Unit one

• Introduction to operating room technique

Outline
– Introduction
– Organization of areas in the operating room
– Personnel organization in the OR

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 Objectives
At the end of this presentation the learner will be able to :
• identify the physical organization of OR
•Differentiate the personnel organization in OR.
•Able to perform the perioperative roles of nursing in the OR .

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 Introduction
An operating room /surgery center/
•Is the unit of a hospital where surgical
procedures are performed.
•Is designed and equipped to provide specialized
care to patients with specific conditions.
•Is unit where all personnel wear protective
clothing to prevent the spread of germs.
•Is brightly lit area.
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 Organization of the Operating Room/OR/
Organization of areas in the OR
• The efficiency of OR depends much upon its:
– physical organization
I. Design
II. Equipments.
III. facilities
– Personnel organization

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 1. Design of the OR
• An intelligent design of the OR :
- facilitates - the efficient movement of pt & staff
- the economical use of space .
• types of designs : many , But
• the basic design principles w/h are common to all
OR must fulfill the following criteria :
1 . Wall and floor surfaces should be
- Smooth
- simple and easy to keep it clean.
2. There should be separate rooms to store clean ,
sterile and soiled equipments & supplies to prevent
cross contamination
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 c…
3. There should be sufficient space to ensure the safe
transportation of pts and staff.
4. The arrangement of the department should be
convenient for the supervisor to control the incoming
and outgoing traffics.
5. The recovery room should be near the OR.

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Design

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 AREAS IN THE OR
1 Post-Anesthesia Care Unit (PACU) is
• located immediately adjacent to the OR
• is staffed by highly qualified nursing personnel
who can quickly assess the patient's:
• cardiac, respiratory,

• physiologic status
– & respond immediately with appropriate assistance.

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 Cont…
• Need documentation about pt condition
• Each recovering patient is assigned to a separate
area that is equipped with
oxygen, suction, electrical outlets, and extensive
monitoring equipment.
• An emergency cart is centrally located and
equipped with a defibrillator ,
airway maintenance supplies, emergency drugs and
other supplies.
• Emergency call buttons are located through out the
department
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 2. Scrub /Sink area
• found in near to the operating suites.
• must be located away from wrapped sterile supplies
• Contains :
• Caps, masks, antiseptic soap, scrub brushes
and eyeglass at each scrub station.
• Universal Precautions may also be found in this
area.
• Scrub sinks never ever , be used for the
cleanup of equipment or instruments.

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 Anesthesia Supply Room
. Is area where used to store all equipment like :
- Anesthesia machines,
- medications
- Airway devices:
LMA
 OPA,
mask ,
ETT,
suction tubes …)

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 4. Sterile Supply Room
• is a clean area and contains all sterilized and packaged
instruments and supplies needed for surgery.
• The supplies must be arranged neatly on shelves
• Supplies here are routinely checked for
"outdates" (expiration dates for the sterility of the
prepackaged supplies) and for package integrity.
• should be dusted frequently with a damp cloth
• have storage cabinets with doors to minimize
exposure of the supplies to room air and dust.

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 Storage areas
• are used to store :
• extra instruments
• equipments
• supplies for each unit

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 workroom
• is located away from the direct traffic of the
operating suites.
• It is divided into two separate areas
• one for clean instruments & supplies
• Other for soiled equipment.

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 5. Equipment Room
• is used to store large apparatus :
such as the operating microscope
image intensifier etc.
• The equipment stored here should be kept free of
dust and cleaned routinely just as in any other area
of the operating room.

• Reading assignment
-Read other types of rooms

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 SURGICAL UNIT
Generally , the surgical unit is divided into four
designated areas :
1. unrestricted area
2.Transition zone
3. semi restricted area
4. Restricted area

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 1. Unrestricted area
-is a point through which staff, patients and materials enter the
surgical unit (serve as an outside –to- inside access area)
- is outside the theater complex
- street clothes are permitted
- traffic is not limited ; a corridor on the periphery accommodates
traffic from outside
- is isolated from the main corridor & other OR suite by doors.
- is control point to monitor the entrance of patients,
personnel, visitors, etc

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 2. Transition zone
• where staff put on surgical attire
• Should allow only the authorized staff (who
perform or assist procedures ).
• Displaying a sign board in local language
limiting the entry of unauthorized persons .

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 3. Semi restricted area
• Is a peripheral area of surgical unit which includes:
- preoperative and recovery rooms,
- storage space for sterile and HLD items,
- corridors leading to the restricted area , work areas
• Limit traffic to authorized staff and patients at all times
• Staff who work in this area should wear surgical attire
and a cap:
- to minimizes bacterial shedding,
– to provide comfort & professional appearance
• The patient may be transferred to a clean inside
stretcher on entry to this area.
• Have door limiting access to the restricted area
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 4. Restricted area
- which consists of the operating room and scrub sinks.
• Limit traffic to authorized staff (staff who perform and
assist procedures) and patients at all times.
• Keep the door closed at all times, except during
movement of staff, patients, supplies and equipment
• Scrubbed staff must wear full surgical attire and cover
head and facial hair with a cap and mask.
• Masks must cover the mouth and nose entirely,
and be tied securely
• Staff should wear clean& closed shoes

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 TRAFFIC FLOW AND ACTIVITY PATTERN
Microbial contamination is minimized by:
- reducing the number of people permitted into an area
- defining the activities that take place there.
• The traffic flow should be limited in:
- procedure areas, surgical units , work areas.
• The space, equipment, and need for a well defined
traffic flow and activity pattern become progressively
more complex as the type of surgical procedure changes
(general to open heart surgery ) surgical units .

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 Cont’d
• To minimize microbial contamination of specific areas :
– Permit only the patient and the staff performing and assisting
the procedures .
– Minimize the number of trainees .
– patients has to wear
• hospital clothes for major surgery .
• their own clean/hospital clothes during minor surgery
– Staff should wear attire and PPE appropriate for the procedure
they are performing.

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• prepared 0.5% chlorine solution should be
available for the immediate decontamination of
instruments and other items after procedures .
• A leak-proof, covered waste container should be
available for the disposal of contaminated waste
items.
• A puncture-resistant container should be
available for the safe disposal of sharps.
• Clean, high-level disinfected, and sterile supplies
should be stored and available in procedure
rooms.
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 Operating room personnel
• There is a logical division of duties among the OR staff.
• OR Team /staff./
surgeon, one or two assistants ,anesthesia provider
nurses (scrubbed, circulating nurse) , machine operator
, cleaner , etc
• each has specific functions.
• has the patient’s life in its hands.
• Works in team for the successful accomplishment of
the expected outcomes of the patient.

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 c..
• The team is subdivided according to the
functions of its members:
1. The sterile team consists of:
1. Surgeon
2. Assistants to the surgeon
3. Scrub nurse
2. The unsterile team includes:
a. Anesthesia provider
b. Circulator/ Runner nurse
c. Operators of specialized equipment or
monitoring devices.
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 Qualities of the Operating Room personnel

1 .stamina /energy, resistance/

Since the job requires
- long hours of standing,
- lifting heavy instrument,
-positioning patients,
which requires good physical condition and
have the energy to complete daily work in a
safe and efficient manner.

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 2 .Emotional stability
• The OR work is stressful, w/c can cause team members
to be tense or to display aggressive behavior while
working.
• So , the OR nurse must be able to cope with self & /or
teammate tension .
• Even the surgeon may express feelings of stress by
being verbally abrupt or harsh.
• not become personally offended by occasional
outbursts.

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 3 .Respect
• Respect for
• the patient’s rights & privacy,
• Team members,
• self (is an important quality of the OR nurse)

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 4 .Stable health
• OR needs daily presence of employees.
• Absenteeism 2ry to health problem increases
the work load on others.
• So to prevent this one must be careful to guard
against illness and injury.
– prevention of injury to the back
– maintenance of healthy skin & respiratory tract
(common areas of illness).

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 5 .Team spirit
• The ability to work with team members
toward a common goal is very important in
surgery.
• The patient expects and should receive the
undivided attention of all .
• So knowing self & others jobs is important .
• put personnel problems aside or bring them
to the attention of the supervisor, who might
able to resolve them.

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 Responsibilities of Each Member
1 .Sterile team members
• wash (scrub) their hands and arms,
• put on (don) a sterile gown and gloves, and enter the
sterile field.
• handle only sterile items.
2 .Unsterile team members,
• do not enter the sterile field;
• they function outside and around sterile field
• handle supplies and equipment that are not considered
sterile.
• Supply sterile equipments for sterile team.

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 A. Responsibilities of the Surgeon
• Preoperative diagnosis and care
• Selection and performance of the surgical
procedure
• Postoperative management of care
B. Responsibilities of the Assistant Surgeons
• maintain visibility of the surgical site
• control bleeding
• close wounds and apply dressings

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 Responsibilities of the Scrub Nurse
• guided and directed constantly by
what the surgeon is doing. This means that the
"scrubbed”nurse must have a constant attention
to the operation field.
• Reviews anatomy, physiology, and the surgical
procedure.
• Assists with preparation of the room
• Scrubs, gowns, and gloves self and other
members of the sterile surgical team.
• Passes instrument to the surgeon in a prescribed
manner.
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• Maintains sterile and an orderly surgical field.
• Assists with the draping procedure. .
• Is constantly alert to any intraoperative dangers.
• Keeps the instrument table neat so that supplies
can be handed quickly and efficiently.
• Anticipates and meets the needs of the surgeon by
watching the progress of the surgery and knowing
the various steps of the procedure. Takes part in
sponge,needle,& instrument counts
• Identifies and preserves specimens properly.
• etc
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 Duties of Circulating
Preoperatively : on Patient Arrival to OR
1.Greets the patient on arrival and assesses his or
her level of consciousness.
2.verify with the patient, the site and side of the
procedure.
3.Completes a preoperative care plan such as
assessment, plan implementation, evaluation of
expected outcome of nursing care during the
perioperative period & explains the
perioperative phases to the patient.
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4. Answers any pts questions.
5 .Communicates to the Scrub nurse any
conditions that would directly affect his or her
preparation for this surgery.
6. Prepares the patient for any sights, smells or
sounds that might be disturbing

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 Patient Arrival within the Surgical Suite
1. Assists in the safe transfer of the patient from the
stretcher to the operating table.
2. Assists anesthesia provider .
3. Directs or participates in the initial sponge, needle and
instrument counts.
4. Applies patient grounding device when applicable.
5. Ensures that the patient is warm and comfortable while
awaiting the start of the surgery.
6. Offers emotional support to the patient before and
during induction of anesthesia.

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 Circulating nurse
• In Intraoperative Phase
1. Assists anesthesia provider during induction.
2. Assists in the safe positioning of the patient
3. Maintains aseptic environment within the surgical suite
4. Receives non sterile ends of suction tubing, electrical
cords, power cables, electrocautery pencils, and other
items that must be connected to non sterile units
5. Ties the gowns of scrubbed personnel
6. Adjusts the surgical lights as needed
7. Prevents the unnecessary movement of personnel into
and out of the surgical suite
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8. Directs and participates in instrument counts
9. Aseptically opens and delivers any additional sterile
supplies needed by scrubbed team members
10. Documents :- supplies used during surgery
- intraoperative nursing care
- incidents that occur during surgery
11 .ensuring surgical specimens & place in the right media
12.notifies support personnel such as the x-ray technician as
needed.
14 .Delivers any medications needed to the scrub nurse
15. Strictly follows procedure for Universal Precautions
16. Communicates to PACU any necessary equipment that
will be needed based on the patient physiologic needs39
 Postoperative Duties of Circulating
1. Assists the anesthetistnurses
during the pt emergence from GA.
2. Assists the surgical team in the transfer of the pt from the
operating table to the gurney(narrow bed on wheels used
in hospitals) .
3. Accompanies the patient with anesthesiologist to PACU
4. communicating relevant information to individual outside
of the OR,
5. Reports the identity and physical status of the patient &
necessary equipment needs PACU nurse
6.Reports any impairment resulting from the operative
procedure.
8. Reports the type and site of drains, catheters, and tubing.
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 Item count
• Items(Sponge, Sharp, and Instruments) are counted
before and after use.
• It is performed for pt & personnel safety, infection
control, and inventory purposes.
• foreign body unintentionally left in pt wound site :
1. can be source of wound infection or disruption.
2. Formation of an abscess and development of fistula
between organs
3. reaction development immediate or delayed for years
4. Sometimes difficult and costly to diagnose.
5. Removal of the object requires major surgery
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 Inventory control
• Inventory control is monitored by accounting
for the instrument set in its entirety.
• Prevent accidental thrown away / discard of
expensive instruments( forceps with drapes )
• Prevent Injury to laundry and housekeeping
personnel by the contaminated sharp edges of
surgical instruments(blades, and needle).
Surgical instruments also can cause major
damage to equipment in the laundry service.

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 Counting Procedure
• is made three times in a surgical procedure.
A. First Count
• The person who assembles and wraps items
for sterilization will count them.
• In commercially prepackaged sterile items,
the count is performed by the manufacturer.

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 B. Second Count
• The scrub and the circulator nurse together
count all items before the surgical procedure
begins and during the surgical procedure as
each additional package is opened and added
to the sterile field.
• These initial counts provide the baseline for
subsequent counts.
Any item initially placed in the wound is
recorded.

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 useful method for counting
• Count loudly
• The circulator immediately records the count for each
type of item on the count record.
• Additional packages should be counted away from
counted items already on the table, incase it is
necessary to repeat the count or to discard an item
• Counting should not be interrupted.
• The count should be repeated if there is uncertainty
because of interruption/any reason.

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 C. Third Count
• Counts are taken in three areas before the surgeon
starts the closure of a body cavity or a deep/large
incision:
1 .Field Count. Either the surgeon or the assistant assists
the scrub nurse with the surgical field count.
2. Table Count. The scrub & circulating nurse together
count all items .
3 . Floor Count. The circulating nurse counts sponges and
any other items that have been passed off the sterile
field. These counts should be verified by the scrub nurse.

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 Co-operation
• team work need coordination .
• Team members should communicate and
should have a shared division of duties .
• The failure of any one member to perform
her/his role can seriously impact the success
of the entire team.
• No one individual can accomplish the goal
without the cooperation of the rest of the
team.

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Economical use of supplies & Equipment
• Most of the hospital equipment :
• is being imported from abroad & costly
• so economical and proper usage of
it is mandatory.
• As the cost of supplies and equipment ↑
, the OR team members should be conscious of ways
to eliminate wasteful practices.
E.g. -Avoid throwing away reusable items
- throw away disposable items only.

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 c..
• The operation room is one of the most
expensive departments of a hospital.
• Adequate instruments and supplies are
necessary for patient care, and cost is not
always the primary consideration.
• Economy becomes a hazard when
exercised beyond the point of safety.
• Nevertheless, supplies do not need to be used
generously, for their availability
• “Just Enough Is Enough”.
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 Principles
• Pour just enough antiseptic solution
• Supplies should be opened only as needed,
not routinely “just in case” they may be
needed
• Do not open another packet of sutures for
the last stitch unless absolutely necessary.
• Turnoff lights when they are not needed

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 Time economy
• Time is money; do not waste it.
• Know the policies and procedures, and follow
them efficiently.
• Learn to do things right the first time and
continue to do them that way;
• time is wasted in correcting errors.
• Time is an important element in the OR.
• If time is wasted b/n surgical procedures, the
day’s schedule is slowed down and later
procedures are delayed.
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• The patients and families become anxious
during these delays.
• reducing time
 can ↓the prolonged administration of
anesthetic agents, and other medication.
Can ↓ hazards of surgery

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UNIT2 Prevention of infection in
operating theatre
• The infection prevention (IP) practices are planned
for use in all types of health care facilities – from
large urban hospitals to small rural clinics.
• The IP principles are based on the guideline issued
by Centers for Disease Control and Prevention,
CDC (Atlanta, Georgia 1996).

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 IP principles
• Consider every person potentially infectious and
susceptible to infection.
• Washing hands before and after any procedure
• Donning gloves before touching anything
potentially infectious and wet such as
 broken skin
mucous membrane,
 body fluids , secretions & excretions,
 soiled instruments and other items
 before performing invasive procedures.

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 c..
• Using personal protective equipment (PPE) to provide
barriers, if splashes or spills of any blood, body fluids,
secretions or excretions are anticipated.
• Using antiseptic agents for cleansing the skin or
mucous membrane prior to surgery,cleaning wounds
• Using safe work practices, such as no recapping or
bending needles, safely passing sharp instruments ,
and disposing sharps in puncture resistant containers.

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 C..
• Processing instruments and other items that
come in contact with blood, body fluids,
secretions and excretions.
• Routinely cleaning and disinfecting equipment
and furniture in patient care areas.
• Disposing contaminated materials and waste
properly.

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Personal Protective Equipment(PPE )
 -are protective barriers and clothing
 provides a physical barrier b/n m/o and the
wearer, thereby preventing m/o from
contaminating hands, eyes, clothing, hair,
and shoes.

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 PPE
• reduces, but does not completely eliminate,
the risk of acquiring an infection.
• must be used effectively, correctly, and
whenever there is a risk of contact with
blood and body fluids.
• Making PPE available and training HCWs to
use it properly are essential.
• Note: Use of PPE does not replace the need
to follow basic IP measures such as hand
hygiene.
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 Principles for Using PPE
• Assess the risk of exposure to blood, body fluids,
excretions, or secretions and choose items of PPE
accordingly.
• Use the right PPE for the right purpose.
• Avoid any contact between contaminated (used) PPE and
surfaces, clothing,
• Discard used PPE appropriately in designated disposal
bags.
• Do not share PPE.
• Change PPE completely and thoroughly wash hands each
time
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 individuals should use PPE:
- HCW who provide direct care to patients
- who work in situations in which they might
have contact with:
– blood , body fluids
– excretions or secretions
- Support staff:
waste handlers , cleaners, laundry staff,
- Laboratory staff who handle pt specimens
- Family members who provide care
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Types of PPE and their recommended uses.
• Gloves :should be worn:
• When there is a reasonable chance of hands
coming in contact with:
 blood or other body fluids,
 mucous membranes, or no intact skin.
• Before -performing invasive procedures,
- handling contaminated waste items /
touching contaminated surfaces.

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 types of gloves con….
• Sterile surgical gloves .
• Disposable (single-use)/ examination gloves
• Utility or heavy-duty gloves (for use in
cleaning instruments, equipment,
contaminated surfaces, and while handling or
disposing of contaminated waste)

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 Caps
• Use it :
• during surgery to prevent flake of skin and
hair from shedding into a patient's wound.
• In scrub suits
• when handling immunocompromised
patients
• When handling patients with infectious
disease
• When performing invasive procedures

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 aprons (Mackintoshes, plastic or rubber )

• Used in which splashing of blood, body

fluids, secretions, or excretions are likely
- Footwear (Closed boots or shoes )
Wear closed shoes to protect your feet from
injury by sharps
 contact with blood or body fluids.

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 Surgical Masks
• should be worn in circumstances where
- splashes of blood, body fluids, secretions, and
excretions are likely,
- the patient has a communicable disease that is
spread via the droplet route.
• It protect the mucous membranes of the nose
and mouth during procedures and patient care
activities.
• should be large enough to cover the HCW‟s
nose, lower face, jaw, and all facial hair.
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• The purpose of the mask is:
• to protect the patient from moisture droplets that
are expelled as HCWs speak, cough, or sneeze;
• to protect the HCW by preventing accidental
splashes of patient's blood or other contaminated
body fluids from entering the HCW,s nose or
mouth.
• Unless the mask is made of fluid-resistant
materials, it is not effective in preventing either of
these.

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 c..
• There are two types of surgical masks:
• The tie-back mask, which has four ties to
fasten the mask around the mouth and
nose. The flexible metal tab is placed above
the bridge of the nose to help secure the
mask and minimize air escape from the sides
• The ear-loop mask is similar to the tie-back
mask except that it has two elastic bands
used for hooking behind the ears.

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 Protective Eyewear
• includes clear plastic goggles, safety goggles,
and face shields.
• used to protect the mucous membranes of
eyes during procedures and patient care
activities that could generate splashes or
sprays of blood, body fluids, secretions, and
excretions.
• .

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 c..
• The following guidelines apply:
• Use protective eyewear that is appropriate for the
particular procedure.
• Discard disposable eyewear appropriately.
• If they are reusable, decontaminate them
according to the manufacturers‟ instructions.
• Masks and eyewear should be worn when
performing any task where an accidental splash
into the face is likely to occur.
• If face shields are not available, goggles or glasses
and a mask can be used together
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 Gowns
• Wear to protect uncovered skin
• to prevent soiling of clothing during
procedures and patient care activities that are
likely to generate splashes or sprays of blood,
body fluids, secretions, or excretions.
• should not be worn outside of the area for
which they are intended,
• soiled or wet gowns should be removed as
soon as possible.

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 PERSONAL HYGIENE AND HEALTH
• Strict personal hygiene is necessary for OR workers.
• Daily baths and frequent shampooing aid in the
maintenance of a healthy surgical environment.
• Fingernails must be kept short, since bacteria are
easily trapped
• Nail polish is strictly forbidden because it serves as a
barrier to effective hand cleaning and scrubbing.
• Excessive make-up should be avoided because minute
particles can be shed onto sterile surfaces.
• Any employee with a respiratory condition, open
sores or wounds, infections of the eyes, nose, or
throat must not work in the operating room. 71
 ASEPTIC PROCEDURES
Hand Washing
• Hand washing a separate activity from the
surgical scrub, should be a routine practice
during the course of a workday
• Research has shown that hand washing has a
dramatic effect on the reduction of disease
transmission in the hospital setting.

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 Hand washing Procedure
1. Use an antimicrobial soap, not plain soap.
2. Use 3 to 5 mL of soap per hand wash.
3. For the antimicrobial action to take effect, the soap
must be in contact with the skin for at least 10
seconds.
4. When washing hands, pay particular attention to the
subungual area. Most of the hand bacteria are found in
this area. Fingernails must always be kept short for this
reason.
5. Always remove rings before washing . The skin under
rings can harbor dangerous amounts and kinds of
bacteria.
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 C ..
6. Health care workers who wash or scrub their hands
frequently are subject to cracked or dry skin.
• Breaks in the surface of the skin, even when very
small, can allow the entry of bacteria.
• SO, Use lotion to prevent this.
• However, do not use skin lotion immediately before
or after hand washing. Because Lotions can inhibit
the residual action of the antimicrobial soap.
• When lotions are used they must be dispensed in
such a way that the user cannot contaminate the
lotion remaining in the container
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75
 TECHNIQUES THAT MAINTAIN
ASEPSIS
The Surgical Scrub
- is the process of removing as many m/o s as
possible from the hands and arms by mechanical
washing and chemical antisepsis before
participating in a surgical procedure.
. Despite the mechanical action and the chemical
antimicrobial component of the scrub process, skin is
never sterile.

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 PREPERATIONS BEFORE SCRUB
• INSPECT HANDS FOR CUTS AND ABRASIONS.
• REMOVE ALL FINGER JEWELRY.
• BE SURE ALL HAIR IS COVERED BY HEADCAP.
• ADJUST THE MASK FIRMLY AND COMFORTABLY
OVER NOSE AND MOUTH.
• CLEAN EYEGLASSES IF WORN.
• ADJUST WATER TO A COMFORTABLE
TEMPERATURE

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 Scrubbing
• All sterile team members perform the hand and arm scrub
before entering the surgical suite.
• There are two methods of scrub procedure.
• One is a numbered stroke method in which a certain number
of brush strokes are designated for each finger, palm, back of
hand and arm.
• Second , is the timed scrub method
• All surgical scrubs are 5 minutes in length.
– All are performed using a surgical scrub brush and
an antimicrobial soap solution

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 c…
• The procedure for the timed 5-minute scrub consists
of the following:
1. Position scrub brushes, antimicrobial soap, and nail
cleaners which are available at each scrub station.
2. Remove watch and rings.
3. Wash hands and arms with antimicrobial soap.
4. Clean subungual areas with a nail file.
5. Start timing. Scrub each side of each finger, between
the fingers and the back and front of the hand for
2minutes.
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 c…
6. Proceed to scrub the arms keeping the hand higher
than the arm at all times.
This prevents bacteria-loaded soap and water from
contaminating the hand.
7. Wash each side of the arm to 3 inches above the
elbow for 1 minute.
8. Repeat the process on the other hand and arm
keeping hands above elbows at all times. If at any time
the hand touches anything except the brush, the scrub
must be lengthened by 1 minute for the area that has
been contaminated.
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 C…
9. Rinse hands and arms by passing them through the
water in one direction only, from finger tips to
elbow.
Do not move the arm back and forth through the
water. Proceed to the operating room suite holding
hands above elbows.
• If the hands and arms are grossly soiled (dirt is
visible) the scrub time should be lengthened.
However, vigorous scrubbing that causes the skin to
become abraded should be avoided
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The Final Rinse
1. Be sure to keep both
arms in the upright
position (careful not to
touch the faucet!) so that
all water flows off the
elbows and not back
down to the freshly
scrubbed hands. Bring
arm through the water
once, starting with the
fingers, then pull the arm
straight out. Do not let
water run down to
hands, must drip off
elbows
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 Drying the Hands and Arms
• After scrubbing, the hands and the arms
should be thoroughly dried before the sterile
gown is donned to prevent contamination of
the gown by strike-through organisms from
wet skin.
• A reusable or disposable towel for drying the
hands is placed on top of the gown during
packaging.

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Drying the Hands and Arms
1. Reach down to the opened
sterile package containing
the gown, and pick up the
towel. Be careful not to drip
water onto the pack. Be
sure no one is within arm’s
reach.
2. Open the towel full-length,
holding one end away from
the no sterile scrub attire.
Bend slightly forward

89
 C..

3. Carefully reverse the towel,

still holding it away from the
body. Dry the opposite arm
on the unused end of the
towel.
4. Dry both hands thoroughly but
independently. To dry one
arm, hold the towel in the
opposite hand and, using the
oscillating motion of the arm,
draw the towel up to the
elbow.

90
Gowning and Gloving Techniques
1. Reach down to the sterile
package and lift the folded
gown directly upward.
2. Step back away from the
table into an unobstructed
area to provide a wide
margin of safety while
gowning.
3. Holding the folded gown,
carefully locate the neckline
91
C..
4. Holding the inside,
front of the gown just
below the neckline with
both hands, let the
gown unfold, keeping
the inside of the gown
toward the body. Do
not touch the outside
of the gown with bare
hands.
5. Holding the hands at
shoulder level, slip both
arms into the armholes
simultaneously. 92
 C..
6. The circulator brings the gown
over the shoulders by
reaching inside to the
shoulder and arm seams.
The gown is pulled on,
leaving the cuffs of the
sleeves extended over the
hands. The back of the gown
is securely tied or fastened at
the neck and waist, touch the
outside of the gown at the line
of ties or fasteners in the back
only. 93
 Gloving
• Hand hygiene coupled with the use of protective
gloves, is a key component in minimizing the
spread of disease-producing m/o & maintaining
an infection-free environment
• Sterile gloves may be put on in two ways:
- By the closed gloving technique
- By the open gloving technique

94
Closed Gloving Technique
• Using the right hand and keeping it
within the cuff of the sleeve, pick up
the left glove from the inner wrap of
the glove package by grasping the
folded cuff.
• Extend the left forearm with the
palm upward.
• Place the palm of the glove against
the palm of the left hand, grasping in
the left hand the top edge of the cuff,
above the palm. In correct position,
glove fingers are pointing toward you
and the thumb of the glove is down 95
 c…
Grasp the back of the cuff
in the left hand and turn
it over the end of the left
sleeve and hand. The
cuff of the glove is now
over the stockinette cuff
of the gown, with the
hand still inside the
sleeve.
96
c….

Glove the right

hand in the same
manner, reversing
hands. Use the
gloved left hand to
pull on the right
glove

97
Gloving the Right Hand

98
Scrubbing, Gowning, and Gloving
Complete

99
100
 Open gloving Technique
1. Pick up the glove by its inside cuff with one hand.
2. Do not touch the glove wrapper with the bare hand
3. Slide the glove onto the opposite hand.
4. Using the practically gloved hand, slide the fingers
into the outer side of the opposite glove cuff.
5. Slide the hand into the glove and unroll the cuff.
6. Do not touch the bare arm as the cuff is unrolled.
7. With the gloved hand, slide the fingers under the
outside edge of the opposite cuff and unroll it gently,
using the same technique.

101
 Techniques of Removing the Gown and Gloves

• The gown is always removed before the gloves .

• Removing the Gown.
1. Grasp the right shoulder of the loosened gown
with the left hand and pull the gown downward
from the shoulder and off the right arm turning
the sleeves inside out

102
 c…
2. Turn the outside of the gown away from the
body with flexed elbows
3. Grasp the left shoulder with the right hand
and remove the gown entirely, pulling it off
inside out
4. Discard the gown in a laundry hamper or in a
trash receptacle (if disposable)

103
 Removing the Gloves
• The cuffs of the gloves usually turn down
• The gloves should be removed so that the bare skin does
not come into contact with the outside of the soiled
gloves.
• Procedure
1. Grasp the cuff of the left glove with the gloved fingers of
the right hand and pull it off inside out.
2. Slip the ungloved fingers of the left hand under the cuff
of the right glove and slip it off inside out.
3. Discard the gloves in an appropriate receptacle.
4. Wash hands.
104
 Housekeeping and Cleaning the OR
• Cleaning is the process that physically removes all visible
dust, soil, blood or other body fluids from inanimate
objects .
• Cleaning can be made in:
1 . daily :
- at the beginning of the day’s activity,
- in between the cases/ surgical procedures .
- at the end of the day
2 . on weekly basis.
• Areas to be considered are walls , floors , ceilings,
storage shelves, all furniture and equipment in the OR
including the operating bed/table.
105
 Cleaning Methods and Frequency
• Cleaning should start with the least soiled area and
move to the most soiled area and from high to low
surfaces.
• Common methods are:
A . Wet mopping - is the most common and preferred
method to clean floors.
 Three techniques can be used:
1. Single-bucket/container/ technique:
• Use just one container of cleaning solution. Change
the solution when it becomes dirty. The killing power
of the cleaning product decreases with the increase of
soil and organic material.
106
 c…
2 . Double-bucket technique:
- Use two different buckets,
- one containing a cleaning solution
- other containing a rinsing solution.
- This method extends the life of the cleaning solution
- fewer changes of solution are required w/h saves both
labor and material costs.
3 .Triple-bucket technique:
- Use a third bucket for wet through out the mop before
rinsing, which extends the life of the rinse water.

107
 B. Flooding
• Flooding followed by wet vacuuming or scrubbing
is recommended in the surgical suite, if possible.
• This process eliminates mopping , thus minimizing
the spread of microorganisms, and increases the
contact time of disinfectants with the surface to be
cleaned.
• But it is necessary to leave the floor wet for several
minutes.
• Flooding is best done at night or at times when
foot traffic is minimal

108
 C .Dusting
- is most commonly used for cleaning walls, ceiling,
doors, windows, furniture, and other environmental
surfaces.
- Clean cloths are wetted with a cleaning solution .
- The double- bucket system minimizes the
contamination of the cleaning solution.
- Dry dusting should be avoided, and dust cloths and
mops should never be shaken

109
 Guidelines for Cleaning Specific Areas
• Housekeeping schedules should be
• planned, written out, and closely followed.
• developed according to the needs of each area.
( Walls, windows, ceilings, and doors )
• In general, routine damp dusting is adequate for these
areas (disinfection is unnecessary). As long as the
surfaces remain dry and intact, these surfaces are rarely
heavily contaminated with microorganisms.
• Wipe daily and whenever visibly soiled (Chairs, lamps,
tables , beds, handrails, lights, tops of doors)
• Pay attention to contaminated areas on these surfaces
and treat any blood or other body fluid spills
110
 CLEANING Schedule
1 .Total Cleaning
Done at the end of each day,
• Remove all contaminated waste containers and
replace with clean containers.
• Close and remove sharps containers if they are ¾ full.
• Remove soiled linen in closed leak-proof containers.
• Wipe all surfaces of the surgical suite, scrub sinks, or
utility areas , and equipment from top to bottom,
floors regardless of whether they were used during
the last 24 hours using freshly prepared 0.5 % chlorine
solution

111
 2. Between Each Case
• guidelines:
• Clean spill with 0.5 percent chlorine solution; if spills
are large, flood the area with 0.5 % chlorine solution.
• Wipe all surfaces and mattress pads with a disinfectant
cleaning solution.
• Wipe all the flat surfaces that have come in contact
with a patient or a patient's body fluids with a
disinfectant cleaning solution.
• Mop the centre of the operating room surrounding the
operating room bed with disinfectant cleaning solution.

112
 c.
• Collect and remove all waste from the OR in
closed, leak-proof containers.
• Close and remove containers from the OR
when they are three-quarters full.
• Remove soiled linen in covered and leak-
proof linen containers.

113
 Unit III : Instrument processing

Preparation of equipment
1. Decontamination
2. Cleaning instruments
3. care of instruments
4. Packing
5. Disinfection & strlization

114
 Decontaminating Equipment
• Instrument should be immediately placed in a germicidal
solution to prevent blood and other substances from
drying on the surface
 For achieving satisfactory decontamination
• Decontaminate the instruments while wearing the PPE
• Immediately after use, place all smaller instruments in an
approved disinfectant, such as 0.5 % chlorine solution, for
10 minutes to inactivate most organisms, including HBV
and HIV.
• Use plastic, noncorrosive containers for
decontamination .
• Decontaminate large surfaces ,by Wiping with cloth
soaked in the 0.5% chlorine solution. 115
 c..
• Make a fresh solution :
• every morning, or after 8 hours, or more frequently if the
solution becomes visibly dirty
• Do not soak metal instruments in water for more than
one hour, even if they are electroplated .
• Do not mix chlorine solutions with either formaldehyde
or with ammonia-based solutions as toxic gas may be
produced.
• Remove instruments from 0.5 % chlorine solution after 10
minutes and immediately rinse them with cool water to
remove residual chlorine before thoroughly cleaning them.

116
 Steps for Making a 0.5% Chlorine
Solution
• 0.5% chlorine solution/ hypochlorite sodium)
can be made from readily available liquid or
powder chlorine.
• Liquid chlorine is available under different
brand names in different concentration.
• e.g.. “Ghion” available in Ethiopia contains
5% chlorine.

117
Formula for Making a Dilute Solution from
Concentrate Solutions

118
 2.Cleaning instruments
- is the removal of all visible dust, soil, and other foreign
materials from the instruments.
- all instruments and equipment MUST be cleaned to
remove organic materials or chemical residue.
- If not cleaned properly, organic matter could:
- prevent the disinfectant or sterilizing agent from
making contact with the instruments & equipment.
- bind and inactivate the chemical activity of the
disinfectant.

119
 Cleaning Agents
- Use liquid soap .
- Liquid soap suspends grease, oil, and other foreign
matters in solution so that they can be removed
easily by the cleaning process.
- Do not use an abrasive cleaner, such as steel wool,
because it can scratch the instruments, which
creates potential sites for m/o to harbor.
- If an instrument or piece of equipment cannot be
cleaned thoroughly,
 do not sterilize or disinfect it,
 discard it. It should not be reused.
120
 Cleaning Methods : 1 .Manual Cleaning
• procedure to clean instruments manually:
• Wear PPE (a plastic apron, thick rubber gloves, eye protection, a surgical
mask or face shield).
• Remove any gross soiling on the instrument by rinsing it in water.
• Take the instrument fully apart and immerse all parts in warm water with
a detergent
• To prevent splashing, keep the items being washed under the surface of
the water.
• Rinse in clean water.
• Pay particular attention to instruments with teeth, joints, or screws where
organic material can be collect.
• Open all jointed instruments.
• Dry the instrument in a drying cabinet or by using a clean cloth.
• Inspect the instrument to ensure it is clean.

121
 care of instruments
• Surgical instruments are expensive and requires
a major investment.
• Surgical procedures become more
complicated, as a result, instruments become
more:
• complex,
• precise in design
• delicate in structure.

122
 c..

• Abuse, misuse, inadequate cleaning or

processing, or rough handling can damage and
reduce the life expectancy of even the most
durable instrument, and the cost of repair or
replacement becomes unnecessarily high.
• Instruments can last for many years if they are
handled or maintained properly

123
 Guidelines to increase the lifespan of
instrument
During surgery:
• Handle instruments gently
• Don’t throw them into basins
• Keep the sharp surfaces of cutting instruments
away from other metal surfaces .
• Use the correct instrument for the job at hand,
– e.g. Heavy needles will damage delicate needle
holders
• Wire sutures must be cut with wire cutters, not
suture scissors
124
 After surgery:
• Decontaminate/clean instruments as soon as
possible.
• Don't allow blood to dry on them.
• Use accepted techniques when sterilizing
instruments.
• Separate sharp or delicate instruments from
others when processing

125
 Packing
• Packaging. Once items are cleaned, dried, and
inspected, those requiring sterilization must be
wrapped or placed in rigid containers and
should be arranged in instrument trays/baskets

126
 Disinfection & Sterilization

Disinfection: is a process by which most (but not all

pathogenic) m/o with the exception of bacterial spores
on inanimate objects are destroyed.
• removes microorganisms from instruments and
equipment
• is not a sterilizing process
• should not be used as a convenient substitute for
sterilization.

127
• is used to destroy organisms on delicate or
heat-sensitive instruments that cannot be
sterilized .
• It is not appropriate for instruments that will
be used in critical sites, because these
instruments must be sterile.

128
 - Factors that influence
the effectiveness of disinfectant
A. Nature of the item. Items with joints and
hinges are more difficult to disinfect.
B. Number and type of microorganisms present
on the object. The higher the level of the item’s
contamination , the difficult it is to disinfect.
Some microbes are more difficult to kill than
others.
C. Amount of soil or organic matter
- which protects microbes and may inactivate
the disinfectant solution. 129
 - c..
D. Contact time. Disinfection requires direct
contact with the agent for a specific time.
E. Concentration of solution.
- The more concentrated the solution has, the
greater is its killing capacity.
- The solution must be used at the concentration
specified by the manufacturer to be most
effective.
- Therefore, the manufacturer’s dilution
instructions must be followed.
130
 - Classification of Patient Care Items
A. Critical items:
- items enter sterile tissue, break the mucosal barrier, or
come into contact with the vascular system
- these must be sterile
E.g. surgical instruments, catheters, needles, implants etc.
B. Semicritical items
- which has contact with mucous membranes and require high-level
disinfection , or sterilization.
e.g respiratory therapy equipment: OPA, LMA, ETT ,NPA….
bronchoscopes, colonoscopies, gastro scopes , sigmoid scopes,
- disinfected by high-level disinfection using chemical disinfectants.
(Glutaraldehyde, hydrogen peroxide )
131
 - C. Noncritical items
• are used in contact only with intact skin.
• Intermediate or low-level disinfection is
adequate.
• E.g. blood pressure cuffs, furniture, linens,
bedpans, and eating utensils

132
 - levels of disinfection
Different products and processes provide different levels
of disinfection, which are classified as :
1. High-level disinfection
- destroys all microorganisms except some bacterial spores
(especially if there is heavy contamination).
- are effective against:
• all vegetative bacteria
• Viruses, Fungi, and TB
• most of them have a demonstrated level
of activity against bacterial spores .
• used primarily for semi critical items

133
 2 . Intermediate-level disinfection
= inactivates
- Mycobacterium tuberculosis, vegetative bacteria,
but it does not always kill bacterial spores
- most viruses( lipid-involved Viruses , non lipid
viruses.)
- most fungi
• are more powerful and kill more resistant m/os
than low-level disinfectants.
• e.g Chlorine, iodophors, and alcohol belong to
this group.
134
 - 3. Low-level disinfectants
• kill most vegetative bacteria, fungi,and lipid-
enveloped viruses,
• but do not kill spores or nonlipid viruses.
• They are less active against the Mycobacterium
tuberculosis and some gram-negative rods, such
as pseudomonas.
• typically used to wipe down items that will
contact only intact skin or for environmental
surface disinfection.

135
 How to Prepare a HLD Container
• For metallic containers, boil water in the covered
container for 20 minutes,
• then pour out the water.
• Replace the cover and allow the container to dry.
• For a plastic container, take the cover off and
immerse both the container and cover in 0.5 %
chlorine solution (the container itself should be filled
with the solution), and leave both to soak for 20
minutes.
• Rinse the cover and the inside of the container three
times with boiled water and allow them to air dry.
136
1
- Methods of
USING Chemical Disinfectants
HLD
A. Glutaraldehyde is generally the most appropriate
chemical disinfectant for high-level disinfection. kills
microorganisms by denaturation of protein. It is most
commonly used in a 2% solution.
B. Formaldehyde(37% aqueous; 8% alcohol)
1. Kills m/os by coagulating protein in the cells
 is effective at room temperature
 It has a pungent odor and is irritating to the eyes and
nasal passages
 Its vapors can be toxic denature

137
 c..
C. Hydrogen Peroxide
interacts with cell membranes, enzymes, or nucleic
acids to disrupt the life functions of m/os
D. Alcohol. 70% to 95%, kills m/os by coagulation of
cell proteins.
E. Chlorine Compounds kill microorganisms by the
oxidation of enzymes.
F. Iodophore, a complex of free iodine with detergent,
kills m/os through a process of oxidation of essential
enzymes.

138
 Steps in Chemical HLD
1. Decontaminate by soaking instruments for 20 minutes in
0.5 % chlorine solution that has been prepared using clean
water or 2 percent to 4 % glutaraldehyde or 6 % hydrogen
peroxide.
2. Disassemble, clean, and dry all instruments.
3. Completely immerse all items in the high-level disinfectant.
4. Remove items using high level disinfected (or sterile)
forceps and handle items wearing sterile gloves.
5. Rinse items well with sterile water (or boiled and filtered
water) three times and air dry them.
6. Use items promptly or store them in a dry, HLD container
with tightly fitting lid.

139
 - Method of HLD C..
2 Physical Disinfectants
A. Boiling / pasteurization - is a method of thermal
disinfection that involves immersion of pre-
cleaned items into water heated to approximately
75 to 100oc for 20 min.
Boiling method:
Cannot be depended to kill spores
Is a nontoxic, high-level disinfection process

140
 - Instructions for HLD by Boiling
1. Decontaminate, (Never put contaminated
instruments in the boiler), clean and dry all
instruments and items to be high-level
disinfected.
2.Completely immerse all items in the water.
For plastic items that float on the surface of
boiling water, it is not necessary that they be
fully covered by the water to achieve HLD if the
pot is covered with lid. Make sure all bowls and
containers to be boiled are full of water.
3. Close lid over pan .
141
 - c..
4.Start timer. Timing should be counted when the water comes to its
full boil .
5.Boil all items for 20 minutes.
6. After boiling for 20 minutes, remove objects with previously high-
level disinfected forceps.
• Never leave boiled instruments in the water that has stopped boiling.
7.Use instruments and other items immediately or, with high-level
disinfected forceps or gloves, place objects in a HLD container with a
tight-fitting cover. Once the instruments are dry, if any pooled water
remains at the bottom of the container, remove the dry items and
place them in another HLD container that is dry and can be tightly
covered.

142
 Cont…
Change the water in the boiler every 1-2 days.
Since as the water boils it leaves a scum of
impurities which will stain the inside of the
boiler and spoil the instrument.
. Inspect the boiler from time to time and keep it
in good condition.

143
B . Steaming :Procedure for HLD by Steaming
1. Place instruments and other items in one of the steamer
pans with holes in its bottom. Do not overfill the pan.
2. Repeat this process until as many as three steamer pans
have been filled. Stack the filled steamer pans on the
top of a bottom pan containing water for boiling. A
second empty pan without holes should be placed on
the counter next to the heat source.
3. Place the lid on the top pan and bring the water to a full
rolling boil.
4. When steam begins to come out between the pans and
the lid, start the timer or note the time on the clock and
record the time in the HLD log.

144
 C..
5. Seam items for 20 minutes.
6. Remove the top steamer pan and put the lid on
the pan that was below it. Gently shake excess
water from the pan just removed.
7. Put the pan you just removed onto the empty
pan. Repeat until all pans are restacked on this
empty pan and the top pan is covered with the lid.
8. Allow items to air dry in the steamer pan before
using them.
9. Using HLD forceps, transfer the dry items to a dry,
HLD container with a tightly fitting cover.
145
 Guidelines for the Use of Disinfectants
• Use the disinfectant in a well-ventilated room
• Make sure that items have been thoroughly
cleaned before attempting disinfection.
• Disassemble all removable parts of the item.
• Thoroughly dry the item before placing it in
the disinfectant.
• Mix the disinfectant as recommended on the
label. Improper mixing can lead to injury of
the patient, the instrument, and the person
working with the solution.
146
 Guidelines c..
• Read the directions for specific precautions.
• Completely immerse all parts of the item in the
solution,
• ensuring that all lumens, creases, joints, and
channels are in contact with the solution and
that no trapped air bubbles are present.
• Do not leave the item in the disinfection solution
for an undetermined time. The solution may
damage the item
147
 Guidelines c…
• Close the container to prevent evaporation of
the solution.
• Thoroughly rinse the item in at least two
fresh rinse solutions to insure adequate
removal of the disinfectant.(use sterile water
and then alcohol)
• Thoroughly dry the disinfected item with a
sterile towel, and place it in a dry, covered
container until ready for use.

148
 -Sterilization
• is the process of destruction of all m/o(non pathogenic
& pathogenic including bacterial endospores) on an
object.
• In the OR is used to destroy all m/o on all objects that
enter the body, such as instruments, catheters, and
needles.
• It is the only process that ensures an item is free from
all microbes.
• protects patients and is recommended for all
instruments and other items that will come in contact
with the blood stream or tissues under the skin, as well
as on drapes and some surgical attire.
• Methods of sterilization :Chemical &Physical
149
 Methods of sterilization
A. Chemical B. Physical
A. Chemical Methods OF STERLIZATION
1. Ethylene oxide gas is used to sterilize items that are
sensitive to heat or moisture
- is highly flammable and explosive in air
- therefore, must be used in an explosion-proof
sterilizing chamber in a controlled environment.
- Its effectiveness depends on four parameters:
Concentration of EO gas, Temperature, Humidity, and
Time (duration of gas exposure)
2. - Gluteraldehyde 2% for 10 hrs
- formaldehyde 8% for 24hrs
150
 B . Physical Methods
• Heat is a dependable physical agent for the destruction
of all forms of microbial life, including spores.
• are of 2 forms: moist heat & dry.
1. Moist heat (steam under pressure) or autoclaving
• is the least expensive, most efficient, and least time-
consuming method and is the method of first choice,
whenever possible
• Steam alone is inadequate for sterilization; however,
when steam is pressurized, its temperature rises.

151
 c..
• It is this moist pressurized heat that causes the
destruction of microbes by coagulation and
denaturation of the protein within the cells.
• The relationship between temperature,
pressure, and exposure time is instrumental in
the destruction of microbes.
• (temperature 121oc, for 20 minutes for
unwarped & 30 ms for warped , pressure
106kpa, & moisture of 100% is appropriate )
152
 Guidelines for Operating and Maintaining
Autoclave Machines
• An autoclave machine will reliably sterilize items only
when it is kept in good working condition and
operated correctly.
• Instructions for the operation and routine
maintenance of autoclave machines should be
included in HCWs‟ basic training.
• To ensure proper steam contact, first decontaminate,
clean, and dry objects before autoclaving, and then
follow these instructions:
• Keep instruments disassembled, opened, and
unlocked.
153
 c.
• Do not stack the instruments.
• Do not wrap the packages too tightly.
• Do not arrange the packs in the sterilizer too
close to each other.
• Position the containers in a way that air can
easily be displaced and steam can have enough
contact with all surfaces.
• Ensure that the small drain strainer at the
bottom of the sterilizer is not closed.
• This could result in trapping air inside the
sterilizer.
154
 c..
• Maintain the appropriate temperature, timing, and
adequate moisture during any autoclaving cycle:
• 121°C throughout the process
• 20 minutes for unwrapped items and 30 minutes
for wrapped items
• 100 percent moisture in the steam
• Follow specific operating instructions from the
manual that was supplied by the manufacturer.
• Ensure that there is at least 7-8 centimeters (3
inches) of space between the packages and the
autoclave chamber walls.
155
•
c..
Place bottles, solid metal, and glass containers on their
sides with lids held loosely in place.
• Do not overload the sterilizer or make packs too large.
• Apply an autoclaving tape on the pack of instruments to
indicate whether a specific temperature or pressure has
been reached.
• Double wrap items using correct wrapping material
(cloth)
• Consult the manufacturer,s manual for proper
maintenance of the sterilizer. In some cases, however, a
weekly flush of hot liquid soap through the exhaust line
will keep it cleaned out.

156
•
2. Dry-Heat(hot air) Sterilization
Can be used if items cannot be autoclaved.
• is a poor alternative to autoclaving
• since it is suitable only for metal instruments and a few
natural suture materials
• destroys pathogens by the process of oxidation.
• can be achieved with a simple oven as long as a
thermometer is used to verify the temperature inside the
oven. Have had limited value, because it is difficult to
maintain the same temperature throughout the load,
while the high temperatures and the length of time
required to achieve sterility make this method undesirable
for many situations. Used only for items that can
withstand a temperature of 170 C.
157
•
2. Dry-Heat(hot air) Sterilization
Can be used if items cannot be autoclaved.
• is a poor alternative to autoclaving
• since it is suitable only for metal instruments and a few
natural suture materials
• destroys pathogens by the process of oxidation.
• can be achieved with a simple oven as long as a
thermometer is used to verify the temperature inside the
oven. Have had limited value, because it is difficult to
maintain the same temperature throughout the load,
while the high temperatures and the length of time
required to achieve sterility make this method undesirable
for many situations. Used only for items that can
withstand a temperature of 170 C.
158
 Cont…
• If items cannot be autoclaved, they can be sterilized
by dry heat for1–2 hours at 170°C.
• Instruments must be clean and free of grease or oil.
• is a poor alternative to autoclaving since it is suitable
only for metal instruments and a few natural suture
materials.
• The major disadvantages of dry heat is :
- it penetrates materials slowly and unevenly

159
 c..
• Decontaminate, clean, and dry all instruments and
other items before sterilizing them. The
manufacturers‟ instructions must be followed, and
the door to the unit must not be opened while it is
in the sterilizing cycle.
• guidelines for sterilizing items using dry heat:
• Wrap instruments in aluminum foil or place in a
metal container with a tightly fitting, closed lid to
help prevent recontamination prior to use.
• When using dry heat to sterilize items wrapped in
cloth, be sure that the temperature does not exceed
170 C (340 F).
160
 c..
• Instruments with cutting edges should be
sterilized at lower temperatures (1600 C ),
because higher temperatures can destroy the
sharpness of cutting edges.
• Place loose instruments in metal containers
or on trays in the oven and heat to the proper
temperature.
• After the appropriate temperature is reached,
begin timing.

161
The recommended length of time depends
on the temperature:
• 60 minutes at 170°C (340°F)
• 120 minutes at 160°C (320°F)
• 150 minutes at 150°C (300°F)
• 180 minutes at 140°C (285°F)
• Overnight at 121°C (250°F)
• After cooling, remove packs or metal containers
(or both) and store in a cool dry area. Loose items
should be removed with sterile forceps and used
immediately or placed in a sterile container with a
tightly fitting lid.
162
 Monitoring Sterilization Procedures
- Chemical Indicators include tape or labels,
A, monitor time, temperature and pressure for steam
sterilization.
e.g .heat sensitive tape that melt at certain
temperatures for a given time resulted in color change
of the tape seen after completion of the sterilization
process Which changes from white to black.
B, monitor time and temperature for dry-heat
sterilization.

163
 c..
• External indicators should be used to verify
that items have been exposed to the correct
conditions of the sterilization process and
that the specific pack has been sterilized.
• Eg. the outsides of the packs of instruments
should not have wet spots, which may
indicate that sterilization has not occurred.

164
SUMMARY

165
 Effectiveness of methods for processing instruments

Method Effectiveness (kill or End point

remove m/os
decontamination Kills HBV, HIV most 10 minute soak
m/os
Cleaning ( water only ) Up to 50% Until visibly clean
Cleaning (with soap & Up to 80% Until visibly clean
rinsing with water)
HLD 95%(does not inactivate Boiling , steaming ,or
some endospores chemicals for 20
minutes
Sterilization 100% High pressure steam ,
dry heat ,or chemicals
Source:
for recommended time
Infection Prevention Guidelines for Health care
166
Facilities in Ethiopia; MoH, 2005).
UNIT 4: GENERAL Surgical INSTRUMENTATION

objectives
• At the end of this chapter, the learner will be able to:
1. Differentiate categories of surgical instruments
2. Identify the use and function of each type of surgical
instrument(SI)
3. Remember parts of each types of SI

167
 Introduction
 Surgical instruments:
 are critical to the surgical procedure.
 To enhance the surgical team performance
each team members has to know:
 each instrument by name,
 how each item is safely handled,
 how each is used.
 Classified according to their function as
 Cutting and Dissecting
 Grasping and Clamping
 Exposing and Retracting
 Probing and Dilating
168
 Cutting and Dissecting SI
• have sharp edges/points.
• used to dissect, incise, separate , penetrate , excise
tissue.
• kept separate from other instruments, and the
sharp edges should be protected during cleaning,
sterilizing, and storing.
• To prevent injury to the handler and damage to the
sharp edges, proper precautions are necessary to
take during the handling and disposing of all
sharps, blades, or scalpels.
• E .g scissors, knives, biopsy punches, scalpels
saws, osteotomes, drills and curettes, needles, etc.
169
surgical blades (scalpels)

170
Disposable Scalpels

171
 Scissors
Main function: To cut and dissect tissue to cut sutures, clothing,
bandages
 Scissors come in a tremendous variety of styles
and sizes: straight, curved and angular versions
 Some scissors have serrated blades to prevent
tissue slippage
• Made from stainless steel
Scissors sub types
Super‐Cut Scissors
Tungsten Carbide Scissors
Operating Scissors
Suture and Wire Cutting Scissors
Dissecting Scissors
Bandage Scissors:
172
 Scissors.

►A, Tissue scissors. Blades may be straight or curved

and either pointed/blunt,
►B, Suture scissors.
►C, Wire cutters and scissors.
►D,Dressing/bandage scissors.
173
…cont’d

174
 …cont’d
• Scalpel Blade
 7 handle with 15 blade (deep knife) is
used to cut deep, delicate tissue
 3 handle with 10 blade (inside knife) is
used to cut superficial tissue
 4 handle with 20 blade (skin knife) is
used to cut skin

• Mayo Scissors

 They can be curved/Straight With thick Shank

 These are used to cut suture materials and cutting tough tissues.
175
 …cont’d
Metzenbaum

 These can be again Curved/Straight and those with thin Shank and curved tips
are used for tissue dissection and cutting delicate tissues
Lister/Bandage Scissors
 The blunt tip is on one edge
 Used to trim bandages to
custom size, to cut through
clothing or gauze, and to help
remove bandages that someone
is wearing. 176
Suture Scissors  Have concave edge on
one side and use in
cutting sutures
Angled Suture Scissors
Straight Suture Scissors-
for subcutaneous, skin or
muscular area

Stitch Scissors

 Used with non-

absorbable sutures

177
A, Osteotomes. B, Rasps.
C, 1-6 Tissue curates.
D, Blunt dissectors,periosteal elevators.
178
 B. Clamping and Grasping
• A Clamp
• Is able to clasps tissue b/n its jaws.
• The most common are the haemostatic clamps,
designed to grasp blood vessels .
• E.g thumb forceps, tissue forceps.
• Grasping instruments
• are used to hold and manipulate structures.
• E.g Needle holder, bone holders, tenaculum …

179
Different types of thumb forceps.
180
Different types of clamps 181
Parts of clamp

182
 Parts of clamp
1 .Tips:should approximate tightly when closed.
• (Exceptions-some vascular and intestinal clamps
that compress tissue only partially).
2 . Jaws - hold tissue securely. Mosly serrated.
3 .box lock - is the hinge joint of the instrument.
4. shank- is the area b/n the box lock and the
finger ring.
5 . Ratchets- interlock to keep the instrument
locked when the instrument is closed.

183
Clamping and occluding instruments

 They are used to compress blood vessels or hollow organs

for hemostasis or to prevent spillage of contents.

184
Straight Mosquito/ Halsted Kelly Clamp

HEMOSTAT COMPONENT HEMOSTAT COMPONENT

Used to clamp skin, small blood Curved or Straight
vessels. Used to clamp larger blood vessels and
To hold sutures aside from tissues
pediatric patients. Curved Kelly- for peritoneum

185
 …cont’d
• Instruments for grasping and holding

186
DeBakey Tissue Forceps Adson Tissue Forceps

 Used to grasp delicate

tissue, particularly in
cardiovascular surgery.  These are either smooth: used to
grasp delicate tissue; or with
teeth: used to grasp the skin.
Russian Tissue Forceps  Other names: Dura forceps.

 They have serration up to

the tips, allowing better
grasp of tissue with
minimum trauma.
187
Randall Stone Forceps Tenaculum

To remove kidney stones

Used to grasp cervix

Backhaus Towel Clamp Allis Clamp

 Has Sharp teeth to hold tissue firmly but cause

damage, only used in tissue, which will be excised
To anchor drapes and  Used to grasp subcutaneous layer and tissue.
towels 188
Kocher/ Oschsner Clamp Babcock Clamp

Straight or Curved and used to grasp

heavy tissue. May be used as a clamp.
Ovum (Foerster)

Used in muscular
and facial layers;
delicate tissue (in
tube, ovary)
For control of bleeding and to grasp sponges
189
Types of blade holders (scalpel handles).
190
Needle holders: (A) serrated tips,
(B) nonserrated tips. 191
 C. Exposing and Retracting SI
• hold tissue or organs away from the area
where the surgeon is working.
• They may be:
• very shallow, as for skin retraction,
• very deep, as for the retraction of abdominal
contents.
• Retractors can be handheld or self - retaining

192
 Handheld Retractors
• have a blade on their handle.
• the blades vary in width and length to correspond to
the size and depth of the incision.
• the blades may be dull or sharp
• some retractors have blades at both ends are
usually used in pairs, and they are held by the first
or second assistant.
• Self-Retaining Retractors
• Holding devices with two or more blades can be
inserted to spread the edges of an incision and hold
them apart.
193
Different types of handheld retractors. 194
Retracting and exposing instruments
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.

195
Senn retractor

196
Different types of self-retaining retractors.

197
 Richardson

Double Single
For deep abdominal and chest incisions; and Used to pull layers of tissue
Deaver
US Army Navy

Used to retract deep abdominal or

For shallow or superficial chest incisions. Available in various
incision and pediatric clients widths. 198
Vein Retractor Volkmann Rake Weitlaner

Used in vein  Used in

stripping (varicose retracting skin Used to open neck muscle
veins) layers and for thyroidectomy
Langenbeck
Skin Hooks Vaginal Speculum

 For visualization  Used to retract thin skin,

of anal/vaginal like eyelids and for eye  For Pap Smear,
area surgeries Visualization 199 of
 D. Probing and Dilating SI
 A probe is used to :
• explore a structure, the depth of a wound or
to trace the path of a fistula.
• to locate an obstruction.
 Dilators are used to:
• increase/enlarge the diameter of a lumen,
such as the urethra, uterine cervix, or
esophagus

200
 C..

Grooved probes Round probes

201
 Care of Surgical instruments
- Are delicate , to prevent damage,
- they must only be used for the purpose for which
they are designed.
- handled with care and separated from other
instruments
- Proper selection ; requires a general understanding of
surgical procedures and a knowledge of anatomy.
• to prevent corrosions or damage, not be immersed in
saline.
• Specialized instruments should be regularly checked by
an appropriately trained person.

202
 UNIT 5
Receiving and positioning of surgical pt.
• Objectives : the learner will able to:
1. Mention some of the responsibilities of the OR
team during receiving the surgical pt.
2. Identify hazards associated with moving a patient
from place to place
3. Describe the effects of positioning on the
patient’s body systems.
4. Describe the safety measures to consider while
positioning, moving and transporting surgical
patients.
203
 Receiving the Surgical Patient
• Regardless of the physical location in which a surgical
procedure will be performed:
• patient should be adequately assessed for :
- Alterations in skin integrity.
- Joint mobility,
- expected outcome that the patient will not be harmed
by positioning for surgical procedure
• Pt Preparations : both physical and emotional

204
 When receiving the patient:
• Greet the patient by name and introduce
yourself
• explain the purpose of coming to the OR.
• Review the patient’s chart for completeness
• Obtain information about understanding of the
surgical procedure
• Check whether all preoperative preparations
have been done
• Answer the patient’s questions about the
surgical procedure
205
 c..
• Encourage the patient & family to discuss their
feelings or anxieties regarding the surgical
procedure and anticipated results.
• Identify any special needs of the patient that
will alter the plan for intraoperative care.
• Reassure & maintain an attitude of hope.
– Avoid using phrases such as
- “Everything will be all right”
- “You are okay.”
• Reinforce the concept that the team will
provide good care.
206
 Positioning the surgical patient
 Each operative position should provide :
accessible & stable operative area for surgeon
adequate space for anesthesia provider:
to administer the anesthetic agent
to follow V/S and IV fluids
 maximum safety and comfort to the patient

207
 Preliminary Considerations for positioning
 a knowledge of anatomy and the application of
physiologic principles
 familiarity with the necessary equipment.
 Patient positioning is determined by:
 the procedure to be performed
 the surgeon’s choice of surgical approach
 the technique of anesthetic administration.
 Factors such as age, height, weight,
 cardiopulmonary status, and preexisting disease (e.g.,
arthritis)
- So, these should be incorporated in the plan of care.

208
 Preparation for positioning a surgical pt
• Before the patient is brought to the OR
the circulating nurse should do:
• determine the proposed position .
• Check the working part of the operating bed
before bringing the patient into the room
• Assemble all attachments and protective pads
anticipated for the surgical procedure.
• Test positioning devices for patient safety
• Check for cleanliness

209
 Safety Measures
• Safety measures to minimize physical injury of
staffs:
– Keep the body as close as possible to the person or
equipment
– maintaining a straight back.
• Lift with the large muscle groups of the legs and
abdominal muscles, not the back.
• Lift with a slow, even motion

210
 c..
• identify the pt before transferring to
operating bed
• assesse the patient for mobility status
• lock operating bed and transport vehicle
before transfer
• Adequate assistance in lifting unconscious,
obese, or weak patients
• Help conscious walking pt from two sides

211
 Cont…
• Moving anesthetized with guidance of
anesthesia provider.
• No body part should extend beyond the
edges of the operating bed or contact metal
parts or unpadded surfaces.
• Limit body exposure to prevent hypothermia
and to preserve dignity.
• Movement and positioning should not
obstruct or dislodge catheters, intravenous
(IV) infusion tubing, and drainage materials
212
 Con….
• Avoid crossing of legs & ankles for pt in supine..
• Apply chest rolls for prone pt
• Apply pillow b/n legs for laterally positioned pt.

213
 Equipment for Positioning
• Shoulder Bridge (Thyroid Elevator)
• Safety Belt (Thigh Strap)
• Lift Sheet (Draw Sheet)
• Arm board
• Wrist or Arm Strap
• Body (Hip) Restraint Strap
• Metal Foot board
• Head rests ,
• Operating Bed
• Pressure-minimizing Mattress, etc

214
 Surgical Positioning
– The position in which the patient is placed on the
operating bed/table depends on the:
- surgical procedure to be performed
- physical condition of the patient.

215
 ) Supine, (B) Trendelenburg, (C)
(A

Lithotomy, (D) modified Sim’s/ Kidney 216

(E) Prone position
(F) Reverse Trendelenburg position
217
 UNIT 6 : Individual/group
Assignment for submission
• Explain the following contents
1. Surgical conscience
2. Areas affected by surgical conscience
3. Protection of the patient
4. Situations that undermine surgical conscience
5. Legal aspects of surgery
6. Criminal responsibilities
7. Common areas of negligence
.Submit at the end of the course
218
 UNIT 7
Wound , wound management and wound closure

• Introduction
• Wound is a break in the normal continuity of a tissue.
• It is caused by a transfer of any form of energy
into the body which can be either to :
• an externally visible structure like the skin
• deeper structures like
- muscles, tendons or internal organs.

219
 c…
• Successful wound management (with rapid and
complete healing and minimal complication)
depends on:
• understanding the basic principles of:
– Assessment wound
– bacteriology
– application of the general principles of wound care.

220
 Assessment of wounds
• adequate assessment, based on relevant
• history and
• PE is important.:
• HX :Mechanism of injury,Time, Place and circumstances,
past and current medical and vaccination states
PE:the integrity and function of the structures. inspection
and specific tests to assess the :
• Extent of skin loss
• Degree of circulation
• Damage to nerves, muscles , tendons, bone etc…
• The degree of contamination
• Presence of foreign body and tissue necrosis
221
 Classification of wounds
• There are many approaches .
• But, generally grouped as:
1 .Closed wounds: which have an intact epithelial
surface, and skin cover not completely breeched.
• Example: Contusion, Bruise, Hematoma
2. Open wounds: caused by injury w/h leads to a
complete breakt of the epithelial protective
surface.
• Example: Abrasion, Laceration, Puncture

222
 Classification
• The traditionaly , surgical wound is classified according to the rate
of wound infection as:
A. Clean wounds:
►non traumatic, non-infected ,
►no break in sterility technique.
- B/se the respiratory, GIT ,GUT not entered.
►Risk of bacterial contamination is low
►Incidence of infection is less than 1.5%
►Antibiotics not needed usually

•
223
 B. Clean-contaminated wounds
• minor break in sterility technique,
• Eg. the oropharynx, respiratory, GIT ,GUT
entered during elective cholecystectomy,
colon resection and appendectomy etc…
• risk of infection remains low (<3%)
• Prophylactic antibiotic is used.

224
 C .Contaminated wounds:
• Fresh traumatic wounds, major break in
sterility, gross spillage from GIT, entrance of
genitourinary or biliary tracts in the presence
of infected urine or bile.
• Risk of infection increased to 5% or more
• antibiotic therapy indicated
• open initially for about 5 days

225
 D. Dirty and Infected
heavily contaminated with bacteria such as: - - abscess
drainage wounds
- foreign bodies,
- fecal contamination,
- gun shot wounds
- accidental wounds in septic environments.
• Risk of infection is high if closed initially
• Antibiotic usage expected
• open initially
• debridement and open wound care

226
 WOUND HEALING
• is a complex biologic process of restoring normal tissue
continuity.
• To do this there are integrated sequences of events leading to
cellular proliferation and remodeling.
• FOUR PHASES OF HEALING
1-Coagulation phase:
• is the first phase of healing which is induced immediately
following injury.
• It is characterized by vaso-constriction, clot formation and
release of platelets and other
substances necessary for healing and help as a bridge between
the two edges.
•
227
 2- Inflammatory phase:
• This phase takes place from time of wounding
up to three days.
• It is characterized by
 classical inflammatory response,
vasodilatation and pouring out of fluids,
migration of inflammatory cells and
leukocytes
rapid epithelial growth.

228
 3- Proliferate Phase:
• known as phase of fibroplasia, starts around the 3rd day
of injury and stays for about three weeks.
• It is characterized by
fibroblast,
 epithelial and endothelial proliferation,
Collagen synthesis,
blood vessel production.

229
 4- Maturation phase:
• Is phase of remodeling,
• takes the longest period for up to one year.
• Equilibrium between protein synthesis and
degradation occurs .

230
 Clinical types of healing
• Traditionally, wound healing can be classified
into three clinical types:
• Healing by first, second and third intention.
• Healing by first intention:
• is healing of clean wound closed primarily to
approximate the ends.
• Healing takes place by epithelialization and
leaves minimal scar.

231
 Healing by Second intention:
• This occurs in wide, contaminated and infected
wounds, which are not primarily closed.
• Healing takes place by granulation tissue formation,
tissue contraction and epithelialization.
• Healing by third intention:
• This occurs in wounds which are left open initially for
various reasons and closed later
• (delayed primary closure) , which is done for
traumatic or contaminated wounds within 3 days of
initial treatment to avoid the risk of wound sepsis.

232
 Secondary closure
• is usually done in 3-7 days of initial RX.
• is effected in contaminated or traumatic
wounds.
• provides a reliable drainage and opportunity
for repeated inspection and debridement as
necessary.

233
 Factors affecting healing
• Healing of a wound can be affected by
• Local factors
• Ischemia and decreased oxygen tension
• Presence of foreign bodies
• Infection , Irradiation…
• Systemic factors
• Systemic diseases :DM, renal failure, malignancy…
• Poor nutritional State
• Decreased resistance due to immune suppression,
chronic infection
• Drug therapy like steroids, cytotoxic agents
234
 Sutures and suture materials
• Objectives :
1.Define suture and suture materials.
2.Discuss the difference b/n absorbable and non
absorbable sutures.
3.Identify the different suture materials.
4. Mention the types of sutures
5 .Prepare suture materials properly.
6. Identify the different parts of a needle.
7.List down the types of needles.
235
 Suture Materials
• Introduction
• Suture(n) /stitch/ is material used for ligating
or approximating tissue;
• Suture (v) is the act of sewing by bringing
tissues together and holding them until
healing has taken place.
• If the material is tied around a blood vessel to
occlude the lumen, it is called a ligature or tie.

236
 Types of Suture Materials
 Sutures are either :
1. absorbable
2. non absorbable.
1 .Absorbable sutures
• are used internally and are dissolved over time by
body enzymes.
• does not require removal.
• May loose strength before the wound has healed
• come in poly/mono/filament sutures.

237
 Con..
 Each have various half-lives and strengths.
 So, the duration for absorption is from
3 days to 3 months dependding on the:
- type of suture
- condition of the tissue,
 Does not stay in the body -> decreasing the risk
for infection
 Causes a greater local tissue reaction than
permanent suture material
238
 suture type
B. Non absorbable Suture
The common absorbable sutures
A .Surgical Catgut
• Surgical Silk
• Plain/ Chromic Surgical
Catgut • Surgical Cotton
B. Synthetic Absorbable sutures • Polyester
• Polyglycolic acid (Dexon) • Nylon
• Polyglactin (Vicryl) • Surgical Steel

239
 Types of absorbable sutures
A. Surgical Catgut:
- Natural
- Made from : - submucosa of sheep intestine
- serosa of beef intestine.
• Used in tissue that heals rapidly.
• Digested by body enzymes and absorbed by tissue
(no permanent foreign body remains.)
 The rate of absorption is influenced by :
• Type of tissue
• Condition of tissue
• General health status of the patient
240
 Types of surgical catgut
B .Plain Surgical Catgut
• Used to ligate small vessels and to suture
subcutaneous fat closure
• Lose tensile strength quickly,
1-2 weeks (usually in 5-10 days)
• Not used to suture any layer of tissue likely to be
subjected to tension during healing.
• Available in sizes 3 to 6-0.
• Color :Usually yellow-tan, it may be blue or black
241
 Con..
• is specially treated to speed absorption and
tensile strength loss.
• May be used for epidermal suturing where
sutures are needed for no more than a week.
• These sutures are used only externally on skin,
not internally, particularly for facial cosmetic
surgery.

242
 Chromic Surgical Catgut
• Is treated in a chromium salt solution to resist
absorption by tissues
• This treatment changes the color from the
yellow-tan to a dark shade of brown.
• used for ligation of larger vessels ,
Subcutaneous, intradermal suturing .
• Absorbed with in 2-3 weeks
Available in sizes 3 to 7-0
• May be dyed blue or black

243
 B. Synthetic Absorbable Sutures
 have great tensile strength
Has slow absorption in the presence of tissue
fluids.
E.g.Vicrcyl need 2-3 months
 used for ligating and suturing.
 it tends to drag through the tissue rather than
passing smoothly.
This action may slow down the sewing process
 Difficult to tie

244
 Non absorbable Suture
• is either
– left in the body (embedded in scar tissue)
– removed when healing is complete, as in skin
closure.
– is used in tissues that heal more slowly

245
 Non absorbable
• A. Surgical Silk - An animal product made from the
fiber spun by silkworm larvae in making their
cocoons.
• Widely used non-absorbable suture
- is easy to handle
- supple and strong.
• Can be used in a wide variety of tissues, ranging from
ophthalmic to cardiovascular .
• Eg - Skin closure, gut anastomosis + hernia
repair + tendon repair.
• Has a multifilament structure

246
 B. Surgical Cotton
• Made from the fibers of the cotton plant
• easy to handle
• Has inferior strength
• Can be strengthening by dipping it into saline
solution prior to use.
• Its application is nearly identical to that of silk.

247
 C. Polyester Suture
•The strongest of all , except surgical steel
•It is usually multifilamented
•Used in a wide variety of tissues, including facial,
cardiovascular, and ophthalmic.
D. Nylon Suture
• Used primarily for skin closure, ophthalmic
procedures, and microsurgery.
• Produces minimal tissue reaction
• Has high tensile strength, and resists capillary action
• The major disadvantages : Stiffness.
248
 Size of suture material
• Suture materials range from smaller gauges for finer tissues
below 0 to thicker gauges above 0.
• 11-0 are thinnest, and 7 are thickest.
• Sizes and diameters are available on a scale . Eg
6-0 = 0.07 mm
5-0 = 0.10 mm
4-0 = 0.15 mm
3-0 = 0.20 mm
2-0 = 0.30 mm
0 = 0.35 mm
1 = 0.40 mm
2 = 0.5 mm
249
250
 F. Surgical Steel
• Made of stainless steel and is the most inert type of
suture available
• Used mainly in the orthopedic surgery to approximate
bone fragments
• Not widely used because of major disadvantages:
– Extremely difficult to handle
– Kinks easily and has a “sawing” effect on tissue
– Because of its springiness it is easily contaminated at
the field
– The sharp ends of the strands can easily puncture a
glove, causing contamination and injury to the
person handling it.
251
 Surgical needles
• needed to safely carry suture material through tissue
with the least amount of trauma
• made of high-quality steel
 Strong enough
 Flexible => not break easily
 Rigid enough to prevent excessive bending
 Sharp enough to penetrate tissue
 has the same diameter as the suture material
 Free from corrosion.

252
 Surgical needles
• available in many sizess & shapes
• straight or curved.
• have three basic components:
• the point,
• the body (or shaft),
• the eye.

253
 Needle points

(A) cutting, (B) side cutting, (C) cutting edges at end of tapered
body, (D)trocar point, (E) taper, (F) blunt. 254
 Body of the Needle
• The body varies in length, shape, and gauge

255
 Eye of the Needle
• The eye is the segment of the needle where
the suture strand is attached.
• classified as
• eyed,
• French eye,
• eyeless (also known as swaged or atraumatic).

256
Handling of eyed and French Eye Needles
• Has disadvantages for the scrub nurse, surgeon and
patient:so
• Each needle must be carefully inspected before and
after use for dull or burred points,
corrosions, and defects in the eye.
• Care must be taken to avoid puncturing when
threading.
• choose an appropriate needle to thread, the needle
should be the same approximate diameter as the
suture size requested by the surgeon.

257
Threading French eye Needles

258
 Eyeless Needle
• is a continuous unit with the suture strand.
• is swaged onto the end of the strand in the
manufacturing process.
• This eliminates threading at the operating bed
& minimizes tissue trauma because a single strand of
material is drawn through tissue.
• Its diameter matches the size of the strand as
closely as possible.
• The surgeon uses a new sharp needle with every
suture strand

259
Tissue effects of needle penetration
A. threaded. B. swaged atraumatic 260
 Placement of the Needle in the Needleholder
• Needleholders have specially designed jaws to
securely grasp surgical needles without damage if
they are used correctly.
• principles in handling needles and needleholders:
• Select a needleholder with appropriate-size jaws for
the size of the needle to be used
Use the shortest holder to reach the work
• Clamp the body of the needle from1/4 to 1/2 of the
distance from the eye to the point (mainly 2/3 in
front & 1/3 behind in body)
• Hold needle with tip of needle holder

261
 Co…
• Use the thumb and 4 finger in the rings of
th

the handle
• Index finger on front of holder to stabilize the
drive
• Strike perpendicularly and follow the curve of
the needle through the tissue for best
control.

262
 c…
Never clamp the needleholder over the swaged area.
Place the needle securely in the tip of the
needleholder jaws
• Pass the needleholder with the needle point up and
directed toward the surgeon’s thumb when grasped.
• Hand the needleholder to the surgeon so that the
suture strand is free and not entangled with the
needleholder
•

263
 -con…
Hold the free end of the suture in one hand while
passing the needleholder with the other hand
• Protect the end of the suture material from
dragging across the sterile field

Placement of a needle in the Needle holder

264
 Methods of suturing
There are two basic methods of suturing:
= continuous & interrupted.
Continuous:
• Simple continuous (running) - can be used to
close multiple layers with one suture.
• The suture is not cut until the full length is
incorporated into the tissue .

265
suturing techniques: A and B: continuous;
C, D, and E: interrupted. 266
 Continuous type
• Simple continuous (running).
- used to close multiple layers with one suture,until the
full length is incorporated into the tissue .
• Continuous running/locking -
• Also called blanket stitch.
• A single suture is passed in and out of the tissue
layers and looped through the free end before the
needle is passed through the tissue for another
stitch.
• Each new stitch locks the previous stitch in place

267
 Intradermal suturing (subcuticular)
• Excellent apposition of dermis and epidermis
• Interrupted or continuous in the dermis
• Highly cosmetic
• Use long lasting absorbable suture (vicryl) if
suture is to be left in.

268
 interrupted
 Simple interrupted.
 Each individual stitch is placed, tied, and cut in succession from
one suture.
 Interrupted sutures are placed separately and tied separately.
 Horizontal mattress.
 Stitches are placed parallel to wound edges.
 Each single bite takes the place of two interrupted sitches.


269
 *Vertical mattress
 uses deep and superficial bites, with each stich crossing
the wound at right angles.
 It works well for deep wounds.
 Edges approximate well
• Inverting sutures
• are commonly used for two-layer anastomosis of hollow
internal organs,
such as the bowel and stomach.
• can be either interrupted or continuous.
* Everting sutures.
• used for skin edges
• can be either interrupted or continuous
270
 Knot Placement
• Each suture placed in tissue usually requires
the placement of a knot to secure the ends.
• Interrupted stitches require individual knots:
-- placement of each knot can influence
- how well the wound heals
- the cosmetic result.

271
 Principles concerning knots and knot tying
1. The knot should be tied away from:
• Vital structures, such as the eye
• Source of contamination, such as the mouth
• Potential irritants, such as the nares
• Potential sources of increased inflammation, such as
the incision line
2. The knot should be tied toward:
• The better blood supply
• The area that provides the best security of the knot
• If possible, where the mark would be less noticeable

272
 Cutting Sutures
• Care is taken to prevent excess suture from
remaining in the wound.
• Suture tails are trimmed close to the knot.
• Considerations for cutting suture:
• Scissors should be stabilized by the index
finger on the screw,
• the blades are angled slightly and slide down
to the area just above the knot, and the
suture is cut with the tips of the scissors.
•
273
 c…
• The tips of the scissors must be visible to
ensure that other structures are not injured
by the cutting motion.
• When removing a suture, a forceps is used to
grasp the suture at the knot.
• Cut the suture between the knot and the skin.
Extract the cut suture with forceps.

274
 UNIT 8
PRINCIPLES OF ANESTHESIA
• Learning Objectives.
• After completing this chapter, the learner will be able to:
1.Differentiate the difference b/n local and general
anesthesia.
2.Mention the routes of administering anesthetics.
3.Manage the adverse effects of local anesthesia.
4.Identify the stages of general anesthesia.
5.List levels of sedation

275
 Introduction
Anesthesiology
• is the branch of medicine that is concerned
with the administration of anesthetic agent to
relieve pain and to support physiologic
function during a surgical procedure.
• The OR team members should be
- aware of the effects of anesthesia on the pt.
- available to assist the anesthesia provider as
needed.

276
 Anesthesia
Is Greek word means negative sensation.
- is the absence of sensation,
- may be produced in - a specific body area
- systemically.
- causes temporary loss of sensations.
- Grouped as
1. general analgesia-when the agent given causes
unconsciousness,
2. local / regional - when an agent is given into a
specific area to cause, the absence of pain.
277
 General Anesthesia (GA)
• is a way to control pain using anesthetic medicine.
• Is reversible, drug-induced loss of consciousness
• A person under GA during procedure:
- Is completely unaware of what is going on
- does not feel pain.
• b/se Anesthesia
- interrupts the pain signals b/n nerve endings & the
brain.
- Depresses the nervous system
- Provides muscle relaxation.
• So ,Licensed professional administering it & monitors pt.
278
 stages of GA
1 . STAGE 1 (Amnesia) /Induction:
- Is the level from beginning of induction of
anesthesia to loss of consciousness (loss of
eyelid reflex).
• Characterized by
 Pain perception threshold is not lowered.
 The pt has an exaggerated sense of hearing
 so all personnel in the room remain as quiet
as possible

279
 STAGE 2 (Delirium/Excitement):
• Characterized by
• uninhibited excitation.
• Pupils are dilated and eyes divergent.
• Agitation, delirium, irregular respiration, and breath
holding are commonly seen.
• Potentially dangerous responses can occur
- e.g. vomiting, laryngospasm, HTN, tachycardia, and
uncontrolled movement.
• => Patient is physiologically unstable

280
 STAGE 3 (Surgical Anesthesia)
- is the level at which surgery may be performed
safely.
The patient is:
relaxed ( in Relaxation stage)
unconscious of pain
physiologically stable
Breathing is steady and automatic
ends at its deepest level with respiratory
paralysis.
281
 STAGE 4 (Impending Death/Overdose)/
• Danger stage.
• begins when the amount of agent causes severe
depression of the CNS
• the patient is in immediate danger of cardiopulmonary
arrest.
- needs redness to handle it.
• Onset of apnea
• Pupils dilated and non reactive
• hypotension to complete circulatory failure can occur.
282
 Methods of Administering
General Anesthesia
1 Inhalation
• by anesthesia machine.
• The patient receives the anesthetic-oxygen
mixture from machine via:
– The endotrecheal tube
– mask that fits snugly around the nose and mouth.
– e. g halthane

283
 2 .IV
 Ketamine
 profofol
 Diazepam
 midazolam
 fentanyl ,…
3 .IM
e.g Ketamine, diazepam, midazolam
These agents are usually injected by the
anesthesia provider about 15 minutes prior to
surgery.
284
 Local Anaesthesia
• is the local loss of : pain, temperature, touch,
pressure and all other sensation.
• The agent acts on
– a single nerve,
– a group of nerves
– on superficial nerve endings.
• During all types of local/regional anesthesia the
patient remains conscious.

285
 Local anaesthetic agents:
- are substance w/c reversibly inhibits/ block nerve
conduction when applied directly to tissue at non-
toxic /appropriate concentrations.
- acts on:
 any part of the nervous system, peripheral or central
 any type of nerve fibres, sensory or motor.
• It numbs only a small, specific area of the body With
it a person is awake or sedated.
• lasts for a short period of time and is often used for
minor outpatient.

286
 Properties of Ideal local Anaesthetic:
– Possess a specific and reversible action.
– No Systemic toxicity
– Rapid onset and long duration
– Active Topically or by injection

287
 Administration
• 1. infiltration - agents injected intracutaneously and
subcutaneously into tissues at and around the incisional
site to block peripheral sensory nerve stimuli at their
origin.
• It is used:
 to suture superficial lacerations
for excision of minor lesions.
In non extensive surgery.

288
 Con..
in highly vascularized areas , epinephrine is
sometimes added to the anesthetic
Adrenaline causes vasoconstriction
- this slow circulatory uptake and absorption
of agents ,
- thus prolonging anesthesia & decrease bleeding
Agents with Adrenaline are contraindicated
for operative procedures in fingers and penis?.
High levels of local anesthetic are toxic
Use a calibrated syringe to avoid over dosage while
administration
289
 2. Nerve block
• Anesthesia of a large single nerve or nerves
• Injection is done not necessarily at the immediate
surgical site,
• The supplying nerve is anesthetized
• Commonly used in surgery that is performed on
fingers and toes

290
 3 .Topical
• Used to numb superficial nerve endings
particularly the mucous membranes (cornea,
nasal/oral mucosa)
• The agent may be
- swabbed,
- sprayed
- applied in drops as for eye surgery
• Useful in preparing the patient for endoscopic
Procedures, awake oral, nasal intubation,
surgical procedure
291
 Classes of Local anesthetics
• Esters • Am”i”des
Cocaine Bupivacaine
Chloroprocaine Lidocaine
Procaine Ropivacaine
Tetracaine Etidocaine

292
 Uses
•Provide anesthesia for a surgical procedure
• Provide analgesia post-operatively or during labor
and delivery
• therapy for patients with chronic pain syndromes
AMIDES & ESTERS
Esters Potency/effectiviness Onset Duration( min)

Procaine 1 Slow 10 minutes 40-60

Chloroprocaine 4 Rapid 30-45

tetracaine 16 Slow 60-180

AMIDES

Lidocaine 1 Rapid 60-120

Plirocaine 1 Slow 60-120

bupivicaine 4 slow 240-480

293
 MECANISIM of action
– Local anaesthetic drugs bind to specific receptor within
the sodium channel producing physical obstruction to
entry of sodium ions.
– It bind to a closed gate and maintain it in the closed
position.
– It is, then, essential that the nerve fires, and the gate
assumes the closed position.

294
 Local anesthetics - Formulation
• Biologically active substances are frequently
administered as
• very dilute solutions which can be expressed
as parts of active drug per 100 parts of
solution (grams percent)
Ex.: 1% solution =
_1 grams__ = _1000 mg_ = __10 mg__
100 cc’s 100 cc’s 1 cc

295
 amides
Bupivacaine -
-A long-acting local anesthetic agent
– Metabolized in the liver.
– Longer onset and longer duration
– Dosage:
1.3 mg/kg – Max 90 mg
0.25 – 0.75% with or without adrenaline 1:200 000

can be given (Epidural, spinal, infiltration,

peripheral nerve block)

296
 Lidocaine
– It highly lipophilic , rapidly absorbed.
– Metabolized only in the liver and its metabolites are less
toxic with no action.
• Dosage:
• 3(3 - 5 )mg/kg,300 mg max with out adrenaline.
• 7mg/kg with Adrenaline
• Used as
 2% plain or with 1:80 000 epinephrine
4% and 10% spray, 2% gel and 5% ointments.
– Onset & duration of action:
• Onset – Rapid , 2 – 3 minutes
• duration 1-2 hours
297
 Esters
– Benzocaine- Topical
– Cocaine- Topical, 3mg/kg max., 30 minutes to one hour
The first and most potent local anaesthetic agent, rarely
used because of the problems of misuse.

– Chloroprocaine- Epidural, infiltration and peripheral nerve

block, max dose 12mg/kg.
– It is unique in it is ability to produce intense
vasoconstriction.
– Tetracaine- Spinal, topical, 3mg/kg max.

298
 LA - Toxicity
• Tissue toxicity - Rare
• Can occur if administered in high enough concentrations
(greater than those used clinically)
• Systemic toxicity – Rare
• Related to blood level of drug secondary to absorption from
site of injection.

299
 S/S OF TOXICITY
• Range from light headedness, tinnitus to seizures on CNS/CVS
collapse
 Stimulation:
• patient may become very talkative or anxious, signs of
tachycardia , fast & weak pulse
• convulsion.
 Depression: patient may appear sleepy and unresponsive, bradycardia, hypo
tension.
• Other signs: patient may develop
 cyanosis, sweating , cold, act restless (signs of shock).
 Fainting, itching, nausea or sudden headache
• Treatment of the Reaction
• Discontinue the anesthetic immediately,
• Oxygen administration may be needed,
• BLS & ALS as needed
300
 Local anesthetics –Vasoconstrictors Ratios
• Epinephrine is added to local anesthetics in extremely dilute
concentrations, best expressed as a ratio of grams of drug : total
cc’s of solution.
• Expressed numerically, a 1:1000 preparation of epinephrine would
be 1 gram epi/1000 cc’s solution =1000mg epi/1000 solution
= 1 mg epi /1cc
1 : 200,000 solution of epinephrine would be:
1 gram epi/200,000 cc’s solution
= 1000 mg epi/ 200,000 cc’s solution
= 5 mcg epi/ 1 cc solution

301
 Regional anesthesia
A local anethetic is injected to block or
ansthetize a nerve or nerve fibers
An anesthetic drug is injected near
a cluster of nerves, numbing a larger area of the
body.
=>Implies a major nerve block
e.g.
• Intravenous block (“Bier” block)
• Plexus - brachial, lumbar
• Central neuraxial - epidural, spinal
302
 Administration : IV Block
• Injection of local anesthetic intravenously for anesthesia of an
extremity.
• Uses
- any surgical procedure on an extremity
- fracture reduction
- large laceration repairs
- Foreign body removal
• Method:
• proximal cuff is inflated to 50 -100mmHg above the normal
SBP
• agent is injected to the vein, not deflated untill
20 minutes from injection . e.g. Lidocaine 0.6ml of
0.5%sollution with out epinephrine used.
303
 c..
Advantages : - technically simple
- minimal equipment use
-rapid onset
Disadvantages:
- duration limited by tolerance of tourniquet pain
- toxicity
c/I :
 HTN,
 cardiac conduction abnormalities
 child < 5y

304
 Plexus Blockade
• Injection of local anesthetic adjacent to a plexus, e.g
cervical, brachial or lumbar plexus
• Uses :
- surgical anesthesia or post-operative analgesia in
the distribution of the plexus
• Advantages:
- large area of anesthesia with relatively small dose
of agent.
• Disadvantages:
- technically complex, potential for toxicity and
neuropathy.
305
 Spinal
• Introduction of the anesthetic in to the subarachnoid space at
the fourth or fifth lumbar interspaces.
• Here the agent does come into contact with the CSF.
• Ideal for surgery of the lower pelvis, such as
cesarean section or hernia repair; procedures in lower
extremities .
• Uses: profound anesthesia of lower abdomen and extremities
• Advantages:
• Technically easy (LP technique), high success rate, rapid onset
• disadvantage:
- “high spinal”, hypotension due to sympathetic block,
- headache.

306
 epidural
•Introduced into the epidural space
no direct contact with CSF
• Uses:
- Anesthesia/analgesia of the thorax, abdomen, lower
extremities
• Advantages:
- has long duration, post-operative analgesia.
• Disadvantages:
- Technically complex, toxicity, “spinal headache”

307
 Choice of Anesthesia
• Selection of anesthesia is made by the anesthesia
provider in consultation with the surgeon and the
patient.
• The primary consideration should be associated
with low morbidity and mortality.
• Choosing the safest agent and technique is a
decision predicated on
• thorough knowledge
• sound judgment and
• evaluation of each individual situation
308
 C..
• An ideal anesthetic agent or technique suitable for all patients
does not exist, but the one selected should include the
following characteristics:
• Provides maximum safety for the patient
• Provides optimal operating conditions for the surgeon
• Provides patient comfort
• Has a low index of toxicity
• Provides potent, predictable analgesia extending into the
postoperative period.
• Produces adequate muscle relaxation
• Has a rapid onset and easy reversibility
• Produces minimum side effects
309
 SEDATION
• There are four levels of sedation
• Minimal sedation
• Moderate sedation
• deep sedation
• General anesthesia
• Occurs along a continuum
Minimal sedation( anxiolysis)
• A drug induced state during w/h pts respond normally
to verbal commands.
• Cognitive function & coordination may be impaired
• Cardiopulmonary functions are unaffected
310
 Moderate Sedation/Analgesia /Conscious sedation
• Is a drug induced depression of consciousness
during w/h Pt responds purposefully to verbal
commands either alone or accompanied by
light tactile stimulation
• Airway is maintained
• Spontaneous ventilation adequate
• Cardiovascular function maintained
• e.g.- fentanyl/midazolam.

311
 Deep Sedation/Analgesia
• Is a drug induced depression of consciousness in w/h Pt:
• cannot be easily aroused
=> “unconscious sedation”
• responds after repeated or painful stimuli
•It may be accompanied by:
loss of protective reflexes (a partial or complete)
->inability to maintain a patent airway
independently.
.
312
 c..
- spontaneous ventilation may be inadequate.
• Moderate loss of ventilatory responsiveness
may occur.
. Patients may require assistance in maintaining
a patent airway.??
• Cardiovascular function may be impaired(but
usually maintained)

313
 GENERAL Anesthesia
• Is a drug induced LOSS OF consciousness w/h Pts:
• are not arousable , even to painful stimuli
• The ability to independently maintain ventilatory
function is often impaired.
• Patients often require assistance in maintaining a patent
airway, and
• positive pressure ventilation may be required because of
depressed spontaneous ventilation or drug induced
depression of neuromuscular function.
• Cardiovascular function may be impaired
• Requires the presence of anesthesiologists /anesthetists
314
 standard
• Patients must be assessed, give informed consent
(risk, benefits, options)
• Must be re-evaluated immediately before sedation
• Status reviewed after sedation
• Have appropriate equipment.
 Pulseoximetery
 Airway devices
 BP cuff,
 EKG monitoring machine
• Everything must be documented

315
 When to sedate?
.IV insertion  Nasal packing.
• LP  • RSI/intubation/
 FB removal  • Diagnostic procedures
• Suturing  • Calming the agitated pt
 Fracture care & reduction  • Cardio version
 Chest tubes insertion  defibrillation
• Many, many more

316
 Sedation medication guide lines
You must know
• the dose limit.
• On set.
• Duration.
• Interaction.
• precautions.

317
 Conclusions
prepare to handle emergencies
• Have suction, airway devices, o2, reversal agents
 Naloxone for Narcotics toxicity .
typical dose for
- adult 0.4 to 2mg
- pedi. 0.1mg/kg IM,SQ,IV,IO,ETT

318
 flumazenil for Benzodiazepines overdose
 adult dose
• First dose 0.2mg IV over 15 seconds
• Second dose0.3mg Iv over 30 seconds, if no adequate
response ,
• Third dose0.5mg IV over 30 seconds
• up to max 1mg
• Paediatric dose 5mcg /kg , then repeat up to 40mcg/kg iv
• BVM available ,
• KNOW EVERYTHING ABOUT ANY MEDICINE YOU GIVE TO A PATIENT
• Assess comorbities .

319
 UNIT 9 HAZARDS IN THE OPERATING ROOM
• Learning Objectives
1.Identify the main dangers in the OR.
2.Explain the factors that increase the hazards in
the OR.

320
 Introduction
• OR has been a place full of hazards for
 the patient
 the care giver.
The primary dangers are :
fire,
chemical exposure to anesthetic agents
direct exposure to biologic materials ..

321
 Classification of Hazards
• Hazards in the OR environment can be classified as :
1 .Physical:
 back injury, fall, irradiation, electricity and fire
2. Chemical:
 anesthetic gases.
 cleaning agents.
3 .Biologic:
 the patient (as a source of pathogenic m/o ),
 infectious waste,
 cuts or needle-stick injuries,
 latex sensitivity
322
 Regulation of hazards
• Standards, guidelines and recommended practices
have been developed by many professional
associations, governmental and nongovernmental
agencies such as MoH,WHO, CDC, the likes.

• The appropriate use of electronic devices is a prime

concern of health care providers seek safer patient
care.
•

323
 Grounding
• Grounding systems are designed to discharge
any harmful electricity directly to the ground
without including the patient in the circuit
• This prevents the inadvertent passage of electric
current through the patient,
• There by preventing shock or burn.
• So, the system is essential for all electrical
equipment

324
 Minimize electrical hazards by:

• Checking electrical equipment before each use

• Checking plugs and cords for exposed wire or damage
• Disconnecting cords by pulling on the plug not the
•
cord
• Using only 3-prong plugs when possible
• Water and electricity do not mix! Keep hands dry &
keep areas surrounding electrical equipment dry
• Keeping cords from kinking while equipment is in use
325
 Fire and Explosion
• Fire is prime concern in the OR.
• b/se Fires in an oxygen-enriched atmosphere
are fundamentally different in character than
those occurring in normal atmosphere.
• The presence of flammable and combustible
liquids, vapors and gases in an oxygen-
enriched atmosphere can result in the
ultrarapid combustion

326
 A fire or explosion
• is the result of a combination of three
• factors, these are:
• A flammable gas, vapor, or liquid (e.g., alcohol,
• A source of ignition (e.g., electrosurgery, static
electricity, …)
• Oxygen (pure or in air) or some other substances
that provide oxygen, such as nitrous oxide gas

327
 Expectations of staff:
• Keep fire pull stations, extinguishers, and fire doors
clear for easy access
• Do not go through closed fire doors during fire
• Keep exits clear
• Prevent fires by keeping these sources separate:
• Heat – anything that can cause a spark
• Fuel – anything that can burn
• Oxygen/Air – oxygen or air

328
 Catastrophic Events in the operating Room
• Unanticipated intraoperative events occasionally occur.
• Although some might be anticipated
• (e.g., cardiac arrest in an unstable patient, massive
blood loss during trauma surgery),
• others may occur without warning, demanding
immediate intervention by all members of the OR team.
• E.g.
• anaphylactic reactions
• malignant hyperthermia.

329
 Anaphylactic Reactions
• Anaphylaxis is the most severe form of an allergic
reaction,
• manifesting with life-threatening pulmonary and
circulatory complications.
• Produced from antibiotics, latex , blood products
and plasma expanders
• An anaphylactic reaction causes
hypotension, tachycardia, bronchospasm and
possibly pulmonary edema.
• rapid intervention are essential

330
 Malignant Hyperthermia
• is a rare metabolic disease characterized by : -
hyperthermia with rigidity of skeletal muscles
that can result in death.
• It occurs in
• Genetic predisposition
• exposure to certain anesthetic agents.
- during general anesthesia often with
inhalants,

331
 The fundamental defect is
• hypermetabolism of skeletal muscle resulting from
altered control of intracellular calcium, leading to
• muscle contracture, hyperthermia, hypoxemia, lactic
acidosis, Tachycardia, tachypnea, hypercabia and
hyperkalemia => ventricular arrhythmias
• MH is generally diagnosed after all
other causes of hypermetabolism are ruled out.
• Unless promptly detected with rapid initiation of
appropriate intervention, MH
• can result in cardiac arrest and death.

332
 Emergency Treatment of
Malignant Hyperthermia
• Stop surgical procedure/anesthesia if possible.
• Hyperventilate with 100% oxygen
• Administer DANTROLENE
• Direct acting skeletal muscle relaxant
– Inhibits Ca2+ release channel
– Reduced muscle twitch force
– 20mg vial is dissolved using 60 mL sterile water.
– 2.5 mg/kg IVP q 5 minutes
• Continue until patient is stabilized
• Undertake body cooling measures:
- Iced NS intravenously
- Cooling blanket
333
 UNIT10 IMMEDIATE POSTOPERATIVE PATIENT
• Learning Objectives CARE
• At the end of the topic learner will be able to:
1.State the most common causes of death within 24 hours
of postoperative period.
2.Identify areas of competences for a nurse working in the
recovery room (RR).
3.Mention some patient care equipment required in the
recovery room.
5.List main emergency drugs required in the recovery
room.

334
 Introduction
• Regardless of the surgical procedure,
the patient should be observed and monitored in the
recovery room(RR) before the patient being
transferred .
• The Recovery Room .
• Room where Patients stay after their operation.
• Has to be well equipped by material & human
resources ( adequate number of trained nurses and
medical staff )to provide care .
• Ideally, it would be desirable to have a nurse for
each recovery room bed

335
 Causes of death
• which documented within the first 24 hours of
anesthetic administration and surgical
procedure were:
- Obstruction of airway - Laryngospasm
- Hemorrhage, - Cardiac arrest, and
- Inappropriate administration of medications
 Contributing factors for this:
 Inadequate postoperative patient care.
 Lack of standardized observation parameters,
 Absence of medical supervision
336
 Postoperative Observation of the Patient
• duration , type of observation & care
will vary according to :
• Patient’s condition (e.g., alert and oriented vs.
unresponsive)
• Need for physiologic support (e.g., ventilator-
dependent, vs. awake and extubated)
• Complexity of the surgical procedure (e.g., open laparotomy vs.
laparoscopy )
• Type of anesthesia administered (e.g., a general inhalation
agent vs. local infiltration)
• physiologic status (e.g., stable vs. unstable V/S

337
 The Recovery Room Patient Care Personnel
• Adequate personnel should be available to monitor
to provide appropriate care for pt
• educatted & trainend in :
a) Airway management techniques, including
positioning, chin lift, jaw thrust, suctioning, bagging,
and placement of an airway
b) Circulatory assessment,
c) Neurological condition
d) Anesthetic agents and their action
e) Medications and their actions
f) Most invasive and minimally invasive procedures
338
 Recovery room nurses competence
• Physical assessment ( heart and lung sounds)
• Recognition of physiologic complications (e.g.,
airway obstruction, hypothermia, pain, N/V ,
oropharyngeal aspiration)
• Management of physiologic emergences
(e.g., airway obstruction, hemorrhage, cardiac arrest)
• Interpretation of monitoring data from
ECG and pulseoximetry devices
• Application of CPR

339
 Documentation
• Institutional policies and procedures should be followed
in documenting the care given in the recovery room.
• Observations involves
• respiratory and circulatory functions, LOC
documented in frequent intervals.
• physiologic and psychologic status are
documented at the time of any significant event (e.g.,
the administration of medication),
- routinely at 5- to 7 minutes interval for the 1st hr
-15- to 30minutes intervals for the 2nd hour and
thereafter.
340
 Discharge of the Patient from RR
• Most patients remain for at least 1hour until they
have sufficiently recovered from
anesthesia and that their vital signs have
stabilized and they are capable of reasonable
self-care.
The patient’s condition is scored according to V/S,
activity level, and consciousness.
• Pt discharge to
- ward - ICU,
- home with follow-up appointment.
341
 Equipment in the Recovery Room
• The variety of equipment required in theRR are :
• Equipment for airway management
• OPA , NPA ,Tracheal tubes (oral and nasal)
• Laryngoscopes
• Suction catheters and tubing.
• Equipment for respiratory support
• Ambubag
• Automatic ventilators
• Equipment for oxygen therapy
• Oxygen flow meters
• Humidifier for oxygen
• Masks and tubing for delivery of oxygen
342
 Equipment for monitoring
• ECG, BP apparatus, Temperature ,UO
• Equipment for intravenous infusion
• Supply of intravenous (IV) fluids ,sets
• Pressure infusers (for pressurizing bags of
intravenous fluid for rapid transfusion)
• Blood filters , Blood warmers,
• Drip controllers or infusion pumps
• General
• Syringes and needles
• Swabs

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 Drugs for resuscitation trolley
• Sodium bicarbonate solution 8.4%
• Adrenaline 1:1000
• Calcium chloride 10%, Atropine
• Lignocaine for intravenous use
• Beta-blocking drugs e.g. propranolol
• A cardiac glycoside, e.g. digoxin
• An antihistamine, e.g. promethazine
• A bronchodilator, e.g. aminophylline
• Antinarcotics agents, e.g. naloxone
• Hydrocortisone, Sterile water for injection
THE END
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