top sheet. 2 Place the instruments in an appropriate-sized sterilization bag. 4 Fold the top sterilization sheet appropriately in a square fold. Add a sterilization strip with the instruments. flat surface and arrange in a square position. and seal the package by removing the adhesive strip protector on the flap. or sterilization machine. if possible. or place the tips slightly into the gauze for protection. Cover the tips of sharp instruments with tip protectors. Consult your facility's guidelines for proper folding technique. After each use. Fold the outer sterilization sheet over the other in a square-fold. .

e. For instance.) 5. It may receive different names depending on its location (i. 4. Peritoneum (a thin one cell thick membrane that lines the abdominal cavity and in certain places reflects inward to form a double layer of peritoneum) Double layers of peritoneum are called . this fascia may become aponeurotic and serve as attachments for the muscle to bone or to each other.Layers of the Abdominal Wall The layers of the abdominal wall vary. It is necessary in the abdominal wall because it offers more flexibility for a variety of functions of the abdomen. etc. transversalis fascia when it is deep to that muscle. it is somewhat different along the lateral sides of the abdomen than it is at the anterior side. however. At certain points. It is also somewhat different at its lower regions. as is the case at the linea alba. It is of the loose connective tissue variety. depending on where it is you are looking. Note the layers a surgeons knife. Lets start out along the lateral side of the abdomen: • • • • • • skin superficial fascia deep fascia muscle subserous fascia peritoneum At the lateral side of the abdomen (1) there is a dotted line passing through the abdominal wall. skin 2. The deep fascia of the abdominal wall is different than that found around muscles of the extremities. subserous fascia also known at extraperitoneal fascia (a layer of loose connective tissue that serves as a glue to hold the peritoneum to the deep fascia of the abdominal wall or to the outer lining of the GI tract. iliac fascia. psoas fascia when it is next to that muscles. a criminal knife or a anatomy student's knife must pass through to get to the peritoneal cavity: 1. Deep fascia (all skeletal muscle is surrounded within its own deep fascia). superficial fascia (this may be as thin as or less than a half inch or as thick as 6 inches or more) 3.

in the midline there is no muscle so a knife would only go through the: 1. omenta. subserous fascia 5.) At the anterior wall of the abdomen.mesenteries. etc. skin 2. deep fascia (in this case a thickened area of deep fascia called the linea alba) 4. falciform ligaments. peritoneum Incision Types . superficial fascia 3. lienorenal ligament.

starting at the edge of the Iliac crest and progressing upwards towards the front of the thigh. total hip replacement.Many different surgical incisions approaches exist. as well as the most appropriate for the required procedure. Anterolateral Approach The Anterolateral Approach is similar to the Bauer Transgluteal Approach. The Bauer incision occurs on the side of the thigh. and extends downward along the side of the thigh. but the incision starts at the greater trochanter on the femur. This approach is more common in patients who require a hip pinning. with the patient lying on his back on the operating table. femoral neck osteotomies. The hip joint area is not easily accessed using this approach. Types of Sutures . Bauer Transgluteal Approach The Bauer Transgluteal Approach is most commonly used for femoral neck fractures. as well as the most common cases which use each specific approach. Here we will describe the most common surgical approaches for total hip replacement. Anterior Approach The Anterior Approach has been called the most versatile. A cushion is often placed underneath the patients buttocks. The incision occurs in a quarter circle shape around the side of the thigh. The Posterior incision occurs at the top of the operating side buttock. It provides broad exposure to the hip. for patients who have severe degenerative hip disease or trauma to the joint. Posterior Approach to the Hip Joint The Posterior approach is most commonly used for the replacement of the hip joint. and cases of slipped epiphysis. The incision travels from just below the top of the pelvis and extends down the side of the thigh. yet most challenging approach to the hip. Often these approaches are dictated by what the surgeon is most comfortable and experienced in. and proceeds in a long arch path down the side of the thigh.

with the major criteria being the demands of the location and environment and depends on the discretion and professional experience of the Surgeons. In general. Monofilament and Multifilament Sutures Sutures can also be divided into two types on the basis of material structure i. • Sutures to be placed internally would require re-opening if they were to be removed. Poliglecaprone and Polydioxanone sutures. Catgut. Polyglactin 910 . Poliglecaprone 25 and Polydioxanone sutures. for example the heart (constant pressure and movement) or the bladder (adverse chemical presence) may require specialized or stronger materials to perform their role. monofilament sutures and multifilament or braided sutures. PVDF. Synthetic and Natural Sutures Surgical sutures can also be divided into two types on the basis of raw material origin i. Nylon (poylamide). Nylon. nonabsorbable externally. and are often non-absorbable to reduce the risk of degradation. As a result. natural and synthetic sutures. The type of suture used varies on the operation. and those which are non-absorbable and must be manually removed if they are not left indefinitely.e.Polyglycolic Acid sutures. PVDF. Monofilament sutures include :. and without re-opening the wound. Non-Absorbable sutures include :. silk and polyester sutures. usually such sutures are either specially treated. absorbable sutures are often used internally. Natural sutures include silk and catgut sutures whereas all other sutures are synthetic in nature. Catgut. Braided sutures provide better knot security whereas monofilament sutures provide better passage through tissues.Polypropylene sutures. Polyester. Multifilament or braided sutures include :. • Sutures to be placed in a stressful environment. .Polypropylene sutures. silk and stainless steel sutures. Monofilament sutures elicit lower tissue reaction compared to braided sutures.e. or made of special materials. Polyglactin 910.PGA sutures.Absorbable and non absorbable sutures Sutures can be divided into two types – those which are absorbable and will break down harmlessly in the body over time without intervention. Absorbable sutures include :. Stainless steel. Sutures which lie on the exterior of the body can be removed within minutes.

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