Scrubbing, Gowning and arranging instruments

1. Define the following terms: 1.1 Pre-operative Nursing 1.1.1 Pre-operative Phase 1.1.2 Intra-operative Phase 1.1.3 Post-operative Phase 1.2 Analgesia 1.3 Anesthesia 1.4 Antiseptic 1.5 Asepsis 1.6 Consent 1.7 Disinfection 1.8 Homeostasis 1.9 Medical Asepsis 1.10 Resident Bacteria 1.11 Sterile 1.12 Sterilization 1.14 Surgery 1.15 Surgical Asepsis 1.16 Surgical Conscience 1.17 Surgically clean 1.18 Transient bacteria 2. Discuss the operating room as to its:

2.1 Personnel 2.1.1 Sterile 2.1.2 Unsterile 2.2 Physical lay-out 2.3 Attire 2.3.1 Components 2.3.2 Steps in donning operating room attire 2.3.3 Importance of wearing attire 2.4 Set-up (Equipment and apparatus) 3. Recognize the importance of the following: 3.1 Scientific Principles involved 3.2 Basic rules of surgical asepsis 3.3 Duties and responsibilities of scrub and circulating nurse 4. Familiarize the following: 4.1 Basic instruments fundamental in basic set 4.1.1 Clamping and occluding 4.1.2 Cutting and dissecting 4.1.3 Grasping and holding 4.1.4 Exposing and retracting 4.1.5 Suturing and stapling 4.1.6 Viewing 4.1.7 Suctioning and aspirating 4.1.8 Dilating and probing 4.1.9 Measuring 4.2 Major pack and minor pack

4.3 Sites for skin preparation 4.4 Operative position 5. Discuss the following: 5.1 Classification of survey according to 5.1.1 Major/ Minor 5.1.2 Purpose 5.1.3 Category of surgery based on urgency 5.2 Common surgical complications 5.3 Different layers of the abdomen 5.4 Common abdominal incisions 5.5 Different types of: 5.5.1 Suture 5.5.2 Suture needle 5.5.3 Blades 5.6 Sterilization Procedure 5.6.1 Types 5.6.2 Advantages and disadvantages 5.7 Operative checklist needed during surgery 5.7.1 Pre-operative checklist 5.7.2 Consent forms 5.7.3 WHO operative checklist 5.7.4 Other checklist for specific operations 6. Show beginning skills in: 6.1 Filling up the consent form: pre-operative checklist 6.2 Opening the sterile pack

6.3 Packing and sterilization 6.4 Perform the following operating room technique 6.4.1 Medical handwashing 6.4.2 Surgical handwashing 6.4.3 Draping 6.4.4 Serving instruments 6.4.5 Assisting in the operation 6.4.6 Circulating

Definition of terms:

Pre-operative Phase

- begins with the patients decision to have surgery and ends with the transfer of the patient to the operating table.

Intra-operative Phase

- begins with the transference of the patient to the procedure room, and ends with the admission of the patient to the designated post anesthesia area.

Post-operative Phase

- begins with the clients admittance to the postanesthesia care unit and ends with the clients complete recovery from the surgical intervention.

Analgesia

- the sensation of pain and the associated psychic reactions are abolished or reduce without impairment of consciousness; the perception of pain is altered. - reduction or absence of response to pain stimuli.

Anesthesia

- a state of narcosis, analgesia, relaxation and reflex loss. - loss of feeling or sensation.

Antiseptic

- chemical agents that fights sepsis by inhibiting growth of microorganisms without necessarily killing them; used only on living tissue.

Asepsis

- absence of pathogenic microorganism.

Consent

- a form signed by the client and witnessed by another person, granting permission to have the procedure described by the clients physician.

Disinfection

- the chemical or physical process of destroying all pathogenic microorganisms except spore-bearing ones.

Homeostasis

- come from Greek word nomoios meaning like and stasis means standing. - state of balance between the supply and demand of essential substances within the body.

Medical Asepsis

- clean technique - concerned with limiting the spread of microorganisms

Resident bacteria Normally picked out by hands in the usual ADL Bacteria living in a specific area of the body. Sterile

- free from microorganisms

Sterilization

- process by which all pathogenic and non-pathogenic microorganisms including spores are killed.

Surgery

- is the term traditionally used for treatment that involve cutting or stitching tissues.

Surgical Asepsis

- sterile technique - refers to keeping microorganisms from specific area.

Surgical conscience

- foundation upon which the skills and techniques employed by the OR nurse are built.

Surgical team

- a group of highly trained individuals who must work together as a coordinated team for the welfare and safety of patient.

Surgically clean

- mechanically or physically cleaned, but unsterile. - items are considered surgically clean by the use of chemical, physical or mechanical means that reduce the number of microorganisms.

Transient bacteria Bacteria temporarily living in a specific area of the body Normally picked out by the hands in the usual activities of the daily living

OPERATING ROOM AS TO ITS:

Personnel
Divided to the function to its Members

o Sterile team
- keep within the sterile team - the part of a surgical gown considered sterile are the sleeves ( expect for the axillary area) and the front the table to a few inches below the neck opening -A sterile team field to have perspiration mopped from his elbow

a) Operating surgeon
- the surgeon must have the knowledge, skills, and the judgement required to successfully perform the intended operation and any to have devotions in procedure necessitated by unforeseen difficulties.

b) Surgical assistant
- under the operating surgeon direction, one or two assistant hold

retractors in the wound to expose the operative site, place clamps on blood vessels in suturing during the operation. * First assistant to the surgeon
The first assistant should be capable of assuming the responsibility of the operating surgeon in case of emergency.

*second assistant surgeon

Qualified nurses and technicians may be utilized as the second or third assistants during operation requiring a physician foe assistant during operation requiring a physician first assistant during operation in which the surgeon deems this assistance is adequate and for which they have been trained

c) Scrub nurse
- is used to designated the nursing remember of the sterile team who actually may or may not be a nurse, the role of the scrub nurse may be filled by a registered nurse, a particular nurse or an Operating room technique.

-keep the way from al the sterile ares - should allow a wide margin of safety when passing the sterile glass areas . should not go with the sterile circle,

o Unsterile Team

a)Anesthesiologist or ansesthetist
-An Anesthesiologist is a person , not necessarily a physician , who administered ansthetics .

b)Circulating nurse plays a role that is vital to the smooth flow of events before, during and after operation .

c)Head nurse - functions in a middle management position as liaison between staff members and administrative personnel

Physical layout
- should be designed and equipped with the patient safety at the forefront 1.) Floors -Should be a piece of linoleum without seems although all the little fibbers made mode of non- porous little are more expensive. 2) Ceiling ` -should be painted with washable that is amenable to cleansing 3) Plumbing - do not need any fancy scrub sink 4) Emergency power - is an important consideration. Enough back up power is necessary for our normally planed replenish 5) Storage space

` -cabinetry is a novel way to store most, if not all if not all the clean items and variety of other clean items and variety of other equipments and supplies.

General 2 2

General 4 4

OB 6 6 Restricted Area

Ophthalmi Laparoscopi c c

8 8

9 9 Semi-

PACU

Restricted
Ophthalmi c

Neurolog y 1 1

Urology 3 3

General 5 5

7 7

Supply Room

R E

Doctors Lounge
Male Doctors Dressing Room Male Staff Dressing Room Female Doctors & Nurses Room

Autoclave

N O

S T R A R E A

Work Room Outpatient Dressing Room

N I C T E D

Dining Room Central Supply

Station
Outpatient Waiting Area

 Attire
- consists of body such as scrub dress, jump suit, pant, or shirt, trouser, head covers, mask, shoe cover and sterile gowns

Components

1)Body cover -variety of suites, fits smugly

2)Head cap -a cap or hood is put on the scrub suit for protection, all facial and head hair must be covered in a restricted area . 3)Mask -covering of the face to prevent any substance to get the face especially the mouth 4)Shoe cover -disposable or canvas cover also must be worn at all time in the restricted area. 5)Shoe - must be comfortable and supportive

Personal protective Equipment

1) Apron -Protects against and agents, radiation when personnel are exposed to radioactive implaints

2) Eyewear

-Worn where a risk of exist blood or blood substance from the patient splashing into the Eyes of sterile team members

3) Gloves -Non sterile latex or gloves are worn to handle any team contaminated by blood substance

o Steps in donning operating room attire

Clean fresh attire is donned each time on arrival at the OR suite and as necessary at the other times, if it is wet or grossly soiled.

NOTE. Showers should be available to personnel in case of gross contamination during a procedure.

Masks and head covers should be changed between patients. As extra precautions , known carrier who participate as sterile team members should.

1. Routinely bathe and scrub with an appropriate skin antiseptic agent; shampoo hair daily 2. Change clothing frequently 3. Wear two masks; use anti microbial nasal ointment. 4. Use two scrub agents successively, double gown and double glove 5. Use no touch technique ; avoid touching any part of an instrument in direct contact with tissue 6. Wash hands frequently

Special attire is worn with laminar airflow system in high risk operation. Attire varies from hospital to hospital but may consist of a presterilized jumpsuit as basic attire, covered by sterile gown and gloves. A vacuum helmet is worn.

o Importance of wearing attire

1) To provide effective barriers that prevent the dissemination of microorganism to the patient 2) Protect personnel from blood and body substance of patients.

SET-UP( equipment & apparatus)

* Operating room table -operating room tables are available that can be flexed, turned from side to side, lowered or raised and placed in the trendelenburg and reverse trendelenburg positions. * Mayo stand - the scrub nurse usually places sterile instruments supplies on the mayo stand once it has been draped in a sterile fashion. * Ring stand -the ring stand is used by the scrub team for rinsing their gloves after it is draped an a sterile fashion. * spotlight s -Spotlights are designed to provide an intense light a relatively small area. They must be easy to clean and should be movable most directions * Back table -there are various sizes and designs of these tables which are used by the scrub nurse for sterile supplies needed during surgery, such as drapes, extra instrument ,and suture. * Kickbuckets -there are usually two kickbuckets in the operating room one is located in each side of the operating table ,and they used by the scrub team for discarding soiled sponges. * Lifts or stand

-Lifts or stand vary in length and height depending upon their use. They are used by nay member of the scrub team who requires more height in order to be functioning member of the team. * Suction -Each operating room must have at least two suctions one for the anesthesiologist at the patients head and other for the scrub team, which is used at the operative site. *X-ray viewer -each operating room should have at least one viewer and preferably two.

Scientific Principles
1. Anatomy and Physiology To know where the incision should be done and their function of the anesthesia to the nervous system and where to drape the patient.

2. Microbiology Sterility must always be maintained in the operating room. Sterile to sterile; unsterile to unsterile

3. Chemistry
-

Using of betadine solution in surgical handwashing.

4. Physics
-

Applying friction during medical and surgical handwashing.

5. Time and Energy Prepare all the necessary materials and avoid contaminating sterile materials.

6. Sociology - Interacting between the members of the OR team. 7. Body Mechanics - Maintain proper posture in carrying the materials, doing the surgical and medical handwashing and assisting the scrub nurse or the surgeon.

Basic rules of Surgical Asepsis

General - Sterile surfaces/ articles may touch other sterile surfaces/ articles and remain sterile; unsterile contact at any point renders a sterile area contaminated. - If there is any doubt about the sterility of an article/ area, it is considered unsterile. - Whatever is sterile for one patient (an opened sterile tray/ tables with sterile supplies) can be used for this patient only. Unused sterile supplies must be discarded/ resterilized if they are to be used again. Personnel - Scrubbed personnel remain in the area of the operation; if a scrubbed person leaves the room, that persons sterile status is lost. To return to the operation, this person is required to go through the procedure of scrubbing, gowning and gloving. - Only a small part of a scrubbed persons body is considered sterile: from front waist to the shoulder area; forearms and gloves. - Therefore the gloved hands must be kept in front and above the waistline. - In some clinics, a special wraparound gown is worn which extends the sterile area. - The circulator and any unscrubbed personnel remain on the periphery of the surgical operating area at a safe distance in order not to contaminate any sterile area.

 Draping - During draping of a table or patient, the sterile drape is held well above the surface to be covered and is placed from front to back. - Only the top of the patient or table which is draped is considered sterile; drapes hanging over the edge are not regarded as sterile. - Sterile drapes are not to be kept in position by the use of clips or adherent material; drapes are not to be moved during the operation. A tear or puncture of the drape permitting access to an unsterile surface underneath renders the area unsterile. Delivery of Sterile Supplies - Packages are wrapped or sealed in such a way that they can be opened easily without risk of contaminating contents. - Sterile supplies, including solutions, are delivered to a sterile field or handed to a scrubbed person in such a way that sterility of the object or fluid remains intact. - Edges of wrappers covering sterile supplies or outer lips of bottles or flasks containing sterile solutions are not considered sterile. - The unsterile arm of the circulator must not extend over a sterile area. Sterile articles are to be dropped at a reasonable distance from the edge of the sterile area. Fluids - Sterile fluids are poured from a point high enough to prevent accidental touching of the sterile receiving cup or basin, but not so high as to produce splashing (this may cause fluid to touch an unsterile surface and then flow back into the receptacle, causing contamination).

Duties of Circulating Nurse

1. 2. 3. 4. 5. 6. Reviews anatomy, physiology and surgical procedures. Assists with preparing room. Practices aseptic technique. Monitors activities of others. Ensures that needed items are available and sterile (if required). Checks mechanical and electrical equipment and environment factors. 7. Arranges furniture in workable order. 8. Identifies and assesses client.

9. Checks chart and relates pertinent data. 10. Admits client to operating room suite. 11. Assists with transferring client to operating room bed. 12. Protects client during induction with anesthesia. 13. Positions client. 14. Helps with insertion or application of monitoring devices. 15. Prepares clients skin for surgical incision. 16. Monitors draping procedure and all activities requiring asepsis 17. Provides well-functioning suction. 18. Completes intra-operative record. 19. Records, labels and sends to proper locations tissue specimens and cultures. 20. Evaluates blood and fluid loss. 21. Coordinates all activities in operating room between team members and other hospital departments. 22. Counts sponges, needles and instruments. 23. Accompanies the client to postanesthesia recovery area. 24. Reports pertinent information to recovery area nurses.

Duties of Scrub Nurse

1. 2. 3. 4. 5. 6. 7. 8. 9. Reviews anatomy, physiology and surgical procedures. Assist with preparation of room. Scrubs, gowns and gloves self and other members of surgical team. Prepares instrument table and organizes sterile equipment. Assists with draping procedure. Passes instruments to surgeon and assistants. Counts sponges, needles and instruments. Monitors practices of aseptic technique. Keeps track of irrigation solution used for more accurate calculation of blood loss. 10. Reports amount of local anesthetics and epinephrine solutions to anesthetist.

Responsibilities of Circulating Nurse

1. Always a registered nurse. 2. Responsible and accountable for all activities during a surgical procedure. 3. Manages personnel, equipment, supplies, the environment and communication throughout the operation. 4. Arranges furniture and equipment in room.

5. 6. 7. 8. 9.

Opens sterile supplies. Tie gowns of sterile team members. Attends to needs and supplies of sterile team members. Identifies and assesses client. Brings client to operating room and transfer to operating room table. 10. Applies and assists in insertion of monitoring devices. 11. Assists anesthesiologist with induction of anesthesia. 12. Positions client for surgery. 13. Performs designated surgical skin preparation. 14. Assists with sterile draping and set up of sterile field around operative site. 15. Monitors sterile technique of surgical team. 16. Collects labels and distributes specimens. 17. Completes intraoperative record. 18. Monitors blood and fluid loss. 19. Counts sponges, instruments and sharps with scrub nurse report results to surgeon. 20. Communicates with surgical team members and others such as client family, pathologist. 21. Applies dressing 22. Assists in transferring client to cart may assist in transporting to postanesthesia care unit. 23. Aids in cleaning room after procedure.

Responsibilities of Scrub Nurse

1. May be a Registered Nurse, Licensed Vocational Nurse or Surgical Technologist who is qualified by training or experience. 2. More than 1 scrub nurse may be needed for complicated operations. 3. Provides services under the direction of the circulation nurse 4. Opens sterile supplies. 5. Scrubs, dons sterile gown and gloves. 6. Assist in gowning and gloving other sterile team members. 7. Prepares instrument tables. 8. Maintains integrity, safety and efficiency of sterile field. 9. Assists with sterile draping of clients operative site. 10. Passes instruments, sutures etc. to the surgeon. 11. Assists with instruments sponge, and sharp counts. 12. Aids in cleaning room after procedure.

Basic Instruments in Basic Set

CLAMPING AND OCCLUDING

A hemostat is used to clamp blood vessels or tag sutures. Its jaws may be straight or curved. Other names: crile, snap or stat.

Hemostat

A mosquito is used to clamp small blood vessels. Its jaws may be straight or curved.

hemostat, mosquito
(left to right)

A Kelly is used to clamp larger vessels and tissue. Available in short and long sizes. Other names: Rochester Pean.

Kelly, hemostat, mosquito

(left to right)

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

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

Crile hemostatic clamp- also called as snap,hemostat,used for clamping tissue or vessels. Miscellaneous:most commonly used,maybe straight or curved.

Towel clip= used for grasping, securing towels or drapes or reducing small bone fractured.

Cutting and Dissecting

Thomas currette- also known as dull currette, this is used for scraping and endocervical and endometrial linings. Miscellaneous:blunt blades

Sims curette- also known as sharp curette, this is used for endocervical and endometrial linings. Miscellaneous: sharp blades

Straight mayo also known as suture scissors, this is used for cutting
sutures,dressing,drains. Miscellaneous :heavy blades

Curved Mayo Scissors- also known as dissecting scissors, this is used for cutting heavy tissue or muscles Miscellaneous :heavy blades

Metzenbaum scissors- also known as Metz, this is used for cutting delicate tissue. Miscellaneous :delicate blades, do not use for suture

Operating scissors- used for cutting delicate tissue or even dressing

Miscellaneous :delicate a heavy blades can have 1 sharp or 2 sharp

Lister scissors-known as bandage scissors, this is used for cutting dressings and bandages Miscellaneous: guarded blades

Iris scissors- used for cutting delicate tissue

Miscellaneous: blade can be curved or straight

Wire cutting scissors (angled blades)- known as wire cutter, used for
cutting wire sutures,wire or wire mesh. Miscellaneous: has 1 serrated blade to avoid slipping

Utility scissors- also known as trauma scissors, trauma shears, used for cutting heavy things like clothing. Miscellaneous: serrated blades

Scalpel handles- also known as knife handle, used holding scalpel blade Miscellaneous: used with no. 11,12 and 15 blade

GRASPING OR HOLDING INSTRUMENTS

Graspers or holding instruments are used most commonly to grasp and hold tissues as in retraction or for suturing.

Thumb forceps Plain (small serrations; little trauma to tissue)- commonly use for Abdominal or general surgery (delicate tissues, G.I tissue).(it depends to the surgeon)

Single-tooth (two sharp teeth on one side general surgery (tougher tissues, muscle) And one on the other Multiple (many small teeth on both sides) general surgery (delicate tissues, peritoneum)

Abdominal or

Abdominal or

Russian (multiple serrations around edges on point)

Allis tissue forceps

An Allis is used to grasp tissue.Available in short and long sizes.A "JuddAllis" holds intestinal tissue; a "heavy allis" holds breast tissue.

Babcock tissue forceps

A Babcock is used to grasp delicate tissue (intestine, fallopian tube, ovary). Available in short and long sizes.

babcock

Pennington tissue forceps- commonly use for Perineal surgery

#7, #3, #4 (left to right)

#7 handle with 15 blade (deep knife) - Used to cut deep, delicate tissue.

#3 handle with 10 blade (inside knife) - Used to cut superficial tissue. #4 handle with 20 blade (skin knife) - Used to cut skin.

Blades
#10 blades usually for skin incisieon #11 blades for small punctures #12 blades curved with cutting surface on the inside #15 used for cutting small vessels and tissue

Blade knife handle- beaver blade handle, used for holding knife handle Miscellaneous: use with series 50,60,70

Gigli saw- also known as wire saw, or bone saw, used for sawing bones Miscellaneous: use with both types o handles

RETRACTING AND EXPOSING

Retracting and exposing instruments are used to hold back or retract organs or tissue to gain exposure to the operative site. They are either "self-retaining" (stay open on their own) or "manual" (held by hand). When identifying retractors, look at the blade, not the handle.

Volkman retractor-also known as rake, use for exposing superficial wounds Miscellaneous: hand held can be sharp or blunt. Weitlaner retractor-use in exposing superficial wound Miscellaneous: self retaining, prongs can be sharp or dull A Richardson retractor (manual) is used to retract deep abdominal or chest incisions A Deaver retractor (manual) is used to retract deep abdominal or chest incisions.Available in various widths. An Army-Navy Rectractor(manual) is used to retract shallow or superficial incisiond. Other names USA or US Army A goulet(manual) is used to retract shallow or superficial incisions

Cerebellar retractor-also known as adson retractor,used for exposing wound Beckman retractor- used in retracting soft tissue. Gelpi retractor-use in exposing superficial wound

Retracting Instruments

U.S. Army-Navy

Volkmann (Rake)

Weitlaner

Deaver

Richardson

Ribbon

Weitlaner retractor

Cerebellar retractor

Beckman retractor

Gelpi retractor

Deaver retractor

army navy retractor

goulet

Suturing and stapling

Surgical staples are specialized staples used in surgery in place of sutures to close skin wounds, connect or remove parts of the bowels or lungs. A more recent development, from the 1990s, uses clips instead of staples for some applications; this does not require the staple to penetrate.

Suture needle

End to end circular stapler

Viewing

Anoscope with obturator- viewing the inside of the anus , retracting

Sigmoidoscope;proctoscope-viewing the inside of the canal and sigmoid colon

Suctioning ad Aspirating
Blood, body fluids, tissue, and irrigating solution may be removed by mechanical suction. Many of these items are available in disposable models. The style of the suction tip will depend on where it is to be used and the surgeons preference. Poole Abdominal Tip The Poole abdominal tip is a straight hollow tube with a perforated outer filter shield. It is used during abdominal laparotomy or within any cavity in which copious amounts of fluid or pus are encountered. The outer filter shield prevents the adjacent tissues from being pulled into the suction apparatus. Frazier Suction Tip The Frazier tip is a rightangle tube with a small diameter. It is used when little or no fluid except capillary bleeding and irrigating fluid is countered, such as in brain, spinal, plastic, or Orthopaedics procedures. The Frazier tip keeps the field dry without the need for sponging. Yankauer Tip The Yankauer tip is a hollow tube that has an angle for use in the mouth or throat, and surface suction.

Dilating and Probing

Bakes common bile duct dilators- use for common bile duct Miscellaneous: comes in diff size

Probe and groove director also known as larry probe and grooved director- it is used probing fistulas ,ducts

Major pack and minor pack

Major pack 1 lap sheet 6 gowns 6 hand towels 6 draping towels 2 mayo cover

Minor pack 6 gowns 6 hand towels 6 draping towels 2 plain sheet

Operative Positions
Supine Position -the supine or dorsal, position is the usual position for inductive for general anesthesia and for entering the major body cavity. -patient lies on his back with his arms in anatomical position and the legs slightly apart. The palm of hands should be facing the body to prevent undue muscle strains on the arms.

Modified Trendelenburg position -is generally used for lower abdominal surgery and some lower extremity surgery. -patient is positioned as in the supine position, and the entire operating table is slightly titled so that the patients head is lower than his feet by 1-5 degrees.

Modified reversed Trendelenburg position

-is generally used for upper abdominal surgery and for neck and face surgery. -this position permit improved operative exposure because gravity keeps the intestine mostly in the lower parts of the abdomen.

Lithotomy Is used in sugeries requiring a perineal approach. The patient is in a supine position during induction with the buttocks near the lower break in the operating table. After the anesthesiologist gives permission, two people lift the patients legs at the same time. The nurse must have good control of the patients leg.

CLASSIFICATION OF SURGERY ACCORDING TO:

MAJOR/MINOR: 1. MAJOR SURGERY These are surgeries of the head, neck, chest, and abdomen.

The recovery time can be lengthy and may involve a stay in intensive care or several days in the hospital. There is a higher risk of complication after such surgeries. Types: 1. 2. Removal of brain tumor Correction of bone malformations of the skull and face.

3. Repair of congenital heart disease, transplantation of organs, and repair of intestinal malformations. 4. Correction of spinal abnormalities and treatment of injuries sustained from major blunt trauma. 5. Correction of problems in fetal development of the lungs, intestines, diaphragm or anus. 2. MINOR SURGERY The recovery time is short and children return to their usual activities rapidly.

These surgeries are most of often done as an out of patient, and patients can return home the same day. Complications from these types of surgeries are rare. Types: 1. 2. 3. 4. Placement of ear tubes Hernia repairs Correction of bone fractures Removal of skin lesions

PURPOSE: 1. DIAGNOSTIC 2. Performed to obtain a biopsy for definitive diagnosis of a mass.

CURATIVE Performed to remove a diseased area. Example: Lumpectomy for breast cancer Appendectomy

3.

RESTORATIVE Performed to restore function. Example: Joint Replacement

4.

PALLIATIVE Performed primarily for comfort measures. Example: Joint debulking

URGENCY 1. EMERGENT PROCEDURES

Need to be performed immediately after identifying the need for surgery. Example: Surgery to stop bleeding from trauma Shooting Stabbing Dissecting aortic aneurism

2.

URGENT PROCEDURES Are scheduled after the determination of surgical need is made. Example: Tumor removal Removal of kidney stones

3.

ELECTIVE PROCEDURES Are scheduled in advance at a time that is convenient for both patient and surgeon. Postponement of the surgery for several weeks or even a month will not cause harm to the patient. Example: Cosmetic procedure

COMMON SURGICAL COMPLICATIONS

1. CARDIOVASCULAR COMPLICATIONS Due to physiological stress of surgery, side effects of the anesthesia or other medications. Myocardial infarction (MI), cardiac arrhythmias, or hypertension are likely during or in the immediate postoperative period. SIGNS AND SYMPTOMS: 1. Chest pain which may radiate to back, neck, jaw, or arm due to ischemia in MI.

2. Shortness of breath due to altered cardiac output and tissue perfusion 3. Dizziness or lightheadedness due to diminished cardiac output and cerebral tissue perfusion or cardiac arrhythmia. 4. Cardiac arrhythmias due to myocardial irritability possibly due to ischemia, medication side effect, electrolyte imbalance. 5. Low blood pressure due to diminished cardiac output.

2.

RESPIRATORY COMPLICATIONS Patients with preexisting respiratory disorders obesity or thoracic or upper abdominal surgical procedures are at greater risk of developing respiratory complications postoperatively. After surgery, patients are not mobile which leads to diminished chest wall and diaphragmatic movement, resulting in a decreased amount of air exchange Pain medications can adversely affect respiratory status by decreasing respiratory drive. SIGNS AND SYMPTOMS: 1. Shortness of breath due to diminished air flow and resultant decreased oxygenation. 2. Chest pain in the area of atelectasis due to collapse of the alveolar sacs within that area o the lung. 3. 4. Productive cough due to pneumonia. Fever due to infection in pneumonia.

5. Sudden onset of chest pain and shortness of breath in pulmonary embolism as clot blocks arterial flow within the lung. 6. Diminished oxygen levels as gas exchange is impaired in atectasis, pneumonia, or pulmonary embolism. 3. GASTROINTESTINAL COMPLICATIONS Following administration of anesthesia or pain medication, patients may experience nausea, vomiting, constipation, or paralytic ileus. Nausea is a common side effect of both anesthesia and pain medication.

Abdominal surgery may cause direct visceral afferent stimulation, resulting in nausea and vomiting. SIGNS AND SYMPTOMS:

1.

Nausea as a side effect of medication.

2. Vomiting due to visceral afferent stimulation or activation of chemoreceptor trigger zone. 3. Mild, generalized abdominal discomfort and distention with paralytic ileus due to decreased intestinal motility. 4. Slow bowel sounds with constipation; absent bowel sounds with paralytic ileus due to change in intestinal motility. 4. INFECTION Skin is the first line of defense against infection. During surgery, this line of defense is penetrated possibly become infected. Wound infection can develop in the postoperative period. Nosocomial infections can also occur at the surgical site. SIGNS AND SYMPTOMS: 1. Increase in pain at surgical wound due to inflammatory process early in infection. 2. Redness at wound edges that spreads if untreated.

3. Drainage from wound site due to bodys response to bacterial presence ( change in color and odor of drainage) 4. 5. Fever due to infection. Elevated white blood cell count.

LAYERS OF THE ABDOMEN

Skin - the outer protective covering of the body consisting of the dermis and the epidermis. Subcutaneous A continuous layer of connective tissue over the entire body between the skin and the deep fascial investment of the muscles. It comprises an outer normally fatty layer and an inner thin elastic layer.

Fascia the fibrous connective tissue membrane of the body that may be separated from other specially organized structures, such as the tendons, the aponeuroses, and the ligaments, and that covers, supports and separates muscles.

Muscle A kind of tissue composed of fibers or cells that are able to contract, causing movement of body parts and organs.

Peritoneum -the serous membrane lining the walls of the abdominal and pelvic cavities (parietal ) and investing the contained viscera (visceral), the two layers enclosing a potential space, the peritoneal cavity.

COMMON ABDOMINAL INCISIONS

Midabdominal Transverse Incision starts on either the right or left side and slightly above or below the umbilicus. It may be carried laterally to the lumbar region between the ribs and crest of the ilium. The intercostal nerves are protected by cutting the posterior rectus sheath and peritoneum in the direction of the divided muscle fibers. The advantages are rapid incision, easy extension, a provision for retroperitoneal approach, and a secure postoperative wound. Examples of use: choledochojejunostomy and transverse colostomy. Pfannenstiel Incision a curved transverse incision across the lower abdomen and within the hairline of the pubis. The rectus fascia is severed transversely and the muscles are separated. The peritoneum is incised vertically in the midline. This lower transverse incision provides good exposure and strong closure for pelvic procedures. Examples of use: abdominal hysterectomy (TAH & TAHBSO).

Subcostal Upper Quadrant Oblique Incision a right oblique incision begins in the epigastrium and extends laterally and obliquely just below the lower costal margin. It continues through the rectus muscle, which is either retracted r transversely divided. Although this type of incision affords limited exposure except for upper abdominal viscera, it provides good cosmetic results because it follows skin lines and produces limited nerve damage. Although painful, it is a strong incision postoperatively. Examples of use: splenectomy

Inguinal Incision (Lower Oblique) extends form the pubic tubercle to the anterior crest of the ilium, slightly above and parallel to the inguinal crease. Incision of the external oblique fascia provides access to the cremaster muscle, inguinal canal, and cord structures. Examples of use: inguinal herniorrhaphy

Longitudinal Midline Incision can be upper abdominal, lower abdominal, or a combination of both going around the umbilicus. Depending on the length of the incision, it begins in the epigastrium at the level of the xiphoid process and may extend vertically to the suprapubic region. After incision of the peritoneum, the falciform ligament of the liver is divided. An upper midline incision offers excellent exposure of and rapid entry into the upper abdominal contents.

McBurneys Incision McBurneys point is located in the right lower quadrant, just below the umbilicus and 4cm (2in) medial from the anterior superior iliac spine. A McBurney incision involves a muscle-splitting incision that extends through the fibers of the external oblique muscle. The incision is deepened, the internal oblique and transversalis muscles are split and retracted, and the peritoneum is entered. This is a fast, easy incision, but exposure is limited. Examples of use: appendectomy

Paramedian Incision a vertical incision made approximately 4cm (2in) lateral to the midline on either side in the upper or lower abdomen. After the skin and subcutaneous tissue are incised, the rectus sheath is split vertically and the muscle is retracted laterally. This incision allows quick entry into and excellent exposure of the abdominal cavity. It limits trauma, avoids nerve injury, is easily extended, and gives a firm closure.

Examples of use: sigmoid colon resection Thoracoabdominal Incision

the patient is placed in a lateral position. Either a right or a left incision begins at a point midway between the xiphoid process and umbilicus and extends across the abdomen to the seventh or eighth costal interspace and along the interspace into the thorax. The rectus, oblique, serratus, and intercostal muscles are divided.

B A C D E F I G H

A - Upper Longitudinal Midline Incision B - Right Upper Paramedian Incision C - Right Subcostal Upper Quadrant Oblique Incision D - Right Midabdominal Transverse Incision E - McBurneys Incision F - Right Inguinal, Lower Oblique Incision G - Lower Longitudinal Midline Incision H - Left Lower Paramedian Incision I - Pfannenstiel Incision J - Thoracoabdominal Incision

TYPES OF SUTURES:
I. Absorbable Suture Sutures that are broken down and dissolve by enzymes produced by the body. Example: Catgut II. Nonabsorbable Suture Not dissolved by enzymes. This suture remains encapsulated in tissue or is removed when used as a skin closure. Nonabsorbable sutures are made of metal, organic material or synthetics.

OTHER TYPES OF SUTURES: 1. Continuous Suture Single suture used to join two wound edges and tied at each end. 2. Interrupted Suture single sutures placed and tied separately. 3. Ligature or tie suture

suture material used to close off ends of severed blood vessels; may be single strands or continuous from a reel. 4. Stick tie or Suture Ligature - suture material on a needle used to ligate a blood vessel. 5. Retention Suture

heavy nonabsorbable suture used to reinforce a wound where unusual stress on the suture line is anticipated. 6. Swaged-on or Autraumatic Suture suture attached to an eyeless needle during the manufacturing.

SUTURE NEEDLES
Classification of needles:
1.Body a. Straight used generally on the skin b. circle mostly internal to skin c. 3/8 circle skin, plastic surgery

2.By the eye a. Eye present will require threading b. Lack of eye the needle and suture are one unit

Atralox double arm (two needles) Atraumatic or swaged on 3.By the point a. Cutting- spear or trocar b. Round tapered point

COMMON SUTURE NEEDLES AND USES Name Keith King Fistula Trocar Scalp Reverse cutting Ferguson Body Straight 3/8 circle circle(heavy) circle circle circle circle (medium siz circle e) Eye Both Both Eye Both Eye Both Both Point Spear Spear Spear Trocar Trocar Spear Round Common usage Skin Retention Back and thigh muscle Cervix Scalp Skin, plastic surgery Subcutaneous, fascia, peritoneum,

abdominal muscle Mayo Gastrointestinal Cardiovascular circle (heavy) circle (thin) circle (double arm 2 needles) Both Both Autromatic Round Round Round Uterine muscle Gastrointestinal surgery Cardiovascular

TYPES OF BLADES Straight Blades (#11) (pkg/10) (pkg/100)

Contour Blades (#10)

ABDOMINAL LAYER

Sterilization Practice
Types: A. Thermal (Physical)
Heat is dependable physical agent for the destruction of

all forms of microbial life, including spores. Most reliable and commonly used method of sterilization is steam under pressure a. Steam under pressure/Moist heat/Autoclaves Heat destroys microorganisms, and this process is hastened by the addition of moisture. Moist heat in the form of steam under pressure causes the denaturation and coagulation of protein or the enzyme-protein system within cells. Direct saturated steam contact is the basis of the steam sterilization process. Exposure time depends on the size and contents of the load and the temperature within the sterilizer.

 Microorganisms die at 130 to 150F (54 to 65C) Some bacterial spores can withstand at 240F (115C) for more than 3 hours. No living organism can survive direct exposure to saturated steam of 250F (121C). Types of Steam Sterilizers 1. Gravity Displacement Sterilizer - air is more than twice as heavy as steam - standard cycle: 250 to 254F (121 to 123C) - exposure time: 15 minutes 2. Prevacuum Sterilizer - air is almost completely evacuated from the chamber before the sterilizing steam is admitted - a period of 8 to 10 minutes effectively removes the air to minimize the steam penetration time - the Bowie-Dick test is performed daily to ensure that the air vacuum pump is functioning properly - temperature controlled at 270 to 276F (132 to 141C for 4 minutes) - complete cycle: 15 to 30 minutes 3. Flash/High-Speed Pressure Sterilizer - may be a gravity displacement or a prevacuum cycle - use only in unplanned, urgent, or emergency situations b. Hot air/Dry heat

 Dry heat in the form of hot air is used primarily to sterilize anhydrous oils, petroleum products, and talc which steam and ethylene oxide gas cannot penetrate. Slow burning process

Types of Dry Heat Sterilizers

1. Mechanical Convection Oven - blower forces hot air in motion around items in the load to hasten the heating of substances and to ensure a uniform temperature in all areas of the oven - Early models: 320 to 340 F (160 to 171C) for 1 to 2 hours Faster portable table-top models: 375 to 400F (190.5 to 204C) - total cycle: 6 minutes for unwrapped items : 12 minutes for wrapped ones 2. Gravity Convection Oven -used for dry heat sterilization - heat is provided by steam in the jacket only -temperature: 250F (121C) or 270F (132C) for at least 6 hours and preferably overnight B. Chemical a. Ethylene oxide gas Used to sterilize items that are sensitive to heat or moisture Chemical alkylating agent that kills microorganisms by interfering with the normal metabolism of protein and reproductive processes, resulting in cell death b. Formaldehyde gas and solution

 a 37% aqueous solution (formalin) or 8% formaldehyde in 70% isopropyl alcohol kills microorganisms by coagulating protein in cells effective at room temperature c. Hydrogen peroxide plasma/vapor Creates a reactive plasma Free radicals of the hydrogen peroxide interact with cell membranes, enzymes, or nucleic acids to disrupt the life functions of microorganisms d. Ozone gas Oxidation, a process that destroys organic and inorganic matter. It penetrates the membrane of cells, causing them to explode. Low temperature method of sterilization e. Acetic acid solution If mixed with salts (Bionox) kills microorganisms by a process of oxidation to denature proteins Takes 20 minutes at a room temperature of 77F (25C) f. Glutaraldehyde solution a 2.4%, 2.5% or 3.4% aqueous solution of activated, buffered alkaline Glutaraldehyde kills microorganisms by the denaturation of protein in cells reusable until it expires effective on room temperature of 77F (25C) g. Peracetic acid 0.2% solution Is an acetic acid plus an extra oxygen atom that reacts with most cellular components to cause cell death h. Hypochlorous acid (electrochemical conversion process) Kills many spores on well-cleaned endoscopes and other heat-sensitive items

 Steriolox liquid chemical HLD system is non-toxic and environmentally safe C. Radiation (Physical) a. Microwave (nonionizing) Produces hyperthermic conditions that disrupt life processes. Heating action affects water molecules and interferes with cell membranes Cycle is 30 seconds

b. Gamma Ray and Beta Particle Sterilization (ionizing) Produces ions by knocking electrons out of atoms Ionic energy that results becomes converted to thermal and chemical energy This energy kills microorganisms by disrupting the deoxyribonucleic acid molecule, thus preventing cellular division and the propagation of biological life. Advantages and Disadvantages A. Steam Sterilization Advantages: 1. Steam sterilization is the easiest, safest, and surest method of on-site sterilization. Heat-stable and moisture-stable items that can be steam-sterilized without damage should be processed with this method. 2. Steam is the fastest method; its total time cycle is the shortest. 3. Steam is the least expensive and most easily supplied agent. It is piped in from the facilitys boiler room. An automatic, electrically powered steam generator can be mounted beneath the sterilizer for emergency standby when steam pressure is low. 4. Most sterilizers have automatic controls and recording devices that eliminate the human factor from the

sterilization process as much as possible when operated and cared for according to the recommendations of the manufacturer. 5. Steam leaves no harmful residue. Many items such as stainless steel instruments withstand repeated processing without damage. Disadvantages: 1. Precautions must be used in preparing and packaging items, loading and operating the sterilizer, and drying the load. 2. Items need to be clean, free of grease and oil, and not sensitive to heat. 3. Steam must have direct contact with all areas of an item. It must be able to penetrate packaging material, but the material must be able to maintain sterility. 4. The timing of the cycle is adjusted for differences in materials and sizes of loads; these variables are subject to human error. 5. Steam may not be pure. Steam purity refers to the amount of solid, liquid or vapor contamination in steam. Impurities can cause wet or stained packs and stained instruments. B. Dry Heat Sterilization Advantages: 1. Hot air penetrates certain substances that cannot be sterilized by steam sterilization or another methods. 2. Dry heat is a protective method of sterilizing some delicate, sharp, or cutting-edge instruments. Steam may erode Disadvantages: 1. A long exposure period is required, because hot air penetrates slowly and possibly unevenly. 2. The time and temperature required will vary for different substances. 3. Overexposure may ruin some substances.

C. EO Gas Sterilization Advantages: 1. EO gas is an effective substitute agent to use with most items that cannot be sterilized by heat, such as plastics with low melting points. 2. EO gas provides an effective method of sterilization for items that steam and moisture may erode; it is noncorrosive and does not damage items. 3. EO gas completely permeates all porous material; it does not penetrate metal, glass, and petroleum-based lubricants. Whether or not it penetrates oils, liquids, or powder depends on the amount in the containers. Not recommended for oils, liquids and powder. 4. Automatic controls preclude human error by establishing proper levels of pressure, temperature, humidity, and gas concentration. 5. EO gas leaves no film on items. 6. EO gas sterilization is used extensively in the preparation of commercially available, packaged, presterilized items, because packaging materials that prolong storage of life. Disadvantages: 1. EO gas sterilization is a complicated process that is carefully monitored. 2. EO sterilization takes longer than steam sterilization; it is a long, slow process. 3. EO gas requires special, expensive equipment. 4. Items that absorbed gas during sterilization, as rubber, polyethyl or silicone, require. 5. Toxic by-products can be formed in the presence of moisture droplets during the exposure of some plastics, particularly polyvinyl chloride. 6. Repeated sterilization can increase the concentration of the total EO residues in porous items. These increased levels can be hazardous unless the gas can be dissipated.

7. EO is vesicant when in contact with skin and mucous membranes. 8. Inhaled EO gas can be irritating to mucous membranes. 9. Long-term exposure to EO is known to be a potential occupational carcinogen, causing leukemia. D. Hydrogen Peroxide Plasma Sterilization Advantages: 1. The process is dry and nontoxic. 2. The by-products of oxygen and water vapor are safely evacuated into the room atmosphere. 3. Aeration is not necessary. 4. A low temperature allows the safe sterilization of some heat-sensitive items. 5. Plasma has significantly less effect on metal than does steam sterilization; corrosion does not occur on moisturesensitive microsurgical and powered instruments. 6. The sterilizer is simple in design and connects to standard electrical oulets. Disadvantages: 1. Metal trays block radiofrequency waves. 2. Hydrogen peroxide is not compatible with cellulose. 3. Nylon becomes brittle after repated exposure to hydrogen peroxide sterilization. 4. This method is not approved in the USA for use with flexible endoscopes with lumens. E. Ozone Gas Sterilization Advantages: 1. The sterilizer generates its own agent using hospital oxygen, water and the electrical supply. It is simple and inexpensive to operate.

2. Ozone gas sterilization provides an alternative to EO gas sterilization of many heat- and moisture-sensitive items. 3. Ozone gas sterilization does not affect titanium, chromium, silicone, neoprene and Teflon. 4. Aeration is not necessary; ozone leaves no residue and converts to oxygen in a short time. 5. Low temperature instrumentation. Disadvantages: 1. Ozone can be corrosive. It will oxidize steel, iron, brass, copper, and aluminium. 2. It destroys natural rubber, such as latex, natural fibers, and some plastics F. Radiation Sterilization Advantage: 1. Ionizing radiation is the most effective sterilization method. Disadvantage: 1. Limited to industrial use Sterilization Process A. Product Associated Parameters a. Boiburden b. Bioresistance c. Bioshielding d. Density e. Biostate is safer for heat sensitive

B. Process Associated Parameters a. Temperature b. Tine

c. Purity of Agent

Anesthesia
1. General Anesthesia pain is controlled by general insensibility it acts by blocking awareness centers in the brain causing amnesia (loss of memory), analgesia (insensibility to pain), hypnosis (artificial sleep) and relaxation (rendering a part of the body less tense) administered through intravenous infusion 2. Regional Anesthesia is the temporary interruption of the transmission of nerve impulses to and from a specific area or region of the body pain is controlled without loss of consciousness These can be used for operations on the lower body such as Caesarean sections, bladder operations or replacing a hip joint Forms of Regional Anesthesia: Spinal Anesthetic often used for lower abdominal, pelvic, rectal, or lower extremity surgery. This type of anesthetic involves injecting a single dose of the anesthetic agent directly into the fluid surrounding the spinal cord in the lower back, causing numbness in the lower body Epidural Anesthetic commonly used for surgery of the lower limbs and during labor and childbirth. This type of anesthesia involves continually infusing medication via a thin catheter that has been placed into the epidural space of the spinal column in the lower back, causing numbness in the lower body 3. Local Anesthesia is injected into a specific area and is used for minor surgical used in procedures such as suturing a small wound or performing biopsy Stages of Anesthesia ONSET PHYSICAL REACTIONS Anesthetic Drowsiness/Dizziness administration to ONSET Auditory and visual loss of hallucinations consciousness Loss of Increase in autonomic EXCITEMEN consciousness to activity T loss of eyelid Irregular breathing, reflexes client may struggle loss of eyelid Unconsciousness SURGICAL reflexes to loss of Relaxation of muscles ANESTHESI most reflexes and Diminished gag and A depression of vital blink reflex function DANGER Depression of vital Client is not breathing STAGE NURSING INTERVENTIONS Close OR doors Keep room quiet Standby to assist client

Remain quiet at clients side Assist anesthesiologist as necessary Begin preparation only when anesthesiologist indicates Stage 3 has been reached and client is breathing well with stable vital signs If arrest occurs, assist

function to respiratory and circulatory failure

Heartbeat may or may not be present

immediately in establishing airway, provide cardiac arrest tray, drugs, syringes, long needles, assist surgeon with closed or open cardiac massage

Stages of Anesthesia STAGE I: RELAXATION (AMNESIA/ANALGESIA) SCOPE o From the beginning of anesthesia to the loss of consciousness, pain sensation is not completely lost, but reaction to pain has been altered. PATIENT REACTION/ BIOLOGIC RESPONSE

o o o o

Feeling of drowsiness and dizziness Hearing becomes exaggerated May appear inebriated Pain sensation is decreased

NURSING IMPLICATIONS

o o o o o

Close the operating room doors to reduce extraneous noises. Confirm proper positioning, including all safety factors. Verify if anesthesia suction is available and working correctly. Reduce talking, unnecessary movement, and noise to only what is absolutely necessary. Remain at the head of the operating room table; assist the anesthesia clinician, and provide the patient with emotional support.

STAGE II: DELIRIUM/EXCITEMENT SCOPE o From the loss of consciousness to the onset of respiratory depression and loss of lid reflexes. PATIENT REACTION/ BIOLOGIC RESPONSE

o o o o

Irregular respiration Loss of lid reflexes Increased muscle tone and involuntary motor response Sensitive to external stimuli (can be startled)

NURSING IMPLICATIONS

o o o o

Avoid any type of extraneous stimulation. Lightly restrain extremities to avoid injury. Remain at the head of the table to assist anesthesia personnel as needed. Remain alert for many emergency situations that could arise.

STAGE III: SURGICAL ANESTHESIA SCOPE o From the regular pattern or respirations to the total paralysis of the intercostals muscle and cessation of voluntary ventilation. This stage can be further divided into four plane ranging from light anesthesia through excessively deep anesthesia. PLANE I: LIGHT ANESTHESIA

o o o o o

Loss of lid reflexes, pupils are smaller Patterns of normal breathing visible Vomiting/ gag reflex gradually is disappearing Respiratory rate and depth may increase Eye movement may still be present

PLANE II: MEDIUM ANESTHESIA (SURGERY MAY BEGIN)

o o o o

Ventilations are more regular, but tidal volume has decreased Loss of eye movement: Pupil in midline, concentrically fixed Vocal cord reflex (which could result in laryngospasm) begins to disappear Decreased muscle tone as anesthesia deepens Begin with decreased intercostals muscle movement Only diaphragmatic activity remains Increased muscle relaxation Begin with intercostals paralysis and progress to complete cessation of spontaneous ventilation If allowed to go deeper, circulatory system failure is imminent Pupils no longer react to light Be available to assist anesthesia personnel as necessary. Validate with the anesthesia appropriate time to position and prepare. Recheck patient positioning and reaffirm safety precautions.

PLANE III: DEEP SURGICAL ANESTHESIA

o o o

PLANE IV: DEEPER ANESTHESIA

o o o

NURSING IMPLICATIONS:

o o o

STAGE IV: DANGER SCOPE o From the time of cessation of ventilation to failure of circulation caused by high levels of anesthesia in the CNS accidentally reached; not desirable. PATIENT REACTION/ BIOLOGIC RESPONSE o Medullary peristalsis, cardiac /respiratory collapse o Pupils fixed and dilated o Pulse rapid and thready o Ventilation ceases, coma develops o Circulatory and respiratory arrest NURSING IMPLICATIONS o Be prepared to assist in emergency resuscitation measure o Obtain emergency cart and defibrillator o Remain in the room at all times o Document all events and therapies as they occur

OPERATIVE CHECKLIST: A. Pre operative checklist Please be aware of the following information: 1. Insurance information and I.D.(for ex, a driver's licence must be available at the time of registration. 2. Consume no solid food, no milk, and/or no orange juice after midnight before surgery. 3. Do not smoke,chew gum or suck on hard candy sfter mightnight before surgery.

4. Stay away from asprin/aspirin products. No Advil or antiinflammatory drugs at least 7-10 days prior to surgery.

On the Day of Surgery, please: 1. Wear NO makeup or nail polish. 2. Wear NO jewelry. 3. Leave valuable at home. We are not responsible for personal items, money,credit cards, wallets, jewelry, etc. 4. Bring a case for contact lenses and/or glasses. 5. Feel free to wear your dentures to the operating room. 6. Wear no metal hair accessories. 7. Wear loose fitting clothing appropriate for the type of surgery being performed.

For 24 Hours After surgery, it is suggested that you: 1. Do not make critical decisions. 2. Do not drink alcoholic beverages. 3. Do not drive a motor vehicle. 4. Do not operate machinery or potentially dangerous machinery. 5. Have an adult stay with you. This is strongly advised.

B. Consent Forms

1. Implied consent

Much of a physician's work is done on the basis of consent which is implied either by the words or the behaviour of the patient or by the circumstances under which treatment is given. For example, it is common for a patient to arrange an appointment with a physician,

to keep the appointment, to volunteer a history, to answer questions relating to the history and to submit without objection to physical examination. In these circumstances consent for the examination is clearly implied. To avoid misunderstanding, however, it may be prudent to state to the patient an intention to examine the breasts, genitals or rectum.

The foregoing notwithstanding, in many situations the extent to which consent was implied may later become a matter of disagreement. Physicians should be reasonably confident the actions of the patient imply permission for the examinations, investigations and treatments proposed. When there is doubt, it is preferable the consent be expressed, either orally or in writing.

2. Expressed consent

Expressed consent may be in oral or written form. It should be obtained when the treatment is likely to be more than mildly painful, when it carries appreciable risk, or when it will result in ablation of a bodily function.

Although orally expressed consent may be acceptable in many circumstances, frequently there is need for written confirmation. As physicians have often observed, patients can change their minds or may not recall what they authorized; after the procedure or treatment has been carried out, they may attempt to take the position it had not been agreed to or was not acceptable or justified. Consent may be confirmed and validated adequately by means of a suitable contemporaneous notation by the treating physician in the patient's record.

Expressed consent in written form should be obtained for surgical operations and invasive investigative procedures. It is prudent to obtain written consent also whenever analgesic, narcotic or anaesthetic agents will significantly affect the patient's level of consciousness during the treatment.

3. Informed Consent

An agreement by a client to accept a course of treatment or a procedure after complete information, including the risks of treatment and facts relating to it, has been provided by the physician.

It is an exchange between a client and a physician. Usually the client signs a form provided by the agency. The form is a record of the informed consent, not the informed consent itself.

C. WHO Operative Checklist In order to implement the Checklist during surgery, a single person must be made responsible for performing the safety checks on the list. This designated Checklist coordinator will often be a circulating nurse, but it can be any clinician participating in the operation. The Checklist divides the operation into three phases, each corresponding to a specific time period in the normal flow of a procedure the period before induction of anaesthesia, the period after induction and before surgical incision, and the period during or immediately after wound closure but before removing the patient from the operating room. In each phase, the Checklist coordinator must be permitted to confirm that the team has completed its tasks before it proceeds onward. As operating teams become familiar with the steps of the Checklist, they can integrate the checks into their familiar work patterns and verbalize their completion of each step without the explicit intervention of the Checklist coordinator. Each team should seek to incorporate use of the Checklist into its work with maximum efficiency and minimum disruption while aiming to accomplish the steps effectively. All steps should be checked verbally with the appropriate team member to ensure that the key actions have been performed. Therefore, before induction of anaesthesia, the person coordinating the Checklist will verbally review with the anaesthetist and patient (when possible) that patient identity has been confirmed, that the procedure and site are correct and that consent for surgery has been given. The coordinator will visualize and verbally confirm that the operative site has been marked (if appropriate) and will review with the anaesthetist the patients risk of blood loss, airway difficulty and allergic reaction and whether an anaesthesia machine and medication safety check has been completed. Ideally the surgeon will be present during this phase as the surgeon may

have a clearer idea of anticipated blood loss, allergies, or other complicating patient factors. However, the surgeons presence is not essential for completing this part of the Checklist. Before skin incision, each team member will introduce him or herself by name and role. If already partway through the operative day together, the team can simply confirm that everyone in the room is known to each other. The team will confirm out loud that they are performing the correct operation on the correct patient and site and then verbally review with one another, in turn, the critical elements of their plans for the operation, using the Checklist for guidance. They will also confirm that prophylactic antibiotics have been administered within the previous 60 minutes and that essential imaging is displayed, as appropriate. Before leaving the operating room, the team will review the operation that was performed, completion of sponge and instrument counts and the labelling of any surgical specimens obtained. It will also review any equipment malfunctions or issues that need to be addressed. Finally, the team will discuss key plans and concerns regarding postoperative management and recovery before moving the patient from the operating room. Having a single person lead the Checklist process is essential for its success. In the complex setting of an operating room, any of the steps may be overlooked during the fast-paced preoperative, intraoperative, or postoperative preparations. Designating a single person to confirm completion of each step of the Checklist can ensure that safety steps are not omitted in the rush to move forward with the next phase of the operation. Until team members are familiar with the steps involved, the Checklist coordinator will likely have to guide the team through this Checklist process. A possible disadvantage of having a single person lead the Checklist is that an antagonistic relationship might be established with other operating team members. The Checklist coordinator can and should prevent the team from progressing to the next phase of the operation until each step is satisfactorily addressed, but in doing so may alienate or irritate other team members. Therefore, hospitals must carefully consider which staff member is most suitable for this role. As mentioned, for many institutions this will be a circulating nurse, but any clinician can coordinate the Checklist process. Focused - The Checklist should strive to be concise, addressing those issues that are most critical and not adequately checked by other safety mechanisms. Five to nine items in each Checklist section are ideal. Brief - The Checklist should take no more than a minute for each section to be completed. While it may be tempting to try to create a more

exhaustive Checklist, the needs of fitting the Checklist into the flow of care must be balanced with this impulse. Actionable - Every item on the Checklist must be linked to a specific, unambiguous action. Items without a directly associated action will result in confusion among team members regarding what they are expected to do. Verbal - The function of the Checklist is to promote and guide a verbal interaction among team members. Performing this team Checklist is critical to its success it will likely be far less effective if used solely as a written instrument. Collaborative - Any effort to modify the Checklist should be in collaboration with representatives from groups who might be involved in using it. Actively seeking input from nurses, anaesthetists, surgeons and others is important not only in helping to make appropriate modifications but also in creating the feeling of ownership that is central to adoption and permanent practice change. Tested - Prior to any rollout of a modified Checklist, it should be tested in a limited setting. The real-time feedback of clinicians is essential to successful development of a Checklist and its integration into the processes of care. Testing through a simulation as simple as running through the Checklist with team members sitting around a table is important. We also suggest using the Checklist for a single day by a single operating team and collecting feedback. Modify the Checklist or the way that it is incorporated into care accordingly and then try the Checklist again in a single operating room. Continue this process until you are comfortable that the Checklist you have created works in your environment. Then consider a wider implementation program.