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Operating Room Course Outline

NURSING SKILLS ENHANCEMENT Click to edit Master subtitle style LEVEL III

TOPIC OUTLINE

Definition of terms Principles of sterile technique Types of surgery Phases of surgery


Peri-operative phase Intra-operative phase Post-operative phase

Instrumentation
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DEFINITION OF TERMS

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Definition of terms

1. ANTISEPTICS Inorganic chemical compounds that combat sepsis by inhibiting growth of microorganisms without necessarily killing them. Used in skin and tissue to arrests growth of endogenous microorganism like resident flora, they must not destroy tissue.

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Definition of terms

ASEPTIC TECHNIQUE Methods by which contamination with microorganism is prevented. CIRCULATOR The unsterile member of the surgical team who attends to the immediate needs of the sterile surgical team.

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Definition of terms

CONTAMINATED Soiled or infected by microorganisms. CUFF The white or green elastic end portion of the sleeves of the gown. DISINFECTION Chemical or physical process of destroying most forms of pathogenic microorganisms except bacterial spores, used for inanimate objects , but not on tissue.
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Definition of terms

ELECTIVE CASE The prepared or scheduled surgical procedure to be done; postponement of which may not be life threatening to the patient. EMERGENCY CASE A surgical procedure that must be done at once; postponement of which may be life threatening to the patient.
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Definition of terms

OPERATING ROOM The place where the surgical procedure is performed. OR SUITE - A specific room inside the operating room where the actual surgical procedure is conducted. RECOVERY ROOM - A place where the patient is transferred after a surgical procedure until he has recovered from anesthesia
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Definition of terms

SCRUB SUITE The prescribed OR attire which is composed of an upper suite and pants. SPECIMEN With very few exceptions, all tissue, including exudates removed from a patient is sent to pathology for examination. STERILE Free of microorganisms including all spores.
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Definition of terms

STERILIZATION Process by which all pathogenic and non- pathogenic microorganisms including spores are killed. STERILIZER Chamber or equipment used to attain either physical or chemical sterilization agent used may be capable of killing all forms of microorganisms.

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Definition of terms

STERILE FIELD An area created inside the OR suite where the sterile drapes, gowns, instruments and sets are being used. SURGICAL TEAM A group of persons who are directly responsible for the patient inside the operating room.

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Definition of terms

SURGERY Is the term traditionally used for treatments that involve cutting or stitching tissue.

It is sometimes used to aid in the diagnosis of a problem. It is a medical specialty that uses operative manual and instrumental technique on a patient that investigate or treat a pathological condition such as disease or injury, to help improve bodily function or appearance or sometimes for some other reason.
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Definition of terms

SUTURE Is an inclusive term for any strand of material used for ligating or approximating tissue. TERMINAL DISINFECTION Cleaning and sanitation of the OR suite to include equipment and furniture using antiseptics after each surgical procedure.

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Definition of terms

THE SCRUB One who performs the hand scrubbing technique, dons sterile gown and gloves, set the sterile field. UNSTERILE Inanimate object that has not been subjected to a sterilization process; outside wrapping of package containing sterile item. WRAPPER TAIL The edge of the linen wrapper.
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PRINCIPLES OF STERILE TECHNIQUE

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PRINCIPLES OF STERILE TECHNIQUE

Only sterile items are used within sterile field.

If in doubt about the sterility of anything consider it not sterile. Gowns are considered sterile only in front from the chest level of the sterile field, and the sleeves from above elbows to cuffs. Sterile only in the area you can see in front down to the level of the sterile field.
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Sterile person are gowned and gloved.

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PRINCIPLES OF STERILE TECHNIQUE

Sterile person are gowned and gloved.

Gowns are considered sterile only in front from the chest level of the sterile field, and the sleeves from above elbows to cuffs. Sterile only in the area you can see in front down to the level of the sterile field.

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PRINCIPLES OF STERILE TECHNIQUE

Tables are sterile only at table level.

Only the top of the sterile draped table is considered sterile. Edges and sides extending below table level are considered unsterile. The scrub person does not touch the part hanging below table level.

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PRINCIPLES OF STERILE TECHNIQUE

Unsterile persons avoid reaching over the sterile field; Sterile person avoid leaning over unsterile area.

Unsterile circulator never reaches over a sterile field to transfer sterile item. Scrub person stands back from the unsterile table when draping it to avoid leaning over an unsterile area.

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PRINCIPLES OF STERILE TECHNIQUE

The scrub person sets basin or glasses to be filled at the edge of the sterile field; the circulator stands near this edge of the table to fill them. Surgeon turns away from the sterile field to have perspiration removed from the brow.

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PRINCIPLES OF STERILE TECHNIQUE

Edges of anything that encloses sterile content are considered unsterile.

In opening a sterile packages, a margin of safety is always maintained.

Sterile field is created as close as possible to time of use.

Sterile tables are set upjust before the surgical procedure. Covering sterile tables for later used is not recommended.
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PRINCIPLES OF STERILE TECHNIQUE

Sterile areas are continuously kept in view.


Sterile person face only sterile area. Sterility cannot be ensured without direct observation. An unguarded sterile field should be considered contaminated.

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PRINCIPLES OF STERILE TECHNIQUE

Sterile person keep well within sterile area.

Sterile persons pass each other back to back at a 30 degree turn. A sterile person faces a sterile field or area to pass . A sterile person stay within the sterile field. They do not walk around or go outside the room.

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PRINCIPLES OF STERILE TECHNIQUE

Sterile person keep contact with sterile areas to minimum.

Sterile person do not lean on sterile table or on the draped patient. Sitting or leaning against an unsterile surface is a break in the technique.

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PRINCIPLES OF STERILE TECHNIQUE

Unsterile persons avoid sterile areas.

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Unsterile person maintain a distance of at least 1 foot( 30 cm ) from any area of the sterile field. Unsterile persons face and observe a sterile area when passing it to be sure they do not touch it. Unsterile persons never walk between two sterile fields. Circulator restricts to a minimum all activity near the sterile field.
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PRINCIPLES OF STERILE TECHNIQUE

Destruction of integrity of microbial barriers results in contamination.

Strike through is the soaking through of barrier from sterile to non-sterile to vice versa.

Microorganism must be kept to irreducible minimum.

A perfect asepsis is an idea. All microorganisms cannot be eliminated. Skin cannot be sterilized. Air is contaminated by droplets.
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TYPES OF SURGERY

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 complications after such surgeries.

Removal of brain tumors Correction of bone malformation and amputations. Exploratory laparotomy
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TYPES OF SURGERY

Minor surgery These surgeries are most often done as an outpatient, and patient can return home the same day.

Hernia repair Excision Biopsy Removal od skin lesion Cauterization

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TYPES OF SURGERY

Elective surgery These are procedures your patients decide to undergo, which may be helpful, but are not necessary essential.

Removal of warts Any plastic surgery/repair.

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TYPES OF SURGERY

Required surgery These are procedures that need to be done to ensure the quality of your patients life in the future.

Cheiloplasty Spinal fusion to correct severe curvature

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TYPES OF SURGERY

Urgent or Emergency This type of surgery is done in response to an urgent medical need.

Vehicular accident Gun shoot Ruptured appendicitis Ectopic pregnancy Etc.

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PRE OPERATIVE PHASE

PHASES OF SURGERY
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PRE OPERATIVE PHASE

This is the time period between the decision to have surgery and the beginning of the surgical procedure.

This is a period during which the nurse admits the patient to the surgical unit and help in the individual prepare physically and emotionally for the operation.

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PREADMISSION PROCEDURES

Tests and records must be completed and available when the patient is scheduled for elective surgical procedure. Pre operative preparations include:

Medical history and physical examination. These must be done and documented by a physician.

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PREADMISSION PROCEDURES

Laboratory tests. Testing should be based on specific clinical indicators or risks factors that could affect surgical management or anesthesia. These include age, sex, pre-existing disease, magnitude of surgical procedure, and type of anesthesia.

Hemoglobin, haematocrit, BUN, and blood glucose ( for 60 yrs and older ). Hematocrit( usually ordered for women of all ages before administration of general anesthesia. )

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PREADMISSION PROCEDURES

CBC, platelet count, activated partial thromboplastin time, and prothrombin time may be also ordered. Urinalysis may be indicated by medical history and/or physical examination.

Blood type and cross-matched. If transfusion is anticipated. Chest x-ray film. (This maybe medically indicated as an adjunct to clinical evaluation of patients with cardiac or pulmonary disease and for smokers, person age 60 and older, and cancer patients.)
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PREADMISSION PROCEDURES

ECG ( for the patient 40 years and older) Written instructions.


NPO after midnight Skin preparation to prepare the surgical site. Surgical procedureon the face, ear, or neck are advised to shampoo hair . Nail polish and acrylic nail should be removed to permit observation on the nail bed during surgical procedure. Jewelry and valuables should be left at home to ensure housekeeping.
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PREADMISSION PROCEDURES

Informed consent.

The patient and legal desingnee must give consent for the surgical procedure. After explaining the surgical procedure and its risk, the surgeon may have the patient sign the consent form. The nurse should witness in signing of the consent.

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PREADMISSION PROCEDURES

Bowel preparation. Enemas till clear may be ordered when it is advantageous to have the bowel and rectum empty. Douche. A douche to cleanse the vagina may be ordered before a vaginal or pelvic procedure. Bedtime sedation for sleep.

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PRE OPERATIVE CHECKLIST


Patient puts on a hospital gown. Jewelry is removed for safe housekeeping. Dentures and removable bridges are removed before administration of general anesthesia to prevent obstruction to respiration.

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PRE OPERATIVE CHECKLIST

All removable prostheses, such as eyes, extremity, contact lenses, hearing aids, eye glasses are removed for safe housekeeping. Long hair maybe braided. Hairpin is removed to prevent scalp injury. Antiembolicstockings or elastic bandages may be ordered for lower extremities to prevent embolic phenomena.
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The patient voids to prevent over distention of the bladder or incontinence during unconsciousness. Time of voiding is recorded. If ordered antibiotic is given to increase the blood level preoperatively.

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PRE OPERATIVE CHECKLIST

Preanesthesia medications are given as ordered. The patient, bed, and chart are accurately identified, and identifications are fastened securely in place. Allergies should be prominently noted on the chart.

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PRE OPERATIVE CHECKLIST

NOTE: Preoperative checklist helps ensure that the patient has been properly prepared. If preparation is inadequate, the surgical procedure may be cancelled. All essential records, including the plan of care, must accompany the patient.

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PREOPERATIVE ASSESSMENT AND TEACHING

Assessment of clients physical and psychological condition.


General appearance: skin, coloring, weight. Level of anxiety.

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PREOPERATIVE ASSESSMENT AND TEACHING

Preoperative instructions like:

Importance to preoperative lab tests and diagnostic exam. Discuss bowel and bladder preparation. Discuss skin preparation.

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PREOPERATIVE ASSESSMENT AND TEACHING


Explain the need to restrict food and fluid at least 8 hours prior to surgery. Explain individual contraptions ordered by physicians. Ex. IV therapy, nasogastric tube, etc. Inquire about allergies to drugs and food if any.

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PREOPERATIVE ASSESSMENT AND TEACHING

Teach and explain the importance of moving, turning, leg exercises, deep breathing and coughing exercises. Check the following documents.

Clinical cover sheet Consent for surgery. Doctors order sheet CP/OB Gyne/ pedia clearance.

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INTRA OPERATIVE PHASE

PHASES OF SURGERY
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INTRA OPERATIVE PHASE

Recheck identification of the patient and review of chart contents by the circulating nurse. Assists in the transferring of the patient to the OR table, proper positioning during induction of anesthesia and in surgery.

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INTRA OPERATIVE PHASE

Know the 4 stages of anesthesia.

Stage 1 : INDUCTION. This is the period between the initial administration of the medication and loss of consciousness. Nursing management are the following: close OR room, keep the room quite, stand by to assists the client.

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INTRA OPERATIVE PHASE

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Stage II: EXCITEMENT. It is the period following the loss of consciousness and marked by delirious activity. The heart rate and respiration is irregular, there may be uncontrolled movements. The combination of spastic movement and irregular respiration this may lead to airway compromise , rapidly acting drugs are used to minimize time in this stage and reach stage 3 as fast as possible. Nursing management are the following: Remain quite at the clients side, Assists the anesthesiologist if necessary.
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INTRA OPERATIVE PHASE

Stage III: SURGICAL. During this stage, the skeletal muscle relax, and the patients breathing becomes regular, eye movement slow, then stop, and surgery can begin. Nursing management is to get ready for the operation and take note of the cutting time.

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INTRA OPERATIVE PHASE

Stage IV: OVERDOSE/DANGER. This is the stage where too much medication has been given and the patient has severe brain stem or medullary depression. This result in a cessation of respiration and potential; cardiovascular collapse. This stage is lethal without cardiovascular and respiratory support. Nursing management is if arrest occur, assists immediately in establishing airway, provide cardiac arrest tray, drug, syringes, assists surgeon with cardiac massage.
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INTRA OPERATIVE PHASE

Responsibilities of the scrub nurse:


Prepare instrument s and supplies Establishing and maintaining the sterile field Anticipating procedural steps and surgeons needs Caring for the instruments Cleaning routines after the procedure.

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INTRA OPERATIVE PHASE

Responsibilities of the circulating nurse:

Helps in the positioning of the patient during induction of anesthesia Preparing the operative area by the surgeon Anticipating needs and requirements of the surgery Caring for specimens, instruments. Cleaning routine after the procedure.

sponges, sharps and instruments counts by the scrub and circulator.


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COUNTING PROCEDURE

A counting procedure is a method of accounting for items put on the sterile table for use during the surgical procedure, Sponges, sharps, and instruments should be counted on all procedures.

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COUNTING PROCEDURE

INITIAL COUNTING

The scrub person should touch each item, he or she and the circulator number each one aloud until all items are counted. The circulator immediately records the count for each type of item on the sponge sponge count sheet/form. Counting should not be interrupted. If uncertain about the count because of interruption, fumbling, or any other reason, repeat it.

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COUNTING PROCEDURE

FIRST COUNTING

Counts are taken in three areas before the surgeon starts the closure of a body activity or a deep or large incision. Field count Either the surgeon or the assistant assists the scrub person with the surgical field count. This area may be counted first. Counting this area last could delay closure of the patients wound area prolong anesthesia.

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COUNTING PROCEDURE

Table count The scrub person and the circulator together they count all items on the mayo table and back up table. The surgeon and the assists may be closing the wound while this count is in process. Floor count - The circulator count sponges and any other items that have been recovered from the floor or passed off the sterile field. These count should be verified by the scrub person.

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INTRA OPERATIVE PHASE

Strict implementation to principles and procedures of asepsis, disinfection, sanitation and safety precautions and practices. Proper documentation in-patient chart.

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POST OPERATIVE PHASE

PHASES OF SURGERY
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POST OPERATIVE PHASE

After the operation the patient is transferred to the recovery room on the stretcher following GA, SA, etc. a complete endorsement on the status of the patient, procedure, medication given, wound and dressing and allergies if any is given to the recovery room nurse by the perioperative nurse.

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POST OPERATIVE PHASE

Monitoring of vital signs (T,RP ,RR,BP ,Temp) every 15 mins per doctors order.

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POST OPERATIVE PHASE

Positioned clients comfortably on bed and provide side rails.

Unconscious patient is positioned on side; no pillows with race slightly down, thus preventing occlusion of the larynx and allowing drainage of mucous and vomitous. Clients who have had spinal anesthesiais to remain flat on bed for a specified period of time.

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POST OPERATIVE PHASE

Assess level of consciousness, orientation to time, place and person.


Not responding Arousable on calling Fully awake Suction airway as indicated.

Provide adequate airway.

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POST OPERATIVE PHASE

Check for the presence of protective reflexes, Ex. Gag, cough. Ability to move extremities and color of the skin, lips, nail beds. Ex. Pale, blotchy, cyanotic, jaundiced. Check condition of operative site, status of dressing, patency character and amount of drainage from catheters, tubes and drains.

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POST OPERATIVE PHASE

Assess the type, location and severity of pain and any side effects such as nausea and vomiting. Medicate the client as indicated. Provide safety using side rails.

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POST OPERATIVE PHASE

Assess the type and amount of intravenous fluids, flow rate and infusion site.

Monitor fluid intake and output Watch for signs of circulatory overload. Ensure that the replacement of fluids lost during surgery is sufficient to maintain blood pressure.

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POST OPERATIVE PHASE

Encourage deep breathing and coughing exercises, leg exercises, moving, turning to prevent post-op complications. Pain management .

Patient should be taught on how to rate their discomfort on a pain scale of 1-10. Use alternative methods of pain control may also be presented like: Destruction, imagery, positioning, music therapy.
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POST OPERATIVE PHASE


Refer to surgeons as necessary. Proper documentation.

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INSTRUMENTATION

INSTRUMENTATION

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Parts of the instrument

Finger ring/ring handle Provides a place for the user to place his her fingers and grip the instrument securely. Ratchet Allows the instruments to be locked in place. Shank Connects the boxlock to the finger ring. Box lock Controls the jaws of the instrument. Also known as the hinge joint.
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Parts of the instrument

Jaws Along with the tip is the working parts of the instruments. The jaw maybe smooth, serrated,or cross-hatched for grasping tissue or suture. Jaws can be straight or curved to various degrees, depending on the intended use of the instrument.

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Parts of the instrument

Tip The tip can be pointed or round and have teeth or no teeth (atraumatic). The intended use of the instruments determines the number of teeth the tip has and how the tip is designed.

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4 Main categories of the instruments

Dissectors - Which may be blunt or sharp, are instruments designed to cut and separate tissue and bone.

Scissor metzenbaum or iris Scalpel/blade

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4 Main categories of the instruments

Clamps/forceps Are instrument specifically designed for holding tissue or other materials, most have an easily recognizable design.

Occluding clamp/forcep usually have vertical serrations or finely meshed multiple rows of longitudinal teeth to prevent leakage and to minimize trauma when clamping vessels. Ex. Mosquito curve and Kelly curve.
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4 Main categories of the instruments

Grasping or holding instruments are used to grasp and hold tissue or bone for dissection or retraction or to assists suturing. Ex; Ochsner (grasp slippery tissue such as fascia), Allis (has multiple fine teeth on the tip so as not to crush or damage tissue.) Bobcock (has curved tip with no teeth, and it grasp delicate structures such as ureters, fallopian tubes.)

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4 Main categories of the instruments

Non clamp graspers Also known as tissue forceps or pick ups and are designed to grip tissue with a minimum amount of trauma. Pick up with teeth are used in thick or slippery tissue. Pick up without teeth can be used on delicate thin tissue. Grasping clamp Can hold objects as well. Sponge forcep can be used to hold tissue, however, they are most frequently used to hold gauze sponges.
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4 Main categories of the instruments

Retractors Are used to assists in visualization of the operative field. They are designed to provide a best exposure with a minimum of trauma to the surrounding tissue. Retractors comes in various sizes with the blade usually at a right angle to the handle.

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Manual Are retractors manipulated by hand. Ex. Army-navy, Richardson, bladder, etc. Permanent Instruments with screw. Ex: selfretaining, Balfour,organization) 2003 copyright (your wetlainer, etc. 8080

4 Main categories of the instruments

Accessory instruments Are designed to enhanced the use of basic instrumentation or facilitate the procedure.

suction tip, cautery pencil, dilators, probe

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Stages of anesthesia

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Stage 1 - INDUCTION
It is the period between the initial administration of the medication and loss of consciousness. During this stage the patient progresses from analgesia without amnesia . Patient can carry out a conversation at the same time. copyright (your organization) 8383 Nursing Management: 2003

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consciousness and marked by delirious activity. The patients heart rate and respiration rate may be irregular. There may be uncontrolled movement, breath holding, vomiting. The combination of spastic movement, vomiting and irregular respiration may lead to airway compromise. Rapid acting drugs are used to minimize time in this stage and reach stage 3 asap.

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Stage 111 - SURGICAL


During this stage, the skeletal muscle relax, and the patients breathing becomes regular eye movements becomes slow then stop, and surgery can begin. Nursing Management: a. Begin the skin preparation only when the anaesthesiologists permits to start, and the patients breathing is stable and the rest of the V/S.

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Stage 1V OVER DOSE/DANGER

This is the stage where too much medication has been given and the patient has severe medullary depression (brain stem). This result in cessation or respiration and potential cardiovascular collapse. This stage is lethal without cardiovascular and respiratory support.

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Nursing Management: a. Assists immediately in establishing airway, provide cardiac arrests tray , drugs, syringes, long needles. b. Assists surgeon with open cardiac massage.

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COMMON TYPES OF ANESTHESIA

1. General A state of unconsciousness produced by anaesthetic agent, with the desired results of amnesia, analgesia, and muscle relaxation. Sensation of pain all over the body is controlled. Drugs used: Inhalation-halothane, isoflurane Intravenous-propofol, ketamine hydrochloride
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Local or Regional block This type of anaesthesia is produced in a limited area and does not affect the consciousness of the client. The sensory nerves in one area or region of the body are anaesthetized. A. Topical anaesthetic drug is applied directly to the skin or into an open wound. B. Local infiltration drug is injected intracutaneously and subcutaneously into the tissue.
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Spinal or Epidural Anaesthesia This type of anaesthesia is produced by injecting an agent beneath the membrane of the spinal cord. Sensation of pain is blocked at a level below the diaphragm. There is no loss of consciousness in clients which had been given spinal or epidural anaesthesia.

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