Topic 1:

1.1 Aims of Peri-Operative Nursing.

aims of peri-operative nursing are mainly to:-

 To integrate the patients care in the operating room.

 To become highly skilled in theatre techniques.
 To allay the fears of the patient
 To be able to impact knowledge to others.

This aims will form basis for your subsequent sessions and practice in
the clinical area.

You are now going to have an overview of the historical background

of peri-operative nursing

1.2 Historical Background of Peri-operative Nursing

In the past there were no theatres, no trained personnel, no anesthesia

and no equipment. Operations were done at home. Problems during this
time included infection, bleeding and pain. You are aware that in the
traditional African communities, each community had its own way of
conducting minor and even major surgeries. Please take a moment to
reflect on this and the possible complications, review the picture below
which reflects the challenges experienced by patients who were
undergoing surgery at the time.

No use of anaesthesia, hence the patient had to be restrained, no pain

medications so the patient felt a lot of pain, look at the equipment being
used and the environment that the surgery is being carried in. all this
challenges led to the development of peri-operative guidelines later on in
this course.
1.2.1 Development of Peri-Operative Systems Over Time.

 In 1700 BC- Alcohol and opium were used to relieve pain by

Napoleon, he performed an amputation while the patient was
asleep for 24 hrs
 1772- Joseph Priestly discovered the use of Nitrous oxide
(laughing gas).
 1842-Dr Crawford discovered use of ether.
 1847-James young began use of chloroform.
 18th century there was use of Trilene
 19th Century there was a major breakthrough by use of
thiopentone and Curare as muscle relaxants.
 16th century, ancient Greeks and Romans used strings as ligatures
to control hemorrhage, other forms of hemorrhage control included
use of hot iron and cautery (Diathermy) which is being used up to
present
 20th century- Ligatures were prepared from metal, nylon and
cotton.
 Infection control-This was as a result of Louis Pasteur proving that
bacteria caused infection.
 1865-Joseph lister used carbonic acid to reduce the growth of
bacteria in wounds.
 Use of gloves was introduced in 1890.

1.2.2 General Layout of the Peri-operative Unit(Theatre)

As you are aware, the other name for a peri-operative unit is theatre,
these terms may be used interchangeably.
The following are factors to consider when choosing the location of
operating theatres

 Geographic isolation:-Should be located in an area with less traffic.

 Bacteriologic isolation: This is to prevent cross contamination
from other areas within the hospital.
 Accessibility to required supplies and equipments for surgery:
Centralizing supplies and equipments for immediate access
without leaving the protected area.
 Availability of specialized personnel for the specialized tasks in
the operating room.

The factors to consider when designing the layout of theatre are:-

 Types of surgery to be performed

 Type of hospital whether teaching, private, county.
 Emergency services provided
 Number of surgeries being performed
 Number of surgeries being performed
 Hours in which the surgical services are offered.

1.2.3 General Organization of the Peri-operative Unit.

A peri-operative unit should be a block of building with rooms leading

preferably from a corridor. It should be self-contained with changing
rooms, shower rooms, toilets, anesthetic room, nurse in charge office
and offices to accommodate the other peri-operative team members as
necessary for easier co-ordination; it should also have operating rooms
and stores e.g. consumable store, sterile store and cleaning material
store.

It should also have the following:-

  A sterilizing room namely -Theatre Sterile Supply Unit or Central
Sterile Supply Unit (TSSU or CSSD)
 A receiving area which is the entry point for patients from the
wards.
 A Recovery room (PACU-post anesthetic care unit) is the waiting
room for patient post operatively before they are taken back to the
ward.

Other rooms can be added depending on the complexity of surgeries

1.2.4 Theatre Layout/Structure

 The walls, floor and roof should be made of labor saving materials
for hygiene purpose e.g:-
 Floor should be made of terrazzo or other similar materials
 Paint should be one that can be cleaned with water maintaining its
original colour.
 Artificial ventilation for oxygen supply pumped through the
ventilators.
 Efficient artificial light and emergency systems for use during
power failure e.g. generators.
 Theatre furniture and fittings should be made of stainless materials
for quick and thorough cleaning.
 Ceilings should be high enough for proper ventilation.
 Doors and corridors should be wide enough for easy movement.
 Trolleys should be fitted with non-electrical conduction rubber
wheels to minimize risks of electrical conduction.

1.3 The Surgical Suite Concept.

The overall floor plan of the surgical suite is divided into three zones
which are directly or indirectly involved in the operative procedure,
equipment, supplies or personnel.

For you to be able to understand better, these zones are described

according to the types of activities, dress code or restriction for that
zone.

1.3.1The Unrestricted (non-restricted area)

The unrestricted area provides an entrance and exit from the surgical
suite for personnel, equipments and patients. Depending on the physical
design of the operating suite, the holding/receiving area, the post
anaesthetic care unit may be found in this zone along with dressing
rooms, lounges, offices and receiving/storage area for supplies to be
used within the surgical suite.

1.3.2 The Semi-restricted Area

The semi-restricted area provides access to the procedure room and

peripheral support areas within the surgical unit. Personel entering this
area must be in proper recommended attire. Traffic control must be
designed to prevent contamination of this area by personel or persons
improperly attired for this zone.The peripheral support areas include
storage area for clean and sterile supplies, sterilization and distribution
area for instruments and non-disposable equipment. Also constitutes
corridors leading to the procedure rooms and sub sterile utility.

1.3.3The Restricted Area

The restricted area includes the scrub room and the adjacent sub-sterile
areas where the scrub sinks and autoclaves are located. Additional
storage for immediate use by adjacent procedure rooms is also found in
the sub-sterile area e.g blankets/solution warmers etc. personnel working
in this area must be in proper operating room attire including a mask for
maximum protection of this area from possible contamination.

Take note

Persons working within the suite must abide by policies to the zones.
There should be a central administration area to provide continuity, co-
ordination and communication within the operating suite.

1.4 Legal Aspects in Peri-operative Nursing

Legal aspects entail what the law requires the peri-operative nurse to do
in theatre before, during and after operation, failure to which patients or
parties involved can file a lawsuit for damages or negligence thereof.
This includes the following:-

1.1.1Informed Consent

From your previous experience in medical-surgical nursing, you are

aware that the nurse is required to get informed consent for any
procedure done to a patient. This also remains the case in patients
undergoing various surgical interventions.

Informed consent is the process of communication between a patient and

surgeon that results in the patient's authorization or agreement to
undergo a specific medical intervention. The surgeon providing or
performing the treatment and/or procedure and not a delegated
representative, should be the one to disclose and discuss with the patient
regarding the following:
  The patient's diagnosis, if known, remember there are also
diagnostic surgeries.
 The nature and purpose of a proposed treatment or procedure
 The benefits and risks of a proposed treatment or procedure
 Alternative treatment options regardless of their cost or the extent
to which they are covered by health insurance

The benefits and risks of the alternative treatment or procedure, the risks
and benefits of not receiving or undergoing the treatment or procedure,
most facilities have a form that needs to be filled and all this details
should be explained to a patient even in an emergency.

The patient's or guardian's written consent for the surgery is a vital

portion of preoperative care. By law, the surgeon who will perform the
procedure must explain the risks and benefits of the surgery, along with
other treatment options. However, the nurse is often the person who
actually witnesses the patient's signature on the consent form. It is
important that the patient understands everything he or she has been
told. Sometimes, patients are asked to explain what they were told so as
to determine how much they have understood.

Patients who are mentally impaired, heavily sedated, or critically ill are
not considered legally able to give consent. In this situation, the next of
kin, spouse, adult child, adult sibling, or person with medical power of
attorney, may act as a surrogate and sign the consent form. Children
under the age of 18(in Kenya) must are signed for by a parent or
guardian.

1.4.2 Documentation

Documentation provides a written account of events. Surgical clinical

records serve as a legal account of the procedures performed to the
patient and provides valuable information to the other care providers.
Documentation in peri-operative nursing is a continuous process and
takes place throughout the surgical process. In addition, documentation
includes routine statistics and care of specimens obtained from the
surgical procedure.

Other nonsurgical related documentation include:- unusual occurrence or

complication in which case there should be an incident report book. A
copy of the medical records and incident report should be filled allowing
the hospital administration to take the appropriate action to resolve the
incident

The nursing responsibilities in documentation include:

 Maintaining a neat, clean and legible clinical record

 Verifying the team members' names as written in theatre duty
roster and duty allocation book.
 Ensuring that all recorded data accurately reflects the peri-
operative events.
 Noting any unusual occurrences and describing events and
patient's condition before, during and after surgery and after any
incident in detail.
 Transparency in record keeping i.e rather than erase or cover a
mistake with white wash, draw a single line through it and write
error then sign against it. If records are to be recopied, attach the
copy to the original paper so as not to be conceived as altering
existing records.

Issues requiring legal action include but not limited to;

 Amputating the wrong leg.

 Operating a patient without the consent.
  Patient's burnt by diathermy.
 Patient falling from stretcher.
 Swabs or instruments left inside patient's cavity.
 Negative discussions on the patient while under anesthesia
(confidentiality

The legal implications of peri-operative nurses include

 Adhere to established safety procedures, this helps to prevent

injury to patients subsequently minimizing the risk of lawsuits.
 Ensure that informed consent has been signed and documented.
 Careful counting of sponges, needles and other equipments during
surgery to prevent any of this being retained in the patient's body.
 Never leave an unconscious patient unattended because of the risk
of falls, aspiration etc.
 A peri-operative nurse working as first assistant to the surgeon is
held to the standards of care of that profession and may lose his/her
licence if negligence in that role is established
 Accurate and complete documentation helps prevent injury and
serve as a record of safety of those measures undertaken.
 Participate in development of the institutional safety procedures,
policies and precautions.
Topic 2

2.1 Types of Surgery

Surgery is any procedure performed on the human body that uses

instruments to alter tissue or organ integrity.

Surgery is usually classified as follows.

Surgery according to seriousness or risk

In this category there is:-

a.Major surgery- Involves extensive reconstruction or alteration in
body parts; poses great risks.

b.Minor surgery- Involves minimal alteration in body parts, this is

often designed to correct deformities, it involves minimal risk compared
with major procedures.

Surgery depending on reason for procedure

The following types constitute this surgery;

Elective surgery-Performed on the basis of client's choice; not essential

and may not be necessary for health.

Urgent surgery- Necessary for client's health,may prevent additional

problem from developing (e.g. tissue destruction);not necessarily
emergency.

Emergent surgery- Must be done immediately to save life or preserve

function of body part.

Required surgery- Has to be performed at some point, can be pre-

scheduled.

Diagnostic surgery-Done to confirm a diagnosis.

Corrective surgery - Excision or removal of diseased body part.

Reconstructive surgery-Restore function or appearance to traumatized

or malfunctioning tissues.

Procurement for transplant- Removal of organs and/or tissues from a

person pronounced brain death for transplantation into another person.
Constructive surgery- Restores function lost or reduced as result of
congenital anomalies.

Cosmetic surgery- Performed to improve personal appearance.

Surgery according to the extent of surgery

In this class we have the following types of surgery:-

Simple surgery - Only the most overtly affected areas involved in the
surgery.

Radical surgery - Extensive surgery beyond the area obviously

involved; is directed at finding a root cause.

Location: Based on the area of the body on which the surgery occurs
(e.g abdominal, heart surgery).

2.2 Surgical Settings

Surgical settings entail environments where surgeries can be performed.

The level of complexity of a surgical intervention determines the choice

of a surgical setting among other factors. The environments include/but
not limited to:-Surgical suites ambulatory/outpatient care settings,
clinics, physician offices, community setting and homes. However there
are advantages and disadvantages of each of the the inpatient and
outpatient surgical environments.

Learn about the advantages and disadvantages of each of the surgical

settings below.
2.1.1Outpatient surgical settings

They are also referred to as ambulatory.

Advantages

 They are less costly

 They have a low risk of infection
 Patients take less time from work
 There is less interruption of routine
 Less stress to the patient.

Disadvantages

 There is less time for rapport

 Also less time for assessment, teaching and evaluation
 There is risk for potential complication post-surgery

2.3 Phases of Perioperative Nursing

There are three peri-operative surgical phases, the preoperative, intra-

operative and post-operative phase.

2.1.1 Preoperative surgical phase.

This phase begins with the decision for a surgical intervention and ends
with transfer of the patient to the operating room (OR)
Nursing Interventions in this phase include: baseline assessment during
interview at the health facility, clinic, office or over the phone and
assessment in the pre-admission unit, client room, holding area or
induction room

Nursing Assessment in the Pre-operative Surgical Phase

This is a baseline assessment which documents the following

information about a client.

 Nursing History- Document the key elements that pertains to the

surgical client's risks and needs. Information concerning advance
directives.
 Medical History- includes past illnesses and the primary reason for
seeking medical care.
 Previous surgeries- past experience with surgery can reveal
potential physical and psychological responses to procedure and
alert you to special needs and risk factors. Complications such as
anaphylaxis or malignant hyperthermia are important for planning.
 Medication History- any medications that might predispose to
surgical complications.
 Allergies- to medications, topical agents used to prepare the skin
for surgery, and latex can create significant risks.
 Smoking Habits - greater risk for complications.
 Alcohol and Controlled Substance Use and abuse- to be prepared
for adverse reactions, such as withdrawal, that may occur during
surgery.
 Client Expectations- to identify the client's and family perceptions
and expectations regarding surgery and health care providers.
 Family Support- Determine the extent of the client's support from
family members or friends.
  Occupation- surgery may result in physical alterations that hinder
or prevent a person from returning from work.
 Feeling- surgery causes anxiety and a feeling of loss of control for
most clients.
 Cultural and Spiritual Factors- cultural differences in the use of
both verbal and nonverbal communication require you to validate
interpretation of cues with the client and family.
 Coping Resources- assessment of a client's feeling and self-concept
helps to reveal whether the client has the ability to cope with the
stress of surgery.
 Body image-surgical removal of a diseased tissue often leaves
permanent disfigurement or alteration in body function.

factors that may increase the risk of complications during surgery

to include;

 Age- Very young and older clients are at risk of complications

because of their immature (very young) and compromised (elderly)
immune systems.
 Nutrition- a malnourished client is prone to poor tolerance of
anesthesia, infection, poor wound healing and the potential for
multiple organ failure after surgery.
 Obesity- They often have difficulty in resuming normal activity
after surgery.

After completing the nursing history, it is important to carry out a

physical assessment. As a nurse you are the patient's advocate, hence
important to have your own independent findings. A head to toe
assessment is key (review NURS 102 topic on health assessment), after
completing the assessment, the following findings may be of concern to
the peri-operative nurse.
Physical Assessment Findings and Implications

On general survey, gestures and body movements may reflect decreased

energy or weakness caused by illness.

Cardiovascular system- alterations in cardiac status are responsible for

as many as 30% of peri-operative deaths.

Respiratory system- a decline in ventilatory function, assessed through

breathing pattern and chest excursion, may indicate a client's risk for
respiratory complications.

Renal system-abnormal renal function can alter fluid and electrolyte

balance and decrease the excretion of preoperative medications and
anaesthetic agents.

Neurologic system- A client's level of consciousness (LOC) will change

as a result of general anesthesia but should return to the preoperative
LOC after surgery.

Musculoskeletal system- Deformities may interfere with intra-operative

and postoperative positioning. Avoid positioning over an area where the
the skin shows signs of pressure over bony prominences.

Gastrointestinal system- alteration of function may result in decreased or

absent bowel sound and distention.

Head and Neck- the condition of oral mucous membranes reveals the
level of hydration.

In cases of elderly patients, it is important to note that there is a decline

of function in all body systems putting them at an increased risk of
developing complications. It is therefore important to plan efficiently to
respond

(c)Considerations in The Elderly

In the cardiovascular system; Coronary flow decreases, heart rate

decreases, response to stress decreases, cardiac output decreases,
peripheral vascular flow decreases and cardiac reserve decreases

In the respiratory system; Static lung volumes decrease, pulmonary

static recoil decreases and sensitivity of the airway receptors decreases

Nervous system; there is increased incidence of post.operative

confusion, increased incidence of delirium, increased sensitivity to
anesthetic agents hence this influences anesthetic dosing.

Renal System; Renal blood flow declines 1.5% per year and renal
clearance reduces.

Gastrointestinal; There is decreased intestinal motility, decreased liver

blood flow and delayed gastric emptying putting them at risk of
abdominal distension.

Musculoskeletal; There is decreased mass, tone, strength and

decreased bone density

Integumentary; There is decreased elasticity, decreased lean body mass,

decreased subcutaneous fat.

d Labratory and Diagnostic Studies

Screening tests depend on the condition of the client and the nature of
the surgery. If a test reveals severe problems the surgery may be
postponed until the condition is stabilized.

Example of tests include but not limited to:- Full haemogram (FHM),
grouping and crossmatching (GXM), urea and electrolytes(U/E), chest
x-ray(CXR).

The peri-operative nurse should ensure that the patient undergoes the
tests indicated and that results and other requirements are ready (e.g
blood) before the next phase or as per the protocols of the facility.

Common Problems During the Pre-operative Phase Include;

Knowledge deficit

Anxiety

Risk for ineffective airway clearance

Risk for ineffective peripheral tissue perfusion

These diagnostic labels and more will form basis of the care planning of
surgical patients during the pre-operative period.

Example 1:-Knowledge deficit: The nurse has to indicate what the

knowledge deficit is about, then make a nursing diagnosis, e.g
knowledge deficit about surgical procedure.
One of the nursing interventions to this nursing intervention is patients'
teaching.

In preoperative teaching, the education plan should begin with

assessment, including baseline knowledge of the patient and family,
readiness to learn, barriers to learning, patient and family concern and
learning styles and preferences.

The content focuses on information that will increase patient's

familiarity with procedural events. This includes surgical experience
(procedural), what the patient may experience (sensory) and what
actions may help decrease anxiety (behavioral).

Peri-operative teaching is an important component in all surgical

interventions, it becomes more useful when started the week before
admission and reinforced before surgery to make the client less
anxious. The content should include:-Surgical procedure, Pre-operative
routines, Intra-operative routines, post-operative routines, sensory
preparation and pain relief. Other teaching needs will be individualized
depending on the patient's condition.

Example 2: Anxiety.

As a nurse you must consider the patient's family and friends when
planning psychological support you should empower their sense of
control.

Activities that decrease anxiety are deep breathing, relaxation exercises,

music therapy and massage; these interventions should be used
concurrently with medication to relieve anxiety.

Pre Anesthesia Management Physical Status Categories

During the pre-operative period, the patient should also be reviewed by
the anesthetist. After review the patient can be classified under the
following categories.

ASA 1: Healthy patient with no disease(ds)

ASA 11: Mild systemic ds without limitations

ASA 111:Severe systemic ds associated with definite limitations

ASA 1V: Severe systemic ds that is a constant threat to life.

ASA V: Moribund patient. Who is not expected to survive without the

operation e.g patient with multiple trauma.

ASA V1: A declared brain-death patient whose organs are being

recovered for donor(applies to certain countries)

E: Emergency

Final Preparation for surgery

After completing the assessments, you should ensure the following

interventions before the patient is taken in for surgery.

All personal belongings are identified and secured.

Jewelry is removed.

Dentures are removed, labeled and placed in a denture cup.

?Patient to verbally confirm the surgical procedures and the surgical site.

verification process is documented in the medical record on the

preoperative checklist.
?The patient is then given pre-operative medications to allay anxiety,
decrease pharyngeal secretions, decrease gastric secretions, decrease
side effects of anesthesia and to induce amnesia. of the commonly used
drugs:-Sedatives/hypnotics(valium), opioid analgesics (morphine),
anticholinergics(Atropine), H2o blockers( Tagamet, Zantac, antiemetics
(Plasil).

2.3.2 The Intra-operative phase

The intra-operative phase starts when the patient is transferred to the

operating room (OR) and ends with the transfer of patient to the
recovery area-Post-Anaethetic Care Unit (PACU).

a.The nursing Interventions during this phase include:

Communicating plan of care, identifying nursing activities, establishing

priorities, coordinating care with team members, coordinate supplies and
equipment, controlling the environment and documenting the plan of
care

b.Roles of the surgical team

Depending on the level of facility, a surgical suite can have the

following intra-operative roles.

i.Surgeon

ii.Anesthesiologist

iii.Scrub Nurse

iv.Circulating Nurse

v.Receiving and Recovery area nurse

vi.Operating Room technicians

i.The Surgeon

The surgeon is responsible for determining the preoperative diagnosis,

the choice and execution of the surgical procedure, the explanation of
the risks and benefits, obtaining informed consent and the postoperative
management of the patient's care.

ii.Scrub nurse

The scrub nurse is involved with preparation of supplies and equipment

on the sterile field; maintenance of patients' safety and integrity;
observation of the scrubbed team for breaks in the sterile fields;
provision of appropriate sterile instrumentation, sutures, and supplies
and sharps count.

iii.Circulating Nurse

The circulating nurse is responsible for creating a safe environment,

managing the activities outside the sterile field and providing nursing
care to the patient, she/ he is also involved with documenting intra-
operative nursing care and ensuring surgical specimens are identified
and placed in the right media. She/he is in charge of the instruments and
sharps count and communicating relevant information to individuals
outside of the OR, such as family members.

iv.Anesthesiologist and anesthetist

Main responsibilities include anesthetizing the patient, providing

appropriate levels of pain relief, monitoring the patient's physiologic
status and providing the best operative conditions for the surgeons.

2.3.3 The Post-Operative Phase

The postoperative phase begins with transfer of the patient to the post-
anaesthetic care unit (PACU) and ends with the discharge of the patients
from the surgical facility or the hospital. The nursing Interventions
include communicating pertinent information about surgery to the
PACU staff and postoperative evaluation in clinic or home.

a.Nursing assessment in the Post-Anaesthetic Care Unit (PACU)

include;

i.Assessment of vital signs( temperature, pulse, respiration and pain)

ii.Presence of artificial airway

iii.Oxygen saturation,

iv.Level of consciousness (LOC) i.e ability to follow commands

v.Urinary output

vi.Skin integrity

vii.Condition of surgical wound,

viii.Presence and state of intravenous lines

ix.Positioning the patient./or/and drains.

b.Nursing diagnoses in the post-operative phase

i.Ineffective airway clearance related to:-increased secretions,

anesthesia, ineffective cough, pain

ii.Ineffective breathing pattern related to:-anesthetic and drug effects,

incisional pain

iii.Acute pain
iv.Urinary retention

v.Risk for infection

Post-operative Management

The general post-operative management includes, maintaining a patent

airway, stabilizing vital sign, ensuring patients' safety, providing pain
relieve and recognizing and managing complications, the general
principles in post operative care are;

i.Ensuring clear airway.

ii.Supporting circulation.

iii.Controlling bleeding.

iv.Preventing infection.

v.Monitoring any complications.

vi.Controlling pain.

vii.Ensuring return of gastric intestinal motility.

viii.Ensuring early and easy ambulation.

ix.Preparing the patient for discharge and home based care.

The specific post-operative management depends on the specific needs

of the individual surgical patient.

Complications that may arise post-operatively include:-

Pertaining to respiratory system, patients can get atelectasis and
pulmonary embolus hence the need for close monitoring.

Pertaining to cardiovascular system venous thrombosis can arise hence

the need for anticoagulation prophylaxis.

Pertaining to gastrointestinal patients can get hiccoughs, abdominal

distention, paralytic ileus and stress ulcers.

Urinary system patients can get urinary retention hence the need for
adequate hydration.

Hemorrhage can also occur which can be due to slipping of a ligature or

suture hence the need for close observation.

Musculo-skeletal system patients are at an increased risk on wound

infection due to tissue alteration, wound dehiscence and evisceration
hence the need for asepsis.

The potential for complications is high in the elderly hence the need for
close monitoring and taking prophylactic measures.

Summary of Nursing Roles;

?Staff education

?Client/family teaching

?Support and reassurance

?Advocacy

?Control of the environment

?Provision of resources

?Maintenance of asepsis

?Monitoring of physiologic and psychological status

In Surgical asepsis

Ensure sterility

Alert for breaks

When caring for post-surgical patient, think of the "4 W's?

Wind: prevent respiratory complications

Wound: prevent infection

Water: monitor Input and Ouput

Walk: prevent thrombophlebitis

Topic 3:

3.1 Anaesthetic Machines and Equipments

The peri-operative nurse should ensure availability of the following
anaesthetic machines and equipments.

Anaesthetic machine and its accessories which are used to administer

anaesthesia, ensure thatat all times they are in good working condition.

ECG monitors and appropriate accessories to monitor patients' vital

signs during surgery.

Pulse oximetry for monitoring oxygen saturation

Rescuscitation trollery complete with all the emergency supplies to treat

any emergency that may arise.

Defibrillator for correcting cardiac arrhythmias.

Glucometers for evaluating blood glucose level

Warmers for blood and infusions

Dripstands for hanging infusions and transfusions

Aotoclaving machines for sterilizing items.

Suction machines for suctioning secretions from the airway.

Suction machines for sucking blood/fluid away from the surgical field.

Operating table and its accessories: Head ring, lithotomy poles and
thoracotomy strips.

3.2 Surgical Instruments Used in Theatre

Surgical instruments should preferably be made of stainless steel, most

of them are named after the persons who invented them, the
manufacturer, surgeon or parts of the body where they are used.
Instruments vary in sizes, shapes, length and depth because they have
been designed for specific procedures.

Instruments are broadly categorized as;

i.Cutting instruments/sharps: They are used for cutting tissue, suture

material and dressings. Also used for dissection of delicate tissues
Metzenbaum scissors) or tough fascia.

ii.Clamping instruments: they are used to control bleeding by

obstructing the lumen of the blood vessels after dissection. They can
also hold or retract tissues, they are available in different sizes and one
can choose depending on the size of blood vessel to be clamped.

iii.Holding instruments: They are also called grasping instruments.

They are used for holding sutures or tissues being manipulated, sutured
or dissected, they include needle holders and tissue forceps and they too
vary in size depending on the tissues where they are used. A sharp tip is
for tough tissues or tissues to be ressected and atraumatic tip for delicate
tissues.

iv.Retracting instruments: they are designed to pull tissues away to

expose the site for surgery. They have a lock mechanism to hold the
retractor open and maintain exposure (self retaining retractors), they can
also be held in place by surgeon or assistant.

The following are examples of retractors; you will come across them
during your clinical rotation in the peri-operative suite
Processing/sterilization of surgical instruments.

The peri-operative nurse should ensure that processing of all

surgical instruments is done according to the manufacturer's instructions.
Some instruments have hinges and screws that require oiling and
mantainance. Surgical scissors require frequent sharpening otherwise
they become blunt.

3.3 Surgical Supplies in the Peri-Operative Unit.

The following are surgical supplies required in the peri-operative unit;

(a) Sterile supplies which include:-

i. Basic pack which contains surgical drapes

ii. Basic set which contains basic surgical instruments

iii. Special sets for specific operations

iv. Supplementary set with extra instruments for addition to a specific

set or basic pack

v. Soft packs to include ratyec gauze, guaze rolls, regal swabs, cotton
balls and sterile crepe bandages
vi. Pledgets/peanuts for blunt dissection, called peanuts because of their
small size.

vii. Anaesthetic trays which contain a sterile tray with kidney dishes and
drapes for anaesthetic use

viii. Sterile basins for use during surgery

ix. Sterile gowns

x. Sterile disposable sucker tubes

xi. Sterile diathermy leads (monopolar and bipolar) for coagulating and
cutting tissues.

B.Medications and consumables

As a peri-operative nurse you should ensure that the following drugs are
available to be used as needed:-Anaesthetic drugs, gases with spares
available, general drugs, emergency drugs, resuscitation drugs,
antibiotics, sofratoule and lubrication jellys as required

(C) Surgical sutures

A suture is a thread wire or other material used in stitching, ligating

blood vessels, suturing internal structures and closing the skin.

(a).Properties of a surgical suture

There are various suture materials available in the market. Selection of

sutures follows the required characteristics, these include whether it is
absorbable or not, it's breaking (tensile) strength, whether it is
monofilament (single strand) or multifilament, its knot-tying properties,
and its reactivity. In other words, three main ways to evaluate the
characteristic of suture material are:

i.physical characteristics

ii.handling characteristics

iii.tissue reaction characteristic

i.Physical characteristics

They are described by the United States Pharmacopeia (USP) as;

?Physical configuration i.e single stranded or multiple strands braided or

twisted.

?Capillarity i.e ability to soak up fluid along strands.

?Diameter i.e determined in millimeters and expressed in USP sizes with

zeros. The sizes range from size 7(heavy) to number 11-0(very fine)
which is the smallest. Sizes 0 to 4-0 are commonly used in general
surgery.

?Tensile strength i.e the amount of weight (breaking load) necessary to

break a suture (breaking strength).

?Knot strength i.e the force necessary to cause a given type of knot to
slip.

?Elasticity i.e the ability to retain the original length even after stretch

?Memory i.e the capacity of a suture to return to its former state after
being reformed (tied) High memory results to low security of the knot.

ii.Handling characteristics
Handling characteristics are described as follows:-

?Pliability i.e how easy the material bends

?Coefficient of fraction i.e how easy the suture slips through tissues and
ties. A suture with high tissue coefficient tends to drag through the
tissues hence difficult to tie because the knots do not set easily.

iii.Tissue reaction characteristics.

Tissue reaction characteristics are described as follows:-

All suture material can cause tissue reaction because of being foreign.
This poses a risk of infection and has the potential of causing tissue
reactions.

It is important to note at this point that there is no suture material which

does not cause tissue reaction or infection, but for patients who may be
at greatest risk, an alternative to sutures are metal clips made of inert
material and is able to staple the tissue together.

(b).Characteristics of an ideal suture.

i.Versatile i.e able to change easily or to be used for many purposes

ii.Ease of handling i.e both comfortable and natural to the surgeon

iii.Minimal tissue reaction i.e unfavorable for infection or tissue reaction

iv.High tensile strength meaning that the knot should not easily fray or
break off while in place.

v. Material that is easy to thread and sterilize and does not shrink in
the tissues.
(c).Aseptic transfer of sutures
 The technique to transfer suture material on the operating field
involves two methods:-
i.Retrieval by scrub nurse using sterile forceps after the circulating
nurse opens the outer wrapper of the suture aseptically.
ii.Flipping the suture packet onto the sterile field. This method is
appropriate during the initial setting of the sterile field particularly
in emergency situations.
(D).Surgical Needles.
Surgical needles are made of steel iron with high carbon content.
They are made with precision and must be handled carefully to
achieve high level of effectiveness and to avoid injuries. There are
reusable eyed needles in different shapes and sizes which have to
be sterilized for reuse, however they have been replaced by needle-
suture (atromatic) combination from manufacturer.

a.Components of Surgical Needles

i. All have eyes, body/shaft and the point

ii. The body determines the shape i.e can be curved or straight
iii. Needle piercing points can either be blunt, cutting or taper(non-
cutting.
iv. The eye is where the thread is attached, it may be round, oblong
or square.

b.Classification of surgical needles

Needles are classified according to shape, type of the point, the

sharp and the eye; Shape refers to the amount of curvature or lack
of it. The curvature can be 1/2, 1/4, 3/8, or 5/8 of a circle where the
needle holder is placed during suturing. Straight needles are
reserved for superficial surfaces including the skin.Points and
shafts are determined by the delicacy of the tissues to be sutured.
 i. Taper point -peritoneum, the heart and intestines
ii. Cutting point - there are three types:- taper cut for tough
fibrous tissue, conventional and reverse cutting. The tougher the
tissues the greater the need for a cutting type shaft.
iii. Blunt point used in organs with high vascularity e.g the liver
and kidneys.
The eye is designed to cause minimal trauma to the tissues. There
are three types
i. Swaged or atraumatic; consist of one or more needles attached
to the suture strand at the factory
ii. Eyed needles;must be threaded
iii. Spring or French eyed needle; has a slip from the inside of the
needle where the suture is secured through a spring
Wound Dressing Materials

a.Purpose of Wound Dressing.

Surgical incisions are covered with a dressing for up to 48hours.

This provides an optimal physiological environment for wound
healing by:--
Keeping the incision free of microorganisms both endogenous and
exogenous
Protecting the incision from outside injury.
Absorbing the drainage and exudates from the wound
Maintaining a moist environment that supports healing
Giving some support to the incision and the surrounding skin
through immobilization of surrounding tissues
Providing pressure to reduce edema and prevent hematoma
Concealing the wound aesthetically.
b.Properties of a dressing material
An ideal dressing material should be:-
i.Large enough to cover the wound and tissues surrounding it
ii.Permeable to gas and vapour allowing circulation of air to the
skin.
iii.Comfortable for the patient
iv.Secure to prevent slippage.
C.Commonly used materials for pressure dressing.
i.Single piece bulk dressing
ii.Combined pads which are gauze covered, absorbent cellulose
material.
iii.Cotton rolls
iv.Fluffed gauze.

D.Types of surgical dressings.

There are different categories of surgical dressings; the choice
depends on the individual patient's needs. They include:-
i.Bolster/tie over dressing
The dressing materials are sutured in place to exert an even
pressure over the autografted wounds to prevent seroma or
hematoma formation.
ii.Wet to dry dressing: These dressing materials are soaked in
sterile saline, they are then applied to the wound and allowed to
dry slowly.
iii.Dry dressing: The dressing material is removed together with
the tissues adhering to it to facilitate new tissue growth. They are
preferred in burn wounds needing debridement. Removal is very
painful and traumatic hence should be removed under anaesthesia.
iv.Stent dressing/fixation:It involves applying pressure and
stabilizing tissues where it is not possible to dress the wound. e.g.
in the face and the neck. Long suture ends can be crisscrossed over
a small dressing and tied.
E.Process of applying dressing in the operating room.
i.Skin over incision is cleaned of blood with sterile saline sponge
and dried.
ii.The circulator opens the dressing after the final count of surgical
swabs and needles.
iii.An adhesive substance may be applied on the skin around the
intermediate layer before applying the dressing material to increase
its adhesion.
iv.The circulating nurse applies the tapes without tension.
v.The surgeon and assistant applies the elastic bandages and
stoskinnettes/casts as needed.
Note that sterile dressings are applied before drapes are removed.
Some dressing materials are radio-opaque and should not be used
as external dressings. This is because they can distort the surgical
count and when the patient is done an x-ray, they may appear to be
inside the incision.
F.Surgical Drains.
a.Origin of surgical drains
Hippocrates described the first drainage system as insertion of a
hollow tin tube with flushing of wine and tepid oil to treat
empyema.
In the 19th century glass tubes were replaced with rubber. In 1897
Atubular drain made with gutta-percha (the coagulated latex from
rubber tree, with a gauze wick inserted through the length of the
lumen) was described by Dr. Charles penrose. It is referred to as
the penrose drain.
(a).Intra-operative Drainage.
Intra-operative drains involves:-
A.Insertion of a nasogastric tube drain through the nose into the
stomach to:
i. Allow for decompression of the stomach
ii. Relieve distension that obstructs the view of the surgical site
iii. Measure blood loss from gastric hemorrhage
iv. Evacuate gastric secretions during anastomosis
B.Insertion of urethral or ureteral catheters preoperatively to drain
out urine from bladder and kidneys. This is mainly done to:-
i. Keep the bladder decompressed
ii. Prevent extravasation of urine into the tissues being operated
on
iii. Apply pressure by ballooning indwelling catheters to control
hemorrhage
iv. Monitor hemodynamic status since good renal perfusion results
in urine output of 0.5ml to 1ml/kg/hour.
(B).Post operative drainage
Post-operative drains allow body secretions and tissue debris to
flow away from the surgical site. This enhances wound healing
by:-
i.Obliterating dead space
ii.Allowing Apposition of tissues
iii.Preventing formation of hematomas and seromas
iv.Preventing tissue devitalization/wound margin necrosis
v.Preventing fluid accumulation.
vi.Minimizing post-operative pain.
vii. Prevent excessive scarring.
a.Description of surgical drains.
There are different types of surgical drains. Let's look at the
following examples.
i.Passive drains:
This type of drains drain by force of gravity with the influence
of pressure, they include:-
?Penrose drain (referred to as a cigarette drain): The drain
serves as a wick and is placed into the surgical area and brought
out through a stab wound in the skin secured with skin sutures.
?Constant gravity drainage: These drains work by Force of
Gravity. Examples are silicon tubes and catheters. The tube is
eventually connected to a drainage bag which is usually
graduated .The bag must be in a position lower than the site to
prevent retrograde reflux.
ii.Active drains
Active drains are attached to an external source of vacuum to
create suction of the area to be drained. A constant gentle
negative pressure vacuum evacuates tissue fluid, blood and air
through the drain.
?Closed wound drainage: These drainage systems are used to
apply suction on to un-infected closed wound e.g. in the
abdomen and joints. They are supplied with a trocher to pierce
through the skin and then a perforated plastic drain is left in the
wound connected to a sterile portable container. They have anti-
reflux valves with prevents backflow e.g. hemovac.
?Sump drains are closed drains used for aspiration, irrigation, or
introduction of medication to e.g a stab wound. They are double
or triple lumen with large lateral openings to minimize clogging
and to create equalized negative pressure at the site to be
drained.
?Chest drainage: Involves drainage of the pleural cavity, this
ensures maximum expansion of the lungs especially after
surgery. One or more tubes can be inserted and if so the upper
tube drains air while the lower tube drains fluid. The tubes are
connected to one or two chest bottles with underwater seal
drainage system.
. The role of the Nurse in Management of Surgical Drains
Drains, catheters and tubes should be availed in theatre and kept
ready for use.
A proper nursing history to rule out hypersensitivity to latex.
The scrub nurse keeps the end of the drain sterile until the time of
connection.
Ensure the connections to the tubings are well secured and achieve
a good fit.
The drain should be dressed separately from the surgical wound.
Monitor for any tension or kinking of the drainage system and act
accordingly.
Bags to passive drains must be kept below the body cavity where
the drain has been inserted to prevent the drainage from going
back.
Monitor amount of drainage, and suction levels as indicated and
document appropriately.
Document appropriately in the nursing records the location and
type of drain.
Monitor the characteristics of the exudates, document and act
accordingly.
Topic 4

4.1 Introduction

1.1 Definition of Anaesthesia

Anesthesia or anaesthesia (from Greek "without sensation") is a state of

controlled, temporary loss of sensation or awareness that is induced for
medical purposes. It may include some or all of analgesia (relief from or
prevention of pain), paralysis (muscle relaxation), amnesia (loss of
memory), and unconsciousness. A patient under the effects of anesthetic
drugs is referred to as being anesthetized.

Anesthesia enables the painless performance of medical procedures that

would otherwise cause severe or intolerable pain to an unanesthetized
patient, or would otherwise be technically unfeasible.

History of Anaesthesia

Since general anesthesia first became widely used in late 1846,

assessment of anesthetic depth was a problem. To determine the depth of
anesthesia, the anesthetist relies on a series of physical signs of the
patient. In 1847, John Snow (1813-1858) and Francis Plomley attempted
to describe various stages of general anesthesia, but Guedel in 1937
described a detailed system which was generally accepted.
The classification was designed for use of a sole inhalational anesthetic
agent, diethyl ether (commonly referred to as simply "ether"), in patients
who were usually premedicated with morphine and atropine. At that
time, intravenous anesthetic agents were not yet in common use, and
neuromuscular-blocking drugs were not used at all during general
anesthesia. The introduction of neuromuscular blocking agents (such as
succinylcholine and tubocurarine) changed the concept of general
anesthesia as it could produce temporary paralysis (a desired feature for
surgery) without deep anesthesia. Most of the signs of Guedel's
classification depend upon the muscular movements (including
respiratory muscles), and paralyzed patients' traditional clinical signs
were no longer detectable when such drugs were used.

Since 1982, ether is no longer being used in the United States. Because
of the use of intravenous induction agents with muscle relaxants and the
discontinuation of ether, elements of Guedel's classification have been
superseded by depth of anaesthesia monitoring devices such as the BIS
monitor, however, the use of BIS monitoring remains controversial

Broad Categories of Anesthesia :

i.General anesthesia General anaesthesia suppresses central nervous

system activity and results in unconsciousness and total lack of
sensation, using either injected or inhaled drugs.

ii.Sedation Sedation suppresses the central nervous system to a lesser

degree, inhibiting both anxiety and creation of long-term memories
without resulting in unconsciousness.

iii.Regional and local anesthesiaRegional and local anesthesia blocks

transmission of nerve impulses from a specific part of the body.
Depending on the situation, this may be used either on its own (in which
case the patient remains fully conscious), or in combination with general
anesthesia or sedation. Drugs can be targeted at peripheral nerves to
anesthetize an isolated part of the body only, such as numbing a tooth
for dental work or using a nerve block to inhibit sensation in an entire
limb. Alternatively, epidural and spinal anesthesia can be performed in
the region of the central nervous system itself, suppressing all incoming
sensation from nerves outside the area of the block.

In preparing for a medical procedure, the anaesthetist chooses one or

more drugs to achieve the types and degree of anesthesia characteristics
appropriate for the type of procedure and the particular patient. The
types of drugs used include general anesthetics, local anesthetics,
hypnotics, sedatives, neuromuscular-blocking drugs, narcotics, and
analgesics.

The peri-operative nurse ensures that the particular drugs are available.

Risks and Complications During Anaesthesia

The risks of complications during or after anesthesia are often difficult

to separate from those of the procedure for which anesthesia is being
given. However, they are related to three factors: the

i. The health of the patient

ii. The complexity (and stress) of the procedure

iii. The anaesthetic technique.

It is important to note at this point that the health of the patient has the
greatest impact. Major peri-operative risks can include death, heart
attack, and pulmonary embolism whereas minor risks can include:-
postoperative nausea and vomiting which may prompt hospital
readmission.
Some conditions, like local anesthetic toxicity, airway trauma or
malignanhyperthermia, can be more directly attributed to specific
anesthetic drugs and techniques.

Types of Anesthesia

Local Anaesthesia

A local anaesthetic numbs a small part of the body. It is used when the
nerves can be easily reached by drops, sprays, ointments or injections.
You stay conscious, but free from pain. Common examples of surgery
under local anaesthetic tooth extractions and some common operations
on the eye.

Regional Anaesthesia

This is when local anaesthetic is injected near to the nerves which

supply a larger or deeper area of the body. The area of the body affected
becomes numb.Examples are spinal and epidural anaesthetics these
injections can be used for operations on the lower body, such as
Caesarian section, bladder operations, or replacing a hip. You stay
conscious, but free from pain.

Other regional anaesthetics involve an injection placed near a nerve or

group of nerves, . This is often called a 'nerve block'. This can allow for
surgery without a general anaesthetic.

Nerve blocks are also useful for pain relief after the operation, as the
area will stay numb for a number of hours

Sedation involves using small amounts of anaesthetic drugs to produce a

'sleep-like' state. It makes the patient physically and mentally relaxed,
but not unconscious.
patients having a local or regional anaesthetic do not want to be awake
for surgery. They choose to have sedation as well.

Procedure for perfoming general anaesthesia

General anaesthesia is a state of controlled unconsciousness. The patient

will not have memory of what happens while they are anaesthetised.

A general anaesthetic is essential for a very wide range of operations.

This includes all major operations on the heart or lungs or in the
abdomen, and most operations on the brain or the major arteries. It is
also normally needed for laparoscopic (keyhole) operations on the
abdomen.

Anaesthetic drugs are injected into a vein, anaesthetic gases are given
for the patient to breathe. These drugs stop the brain from responding to
sensory messages travelling from nerves in the body.

Anaesthetic unconsciousness is different from a natural sleep because

patients cannot be woken from an anaesthetic until the drugs are stopped
and their effects wear off. You will learn more on the phases of general
anaesthesia.

The patient should closely be monitored during anaesthesia.

Combinations of anaesthesia

Anaesthetic techniques are often combined. For example, a regional

anaesthetic may be given for pain relief afterwards, and a general
anaesthetic to induce amnesia.
Stages of Anesthesia

Stage I (stage of analgesia or disorientation)

This is from the beginning of induction of general anesthesia to loss of

consciousness.

Stage II (stage of excitement or delirium)

From loss of consciousness to onset of automatic breathing, eyelash

reflex disappears but other reflexes remain intact and coughing,
vomiting and struggling may occur; respiration can be irregular with
breath-holding.

Stage III (stage of surgical anesthesia)

From onset of automatic respiration to respiratory paralysis.

It is divided into four planes:

Plane I - from onset of automatic respiration to cessation of eyeball

movements. Eyelid reflex is lost, swallowing reflex disappears, marked
eyeball movement may occur but conjunctival reflex is lost at the bottom
of the plane

Plane II - from cessation of eyeball movements to beginning of paralysis

of intercostal muscles. Laryngeal reflex is lost although inflammation of
the upper respiratory tract increases reflex irritability, corneal reflex
disappears, secretion of tears increases (a useful sign of light anesthesia),
respiration is automatic and regular, movement and deep breathing as a
response to skin stimulation disappears.

Plane III - from beginning to completion of intercostal muscle paralysis.

Diaphragmatic respiration persists but there is progressive intercostal
paralysis, pupils dilated and light reflex is abolished. The laryngeal
reflex lost in plane II can still be initiated by painful stimuli arising from
the dilatation of anus or cervix. This was the desired plane for surgery
when muscle relaxants were not used.

Plane IV - from complete intercostal paralysis to diaphragmatic paralysis

(apnea).

Stage IV: from stoppage of respiration till death.

Anesthetic overdose-causes medullary paralysis with respiratory arrest

and vasomotor collapse. Pupils are widely dilated and muscles are
relaxed.

In 1954, Joseph F. Artusio further divided the first stage in Guedel's

classification into three planes.

i. 1st plane The patient does not experience amnesia or analgesia

ii. 2nd plane The patient is completely amnesic but experiences only
partial analgesia

iii. 3rd plane The patient has complete analgesia and amnesia
C.Indications of the Different Types of Anaesthesia.
Spinal anaesthesia
Spinal anaesthesia is indicated in surgical procedures below the
diaphragm especially in Patients with cardiac or respiratory disease
Advantages include: it facilitates mental status monitoring and has
a shorter recovery.
Disadvantages to use includes requirement for necessary extra
expertise and possible patient pain.
Spinal anaesthesia is however contraindicated in patients with
coagulopathy and uncorrected hypovolemia
Medications commonly used include:-Lidocaine, bupivacaine and
tetracaine.
During spinal anaesthesia Patient assessments should include
continuous heart rate, rhythm, and pulse oximetry monitoring,level
of anaesthesia , motor function and sensation return
monitoring.
Complications that may arise with spinal anaesthesia include
hypotension, bradycardia, urine retention, postural puncture
headache and back pain.
Spinal analgesia
Spinal analgesia is indicated in postoperative pain from major
surgery
The drugs used include lipid-soluble drugs, preservative-free
morphine
Monitoring recovery: Closely monitor for respiratory depression,
urine retention, pruritis and nausea and vomiting.
Drugs/anaesthetic agents used in General Anaesthesia.
Premedication
This is treatment given to the patient 30 minutes before going for
surgery. It is not advisable to give premedication to paediatrics.
Drugs given include:-Atropine 0.6mgs intramuscular (adult dose)
to reduce secretions, Pethidine 50mgs intramuscular (Adult dose)
to allay anxiety.
The stages of general anesthesia include:- Induction, maintainance
and reversal
You are going to start with the agents used for induction of
anaesthesia.
D.Induction of anaesthesia-volatile agents
ETHER-No longer used as it is highly inflammable in the presence
of diathermy and it irritates the respiratory tract.
TRILENE-No longer manufactured. It used to cause tachypnoea
and vomiting.
HALOTHANE-Used in induction. Can cause halothane hepatitis.
ISOFLULANE-Currently used more than halothane due to its
reduced side effects.
The following are agents used to maintain anaesthesia
Mantainance of Anesthesia- Volatile agents
To maintain anesthesia oxygen+Nitrous oxide+one volatile agent
are given.
Intravenous agents include:-
Barbiturates e.g. Sodium thiopentone (Thiopental)- induces sleep
very quickly i.e. in 10 seconds.
Ketamine -Can be used alone in minor surgeries. Side effects
include bad dreams+ elevated blood pressure.
Muscle relaxants include;
They are divided into short acting and long acting muscle
relaxants.
Short acting (Depolarizing) relaxants e.g. suxamethonium (scoline)
is used in intubation.
Long acting (Non- Depolarizing) relaxants e.g. Pancuronium,
Tracurium and Nimbex.
These drugs are used to maintain anesthesia.
Analgesic agents include:-
They are used for pain relieve e.g.
Pethidine,morphine,Fentanyl,Dicofenac, Tramadol+ plasil
E. Reversal of anaesthesia
Anesthesia is reversed by administering Neostigmine 2.5 mgs IV
and Atropine 1.2 mgs IV
 There are different types of incisions that the surgeon will make:
Surgical Incisions
The site of surgical incision is chosen to gain quick, easy access
and exposure to underlying pathologic conditions. The aims are to
minimize trauma, bleeding and post operative discomfort, also to
maximize wound strength and to afford ample room to accomplish
the intended surgery.
Each incision has advantages and disadvantages regarding
adequacy of exposure, length of time required for closure,
disruption of surrounding blood and nerve supply, underlying
muscles that must be cut or slip, incidence of postoperative wound
hernia, effect on pulmonary function and cosmesis.
Developments in technology and surgical techniques have
advanced the use of minimally invasive approaches, which
decreases the use and extent of abdominal incisions and preserves
the integrity of the abdominal wall.
The abdominal wall consists of various tissue layers through which
dissection is necessary to enter the abdominal cavity. The nine
layers include, the skin, camper's fascia, scarpa fascia, external
oblique muscles, internal oblique muscles, transverses muscles,
transversalis fascia, preperitoneal fat and perioneum The fascia
layer, consisting of bands of tough fibrous connective tissue,
surrounds the muscle anteriorly and posteriorly. The peritoneum is
a serous membrane lining the abdominal cavity (parietal
peritoneum) and the surface of the abdominal organs (visceral
peritoneum).

Vertical Midline Incisions

It is the simplest abdominal incision to perform. It is an excellent

primary incision and offers good exposure to any part of the
 abdominal cavity. Hemostasis is easily achieved and fewer layers
are traversed. The incision can be extended from below the sternal
notch, distally around the umbilicus, back to the midline, and down
to the symphysis pubis. The peritoneum is incised which gives
entry to the peritoneal cavity. Post operative hernias are more
common above the umbilicus than below it.
The paramedian incision, also called a rectus incision, is a vertical
incision placed approximately 4 cm (2 inches) lateral to midline on
either side of the upper or lower abdomen. Paramedian incisions
take longer to create and close and are more prone to herniations.
Closure of paramedian and midline incisions begin with the
peritoneum. The peritoneum and posterior fascia may be sutured
together as a single layer in a continuous stitch with absorbable
sutures. Wound dehiscence, a potential complication of abdominal
surgery is separation of the unhealed incision. When dehiscence is
severe, bowel or other abdominal structures may protrude
(evisceration). Dehiscence and evisceration are most common with
midline vertical incisions.
Anterior fascia, subcutaneous tissue and skin are closed as separate
layers. Anterior fascia and muscle may be closed with interrupted
nonabsorbable synthetic sutures. Subcutaneous layer may be
closed with absorbable interrupted suture. Skin edges may be
approximated and secured with interrupted nonabsorbable
synthetic sutures, skin staples, subcuticular continuous closure
with an absorbable suture.

Oblique Incisions

They include McBurney incision, Lower Oblique Inguinal incision

and Subcostal incision.
i.McBurney Incision
 This incision is most commonly used for open prostatectomy. It is
an 8 cm oblique incision that begins well below the umbilicus goes
through Mcburney point and extends upwards towards the right
flank. The external oblique muscles and fascia are divided bluntly
(split in the direction of the fibers) and are retracted. The internal
oblique muscles, transverse muscle and fascia are also split and
retracted. The peritoneum is incised transversely.
The incision is quick and easy to close and allows a firm wound
closure.
It does not permit good exposure and is difficult to extend.

ii.Lower Oblique Inguinal incision.

An oblique right or left inguinal incision extends from the pubic

turbercle to the anterior iliac crest. This is the standard incision for open
inguinal herniorrhaphy.

Incision through the external oblique, the muscle gives access to the
cremaster muscle, inguinal canal and cord structures.

The incision does not interrupt major abdominal arteries.Long, lower

abdominal oblique incisions can be used for transplant, urologic and
vascular procedures.

iii. Subcostal Incision

It is made on the right side (Kocher incision) when used for open
procedures of the gallbladder, billiary system and pancrease.
A left subcostal incision is used for surgery of the spleen. This
incision provides limited exposure unless the patient is short with a
wide abdomen and wide costal margins.
It provides good cosmetic results because it follows the skin lines
and nerve damage is minimal. Tension on the skin edges is less
 than that of a vertical incision, permitting wider retraction and
exposure with less respiratory impairment during the procedure.
The oblique incision begins in the epigastrium, extending laterally
and obliquely downward to just below the costal margin. It
continues through the rectus muscles which is retracted or
transversely divided.
A chevron incision (joined right and left subcostal incisions)
provides excellent exposure for gastric, duodenal, pancreatic and
portal system procedures.

Transverse Incisions

This incisions include: Pfannestiel incision, Mid abdominal

transverse incision and thoracoabdominal incision.
i.Pfannestiel incision
It is used for pelvic surgery.
It is a curved transverse incision across the lower abdomen through
the skin, subcutaneous layer and rectus sheath, approximately 1 cm
above the symphysis pubis, usually within the pubic hairline.
It is the standard incision for open obstetric and gynaecologic
procedures.
The rectus muscles are separated along the midline and the
peritoneum is entered through the midline vertical incision.
It provides good exposure and a strong postoperative scar that is
cosmetically acceptable.
ii.Midabdominal transvere incision
This incision is used on the right or left for a retroperitoneal
approach. The incision begins slightly above or below the
umbilicus on either side, is carried latterly to the lumbar region at
an angle between the ribs and the iliac crest, follows langer,s lines
of tension of the abdominal wall, and runs parallel to vessels and
nerves, rarely causing permanent damage.
The skin and subcutaneous tissue are incised, the anterior sheath is
split, the rectus muscle is divided and the vessels within the rectus
are clamped and ligated. The posterior rectus sheath and
peritoneum are cut in the direction of the fibers, preserving the
intercostals nerves. The peritoneum is incised along the midline,
and the incision is extended laterally to the oblique muscle.
This is a standard incision for transverse colectomy or colostomy
and choledochojejunostomy.
iii.Thoracoabdominal incision
This is the standard incision for surgery of the proximal stomach,
distal esophagus and anterior spine.
The patient is placed lateral position. The incision begins at a
midpoint between the xiphoid and umbilicus and extends
posteriorly, across the seventh or eighth interspace and
midscapular line into the chest. The rectus, oblique, serratus and
intercostals muscles are divided down to peritoneum and pleura.
The costal cartilage and diaphragm are then divided. The incision
sacrifices the superior epigatric artery.
The wound is closed in layers with an interrupted suture technique.
The peritoneum and pleura may be closed with an absorbable
suture material, whereas the muscle and fascia layer may be closed
with either an absorbable or nonabsorbable synthetic suture
material. Skin edges are approximated and secured with suture,
staples, skin bonding adhensive or skin tapes strips.
TOPIC : SAFETY AND INFECTION PREVENTION IN THE
OPERATING ROOM

5.1 History of Infection Control

In 1847: Ignac Semmelweis experienced a 20% maternal mortality in his

hospital in Vienna, caused by puerperal sepsis secondary to
streptoccocal infection. The maternal mortality at home was 1%. He
concluded that doctors themselves were transmitting the diseases
between patients and he mandated that they wash their hands with a nail
brush and chlorine (HTH). Infection fell to 1%. However, elsewhere
doctors' practices didn't change. It was inconceivable to imagine that
doctors were killing patients. It was proposed that vapours were
responsible. Instead of being acclaimed, Semmelweis was dismissed
from his job and eventually died in a lunatic asylum.

In 1856: Florence Nightingale brought mortality down dramatically

during the Crimean War just by instituting basic hygiene like ventilation,
improved sewers and antisepsis.

In 1862: Louis Pasteur proposed the first germ (bug) theory.

In 1867: Joseph Lister proposed the routine use of the antiseptic carbolic
acid (phenol) in The Lancet.

In 1928: Alexander Fleming discovered penicillin.

In 2006: Peter Pronovost, a Johns Hopkins doctor, proposed a five-point

checklist protocol (NEJM, 2006) that greatly reduced infections (by
66%) when inserting a line for Central Venous Pressure monitoring
(CVP). In recognition of this, he was elected as one of Time magazine's
top 100 people of the year in 2008.

2020 - The Covid 19 pandemic was a wakeup call for countries to

institute more infection prevention measures especially in the operating
room. More policies will be drafted in response to this.

5.2 Principles of Infection Prevention in The Operating Theatre

Safety of the patient is of utmost importance, handle needles safely

otherwise you can prick self or the patient unnecessarily, prevent falls
from operating table or stretcher by use of stretchers fitted with side
rails, Prevent diathermy burns. Place the neutral plate as instructed by
the manufacturer, Handle swinging doors carefully to avoid knocks.
Sliding doors are best recommended for use, in cases of fire outbreak
learn how to properly use the fire extinguishers.

Environmental Cleaning of the Operating Theaters

Cleaning should include preliminary cleaning i.e. proper preparation of

the theatre before the first case and interim cleaning performed after
each case. Adequate time should be allowed for disinfection and set-up
of the procedure room before the next patient; terminal cleaning at the
conclusion of the day's schedule, all theatre areas should be terminally
cleaned; in addition to routine cleaning, weekly or monthly cleaning
should be set up with the environmental/public health personnel. There
should be a simple, clear, cleaning policy that can be adhered to easily.
The cleaning of operating room equipment for the operating room must
be dedicated and kept separate from the outer zone.

Principles of Infection Prevention in The Operating Theatre Cont..

5.2.2 Instruments

Used instruments should be counted, decontaminated and counted again

in the theatre sluice room before sending them to the Central Sterile
Services Unit (CSSU).

5.2.3 Waste and Linen

Waste should be segregated and disposed with minimal handling

because there is a risk of blood-borne pathogen transmission. Body
fluids can be disposed off in the sluice room (or as per facility protocols)
by staff with appropriate protective clothing (appropriate gloves, aprons
and eye protection.

Follow the facility's guidelines for processing used equipments and

instruments, this is because the history and diagnosis of a patient cannot
reliably predict those patients with blood borne and infectious
pathogens.( remember the case of Covid 19 that hit Kenya in 2020?.

Used linen should be contained in hampers or in soiled laundry bags at

the point of use. Soiled linen should be placed in fluid proof bags, other
contaminated linen should be handled and disposed according to the
facility's medical waste management procedure.

5.2.4 Suction Apparatus,ventilators and Transportation Carts

These equipments should be fitted with bacterial filters in order to

prevent contamination of the machines.

Supplies in and out of theatre should be transported using covered carts.

Soiled items should be transported in covered containers from clean area
to decontamination area. All soiled items should be kept away from the
clean area

5.2.5 Traffic Patterns

Traffic flow for patients and instruments should be unidirectional as

shown n the table below.

Top-bottom one way traffic flow for patients and instruments in theatre.

Patient Instrument

Traffic in Sterilizing unit

Holding area Strelizing theatre store

Induction room Setting room

Operating room Operation room

PACU(Post anaesthesia care unit) Sluice room

Traffic out Processing unit

5.2.6 Temperature and Humidity Control

The temperature in the operating room should be carefully regulated and

monitored. The points are temperature 18-24C and humidity at less than
55% to ensure patients' and staff comfort, this is because low humidity
can lead to production of electrostatic sparks. The operating room should
be 1?C cooler than the outer area, this will help in outward movement of
air because the warmer air in the outer area rises and the cooler air from
within the operating room moves to replace it.

5.2.7 Ventilation and Air Exchange System

A recommended air ventilation system e.g. air supply and exhaust

positive pressure with respect to corridors and adjacent areas in the
operating room should always be maintained. The number of operating
theatres supplied by Air Handling Units should be consistent with the
number specified by the AHU manufacturer. There should be routine
maintenance of the AHUs, they should only be switched off when they
are being serviced. Air changes should be maintained at 15-20 air
changes per hour, of which at least 3 should be fresh air from outside.
All air is filtered with appropriate pre filters; a filtration efficiency of
30% followed by final filter at 90% air supply. Air should enter at the
ceiling and exhausted near the floor.
Items placed against a wall exhaust at floor level e.g furniture and other
portable items can inhibit air changeover in the operating room, this
should be prevented.

Free air conditioning in theatre i.e with fans is highly discouraged. This
is because the fans will keep a stream of air circulating round but no
definite air exchange. This air can act as a medium for circulating
disease causing micro-organisms.

Principles of Asepsis in the Operating Room.

As you can remember, you learnt about this in details in your first year. I
hope you have reviewed that already. Remember the universal
precautions in infection prevention.

Aseptic technique is a set of specific practices and procedures performed

under carefully controlled conditions with the goal of minimizing
contamination by micro-organisms. Aseptic technique is important in the
operating room because of the direct and extensive tissue disruption
hence it is a key measure to prevent post-operative infections.

The following practices are the standard principles of asepsis and

should be observed at all times in the operating room

i.The operating room should be ready for any type of surgery always

ii.Preparations are guided by the specific surgery to be perfomed

iii.All operating rooms should be ready for general anaesthesia

regardless of the type of anaesthesia to be given.

iv. Psychological and physical preparation is a pre-requisite for surgery

including emergency surgeries.
v.General cleanliness should include preliminary, interim, terminal and
weekly and monthly cleaning of the entire operating room.

vi.Always ensure air conditioning, optimum humidity and room

temperature.

vii.Solutions for prepping the skin nd use during surgery should always
be made in advance.

viii.Provide receivers for refuse (called kick about because they are
meant to be moved about by kicking) with color coded linear bags and
prick proof boxes/containers

ix.Avail adequate protective wear to include surgical aprons and

googles.

x.Sterile supplies, sets, surgical gauze sponges should be ordered in

time. Always check the theatre list to guide ordering.

xi.Ensure there are enough consumables to include syringes, needles,

cannulae, bacterial filters, suction catheters and sutures.

xii.Stock enough anaesthetic gases, medications. Assembling of

machines should be done on time and any checks done in advance.

xiii.Ensure you have specimen containers as needed before hand and

organize on how the specimens will be transported .

xiv.Enough stationary should always be availed as per the facility's

guidelines

xv.A complete surgical team should be present at all times.

5.4 Process of Preparation for Surgery

5.4.1Preparation of the operating room.

The following interventions should be done.

i.Sterilization of instruments and other supplies to be used during the

surgical procedure

ii.use of sterile consumables e.g. sterile sutures, sterile gloves

iii.Use of aseptic techniques during surgery

iv.Scrubbing to minimize micro organisms.

v.Ensure high dusting of the walls, clean trolleys, drip stands, operating
tables, operating lights .Use disinfectants e.g. sodium hypochlorite.

vi.Clean the floors by scrubbing the terrazzo floors with a brush +soap
and water.

vii.Return all the machines to respective areas. Such machines includes

Diathermy machine, anesthetic machine, suction machine, operating
table, defibrillator, heart lung machine e.t.c.

viii.Ensure that these machines are functioning properly.

ix.Drape operating table ready to receive patient.

x.Set anaesthetic tray ready for use.

xi.Ensure all required instruments and consumables are avail

5.4.2Preparation of the nurse

After entering the operating suite the peri-operative nurse should go to

the changing room, visit toilet to empty bladder, take a shower, lock
personal belongings in to a locker, change into theatre attire i.e. shirt,
trouser then boots. Cover head with a cap -male cap or the female cap (-
cover your hair completely), the nurse should then wear a sterile gown,
staff with upper respiratory tract infections should not be allowed in the
operating room, ensure proper cleaning of the incision site

5.4.3Preparation of the Nurse-Scrubbing

This is done to remove micro organisms from the hands and arms by
mechanical washing and chemical disinfection before taking part in
surgical procedure.

5.4.4Preparation of the Nurse-Gowning

After washing hands, the nurse should dry hands and arms using a terry
towel, she/he then picks the gown, makes a step back, holding the gown
at the neck band lets it roll, then opens the gown and puts it on, the
circulating nurse then ties the straps/tapes of the gown.

5.4.5Preparation of the Nurse-Gloving

Gloving is the act of wearing sterile gloves to perform a surgical

procedure.

Closed method of gloving is most recommended. Do not use the open

method.

The circulating nurse picks the sterile gloves, together with the scrub
nurse they confirm the expiry date and whether the package is tone. The
circulating nurse then opens the package, the scrub nurse then puts on
the sterile gloves using the closed method of gloving. In a prayer
position the scrub nurse moves to the setting room.

5.4.6Patients' skin preparation.

Use a sponge holding forcep with a swab attached to it, soaked in strong
disinfectant clean the incision site, then drape the operation site ready
for surgery, when spirit or alcohol is used to clean the operation site
always dry the area before starting surgery, to prevent burns from
diathermy machine.

5.4.7Draping of patient

The purpose of draping is to maintain an adequate sterile field of

operation

Scrub nurse hands over sterile towels to cover the area above the
operation site and below and on the sides. After draping, the scrub nurse
moves trolleys next to the already created sterile field.

5.4.8Positioning the Patient.

This involves placing the patient on operating table, take care of the
pressure areas to prevent nerve injury.

The following are examples of positions that can be used for specific
surgeries.

i.Supine position where the patient lies on the back with arms on the
sides resting on the arm boards e.g. laparatomy, appendicectomy.

ii.Prone position where the patient lies on the front i.e. anterior part of
the body placed on the operating table.

iii.Reverse-trendelenburg position patient lies supine with head raised

than the foot. e.g. in craniotomy.

iv.Trendelenburg position where the patient lies supine, foot of the

operating table raised, head lowered. used for pelvic operations e.g.
prostatectomy, laparoscopic procedures
v.Kidney position where the bridge of the table is raised to elevate the
loins between the lower limbs and iliac crest.

vi.Lithotomy position where the patient lies supine, legs raised on the
stirrups e.g. used in repair of recto-vaginal, recto-vaginal fistula (rvf,vvf)
and vaginal hysterectomy.

vii.Laminectomy position where the patient is positioned prone with

head projected over the table and supported on the forehead resting on a
horseshoe fixed on the table.

Topic 6: Assessment of Patients with Disoders of the Ear

Anatomic and Physiologic Overview of Ear

The ears are a pair of complex sensory organs located in the middle of
both sides of the head (that attaches to the temporal bone of cranium) at
approximately eye level.

Anatomic overview of the ear.

6.1.1 Anatomy of the external ear

The external ear, housed in the temporal bone, includes the auricle (i.e.,
pinna) and the external auditory canal. The external ear is separated
from the middle ear by a structure called the tympanic membrane (i.e.,
eardrum).

a.Auricle

The auricle, attached to the side of the head by skin, is composed

mainly of cartilage, except for the fat and subcutaneous tissue in the
earlobe. The function of auricle is to collect the sound waves and direct
vibrations into the external auditory canal.

b.External Auditory Canal

The external auditory canal is approximately 2.5 cm long. The lateral

third is an elastic cartilaginous and dense fibrous framework to which
thin skin is attached. The medial two thirds is bone lined with thin skin
that contains hair, sebaceous glands, and ceruminous glands, which
secrete a brown, wax like substance called cerumen (i.e., ear wax). The
external auditory canal ends at the tympanic membrane. The ear's self-
cleaning mechanism moves old skin cells and cerumen to the outer part
of the ear.

Anatomy of the Middle Ear

The middle ear, an air-filled cavity, includes:- The tympanic membrane
laterally and the otic capsule medially. The middle ear is connected by
the tube (1 mm wide and 35 mm long) to the nasopharynx and is
continuous with air-filled cells in the adjacent mastoid portion of the
temporal bone.

Normally, the tube is closed, but it opens by action of the tensor veli
palatini muscle when performing yawning or swallowing. The tube
serves as a drainage channel for normal and abnormal secretions of the
middle ear and equalizes pressure in the middle ear with that of the
atmosphere.

The middle ear.(source; Gray's Anatomy for students)

a.Tympanic Membrane

The tympanic membrane (i.e., eardrum), about 1 cm in diameter and

very thin, is normally pearly gray and translucent. The tympanic
membrane consists of three layers of tissue: an outer layer, continuous
with the skin of the ear canal; a fibrous middle layer; and an inner
mucosal layer, continuous with the lining of the middle ear cavity. The
tympanic membrane protects the middle ear and conducts sound
vibrations from the external canal to the ossicles.

b.Ossicles
The middle ear contains the three smallest bones (i.e., ossicles) of the
body: - malleus, - incus, and - stapes. It has vibratory, resonance
function and modify the external stimulus. The ossicles, which are held
in place by joints, muscles, and ligaments, assist in the transmission of
sound.

Anatomy of the Inner Ear

The inner ear is housed deep within the temporal bone. The organs for
hearing (i.e., cochlea) and balance (i.e., semicircular canals), as well as
cranial nerves VII (i.e., facial nerve) and VIII (i.e., vestibulocochlear
nerve), are all part of this complex anatomy. The cochlea and
semicircular canals are housed in the bony labyrinth. The bony labyrinth
surrounds and protects the membranous labyrinth, which is bathed in a
fluid called perilymph.

inner ear. (source; Gray's Anatomy for students)

Membranous Labyrinth

The membranous labyrinth is composed of the utricle, the saccule, the

cochlear duct, the semicircular canals, and the organ of Corti. The
membranous labyrinth contains a fluid called endolymph. The three
semicircular canals-posterior, superior, and lateral, which lie at 90-
degree angles to one another and contain sensory receptor organs,
arranged to detect rotational movement. These receptor end organs are
stimulated by changes in the rate or direction of an individual's
movement.

Organ of Corti

The organ of Corti is located in the cochlea, a snail shaped, bony tube
about 3.5 cm long with two and one-half spiral turns. The organ of Corti,
also called the end organ for hearing, transforms mechanical energy into
neural activity and separates sounds into different frequencies.

Functions of the Ears

?Hearing: Hearing is conducted over two pathways: air and bone.

Sounds transmitted by air conduction travel over the air filled external
and middle ear through vibration of the tympanic membrane and
ossicles. Sounds transmitted by bone conduction travel directly through
bone to the inner ear, bypassing the tympanic membrane and ossicles.
Normally, air conduction is the more efficient pathway (AC>BC)

?Sound conduction and transmission(Physiology)

Sound enters the ear through the external auditory canal causes the
tympanic membrane to vibrate. These vibrations transmit sound through
the action of the ossicles to the oval window as mechanical energy. This
mechanical energy is then transmitted through the inner ear fluids to the
cochlea, stimulating the hair cells, and is subsequently converted to
electrical energy. The electrical energy travels through the
vestibulocochlear nerve to the central nervous system, where it is
analyzed and interpreted in its final form as sound.

Assessment of Patients Presenting with Ear Disorders.

Assessment should always start with a health history.

6.2.1 Health History and Physical Assessment.

It includes all the components that are applied in other body system i.e
Date of History, Identification. Chief compliant, history of present
illness, history of past illness, Current health status (Current medication,
addictive drugs and allergies), family history, psychosocial and
personal history.

Physical Examination: The external ear is examined by; Inspection of

external ear for the presence of scars, lesions, symmetry, attachment,
any abnormal discharge, color e.t.c. the tympanic membrane is inspected
with an otoscope. Inspection of the middle ear with middle ear
endoscopy and direct palpation for:- tenderness, presence of malignancy,
free movement, circulation, e.t.c.

6.2.2 Otoscopic Examination

Done to examine the external auditory canal and tympanic membrane.

The otoscope should be held in the examiner's right hand, in a pencil-
hold position, with the bottom of the scope pointing up. Before inserting
the otoscope it is important to straighten the external auditory canal by
manipulation; Grasp the auricle firmly but gently and pull it upward,
backward, and slightly away from the head in an adult. Grasp the
auricle firmly but gently and pull it down ward, backward, and slightly
away from the head in Children. Proper otoscopic examination of the
external auditory canal and tympanic membrane requires that the canal
be free of large amounts of cerumen. The healthy tympanic membrane is
pearly gray and is positioned obliquely at the base of the canal. Steady
the hand against the patient's head to avoid inserting the otoscope too far
into the external canal.
Steady the hand against the patient's head to avoid inserting the otoscope
too far into the external canal as shown in the figure below.
Evaluation of Gross Auditory Acuity

Some patients visiting a health facility may need more extensive

assessments as you are going to learn next, a general estimation of
hearing can be made by assessing the patient's by; whisper test, Weber
's test and Rinne tests.

a.Whisper Test

Whisper Test is usually done to exclude one ear from the testing, the
examiner covers the untested ear with the palm of the hand. Then the
examiner whispers softly from a distance of 1 or 2 feet from the
unoccluded ear and out of the patient's sight. The patient with normal
hearing acuity can correctly repeat what was whispered.

b.Weber Test (Lateralization Test).

The Weber test uses bone conduction to test lateralization of sound. A

tuning fork (ideally, 512 Hz), set in motion by grasping it firmly by its
stem and tapping it on the examiner's knee or hand, is placed on the
patient's head or forehead. A person with normal hearing will hear the
sound equally in both ears or describe the sound as centered in the
middle of the head. In cases of conductive hearing loss, such as from
otosclerosis or otitis media, the sound is heard better in the affected ear.
In cases of sensorineural hearing loss, resulting from damage to the
cochlear or vestibulocochlear nerve, the sound lateralizes to the better-
hearing ear. The Weber test is useful for detecting unilateral hearing
loss.

a.Rinne's Test

In the Rinne test (pronounced rin-ay), the examiner shifts the stem of a
vibrating tuning fork between two positions: 2 inches from the opening
of the ear canal (i.e., for air conduction) and against the mastoid bone
(i.e., for bone conduction). Normally, sound heard by air conduction is
audible longer than sound heard by bone conduction. The Rinne test is
useful for distinguishing between conductive and sensorineural hearing
losses. With a conductive hearing loss, bone-conducted sound is heard
as long as or longer than air-conducted sound, whereas with a
sensorineural hearing loss, air-conducted sound is audible longer than
bone conducted sound.
Diagnostic Evaluation Includes the Following Tests.

i.Audiometry:-A test to check the ability of hear sounds.

ii.Tympanogram/tympanometery is an examination used to test the

condition of the middle ear and tympanic membrane

iii.Auditory brain stem response (ABR)- is extracted from ongoing

electrical activity in the brain and recorded via electrodes placed on the
scalp.

iv.Electronystagmography (ENG) - used to evaluate patients with

dizziness, vertigo, or balance dysfunction or to record involuntary
movements of the eyes caused by a condition known as nystagmus.

v.Platform posturography(TOB- TEST OF BLANCE)

vi.Sinusoidal harmonic acceleration- to check the vestbular function

vii. Middle ear endoscopy

Topic 7:
External Ear Disorders

7.1.1 Cerumen Impaction

Cerumen impaction is a common complaint in most patients seeking

care for partial hearing loss. Cerumen normally accumulates in the
external canal in various amounts and colors. Although wax does not
usually need to be removed, impaction occasionally occurs, causing
otalgia, a sensation of fullness or pain in the ear, with or without a
hearing loss. Accumulation of cerumen is especially significant in the
geriatric(elderly) population as a cause of hearing deficit. Accumulated
cerumen (earwax) may become impacted due to use of cotton swabs to
clean ears and may be a problem for some people. Cerumen becomes
drier in elderly people, making impaction more likely.

Management of patients with Cerumen Impaction; Cerumen can be

removed by the following standard methods depending on how the
patient presents.

Irrigation: unless the patient has a perforated eardrum or an inflamed

external ear (i.e., otitis externa), particularly if it is not tightly packed in
the external auditory canal, irrigation (ear syringing) is preferred.

Suction: It involves using any softening solution two or three times a

day for several days is generally sufficient. Instilling a few drops of
warmed glycerin, mineral oil, or half strength hydrogen peroxide into
the ear canal for 30 minutes can soften cerumen before its removal.

Instrumentation: If the cerumen cannot be dislodged by these methods,

instruments, such as a cerumen curette, aural suction, and a binocular
microscope for magnification, can be used. Direct visual, mechanical
removal can be performed on a cooperative patient by a trained health
care provider. To prevent injury, the lowest effective pressure should be
used.

Ceruminolytic agents, such as peroxide in glyceryl are available;

however, these compounds may cause an allergic dermatitis reaction.

7.1.2 Foreign Bodies in the Ear.

Some objects are inserted intentionally into the ear by adults who may
have been trying to clean the external canal or relieve itching or by
children who introduce the objects. Other objects, such as insects, peas,
beans, pebbles (Sand/stone), toys, and beads/droplet, may enter or be
introduced into the ear canal. In either case, the effects may range from
no symptoms to profound pain and decreased hearing. Common clinical
presentations may range from no symptoms, swelling, profound pain to
partial hearing loss.

Management of patients with foreign bodies in the ear;the three standard

methods for removing foreign bodies are the same as those for removing
cerumen: Irrigation: Foreign vegetable bodies and insects tend to swell;
thus, irrigation is contraindicated.

Suction, and Instrumentation: Usually, an insect can be dislodged by

instilling mineral oil, which will kill the insect and allow it to be
removed. In difficult cases, the foreign body may have to be extracted in
the operating room with the patient under general anesthesia

7.1.3 External Otitis (otitis externa)

It is an inflammation of the external auditory canal usually caused by an

acute infection, the causes of Otitis externa include;
i.The causes include water in the ear canal (i.e., swimmer's ear), trauma
to the skin of the ear canal, systemic conditions (such as vitamin A
deficiency an endocrine disorders

ii.Bacterial infections of the external ear are most commonly from

Staphylococcus aureus and Pseudomonas species.

iii.Fungal infections are most commonly by is Aspergillus

iv.Dermatosis such as psoriasis, eczema, or seborrheic dermatitis can

also cause otitis externa.

v.The condition can also be as a result of allergic reactions to hair spray,

hair dye, and permanent wave lotions which can cause dermatitis, which
clears when the offending agent is removed.

a.Clinical Manifestations of Otitis externa.

Patients often present with pain, discharge (yellow or green and foul
smelling), aural tenderness which is usually not present in middle ear
infections, high temperature, cellulitis, lymphadenopathy, pruritus,
hearing loss, feeling of fullness, erythematous and edematous ( on
otoscopic examination) and in fungal infections, hair like black spores
may be visible.

b.Medical Management of patients with Otitis externa.

The principles of therapy are aimed at, relieving the discomfort,

reducing the swelling of the ear canal, and eradicating the infection.

Patients may require analgesics for the first 48 to 92 hours, antibiotic

ear drops, Antifungal- ear drops e.g clotrimazole ear drops 1% 2-3
times daily for at least 14 days. The patient should be instructed to
avoid swimming and not allow water to enter the ear.
c. Nursing Management of patients with Otitis externa.

Nurses should teach patients not to clean the external auditory canal
with cotton-tipped applicators, to avoid swimming, and not to allow
water to enter the ear when shampooing or showering.

They should teach patients that cotton ball can be covered in a water-
insoluble gel such as petroleum jelly and placed in the ear as a barrier to
water contamination. Infection can be prevented by using antiseptic otic
preparations after swimming (eg, Swim Ear, Ear Dry)

7.2 Middle Ear Disorders

7.1.1Tympanic membrane perforation

The causes of tympanic membrane perforation include: infections,

trauma (skull fracture, explosive injury, or a severe blow to the ear,
foreign objects (eg, cotton-tipped applicators,match pins, keys that have
been pushed too far into the external auditory canal.

Medical Management of tympanic membrane perforation; Most

tympanic membrane perforations heal spontaneously within weeks after
rupture. In the case of a head injury or temporal bone fracture, a patient
is observed for evidence of cerebrospinal fluid leakage, otorrhea or
rhinorrhea (a clear, watery drainage from the ear or nose), respectively.
While healing, the ear must be protected from water.

Surgical management:-Tympanoplasty - surgical repair of the tympanic

membrane, surgery is usually successful in closing the perforation
permanently and improving hearing.

7.2.2Acute otitis Media

 It is an acute infection of the middle ear, usually lasting less than 6
weeks. Acute otitis media is an inflammation and infection of the middle
ear caused by the entrance of pathogenic organisms, with rapid onset of
signs and symptoms. It is a major problem in children but may occur at
any age.

The causes are primarily Streptococcus pneumoniae, Haemophilus

influenzae, and Moraxella catarrhalis. Other causes are Inflammation of
surrounding structures e.g sinusitis, adenoid hypertrophy, allergic
reactions e.g allergic rhinitis. It is usually present in the middle ear,
resulting in a conductive hearing loss.

Clinical Manifestations of Acute Otitis Media include; Most patients

with Acute Otitis Media present with:- Otalgia : -Ear pain which is
unilateral in adults and may awaken the patient at night, pain relieved
after tympanic perforation, purulent drainage from the ear , fever,
headache, hearing loss (conductive hearing loss), the patient reports no
pain with movement of the auricle, on physical assessment the tympanic
membrane is erythematous and often bulging.

Diagnostic Evaluation ; Pneumatic otoscopy will show a tympanic

membrane that is full, bulging, and opaque with impaired mobility (or
retracted with impaired mobility). Cultures of discharge through
ruptured tympanic membrane may suggest causative organism.

Medical Management of Acute Otitis Media; Antibiotics e.g Co-

trimoxazole, 4mg/kg trimethoprin 20mg/kg sulphomethaxozole twice a
day for 5 days. Amoxicillin, 20-40mg/kg/day divided into 3 doses for 5
days, the external auditory canal should be cleaned and covered with
cotton
Surgical management of Acute Otitis Media; Myringotomy: An incision
in the tympanic membrane is known as myringotomy or tympanotomy.
The incision heals within 24 to 72 hours, it is Indicated for analysis of
drainage (by culture and sensitivity testing) If pain persists. If episodes
of acute otitis media recur and there is no contraindication, a ventilating,
or pressure-equalizing tube may be inserted. The ventilating tube, which
temporarily takes the place of the eustachian tube in equalizing pressure,
is retained for 6 to 18 months. Ventilating tubes are more commonly
used to treat recurrent episodes of acute otitis media in children than in
adults.

Complications that may occur due to acute otitis medis include:-

Chronic otitis media, mastoiditis, meniningitis and brain abscess

7.2.3 Serous Otitis Media

Serous otitis media (i.e., middle ear effusion) implies fluid, without
evidence of active infection, in the middle ear.

Causes of Serous Otitis Media; From your previous lessons in child

health and paediatric nursing, you learnt that the common causes of
Serous Otitis Media (SOM) in children is eustachian tube obstruction
which causes negative pressure in the middle ear, in adults however the
common causes are eustachian tube dysfunction which is normally
concurrent with upper respiratory infection or allergy, radiation therapy,
barotraumas which results from sudden pressure changes in the middle
ear caused by changes in barometric pressure, as in scuba diving or
airplane descent and carcinoma e.g nasopharyngeal cancer.

Clinical manifestations include ; Conductive hearing loss, The patient

will report feelings of fullness in ear and sensation of congestion and
popping and crackling noises. On physical assessment the tympanic
membrane will appear dull.

A diagnosis can be made by carrying out an otoscopic examination

which will reveal a dull tympanic membrane and air bubble shown in the
middle ear. An Audiogram can be done to exclude conductive hearing
loss.

Management of SOM will include surgery ;Myringotomy will be done

to relieve pressure or drain fluid by incision, A tube may be placed to
keep the middle ear ventilated. Corticosteroids can also be given and a
Valsalva maneuver can be done but cautiously

7.2.4 Chronic Otitis Media(COM)

Chronic otitis media is the result of repeated episodes of acute otitis

media causing irreversible tissue pathology and persistent perforation of
the tympanic membrane. Chronic infections of the middle ear, damage
the tympanic membrane, destroy the ossicles, and involve the mastoid.
The most common organisms are group A beta-hemolytic, streptococci,
S. pneumoniae, and H. influenzae. Other organisms may be present,
such as Pseudomonas, Proteus, and Bacteroides species.

Clinical Manifestations; Presence of a persistent or intermittent foul-

smelling otorrhea, pain is not usually experienced, except in cases of
acute mastoiditis. On otoscopic examination a perforated tympanic
membrane is evident. Cholesteatoma which is an an ingrowth of the
skin of the external layer of the eardrum into the middle ear is present,
audiometric tests often show a conductive or mixed hearing loss.

Diagnostic Evaluation; On assessment, air conductive hearing loss is

present through audiometric tests. X-rays may show mastoid pathology
e.g cholesteatoma or haziness of mastoid cells. Culture of exudate from
middle ear through ruptured tympanic membrane or at time of surgery.

Medical Management: Suctioning of the ear, instillation of antibiotic

drops or application of antibiotic powder is part of the management of
chronic otitis media. Systemic antibiotics are usually not prescribed
except in cases of acute infection, the ear should always be kept dry by
wicking.

Surgical management; Involves a tympanoplasty which is the most

common surgical procedure. There are five types of tympanoplasties:-

?Type I myringoplasty -closing the perforated TM, and it is the simplest.

?Types II through V-more extensive.

?Ossiculoplasty -surgical reconstruction of the middle ear bones

(ossicles.)

?Mastoidectomy: The objectives of mastoid surgery are to remove the

cholesteatoma, gain access to diseased structures, and create a dry and
healthy ear.

Complications of chronic otitis media are facial nerve palsy, chronic

mastoiditis, meningitis and brain abscess.

You are now conversant with conditions of the middle ear, next you are
going to learn about disorders of the inner ear.

7.3 Inner Ear Disorders (IEDs)

The common complaints of patients with inner ear disorders are

dizziness (altered sensation of orientation in space), vertigo
(misperception or illusion of motion of the person or the surroundings).
Most people with vertigo describe a spinning sensation or say they feel
as though objects are moving around them, ataxia (failure of muscular
coordination due to vestibular system), nystagmus (an involuntary
rhythmic movement of the eyes) which can be horizontal, vertical, or
rotary.

7.3.1Motion sickness

Motion sickness is a disturbance of equilibrium caused by constant

motion (aboard a ship, while riding on a merry-go-round or swing, or in
the back seat of a car) that over stimulates the vestibular system.

Clinical Manifestations; Sweating, pallor, vertigo, nausea and vomiting.

These manifestations may persist for several hours after the stimulation
stops.

Management of Motion sickness;Includes administration of over-the-

counter antihistamines, Anticholinergic medications (scopolamine
patch, promethazine, e.t.c.). The patient is advised to avoid potentially
hazardous activities like operating heavy machinery, driving e.t.c.

7.3.2 M?ni?re?s Disease

M?ni?re's disease is an abnormal inner ear fluid balance caused by

malabsorption in the endolymphatic sac. M?ni?re's disease
(endolymphatic hydrops) is a chronic disease that involves the inner ear
and causes a triad of symptoms i.e vertigo, hearing loss, and tinnitus. M?
ni?re's disease appears to be equally common in bot genders.

Clinical Manifestations;Sudden attacks occur, in which patient feels that

the room is spinning (vertigo); may last 10 minutes to several hours.
Dizziness, tinnitus, and reduced hearing occur on the involved side.
Headache, nausea, vomiting, and incoordination are also present.
Sudden motion of the head may precipitate vomiting. Irritability and
other personality changes may occur. After multiple attacks, tinnitus and
impaired hearing may be continuous.

Assessment and Diagnostic Findings ; Mainly made rom history,

physical assessment, audiogram. electronystagmogram.

Pharmacologic therapy; Involves administration of antihistamines

(meclizine), tranquilizers (diazepam), antiemetics (promethazine
(Phenergan)) suppositories. Diuretic therapye.g hydrochlorothiazide).
Vasodilators (nicotinic acid, papaverine hydrochloride and
methantheline bromide.

Surgical management; Destructive surgery i.e labyrinthectomy is

recommended if the patient experiences progressive hearing loss and
severe vertigo attacks which interferes with normal tasks. It can result in
total deafness of affected ear.

7.3.3 Labyrinthitis

Labyrinthitis is an inflammation of the inner ear vestibular labyrinth

system. It may be due to a viral or bacterial infection.

Causes;The causes can be bacterial i.e complication of otitis media, they

can also be viral in origin i.e as in mumps, rubella, rubeola and
influenza, viral illnesses of the upper respiratory tract, herpetiform
disorders of the facial and acoustic nerves (i.e., Ramsay Hunt
syndrome).

Clinical Manifestations include; Sudden onset of incapacitating vertigo,

Nausea, vomiting, various degrees of hearing loss, and tinnitus.

Management; Intravenous antibiotic therapy, fluid replacement,

vestibular suppressants (meclizine), antiemetics and symptomatic
management for the viral one.
Topic 8

8.1 Physiology of Smell

To be able to smell, chemical particles from smelling substances get into

the nose and epithelia cells on the upper part of the nose, where olfaction
or smelling is carried out. The olfactory nerve is a cranial nerve involved
in enabling the sense of smell. Taste is facilitated by the taste buds found
on the tongue. The tongue can distinguish sweet, sour, bitter, salty and
other tastes. A part of the glosso-pharyngeal nerve supplies the tongue
with its sensory ability.

8.2 Management of Patients with Disorders of the Nose.

8.2.1Epistaxis
 It is hemorrhage from the nose. It can be an anterior bleed which most
of the time involves Kiesselbach's plexus vessels. An anterior bleed is
hence easy to locate and treat.

A Posterior bleed however involves larger vessels hence causes severe

bleeding. It is harder to locate and treat.

Etiology of epistaxis; The common causes of epistaxis are dry cracked

mucosal membrane, trauma, nose picking, blunt contact, forceful nose
blowing, sneezing, hypertension, chronic infections, substance abuse,
arteriosclerosis, liver disease, chronic bleeding disorders, leukemia,
hemophilia, anticoagulant therapy etc.

Management anterior bleeds; can be managed by simple first aid as

follows:

?Apply pressure for 5-10 minutes.

?Apply ice packs to nose and forehead.

?Sitting position leaning forward.

?Discourage swallowing blood

?Drugs that can be used include topical vasoconstrictors, Adrenaline

nasal spray or on cotton swab held against bleeding site.

?Sitting position leaning forward.

?Chemical cauterization: Silver nitrate, gelfoam.

?Pre-packing with topical anesthetic i.e tetracaine

?Nasal Packing for anterior bleeding by petroleum gauze for at least 24-
72 hours.
Posterior bleeds can be managed by simple first aid as follows:

?Nasal Packing: Pack both anterior and posterior for 2-5 days.

?Monitor for hypoxemia.

?Administer oxygen as ordered.

?Frequent oral hygiene.

?Administer narcotic analgesics as ordered.

?Monitor for complications which may include toxic shock syndrome,

otitis media, sinusitis.

?Endoscopic Surgery

?Cauterizing bleeding vessels

?Ligation of internal maxillary artery.

8.2.2 Nasal Polyps

Nasal polyps are benign grapelike growths of mucous membrane, they

form in areas of dependent mucous membrane. They are usually bilateral
and the stem-like base makes them moveable. They may enlarge and
cause nasal obstruction.

Management of Nasal polyps; Nasal polyps can be managed by topical

corticosteroid nasal sprays and low-dose oral corticosteroids.. Nasal
packing can be done to control bleeding and the patient should be
advised to avoid blowing the nose 24-48 hours post removal of packing,
to avoid straining at stool, vigorous coughing and strenuous exercise.
The patient should be monitor for bleeding which may be characterised
by frequent swallowing or visible blood at back of the throat. Surgery
can also be done (Polypectomy) under local anesthesia, Laser surgery to
remove polyps may also be done, the patient may require multiple
surgeries as polyps tend to recur.

8.2.3 Deviated Nasal Septum

A deviated septum may result from trauma or maybe present from birth
and causes nasal obstruction

Management; Relief of airway obstruction, repair of visible deformities

i.e reshaping the nose by manipulation of septal cartilage by; moving,
rearranging and augmenting.

Surgery is also indicated i.e septoplasty or submucous resection,

rhinoplasty or surgical reconstruction of the nose.

Post operatively bilateral Nasal packing is indicated for 72 hours, a

temporary plastic splint for 3-5 days.

Reassure the patient that swelling subsides within 10-14 days and
normal sensation will return within several months.

8.2.4Rhinitis

Rhinitis is an inflammation of the mucous membranes of the nose. It has

different classifications i.e based on duration:-Acute or chronic, based
on cause:- Allergic rhinitis /hay fever /:due to allergy,non-allergic
rhinitis and following upper respiratory tract infections (Bacteria and
Viral).

Acute Rhinitis/Coryza /common cold ;Acute rhinitis affects almost

everyone at some time and most often in cold seasons e.g winter.

Causes of Acute Rhinitis; The most common causes are mainly viruses,
i.e Rhinovirus, Corona virus, Adenoviruses, Influenza virus,
Parainfluenza virus, Echovirus, Coxsakiervirus, Respiratory syncytial
virus (RSV), Each virus may have multiple strains. For example, there
are over 100 strains of rhinovirus, which accounts for 50% of all colds.

Acute rhinitis is highly contagious because the virus is shed for about 2
days before the symptoms appear and after 3 days of the symptom. It is
normally spread by; droplet nuclei from sneezing and contaminated hand
or fomites. Secondary invasion by bacteria may cause pneumonia acute
bronchitis, sinusitis and otitis media.

Clinical manifestation of Acute rhinitis; Sneezing, nasal discharge

(runny nose, nasal obstruction, head ache, nasal congestion, chilliness,
nasal itchiness, fever, nervousness, sore throat ans general malaise.

Medical management of Acute Rhinitis ; Acute Rhinitis is usually self -

limiting and lasts for about 1 week.The goal of management is mainly to
relieve symptoms, inhibit spread of the infection and reduce risk of
bacterial complication.

?Ensure adequate fluid intake, encourage rest, prevent chilling, increase

intake of vitamin C.Expectorants may be used as needed to, warm salt-
water gargles to soothe the throat.

?Nonsteroidal anti-inflammatory agents such as aspirin or ibuprofen to

relieve pain (headache)

?Antihistamines e.g chlorpheniramine maleate , diphenhydramine

(Benadryl) Topical(nasal)decongestant e.g. oxymetazoline maleate
phenylephrine (Neo-synephrine), pseudoephedrine orally.

?Zinc lozenges may reduce the duration of cold symptoms if taken

within the first 24 hours of onset.
?Amantadine (Symmetrel) or rimantadine (Flumadine) may be
prescribed prophylactically.

?Antimicrobial agents (antibiotics) should not be used because they do

not affect the virus or reduce the incidence of bacterial complications.

Nursing Management of Acute Rhinitis; Health education to the patient

to:-Perform hand hygiene often, use disposable tissues, avoid crowds
during the flu season, avoid individuals with colds or respiratory
infections, obtain influenza vaccination, if recommended especially if
elderly or diagnosed with a chronic illness.

8.2.5 Chronic Rhinitis

Chronic rhinitis is a chronic inflammation of the nasal mucosal

membrane characterized by increased nasal mucus. It is caused by
repeated acute infection or allergy or by vasomotor rhinitis instability of
the autonomic nervous system caused by stress, tension, or some
endocrine disorder)

i.Clinical manifestation chronic rhinitis There is usually no acute

symptom, Patients present with nasal obstruction (stuffiness), pressure in
the nose, polyp formation and vertigo.

ii. Management and Nursing interventions; The patient with chronic

rhinitis due to allergy (allergic rhinitis) is instructed to avoid
allergens and irritants i.e dust fumes, odor, powder sprays. The
patient should also ensure compliance to medications including
nasal sprays and nose drops obtain additional rest, drink enough
fluids
8.2.6 Sinusitis

The location of the sinuses.

Sinusitis is an inflammation of the mucous membranes in the sinuses.

Sinusitis can be: - Acute bacterial, Sub acute or Chronic.

i. Acute Sinusitis ; The most common types of acute sinusitis are:

Allergic (usually seasonal) , Viral, Acutebacterial (Streptococcus
pneumonia,haemophilus influenza, beta hemolytic streptococcus,
klebsiella pneumonia and various anaerobic organisms).

ii. Clinical manifestations of acute sinusitis There is slowly

developing pressure over the involved sinus, general malaise, fever,
malaise , systemic symptoms i.e., achiness, stuffy nose, persistent cough,
postnasal drip, head ache, redness and itching of the eyes ans signs of
tooth infection.

iii. In acute frontal and maxillary sinusitis; Pain usually does not
appear until 1 to 2 hours after waking up.It increases for 3 to 4 hours and
then becomes less severe in the afternoon and evening. Usually this is
due to increased drainage as a result of gravity from standing during the
day.Bloody or blood tinged discharge from the nosein the first 24 to 48
hours. The discharge rapidly becomes thick, green, and copious,
blocking the nose.

iv. Diagnosis ;A history and physical examination will be done which

will show tenderness in the involved sinus, hyperemic and edematous
nasal mucosa, the turbinate's are enlarged. An X-ray examination will
show a clouded sinus and fluid level is visible.

v. Management; The aim of management is to relief pain and

shrinkage of the nasal mucosa.Analgesics e.g ibuprofen, oral
decongestans e.g pseudoephedrine, Antibiotics e.g Amoxicillin for 10-
14 days.Failure of the infection to respond to Amoxicillin is an
indication indication for aspiration of the maxillary sinus to take
specimen for culture and sensitivity and to remove the accumulated
secretions vi. Acute frontal sinusitis with pain, tenderness, and edema of
the frontal or sphenoid sinus require hospitalization because of the risk
of intracranial complications or osteomyelitus. High doses of parenteral
antibiotics, nasal decongestants or by pspray are administered.

8.2.7 Chronic Bacterial Sinusitis

Chronic bacterial sinusitis develops when irreversible mucosa damage

occurs Damage can result from recurrent attacks of acute sinusitis or
from suppurative sinusitis either being untreated or inadequately treated
during the acute or sub acute phase.

Etiology: Micro-organisms that cause chronic bacterial sinusitis are

mainly Staphylococcus aureus, H. influenza and anaerobes e.g
Klebsiella
Clinical manifestation of Chronic Bacterial Sinusitis; Patients will
present with Nasal congestion, thick green purulent discharge present for
at least 3months, fever, facial pain, light headedness but no headache.

Diagnosis is mainly by culture and sensitivity

Management of Chronic Bacterial Sinusitis; Medical and nursing

management includes:-

?Decongestants

?Antibiotics according to results of the culture.

?Nasal saline irrigation and surgery are the major treatments.

?Patient benefits from things that increase the drainage.

?Increasing the humidity (steam bath hot shower, facial sauna.

?Increasing fluid intake and applying local heat (hot wet packs).

You have successfully completed learning about conditions of the nose.

You can now be able to participate in the management of patients with

disorders of the nose when you go for your clinical placement.

Management of Patients With Disorders of the Throat

Anatomic and Physiologic review of throat

 Pharyngitis

It is an inflammation of the throat.

Acute pharyngitis ;Acute pharyngitis is a febrile inflammation of the

throat that is 70% viral and 30% bacterial (hemolytic
streptococci,staphylococci).It is the most common throat
inflammation.A severe form of acute pharyngitis(strep throat) because
of the frequency of streptococci as the causative organism.

Clinical manifestation of Acute pharyngitis; Patients will present with

dryness of the throat, fiery read throat and pharyngeal membrane and
tonsils, severe pain which can lead to difficulty in swallowing, enlarged
and tender cervical lymph nodes, fever, malaise, sore throat, hoarseness,
cough and rhinitis.

Complications of Acute pharyngitis; The most common complications

are:-Sinusitis, otitis media, peritonsilar abscess, mastoiditis, cervical
adenitis, rheumatic fever and rheumatic nephritis

Diagnosis is mainly through a throat culture. A nasal swab and blood

may also be taken for culture and sensitivity.
Medical management;Penicillin is the drug of choice, erythromycin can
also be given for 10 days for those patients who are hypersensitive to
penicillin.Patients are advised to take a liquid and soft diet, lozenges to
relieve local soreness.

Nursing interventions;The nurse should encourage the patient to have

bedrest during the febrile stage, ensure proper tissue disposal, also assess
for a skin rash because pharyngitis may precede some communicable
diseases. Warm saline gaggles or irrigations can also be used.
Analgesics can be administered as ordered and prophylactic antibiotic
therapy for patients with a histoer of rheumatic fever or infective
endocarditis to prevent re-infection.

Chronic Pharyngitis

It is a persistent inflammation of the pharynx. It is common in adults

who work or live in dusty surroundings, use their voice to excess, suffer
from chronic cough, and habitually use alcohol and tobacco.

Types of chronic pharyngitis; There are three types of chronic

pharyngitis: Hypertrophic:-general thickening and congestion of the
pharyngeal mucous membrane:- Atrophic: probably a late stage of the
first type where the membrane is thin, whitish, glistening, and at times
wrinkled, chronic granular ("clergyman's sore throat?): characterized by
numerous swollen lymph follicles on the pharyngeal wall.

Clinical Manifestations of chronic pharyngitis; The patients will present

with a constant sense of irritation or fullness in the throat, mucus that
collects in the throat and can be expelled by coughing, and difficulty
swallowing.

Medical Management of chronic pharyngitis; The goal of medical

management is to relieve symptoms, avoiding exposure to irritants, and
correcting any upper respiratory, pulmonary, or cardiac condition that
might be responsible for a chronic cough. Nasal sprays or medications
containing ephedrine sulfate or phenylephrine hydrochloride(Neo-
Synephrine) can be given. Antihistamine decongestant medications, are
taken orally every 4 to 6 hours. Anti-inflammatory and analgesic agents
like Aspirin or acetaminophen.

4 Nursing Management; Health education to the patient to:- Avoid

contact with others until the fever subsides, avoid alcohol, tobacco,
second-hand smoke, and exposure to cold. The patient should minimize
exposure to pollutants by wearing a disposable facemask, drink plenty
of fluids, Gargle with warm saline solutions and take lozenges to keep
the throat moistened

Tonsillitis and Adenoiditis

Tonsillitis is inflammation and enlargement of the tonsil tissue.Tonsil

tissue

is situated on each side of the oropharynx.

It is caused by group A streptococcus as the most common organism.

Adenoiditis on the other hand is inflammation of the adenoid tissue The

adenoid consist of an abnormally large lymphoid tissue mass near the
center of the posterior wall of the nasopharynx. Infection of the adenoids
frequently accompanies acute tonsillitis.

Clinical manifestations of tonsilitis and adenoiditis; Patients with

tonsillitis will present with a sore throat, fever, chills, general muscle
ache, snoring and difficulty in swallowing. Patients with adenoiditis will
present with mouth breathing, earache, draining ear and Yellowish
exudates.
Diagnosis: A Diagnosis can be made through history and physical
assessment. A tonsil swab for culture can also be done and an
audiometric examination to rule out hearing loss.

Management of tonsillitis and adenoiditis; The patient is treated with

antibiotics preferably benzantine penicillin. Tonsillectomy and
adenoidectomy are indicated if the patient has repeated bouts of
tonsillitis, respiratory obstruction, hypertrophy of the tonsils and
adenoids, recurrent otitis media and peritonsillar abcess. Ensure mouth
care for comfort, prophylactic penicillin should be given and education
to the patient to complete therapy.

8.3.4 Laryngitis

Laryngitis is an inflammation of the larynx.

It is commonly associated with voice abuse, exposure to dust, chemicals,

smoke and other pollutants.

It almost always results from a bacterial invasion i.e acute rhinitis or

nasoparyngitis. The onset of the infection is also associated with sudden
temperature changes, deficiencies in diet and lack of immunity.
Laryngitis is common tn winter and it is easily transmitted.

Chronic laryngitis will present wilth persistant hoarseness or complete

loss of voice(aphonia).Severe cases may be as a result of chronic
sinusitis and chronic bronchitis.

Management; For acute laryngitis management entails health education

to the patient to rest the voice, avoid smoking, resting in bed and
inhaling cool steam or an aerosol. For chronic laryngitis Resting the
voice, effectively treating any primary respiratory tract infection and
restricting smoking.
Nursing interventions; Nursing interventions include:-instructing the
patient to rest their voices, maintaining a well humidified environment
and increasing their fluid intake.