Nursing staff : (Flow chart - 13.3) y Sreenamsane “a a paeaoul) = Nursing sens | Flow Chart -13.3 : Nursing staff Anaesthetic section : (Flow chart - 13.4) [Grier anaesthetic t ‘Assistant anette } + Anaeshete suis + Freese | Flow Chart 134: Anaesthac section stat DUTIES AND RESPONSIBILITIES OF NURSE INOT Duties and responsibility of Senior manager © Maintenance of a high standards of patient care Planning and ordering equipments A Welfare and professional development of staff * Liaison with other department Duties and responsibility Theatre nurse (7+ Daily management ofthe theatre + The safety and welfare of patient + Ordering stock + Organizing Continuing education for staff 7 Liaison with surgeon and anaesthesia regain ‘peration lists and equipments orde 2 a © Discussion of proble e sei problem withthe senior manager Aoiic x and responsibility of scrubbed assistant fore th for the operation Chapter 13 : Per-operative Nursing ley and bowel stand sterile drapes. A Metta, 1, needles, blades, mops, Collecting suture material gauze and cotton. poke Draping mayo table and preparing intially requir d instruments. Check patients identity with the name Ensuring safe positioning of the patient st ositioning of Ca 2 During operation «Handling skin preparation agents an to the surgeon. + Assisting in draping ‘+ Positioning mayo table. + Arranging diathermy and suction. Passing instruments, swabs and sutures to the surgeon. + Keeping an accurate count of extra instruments and swabs collected during the operation and ensuring that they are charted by the circulator. + Anticipating the needs of the surgeon. + Ensuring adequate discipline and minimum disturbance within the theatre, At the end of the operation + Conforming that all instruments swabs and mops are accounted for + Removing instruments from mayo table + Collecting from the circulator + Disposing of blades and needle: containers + Removing drapes + Ensuring thatthe perioperative area is clean + Ensuring that the patient gown is clean and dry + Covering the patient with a clean s + Returning instrume ‘band, case paper. \d swabs on holder into appropriate et ee s for washing and sterilization Completing entries in the operation register A circulator is a person who help the scrubbed 4nd is available throughout the procedures Before the operation assistant Checking that the theatre has been clea Confirmation that lights suction and auipmentarein working oder + Ensuring that the temperature and humidity c Eng tht he temp humidity controls + Collecting the cessaly equipments and stocks Preparing sterilised | gowns and gloves, "2 Ying gown to surgeon and scrubbing nurse diathermy | yD RK >+ Opening instruments pack, bowel equips + Assisting with counts and records. nts for scrubbed assistant. During the operation + Being available in the th g diathe are, my and suction leads. and recording swabs and mops arc bowls with sterile wate swabs collecting bowls conveniently of the scrubbed assistant + Anticipatin + Ensuring th the requirement of the team. all doors ofthe theatre remain closed. *+ Assisting with the count and records before the end of the operation. + Preparing the wound d After operation + Handii + Helping he removal of the drapes. + Helping with the p to the recovery ward. + Removing the instruments trolley and other equipment to the suitable room essing to the scrub tion ofthe patient for shifting + Ensuring that the theatre is clean after surg ry _ INSTRUMENTS IN OT General set of instruments + Sponge holding forceps + Towel clips -6 + A.n0-4 knife with no -20 lade and n0-3 knife handle with n0-10, 11 or 15 blade + Toothed dissecting forceps shorts-2 + Mein does curved dissecting + Non toothed dissecting forc s, short and long each * One dozen curved fine lsemostats * One dozen 6 inch spencer wells artery forceps + Twomoyninan gall bladder cramps + Two large largenbecks retractors + Kelly s deep retractors * Suction nozzle tubing and quiver * Sponge holder for deep mopping Four Doyens and two Backhaus tetra clips Four Doyens and two Backhaus + wo Doyens intestinal occlusion clips ‘Text book of Medical Surgical Nursing ick and other 1g Vol~ | nd wo littlewoods tissue forceps naar the surgeon assistant 0 ae 1 needle holder + Mayo Hegal Suture scissors li SUTURE MATERIALS Suture Materials th ‘used for any strand of material used aoe approximating tissues itisalsO synonymous for atng oF SPP suture denotes the actof sewing with stl: sues together and holding them until healing If the material is tied around a blood the lumen, itis called a ligature or tie, A reedle fora single stitch for hemostasis ature. A free tie is vessel to occlu ‘as a stick tie or suture li werele strand of material handed to the surgeon or ‘icstant to ligate a vessel. A tie handed to the surgeon in he tip of forceps is referred to as a tie on a passer Types of Suture Materials al suture materials are classified as either absorbable. suture at is referred to as orn on absorbable (Flow chart - 13.5) hatin Morland [-Polyglyeolic) [— "PDS Myon pakeoms) pany (Meta we rte") [ Sa Oly propytene a * Staink Pylene Metal wirearesull ofthe enzymatic action not require removal, Absorbab) polyfilament (braided) and sutures. Each have various halt, length of time needed by absorsn? A. Surgical Catgut: + Collagen manufactured from the submuco intestine or serosa of beef intestine tt SHEP + Condition of tissue + General health status of the patient + Type of surgical catgut Plain Surgical Catgut + Love tensile strength quickly, usually in Sto 10 days ‘+ Used to ligate small vessels and to suture subcutaneous fat + Not used to suture any layer of tissue likely 10 be ‘subjected to tension during healing. ‘+ Available in sizes 310 6-0. : + Usually used in its natural yellow-tan color, it may be dyed blue or black + Fast absorbing plain surgical catgut is specially aa Srp od tte Peg : suturing where sutures MNS Prepccee eue B. Synthetic Absorbable Sutures * Are absorbed by a slow hydrolysis process in the Presence of tissue fluids. + They are used for ligating and suturing, ‘+ They are extremely inert and have great tensile strength * Can be used in nearly all tissues, + Asa disadvantage, it tends to drag through the tissue father than passing smoothly This action may slow down the sewing process. * This type of suture also requires special techniques fortying + The sutures included in this group are: * Polyglycolic acid ( Dexon) suture + Polyglactin 910 ( Vicryl ) suture + Polydioxanone (PDS) Suture + Polyglicaprone (Monocry!) suture Non absorbable Suture Nonabsorbable suture is either left in the body, where itbecomes embedded in scar tissue, or it is removed when healing iscomplete, asin skin closure. Its used in tissues that heal more slowly than those requiring any type of absorbable suture, A. Surgical Silk * An animal product made from the fiber spun by silkworm larvae in making their cocoons + Widely used non-absorbable suture that is easy to handle and is both supple and strong, + Can be used ina wide variety of tissues, ranging from ophthalmic to cardiovascular + Has a multifilament structure and is weated with Teflon ‘ora similar coating to prevent tissue drag and flaking. B, Surgical Cotton ‘Manufactured from the fibers of the cotton plant + Supple and easy to handle ‘+ Has inferior strength and tendency to flake + Can be strengthening by dipping it into saline solution prior to use. + Itsapplication is nearly identical to that of silk, C. Polyester Suture Bins =iee OC D. Nylon Suture ‘+ Used primarily for skin closure, ophthalmic procedures, and microsurgery. Produces minimal tissue reaction Has high tensile strength, and resists capillary action ‘The major disadvantages of nylon are its elasticity and stiffness, which necessitate the laying of many knots. E. Polypropylene (Prolene) Suture + Extruded into a monofilament strand. + The most inert of the synthetic materials and almost as inert as stainless steel. Easier to handle ‘+ Can be used in the presence of infections. + The material of choice for many plastic surgery and cardiovascular procedures because of its smooth passage through tissues, as well as its strength and inertness. Frequently used for retention sutures. F, Surgical Steet + Made of stainless steel and is the most inert type of suture available, + Used mainly in the orthopedic surgery to approximate bone fragments, ‘+ Not widely used because of major disadvantages: ¥ Extremely difficult to handle ¥ Kinks easily and has ¥- Because ofits springiness itis e atthe field The sharp ends of the strands can easily puncture 4 glove, causing contamination and injury to the person handling it. Suture Sizing and Packaging ‘The diameter of the suture strand. determines its size Size Ois smaller than size 1.Size 2-0(00)is smaller than size O, and so on, Suture as small as 11-0 and as large as, ‘number Tare available. Stainless steel sutures have an ‘additional size indicator called Brow and Sharp (B & S) gauge, Stee! suture may be referred toby ether method, ‘The length of the suture is standardized. Strands are precut (17, 18, or 24 inches) or full length (54 or 60 inches). Acontinuous reel isalso available which allows the surgeon to tie vessels in quick succession. Suture is available in peel-apart packages for convenient and quick distribution. The circulator distributes suture by peeling back the outside wrapper and exposing the inner Packet of suture. effect on tissue ly contaminated Sat i Factors that influence the choice of suture material «Biologic characteristics of the suture material © Healing characteristics of the tissue © Location and length of the incision Presence of absence of contamination and/or infection Patient problems such as obesity, debility, advance age and diseases Physical characteristics ofthe material such as ease ‘of passing through tssue, knot tying and other personal preference of the surgeon Methods of Suturing “There are two basic methods of suturing and various ways toutilize the twotechniques. The suture is either running ullizinga single continuous suture, or els it 1s interrupted Interrupted sutures are placed separately and tied separately. Suturing techniques are depicted in Figure 10.9. Examples of suturing techniques that direct the wound edges for specific healing mechanisms include, but are not limited to, the following: Everting sutures. These interrupted (individual stitches) ‘or continuous (running stitch) sutures are used for skin edges. + Simple continuous (running). This suture ean be used toclose multiple layers with one suture. Thesuture is ot ‘cut until the full length is incorporated into the ussue + Simple interrupted. Each individual stitch is placed, Uied, and cut in succession from one suture (Figure 108,C), + Continuous running/locking; also known as & blanket stitch, A single suture is passed in and out of the tissue layers and looped through the free end before the needle is passed through the tissue for ‘another stitch. Each new stitch locks the previous stiteh in place + Horizontal mattress. Stitches are placed parallel to wound edges. Each single bite takes the place of ‘wo interrupted stitches (Figure 10:8, D) + Vertical mattress. This suture uses deep and ‘superficial bites, with each stitch crossing the wound at right angles. I works well for deep wounds, Edges approximate well. + Inverting sutures. These sutures are commonly used for two-layer anastomosis of hollow internal ofpans. such as the bowel and stomach, Placing (wo layer ‘Prevents passing suture through the lumen of the fea! ‘and creating a path for infection. These stitches ¢2 be either interrupted or continuousKnot placement Each suture placed in tissu issue usually requi Placement of a knot to secure the ends, vies the stitches require individual knots, and therefore and the cosmetic result, Principles concernin, the following 1. The knot should be tied away from: + Vital structures, such as the eye B knots and knot tying include + Source of contamination, such as the mouth + Potential irritants, such as the nares + Potential sources of increase as the incision line 2. The knot should be tied toward: + The better blood supply + The area that provides the best security of the knot + If possible, where the mark would be less noticeable Cutting Sutures Care is taken to prevent excess suture from remaining in the wound, Suture tails are trimmed close to the knot d inflammation, such Considerations for cutting suture include the following: + Scissors should be stabilized by the index finger on the screw, the blades are angled slightly and slide down to the area just above the knot, and the suture is cut with the tips of the scissors. The tips of the scissors must be visible to ensure that other structures are not injured by the cutting motion + A hemostat and/or second suture should be available inthe event that the knot is inadvertently cut, releasing. the sutured tissue. + Ahemostat may be placed on one of the suture ends to stabilize the suture to be cut. + When removing a suture, a forceps is used to grasp the suture atthe knot. Cut the suture between the knot and the skin, Extract the cut suture with forceps EQUIPMENT INOT Equipment are permanent articles and may be classified as aed and non movable. OT equipments are made Of stainless steels so that antiseptic wash before and after the surgical procedure is possible. This helps cross infection from contamination. Following are the furniture and equipments used in oT + Operation table + Operation table matters + Mayo stand + Instrument trolley + Overhead (Gerhardt) table + Ring stand + Trolley /table for scrub attire + Skin preparation trolley + Miscellaneous equipments trolley + Kick bucket + Sitting soo! + Standing platform + Anesthetic trolley + Cardiac monitor + Defibrillator + Anlficial respiration or ventilator + Pulse oximeter + Suction unit + Oxygen supply device + IV stands / Hooks / Poles + OT light + Operative microscope + X-ray machine + Cryosurgery unit + Image intensifier + Closed circuit television + Computers + Tracheostomy + Sterilizer + Fireextinguisher + Alarm bell + Wall clock + Music system + Racks, Shelves, Almirah + Stretchers, Trolley, wheel chair 1) Operation table Operation table Itis the most. on w/e pt lies or restmechanism to facilitate to work of the surgical team. OT ‘are designed for specific operations. Generally OT has all operation tables that is designed to suit a wide variety of operations such as general as well as specific operations. The standard operation table is divided into 3 t05 sections joined, ‘This arrangement allows articulations of the different sections of the table top by flexing or by extending the joints w/e facilitates the position of the patients forrequired surgery. The foot end can be lowered & patients buttocks can be brought to the lower edge in lithotomy position OT table has a single or double armed W/c can be adjusted with the table top at 90 degree which can be also be locked to prevent their movement, Pts arms are placed on the arm board to facilitate surgery on any part of the arm, hand, finger, facilitates injection, infusion, monitoring pt’s pulse. OT table also consist of shoulder braces ,body braces,thigh straps, knee braces used to fixed with the OT table, Itis used to stabilized pt;s body in various position. OT table also has stirrups on w/e legs are hung & supported in lithotomy position, 2) Operation table mattress : Operation table mattress A rubber mattress fits the ‘operation table. The mattress is firm covered with a water proof cover to prevent its damage, The mattress is further covered with conductive rubber to Prevent electrical hazards. The mattress can be fixed with OT table top by means of clips or hooks. It can be removed low cleaning of the OT table top. 3) Mayo stand: Mayo stand It is a frame on w/c a rectangular stainless steel top can be fixed. The base of this frame can be slided under the operation table & top comes over the sterile field on which instruments, sutures, ligatures, sponges ete can be laid. These can be conveniently used by the serub Surgeon during surgery as it provides easy access, 4) Instrument trolley : is put on the. sterile surface on we instrume, nurse stands during surgery. This provide a large surface instruments .extra drapes, sponges ete area on w/e more can be kept. 6) Ring sary be One or ore aetna Ring stan Se red by sterile circular frames which are ces i drapes to make a sterile surface. Then sterile basins containing sterile warm nora saline water are placed on the ring Itis used for rinsing blood stained instruments, soaking Sponges of washing blood stained gloved hand during surgery. ; 7) Trolley /table for scrub attire : Trolley /table for scrub attire The scrub personnel have to wear sterile gown & gloves after scrubbing & drying their hands. separate trolley ora table is setup on which sterile packets containing scrub gowns & gloves packels are kept so that they can be picked up or handed over conveniently, 8) Skin preparation trolley : Skin preparation trolley A skin preparation trolley with? to3 sponges holding forceps, 2 to 3 large bowls containing antiseptic lotion & lots of sponges is prepared for cleaning the operation site before the operation procedure is started. After skin cleaning is over the trolley is removed from OT. 9) Miscellaneous equipments trolley : Miscellaneous equipments trolley Another trolley is set with miscellaneous & clean articles such as in infusion Seis, transfusion sets, infusion fluids, antiseptic lotions, Specimen bottles scissors etc. 10) Sitting stool : Sitting stool When the operation is of long duration the Surgeon may like to sit & do the operation. The sitting Stool is stainless Steel with adjustable heights. The stool ‘op should be spacious enough to allow comfortable siting.a are Chapter - 13 : Perioperative Nursing 13) Anaesthesia trolley : The anaesthesia trolley contains anaestl anaesthetics equipments, 02 mask, Endo of different sizes, Endotracheal laryngoscopes etc. 14) Cardiac monitor : This is an apparatus which is i for monitoring cardiac functioning of te oar surgery. 15) Defibrillator : pia ee resuscitative equipment used for cardiac 16) Artificial respirator or ventilator : This apparatus is used for pulmonary resuscitation for ‘maintaining patients pulmonary function 17) Pulse oximeter = Itis adevice used for pulse oximetry that is for measuring hemoglobin & 02 saturation of blood. 18) Suction unit : thetic drugs, tracheal tubes connectors, Modern operation theatres are equipped with inbuilt suction unit. Most of the OT have portable suction unit either with one bottle or two bottles. A suction apparatus is used for suctioning of the operation site through a sterile suction, catheter, 19) 02 eylinder = All modern OT have inbuilt 02 supply channels from a central source through the 02 pipeline & O2 sockets. OT keeps one or two 02 cylinders for’ ready use & the cylinders should be complete with regulator, humidifier etc. 20) VV stands/hooks/poles WV stands/hooks/poles I'v hooks or poles are preferably ceiling mounted such a s hanging from the ceiling, They should be movable & adjustable to any height, the mounted designs cluttering of OT floor with too many equipments & provide maximum space for the OT personnel to move about freely. It also allows free movement of stretcher, trolley ete in the OT. 23) X-ray machine : OT has a portable X-ray machine. This ceiling mounted. This X-ray machine is use ray film during the surgery. 24) Cryosurgery unit : Cryosurgery devices can also be ceiling mounted & can ‘be used in OT as & when needed. The selective exposure of tissues to extreme cold, often by applying a probe containing liquid nitrogen, to bring about the destruction, or elimination of abnormal cells 25) Image intensifier : This is a device used in OT can also be ceiling mounted. 26) Closed circuit television: Closed circuit television system with cei cameras which will project full & an excellent view of the operation to the central monitor at the nurses: desk can also be installed. This will allow the pers determine the progress of the operation. These cameras are movable & adjustable so that they can be moved just above the operation site. Even the others OT members as well as the visitors can have full view of the surgery through the video cameras. 27) Computers Computers in OT is an essential gadget for maintaining, data base of the surgical patients, Computers data base helps the circulatory nurse &all concerned to feed information about patients profile such as patients name, ‘age, gender, registration no, bed no, ward no, D.O .A, religion, education, occupation, marital status, address, agnosis, reoperative assessment, assessment of diagnostic tests, preanaesthetic assessment, preoperative nursing care, 28) Tracheostomy set : A tracheostomy set with tracheostomy tubes of different sizes should be kept ready in OT to meet the emergency. 29) Sterilizer : The small sterilizer is kept in OTY in sterilization room for sterilization purposes. Small items in small no: can be Sterilized in such sterilizers though major supply of sterilized equipments comes from central sterilization supply also may be xd to take X- T which is kept ready for in case there is31) Alarm bel Alarm bell Operation theatre has a ringing alarm bell for emergency use. 32) wall clock : this is an essential item which is kept in OT for monitoring timings. 32) Music system : OT should have central music system where soft music can be played throughout which is very soothing to the Personnel as well as to pt’s when they are awake. 33) Racks, shelves, almirah : OT has a good number of steel racks, shelves & almirah which provides storing space for clean articles, sterile articles, sterile linens, sterile instruments, others articles, emergency equipments, emergency medicines & injections, infusions fluids, antiseptic lotion etc. 34) Stretchers, trolleys, wheel chairs : There should be number of stretchers, trolleys, wheel chairs in OT for transportation of pt to OT & also from the OT to the recovery room or to the wards or OPD. OT TABLE AND SETS FOR COMMON SURGICAL PROCEDURE + The modem operating table is designed to facilitate various positioning for the different operations. + Ithas got several fittings, which are easily operatable even during the process of surgery. + The theatre nurse should be quite familiar with the working of the particular table so that she can make any desired adjustment speedily before and during the progress of operation, + Extra table fitting should never be placed on the floor. But itshould be kept ona side trolley for the easy supply tany time when required. + The operating table consist of three pieces for easy adjustment ; small head piece , big middle piece for trunk and lower piece for the lower extremities, + Itisan adjustable kidney bridges fitted on the middle piece of the table at the kidney of an adult patient , POSITIO} COMMON POSITIONING THE PATIENT Each operative position represents an agreement between jeen the surgeon and the anesthesia provider 10 the patient, ‘The surgeon requires, 7 anche accessible, stable operative Text book of Medi ‘The result must come well within the rules for maximum safety and comfort tthe patient Preliminary Considerations é a4 sitioning for a surgical procedure is a facet of ‘This is as important to patient outcome as adequate preoperative preparation and safe anesthesia, ; Proper positioning requires knowledge of anatomy and the application of physiologic principles, as well as. familiarity with the necessary equipment. Safety is a primary consideration. z Patient positioning is determined by the procedure tobe performed, with consideration given to the surgeon's choice of surgical approach and the technique of anesthetic administration. Factors such as age, height, ‘weight, cardiopulmonary status, and preexisting disease: (cg., arthritis) also influence positioning and should incorporated into the plan of care. , Preoperatively, the patient should be assessed for: ' + Alterations in skin integrity 3 + Joint mobility, and : 4 patient care. + The presence of joint or vascular prostheses. The expected outcome is that the patient will not be harmed by positioning for surgical procedure. Responsibility for Patient Positioning The choice of position for a surgical procedure is made by the surgeon in consultation with the anesthesia provider, Adjustments are made as necessary for the administration of anesthetic and for maintenance of the patient's Physiology. In essence, patient positioning is a shared ‘esponsibility among all team members. The anesthesia Provider has the final word on positioning when the Patient's physiologic status and monitoring is in question. ‘Timing of Patient Positioning and Anesthetic Administration Ps The following states the time at which the patient is: Positioned and/or anesthetized, fe i eo (Tansfer from the stretcher to the operating * Patient is usually placed face up on his/he * The patient may either be anesthetized in this % 4nd then positioned for the surgical p a Positioned, anesthetized.