Capitol University

Corrales Extension, Cagayan de oro city

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

Submitted by: Huemer O. Uy

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

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

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

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

Surgical Skin Preparation

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

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

Layers of the Abdominal Wall

The layers of the abdominal wall vary, depending on where it is you are looking. For instance, it is somewhat different along the lateral sides of the abdomen than it is at the anterior side. It is also somewhat different at its lower regions. Lets start out along the lateral side of the abdomen:

skin superficial fascia deep fascia muscle subserous fascia peritoneum

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

mesenteries, omenta, falciform ligaments, lienorenal ligament, etc.)

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

Incision Types

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

Types of Sutures

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